TH jjMiACTICAL AND SYSTEMATIC TREATISE FRACTURES AND DISLOCATION? BT A. J. HOWE, A. M., M. D. PROFESSOR OF SURGERY IX THK ECLECTIC MEDICAL INSTITUTE. FOURTH EDITION. CINCINNATI: JOHN M. SCUDDERS 1891. , I IHT/;SO?TL*0 nO 3D: /-] ; " 'HI Entered According to Act of Congress in 1870, by JOHN M. SCTJDDER, in the Clerk's oflio* of the District Court for the Southern District of Ohio. CONTENTS. PART I. FRACTURES. PAGE. PREFACE 11 CHAPTER I. General Observations upon the Nature and Treatment of Fractures... 17 CHAPTER II. Signs of Fracture 22 CHAPTER III. Process of Union 29 CHAPTER IV. Non-union, or False-joint after Fracture 36 CHAPTER V. Defective Union ~ 41 CHAPTER VI. General Remarks in Regard to the Treatment of Fractures 43 CHAPTER VII. Reduction of Displaced Fragments 49 CHAPTER VIII. Apparatus for the Treatment of Fractures 52 CHAPTER IX. Re-dressings 64 CHAPTER X. Movements allowed a Patient. 66 CHAPTER XI. Management of Compound Fractures 67 CHAPTER XII. Diastasis, or Separation of an Epiphysis 72 CHAPTER XIII. Fracture of the Cranium 74 CHAPTER XIV. Fracture of the Inferior Maxillary 80 CHAPTER XV. Fracture of the Hyoid Bone and Laryngeal Cartilages 88 CHAPTER XVI. Fracture of the Vertebrae..- 91 (iii) iy CONTENTS. PAQ, CHAPTER XVII. Fracture of the Ribs and Costal Cartilages 95 CHAPTER XVIII. Fracture of the Clavicle 104 CHAPTER XIX. Fracture of the Scapula 110 CHAPTER XX. Fracture of the Humerus .. 117 CHAPTER XXI. Fracture of the Ulna 137 CHAPTER XXII. Fracture of the Radius 145 CHAPTER XXIII. Fracture of the Bones of the Hand 161 CHAPTER XXIV. Fracture of the Pelvic Bones 165 CHAPTER XXV. Fracture of the Femur 171 CHAPTER XXVI. Fracture of the Patella 215 CHAPTER XXVII. Fracture of the Leg 221 CHAPTER XXVIII. Fracture of the Bones of the Foot ~ 249 PAKT 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 .T. 355 CHAPTER XI. Dislocation of the Femur 359 CHAPTER XII. Dislocation of the Patella 388 CHAPTER XIII. Dislocation of the Tibia 391 CHAPTER XIV. Dislocation of the Tibio-fibular Articulations 397 CHAPTER XV. Dislocation of the Ankle 399 CHAPTER XVI. Dislocation of the Bones of the Foot , .. 400 ILLUSTRATIONS. FRACTURES. riGCEJE. 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 lb'. 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. Huuierus, divided into thirds 117 34. Carved and hinged splint for the shoulder. 119 35. Fracture of the surgical neck of the humerus 120 3G. Woven wire splint for fractures about the shoulder 121 (Vll) viii IIIUSTRATIONS. TIOCBE. 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... 120 40. Double fracture of the humerus 120 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 of the humerus 129 45. Fracture of the internal condyle of the humerus 130 46. Dressing for fractures of the condyles of the humerus. 131 47. Fracture of the olecranon and coronoid processes of the ulna 137 48. Dressing for fracture of the olecranon 138 49. Fracture of the shaft of the ulna 1 142 50. Fracture through upper extremity of the radius 147 51. Shows action of rotating muscles o forearm 148 52. Fracture through middle of the 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 Colics' fracture of the radius 151 56. Colics' fracture of the radius 152 57. Splints and dressing for treatment in Colics' fracture of the radius. 155 58. Single splint for treating Colics' fracture of the radius 150 59. Fracture of both bones of the arm 157 60. Comminuted fracture of both bones of forearm , 158 61. Dressing for fracture of the bones of the forearm 159 62. Fracture of the bones of the hand 1(12 63. Fracture of a phalanx of the finger 103 64. Fracture of the os innominatum ]00 64. Section of the head and neck of femur. 173 65. Fracture of the neck of the femur within the capsule 179 66. Consolidation after fracture of neck of the femur 1H) 67. Ligamentous union after fracture of the neck of the femur 181 68. Excess of callus after extra-capsular fracture of the femur 1>2 69. Bony union after fracture of the neck of the femur 1 s I 70. Fracture of the greater trochanter at its extremity 1>5 71. Fracture of the cervix femoris and greater trochanter ]85 72. Fracture of the trochanter major l>ii 7.'!. " 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 tor making extension 199 80. Barges' fracture apparatus applied - (l " 81. Fracture of the upper third of the femur 2<>1 82. Fracture of the lower third of the femur 2<>7 83. Fracture of the femur just above the condyles 2US ILLUSTRATIONS. ix P AO 84. Fracture of the internal condyle of the femur 212 85. Fracture of both condyles of the femur 212 86. Wire appliance for treating fractures near the knee 213 87. Fracture of the patella 216 88. Ligamentous union after fracture of the patella 218 89. Dressing for fracture of the patella 219 90. Fracture of both bones of the leg 222 91. Fracture of both bones of the 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 of the fibula and dislocation of the ankle 243 104. Dressing for Potts' fracture of the fibula 245 105. Dupuytren's dressing for Potts' fracture 246 DISLOCATIONS. 106. Dislocation of the lower jaw 209 107. Appearance of the face produced by dislocation of the lower jaw. 292 108. Dislocation of the head of the 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 of the head of the radius forwards 342 115. Dislocation of the 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. 373 x ILLUSTRATIONS. neuu. PAGE 121. Dislocation of the head of the femur downwards, into the thy- roid foramen 377 122. Dislocation of the femur forwards, upon the pubes 381 123. Dislocation of the patella. 388 124. Dislocation of the tibia , 391 125. Lateral dislocation of the knee 394 126. Dislocation of the foot outwards 400 127. Dislocation of the foot backwards .. 403 J The improvements and modifications which have recently taken place in the management of fractures and dislocations, and the fact that the ordinary text-books to be found in every physician's library contain too little on the nature and treat- ment of these lesions, and the special treatises too much, have induced me to venture upon the task of preparing a work specially adapted to the wants of the great mass of medical men. Accidents involving fractures and dislocations commonly fall into the hands of the nearest and most available practi- tioners, who may need practical suggestions in regard to the most approved methods of treating this class of injuries, especially as such accidents frequently involve great profes- sional responsibility. On account of the roller bandage being too often applied improperly, I have endeavored to enforce a due consideration of the dangers 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 winch 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 !,<((. UK- 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 1 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 of the 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 di>locations by what has been called the "manipulating plan," are en- couraged as a substitute for the more dangerous method of overcoming displacements by the aid of pulleys and other mechanical means for multiplying force. Since the introduction of anaesthesia into surgical practice, there is less need of vio- lent measures to replace luxated bones. It is now known that obstacles to the easy return of a displaced bone, consist essen- tially in tense tissues which can generally be rendered lax by PREFACE. xiii changing the position of the dislocated limb. However, it is not to be understood, if a displaced bone can not be reduced by manual dexterity alone, that no other means are to be tried. But the manipulating plan in intelligent and persever- ing hands, has been so generally successful, that it would be rash to try harsher means until repeated and varied trials of the "physiological method" have failed. In preparing this work on Fractures and Dislocations, I have taken the liberty of drawing from every available source of information, and have not always given credit for material employed. This omission did not arise from a reckless dispo- sition to appropriate the ideas of others ; but in an early attempt to give each author his due, I found that A had drawn from B, and B from C, and so on, and therefore I abandoned an undertaking which at best must have been imperfect, laborious, and unsatisfactory. In presenting this book to the profession, it is with no in- flated estimation of its merits; indeed I know it has glaring defects, some of which may be placed to a lack of time for carefully correcting and amending what has been prepared amid countless interruptions, and during the busiest of pro- fessional life. Whether it will accomplish what I have de< signed, time and readers must decide. It is offered as a guide to the multitude of practitioners scattered through the coun- try, who have comparatively limited facilities for becoming acquainted with the best methods of treating a class of inju- ries which often baffle the most experienced surgical talent. I. FRACTURES. CHAPTER I. FRACTURES. GENERAL OBSERVATIONS UPON THEIR NATURE AND TREATMENT. THE bones preserve the outline of the human figure, giving support and protection to the soft tissues ; and serve the pur- pose of levers upon which muscular force is displayed. Hav- ing a large proportion of earthy matter in their composition, they are necessarily brittle, breaking under the influence of unusual forces, directly or indirectly applied. When a muscle, tendon, ligament, or other soft structure, is mechanically separated, the injured part is said to be torn, rup- tured, or lacerated ; but the forcible separation of a bone into two or more pieces, is always called ^fracture. 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 then* 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 anc 1 successful management. The principles of diagnosis and treat- ment have become so well established that the surgeon who tails to perform his duties according to the most approved rules, is held responsible for such detects and deficiencies us are justlv chargeable to bis 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 divi k"l into two classes, the fi)rj>le and the conipoantL In a simple fracture the lesion is uncom- plicated with injuries of the soft tissues. A compound fracture has for its essential character a wound of the skin. with which the fracture communicates. There are two ways in which the wound may be produced at the time of the acci- dent : from without, by the direct force which fractures the bone ; or from within, by the end of one or both fragments being thrust through the soft parts, either by the continu- ance of the original force, or by the weight of the body. The latter mode is the more frequent; consequently compound fractures are more common in the leg than in any other part of the body. If caused by direct force the contusion will bo 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 lias 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 generally, though not always, more or less displacement of the fractured ends, giving the limb an angular, twisted and strongly marked deformity. The partial fracture is exceedingly rare, the com- plete very common. A fracture is said to be comminuted, when the bone is broken into many small pieces, some of which are often completely separated from the periosteum, losing all source of nourish- GENERAL OBSERVATIONS. 19 nient, and requiring to be removed either naturally or artifici- ally, before the other fragments ean 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 unfrequentiy 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 tlesh is lacerated or contused, rendering the injury very serious in its nature. A frac-ture complicated with much bruising and laceration of the soft parts, requires a long period to undergo reparation. The primary shock, and the subsequent suppuration, tell upon the patient's health ; ami the pus and debris about the ends of the hones, prevent a speedy union of the fragments. The fragments of a simple, uncomplicated fracture, ordina- rily become consolidated in rive or six weeks, yet as many months may be consumed in the repair of a compound injury \vitli perverse complications. The direction a fracture takes may be ol>I!f/ne or //' 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 of the bone. Fractures near the extremities of long bones, and in the flat, and irregular shaped, as the scap- ulfe and vertebrae, are apt to be more transverse than oblique. When the lines of separation radiate from a central point of the bone, at which the violence was received, they are regarded as stellate ; and when the broken ends of bone are full of spicula or serrations, which may interlock like opposing teeth, the frac- ture is dentate. The course of the fracture has a bearing on the reduction of the fragments, and their retention in apposition. Transverse fractures, especially if they be dentate, when once reduced, are not easily displaced ; and these conditions often present obstacles to ready reduction. If the line of separation be oblique the 20 FRACTURES. reduction is not difficult, but there is a disposition on the part of the fragments to slide past each other. As may naturally be supposed, all bones are not equally liable to fracture. Some are more exposed to injury than others, and some are increased or diminished in strength by their shape. It is plainly observable that the long bones are the most frequently fractured, while the short ones are com- paratively seldom broken, and always by direct violence. There are certain morbid conditions of the bones which ren- der them unusually fragile. Rickets, caries, necrosis, cancer, scrofula and syphilis, may so affect the 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 chemically altered ; the earthy matter predominates over the animal, a condition which favors brittleness. In young people, the disproportion in the compo- nent parts is reversed; the animal matter predominates, so that the bones bend under the weight of the body, or under the action of the muscles. Children with bow-legs usually have a deficiency of lime in the skeleton. A disproportion between the strength of the bones and the power of the muscles also predisposes to fracture. Great mus- cular development, coupled with a rapidly acting nervous sys- tem, may prove too powerful for slender bones. The hunio- rus and the femur have both been broken simply by muscular exertion. The olecranon, patella, and the os calcis are levers which, while enduring violent and sudden forces from the mus- cles acting upon them, are occasionally broken. Few bones are placed at such disadvantage for resisting muscular action. Tables drawn up to exhibit the comparative frequency of fractures in the different bones, vary somewhat. According to GENERAL OBSERVATIONS. 21 some authors the ribs are the most frequently fractured ; the clavicle standing next in the order of frequency ; the radius taking the third place ; the humerus the fourth ; the femur the fifth ; the fibula the sixth ; and the tibia the seventh. Both bones of the leg are broken at the same time more frequently than either singly. According to my own observation and experience the radius is the most frequently broken, the clav- icle next, and the ribs take the third place. \Vhen a bone breaks at the point where force is applied the fracture arises from direct violence ; a fracture of the radius or hurnerus arising from a fall on the hand, is said to be by coun- ter-stroke (contre-cottp), 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 tro chanters, 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. 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, arc peculiar to fracture. Crepitus, when it ran 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 produced, yet the sound is heard in only a small proportion of cases. Pain is not a reliable sign of fracture, for it is sometimo slight, being scarcely complained of unless motion be imparted to the fragments. However, in most instances, the pain is so acute and agonizing that it calls forth cries of distress, elicit- ing the deepest sympathy. In fractures that have existed several hours, the swelling having cheeked the preternatural mobility and masked the deformity, the pain which maybe 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 exist eii' 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 tho fragments and the interlocking of the serrations may account in part for these seeming anomalies or inconsistencies. It is certainly true that in most instances fractures inflict a notable hindrance, or an entire incapacity, of motion in the limb. The patient generally expresses his inability to use the fractured limb, and refuses to make even moderate effort, being intuitively conscious of the loss of power. The swelling attendant upon a fractu red-injury may take place immediately, or not be marked for several days. At the instant of fracture there is often, but not always, an effusion of blood around the fragments, and an extravasation into the surrounding tissues, constituting strictly an internal ecchymosis, which may 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- tinuitv in the bone. In the clavicle, the mere weight of the O shoulder will produce the angle, and if the arm be grasped and moved up and down the mobility can be readily discov- ered. 24 FRACTURES. Motion can be easily produced in the shafts of the long bones, which have been fractured, but it is not so readily demonstrated when the solution of continuity is near joints. The portion of bone connected with the articulation, is so small or short, that it can not be easily fixed so the long frag- ment can be moved upon it. And then, the natural move- ments of the joint in such immediate proximity to the frac- ture, tend to obscure the mobility peculiar to the lesion. In fracture of the radius through its carpal extremity, very little mobility can be developed by manipulation of the parts. Displacement of the fragments is betrayed by the change in the form of the limb; often an experienced surgeon can at a glance divine the nature of the injury by the deformity. It would be unsafe to trust too much to tirst 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 wi none should exist, the sign is valuable. One fragment resting * C7 O iii front or to one side of the other, constituting a salient projection which can not only be seen, but felt as the lingers 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 .* t >/>n between the fragments. Muscular action is the cause of thU displacement, and it always produces more or less deformity after fractures ; it twists fragments of the fibula away from each other ; and in fractures of the forearm, it drags the frag- ments of the radius and ulna into contact- with one another, and if the pieces of bone be not kept in their proper relation-. all the fragments may lie 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 FKACTUUE. 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 ivasons, 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 draw r n 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 feit and heard ; therefore as a sign of fracture it is extremely valuable. To the patient and bystanders, who hear the crep- itation, the sound is particularly convincing. The surgeon enjoys a double satisfaction in the sound, for it not only gives decisive evidence of the nature of the injury, but proves that the fragments are in juxta-position, no muscle or other struc- ture intervening. The snapping of tendons, and the crackling of emphysema- tous tissues, resemble slight or indistinct osseous crepitus, yet the surgeon, manipulating the injury, feels rather than hears the crepitation, and judges or discriminates by that sense. Crepitus can be made most distinct soon after the reception of a fracture ; the changes which take place in the course of the inflammatory stages of the injury, and the healing pro- cess, thwart all efforts to elicit crepitation. Fractures are often dangerous injuries. The violence pro- ducing them may be of such a nature as to lacerate the soft tissues, and to inflict the most serious wounds. The sharp ends of the fragments sometimes sever or puncture large blood-vessels, and destroy the integrity of important nerves, subjecting the parts involved to the dangers of gangrene or extensive sloughs. Not unfrequently an injury involving a fracture, is of such a serious nature that amputation becomes imperative. Fractures extending into the joints always excite 26 FKACTTKKS. tho gravest apprehensions; they may turn out well, yet there is 110 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 excerd- 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 hot directed efforts to understand the nature of the accident : sometimes it is best to postpone the examination until the child has recovered from its nervous condition. Incomplete fracture, when it exists, and that is seldom, must necessarily be confined to the young. The bones of old sub- jects, from the amount of earthy matter in their composition. break like a dry stick. The bones of the arm are most liable to the partial or "green-stick" fracture (Figure 1). The humerus, during childhood, has been found bent. It then ofters considerable resistance to straightening or reduction. The child is averse to motion in the limb, and guards ir against subsequent injury. An attempt at quirk and forcible reduction may complete the tract u re. SIGNS OF FRACTURE. Fissure of a bone is commonly an obscure injury to diag- FIO. i. nose. In most instances of suspected fissure the evidence must be founded on what is little better than conjecture. The bone could not well be fis- sured without tearing the periosteum and the medullary membrane ; and the suffering would be long continued. The danger of these cases is illustrated by an example from Duverney. A man received a kick from a horse on the center of the left tibia. This was followed by severe pain and sloughing of the skin, which, however, readily healed, and the patient went about as cured. Three months later he was again confined to his bed by the accession of sudden, acute pain. After much ineffectual treatment by emollients, the bone was exposed, and a long deep fissure was found, the edges of which were raised twice, giving exit, on the second occasion, to pus. Subsequently the a u!-e? bone was trephined, and an abscess laid bare in the medullary cavity. Railway accidents produce fractures which, from their com- plications, and serious nature, deserve to be considered by themselves. The severer forms of injury, from the paralyz- ing character of the shock, and the number of parts impli- cated in the lesion, are apt to terminate fatally. An arm or leg, suffering from, fracture by a rail road 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 bod}* except the injured limb, which remained cold and pulseless, the docter in con- sultation with two other physicians, decided to amputate the arm. The injury was of such a crushing character that it was presumed the limb would slough, and greatly endanger the patient's life. The three medical men in council, had no misgivings in regard to the requirements of the case. There seemed to them an imperative necessity for amputation, and they accordingly removed the limb. The patient made a good recovery, and for the time appeared satisfied with the opera- 28 FRACTURES. tion ; but some rival physicians got posession of the amputa- ted limb, and injected the arteries ; the vessels proved to be untorn, at least they sustained an injection. The young man who had lost the arm was made to believe that his limb had been needlessly sacrificed, and, therefore, sued Dr. Witham and his associates, for damage to the extent of ten thousand dollars. A breakman on a freight train gets a leg or an arm broken by the moving cars, or receives a crushing injury by being thrown from his position. The shock may be so great that he will never react; or he may die from a multiplicity of in- juries, that do not manifest themselves at first. A question arises, in the contemplation of these terrible injuries, what is bestto be done? Ordinary rules applicable in surgical injunc-. 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 lite. 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 quite frequently proves illusive. However, in doubtful cases it is well to wait for reaction and other recuperative sign.-. There is danger in resorting immediately to operative nie-as.- ui'fs. While a patient niignt not know that lie 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 sacritice 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 braised, the healing process sets in earlier and terminates sooner, than in compound, complicated, and comminuted fractures. The effusion of considerable blood is tm 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 tirst 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 davs. This (29) 30 FRACTURES. may be called the inflammatory stage of the difficulty. For the succeeding five days the swelling subsides, and a great part of the effused blood the debris of the injury is removed; during the next five days there is an effusion of plastic material, of jelly-like consistence, which is to be elabo- rated into a firmer bond between the fragments. Fifteen days have now passed, and the union is a " rope of sand." If the parts be cut into and examined, the extravasated blood will be gone, an abundance of unorganized lymph will be seen between and about the fragments of bone, and the muscles and other soft tissues adjacent to the injury will seem to be glued together. The lymph is yellowish white, but the sur- rounding structures under the influence of the reparative 'action, have a pinkish hue, the reddish color coming from minute blood-vessels which are pushing their way into tin 1 newly forming material. Although the blended soft tissue around the bone assist in giving firmness to the parts, the fragments themselves move about as freely as when the frac- ture first occurred. Half of the time ordinarily consumed in the treatment is now passed, and the real work of repair is but just begun. During the next five days the plastic lymph becomes organ- ized into cells and fibrous bands. By the twentieth day the fragments are bound together by this newly formed connec- tive tissue, so that there is considerable firmness established between the ends of the fragments and the surrounding structures. The limb at this time will bend, but has not the mobility peculiar to a recent fracture. From the twentieth to the twenty-fifth day the osseous corpuscles are deposited in the meshes of the fibrous connec- tion. The new bony material is thrown out first and most rapidly from the periosteum and 'the medullary membrane, but is not placed with much regularity. At first there is an excess of corpuscles at one point, and a deficiency at another ; but by the twenty-fifth day, in a young patient, under favor- able circumstances, the bony connection is sufficiently abun- dant and consolidated to sustain itself without artificial assist- ance. The osseous union is not yet complete ; in places there is too much of the fibrous, and not enough of the bony mate- rial ; and there is not that complete consolidation which proves to be unyielding. In fractures of the leg, the osseous union PROCESS OF UNION. 31 is often so imperfect by the thirtieth day, that the uniting material may yield, allowing of shortening in cases inclined to overlap. I recently took oft' a dressing from a fractured femur that had been on thirty days. There seemed to be per- fect consolidation of the fragments, and careful measurement showed that the legs were of equal length. The patient, a lad of ten years, began to move about on crutches, and grad- ually to press the foot of the lame side to the ground. In two weeks after the fracture-dressings were removed, I again made a measurement, and found that the fractured limb was fully a half inch shorter than its fellow. As the measurements in both instances were made with scrupulous exactitude, the conclusion to be drawn was that the dressings were removed before the ossification was sufficiently complete or consolidated to resist the normal muscular tension. It is of the utmost importance that the surgeon understand, as nearly as possible, what is going on from day to day in the process of repair in a fractured bone. The differences of ac- tivity at the various ages of life, and the modifying influences arising from the kind of fracture, and from the region of body injured, to say nothing of general health, and minor considera- tions, render certainties out of the question, and leave a wide scope for conjecture and speculation. The most experienced surgeon can not, from manipulation or the appearances of the limb, determine positively when a fracture-dressing may be removed. If every part of the treat- ment has been satisfactory, and there be no known reason why the healing processes have not accomplished what they usually do in a given time, it may be presumed that a good union has been effected in four, five, or six weeks, as the particular case might seemingly require. If there be mobility, crepitus, or other signs of non-union at a time when a complete result ought to be expected, it would be certain that the fracture- dressing should be continued for a week or two, but there is no way to determine just how many more days the treatment ought to be continued, nor could it be positively determined whether a union would ever occur. After four, five, or six weeks have elapsed from, the reception of the 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 82 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 1C 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 Union of broken ribs, with "bridges '' of bone in the coursf of the interr-ostnl 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 pai'ts. 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 or repair in broken bones. In young subjects and in the inferior animals the presence of cartilaginous tissue has been observed, but as there are numerous instances in which its presence is not constant, the necessity for its existence is questionable. In adults the intervention of cartilage is exceedingly rare ; and union without any perceptible callus is the rule, and not the exception, in well treated cases. The agency of granulations in the repair of compound frac- tures becomes almost a necessity. In the union of simple 3 34 FRACTURES. fractures, especially if inflammation be restrained within ordi- nary ranges, no granulations are interposed. In the majority of cases the reparative material employed in the union of fractures, is similar to that employed for the repair of soft tissues by adhesion. This material is supplied from the vessels of the surrounding tissues, and by those of the bone and of the periosteum. The vessels of the medullary membrane also contribute a share in the work of furnishing supplies. If the fragments be kept at rest and in strict appo- sition, the reparative material is found chiefly, if not entirely, between them. When from irritation, motion, or want of apposition between the fragments, it extends outside the broken ends of the bone, it gets between the periosteum and the bone, and even into the adjacent tissues. The diagrams in Paget's Surgical Pathology, which represent the periosteum as having been separated from the bone to allow, as it weiv. room for the " ensheathing " callus, may faithfully ropm-mr 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 fractun-. 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 Aveek after the injury. In in- fants the time of union is reduced to fifteen or eighteen days ; PROCESS OF UNION. 35 Fio. 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 oc 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- i 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 till 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 synovia! 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 ol restoring the functions of the joint. Shows uniting medium whore the fragments overlip. CHAPTER IV. NON-UNION OR FALSE JOINT AFTER FRACTURE. It is a fortunate circumstance in the history of broken bones, that the fragments rarely fail to unite through the medium of osseous material. The process of union may be delayed or completely arrested at any period of its progress. And as there is no precise time when consolidation is effected, a tardy union should not be looked upon as evidence of a total lack of uniting capacity between the fragments. If there be no bony union in ten or twelve weeks after fracture, the surgeon begins to grow uneasy in regard to the result, and to cast about for the cause of the delay or inability. Certain fractures frequently fail to unite by osseous mate- rial. The neck of the femur, within the capsular ligament, seldom unites by bony union ; the patella, from the fragments being held at a distance apart by the contraction of the quad- riceps muscle, often makes only a fibrous connection of its fragments; the olecranon and the coronoid processes of the ulna omit the osseous union for a similar reason ; the condylcs 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. Listen met with only one case in his OAvn practice. Hamilton estimates that one case does not occur in five hundred fractures. According to JS"orris' tables, the humerus and the femur are bones most liable to non-union. This circumstance goes to show that motion has much to do with the failure to unite. When the tibia alone is broken, it rarely fails to obtain bony union, yet after a frac- ture of both bones of the leg, false joint stands next in fre- quency to similar defects in the humerus and femur. The constitutional causes of non-union include all those con- ditions in which the powers of the system are much impaired. Old age, pregnancy, lactation, syphilis, scurvy, and especially the extreme debility of shattered inebriates, have been ob- served as causes retarding osseous union. Patients having been subjected to courses of mercury, and other prolonged devital- izing treatment, suffer from retarded union after fractures, and sometimes wholly fail to obtain consolidation of their broken bones. Larrey frequently saw, in his extensive cam- paigns, cases of false-joint that he attributed to poor diet, and kindred causes. Dropsical subjects suffer from pseudarthrosis, and very generally from retarded union. The local causes of ligarnentous 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, prodiu-os an aincniic 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 partial!}- 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. Xumerous 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 he sufficient to heal the broken bones. The local means devised for the successful man a ire - ment of ununited fracture, are numerous and varied; but the object of all is the same, namely, to excite action in the parts around the ends of the fragments and to make them throw out material proper for their consolidation. Blisters, friction, rasping, removal of the fractured ends, setons, drilling of the bones, and other means have been tried, and with various de- irives. 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 lias 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." T\vo 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, wiU answer the purpose. The .point of an aw T l which makes few chips is preferable to others. ^on-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 tascias 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 u saw can be used in the freshening process. The affair is then like a compound fracture, andean he treated successfully with a firm dressing. It the tibia be the subject of non-union the foot must be kept flexed on the leg till consolidation is known to have taken place. It is astonishing how much can be gained by strapping the foot in a flexed state to the k-g 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 \. 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 of the 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 KKACTLUKS. be attempted in a consolidation over six months old. The new fracture is not attended with a deficiency of healing- power ; iu 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- louging 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 ot the soft tissues upon the part. In very objectionabl-e instances the salient point of bone maybe cut down upon, and removal with the saw or bone nippers. Chronic pains at the seat of fracture may be modified i>\ the application of stimulating liniments, and by the u- 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 \veek> m 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 aud even months. I have made sati- 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 tin- surgeon has only to maintain the parts involved in the in- jury, at rest, and to guard against displacement. These general statements render the subject apparently simple, for they make no allusion to the various complications which render this branch of surgery one of great responsibility. In the ordinary discharge of those professional duties which fall to the lot of the country practitioner of medicine and surgery, there are none so trying and difficult to perform suc- cessfully as those pertaining to the management of broken bones. The inexperienced physician may avoid performing what are ordinarily considered surgical operations, but if called to a fracture he does not feel like shirking the respon- sibilities of the case. A medical man would lose caste, and be considered timid, if he should decline to take charge of a fracture, though he knows that the public holds him pecuni- arily responsible for the result of the treatment, There is a wrong sentiment in every community in regard to the dutie> and responsibilities of a physician, called to take charge of fractures. The medical practitioner has a right to decline any case he pleases on the ground of inexperience on his part. It is not absolutely necessary that a fracture be " set " the very hour it is received. The patient can be made compara- tively comfortable until the services of an experienced sur- geon, who is willing to assume the responsibilities of the case, (43) 44 FRACTURES. can be secured. The people should be made to un-. 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 fiat splints for the forearm or leg. Splints of gutta-percha are easily moulded to the contour of the body. Cut into proper shape and size, they may be softened in hot water, and then made to fit the part to receive them. FIG. 9. Splint-material consisting of wooden strips glued to leather. FIG. 8. ! gutta-percha splints. ' \v li-n splints. SPLINTS. 5l What are ordinarily called " carved splints," several of which are represented in the accompanying diagram, arc 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 cat and moulded into various lengths and shapes to fit the arms alid legs, and fitted with hinges to span the joints. Applianees 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 size.-; and shapes must conform. Wo re t> 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 maybe 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 strip* applied. its two ends made to adhere to the sides of the leg and ankle, leaving a loop below the hollow of the foot. These ends will gradually slide down the limb unless they be bound in place by other strips, which are applied circularly about the leg and ankle, covering the two parts of the first piece at each turn. Finally, a strip or two may be applied diagonally to the others, to hold all firmly in place. A block of wood may be placed in the loop to prevent pres- sure upon the ankle when the extending force is applied. SPLINTS. 61 The strips will firmly adhere for months unless some alco- holic lotion be allowed to come in contact with them. They rarely need removing during the whole period of treatment. A doable 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 Hexed 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 Hexed, constitute an easily constructed double inclined plane, which may answer every purpose of a more compli- cated apparatus. 62 FKAOTUKS. 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 Amesbnry 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 ii] per plane receiving the trunk, is raised at the holster- end ; the middle one, intended for the thighs, is made of tw<> pieces sliding on one another so as to suit limhs of different lengths, and forms with the third piece a douhle inclined plane; this last, which supports the legs, has a foot-piece, u>ed to confine the feet when it i- necessary, and always serving to sustain the weight of the hed 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 La- sin titted to it to receive the fucal 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 surgieal and mechanical mechanism, but it is too complicated and ex- pensive for ordinary use. The diagram presented to illustrate the appliance, shows that the machine could not be constructed for less than fifty dollars ; and is made of so many different SPLINTS. 63 materials that it would require a carpenter, blacksmith and upholsterer to construct the apparatus. Many intricate con- trivances of varied merit have been pressed upon the attention FIG. 14. Burire's fracture-bed. of the profession from time to time, but none have come into general use. If a surgeon were to possess all the different ap- pliances devised to treat fractures, he would need extensive store rooms in connection with his office, to give them shelter. The simplest and best method of exerting extension and counter-extension in the treatment of fractures of thelegand 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 eight 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 lias 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) IvE-DRESSINGS. 65 As soon as the swelling has subsided, and the shrinking of the limb permits the bandages to become loose, a renewal of the dressing should take place. It is probably best, in favor- able cases, to re-dress once a week while the retentive treat- ment lasts. The limb may be looked at ofteiier. A case that is convenient to* watch may be seen every other day ; if it be at a distance, and circumstances do not favor any more attention than is absolutely necessary, a revisit and redressing once in ten days may do just as well as daily inspections. There is generally intelligence enough among the patient's friends to be entrusted with the execution of certain instruc- tions pertaining to the case. If yellow blisters, or a livid color of the skin, show themselves between the folds of the bandage or anywhere beneath the dressings, the surgeon can be informed of the untoward condition. A too tight dressing- can be loosened by cutting a few of the turns of the bandage partly or wholly in two; and, in the event of loosening, a few additional tapes can be tied around the dressing. In fractures of the thigh or leg, the surgeon should, every time he visits the patient, compare the two limbs in regard to length, direction of feet, and general aspect. This can be done before the dressing is removed. The patient, while his limbs are inspected, should be made to lie on his back, straight in bed. A slight twist of the pelvis makes a great difference in the apparent length of the legs. With the trunk and limbs straight, accurate measurements with a tape or inelastic cord should be made from the symphysis pubis to the inner mal- leolus of both ankles. The placing of the two heels together and observing whether one is below the other, is a good test of the relative length of the limbs. If there be evidence of shortening, the dressing should be taken off, and the defect or displacement remedied. Re-dressings for such a purpose are always proper, even at the risk of disturbing the healing pro- cess. There is always an urgent necessity, on the part of both surgeon and patient, to avoid deformity if possible. 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 bo guarded against. In fact, the patient, to avoid pain, is very likely to rairy a broken arm with much care. If the dressing become loose, the morion 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 sound foot may press against it, in efforts to raise the pelvis, may be of considerable service. (66} CHAPTER XI. MANAGEMENT OF COMPOUND FRACTURES. The directions given by Ambrose Pare, himself an eminent surgeon, to his surgical attendant, when he received a com- pound fracture of the leg, are quite explicit. " If the wound be too small, enlarge it with a razor, that YOU may the more easily replace the bones in their natural position ; and carefully explore the wound with the fingers, in order to remove such fragments and bits of bone as maybe 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 substa; and the fragments adjusted, the treatment is much the same as in simple fractures. Compound fracture. 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) ' 68 FRACTURES. dressing is being put on, is covered in ; but, after the dressing has become consolidated, a hole or door is cut so as to expose the wound. The edges of the wound are not to be drawn together with sutures, but a piece of tin-foil, or a lead plaster, may be em- ployed to shield the lacerated parts. As previously stated, the many-tailed bandage is well suited for the treatment of such injuries, inasmuch as the wound can be often exposed without disturbing the limb. Care must be exercised that flies do not deposit their ova in the saturated folds of cloth about the wound. The immovable apparatus is not generally suitable for com- pound fractures. Unpleasant complications have too often arisen when it has been used. Malgaigne says of it : " Un- happily we have too much reason to fear pus will burrow be- tween the integuments and the muscles, and between the muscles and the bones, endangering the limb and even the life of the patient. I once had to treat an old soldier, a stout, sanguine man, who fell from a ladder, and sustained a com- pound fracture of the tibia at its lower part. The immovable apparatus was employed ; on the eighteenth day it had to be removed on account of the insupportable fetor. Four days later, pus flowed abundantly from the heel. On the twenty- ninth day, the increased discharge and the excessive fetor made a fresh removal necessary; the whole leg was pasty and flaccid ; a probe, introduced by the wound, passed up several inches between the two bones ; the tibia was denuded at its external face; sinuses were formed in the limb above and below. Several surgeons regarded amputation as unavoidable. This, however, was postponed, and by great care, after three incisions had been made, and a long train of severe symptoms had been overcome, a satisfactory cure was effected by the end of six months." The application of carbolic acid in a dilute form, to the wound of a compound fracture, is valuable to remove the fetor; to prevent a profuse suppurative condition ; and to favor the formation of firm and healthy granulations. TOPICAL TREATMENT. 69 TOPICAL AND CONSTITUTIONAL TREATMENT. It was once customary to apply cerates, poultices, and fo- mentations to fractured limbs. At a later period in the history of surgery, it was a common practice to soak the dressings in laudanum, braudy, lead-water, camphorated liquids, and various other lotions. At the present day, dilute tinctures of aconite, arnica, and wormwood, are thought to be valuable applications ; rum and whisky have always en- joyed a popular reputation for allaying inflammation in almost every kind of injury. Some practitioners order the frequent application of water to fracture dressings, with the object of cooling the inflamed tissues beneath. The reasons adduced for employing cooling, stimulating, and anodyne lotions are not without plausibility, ;yet, in prac- tice, it is found that more harm than good follows any kind of topical medication. A common muslin bandage creases upon being wetted, often rendering the dressing harmful ; then, if allowed to dry, as is frequently the case, it will be too loose. Blisters are more likely to occur under wet dressings; eruptions and discolorations, with itching and other unpleasant sensations, are among the troublesome effects produced by lotions. I invariably lind 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, or watch it carefully until parts thus effected are sound. 70 FRACTURES. 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. Di-fi reusing 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. Ftln-ile ,i/i>ij>tom$ may be allayed by the use of aconite, or kindred agents. The evacuation of the bowels by the inilu- ence of an enema, or a mild purgative, frequently arrest.- feverish paroxysms. A hot skin may be cooled by the fre- quent use of the wet sponge. In case of " chills " and In- 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 suite of the limb, and needs encouragement to make him exei properly, and to employ those means which tend to re-estab- lish the functions of the part. Extreme timidity prevents patients from giving their eonvale-cinir limbs a desirable CONVALESCENCE. 71 amount of action. There is an instinctive dread tliat the limb may be re-broken, or that it will not sustain the weight of the body. It is a discreet precaution to keep patients who have sus- tained a fracture of the thigh, or of both bones of the leg, in bed for a week or two after the consolidation is known to have been established. As has been previously stated, there is yet danger of a gradual yielding of the newly-formed callus > yet during this confinement to the bed, the limb may be moved at the joints, and rubbed with the hand or coarse towels. At length the patient may venture upon crutches, and then to take gentle exercise with the support of a cane ; and, finally, he will walk without any assistance, though with a limp in the gait even when there is no shortening or other deformity. Sometimes a patient is so fearful of a fall or a second acci- dent, that he has to be coaxed and urged into sufficient exer- cise to invigorate the limb. Liniments and douches are of questionable utility so far as medication is concerned, but their indirect effects may prove exceedingly advantageous. The patient is recreated while applying a liniment; and the circulation of the limb is improved by the friction employed in the application. There is a popular notion that certain penetrating or oleaginous liniments will impart suppleness to stiffened joints and rigid tissues; this prejudice maybe turned to the advantage of the sufferer, for he will industriously employ any means that have ascribed to them the desired qualities. Patients are to be impressed with the importance of em- ploying considerable force in the flexion and extension of par- tially anchylosed joints; and of keeping up this action for weeks and even months in obstinate cases. Persevering efforts of this kind have accomplished wonderfully beneficial results. Flannel bandages should be kept applied for weeks and months to legs inclined to swell, especially if the veins be varicose. At length the bandages may be laid aside, and elastic stockings worn continuously to keep the limbs in good condition. Elderly persons make exceedingly slo\v recoveries ; and if of irritable temperaments, are querulous and de- spondent. CHAPTER XII. DIASTASIS, OR SEPARATION OF THE EPIPHYSIS. Strictly speaking, there can be no fracture without breaking of osseous material, yet the forcible separation of the epiphy- sis from the shaft of the bone, through the cartilaginous con- nection, in young subjects, is a lesion analogous to fracture. It is an accident that can not always be distinguished from fracture ; and the treatment of the lesion should be the same as that directed for a broken bone. In the diagnosis of the case, clear and distinct crepitus will be wanting, but all the other signs of fracture may be present. All the long bones, from birth to fifteen years of age, are subject to this peculiar injury. Both extremities of the humerus, radius, femur, and tibia, have been separated from the shaft, through the cartilages interposed in growing bones, between these distinct ossific parts. The separation may take place during the careless delivery of a child. The obstetrician, unless he bears in mind the dangers of diastasis, may, in at- tempts to bring down an arm or leg, sever the cartilaginous connections of the hnmerus 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 ordinarj 7 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 aspe -t of the arm, sloughed. This was the state of the case \vlieu I \vas ;i