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PRACTICAL AND SYSTEMATIC
TREATISE
ON
Fractures  and Dislocations.
BY
       A J. HOWE, A. M., M. D.

PROFESSOR OF SURGERY/ IN THE ECLECTIC MEDICAL INSTITUTE.
THIRD EDITION.
King Scudder,
 Cincinnati. 0,               'J3j 33"0
    CINCINNATI:

JOHN M. SCUDDER:
         1883. 
M'tA
Entered According to Act of Congress in 1870, by John M. Sotdder, ia the Clerk's oflioe
              of the District Court for the Southern District of Ohio. 
J£. M.   ;   STTTUTE
   lie:,.ir,y.
CONTENTS.
PART  I.  FRACTURES.
PAGE.
 Preface..............................................................................  11
                          Chapter I.
 General Observations upon the Nature and Treatment of Fractures...  17
                         Chapter II.
 Signs of Fracture........................................................................  22
                         Chapter III.
 Process of Union.......................4...............................................  29
                         Chapter IV.
 Non-union, or False-joint after Fracture.........................................  36
                          Chapter V.
 Defective Union.........................................................................  41
                         Chapter VI,
 General Kemarks in Kegard to the Treatment of Fractures...............  43
                         Chapter VII.
 Reduction of Displaced Fragments................................................  49
                       Chapter VIII.
 Apparatus for the Treatment of Fractures........~............................  52
                         Chapter IX.
 Ke-dressings..............................................................................  64
                         Chapter X.
 Movements allowed a Patient........................................................  66
                         Chapter XI.
 Management of Compound Fractures.............................................  67
                        Chapter XIL
 Diastasis, or Separation of an Epiphysis........................................  72
                        Chapter XIII.
 Fracture of the Cranium..............................................................  74
                        Chapter XIV.
Fracture of the Inferior Maxillary................................................  80
                        Chapter XV.
Fracture of the Hyoid Bone and Laryngeal Cartilages.....................  88
                        Chapter XVI.
Fracture of the Vertebrae..........................................................  91 
iv                  .     Contents.
                                                           PAGE
                        Chapter XVII.
Fracture of the Ribs and Costal Cartilages.....................................  95
                        Chapter XVIII.
Fracture of the Clavicle............................................................... 104
                        Chapter XIX.
Fracture of the Scapula............................................................... HO
                         Chapter XX.
Fracture of the Humerus............................................................ 117
                        Chapter XXI.
Fracture of the Ulna................................................................... 137
                        Chapter XXII.
Fracture of the Radius.........................................................•..... 145
                        Chapter XXIII.
Fracture of the Bones of the  Hand...................»........................... 161
                        Chapter XXIV.
Fracture of the Pelvic Bones....................................................... 165
                        Chapter XXV.
Fracture of the Femur................................................................. 171
                        Chapter XXVI.
Fracture of the Patella................................................................ 215
                        Chapter XXVII.
Fracture of the Leg................................................................... 221
                       Chapter XXVIII.
Fracture of the Bones of the Foot............................................... 249

                             * m *


        PART Ii:  DISLOCATIONS,

                          Chapter I.
General Considerations................................................................ 225
                          Chapter II.
Dislocation of the Jaw................................................................. 290
                          Chapter III.
Dislocation of the Vertebrae....................................................... 297
                          Chapter IV.
Dislocation of the Ribs................................................................ 303
                          Chapter V.
Dislocation of the Clavicle.......................................................... 305
                          Chapter VI.
Dislocation of the Scapula........................................................... 310
                          Chapter VII.
Dislocation of the Humerus......................................................... 314 
                           Contents.                         7
                                                            PAGE,
                         Chapter VIII.
Dislocation of the Radius and Ulna at the Elbow............................ 335
                          Chapter IX.
Dislocation of the Wrist.............................................................. 349
                          Chapter X.
Dislocation of the Phalanges........................................................ 355
                          Chapter XL
Dislocation of the Femur............................................................. 359
                         Chapter  XII.
Dislocation of the Patella............................. .............................. 388
                         Chapter XIII.
Dislocation of the Tibia............................................................... 391
                         Chapter XIV.
Dislocation of the Tibio-fibular Articulations................................. 397
                          Chapter XV.
Dislocation of the  Ankle............................................................ 399
                         Chapter XVI.
Dislocation of the Bones of the Foot.............................................400 
 
ILLUSTRATIONS.
                     .   FRACTURES.

 FIGURE.                                                         PAGE.
  1.  Partial or " green-stick " fracture.......................................... 27
  2.  Specimen of broken ribs...................................................... 33
  3.  Method of union when fragments overlap................................. 35
  4.  Brainard's perforator or drill................................................ 39
  5.  Method of making a " reverse " in a spiral reversed bandage...... 53
  6.  Bandage of strips................................................................. 55
  7.  Lined splint material............................................................ 58
  8.  Moulded gutta-percha splints................................................. 58
  9.  Carved wooden splints.......................................................... 58
 10.  "Wire breeches".'.............................................................. 59
 11.  Adhesive strips to make fast to the leg, for purposes  of extension. 60
 12.  Double inclined plane fracture box.......................................... 61
 13.  Welch's double inclined apparatus.......................................... 62
 14.  Burge's fracture bed............................................................ 63
 15.  Compound fracture of the leg................................................ 67
 16.  Separation of the lower epiphysis of the humerus...................... 73
 17.  Fracture of the lower jaw...................................... .............. 80
 18.  Pasteboard splint for moulding to the chin................................ 84
 19.  Moulded pasteboard splint for the chin...................................  84
 20.  Dressing for fracture of the inferior maxillary........................... 84
 21.  Application of silver wire to adjacent teeth..............................  85
 22.  Fractured rib....................................................................... 69
 23.  Union of broken ribs........................................................... 100
 24.  Fracture of the Sternum....................................................... 102
 25.  Fracture of the Clavicle...,.............................................„...... 105
 26.  Deformity after fracture of the clavicle.................................... 107
 27.  Posterior view  of Fox's dressing for fracture of the clavicle........ 108
 28.  Anterior view of'Fox's dressing for fracture of the clavicle....... 108
 29.  Fracture of the shoulder blade............................................... Ill
 30.  Fracture of the acromion...................................................... 112
 31.  Fracture of the coracoid process............................................. 113
 32.  Fracture of the neck of the scapula......................................... 114
 33.  Humerus, divided into thirds............................................... 117
34.  Carved and hinged splint for the shoulder................................. 119
35.  Fracture of the surgical neck of the humerus........................... 120
36.  Woven wire splint for fractures about the shoulder.................. 121
                              (vii) 
viii                       Iiiustrations.
 FIGURE.                                                           PAGE,
 37.  Fracture of the shaft of the humerus......................................  123
 38.  Dressing for fracture of the shaft of the humerus.....................  124
 39.  Diastasis, or separation of the lower epiphysis of the humerus...  126
 40.  Double fracture of the humerus............................................  126
 41.  Deformity after fracture of the humerus..................................  128
 42.  Fracture of the epitrochlea....................................................  129
 43.  Fracture of the external condyle  of the humerus.......................  129
 44.  Fracture of both condyles ofthe humerus................................  129
 45.  Fracture ofthe internal condyle ofthe humerus........................  130
 46.  Dressing for fractures ofthe condyles ofthe humerus................  131
 47.  Fracture ofthe olecranon and coronoid processes  ofthe ulna.....  137
 48.  Dressing for fracture ofthe olecranon......................................  138
 49.  Fracture ofthe shaft of the ulna.........1...................................  142
 50.  Fracture through upper extremity ofthe radius........................  147
 51.  Shows action of rotating muscles  of forearm...........................  148
 52.  Fracture through middle ofthe shaft of the radius....................  148
 53.  Union of radius and ulna after fracture..................................  149
 54.  Barton's fracture of the radius..............................................  150
 55.  " Silver fork " appearance of the arm after Colles' fracture of the
        radius............................................................................  151
 56.  Colles' fracture ofthe radius..................................................  152
 57.  Splints and dressing for treatment in Colles' fracture of the radius.  155
 58.  Single splint for treating Colles' fracture of the radius...............  156
 59.  Fracture of both bones ofthe arm..........................................  157
 60.  Comminuted fracture of both bones of  forearm.........................  158
 61.  Dressing for fracture ofthe bones ofthe forearm.......................  159
 62.  Fracture  ofthe bones ofthe hand........................................... 162
 63.  Fracture  of a phalanx of the finger.........................................  163
 64.  Fracture  of the os innominatum............................................  166
 64.  Section ofthe head and neck of femur.....................................  173
 65.  Fracture ofthe neck of the femur within the capsule.................  179
66.  Consolidation after fracture of neck ofthe femur.....................  180
 67.  Ligamentous union after fracture of the neck ofthe femur.........  181
 68.  Excess of callus after extra-capsular fracture of the femur.........  182
69.  Bony union after fracture of the neck of the femur...................  184
70.  Fracture ofthe greater trochanter at its extremity.....................  185
71.  Fracture ofthe cervix femoris and greater trochanter................  185
72.  Fracture ofthe trochanter major.............................................  186
73.  " Wire breeches " applied......................................................  188
74.  Fracture of the shaft of the*femur.........................................  192
75.  Straight splint in the treatment of fractures of the femur..........  195
76.  Extension obtained by means of adhesive strips........................  197
77.  Dressing for fractures of'the femur.........................................  198
78.  Union of fragments of femur with overlapping..........................  199
79.  Weight and pulley for making extension..................................  199
 80.  Burges'fracture apparatus applied........................................  200
 81.  Fracture of the upper third of the femur.................................  201
82.  Fracture of the lower third of the femur..................................  207
 83.  Fracture of the femur just above the condyles..........................  208 
                          Illustrations.                        ix
 riUURE.                                                           PAGE
 84.  Fracture of the internal condyle ofthe femur.......................... 212
 85.  Fracture of both condyles of the femur.................................. 212
 S6.  Wire appliance for treating fractures near the knee.................. 213
 87.  Fracture of the patella......................................................... 216
 88.  Ligamentous union after fracture of the patella....................... 218
 89.  Dressing for fracture of the  patella........................................ 219
 90.  Fracture of both bones of the leg........................................... 222
 91.  Fracture of both bones ofthe leg at the same point.................. 223
 92  Fracture of both bones of the leg near the ankle...................... 225
 93.  Handkerchief hitch just above the ankle, for making extension. 229
 94.  Gaiter appliance  to the ankle, for making extension................ 229
 95.  Adhesive  strip fastening to the leg, for making extension......... 230
 96.  Dressing for fracture of both bones of the leg......................... 230
 97.  Fracture box, for treating the leg after both bones are broken.... 231
 98.  Fracture of both bones  of the leg, showing consolidation of
         fragments...................................................................... 232
. 99.  Fracture of  the tibia alone................................................. 237
 100.  Dressing for treating the leg after fracture of the tibia.............. 238
 101.  Double fracture of the  fibula............................................ 241
 102.  Potts'fracture of the fibula................................................  242
 103.  Fracture ofthe fibula and dislocation ofthe ankle................. 243
 104.  Dressing for Potts' fracture of the fibula............................... 245
 105.  Dupuytren's dressing for Potts' fracture................................. 246


                      -------------♦-•-«-------------



                      DISLOCATIONS.



 106.  Dislocation ofthe lower jaw................................................. 209
 107.  Appearance of the face  produced by dislocation of the lower jaw. 292
 108.  Dislocation ofthe head ofthe humerus inwards (subcoracoid)... 317
 109.  New socket formed under the coracoid process........................ 321
 110.  Subglenoid dislocation of the humerus.................................... 326
 111.  Subspinous dislocation of the humerus.................................. 329
 112.  Dislocation of the elbow...................................................... 336
 113.  Dislocation of the elbow..................................................... 338
 114.  Dislocation ofthe head of the radius forwards........................ 342
 115.  Dislocation ofthe head of the radius backwards..................... 343
 116.  Dislocation of the carpus backwards.......................;............. 350
 117.  Dislocation of the carpus forwards........................................ 351
 118.  Dislocation of the first phalanx of the thumb forwards........... 355
 119.  Dislocation  of the head of the femur upwards and backwards,
         upon the dorsum of  the ilium.............................'.............. 361
 120.  Manner of reducing dislocations of the femur by the manipulat-
         ing plan.....j................................................................... 373 
x                          Illustrations.
nacRB.                                                           PAQE
121.  Dislocation of the head of the femur downwards, into the thy-
        roid foramen.................................................................. 377
122.  Dislocation of the femur forwards, upon the pubes.................. 381
123.  Dislocation of the patella..................................................... 388
124.  Dislocation of the tibia........................................................ 391
125.  Lateral dislocation of the knee..........................................■•• 394
126.  Dislocation of the foot outwards........................................... 400
127.  Dislocation of the foot backwards......................................... 403 
PREFACE.
   The improvements  and modifications which have recently
 taken place in the management of fractures and dislocations,
 and the fact that the ordinary text-hooks to be found in every
 physician's library contain too little on the nature and treat-
 ment of these lesions, and the special treatises too much, have
 induced me to venture upon the task of preparing a work
 specially adapted to the wants of the great mass of medical
 men.
   Accidents involving fractures and  dislocations commonly
 fall  into the hands of the nearest and most available  practi-
 tioners, who may need practical suggestions in  regard  to the
 most approved methods  of treating  this class of  injuries,
 especially as such accidents frequently involve great profes-
 Bional responsibility.
   On account  of the  roller  bandage being too often applied
 improperly, I have  endeavored to enforce a due consideration
 of the dangers attendant  upon  its careless application; and
 have urged the importance  of  employing as light dressings
 in each lesion as are compatible with efficiency.
  Lotions  of various kinds which have generally been used
 in the treatment of fractures do not meet  with my approval,
 for the reason that they induce vesications and render the
 patient uncomfortable  in  many ways.   A  bandage which is
 occasionally wetted will not maintain  equable pressure, and
 may become the source of  perilous constrictions.
  In treating fractures  of the lower extremities, neither the
double inclined plane nor the long straight splint, secures sat-
isfactory results, therefore I have recommended the " natural
                             (xi) 
xii
Preface.
method"  of  producing  extension  and counter-extension.
The cleverly constructed specimens of mechanical art which
have lately been invented to obviate  shortening, may gratify
the  taste of those  who have ample means to invest in novel-
ties ; but the majority of medical men can not afford  to  pur-
chase more apparatus than may be absolutely needed, conse-
quently I have depicted and commended the simplest methods
of treating fractured limbs.  I have  not advised the use of
any  appliance  that could not be extemporized from materials
to be found in every farm house.   " Sets " of splints and ap-
pliances  serve  to make a show in a physician's office, but only
a few pieces in each are of any practical utility, even if fur-
nished in assorted sizes.  A moulded  or carved splint, though
made especially to fit a case under treatment, will soon become
inapplicable from increase  or subsidence  of  swelling.   A
splint carved into grooves and. ridges with the design of con-
forming  to the natural outline of the  arm, wrist, and hand, is
calculated  to  deceive the unwary into the neglect of more
simple means, which, if rightly applied,  will answer better
purposes.  It  is  therefore advised  that the surgeon construct
from thin boards  of  soft wood, such splints of requisite width
and  length as  each case may demand.
  I have designed most ofthe illustrations, and in no instance
is a topic introduced for the purpose of exhibiting an  old pic-
ture; and no subject is distorted to meet the requirements of
obsolete  diagrams.
  In Part  Second, well directed efforts to reduce dislocations
by what has  been  called the "manipulating plan,"  are en-
couraged as a  substitute for the more dangerous method of
overcoming displacements by the aid of pulleys and other
mechanical means for multiplying force. Since the introduction
of anaesthesia into surgical practice, there is less need of vio-
lent  measures to replace luxated bones.  It is now known that
obstacles to the easy return of a displaced bone, consist essen-
tially in  tense  tissues which  can generally be rendered lax by 
                         Preface.                      xiii
changing the position of the dislocated limb.  However, it is
not to be understood, if a displaced bone can not be  reduced
by manual dexterity alone, that no  other  means  are  to  be
tried.  But the manipulating plan in intelligent and persever-
ing hands, has been so generally successful, that it would be
rash to  try harsher means until repeated and varied trials of
the " physiological method" have failed.
  In  preparing this  work  on Fractures and Dislocations, I
have taken the liberty of drawing from every avalab'e source
of information, and have not always given credit for material
employed.  This omission did not arise from a reckless dispo-
sition  to appropriate the  ideas of others ; but in an early
attempt to give each author his due, I found that A had drawn
from B, and B from C, and  so on, and therefore I  abandoned
an  undertaking  which at  best  must have been  imperfect,
laborious, and unsatisfactory.
  In presenting this book to the profession, it is with no in-
flated estimation  of its merits; indeed I  know it has glaring
defects,—some of which may be placed to a lack of time for
carefully correcting and amending  what has  been prepared
amid countless interruptions, and  during the busiest of pro-
fessional life.  Whether it will accomplish  what  I have de-
signed, time and  readers must decide.  It is offered as a guide
to the  multitude of practitioners scattered through the  coun-
try, who have comparatively  limited  facilities for becoming
acquainted with the best methods of treating a chrss of inju-
ries which often  baffle  the  most experienced surgical talent. 
 
  PAET I.




FRACTURES. 
 
CHAPTER  I.

                fractures:
General  Observations  uroN their  Nature and  Treatment.
   The bones preserve the outline of" the human figure, giving
 support and protection to the soft tissues; and serve the pur-
 pose of levers upon which muscular force is displayed.  Hav-
 ing a large proportion of earthy matter in their composition,
 they are  necessarily brittle, breaking  under the influence of
 unusual forces, directly or indirectly applied.
   When a muscle, tendon, ligament, or other soft structure, is
 mechanically separated, the injured part is said to be torn, rup-
 tured, or lacerated; but the forcible  separation of a bone into
 two or more pieces, is always called afracture.
   Bones are organized structures; when they are broken, the
 reparative processes  can mend  or consolidate the fragments,
 rendering a fractured arm or leg as strong as ever in the course
 of a few weeks.  That the uniting forces  may be as efficient
 as possible, the fragments of bone must be kept in apposition.
   The healing action  firmly  joins the  pieces after they have
 been adjusted and retained in their places; and it is the office
 of the surgeon to  place the broken parts in their right posi-
 tion, and to hold them there  by  the use of such appliances as
 the nature of each case demands.
   Fractures vary in extent and  direction,  and the  forces act-
 ing upon the fragments produce  a variety of deformities, there-
 fore it becomes important to draw distinctions between them,
 and to lay down some definite rules for their recognition and
 successful management.  The principles of diagnosis and treat-
 ment have become so  well  established  that the surgeon who
fails to perform his duties according to the most  approved
rules, is  held responsible for such  defects  and deficiencies
as are justly  chargeable to his  negligence  or  ignorance;
         2               (17) 
18
Fractures.
and the practitioner of medicine and surgery cannot undertake
to treat a fracture without placing his professional reputation
in jeopardy, and assuming the risks of  vexatious and expen-
sive litigation.
  Fractures are primarily  divided into two classes, the sin-pie
and the com pound.   In  a simple fracture the lesion is uncom-
plicated  with injuries  of the  soft tissues.   A  compound
fracture has for its essential character a wound of the skin,
with which the fracture communicates.   There are two ways
in which the wound may be produced at the time of the acci-
dent :— from without,  by the  direct force which  fractures
the bone ; or from within,  by the end of one or both fragments
being  thrust through the soft parts, either by the continu-
ance of the original force,  or by the weight ofthe body.  The
latter mode  is the more frequent; consequently compound
fractures are more common in the leg than in any other part
ofthe body.  If caused  by direct force the contusion will be
considerable, and likely to  be followed by inflammation, suppu-
ration and sloughing; if simply incised or lacerated by the pro
trusion of a sharp fragment of bone, the wound may unite by
first intention, converting the compound  into a simple fracture.
It may be remarked in this connection, that a fracture, simple
at first, may be rendered compound by ulceration of the skin
over a broken subcutaneous bone, as in oblique fracture of the
tibia; and by the formation and bursting of an abscess at the
seat of injury.
  The partial fracture  exists only when a* portion of the bone
breaks, the fracture stopping  before  it extends completely
through its substance, so as to leave the fractured portions still
continuous in some part with the rest of the bone.  This has
been graphically called the "green-stick" fracture.   In the com-
plete fracture all continuity is destroyed, and the portions of
bone are separated from one another : in the former kind  the
limb seems to be bent, while in the latter  there is  generallv,
though not always, more or less displacement of the fractured
ends, giving the limb an angular, twisted and strongly marked
deformity.  The partial fracture is  exceedingly rare, the com-
plete very common.
  A fracture is said to be  comminuted, when the bone is broken
into many small pieces, some of which are often  completely
separated  from the periosteum, losing all  source of nourish- 
General Observations.                19
 ment, and requiring to be removed either naturally or artifici-
 ally, before the other fragments can unite.
    A complicated fracture denotes the additional lesion of an im-
 portant blood-vessel or nerve, or the extension of the fracture
 into a neighboring  joint.    Fractures  are  not  unfrequently
 attended with such serious complications that death is the re-
 sult.  If a fracture extend into a joint,  the high degree of in-
 flammation, and the interference of the reparative material,
 often bring about partial or complete anchylosis.   A compound
 fracture is necessarily complicated; the flesh is lacerated  or
 contused,  rendering  the  injury very serious  in its nature.  A
 fracture complicated with much bruising and laceration ofthe
 soft parts, requires a long period to undergo  reparation.   The
 primary shock, and the subsequent suppuration,  tell upon the
 patient's health ; and the pus and debris about the ends of the
 bones, prevent a  speedy union  of the fragments.
   The fragments of a simple, uncomplicated fracture,ordina-
 rily become consolidated in five or six weeks, yet as many
 months may be consumed in  the repair  of  a  compound injury
 with perverse complications.
   The  direction a fracture takes may be oblique  or transverse,
 though the line of separation, in a strict sense of  those terms,
 is  rarely the  one or the other.  The manner in which the in-
 jury is received,  has some influence over the  direction of the
 fracture.   Direct violence produces fractures more transverse
 than oblique; and an indirect force, as when a person in a fall,
 strikes upon the feet and receives a fracture of the leg, favors
 obliquity in the line of  separation, especially if the  fracture
 occurs to the shaft ofthe bone.   Fractures near the extremities
 of long bones, and in the flat,  and irregular shaped, as the scap-
 ulae and vertebra, are apt to be more transverse than  oblique.
   When the lines of separation radiate from a<central point of
 the bone, at which the violence was received, they are regarded-
 as stellate; and when the broken ends of bone are full of spicula
 or serrations, which may interlock like opposing teeth, the frac-
 ture is dentate.
  The course ofthe fracture has a bearing on the reduction  of
the fragments, and their retention  in apposition.   Transverse
fractures, especially if they be dentate, when once  reduced, are
not easily displaced; and these  conditions often present obstacles
to ready reduction.  If the line of separation be oblicpiie the 
20
Fractures.
reduction is not difficult, but there is a disposition on the part
of the fragments to slide past each other.
  As may  naturally be supposed, all  bones  are not equally
liable to  fracture.  Some are more exposed to injury than
others, and some  are increased or diminished in strength by
their shape.  It is plainly observable that the long bones are
the most frequently fractured, while the short  ones are com-
paratively seldom broken, and always by direct violence.
  There are certain morbid conditions of the bones which ren-
der them unusually fragile.  Rickets,, caries, necrosis, cancer,
scrofula and syphilis, may so affect the bones that they are lia-
ble to break from very slight causes.  A dozen fractures, occur-
ring at  different  times,  and  from trivial forces,  have been
treated in a boy under  twelve years of age.  Three of them
were of the right humerus, and occurred in the act of throwing
a stone.  Esquirol possessed the skeleton of a woman, in which
the traces of more than two  hundred  fractures, occurring at
different periods,  could be  counted.   The peculiar liability to
fracture in the bones of certain individuals does not necessarily
retard the uniting process.  In some instances the  recovery is
unusually rapid.  Stanley records one case, however, in which
it was difficult to  obtain a union.
  There is  a  tendency to fracture in old  people, from the
fact that their bones become chqmically altered ; the  earthy
matter predominates over the animal, a condition which favors
brittleness.  In young people, the disproportion in the compo-
nent parts is reversed; the animal matter predominates, so that
the bones bend under the weight of the body, or under the
action of the muscles.  Children with bow-legs usually have a
deficiency of lime in the skeleton.
  A disproportion between the strength of the bones  and the
power of the muscles also predisposes to fracture.   Great mus-
cular development,  coupled with a rapidly acting nervous sys-
tem, may  prove too powerful for slender bones.  The hume-
rus and the femur have both been broken simply by muscular
exertion.  The olecranon, patella, aud the os calcis are levers
which, while enduring violent and sudden forces from the mus-
cles  acting upon  them, are occasionally broken.  Few bones
are placed at such  disadvantage for resisting muscular action.
  Tables  drawn up to exhibit the comparative frequency of
fractures in the different bones, vary somewhat.   According to 
General Observations.
21
 some authors the  ribs are the most frequently fractured;  the
 clavicle  standing  next in the order of frequency; the radius
 taking the third place; the humerus the fourth; the femur the
 fifth;  the  fibula the  sixth ;  and the tibia the  seventh.  Both
 bones  of the leg are broken at the same time more frequently
 than either  singly.  According to  my own observation and
 experience the radius is the  most frequently broken, the clav-
 icle next, and the  ribs take the third place.
   When a bone breaks at the point where force is applied the
 fracture arises from direct violence ; a fracture of the radius or
 humerus arising from a fall  on the hand, is said to be by coun-
 ter-stroke (contre-coup), or indirect violence.  A person falling
 from a height and striking upon the feet, does not  sustain a
 fracture of the calcaneum or metatarsal  bones, but  the force
 is transmitted through the foot to the tibia, or even through it
 to the  femur, and acts indirectly to a degree that severs  one of
 those  long bones  at  a weak  point.   The  radius commonly
 gives way, from indirect  violence, near its  lower extremity ;
 the humerus at the external condyle; the femur just below the
 trochanters, the tibia through  its lower third.  The fibula  is
 often broken by a twisting force in the fall of  the body to the
 ground  after the  tibia has  yielded to the counter-stroke.   It
 is reasonably supposed  that muscular tension has something
 to do  with fractures commonly considered as taking  place
 from indirect  violence, for  a  dead body may be let fall  the
 same distance and it will receive no broken  bones from the
 counter-stroke.  The loose and passive condition of the bodies
 of drunkards seems to shield them from fractures while sus-
 taining fearful falls.
  A person in falling from a height, often seizes at some object
 to arrest his descent,  or strikes some object on the way down,
 either  of which imparts a whirling  motion to the  trunk, so
 that in accounting for the injury upon the theory of counter-
 stroke, the compound motion should be estimated.
  The great degree of bruising of the soft parts, with ecchy-
 mosis,  is sufficient  in some situations to prevent  the fracture
 from being discovered.   This is often the case in  crushing
 injuries  of the hand or foot.   Direct violence of a  crushing
 nature, applied near the joints, may break the articular surfaces,
causing effusions and  swelling which tend to obscure the real
 nature of the injury. 
CHAPTER  II.
v1
SIGNS  OF  FRACTURE.
  The symptoms of fracture are  quite distinct  and reliable.
The patient hears a snap at the time of receiving the injury,
and feels such a piercing pain, that the nature of the lesion is
impressed upon the mind of the sufferer.  Loss of power in
the part implicated, and unnatural mobility at the point  of
injury, causing the limb to assume unusual twists and angular
deformities,  are  peculiar to fracture.  Crepitus, when it can
be elicited, is the most decisive of  all the signs of fracture.
  The snap,  whether heard by the patient, or by persons who
chance to be near, is a symptom of some value, though the
sound may be produced by  other causes,  such as the rupture
of tendons, ligaments, or the breaking of a stick or other for-
eign substance at the time the injury is received.  It is almost
impossible for a fracture to occur without a loud and distinct
snap being produeea, yet the sound is heard in only a  small
proportion of cases.
  Pain is nol/a reliable sign of fracture,  for it is sometimes
slight, bein^scarcely complained of unless motion be imparted
to the fragments.   However, in most instances', the pain is  so
acute and agonizing  that it calls forth cries of distress, elicit-
ing the deepest  sympathy.   In fractures that have existed
several hours, the swelling having checked the  preternatural
mobility and masked the deformity, the  pain which may be
produced by motion, becomes a valuable  diagnostic sign.   If
the finger be passed slowly and carefully over the whole length
of the suspected bone, the  absence of all pain on  pressure
proves its integrity, unless the parts  have  been subjected
directly to external violence.  On  the contrary, the existence
of pain, more or less severe, at a circumscribed spot, would
afford strong presumptive evidence of fracture.
                          (22) 
Signs of Fracture.                 23
   Loss of power in a limb is not necessarily a diagnostic sign
 of considerable importance.  A patient with a fractured radius
 can often use the hand to  the astonishment of  by-standers
 who afterwards learn the  true nature of the injury ; a broken
 fibula  does not always restrain a patient from walking; and a
 man with a fractured  cervix femoris has been  known to use
 the limb  with a freedom truly puzzling.  The impaction  of
 the fragments and  the interlocking  of the serrations may
 account in part for these seeming anomalies or inconsistencies.
   It is certainly true that in most instances fractures indict a
 notable hindrance,  or  an  entire incapacity, of motion in the
 limb.  The patient generally expresses his inability to use the
 fractured  limb, and refuses to make even  moderate  effort,
 being  intuitively conscious of the loss of power.
   The swelling attendant  upon a  fractured-injury may take
 place  immediately,  or not  be marked for several days.  At
 the instant  of  fracture there is  often, but not  always,  an
 effusion of blood around the fragments,  and an  extravasation
 into the surrounding tissues, constituting  strictly an internal
 ecehymosis, which  may not betray itself unless the tissues are
 laid open.   This effused  or extravasated blood, especially in
 elderly patients, finds  its way gradually to the integuments
 at quite a distance from  the seat of  injury, discoloring the
 limb to an extent which excites alarm.
   In fractures communicating with  a joint, the blood mixes
 with  the  synovial  fluid,  and contributes not a little to  the
 general tumefaction.   The swelling following a fractured
 patella may be so great that, if the injury  be not seen for two
 days after the accident, it is very difficult to determine the
 nature of the lesion.  The same obscurity attends  fractures
 into, or near all the joints, if the patient be not examined
 soon after the accident has  occurred.
   Preternatural mobility is  a characteristic sign of fracture.
 To develop  this decisive diagnostic symptom  one fragment
 must   be held fixed while  the other is moved in different
 directions; the limb is then observed to  bend, the angle being
 at the  seat of fracture, indicating, at once, a solution of con-
 tinuity in the bone.  In  the clavicle, the mere weight of the
shoulder will  produce the angle, and if the arm  be grasped
and moved up and  down  the mobility can be readily discov-
ered. 
24
Fractures.
  Motion ean be easily produced  in  the shafts of the long
bones, which  have been  fractured, but  it is not  so readily
demonstrated  when the solution of continuity is near joints.
The portion of bone connected with the articulation, is so
small or short, that it can not be easily fixed so the long frag-
ment can be moved upon it.  And then, the  natural  move-
ments of the joint in such immediate proximity to the frac-
ture, tend to obscure the  mobility peculiar to the lesion.  In
fracture  of the radius through its carpal extremity, very little
mobility can be developed by manipulation of the parts.
  Displacement of the fragments is betrayed by the change in
the form of  the limb; often an experienced surgeon can at a
glance divine the nature of the injury by the deformity.  It
would be unsafe to trust too much to first appearances; the
deformity might be due to luxation or to a severe contusion.
  If a fractured limb present a bend or angle at a point where
none should exist, the sign is valuable. One fragment resting
in front or  to one side of the  other, constituting  a salient
projection which can not only be seen, but felt as the fingers
are pressed along the bone, is  quite decisive as to the nature
of the  injury ;  deformity  by  rotation,  as when the  hand
or foot is twisted around into an awkward position after frac-
ture of the arm or leg, indicates what kind of an  injury has
been sustained.  Shortening of a limb, which can generally
be determined by measurements between prominent points in
the skeleton, is a sign  of great value in establishing a diagno-
sis.  If there be no displacement, the spicula of the fragments
hold each other interlocked, so that no shortening is percep-
tible.  Fractures of the olecranon, patella, and os calcis, are
apt to be attended  with a considerable degree of separation
between the fragments.   Muscular action is the cause of this
displacement, and  it always produces  more or less  deformity
after fractures ; it  twists fragments of the fibula aw a v from
each other;  and in fractures of the forearm, it drags the frai-
ments of the radius and ulna into contact with one another,
and if the pieces of bone be not kept in their proper relations,
all the fragments may be so united as  to prevent rotation.
  Crepitus is a grating sound, produced by rubbing one frag-
ment of bone against  another.   It is  the most positive of all
the signs of fracture, though, unfortunately as a  diagnostic 
Signs of Fracture.
25
symptom, it cannot always be elicited on account of the inter-
locking of the ends of the fragments.
  If there be much  separation  between  the  fragments, as
there usually is in fractures of the patella, crepitus can not,
for obvious reasons, be elicited ;  and extensive overlapping is
also  opposed to the  production of crepitation.  A  coagulum
of blood, piece of muscle,or other soft tissue interposed between
the ends of broken bones may interfere mechanically to prevent
crepitus ;  and many other conditions are opposed to the suc-
cess of efforts designed to elicit crepitation.
  It  often happens in fractures through the neck of the thigh
bone, that free motion can be produced,  yet  no crepitus is
elicited, one portion of bone being drawn up beyond the other.
In these cases  if the limb  be extended, so  as to  bring the
ends of the fragments in apposition, and the leg be rotated,
a distinct crepitus can be obtained.
  In  the majority of fractures the  crepitus can be distinctly
felt and heard ; therefore as a sign of fracture it is extremely
valuable.   To the patient and bystanders, who hear the crep-
itation, the sound is particularly convincing.   The surgeon
enjovs a double satisfaction in the sound, for it not only gives
decisive evidence of  the nature of the injury, but proves that
the fragments are in juxta-position, no muscle  or other struc-
ture  intervening.
  The snapping of tendons, and the crackling of emphysema-
tous tissues, resemble slight or indistinct osseous crepitus, yet
the surgeon, manipulating  the injury, feels rather than hears
the crepitation, and judges or discriminates by that  sense.
Crepitus can be made most distinct soon after the reception
of a  fracture ; the changes which take place in the  course of
the inflammatory stages  of the injury, and the healing pro-
cess, thwart all efforts to elicit crepitation.
  Fractures are often dangerous  injuries.  The violence pro-
ducing  them may be of such a nature as to lacerate the  soft
tissues, and to inflict the most serious wounds. The  sharp
ends of  the fragments sometimes sever or puncture large
blood-vessels, and destroy the integrity of important nerves,
subjecting the parts involved to the dangers of gangrene or
extensive sloughs.   Not  unfrequently an  injury involving  a
fracture, is of such a serious nature that amputation becomes
imperative.  Fractures extending into the joints always excite 
26
Fractures.
the gravest  apprehensions;  they may turn out well, yet there
is no certainty of a perfect result.  Partial or complete anchy-
losis is a common sequence of fractures involving an articula-
tion.
  Other injuries often simulate fractures, therefore the surgeon
must discriminate  between  the  symptoms of dislocations,
sprains, fractures, and  other lesions.  A differential diagnosis
cannot  always be made out until the patient is placed under
the'influence of chloroform.   The  peculiarities of dislocation
must be well understood,  or the differences between the signs
of the two injuries will not be apparent.   It must  be known
that a  fractured limb  is  characterised by unusual mobility,
and that a dislocated one is unnaturally rigid ; that a fractured
bone is  easily reduced  but it will not stay in  place,  and a dis-
located  one is difficult to reduce, but once returned to its nor-
mal position, it will generally stay there.   An examination
and comparison of the most prominent processes, in fractures
near the joints, may preclude  error of  diagnosis.   In a severe
bruise or strain the real condition of the injury can be deter-
mined  by a negative method of examination  and  reasoning.
If  it be satisfactorily demonstrated, in a  doubtful  case, that
neither  a fracture nor a dislocation  exists, the logical conclu-
sion is that the lesion is a sprain, bruise, or contusion.
  Children sometimes receive  serious injuries that are exceed-
ingly difficult to recognize.   They  are unable to tell how the
hurts were received, or to give an  intelligent explanation of
the  pain or other conditions  of the parts implicated in the
injury.   Their fright,  sobs, and agitation,  thwart  the best
directed efforts to understand  the nature of the  accident;
sometimes it is best to postpone*  the  examination until the
child has recovered from  its nervous condition.
  Incoinplete  fracture, when  it exists, and that is seldom, must
necessarily be confined to the young.   The bones  of old sub-
jects, from the amount of earthy matter in their composition,
break like a dry stick.  The bones  of the arm are most liable
to  the  partial or "green-stick"  fracture   (Figure 1).  The
humerus, during childhood, has been  found bent.  It then
offers considerable resistance to straightening  or reduction.
The child is averse to motion in the limb, and  guards it
against subsequent injury.  An attempt at quick and forcible
reduction may complete the fracture. 
Signs jof Fracture.
27
   Fissure of a bone is commonly an obscure injury to diag-
            nose.  In most instances of  suspected fissure the
            evidence must be founded*on what is little better
            than conjecture.  The bone could not well be fis-
            sured  without tearing the periosteum  and  the
            medullary membrane ; and the suffering would be
            long  continued.  The  danger of  these  cases is
            illustrated by an example from Duverney.  A man
            received a kick from a  horse on the. center of the
            left tibia.   This was followed by severe pain and
            sloughing  of the skin, which, however, readily
            healed, and  the  patient  went  about as  cured.
            Three mouths later he was again confined to his
            bed by the accession of sudden, acute pain.. After
            much ineffectual treatment by emollients, the bone
            was exposed, and a long deep fissure was found, the
            edges of which were raised twice, giving exit, on
            the  second  occasion,  to  pus.   Subsequently the
 Psatick*'ft4cfurenbone  was  trephined, and an abscess laid bare in
            the medullary cavity.
   Railway accidents produce fractures which, from their com-
 plications, and serious nature,  deserve to be considered by
 themselves.  The severer forms of injury, from the  paralyz-
 ing  character of the shock, and the number of parts impli-
 cated in the lesion, are apt to terminate fatally.  An arm or
 leg, suffering from fracture by a railroad accident, is generally
 so badly bruised and mashed, that it may require amputation.
   In 1868,Dr. C. E. Witham, of Walton, Iowa, was called to
 take professional charge of a man who received a fracture of
 both  bones of the  forearm  while shackling  cars.   In  the
 course  of twenty hours from the time of the accident, reac-
 tion having taken place in the entire body except the injured
 limb, which remained cold and pulseless, the  docter in con-
 sultation with two other physicians, decided to amputate the
 arm.  The  injury was  of such a crushing character that it
 was presumed the limb would  slough, and greatly endanger
 the patient's life.  The three medical men in council, had no
 misgivings in regard to the requirements of the case.   There
 seemed  to them an imperative necessity for amputation,  and
they accordingly removed the limb.  The patient made a good
recovery, and for the time appeared  satisfied with the opera-
 
28
Fractures.
tion ; but some rival  physicians got posession of the amputa-
ted limb, and injected the arteries ;  the vessels  proved to be
uutorn, at least  they sustained an injection.   The young
man who had lost the arm was made to  believe that his limb
had been needlessly sacrificed, and, therefore, sued Dr. With am
and his associates, for damage  to the extent of ten thousand
dollars.
  A breakman on a freight train gets a leg or an arm broken
by  the  moving cars,  or receives a crushing injury by  being-
thrown from his  position.  The  shock may be so great that
he will never react; or  he may die from a multiplicity  of in-
juries, that do not  manifest themselves at first.  A  question
arises, in the contemplation of  these terrible injuries, what is
best to be done ?   Ordinary rules applicable in surgical injuries,
fail to meet  the   exigencies of  the cases.   A conservative
course, which in ordinary accidents succeeds so well, too often
fails in these dangerous injuries.  To  attempt to save a limb
that has suffered  a compound, comminuted, and  complicated
fracture, may result in the sacrifice of life.
  Threshing machines, sorghum mills,  and  other  modern
agricultural  implements,  to say nothing of the powerfully
moving machinery of our great manufactories, are constantly
producing fractures and other injuries which tax the skill and
ingenuity of the most experienced surgeons.
  If the principal arteries and nerves of a limb  be lacerated
or severely injured, the hope of recovery  without amputation
qnite frequently proves illusive.   However,  in doubtful cases
it is well to  wait for  reaction aud other recuperative  signs.
There is danger in resorting immediately to  operative  meas-
ures.   While a patient might not know  that  he had lost a
limb through surgical  incompetence, there is an awful respon-
sibility in the procedure which  a lively conscience could not
easily endure.  "Did  I sacrifice a limb that  might have been
saved ?" 
                      CHAPTER   III.


                   PROCESS  OF  UNION.

                         ---------------» ■» .--------------

      The dearth of  opportunities for examining broken bones
    during  their various stages of  repair, has  prevented that
    thorough knowledge of the changes taking place from day to
    day during the healing process, which is so interesting and in-
    structive.    Experiments  upon  animals  have contributed
    something to a better understanding of the subject, yet vary-
    ing conditions have stood  in the way of rigid comparisons.
    In man, a steady unvarying course of repair is not to be ex-
    pected in  all cases.  One person with fracture of  the tibia
    may walk on the limb in five or six weeks from the  accident:
    another person, with a similiar fracture, and  every  condition
    seemingly as favorable, may not walk for three months: in
    fact, no bony union  may take place,  the patient  having to
•   hobble about for the rest of life with a false-joint at the seat
    of fracture, the connection  between the fragments being lig-
    amentous and not osseous.
      In the simplest forms of  fracture, where the periosteum is
    not much damaged, and   the soft tissues are not  severely
    bruised, the healing  process sets in  earlier  and  terminates
    sooner,  than in  compound, complicated, and comminuted
    fractures.  The effusion of  considerable blood is an obstacle
    to early efforts at repair.  If the periosteum be stripped from
    the fragments, and torn into shreds, the course of recovery
    will necessarily be prolonged.
      During  the first few  days the inflammatory action runs
    high, and the swelling and  local  disturbances create serious
    trouble.  The swelling may commence as soon as the accident
    occurs, or come on anytime within a day or two.  The violence
    of the inflammatory action may be reached on the second day,
    but there is no marked subsidence for five or six days.   This
                            (29) 
30       •              Fractures.
may be called the inflammatory stage of the  difficulty.  For
the succeeding five days the swelling subsides, and  a  great
part of  the  effused  blood—the debris of  the  injury—is
removed; during the next five days  there is an effusion, of
plastic material, of jelly-like consistence, which is to be elabo-
rated into a firmer bond between the fragments.   Fifteen days
have now passed, and the union is a " rope of sand."  If the
parts be cut into and examined, the extravasated blood will
be gone, an abundance of unorganized lymph will  be  seen
between  and about the fragments of bone, aud the muscles
and  other soft tissues adjacent  to the  injury will seem to be
glued together.   The lymph is yellowish white, but  the sur-
rounding structures under the influence of  the reparative
action, have  a pinkish hue, the reddish color  coming from
minute  blood-vessels which  are pushing  their way  into the
newly forming material.   Although the blended soft tissues
around the  bone assist in giving firmness to the parts, the
fragments themselves move about as freely  as when the frac-
ture first occurred.
  Half of the time ordinarily consumed in the treatment is
now passed, and  the real work of  repair is but just begun.
During the next  five days the plastic lymph becomes organ-
ized into cells and fibrous bands.  By the twentieth day the
fragments are bound together by this newly formed  connec-
tive tissue, so that there is considerable  firmness  established   •
between  the  ends of the fragments  and  the surrounding
structures.  The  limb at this time will bend,  but has not the
mobility peculiar to a recent fracture.
  From the  twentieth to the twenty-fifth day the  osseous
corpuscles are deposited in the meshes of the  fibrous connec-
tion.  The  new  bony material  is  thrown out  first and most
rapidly from  the  periosteum and  the  medullary  membrane,
but is not placed with much regularity.  At first there  is an
excess of corpuscles at one point, and a deficiency at another;
but by the twenty-fifth day, in a young  patient, under favor-
able circumstances,  the bony connection is sufficiently abun-
dant and consolidated to sustain itself without artificial assist-
ance.  The osseous union is not yet complete ; in places there
is too much of the fibrous, and not enough of  the bony mate-
rial ; and there is not that complete consolidation which proves
to be unyielding.  In fractures  of the leg, the  osseous union 
                                              ECLEC1 IU

                                              MEDICAL
                    Process of Union.         aai I^PPF*

 is often  so  imperfect by  the thirtieth day, that fhiiwrjsi/gDY
 material may yield, allowing of shortening in  cal»'rrMirmcr
 to overlap.  I recently took off a dressing from a fractured
 femur that had been on thirty days.  There seemed to be per-
 fect consolidation of the fragments, and careful measurement
 showed that the legs  were of equal length.   The patient, a
 lad of ten years, began to  move about on crutches, aiid grad-
 ually to press the foot of the lame side to the ground.  In two
 weeks after the fracture-dressings were removed, I again
 made a measurement, and found that the fractured limb was
 fully a half inch shorter than its fellow.  As the measurements
 in both instances were made with scrupulous exactitude, the
 conclusion to be drawn was that the dressings were  removed
 before the ossification was sufficiently complete or consolidated
 to resist the normal muscular tension.
   It is of the utmost importance that the surgeon understand,
 as nearly as  possible, what is going on from day to day in the
 process of repair in a fractured bone.  The differences of ac-
 tivity at the various ages of life, and the modifying influences
 arising from the kind of fracture, and from the region of body
 injured, to say nothing of general health, and minor considera-
 tions, render certainties out of the question, and leave a wide
 scope for conjecture and speculation.
   The most  experienced surgeon can not, from manipulation
 or the appearances of the limb, determine positively when a
 fracture-dressing may be removed.  If every part of the treat-
 ment has been satisfactory, and there be no known reason why
 the healing processes have not accomplished what they usually
 do in a given time, it may be presumed that a good union has
 been effected in four, five, or six weeks, as the particular case  •
 might seemingly require.   If there be mobility, crepitus, or
 other signs  of non-union  at a  time when a complete result
 ought to be  expected, it would  be  certain that the  fracture-
 dressing should be continued for a week or two, but there is
 no way to determine just how many more days the treatment
ought to be  continued, nor could it be positively determined
whether a union w^ould ever occur.  After four, five, or six
weeks have elapsed from the reception ofthe injury, and upon
the removal of the dressing the limb is found to be firm at the
point of fracture, the .presumption  is  that union has taken 
32
Fractures.
  place, and the surgeon would feel justified in laying aside the
  usual retentive supports.
    When  the  fragments do not accurately  correspond,  the
  uniting medium occupies externally the angle between them,
  and extends partly into and across the medullary canal.  When
  they completely overlap, and even when there is an interval
  between them, provided it is not too great, the same rule pre-
  vails.  The reparative material simply extends between them,
  bridging over the interval, and filling up all angles and irreg-
  ularities.  It  does  not  cover  the free ends of the fragments,
  nor occupy the medullary canal.
    According to Dupuytren, the method of union  in broken
  bones  is  by a superabundance of reparative material at the
  seat of fracture, called " provisional callus."  It may be likened
  to the mass of solder employed to join the ends of two pieces
  of leaden pipe, or to a " ferule " on a whip-stock. The re-
  parative material used to blend or weld the ends of the frag-
  ments, and  not carried away by absorption  at a period more
  or less remote, takes the name of permanent,  " definitive,"  and
  uniting callus.
    Mr. Paget holds that the mode of union through the agency
  of a provisional callus, is peculiar to the process of reparation
  in animals whose broken bones are in constant motion, or not
  fixed by dressings.  He teaches  that  the only bones which
  normally and constantly unite by this process, in man, are the
  ribs, the motions of which can not be fully restrained.   Occa-
  sionally it is seen in the clavicle and  humerus ; rarely in the
  tibia, fibula, and other bones.  In children, whose motions  it
  is not easy to restrain, the  " ensheathing " callus is quite fre-
• quent; according to Hamilton, almost constant.
    Dupuytren entertained the idea that the provisional callus
  was intended as a temporary support during the mobile stages
  of repair.  It is now known that a " provisional " callus is not
  necessary in the union of broken  bones; and  only exists  in
  cases where it  is impossible  to  restrain motion  in the frag-
  ments.  The  accompanying cut, (Fig.  2), from a specimen  in
  my possession, shows that in the union of fractured ribs, where
  respiration keeps up constant motion  of the fragments, there
  is not  only a large  amount of provisional callus, but bridges
  of bone reaching from one rib to another along the course of
  the intercostal muscles, are built up  as if to  support,  or  to 
Process of Union.
33
steady, the moving fragments.  I have another specimen from
a leg, in which both bones were broken near the ankle, and a
long, curved spur of new-made bone was sent backward from

                           Fio. '2.
  Union of broken ribs, with " bridges '' of bone in the course of the interrostfil muscles.

the tibia, at the seat of fracture, to the tendo Achillis, as if to
gain  support from that rather stable tendon.  The excessive
production of callus thrown out in the repair of fractures in
the  neighborhood of joints, especially of the hip-joint,  is a
strengthening buttress pushed out to give stability to  moving
parts.
   When a broken bone is not accompanied with much injury
to the surrounding soft tissues, and there is no displacement;
and  when  the fragments are steadily held in place,  without
motion or disturbance, there is no ring or ferule of reparative
material employed  in the union ; but the opposed broken sur-
faces of the fragments unite without  ridge or outside callus,
by a process akin to that called " first intention " in wounds.
  It is still a question whether the intervention  of cartilagin-
ous material  ever exists, or. is necessary, in the last stages ol
repair in broken bones.   In young subjects and in the inferior
animals the presence of cartilaginous tissue has been observed,
but as there are numerous instances  in Avhich its  presence is
not  constant, the necessity for its existence is questionable.
In adults  the intervention of cartilage is exceedingly rare;
and union without  any perceptible callus is the rule, and  not
the exception, in well treated  cases.
  The agency of granulations  in the repair of compound frac-
tures becomes  almost a  necessity.   In the  union of simple
          3 
34
Fractures.
fractures, especially if inflammation be restrained within ordi-
nary ranges, no granulations are interposed.
  In the majority of cases the reparative material employed
in the union of fractures, is similar to that employed  for the
repair of soft tissues by adhesion.  This material is  supplied
from the vessels of the surrounding  tissues, and by those of
the bone and of the periosteum.  The vessels of the medullary
membrane also contribute a share in the work of furnishing
supplies.  If the fragments be kept at rest and in strict appo-
sition, the reparative material is found chiefly, if not  entirely,
between them.  When from  irritation,  motion, or  want  of
apposition  between  the fragments,  it extends outside the
broken  ends of the bone, it gets between the periosteum and
the bone, and even into the adjacent tissues.   The diagrams
in Paget's Surgical Pathology, which represent the periosteum
as having been separated from the  bone to allow, as it were,
room for the  " ensheathing "  callus, may faithfully represent
the ideas of the author, but they do  not represent  the  true
healing  state.  The reparative material gets upon the outside
or external surface of the periosteum, as well as between that
membrane  and the bone.  The reparative  material  extends
into the medullary cavity, but never between the medullary
membrane and the bone.
  The shaping or modelling of  the excess of  reparative mate-
rials after the union is complete, is a work of time.  All rough
and unnecessary projections are removed by absorption ; the
sharp points left by the overlapping  of ill-uniting fractures,
whether deep or superficial,  are first softened by the disap-
pearance of their earthy matter, and subsequently removed,
and the rough surfaces rounded off.  The pressure and  fric-
tion of the muscles,  are the  chief agencies in the  work  of
polishing and  absorption.
  In fragments.that overlap, a hard bony cap covers  the  ends
of the fragments, and the compact  walls resting against one
another, (Fig. 3), and the cancellous tissue of both communi-
cate, the new connecting material being more vascular and
spongy  than the walls of the old bone.
  Although the  dressings can generally be  removed  with
safety in from four to six weeks, ossification  is rarely com-
pleted before the ninth or tenth week after the injurv.  In  in-
fants the time of union is reduced to fifteen  or eighteen days; 
Process of Union.
35
Fig. 3.
 in old age two or three months are required to consolidate
                    the fragments.   If the fragments overlap
                    or rest faultily with one another, the time
                    of reparation is greatly retarded; in cases
                    of double fracture, in which it is difficult
                    or impossible to prevent riding, the work
                    of repair is always tedious.
                      Compound fractures require about three
                    times as long a period to complete the
                    union as the simple.   Fractures from gun-
                    shot wounds, on account of damage to
                    soft  parts, and the comminution  of the
                    bone, are exceedingly tedious in the pro-
                    cess of cure.  When there has been ac-
                    tual  loss of bone, as  by the removal of
                    splinters,  or  comminuted  portions, the
                    time occupied in the restoration is very
                    much prolonged.
                      A fracture extending into a  joint is
                    never followed by reunion of the articular
cartilage.  The bone unites, leaving an interval between the
borders of the cartilage, which may or may not fill with fibrous
tissue.  Sometimes a ridge of osseous material projects into
the space between the broken cartilage, which, by interfering
with  the  functions of the joint, favors anchylosis.   In frac-
tures  penetrating the articulations, the synovial membrane be-
comes thickened by inflammation, the sheaths of passing ten-
dons get blocked up with effused and organized plastic lymph,
so that considerable  stiffness., if  not genuine anchylosis, is
likely  to follow.  Passive motion after the bony fragments
have  united  with osseous material, is  the proper method of
restoring the functions of the joint.
Shows uniting medium where
  the fragments overlap. 
CHAPTER   IV.
NONUNION  OR  FALSE JOINT  AFTER FRACTURE.
  It is  a fortunate circumstance in the history  of  broken
bones, that the fragments  rarely fail to unite through the
medium of osseous material.  The process  of union  may be
delayed or completely arrested  at any period of its progress.
And as there is no precise time when consolidation is effected,
a tardy" union  should not be looked upon as evidence of a
total  lack  of  uniting  capacity between the fragments.  If
there be no bony union in ten or twelve weeks after  fracture,
the surgeon' begins to grow uneasy in regard to the result, and
to cast about for the cause of the delay or inability.
  Certain fractures frequently'fail to unite  by osseous mate-
rial.  The neck of the femur, within the capsular ligament,
seldom unites by bony union; the patella, from the fragments
being held at a distance apart by the contraction of the quad-
riceps muscle, often  makes only a fibrous  connection of its
fragments; the olecranon and the coronoid processes of the
ulna omit the osseous union for a similar reason; the  condyles
of the humerus occasionally fail to effect a bony consolidation
with the shaft, when  free motion is not restricted by a proper
dressing.  But these  bones, having special causes  for failure
to unite, do not come so  particularly under consideration  in
this place.
   When there is failure to unite in fractures which ordinarily
consolidate in the usual  time, the defect may be regarded as
pseudarthrosis  from  extraordinary causes.   In such cases a
soft ligamentous substance remains between the  ends of the
fragments, and shows  no  disposition to become  ossific.  In
rare instances no ligamentous substance is formed.  The ends
of the fragments become smooth and rounded, constituting a
                          (36) 
False Joint  after Fracture.
37
 real false joint.  The ends  of the bones  move freely against
 one another, being retained in  their place by a kind of cap-
 sule, which is lined with synovial membrane.
   Ununited fractures are so exceedingly rare that some expe-
 rienced surgeons never met with a case.  Lonsdale found but
 four or  five cases out of four thousand fractures treated at
 Middlesex  Hospital,  London.  Liston met with only one case
 in his  own  practice.  Hamilton estimates that one case does
 not occur in five hundred fractures.  According to Norris'
 tables, the  humerus  and the femur are bones most liable to
 non-union.   This circumstance goes to show that motion has
 much  to do with the failure to unite.   When the tibia alone
 is broken, it rarely fails to obtain bony union, yet after a frac-
 ture of both bones of the leg, false  joint stands  next in fre-
 quency to similar defects in the humerus and femur.
   The constitutional causes of non-union include all those con-
 ditions in which the powers of the sj^stem are much impaired.
 Old age, pregnancy, lactation, syphilis, scurvy, and especially
 the  extreme debility of  shattered inebriates, have  been ob-
 served as causes retarding osseous union.  Patients having been
 subjected to courses of mercury, and other prolonged devital-
 izing  treatment, suffer from  retarded union after  fractures,
 and sometimes wholly fail to  obtain consolidation of their
 broken bones.   Larrey frequently saw, in his extensive cam-
 paigns, cases of false-joint that he attributed to poor diet, and
 kindred causes.  Dropsical subj ects suffer from pseudarthrosis,
 and very generally from retarded union.
   The local  causes of ligamentous connections and false-joint,
 are numerous and varied.  Disease of the bone, the presence
 of a foreign substance, separation of the fragments, and motion,
 are  the  most  prominent.   Obstruction to the circulation,
 whether from morbid conditions, or  tight bandaging, always
 retard and  may prevent  bony union.  Immovable dressings,
 especially if applied too tightly, obstruct  the local circulation
 and delay  the  healing processes.   A tight bandage, made
 uncomfortable  by the use of anodyne, refrigerant, and stim-
 ulating lotions, produces an aiuemic condition of the  limb that
opposes rapid  and satisfactory recoveries.  Consolidation of
the fracture is arrested by a faulty application of  the bandage
or dressings. I have  seen an arm above the  elbow  bandaged
so tightly that the hand and forearm were nearly strangulated. 
38
Fractures.
Such a radical interference with the  nutrition of the limb
must obstruct or wholly arrest the reparative action.
  The appearance of a fractured limb in which the work of
repair has been suspended, is peculiarly striking.  The wasted
flesh, the scaly and dead condition of the cuticle, the puffy or
flabby state of the member, are always  observable, and indi-
cate the greatly enfeebled nutritive action.
  Fatty degeneration in a limb partially paralyzed, though
not previously mentioned by any author, is a cause of baffled
reparation.  In one case of this kind, I was unable to establish
a bony union for  five months.  Even then the consolidation
was effected  with such imperfect  material  that the woman
sustained a second fracture within a year.  She died of gen-
eral debility in  a  few months after the second accident, and
at the time  of her death there had been no progress in the
work of repair.
  To repeat, movement  of the fragments, whether  due to the
patients' restlessness, to  some defect in the apparatus  used, or
to any other cause, is the obstacle which most directly inter-
feres with union.  In forty-four cases investigated  by Norris,
movement of the broken ends was clearly made out in twenty-
two and strongly suspected in several others.
  Numerous  measures  have  been devised  for  the  cure of
pseudarthrosis.  If there be a  constitutional  vice, an  attempt
should be made to correct it, or so modify it that the recupera-
tive powers of the system may be sufficient to heal the broken
bones.  The  local means  devised for the successful manage-
ment of ununited fracture, are numerous and varied;  but the
object of all is the same, namely, to exc\te action in the parts
around the ends  of the fragments and to make them throw
out material proper for their consolidation.  Blisters, friction,
rasping, removal of the  fractured ends, setons,  drilling of the
bones, and  other means  have been tried, and with various de-
grees of success.  Blisters can accomplish but little, as the
effect of the irritation does not reach deep enough ;  rubbing
of the sluggish fragments roughly together may arouse a new
action which  will result  in union ; the opening  of the fracture,
and rasping  the  broken ends of the  bone, has been recom-
mended, though the results are not flattering;  excision of the
rounded and polished surfaces  has  been performed with suc-
cess ;-the  seton applied by passing a long flat needle, armed 
False Joint  after Fracture.            39
with a skein of silk, either between or close by the ends  of
the bone, and kept there till sufficient action is produced  in
the part to cause the adjacent textures to be excited to  throw
out the proper reparative material, has been highly recom-
mended.
  Dressing  the leg—in the  event  of the non-union being in
one of the lower extremities—with a firm support of splints
and bandages, and putting the patient on crutches to exercise
in the open  air, is an excellent method of improving the gen-
eral  health, and of arousing sufficient  action in the limb to
start or re-establish the healing process.  Bearing some weight
upon the  leg produces friction between the fragments, and
promotes vital activity.  Exercise on crutches, with gentle use
of the fractured leg, might remove or press out  of position a
piece of ligament, muscle or other soft tissue that had effected
a lodgement between the fragments of bone.
  Drilling the bone near the fracture for the purpose  of in-
serting ivory pegs, around which a silver wire or hempen cord
fastens the fragments in contact, has succeeded in establishing
a union in a few instances; but the method has also failed.
  The late Dr. Brainard, of Chicago, suspected that the drill-
ing accomplished more good than the pegs and  fastenings,
therefore he tried perforating the sluggish fragments at their
ends, with an awl or perforator.  The instrument devised by
him has a stock that admits of a change in the size of the
                          Fig. 4.
Brainard's perforator or drill.
drills, though that is a complication not  absolutely necessary.
His  directions for  using the instrument are as  follows: " In
case of  an oblique fracture, or one with overlapping, the skin
is perforated with the instrument at such a point as to enable
it to be carried through the ends of the fragments, to wound
their surfaces, and to transfix whatever tissue may be placed
between them.  After having transfixed them  in  one  direc-
tion, it is withdrawn from the bone, but not from the skin, its
direction  changed, and  another perforation made, and this
operation  is  repeated  as often  as may be desired."  Two or 
40
Fractures.
three perforations, according to Dr. Brainard, are enough to
commence with ;  more may be tried if the first fail to accom-
plish the object designed.   After  the  perforations have been
made, the limb should be. dressed  as in a recent fracture,  and
kept at rest for several weeks before observations are made to
determine whether consolidation has commenced or perfected
a union.  Of all the means devised and recommended for the
treatment of ununited fractures, the plan of Dr. Brainard has
been attended with the greatest degree of success.  It is easy
to put in practice, as any awl or drill which can be  trusted to
perforate bone, will answer the purpose.  The point of an awl
which makes few chips is preferable to others.
  Non-union is not so distressingly inconvenient as might be
supposed.  In the leg it is the worst;  but even there a heavy
leather apparatus, with side-irons, or a mechanical support of
some kind, can be worn, which will enable the patient to walk
tolerably well.  In the arm, the functions of the  member are
generally preserved in a good degree, and the limb is  not
without strength and general usefulness.
  The freshening of the ends of the fragments can be accom-
plished  by cutting the skin and fascias over the fracture, pull-
ing the  edges of the  wound apart with  retractors and then
.cutting  off the smooth extremities of  bone with pliers;  even
a saw can  be used in the  freshening process.   The affair is
then like a compound fracture, andean be treated successfully
with a firm dressing.  If the tibia be the subject of  non-union
the  foot must be kept  flexed on the leg till consolidation is
kuown  to have taken place.  It is astonishing how much can
be gained by strapping the foot  in a flexed  state  to the leg
above.  The manoeuvre can be accomplished with a long  loop
of adhesive plaster, the middle going under  the ball of  the
foot or the toes, and the ends extending to the calf of the leg. 
CHAPTER  V.
DEFECTIVE  UNION.
   Some united fractures are subject to frequent and long-con-
 tinued pain, analogous to the neuralgia of cicatrices in soft
 parts; others are kept irritable by an  exuberance  of callus
 which piles up in ridges about the seat of injury.
   There are three species  of deformity resulting from mal-
 union : Junction with permanent displacement, angular, rota-
 tory, or shortening;  union of two contiguous bones, as of the
 radius and ulna ; and projection of one ofthe fragments.
   Angular deformity can  sometimes be  remedied by gradual
 compression.  This may be applied with a common fracture
 apparatus, and by mechanical contrivances suited to the indi-
 vidual case.  A splint may be placed opposite the concavity
 of the angle, and the bone drawn toward it; or it may be fixed
 to one fragment on the convex side, and perform the part  of
 a  lever to which the  other is to be drawn by means of band-
 ages ;  or, the  projecting  angle may be pressed between two
 opposing splints.  The bandages must  be kept  tightened  in
 order that the pressure may  be maintained.  The  pressure
 may be begun as late  as five or six weeks after the fracture  is
 received, and be kept up for several weeks.  Ordinary exten-
 sion, combined with pressure, aids in the straightening process.
   Re-fracture has been resorted to in cases of distorted union.
 This is to be done gradually with the hands and the knee, and
 not violently with a mallet or quick motion across the edge
 of a board or bedstead.
   There  is some danger  of breaking the bone in the wrong
place, though the callus generally yields in preference to a new
place.  This tendency to break through the callus arises from
the fact that in those cases requiring refracture, the  union  is
apt to be irregular and otherwise faulty.  Refracture is not  to 
42                      Fractures.
be attempted in a consolidation over  six months old.   The
new fracture  is  not  attended with a  deficiency of  healing
power;  in many cases the reparative process in the effort at
reunion, seems to have been accelerated.
  After the union of two contiguous bones, as of the radius
and "ulna, an attempt to  effect a separation of parts not be-
longing together, should  be  made in cases  promising relief.
A patient under chloroform does not suffer from the force the
surgeon  applies.  An  assistant, to steady the shoulder and
elbow, gives the surgeon an opportunity to exert great  pro-
nating and supinating power upon the arm.
  A projecting point of bone at the seat of fracture, is gener-
ally rectified  in  a great measure by the ordinary pressure of
the soft  tissues upon the part.  In very objectionable instances
the salient point of bone maybe cut down upon, and removed
with the saw or  bone  nippers.
  Chronic pains  at the  seat of fracture may be modified by
the application  of stimulating liniments, and  by the use  of
flannel bandages.  Enlarged capillaries and varicose veins, are
also relieved by the bandaging.
  When partial anchylosis takes place at the knee or elbow
joints, it is generally good surgery to put the  patient under
the influence  of an anaesthetic, and with  force separate the
fortuitous connections.   After a well executed operation of
this kind, passive motion should be kept up for several weeks
in order to thwart attempts at re-union, and to favor a resto-
ration of the  functions of the joint.  In cases of anchylosis,
if recent, and free from other complications,  an attempt to
regain motion is seldom attended with harm, and is often fol-
lowed with happy results. However,  little good  will be ac-
complished unless passive motion be brought to bear several
times a  day for weeks and even months.  I have made satis-
factory  gains  in lessening anchylosis after six months have
elapsed.   Nature is ready to favor any efforts directed to the
perfection of her plans or tendencies. 
/
                  CHAPTER   VI.

GENERAL  REMARKS  IN REGARD TO THE  TREATMENT
                    OF  FRACTURES.
   The treatment of fractures consists in reducing the broken
 ends of bone to direct apposition, and in keeping them in place
 until consolidation is effected.  There are some cases in which
 there is no call for reduction, the relative position of the frag-
 ments being unchanged by the  accident.  In  such instances
 the surgeon has only to maintain the parts involved in the in-
 jury, at rest, and to guard against displacement.
   These general statements  render  the subject apparently
 simple, for they make no allusion to the various complications
 which render this branch of surgery one of great responsibility.
 In the ordinary discharge of those professional duties which
 fall  to the  lot of the country practitioner  of medicine and
 surgery, there are none so trying and difficult to perform suc-
 cessfully as  those pertaining  to the management of broken
 bones.  The inexperienced physician  may avoid performing
 what are  ordinarily considered surgical  operations, but if
 called  to a fracture he does not feel like shirking the respon-
 sibilities of the case.  A medical man would lose caste, and
 be considered timid, if he should decline to take chara-e of a
 fracture, though he knows that the public holds him  pecuni-
 arily responsible for the result of the treatment.   There is a
 wrong sentiment in every community in regard to the duties
 and responsibilities of a physician, called to take charge of
 fractures.   The medical practitioner has a right to decline any
 case  he pleases on the ground of inexperience on his part.
  It  is not absolutely necessary that a fracture be "sot" the
 very hour it is received.  The patient can be made compara-
tivelj* comfortable until the services of an experienced sur-
geon, who is willing to assume the responsibilities ofthe case,
                           (43) 
44                      Fractures.
can be secured.  The people should be made to  un-. itand
that a fractured bone needs, for its skillful manageird t, the
highest order of surgical  ability.  A man maimed or lamed
for life by a crooked or shortened limb, is often a striking ex-
hibition of professional incompetency.  The victim of a blun-
deringly prescribed dose of medicine may go to the grave and
be forever unseen, or fortunately recover, bearing no evidence
of malpractice, but a bad piece of surgery follows the author
of it like " a shadow," reminding him of inattention and in-
discretion.
  It is not to be understood that a competent surgeon never
has any unfortunate cases; very far from it. Even the  most
experienced  are  charged  with malpractice, and sometimes
justly.  If  a young practitioner expects to treat fractures,
he should spare no pains to thoroughly inform himself  upou
all such injuries, and especially upon those that  are  oftenest
followed by defects and deformities leading to  malpractice
suits.  He should study the nature  of rotation in  the forearm,
and the causes that lead to its arrest in the treatment of  frac-
tures of the radius  and ulna ; he will learn the necessity of
being guarded in his prognosis when about to engage in the
treatment of a fracture of a condyle; he must not be too cer-
tain  of a fortunate  result in fractures of the  shaft of the
femur, though the nature of the injury be very  plain;  over-
lapping and consequent shortening will have to be battled all
through the healing process ;  in a plain fracture of the  tibia,
he is not to  be satisfied that the diagnosis is complete till the
fibula, its whole length, has been carefully examined and pro-
nounced intact;  finally,  he  is to master that  frequent in-
jury, fracture of the fibula just above the malleolus, compli-
cated with dislocation of the tibio-tarsal articulation.
  In the management of surgical cases the  physician  is held
responsible for an  average result.  In other words, he must ex-
hibit as much skill and attention as are  ordinarily displayed
by the profession  at large.   The term " ordinarily," as used
in this  connection, is susceptible  of no precise  or inflexible
definition ; hence there must always be difficulty in applying
its import or meaning in every case.
  In a rural district, where opportunities for treating and ob-
serving surgical cases are necessarily limited, a less degree of
skill  must  pass as ordinary, than  in  cities and  large towns 
General Remarks.
45
where exist greater facilities for observation and experimental
knowledge.  Besides, the country practitioner is not expected
or required to have at hand for all emergencies, the most novel
instruments and appliances ;  or to leave his business and spend
time and money in seeking them, granting that he knows what
is best or most approved.  If the physician exercises ordinary
skill, care and caution, and makes good use of materials within
reach, or manages the case well, taking all circumstances.into
consideration, he is not  pecuniarily liable for an unfortunate
result.  This is not written as an apology or excuse for igno-
rance, blundering and inattention, which are never pardonable,
but to place the question of pecuniary responsibility in the
light in which it is held by the courts.
  If medical men were to be held strictly accountable for the
results of injuries and surgical operations, few practitioners
would hazard their reputation and property in cases involving
the dangers of alleged  malpractice.   Patients would call in
vain for surgical aid at a time when professional services might
be of vital importance.
           FIRST ATTENTIONS TO THE PATIENT.

  A person with a fracture of the upper extremity, can sup-
port the injured member with the sound  hand,  and seek a
surgeon himself, or go home, and have one  summoned to his
assistance.  A patient will  carry his own  broken arm  with
more steadiness than any assistant.  Walking producss less
motion between the fragments, than riding.
  When a fracture occurs  to the bones of the leg or to the
femur, the patient is not able to walk.  The pain attendant
upon being removed home from the place* of accident, is often
intolerable.  The  following  is the language  of that famous
surgeon, Ambrose Pare, who, just as he was going on board a
boat, had his  left leg broken  by the kick of a horse : " Having
received the  blow, and  dreading lest the horse should repeat
it, 1  made a step backward ; but suddenly  falling to the
ground, the broken  bones  stuck  out, piercing the flesh, the
stocking, and the boot;  from which I felt the most intolerable
pain.   Very soon I was carried to the boat, to  be  taken to
the other side,  that I might  be dressed.  But the jolting thus
caused nearly killed me, since the broken ends of the bones
tore the flesh, and those who bore me were unable to fix them. 
46                     Fractures.
On landing I was carried to a house in a  village, with even
greater suffering than I had endured in the boat; for one car-
ried my body, another my leg, and another my foot; and in
walking along they did  not  keep in step.  At length, how-
ever, I was laid on a bed to take breath ; and here, while the
dressings were in preparation, I found myself in perspiration
all over; had I been plunged in water I should not have been
more thoroughly wetted."  The great surgeon, Percival Pott,
had a similar experience to  that of Pare.  Falling from a
horse in Southwark, in the suburbs of London, he  broke his
leg, and the jagged end  of the bone pierced the skin.  Esti-
mating the suffering he would undergo if carried home in a
carriage, he sent for men, and some poles suitable for support-
ing his body.  He purchased a door, and made the men nail
the poles to it;  once mounted upon this improvised litter, he
rode home in comparative  comfort, though his sufferings alto-
gether were intense.
  A door or shutter taken from its hinges, constitutes a ready
litter, upon which a patient with a broken leg can ride  home
without serious jolting.  A carriage is difficult of ingress and
egress; a wagon, with its bottom covered with straw or a bed,
is a pretty good ambulance, and is oftener employed than any
other means of transportation.
  The patient having been brought near the bed, the clothing
should  be  carefully removed.    While  the broken  leg is
steadied, the seam of pants is ripped  the whole length, so the
garment can be  removed  without difficulty.  The patient is
now ready  to take the bed, and to have the limb dressed.

      POSITION A  FRACTUEED LIMB SHOULD TAKE.

  A great  deal  of  discussion has arisen  among surgeons in
regard to the position a  limb should take in order to assist in
the reduction of the fracture,  and  to facilitate the healing;
process.
  In fractures of the upper extremity, it is almost invariably
the custom to  keep the  elbow at a right angle, the forearm
being supported in a  sling.  There is  but one exception to
this  rule, and that is in  fracture of the olecranon.   In this
particular lesion the arm must be  kept fully extended to relax
the triceps, and to favor apposition of the fragments. 
General Remarks
47
  In  the lower  extremities the attitude of  partial flexion  is
that  admitting  of comfortable  repose.  Pott  claimed that
from  the muscles arises the whole difficulty of reduction—the
resistance depending upon the position of the limb, by putting
them in a state of tension.  To  avoid this tension the limb
should be so placed as to relax the muscles, that they may offer
the least possible resistance..  Such a position is that of semi-
flexion.
  Desault took an opposite view.  He contended tl'iat in semi-
flexion there is  difficulty  in making the necessary extension
on the broken bone; that in such a position there is an im-
possibility  of accurately comparing the two limbs;  that  it
favors derangements of the fracture while  the  patient has "a
movement of the bowels.   He also urged the impracticability
of firmly fixing the leg in a flexed position; and  the trouble
of adopting this method when both limbs were broken ; and,
lastly, the results of experience were against' it.   Bichat  as-
serted that what was gained by relaxing one set of muscles,
was lost by the tension of  others.
  Dupuytren, in reviewing the subject, announced that while
extreme flexion would  stretch the extensors, and complete ex-
tension made tense the flexors, partial flexion was a position
of ease, which is the best  condition for reduction.
  Malgaigne asserts that  experiments  made upon the dead
subject  could not settle the question of the most desirable
attitude, for the cadaveric rigidity is quite different from vital
contractions.   " Muscular action can not be studied  except
where it exists;  hence  experiments must be made of necessity
upon  the living  subject."   He alleges that complete extension,
like complete flexion, is a  fatiguing  and painful position when
kept up a long time.
  Boyer says :   " Sometimes the difficulty  of the 'reduction
arises from the forced extension of the limb and the unequal
stretching of the muscles  ; it may be obviated by putting the
limb in  a state of semiflexion."
  A  patient with a fractured leg which confines him  to the
horizontal position, can be attended with the least trouble if
he be placed on a narrow bed, a mattress of cotton or hair
being used  instead of feathers. A  number of pillows,  to
cushion and support aching  and uneasy parts, can be put  to
good use.  Bags, holding a peck or more, made of strong cloth 
^4ifir y                Fractures.

 «^iftling, and filled with nice dry sand, are exceedingly use-
  tJfoto put under the  knee, if semiflexion be adopted, or to
  b^Tster the limb at any point.  Several of these sand-bag sup-
  ports may be needed to wedge up the trochanters, and to pre-
  vent the limb from becoming everted.  The heel which grows
  restive under pressure, is generally put at ease  between two
  small sand-bags.
     The weight of heavy bed clothes can be kept from the foot
  and limb, by means  of hoops taken from a keg.  Two half
  hoops can be fastened in  the middle, and then twisted a little
  from one another at their free ends, so as to form a four-legged
  screen for the foot, knee, or other part of the limb.
     To prevent the trunk from sliding down the bed, a perineal
  band may be used.   This can be fastened to the head  of the
  bed, and be  made to  serve as counter-extension, to  oppose
  ordinary extension, which is made downward from the knee,
  leg, or foot.  A firm piece of buckskin forms the best perineal
  band. It is soft, unirritating, and strong.  A belt of drilling
  or firm muslin, padded to prevent irritation at points of pres-
  sure, will answer the purpose.
     The elevation of  the  foot of the bed by placing blocks or
  bricks under the foot-posts, is a method of getting  up coun-
  ter-extension, now considerably in use.  The extending strips
  or apparatus for extension, being made fast to the foot-board,
  the inclination of the body toward the head of the bed, is a
  simple manner of accomplishing what otherwise would require
  a perineal band, and other disagreeable and complicated ma-
  chinery.  This plan was  devised by Dr. Van Ingen, of Sche-
  nectady, N. Y.  He  called it the " Natural extension."   To
  avoid unpleasant sensations  from having the head too low,
  high pillows may be used.  The elevation  of the foot tends
  to prevent oedema and congestion of the limb.
^* ^ * », <. 
-CLECTIO
   <EDICAL
     '.LEGE
          CHAPTER   VII.

REDUCTION  OF DISPLACED  FRAGMENTS.
  Before any efforts  are made to reduce or adjust the  dis-
placed fragments, it  is best  to prepare and  have at hand,
splints, bandages, compresses, and  such appliances as may be
needed  in the dressing.  Every effort to  pull and squeeze a
fractured limb, is attended with intense pain ;  and repetitions
of purposeless manipulations may do harm to  the  parts in-
volved in the injury.
  Everything being ready for the dressing, the reduction may
be made, if any be required.  In many instances there is no
displacement, consequently no reduction is requisite.  Inex-
perienced practitioners give  every limb, before they place it
in a fracture apparatus, an  energetic pulling, and not a  few
vigorous twists, to reduce, perhaps, what does not need reduc-
ing.   It is folly to suppose that the extent, direction, and dis-
placement of every fracture  can be accurately determined by
an examination.  The depth of the  fractured bone, and the
swelling of the soft  parts, may preclude a satisfactory diag-
nosis.  The usual signs of fracture having been observed, and
comparisons made with the other limb, the existence of dis-
placement can be pretty accurately determined.  Shortening
or overlapping of  fragments can  generally be  overcome by
extending and counter-extending forces applied by the hands
of assistants.  In  obstinate  cases of muscular  contraction,
chloroform maybe  used to overcome  it, and to put the patient
into that insensible condition which admits of free manipula-
tion and examination of injured parts.
  As  soon as sufficient extension has been made to overcome
the resistance of the  muscles, the ends  of the broken bone
are to be placed as  nearly as possible in their natural relations.
        4                  ^     ^-^itDiCAL t;i^ 
50                      Fractures.
This is called adjusting,  setting,  or coaptating the broken
bones;  and  is  generally  supposed  £o  be  a  very skillful
manoeuvre, though not half so difficult to perform, as to keep
the bones in place when once adjusted.
  In fractures of subcutaneous bones  it  is generally easy to
see when the extension is  sufficient, and  the  coaptation per-
fect.  The  sudden restoration  of  the natural outline of the
limb is pretty good evidence of the mutual adaptation of the
fragments.   Measurements and comparisons with the opposite
limb, afford valuable aid in determining the relations of the
fragments;  and are decisive when other  evidences of reduc-
tion fail.
  In the event of a serrated or impacted fracture, it is neces-
sary to extend the limb beyond its natural  length, and then,
by  partial  rotation, to coax the  fragments into apposition.
If soft parts intervene between the  fragments, they are gen-
erally released by extension and rotatory manoeuvre-;.
  As a general rule, the sooner reduction  is effected after the
accident, the better.   Some surgeons recommend that the re-
duction be  delayed for  three  or four, or even ten or twelve
days, or until inflammation has subsided.   No reparative pro-
cess of a substantial nature being yet commenced, the position
of the fragments during that period does not interfere  with
the dekvyed reduction, nor affect the final result.  However,
immediate reduction  has great advantages.  It restores the
patient to comparative comfort, and diminishes the  dangers of
spasmodic twitchings and other evils resulting from the mal-
position of  the parts.
   When reduction is  delayed  for several days after the acci-
dent, the fragments become more or less fixed by effusions into
the surrounding tissues; and the muscles, accustomed to  a new
position, offer considerable resistance to a change.
   If the surgeon is not called for three or four days after the
reception of the injury, or until  the inflammation is  at  its
height, it may be advisable for the time  to use such remedies
as tend to lessen the inflammatory action, and to put off the
reduction until the parts are more manageable.   The disturb-
ance of an irritable injury, when much inflammation and ex-
cessive ecchymosis exist, has provoked convulsions, uncontrol-
lable twitchings, and  even tetanus.  On the  other hand, ac-
cording to  Velpeau, neither inflammation, nor  spasm,  should 
Reduction of Displaced  Fragments.         51
induce any delay; so far from that, immediate reduction is the
quickest and surest method of alleviating them.
  Malgaigne declares that, on account of muscular contrac-
tion and spasm, he has been frequently thwarted in his efforts
at reduction, even with good assistants, and therefore has been
obliged to resort to mechanical means to  multiply force.  As
he says nothing about the relaxing effects of chloroform, it is
probable that he did not use the agent..   Under the influence
of profound anaesthesia, few patients will be met whose  mus-
cular condition can resist well directed efforts at reduction.
  Several surgeons have been obliged to saw off the protrud-
ing fragment in compound fracture, before a reduction could
be effected.   Cases treated in that manner have been reported
as doing well, union taking place  as readily as in ordinary
compound fracture.  Of course, there would be as much short-
ening as there was length of bone removed, yet that would
be moderate in most instances.
  In managing a compound fracture the  finger is  to  be em-
ployed to ascertain if there be present in the flesh detached
pieces  of bone that need removing.  To leave such pieces
would  endanger non-union, prolonged suppuration, and other
serious troubles.  When a fragment of bone protrudes through
a wound in  the flesh, it is best to enlarge the aperture in the
integument, in order to secure reduction.  A large wound in
the  skin heals about as quickly as a small one.  Besides, an
opening of considerable size the more readily admits explo-
rations with the forefinger.   And if detached fragments, that
may perish, be present, the external wound offers an excellent
opportunity to extract them.  Iu a comminuted fracture the
opening made in the fiesh is indispensable to a right under-
standing of  the situation of affairs. 
CHAPTER  VIII.
APPARATUS  FOR THE  TREATMENT  OF FRACTURES.
    Much ingenuity has been displayed in the  invention and
  construction of apparatus for treating fractured bones.   The
  apparatus for retention includes bandages, splints, junks, me-
  chanical contrivances for maintaining extension, immovable
  dressings, together with  belts, adhesive  plaster, woven  wire,
  and various means to enable  the surgeon to manage special
  cases.
    Bandages, or  rollers, as the}' are sometimes  called, can be
  made of several different materials.  Those  most commonly
  used are made of old sheets, or  unbleached muslin.  Flannel
  makes an excellent bandage.  It is elastic, and does not slide,
  one fold over another, as freely as cotton fabrics.
    An  arm-bandage  should be  at  least two inches wide, and
  eight yards long; a leg-bandage, two and a half inches wide
  and ten yards long;  and  a rib-bandage, five inches wide and
  twelve yards long.  There is no inflexible rule  governing the
  dimensions of bandages,  yet it is of considerable importance
  that the width and length of a bandage be properly adapted
  to the part to be treated.  A bandage which is to extend from
  the hand to the elbow, or from the foot to the knee, need not
  be so long as indicated above.  A bandage should be cut off
'  as soon as enough has been used ; no advantage is gained by
  making more turns than  are necessary.
    All bandages should be  rolled into a firm, even, and com-
  pact mass.  This may be done perfectly well with the hands,
  or  upon the knee, after the roll  is started.  An assistant may
  take the kinks and twists out of the strip as it is being rolled.
    A bandage which is used with plaster of Paris, to constitute
  an immovable dressing, ought to be made of coarse muslin, so
  as to retain the gypsum in its meshes.
                          (52) 
Apparatus for Fractures.              53
  As far as practicable, the bandage ought to be made of one
continuous piece, or with few joinings; and  the selvedges
should always be torn off.   In a word, the surfaces and edges
of the bandage  ought to be as smooth and even as they can
be made; and there  should be nothing which can press un-
equally upon the limb, to constrict or irritate it in any way.
  In applying a roller it is desirable to seeure the end of the
bandage by the first turn or two, in order that the proper trac-
tion may be sustained without slipping.   A turn  is generally
taken around the wrist or ankle for no other purpose but to
fix the commencement of the bandage.

                          Fig. 5.
     Method of making a " reverse " in a spiral reversed bandage.

  When a bandage  is  to rest  in  contact with the skin, it
should be  applied  flatly to the  surface—there  should be no
creases nor puckers.  Where the part to be bandaged is of
nearly uniform calibre,  as, for example, the forearm a short
distance above the wrist, the roller may be carried around the 
54                      Fractures.
limb circularly, forming what is  called a " spiral bandage."
Each turn of the roller ought to overlap about a third of the
preceding one, and no intervals or gaps be left between the
turns.  But the conical outlines of the human  limbs do not
readily admit of the simple application of the circular bandage.
It becomes necessary, therefore, to apply the roller by making
" reverses," (Fig. 5), or to adopt some other plan suited to the
contour of the limb.   It is not easy to describe  in words the
method of making " reverses," but the accompanying illus-
tration shows how they are made.
  In a fracture dressing it often becomes necessary, in  order
to exert  a considerable degree of pressure on a  particular
point, to place a wad  of lint or folded cloth, called a compress,
underneath the bandage.   The  pad or compress is to be of a
size and shape to fit or suit the part pressed upon ;  and some
care must be exercised to confine the compress to the spot
where the extra pressure is needed.
  When  the arm  is bandaged, the limb should be  covered
from  the  fingers  upward  to the elbow or shoulder; and the
leg, when  properly bandaged, is covered from the toes upward
to the knee or hip.   This will prevent the hand or foot from
becoming  swollen and cedematous.
  When  a bandage  is used to give support or to make pres-
sure, great care should be taken that it is not so tight in any
part as to  cause constriction.  Cases are on record in which
the most disastrous results have been brought about by a ban-
dage being drawn too tightly.   Limbs  have sloughed exten-
sively, or become mortified, requiring immediate amputation,
for no other reason than that the bandage which was intended
to give even and  gentle  support, has been applied with so
much pressure as to stop the circulation, and to  establish gan-
grene.
  It is the  duty of  the surgeon to dress a  fractured limb for
the first time as if he expected it to  swell.  This may save
him the trouble of being called to loosen the bandage, and
the patient a great amount of needless suffering.
  As a general rule, a bandage ought not to be applied under-
neath a splint.  The  splint should be  well  padded with raw
cotton, tow, or soft cloth,  then wound with strips of muslin,
and laid next the  skin. 
Bandages.
55
Fig. 6.
  Many-tailed Bandage.—This is made of strips long enough
to go once and a half around the limb.  These, to the num-
ber  of  fifteen  or twenty, may be  laid, before  application, in
regular order,  from above downward,  one overlapping  the
other for about a third of its width.  The strips may be kept
in their places by a longitudinal band,-stitched to their centre.
                    When the bandage has been prepared,
                    the limb is laid  upon it, or the strips,
                —7 arranged upon apiece of pasteboard, are
 \        ' =     ~7 slipped under the limb ; and then each
 >         \       /,. separate  piece is made to  encircle  the
 \        •'        / limb, beginning with the lowest, the ends
  -------jirj-------'  being brought up, one on each side, and
       , >r         crossed in front. One end of the last piece
Bandage of strips, or many-                                 x
     tailed bandage.      only needs pinning; the others are held
by the  overlapping.  This has been  called the  bandage of
Scultetus, and  is convenient in  compound fractures, as  the
lacerated tissues can be examined without disturbing the limb
the ends of the bandage being laid off for the time, and then
returned to their places.
  Another similar bandage is made by taking a piece of cloth
long and broad enough to envelop  the limb, and tearing it on
each side into tails, leaving a few inches in the middle untorn,
to support the tails or strips.  The  ends are brought around
the limb, and lapped, as in the bandage of Scultetus.
BANDAGES  PREPARED  WITH  STARCH, ETC.
  What is  called an " immovable apparatus," is generally
made by saturating the bandages  surrounding the limb  with
a liquid which, after it is dry, gives a great degree of solidity
to the dressing.   By means  of this the patient is sometimes
enabled to leave his bed in a few days after he has met with
a fracture of the leg, or even of the thigh, and to go about on
crutches during the time  that union is taking  place.
  The starch-bandage may be made as follows:  The starch is
mixed with water until it forms a thick paste.   The surgeon, 
56                     Fractures.
having at hand rollers, lint, strips of pasteboard, and the basin
of paste, lays a piece of broad tape along the front surface of
the space to be  bandaged, (for a purpose to be presently ex-
plained), and then begins the application of the dressing.  A
common roller, made  of muslin  or flannel, is run upon the
broken part, whether foot, ankle, leg, or thigh, and an assist-
ant, with a brush or swab, applies the starch-paste to the ban-
dage as  it goes on.  Strips  of pasteboard, leather, or other
bracing material, are dipped in the paste, and then laid along
the limb upon the first  layer of bandage, to strengthen the
dressing; over these splints another roller is  applied, the as-
sistant all the time using as much paste as may seem sufficient
to stiffen and consolidate the dressing.  Even the third roller
may be employed in this way to  give  additional strength to
the dressing.
  Extension and counter-extension should be kept up by some
of the means already indicated, for thirty or forty hours, when
the dressing becomes hard and immovable.  If in the course
of a  few days, it be found that a subsidence of swelling has
left the dressing loose, the  piece of tape laid on the limb at
first, may be used to lift the hardened case from the skin, so
it  can  be ripped open the  whole length.  The same means
may be used to free the constriction in the event of swelling.
Suetin devised  scissors, one  blade  having  a  probe point, to
slit up the starch-bandage, and to cut a hole in it to correspond
to the sore in a compound fracture.  A grooved director and
a bistoury will answer the purpose of the scissors.
  If the limb shrinks away to a considerable extent, the old
apparatus should be removed, and a new one put on.  An im-
movable dressing is to extend to the knee in case of fracture of
the leg; and to begin above the knee and extend to the body,
in case of fracture o£^he femur—the knee-joint being left free
in both instances.  The ankle-joint maybe covered, the dress-
ing beginning at the toes.  Lint should he carefully packed
between the ankle and the tendo-Achillis, on  each  side, that
the dressing may not bear too heavily on the prominences of
the joint.

  Gypsum Bandage.—A plaster of Paris bamiage has the same
general features as  the starch-apparatus.  A  coarse roller of
muslin is thoroughly dusted with the powdered gypsum, and 
Splints.
57
then applied to the limb.  While the bandage is being put on,
it should be moistened and freely dusted with the dry powTder
hi order to strengthen or stiffen the application.  It is well to
wrap the limb in flannel or soft lint before applying the gyp-
sum bandage.   This precaution may save troublesome irrita-
tion.  Three rollers, well powdered while being applied, gen-
erally make a stiff, immovable apparatus.
  The advantage  of gypsum over starch is that it dries or
"sets"  immediately.  On the contrary, it is heavier and not
so easily cut away  in the event of its being  too tight or too
loose.  When  plaster of Paris is  used, extension should be
kept up by assistants for a few minutes, or until the stiffening
ingredient has become solid.
  The immovable apparatus is frequently employed in hospi-
tals  and public  institutions,  but  it has not been extensively-
used in  private practice.  There seems to be  no good reason
why it is not more commonly adopted, as every house contains
starch, and the other means needed to complete the dressing.
                        SPLINTS.


   Splints are made of various substances, according  to  the
caprice of the surgeon, or the nature of the materials at hand.
Wooden splints are by far the most commonly used in coun-
try practice; and, in the majority of  instances, they are  the
best.
   From  time to time splints of various materials have been
introduced, so that a surgeon in a large  city can make his
choice among a number of appliances, and select that which
he may fancy, or is best suited to his purpose.
   The country practitioner derives little instruction and con-
solation,  in case of emergency, from illustrations and teach-
ings which deal only in " patent splints" and complicated con-
trivances that can  not at the time be  obtained.   With a few
practical suggestions he can, if moderately ingenious, make
from thin boards all the splints he may need, or, at least, con-
struct a temporary appliance which will do till the village car- 
b8
Fractures.
Ftg. 7.
U
Tl
u^
penter  can furnish him with  a more suitable apparatus.   A
shingle, a piece of lath,  a cigar box,  sole leather, binders'
            board, pieces of tin, and  other materials adapted
            to the purpose, can be pressed  into  service.   A
            surgeon of expedients  is rarely baffled through
            want of appliances.   Strips  of  bark, or even  a
            trough of bark taken  from a sapling, can often
            be used with great satisfaction in dressing a frac-
            tured  arm  or leg.  Surgical instrument makers
            keep for sale lined splint-material, which consists
            of thin board sawed into parallel strips, and held
            in place by a piece of pliable leather glued to one
glued to leather, g^i^   Splints cut  of  any  desired  length  and
width from the lined material/can be used in  two  -ways : to
envelope an  arm or thigh, as  a concave splint,  the  leather
acting the part of a hinge between the strips ; and, with the
wooden side toward the limb, to answer as flat splints for the
forearm or leg.
                 Splints of gutta-percha are easily moulded to
                the contour of the  body.   Cut into proper
                shape  and size, they may be softened in hot
                water, and then made to fit the part to receive
                them.
                                     Fig. 9.
Splint-material
 consisting of
 wooden strips
       the
Fig. 8.
Moulded gutta-percha
     splints.
Carved wooden splints. 
Splints.
59
  What are ordinarily called  " carved  splints,"  several of
which are represented in the accompanying diagram, are made
from thin boards, and bent into desired shapes, the wood hav-
ing first been rendered pliable by the action of steam.   These
appliances are cut and moulded into various  lengths  and
shapes to fit the arms and legs, and fitted with hinges to span
the joints.   Appliances of this kind are put up in " sets," and
sold about the  country, by Welch, .Day, and other manufac-
turers of such wares.
  Although such curiously  fashioned and highly polished
pieces of surgical mechanism, make a display, it is plain that
they constitute  a Procrustean bed, to  which patients  of all
sizes and shapes must conform.
  Woven wire  has been cut, bent,  and  soldered  into various
forms for the support of fractured limbs. (Fig. 10.) The "Wire
breeches," represented in the accompanying illustration, are
a sample of the manner in which woven wire may be wrought
to suit the purposes of the surgeon.  This apparatus is one of

                          Fig. 10.
                      " Wire breeches."


the best that can be employed to treat fractures of the neck of
the femur.   The screw  in  the foot piece permits of making
extension, and the shape of the upper extremity of the machine
is such that the tuber ischii can easily rest against it for coun-
ter-extending support.  The length of the limbs can be accu-
rately compared while the patient is in the apparatus; and the
wire extends so far above the hip-joint that the constant mo-
tion between the fragments is  prevented.  The patient can sit
up in the apparatus; and by having its upper extremity raised
upon a temporary support, the alvine evacuations can be  re- 
60                      Fractures.
ceived in a bed-pan.  The apparatus should be lined with
thick flannel before the patient is put into it.
  All the edges of the wire-gauze have a heavy wire soldered
into them, to give the machine a finish, and proper firmness.
The " wire breeches "  were first devised for the  treatment of
hip-disease.
  Concave and angular wire splints, of various patterns for the
shoulder and other  joints, have been in reputable use.  They
admit free ventilation,  and are not particularly heavy.
  Adhesive Strips.—One  of  the greatest  improvements in
the treatment  of fractures of the leg, where it is necessary to
effect and maintain  extension and counter-extension, has been
the introduction into use of adhesive strips, to take  the place
of  a  gaiter or other  contrivance fastened  upon the ankle.
Every practitioner who has had occasion to make fast to  the
foot and  ankle with the means formerly in use, fully appre-
ciates the difficulties growing out of attempts  to produce  ex-
tension.  Blisters, irritations and excoriations were the results
of the gaiter  and kindred appliances.  Adhesive strips well
applied, and carefully retained in place  by the  circular and
oblique turns of other strips, keep their hold, and are  borne
with ease.  The extending part of the dressing with adhesive
strips, may be applied as  follows:  One long strip is cut, and
                          Fig. 11.
Adhesive strips applied.
its two ends made to adhere to the sides of the leg and ankle,
leaving a loop below the hollow of the foot.  These ends will
gradually slide down the limb unless they be bound in place
by other strips, which are applied circularly about the leg and
ankle, covering the two parts of the first piece at each  turn.
Finally, a strip or two may be applied diagonally to the others,
to hold all firmly in place.
  A block of wood may be placed in the loop to prevent pres-
sure upon the ankle when the extending force is  applied.
i 
Splints.                       61
  The strips will firmly adhere for months unless some alco-
holic lotion be allowed to come in contact with them.  They
rarely need removing during the whole period of treatment.
  A double inclined plane apparatus is one of the  various con-
trivances to keep up a natural extension  and counter-exten-
sion in fractures of the leg and thigh.  It consists  of two
boards, hinged in the middle, and long enough to reach from
the tuber ischii to the heel.  There is a foot-board connected
with the leg-piece;  and this is sometimes made adjustable  so
it may be  always placed in contact with the foot, whatever be
the length of the limb.  The double inclined plane is hinged
at its upper extremity to a frame or board—the bed-piece—and
is held flexed at any angle by notches in the lower end of the
bottom board. (Fig. 12.) Side-boards maybe nailed or hinged
to the halves of the double inclined  plane bed or  bottom

                          Fig. 12.
Double inclined plane fracture box.
pieces, to form  a fracture-box.  Into this, cushions  or sand-
bags  can be laid, and then the broken limb  may be placed
upon them, and secured by tapes and other supports.
  Double inclined plane apparatus, with various modifications,
has been in use for centuries.  The weight of the body and
thigh sliding down the upper plane, produces counter-exten-
sion, and the inclination of the leg down the lower plane—
extension.   Additional extending force is  applied by means
of the adjustable foot piece and screws.
  Two pieces of board, hinged  with leather in the middle,
having a cord to reach from one board to the other, to hold
them flexed, constitute an easily constructed double  inclined
plane, which may answer every purpose of a more compli-
cated apparatus. 
62
Fractures.
  Fracture-beds are intricate and costly affairs,  rarely  con-
structed for patients in private practice.  They are not exten-
sively used even in hospitals.  A description of one will answer
for all.  That of Amesburyv.is perhaps as good  as any ever
constructed.   It  consists of a  horizonal  frame, supporting
three pieces  of wood, or planes, hinged together, and  long
                            enough, when connected, for an
                            adult to lie stretched out upon.
                            The upper plane receiving the
                            trunk, is raised at the bolster-
                            end ;  the middle one, intended
                            for the thighs, is made of two
                            pieces sliding on one another
                            so as to suit  limbs  of different
                            lengths, and forms  with  the
                            third piece a  double inclined
                            plane; this last,  which supports
                            the legs, has  a foot-piece,  used
                            to confine  the feet when  it is
                            necessary,  and  always serving
                            to sustain the weight of the bed
                            clothes.   The upper  of these
                            planes is to be supplied  with
                            a   thick   mattress;   the  two
                            others,, with  similar ones  only
                            half  as  thick.  The middle
                            one has an opening, with  a ba-
                            sin fitted to  it  to  receive the
                            fgecal evacuations; and the pel-
                            vis is fixed by means  of a belt
                            passing across the upper of the
                            three planes.    The hinges  of
                            the apparatus allow the differ-
                            ent  angles to be changed  at
will.  Burge's apparatus, (Fig. 14.) consisting of a bed, and
an arrangement to make extension and counter-extension in
treating fractures of the  femur, is a useful piece of surgical
and mechanical mechanism, but it is too complicated and ex-
pensive for ordinary use.   The diagram presented to illustrate
the appliance, shows that the machine could not be constructed
for less than fifty dollars; and is made of so many different
 
Splints.                       63
materials  that it would require a carpenter, blacksmith and
upholsterer to construct the apparatus.  Many intricate con-
trivances of varied merit have been pressed upon the attention
                          Fig. M.
of the profession from time to time, but none have come into
general use.  If a surgeon were to possess all the different ap-
pliances devised to treat fractures, he  would need extensive
store rooms in connection with his office, to give them shelter.
  The simplest and best method  of exerting extension and
counter-extension in the treatment of fractures  of the leg and
thigh, is to secure the limb to the foot of the bed by using ad-
hesive strips upon the leg and ankle as an attachment for a
cord to  make fast to the lower end of the bed.   Elevation of
the" foot-posts by means  of blocks piled one upon another, to
the height of eiadit or ten inches, secures a sliding inclination
of the patient's body towards the head of the bed, and thus
exerts both extension and counter-extension upon the broken
limb.  The force exerted is sufficient  and easily borne.  A
restless child will bear this dressing without complaining.  If
splints be kept snugly applied to the fractured limb, the re-
sult will be recovery without shortening or other deformity. 
CHAPTER   IX.
RE-DRESSINGS.
  After a fractured limb  has been dressed, or " put up," to
use a phrase of the  London hospitals, it becomes a question
when it should be re-dressed.   According to some of the older
authorities a definite time should be allowed to pass before the
dressing is meddled with;  and not .a few timid followers of
revered authority have permitted their patients to suffer need-
less torture, inflicted by swelling and tight bandages,- because
the prescribed time for re-dressing had not arrived.
  Whenever a fractured limb undergoing treatment is painful,
it  is in danger,  and  should be undressed at once, that the
cause of  the distress  may be ascertained and  averted.  If
local pain and general uneasiness arise within twelve hours
after the bandage or apparatus is applied, the limb should be
re-dressed.  An opiate or anodyne  to allay the pain excited by
the movements of the limb during the manipulations of dress-
ing, may not be out of place, but repeated and heavy doses
of any narcotic to allay the distress occasioned by the constric-
tion of a tight bandage, may benumb the pain;  yet while the
wails of the patient are thus silenced, the dreaded gangrene
may be doing its fatal work.
   If the first dressing is well applied, and no swelling  comes
on to convert the retaining tapes and bandages into constrict-
ing cords, the compresses, splints and bandages may be left in
place for several days.  I have frequently left the dressings  a
week or ten days without interference.  Frequent renewals,
without substantial reasons for them, are worse than useless.
They hinder the healing process, give the fragments an oppor-
tunity to play upon one another, and to overlap in cases where
that condition is possible.
                           (64) 
Re-dressings.
65
  As soon as the swelling has subsided, and the shrinking of
the limb permits the bandages to become loose, a renewal of
the dressing should take place.   It is probably best, in favor-
able cases, to re-dress once a  week while the retentive treat-
ment lasts.  The limb maybe looked at oftener.   A case that
is  convenient to watch may be  seen  every other day;  if it
be  at a distance, and  circumstances do not favor any more
attention than is absolutely necessary, a revisit and redressing
once in ten  days may do just as  well  as daily inspections.
There  is generally intelligence  enough among the patient's
friends  to be entrusted with the  execution of certain instruc-
tions pertaining to the case.  If yellow  blisters, or  a livid
color of the skin, show themselves  between the folds of the
bandage or anywhere beneath the dressings, the  surgeon can
be informed of the untoward condition.  A too tight dressing
can be loosened by  cutting a  few of the turns of the bandage
partly or wholly in two ; and, in the event of loosening, a few
additional tapes can be tied'around  the dressing.
  In fractures of the thigh or leg, the surgeon should, every
time he visits the patient, compare the two limbs in regard to
length,  direction of feet, and general aspect.  This can be clone
before  the dressing is removed.   The patient, while his limbs
are inspected, should be made to lie on his back, straight in
bed.  A slight twist of the pelvis makes a great difference in
the apparent length of the legs.  With the trunk and limbs
straight, accurate measurements with a tape or  inelastic  cord
should be made from the symphysis  pubis  to the inner mal-
leolus of both ankles.  The placing of the two heels together
and  observing whether one  is below the other, is a good test
of the  relative length of the limbs.  If there be evidence of
shortening, the dressing should be taken off, and the defect or
displacement remedied.  Re-dressings  for  such a purpose are
always proper, even at the risk of disturbing the healing pro-
cess.  There is always an urgent necessity, on the part of both
surgeon and patient, to avoid deformity if possible.
5 
CHAPTER  X.
MOVEMENTS ALLOWED A PATIENT.
  After a fracture of the arm has been dressed, and  the limb
is suspended in a sling hanging from the neck, the patient can
take moderate exercise upon his feet.  Motion at the point of
fracture, for obvious reasons, is to be guarded  against.   In
fact, the patient, to avoid pain, is very likely to cai ry a broken
arm with much care.  If the dressing become loose, the motion
between the fragments  tends to establish false-joint.
  After fractures of the femur, and of both bones of the leg,
the patient must keep  quiet  in bed during treatment, unless
an immovable  apparatus be applied.  In a fracture of one of
the bones of the leg, the condition is different.   The unbroken
bone prevents  shortening, and acts as a stay or support to  the
one fractured.  A  patient with a  broken tibia or fibula well
dressed, can go about on crutches.
  In fractures  of the femur, it is dangerous  for the patient to
go on crutches, even if the immovable apparatus be employed.
If the fracture  be of the cervix, or through the  upper third of
the bone, it is  difficult for the bed-pan to be used without im-
parting more or less  motion  to the fragments.   A cord sus-
pended from the ceiling, which can be 'grasped, enables  the
patient to raise himself with less motion than he can be raised
by the efforts  of assistants.   If the  patient is  too  feeble to
raise himself, an assistant can do it by placing a hand in each
loin, and lifting upwards and  drawing backwards at the same
time.  This  prevents the  body from sliding down in bed, or
the pelvis from descending upon the broken  thigh.  The body
may also be kept from sliding downwards, by using a perineal
band, which is to be tied to the head of the bed.  A box or
block  so placed  that the sohnd foot may press against it, in
efforts to raise the pelvis, may be of considerable service.
                           (66) 
J
            CHAPTER   XI.

MANAGEMENT  OF  COMPOUND FRACTURES.
  The directions given by Ambrose Pare, himself an eminent
surgeon, to his  surgical attendant, when he received a com-
pound fracture of the leg, are quite explicit.  " If the wound
be too small, enlarge it  with a razor, that you  may the  more
easily replace the bones in their natural position ; and carefully
explore the wound with the fingers, in order to remove such
                              fragments and bits of bone as
                              may be completely detached
                              and  press  out  the   blood
                              which  has become effused
                              about  the wound."   This
                              suggestion, to clear the cav-
                              ity of the wound from blood
                              and  splinters, is generally to
                              be followed. Small fragments
                              isolated from the periosteum,
                              are  likely to  create as much
                              trouble as other foreign bod-
                              ies in the flesh.
                                 The wound  once cleared
                              of coagula, splinters,  dirt,
                              and  other foreign substances,
                              and  the fragments adjusted,
                              the  treatment  is much the
                              same as in simple fractures.
                              The dressing should  be so
                              applied as not to permanent-
ly cover and choke the wound, for it  must have an opportu-
nity for the free escape of pus and other  fluids.  When  the
immovable apparatus  is  employed,  the  wound,  while  the
                         (67) '
Fig. 15.
Compound fracture. 
68
Fractures.
dressing is being put on, is covered in ; but, after the dressing
has become consolidated, a hole or door is cut so as to  expose
the wound.
  The edges of the wound are not to be drawn together with
sutures, but a piece of tin-foil, or a lead plaster, may be em-
ployed to shield  the lacerated parts.  As  previously stated,
the many-tailed bandage is  well suited for the treatment oi
such injuries, inasmuch as  the wound  can be often exposed
without disturbing the limb.  Care must  be exercised that
flies do  not deposit  their ova in the saturated folds of cloth
about the wound.
  The immovable apparatus is not generally suitable for com-
pound fractures.   Unpleasant complications have too often
arisen when it has been used.  Malgaigne  says of it: " Un-
happily we have too much reason  to fear pus will burrow be-
tween  the integuments  and  the muscles,  and between the
muscles and the bones, endangering the limb  and even the
life of the patient.  I once had to treat an old soldier, a stout,
sanguine man, who  fell  from a ladder,  and sustained a com-
pound fracture of the tibia at its lower part.   The immovable
apparatus was employed ; on  the eighteenth day it had to be
removed on account of the  insupportable fetor.  Four days
later, pus  flowed abundantly from the heel.  On the twenty-
ninth day, the increased discharge  and the excessive fetor
made a fresh removal necessary; the. whole  leg was pasty and
flaccid ; a probe, introduced by the wound,  passed up  several
inches between the two bones ; the tibia was  denuded  at its
external face; sinuses were  formed in  the limb above  and
below.  Several surgeons regarded amputation as unavoidable.
This, however, was postponed, and by great care, after three
incisions had been made, and a long train of severe symptoms
had been overcome,  a satisfactory cure was effected by the
end of six months."
   The application of carbolic acid  in  a  dilute form, to the
wound  of a compound  fracture, is valuable to  remove the
fetor; to  prevent a  profuse suppurative  condition ;  and to
favor the formation of firm and healthy granulations. 
Topical Treatment.
69
  TOPICAL AND  CONSTITUTIONAL  TREATMENT.

   It  was once customary to  apply cerates, poultices, and fo-
 mentations to fractured limbs.   At  a  later period  in the
 history of surgery, it  was a common practice to soak the
 dressings  in laudanum,  brandy,  lead-water, camphorated
 liquids, and various other lotions.  At the present day, dilute
 tinctures of aconite, arnica, and wormwood, are thought to
 be valuable applications ; rum and  whisky have always en-
 joyed a popular reputation for allaying inflammation in almost
 every kind of injury.   Some  practitioners order the frequent
 application of water to fracture dressings, with the object of
 cooling the inflamed tissues beneath.
   The  reasons  adduced  for employing cooling, stimulating,
 and anodyne lotions are not without plausibility, vet, in prac-
 tice, it is found that more harm than good follows any kind
 of topical  medication.   A common muslin bandage  creases
 upon being  wetted, often  reuclering  the dressing harmful;
 then, if allowed to diy, as is frequently the case, it will be too
 loose.   Blisters are more likely to occur under wet dressings;
 eruptions anddiscolorations,.with itching and other unpleasant
 sensations, are among  the troublesome effects produced by
 lotions.  I invariably find that fractured legs do the best when
 treated with dry dressings.  Much is said by those whose ex-
 perience* ought  to  render them competent authority, about
 applying evaporating lotions to fracture injuries of the elbow,
 knee, and other large joints, yet the instances are few in which
 I could approve of such treatment.
  The extensive ecchymosis that occasionally attends upon a
 fracture of the leg, excites dire apprehension on the part of the
 patient, yet the extravasation of blood and discoloration rarely
 result in any harm.  Neither  leeches nor stimulating  lotions
 will  prevent the  spread  of the discoloration, or remove the
 effused blood and serum.
  If, upon the renewal  of a dressing, it be found that large
blisters exist, the bags of serum maybe punctured, care being
exercised that the subsequent dressing does not press upon
the parts lest suppuration and sloughing follow.   The surgeon
should frequently re-dress a limb  in a blistered condition, 01
watch it carefully until parts thus effected are sound. 
70                     Fractures.
   Muscular twitching is occasionally a disagreeable complication
 which needs subduing.   The application of chloroform to the
 limb may allay the difficulty ; the internal use of an opiate
 has been attended with relief, though some patients of great
 nervous  excitability  grow  worse  under its  administration.
 Chlorodyne has  a far  more desirable effect upon spasmodic
 conditions.
   Distressing pain attendant upon the reception of a fracture,
 and the disturbance caused by the reducing process, ought to be
 assuaged by anodynes  in doses gauged by the severity and
 continuance of the distress.
   Febrile symptoms may be  allayed by the  use of aconite, or
 kindred agents.  The evacuation of the bowels by  the influ-
 ence  of  an enema, or  a mild purgative, frequently  arrests
 feverish  paroxysms.  A hot skin  may be  cooled by the fre-
 quent use of the wet sponge.  In case of " chills " and hectic,
 from exhaustive  suppuration, iron, quinine, and the mineral
 acids may be employed  to advantage.
   The diet should be light for the first few days after the in-
jury, but in the course of a week or ten days, it may be  sub-
 stantial and nourishing.
   Excoriations on the nates arising from unsuitable  beds, and
 a prolonged recumbent  position, may generally be prevented
by the use  of a  soft  piece  of buckskin to parts threatened
with such a disagreeable complication.  Air and water-cushions
are useful  in  protecting parts irritable  and excoriated from
prolonged pressure of the bed.


                   CONVALESCENCE.


   There is generally too little attention given to patients after
the fracture  apparatus  is removed.  The limb, though the
broken  bone  has united, remains  stiff, swollen, weak  and
tender.   Compression  and inaction have established a condi-
tion of atrophy;  and  the neighboring joints have  lost their
suppleness.  A patient is very sensitive to this enfeebled state
of the limb, and  needs  encouragement to make him exercise
properly, and to employ those means which  tend to  re-estab-
lish the  functions of the part.   Extreme  timidity prevents
patients  from  giving their convalescing limbs a  desirable 
                        Convalescence.                  # 71

   amount of action.  There is an instinctive dread that the limb
   may be re-broken, or that it will not sustain the weight ofthe
   body.
     It is a discreet precaution to'keep  patients who have sus-
   tained a fracture of the thigh, or of both bones of the leg, in
   bed for  a week or two  after the consolidation is known to
   have been established.   As has  been previously stated, there
   is yet danger of a gradual yielding of the newly-formed callus >
   yet during this confinement to the bed, the limb may be moved
   at the joints, and rubbed with the hand or  coarse towels.  At
   length the patient may venture  upon  crutches, and  then  to
   take gentle exercise with the support of a  cane;  and, finally,
   lie will walk without  any assistance, though with a  limp  in
   the gait even when there is no shortening or other deformity.
     Sometimes a patient is so fearful of a fall or a second acci-
   dent, that he has to be coaxed and  urged into sufficient exer-
   cise to invigorate the limb.  Liniments and douches are  of
   ifuestionable utility so far as medication is concerned, but
   their indirect effects may prove  exceedingly  advantageous.
   The patient is recreated while applying a  liniment; and the
   circulation of the limb is improved by the  friction employed
   in  the application.  There  is a  popular  notion  that certain
   penetrating or oleaginous liniments will impart suppleness to
   stiffened joints and rigid tissues; this prejudice maybe turned
   to  the  advantage  of  the sufferer, for  he  will industriously
   employ any means that have ascribed to  them  the desired
,   qualities.
     Patients are to be impressed with  the importance of em-
   ploying considerable force in the flexion and extension of par-
   tially anchylosed joints;  and  of keeping'up this action for
,   weeks and even months in obstinate cases.   Persevering efforts
   of this kind have accomplished wonderfully beneficial results.
     Flannel bandages should be  kept applied for weeks and
   months to legs  inclined  to swell, especially if the  veins be
   varicose.   At length the bandages may be laid aside, and
   elastic stockings worn continuously to keep the limbs in good
   condition.  Elderly persons make exceedingly slow recoveries ;
  and  if  of irritable temperaments, are querulous  and de-
  spondent. 
<
              CHAPTER   III.

DIASTASIS, OR SEPARATION OF THE EPIPHYSIS.
  Strictly speaking, there can be no fracture without breaking
of osseous material, yet the forcible separation of the epiphy-
sis from the shaft of the bone, through the cartilaginous con-
nection, in young subjects, is  a lesion analogous  to fracture.
It is an accident that can not always be  distinguished from
fracture ; and the treatment of the lesion  should be the same
as that directed for a broken  bone.  In the diagnosis  of the
case, clear and distinct  crepitus  will be wanting, but all the
other signs of fracture may be present.
  All the long bones, from  birth to fifteen years of age, are
subject  to  this  peculiar injury.  Both  extremities of  the
humerus, radius, femur, and  tibia, have been separated from
the shaft, through the cartilages interposed in growing bones,
between these distinct ossific parts.  The separation may take
place during the careless delivery of a child.  The obstetriciau,
unless he bears  in mind the  dangers of diastasis, may, in at-
tempts to bring down an arm or leg, sever the cartilaginous
connections of the humerus  or  femur.  If such  an accident
should occur, it would be known by the flaccid, mobile condi-
tion of the broken limb.  Swelling and discoloration  would
soon exhibit themselves ; and, in  handling the child, the in-
stability of the member would be observable.  The limb would
fall powerless into  unnatural attitudes.  Once discovered, the
injury should be treated like an ordinary fracture.
  I was once called to attend a  lad of five or six years of age,
who  had separated  the lower epiphysis  (Fig. 16)  of the
humerus, by a fall upon the  curbstone.   The  physician  first
summoned to take charge of the  case, bandaged the arm  so
tightly that the soft parts, on the  anterior aspect of the arm,
sloughed.  This was the state of  the case when I was asked
                            (72) 
Diastasis.
73
to take charge of it.  The shaft of the humerus protruded
through the opening made by  the  slough, converting the
lesion into something  like a  compound fracture.  The pro-
truding bone was denuded of periosteum, and pus was dis-
charged through two sinuses above the main opening.  The

                         Fig. 16.
          Separation of the lower epiphysis of the humerus.

 fortunate discovery of granulations upon the end of the pro-
 truding bone, suggested the idea of extending the limb until
 the projecting  bone would sink into its natural place and
 position.   Accordingly, the hand was suspended to the bed-
 frame above, so that the weight of the body, by extension,
 kept the bone  where it  ought to be, in the bottom of the
 wound.   The period of recovery was prolonged, and attended
 with profuse suppuration, yet in the end the result was quite
 satisfactory, considering the condition of the limb.
   Diastasis often takes place at the point of the elbow,—there
 is a partial separation of the epitrochlea.  The injury is at-
 tended w'th  great pain;  and  occurring in children whose
 joints are loose and who sob a great deal, the surgeon  is puz-
 zled  to know what kind of an accident has happened.  No
 crepitation can be elicited, and little displacement is apparent.
   It is safe to manage these obscure  and doubtful cases by
 placing an angular piece of binder's board on  the posterior
-aspect of the limb, the  ends extending three or four inches
 above and below  the joint, and wrap splint and arm with a
 bandage.  If a piece of binder's board eight inches long and
 three or four inches wide be cut into  on  each side, the inci-
 sions extending obliquely towards the centre of the material,
 the piece can easily be bent into a nest that  quite accurately
 fits over the  joint of the elbow. 
    CHAPTER  XIII.

FRACTURES  OF THE  CRANIUM.
  In the division of surgical subjects, fractures of the cranium,
from the nature of the  injuries and the peculiarity  of their
treatment, 'are always  placed  among wounds of the head.
The gravity of such lesions depends essentially upon injuries
and disturbances ofthe brain, therefore a consideration ofthe
fracture alone would not reach the most important part ofthe
subject.  The treatment  of fractures  of the cranium  is not
based upon the ordinary rules pertaining to broken bones, but
upon  the  brain-symptoms.  Unaccompanied with  cerebral
complications, such fractures though almost always compound,
are not to be interfered with.  It is an established  rule that
simple fractures of the skull, even with depression, but with-
out encephalic symptoms, are to be let alone.  In the severer
cases, the surgical interference chiefly consists in trephining,
an operation performed in order to elevate or remove frag-
ments  of bone, and designed to relieve the brain-symptoms.
Fractures  of the cranium, then, will not receive attention in
this connection.   The  bones  of  the  face, though classed as
belonging to the  skull, may be broken without necessarily
disturbing the brain ; and require the same general treatmeut
as fractures in other parts of the body.

     FRACTURE OF THE  ZYGOMATIC  ARCH.

  A fracture of the zygomatic process of the temporal bone
is an exceedingly rare aocident.  A direct blow, as a fall upon
the side of the head, is  the  kind of violence most  liable to
break this bony arch.  Although very prominent and slender,
the process is protected by coverings of integument, fat, fascia,
muscle, and other soft structures.
                           (74) 
Fractures of the Nasal  Bones.
75
  A simple fracture of the zygoma is an unimportant injury,
but a force that breaks the process of bone, is generally suffi-
cient to do other mischief.  Concussion  of the brain  is  the
frequent attendant of such a lesion.  A depression of the ai;ch
interferes with the temporal muscle..  The swelling that follows
the injury also impedes the functions of the  parts implicated.
  Treatment.—In  cases  where  the  temporal- muscle plays
easily, and the depression ofthe arch is not distinct, no treat-
ment is necessary, unless it be that employed  in ordinary con-
tusions.  Duverney directs, in the event of depression  of the
arch, that the surgeon put his finger in the back  part  of the
patient's mouth, against the  inner surface of the cheek, and
press the displaced fragments back into their natural line.
An  attempt  to bring  force against  the inner surface of the
zygomatic arch, by a finger in one's own  mouth, shows that
such a method of reduction is impracticable.
  Ferrier brought the pieces to their natural  level, by cutting
down upon the fracture, and elevating them  with a spatula.
  In the  only case  I  ever saw, the patient had been struck
with a heavy chisel.  A plain depression in the arch could be
felt; and the sufferer could  open and shut the mouth with
.difficulty.  There  was marked ecchymosis in the region hurt.
The skin was broken, but there was no wound in the soft parts
reaching to the bone.  I pushed the point of a strong tenaculum
beneath the  depressed bone, and with a lever-like  motion,
forced the displaced fragment into line.   There was a perfect
recovery in six or eight  weeks,  no perceptible  deformity fol-
lowing.  The point of an instrument, like a carpenter's scratch-
awl, might be employed as a lever to overcome the displace-
ment.

          FRACTURE OF  THE  OSSA NASI.

  A not unfrequent injury is fracture of the  nasal bones.   It
may be produced  by the kick of a horse or mule, and by the
forces of moving machinery. A circular saw might throw a
block  of wood  with sufficient  velocity to crush the bones of
the nose.   The handle of a windlass, while heavy weights are
beins; raised, may slip out of the hand of a laborer, and  so
quickly take the reverse direction as to strike the workman
across the bridge of the nose. 
76
Fractures.
  Violence producing fracture of the nasal bones, rarely stops
with that injury.   The  ascending processes of the superior
maxillary are  adjacent to  the  ossa nasi, the central lamella,
and cells of  the ethmoid  are directly beneath, and the  vomer
and turbinated bones not far away.  The  nasal duct may be
lacerated, and the Schneiderian membrane is sure to be torn.
The  symptoms of fracture which  amount  to reliability, are
displacement.  This may elude observation,  on account of the
great swelling which immediately follows the accident, unless
the surgeon  presses  his fingers deep into the tumefied tissues,
and thus discovers that the nasal bones, wholly or in part, are
depressed below their natural position.  The profuse hemor-
rhage from the anterior nares, and other conditions  generally
attendant upon fracture  of the nose, assist  in the  diagnosis,
yet, without other  evidence  of fracture,  the  case  would be
likely to pass unrecognized.  Ecchymosis and swelling, which
extend to the eyelids, are the usual concomitants of contusions
in the vicinity of the nose, and do not indicate the existence
of a fracture.  Even the  introduction of a probe into the nos-
trils determines nothing positively, unless if forces  one frag-
ment against another, producing crepitus.  The  nasal bones
may be broken and displaced, yet the fragments may be so
wedged against  one another, and between  other bones, that
no crepitus can be elicited.  When the fracture is much com-
minuted, motion between the fragments  can  easily be given
by holding the nose between the finger and thumb, and push-
ing it laterally, or from side to side.  If a grooved director be
carried up the nostril beneath the fragments, and the finger be
held  upon the outside injury, alternate motion given by either
instrument may disclose  crepitus, and a pretty clear idea of
the state of  the parts.  In the event of a wound exposing the
bones,  it would not  be difficult to discover whether a fracture
had been received or not.
  Treatment.—Diagnosis having been established,  the  sur-
geon's next  duty is  plain, though not  easily accomplished in
every instance.  A prafuse and persistent hemorrhage  is to be
arrested before dangerous syncope comes  on.  The displaced
fragments of bone ought to be reduced, if possible, for no de-
formity is so  noticeable  as a flattened or distorted nose.  A
female catheter, grooved director, or other similar instrument.
may  prove a sufficiently firm lever when inserted in the nose. 
Fractures of the Nasal Bones.
77
 to force the fragments back into place, but in some instances,
 a pen-handle, or piece of hickory wood whittled into the form
 of a pencil, may be  required  as a lever to elevate the bones
 from their depressed position.   This elevator, first carried up
 one nostril, and then the other, to a point beneath the depres-
 sion, then, being poised on tne forefinger which rests on the
 upper  lip, is  made, by a lever motion, to pry the fragments
 into their normal position.  Once replaced, the bones will stay
 where  they belong.  Pledgets  of lint  stuffed 'into the  nasal
 cavities to prevent the bones from falling out  of place, can not
 accomplish any good purpose.   Petit remarks : " These plugs
 are only of use to  contain the  medicaments; and those who
 have thought of putting plugs of lint with  the idea of sup-
 porting the bones, for  fear they should be  displaced, have
 never made the reduction of a  single fracture of the nose :
 experience would have taught  them that it requires more force
 to depress these bones that have just been replaced, than was
 necessary to raise them up with the elevator."
   If the bones be much comminuted, the parts may be  quite
 moveable and require some lateral support.   This  may be
 brought to bear by the use of small compresses, one placed on
 either side of the nose, and held there with strips of adhesive
 plaster.
   In many accidents, the fracture of the nasal  bones is the
 least important part of the inj ury.  There may be emphysema,
 the air  from the nostrils finding its way from cell  to  cell, or
 tissue to tissue, till the parts about the eyes and face are dan-
 gerously infiltrated; lachrymal fistula  is another unpleasant
 complication ; and the crista galli of the ethmoid bone may be
 forced  upwards or to one  side, and do serious harm to the
 brain, or structures within the  skull.
   A lateral  deviation of  the nasal appendage  is not so objec-
 tionable a deformity  as  flattening  or  sinking down of the
 bridge,  yet  much care should  be exercised from day to day,
 during the healing process, to prevent any lateral tendency.
 As soon as the swelling about the nose and eyelids subsides,
 any depression or lateral deviation can be readily detected;
 and if the injury be not more than two or three weeks old, the
 defect  may  be remedied.  After consolidation of the frag-
ments, no correcting operation  should be  adopted, so far as
 the position of the bones is concerned. 
78                     Fractures.


        FRACTURE OF  THE  MALAR BONES.

  The bones of the face may be broken by direct violence;
and, when  broken, the  displacement is generally by depres-
sion.  There will necessarily be a severe  contusion, and not
unfrequently a wound clear to the bone. No crepitation can
be elicited,  unless the comminuted fragments can be  made  to
move against one  another.   The evidence of fracture is de-
rived from displacement, and that is almost always by depres-
sion.  The  swelling, which arises rapidly, masks  the bony
displacement, so that  the true condition of the parts has  to
be ascertained by indentations made with the fingers.
  A though the malar  bone is very prominent, and nearly
subcutaneous, it  is  not  easily broken, or forced out  of place.
In prize fights the projecting  cheeks  are especially exposed
to blows, yet in the whole history of such " sports," not  an
instance of a broken malar  has occurred.   I have never been
called to treat a fracture of  this bone, but if I had an accident
of the kind to manage, I should expect to  treat it as I would
a depressed zygoma.  There is generally in connection with
the fracture, a wound of the integument covering the  bone,
and through this an awl-like lever might be  used  to elevate
the depressed fragments.


FRACTURE OF THE SUPERIOR MAXILLARY BONES.

  Fragments by direct  violence, are occasionally  detached
from the front portions ofthe superior maxillary bones.   The
nasal or ascending processes, as has already been indicated,
may be  broken by the same force that breaks the ossa nasi.
  In a case that came under my observation, a  man, in  a fall
from the loft of his barn, struck upon  the tire of a wagon,
and  sustained a  fracture  of one superior maxillarv.  The
break beginning in the median line and extending back to the
incisive  and canine fossre, separated from the main bone a seg-
ment of the alveolar arch containing  four  teeth.   There had
been a tooth—the first molar—extracted, which  perhaps weak-
ened the bone  at  that  point, and allowed the fragment the
more easily to be turned into the mouth.  The  soft palate was 
Fracture of the Upper Jaw.
79
 not much.lacerated, therefore the piece of bone did not become
 completely detached from its connections.  The upper lip was
 extensively bruised ; and there were injuries to other parts of
 the body.
   I  had no  difficulty in pulling the segment of the alveolar
 arch back into its place, and retaining it there.  None of the
 teeth were loosened from their places, though there must have
 been some interruption to their nervous and vascular supplies.
 The wound received no dressing except a wiring together of
 the  two front or incisor teeth.  The loss of a tooth beyond
 the other extremity  of the fragment, prevented the application
 of another wire at that point.   The recovery was perfect, no
 defect or deformity following the injury.
   Cases similar to the  one described, are reported in sevflfcd of
 our medical journals, and by Hamilton and Malgaigne in their
 Treatises.  In the treatment of fractures ofthe superior max-
 illary, the rule is to save the detached parts if possible; and
 if the mucous membrane of a  fragment be not  entirely sep-
 arated from that connected with the main part of the mouth,
 the union of the piece in its  original  place, may generally be
 expected.  The separation of splinters in the operation of ex-
 tracting teeth, is commonly final, there  being no attempt to
 effect consolidation with the rest of the bone.
   In the management  of a fracture of the upper jaw, includ-
 ing" a  segment  of the alveolus, it  is well to wire  the teeth
 together at the  extremities  ofthe fragment, and  then bind
 the inferior maxillary against  it, with  bandages around  the
 head and under the chin.
   When a bullet enters the antrum, and carries with it small
pieces of bone, the cavity must be cleared of the missile and
the detached osseous fragments, or prolonged suppurative ac-
tion will ensue.   It is  better to take care of such  an  injury
well  at first, than to wait until  the complications are unpleas-
ant, and perhaps dangerous.   With a drill the antrum can be
entered without incising the cheek.  The lip is held up while
the operator perforates the cavity of the jaw  above the roots
of the teeth. 
CHAPTER  XIY.
V
FRACTURE  OF THE  INFERIOR  MAXILLARY.
  The lower jaw, from its situation, is exposed to injury; and
parts of the bone, which are thinly covered, receive  blows
with full force.   However, the inferior maxillary, in  shape
and mobility, is signally protected against fracture.  A  heavy
blow directly in front, tells powerfully upon the symphysis, as
the bone does not have an opportunity to slide or otherwise
escape the full effect of the stroke;  but a blow upon the side
of the jaw is decomposed by the  lateral  sliding of the  bone.

                         Fig. 17.
Fracture of inferior maxillary bone.
  The  under-jaw is weakest at a point just in front of the
insertion of the masseter muscles; at least, fracture takes
place more frequently there than at any other place.  Direct
violence, as the kick of a horse, is the common cause of a
broken inferior maxilla.  Boyer  maintains that the solution
of continuity never occurs just  at the symphysis.   In two
instances I have seen  fracture in the  median line.  Plenty
of similar cases have  been reported.   In adult  age  the
                          (80) 
The Inferior Maxillary.
81
bone is very strong at the symphysis, yet the frequency of
fracture at that point indicates that the strength of the bone
may be overcome by a powerful blow centrally applied.
   The bone is rarely broken in two places.  A crushing kind
of force, as where the face is run over by a loaded wagon, may
inflict a  double fracture.  The neck of the condyle is rather
slender, and,  in  a divided  muscular action, in conjunction
with a complication of forces  acting in a fall,  it may  be
broken.   The coronoid  process is so well protected  by the
zygoma and thick muscles, that a fracture of it must be exceed-
ingly rare.  The ramus  may  be separated from the body of
the bone  at the angle, or a little above.
   Fracture of the lower jaw may  be simple, compound, com-
minuted and complicated—the nature ofthe injury depending
much upon  the violence sustained.   A segment of the alveolar
arch, taking with it several  teeth, is occasionally detached.   In
such cases,  the gums and mucous membranes of  the  mouth
are lacerated.
   Bonn gives  an account  of a fracture in combination with
dislocation of the lowrer jaw.  The same force in one direction
did not occasion the double injury, but a series of forces acting
at different times and in different directions, as when a man,
in falling from a high building, strikes  a scaffolding on his
way  down, and  receives  one  kind of  injury,   then   -as
he reaches the ground covered with  rubbish, sustains another
kind of hurt or a multiplicity of injuries.  It would be diffi-
cult to account for certain complicated injuries, except on the
theory of the action of a variety of  forces.
  A jaw that has been weakened by ulceration around dis-
eased fangs  of teeth, may break under the force a  dentist  im-
parts in the act of extracting  a  neighboring tooth.   I once
saw a jaw that had been broken while a dentist was extracting
the lower teeth to prepare the mouth for an artificial set.  The
bone was  carious at the point  of fracture ; and had been thus
rendered  by an  old fang that was completely hidden  by the
over-growing gum.  Suspecting a diseased state of the bone,
for the dentist assured me that he used  only moderate force,
I explored the fractured  ends with  a slender dental  instru-
ment, and discovered and dislodged  the old fang.   Suppura-
tion kept  up for three or four  weeks, and then the fragments
united as in an ordinary fracture of  the jaw.
       6 
82
Fractures.
  Muscular action has been known to produce fracture of the
neck of the condyle.  Professor #Joseph Pancoast once met
such a case in the Jefferson College Clinic.  An old man suf-
fered the lesion while in a paroxysm  of violent coughing.
  Mr.  Holmes, of  London,  exhibited  to  the Pathological
Society a specimen of a fractured portion of the neck of the
lower jaw driven into the meatus auditorius  externus.  Vio-
lence  producing  fracture of the inferior  maxillary, may be
sufficient to crush the  bones of the- face, and  to  injure the
brain.
  In most of the  instances coming under my  observation, the
direction of the fracture has been  more transverse than ob-
lique.  This has not always been the experience of other ob-
servers.   Reports of a great variety of cases show that the
course of the fracture in this bone may be  similar  to that in
the long bones.
  When fracture  occurs in the body of the jawr the symptoms
are plain, and  distinctly indicate the nature  of  the injury.
There is mobility of the parts, crepitus, and irregularity in the
line of the teeth ; the gums are torn  and bleeding, the mouth
is  usually  partly open, the  saliva  dribbles  away, and the
patient, in making  known his wants and sufferings, utters
words without allowing much motion  of  the mouth.  One
fragment rarely takes the same line as the other, but there is
apt to be a rocking of the  short piece, and a displacement
above or below the long fragment, or overlapping  as in frac-
tures of the long bones.
  When fracture occurs in the. ramus, or about the neck, or
coronoid process ofthe bone, the displacement is either incon-
siderable,  or in such a situation as to be  recognized with some
difficulty.  The pain at the point of injury, the mobility, and
crepitus,  are signs that might be expected, and when the latter
can be heard or felt, it is not  to be mistaken.
  Sometimes the bone is splintered  at the time of the frac-
ture, or a  small  portion becomes carious afterwards, causing
exfoliation to take place before the part will unite.   Abscesses
forming in connection with these cases are often very tedious
and difficult to cure.
  The tearing ofthe gum, a frequent complication in fracture
of the lower jaw, is not to be considered fully in the light of
a " compound " injury, for the laceration is within the mouth, 
                 The Inferior Maxillary.               83

so  that the  healing process is not much prolonged  by the
wound in the soft.tissues.
   The reduction of  fractures of the inferior  maxillary is not
generally attended with  serious obstacles.  Manipulation of
the  broken  parts is most  conveniently conducted while the
patient is sitting on a stool or low chair, and the  operator is
seated behind him.  Then the surgeon with the patient's head
leaning against  his breast, can with  his thumbs and fingers
press the displaced  fragments into  line.  Any loosened tooth
had better be removed, lest it interfere with perfect apposition
of the fragments, and the healing process.
   The surgeon, leaning over the  patient, as indicated, has a
good opportunity to feel any irregularities  along the base of
the  bone, or want of harmony  in  the dental arches and
planes.  If the surgeon is unable to adjust the  fragments  by
sitting behind the patient, he can have an assistant take his
place to  support and  steady the head, while he, standing in
front of the  patient, has a better opportunity to  manipulate
the jaw.
  If a tooth  is merely loosened, and is not in danger of getting
oetween the  fragments, or of interfering with the healing pro-
cess, an attempt may be made to save  it.  Having had  some
trouble with  a loose tooth I tried to save in one instance, I am
not  so  " conservative"  in my notions in regard to saving
teeth as were my early teachers.

  Treatment.—The common method  of treating fracture of
the  inferior  maxillary, is to fix the lower jaw firmly against
the upper, either directly, or by placing two pieces of cork be-
tween the teeth,  and then applying a  bandage  tightly under
the chin and over the top of the head.  The dressing is to  be
kept on for four or five weeks.  During this time the patient
must live  on  liquid food, or such  as he can  swallow without
mastication.   It is quite desirable that the nourishment should
be rich and stimulating, therefore beef, mutton, and chicken
broths, in which bread is soaked or softened, should constitute
a part of the patient's diet.
  The variety of "splints" and  dressings  devised  to  treat
fracture of the inferior maxillary, is  greater than necessary.
In  hospitals  where gutta percha and other  splint-material is
at hand, such substances seem  very satisfactory for moulding 
84
Fractures.
A piece of pnsteboard, split at each
 end toward the middle, to be
     folded to fit the chin.
Fig. 19.
purposes.  However, it is my design not to give undue prom-
inence to means and methods only practicable in public insti-
tutions, or in large  cities where almost any mechanical con-
trivance can be  obtained  at short notice;  but to make  such
                              suggestions  and give such  di-
 ___________^ '   _________   rections as may enable a prac-
                              titioner in  a  rural  district to
                              fix  up his  case  satisfactorily^
                              with  materials  at  command.
                              A  p^ece of pasteboard  about
                              eight inches long, and four or
                              five broad, may be taken  and
                              split up  the middle from each
                              end to within an inch of the
                              centre.  The material is then
                              to  be dipped  in warm water,
                              to make it soft and pliable, and
                              folded,  as   indicated in  the
                              wood-cut.   The  splint  thus
                              moulded can be applied to the
                              chin; and by a  little manipu-
                              lation, it maybe made to adapt
                              itself closely to the  part, so it
                              shall  give  equal and uniform
                              support.' It may be retained
                              in  place by a four-tailed ban-
                              dage, or  a roller  carried  in
                              front of the chin, and around
                              the base of the head below the
                              ear, then across the top of the
                              head obliquely, and  under the
                              chin and over the head a2:ain,
                              as  depicted in the  wood-cut.
                              At the points  where  the turns
                              of  the   bandage  cross  each
                              other, pins  should  be used to
keep the dressing from slipping out  of place.  Gutta percha,
cut like the pasteboard, and soaked in very hot water to make
it  pliable, may be used  in  the way just  described. A firm
piece of sole leather  answers an excellent purpose.  Tough
bark is not without its desirable qualities in treating fracture
Pasteboard folded ready to be applied
         to the chin.
Fig. 20.
Pasteboard applied to chin, and held
     in place by a bandage. 
The Inferior Maxillary.              85
of the inferior maxillary when other means  can not be com-
manded.
  The emploj'ment of silver  wire as a ligature to fasten
together contiguous teeth on each side of the  fracture, is the
most reliable and satisfactory means of holding the fragments
adj usted.   A strong silk or hempen cord will  do in place  of
the-  silver  wire.  Even an iron wire may be used in case no
silver  wire is  at  hand.   In  one  instance coming to my
knowledge, a piece of tough  iron wire was used to twist
together adjoining teeth in fragments of the under jaw, and
it held its place for three wreeks.  At the end of that time no
further retentive means were needed.
  If silver wire be  used, a large size, ordinarily employed for
sutures, should be selected.  There  is generally space  enough
between the teeth, near the gum, for one  end of the  wire  to
pass readily.   A piece from twelve to fifteen inches in  length
is long enough.   After one end is carried through to the mid-
dle of  the ligature, it may be bent, and pushed back  out  of
                             the  mouth between  the two
                             teeth nearest the  other frag-
                             ment.   Then,  with the  two
                             ends of the wire in his  hands,
                             the surgeon can draw the pieces
                             of bone together and hold them
                             in apposition, by twisting the
                             ends   of  the  wire  ligature
                             around each  other.   After a
                             secure fastening  is made  in
                             this way, the free ends of wire
                             may be cut with scissors, down
                             to the twist. Finally, the rough
                             end  of the fastening may be
                             bent  with forceps,  and  thus
                             kept from  jagging  the lip.
Forceps  may be  employed with advantage  in carrying the
wire, between the teeth.
  A silk or hempen thread may be passed between the teeth
by the aid of a short needle.  The  wire may be carried twice
around the necks of adjoining teeth, with the view of greater
strength and security, but a single ligature is generally better
than two.
Silver wire passed around two teeth
 adjacent to fracture of jaw, and
     ready to be twisted. 
86                      Fractures.
   If the tooth next the fracture be loose, or missing, the liga-
ture may be made to surround the next in the row.
   Where no teeth exist, the fragments may be perforated  on
each side of the fracture, and a silver wire  ligature employed
to fasten the pieces of  bone together.
   1 have had such  excellent success in ligaturing  the  teeth,
and the results have been so  satisfactory, that I feel  like be-
stowing great praise upon this plan of joining the  fragments
in the treatment  of fractures  of the lower jaw.   It permits
free  movements of the mouth, although mastication is not to
be admitted.   If the patient can not  be  trusted to keep the
jaw pretty quiet after the teeth are wired together, it will  be
best to finish the dressing with the pasteboard cap for the chin,
and the roller  to keep it in place.
   Ivory and metallic clamps to fit the chin, and others to be-
stride the alveolar arch, have been  employed with  success.
Perhaps  there may be instances where it is impracticable
to use the wire suture; and  a chin  or clamp dressing is the
only means left which can be employed.  However, the paste-
board, gutta percha, or leather  chin-piece,  is never beyond
reach.
  I have seen  cases where all means, except the wire ligature
around the teeth, have  failed to keep the fragments in apposi-
tion and  at rest.
  Fractures through the ramus,  neck of the condyle, or coro-
noid process, can  not,  of course, be  treated with  the  silver
wire ligature.  In  such cases the chin dressing, with bandages,
constitutes the only means that  contribute  to the  support of
the broken parts.  Such fractures are beyond reach, and  the
fragments continue under the control of  the masseter and
pterygoid muscles.  The coronoid process, as has been stated,
is rarely broken  ; and even  when fractured, the temporal mus-
cle, on account  of the  great extent of its insertion, does not
generally displace the fragment.
  Delayed union and false-joint  are occasional defects the sur-
geon has to encounter in the management of fractures of the
lower jaw.  One of the alleged reasons for these defects is
that the saliva may have free  access  to the broken surfaces,
dissolving and washing away the reparative material;  but a
more acceptable explanation  is that the inferior maxillary is
to spme extent, a floating bone, subject to motion at every act 
The Inferior Maxillary.
87
 of speaking or swallowing.  Want of steadiness in Iroken
 bones always delays union, or altogether prevents that result.
 In one of my cases, complete consolidation did not take place
 for over a year from the reception of the fracture.  The mo-
 bility during the later period of the consolidating process, was
 very slight, and did not inconvenience  the patient.  The frac-
 ture was through the symphysis,  and the accompanying inju-
 ries were so severe that there was little hope of a recovery for
 several weeks.
   Allusion  has been made to the use of corks between the
 teeth.  These when used are designed to keep the jaws apart
 so that food can be taken.   The corks should be wedge-shaped,
 and channeled above and below for the reception of the teeth.
 There are objections to any material used in this  way.  Even
 the gutta percha wedges recommended by Hamilton impart an
 unpleasant flavor to the mouth as long as they are worn.  In
 one  instance, where the teeth were too closely  set to allow  of
 nutrient fluids to be easily sucked between them, I used leaden
 wedges, channeled for  the teeth, and  curved to correspond
 with  the arches of the jaws.  I was well pleased  with the part
 they served.  These interdental splints are not needed in cases
 treated by fastening the fragments together with silver wire
 inserted between the teeth.
   In the event of double fracture, a segment  of one side  of
 the jaw being detached,  it  may be difficult to use the wire far
 back in the mouth. However, if the  front end of  the de-
 tached piece of bone can be secured by suture to the long and
 more stable fragment, the result will generally be more satis-
 factory  than when treated with chin splints and bandages.
   When fracture of the  jaw is left untreated  during the pe-
 riod of  union, the fragments do  not rest  accurately in appo-
 sition, but sufficient displacement  exists  along the  dental
 arches to render  mastication  unpleasant.  Afterwards the
 surfaces  of  the  teeth wear unevenly,  and  become liable  to
 early decay.  Considering how easy it  is to diagnose fracture
ofthe inferioj- maxillary, it seems strange that so many cases
are overlooked, and allowed to pass without treatment. 
          CHAPTER   XV.

FRACTURE  OF THE  HYOID  BONE, ETC.
  The os hyoides is exposed not rarely to one kind of violence,
viz., the grip of an antagonist.  Other  causes might be enu-
merated, but the one mentioned breaks the hyoid bone more
frequently than all others together.  The shape ofthe bone is
such that the thumb on one side of the throat and the fingers
on the other, tend to force the two great cornua towards each
other.  The fracture may take place through the body of the
bone, or, as is oftener the case, through  one of the branches.
  While the head is bent forward, the hyoid bone is protected
by the under jaw; with the head thrown back, the  bone be-
comes exposed to blows, and other kinds of violence.   Ollivier
reports that a woman, fifty-six years of age, made a false step
and fell, her head being thrown forcibly backwards.   She re-
ceived, from muscular action, a fracture of  the greater  cornu
of the hyoid; and heard a distinct crack at the  upper part of
the left side of the neck, at the moment she fell. Dr.  P. G.
Fore, of Cincinnati, had a case, which was sustained by  a
direct blow, received in falling down stairs, a projecting brick
inflicting the injury.
  The signs  of  fracture of the  hyoid are generally well
marked.   The snap is audible, and quite often  heard by the
patient;  the pain, coming  on immediately, is severe, and is
quickly followed by notable external swelling ;  discoloration,
the result of ecchymosis, appears sooner  or later;  and the
patient can not speak or swallow without occasioning distress.
Crepitation can  not always be elicited, owing in part to the
displacement, and in part to the difficulty of manipulating the
fragments. The finger carried back along the floor  of the
mouth to the root of the tongue, may discover the rough ends
of the fragments.  The treatment consists more in combatting
                          (88) 
The Hyoid Bone.
89
 inflammation, and enjoining a quiet, easy position, than in any
 kind of retentive dressing.
   In the event of displacement, the  finger of one  hand is
 passed into the throat, and the other hand, externally, assists
 in adjusting the pieces.  Once in place, the fragments are not
 generally drawn  out of position, especially if the head be kept
 inclined forward, aud in a state of repose.   The patient may
 have to be fed through a tube for a few  days.  The recovery
 is generally complete in  four  or five  weeks.  Dr. George
 Harley, in Holmes' System of Surgery, reports a case of frac-
 ture of the hyoid bone, which illustrates the peculiarity of the
 symptoms, and refers to a bandage employed in the treatment.
 " On the 28th of March, 1856, a little  girl, aged  six  years,
 while jumping, fell with her neck across the rail  of an iron
 bedstead.  She was instantly seized  with  a fit of coughing,
 great dyspnoea, an inclination to vomit, and a copious flow of
 saliva.  The saliva  was  partly  tinged  with blood.  When
 brought to us, which was almost immediately after the receipt
 ofthe injury,  there was distressing difficulty of breathing, the
 face was of a livid blackness, and  there  were all the other
 symptoms of impending death by apncea.  On examining the
 neck, there was  found a sharp  body projecting beneath the
 skin.  It was  very angular and quite moveable.   Oi\ close in-
 spection it was found to be the displaced ends of the fractured
 hyoid bone.  One end of the body rode  over the  other.  By
 a little manipulation the  fracture was  reduced, and all the
 symptoms of impending suffocation, together with the copious
 flow of saliva, etc., rapidly subsided.   A bandage was placed
 around  the neck  to keep the ends of the bone in their place;
 and  with the exception  of a smart attack of fever, which
 lasted three days, the child made an uninterrupted recovery,
 and without any  deformity, except a slight fullness caused by
 the callus ; but even this after a time disappeared."
  In the case just cited, the fragments nearly perforated the
 skin ; in some cases the sharp ends puncture the mucous mem-
 brane ofthe pharynx, pricking and irritating to an intolerable
 degree.   Proper reduction consists in replacing the fragments
 so the ends shall be at  a  distance from sensitive parts.  A
handkerchief tied snugly around the neck  would steady the
muscles, and prevent, in some measure, the  recurring inclina-
tion to swallow. 
90
Fractures.
FRACTURE  OF  THE  LARYNGEAL  CARTILAGES.

  The cartilages of the larynx are sometimes broken, the re-
sult of a blow or fall upon the front  of the  neck, or' from  a
forcible squeeze of the throat.  M. Ladoz has  no doubt this
fracture is produced exclusively by violence inflicted with the
hands and nails.  Plenck has seen a case in which the thyroid
and cricoid  cartilages were both broken by  a fall against the
edge of a bucket.  Dr. Frank Hamilton reports a case arising
from the kick of a horse.
  Injuries of this kind are extremely  dangerous to life, in con-
sequence of impediments to  respiration, either immediately
after the injury, from displacements, and  effusion  of blood ;
or, subsequently, from emphysema, and cedematous infiltration.
The neck has a swollen and distorted appearance, the voice  is
altered or entirely lost, and the act of swallowing is attended
with difficulty.  Cough supervenes, and the respiration becomes
changed to a disagreeable whistling or crowing.  The emphy-
sema, by becoming general, is a serious complication, though
the greatest danger is from rapidly approaching suffocation.
  An  attempt should be made to overcome  the occlusion of
the glottis, by cutting down upon the  larynx, and even into it,
that  the infiltrated and cedematous  tissues  may be relieved,
and the fragments of cartilage pushed into place.
  A grooved  director or  small elevator, entered through  a
lacerated or artificial opening, is a serviceable  instrument to
raise and to adjust  fragments.  The  emphysema, if confined
to regions around the  injury,  is nearly harmless, and may be
let alone.  Punctures to  relieve the infiltrated areolar spaces,
will do some harm and no good.  The introduction of a laryn-
geal  tube, to breathe through, might  be  of service in cases
where suffocation was imminent.  Evaporating and anodyne
lotions would be indicated to  subdue  or hold in check a  high
grade of inflammation. 
CHAPTER  XVI.
FRACTURE  OF  THE VERTEBRAE.
  Severe injuries and displacements of the bones of the back,
are generally complicated, fracture and dislocation being liable
to occur at the  same time.  It seldom happens, from the me-
chanism of the  vertebral column, that a simple fracture or
dislocation occurs as a distinct and uncomplicated lesion.  In
the cervical and lumbar regions, where motion is not restrained'
by the vertical articular surfaces, dislocation can occur without
the absolute necessity of  a fracture;  but in the dorsal  region,
where the processes overlap,  and are closely locked, simple
dislocation seems impossible.
  In the management of injuries about the  extremities, it is
exceedingly important to draw nice distinctions between frac-
tures  and dislocations, that the proper treatment for each may
be applied understaudingly ; but in grave injuries of the back,
the breaking of  the tip end of a spinous or transverse  process
is not the serious part of the trouble.  If dislocation exist, the
displacement is to be  overcome, but the  gravity of the  case
depends upon the condition ofthe spinal cord.  That delicate
and important organ  is liable  to be compressed by the dis-
placement of vertebrae; and the reduction of the bones is more
to give relief to  the cord than to get rid of a deformity.
  Fractures  of the vertebral bones  coming from direct vio-
lence, arise mostly from blows; but they result from indirect
violence, as when a man,  in falling from a height, strikes upon
the head or upon the nates.   The parts hitting the earth may
escape with  bruises, yet the force is continued upward, and
breaks some of the vertebral bones.
  The throat, chest and abdomen protect from direct violence
the vertebral chain of bones in front, therefore the force must
come  from the  rear,  or  from above  while the body  is bent
                         (91) 
92
Fractures.
 forwards.  A miller's carman, standing in his wagon, was  re-
 ceiving into  it heavy sacks of corn, let  down by ropes  from
 the high story of a grocery ; one of the sacks slipped, and in its
 descent, struck the neck and shoulders of the workman. The
 force fractured the spinal coluniu at the  fifth  dorsal vertebra.
   A heavy force, striking the back, making it suddenly bend
 beyond its ordinary incurvation, is very likely to wedge  off
 some of the  processes.  In the dorsal region  the  imbrication
 or overlapping is so considerable that not much flexibility ex-
 ists, but in the cervical and lumbar regions,  there may be a
 good degree  of incurvation without fracture.

   Effect  of Fracture upon the Spinal Cord. — A fracture
 of the vertebral column at any point between the  occiput and
 the  third  lumbar vertebra, where  the  cauda  equina  begins,
 generally inflicts injury upon the spinal cord ;  and  all the body
.below the fracture at once loses, more or less completely, both
 motive power and sensation.  The  great nerve center, being
 impinged  upon, or compressed,' loses its functions, and the
 parts  depending upon it for  nerve  supplies, are paralyzed.
 The higher in the column the fracture occurs, the  greater the
 part of the body affected—in other words, the graver the con-
 sequences.  The fracture  of a cervical vertebra makes the case
 extremely dangerous, owing to effects  upon  the  spinal cord
 high up, where the respiratory nerves arise.
   The  length  of time  a patient will sometimes live after a
 fracture ofthe vertebral column, with all the distressing  afflic-
 tions of paralysis, is quite astonishing.  Persons have lived
 thirty years  under such  unfortunate circumstances.   Even
 with the fourth cervical vertebra broken, a patient has  lived
 more than a year. Mr. Page reports  the case  of a Scotch
 gentleman, twenty-six  years of age, the heir to  extensive
 landed property, who, while running on  the edge  of a terrace,
 accidentally  fell upon a hard road beneath, a  height of ten or
 twelve feet, and injured his neck.   From that moment  every
 part of the body, with the exception of the  head, was com-
 pletely paralyzed, the power of rotating the  head  being  all
 that remained to him.
   When a man has the  spinal  cord crushed  or torn, so low
 down that respiration  is not materially affected,  it is not the
 direct injury and loss of function in parts below, that destroy 
Of the Vertebra.
93
 life.   If the circumstances be favorable the fracture will con-
 solidate and prevent motion dangerous to the cord if that  re-
 main intact; the parts paralyzed may become atrophied, but
 that does not prevent vital  continuance.  However, there are
 formidable causes which, sooner or later, exhaust the  strength
 of the patient.  Bed-sores on the hips, coupled with disorders
 of the urinaiy organs, by combined influences, at length  make
 life succumb.  A  remarkable feature of the sores is that they
 form and extend with unusual rapidity.  In a few days, before
 nurse or friends suspect any difficulty of the kind, large sloughs
 have  separated  from the  regions  of the sacrum and  hips.
 The patient, feeling no pain in  the region, does not ask  to be
 turned iu bed, hence the prolonged  pressure and irritation
 upon one spot, which result in  disorganization of the tissues
 involved.
   Owing to the bladder being deprived of sensation,  a condi-
 tion which frequently results in over-distension of that viscus,
 and which calls for the repeated use of  catheters, derange-
 ments of the mucous lining of the  urinary tracks begin, and
 continue with varying phases till the  gravest  effects are im-
 pressed upon the system already weakened or  seriously im-
 paired from  other causes.
   In simple fracture of the  spinous, transverse, and articular
 processes, as pictured in surgical works, the lesion does not
• generally appear formidable, but when the bodies of  the ver-
 tebrae and the walls of the spinal canal, are broken, the pro-
 longed and deplorable results tax the patience of friends and
 the ingenuity of the surgeon.

   Treatment.—A patient with suspected fracture of the ver-
 tebrae  should be taken home in  an easy horizontal position, on
 a door or shutter; and, after his clothes are cut from him, he
 should be laid on a mattress.  The  surgeon should  see that
 extension and  such manipulation be  employed as shall  favor
 the return of  any displaced fragments to their  places.  A
 slight change of posture may be all that is  needed to correct
 a marked deformity.
   Sand-bags should be prepared at once, and so employed as
 to  sustain the  attitude  thought to  be the most desirable.
 Common feather pillows answer a good purpose in- bolstering
 up the head and shoulders, but the hips should be propped up 
94
Fractures.
with  something more substantial.  Sand-bags will be  found
useful in every case, though the service of air and water-pillows
is needed for parts inclined to slough.  A piece of buckskin
next to the integument is better than lint or other fine tex-
tures.   In the event of sloughing, the use of carbolic acid to
the raw surface  is  excellent.  The agent  corrects fetor, and
hardens the tissues to which it is applied.
   It is  still a question whether any operative  measures are
ever justifiable, undertaken to relieve compression ofthe cord.
The trephine has been  employed with success in a few in-
stances, though there seems to be no definite indication  for its
use.  There is no sign to distinguish between the compression
made by a piece of bone and that  arising from effusions into
the vertebral canal.  The diagnosis depends more  upon infer-
ence than substantial evidence, therefore the operation can
never be performed under well grounded convictions.
   If a surgeon  meets a case in which the indications point
emphatically to an operation, he should not hesitate to execute
what that exceptional case requires.   To be always governed
by general principles deduced from the majority rule, leaving
no latitude  for  exceptions, which may always exist,  would
impose  undue restrictions upon a progressive  science.
   The pain  arising from the fracture of a vertebra and from
compression  of  the  cord,  is generally not severe, therefore
the inexperienced  practitioner may overlook the  injurv.  If
the patient after sustaining an injury of the  back, be  unable
to move the legs, it is wise to look after a lesion of the spinal
cord, and in doing so it is not best to turn and twist the trunk
violently lest an additional injury  be inflicted.
   In some instances it is impossible to determine  dat manipu-
lation whether fracture  exists or not.  During the examina-
tion of a patient having a broken back it is desirable to turn
the body by lifting and pulling upon the sheet which is spread
beneath the trunk.  A rolling motion is thus imparted which
does not disturb injured parts. 
CHAPTER  XVII.
v
FRACTURE OF  THE  RIBS, ETC.
  The length of the  ribs, their  curved shape, together with
their articulation to the sternum  by means of elastic cartilages,
contribute to their power of resisting forces, which otherwise
would be  continually causing fracture of these bones.  Even
as it is, with all  their  advantages for resisting fracture, such
lesions are extremely common, forming about one-tenth of all
fractures.
  The elasticity of the ribs varies greatly with age; the young
rarely suffer from broken rib, while  in elderly people, whose
bones have  become unyielding  and  brittle, the injury is  ex-
ceedingly  frequent.
  The anterior extremities of the ribs being more elastic and
less firmly fixed than  their vertebral ends, fractures of these
bones occur less often in  front ofthe middle than behind that
point.  A rib  may break at  a  point  remote from the part
struck, for it will first bend to a  certain extent, and then yield
at the point where the flexibility ceases.  A given amount of
compressing force applied to the front of the chest of a young
person, makes a rib snap away back near its angle; the same
force, applied to the same spot on the thorax of an old subject,
breaks the bone in its middle or  more anteriorly.
  A direct force against the side ofthe chest, breaks a rib and
carries the  ends of the fragments  inwards, lacerating  the
pleurae and lungs.  A force applied  to  the front of the chest,
renders  the  rib more convex, or hoops it, so that when the
fracture occurs  the ends of the fragments will be  directed
towards the  skin, and away from the viscera of the thorax.
  If a person be thrown forcibly against any projecting point,
like  the corner of  the table, one  rib  is broken;  but  the
kick of a horse, or the crushing force of  a carriage wheel,
                           (95) 
96
Fractures.
generally breaks two or more of the costal bones.^ Several
ribs are broken in severe injuries of the chest.
  The fracture of a rib may be incomplete, the bone being
simply fissured.  In  such cases there would be no displace-
ment, though there might be angular deformity in a percepti-
ble degree.  In complete fracture of the ribs the periosteum

                         Fig. 22.
may not  be torn, giving no opportunity foT displacement or
deformity.   The intercostal muscles assist in steadying the
fragments and in preventing displacement; and the bones are
firmly fixed both in front and behind; consequently there  is
seldom much shortening  or dther displacement.  The ends of
the fragments resting against each other, are moved sufficiently
by active respiration to elicit crepitus.
  In the event of the thorax being caught between two op-
posing forces, and in severe and  complicated accidents, frac-
tures may be produced on both sides of  the chest; though in
the majority of instances, only one side becomes involved.   A
rib may be broken in two or more places, yet the long bones
of the extremities suffer comminuted fracture much more fre-
quently.   The first rib being short, and protected by the clav-
icle, is seldom fractured ; the last two, or floating ribs, on ac-
count of their natural mobility, scarcely offer resistance suffi-
cient for a force to act on them; the ribs most frequently frac-
tured are the upper false, and the lower true, these being the
longest and the most exposed to injury.
   A simple fracture of one or more ribs, uncomplicated with
lesions of the lungs and  other important  structures, is not  a
dangerous injury ; but when the pleurae and pulmonary organs,
to say nothing of the heart and  large  blood vessels, are in- 
Of the Ribs.
97
  volved  in  the  accident, the most serious consequences are to
  be feared.   An analysis of 136 cases admitted into Guy's  Hos-
  pital, during five years ending in I860, exemplifies the relative
  proportion of complicated and uncomplicated fractures ofthe
  ribs; 108 were uncomplicated, of which 8 only had secondary
  inflammation, proving fatal  in  two  instances from previous
  old-standing disease ; 28 were complicated, 16 with emphyse-
,  ma,  of  whom four had symptoms of pneumonia, though all
  recovered, and of the  remaining twelve,  6 died at once  from
  fatal collapse, and 6 recovered.  Of the latter, 3 had haemop-
  tysis and emphysema, and 3 extensive injury  and severe  in-
  flammatory symptoms.
    The  ordinary symptoms of fractured ribs are quite  clear
  and  definable.    The  patient  declares  he  felt something
  break, or give way ; he feels acute pain at the seat of injury ;
  and  complains of a  severe stitch  in the side or catching of
  breath  during a  deep inspiration ;  the  slightest attempt to
  cough disturbs the fracture, and gives rise to the sensation of
  grating; movements of the ribs on the affected side, and even
  on the sound side, on account of the consonance of action, are
  guardedly suppressed, and respiration is carried  on through
  the  movements ofthe diaphragm;  the  arm  on the injured
  side  is held steady and in such a position as to relax the  mus-
  cles extending from that member to the  thorax.   Crepitation
  sometimes results  from the motion of respiration, and can
  generally be produced by manipulating the chest.  The hands
  placed  on  each side  of the supposed seat of fracture, or on
  each side of the chest, and moved alternately, excite sufficient
  motion  to elicit crepitus.   When the fracture is situated very
  far back, it is more difficult to produce crepitation.  The  hand
  placed  upon a point opposite the fracture,  and  made,  by a
  sudden  impulse, to impart motion by indirect force, sometimes
  causes a grating  of  the ends of the  fragments.  The ear
  placed against the seat of injury may detect crepitus, the
  patient  being requested  to cough while the  auscultation is
  made.   Crepitus,  though an essential indication  of fracture,
  is" sometimes wanting, and its absence should not positively
  decide against the possible  existence of such  an injury.  If
  there be spitting of blood, and escape  of  air into the cel-
  lular tissue, the evidence of fracture is quite  convincing, even
  if no crepitus can be discovered.
        7 
98                     Fractures.

  The prognosis  is generally favorable, though of course it
will be modified according to the primary and secondary com-
plications.  In  old  and elderly persons, especially if they be
at the time subject to bronchitis, asthma, or. other forms  of
chronic disease, a guarded  prognosis should  be given, even
if the fracture be  uncomplicated.  Such individuals often suc-
cumb, in the one instance, to shock from  their  low state  of
vitality ;  and in the other, to a  kind of asphyxia from  ina-
bility to free the lungs of the accumulated mucous secretion.
The pleura is very liable to become inflamed, either from the
fractured  ends  rubbing against it, or from a direct wound
caused by a spiculum  of bone lacerating it.   The lungs them-
selves are not unfrequently  wounded, and, as a  consequence,
take on  serious inflammation.  The cavity of the chest, be-
tween the pleurae, may get filled with purulent fluids, and col-
lapse of the lung  result.  The escape of air  from a wound of
the lung, may till the  chest and compress the organ, and  find
its way through rents in the pleurae, to the cellular tissue ex-
ternal to the chest, a fact that may be known by a peculiar
crackling felt when the skin is pressed on.   The emphysema
is at first confined to the side of the chest, and is situated  near
to the fracture; but gradually, as the patient goes on inspir-
ing, fresh supplies of  air escape, until it occupies an.immense
extent of surface, sometimes spreading over the  whole body,
even down to the fingers and toes.   A  moderate  amount  of
emphysema is not especially  dangerous, but when it encroaches
upon the space  needed for the action of the lung, and tills  a
great part of the superficial cellular tissue of the body, the
respiration becomes impeded to  a fearful  extent,  and the
movements of the body, from the  puffy swelling, uncomfort-
ably restrained.
  The intercostal artery, running just within the lower edge of
the rib, is in some danger of being punctured or lacerated by
the sharp end of a broken and depressed bone.   Complicated
accidents of this kind are exceedingly rare, but quite  within
the range of possibilities.

  Treatment.—The  local treatment  consists in keeping the
ribs in as perfect  a state of  rest as possible.  The best plan to
accomplish this object, is to  apply long strips of adhesive  plas-
ter, extending from the spine to the sternum  of the affected 
Of the Ribs.                    99
 side.  Enough strips an inch and a half or two inches wide,
 must be used to cover a space several inches broad, the dis-
 tance  covered depending  upon the number of ribs broken.
 These stay in place better than a bandage, and do not interfere
 with the movements of the sound side of the chest.
   In those cases  where  the  ends of the fragments sink in
 toward the pleura, and compression at two opposite points on
 the chest remote from the injury will pry the pieces of bone
 outwards, (a manoeuvre that is practicable in some, instances,)
 a wide flannel bandage may be used ; also  compresses  at the
 points where the desired leverage can be obtained.  The use
 of  pasteboard and other splint-material to stay the broken ribs
 and to impede the normal motions of the chest, can accomplish
 very little substantial good.
   Some restless patients refuse to  have any dressing applied,
 declaring that they cau not endure the confinement imposed
 upon the  respiratory organs.  In nearly all cases coming under
 my observation and treatment, the restrictions placed upon
 the movements of the ribs by the adhesive strips, have been
 described as  grateful.  The sense of relief, and security against
 irregularity of respiration, have been acknowledged by patients
 thus treated.
  Purulent collections  in  the cavity of the thorax, are, to be
 removed by the use of the trocar, as in ordinary cases of em-
 pyema.  The escape of air into  the cellular  tissue  can not
 always be prevented.  Well adjusted  compresses around the
 thoracic opening, fastened in place with adhesive strips and a
 bandage, may arrest the further issue of air.  In case the em-
 physema become wide-spread  and troublesome,punctures may
 be  made  in  the skin to let the air out.  A compressed lung,
 from the collection of air in the cavity of the pleura, has been
 relieved by an incision made in the intercostal space some dis-
 tance above or below the fracture.
  To dull the acuteness of the pain, and to arrest the inclina-
 tion to cough, the patient should be kept under the influence
 of opiates for several days.  Gelseminum, aconite, veratrum.
 and other vascular and respiratory sedatives may be adminis-
tered to advantage.  Antimony and bloodletting are altogether
too depressing and devitalizing to be employed, though they
still are held  in favor among the advocates of the theory thr,t
inflammation is an exalted state of the vital powers. 
100
Fractures.
  In four or five weeks from the reception of a fractured  rib,
the patient so far recovers that he can attend to his usual avo-
cation, when  all treatment may be suspended.  Usually a large
callus forms at  the seat of fracture.   This excess of reparative
material  is supposed to depend mostly upon  the  constant
motion kept up by respiration.

                          Fig. 23.
Showing bridges of osseous reparative material deposited betweeri
    broken ribs, in the course of the intercostal muscles.
  In some instances the  callus extends  obliquely along the
course of  the intercostal  muscles,  and joins  several  ribs
together with osseous bridges.
  Want of bony union follows fractures of the ribs in a larger
proportion of cases than in other bones.  This defect is pre-
sumed to arise from the impracticability of keeping the frag-
ments  in  a state  of repose.   Fortunately the state of false-
joint is not attended with serious inconveuiences.
  .Necrosis of one  or  the other of the fragments has  been
known to follow fracture and to become a chronic trouble.
At a proper time exsection may be performed to get rid of the
dead bone.
    FRACTURE OF  THE  COSTAL CARTILAGES.

  The sterno-costal cartilages maybe broken by forces similar
to those which fracture  the ribs.  In old age the cartilages
become ossified wholly or in part, so that, by losing their or-
dinary elasticity, they do not escape being fractured.   The
lesion  is so  rare that it  was scarcely mentioned till modern
times.   Magendie having observed five  cases in two years,
wrote a thesis upon the subject;  Malgaigne states that he has 
                                                         • ;nci
                     Of the Sternum.                  101

seen only three cases ; and that at the Hotel Dieu, there  was
but one case in 2328 cases of fracture generally.   He attributes
this paucity to the probable omission  of the lesion in the hos-
pital returns.
   The cartilage of the eighth rib has been most frequently
broken; then, those immediately above it.  One fragment is
liable, to overlap the other, which renders the diagnosis easy,
and the parts may become united in that position.   Osseous
materia] consolidates the fragments.  No subsequent ill effects
are reported.   Though the callus is  bony, the original carti-
laginous condition of the broken parts remains unchanged.
The prognosis, in  cases  uncomplicated with serious  internal
injuries, is favorable.  The diagnosis, unless one piece overlaps
the other, is difficult.  No true crepitus  can be elicited, but
the other symptoms are the same as in fracture of the rib.
   The treatment  consists  in applying adhesive strips,  a foot
or more in length, across the injured spot.   The chest bandage
is not required, though it  may be used to modify the move-
ments of the thorax in case pain is aggravated by the respira-
tory movements.  Malgaigne found the bandage useless, but
succeeded in keeping the fragments in apposition by the use
of a light inguinal truss, with a soft compress.  In twenty days
the union was perfect, no inequality or deformity remaining.


           FRACTURE  OF  THE  STERNUM.

   Crushing injuries that break the ribs and the  vertebrae, are
liable to fracture the sternum.  The bone, by its articulation
with the  clavicles  and the  cartilages of  the .true ribs,  yields
sufficiently to escape fracture from ordinary violence ; hence,
uncomplicated fracture of the sternum is a rare accident,   The
elasticity of the costal cartilages and the ribs, which are like
hoops, deadens the shock and decomposes the force of a blow.
Separation of the manubrium from the gladiolus, is more fre-
quent than true fracture through parts wholly osseous.  In
advanced  age, when the  original parts of the bone are com-
pletely ossified, the point corresponding with the primary divi-
sion between the upper two pieces, proves to be  the  weakest,
At least, fracture generally takes place at that  point.  (Fig.
24.)   The course  of the  fractured  line is across the bone 
102
Fractures.
Fig. 24.
Section of theater
 num, showing
 fracture and
 displacement.
transversely;  and one fragment may be driven in so as to be
overlapped by the other.  There may be perceptible displace-
ment without one piece getting behind the other.
                 The causes of the injury are generally direct
               violence, though persons striking on the back,
               and having the body bend suddenly in a  fall,
               have  sustained  fracture  of  the  sternum.
               Chaussier  reports two cases arising from mus-
               cular action, during parturition.   The females
               were in labor with  a  first child, and threw
               back their heads, curving the body backwards.
               A celebrated vaulter, whilst bending his body
               backwards  in the  feat of  raising  a heavy
               weight with his teeth, broke the sternum.
                 The symptoms are: a sensation of breaking
               or cracking at the time of the accident, inter-
               ference with respiration, and sharp pain at the
               seat of injury.  Crepitation may be produced
               by manipulating the chest, or by movements
               of the body.   The  displacement, when any is
               present, is  decisive in its character, but if the
fibrous  and fascial investments remain untorn, there may be
no overlapping of the fragments.  Swelling and effusions may
obscure the usual diagnostic signs.
  Fracture of the sternum may be complicated with  lacera-
tion of the integuments, and severe  injury of the thoracic
viscera.  The spongy nature  of the internal  structure of the
bone, favors the  formation  of abscess.   The pus, in such a
case, would be more liable to collect or  burrow in the  medi-
astinal space than in the cavities of the pleurae.  Caries is not
uncommon after  fracture  of the sternum; and the pus  and
debris may cause  trouble unless they readily find their way to
the surface.
  Longitudinal fracture of  the sternum  is excessively rare.
A case is quoted by Malgaigne : A mason, aged 60, fell from
a scaffold on  some  large stones, and received a longitudinal
fracture of  the sternum; the left  portion   overlapped  the
right.  Reduction was effected  by drawing  the  arm  to  the
side, and carrying it backwards, then pressing firmly on  the
middle of the right sternal ribs, making alternate movements
from before backwards, so as to disengage the  fragments  ; at 
Of  the Sternum.                  103
the same time gentle pressure was made on the left or riding
portion, so as to keep it on its own level.   After reduction, a
compress  was applied, and maintained by a  firm bandage.
The case was successful at the end of six weeks; no deformity
resulted.

  Treatment.—The plan of treatment to be adopted in frac-
ture of the sternum, is to prevent, as much as possible, motion
taking place between the two portions of  bone, whether they
rest in apposition  or not.   If  one fragment overrides  the
other, moderate efforts should be made to reduce them, which
may be accomplished by manipulating the chest.  But  if re-
duction is impracticable by such means, it is not advisable to
use hooks or elevators to raise the depressed piece.  It is
found by experience that overlapping  does not prevent con-
solidation, or produce serious inconvenience, even if the pieces
of bone unite, with one fragment depressed below the other.
  Adhesive strips, applied vertically and transversely, prevent
motion, and retain the fragments in contact with one another.
A flannel  bandage in some instances where respiration  is at-
tended with pain, may be used  to surround and moderately
compress the chest.  The fabric is more elastic than cotton or
linen, and one fold or turn will not slide upon another.   The
horizontal position, and moderate doses of quieting medicine,
soon put the patient in a state of ease.  Coughing, laughing,
or sneezing, are instinctively avoided by the patient, therefore
protests against such acts are useless.
  Position sometimes affords considerable relief.  A firm pil-
low  or a  large bag of sand placed under the back, to  curve
the  trunk in that direction, puts extension and counter-exten-
sion upon the sternal fragments, favoring reduction, apposi-
tion, and repose of the broken parts.
  Many persons possess such deformities  of the sternum that
the  surgeon called to an  injury of  the central  aspect of the
chest, might, from the distorted appearances, be led to suspect
fracture and displacement when neither existed. 
         CHAPTER  XVIII.
N
     FRACTURE  OF  THE  CLAVICLE.
  The clavicle is exposed to direct and  to  indirect  violence;
and the bone breaks from one influence about as frequently
as it does from the other.  Blows are always diable  to be re-
ceived, and the body is often thrown against  unyielding sub-
stances, hitting the clavicle with direct forces  which result in
fracture.   Falls upon the hand, the elbow, and especially upon
the  shoulder, impart forces sufficient to produce fracture ; the
radius, humerus, and scapula escape by conveying the  shock
or impulse along to the next bone in the order of articulation.
The clavicle being slender  and situated disadvantageously to
take the violence communicated to it, breaks at its weakest
or most severely tested point.
  The two extremities of the bone are stronger than its cen-
tral part, and are connected to' the sternum and scapula by
means of protecting ligaments, which render the ends capable
of offering much more resistance than the middle of the bone,
which has no such support.
  When the fracture is occasioned by a blow, or by the body
coming in contact with some hard substance, it is apt to be
more serious in its nature and consequences, from the contu-
sion and mischief done by the broken ends, than in fractures
coming from indirect violence.  The situation of the fracture
in the majority of instances, is near the centre of  the bone.
When* the fracture is not far from the  extremities, the acci-
dent occurs near  the acromion more frequently than in the
immediate  vicinity of the  sternum.  The  parts  of the bone
between the curves seem to possess the least powers of resist-
ance.   When the clavicle is broken near its middle, (Fig. 25),
or between the middle and the sternum, the inner fragment is
usually retained in its place by the ligaments, and counter-
                        (104) 
Of  the Clavicle.                 105
balanced  muscular action; and  the outer fragment in some
instances is drawn a little downwards, in others it is elevated
above the inner.  If the fracture be outside the middle ofthe

                          Fig. 25.
Fracture of clavicle near the middle of the bone, showing
       overlapping and angular deformity.
bone, the broken ends of both fragments are generally drawn
upwards.  Dr. R. W\ Smith, of Dublin, in his " Treatise on
Fractures  ill  the vicinity of Joints," gives  a description  of
several specimens of fractured clavicle, in all of which the frac-
ture described was within two inches of the acromial extrem-
ity.  According to his illustrations, the broken ends of both
fragments  were drawn upwards, except in one or two instan-
ces where the fracture occurred between the coraco-clavicular
ligaments.   By the  action of the trapezius muscle the frag-
ments were elevated until they formed  nearly a  right angle
with each  other, and large masses of osseous material  (excess
of callus)  were poured  around the seat  of injury, even  con-
necting  the irregular bony  mass with the coracoid process.
The coraco-clavicular ligaments" were  either ruptured  or lost
in the excessive reparative material.
  Fracture of the clavicle occurs at all ages of life ; it is met
in infancy  and extreme  old age, and at  all periods between.
Males are  more  exposed by their  habits and occupations, to
blows, falls, and fatal accidents, therefore they more frequently
suffer fracture of the clavicle than females.
  The fracture may be simple,  compound, comminuted, and
complicated;  it  may be transverse, oblique, or intermediate,
partaking  of  both varieties so far as direction is  concerned.
  The prognosis, so  far as prospects for a good use of the arm
are to be considered, is favorable;  but so far  as  deformity is
concerned, exceedingly unfavorable.   Few fractures  of the
clavicle unite  without more or less displacement,   In most  in-
stances there  is shortening either from  angular deformity or
from overlapping.  This common defect arises from  various
causes.  In some instances  the  dressing is not suitable,  or is 
106
Fractures.
not kept well applied;  in others, the patient, not being much
inconvenienced by the injury, fails to carry out the injunctions
of his  surgical attendant.  It is  needless to enumerate the
causes  of deformity.  The weight of the arm dragging  upon
the shoulder and clavicle, tends to produce  displacement, un-
less the member be well supported.
  The  symptoms of fracture of the  clavicle are  very evident
in the  majority of cases; the  shoulder falls downwards and
forwards, the level of the acromion being much lower  on the
injured than on the sound side.   The shoulder and arm are
nearer  the  chest,  obliterating, apparently, the  axillary space.
One or the  other of the fragments will be unusually prominent
at the seat  of fracture ; and the overlapping and displacement
can be* distinctly seen and  felt.  Crepitus can  generally be
produced by taking  hold  of the  shoulder  and moving it up
and down,  while it is held outwards.  As soon as the arm  is
left unsupported it falls downwards and inwards, producing
the characteristic deformities.  The  patient  experiences great
pain in these forced movements, and in  his own attempts to
move the limb.  He  is unable  to  bring  the hand across the
chest to the opposite shoulder.  The mobility observed at the
point of fracture, when the arm is moved, is quite decisive as
to the nature of the injury.  In most instances the evidence
of fracture is so clear that crepitus need not be sought.   The
appearance of the patient before the clothing  is removed, is
generally such that an experienced surgeon suspects at once
the nature of the injury.   An individual  with a  fractured
clavicle, is  careful to support the elbow of the injured  side in
the hand of the sound side.   This is to take the weight of the
limb from the parts involved in the fracture, and to  keep the
shoulder up in its natural position.  The patient is  generally
conscious of the nature of the injury. He complains of numb-
ness in the fingers, which may be  produced by the pressure of
one  of the fragments  on. the  axillary plexus of nerves.  In
some ca^es the pain is intense and sickening, while in others,
very little distress is  experienced.

  Treatment.—The  numerous contrivances devised and em-
ployed to treat fracture of the clavicle, indicate the difficulties
in carrying out what is. so plainly demanded.  The shoulder
is to be held upwards, outwards and backwards  : to perform 
Of the Clavicle.
107
Fig. 26.
Unsightly d<'l<>nnity following
 badly treated fracture of the
       clavicle.
this simple feat, a dozen kinds  of apparatus are in practical
use ; and all seem to bear evidence of ingenuity.  If a patient
would submit to the confinement of lying on the back in bed
for three or four weeks, the head being fixed on a pillow, and
                        both  arms confined  to the side of
                        the body, no special apparatus need
                        be  used.    Young  ladies,  who^e
                        dresses  expose  the   neck,  and in
                        whom it is particularly desirable to
                        preserve the symmetry of the clavi-
                        cle, may put this plan in  practice.
                        Men  and  boys will  not submit to
                        such  restraints,  therefore   some
                        method of treatment must be adopt-
                        ed to  render them comfortable  dur-
                        ing the healing process, and allow
                        them  out-door exercise.  A moder-
                        ate amount of shortening and nod-
                        ular deformity at the seat  of frac-
ture, is  not often  minded by them, provided  the arm is at
length strong and  useful.
   The dressing of Dr. Fox, introduced in 1828, is  much in
use, and answers a very good purpose.  It consists of a stout
wedge-shaped pad,  the thick end to be  used upwards in the
axilla of the injured side, to serve  as a fulcrum over which
the arm performing the part of a lever is drawn outwards by
other parts of the dressing.  A sling, like.a ripped coat sleeve,
made of strong cloth, extends over the forearm and  elbow,
and has tapes at each end; a stuffed  ring  is slipped on the
sound arm quite over the shoulder.   To this the tapes of the
sling  are  tied, to  lift the shoulder upwards  and outwards.
That the pad in the arm-pit may not escape from its place, its
upper end should have a couple of tapes, one to  tie to the ring
in front, and the other behind the chest.  The accompanying
drawings explain the dressing better than words.   If the sfir-
geon, when  he is first called to  a case, can not wait for the
dressing to be made, he can dress the arm  with  the handker-
chief, and leave directions for the making of the wedge, ring,
and sleeve-sling.  The wedge may be made of strong cloth,
and stuffed with cotton, tow, or hair.   The upper or thick end
should be  packed densely with  the stuffing, that it may fulfill 
108                     Fractures.
Fig. 27.
Front view of
for fracture of
the purpose for which it is designed.  The ring may be stuffed
with cotton, wool, or hair.   The sling needs  no padding, yet
it should be soft and yielding.
                                     Very good results have
                                    been obtained  with the
                                    handkerchief  dressing.
                                    It consists in placing a
                                    long roll of cloth in the
                                    arm-pit  as a  fulcrum,
                                    and  using a  common
                                    cotton  handkerchief as
                                    a sling  to support the
                                    elbow,   and   hold  the
                                    forearm up towards the
                                    opposite shoulder. The
                                    ends of  the  handker-
                                    chief  are to  be tied
                                    around the neck.
                                     Dr. Lewis modified the
                                    dressing  of Fox, using
                                    the  pad and  sling, with
                                    wide straps to  cross the
                                    chest in  front  and be-
                                    hind.  It is not superior
                                    to the Fox dressing.
                                      Some years since, Dr.
                                    Huutoon introduced to
                                    the  notice of the profes-
                                    sion a dressing which
                                    he  called his  " Yoke-
                                    Splint," consisting of a
                                    yoke-shaped  piece  of
                                    wood, hollowed  out  on
                                    the  under surface, so as
                                    to fit the neck and both
                                    shoulders.   The  ends
                                    extend some inches be-
yond  the shoulder; and to  which are attached two stuffed
straps  to pass  through each axilla.   These  straps  can  be
buckled so tightly as to elevate the shoulders, and carry them
outwards and backwards, a handkerchief or other appropriate
Fox's dressing
 the clavicle.
Fig. 23.
Posterior view of " Fox's dressing " for fracture of
            the clavicle. 
Of the 'Clavicle.                 109
sling supports the forearm  .and elbow in front of the chest.
Such an apparatus will do for adults, but is unfit for children.
  Long strips of adhesive plaster, carefully applied, constitute
a good dressing to hold the  arm and shoulder immovable in
young and restless patients.   The first piece is looped  at  one
end around the  upper part of the  arm  on  the injured side,
and  then the rest of the strip extends across  the back,  and
up over  the shoulder ofthe  sound  side, to the  front'aspect of
the thorax, adhering all  the way.  One end  of  the  second
piece of plaster is stuck to   the posterior aspect  of the arm
on the injured  side, and passes over the point of  the  elbow,
ulnar part of forearm, and up across the sound shoulder to
the back where  it firmly adheres.  This adhesive  plaster  roll
is easy to apply, and will  not get  out of place.   If well  put
on it will not have to be removed or renewed during the four
weeks of healing.
  Many years ago  it was customary to place a  pad  in  the
axilla, and then  envelope the  arm, shoulder and chest in a
very long bandage.  This is  now discarded  on  account of its
confining the chest, and  of the difficulty  of  keeping it in
place.
  About a year  ago I adjusted a fractured clavicle with hand-
kerchiefs.  The patient was  an  old German, who received  the
injury by a fall on his shoulder in the street.  .Upon visiting
hirn  the second  day I found the  dressing had been thrown
aside; and learned from the  old man's son that his father had
refused to have anything done in the way of treatment.  The
patient was thin of flesh, so that in the movements of the arm
motion could be distinctly observed between the  fragments.
There was great angular deformity caused by the arm  falling
so low.   No particular pain was complained of.  The patient
used his  hand every day, though very carefully.  I  called once
in a week or so to watch the progress of the healing process
under no treatment.  There  was so much motion between  the
ends of  the fragments, that I was  afraid of non-union.   At
the end  of three weeks from the date of the injury, a  pretty
firm callus had united the  broken  ends, though there was a
salient projection of the fragments  upwards.  In  five  weeks
the patient said he was well  as ever, and claimed credit  for
success in his let-alone treatment. 
✓
       CHAPTER   XIX.

FRACTURE  OF  THE  SCAPULA, ETC.
  The shoulder-blade glides easily and freely in all directions,
therefore it is well  prepared to decompose forces or to yield
sufficiently to  escape fracture.  Resting upon the convexity
of the ribs and  muscular  cushions,  the bone rarely suffers
from  lesions peculiar to more  rigid and unyielding parts of
the skeleton.
  The scapula is deeply covered with muscles, except at points
which project quite prominently.  The spine of the  bone, the
acromion and the coracoid processes,  though subject to mus-
cular  action and  external violence, escape fracture with almost
as much certainty as the blade itself.  Fracture of the body
ofthe scapula occurs in combination with other injuries when
the trunk is severely crushed, as by the fall of a heavyweight
upon  it, or by the force of moving machinery.  A fall back-
ward  upon some projecting point may produce fracture ofthe
blade without the necessity of serious complications.
  The thin plate of bone below the spine may be  broken, the
fracture  being  transverse,  oblique,  irregular, or  stellated.
Motion and crepitus  are the two most important symptoms.
The numerous muscles arising all along  its  flat surfaces, and
crossing  the  line  of fracture,  prevent  much displacement.
Sometimes motion ofthe arm and shoulder will cause crepitus,
which may be felt by laying the hand flat on the dorsum of
the bone  while  it is being so moved.  In muscular and fat
subjects, and where there is little displacement, the  diagnosis
is often attended  with difficulty, but in others the signs  are
quite plain and obvious.  To ascertain if the spine of the bone
be fractured, it will be necessary to press it forcibly  with both
hands while the  patient's arm is carried backwards and for-
wards, to produce crepitus, and to disclose the line of separa-
                           (110) 
Of the Scapula.                  1IJ
 tion.  When  the  fracture extends through  the body of the
 bone,  including the spine, the  course of  the bony solution
 must be disclosed by movements imparted to the fragments,
 using the arm as a lever to incite the motions.   Occasionally
 the body of the scapula is broken into several pieces.   In such
                         instances it is impossible to accurate-
                         ly trace the outlines  of  the frag-
                         ments, or to retain the  fragments in
                         place by any kind of a dressing.

                          Treatment of Fractures through
                         the  Body of  the  Scapula. — The
                         fragments  having been reduced as
                         completely as possible  by manipula-
                         tion, a broad bandage or strip of ad-
                         hesive  plaster  should be  applied
                         around the arm, chest  and shoulder,
                         (including the scapula), so as to hold
                         the broken bone steady in one posi-
                         tion, and prevent  motion between
  Fracture of the wade of the      the  fragments  by a shifting condi-
         scapula.                 t°        J         o
                         tion of the arm.  The  elbow should
 be supported  in a  sling.   Slight deformities from overlapping
 of the fragments,  rarely do any harm. As soon  as consolida-
 tion takes  place, the functions  of the limb are regained by use.
 Rough overlapping and irregular callus may, for a time, im-
 pede the easy action of the muscles, yet these contingent de-
 fects will not be permanent.


     FRACTURE   OF THE  ACROMION  PROCESS.


  The acromion process being the most prominent part of the
 shoulder, is liable to be broken across when a blow is received
 directly from above, in falls upon the shoulder, and also, per-
haps, by upward pressure of the head of the humerus, in falls
upon the elbow or hand.  The most frequent accident to the
acromion, of a fractured nature, is the separation of the epi-
physis  in young subjects.  The accompanying cut illustrates
pretty  nearly the line of separation. In cases of  real fracture,
the process is broken nearer the root tbah the apex.  The ex-
 
112
Fractures.
Fracture of the acromion process.
treme tip may be broken off; and there may be genuine frac-
ture in adults, at the epiphyseal line.
  The most  frequent cause of fracture of the acromion pro-
        Fig.30.          cess, is  by the person falling side-
                        ways  against some  hard  resisting
                        body, so  as  to  strike the  top  of
                        the shoulder as well  as  the  side
                        of it.   Fracture from upward pres-
                        sure of the humerus must be exceed-
                        ingly  rare.  In cases reported, the
                        cause was merely conjectured.  The
                        acromion, in the dry bone, appears
                        weak and  unsupported,  but in its
                        vital state, strengthened with muscles
                        and fibrous bands, and sustained by
                        ligamentous  connections with the
                        humerus and clavicle, to say nothing
                        of its sharing in the  gliding charac-
ter • of the  scapula, it is capable  of offering great resistance,
and generally escapes fracture.
  The symptoms of fracture of the acromion are: dropping
of the shoulder, and inability to raise the arm  outwards, at a
right angle with the trunk.  The  shoulder loses  its salient
prominence, its extremity being sunk.  On passing the fingers
along the  spine  of the scapula,  towards the tip of the acro-
mion, a  sudden depression is felt  at the seat of fracture, and
mobility of the process  itself can be  perceived.   On raising
the arm so  as to bring the fragments in apposition, all the ab-
normal appearances are lost; and crepitus, which is absent  as
long as the arm hangs down, can now be obtained.   " In a fat
person," says Lonsdale, " or where there is  much  swelling
present, the nature of the accident is not  easy to  discover,
owing to the difficulty of feeling the extremity of the process,
and of distinguishing  the exact  point at which the motion
and crepitus  are produced.  I lately saw a case of this kind,
where the patient did not apply for relief for  two  days after
the accident; the whole shoulder  was greatly  swollen, and
it was impossible to say whether any fracture existed, or  in
what situation it might be, if one were present.  As  soon  as
the swelling subsided, however, the acromion was found to be 
Of the  Coracoid Process.
113
fractured, and to be depressed some way below the spine cf
the bone."
  Treatment  of Fracture of the Acromion  Process.—The
principal indication is to support the elbow, so that the acro-
mion may be raised by the head of the humerus:  the hand-
kerchief sling ma}" be made to  do this, care  being taken to
elevate  the  elbow, and to keep the arm  straight across the
front ofthe  chest,   The counterbalancing action ofthe trape-
zius and deltoid  muscles, prevents lateral  displacement.  A
roller of adhesive plaster,  to wind round the neck and under
the elbow and arm, stays in place better than any sling or
common roller dressing.
  The  acromion, when fractured, does not always unite by
bony union.  The cause of this defect is supposed  to depend
upon a want of close contact of the broken ends.  Probably
that has more to do with the lack of  osseous connection than
any peculiarity in the situation of the process.  To avoid non-
union, is to make the head of the humerus hold the extremity
of the  acromion  steadily  upwards.  If the broken  surfaces
can be brought in contact and  held  there, the consolidation
will generally be complete and satisfactory.

     FRACTURE  OF  THE .CORACOID PROCESS.

         Fig. 31.            The coracoid process is short and
                        very strong; it  is  well  protected,
                        and shares  in  the instability of the
                        scapula ;  indirect violence can have
                        but little influence upon it, therefore
                        when broken, the process must be
                        separated by a blow or direct  force
                        of some kind.  The process derives
                        some  support from  the  coraco-cla-
                        vicular ligaments, and is sheltered
                        in its position by the  clavicle and
                        the head of the humerus.
                          When the  coracoid  process  is
                        broken, the nature  of the injury is
 Fracture of the coracoid process.   diSCOvered  by  the  displacement
downwards and forwards.   The separated  process  of bone  is
displaced by the action of the three muscles that are attached
        8
 
114                     Fractures.
to it; motion in the process may be observed  when the arm
is moved in various directions.  Crepitus can not be discovered
unless the arm is so held as to relax the muscles, allowing the
broken surfaces ofthe fragments to come together.  Manipu-
lation may then produce the grating sound.  In injuries about
the shoulder, the diagnosis is often made out by carefully ob-
serving the relative positions of the prominent  points.  The
distance  between the acromion  and  the  coracoid processes,
measured with the fingers and the eye, as compared with that
found in  the sound  shoulder, is quite important in forming  a
conclusion, especially in distinguishing fracture  of the cora-
coid process from fracture of the neck of the scapula.

  Treatment.—A sling for the arm, whether it be a sleeve,  a
handkerchief, or the roller plaster, is the only dressing needed.
This apparatus is designed to support the arm for the purpose
of relaxing the biceps, coraco-brachialis, and pectoralis minor
muscles.  Bandages, compresses, etc., are not required.


  FRACTURE OF THE  NECK  OF  THE SCAPULA.

         Fig. 32.           The accompanying diagram shows
                         pretty  clearly what is meant by
                         fracture of the neck of the scapula ;
                         it  exhibits  the  line   of fracture
                         somewhere  near  its  occurrence,
                         taking with the free and separated
                         piece, the coracoid process and the
                         glenoid cavity and rim, and leaving
                         joined  to the blade  or body of the
                         scapula, the spine of the bone and
                         its terminal acromion process.  If
                         the dried bone be examined, it will
                         be readily seen where this  isthmus
 _,  ,   ,.,    ,  ,,,     ..  or narrowed place is.  The con-
 Fracture of tho neck of the scapula.              J-
                         striction makes the  scapula appear
weak at  that part of the bone, but facts do  not i ushiin this
view in regard to fragility.  There are very few, if any, speci-
mens in  the cabinets of Europe or  America, showing that
this fracture has  occurred.  Several surgeons  competent to
 
Neck of the Scapula.
115
 recognize the injury have met with the fracture in the living
 subject.  Duverney had an opportunity to examine  one case
 in a woman who was killed on the spot  from other injuries;
 he says, " On examining the left arm, I  thought it was  dislo-
 cated ;  I  made  an incision  through the integuments and
 muscles, and opened the capsule ; the head of the  humerus
 occupied the cavity, but I then discovered the fracture of the
 neck of the scapula."
   While a student of medicine, a young  man came to the
 office of my preceptor, for treatment.  The patient had, a few
 minutes before, fallen against a tree and pile of stones,  while
 playing foot-ball.   He supported the arm of the injured side
 with the hand of the sound side, as a person will who  has a
 fracture of the clavicle or dislocation of the shoulder.   After
 removing the  clothiug from  the upper part of the body, I
 thought I recognized a dislocation of the right shoulder, and
 proceeded to reduce it in  the  usual way by manipulation.
 There  was no difficulty in restoring the arm to its natural
 position, but it would not stay there ; the head ofthe humerus
 would immediately, if not   prevented, slide into the axillarv
 space,  leaving a hollow beneath the acromion.  I tried to
 divine  the  cause of this perverse state of things, and conjec-
 tured   that  the  head  of   the  humerus did not slip  back
 through the rent in the capsular ligament, but in some wav
 folded the ligament in front of itself while returning to  the
 joint.   I  was  so certain of this condition that I considered
 the  propriety  of enlarging the rent with the point  of a
 knife carried through the  soft  parts, down to  the capsule.
 Fortunately I  did  not  put  the  rash  thought into execution,
 but began anew to consider  the case.   The arm was not rigid
 as it usually is when the shoulder is dislocated ; but the limb
 had the mobility common to a fracture injury.  Great pain
 attended  the manipulations, and the  tissues about the  joint
 were  soon  swollen so as to render obscure some points  that
 were at first quite prominent.  However, I began to search
 for proofs of a fracture, and  looked at a dried scapula and
 humerus, to  help my diagnostic  powers.  The formation  of
 the neck of the scapula suggested what might be the nature
 of the injury.  I then turned to the patient, and hunted  for
the coracoid process.  I found it held the same relative posi-
tion to the head of  the humerus that  it  normally did, but it 
116
Fractures.
was  a long way too far from the acromion which remained
immovable in its usual place.  I then reduced the head of the
humerus to its normal position beneath  the acromion, and
found that the coracoid process had followed the head of the
humerus,  taking  its place  on the  inside of the joint,  at a
proper distance from the acromion.   To verify the new diag-
nostic conclusion, I moved the shoulder back and forwards,
causing distinct crepitation ; and allowed the displacement to
occur again, in order that I might carefully note the relative
position ofthe coracoid process to the humerus and acromion.
Every point in the diagnosis became so plain that there could
be no mistaking any one of  them.   The neck of the scapula
was broken, and no other injury existed.
  In the treatment I used a firm pad in the axilla, to keep the
head ofthe humerus away from the  chest, and held the elbow
upwards with a sling.  I also fastened the arm to  the  side of
the chest, to obviate motion at the seat of injury.  In four
weeks the dressing was removed, and gentle motion  allowed
to the arm.  The broken surfaces in this kind of fracture are
small, therefore the apposition of fragments ought to be per-
fect, and the motion as  much restrained as possible.   Fox's
dressing for broken clavicles is a desirable appliance for treat-
ing fracture of the cervix scapulae.
  The two strips  of adhesive plaster, each two inches wide
and a yard long, so useful in treating fracture of the clavicle,
are well adapted to retain the shoulder in place while treating
fracture of the scapula of any variety.  A loop a little larger
than the arm is made to encircle the limb near tile  shoulder,
and the rest of the strip crosses the back and passes over the
shoulder to the chest.  This is to hold  the shoulder outward
and backward.   And the other strip, which is made to adhere
to the posterior aspect of the  arm,  the elbow, and  the ulnar
part of the forearm, is to cross the  sound  shoulder and reach
down upon  the back, crossing the  first strip.   It is  well  to
split this second strip where it passes the point of the elbow.
The dressing keeps every part of the arm and shoulder snug
and steady. 
V
CHAPTER  XX.
FRACTURE OF  THE  HUMERUS
Fig. 33.
  Anatomically the humerus is  divided into the head, neck,
tuberosities, shaft,  and  condyles;  surgically,  the bone is
divided into the upper, middle, and lower thirds, and it has a
surgical neck below the tuberosities.  The anatomical neck is
                     marked by a slight constriction between
                     the  round head and the  tuberosities.
                     The  condyles make  up the lower ex-
                     tremities of the bone, including the ar-
                     ticular surfaces, and the lateral projec-
                     tions which can be felt so prominently
                     beneath the skin. The thin crests which
                     extend from the condyles upwards until
                     they are lost  in the shaft of tne bone,
                     are called condyloid ridges.  The shaft
                     of the humerus  extends from the tuber-
                     osities to the condyles.  A deep groove
                     between the tuberosities, is occupied by
                     the  tendon  of  the long  head of  the
                     biceps.  This brief description, together
^^fSuSi^^of^with the accompanying diagram, brings
 Jio^/SiSiiTotSSJSto mind many ofthe peculiarities ofthe
 dvle; 6, external condyle.     ,        i    .n        -.,•     ,,   ,•
  y   '                bone, and will save calling attention
repeatedly to each part involved in fractures of the humerus.
    FRACTURE  AT  THE  ANATOMICAL  NECK.

  Pathological museums and  autopsies furnish  indisputable
evidence of an occasional fracture through the upper extrem-
ity of the humerus, at a point  where the bone is strong and
well protected from external injuries.   The fracture alluded
                           (117) 
118
Fractures.
 to is within the capsular ligament, no  muscles having  any
 connection with the articular fragment.
   The lesion is generally produced by falls, the shoulder com-
 ing in direct and violent contact with the ground or some hard
 substance.  In rare instances the evidence  seems to be that
 great force conveyed upward from the hand and elbow, in falls
 upon those parts, has resulted in separating  the head of the
 humerus from the remainder of the bone.
   In the event of impaction, a  condition in which the end of
 one fragment is driven into the cancellated tissue ofthe other,
 the broken structures lend support to each other, and by their
 intimate relation  favor osseous union of the  fragments.  If
 there be no impaction, the head of the  humerus  is a loose
 piece  of  bone entirely within the capsular  ligament, cut off
 from nutritive supplies, and  free to move in every direction,
 even turning over so as to present its articular  surface to the
 broken end ofthe lower or long fragment.  Cases are reported
 in which the detached head ofthe humerus has become united
 to the shaft  of the  bone in every conceivable attitude.   In
 rare  instances, no consolidation nor union  of any kind has
 taken place between the fragments, but the head of the bone
 has  continued in the joint as a foreign body.
   Bony union is effected in the  majority of cases, yet with an
 excess  of reparative material about the broken end of the
 lower fragment, and with such irregularities  of surface that
 the function of the joint is impaired.
   The symptoms of fracture at the anatomical neck of the
 humerus  are mostly those attendant upon fractures  of other
 bones. Pain, swelling, and  inability to  raise  the hand, are
 common signs ; the flattening of the shoulder, when present,
 may lead to the suspicion that  a dislocation exists, therefore
 the  distinctive features of the two  injuries must be carefully
 compared.  The displacement attendant  upon fracture is easily
 overcome, yet the deformity is at once reproduced  as soon as
 the  limb is left to itself;  a dislocated bone is  not  readily re-
 turned to place, but, having been restored to its normal posi-
 tion, it will stay there.
   After fracture of the anatomical neck  of  the humerus, the
 arm is excessively mobile, and falls or hangs powerless by the
. side of the body; the depression beneath the acromion is not
 so great as in dislocation ; and in rare instances the detached 
Of the Tuberosities.
119
head  of the  humerus can be fixed with the fingers, so that
crepitus can be elicited.   In  dislocation of the  shoulder the
arm is rigid,  with the elbow standing off from the side.
  The treatment for  fracture through the anatomical neck of
the humerus, is quite the same as in. all the fractures that
occur about the shoulder-joint.  The axillary pad as a fulcrum,
the arm as a  lever, and slings to force the displaced parts into
position and  to keep them there, comprise a suitable dressing.
To  prevent motion, the arm should  be bandaged to the side.
The sling  or handkerchief to support the elbow and arm
should not force the humerus powerfully  upwards.  As the
excessive  reparative material sent  out  from the lower  frag-
ment  is sure to impede the movements  and impair the  func-
tions  of the joint, the surgeon should announce in  advance,
to the patient, what may be expected  in  the way of a cure.
Passive motion, begun  about four weeks  after the accident,
may help to restore the usefulness of the joint.
Fig. 34.
         FRACTURE  OF THE  TUBEROSITIES.

   Direct  violence and  muscular action are the only agencies
that separate the tuberosities of the humerus from the body
of the  bone.  Accidents of this  kind are exceedingly rare,
                  and liable to be confounded  with other in-
                  juries about the joint.  In dislocation ofthe
                  head  of the humerus, the  three powerful
                  muscles inserted into the greater tuberosity,
                  may detach the lump of bone to which they
                  are connected.   In the dislocation outwards,
                  the lesser tuberosity may be fractured in the
                  same  way, by the action of the subscapulars.
                    A satisfactory diagnosis could not be made
                  out in such injuries unless the bony tubercles
                  can be moved independently of the remain-
                  der of the bone.  Pain, swelling, and aver-
                  sion to movements of the arm, might cause
                  the surgeon to suspect the existence of frac-
                  ture,  but  the  suspicion would not be well
                  founded  unless the fingers could feel the do-
tached fragment, and make it grate  against the surface from
which it was detached.
Carved splint for the arm,
 and hinged to it a shoul-
 der piece 
120
Fractures.
  The indications in the treatment are to keep the arm and
shoulder at rest  for three or four weeks.   A concave splint
that fits  the shoulder, maybe used to cover the injured re-
gion ; and a sling employed to fasten the arm to the  front of
the chest.
FRACTURE  OF  THE  SURGICAL  NECK OF  THE
                      HUMERUS.

  The constricted portion of the shaft  of the humerus, just
below the tuberosities, is  a common  seat of fracture.   The
line of separation is above the insertion of the pectoralis major
and latissimus dorsi muscles ; and is  usually more transverse
than oblique in direction.  The amount  of displacement is
considerable, but varies in  different cases.  In  characteristic
examples the upper fragment is tilted upwards and  outwards
by the action of the muscles inserted into the greater tuber-
   Fig. 35.      osity, the lower  fragment is  drawn inwards
               towards the axilla, by those inserted into the
              bicipital groove, while the various muscles ex-
              tending from the scapula to the humerus below
              the line of fracture, produce shortening.
                The symptoms are  generally very evident
              and not liable to be mistaken  for dislocation.
               When the  arm is rotated,  the head of the
              humerus  remains motionless  in the glenoid
               cavity.  The mobility  of the shaft or lower
               fragment  is  marked, and crepitus is distinct
               when extension is made, or the broken ends of
              bone are moved  while in apposition.   Frac-
               ture at the line of junction of the  epiphysis,
               in  young  subjects, resembles true fracture
               through  the surgical neck of the bone in old
               subjects.   The only discoverable difference is
               a less marked crepitation in the  cartilaginous
separation.   Fracture  through the surgical  neck of the
humerus, in adults, is generally a half inch or more below the
line where separation of  the epiphysis occurs in the young.
  If the injury be  not seen  until the parts have become ex-
cessively tender, and much swelling has supervened, fracture
through the surgical neck will closely resemble dislocation of
Fracture through the
 surgical neck of the
 humerus. 
Of the  Humerus.
121
Fig. 36.
 the shoulder.  However, in case of doubt and uncertainty, the
 patient may be put under the  influence of chloroform, when
 the nature of the lesion can be determined.  In case of frac-
 ture, the space beneath the acromion will be found filled with,
 the head of the bone ; the humerus will not stay reduced, but
 slide towards the axillary space as sooir as  left to itself; and
 great mobility at the seat  of injury will  be observable.  All
 of these signs present unequivocal  evidence of the  existence
 of fracture.
   From a consideration of the anatomy  of  the region,  it
 would seem that a fracture through the surgical neck of the
 bone could not take place without marked displacement and
 deformity.  In a small proportion of instances, however, there
                          is no perceptible disjunction of the
                          fragments, a  state  of  apposition
                          which is probably favored by the
                          interlocking  of  serrations in the
                          broken ends, and by the restraining
                          influence of the tendon ofthe long
                          head of  the biceps.  ' Malgaigne
                          rarely  met   with   displacement,
                          though  in  this  he  differs widely
                          from other experienced observers.

                           Treatment.—It is not  always easy
                          to reduce the fragments to a state
ASTa!e™^             of Perfect apposition, owing to the
 SSg^'ti^iffiSnW^tSfflS shortness of  the upper fragment,
 fracturesof upper end of humerus.   ^  ^ ^^ ^.^ q£ ^ mug_
cles attached to the two fragments.   Extension and manipula-
tion, aided when necessary by the relaxing effects of chloro-
form, will generally restore the broken ends to their proper
places.   A roller bandage may  be used to envelope the limb
from the fingers to the shoulder, to restrain muscular twitch-
ings  and to  prevent congestion and swelling, yet this is not
absolutely necessary.   The primary bandage, as this is some-
times called,  is going more and more out of use.  A concave
shoulder splint, made  of leather, gutta percha, carved wood
with a hinge, or woven wire bent and soldered to fit the parts,
is quite essential for the outside of  the  limb.   Two or three
short board splints may be padded and laid on the  inside  of
 
122
Fractures.
the arm, reaching from the axilla to near the condyles.   These.
including the one that caps the shoulder,  may be fastened in
their places  with tapes, or bandages.  A firm compress is
placed in the axilla,  to prevent  the upper extremity of the
long fragment from inclining too much inwards, and a band-
age fastens the elbow to the side of the body.   The weight
of the arm is to be left free  to act as extending force.  A
handkerchief dropped from the neck is always convenient for
the hand to rest in.  No sling should be employed to support
the elbow or weight of the arm.
  It must be borne in mind  that  ordinary dressings for  frac-
tures through the middle third of the shaft of the humerus,
and which reach only about  as high as the seat of the injury,
are not efficacious in  restraining motion  between the frag-
ments.  Such dressings get no hold  upon the  upper fragment
and the scapula, therefore they can not steady the parts and
prevent mobility.
  There is some danger of false-joint, especially if motion  at
the line of separation be not thoroughly restrained.   It is
found that a fracture through the  surgical neck of the hume-
rus, does not become consolidated as soon as fractures lower
down in the bone.   The delay may be charged to the  mobil-
ity, for the more  quiet the fragments the sooner is the healing
process  accomplished.

FRACTURES OF THE SHAFT  OF THE  HUMERUS.

  All fractures occurring between the surgical  neck of the
humerus and the condyles of the bone, are commonly spoken
of as fractures of the shaft of the os humeri.  Such lesions
are extremely easy to recognize, and are not  usually difficult
to treat.   There is no  joint near to mask the injury, nor  com-
panion bone,  as in the fore-arm and leg, to obscure the diag-
nosis, or to modify the treatment.
  Fractures of the shaft arise from direct and indirect forces ;
a direct force usually comes in the shape of a blow, or a fall
upon some hard substance; the indirect acts upon a part of
the bone remote from  the point struck, as when  a person falls
with the  arm extended from  the body, the elbow being the
part that receives the  shock, but  the  shaft of the humerus,
several inches from the point hit, may be  the part to yield. 
Of the Humerus.                 128
Fig. 37.
Fracture  of the shaft of the ^  |i  V.Pi110.  vpymT-rorl
 humerus between the inser- Staniiy Deillg  leporteO.
Direct violence, besides breaking the bone, commonly inflicts
more or less injury to the soft parts, which is manifest in the
bruising, discoloration,  and ecchymosis;  the indirect  force
                    seldom produces much disturbance to the
                    tissues in  the  vicinity of the  fracture,
                    though at the point receiving the shock,
                    there maybe serious contusions.  Muscu-
                    lar  action is often sufficient to fracture
                    the humerus.  I once treated a lad's arm
                    which  was broken while  in  the  act  of
                    throwing a stone.  The patient heard the
                    bone  " snap like the break of  a dry
                    stick," and his arm fell powerless  to his
                    side.  The fracture was near the junction
                    of the lower with the middle third of the
                    bone.   Fractures from  muscular, action
                    are not uncommon ;  cases happening  in
                    different parts of the country  are con-
                                            in the medical
 and thetddtPoeidtSJSscie™a,ior journals.  It may be remarked that there
                    is no particular point in the shaft  of the
humerus that gives way to muscular force, for reported cases
show that  fractures from such causes occur at any point ex-
cept through the articulating extremities.
  The  displacement following fracture of the shaft of the
humerus, is not always appreciable, for the fractured surfaces
may remain in contact, the serrations so interlocking as not
to be easily moved from their apposition.  In most instances,
however, the contact is lost, and the. muscles draw the frag-
ments past  one another.   In some instances the angular de-
formity is great when there is no shortening; and the defect
produced by rotating one fragment upon the other, may cause
a more  marked and  awkward defect than either of the distor-
tions just mentioned.
  The distinctions between fractures above and fractures below
the insertions of certain muscles, so far  as the deformity is
concerned, are of not much practical importance.  The  diag-
nosis is  extremely easy whether "the line of separation is trans-
verse or  oblique, or the broken  end of the lower fragment
rests upon the inside or the outside  of the other, in the over-
lapping. 
124
* RACTURES.
Fig. 38.
  Treatment.— The fragments having  been adjusted,  foui
small, straight, well-padded wooden splints should be applied,
one on each side of the arm, extending several inches above
and below the seat of fracture, and retained in place by means
of tapes tied  around all.   Over  the  whole, including arm,
splints, and tapes,  a roller bandage ought to  be  applied as it-
gives support to  the  dressing  that can not be obtained by
straps and buckles, or  a multiplicity of ties.  A  primary
                               bandage, reaching  from the
                               fingers to the shoulder,before
                               the splints are applied, is not
                               necessary, although  some sur-
                               geons  contend  that  this  is
                               valuable to prevent excessive
                               swelling and muscular twitch-
                               ings. The splints may be pad-
                               ded with cotton, or wrapped
                               with  soft muslin.   A sling
                               dropped down from the neck
                               is convenient for the fore-arm
                               or hand  to rest in.   All me-
                               chanical   contrivances   for
                               keeping  up extension  and
counter-extension, as Swinburne's apparatus, are open to such
serious  objections that  they have  fallen into  disuse.  The
weight of the arm counteracts the retraction of the muscles.
If there be slight  overlapping in  oblique fractures, no great
trouble attends the defect.   A shortened arm is not so objec-
tionable as a shortened thigh.
  In  compound fractures  of the humerus,  the arm  may be
kept dressed with  three splints.   Tapes may be  used instead
of a bandage to keep them in place.  The patient should keep
in bed for a week  or two, until the violence of the inflamma-
tion and the purulent discharge  subside.
Dressing for fracture of the shaft of the hu-
 merus.  3, and 4, are not seen, and refer to
 two splints on the other side of the arm. 
Of the Shaft of the Humerus.
125
FRACTURES OF  THE  SHAFT  OF THE  HUMERUS
           JUST ABOVE THE CONDYLES.

  Falls upon the  hand or upon the elbow are not unfrequently
attended with fracture of the humerus above  the  condyles,
across the condyloid ridges.  In young subjects, the separation
of the lower epiphysis occurs in this  region, and  presents
nearly all the characteristics  of a true fracture.  Figure 39
represents an injury of this kind rendered compound by a too
tight dressing, which resulted in sloughing, and a protrusion
of the broken end of the upper fragment.   The epiphyseal

                          Fig. 39.
Separation of the lower epiphysis of the humerus, the injury rendered compound by
        a slough and protrusion of lower end of upper fragment.
fragment retained its place  in articular connection with the
radius and ulna.  The case was treated, after it came into my
hands, by extension, to enable  the protruding bone to sink
into place.  The  boy's hand  was tied high up to the bedpost,
so that the weight of the body in pulling downward, exerted
the proper force to accomplish the purpose.
  The humerus just above the condyles is very thin and pris-
matic, expanding laterally at the expense of its thickness or
rotundity.   This  irregular shape  undoubtedly weakens the
bone  in that region.   A fall upon the elbow in a bent position,
seems to be the most frequent  cause of fracture  at  all ages.
The powerful action of the muscles passing from the upper
arm to the fore-arm usually tends to shortening and riding of
the fragments.   In  most cases  the lower fragment  is  drawn
backwards and upwards by the triceps, producing an appear-
ance similar to that caused by dislocation of both bones of the
fore-arm backwards.   The distal extremity of the upper frag- 
126                     Fractures.
Fig. 40.
ment projects in front of the arm, making a prominence just
above the elbow on its anterior aspect; the olecranon projects
backwards, forming a hollow space in the arm just  above it,
which corresponds with the unnatural fullness in front.  The
general  appearance of the  deformity is that of dislocation ;
              and the restricted motion favors the same idea?
              though the immobility is not so marked as in
              dislocation.   When doubt exists in regard to
              the  nature of the  injury,  the  distinction  be-
              tween  fracture and dislocation can be drawn
              as follows : an extending force in case of frac-
              ture, competent  to overcome  muscular con-
              traction, temporarily obliterates the deformity,
              but, as soon as the force is relaxed, the displace-
              ment reappears ;  in case of dislocation, it  re-
              quires great force to restore the parts to posi-
              tion, and once in place they will stay there.
                 When  the broken surfaces are  brought in
              contact  by extension and manipulation, and
              slight motion is imparted to the fragments,  dis-
              tinct crepitus is elicited.  It will also be found,
              in the event of  fracture,  that  the condyles.
              which can alwavs be felt beneath the integu-
ments, follow the radius and ulna in any motion imparted to
the arm; and such movements are not in consonance with the
lower end of the long fragment.   In dislocation, the condyles
continue as part of the humerus, and the olecranon is displaced
backwards, forming a distinct prominence by itself, and  the
condyloid eminences are distinct from it.  The  distance from
the acromion process to the internal condyle is less in the event
of fracture than in dislocation.
Double fracture of
 the humerus
  Treatment.—The fracture being near the joint  it is not
easy to retain the fragments steadily in place.  Reduction is
to be effected* as already intimated, by grasping the  arm with
one  hand, and  the fore-arm with the other, making sufficient
extension and  counter-extension to  overcome the  muscular
contraction.  In this way the fragments may be brought into
apposition.   To keep  them  there the elbow should, with
proper splints, and other dressings, be fixed at  a  right  angle
A jointed  wooden splint  may be  used if at hand or readily 
                Of the Shaft of the  Humerus.           127

  attainable.   A strip of tin, zinc, or other metal which can  be
  bent to a right angle, maybe employed when well padded, on
  the front aspect of the elbow, a firm compress being used be-
  tween the splint and the lower end of the upper fragment, to
  prevent the end of the bone  from  pressing  forward" I have
  used a piece of bark, partly broken in the middle, also two
  pieces of lath, an  end of each hinged  together with a firm
  piece of leather.   A strip of gutta percha  softened in warm
  water and moulded to the parts while they are  in  good posi-
  tion, makes a nice splint for the front or back  aspect of the
  arm.  If  a  firm  splint be used on the anterior part of the
  flexed limb, a  piece of pasteboard may be  employed on the
  back part.   These splints, whatever be their material, are  to
  be bound in place with tapes and bandages, and the arm sup-
  ported in a sling.   At the end of three or four  weeks, the
  dressing is to be removed, and the  joint carefully subjected  to
  passive motion, to obviate anchylosis.
   Delayed union,  or no  union at  all, is quite common after
 fractures through any part of the shaft  of the humerus.  In
 fractures near the joints, it is extremely difficult to prevent all
 motion, therefore a fracture just above the condyles, is liable
 to failure of the healing process, or,.at least, to a delay ofthe
 reparative action.   Dr. Frank Hamilton does not think that
 mobility at the seat of  fracture, is so often the cause of  non-
 union as is generally supposed.  In  case of delayed union in
 fractures  of  the shaft of the humerus, he  advises that the
 entire arm, from the hand to the shoulder, be dressed with a
 long splint, the arm being kept in a straight position, and
 allowed to hang down at full length.  In one or two instances
 of delayed union, he succeeded in effecting a complete cure by
 the method just indicated.  In one  case he  first overcame  a
 partial anchylosis of the elbow,  in order  that the arm might
 be straightened;  and then used a  gutta percha  splint  that
 reached from the top of the shoulder to the fingers.
   The pressure of the lower end of  the upper fragment upon
 the brachial artery, or the median nerve,  may operate unfavor-
 ably upon the nutrition and functions of the forearm and hand.
 Several cases of alleged malpractice  have been tried in differ-
 ent parts ofthe country, which grew out  of the enfeebled  con-
 dition of the  parts below the fracture. It  is worthy of remark,
that  distinguished  surgeons, while giving testimoiiv in these 
128
Fractures.
Fig. 41.
litigations, have differed  widely in regard to the cause of
paralysis in the fingers, sloughing, etc.   Some  have declared
that the defects were owing to injuries done to the artery and
              nerve by the broken end of the bone—condi:
              tions which no surgeon could always avoid ;
              and others were  of the opinion  that  tight
              bandaging, compresses, and a lack of adjust-
              ment of the fragments, were the causes of the
              difficulty.  It  is highly probable that in rare
              instances the trouble has been in the injury in-
              flicted by the  fragments, but in cases coming
              under my observation the defect has  depended
              upon  lack of proper reduction  of  the  frag-
              ments, tight  bandaging, and the injudicious
              use of splints  and  compresses.
                If  the fracture  be oblique,  and the sharp
              edge of the upper fragment project forward,
              as it is always inclined to do, the brachial artery
              and median nerve are about sure to be pressed
              out  of place  and irritated.  However, if the
              reduction is perfect, and the dressing retains
the fragments in place, the edges  of the broken bone are cov-
ered by one another.  Even if the apposition be made perfect
at the time of dressing, a  fresh displacement may take  place
in a few hours.  Fracture just above the  condyles  must not
only be well dressed in the first instance, but it must be  care-
fully watched, and redressed as often as there  is  a  suspicion
that everything is not going right.
   11 ty ;
ture  of humerus
through its lower
third.
FRACTURES OF   THE  CONDYLES
                    HUMERUS.
OF  THE
  The condyles of the humerus are often fractured.  They are
much exposed to direct violence, and may be broken by indi-
rect forces.  The simplest form of such injuries is a separation
of the tip ofthe inner condyle (epilrochlea), for the lesion  does
not involve the articulation.  It may be occasioned by muscu-
lar action, though more commonly by direct falls upon the
inner side of the elbow.  The symptoms of this fracture are
very evident, for the separated portion of bone can be easily 
Of the Condyles  of the  Humerus,
129
 moved, and crepitus is elicited by the motion.  The swelling
 may alter the appearance of the articulation, yet a close ex-
 amination shows that the joint is unimpaired, and no marked
   Fig 4°    displacement exists.  The capsular ligament and
            ligamentous structures adhering to the fragment,
            keep it from leaving its position.  The  muscles
            arising  from the epitrochlea may tilt the piece a
            little inwards, yet not sufficiently to  require any
            special appliance to oppose the tendency.  Very
            little treatment is required  to secure  a fortunate
            result.   If the arm be carried in  a sling for sup-
 port, and to maintain semiflexion ofthe limb, a good recovery
 will  be made.   The accident  occurs mostly in  children, in
 whom the  epitrochlea is connected only by cartilaginous
 material, the tip of  bone being an  epiphysis. Cases are re-
 ported in which  the accident has happened  to adults, and in
 whom the detached fragment has been drawn downwards an
 inch or more by the powerful muscles arising from it.
   Fractures through the articular surfaces  are  of  a more
 serious character.   They may  effect the inner or the outer
 condyle, extending from that part of the bone which meets
 r       the ulna or radius, and continue obliquely upwards
          and inwards, or upwards and outwards through the
          condyloid ridge, detaching a  piece of  bone some-
          what as represented in the accompanying diagrams.
          In instances more or less rare, the two condyles are
          split apart, the line  of fracture dividing so as to
 Fthe'exeternai terminate  in  both condyloid ridges.   This would
 the humerus, constitute a comminuted and complicated fracture,
            allowing the radius and ulna to be drawn up be-
            tween the  fragments, the displacement being in
            part  a dislocation.  In  such  a case the distance
            between the two condyles  would be  too great,
            and the arm would have the appearance of a frac-
            ture of  the humerus just above the joint, or a
Fracture of both  ,. .     .     r ,    -.-.
 condyles of the  dislocation Of tlie elDOW.
             In  fractures through  the internal condyle, in-
volving the  articular  surfaces, the  line of  separation extends
from the middle of the trochlea, or concave articular  surface
which receives the  ulna, through  the fossse or depressions
which receive the two upper  processes of the ulna, and termi-
        9
 
130                     Fractured
nates just above the epitrochlea.  This  fracture is generally
caused by direct violence,, the force of the blow in falls  being-
received directly upon the condyle.  It is an  injury confined
           almost exclusively to childhood, and is not as com
           inon as fracture of the external condyle.
             The displacement  of the detached fragment 'is
           not great when the arm is  semiflexed and in an
           easy position.  The separated condyle can not be
           drawn downwards, for the ulna prevents such a
Fractui-eofthe  displacement; the muscles arising from it will  not
 internal con-      .,   n .,  .         ,-,    -,            -,      -,
 dyie  of the  permit of its being pushed or drawn upwards ;  and
 humerus.     it       ,             -i j    , i      -i    •, •
           the ligaments are  opposed to other  malpositions.
However, the  fragment can be moved when grasped with  the
fingers,  and made to follow the ulna  in flexing and extending
the arm.  These movements  are  almost  certain to  produce
crepitation.  The distance between  the condyles is generally
increased a little, and there is  a peculiar  deformity noticed
which is partly produced by the swelling,  and partly by a twist
in the arm.  When the limb is grasped above and below  the
elbow, greater lateral motion can be imparted to the joint than
could be if no fracture existed.  This is a valuable diagnostic
manoeuvre in ascertaining a fracture of cither condyle.  These
deflections  do not  determine which condyle is broken,  but
with  a  finger on each, while lateral  movements are imparted
to the joint, the point can be determined.

  Treatment.—Anchylosis, partial or complete, is the danger
to be apprehended while treating fractures of either  condyle.
As has been stated,  the displacement can not be great, there-
fore  hard splints, compresses, and tight bandages are not re-
quired.   However, few patients are satisfied unless the broken
bone is  "set," and'the injured part dressed with splints  and
bandages.  To satisfy this .popular demand is  quite desirable
when it can be done without detriment to the case.   In hos-
pitals, where  patients are under  the control of rigid profes-
sional directions, it  may do to keep the arm resting on  a  pil-
low,  without any dressing or treatment, except topical  reme-
dies to keep down inflammation.   In private practice such  a
course would  be severely criticized; and unless the medical
attendant had a firm hold  on the patient's confidence, he
would be in danger of being  dismissed  for pursuing such a 
Fig. 46.
              Of the Condyles of the Humerus.          131

  course.  Fortunately for those who have to conform to  popu-
  lar prejudice, fractures of the condyles can be dressed with
  pliable splints and a bandage.  A piece of pasteboard twelve
  inches long and  six  inches wide, should  have  two  inci-
  sions made in each side to within an inch of each other, as
                              indicated in the diagram.   This
                             .may then be wetted, lapped and
                              bent, so it will cover the flexed
                              elbow,  as seen  in  Figure 4b\
                              After  the arm  is manipulated,
                              to overcome the displacement if
                              there  be any, and the limb is
                              flexed  to nearly aright angle, the
                              pasteboard splint is applied, and
                              a  bandage  reaching  from the
                              fingers  to near the shoulder, is
                              snugly  made to envelope the:
                              limb.  Great swelling usually at-
                              tends fracture of the condyles,
                              therefore some allowance should
                              be made for that state if the arm
                             1*3  dressed  before the  swelling
                              has  reached its height.   Once
                              dressed in  the  way  indicated,
                             the arm may be carried in a lontr
                             sling let clown from  the neck.
                             A gutta. percha splint moulded
 to the flexed arm answers a good  purpose.  Sole leather cut,
 wet, and moulded, as indicated for  the pasteboard splint, is
 perhaps as  good  material  as can  be  employed.  Angular
 wooden and metal splints are not desirable, on account of  their
 unyielding nature.  I have used an angular woven wire splint
 with much satisfaction, though it has its objections.
   The arm should be redressed every two or three  days, and
 oftener if great pain and swelling seem to demand it.   At the
 end of two weeks the elbow should be subjected daily to gentle
 passive motion.  In three weeks from the accident the dress-
 ing maybe wholly removed, and more forcible passive motion
 imparted several times a day.  If the limb be left to itself the
joint is almost certain to become anchylosed, therefore it  will
 not do to trust so important a  proceeding to the patient.
Quadrangular piece of pnstcboard cut into
 at the sides to make it conform to the
 bend of the elbow, and the same applied
 to the arm. 
132                     Fractures.
The operation of forcibly flexing and extending the limb is
attended with considerable pain ; and the patient in attempt-
ing  to  follow  directions is  liable to be deceived as to the
amount of  motion imparted.   Movements  of  the shoulder
lead to the conclusion that the motion is in the elbow.  When
the arm is forcibly flexed or extended, it should be held to the
maximum of those states for  several minutes in order that the
pressure imparted to the callus or excess of reparative material
may stimulate absorption.
  Voluntary motion, on account  of the stiffness of the muscles,
is  of little value.  In forced motion the joint seems to lock,
as a hinge  into which  a nail has accidently slipped, stopping
the normal sweep  of flexion.   This impediment  arises from
the amount of  uniting callus in  the articulation, which inter-
feres with the play of the hinge.
  Passive motion should be kept up for  a  year, if sufficient
range  of  motion be not obtained  before  that time.   The
patient  should be directed to voluntarily put his fingers to his
cravat, chin, mouth, and forehead every day.  He can  thus
determine whether he gains in the extent  of motion.  I have,
iu several  instances, taken an arm that was  quite  immovable
when the  dressings were removed, and restored  it to perfect
action in the course of a few  months.  I may add  that I have
never failed to  establish a satisfactory range of motion in the
elbow in cases of threatened or impending anchylosis follow-
ing fracture of  a condyle.   There is scarcely  a fracture of any
bone which  is followed with so many unsatisfactory results as
a broken condyle of the humerus.  Litigations are numerous
in which attempts are made to recover damages from the sur-
geon who is unfortunate enough to  be afflicted with unsatis-
factory results.   Some of our most experienced surgeons have
refused to treat a broken  condyle until the  patient and  the
patient's friends are informed that the case  would not be un-
dertaken unless assurance be given that no litigation is to  be
commenced, or damages claimed in the  event af anchylosis
or other serious defect in the  joint. 
Of the External  Condyle.            133
     FRACTURE OF  THE  EXTERNAL  CONDYLE.

   The  external condyle is broken more frequently than the
 internal, especially in adults.   Children  are  extremely liable
 to fracture of either condyle, though the inner oftenest suffers.
 The external condyle is frequently broken by direct  violence,
 as by a blow or fall; yet it may become disjoined by indirect
 violence, the hand receiving the shock of a fall, the force being
 conveyed from the hand through the radius to the humerus.
 Although  authors have hitherto neglected  to speak of the
 fracture as occurring from  indirect violence, I have  met with
 several examples ofthe lesion, in which the evidence was tliat
 no violence  had been  received  except  upon the open hand
 thrown out  to break the  fall.   In September, 1868, I stood
 watching the work of some paperers, wdien one of the work-
 men, John Fordice, who stood on the head of a barrel, lost
 his poise, reeled,  and fell to the floor.   He broke the force of
 the  fall with his outstretched hand, but  received  an injury of
 the elbow that gave  an audible snap.  Being present at the
 time of the accident, I had an  opportunity to determine the
 nature of the lesion before  swelling set in.  The external con-
 dyle could be easily moved  with  the  thumb  and finger, and
 crepitus was distinctly  produced by the motions  imparted.
 The fragment was forced upwards, and the arm  seemed de-
 flected to the radial side, as well  as inclined to remain  in a
 position of partial flexion.   The elbow gained in  lateral mo-
 bility,  and appeared wider between the condyles.   In a few
 minutes swelling came  on and  obscured  some of the  signs
 that were  marked at first.  The. fragment then was not so
 easily moved on  account of the  effusions in and about the
joint, and the  crepitus was not  so plain.  If I had not seen
 the man strike on his hand while falling, or had not examined
 the case for an hour after the injury, I  might have  suspected
 that some of the  swelling and discoloration which came on at
 the seat of injury, was caused by the elbow striking heavily
 against some hard substance, and that the fracture  may have
 been caused by direct  violence.  Persons  who sustain frac-
 tures by falls -are often confused, and not positive whether the
 elbow hit something heavily, or the force was received on the
 palm of the hand.  Dislocations of the head  of the radius 
134
Fractures.
frequently occur from a fall received upon the hand.  In one
case reported by Hamilton, the dislocation occurred backwards
in conjunction with  fracture ■ of the outer condyle.  But in
that case the patient was confident he struck the ground with
the back of his elbow.  It is not easy to conjecture how this
double injury could  arise from  a single  force applied all at
once, to say nothing  of the backward dislocation of the head
of the radius.

  Treatment.—The displacement being slight in almost every
instance, there  is no reduction to be accomplished.  The arm
should be dressed in the semiflexed position, and  the same
shaped pasteboard splint employed, as was recommended for
,fracture of the internal condyle.  The  passive motion should
he commenced by the fifteenth day, and kept up daily for a
week or two longer before the dressing  is laid aside.   If the
muscles and soft tissues be much stiffened, and there  be evi-
dence  of impending  anchylosis, the arm should be forcibly
flexed and extended several times a day until the functions of
the articulation are fully restored.  The services of some friend
or strong member ofthe family should be secured to regularly
perform this important part of the treatment, for there exists
the same danger of  bony anchylosis as in the repair of the
other condyle.   The  arm should also be exercised in the mo-
tions of pronation and supination.  In the process  of repara-
tion osseous material  not only encroaches upon  the fossse  of
the humerus,  but makes connections  Avith the head of the
radius, preventing the normal rotation of the fore-arm.
   In rare instances the detached condyle fails to consolidate
with the rest of the bone.  Such a state does  not impair the
use of the limb to a degree that warrants the  usual  surgical
interference devised to overcome false-joint or non-union.
   In the event of anchylosis there maybe exceptional  cases
in  which, while the patient is. under profound  anaesthesia,
attempts to break up the osseous connections might be  justi-
fiable.   In October, 1867, Thomas Anson, of Indiana, came to
me with anchylosis of the elbow following fracture of the ex-
ternal condyle.   The arm was broken  ten weeks  previously,
and had been treated in the usual way by the family physician.
As near as I  could  learn, no particular  directions had been
given about passive motion to  obviate  anchylosis,  but at the 
Of the External Condyle.
135
end of four weeks, when the dressings were removed, the arm
was allowed to remain in the same semiflexed position it had
been made to assume during the treatment.   I put the patient
under  the influence of chloroform, and broke  the osseous
bridges that joined the head ofthe radius to the consolidated
external condyle.  No great amount of inflammation followed
the disjunction.  Anodyne and evaporating lotions were kept
on the joint for five or six days, and not much motion per-
mitted, though no splints or dressings were used to overcome
mobility.  Finding that no severe inflammation was likely to
arise, the joint was subjected to  almost hourly  exercises in
flexion and extension.  The patient went home on the tenth
day after the operation, with directions to keep up the passive
motion for weeks, and months if necessary.   In a letter writ-
ten six weeks after he left for  home, he wrote that he  could
flex and extend his arm voluntarily,  to a degree sufficient for
all practical purposes.
  Anchylosis  of long standing should not be treated in this
way, for the limb is  not useless though the elbow  be stiff, arid
attempts to break up the articular adhesions  and  connections
might  result  in no  substantial  advantage.   It is only while
anchylosis is recent that a forcible disruption is justifiable.
A. successful attempt to sunder the adventitious structures has
been  made six or eight months  after the  reception of the
original injury, and  other efforts have failed at the expiration
of three months.
  Injuries of a crushing character inflicted upon the  elbow,
bruising the flesh and breaking the osseous structures  of the
articulation, are sometimes sufficiently grave to demand am-
putation.  However, unless the brachial artery and median
nerve are known to  be lacerated, it  is commonly prudent to
wait a  few days to ascertain what may then be the indications.
There is generally no pressing necessity for haste after such
injuries, though every sign of  vitality has departed from  the
extremity, and gangrene is apparent.
  If there be feeble  pulsation  at the wrist, and partial sensa-
tion in the hand, there is a possibility, if  not a probability, of
saving the limb.  At any rate, a primary amputation, as it is
called,  should not be performed unless the limb, after reaction
has taken place in the rest of  the body, remains cold and ca-
daverous—pulseless and senseless.  If sufficient vitality remain 
136
Fractures.
to warrant an attempt to save the arm, a few days will disclose
the fact whether the limb must be sacrificed to save life, and
amputation can then be performed with not much greater risk
than would have been incurred just after the accident.
  In compound and  comminuted fracture of the elbow, the
finger  may be used to  explore the joint, to ascertain if any
loose pieces of bone need  removing.  Small fragments  com-
pletely disengaged, or cut off from nutritious supplies, are
about sure to act as foreign bodies in the joint; and may do
as much mischief as pieces of wood, cloth, or common gravel
in their position.   All  such pieces of isolated bone should be
removed, and the limb placed on a pillow, in an easy attitude,
for several days.  The parts implicated  in the injury should
be kept wet with water, and lightly covered.   The foetor may
be corrected to some extent by the use of dilute carbolic acid.
As soon as it  becomes known  that  the limb can be saved,
though with no hope of motion in the joint, the arm . should
take the position of semiflexion,  as the member, wheu  anchy-
losed, is the most useful in that attitude.  Many an arm, con-
demned to amputation by  surgical attendants, has been, saved
as a valuable limb, by the stubborn refusal  of the patient to
submit to what  was  professionally decreed.   In one case, in
which the joint was so opened that the finger could be passed
through  and feel the artery pulsating in  front,  Sir  Astley
Cooper proposed amputation, but the patient refused to  sub-
mit to it, and his arm was  saved and became useful.
  A disposition  to amputate after the  reception  of severe
injuries is the  peculiarity  of those  surgeons who have held
commissions in the volunteer army.   The  inclination to lop
off a lacerated limb springs  from a desire to execute a nota-
ble operation, which may  go to sustain a reputation for sur-
gical ability.  However, an old army surgeon  is apt to be as
conservative as the civil practitioner.
  If a limb is to be a  source of danger to  life through pro-
longed suppuration, or from  tetanic complications, it is well
to amputate early ; yet tetanus may generally be averted by
placing injured parts in easy attitudes; and a perilous suppu-
ration can not be determined for weeks, or perhaps months.
Amputation after fractures is to  be  avoided if possible. 
      CHAPTER  XXI.

FRACTURE OF  THE  ULNA
  The ulna, the companion of the radius in the skeleton of
the fore-arm, does  not  constitute an important  part of the
wrist  joint, but enters more  largely than its fellow into the
articulation of the elbow.  The bone terminates  at its upper
extremity, in a prominent process—the olecranon—which is a
lever  for the action of the triceps.  This process, behind the

                         Fig. 47.
            Shows fracture of the olecranon and coronoid processes.

articulation, is  thinly covered, and exposed to blows of suffi-
cient severity.to cause fracture.  If the fore-arm be suddenly
and forcibly extended, the olecranon, either by the action  of
the triceps or tjie violent contact of the humerus in extreme
extension, is liable to be broken off from the rest of the bone.
The summit or extreme tip of the process may be detached
in extremely rare cases, though the fracture usually separates
the greater part of the olecranon.   In falls  directly upon the
part, the greater portion of the process is likely to be broken
off.  The line of separation is commonly transverse ; and the
displacement upwards in the direction of the triceps, renders
the nature of the accident quite easy to understand.  In some
instances, where the ligamentous  structures are  untorn, and
the arm has not been flexed, the displacement is scarcely per-
ceptible.   In most cases the process is retracted to so great an
extent by the  triceps, that every connecting medium must be
torn through, the fragment being entirely under the control
of the muscle.  Flexing the arm  puts  the triceps on the
                          (137) 
138                     Fractures.
stretch, and necessarily widens the breach between the frag-
ments.  Displaced as the process usually is after fracture, it
can be distinctly felt an inch or so above its ordinary location,
and is easily movable from side to side.  Power  of voluntary
extension  is almost  entirely lost after fracture of the olecra-
non, and  pain is  aggravated  by movements of  the  limb.
Swelling quickly follows the injury, and tends  to  obscure the
diagnosis  if the patient  be  not examined for several hours
after the accident.   Crepitus can not be elicited unless the arm
be extended, and the triceps pressed downwards, so that the
broken surfaces may be brought in contact.
  In doubtful cases, when there is no  apparent displacement,
the finger  placed upon the olecranon while the arm is flexed,
will discover the line of separation which  is always more or
less marked by a lack of perfect apposition.   If the arm be
put into extreme flexion,  the fragments are forced apart and
a palpable depression is felt between them.

  Treatment.—It is plainly evident that fracture of the ole-
cranon is to be treated with the arm in a state  of extreme ex-

                         Fig.  48.
Splint and dressing for fracture of the olecranon process.
tension ;  and a long splint reaching from near the shoulder to
the hand, and bound to the front aspect of the limb, will keep
the arm  from being flexed.  A roller bandage begun at the
fingers should extend to the elbow.; then another started  near
the shoulder is made in its turns to envelope the arm down to
and including the elbow.  The first prevents undue congestion
and swelling, and the other forces  the  triceps downwards so
that the detached olecranon  may come in contact with the
rest of the bone.   The long  straight splint is now placed on
the front of the  arm and fastened there by  the turns of an-
other roller.  This dressing holds  the limb in a straight posi-
tion, which is somewhat awkward, but it is the  only way the 
                        Of the Ulna.                  139

  broken surfaces can be brought into apposition and held there
  securely.  As there is danger of severe  inflammation in the
 joint, anodyne and evaporating lotions should  be applied  to
 the  elbow for several  days.  The dressing may be taken off
 and re-applied occasionally during the healing process, though
 the joint should not be  fully flexed for five or six weeks, lest
 the  fragments be forced apart.   At the expiration  of that
 time, the state of the parts involved in the injury should be
 carefully observed, to ascertain whether the union of the frag-
 ments be osseous.   If the consolidation  be perfect, whatever
 of stiffness and anchylosis exist, should be overcome by passive
 motion.  The arm should not be fully flexed at first, but there
 ought  to  be  a gradual restoration of the functions  of the
 joint.  If the  union be fibrous, which by some  surgeons is
 thought to be  the normal state after fracture of the olecranon,
 the connecting bands will be so short that the use ofthe limb
 is but slightly  impaired.  Extension can be performed even if
 the union be fibrous or ligamentous.  In  the  event of false-
 joint, especially if the connecting bands be short, it is not best
 to  attempt the establishment of bony union by any  of the
 means usually  employed for such purposes.
   The only objections raised against dressing the  arm in the
 extended position is, that if anchylosis does take place, the limb
 is not in a good attitude for service.  It is justly claimed that
 if the joint is to be permanently stiff, the semiflexed position
 is far preferable to a straight attitude.  However, it is found
 in practice that the cases in which complete anchylosis results,
 are extremely uncommon.   If the articulation be severely in-
 jured at the time the fracture- occurs,  so that anchylosis seems
 inevitable, it might be  wise  to dress the arm in a position
 which would be most useful, for if the elbow be anchylosed
 it would make little difference whether the olecranon Avas
 consolidated or not.
  It is recommended by  Hamilton that moderate flexion and
 extension be  performed  e\ery day, while  the  dressing  is off,
the finger pressing downwards upon the olecranon, to obviate
anchylosis, but this increases greatly the risk of fibrous union,
and opposes in  a  slight  degree anchylosis which is very un-
likely to occur. 
140                    Fractures.
     FRACTURE OF  THE  CORONOID PROCESS.

  Fracture ofthe coronoid process must be an extremely rare
accident.  The surgeons are few who have been positive  that
they have seen a case.  Several cases have been reported, but
full credence can not be placed in all of them.  The accident
is said to occur in connection with dislocation of the radius
and  ulna  backwards, and  sometimes  perhaps without  that
complication.  It has been stated by surgical writers that the
action of the brachialis anticus would break the process ; their
language being that the muscle is.  inserted into the process,
when in fact it is inserted below or at the base of that promi-
nence of bone, and has no direct action upon it.  The  occa-
sion for distrust in some of the reported cases comes from the
anatomical error into which writers have so frequently fallen.
In  a malpractice suit tried  in  the  State  of  New  York,
one of the surgical experts in his testimony in regard to dis-
location of  the radius and  ulna backwards, stated  that the
brachialis muscle was inserted into the apex  of the coronoid
process.   Mr.  Liston, in his Operative  Surgery, mentions the
case of a boy who broke the coronoid  process by the action
of the brachialis muscle  while hanging  from a high  wall.
Notwithstanding our  great  regard  for such  high authority,
it  will be convincing to any one referring to the anatomy of
the parts involved in  the alleged injury and  considering the
action of  the muscle upon the process while a boy was hang-
ing by the arm, that no such lesion could take  place.   The
boy's weight as he was suspended by the hand, would  draw
the coronoid process away from  close contact  with the hume-
rus,  and  the brachialis anticus  muscle, being inserted at the
base  of the process, also  passing over it, would press  upon
its apex, the action tending to retain the  bony prominence  in
place, and not to detach it, while the arm was in extreme ex-
tension.   The coronoid process is  not an epiphysis, with  a
cartilaginous connection with the  shaft of the ulna during
childhood;  which is  another  circumstance  opposed to the
theory of fracture from muscular action, though it is declared
by nearly all writers upon the subject, that children  and not
adults, are liable to the accident. 
Shaft of the Ulna.
141
   It is not denied  that  direct violence, as  the passage of a
 wheel over the part, may break off the coronoid process; and
 it is quite certain that in dislocations of the ulna backwards,
 the point of bone' is occasionally severed from its connections
 with t^lie main part of the bone.

   Treatment.—The dislocation having been reduced, for the
 fracture is presumed not to occur except in  conjunction with
 that injury, the arm should be kept in a state of partial flexion
 to prevent a recurrence of the luxation.  The limb may be
 bandaged from the fingers to a point above  the elbow,  and a
 compress employed to retain  the  detached process in  place.
 This dressing can be employed for four or five weeks, though
 the articulation is to be gently exercised daily to prevent an-
 chylosis.  The difficulty of retaining  so small  a fragment
 steadily in position, and the scanty nutritive materials finding
 their way to the process after its violent separation from the
 shaft, would be liable to insure a ligamentous, and not a bony
 connection.   If the detached process never obtained  a firm
 connection with the shaft of the ulna, the osseous material
 poured  out to consolidate the  fragments, would  constitute a
 barrier  against repeated dislocations.  The functions of the
joint, under such circumstances, must be more or less  im-
 paired,  for the elbow is liable to  chronic  defects after even
 moderate injuries.  It is vastly more important to secure free
 motion  to the joint, than to be striving for bony union, which
 would be utterly useless  in the event of anchylosis.


   FRACTURE OF  THE  SHAFT  OF  THE  ULNA.

  The shaft of  the ulna,  when fractured  singly,  is always
broken by direct  force.  If the radius be previously broken,
the ulna may be brought under the  influence of the  indirect
force, and be fractured by it.  When the hand.is extended in
falls to  save the head and trunk  from violence, the radius,
from the  mode of  articulation  in the fore-arm,  receives the
force  of the blow  and either breaks just above the wrist, or
conveys the shock to the humerus ; thus the ulna is preserved
from heavy concussion.  The ulna is subject, then, to  direct
violence, either in  striking  against some hard  body,  or in 
142                     Fractures.
warding a blow aimed at the body.   The arm is raised in pro-
tecting the  head, to  an  attitude which presents its ulna side
toward the threatening violence.  Also in falling backwards,
the arm is thrown in advance of the trunk to shield  it from
injury, and receives a violent shock on its ulnar  side.   While
descending stairs, a slip of the feet forwards throws the body
backwards, and the ulnar sides of  the  arms  come  directly
against the edge of  a step.
  The situation of the fracture under such circumstances, de-
pends of course upon the part of the bone struck.  The lower
half of the bone is smaller and weaker than  the upper half,

                          Fig. 49.
Fracture of the ulna above the origin of the pronator quadralus,
   showing the action of that muscle upon the lower fragment.
 and should consequently be most frequently broken, all other
 conditions being equal.  A force producing fracture of the
 shaft of the ulna, is very liable to convert the lesion into one
 of a compound nature.
  The symptoms of fracture are usually very prominent.  The
'bone  being thinly covered, the displacement is generally quite
 marked.  However,- in  some instances, especially towards the
 upper extremity of the bone, the fragments may be interlocked,
 or held in place by  the periosteum, so that no  disjunction
 occurs.  Iiufractures through the lower portion of the bone.
 the upper fragment remains nearly in the place occupied before
 the fracture, owing to the firm and  wide articulation at the
 elbow, and the lower fragment is drawn towards the radius by
 the action  of  the pronator  quadratus  muscle.  If the upper
 end of the lower fragment take any other position, it is driven 
Shaft of the  Ulna.
143
 there by the force that produced the fracture, and the muscular
 action was too feeble to restore it to the place it would take if
 uninfluenced by the paralyzing blow.   When the broken ends
 are brought in contact, in the manipulations of the arm, cre-
 pitus is distinctly felt and heard.   The power  of rotation is
 impaired by fracture  of the ulna, and in fact all the functions
 of the fore-arm are restrained by the  swelling,  pain, and loss
 of power attendant upon tke lesion.
  In May, 1865, I was called to Mollie Shannon, a stout Irish
 girl,  who  fell backward from a stool while  hanging  out
 clothes.  The fall brought  her upon  a flight of back stairs,
 and she slid  to the bottom, lighting upon a brick pavement.
 I saw her in a few minutes  after the injuries were received.
 She was complaining bitterly  of her arm near the elbow, and
 refused, to allow me  to examine it as thoroughly as I  desired,
 on  account of  the  pain  which  the  slightest  manipulation
 seemed to produce.   I therefore gave  her chloroform until I
 could handle the limb, and ascertain the nature and extent of
 the injury.  A contusion about five inches below the elbow on
 the  ulnar  aspect of the arm, led to a critical examination of
 the  bone  beneath.   I found  a fracture of the ulna at  that
 point, though not much displacement existed.   There  was
 swelling about the elbow, which, with  a huge development of
 the muscles, rendered the nature of any injury in that region
 perplexiugly obscure.  The rigidity of the joint, and the pe-
 culiar twist, amounting to marked distortion, which the limb
 assumed, favored the idea of dislocation of the head of  the
 radius.  To this conclusion I  at length arrived, though  not
 with that certainty which fully satisfies the mind.  After put-
 ting the patient under profound anaesthesia I succeeded in re-
 ducing the dislocation, and then the arm became supple, and
 the fracture of the ulna permitted of the plainest crepitation,
 which could  not be elicited  until the luxation was reduced.
 To understand how both injuries were produced  is not easy,
 unless the  ulna was  broken  against  the  sharp angle of the
 post at the head  of the  stairs, and at the time she fell from
 the stool; the dislocation of the head  of the radius upon the
anterior aspect of the condyle, must have been done when she
landed at the foot of the stairs, where the great weight of her
body came upon the injured arm, which, she said, " doubled
 up under me."  The case made a good  recovery. 
144
Fractures.
  Treatment.—It is not generally a difficult matter to reduce
a simple fracture of the ulna.   The broken ends, whether they
project in one direction or another, or the upper  fragment be
in position and the lower dragged into the interosseous space,
toward  the radius, can commonly be manipulated into appo-
sition without deviation from the natural course of the bone.
The fragments once brought into line and properly adjusted,
two padded board splints, wider  than the  arm, and reaching
from the elbow to the fingers, are to be bound to the anterior
and posterior aspects  of the arm, while  the hand is held half
way between pronation and supination.  No roller should be
applied  except the one that holds the splints in  place.   Any
circular compression is extremely liable to  press  one or both
fragments  into the interosseous  space, where they may unite
to the radius, destroying the functions of pronation and supi-
nation.  If the fracture be through the lower third  of the
bone,  and the lower fragment is quite forcibly drawn toward
the  radius, two long,  firm compresses should be laid between
the  radius and ulna, beneath the splints.  These tend to wedge
the  bones apart. The width of the splints prevents anything
but lateral  compression.   As  the bandage, while it is being
put on,  passes across from one splint to  the  other, the  upper
and lower surfaces of the arm remain untouched, thus entirely
obviating  circular compression.  After  the  arm' is properly
dressed, it may be carried  in a sling. The  redressings need
not be frequent unless there arise a  suspicion that all  is not
well.  In  the usual time, which is about four or five weeks,
the  dressings may be finally removed.  False-joint after frac-
ture of  the shaft of the ulna is extremely rare. •  The callus is
plainly felt for months, on account of the subcutaneous loca-
tion of the bone. 
CHAPTER  XXII.
FRACTURE  OF  THE  RADIUS,  ETC.
  The upper third of the radius, from its being buried deeplv
in muscles, is seldom fractured ;  the middle third is not broken
any more frequently than the ulna ; but the lower third is
fractured more often than any part of any other bone in the
body.
  Fracture of  the neck of the radius is admitted by every ex-
perienced surgeon to be extremely rare.   Dr. Markoe, of New
York, thought he met with a case in which the signs pointed
inevitably to a fracture through the neck of the radius, but
the autopsy showed that he had been mistaken.  The injury
proved to be a dislocation of the head of the radius forwards,
and a fracture of the ulna near  the  elbow.   The mobility of
the parts and the  crepitus  which seemed to come from the
radial side of the arm, led to  the error of diagnosis.   Mutter's
cabinet in  Philadelphia, contains a specimen  of  fracture
through the neck of the radius, which I have examined.   The
history of the  case is unknown.  The fracture united  with
considerable deformity, which must have interfered consider-
ably with the functions of the elbow.
  In  the winter of 1855, Mr. Noyes, of Boston, was thrown
from  a sleigh in Lowell, and received a severe injury about
the elbow.   He went to a hotel, and requested that a surgeon
be called to treat his arm. The landlord sent for Dr. Nathan
Allen, his family physician.  Upon his arrival, the doctor ex-
amined the injury, and pronounced it a sprain.  He applied a
bandage  to suppress the swelling, and ordered wormwood and
rum as a topical  application.   Several professional visits  were
made  Mr. Noyes while he was  at  the  hotel, and assurances
were given that in a few days the patient would be able to
resume his  business.  After  several  weeks Mr. Noyes found
      • 10                  (145) 
146
Fractures.
that he could not bend the elbow except in  a  very moderato
degree; he could not carry his fingers to the  chin, even if the
head was bent to meet  them.  Accordingly he went  to the
late Dr. John C. Warren, of Boston, for an opinion in regard
to the nature of  the injury and the prospects of a cure.   Dr.
W.  asked " who had treated the arm;"  and  upon being told
that it was Dr. Allen, he would not look at  the case, as Dr.
A. was a professional brother in  the Massachusetts Medical
Society.  Mr. N. then went to Dr. Kimball, of Lowell, a sur-
geon of some repute.  Dr. K. examined the arm, and called
his student's attention to what he called a fracture of the condyle.
Mr. N. then went to  Dr. Walter Burnham, of Lowell, also a
surgeon of large experience, who  pronounced the injuiw a
fracture of the neck of the radius, which was ununited.  Mr.
N. now supposed that he had been maltreated by Dr. Allen,
and sued him for damages.   The case was tried at East Cam-
bridge, in Middlesex County, in January, 1856, and resulted
in a disagreement ofthe jury.  The testimony given in court
was singularly conflicting, coming as it did from some of the
most accomplished and experienced surgeons in the State.
  It was  also a matter of surprise /to Mr.  Noyes that Dr.
Kimball, who had directed his student to observe an old  frac-
ture of the condyle,  should  then under oath declare  that
the  arm had never sustained a fracture.   The real state of the
limb, at the time ofthe trial was as follows: there was partial
anchylosis at the elbow,  flexion being greatly impeded, as has
been stated; pronation and supination restricted;  and a  grat-
ing could be produced just below the elbow by passive efforts
at rotation of the fore-arm.   There  was no evidence that the
condyles of the  humerus had ever been broken.   The  ulna
seemed perfect in its  processes and  proportions, bearing  no
sign of fracture.   The head of the radius was  not dislocated.
for it could be grasped with the thumb  and finger, and plainlv
rotated, and it could be  held  still while the  hand and lower
extremity of the bone were rotated.  These movements elicited
a crepitating sound much like that heard in the motions of a
false-joint.  The evidence of fracture of the neck of the radius
was  reached by a logical necessity, on the  application  of a
method of reasoning much resorted to in the diagnosis of dis-
eases, viz:, reasoning by way of exclusion.  That  there had been
a fracture about  the joint was quite plain, and  as the humerug 
Of  the Radius.
147
and ulna were excluded from the possibility of having been
fractured, the upper extremity of the radius alone remained
unexcluded, and every symptom in the case indicated fracture
of the neck of the bone, whether the injury had previously
been met or not by surgeons high in authority.
  In  fractures  of the head or neck of the radius,  the arm
should be flexed to relax the biceps which has its insertion just
below the tubercle and tends  to displace the upper extremity
of the long fragment.   The  pasteboard splint recommended
for fracture of the condyles of the humerus, would be  excel-
lent to steady and support the parts implicated in the injury.
At the end of three or four weeks motion should be imparted
to the joint to obviate anchylosis.
  In fractures of the radius which very rarely occur  between
the attachment of the biceps and the insertion  of the pronator
radii teres, the fragments are acted upon by muscles  exerting
their forces in different directions.   The supinator brevis rolls

                          Fig. 50.
Fracture ofthe radius between the insertions ofthe supinator hrevis and pronator radii teres.
          The fragments are separated by the action of these muscles.

                           Fig. r>I.
Arm supinated to bring the k>.v2r f.igm^nt into apposition with the upper.
the short, upper piece of bone outwards, and the antagonistic
pronator pulls the lower piece inwards, somewhat as exhibited
in Figure  50.  Now,  as  the upper fragment is  short  and
thickly covered with muscular tissue,  it can  not  be moved
from the position given to it by the supinator brevis; but the 
148                     Fractures.

lower fragment can be made to come in contact with the upper
by the extreme supination of the fore-arm, as seen  in  Figure
51.   To treat such a fracture successfully, the arm would have
to be dressed in the attitude  of  extreme supination, and re-
tained  in that position until the consolidation of the fragments
was  sufficient to allow  of  rotation, and  not endanger the
breaking up of the callus.  I  have never treated but one case
of the  kind, which was  produced by a pistol bullet, and in
that  I followed the course just laid down.  The recovery was
not rapid, for the injury was rendered compound by the bullet
wound.  Two splints made of thin boards, two inches and  a
half  wide, and reaching from  the elbow  to  the  ends of the
fingers, were bound in place  by a* roller while the arm was
supine.  The back of the hand was allowed to rest  in a sling,
strict orders being given  to keep the thumb directed away
from the body.   The  position was  irksome at first, but in a
few days it was maintained without effort.
  Fracture through the middle third of the radius,  belowT the
insertion of the pronator radii teres, is generally  caused by

                         Fig. 52.
Fractnre of the middle third of the radius. The biceps (2) tends to pull the upper fragment
     in one direction, and the pronator quadratus (7) the lowei fragment into the
                       interosseous space.

direct violence, and happens about as rarely as fracture through
the middle third ofthe ulna.  The diagnosis is  unattended
with  difficulty.   Rotation developes so much displacement
that the ends of the  fragments can  be distinctly felt beneath
the integuments.  Crepitus can  also be produced  when.the
fragments  are brought in contact and rubbed against one an-
other.  The inclination of  the broken  ends is  to take a posi-
tion in the interosseous space, approximating  the ulna.
  The treatment is the same as for fractured ulna in the same 
£<^°
                     Of the Radius.           tJ\^\l49    -^£

region.   Two straight spliuts, wider than the arm, t{\jQfrA!&~    yj
circular compression, and padded to  prevent excoriatku^fjfr kv* *
the skin, are to be bandaged to the dorsal and front a^^XJoT
the fore-arm.  A compress placed under each splint between
the bones, so as to force  the  fragments away from  the  ulna,
tends to prevent the reparative material from soldering one or
both broken ends to the ulna, as represented in Figure 53.  If
one or both fragments become welded to the  ulna, the condi-
Fig, 53.
          Consolidation of fragments of radius with the ulna, preventing
                     rotation of the fore-arm.

tion is  fatal to rotation.   Ordinarily it  is not  necessary, in
treating fractures near the  middle of the radius, to use splints
extendiug farther than from  the elbow  to  the hand.  These
reach quite  a distance  above  and below the  line of fracture, so
that no motion at the point of separation can take place if the
splints be efficiently held with bandages.   Figure 61 represents
the splints padded and held  in place with  a couple of tapes
preparatory to receiving the bandage.


FRACTURE  THROUGH  THE  LOWER  THIRD   OF
                      THE  RADIUS.

  There is  no  part of the  skeleton so subject to fracture as
the lower extremity of the  radius.   The  lesion  occurs from
indirect violence.  The hand in a fall is put forth to arrest the
progress of the descent, and to save the head and the trunk
from serious blows and concussions.   These uses are the occa-
sion of  so many fractures of  the radius near  the  wrist.   The
expanded articular extremity of the  bone receives the carpus,
leaving the  ulna free from  the shocks sent along from the
hand to the  fore-arm.' The lower  end of the radius, though
quite large,  has a  thin shell of hard bone upon the  outside,
and an abundance of cancellated structure  within.
  Several distinguished surgeons in this  country  and  abroad,
have written upon the  nature, appearances, and  treatment of 
150
Fractures.
fractures occurring at the lower extremity of the radius, and
a few of them have gotten their names associated with varie-
ties of the injury.  In 1814  Dr. Abraham Colles, of Dublin,
published  an article  in the Edinburgh Medical and  Surgical
Journal, upon the peculiarities of a fracture commonly occur-
ring about an inch from the carpal extremity of the radius ;
and since that time all fractures of the lower portion of the
radius, except such as involved the  articular surface of the
bone, have been called  " Colles' fracture."   In  1838, Dr. J.
Rhea Barton,  of Philadelphia, published  an  article in  the
Philadelphia Medical Examiner, on the subject of fractures of
the  carpal extremity of the  radius.   He called  particular
attention to such fractures as involved the articular surface of
the bone, claiming that in many instances the line  of separa-
tion was not so far from the  wrist-joint as described by Colles.
Since the publication of the  article American surgeons have

                          Fig. 54.
 "Barton's fracture" of the lower extremity of the radius. The action of the snpinator
     longus and pronator quadratus is exhibited in the position of the fragments.
commonly called the injury, when the articulation is involved,
" Barton's fracture." Both writers have described injuries pro-
duced by the same causes, and presenting the same peculiari-
ties.  There is no difference between  Colles' fracture and Bar-
ton's fracture, unless it be that the latter name belongs to such
lesions  as present  a break extending to the carpal articular
surface.  In  the production  of both  fractures  the hand is
thrown out instinctively to break the force of a fall, and when
the carpus   meets the earth  or the resistance  of anything
stable, the momentum of the body causes a fracture at the
weakest part of the bone.
  The  deformity following fracture of the  radius near the
wrist is observable, yet to an  inexperienced person the nature
of the difficulty is rather obscure.   The swelling which rapidly 
Of the Radius.
151
supervenes,  masks  the irregularities of the broken  surfaces,
and otherwise conceals the symptoms of fracture.  The  ap-
pearances of  the parts may lead to the suspicion  of ladio-
carpal luxation.  If the hand and fore-arm of the patient be
grasped  and subjected to  extending and  counter-extending
forces, the injured limb in case of fracture, will be  made to
assume its natural outlines and projections.   In the  event of
radio-carpal dislocation, which is an exceedingly uncommon
lesion, the deformities can not readily be  overcome by such
force ; and when once in place the bones will stay there.   The
deformities attendant upon fracture are  easily overcome,  but
they will immediately recur  upon  the relaxation of the re-
ducing forces.
  The peculiar appearance of an  arm suffering from fracture
of the carpal extremity of the radius, has been compared to
the outline of a silver fork.  The accompanying diagram re-
presents  it pretty well.  An elevation presents on the wrist,
                          Fig. 55.
   "Silver fork " appearance of the hand and arm after Colles' fracture of the radius.
extending to the back of the baud.  This dorsal prominence
is nearly apposite or a counterpart to a deep sulcus or depres-
sion on the  palmar aspect of the wrist.  Higher on the front
ofthe arm, above the sulcus, is a marked prominence.  Besides
these deformities, there is an abnormal projection of the lower
extremity of the ulna, as if the carpus was dislocated laterally
to the radial side.  The  muscles going to the thumb tend to
pull the hand away from the ulna.
   In seeking positive evidence ofthe fracture under consider-
ation, crepitus  becomes  important.  This valuable sign  can
generally be elicited by grasping the hand and arm, and  im-
parting various movements to the wrist.  The  finger pressed
upon the radius immediately above the articulation, while the
movements  just spoken of  are made, will discover the sharp
or rough edges of the broken ends of the fragments, or such 
152
Fractures.
irregularities m the bone within an inch  or two of the joint,
as will be quite conclusive as to the nature of the injury, the
direction of the line of fracture, and the  size and shape of the
lower fragment.  The skeleton drawing  in the accompanying
diagram represents pretty accurately  the line  of separation

                          Fig. 56.
Fracture through the lower extremity of the radius, showing the tendency of the
               hand to slide away from the ulna.
just above the radio-carpal articulation.  The short fragment
is larger in some instances and smaller in others.   It  is well
to bear in mind, while considering the  relative positions the
fragments take, that the supinator longus is inserted into the
lower  fragment,  dragging it and the carpus attached to it,
away from the ulna, and the pronator  quadratus drags the
lower  end of the upper fragment toward the ulna, making the
arm just above the wrist rounder, or less flattened, than usual.
  Colles' fracture of the radius happens at all periods  of life,
from infancy to old age.  Females not being so much exposed
to the violent accidents of life as the other sex, suffer less from
all kinds of fractures.  In September, 1868, a gentleman and.
two ladies were thrown from a carriage, while riding  on the
Reading pike.   The gentleman jumped before the carriage
had fully upset,  and landing heavily on one foot, received
Pott's fracture of the fibula; the two ladies were hurled vio-
lently  to the  earth, with  hands extended to  save more vital
parts,  and each sustained a fracture  of the right  radius near
the wrist.  If sex had any bearing on these  injuries, it must
have been confined to the conduct of each in an  emergency,
the man  preferring the  risks of a leap to the more  passive
course of being thrown upon his hands and head.
  The deformities following Colles' fracture present unmis-
takable characteristics, whether treated well or ill,  or not 
Of the  Radius.
153
 treated at all.   Some years ago I examined the wrists  of Mr.
 Coleman,  an English gentleman, who on a voyage from Cal-
 cutta  to  New  York, was thrown against some luggage by a
 violent lurch of the ship.  He received the common fracture
 of the radius  in  both  arms, and as there was no surgeon on
 the vessel, no treatment was instituted except the application
 of a wet cloth  to keep down inflammation.  Beiug injured off
 the Cape of Good Hope, it was several weeks before he arrived
 in port.   It was then too late to have anything done to remedy
 the deformity.  However, the wrists were fully as mobile and
 useful at  the  end of two  months from  the  injury as they
 wrould have been if subjected to the usual treatment, and the
 deformities were not greater than  in many cases which have
 passed through surgical  hands.  I  was  surprised  to  see no
 worse results in cases never treated.
   The examination of cabinet specimens reveals the fact that
 there is more or less impaction in many cases,  the upper frag-
 ment being driven into the lower.  In one specimen belonging
 to me, taken from the arm of a man who was  killed by a fall,
 the lower  fragment is split into three pieces, the  line of frac-
 ture running through the carpal articular surface; and to every
 appearance the comminution was produced by the impacting
 and wedging forces of the  upper fragment.   The  primary
 fracture was about an inch above the carpo-radial articulation;
 the splitting of the lower fragment must have been of a
 secondary  nature, and was probably produced  by the impetus
 of the body after the hand had struck the earth  and received
 the earliest lesion.
   The symptoms of fracture of the radius near the wrist are,
 pain, swelling, greater  or less inability to use the hand and
 arm, and all the deformities already described.  Crepitus can
 not always be produced, though the cases are rare in which it
 can not be  elicited by varied manipulation.   In young subjects
 the results  of well treated cases are quite  satisfactory, but in
 elderly persons, some degree of anchylosis, and stiffness in the
wrist and  fingers, lasts for weeks, months, and even  years.
The sheaths of the tendons lose their slippery functions, and
a troublesome  sensitiveness  chronically affects the hand and
wrist.
  Treatment.—Many ingenious contrivances  have  been de-
vised for successfully treating fractures through the  lower 
154
Fractures.
third of the radius.  In fact, some of our works on fractures
contain so many plans, with lengthily expressed approvals and
objections, that the inexperienced reader finds some difficulty
in selecting the most feasible plan.  It is thought best, there-
fore, to describe a  simple method of dressing the arm, which
can be readily put in  practice in the country, where a thin
board, knife, and bandage can be obtained.  The dorsal splint
may be a piece of cigar box, two and a half inches wide and
long enough to reach from near the  elbow to the back of the
hand.   Before application it should be wound  with  strips .of
muslin or old cloth; the palmar splint may be whittled from
the thin cover of a box, or from a shingle, or lath.  Its shape
may be something like the profile  of the hand and arm, or
like that  represented by No. 1  in figure  57, which is broad
near the lower end, and cut obliquely across, so that the upper
or longest border corresponds with the thumb side of the hand.
To this broad  and  obliquely cut extremity a compress large
enough to fill the hollow of the hand, is bound.  The com-
press may be  made  of a strip of bandage, compactly rolled.
This is to be fastened in place by the same strip which is used
to envelope the splint.  The obliquity of the compress when
the splint is applied, forces the  hand to the ulnar side, thereby
producing a degree of extension upon the lower fragment.
  A compress is placed between the splint and the prominence
ofthe arm on the palmar surface, and another small compress
is placed on the prominence of fhe back  of  the wrist, under
the dorsal splint.   A piece of tape is tied around  the splints
near the hand, and another near the  elbow, to retain  the
dressings thus far applied, in place.  Extension is now made
on the fingers  to adjust the fragments ; and the lower tape is
tightened to prevent the displacement from recurring.  Over
the whole dressing thus far applied a roller bandage is snugly,
though not tightly wrapped.   Figure 57  represents the two
splints before they are applied, and the arm after it is fully
dressed.  The fingers and thumb are left exposed, and can be
used enough  to prevent anchylosis, or  even much stiffness.
This dressing  is simple in  its  construction, easily worn, and
prevents motion  between  the fragments.   I  have obtained
better results with it than with more complicated  and expen-
sive apparatus.  The width ofthe splints must always exceed
the width of the arm in order that there shall  be  no circular 
Of the Radius.                  155
constriction.   No enveloping bandage is to be used  upon the
arm before the splints are applied.  No water or other topical
application is to be employed, for the wetting of the bandage

                          Fig. 57.
No 1 is the palmar splint ready for use; and No. 2 the dorsal splint. The arm is represented
         as dressed in the treatment of " Colles' fracture. " of the radius.
shrinks the cloth, and makes the dressing too tight.   The limb
should be seen the next day after the accident, and the band-
age loosened if it seem to inflict pain or to arrest the circula-
tion.   It is better to re-dress the limb than to take any risk of
mischief from strangulation.  After the swelling has subsided,
which will  be in eight  or ten  days after the accident, the
dressing may be  left undisturbed for a week  at a  time.  In
four or five weeks, as a general rule, the consolidation will
be complete, and the dressings may be laid aside.   However,
passive motion should be kept up for several weeks  longer or
until the functions of the fingers and wrist are re-established.
Persons advanced in years are liable to neuralgic pains in the
hand and at the seat of injury.   This difficulty, if prolonged,
and  much troublesome, may be  ameliorated  by the use  of
stimulating and anodyne  liniments.   The excess of reparative
material sometimes thrown out around the end of the upper
fragment, constitutes a hard ridge at the seat of fracture, and
seriously impedes the play of the tendons  in that region.  In
time this excess of callus will be absorbed, leaving  the  parts
nearly in their normal state.
  An impending evil after fracture of the radius   near the
wrist, is false joint, which generally occurs where the patient
has used the fore-arm at too early a period, or where motion
at the wrist has not been  guarded  against during the treat-
ment.  Two ordinary straight splints, though they extend be-
yond the fingers, do not restrain motion  at the seat of fracture 
156                      Fractures.
as well as the palmar splint, with its roller-like compress for
the hollow  of the hand.  The dorsal splint resting upon the
back  of  the hand  also  serves to check that tilting  motion,
with the  lower end of the ulna for a pivot, which is so promo-
tive of non-union of the fragments.

                          Fig. 58.
The arm exhibits the deformity attendant upon fracture through the lower extremity of the
   radius. A single splint, like the one represented, will answer to dress the fracture.

  Some surgeons employ only one splint in the dressing for
fracture through the lower extremity of the radius ; and claim
to have obtained good results from such an appliance.  I have
secured satisfactory recoveries from the single splint, with a
roller bound obliquely upon the wide end, to rest in the hollow
of the hand, but I prefer using also  a dorsal splint.
  If the dressing gets too loose, and the patient begins to use
the hand before the consolidation is quite effected, the  vital
operations are perverted.   Instead  of  continuing to furnish
reparative supplies, they begin to remove the  callus  or uniting
material, and make way for false-joint.   In one case that came
under my observation, the consolidation was nearly perfect on
the twentieth  clay; there was plenty of  callus, and  every evi-
dence of a complete repair.   The patient now thought it was
all useless to hamper his arm any longer, and assumed the re-
spoiisibilit}' of throwing aside the dressing and  using the arm.
At once the operations  of nature became opposed to  consoli-
dation, and in a few weeks removed the  reparative material
and established a false-joint where there might have been con-
solidation by a week more of retentive treatment. 
Of the Radius.                  157
   A little girl was brought to me not long since with an arm
 that had been fractured through the lower extremity of the
 radius  five weeks previously.   The medical attendant had
 dressed the limb in the usual way, but the dressing had been
 loosened by the child's mother, and taken off altogether before
 the  physician had  given directions for such a course.  The
 little girl had used her arm at play, keeping up motion at the
 seat of injury where there should be absolute rest.  The  con-
 sequence was that the fragments failed  to  unite, though  the
 upper fragment furnished an abundance of reparative material.
 I regarded it as  not too late for an attempt to re-establish the
 healing process, so I  put  on the dressing recommended for
 the treatment of this  fracture, employing starch paste at each
 turn of the bandage.  In fact, the roller was employed up and
 down  the  arm  two  or three times, and  the paste freely
 applied, as the wrapping continued, to constitute an immov-
 able dressing. The rigid case thus constructed, was ordered
 to be worn six weeks  at least.   Consolidation  followed, and a
 good result was  obtained.


 FRACTURE OF BOTH BONES OF  THE FORE-ARM.

  The  radius and ulna are often broken at the same time.
The injury is produced by direct violence.  A blow, the pas-
sage of a wheel over the arm, and moving machinery, are the
common causes.  The middle and  lower extremities of the
bones are broken more frequently than the upper thirds which
are protected in  a measure by the deep coverings of muscles.
In regard to the  frequency of such accidents, the analysis of 
158
Fractures.
tables shows that  both bones' of the  fore-arm  are oftener
broken than the ulna singly.
  The diagnosis is  usually simple; the pain, loss of power, the
unnatural bend in the arm, the separate mobility of the upper
and lower fragments, and the crepitus, constitute signs  which
are too plain to be  mistaken.   The displacement of the frag-
ments may not be observable in some instances, for the broken
ends do not always become disengaged, but in most cases the
deformity is so great as to indicate at once the nature  of the
injury.  When there is overlapping of the fragments there
must, of necessity, be shortening of the  arm.   The peculiar
distortion produced by bending the limb near the seat of frac-
ture, can not be misapprehended.  Crepitus can be elicited by
grasping the arm above and below the fracture, and rotating
the limb while it is brought to its normal length and position
by extension.
  The  tendency  of the fragments is to sink into the  inter-
osseous  space, where they will unite en masse  unless well
directed efforts are made to keep the ends of the two  bones
away from each other.  In some instances one fragment will
keep aloof from  the  others which  incline to group.   If the
bones be  broken  conjointly and by direct violence,  much
damage may be done to the soft tissues, resulting in sloughs,

                         Fig. 60.
Comminuted fracture of both bones of the forearm.
protrusion of the fragments, and the most dangerous compli-
cations.  Compound and comminuted fractures of both bones
of the fore-arm have generally been considered a sufficient
cause for immediate amputation, but  such a course  is not
always necessary, as the following case will show.  In October,
1865, Mr. William Moffit, living on Longworth Street in this 
                    Of the Fore-arm.                  159

city, had his arm drawn between the rollers of a leather split-
ting machine.   The crushing  power  to which the limb was
subjected, broke the radius and ulna into  fragments, each  an
inch or two in length, beginning near the wrist and extending
to the elbow.  The arm felt like a bag with pieces of broken
ice in it.   Some of the  pieces of bone projected through the
skin.   Dr.  E. N. Cashing, of Covington, Ky., was in my office
at the  time I was  summoned  to the case, and assisted in  ar-
ranging  and adjusting the  fragments, and in dressing the
limb.  It is needless to say that it was utterly impossible to
bring every fragment into perfect apposition at both ends, but
the fragments of the two bones were pressed into  rows, and
the natural contour ofthe limb was well restored and preserved.
Splints and bandages were used to keep the pieces  and parts
steadily in place.   No  severe  pressure was applied through
fear of gangrene.   In less than two months the arm was freed
from its dressings, and put under passive  motion.   The  limb
lost only a small share  of its functions, and therefore became
quite useful. Pronation and supination were partly lost; and
the elbow  and wrist  did  not recover their full  extent of
motion.
  In treating fractures of both bones of the fore-arm, two
splints reaching from the elbow to the wrist, and wide enough

                          Fig. 61.
  Two splints, wider than the arm, and padded, are represented as tied in place with tapes
          preparatory to the reception of the roller or circular bandage.

to prevent circular constriction  of the arm, are to be  em-
ployed upon the front and dorsal aspects of the limb.   Tapes
may be used  to  retain the dressing in place until the frag-
ments  are  coaptated, and everything is ready for the roller
bandage.  As in all other fractures of the fore-arm, no primary
bandage is to go on next the skin.   The constricting influence
of such a bandage would force the fragments into the inter-
osseous space  where they are liable  to unite  in  a group.
The  retentive bandage should  be applied lightly  at first. 
160                    Fractures.
Several cases are recorded in which the limb has had to be
amputated, through  the folly  or  carelessness  of  too  tight
dressings.  There is  time enough for snug compression after
inflammation and swelling have subsided.   Inexperienced
surgeons often commit the error of strangling the local circu-
lation by a tightly drawn  retentive  dressing.   There  is no
other excuse for these repetitions in regard to the application
of dressings to a broken arm, except in the fact that serious
and fatal mistakes continue to  be made by practitioners of
medicine and surgery who have either not had an opportunity
to read impressive lessons on the subject, or they are too heed-
less to learn what is enjoined but once.
  A girl, Miss S., had her  arm broken while at work  at a
printing press. The physician under whose professional charge
the patient fell, wrapped the limb from the fingers to the ax-
illa with  new and thick  drilling, and  then ordered  the wrap-
pings kept wet all the time.  Morphia  and chloral were ad-
ministered to keep pain in  check.  Two days after the injury
I saw the ease and advised  amputation, as gangrene had ap-
peared from the fingers to a distance  above the elbow.  My
plan was rejected, and the late Dr. Geo. C. Blackmail was in-
vited  to manage the  case.  The doctor said at once the arm
could and must be saved, and the patient was taken  to the
Good Samaritan  Hospital.  In a few days the  arm dropped
from the scapula, unaided amputation having occurred at the
shoulder joint.  The separation was attended by no bleeding
or other  mishap.  The cicatricial line  was  nicely  puckered,
and every feature of the reparative  process was  admirable.
The dead arm gave issue to a horrible stench while the sepa-
ration at the shoulder was going on, yet the surgeon  had given
his word that no amputation was necessary, and he was ob-
stinate enough to stick to it.  The case shows what the unas-
sisted recuperative powers of the body will accomplish when
left to themselves.
   A similar case  occurred in  Lowell, Mass., twenty-five years
ago.   When the results of unskillful bandaging bad appeared,
surgeons gathered with  the idea of amputating, but gave up
their  purpose on the ground that the patient would not sur-
vive the  operation.   In less than a week the head of the hu-
merus dropped  from its  socket,  and in two days more all the
soft tissues became  disconnected at the border of  the  axilla. 
CIUPTER   XXIII.
FRACTURE  OF  THE BONES  OF  THE  HAND.
  The bones of the hand, including the carpus, metacarpus,
and phalanges, are seldom broken.  The carpus has  no long
bones, but a group of  eight pieces, rounded and  angular,
which are held together by ligaments and other fibrous struc-
tures, so  that even if one or more were broken or  crushed,
there would be no particular displacement or special  signs of
fracture.   It would be  more in accordance with a rational
division of subjects if fractures of the  carpus were arranged
under the head  of wounds or severe  bruises.   The carpal
bones can not be broken unless by direct violence of a crush-
ing character, as  by the  passage over  the wrist,  of a cart-
wheel, or by being caught between the hunters of rail-cars.
  The treatment should consist in adjusting displaced  parts as
well as possible, and in using a bandage  upon the hand, wrist,
and fore-arm, to restrain motion.  The topical use of anodynes
and cooling lotions, would be indicated.   In the management
of a gunshot wound of the wrist, in which  there must have
been a crushing of one or more carpal bones, my patient ex-
hibited signs of tetanus.  Chloroform  constantly  applied to
lint laid upon the wound, seemed to allay the nervous  irrita-
tion.

    FRACTURE  OF THE METACARPAL BONES.

  Direct  violence upon  the  back of the hand, and  indirect
force, as by blows upon the ends of the  knuckles in pugilistic
encounters, may produce fracture of one or more ofthe meta-
carpal bones.  I  have  treated cases that were produced by
both causes.   Two years ago, John Benson, of West Virginia,
came  to  my office one morning with the right hand swollen
       11                 (161) 
162
Fractures.
and very painful.  About sunrise that morning, he got into a
fight with a negro deck hand on the Annie Laurie.  He says
he struck at his assailant, and missing him, his knuckle hit a
box of freight; something  in his hand cracked like a.pistol,
and  his  hand became too painful  to use.  At the middle of
the metacarpal bone of the ring finger a tumefaction existed,
and back and forward pressure  produced motion between  the
fragments of the broken bone, and  elicited crepitus.
  In June last a boy came to my office from the printing  de-
partment of Stannage & Co., and complained bitterly of  his
hand, which had been injured in a printing press.  I found
three of  the metacarpal bones broken, and the first phalanx

                          Fig.  62.
    Fracture of three of the metacarpal bones, and the first phalanx of the thumb.
               The hand was crushed m a printing press.

of the thumb.  I  applied  to  the  hand  and  arm the palmar
splint used for fracture of the lower extremity of the radius,
and retained it in place with a  bandage.   The  injury proved
to be  very painful, and the inflammation ran high.   The back
of the hand was kept wet with the tincture  of aconite.   At
the end of  three weeks the dressings were removed, at which
time the consolidation seemed  to be complete.  However, the
stiffness of the metacarpophalangeal joints was so great that
forcible passive motion had to be employed for  weeks, before
the functions were sufficiently  restored to allow of his volun-
tarily opening and shutting the hand.   Slight  displacement
of the fragments  toward  the palm existed at the time I first
saw the hand, and this  deformity  was not entirely overcome
by the treatment.  The  boy was  so  stubborn  and refractory
that I could not  carry out my plan of  treatment fully.  He
objected to a moderately tight dressing, and would not submit
to efficient passive motion.  In treating fractures of the meta-
carpal bones, the plan of causing the hand to grasp a  large 
Of the Phalanges.
163
 ball, and then binding a roller around the whole, as  recom-
 mended by Sir Astley Cooper, is not so valuable as the  palmar
 splint, with a  roller compress bound  to its end  obliquely, to
 fill the hollow of the hand.  This dressing leaves the  fingers
 free, and  prevents the  ends  of the  fragments from sinking
 down toward the palm.  If the metacarpal bone of the thumb
 be broken  singly, the palmar  splint having the roller com-
 press attached, is the best apparatus that  can  be  employed to
 give the fragments support and prevent motion and displace-
 ment.

          FRACTURE OF  THE PHALANGES.

  From  the exposed situation  of the bones of the  fingers,
 fracture of one or more of the phalanges is an occasional in-
jury demanding consideration.   Direct violence is  by  far  the
 most common cause  of the  lesion, though  a blow upon the
 end  of a  finger, as in  attempts to stop or catch a ball, may
 produce fracture of the first or second phalanx.
  A simple fracture  of the  finger may  be produced by the
 great velocity  of the force applied.   The phalanges have been
 broken by a smart blowr of a cane, though no resistance was
 offered on the  opposite side of the  fingers.  A phalanx. is
 seldom broken in more than one place, and generally near the

                          Fig. 63_________


                ^^^^^
                   Fracture of a digital phalanx.

middle.  A  crushing force not unfrequently produces a com-
minution of the bone, including its articular extremities, and
perforation of the integuments.
  The  symptoms of simple fracture are crepitus and mobility
of the  fragments;  sometimes the shape of the finger will de-
termine whether it is broken or not.   If the flesh be mashed
and the bone crushed, one of the joints of the finger is about
sure  to be involved; and  the  symptoms must depend very
much upon the severity of the injury.

  Treatment.—Simple fracture  of a  finger is to be managed
on the usual  plans followed in treating the long  bones.   A 
164                    Fractures.
narrow straight wooden splint is fastened beneath the finger,
with a small compress against the point of fracture to support
the ends of the broken bone, and to fill up the concavity which
naturally exists between the joints.   A  strip of pasteboard
laid upon the dorsal surface of the finger, offers moderate re-
sistance to motion between the fragments, and serves to keep
the bandage from constricting the integument.  At the end
of the third or fourth week,  when the dressing is  finally re-
moved, well directed  passive motion is  needed to get rid of
the stiffness which  depends  upon deposits of lymph  in the
sheaths of the tendons.
  Broken fingers left to themselves, without treatment, do not
turn out  well.  They become angularly deformed, deflected
laterally, or rotated on their  axis, constituting permanent de-
formities that are sources of much regret to the patient  ever
afterwards.  I have been solicited to break a deviated finger,
and attempt to straighten it.   I have never seen  a  case  that
seemed to  justify the measure, though  such an  operation
would not always be unwarranted.
  Compound fractures of the fingers, with mashing of the
soft parts, can sometimes be brought into proper shape by the
use of sticking plaster.  Such injuries, however, do not prop-
erly come  under the head of fractures, so far as adjustment
and treatment are concerned, but must be managed  according
to the principles involved in the treatment of wounds. 
CHAPTER  XXIY.
FRACTURE  OF  THE  PELVIC  BONES.
  Crushing  forces, as when a man is caught between heavy
moving bodies, or strikes in the region of the hip at the ter-
mination of a long fall, may produce fracture of some part of
the pelvic circle.  The symphysis  pubis  has  been  separated
by the throes of labor, though such an  accident must be ex-
ceedingly uncommon.  Several cases have  been reported in
which forcible separation of the two pubic bones occurred at
the symphysis from injuries received while coupling cars, and
in railway accidents generally.  I was once called  to see an
old negro in Louisiana, who had been kicked by a mule in the
region of the pubes.  He  was unable  to urinate, and while
introducing the catheter I discovered a sinking in of the body
ofthe os pubis on the left side, at a point outside ofthe spine
of the bone.  The line of separation must have extended into
the thyroid foramen, though the ramus of the pubis did not
appear to be broken.  The  fractured surface of the end of the
outer fragment could be distinctly felt, but  the  other surface
was too much depressed to  be manipulated.  No mobility ex-
isted, and on account of the swelling no deformity was ob-
served until in the attempt  at catheterism the left  wrist dis-
covered an  irregularity of  the  parts.   The patient was not
aware that  a  fracture had been received,  but supposed  his
bladder was ruptured.  The urine was not bloody,  and there
was no evidence that severe internal injury had been inflicted.
The depressed bone ^could  not be brought back into place;
yet some months afterwards I heard that the patient suffered
no inconvenience from his injuries.
  Fractures of the pelvic bones are not necessarily dangerous
of themselves ; but the terrible forces which  produce them are
apt to inflict greater or less  injury to important parts in their
                       '   (165) 
166
Fractures.
immediate vicinity.   Fragments of bone may perforate the
rectum and bladder, or do such mischief to the viscera of the
pelvis as may seriously interfere with  the functions of those
organs.  The gravity of  such injuries can not always  be de-
termined at the earlier examinations.'  The crest ofthe ilium,
and  the  anterior superior  spinous process may be broken off
by moderate  forces, as by a kick from another individual, but
the massive strength of the deeper parts and their  protective
coverings and  connections, serve  to  shield them from the
damaging influence of all ordinary forces.
  In 1860, Andy Rice, in the employ of McHenry & Carson,
fell through  the hatches of four  stories, and struck against
hard substances in the cellar.  He  sustained  a multiplicity of
injuries,  and fully recovered from  all of them.  At first he
complained most of his left shoulder,  which was  dislocated.
This I reduced  without removing his coat  or chano-ino- his
position.   Finding that  he had several fractures I had him
taken home.   I  there learned by examination that one femur
was broken just below the lesser trocanter; that the under
jaw was broken  at the symphysis ; that three ribs  were  frac-
tured ; and that the left os innominatum was broken into at
least three pieces.  It was difficult to* determine just where
                             all the lines of separation ex-
                             tended.   The great  arc of the
                             ilium  could be  easily  moved
                             by  taking  hold of it,  and
                             the   motions  were   attended
                             with distinct crepitus.  Its line
                             of separation must  have  been
                             nearly like the upper one repre-
                             sented in  the accompanying
                             figure.  The movement of this
                             piece  gave little pain ;  but in
                             attempts to diagnose the other
                             fractures of the  innominatum
                             great  distress was  produced.
                             The greatest  degree of  pain
   Fractures cf the os innominatum.     Seemed  to arise  from motion
                             imparted to the fragments of
the femur.  The pubic part of the bone was certainly broken
through the ramus and body.  This left the femur articulated
 
Of the  Sacrum.
167
 to  a large movable fragment of the innominatum, that was
 free  from still  another  fragment which was firmly united to
 the sacrum.   The costal segment was the  most mobile, then
 the large piece that contained the  acetabulum; the  smaller
 fragment connected to the sacrum had no perceptible mobility,
 and the pubic fragment continued firm on account of its junc-
 tion at the  symphysis.   The catheter had to be used a few
 times, but there was no  blood in the urine.   The symptoms
 were so terribly severe for more than a week that there seemed
 little ground for hope.  The pelvis now has its natural shape,
 excepting a slight abnormal twist in the left os innominatum,
 which does  not cause lameness.
   The treatment of fracture of the pelvic bones consists in
 applying  such bandages, straps, belts, or  apparatus, as shall
 restrain  all  motion between  the  fragments.   In the case of
 Andy Rice  I used the  " woven wire breeches," figure  10.
 This apparatus served several purposes: 1st, to keep up ex-
 tension and  counter-extension for the fractured thigh ; 2d, to
 steady the pelvic fragments ; and 3d, it proved useful in hand-
 ling the patient during the six weeks of treatment.
  A wide belt of strong cloth or leather to buckle around the
 pelvic region, serves to steady a simple fracture of the ilium,
 ischium, or pubes.   The patient is unable to walk, or to assume
 the erect posture, if anything more than a salient point is
 broken from the pelvic bones.  The  powerful muscles  acting
 upon any considerable fragment, would  disturb  it too much
 for active exercise.
  Fracture extending into the acetabulum,  seriously interferes
 with the hip-joint;  and the diagnosis of such  an  injury must
 be exceedingly obscure.   Cases have been dissected  in  which
 it had been demonstrated that a stellate fracture of the  ace-
 tabulum   was produced  by  a blow upon the  trochanters
 of the femur, the force telling through the head of that bone.


           FRACTURE OF THE  SACRUM.

  The sacrum, as a dry specimen, removed from its connec-
tions with the other pelvic bones, is not difficult to break, but
in its normal state, wedged between the ossa innominata, and
covered with ligamentous and other firm tissues,  the bone is 
168
Fractures.
iu little danger of being broken.   A kick or a powerful blow,
such as may be  received  in  a fall, might cause a fracture of
the bone at  any point,  the line of separation running in any
direction.   The processes of the bone may be broken off, or a
fracture may extend only as far as the central or spinal canal.
In most instances, it is found  that fractures of the sacrum ex-
tend through the lower third of the bone, and mostly in a
transverse course.
  If the lower fragment be carried in towards the rectum the
functions of that tube might be seriously interfered with.  A
patient suspected of having a broken sacrum should be made
to lie on the abdomen while an examination is going on, and
an attempt made to overcome any considerable  displacement.
The finger  carried into the rectum may be the  only means of
discovering the full  extent of  the  mischief, and in correcting
such deformity as lays within digital power.  A lithotomist's
scoop,  or any instrument of proper proportions and strength,
might  be used in the rectum to  press the deflected fragment
back into place, care being used not to injure the soft parts.
  The  patient should keep quiet in the horizontal position for
a few  weeks, to allow the healing process to consolidate the
fragments.   The bowels should be kept  in a  soluble  state
during the treatment, to prevent accumulations of gas and
stercoracious matter near the seat of the injury.  Hamilton
recommends that the bowels be kept constipated in order that
the accumulation of hardened  material  in the rectum may
press back  into line  the displaced fragment, and act as a splint
on the  inner surface of the bone.  The suggestion is quite in-
genious, but the practical working of the plan is questionable.

           FRACTURE OF THE  COCCYX.

  A fracture  of the cornua of the coccyx, and  a partial dis-
location of the bone  inwards, constitute  an injury, which  is
caused by a direct blow, kick, or other violence  telling  upon
the bony appendage.  The lesion has been reported as occur-
ring from parturient efforts.   If such be the case the subjects
must  have been sufficiently advanced in life to have the bone
consolidated  to the sacrum.  In young women  the mobility
of the  coccyx allows the bone  to yield to forces brought  to
bear upon it during the last stage of  labor. 
Of the Coccyx.
169
   I have never seen  but one case of a broken coccyx; and
 this accident occurred to a man standing on the platform of a
 car as the train was suddenly put in motion by the engineer.
 The point or angle of  the iron railing struck the passenger in
 the coccygeal region, and caused a  sickening  sensation from
 the severe shock to the nervous system.   After receiving the
 injury the patient took a seat inside the coach, and although
 in severe pain, and complaining of a general uneasiness, he
 chatted  with  a fellow traveler, reaching home  that night.
 Before morning he took a " chill;" and had his family physi-
 cian summoned.   He  no longer complained of distress in the
 region hurt, but asked to be relieved of a sense  of constric-
 tion in the bowels, and nausea at the  stomach. Morphia was
 administered in large and repeated doses.  This relieved him
 of  the acute distress, yet he declared that there Avas some ter-
 ribly deep seated  disease about him that would  terminate
 fatally.  The bowels were evacuated by the influence of cathar-
 tics, and the bladder at length had to be  relieved by catheter-
 ism.  On the tenth day after the injury he died; and none of
 his medical and surgical  attendants had suspected  the true
 cause of death.  An autopsy was held, at which I was  present.
 The physician using the scalpel, remarked that he should first
 look for abscess ofthe liver, or for pus in  or about that organ.
 Finding no cause for death in the viscera  of the abdomen, and
 observing considerable redness in the pelvic colon, the peri-
 neum  and  anus were  inspected.  The discoloration  in that
 region led to the suspicion that the difficulty had  been some-
 where about the lower end of the spinal  column.  The body
 being  turned  over, the signs of decomposition in the region
 of the coccyx were strikingly apparent.   A careful dissection
 showed that the  coccygeal horns or processes wTere  broken,
 and the bone somewhat displaced inwards.  The entire coccyx
 except the detached cornua, was blackened, and bore  the ap-
 pearance of having been dead for many days.  An apparently
 trifling injury, which had not attracted the attention of several
 physicians in consultation, and which produced more  general
 than local disturbance, terminated  fatally.  This case is not
without  parallel.  Cloquet, Petit, and other surgical writers
 upon the subject of fracture and dislocation  of the  coccyx,
speak  of the dangers  of caries, as if the bone, after serious
 lesions, was liable  to mortification.  Whether  anything could 
170
Fractures.
be  done to  arrest the tendency to necrosis, if undertaken
promptly, is not demonstrated.  It  is plainly the duty of the
surgeon, when called to a  case of fracture  of the coccyx, to
overcome any inward displacement by manipulation, using the
finger in the rectum; and  to keep  the  patient at rest by the
use of opium suppositories and such other local means  of a
quieting or stimulating character, as would  afford relief and
promote a restorative action in a severe  bruise or other wound
in that region.
  It is not easy to diagnose fracture of the coccyx.   Pain of
a severe character might  arise from shock or concussion, as,
also, a  general uneasiness, on account  of the  constitutional
disturbance.  With a finger in the rectum and the thumb on
the coccyx, a great increase of mobility  might be determined,
as well as displacement; but crepitation, that distinctive  sign
of fracture, can not certainly be obtained, owing to the broken
surfaces of bone being small, and the motion imparted not of
a kind likely to cause rubbing of the broken parts against one
another. It is not improbable that  fracture ofthe coccyx has
occasionally passed unobserved, or  for  a bruise  in the region
of the  sacrum ;  and a severe  concussion in that part of the
body followed by sharp pain in attempts to walk, and during
defecation, has been regarded as a case of coccygeal fracture.
The great  mobility of the coccyx  in young subjects might
contribute  to the  deception.   Fracture arising  from the dis-
placing  force  of the child's head in parturition, is quite differ-
ent in  character from that produced by a kick or fall upon
some  projecting substance.  The shock is  much less when
produced by the  forward movements of  a child's  head.  When
produced by accidental violence there may be a vast excess of
force over that actually required to break the bone ; and  this
excess would  naturally increase the  dangers of the case. 
       CHAPTER  XXV.'

FRACTURE  OF  THE  FEMUR.
   The  length of the femur and the exposure of the bone to a
 variety of forces, contribute to  its liability to fracture.  The
 muscles surrounding the femur afford a  certain amount  of
 protection against external shocks, yet this shielding influence
 is more than counterbalanced by the strain the bone receives
 from their action.  The different fractures  to which the bone
 is  subject,  and the  complicated  appliances  recommended
 for their treatment, constitute a  series of topics well calculated
 to overwhelm the student who first directs his attention to this
 branch of surgical study.  Unless the diagnosis of such injuries
 be  clearly made out,  and the  treatment necessary  to the
 accomplishment of good results be clearly  understood,  and
 efficiently carried out, the most  lamentable consequences may
 be expected.  An imperfect  conception of the  nature  of the
 accident, or a " trust-to-luck " management ofthe injury, will
 surely lead to the chagrin and disgrace of the surgical attend-
 ant, and to the permanent crippling of the unfortunate patient.
 No medical practitioner should assume  the  responsibility of
 treating a fractured  thigh, unless he comprehends what is
 absolutely necessary to insure at least an average recovery.   A
 perfect  result cannot be attained in all instances, for the cir-
 cumstances under which some cases have  to be treated may
 thwart  the  best directed efforts of the  surgeon.   However,
 want of skill is the most common cause of bad recoveries.
  The neck of the femur is placed at an oblique angle  to the
 shaft of the bone, and in old age it more  nearly approaches a
right angle.  This  peculiar  conformation in advanced life,
together with an increased amount of cancellated tissue on
the inner structure, renders the bone weak at a point subjected
to considerable lever power.
                           (171) 
172                     Fractures.
  The trochanters are stout processes of bone, but the greater
ofthe two being subjected to direct violence in falls, and the
lesser to the action of powerful muscles, they maybe discon-
nected from the shaft, or forced into the central spongy struc-
tures.
  The shaft of the femur is very long, offering forces a favor-
able opportunity to break  it in pieces.  The muscles  exert
great influence upon a bone which offers the advantage of such
extensive lever power.  Indirect forces received by the foot,
and transmitted upward to the great curve just above the
middle of  the shaft of the femur, very frequently produce
fractures at that point.
  The condyles spread out into a broad base to give steadiness
to the knee-joint,  but they have so much spongy  structure
within, that they are not adapted to offer powerful resistance
to direct forces.   The resisting power of a bone must not be
reckoned by its size, for the middle of the shaft, which is the
smallest part ofthe bone, is probably the strongest.
  The causes which produce fractures ofthe thigh are numer-
ous.   When the  direct force acts, it generally happens that
the limb  is- crushed by some heavy weight falling upon it, or
by a loaded wagon passing  over it.  When an  indirect force
acts, it is most frequently found  that the person falls from a
height, with the thigh in such a position that the bone snaps at a
point  remote from the part receiving the shock.  An irregu-
larity in the ground sometimes imparts a twist to the leg which
may prove too great for  the brittle neck of the femur.  A
person fancying he is treading upon level ground, takes a
false step unawares, and  the muscles not being  employed to
resist  the impetus, or  to counteract the accidental  twist un-
expectedly given to the limb, he receives a fracture ofthe neck
ofthe thigh bone.

   FRACTURE  OF   THE  NECK  OF  THE FEMUR.

 The  neck ofthe thigh bone has been invested with unusual in-
terest, both on account ofthe frequency of fracture occurring at
that point,and thelearned discussions that have taken place con-
cerning the possibility and probability of bony union taking
place here as in fractures through other parts ofthe bone. A quo-
tation from Mr.Lonsdale expresses some of the reasons why frac- 
Of  the Femur.
173
tures through the cervix femoris are so frequent: "It is an acci-
dent that is met with chiefly in old people, and very seldom,
indeed, in young.   The  structure of the bone in old people
becomes altered, owing to the deficiency of the animal matter
in it, causing the earthy to be in  excess, which  gives a brit-
tleness to it, that does not exist in the, bones of young people.
This part ofthe bone is also naturally of a loose, cancellated
structure, and when deprived of its animal matter, will become
weak and ill calculated to receive  any severe  shock, either
from the weight ofthe body, or from a blow directly  applied
to the part.  There are  other causes also which tend to pro-
duce fracture of this part ofthe bone.
Fig. 64.
Bection ofthe head, neck, and upper extremity of the Shaft of the Femur, showing the inner
          cancellated texture, and natural shape of this part of the bone.

   The muscles surrounding the hip-joint in old people waste,
causing this part to become flattened, and to have compara-
tively little covering upon it; so that a fall upon the posterior
part of the hip, which, in  a younger  person, in  whom  the
muscles act as a  cushion, might tell with little force  directly
on the trochanter, or neck of the bone, would in an old one, 
171                     Fractures.
 where this cushion is absent, be sufficient to produce fractnre
 In old people, also, the  whole body loses its elasticity, all the
 movements are heavier, and more awkward and less secure,
 so that falls are likely to take place from trifling causes, with-
 out the power of resisting them;  for though a younger per-
 son might break  his fall  by the use  of his arms,  or by the
 strength and activity of his body generally, an old person can
 not, but  falls like a dead weight, and the shock, of course,
 becomes much greater than  it otherwise would be.  All these
 circumstances taken together cause this kind of fracture to be
 much more frequent in  old than young people."
   Sex has something to do with the frequency of the fracture.
 In  women the pelvis  is wider, and the neck of the femur is
 longer, and  it joins the  shaft nearer a right angle than*it does
 in men.  Elderly females are apt  to lose confidence  in  their
 pedestrian  powers, which, so far  as it  goes, favors fracture;
 besides, their bones and bony supports  are weaker  or less de-
 veloped than in the other sex, being therefore less capable of
 offering resistance to forces acting upon the skeleton.  Elderly
 persons, if they fall heavily  upon the trochanter, may sustain
 fracture of the neck ofthe femur.  This kind of violence has
t been  called  direct, though it is not more so than when a per-
 son, in falling, or in taking a false step, sends a force from the
 foot up  to  the  neck ofthe bone.  Indirect violence, then,
 must be considered the common cause of fracture through the
 cervix femoris.
   A  fracture near the head of the bone, and wholly within
 the capsular  ligament, is generally transverse, while the direc-
 tion of the fracture is likely to be oblique, if it be near the
 trochanters,  making the line of separation partially within
 and partially without the cavity of the  joint.
   It is quite essential to understand the place where the solu-
 tion of continuity exists, for in a fracture near the head of
 the bone ossific union need not be  expected, but in  a  fracture
 extending outside the femoral attachment ofthe capsular lig-
 ament, bony union maybe reasonably expected, with a strong
 and useful  limb.  It will generally be found that fractures
 wholly within the capsular ligament, result  in ligamentous
 unions;  and that a break iu the bone outside the ligament is
 about sure to end in osseous consolidation.  In fractures partly
 within and partly without the ligament, as  when the line of 
Of the Femur.                 175
separation is oblique, or  irregular in  its course, crossing  the
attachment  of the ligament to  the bone, the union  is most
likely to be  osseous,  though it may be fibrous.
  Displacement has considerable to do with consolidation,
though not so much  as mobility.  If the  separation of  the
broken surfaces be so great that there is scarcely any  contact,
bony union  is not to be expected ;  and  if in addition to dis-
placement, there  be constant rocking  of one fragment upon
the other, efforts  at consolidation are  thwarted.
  Much has  been  said about  lack  of reparative  supplies
afforded to the articular fragment, as if it were completely cut
off from vascular •connections, except  through the ligamen-
tuni teres.  In some instances, especially if the synovial mem-
brane b.e torn, as it is likely to be, the head of the bone is
completely isolated except  through the round ligament.  This
theory in regard  to scanty  nutritive supplies, is supported by
the fact that large quantities of  reparative bony material  are
deposited around the end of the lower fragment, constituting
an excess of callus, while the scantiest amount is accumulated
about the end of  the short or upper fragment.  The  s3miptoins
of a fracture within  the  capsule  are,  shortening of  the  limb,
eversion of the foot, motion between  the fractured portions
ofthe bone, crepitus, great pain about the joint, and inability
to move the limb, or to bear the weight of the body  upon it.
The shortening is not marked directly after the reception of
the fracture, but it increases from day to day till it reaches an
inch or more   The shortening may be  overcome by  making
extension, and as soon as this force is relaxed, the limb draws
up again.  It requires considerable care, and regard for accu-
racy, to ascertain whether  one  leg be longer than  the other.
A limb is often supposed to be shorter  than  the other, when
the  position of the patient's body produces the  deception.
Anybody can lie  upon the back, and so twist the pelvis as to
make one leg appear of a  different length  from  the other.
In the  examination of  a  patient to  ascertain the  relative
length  of the limbs,  the* pelvis must be placed straight with
regard to the transverse diameter of the body; for any obli-
quity in this direction will  give a corresponding  obliquity to
the  lower extremities, and cause one  to appear longer than
the  other.  The  pelvis being quite  straight, the two knees
ought to correspond, and the two heels  also, if both limbs  are 
176
Fractures.
         of the same length.  After observations have been taken, with
         the body carefully arranged as just  indicated, measurements
         should be taken to determine exactly the amount of shorten-
         ing, if any exist.  The patient being placed in bed, and care
         taken that the shoulders and pelvis are parallel to one another,
         and the legs in conformity to the straight attitude, a piece of
         tape  or  inelastic cord is  made to take the distance from the
         anterior  superior spinous process  of the ilium to the  patella
         or external malleolus ; or, what is better, from the symphysis
         pubis to  the internal malleolus of each ankle.  Any well de-
         fined  and unvarying point in the body is as good as those in-
         dicated ; the upper or lower extremity of the sternum, or the
         umbilicus, will answer as a point  to  commence the measure-
         ment. As the patella is rather moveable, it will be necessary
         to measure to the lower point of the bone when it is  pulled
         upwards, in order to arrive at accuracy.  Shortening alone  is
         not a sure indication of fracture, for the limb may have been
         shrunken from childhood, or drawn  up from dislocation, but
         in connection with other signs, this becomes valuable.   In rare
     #    instances there may be  fracture and  no displacement, or
         shortening.  Mr. Stanley relates the  following case,  which
         illustrates the point.  " A man aged sixty, was knocked down
         in the street; he complained of pain in the hip, but there was
         neither shortening nor eversion  of the  limb, and its several
         motions  could be executed with perfect  freedom and power.
         A  fracture was not suspected ;  the patient, therefore, was
         merely confined to his bed.  In the  fifth week from the date
         of the accident  he died from another cause.  No  trace of in-
         jury was found in the  parts around the hip joint, but small
         effusions of blood, apparently not recent, were discovered be-
         neath the synovial and fibrous membrane, covering the neck
         of the femur, also beneath  the synovial membrane covering
         the ligamentum teres.  The head and neck of the bone were
         sawed through their middle, and in each portion a dark line,
         evidently occasioned by the effusion of  blood, was seen ex-
         tending  through the bone at the base of the neck.  A  fracture
         was discovered  extending along this line; but the broken sur-
         faces were in contact, and the synovial and fibrous membrane
         covering the neck ofthe bone was uninjured."  " In this case,"
         Mr. Stanley very pertinently remarks,  " if an attempt had
v  ■      been made to  walk at the end  of two  or even three weeks 
Of the Femur.
177
 from the accident, a separation of the fractured  surfaces, and
 consequent  shortening of the limb, would have  been the
 result."
   Either from the natural inclination of the foot to gravitate
 outwards, or from the action of the rotator muscles, the foot,
 after fracture of the cervix femoris, is almost always found to
 be in a state of eversion.  In extremely rare instances, mostly
 where the  force  producing the fracture violently twists the
 foot  inwards, the limb  may continue in that position.  It is
 highly probable that impaction  has considerable to do with the
 position of the  limb in cases varying essentially  from the
 usual attitude assumed after fracture of the neck ofthe thigh
 bone.  The fragments may be interlocked, or the lower one
 may  be driven through the capsular ligament, and held in an
 inverted position until extension frees one or both pieces from
 the  entangled state.  If the  limb be  somewhat fixed, in an
 everted or an inverted position, there exists a mechanical ob-
 stacle to rotation either in one direction or the other.
   W7hen crepitation can be produced  by motion imparted  to
 the limb, it is  conclusive of fracture; but in many instances
 this decisive and distinctive sign can not be  produced.  The
 round head of the bone and its free motion in the acetabulum
 require the least interlocking of the fractured surfaces to cause
 the  lesser fragment  to follow the natural movements of the
 larger.   The  articular fragment is so nearly concealed in the
 cotyloid cavity that it can not be seized and held  fast while
 the o'iier is made to grate against it.  Crepitus can be elicited
 in nearly every instance of fracture of the neck of the femur,
 if the lower fragment be forcibly extended and carried through
 all the motions possible for the limb to take, yet a rash course,
 simply to produce crepitation, would not be justifiable.   There
 are plenty of points to  decide the question of fracture, even
 if crepitus be not sought.
   It is not a little singular that a patient with a broken thigh
 bone  can  walk directly  after receiving the injury.  Asa gen-
 eral thing the patient falls immediately upon the reception  of
 the fracture ; or, having received the fracture by the fall, he
is unable to  rise ; yet there are notable instances in which
patients  have  not only risen from  the ground, but  walked
almost  as if nothing serious had happened.  These unusual
powers  after  fracture, are  difficult to be understood.   Theo-
      12 
178                     Fractures.
rists have attempted to explain them on the supposition  of a
firm impaction, and on  the  ground that the fragments were
interlocked.  It has also been claimed that in such cases  the
untorn  periosteum  holds  the pieces  in  exact  apposition.
Usually the loss of voluntary power is complete,and the limb
falls into a state of eversion characteristic of the injury.
  Any one familiar with all the peculiarities of the limb after
fracture  of the cervix femoris, has observed the change of
position  assumed by the great trochanter.  In the event o:
shortening, the bony prominence is drawn upwards, so that i)
occupies a site nearer the ilium ;   eversion throws it back-
wards;  and impaction,  when  it  exists, carries  the process
closer to the acetabulum, giving the limb a  flattened appear-
ance not seen in the sound thigh.  Another notable feature
of the trochanter is, that in rotating the limb the  bony pro-
tuberance does not describe the segment of so  large a  circle
as it does in its natural state.
  Pain  and Swelling.1—There is rarely much pain in what is
called intra-capsular fracture, unless the  limb be moved or
disturbed by manipulation.  Gently extended and propped
up on each side, the broken limb is affected with  little or  no
distress.   However, any  efforts to voluntarily move the  limb,
or any attempts to discover the nature of the injury by rude
handling, are attended with severe pain.  The  swelling  may
be moderate, especially if no violence be done to the parts in-
volved, except mere fracture.
  In many cases the normal size of the limb renders manipu-
lation at the seat of injury quite useless ; the diagnosis, there-
fore^ is based  more upon measurements, eversion, and  other
signs already indicated, than upon  the senseless kneading that
inexperienced practitioners are apt to  apply directly to  the
parts about the hip joint suspected of fracture.  If each diag-
nostic symptom be carefully considered, enough signs v ill be
discovered to  decide almost  any case, though some  signs of
fracture may not be prominent.  Generally  it requires only a
superficial examination to determine the nature of the injury ;
in rare cases the closest  scrutiny is demanded  to decide  the
matter.  It is quite essential that the evidence of fracture  be
ascertained when  it exists, in  order  that the treatment may
be well  directed.  To confine a patient, hampered with frac-
ture dressings, to the  horizontal position for  weeks  and 
Of the Cervix Femork
179
   months, under the supposition that a fracture  exists when
   really it does not, would be quite unpardonable.


   FRACTURE  OF THE  CERVIX  FEMORIS  WITHIN
                      THE  CAPSULE.

    In a recent fracture of the neck of the femur within the
  capsule, the tissues immediately involved  are reddened, and
  there is an abundant effusion of lymph, and not much extra va-
             Fig. 65.            sation of blood.   The  capsu-
                                lar ligament may preserve its
                                integrity, and, also, the syno-
                                vial membrane;   these struc-
                                tures, however,are quite likely
                                to be lacerated, especially the
                                delicate coverings ofthe bone
                                at  the  seat of fracture.  In
                                the course of a few days the
                                presence of reparative  mate-
                                rial  is discoverable, and osse-
                                ous  particles  at  length find
                                their way  to the borders of
                                the  fractured  surfaces;  yet
                                before any bony matter is ex-
                                uded, plastic lymph, floating
                                in an  abundance  of synovial
                                fluid and gathered in shreds
 to the torn tissues, shows a disposition to connect the  frag-
 ments with fibrous bands.
   In old cases, the capsular  ligament  becomes thickened, es-
 pecially at its upper part, which has to sustain the weight of
 the body in walking, the long fragment pressing up against it
 for support at every step.  In cases -where no impaction exists,
 and no real progress is  made towards osseous consolidation, a
 variety of  conditions are found within the capsule of the
joint; in some cases the organized bands of plastic material
form a pretty  firm connection between  the fragments, the
patient being able to walk with some assistance from cane or
crutch ; in  other instances  the  fibro-ligamentous  bands are
slender or too long to be of any service as connecting media
between the fragments; finally, the fractured surfaces  may
Fracture of the cervix femoris within the
          capsule. 
180
Fractures.
Fig. 66.
  mutually yield to  one another, the short fragment becoming
  excavated and polished, and the cervical portion of the long
  piece rounded into a conical knob to fit into the cup-like cav-
  ity presented to it.  Such a false joint would be a troublesome
  affair, yet not necessarily prevent  the person from  enjoying
  somewhat  restricted  locomotion.   Absorption  occasionally
  alters the  broken parts in  a wonderful manner.  The  short
  piece has been completely removed by the absorptive processes,
  and the  upper end of the long fragment has been  dissolved
  and removed, the absorption reaching into the greater tro-
  chanter, leaving nothing but the shaft of the bone which was
  steadied in place by the muscles inserted into it, and by the
  condensed tissue surrounding it.  In the event of impaction,
  the  cervical portion of the long fragment being driven into
  the cancellated structure ofthe head ofthe bone, the connec-
                             tion is so intimate that the pieces
                             mutually steady each other, and
                             favor bony consolidation.
                              A great deal of interest attaches,
                             at the present time, to the ques-
                             tion whether  bony union ever
                             follows fracture  of the  cervix
                             femoris, the  line  of separation
                             being wholly within the capsule.
                             It  is pretty generally  admitted
                             among   surgeons   who   have
                             studied pathological specimens,
                             that such a fracture, if impacted,
                             may result in  consolidation ; but
                             if the break  be  simple, entirely
                             within  the capsule, and uncom-
                             plicated with impaction, or tear-
                             ing of the capsular ligament, the
                             union  is  most likely to be liga-
  mentous  and imperfect  at that.  Much ingenuity  has been
  displayed  in  attempting  to account  for  the lack  of  bony
  union ; the fact  that  motion  between the fragments can not
  be arrested by any ordinary apparatus, has some  bearing  on
Ahe  question; the  abundance of synovia  secreted under the
  mfluence of prolonged irritation, diluting and otherwise im-
  pairing the qualities of the reparative materials, is adverse to
Consolidation following impaction.
\ 
Of  the Cervix Femoris.               181
 consolidation of the fracture ; but the chief obstacle to repair
 seems to reside in the almost complete isolation from vessels
 and  nerves, to which  the head of the bone and remnant of
 the neck are subjected by the fracture.  The ligamentum teres
 is a small band of dense white tissue, with scarcely a vascular
            YiQm 67.            s'£n m it'   An adequate sup-
                               ply  of  reparative  material
                               could not be expected to find
                               its way through such attenu-
                               ated  channels.   If the frag-
                               nients could be maintained in
                               perfect apposition for a few
                               days it is possible that a direct
                               union,  similar  to  what  is
                               known  as "first  intention"
                               in wounds of the soft tissues,
                               might occasionally take place,
                               which might in time ensure
                               osseous   consolidation.   In
                               some of those rare instances
                               in which early union is known
 Ligamentous union following fracture ofthe to have taken place after ill-
   neck of the femur within the capsule.                „
                               tracapsular  fracture,  without
 impaction, it  is probable that the results followed perfect co-
 aptation, freedom from motion, and the quick restoration  of
 the usual channels of supply.
   Where the  line  of separation  is partly within and partly
 without the capsule, giving the otherwise isolated fragment an
 opportunity to  get its  supplies without  drawing for them
 through the round ligament, the  chances in favor of bony
 union are greatly increased.


 EXTRA-CAPSULAR  FRACTURE  OF  THE  CERVIX
                        FEMORIS.

  In extra-capsular fractures, i. e., where the line of separation
is entirely outside the apparatus of the joint, the upper frag-
ment having a good supply of vessels entering it  by the many
foramina so  conspicuous in that part of the bone, the union J
is  likely to  be  osseous.  Even  if the line of fracture extendr
slightly beyond or within the capsule, it does not seem to iiir-
/ 
182
Fractures.
Fig. 68.
terfere with consolidation in cases where the greater part  of
the fracture exists in the trochanter and that part ofthe neck
immediately adjoining it.  It is not uncommon, in falls upon
the trochanter, for the fractured cervix to penetrate  the can-
cellated structure of that great process of bone, and even  to
act the part of a wedge and split it.  Sometimes the two tro-
chanters are  rent asunder  by this  wedge force, more or less
impaction taking place in  every instance.  Specimens  are  in
existence which show the line of separation to be through the
trochanter major, the upper part remaining with the neck  of
the  femur, and the lower with the shaft of the bone.  In a
greater number of cases, however,  the fracture is multiple  or
comminuted, the trochanter being broken into several frag-
                         ments, and the cervix femoris de-
                         tached from all of them.
                            Although bony union is the rule,
                         in  extra-caps ular fractures,  the
                         healing  process  is  slow,  and the
                         consolidation of the cervix  to the
                         trochanteric   fragments  is  more
                         tardy than  it  is in fractures lower
                         down.   A. notable  feature con-
                         nected  with consolidation of frac-
                         tures near the hip-joint is the great
                         exuberance  of   ossific   deposits,
                         which interfere  with the motions
                         of the limb,  and tend  to  deceive
                         any one examining the parts with
                         the object of ascertaining the orig-
 Exoess of callus after extracapsular  •  i 0+r.j-„ _f +]-.„ :„:,,,,„
      fracture of the femur.      mai State 01 ttie 111JU1}.
  Rough points in the reparative material  render muscular
movements painful; and may inflict permanent lameness upon
the patient.  These ledges of bone may become rounded off"
in  time, yet their complete obliteration need not be expected.
  The symptoms  of extra-capsular fracture very closely re-
semble those manifested by fracture within the capsule; there
is  shortening, eversion, inability to move the limb, and the
other signs peculiar to fractures in  general.   If the great tro-
chanter be  involved in the*fracture, the mobility of the frag-
ments, and the attending crepitus, would be distinctive  of
extra-capsular  lesion.   In  the extra-capsular variety the
 
                   Of the  Cervix Femoris.              183

 shortening of the limb is immediately to the extent of an inch
 or  more, while in the other  variety the shortening rarely
 reaches its maximum for several days.
   The accidents which are most liable to be confounded with
 fractures  of the  neck of the femur, are dislocations of the
 head of the femur upon the pubes, severe contusions -of the
 hip, paralysis, and absorption  of the neck of the thigh bone
 from chronic arthritis.  A fracture of the acetabular cavity,
 the bottom being driven into the pelvis, the head ofthe femur
 following, may present features leading to  the  suspicion- that
 the cervix femoris is broken.   However, a critical  considera-
 tion of each symptom, and a careful analysis of each group of
 signs, will lead to a rational  solution of almost every case.
 If the surgeon is not able to determine the exact course of
 the fracture in every case it is practically of very little impor-
 tance, for the  treatment is substantially the same for all  frac-
 tures in the vicinity of the joint.  The real nature  of obscure
 cases can  only be determined after death.  Very few suits, for
 alleged malpractice, have grown out  of imperfect  recoveries
 after fractures of the neck of the femur, for the reason that
 even the  most experienced surgeons are averse to giving a
 positive opinion  in regard to obscure injuries about the hip
'joint.  In a recent case of severe injury in the vicinity of the
 hip joint, where great pain and swelling are in the way of a
 satisfactory examination, it is  best to put the patient under
 the influence of chloroform, when a more thorough explora-
 tion can be carried on.
   Some very interesting specimens of defective and deformed
 femurs are in  existence, which  have been selected and pre-
 served  to show that  bony union  will take place after intra-
 capsular fracture.  Sir Astley Cooper had gained the reputa-
 tion  of having taught that  ossific union could never take place
 if the line of fracture was wholly within the capsule.  Certain
 other surgeons took  a  different view  of the  question, and
 hunted the museums and graveyards for thigh bones which
 tended to  disprove the teachings accredited  to Mr.  Cooper.
 The  specimens were sawed through and through  in order to
 display the white line of ivory  hardness that seemed to mark
 the  consolid'ition of the fragments.  Many of the  specimens
 supposed  to represent the line of union, were cast aside as
 spurious, and as representing the effects of chronic arthritis, 
184                    Fractures.
or fracture partly outside the capsular ligament.  The numer-
ous specimens were narrowed down by professional criticism
to a half dozen, more or less, of bones that furnish evidence
of having been broken  within the capsule, and afterwards
consolidated.  The late Prof. R. D. Mussey obtained  a few
pathological  specimens of the  thigh  bones, which offered
quite  convincing  proof of having  been fractured within the
capsule, and  of osseous union following the injuries.  These
specimens were taken to Europe and exhibited to distinguished
surgeons there for the purpose of eliciting opinions concerning
the evidence of fracture and subsequent consolidation.  It is
a verity that  " doctors disagree," and in regard to the morbid
marks borne by the bones in question, there was not a unity
of opinion.  Of one specimen  which had been regarded  as
clearly indicating the  line  of  osseous union after  fracture
within the capsule,  Mr. Cooper said there never had  been
any fracture in the case, or, if there had, the line of separation
had run outside the capsular ligament.  Mr. John Thompson,
of Edinburgh, declared " upon his truth and honor " that a
fracture had never existed in the specimen, but the changes  in
                             the shape and appearances of
                             the bone  were due to chronic
                             inflammatory  action  and ab-
                             sorption.   Other pathologists
                             abroad believed that the  bone
                             had been fractured. American
                             surgeons who have examined
                             the specimens generally agree
                             in the opinion that intra-cap-
                             sular fracture once existed in
                             them.  There is also a specimen
                              ofthe same kind in the Wistar
                             and Horner Museum of Phila-
                             delphia, and one  belonging  to
                             Prof. Willard Parker, of New
                             York.  Prof.  H. II. Smith, of
                              Philadelphia,  thinks  that Dr.
                             Parker's  specimen  does not
bear positive evidence of fracture ; or, if a line  of separation
did exist,  it must  have  been  partly extra-capsular.   In a
specimen of mine, exhibited by figure 69, the  primary frac-
Bony union after intru-eapsular fracture ;—
     with evidence of impaction. 
Of the  Greater  Trochanter.
185
ture was undoubtedly intra-capsular, but impaction must have
taken place, as indicated by the disturbance of the cancellated
structure ofthe trochanters.  As before stated, the impaction
of the fragments  favors consolidation in a variety of ways,
therefore such specimens are not legitimate evidence in settling
the question of osseous union after simple, uncomplicated  in-
tra capsular fracture.
Fig.
  FRACTURES  OF  THE GREATER TROCHANTER.

   Fracture of the trochanter major, uncomplicated with frac-
tures of the neck or shaft of the femur, is an  extremely rare
accident.  Only a few cases have fallen under the notice  of
               surgeons, and some of these were not discov-
               ered  or verified until after death.  The accom-
               panying diagram represents  a  simple fracture
               of the  process, uncomplicated  with more ex-
               tensive lesions of the bone.
                 A  splitting of the trochanter which  is  pro-
               duced by impaction in connection with fracture ,
               of the cervix femoris, is more properly consid-
              ered  as a part of the injury to the  neck of the
              bone.
                 Heavy falls  upon the  hip may produce a
                         chipping off of the  the tip  of the
                         trochanter,   to  a  greater  or less
                         depth; and age has not  so much  to
                         do with the injury  as  it has with
                         fractures of the cervix femoris.  The
                         break is not  always characterized by
                         displacement, for the fibrous struc-
                         ture covering the  process may con-
                         tinue untorn, and hold the fragment
                        in place.  If the enveloping fibrous
                         tissue be lacerated the fragment will
                        be drawn some distance away from
                        the rest of the bone, by  the muscles
Comminuted fracture of the  cervix  inserted into it. Ill  Slicl'l a Case the
femoris and ofthe trochanter major.                       t  i i   p i  •
                         detached fragment could  be felt  in
its mobile state, though  it would be difficult to bring it  in
contact with the other fragment unless the limb, carried into
Fracture of the ex-
 tremity of the
 greater trochanter
Fig. 71.
 
186                     Fractures.
extreme abduction, sufficiently favored apposition to allow  of
contact.  Once brought into place the piece might be rubbed
against the broken surface it originally left, and be  made  to
produce crepitus.
  The exposed position of the great trochanter leads to the
conclusion  that  the  process  might be frequently broken, but
experience  does  not sustain  the inference.  Probably, if the
neck  of the  femur could better maintain its integrity under
severe shocks, the trochanter would be*the more frequently
broken.  As it is, the yielding of more fragile parts, saves the
trochanter.
                In  the  event of fracture, separating the
              greater part of the process, the pain, swelling,
              and deformity might lead to the supposition
              that some more important lesion had been sus-
              tained, therefore a careful diagnosis should be
              entered into before  a conclusion is  drawn.   A
              patient with a broken trochanter might not be
              fortunate enough to secure bony union, though
 chanter major. "  the detached fragment be kept at rest, and  in
              a state  of  partial apposition.   The horizontal
attitude of the body, with  the fragment drawn downwards by
means of adhesive strips applied while the leg is abducted, is
about all that can be done to  secure a favorable result.


TREATMENT  OF  FRACTURES  OF  THE  NECK OF
                      THE  FEMUR.

  Substantially the same kind of treatment is indicated for all
kinds of fractures  about the neck of the femur, whether the
line of separation be intra or  extra-capsular, or partly within
and partly without the capsule, including impaction  and split-
ting of the  greater trochanter.  The points to be overcome are
shortening, eversion, and mobility.  The object to be gained
in intra-capsular  fracture is a short and firm ligamentous
union, and  if consolidation incidentally incline to  take place,
it should be favored'by the treatment; in extra-capsular frac-
ture  osseous  union may be reasonably expected,  and proper
dressings favor  the  desired  result.   However, the  kind  of
patients liable to  fracture of the  neck of the femur is such,
that confinement to the horizontal position, and the irritation
 
Of the Neck  of  the Femur.
187
produced by dressings, are not borne without  complaint and
opposition.   Some old people are so restive under the restraint
of fracture dressings that they will assume the responsibility
of throwing them all off.  I well remember, in my professional
beginnings, of having spent an hour  or twro in dressing an
old man's thigh who had broken his cervix femoris by step-
ping on his grandchild's playthings.  I congratulated  myself
upon the success of having dressed the  limb so skillfully.  The
next morning I called to see how my surgical case progressed,
not doubting but all was right.  My patient appeared at ease
and composed.  Upon asking him  how the leg was doing, he
said, " I could not endure your traps an hour, so I threw them
aside, and put in practice my own plan, which you can  inspect
but not interfere with."   The apparatus for producing exten-
sion and  counter-extension, with  all  additional straps, and
trappings, were gone, and the patient  had placed the  tendo-
Achillis of the fractured limb between the toes of the sound
foot; and thus he  produced moderate  extension, prevented
eversion, and  maintained the  limb in a state of ease.   He ab-
solutely refused to have any dressings applied to the limb, and
kept up his novel plan of treatment quite steadily for  Aveeks.
He at length got up with a  useful limb,  consolidation  having
taken place, though there was shortening to the extent of an
inch or more,  and much stiffness about the hip-joint,  owing
in part to an excess  of callus, or " buttress of bone," thrown
out near the trochanteric lines.
  Experience teaches that a great amount of extension should
not be made even if the shortening be  not entirely overcome;
first, because patients can not endure the forces applied;  and,
second, because the fragmeuts are found not to rest in apposi-
tion if subjected to much traction.  The eversion  can be easily
overcome by the judicious  use  of  sand bags or other easily
pressing props.
  The long splint, so called, which reaches from the foot  to
near the armpit, or the long double splint, extending from the
axillae down on each side of the body and along the outsides
of the legs to a  foot-piece, requiring perineal bands to  secure
counter-extension, is painful  to wear, even insupportable  in
many instances.
  A wide belt of cloth buckled around the hips, with a notch
near the anus to facilitate evacuations,  serves a good purpose 
188
Fractures.
in steadying the broken cervix, especially if the patient  be
placed on  a firm mattress, with the knee moderately flexed
over a large sand bag.  This arrangement can be made still
more complete by strapping the lower part of the thigh or the
ankle to the foot of the bed, raising the posts a little by put-
ting bricks under them, to give the patient's body a slight in-
clination toward the head ofthe bed.   I have treated patients
in this way quite comfortably for them and satisfactorily to
myself.   The " wire breeches" figure 10, fill  the most inclica-
The " wire breeches " applied.
tions  of any species  of apparatus yet invented for the treat-
ment  of fractures through the cervix femoris.   It  should be
well padded to obviate excoriations, and made so nearly to fit
the body and limbs as to  be  comfortable.  Extension is made
from the foot-piece, and counter-extension against the tuberosi-
ties of the ischium.   The apparatus allows the patient to be
bolstered  up in bed, without imparting much motion to  the
fragments ; and it has an opening left between the  leg pieces
for evacuations of the bowels to pass.   I have used  the " wire
breeches "  in two or  three cases, and secured the happiesl
results.
  Cases are reported as  having been successfully treated bv
placing the limb over a double inclined plane made of pillows
or junk.   This is an easy attitude, and  the  plan is so simple
that it may be readily put in  practice under almost any circum-
stances.  The inexperienced practitioner is  apt  to  think, be-
cause  fracture of the neck of the femur is a serious lesion, that
a complicated apparatus is demanded  for its treatment.  The 
Of the Neck  of  the Femur.            189
quicker he dismisses such an idea the better it Avill be for him-
self and patient.   Death has ensued from the confinement of
feeble and aged persons in a too rigid and  " scientific appara-
tus."  If a  patient does  not  bear the straight splint or any
other, without becoming exhausted by the restraint and hori-
zontal position, all dressings should be laid aside, and attention
paid to comfort and general recuperation.   No particular kind
of dressing, then, can be carried out in all cases.  The surgeon
must consider the  condition of his patient before applying the
treatment, and modify it from time to time as circumstances
seem to demand.  A young person can generally endure such
restraint  as  shall  favor consolidation,  and some old people
bear up remarkably well under confining influences for weeks
together. The diet should be nourishing and easily digested;
the bowels  need not be  disturbed  by frequent evacuations ;
and an anodyne may be taken to allay severe pain.
   The question may arise among those who have  feAv oppor-
tunities to treat fractures  of the cervix femoris, either within
or  without  the capsule, or through the trochanters, why an
effort need be made to distinguish one fracture from the other,
since the same kind of  treatment  is recommended for all of
them ?   Practically it is  not of vital importance to  discrimi-
nate between the  different forms  of lesion, and to trace  the
line of separation Avith the idea that nothing serviceable  can
be done till the course of the fracture has been established be-
yond a doubt; yet it is  an accomplishment worth possessing
to be able to tell the patient that the case is one of intra-cap-
sular fracture, and that  such injuries generally unite AA'ith  lig-
amentous material, and that permanent lameness may be  ex-
pected ;  or,  that the fracture is one  of  the  extra-capsular
variety, and ossific union may reasonably be  anticipated.  In
a mixed  or doubtful case the best surgeons must acknowledge
the imperfection of the art of diagnosis and the uncertainty of
the result of  the injury,  even when scientifically treated.  Im-
paction is a condition favorable to bony union ; and impaction
generally arises from a  heavy fall  on the trochanter, driving
the cylindrical and perhaps sharpened cervix into  the cancel-
lated structures of the expanded part of the bone.
  It is to be borne in mind that an intra-capsular fracture
generally occurs in old subjects, from a trip of the foot on the
carpet, or from some trivial cause, and commonly not from  a 
190
Fractures.
fall on the trochanter; that the shortening, eA^ersion, and other
familiar  signs  attend   extra-capsular  fractures,  and 'are
therefore not differential or distinctive in character ; but in  a
simple fracture  wholly Avithin the capsule, the limb  appears
flabby, poAveiiess, immovable,  and as. if paralyzed, Avith  the
Avhole expression altered.
  In extra-capsular fractures, whether impacted or not, bony.
union may be expected, though the excess of callus employed
in the repair of the injuiy, is likely to impede motion, and to
create considerable local deformity.  In the event .of shorten-
ing after consolidation,  the defect may be partly remedied by
a higher heeled shoe.  Exercise  facilitates the removal of ir-
regular and sharp projections, and helps to restore strength to
the limb, and confidence in putting it to use.
  When called to take charge of a fractured hip, the  surgeon
should place himself right with the patient and friends by ex-
plaining the nature of  the injury, and the probabilities of a
good or imperfect result.  The prognosis should be carefully
guarded, for old people  frequently die from the irritation and
restraint consequent upon fractnre of the femur.  Bed sores
upon the sacrum and sloughs upon the heel render the patient's
sufferings  exceedingly  irksome.  Loops  let down from the
ceiling where the patient can grasp them with the hands, to
assist in movements of the body, serve  an excellent purpose.
Little comforts are highly appreciated, and  if brought about
by the surgeon's suggestions they add to his reputation for skill
and attention.  A  piece of buckskin large enough to cover
the excoriated hips of a bedridden patient, may save  a great
deal of distress, and contribute much to the healing of irritated
and ulcerated parts.  Dressed deer-skin, Avith the hair left on,
is often exceedingly agreeable.  The soft leather is much more
comfortable to the irritated skin than any kind of cloth.


  FRACTURES  OF THE SHAFT  OF THE FEMUR.

  Fractures occurring beloAV the  lesser trochanter, and above
the condyles, properly belong to the shaft of the bone.  The
line of separation is not confined to any particular  locality,
but is found  in  the upper, middle, and lower  thirds.  The
point a little above the center  of the bone is more  liable to 
Of the Shaft of the Femur.            191
 yield to indirect violence than any other.  The  greatest num-
 ber of cases coming under my observation presented a fracture
 a few inches beloAV the trochanters.  The bone has generally a
 little sharper curve in  that region than  pervades the entire
 shaft, Avhich may be the  reason that  the accident occurs so
 often at that point.  It has been a question whether the shaft
 of the  femur is broken most frequently by indirect violence,
 as in falls, Avhen the person strikes upon the feet, and has the
 force transmitted upwards to the thigh  bone ; or by direct
 violence, as a blow, or the passage of a  wheel over the limb.
 The prevailing  impression among  surgical  writers upon the
 subject, is that  the direct application of  force  breaks more
 femurs than indirect agencies.
   Those avIio have had limited experience in the management
 of broken femurs are exceedingly prone to talk of oblique and
 transverse fractures  of the bone, as if one or the other variety
 was certain to take place; and as if being particular in calling
 attention to the direction of the line of separation  Avas an in-
 dication of Avisdom concerning the subject.   As has already
 been stated in  another place, it is seldom  that a fracture is
 wholly oblique, or wholly transverse,  but an  irregular and
 mixed condition prevails, the line of  separation being oblique
 in some places and transverse in others.  The broken surfaces
 in a fractured femur, present many serrations which may in-
 terlock and prevent overlapping, but  the general course of the
 line of  separation partakes of a predominant obliquity in  the
 majority of cases.  Unless the fracture be  compound, one
 fragment being  driven out through the flesh, the direction of
 the line  of separation is not always easy to determine, for the
 depth of the soft tissues is too great to  admit of such  a dis-
 crimination.
   The prevailing  opinion seems to  be that it is exceedingly
 difficult to treat successfully an oblique fracture ;  the presump-
tion being that broken  surfaces with  much obliquity favor
overlapping,  and surfaces fractured  transversely,  if held in
apposition, Avill prevent overriding and the attendant shorten-
ing. However,  it Avill  be found of  ATery little importance
practically Avhether the  line of separation be transverse,  ob-
lique, or a compound of the two directions.  If the limb be
properly treated there will be little or no shortening;  and if
managed improperly there will be shortening, though the line 
192
Fractures.
of  separation  be transverse.  If  the  accident occur from
direct violence, the line of separation between  the  fragments
is  more  trans\Terse than  oblique;  and if the fracture arise
from indirect violence the greater will be  the obliquity.


FRACTURES  OF  THE  UPPER  THIRD  OF  THE
       SHAFT,  BELOW  THE  TROCHANTERS.

  Quite a common place for fracture of the femur to occur is
at  a point a few inches beloAv the trochanter minor.  It is a
place where the muscular forces greatly influence the relative
positions of the fragments, and oppose in  some degree the  in-
fluence  of the dressings.   There is always considerable dis-
placement whether the fracture be oblique or transverse.  The
 »wer fragment is draAvn upwards, backwards,  and a little  in-
 wards, and the upper fragment is dra-Avn fonvards, and a little
outwards, causing an overlapping of tAvo or three inches, Avith
the position of the fragments as represented in the accompany-
ing diagram.  The lower fragment sometimes  acts upon the

                          Fig. 74.
Fracture through the upier third ofthe shaft of the femur, showing (he tendency
                 of the fragments to overlap.
upper, making it project forwards and outwards, contributing
to produce angular distortion.  Sir Astley Cooper and his fol-
loAvers haA^e  attributed this position  of the upper fragment
solely to the action of the psoas and iliacus muscles.  " And,"
says Mr.  Cooper, "to prevent this .horrid distortion two cir-
cumstances ought strictly to  be observed;  the one is, to ele-
vate the knee very much  over the double inclined plane ; and
the other, to place the patient in a sitting position, supporting
him by pillows during the process of union."  The distortion,
however, is in some measure due to the forces  acting on the
loAver fragment,  and to a certain degree upon the forces which
produced  the injury.  The psoas, iliacus, and pectineus mus- 
Of the Femur.                 193
 cles tend to elevate the lower end of the upper fragment, but
 not to the extent claimed by Mr. Cooper.
   Muscular action bejng deprived of its normal influence upon
 the bone in  consequence of the fracture, exerts forces upon
 the fragments of a rotatory character, so that the periphery
 of one piece does not correspond  to that of the other piece.
 It is difficult to discover this defect, and to remedy it, although
 the limb will  not be restored perfectly to usefulness if such a
 defect exist.
   The symptoms of fracture of the shaft of the femur below
 the trochanters are similar to those met in other  fractures of
 the long bones.  Pain,  SAvelling, and deformity are prominent
 characteristics ; inability to  move  the limb or to bear Aveight
 upon it, is a necessary condition ; great mobility at the seat of
 injury may be expected, as Avell as crepitus when the  broken
 surfaces are made to  confront  one another.   The shortening
 is  marked, amounting in  some instances to several inches.
 Impaction is very rare, therefore the shortening is due to.over-
 lapping and angular deformity   Eversion of the foot is gen-
 erally observable, as if the limb naturally inclined to roll out-
 ward, falling  powerless and subject alone to gravity.   In rare
 instances  the lower fragment is found in front of the upper, a
 position into  which  it may have been forced by the power
 Avhich produced the fracture.   And Avhen the upper fragment
 is thus behind the other, the psoas and iliacus do not tilt the
 lower end of the upper fragment forward, making  a  marked
 prominence on the anterior aspect of the thigh, except in cases
 where the breaking force threw the fragments into that  posi-
 tion.  In  such instances there is no force in the muscles  com-
 petent  to radically alter  the position of  the fragments or to
 change their relative  positions.

   Treatment.—There are two distinct attitudes in which the
 leg may be placed in  the management of  fractures below the
trochanters: one is the straight position of the limb, and was
always  employed, so  far  as is known, until Percival  Pott, a
little more than a century ago, came out with  his " physio-
logical " notions in regard to the position the  limb  should be
made to  assume during  the treatment of fractures  of the
thigh.   Mr. Pott claimed that the muscles caused displacement
of the fragments while in a state of tension, and therefore sug-
      13 
194
Fractures.
gested that their contractile forces could be neutralized by
posture alone ; and he proposed to flex all the parts involved in
a fracture in order to secure apposition of fragments Avithout
the employment of force.   For instance, if he Avished to treat
a patient Avith a fractured femur, he flexed the  leg upon the
thigh, and the thigh upon the abdomen, and kept the limb in
that position for several  weeks, using no  splints, junks, or
other mechanical contrivances to keep the fragments at rest,
and to perform extension.  This bold and seemingly rational
plan  created a  revolution in the ideas of English surgeons;
and among its  able  supporters Avas Sir Astley Cooper, Avho
added mechanics to  physiology.  He placed the flexed limb
upon a double inclined plane, by which the muscles were  re-
laxed, the aveight of the leg  on an  inclined   plane  estab-
lished extension, and the weight of the body and the upper
part of the thigh, produced counter-extension.  The  ekwation
of the loAver part of the thigh made the lower fragment cor-
respond to the  pitch  the upper  fragment generally  assumed.
Mr. Amesbury, a little later, modified the simple double  in-
clined plane of Cooper, by adding to it means for producing
active extension and  counter-extension.   American  surgeons
have improved  upon  the splint of Amesbury, though all in-
volve the  physiological principle adopted  by Pott, and  the
additional mechanical principle of Cooper.  At length a reac-
tion took place in the minds of European and American sur-
geons ; and though the straight and the flexed plans of treat-
ing fractures of the thigh are both in reputable use, the method
of treatment Aviththe long straight splint  isfolloAved in nearly
all  the  hospitals at home and abroad.  In the rural districts
of this country the double inclined plane apparatus is in com-
mon use.   A\ nether the Pott and Cooper  plans  have  certain
captivating ideas in  connection with them that readily per
suade the country  practitioner; or the " sets."  of fracture
splints and appliances, all  of which embrace a double imdined
plane apparatus, with attractive illustrations to show the prac-
tical Avorkings  of the splints, hoav hawked about from town to
toAvn, contribute to the belief that  all eminent  surgeons em-
ploy such in their practice, are subjects of interesting inquiry.
That truly great and illustrious surgeon, the late  Dr. Valentine
Mott, never "reacted," or went back to the straight attitude
for a fractured thigh.   He once said to his class, in  my hear- 
Of the Femur.
195
ing, that  if he should  ever  be so unfortunate as to sustain a
fracture of the femur, he should  insist on having it treated
upon the  double inclined plane.
  The straight splint is a piece of board nearly an inch thick.
and about  four  inches wide, pierced  with two holes at its
upper end, and  notched  two  or  three  times  at its lower
end,  and  long enough  to reach from the borders  of the
axilla to four inches  below the foot.   The  splint  should be
well padded its whole length ; and the  pad should be  pierced

                          Fig.  75.
     f\»_ miili'1111_________________.....lli'l!!'       iilllllH||i|l     ill'"!!!1'
    The " straight splint" applied.  The cushion to be used between the splint and the
         patient's limb, is represented by the upper object of the wood cut.

 with holes corresponding to those in the splint, so that the
 ends of the perineal bands may slip  through them easily, and
 be loosened or tightened as occasion may require.  The peri-
 neal band may be a silk pocket handkerchief, a Avide strip of
 buckskin, or any  belt  of strong and  unirritating material.  It
 is to be long enough to reach through the perineum betAveen
 the genitals and the thigh, one end extending in front, along
 the groin, and the  other behind the buttock, to the holes in
 the splint through  Avhich the two  ends pass, to be tied  in a
 bow-knot.  In applying the apparatus, the surgeon, after ad-
 justing the fracture, takes the perineal band and applies it to
 the patient's perineum, bringing up one end  in  front of,  and
 the other behind this part of the body.  He then lays the
 splint along the outer  side ofthe affected limb, against a long
 cushion  to  protect  tender parts, and  proceeds to fasten  the
 foot to the notches in the loAver end of the appliance.  Before
doing  this, it is a good  plan to bandage the foot and  ankle 
196
Fractures.
with a flannel roller in the ordinary Avay, to protect them fron:
the pressure of the splint, and to prevent them from SAvelling ;
or, instead of this, the foot may be enveloped in a  layer of
cotton-wool.  The surgeon should then take  a muslin roller,
and  make a feAV turns round the foot and ankle in the form
of a figure-of-8, so as to obtain a firm hold; after Avhich he
should carry the  bandage  in  a regular Ayay round the ankle
and through the notches in the lower end of the splint, so  as
to fasten it securely to the foot.  He should then get an assist-
ant to make extension from the foot Avhile he dnuvs the peri-
neal band tight, and ties it in  a boAV on the outer side of the
splint.   In order to keep the apparatus in position it is some-
times necessary to apply a bandage OATer both the leg and
splint from the foot upAvards as far as the thigh, and also to
put a  feAV turns of a broad roller round the patient's chest.
The thigh on each side of the seat of fracture may have  a
piece of  splint material or pasteboard bound to it  Avith tapes
to make  the broken parts feel more secure.  This dressing,  if
well applied, and no serious complaints are made, may stay on
for  Aveeks, even till  bony  union has taken place.   If at any
time after its application, the dressing produce general uneasi-
ness, it may be removed,, and the fault, should any be found,
corrected.  The patient gets up with more general stiffness  of
the joints after this straight dressing has been employed, than
after a double inclined plane splint has been used.
  The straight splint is irksome at first, owing in part to the
great restraint imposed upon so considerable a portion of the
body.  However, in a few days the patient gets over the feel-
ing of being rigidly confined, and passes the  remainder of the
time Avithout much complaint.
  A great deal may be done  toAvard keeping the fragments
in apposition, by simply attending to the position of the limb,
Avithout  the application of any splint.  If the patient has a
good degree of self control, he may be laid  on his  back, and
the limb can be kept  straight by the use of several  sand bags
placed along the leg from the hip to the foot.
  Extension may conveniently be made by fastening the ends
of long pieces of adhesive plaster to the sides of the leg,  Avith
the  ends extending  beloAv the sole of the  foot; the pieces
should reach  nearly  to the knee, and over these other strips
should be applied in  a circular manner till the leg is enveloped 
Of  the Femur.                   197
as if in a bandage.   The circular strips prevent any slipping
or yielding when power is applied, and distribute the pressure
falling upon the circumference of the limb.  A short block of
Fig. 76.
 Strips of adhesive plaster applied to the leg longitudinally, and held from slinDinff bv tho
            circular wrapping of other pieces ofthe same material.

 wood a little longer than the Avidth of the ankle may be placed
 in the loop after the long loose ends are tied together, to pre-
 vent the downward strain from compressing the tissues on the
 sides  of the joint.  Around  this block and  the loop a cord
 maybe fastened, Avhich then  extends over the  foot ofthe bed
 and  sustains a weight.  The extension thus produced need
 not be so great as to distress the patient,  Moderate  but con-
 stant traction upon the limb is all that may be desired.
   After the foot and leg have been  arranged with the extend-
 ing  apparatus, the  thigh demands separate  attention.  The
 fragments should be adjusted Avhile assistants are producing
 temporary extension and counter-extension with their hands •
 and  then four or five common wooden splints a foot long, and
 two   inches  wide,  made  of lath or thin boards,  and evenly
 wrapped with cloth, are  to be placed at a little distance from
 one another, parallel Avith the course of the femur, and reach-
 ing  above  and below  the line of fracture ; where they are to
 be firmly bound with tapes.   Over all of these a roller or many
 tailed bandage is  to  be  snugly applied.  This  part  of the
 dressing prevents mobility  between the fragments, and con-
 tributes to the  comfort of the  patient.  The limb may be made
 still  more  comfortable by placing a sand bag  under the knee
 to flex it a little.   Extension  may be  made by fastening  the
 limb to the foot of the bed  by means of a cord reaching from
 the loop  of adhesive  strips to the  lower bed rail, and then
 raising the foot of the  bed upon a couple of bricks to give the
patient's body an  inclination toAvard the  head of the  bed.
This is the easiest and most natural method of securing  ex- 
198
Fractures.
tension and counter-extension Avithout complicated apparatus.
Any desired  amount of  extending and counter-extending
power can be secured by this arrangement.  If the foot of the

                           Fig. 77.
The splints upon the thigh prevent motion between the fragments ofthe femur ; the adhesive
  strips upon the leg and ankle make a comfortable fastening to the limb; the fastening
    is secured to the bed rail; and the foot of the bed is raised on blocks or bricks to
              incline the patient's body in the opposite direction.

bed  or lounge  be raised high enough to haA^e the patient's
body incline effectively in the opposite direction or toAvard the
head of the bed, great extending force may be  brought to
bear upon  the  limb.  I have such confidence in this manner
of treating a  fractured thigh  that  I feel  like urging its use
upon my professional brethren.  Very feAV  perfect results can
be secured by the use  of the long straight splint;  and the
double inclined plane apparatus which goes with almost eATery
u set" of splints or fracture appliances, does not give general
satisfaction.
  About one-third of all cases of fracture of the shaft of the
femur, as  ordinarily treated by physicians and surgeons  of
every grade of skill turn out favorably, or without  perceptible
or appreciable  deformity; another  third  of all cases treated
exhibit so little shortening or other defects that in the course
of time they fail to attract personal or professional attention;
the  remaining  third are so seriously  defective, either  from
shortening or other deformities, that the patient is temporarily
or permanently compelled to walk lame,  or forever made a
cripple.
  The defect is generally shortening Avhich comes  from  over-
lapping of the fragments; and, in addition, there may be  an-
gular  deformity,  as seen in  the following  diagram.   The
shortening in  the cases attracting attention, which constitutes 
Of  the Femur.
199
FiG. 78.
• about one-third  of all fractures  of the  shaft of  the femur,
amounts to three quarters of an inch.   No shortening Avhich
                      is less than half  an inch attracts atten-
                      tion or proves a  serious source of com-
                      plaint ; but  in rare instances the over-
                      lapping reaches  several inches.
                        In several mal-practice suits in Avhich
                      I have been  called to give  testimony as
                      an expert, I have found the shortening
                      to be from one to three inches.  In  ad-
                      dition to  the shortening there has gen-
                      erally been angular deformity, and  ex-
                      cess of callus which seriously interfered
                      with the functions of the limb.  In some
                      of  these  malpractice  cases the  fault
                      seemed to result from surgical incompe-
                      tency ; and  in  others  the  defect may
                      have arisen from untoward  circumstan-
                      ces  beyond  the control of the profeS-
Union of the fragments with
 shortening, and angular de-
 formity.
>v
sional attendant.
Fig. 79.
Extension by means of a weight and pulley; counter-extension is produced by a perineal
             band which may be fastened to the head of the bed.
  Weight  and  Pulley for Making  Extension.—Another
method  of applying extension  in the treatment of a broken
femur, consists in employing weight to a cord Avhich reaches,
from the loop of adhesive strips over the foot rail of the bed.
The fastening to the limb may be  made with a  piece of belt 
200
Fractures.
leather  secured  to  the thigh above the  knee with lacings.
This leather band may have loops fastened to each side  of itj
from which cords extend over the foot of the bed for the pur-
pose of sustaining Aveight.  It is well to have the knee gentlv
flexed by means of  a sand  bag  or  cushion placed under the
joint.  Instead of producing counter-extension Avith a peri-
neal belt, the foot of the bed may be raised on blocks, to give
the patient's body an inclination in the direction of the head
of the  bed.  This dressing is not complete without straight
splints are bound to the thigh ;  and sand bags used to obviate
rotation.
  Mr. Burge, of NeAv York, has invented  an  apparatus for
treating fracture of the femur, Avhich  is  represented by the
accompanying diagram.  The machine  has been successfully
employed in some of the NeAV York hospitals.   It holds the

                          Fig.  80.
Burge's fracture apparatus applied.
limb in the straight attitude, but allows the patient to take the
sitting posture; and provides for the escape of alvine evacua-
tions without disturbing the fragments of bone.  Various in-
tricate contrivances have been devised to treat fractures of the
femur, but it is questionable whether they are superior to the
more simple plans already described.  The most of them are
too costly for the ordinary practitioner  Avho might not  have
an opportunity once in ten years to put one of them in prac-
tice.  To  study the different  parts entering into the Burge
apparatus, for instance, would  require more time than to dress
a limb with  more simple means.  To  a practitioner inexpe-
rienced  in the different machines invented to treat fractures 
r4 Iptf?
nchnati, 0.
Of the Femur.
201
Fig. 81.
 of the thigh, the diagrams representing such apparatus  in
 works on surgery, offer more confusion than illustration.   The
 fracture beds of Jenks, Daniels, Burge, and others, cost from
 fifty to a hundred dollars, therefore  the surgeon of limited
 pecuniary means could ill afford  to  possess one or more of
 them.
   A fractured femur  needs to be treated with retentive means
 for a period of six or eight weeks in the young and vigorous,
 and^ for ten  or twelve weeks in patients advanced in years.
 A limb may appear firm, as if consolidation had taken place
 at the end  of five weeks, yet it is not safe to lay aside the
 dressings  and trust the patient on crutches lest shortening
 occur.   As  has  been  remarked  in  another  place,  the
uniting material continues soft and yielding for many weeks
after osseous consolidation between the  fragments  seems to
                have been effected.  Many a surgeon of large
                experience   in  treating fractures  has  dis-
                charged his patient Avith one  leg as long as
               the  other, and has been  astouished some
               weeks after to find that shortening had taken
               place.  It may be  remarked  in this connec-
               tion, that there is no Avay to determine Avhen
               the fragments are  so far consolidated  that
               shortening will not  take place.  Experience
               shoAVS that the uniting medium generally be-
               comes unyielding at the expiration of  ten or
               twelve weeks after the reception of the frac-
               ture.   In young patients seven or eight Aveeks
               may be long  enough to continue the retentive
               dressing.  I have never had occasion to cen-
               sure myself for keeping a fractured thigh in
               its dressing too  long; but several  times  I
               have  regretted  having laid the  apparatus
               aside too soon.
                 After the fracture has become consolidated
               there remains  at the seat of injury an enlarge-
               ment  Avhich  may annoy  a  nervous patient
               This hypertrophy comes mostly from the  ex-
               cess of reparative material  employed  in  the
                At first the lack of perfect apposition of  the
   Consolidation after
 fracture through the
 upper third of the fe-
 mur, showing some
 permanent enlarge-
 ment at line of union
 and  slight angular
 deformity.
healing process
fragments may present some sharp and  jagged edges, which 
202
Fractures.
will irritate the soft tissues, and paralyze the muscles to some
extent, but in time the rough points will be removed by ab-
sorption, and the enlargement will be forgotten.
  A moderate degree  of angular  deformity will  not prove a
serious impediment to locomotion, therefore it should not  be
meddled Avith in old cases.  Unless  the defect be very great,
any attempt to break the femur over again is not justifiable.
In extreme angular deformities an awl or drill maybe used to
perforate the bone  at the point of union, until there is so little
osseous material left  that  it  can, Avith proper apparatus, be
pressed into line, or re-broken, Avhen the limb can be treated
in the straight attitude until the  fragments re-unite.  It may
be incidentally remarked, that the lameness dependent upon
shortening, generally diminishes.  The twisting of the pelvis
and  the ATertebral column tend to conceal the defect.  A
higher  heeled shoe worn on  the lame side will  improve the
gait.

  FRACTURES  OF  THE MIDDLE THIRD  OF THE
                        FEMUR.

   The  middle  of  the shaft of the  femur is broken  about as
frequently as those parts  ofthe  bone near the extremities;
and  when  a fracture exists  near the centre of the bone, the
manner of  treatment does not differ essentially from that de-
manded at  points some  distance from the middle line.  The
same forces which break the femur at points higher  or lower
in the bone, may produce a fracture of the middle third ; and
the signs of the  injury  could not  be substantially different
from  those in fractures through other parts  of the bone.
There  Avould be  inability to  move  the limb, eversion of the
foot, shortening,  angular deformity, and  crepitus when the.
broken ends of the fragments Avere  brought in contact.   The
mobility at  the seat of the injury would be so  marked that
even the unprofessional observer could not fail to  recognize
the nature  of the lesion.   The line of separation between  the
fragments may be  oblique, transverse, or intermediate between
those directions, partaking in part of each.   There is the same
tendency for the fragments to overlap, producing shortening,
as after fractures higher  up or loAver doAvn the shaft ofthe
femur.   The same dressing will be required as for  a fracture 
Of the  Femur.
203
 just  below the lesser trochanter; there will be  the  same
 danger of defects and  deformities as in fractures at  other
 points in the bone ; and it will require about the same length
 of time for the reparative forces to effect consolidation of the
 fragments.  " These fractures,"  says Malgaigne, " when sim-
 ple and Avithout  displacement,  unite  in forty or fifty days;
 sometimes they  require  two or  three  months,  Avhen the
 fragments  overlap one another, being in contact only by their
 lateral  surfaces.   When  the  two ends can not be made to
 oppose one another, so as themselves  to counteract the mus-
 cular contractions, it is impossible to preserve the  normal
 length of the limb, whatever be  the apparatus or method em-
 ployed.  There  has been too much discrepancy of opinion
 among surgeons in regard to this.  Hippocrates gives the idea
 that the shortening  can  always be obviated; Celsusgoesto
 the opposite extreme, declaring that a thigh once broken must
 ever remain shorter than its fellow.  At a period by no means
 remote from  our  oavii, Desault  claimed to cure all fractures
 Avithout shortening,  and his journal  contains several  such
 cases.   In  imitation of him  many surgeons have varied, cor-
 rected, and improved apparatus for permanent ex'ension, and
 have  announced as  complete successes from  them.  I must,
 hoAvever, state positively that I have never obtained anything
 of the  kind,  either  A\rith contrivances of my own, or with
 those of others,  or even Avhen I have invited the inventors of
 such apparatus to  apply them in  my Avards.   I haA'c more than
 once examined persons said to be cured without any shorten-
 ing,'but always discovered such shortening by actual measure-
 ment.   Some have deceiAred themselves in regard to the merits
 of their treatment; they have happened to meet with fractures
 in which there could be no overlapping on account  of an  in-
 terlocking  of the serrations, and imagined they had corrected
 a shortening which never existed.  In short, Avhen the  frag-
 ments remain in contact,  or when we can replace them and
keep them so by means of their serrations, it is easy to cure a
fracture of the femur Avithout shortening ; in the  absence of
these  tAvo conditions the thing is simply impossible.
  " Several distinguished surgeons ofthe present day, recogniz-
ing this impossibility, have abandoned  the idea of permanent
extension.  They allege moreover that  an overlapping of even
as much as an inch is of slight consequence, and involves no 
204                     Fractures.
limping.  I can not entertain this view.  I have seen persona
walk very well with one-third of an inch shortening, but Avith
more than this they either limp, or must, wear a thick soled
shoe; or possibly their halt is masked by a lateral inclination
of the spine.  Hence we see how grave a fracture, with over-
lapping, must always be, and what caution we should observe
in giving a prognosis."
   Although the upper fragment rides usually upon the lower,
and  the tension  of the  muscles seems to favor the flexed or
" physiological position" recommended by Pott, Cooper,  and
others, many of the most experienced surgeons ofthe present
day, both in Europe  and America,  employ the long straight
splint, instead of  the  double inclined plane, to treat fractures
near the middle  of  the thigh.  To the latter plan, Desault
makes the following objections : " the difficult}' of making
extension and counter-extension while the limb is  in a state
of flexion—the impossibility of comparing,  Avith precision, the
injured  thigh with that of the sound  side, in  order to judge
of the regularity  of the  conformation—the uneasiness which
this position continued for a long time  occasions, although at
first  it may appear natural—the inconvenience and painful
pressure of a  part of the trunk upon the great trochanter of
the injured side—the  derangement to Avhich  the limb  is  ex-
posed when the patient goes to  stool—the  difficulty of fixing
the limb sufficiently to prevent movements of the femur—the
evident  impossibility of this method Avhen  the two thighs are
fractured—lastly,  experience so little  favorable in France to
this position."  Such Ave re the motives, says Lonsdale, Avhich
determined Desault to have recourse to it no more, after hav-
ing tried it on two patients, one of AAiiom had a considerable
shortening, in spite of the most scrupulous attention.
  The objections  to  a  flexed condition of the limb over a
double inclined plane, as offered  by Desault, are umvorthy so
eminent a surgeon.  The experiment  upon only two patients
Avas too limited for a weighty argument; and then to say  that
experience  Avas against the  position, shows that prejudice  ex-
ercised an undue  influence over his  mind.  It is unfortunate
that  no tables are drawn  up to show under Avhich plan of
treatment the least amount of shortening occurs.
  I have had the best success Avith cases managed Avith a sand
hag  under  the partially flexed knee, and  extension applied 
                      Of the Femur.                  205

from the leg by means of adhesive strips, the counter extend-
ing force being derived from the descent produced by elevating
the foot of the bed.   A  firm mattress is quite essential to the
carrying out  of  several points  in  the treatment.  In a soft
feather bed it  is quite impossible to bolster up the leg to obvi-
ate eversion, and  to determine how the dressing is accomplish-
ing its various objects.   On a mattress every indication can
be  fulfilled, and  every defect watched and guarded against.
I believe  in securing every advantage that can be derived
from position.  Even while  using the long straight splint, the
limb may be made fast to the foot of the bed, and the body
given an inclination toward the head of the bed by elevating
the loAver  parts as already  indicated.  However, there is no
necessity for complicating the means if the straight splint ac-
complishes all that may be desired.  Experience teaches  that
very feAV cases of fracture of the shaft of  the femur can be
trusted Avithout some kind of extending and counter-extend-
ing forces being employed clear through the course  of treat-
ment.
  The double  inclined plane fracture appliance of Amesbury,
and kindred  contrivances,  may possess principles  which, if
carried into execution  by  surgeons  possessing mechanical
skill, might secure the happiest recoveries ; but the complica-
tions of the machines often confuse the professional attendant,
and lead him to trust more to the apparatus than he would to
a contrivance  easier to  be understood.   I recently saw a
patient under  treatment for fracture  near the middle of the
femur; and the  double  inclined plane splint of artistic con-
struction was performing its part  so badly that I asked the
doctor what he  designed to accomplish with the appliance ?
He appeared  unable  to explain  what the machine ought to
perform, yet expressed  confidence in the powers of the appa-
ratus to avert  deformity in the  limb.  If he  had understood
what  the broken femur needed, he could have used almost
any method to accomplish the object;  but having no rational
theory in regard to the wants of the case, he  trusted blindly
to the  virtues of the appliance.   The thigh-piece of the splint
Avas so  short that the body of the patient, bolstered up Avith pil-
lows and other material, slid down against the apparatus, pro-
ducing an angle and overlapping at the line of fracture, which
would  not have occurred  if the limb had laid straight on a mat- 
206
Fractures.
tress, no dressing being employed.  The splint was  so defec-
tive, or was so faultily applied, that the case Avas damaged by
the treatment.  In a soft bed, Avith the narrow  double inclined
plane splint  toppling about,  and  the  body  pressing  doAvn
against the fracture, there is  little hope of  a  reputable cure.
The  double inclined plane under such circumstances is infin-
itely inferior to the long straight splint of Desault.   With the
" physiological method-" so imperfectly or wretchedly put into
practice, it is no wonder a reaction in favor of the old-fashioned
straight dressing took place.
  American surgeons have displayed much ingenuity in con-
structing apparatus for treating fractures ofthe leg.  Not less
than half a dozen have gotten their names  associated with
splints.  Dr.  Wm. Gibson introduced an  apparatus  with  a
couple of long splints reaching from the axilla down on each
side  of the trunk and  legs to a foot-piece, to which the  feet
ofthe patient Avere secured.  This kept both legs parallel  and
the body straight Avith them ; and prevented lateral twisting
and SAvaying, and  served as a kind of litter to raise the patient
for defecation.  The foot-piece could be moved up and doAvn
on the straight pieces, and held at any desired place by means
of holes and pegs.  The  upper  crutch-headed  extremities
rested  in the axillae,  and the movements  of   the foot-board
dowiiAvards secured the necessary traction.  Dr. Joseph Harts-
horne used a similar apparatus, though only one splint reached
the arm-pit, the other being placed on the inside ofthe broken
leg, reaching to the perineum, Avith a crutch-like head to pre-
vent excoriation.   The  foot-piece Avas moved by means of a
wooden screAV passing through a  cross-piece.   None of these
more or less ingenious contrivances are  so simple and effective
as the adhesive plaster extending apparatus, with elevation of
the  foot  of  the  bed for  counter-extension.    Besides,  this
method leaves the thigh free  to be dressed  with common re-
tentive means.
  In fractures  somewhere near the middle of, the thigh, the
immovable or starch dressing may«be applied about the eighth
day, and then the foot can be released from powerful traction.
A compound injury is to be treated like a simple fracture, ex-
cept the puncture in the flesh is to  be left   open to facilitate
discharges. 
Of the Femur.
207
  False-joint is an unfortunate termination, which may happen
in any case of fracture of the long bones, and in the  practice
of any surgeon.   No  display of skill will absolutely obviate
non-union, though a  well applied retentive  apparatus, after
proper adjustment of  the fragments,  is believed to favor con-
solidation.
Fig. 82.
 FRACTURE  OF  THE  FEMUR  JUST  ABOVE  THE
                        CONDYLES.

   Fractures  of the  femur above  the  condyles, in  the lower
 third of the bone, are  not rare; they are generally produced
 by direct causes, though indirect violences, as heavy falls upon
                  the feet, may break the femur at any point.
                  The  direction of the line of  separation  is
                  rarely transverse  or fully oblique.  Cases are
                  reported in which the line of separation has
                  been  nearly transverse ; and others in which
                  the obliquity Avas  uniform  all  the  way
                  through, the broken surfaces exhibiting only
                  minute serrations.  The circumference of
                  the bone increases from near the middle of
                  the femur to the Avidest part of the condyles,
                  and as the periphery increases the cancellated
                  tissue augments,  making so much  spongy
                  material  in the lower extremity of the bone
                  that the upper fragment may be driven into
                 it, producing a state of impaction.
                   In a simple  fracture Avithout penetration
                 or impaction,  the upper fragment usually
                 occupies  a  position in front of the lower,
                 producing shortening.  There has been some
                 speculation in regard to the influences which
^SSrSSSSio*!  produce  this  position  of  the  fragments.
 ^SdWi!li0uISrrldS:  The act^'1 of the gastrocnemius upon  the
 orinity'           condyles, which project backwards, forming
levers of considerable length, is the principal reason why the
lower  fragment is tilted so poAverfully backwards.   It is no
uncommon  occurrence  for the  lower end of the upper frag-
ment to encroach upon the normal position ofthe patella, and
even penetrate the synovial cavity beneath that bone, making
 
208
Fractures.
a complicated injury quite  serious in its nature.  The upper
fragment occasionally gets pushed out through the flesh, pro-
ducing  a  compound fracture.  In 1865 I was called to Peter
Mecklin, a German laborer, who fell  from a high bank in a
quarry.   He struck, in his  fall, upon  a projecting rock, and
then fell several feet  further to a plane landing.   His com-
rades found him Avith the broken femur pushed  through the
soft structures on the inside of the  knee.  I saAv the patient
in about two hours after the injury, and observed the broken
end  of  the  upper fragment still protruding; the lower frag-
ment Avas iu place so deeply buried in flesh that its  fractured
end could scarcely be outlined by manipulation.  After strip-
ping the  leg of pants  and boot, an  attempt Avas  made, by
means   of assistants, to extend  the limb sufficiently to allow
the protruding  bone to go back into place, but such efforts
Avere in ATain.   I then sent for chloroform, and, Avhen the
anaesthetic arrived, I put the patient profoundly under its  in-
fluence, and exerted   powerful  traction  upon the  limb.
This course proved  successful ; the  bone went back into
place in apposition  A\ith  the  other fragment.  Although the
fracture was marked with considerable obliquity, the consoli-
dation took place with not more than a half  inch  shortening.
I saAV one case of compound fracture of the shaft of the femur
in its lower third,  in Avhich  the resistance to  a return of the
fragment, balked the efforts of two  quite accomplished sur-
geons, in'their efforts at reduction.  The end of the fragment
Avas  finally  saAved off, to allow it to go back through the rent
made in the flesh.   It is possible that such a proceeding might
be justifiable in  extremely rare cases,  but it should be avoided
if possible.
                          Fig. 83.
   Fracture of the femur just above the condyles, which shows the tendency of the
            lower fragment to encroach upon the poph«-.,l space.

  The broken end of the loAver fragment being tilted back-
ward by the action of the gastrocnemius, its sharp edge may
do harm  to  the vessels  and  nerves of the popliteal region.
Paralysis  of the foot, and aneurism of the artery, are said to 
Of the Femur.                  209
 have followed such an  injury.  Malgaigne in his criticisms
 upon what Boyer says  of the  backward  movement of  the
 loAver fragment, declares that such a displacement is purely
 imaginar}'.   Hamilton reports a case treated by a surgeon  of
 Lock port, N. Y., in Avhich parts  of the foot  sloughed after
 fracture of the  femur just  above the condyles; and there
 seenu'd to be great danger of death to  the leg.   All the dress-
 ings  were throAvn off, and  efforts made to restore vitality to
 the leg.   The limb recovered with shortening, and the loss of
 the toes and part of the foot.  The surgeon at  length sued
 the  father of the patient for the recovery of his professional
 bill.  The case Avas litigated on the ground that the  dressings
 had been so tight as to impede the circulation  and  to invite
 gangrene.  The surgeon got judgment in his favor on the  tes-
 timony  of several distinguished surgical  Avitnesses  Avho  de-
 clared that the sloughing arose from injury done to the nerves
 by the  loAver fragment of the femur, and  that no amount of
 skill and and attention could have averted  the evil.
   In  fractures so near a large joint the dangers are greater
 than  Avhen the femur is broken at a distance from its articula-
 tions.   If the upper  fragment is dragged  down against the
 patella the injury may be folloAved by a high grade of inflam-
 mation, and anchylosis.
   The symptoms of fracture just above the condyles, are gen-
 erally marked; the pain, SAvelling, inability to  move the limb
 or to bear weight on it, necessarily attend the accident."' Cre- •
 pitus may be produced if the broken surfaces can be rubbed
 against one another, but in the event of much overlapping the
 grating Avill be absent.  In cases of many hours standing, the
 swelling obscures the characters Avhich declare  themselves so
 plainly  just after the accident occurs.  However, the angular
 deformity AAiiich is very great, or can be made so by manipu-
 lating the limb, is a convincing sign of fracture.  The lateral
 mobility Avhich  does  not belong to the knee, is another con-
 clusive diagnostic sign.

  Treatment.—It seems unnecessary, after what has already
 been said concerning the treatment of fractures  of the shaft
 of the femur, to give anything more than  general directions
for the  management  of  fractures just above  the condyles.
The reduction can sometimes be easiest effected by flexing the
        14 
210
Fractures.
leg, and putting the arm just above the calf, for the purpose
of making extension.  A straight downward pull upon the
heel and foot exerts traction upon the gastrocnemius, thereby
tending to tilt the broken end of the lower fragment back-
wards.  If the fragments can not be adjusted without the in-
llnence of an anaesthetic, there should  be  no hesitancy in its
early employment.
  Cures effected Avith the aid of the long straight splint are
not very satisfactory ; shortening to the extent of one or two
inches being a common result, to say nothing of other glaring
defects.   The long straight splint, for the  purposes of effect-
ing extension and counter-extension, has many advocates, but
it finds little favor with me in the treatment of such injuries;
the double inclined plane apparatus does better, yet it has its
objections.  It is better to envelope the thigh with retentive
splints, the pieces of  lath or thin board being laid longitudi-
nally with the limb, across the fractured line in the bone, where
they are to be bound in place with tapes and bandages.   Ex-
tension can be made from the leg and ankle  by  means of ad-
hesive strips, using the weight and pulley, or raising  the  foot
of the  bed on blocks after making the  limb fast to it.   To
relax the muscles of the thigh and  leg  a  large sand bag or
cushion  is to be placed under the knee to keep it permanently
flexed.  The  limb may also be  bolstered up and kept  in a
straight line by means of several sand  bags  placed along its
sides at places where support  is needed.  Whatever be the
dressing applied, it should be employed for six or eight weeks,
and  even longer in old subjects.  After the extending and re-
tentive appliances have been laid aside, no Aveight should be
borne upon the limb until several Aveeks more have elapsed
lest overlapping and angular deformity take place from vield-
ing  of the new formed  callus  or  uniting medium.  During
this  convalescing inteiwal gentle motion should  be kept up at
the knee to obviate stiffness and anchylosis, and the limb  may
be rubbed with stimulating liniments to restore the normal
activity of the muscles.   Until consolidation takes place and
while the  retentive dressings are  in use, measurements and
comparisons  of the  two limbs should be often made.   The
general  contour and condition of the leg should be observed
at every visit, and any deviation or defect guarded against bv
re-adjustments of the appliances,  or by changing the entire 
Of the  Femur.                  211
plan of treatment if deemed necessary.  The state of the cir-
culation in the  foot, and the  condition of the skin where
dressings bear heavily, must not be neglected.  A tight wrap-
ping can generally be loosened by cutting part way through a
feAV turns of the bandage; and a loose dressing may be made
tighter by the application of a feAV additional strips employed
as ties.  The surgical attendant must bear  in  mind that the
tendency of a  broken thigh is to deformity, and that the per-
verse inclination must be constantly and efficiently opposed,
leaving  nothing to " luck" or hazard.
 FRACTURE OF  THE CONDYLES  OF THE FEMUR.

   Fracture of one or both condyles is, fortunately, a rare acci-
 dent, for the injury is attended with  dangers  of a  serious
 nature.  The knee-joint is exceedingly intractable^vhen sub-
 jected to the  influence  of disordered  action.  Effusions into
 the articular  structures are  attended Avith great  distress and
 constitutional disturbance.
   The force  which  breaks  a  condyle of the  femur may  be
 direct, as when a heavy weight falls upon the knee ; or it may
 be indirect, as when a person in falling  strikes in such a way
 as to have the violence communicated to the side ofthe femur
 which  did  not receive  the  primary impression.   The disen-
 gaged fragment may include the articular surface ofthe inner
 or outer  condyle  and four  or  five inches of the condyloid
-ridge, terminating in a point  at its upper  extremity.  One
 condyle is broken about as often  as the other, though the
 inner is less protected from  direct violence.
   The muscular forces exerted  upon a  broken condyle  are an-
tagonized to a great extent; the.two vasti  pull upwards and
the gastrocnemius downwards.   The lateral  and  crucial lila-
ments are opposed to much displacement, unless both condyles
give way, allowing the central wedge-shaped shaft in its course
downwards, to force them asunder.
  I have  the  specimen of a fractured internal condyle which
was taken from the leg of Thomas R.,  a  laborer, who lost his
life by falling  to the bottom of  a well, Avhich  was  being dug.
In the  descent the knee hit against the  edge of a heavy tub
attached to a windlass used  in raising  the earth  which  was 
212
Fractures.
 being excavated.  The line of separation in the broken bone
 begins near the centre of the articular concavity at the lower
 end ofthe bone, and extends upwards and inwards about five
               inches,  terminating in the  condyloid  ridge.
               The broken surfaces are rough Avith the  usual
               spiculoe, but bear  no marked  irregularities.
               The separated condyle was  not displaced by
               the force  Avhich produced the fracture.
                 The symptoms of a broken condyle are not
               marked and palpably distinctive,  though the
               diagnosis  can be determined by a careful man-
Fracture of the inter-  .  .  ,.    r-  , 1           mi  '   •      IT
 nai condyle of the  lpulation  of  the  parts.   lhe  pam, swelling,
               and  inability to bear weight on the limb, are
features  that could not well be absent.   The joint in its nor-
mal state admits only of the hinge  motion,  backward  and
forward,  but after fracture of either condyle the lateral motion
which can be imparted to the joint clearly indicates the nature
ofthe injury.   The  separation ofthe epiphyseal extremity of
the bone in a young subject, might obscure  the difficulty, as
might a transverse fracture of the femur  close  above  the con-
dyles.  Crepitus  can be  elicited in  either  kind  of  fracture,
therefore the existence of  that  sign would not throw much
light upon a doubtful case.   However, when a  condyle is sep-
arated from the rest of the bone the disengaged fragment can
be grasped, and moved independently of the  rest of the femur,
and the  movement  is attended Avith a crepitating sound that
corresponds with the  motion.   The  increased width of the
joint is another sign of some value, aud  should not  be neg-
              lected.  If the fracture be caused  by the pas-
               sage of  a  wheel over the joint,  or  by  any vio-
               lence of a crushing  character, the loAver 'ex-
               tremity of the femur may be broken into sev-
               eral  pieces, some  of which may be so isolated
               from nourishing tissues that they Avill  become
               foreign bodies, creating grave local  and general
               disturbance.  The suppuration attendant upon
FcondyieSs offth?fi tue discharge of such pieces of bone, exhausts
              the patient, and  occasionally necessitates am-
putation  to save life.  The case of  a boy Avith a compound
fracture,  is reported in Braithwaite's  Retrospect, Vol.  XV., in
which a good recovery was made, though a  piece of the ex-
Fig. 85.
 
Of  the Femur.
213
ternal coudyle Avorked its Avay out in the course of three  or
four months from the reception of the accident.

  Treatment.—The gravity of the lesion  requires more pa-
tience  and skill  to  combat inflammation  and  to avoid the
necessities of amputation than to adjust the fragments and to
retaiu  them  quietly in place.  Anodynes and cooling lotions
must be topically used, and opiates  administered internally.
The employment of the long splint, which necessitates the
straight attitude, is out of the question.  If only one condyle
is broken, and there is no displacement, the knee should  be
moderately flexed by being placed on  a sand bag.  If the foot
is forcibly inclined to eversion, the tendency may be counter-
acted by other bags arranged along  the outside of the limb.
  In the event of a double fracture, both condyles being sep-
arated from the shaft, there is considerable shortening to  be
overcome.  This can notbe accomplished by using the straight
apparatus of Desault, or the double-inclined  plane  splint in
common use.  A moderate degree of flexion is  one of great-
est  ease  and repose; and should anchylosis  take place the
limb is the most serviceable in that position.  The use of ad-
hesive plaster repeatedly described, is the easiest method of ap-
plying extending force, and the inclination of the body in the
opposite direction, produced by elevating the foot of  the bed,
is the most comfortable  manner  of obtaining counter-exten-
sion.   If the knee be too Avide, a leather or pasteboard splint
should be bound  around the limb, enveloping the joint and a
few inches of the  leg  and thigh.  Should the soft parts  be
much bruised, no stiff dressing  can  be endured.  As  soon,

                          Fig. 86.
     A woven wire appliance to support the leg after fractures near the knee-joint.

however, as the flesh wounds have sufficiently healed to  re-
ceive a slightly compressing support, it may be employed to
advantage.
  Passive motion should  be begun by the thirtieth day in a
gentle manner  at first, and kept up for months  or  until the 
214                     Fractures.
functions of the joint  are fully restored, or recovered as far
as practicable.  Passive motion  is  as  essential during the
period of convalescence  after fracture of a femoral as in the
final treatment of a humeral condyle, but the knee will not
endure the rough usage that can be imposed on the elbow.
  In the earlier part of the treatment a tendency to deflection
to the right or left is to be guarded against as well as shorten-
ing.   The leather or pasteboard splints if allowed to extend
above and below the knee, and  if'kept snugly bound in place
with a bandage or multiple ties, operate against lateral defor-
mity, and the  extending  and counter-extending  forces  resist
the overlapping.   Eversion of the foot and limb is prevented
by the use  of  sand bags.  Moderate flexion  of the knee re-
laxes the muscles of the  leg.  The ordinary double inclined
plane fracture box or appliance for the leg, constitutes a very
serviceable dressing for treating a  femur broken  at the  con-
dyles.   In  a  case  of comminuted fracture  of the  lower ex-
tremity of the femur, including a severance of both condyles,
which recently came under the  treatment of Drs. Potter and
Clarke, of  Hamilton, O., the  double inclined plane  apparatus
was used ;  and the result could  not be more satisfactory. By
the courtesy of the surgical attendants  I Avas invited to see
the case under treatment, and was pleased with  the skillful
management of the means employed. 
CHAPTER  XXVI.
FRACTURE  OF  THE  PATELLA.
   The patella is  much exposed to direct violence, but the
 facility with which it slides in various directions, saves it from
 fracture.  Indirect violence  cannot  reach it; but  muscular
 action exerts  a powerful influence  upon it.  The size and
 shape of the bone contribute to its immunity from fracture.
   The patella is  a sesamoid  groAvth  in  the  tendon of the
 quadriceps extensor cruris muscle, and plays the part of a ful-
 crum  and  lever at the same time.  In the former office it can
 not be crushed by muscular action ; but in the latter capacity
 it may be  snapped, the fracture  running  through the bone
 transversely.  A blow  may break  it longitudinally, or crack
 it into several  pieces.   The patella is broken  by muscular
 force  more frequently than any  other  bone in the body.
 When the knee is slightly bent the bone is supported upon the
 condyles of the femur on its transverse axis only, becoming
 wholly a lever, and losing its character of fulcrum.  Its upper
 edge is  then-elevated and unsupported, as well as its lower,
 which is held rigidly in place by the ligamentum patellae.
 Under these circumstances the rectus femoris and its  associate
 muscles, no longer act in a direction corresponding Avith the
 longitudinal axis of the bone, but nearly at right angles with
 it.  In a violent effort  to save the body from falling back-
 Avards, the  bone may snap transversely.   In one instance I
 knew a boy to break one of his patellae "While jumping a Avide
 ditch.  As  he landed the body dropped doAvn so as to bring
 the knee into  extreme flc.\i<>u,  and he  says the  knee-pan
snapped  at that time.  In that  instance the conditions were
not favorable to a fracture of the patella, for its position was
such Avhen  the knee Avas excessively flexed, that its centre was
unsupported, and the force acted in the  direction  of  the ver-
tical axis of the bone, and no leverage could be obtained upon
                          (215) 
216                     Fractures.

it.  In order that the patella maybe placed in the most favor-
able position  for the muscular force to act upon it, the Jinee
must be only moderately flexed; then the ligamentum patellae
holds the bone poised on its centre, betAveen the condyles of
the femur, and the muscles act upon its  upper edge.  Extreme
force is not brought upon the patella  Avhen  it plays the part
of a lever, except a person in Avalking, slips Avith one or both
feet, and in  an effort to resist a fall, or to recover an equipoise
of the body, he attempts to straighten the knee Avhich has be-
come partially flexed.  It is just at this  time that the patella is
placed  under the most favorable conditions for the muscles to
act upon it; and it is  at  this moment that the muscles act
suddenly in  the most powerful manner.  While the  knee is
bending it  is  instantly checked  in its course of flexion, and
changed to a state of extension.  If the patella be poised on
its  articular apex, its integrity is severely tested; but if the
leg be nearly straight or  extremely flexed, the force acts in a
straight line with the bone, and the tendon above or below the
bone is put to a dangerous test.  The patella is ordinarily
strong  enough to resist any muscular force that can be brought
to bear upon  it, but, as  has been stated, if it be caught in a
poised  position between  the condyles Avhen great and sudden
power is exerted on the part of the muscles,  the bone is put
to a disadvantageous strain, and may snap, as a short stick is
made to break across the knee by the power  of the hauds.
  A person  in going doAvn stairs  may catch the heel  or par-
tially stumble, and in the effort to shun a fall receive a frac-
              tured patella.  By far the most common cause
    Ftg 87
              of a broken patella is direct violence; the kick
              of a  horse,  the  hitting of the bone  against
              some solid substance in  a fall, the  bloAv  of  an
              axe, hammer, or  implement  violently hurled
              by  moving  machinery, are  all well known
              causes:
Trthesv atelirncture °f  Tne sJmPtoms of transverse fracture ofthe
              patella are prominent and unmistakable.  The
patient feels the sudden separation ofthe bone, and generally
declares that he heard the snap attending it.   He is unable to
extend or advance the leg,  and seems to be instinctively con-
scious  of  the nature of the  injury.  The  lower  fragment
remains in place,being held there by the ligamentum patellae;
 
Of the Patella.
217
but the upper fragment is drawn upward sometimes to the
extent of several  inches—generally an  inch or two.  The
upper  fragment can  be found  as  the hand is slid  down the
thigh near the  knee, and the fingers find a yielding depres-
sion between the fragments.  Just above the lower fragment,
the knee,  when the leg is flexed, evidently has lost something
which normally produces a fullness there.
  Xo  crepitus  need be expected  unless the leg be extended
and the  quadriceps be pressed powerfully doAvmvards, so as
to allow the fragments to reach  each other:  if once brought
in contact by the above means  the broken surfaces may be
made to grate against each other.
  Considerable  swelling takes place from effusions  of lymph
and extravasation of blood.   If the limb is  not seen for sev-
eral hours succeeding  the accident, the swelling v\ ill mask
some   of  the  prominent  symptoms, yet  the fingers firmly
pressed along the  anterior aspect of the limb in the vicinity
of the joint, Avill discover the upper fragment dragged up-
ward, and the abnormal depression between the  pieces.  The
furrow between the  condyles  will also be recognized if the
fingers are pressed into that sulcus.
  In an oblique fracture of the patella the signs of  the lesion
will be as apparent as in a transverse separation.  In multiple
or  stellate fracture  the fragments may not be displaced, but
all  Avill be held in  position by the tendinous surroundings.
In such a case crepitation could be readily elicited, and move-
ments of the limb would cause sufficient irregularity of the
pieces to be discoverable with the aid ofthe fingers.  Flexion
of the limb  Avould produce separation  of some of the frag-
ments, as  the quadriceps  must  take one or more  pieces of
bone along Avith it as contraction ofthe muscles ensues.
  In a longitudinal fracture of the patella there may be lateral
separation of the fragments, .though the beveled and project-
ing condyles on each side  tend to keep  them in place.   The
action of  the vasti muscles, pulling in opposite directions, the
force  being from  the centre towards the sides of the limb,
may separate the fragments when the leg is flexed.
  One of the peculiarities of a fractured patella is that the
fragments unite very  frequently with fibrous material, and
rarely  consolidate  Avith bony  matter.   The length  of the
fibrous bauds depends upon the  distance existing between the 
218                    Fractures.
fragments  during the healing process.  It is not uncommon
to find the fibrous connection nearly an inch in length.  In
              the case of Mary Adams, of  Covington, Ky.,
              who broke the right patella transversely by a
              tumble on some out-door steps, I secured a
              very short ligamentous  union, so  that she
              walked well at first, but in less than a year the
              connecting band had stretched, torn, or yielded,
              so that  there  were two  inches between the
              fragments  when the  leg  was forcibly flexed.
Ligamentous union  j)  Coale  presented to the Boston Society for
  after transverse  ^v' ^      1                            J
  frateHae °f  the  Medical  Improvement,  a  specimen of a frac-
              tured  patella  taken  from a  man  sixty-five
years old, the fracture having occurred ten years before.  Dr.
C.  reports that  the  fragments at first were  so closely united
that no separation between  them  could be  discovered ; but
subsequently they became disjoined at their  outer edges one
inch, and at their inner edges very much  less.
  Treatment.—The sooner the limb  is properly dressed, after
fracture of the patella, the easier it will be to accomplish the
chief object of the treatment.  The  muscles  attached to the
patella are  so poAverful that their contraction goes on from
day to day  until at the end of a week or  two  a space of two
or three inches -between the fragments exists, though the sep-
aration of the pieces of bone may have been less than an inch
at first.  Immediately succeeding the  fracture the two por-
tions of bone  can be easily brought into contact, whereas  in
the  course of a  feAV  days the muscles have become so much
contracted  and accommodated, as it Avere, to their new posi-
tion, that  it is  often quite impossible to elongate them suffi-
ciently to bring  the piece of bone connected Avith them down
far enough  to meet the lower portion :  the  consequence  of
which  is, that direct  apposition and consolidation are never
obtained, but a  kind of ligamentous  or fibrous union is the
result.   It is generally believed among experienced surgeons
that the'great rareness of bony union in  transverse fractures
of the patella must be owing simply to the difficulty of keep-
ing the fragments in  sufficiently  close apposition ; if contact
of the broken surfaces could be produced and steadily main-
tained for several Aveeks, bony union might be expected as in
other fractures.
 
Of  the Patella.
219
  A modification of the dressing employed by Mr. Cooper is
represented in the accompanying diagram, and may be applied
as folloAvs ; carry a circular bandage from the toes to the knee,
binding two strips of uniting bandage Avhich  are laid on the
sides of the leg, the upper ends being left free for tying above
the upper fragment  when it  is bandaged down into place.
Another roller is to be applied, beginning at  the,upper part

                          Fig. 89.
Circular bandages above and below the knee serve to hold firmly in place two sets of uniting
       tapes which are to be tied above and below the fragments of the patella.

of the thigh and bandaging downward Avhile an assistant with
both hands near the knee pulls poAverfully upon the quadriceps.
The bandage secures and maintains the stretching and exten-
sion applied by the assistant.   Tavo strips of -strong cloth are
to be  laid  upon the sides of the thigh, and  covered by the
spiral bandage, as Avas done beloAv the knee.   The free ends
of the uniting bandages are to be tied above  and below the
fragments, a compress  being placed  where the knots are to
rest.  If the uniting strips be tied snugly, they exert a  pow-
erful  influence  toAvards bringing the fragments in contact.
To finish the dressing a compress may be laid on the patella,
and held in place by a  few turns of a third roller, Avhich also
covers in the space between the other bandages and secures
equal pressure the Avhole length of the limb.   A long splint
may be bound to the posterior aspect of the leg to prevent the
slightest degree of flexion at the knee.  The rectus femoris is
freed  from tension by elevating the leg on  cushions  or  other
supports.
  The dressing jmt  described  operates very Avell AAiien the
bandages wholly prevent the ties from slipping, but practically
it is found that they will not.   To obviate that serious defect
Dr. Sanborn, of LoavcII, Mass., devised a modification of the
old plan, using adhesive strips in place of the ties or uniting
bandages.   He recommends a strip of ordinary adhesive plas- 
220
Fractures.
ter four feet long and two and a half inches wide to be applied
to the anterior aspect of the limb from the upper portion of
the thigh to the middle of the leg, leaving a free loop at the
knee for purposes  presently to  be explained.   The  ends of
the strip to  within a few inches of the knee, are bound in
place by a couple of rollers—one for the  foot and leg, as in
Cooper's dressing, and the other for the thigh.   A hard roller
compress is placed immediately above  the upper fragment,
and then a small stick, as a twister, is  put through the loop,
and revolved until great poAver is brought  to bear upon the
parts to  which the adhesive strip  is attached.  This  is  an
efficient and easily applied apparatus, and good results maybe
obtained from its use.   I have  employed it  in one instance,
Avith the addition of a single  inclined  plane  to  elevate the
foot, and secured a bony union of the fragments.
   If the fracture occurs  from  direct violence  there Avill be
danger  of  a high grade  of inflammation  and anchylosis
Cooling and anodyne lotions  that will not  interfere with the
dressings, should be freely employed during the early part of
the treatment.  At the expiration of four or five Aveeks from
the reception of the injury, passive'motion  is to be instituted,
and kept up until the functions of the joint are restored.
  In a case of vertical or  longitudinal fracture the knee-joint
should be enveloped in  strips of  adhesive plaster to retain the
fragments steadily in  juxtaposition.  The tendency is to lat-
eral displacement of the fragments in a  moderate degree, and
the adhesive strips are used to counteract it.  Osseous  union
is pretty certain to folloAV this treatment.  Arthritis  and an-
chylosis  are  the most dangerous conditions to be guarded
against.
  I have never met Avith a case of a recurrence of the  lesion
after fracture of the patella, but such accidents  are reported.
I am inclined to think that there Avas no bony  union  in such
cases, and that the  " recurrence " Avas merely a tearing ofthe
fibrous connection.
   It is rare for a patient to recover entirely after having  sus-
tained fracture of the patella.  In the event of fibrous union
of the  fragments the power of extendiug the leg is impaired;
and  bony union  is generally followed .by  excesses of callus
that impede the  motions  of  the joint.   A complete  restora-
tion of all the functions of the limb  is a fortunate issue. 
CHAPTER  XXVII.
FRACTURES   OF  THE  LEG.
   The bones ofthe leg are parallel in direction, but quite dif-
 ferent in size, shape, and function ;  the tibia is large,* and by
 its broad articulation Avith the femur and tarsus, is evidently
 designed to 'support the  weight of the  body ; the fibula is
 small, and  is destined not to  sustain weight, but to give at-
 tachment to many muscles, and its lower end contributes to
 the formation.of the ankle joint.  The tibia has broad articu-
 lar extremities and a triangular shaft; the fibula has moderate
 sized  extremities,  and a slender prismatic shaft.   The two
 bones have quite different offices to perform,  yet they are so
 intimately associated in their anatomical relations  that both
 are more frequently broken by a single accident than either
 is fractured separately.  A force sufficient to break the tibia
 is generally powerful enough to reach the fibula and to break
 it also.
   The tibia being thinly covered, is exposed to direct violence,
 and peculiarly  liable to compound fracture;  the fibula is
 pretty well buried in soft tissues, and Avhen broken, its frag-
 ments rarely puncture the skin.
   The causes of fracture  of  the leg are either direct, as  the
 passage of a Avheel over the  limb ;  or indirect, as in landing
 heavily upon the feet, from a jump or fall.  The relative fre-
 quency of these causes in the production of fracture has been
 \Tariously estimated by different authors.   Hamilton considers
that four-fifths of them come from direct violence, Avhile Mal-
gaigne found that in sixty-seven fractures of the leg observed
by him, thirty-six Avere produced by direct, and thirty-one by
indirect violence.  There  are some parts  of the tibia,  as the
head and lower extremity, that rarely yield from the influence
of an indirect force ; but when  a  person in a jump  or fall
                          (221)   ' 
222                    Fractures.
 comes to the ground on his feet, the force is likely to act ob-
 liquely upon the shaft ofthe bone, and snap it across. Direct
 forces may fractnre any part of the bone, for all parts are ex-
 posed to the  influence of kicks, blows, projectiles, falling
 bodies, and moving machinery.
   Both bones  of the leg  may  be broken, as has just been
 stated, at the same time, or by the same accident; if the vio-
 lence be direct the fracture may be on  the  same  line in the
 two bones ;  if indirect, the tibia is liable to yield in  its lower
 third, and the fibula  somewhere above its  middle.   Peculiar
                       circumstances  may  alloAV  the  indi-
                       rect force to break  the  two bones in
                       the same line ; and  others may occur
                       which cause the direct force  to break
                       each at different points.  ,
                         When the  indirect force acts, the
                      fibula must almost always break  after
                      the fracture of the tibia has taken place,
                       for the force continues on upwards and
                      comes  upon the fibula Avith the  addi-
                      tional weight of the body of the person
                      which  is no longer supported by the
                      tibia, consequently the  whole  stress
                      tells on the slender fibula above where
                      the other bone  gave way, producing a
                      fracture in its upper third.  A violent
                       and sudden twist of the ankle, which
                      is force  indirectly applied, may cause
 fracture of both bones just above the joint, the line of separa-
 tion being nearly on the same level.
   It is rare to find the fibula broken below the point of frac-
 ture in the tibia, even though direct force has caused the in-
jury.  If the leg be  broken by a wheel passing over it ob-
 liquely, the  fibula being struck at a point lower doAvn than
 the tibia is hit, the line of separation in the two bones  must
 correspond Avith the points subjected to violence.
   The direction the fracture takes is much the same it  is in
 the long bones generally : if the force be indirect, the oblique
 course prevails ; if direct, the transverse.  In most  instances
 the line of separation is irregular, but inclining to the oblique.
 The tibia  is  most liable to exhibit a predominance of obliquity
Fracture of both bones of the
 leg; the fibula through its up-
 per, and the tibia through its
 lower third. 
Of  the Leg.
223
Fig. 91.
  in the line  of its fractures;  and the fibula shows a tendency
  to the transverse direction in  the line of its separations.
    Displacements may take place as in fractures of other bones,
  and from similar causes ; in transverse fractures the fragments
  may not become disengaged,  at least there is less tendency to
  displacement; in oblique fractures, on the contrary, there is
  nearly ahvays overlapping, sometimes  to  a considerable  ex-
  tent, as Avhen the fracture is caused by a fall on the feet from
  a  height, for the force being more than sufficient to break  the
  bones, continues to  act, and  so  displaces them.  Combined
  Avith this  there  is usually some  rotatory displacement,  due
  partly to the force received and partly to muscular action.
    The signs of fracture in the bones of the leg, are generally
  well  marked,  though not always comprehended in their
  utmost significance.   In other Avorcls, it may be plain that a
  fracture exists, but it is not generally an easy matter to deter-
                          mine Avhether one bone is broken or
                          both, and what  is the direction  of
                          the fracture, the  extent of the injury
                          in all its bearings and complications,
                          and what obstacles are to be over-
                          come in the treatment.  The crepi-
                          tus,   mobility,  and  deformity   are
                          commonly detected upon the slight-
                          est  examination. The  tibia is  so
                          near the  skin   that  the smallest
                          amount  of displacement is readily
                          detected by passing the fingers along
                         the  course  of the bone ; the fibula
                         is more deeply covered, yet thorough
                         manipulation can not fail to discover
                         the place where  the separation  ex-
                         ists.   The surgeon, in  examining a
                         leg  which has sustained a fracture,
should not be content Avith the discovery of a break in one
bone, but he  should carefully  scrutinize  the  other.   It has
been  already stated that a fracture of both bones in a single
accident, is more common  than the fracture of  one bone
singly, therefore in a given case the probabilities are  ahvays
in favor of both bones having been broken.  In the treatment
of fractures of the leg it is of the utmost  importance to de-
Fracture of both bones of the leg on
 nearly the same plane, the result of
 direct violence. 
224               ,     Fractures.
termine AAiiether one bone is broken or tAVo; if only one bone
be broken there may be a rotatory.or twisting kind of defor-
mity, but there can be no serious degree of shortening ; if both
bones be broken, and the surgeon discover  a fracture in one
alone, and treat the injury according to his faulty diagnosis,
the most serious consequences are sure to be the result.
  In considering the displacement that occurs in fractures of
both, bones  of the leg, it may be easy to  determine, for in-
stance, that the upper fragment of the  tibia takes a position
in front of the lower fragment; but to decide upon  the rela-
tive positions of the fragments of the fibula may be attended
with some difficulty.  The force that displaces the fragments
may be of two kinds,—it may come from muscular action
pulling the lower fragment above the upper; or it maybe that
which causes the fracture, driving one portion of bone  from
its contact with the other after the break has occurred.  It is
more probable that the same force would go on acting after it
has fractured the bones, than  it should cease directly.  When
the fragments are once displaced by the force  producing the
fracture, the  muscles exert an action  upon them, and may
oppose reduction.
  Overlapping is one ofthe most important and  constant fea-
tures in fractures of both bones of the leg.  To recount all of
the muscles  that  either produce or maintain the retraction'
Avould be simply enumerating the entire list that  make up the
motive power of the leg.  The line  of action is  towards the
knee, the broken ends  of the  lower fragments  being pulled
upAvards past the fractured surfaces of the  upper fragments.
The  weight of the  limb causes a part of the angular and rota-
tory deformity, and the winding course of some  of  the  mus-
cles the rest of it.   The direction of the force producing the
fracture Avill ahvays vary the line of the displacement; for,
applied from  the  outside of the limb it will be disposed to
displace the  portions of bone inAvards; and applied  from the
inside,  it influences them in the opposite direction.
  The  fibula, in fractures of both bones of the leg, has very
little influence upon displacement; the fractured ends present
so small  a surface that very little force destroys their apposi-
tion, and if the bone be broken into more than two pieces the
muscles destroy their parallelism, so  that  perfect coaptation
of the fragments is exceedingly rare. 
Of  the Leg.
225
Fig. 92.
   In fractures very high up, near or through the head of the
 tibia, where  they may be  when direct  force inflicts the  in-
 jury, the displacement is slight, unless the fracture be much
 comminuted; for, in this situation the structure of the bone
 is cancellous, which causes'it to break with a more irregular
 fracture, giving the  surfaces a rough, uneven shape, by which
 the ends of the bone are locked within  one  another, and  re-
 quire a powerful force to  displace them.  Fracture through
 the head of the tibia, or through the lower extremity of it, is
 liable to be oblique or  nearly vertical in  its course, a circum-
 stance that always renders  it doubtful whether the knee or
 ankle-joints are not  complicated in the injury, rendering the
 nature of the lesion  much  more serious than a fracture ofthe
 shaft of the bone.
   Fracture of the internal  malleolus and  of the fibula  a feAV
 inches above the joint, accompanied with partial or complete
                     dislocation of the ankle, is an injury of a
                     complicated nature,  and is essentially the
                     s.ime as " Pott's fracture " of  the fibula,
                     Avith laceration  of the deltoid ligament,
                     and  displacement of the tibia  from the
                     astragalus to a certain extent.
                       Fractures  through the extremities of
                     the bones  of the leg are not easily diag-
                     nosed, especially if the patient be not ex-
                     amined  until swelling has rendered the
                     case obscure.  These accidents are ahvays
                     accompanied Avith more  ecchymosis and
                     SAvelling than fractures at a distance from
                     the joints, owing to the nature of the
                     force that produces the injury, and to the
                     fact that the articular structures arc more
                     or less injured  at the same time, Avhich
                     causes  the effusion to be greater than it
                     otherAvise would be.  On July 6th, Dr.
                     A. P.  Freeman and  myself Ave re called
                     to  treat Mrs. Taylor, of West Covington,
                     Ky., who had the evening before broken
her left leg just above the  ankle.  There was (onsiderable
swelling and discoloration  twelve hours after  the accident
occurred.  The general contour ofthe leg showed that afrac-
      15
Fracture of the tibia and fibur
 .a near the lower extremi-
 ties of those bones. 
226                    Fractures.

ture existed near the ankle, but the line of separation in both
bones could not be determined without careful  manipulation.
Crepitus decided the nature of the injury, though it could not
be ascertained at first whether the grating sound came from
the tibia or fibula, or both.  The concavity on the outside of
the leg led to the suspicion that the fibula Avas broken, and
lateral motion, Avith the finger on the suspected point, made
the existence  of fracture  certain.  Antero-posterior motion
developed crepitus  between "the fragments of the tibia;  and
the fingers  pressed upon  the bone just above the ankle  dis-
covered the  line of separation.  It Avas easier to comprehend
the break in the fibula than it Avas the certainty of fracture
and the line of  separation  in the  tibia.   The deviation from
the ordinary shape  ofthe limb, consisting  of  some angular
defect, a visible twist or rotatory deformity in the loAver part
ofthe leg, made it apparent that both bones had been broken.
The line of separation in the  tibia Avas too nearly transverse,
and there Avas too little displacement to admit of overlapping,
therefore whatever of deformity existed was overcome  by ex-
tension made with  the  hands.   Common thin board  splints
were  wrapped  with*muslin, and applied to  each side of the
leg, and  bound  in place  Avith  encircling tapes and a roller,
compresses being used to help secure the normal shape ofthe
limb.   In  five  weeks  consolidation Avas complete, and  no
shortening or  rotatory  deformity remained.   ]STo extending
force Avas used  after the reduction, for none  was required.
The interlocking of the fragments of the tibia Avould not ad-
mit of overlapping.
  In fractures of both bones ofthe leg near the knee, the line
of separation can be discovered between the fragments of the
fibula, but the course of the fracture-line in the tibia is often
quite difficult to make out.  The tibial fragments  are  apt  to
remain interlocked, OAving to their broad surfaces, and to the
little  power of the muscles over them.   Crepitus may some-
times be elicited, but it may not be easy to determine whether
it  is between  the  fragments of the tibia or fibula.  If much
displacement happens to  be  produced  by  the force which
caused the fracture, or if the line of separation be oblique, the
nature and extent of the injury are not difficult to understand.
  Fractures of  the bones of the leg remote  from the joints,
are  attended  with signs quite unmistakable.   Crepitus  is 
Of the Leg.                    227
easily produced, owing to the mobility that exists betAveen
the fractured portions.  When the fracture exists in the tibia
only, the  same facility does not  always exist, for the fibula
then serves as a splint to a certain extent, and keeps the frac-
tured ends of the tibia in  apposition.
  Crepitus, for various reasons, can not ahvays be produced
even Avhen both bones are broken somewhere near their mid-
dle ; but  the  angular deformity which can be  produced by
bending the leg in any direction, sufficiently demonstrates the
nature of the lesion.
  The inner and fore part of the tibia being quite superficial;
a fracture of the shaft of  the bone may  at once be recognized
by passing the finger along the anterior spine ; for any irregu-
larity along this surface will be easily disco\Tered, and indicate
the position  of the fracture.   The point of fracture in the
fibula is not, as already stated, on the same level with  that of
the tibia, especially Avhen  the  fracture  is caused by indirect
force ; for the fibula is found to yield  at a point someAvhere
above the place the tibia breaks.  The most frequent kind of
displacement in the fibula is inward toward the tibia, causing
a depression which  may be felt when .the finger is  pressed
along the outside of the bone;  and the ends of the tibia can
not be displaced to any great extent without the ends of the
fibula moving with them.   Overlapping  of the fragments of
the tibia can not take place without the same amount of dis-
placement occurs in the fibula.


TREATMENT OF FRACTURES OF BOTH  BONES OF
                       THE  LEG.

  As already indicated, when detailing  the course pursued in
the treatment of  Mrs. Taylor's leg,  extension and counter-
extension are not always required in the management  of frac-
tures of both bones of the leg.  However, if there be shorten-
ing,  or an opportunity to overlap on the part of the  frag-
ments, as there almost always is when the fracture is through
the shafts ofthe bones, those forces must be steadily and per-
sistently maintained as long as a retentive apparatus is neces-
sary, otherwise some degree of deformity will be inevitable.
If there is a disposition to overlap, as there necessarily will be 
228
Fractures.
when the fracture is oblique, the difficulty in preventing this
deformity is exceedingly great.  The surgeon may effectually
reduce the fragments to their proper  places,  and carefully
apply suitable means to retain them there, yet the tendency
to overlap is so pressing that the pieces of bone will slip past
each other, unless  watched and  guarded  against  with the
utmost  patience and skill.  The facility  with  which the
broken  surfaces escape from one another, while the dressing
is being applied, has been observed by every one familiar with
such injuries.   The force and dexterity required to effect re-
duction in the  event  of much  overlapping, and  in irritable
patients whose muscles fly into a state  of spasm as soon as the
limb is touched, are far from trifling.  The influence of chlo-
roform is sometimes needed to accomplish a successful reduc-
tion.  In reducing fractures of the leg, an assistant should be
placed so as to fix the knee firmly, Avhile the foot is grasped,
and steady and Avell directed extension is made downwards,
care being taken to unlock or disengage the fragments by gen-
tle rotatory motion. In manipulations of a broken leg it should
be borne in mind  that  large arteries,  veins and nerves, pass
along near the rough and sharp  edges of the fragments, and
may be seriously injured by careless  handling of the limb.
   It is the custom of  some surgeons to alloAV a broken leg to
remain  several days under the influence of cooling and ano-
dyne lotions,  before an attempt is made at reduction.   This
course might do in a hospital where  the patient has no choice
of surgical attendants, but in private practice the most eminent
practitioner is not sure of holding his  case if he folloAV such a
course.  Policy, then, is against the practice, even  if it  have
some points  in its favor; but according  to my experience
there is no better time to adjust a fractured  bone than as soon
as it can be done conveniently.   The muscles do not readily
relax after they have  been allowed  to contract for several
days ; besides, the patient does not rest well with the limb in
a broken and unsupported state.  There is a feeling of insecu-
rity in an undressed fracture that is  absolutely tormenting ;
every motion of the body imparts pain and invites a spasmodic
action of  muscles in the vicinity of the fracture.  If it be im-
possible to reduce a compound fracture on account of the mus-
cular contraction  and spasm, the influence of  an anaesthetic
will put the  patient into  such a state of relaxation that the 
Of the Leg.
229
Fig. 93.
worst case can be managed successfully.  If the wound in the
integument be too small for the protruding fragment to return,
it may be enlarged slightly to take off the tension.  The ne-
cessity for saAving oft" a piece of the bone in  order to  accom-
plish easy and speedy  reduction, can rarely or never exist.
However, it would be necessary to resect a point of the bone
if it could not be returned to its proper position, yet  such a
procedure is to be avoided if possible.  I  can not endorse the
following from Prof. Hamilton : " Resecting  thus the end of
an oblique fragment does not  generally affect in any degree
the length ofthe limb, or interfere Avith a prompt and  perfect
                 cure,  but on the contrary it often is  advan-
                 tageous in every point of view."
                   The application of extending force  in
                 those instances  Avhere  the overlapping de-
                 mands it, taxes the ingenuity of those unac-
                 customed to make a " hitch " upon the foot.
                 Barton's handkerchief, as  it is  sometimes
                 called, may be employed  as a  means  of
                 making extension.  It can be applied as fol-
                 lows:  a handkerchief of  good  size being
                 folded into a cravat, is so laid against the
                 point of the heel that one-third of the hand-
                 kerchief shall be on one side and two-thirds
                 on the other; after which the longest end
                 is to  be carried  round across the instep to
                 the opposite side,  where  it takes  a  turn
                 around the other extremity of the handker-
                 chief, and is then carried  under the sole of
                 the foot to the other side of the ankle, where
                 it takes  a fold around the first turn.  The
                 tAvo free ends reaching beloAv  the foot are
                 to be  used for making extension with what-
                 ever apparatus the surgeon chooses to em-
                 ploy.   A gaiter has been one of the means
                 of making fast to the ankle, Avhen extension
                 is needed;  but if the fracture be near the
ankle-joint, the folded handherchief is not endurable Avithout
great suffering  and  excoriation.   The  heel  and structures
about the  ankle  are proverbially intolerant of pressure, and
the accident renders them more so.
Hitch made upon the
 ankle and foot with a
 handkerchief folded
 like a cravat.

     Fig. 94.
A gaiter-like appliance to
 make fast to the ankle. 
230
Fractures.
Fig. 95.
  The adhesive strip fastening is the least objectionable of all
kindred  contrivances  for  making extension.   The foot and
                ankle are  to be covered in Avith narrow strips
                of  adhesive  plaster, then the  vertical side
                strips of greater width are made to adhere
                partly to the skin and in part to the envelop-
                ing material, and, finally, over both a few en-
                circling strips  are  applied, which complete
                the first stage of the dressing.   The surgeon
                can take  his  choice of these three forms of
                making fast to the foot and ankle, but I much
                prefer the " hitch "  by  adhesive strips.
                  If the fracture be  higher up, long pieces of
                adhesive plaster may be used  and a firmer
                hold  secured.  A   roller  may be used  to
                envelope  the  leg after the strips are applied
                if its compressing influence seems to be neces-
                sary, though I am not in favor of a bandage
                next the skin which may exert a constricting
                influence.
Adhesive strip fasten
 tm^alfkie*0 for fthe    Tne Iiex* step in  the dressing consists in
 exten°sSion.of making applying the retentive apparatus, which may
                          consist of two wooden side splints,
                          well wrapped ;  and over these the
                          ends of a many tailed bandage may
                          be lapped to  hold them securely in
                          place.  Figure 96 shoAvs the dress-
                          ing in this second stage, Avith a feAV
                          of the loAver strips lapped across.
                          Twto or three encircling ties may be
                          used  to  retain the splints  in  place
                          until the full retentive influence of
                          the many tailed bandage is brought
                          to bear.   A  roller may be used in-
                          stead of the bandage of strips.   I
                          prefer the roller in ordinary simple
                          fractures; and  the  bandage  of
                          strips in compound injuries, for the
                          latter is  the easiest  to  be opened
                          and closed when the wound is ex-
Dressing for the leg, after both bones  a-rrnnpd
 are broken, in progress of applica-  diiiiUBU.
 tion.
Fig. 96.
 
Of  the Leg.                     231
   The next step in the dressing is to give the leg the position
 it is going to occupy, and to apply the extending and counter-
 extending forces.   The double  inclined plane apparatus is
 used by some surgeons  to give  the  limb the flexed position
 and to secure not only what force there is to be obtained by
 this attitude, but to apply by means of ties and screws as
 much in addition as may be demanded.   Other surgeons pre-
 fer the straight position of the limb, using a fracture box, as
 it is called, or a contrivance  made of boards to reach along
 the sides of the leg, a  bottom piece, a foot piece  which is
 nailed to the bottom and side pieces, and a movable foot piece
 to Avhich the gaiter, handkerchief, or the side strips ofthe ad-
 hesive application, are tied.  If the double inclined  plane be
 used, counter-extension may be left to the Aveight of the thigh
 and body, and extension made by lashing the foot to the mov-
 able foot-piece of the apparatus, and then draAving it steadily
 dowiiAvards by  turning  the screAvs, or by other means em-
 ployed to accomplish the same object.  To describe all  the in-
 ventions and  improvements of this kind  introduced  to  the
 notice of the profession, Avould require more space than can
 be granted in a  work of this kind.  The accompanying  cut
 represents  an apparatus 'for  making extension and counter-
 extension below the knee.  The foot is fastened  to the mov-
able foot-piece by means of a gaiter; and the counter-extend-

                          Fig. 97
1, Side of fracture box; 2, bottom of fracture box ; 3, movable foot-piece; 4, wooden screws
    to adjust foot-piece; o, gaiter ; 6, belt of leather encircling the leg below the knee,
         for counter-extending force; 7, hooped rod to sustain the force.
ing force is obtained by means of a piece of sole leather which
is laced together after encircling the leg just below the knee.
Some tapes extend from holes or loops in  the upper  edge of
the leather band, to an iron rod, which is hooped, and has its
tAVO  ends  secured  to  the upper  extremity of the box,—the
hoop is made adjustable by means  of a couple of wire loops
driven into the upper ends of the sides of the box.  The same 
232                     Fractures.
principle is applied to  every apparatus  of the kind, though
many of these contrivances vary in general characteristics.
  It is not necessary to  employ a complicated apparatus to
treat successfully fractures of both bones ofthe leg.  The ex-
tending strips of adhesive plaster maybe attached to the foot
of the bed, and then counter  extension can be produced by
elevating the foot  posts of the bedstead, as already recom-
mended in the treatment  of fractures of the thigh. If this
method be adopted a  sand  bag should be placed under the
knee, and other bags may be laid against the outside  of the
limb to thwart the tendency to  eversion.  In some  instances
the leg should be supported between two junk bags in  order
to take the weight  of the limb  from the  heel which is  liable
to slough under prolonged though moderate pressure.   If the
ends of the splints press heavily at  their upper or  lower ex-
tremities,  so as to threaten ulceration,  cushions of cotton,
hair, or wool should be  placed  under  them.  The limb must
    Fig. 98.      he watched very narrowly, to prevent any
                 morbid  action from doing serious  mischief.
                 Vesication  is a  common condition  after
                 fractures of the leg; and  the  bladders of
                 serum that form .beneath the dressings, out
                 of sight, may break and  degenerate into
                 ulcers and ugly sloughs.  If the vesicles are
                 very large and tense, they may be pricked
                 to alloAv the serum to escape.   These blis-
                 ters commonly dry  up in the course of a
                 week  or two,  and leave no bad  effects.
                   In a fracture of both bones of the leg, es-
                 pecially  if the tibia be broken at one point,
                 and the.fibula at another, the  tendency to
                 overlap on the part of the fragments is con-
                 siderable, therefore careful and  persevering
                 efforts must be made to obviate shortening.
                 The accompanying diagram represents with
                 scrupulous exactness the bones of the leg
              JegJ as found after having been under the  treat.
                 ment  of a  surgeon   of more than ordinary
skill and experience.  The patient died of visceral disease in
five months after receiving the  fracture.  The limb Avas three
quarters  of an  inch too  short, as may be judged by the
Consolidation of the f
 inents after fractun
 both bones of the
 showing deformity. 
Of the Leg.
233
overlapping of the fragments, and there was angular defor-
mity, besides some arising from rotation.  The upper fragment
of the fibula split, and the Avedge shaped broken edge of the
lower fragment Avas forced between the splinters.   The injury
occurred from indirect violence,  the patient in a fall striking
upon one foot.   The consolidation between the fragments Avas
found to be complete, but the rough points of the badly op-
posed fragments Avere little affected by the polishing process
Avhich  at  length  makes  such  irregularities comparatively
smooth.
  Measurements during treatment should be  frequently made
to determine Avhether shortening is taking place.  With the
body straight, and the legs parallel, a  tolerably correct  com-
parison can be made betAveen the  lengths of the tAvo  limbs.
However, it is more satisfactory to measure from the umbilicus
or symphysis pubis to the inner  malleolus of  each  ankle.  If
the patient be a woman the measurement may be made  from
the patella? to the malleoli.
  When the two limbs are side  by side, any deviation of the
broken leg, as by rotation, is quickly detected.  As a sight is
taken up the limb  to the body the great toe should be on a
line that strikes the inner edge of  the patella.
  The foot must be watched to see that the heel be not draAvn
upwards too much by the  contracted condition of the  sural
muscles acting through the tendo-Achillis.   When the obli-
quity of  the fracture favors that kind of contraction, as well
as a slipping baclovards of the  foot and whatever of leg  is
beloAv the break in the bone, the inclination or tendency must
be arrested by the dressings and the proper use of sand bags.
If a cushion or junk bag  be carelessly placed just above the
fracture the weight of the leg would tend to displace the foot
backwards.
  In cases admitting of the leg  resting  upon  its side, that
position is favorable to ease and apposition.  Some surgeons
prefer to dress the leg with the view of having the limb gently
flexed and laid  upon its  side.  After fracture of one of the
bones of the leg the limb may be placed in any attitude, for
no extending apparatus interferes Avith free  movements; but
when both bones are broken, and there be danger of overlap-
ping, the limb can not be freed from the machine or apparatus
that has to be employed to secure extension. 
234
Fractures.
  In some instances it may do to lay aside the ordinary appli-
ances, and to adopt  the  stiff dressing in  their  stead.  The
common starch dressing, Avhen once dry, Avill obviate the ten-
dency to shorten.  However, the limb may shrink after it has
been in the immovable dressing for a few days, affording op-
portunity for lateral displacement  and shortening.  I never
feel satisfied  Avith a  starch dressing when both bones are
broken.   In exceptional cases, Avhere it becomes necessary for
the patient to be moved by carriages and railroads before con-
solidation of the broken  bones has taken place,  the immov-
able or stiff dressing should most certainty  be employed.
  Debilitated, dropsical, and broken  down  constitutions are
exceedingly unfavorable to rapid bony union; and in an occa-
sional  instance no consolidation Avill take place.  In  1862 a
raftsman on the river got his leg caught in some  lumber and
broke  both bones in  the  lower  third of the limb.  He Avas
taken to the  house of Mr. Harrison,  of Newport, Ivy.  I ac-
cepted an invitation to take charge of the case, and treated it
in the ordinary Avay.  In the course of ten days the limb took
on a flabby, dropsical appearance, and presented evidences of
defective  vitality.   At the end of four Aveeks from the acci-
dent, I perceived crepitus betAveen the fragments, and the limb
exhibited almost as much mobility at the  seat of fracture as
at first.  The  limb was  redressed, and the patient Avho Avas
seriously impaired in health from the excessive use of liquor
and exposure, was-put upon a stimulating and nourishing
diet, and  three glasses of ale a  day Avere allowed him.   He
soon began to improve in general appearance, and the  leg
which Avas redressed once a Aveek, showed more firmness and
vitality.   At the end of the eighth Aveek the limb had stiffened
at the point of fracture, very little deformity existing.  I now
put the leg in a starch dressing, and had the patient begin to
take exercise on crutches.  In four months from the reception
of the injury, the patient walked to my office, using a cane to
steady himself.  There Avas no perceptible shortening, though
the upper fragment of the tibia  projected so  it could  be
plainly felt.  The consolidation seemed as  perfect as in any
case.  During the early part of the treatment I was afraid of
false joint, but the  sequel shoAved that the case Avas to  be
looked  upon  as  representing  delayed or  tardy'reparative
action. 
                       Of the  Tibia.                   235


        FRACTURE  OF  THE  TIBIA  SINGLY.

   As  has been previously stated, a force which  breaks  the
 tibia is generally sufficient to snap the fibula also.   However,
 the tibia is sometimes broken singly, the fibula remaining in-
 tact.   Direct violence, such as the kick of a horse, or a bloAV
 from  some hard body, may be  the  cause.   James Bucking-
 ham, in January, 1864, slipped while stepping from the street
 to  the sidewalk at the corner of Sixth and Elm Streets,  and
 hit his leg live or six inches beloAV the knee against the sharp
 corner of the curb-stone.   He distinctly heard something
 snap,  and immediately experienced  great pain in the limb.
 He Avas near home  and attempted  to Avalk the distance,  but
 the distress occasioned by an effort to use  the leg compelled
 him to sit down.  It was before daylight in the morning,  and
 as  nobody passed along to help him, he dragged himself home
 the distance of a square, on his hands and sound hip and  leg.
 In  an  hour or so after the accident I found the tibia broken a
 few inches beloAV the knee, and the fibula as sound as ever.
 The upper fragment projected a little,  but there Avas no per-
 ceptible rotation of the leg below, or other deformity.
  In 1867, Fritz Gorman, a lad of eight years, was hit by a
 runaway horse,  on Front Street, and received an injury ofthe
 leg.  I Avas called to the case, and found a fracture  of the tibia
 three inches above the ankle, Avith the  anterior sharp edge of
 the upper fragment protruding through the skin.  The fibula
 had escaped fracture.  These cases are mentioned, not as pos-
 sessing any special interest; but to shoAv  what kind of forces
 may break the tibia alone.  In the first case  the patient  said
 " the weather was so cold there must have been frost in his leg."
 There  is a popular notion that the bones are more fragile when   •
 the Aveather is  intensely cold.   Probably this is an  error
 founded on the fact that more fractures occur in frosty weather
 than at other seasons, the sufferers ascribing their misfortunes
 to osseous fragility and not to the slippery condition of every-
 thing frosted, where the real cause  should be placed.  It is
 possible that the highly contractile state of the muscles  may,
in cold weather, increase the frequency of broken limbs ; and
 if it be a fact that intoxicated persons whose  muscular system
is in  a loose, flaccid condition, can  receive heaAry falls  and 
236                     Fractures.
   enjoy an immunity from fractures, it becomes highly probable
   that a tense state of the soft tissues favors fracture.
     In fracture ofthe tibia the line of separation may be trans-
   verse, oblique, or irregular in its course.  Being the result of
   direct violence in a majority of instances, the transverse vari-
   ety prevails, especially if the fracture be near the extremities
   of the bone.   I Avas-  once called by Dr. Wm.  Sherwood, of
   this city, to see a case in his practice, in which the fracture
   extended transversely through the tibia within  two inches of
   the knee-joint,—the fibula Avas not  fractured.  There  was
   little or no  displacement, and consolidation took place in five
   or six weeks.  Direct  violence Avas the cause of the injury.
   Dr. Van Ingen, for a while  in this  city, exhibited to me a
   drawing which he had made to represent an oblique fracture
   through the upper part of the tibia, the line of separation ex-
   tending into the knee-joint.  He says the case was treated by
   him successfully near Schenectady, N. Y.   His  diagram  also
   showed a fracture of the inner condyle of the femur, which
   was a part of the same accident.  It is possible«Jie may have
   been mistaken in regard to the extent of the  injury.
     I once took professional charge of a teamster  who, in jump-
   ing from his wagon to  the ground, received a longitudinal
   fracture of the lower extremity  of the 'tibia.  The line of
   separation began in the articular surface of the lower end of
   the bone, and terminated  tAvo inches above the joint, disen-
   gaging  a wedge-shaped splinter of bone, including the inter-
   nal malleolus.   The piece united without displacement or de-
   formity, but the function ofthe joint was restricted by partial
   anchylosis,  lasting a  year or more.  The  patient ultimately
   recovered the full use  of the limb.  In fractures of  the tibia
   through the loAver third of the bone, the foot, including the
.   leg beloAV the fracture, is liable to  exhibit a twist, indicating
   more distortion than might be expected after a fracture of
   only one bone  of the leg.  The twist in the limb is permitted
   by the length  and sleuder state of the fibula,  and its lateral
   mode  of articulation.
     The symptoms of fracture of the tibia alone, are quite dis-
   tinct and easy of recognition, if the solution of continuity be
   anywhere near the centre  of the  bone, for the inequality at
   the line of  separation  will be felt Avhen the finger is pressed
   along the spine of the bone;  but if the break be near either 
Of  the Tibia.                   237
 extremity, and the direction of the fracture line be transverse,
 without appreciable displacement, the diagnostic  powers of
 the surgeon may be put severely to the test.  The perfect con-
                         tact ofthe fragments often prevents
                         crepitation, and the existence of the
                         fracture has to be inferred from the
                         nature  of  the  -force  applied, the
                         sharp, circumscribed and  persistent
                         pain increased by pressure or an at-
                         tempt  to  walk, and  the local en-
                         gorgement.   If mobility and crepi-
                         tus can be detected when the frag-
                         ments are pressed in opposite direc-
                         tions  the  diagnosis  of fracture  is
                         made out, but not of the tibia .alone;
                         for, the diagnosis is  not complete
                         until it is decided that  the lesion  is
                         limited  to  the  tibia, and that the
                         fibula remains unbroken.  When  it
 Fracture of the tibia; the nbuia    j8 knoAvn that a fracture of the leg
  remaining unbroken.                                          o
                         exists it is  safe  to  consider both
 bones broken, until it is positively determined that the fibula.
 is intact.  The crepitus elicited may come from a fracture of
 one bone or both.   To determine whether the fibula be broken
 the bone must be tested its entire length.   The finger is to be
 pressed along its course sloAvly while the limb is carried back-
 Avarcls and forwards and laterally to develop a point in which
 there is mobility or inequality.

   Treatment   of  Fractures  of the Tibia. — In most in-
 stances  a fracture  of the tibia alone  can  be managed Avith
 ease  and success.  The coaptation of the  fragments Avhen
 there is displacement, is  generally not  a  difficult  matter.
 If the projection of the upper fragment forward be consider-
 able, it may require some tact to get it back into place.   The
 influence of an anaesthetic maybe employed to overcome mus-
 cular rigidity.   The  tendo-Achillis has been divided to over-
come the spasm and contraction  of  the gastrocnemius and
soleus, but such  a  course is rarely if ever necessary.  I have
never seen a case that demanded  a section  of the tendon to
assist in reduction.
 
238
Fractures.
  The twist or rotation which follows a fracture near the ankle
is  worse to overcome than  the angular deformity folloAving
fractures of the tibia higher  up.
  In an ordinary case the limb from the toes to the knee may
be enveloped, not tightly, in a common muslin roller to mod-
               ify swelling, congestion, and muscular action ;
               two  lath  splints  long enough to reach from
               the  knee to the ankle may be  laid  on the
               sides of the leg, and  bound there by another
               roller.   If there be much tendency to the for-
               Avard projection  of either fragment  a third
               splint may be laid upon the posterior aspect
               of the leg, and a  compress upon the anterior
               surface of the limb near the fracture, and so
               placed as to bear upon the projecting piece of
               bone, though not at its very point.   Side
               splints have been prepared with concavities to
               fit the form of the  leg, and Avith holes near
               their loAver ends to avoid pressure upon  the
splints being bound  malleoli.  These carved and nicely construct-
 to the leg after frac-                                  d
 tureot the tibia.    eci splints are applied with ease, and they an-
SAver an excellent purpose in  most instances.   Almost every
surgeon has on hand  more or less of such appliances for treat-
ing fractures.   He also keeps ready prepared a supply of rol-
lers, raAv  cotton,  adhesive plaster, and  other material for
emergencies.  Some houses have  so few comforts  and imple-
ments, that the surgeon is greatly troubled to find material
from which to construct splints and  bandages.   And on re-
markable  occasions, when from  a railroad accident, or from
the fall of a building, a dozen fractures may need  attention  at
once, ample  preparation  for  the extraordinary occasion  re
dounds to the credit  and advantage of the surgical attendants.
HoAveA^er, if a practitioner of medicine and surgery be called
to treat a fracture, and he be not prepared with the usual ap-
pliances, he should  be competent to construct extemporane-
ously such splints and bandages as the necessities of the case
demand.  Sheets may be torn into strips, seAved together, and
wound into rollers ; splints can be whittled from  lath or shin-
gles, cigar boxes, and thin boards; pillows do for cushions and
supports until bags of dry sand can be obtained
 
Of the Tibia.
239
   After a fracture of the tibia has been dressed, the limb may
 be laid in  a position  favorable to ease  and repose.   The
 patient need not be confined to bed, but may lie upon a sofa
 or lounge.  The limb may be flexed, extended, or laid on its
 side, just as the patient chooses.  The  fibula prevents short-
 ening, and  the splints, bandages, compresses, and other parts
 of the dressing obviate mobility, rotation,-and angular defor-
 mity.   Lotions shrink the bandages, and favor  vesication of
 the skin, therefore it is generally better to allow the dressings
 to continue  dry.  An  opiate  may be needed to subdue pain
 during the first few days.  The bowels* should be moved every
 tAvo or three days, and  the diet, after the first week, ought to
 be quite nourishing.
   The  immovable dressing,  of starch, or plaster of  Paris, is
 suitable for treating fractures of the tibia.  It may be Avell to
 keep the limb in an ordinary dressing for a Aveek or ten days,
 or until the SAvelling subsides, and then it saves trouble to en-
 case the leg in a stiff dressing, and let the patient go about on
 crutches.  Even with the ordinary dressing the patient can
 get about on crutches Avithout pain, or danger of mobility at
 the seat of fracture.   However,  no weight should be borne on
 the limb for five or six weeks after the accident.  Consolida-
 tion to the extent of preventing mobility may take  place in
 four Aveeks, but the callus is not sufficiently hard in all  its
 parts to obviate deformity under great pressure.  There  can
 be no harm in keeping  light splints and a bandage applied to
 the leg for a Aveek or two after the ordinary time for undress-
 ing a limb has passed.
  After fracture of the  tibia extending into the knee-joint, the
 danger is anchylosis, therefore the limb  should be  slightly
 flexed, and placed on a pillow or between two sand bags so
 arranged as  to support the  knee and produce some lateral
 pressure.  Lotions may be used for two Aveeks, then paste-
 board,  leather,  gutta percha,  or other pliable splints.  In four
 or five weeks from the accident, passive  motion  ought to  be
 begun  and kept up for months,  or until the joint recovers its
 functions.
  In a longitudinal fracture of the lower end of the tibia, in-
cluding the inner malleolus Avith the detached fragnient, the
foot and leg should  be  bandaged, and  great  vigilance exer-
cised to prevent any lateral  distortion at the ankle.  If the 
240
Fractures.
foot incline too much outward or inward, the tendency may
be overcome Avith a properly applied splint, compresses, band-
ages and sand bags.

          FRACTURES  OF  THE  FIBULA.

  The fibula being  a slender bone, may be broken  at  any
point, especially by direct violence.  A smart blow upon the
outside of the leg has been known to snap the fibula into frag-
ments.  But the most common cause of fracture in  this bone
is  a sudden and  Aiolent twist of the foot  outwards, Avhich
dislocates the ankle and breaks the fibula a feAV inches above
the outer malleolus.  The accident  often arises from getting
the foot caught in  a hole or cleft Avhile Avalking.   Sir Astley
Cooper fractured his right fibula by falling, after his foot  Avas
entangled betAveen two pieces of ice.  Booth, in  his  leap to
the stage of the theatre, after shooting President Lincoln, had
his foot poAverfully deflected by having the spur  on his boot
catch in a displayed flag, aud thereby sustained a fracture of
the fibula.
  The frequency of  fracture  of the fibula and dislocation of
the ankle  from forcible abduction of  the foot, is notable.
Every experienced surgeon, Avhen called to an injury of the
leg at a point near the foot, at once examines  the  fibula  just
above the external malleolus, as if he expected to find the
bone broken at that point.  In fact the lesion is too common
to escape the observation of any practitioner of moderate ex-
perience.
  The office of the fibula is not to take part in  supporting the
weight  of the body, but  to strengthen  and complete the
mechanism of the ankle-joint upon its outside.    The bone
also serves to give  attachments to a  large number of muscles,
and lends support to the tibia.
  A kick, or smart bloAv of any  kind, is enough to produce a
fracture  of the shaft anyAvhere between its two extremities.
I have treated fracture of the fibula through the upper third
of the bone which was caused by the rapid passage of an or-
dinary buggy wheel; and in another  instance the kick  of a
steer Avas the cause.   In both instances the men were  able to
walk after the injuries were received, though  great pain at-
tended the taking of each step.  Considerable tumefaction 
Of the Fibula.
241
 occurred at the seat of fracture; and, the upper fragment being
 driven inwards  in both cases, I Avas able to detect the dis-
 placement by pressing the fingers along the  course  of  the
 bone.   The projecting end of the lower fragment stood  out
 distinctly, and could be seen as a salient point,  as well  as felt.
 No particular mobility was discovered,  but the foot could  be
    Fig. 101.   rotated to a greater extent, or through a larger
              arc, than in the sound leg.  Distinct crepitation
              was not elicited, for the  broken  surfaces could
              not be brought in apposition, though manipu-
              lation of  the  limb forced them  in contact.
              The  dressing in each case  consisted of two
              padded side  splints  and  a  bandage.  Both
              cases recovered  Avithout apparent deformity,
              or defect in the functions of the limbs.
                 The specimen represented in the accompany-
              ing  diagram  shows  a  double fracture of the
              fibula above the middle of the bone, aud the
              central fragment deflected, probably by mus-
              cular action, from its normal course.  The ap-
              position is far from perfect, yet the reparative
              action formed an osseous connection between
              the fragments.  The tibia  sIioavs no sign of
              ever  having been  broken.   The double frac-
              ture  may  have been produced by  the same
              kind  of violence that would cause a single frac-
              ture.  There Avas a slight deformity apparent in
that part of the  limb before a full dissection revealed the true
state ofthe parts.   The history of the case is not  known.   I
have another specimen of the bones of the leg in which  the
tibia shows the marks  of an old fracture three inches above its
lower extremity, and the fibula a double fracture at about the
junction of the  middle and upper thirds,  Avhich shows a  de-
flection of  the middle fragment much as is seen in the above
diagram.   Probably  both the tibia and  fibula were broken  at
the same time, and by indirect violence.  As previously stated,
the most frequent  fracture of the  fibula is that caused by a
twist of the ankle, which also ruptures  the internal lateral or
deltoid ligament,—a strong band that binds the inner malleo-
lus  down to  the bones of the tarsus.  The tibia being thus
disengaged from its connection with the inner ankle, becomes
      16
Fracture of the fib-
 ula through its
 upper half; show-
 ing deflection of
 the central frag-
 ment. 
242                     Fractures.
 partially dislocated.  This complicated injury, from having
 been particularly described by Mr. Pott, is called "Pott's frac-
 ture."   His Avords are as follows : " I have already said, and
           pIG  iQ2             ^  Avill  obviously  appear  to
                               every one Avho  has  examined
                               it,  that  the support of the
                               body, and the due and proper
                               use and execution of the office
                               of  the ankle,  depend almost
                               entirely on  the  perpendicular
                               bearing of the  tibia upon the
                               astragalus, and on its firm con-
                               nection   Avith  the fibula.  If
                               either of these be perverted or
                               prevented, so that  the former
                               bone is forced from its just and
                               perpendicular position on the
                               astragalus ; or if it be separated
                               by violence from its connection
                               Avith the latter, the joint of the
                               ankle will suffer a partial dis-
                               location internally; which par-
                               tial dislocation can not happen,
 without not only a  considerable extension or  perhaps lacera-
 tion of the bursal  ligament  of the joint,  which  is lax and
 weak, but a laceration of those strong tendinous bands, which
 connect the lower end of the  tibia with  the astragalus and os
 calcis,  and which constitute in a great  measure the ligamen-
 tous strength  of the joint of the ankle.  This  is  the  case,
 when  by leaping or jumping the fibula breaks in  the  weak
 part, within two or three inches of its lower extremity."
    Strictly in accordance with  Pott's description, a simple frac-
 ture of the fibula through its lower third, whether by  direct
t violence or other force, does not cover all the lesion he has
 described.   In other words, '• Pott's fracture " calls for lacera-
 tion of the internal  lateral ligament, and partial luxation  of
 the tibia, as well as a fracture of the fibula  three inches  above
 the lower extremity.  I have seen the fibula fractured through
 its lower third, by direct violence ; and the astragalus remained
 in place, and the deltoid ligament escaped untorn ; and I have
 also treated cases where the description  of Pott was applicable
" Pott's fracture," or dislocation of the
 astragalus from the tibia, and fracture of
 the fibula above the ankle joint. 
Of  the Fibula.
243
 so far as the broken fibula and tibial  displacement are con-
 cerned, but the inner malleolus Avas fractured instead of there
 being a laceration of the ligament which is attached to that
 process of bone.   And in one instance, that  of a boy of six-
 teen who had  a splay foot and lax ligaments, the  fibula "was
 broken by forcible eversion or rotation of the foot  outward?,
 and the tibial part ofthe articulation remained intact, as well
 as the  ligamentous structures about  the ankle joint.  Still
 further, the  fibula has been broken by powerful adduction  or
 inversion of the foot, the bone yielding to the pressure of the
 astragalus against the external malleolus.  Malgaigne affirms
 that there is no displacement (luxation) nor laceration of lig-
 ament, external or internal,/when the fracture is caused by ex-
 treme  adduction ; that if any displacement be found it is
 secondary, being produced by the patient's attempt to Avalk.
 However, it must be admitted by every surgeon conversant
 with fractures, that in  a large proportion of cases in which
 the fibula is broken a few inches above the external  malleolus,
         p   iq4         the internal lateral ligament is rup-
                         tured and  the astragalus  more  or
                         less displaced from its usual junction
                         with  the  lower end of  the tibia.
                         Pott  has  described a complicated
                         lesion that occurs in more than half
                         of the injuries in which the fibula is
                         broken near its lowesr extremity.
                           Fracture of the fibula through its
                         lower third may also be complicated
                         with  a  dislocation of  the  tarsus
                         backwards.  A  person  in  falling
                         from a height may strike  on an in-
                        clined surface, or a hard  substance
                        that keeps the heel  raised  ; and the
       * u *v . ^   «.  i,  force caused by the descent continu-
Fracture of the fibula above the ankle,               J
 and dislocation of the tarsus back- jno-  dislocates the foot backwards,
 wards.                      i- 7                              •
                        and  breaks the fibula a feAV inches
above the ankle by a lateral or twisting motion.   In such an
injury the lower fragment of  the fibula follows  the bones  of
the tarsus, and abandons all contact with the' long  fragment.
This lesion is analogous to Pott's fracture, the foot being dis-
located backwards, instead of outAvards.   The dislocation,  in
 
244
Fractures.
both  cases, is the leading feature  of the injury.   The foot,
hoAvever, can be quickly replaced,  while  it requires several
weeks' treatment to secure union between the fragments of the
fibula.
  The symptoms of AAdiatis called "  Pott's  fracture " are quite
marked ; yet the patient, as soon as the injury is received, often
reaches down and  twists the  foot back  into place, thereby
overcoming those prominent signs which  so clearly indicate
the nature and extent of this complicated  lesion.  After the
foot has been replaced the limb appears so natural in contour
that the inexperienced  practitioner may  be  led to suppose
that no serious  injury exists.   I was  once  called to see Mr.
Homian, printer, living then on  Elizabeth  Street, who had re-
ceived a severe  twist of  the foot by having it caught in a
crevice of the sidewalk.  He suffered so much pain that he
hired a. passing hackman to carry him home.   A physician of
considerable surgical acquirements was called ; but  before' he
arrived the patient with his hand had overcome the distortion
in his foot.  The doctor examined the ankle, and pronounced
the difficulty a sprain;  he visited  his patient  every day for
about  a  week, and ordered a lotion which was prescribed at
his first visit, to be continued.  Mr. Homan becoming dissatis-
fied with the progress of the cure, discharged his medical at-
tendant, and  invited  me  to take professional  charge of the
case.   According to my usual custom when called to an injury
of the ankle, I carefully hunted for  fracture of the fibula just
above the ankle.  There was much  SAvelling  about the joint;
and it was apparent when the two limbs were compared, that
the injured leg presented a little greater concavity on its out-
side, above the  ankle, than the other. The fingers in being
pressed along the course of the fibula discovered at the point
of preternatural concavity, a slight irregularity in  the bone.
Lateral rocking of the foot produced great pain, and  caused
crepitus.  The forced rocking  of the foot also developed mo-
bility between the fragments, which the finger held upon the
suspected point readily discovered.  The foot could be  rocked
outward in a greater degree than is natural; and when  once
displaced in  that direction it was inclined to stay in that
position.
   In an ordinary case of Pott's fractnre, the patient not having
returned  the foot to its normal position, the deformity will 
Of  the Fibula.
245
 appear like a dislocation  of the foot outAvards, though such
 an injury can not exist Avithout fracture  of the fibula.  The
 pain and swelling are noteworthy signs, though not sufficiently
 distinctive  in  their  character to establish a diagnosis.  The
 fractured ends of the fibula Avill be  driven or held in against
 the tibia, making a depression at the point of fracture.  Per-
 sons having bad shaped feet, with a great concavity a little
 above the ankle, on the outside of  the leg, and with the ex-
 ternal malleolus projecting outward, giving great width to the
 articulation, are prone to have such lax deltoid ligaments that
 the foot can hardly be kept in place even when no fracture
 exists.   A  weak ankle of that kind  makes a bad recovery
 after " Pott's fracture ;" and the result is far from satisfactory
 even AAiien good treatment is followed.

   Treatment of Fractures of  the Fibula.—A fracture  of
 the fibula, not connected with dislocation  of the foot, may be
    Fig. 104.       treated with a common lath  splint laid along
                 the outside of the leg, and a bandage  to  re-
                 tain it in  place. No  shortening of the limb
                 cau  occur, nor serious displacement  of any
                 kind, for  the tibia  is the  chief bone in main-
                 taining the stability of the  leg.  A patient
                 with a fractured fibula above the loAver third
                 of the bone, can Avalk after the limb is dressed
                with a splint and  bandage.  However, it is
                 always best not to use the leg except with the
                greatest  care, and  Avith  the aid of a  cane.
                 The fragments need to be kept  quietly in ap-
                 position  in  order that  the  union   may  be
                 osseous.
                  Pott's fracture needs  a skillfully applied
                 dressing.   After the reduction, Avhich consists
                 in twisting the foot into its natural shape, the
                 leg  may have applied to its inner and outer
Splints and compresses g^gg a COuple of lath Splints, tAVO inches Or
 ready tor ties and ban-            1           r
 dages, to constitute a  more wic]e  and long enough to extend from
 dressing for "Fottb            ?        o     o
 •fracture."          near ^e knee to the sole of the foot.   Under
the lower end of the outside splint  a firm compress is  to be
used to force or rock the foot inwards when the roller is made
to perform its part of the work.  The outside splint bridges
4 
246                    Fractures.
over the depression Avhich exists where the broken  ends of
the fibula are, and prevents the turns of the circular  bandage
from dropping into it;  and the pressure brought to bear upon
the very loAvest point of the external malleolus tends to force
the broken end of the lower fragment away from the tibia
and into its proper position.   After the dressing is applied the
patient may Avalk on crutches, using the maimed limb Avith care.
In four or five Aveeks, consolidation may be expected to take
place.  The limb need not be undressed often during the treat-
ment, for the fracture generally does  well  if properly treated
in the beginning.   No leeches or fomentations can be of much
seiwice,  and  they  may do  serious harm.  Great pain may
attend the injury for the first few days, yet an  elevated posi-
tion of the leg, and an easily fitting appliance favor a state of
comfort and repose.  An opiate given twice a day Avhile the
inflammation continues, keeps the patient  from complaining.
Any large blisters charged with serum may be pricked, and
excoriated parts kept from pressure.
  The dressing devised by Dupuytren, in  his oAvm language,
"consists  of  a cushion, a  splint, and two bandages.  The
               cushion, made  of cloth, and filled two-thirds
               with chaff, should be  tAvo feet and a half  in
               length, by four or five inches in  width, and
               three or four thick. The splint, from eighteen
               to twenty inches in length, two inches and  a
               half wide, and three or four lines thick, should
               be  made  of  firm  and  slightly flexible Avood.
               Lastly,  the  bandage  should be four  or five
               yards in length.  The cushion, folded upon  it-
               self in the form of a wedge, is applied to the
               inner side of the fractured  limb, and laid upon
               the  tibia, its base directed doAvnwards, being
               applied upon the internal malleolus, not pass-
               ing beloAV it; its apex  being above  and upon
               the internal condyle of the femur.  The splint
               applied along this cushion should pass below
DHKjiiS!Sd  i1:' from four to six inches, an<l extend below
  m|iin&ciare  the  inner edge of the foot  for three or four
  of the fibula.      inches.  These first pieces of the apparatus are
fixed to the upper part of the leg, by a few turns of bandage
directed from above doAvinvards;  in this state the splint, pro-
 
                      Of the Fibula.                   247

 longed like a kind of lever  below the base of the  cushion,
. leaves between it aud  the foot a space equal  to  the thickness
 of the cushion, that  is to  say, from  three to four inches.
 This extremity of the  splint  wull serve as a ' point d'appni,'
 to bring the foot from Avithout inwards.  For this purpose the
 end of a second bandage is fixed to it, and then directed  suc-
 cessively from the splint over  the upper surface of the foot,
 upon  its  outer side,  under  the sole of  the foot, upon the
 splint; then from this upon the instep and under the heel, to
 return again to the splint, and to be continued  in the same
 manner until  all the  bandage is used; thus  embracing in the
 same circles, which can be tightened at pleasure, the splint and
 the instep, and the splint and the heel alternately.  The  foot
 is brought into such  a state of adduction  that its  external
 edge becomes inferior, the sole of the foot directed inwards,
 aud its internal edge upwards."
   It Avill be seen by  the diagram,  and  be understood by the
 description, that the dressing of Dupuytren will accomplish
 the object for which it is designed.  The splint is a lever, the
 pad a fulcrum, and the bandage through the power imparted
 to it, is the force to draAv the  foot-inwards; and the action of
 the lower turns of the roller in drawing the  lower end of the
 external malleolus inwards, necessarily tilts  the broken  end
 outwards, or away from the tibia, the space in the vicinity of
 the fracture being purposely left bare or  uncompressed.  So
 the broken ends, whether locked against one another or  not,
 may be left unobstructed to return  to their  normal position.
   I prefer using two splints, for they stay in place better than
 one, and constitute an  even and firm dressing for the  leg  and
 ankle  joint; in Dupuytreu's dressing his upper bandage con-
 stricts the leg near the knee, and tends to press the loAver end
 of the long fragment into  the  interosseous space.  In  the
 dressing I have recommended, a compress  is used below the
 external malleolus, large enough to keep the outside  splint
 from  bearing on the  malleolus itself;  and another compress
 on the inner ankle to keep the inside splint from pressing on
the internal malleolus, and to allow  the foot to be rocked in-
wards  Avithout hitting  the splint.  There  is  no  necessity for
canting the  foot too far inwards ; an excess of inversion is not
desirable.' 
248
Fractures
  In cases where no displacement is  perceptible I dress the
ankle with pieces of pasteboard and a bandage, to strengthen
the weakened parts, so the patient may hobble about with the
aid of a cane or crutch.   I have seen  very good recoveries
made without any dressing.
  If a patient recover from Pott's fracture, with a weak ankle,
he can derive some benefit from a shoe with side irons  fas-
tened to it, such as is worn to correct weak ankles from other
causes.  Even a stiff boot or brogan lends some aid.
  In the case of Harry Edwards,  who in a leap from the  cars
in motion near Brighton Station, broke both bones of one leg,
and the fibula  a little  above the ankle joint in the other, I
used two strips of adhesive plaster an inch wide and fourteen
inches long, to treat the latter fracture.   One end of each strip
was applied to the outside  of the foot and ankle ; and  then
the two strips were draAvn under the heel and sole, and Avhile
the foot was twisted inAvards, the other ends of the adhesive
plaster  Avere  applied to the leg on its  inner aspect.  These
strips prevented the foot from becoming everted-;  and as the
patient  had to be confined to his bed for several weeks on ac-
count of the fractures in the other leg, the broken fibula con-
solidated long before the  other  leg was well.   The adhesive
strips accomplished every purpose sought in a more compli-
cated dressing.
  Potts' fracture, is exceedingly common, therefore the inex-
perienced practitioner should study its every phase.  As much
may be said of all fractures, yet the most frequent lesions are
those the young physician should study first.  As soon  as a
medical man  has had a feAV fractures of the leg to treat, he
studies such injuries all the closer, for he sees Iioav important
the simplest features become/ Besides, he finds that good re-
sults are only obtained  by thoughtful attention.   There is no
such thing as good  fortune in the treatment of fractures  of
the leg.  Every tendency is to deformity of some kind, there-
fore each defect and distortion is to be provided against  at
repeated dressing.  In the  management of such lesions, the
surgeon can not afford to be careless or in a hurry.  The pa-
tient's  comfort  and the  reputation of the medical attendant
hinge upon the  application  of sound sense to every part  of
the dressings. 
CHAPTER  XXVIII.
FRACTURE  OF  THE  BONES OF THE FOOT.
   The anatomical resemblance between  the hand and foot,
 necessitates a similarity in the nature of the injuries peculiar
 to both.  The tarsal bones are cuboid in shape, and contain a
 large proportion of spongy material; therefore they are sub-
 ject to fracture  from direct violence alone.  The nature of the
 force producing a fracture of one of these bones  must be of a
 crushing  character, consequently the injury done to  the soft
 parts Avill constitute the leading feature  of the  lesion.  The
 os calcis partakes, to a certain extent, of the character of a
 long bone.  At  any rate, its projection backwards forms the
 arm of a. levTer which is acted  upon by the powerful  muscles
 of the  calf of the leg, and may be fractured by them.  The
 carpus has no bone Avhich, from its  shape, is subject to great
 muscular poAver.  The astragalus, situated so as to receive the
 entire articulation of the loAver end of the tibia, is necessarily
 subjected to immense forces, and occasional!j7 crumbles under
 their influence.  These two bones, then, may be broken  by
 indirect violence, but the cuboid, scaphoid and three cuneiform
 bones can only be broken by the fall of a heavy weight upon
 them or by the passage of a Avheel over that part of the foot
 which they occupy.  The fracture can hardly be simple under
 these circumstances, for the force must bruise the soft parts
 practically to the extent of rendering the fracture compound.
  The os calcis in a heavy person, who raises himself  quickly
 upon  the toes, is  subjected to a powerful force, though the
tendo Achillis is more likely to break than the bone.   Either
accident must be extremely rare, for few  surgeons have ever
met with a case.  The projection of the os calcis posteriorly
exposes the bone to direct violence.   A miller of my acquaint-
ance had his right os calcis broken by the end of a crowbar
                          (249) 
250
Fractures.
Avhich Avas violently hurled by the fall of a log from a wagou.
He wore a Ioav cut shoe, but it did not prevent the bar from
inflicting upon the heel a telling blow.
  The astragalus is broken by a thrust of the tibia against it;
as Avhen a  person jumps  from a height and comes to the
ground with the tibia placed vertically on the astragalus, the
shock being sufficient to split or crush the bone.  Mr. Lons-
dale  reports a case of the kind coming under his observation:
" The patient  was treated for a seArere  sprain, there being no
reason  to suspect fracture ; the  inflammation of  the joint,
hoAveArer, was  so great, and the man's constitution became so
much affected, that the patient died on the tAvelfth day.  The
case  Avas considered peculiar, from the severity of the symp-
toms ; on opening the joint, however, after death, the astrag-
alus  Avas found to be split, in two  or  three  directions, Avhich
fully accounted for the constitutional  disturbance, and for the
other serious defects produced by it."  An isolated fragment
ofthe astragalus could not Avell escape from the joint  Avithout
such serious disorganization as to  endanger  the  articulation,
to say nothing of perils to life.
  In fractures of the  os calcis, the strong plantar fascia pre-
vents the disengaged  fragment from being draAvn far upAvards
by the  gastrocnemius and soleus  muscles, though  surgical
writers speak  about the separated piece being drawn upAvards
several inches.  In the case of Mr. Conklin, the  miller, Avhose
heel  bone was broken by the iron  bar, there Avas no  marked
separation of  fragments, but the fullness in Avhat  is  termed
the  holloAv  of the foot, Avas marked, and the heel seemed to
be elongated.  Manipulation discovered mobility and crepitus.
The  pain and swelling Avere considerable, though the patient
claimed that the contusion produced  by the missile,  Avas the
chief cause  of the distress.  The inability to Avalk A\Tas mani-
fest  as soon  as an effort Avas made to take a step.
  The treatment adopted in that case maybe applicable in all
similar  cases.  While the foot Avas  moderately extended  it
Avas  encased in strips  of adhesive plaster until every part Avas
covered in;  then two long strips Avere attached  to the top of
the instep by their loAver  ends, and then extended doAvn on
each side of  the foot to  the  sole Avhere they crossed  each
other and came up on each side of the heel and so on to the
calf  of  the leg where they Avere made to adhere.   These kept 
Of the Bones of the Foot.            251
the foot in a state of extension.  The knee was flexed  over
pillows, and  the limb was kept in a state of  comparative
repose for several weeks.   The consolidation was complete,
though the functions of the foot remained someAvhat im-
paired.  The point of the heel appeared to  be raised  a  half
inch or so.
  The kind of apparatus commonly recommended is a slipper-
like toe-piece  nailed to a Avooden sole or foot-board as a  base
for the application of mechanical forces;  a  pad is placed just
above the heel, which has a long strap attached to it; this is
first carried doAvn through  a ring in the wooden sole, through
which it acts like the cord of a pulley, and then extends above
the calf of the leg where it is confined by  the circular turns
of a bandage.   The appliance is not equal in merit to  the ad-
hesive strip contrivance just described.
  Fractures of the other tarsal  bones  admit of no apparatus
to overcome displacement, and  to  prevent  mobility; but the
injury is to be treated like other severe injuries of the  foot,
no special regard being paid to  the fragmentary state of one
or more of the bones.  The inflammation and suppuration are
to be managed on the general principles involved in the treat-
ment of wounds. Amputation is required sooner or later in
some of the worst cases,  though a  laying open of the foot and
the removal of isolated and carious fragments ma}7 save life
and a more or less useful foot.
  The metatarsal bones are less exposed  and more  exempt
from fractures than  the corresponding  bones  in the hand.
The forces Avhich break the metatarsal bones are the  passage
of a wheel, and the fall of heavy aveights.   Hermann Frieling,
while removing  a safe on.Third  Street, had his foot caught
between the side of the safe and the door  post, and received
a fracture of the three outer metatarsal bones. H e was carried
home, and the boot Avas cut from his foot before I saAv him.
Swelling and discoloration  marked the line where the sharp
corner of  the safe  had pinched  his foot. Crepitation was
elicited by manipulation  ; there was no displacement discover-
able.   I placed a compress on the sole against the seat of in-
jury and bandaged the foot. In ten days he walked upon his
heel, with the assistance of a  cane;  and  entirely recovered,
Avithout deformity or defect, in five or six Aveeks from the re-
ception of the injury. 
252                    .Fractures.
  The fragments, after fracture of the metatarsal bones, are
liable to project upwards, though the direction they take de-
pends somewhat upon the force which produced the injury.
If the healing process takes place with the ends of the frag-
ments  projecting  upwards, the salient  points  are  constant
sources of irritation from the pressure of the boot  or  shoe;
and if they sink downwards, so as to produce a prominence
on the sole of the foot, the defect is still worse, for the points
pressed upon in walking will be constantly tender.  The pha-
langes of the toes are seldom broken.  The first phalanx of
the great toe is fractured more frequently than the bones of
all the other toes taken together.   The fall of a heavy Aveight
upon the great toe, or direct violence quickly applied, is gen-
erally the cause of fracture of this digit.   The other toes are
so small aud yielding that they  commonly escape fracture
though the great toe be caught and broken.
  The signs  of fracture in the first phalanx of the great toe
are sufficiently marked for  ready recognition.   The  displace-
ment  is generally inconsiderable,  but mobility and crepitus
can be elicited.
  The treatment for fracture of the great toe consists in bind-
ing a splint to its under surface, and keeping the foot at rest
during the period of reparation.   Lonsdale says that fractures
of the great toe  are  attended with great  irritation,  which
affects the  absorbents all the way to the groin, causing ab-
scesses to form in different parts of the  limb,  and producing
great  constitutional disturbance.  Probably these  complica-
tions arise from the contusion  which is apt to be severe  when
a toe is broken. Bruises of the great toe, if followed by deep
suppuration,  are  attended  with constitutional  disturbances
whether the phalanges be broken or not. 
PART II.
DISLOCATIONS 
 
DISLOCATIONS.
                    CHAPTER  I.

          GENERAL  CONSIDERATIONS.


   The term Dislocation, or luxation, is employed to  signify
 the sudden and forcible separation ofthe articular surfaces of
 tAvo or more bones.  The  displacement  is commonly caused
 by accidental violence, and is  generally attended Avith lacera-
 tion of the surrounding ligamentous and  connective tissues.
   Dislocations  are  injuries of frequent  occurrence,  and, if
 alloAved  to  remain unreduced, they constitute a  serious  and
 lasting class of deformities ; consequently the practitioner of
 medicine and  surgery, who holds himself in readiness to
 assume the responsibilities of such lesions must give the sub-
 ject of luxations a vast amount of careful study, or he  will
 inflict permanent lameness upon  those  so unfortunate as to
 call for his services.  Almost all physicians are ambitious to
 attend to surgical cases on account of the eclat arising  from a
 quickly performed operation ;  but in order to accomplish  sat-
 isfactorily all their laudable aspirations  may crave, intense
 thought  must  be  given to the mechanism aiurpathology of
 the joints.   There  is no such anomaly as a " natural bone
 setter,"  any more than there is a natural engineer or Avatch
 repairer.   A man may have a love for the principles involved
 in nicely constructed machinerj7, and  a  desire  to become  a
 practical machinist,—a   love  and  desire which   constitute
genius, but the  possessor is not a finished artisan until  he  can
practically apply the principles of the art or  science—an at-
tainment which is the result of prolonged study and persever-
ing toil ;  a young man may feel an intense longing to  master
a ship, and study navigation for that purpose, which is a pre-
                           (255) 
256 •                   Dislocations.
requisite to success, but he Avill never find the capitalist who
will entrust a valuable cargo to his care until he  has crossed
the seas and learned the winds and the seasons, the currents
and counter-currents of the ocean, and something of the varied
influences known only to the practical navigator.  Any claims
for natural gifts  in navigation  Avould be treated with con-
tempt.
  A feAV individuals have gotten  the credit  of being natural
bone setters, but their merits,  so far  as they go, depend more
upon tact than skill;  and the prevailing credulity of the peo-
ple has given them more reputation for ability than might
reasonably be expected from their limited success.   A  family
by the name of Whitworth, in England, and another  by the
name of Sweet, in Connecticut, have assumed to possess these
Avonderful inborn qualities.   For two or three generations,
one or more of the male members of these  families claimed
to possess a secret power for  reducing dislocated bones; and
not a feAV persons  of  average intelligence give credence  to
these preposterous assumptions.   Any uneducated man Avith
a large  endowment of boldness and self assurance, claiming
to be a  natural bone setter,  could by giving every distorted
joint coming in his  way, a  severe  pulling and tAvisting,
accomplish some cures; the successes Avould  be heralded  far
and near, and the failures would pass nnmentioned and mi re-
membered, consequently  he would soon gain considerable ex-
perience in handling defective joints, and if he proved to be a
good learner he would acquire considerable  skill in his pre-
tended art.  Having received  no lessons in anatomy and sur-
gery, success even in a single case Avould be accepted  by the
popular mind as positive evidence of innate powers.  Love of
the marvellous is so infatuating that every age will have  to
endure  its quota  of  imposters.   However,  it is not to  be
denied that these charlatans have done some good indirectly.
The fact that a dislocated bone could be reduced by manipu-
lation, without the aid of pulleys and other instruments  for
multiplying force, led such discreet  surgeons as Dr. Nathan
Smith, to put the manipulating plan into successful practice *
  The Whitworths, Sweets, and  others of their order, studi-
ously keep to  themselves their plan of operating, though

  *Soe "Surgical Memoirs of Dr. Nathan Smith," hy his son, Dr. Nathan R.
Smith, of Baltimore. 
Dislocations.
257
competent observers declare that it is not essentially different
from the plan uoav folloAved by the most intelligent'portion
of the profession.  Being aAvare of their general incompetency
in surgical science, these " natural bone setters " preferred to
keep secret the little knoAvledge they possessed, hoping to re-
tain this  meagre  advantage over those  who  in  every other
respect Avere their superiors.  Probably a  similar feeling actu-
ated  the  Chamberlains to  keep as a secret in their family a
knowledge of the obstetric forcep.   Such detested selfishness,
by a  law as  unvarying  as  that of gravitation, Avill taint the
name of those Avho in any branch ofthe healing art, withhold
know ledge AATiich accident or genius has placed within their
power.   Anything in medicine or surgery which Avill  benefit
our felloAV men ought to be the common property of mankind ;
and  he possesses a sordid spirit'who from selfish motiAres  Avill
not  promulgate a secret which Avill ameliorate the condition
of the unfortunate.  The dabbler in secrets  is, by the common
consent of all good men, branded indelibly  Avith the disgrace
that cleaves to the quack and the charlatan.
  The manipulating plan of reducing dislocations  is uoav Avell
understood by those having a knowledge  of the anatomy of
the joints, and of the muscles,  ligaments, and other struc-
tures involved in a luxation.
  The use of  anaesthetics in overcoming the rigidity of dislo-
cated limbs, l)as also contributed to overthrow the old method
of replacing a displaced bone by mechanical violence.  In the
present advanced  stage of knowledge pertaining to disloca-
tions there is little use for the pulleys, straps, hooks, and other
appliances so indispensable a half century ago ; and it is to be
hoped that knoAvledge Avill still further advance, so that these
contrivances shall be looked upon more as objects of curiosity
and implements of torture than as the appliances of an en-
lightened profession ; and that the cruelties practiced Avith them
will be associated with those of the old Spanish  Inquisitions.
  It seems a  pity that somebody before  Dr. Nathan Smith's
time did  not take a hint from the Whitworths or  Sweets, and
study out and put in practice a principle  of reduction in dis-
locations Avhich was demonstrated by those  charlatans to have
an existence.  Perhaps  the spirit  of the  profession Avas too
arrogant to receive suggestions  from such  a source.  Unfor-
tunately  for the world, good ideas are often kept from seeing
      17 
258                    Dislocations.
the  light on account  of the illiberality of the  influential
classes.                    ,
  The joints are generally encased in  capsular  ligaments;  at
some point there maybe a thickening  and a strengthening of
the  ligamentous  tissues, and this augmentation may receive
the designation of a distinct band of fibers, yet these several
ligaments, as the anterior, posterior, and internal and external
lateral, generally go to make up one  continuous structure
which encloses the entire articulation.   In nearly all instances
of dislocation this ligamentous bag or capsule is torn by the
force  that  displaces the  bone;  in rare  cases the ligament
stretches sufficiently to  allow the bone to remain partially dis-
placed.  The bone, after it has been forced through a rent  in
the  capsule, is often dragged  away from the opening, or so
twisted by muscular contraction  that it is no  longer in a fav-
orable position to return through the laceration. This is par-
ticularly the case with  the  shoulder and  hip joints.  But if
the limb be carried to the attitude it was forcibly made to as
sume when the head of the bone escaped from the  socket, the
part protruding through the capsule Avill be in a favorable po-
sition  to  return.  In attempts to  reduce dislocations of the
hip and shoulder the surgeon must seek to get  the limb into
that attitude ; and if he succeeds, very little force Avill be re-
quired  to complete  the reduction.   Direct  violence rarely
knocks a bone  out  of  place ; dislocations are  generally pro-
duced by forces acting upon  the displaced  bone  as  a  lever,
some portion of the articular structures performing the part of
a fulcrum.   Muscular force assists in producing dislocations,
and  the power continuing prevents the return  of the  bone to
its  normal  position.  HoAvever,  the antagonistic muscles, if
given  an  opportunity to act advantageously, assist in all ra-
tional  attempts at reduction.   A proper appreciation of the
construction of joints, and  of  the functions  of muscles and
other  tissues surrounding them, has  created  a revolution in
the  art of reducing  luxations.  In the  " Surgical Observa-
tions"  of Dr. J. Mason  Warren, page 354, the revolution is
acknowledged to the following extent: "The  use of ether has
made a very great change in the  practice pursued in the  treat-
ment of dislocations of the hip, which can uoav be verv fre-
quently reduced by normal assistance  only, thus enabling USj
in many  cases,  to dispense entirely  Avith pulleys ; and, by 
Dislocations.
259
successive movemeuts  of flexion, abduction, and rotation, to
restore the head  of the bone to its  socket  with remarkable
facility."   This is an acknowledgment from  high authority in
regard to a joint which, when dislocated, once called  for  ex-
tending apparatus of the most powerful kind.  Dr.  W.  W.
Reid, of Rochester, X.  Y., who has  written out an  exceed-
ingly clear  plan  for reducing  dislocations of the femur by
manipulation, says, in concluding  his paper on the subject:
" Dislocation  of the hip on  the  dorsum ilii, an accident so
serious to the patient, and so formidable to all surgeons, is re-
duced Avith the greatest ease,  in a feAV minutes, Avithout much
pain, Avithout an assistant, Avithout pulleys, Avithout ' Jarvis'
Adjuster,' or any other mechanical means, simply by flexing
the leg upon the thigh, carrying the thigh over the sound one,
upward over the pelvis, as high as the umbilicus, and then by
abducting and rotating it."  Dr. Reid has succeeded in reduc-
ing  dislocations  of  the femur in several  instances  by  the
" natural plan," and therefore does not speak from a theoret-
ical point of A'iew alone.  The plan has been carried into suc-
cessful operation by a great number of  surgeons, and ahvays
without failure Avhen Dr. Reid's rules Avere followed.  Jarvis'
Adjuster, once so  popular that the inventor could hardly fill
orders as fast as they were given, has gone almost entirely
out of use, and young surgeons rarely indulge in the expense
of a set of pulleys.   In  my OAvn practice I have found no case
of recent dislocation that could  not readily be reduced by
manipulation, under chloroform.   Our older works on dislo-
cations, from Cooper to Hamilton, have a great  display of il-
lustrations to sIioav Iioav the pulleys should be applied in efforts
to reduce luxations of the hip and shoulder, yet there is rarely,
if  ever, a necessity for folloAving those directions.   Perhaps
the publishers of modern  surgical  works, Avhose illustrations
belong mostly to the past, have  been ambitious to make a
numerical display of cuts, caring little whether  they contrib-
uted to perpetuate a fundamental  error in practice or not.
Dr. Reid, in his essay, read at  the annual meeting ofthe Mon-
roe County Medical Society, in May, 1850, says, "Having A\it-
nessed, on several  occasions,  the  inquisitorial torture inflicted
upon the unfortunate patients—their screeching—their piteous
begging to be released—the slipping of  bandages—the yield-
ing and re-adjusting of fixtures—the delay—the  duration of 
260
Dislocations.
  the operation, sometimes two or three hours,—the exhaustion
  of the patient, and after all, in some instances, a  failure, and
  the patient a cripple for life, a profound horror and  prejudice
  against the use  of pulleys seized me (Jarvis' Adjuster had not
  then  been invented), and I could not avoid the com ietion that
  a great poAver was unnecessary, and that it must  be misap-
  plied.  Preceptors, professors and authors Avere interrogated.
  The unanimous reply to all my queries AATas—' to overcome the
  contraction  of the  great muscles, which drew up and short-
  ened the limb, viz.,  the glutei, triceps  femoris, the iliacus  in-
  terims and psoas magnus.'   But do these same powerful mus-
  cles contract, and shorten the limb Avhen there is fracture  in
  the neck of the femur? Yes.   And you tell me that one of
  the diagnostic symptoms between fracture and dislocation  on
  the dorsum is, that in fracture the limb can be easily extended
  to its normal length, by the strength of one man, Avhile  in
  luxation it can not.  Noav why do these great muscles require
  so much more force to overcome them in one  case than in the
  other ?  To this I could get no satisfactory or even plausible
  reply." _
    It  Avill  be seen that  Dr.  Reid looks upon the mechanical
  method of reducing dislocations of  the hip as senseless in the
  extreme;  and indicates a physiological plan Avhich consists in
  giving the limb an attitude Avhich relaxes the muscles, and
  places the bone in a position favorable to a return through the
  laceration in the capsule.  To  pull  the limb straight  cIoavu-
  wards, as is done by mechanical appliances, renders  some of
• the muscles rigidly tense, and constricts the neck of the bone
  with the untorn  portion of the capsular ligament.
    Every joint not being ball and socket, like the shoulder and
  hip, the same kind of  manipulation Avill  not succeed with
  them Avhen dislocated, yet the principle of placing a bone  in
  the exact attitude in Avhich displacement Avas effected, is the
  position favorable to reduction.  For instance, the first pha-
  lanx  of  the thumb is dislocated backAvards by a force Avhich
  throws it into extreme  flexion, the bone being a lever to tear
  the capsular ligament, and the  muscles a secondary force  to
  draw it  back after the usual points of resistance are overcome.
  The bone having been dislocated while in extreme flexion, re-
  turns to nearly its normal attitude as soon as the flexing force
  is removed,  for the  projecting articular rim has dropped into 
Dislocations.
261
a depression behind the head, of the metacarpal bone.  Now,
to make extension straight forward Avould not effect reduction
unless the force be great enough to rupture the yet untorn
portion of the ligament Avhich is  rendered tense  by the dis-
placement of the phalanx.  But if the thumb be carried into
extreme flexion, where it was when luxation  took place, the
projecting rim is lifted from the depression spoken of, the un-
torn  portion of the ligament  is  relaxed,  and  everything is
made ready for the reducing manoeuvre, which consists in the
operator placing his thumb firmly behind the displaced pha-
lanx where it is to perform the part  of a fulcrum, Avhile  the
dislocated thumb is used as a lever to pry the displaced bone
into its normal position.
  In  the upper extremity the bone  nearest the trunk is re-
garded by all authors as the one from which  the  distal bone
is dislocated ; for instance, the  humerus is dislocated from the
scapula, the radius and ulna from the humerus, and so on, but
in the.loAver extremity the rule is not maintained by all;  the
femur is regarded as dislocated from  the acetabulum, and the
tibia from the femur, but several  authors  have changed  the
rule  so  far  a?  the tibio-tarsal   articulation  is  concerned.
Cooper, Malgaigne, Hamilton,  Gross, and others,  regard dis-
locations of the ankle  as displacements of  the tibia fonvards,
backwards, etc.   On the  contrary, many prominent  French,
English, and German surgeons, adhere to the  rule as applied
to other joints, and speak of dislocations  of the foot when
the luxation is at the ankle.
  There seems to be no valid reason  for this  exception to  a
rule that ought to be general;  and it vyould have been credit-
able in Hamilton, Gross, and other American surgical Avriters,
if they had lent their great influence toward  correcting this
manifest error in the manner of considering the subject.
  Dislocations need to be considered  in a variety of  aspects;
they have been divided into congenital and traumatic as gen-
eral classes ;  and subdivided into the simple, compound, com-
plicated, partial, complete, recent, ancient, primitive, and con-
secutive.
  Congenital  dislocation  is  a lesion intimately connected
with  malformations and  defects of childhood, and does  not
legitimately belong to that great class of accidents ordinarily
embraced under the head of  luxations.  Robert Smith, of 
262
Dislocations.
Dublin, reports a case of congenital dislocation of the jaAV, in
an idiot, and states that the upper jaAV  projected beyond the
the lower, and the mouth could be freely opened and closed;
the reverse order of signs is observed in accidental luxations of
that bone.  Certain dislocations of the shoulder seen in youug
subjects are  occasionally not  complete luxations, but partial
displacements arising  from paralysis or irregular muscular
contractions.  Dupuytren  looked upon these defects of the
shoulder-joint as  the  result of arrested  development in the
bones constituting the articulation, the socket  being mostly
at fault.   Chelius and  Cruveilhier ascribe them to the position
of the foetus in the womb.   Guerin considers them as the pro-
duct of an  active or primary retraction  of the muscles, the
remote cause of Avhich is to be sought in the affection of  some
central part of the nervous system ; and that they result from
the same causes as  club-foot, Avry-neck, etc.  I have seen a
partial  dislocation of  the head of the radius, congenital in
character, in a bright little girl having  no other  defects, ex-
cepting that one.  The  entire elboAv joint Avas considerably
involved in the imperfect development  which permitted the
luxation.  By the fifteenth year  the arm so far recoA^ered,
without treatment, that the limb Avas as useful  as the other,
and no apparent deformity existed.
  Robert  Smith reports several congenital dislocations of the
wrist, in Avhich there Avas defective development  of the arm
bones, and distortions  of the carpus.  His observations  Avere
founded upon dissections; and he criticises  the speculations
of Dupuytren and Cruveilhier  in regard to cases  of theirs
Avhich they regarded as  the result of epiphyseal injury.  A
certain preternatural laxity of the soft tissues, brought  about
in some instances by  nervous disorders and  faulty nutrition
is found  in  these cases of congenital luxations of the Avrist,
as well as of some of the other joints ; and a large  share of
which Avill improve by growth and age.  Some of these cases
are not true  dislocations, but partial luxations arising from
extreme flexion and  extension.
   Congenital dislocations of the femur are occasionally met in
defective  organizations, or as Cruveilhier says, vices de confor-
mation.   He found in one case, in connection Avith club-feet
and club-hands, a congenital luxation of both thigh bones ;
the foetus died at birth, and Avas found to be without kidneys 
Dislocations.
263
 and testes, and marked with other deficiences ; the heads  of
 the thigh bones Avere flattened, and the cotyloid cavities were
 shalloAA^.
   Dr. J. M.  Carnochan, who has given considerable attention
 to infantile deficiences, says that  " Congenital  defects occur-
 ring in the ilio-femoral articulation result from active morbid
 muscular retraction ; that morbid muscular retraction itself is
 to be traced  to a morbid condition of the central ganglionic
 mass of the  cord ; and this pathological condition  is either
 located in  the ganglionic mass, or conveyed thither by the in-
 cident-excitor nervous influence of the excito-motor apparatus
 of the medulla spinalis."  This is  not given with Prof. Car-
 nochan's usual perspicuity.
   The  gait  in  congenital  dislocation of the thigh  on both
 sides, is peculiar and unmistakable ;  no other motion  is like
 that which is occasioned by this lesion : it is a rolling motion
 of the  trunk together Avith double  lameness; and  yet it is
 painless and  rapid.  In  some instances the nciwous defect is
 so great that the individual is compelled to move  about in a
 go-cart, being unable to balance the body and move the limbs
 Avith  any degree of certainty.
   Congenital dislocations of the knee are generally sub-luxa-
 tions resulting from abnormal muscular contractions; and, to
 be substantially benefited, require subcutaneous section of the
 ham-string tendons, and mechanical extension ofthe limbs.
  Partial dislocation of the ankle, as a congenital defect, is a
 species  of  " Aveak-ankle,"  the ligamentous and fibrous tissues
 being too lax or undeveloped to sustain the lateral strain  ne-
 cessary to  a firm joint.  The foot seems to be affected Avith a
 variety of talipes, and flaps about Avith much  uncertainty.   A
 shoe with side irons extending up the leg, and fastened to the
 limb with a hoop and strap, affords some relief, and assists in
 a cure or substantial improvement.
  Congenital dislocations, from what  has just been  said  of
 them, are to  be looked  upon as the result  of arrested or per-
 verted development, and are not, except in rare instances, to
 be treated  by a process  of rapid reduction, like those luxations
that occur suddenly from accident.
   Traumatic  dislocations are the forcible separation of the ar-
ticular  surfaces of two or more bones, in which  the  loss  of
poAver is instantaneous, and the luxated part is  excessively 
264
Dislocations.
rigid.  The names of the varieties have already been given.
A simple  luxation is unaccompanied with serious complica-
tions, though there is generally a rupture of the  ligamentous
structures.  It may be caused by external violence, and mus-
cular contraction.  The humerus is often dislocated by the ac-
tion  of the muscles only.  A convulsive  condition  has been
known to produce dislocation of several  of the joints.  The
term compound is applied to a dislocation, in connection with
which the displaced bone is forced through the flesh and skin,
or an opening  is made in  some other way, communicating
Avith the cavity of the articulation.
  A complicated dislocation is one in which there is a more ex-
tensive  lesion than  simple displacement or separation of ar-
ticular surfaces  : the term implies that  the soft parts have
been extensively lacerated, including nerves and bloodvessels;
or that a fracture has been produced  in connection with the
dislocation.
  A partial luxation'is one in which the articular surfaces are
not  wholly remoAred  from  one  another, though the fmiction
of motion in the joint is temporarily arrested by the displace-
ment.  In such  dislocations the  ligamentous surroundings are
not necessarily torn, the fibrous structures being sufficiently
elastic to  admit  of the disjunction.  The injury is someAvhat
rare; probably such  displacements are  occasionally reduced
without  the medical attendant fully understanding whether
the luxation was incomplete or not.
  In a complete dislocation  the displaced bone is forced entirely
clear of the other so far as  corresponding articular surfaces
are concerned, and finds lodgment in a new position, gener-
ally near the old situation, as  when the head of the  luxated
femur rests against the border of the acetabulum.   In a com-
plete dislocation the capsular ligament  is necessarily torn, and
the head  of the luxated bone escapes through the rent.
   A recent dislocation is one that has not existed many Aveeks;
in fact, a luxation of some joints is old at the end of a Aveek,
for it is not time alone that renders a dislocation old in a sur-
gical sense.  If such changes have taken  place in the struc-
tures about the  joint as to render reduction unsafe or  imprac-
ticable, the dislocation is  practically old though it have ex-
isted only a feAV days.  A  dislocation, then, may be considered
recent, if it can be reduced Avithout danger of rupturing im- 
Dislocations.
265
portant nerves, blood-vessels, and other structures Avhich have
become changed in  their conditions  by inflammatory action,
or rendered unfit to assume their normal relations.
  An old or ancient dislocation is one in  Avhich such  changes
have taken place in and about the joint as to render attempts
at reduction  unsafe  and uncertain.   It is not uncommon to
meet Avith  luxations which have escaped detection  or passed
unreduced  for several weeks or  even  months;  and the ques-
tion arises Avhether an attempt to overcome the displacement
is justifiable.  The humerus has been replaced after being out
six months and more, but to reduce a luxated elboAV tha]t had
been  out six weeks,  Avould be to inflict an amount of injury
that might result in death.   Since the introduction of chloro-
form  into surgical practice, well  directed attempts at reduction
of  ancient  dislocations  have not been  attended  Avith those
serious injuries that  Avere Avont to occur, and the efforts have
been reAvarded Avith  far more successful results.  By the man-
ipulating plan the displaced bone is  not so liable  to  be frac-
tured, nor  is the danger of rupturing blood vessels so  great,
as when no  anaesthetic Avas used, and pulleys and other in-
struments for multiplying force  were generally employed.
  A dislocated bone generally remains in the place it origin-
ally took when luxation occurred;  it may then  be called a
primitive dislocation, as distinguished  from a luxation in Avhich
the displaced bone  is made to  abandon its original position
and take up Avith another, AA'hich is called a consecutive disloca-
tion.  For  instance, a  man may haA^e  a dislocation of the
shoulder, the head of the humerus being forced beneath the
coracoid process; and  in going home  or in  being, removed
from  one place  to  another,  the bone may get forced  inside
the process and be drawn up against the clavicle: the former
would be a primitive, and the  latter might be considered a
consecutive dislocation.
  Joints Avhich admit the most extensive range of motion, as
the ball and socket,—the shoulder and the hip—are the most
frequently  dislocated; the ginglymoid, as the knee and elboAV
—being more restricted in their motions, rarely get displaced.
According to the tables of  Malgaigne, the shoulder is dislo-
cated oftenerthan all tne other  joints in the body.   The hip
has a deeper socket, and is not so much exposed to displacing
forces as the shoulder.  The vertebrae are so firmly bound in 
266
Dislocations.
place by ligaments, and prevented from displacement by com-
plicated processes, that they seldom suffer luxation.
  There are feAV physicians of ten years' experience but have
met Avith dislocation of the shoulder;  yet they may not have
seen a luxation of any other joint.  I  once asked an old sur-
geon of extensive experience to give me a list of the disloca-
tions he had been called upon  to treat; and this is his report:
Dislocation of the inferior  maxillary, 2 ; ofthe cervical  Arerte-
brre, 1;  of the clavicle, 2 ;  of the humerus,  11 ; of the radius,
3 ; of the thumb, 3 ; of the fingers, 2; of  the femur,  2 ; of
the patella,  2 ; of  the  tibio-tarsal articulation,  complicated
with fracture of the fibula, 5 ; of the toes, 3.   It Avill be seen
that in his practice  the shoulder Avas found dislocated far more
frequently than  any other  joint, though the number  is less
than all the  other luxations counted together.  He had never
seen a  dislocation of both bones  of the arm  at the elboAV,
although it is not an extremely uncommon accident;  and had
never met with a complete dislocation of the knee, though he
said he had found the joint in a painful and rigid state  which
he diagnosed as  displacement ofthe semilunar  cartilages.
  Age has an influence upon the relative frequency of disloca-
tions ; the very young and the A-ery old are  not liable to such
accidents; in middle  life luxations  most  frequently  occur.
The elastic condition of the tissues in youth, serves to decom-
pose forces tending to produce luxations, the pliant structures
yielding sufficiently to  avert  the accident; in advanced age
the bones become brittle, therefore they are more liable to be
fractured than to be dislocated.   Thus, if an individual sev-
enty years old sustains a severe injury at the hip, a dislocation
could scarcely be expected, yet a fracture of the .neck  of the
femur Avould be highly probable.  Elderly persons Avho suffer
severe injuries ofthe shoulder, are most likely to sustain frac-
tures of  the clavicle, though  dislocation of the humerus has
been met in persons advanced in life.
  The causes of dislocation are  sometimes quite insignificant,
or apparently so.  A girl  of sixteen dislocated  the  shoulder
in attempting to  throAv the loop of a string over a peg  a little
higher than  she could reach ;  another school girl dislocated
the head of the  radius Avhile she and a companion Ave re play-
fully SAAinging arms ; the thumb has been luxated from seem-
ingly trivial  causes ; the  under jaAV  is frequently dislocated 
Dislocations.                    267
 Avhile  gaping; the patella  may be  displaced outwards when
 the patient had no reason to suspect even a mild form  of in-
 jury.  Muscular action in such instances seems to be adequate
 to produce luxation.  If a bone has been dislocated once it is
 ever after liable to the same accident:  at least, it is  not un-
 common for  some joints  to suffer dislocation a number  of
 times.
   External violence may operate directly aud indirectly in pro-
 ducing  luxations; thus, a severe bloAv  upon  the  top of the
 shoulder may drive the head of the humerus downwards into
 the axilla ; but if the hip be dislocated by a force received  on
 the knee, the action is indirect.  There  are not many joints
 that can be dislocated by direct violence;  the shoulder is one,
 and I have known the patella to be knocked out of place by
 a bloAv.  A combination of  forces most  frequently produces a
 dislocation.   For instance, the elbow is  forced  upwards until
 the humerus as a lever acts  across the acromion as a fulcrum,
 to lacerate the capsular ligament; at this point in the progress
 of the injury the muscles jerk the head of the  bone out of its
 normal relations Avith the joint.  A drunken man Avhose mus-
#cles are in a  state of relaxation, rarely  sustains a  dislocation
 though exposed to the action of forces  that favor such inju-
 ries.    In order to  produce a luxation  of the shoulder in a
 cadaver,  the  operator  must first rupture the  capsule of the
 joint by using the arm as a lever, then push the bone through
 the rent.  Dead muscles Avill not complete the injury after the
 capsule has been lacerated and the bone is presented in a fav-
 orable attitude  for displacement.  When a bone is dislocated
 in life the limb is generally in such a position at the time of
 the accident  that the antagonism ofthe muscles is for the
 moment destroyed,—one set being relaxed and another, Avhose
 action  is in  an opposite  direction, put violently  upon  the
 stretch.
   Symptoms.—Timothy Holmes, in his System of Surgery, says  :
 " A complete dislocation  is, in typical  cases,  attended Avith
 such very distinct symptoms, that  Avhen  these are fairly de-
 tailed upon paper the reader is tempted  to say that the injury
 is unmistakable.  Yet the  great number of old  unreduced
 dislocations Avhich are still  seen, even in patients  Avho  have
 been from  the first under  medical  supervision, proves that,
 notwithstanding the elaborate care with Avhich the symptoms 
268                    Dislocations.
of dislocation in general, and of each special injury in partic-
ular, have been described ever since the time of Astley Cooper,
such mistakes  can not always be avoided, even  by well-in-
formed and careful men ;  and it is no doubt true  that errors
in diagnosis on this  head  will sometimes occur to the best
surgeons,  in consequence of extreme  depth of the parts, of
great effusion and SAvelling over them, or of complication with
other injuries; but with  proper  care such mistakes ought to
be ATery seldom made  even at  the time  of the accident, and
attention to the subsequent progress of the case  will  ahvays
enable the surgeon to correct his error while there  is yet a fair
prospect of easy reduction."  I take pleasure in being able to
offer such distinguished testimony in favor of opinions so near
in conformity  Avith my oavu.   In  the  malpractice  suit of
" Larkiu versus Jones," tried  at  Marion, Grant  Co., Intl., in
April, 1869, 1 declared to the court that it Avas no  rare or un-
common  occurrence for physicians  of average  professional
qualifications and  experience,  and  of  considerable  surgical
pretensions, to  fail to  discoATer dislocations, even Avhen called
early, and having opportunity to examine the   case before
swelling and other conditions tending to mask the real  state
of the injury, had  come  on.  I cited cases of dislocation of
the shoulder Avhich had passed undetected through the hands
of quite pretentious surgeons.  This opinion Avas attacked as
unsound,  by Dr. Win. Lomax, and other physicians of Grant
County,  Avho  thought a  dislocation  of the shoulder would
never be  overlooked  by  a  physician of ordinary skill  and
ability, though the inj ury be of two days' standing Avhen first
observed.  All claimed to have had  several cases of disloca-
tion of the shoulder to treat, and denied ever Inning  been in
doubt in regard to the nature of the injury.
  The general  symptoms  of dislocation  are, great pain sud-
denly following the accident, loss of motion and rigidity in
the articulation, change in the natural contour of the joint,
shortening of the  limb in  most  instances, loss of voluntary
motion  except to  a limited extent and in certain directions,
absence of crepitus, a disposition to remain in place after the
luxated  bone  is reduced.   Fractures have  quite diflerent
symptoms; they are attended Avith pain and deformity, as are
dislocations, but there is an increase of mobility, the existence
of crepitus, the pain  is  not overcome  by reduction,  and the 
Dislocations.
269
 displaced bone will not  stay in place when adjusted.  There
 are tAvo distinct injuries, a  fracture and a  dislocation, of the
 shoulder, Avhich  closely resemble each  other;  a luxation of
 the humerus  inwards appears much like a fracture of the
 neck of the scapula.  The  fracture allows of free passive mo-
 tion, and crepitus can generally be produced after reduction;
 and when adjusted and left to itself the displacement readily
 occurs.   In dislocation the  arm is rigid, and will not admit of
 passive motion, aud reduction having been effected the  dis-
 placed bone will remain in  its natural position Avithout assist-
 ance, no crepitus can be elicited, and the  coracoid  and acro-
 mion  processes maintain  the  same distance  between each
 other.
   Fractures of the neck ofthe femur are characterized by in-
 creased mobility and eversion  of the  foot;  dislocation  of the
 femur is attended with great  rigidity and inversion of the foot.
   Injuries about the other joints exhibit  certain signs Avhich
 indicate Avhether a fracture or a dislocation exists ; and when
 luxated the natural  axis  of  the bone is so changed that it no
 longer corresponds Avith its socket, there is intense pain Avhere
 the head  of the bone rests in  its neAv situation,  and the limb
 is greatly benumbed as Avell as rigid.
   If the symptoms  be not  sufficiently distinctive to remove
 all doubts in regard to the nature of  the accident, the patient
 may be put under the influence of  anaesthesia, and then care-
 fully examined.
  Pathological Anatomy.—In a recent dislocation it is found
 that the capsular ligament is torn, and more or less injury may
 be  done  to  the  adjacent  tissues;  muscles  are sometimes
 severed from their attachments, ruptured, or stretched, accord-
 ing to the nature and est*tr\t ofthe displacement.  The great
 nerves in  the vicinity of  the joint (such as the circumflex  be-
hind  the  shouJfler) are often  compressed or lacerated; hence
severe pain  at the  time  of the accident,  and a succeeding
paralysis  of the parts  supplied  Avith these nerves,  which
is sometimes irremediable.   Blood vessels may be pressed upon
so as to obstruct the circulation in the limb. Dr. Goldsmith,
of Louisville, reports a case of dislocation of the femur on to
the brim of  the pelvis so as to lie under the femoral artery.
Remaining unreduced, in two months it produced a diffused
aneurism  of that vessel. 
270
Dislocations.
  It is rare to find a simple dislocation of the ankle, for frac-
ture of the fibula is almost a sure complication ; and  a back-
ward  luxation of the ulna  is liable to be complicated with
fracture of the coronoid process.
  If the bones be  restored  to their natural position, all of
these  defects  and lesions  are soon repaired.  The ruptured
capsule heals, the stretched and lacerated  muscles, tendons,
and fibrous tissues regain, in a great measure, if not entirely,
their former condition, and even the nerves which may have
been contused or lacerated, may at length recover their AATonted
functions.  To ensure perfect restoration it  is necessary that
the bone be not allowed  to escape  from its normal  position
while the recovery is made ; a repetition of the luxation might
prevent the healing of the rent in the capsule, and the return.
of strength to the disabled parts.
  If, on the contrary, the dislocation remain unreduced,  other
changes, besides those which immediately attend the accident,
necessarily follow.  These  arise from prolonged irritation and
inflammatory action, as well as from efforts to establish a sub-
stitute for the old joint.  The  head  of the dislocated bone
forms for itself a cavity or new socket in the bone  upon Avhich
it is thrown,—a cavity which is  produced in  part by absorp-
tion under pressure, and in part by deposits of osseous mate-
rial around the forming socket.  The neAV articular cavity has
furnished to it something akin to synovial tissue,  and the old
socket becomes filled with fibroid structures.   The ginglymoid
articulations do not make so much  progress towards establish-
ing neAV joints as the ball and socket variety.  In  many in-
stances complete anchylosis takes place,—a  condition Avhich is
not uncommon in  unreduced dislocations of the  small joints.
  The muscles and tendons directly influenced bA* a dislocated
bone  become materially and functionally  altered;  in  some
ancient dislocations, the relaxed muscles may be shortened or
retracted to an extent that can never be overcome ;  the ten-
dons get torn from their  attachments and  forced from their
positions  (as  is often the case  Avith the long tendon of the
biceps) ; and from inflammatory action the various tissues may
become blended in a mass, so that an attempt to break up
these adhesions Avould be attended Avith laceration.  Adventi-
tious  bony material has been found in these  blended masses,
as if the conservative vital forces were engaged in furnishing 
Dislocations.
271
osseous matter to repair a fracture or to construct a  neAV ar-
ticulation.
   The head of the radius throAvn upon the anterior  or poste-
rior aspect of the humerus, may unite by osseous or fibrous
material so as to prevent rotation, as Avell as impede flexion
and extension of the forearm.   The backward dislocation of
the ulna, if left unreduced, Avould be folloAved by such changes
of various kinds, articular, ligamentous, and muscular, as to
result in permanent deformity in a few weeks.
   Evidence is furnished by dissection that in  rare  cases the
rent  in the capsular ligament so far unites in a few  days that
the hole Avhich admitted the passage  of the  bone out of the
joint, will no longer permit it to go  back again.  Hilton, in
Guy's Hospital Reports, relates  a case dissected three Aveeks
after the accident, in which the  rent in the capsule 'had so far
healed as to prevent a return of  the head  of the  bone.  The
femur, when left  unreduced upon the dorsum ilii for two or
three months, is prevented from  returning to the acetabulum
by a narrowing of the rent through AAiiich it escaped from the
joint; but if Avell directed means be  employed to reduce the
bone to its proper position, the repaired ligament will so far
yield as to alloAV the head of the femur to go back into place.
   Structures  throAvn  into disuse on account ofthe dislocation,
undergo gradual  atrophy; and any  part of  the organism,
whether vessel, nerve, or bone, that  is pressed upon, suffers
marked alterations, if not entire obliteration.
   When firm adhesion takes place between  a large  artery or
vein and the dislocated bone, there is great risk of serious or
even fatal consequences from laceration of such vessels during
attempts  at  reduction.  In  Eve's  " Collection of  Surgical
Cases " are a few reports of serious injuries following attempts
at the reduction of luxations.  The}7  are all  translations from
French journals.   " In one of them the attempts to reduce the
dislocated joint produced  a rupture  of the axillary  artery,
gangrene, and subsequently, the  death of the patient.
  " In another, hemiplegia ensued, most likely in consequence
of extravasation in the brain, from efforts  used in the reduc-
tion ; the paralysis gradually diminished,  but the loAver ex-
tremity never recovered its natural  heat and sensibility, and
the use of the arm Avas almost completely lost. 
272                   Dislocations.
   " In a third case the dislocated shoulder Avas reduced thirty-
 eight days after the accident; immediately after the operation,
 emphysema supervened over the arm and  a great part of the
 back; very soon afterwards violent headache and hemiplegia
 ensued, and proved fatal on the twelfth day.  On examination,
 the brachial plexus was  found  extensively  lacerated; at the
 sixth, seventh, and eighth cervical  and the  first dorsal verte-
 bras, the spinal cord Avas SAATollen, softened, and  of a reddish-
 brown color.
   " In the fourth, case, the reduction Avas followed by an enor-
 mous painful sAvelling of  the  extremity, the arm could never
 be used, and the fingers only retained a very small degree of
 sensibility and motion.
   " In a case of dislocated hip, the reduction Avas made very
 soon after the accident, and the head of the  femur  Avas very
 distinctly heard to  slip into the  cotyloid cavity ; the patient
 died, however, five days after the  operation.  The anterior
 and  exterior part of the hip Avas found  ecchymosed; the
 pyriformis, gemelli, and  quadrates femoris, the capsule and
 liganientum  teres Avere ruptured, and the  cavity of the joint
 was filled Avifh pus.  In this case, the  fatal  termination Avas
 apparently rather the  result ofthe dislocation, than  of the re-
 duction ; the observations, hoAvever, of  M.  Faubert, show Iioav
 cautiously the attempts at reduction ought  to  be made, and
 how necessary it is to  consider Avhether a sufficient extending
 force can be used, Avithout iuflicting  serious  injury on the
 patient."
   It  Avill  be observed that  extending force Avas relied on in
 these unfortunate attempts at  reduction ;  and  it  is not eA'en
 suggested that  there  may be  an easier and safer Avay of re-
 ducing dislocations.  I have knoAvn thehumerusto be broken
 in  a fruitless attempt to reduce an ancient  dislocation with in-
 struments for multiplying force.  Such an instance  occurred
 in  this city a fevv years ago, but the surgeon  did not see fit  to
 report the case that the profession at large might be benefited
 by the lesson it conveyed.
   Another unfortunate attempt to reduce  an ancient disloca-
 tion of the shoulder (if the diagnosis Avas  correct) Avas  made
'in  this city some years ago, and  the surgeon (Dr. George  C.
 Blackmail) published an account of the case. The " Western
 Lancet "  for November, 1856, contains  the doctor's version  of 
Dislocations.
273
 the nature of the injury, the operation to effect reduction, and
 the result.  In a letter to the editor of that journal, he says:
   " About the 10th ult, aided by yourself, 1 succeeded in  re-
 ducing by  manipulation, without the pulleys, a dislocation
 into the axilla, of eighty days' standing.  The reduction Avas
 accomplished in a very feAV minutes, under the influence  of
 chloroform and ether, and the next morning  the  patient left
 for the country, in a comfortable condition.  Since that I have
 received no tidings from him.  Encouraged by the result in
 this case, another patient, himself a physician, a tall, athletic
 man, and about fifty years  of age, decided to submit to the
 same manipulation, although his arm had been dislocated  for
 about sixteen Aveeks.  The dislocation  Avas doAviiAvards  and
 iiiAvards, and about the tenth Aveek an unsuccessful attempt,
 by another surgeon, had been made Avith the pulleys, to Avhich
 the force of six men Avas applied for tAvo and a half hours.
 The patient being under the influence of chloroform and ether,
 aided by yourself, Drs. Fries,  Cary, Graham and Kauffman, I
 commenced  my manipulations, adducting,  rotating,  abduct-
 ing, and ele\~ating the arm.  These efforts had been made  for
 about ten minutes,  and the  least  possible violence  employed,
 when a tumefaction appeared in the pectoral region, Avhich in
 a feAV minutes attained a considerable size.  Supposing that
 the axillary artery Avas ruptured, as no pulse could be felt at
 the wrist, a ligature Avas immediately applied to the vessel at
 the upper part of its course.  The  operation  Avas performed
 about 10 o'clock a.  m., and compression ofthe pectoral region
 made by means of a sponge and  broad roller.  On removing
 this the next morning,  the tumefaction had nearly disappeared.
 The patient continued comfortable, and about nine days after
 the application of the  ligature, I  Avas compelled to leave  the
 city on a professional visit to Indiana.   I left on Friday after-
 noon and returned  on Monday  morning,  at  which time I
 learned that  my patient  had  died on  Sunday morning, from
 hemorrhage at the seat of ligature.  Tavo physicians, his most
 intimate friends, lodged in  the same house Avith him,  but  be-
 fore they reached his bedside  the  quantity of blood lost Avas
 so great that he sank exhausted in about two hours from  the
 first and  only attack  of hemorrhage.   Previous  to  my  de-
parture for Indiana, I had suggested  to the physicians  in
charge, the importance of having compressed sponge at hand,
       18 
274                   Dislocations.
to be used in any emergency of the kind, but  this was not
used by the attendant; instead of applying pressure instanta-
neously, he  went in  search  of the  physicians,  avIio, at that
early hour in the morning were in bed.   The time  thus lost
unquestionably led to the fatal  catastrophe.
  " I might refer you to numerous instances of success in the
reduction of old dislocations—from two to six months'  stand-
ing—Avhich have, occurred since the  days  of Wiseman, but I
propose to notice only the accidents  by Avhich some of these
attempts have occasionally been folloAved.  One of the earliest
recorded, so far as we have been able to learn, is  the case  re-
ported by Default
  " During the effort of this surgeon to reduce an old disloca-
tion, suddenly a considerable ' turn ear aerienne ' appeared below
the clavicle, Avhich  Desault attributed to the ' degagement de
l'air amasse entre les cellules rompues du tissu cellulaire!'   In a
few days this tumor entirely subsided under the  influence  of
' astringents et une compression methodique'   Whether it was the
result of a disengagement of air from the lacerated cells  of
the cellular membrane, as supposed by Desault, or  of  a rup-
ture of blood vessels, Ave leave  the reader to determine.
  " It  is  someAvhat singular that Desault should  have met
with tAvo cases of this extraordinary  phenomenon.  Pellatan's
explanation, in our opinion, throAvs some light on this subject.
In an attempt to reduce a luxation of four months'  standing,
the same kind of Humeur aerienne' appeared.   It Avas opened,
and the hemorrhage from the torn artery Avas fatal.
  " Malgaigne states that he is acquainted Avith  but a single
instance of  an  ' emphyseme veritable' folloAving  a reduction,
and that is the one  reported by Flaubert.   The patient, a
female  set. 70, screamed violently during the operation, and
Malgaigne is disposed to believe that the emphysema Avas in-
dependent of the luxation, or the reduction.
  " Malgaigne,  himself,  attempted  reduction  in a case of
sixty-eight days' standing, but Avas  forced to discontinue  his
efforts  in consequence of the  sudden appearance of a tuine-
factiou in the axilla, aud  on the shoulder.  Ice Avas applied,
and in the course of a feAV hours the SAvelling was arrested,
and by the twenty-second  day, the blood Avhich he  thinks
came from  ruptured muscular branches, Avas completely ab-
sorbed. 
Dislocations.                    275
  " A case occurred to Flaubert, in  AAiiich, besides the tume-
faction, the pulse could not be felt  at the Avrist.  The  hand
was cold, insensible, and immovable.  The next day, hoAvever,
the pulse returned to the wrist, and in the course  of tAventy-
six  days the  effused blood Avas  absorbed.  Froriep lost a
patient from a rupture  of the  axillary  vein, Avhich  proved
fatal in an hour and a half after the operation.   The reader
may find in the comprehensive  treatise of Malgaigne, details
of cases in Avhich the axillary artery was ruptured.  We pass
over those  observed by Verduc, Petit, Platner,  Delpech, and
that referred to by Sir Charles  Bell, in his  Operative Surgery
The late Dr. John C. Warren tied the subclavian to arrest the
progress of an enormous aneurismal tumor  in the axilla, the
result  of the reduction  of a recent dislocation, and  of sup-
posed  pressure of the operator's boot.   In this  instance the
coats of the  artery Avere so contused that sloughing took
place  during a fit  of coughing, five  days after the accident.
In  1824, M. Leudet lost a  patient at the hospital at Rouen.
The dislocation Avas only of eleven days' standing, and Avas
complicated with a fracture of the margin of the  glenoid
cavity, as in the two fatal cases which occurred in the practice
of Prof. Gibson, of Philadelphia.   The  latter  cases  are too
familiar to  every surgical student to require particular men-
tion in this  place.   Prof.  Gibson, in connection  Avith  the re-
port of  the  above  cases, gives  briefly the details of a fatal
operation by David, of Rouen.  The luxation had  existed
several months, and great  force Avas employed  in the reduc-
tion.   This  resulted in  an inflammation, mortification, and
death.  Some years since, Lisfranc attempted the reduction in
a case of four months'  standing.  He succeeded ; but on vis-
iting the patient an  hour  afterwards he was found dead.  His
death Avas attributed to cerebral congestion, as the autopsy
showed the  axillary artery, veins, and nerves uninjured.  In
the same volume, MM. Lenoir and Larrey  refer to cases in
which they have met with lesion of the  brachial plexus, giv-
ing rise to paralysis, and yet these Avere recent cases, and the
reduction was most readily accomplished.   But  I will not
multiply cases of this kind ; those already related will suffice,
in the  minds  of  many, to answer the  question—At  what
period of time after a dislocation of the shoulder, is an attempt
at reduction justifiable ?   When  Prof.  Gibson  lost his first 
276
Dislocations.
patient, he Avrote that  'should a case similar in external ap-
pearance to that of James Schofield again  occur, I shall feel
justified in adopting a similar course.'  When he had lost his
second  patient,  (John Langton), he expressed  his vieAvs as
follows : " The conclusions Avhich I am iioav prepared to draw
are directly the reverse of Avhttt I have stated in some of the
foregoing pages; I am uoav disposed to condemn, in the most
unqualified terms, all  attempts  at  the restoration  of ancient
luxations ofthe humerus and  other bones—except in cases
where the patient is  remarkably  thin and debilitated, and
where there has been little or no inflammation at the time of,
or subsequent to the displacement.'  At a meeting of the So-
ciete de  Chirurgie of Paris, July 3, 1850, M. Maisonneuve re-
ported a case in Avhich, after M. Velpeau had failed, he suc-
ceeded in reducing a luxation of the shoulder of tAVelve Aveeks'
standing, and elated Avith this triumph over the veteran of La
Charite, he asserts there are but few cases in which, Avith the
aid of chloroform, we  may not succeed.   ' Quelles resistances y
a-t-il a  vaincre ici, en efifct ?' he asks.  ' M n'y a  presque pas
d'engrenage; les  muscles sont neutralises par le chloroforme; il ne,
reste done que des adherences fibreuses : I'on pourra presque toujours
les surmonter, ou les rompre.'   But these fibrous adhesions are
not  the only obstacles to  overcome;  where the  tissues sur-
rounding the head have become consolidated by inflammation,
the  axillary vessels and nerves must be in danger of lacera-
tion. Perhaps, however, as M. Maisonneuve suggests, this
accident may be avoided by ' extensions preparatoires,' as in the
attempts to restore contracted limbs to their natural shape."
   Cases attended with success are frequently reported, after
the dislocation has existed from six  Aveeks to as many months.
Attempts attended Avith failures must be  quite common, but
accounts of them rarely get into print.  If all the  bad conse-
quences had occurred in cases subjected to the  action  of pul-
leys and Jarvis' Adjuster, the blame might be mostly charged
to those poAverfully acting  instruments, but where  gentle
manipulation  alone was employed there have been some un-
fortunate results.   In ancient dislocations  of the  shoulder, a
joint that has  been attended with a large proportion of un-
fortunate attempts at reduction, the arm should be subjected
to such movements as Avould tend to detach the head  of the
humerus from any adventitious connections with the  struc- 
Dislocations.                    277
 tures  in the  armpit.  The surgeon  can generally discover
 during these preparatory manipulations whether the adhesions
 are firm and extensive; and he  will  be  governed somewhat
 by the evidence thus obtained.   If the head of the dislocated
 bone can .be rotated and moved freely in every direction Avith-
 out seeming to disturb the blood vessels of the axilla, there is
 very little danger of doing mischief in moderate  attempts at
 reduction.  I  have seen a surgeon  use his boot heel in the
 axilla as a fulcrum, and then exert all his strength in a violent
 and excited manner to effect a reduction by pulling and twist-
 ing the arm in all  directions, Avithout regard to method or
 reason.
   If a vessel be ruptured, which is made known by a quickly
 forming tumor in the axilla, and by loss of pulse at the wrist
 if the main artery be torn, the grave  question arises, What is
 then best  to  be done ?  -Of course, any additional efforts to
 effect a reduction must be abandoned  ; and well directed mea-
 sures promptly adopted to  arrest the  extravasation of blood.
 If it be certain that the axillary artery is  ruptured, compres-
 sion should be made  upon the subclavian A\iiere it crosses  the
 rib ; and the force should not be relaxed for forty-eight houis
 or more.   It is possible that in the course of time the blood
 already extravasated  Avould form a firm coagulum and arrest
 the hemorrhage.   Well directed and  prolonged compression
 has  resulted favorably; and  ligation  of the  subclavian and
 axillary have, in  the  few instances performed, proved  fatal.
 Certainly such Avant of success attending deligation, does  not
 warrant a repetition ofthe operations, though Ave reason Avith
 ourselves that there can be no hope except in the ligature.
  Generally a  bone Avhich has been dislocated, will remain in
 place when once returned to its natural position, especially if
 a little care be  exercised  in the use of the limb for a few
 weeks, or until it  is  presumed that  the rent in the capsular
 ligament has healed, and the different  tissues involved in  the
 injury have returned to their normal state and relate condi-
 tions.  HoAvever, in rare instances, there seems to be a dispo-
 sition  for the  luxation to recur upon the most trivial oppor-
tunity.   I  once had  a patient whose shoulder I reduced five
times,  at intervening  periods of  a  feAV Aveeks ; and  the last
time I kept the arm in a sling for two  months as a safeguard
against a recurrence  of  the accident.   I had  induced the 
278                   Dislocations.
patient  to  keep the arm by the side for two Aveeks, but that
length of time did not prove sufficient to prevent a recurring
luxation.  The patient was a  woman about thirty years of
age, Avho received the first dislocation—of the right  shoulder
—in a fall from a wagon; within a week she dislocated the
arm again Avhile SAveeping, the hand being raised at  the time
and the elboAV projecting out ward from the body and upward ;
the third displacement occurred Avhile fixing a Avindow curtain
as high  as she could reach; the fourth happened in the act of
sa\ing herself from a fall; and the fifth and last,  Avhile hang-
ing clothes on a line higher than her head.  All  of the acci-
dents  occurred  within a  period of  six months ;  and in each
instance there Avas no trouble in  reducing the boiie  to  place
by ordinary manipulation, no chloroform being used.  I began
to suspect that the edges of the rent in the capsule had become
covered Avith synovial membrane, and thereby offered an open
and smooth  passage-way for the  escape of the bone  from its
normal position.  The suspicion grew stronger from the fact
that each succeeding  reduction Avas attended Avith less and
less trouble.  Whether the  rent ever closed I am unable to
state; yet sufficient  contraction took  place in it during the
long period in which the arm Avas bound to the side by means
of a sling, to be a protection against another accident  of the
kind.   Dr. Jay, of Marion, Indiana, once had a similar case to
manage.  He reduced  a recurring dislocation of the shoulder
several  times; and at length the  patient,  upon having his
arm re-dislocated, applied to another surgeon for  relief.   The
second surgical attendant  was  not  on friendly relations Avith
the first, therefore he led the patient to believe that  the dis-
placed bone had never been properly reduced, and instigated
him to  commence a  suit for the recovery of damages.   The
plaintiff, however, failed to get a decision in his favor.
  In  the September number (1869) of the  Western Journal of
Medicine, W. R.  Thompson, M.D., of Vandalia, O., reports a
case of  recurring dislocation of the hip, AAmich is not Avithout
interest. " April 9th,  1869,  I  visited a patient in conjunction
with  Dr. H. B. Nimemaker,  for the purpose of reducing a
dislocation of the head of the  femur of three days' standing.
Our patient, a boy, aged sixteen years, muscular and healthy,
had been playing with a  colt, which became  unmanageable,
running violently against him,  dislocating  the head  of the 
Dislocations.
279
femur upward and backward, upon the dorsum of the  ilium.
The injured limb lay in a semi-flexed position, the heel ab-
ducted  and the toes inverted, resting on  the instep  of the
opposite foot.  Measurement revealed about  an inch  and a
half of  shortening.   The patient was put under the influence
of chloroform, and the dislocation reduced by manipulation,
(Reid's method).  The first effort Ave made the head  glided
from its bed; the circular movement brought it under the
acetabulum, converting it into a sub-pubic dislocation. The
movement Avas then reversed, Avhich  brought the head  of the
bone to its first position on the  dorsum ilii.   The limb Avas
again brought across its  felloAV, and the  circular   move-
ment carefully made, at the same time guarding the head  of
the bone from passing around the socket.  To our gratifica-
tion the head passed in Avith an audible snap, the limb assum-
ing its  normal position.   The patient Avas then placed  in the
horizontal attitude, and the injured limb secured to its  fellow
by means of a roller extending from the ankle to the knee.
On the folloAving da}T, on our first visit, the hip-joint Avas found
to have been dislocated during the night.   The boy, contrary
to most positive orders, had attempted to raise himself up in
bed, and at the same time turning partially around, threw the
head of the bone out; the leg assuming the same position as
Avhen Ave first saw it.  Again the  patient was placed  under
the influence of an anaesthetic, and the luxation reduced as in
the first operation.  He Avas then secured firmly by means of
a splint and bandage to the couch  in which he lay, in order
to guard against a third luxation.  In this secured position he
lay for seven days, doing well, except some slight peritonitis
occasioned by other injuries received in conjunction with the
first dislocation.   During the night following the seventh day,
he loosened  the bandage which held  his head  and shoulders
to the bed.  Finding himself again free, his first impulse Avas
to get  up.  (He  seemed  unable to appreciate his condition.)
In this attempt he again threw the head  of the bone out of
the socket.   This, in our  opinion Avas easily accomplished.
In  the  first place, there was  an extensive laceration  of the
capsular ligament, allowing the head to glide easily from the
socket; and secondly, the limb in its secured  position  to the
splint and bed, with the shoulders and body free to move in
the direction  of the erect posture, and to the right.   These 
280                   Dislocations.
movements would, under the circumstances, certainly produce
a dislocation (the left limb being the injured one).  At our
request, Dr. J. C. Reeve, of Dayton, Ohio, Avas called in coun-
sel, in order to  fortify  ourselves  against  any subsequent
trouble, in a legal point of  vieAV.  The patient  Avas again
anaesthetized, and Dr. Reeve thought, upon first examination,
there might be fracture within the capsular ligament; but,
upon further investigation, coincided with our previous diag-
nosis.  We then proceeded to  reduce the luxation in the man-
ner before mentioned, and with similar success.  At  the doc-
tor's  suggestion, the splint  was reduced in width from five
inches to three, and not to be  secured to the bed, and the toe
was everted to about seventy-five degrees—the foot abducted
about four inches from the normal  axis of the leg—the body
was secured to the bed as was  previously done.  In this posi-
tion he lay for three weeks,  after Avhich time  the  splint  was
removed and passive motion induced.
  " At the time of Avriting the above,  the boy Avas able to
Avalk  Avithout crutches, though there is still some lameness—
the foot is still in an abducted  position, with the toe everted,
giving him altogether an awkAvard appearance.
  " In this case the difficulty did not consist in the reduction
of the dislocation, but in  retaining it in its normal position
after reduction ; and it is our opinion the injured limb should
always be  secured  with a splint,  the normal  axis  of the leg
maintained, and the toe but  slightly inclined outwards.  It
will be seen that the splint in this case was left on  someAvhat
longer than would be required in the majority of cases."
  In the above  case it seems strange that the  toes remained
everted and the foot abducted after the reduction Avas effected,
unless the  head of the femur was fractured or a  notch  was
broken out of the rim of the acetabulum.
  Case CCXV. of Dr. J. Mason Warren's Surgical Observations,
Avas someAvhat similar to that just quoted.  The bone slipped
out of place in a few minutes after it Avas reduced, while the
limb Avas slightly raised for a more thorough inspection.   The
experiment of reduction and luxation Avas performed several
times to see what Avas the probable cause of  the  easy recur-
rence. Slight crepitus showed that a fracture ofthe acetabu-
lum or head of  the femur existed, probably of the  upper and
back part of the cotyloid  border.  Hence, DesauU's fracture 
Dislocations.
281
apparatus was employed for three weeks.  At the end of that
time the patient threAv off the splint, and began to use his leg.
While turning around the bone  slipped from its socket, and
in the course of a Aveek the accident occurred a number of
times upon the most  trivial  occasions.  A permanent  splint
was then put on, and the leg kept quiet in a  straight attitude
for several months.  After the fracture dressing Avas removed
the joint sloAvly regained its mobility.  Dr. Warren pertinently
remarks that if the patient had passed into other hands Avhen
some of these recurrences of the  dislocation took place " it
might easily haATe been urged that the dislocation had  never
been reduced."
  In cases of old dislocation of  the shoulder, the accident re-
curring over and over again, there is little  skill required in
effecting a reduction.  Some persons in Avhom the shoulder is
so affected, have learned to  reduce the  dislocation  for  them-
selves, by reaching over a gate, taking hold of one of the  lower
bars, and hanging in this position, Avhen the  mere weight of
the body is sufficient to restore the parts to their place.  The
non-professional brother of a patient of my acquaintance had
learned the manner of reducing a frequently recurring  dislo-
cated shoulder, and performed this service Avhenever required.
Some loose jointed children practice dislocating, Avholly or in
part, some articulation of the thumb or  of  the fingers ; the
reduction is performed with equal facility.

  Causes of Dislocation.—As has been stated previously, ex-
ternal violence and muscular contraction are  the frequent and
prevailing causes of dislocation.  A bloAv upon  the top  ofthe
shoulder, escaping the acromion but hitting  the head   of the
humerus, may force  the latter bone doAvmvards, beloAV the
glenoid cavity,  into the axillary or subglenoid space.   It is
possible that the femur, when the limb is  in  a state of abduc-
tion, may be driven dowiiAvards in the same manner, so that
the head of tne bone shall find a  lodgment in  the thyroid fora-
men.    The patella is knoAvn  to  have been dislocated by a
direct bloAv.  Either end of the  clavicle may be forced out of
articulation by direct violence.  I reduced a  luxation  of one
condyle of the  jaw, that Avas produced by a  kick.
  The indirect  force  most commonly produces dislocations,
whether the articulation, at which the accident occurs,be of one 
282                   Dislocations.
kind or another.  A powerful force  suddenly applied to the
elboAV, carrying the arm excessively upward, may rupture the
capsular ligament of the shoulder joint, and thus open the
Avay for a luxation.   The hand thrown forward to break  a
fall, may receive a force Avhich is safely transmitted through
the carpus, and shaft of the radius, Avithout fracture or  dislo-
cation of those parts, but  the  head of the radius may be
Avrenched from its connection with the external condyle.  It
is not ahvays easy to determine the essential cause of disloca-
tion ;   an injury is received in some  unknoAvn manner, which
proves to be a luxation.  The patient can not positively tell
whether the  violence was applied to the arm or to the shoul-
der, to the hand or to the elboAV.  A bruise upon some point
remote from the luxation or directly upon the joint, may lead
to a rational  interpretation  of the  cause, yet thOre may be
several contusions, and all be produced by forces independent
of that Avhich caused the dislocation. Generally a limb in  a
state  of luxation is  a little  shorter than  natural, though it
may be longer; in most instances it is either longer or shorter,
and rarely retains the same length as the other limb.   In a
dislocation doAvtnvards of the humerus  (subglenoid) the arm
is lengthened about two  inches; if the head of the bone  be
thrown under the coracoid process (subcoracoid) the arm is
lengthened about three  quarters of an inch, and if the dis-
placement extend inside the coracoid process the head  of the
humerus  rises  tovvard the clavicle and the arm is shortened.
In  dislocations  of the hip, the leg is  two  or three  inches
shorter if the head of  the femur be thioAvn upon the dorsum
ilii, and the limb is longer if the dislocation be doAvmvard into
the thyroid foramen.   In dislocations of a ginglymoid  articu-
lation, the limb is rarely lengthened, and is generally shortened.
  A dislocated  limb ahvays has a constrained and distorted
appearance, Avhich is diagnostic  of the injury.  A dislocation
of the radius and ulna backwards resembles  a deformity fol-
loAving a fracture of the shaft of the humerus just aboA7e the
condyles, yet the rigid state of the parts involved in the dis-
location, and the mobility in fracture, ought to be sufficiently
marked to remove doubt in any case, to say nothing of other
distinctive features in each.
  The pain and disagreeable numb sensations attendant upon
a recent dislocation, aid in  the  diagnosis, though such signs 
Dislocations.
283
are not  sufficiently characteristic  of  the injury to settle a
question involved in doubt.  Not much can be determined by
the swelling, for other injuries have that symptom in a greater
or less  degree, the amount  not always depending upon the
severity of the lesion.
  Fractures near the joints and sprains resemble dislocations.
A sprain is attended Avith pain, SAvelling, and stiffness  which
may be taken for the rigidity of luxation.  However, a limb
simply sprained  can be made to move in all its normal direc-
tions, and no ugly deformity, beyond  that  caused  by the
swelling, can be discovered.  In a fracture crepitus can almost
ahvays be elicited, a sign which is  unmistakable.  Dislocated
joints and  even those  merely stiffened from disuse, may be
made to  yield a  creaking, crackling noise, but it is not the
sharp, harsh grating sound knoAvn as the genuine  crepitation
of fracture.
   It is difficult to reduce a dislocated bone, and when reduced
it will generally stay in place;  not so in a  difficulty consisting
purely of a  fracture.  In  the latter injury the  reduction  is
easy, and the displacement returns to the parts as soon as left
to themselves.  For instance,  a fracture  of the neck  of the
femur is attended witli shortening, and, in some instances, in-
version  of the toes—both marked  features of dislocation of
the hip, yet in the event of fracture the shortening could be
readily  overcome by moderate extension ; and  if this force
Avas relaxed, the shortening would reappear.  In the event of
dislocation, the shortening could not  well be overcome and
the toes be brought into their natural attitude Avithout  reduc-
tion ; and when  the head of the bone Avas once  replaced it
Avould not leave its situation as soon as the limb Avas  left  to
itself.  In addition to these differential signs, the mobility in
fracture and the  rigidity in dislocation, are quite  distinctive,
and, therefore, valuable.
  The sooner the investigation of  an  injury is held after an
accident, the  clearer will  appear the differential signs; and
the less distress  will be inflicted upon the patient in establish-
ing the  diagnosis..  If two or  three days pass before the in-
jury is seen by the surgeon, he  will be balked by the SAvelling,
the tenderness, and the tumid condition of the infiltrated tis-
sues.  It  is  advised by Malgaigne, in obscure cases, to insert
a slender and Avell tempered  needle through the tissues to the 
284                    Dislocations.
articulation ; and Avith its point explore the structures  of the
joint.   If the head of the bone be in place the progress of the
needle Avill be arrested ; but, if out of place, the hollow space
it. once occupied will be reached, and the diagnosis established.
It is far better to use  an exploring  needle  than to remain  in
doubt concerning the nature of the  injury.  The point of
penetration should be selected so as not to endanger the punc-
ture of a large vessel  or nerve.
  Sensitive females, or those possessing peculiarly impressible
nervous systems, may claim that they have a dislocated joint,
aud simulate luxation to an extent likely  to deceive the un-
wary.  The knee is the joint most  liable to be attacked Avith
such symptoms as are generally the result  of hysterical com-
plications.  So irregular becomes the distribution  of nerve in-
fluences that  the parts about the joint may sAvell and become
distorted, or Avaste asif struck Avith palsy.   The patient claims
to have slipped and displaced a bone, and ever after Avas un-
able to Avalk or even  move the joint.   Manipulations and
passive  motions  are  attended Avith excruciating pain.  In
some instances the rigidity of the  articulation is Avell calcu-
lated to mislead, the physician being convinced that no lesion,
other than luxation, could present such articular fixedness.
  These neuropathic  affections of the joints are called forth
at first  by the feelings and imaginings  of the patient, Avho
having once or twice  given way to the belief that she is suffer-
ing from a dislocation or other serious lesion of the joint, de-
ceives herself into the full conviction of having a real malady.
This feeling indulged in for a few Aveeks or months, disturbs
the nutritive  functions of  the part claimed to be displaced  or
disordered, and in  time a  real deformity exists,  which is  in
danger of becoming permanent.  If the surgeon be persuaded
that no luxation or real defect exists, he may have chloroform
administered and go through with the mock performance of
reducing a dislocation, or of executing some important opera-
tion.  Patients have  thus  been deceived  into a  cure AAiiich
could not be  accomplished in any other way.

  General-Treatment of Dislocations.—From A\hat has been
previously Avritten it Avill be seen that  I am in favor of reduc-
ing dislocated bones by such gentle movements of the limb in
certain  directions as  shall  relax the  muscles and bring the 
Dislocations.
285
 head of the displaced bone into a position favorable to its  re-
 turn through  the  same  rent in  the  capsular ligament, that
 permitted  the  egress.  This is  to be accomplished more by
 tact than by force—arte non vi.  HoAvever, dislocations of the
 gi ugly moid articulations  can not be reduced Avithout more or
 less force is used.   The poAver is not to be employed rigidly
 in a straight line, but advantage is to be taken ofthe muscles,
 relaxing them  as much as possible, and by twisting and rock-
 ing motions the impediments of bony prominences are to be
 overcome.   For instance, in case of dislocation of the ulna
 backAvards, extension from the Avrist and counter-extension
 from the shoulder,  with the Avhole arm in a straight attitude,
 Avill avail  nothing, except it defeat the  object to be accom-
 plished, unless force enough  be employed to break and tear
 through every  obstacle.   The knee is another joint, when lux-
 ated, that requires  force to reduce it, yet the leg needs  to be
 flexed, and the force used against the ham, and not upon the
 foot Avith the limb in a straight position.  A little coaxing in
 the management of dislocations, often proves effectual  when
 arbitrary force is obstinately resisted.   Intelligent manipula-
 tion manifested in accordance Avith a good understanding  of
 the anatomy and pathology of the articulation, will generally
 succeed in reducing a dislocation Avhen brute force Avould fail
 or be attended  Avith unnecessary suffering and lasting injuries.
  The accomplished surgeon  considers Avell every phase  of
 each case, rarely allowing himself to be completely thwarted;
 if one method  of reduction does not succeed, he tries another,
 being ever fertile in expedients  and resources.  He  even en-
 lists the power of the muscles to assist in the work of reduc-
 tion. The expert-bone-setter does not, Avhen called to treat a
 dislocation, first look about for pulleys and other contrivances
 for multiplying force that he may violently drag the bone back
 into place,  regardless of consequences.   The ignorant and in-
 experienced are ever embarrassed; and in order to mask their
 inefficiency, they often resort to violent measures that are en-
 tirely unnecessary.   Natural prominences about  the  joints
 have been taken for deformities; and a simply sprained articu-
lation has been subjected  to the stretching influence of Jarvis'
Adjuster.   The physician Avho  has courage  to acknowledge
his  incompetency to  treat a surgical  injury is  a moral hero
who Avill not go through the world Avith  merits unrewarded. 
286
Dislocations.
The most skillful and experienced surgeon is often baffled or
utterly thwarted in his efforts to reduce a dislocation; and his
failures teach him to be charitable in passing criticisms upon
those Avhose opportunities to acquire and put in practice  sur-
gical knoAvledge have been necessarily limited.
  With the patient under chloroform the majority of luxa-
tions will yield to Avell directed and persevering manipulation :
if that fails, extension and counter-extension should be made
by the hands of assistants, and Avhile these forces are being
applied, the  surgeon should give proper directions, and en-
deavor Avith  his oavii hands to  rotate the limb  or to impart
such movements to it as shall favor reduction.
  These efforts having failed, the surgeon may deem it advis-
able to resort to Jarvis' Adjuster, the pulleys, or some other
contrivance for multiplying  force.  A strong cotton handker-
chief, or a Avide strip of firm muslin may be made fast to the
wrist (if force  is  to be  applied to the  arm) by  the common
double slip-knot or what is called the " clove  hitch," for the
application ofthe extending force ; a wide toAvel or folded sheet
put around the chest, just under the arm, Avill do  for making
the counter-extension.   Tavo large staples  or  spikes  driven
into door  posts or Avindow  sills, or  any firm fastenings in a
wood shed or back room, a few feet distance from  one another,
will ansAver for points to make fast to when everything  is in
readiness.  Let the toAvel or sheet surrounding  the patient's
chest be tied  to one spike or staple, and a strong  cord or rope
doubled upon itself, be tied between the  other spike or staple
and the extending handkerchief placed on the patient's wrist.
A  stick  or  cane  inserted  betAveen the two  thongs  of the
double rope  may now be revolved as in a Spanish Avindlass,
until the extending bands are made  tort.  It Avill be seen that
great extending and counter-extending force can, in thisAA^ay,
be  brought to bear upon the  arm.  The contrivance  is so
simple that it can be gotten  up in a feAV  minutes  in any farm
house; and it  serves all  the purposes  of costly blocks  and
pulleys.  Since the discovery of anaesthesia and rational man-
ipulation, there is seldom a  call for such mechanical contriv-
ances as  constituted a necessary part of the surgeon's para-
phernalia a half century ago. I have reduced  dislocations in
subjects of great muscularity, without assistance or appliances;
and although I have possessed a Jarvis' Adjuster for fifteen 
Dislocations.                    287
years I have rarely put it into use.  I  begin  to regard it  as
entirely superfluous.
  It Avas  formerly considered  necessary to  subdue muscular
tension and to reduce the poAvei's of the system by the use of
Ararm baths, venesection  and  tartarized  antimony; but the
discovery  of .anaesthesia has entirely superseded those agents.
The forcible, prolonged, agitating and painful attempts to re-
duce dislocations, AAiiich Ave re common to older surgery, are
scarcely heard of iioav.  The old notion that the muscles had
to be " tired out " by the prolonged traction  of a number of
men, or by various mechanical contrivances, some of'them of
the most  ludicrous  nature, Avhich may be seen depicted  in
old books of surgery, has been almost entirely supplanted by
more rational ideas and sounder principles.
  In France an instrument called a dynamometer is used  in
connection with the pulleys, in  order that  the precise force
employed may be accurately measured. This is a refinement
that has not been introduced into American practice.   Inas-
much as different degrees of force are required in individual
cases, and it never having been ascertained Iioav much force
may be safely applied in a  given case, the instrument could
have no practical value.
  It should be remarked  for the benefit of those who may
employ pulley force, that the surgeon is to watch the condition
of the joint while the extension is being made; and as soon
as the head of the bone seems to be  opposite the empty ar-
ticular cavity, he is to order the extension to  be relaxed, and
at the same time he completes the reduction by pressing  or
pulling the bone into place.-  If he fails to return the head of
the bone to its normal position, and it  sinks back into its neAV
formed bed, the pulley force is to be reneAved, and a fresh
attempt made to return the bone at the nick of time Avhen the
assistant  relaxes the extending cord.  The  handkerchief  or
bandage applied above  the  wrist, elbow, ankle, or knee, as  a
fastening to hitch the  ropes to, may,  in prolonged efforts  at
reduction, excoriate  the constricted parts, and the wounds be
folloAved by dangerous sloughing.  It  is to be borne in mind,
therefore,  that there are Avorse evils  than a  dislocated bone;
and a surgeon might bring discredit upon himself by hopelessly
ruining  a limb, even if he succeeds  in the  reduction by the
exhibition of unwarranted  violence. 
288
Dislocations.
  Reduction having been  accomplished, the position  of the
replaced bone must be maintained by bandages, or slings, for
a certain period; generally a Aveek is sufficient to confine most
of the joints ; the shoulder  should be kept in a state of repose
for tAvo Aveeks.   High grades of inflammation require topical
applications of  evaporating and anodyne  lotions.  In  the
event of suppuration the pus-should be eATacuated at a proper
time, and efforts made to prevent anchylosis.
  Tenotomy has been performed in order to overcome what
seemed to  be the chief resistance to reduction.  The  tendo-
Achillis has been subcutaneously divided to facilitate the re-
turn of the foot to its normal place Avhen luxated backwards ;
and  so have the tendons of the thumb been seiwed to accom-
plish reduction.  In regard  to  these  operations I may say,
that there  is  no serious objection to tenotomy if reduction
can not be effected in any other way; but with the free use of
an anaesthetic,-it is not probable that such measures are ever
necessary.
  In compound and complicated dislocations there can be no
definite rules AAiiich AAill  reach  many cases.   The lesions are
generally of such a serious and complex nature, that the sur-
geon must manage each according to its  individual  peculiari-
ties.  A joint badly crushed  as Avell as dislocated, with injury
of the passing vessels and  nerves, may require amputation or
resection to save life.  However, there is generally no  neces-
sity for haste in resorting to extreme measures unless the  dis-
organized condition of the  limb demands prompt action. The
conservative spirit  of modern  surgery has saved  limbs that
would have been  sacrificed  at  once in  Sir Astley Cooper's
time.  Loose pieces of bone deprived of nutritive connections
should be removed in compound injuries, and then  if the re-
duction be accomplished, and the joint treated like a fracture
or in accordance Avith the demands of the  case, a  serviceable
limb may be saved to the patient.   Compound dislocation of
the  knee, complicated  Avitli  fracture  of the patella, and the
condyles of the femur, generally demands amputation  to save
life.  The  dangers from primary shock, subsequent pyaemia,
and irritative fever, constitute well grounded objections to any
argument advanced in favor of  attempting to save the  limb.
  If a dislocation be complicated Avith a  fracture, the luxation
should be overcome first, if possible, and then the fracture 
Dislocations.
289
 may be treated as a simple injury, for a dislocated bone left
 until a fracture has united, is not easy to be returned to place.
 The older  Warren, of Boston, once had  a case of shoulder
 dislocation  and fracture  ofthe  humerus  on the same side;
 aud he was unable to reduce the luxation  until the broken
 bone Avas repaired.  This course  is commended by Malgaigne,
 and it even might be necessary when the fracture Avas so near
 the head of the bone as to render it impossible to  overcome
 the dislocation until the fragments of the humerus had united
 so  as to make a lever of the arm.
  My experience  with compound dislocations leads  me to
 commend an attempt to  save the limb Avithout  amputation.
 Two years ago I was called to an injured elbow in winch  the
 radius and ulna were projecting through the flesh on the pos-
 terior aspect of the arm.  I gave the patient chloroform, and
 rather easily pulled the  luxated bones into position.  I dressed
 the iimb in  a semiflexed position, and  left the wound  in  the
 skin as it Avas.  Inflammation was held repressed by the use
 of  cooling lotions, and the internal use of chloral hydrate.
 Considerable suppuration attended the healing  process, and
 the elboAV was  somewhat stiff.  In this case there appeared
 no  excuse for amputation.
  A boy was playing base ball and received a compound dis-
 location of the ring finger at the knuckle joint.  It required
 great traction to pull the  luxated bone into place.  However,
 Avith force and manipulation  I succeeded in the reduction.   I
 bound the finger in splints, and kept the lesion wet with cool-
 ing lotions.   In four weeks the finger was well, yet someAvhat
 stiff at the injured joint.  Passive motion  for  three months
 completely restored the functions of the joint.
  I  was once  called to Dr.  MeKinney, of Defiance, 0.  He
 had received a compound dislocation of the  ankle the day
 previously.   Amputation  had  been  advised,  but I opposed
 such a procedure.  The patient was a very large man and the
 injured  limb swelled  prodigiously.  The dislocation was re-
 duced, and  the limb left Avithout splints  or other dressings
 except pledgets of lint laid upon the the wound.  There ap-
peared to be no disposition to a re-dislocation.  The swelling
ofthe leg was so great that phlyctenae appeared and gangrene
threatened.   The patient made a good recovery,  yet with re-
stricted  action of the ankle-joint.
    19 
CHAPTER  II.
DISLOCATIONS  OF  PARTICULAR  JOINTS.
            DISLOCATION  OF THE JAW.

   The under jaAV is articulated, through its condyles, with the
 glenoid  cavities  of the temporal  bones.  In each temporo-
 maxillary joint is a bi-concave fibro-cartilage, Avith synovial
 membrane on both surfaces, which facilitates the ATarious mo-
 tions of  the articulation, and in a measure prevents luxation,
 for its elastic substance lessens shocks, and its shape  deepens
                        the articular cavity*  The  glenoid
                        cavities  are  bounded  in front  by
                        ridges of bone called the eminentiae
                        articulares ;  and in laughing, yaAvn-
                        ing, and other forward movements
                        of the loAver jaw, the condyles rest
                        upon  these bony prominences; but
                        the ligaments of the temporo-max-
                        illary joints, prevent the condyles
                        from dropping into the zygomatic
    Dislocation of the lower jaw.  fossse in  front of the eminentiaa  ar-
                        ticulares, or from becoming dislo-
 cated.   HoAvever, an  extreme doAvnward and forward motion
 of the jaAV, as sometimes takes place in gaping, ruptures the
 ligaments, and luxation ensues.  Muscular action, then, is suf-
 ficient to produce the lesion.  Sir  Astley  Cooper reports the
 case of  a boy who had his jaAV dislocated by an apple forced
 into his mouth ; and Dr.  Physick, of Philadelphia, kneAV  a
 woman to dislocate her jaAV Avhile scolding her husband.  Dr.
 E. Andrews,  of Michigan, reports a case in the Peninsular
. Jouynal of Medicine, in Avhich a patient Avhile vomiting from
 the effects of lobelia, received a dislocation of the jaAV; other
 emetics of the same kind had  been frequently taken,  but no
                            (290)
 
Of the Jaw.
291
ill effects had folloAved except a sensation of slight spasm at
the joint.  Malgaigne met Avith four cases of luxation of the
jaAV from vomiting, and five from convulsions.  Dentists not
unfrequently dislocate the jaAV on one or both sides AAiiile en-
gaged in extracting teeth, removing old fangs, and even Avhile
excavating and  filling.  Dr. Gilbert, of Buffalo, in  a Thesis
upon Dislocation  of the Inferior Maxillary, relates a case of lux-
ation of both condyles fonvard, under  the zygomatic arches,
Avhich  occurred  Avhile  he  Avas taking  an impression of the
lower alveolar ridges, for the purpose of making an artificial
set of teeth.
  Direct violence occasionally produces luxation of the loAver
jaAV.  A heavy  lateral blow, or the kick of a horse or mule,
the  force being directed fonvards  as well  as laterally, may
dislocate one or  both  condyles.
  Children and  elderly persons are not subject to this accident,
though a case in one  of the  extremes  of age is  occasionally
reported.  Nelaton found a dislocation of the jaAV in a person
above seventy, Avhose gums were toothless.
  Luxations of the jaw occur most frequently in persons from
fifteen to thirty-five years of age ; and in females much oftener
than in males.   A laxity of the ligamentous structures about
the articulations favors dislocation, whether the subject be of
one sex or the other.   As soon as the condyles become thrown
slightly in front of the articular  eminences, the jaAV is spas-
modically forced fonvard by the  combined actiou ofthe mas-
seters and internal pterygoid muscles.
  A backAvard  dislocation is impossible unless the  osseous
structure of the  external ear is broken at the same time.   Dis-
location  of one condyle fonvard,  the other being left in place,
is an accident of not  extremely rare occurrence; though both
condyles are much more frequently luxated in one injury.
  The symptoms of dislocated jaw are so marked and charac-
teristic, that, says Robert Wm.  Smith,  " Ayere there  not re-
corded cases  to the  contrary, we  could  scarcely suppose it
possible that the true nature of  the accident could  be over-
looked. *  *  The mouth remains widely opened, and the indi-
vidual is unable to close it; the incisor teeth of the loAver pro-
ject beyond those of the  upper jaw; the saliva Aoavs from
the  mouth involuntarily and profusely ;  speech is difficult,
and the pronunciation of labial consonants impossible ; deglu- 
292
Dislocations.
Appearance of the lower part
 of the face produced by dis-
 location of the inferior max-
 illary.
tition can  not be performed, and the motions of the tongue
are limited."
  " The masseteric regions of the cheeks are flattened, a de-
pression is observed in front of the auditory canal, immedi-
ately below the horizontal root of the zygoma, and the  finger
can be sunk into the parotid space.  The coronoid process
forms beloAV the malar bone, a prominence which is very visible
                     externally, but Avhich is most distinctly
                     felt through the mouth."
                       " There is likewise an evident fullness
                     in the temporal fossa, between the eye-
                     brow  and  the ear,  immediately  aboATe
                     the zygoma.   This prominence (Avhich
                     does  not seem to have been noticed by
                     any writer except Mr. Adams) appears
                     to  be  thus produced: As  soon as the
                     condyle has cleared  the articular emin-
                     ence, it at once becomes placed upon a
                     higher level than the apex  of the  coro-
                     noid process; it is elevated in the  same
                     proportion as the coronoid process  is
depressed.  It thus comes into  contact with and pushes up-
wards the posterior fibres of the temporal  muscle, Avhich pass
horizontally, or nearly so, over the  pulley-shaped surface of
the zygoma.  To the displacement and  stretching of these
fibres over the upper surface of the condyle, the prominence
alluded to is, I conceive, to be ascribed."
   The coronoid  process can be felt through the cheek,  or
within  the mouth; and the  relation of the teeth is altered.
The pain in a recent case is  intense ; but  becomes  mitigated
in the course of a few days in cases left unreduced.
   When  one condyle is dislocated the anterior arch of the
 jaw  inclines  to the right or left side as the case may be, giv-
ing the  lower part of the face a distorted appearance.  The
mouth is not held Avide open, as in the double dislocation, but
the parallelism of the teeth is destroyed, and the jaAV is rigidly
fixed in the distorted state.
   When  luxation of the condyles is left unreduced for  several
weeks or months, the chin gradually becomes eleAfated, the
patient is enabled to close the mouth, the involuntary Aoav of
 saliva ceases, the faculty of speech is  regained, and most  of 
Of  the Jaw.
293
 the characteristic signs of the nature ofthe injury disappear ;
 but the projection of the chin, and the adA^ance of the lower
 incisor teeth still remain, making the loAver segment of the
 face rather unsightly.   In fact, the general mobility of the jaw
 is never fully recovered, if the bone be left unreduced.
    Mr. Hey, iu speaking of dislocation  of one condyle, does
 not admit that the chin is carried off to  the side opposite the
 lesion, but declares that he  could see no  alteration in the posi-
 tion of the chin.  The symptom mo*t  diagnostic, according
 to his description, is a small hollow or depression which can
 be felt behind the condyle that is dislocated ; and  the other
 side is natural or free from  any such empty space.
    When the mouth is open to its utmost extent, the  tips or
 extremities  of the condjies rest on the articular eminences
 which bound the glenoid cavity in front; and being poised on
 those eminences, the muscles have an opportunity to jerk the
 condyles in front of those ridges.  Even if the masseters and
 pterygoids hold steadily, constituting a fulcrum, the chin de-
 pressing  muscles, acting on the  long arm of the lever, may
 readily accomplish the displacement of the condyles forward.
 This vieAv of the mechanism of the under jaw, explains  Avhy
 gaping produces luxation oftener  than all other causes com-
 bined.   Besides, it is common for the muscles of the neck and
 face to act irregularly during the  effort of yawning.
   Reduction  of a dislocated jaAV  has been effected after the
 bone has  been out of place several Aveeks, and even months.
 There is  no objection to an  attempt being made at reduction,
 e\7en if six months have elapsed  from the time of the acci-
 dent.   HoAvever, it might be difficult to keep the bone in place
 after it had been luxated so long; and after the  implicated
 parts have become accustomed to  their neAV relations, there is
 no longer a pressing  demand for  surgical interference.  The
 best time to effect reduction  is immediately after the accident;
 and the patient, though unable to speak,  is frantic  for relief.

   Treatment.—To reduce a dislocated jaw of recent occur-
 rence no chloroform is generally needed.  The patient is  to
 be  seated  on  a Ioav stool, Avith his head resting  against an
assistant's  breast;  the  surgeon  places himself in front of the
patient, and  inserts  his thumbs,  previously Avrapped Avith
pieces  of cloth, into the mouth as  far back as possible and 
294                   Dislocations.
presses upon the loAver molars, Avhile the fingers beneath  the
chin elevate  the anterior  extremity of the dislocated bone.
The thumbs, if they were strong enough, would  depress  the
condyles beloAV the articular eminences and the internal ptery-
goids Avould snap them into place; but the assistance of the
fingers, acting on the anterior portion of the bone as  a lever,
is required to overcome the poAver of the temporal, masseter,
and  internal  pterygoid muscles.  Each  thumb is not only a
fulcrum, but it is made* a power to depress the  back  part  of
the jaAV and disengage it from the zygomatic fossa.   By this
double poAver exerted advantageously by the thumbs and fin-
gers the reduction can generally be accomplished  in  a brief
space of time.  The jaAV needs pulling fonvards a little in the  '
effort at reduction, in order to facilitate the escape of the pro-
jecting condyles from the cavities in  Avhich they have been
resting.   As the surgeon feels the movement that is  to result
in reduction, he quickly slips his thumbs between the teeth
and cheeks to  escape the effects of the sudden closure of the
jaAvs.  The first time I attempted this feat the side of each
thumb Avas pinched into a  " blood-blister."
  If trouble is experienced in this attempt Avithout chloroform,
the patient may be brought under the influence of ansesthesia,
when less force  is  required to effect the reduction, and the
muscles being relaxed there is less danger of receiving a bite
at the time the condyles slip into place.
  Another method of reducing dislocations of the under-jaAV
is to place a couple of vial  corks or pieces of soft Avood as far
back between  the grinders  as  possible, each to  perform the
part of a fulcrum, and then with the hands or a strap beneath
the chin,  exert sufficient upward force  to pry the  condyles
doAViiAvards to the level of  the articular eminences Avhere the
muscles can pull the bone into place.  This plan  is  executed
while the  patient sits on  the floor, Avith his head resting be-
tAveen the knees of the surgeon who sits in a chair behind the
person operated upon.   M.  Nelaton has  reduced dislocations
of the inferior maxillary, Avhile standing  behind  his patient,
by resting his fingers against the mastoid processes,  and with
nis thumbs upon the  projecting coronoid  processes, forcing
them doAvnward to a point Avhere the contracting muscles
could finish the reduction.   This manoeuvre could hardly be 
Of the Jaw.
295
 accomplished unless the patient Avere well under the influence
 of an anaesthetic.
   An old plan was to use pieces of wood the size of a narrow
 ruler, as levers in the mouth to depress the angles of the jaw
 sufficiently to effect reduction.  In the  case of Mrs.  Harts-
 horne aa'Iio dislocated her jaw at the Sherman House, Avhile
 gaping, I found it necessary to use a lever of wood to disen-
 gage one condyle.   Her husband would not alloAv me to employ
 chloroform ;  and  one of my thumbs was suffering from a
 sprain, so that I could not exert sufficient force  to dislodge the
 condyle from its abnormal bed.
   There is no objection to reducing one side at a time, if the
 operator has not power in his  hands to accomplish the full re-
 duction  at once.   The  prudent surgeon  will employ force
 Avith care, in reducing dislocations, and inflict as little damage
 upon the patient as possible.  Reluxation should  be  guarded
 against by the use of a bandage over the head and under the
 chin to prevent the mouth being opened too Avide either while
 eating, gaping, laughing, or sleeping.  A handkerchief folded,
 and, after passing under the chin, tied on the top of the head,
 serves to prevent a Avide  separation of the jaws, and to remind
 the patient that the danger of reluxation still exists.  The re-
 tentive means may be employed a Aveek or ten  days; and in
 the event of a second  accident and successful  reduction, the
 bandage should be worn  for six Aveeks.  The jaws are not to
 be so firmly closed by the retentive dressing as to prevent the
 taking of food.
   I  am  acquainted  with a case of recurring luxation  of the
 inferior  maxillary;  and  the patient himself, after haATing it
 reduced  a few  times, learned the art of replacing the boneJ
 He generally emplo}7s a wooden  roller of the diameter of a
 pen-holder, two inches and a half  long, as a fulcrum  between
 the molar teeth, Avhile Avith the  hands  he elevates  the chin
 and forces the jaw back into its sockets.   He says the bone
 Avas first dislocated when he was young.  A brother playfully
 struck him on  the  chin while he was in the act of gaping.
 Reluxation took place in  a Aveek after the first reduction ; and
the recurrence has been frequent ever since. He Avore a gum
 elastic bandage  over the  head and under the chin for a year
 or more,  and although the number of luxations decreased the
casualty  Avas not Avholly  prevented.  Finding  that  the clis- 
296
Dislocations.
placement of the jaw at length gave very little pain, and that
he could return the bone to place without  difficulty, he took
no further special precaution against the accident.
  If an ancient dislocation of the inferior maxillary disfigured
the patient, and was the source of pain and other serious  an-
noyances, the subcutaneous  section of the masseters might
alloAv  of  reduction; and if there  still existed  formidable  ob-
stacles to a  return  of the bone, the  temporal and internal
pterygoids might be divided, leaving  no muscular  resistance
to reduction.
  Sub-luxation of the loAver jaAV is a species of displacement
not exceedingly rare, especially in persons who possess a lax
state of the ligaments.  The difficulty is  someAvhat trouble-
some, for the patient is not able to close the mouth until  the
condyles are  replaced. Sir Astley Cooper  thought the acci-
dent depended upon the condyle slipping off  from the inter-
articular cartilage, but in a case I had an opportunity to ex-
amine, I  was  confident the cartilage followed the condyle,  and
its concave centre impinged on the articular eminence in front
of the glenoid cavity.  Bransby B. Cooper states that " the
interarticular cartilage is ahvays displaced with the condyloid
process of the bone."
  Very little  skill  is  required to overcome  a sub-luxation.
Depression of the jaw, together Avith lateral motion, relieves
the "hitch,"  and the muscles replace the bone, and the inter-
articular cartilage.  No ligament or other tissue is lacerated,
therefore it is useless to employ a retentive dressing.  Bathing
the maxillary joints frequently in cold Avater or  astringent
lotions, might prevent a recurrence of the  displacement.  A
spasmodic contraction of  the digastric and genio-hyoid mus-
cles while gaping in cold Aveather, has been regarded as a sub-
luxation, but it is a difficulty quite distinct and different from
articular displacement. The spasmodic state  leaves the mus-
cles sore beneath the chin, and in sub-luxation the soreness is
confined to the region of  the articulation. 
CHAPTER  III.
DISLOCATION  OF  THE VERTEBRA.
   The intricate articular connections betAveen the bones com-
 posing the spinal column, render uncomplicated dislocations
 of the  vertebrae  exceedingly rare.  Sir Astley Cooper  says :
 " I have never Avitnessed a separation of one vertebra from
 another through the intervertebral substance, Avithout fracture
 of the articular processes ; or, if those processes remain un-
 broken, without a fracture through the bodies of the vertebrae."
 Other surgeons and surgical writers have declared that a dis-
 location can  not occur  anywhere in the  vertebral column
 without the  concurrence of fracture; and any anatomical
 student Avho has  attempted to disarticulate the \Tertebral chain
 in a fresh subject, has been impressed Avith the  difficulties  at-
 tendant upon such separation.  The bones interlock and over-
 lap to a degree that seems to forbid luxation; and the fibrous
 structures which bind the bodies of these bones and their pro-
 cesses together, seem to be stronger than the osseous material
 itself.  HoAvever,  there have been reported during the last
 few years a number of well authenticated dislocations of the
 vertebrae, in different regions of the column.
   It is not extremely rare  to find luxations of the  vertebrae
 from disease, the process of displacement  being gradual, and
 the result anchylosis or death.  Some years  ago I Avas called
 to a lady who had been having the head draAvn forwards and
 to one  side  until the left ear rested between the nipple and
 the armpit of the corresponding side of the body.   The ex-
 traordinary contraction  had  wrenched  at least three of the
 cervical Arertebrae  from  their articulations,  and greatly dis-
torted tAvo  others.  But this and similar cases do not properly
belong to the subject of luxations, for they do not occur sud-
                           (297) 
298                   Dislocations.
denly from accidental violence, and are not amenable to  the
treatment usually employed to replace dislocated bones.
  In 1856 I Avas summoned to an Irishman Avho had fallen from
a chamber windoAV to the ground, head foremost.  I found the
patient with his head twisted to one side and  rigidly held in
that position.   He uttered cries of distress, and called lustily
for relief: "A stitch in my neck, docther,  a  stitch in  my
neck."  I took hold of his ears and  endeavored  to pull and
tAvist his head into its natural position, but Avas unable to ac-
complish my object.  I  could feel a bony displacement to ex-
ist between the third and  fourth  vertebrae,  by pressing my
fingers into the soft structures  of the neck, though I Avas un-
able to  discover  the exact nature or extent of the luxation.
Perhaps another vertebra Avas implicated in the displacement.
By the help of assistants who laid hold of the patient's head
and feet and made powerful extension  and counter-extension,
together with some twisting motion, reduction, Avhich Avas at-
tended with an audible snap, Avas accomplished.   The patient
then moved his head and neck with ease and  complained no
more of sharp pain.  He suffered from great  soreness in the
neck for a week or more, yet recoA-ered without  physical de-
fect  or  lasting functional  impairment.  I am  quite sure no
process of bone Avas broken ; and that the injury Avas a simple
luxation, occurring between tAvo or more of the cervical ver-
tebrae.
  The Lancet for  '49 contains the report of a  case of disloca-
tion of the cervical vertebrae in a seaman, Avho in descending
the fore-ladder caught his foot  and fell forwards, striking on
the right side of the head, Avithout  inflicting any Avound on
the scalp.  " When taken up, he  Avas found to be quite help-
less, and on being brought into the sick-berth, the  chief seat
of pain  Avas referred to  the back of the neck, Avhich, on ex-
amination, presented considerable irregularity of the spinous
processes of the fifth and sixth cervical vertebrae, Avith a bulg-
ing  of the muscles on  the right side, corresponding to the
position of the transverse processes of the above-named ver-
tebrae."   Head and neck rigid, face turned toAvard the point
of the shoulder, and bent forward ;  respiration  natural, and
questions answered coherently, though there was considerable
paralysis of the extremities.   Extension and counter-exten-
sion Avith pressure made by the surgeon on the swelling of the 
Of the  Vertebra.
299
right side of the neck, reduced the dislocation.  The reduc-
tion w^as followed by a restoration of impaired functions.
  Mr. Lawrence, of London,  says:  " The possibility of the
occurrence of complete dislocations of the vertebrae  Avithout
fracture, has long been a disputed point among man}7 of the
first surgical Avriters.   Boyer and Sir A. Cooper are of opinion
that  such  an accident can not happen ; and Delpech asserts,
without qualification, that a careful examination of the form
and situation of the bones  must convince  the observer that
such accidents can not occur.  The case of Charles  Butcher,
who slipped on some steps, Avhile carrying a heavy load on his
head, in the end  proved that a vertebral luxation  can occur.
The accident Avas folloAved by  complete insensibility, and loss
of voluntary motion  beloAV the neck.  Functions ofthe brain
not  disturbed; respiration  apparently  performed merely by
the diaphragm;  pulse Aveak and slow ; body cold; penis in  a
state of erection.  No irregularity of the spinous  processes could-
be observed."  Death took place in four days after the reception
of the injury.  The autopsy revealed a luxation between the
fourth and fifth   cervical  vertebrae : " After  cutting aAvay the
muscles from the back of the spine, the cartilaginous surfaces
ofthe superior articular-processes of the fifth cervical \Tertebra
came into vieAV ;  they Avere exposed in eonsecjfuence of the in-
ferior processes of the fourth vertebra  having been completely
dislocated forwards, and remaining fixed  in  their unnatural
position.  The yelloAV ligaments connecting the laminae ofthe
tAVO vertebrae Avere torn through, and  the  bifid apex of the
fourth spinous process, lay in close contact with the  basis of
the fifth.   On the front of the column an  unusual projection
was observed, but the anterior  longitudinal ligamentous ex-
pansion Avas entire.   The body of the fourth  was completely de-
tached from that of the fifth vertebra, the connecting fibro cartilage
being torn  through, and the body of the former  projected by its
whole depth in front of the latter."
  M. Roberts, of Paris, reports  the  case  of a carpenter who
in attempting to  raise a heavy  scaffolding pole and at a certain
point being unable to sustain it any longer, received its weight
upon his  back.   The accident was immediately folloAved by
complete paralysis below the point injured.  No projection or
irregularity could be discovered at  the seat of the  lesion ;
death occurred on the eleventh day.   Dissection shoAved that 
300
Dislocations.
the fifth was separated from the sixth dorsal vertebra, the lat-
ter being driven inwards so as to encroach upon the medias-
tinal space.  The ligaments Avere torn, and  the articular sur-
faces separated, between the t\vo bones.   There was no frac-
ture of any process; and the displacement  Avas sufficient to
compress the spinal cord.
  There are several cases of dislocation of the last  dorsal  on
the first lumbar vertebra reported, but some of them will not
admit of full credence.  The case referred to in Schmucher's
surgical Avork, is one of this class.
  The NeAV  York Journal of Medicine for 1852, contains the
account of a  case of dislocation and fracture of the  dorsal
vertebrae, which occurred in the practice of Dr. Graves, of
NeAV Hampshire.  The injury Avas  produced by the fall of a
door, the man being under it  in a stooping  posture.  The
lower extremities were  immediately paralyzed, and priapism
took place, lasting several hours.  At the seat of the injury,
which was at the junction ofthe lumbar and dorsal vertebrae,
there was a marked appearance of displacement of  the parts,
which seemed to  arise from a fracture and dislocation, or a
sliding of the body  of one vertebra  over another.   The sur-
geon placed  the  patient on his belly, and  fastened a folded
sheet under his arms aud another above his hips :  chloroform
having been  administered, extending and counter-extending
forces Avere applied  by means of the sheets, and the displaced
vertebrae were reduced.  Paralysis  continued  until the  six-
teenth day, when slight sensation returned to the feet: during
this time the urine had to be discharged by  the daily employ-
ment of a catheter ;  and the boAvels Avere occasionally moved
by the assistance of enemas.   In six  or eight Aveeks the patient
recovered the use of his limbs; and the normal evacuations
took place without  artificial aid.  Galvanism  Avas  employed
for several months ; and ultimately the recovery Avas complete,
though a prominence remained at the seat of injury.
  The only suspicious circumstance  about this  case is that the
falling door is reported to have struck the  man " across the
shoulders," and the dislocation is claimed to  have been  " at
the junction of the lumbar and dorsal vertebrae."  Perhaps a
mistake crept into the report, as it Avas not  made  directly to
the Journal by Dr.  Graves, but came through the  hands of
Prof.  Willard Parker, of New York.  The case terminated 
v.;,juii, (>.
                    Of the Vertebra.                 301

much more fortunatel}7 than similar injuries generally do, but
this circumstance need not necessaril}' cast suspicion upon its
authenticity.
  Death has occurred from attempts to  effect reduction in
cases of vertebral luxations.  There Avould evidently be more
danger  existing in cases  complicated Avith fracture, for  the
fragments might be forced against the cord and do irreparable
mischief  Dupuytren  expresses  a caution in  regard to  the
treatment of spinal  dislocations  in  the folloAving language:
" the reduction of these dislocations is very dangerous, and Ave
have often knoAvn an individual to perish from the compres-
sion or elongation of the spinal  cord  which always attends
these attempts."
  Dr. Ayres, of Brooklyn, N. Y., reports in the  NeAV  York
Journal of Medicine, for January, 1857, a case of dislocation
occurring between the cervical vertebrae from some unknown
cause, as the man Avas drunk at the time  he received the in-
jury.  The neck Avas rigid and exhibited a peculiar deformity
which could not attend any lesion except luxation  of one or
more of the cervical \rertebrae.  There Avas no  paralysis;  but
intense  pain attended the  displacement.  Great difficulty was
experienced  in  attempts  to drink  or SAvalloAv  food.  The
oesophagus  and larynx  seemed  to be pressed upon by  the
bulging fonvards  of several of the cervical vertebrae.  The
back  of the  neck was rendered excessively concave and the
integument AAras thrown into folds as it is  when the back of
the head  is  forced  back against the shoulders; the front of
the neck presented a corresponding convexity.  Between the
spinous processes of the  fifth and sixth cervical vertebrae,  a
marked depression  could be  felt, and  this was the point at
Avhich  the greatest  distress was felt  by the patient.  Dr.
Ayres, Avith several  surgical assistants who concurred with
him in the diagnosis, performed a successful reduction while
the patient  was  under the influence of chloroform.   Exten-
sion Avas applied to the  head and counter-extension to  the
shoulders, and while the head Avas rotated and pressure made
upon prominent points in the  neck, the  displaced bones re-
turned to position, and the head and neck resumed their nat-
ural attitude and  aspect.  The difficulty of swalloAving and
expectorating soon passed off, and no lasting ill consequences
followed the luxation or the  reduction.  This with several 
302
Dislocations.
other equally successful attempts at reducing dislocated verte-
brae, shows that in all favorable cases, Avell directed  efforts
should be made to overcome the displacement.
  The execution of criminals  by hanging was designed to
bring about death by dislocation and not by strangulation, as
is often the case.  If death takes place suddenly the trans-
verse ligament of the atlas gives way, and the odontoid pro-
cess of the axis becomes free to impinge  upon the cord at a
vital point   Besides the  rupture of the  transverse ligament
and  the  odontoid displacement, the posterior  atlo-axoidean
ligament may be torn, permitting a separation of the atlas
from the axis.
  The playful but dangerous practice  of raising a child by
the ears, and asking it to " see  London," has  been attended
with dislocation at the atlo-axoidean articulation and  sudden
death.
  The dreadful and prolonged sufferings which follow disloca-
tions  of the vertebrae, are among the Avorst  that  can  be in-
flicted upon the human  body.   All  the complex horrors of
paralysis are liable to follow these luxations, such  as  bed
sores, artificial evacuations of the bladder and rectum, utter
dependence upon  others to have eA^eu necessary Avants sup-
plied, and the perversions of the secretions to an  extent  that
renders every phase of life  disagreeable, and  death Avelcome.
  In a dislocation of the last dorsal vertebra, Avhich occurred
in a laborer engaged upon the  government  buildings  in this
city, no reduction could be  effected,  and the patient lived
twenty-seven days.  The man  did  not suffer excruciatingly
from the first, but was unable to move the pelvis and  legs.
He  rode home and talked cheerfully all the Avay.   He could
not believe he was seriously or  dangerously hurt, and avou-
dered Avhy  he could not move his legs.   The urine was draAvn
with a catheter for ten  days, and then it began to dribble, and
flowed incontinently till death.   The bowels Avere evacuated
by means of enemas, except when profuse liquid discharges
escaped involuntarily.   Bed-sores formed upon the hips, and
at length the flesh on the  legs became gangrenous in spots.
Death occurred from exhaustion and septicaemia. An  autopsy
revealed the dislocation and a partial fracture of an articular
process of  the vertebra above the one displaced.   The cauda
equina Avas pinched by the dislocated bones. 
CHAPTER  IV.
DISLOCATION  OF  THE  RIBS.
   The ribs do not properly articulate Avith the sternum, there-
 fore they can only be dislocated at their vertebral extremities.
 The separation of a rib from its  cartilage, or of its  cartilage
 from the sternum, ought to be regarded as a fracture and not
 as a dislocation.   That condition of the chest ordinarily known
 as  " chicken breast," depends  upon a bending  of the carti-
 lages, and is not a luxation in the true interpretation of  that
 word.
   The heads ofthe ribs have  firm  connections with the bodies
 of  the vertebrae, and their tubercles articulate Avith the  trans-
 verse processes of the dorsal chain, rendering their  displace-
 ment exceedingly difficult and necessarily  rare.   The loAver
 ribs, embracing the false and floating, having less support, are
 the most frequently  dislocated.
   The displacement is necessarily inwards, though  the force
 producing the  dislocation  may carry the rib aboAre  or below
 its  normal position.   The accident, when  it occurs, is  pro-
 duced  by direct  violence,  such as  kicks and blows;  and  it
 Avould be extremely  difficult to determine A\iiether a fracture
 or luxation was  the result.  Depression, mobility, and pain,
 Avould  be characteristic of either  lesion.  Crepitus would be
 indicative of fracture, yet  one rib  might be dislocated, aud
 another broken.  The fracture of a  spinous or transverse  pro-
 cess might furnish the crepitation, and lead to the conclusion
 that the injury did not involve dislocation.  Last year I had
 an opportunity to examine the body of a man who died from
 kicks received Avhile he Avas lying upon the  ground.  Several
 ribs Avere broken, some of them in tAvo places, and the tenth
 and eleventh, on the left side, were dislocated.
  Bransby Cooper reports the following case of a luxated rib :
" Mr. Webster, surgeon at  St. Albans, when examining the
                         (303) 
304                    Dislocations.

body of a patient Avho had died of fever, found the head of
the seventh rib throAvn upon the front of the corresponding
vertebra, and there anchylosed.   Upon inquiry, Mr. Webster
learned that this gentleman, several years before, had been
thrown from his horse across a  gate, for  which accident he
had  been subjected to the treatment usually followed'in frac-
tures of the ribs, and there is every reason to believe  that it
was at this time that the dislocation occurred."
  Other dislocations of  the  kind may occasionally occur, but
as there  is  no opportunity to verify the diagnosis until after
the death  of the  patient, they  remain undiscovered.  And
even if they Avere discovered, it would be a difficult matter to
restore a  displaced  rib to its  natural  position.   A bandage
might  be applied to the chest to restrain the costal movements
and compel the patient to breathe mostly by the action of the
diaphragm; and the region of the injury might be subjected
to the  influence of chloroform and aconite, or the subcutane-
ous action of morphia, and anodynes might  be administered
internally, but all this would be  appropriate in fracture of the
rib, hence there is  no necessity for a differential diagnosis be-
tAveen  the two injuries, as  nothing Avould be gained by the
discrimination.  A patient, therefore, need not be subjected
to distressing and perhaps dangerous examinations to  deter-
mine whether fracture or dislocation of one or more ribs ex-
isted.  To be convinced that the one or the other lesion  had
been received, is practically sufficient for the surgeon.   There
being several authenticated cases of costo-vertebral  disloca-
tions, a question on that^point no longer exists : and the injury
being  necessarily  serious the  prognosis  should be  ahvays
guarded.  In  simple dislocation or fracture of the rib, Avith-
out much injury to  the thoracic  viscera, a recovery may be
expected; but  with several ribs broken or dislocated, the re-
sult is  problematical. A  force  AAiiich breaks or luxates sev-
eral ribs is about sure to extend to the organs within, and in-
flict dangerous lesions upon them. 
CHAPTER  V.
DISLOCATION  OF  THE CLAVICLE.
   The firm ligamentous connections of  the  clavicle  to the
 sternum and the  scapula give forces a better opportunity to
 break the bone than to dislocate it.  The  acromial extremity
 of the claAicle is the most completely covered'with soft tis-
 sues ;  and in addition to  the acromio-ciavicular ligaments
 which form a capsule for the joint, the coraco-clavicular fas-
 ciculus of ligamentous fibres holds the clavicle in firm connec-
 tion with the scapula.  This strong articulation would seem-
 ingly prevent  luxation, yet the joint  suffers  such a  lesion
 more frequently than the  sterno-clavictilar articulation.  Of
 twenty-three dislocations of the clavicle observed by Hamilton,
 five AA-ere at  the sternal end  and  eighteen at the acromial
 (scapular dislocations).  The movements  at the  articular ex-
 tremities of the clavicle are of a gliding character and quite
 limited in range, so that it is impossible for the articular sur-
 faces to undergo much change in their relation to each other,
 or that any of the ligaments can be put greatly on the stretch.
 Ceteris paribus, the greater the extent  of  motion in a joint,
 the greater the liability to dislocation.
   The sternal end of the clavicle may be dislocated forwards,
 backwards, and upAvards.  The cartilage of the first rib pre-
 vents displacement downwards.  The forward dislocation  is
 the most frequent, and may be partial or  complete.  In  the
 latter, the  head of the bone, besides projecting  forwards,  is
 depressed below its  natural level; in  the incomplete, it'is
 usually  slightly raised.
  Luxation  of the sternal end ofthe  clavicle  is generally pro-
duced by a fall  upon the point of the shoulder,  the force driv-
ing the  bone  inwards or forwards.  It is probable that the
shoulder is carried a little backwards as well as inwards, or
      20                   (305) 
306
Dislocations.
 the head of the clavicle would not slide  out  of its place, but
 break someAvhere in its course.  The nature and direction of
' the forces which produce dislocations of the clavicle are not
 alwavs  understood.   Quite contrary causes have been alleged
 as producing these displacements.
    Symptoms.—The prominent head of  the  clavicle seen and
 felt in its abnormal situation, covered only by the integument,
 leaves no doubt  as  to the nature of the injury.   Where the
 head of the bone  should be there is a depression into which
 the  finger  may be  thrust.  The corresponding shoulder still
 holds its position a little back where it has been  driven ; the
 movements of the arm are restricted; and great pain is felt
 at  the point  of  displacement.  The  sterno-cleido-mastoid
 muscle in the lower  part of its course, is rendered salient;
 and the tension of the muscle draws the head slightly down-
 wards and to one side, as in " Avry-neck."
    Movements imparted to the shoulder sensibly affect the dis-
 placed  head of the bone;  raising the shoulder depresses the
  head of the clavicle, and depression of  the shoulder elevates
 it; if the shoulder be forcibly carried  backwards, the head
  of the clavicle drops into place, or is brought to a point favor-
  able  to reduction.
    A  fracture near the sternal end of the clavicle  may exhibit
  deformities similar in appearance to dislocation  of  the  head
  ofthe  bone: and  I have  seen syphilitic enlargements, and
  periosteal tumors Avhich closely resembled a luxation.
    The  displacement, if considerable or  complete, has not oc-
  curred Avithout laceration  of the anterior and posterior sterno-
  clavicular ligaments, and the rhomboid could hardly escape
  being torn.  The inter-articular cartilage may remain in con-
  nection with the sternum or folloAV the head of the clavicle.

    Trkatment.—It  is  not a difficult matter to bring the head
  of a dislocated clavicle to the point of 'reduction, by drawing
  the  shoulder  outAvards  aud backwards,  the surgeon's  knee
  being placed between the scapulae of the patient; but to press
  it  completely into  place  and  keep it  there, quite baffles the
  best skill.  The great disposition of the bone to slip out of
  place when successfully reduced, has led to  the invention of
  many  methods intended to keep it  in its normal  position.  In
  most instances, no  kind  of retaining apparatus yet devised, 
Of the Clavicle.                  307
 will effectually retain the bone in position.  In most cases the
 reduction can not be accomplished, and in the few in which
 the bone is replaced, the luxation has again occurred in a few
 minutes, or a feAV days at most.  Fortunately the utility of
 the limb is  not substantially impaired,.even if the bone con-
 tinues unreduced.
   The dressing ordinarily used for fracture of the clavicle is
 as  useful as  any to retain the head of the bone in place, and
 as  a protection  against a recurrence of the luxation.  The
 shoulder is to be carried outwards and backwards, and  kept
 fixed in that position.  Sir  Astley Cooper recommended an
 apparatus something like a common shoulder brace to carry
 out the indications.  A pad in the axilla and a sling to support
 and steady the  arm, constitute a serviceable  appliance.  A
 thoracic bandage, Avith a pad in the arm-pit as a fulcrum over
 which the  arm  acts as a leATer to pry the shoulder outwards,
 has been employed with success.  Velpeau bandaged the arm
 to the side, with the hand'carried  to the opposite shoulder.
 Nelaton recommended that pressure be kept upon the  head
 of  the replaced  bone, and used a truss  for that purpose, the
 pad being placed over the articulation and the spring passing
 under the  axilla of the  sound side.  The dressing is to be
 Avorn and the pressure kept up for six Aveeks or tAvo months.
  Luxation  ofthe Sternal End ofthe  Clavicle Upwards.—This
 accident has only recently acquired an established place in sur-
 gical pathology ; the older surgeons doubted the possibility of
 its occurrence.  Malgaigne has collected five examples; and the
 Buffalo Medical Journal contains an account of another that
 happened in  the practice of Dr.  Rochester.   They were  all
 occasioned by a violent force that carried the shoulder doAvn-
 Avards and imvards.  The patient of Dr. Rochester was caught
 under the bar of a gateway while seated upon a load of Avood,
 and had the  shoulder forced  dowmvards and a little back-
 wards.   The sternal extremity of the clavicle Avas driven up-
 wards in the direction  of  the chin, until  it rested on the thy-
 roid cartilage, the displacement being followed by difficulty of
 breathing and loss of  speech.  The reduction Avas easily ef-
 fected, but no kind of  apparatus would retain  the bone per-
fectly in  place.  The head  of the bone  ahvays  remained a
 little above and a half  inch in  front  of its natural position,
though the arm retained its usefulness. 
308
Dislocations.
  The symptoms  of this rare  dislocation  are very  marked.
the head of the bone being felt  above the upper border of the
sternum, and near the median line of the neck ;  a depression
can be felt where the head of the bone belongs, and the space
between the first rib ancl clavicle is increased.  There is prob-
ably complete rupture of all the ligaments of the joint, as  Avell
as of the  costo-clavicular.  The reduction  is readily effected
by lifting the shoulder upAvards, and  carrying it outAvards,
the head  of the bone at the same  time being pressed doAvn
into position.  Retention is difficult, if not impossible.  In
none of the cases yet reported has there been one of success-
ful retention, though the displacement did not seriously impair
the functions ofthe arm.  The  treatment after reduction con-
sists in the use of such appliances as shall steadily retain the
shoulder upward and  outAvard.   A pad in the axilla, and a
sling to keep the elbow to the chest,  with the hand draAvn up
toAvards the opposite shoulder, are the simplest and  most ef-
fective means at  command.  It is difficult to maintain con-
tinued pressure downwards upon the head of the bone.
  Dislocation of the Sternal End of the Clavicle Backwards.—A
combination of forces, as in accidents of a crushing character,
may displace the sternal  end of the clavicle backAvards, com-
pelling  the head of the bone  to  take a  position behind its
normal  location.   This dislocation is rare, yet several cases
have been reported.  If a force drive the clavicle inwards at
the same time the backward luxation occurs, the head of the
bone may press disagreeably and  even  dangerously upon the
trachea aud oesophagus.
  The Medical Times and Gazette contains  the  account of a
case AAiiich occurred  in  the practice  of Dr. Morgan, at the
Middlesex Hospital, in 1852.  " A girl, ten years  of  age, Avas
knocked down by  a carriage, and appears to have been trod-
den  on by one of  the  horses.   On  admission,  she  suffered
much from dyspnoea, the head Avas inclined forwards and could
not be raised without extreme pain.   There  Avere marks of
bruising over the right shoulder and clavicle.   Where the
head ofthe bone should  be, there Avas a depression into which
the fingers might be thrust, and the articular surface of the
sternum could be distinctly felt, while the head of the clavicle
was  evidently behind it. 
Of the Clavicle.                 309
  " On placing the knee against her spine, and gently drawing
the tAvo shoulders backAvards, the bone Avas easily restored tc
its pioper place, causing obvious relief to  the  dyspnoea; but
immediately on leaving hold  of the  shoulders, the  bone fell
back, and the dyspnoea returned.   A splint Avas  then placed
across the shoulders, Avith a pad between it and the spine, the
shoulders being draAvn to the splint by a bandage ;  by these
means the bone Avas kept firmly in its place, pilloAvs  being so
arranged along the patient's back that the splint should not
feel uncomfortable.  On  the  apparatus being fixed, she could
lean her head backAvards, and stated that her pain Avas much
relieved.   The splint Avas kept on for a fortnight;  the  bone
then being quite steady in its place.  She Avas  allowed to re-
main in b.ed Avithout any bandage.  The articulation became
in four Aveeks quite as firm as that on the other side ; and the
arm could be moved Avithout causing any pain."   This report
gives the cause  of the  dislocation,  depicts the prominent
symptoms, and offers a plan of treatment  Avhich proved suc-
cessful, at least in that one instance.   Other cases are reported
which throAv no additional light upon the character  of the in-
jury or its surgical management.  In one or two instances in
which reduction Avas never accomplished, the functions ofthe
arm were not seriously impaired.
  If an attempt be made to save  a leg that has suffered com-
pound dislocation .of the knee, let  there be  free discharge
from the \vound, and perfect rest.   Evaporating lotions Avould
keep the injured  parts cool,  yet warm Avet  cloths would do
best to keep off tetanus and some other dangerous complica-
tions.  The danger comes  from shock, suppuration, tetanus,
and gangrene.  The swelling is  usually great and the pain
fearful.   Then  it is to  be considered that a patient Avith an
open  injury to the knee may seemingly do well for a few
days, and then sink and  die Avithout  apparent cause  for the
sudden change for the worse. 
CHAPTER  VI.
DISLOCATION  OF  THE  SCAPULA.
               Dislocations of the scapuloclavicular articulation ha cc gener-
             ally been described  as " luxations  ofthe  acromic.l end  ofthe
             clavicle,"  but  in 'order to  establish  uniformity in oar nomen-
             clature, Avhich has now discarded such terms as  " dislocation
             of the radius and ulna upon the carpus," " dislocation of the
             tibia  at  the  ankle," etc.,  it seems  necessary to  consider the
             acromion process of the scapula as dislocated from the clavicle,
             the latter being the more fixed point and nearest to the trunk
             Use Avill  make this naming of the injury seem correct when
             it is once rendered familiar. Luxation at this joint is more
             frequent  than at the sterno-clavicular articulation.  In the
             great  majority of cases the acromion is forced  beneath the
**            outer  end ofthe clavicle; in rare  instances the acromion is
             made  to  take a position above the clavicle ; and in extremely
             rare accidents the displacement is carried so far that the cora-
             coid process, as well as the acromion, takes a higher level than
             the clavicle.
               The causes ofthe injury are falls  upon the extremity ofthe
             shoulder, and kicks and bloAvs upon the same point.  Direct
             violence,  applied to the scapula, generally produces the lesion,
             though if the shoulder be fixed, and a force come from the
             opposite  side of the  body in a Avay to tilt the outer end of the
             clavicle upAvards, luxation may be  produced by an indirect
             action.
               The symptoms of dislocation of the  scapula  downwards,
             are tolerably well marked ; the  acromion is overlapped by the
             clavicle which projects sufficiently to be  distinctly felt; the
             pain  is severe, and the motions of the  arm are restrained;
             the shoulder appears  slightly depressed, and  the arm some-
             what  lengthened, the deformity partaking few of the features
             of a dislocation of the humerus.
                                        (310) 
Of  the Scapula.
311
  In complete luxation the ligamentous structures, including
the coraco-clavicular  ligament, are  lacerated; and  the soft
parts covering the articulation may be bruised and torn.  If
the displacement be great the acromion is driven inwards be-
neath  the clavicle so far  that  the end of the bone forms a
prominence immediately under the skin outside the acromion.
  Treatment.—By drawing the shoulder outwards and back-
Avards, and pressing upon the outer  end of the clavicle, the
bones can easily be restored to their natural relations.   There
is ahvays great difficulty in retaining them in position, owing
to the  narroAvness and obliquity of the articulating surfaces,
as well as the action of the clavicular portion ofthe trapezius
muscle.  HoAvever, the parts implicated in the displacement
soon adapt themselves to their neAV relations, and the utility
of the arm and shoulder  is  but  little impaired.   Notwith-
standing the difficulty of retaining the bones  in their  natural
relation, success has occasionally attended a Avell directed and
prolonged effort.  The ordinary dressing for  fracture  of the
clavicle, consisting of a pad  in the axilla and a sling to lift
the elbow upwards and bring it inwards, is  a  proper retentive
appliance.  A thick compress placed upon the  outer  end of
the clavicle, and bound down by a long strip of adhesive plas-
ter  reaching from the lower ribs posteriorly to the lower end
of the sternum auterioiiy, prevents  a recurrence of the dis-
placement, and  Avith the rest  ofthe dressing, helps to keep
the articular surfaces  steadily in  apposition.   The compress
may be held in place by a strip of adhesive plaster passed over
it and  under the elboAV ofthe same side.  A short strip reach-
ing from the compress to the side of the  neck  will prevent
the other part of the dressing from slipping over the point of
the shoulder.  Various contrivances have  been  devised to
keep the bones in their relative positions, but none  of them
have universally succeeded.  The mobility of the scapula  is
the greatest obstacle to continued adjustment.   Tourniquets
have been recommended to retain  the bones in apposition, the
strap  passing under the  elbow and the pad resting on the
outer end of ihe clavicle.  Shoulder  straps  connected Avith a
sling at a point where the elboAV rests, have been employed by
various surgeous, but with all the modifications ingenuity has
called forth, no appliance has been invented Avhich will satis-
factorily fulfill all the indications. 
3X2                   Dislocations.
■■  ■ fDislocation ofthe Scapula Upward.—What has  been called
  "jnfra-acromial" dislocation of the clavicle, or the upward dis-
  'placetiieilt O.f the  scapula as regards the acromial extremity
  of the clavicle, is an exceedingly rare accident.  Two oppos-
  ing forces acting upon the clavicle and  scapula, the  one de-
  pressing the former, and the  other elevating the latter bone,
  might produce the injury.  In the case  reported by Tournel,
  the patient Avas knocked doAvn by  a horse and trod on.   In
  looking  at the  articulated skeleton it might  seem that the
  scapula could not be dislocated upwards without at the same
  time fracturing the coracoid process,  yet  experiments upon
  the cadaver sIioav that the shoulder-blade may be rocked out-
  wards sufficiently to permit this acromio-clavicular displace-
  ment Avithout breaking the coracoid process.  The dislocation
  must  be attended Avith  rupture of the acromio- and coraco-
  clavicular ligaments.  The general  symptoms  will be those
  attending ordinary injuries of the kind ; and the special diag-
  nostic  marks will  be as  follows:  the acromion stands out
  prominently, and on its inside a  depression can  be discovered
  with the fingers, the end of the clavicle being below the articu-
  lar facette on the acromion.  If  much SAvelling has not taken
  place, the positions of the two bones can be accurately deter-
  mined by careful manipulation.
     Treatment. — Reduction is accomplished by draAving the
  shoulder outwards, and rocking  the scapula gently to disen-
  gage  the acromion from the end  of  the  clavicle.  These
  manoeuvres are sufficient to bring the articular surfaces of the
  two bones into apposition.  This form of  acromio-clavicular
  dislocation, when once reduced, is not  so troublesome as the
  other more common variety.   The return of the scapula to its
  natural position presents the  coracoid process  as an  obstacle
  to the descent of the  clavicle.  After  reduction is  accom-
  plished, it is only necessary to secure the arm to  the  side  of
  the thorax and prevent all motion at the shoulder for  two  or
  three Aveeks.  A handkerchief extending under the  arm  of
  the injured side and tied across the  neck on the  sound side,
  Avill hold the scapula snugly to the thorax  and prevent that
  tilting of the bone  Avhich  favors the acromio-clavicular dis-
  placement.
     Dislocation of the scapula  upward and backward, so as to
  throw the coracoid process above the clavicle,  is an accident 
                                            ECLECTIC

                     Of the Scapula.        tylE.DI©©^'""

 that Avas not recognized  by the  older surgical ^^i^Ulȣe^ *""
 lesion is iioav generally called the infra-coracoid dlslcuyU
 the  clavicle, though in accordance Avith our adl$*ll#fccMi
 clature, as Avell as in fact, it is a  scapular displacement.   The
 pathology of this accident is not Avell underscood, at least it
 has not been Avell described; and the cause  of the  injury is
 decidedly problematical.   The force must  be of a character
 to rotate the scapula and Avreuch it  from its connections Avith
 the clavicle.  In reality, the  injury must be  an  exaggerated
 form ofthe  upward dislocation ofthe scapula, that bone being
 forced outwards and upAvards to a degree Avhich  throws the
 coracoid  process above  the clavicle, the  latter.bone being
 made to take a position in the axilla.  Such a peculiar injury
 must be exceedingly rare; and it is not  strange that its ex-
 istence should be doubted.  HoAvever, the most unaccountable
 accidents Avill occasionally occur to  astonish the  incredulous,
 and  this  may be one  of them.   It is easier to see Iioav the
 bones can take that unusual position, than to understand the
 complex nature of the forces necessary to effect the displace-
 ment.
  If I Avere  called to treat such an injury I should attempt to
 reduce the dislocation by placing the knee in  the armpit, and
using the arm as a lever to bring the scapula back into place ;
the upward pressure of the knee would tend  to dislodge the
clavicle from the  axilla and direct it back into place ; while
the scapula could be made to rotate in any direction by move-
ments imparted to the arm. 
CHAPTER  VII.
DISLOCATION  OF  THE  HUMERUS.
  Dislocation of the shoulder is so common an  occurrence
that it is deserving of unusual attention.   A practitioner of
medicine and surgery will not pursue an active part in his pro-
fession for many years without being called  upon to  take
charge of a shoulder luxation ; though he may never encoun-
ter in a long career of practice, one-half the different disloca-
tions described in his text books.
  The humerus is dislocated, according to the tables of  Mal-
gaigne and several other authors, more frequently than all the
other bones of the body together.  This fact in itself is suffi-
cient to demand for the subject the most profound considera-
tion.
  The peculiar structure ofthe shoulder-joint, the shallowness
of its socket, the large size and globular form of the head of
the humerus, the extensive movements and long leverage af-
forded by the arm, and its frequent exposure to injury in pro-
tecting the more important central  organs of the body, are all
circumstances AAiiich contribute to the facility and  frequency
of dislocation.  On  the contrary, the great mobility  of the
scapula, and the flexibility of the spinal column, Ayhicli serve
to transmit and decompose forces, operate  as counter-balanc-
ing influences.
  Age exerts a  marked influence upon  dislocations  of the
shoulder, the accident being  extremely rare during childhood
and  old  age, though I have met with an  example in  a  child
under a year old, and another in a woman over se\7enty.   Mr.
Watts, house-surgeon  to Middlesex Hospital, treated a case
of dislocation forAvards in an infant fourteen days  old.  The
accident most frequently occurs in adults from thirty to  sixty
years of age.
                        (314) 
Of the Humerus.
315
  Strange though it may be, the pathology of this common
injury is still imperfectly understood.   Surgical Avriters ofthe
French  School,  in seeking for distinctions and refinements,
have contributed not a little to involve the subject  in inextri-
cable confusion.   The  student is apt  to be discouraged when
he finds his author has described eight or ten different forms
of luxation peculiar  to  one joint.  But, Avhen  he finds  that
there are only three  principal displacements of the  humerus
to study, and that all other forms so elaborately described by
some authors, are mere variations of one or the other of the
three kinds, he is encouraged to enter upon the study of them
with greater zeal.
  The old method of describing the different luxations of the
shoulder under  the  nomenclature  of doAvirvvards, forwards,
backwards, etc., often led to confusion, none of them indicat-
ing definitely the exact position of the head of the humerus.
Names derived from the position  the head of the bone in its
new situation assumes in regard to certain Avell defined points
on the scapula, are more concise, definite, and expressive.  For
instance, the " backward " dislocation is called the subspinous
luxation of the humerus, the word in  Italics indicating  that
the head of  the humerus rests beneath the spinous process of
the scapula ;  the " downward " dislocation is designated as the
subglenoid, meaning that the head of the humerus is thrown
beneath the glenoid  socket; and the " fonvard " or " inward "
dislocation, takes the  name  of subcoracoid, to  shoAV that the
head  of the  humerus  is forced beneath the coracoid process.
And if the force be sufficient in any case to carry the displaced
bone  very far iiiAvards or forwards, so it shall fall inside the
coracoid process and beneath  the clavicle, the luxation  may
be called  intra-coracoid or .subclavicular, to indicate definitely
the extent of the displacement and the position the head of
the humerus has assumed.   This  is a  modification  of the no-
menclature adopted  by  Malgaigne ; and it is hoped that the
attempt to simplify the  system Avill prove adATantageous to the
beginner in  the  study of this othenvise vexatiously complex
classification. I shall  commence Avith Avhat  I regard as the
most frequent variety of luxations of the humerus.
  Subcoracoid.—This is what the older writers have pronounced
a dislocation fonvards;  and as a form or  variety of displace-
ment, embraces the intra-coracoid  of Malgaigne, his two varie- 
316
Dislocations.
ties being brought under one head from the fact that the dif-
ference between them is rather of  degree than of kind.  If the
critical reader is not satisfied Avith  this manner of considering
the subject, he may regard the terms  employed as expressing
sub varieties of one common form.
  In each of  the three varieties of dislocation the head ofthe
humerus rests against the  rim  of the  glenoid fossa.  If the
displacing force  drives the head of the bone far iirwards, so it
shall  rest inside the coracoid  process, establishing the subcla-
vicular variety, there may be some space between the glenoid
rim and the humerus, though  not  as much as mere reasoning
upon  the subject Avould lead us to suppose.  Dissections of the
parts  involved in the subcla\icular dislocation suoav that rota-
tions  of the  scapula and humerus bring the two bones into
pretty intimate relations.  If the teres  minor, and the infra-
and   supra-spinatus muscles continue untorn,  they will not
permit the head of the humerus to remain at a distance from
the glenoid border unless some obstacle  intervene.  Should
the head of the  humerus be forced Avithin the coracoid pro-
cess and there lodge or become  fixed, the dislocation would
be truly intra-coracoid, but such is not  often the  case.
  For many years I have been inclined to dissent from the
commonly accepted opinion in  regard  to the most frequent
form  of dislocation at the shoulder-joint.   I critically exam-
ined every case coming under  my observation, Avhether in the
living or the dead subject.  I frequently met with the sub-
coracoid  variety, and  rarely  with the  subglenoid  (" down-
ward"),  though  many of the lesions  I  carefully investigated
and found to  be  subcoracoid, had been pronounced downward
dislocations by  surgeons of more than ordinary experience
and ability.   At length 1 was gratified Avhile looking up au-
thorities on this  subject, to find that Malgaigne regarded the
subcoracoid variety as happening  more frequently than any
other  form of shoulder dislocation;  and  Mr. Flower, in  his
surgical contribution to Holmes' System of  Surgery, says : " Of
forty-one specimens of dislocation  of  the  shoulder-joint, pre-
served in  the different anatomical museums  in  London,  as
many as thirty-one undoubtedly belong to this form; and of
fifty recent cases Avhich have come under  the  observation of
myself, or gentlemen in Avhom I can place perfect confidence,
and of Avhich I have full particulars, in forty-four the head of 
Of  the Humerus.
317
  the humerus was placed so closely beneath the coracoid pro-
  cess as to justify the appellation of < subcoracoid.'  In the face
  of these facts, it is difficult to understand how the wide-spread
       Fig. 108.       error of regarding the subglenoid as the
                      typical form of dislocation at the  shoul-
                      der-joint, should have been so long main-
                      tained.  A simple  process  of reasoning
                      upon  the anatomical  structure  of the
                      part Avould suffice  to show that,  Avhen-
                      ever the  humerus  is  thrown  from  its
                      socket,  it will  almost  of  necessity be
                      drawn upAvards until it is arrested either
                      by the coracoid  process in front, or the
                      spine or acromion behind.  Even in the
                      dead  subject,  Avhen dislocation is arti-
                      ficially produced by forcibly elevating the
                      arm, Avhile  the  scapula  is fixed,  the
                      humerus is almost ahvays draAvn up close
                      against the under surface ofthe coracoid
                      process; a fortiori,  in  the  living, must
                      the  action of the deltoid, coraco-brachi-
                      alis, and biceps  cause  it to assume this
                     position.  The truth is, that nearly all
 the cases of ' dislocation  into  the axilla,'  or ' downwards,'
 described as so common by Sir A. Cooper, and all subsequent
 authors, have really been examples of this variety, to which
 the anatomical characters of the more rare 'subglenoid' dis-
 location have been erroneously applied."
   In a case of alleged malpractice tried in Marion, Grant Co.,
 Indiana, in April, 1869, between Larkin versus Jones, I was
 called to give testimony in relation  to  the injury sustained by
 the plaintiff.   Mr. Larkin had fallen from a load of grain six
 months previously, receiving an injury of the shoulder.  Dr.
 Jones was summoned to treat the  injury two  days after the
 accident, and, as he claims, was  not permitted to make a sat-
 isfactory  examination of  the  shoulder, the  patient  being
 peevish, and the  parts involved in the injury greatly swollen
 and extremely sensitive.  The doctor suspected the existence
 of a serious lesion, such as a  fracture  or  dislocation, but left
 some liniment to allay the inflammation, and directions to be
called again as soon as the swelling and tenderness sufficiently
Dislocation of the head of
 the humerus inwards (sub-
 coracoid.) 
318
Dislocations.
subsided, to admit of a satisfactory examination.  Mr. Larkin
did not send for Dr. Jones again, nor any other physician, but
let the arm go as it Avas for four Aveeks.   He  then exhibited
his shoulder to Dr.  Horn, Avho discovered the existence of a
luxation, and sent the patient to Dv.  Win. Lomax for  treat-
ment.   It Avas decided  not  to  attempt  reduction ; and  Mr.
Larkin entered suit against Dr.  Jones on the ground of neg-
lect to discover a dislocation, and claimed ten thousand dollars
as damages.  At the trial Dr. Lomax and seven other prac-
tising  physicians  and  surgeons of Marion, Jonesboro,  and
vicinity, testified that the injury sustained by the plaintiff Avas
a  doAvmvard * dislocation (subglenoid) of the humerus ;  and
that this was the common form of shoulder dislocation.   In
my testimony and cross-examination, I declared that the head
of the displaced humerus in  Mr.  Larkin's injured shoulder,
Avas resting beneath the coracoid process: and  that  this was
the most common form of shoulder dislocations.  The testi-
mony  Avas received with marked discredit  by the  medical
friends of the plaintiff;  yet the defendant was acquitted.
  The head  of the  humerus in Larkin's case, could be  dis-
tinctly felt beneath  the coracoid process; and measurements
from the acromion to the olecranon while the arm  was flexed,
shoAved that the arm was  lengthened to the extent of half or
three-quarters of an inch.  If the dislocation had been (Ioavii-
wards  (subglenoid),  it Avould  have been  lengthened' an inch
and  a  half,  or  more than the  Avidth  of the glenoid socket.
Subcoracoid dislocation  may  be  produced either by a  direct
force applied to the head of the humerus,  displacing it imvards
and  fonvards, as a  Uoav  or fall  upon the shoulder ;  or, more
frequently, by forcible elevation of the lower end of the bone,
such as may be caused by a fall upon the  elbow or hand, Avhen
extended from the  body.  In those  eases coming under my
observation, the cause of the displacement has most frequently
been a fall upon the elbow or hand, though  in  Mr.  FloAver's
cases direct violence, as falls or Uoavs upon the shoulder, pro-
duced dislocation in the most instances.  It  occasionally hap-
pens that the cause can not be definitely  ascertained,  the
patient bearing marks of  violence in several places, and  not
being able to .decide Avhat force produced the displacement.
As a general rule, dislocations at  any articulation, are  rarely
produced by a  direct bloAv  on the joint.  Mr.  Bryant, in 
Of the Humerus.
319"
Cooper's  Surgical Dictionary, states*that, "in  thirty-one out
of thirty-four cases, the cause of the injury Avas a  direct fall
upon the shoulder, either forwards, backAvards, or outwards.
In twTo instances only of dislocation doAvn wards, and forwards,
Avas the bone displaced by a fall on the extended arm."   Mal-
gaigne says: "the subcoracoid luxation, Avhich is the  most
common  dislocation, is the  effect of  a direct blow on the
shoulder, the arm not being raised."  Warren  in his Surgical
Observations, expresses the opinion that when direct force, the
arm being by the side, knocks the head of the humerus out
of its socket, the rim of the glenoid cavity must at the  same
time be broken.

  Symptoms.—Certain symptoms, such  as pain, Avant of mo-
tion, and SAvelling in the region of the  injury, accompany all
dislocations, but the  subcoracoid  ATariety of shoulder disloca-
tions has a few characteristics peculiar to that form of  luxa-
tion:  the elboAV projects from the side, and  can not be made
to approach the chest Avithout causing pain; the  movements
of the forearm and hand are not much  impaired, though the
sensation of numbness which comes from pressure of the head
ofthe humerus on the brachial plexus of nerves, is someAvhat
disagreeable.  On comparing  the two  shoulders  a striking
change  is observable  on  the  injured side, especially  if the
patient be lean and the injury recent.  The  natural roundness
is lost, the acromion appears remarkably prominent, and be-
neath it  there is a depression into Avhich the fingers can be
pressed, proving that  the  head  of the  humerus  has left  its
socket;  and  in  some  spare  subjects, even  the form of the
glenoid fossa can be distinguished through  the fibres of the
deltoid.   The axis of the  humerus is  evidently altered ;  in-
stead  of being directed to the glenoid caA-ity, it points to a
spot internal, anterior to, a*nd beloAV it.   If the head of the
humerus rests on the point of the coracoid  process, the arm,
measuring from  the  acromion  to the external condyle, and
comparing it Avith  the opposite  side,  is  lengthened; if it
presses in behind the coracoid process, or gets forced  Avithin
that osseous projection, so as to become subclavicular, the arm
is shortened.   According to  Mr. Flower, of forty-four cases
of subcoracoid dislocation, the arm Avas elongated in nineteen,
unaltered in eight, and shortened in seventeen ; the greatest 
320
Dislocations.
elongation being one inch, the greatest amount of shortening
seven-eighths  of  an inch.  Measurement  of the vertical cir-
cumference of the shoulder, by carrying a tape over the acro-
mion and under the axilla, ahvays gives an increase of one to
two  inches  over the uninjured side; an important diagnostic
sign, common  to all forms of dislocation  of the  humerus, as
pointed out  by Mr. Callaway, in his "Dissertation upon  Dis-
locations and Fractures of the Clavicle and Shoulder-Joint."
The  head of the humerus can be distinctly felt  beneath the
pectoral muscles; the tumor produced  by its globular form
can be seen ; and any movements imparted  to  it by rotating
the arm can be both seen and felt.   The head of the humerus
lies on the anterior surface of the neck of the scapula, imme-
diately below the coracoid process.  The subscapular muscle
is raised from  the neck of the scapula, and stretched over the
front of, or  above the head of, the humerus.   The muscles
from the back of the scapula (teres minor, and infra- and
supra-spinatus) are draAvn tightly across the glenoid  fossa,  or
one or more of them may be ruptured, or detached from the
bone.  In some cases, the greater  tuberosity is  broken off,
and the muscles inserted  into the fragment then  drag  it into
the glenoid fossa.  The tendon ofthe long head of the biceps,
contrary to the views of  Hamilton,  is rarely broken asunder,
or completely  detached from its insertion.  The great  A'essels
and nerves are displaced  inwards, the circumflex  nerve being
either stretched or compressed to an extent AAiiich frequently
causes paralysis of the deltoid muscle.  I  have seen patients,
years after a successfully  reduced dislocation of the shoulder,
who could  not raise the arm beyond an angle of 45° or 50°,
though all the other motions Avere perfectly restored.
  The capsular ligament in complete dislocation,  is torn  suffi-
ciently to alloAV the head  of the humerus  to  escape through
the aperture;  and in those cases tllat will not stay in place
after reduction is effected, there is a strong presumption that
the edge of  the glenoid rim is fractured.
  When left unreduced a neAV shalloAV socket is formed  upon
the anterior surface of the neck of  the scapula, partly by the
absorption of old bone, and partly by the deposit of  neAV,
around its edge.  The exact position of this socket varies ac-
cording to the extent of  the displacement;  in some instances
the new cavity is formed more or less at the  expense of the 
Of the Humerus.
321
Fig. 109.
  anterior portion of the glenoid fossa, which is  gradually le-
  moved  by absorption  under  pressure, so that the  original
  socket is greatly encroached upon.   A corresponding change
                            takes place in  the  head of the
                            humerus ; the part hearing  upon
                            the edge of the glenoid'fossa, has
                            a hollow excavated in it, the sur-
                            faces of the two bones in  apposi-
                            tion accommodating themselves
                            to each  other, and  thus  a  rude
                            kind of joint, Avhich  allows of a
                            certain   amount  of  motion,  is
                            formed.  The  under surface of
                            the  coracoid  process, especially
                            near its tip, becomes smooth  and
                            eburnated,  shoAving upon dissec-
                            tion  that it has contributed to the
                            formation of the neAV articulation.
                              In those cases  where the  head
 New socket 'orme^under the coracoid of the humem8 ig thrOAVli within
                            the coracoid process, constituting
 the  subclavicular  variety, or  the " intra-coracoid "  of Mal-
 gaigne, the head ofthe os humeri being wholly on the sternal
 side of  the coracoid process, sometimes coming forwards so as
 to appear just beneath the skin, and at others deeply buried
 in the subscapular fossa, the new socket is  not formed on  tne
 rim or border of the glenoid fossa, and the globular extremity
 of the humerus maintains its accustomed shape.  If the head
 of the  humerus touch the inner surface of the blade of the
 scapula, a shallow depression is formed in that  bone, aud the
 head of the humerus is slightly flattened at a spot Avhere the
 bones meet, and there becomes divested of its cartilage, though
 from friction the parts in  articular  contact become polished
 and hardened.  If the greater tuberosity reach the anterior
 edge of  the glenoid fossa, or any part of the coracoid process,
 the points of contact "will soon sIioav the peculiarities of a neAV
 articulation.  In extremely rare cases the cla\icle has exhibited
 a slight depression Avhere the head of the humerus has reached
 it.  Uoav long it takes  to form a new socket when the head
 of the humerus is forced to take lodgment outside its normal
position, is  not known, for the history of old dislocations is
      21 
322
Dislocations.
seldom obtained.   Probably it requires a year or more for the
most of those changes to occur which are observed in ancient
dislocations.   In  a specimen in St.  BartholomeAv's  Hospital
Museum, in Avhich the luxation is said to have occurred three
mouths before death, absorption of the  anterior edge of the
glenoid fossa  has already commenced, and some  bone is de-
posited in the margin of the neAV socket.
  It is a singular circumstance that so many surgical Avriters
should have regarded  subcoracoid dislocations as " partial "
in their  nature, unless it came from the fact that Sir Astley
Cooper, in  his treatise  on Fractures and Dislocations, AAiiich
has been " authority" so long, described an incomplete luxa-
tion of the head of the humerus, of  the subcoracoid variety.
Hamilton, after reviewing and criticizing the opinions of those
Avho claim to have had partial dislocations to treat, says : " I
shall content myself AAith declaring that the existence of this
or of any other form of partial luxation ofthe shoulder-joint,
as a traumatic accident, has not up to this moment been fairly
established;  and that the anatomical  structure of the joint
renders its occurrence exceedingly  improbable, if not abso-
lutely impossible."  It may be remarked, incidentally in this
place, that  in  many of those cases Avhich have been regarded
as partial dislocations of the shoulder, the lesion consisted of
a rupture or displacement of the long head of the  biceps ten-
don, an accident which is characterized by a  sufficient  dis-
placement of the head of the bone upAvards and forwards be-
tween the coracoid and acromion processes, to give the defor-
mity the appearance of a partial luxation.   The long tendon
of the biceps having its origin from  the upper part ofthe rim
of the socket, and passing over the head of the humerus  and
doAvn through the bicipital groove of that bone, serves to biiid
the articular surfaces of the two  bones in close  apposition,
consequently a rupture of this tendon would he followed by
more or less displacement Avhich might be regarded as incom-
plete luxation.

  Treatment.—All scapulo-humeral  dislocations of recent oc-
currence, can be successfully reduced by manipulation if the
patient be thoroughly under the influence of  chloroform at
the time the effort to replace the humerus  is made.   In very
many cases no anaesthetic is needed,  but in muscular subjects, 
Of the Humerus.
323
especially if the injury be of two or three days' standing, it is
useless to attempt a  reduction  before an  advanced  stage  of
anaesthesia is reached.  The  use of nauseants, fomentations,
and other relaxing agencies, has  been  entirely superseded  by
anaesthesia.   The pulleys, Jarvis' Adjuster, and other contriv-
ances for multiplying force, have also lost their importance.
  In a subcoracoid dislocation, as Avell as in other luxations  of
the shoulder, the projecting edge or rim of the glenoid socket
is an obstacle to  reduction ; the  stretched  muscles and tense
ligamentous structures also oppose a return  of the  displaced
bone, unless the arm be carried into a position Avhich relaxes
those tissues.   To attempt reduction by extension alone is sure
to increase  the strain on the already overstretched muscles
and ligaments.
  To proceed systematically,  Avhether chloroform is used  or
not, let the patient lie  upon a  sofa, Ioav bed, or the floor, and
then the-arm seized  near the elboAV is to be  carried off  from
the body and  elevated as much as possible; the fingers of the
surgeon's other hand  rest upon  the  shoulder to steady the
scapula, and his thumb is pressed into  the axilla, against the
head of the humerus, to act in part as a fulcrum over Avhich
the patient's  arm as  a  lever is made, by a  quick doAvnward
movement, to pry the head of the bone from behind the pro-
jecting border of the glenoid  socket, bringing  the head  of
the humerus to a point "Where the force of the thumb and  of
the tense muscles will inevitably complete the reduction.  The
hand  which  has hold of the  patient's  arm  near the elbow,
should  SAvihg it  slightly backAvards and  forwards while the
arm is forcibly elevated, in order to disengage the head'of the
hone  from its place of lodgment; and then, in bringing the
elboAV downwards to the side of the thorax, or across the  front
of the chest, the motion is to  be imparted suddenly in order
to be as effective as  possible.   The patient, if not  under the
influence of chloroform, ahvays  holds the muscles  in a state
of rigid resistance while the surgeon is manipulating the arm,
therefore the quick motion is expected to put the patient off
his guard.  It is to be  borne in mind that the forearm should
be flexed on the arm Avhile manipulation is going on, that the
biceps may be relaxed.
  If the first attempt at reduction fail, it will be because the
scapula slips  from  the surgeon's fingers, and destroys the 
324
Dislocations.
leverage which is designed to lift  the head of the humerus
from behind the projecting edge of  the glenoid fossa ;  there-
fore another effort must be made, and the attempts repeated
until success  crowns the  undertaking.   Those who are not
strong in the hands may use the heel (the boot being removed)
as a fulcrum in the axilla or against the head of the humerus ;
this leaves both hands free to execute the  reducing manoeuvres
upon the arm.  Some surgeons prefer to  employ the  knee in
the armpit instead of the heel; and to have the patient lie.on
the floor Avhile the manipulation is performed.  The return of
the bone to the socket is generally accompanied Avith an audi-
ble snap; and the natural mobility of the arm is restored at
the same instant.  In most instances the natural contour of
the shoulder returns as soon as  reduction is  effected, but in
rare cases the head of the humerus rests aAvkwardly  in the
socket, AAiiich, in addition to the SAvelling, gives the region a
deformed appearance.
  Reduction has been accomplished by extension  and  coun-
ter-extension, applied  as folloAvs: the patient lying upon his
back, the surgeon seated by the affected  side, places his  heel
well up into the  axilla, so as to press upon the loAver border
of the  scapula, and then with  both hands hold of the wrist
exerts all the traction he can command, all the while rotating
the arm and  endeavoring to engineer  the bone back into
place.
  Surgeons OAvning Jarvis' Adjuster, and having employed it
successfully in several instances, still have faith in its qualities,
and persist in claiming that there are cases that can not be re-
duced without it as a means of  exerting powerful extension
and counter-extension.
  I have never met with a recent dislocation  of the shoulder
that, in my  present belief, could not have been  reduced by
manipulation, the patient being thoroughly under the influence
of chloroform.  In October, '68,  I was called to Hamilton, O.,
to assist in the reduction of a  subcoracoid dislocation  of the
humerus which  fell into  the hands of Dr. Markt.  Several
futile attempts had been made to effect a reduction ; and their
failure, in my opinion, depended upon imperfect anaesthesia.
The patient Avas a young German, of remarkable muscular de-
velopment;  and possessed a nervous system that would  bear
an  unusual  amount of chloroform  wijthout  being overcome 
Of the Humerus.
325
I used eight or ten ounces of the best chloroform on a hand-
kerchief held quite close to the nose before stertorous breath-
ing was produced.  As soon as that stage of profound anaes-
thesia was reached, the muscular system became relaxed, and
reduction took place by the force of the hands alone.
  In some eases Avhich for some time resist the usual efforts at
reduction, it is found that success attends modifications ofthe
ordinary procedure ; for instance, the arm is to be carried for-
cibly backAvards as Avell  as upAvards, or it has to be extended
by the force of two or three assistants, to effect some  change
in the position of the head of the humerus,  or relieve it from
the restraining influence  ofthe untorn  portion of the capsular
ligament, or to perform some other feat more  empirical than
scientific, Avhich shall so  modify the relations of the parts in-
volved in the injury, as may result in an easy  replacement of
the luxated bone.   I have seen a person inexperienced in  the
management of dislocations reduce a displaced bone that had
baffled a skillful surgeon for  hours. HoAvever, there  are  not
enough of such chance cases to justify an entire dependance
upon the results of blundering.
  After reduction has been accomplished, the  joint should be
kept at rest for two or three weeks, the arm being placed in a
sling, Avith the elbow bound to the side.  It may be  Avell to
guard against elevating the elbow or thro wing it outAvards and
upwards for several months.   A recurring dislocation is a great
perplexity, therefore it is best to follow precautions likely to
prevent such accidents.
  The subcla\icular  variety of dislocation  is generally very
difficult to manage.  The coracoid process is an obstacle in
the path  leading  to  a return of the  head of the humerus.
The arm  must be  drawn  dowmvards so the head of the
humerus ma}' pass clear of that process ; and then manipulated
as if the  displacement Avere  of the common variety.  The
heel in the space between the arm  and  the chest, Avith both
hands exerting extension and rotation, will  generally effect a
dislodgment of the luxated bone, and successful reduction. 
326
Dislocations.
SUBGLENOID  DISLOCATION  OF  THE   HUMERUS

  What is generally called the " doAvmvard," " dowmvard and
iiiAvard," and  "axillary" luxation of the shoulder, is a dis-
placement of the head  of the humerus so that it occupies a
position below the socket, the capsular ligament being torn at
its loAver part.  This has commonly been regarded by surgical
writers as the most frequent luxation of the humerus, but  as
I have  already stated in another place, the lesion is far less
frequent than the subcoracoid variety of shoulder dislocations.
  The head of the humerus being throAvn  below the glenoid
fossa, finds lodgment  upon the inner border  of the inferior
costa of the scapula, somewhat as represented  in the accom-
panying diagram (Figure 110).  AVhy the globular head  of
                        the  os  humeri  should ever become
                        poised  on the thin  border of  the
                        blade-bone, is almost a mystery,  but
                        there it has been found in a feAV in-
                        stances.  Probably the untorn edge
                        of  the  capsular  ligament prevents
                        the head ofthe humerus from rising
                        up to a point beneath the coracoid
                        process.   An  examination of  the
                        scapula sIioavs that the inferior costa
                        ofthe bone terminates in two crests,
                        leaving a wide groove between them
                        at a point  corresponding  with  the
                        cervix scapulae.   In this scaphoid
                        fossa the head of the humerus finds
                        lodgment; and the inner of the two
 subglenoid dislocation of the     crests or borders of the groove pre-
       humerus.                 ,   ,              .. ,.
                        vents the humerus from sliding  up-
wards.  Mr. FloAver says, that " In  the  only two  specimens
of unreduced  dislocations of this kind that I have been able
to find in  the anatomical museums of London, a new osseous
socket has formed for the head of the humerus on  the upper
part of the anterior border of the inferior costa of the scapula,
encroaching considerably upon the lower and anterior part of
the glenoid fossa.  One  of these has been figured  by Sir  A.
Cooper, and its subsequent reproduction by other authors has
 
Of the Humerus.                  327
 contributed much to  confirm  the  error of regarding this as
 the usual form of dislocation at the  shoulder.  From exami-
 nations of specimens in museums, and from numerous recent
 cases, I should conclude that not more than one in  ten  of all
 dislocations of the humerus can properly be called subglenoid."
 There is a specimen in King's College Museum, (No. 1342),
 Avhich is intermediate between subcoracoid and subglenoid.
   The servile  copying  of diagrams from Cooper?s Avork on
 Fractures and Dislocations, and the  Avording of the text to
 conform to the illustrations, has done much toAvards perpetu-
 ating errors even in  recent Avorks on Surgery.  Old figures
 representing reductions of the humerus and  femur by means
 of pulleys, and other appliances, showing Iioav  to employ ex-
 tension and counter-extension as methods of reduction, have
 contributed more than any other influence to perpetuate bar-
 barous practices in the  application of force.   Even if better
 methods  of reducing dislocated bones are described in  the
 text,  many indolent  practitioners  will neglect  the printed
 directions, and be governed only by the pictures which  make
 deeper impressions than prosy descriptions.
   The s}Tmptoms of subglenoid dislocation of the shoulder are
 not strikingly different from those manifested in the subcora-
 coid A'ariety of luxation.  The depression beneath the acro-
 mion process is greater; the arm is lengthened to the extent
 of the diameter of the glenoid fossa, unless,  in being Avorked
 at, the head of the bone  leaves the bifid ridge on Avhich it
 usually rests and becomes embedded deeply in the subscapular
 fossa ; and there is an inch or  more of space between the head
 of the humerus and the coracoid process.   Measurements are
 uncertain unless they be conducted Avith great care,  both arms
 being made to assume the same positions Avhile measured, al-
 loAvance being also made for the rotated attitude ofthe injured
 arm.  In this  as in the subcoracoid variety of dislocation  the
 patient is unable to make the hand of the injured side  touch
 the sound shoulder; neither  can the surgeon execute  the
 manceuA're unless the  patient be under the influence of chloro-
form ;  and then there would be danger of lacerating the tense
tissues in the endeavor.   The  rigid condition of the arm, its
ugly projection from the side,  the painful numbness of  the
whole limb, and disposition of the patient to  support the arm
with the Avell hand, constitute signs  that point pretty clearly 
328                   Dislocations.
 to some kind  of a  scapulo-humeral  dislocation.  The causes
 of subglenoid dislocation of the shoulder are direct violence
 upon the top of the humerus, falls upon the hand or elbow
 while the body is descending, and the forcible elevation of the
 elboAV, making the  acromion a fulcrum over which  the lever-
 age of the arm is sufficient to tear the capsular ligament on
 its under side  and contribute to  the  displacement.  Muscular
 action Avhile the arm and elbow  are  quickly thrown upward,
 has been known to produce the  " doAvmvard " luxation.

  Treatment.—The management of a subglenoid dislocation
 does not differ essentially from that already laid down for the
 reduction of  a  subcoracoid dislocation.  The arm is to be
 seized just above the elbow and carried forcibly upward and
 outAyard, and the scapula is to be fixed.by the exertion of the
 fingers, AAiiile the thumb performs the part of a fulcrum and
 helps push the head of the humerus into place at the instant
 the quick doAvnward and inAvard movement of the arm is ex-
 ecuted.  One attempt failing, several repeated  efforts should
 be made, each being someAvhat different from the  preceding
 in order to give  variety to the manoeuvres.   The heel or knee
 being placed in the axilla, both hands can be used in extend-
 ing, rotating, and SAveeping the arm from a position of extreme
 elevation to one  of extreme depression alongside or  across the
 chest.  One hand  holds the forearm  flexed and  the other
 guides the elbow.   Chloroform should be  freely employed in .
 all cases that resist the first efforts or are extremely painful.
 If the surgeon sees the patient soon after the accident, he may
be able to effect reduction Avithout resort to anaesthetics.   I
have reduced a dislocated  shoulder  Avithout  even waiting to
take off the  patient's coat.  I have seen  the armpit severely
bruised by the surgeon's boot in attempts  at reduction ; and
here express my disapprobation of such  rough usage. I have
also seen the arm above the wrist and elboAV terribly excoriated
by the action of towels and straps employed in making exten-
sion.  Proper care manifested during manipulation  saves  the
patient from these painful and  unsightly marks.   A bold and
efficient surgeon  generally acquires the  reputation  of being
 rough, and he  deserves  this discredit  if  he heedlessly and
heartlessly inflicts  unnecessary  injuries upon  his   patients.
Skillful and gentle manipulations accomplish more in reducing 
Of the Humerus.
329
 dislocated bones than brute force put forth without a rational
 method in view.  The retentive  dressing to be employed after
 reduction is effected, may be the  same in all kinds of shoulder
 dislocations.  The arm is to be suspended in a sling, and tied
 to the side for tAvo or three weeks ;  and care exercised about
 elevating the arm for several months.


 SUBSPINOUS  DISLOCATION  OF  THE  SHOULDER.

   What has been generally called a " backward " luxation of
 the humerus, the head  of  the  bone being forced from its
 usual position to one beneath the spine ofthe scapula, outside
                          of the glenoid socket, is an injury
                          of uncommon occurrence.   Out of
                          159 cases of scapulo-humeral luxa-
                          tion recorded in  the Middlesex
                          Hospital, three Avere of this variety.
                          Its  characters are so well marked,
                          that it is not liable to be confounded
                          Avith any of the others.  There are
                          said to be four good  specimens, il-
                          lustrating its effects, Avhen left  un-
                          reduced, in the different anatomical
                         museums of London.   The head of
                         the  bone, when  dislocated back-
 subspinousdislocation of the humerus. Avards, Avould natu rally rest  on  the
                         neck of the scapula  near  the  pos-
 terior  edge of the glenoid fossa, but in case the displacing
 force continued after  the luxation Avas  accomplished, the head
 ofthe humerus  might be. driven  back two  or three inches
 upon the  dorsum of the scapula.  In cases  of great  displace-
 ment the  lesser tuberosity of the  humerus is found to be  sep-
 arated (broken), or the tendon of the subscapularis is  detached
 from its humeral  connection.
  In an  unreduced  dislocation  of several  years' standing,
 which I once had the opportunity to dissect, I found the  part
 of the head ofthe humerus Avhich rested against the posterior
 edge of the socket and the  neck of the scapula, someAvhat
flattened  and eburnated;  and a new socket  had  formed,
slightly excavating the blade, and considerably the base of the
 
m
Dislocations.
acromion.  There was  very little osseous material throAvn
around the new socket.   Pressure of the head of the humerus
upon the posterior edge of the glenoid rim had  caused some
encroachment upon that segment or  ledge of bone, but the
articular face of the glenoid cavity had not been altered.
The tendon of the subscapular muscle had been  torn from its
humeral attachment, and the old capsular ligament Avas thinned
and in places lost by being blended Avith the other soft  tissues
of the region.
  The head of the bone formed  a marked protuberance be-
neath and outside of the acromion, giving the shoulder the
appearance of being Avidened on that side; the depression be-
tween  the acromion and the coracoid  processes, Avas not
marked, but  could  be distinctly  felt by pressing the fingers
into the old socket.  The elboAV Avas  inclined  to  take a posi-
tion a little more inAvard than natural.   Whatever may have
been the rigidity of the arm directly after the accident,  or the
restrictions upon a wide range of motion,  at the  time  of the
patient's  death  the limb  could  be  moved freely in every
direction.
  The causes of subspinous dislocation would  probably be
falls upon the arm Avhile the elboAV is throAvn forcibly in front
of the chest.  At any rate, this  seems to be the only Avay a
dislocation of the kind can be produced in the cadaver.  The
feAV surgeons Avho have had a case to treat Avere not generally
able to ascertain the position  of  the arm Avhen  luxation oc-
curred, or the positive and direct  cause of the accident.   Con-
vulsive muscular action is said to  have produced  the luxation
in one instance, and falls of various kinds in the others.  The
dislocation was  not ahvays discovered until days  or  Aveeks
after the accident, yet reduction  Avas accomplished  in  nearly
every case, though the head of the bone had been  displaced
for a number of days  before an attempt at reduction Avas
made.

  Treatment.—The rule for reducing this form of dislocation
is to stand behind the patient Avho is seated in a  chair or on a
stool; the surgeon Avith one hand takes hold of  the back of
the arm near the elboAV and forces it  across the chest, in front,
as far as it Avill go ; he then puts the other hand on the top of
the shoulder, the fingers resting on the acromion to  steady the 
Of  the Humerus.
331
 scapula, and to lend efficiency to the  thumb  in the work  of
 being a fulcrum and in pushing the head of the humerus into
 place when the  patient's  arm is suddenly SAVung  backAvards.
 This manoeuvre, accomplished  by both hands operating sep-
 arately,  will  replace the bone, especially if the patient  be
 thoroughly relaxed by the influence of anaesthetics.
   Direct extension has  proved  effectual in  reducing this dislo-
 cation.   In fact, any dislocation of the shoulder  may be  re-
 duced with the pulleys  and other appliances for exerting great
 force, yet the mechanical resistance offered by the untorn por-
 tion  of the  capsular ligament, is such that  the bone can not
 be replaced by extension Avithout lacerating the tissues made
 more tense by the operation.  Extension drags the head  of
 the  bone aAvay from the opening in  the ligament through
 Avhich it escaped, and places the caput humeri in a position
 unfavorable to an  easy return over the glenoid rim.
   Mr. Flower gives  the  folloAving plan Avhich he has never
 known to fail: " The patient is seated on a high chair, Avhich
 is placed about tAvo feet from the post of an open doorway.
 The  surgeon, leaning his back against the  door-post, places
 one  foot upon the side ofthe chair, and, Avith his knee pressed
 into the axilla and both hands  upon the shoulder, steadies the
 patient's  body.   A jack-toAvel  is then fixed by a clove-hitch
 knot to the patient's arm, just above the elbow; and by its
 means tAvo or more assistants, placed on the  other side of the
 doorway, make  steady  extension  horizontally  outAvards."
 This plan is for reducing dislocations " downwards " and " for-
 wards," but is open  to the same objections  as other contriv-
 ances to produce extension.  It is found to be an  unscientific
 plan for reducing dislocations, and though it Avill  yet be fol-
 lowed by a few superannuated  practitioners, the more rapid,
 and less dangerous " physiological" process, iioav so Avell un-
 derstood, continues to gain  favor, and  rarely or  never  fails
 Avkere success by any method is possible.
   Compound Dislocation  of the Shoulder.—It has been a  ques-
 tion  Avhether a compound dislocation of the  shoulder should
be reduced, or the head of the  humerus resected.   Although
I have never had such an injury to treat at the shoulder-joint,
I am persuaded that I should proceed at once Avith an attempt
at reduction.   If the head  of the bone  would  not  return
through  the hole  in  the skin I should enlarge the opening. 
332
Dislocations.
and then make a powerful effort at reduction.   If this course
failed it Avould  then be in order to exsect the head of the
humerus and enough of the shaft to facilitate a return of the
bone to its place.
  Dislocation ofthe Humerus, with Fracture near the  Upper End
of the Bone.—The older surgical Avriters declared that  a  dislo-
cation  of the shoulder, complicated  Avith fracture  of the
humerus near its upper extremity, could not be reduced until
the fracture had united.  Dr. J. M.  Warren, in his Surgical
Observations, says, " I have had to treat several cases of  dislo-
cation  of the shoulder, with fracture of the neck  of the
humerus.  In two instances in Avhich  I  was called while the
muscles Ave re still relaxed, and before the patient had recovered
from the depressing influeuce of the shock, it Avas found pos-
sible to  effect reduction by making extension of the shaft of
the bone, at the same time working the separated head into
its socket by firm pressure Avith the thumbs.  In case reduc-
tion can not be thus effected, it is still a question whether the
shaft of the bone should be carried back into the old  socket,
so as thus  to make at once the best  practicable joint; or
Avhether it should be placed  in apposition with the head, and
an attempt made at reduction after  such a lapse  of  time as
may be thought sufficient for the union of the  fragments to
take place.  The latter method Avas tried Avith success, by Dr.
John C. Warren, on a young man, Avhose case he reported in
the 'Boston  Medical and Surgical Journal' for 1828.   Im-
mediate reduction having been  attempted in vain, fracture-
apparatus was applied.  After  seven Aveeks, extension Avas
made with pulleys, and the dislocation  reduced.  The case is
quoted by Malgaigne, Avho considers the precedtnt Avorthy to
be folloAved in similar cases.  I also attempted the same  treat-
ment in a case Ayhicli occurred nearly twenty years ago  ; but,
in the  attempt  to break up the adhesions Avhich had formed
during  the  six  or  eight Aveeks that had  elapsed, the  callus
gave Avay, and the fracture Avas reproduced.  The broken end
of the bone Avas then placed in the  glenoid cavity,  and  the
patient  recovered Avith a very useful arm.  In another case
Avhich  came under my notice, the arm had been paralyzed by
fruitless attempts at reduction.  I saAV the patient, in consul-
tation Avith other surgeons, at the end of seven Aveeks, when
it Avas  decided  to leave the  broken end of the bone in  the 
Of the Humerus.                 333
socket.   I afterwards learned that the paralysis gradually
passed off, and that the patient recovered the use of the
arm."
  If the fracture  be at  some distance from the head  of the
humerus the  limb could be temporarily dressed firmly Avith
splints, and then  employed as a lever as if no fracture had
occurred; and if the break be near the head of  the humerus,
the head itself  might possibly be  pushed into  place  by the
power of the thumbs, especially if the patient be profoundly
under the influence of chloroform.   The first attempt failing,
repeated efforts may be made every da}' for a week or more.
  Dr. Watson, of NeAV York, reported a case to the Academy
of Medicine, in May, 1855, in Avhich dislocation of the humerus
existed, and a fracture near the head  of the bone.  The  in-
jury Avas produced by a blow from a steam engine; and the
patient Avas not  treated until the  morning after  the  accident.
A sweeping motion Avas given  to the  arm while the fingers
Avere  pressed  against  the head of the bone in the axilla, and
reduction Avas effected.   The arm was then treated for a suc-
cessful cure of the fracture.
  It remains a question in the event that attempts  at  reduc-
tion failed, Avhether it is best to adjust the fracture and retain
the fragments in apposition until osseous union has taken
place, trusting to a successful reduction of the  dislocation  at
the end of six Aveeks, or after the fragments are presumed  to
be  sufficiently consolidated to  alloAV  the arm  to  be safely
handled  in the manipulating process necessary to accomplish
reduction ; or to  place the broken end of the shaft in the
empty glenoid cavity, trusting to the usefulness  of a joint ob-
tained under such circumstances.  1 am inclined to the belief
that it is best,  if the  reduction  can not be effected at trials
made during the first ten days,  to treat the fracture  with the
broken ends in  apposition, and  at  the  expiration  of six  or
seven Aveeks, or after consolidation of  the fragments  is  pre-
sumed to have taken place, attempt to effect a  reduction  of
the dislocation.  It is well knoAvn that a dislocated  shoulder,
if left unreduced,  at length regains a great part  of its  useful-
ness, or as much at least as an arm would have,  AAiiich had a
joint made of the fractured shaft placed directly in  the gle-
noid socket. 
334                   Dislocations.
  In rare instances the fragments would fail  to unite, a false
joint being established.  Such  a  termination Avould not be
Avorse than  a  union of the fragments  Avith the bone unre-
duced ;  or a joint produced from the broken end of the long
fragment of the humerus, the  short fragment being left to
itself in the axilla.
  If a patient Avith a dislocated shoulder and fracture of the
humerus near  its upper extremity, be put profoundly under
an anaesthetic, the short fragment  can be manipulated Avith
considerable ease, especially if the patient be not too muscu-
lar.  I have recently had such a complicated injury in  a lad
twelve years of age.   The accident happened by a fall from a
horse that Avas frantically running  aAvay.  The boy says  the
dislocation  occurred first, and the fracture immediately after-
Avards.   I laid  the patient upon a Ioav bed, aud produced ster-
torous breathing with chloroform ; and then manipulated the
short upper fragment of humerus for  nearly an hour.  At
length I got the position all right for a return of  the head of
the bone through the aperture in the capsular ligament, and
Avith my thumb pushed the luxated part into its socket.  At
first the swelling and stiffness seemed to impede and balk my
efforts, but the longer I Avorked the easier it AATas to render
the conditions favorable to reduction.  The arm Avas carried
to position as if no fracture existed, and the fractured sur-
faces of the tAvo fragments Avere kept in apposition during
the movements.  No other rules can  be given in regard to the
management of such a case.   As soon  as  reduction of the
luxation occurs the limb is to be carefully dressed to secure a
good result from the fracture.
  I have examined a case in AAiiich there seems to have been
dislocation  of  the shoulder and separation of the epiphysis—
head from shaft—in a little girl.  The accident occurred more
than a year preA'iously, therefore I did  not  undertake to re-
duce the luxation.   The head of the bone and  the shaft had
united at an angle that Avas beneficial rather than otherwise.
The deformity Avas not great, and  the functions  of the limb
were better than might be expected.  The  mother reported
that the child Avas regaining the use of its arm very rapidly.
It was easy to diagnose the injury, from the fact that the head
of the humerus Avas out of its socket, and the angle alluded
to presupposes fracture. 
CHAPTER  VIII.
DISLOCATION OF  THE  RADIUS  AND ULNA AT THE
                   ELBOW-JOINT.
   Dislocation  of the elboAV, both bones of the forearm being
 displaced, is not  a common accident, and occurs mostly in
 childhood  and youth.  The injury, according to statistical
 tables, is peculiar to boys between the ages of five and fifteen
 years.   Of thirty-three cases observed by Hamilton, nineteen
 Avere in children under fourteen years of age.
   Malgaigne concludes, from experiments upon the dead sub-
 ject, and from  careful  examination and interrogation  of
 patients who have met with  the accident, that  the most  fre-
 quent  cause of nearly every form of luxation at the elboAv-
 joint, is a twist given to the ulna, Avhich brings the coronoid
 process successively inwards, doAvmvards, and backAvards, and
 which  may be produced by a fall upon  either the  internal
 border of the forearm, or the inner side of the olecranon.
 Other authors  state that this injury is more frequently effected
 by a fall in Avhich the palm of the hand comes into violent
 contact Avith the ground, so that the  forearm is driven directly
 back under the  lower end  of the humerus.  Hamilton  has
 knoAvti  one case  to occur from a blow upon the back  and
 lower part of the  humerus. *
   The  bones  may be displaced backwards,  forwards, or to
 either side; there  also  may  he intermediate  forms, as back-
 wards and outAvards, and backAvards and inwards.  Each form
 may be partial or complete, and ohe or both  bones may be
 displaced ; or the ulna may be dislocated backAvards as regards
 the  loAver  end of  the  humerus, and the radius forwards.
 Some of these different forms of dislocation  may be compli-
 cated Avith fracture of the olecranon  or  coronoid process  of
the  ulna;  either  of the condyles of the humerus  may be
broken ; and the injury may be compound.
                          (335) 
336
Dislocations.
   The complex structure of the elbow-joint, and the depth to
 which portions of the articulation are buried in muscles, to-
 gether Avith the great swelling to which all lesions of the parts
 are especially liable,  render any of the injuries peculiar to the
 bones exceedingly  difficult to  diagnose.   Fracture  of  the
' humerus just above  the elboAV  takes  the semblance of dislo-
 cations of both bones of the forearm  backAvards; fracture of
 either condyle may be mistaken for a luxation of one  or both
 bones of the forearm ;  and a complication of  fractures  and
 dislocations may result from a single  accident.
   The elbow-joint is exceedingly liable to high  grades of in-
 flammation, and to anchylosis after a fracture implicating the
 articulation, or a dislocation.   Many of the injuries  peculiar
 to the elboAV  either pass  unrecognized or are  badly  treated,
 therefore  more  deformities of this joint are to be met than
 of any other articulation.   It is of the utmost importance,
 then, that  the  anatomy and pathology of the  elbow be  well
 studied.
   Some forms of elboAV dislocation are exceedingly rare :  lux-
 ation of both bones  of the forearm backwards and upAvards is
                         the  most common  of all of them.
                         When this is complete, the coronoid
                         process  (if not fractured) is forced
                         back into the olecranon fossa ofthe
                         humerus.   According to Malgaigne,
                         this condition is not so common  as
                         the  incomplete form, in  AAiiich the
                         process  rests  upon  the trochlea of
                         the  humerus.  The radius almost
                         ahvays maintains its  relative  posi-
                         tion to the  ulna, being held there by
                         the orbicular ligament.   All the lig-
                         aments  of  the elboAV joint, except
                         the  posterior, are generally torn in
                         •a dislocation of the  radius and ulna.
                          The symptoms in this  dislocation of
                         both  bones  of  the forearm back-
                         Avards, are  marked  and characteris-
                          tic ;  the limb  is in  a semi-flexecl
  state, and rigid; the elboAV seems to be thicker antero-poste-
  iroiiy, and the olecranon projects backAvard in  a marked de-
Fig. 112.
Dislocation of radius and ulna
       backwards. 
Of  the Radius and Ulna.
337
gree, reaching above the condyles ofthe humerus ; the triceps
tendon stands out conspicuously, though it is  not tense ; the
forearm  generally  exhibits a  twisted  appearance, inclining
strongly to pronation.   When the hand is rotated the head of
the radius,behind the humerus, can be felt rolling in its usuai
relation Avith  the ulna.  Anteriorly, as if embedded  in the
flesh of the forearm, the loAver end of the humerus can be
felt, Avith the tendon of the biceps and the brachialis anticus
muscle stretched  over it.  Any attempt to flex or extend the
elbow  is  found  to be  painful and quite impracticable.  In
front the forearm  is shortened to a noticeable extent, Avhile
the posterior aspect retains its usual length.  The  fingers are
moderately flexed, and can not be moved Avith ease; they are
also benumbed by pressure on the nerves aboATe.
  If great swelling has taken place before the injured  limb is
seen, and-any doubt arises in regard  to  the nature  ofthe
lesion, it may assist in the diagnosis to bear in mind that only
one injury appears like a dislocation  of both bones  of the
forearm backAvards, and that is fracture of the humerus just
above the condyles, and the distinction  between the two inju-
ries may be draAvn as folloAvs :  in dislocation the arm is rigid,
and the deformity can  not  be overcome Avithout reduction,
AAiiich is accomplished Avith difficulty, and when once replaced
the  bones Avill stay there ; while in fracture, there is great
mobility at the seat of injury, the reduction  is accomplished
with comparative ease, and Avhen the  reducing force is dis-
continued the deformity will at once be reproduced.  Besides,
in the event of fracture of the humerus, crepitus cau  readily
be elicited.
  A lateral displacement of the bones of  the forearm at the
elboAV  may be readily recognized by the peculiarities of the
deformity.  In most instances the luxation is incomplete, i. e.,
both bones are not thrown so far laterally, as to have no con-
tact Avith the articular surfaces of the lower extremity of the
humerus.   In the outward, dislocation, which is the  most com-
mon, the  radius  does  not touch the  articular surface of the
condyle, but the ulna  rests upon the spot the radius  usually
occupies.
  The joint is  rigid, and semi-flexed, with the hand inclined
to pronation.   The elbow-joint has  an  unsightly avpearance,
which is characteristic of the lesion.  In the outAvaid disloca-
      22 
338
Dislocations.
Fro. 113.
tion ofthe two bones, the head ofthe radius can be distinctly
felt under the skin, and the internal  condyle projects most
strikingly, the  epitrochlea and  even a  part  of  the  trochlea
being distinctly felt.
  If the lateral displacement be inwards, both  bones of the
forearm are not  forced completely clear of the articular sur-
faces of the lower end of the humerus, but the radius reposes
               in  the  trochlea,  and the ulna upon  the epi-
               trochlea.   In some cases the  head  of the
               radius  might rest in front of the trochlea, or
               fall back into the olecranon  fossa.  In  all of
               these dislocations much injury is  sustained by
               the ligaments, muscles  and nerves,—the ulna
               nerve being particularly exposed to bruising or
               compressing forces.
                 Dislocation of both  bones of the forearm
               forwards has been denied as being possible,
               unless there was first a fracture of  the olecra-
               non process ; but Velpeau, Monin aud Denuce,
               have each reported a case, establishing the ex-
               istence  of such an injury, Avhether it can be ac-
               counted for or not by any process of reasoning.
               In  Velpeau's case the accident occurred by the
               passage of a carriage  Avheel over the arm.
               When first seen by the  surgeon, both bones of
Dislocation of the ra-
 dius and ulna in-
 wards. The head of
 the radius rests on  .
 the trochlea and the  the  forearm Avere found in front of the lower
ulna on
trochlea.
the epi-
               extremity of the humerus, the radius reposing
              in the coronoid fossa, and the olecranon  upon
the condyloid  ridge, the ulna being  carried  upwards  and a
little  outwards.  According  to  Denuce, the  summit of the
olecranon rests against the inferior part of the trochlea  of the
humerus, and the head of the radius is beloAA:  and  someAvhat
separated from the external condyle; the prominence ofthe
olecranon disappears from behind the  joint, and on each side
the condyles of the  humerus  are unusually prominent.  The
joint is  rigid, and  the arm is flexed at least to a right  angle.
  The several dislocations of the elbow are not ahvays clearly
defined as distinct displacements.  In some instances the luxa-
tion is partially lateral and partially backAvards, or fonvard so
far as the radius is concerned, and lateral as regards the ulna.
In these  extraordinary accidents, the violence is probably of a 
Of the Radius and  Ulna.
339
tAvisting nature, or partakes of complex motions, the patient
being unable to define the cause Avith much clearness.  A sur-
geon looking on Avhen the accident occurred, might  not  be
able to describe Iioav it Avas produced.

  Treatment.—When both bones of the elboAV are dislocated,
their reduction is not generally attended Avith much difficulty,
especially if chloroform  be brought into requisition.  In the
backAvard dislocation,  the surgeon may be able to replace the
bones by placing one hand against the forearm near the elboAV,
and pressing  Avith all his might Avhile  Avith the other hand
grasping the patient's  Avrist he employs extension, and at the
same time uses the limb as a  lever—the  other hand being a
fulcrum—to disengage any locking of  elevations and depres-
sions, and  to  force  the  bones of the  arm into their relative
positions.  Sir  A. Cooper recommended that the patient sit
in a chair, and the surgeon, resting his foot upon the edge of
the  seat, places his  knee upon the inner side of the elboAV-
joint, Avhile he grasps  the wrist with his hands ; he then bends
the elboAV sIoavIv, but forcibly at the same time pressing  Avith
his knee upon the upper part  of the radius and ulna, so as to
disengage their articular surfaces from the loAver end of the
humerus.  Mr.  Skey  advocates that one assistant  hold the
upper arm, and another pull   steadily upon  the wrist, and as
soon as the coronoid process is brought beloAV the level of the
trochlea of the humerus, the muscles are powerful enough to
bring the bones into their natural place.
  In those cases where much difficulty is experienced in the
reduction, it is probable that the lateral  ligaments, remaining
untorn, act as poAverful obstacles to a return of the  bones to
their normal  positions.  If there be reason  to suppose that
these ligaments oppose  reduction, and  the obstacles can not
be  overcome in  any other way, the joint must  be  extended
beyond the straight attitude, in order to tear the most un-
yielding bands, and then reduction may be easily effected.
  The  treatment after reduction consists in  keeping the arm
in a sling for two or three  Aveeks, and  applying anodynes to
the joint to suppress high grades of inflammatoiy action, each
day employing passive motion as  a  preA-entive of anchylosis.
  It may be of importance to mention that surgeons of great
experience have failed to detect dislocation of both  bones  of 
340                   Dislocations.
the forearm  backwards;  and they  have also  gone through
with the forms usually employed to effect reduction, and sup-
posed they had accomplished  their  object, yet have left the
bones unreduced.   If these mistakes happen to accomplished
surgeons, the inexperienced practitioner of medicine and sur-
gery should be particularly on his guard against  erroneous
conclusions.
  If a month ormore has elapsed before reduction is attempted,
great difficulty will be encountered in the endeavor to replace
the bones.  Cases  are  on  record in AArhich reduction was ac-
complished after the displacement had existed for five or six
months.  The successful cases are about sure to be reported,
and the larger proportion  of attempts Avhich turn out as fail-
ures, never get into print.  Death has occurred from violent
attempts to reduce recent and ancient luxations of the elboAV.
However, failures and unfortunate results  should not deter  a
surgeon from making well directed efforts in favorable  cases
even if several months have elapsed from the time ofthe acci-
dent, for the number of successful results is quite large, estab-
lishing the principle that a fair trial is legitimate.
  In lateral dislocations of both bones of  the forearm, reduc-
tion is to be accomplished by extension and lateral  pressure,
the soft tissues being first relaxed by the use  of chloroform.
If the luxation be  not purely lateral, but combined Avith some
backAvard displacement, the restoration of the bones to their
proper places is to be accomplished by varying the direction
of the forces applied.  No set rules are applicable  for  every
case, consequently the surgeon has to rely to a  greater or less
extent upon his own ingenuity and resources.  My experience
in treating dislocations of the  elboAV, has  taught  me  that no
plan, rule, or method, will invariably prove successful; but if
one course failed, I at once made trial of another, and in  the
end have always succeeded, except in one instance AA-hich Avas
in trying to  reduce a case of six months' standing.  I have
never seen a dislocation of both bones forward, but if I should,
it seems to  me that I could replace the bones by having as-
sistants  make extension and  counter extension Avhile I used
the force of my hands in pulling the humerus forwards and
pushing the forearm backAvards.  I have yet to be  convinced
that a dislocated elbow needs only to have itsuntorn ligaments
relaxed  by position of the limb, to secure an  easy reduction. 
Of the Radius.
341
 If the lateral ligaments be lacerated the anterior and posterior
 parts of the capsule are too loose to offer much resistance.
   Dislocations of the elboAV should be reduced as early as pos-
 sible after the reception of the  injury.   If the  bones be left
 displaced for a number of days, the inflammation runs so high
 that changes  of an unfavorable character  take place in the
 joint, leading sometimes to permanent defects in the articula-
 tion.   A luxation of three weeks' standing is  more difficult
 to reduce at the elboAV, than one of six weeks at the shoulder.


 DISLOCATION  OF   THE  HEAD  OF  THE RADIUS.

   The  head of the radius has  a double articulation, radio-
 humeral, and radio-ulnar; aud it can  not be displaced to any
 great extent Avithout a-rupture of the external lateral and or-
 bicular ligaments, losing its articular connection Avith the ex-
 ternal condjie of the humerus, and the  sigmoid  notch  of the
 ulna.  The  accident is one peculiar to youth, though it may
 occur in  adult  life.  It is generally produced by a fall upon
 the palm of the hand, the direction  of the force acting in a
 manner favorable to the dislodgnient of  the upper end of the
 radius from its articular relations ; a sudden jerk or tAvist im-
 parted to the hand has been knoAvn to luxate the head  of the
 radius; and a fall  or bloAv upon  the elboAV may displace the
 bone.   In one case that came  under my observation, the boy
 fell from a high Avail sideways, the body whirling as the hand
 met the ground; in another case a boy had his elboAV caught
 in a sAvinging gate in such a way as to force the head  of the
 radius  from its normal position to  one behind the external
 condyle ; and I have treated a third case that happened in a
 scuffle.   The patient said  the other boy  fell on him Avhile his
 arm was confined underneath his body.
  The radius may be displaced forwards, backwards, and di-
 rectly outwards.  The fonvard  dislocation is  far  the  most
 common; the backAvard less frequently;  and the outward ex-
 ceedingly rare.  In children of a lax condition of the fibrous
 structures, a partial dislocation or sw6-luxation, the ligaments
 not being torn, is a common occurrence.   Such a displacement
is not attended with pain, the child throwing the head of the
radius into a state of deformity,  and returning it again with- 
342                  Dislocations.
out any particular discomfort.   As the child advances in years
the ligaments increase in firmness, so that the defect no longer
exists.
  In the jorward dislocation, the head of the radius is found
in front of the external condyle of the humerus; the forearm
is fixed in a moderately flexed state, either prone, or halfway
between pronation and supination.  Bending of the elboAV is
prevented by the head  of the radius  coming in contact with
the front of the humerus; and complete  extension  causes

                         Fig. 114.
Dislocation of the head of the radius forwards.
pain.   The head of the radius can be defined in its new posi-
tion, and when the hand is rotated, it can be seen and  felt to
folioav those movements.   The whole forearm presents a pecu-
liar and characteristic twist, Avhich is occasioned by the altered
situation of the upper end* of the radius.  The tendon  of the
biceps stands prominently forwards in the bend of the elboAV ;
and the  finger can  be pressed into a depression at the point
vacated by the head  of the radius.
  The backward displacement is characterized by that peculiar
attitude of the limb  AAiiich denotes the nature of the injury,
though the position of the head of the radius can not  be de-
termined positively without careful  examination.   The  fore-
arm is semi-flexed, and held fixed  in a state of pronation, un-
less the internal condyle be broken in the same accident, which
is not an uncommon complication.  The  head of the radius 
Of the Radius.                  343
can be felt behind the external condyle, quite superficial, the
finger being easily pressed into the cup in the upper end  of
the bone, and  be made to feel the button-like termination
which plays in the orbicular ligament.

                         Fig. 115.
Dislocation of the head of the radius backwards.
   Dislocation of the head  of the radius outwards, must be a
 form of displacement rarely met, for there are only two or
 three cases reported by American surgeons, and only four by
 Paul Denuce, who may not have been correctly informed in
 regard  to  them all.  Before his " Memoire "  Avas published
 (1854) dislocations of the head  of the radius  were supposed
 to be  confined  to  the  forward and backward  displacements.
 It may  even noAV be a question Avhether the outward disloca-
 tion is not a modification of one or the other of the two Avell
 defined displacements of the head of the radius   Dr. Willard
 Parker reports a case of outward dislocation in  the NeAV York
 Journal of Medicine for March, 1852, stating that a child four
 years old fell down stairs " backwardly, Avith the right arm
 twisted behind  the back, in such  a  position that the Avhole
 weight of her body came upon her  arm."
  It is plain that the head of the radius can not be displaced
 outAvard to any considerable extent without a rupture of the
 upper end of the interosseous ligament, as well as a laceration
 of the orbicular, external lateral, and the capsule enclosing
the articulation.   A force competent to commit that damage. 
344
Dislocations.
would be likely to produce fractures and other injuries to ad-
joining parts.

  Treatment.—It is not generally a difficult matter to reduce
dislocations of the head of the radius, though the bone is not
easily kept in place when once the barriers to displacement
have been broken down.  A great many prosecutions to re-
cover damages for malpractice have groAvn out of the fact that
a recurrence  of the dislocation is,very  common.  The  non-
professional suppose that a bone is not properly reduced or
skillfully treated after reduction, if it gets out of place  in  a
few  days  or  weeks after it has  passed through a surgeon's
hands; and there  are also plenty of medical wiseacres who be-
lieve or pretend to believe about the same thing.   A few days
ago'a father brought his son into my office, and asked me to
examine the lad's arm.  I suspected the motive, and soon sat-
isfied myself by inquiries that my suspicion Avas Avell founded.
A physician  of respectable  talents had treated the arm six
weeks previously, for dislocation of the  head of the  radius;
in three Aveeks from  the accident the bone was found to be
displaced, and the father then took the patient to  another
physician, who said that the arm had not been properly treated,
that the luxation had never been reduced.   This statement
made the parent believe he had been imposed upon by an in-
competent medical attendant;  and he at  once took  steps
toward entering a suit for damages. I  returned  the  bone to
its natural position, and bound  a compress in front of the head
of the radius, the dislocation being forwards.   Having assured'
the father that a dislocation of the head of the radius was
liable to recur, and that the physician Avho first treated the in-
jury had probably reduced the dislocation properly, he  Avent
away contented, and abandoned his intention to prosecute.
  In a forward dislocation, the wrist is to be grasped with one
hand, and the elbow with the other, and while the forearm  is
moderately flexed, considerable supinating force will effect re-
duction, especially if the thumb be used to push the head of
the radius into position.  If this manoeuvre, several times at-
tempted, do not succeed, poAverful extension and counter ex-
tension may be employed, the thumb pressing hard upon the
displaced  bone.   It is probable that either plan would prove
successful even without chloroform, but if the patient be mus- 
Of the Radius.
345
cular and the  resistance  considerable, anaesthesia should be
brought into service.
  There exists some difference of opinion in regard to the at-
titude of the arm while reduction is being attempted.   Cooper
applied a supinating force with extension, and Denuce directs
that the arm be kept in a state of pronation while extension
is made.   It is  to  be  presumed, hoAvever, that the advocates
of several distinct plans  have succeeded  in  their favorite
methods;  I am satisfied that the reduction can be effected by
several distinct manoeuvres, though in all it is essential that
there be pressure of the thumb on the head of the radius to
steady it, to help direct it into place, and to  perform the part
of a fulcrum when  the arm is used as a lever to force the re-
duction of the displaced bone.
  In the  backward luxation the forearm  needs flexing and
pronating at the same  time that powerful thumb  pressure be
brought to bear upon the head of the radius to force it into
its normal  position.   Gross says  that the  reduction is to be
effected by flexion  and supination.  As  long  as  there exist
such discrepancies in regard to the direction the forearm is to
take in facilitating reduction, it will be safe for the inexpe-
rienced practitioner to try one method, and if that fails, to re-
sort to another.  In the single backward dislocation I had to
treat, I pronated the  hand, and forced  the radius into place
with my thumb, the reduction being accomplished easily.
  The outward dislocation needs no special rules for its reduc-
tion.   Extension and  rotation  of the forearm inwards will
place the bones in a favorable position,as regards one another,
for the pressure of the thumb or fingers to return the bone to
place.
  After the reduction of either form of dislocation the arm
should be dressed  Avith pasteboard splints, with the forearm
neither flexed nor extended. Some  surgeons employ a  stiff
angular splint to prevent motion at the joint.  After sufficient
time has elapsed for the torn ligaments to heal, the dressings
are to be removed and passive motion instituted.  It will be
Avell if the patient does not completely flex or extend the limb
for several months. 
346
Dislocations.
      DISLOCATION  OF  THE  ULNA  BACKWARDS.

     Displacement  of the ulna  singly is  a recognized injurv
   among surgical writers, though both bones of the forearm are
   more likely to be dislocated together, than  the ulna alone,
   from 'the fact that the radius is more strongly bound to the
   ulna than to the humerus.  A force, then, which  is  competent
   to luxate the ulna backAvards, must almost  of necessity carry
   the radius Avith it.  In the feAV cases reported, of dislocation
   of the ulna backwards, the radius was displaced  to a certain
   degree, if not fully luxated.  Tn the case  reported by Sir Ast-
•   ley Cooper, the radius Avent with  the ulna  to the  extent  of
   having to form a new socket for itself on the external condyle.
     Pirrie's Surgery contains a  brief account  of a case of back-
   ward dislocation of the ulna which occurred in the practice
   of Gosset.  Even in this there must have been as much lateral
   displacement as  backward, for the coronoid process lodged on
   the internal condyle, and the  radius may have been  partially
   displaced.  As has been previously stated, in injuries of the
   elbow  the best  surgeons  may be deceived in regard to the
   nature and extent of a given  lesion.
     The signs of dislocation of the  ulna  backward would be
   great rigidity of the articulation,  and a marked projection of
   the olecranon behind the joint.  If the ulna  has been forced
   backwards singly, the  orbicular ligament Avould have to be
   lacerated, as Avell as a part of the interosseous, to allow the
   radius to remain in its normal place.
     Reduction was accomplished in  Gosset's case, " by extension
   and counter-extension applied by  tAvo persons pulling in oppo-
   site directions, and by the pressure  of the  olecranon process
   doAvrnvards and outwards, while  the  forearm Avas suddenly
   flexed."  In  other words, the same method of reduction Avas
   employed as is commonly recommended to replace  both bones
   of the forearm when they are luxated backAvards. 
Of the  Radius.
347
DISLOCATION   OF   THE   LOWER  END  OF  THE
             RADIUS  FROM  THE  ULNA.

  Hamilton, following  Sir A.  Cooper, and  Malgaigne, has
spoken of forcible separation of the radius and ulna at  their
inferior articulation, as  dislocation of the loAver  end of the
ulna from the radius; but in accordance Avith the  nomencla-
ture employed in describing luxations in other joints, this in-
jury should be regarded as a dislocation of the radius.   The
ulna is the fixed bone, the radius moving upon it, the displace-
ment, therefore, is of the latter from the former.
  The accident, as an uncomplicated lesion, is one of extreme
rarity.  Sir  A. Cooper  does not mention  having met with a
single  case ;  and other  surgeons  of the most extensive expe-
rience, have never seeu an example of the  injury.   Malgaigne
has a report of several cases, though some of them were  com-
plicated Avith fracture, aud others may have been mistaken for
that kind of  injury.
  The displacement may be caused by excessive pronation or
supination of the  hand, as by wringing clothes, or seizing a
child by the hand as  it  is falling, giving the arm a violent
tAvist.
  The displacement  is accompanied Avith rupture of the sacci-
form ligament, and as the hand goes with the radius, the car-
pal connection with  the ulna is broken, allowing  the styloid
process of the ulna to form a marked prominence, if it does
not actually pierce the skin.
  The displacement  may be forwards  or backAvards; the for-
mer is the most common accident.  In the forward dislocation
the hand is held firmly in a state of pronation, with the fingers
someAvhat flexed ;  the axis of the little finger no longer corre-
sponds Avith the ulna; and the Avrist has a peculiar contorted
appearance not met in any other injury.
  The reduction is to be effected by extension applied to the
hand, supinating it at the same time.  The radius and  ulna
must also be pressed into their natural  relations Avith each
other, Avhile the extending and supinating forces are applied.
  In the backward dislocation the  signs of the displacement
are in some respects  the reverse of those in the other variety
of luxation;  the  hand  is powerfully  supinated,  the fingers 
348
Dislocations.
being moderately flexed, and the Avrist having a peculiar twist
in it Avhich is not a deformity belonging to a fracture.
  The reduction is to be accomplished by extension and pro-
nation exerted upon the hand, Avhile an effort is made to press
the tAvo  bones into their normal relations Avith each other.
  As there is great liability to a recurrence of  either form of
luxation, Avhile the torn ligaments remain ununited, the fore-
arm and hand should be dressed Avith the same appliance  re-
commended for the treatment of a fracture through the loAver
extremity of the radius.  The  dressing should be  worn  for
two  or  three weeks, and  then the arm ought not to be sub-
jected to  pronating  and supinating forces for six or eight
Aveeks more.
  In a ca?,e of alleged malpractice  that never came to trial, I
had an opportunity to see Iioav medical men  of considerable
experience Avill differ in regard to the nature of a surgical
injury.  The defendant in the  case Avas charged  A\ith   not
having discovered aud treated a dislocation of the ulna from
the radius, the allegation being that the young woman  Avas
seriously damaged by said neglect.  The prosecutrix had been
thrown  from a wagon, aud in the fall sustained an  injury of
the Avrist.   The physician  having the case in  charge did   not
discover a lesion beyond that of a sprain, aud applied a band-
age to the hand and wrist, and ordered  arnica applications.
Iu the course of a few months a peculiar and marked laxity
of the ligaments of the Avrist came on,  so that  the  patient
could voluntarily make  an aAvkward deformity at that joint.
In some of these forced  attitudes or positions, the limb  ap-
peared as if the hand and radius had been forcibly separated
from the ulna, or that the ulna  had been torn loose from  the
radius,  hence the  charge  of malpractice.  Before the trial
came off the girl saAv several eminent  surgeons in the coun-
try, and all advised her to drop the suit  on  the ground  that
no real luxation existed, but that her Avrist had been so injured
that the soft tissues,  especially the ligaments, Avere rendered
unnaturally pliant  or yielding; that loose joints in any part
of the body were not uncommon, particularly in the young.
There Avas evidently an hysterical complication which in some
instances will produce queer conditions of the body.
  Six physicians of the place Avere ready to swear that dislo-
cation existed, but the limb at length became as useful as the
other, aud scarcely more deformed. 
CHAPTER  IX.
DISLOCATION   OF  THE  WRIST.
   The older surgical writers, back to the time of Hippocrates,
 regarded dislocation of the hand or carpus from the lower
 end of the radius and ulna, as an accident  of frequent occur-
 rence, but within fifty years it has been  ascertained that the
 injury is exceedingly rare, and that most of those lesions once
 regarded as dislocations are noAV presumed to have been frac-
 tures  of the loAver extremity of the radius.  This error of
 diagnosis was suspected  by Pouteau, and positively avoAved
 by Dupuytren who gave the subject great  attention.  It  is a
 matter of no little surprise that the surgeons  of a century ago
 so often met Avith dislocations of the wrist, and that  Dupuy-
 tren and his follOAvers should have found so  few.  Although
 it is quite evident that fractures of the inferior extremity of
 the radius were  once thought to be luxations  of the wrist, the
 bold assumptions of Dupuytren have not been fully sustained
 by critical observers of more recent times.  Dislocation of the
 carpus  upon the radius and ulna  is undoubtedly a rare form
 of accident, yet  the lesion is proved by dissection to have had
 an  existence.   In  some  instances the dislocation  has been
 compound, and in others it is complicated with fracture of the
 rim  of the  articular cavity at the  lower extremity of  the
 radius.
  The displacement may be in either of two directions, back-
 wards or fonvards.   In the former variety the carpus is thrown
 upon the dorsum of the Avrist, and the ends ofthe radius and
 ulna form an abrupt prominence on the palmar aspect of the
 carpus.   The general aspect of the wrist is that of fracture
 of the radius, yet a careful examination of the parts Avill  de-
 termine the difference betAveen the  two injuries.  In fracture
of the radius the deformity can be mostly overcome by seizing
                          (349) 
350
Dislocations.
the hand and making extension, and when this force is re-
moved and the limb is left  to itself unconstrained, the defor-
mity at once  returns; in dislocation  of the Avrist backwards,

                         Fig. 116.
Dislocation of the carpus backwards.
great reducing poAver is, required to restore the parts to their
normal places, and when once reduced they Avill stay in place.
  In September, 1863, Peter Sullivan, a laborer, while  exca-
vating a bank of earth in the vicinity of the city, fell from  a
ledge six or eight feet in height, and struck on the knuckles
of his right hand which grasped the boAvl of a large brianvood
pipe.  He sustained a severe injury of the Avrist, compelling
him to  abandon  his  Avork  and come to the city for surgical
attention.   He Avalked to the street railroad and then rode to
my office.   I found the  Avrist  appearing much as it does in
fracture near the loAver extremity af the radius, though Avith
sufficient difference in  several respects to institute a  more
thorough investigation of the lesion.  The Avrist Avastoo rigid
for  fracture, the elevation on  the back of the Avrist Avas  too
abrupt for the usual dorsal tumor attending a broken radius,
and the  palmar lump  was too near  the hand.  The fingers
Avere flexed; and the styloid processes of the radius and ulna
could be felt occupying the same plane, Avhich is not the case
in fracture.   The arm just aboA7e the dorsal tumor maintained
its usual Avidth and flatness, and was not rounded as it is found
after fracture of the radius through its loAver extremity.
  I attempted to  reduce the dislocation, for such it Avas, by
taking the patient's hand in mine, and making extension ; but
he complained so much of pain as soon as I  used  any fore£,
that I administered to him enough  chloroform to deaden his
sensibilities and to relax his muscles to some  extent.  I then 
Of the Wrist.                   351
made extension with  one hand, first flexing the Avrist a little
to get the thumb of the other hand so it could both act as  a
fulcrum as I applied extension and push the carpus fonvard
into its relative position with the radius and  ulna.  I had to
use  considerable force  to  effect reduction  Avhich  was  an-
nounced by an audible snap.  I then dressed the Avrist in  a
bandage for a feAV days, when the patient claimed to be Avell,
and I lost sight of him.  In this case I  endeavored to ascer-
tain whether the muscles or the untorn ligaments opposed re-
duction ; and could not solve the question, though it seemed
to me that the tendons and their sheaths offered  the greatest
obstacles.
  A dislocation ofthe carpal bones forwards is an injury more
seldom met than the backAvard  displacement.  The accident
is  produced by falls, the  hand  so striking as to force it into
extreme extension.    The displacement  is easily recognized
by the character of  the deformity.  The loAver extremities of
the radius and ulna form a Avell marked projection backwards

                         Fig. 117.
Dislocation of the carpus forwards.
 and the carpus fonvards.  The  styloid processes  of the  two
 forearm bones are so prominent and Avell defined that no mis-
 take  could  be made in regard  to  the nature of the injury.
 The wrist and  hand are rigidly stiff, and can not be made to
 assume their natural relation in  regard to  the  forearm, as in
 case of fracture.
  There are some congenital defects of the Avrist which present
 the  appearances of dislocation,  but they are  quite different
 from an ordinary luxation  produced suddenly by violence.
  Reduction of  a dislocation of  the carpus forwards is  to be
 produced by bending the hand a  little more backward so as to
place the thumb Avell against it in the  capacity of a fulcrum
and to help press the bones into  place Avhen extension is made 
352  •                 Dislocations.
by the surgeon, grasping the patient's hand in his own and
making poAverful extension.  After reduction is accomplished
the Avrist may be treated to a cooling and anodyne lotion, and
used with care until the lacerated ligaments are healed.


DISLOCATION  OF  THE  BONES  OF THE CARPUS
               FROM ONE   ANOTHER.

  There is a popular notion that some  of " the  little bones  in
the Avrist" may get out of place; and in fact, it has been
shoAvn by dissection that the carpal bones may be displaced.
The head of the os magnum suffers a partial  luxation from
the cavity formed for it by the scaphoid and semi-lunar bones.
The displacement, observed mostly in females of a lax condi-
tion of the ligaments, is caused by forced flexion of the Avrist,
either in falls, or from accidents  in  which a severe twist is
given to the hand and  wrist.  The nature of the injury is re-
cognized  by an unnatural projection  on  the  dorsum of the
carpus, Avhich  increases Avhen the  Avrist is  flexed, and dimin-
ished Avhen it is extended.
  The reduction can generally be  effected  by  pressure upon
the tumor, especially if extension be  made at  the same time
upon  the fore- and middle-fingers.  When once reduced the
bone  should be held in  place by a compress and bandage.
  Richerand once met Avith a luxation  of the os magnum
Avhich happened  to a woman  in  the throes  of labor.  She
seized the edge of her mattress aud squeezed it forcibly, turn-
ing her  Avrist fonvards.  She heard  something snap,  and a
tumor immediately formed on  the back of her Avrist, which
gave  her great pain.  The  extended hand showed no  defor-
mity, and the  difficulty never received any treatment.   Cho-
part reports having seen a similar case ; and Bransby Cooper
says :  " I have known  the os magnum to  be dislocated back-
Avards from its articulation Avith the scaphoid and lunar bones.
The  subject of this accident Avas a carpenter, an out-patient
of my colleague, Mr. Calhaway.  In this case,  the appearance
Avas that of a hard fixed tumor on the dorsal surface of the
carpus :  the man described the injury  to have been originally
caused three years before, by a very forcible grasping exertion
of the hand.  The  displacement  frequently recurred, and  he 
Of the Wrist.                  353
 could generally slip  the  bone back into its place by pressure
 of the thumb."
   Similar dislocations of  some ofthe other carpal bones have
 been recorded.  Erichsen mentions having seen dislocations
 of the semilunar and pisiform bone.  The latter Avas displaced
 by an effort to lift a heaA-y weight, and the bone Avas drawn up
 the arm to  the distance of nearly an inch by the flexor carpi
 ulna lis.
   A case is  reported by Maisonneuve, of simple dislocation
 backAvards  of the second  row of carpal bones from the first,
 caused b}' a fall from a height of forty feet.   The  nature of
 the injury Avas verified by dissection.
   The different bones ofthe carpus are so firmly bound together
 with ligaments, and so strongly held in place by passing ten-
 dons, that no ordinary accident is  likely  to displace  one or
 more of them.  A bloAv of the nature of a driven punch, and
 a gunshot  wound, very frequently displace these bones, but
 the nature of the injury differs  essentially  from ordinary dis-
 locations, and has no claims to be considered in this connection.


   DISLOCATION  OF   THE  METACARPAL BONES.

   Displacement of the metacarpal bone of the thumb from the
 os trapezium, either forwards or backAvards, is possible, though
 the  injury is  not  common.   The backward luxation is the
 most  frequent, and is   caused  by a fall upon the  thumb,
 throAviug it into a state of extreme flexion.   The fonvard dis-
 location may be caused by a force  throwing the thumb vio-
 lently backward, or  by  direct  violence.   In a case  coming
 under my observation the displacement was caused by the fall
 of a  heaA7y  rock Avhich  struck the metacarpal bone  of the
 thumb near its carpal extremity, and forced it inwards or for-
 wards.  The soft tissues covering the bone  at the seat of in-
 jury were severely bruised, but the dislocation  Avas not thus
 rendered compound.  The injury Avas recognized by pressing
 the  fingers  into the  depression caused by the displacement,
and  by other ordinary signs  of luxation.   Chloroform Avas
administered, when by extension and pressure in the  holloAv
of the hand against  the projecting  bone in that region, the
reduction was accomplished.   The backward luxation is the
      23 
354
Dislocations.
easiest to reduce, though the assistance of anaesthesia may be
needed  in  successful  attempts  to  reduce either form of the
injury.
  Malgaigne has collected accounts of dislocations Avhich hap-
pened to three other of the metacarpal bones.  In one of them,
Uourguet's case, the carpal extremity of the metacarpal  bone
of the index finger was displaced forwards by a great and
sudden  force being applied to the back ofthe hand.  A great
depression at the point of luxation  indicated the nature of the
injury.  Reduction was effected by extension applied to the
finger and pressure made in the palm near the thumb.  In the
case seen by Roux, there was a backAvard luxation of the me-
tacarpal bone of the great finger.  The accident happened in
a mine, from the explosion  of blasting poAvder.  The  promi-
nence of the bone on  the dorsum of the  hand indicated the
nature of the difficulty.   Reduction Avas effected by extension,
and pressure on the  displaced  bone. There Avas ahvays a
tendency to  reluxation  Avhen  the hand Avas straightened.
Hamilton mentions having seen  one case of luxation of the
metacarpal bones of the index and great fingers, the accident
being caused by a blow gi\Ten with the fist or clenched hand.
It Avas an old case, the bones becoming reluxated after having
been reduced.
  The carpo-metacarpal articulation  of the thumb closely re-
sembles a ball and socket joint, hence a luxation Avould  have
to be managed  on principles that  govern the overcoming of
dislocations  of  the shoulder and hip.  In other Avords, the
articular head of the bone Avould be forced through a rent in
the capsular ligament; and a  return of the bone must be
through the aperture of escape.  The reduction  is not to be
brought about  by forcible  extension  and counter-extension,
but by the manoeuvre  of  placing the thumb in the attitude it
assumed Avhen  luxation occurred,  and then prying the  head
of the bone into place, the operator's tliumb being used as a
moving or sliding fulcrum in the application  of forces.  And
because the leverage is so restricted it is not easy to overcome
this dislocation. In fact, the feat is nearl}T impossible unless
the patient be put under the influence of an anaesthetic. 
CHAPTER  X.
DISLOCATION OF  THE  PHALANGES.
  Dislocation of the First Phalanx of the Thumb.—This
injury is of frequent occurrence ; especially the backward dis-
placement, the end of the  first phalanx being throAvn upon
the extremity of the metacarpal bone.  The cause is generally
a fall upon the end of the thumb, or upon the last knuckle of
that digit.  The  symptoms are so distinctly marked that there
is  no danger of error in the diagnosis.  The pain is great;
there is inability to move the joints of the thumb ; and the
bones being sparsely covered,  the  displacement becomes
strikingly apparent.
  The reduction is not difficult, though the older surgical
writers speak of subcutaneously dividing the lateral ligaments
of the joint, and the tendons of the flexor muscles.  I  have
reduced this dislocation several times, and have  never found

                        Fig. 118.
            Dislocation of the first phalanx of the thumb forwards.

any serious trouble in the  operation.  In  either form of dis-
placement I extend  or flex the luxated digit to get my own
thumb well placed against  the end of the  dislocated bone,
then I make extension and at the same time push the phalanx
into place.   I have never 3'et met a case that required the use
of a tape, or other appliance to fasten upon the thumb, as a
                          (355) 
356
Dislocations.
means of obtaining a better hold for the purpose  of making
extension.
  Mr. Flower says : " After a fair trial of all the above mea-
sures, reduction has still been  unaccomplished in so many
cases, that both the cause of the difficulty and  the means by
Avhich it ought to be overcome, have become a  standard  sub-
ject for research and speculation among surgeons of all coun-
tries.  Although much difference of opinion has certainly ex-
isted upon this point, the majority of writers have agreed that
the flexor brevis poinds muscle is in some way the chief ob-
stacle to reduction.  Dissection of dislocations artificially pro-
duced upon the dead subject, shoAVS that Avhen  the phalanx is
completely carried on to the dorsal surface of the  metacarpal
bone, the two attachments of the flexor brevis, Avith their con-
tained sesamoid bones, slip over its Avide head, and tightly
embrace its neck.  It is evident that the bone can only be dis-
engaged from this situation with difficulty.   The only success-
ful Avay hitherto devised to overcome this, is the subcutaneous
section  of one, or even both  of the tendons of the muscle.
The cause of occasional failure of even this  someAvhat  severe
proceeding is, I believe, the  difficulty of effecting  a complete
division of all the  opposing fibres.   I have found, in the  dead
subject, that  a division of-the fascia Avhich connects together
the tAvo sesamoid bones, by allowing the tendons to separate
from each other, quite up to their insertion, materially facili-
tates reduction, without resorting to the section of the  muscle
itself; but I  have not yet had aii  opportunity of trying this
on the living."  Dr. Humphrey, also on anatomical grounds,
recommends  an endeaAror to draAV the sesamoid bones for-
wards, by means of blunt hooks inserted through  an incision
in the skin.
  Hamilton failed in one case to effect reduction, though he
used chloroform, and the " Indian puzzle."  The parents  of
the girl Avould not allow the flexor tendons and lateral ligaments
to be divided, so the patient had to go Avith the thumb still
dislocated.   If a surgeon of his ability and experience failed
to effect reduction, there are occasionally cases  that Avill baffle
the skill of the most expert.
  I hold  to the  opinion that there  is something radically
Avrong  in the usual manner of applying the reducing forces
The dorsal  dislocation is produced by forced flexion of the 
Of the Phalanges.                357
 thumb ; and as soon as the displacement occurs, the digit re-
 turns part way from this extreme flexion.  Now, in a rational
 attempt at reduction, the thumb should be carried to the ex-
 treme point of flexion, and the thumb of the surgeon should
 then hold the displaced bone  so  it can not slip when the
 patient's thumb is extended.  It is clear that by this manoeuvre
 the surgeon's thumb  acts the  part of a fulcrum, while the
 patient's digit is employed as a lever to pry the dislocated bone
 into place.  In the palmar dislocation, the reverse of the above
 movements should be folloAved.   Dislocation takes place from
 forced extension, and then the thumb falls back towards its
 normal attitude ; reduction, therefore, is to be  accomplished
 by tilting  the  digit backAvards to the point it Avas forced to
 assume before luxation occurred, and then the displaced end
 of the phalanx being held rigidly Avhile  flexion is made, suc-
 cess attends the manoeuvre.  At least the plan is right, and if
 it fail once it may be tried again, and repeated until the re-
 duction  is accomplished.
   Dislocations of the First Phalanges of . the Fingers.—
 The first phalanx of the index and little fingers are more fre-
 quently luxated than the corresponding bones of the great and
 ring fingers.  The more exposed positions of these digits con-
 tribute to the frequency of the accident,  though such lesions
 are quite rare.  I have seen a fonvard dislocation of the fore-
 finger, which Avas caused by the digit being caught in a cog-
 wheel ; and a dislocation ofthe little finger backAvards, AAiiich
 was produced  by the  explosion  of poAvder in a flask.   The
 deformity in  both cases Avas quite distinct, especially in the
 little finger.  The abrupt projection of the displaced bone Avas
 distinctly seen and felt.  In the forefinger the nature  of the
 injury Avas not so apparent, though by a little manipulation
 the displacement became too evident to be mistaken.
   The reduction was effected by extension and a pushing of
 the bones into place, the luxation being managed on the plan
 of first tilting the luxated digit backwards in the forward dis-
 placement, and forwards in the  backAvard  displacement, the
 reason for Avhich being already given in  the directions for re-
 ducing the first phalanx of the thumb.
  Dislocation of the  terminal phalanx of the thumb, or of the
second and third phalanges ofthe fingers, is an accident easily
recognized.  Falls or blows upon the ends of the digits  com- 
358                   Dislocations.
 monly produce the displacement.  The  reduction would be
 reasonably easy if a  firm hold Ave re practicable.  Although
 the " Indian puzzle," a cylinder of basket-Avork, made to ap-
 pear like a snake in the act of sAvalloAving the finger, is highly
 recommended to secure a fastening, yet I have had no  occa-
 sion to use the cunningly devised toy for the purpose of ap-
 plying adequate extension.  The strength of my own fingers
 has thus far proved sufficient to effect reduction.
   The violence done to the  digital articulations  in cases of
 dislocation, is apt to be followed by a high degree of  inflam-
 mation, endangering the condition of anchylosis.   In  rare in-
 stances, complicated with severe injuries  to the joint  and its
 investing tissues, it may be best to amputate, to avoid  tetanus
 and other serious complications.
  The game of base-ball has greatly increased the number of
phalangeal luxations.  Such extreme exertion is given to the
act of catching a hard, heavy, and SAviftly moving ball, that
injuries to the fingers are not thought of, hence the frequency
of digital  dislocations.  And the  lesion  is frequently of the
compound  character, therefore the more  serious.  The luxa-
tion is commonly produced by the ball being received on the
end of the finger extended to  guide the  missile into the hol-
low of the hand.   The injury may occur at either of the pha-
langeal  joints, and at the metacarpo-phalangeal articulations.
The  displacement is   attended with keen pain, yet  excited
players  have been knoAvn to keep on Avith the game after  a
dislocation had been sustained.
  In  the  management of a dislocated finger after reduction
has been effected, little need be advised except that the injured
digit be alloAved to rest a fe\v days under cooling lotions, and
then  begin  passive motion  to prevent anchylosis.   In most
instances, unless the cartilages be crushed, the injury will be
overcome  Avithout permanent  stiffness.
  It may be Avell to  remark  that if anchylosis  must take
place, the finger should be kept in a partially flexed state.   A
stiff* finger in an extended or straight attitude is an awkAvard
affair. 
CHAPTER  XI.
DISLOCATION  OF  THE  FEMUR.
  PoAverful forces are often brought to bear on the shaft of
the femur as a lever to dislodge the head of the bone from its
deep socket.  The capsule of the joint is strong, and its an-
terior and inferior aspects are strengthened by that aggrega-
tion or reinforcement of fibres, called the ilio-femoral ligament,
to say nothing of the protecting influences of the ligamentum
teres and the cotyloid ligament.
  According to the statistics of Malgaigne, .collected at the
Hotel Dieu, the hip stands next to the shoulder in the relative
frequency of displacements.
  There Avere, of  491 cases of dislocation,—of the
Shoulder...........................................321
Hip................................................... 34
Clavicle............................................. 33
Elbow.............................................. 20
Foot................................................. 20
Thumb............................................ 17
Wrist................................................ 13
Fingers................................................7
Jaw......................................................7
Knee...................................................6
Radius.................................................4
Patella.................................................2
Spine...................................................1
  These tables sIioav that about ten dislocations occur at the
shoulder-joint where one happens to the hip, yet the latter
articulation is more frequently luxated than the thumb or jaw
Avhich are generally supposed to  be specially liable  to such
accidents.  It is  possible that the statistics of Malgaigne do
not justly represent the relative liability of each joint to lux-
atiou ; yet tables  collected in other Hospitals shoAv that the
hip-joint is one Avhich often suffers luxation.
,  The lesion is  more  common to men than Avomen, for the
obvious reason that males are most exposed to  such  violence
as produces these graver accidents  of life; and  the injury is
mostly confined  to ages ranging  from  twenty to forty-five,
embracing a period of life devoted to enterprises fraught Avith
         The earliest recorded age at which dislocation at the
                          (359)
dan get 
360                   Dislocations.
  hip has occurred, is eighteen months, and the oldest, eighty-
  six years.  During  childhood a force competent to dislocate
  the femur would be more apt to separate the epiphyses of the
  bone;  and after the age of fifty, the bones become  so brittle
  that fracture of  the neck of the femur is more liable to occur
  than displacement of the head of the bone from the acetabu-
  lar cavity.
     Much has been Avritten concerning spontaneous dislocation
  of the hip  arising from disease of the joint during  early life,
  but complete luxations from such a cause must be exceedingly
  rare; and  they  are of a nature not to be considered in this
  connection.  According to  Cooper, persons have existed Avho
  possessed the power of voluntarily dislocating their hip, and
  again reducing it.   Paralysis ofthe muscles on one side of
  the joint, has been known to effect dislocation in the opposite
  direction.                                        ,
—    Dislocation of the coxo-femoral articulation resulting from
  violence, may occur in four directions :
     1st.  The head of the  bone  may  be forced upwards, and
  more or less backwards, upon the dorsum ilii.
     2d. Far  backwards, and slightly  upAvards, into  the great
  ischiatic notch.  This is really a modification of the preceding
  and not a distinct form of luxation.
     3d. DoAvnwards and iiiAvards, into the obturator foramen.
     4th. Upwards and inwards, upon the body of the pubes.
     These last two displacements belong to  one form, viz., the
  dislocation  imvards, the range upAvards  to the pubes, and
  doAvnwards to the thyroid  foramen depending much upon the
  direction of the force received, or  some modifying  circum-
  stance.  The same observation may be made concerning the
  first two mentioned forms of displacement, it being positively
  known that the  head of the bone may occupy both positions
  in a single accident, or during attempts at reduction.  There
  is no precise spot where the head  of the bone ahvays  rests
  when dislocated, but a Avide range is given to the position oc-
  cupied.  The different attitudes assumed by the toes and foot
  in different cases clearly indicate that the head  of  the femur
  is subject to considerable variety of  position.
     The relative proportion of the different varieties of displace-
  ment, is, according to Sir A. Cooper, the folloAving: in tAventy
  cases of all kinds, there AAill be twelve on the dorsum ilii, five 
Of the Femur.
361
 into the ischiatic notch, two into the obturator foramen, and
 one on the pubes.   Or, considering only two varieties  of dis-
 placement, there will be seventeen backAvards, and  three for-
 wards, shoAving a vast preponderance in the backAvard direc-
 tion.  In seventeen cases observed by Malgaigne, eleven were
 either iliac  or ischiatic, four pubic, and  two obturator,  or
 eleven backAA^ards and  six  forwards.  Of the 104 cases col-
 lected by Hamilton, eighty-three were backwards, and twen-
 ty-one fonvards, or in the ratio of four in the former direction
 to one in the latter.
   Backavard and Upavard Dislocation.—In the common dis-
 location backAvards, the head of  the femur wholly leaves the
 articulation, and takes a position on the outside of the socket,
 resting on  the dorsum of the ilium, or betAveen the gluteus
 maximus and medius, or as far back as the pyriformis mus-
 cles.  The great displacement necessitates the  rupture  of the
 teres and capsular  ligaments.  The small rotator muscles are
                            put greatly on the stretch, or are
                            more or less lacerated.  The lux-
                            ation is attended with consider-
                            able  effusion  of blood  in  and
                            about the  joint, and  the parts
                            implicated in  the injury are apt
                            to bear marks of violence.
                              The symptoms of the disloca-
                            tion are strongly marked,  and
                            characteristic of the injury : the
                            limb is shortened from  one  to
                            three inches, commonly from an
                            inch and a  half to two inches ;
                            it is inverted, slightly flexed, and
                            inclined forwards and inwards,
                            the  toes resting on the opposite
                            foot  near the  ankle; the great
Dislocation of the head of the femur up-     ,        .    ..  ,   „      ,
 wards and backwards, upon the dorsum  trochanter   IS  tilted  forwards,
 of the ilium.                     .
                            giving a full  appearance  over
and  just above the acetabulum, and the head of the femur,
in thin persons, can be felt beneath its gluteal covering, in its
neAV position.  The limb is rigid,  and can not be elongated,
extended, or abducted Avithout great  pain ;  it may be  flexed,
adducted, and rotated inwards, in  a moderate degree, Avithout
 
362                   Dislocations.
creating much distress.   It is useful in determining the posi-
tion of the head of the bone, to have the  patient take the
erect attitude, standing on the sound limb.   The great toe of
the luxated limb will then approach the instep of the opposite
foot, and the knee will press against the opposite thigh some-
what above the patella.   The pain in the region  of the dislo-
cated hip, extending to the knee and foot of the  affected side,
is intense, and the patient carefully guards against all motion.
  The  causes of dislocation of the  coxo-femoral articulation
are of a multiple character, though the displacement is usually
produced by a fall, in which the force coming in  contact with
the foot or knee, carries the limb in front of  its fellow and as
high up as the abdomen and perhaps to the thorax, the femur
being converted into a lever of the first  power, the anterior
edge of the  acetabulum constituting a fulcrum, the head and
neck of the bone  being  the  short  arm  of  the  lever,  Avhich
overcomes the weight or resistance, Avhich is the  capsular and
other ligaments.  If the pelvis be held firmly in  the cadaver
and the flexed leg and thigh be forced into extreme adduction
or across the loAver part of the trunk, the coxo-femoral liga-
ments Avill be heard to snap ; and if an outvvard force, exerted
parallel to the femur, be now imparted to the limb, to  corre-
spond with a poAver that would come from living muscles, the
backward dislocation will be accomplished^  It is difficult for
me to  understand Iioav the outAvard dislocation can be pro-
duced in any other manner.   It is possible that the fall of a
mass of earth  or  other  heaA'y weight, upon the back  Avhilst
the body is bent forward in a  stooping posture, may produce
the backward  dislocation of  the hip, but it seems to me the
violence must be done to the joint by the  thigh being doubled
under the descending trunk, the lower end of the femur acting
as a lever to pry the head of the bone out of its socket.  In
December, 1867, Gus. Bovine, living on Freeman  St.,  fell in
a tobacco manufactory on Sixth Street, and  struck  his  right
knee against a tobacco hogshead that laid upon its side under
a hatch  through Avhich the  fall occurred.  A couple  of his
fellow workmen, avIio Avere standing near when  the accident
happened, said they distinctly heard the breaking sound in the
joint as distinct from that of the collision.  Be this as it may,
the outside  of the knee Avas bruised, showing the point hit;
and Avhen the patient Avas raised from the prone position in 
Of the Femur.
363
 which he lay, the dislocated thigh Avas found at a right angle
 with the trunk, and beneath the loAver part of the abdomen.
 When I saw the patient first he had been taken to his home;
 and his leg occupied the usual position that it does in disloca-
 tion of the hip : the great toe Avas resting on the tarsus of the
 opposite foot, the knee pressed the thigh of the well limb, just
 above the patella, the great trochanter Avas rotated forwards
 and occupied a position nearer the anterior superior spine  of
 the ilium than natural, and the normal contour of the region
 of the hip  indicated  luxation.   By rotating  the limb, Avhile
 the fingers were pressed doAvn upon the head of the bone, its
 rotundity could be discovered and the motion distinctly felt.
 The leg was stiff,  and many of the muscles appeared tense and
 others relaxed, so that the limb felt as if under the influence
 of distorting forces.  I gave the patient chloroform, and re-
 duced the displacement by the " physiological" 01 manipu-
 lating plan.
   When  a  femur  is recently dislocated upon the dorsum of  ^
 the ilium, the shortening is more apparent than real.  If the
 patient rest straight upon the back, and the legs be arranged
 parallel Avith each  other, and perpendicular Avith the trunk,
 measurements  will show that the dislocated leg is not more
 than an inch shorter than its felloAV.  But it is impracticable
 to bring the limbs parallel with each other unless the patient
 be under the influence of an anaesthetic, and then  the dislo-
 cated leg will have a strong inclination to  flex, and tAvist in-
 Avards.  If the dislocation be left unreduced for several days,
 it Avill be found that the shortening of the limb has increased
 from one inch to tAvo inches.
   Diagnosis  in the Backavard Luxation of  the  Femur.—
 The common signs of dislocation of  the femur backwards
 have  been already noticed, but  the  fact has  not been men-
 tioned in this  connection  that there is a slight resemblance
 between the features of a luxated hip and those A\iiich belong
 to a fracture  of the neck  of the femur within the capsular
 ligament.   In the shortening of the limb they agree,  but in
 almost every other respect they differ.  In fracture, the  limb
is everted, and more moveable than in dislocation; it  is also
capable of elongation by  moderate extension, but becomes
shortened on the remission of the extending force.  Fracture
occurs mostly in old people, and from slight causes ; and ere- 
364
Dislocations.
  pitus is a sign indicating the nature of the injury AA'hen that
  sound can  be  obtained, and  it generally can be elicited by
  slight rotation  of the limb Avhilst extension is being applied.
  In comparatively rare cases the limb is inverted after fracture,
  so that in this peculiar feature resemblance to  dislocation ex-
  ists, yet the remaining characteristics ofthe two injuries—the
  differential signs—are generally plain and distinctive.  Robert
  Wm.  Smith, in his Treatise  on Fractures  in the Vicinity ofthe
  Joints, Case XXIX, reports as folioavs :  " Patrick Murphy, set.
  80, transverse serrated fracture of the  neck of the femur ex-
  ternal to the capsule, at the line of junction of the cervix Avith
  the  shaft of the bone:  a  second  fracture detached the tro-
  chanter major, Avhich  was draAvn  upwards and backAvards,
  carrying with it the insertions of the pyriformis, gemelli, and
  obturator muscles.   The trochanter minor Avas likewise sep-
  arated from the shaft of the femur, and along Avith it, the in-
  sertion of the psoas and  iliacus interims ; a large quantity of
  blood  Avas poured out betAveen the fragments, and among the
  muscles around the joint.   The limb Avas shortened two inches,
  the foot inverted, and the entire limb in a state of adduction ;
  the  trochanter major could  be felt upon the dorsum of the
  ilium,  a little above the situation of the sciatic notch.  This
  case was at first supposed to haA'e been an example of luxation
  upon  the dorsum  of the  ilium.  The  patient died upon the
  fourteenth day after the  accident."   The case is reported to
  show that a comminuted fracture of the  upper extremity of
  the femur may resemble a  dislocation in so many respects as
  to be mistaken for that injury,  even by surgeons of the greatest
  experience and acumen.  However, Mr. Smith does not  state
 whether the limb was rigid as in dislocation, and no mention
  is made of the diagnostic mauceuvre of extending the limb to
  ascertain if it could be easily elongated, and if so, Avhether upon
  relaxing the force the shortening Avould be resumed.  These
  differential signs, taken  in connection Avith the advanced age
  of the patient, ought to decide a  doubtful case.  It is pre-
  sumed that the faulty  diagnosis resulted from  placing too
  much importance upon the adduction and  inversion.
   Fracture ofthe acetabulum  is another injury Avhich permits
, the limb to assume many of the aspects  peculiar to dislocation
  of the hip.   Several examples of the kind are  given by
  Cooper, Malgaigne, Earl, and others.  The shortening and in- 
Of the Femur.                  365
 version of the limb AAiiich characterized some of these cases,
 was due either to the head of the bone being  driven through
 the acetabulum into the pelvis, or to its escape from the ace-
 tabulum through the superior and posterior border of that
 cavity.  In  the event of a fracture of the cotyloid border, al-
 lowing  the  head of the bone to escape, the reduction Avould
 be comparatiA^ely easy, but there being no obstacle to a recur-
 rence of the displacement, the dislocation would be repeated
 as soon as the extending and restraining forces Avere removed.
 Arthritis, rheumatism, contusion, spasm of the muscles, and
 other injuries  and complications of a pathological  character,
 may be mistaken for dislocation, and be  treated accordingly.
 It may be remarked that some mysterious defects  about the
 coxo-femoral  articulation, which Avere not  dislocations, yet
 treated  as such by presumptuous  " bone-setters," have been
 benefited by their senseless manipulations.
  Dislocations of the hip have been overlooked, owing  to
 some complication  or perplexing circumstance.   Fergusson's
 Surgery contains the folloAving example :  " A young Avoman,
 about her full time of pregnancy, had a severe fall, and Avas
 carried  to  bed in a helpless  condition; labor came on imme-
 diately after, and she had a difficult time.   A severe  rheumatic
 fever, as it  was supposed, came on, and  for some Aveeks her
 life was despaired of."  Mr.  Fergusson Avas  asked  to see her
 when she Avas comparatively Avell,  about three months after
 the accident, and then, for the first time, a dislocation  of the
 hip was detected.   The same surgeon also relates another case,
 where a dislocation of the hip was complicated Avith a fracture
 of the femur in its  loAver third, and the dislocation Avas not
 detected till it Avas  too late to attempt its  reduction.
  The ischiatic variety of the backAvard  dislocation is not  a
 primary form  of displacement, but consecutive to the luxation
 upon the dorsum ilii.   The same kind  of  violence Avhich pro-
 duces the ordinary backAvard and  upward  dislocation, may
 also throAv the head of the bone a little farther backAvard into
 the great ischiatic notch, Avhere the head of the bone rests on
 the pyriformis muscle and against the sacro-sciatic  ligaments.
 The symptoms are substantially the same  as  those  belonging
to the iliac dislocation, though the shortening is not so great;
the distance between  the great trochanter and the anterior
superior spinous process of the ilium is increased  (instead of 
366
Dislocations.
diminished, as in the primary variety of the backAvard dislo-
cation), and the head of the femur is too deeply buried in the
ischiatic region to be felt, except in very spare subjects.  In a
patient Avho  came under the observation  of Dr.  Gross, the
head of the femur could be distinctly felt in the sciatic notch,
" rolling under the finger when the limb Avas rotated upon its
axis."  The  author does not  state Avhether  the patient was
emaciated or  not, though  it is presumed  from this circum-
stance  that he Avas.  Taking all the  symptoms of ischiatic
dislocation into  consideration, it Avill  be  observed that this
variety of displacement causes someAvhat less deformity in the
limb than the dorsal luxation : thus the shortening rarely ex-
ceeds a half inch, the point of the great toe rests on the top
of the  great  toe of  the sound side, the knee  projects but
slightly beyond the other,  and the adduction, inversion, and
flexion, are less than in the other variety.   The limb is fixed,
and all voluntary movements are lost.  It is quite  probable
that one variety  of the luxation is sometimes mistaken for the
other.  Mr.  Cooper  says that  the  ischiatic  dislocation  is
" most difficult both  to  detect  and reduce," there being less
deformity and less fixture of the limb  than in any other of
the displacements of  the thigh-bone.  " This obscurity (says
Mr. Syme,) is much increased by attempts to effect reduction,
since a moderate degree of extension almost entirely removes
the shortening and the inversion, Avhich are usually considered
the most characteristic  symptoms.  1  think  it, therefore, of
consequence to state, that there is another feature of the injury
which, according to my experience, is never absent—ahvays
well marked—and  not met  with in any other injury of the
hip-joint, Avhether dislocation, fracture, or bruise.  This is an
arched form  of the  lumbar part of the spine, which can not
be straightened  so long as the thigh is straight, or in a line
with the  patient's trunk.  When the limb is raised, or bent
upward upon the pelvis, the back rests flat  upon the bed; but
as soon as the limb is allowed to descend,  the back becomes
arched as before.  By attention to this symptom, I have been
enabled to recognize the existence of dislocation into the ischi-
atic  notch, Avhen it  had been unnoticed by others ; and on
one occasion, Avhen it was supposed that the replacement had
been effected through powerful extension by the pulleys." 
Of the  Femur.
367
  Whether the ischiatic  dislocation be consecutive upon the
dorsal displacement or not, it is quite certain that in attempts
to reduce  one variety of dislocation the other may be pro-
duced.  Many cases are reported in Avhich the efforts at re-
duction baffled the  surgeon by the tendency of the head of
the bone  to  slip from the dorsum ilii  to  the sciatic notch,
and vice versa; and  even from the latter point to the thyroid
foramen.   The CCXVII. of Warren's  Surgical  Cases, is an
instance of the  kind.   The patient Avas thirty-six years old ;
he sustained the dislocation Avhile attempting  to lift  another
man ; he fell in making the effort, and the weight ofthe lifted
man came against  the thigh and pelvis.   For twenty-three
days the injury Avas supposed to be a sprain ; at the end of
that time the patient Avalked a mile and a quarter to a railway
station, and took the  cars for Boston, Avhere he came under
the treatment of Dr.  Warren in  the Massachusetts  General
Hospital.   The limb was found to be shortened two inches,
and more movable than is generally the case—a circumstance
which may have arisen from the exercise the limb got in the
Avalk to the station.  The patient Avas etherized, and subjected
to the action  of pulleys, but the effort failed.  Reid'splan Avas
then tried, which also failed, the only effect  being to carry the
head  of the  bone from  its old position on the dorsum of the
ilium, to a neAVone in the foramen ovale.  It Avas uoav brought
back to the point it originally occupied, and the pulleys Avere
again tried ;  and by lifting the trochanter and rotating the
limb suddenly outwards, the head of the bone slipped into its
normal place with a snap.
  The NeAV York Journal of Medicine for  1855, contains the
report of a similar shifting state of the head of the femur  in
attempts at reduction.   The case happened  in the NeAV  York
Hospital under the practice of Dr. Markoe.  The patient, seven
weeks previous  to  the unfortunate  attempt at reduction, re-
ceived the  dislocation of the femur upon the dorsum ilii, by a
fall from a rail-car Avhile it Avas in motion.   He was put under
the influence  of ether and Reid's method  Avas tried.  " The
head of the bone descended as  usual, until  it came opposite
the loAver  margin of  the acetabulum, but from that point, as
the limb Avas brought down, it  slipped on to  the foramen
ovale.   The manipulation Avas repeated several times, Avith all
care, A^arying the degree of abduction  at the various trials. 
368
Dislocations.
but Avithout success.   It Avas impossible to make the head rise
over the lower border of the acetabulum so as to slip into its
place.  After numerous thorough and careful trials, the man-
ipulation Avas abandoned and the pulleys ordered to be ap-
plied.  Before this Avas done, it was thought best to place the
head of the bone on the foramen ovale, and from that point to
try and reduce it by the usual method recommended by Sir
Astley Cooper.  The head  Avas  accordingly placed  on the
foramen, and while  the upper part of the thigh Avas grasped
by an assistant and lifted strongly outAvards, I  took hold of
the ankle  and  made extension  and  adduction.  The head
seemed not to move at all under this force, and  AAiiile making
strong adduction a crack Avas heard, everything became loose
about  the joint, and  on examination  it  Avas evident  that a
fracture  of  the  cervix  had taken place, leaving the head on
the foramen ovale.  There Avas nothing further to be done,
but to put the limb up in the straight apparatus, hoping that,
if  we could obtain union, he would have  as useful a limb as
those ordinarily  left by fracture of the cervix, and certainly a
better limb than if the dislocation had been untouched."

  Treatment.—Quite a revolution has occurred in recent times
in regard to the best method  of reducing  dislocations  of the
coxo-femoral articulation.  Our older works are profusely illus-
trated Avith appliances for exerting great  force  in  the reduc-
ing process.  Pulleys are the principal means  recommended
for applying extension.  They are used in the folloAving man-
ner : the patient is  placed  on his back upon a lounge, table,
or bench, in a locality Avhere strong hooks or staples, within a
feAV feet of the patient's position,  can be fixed to  a door-post
or some immovable object.   A long toAvel  or  stout piece of
muslin, several yards long, is carried between the limbs so that
its  middle shall rest on a  soft compress placed against the
perineum, and its ends, the one  passing over  the groin, and
the other over the buttock, are to be tied together and slipped
over the hook or staple Avhich is  beyond the patient's head ;
the pulleys are made  fast to the hook or staple which is a feAV
yards  beloAV the patient's feet, and reaches to a Avide  leather
strap buckled or laced around the thigh just above the knee,
or to a toAvel fastened by a clove-hitch, surrounding the  limb
at the same point, the skin being protected previously Avith a 
Of.the  Femur.
369
 wet Avrapping cloth.  The hooks or staples should be  secured
 at points in the room, so that the extending and counter-ex-
 tending forces shall be on a line Avith the axis of the patient's
 body.  Everything ready, the free end ofthe cord in the mul-
 tiplying pulley may have traction gradually made upon it, till
 the head of the bone has approached the acetabulum.   The
 surgeon iioav uses his hands, or a toAvel around the upper part
 of the thigh, to direct the head of the  bone into its place.
 Sometimes the foot or knee may  be seized at the proper time
 during the extension, and such rotation imparted to the limb
 as shall  secure reduction.  It  is  said that Avhen pulleys are
 used the head of the bone slips into  the acetabulum Avithout
 any audible  snap, so  that  there are no means of judging
 Avhether the bone is in  its place, except by relaxing the exten-
 sion, unloosening the apparatus, comparing the length of  the
 two limbs, and ascertaining  that  the relative position of  the
 trochanters to the spines of  the'ilia  are  alike.  HoAvever, if
 the surgeon  have  hold  of  the limb Avhile extension is being
 made, he will, while aiding the reduction of the  bone, recog-
 nize  its return to the  proper  place.   The head of the bone
 having been returned to its socket, and the apparatus removed,
 the natural  contour of the  limb, and the movements of the
 joint, will be found perfectly restored, Avhich are reliable tests
 of reduction.
   In 1845, Prof. Gilbert, of Philadelphia, published in  the
 American Journal of Medical Sciences, a method of multiplying
 extending force which is effective and more simple in  its ap-
 plication  than pulleys.  It is  a mechanical appliance which
 can be commanded on almost every occasion, even in a rural
 district.   It  consists  in  the  utilization of a  " twisted rope."
 The patient is first arranged as for the use of pulleys; then,
 after the perineal belt or towel  is secured beyond the patient's
 head to a hook, staple, or substantial object, and the band of
 cloth or leather is made to surround the thigh above the knee,
 a bed-cord, clothes-line, or other strong-rope, is doubled and
 made fast to the extending band, and again to a hook or
 staple within a feAV yards of the patient's knee, in the axis  of
 the limb.   A stick is iioav passed between the doubled or re-
doubled rope at a point equidistant from  the staple and the
patient's knee; and used as a double lever to twist the thongs
or strands, thereby producing steady but powerful extension.
      24 
370                   Dislocations.
The limb is to be managed by the surgeon in every respect as
it should be whilst pulleys are applied.
  The method of reducing a dislocated femur by manipula-
tion, has been practised from the  earliest times ; but no sys-
tematic  and Avell described and defined method of this char-
acter  Avas known to the profession until quite recently.  In
the translated works of Hippocrates, the following language
is  used  in  regard to the  manipulating plan :  " In some the
thigh is reduced with no preparation, Avith slight extension
directed by the  hands,  and  Avith  slight movement; and in
some  the reduction  is effected by bending the limb at the
joint, and making rotation."  In the " Chirurgical Treatises "
of Richard Wiseman, published in  1676, the directions for re-
ducing  a -dislocated femur, shoAV  that  the " physiological"
principle of replacing the bone Avas pretty clearly understood,
and put into successful practice. " If the thigh-bone be lux-
ated iinvards, it may be reduced  by the hand of .the chirur-
geon, viz. : he must lay one hand on the thigh, and the other
on the patient's leg, and having someAAiiat extended it toAvard
the sound leg, he must suddenly force the knee up toAvard the
belly, and press back the head of  the femur into its  acetabu-
lum, and it will snap in.  For there is no need of so great ex-
tension in this kind  of luxation ;  for the most considerable
muscles being upon the stretch, the boAving of the knee afore-
said reduceth it."  Daniel  Turner, Avho published his Art of
Surgery  in 1742, must have been familiar Avith a manipulating
process  of reducing coxo-femoral  dislocations, for  he gives
rules, Avhich indicate a knoAvledge  of  such a method.  In the
Edinburgh Medical Commentaries  for 1776, he reports a plan
of reduction which Surgeon Thomas Anderson seems to have
hit upon when  preseut at a case of dislocation, to reduce
Avhich pulleys were unsuccessfully employed.  He says : " I
was  convinced that attempting the reduction in the  common
method, Avith  the  thigh extended, Avas improper, as the mus-
cles Avere all put on the stretch, the action  of which is, per-
haps, sufficient to overbalance any extension  we can apply.
But by bringing  the thigh to near a right angle  with the
trunk, by Avhich the muscles Avould be greatly relaxed,  I im-
agined that the reduction might more readily take place, and
with much less extension. 
Of the  Femur.
371
   " When  I  made this examination, he Avas lying on a table
 on his back.  I raised  the  thigh to about a right angle Avith
 the trunk, and Avith my right hand at the  ham, laid hold of
 the thigh, and made what extension I could.  From this trial
 I found I could dislodge the head of the bone.   At the same
 time that I did this, with my left hand at the head and inside
 of  the  thigh, I pressed it toAvard the acetabulum, Avhile  my
 right gave the femur a little circular turn, so as to bring  the
 rotula inwards to its natural situation ; and on the second at-
 tempt, it Avent in with  a snap observable to the gentlemen
 standing around, but more so to the poor mau, Avho  instantly
 cried out he Avas Avell and free from pain.  His knees could
 then be brought together ; the legs  Avere of the same length,
 and the foot in its natural  situation.  The knees Avere kept
 together for some time with a roller, to confine the motion of
 the thigh; and in three weeks he Avas at his work, Avithout
 the least stiffness in his joint."  Thirty or forty years later, or
 as early as 1815, Dr. Nathan Smith, a#surgeon well known at
 that time throughout New  England, was in the habit of re-
 ducing dislocations by a manipulating plan, for in a case of
 alleged malpractice in Avhich he Avas an expert, he affirmed in
 the following  language : " I do not think that the  mechanical
 powers, such as the Avheel and axle, or the pulleys, are neces-
 sary to  reduce  a  dislocated hip,  or any other dislocation."
 The same doctrine he used to teach to his classes, as Professor
 of Surgery; and some of his pupils have been knoAvn to carry
 his instructions into  successful execution.  According to an
 article published in the Boston Medical and Surgical Journal
 for May, 1840, Dr. Luke HoAve, a former pupil of Dr. Nathan
 Smith, remembered and practiced the teachings of his precep-
 tor.  Dr. HoAve says, in reporting  a  case:  " The patient  Avas
 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 inclined to take, which Avas
 towards the breast of the opposite side, till the descent of the
 head of the bone gave an  inclination  of  the knee outwards,
 when I  made use of the leg, being at a 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 audi-
ble  snap.  D.uring this operation, the two assistants who  had
been placed to make the lateral extension and  counter-exten- 
372
Dislocations.
sion, if ultimately required, Avere directed to draw moderately
at their towels.  How much of the success of the operation is
to be imputed to their extension, and the rotation of the thigh
bv the leg;, I am unable to determine ;  but as Dr. Smith sue-
ceeded Avithout the aid of either, and as the head of the femur
seemed to descend by  an  easy and natural process, I am in-
clined to believe that all that is necessary in such cases, is to
elevate the knee, Avhen  the ilium, the muscles  attached  to it,
and perhaps the ligaments, become the natural fulcrum, over
which the thigh, as a lever, acts to bring the head down and
imvards into the socket."  In 1833, Dr. Wooster Beach,  in his
" Treatise on  Surgical  Diseases," described a  process of re-
ducing dislocations of the femur, which  depended upon manual
dexterity, and is correct in many particulars.  It is as folloAVS :
" Instead of its being performed by extension  and  counter-
extension, it is done by  a compound movement.  The patient
must be placed upon a table, upon the  floor, or a bed, upon his
back; then the practitioner seizes the  dislocated leg, and  flexes
or bends it a little, taking hold principally of  the knee Avith
one hand and the ankle Avith the other.  After haAing very
much flexed the leg upon the thigh, for the purpose of con-
structing the leg into a lever, he carries it a little outward  ; in
the next place the thigh is to be gradually  abducted; and
lastly,  the  operator freely pushes the  leg  upward upon  the
pelvis, by the knee, toAvard the face, inclining the knee a little
to the opposite side."
  In the August number, 1851, ofthe Buffalo Medical Journal,
Dr. W. W. Reid, of Rochester, N. Y., published an account
of his  method of reducing dislocations of the thigh, which
does not differ essentially from those  already quoted, except
that  the rules laid doAvn are definite and practicable.   His
directions are  as follows : "Place  the patient on his back, on
a Ioav firm table, the floor or ground is  better ; let the operator
stand or kneel on the  injured side,  and seize the ankle with
one hand, and the knee  Avith  the other; then flex the leg on
the thigh ; next strongly adduct it, carrying it over the sound
one, and at the same time, upAvard over the pelvis by a kind
of semicircular sweep, as high as  the umbilicus; then abduct
the knee gently;  turn the toes outward, the heel inward, and
the foot across the opposite  and  sound limb, making  gentle
oscillations of the thigh, Avhen the head of the bone Avill  slip 
Of the Femur.
373
into its socket Avith a slight jerk and an audible snap, and the
Avhole limb will slide  easily down into  its natural position
beside the other.  In a recent case theAvhole operation can be
accomplished in less time than it can be described."

                          Fig. 120.
Manner of reducing dislocations of the femur by the "manipulating plan."
   Dr. Reid  reduced three dislocations upon the dorsum ilii
 successfully, and had no failures ; and since the publication of
 his "plan,"  many other surgeons have  followed it, and gen-
 erally Avith the happiest results.  Some failures are reported
 as having attended efforts at reduction ; but  it is possible, if
 not probable, that the manipulation was  not conducted skill-
 fully  or  perseveringly.  If the limb be  not elevated or lifted
 Avell at the time the sweep outAvard is given, the  head of the
 bone  may slide from  its position, and  not enter the socket.
 In some instances the head of the femur slips down into  the
 thyroid foramen;  and in a feAV cases it has slid outAvard into
 the ischiatic  notch.  If one attempt at reduction fails, another
 should be undertaken; and  even a half dozen or more trials
 may be made, each being varied to some extent.   Dr. Bigelow
 thinks that  the ilio-femoral  ligament, which is  an accessory
band  of fibers to strengthen the capsule on its anterior aspect, 
374
Dislocations.
plays an important part as an obstacle to  reduction, and it;
shifting the head of the femur from one position to another ;
and in certain cases he recommends that the luxated limb be
used as a lever to lacerate the capsular ligament still more, to
facilitate reduction.  As the tense untorn portion of the cap-
sule  is  often the chief obstacle to reduction, the suggestion
may be put into practical operation in some instances.  It is
clear that the manipulating method of reducing dislocations
cousists in placing the luxated limb in an attitude Avhich shall
relax tense tissues Avhether they be muscular or ligamentous.
At last, after repeated failures, the pulleys may be  tried, for
prejudice  against such  appliances should  not prevent  their
being used  as  a dernier resort.  And even  after  the  pulleys
have been tried and proved inefficient, the manipulating plan
may again be resorted to with success.  I should  recommend
the employment of  ether or chloroform in eA^ery instance, un-
less there  existed a  centra-indication, or positive aversion, to
its use.
  A case  reported  by Dr. Markoe, illustrates what has just
been stated : "  The  first opportunity Avhich presented itself
for  the trial of the neAV method, was in the case of an Irish
laborer, Avho  was  brought  into  the New York  Hospital,
November 30th, 1852, with  a luxation of the right thigh. He
had been  struck, a  short time before admission, by the coav
catcher of a passing railway train, and thrown some distance,
and in  his fall, probably,  the  accident  Avas produced.  The
symptoms  Avere those of the  dislocation  on  the dorsum ilii,
the head  lying rather  lower doAvn  and nearer the ischiatic
notch than usual.  The thigh Avas shortened about tAvo inches,
tended across the other, Avitli the  ball of the great toe of the
injured limb touching the instep ofthe other foot, fixed  in its
position, and the head  of the femur Avas felt  in the position
above  described Avhen the thigh Avas rotated  on its axis.  In
addition to this injury, he had received a compound fracture
of the left leg,  three inches above the ankle, together Avith a
good deal of bruising of other parts of his body.  The patient
was etherized to the extent of complete relaxation, and Jarvis'
Adjuster was applied.   It broke on the first trial of extension,
and  was laid  aside.  This mischance suggested the trial of
Dr. Reid's plan, which Avas accordingly adopted.   The opera-
tor, Dr. Buck, after bending the leg upon the thigh, gradually 
Of the  Femur.                  375
 adducted the thigh, Avhile at the same time it was being flexed
 upon  the  trunk.   Carrying the  limb  thus bent at the knee,
 and strongly adducted over the  sound thigh, by a gradual
 SAveep over the abdomen, and then slowly and steadily abduct-
 ing the limb so as to carry the knee outAvards, making at the
 same  time a rocking motion  by moving  the leg backwards
 and fonvards, had the effect  of dislodging the head of the
 femur from its new position, and making it approach the ace-
 tabulum ;  but it did not enter the socket.  From the position
 above indicated, the limb was  uoav  brought  down sloAvly
 toAvard a straight position, still kept in a  state  of forced ad-
 duction.  This last manoeuvre seemed to have a very poAverful
 influence in forcing the head toAvard the acetabulum, but the
 A\iiole proceeding Avas completed Avithout success.  It Avas ob-
 served, hoAvever, that the head had been moved a little higher
 on the dorsum  than it Avas before. The same manipulation
 was iioav again practised more deliberately  and more carefully
 than  before, and as the limb was being brought  doAvn ab-
 ducted, AA'e  had  the satisfaction of seeing and hearing the re-
 duction effected by the  head  of  the bone slipping into its
 socket.  All deformity had disappeared, and the motions Avere
 free in all directions.   The  other injuries  Avere properly
 attended to, and the recovery from the effects of the luxation
 Avas rapid  and satisfactory."  Dr. Warren, in his "Surgical
 Observations,"  Case  CCXX, reports having to  modify the
 method of  Reid before reduction was  accomplished.  After
 having made the knee describe a segment over the abdomen,
 the head of the femur slipped partially around the socket, but
 did not enter that cavity, thus altering the seat of the disloca-
 tion,  though not effecting  reduction.   The ankle  Avas  now
 seized and  moderate extension applied, yet this did not accom-
 plish the object,  though a noise Avas heard as if reduction was
 effected.  The leg,however, retained the abnormal shortening.
 The limb was again extended Avith considerable force, and the
 trochanter  Avas lifted by the surgeon's  hand, when  the  bone
went into place Avith an audible snap.   In this case the move-
ments given to  the limb by  the " physiological" method,
brought the head of the bone to the border or rim of the  ace-
tabulum, and simply required  being pushed from this lodg-
ment into the cavity. 
376
Dislocations.
  Displacement into the ischiatic notch can be overcome by
the same  class of manipulations.  It is only a variety of the
backAvard dislocation, consisting mostly in degree of displace-
ment—i. e., the head of the femur is thrown farther outAvards
or backwards than it is in the dorsal luxation.  To effect re-
duction the leg is to be flexed on the thigh, the thigh  on the
abdomen,  the knee being made to rest on the belly as high as
the umbilicus ; and  then  takes the  outward SAveep till  the
thigh comes to a right angle with the trunk,  the surgeon lift-
ing upon the limb so as to help the head of the femur to ap-
proach the socket, and to enter  it as the leg is allowed to slide
down into a position beside its fellow. If the manoeuvre is
not a success, the dislocation Avill have been changed from an
ischiatic into a dorsal  displacement.   And the rules already
given for  the reduction of that  luxation  will then  be appli-
cable.   According to  the London Medical Times and. Gazette,
for August, 1856, Mr.  Wormald succeeded with the manipu-
lating plan in  a case that had been dislocated six Aveeks, and
in which the pulleys had been repeatedly used in vain.
  A few cases of serious injury are reported as having occurred
from the manipulating plan of  reducing dislocations, though
in not so  large a proportion of  instances as in the method by
extension. Violent handling of a dislocated thigh may result
in fracture  of the  neck of the femur; or, the head of the
bone in changing its position, as it sometimes does, may rup-
ture muscles or do other mischief that may result in abscess
and  caries.   It  should be borne in  mind as an established
principle peculiar to the plan of reducing  dislocations of the
thigh by manipulation, that  the  knee, after  the leg is flexed
on  the thigh, is  to be carried  in those directions only which
offer the least resistance, and then reduction Avill generally be
effected, and no mischief arise from the  manoeuvres.  After
the  limb has taken the SAveep over  its felloAv, up toAArard the
face of the  patient, it is to be  abducted more than to a right
angle  Avith  the trunk, then  it is to be gently oscillated and
lifted Avith a strong force, Avhen the surgeon will  either per-
ceive that reduction is being accomplished, or that the effort
is a  failure, the head of the bone sliding around the  base of
the socket.  If the surgeon feels that the  attempt is a failure,
Avhile the  limb is yet in a state  of flexion, he  need  not bring
the foot and knee doAvn parallel Avith the  other  limb, but re- 
Of the  Femur.
377
Fig. 121.
 peat the manoeuvre from the point the failure is perceived.
 This will save the head of the bone and the trochanters from
 ploughing the soft tissues so exteusively in different directions.

   Dislocations  Doavnwards and Inwards, into the Obtura-
 tor Foramen; or, Inavards and Upavards, upon the Pubes.—
 In the dislocation doAvinvards, the head ofthe femur is forced
 into the obturator foramen, rupturing in its descent the round
 and capsular ligaments, and  putting upon  the stretch the
                  psoas  and  iliacus muscles, as well  as the
                  glutei and the pyriformis.  The head of the
                  bone rests upon the external obturator mus-
                  cle, and indents the obturator  membrane.
                  This injury  is produced by forced abduction
                  of the limb, as Avhen  a  heavy Aveight falls
                  upon the hips of an individual Avhile the
                 body is bent; or by a fall from a horse, the
                 foot  becoming  entangled in the  stirrup.
                 Pirrie kneAV of a  case  caused by a person
                  jumping  out  of bed  in  haste; the right
                 foot became  entangled  by  the blankets
                 while the left foot reached the floor. The
                 luxation has also been known  to occur while
                 a person was entering  a  carriage, one foot
                 being on the ground, and the  other on the
                 step of the  vehicle, just  as the horses sud-
 Di1°he1h7^              started.   In  fact,  any accident  by
                 which the thighs become suddenly and. vio-
 lently separated from each other, may produce the dislocation
 of one or both femurs into the thyroid foramen.  In most of
 the instances reported  the  displacement has been caused by
 the fall of heavyweights upon the hips, crushing the individ-
 ual to the earth, one or both thighs being forced outwards.
 The leverage of the shaft of the femur, under such circum-
 stances, brings the head of the femur to the lower segment of
 the socket, ruptures the capsular ligament  at that point, and
 forces the  bone through this rent,  doAvn  into  the foramen
 ovale.
  Symptoms.—The limb is held rigid, and takes  a position in
advance of the other; it is lengthened to the extent of about
tAvo inches; and the foot is not turned either  inward or out-
 
378                   Dislocations.
ward ; the trochanter major is less prominent than natural,
the body is bent forwards and inclines to the  injured side by
the tension of the muscles.   The limb can be abducted, but
can not be made to approach the  other  without exciting  in-
tense pain and numbness.  No form of fracture produces these
symptoms.
  Treatment.—No pulleys or kindred appliances are required
to effect reduction.  The patient is to be placed on the sound
side, and then the surgeon grasps the foot and knee much as
he Avould  in attempting  a reduction with the head of the bone
on the dorsum ilii; he flexes the leg on the thigh, and carries
the limb into a position  of extreme abduction, or to the point
it was made to assume  Avhen the dislocation  occurred.  One
hand iioav clasps the knee, and forces it  into extreme abduc-
tion, while the other hand placed  on the inside  of the thigh
near the  body, pulls the head of the bone upwards and out-
Avards, into the socket.   If the surgeon be not strong enough
in his hands to accomplish this manoeuvre  successfull}', he can
employ assistants to help him execute his plan.   A toAvel  sur-
rounding  the  thigh near the trunk and pulled outwards  and
upAvards  by assistants, Avhile the surgeon SAveeps the knee in-
wards, may prove of signal service.  A serious objection to
assistants is, that they may direct the head of the bone around
and not into, the socket, converting one  variety of dislocation
into  another.  This accident  has several times occurred.  It
may not  be amiss to  remark, that should such an accident
occur, the head  of the  bone must be  brought back into its
original position before an attempt at reduction is again made,
in order that the head of the femur may be in the  best place
to re-enter the socket through the rent in  the capsular  liga-
ment.
  In the  case of Mr. Ashfield who dislocated his left femur
into  the  thyroid  foramen, by being  throAvn  from his horse
Avhile descending Kemper  Lane, in September, 1868,  I first
flexed the leg upon the thigh, then carried the limb outwards
and upwards, into extreme abduction, as the first step in the
proceeding: I next placed my foot, from AAiiich the boot had
been previously removed for the purpose, against the perineum
or betAveen the ramus of the ischium aud the upper extremity
of the  thigh, and used it as a fulcrum, Avhile Avith my hands I
brought the limb over across its fellow, Avhen  the head of the 
Of the  Femur.                  379
 bone slipped into the socket with an audible snap.  The re-
 duction was accomplished much more easily and expeditiously
 than I anticipated.   The patient Avas under chloroform, and
 resting upon his back on the floor, during the effort to replace
 the bone.  Dr. Warren, Case CCXXIII. in his work already
 referred  to, experienced less difficulty  in effecting reduction
 than is generally encountered.  The dislocation Avas produced
 by the fall  of a house.   The  patient,  Avhen first seen by the
 surgeon, Avas lying  on his back, the leg  being flexed and  the
 thigh standing oft' from the body at an  angle  of 45°.   In  the
 usual place ofthe  trochanter  there was a hollow ; and the
 foot  Avas  someAvhat everted.  The  limb Avas rigid; and  the
 patient made a great outcry as  soon as it Avas touched.   Hav-
 ing been conveyed to the Hospital on a litter, ether was  ad-
 ministered, and the displaced bone returned to the  socket by
 "very slight  manipulation," conducted in the manner just
 described.
   The Philadelphia Medical Examiner,  for 1838, contains the
 translation from a Prussian  Medical  Journal, Avhich reports a
 simultaneous  dislocation  of both  femurs into the thyroid
 foramina.
   " A sailor Avas sitting astride  a plank,  Avhen a Avave suddenly
 forced him up  against a cross  beani, Avhich  struck his back
 violently, Avhile the plank  Avas still betAveen his legs.  The
 poor felloAv Avas lying on his back, when Dr. SinogoAAitz Avas
 summoned to  his assistance.  Both limbs Avere quite motion-
 less, and evidently much deformed from their natural  figure.
 The thighs Avere separated, the  one from the other, and could
 not be approximated ; the trochanters Avere  much  loAver and
 less prominent than usual,  and the  muscles of the hips over
 them were in a state of extreme tension.  The body Avas bent
 immoA^ably  forwards and dowmvards upon  the thighs ;  the
 knees Avere moderately flexed, and the toes  Avere not  turned
 either inwards or outAvards.  The  diagnosis, therefore, Avas
 that the heads of  both of the thigh-bones were dislocated
 doAvmvards and iu\vards.  The reduction Avas effected  in  the
folloAAing manner :  The pelvis being secured by two assistants,
the surgeon took his place between the  limbs of the patient*
and having put a towel round the right  thigh above the knee,
he passed the  noose of it over his oavh neck.   Extension Avas
 then  made  by means of a  toAvel  made fast above the ankle, 
380                    Dislocations.
and inclined a little to the left side, and while this Avas steadily
continued, Dr. S. lifted the head of the bone, and directed it
upAvards and someAvhat  outwards, by  raising and  stretching
out his head  with all his power.  It slipped into  the socket
Avithout any noise.  The left limb  Avas then reduced in nearly
a similar manner.  The mobility of the limbs Avas almost im-
mediately restored, at least in the horizontal position; but
several months elapsed before  the patient could Avalk Avith any
degree of ease.  The  tediousness of the recovery Avas OA\ing
in a very great  measure to the severe iujury of the lumbar
vertebrae, Avhich he sustained at the time ofthe accident.  For
three Aveeks the  sphincters  of the bladder and rectum  Avere
quite paralyzed."
  The cotyloid  notch  in the loAver  border or Awalls of the
socket, offers an easy  passage  way for the return  of the  head
of the  femur from  the thyroid  foramen to  the  acetabular
cavity.  This  circumstance  in the construction of the socket,
greatly facilitates  the process of reduction.   Sometimes the
return of the  bone to the socket is effected by some slight
movements ofthe  limb imparted by a 11011-professional attend-
ant.   The poAverful muscles put  upon  the stretch by the dis-
placement, are ready to lend their  force in returning the bone
as soon as a little rocking or rotation is imparted to the  limb,
to disengage the head of the bone from obstruction in the Avay
of reduction.
  In reducing any variety of hip dislocation, the inexperienced
surgeon can remember to carry the limb in those directions
only Avhich are assumed most  easily.   For instance, the leg is
to be flexed as far as it Avill go readily; then  the knee is to be
carried outwards and upAvards  in a state of abduction until
some resistance is  offered to the  SAveep in those directions, the
limb reaching nearly to  the thorax in some eases before its
course is arrested ; finally, the thigh, with the leg flexed be-
hind  it, is  to be  moved iiuvards and doAvnwards, across the
opposite thigh, completing the manoeuvre Avhich  is to result
in the return of the head  of the bone to its natural socket.
If the thigh be carried too high, the knee reaching the thorax,
there is danger of throwing the head of the femur, not into
its socket, but around the acetabulum,  into the  ischiatic notch.
Experience sIioavs that  the thigh may be safely carried to  a
right angle with the  trunk, and not endanger  the slipping of 
Of the Femur.
381
Fig. 122.
  the head of the bone beloAV the socket and backAvard towards
  the ischiatic notch.   Markoe carried the knee too high in one
  instance, and converted the thyroid into an ischiatic disloca-
  tion.
    According to the North-:Western  Medical  and  Surgical
  Journal, for  1852, the late Dr. Brainard, of Chicago, reduced
  a dislocation of the femur, which had  been displaced into the
  thyroid foramen, by using a piece of Avood, well padded, as  a
  fulcrum, betAveen the thighs, and employed the  luxated  limb
  as a lever to pry the head of the bone  into place.  Before he
  tried this plan, the pulleys and Jarvis' Adjuster had been  used
  unsuccessfully.
   Dislocation  Upwards  and Inavards  upon the  Pubes.—Al-
  though this is called a dislocation upon the pubes, the head of
  the femur rests more upon the ilio-pubic  groove outside the
  psoas and iliacus muscles, hence  Malgaigne has  called it the
                    ilio-pubic luxation, a term which- better
                     designates the position of the bone,  than
                    that employed by  Cooper and his follow-
                    ers.
                       It is an extremely rare form of disloca-
                    tion, few cases of  the kind  having been
                    observed,  and, of  course,  still fewer dis-
                    sected.   It is a forward  variety of dis-
                    placement, and does not occur more fre-
                    quently than what  is sometimes called the
                    perineal dislocation, a form  of  luxation
                    in Avhich the head  of the femur is thrown
                    far forwards and finds lodgment upon the
                    ramus of the ischium.
                      The ilio-pubic dislocation may be caused
                    by a  misstep, or a throwing  of the body'
                    backwards to save  a fall Avhen the foot is
                    placed in  a  hole in the ground, or upon
an unstable substance.  Any force Avhich suddenly carries the
thigh outAvards and rotates it at the same time, tends to pro-
duce this form of dislocation.  The fall of a bank of earth, or
the wall  of a building, striking  the back or  hips when the
body is bent, in such a Avay as to force  one thigh backwards
tAvisting it behind the other, may also produce the luxation
under consideration.
Dislocation forwards upon
     the pubes. 
382                   Dislocations.
  Symptoms.—The limb  is everted, abducted, and shortened
to the extent of an inch or more.  The buttock is flattened,
the trochanter is nearer the  anterior superior  spine of the
ilium than natural.  The hemispherical head of the femur can
be felt upon the horizontal ilio-pubic bar, outside the femoral
vessels.  As some of these signs exist in common  with fracture
ofthe neck ofthe femur, their  differential peculiarities should
be pointed out.  In fracture, crepitus  may be  elicited, and
motion in  various directions  may be easily imparted to the
limb, the eversion of the foot  may be overcome  by  moderate
force, the limb can readily be pulled dowii or extended to  its
normal length, and  the head of the bone being in the socket
can not be felt.  In dislocation, though there be shortening
and eversion of the foot, there is no crepitus, the limb is rigid,
the, eversion and  shortening not being easily overcome; and
the head of the bone may be distinctly felt in the groin.  The
thigh, in dislocation, is slightly flexed, and stands off from its
fellow, Avhich is not the case in fracture of the cervix femoris.

  Treatment.—Powerful extension may effect reduction,  es-
pecially if a towel be put around the thigh near the body, and
great force be used in pulling the upper  extremity of the limb
outAvards or aAvay from its fellow.  If this plan should fail,
the patient may be placed on his sound side, on the floor or a
Ioav bed, and the leg flexed on the thigh and the limb abducted
to a point nearly at a right angle Avith the trunk,  and  then
adducted much as in the manner directed for reducing dislo-
cation into the thyroid foramen.  By this manoeuvre the head
of the femur  may be dislodged from its  position on the ilio-
pubic bar, and returned to the socket.  If pressure can be
made on the  head  of  the bone, so as to help it knvards the
acetabulum, while  the rotating or adducting SAveep of the
knee  is made, the reduction is more sure to attend the effort.
  All  surgeous who have reduced dislocations  " upon  the
pubes " do not agree in their manner of operating ; one claims
to have proceeded nearly in the course indicated above ;  and
another manipulates the limb much as directed in reducing a
dislocation upon the  dorsum ilii.   But Iioav success could
attend adduction before the thigh is first abducted to bring
the head  of the  bone  to the  rim of the socket, is more than
I can  comprehend, unless the dislocation  be " incomplete," 
Of the  Femur.
383
 the head of the bone being simply dislodged from the socket,
 and resting on the rim of the acetabulum.   In this, as in other
 dislocations  of the thigh, the limb should be carried in those
 directions offering least resistance, and then the operator can
 hardly go astray, even though he has made a faulty diagnosis.
   Anomalous Dislocations of the Hip-Joint. — Among the
 so-called anomalous dislocations ofthe hip may be mentioned
 the upward displacement, the head of the bone being made to
 occupy the notch between the anterior superior and the ante-
 rior inferior spines of the ilium ; or the head of the bone may
 rest immediately above the margin of the acetabulum, on a
 level with the anterior inferior spine of  the ilium, and to its
 outside.   These are displacements that belong to the backward
 variety,  if the  head of  the bone be outside ofthe iliac spines;
 and to the fonvard variety, if the head of the femur be in front
 of those processes ; and must be treated according to the rules
 plans, and methods, laid doAvn for successfully managing those
 forms of luxation.
   Downward dislocations vary from the ordinary  forward or
 backward dislocations, just  as do  the upward  luxations.
 OlliAier  gives a description of one of these forms  of disloca-
 tion, AAiiich Avas met in 1819, but not published till 1823; a
 Woav upon the  inner aspect of the thigh near the knee, drove
 the limb violently outwards, where it remained in a rigid state
 of abduction, slightly flexed and  rotated iiiAvards; the head
 of the bone could not be felt anywhere, and there Avas a IioIIoav
 m the situation of the great trochanter.  By imitating on the
 dead subject the mode in which the displacement  took place,
 the surgeon found that the head of the bone Avas thrown  im-
 mediately below the acetabulum, and behind the cotyloid cav-
 ity,  upon  the  tuberosity of  the  ischium  or into  the lesser
 sciatic notch.   Mr. Keate, in the J^ancet, reports a similar case,
 Avhich AAras caused by a horse falling backAvards Avith his rider
 into a narrow ditch.  The  reduction was accomplished by first
 bringing the  head of the bone into the thyroid foramen, and
 then into the socket.   It is probable that  many of these so
 called anomalous dislocations were primarily either  forward Or
 backward, varying  according to circumstances in the upward
 or dowriAvard direction ; and that new  and additional forces
 compelled the head of the bone to  take a position in a second-
ary or consecutive location quite at variance Avith the ordinary 
384
Dislocations.
displacement.   This \ie\v is in accordance Avith the Avell knowo
conversion of a dorsal into an  ischiatic or thyroid luxation,
while manipulating the limb  in legitimate attempts at reduc-
tion.
  After-Treatment.—After  a dislocated femur has been re-
duced, a long splint reaching from the foot to the  thorax, or
at least above the hip, tied to the trunk at its upper extremity,
to the thigh at its middle, and to the foot or ankle at its lower
end, should be Avorn for three or four weeks, or until it is pre-
sumed that the rent in the capsular ligament is healed, and
other injuries about the joint have been repaired.  The splint
keeps the joint  motionless, thereby preventing those move-
ments  that favor re-dislocation.  Locally applied sedatives
may restrain high grades of inflammation that might result
in abscess and other serious complications.
  Ancient Dislocations of the Coxo-Femoral Articulation.
—There is  no  set time ■ at Avhich a  reduction of a  dislocated
hip may not be attempted, though there is not much  hope of
success after three or  four months  have elapsed from the re-
ception of the accident.  Malgaigne reports haAing knoAvn a
dislocated hip to be successfully reduced after  the head of the
femur had been displaced for a Avhole year.  In March, 1856,
Dr. Blackmail, at the Commercial Hospital,  in this  city, re-
duced a dislocation of the hip that Avas of six  months' stand-
ing.   The  reduction A\*as accomplished by the manipulating
plan.  Dr.  Dupierris,  a Cuban surgeon of distinction, also re-
duced  a dislocation of the femur, which had been received
more than  six months  previously.  The operation Avas per-
formed by manual dexterity,  and not by the aid of  pulleys or
other appliances for multiplying force.
  Such results at late  periods  after  the accidents occurred,
warrant the attempt at reduction, even if seATeral months have
elapsed from the  time the  luxation  is received.    Though
the acetabular cavity be partially filled during the long absence
of the head of the femur, the  return of that bone will soon
re-establish all the functions of the joint.
  It Avould not be Avise to consider these successful efforts at
reduction, in ancient dislocations, as establishing a rule, for in
all probability many unsuccessful  attempts, even in cases  of
not more than two or three months' 'standing, have been made ;
and because they proved to be failures, they passed unreported. 
Of  the Femur.                   385
It Avould be safer, then, to consider these successes  in the re-
duction of dislocations of six months' standing, as exceptions,
and the unreported failures as constituting the rule.
  Congenital Dislocations of the Hip.—These constitute  a
class of difficulties that, as a general rule, can not be remedied
by the ordinary methods of reducing luxations, therefore they
are  not strictly admissible in this connection.  In the majority
of such instances  there is some osseous defect about the articu-
lation, to say nothing of lax  ligaments and muscles.   Occur-
ring mostly in children of a scrofulous and flaccid condition,
or those having  a  soft  and yielding  state of the bones, the
acetabular Avails become elongated upward, or the head ofthe
femur absorbed to an extent that displacement is a necessity,
and can not be fully remedied.
  Partial Dislocations  or the Femur. — Occasionally  cases
Avill be met, especially in the  }*oung, Avhere  there  is  some
strange defect of  the coxo-femoral  articulation which resem-
bles a dislocation in many respects, yet no positive evidence
exists that the  head  of the  femur completely leaves  its
socket.  In some instances it seems probable that the head of
the bone rests on the edge of the acetabular canity, being pre-
vented from descending on the slope outside the cavity by the
untorn state of the  capsular ligament, yet it does not seem
possible  that  in  anything like a normal state of the fibrous
tissues the capsular ligament will stretch  sufficiently to alloAV
the head of the  femur to rise out of its deep socket and take
a position on  the  border of the cavity and there rest poised
until  absorption,  under pressure, has formed an imperfect cup
for  the point  of the bone to move in, and not be liable  to
escape, either  inside or  outside  the true articular cavity.
HoAvever, surgeons of unquestioned ability have reported in-
complete luxations  of the femur, giving the lesion a legitimate
place among hip-joint dislocations.  It is  probable that some
mistake has arisen in regard to the nature and.  extent  of the
injury, yet Avhen  a limb bears several of the prominent signs
of dislocation, and no other lesion is suspected, it would natu-
rally  be pronounced luxated.  There are some mysterious de-
fects  more or less peculiar  to  the coxo-femoral articulation,
that may require a  long  course of inquiry and investigation
to clear up.  About a year ago I Avas called to  see a little girl
who had  been hurt in the  street, and  Avas unable  to  Avalk
      25 
386
Dislocations.
home; she had complained of something breaking or giving
Avay in her hip, and her physician went through with a variety
of manipulations, and claimed to haA~e reduced a dislocation.
At the time I Avas called, tAvo weeks after the reception of the
injury, the trochanter was very prominent, the leg Avas  rigid,
inverted, and to all appearance an inch  or two  shorter than
the other.
  The  parents remarked that if the limb was  ever  dislocated
the bone Avas still out of place, for it had presented the same
appearance  ever  since  the accident, notwithstanding  the
doctor's claims to having effected reduction.  Movements  im-
                     V
parted to the limb gave great pain ;  there was no crepitation,
or other marked sign of fracture; the head of the femur was
not outside the socket, though it seemed lifted part  way out,
and could not be made to return.  I interpreted the symptoms
as indicating inflammation of the joint, the head of the bone
being  raised in  the  socket by SAvelling, effusions, or morbid
products in the bottom of the socket.   The girl uoav Avalks
about,  with the foot inverted, the limb apparently shortened,
though a twist in the pelvis prevents that feature from being
observable; she is a little lame, but  is  improAing in her gait
and general appearance.  I think there never was in her case,
any form of traumatic dislocation, but that she labored under
a species of hip-disease.
  Dislocation  of the  Hip Complicated  with  Fracture of
the  Femur.—Under extraordinary  circumstances the head of
the femur may be'dislocated, and then, in the same accident,
the neck of the bone  or upper extremity of the shaft, may be
broken.   The London and Edinburgh  Monthly Journal of
Medical Science, for December, 1843, contains an account of
such an injury, which Avas verified by a dissection made after
the patient's death, Avhich occurred twelve years after the  re-
ception of  the  injury.   The dislocation  Avas of  the  pubic
variety, and the head  ofthe femur Avas completely disengaged
from the neck and shaft of the bone.  It is not stated in  the
report whether any attempt had been made to reduce the  dis-
location, during Avhich the neck of the femur may have been
accidentally broken.   It is not improbable that in some in-
stances the femur is broken in attempts at reduction; and the
complication may not have been recognized or acknoAvledged.
In the event of dislocation and fracture  of the femur in  the 
Of the  Femur.
387
same accident, a judicious attempt should  be made to push
the  head of the bone into the socket, before the fracture is
treated.  If the effort fail, the question Avould arise Avhether
it is best to seek a union of the fragments, or, if the fracture
was through the neck of the bone, to preserve the limb in as
natural a position as possible, and expect only such a state of
the parts as exists in a case of non-union after fracture  of the
cervix femoris.  If  the fracture Avas through the shaft  of the
bone at some distance from the cervix, and the reduction  of
the dislocation could not be accomplished, a good union of the
fragments should be secured,  and then an attempt might be
made to replace the head of the bone, as in  an  ordinary case
of ancient  or chrouic dislocation.  The attempt at reduction
should  not be made until the fracture has been treated eio*ht,
ten, or twelve Aveeks, the age and vigor of the patient influ-
encing the  time consumed in the treatment.
  In connection with the diagnosis  of dislocated femurs, it
must be borne in mind that in luxation upon the dorsum ilii,
the back arches prominently  upAvards as the patient rests up-
on a table or level surface ; and the muscles of the thigh are
baggy underneath,  aiid tense or drawn  doAvn to the bone on
top, or on  the front aspect of the  femur.  In a  dislocation
into the thyroid foramen the muscles and tendons on the  in-
side of  the thigh near the  groin are tort.  It is to be remem-
bered also that a consecutive dislocation upou the dorsum ilii,
the luxation being  first iuto  the  foramen ovale, must  be  re-
duced by carrying the head of the femur back to the thyroid
foramen, then into place.  When the head of  the femur has
passed from the foramen ovale to the dorsum ilii, it can not
go directly into  the socket, for no  aperture  exists through
Avhich it can pass, but it must retrace  its steps—it must go
back by the route taken  in the beginning.
  In reducing dislocation of  the  hip, the patient  is handled
best on the floor, Avith a quilt for a bed.  If one kind of man-
ipulations do not succeed, the surgeon  is to take a rest, and
reconsider all  the conditions  of the case.  He  is  to question
himself whether or not a consecutive dislocation  has not  in-
tervened since the first occurred.   The  surgeon commencing
the introductory manipulation may convert a primary into  a
secondary or consecutive luxation. 
CHAPTER  XII.
DISLOCATION  OF  THE  PATELLA.
Fig. 123.
  The patella may be dislocated laterally, i. e., outAvards or in-
wards ; and  the  bone has been forced upon its edge.  It can
not be dislocated dowiiAvards ; nor upwards without a rupture
of the ligamentum patellae.  The outward displacement is not
an  uncommon accident, but the other  forms  are quite rare.
Muscular action  is the most  common cause of the displace-
ment, though direct violence, as a bloAv upon the knee received
              in a fall, has been  knoAvn  to  force the bone
              from  its natural position.  Young Avomen of
              lax ligaments, Avhose Avide hips, and approxi-
              mating knees, throAv the patella inside of a
              line  drawn  from the  tubercle of the tibia,
              where  the ligamentum  patellae is inserted, to
              the centre ofthe origin and action ofthe qua-
              driceps muscle, are most liable to this accident.
              It is ob\Tious that the muscles which, in going
              to their insertion, are made to swerve inwards
              to embrace  the patella, Avould in their con-
              tractions tend to displace that bone outwards.
              There are several varieties of the outward dis-
              placement ; the bone may be partially luxated
              or thrown so far outwards that the inner artic-
              ular half of  the patella would rest upon the
              outer  condjie ; and  OAving to the obliquity of
              the surfaces  in contact, the outer edge of the
Di8ltenaSStSaJdfy.pa" "bone is made  to project prominently.  In a
              complete dislocation,  the patella is throAvn
wholly outside the most prominent point of  the external con-
dyle, and the inner edge of the displaced  bone  is made  to
project forward.  The capsule of the joint is more  or less
                         (388)
 
Of the Patella.
389
 lacerated by the complete luxation.   The inward dislocation,
 which is a rarer form of injury, is generally produced by direct
 violence, and not by muscular action.  BIoavs received in falls,
 are the common cause.
   In the dislocation edgeAvays the patella is turned on its axis,
 so that the articular surfaces of the patella  face iinvards, and
 the front surface outAvards, the outer edge of the  bone being
 buried in the fossa between the coudyles.
   There is no difficulty in  detecting the nature of these dis-
 placements ; the patella can be easily felt in its unnatural posi-
 tion, the bone being forced upon its edge or too far iiuvards,
 or outAvards.  The knee after luxation of the  patella is  par-
 tially flexed 'aud too firmly fixed to admit of voluntary motion.
 Any attempt to move the limb  is attended with great pain.
 In the lateral dislocation the Avidth of the knee is increased ;
 and the position  usually occupied by the  patella presents a
 depression to be  both seen and felt.  In April, 1860, I was
 called to see a boy  on Fifth Street, opposite the Market House,
 Avho in falling down stairs hit his left knee against the corner
 of a box, and received a  dislocation of the patella inwards.
 The mother who Avas near Avhen the accident occurred, carried
 the boy up stairs, and  tried to make him stand and Avalk; but
 he complained that his knee Avas broken, and he could not use
 it.  I found the leg considerably flexed,  rigid, and excessively
 painful.  After taking off the patient's pants, I reeognized the
 nature of the injury at once ; and proceeded Avithout delay to
 replace the bone.  1 encountered more resistance  to a return
 of the bone than I had anticipated.  At first I attempted to
 extend the limb to relax the quadriceps, but could not  do  it
 Avithout eliciting the sharpest cries from the patient.  I found
 the patella Avould not  readily slip  over the  high  edge of the
 inner condyle, so I sent for chloroform, and when  the  patient
 was well under its influence, I had no trouble in  pulling the
 patella outwards into its place, the fingers being strong enough
 to lift it to a point Avhere the action of the muscles would re-
 place the bone.
  Treatment. — The  outward  displacement may generally
be  overcome by  slight  movements  of the joint,  and firm
pressure made against the outside of the bone ; but the displace-
ment inAvards, and the edgeways dislocation, are more diffi-
cult to replace or return to position.   In these  forms of dis- 
390                   Dislocations.
placement great force is  required to effect reduction, and all
movements  are attended  Avith extreme pain,  therefore the
quieting  and relaxing effects of  an  anaesthetic should be
brought into requisition.  A case is reported by Dr. Gazzoni,
of Pittsburg, Pa., in Avhich a  man in a Avrestling match was
throAvn, and was unable to rise on account of the patella hav-
ing been dislocated upon its axis, the edge ofthe bone resting
in the sulcus between the condyles.   Varied  and repeated at-
tempts  at reduction failed;  the  doctor, by the advice of an-
other  physician,  divided  subcutaneously  the  ligamentum
patellae close to the tubercle of the tibia, and then made efforts
at reduction but failed; bleeding to syncope Avas tried, yet the
bone could not be adjusted; the next day the leg Avas flexed
on  the  thigh, and  the thigh on the pelvis, and then the leg
suddenly  straightened, according  to the suggestion  of Dr.
Watson, who placed his patient in a chair, and then taking
his foot upon the shoulder, flexed the knee a little by the for-
ward inclination of the body, and then suddenly extended the
leg, the hands being used to help execute the manoeuvre.  This
plan succeeded Avith Dr.  Gazzom upon a fourth trial.
  Mr. FloAver  had a case in a lad who fell betAveen the seats
of a theatre gallery, the patella being forced half Avay round
and turned up edgeAvays, between the condyles  of the femur
and the head of the tibia.  The limb Avas extended, and all
attempts at  reduction by bending the  knee, manipulating the
patella, etc., Avere unavailing.   Chloroform was then admin-
istered, and the bone easily replaced.
  If the ligamentum patellae be ruptured or extremely relaxed,
the patella  may be displaced  upAvards.  This  could  not be
legitimately considered a dislocation, but a rupture of the ten-
don.  Such  an  injury should be treated in every respect as if
it Avere a fracture of the patella.
  It is often difficult to keep a patella, Avhich has  once been
dislocated, in place ; therefore Avhen the bone is once reduced,
an  elastic knee-cap should  be worn, or an apparatus Avith a
ring or disc on the  side  the dislocation has occurred*  Side
irons extending a feAV inches above and beloAV the knee, jointed
'in the middle, and having a semi-circular iron  band at each
end to surround the posterior half of the leg and thigh, and
straps to buckle over the front part, may beAvorn to strengthen
the joint and to prevent re-luxation. 
CHAPTER  XIII.
DISLOCATION  OF  THE  TIBIA.
Fig. 124.
   The tibia  may be dislocated forwards, backwards, and to
 either side, though it is  seldom  displaced  in any direction.
 The articular surfaces at the knee-joint being large,  and the
 connecting ligaments exceedingly strong, luxation can not be
 produced Avithout great displacing power be brought to bear.
   The lateral dislocations  are frequently partial, but  the  for-
 Avard and backAvard luxations are generally complete, the tibia
 being also rotated in some degree upon its axis.
                      In the backward dislocation the head of
                   the tibia forms a projection in the ham,
                   and a deep depression exists in front of
                   the knee, beloAV the protuberant condyles
                   of the  femur.   The  loAver  end  of the
                   patella follows the tibia, and thus becomes
                   placed horizontally, Avith its anterior sur-
                   face  looking  downwards and its  upper
                   margin forwards.   The limb   may  be
                   straight or forcibly extended.  The mus-
                   cles  about the  knee  are nearly  all  put
                   upon  the  stretch, and  the vessels  and
                   nerves of the popliteal  space are com-
                   pressed.  If the tibia be thrown  entirely
                   behind the articular surfaces of  the con-
                   dyles, the  crucial ligaments will  be torn,
                   and other tissues about the joint stretched
Dislocation of  the tibia      Linoi-a+nrl
     backwards,        Ol UlCeiatea.
                     The backAvard luxation  is  generally
produced by direct violence applied to the upper and front
part of the tibia when the knee is bent.
                           (391)
 
392                   Dislocations.

  Treatment.—When  the  patient is under chloroform there
is  no great difficulty in  reducing the bone by manipulation.
If ordinary manipulation fail, an assistant may hold the thigh
upon'the arm of a sofa, foot-board of a bed, or any projecting
ridge, while the surgeon extends the leg if it be flexed, or
flexes it if in a state of extension, at the  same time  pulling
the leg into position.  It  is rarely necessary to  make use of
pulleys or other appliances  for  exerting  poAverful extending
and counter-extending forces.   The hands of another assistant
to push the tibia fonvard and the femur .backward, might aid
in the work of reduction.
  Dr. Rose, in the ProAincial Medical Journal, reports being
present Avhen a woman -had the tibia dislocated backwards by
a fall occasioned by a carriage being driven furiously against
a ladder on which she was  standing.  The knee was rigidly
held in a state of fixed extension.  The patient being relaxed
from the shock of the injury, the doctor had no  difficulty in
pressing the displaced bones into position ; and in the course
of a feAV  weeks, under the influence of local antiphlogistic
treatment, the woman made a successful recovery.
  The forward dislocation of the tibia is a rare accident, and
presents features quite  the reverse of the backAvard displace-
ment : the tibia aud patella project forwards, and the condyles
of the femur produce a SAvelling in the ham.   The popliteal
artery and nerves are compressed to the extent of endangering
gangrene; the ligaments about the joint are lacerated; and
the limb is more  or  less  shortened and extended.  The pro-
jection of the leg bones in front and the femur behind, clearly
indicate the nature of the displacement.
   The causes of this injury in  cases reported, have been the
stepping into a ditch Avhile carrying a heavy Aveight; the fall-
ing of a heavy spar on a  man's back, the knee being forced
to give  Avay under the  Aveight and shock; and direct bloAVS.
Malgaigne is of the opinion that neither the forward  nor the
backward dislocation of the tibio-femoral articulation is com-
plete, though it Avould  be difficult to account for the shortening
in the cases reported, if the luxations Avere only partial.
   October 10th, 1860,1 was called by Dr. Adams, of Covington,
Ky., to see  a negro boy who received an injury of the knee
by falling into a coal barge anchored in the  Licking river.
The boy in falling backwards struck the edge of a projecting 
Of the  Tibia.
393
 board, which hit just above  the  calf of his right leg.  The
 upper part of the leg was  driven  forwards, and the condyles
 of the femur Avere prominent in the popliteal space.  The for-
 ward dislocation of the tibia  Avas unmistakable;  and its-re-
 duction Avas effected by manipulation, while the lower part of
 the  thigh  projected over  a chair.  The leg Avas found in a
 forcibly extended position.  The  boy received other injuries
 of a serious nature, but ultimately recovered perfectly from
 all.   His left ulna Avas broken by  direct violence  through its
 upper- third, and it  Avas  thought  that the eighth rib was
 broken near its angle.
  Dr. Sanborn,  of LoavgII, Mass., reports through the Boston
 Medical  and Surgical  Journal, for 1856, a case of dislocation
 of the tibia fonvards which Avas produced by moving machin-
 ery in one of the factories of the city, the man being caught
 in a belt and carried round a shaft, the leg hitting the timber
 above at each revolution.   At first sight the limb seemed  to
 be broken in many places ; it Avas shortened by several inches
 and  shapeless ;  a closer examination proved that  no fracture
 existed, but a complete dislocation of the tibia fonvards, the
 condyles of the femur being driATeu down beneath the gastroc-
 nemius muscle ;  and the  tibia rose up  in  front, forming  a
 marked projection.  An assistant held the pelvis, and the sur-
 geon grasped the ankle and  drew  the leg doAvnwards to its
 proper length;  and the bones then  slipped into  place.  The
 patient made a satisfactory recovery.
  The treatment of the forward dislocation is to be  managed
 on precisely the  same principles  as the  backward luxation;
 the patient is to be put  under the  relaxing and stupefying
 effects of chloroform, and  then the surgeon extends the leg
 and  pushes the  displaced  bones into their natural  relations.
 If he is unable to accomplish reduction alone, he  can engage
 the strength of assistants to good advantage.   In  those cases
 of fonvard and backAvard dislocations which obstinately oppose
 reduction, it is not improbable that the lateral ligaments,
when they escape untorn, offer the chief resistance.  To over-
come these obstacles the leg would have to be  forcibly flexed
or extended to relax the tense tissues.   If the leg  Avas found
in a  partially flexed condition, it Avould have to be flexed still
more; if in a state of extension, it should be extended  even 
894
Dislocations.
beyond the straight attitude, before the displaced bone would
slide into place.
  The outward and inward dislocations of the head of the tibia,
as has already been stated, are, on account of the width of the
knee-joint, only partial.  A  violent twist of the leg, coupled
with the displacing force the leg often sustains in a fall of the
body, and the effects of moving machinery, are accounted as
the common causes of lateral  dislocations of the tibia.  The
signs of the  displacement are too strongly marked  to  pass
                      undetected.  There  is  no shortening,
                      but the limb is rigid,  slightly flexed,
                      with  the  foot  inverted  or everted as
                      circumstances may direct.  The prom-
                      inent projections laterally ofthe femur
                      to one side, and the tibia and fibula to
                      the other,  exhibit the true state of the
                      injury.   The . width  of the  joint is
                      greatly increased, and  the  limb  Avill
                      almost ahvays present a tAvisted appear-
                      ance, there being some rotation of the
                      tibia upon its axis.  The accident can
                      not occur without considerable lacera-
                      tion of ligaments,  and  straining  of
                      muscles.
                        Treatment.—Lateral dislocations of
                      the knee are reduced Avith greater facil-
                      ity than any other luxation of impor-
                      tance in the body.  An assistant holds
Lateral dislocation of the tibia, ^he thigh fixed, and the surgeon makes
extension  and pushes the head of the tibia in the direction
favoring a  return of the bones to  their natural positions.
After reduction is accomplished, the joint must be kept per-
fectly motionless  for two or  three  Aveeks, and the ordinary
remedies employed for preventing or  subduing inflammation.
Passive motion, which would be serviceable in preventing an-
chylosis, might also interfere Avith the healing of the lacerated
ligaments; therefore it should be employed with due regard
to the state of all the parts implicated.
  Displacements of the  Semilunar Cartilages.—Chronic in-
flammation of the knee-joint,  caused by a strain, or other  in-
jury, is sometimes followed by thickening of the semilunar
 
Of the  Tibia.
395
cartilages, and by elongation of the ligaments which  connect
them with the tibia;  and it may create other difficulties with
the internal Avorking of the joint, so that the cartilages  may
become displaced by some trivial effort in the use of the foot.
For the time the patient falls, or is unable to walk until  the
limb is gently flexed and twisted, when the defect is overcome,
and the leg resumes all its functions without evidence  of
serious impairment.   This injury has passed among  surgical
Avriters and teachers as a sub-luxation of the semilunar carti-
lages, though little is positively known in regard to the path-
ology of the difficulty.   It is possible  that  the  cartilages  do
become slightly displaced, so that some part of their structure
gets pinched between the condyles of the femur and the head
of the tibia.  Surgeons have declared that they have found
the cartilages projecting outAvards at some part of  the articu-
lation.  In a feAV instances Avhat was supposed to be a displace-
ment of the semilunar cartilages, has turned out to be  loose or
false cartilages in the joint.   M. Gimelle has related a case of
this kind, the mistake being corrected by Larrey Avho  cut into
the joint and removed the foreign body.
  In some patients, either from lax ligaments, or a predispo-
sition to joint affections, the knee is constantly tender  and  un-
stable.  A slight twist imparted to the joint in walking, or
even Avhile turning in bed, is folloAved by sickening pain, and
acute arthritis.  The difficulty may be regarded in most in-
stances as a morbid  sensibility of the joint  structures which
will pass off in the course of time, even  if nothing be done ;
but it would be judicious to put such patients on tonic and re-
storative treatment to remove any constitutional dyscrasia, and
to bathe, and galvanize the knee.   If in any case there existed
evidence of displacement, Avhether of cartilage  or bone, the
limb should be extended, flexed, and rotated, until the parts
displaced  resumed their proper  positions and  functions.  I
have seemingly relieved a difficulty of this kind by flexing the
knee  to  its utmost, then suddenly straightening the limb, re-
peating the operation with  the addition of a slight  rotatory
movement.   " Natural bone-setters" have occasionally gained
great advantages  by imparting to a disordered joint certain
movements of this kind.
  Whether anything like reduction is effected  or not, some
degree of synovitis will attend the injury, which needs to  be 
396
Dislocations.
subdued by proper management.  As all such difficulties of
the joint are  liable to be repeated sooner or later, an elastic
knee-cap should be Avorn for months or even years.
  Compound dislocation of the knee is one of the most danger-
ous accidents that occur to a limb.  Besides the injury to the
soft parts, Avhich must be considerable, large articular surfaces
are exposed to the influences ofthe air, and subjected to those
changes which begin in shock and end in suppuration.  The
popliteal artery, veins and nerves, are stretched, or torn, so
that complications ofthe most dangerous character can scarcely
be escaped.  In  most instances  it Avould not be advisable to
attempt to save the limb ; though, if the subject  of  the  acci-
dent be vigorous,  and the vessels and nerves apparently not
much injured, an attempt to save the limb would be justifiable.
HoAvever, the entreaties of the patient or those of his friends,
who can not comprehend the extreme dangers of a compound
dislocation of  the knee, should not, in a seA^ere case,  deter the
surgeon from expressing  his views in decisive terms, nor
SAverve  him  from his  plain path of  duty.   Many a timid,
vacillating, or too easily influenced surgeon  has, AAiien too
late, regretted having trusted to the recuperative poAvers of
nature in severe  injuries of the knee-joint.  Amputation,  or
even resection,seems a harsh and uncompromising measure to
adopt in case of compound dislocation of the tibio-femoral
articulation, yet  the  more experience a surgeon has the less
he is disposed to trust to any conservative course in the man-
agement of compound lesions of the knee.
# 
CHAPTER  XIV.
DISLOCATION  OF  THE TIBIO-FIBULAR  ARTICULATIONS.
   Separation  of the tibio-fibular connections  must be ex-
 tremely rare, for two principal reasons:  1st, no considerable
 force can be so directed as to tell effectively toAvards separating
 these bones; and  2ndly, the interosseous ligament,  together
 with the ligamentous fastenings between the tibia and fibula
 near the extremities of these  bones, render their disjunction
 exceedingly difficult.  If all the ligaments connecting these
 two bones be  preternaturally relaxed some displacement of
 the fibula Avould be admissible, Avithout, hoAvever, presenting
 a dislocation in the ordinary acceptation of the term. Dislo-
 cation  of either end of the fibula may attend a fracture of
 the tibia; but as a distinct lesion, unaccompanied with frac-
 ture, the fibula  is seldom disengaged  from its articular rela-
 tions Avith the  tibia at either of its extremities.  The upper
 end of the fibula is reported to have  been displaced forwards
 and backAvards.
  In the forward dislocation, three or four examples of which
 haA^e been collected, there Avas doubt  whether muscular action
 or  direct  violence produced the  displacement, though  it is
 probable that the latter  cause was the  true one, inasmuch as
 little muscular force can be exerted in the forward direction
 upon the upper extremity of that  bone.  In the  extreme
 flexed state of the limb, as in  a squatting attitude, the thigh
 presses the upper end of the fibula fonvards, and the muscles
 arising from the anterior aspect ofthe upper half ofthe bone,
also tend to displace it fonvards.  With these forces at Avork,
and a direct bloAv coming at  the same time, the head of the
fibula might be throAvn in front of its normal position.
                           (397) 
398
Dislocations.
  The signs  of this displacement are tolerably plain.   The
head,of the fibula is not in its natural position, but its pres-
ence is discoverable near the ligamentum patellae;  the biceps
flexor  cruris, Avhich  is inserted into the head of the bone, is
put upon the stretch; and the natural contour of the leg just
beloAV the knee, is lost.
  Treatment.—Dislocation of the head of the fibula forward,
is reduced by extending the leg and rotating the foot out-
Avards, the surgeon at the same time pressing the bone back
into its natural position.   Rest for a couple of  weeks will
alloAv the torn ligaments time to heal.
  Dislocation of the upper  end  of the fibula backwards is a
rarer accident than the forward displacement.   Direct violence
is the  chief cause, though the action of the external  ham-
string  muscle might assist  in the luxation.   Malgaigne has
reported a case or two in Avhich muscular action  and  direct
force seemed to have produced the displacement.  The head
of the fibula Avas thrown behind its usual position, and  could
there be  distinctly felt  beneath the  skin.  The reduction is
accomplished by flexing the  leg to relax the biceps, and then
the bone  may be  pushed into its normal place.   Unless the
leg is kept flexed at the knee for tAvo or three weeks there is
danger that the luxation may be reproduced.  A compress
bound against the posterior  aspect of the bone, will assist  in
keeping the head of the fibula in its natural position.
  Dislocation  of the  loAver  end of the fibula from its  tibial
connection has been reported.   The displacing  force of a
passing wheel, might throw the loAver end of the fibula back
toward the tendo-Achillis;  and a similar force acting upon
the bone  Avhile the leg was resting upon its anterior  aspect
might possibly effect a fonvard displacement.  Either variety
of luxation Avould be difficult  to overcome.  While the foot.
Avas rocked inwards  the surgeon should make an effort to
push or pull the bone into place.  Once restored to its natural
position there would be no  particular danger of a reproduc-
tion of the lesion. 
CHAPTER  XY.
DISLOCATION  OF THE  ANKLE-JOINT.
  FolloAviiig the nomenclature heretofore adopted, luxations
at the ankle will not be regarded as dislocations of the lower
end of the tibia.  In all other dislocations the  distal part of
the limb  is assumed to be displaced, though it may not be
strictly correct in all instances.  The  foot may be held fixed,
and a displacing force throw the tibia forward on the astraga-
lus, the tibia being the bone displaced: the same  thing may
happen to other joints.  For example, the arm may be caught
and held  immovably, Avhile a force twists the body until the
scapula is displaced from the head of  the humerus.  This cir-
cumstance does not do aAvay Avith the fact that  the injury, so
far as surgical recognition is concerned, is a dislocation of the
humerus.   Those Avho contend for exceptions to ordinay rules,
as applied to dislocations, gain nothing, and contribute their
support to what can be correct only a part of the  time.  In-
deed,  in  not a  few instances neither form of language could
be strictly correct, for  the displacement is mutual, i. e., a
double force produces the dislocation,—one drives the tibia
forwards, for example, and the other propels the astragalus
backAvards in the same accident.  It is absurd, then, to destroy
the harmony of nomenclature by adherence to an exception
which presents no compensating advantages.
  Dislocations ofthe foot at the ankle-joint take place in four
directions ; and, mentioned in the order of frequency, they
stand  as follows : outAA^ards, imvards, backwards, and forwards.
  In the outward dislocation, the injury is commonly compli-
cated  with a fracture  of the fibula a few inches above the
malleolus.  The foot is strongly everted, the outer edge of the
sole being elevated, and the inner resting on  the ground.   A
                          (399) 
400
Dislocations.
depression exists  at the seat of fracture, and  the internal
malleolus projects prominently.
  The injury is produced by a violent tAvist or Avrench  of the
foot outAvards, as in  stepping on the outer edge of the foot the
                              sole comes doAvn  upon  a roll-
                              ing stone or a projection  of
                              frozen earth.  It is often caused
                              by a fall, the  weight of the
                              body being  received on the
                              outer half of the sole,  giving
                              the leg a cant inwards.   This
                              injury  has already been  de-
                              scribed in the chapter on frac-
                              tures of  the  fibula; one part
                              of  the accident rarely  occurs
                              except  in  combination  Avith
                             the other.  In  extremely rare
                              instances, the  fibula  may be
                             broken just above the  ankle-
                              joint, Avithout  dislocation  of
                              the astragalus; and occasiou-
   Disiocation of the foot outwards.      ally the foot  maybe  luxated,
                             partially  or completely, Avith-
out the fibula being broken.  HoAvever, the double form of
injury is to be expected in the majority of cases.   Besides the
fracture of the fibula, either the internal malleolus is broken,
or the internal lateral ligament (deltoid)  is torn.  If the loAver
end of the tibia be broken, as Avell as the fibula, and  the foot
throAvn outAvards Avith these two inferior fragments, the injury
is not legitimately a  dislocation, but a  fracture  of both bones
of the leg.  Boyer relates a singular case in which the dislo-
cation of the foot Avas not attended with fracture of the fibula,
but Avith displacement of that bone at  its upper  extremity.
It  is  possible for  the foot to be throAvn outAvards, the fibula
not suffering fracture but separation from the  tibia  at the
peroneo-tibial articulation.  Such accidents have occurred, un-
less there has been some mistake  on the part of those Avho
reported them.
  The ordinary form ofthe accident is sometimes adjusted by
the patient before the surgeon ha3 an opportunity to examine
the parts implicated  in the accident.  Finding  his foot in an
 
Of the  Ankle-Joint.               401
 awkward  state of deformity, the patient reaches doAvn and
 tAvists it back into place; and then after being carried  home,
 he has his ankle bathed in liniments, believing the injury only
 a sprain, and does not send for a surgeon until he finds that
 the difficulty is more serious and tedious than at first antici-
 pated.  Called several days after the accident and the  return
 of the foot to nearby its natural position, the surgeon must not
 be misled by  the patient's opinion  of the case; but should
 seek the depression in the course of the fibula an inch or two
 above the ankle, and rotate  the foot  to elicit crepitation.
 Though the parts be  SAvollen, a careful examination will reveal
 the nature of the injury.  If asked  the  question, the  patient
 Avill remember haAing, Avith his  oavii hands, tAvisted the dis-
 torted foot into position.   In the event of dislocation, Avithout
 fracture of the fibula, the  reduction is  too difficult  for the
 patient to  accomplish, and the surgeon Avill then find the parts
 involved in the injury just as the accident left them.
   Treatment.—The outAvard dislocation of the ankle, as has
 already been intimated, is not difficult to  overcome.  In most
 cases the surgeon, after flexing the leg on the  thigh to  relax
 the gastrocnemius, can Avith his hands press the  foot into its
 natural position.   It may facilitate the  operation by gently
 rocking  the foot while moderate extending force is applied.
 After  reduction  is accomplished, two side splints are to be
 used, Avith a compress between the lower end  of the outside
 splint  and  the external malleolus, or the outside of the foot
 just beloAV the  malleolus, as recommended in the treatment
 of "Pott's fracture"  of the fibula.   In some instances, Avhere
 the internal lateral ligament is torn  across, as  it generally is,
 the ankle will remain weak, with  a  tendency for the  foot to
 turn out too  much,  especially when a  step is made upon an
 uneATen surface.
   Hamilton reports two cases in his  work  on Fractures and
 Dislocations, in which the reduction could not be effected on
 account of some  obstacle in the articulation, which may haAre
 arisen from fracture of the lower  extremity of the tibia, the
 small fragment being in  the way of reduction.   He also re-
 ports having amputated the limb for compound dislocation of
 the foot outwards ;  and a dissection exhibited a fracture of
the outer part of the articular surface of the tibia, the wedge-
    26 
402
Dislocations.
shaped fragment occupying a position in the joint adverse to
reduction.
   When the top of the astragalus has slipped aAvay from the
articulating surface of the  tibia, and lodged in the channel
between  that bone and the outwardly displaced external mal-
leolus, the reduction can not be exceedingly difficult to effect;
and if the  displacement could not be overcome by ordinary
means, the inference would  be that a piece  of the outer side
of the tibia had been chipped off, and dropped doAvn between
the astragalus  and the main fragment  of the tibia, either
maintaining the upright attitude or turning over upon its side
and becoming an obstacle in the capacity of a wedge.
  The dislocation of the ankle inwards is a rare  accident, and
must occur from a forcible rocking of the foot upon  its axis
in a direction calculated to split off the internal malleolus, and
to stretch aud tear the external lateral ligaments of the joint.
In this injury the foot is thrust inwards, so that the outer edge
of the sole  meets the ground, and the inner edge is raised,
making the bottom of the foot  present toAvard .the opposite
foot.  The lower end of the fibula, or the external malleolus,
projects very prominently ; the Avidth of  the joint is increased;
and the internal malleolus is displaced and moves Avith the as-
tragalus.  In a  case that recently came under my observation,
the internal malleolus Avas broken, and the fibula Avas fractured
three inches above its loAver extremity.  If I had not seen the
deformity before it AAras overcome, I should have been disposed
to believe that the luxation had been  originally outAvards, and
that in the  eff'oi'ts at reduction, the foot had been rotated too
far inwards.  The accident happened by a fall from a building,
the foot  striking among some rubbish.   It is not improbable
that the  displacement Avas primarily outAvards,  breaking the
fibula aboAre  the ankle, and  the  internal  malleolus, by the
strain on the deltoid ligament; and that by a further  descent
of the body the  foot received an inward cant AAiiich threAV it in
that direction beyond its usual limit.
  Treatment.—The inward dislocation of the  ankle is ahvays
reduced  Avith  ease.  If the patient has not turned  the foot
into place Avith his oavii hands, the  surgeon has only  to  seize
the foot and make extension, at the same time rotating it out-
wards.  No powerful forces are required to replace the luxated
bones, or to adjust the displaced fragments.  The healing pro- 
Of the  Ankle-Joint.                403
Fig. 127.
 cess will occupy four or five weeks, and during this time  the
 two leg splints should be worn, with a compress betAveen the
 inside of the foot, beloAV the malleolus, and the lower end of
 the splint.  Any rotation or distortion of the foot is  to be
 corrected during the time the dressing is worn, by the judicious
 use of adhesive strips, which in their application are to  begin
 at the base of  the great toe and cross the hollow of the foot
 obliquely, along the course of the peroneus  longus  muscle,
 and thence over the external malleolus and up the leg on its
 anterior aspect.   The position of the foot can be regulated by
 the proper employment of strips of adhesive plaster, even if
 no splints  be applied, though the use of splints keeps the ankle
 from turning  laterally in either direction.  If the fragnient
 embracing the internal malleolus unites to the rest of the bone
 by osseous consolidation, the cure will  generally be satisfac-
 tory ; but if it make only a ligamentous connection the  ankle
 must always remain weak.
                           Dislocation of the foot backwards
                         may take place in a leap from  a car-
                         riage  in  motion, or from a fall in
                         Avhich the heel catches or the toes
                         meet  something solid, the impetus
                         of the body  carrying the leg for-
                         Avards.  The  displacement is gener-
                         ally accompanied Avith a fracture of
                         the fibula just above the  ankle, the
                         lower fragment, constituting the ex-
                         ternal malleolus, remaining in con-
                         tact Avith the astragalus.  The tibia
                         takes a position in front  of the as-
                         tragalus, on the navicular and cunei-
                         form  bones.
                           The  symptoms  of this accident
                         are a shortening of the anterior part
of the foot  and a lengthening  of  the heel.  The toes are
pointed  dowmvards, and the extremity of the tibia forms a
projection in front of the ankle.   The tendo-Achillis is arched,
and the tendons on the  top of the foot are tense and sharply
defined.
  Treatment.—This variety of dislocation is commonly re-
duced Avithout much difficulty, though considerable extending
Dislocation of the foot backwards: 
404                   Dislocations.

force is required before the bones of  the leg and foot can be
pulled and  pushed into their proper positions.  The flexing
of the leg on the thigh relaxes the gastrocnemius muscle,
therefore an assistant should put his  arm under the lower ex-
tremity of the  thigh, to make counter-extension, Avhile the
surgeon makes extension with one hand on the patient's heel
and the other on his toes.   The dressing and after-treatment
should be much like that recommended for treating the lateral
dislocations of the ankle.  Due regard must be exercised for
the fracture  of the fibula.
  In some cases it may be found difficult to maintain the parts
in place after reduction is accomplished.   However, if the foot
is  kept flexed on the leg, and the heel made to support the
weight of the limb, the tendency to displacement is mostly
overcome.  In cases Avhere the heel Avill endure pressure, and
the anterior  part of the leg near the ankle, some additional re-
tentive means may be employed.  If the foot and  leg be placed
in a box, with the heel suspended on a strip  of buckskin, an-
other strip of the same material may be made to press on the
front of the leg by passing the ends  through two holes bored
in the sides of the box beloAV the level of the limb, and then
tied over the top of the  box.   Great watchfulness is needed
to prevent a slough of the heel, for such a complication is fre-
quent,  and its effects tedious, and distressing.
  Dislocation of the foot forwards is the rarest form of dis-
placement occurring  at the ankle-joint.  The  injury arises
mostly from falls, the foot meeting the ground Avith  the toes
elevated, and there remaining fixed Avhile the descent of the
body carries the leg bones doAvn behind the summit of the as-
tragalus.  One  of the  best described cases is that of Mr.  R.
W. Smith, in the Dublin Quarterly Journal of Medical Science,
for May, 1852.  The subject of the accident was a sailor, Avho,
while assisting to raise a very heavy cask on board ship, hav-
ing at  the same time one leg much flexed on the  foot, and the
thigh on the leg, was struck by the falling of a cask just above
the knee, forcing the distal end of the  tibia backAvards from
off the astragalus on the upper and posterior surface of the
calcaneum.  The symptoms of this accident  Avere, a lengthen-
ing of  the dorsum ofthe foot to the  extent of one inch, and a
shortening of the leg to the extent of half  an inch, the two
malleoli being so much nearer the ground.   The projection of 
Of the Ankle-Joint.
405
the heel had disappeared, and the tibia formed a remarkable
projection in front and to the inner side ofthe tendo-Achillis.
The fibula  Avas uninjured; but  the extremity  of the  inner
malleolus received a fracture.
   The only accident Avith which this could be confounded is a
fracture of the tibia immediately above the ankle-joint; but
the situation of the malleoli  Avould be decisive of the nature
of the injury.  "In the fe\v cases of this accident Avhich have
been published," says Mr. Carsten Holthouse, " reduction Avas
not effected, and the patients remained very lame;  but there
seems  to  be no reason  Avhy cases of this description, if seen
early and properly recognized, should not  be reduced  in  a
similar manner to the  lateral dislocations,  and treated in all
respects similarly."
   A dislocation of the  foot forwards could not take place
without extensive laceration of nearly  all  the  ligamentous
structures about the joint; and  the tendons passing behind
the tAvo  malleoli  are put greatly upon  the stretch, and may
drop from their sheaths into the mortise-like excavation usually
occupied  by the astragalus.
   Treatment.—The forward luxation of the foot can not be
overcome without Avell-directed  and  vigorous  efforts  on the
part of the surgeon and  assistants.  The aid of chloroform in
.relaxing the muscles is invaluable ; and the patient should be
made  to  take the  agent until  he is  profoundly under its
influence.   The injured  limb should then  be  flexed at the
knee, and held by an assistant; the foot is to be extended by
the hands of another assistant; and the surgeon pulls the leg
fonvards and pushes the  foot backwards.   If several  efforts of
this kind prove unsuccessful, the  most unyielding tendons may
be divided subcutaneously, to facilitate  the  reduction.   Once
in place, great care must be exercised to  prevent a recurrence
of displacement.  The weight of the limb  must not rest on
the heel, but on the leg above the ankle.   The limb should be
kept at rest for several Aveeks, or until it is presumed that the
torn ligaments have united. 
CHAPTER  XYI.
DISLOCATION  OF  THE BONES OF THE  FOOT.
  Says Mr. Robert Wm.  Smith, in his Treatise on Fractures,
etc., " The  mechanism by which the  bones of the foot are
secured against the effects of external violence, is so complete
and powerful, that Ave seldom have opportunities of Avitness-
ing luxations of the bones of  the tarsus from one another, or
their displacement from the metatarsal range."
  The os calcis has been dislocated  from its relations with the
astragalus, and in the same injury the scaphoid bone has been
disconnected  from its  astragaloid relations, these bones with
the rest of the foot going backAvards, causing the head of the
astragalus to take a position upon the instep, where it forms
a tumor, projecting almost through the skin.  The foot is
shortened in front of the  leg,  and the heel  is elongated.  An
example  of  this  injury  is reported by Macdonnell, in the
Dublin Journal.  On the 6th of August, 1838, Mr. Carmichael
Avas  riding at  a brisk trot when his horse suddenly fell.   To
prevent being pitched forwards, he  threAV himself back in the
saddle, and strongly extended his  legs to  meet the ground.
The shock of this descent was accordingly received upon the
anterior  extremities  of the metatarsal bones, especially  the
metatarsal bone of the great toe of the right foot, which alone
came to  the ground.  The  folloAving Avere the  symptoms:
" The toes were turned outAvards, the inner edge of the foot
forming an angle of  about 30° Avith its natural direction ; the
sole was  slightly turned outAvards, and the outer edge slightly
elevated.  The concavity of the  tendo-Achillis  posteriorly
Avas manifestly increased, and the heel lengthened.   On grasp-
ing the  soft parts betAveen  the tendo-Achillis and tibia, Ave
found the distance betAveen these parts much greater than in
the other foot.  The absence of the  hard projection, Avhich
                          (406) 
Of the Bones of the Foot.
407
would have been formed by the upper articulating surface of
the astragalus, had it passed backAvards with the other tarsal
bones, Avas  evident.  The  malleoli  Avere perfectly  defined.
BeloAV and before the inner there Avas a hard prominence, over
which the skin Avas tense, formed by the inner surface of the
astragalus brought into relief by the dislocation, and the slight
eversion of the sole of the foot.  Much the most striking part
of the deformity consisted in a prominence on the dorsum of
the foot.  Immediately in front of the tibia it presented a flat
surface broad enough to receive the finger,  aud from Avhich
there Avas an abrupt descent upon the anterior part ofthe tar-
sus.   Over this projection, caused by  the head of the  astraga-
lus, the integuments Ave re so tense that it was evident a very
small additional force Avould have driven it through the skin.
Lastly, on taking the distance from the point of the  internal
malleolus to  the extremity of the  great toe with  a tape-
measure, I found it to be nearly exactly an inch less than the
distance  betAveen the same points in the left foot.  We could
detect no fracture.   The foot could  be flexed and extended,
but it occasioned great pain."  To understand this dislocation
better, it must be  considered  that the  astragalus retains its
normal connections Avith the tibia and external malleolus, and
becomes disconnected from the calcaneum and scaphoid bones,
they passing backAvards.
  The reduction of such a dislocation is to be effected by the
strength of the surgeon's hands, the patient being anaesthe-
tized, and his leg  flexed and managed bj an assistant, who
pulls  the tibia, fibula, and astragalus backAvards, and the sur-
geon, Avith  one hand on the  patient's heel and the other on his
instep, exerts extension and a fonvard movement of the foot.
Some twisting and rotation  of the  foot facilitate the return
of the displaced bones to their normal relations.
  Dislocation of the calcaneum and  the other" bones of the
foot  forwards, the astragalus  alone being left iu connection
with the bones of the leg, is an exceedingly uncommon acci-
dent.   Malgaigne finds but  one example,  and  that is reported
by M. Parise.   The injury  happened to a quarryman Avho,
while at  Avork, with his left  foot resting on a block of stone,
and his right on the ground, Avas throAvn forcibly fonvards by
the falling  of a  mass of stone ; the  thigh being at the same
time strongly flexed on the trunk, the leg on the thigh, and 
408
Dislocations.
the foot on the leg.  The folloAving symptoms were observed ;
the foot  was flexed;  the projection  of the heel had disap-
peared ; and the bones of the leg Avith the astragalus in its
normal relation Avith them, were found behind the calcaneum,
or Avere resting upon  its posterior extremity.  As no crepitus
was discoverable it Avas presumed that  the injury was a dislo-
cation ; but the pain and the  SAvelling  were so great, that a
complete  examination could not be made, and reduction was
not attempted.  Nine months afterwards the condition of the
limb  was as folloAvs : the foot was flexed  at  a right  angle
Avith  the  leg, its point inclined inAvards, and its inner border
slightly depressed ; it Avas elongated in front of the bones  of
the leg, and the projection of the heel was completely effaced.
At the level of, and  a little  below the malleoli, posteriorly,
was a bony projection, AAiiich pushed  backwards the  tendo-
Achillis beyond  the  heel.  Above this projection there Avas
another less marked, formed by the posterior  and inferior
margin of the tibia; the malleoli were not separated from
each  other, nor  did they present  any traces  of fracture.  The
extensor tendons of the toes  Avere stretched over the instep,
and beneath these on the outer  side Avas a  projection, Avhich
appeared to be the head of the  astragalus, and  immediately
in front of this a depression.  Flexion and extension of the
ankle-joint existed to.a limited extent.
   It is possible that this displacement could not be overcome,
but if chloroform had been administered, it is quite probable
that a surgeon to pull the foot backAvards, and  an assistant to
pull the leg fonvards, might have accomplished reduction.
Flexion  of  the leg and extension of the foot, Avould favor a
return of the bones to their accustomed places.
   Dislocation of the foot sideways at the calcaiieo-astragaloid
joint, is apt to be incomplete and compound ;  the astragalus
rests on a portion of the os calcis, and is not thrown upon its
side, as it Avould be if the dislocation Avere complete. Forced
adduction  and  abduction are the principal causes of these
lateral dislocations of the calcaneum.
   In  the  outward dislocation the foot is abducted, the outer
border of the sole being raised, and the inner  resting on  the
ground.   The external malleolus is buried in the fossa caused
by the eversion of the foot, and the inner malleolus and  the
head  of the astragalus project unnaturally inwards.  In thir- 
Of the Bones  of the Foot.            409
teen examples of this variety of dislocation collected by Broca,
nine Ave re compound, and in six the fibula was broken.
   The inward  dislocation at the  calcaneo-astragaloid joint,
presents deformities  similar to the varus form of club-foot;
the foot is inverted, and its inner border raised.   The head of
the astragalus  and the external malleolus project beyond the
outer border of the foot, and a deep depression  exists  beloAV.
On the inside  of the foot an elongated projection, formed by
the inner border of the calcaneum, completely masks  the in-
ternal malleolus.   The scaphoid bone can be felt nearer to the
os calcis than natural, and thus the inner border of the foot is
shortened and  rendered someAvhat concave, Avhile the outer is
lengthened and made unnaturally  convex.
   The Avidest  difference seems to exist in the difficulties en-
countered by the  several surgeons who ha\'e reported cases of
dislocation of the bones of the tarsus.  Probably the kind
and degree of displacement are not ahvays the same ; and it
is possible that  all  cases Avere not managed  Avith the same
amount of intelligence and perseverance. In  not a few in-
stances  the ligaments of  the tarsus, and  the  tendous passing
from the leg  to their insertions in the foot, act as  mechanical
impediments to  the  return of  the displaced  bones;  in ex-
tremely rare  cases, they may become insuperable obstacles to
reduction.  In  those cases in which it  is apparent that the
tendons offer the principal resistance to reduction, it is advis-
able to divide subcutaneously the tendo-Achillis, and perhaps
the tibialis anticus and posticus.
  In* some dislocations about  the foot  aud ankle it  is ex-
tremely difficult to determine the exact nature of the  injury,
one lesion so much resembles another.  There are deformities
attendant upon fractures in the  immediate vicinity  of the
ankle, that appear like those following luxations of the bones
of the tarsus, therefore the surgeon should exercise his powers
of discrimination if he Avould  escape making a faulty diag-
nosis.  Those injuries which are compound, do not present so
many difficulties in the way of a correct solution of the mys-
tery.  It Avould not ordinarily be easy to diagnose a rotation
ofthe astragalus, in which the upper or trochlear surface pre-
sented inwards, and its outer surface upwards ;  but if the ac-
cident leave an opening to the bone the insertion of the fingei
might determine  exactly the nature of the displacement. 
410
Dislocations.
  According to the results of cases collected by M. Broca, it
is much safer to let a dislocated tarsal bone, which can not be
reduced, remain in its  abnormal  position than to attempt to
remove it;  and amputation, which  has so many times been
adopted  at  once after some of the tarsal dislocations, should
not be considered as long as there  existed  a  possibility of es-
caping gangrene, and other serious complications.  In acci-
dents of a  crushing  character, breaking and  displacing  the
bones, and compounding the injury by lacerating the soft  tis-
sues, no special rules can be given  Avhich would be generally
applicable, yet in the management  of such injuries, the  accom-
plished surgeon who is accustomed to act in emergencies, and
is governed  by the general principles of his science, knows as
Avell Avhat the necessities of each  particular  case demand, as
if he had just studied a Avritten direction for the treatment
of such a case.
  The astragalus, when it is displaced, may  become so com-
pletely isolated from nutritive connections, as to be in  danger
of necrosis.   Under such circumstances, it would be better to
extract the bone at once, than to leave  it Avhere  by prolonged
irritation it  might jeopardize the limb, or even the life of  the
patient.
  Mr.  Burnett, in the London Medical Gazette, for 1837, de-
scribes the  case of a gentleman Avho, in taking a leap Avhile
fox-hunting, dislocated the scaphoid bone from  its connections
with the cuneiform bones.   A avouik!  three  inches in length
Avas  made in the instep  through Avhich the scaphoid and part
of the astragalus protruded.  By making steady pressure on
the bone for fifteen minutes  it  Avas  reduced. The  Avouud
healed, and  the patient  recovered the free  use of the foot.
Piedagnel Avas unable to reduce  a  displaced  scaphoid that
came under  his obseiwatiou; andthebone being broken longi-
tudinally, and the accident compound,  he amputated the foot.
  In the  case  of Walker, reported  in The Medical Examiner,
for 1851, the scaphoid Avas forced fonvards and upAvards, as a
stone is forced from an arch.  By bending the foot doAvnwards,
the surgeon  Avas enabled to press the projecting and displaced
bone back into its normal position.
  Malgaigne has not  seen a case of dislocation of  the  cuboid
bone, nor has he confidence in the reports of those Avho claim
to have met Avith the accident.  The assertion  of Piedagnel.
                                                     ©    * 
Of the  Bones of the Foot.
411
 that the bone maybe displaced in three directions, is probably
 based upon speculation, as other surgeons, since his time, have
 enjoyed great opportunities for observing such displacements,
 if they were of even rare occurrence, and  no Avell authenti-
 cated accident of the  kind  has been reported.   There seems
 to be nothing in the shape of the bone, or in its connections,
 to prevent displacement; and that is probably Avhy it has been
 stated  that the bone may be  dislocated doAvnwards, inwards
 and upAvards.
   The internal cuneiform bone may be luxated from its sca-
 phoid connection in an upward and inward direction, as if in-
 fluenced by the action of the  tibialis anticus muscle; and its
 anterior extremity may also be forced from its metatarsal rela-
 tions, though in conformity with the nomenclature  adopted in
 this work, such a displacement must be considered as a luxa-
 tion of the metatarsal bones.   All three cuneiform bones have
 been luxated upAvards, the  deformity being marked, and the
 diagnosis easy, on account of the bones  being thinly covered
 on the dorsum of the foot.  The reduction, when the internal
 cuneiform is  displaced singly, or the  three together,  is not
 difficult.  The foot is seized  in such a Avay that the hands
 bend the anterior part of the foot doAvnwards, and the thumbs
 press the bone or bones back into place.


   DISLOCATION  OF THE METATARSAL  BONES.

   Robert Wm. Smith, of Dublin, makes the folloAving appro-
 priate  remarks:  " When Ave reflect  upon the  admirable
 mechanism of the  foot; when we consider the beautiful con-
 struction of its arches, the peculiar forms of the tarsal bones,
the extent of their articulating surfaces, and their mode of
adaptation to each other; Avhen we also take into account the
number  and  strength of the ligaments   Avhich bind them
together, the arrangement ofthe muscles, tendons, and tendi-
nous expansions in  the plantar region, and  the very slight de-
gree of motion Avhich is  permitted  to the  bones ;—A\iien  we
reflect upon all these conditions, we find, that in the mechan-
ism of this  solid, but at the same time, highly elastic fabric,
nature  has adopted  every  provision  calculated  to  ensure
strength, and immunity from external violence. 
412
Dislocations.
  " Notwithstanding, hoAvever,  these  numerous and  varied
sources of security, the bones of the foot occasionally suffer
displacement, when subjected to the influence  of great exter-
nal force."
  Sir Astley Cooper observes: "The metatarsal bones I have
never known luxated ; their union Avith each other, and irreg-
ular connection with the tarsus, prevent it; and if it ever hap-
pens, it must be a very rare occurrence."
  Mr. Robert  Smith, whose words have just been quoted,
twice had  an  opportunity of ascertaining by post mortem  ex-
amination, that  the  metatarsus  and internal cuneiform bone,
Avere dislocated upwards and backwards, the luxations having
remained unreduced many years.   The appearance of the foot
in both instances indicated pretty clearly the nature  of  the
accident.   The  heel preserved  its  natural relations  to  the
bones of the leg; but the foot in front of the ankle-joint Avas
shortened  an inch  or  more; the  inner edge of the foot Avas
elevated, and the outer depressed ; the sole of the foot exhibits
a rounded appearance,  and the dorsum a transverse promi-
nence, situated about an inch below and in front ofthe  ankle-
joint.   Upon  examining  the  skeleton of the foot, the meta-
tarsal  bones, and the internal  cuneiform, Avere found  dislo-
cated upAvards and backwards upon the tarsus.  The accident
which effected the displacement Avas a fall from a horse.
  In the second  example the history of the case was not ascer-
tained.   The patient died of malignant disease of the abdomen
at the Richmond Hospital;  and as he did not Avalk lame, no
inquiry Avas made concerning the conditio^ of the foot Avnich
appeared simply fore-shortened in front of the ankle-joint.
The appearance  of the foot in every particular, Avas  like that
of the other just described.  Dissection shoAved that the second,
third, fourth and fifth metatarsal bones, and the  internal
cuneiform bone, Avere dislocated upAvards and backAvards upon
the tarsus.  Anchylosis  had taken place between  the  tarsus
and  metatarsus, and osseous buttresses had been thrown  out
to assist in the consolidation.  Mr. Smith thinks the disloca-
tion is liable to occur " when  a person, in falling or leaping
from a considerable height, alights upon the anterior part of
the foot.   Under these  circumstances, the limb is submitted
to the operation of two forces operating in opposite directions ;
one, the  weight  of the body and impulse  of the fall, tending 
Of the Bones of the Foot.            413
 to  depress  the  tarsal bones; the other, the resistance of the
 ground, tending to displace the metatarsus upwards ; the ar-
 ticulating surfaces thus glide past each other, and the anterior
 part of the foot is then drawn backAvards, and the aspects of
 its  surfaces altered by muscular action."
  In  the injuries just described  it  AAill be observed that the
 first metatarsal bone—the one to which the great toe belongs—
 was not dislocated,  strictly speaking, but, as  it went upAvards
 aud backwards it folloAved the rest of the metatarsal row, and
 the internal cuneiform bone, to which it maintained it3 normal
 connections.
  Mr. Smith  thinks that the tAvo cases  of dislocation of the
 metatarsus upon the tarsus related by Sanson, as having  hap-
 pened in the practice  of Dupuytren, may have been strictly
 such, but he inclines to the opinion that the internal cuneiform
 bone  preserved its connections Avith the first metatarsal bone ;
 and if that condition Avas overlooked, he regards it as not the
 slightest disparagement to the judgment of that great surgeon.
 The tAvo cases dissected by Smith were found unreduced; and
 it is not knoAvn Avhether attempts at reduction Avere ever made.
 Dupuytren found it impossible to reduce the  bones to place in
 the two cases  coming under his treatment.
  In a case of dislocation of the metatarsus under the tarsus,
 reported in the Dublin Quarterly Journal of Medicine, 1854, as
 falling to the practice of Mr. Tuffhell, in  the Dublin  City
 Hospital, reduction Avas not accomplished, though the most
 poAverful and persevering efforts Avere made.   The accident
 happened to a trooper Avhose horse fell upon the soldier's right
 leg and foot, crushing them against the ground.   In six months
 after the accident the patient Avas able to walk upon the  heel
 and outside of the foot, but could  not bear  any Aveight upon
 the sole on account of the  burning,  lancinating pain excited
 by the endeavor.
  Dr. Hershey, of Williamsville, N. Y., in  1856, reported to
 the Boston Medical and  Surgical  Journal, a dislocation of the
first, second, and third metatarsal bones upon the tarsus.  The
accident occurred to a young man who  was  suddenly dis-
mounted from a horse.  The reduction Avas  accomplished as
follows : an assistant  made  counter-extension upon the heel,
and the1 surgeon grasped the anterior  extremity of the  foot
with both hands, made extension, bent the toes downwards, 
414                   Dislocations.
and  Avith his thumbs  pressed the projecting bones back to
their natural position.
  A lateral dislocation  of the metatarsal bones outwards is re-
ported by Dr. Gross to  have occurred in the.practice  of Drs.
Green and Swift, of Easton, Pa.  The accident happened to
an elderly gentleman who, in falling down a flight of stairs,
sustained the  injury.  The metatarsal bones were all forced
laterally  outwards to the extent of a half inch or more ;  and
the foot is reported to have been shortened and t\visted.
  The reduction Avas accomplished by extension, and pressure
in directions calculated to return the displaced bones to their
natural positions.


DISLOCATION  OF THE PHALANGES  OF THE TOES.

  The great toe is dislocated at the  metatarso-phalangeal  ar-
ticulation much more  frequently than the other toes.  Of
twenty-two cases, confined  to the first roAV of phalanges, re-
ported by Malgaigne, the great toe suffered luxation in nine-
teen instances ; and in  the three  other cases, all the toes Avere
dislocated at once.  The  displacements  are generally, if not
always, upwards, the phalanges  being forced upon the meta-
tarsal bones.
  Partial displacements of the toes are  common ;  and com-
pound luxations are more  frequent  than  in displacements at
other, joints.   There seems to  be a certain analogy betAveen
the dislocation of the first phalanx of the great toe, and that
of the corresponding  phalanx of the  thumb ; and a similar
difficulty is experienced in the reduction.   As both  joints are
organized on the same general plan, it Avould be strange if
the like causes did not  produce like effects, the same kind of
resistance being offered in both articulations.  In the only
case of dislocation of the great toe at its metatarso-phalangeal
articulation, that has come under my treatment, I  met Avith
no serious obstacles to a  ready reduction.   Extension  Avas
made upon the toe by an assistant, and Avith my hands around
the sides of the foot to exert counter-extension, pressure Avith
the thumbs against the projecting and  displaced  phalanx,
effected  reduction.  In the event of  failure after employing
all ordinary means, it would be justifiable to divide the oppos- 
Of the Bones of the Foot.
415
ing barriers, Avhether they be ligaments, or  tendons, or both,
though such a course should be avoided if possible.
  Dislocation of the second roAV of phalanges, is  an accident
of extremely rare occurrence.  Reduction, by means of exten-
sion and pressure, has not been difficult in* the feAV cases re-
ported.
  The terminal bones of the toes have been  luxated;  and the
accident, as Avith other dislocations  of  the  toes, generally
arises from falls received in horsebac'k exercise.   A crushing
force so directed as to double the toes under the foot, is  the
one which commonly produces  displacement of one or more
of the phalanges.  The pain attendant upon the displacement
is severe ; and the deformity denotes the character of the in-
jury.  Reduction  may be accomplished by the ordinary man-
ipulation required to reduce displaced digital extremities. 
 
INDEX.
              PART 1.  FRACTURES.

                                                                    PAGE
Acromion process, fracture of the........................ ..............................  Ill
Adhesive strips, for making extension..................................................   60
Apparatus for treating fractures........................................................   52
Appliances, defects of,  in fractures of the femur....................................  205
    adhesive strip, as a fastening to the leg.........................................  230
    handkerchief, as a fastening to the leg ....................... .................  229
    gaiter, as a fastening to the ankle................................................  229
Astragalus, fracture ofthe........................................................ ......  249
Attitude of limb  in treating fractures of the femur...............................  193
Bandages.......................................................................................   52
Brainard's perforator, for treating  false-joint........................"................   39
Burges' fracture-bed................................................................  .......    63
Burges' fracture apparatus for treating fractures of the femur................  200
Calcaneum, fracture of the........................................... ....................  250
Callus, soft and yielding after apparent consolidation............................   31
    provisional..............................................................................   32
    yielding nature of, after fractures of the femur..............................  201
Capsule of hip-joint..........................................................................  179
Carpus, fractures of the...................................................................  161
Cartilages, costal, fracture of the........................................................  100
    laryngeal,  fracture of the............................................................   90
Cervix femoris, fractures of the..........................................................  172
    scapulae, fracture of the..............................................................  114
Clavicle, fracture of the....................................................................  104
Coccyx, fracture  of the....................................................................  168
Condyles of the humerus, fractures of the............................................  128
    of the femur, fractures of the......................................................  211
Convalescence........................................................................... ......   70
Costal cartilages, fracture ofthe.......................................................  100
Coracoid process, fracture of the.........................................................  113
Cranium,  fractures ofthe..................................................................   74
Crepitus as a sign of fracture...........................................................   2-1
Dangsrous complications in fracture injuries.........................................   25
Defective union after fractures............................................................   41
Diastasis,  or separation of epiphysis of the humerus..............................  125
    or separation of epiphyses in general...........................................   72
Differential signs of fracture and dislocation........................................   26
Direct and indirect forces  as causes of fracture.....................................   21
Direction ofthe line of separation,  as oblique, transverse, etc..................   19
           27 
418                            index.
                                                                   PAGE.
Dislocations, (see Part Second)........................................... ..............  255
Division and subdivision of the subject of fractures..............................   18
Dressings........................................................................................
Dupuytren's splint and fracture dressing.............................................  246
Epiphysis, separation of................................•....................................   '2
Epiphysis of the humerus, separation of the.......... ............ .................  125
Exercise allowed a patient treated for fracture......................................   66
Extension, adhesive strips in making...........................,.............   60
Fracture, general observations upon nature and treatment of..................   17
    division and subdivision of subjects of, as simple, compound, partial,
      complete, comminuted and complicated.....................................*.   18
    direction of the  line of  separation in, as oblique, transverse, etc........   19
    comparative frequency of, in different bones.................................   20
    causes of, as direct and indirect violence........................................   21
    signs of, as pain, mobility, crepitus, etc.........................................   22
    incomplete or "green-stick".......................  ...........•..... ............   26
    with dangerous  complications...................................... ................   25
    rendered serious by railway accidents, etc.......................................   27
    apparatus...................................................................................   52
    beds........................................................................................   62
    process of union and method of repair in......................................   29
    non-union  after........................................................................   36
    defective union  after..................................................................   41
    responsibility in the treatment  of................................................   44
    management of compound...,.....................................................   67
    ofthe cranium.....,......................................................................   74
    of the zygomatic arch.................................................................   74
    of the nasal bones......................................................................   75
    ofthe malar bones..................................................................   78
    of the superior maxillary............................................................   7.8
    ■ of the inferior maxillary.............................................................   80
    of the hyoid bone....................................... ................................   88
    of the laryngeal cartilages...........................................................   90
    of the vertebra?.......................................................................  91
    of the ribs................................................................................   95 .
    of the costal cartilages................  ...............................................  100
    of the sternum.........................................................................  lol
    ofthe clavicle.............................................. ...........................  104
    ofthe scapula..........................................................................  110
    of  the acromion process..............................................................  Ill
    of the coracoid  process..............................................................   113
    of  the neck of the scapula...........................................................  114
    of  the humerus.  .........................................................................  117
    of  the anatomical neck ofthe humerus..........................................  117
     of  the tuberosities of the humerus.................................................  119
     of  the surgical neck of the humerus..............................................  120
     of  the shaft of the humerus.........................................................  122
     of  the humerus just above the condyles.........................................  125
     of  the condyles of the  humerus....................................................  128
     of  the internal  condyle............................................................... 129
     of  the external condyle...............................................................  133 
                                   INDEX.                            419
                                                                     PAGE.
  Fracture, of the ulna (olecranon process).................'........................... 137
      of the coronoid process of the ulna............................................... 140
      of the shaft of the ulna............................................................... 142
      of the radius............................................................................ 14Ti
      of the shaft of the radius............................................................. 148
      of the radius, (Colles')............................................................... 150
      of the radius, (Barton's)............................................................... 150
      of the carpus, metacarpus and hand..............................................  161
      of the phalanges........................................................................  163
      of the pelvic bones, as ilium, ischium and pubes.............................. 165
      ofthe sacrum.......................................................................... 107
      ofthe coccyx........................................................................... 168
      of the femur..............................................................................  171
      of the neck of the femur.............................................................  1 72
      of the cervix femoris within the capsule (intra-capsular)....;.............  179
      of the neck of the femur outside the capsule (extra-capsular)............  180
      of the trochanter major...................................  ...........................  185
     of the shaft of the femur............................................................  ] 90
     of the shaft of the femur just below the trochanters........................  192
     of the shaft of the femur just above the condyles............................ 207
     of the condyles of the femur........................................................ 211
     of the patella............................................................................ 215
     of both bones of the leg............................................................... 2 21
     of the tibia, singly.............................,...................................... 235
     of the fibula.....___.................................................................. 240
     of the fibula, Pott's..................................................................... 242
     of the bones of the foot.............................................................. 249
     of the astragalus.................................................. ...................  249
     of the os calcis.......................................................................... 250
     of the metatarsal bones .............................................................. 251
     of phalanges of the toes............................................................. 252
 Femur, fracture of the..................................................................... 171
     fracture of neck  ofthe............................................................. 172
   '  fracture of the shaft of the..........................................................  202
     fracture of the condyles of the.....................................................  211
 Fibula, fractures of the.................................................................... 240
     Pott's fracture of the..................................................................  242
     and tibia, fracture of the...........................................................  221
 Gaiter, fastening upon the ankle.......................................................  229
 General observations  upon the nature and treatment of fractures............   17
 General treatment of fractures...........................................................   43
 Gibson's apparatus  for treating fractures of the thigh.............................  206
 Gypsum dressing...........................................................................   56
 Hand, fractures of the.....................................................................  1("'1
 Ilamilton, in regard to mobility at seat of fracture................................  127
Humerus, separation of its lower epiphysis..........................................   73
    fracture of the..........................................................................  117
    fracture of the anatomical neck of  the....................  .....................  117
    fracture of the  tuberosities o" the...............................................  119
    fracture of the surgical neck ofthe...............................................  120
    fracture ofthe shaft of the..........................................................  122
• 
420                             INDEX.
                                                                     PAGE.
Huntoon's yoke-splint for treating fracture of the clavicle.....................  108
Hyoid bone, fracture of the..............................................................   88
Ilium, fracture of the........................................................................  165
Incomplete, or "green stick" fracture................................................   26
Immovable fracture dressing.............................................................   55
Impaction in fractures of the neck of the femur..............................—  177
Innominatum,  fracture ofthe............................................................  165
Ischium, fracture of  the.................................................................  165
Jaw, fractures of upper........................................................  ......   78
Jaw, fractures  of lower.....................................................................   80
Laryngeal cartilages, fracture of the...................................................   90
Levis'  dressing for fracture of the clavicle..........................................  108
Ligamentous union after fracture of the neck ofthe femur.....................  181
Ligament, capsular, of the. hip-joint....................................................  179
Ligamentous union after fracture of the patella...................................  218
Malar  bone, fracture of the................................................................   78
Malgaigne and others on shortening after fracture of the femur..............  203
Management of fractures..................................................................   43
Many-tailed bandage......................................................................   55
Maxillary, superior, fracture of  the....................................................   78
    inferior, fracture of the............................................................   80
Metatarsus, fracture of the................................................................  251
Mobility as a sign of fracture.............................................................   22
" Natural method "  of producing extension...........................................   48
    of applying extension in treating fractures of the femUr.................  198
Nasal bones, fracture ofthe..............................................................   75
Neck of scapula, fracture of the........................................................  114
Neck of femur, fracture of the...........................................................  172
Olecranon process of ulna, fracture of the..........................................  137
Osseous fragility........................................................................ .....   20
Paget, ensheathing  callus of...............................................................   34
Partial fracture (incomplete)..........................................................   26
Patella, fracture of the....................................................................  215
Pelvic bones, fracture of the..............................................................  165
Phalanges of the hand, fracture of the................................................  163
    of the foot, fracture of the.......................................................  ...  252
Pott's fracture of the fibula...............................................................  242
Pubes, fracture ofthe........................................................................  165
Radius, fracture of the......................................................................  14T,
    fracture of the  neck of the.........................................................  14.i
    fracture of the  shaft of the........................................................  148
    Colics' fracture of the................................................................  \x>Q
    Barton's fracture ofthe..................................................,.....   ...  150
Reduction of fractures....................................................................   49
Re-dressings  of fractures...................................................................   64
Responsibility in the treatment of fractures.........................................   44
Ribs, fracture of the................................  .......................................   95
Sacrum, fracture of the....................................................................  167
Sand bags in the treatment of fractures of the leg................................   47
Scapula, fracture ofthe....................................................................  HO
Shoulder blade, fracture of the..........................................................  1U1 
                                 INDEX.
                                                                     PAGE
 Signs of fracture......................................'........................................  2°
     differential, of fractures and dislocations.......................................  2(J
 Silver wire to fasten together fragments of lower jaw...........................  85
 Smith, of Dublin, on fracture of the clavicle........................................ 105
 Spinal cord, injuries ofthe.............................................................  92
 Splint, long straight, for treating fractures of the thigh......................... 195
     Dupuytren's ..................................,....................................... 246
 Starch bandage, treatment of a case with............................................ 2.'!4
 Sternum, fracture of the........................................................ ........... 101
 Swinburne's method of making extension............................................ 124
 Tarsal bones, fractures of the...............'............................................. 249
 Tibia, fracture of, singly.................................................................  235
 Thigh bone, fracture of the................................................................  17;
 Treatment of fractures.....................................................................  43
 Trochanter, fracture of the................................................................ ]85
 Ulna, fracture of the olecranon process of the....................................... 137
     fracture of the coronoid process of the.........................................  140
     fracture of the shaft of the....................................'....................  142
 Union of fractured bones.................................................................   29
    by " first intention."...................................................................   33
    defective...................................................................................   41
    ligamentous, after fracture ofthe neck of the femur.......................  181
    ligamentous after fracture of the patella.......................................  218
 Weight and pulley for extension.........................................................  199
 " Wire breeches ".............................................................................   59
    in the treatment of fracture of the neck of the femur.......................  188
Zygomatic  arch, fracture of the..........................................................   74
              PART II.  DISLOCATIONS.


Ancient dislocations, dangers in attempts at reduction of........................  271
Ancient dislocation of the hip-joint.....................................................  384
Ankle, dislocation of the................  ..................................................  399
Axillary vessels, dangers of rupture of, in attempts to reduce ancient  dis-
      locations of the shoulder...........................................................  273
Beach on  the reduction of dislocations of the hip by manipulation..........  372
Blackman on the reduction of  ancient dislocations  of the shoulder...........  272
Carpal bones,  dislocation of the.........................................................  352
Carpus, dislocation ofthe.................................................................  349
Cartilages of the knee, displacements of the.........................................  394
Causes of  dislocations.......................................................................  281
Clavicle, dislocation of the................................................................  305
Dislocation, general consideration  of the subject...................................  255
    an injury  of  frequent occurrence.................................................  255
    division of the subject of.............................................................  261
    congenital...................................................................  ............  261 
422                             Index.
                                                                    PAGE
Dislocations,traumatic..........................................•...........................  263
    partial......................................................................................  264
    ancient................................................................•........ ..........  265
    dangers in attempts at reduction of.......'....................»...................  271
    relative frequency of...................................................................  266
    symptoms of............................................................................  26<
    alleged malpractice following...........................•••.........................  268
    recurring, of the shoulder.........................................................  277
    causes of......................................................................•"•............  281
    general treatment of...................'..............................................  284
    compound...............................................................................  288
    of the inferior maxillary.............................................................  290
    of the vertebrae......................................................................  297
    ofthe ribs...............................................................................  303
    of the clavicle......,.....................................................................  305
    of the scapula..........................................................................  310
    ofthe humerus........................................................................  314
    of the shoulder.........................................................................  314
    of the humerus,  with  fracture......................................................  332
    of the elbow...........................................................................  335
    of the head of the radius forwards................................................  341
    of the head of the radius backwards.............................................  343
    of the ulna backwards................................................................  346
    of the radius from the ulna........................................................  347
    of the wrist............................................................................  349
    of the carpal bones...................................................................  352
    of the metacarpal bones............................................................  353
    of the phalanges of the fingers....................................................  355
    of the thumb... ........................................................................  355
    of the fingers............................................................................  357
    of the femur.............................................................................  359
    of the hip.................................................................................  359
    of the hip, anomalous................................................................ 383
    of the hip, ancient..................................................................... 384
    of the hip, congenital................................................................... 385
    of the hip, partial......................................................................  385
    of the hip, and fracture............................................................... 386
    of the patella..........................................................................  388
    of the tibia................................................................................ 391
    of the knee................................................................................ 391
    of the knee, compound.............................................................. 396
    of the tibio-fibular articulations.................................................... 397
    of the fibula.............................................................................. 398
    of the ankle...............................................................,...........  39:1
    of the bones of  the foot............................................................... 40<:
    of the metatarsus...............................................,....................... 411
    of the phalanges of the toes........................................................ 414
 Elbow, dislocation of the.................................................................. 335
 Femur, dislocation ofthe...............................................................  359
 Fibula, dislocation of the................................................................... 398
 Fingers, dislocation  of the ............................,................................... 357 
                                   Index.                              423
                                                                      PAGE.
 Foot, its dislocation outwards............................................................  399
     dislocation of the bones of the ............;.....................................  406
 Frequency of the diflerent dislocations.................................................  266
 Gibson on the reduction of ancient dislocations.....................................  275
 Gilbe."l!a substitute for the pulley force......-.v.'......".................................  369
 Hip, dislocations of the....................................................................  350
     dislocation of the, with fracture of the femur.................................  386
     congenital dislocation ofthe.......................................................  385
     recurring-dislocation  ofthe.......................................................  278
 Humerus,  dislocation of the ...............-..............................................  314
               with fracture..................;.......................'.....................  332
     ancient dislocations of the..........................................................  272
 Hysterical affections simulating dislocations.......................................  284
 " Indian puzzle "..............................................................................  358
 Jarvis Adjuster................................................................................  286
 Jaw, dislocation of the..............................  .....................................  290
 Joints, comparative frequency of dislocations  at the ............................  359
 Jones' case of alleged malpractice......................................................  268
 Knee-pan, dislocation of the...............................................................  388
 Knee,  dislocation ofthe.....................................................................  391
     displacement of the semilunar cartilages  ofthe.........-.....................  394
     compound dislocation ofthe.........................................................  396
 Larkin  versus Jones, suit for alleged malpractice...........................  268,  317
 Ligaments of joints..........................................................................  258
     untorn portions of......................................................................."260
 Luxation, see Dislocation ..................................................................  255
 Malpractice—Larkin versus Jones...!............................................  268,  317
 Markoe  on the reduction  of  dislocation of  the hip.,..............................  374
 Manipulating plan for reducing dislocations of the hip, history of the.....  370
 Metacarpus, dislocation of the............................................................  355.
 Metatarsus, dislocation of the............................................................  411
 "Natural bone setters".....................................................................  255
 "Natural plan" of reducing dislocations of the  hip, by Reid.................  259
 Paralysis following dislocation of the vertebra?.....................................  300
 Patella, dislocation of the..................................................................  388
 Pathology of dislocations..................................................................  260
 Phalanges of  the fingers, dislocation of the..........................................  355
    of the toes, dislocation of the.......................................................  414
 Pulleys,  on the use of, in  reducing dislocations................................  259,  3<)8
 Pulley force,  Gilbert's substitute for....................................................  369
 Radius, dislocation of the..................................................................  342
                  from the-ulna.........................................................  347
 Reid's manipulating plan of reducing dislocations of the hip-joint....  259,  372
 Recurring dislocation of the hip.........................................................  278
 Relative frequency of dislocations......................................................  266
 Ribs, dislocation of the......................................................................  303
Scapula, dislocation of the.................................................................  310
Semilunar cartilages of the  knee, displacements of the...........................  394
 Shoulder, recurring dislocation of  the..................................................  277
     ancient dislocations of the...........................................................  272
     dislocation ofthe.....................................................................  314 
424                              Index.
                                                                      PAGE
Spanish windlass for multiplying force................................................  286
Smith, Dr. Nathan..........................................................................  256
Sweet, "a natural bone setter."...........................................................  256
Tarsal bones, dislocation of the..,........................................................  406
Tarsus, dislocation of the.............V,...................................................  399
Tenotomy to facilitate reduction of dislocations...................................  288
Tibia, dislocation  of the.......................................••....".......................  319
Tibio-fibular dislocation.......,........................'.............................-........  397
Thumb, dislocation  of the..........■•■...........................>.. .........-. .........:..  355
Ulna and radius, dislocation of the,- at the elbow....................t.............  335
    dislocation of the) backwards.......................*..............................  346
Vertebrae, dislocation of the...............................................................  297
Warren on-dislocation of the  hip......................................................  375
Whitwoith  "a natural bone setter."...................................................  256
Wrist, dislocation of the...................................................................  349
 
 
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