REPRINTED FROM 
Annals of Gynecology and Pediatry, 
November, 1800. 
Traumatic Separation of the Lower Epiphysis 
of the Femur. 
By JOHN H. PACKARD, M.D., 
Surgeon to the Pennsylvania Hospital and to St. Joseph's Hospital, Philadelphia. ORIGINAL COMMUNICATIONS. 
Traumatia Separation of the Lower Epiphysis of the 
Femur. 
\, BY JOHN H. PACKARD, M.D., 
Surgeon to the Pennsylvania Hospital and to St. Joseph's Hospital, Philadelphia. 
Separations of the epiphyses are 
mentioned briefly by most surgical 
writers, with the statement that they 
are practically undistingqishable from 
fractures in the neighborhood of 
joints. To this, however, there is 
certainly one notable exception in 
the case of the largest of the epiphy- 
ses, that at the lower end of the 
femur. Upon this particular lesion a 
valuable and elaborate paper was 
published in 1884, by Delens, giving 
a case of his own, and quoting at more 
or less length twenty-seven others. 
But in fact there are now over sixty 
cases on record in which detachment 
of this portion of the growing bone is 
claimed to have occurred. With re- 
gard to some of these, indeed, the de- 
tails given are insufficient; while in 
others there is ground for questioning 
the accuracy of the diagnosis, and in 
still others one can only pronounce 
the Scotch verdict of “not proven.” 
Absolute certainty can scarcely be 
arrived at in this matter except where 
the injury is compound and the bone 
exposed, or where by amputation of 
the limb or the death of the patient 
an opportunity is afforded of dissect- 
ing the parts. 
A case of my own may serve as an 
apt illustration: 
Owen McK., aged 9, was admitted to 
St. Joseph’s Hospital April 16, 1889, 
having had his right leg caught in 
the wheel of a wagon behind which 
he was clinging. From yX~" appear- 2 
JOHN H. PACKARD. 
ance of the anterior face of the limb, 
a hasty observer might have sus- 
pected a forward luxation of the knee; 
but upon examination the true nature 
of the lesion was at once apparent. 
At the lower and back part of the 
thigh there was a large wound, 
through which protruded the end of 
the shaft of the femur, bare of perios- 
teum ; the condyles were still partly 
in contact with the tibia, but the 
whole epiphysis was rotated so that 
its articular face looked forward (up- 
ward as the boy lay on his back), and 
the upper cup-shaped surface back- 
ward. This was due to traction by the 
two heads of the gastrocnemius mus- 
cle. Ether was given, and a careful ex- 
amination showed that although there 
was great bruising and laceration of 
the soft parts, the vessels had not been 
torn, but with the nerve had slipped 
aside around the end of the diaphysis; 
they were, however, sharply stretched, 
and the blood in the artery was coag- 
ulated. Reduction of the protruding 
bone was found to be impossible, and 
an attempt to save the limb by resec- 
tion seemed to be attended with so 
much risk, in view of the damage to 
the soft parts, that amputation was 
decided upon. The operation was 
done just below the middle of the 
thigh, and the boy made an excellent 
recovery. 
Upon dissection it was found that 
the epiphysis had been almost cleanly 
separated; entirely so but for a very 
small splinter detached from the end 
of the diaphysis at the inner side. 
The skeleton of the removed limb is 
in the Museum of the Pennsylvania 
Hospital. 
Dr. R. H. Harte informs me that 
he has in his wards at the Episcopal 
Hospital, in this city, a case very simi- 
lar to the one now detailed. The pa- 
tient, a boy about 14 years old, had 
his leg caught in the wheel of a car- 
riage behind which he was clinging, 
and the lower epiphysis of the femur 
was cleanly separated, carrying with 
it the ossifying cartilage. The de- 
nuded shaft projected through the 
large wound. So great was the vio- 
lence that the leg was torn off below 
the knee ; and there was no rotation 
of the epiphysis such as existed in 
my case, perhaps because the lower 
connection of the gastrocnemius was 
severed. 
Primary amputation was performed, 
and the boy is doing well. 
In these instances, as in the twenty- 
four other cases in which the cause of 
the lesion was the entanglement of 
the limb in a moving wheel, the me- 
chanism would seem clearly to have 
been chiefly an over-extension of the 
knee ; along with this there was pro- 
bably some lateral stress, and a cer- 
tain degree also of twisting of the leg 
upon the thigh. Under such circum- 
stances the ossifying cartilage be- 
tween thediaphysis and the epiphysis 
breaks away, and the latter is stripped 
or peeled off from the former. In 
fact, this is a genuine avulsion of the 
thin cap of bone which constitutes 
the epiphysis, and differs materially 
from the supra-condyloid fracture of 
the femur sometimes met with in 
adults. This difference extends also, 
as will be presently shown, to the 
clinical history of the two forms of 
injury. No other epiphysis in the 
body is situated at such a disadvan- 
tage, in the leverage afforded by the 
leg, in the strong ligamentous con- 
nections with the tibia, and in the SEPARATION OF LOWER EPIPHYSIS OF FEMUR. 
3 
width and thinness of the layer which 
is attached to the shaft through the 
medium of the ossifying cartilage. 
Other forms of indirect violence 
have been known to produce this le- 
sion, by a mechanism apparently the 
same. Thus in two instances the 
leg was caught in a cable, and in 
seven in machinery; in five the de- 
tachment took place as the result of 
surgical procedures, as for the forci- 
ble correction of anchylosis or de- 
formities j1 in three the patients 
fell while running, and in one a 
boy was precipitated from a height 
of eighty feet; in one the leg was 
caught between two beams, and in 
another it sank into a hole in the 
ground as far as the knee ; finally, in 
one case a boy was playing leap-frog, 
and alighted on his feet with his feet 
widely separated. 
Dr. W. B. Hopkins kindly permits 
me to mention here a curious case 
which came under his care some 
years ago. A girl aged 16 had bony 
anchylosis of one knee, at a right 
angle; she had a fall, and the lower 
epiphysis of the femur was separated 
from the shaft; under ether the limb 
was straightened and put up in plas- 
ter of Paris, and an excellent result 
was ultimately obtained. 
Direct violence is said to have 
caused this injury in two cases by 
forcible contact with resisting bodies; 
in one by the fall of a mass of rope 
against the knee, and in one by the 
kick of a horse; in one the accident 
is described as a “colliery crush,” 
and in four the little patients were 
run over by vehicles. Some of these 
cases would probably find a more ap- 
propriate place in the category of 
supra-condyloid fractures. 
In eight of the reported cases no 
details are given as to the mode in 
which the injury was sustained. In 
one instance, which has by frequent 
quotation become classical, this lesion 
occurred during birth, by traction on 
the leg of a child. But as the child 
was dead, and putrefaction had al- 
ready set in,2 the case cannot fairly 
be regarded as one of traumatic sepa- 
ration. 
The compound character of the 
lesion, which is distinctly mentioned 
as regards thirty-one of the cases in 
which details are given, may be as- 
cribed either to the excessive tension 
of the skin, or to the outward thrust 
of the extremity of the diaphysis, or 
to both these conditions combined. 
And it may be noted that the amount 
of violence in all these cases was very 
great. Where it was less, as when 
the lesion was due to a mere fall, or 
occurred as an accident during surgi- 
cal procedures, the damage to the 
soft parts was by no means so serious. 
In very many of the cases of this 
injury there is found attached to one 
portion of the epiphysis a splinter of 
the shaft. Sometimes this has been 
of considerable size; in my own case 
it was extremely small. My belief is 
that such a splinter is always at the 
side of the epiphysis at which the 
rending terminates; and it does not 
seem to me to alter the essential 
character of the lesion. 
The separation begins at and mainly 
1 Volkmann says: “ I have three times seen separa- 
tion of the lower epiphysis of the femur produced in 
cases of chronic inflammation of the hip-joint in chil- 
dren by very gentle force, as in handling the limb for 
the application of a plaster-bandage, or in the attempt 
to elicit crepitation in the hip-joint.'’ 
* “ M'ais, alt£re par la putrefaction, le membre inf> 
rieur c'da it mes tractions, le genou s’allongea, et les 
Epiphyses se detacherent du tibia et du femur.”—Mad. 
La Chapelle. Pratique des Accouc/iemens, tome ii, p. 
22 V 4 
JOHN H. PACKARD. 
follows the upper surface of the con- 
joining cartilage, and the breaking off 
of a small portion of the diaphysis is 
a mere incident. 
In Rougon’s case, reported by Dol- 
beau, it is expressly stated that there 
were no bony splinters. Here the 
injury was the result of direct vio- 
lence, a mass of rope striking the boy 
on the lower part of the thigh. 
Bryant1 gives a cut representing a 
museum specimen, in which the whole 
epiphysis is cleanly separated from 
the shaft; but nothing is said of the 
character of the case, or of the mode 
in which the disjunction was brought 
was adherent to the protruding end of 
the diaphysis. 
A very marked feature of this in- 
jury, noted in a large number of the 
cases, and probably present in all, is 
the stripping of the periosteum from 
the diaphysis. The explanation of 
this is to be found in the sudden pro- 
jection downward of the end of the 
diaphysis, by which a sort of button- 
hole is burst open in the periosteum, 
and through this the bone is forced, 
just as it is later through the skin. 
How far it may protrude is deter- 
mined perhaps partly by the direction, 
and partly by the degree of the vio- 
Tilting of epiphyseal fragment by gastrocnemius (p. 115). The 
patella Is left out in order to avoid complexity. 
about. Holmes2 speaks of four speci- 
mens in the Museum of St. George’s 
Hospital, two of them being separa- 
tions mainly following the epiphysial 
line, but detaching also splinters of 
the shaft, and the other two being 
separations in which the two condylar 
portions are broken apart. No his- 
tories are given, so that these speci- 
mens also lack the value which they 
might otherwise have. 
In one instance, reported by Richet, 
it is stated that the ossifying cartilage 
lence exerted upon the limb. In one 
instance, reported by Broca, the bone 
was bared as far up as the trochan- 
ters. It should be remembered that 
in early life the connection between 
the bone and its investing membrane 
is looser and more easily severed than 
in adult age. In one of Hutchinson’s 
cases, it is stated that the periosteum 
formed at the posterior part of the 
epiphysis a fold which interfered with 
reduction. In the cases in which re- 
duction has been effected, or in which 
the limb has been saved by resection 
of the diaphysis, it would appear that 
the periosteum closes in again upon 
1 Manual for the Practice of Surgery. 2d Am. ed., 
p.804. 
* Surgical Treatment of the Diseases of Infancy and 
Childhood. 1868, p. 258. SEPARATION OF LOWER EPIPHYSIS OF FEMUR. 
5 
the bone, and that no permanent harm 
is done by the temporary separation. 
The tilting of the epiphysis by the 
traction of the gastrocnemius, very 
noticeable in my case, has been ob- 
served also by Fontenelle, Liston, 
Hutchinson, Verneuil, Broca, Wheel- 
house and Little. The fibrous struc- 
tures of the knee would, of course, 
undergo much stretching, and proba- 
bly the crucial ligaments have been 
sometimes torn away, but accurate 
observations on these points are 
wanting. In one case, Atkinson’s, 
the epiphysial fragment is said to 
have been displaced anteriorly on to 
the anterior tibial artery was torn 
open, and in another, related by Dr. 
Willis S. Davison, of Pennsylvania, 
the popliteal vessels were ruptured.” 
In a case of Verneuil’s, the end of 
the diaphysis had severed the artery 
and vein, but the nerve had slipped 
round to its outer side. 
Gangrene has several times ensued 
from the pressure of the end of the 
diaphysial fragment against the ves- 
sels. Wheelhouse3 says: “I have 
seen the popliteal artery and vein 
both cut across by a sharp seques- 
trum in making its way to the sur- 
face.” 
This cut shows diagramror tically the relations of the femur with its detached 
epiphysis to the patella and libii. The dotted line shows the skin, which is tense 
and on the point of rupture by the end of the diaphysis thrust against it. 
th 2 shaft of the femur, and to have 
become firmly attached there by bony 
callus. 
In a somewhat doubtful case re- 
corded by Quain, and in one figured 
by Holthouse,1 the epiphysial frag- 
ment has itself been broken in the 
middle, each condyle constituting a 
separate portion. 
The condition of the vessels and 
nerve has varied considerably in 
different cases. Sometimes merely 
stretched, they have been in other in- 
stances, as in my own, slipped aside; 
in others again they have been rup- 
tured. Gross2 says that “in one case 
Little says of a case treated by 
McBurney, that “the internal pop- 
liteal nerve was so stretched, the pain 
so intense, and the deformity so 
great, that amputation was resorted 
to. The case was of two or three 
months’ standing, and strong bony 
union had taken place. The patient 
died of tetanus.” 
Damage to the knee-joint has been 
observed in a number of cases, but 
much more rarely than might d, priori 
be supposed. It would seem some- 
times to have occurred as a secondary 
consequence, as in a case reported by 
Adams, and in one by Liston. Total 
1 Ilolmes’System of Surgery, vol. i. 
3 System of Surgery. Ed. 1882, vol. i, p. 1019. 
3 Lecture on the Surgery of the Epiphyses. Brit. 
Med. Journal, March 7,188^. 6 
JOHN H. PACKARD. 
resection of the knee has been done 
in a few instances. 
As to the age of the patients, the 
average of forty-five in which it is 
stated was a little over 7 years. The 
youngest was 18 months, and the old- 
est 18 years. 
With regard to sex, there are nine 
cases in which the subjects are stated 
to have been girls; and of these, 
strangely , enough, three sustained 
their injuries by entanglement in the 
wheels of wagons behind which they 
were clinging. 
The symptoms usually attending 
this lesion have perhaps been suffi- 
ciently set forth, and a few words 
only need be said as to its diagnosis. 
There are but two forms of injury 
likely to be confounded with it: frac- 
ture of the femur low down and luxa- 
tion of the knee. But fractures in 
this part of the bone, rare at any age, 
are especially so in children; they 
should present the ordinary rough 
grating of broken bone instead of a 
soft crepitus caused by contact of the 
rounded end of the shaft with the epi- 
physial fragment or with the head of 
the tibia. Of course, if there be a 
considerable piece of the shaft broken 
off along with the epiphysis, there 
may be grating also; but then the 
two conditions would be combined, 
and it would be an unimportant ques- 
tion between them. Reduction is, 
judging from the limited records of 
such fractures in children, as well as 
from experience in adult cases, a mat- 
ter of no great difficulty ; whereas in 
epiphysial separations it has often 
been found impossible, and always 
troublesome, either to effect it or to 
maintain it. 
Luxations of the knee, except as 
the result of disease, are even more 
rare in early life than the fractures 
just referred to. In the very few re- 
liable instances on record, the separa- 
tion of the joint surfaces was not 
complete. But in my own case, as in 
one reported by Holthouse, the idea 
of luxation was at first suggested by 
the distortion of the limb. Such a 
mistake could not, of course, fail to 
be corrected, when the epiphysial 
disjunction is compound, upon exarrr- 
nation; when it is simple, the abnor- 
mal mobility would serve to distin- 
guish it from dislocation, in which 
the movements of the leg upon the 
thigh are restricted in a marked de- 
gree. Yet in non-compound cases 
swelling is apt to occur very rapidly, 
and obscures everything; as in an 
instance reported by Atkinson, in 
which twenty-five days elapsed before 
the outline of the limb could be de- 
fined. 
The gravity of this injury is shown 
by the fact that in twenty-eight of 
the cases amputation was performed. 
In twelve it was primary, in nine sec- 
ondary, in five it was done at a very 
late period, and in two the time is not 
stated. 
Resection of the end of the shaft 
was resorted to in six cases, in four of 
which complete success ensued, in 
one the result was doubtful at the 
time the patient left the hospital, and 
in one it is not stated. 
Resection of the knee-joint was 
done in two cases, in both of which 
amputation was afterward performed, 
although in one the reason for this 
course does not clearly appear; in the 
other the limb had been accidentally 
refractured. 
Reduction was accomplished in 
fourteen cases, successfully except in 
an instance reported by Richet, in SEPARATION OF LOWER EPIPHYSIS OF FEMUR. 
7 
which the patient died of purulent 
infection on the fifteenth day. One 
boy recovered with a stiff knee ; two 
had good motion; of seven it is mere- 
ly said that they did well, or had use- 
ful limbs, while in two it is only 
stated that consolidation occurred. 
Amputation was demanded in the 
primary cases either by destruction 
of the limb or by damage to the 
bloodvessels. The secondary opera- 
tions were performed for haemorrhage, 
for abscess and for gangrene. Of the 
late operations, one was required on 
account of great stretching of the 
nerve, one for aneurism, one for ab- 
scess involving the knee-joint, one at 
the request of the patient after resec- 
tion, and one for fracture after resec- 
tion. 
In three cases no operation is re- 
corded, and the patients all died; in 
one the knee-joint suppurated, in an- 
other it was opened at the time of 
the accident and a fracture extended 
up the shaft, while in the third other 
very severe injuries had been sus- 
tained. 
Concerning nine cases, we have 
mere mention without detail, so that 
but for completeness they might be 
set aside altogether. 
As to the questionable cases : One, 
reported by Trelat, was only seen by 
him three years after the injury, the 
girl being then 18 years old. Anoth- 
er, by Quain, is said to have been a 
compound fracture through the exter- 
nal condyle, with simple fracture of 
the lower third of the femur; it oc- 
curred in a boy about 11 years of age 
by the entanglement of the leg in a 
wheel, but there is no evidence of 
genuine avulsion of the epiphysis. 
Turgis Says that in his case he only 
suspected that the lesions had been 
of this character. 
Lastly, in Halderman’s case, it is 
stated that “the line of separation 
could with difficulty be made out, but 
it was finally located two inches above 
the articular plane in front,” which 
clearly proves that the lesion was a 
fracture in the lower third of the 
femur, as indeed would appear also 
from the account of the dissection. 
In determining upon the proper 
treatment to be followed in any case, 
certain points should first be ascer- 
tained. 
Whether the injury be simple or 
compound, the condition of the ves- 
sels is of prime importance; if they 
are ruptured or irreparably damaged, 
amputation should be done at once. 
Next, the possibility of reduction 
should be determined; and if this 
can be effected, the limb should be 
put in the best position for its main- 
tenance. If reduction is out of the 
question, the end of the diaphysis 
may be sawn off and the attempt 
again made. 
Delens suggests that the diaphysis 
should be sawn off as high up as it is 
stripped of the periosteum; but this 
is by no means necessary, and would 
often involve such a shortening of the 
limb as would be worse than its 
loss by amputation. On the contrary, 
only so much should be sacrificed as 
to permit of reduction being accom- 
plished. 
Division of the two heads of the 
gastrocnemius muscle might very 
readily be done to correct the rota- 
tion of the epiphysis; if there is a 
very large wound, through this, and 
if not, by a subcutaneous incision on 
either side. Such a procedure would 8 
JOHN H. PACKARD 
greatly facilitate reduction, and cer- 
tainly would favor the restoration of 
the normal condition of the knee- 
joint. 
Resection of the entire joint must 
be rarely required, and has, of course, 
the great disadvantage of leaving the 
whole limb stiffened. 
As to the position in which the 
limb should be placed if an effort is 
to be made to save it, either with or 
without taking away any portion of 
bone, it would appear that the knee 
has always been kept straight except 
in one case (Simon’s). In this case, 
about which we have no details, it is 
said that the leg was treated in flex- 
ion, with a back splint. Something 
must probably depend upon the 
chances for a movable knee; if this 
is out of the question, there can be 
no doubt that the straight position is 
the best. And where the epiphysial 
fragment is rotated so that the con- 
dyles look upward (the patient lying 
on his back), and this rotation in my 
case was very obstinate, flexion of 
the knee would, of course, carry the 
head of the tibia further away from 
the articular surface of the condyles, 
unless the rotation is overcome, and 
the condyles well brought down into 
place. 
But if the natural relations of the 
parts can be restored, it seems to me 
that after a few days flexion may be 
gently and cautiously tried, and grad- 
ually increased, with passive move- 
ments, so as to prevent the necessity 
for the breaking up of adhesions at a 
later date. 
For the retention of the parts in 
shape, a “ back splint ” has been gen- 
erally employed, but I should prefer 
the application of splints of sheet 
zinc or of binders’ board moulded 
along the whole length of the outer 
and inner sides of the limb, well 
lined, and held in place by a very 
accurately laid bandage. When flex- 
ion is to be made, fresh splints with 
suitable angles should, of course, be 
prepared. Suspension might - very 
well be employed, and may add to the 
comfort of the patient. Perhaps I 
need hardly urge the importance of 
watching the condition of the foot, 
lest the circulation should be inter- 
fered with and gangrene ensue. 
At the present day, no intelligent 
surgeon, dealing with a compound in- 
jury of this kind, would fail to give 
his first care to making the wound 
thoroughly asept:c ; and if the knee- 
joint has been opened, this should, of 
course, be included in the steriliza- 
tion. 
It may be of interest to mention a 
case of this injury in a foal, commu- 
nicated to me by Dr. R. S. Huide- 
koper. animal, five months old, 
in rushing through a gateway struck 
the stifle of the near hind leg against 
a heavy post. When seen by Dr. H. 
in consultation, there was excessive 
lameness ; but as the animal limped, 
the leg swung with an unnatural mo- 
tion, and there was found to be loose- 
ness and slight crepitus in the neigh- 
borhood of the femoro-tibial articu- 
lation. The exact nature of the injury 
could not be determined on account 
of the swelling of the parts. Abscess 
ensued, the animal wasted rapidly, 
and was destroyed. The autopsy 
showed a separation of the lower epi- 
physis of the femur, with laceration 
of the surrounding tissues, and a 
large abscess. 
Space is wanting for the citation at 
any length of the records of cases of 
the injury now discussed, but for the SEPARATION OF LOWER EPIPHYSIS OF FEMUR. 
9 
convenience of those who may wish 
to examine them, I append a list of 
references, embracing all the writings 
on the subject which have been with- 
in my reach. Delens, in the paper 
before referred to, mentions two or 
three theses to which I have not had 
access. 
Fontenelle, Archives Generates, etc., 
Oct., 1825. 
C. Bell, “Observations on Injuries 
of the Spine and Thigh-bone.” Lon- 
don, 1826, p. 42. 
R: Alcock, Medico-Chirurgical 
Transactions, 1840, p. 311. 
Liston, “Elements of Surgery.” 
London, 1840. 
C. Hawkins, Lancet, May 7th, 1842. 
White, Ibid. 
James, Ibid. 
R. Adams, Todd’s Cyclopaedia of 
Anatomy and Physiology ;art. ‘1 Knee- 
joint,” Vol. Ill, p. 69. London, 1839-47. 
Quain, Lancet, March nth, 1848. 
Jarjavay. “ Traite d’ Anatomie Chi- 
rurgicale,” 1852, Tome I, p. 70. 
Trelat, Archives Generales, etc., 
July, 1854 ; also, Le Progres Medi- 
cale, Aug. 21st, 1875. 
Canton, Lancet, Aug. 28th, 1858; 
also, Trans, of Pathological Society 
of London, i860. 
Hilton, Med. Times and Gazette, 
Feb. 12th, 1859. 
Holmes, Trans, of Pathological 
Society of London, 1862 (two cases) ; 
also, “ Surgical Treatment of the Dis- 
eases of Infancy and Childhood,” 
London, 1868. 
Hutchinson, Trans, of Pathologi- 
cal Society of London, 1862; also, 
Ibid., 1864. 
Little, New York Journal of Med- 
icine, Nov., 1865 ; also, “Illustrated 
Medicine and Surgery.” New York, 
1862. 
Voss, New York Journal of Med- 
icine, Nov., 1865. 
Buck, Ibid. 
Volkmann, Virchow's Jahresbericht, 
1866, Bd. II, p. 337. 
Gay, Lancet, Oct. 12th, 1867. 
Rougon (reported by Dolbeau), 
Bull, de la Societe de Chimrgie, 1867, 
p. 120. 
Hey, British Medical Journal, Dec. 
4th, 1869. 
Wheelhouse, Ibid. 
Maunder, Lancet, Feb. 5th, 1870. 
Leisrink, Archiv. fur Klin. Chirur_ 
gie, 1872, p. 436. 
Chauvel (quoted by Spillmann), 
Diet. Encyclopedique, art. “ Cuisse,” 
1872. 
Callender, St. Bartholomew’s Hos- 
pital Reports, 1873. 
Tapret and Chenet, Bull, de la So- 
ciete Anatomique, Jan. 8th, 1875. 
St. Thomas’ Hospital Reports (sta- 
tistical table), 1875. 
Marcano, Bull, de la Societe Anat. 
omique, Third Series, Tome X, 1875, 
p. 228. 
Richet, L' Union Medicate, March 
16th, 1876. 
Sheppard, St. Thomas’ Hospital 
Reports, 1877. 
Simon, Ibid, (quoted by Sheppard). 
Smallwood, “Hamilton on Frac- 
tures and Dislocations,” 1877. 
Reeve, Cincinnati Lancet and Clinic, 
Nov. 16th, 1878. 
Allis, Trans, of Pathological So- 
ciety of Philadelphia, 1878, p. 7. 
Turgis, Bull, de la Societe de Chi- 
rurgie, 1878, p. 787. 
Holthouse, Holmes’ “ System of 
Surgery,” Vol. I, 1880. 
Menard, Revue de Chirurgie, 1881, 
P- 738. 
Davison, Gross’ “System of Sur- 
gery,” 1882.  JOHN h! PACKARD. 
10 
Puzey, Brit. Med. Journal, Oct. 
21 st, 1882. 
Bruns, Archiv fur Klinische Chimr- 
gie. 1882, p. 254. 
Delore, Ibid, (quoted in Bruns’ 
tables). 
McBurney (quoted by Little). “ Il- 
lustrated Medicine and Surgery.” 
1882. 
Halderman, New York Med. Record, 
June 3d, 1882. 
Atkinson, Brit. Med. Journal, July 
14th, 1883. 
Robson, Liverpool Medico-Chirur- 
gicalJournal, July, 1883. 
Black, Ibid, (quoted by Robson). 
Rathbun, St. Louis Courier of Med- 
icine. March, 1884. 
Verneuil, Memoires de Chintrgie, 
Tome III, 1884, p. 400. 
Broca, Bull, de la Soc. Anatomique. 
Fourth Series, 5, Tome IX, 1884, p. 
40;. 
Winslow, Maryland Med. Journal, 
June 21st, 1884. 
Bryant (reported by Rhys), Brit. 
Med. Journal, May 31st, 1884. 
Bryant (reported by Walker), Ibid. 
Wheelhouse, Ibid.. 24th, 1884. 
McGill, Ibid. 
Delens, Archives G tins rales, etc., 
March and April, 1884.® 
Broca, Bull, de la Societe Anatom- 
ique, Fourth Series, Tome X, 1885, 
p. 228. 
Reverdin, Revue dc la Suisse Ro- 
mande, May 15th, 1886. 
Hutchinson, Illustrations of Clini- 
cal Surgery, Vol. II, 1888. 
W. B. Hopkins, personal communi- 
cation. 
R. H. Harte, personal communica- 
tion. 
R. S. Huidekoper, personal com- 
munication. 
John H. Packard, case given above.