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Return this book on or before the 
 Latest Date stamped below. 
 
4 
 
A 
 
 TREATISE 
 
 DISLOCATIONS 
 
 AND 
 
 FRACTURES OF THE JOINTS 
 
 By sir ASTLEY COOPER, BART., F.R.S., 
 
 SERGEANT-SURGEON TO THE KING, »fec, &€, &C. 
 
 Second American from the sixth London edition. 
 
 REVISED AND GREATLY IMPROVED WITH THE ADDITION OF NUMEROUS 
 AND VALUABLE ILLUSTRATIONS. 
 
 TO WHICH ARE ADAPTED THE 
 NOTES AND REFERENCES TO THE FIRST AMERICAN EDITION, 
 
 By THE LATE JOHN D. GODMAN, M.D. 
 Lecturer on Anatomy and Physiology, Professor of Physiology in the Philadelphia 
 Museum, Member of the Academy of Natural Sciences, &c, &,c 
 
 BOSTON: 
 
 LILLY & WAIT AND CARTER & HENDEE. 
 
 N. YORK, G. & C. »fe H. CARVILL & E. BLISS ; ALBANY, LITTLE & CUM- 
 MINGS; PHILADELPHIA, CARY & HART ; NEW ORLEANS, 
 M. CARROLL ; PORTLAND, S. COLMAN. 
 
 1832. 
 
Entered according to Act of Congress, la the year 1832, 
 By Lilly & Wait, 
 In the Clerk's Office of the District Court of Massachusetts. 
 
^ 17. )^ 
 
 TO THE ^ 
 
 STUDENTS OF ST THOMAS'S AND 
 GUY'S HOSPITALS. 
 
 My Dear Young Friends, 
 
 This Work has been composed for your use ; 
 and if you derive advantage from it, my principal 
 object will be attained. I cannot, however, omit 
 this opportunity of expressing my gratitude for the 
 affectionate and respectful manner in which you 
 have always received me as your instructer. Your 
 parents and relatives, many of whom were my 
 pupils, are also entitled to my most grateful acknow- 
 ledgments ; they fostered me in early life ; and by 
 their friendship and recommendation have largely 
 contributed to procure to me a degree of success 
 which, I fear, is beyond my merits, and a course of 
 uninterrupted happiness which few have been per- 
 mitted to enjoy. 
 
 Believe me, always. 
 
 Your affectionate Friend, 
 
 AsTLEY Cooper. 
 
PREFACE TO THE FIFTH EDITION. 
 
 It is incumbent on me to observe, that although 
 I believe the matter of this Work to be correct, and 
 regard it as the result of a considerable share of 
 experience, jet I am aware that the reader may de- 
 tect a too familiar mode of expression, and may 
 censure me for want of attention to its style. The 
 familiarity of the diction arises from my desire to 
 be perspicuous. I prefer plain and simple language 
 to an elaborate and ostentatious phraseology, just as 
 J would a good plain suit to the finest embroidered 
 dress ; and am ready to own, that my thoughts are 
 more steadfastly directed to the matter which 1 
 give, than to the manner in which it is conveyed. 
 
 I am much indebted to my friends for their com- 
 munications ; the life of man is too short to allow 
 him, even with the greatest industry, zeal, and with 
 the most advantageous opportunities, to witness all 
 the varieties of accident or disease ; and I should 
 feel that I wa^ not properly discharging my duty, if 
 I omitted to avail myself of all the evidence which 
 
vi 
 
 PREFACE. 
 
 might be adduced by those on whose respectable 
 testimony I could depend. 
 
 While, then, I sincerely thank my friends for their 
 kindness, I wish to state to them and to others, that 
 they will always oblige me, by giving me any infor- 
 mation which it is in their power to convey upon 
 this or any other subject in surgery. 
 
 In looking over the following pages on disloca- 
 tions, I feel that my professional brethren will be 
 disposed to think that I have limited to too short a 
 period the attempts at reduction. It has been 
 stated, that dislocations have been reduced at four 
 and even six months after the injury, and this as- 
 sertion I am not disposed to deny ; indeed, I have 
 myself had an opportunity of witnessing examples 
 of the fact ; but, excepting in very emaciated, re- 
 laxed, and aged persons, I have observed that the 
 injury done in ^he extension, has been greater than 
 the advantage received from the reduction; and, 
 therefore, in the case of a very strong musculai: 
 person, I am not disposed, after three months, to re- 
 commend the attempt, finding that the use of the 
 limb is not, when reduced, greater than that which 
 it would have acquired in its dislocated state. Let 
 this be fairly represented to the patient ; and then, 
 at his request only, the reduction should be attempt- 
 ed : but, ' with all appliances and means to boot,' 
 the extension must be very gradually made, and 
 without violence, to avoid injury to the muscles and 
 nerves. 
 
PREFACE. 
 
 vli 
 
 I have stated, that in fractures of the upper part 
 of the thigh-bone, the foot is generally everted ; to 
 which there is sometimes an exception ; for I have 
 seen a case of Mr LangstafFs, surgeon in the city, 
 in which the foot was inverted, and the bones, al- 
 though they rubbed against each other, had not 
 united. 
 
 Mr Guthrie considers it probable, that the inver- 
 sion of the foot in fractures of the upper part of 
 the thigh-bone, which now and then happens, arises 
 from a diagonal fracture through the trochanter 
 major. The gluteus medius and minimus, with the 
 tensor vaginse femoris,draw the thigh-bone forw^ards, 
 and roll it inwards. He showed me a preparation 
 which confirmed this opinion. 
 
 I have received from Mr Brindley, surgeon of 
 Wink Hill, an account of a dislocation of the os 
 femoris, which the patient is able to produce and re- 
 duce when he chooses ; the man is fifty years of 
 age. Mr Morley, of Uttoxeter, has transmitted to 
 me a case of compound fracture of the head of the 
 OS humeri: the end of the bone was sawn off, the 
 bone reduced, and the patient did well ; the length 
 of the limb differed but little from that of the other. 
 And Mr White, of the Westminster Hospital, has 
 shown me a case of dislocation of the os femoris 
 from ulceration, in which the head of the femur 
 was sawn off, and the person recovered. 
 
 I have been accused of publishing doctrines, re-^ 
 specting fractures of the neck of the thigh-bone, 
 
viii 
 
 PREFACE. 
 
 which differ from those of my medical brethren, and 
 this I am perfectly ready to acknowledge ; on the 
 other hand, I have heard that I am abused for not 
 having admitted that others had previously given 
 similar opinions. To this animadversion I have 
 only to reply, that I began to deliver lectures in the 
 year 1792, and that I never failed in them to give 
 publicity to the opinions which I have here advanc- 
 ed. I have procured early copies of my lectures, 
 taken by some of my students, and could obtain a 
 great number of others, which show that my opinions 
 of non-union were those which the present volume 
 contains. By a comparison of the dates of my lec- 
 tures, with that of the publication alluded to,* it 
 will be readily seen who had the priority in forming 
 those opinions. 
 
 UNION OF THE FRACTURED CERVIX. 
 
 The earliest notes of my lectures (and my first 
 lectures were given in 1792), were in these terms ; — 
 
 FRACTURES OF THE THIGH BONE AT ITS CERVIX. 
 
 'These fractures seldom, if ever, become after- 
 wards united, for which two reasons may be given ; 
 firsts that the uniting matter is thrown into, and lost 
 in the joint ; and, secondly^ that the fractured por- 
 
 * Principles of Surgery by John Bell, published in 1801. 
 
PREFACE. 
 
 ix 
 
 tions of the bone are not in apposition, the thigh- 
 bone being drawn from its head (which still re- 
 mains in its socket) by the action of the glutei 
 muscles.' 
 
 Extract from Sir Astley Cooper^s Surgical Lectures^ 
 delivered in the year 1 793, taken from the notes of 
 Mr Fiske. 
 
 * When a bone which forms part of a joint is 
 fractured transversely, union seldom takes place be- 
 tween the fractured ends, as in the patella and ole- 
 cranon ; where the same effusion of blood takes 
 place, but is lost in the cavity of the joint, from 
 which it receives vessels, and becomes of a liga- 
 mentous substance. When the cervix of the os fe- 
 moris is fractured, it becomes united to the capsular 
 ligament by bands : the reason for this kind of union 
 taking place is exactly the same as in a trepanned 
 skull; for the action of the muscles inserted into 
 the upper part of the bone draws it upwards, and 
 those into the lower part draw it downwards, and 
 the space becomes too great for the vessels of the 
 bone to shoot into the coagulated blood and form 
 it into bone. This, I think, will hold good, though 
 it is different from the opinion of many men.' 
 
 Charles Fiske. 
 
 Saffron Walden^ 
 
 JVov, Uth, 1824. 
 2 
 
X 
 
 PREFACE. 
 
 From Mr Ltikyn, of Faversham. 
 
 Dear Sir : — I am sorry to say that my notes on 
 your surgical lectures, delivered in 1793, are very 
 short ; in the one on simple fractures you said, 
 * There are some fractures that happen in joints 
 that never unite, as in the neck of the thigh-bone ; 
 the blood is extravasated into the joint, and only 
 ligamentous matter deposited, the vessels shooting 
 into the coagulum coming from the ligament. Ano- 
 ther reason is, the parts cannot be kept in ap- 
 position.' 
 
 I remain, dear Sir, 
 Faversham, Your very obedient servant, 
 
 JVov. \2th, 1824. Robert Lukyn. 
 
 From Dr Pidcock^ of Watford, 
 
 My dear Sir : — In a copy I made of the lecture 
 on simple fractures there is this brief remark on the 
 subject of your inquiry : ' In fractures of the cervix 
 femoris the ends of the bone are never opposite to 
 each other ; the callus is thrown into the acetabulum, 
 and union never takes place.' 
 
 Watford, I remain very faithfully your's, 
 
 JYov. \4th, lcJ24. John Pjdcock. 
 
 Pupil in 1794-5. 
 
PREFACE. 
 
 From Mr Pulley^ of Bedford, 
 
 Dear Sir : — I send jou with much pleasure your 
 observations on fractures of the neck of the thigh- 
 bone. You will find my language incorrect in some 
 parts, owing to the hurry of transcribing, arising 
 from the multiplicity of matters then to be attended 
 to ; but I can vouch for the accuracy of the state- 
 ment, and had much rather send you an exact copy 
 of the lecture now in my possession, not knowing 
 the reason of your present application. 
 
 * Fracture of the neck of the thigh-bone. — This 
 fracture never unites ; tell the patient this, and that 
 he must be lame for life. When the injury happens 
 with persons not more than fifty-five years of age, 
 the recovery may be so far that the patient may be 
 able to walk with a stick ; but should it happen 
 with very old people, they will never after be able 
 to walk out without crutches. The fractured cer- 
 vix does not unite, because the extravasated matter, 
 or coagulable lymph thrown out for union, is lodged 
 in the joint, so that it is not applied to the ends of 
 the bone ; besides, union cannot be effected, as the 
 ends of the bones are so far removed from each 
 other. Attempts have frequently been made to ef- 
 fect a union, but they have never succeeded.' 
 I remain, dear Sir, 
 
 Bedford^ Your most obedient servant, 
 
 JVov. \2th, 1824. John Pulley. 
 
 Pupil in 1796. 
 
Xii PREFACE. 
 
 From Mr Weekes, of Hurst-per-Pdint, Sussex. 
 
 Dear Sir : — I am sorry I have been prevented 
 ansv^ering your letter before ; but upon referring to 
 your lectures, I find the • following observations, 
 viz : — 
 
 * Of fracture of the cervix femoris. — This is of 
 frequent occurrence, but seldom if ever happening 
 but in people of advanced age. These fractures 
 are often supposed to be cured, but in reality they 
 never are. People, after these fractures, should al- 
 w^ays w^alk w^ith a stick ; and if they are stout and 
 fat, crutches are admissible. 
 
 ' The reason why fractures of the cervix femoris 
 do not get w^ell so soon as fractures of the trochan- 
 ter is, that in the former the callus becomes extra- 
 vasated in the joint, and renders union of the bone 
 impracticable.' 
 
 I remain, dear Sir, 
 
 Your very humble servant, 
 Hurst-per-Pomt, H. Weekes. 
 
 Sussex, 
 
 Pupil in 1796. 
 
 From Mr Overend, of Sheffield, 
 
 Dear Sir . — In referring to my notes of your 
 lectures on fracture of the cervix femoris, delivered 
 
PHEFACE. xiii 
 
 in the year 1 797, I find the following observations. 
 After describing the appearances indicating the frac- 
 ture of this part of the thigh-bone, my notes state — 
 
 ' A crepitus in fracture of the cervix femoris can 
 never be observed, originating from the tv^^o extre- 
 mities of the broken bone never being in contact, 
 and, consequently, a bony union never takes place : 
 in the first instance, from the want of contact ; and, 
 secondly, from extravasation surrounding the affect- 
 ed part, which progressively becomes vascular, and 
 forms a ligamentous union, if union at all' 
 
 Your obedient, humble servant, 
 
 Sheffield^ Hall Overend. 
 
 JVov. \4th, 1824. 
 
 Dr Jeffries, of Liverpool, took the following JYotes of 
 my Lectures in the year 1797. 
 
 ' In the cervix femoris, a union never takes place ; 
 the leg is much the shortest, the foot and knee turn- 
 ed outwards, and great motion at the hip-jdint : oc- 
 curs only in old people. The fractured surfaces 
 become smooth by callus, but no union ever follows, 
 because the two pieces of bone are never applied, 
 and the callus matter is lost within the cavity of the 
 joint.' 
 
xiv 
 
 PREFACE. 
 
 From Mr Alexander, of Cor sham, Wilis, 
 
 ' The cervix of the os femoris is a part that never 
 unites. It is an accident v^hich generally occurs in 
 old people after the age of fifty-six : the limb be- 
 comes shortened, and the knee and foot turned out- 
 wards. Ligamentous matter only is poured out into 
 the joint and around the head of the bone.' 
 
 Richard H. Alexander. 
 
 Attended in 1797-8-9; believe the notes were 
 taken in 1798. 
 
 Fro7n Mr Rose, of High Wycombe. 
 
 Dear Sir : — I am sorry to have been prevented 
 by various engagements attending to your request 
 earlier, in sending you the extract from the lecture 
 delivered by you, on the subject of fracture of the 
 cervix of the os femoris, in the year 1798. 
 
 * The reason why this fracture does not unite : — 
 First, ^ one cause is, that the callus is effused into 
 the cavity of the joint : secondly, the head of the 
 bone cannot be kept in apposition with the cervix, 
 which explains why the patient is always lame.' 
 
 Youthen related some cases published by Desault, 
 wherein he stated his having succeeded, and union 
 had taken place ; but as they were in young sub- 
 
PREFACE. 
 
 XV 
 
 jects, you expressed your opinion, that they were 
 fractures of the trochanter, and not of the cervix. 
 
 1 am, dear Sir, 
 Your faithful and obedient servant. 
 High Wycombe, William Rose. 
 
 Jlug. 30th, 1824. 
 
 JYotes on Fracture of the Neck of the Thigh-Bone, 
 taken from Sir Astley Cooperh Lectures in 1799, 
 by W, Jackson. 
 
 * This fracture never unites, therefore you must 
 inform your patients they will always be lame.' 
 
 . The expression * never unites,' is a little too 
 strong, for it will be seen in my work that I have 
 mentioned certain exceptions in which such union 
 might be possible ; but still lameness is a never- 
 failing consequence. It may be also stated, that in 
 addition to the two causes of want of union which 
 I have mentioned, there is a third, which I have 
 much dwelt upon in this work, viz, cessation of the 
 supply of blood to the head of the bone, excepting 
 through the medium of the ligamentum teres, cans- 
 
xvi 
 
 PREFACE. 
 
 ed by the laceration of the reflected ligament and 
 periosteum. 
 
 The question of union or non-union of the frac- 
 ture of the neck of the thigh-bone, as a general 
 principle, involves very important consequences ; as 
 the infirmity w^hich invariably follows these acci- 
 dents w^ould expose every surgeon in the kingdom 
 to an action for neglect or w^ant of skill, if such 
 fractures were really capable of uniting, so as to 
 render the limb firm, and prevent the lameness which 
 in every case that I have seen was the uniform re- 
 sult, although union in a large proportion of them 
 was attempted. 
 
 If I were called upon to give evidence in a court 
 of justice in such a case, I should say, that the con- 
 sequent lameness was not imputable to any want of 
 skill, but to the nature and seat of the fracture, as 
 I have never seen an instance in which it did not 
 occur. But to those who hold a contrary opinion, 
 all that could be said is, ' you have exposed yourself 
 to this action from want of proper attention to the 
 issue of these accidents, and are culpable, according 
 to the very doctrine which you maintain.' 
 
 Since writing the above observations, I have re- 
 ceived the following letter and case. 
 
PREFACE. 
 
 xvii 
 
 Dear Sir Astley : — I beg to forward you a note 
 of a case of fracture within the capsular ligament, 
 which fully illustrates your opinion of the nature and 
 consequences of that injury. I have abstained from 
 drawing any conclusions on the case, confining my- 
 self to its history and dissection. The bones, not 
 yet subjected to any preparation, are in my posses- 
 sion, and if considered as worthy a place in the 
 museum, I shall feel great pleasure in forwarding 
 them to you- 
 
 I am, with great respect, 
 Sheerness, Your obedient servant, 
 
 Dec. Is/, 1824. Arch. Robertson. 
 
 Case. —On the 25th of June, 1822, William 
 Daruin, aged sixty-two, a tall, athletic convict, of a 
 sanguine temperament, fell, with a very inconsider- 
 able violence across a piece of timber in the Dock- 
 yard, his left hip coming in contact with the wood. 
 On rising, he felt an acute pain in the region of the 
 acetabulum, but no other inconvenience, for he walk- 
 ed on board to exhibit himself to the surgery man. 
 From finding him ranked up with the sick of the 
 hulk on my morning visit of the 26th, from his walk- 
 ing on board, and from his own account of the ac- 
 cident, I did not suspect any serious injury of the 
 joint, and treated the case as one of concussion. 
 On the 29th, however, he complained of a very sud- 
 den and very agonizing accession of pain, which 
 
 induced me to subject him to a more critical ex- 
 3 
 
xviii 
 
 PREFACE. 
 
 amination. No evident alteration in the size of 
 either hip could be discerned, but a shortening of 
 the limb was conspicuous, which was rendered more 
 evident by making him stand on the sound limb ; 
 extension removed this difference, but on being freed 
 from restraint, it again assumed its morbid shape ; 
 the knee and foot were everted, and rotation greatly 
 increased his pain. 
 
 I removed him to the hospital as a case of fracture 
 within the capsule, but a continued attention for a 
 period of six months to position (chiefly with the 
 view of restraining the motion of the pelvis and of 
 securing the limb), made no other alteration in the 
 symptoms than a gradual diminution of pain. A 
 pair of crutches were given him, he was placed on 
 the invalid list, and remained so till the 26th of 
 December, when he died from general dropsy. 
 
 On dissection, the injury proved a transverse frac- 
 ture of the head of the femur within the capsular 
 ligament. No species of union had taken place. 
 The upper portion of the fractured bone was retain- 
 ed in situ by the sound ligament ; tolerably smooth 
 on its surface, but without any ossific deposit. The 
 lower portion very irregular, with several detached 
 pieces of bone adhering to the insertion of the cap- 
 sular ligament. Between the acetabulum and the 
 portion of bone retained in situ by the ligament 
 were several small oval-shaped loose cartilaginous 
 substances, apparently fragments of bone ; the cap- 
 
PREFACE. 
 
 xix 
 
 sular ligament partially lacerated, in a line above 
 the trochanter major, and greatly thickened in its 
 insertions. 
 
 Arch. Robertson. 
 Convict Hospital Ship, Sheerness, 
 ]st Dec, 1824. 
 
 I may be permitted in this place to observe, that 
 I have just added to the collection at St Thomas's 
 Hospital, a fracture of the patella, in which the por- 
 tions of bone are in contact, and in w^hich an ossific 
 union appeared at first sight to have been produced 
 that might have w^arranted such an inference in the 
 living body ; yet the union is only ligamentous. 
 
 A. C. 
 
 December, 1824. 
 
CONTENTS. 
 
 Page 
 
 On Dislocations in general, 24 
 Particular Dislocations, 66 
 Dislocations of the Hip-joint, ib. 
 Dislocation upwards, or on the Dorsum Ilii, 68 
 Dislocation downwards, or into the Foramen Ovale ^ 79 
 Dislocation backwards, or into the Ischiatic Notch, 90 
 Dislocation on the Pubes, 101 
 Fractures of the Os Innominatum, 113 
 Fractures of the Upper Part of the Thigh-Bone, 122 
 Fractures of the Neck of the Thigh-Bone, within the Cap- 
 sular Ligament, 124 
 Additional Observations on Fractures of the Neck of the 
 
 Thigh-bone, 159 
 Fractures of the Cervix Femoris, external to the Capsular 
 
 Ligament, and into the Cancelli of the Trochanter Major, 163 
 
 Fractures through the Trochanter Major, 175 
 
 Fracture of the Epiphysis of the Trochanter Major, 187 
 
 Fractures below the Trochanter, 189 
 
 Dislocations of the Knee, 191 
 
 Dislocation of the Patella, 193 
 
 Dislocation of the Patella upwards, 196 
 
 Dislocation of the Tibia at the Knee-joint, 198 
 Partial Luxation of the Thigh-bone from the Semilunar 
 
 Cartilages, 202 
 
 Dislocation of the Knee-joint, 206 
 
 Compound Dislocation of the Knee-joint, 208 
 
 Dislocation of the Knee from Ulceration, 210 
 
 Fractures of the Knee-joint, 212 
 
 Fracture of the Patella, ib. 
 
 Perpendicular Fracture of the Patella, 221 
 
 Compound Fracture of the Patella, 224 
 
CONTENTS. 
 
 Page 
 
 Oblique Fractures of the Condyles of the Os Femoris into 
 
 the Joint, 228 
 Compound Fracture of the Condyles of the Femur, 230 
 Oblique Fractures of the Os Femoris, just above its Con- 
 dyles, 232 
 Compound Fracture, just above the Condyles of the Os 
 
 Femoris, 234 
 Simple Fracture above the Condyles of the Os Femoris, 236 
 Fracture of the Head of the Tibia, 239 
 Dislocations of the Head of the Fibula, 240 
 Dislocations of the Ankle-joint, 242 
 Simple Dislocation of the Tibia inwards, * 243 
 
 Simple Dislocation of the Tibia forwards, -246 
 Partial Dislocation of the Tibia forwards, 247 
 Simple Dislocation of the Tibia outwards, 249 
 Compound Dislocation of the Ankle-joint, 25! 
 Compound Dislocation of the Tibia inwards, 26 1 
 
 Compound Dislocation of the Tibia outwards, 262 
 On removing the Ends of the Bones, 288 
 Additional Cases of Compound Dislocation of the Ankle-joint, 312 
 Cases which render Amputation necessary, 317 
 Fractures of the Tibia and Fibula near the Ankle-joint, 335 
 Fracture of the Tibia at the Ankle-joint, 337 
 Dislocation of the Tarsal Bones, 339 
 Simple Dislocation of the Astragalus, ib. 
 Compound Dislocation of the Astragalus, 343 
 Dislocation of the Os Calcis and Astragalus, 362 
 Dislocation of the Os Cuneiforme Internum, 357 
 Dislocation of the Toes from the Metatarsal Bones, 359 
 Dislocations of the liOwer Jaw, ' 360 
 
 Complete Luxation of the Jaw, 362 
 Partial Dislocation of the Jaw, 365 
 Subluxation of the Jaw, ib. 
 Dislocations of the Clavicle, 367 
 Junction of the Sternal Extremity of the Clavicle with the 
 Sternum ib. 
 
CONTENTS. 
 
 xxiii 
 
 Page 
 
 Dislocation of the Sternal Extremity of the Clavicle, 369 
 Junction of the Clavicle with the Scapula, 373 
 Dislocation of the Scapular Extremity of the Clavicle, 375 
 Dislocation of the Clavicle, with Fracture of the Acromion, 377 
 Structure of the Shoulder-joint, 379 
 Dislocation of the Os Humeri, 383 
 Dislocation in the Axilla, 384 
 Dislocation forwards, behind the Pectoral Muscle, and be- 
 low the middle of the Clavicle, 399 
 Dislocation of the Os Humeri on the Dorsum Scapulae, 403 
 Partial Dislocation of the Os Humeri, 407 
 Fracture of the Neck of the Os Humeri, with the Disloca- 
 tion forwards under the Pectoral Muscle, 410 
 Compound Dislocation of the Os Humeri, 412 
 Partial Dislocation of the Os Humeri forwards, 413 
 Dislocation of the Os Humeri backwards, 416 
 Fractures near the Shoulder-joint, liable to be mistaken for 
 
 Dislocations, 418 
 Fractures of the Acromion, 418 
 Fracture of the Neck of the Scapula, 420 
 Fracture of the Neck of the Os Humeri, 422 
 Structure of the Elbow-joint, 425 
 Dislocations of the Elbow-joint, 429 
 Dislocation of both bones backwards, 430 
 Compound Dislocation of the Os Humeri at the Elbow- 
 joint, 431 
 Lateral Dislocation of the Elbow, 434 
 Dislocation of the Ulna backwards, 436 
 Dislocation of the Radius forwards, 437 
 Dislocation of the Radius backwards, 441 
 Lateral Dislocation of the Radius, 442 
 Fractures of the Elbow-joint, 443 
 Fractures above the Condyles of the Humeri, 443 
 Fracture of the Internal Condyle of the Os Humeri," 446 
 Fracture of the External Condyle of the Os Humeri, 447 
 Fracture of the Coronoid Process of the Ulna, 449 
 
CONTENTS. 
 
 Page 
 
 Fracture of the Olecranon, 450 
 Compound Fracture of the Olecranon, • 457 
 
 Fracture of the Neck of the Radius, ib. 
 Compound Fractures and Dislocations of the Elbow-joint, 458 
 Structure of the Wrist-joint, 462 
 Dislocations of the Wrist-joint, 464 
 Dislocation of the Radius at the Wrist, 466 
 Dislocation of the Ulna, 467 
 Simple Fracture of the Radius, and Dislocation of the Ulna, 468 
 Fracture of the Lower End of the Radius, without Disloca- 
 tion of the Ulna, 470 
 Compound Dislocation of the Ulna, with Fracture of the 
 
 Radius, 471 
 Dislocation of the Carpal Bones, 474 
 Compound Dislocation of the Carpal Bones, 476 
 Dislocation of the Metacarpal Bones, 479 
 Fracture of the Head of the Metacarpal Bones, 480 
 Dislocations of the Fingers and Toes, 482 
 Dislocation from Contraction of the Tendon, 483 
 Dislocation of the Thumb, 485 
 Dislocation of the Metacarpal Bones from the Os Trapezium, 486 
 Dislocation of the First Phalanx, 489 
 Dislocation of the Second Phalanx, 492 
 Dislocation of the Ribs, ' 493 
 Injuries of the Spine, 495 
 Concussion of the Spinal Marrow, 498 
 Extravasation in the Spinal Canal, 499 
 Fracture of the Spine, 502 
 Fractures of the Bodies of the Vertebrae, with Displacement, 504 
 Inflammation and Ulceration of the Spinal Marrow, 511 
 
 Plates and Explanations. 
 
A TREATISE, &c. 
 
 DISLOCATIONS IN GENERAL. 
 
 Definition, — A dislocation is a displacement of 
 the articulatorj portion of a bone from the surface 
 on which it was naturally received. 
 
 JYecessity of prompt assistance ; instances of mistake. 
 — Of the various accidents which happen to the body 
 there are few which require more prompt assistance, 
 or which more directly endanger the reputation of a 
 surgeon, than cases of luxation. If much time shall 
 have elapsed before the attempt at reduction is 
 made, the difficulty of accomplishing it is propor- 
 tionably increased, and not unfrequently becomes 
 insuperable; and if the nature of the injury be un- 
 known, and the luxation consequently be left unre- 
 duced, the patient will remain a living memorial of 
 the surgeon's ignorance or inattention. ' What is 
 the matter with me V said a patient who came to 
 my house, placing himself before me and directing 
 4 
 
26 
 
 DtSLOCATlONS IN GENERAL. 
 
 my attention to his shoulder: ' Why, Sir, your arm 
 
 is dislocated.' — ' Do you'say so ! Mr told me 
 
 it was not out.' — ' How long lias it been dislocated?' 
 — ' Many weeks,' he replied. — 'Oh then you had 
 better not have any attempt at reduction made.' — 
 
 He said, ' Well, I will take care that Mr has 
 
 no more bones to set ; for 1 will expose his ignorance 
 in that part of the country in which I live.' — He 
 was a man of malevolent disposition, and carried his 
 threat into execution, to the great injury of the sur- 
 geon, who was also frequently reminded of his want 
 of skill, by meeting his former patient in his rounds; 
 and, what was worse, by hearing the following ob- 
 servation frequently repeated: ' Mr is a good 
 
 apothecary, but he knows nothing of surgery.' 
 
 In a dislocation of the os femoris, which still re- 
 mains unreduced, a consultation was held upon the 
 nature of the injury, and after a long consideration, 
 a report was made by one of the surgeons to this 
 effect : ' Well, Sir, thank God, we are all agreed 
 that there is no dislocation.' 
 
 Knowledge of anatomy necessary, — A considera- 
 ble share of anatomical knowledge is required to 
 detect the nature of these accidents, as well as 'to 
 suggest the proper means of reduction; and it is 
 much to be lamented, that students neglect to inform 
 themselves sufficiently of the structure of the joints. 
 They often dissect the muscles of a limb with great 
 neatness and minuteness, and then throw it away, 
 without any examination of the ligaments, cartilages, 
 or ends of the bones ; a knowledge of which, in a 
 surgical point of view, is of infinitely greater import- 
 ance ; and from such negligence arise the errors 
 into which those novices fall when they embark in 
 the practice of their profession; for the dislocations 
 of the hip, the elbow, and the shoulder, are scarcely 
 to be detected, but by those who possess accurate 
 
DISLOCATIONS IN GENERAL. 
 
 27 
 
 anatomical information. Even our hospital surgeons, 
 who have neglected their anatomy, mistake these 
 accidents; and I have known the pulleys applied to 
 an hospital patient, in a case of fracture of tlie neck 
 of the thigh-bone, which had been mistaken for a 
 dislocation, and the patient exposed, through the 
 surgeon's ignorance, to a violent and protracted ex- 
 tension. It is therefore proper, that the form of 
 the extremities of the bones, their mode of articula- 
 tion, the ligaments by which they are connected, 
 and the direction in which their most powerful mus- 
 cles act, should be well understood. 
 
 Difficulty from tumefaction. — Yet it would be an 
 injustice not to acknowledge, that the tumefaction 
 arising from extravasation of blood, and the tension 
 resulting from the inflammation, which frequently 
 ensues, will, in the early days of the accident, ren- 
 der it difficult for the best surgeon perfectly to as- 
 certain the exact extent of the injury ; and, there- 
 fore, conclusions drawn at a time when the muscles 
 are wasted, and the swelling is dispersed, when the 
 head of the bone can be distinctly felt, and the mo- 
 tions of the limb are found to be impeded in a par- 
 ticular direction, if they tend to the prejudice of 
 the individual who may have given a different opin- 
 ion under circumstances so much less favorable for 
 forming a correct conclusion, will be both illiberal 
 and unjust. 
 
 Symptoms. — The immediate effect of dislocation 
 is to change the form of the joint, and often to pro- 
 duce an alteration in the length of the limb; to oc- 
 casion the almost entire loss of motion in the part 
 after the muscles have had time to contract, and to 
 alter the axis of the limb. This altered position of 
 the limb has been attributed, by some surgeons, to 
 the influence of the remaining portion of ligament; 
 but, in every accident, the direction of the bone is 
 
28 
 
 DISLOCATIONS IN GENERAL. 
 
 too much the same to induce the beh'ef that it is 
 chiefly the effect of muscular influence; for the hga- 
 ment is extensivelj torn, in most cases scarcely any 
 portion of it remaining whole, particularly in disloca- 
 tions of the thigh, yet the position of the limb under 
 the different species of dislocation is found subject 
 to little variation. The form of the bone has, how- 
 ever, some influence on its future position: for in 
 fractures of the neck of the thigh-bone, the knee is 
 turned outwards; while in dislocations, it is turned 
 inwards; a difference which arises from the greater 
 capacity of the bone to roll upon its axis when the 
 neck is broken. 
 
 In the first moments, however, of the dislocation, 
 considerable motion remains, and the position is not 
 so determinately fixed as it afterwards becomes; for 
 1 have seen a man brought into Guy's Hospital, who, 
 but a few minutes before, had the thigh-bone dislo- 
 cated into the foramen ovale, and I was surprised to 
 find in a case otherwise so well marked, that a great 
 mobility of the bone still existed at the dislocated 
 part; but in less than three hours, it became firmly 
 fixed in its new situation by the permanent, or, as it 
 is called, tonic contraction of the muscles. 
 
 Length of limb altered; effusion of blood, — In 
 some dislocations the limb is rendered shorter, and 
 thus the muscles influenced by it are immediately 
 thrown into a state of relaxation; but if the limb 
 be elongated, the tension of the principal muscles 
 around the joint is extreme, and they are sometimes 
 stretched to laceration. Blood is often effused in 
 considerable quantity around the joint, which ren- 
 ders detection of the accident difficult; the swelling 
 being sometimes so considerable as to conceal entire- 
 ly the ends of the bones. This effusion is in pro- 
 portion to the size and number of the vessels lace- 
 rated. 
 
DISLOCATIONS IN GENERAL. 29 
 
 Eff'ects of pressure from the dislocated hone. — A 
 severe but obtuse pain arises from the pressure of 
 the head of the bone upon the muscles, and, in some 
 cases, this pain is rendered more acute from its 
 pressure upon a large nerve. From this cause also 
 is produced a paralysis of the parts below, instances 
 of which occur in dislocations of the shoulder. In 
 other cases, the bone presses upon important parts, 
 so" as to produce effects dangerous to life. I have 
 for many years mentioned, in my lectures, a case of 
 a dislocated clavicle, pressing upon the oesophagus, 
 so as to endanger life ; of which Mr Davie, of 
 Bungay, was so kind as to send me an account. J 
 shall give a more detailed history of this case here- 
 after. 
 
 Criteri07i of the accident by rotation. — In most 
 dislocations, the head of the bone may be readily 
 felt in its new situation ; and the rotation of the limb 
 best discovers the nature of the accident, as, by this 
 movement, the head of the bone is found to roll. 
 The natural prominences of the dislocated bone, in 
 some instances, either disappear, or become less con- 
 spicuous, — as the trochanter in luxations of the hip- 
 joint; but the contrary result ensues in dislocations 
 of the elbow; for there the olecranon is more than 
 usually prominent, and serves as the principal guide 
 for discovering the nature of the injury. 
 . Crepitus. — The more remote eft'ects of the acci- 
 dent are, that frequently a sensation of crepitus is 
 produced by the effusion of adhesive matter (fibrin) 
 into the joint* and bursas; the synovia becomes in- 
 spissated, and crackles under motion, a circumstance 
 of which every practitioner should be aware, as he 
 may be otherwise induced erroneously to suspect the 
 existence of fracture. 
 
 Infiammation and suppuration. — The degree of 
 inflammation which succeeds to these accidents is 
 
30 
 
 DISLOCATIONS IN GENERAL. 
 
 generally slight ; but in some cases it becomes so 
 considerable as to produce a tumefaction, which, 
 added to that resulting from extravasation of blood, 
 frequently renders the detection of the injury ex- 
 ceedingly difficult. Sometimes, after the reduction 
 of dislocations, suppuration ensues, and the patient 
 falls a victim to excessive discharge and irritation. 
 Mr Howden, who was one of our most intelligent 
 apprentices at Guy's Hospital, and was afterwards 
 surgeon in the army, related the following case: — 
 'A man had his thigh dislocated upwards and back- 
 wards on the ilium, which was soon after reduced; 
 the next dav a considerable swellino: was observed 
 on the part, which continued to increase, accompa- 
 nied with rigors, and in four days the patient died. 
 On dissection, the capsular ligaments, and ligamen- 
 tum teres, were found entirely torn away, and a con- 
 siderable quantity of pus extravasated in the sur- 
 rounding parts.' See JMinutes of the Physical So- 
 ciety^ Guyh Hospital, JYovember 12, 1791. — I attend- 
 ed the master of a ship, who had dislocated his 
 thigh upwards; an extension was made, apparently 
 with success; but in a few days a large abscess form- 
 ed on the thigh, which destroyed the patient ; for- 
 tunately, however, such a result is by no means com- 
 mon. 
 
 When, from length of time, or any other cause, 
 the reduction of the limb is rendered impracticable, 
 the bone forms for itself a new bed, and some de- 
 gree of motion is gradually recovered; although in 
 neglected dislocations of the lower extremity, the 
 patient is ever after lame ; and in those of the up- 
 per, the motion and power of the limb are very 
 much diminished. 
 
 j^ppearances on dissection ; ligaments, — On ex- 
 amination of the bodies of persons who die in con- 
 
DISLOCATIONS IN GENERAL. 
 
 31 
 
 sequence of dislocations arising from violence, the 
 head of the bone is found completely removed from 
 itssocket. Thecapsular ligament is torn transversely to 
 a great extent: the peculiar ligaments of joints, as the 
 ligamentum teres of the hip, are torn through; but 
 the tendon of the biceps, in dislocations of the os 
 humeri, remains uninjured, as far as I have been 
 able to ascertain by dissection ; although I would 
 by no means be understood to say that this is uni- 
 versally the case. 
 
 Tendons, — The tendons which cover the liga- 
 ments are also torn ; as the tendon of the subscap- 
 ularis muscle, in the dislocation in the axilla; and 
 according to the extent of this laceration, is the fa- 
 cility with which the accident recurs after reduction; 
 a circumstance frequently very difficult to obviate. 
 
 Muscles, — The muscles also are influenced by the 
 nature of the accident, being in some cases put upon 
 the stretch, even to laceration; as the pectineus and 
 abductor brevis, in dislocations of the thigh down- 
 ward ; "and large quantities of blood become extraj 
 vasated into the cellular membrane. 
 
 Dissections of old dislocations, 8rc, — The appear- 
 ance of joints which have long been dislocated, de- 
 pends not only on the length of time that has elap- 
 sed from the accident, but also on the structure upon 
 which the head of the dislocated bone is thrown ; 
 for if it be found embedded in muscle, its articular 
 cartilage remains, and a new capsular h'gament forms 
 around it, which does not adhere to its cartilaginous 
 surface. This ligament, in d slocations of the femur, 
 contains within it the head of the bone, with the 
 lacerated portion of the ligamentum teres united to 
 it. (See plate,) In these instances the bones them- 
 selves undergo little change. The capsular ligament 
 is formed from the surrounding cellular tissue ; which, 
 being pressed upon by the head of the bone, be- 
 
32 
 
 DISLOCATIONS IN GENERAL. 
 
 eomes inflamed, thiclcened, and condensed. By this 
 means a substance is produced somewhat less dense 
 than original ligament, but still possessing sufficient 
 firmness to bear considerable pressure, and to fur- 
 nish some degree of support. 
 
 Head of the bone resting oti another bone, Src, — But 
 if the head of the dislocated bone be placed on the 
 surface of another bone, or upon a thin muscle over 
 it, that muscle becomes absorbed, and the bone un- 
 dergoes a remarkable change ; thus it is found, if 
 the dislocation be not reduced, that both the ball 
 and the bone which receives it are changed in their 
 form. The pressure of the head of the bone pro- 
 duces absorption of the periosteum, and of the ar- 
 ticular cartilaginous surface of the head of the bone; 
 a cmooth hollow surface is formed, and the ball be- 
 comes altered in its shape to adapt it to its new sur- 
 face ; and whilst this absorption proceeds upon the 
 part on which the head of the bone rests, an ossific 
 deposit takes place around it from the periosteum, 
 which is there irritated, but not absorbed. ' 'By the 
 deposition of this bony matter between the perios- 
 teum and the original bone, a deep cup is formed to re- 
 ceive the head of the bone ; and perhaps no instan- 
 ces can be adduced which more strongly mark the 
 powers of nature in changing the form of parts to 
 accommodate them to new circumstances, than these 
 effects of dislocation. (^See plates 2, 3, and 4.) 
 
 The new cup which is thus formed, sometimes so 
 completely surrounds the neck of the bone, as to 
 prevent its being separated without fracture (see 
 plate) ; and the socket is smoothed upon its internal 
 surface, so as to leave no projecting parts which can 
 interrupt the motion of the bone in its new situation. 
 
 The muscles losing their action, become diminish- 
 ed in bulk, and reduced in their length, in proportion 
 to the displacement of the bone towards their ori- 
 
DISLOCATIONS IN GENERAL. 
 
 33 
 
 gin; and if the dislocation has been long unreduced, 
 they lose their flexibilitj, and tear rather than yield 
 to extension. 
 
 Dislocations from relaxation. — Although disloca- 
 tions happening from violence are accompanied by 
 laceration of the ligaments of the joint, yet they may 
 occur from relaxation of the ligaments only, of which 
 the following case is an example. 
 
 Case, — A girl came to my house who had the 
 power of throwing her patellae from the surfaces of 
 the condyles of the os femoris. Her knees were 
 bent considerably inwards; and when the rectus 
 muscle acted upon the patella, it was drawn from 
 the thigh-bone into a line with the tubercle of the 
 tibia, and laid nearly flat upon the side of the ex- 
 ternal condyle of the femur. She came from the 
 south of Europe, where she had been brought up as 
 a dancing girl from her earliest years, gaining her 
 daily bread, as we see children in the streets of Lon- 
 don, by dancing upon elevated platforms; and she 
 imputed to these continued and early exertions the 
 weakness under which she laboured. 
 
 Dislocation from accumulation of Synovia. — A si- 
 milar relaxation of ligaments, is also produced by an 
 accumulation of synovia in joints. Mr Shillito, sur- 
 geon at Hertford, requested me to see a female do- 
 mestic belonging to a family in ray neighbourhood, 
 who had a great enlargement of the knee-joint from 
 an inordinate secretion of synovia; and when this 
 became absorbed, the ligaments remained so much 
 relaxed, that the efforts of the muscles in walking 
 dislocated the patella outwards. I ordered her into 
 the hospital, that the students might observe this 
 case, of which the following is an account. 
 5 
 
34 
 
 DISLOCATIONS IN GENERAL. 
 
 Case ; dislocation from relaxation, — Ann Parish 
 was admitted into Guy's Hospital in the autumn of 
 1810, for a dislocation of the left patella from re- 
 laxation of the ligaments. She had for four years 
 previously a large accumulation of synovia in that 
 knee, causing some pain, and much inconvenience in 
 walking. Blisters had been applied without much 
 effect, and other means tried for four montlis before 
 her admission. When the knee had acquired con- 
 siderable size, the swelling spontaneously subsided, 
 and she then first discovered that the patella be- 
 came dislocated when she extended the limb. She 
 suffered some pain whenever this happened, and she 
 lost the power of the limb in walking, so that she 
 fell when the patella slipped from its place, which 
 it did whenever she attempted to walk without a 
 bandage. Tlie patella was placed upon the external 
 condyle of the os femoris, when thrown from its na- 
 tural situation, to which it did not return without 
 considerable pressure of the hand. In other re- 
 spects her health was good. Straps of adhesive 
 plaster were ordered to be applied, and a roller to 
 to be worn, which succeeded in preventing the dis- 
 location so long as they were used, but the bone 
 again slipped from its place whenever they were 
 removed. \ knee-cap, made to lace over the joint, 
 was ordered for her.^ 
 
 * A.very interesting case of spontaneous dislocation from re- 
 laxation of the ligaments is related by Dr Osborne of Cork, in 
 the Edin. Med. and Surg. Journal for Oct. 1810. The patient 
 when about to embark with his regiment was suddenly seized 
 with so violent a pain in his side as to disable him entirely, and 
 the staff physicians were of opinion that his liver was badly dis- 
 eased, fie was sent to his father in Ireland, where he was 
 seen by Dr Osborne, who found him in a state of great emacia- 
 tion and debility; the liver being sensibly enlarged, and feeling 
 tough and doughy. His urine was scanty and deposited a sedi- 
 ment, between red and white, in colour. ' His right leg was 
 
DISLOCATIONS IN GENERAL. 
 
 35 
 
 Paralysis. — Dislocation sometimes arises from a 
 loss of muscular power ; for when the muscles are 
 kept long and forcibly extended, their tone becomes 
 destroyed ; or if, from a paralytic affection, they 
 lose their action, a bone may be dislocated easily, 
 but is as readily replaced: of the first of these two 
 causes, the following case is an illustration. 
 
 Case, — Mr. , a gentleman now residing in 
 
 the City, passed some of his early life in the East 
 Indies ; it happened, that, as a junior officer on board 
 his ship, he had been placed under the orders of 
 one of the mates when the captain was on shore, 
 and for some trifling offence this young gentleman 
 was punished in the following manner: — His foot 
 was placed upon a small projection on the deck, and 
 his arm was lashed tightly towards the yard of the 
 ship, and thus kept extended for an hour. When 
 he returned to England, he had the power of rea- 
 dily throwing that arm from its socket, merely by 
 raising it towards his head ; but a very slight ex- 
 tension reduced it ; the muscles were also wasted, 
 as in a case of paralysis. A prosecution was com- 
 
 three inches shorter than the left^ which on inspection was found 
 to be in consequence of the head of the thigh bone having slip- 
 ped out of the acetabulum, and of this he could give no account, 
 unless it had happened when on board of ship, whilst changing 
 from hammock to hammock, but that he never had any sense of 
 uneasiness nor pain^ either then or at any other time.' 
 
 In six weeks, by the aid of light nourishing diet the general 
 health of the patient was made firm and hale, though the dislo- 
 cation upwards still continued. He took Cinchona during a 
 month longer and the dislocated bone was entirely restored to 
 its place. Had the ligaments been ruptured the bone would 
 have remained out, but as the condition was produced by the 
 relaxed state of the ligaments following constitutional debility, 
 as soon as the strength of the system was renewed, the liga- 
 ments were restored to their natural condition, and by their im- 
 perceptible contraction the head of the thigh-bone was return- 
 ed to the socket. J. D. G. 
 
36 
 
 DISLOCATIONS IN GENERAL. 
 
 nienced for this act of cruelty, and I was subpoenaed 
 to give evidence; but the petty tyrant chose to pay 
 the forl'eit of his misconduct prior to the commence- 
 ment of the trial. 
 
 I have also seen in a dislocation of the thumb, tlie 
 first phalanx capable of being thrown from the os 
 metacarpi pollicis, merely by the action of the mus- 
 cles, from a relaxed state of the ligament. 
 
 Of the influence of paralysis, the following case is 
 an example. 
 
 Case, — I was desired to see a young gentleman, 
 who had one of those paralytic affections in his 
 right side which frequently arise during dentition. 
 The muscles of the shoulder were wasted ; and he 
 had the power of throwing his os humeri over the 
 posterior edge of the glenoid cavity of the scapula, 
 from whence it was easily to be reduced. 
 
 In these cases, particularly in the latter, no lace- 
 ration of the ligaments could have occurred; and 
 they show the influence of the muscles in preventing 
 dislocation from violence, and in impeding its re- 
 duction. 
 
 Dislocation from ulceration, — Dislocations arise 
 from ulceration, by which the ligaments are detach- 
 ed, and the bones become altered in their form. We 
 frequently find this state of parts in the hip-joint; 
 the ligaments ulcerated, the edge of the acetabulum 
 absorbed, the head of the thigh-bone changed both 
 in its magnitude and figure, escaping from the ace- 
 tabulum upon the ilium, and there lorming for itself 
 a new socket. There is in the anatomical collection 
 at St Thomas's Hospital, a pr'eparationof the knee 
 dislocated by ulceration, anchylosed at right angles 
 with the femur, and the tibia turned directly for- 
 wards. A boy, in Guy's Hospital, had his knee dis- 
 
DISLOCATIONS IN GENERAL. 
 
 37 
 
 located by ulceration, with the tibia thrown on the 
 inner side of the external condyle of the os ferno- 
 ris; and a girl, in the same hosjjital, had the knee 
 dislocated by ulceration, the head of the tibia being 
 placed behind the condyles of the os femoris.* 
 
 Fracture and dislocation. — Dislocations are some- 
 times accompanied with fracture. At the ancle- 
 joint, it rarely happens that dislocation occurs with- 
 out a fracture of the fibula; and at the hip-joint, the 
 acetabulum is occasionally broken: — of this an ex- 
 ample will be seen in the following case. 
 
 Case; dislocation ivith organic lesion. — Thomas 
 Steers was admitted into Guy's Hospital, on the 28th 
 of October, 1805, with a dislocation of the os femo- 
 ris into the ischlatic notch. The dislocation was re- 
 duced by a very slight extension, compared with that 
 which is commonly required: this was imputed to 
 the muscular relaxation caused by nausea, the patient 
 having vomited at the time of his admission. 
 But he soon complained of severe pain, extending 
 over his abdomen, and he died on the day following 
 his admission. Upon inspecting his body, the intes- 
 tlnum jejunum was found ruptured; and upon exam- 
 ination of the hip-joint, a portion of the edge of the 
 acetabulum was discovered to be broken off. 
 
 Dislocations of the os humeri also are sometimes 
 accompanied with fracture of the head of that bone; 
 of which there is a spocimen in the Museum of St 
 Thomas's Hospital. The coronoid process is occa- - 
 
 * See Mr Brodie's very interesting work on the diseases of the 
 joints. Tiie same work is reprinted in volume 5tii, of the Ec- 
 lectic Repertory, of Philadelphia, page 168. J. D. G. 
 
38 
 
 DISLOCATIONS IN GENERAL. 
 
 sionally broken in dislocations of the ulna, producing 
 a species of luxation, which does not permit the bone 
 to be afterwards preserved in its natural situation. 
 
 Dislocation and fracture. — When a bone is both 
 broken and dislocated, it is proper to endeavour to 
 reduce the dislocation without loss of time, taking 
 care that the fractured part be strongly bandaged in 
 splints, to prevent any injury to the muscles; for if 
 this be not done at first, it cannot be afterwards ef- 
 fected without danger of re-producing the fracture. 
 
 If a compound fracture of the leg, and a disloca- 
 tion of the shoulder happen in an individual at the 
 same time, the reduction of the arm should be im- 
 mediately undertaken, after the fractured limb has 
 
 been secured in splints. The Rev. Mr H , 
 
 from the accident of being thrown from his chaise, 
 had a compound fracture of the leg, and a disloca- 
 tion of the shoulder forwards. The dislocation was 
 not at first observed, nor was its reduction attempted 
 till a fortnight had elapsed. The trial proved un- 
 successful, as, from a dread of fever and injury to the 
 leg, sufficient extension could not be used. 
 
 The accidents which have been called dislocations 
 of the spine, are generally fractures of the vertebrae, 
 followed by displacement of the bones, but not of the 
 intervertebral substance; even the articulatory pro- 
 cesses are broken, as well as the bodies of the ver- 
 tebrae, so that they are not triie dislocations of the 
 spine, excepting those of the upper cervical verte- 
 brae, dislocations of which are said to have occasion- 
 ally occurred. The injuries of the spine, which pro- 
 duce paralysis of the lower extremities, arise from 
 fractured portions of the bodies of the vertebrae, 
 pressing upon, and sometimes lacerating the medulla 
 spinalis. 
 
 Compound dislocations. — In compound dislocation^, 
 
DISLOCATIONS IN GENERAL. 
 
 39 
 
 not only the articulatory surfaces of the bone are 
 displaced, but the cavity of the joint is laid open by 
 a division of the skin and the capsular ligament. 
 The immediate effect of compound dislocation is to 
 occasion the extravasation of blood into the joint, 
 and to allow the escape of the synovia. 
 
 Danger. — Compound dislocations are attended 
 with great danger, and for the following reason: — 
 When a joint is opened, inflammation of the la- 
 cerated ligaments and synovial surface speedily suc- 
 ceeds; in a few hours suppuration begins, and granu- 
 lations arise from the surface of the secreting mem- 
 brane; which, being of the mucous kind, is more 
 disposed to the suppurative, than to the adhesive 
 inflammation. But tlie same process does not im- 
 mediately -ensue upon the ex-trcmity of the bone, 
 because it is covered by the articular cartilage. 
 This cartilage, before the cavity fills with granula- 
 tions, becomes absorbed, by an ulcerative process 
 instituted on the ends of the bones, but sometimes 
 beginning from the synovial surface. The bone in- 
 flames, the cartilage becomes ulcerated, numerous 
 abscesses are formed in different parts of the joint, 
 and at length granulations spring from the extremi- 
 ties of the bones deprived of their cartilages, and 
 fill up the cavity; generally these granulations be- 
 come ossified, and anchylosis succeeds ; but some- 
 times they remain of a softer texture, and some de- 
 gree of motion in the joint is gradually regained. 
 
 This process of filling up joints requires great 
 general, as w^ell as local efforts; a high degree of 
 irritation is produced ; and if the constitution be 
 weak, the patient, to preserve his life, is sometimes 
 obliged to submit to amputation. 
 
 Injury to muscles^ blood-vessels^ etc. — In addition to 
 the above circumstances, the violence necessarily in- 
 flicted on the parts, in compound dislocations, the in- 
 
40 
 
 DISLOCATIONS IN GENERAL. 
 
 jury of the muscles and tendons, and the laceration 
 of blood-vessels, necessarily lead to more important 
 and dangerous consequences than those which follow 
 simple dislocations. 
 
 Treatment, — With respect to the treatment of 
 compound dislocations, I propose to reserve my re- 
 marks for that part of the work which relates to. 
 injuries of the ankle, where such observations will 
 be required, and whore they will be better under- 
 stood ; and thus a repetition, superfluous, and per- 
 haps irksome, will be avoided. I shall just remark, 
 that some joints are more liable to compound dis- 
 locations than others. The hip-joint is scarcely ever 
 so dislocated ; of the shoulder I have known two 
 instances; but the elbow, wrist, ankle, and fingers, 
 are frequently the seats of this accident ; and I have 
 seen an instance of it at the knee. 
 
 Some joints more easily dislocated than others. — In 
 consequence of their different formation, we find 
 that in some joints, dislocation is much more frequent 
 than in others. Those which have naturally exten- 
 sive motions are easily luxated, and hence the dislo- 
 cation of the OS humeri occurs much more frequent 
 ly than that of any other bone; and having once oc- 
 curred, it happens again easily in the mere natural 
 elevation of the arm. It is wisely ordained, that in 
 those parts to which extensive motion is assigned, 
 and for which great strength is required, there is a 
 multiplicity of joints. Thus, in the spine, in which 
 great strength is necessary to protect the spinal mar- 
 row, numerous joints are formed, and the motion 
 between any two of the bones is so small, that dis- 
 locations, except between the first and second verte- 
 brae, rarely occur, although the bones are often dis- 
 placed by fracture. 
 
 The carpus and the tarsus are constituted on a 
 similar principle ; they allow of considerable motion, 
 
DISLOCATIONS IN GENERAL. 
 
 41 
 
 yet maintain great strength of union. For if the 
 motion between two bones, as in the spine, be mul- 
 tiphed by twenty-four, and that at the carpus by 
 eight, the result will show that great latitude of 
 motion is given, and the strength of the part pre- 
 served ; whilst, if the spine had been formed of a 
 single joint, dislocations might have easily happened, 
 and death from this cause might have been a fre- 
 quent consequence. 
 
 Partial dislocations, — Dislocations are not always 
 complete, since bones are sometimes but partially 
 thrown from the articulatory surface on which they 
 rested ; this species of dislocation now and then oc- 
 curs at the ankle-joint. An ankle, afterwards given 
 to the Museum at St Thomas's, was dissected at 
 Guy's Hospital, by Mr Tyrrell, and was found par- 
 tially dislocated ; the end of the tibia still rested in 
 part upon the astragalus, but a larger portion of its 
 surface rested on the os naviculare ; and the tibia, 
 altered by this change of place, had formed two 
 new articulatory surfaces, with their faces turned in 
 opposite directions towards the two tarsal bones. 
 (See Plate.) The dislocation had not been reduced. 
 The knee-joint is, I believe, rarely dislocated later- 
 ally in any other way; for its extensive articular sur- 
 faces almost preclude the possibility of complete dis- 
 placement. The OS humeri sometimes rests upon 
 the edge of the glenoid cavity, and readily returns 
 into its socket; and the elbow-joint is dislocated par- 
 tially, both in relation to the ulna and the radius. 
 
 The lower jaw is also sometimes partially dislo- 
 cated, but in a different manner; one of the joints 
 being luxated, and the other remaining in its place. 
 
 Cause, — Dislocations are generally occasioned by 
 violence, and the displacing force usually takes effect 
 whilst the bone is in an oblique direction to its sock- 
 et ; but the muscles must necessarily have been in a 
 6 
 
42 
 
 DISLOCATIONS IN GENERAL. 
 
 great degree unprepared for resistance, otherwise 
 the greatest force would hardly have produced the 
 effect: when they are unprepared, the injury will 
 often ensue from very slight accidents. A fall, in 
 walking, will sometimes dislocate the hip-joint, when 
 the muscles have been prepared for a different exer- 
 tion. 
 
 While dwelling on this subject in my lectures, I 
 have usually adverted to the execution of, Damien, 
 as illustrative of this position. 
 
 Resistance of muscles. — Damien was executed for 
 the attempt to murder Louis XV. Four young 
 horses were attached to his legs and arms, and were 
 forced to make repeated efforts, to tear his limbs 
 from his body, but could not effect this purpose ; and 
 after fifty minutes, the executioners were obliged to 
 cut the muscles and ligaments to effect his dismem- 
 berment ; or, in homelier phrase, to hew him limb 
 from limb. 
 
 The following is the French account of this exe- 
 cution. 
 
 ' II arriva a la place de Greve a trois heures 
 et un quart, regardant d'un ceil sec et ferme le lieuy 
 et les instrumens de son supplice. On lui brula 
 d'abord la main droite ; ensuite on le tenailla, et on 
 versa, sur ses plaies, de I'huile, du plomb fondu, et 
 de la poix-resine. On proceda ensuite a I'ecartelle- 
 ment. Les quatre chevaux firent pendant cinquante 
 minutes des efforts inutiles pour demembrer ce 
 monstre. Au bout de ce terns la, Damien, etant 
 encore plain de vie, les bourreaux lui couperent avec 
 de bistouris, les chairs et les jointures nerveuses des 
 cuisses, et des bras; ce qu'on avoit ete oblige de faire 
 en 1610 pour Ravaillac. II respiroit encore apres 
 que les cuisses furent coupees, et il ne rendit I'ame 
 que pendant qu'on lui coupoit les bras. Son supplice 
 depuis I'instant qu'il fut mis sur I'echafaud, jusqu'au 
 
DISLOCATIONS IN GENERAL. 
 
 43 
 
 moment de sa mort, dura pres d'une heure et demie. 
 II conserva toute sa connoissance, et releva sa tete 
 sept ou huit fois, pour regarder les chevaux, et ses 
 membres tenailles et brules. Au milieu des tourmens 
 les plus affreux de la question il avoit laisse echapper 
 des plaisanteries.' — Dictionnaire Historique* 
 
 Dislocations rare in old persons. — Old persons are 
 much less liable to dislocations than those of middle 
 life, because the extremities of bones in advanced 
 age are often so soft as to break under the force 
 applied, rather than quit their natural situations. 
 Persons of lax fibre are prone to dislocation, because 
 their ligaments easily tear, and their muscles pos- 
 sess little power of resistance. From these circum- 
 stances old people would be exposed to frequent 
 dislocations, but for the softened state of the ex- 
 tremities of their bones. 
 
 Dislocations rare in the young. — Young persons 
 are also very rarely the subjects of dislocations from 
 
 * At a quarter after three, P. M., Damien arrived at the place 
 of execution, viewing with a dry and steady eye the situation 
 and instruments of his punishment. First his right hand was 
 burned ; then he was torn with pincers, and boiling oil, melted 
 lead and pitch were poured on the wounds. The separation of 
 the body ensued. During fifty minutes, the four horses made 
 useless efforts to dismemljer this monster. At the end of this 
 time, while Damien was quite alive, the executioners cut with 
 knives the flesh and ligaments of the thighs and arms, as they 
 were obliged to do in the case of Ravaillac in 16 JO. He breathed 
 after his thighs were cut and did not expire until they were cut- 
 ting his arms. His execution from the time he was placed on 
 the scaffold till the moment of his death, lasted nearly an hour 
 and a half. He continued perfectly sensible, and raised his head 
 seven or eight times to look at the horses and his torn and burnt 
 limbs. In the midst of the most frightful agonies of the torture 
 he had uttered pleasantries. 
 
 It is scarcely possible for us to conceive of ^ monsters^ more 
 horrid than the executioners and spectators capable of perpetrat- 
 ing and witnessing such a punishment y"* unless we think of the 
 judges by whom it was decreed. J. D. G. 
 
44 
 
 DISLOCATIONS IN GENERAL. 
 
 violence ; but now and then such accidents do occur; 
 and I have described an instance of them in a child 
 at seven years of age. It generally happens that 
 their bones break, or their epiphyses give way, rath- 
 er than that the parts suffer displacement. I read 
 of dislocations of the hip in children, but their his- 
 tory is that of diseases of the hip-joint, in which 
 the dislocation has arisen from ulceration. A child 
 was brought to me from one of the counties north 
 of London, for whom repeated extensions had been 
 made by one cf those people called hone-setters, — 
 but who ought rather to be called dtslocators, — 
 for a supposed dislocation of the hip-joint. Upon 
 examination, I found the case to be that disease of 
 the hip which is so common in children ; and for 
 this only, was a child wantonly exposed to a most 
 painful extension. That in this enlightened country, 
 men, without education, should be suffered with im- 
 punity to degrade a most useful profession, and tor- 
 ture those who have the folly, or the simplicity to 
 apply to them, is a disgrace to our laws, that calls 
 loudly for prevention. 
 
 Elbow-joint dislocations. — Dislocations of the el- 
 bow-joint in children are said to be of frequent oc- 
 currence. Surgeons have been heard to say, ' I have 
 a child under my care with luxation of its elbow, 
 and I can easily return the bone into its place, but it 
 directly dislocates again.' Such a case is, in reality, 
 an oblique fracture of the condyles of the os hume- 
 ri, which produces the appearance of dislocation, by 
 allowing the radius and ulna, or the ulna alone, to 
 be drawn back with the fractured condyle, so as to 
 produce considerable projection at the posterior part 
 of the joint. 
 
DISLOCATIONS IN GENERAL. 
 
 45 
 
 TREATMENT. 
 
 Reduction^ 8{c, — The reduction of dislocations is 
 often difficult ; and in some of the joints, the form 
 of the bone may occasion impediments. Thus, when 
 the socket is surrounded by a lip of bone, as in the 
 hip-joint, the head of the bone, during the act of 
 reduction, stops at this projection, and requires to 
 be lifted over it ; another difficulty occurs when the 
 head of the bone is much larger than its cervix, as 
 for example, in the dislocation of the head of the 
 radius; but still these causes are slight in compari- 
 son with others which we have to detail. 
 
 Capsular ligaments, — The capsular ligaments are 
 by some supposed to resist reduction ; but those 
 who entertain this'opinion must forget their inelas- 
 tic structure, and cannot have had opportunities of 
 witnessing by dissection, the extensive laceration 
 which they sustain in dislocations from violence. 
 The capsular ligaments, in truth, possess but little 
 strength either to prevent dislocation, or to resist 
 the means of reduction; and if the tendons with 
 which they are covered,^and the peculiar ligaments 
 of the joints did not exist, dislocation must be of 
 very frequent occurrence. 
 
 Tendons ; peculiar ligaments, — The joint of the 
 shoulder, and those of the knee and elbow, are 
 strongly protected by tendons ; the shoulder by those 
 of the spinati, sub-scapularis and teres-minor mus- 
 cles ; the elbow by the triceps and brachialis ; the 
 knee by the tendinous expansion of the vasti : but 
 still some ligaments resist dislocations ; these, how- 
 ever, are the peculiar, not the capsular ligaments. 
 The wrist and the elbow have their appropriate 
 lateral ligaments to give additional strength to these 
 joints. The shoulder, instead of a peculiar ligament, 
 
46 
 
 DISLOCATIONS IN GENERAL. 
 
 has the tendon of the biceps received into it, which 
 lessens the tendency to dislocation forwards ; the 
 ligamentum teres of the hip-joint prevents facihtjof 
 dislocation downwards ; the knee has its lateral and 
 crucial ligaments; and the ankle, exposed as it is to 
 the most severe injuries, is provided with its deltoid 
 and fibular tarsal ligaments, of very extraordinary 
 strength, to prevent dislocation. The bones of this 
 joint often break rather than their ligaments give 
 way; however, in many of the joints, as these liga- 
 ments are torn, they afford no resistance to the re- 
 duction of dislocations, as in the hip, elbow, and 
 wrist; but if one of them remain, it produces dif- 
 ficulty in the reduction, as I have seen in the knee- 
 joint. 
 
 Muscles. — The difficulty in reducing dislocations 
 arises principally from the resistance which the mus- 
 cles present by their contraction, and which is pro- 
 portioned to the length of time which has elapsed 
 from the injury; it is therefore desirable that the 
 attempt at reduction should not be long delayed. 
 
 The common actions of the muscles are volun- 
 tary or involuntary, but they have a power of con- 
 traction independent of either state. 
 
 Fatigue of muscles. — A muscle, when excited to 
 action by volition, soon becomes fatigued, and re- 
 quires rest. The arm can be extended only for a 
 few minutes, at right angles with the body, before 
 it feels a fatigue which requires a suspension of ac- 
 tion ; and, indeed, the same law governs involuntary 
 action, as the heart has its contraction and relaxation. 
 
 Permanent contraction. — But when a muscle is 
 divided, its parts contract; or when the antagonist 
 muscle is cut, the undivided muscle draws the parts 
 into which it is inserted, into a fixed situation. Thus, 
 if the biceps muscle be divided, the triceps keeps 
 the arm constantly extended ; if the muscles on one 
 
DISLOCATIONS IN GENERAL. 
 
 47 
 
 side of the face be paralytic, the opposing muscles 
 draw the face to their side. This contraction is 
 not succeeded by fatigue or relaxation, but will con- 
 tinue an indefinite time, even until the structure of 
 the muscle becomes changed ; and its contraction 
 increases from the first occurrence of the accident. 
 Thus it is, that when a bone is dislocated, the mus- 
 cles draw it as far from the joint as the surrounding 
 parts will allow, and there retain it by their con- 
 traction. It is this resistance from muscles, aided 
 by their spontaneous contraction, which the surgeon 
 is required to counteract, [f an extension be made 
 almost immediately after a dislocation has happen- 
 ed, the resistance produced by the muscles is easily 
 overcome : but if the operation be postponed for a 
 few days only, the utmust difficulty occurs in its ac- 
 complishment. 
 
 Vis tonica of muscles. — Mr Forster, son of the 
 surgeon of Guy's Hospital, informed me, that in a 
 fatal case of fracture of the thigh-bone, which be 
 had an opportunity of dissecting before its union^ 
 the ends of the bones overlapped, and the muscles 
 had acquired a contraction so rigid, that he could not, 
 even in the dead body, bring the bones to their nat- 
 ural position, after employing all the force he was 
 capable of exerting. It is this state of muscles in 
 dislocations, which gives rise to the difficulty in their 
 reduction, and which, even in the dead body, is still 
 capable of opposing a very considerable resistance.* 
 
 * We must remember, under such circumstances, that the 
 nature of the fibre has been very materially altered, and instead 
 of true muscular texture has become a dense fibrous matter more 
 resembling ligament than any other substance. Corresponding 
 to this alteration is the change subsequently mentioned, where 
 the socket for the bone is not only filled up by the deposition of 
 ' adhesive matter,' but the proper figure of the socket is de- 
 stroyed by absorption of the bony edges. J. D. G. 
 
48 
 
 DISLOCATIONS IN GENERAL. 
 
 That the muscles are the chief cause of resistance, 
 is strongly evinced by those cases in which the dislo- 
 cation is accompanied by injury to any vital organ, 
 and when the power of muscular action is diminish- 
 ed; for it is then found, that a very slight force is 
 sufficient to return the bone to its situation. Thus, 
 in the case already mentioned, of the man who had 
 an injury to his jejunum, and a dislocation of his hip, 
 the bone was restored to its place with little diffi- 
 culty. 
 
 Other difficulties, — When a dislocation has long 
 existed, difficulties arise from three other circum- 
 stances. The extremity of the bone contracts adhe- 
 sion to the surrounding parts, so that even when in 
 dissection the muscles are removed, the bone cannot 
 be reduced. In this state I found the head of a 
 radius, which had been long dislocated, resting upon 
 the external condyle of the os humeri, and which is 
 preserved in the collection at St Thomas's Hospital 
 (see plate) ; and in a similar state 1 have seen the os 
 humeri when dislocated. The socket is also some- 
 times so filled with adhesive matter, that if the bone 
 were reduced, it could not remain in its original sit- 
 uation, and the original cavity is in part filled with 
 ossific matter, so as to render it incapable of receiv- 
 ing the head of the bone. Lastly: a new bony 
 socket is sometimes formed, in which the head of the 
 bone is so completely confined, that nothing but its 
 fracture will allow it to escape from its new situation. 
 (See plate.) 
 
 Means of reduction. — The means to be employed 
 for the reduction of dislocations, are both constitu- 
 tional and mechanical ; force alone is in general ob- 
 jectionable, since it would be required in so great a 
 degree as to occasion violence and injury ; and it will 
 in the sequel be shown, that the most powerful me- 
 chanical means fail when unaided by constitutional 
 
DISLOCATIONS IN GENERAL. 
 
 49 
 
 remedies. The power and direction of the larger 
 muscles are, in the first instance, to be duly appre- 
 ciated, as these form the principal causes of resist- 
 ance. 
 
 Constitution ah — The constitutional expedients ap- 
 plicable for the purpose of reduction are those 
 which produce a tendency to syncope, and this ne- 
 cessary state may be best induced by one or other 
 of the following means, viz : bleeding, warm-bath 
 and nausea. Of these remedies, I consider bleeding 
 the most powerful ; and, that the effect may be pro- 
 duced as quickly as pos^^ible, the blood should be 
 drawn from a large orifice, and the patient kept in 
 the erect position, for by this mode oi depletion, 
 syncope is produced before too large a quantity of 
 blood is lost. . However, the activity of this practice 
 must be regulated by the constitution of the patient; 
 if he be young, athletic, and muscular, the quantity 
 removed should be considerable, and the method of 
 taking it away should be that which 1 have de- 
 scribed. 
 
 Secondly; in those cases in which the warm-bath 
 may be thought preferable, or where it may be con- 
 sidered improper to continue the bleeding, the bath 
 should be employed at the temperature of J00° to 
 110°; and, and as the object is the same as in bleed- 
 ing, the person should be kept in the bath at the 
 same heat till the fainting effect is produced, when 
 he should be immediately placed in a chair, wrapped 
 in a blanket, and the mechanical means employed 
 which I shall hereafter particularly describe. 
 
 Of late years, I have practised a third mode of 
 lowering the action of the musclqs, by exhibiting 
 nauseating doses of tartarized antimony; but as its # 
 action is uncertain, frequently producing vomiting, 
 which is unnecessary, I rather recommend its appli- 
 cation merely to such extent as to keep up the state 
 7 
 
50 
 
 DISLOCATIONS IN GENERAL. 
 
 of syncope already produced by the two preceding 
 means ; this its nauseating tendency will most readily 
 effect, and so powerfully overcome the tone of the 
 muscles, that dislocations may be reduced with much 
 less effort, and at a much more distant period from 
 the accident, by the&e means, than in any other way.* 
 The two cases related in the following pages, one 
 from Mr Norwood, surgeon, at Hertford, and the 
 other from Mr Thomas, apothecary to St Luke's 
 Hospital, will illustrate the efficacy of the treatment 
 recommended. By the combination of bleeding, the 
 warm-bath, and nauseatin§^-doses of tartarised anti- 
 mony, two dislocations w^ere reduced at a more dis- 
 tant period from the accident than I have ever 
 known in any other example. One of these cases 
 occurred at Guy's, and the other at St Thomas's 
 Hospital, at the time when these gentlemen were 
 officiating as dressers. (^See cases of dislocation on the 
 ilium.) 
 
 Opium. — The effect of opium I have never tried, 
 but it would probably be useful in a large dose, from 
 its power of diminishing muscular and nervous in- 
 fluence.t 
 
 Mechanical means. — The reduction of the bone 
 is to be attempted, after lessening the power of the 
 muscles, by fixing one bone, and drawing the other 
 towards its socket. It is now generally agreed 
 among the most eminent surgeons, that force should 
 
 * Mr Burford Wilmer proposed the use of tartar emetic in the 
 following manner, in the London Medical and Physical Journal 
 for 10 10. Having every thing in readiness to effect the reduction, 
 the medicine was administered, and as soon as the nausea and 
 faintness were fairly evident, the reduction was begun, and fin- 
 ished with comparative ease while this state continued. 
 
 J. D. a 
 
 t The administration of spirits until full intoxication was pro- 
 duced, has several times been resorted to in this country. T?he 
 practice cannot be generally recommended. J. D. G. 
 
DISLOCATIONS IN GENERAL. 
 
 51 
 
 be only gradually applied ; for violence is as likely 
 to tear sound parts, as to reduce those which are 
 luxated; and it is apt to excite all the powers of 
 resistance to oppose the efforts of the surgeon. 
 Hence it becomes his duty to produce, gradually, 
 that state of fatigue and relaxation which is sure to 
 follow continued extension, and not to attempt at 
 once to overpower the action of the muscles. 
 
 One great cause of failure in the attempt to re- 
 duce dislocations, ai'ises from insufficient attention to 
 the fixation of that bone in which the socket is plac- 
 ed. For example: in attempting to reduce a dis- 
 location of the shoulder, if the scapula be not fixed, 
 or if one person pull at the scapula and two at the 
 arm, the scapula will be necessarily drawn with the 
 OS humeri, and the extension will be very imperfectly 
 made; the one bone, therefore, must be firmly fixed, 
 or drawn in the opposite direction, while the other 
 is extended. 
 
 Compound 'pulley. — The force required may be 
 applied either by the exertion of assistants, or by a 
 compound pulley; but the object is to extend the 
 muscles by gradual, regular, and continued efforts; 
 in cases of difficulty recourse should always be had 
 to the pulley; its effect may be gentle, continued, 
 and directed by the surgeon's mind; but when assist- 
 ants are employed, their exertions are sudden, vio- 
 lent, and often ill directed ; and the force is more 
 likely to produce laceration of parts, than to restore 
 the bone to its situation. Their effiarts are also fre- 
 quently uncomblned, and their muscles as necessarily 
 become fatigued as those of the patient, whose resist- 
 ance they are employed to subdue. 
 
 In dislocation of the hip-joint, pulleys should al- 
 ways be employed; and in those dislocations of the 
 shoulder which have long remained unreduced, they 
 should also be resorted to. I do not mean to doubt 
 
 OF ILL IJO. 
 
52 
 
 DISLOCATIONS IN GENERAL. 
 
 the possibility of reducing dislocations of the hip by 
 the aid of men only, but to point out the inferiority 
 of this mode to the mechanical means. The em- 
 ployment of pulleys in dislocations, is not a modern 
 practice : Ambrose Pare frequently had recourse to 
 them, and good practical surgeons have used them 
 since his time; — most writers on surgery have also 
 mentioned their use, but they have not duly appre- 
 ciated them. Mr Cline, whose professional judgment 
 every one must acknowledge, always strongly re- 
 commended them. 
 
 Relaxation of the stronger muscles. — During the 
 attempt to reduce luxations, the surgeon should 
 endeavour to obtain a relaxation of the stronger 
 opposing muscles. The limb should therefore be 
 kept in a position between flexion and extension, as 
 nearly as that medium can be obtained. Who has 
 not seen, in the attempt to reduce a compound frac- 
 ture in the extended position of a limb, the bone, 
 whicti could not be brought into apposition under 
 the most violent efforts, quickly replaced by an intel- 
 ligent surgeor), who has directed the limb to be bent, 
 and the muscles to be placed in a comparative state 
 of relaxation? 
 
 Whether the extension should he applied to the dis- 
 located bone. — A difference of opinion prevails, 
 whether it is best to apply the extension on the 
 dislocated bone, or on the limb below. M. Boyer, 
 who has long taken the lead in surgery in Paris, 
 prefers the latter mode. As far as I have had an 
 opportunity of observing, it is generally best to 
 apply the extension to the bone which is dislocated. 
 There are, however, exceptions to this rule in the 
 dislocation of the shoulder, which I generally re- 
 duce by placing the heel in the axilla, and by draw- 
 ing the arm at the wrist in a line with the side of 
 the body. 
 
DISLOCATIONS IN GENERAL.* 
 
 53 
 
 Influence of the mind. — In the reduction of dislo- 
 cations, great advantage is derived from attending 
 to the patient's mind ; the muscles opposing the ef- 
 forts of the surgeon, by acting in obedience to the 
 will, may be made to desist from that action by di- 
 recting the mind to other muscles. Several years 
 since, a surgeon in Blackfriars' Road, asked me to 
 see a patient of his with a dislocated shoulder, wliich 
 had resisted the various attempts he had made at re- 
 duction. I found the patient in bed, with his right arm 
 dislocated; I sat down on the bed by his side, placed 
 my heel in the axilla, and drew the arm at the wrist; 
 the dislocated bone remained unmoved, I said, ' Rise 
 from your bed. Sir;' he made an effort to do so, 
 whilst I continued my extension, and the bone snap- 
 ped into its socket. For a siniilar reason, a slight 
 effort, when the muscles are unprepared, will accom- 
 plish the reduction of dislocation, after violent mea- 
 sures have failed. 
 
 The reduction of the limb is ascertained by the 
 restoration of its natural form, by the recovery of 
 its original motion, and by a snap, or sudden sound 
 which is heard when the bone returns into its arti- 
 culatory cavity. 
 
 Second dislocation. — After a bone has been re- 
 duced by the pulleys, it will not remain in its situa- 
 tion without the aid of bandages to support it until 
 the recovery of muscular action. In the hip, how- 
 ever, dislocation rarely occurs a second time, but the 
 shoulder and the lower jaw very frequently slip 
 again from their sockets, owing to the little depth of 
 the cavity into which the head of the bone is re- 
 ceived ; and, therefore, they require bandages for a 
 considerable period. 
 
 Rest of the limb. — Rest is necessary for some 
 time after the reduction of the limb, in order to pro- 
 duce an union of the ruptured ligament, which 
 
04 
 
 i)ISLOCATIONS IN GENERAL. 
 
 would be prevented by exercise. The strength of 
 the muscles and ligaments may also be greatly pro- 
 moted by effusion of cold water upon the limb, and 
 by subsequent friction. 
 
 Old dislocations not to be reduced. — -I believe that 
 much mischief is produced by attempts to reduce 
 dislocations of long duration in very muscular per- 
 sons. I have seen great contusion of the integu- 
 ments, laceration and bruises of muscles, tension of 
 nerves, inducing an insensibility and paralysis of the 
 hand, occasioned by an abortive attempt to reduce a 
 dislocation of the shoulder j so that the patient's 
 condition has been rendered much worse than be- 
 fore. In such cases, even when the bone is replaced, 
 it has often proved rather an evil than a benefity 
 from the violence of the extension. 
 
 In those instances in which the bone remains in 
 the axilla, in dislocations of the shoulder, a service- 
 able limb, and very extensive motions of it may be 
 regained, although reduction has not been effected. 
 Captain S- — — , who had dislocated his shoulder 
 four years before, called to show me how much mo- 
 tion he had recovered, although the arm still re- 
 mained unreduced. 
 
 Time for attempting reduction. — I am of opinion, 
 that three months after the accident for the shoul- 
 der, and eight weeks for the hip, may be fixed as 
 the period at which it would be imprudent to make 
 the attempt at reduction, except in persons of ex- 
 tremely relaxed fibre, or of advanced age. At the 
 same time, I am fully aware, that the shoulder has 
 been reduced at a more distant period than that which 
 I have mentioned; but, in most instances, the reduc- 
 tion has been attended with the results I have just 
 been deprecating. 
 
 In cases of unreduced dislocation, the only course 
 which the surgeon can adopt, after the inflammation 
 
DISLOCATIONS IN GENERAL. 
 
 5.0 
 
 which the injury produces has subsided, is, to advise 
 motion of the limb, and friction of the injured part; 
 — The former, to produce a new cavity for the 
 head of the bone, to assist in forming a new liga- 
 ment, and to restore action to muscles, which they 
 would otherwise lose by repose the latter, to pro- 
 mote absorption, and remove the swelling and ad- 
 hesions which the accident has caused. 
 
PARTICULAR DISLOCATIONS. 
 
 DISLOCATIONS OF THE HIP-JOINT. 
 
 Jlnatomy of the joint. — The acetabulum of the 
 hip-joint is deepened by a cartilaginous ridge, which 
 surrounds its brim; and although in the skeleton it 
 is not a complete cup, yet it is rendered such in the 
 living subject, by an additional portion of cartilage, 
 which fills up a depression in the bone in the infe-* 
 rior and anterior part of the cavity. 
 
 Ligaments, — The ligaments are two : the capsu- 
 lar arises from the edge of the acetabulum, and 
 passing over the head and neck of the bone, is in- 
 serted into the cervix of the os femoris at the root 
 of the trochanter major. It is much more exten- 
 sive on the anterior than on the posterior portion of 
 the neck of the bone. The inner side of this liga- 
 ment is a secreting surface, producing the synovia ; 
 and a reflected portion of it towards the head of 
 the bone is also provided with a similar secreting 
 surface."^ 
 
 It has been universally understood hitherto, that the capsu- 
 lar ligaments of the joints are peculiar, or independent struc- 
 tures. During the last winter I was led hy a number of careful 
 researches to discover that the capsular ligaments of the great 
 joints are formed from, the fascia covering the muscles. The 
 great capsule of the hip-joint is made up by the different lay- 
 ers of the Fascia Lata, and the capsule of the shoulder joint is 
 
PARTICULAR DISLOCATIONS. 
 
 57 
 
 On the anterior surface of the neck of the thigh- 
 bone, the capsular h'gament is received into a line, 
 which extends from the trochanter major to the 
 trochanter minor. The synovial secreting surface 
 is reflected towards the head of the bone, and the 
 ligament is reflected close on the neck of the bone, 
 to form the periosteum; whilst its fibres are inter- 
 serted with the common periosteum, below the in- 
 sertion of the ligament, into the bone. 
 
 On the posterior surface the capsular ligament is 
 received upon the neck of ilie bone, nearly midway 
 between the edge of the head of the bone and the 
 trochanter major. The common periosteum on the 
 neck of the bone incorporates with the reflected 
 ligament, to form the periosteum of the neck of the 
 bone within the capsule.* 
 
 The ligamentum teres is contained within the cap- 
 sular ligament, and proceeds from a depression in 
 the lower and inner part of the acetabulum, to be 
 fixed in a hollow upon the inner side of the thigh- 
 bone : it has a tendency to prevent dislocations in 
 all directions, 'but particularly the dislocation down- 
 wards ; for when this dislocation occurs, the thighs 
 are widely separated from each other, as in fencing; 
 
 a simple continuation of the fascia covering the biceps flexor 
 cubiti, which 1 have called ' Fascia Hunieri.' When the inter- 
 esting manner in which these faciae surround the muscles and 
 form the sheaths for the vessels, is understood, the important 
 bearing these facts must have on the physiology and pathology 
 of the joints, will be clearly perceived. For a full description 
 of the relations existing between these parts, 1 must refer the 
 reader to the ' Anatomical Investigations' recently published. 
 
 J. D. G. 
 
 * Query. — Can this ligamentous periosteum be one cause of 
 a ligamentous union in fractures within the joints? I believe 
 that when an union of the neck of the thigh-bone is met with, 
 it must be in a case in which this Hgamentous sheath of the 
 cervix has not been torn. {See Plate XIII, Jig. 3.) 
 B 
 
58 
 
 PARTICULAR DISLOCATIONS. 
 
 and the head of the thigh-bone would be in danger 
 of slipping from its socket, were it not prevented by 
 this ligament — an example of its use, which shows 
 the principal reason of its formation.* 
 
 Mode of dislocation. — The thigh-bone I have 
 seen dislocated in four directions : — First, upwai'ds, 
 or upon the dorsum of the ilium. Secondly, down- 
 wards, or into the foramen ovale. Thirdly, back- 
 wards, and upwards, or into the ischiatic notch ; and, 
 Fourthly, forwards, and upwards, or upon the body 
 of the pubes. A dislocation downwards and back- 
 wards, has been described by some surgeons, who 
 have had opportunities for observation ; but I have 
 to remark, that no dislocation of that description 
 has occurred at St Thomas's or Guy's Hospital, 
 within the last thirty years, or in my private prac- 
 tice ; and although 1 w-ould not deny the possibility 
 of its occurrence, yet I am disposed to believe that 
 some mistake has arisen upon this subject. 
 
 DISLOCATION UPWARDS, OR ON THE DORSUM ILIl. 
 
 Dislocation on the dorsum ilii, — This dislocation 
 is the most frequent of those which happen to the 
 hip-joint: and the following are the signs of its ex- 
 istence. 
 
 Symptoms, — The dislocated limb, is from one 
 inch and a half, to two inches and a half shorter than 
 the other, as will be seen by comparing the malleoli 
 
 * The ligntnentnm teres does not arise from the depression 
 at the bottom of the acetabuhim, nor are the connexions at this 
 point very strong. The round ligament really arises from that 
 ligament which completes the circle of the acetabulum at the 
 anterior [»art. This interesting and easily demonstrable fact, 
 appears to have been first remarked by our celebrated country- 
 man, the late professor Wislar. J. D. G. 
 
PARTICULAR DISLOCATIONS. 
 
 59 
 
 interni, when the foot is bent at right angles with 
 the leg. The toe rests upon the tarsus of the other 
 foot; the knee and foot are turned inwards, and the 
 knee is a little advanced upon the other. When 
 the attempt is made to separate the leg from the 
 other, it cannot be accomplished, for the limb is 
 firmly fixed in its new situation, so far as regards its 
 motion outwards; but the thigh can be slightly bent 
 across the other. If the bone be not concealed by 
 extravasation of blood, the head of the thigh-bone 
 can be perceived during rotation of the knee inwards, 
 moving upon the dorsum ilii; and the trochanter 
 major advances towards its anterior and superior 
 spinous process, so as to be felt much nearer to it 
 than usual. The trochanter is less prominent than 
 on the opposite side, for the neck of the bone and 
 the trochanter rest in the line of the surface of the 
 dorsum ilii; and upon a comparison of the two hips, 
 the roundness of the dislocated side will be found to 
 have disappeared. A surgeon, then, called to a 
 severe and recent injury of the hip-joint, looks for 
 difference in length, change of position inwards, dim- 
 inution of motion, and decreased projection of the 
 trochanter. 
 
 Distinction from fracture of the neck of the femur, 
 — The accident with which the dislocation upwards 
 is liable to be confounded, is the fracture of the neck 
 of the thigh-bone within the capsular ligament. Yet 
 the marks of distinction are, in general, sufficiently 
 strong to be unequivocal to a person commonly at- 
 tentive. In a fracture of the neck of the thigh-bone, 
 the knee and foot are generally turned outwards; 
 the trochanter is drawn upwards and backwards, 
 resting upon the dorsum ilii; the thigh can he readily 
 bent towards the abdomen, although with some pain; 
 but, above all, the limb, which is shortened according 
 to the duration of the accident, from one to two 
 
60 
 
 PARTICULAR DISLOCATIONS. 
 
 inches, bj the contraction of the muscles, can be 
 made of the length of the other' by a slight exten- 
 sion; and when the extension is abandoned, the leg 
 is again shortened. If the limb, when drawn down 
 be rotated, a crepitus can often be felt, which ceases 
 to be perceived when rotation is performed under a 
 shortened state of the limb. Fracture of the neck 
 of the thigh-bone, within the capsular ligament, rarely 
 occurs but in advanced age; and tlie most trifling ac- 
 cident is sufficient to produce it, in consequence of 
 the interstitial absorption which this part of the bone 
 undergoes at advanced periods of life. Fractures 
 .externally to the capsular ligament, occur at any age, 
 and they are easily distinguished by the crepitus 
 which attends them, if the limb be rotated and the 
 trochanter compressed with the hand. The position 
 is the same as in fractures within the ligament. 
 Fractures of the neck of the thigh-bone are very 
 frequent accidents when compared with dislocations. 
 (^See the plate of the positions of the limh in disloca- 
 tions,) 
 
 Disease of the hip-joint, — Diseases of the hip-joint 
 can scarcely ever be confounded with dislocations 
 from violence, but by those who are ignorant of 
 anatomy, and who are very superficial observers. 
 The gradual progress of the symptoms, the pain in 
 the knee, with the apparent elongation at first, and 
 real shortening afterw^ards; the capacity for motion, 
 yet the pain given under extremes of rotation, as 
 well as of flexion and extension, are indications of 
 difference which would strike the most careless ob- 
 server. The consequences of a disease of this kind, 
 when it has existed for a great length of time, are, 
 ulceration of the ligaments, acetabulum, and head of 
 the bone, which allow of such a change of situation 
 of parts, as sometimes to give the limb the position 
 pf dislocation; but the history of the case at once 
 
PARTICULAR DISLOCATIONS. 
 
 61 
 
 explains to the medical attendant the nature of 
 the disease. 
 
 Cause. — This dislocation may be caused by a fall 
 when the knee and foot of the patient are turned 
 inwards, or by a blow whilst the limb is in that 
 position; — the head of the bone being thus displaced 
 upwards, and turned backwards. 
 
 In the reduction of this dislocation, the following 
 plan is to be adopted : — let the patient lose from 
 twelve to twenty ounces of blood, or even more if 
 he be a very strong man; then place him in a warm 
 bath, at the heat of 100", and gradually increase it 
 to 110°, until he feels faint. During the time he is 
 in the warm bath, give him a grain of tartarized 
 antimony every ten minutes until he feels some nau- 
 sea; then remove him from the bafh and put him 
 in blankets: he is then to be placed between 
 two strong posts, about ten feet asunder, in which 
 -two staples are fixed ; or rings may be screwed into 
 the floor, and the patient be laid upon it. My usu- 
 al method is, to place him on a table covered with 
 a thick blanket, upon his back; then a strong girth 
 is passed between his pudendum and thigh, and this 
 is fixed to one of the staples. (See plate.) A wetted 
 linen roller is tightly applied just above the knee, 
 and upon this a leathern strap is buckled, having two 
 straps with rings at right apgles with the circular 
 part. The knee is to be slightly bent, but not quite 
 at a right angle, and brought across the other thigh 
 a little above the knee of that limb. The pulleys 
 are fixed in the other staple, and in the straps above 
 the knee. The patient being thus adjusted, the sur- 
 geon slightly draws the string of the pulley, and 
 when he sees that every part of the bandage is 
 upon the stretch, and the patient begins to complain, 
 he waits a little to give the muscles time to become 
 fatigued; he then draws again, and when the pq.tient 
 
62 
 
 PARTICULAR DISLOCATIONS. 
 
 suffers much, again rests, until the muscles yield. 
 Thus he gradually proceeds until he finds the head 
 of the bone approach the acetabulum. When it 
 reaches the lip of that cavity, he gives the pulley 
 to an assistant, and desires him to preserve the same 
 state of extension, and the surgeon then rotates the 
 knee and foot gently, but not with a violence to ex- 
 cite opposition in the muscles, and in this act the 
 bone slips into its place. In general, it does not re- 
 turn with a snap into its socket when the pulleys are 
 employed, because the muscles are so much relaxed, 
 that they retain not sufficient tone to act with vio- 
 lence ; and the surgeon ascertains the reduction only 
 by loosening the bandages, and comparing the length 
 of the limbs.* 
 
 It often happens that the bandages get loose be- 
 fore the extension is completed, an accident which 
 should be carefully prevented by having them well 
 secured at first ; but if they require to be renewed, 
 this should be expeditiously performed, to prevent 
 the muscles havinor time to recover their tone. 
 
 It is sometimes necessary for the operator to lift 
 the bone, by placing his arm under it near the joint, 
 when there is difficulty in bringing it over the lip 
 of the acetabulum; or a napkin may be passed un- 
 der the bone, as near the head as possible, and by 
 
 * No one can compare the certainty and regularity with 
 which pulleys act, with the uncertain and often discordant exer- 
 tions of assistants, and not be convinced of the decided superior- 
 ity of the former. The surgeon can rely on the pulley for re- 
 sults that are in many instances lost for want of accurate co-ope» 
 ration in his assistants, or from their becoming fatigued before 
 the muscles of the patient relax. We are therefore induced to 
 hope, after what has been said by our experienced and justly 
 distinguished author, that our practitioners will provide them- 
 selves with an apparatus which at a small expense, insures them 
 against loss of time, or injury from the ignorance and impa* 
 tience of assistants. J. D. G, 
 
PARTICULAR DISLOCATIONS. 
 
 63 
 
 its means an assistant may raise it. After the re- 
 duction, in consequence of the relaxed state of the 
 muscles, great care is required in removing the pa- 
 tient to his bed. 
 
 I have seen reduction of the bone effected, even 
 where the extension was not made in the best pos- 
 sible direction ; for when the muscles have not had 
 time to settle, they will allow the bone to be re- 
 stored into its socket, even when extension is made 
 in a direction not the most favourable for its reduc- 
 tion. I cannot by any means subscribe to the me- 
 thod adopted by the late Mr Hey, although no per- 
 son ever felt greater respect for his talents, more 
 highly appreciated his acquirements, or is more dis- 
 posed to pursue the study of the profession in the 
 mode which be so successfully adopted. The direc- 
 tion which he gave to a limb, in the case which he 
 has represented of this accident, was one little cal- 
 culated for success, in cases Avhere the means were 
 not used immediately after the injury had been sus- 
 tained. But I state this with great deference, be- 
 cause I am not sure, that in all respects, I under- 
 stand the description of the method which he adopt- 
 ed ; nor do I think that I should be able, from that 
 description, to be certain that I was pursuing the 
 means by which he succeeded. 
 
 I may here observe, and I trust without ostenta- 
 tion, that the methods which I have recommended, 
 are the result of considerable experience; that they 
 have been successful in a great number of cases; 
 and that they have very rarely failed, under the 
 most disadvantageous circumstances. They may re- 
 quire a little variation, from some slight difference 
 in the position, but this will only be an exception to 
 a general rule, and will very rarely occur. 
 
 The following cases will serve as illustrations of 
 the history and treatment of dislocations on the 
 
64 
 
 PARTICULAR DISLOCATIONS. 
 
 dorsum ilii; the first of them points out, in a strik- 
 ing manner, the evils that ensue when dislocation of 
 the hip-joint remains unreduced, and the advantages 
 arising from the use of pulleys in effecting its re- 
 duction. It shows also that. such dislocation may 
 happen in a strong healthy man, even after he has 
 attained the age of sixty. 
 
 Dislocation on the Dorsum Ilii. 
 
 Case. — James Ivory, aged sixfy-two, of Potten* 
 send, Herts, on the 7th of February, 1810, was 
 working in a clay-pit about twenty-five feet below 
 the surface of the earth, when a large quantity of 
 c\'dj fell in upon him, while he was in the act of 
 stooping with his left knee bent rather behind the 
 other; and he was in this position buried under the 
 earth. Being soon removed from this perilous situ- 
 ation, and carried home, a surgeon was sent for; 
 who, discovering the accident to be a dislocation, di- 
 rectly employed some men to extend the limb, 
 whilst he attempted to push the head of the bone 
 into the acetabulum ; but all his efforts were un- 
 availing, as, unfortunately for the patient, pulleys 
 were not employed. The appearances of the limb 
 at present, when nine years have elapsed since the 
 accident, are these : the hmb is three inches and a 
 half shorter than the other, and the patient is oblig- 
 ed to wear a shoe having an additional sole of three 
 inches on that side, which lessons, though it does not 
 prevent, his halt in walking. When he stands, the 
 foot of the injured limb rests upon the other; the 
 toes are turned inwards, and the knee, which is ad- 
 vanced upon the other, is also inverted, and rests 
 upon the side of the patella of the sound limb, and 
 upon the vastus internus muscle ; it is also bent, and 
 
PARTICULAR DISLOCATIONS. 
 
 65 
 
 cannot be conapletely extended. The thigh, from 
 the unemployed state of several of the muscles, is 
 very much wasted; but the semi-tendinosus, semi- 
 membranosus, and biceps, in consequence of the 
 shortened state of the limb, form a considerable 
 rounded projection on the back part of the thigh. 
 The trochanter major is seven-eighths of an inch 
 nearer to the spine of the ilium of the injured side 
 than of the other. On viewing him behind, the tro- 
 chanter major is seen projecting on the injured side 
 much farther than on the other ; the situation of the 
 head of the bone on the dorsum ilii, is easily per- 
 ceived ; and when the limb is rotated inwards, it is 
 still more obvious. The spinous processes of the 
 ilia are of an equal height. In the sitting posture, 
 the foot is turned very much inwards, and the knee 
 is placed behind the other, whilst the toe only 
 reaches the ground. If fatigued, he experiences 
 pain in the opposite hip, and in the thigh of the in- 
 jured limb. This unfortunate man finds it an ardu- 
 ous task to gain his bread by his labour, as he can- 
 not stoop but with the greatest difficulty, and is 
 therefore obliged to seek those employments which 
 least require that position. When he attempts to 
 take any thing from the ground, he bends the knee 
 of the injured limb at right angles with the thigh, 
 and throws it far back. He can now stand for a few 
 seconds upon the dislocated limb, but it was twelve 
 months before he could endure that posture. When 
 in bed, he finds it painful to lie on the injured side. 
 His hip, without any apparent cause, is much weaker 
 at some times than at others. When sitting down 
 to evacuate his faeces, he is obliged to support him- 
 self by resting the injured knee against the tendo 
 Achillis of the other leg, placing his right hand on 
 the ground. He now walks with two sticks ; at 
 first he employed crutches, and these he used for 
 9 
 
66 
 
 PARTICULAR DISLOCATIONS. 
 
 twelve months, after which he was enabled to trust 
 to one crutch and a stick, until his limb acquired 
 greater strength. In getting over a stile, he raises 
 the injured limb two steps, and then turns over the 
 sound limb; but this he cannot accomplish when the 
 steps are far apart; and he is frequently obliged 
 either to turn back, or to take a circuitous route. 
 When lying with his face downwards, the dislocated 
 hip projects very much. He sometimes falls in 
 walking, and would very frequently fall, but that he 
 takes extreme care, as the least check to his motion 
 throws him down. The knee is bent, and the short- 
 ening of the limb partly originates in that circum- 
 stance. 
 
 The following cases illustrate the method of re- 
 duction detailed in the preceding pages, and show 
 in strong colours, the advantages to be derived from 
 constitutional treatment, and the use of pulleys. 
 
 Case. — John Forster, aged twenty-two years, was 
 admitted into the Chester Infirmary, July 10th, 18 18, 
 with a dislocation of the thigh on the dorsum ilii, 
 occasioned by a cart passing over the pelvis. Upon 
 examination, I found the leg shorter than the other, 
 and the knee and foot turned inwards. The patient 
 being firmly confined upon a table, I extended the 
 limb by pulleys, for fifty minutes without success, and 
 he was returned to bed for three hours; after which 
 he was put in the warai bath for twenty minutes, 
 and the extension was repeated for fifteen minutes, 
 unsuccessfully ; I therefore took twenty-four ounces 
 of blood from him, and gave him forty drops of 
 tinct. opii. Continuing the extension, but not suc- 
 ceeding in producing faintness, I gave small doses of 
 a solution of tartrate of antimony, which, in a quar- 
 ter of an hour, produced nausea ; in ten minutes 
 afterwards, I succeeded in reducing the limb, and in 
 
PARTICULAR DISLOCATIONS. 
 
 67 
 
 less than a fortnight he left the infirmary quite well. 
 Unfortunately, he began to work hard immediately, 
 and brought on an inflammation of the hip, of which 
 he has not recovered. 
 
 Chester, S. R. Bennett. 
 
 Sir: — I beg leave to forward to you the particu- 
 lars of the following case. 
 
 Case. — John Lee, aged thirty-three, of a strong and 
 robust constitution, in passing over a foot-bridge, Oc- 
 tober 9th, 1819, fell from a height of about four feet 
 on a large stone, and dislocated his left hip. I 
 did not see him until the 4th of December, when I 
 found the limb full three inches shorter than the 
 other, the knee turned in, the foot directed over 
 the opposite tarsus, and the trochanter major brought 
 nearer the spinous process of the ilium. On laying 
 the man on his face, the head of the femur and 
 trochanter could be distinctly seen on the doisum 
 ilii, so as to leave not the slightest doubt of the na- 
 ture of the injury. With the assistance of a neigh- 
 bouring practitioner, I immediately set about to re- 
 duce it ; a girth was applied between the legs, and 
 a bandage over the knee, to fix the pulleys, etc, in 
 the usual manner. I then made the extension 
 downwards and inwards, crossing the opposite thigh 
 two-thirds downwards; and immediately when the 
 extension was commenced, I gave him a solution of 
 two grains of tartar emetic, which was repeated five 
 times every ten minutes, but it produced very slight 
 nausea. 1 shortly after bled him to sixty ounces 
 without syncope ; and after keeping up the extension 
 gradually for about two hours, with all the force one 
 man could employ with the pulleys, we found the 
 limb as long as the opposite ; we then endeavoured 
 to lift the head of the bone over the acetabulum, 
 
68 
 
 PARTICULAR DISLOCATIONS. 
 
 by means of a towel under the thigh and over one 
 of our heads, at the same time rotating the limb 
 outwards with all the force we were able to exert; 
 the foot at length became somewhat turned out, and 
 the head of the bone to be less distinctly felt, and in 
 about half an hour we heard a grating of the head 
 of the bone, when the man instantly exclaimed it was 
 replaced;* and, upon examination, finding the foot 
 turned out, the limb of its natural length, and no 
 appearance of the head of the bone on the dorsum 
 ilii, we concluded it must be within the acetabulum, 
 and desisted from any further violence, put the man 
 to bed, and tied his legs together ; his foot immedi- 
 ately became sensible, which it had not been before 
 since the accident, and he altogether felt easier. A 
 large blister was applied over the trochanter, and he 
 slept well in the night, and complained of pain only 
 in the perineum and just above the knee, where the 
 bandages had been applied ; there was no subse- 
 quent fever, nor any unpleasant symptom what- 
 ever. 
 
 In a few days the man could bear slight flexion 
 and extension without pain, and in a week some de- 
 gree of rotation ; the limb became gradually stronger, 
 and the power of motion so increased, that on the 
 twelfth day he could by himself bring the thigh at 
 right angles with the body. He was now taken out 
 of bed; bandages were applied round the thigh and 
 pelvis; and he could stand perfectly upright, so as 
 to walk with his heel on the ground with the assist- 
 ance of crutches : and from exercise, he grew so 
 rapidly stronger, that on the twenty-second day he 
 left off one crutch, and on the twenty-fifth the 
 
 * In dislocations which have long remained unreduced, the 
 bone does not usually snap into the socket at its reduction. — 
 A. C, 
 
PARTICULAR DISLOCATIONS. 
 
 69 
 
 other. In a month he was able to walk without a 
 stick ; and in five weeks, having particular business, 
 he walked nearly twenty miles, perfectly upright, 
 and without the least limping. 
 
 Collumpton, Devon. Your's very truly, 
 
 Jan, 27, 1820. S. Nott. 
 
 The following case forms a striking contrast to the 
 preceding, and to some of those hereafter related. 
 
 Case. — I was desired to visit a man aged twenty- 
 eight years, who, by the overturning of a coach, had 
 dislocated his left hip more than five weeks before ; 
 and who had been declared not to have a dislocation, 
 although the case was extremely well marked. His 
 leg was full two inches shorter than the other; his 
 knee and foot Avere turned inwards ; and the inner 
 side of the foot rested upon the metatarsal bones of 
 the other leg. The thigh w^as slightly bent towards 
 the abdomen, and the knee was advanced over the 
 other thigh. The head of the thigh-bone could be 
 distinctly felt upon the dorsum of the ilium; and 
 when the two hips were compared, the natural round- 
 ness of the dislocated side had disappeared. I used 
 only mechanical means in my attempts at reduction; 
 and although I employed the pulleys, and varied the 
 direction of repeated extensions, I could not succeed 
 in replacing the bone, and this person returned to 
 the country with the dislocation unreduced. 
 
 The following case was communicated to me by 
 Mr Norwood, surgeon, Hertford. 
 
 Case. — William Newman, a strong muscular man, • 
 nearly thirty years of age, was admitted into Guy's 
 Hospital, on Wednesday, December 4th, 1812, under 
 the care of Mr Astley Cooper, for a dislocation of 
 the hip-joint. In springing from the shafts of a wag- 
 
70 
 
 PARTICULAR DISLOCATIONS. 
 
 on, on Thursday, November 7th, his foot slipped, 
 and his hip was driven against the wheel with con- 
 siderable force. He immediatelj fell, and being 
 found unable to walk, was carried to Kingston Work- 
 house, which was near the place where the accident 
 happened. On the evening of that day, he was ex- 
 amined by a medical man, but the nature of the acci- 
 dent was not ascertained. He remained at Kings- 
 ton until the 30th of November, and was then re- 
 moved to Guildford, his place of residence, and from 
 thence, on the 4th of December, to Guy's Hospital. 
 On examination, the head of the thigh-bone was 
 found resting on the dorsum ilii; the trochanter was 
 thrown forward towards the anterior superior spi- 
 nous process of the ilium. The knee and foot were 
 turned inwards, and the limb was shortened one inch 
 and a half; the great toe rested upon the metatarsal 
 bone of the other foot, and there was but little mo- 
 tion in the limb. 
 
 On Saturday, the 7th of December, being thirty 
 days after the accident, an extension was made to 
 reduce the limb ; and previously to the application 
 of the bandage, he was bled to twenty-four ounces 
 from his arm ; in about ten minutes after this he 
 was put into a warm bath, where he remained until 
 he became faint, which happened in fifteen minutes; 
 he then had a grain of tartarized antimony given 
 him, which was repeated in sixteen minutes, as the 
 first dose did not produce nausea. The most dis- 
 tressing nausea was now quickly produced, but he 
 did not vomit ; and while under the influence of this 
 debilitating cause, he was carried into the operating 
 theatre in a state of great exhaustion. Being placed 
 on a table on his left side, the bandage was applied 
 in the usual manner to fix the pelvis, and the pulleys 
 were fastened to a strap around the knee ; the thigh 
 was drawn obliquely across the other, not quite two 
 
PARTICULAR DISLOCATIONS. 
 
 71 
 
 thirds of its length downwards, and the extension 
 was continued for ten minutes, when the bone slipped 
 into its socket. The man was discharged from the 
 hospital in three weeks from the period of his ad- 
 mission, making rapid progress towards a recovery 
 of the perfect use and strength of the limb. 
 
 For the history of the following case, I am oblig- 
 ed to Mr Thomas, apothecary to St Luke's Hos- 
 pital, who attended to it while acting as dresser at 
 St Thomas's Hospital. 
 
 Case, — William Chapman, aged fifty years, was 
 admitted into St Thomas's Hospital, on Thursday, 
 September 10th, 1812, with a dislocation of the left 
 hip upon the dorsum ilii, which was occasioned by 
 the mast of a ship falling upon the part and throw- 
 ing him down, on the Wednesday six weeks prior to his. 
 admission into the hospital. It was reduced on Fri- 
 day, the 11th of September, in the following man- 
 ner. The patient was bled by opening a vein in 
 each arm, and thirty-four ounces of blood were taken 
 away. He was then put into a warm bath, and a 
 grain of tartanzed antimony given to him, which 
 was repeated every ten minutes ; this, with the pre- 
 vious means, produced fainting and nausea. 
 
 The patient was then placed on a table on hi& 
 right side, and a girth was carried between his 
 thighs and over his pelvis, so as completely to con- 
 fine it ; a wetted roller was applied above the knee, 
 and upon it a leathern belt, with rings for the pul- 
 leys. The extension was then made in a direction 
 causing the dislocated thigh to cross the other be- 
 low its middle, and in half an hour the reduction 
 was accomplished. 
 
 The three following cases show that we are not 
 to despair of success, even when a considerable time 
 has elapsed after the accident. 
 
72 
 
 PARTICULAR DISLOCATIONS. 
 
 Case. — Mr Mayo has mentioned the case of 
 Wiiliarn Honey, who came into the hospital in 
 August, 1812: the dislocation had taken place seven 
 weeks before, and was reduced the day after his ad- 
 mission ; he was discharged, cured, on the 18th of 
 November. This was a dislocation on the dorsum 
 ilii. 
 
 Case, — Mr Tripe, surgeon at Plymouth, has • 
 sent to the Medico-Chirurgical Society, an account 
 of a case of dislocation of the thigh-bone on the 
 dorsum ilii, which had happened seven weeks and 
 one day prior to his making an extension, in which 
 he was so fortunate as to succeed in restoring the 
 bone to its natural situation. 
 
 The following instances prove, indeed, that the 
 dislocation on the dorsum ilii may be reduced with- 
 out pulleys ; but they show at the same time, how 
 desirable that mechanical aid would have been, es- 
 pecially in the two first instances. 
 
 Case. — William Piper, aged twenty-five years, 
 sustained an injury from the wheel of a cart, laden 
 with hay, which passed between his legs and over 
 the upper part of his right thigh. Mr Holt, sur- 
 geon at Tottenham, was sent for nearly a month 
 after the accident had happened; he found him in 
 great pain, attended with fever, and with much local 
 inflammation and tension. He bled him largely, 
 purged him freely, and applied leeches. The in- 
 jured leg was shorter than the other, and the head 
 of the bone was seated upon the dorsum ilii; the 
 knee and foot were turned inwards. 
 
 As I visited Tottenham frequently at that time, 
 Mr Holt asked me to accompany him to see the 
 man, and we agreed on the propriety of making a 
 trial at reduction. Mr Holt and myself, assisted by 
 five strong men, exerted our best endeavours for 
 
PARTICULAR DISLOCATIONS. 
 
 73 
 
 that purpose. Repeatedly fatigued, we were sev- 
 eral times obliged to pause and then renew our at- 
 tempts. At length exhausted, we were about to 
 abandon any further trial, but agreed to make one 
 last effort ; when, at fifty-two minutes after the 
 commencement of the attempt, the bone slipped 
 info its socket. 
 
 Case, — In a case also, which I attended with 
 Mr Dyson, in Fore Street, I succeeded in reducing 
 the limb without the use of pulleys ; but the vio- 
 lence used was so great, and the extension so une- 
 qual (our fatigue being nearly as severe as that of 
 the patient), that I am confident no person who had 
 used pulleys in dislocation of the hip, would have 
 recourse to any other mode, excepting in dislocation 
 into the foramen ovale. 
 
 Case, — Mary Bailey, aged seven years, was ad- 
 mitted into Guy's Hospital, June 16th, 1819, under 
 the care of Mr Astley Cooper, for a dislocation of 
 the OS femoris upwards on the dorsum ilii. This 
 accident was occasioned by the child swinging on 
 the shaft of a cart, Avhich, being insecurely prop- 
 ped, suddenly gave way, and she fell to the ground 
 upon her side. The nature of the accident was 
 perfectly evident ; the limb on the dislocated side 
 was at least two inches shorter than the other; the 
 toe rested on the tarsus of the opposite foot, and 
 was turned inwards ; the knee was also inverted 
 and rested on the other. The child was admitted 
 into the hospital at half-past five in the afternoon, 
 the accident having happened rather more than 
 half an hour before. Where so little resistance 
 was expected the pulleys appeared unnecessary, and 
 towels were substituted, one being applied above 
 the knee, and the other between the pudendum and 
 thigh ; then, the knee being bent, and the thigh 
 brought across the other just above the knee, gra- 
 
 10 
 
74 
 
 PARTICULAR DISLOCATIONS. 
 
 dual extension was made, and in about four minutes 
 the head of the bone suddenly snapt into its socket. 
 On the seventh day the child was walking in her 
 ward, and suffered little inconvenience. 
 
 To Mr Daniell, one of Mr Lucas's dressers, I am 
 obliged for the foregoing particulars ; he having re- 
 duced the limb in the presence of many of the 
 students. 
 
 In the following case the extension was made at 
 the ankle, and it is consequently w^orthy of notice. 
 
 Case, — My dear Sir: — Wilham Sharpe, an ath- 
 letic young man, in wTestling received a fall; his an- 
 tagonist falling with and upon him, their legs were 
 so entangled that he cannot say how he came to the 
 ground. He complained of great pain in the hip^ 
 and was incapable of rising. About twenty minutes 
 after the accident, I found him lying on his belly in 
 the field where it had occurred, and the left limb 
 in a trifling state of abduction, shortened, and the 
 knee and foot turned inwards, the prominency of the 
 trochanter gone, and the head of the bone obscurely 
 felt on the dorsum ilii. He was conveyed home, and 
 in order to reduce the dislocation, for such I consid- 
 ered it, I placed the man on his right side diagonally 
 across a four-post bedstead. The centre of a large 
 sheet rolled up was passed in front and behind the 
 body, and fastened to the upper bed-post, as low as 
 possible. The centre of a napkin, rolled in like 
 manner, was then applied upon the dorsum ilii, be- 
 tween its crista and the dislocated bone ; and each 
 extremity being brought under the sheet, forwards 
 and backwards, was reflected over it and tied in the 
 centre, by which means I hoped (o keep the pelvis 
 secure; the counter-extending force was applied 
 above the ankle (it appearing to me to interfere less 
 with the muscles upon the thigh), first, by rolling 
 
PARTICULAR DISLOCATIONS. 
 
 75 
 
 round a wetted towel, and then placing upon this 
 the end of a long or jack-towel : three men were 
 now directed to pull gradually -and steadily; and 
 when I perceived that the head of the femur was 
 brought down to the edge of the acetabulum, I 
 raised it a little with my clasped hands placed under 
 the upper part of the thigh', and immediately the 
 head of the bone entered the cotyloid cavity with a 
 smart snapping noise. The man had considerable 
 pain about the hip and knee for some time, but is 
 now quite well. 
 
 I am, dear Sir, 
 JYottingham, Your's truly, 
 
 August 8th, 1819. Henry Oldknow. 
 
 Dudley, January \9th, 1824. 
 Case, — Dear Sir : • — A youth, about sixteen or 
 eighteen years of age, while at his work in a pit, 
 was buried under a fall of coals ; and besides being 
 severely injured in several other parts of his body, 
 had one hip dislocated on the dorsum of the ilium, 
 and the same thigh broken about the middle of the 
 bone. As the reduction of the hip was, of course, 
 impracticable, the thigh was bound up in the usual 
 manner, and treated without any reference to the 
 dislocation of the joint, with a hope that when the 
 thigh-bone was re-united, the hip might possibly be 
 reduced. At the end of live weeks, the bone ap- 
 pearing tolerably firm, I had a very careful but un- 
 remitting extension of the limb made by means of 
 pulleys, and, in less than half an hour, had the satis- 
 faction of feeling the head of the bone re-enter the 
 socket. It is very probable that the reduction would 
 have been accomplished in less time, had I dared to 
 allow a more powerful extension of the limb, but 1 
 very much feared lest a separation of the newly 
 
76 
 
 PARTICULAR DISLOCATIONS. 
 
 united bone should be produced by it. The patient 
 became so upright as to show scarcely any signs of 
 lameness afterwards. 
 
 1 have met with several instances of these acci- 
 dents conjoined with another injury, which at first 
 sight presented a complication sufficiently embar- 
 rassing, but without being, in reality, productive of 
 much additional difficulty. I allude to cases, in 
 which, with dislocation of one hip, there has been a 
 fracture of the bone of the opposite thigh. In such 
 circumstances, I have fixed some splints temporarily, 
 but very firmly, upon the broken limb, and then, 
 turning the patient on that side, have proceeded to 
 the reduction of the dislocated hip in the usual way. 
 After this has been accomplished, I have taken the 
 splints from the broken limb, and bound it up again 
 in the customary manner ; and every case which 1 
 have seen has done well, without any additional in- 
 convenience. 
 
 \ once witnessed a case, which I mention rather 
 for its singularity than for any practical inference 
 which it furnishes. — A man had received, I forget 
 how, a severe hurt on one of his hips. When laid 
 on a bed for examination, the thigh-bone was found 
 not to be broken, and the limbs were exactly of the 
 same length ; but the foot of the injured side turned 
 somewhat inwards, and any attempt to move the 
 hip-joint was extremely painful. On a more careful 
 examination of the parts about the hip, it was plain 
 that the thigh-bone was dislocated, and that its head 
 was on the dorsum of the ilium, and yet the limb 
 seemed not at all shortened. A brief enquiry, how- 
 ever, led to an explanation of this apparent anomaly. 
 It appeared that the opposite thigh-bone had been 
 formerly broken, and had united in such a way as 
 to leave the limb several inches shorter than it had 
 originally been ; and the dislocation of the other 
 
PARTICULAR DISLOCATIONS. 
 
 77 
 
 thigh upwards, had now brought that to a corre- 
 sponding length. It is scarcely needful to add, that 
 the reduction of the dislocation restored the patient 
 to his former lameness, and to the deformity produc- 
 ed by limbs of unequal length. 
 
 I remain, dear Sir, 
 
 Your most obedient servant. 
 To Sir Astley Cooper, John Badley. 
 
 Dislocation of the Thigh upon the Dorsum Ilii, with 
 Fracture of the Thigh-Bone, 
 
 Case, — Abraham Harman, aged thirteen years, 
 a patient under Mr Forster, in Guy's Hospital, gave 
 the following account of his accident. 
 
 About four months prior to this time, he drove 
 his master's horses to a chalk-pit ; he went down 
 into the pit to pack the chalk, and to break it into 
 small pieces, and while he was thus occupied, the 
 side of the pit gave way, and a large piece of chalk 
 striking him violently on the hip, knocked him down. 
 Being immediately taken to a neighbouring public- 
 house, a surgeon was sent for. The thigh was dis- 
 covered to be fractured near its middle, but very con- 
 siderable contusions prevented the dislocation from 
 being at first discovered. Fomentation and other 
 means of reducing the swelling at the hip having 
 been^ employed, it was ascertained that the thigh 
 was also dislocated, and some attempts were made 
 to reduce it ; but the fracture would not then bear 
 the extension, and the boy was sent to the hospital. 
 No attempts have since been made to reduce the 
 bone. 
 
 This case presented unusual difficulties ; and the 
 probability is, that dislocation thus complicated with 
 fracture, will, generally, not admit of reduction ; as 
 
78 
 
 PARTICULAR DISLOCATIONS. 
 
 an extension cannot be made, until three or four 
 months have elapsed from the accident, and then 
 only with strong splints upon the thigh, to prevent 
 the risque of disuniting the fracture. 
 
 Marlborough, Feb, 12, 1823. 
 
 Case. — Sir: — Permit me to send you the fol- 
 lowing case of dislocation of the thigh-bone on the 
 dorsum of the ilium. 
 
 George Davies, aged thirty-five, on the first of 
 the present month, in descending a flight of steps 
 at a mill in this neisfhbourhood, with a sack of 
 wheat on his back, missed a step or two, and \u en- 
 deavouring to regain his footing, the whole weight 
 of the load fell upon him, and the violence of the 
 shock bore him down several steps lower, where 
 he lay totally incapable of further motion till as- 
 sistance was procured. 
 
 He was then conveyed to the adjoining village. 
 On examination, the limb was found considerably 
 shorter than its fellow, the foot turned inwards, and 
 resting upon the tarsus of the other leg. The head 
 of the bone was distinctly felt, lodged among the 
 glutei muscles. All the other symptoms were un- 
 equivocal. In about three hours after the occur- 
 rence of the accident, due prepdration having been 
 made, thirty ounces of blood were taken from the 
 arm, the pulleys were adjusted according to your 
 directions, and gradual extension being made, the 
 head of the bone was eventually brought on a line 
 with the acetabulum; a towel was now passed un- 
 der the thigh, by which means the bone was elevat- 
 ed, and suddenly, with an audible snap, it slipped 
 into its proper cavity. The man is going on well, 
 but as he is still suffering from the effect of the con- 
 
PARTICULAR DISLOCATIONS. 79 
 
 tusion, he has not been allowed to make much use 
 of his limb. 
 
 Your's respectfully, 
 
 T. Maurice. 
 
 P. S. The reduction was accomplished in about 
 ten minutes. 
 
 DISLOCATION DOWNWARDS, OR INTO THE FORAMEN 
 OVALE. 
 
 Anatomy. — The foramen ovale is formed by the 
 junction of two bones, the ischium and the pubes ; 
 it is situated below the acetabulum, and is somewhat 
 near the axis of the body. It is filled by a ligament 
 which proceeds from the edges of the foramen, and 
 has an opening in its upper and anterior part, to 
 permit the passage of the obturator blood-vessels^ 
 and the obturator neive. It is covered on its ex- 
 ternal and internal surface by the obturator exter- 
 nus and obturator internus muscles. 
 
 Mode of accident. — This dislocation happens 
 when the thighs are widely separated from each 
 other. The ligamentum teres and the lower part 
 of the capsular ligament are torn through, and the 
 head of the bone becomes situated in the posterior 
 and inner part of the thigh, upon the obturator ex- 
 ternus muscle. 
 
 It has been erroneously supposed, that the liga- ' 
 mentum teres is not torn through in this dislocation; 
 because in the dead body, when the capsular liga- 
 ment is divided, the head of the bone can be drawn 
 over the lower edge of the acetabulum without 
 tearing the ligamentum teres. But the dislocation 
 in the foramen ovale happens whilst the thighs are 
 
80 
 
 PARTICULAR DISLOCATIONS. 
 
 widely separated, during which act the hgatnentum 
 teres is upon the stretch ; and when the head of 
 the bone is thrown from the acetabulum, this liga- 
 ment is torn through before it entirely quits the ca- 
 vity. 
 
 Symptoms, — The limb is in this case two inches 
 longer than the other. The head of the bone can 
 be felt by pressure of the hand, upon the inner and 
 upper part of the thigh towards the perinaeum, but 
 only in very thin persons. The trochanter major is 
 less prominent than on the opposite side. The body 
 is bent forwards by the tension of the psoas and ilia- 
 cus internus muscles. The knee is considerably ad- 
 vanced if the body be erect; it is widely separated 
 from the other, and cannot be brought, without great 
 difficulty, near the axis of the body to touch the 
 other knee, in consequence of the extension of the 
 glutei and pyriformis muscles. The foot, though 
 widely separated from the other, is generally neither 
 turned outwards nor inwards, although 1 have seen 
 it varying a little in this respect in different instan- 
 ces; but the position of the foot does not in this 
 case mark the accident. The bent position of the 
 body, the separated knees, and the increased length 
 of the limb, are the diagnostic symptoms. The po- 
 sition of the head of the bone is below, and a little 
 anterior to, the axis of the acetabulum ; and a hol- 
 low is perceived below Poupart's ligament. 
 
 Dissection. — There is an excellent preparation of 
 this accident in the collection at St Thomas's Hospi- 
 tal, which I dissected many years ago. The head 
 of the thigh-bone was found resting in the foramen 
 ovale, but the obturator externus muscle was com- 
 pletely absorbed, as welt as the ligament naturally 
 occupying the foramen, now entirely filled by bone. 
 Around the foramen ovale bony matter was deposit- 
 ed so as to form a deep cup, in which the head of 
 
PARTICULAR DISLOCATIONS. 81 
 
 the thigh-bone was inclosed, but in such a manner as 
 to allow of considerable motion; the cup thus form- 
 ed, surrounded the neck of the thigh-bone without 
 touching it, and so inclosed its head, that it could not 
 be removed from its new socket without breaking its 
 edges. The inner side of this new cup was extreme- 
 ly smooth, not having the least ossific projection at 
 any part to impede the motion of the head of the. 
 bone, which was only restrained by the muscles from 
 extensive movements. The original acetabulum was 
 half filled by bone, so that it could not have receiv- 
 ed the ball of the thigh-bone if an attempt had been 
 made to return it into its natural situation. The 
 head of the thigh-bone was very little altered; its 
 articular cartilage still remained ; the' ligamentum 
 teres was entirely broken, and the capsular ligament 
 was partially torn through ; the pectinalls muscle 
 and adductor brevis had been lacerated, but were 
 united by tendon; the psoas muscle and lliacus in- 
 ternus, the glutei and pyriformis, were all upon the 
 stretch. Nothing can be more curious, or, to the 
 surgeon and physiologist, more beautiful, than the 
 changes produced by this neglected accident, which 
 exemplify the resources of nature in producing re- 
 storation. 
 
 Reduction, — The reduction of this dislocation, is, in 
 general, very easily effected. If the misfortune be 
 of recent occurrence, it is requisite to place the pa- 
 tient upon his back, to separate the thighs as widely 
 as possible, and to place a girth between the puden- 
 dum and the upper part of the luxated thigh, fixing 
 it to a staple in the wall. The surgeon then puts 
 his hand upon the ankle of the dislocated side, and 
 draws it over the sound leg, or, if the thigh be very 
 large, behind the sound limb, and the head of the 
 bone slips into its socket. I saw a dislocation thus 
 reduced, which had happened very recently, and 
 11 
 
82 
 
 PARTICULAR DISLOCATIONS. 
 
 which Avas subjected to an extension in St Thomas's 
 Hospital, almost immediately after the patient's ad- 
 mission. In a similar case, the thigh might be fixed 
 by a bed-post received between the pudendum and 
 the upper part of the limb, and the leg be carried 
 inwards across the other. But in general it is re- 
 quired to fix the pelvis by a girth passed around 
 it, and crossed under that which passes around the 
 thigh, to which pulleys are to be attached, otherwise 
 the pelvis will move in the same direction with the 
 head of the bone. (See Plate.) 
 
 In those cases in which the dislocation has existed 
 for three or four weeks, it is best to place the pa- 
 tient upon his sound side ; to fix the pelvis by one 
 bandage, and to carry under the dislocated thigh 
 another bandage, to which the pulleys are to be 
 affixed perpendicularly ; then to draw the thigh up- 
 wards, whilst the surgeon presses down the knee 
 and foot, to prevent the lower part of the limb from 
 being drawn with the thigh-bone. Thus the limb is 
 used as a lever of very considerable power. Great 
 care must be taken not to advance the leg in any 
 considerable degree, otherwise the head of the thigh- 
 bone will be forced behind the acetabulum into the 
 ischiatic notch, from whence it cannot be afterwards 
 reduced. 
 
 Dislocation of the right Thigh into the Foramen 
 Ovale, 
 
 Case. — While a gentleman was riding on horse- 
 back on the 4th of January, 181<], the animal sud- 
 denly started to the right side ; and as the rider 
 endeavoured to keep his seat by the pressure of the 
 right thigh against the saddle, he , was thrown, and 
 from the fall received a severe contusion upon his 
 head, which produced alarming symptoms. On the 
 
PARTICULAR DISLOCATIONS. 
 
 83 
 
 following day it Avas observed that the riglit thigh 
 was useless, and that the knee was raised and could 
 not be brought into a straight line with the other, 
 having at the same time a direction outwards, which 
 required it to be tied to the other knee : the symp- 
 toms of injury to the head precluded, at this time, 
 the attempt at reduction. In fourteen days he was 
 so far recovered that he was able to rise from his 
 bed, and in a month he began to walk with 
 crutches. 
 
 On November Isr, 1818, I first saw him; and the 
 appearances of the injured limb were then as fol- 
 low : — the thigh was longer than the other by the 
 length of the patella; the knee was advanced; and 
 when he was in the recumbent posture, the injured 
 leg could not be drawn down to the same length 
 with the other. The upper part of the thigh-bone 
 was thrown backwards, so as to render the hollow 
 of the groin on the injured side deeper than that 
 on the other. The toes were rather everted, but 
 when the body was erect, were capable of resting 
 on the ground, though the heel was not. The head 
 of the bone could not be felt, and the trochanter 
 was much less prominent than usual. When the 
 upper part of the thigh-bone was pressed against 
 the new acetabulum, and moved, there was a sen- 
 sation of friction between two cartilaginous surfaces, 
 which, although not easily described, is readily dis- 
 tinguished from the crepitus occasioned by a frac- 
 tured bone. In a sitting posture the injured leg 
 was two inches longer than the other; and to that 
 degree the knee was projected beyond the sound 
 one. In progression the knee was bent ; and the 
 body being thrown forwards the patient rested 
 chiefly upon his toe, and halted exceedingly in walk- 
 ing. The sartorius and gracilis muscles were very 
 much put upon the stretch. At first he suflTered 
 much from pain in the dislocated hip and thigh, but 
 
PARTICULAR DISLOCATIONS. 
 
 is now free from pain, unless when he attempts to 
 stand on that limb onljc His toe, at first, was with 
 difficulty brought to the ground, but he is now im- 
 proved in walking ; for when he first made trial, 
 with the assistance of a crutch and stick, he could 
 not exceed half a mile, but he is now able to walk 
 two miles. In flexion his thigh admits of consider- 
 able motion, but he cannot extend it further than 
 to bring the ham to the plane of the other patella. 
 The knees cannot be brought together, but he ad- 
 vances one before the other in the attempt. He 
 can sit without pain, but the jolting of a carriage 
 hurts him exceedingly; and the attempt to sit on 
 horseback produces excessive suffering. He cannot 
 straighten his leg when his body is erect, nor can 
 he stoop to tie his shoe on the injured side. Pain 
 is produced by resting on that hip in bed. No at- 
 tempt was made to reduce the limb ; the injury to 
 the head might have rendered it dangerous in the 
 commencement, and at the time when I saw him 
 there was no chance of success. 
 
 Dislocation of the right Femur downwards, or into 
 the Foramen Ovale. 
 
 Sir: — Inclosed is the case of dislocation which 
 you requested me to forward to you, and I am sor- 
 ry it has not been in my power to put you in pos- 
 session of it before, for reasons which I stated when 
 I saw you last. 
 
 I am, Sir, 
 
 LeadenhaU Street, Your obliged servant, 
 
 February Mith, 1820. J. S. Daniell. 
 
 Case. — Mr Thomas Clarke, a farmer, about fifty 
 years of age, was driving home in his cart from 
 
PARTICULAR DISLOCATIONS. 
 
 85 
 
 market, when the horse took fright and ran away 
 with him. The following is the account he gives 
 of the manner in which the accident happened: — 
 in his endeavour to stop the horse, he fell over the 
 front of the cart on his lace, and the knee struck 
 against some part of it in the act of falling, by 
 ^by which means the thighs were separated; the 
 ^heel, he also states, passed over his hip.* 
 
 My friend, Mr Potter, of Ongar, in Essex, whose 
 ability as a surgeon in that neighbourhood is justly 
 appreciated, was consulted in this case, between two 
 and three weeks after the accident had happened ; 
 and, as I was visiting him at the time, 1 had the 
 pleasure of accompanying him. 
 
 The nature of the accident was extremely evi- 
 dent ; the limb was fully three inches longer than 
 the other, the body bent forwards, the knees sepa- 
 rated, and the foot rather inclined outwards ; these 
 were the leading diagnostic marks. Mr Potter, hav- 
 ing clearly ascertained the position of the dislocated 
 limb, I accompanied him the following morning, in 
 order to assist in the reduction; and the following 
 were the means employed. 
 
 Our first object was to produce relaxation ; and 
 finding the patient was sufficiently strong to bear the 
 plan usually recommended in cases of dislocation, 
 where much resistance is expected, we drew away 
 some blood from the arm ; this, however, was not 
 sufficient for our purpose, and a solution of tartar 
 emetic, which we had brought with us, was adminis- 
 tered. The patient was laid upon his side, close to 
 the edge of the bed (that being the most convenient 
 place), a girth was passed round the pelvis, and car- 
 ried through the frame of the bedstead, which com- 
 
 * Q^uery. — Was this, or the extended state of the limbs, the 
 cause of the dislocation ? A. C, 
 
86 
 
 PARTICULAR DISLOCATIONS. 
 
 pletely prevented the possibility of the body moving 
 whilst extension was going on ; a second girth was 
 applied between the thighs, fixed to the one above, 
 to which the pulleys were attached. Whilst exten- 
 sion was making, Mr Potter took hold of the limb at 
 the knee, and drew it rather upwards, and towards 
 the sound thigh, occasionally rotating the limb. 
 When the extension had been continued about ter^ 
 minutes, the nausea produced by the tartar emetic 
 was so excessive, that the patient begged of us to 
 desist until the morrow, observing, he felt so bad, 
 that he was fearful of falling off the bed; this ex- 
 clamation, it hardly need be said, was a stimulus to 
 our proceeding; and in five minutes after, the limb 
 was. suddenly heard to snap into its original cavity. 
 The patient was put to bed^ a roller being applied 
 round the pelvis, and at the end of five days, he felt 
 so well that he left his room ; and at the expiration 
 of a short time, suffered no other inconvenience than 
 stiffness in the joint. 
 
 J. S. Daniell.* 
 
 Mischief from improper extension* — Although a 
 dislocation into the foramen ovale, may be occasion- 
 ally reduced by attempts made in a very inappropri- 
 ate direction, yet an instance has occurred which 
 shows the mischief that may arise from an error in 
 this respect. 
 
 I once saw the following case. 
 
 Case. — A boy, sixteen years old, had a dislocation 
 of the thigh into the foramen ovale : he was placed 
 
 * Mr Daniell's knowledge of his profession, and his zeal in 
 the pursuit of it, which I have had frequent opportunities of 
 observing, warrant the most sanguine hopes of his success in 
 practice. — A. C. 
 
PARTICULAR DISLOCATIONS. 
 
 87 
 
 upon his sound side, and an extension of the superior 
 part of the thigh was made perpendicularly; the 
 surgeon then pressed down the knee, but the thigh 
 being at that moment advanced, the head of the 
 bone was thrown backwards, and passed into the 
 ischiatie notch ; from which situation it could not 
 be reduced. 
 
 I am indebted to Mr Key, for the particulars of 
 the annexed case, which Avas admitted into Guy's 
 Hospital, under Mr Forster. 
 
 Dislocation of the Thigh into the Foramen Ovale. 
 
 Case, — Stephen Holmes, aged forty-one, while 
 working in a gravel pit, at Camberwell, was sudden^ 
 ly overwhelmed by a large mass of gravel, and re- 
 mained buried under it, till dug out by his com- 
 panions. When the gravel was removed, he was 
 found in a sitting posture, with his legs widely sepa- 
 rated, and unable to approximate them. In this po- 
 sition he was brought to Guy's, about seven o'clock 
 in the evening, an hour after the accident had hap- 
 pened, and was placed under the care of Mr Carey, 
 dresser to Mr Forster. 
 
 Being undressed and placed in bed in the recum- 
 bent posture, he was seen lying with his left thigh 
 bent upon the pelvis, his knee consequently elevat- 
 ed, and the whole limb fixed at a considerable dis- 
 tance from the other. On carrying the eye to the 
 upper part of the thigh near the hip-joint, a consid- 
 erable change in form was manifest ; the projec- 
 tion of the trochanter was entirely lost, and in its 
 place a deep hollow was perceptible ; while, at the 
 inner part of the thigh, near the pubes, a distinct 
 projection appeared, having the form of the head 
 
88 
 
 PARTICULAR DISLOCATIONS. 
 
 of the bone covered by the adductor muscles. From 
 these general appearances, we regarded the acci- 
 dent as a dislocation of the femur into the foramen 
 ovale of the pelvis, and proceeded to make a more 
 minute examination of the limb, to ascertain the 
 precise nature of the injury. 
 
 The man was desired to rise from his bed and sit 
 on the edge of it, which he did without incon- 
 venience or pain ; in this position his left knee pro- 
 jected at least two inches and a half beyond the 
 sound limb ; this apparent elongation of the leg, 
 arose principally from the oblique bearing of the 
 pelvis, the real elongation being afterwards ascer- 
 tained to be not more than an inch and a quarter. 
 In the erect posture, which he maintained with some 
 difficulty, his body was bent forward in consequence ' 
 of the projection of the pelvis over the thigh : the 
 knee was bent, and the toe, which was slightly in- 
 verted, rested on the ground; the whole limb was 
 advanced before the sound one, and remained in a 
 state of abduction. He was then laid upon a firm 
 table on his back, and the capability of motion in 
 the limb was carefully noted. His knee was first 
 bent toward his breast without any difficulty, and to 
 as full an extent as the opposite limb ; the power of 
 abduction was also complete, and the attempt was 
 unattended with pain ; but extension and adduction 
 of the thigh were the motions most impeded. When 
 the limb was made to approximate to the sound 
 one, which could not be done without producing 
 pain and numbness on the inner side of the thigh, 
 the patellae remained eleven inches distant from 
 each other ; and as soon as the hand was withdrawn 
 from the ankle, the leg flew outward with a spring 
 from the reaction of the two small glutaei. The 
 limb could not be carried backward, but remained 
 permanently bent at the hip-joint ; and when any 
 attempt was made to fix it, the patient complained 
 
PARTICULAR DISLOCATIONS 
 
 89 
 
 of great pain in the direction of the psoas and ihacus 
 muscles. The depression observed at the site of the 
 trochanter was such as to render it difficult to feel 
 that process; while on the inner side of the thigh, 
 a distinct projection was formed by the head of the 
 bone, which could be felt under the adductors. 
 These latter muscles were rendered very tense by 
 the projecting bone. The nates appeared to pre- 
 serve their usual form. 
 
 Reduction, — Having never had an opportunity of 
 witnessing this kind of dislocation since my attendance 
 at the hospitals, during the last eight years, I wished 
 to see how far the method of reduction which you 
 have laid down was applicable in the present case. 
 Your 'Treatise on Dislocations and Fractures' be- 
 ing in the hands of one of the students, we referred 
 to the plate, and proceeded to apply the pulleys and 
 bandage in the manner there delineated. The ap- 
 paratus being once carefully and securely adjusted, 
 required no alteration, as it neither slipped from its 
 situation, nor occasioned any inconvenience to the 
 patient. Extension was then made by drawing the 
 displaced limb across its fellow, while the pulleys 
 drew the head of the bone outwards : but in doing 
 this, we ran some risk of throwing the head of the 
 femur into the ischiatic notch ; for the thigh beins: 
 large and fleshy at the back part, was, when drawn 
 across the other, necessarily carried somewhat for- 
 ward, and thus tilted the head of the bone back- 
 ward. Had any alteration taken place in the situ- 
 ation of the head of the femur durins: this exten- 
 sion, it would have been carried under the acetabu- 
 lum into the ischiatic notch ; it was therefore thought 
 advisable to carry the leg behind the sound one; 
 and as soon as this was done, the head returned, 
 with an audible crack, into the acetabulum. The 
 whole extension occupied fifteen minutes. 
 
 12 
 
90 
 
 PARTICULAR DISLOCATIONS. 
 
 This species of dislocation of the femur, is by 
 far the most easy of reduction of any that has come 
 under my observation; and it may be presumed, 
 that had the leg at first been carried behind instead 
 of before the other, the replacement of the limb 
 might have been effected immediately. Where the 
 limb is large it is impossible to carry it in a right 
 line across its fellow ; and, perhaps, in order to 
 avoid the danger to which I have alluded, and which 
 I have often heard you point out in your lectures, it 
 would be as well to adopt the line of extension which 
 in this instance answered so Avell. 
 
 October 15, 1822. — This patient could stand by 
 the side of his bed without support in a week after 
 the accident. 
 
 W. A. Key. 
 
 DISLOCATION BACKVTARDS, OR INTO THE ISCHIATIC NOTCH. 
 
 Anatomical structure, — The space which is called 
 the ischiatic notch is bounded above and anteriorly 
 by the ilium, posteriorly by the sacrum, and inferior- 
 ly by the sacro-sciatic ligament. It is formed for the 
 purpose of giving passage to the pyriformis muscle 
 and to the sciatic nerve, as well as to the three ar- 
 teries, the gluta3al, the ischiatic, and the internal pu- 
 dendal. In the natural position of the pelvis, it is 
 situated posteriorly to the acetabulum and a little 
 above its level. When the head of the bone is 
 thrown into this space, it is placed backwards and 
 upwards, with respect to the acetabulum ; therefore, 
 although I call this the dislocation backwards, it is 
 to be remembered that it is a dislocation backwards 
 and a little upwards. 
 
 JYature of the accident, — In this dislocation the 
 head of the thigh-bone is placed on the pyriformis 
 
PARTICULAR DISLOCATIONS. 91 
 
 muscle, between ihe edge of the bone which forms 
 the upper part of the ischiatlc notch, and the sacro- 
 sciatic ligaments, behind the acetabuham, and a little 
 above the level of the middle of that cavity. 
 
 Detection difficult. — ^ This dislocation is the most 
 difficult both to detect and to reduce : to detect, 
 because the length of the limb differs but little, and 
 its position, in regard to the knee and foot, is not so 
 much changed as in the dislocations upwards: to re- 
 duce, because the head of the bone is placed deep 
 behind the acetabulum, and it therefore requires to 
 be lifted over the edge of that cavity, as well as to 
 be drawn towards its socket. 
 
 Signs. — The signs of this dislocation are, that 
 the limb is from half an inch . to one inch shorter 
 than the other, but generally not more than half 
 an inch ; that the trochanter major is behind its 
 usual place, but is still remaining nearly at right 
 angles with the ilium, with a slight inclination to^ 
 wards the acetabulum. The head of the bone is 
 so buried in the ischiatic notch that it cannot be dis'» 
 tinctly felt, except in thin persons, and then only by 
 rolling the thigh-bone forwards as far as the compa- 
 ratively fixed state of the limb will allow. The 
 knee and foot are turned inwards, but less than in 
 the dislocation upwards ; and the toe rests against 
 the ball of the great toe of the other foot. When 
 the patient is standing, the toe touches the ground, 
 but the heel does not quite reach it. The knee is 
 not so much advanced as in the dislocation upwards, 
 but is still brought a little more forwards than the 
 other, and is slightly bent. The limb is so fixed 
 that flexion and rotation are in a great degree pre- 
 vented. 
 
 Dissection, — There is a good specimen of this 
 accident in the collection at St Thomas's Hospital, 
 which I met with accidentally, in a subject brought 
 for dissection. The original acetabulum is entirely 
 
92 
 
 PARTICULAR DISLOCATIONS. 
 
 filled with a ligamentous substance, so that the head 
 of the bone could not have been returned into it. 
 The capsular ligament is torn from its connexion 
 with the acetabulum, at its anterior and posterior 
 junction, but not at its superior and inferior. The 
 Jigamentum teres is broken, and an inch of it still 
 adheres to the head of the bone. The head of 
 the bone rests behind the acetabulum on the pyri- 
 formis muscle, at the edge of the notch, above the 
 sacro-sciatic ligaments. The muscle on which it 
 rests is diminished, but there has been no attempt 
 made to form a new bony socket for the head of 
 the OS femoris. Around the head of the thigh- 
 bone a new capsular ligament is formed ; it does 
 not adhere to the articulatory cartilage of the ball 
 of the bone which it surrounds, but could, when 
 opened, be turned back to the neck of the thigh- 
 bone, so as to leave its head completely exposed. 
 Within this new capsular ligament, which is formed 
 of the surrounding cellular membrane, the broken 
 ligamentum teres is found. (See Plate,) The tro- 
 chanter major is placed rather behind the acetabu- 
 lum, but inclined towards it relatively to the head of 
 the bone. 
 
 In this specimen, from the appearance of the 
 parts, the dislocation must have existed many years ; 
 the adhesions were too strong to have admitted of 
 any reduction, and if reduced, the bone could not 
 have remained in its original socket. 
 
 Cause, — This species of dislocation is produced 
 by the application of force, when the body is bent 
 forward upon the thigh, or when the thigh is bent 
 at right angles with the abdomen ; in which posi- 
 tions, if the knee be pressed inward, the head of 
 the bone is thrown behind the acetabulum. 
 
 The reduction of the dislocation in the ischiatic 
 notch, is, in general, extremely difficult, and is best 
 
PARTICULAR DISLOCATIONS. 
 
 93 
 
 effected in the following manner : the patient should 
 be laid on a table upon his side, and a girth should 
 be placed between the pudendum and the inner 
 part of the thigh, to fix the pelvis. Then a wet- 
 ted roller is to be applied around the knee, and 
 the leathern strap over it. A napkin is to be car- 
 ried under the upper part of the thigh. The 
 thigh-bone is then to be brought across the middle 
 of the other thigh, measuring from the pubes to 
 the knee, and the extension is to be made with the 
 pulleys. Whilst this is in progress, an assistant 
 pulls the napkin at the upper part of the thigh 
 with one hand, rests the other upon the brim of 
 the pelvis, and thus lifts the bone, as it is drawn 
 towards the acetabulum, over its lip. For the nap- 
 kin I have seen a round towel very conveniently 
 substituted, and this was carried under the upper 
 part of the thigh, and over the shoulders of an 
 assistant, who then rested both his hands on the 
 pelvis, as he raised his body, and lifted the thigh. 
 (See Plate.) 
 
 Although the preceding is the method in which 
 this dislocation is most easily reduced, yet I have 
 seen a different mode practised; and I shall men- 
 tion it here, as it shows how the muscles opposing 
 the pulleys, will draw the head of the bone to its 
 socket, when it is lifted from the cavity into which 
 it has fallen. 
 
 Case, —A man, aged twenty-five, was admitted 
 into Guy's Hospital, under the care of Mr Lucas ; 
 upon examination, the thigh was found dislocated 
 backwards; the limb scarcely differed in length 
 from the other, being not more than half an inch 
 shorter ; the groin appeared depressed ; the tro- 
 chanter was resting a little behind the acetabulum, 
 but inclined upon it ; the knee and foot w^ere turn- 
 ed inwards, and the head of the bone could, in this 
 
94 
 
 PARTICULAR DISLOCATIONS. 
 
 case, be felt behind the acetabuhmi. An extension 
 was made bj pullejs in a right hne with the body ; 
 at the saoie time, the trochanter major was thrust 
 forward with the hand, and the bone returned in 
 about two minutes into its socket with a violent 
 snap. 
 
 1 have already mentioned, that I have seen no 
 instance of a dislocation downwards and backicards ; 
 and when I state, that I have been an attentive 
 observer of the practice of our hospitals for thirty 
 years, was also for many years in the habit of 
 daily seeing the poor of London at my house early 
 in the morning, and have had a considerable share 
 of private practice, I may be allowed to observe, 
 that if such a case does ever occur, it must be 
 extremely rare. I cannot help thinking, also, that 
 some anatomical error must have given rise to 
 this opinion, as, in the dislocation downwards and 
 backwards, the head of the bone is described as 
 being received still into the ischiatic notch; but 
 this notch is, in the natural position of -the pelvis, 
 above the level of the line drawn through the 
 middle of the acetabulum ; and hence it is, that the 
 leg becomes, not shorter, but longer, when the bone 
 is dislocated into the ischiatic notch. 
 
 Dislocation of the right Thigh into the Ischiatic JVotch, 
 
 The following cast) I received from Mr Rogers, a 
 very intelligent surgeon at Manningtree. 
 
 Case. — Dear Sir : — William Dawson, aged thirty- 
 four, on the irnh of August, 1818, while spending 
 his harvest-home with several of his companions, 
 became quarrelsome with one of them, who threw 
 him down, and trod upon him. Upon extricating 
 himself, and endeavouring to rise, he found some 
 
PARTICULAR DISLOCATIONS. 
 
 95 
 
 serious injury to his right thigh, rendering him inca- 
 pable of standing; in this state he was dragged by 
 his associates tor many hundred yards into a stable, 
 where he lay till the next morning. I then saw him 
 lying upon a mattress, with the hip and thigh on the 
 right side prodigiously swollen and painful ; and I 
 was particularly struck with the appearances of the 
 knee and foot on the same side, which w^ere very- 
 much turned inwards, but the limb was scarcely 
 shortened. I ordered him to be carefully conveyed 
 home upon a shutter, supported by six men, a dis- 
 tance of about half a mile. From the immense 
 swelling and general enlaVgement of the whole of 
 the thigh, and of the soft parts around, the pelvis, 
 it was impossible to ascertain exactly the state of 
 the injury ; but it was fully impressed upon my mind, 
 that there was some unusual dislocation of the head 
 of the thigh-bone. He was accordingly ordered 
 immediately to lose blood, both by general and to- 
 pical means, and emollient poultices were applied to 
 the whole of the swollen parts ; brisk purgatives 
 were also administered, succeeded by saline medi- 
 cines, and a quiet position was enjoined for eleven 
 days, by w^hich time the swelling began somewhat 
 to subside. Still the precise nature of the injury 
 was not satisfactorily evident ; but it w^as thought by 
 Mr Nunn, of Colchester, and Mr Travis, of East 
 Bergholt, wdio had kindly come over to witness it, 
 that there was a luxation. The only difficulty we 
 had in reconciling this notion to ourselves was, the 
 belief in our minds that no author had adduced an 
 instance of this accident, without an alteration in 
 the length of the limb, except it might be Mr Astley 
 Cooper, in his new publication, which neither of us 
 had yet seen. We accordingly had recourse to a 
 minute examination of the skeleton; when we im- 
 mediately fancied we could account for the absence 
 
96 
 
 PARTICULAR DISLOCATIONS. 
 
 of the usual marked signs of displacement of the 
 head of the bone, excepting the inversion of the 
 knee and foot, in this kind of luxation; for we 
 noticed, that if the head of the bone be luxated 
 sideways into the ischiatic notch, it will produce 
 scarcely any difference in the length of the limb. 
 Trusting that a little further delay might not be 
 attended with any material disadvantage, but give a 
 chance for the entire subsidence of all the inflamma- 
 tion and swelling, we proposed meeting again as soon 
 as we conveniently could, by which time we might 
 consult Mr Cooper's book. We accordingly met 
 on Sunday, the 30th of "August, which was fifteen 
 days after the accident ; and from the complete re- 
 moval of all swelling, the whole of the femoral bone 
 was satisfactorily traced to its rounded head, which 
 was lodged in the ischiatic notch. 
 
 Upon referring to the ' Essays,' which we had 
 now before us, we had the case delineated and de- 
 scribed ; and as it was e-xhibited in a plate, we had 
 only to imitate, in order to accomplish the reduction 
 of the bone. In the presence of two or three other 
 medical gentlemen, who had now joined us, we com- 
 menced the operation; and as it would be unnecessa- 
 ry to state every particular, considering the manner in 
 which the position of the patient, and the fixing of 
 the pulleys and towels, are demonstrated by that 
 publication, suffice it for me to remark, that, 
 after ten or twelve minutes of gradual extension, the 
 reduction of the bone was most readily and admir- 
 ably accomplished. 
 
 Preparatory to commencing the operation, we 
 took thirty ounces of blood from the arm ad deli- 
 quium, and afterwards, while fixing the pulleys, etc, 
 we gave four grains of tartarized antimony, at inter- 
 vals, to produce nausea. Immediately after the 
 operation, we gave one grain of opium, applied seda- 
 
PARTICULAR DISLOCATIONS. 
 
 97 
 
 tive lotions to the parts, and proceeding carefully 
 for about a fortnight, the patient was enabled to 
 move upon crutches, and was shortly after sent home 
 perfectly well. 
 
 1 am yours respectfully, 
 
 John Rogers. 
 
 Manningtree, August 15th, 1818. 
 
 The relation of the foregoing case, from the kind 
 manner in which Mr Rogers has expressed himself, 
 may savour a little of vanity; but I shall readily 
 suffer this imputation, and shall not shrink from 
 avowing the satisfaction which I feel, whenever my 
 endeavours have in any degree conduced to the 
 advantage of my professional brethren, or to the 
 benefit of those who may be placed under their 
 care. 
 
 Incorrect description by authors, — The dislocation 
 into the ischiatic notch has been, as far as I know, in 
 every author who has written on the subject, incor- 
 rectly described; for it has been stated, that the 
 limb was lengthened in this accident, and I need 
 scarcely mention the mistakes in practice which have 
 originated in so erroneous an opinion : one instance, 
 however, of such an error I must here give. A 
 gentleman wrote to me from the country in these 
 words: — 'I have a case under my care of injury to 
 the hip, and I should su|>pose it a dislocation into the 
 ischiatic notch, but that the limb is shorter, instead of 
 being longer, as authors state it to be.' Into this error 
 those authors must have fallen from having examined 
 a pelvis separated from the skeleton, and observed 
 that the ischiatic notch was below the level of the 
 acetabulum when the pelvis was horizontal, although 
 it is above the acetabulum in the natural oblique 
 13 
 
98 
 
 PARTICULAR DISLOCATIOJSS. 
 
 position of the pelvis, at least, as regards the hori- 
 zontal axis of the two cavities. It is to be remem- 
 bered, that there is no such accident as a dislocation 
 of the hip downwards and backwards. 
 
 I am indebted to Mr James Chapman, dresser at 
 Guy's Hospital, for the following particulars. 
 
 Case. — John Cockburn, a strong muscular man, 
 aged thirty-three, was admitted into Guy's Hospital 
 on the 31st of July, IJilO. While carrying a bag of 
 sand, at Hastings, on the 24th of June, he slipped, 
 and dislocated the lei't hi[)-joint ; and the following 
 is the account he gives of the accident: — the foot 
 on the affected side was plunged suddenly into a 
 hollow in the road, which turned his knee inwards 
 at the same time that his body fell with violence 
 forwards. On the day on which the accident hap- 
 pened, two attempts were made to reduce the dislo- 
 cation by pulleys, but without success; and on the 
 27th of June, a third, but equally unsuccessful, trial 
 was made, although continued for nearly an hour. 
 He was directed to Guy's Hospital by Mr Stewart, 
 surgeon at Hastings. 
 
 It w^as found upon examination, after he had been 
 admitted, that the thigh was dislocated backwards 
 into the ischiatic notch, the limb was a little short- 
 ened, the knee and foot were turned inwards, and 
 the toe rested on the ball of the great toe of the 
 other foot; the head of the bone could not be felt; 
 the trochanter major was opposite the acetabulum, 
 the rim of which could be distinctly perceived. 
 When the body was fixed, the thigh could be bent 
 so as nearly to touch the abdomen. The patient 
 was carried into the operating theatre soon after his 
 admission; and when two pounds of blood had been 
 taken from him, and he had been nauseated by two 
 grains of tartarized antimony, gradually administer- 
 
PARTICULAR DISLOCATIONS. 
 
 99 
 
 ed, extension was made with the pulleys in a right 
 line with the body, and the upper part of the thigh 
 was raised wiiile the knee was depressed ; the ex- 
 tension was continued al least for an hour and a half, 
 during which time he took two grains more of tar- 
 tarized antimony, by which he was thoroughly nause- 
 ated ; the attempts, however, at reduction did not 
 succeed. 
 
 On the third of August, the tenth day from the 
 accident, Mr Astley Cooper succeeded in reducing it 
 in the following manner ; — he ordered so much 
 blood to be taken from the arm as to produce a 
 feeling of faintness. A table was placed in the 
 centre, between two staples, upon which the patient 
 was laid on his right side ; a girth was passed be- 
 tween the scrotum and the thigh, and carried over 
 the pelvis to the &ta[)le behind hiijj ; and thus the 
 pelvis was, as far as possible, fixed ; a wetted roller 
 was carried around the lower part of the thigh, 
 just above the knee, and a leathern strap buckled 
 on it, to which, and to a staple before the limb, the 
 pulleys were fixed. The body was bent at right 
 angles with the thigh, which crossed the upper part 
 of the other thigh; then the extension with the 
 pulleys was begun, and gradually increased until it 
 became as great as the patient could bear. An 
 assistant was then directed to get upon the table, 
 and to carry a strong band under the upper part of 
 the thigh, by which he lifted it from the pelvis, so 
 as to give an opportunity for the head of the bone 
 to be turned into its socket. Mr South, who held 
 the leg, was directed to rotate the limb inwards, and 
 the bone, in thirteen minutes, was heard to snap 
 suddenly and violently into its socket. 
 
 I believe, that in this case, I should not have 
 succeeded in reducing the limb, but from attention 
 to two circumstances : first, I observed that the 
 
100 
 
 PARTICULAR DISLOCATIONS. 
 
 pelvis advanced within the strap which was employ- 
 ed to confine it, so that the thigh did not remain at 
 right angles; and I was obh'ged to bend the body 
 forward to preserve the right angle during exten- 
 sion ; and, secondly, the extension might have been 
 continued for any length of time, yet the limb 
 would never have been reduced, but by the rotation 
 of the head of the thigh-bone tow^ards the ace-- 
 tabulum. 
 
 Mr Wickham, jun. of Winchester, has had the 
 kindness to inform me of a case of this dislocation 
 which had been admitted into the Winchester 
 Hospital, under the care of Mr Mayo, one of the 
 surgeons of that institution, w^ith whose permission 
 the following circumstances are related. 
 
 Winchester, August 10th, 1819. 
 Case. — John Norgott, aged forty, was brought 
 to the hospital on the 27th of December, 1817, 
 from the neighbourhood of Alton, with an injury of 
 the hip; twelve days had elapsed since the accident, 
 Avithout his being aware of the nature of the injury. 
 He reported that his horse had fallen with him and 
 on him, so that one leg was under the horse, whilst 
 his body was in a half-bent position, leaning against 
 a bank. He was of middle stature, but very mus- 
 cular; the leg was very inconsiderably shorter than 
 the other, and but little advancing over it ; in fact, 
 the immobility of the limb was the chief criterion 
 of the dislocation ; for the head of the bone was 
 thrown into the ischiatic notch. The mode of re- 
 duction was simple : Mr Mayo had the limb extend- 
 ed by the pulleys, so as to bring the head of the 
 bone to the edge of the acetabulum, over which it 
 was then tilted by a towel, fastened round the 
 
PARTICULAR DISLOCATIONS. 
 
 101 
 
 patient's thigh and the neck of an assistant. The 
 man remained three or four weeks before he was 
 allowed to leave the house ; but on the 4th of Feb- 
 ruary, he was discharged cured. 
 
 The following case was communicated by Mr 
 Worts, dresser to Mr Chandler, surgeon to St 
 Thomas's Hospital. 
 
 Case. — James Hodgson, a sailor, aged thirty-eight 
 years, a strong muscular man, was admitted into St 
 Thomas's Hospital, on Tuesday, the 18th of Feb- 
 ruary, for an injury which he had received in his left 
 hip; his foot having been raised from the ground 
 upon a chest of fruit, when another fell upon his 
 thigh, striking the knee inwards ; he fell, and being 
 taken up extremely hurt, he was directly brought 
 to the hospital. Upon examination, I conceived that 
 it was a dislocation of the hip-joint, and that the 
 head of the bone was thrown into the ischiatic 
 notch. Some difference of opinion, however, arose 
 upon the subject; and as considerable tension exist- 
 ed, which prevented the head of the bone from 
 being distinctly felt, I ordered an evaporating lo- 
 tion, and left the case for further inquiry. On re- 
 flection, my opinion was strengthened concerning the 
 nature of the injury, as it was clearly pointed out by 
 the diminished length of the leg, which was three 
 quarters of an inch shorter than the other, and by 
 the inversion of the foot; although there was in this 
 case more power of flexion in the limb than might 
 have been expected, but no rotation outwards. Mr 
 Chandler saw the case on Saturday the 12th, and, 
 on account of the tension, he ordered some leeches 
 to be applied to the part, and the lotion to be con- 
 tinued. Mr Cline saw it this afternoon, and thought 
 it a dislocation in the ischiatic notch. 
 
102 
 
 PARTICULAR DISLOCATIONS. 
 
 Monday morning, the 14th. The swelhnghad great- 
 ly subsided, and I thought I could now feel the head 
 of the bone on rotation of the limb. Mr Chandler 
 saw the case again this morning, and expressed a wish 
 for Mr A. Cooper to see it. Mr Cooper, at my re- 
 quest, very kindly saw^ it in the evening, and immedi- 
 ately declared it to be a dislocation into the ischiatic 
 notch; and upon his rotating the thigh, I could much 
 more distinctly than before feel the head of the bone 
 in the ischiatic notch. Mr Cooper recommended me 
 to take away blood, which I did the next morning, 
 to the amount of sixteen ounces ; this considerably 
 relieved the pain the man had previously suffered, 
 and the tension continued to abate till the Saturday 
 morning following, when Mr Chandler again saw him, 
 and he thought it had sufficiently subsided to justify 
 the attenx|rtat reduction. I accordingly made prepar- 
 ations in the following manner: — at about half-past- 
 two o'clock, I took sixteen ounces of blood from the 
 patient, which produced no sensible effect ; at ten 
 minutes past three, I took about twenty-seven ounces 
 more, and while the blood was flowing, gave him a 
 grain of emetic tartar; this 1 repeated till he had 
 taken five grains at intervals of a few minutes ; and as 
 he was becoming faint, he was taken into the thea- 
 tre. I applied the bandages and pulleys to the pel- 
 vis and to the knee, bringing the thigh over the other ; 
 we kept up the extension about ten or twelve minutes 
 before we used the strap to raise the head of the 
 bone, and until I thought it had made some progress 
 towards the acetabulum. We then continued the 
 extension, gradually increasing it, at the same time 
 endeavouring to raise the head of the bone and turn- 
 ing the knee outwards, for about fifteen minutes. 
 I had now lost the head of the bone, but still, as it 
 had not made the usual noise in its reduction, I thought 
 that it would be wrong to jremove the pulleys, as the 
 
PARTICULAR DISLOCATIONS. 
 
 103 
 
 action of the muscles, if the bone had not been reduc- 
 ed, would have again drawn it up, in which opinion 
 Mr Martin, who assisted me, concurred. The man 
 was now very faint, the extension was therefore con- 
 tinued for about twenty-five minutes longer, when 
 the strap at the knee getting rather loose, we remov- 
 ed the pulleys, upon which it was found that the 
 thigh could now be moved in any direction, and that 
 its position was perfectly natural. The bone was 
 replaced, but at what time it had gained its situation 
 no one could judge, neither could the man describe 
 any feeling that could have indicated it ; he was car- 
 ried to bed in a very faint state. 
 
 He had no sickness during or after the extension. 
 1 gave him a grain and a half of opium at night, 
 which procured rest. 
 
 Sunday morning. — He had some pain remaining, 
 but it was greatly abated, and the thigh could be 
 moved in any direction. 
 
 Feb. 22, 1820. W. Worts. 
 
 Mr Worts naturally expresses surprise that the 
 bone was reduced without its entering the acetabu- 
 lum with the usual iioise ; but when the muscles have 
 been some time contracted, and when the patient is 
 rendered faint by bleeding, and by the nausea of tar- 
 tarized antimony, they do not act with the same 
 violence as in the first few hours after the accident. 
 
 toisLocATioN ON the pubes. 
 
 Cause, — This dislocation is more easy of detec- 
 tion than any other of the thigh. It happens when a 
 person, while walking, puts his foot into some unex- 
 
104 
 
 PARTICULAR DISLOCATIONS. 
 
 pected hollow in the ground; and his body at the 
 moment being bent backwards, the head of the bone 
 is thrown forwards upon the os pubis. A gentle- 
 man, who had met with this dislocation in his own 
 person, informed me that it happened whilst he was 
 walking across a paved yard in the dark : he did not 
 know that one of the stones had been taken up, and 
 his foot suddenly sunk into the hollow, and he fell 
 backwards. When his limb was examined, the head 
 of the thigh-bone was found upon the os pubis. 
 
 Symptoms, — In this species of dislocation the 
 limb is an inch shorter than the other, the knee and 
 foot are turned outwards, and cannot be rotated in- 
 wards, but there is a sh'ght flexion forwards, and 
 outward; and in a dislocation which had been long 
 unreduced, the motion of the knee backwards and 
 forwards was full twelve inches ; but the striking 
 criterion of this dislocation is, that the head of the 
 thigh-bone may be distinctly felt upon the pubes, 
 above the level of Poupart's ligament, on the outer 
 side of the femoral artery and vein ; and it feels as 
 a hard ball there, which is readily perceived to move 
 by bending the thigh-bone. 
 
 JVot detected. — Although this dislocation is appa- 
 rently easy of detection, I have known three in- 
 stances in which it was overlooked, until it was too 
 late for reduction; of one, there is a preparation at 
 St Thomas's Hospital ; another occurred to a gen- 
 tleman from the country, in whom it was not dis- 
 covered until some weeks after the accident, who 
 then submitted to an extension which did not suc- 
 ceed, and came to London to ask my opinion, when 
 I advised him against a further attempt; and, in- 
 deed, he himself was disinclined to any other trial. 
 The third was a patient in Guy's Hospital, who was 
 admitted for an ulcerated leg, and was found to have 
 a dislocation upon the pubes, which had happened 
 
PARTICULAR DISLOCATIONS. 
 
 105 
 
 some years before. It really must be great care- 
 lessness which leads to this error, as the case is so 
 strikingly marked. 
 
 Dissection, — I dissected one of these dislocations, 
 and we have it preserved in our anatomical collec- 
 tion. It shows changes of parts nearly equal to 
 those of the dislocation into the foramen ovale. The 
 original acetabulum is partly filled by bone, and 
 partly occupied by the trochanter major, and both 
 are much altered in their form. The capsular li- 
 gament is extensively lacerated, and the ligamen- 
 tum teres is broken. The head of the thigh-bone 
 had torn up Poupart's ligament, so as to penetrate 
 between it and the pubes. The head and neck of 
 the bone were thrown into a position under the ilia- 
 cut internus and psoas muscles ; the tendons of which, 
 in passing to their insertions over the neck of the 
 bone, were elevated by it, and put on the stretch. 
 The crural nerve passed on the fore part of the 
 neck of the bone upon the iliacus internus and psoas 
 muscles. The head and neck of the thigh-bone 
 were flattened, and much changed in their form. 
 Upon the pubes a new acetabulum is formed for the 
 neck of the thigh-bone, the head of the bone being 
 above the level of the pubes. The new acetabulum 
 extends upon each side of the neck of the bone, so 
 as to lock it laterally upon the pubes. {See Plate.) 
 Poupart's ligament confines it on the fore part; on 
 the inner side of the neck of the bone passed the 
 artery and vein, so that the head of the bone was 
 seated between the crural sheath and the anterior 
 and inferior spinous process of the ilium. 
 
 Distinguished fromjracture. — This accident might, 
 by an inattentive observer, be mistaken for a fracture 
 of the neck of the thigh-bone; but the head of the 
 bone felt upon the pubes will decide its nature. 
 
 Reduction, — In the reduction of this dislocation, 
 14 
 
106 
 
 PARTICULAR DISLOCATIONS. 
 
 the patient is to be placed on his side on a table; -a 
 girth is to be carried between the pudendum and in- 
 ner part of the thigh, and fixed in a staple a little 
 before the line of the body. The pulleys are fixed 
 above the knee, as in the dislocation upwards, and 
 then the extension is to be made in a line behind the 
 axis of the body, the thigh-bone being drawn back- 
 wards. (^See Plate,) After this extension has been 
 for some time continued, a napkin is placed under the 
 upper part of the thigh, and an assistant, pressing 
 with one hand on the pelvis, lifts the head of the 
 bone, by means of the napkin, over the pubes and 
 edge of the acetabulum. 
 
 The following case, which occurred in Guy's Hos- 
 pital, at the time when my friend, Mr now Dr Gait- 
 skill, was dresser to Mr Forster, will best exemplify 
 the mode of reduction. He was a dresser in the 
 years 1803 and 1804. 
 
 Bath, August 1 3tK 1 8 1 7. 
 Dear Sir : — The report of the case of dislocated 
 thigh, which I have sent you, contains every material 
 circumstance within my recollection ; it will afford 
 me much pleasure if you can extract from it any 
 thing useful or conducive to your purpose. 
 
 I remain your's most sincerely, 
 
 Joseph A. Gaitskill. 
 
 Case. — A. B. with a dislocation of the os femoris 
 upon the pubes, was admitted into Guy's Hospital, 
 under Mr Forster, during the time 1 was one of his 
 dressers. 
 
 The length of the limb was somewhat diminished; 
 the foot and knee were turned outwards ; but the 
 circumstance which more clearly evinced the nature 
 of the accident was, that the head of the thigh-bone 
 
PARTICULAR DISLOCATIONS. 
 
 107 
 
 could be distinctly perceived under the integuments 
 near the groin, where its shape could be ascertained, 
 as well as its motion felt, when the thigh was 
 moved. The accident had happened from a slip or 
 fall he had sustained about three hours before. 
 
 With respect to the reduction; as the man was 
 brought into the hospital in the evening, when Mr 
 Forster was absent, I considered it to be my duty 
 to attempt to replace the bone immediately. I there- 
 fore ordered the patient to be carried into the op- 
 erating theatre ; whilst this was doing, 1 invited my 
 three brother dressers into the surgery, informed 
 them of the accident, and, to avoid confusion, request- 
 ed each to take some particular part in the process 
 of reduction. The patient was placed on his sound 
 side on a table, the pulleys were applied to the 
 thigh in the usual manner, and extension was begun 
 in a straight line, with the design of raising the head 
 of the bone into its socket, but without success. 
 Reflecting then a moment on the mechanism of the 
 bones, and their new relative situation, I changed the 
 line of extension to a little backwards and down- 
 wards, and passing a towel over my own shoulders, 
 and under the superior part of the man's thigh, rais- 
 ed it by extending my body. 
 
 The leg being kept bent, as from the beginning of 
 the operation, nearly to a right angle with the thigh, 
 I requested one of the dressers to take hold of the 
 ankle, and raise it, keeping the knee at the same 
 time depressed, by which means the thigh was turn- 
 ed over inwards, and in a very short time, the head 
 of the bone snapped into its acetabulum. 
 
 J. A. G. 
 
 The following case was admitted into St Thomases 
 Hospital, under the care of Mr TyrrelK 
 
108 PARTICULAR DISLOCATIONS. 
 
 Guildhall, Feb. 7th, 1823. . 
 
 My dear Sir: — I take this opportunity of giving 
 you the particulars of the case of dislocation on the 
 pubes, which you wished for. 
 
 Case, — Charles Pugh, aged fifty-five, a cooper, 
 about the middle size, on the evening of the 23rd 
 of January, during the time he was making water at 
 the corner of a street, was struck on the back part 
 of the right hip by the wheel of a cart ; and the 
 blow knocked him down. He w^as taken up by 
 some persons passing, who, finding that he was not 
 able to walk, took him to St Thomas's Hospital. 
 The accident happened about nine o'clock in the 
 evening, and I was sent for between twelve and one 
 o'clock, when I found a dislocation of the right femur 
 on the pubis, the particulars of which were as follow. 
 
 The head of the bone could be distinctly felt 
 below Poupart's ligament, immediately on the outer 
 side of the femoral vessels. The foot and knee 
 were turned outwards, with very little alteration in 
 the length of the limb. The thigh was not flexed 
 towards the abdomen, and was almost immovable, 
 admitting only of partial adduction and abduction. 
 The limb could be rotated outwards, but not at 
 all inwards. I immediately had the man taken into 
 the operating theatre, and speedily succeeded in 
 reducing the dislocation by the following means : — 
 the patient was placed on his left side, a broad band 
 was passed between the thighs, and, being tied over 
 the crista of the ilium on the right side, was made 
 fast to a ring fixed in the wall. A wet roller hav- 
 ing been put on above the right knee, a bandage 
 was buckled over it, and its straps attached to the 
 hooks of the pulleys, by which a gradual extension 
 was made, drawing the thigh a little backwards and 
 downwards. When this extension had been kept 
 
PARTICULAR DISLOCATIONS. 
 
 109 
 
 up a short time, I directed another bandage to be 
 appHed round the upper part of the thigh, close to 
 the perineum, by means of which the head of the 
 bone was raised, and in the course of a few minutes 
 the reduction was easily accomplished. The pa- 
 tient had not been bled or taken any medicine, he 
 suffered but little after the reduction, and was able 
 to walk without pain or inconvenience five or six 
 days afterw^ards. On the day following the accidejit, 
 he could move the limb freely in all directions with- 
 out pain, but did not attempt to walk until the 
 period I have mentioned. 
 
 If I have omitted any points, or if you have any 
 wish for further particulars, a message or a note by 
 post will much oblige, 
 
 Your's very sincerely, 
 
 Frederick Tyrrell, 
 Surgeon to St Thomas's Hospital 
 
 m 
 
 From what I have had an opportunity of observ- 
 ing on the subject of dislocations, I believe that the 
 relative proportion of cases will be in twenty as fol- 
 lows: — twelve on the dorsum ilii ; five in the ischi- 
 alic notch ; two in the foramen ovale; and one on 
 the pubes. 
 
 The cases I have here detailed, with the dates at 
 which they were presented, manifest the frequent 
 occurrence of this accident to the thigh. How it 
 escaped the observation of surgeons of eminence of 
 former times, is a matter of surprise, that can only 
 be accounted for by the difficulties which then ex- 
 isted in the pursuit of anatomy, and more especially 
 of morbid anatomy; and it is a curious circumstance, 
 that Mr Sharpe, formerly surgeon of Guy's Hospital, 
 author of a Treatise on Surgery, and in many re- 
 spects an excellent surgeon, who had a large share 
 
110 
 
 PARTICULAR DISLOCATIONS. 
 
 of the practice of this town, did not, as 1 was in- 
 formed by Mr Cline, beh'eve that a dislocatiorj of 
 the thigh-bone ever occurred. 
 
 It is really gratifying to observe the advancement 
 of knowledge in the profession at the present period 
 compared with that of fifty years ago. What 
 should we thmk of a surgeon in the metropolis in the 
 present day, with all his opportunities of seeing dis- 
 ease in the large hospitals of this city, who doubted 
 the existence of a dislocation of the thigh, when we 
 find that our provincial surgeons immediately detect 
 the nature of these injuries, and generally succeed 
 in their attempts to reduce them? Let them never 
 forget, however, that it is to their knowledge of 
 anatomy, and, more especially, of morbid anatomy, 
 that they are indebted for this superiority. 
 
 Mr Charles H. Todd, surgeon to the Richmond 
 Surgical Hospital, and Professor of Anatomy and 
 Surgery at Dublin, has lately published ' An Account 
 of a Dissection of the Hip-joint after recent Luxa- 
 tion, with Observations on the Dislocations of the 
 Femur upwards and backwards;' from which the 
 fallowing case is extracted. 
 
 Case, — In the summer of 1818, a robust young 
 man, in attempting to escape from his bed-room win- 
 dow, in the second floor of a lofty house, fell into a 
 flagged area; by which accident his cranium was 
 fractured, and his left thigh dislocated upwards and 
 backwards. 
 
 The dislocation was reduced without difficulty ; 
 however, an extensive extravasation of blood having 
 taken place on the brain, the patient lingered in a 
 comatose state for about twenty-four hours, and then 
 died. On the next day, dissection was performed, 
 and the following appearances were observed in the 
 injured joint and the parts contiguous to it. 
 
PARTICULAR DISLOCATIONS. 
 
 On raising the gluteus maximus, a large cavity, 
 filled with coagulated blood, was found between that^i 
 muscle and the posterior part of the gluteus medlus : 
 this was (he situation which had been occupied by 
 the dislocated extremity of the femur. The gluteus 
 medius and minimus were uninjured. The pyriformis, 
 gemini, obturatores, and quadratus, were completely 
 torn across. Some fibres of the pectinalis were also 
 torn. The iliacus, psoas, and adductores were un- 
 injured. The orbicular ligament was entire at the 
 superior and anterior part only, and it was irregularly 
 lacerated throughout the remainder of its extent. 
 The interarticular ligament was torn out of the de- 
 pression on the head of the femur, as in Dr Scott's 
 case, its attachment to the acetabulum remaining 
 perfect. The bones had not sustained any injury. 
 
 The following case, which has recently appear- 
 ed in one of the Medical Journals, from Mr Cor- 
 nish, surgeon at Falmouth, I have thought proper 
 to subjoin, though I must observe, that there is 
 reason to suspect some mistake in the relation, not 
 of the narrator of the case, but of the man him- 
 self; as I have carefully examined the books of- 
 both hospitals at the period specified, and can find 
 no such name. It is,' however, possible that the 
 patient may be able to explain the difficulty; but 
 I wish Mr Cornish to make further enquiries. 
 
 Case, — In 1812, Mac Fadder, a seaman, about 
 twenty years of age, in coming up from Green- 
 wich to London on the outside of one of the stages, 
 fell from the coach and injured his hip. He was 
 carried into St Thomas's Hospital, and became Mr 
 Cline's patient. His case was treated as fracture 
 of the neck of the thigh-bone. Having, after the 
 lapse of some months, experienced no relief from 
 the means that were adopted, he was dismissed 
 
112 
 
 PARTICULAR DISLOCATIONS. 
 
 with the assurance, that the limb would be" useless 
 ^ to him as long as he lived. 
 
 The man was subsequently taken into Guy's Hos- 
 pital. Sir A. Cooper, whose patient he became, 
 thought that the head of the femur was out of the 
 socket ; and after bleeding him, putting him into the 
 warm bath, and admmistering nauseating doses of 
 tartrate of antimony, endeavoured to reduce the 
 dislocation. The attempt was unsuccessful, as were 
 also others that were afterwards made, and he was 
 again dismissed as an incurable cripple. 
 
 In 1813, about twelve months after the accident, 
 the man presented himself on crutches at the Fal- 
 mouth Dispensary, when he gave me the foregoing 
 history of his case. On examining him, I found 
 the injured limb about two inches and a half shorter 
 than the other, entirely useless, producing great pain 
 on bringing it to the ground, and the knee and foot 
 turned inwards. There was considerable distortion 
 about the joint ; and the head of the bone appear- 
 ed to have formed a bed for itself among the mus- 
 cles on the dorsum ilii. In short, he had every 
 diagnostic symptom of the dislocation upwards. 
 
 In consequence of the duration of the accident, 
 and the failure of the attempts at reduction under 
 the management of Sir A. 'Cooper, I considered 
 his case' a hopeless one, and therefore did nothing 
 for him. 
 
 In March, 1818, I met the man carrying a heavy 
 basket on each arm, and walking without the slight- 
 est degree of lameness. Although I intimately 
 knew his person, having seen him on crutches 
 about the town for two or three years, I passed 
 him, hardly believing it within the compass of pos- 
 sibility, that he could be my lame patient; but af- 
 ter having walked twenty yards or more, I ran back 
 after him to ascertain the fact. On satisfying my- 
 
PARTICULAR DISLOCATIONS. 
 
 113 
 
 self of his identity, of which 1 entertained such 
 doubt, and on enquiring into the cause of his cure, 
 he informed me, that in the summer of 1817, Jive 
 years after the accident, whilst on a passage from 
 Falmouth to Plymouth, in a little coasting vessel, 
 * the ship made a lurch,' by which he was thrown 
 out of his birth. At the moment he fell, he heard 
 a loud crack in his hip, and from that time he put 
 aside his crutches, and recovered the perfect use 
 of his limb. The man is now doing duty, as an 
 able seaman, on board a ship which trades from this 
 port to London. 
 
 The practical importance of this case is not, per- 
 haps, equal to the curious character of its termina- 
 tion. ' It proves,' says Mr Cornish, ' the possibility 
 of reducing a displaced joint, even after the lapse of 
 years, when every impediment to reduction may be 
 fairly supposed to exist (particularly the oblitera- 
 tion of the acetabulum), and when most surgeons 
 would judge the attempt hopeless ; and it serves to 
 illustrate the proposition, that a slight effort, when 
 the muscles are unprepared, will succeed in reduction 
 of dislocation, after violent measures have failed." '^ 
 
 * We must at least suppose this case to have been an ex- 
 ception to a very general rule, as we find in very short lapses of 
 time, compared with the duration of this dislocation that the 
 cavity of the joint is filled up and almost obliterated, a new 
 socket formed for the bone, and the muscles altered to suit the 
 condition caused by the displacement. Although we may be 
 led by the event to /iope — even against probability, yet there 
 are too many circumstances unknown in regard to this case, to 
 justify us in drawing any general conclusion. J. D. G. 
 
 15 
 
FRACTURES OF THE OS INNOMINATUM. 
 
 Mistake, — As these accidents are liable to be 
 mistaken for dislocations, and as any extension made 
 for them adds extremely to the patient's sufferings, 
 and would be liable to produce fatal consequences if 
 there existed previously a probability of recovery, 
 I am anxious to say a few words upon them. 
 
 Symptoms, — When a fracture of the os innomi- 
 natum happens through the acetabulum, the head 
 of the bone is drawn upwards, and the trochanter 
 somewhat forwards, so that the leg is shortened, 
 and the knee and foot are turned inwards : such a 
 case may be readily mistaken for dislocation into the 
 ischiatic notch. If the os innominatum is disjointed 
 from the sacrum, and the pubes and ischium are 
 broken, the limb is a slight degree shorter than the 
 other; but in this case the knee and foot are not 
 turned inwards, but outwards. Of the first of these 
 accidents I have seen two examples, of the latter 
 only one. 
 
 Detection. — These accidents are generally to be 
 detected by a perceptible crepitus on the motion of 
 the thigh, if the hand be placed upon the crista of 
 
FRACTURES OF THE OS INNOMINATUM. 115 
 
 the ilium; and they are attended with more motion 
 than occurs in dislocations. 
 
 With respect to the appearances on dissection, 
 they will be seen in plate seven. 
 
 Case. — A man was brought into St Thomas's 
 Hospital, in January, 1791, on whom a hogshead of 
 sugar had fallen. Upon examination the right leg 
 was found about two inches shorter than the left, 
 and the knee and foot were turned inwards ; these 
 circumstances induced the surgeon under whose care 
 he fell to think the case a dislocation, although, as 
 he stated, the limb appeared to be more moveable 
 than usually happens in such accidents, and there 
 was a great contusion and considerable extravasation 
 of blood. The surgeon used the utmost caution in 
 making a very slight extension, in order to bring the 
 legs to an equal length, in which he did not succeed ; 
 and whilst it was performing, a crepitus was dis- 
 covered in the os innominatum. The man had a re- 
 markable depression of strength, and paleness of 
 countenance, and appeared to be sinking. In the 
 evening he died. 
 
 Upon examination of the body the following ap- 
 pearances were observed: — The posterior part of 
 the acetabulum was broken off, and the head of the 
 thigh-bone had slipped from its socket ; the tendon 
 of the obturator internus, and the gemini, tightly 
 embraced, the neck of the bone; the fracture ex- 
 tended from the acetabulum across the os innomina- 
 tum to the pubes; the ossa pubis were separated at 
 the symphysis nearly an inch asunder, and a portion 
 of the cartilage was torn from the right pubes, and 
 adhered to that on the left side; the ilia were sepa- 
 rated on each side, and the pubes, ischium, and ilium 
 broken on the left side ; the abdomen contained about 
 a pint of blood, and the left kidney was greatly 
 
116 FRACTURES OF THE OS INNOMINATUM. 
 
 bruised ; the integuments were stript off the patella 
 and knee on one side, so as to expose the capsular 
 ligament. 
 
 In a second case of this kind, which was admitted 
 into St Thomas's Hospital, having the appearance 
 of the dislocation backwards, the patient lived four 
 days. On examination, the fracture was found pass- 
 ing through the acetabulum, dividing the bone into 
 three parts ; and the head of the thigh-bone was 
 deeply sunk into the cavity of the pelvis. 
 
 The following case of fracture and dislocation of 
 the bones of the pelvis lately occurred in Guy's Hos- 
 pital : I am obliged for the particulars to Mr Sand- 
 ford, who attended to this patient as dresser* 
 
 Case, — Mary Griffiths, aged thirty years, was 
 admitted into Guy's Hospital at five o'clock in the 
 afternoon of the 8th of August, 1817. Her pelvis 
 had sustained a severe injury, from her body being 
 pressed by the wheel of a cart against a lamp-post. 
 
 A small quantity of blood had been taken from her 
 arm previous to her admission ; and as she was very 
 pale, her pulse extremely weak, and her faeces pass- 
 ed involuntarily, no more blood was drawn* 
 
 Soon after her admission she was examined ; when, 
 by placing her on the face, with one of my hands on 
 the back of the right ilium, and the other on the 
 pubes of the same side, a distinct motion and crepitus 
 could be perceived. The posterior spine of the 
 ilium projected upwards, above its usual junction 
 with the sacrum, and it was thought that the ilium 
 was dislocated from the sacrum, with some fracture, 
 cither of the ilium, or the sacrum. When she was 
 turned on her back, and examined per vaginam^ the 
 pubes were found passing more into the cavity of 
 the pelvis than usual. A large quantity of blood 
 was efTused from the last rib to the upper part of 
 the thigh, on the right side. 
 
JF'RACTURES of the OS INNOMINATUM. 
 
 117 
 
 It was now a question whether this extravasated 
 blood should not be discharged by making an open- 
 ing through the integuments, as it appeared to be 
 fluid; but upon consideration, it was thought that 
 the vessels would still bleed, that she could not bear 
 the loss of blood in her weakened state, and that 
 the blood, when coagulated, would form the best 
 security against further effusion. All that was done, 
 therefore, was to roll a broad bandage round the 
 pelvis to fix it firmly, to give tinct. opii. gt. xxx., and 
 to draw off the urine from her bladder, which con- 
 tained about a pint. 
 
 In the evening, the extravasation of blood was 
 somewhat increased, and she complained of a prick- 
 ing sensation in the right thigh and leg, which in- 
 duced her to loosen the bandage. She had vomited; 
 her feet were cold; she had severe pain, and great 
 thirst; her pulse was 90, and small. 
 
 On the 9th, she complained of a sensation of one 
 side tearing from the other; and, upon examination 
 of the lower extremities, that on the right side was 
 found shorter than the other; there was numbness 
 also on that side. Her tongue was furred, but her 
 pain and thirst somewhat less ; and she had not 
 the same coldness in her feet as she had the night 
 previous. 
 
 As her bowels had not been relieved since her 
 admission, aperient medicine wms given to her; and 
 the bladder being incapable of emptying itself, a 
 catheter was employed. The ecchymosls was of 
 great extent, and it was doubtful whether it could be 
 absorbed. A pillow was placed against the right 
 side to support the pelvis, and another was put 
 under the knee, to preserve the limb in an easy 
 position. 
 
 In the evening of this day, her pulse was 112. 
 She complained of much pain in the right side and 
 
118 
 
 FRACTURES OF THE OS INNOMINATUM. 
 
 groin. The catheter was again obliged to be used, 
 and aperient medicines to be repeated. 
 
 On the morning of the 10th, she complained that 
 the bones of the pelvis moved upon each other, 
 even more than at any former period, and that she 
 had suffered severe pain ; the tongue was now fur- 
 red, her pulse fuller, but her bowels had been re- 
 lieved, and she had made water without assistance. 
 At one o'clock this day, her pulse being fuller, and 
 120 in a minute, with great heat of skin, I bled her 
 to the amount of ten ounces; but the blood did not 
 exhibit any signs of inflammation, nor did the loss of 
 blood produce any apparent effect in relieving her 
 symptoms. 
 
 In the evening, her pain and fever had increased; 
 and as she complained of the tightness of the ban- 
 dage which still surrounded the pelvis, it was re- 
 moved. The catheter was again obliged to be em- 
 ployed. Some saline medicine, with opium, was di- 
 rected for her. 
 
 On the 1 1th, she stated that she had passed a good 
 night. Her pulse was 120 and softer; her tongue 
 furred ; she was directed to continue her medicines. 
 
 A stimulating lotion was ordered for her on the 
 12th, to produce an absorption of the extravasated 
 blood. Some spots appeared of a very dark colour, 
 where the ecchymosis had been most severe, and 
 the cuticle was abraded upon those parts. 
 
 On the 13th, her report was more favourable; 
 her bowels were open, and her bladder did not re- 
 quire the assistance of the catheter. However, 
 she still complained of severe pain in the hip. 
 
 14th. As the excoriated parts seemed disposed 
 to slough, a puncture was made through the integu- 
 ments, nearly opposite to the trochanter major, and 
 a quart of serum, mixed with the red particles of 
 blood, and with a substance which appeared adipose, 
 was discharged. 
 
FRACTURES OF THE OS INNOMINATUM. 1 1 9 
 
 On the 15th the fseces and urine had passed into 
 her bed, and she requested to be removed to an- 
 other; her pulse was 112. The puncture made 
 yesterday does not seem disposed to heal, and a poul- 
 tice was directed for it. 
 
 16th. She expressed herself relieved by her re- 
 moval into another bed ; her pain is less severe ; 
 her pulse but 108. She was now directed a diet to 
 support her strength, and some porter was given her ; 
 but on the 17th, as she had been observed to be 
 slightly delirious the preceding night, the quantity of 
 porter was lessened. 
 
 On the 18th, the sloughing of the part, which had 
 been excessively bruised, had considerably increased ; 
 yet her tongue was cleaner, and her skin of its 
 natural heat. 
 
 On the following day she appeared better ; had 
 passed a good night; she was ordered a poultice of 
 stale beer-grounds to the hip ; and as she strongly 
 requested it, she was turned on her left side, as her 
 impression was, it would relieve the pain she felt on 
 the right side. 
 
 The sloughing of the superior and posterior part 
 of the thigh had increased upon the 20th ; and she 
 was ordered the decoction and tincture of bark, 
 with saline medicine if her thirst became urgent; 
 and a more nutritious diet. 
 
 On the 21st, the sloughing had increased; the 
 tongue was furred; her pulse was 120. On the 
 22nd she was worse ; and on the 23rd, her stomach 
 rejected every thing; she had a strong impression 
 that she could not recover; she refused her medi- 
 cine, and the slough had increased. In the evening 
 of the 24th, she died. 
 
120 FRACTURES OF THE OS INNOMINATUM. 
 
 Examination, 
 
 On the 25tb, the body was examined. — A frac- 
 ture was found passing through the body of the 
 pubes on the left side, and through the ramus of the 
 left ischium. 
 
 The right os innominatum was separated from the 
 sacrum at the sacro-iliac symphysis, and a part of 
 the transverse processes of the sacrum were broken 
 off, and torn from the sacrum with the ligaments. 
 The cartilage and ligaments of the symphysis pubis 
 were torn, and the left sacro-iliac symphysis had 
 given way ; the ligament over it being torn, and the 
 bones separated sufficiently to admit of the handle 
 of a scalpel being received between them. (See 
 Plate.) 
 
 Blood was found extravasated in the pelvis, be- 
 hind the peritonaeum. 
 
 Jonathan Sandford, 
 
 I have known three instances of recovery from 
 simple fracture of the os innominatum : two of these 
 were fractures of the ilium, and the nature of the 
 accident was easily detected by the crepitus which 
 was perceived upon moving the crysta of the ilium 5 
 the third case was a fracture at the junction of the 
 ramus of the ischium and pubes. In the two first 
 a circular roller was applied upon the pelvis, 
 and the patient was freely bled ; but in the latter 
 no bandage was employed. I have also known a 
 compound fracture of the os innominatum recover ; 
 but Mr Hulbert, surgeon, sent me a compound frac- 
 ture of the ilium, which had proved fatal. 
 
 Several cases have also occurred within my 
 knowledge of fracture of the pubes, near its sym- 
 
FRACTURES OF THE OS INNOMlNATUM. 121 
 
 physis, accompanied with laceration of the bladder, 
 each of which proved destructive ; but when the 
 bones have been broken without injury to the blad- 
 der, the patients have recovered.* The bladder is 
 burst or not, in this accident, according to its state 
 of distension or emptiness at the moment of the 
 accident ; for, if empty, it escapes injury. 
 
 * There is at this time (Sept. 1823), a case in Guy's Hospit- 
 al, in which the bladder is believed to be ruptured below the 
 reflexion of the peritonaeum, and between it and the pubes, 
 and the man appears to be recovering by wearing a catheter. 
 But in cases where the injury is above the line of reflexion of 
 the peritonaeum, the urine escapes into the cavity of the abdo- 
 men, and excites general inflammation. 
 
 16 
 
FRACTURES OF THE UPPER PART 
 OF THE THIGH-BONE. 
 
 Before 1 enter into a description of the disloca- 
 tions of other joints, it will be proper to point out 
 the fractures incident to the upper part of the 
 thigh-bone, as it is essentially necessary that these 
 accidents should not be confounded with dislocations, 
 or with each other, a mistake which has but too 
 frequently happened. Indeed, it must be confessed, 
 that their discriminating marks are sometimes with 
 difficulty detected, and that the different species of 
 fracture are likewise frequently confounded; for 
 three distinct species, very different in their nature 
 and in their result, have been described and classed 
 under the indiscriminate appellation of fracture of 
 the neck of the thigh bone. Hence has arisen that 
 difference of opinion, which has led to much dis- 
 cussion respecting the processes which nature em- 
 ploys for their cure, and which less hypothetical 
 reasoning, and more attention to the development 
 of such accidents by dissection, would have been 
 the means of preventing. Whilst one surgeon as- 
 serts that all attempts to cure them are unavailing, 
 
FRACTURES OF UPPER PART OP THIGH-BONE. 123 
 
 another maintains that they admit of union like 
 fractures of other bones ; which latter opinion is 
 only true as far as regards two species of these 
 fractures. 
 
 I shall now, therefore, proceed to state the results 
 of my observations in living persons who have been 
 the subjects of these accidents ; of my examination 
 of the dead body; and of some experiments upon in- 
 ferior animals, which illustrate this subject. 
 
 These accidents are more frequent than disloca- 
 tions of the thigh-bone ; for, whilst there are receiv- 
 ed into the hospitals of Guy's and St Thomas's (con- 
 taining about nine hundred persons), not more upon 
 an average than two such dislocations in a year, the 
 wards are seldom without an example of fracture 
 of the upper part of the thigh-bone. 
 
 Different species of Fracture of the Upper Part of the 
 Thigh-Bone, 
 
 . These are, as we have already observed, three in 
 number. 
 
 First : That in which the fracture happens through 
 the neck of the bone entirely within the capsular 
 ligament. 
 
 Secondly : A fracture external to the ligament, 
 through the neck of the thigh-bone at its junction 
 with the trochanter major; by which the trochanter 
 is split, and the neck of the thigh-bone is received 
 into its cancelli. 
 
 Thirdly : A fracture through the trochanter ma- 
 jor, beyond its junction with the cervix femoris. 
 
124 
 
 FRACTURES OP THE UPPER PART 
 
 FRACTURES OP THE NECK OF THE THIGH-BONE, WITHIN 
 THE CAPSULAR LIGAMENT. 
 
 Appearances ; difference in length, " The appear* 
 ances which are produced by this fracture are as 
 follow : — the leg becoQies from one to two inches 
 shorter than the other 5 for the connexion of the 
 trochanter major with the head of the bone,by 
 means of the cervix, being destroyed by the frac- 
 ture, the trochanter is drawn up by the muscles as 
 high as the ligament will permit, and consequently 
 rests upon the edge of the acetabulum, and upon 
 the ilium above it. The difference in the length of 
 the limbs is best observed by desiring the patient 
 to place himself in the recumbent posture on his 
 back, when, by comparing the malleoli, it will be 
 generally found that one leg is shorter than the other. 
 The usual state of the limb is, that the heel on the 
 injured side rests in the hollow between the malleo- 
 lus internus and tendo Achillis of the other leg ; but 
 there is some variety in this respect ; a fork is some- 
 times formed in the trochanter minor, which catches 
 the neck of the bone, and prevents a greater ascent 
 than half an inch. (^See Plate.') Mr Brodie informed 
 me that he dissected a case in which the cervix was 
 obliquely broken, and in which the upper part of the 
 bone prevented the ascent of the lower. On the 
 other hand, when the fracture has happened for 
 a length of time, and the patient has borne upon the 
 injured limb, the ligament becomes extended, and 
 the leg is shortened four inches ; of this Mr Lang- 
 staff mentioned to me an instance in a man of the 
 name of Campbell, aged eighty-two, in whom the 
 heel was obliged to be elevated four inches to 
 make the bearing of the limbs equal. 1 saw the 
 
OF THE THIGH-BONE. 
 
 125 
 
 fractured parts in this man, and the shoe he wore, 
 which entirely verified Mr L's statement. The 
 retraction is at first easily removed by drawing down 
 the shortened limb, when it will appear of the same 
 length with the other ; but immediately this extension 
 is abandoned, and the patient exerts himself, the 
 muscles draw it into its former position; and this 
 appearance maybe repeatedly produced by extending 
 the limb. This evidence of the nature of the accident 
 continues until the muscles acquire a fixed contrac- 
 tion, which enables them to resist an extension which 
 is not of a powerful kind. 
 
 Foot turned outward. — Another circumstance 
 which marks the nature of this injury is, the ever- 
 sion of the foot and knee ; and this state depends 
 upon the numerous and strong external rotatory 
 muscles of the hip-joint, which proceed from the 
 pelvis to be inserted into the thigh-bone, and to 
 which very feeble antagonists are provided: the ob- 
 turatores, the pyriformis, the gemini and quadratus, 
 the pectinalis and triceps, all assist in rolling the 
 thigh-bone outwards; whilst a part of the glutasus 
 medius and minimus, and the tensor vaginae femoris, 
 are the principal agents of rotation inwards. It has 
 been denied that this eversion is caused by the mus- 
 cles, and it has been attributed to the mere weight 
 of the limb; but any one may satisfy himself that it 
 arises chiefly from the muscles, by feeling the re- 
 sistance which is made to any attempt at rotation of 
 the thigh inwards.^ This difficulty is also in some 
 
 * In the sound state of the limb, when we rest it on a plane, 
 the body being recumbent, and allow the muscles to relax, it 
 Invariably falls to the outside. The weight of the foot acting 
 on so long a lever is sufficient to effect this. The thigh being 
 shortened ' one or two inches,' it is not difficult to understand 
 how the psoas, ihacus and pectinaeus may fix it against the ilium. 
 
126 FRACTURES OP THE UPPER PART 
 
 measure attributable to the length of the cervix fe- 
 moris, which remains attached to the trochanter 
 major; because in proportion to its length, by rest- 
 ing against the ilium, the trochanter is prevented 
 from turning forwards. 
 
 Directly that the bed-clothes are removed, two 
 circumstances strongly arrest the attention of the 
 surgeon : namely, the diminished length of the in- 
 jured limb, and the eversion of the foot and knee. 
 In the dislocation upwards, the head and neck of 
 the bone prevent the trochanter from being drawn 
 backwards, whilst the broken and shortened neck 
 of the thigh-bone, in fracture of this part, readily 
 admits it ; and hence the reason that the foot is in- 
 verted in luxation, and everted in fracture. It is, 
 hovv'ever, proper to state, that an exception to this 
 rule does now and then exist, and that the limb is 
 found inverted ; but it is of extremely rare occur- 
 rence. Several hours must elapse before this ever- 
 sion assumes its most decisive character, as the mus- 
 cles require some time to assume a determined con- 
 traction; and this is the reason why the injury has 
 been mistaken for dislocation on the dorsum ilii. 
 The surgeon having been called soon after the acci- 
 dent has happened, before the muscles had acquired 
 that state of contraction to which they are liable, 
 has been led to mistake the nature of the injury, 
 because the foot is not so decidedly everted as it 
 afterwards becomes; and for this reason patients, 
 even in hospital practice, have been exposed to use- 
 less and painful extensions. 
 
 Degree of pain. — In fractures of the neck of the 
 bone within the ligament, the patient, when per- 
 
 and together with the external muscles prevent the rotation in- 
 wards, although this position is originally produced by the 
 gravity of the limb. J. D. G. 
 
OP THE THIGH-BONE. 
 
 127 
 
 fectly at rest in the horizontal posture, suffers but 
 little ; but any attempt at rotation is attended with 
 some pain, because the broken extremity of the 
 bone then rubs against the inner surface of the cap- 
 sular ligament, upon Avhich it is drawn by the action 
 of the muscles. The pain is felt in this accident in 
 the upper and inner part of the thigh, opposite to 
 the insertion of the iliacus and psoas muscles into 
 the trochanter minor, or sometimes just below this 
 point. 
 
 Degree of motion, — The perfect extension of the 
 thigh may be easily effected, but flexion is more diffi- 
 cult, and somewhat painful ; and its degree depends 
 upon the direction in which the limb is bent; if the 
 flexion be outwards, it is accomplished with but lit- 
 tle comparative suffering ; but if the thigh be direct- 
 ed towards the pubes, the act of bending the limb 
 is with difficulty accomplished, and is attended with 
 greater pain ; for the movement is easier or more 
 difficult, in proportion as the neck of the bone is 
 shorter or longer. 
 
 Situation of the trochanter major, — In this acci- 
 dent the trochanter major is drawn up towards the 
 ilium, but the broken neck of the bone attached to 
 the trochanter is placed nearer the spine of the ili- 
 um than the trochanter itself, in which situation it 
 afterwards remains; and this alteration of position 
 makes the trochanter project less on the injured 
 side, because it is no longer supported by the neck 
 of the bone, as in its natural state, but rests in close 
 apposition with the edge of the acetabulum, and is, 
 consequently, much more concealed than usual, until 
 the muscles waste from the duration of the injury, 
 when the trochanter can bo distinctly felt upon the 
 dorsum ilii; but there will be a greater or less pro- 
 
128 
 
 FRACTURES OF THE UPPER PART 
 
 jection according to the length of the fractured 
 cervix attached. 
 
 Jlppearance in the erect position* — If doubt exist 
 of the nature of the accident, let the patient be di- 
 rected to stand by his bed-side, supported by an 
 assistant, and to bear his weight upon the sound limb ; 
 the surgeon then observes the shortened state of the 
 injured leg ; the toes rest upon the ground, but the 
 heel does not reach it ; the knee and foot are evert- 
 ed ; and the prominence of the hip is diminished. 
 The least attempt to bear upon the injured limb is 
 productive of pain, which seems to be occasioned by 
 the tension of the psoas, iliacus, and obturator exter- 
 nus muscles, in the attempt, as well as by the pres- 
 sure of the broken neck of the bone against the in- 
 terior surface of the capsular ligament. 
 
 Crepitus, — A crepitus like that which accompa- 
 nies other fractures might be expected to occur in 
 this accident, but it is not discoverable when the pa- 
 tient rests on his back with the limb shortened; if, 
 however, the leg be drawn down, so as to bring the 
 limbs to the same length, and rotation be then per- 
 formed, the crepitus will be observed, as the broken 
 ends of the bone are thus brought into contact; but 
 the rotation inwards most easily detects the fracture. 
 When the patient is standing on the sound leg, with 
 the fractured limb unsupported, by rotating it inwards, 
 the crepitus will sometimes be perceived, as the 
 weight of the limb brings the broken bones nearer 
 in apposition. 
 
 More frequent in ivomen. — Women are much 
 more liable to this species of fracture than men : we 
 rarely in our hospitals observe it in the latter, but 
 our wards are seldom without an example of it in the 
 aged female. The more horizontal position of the 
 neck of the bone, and the comparative feebleness of 
 
OF THE THIGH-BONE^ 
 
 129 
 
 the female constitution, are the probable reasons of 
 this peculiarity.'^ 
 
 To the circumstances I have already mentionedj 
 as strongly characterizing this accident, must be add- 
 ed the period of life at which it usually occurs; for 
 the fracture of the neck of the thigh-bone within 
 the capsular ligament, seldom happens but at an 
 advanced period of life, whilst the other fractures 
 which I have to describe happen at all periods : and 
 hence has arisen the great confusion with respect to 
 the nature of this injury; for we find that surgeons 
 of the highest character have confounded fractures 
 external to the capsular ligament with those which 
 are within the articulation ; and mention the latter 
 as occurring at a period of life in which they scarcely 
 ever happen.f It has been also said, that in early 
 life these boneS will readily unite ; an assertion 
 which I notice only to show the confusion which has 
 arisen on this subject. 
 
 Changes in age in the bones, — Old age, how- 
 ever, is a very indefinite term ; for in some it is as 
 strongly marked at sixty, as in others at eighty 
 years. That regular decay of nature which is call- 
 ed old age, is attended with changes which are 
 easily detected in the dead body ; and one of the prin- 
 cipal of these is found in the bones, for they become 
 thin in their shell, and spongy in their texture. 
 The process of absorption and deposition varies at 
 different periods of life ; in youth the arteries, which 
 
 - * The greater width of the pelvis in women, and the distance 
 to which the upper part of the thigh-bones are thereby remov- 
 ed from each other, as it throws the feet nearer to the central 
 line of the body, must render the neck of the thigh-bone in them, 
 much more liable to fracture from shocks received on the feet, 
 than in men. The force in this case is exerted immediately on 
 the neck of the bone, while in a man it would be chiefly spent on 
 the acetabulum. J. D, G. 
 
 t I allude particularly to Desaalt. — A. C. 
 17 
 
130 
 
 FRACTURES OF THE UPPER PART 
 
 are the builders of the body, deposit more than the 
 absorbents remove, and hence is derived the great 
 source of its growth. In the middle period of life 
 the arteries and absorbents preserve an equilibrium 
 of action, so that, with a due portion of exercise, 
 the body remains stationary ; whilst in old age the 
 balance is destroyed, because the arteries act less 
 than the absorbents, and hence the person becomes 
 diminished in weight ; but more from a diminution 
 of the arterial than from an increase of the absorb- 
 ent action. This is well seen in the natural changes 
 of the bones, their increase in youth, their bulk, 
 weight, and little comparative change during the 
 adult period, and the lightness and softness they ac- 
 quire in the more advanced stages of life ; hence 
 the bones of old persons may be cut with a pen- 
 knife, which is incapable of making; any Impression 
 on those of adults. Even the neck of the thigh- 
 bone in aged persons is sometimes undergoing an 
 interstitial absorption, by which it becomes shorten- 
 ed, altered in its angle with the shaft of the bone, 
 and so changed In its form as to give an idea, upon 
 a superficial view, that it has been the subject of 
 fracture, thus leading persons into the erroneous sup- 
 position, that the bone has been partially broken 
 and reunited ; but it requires very little knowledge 
 of anatomy to distinguish in the skeleton, the bone 
 of advanced age from that of the middle period of 
 life. 
 
 ^ge at which it occurs, — The age at which frac- 
 tures of the neck of the thigh-bone within the cap- 
 sular ligament generally occur, is a most important 
 consideration ; and as it is one on which the prac- 
 tice to be pursued by the surgeon very much de- 
 pends, 1 shall take the liberty of making the follow- 
 ing statement. 
 
 1 have been forty years at St Thomas's and Guy^s 
 Hospitals ; and, for thirty years, have had more than 
 
OF THE THIGH-BONE. 
 
 131 
 
 my share, and mucli more than I merited, of the 
 practice of London. We have eight hundred and 
 fiftj patients in the two hospitals ; and 1 believe 
 that in the two hospitals, eight cases of fractures 
 of the upper part of the thigh-bone occur in each 
 year ; but in order to avoid exceeding the average 
 number, 1 will consider them only as five per an- 
 num; thirty-nine multiplied by five, produce one 
 hundred and ninety-five ; add to these one case only 
 in each year, in my private practice of thirty years, 
 they will collectively amount to two hundred and 
 twenty-five cases ; now, in that time, I have only 
 known two cases of fracture of the neck of the thigh- 
 bone within the capsular ligament occur under fift]j 
 years of age; one was in a patient aged thirty-eight, 
 who had an aneurism of the iliac artery ; and the 
 other has been kindly shown to me by that excel- 
 lent anatomist, Mr Herbert Mayo. 
 
 This fracture, then, rarely occurs under fifty years 
 of age; and dislocation seldom at a more advanced 
 period, although there are exceptions to this rule; 
 for I have myself once seen the fracture at thirty- 
 eight years of age, but it was very oblique ; and a 
 dislocation of the thigh at sixty-two; but the period 
 of life between fifty and eighty years is that at 
 which the fracture most usually occurs; for from 
 the different state of the bone, the same violence 
 which would produce dislocation in the adult, occa- 
 sions fracture in old age. But when dislocation does 
 occur between the age of sixty and seventy, it is in 
 persons whose constitutions are particularly strong, 
 and in whom age has not produced those changes in 
 the bones which I have already endeavoured to 
 point out. 
 
 Slight cause producing this fracture, — That this 
 state of bone in old age tends much to the produc- 
 tion of fractures, is shown by the slight causes which 
 often occasion them. In London, the accident most 
 
132 
 
 FRACTURES OF THE UPPER PART 
 
 frequently occurs when persons, walking on the edge 
 of the elevated foot-path, slip upon the carriage 
 pavement ; though the descent be only a few inches, 
 yet, being sudden and unexpected, and the force act- 
 ing perpendicularly, with the advantage of a lever 
 in the cervix, it produces a fracture of the neck of 
 the thigh-bone; and as a fall is the consequence, the 
 fracture is imputed, by ignorant persons, to the fall, 
 and not to its true cause. Other trival accidents 
 may occasion the misfortune. I was informed by a 
 person who had sustained a fracture of this kind, 
 that being at her counter, and suddenly turning to a 
 drawer behind her, some projection in the floor 
 caught her foot, and preventing its turning w^ith the 
 body, the neck of the thigh-bone became fractured. 
 A fall upon the trochanter major will also produce 
 it; but I have dwelt particularly on the slight causes 
 by which it is occasioned, that the young surgeon 
 may be upon his guard respecting it, as he might 
 otherwise believe that an injury of such importance 
 could scarcely be the result of a slight accident, and 
 that excessive violence is necessary to break the 
 neck of the thigh-bone ; such an opinion is as liable 
 to be injurious to his reputation, as th6 error of con-^ 
 founding this accident with dislocation. 
 
 Union of this fracture. — Much difference of 
 opinion has existed upon the subject of the union of 
 the fractured neck of the thigh-bone : it has been 
 asserted that these fractures unite like those of other 
 parts of the body; but the dissections which I made 
 in early life, and the opportunities I have since had 
 of confirming my observations, have convinced me, 
 that fractures of the neck of the thigh-bone,— 
 those of the patella, — olecranon, — and condyles of 
 the OS humeri, — and that of the coronoid process 
 of the u\n'a, genera I hj unite by ligament, and not by 
 bone. This principle I have taught in my lectures 
 for thirty years; i^nd it is a most essential point, as 
 
OF THE THIGH-BONE. 
 
 133 
 
 it affects the reputation of the surgeon. I was called 
 to a case of this fracture, in which the medical at- 
 tendant had been promising, week after week, an 
 union of the fracture, and the restoration of a sound 
 and useful limb. After many weeks, the patient 
 became anxious for further advice: I did all in my 
 power to lessen the erroneous impression which had 
 been madei, bj telling the patient that she might ul- 
 timately walk, although with some lameness: and 
 taking the surgeon into another room, asked him 
 upon what grounds he was led to suppose there would 
 be union, to which he replied, he was not aware but 
 that the fracture of the neck of the thigh-bone would 
 unite like those of other bones of the body. The 
 case, however, proved unfortunate for his character, 
 as this patient did not recover in tiie usual degree. 
 
 Young medical men find it so much easier a task 
 to speculate than to observe, that they are too apt 
 to be pleased with some sweeping theory, which 
 saves them the trouble of observing the processes 
 of nature ; and they have afterwards, when they 
 embark in their professional practice, not only every 
 thing still to learn, but also to abandon those false 
 impressions which hypothesis is sure to create. 
 Nothing is known in our profession by guess ; and I 
 do not believe, that from the first dawn. of medical 
 science to the present moment, a single correct idea 
 has ever emanated from conjecture : it is right, 
 therefore, that those who are studying their profes- 
 sion, should be aware that there is no short road to 
 knowledge ; that observations on the diseased living, 
 examinations of the dead, and experiments upon 
 living animals, are the only sources of true knowl- 
 edge ; and that inductions from these are the sole 
 basis of legitimate theory. 
 
 In all the examinations which I have made of 
 transverse fractures of the cervix femoris entirely 
 
134 FRACTURES OF THE UPPER PART 
 
 within the capsular hgament, 1 have never met with 
 one in which a bony union had taken place, or which 
 did not admit of a motion of one bone upon the 
 other. To deny the possibility of this union, and to 
 maintain that no exception to the general rule can 
 take place, would be presumptuous, especially when 
 we consider the varieties of direction in which a 
 fracture may occur, and the degree of violence by 
 which it may have been produced; as, for example, 
 when the fracture is through the head of the bone,* 
 and there is no separation of the fractured ends; or, 
 when the bone is broken without its periosteum 
 being torn; or, when it is broken obliquely, partly 
 within and partly externally to the capsular liga- 
 ment; but I wish to be understood to say, that if 
 ever it does happen, it is of extremely rare occur- 
 rence, and that I have not yet met with a single 
 decisive example of it.t As a proof that the gene- 
 ral principle which I have stated is correct, I sub- 
 join the following account of forty-three cases, from 
 different collections, of non-union by bone, in frac- 
 tures of the neck of the thjgh-bone, 
 
 * Much trouble has been taken to impress the minds of the 
 public with the idea, that 1 have in this work denied the possi- 
 bility of union of the fracture of the neck of the thigh-bone ; 
 and therefore I beg- at once to be understood, that I believe the 
 reason why fractures of the neck of the thigh-bone do not Unite 
 is, that the ligamentous sheath and periosteum of the neck of 
 the bone is torn through, and that there is, in consequence of 
 this circumstance, a want of nourishment of the head of the 
 bone ; but if a fracture should happen without the reflected 
 ligament being torn^ I can readily believe that as the nutrition 
 would continue, the bone might unite ; but the character of the 
 accident would differ; the nature of the injury could scarcely 
 be discerned, and the patient's bone would unite with little at- 
 tention on the part of the surgeon. — A. C. 
 
 t In Mr Cross's account of his visit to the French hospitals, 
 some interesting matter upon this subject will be found. — A. C. 
 
OF THE THIGH-BONE. 
 
 135 
 
 7 specimens, 
 
 1 ditto. 
 6 ditto. 
 
 12 ditto. 
 
 6 ditto. 
 
 6 ditto. 
 
 2 ditto. 
 2 ditto. 
 1 ditto. 
 
 43 
 
 To these I have to add another, from an experi- 
 ment upon a living animal ; while, on the contrary, 
 only a single instance meriting a moment's attention 
 has yet been produced : in this case, the same ap- 
 pearances were found in both the thigh-bones ; and 
 even these resembled Avhat 1 have several times 
 observed in the dead body, arising from a softened 
 state of the bones. I have given a plate of some 
 of these appearances, and the preparations I shall 
 at all times be happy to show to any of my profes- 
 sional brethren who may wish to see them.* 
 
 * The observations of one whose experience and opportuni- 
 ties have been so singularly good as those of Sir A. Cooper, in 
 addition to what has been advanced on the same subject by 
 other celebrated surgeons, must convince the reader of the 
 impropriety of crediting such loose and general assertions as 
 are to be found in many of the popular works on surgery, es- 
 pecially in relation to the practicability of procuring a bony 
 union, when the neck of the thigh-bone has been fractured 
 within the capsule. Desault in particular writes with his usual 
 extravagance on this topic, and concludes by saying ' that the 
 progress of these fractures is the mine with that of all others, 
 and that when treated with equal skilly there is no reason why 
 their termination should not be equally favourable.'' Though 
 we can believe in the possibility of a cure by bony union in 
 such a case, yet as the uniform experience of a majority of the 
 most enlightened surgeons, is against such a recovery, we should 
 recommend, that the young practitioner be careful not to injure 
 
 In the collection at St Thomas's, 
 In the college of surgeons, 
 In St Bartholomew's, 
 At Dublin, 
 
 In Mr Langstaff's, of Basinghall-street, 
 
 In Mr Bell's and Mr Shaw's, 
 
 In Mr Brookes's, 
 
 In DrMunro's, 
 
 Mr Mayo's collection, 
 
136 FRACTURES OF THE UPPER PART 
 
 Cause of the want of union. — Having thus ex- 
 plained the ordinary result of these cases in rela- 
 tion to their want of union, I shall now proceed to 
 state the reasons which may be assigned for the 
 absence of ossific union in the transverse fracture 
 of the neck of the thigh-bone within the capsular 
 ligament. 
 
 Want of proper apposition, — The first reason is 
 the want of proper apposition of the bones: for if 
 their broken extremities in any part of the body 
 be kept much asunder, ossific union is prevented. 
 
 In a boy, who had a compound fracture of the 
 tibia, without the fibula beino^ broken,* and who had 
 the protruded end sawn off, the two extremities 
 were prevented from coming in contact by the fibu- 
 la, and union never occurred. My friend, Mr Smith, 
 an excellent surgeon, at Bristol, had a similar case 
 under his care, in which a portion of the tibia hav- 
 ing been sawn otF, the fibula, remaining whole, pre- 
 vented ossific union. t 
 
 his own reputation and profession by rashly prognosticating 
 what can rarely or ever be realized. In Dorsey's Elements 
 (vol. i, p. 193,) the ideas of Desaiilt are repeated. All the 
 cases referred to by Boyer and Desault, may be explained by 
 recurring to what our author has said on the changes produced 
 in the bones by age. J. D. G. 
 
 * If the fibula be broken, large pieces of the tibia will sepa- 
 rate, and yet ossific union will ensue. — A. C. 
 
 t The particulars of the case were as follow: — The boy 
 was admitted into the Bristol Infirmary for disease of the tibia ; 
 and the diseased portion not exceeding more than from two to 
 three inches in length, that part of the bone was removed by 
 the saw. In a month the limb had acquired so much firmness, 
 that the boy was permitted to walk about the ward, which he 
 was able to perform tolerably well, and in six weeks no doubt 
 was entertained that ossification had taken place in the uniting 
 substance ; at this time he sickened with the small pox and 
 died. Upon examination, the edges of the extremities of the 
 tibia were found absorbed and rounded, and on the inferior por- 
 
OF THE THIGH-BONE. 
 
 137 
 
 This fact is easily seen by experiments on ani^ 
 mals : 1 sawed seven-eighths of an inch of the ra- 
 dius from a rabbit, and the ends of the bones were 
 not united to each other, but only to the ulna. I 
 also sawed off the extremity of the os calcis,*and 
 suffered it to be drawn up by the action of the gas- 
 trocnemius muscle, and it united only by ligament. 
 (See Plates.) 
 
 The following communication is from Mr Benja* 
 min Bell, of Edinburgh.^' 
 
 26, aS^^ Andrew Square, Edinburgh ; 
 
 August 1th, 1823. 
 
 My dear Sir: — Excuse the freedom I take in 
 communicating to you the outline of a case, the re- 
 sult of which I had an opportunity of observing a 
 short time ago; as it is connected with the subject 
 so admirably developed in your late valuable publi- 
 cation, it may, perhaps, prove interesting. In the 
 progress of a tour through some parts of Cumber- 
 land last month, I had occasion to visit Whitehaven; 
 Mr Fox, an able and intelligent surgeon, of that 
 place, was so kind as to show me the case alluded 
 
 tion a bony callus had formed, about three quarters of an inch 
 in extent; no ossific matter was discoverable in the greater 
 part of the space originally occupied by the diseased bone, but 
 a tough, though thin ligamentous band extended from the supe- 
 rior to the inferior portion of the tibia. — See Medical Records 
 and Researches. — A. C. 
 
 * A highly respectable and intelligent individual ; grandson 
 of Mr Benjamin Bell, who was a most useful man to the pro- 
 fession by his publications : and son of Mr George Bell, also a 
 most able surgeon, of Edinburgh : Mr Bell is likely to be a 
 worthy successor to such a father. — A. C. 
 
 IB 
 
138 
 
 FRACTURES OF THE UPPER PART 
 
 to. He was also so good as to favour me with an 
 account of its progress. 
 
 Case,— June, 1822. — William Coulthard, aged 
 thirtj-five, of a plethoric hahit, a miner, while stem- 
 ming a bore, preparatory to blasting a rock, the 
 powder, in consequence of the friction, inflamed, 
 and exploding, gave rise to the following accident : 
 — One portion of the rock struck him in the peri- 
 nasum, and occasioned a compound fracture of the 
 tuberosity of the left ischium, which was followed 
 by profuse haemorrhage. Another portion of the 
 rock came in contact with the left leg, about four 
 inches below the knee, and shatteied the tibia and 
 fibula. Four large loose pieces of bone were ex- 
 tracted, by Mr Fox, immediately after the accident. 
 These portions, when united, formed about six 
 inches of the entire cylinder of the tibia. The 
 sides of the wound were then drawn together, and 
 retained ' in situ' by adhesive plasters.- The limb 
 was placed in a proper position, and secured by pads 
 and wooden splints. In a short time the wound in 
 the leg healed up; three months, however, after it 
 had healed, an abscess formed, and another small 
 portion of bone came away, probably a part of the 
 fibula. The wound healed again without any unto- 
 ward symptom. 
 
 The day on which I saw him (July 22nd, 1823), 
 the leg in which the injury had occurred appeared 
 to be about two inches shorter than the other. A 
 large cicatrix occupied the fore and middle part of 
 the shin; the patient could extend the leg and 
 stamp on the floor with considerable force; the 
 muscles were plump and ffrm ; but the leg was to a 
 certain extent flexible, and could be slightly bent by 
 the hands in four different directions : backwards, 
 
OF THE THIGH-BONE. 
 
 139 
 
 forwards, to the right and to the left, on seizing it 
 below the knee (above the fracture), and at the 
 ankle. He suffered no pain, and permitted the 
 limb to be freely handled, but could not, at that 
 time, bear the whole weight of the body upon it. 
 It seemed to me as if the space between the two 
 ends of the fractured bones had been filled up with 
 a sort of ligamento-cartilaginous matter, resembling 
 that found in cases of fracture of the neck of the 
 femur external to the ligament, or in that occur- 
 ring in ill-treated cases of transverse fracture of 
 the patella. Whether that conjecture be right or 
 not, it is difficult to determine. 
 
 A number of small pieces of bone hav^ been ex- 
 tracted from the wound in the perinoeum, and a 
 pretty large loose portion can be felt at present with 
 the probe. In other respects the man's health is 
 good, and he expresses an anxious desire to return 
 to his work. 
 
 Your much obliged, 
 
 And sincerely grateful Pupil, 
 
 Benjamin Bell, 
 
 The neck of the thigh-bone when broken, is 
 placed under similar circumstances ; for, by the con- 
 traction of the rnuscles, it is no longer in apposition 
 with the head of the bone, and is, therefore, pre- 
 vented from uniting; if this, however, were the 
 only obstacle, it would be argued that the retraction 
 of the thigh-bone might be prevented by bandaging 
 and extension, the truth of which cannot be denied; 
 but it is scarcely possible, even for a few hours, to 
 preserve the limb in exact apposition, as the patient, 
 on the slightest change of posture, produces instant 
 retraction, by bringing into action those powerful 
 
140 FRACTURES OF THE UPPER PART 
 
 muscles which pass from the pelvis to the thigh- 
 bone. 
 
 So in fractures of the patella, although we often 
 do all in our power to prevent retraction of the 
 muscles, yet it very rarely happens that we are able 
 to support a con)plete approximation of the bonee. 
 
 Msence of coritinned pressure, — The second cir- 
 cumstance which prevents a bony union in these' 
 fractures is, the want of pressure of one bone upon 
 the other, even if the length of the limb were pre- 
 served : and this will operate in preventing an os- 
 sific union in cases where the capsular ligament is 
 not torn ; and in all those which I have had an op- 
 portunity ©f examining, it has not been lacerated. 
 The circumstance to which I allude proceeds from 
 the secretion of a quantity of fluid into the joint ; 
 from the increased determination of blood to the 
 capsular ligament and synovial membrane ; a super- 
 abundance of serous synovia, — that is, synovia much 
 less mucilaginous than usual, — which extends the 
 ligament, and thus entirely prevents the contact of 
 the bones, by pushing the upper end of the body of 
 the thigh-bone from the acetabulum. After a time 
 this fluid becomes absorbed, but not until the inflam- 
 matory process has ceased, and ligamentous matter 
 has been efl'used into the joint from the interior of 
 the synovial surface. The muscles, also, do not in 
 this accident produce pressure between the broken 
 extremities of bones, which so greatly conduces to 
 the union of other fractures; for if two broken 
 bones overlap each other, on that side on which they 
 are pressed together, there is an abundant ossific 
 deposit: but on the opposite side, where there is no 
 pressure, scarcely any change is observed. So also 
 we find that, if the ends of the bones be drawn from 
 each other by the action of muscles, as sometimes 
 happens in the fractures of the os femoris, tibia, os 
 
OF THE THIGH-BONE. 
 
 141 
 
 humeri, radius and ulna, union is not effected until 
 the surgeon, by a strong leathern bandage tightly 
 buckled around the limb, compels the bones to press 
 upon each other, and thus support tfie necessary in- 
 flammation for the production of ossific union. When 
 a fracture occurs amidst muscles, those which are 
 inserted into the fractured part of the bone, have 
 generally a tendency to keep the extremities of the 
 bones together, with some few exceptions; but when 
 a fracture occurs in the neck of the thigh-bone, the 
 muscles have only an influence upon one portion of 
 the fractured bone; and this influence serves to draw 
 one part from the other. 
 
 Liittle action in the head of the bone, — But the 
 third and principal reason which may be assigned 
 for the want of union of this fracture is, the almost 
 entire absence of ossific action in the head of the 
 thigh-bone when separated from its cervix; its life 
 being supported by the llgamentum teres, which has 
 only a few minute vessels, ramifying from it to the 
 head of the bone.* The structure of the neck of 
 the thigh-bone, and of the parts surrounding it, is ex- 
 plained in the account of the anatomical plate con- 
 nected with this part of my subject. But here it 
 may be observed, that the neck and head of the 
 thigh-bone are naturally supplied with blood by the 
 periosteum of the cervix, and that when the bone 
 is fractured, if, as most frequently happens, the pe- 
 
 * In reviewing what I have written on the structure of the 
 head and neck of the thigh-hone, 1 fear that some misconcep- 
 tion might arise, of this passage, in which I say that the head 
 and neck of the bone are supplied with vessels from the reflect- 
 ed ligament and hgamentum teres. Now 1 do not mean that 
 this is the only supply,, for it is well known that vessels pass 
 through the interior of the neck of the bone ; bul as these are 
 torn through by the fracture, only those of the untorn reflected 
 ligament and ligamentum teres remain, and it is principally those 
 jof which I have given a view in plate 13. — A. C. 
 
142 FRACTURES OP THE UPPER PART 
 
 riosteurn be torn through, the means of ossific ac- 
 tion are, in consequence of such fracture and lacer- 
 ation, necessarily destroyed in the head of the bone. 
 Scarcely any change, therefore, takes place in the 
 head or neck of the bone attached to it ; no deposit 
 of cartilage or bone, similar to that of the other 
 fractured bones, is produced ; but the deposit which 
 does take place, as will be seen in the plates of frac- 
 ture of the neck of the thigh-bone, consists of liga- 
 mentous matter, covering the surface of the cancel- 
 lated structure with little patches like ivory on the 
 head of the bone.* 
 
 Dissection of this fracture, — The appearances 
 which are found on the dissection of these injuries 
 are as follow : — the head of the bone remains in 
 the acetabulum attached by the ligamentum teres. 
 There are, upon parts of the head of the bone, 
 very small white spots like ivory. The cervix is 
 sometimes broken directly transversely, at others 
 with obliquity. The cancellated structure of the 
 broken surface of the head of the bone and of the 
 cervix, is hollowed by the. occasional pressure of the 
 neck attached to the trochanter, and consequent ab^ 
 sorption; and this surface is sometimes partially 
 coated with a ligamento-cartilaginous deposit. The 
 cancelli are rendered firm and smooth by friction, as 
 we see in other bones which rub upon each other . 
 when their articular cartilages are absorbed. Por- 
 tions of bone are formed or broken off, and these 
 are found either attached by means of ligament, or 
 floating loosely in the joint, covered by a ligament- 
 ous matter; but these pieces do not act as extrane- 
 
 * But if I attempt to prevent union in a fracture external to 
 a joint, 1 find, by moving the bone from time to time, that in 
 proportion to that motion is the quantity of callus produced ; 
 which is just the reverse in the accidents I am now describing, 
 — A. C. 
 
OP THE THIGH-BONE. 
 
 143 
 
 0U9 bodies, so as to excite inflammation, and thus 
 produce their discharge, any more than those loose 
 portions of bone covered by cartilage, which are 
 found so frequently in the knee, and sometimes in 
 the hip and elbow-joints. With respect to the neck 
 of the bone which remains attached to the trochan- 
 ter major, the most remarkable circumstance is, that 
 it soon becomes in a great degree absorbed, only a 
 small portion of it remaining ; its surface is yellow, 
 and extremely smooth, if the bones have rubbed 
 against each other. Some ossific deposition I have 
 seen manifested around this small remaining part of 
 the neck of the bone, and upon the trochanter ma- 
 jor and thigh-bone below it, in several examples of 
 this fracture. We do not, however, observe the 
 same process of union as in other bones, but a liga- 
 mentous instead of an ossific union. 
 
 Ligainent and synovial membrane. — The capsular 
 ligament enclosing the head and neck of the bone 
 becomes much thicker than natural, but the synovial 
 membrane undergoes the greatest change from in- 
 flammation, being very much thickened, not only 
 upon the capsular ligament, but also upon the re- 
 flected portion of that ligament upon the nqpk of 
 the bone, as far as the edge of the fracture. 
 
 Effusion into the joint ; new ligament^ 8^c. — With* 
 in the articulation is found a large quantity of serous 
 synovia ; by which term I mean to express, that the 
 synovia is less mucilaginous, and contains more serum 
 than usual, mixed with a small quantity of blood; 
 this fluid, by gradually extending the ligament, sepa- 
 rates for a time one portion of bone from the other; 
 it is produced by the inflammatory process, and be- 
 comes absorbed when the irritation in the part sub- 
 sides. I do not know the exact period at which 
 this change takes place, but I have seen it in the 
 recent state of the injury. Into this fluid is poured 
 
144 
 
 FRACTURES OF THE UPPER PART 
 
 a quantity of ligamentous matter, by the adhesive 
 inflammation excited in the synovial membrane, and 
 flakes of it are found proceeding from its internal 
 surface, uniting it to the edge of the head of the 
 bone. Thus the cavity of the joint becomes dis- 
 tended, in part by an increased secretion of synovia, 
 and in part by the solid effusion which the adhesive 
 inflammation produces : the membrane reflected on 
 the cervix femoris is sometimes separated from the 
 fractured portions, so as to form a band from the 
 fractured edge of the cervix to that of the head of 
 the bone ; bands also of ligamentous matter pass 
 from the cancellated structure of the cervix to the 
 head of the bone, serving to unite, by this flexible 
 material, the one broken portion of bone with the 
 other. 
 
 The trochanter is drawn up, more or less, in diffe- 
 rent accidents ; and in those cases in which it is very 
 much elevated, I have known a considerable ossific 
 deposit take place upon the body of the thigh-bone, 
 between the trochanter major and the trochanter 
 minor. When the bone has been macerated, its 
 head is much lighter and more spongy than in the 
 healtUy state, excepting on those parts most exposed 
 to friction, where it is rendered smooth by the attri- 
 tion which gives it a polished surface. 
 
 These, then, are the usual appearances on dissec- 
 tion : there are, however, two preparations in the 
 Royal College of Surgeons in London, which have 
 been sent as specimens of union by bone of the cer- 
 vix femoris ; but as I may be thought prejudiced in 
 favour of the opinion I have advanced, I shall give 
 that of an excellent anatomist, whose loss we have 
 had lately to deplore. Mr Wilson says, ' 1 have ex- 
 amined very attentively these two preparations, and 
 cannot perceive one decisive proof in either, of the bones 
 having been actually fractured,'* 
 
OF THE THIGH-BONE. 
 
 145 
 
 This circumstance, of want of ossific union, is not 
 peculiar to the neck of the femur, as will be seen in 
 our account of fractures of the condyles of the os 
 humeri, of the coronoid process of the ulna, and of 
 bones generally, when seated within the capsular 
 ligament. 
 
 It appears then, as a general principle, from the 
 account which I have given of the dissection of those 
 whose bodies have been examined after having suffer- 
 ed from this fracture, that ossific union is not pro- 
 duced; that nature makes slight attempts for. its 
 production upon the neck of the bone, and upon the 
 trochanter major, but scarcely any upon the head of 
 the bone; and that if union be produced, it is by 
 means of ligament. 
 
 Mr Stanley, for whom, both as an anatomist and 
 a surgeon, I have great respect, has met with the 
 appearance of fracture in the neck of each thigh- 
 bone, in the same subject. 1 do not mean to deny 
 the possibility of the necks of both thigh-bones in 
 this subject having been fractured, because that point 
 can only be determined by the history of the acci- 
 dent, and by a very careful and accurate examination 
 of several sections of the bones; but I can show that 
 similar effects are produced by disease. 
 
 The neck of the thigh-bone in adult persons of 
 middle age, has a close cancellated structure, with 
 considerable thickness of the shell which covers it ; 
 but in old subjects, the cancellated structure of the 
 shaft of the bone, which is formed of a coarse net- 
 work, loaded with adipose matter, is often extended 
 into the neck of the bone, and the shell which cov- 
 ers it becomes so thin, that when a section is made 
 through the middle of the head and cervix, it is 
 found diaphanous; of this I have several specimens. 
 As the shell becomes thin, ossific matter is deposited 
 on the upper side of the cervix, opposite the edge 
 19 
 
146 
 
 FRACTURES OF THE UPPER PART 
 
 of the acetabulum, and often a similar portion at its 
 lower part, and thus the strength of the bone is in 
 some degree preserved ; this state may be frequently 
 seen in very old persons. Mr Steel, of Berkhamp- 
 stead, one of the most intelligent surgeons, and most 
 respectable men 1 know, gave me the thigh-bone of 
 a person thus altered, whose age was ninety-three. 
 
 When the absorption of the neck proceeds faster 
 than the deposit on its surface, the bone breaks from 
 the slightest causes, and this deposit wears so much 
 the appearance of an united fracture, that it might 
 be easily mistaken for it. Before the bone thus 
 alters, we sometimes meet with a remarkable but- 
 tress shooting up from the shaft of the bone into its 
 head, giving it additional support to that which it 
 receives from the deposit of bone upon its external 
 surface. But another change is also produced from 
 disease, of which the following is the history, and 
 which directly applies to the subject before us. 
 
 Old bed-ridden and fat persons (generally females), 
 are often brought into our dissecting-room with some 
 of their bones broken (and more frequently the thigh- 
 bone than any other) in being removed from the 
 grave. If the cervix femoris of such persons be 
 examined, it will be found that the head of the bone 
 is sunken down upon its shaft, and that the neck of 
 the thigh-bone is shortened, so that its head is in 
 contact with the shaft of the bone opposite to the 
 trochanter minor; and at the part at which the 
 ligament is inserted into the neck of the bone, the 
 phosphate of lime is absorbed, and a ligamento-car- 
 tilaginous substance occupies its place ; either ex- 
 tending entirely through the neck of the bone, or 
 partially, so that one section exhibits signs of it, 
 and in another it is wanting. The bone, in some 
 cases, is so soft and fragile, both in its trochanter and 
 head, that it will scarcely bear the slightest hand- 
 
OF THE THIGH-BONE. 147 
 
 ling; and the motion of the thigh-bones in the aceta- 
 bulum is almost entiielj lost, so that ihe persons 
 must have had little use in their lower extremities. 
 
 During the last winter we had two instances of 
 ■ this alteration in the neck of the bone, and it is an 
 appearance which 1 have several times seen. 
 
 In examining the body of an old subject, very 
 much loaded with fat, in the dissecting-room of St 
 Thomas's Hospital, 1 found lhat the gentleman who 
 had dissected one limb, had cut through the ca[)sular 
 ligament of the hip-joint, and tried to remove the 
 head of the thigh-bone from the acetabulum ; but 
 the neck of the bone broke on the employment of a 
 very slight force, and upon a further trial to remove 
 it, the bone crumbled under his fingers. As the 
 other limb was not yet dissected, I requested Mr 
 South, one of our demonstrators, to remove, with 
 care, the upper part of the thigh-bone; but although 
 he used great caution in doing it, he could not re- 
 move the bone without fracturing the upper part of 
 its shaft ; but he succeeded in removing the upper 
 part of the bone, so that it might be preserved; and 
 of this I have given plates. 
 
 We have here, then, a case in which the neck of 
 the bone was absorbed, so that the head was brought 
 in contact with the trochanter; in which, most de- 
 cidedly, there had not l^ee'n a fracture, although it 
 had in some parts the appearatice of one; and in 
 which the dis6ase occurred in each hip-joint. 
 
 Another case of the same kind was examined by 
 Mr Soutb,. daring the last winter, which, so far as it 
 relates to the Softened state of the upper part of the 
 thigh-bone, Avas similar to the former; the heads 
 were spongy, the necks were shortened, so that 
 there was scarcely any remaining ; each trochanter 
 was light in weight, spongy, and very large ; and 
 there was little if any motion in either of the hip- 
 
148 FRACTURES OF THE UPPER PART 
 
 joints; so that both limbs appeared, at first sight, as 
 if dislocated upon the pubes. 
 
 But the best specimen of this state of the bone is 
 the following, which I preserve with the most assid- 
 uous care, and value in the highest possible degree:- 
 — I have had for twenty years in the collection of 
 St Thomas's Hospital, the thigh-hone of an old 
 person, in which the head of the bone had sunken 
 towards its shaft. I have been in the habit of 
 showing this bone twice a year as a specimen how 
 bones sometimes become soft from age and disease, 
 and from the absorption of their phosphate of lime; 
 and I have frequently cut with a penknife both its 
 head and its condyles, to show this softened state. 
 On sawing through its cervix, the cartilage, deprived 
 of its phosphate of lime, had dried away in several 
 parts, and the appearance was such that a person. 
 Ignorant of the change, would have declared it to be 
 a fracture ; only, that in some sections the cartilage 
 had taken different directions, and in some the bone 
 was not yet entirely absorbed. There is also in the 
 Museum of St Thomas's Hospital, a skeleton in 
 which both the thigh-bones, and each os humeri, are, 
 in a subject extremely altered by rickets, divided 
 by similar portions of cartilage, in which no ossific 
 matter exists. 
 
 The plates which are appended will afford better 
 ideas of those morbid changes than words can con- 
 vey ; and I hope Mr Stanley, also, will give plates 
 of his preparations ; hoth^ however, should be en- 
 graved, as, without both, the public cannot form a 
 correct opinion. 
 
 I have been led to prosecute the inquiry by ex- 
 periments upon animals. I found it difficult to suc- 
 ceed in breaking the bone in the direction 1 wished, 
 and, after a great number of experiments, was suc- 
 cessful only in the following instances; the prepara- 
 
OF THE THIGH-BONE. 
 
 149 
 
 tions of these I have preserved, and they may be 
 seen in the Museum at St Thomas's Hospital. (See 
 Plate.) 
 
 Experiment I. 
 
 The neck of the thigh-bone was fractured in a 
 rabbit, on October 28th, 1818; and on December 
 1st, 1818, as the wound had been some tin)e healed, 
 I dissected the animal. 
 
 Jlppearance on dissection. — The capsular ligament 
 was much thickened; the head of the bone was 
 entirely disunited from its neck, but adhered by a 
 new ligamentous substance to the capsular ligament ; 
 the broken cervix, which was very much shortened, 
 played on the head of the bone, and had smoothed 
 it by attrition; the head of the thigh-bone had not 
 undergone any ossific change. 
 
 Experiment IL 
 
 The neck of the thigh-bone was broken in a dog, 
 November 18th, 1818, and the animal was killed on 
 the 14th of December following. 
 
 Dissection. — The trochanter was much drawn up 
 by the action of the muscles, so that the head and 
 cervix femoris were not in apposition. The capsu- 
 lar ligament was much thickened, and contained a 
 large quantity of synovia. 
 
 The joint was lined with adhesive matter of a 
 ligamentous appearance, adhering to the head of 
 the bone, which did not seem to be changed by any 
 ossific process; but the thigh-bone around the cap- 
 
150 
 
 FRACTURES OF THE UPPER PART 
 
 sular ligament, the trochanter major, and the bone 
 a httle below it, were enlarged. . 
 
 We find, therefore, by these dissections, that 
 what appears in the human subject after this acci- 
 dent, takes place also in other animals; and that 
 motion, want of apposition and pressure, with the 
 little ossific action in the head of the bone, under 
 these circumstances, produce a deficiency of bony 
 union, as in man. 
 
 Tlie two preparations which I have preserved, 
 were the only examples in which the experiment 
 was complete in relation to the transverse fracture ; 
 but I [lave two other interesting preparations deriv- 
 ed from these experiments. I also made a great 
 number of others, in wliich the fractures continued 
 com[)ound; in each of these the head of the bone 
 either became absorbed, or was discharged by ulcer 
 ation; and I never could succeed in uniting the 
 head to the neck of the bone. I have since divid- 
 ed the neck of the thigh-bone in a dog, and the 
 head of the bone was three-fourths absorbed. By 
 way of contrast, I have also divided the bone ex- 
 ternally to the capsule, in five instances, and have 
 preserved the bones; the wounds united by adhe- 
 sion, and every bone has been healed by ossific 
 union; the natural inference is, that fractures within 
 the capsule are not at all susceptible, but that frac- 
 tures external to it are readily susceptible of union 
 by bone. As to the notion that tlie bearing upon 
 the limb, or its weight, may have influence to pre- 
 vent union in these animals, I have only to observe, 
 that the muscles become contracted, the limb is 
 drawn up, and the animal cannot bear upon it for 
 several weeks. 
 
OF THE THIGH-BONE. 
 
 151 
 
 My friend, Mr Brodio, has furnished me with the 
 following account of an experiment which he made 
 upon the ^ame subjecl, wliicii fully conhrins mj ob- 
 servations. 
 
 Dear Sir: — The circumstances of the experi- 
 ment which I mentioned, were briefly these. The 
 tibia of a guinea-[)ig was broken at the lower end. 
 A month afterwards the animal was killed. On dis- 
 section, I found a IVacrure extending across the tibia, 
 transversely, and so close to the ankle-joint, that it 
 was situated at that part of the bone which is cov- 
 ered bj the reflected layer of the synovial mem- 
 brane. The synovial membrane itself, and the liga- 
 ments of the joint, appeared to have been very little 
 injured, and the broken surfaces had remained in 
 good apposition; nevertheless, there was not the 
 smallest union of them, either by bone or liganient, 
 and there had been no formation of callus round- the 
 fracture. The bone in the neighbourhood of the 
 fracture had become compact and hard, in conse- 
 quence of the ossification of the medullary membrane 
 lining the cancelli. 
 
 I am, dear Sir, your's truly, 
 Saville Row ; B. C. Brodie. 
 
 August mh, 1823, 
 
 Professor Burns, of Glasgow, has had the great 
 kindness to send me the following observations. 
 
 Permit me to offer my warmest thanks for the 
 pleasure and edification I have received from the 
 study of your late work. I was early led to attend 
 to the process adopted by nature in forming a new 
 articulation in injuries to the hip-joint, by the dissec- 
 tion of a dog which I had when a boy, and which 
 had the hip fractured. Many years afterwards 1 
 
152 FRACTURES OF THE UPPER PART 
 
 examined the parts, and found the fragment of the 
 cervix belonging to the head absorbed, the head it- 
 self filling the acetabulum ; the shaft of- the bone 
 expanded ; a new head formed for a new socket, 
 and the whole enveloped in a dense capsule or cov- 
 ering. 
 
 In a fracture of the os femoris external to the 
 capsule, the gluteus medius and minimus seem to act 
 as a cushion to stop the ascent of the end of the cer- 
 vix, whilst the fragment attached to its head will, 
 perhaps, atford some opposition ; but in the fracture 
 within the ca[)sule, the end of the cervix is drawn 
 more freely up under the gluteus medius, and lodged 
 behind the inferior spinous process of the ilium. 
 
 Is this the explanation of the greater shortening 
 in the one fracture than in the other? 
 
 Nothing can better explain the want of ossific 
 union than the principle you have laid down. 
 
 John Burns. 
 
 Glasgow, 1823. 
 
 Having by experiment verified the results I have 
 mentioned, 1 was next anxious to learn if the head 
 and neck of the thigh-bone would unite under a lon- 
 gitudinal fracture, partly within and partly external 
 to the capsular ligament, in which apposition, contact 
 and pressure, are maintained ; and for this purpose 
 1 made the following experiment. 
 
 Experiment IIL 
 
 Longitudinal fracture, — I divided the head, neck, 
 and a portion of the trochanter major of the thigh- 
 bone of a dog longitudinally, by placing a knife on 
 the trochanter major, and striking it down towards 
 
OF THE THIGH-BONE. 
 
 153 
 
 the acetabulum through the head of the bone. The 
 animal was killed twenty-nine days after, and the 
 following appearances presented themselves. 
 
 A portion of the trochanter major had been bro- 
 ken off, and was only united by cartilage. The 
 head and neck of the bone, which had been longi- 
 tudinally broken, were united ; the neck by a larger 
 quantity of ossific deposit than that which joined the 
 separated portions of the head of the bone, and so 
 irregularly as to make a beautiful preparation, and 
 show the circumstance most clearly. (See Plate.) 
 This bone may be seen in the collection at St 
 Thomas's Hospital. 
 
 Whether the union began in the fracture exter- 
 nally to the ligament, and proceeded inwards, or 
 whether on the whole surface at once, it is impos- 
 sible to ascertain ; but the coalescence was firm, 
 though, as I have stated, I thought more so at the 
 neck than at the head of the bone. The union in 
 this case is readily explained. Apposition was sup- 
 ported; the vessels of the head of the bone and 
 cervix remained whole ; and, therefore, this experi- 
 ment shows at once why the longitudinal unites, and 
 the transverse, in general, does not unite. 
 
 Union of these bone^. — Thus then, it appears, that 
 in a longitudinal fracture of the head and neck of 
 the bone partly external to the ligament^ if the bones 
 be applied to each other, pressed together, and in a 
 state of rest, and the vessels remain, ossific union can 
 be produced; although the ossific deposition is ex- 
 tremely slight when compared with that of other 
 bones. 
 
 Diagnosis. — The fracture of the neck of the 
 thigh-bone may be confounded with the dislocation 
 of the OS femoris upon the dorsum ilii ; with that into 
 the ischiatic notch; and with that upon the pubes ; 
 20 
 
154 FRACTURES OF THE UPPER PART 
 
 as in all these luxations the limb is shorter. From 
 the two former it may be distinguished by the ever- 
 sion of the foot, and by the mobility of the limb in 
 fracture ; and from the latter by the ball of the os 
 femoris being felt in the groin in the dislocation on 
 the pubes ; otherwise the eversion of the foot in 
 both cases might lead to their being confounded. 
 
 Treatment. — With respect to the treatment of 
 fractures of the neck of the thigh-bone within the 
 capsular ligament, various are the means to which 1 
 have had recourse, and which I have known resort- 
 ed to by others, for the purpose of producing union 
 in this accident, but all without avail. 
 
 One mode has consisted in placing the fractured 
 limb over a double inclined plane, thus maintaining 
 a regular and constant extension, which, by raising 
 the planes at the knee, may be increased to any de- 
 gree that the surgeon may require, or the patient 
 can bear ; at the same time, a bandage is applied 
 around the pelvis and upper part of the thigh, to 
 bring the neck of the bone, as much as possible, in 
 approximation with the head from which it has 
 been separated; and this extension, with pressure, 
 has been steadily preserved for three months. With 
 respect to the patient's body, it has been placed at 
 an angle of forty-five degrees. 
 
 A second method has consisted in placing a board 
 at the foot of the bed, upon which the foot of the 
 sound limb rested, so as to prevent the descent of 
 the body in the bed ; the other limb was then ex- 
 tended as much as possible, and a weight, appended 
 to the foot, was suffered to hang through a hole in 
 the board over the end of the bed, in order to sup- 
 port the extension with regularity and steadiness for 
 several weeks. 
 
 In a third method, the patient has been placed in 
 bed with both limbs extended to the utmost possible 
 
OF THE THIGH-BONE. 
 
 155 
 
 degree, and then the two feet have been bound to- 
 gether by a roller, passed from the foot on the in- 
 jured side under the sound foot, so as to make one 
 Jimb steadily preserve the extension of the other. 
 This may also be effected by an iron plate affixed to 
 the shoe on the sound foot, with a screw passed 
 through a hole in the plate, and having a band fixed 
 to the other foot, which may be tightened by turn- 
 ing the screw, and the foot, by this means, be kept 
 constantly extended. 
 
 A fourth mode employed for this purpose has 
 been the application of Boyer's splint, with the in- 
 tention of extending the limb from the pelvis; but 
 this splint, though it answers well for fractures of 
 the thigh under ordinary circumstances, has a ten- 
 dency to prevent union in those fractures which oc- 
 cur at the upper part of the bone, by the pressure 
 of its band upon the inner and upper portion of the 
 thigh. 
 
 Mr Hagedorn has recommended a machine for 
 fractures of the neck of the thigh-bone, which is very 
 ingenious in its construction. It consists of a long 
 splint to extend from the hip to the foot, and to be 
 firmly applied, by means of proper straps, to the 
 sound limb; at the bottom of this is fixed a broad 
 foot-board, perforated with a sufficient number of 
 openings to receive the bands, by means of which 
 both feet are to be securely fixed to it ; these band- 
 ages are attached to a kind of leathern gaiter, made 
 to lace tight round the ankle, and the upper part of 
 the splint is kept close to the hip by means of a 
 broad bandage carried round the pelvis. By this 
 machine the extension of the limb is tolerably well 
 effected, so long as the patient can be kept still; 
 but a displacement of the bones will invariably be 
 the consequence of every motion which the evacua- 
 tion of the faeces will necessarily require. I am 
 
156 
 
 FRACTURES OF THE UPPER PART 
 
 never so wedded to any opinion as to be prevented 
 from trying, or from wishing others to employ, every 
 means which appear plausible or ingenious; and, 
 therefore, I think that this instrument ought to have 
 a fair trial. ^ 
 
 Mr Earle is of opinion, that these cases may be 
 cured by long continued attention in keeping the 
 parts at perfect rest, I think a trial should be made 
 of the bed recommended by Mr Earle, and heartily 
 wish him success in his laudable attempt to prevent 
 the lameness and shortening of the limb in cases of 
 fracture within the capsule ; which has invariably 
 been the result in those cases which I have had an 
 opportunity of observing. 
 
 But all the means which I have seen used have 
 been found unavailing. I have been baffled at every 
 attempt to cure, and. have not yet witnessed one 
 single example of union in this fracture. I know 
 that some persons still believe in the possibility 
 of this union, by surgical treatment, and that instan- 
 ces of success have been published ; but I cannot give 
 credence to such cases until I see that the authors 
 were aware of the distinction between fractures 
 within and fractures external to the articulation. 
 
 The following anecdote was related to me by an 
 intelligent surgeon, who had been attending an hos- 
 pital on the Continent for some time. One of the 
 surgeons belonging to it observed, ' Some of the 
 English surgeons do not believe that we unite frac- 
 tures of the neck of the thigh-bone ; now there is 
 one that you shall examine, as the patient is dying.' 
 A few days after, the patient died, and the joint was 
 
 * For a modification of Hagedorn's apparatus by Professor 
 Gibson, and an ingenious application of the single inclined plane, 
 see the Philadelphia Journal of the Medical and Physical Scien- 
 ceSj and the 1st vol. of Gibson's Surgery. J. P. G, 
 
OF THE THIGH-BONE. 
 
 157 
 
 examined, when the bone was found stiH disunited. 
 The surgeon of the hospital only made a significant 
 shrug of disappointment. 
 
 The cases in' which union might be produced are 
 two : one, in which the periosteum covering the 
 neck of the thigh-bone is not torn through, a cir- 
 stance which now and then happens; the other, in 
 which the head of the bone is broken, so that the 
 cervix still remains in the acetabulum: but in neither 
 of these cases will the limb exhibit the shortened 
 state which the fracture of the neck of the bone 
 usually produces, and, therefore, the common cha- 
 racters of the accident will be wanting. Even in 
 such cases, I would, in consideration of the confine- 
 ment and danger of bony union, prefer a ligamentous 
 union, as well from, regard to the health and life of 
 the person, as, I believe, to the subsequent use of 
 the joint. 
 
 The various attempts at curing these cases having 
 failed, and the patients' health having invariably suf- 
 fered under the trials made to effect union, 1 should, 
 if I sustained this accident in my own person, direct 
 that a pillow should be placed under the limb 
 throughout its length; that another should be rolled 
 up under the knee, and that the limb should be thus 
 extended for ten days or a fortnight, until the inflam- 
 mation and pain had subsided. 1 should then daily 
 rise and sit in a high chair, in order to prevent a 
 degree of flexion, which would be painful; and, 
 walking with crutches, bear gently on the foot at 
 first ; then, gradually more and more, until the liga- 
 ment became thickened, and the muscles increased 
 in their power. A high-heeled shoe should be next 
 employed, by which the halt would be much dimin- 
 ished. Our hospital patients, treated after this man- 
 ner, are allowed in a few days to walk with crutches; 
 after a time a stick is substituted for the crutches, 
 
158 
 
 FRACTURES OF THE UPPER PART 
 
 and in a few months they are able to use the limb 
 without any adventitious support. 
 
 The degree of recovery in these cases is as fol- 
 lows: — if the patient be very corpulent, the aid of 
 crutches will be for a long time required; if less 
 bulky, a stick only will be sufficient ; and where the 
 weight of the body is inconsiderable, the person will 
 be able to walk without either of these aids, but 
 will drop a little at each step on that side, unless a 
 shoe be worn having a sole of equal thickness to 
 the diminished length of the limb. In every case, 
 however, in which there is the smallest doubt 
 whether it be a fracture within, or external to the 
 ligament, it will be proper to treat the case as if it 
 were the fracture which I shall hereafter describe, 
 and which admits of ossific union. 
 
 It is gratifying to find opinions which have been 
 for thirty years delivered in my lectures, confirmed 
 by the observations of intelligent and observing per- 
 sons ; and, therefore, it was with pleasure that I 
 read in the Dublin Hospital Reports, the account of 
 the dissection of several cases of fracture of the cer- 
 vix femoris, by my friend, Mr CoUes, of Dublin, (a 
 man excellently informed in his profession) who 
 found in them similar want of ossific union, in the 
 fracture within the ligament, to that which I have 
 described. A few contributions of a similar kind, 
 from the ardent cultivators of morbid anatomy, 
 would soon prevent persons from being tortured 
 with trials, which have been frequently repeated, 
 and found to be uniformly unavailing, 
 
OF THE THIGH-BONE. 
 
 159 
 
 ADDITIONAL OBSERVATIONS ON FRACTURES OF THE 
 NECK OF THE THIGH-BONE. 
 
 The following letters, which were appended to 
 the former editions of this work, merit a permanent 
 record; each of them being interesting in regard to 
 the facts upon this subject. One is from Mr Stan- 
 ley, Assistant-Surgeon of Saint Bartholomew's Hos- 
 pital, and Demonstrator of Anatomy at that hospital; 
 one from Dr Monro, Professor of Anatomy at Edin- 
 burgh ; and the other from Mr CoUes, Professor of 
 Anatomy and Surgery at Dublin. 
 
 Lincoln'^ s Inn Fields^ February 25th, 1823. 
 
 My dear Sir: — We have in the Museum of St 
 Bartholomew's, twelve specimens of fractures in 
 the neck of the thigh-bone; six external to the 
 capsule, and united, and six within the capsule. In 
 three of the latter there is no union, and in the 
 other three there is union by ligamentous matter. 
 I remain, dear Sir, 
 
 Yours most respectfully, 
 Edward Stanley. 
 
 This letter shows the difference of fractures 
 within and fractures external to the ligaments, in 
 regard to their union. 
 
 Edinburgh, February \lth, 1823. 
 
 Mr dear Sir Astley : — In answer to jour query 
 respecting fracture of the neck of the thigh-bone, I 
 beg leave to inform you, that I have had an oppor- 
 
160 
 
 FRACTURES OF THE UPPER PART 
 
 tunity of examining two cases only after death, and 
 in both of these, the broken ends of the neck of 
 the bone were united by a substance somewhat like 
 to ligament. 
 
 I have seen several persons who had, during their 
 lives, a fracture of the neck of the bone, but in all 
 of them a bony reunion had not taken place. 
 
 In the catalogue of the Museum which was be- 
 queathed. to the University by my father, mention is 
 made of the fracture of the neck of the thigh-bone 
 which had re-united by a bony union. Upon exam- 
 ining the preparation with attention, it appears to 
 me, that there has been no fracture, but a disease in 
 the trochanter major, and that a number of osseous 
 speculoe have shot upwards within the capsular 
 ligament, giving the appearance of an ill-set fracture. 
 
 Should you wish to have a drawing of this pre- 
 paration, I shall have great pleasure in sending it 
 to you. 
 
 There is also a specimen in the Museum of a 
 fracture of the thigh, about four lines beyond 'the 
 insertion of the capsular ligament, at the root of 
 the trochanter. 
 
 Your's most truly, 
 
 Alexander Monro. 
 
 Stephen^ s Green, February 12^/^, 1823. 
 My dear Sir: — Since the receipt ot" y6ur letter, 
 1 have carefully examined all the specimens of 
 fractures of the neck of the thigh-bone contained 
 in both Museums of our College of Surgeons. In 
 that which is appropriated to the use of the School, 
 I find seven instances of fracture within the liga- 
 ment ; each of these has been described in my 
 paper on this subject, in the Dublin Hospital Re- 
 ports. Since the publication of that Essay, the 
 
OF THE THIGH-BONE. 
 
 161 
 
 conservator of the College Museum has collected 
 live Sjiecimens of fracture within the ligament. In 
 this Museum are also four instances of fracture ex- 
 teinal to the condyle ligament. In the School 
 Museum are two instances of fracture external to 
 the ligament. Of this latter description of fracture, 
 fewer than one half the number are united by bony 
 union. Of the fractures within the ligament, not 
 one has made a nearer approach to bony union than 
 that described in the paper alluded to. I must say, 
 that 1 have never yet seen an instance of bony 
 union where the fracture had been within the liga- 
 ment. We have very many specimens of a disease 
 of the head and neck of the thigh-bone, which is 
 of frequent occurrence amongst our labouring poor. 
 On this subject 1 have some idea of writing a paper 
 for the next volume of the Dublin Hospital Reports, 
 and of endeavouring to show, that in all probability, 
 the supposed cases of fracture within the ligament 
 united by bone, were merely instances of this 
 disease. 
 
 If you have any wish for them, I shall have great 
 pleasure in sending you sections of some of these 
 cases, which I am certain might be passed upon many 
 surgeons for fracture of the neck of the bone. . 
 
 I am, my dear Sir, 
 
 Your sincere friend, 
 
 A. COLLES. 
 
 I have also seen three cases of this fracture in 
 the dead body since the publication of the second 
 edition of this work. 
 
 First ; — A very old female was brought into the 
 dissecting-room at St Thomas's Hospital, whos ; right 
 limb was everted, and was an inch and a half shorter 
 than the left. Upon dissection, the sciatic nerve 
 
 21 
 
162 
 
 FRACTURES OF THE UPPER PART 
 
 had the appearance of having been bruised ; a small 
 portion of bone was broken off at the Insertion of the 
 obturator externus muscle ; a similar portion of bone 
 was separated at the upper part of the Insertion of 
 the quadratus femorls. The capsular ligament was 
 torn at the part at which it is covered by the iliacus 
 internus muscle. The capsular ligament being further 
 opened, was found to contain a small fragment of 
 bone ; and it was filled with adhesive ligamentous 
 matter, poured out bj Inflammation, and adhering 
 to the internal surface of the capsular ligament, to 
 the remnants of the cervix femoris, and, slightly, to 
 the head of the bone. The cervix femoris had been 
 broken close to the head of the bone, and entirely 
 within the capsular ligament. The head of the fe- 
 mur remained in the acetabulum unaltered, except- 
 ing that its surface was partially covered by liga- 
 ment. The neck of the bone was so absorbed, that 
 the portion of it which remained was smaller than 
 the trochanter minor. Its cancellated structure was 
 covered by the effused ligamentous matter. There 
 was not the slightest appearance of ossific union, or 
 even of bony deposit, although this injury must, from 
 the changes produced by inflammation, have hap- 
 pened from two to three months before death. 
 When I had raised the thigh-bone one inch and a 
 half, it was prevented from rising higher by the 
 lower portion of the gluteus minimus, and by the 
 capsular ligament. 
 
 Second: — Mr Clarke gave me a preparation 
 made from the body of a man, eighty-two years of 
 age, tall and remarkably strong for the time of life, 
 who died eight weeks and four days after having 
 fractured the neck of the thigh-bone. Upon inspec- 
 tion, not the least attempt at ossific union was found. 
 The ligamentous sheath of the cervix femoris was 
 only partially torn. 
 
OF THE THIGH-BONE. 163 
 
 Third : — Mr Key, surgeon to Guy's Hospital, 
 gave me the head and neck of the thigli-bone, taken 
 from a subject brought into the dissecting-room ; in 
 which case, the neck of the thigh-bone was absorb- 
 ed. The head of the thigh-bone was entirely de- 
 tached from the cervix. No ossific process existed 
 in the cancelli of either the neck or head of the 
 bone, but some ossific deposit appeared around the 
 insertion of the ligamentum teres. 
 
 1 have a patient in Guy's Hospital at this time, 
 with a fracture of the neck of. the thigh-bone, in 
 whom the following circumstances are to be observ- 
 ed : — When placed in the recumbent posture, the 
 limb is one inch and a half shorter than the other ; 
 but when he is standing, the injured limb is two 
 inches and a half shorter than the sound limb : the 
 cause of this contrariety is as follows: When he is 
 recumbent, and the spinous processes of the ilia are 
 in the same line, the shortening is only from the re- 
 traction of the thigh-bone; but when he is standing, 
 he throws the axis of his body into the thigh of the 
 soundJimb, to enable him to support himself ; and 
 elevating the pelvis, raises the injured limb one inch 
 more than when he is recumbent. 
 
 FRAClrURES OF THE CERVIX FBMORIS EXTERNAL TO THE 
 CAPSULAR LIGAMENT, AND INTO THE CANCELLI OF THE 
 TROCHANTER MAJOR. 
 
 The symptoms of this accident in some respects 
 resemble those of the fracture within the ligament, 
 and they require much attention to distinguish them 
 accurately; but the result is entirely different; so 
 that a favourable opinion may be given as to the 
 restoration of the bone by an ossific union. 
 
164 
 
 FRACTURES OF THE UPPER PART 
 
 Symptoms, — In this accident, the Injured leg is 
 shorter than the other by one half to three quarters 
 of an inch ; the foot and toe on that side are evert- 
 ed, from the loss of support which the body of the 
 thigh-bone sustains in consequence of the fracture.; 
 much pain is felt at the hip, and on the inner and 
 upper part of the thigh ; and the joint loses its 
 usual roundness. 
 
 Diagnostic marks; union of the hone, — The dis- 
 tinguishing signs of this accident are, — First : — It 
 sometimes occurs at the earlier periods of life ; for 
 it happens In the young, and in the adult under fifty 
 years of age, although I have known it at a later 
 period, when it often proves fatal ; but if the above 
 symptoms are seen at any age under fifty years^ there 
 will be generally found a fracture external to the 
 capsular ligament, and capable of ossific union. Sev- 
 eral of these cases which have fallen under my no- 
 tice have occurred under that period ; and, there- 
 fore, a surgeon called to the bed-side of a patient 
 who has an injury to the upper part of the thigh- 
 bone, if he finds the age of the patient to be under 
 fifty years, will, with very few exceptions, be war- 
 ranted in pronouncing it either a fracture just ex- 
 ternal to the ligament, or one through the trochanter 
 major. But I also mention that both fractures occur 
 in age, and therefore no discrimination can be drawn 
 between the two, in advanced age, but by the most 
 careful examination. 
 
 From severe injuries, — Secondly : — These cases 
 may be in some measure distinguished by the seve- 
 rity of the accident which produces them; for 
 whilst the internal fracture happens from very slight 
 causes, this, on the contrary, is produced either by 
 severe blows, or falls upon the edge of some pro- 
 jecting body, as against the edge of the curb-stone, 
 or from the pressure of laden carriages passing over 
 
OF THE THIGH-BONE. 
 
 the pelvis. My experience has taught me, that a 
 very shght accident generally occasions tlie fracture 
 within the capsule, and a violent blow or tail, the 
 other; the first is an accident upon which the fall 
 often succeeds, the other is generally the conse- 
 quence of that fall. Many of those within the caj)- 
 sule which I have witnessed, were produced by the 
 person's slipping from the curb-stone to "the road- 
 way;"* not that I mean to deny, that a fall will, and 
 do6s occasionally, produce a fracture within the 
 capsule, or that in a very old person, a fracture may 
 occasionally happen in any part of a bone, from a 
 slight cause compared ^vith that which produces it 
 in the young. 
 
 Crepitus, — Thirdly : — It may be generally known 
 by the crepitus which attends it upon slight motion ; 
 and so small is the retraction, that it is unnecessary 
 to draw down the limb to distinguish the grating of 
 one bone upon the other. 
 
 Fourthly : — Great ecchymosis often attends it. 
 
 Swelling. — Fifthly : — Swelling and tenderness 
 to the touch quickly succeed upon the upper part 
 of the thigh, from the inflaaimation which this in- 
 jury produces. 
 
 Severe pain. — Sixthly : — This accident is gener- 
 ally marked by much greater severity of sutfering 
 than the fracture within the ligament, slight motion 
 producing excruciating pain, which does not happen 
 in an equal degree in the fracture within the 
 liga-ment. 
 
 Seventhly : — There is a high degree of irrita- 
 tive fever, and many months elapse before the pa- 
 tient recovers any use of his limb. 
 
 * Slipping from the ciirb-stone to the road-way produces a 
 violence in the perpendicular direction ; falling against the 
 edge of the curb-stone often produces the fracture external to * 
 the capsule. — A. C. 
 
166 
 
 FRACTURES OF THE UPPER PART 
 
 Dissection. — Upon dissection of these cases, the 
 seat of the fracture is found to vary very much in 
 different examples, being more or less complicated, 
 but it is external to the capsular ligament; and the 
 fracture is placed at the neck of the root of the 
 thigh-bone, the trochanter is sp)lit, and the neck of 
 the bone is received into its cleft. The trochanter 
 major is often broken into several portions. 
 
 We have few opportunities of dissecting these 
 cases in the young, because they recover from the 
 accident ; and, therefore, the examination of them 
 has been most frequently made in aged persons, to 
 whom they often prove fatal. The following cases 
 will explain the appearances on dissection. 
 
 Mr Powell, surgeon, of Great Coram Street, pre- 
 sented me with a valuable preparation, taken from 
 a patient of his who died fifteen months after the 
 accident, and the following is the history of the 
 case. 
 
 Fracture of the JVeck of the Thigh-Bone, 
 
 Case, — Mary Clements, aged eighty-three and a 
 half years, when walking across her room, October 
 1st, 1820, supported by her stick, which from the 
 debility consequent upon old age she was obliged to 
 employ, unperceived by herself, placed her stick in 
 a hole of the floor, by which, losing her balance, and 
 tottering to recover herself from falling, which she 
 would have done but for those near her, she found 
 she had, as she supposed, dislocated her thigh-bone. 
 When called to her, she was lying upon her bed, in 
 much pain, with the thigh shortened, and the foot 
 everted. Suspecting the nature of the accident, I di- 
 rected extension to be made by the foot, which I 
 found was readily brought to correspond with the 
 
OF THE THIGH-BONE. 
 
 167 
 
 opposite side ; and upon rotating the llrnb I discov- 
 ered a crepitus, which fully confirmed me in the 
 opinion that some part of the neck of the femur was 
 broken. With a view to the union of the bone, I 
 first placed the limb in a straight position, making a 
 permanent extension by fixing the pelvis and extend- 
 ing from the ankle ; but as the mental faculties were 
 nearly as much shaken as the corporeal, and she 
 could not be induced to keep up the extension re- 
 quired,! was obliged after a few days to change my 
 plan for that of two boards united together at right 
 angles, over which the thigh was placed, and was 
 supported by pillows kept in their position by later- 
 al pegs. In a very few days this position, in which 
 she at first expressed herself comfortable, became 
 so irksome, that she would no longer submit to it, 
 and I was obliged again to abandon my wish to be 
 decidedly uselul to her. From this period she 
 adopted any position that was most comfortable to 
 herself, but generally as the easiest state, lay upon 
 the same side as the accident, with the limb drawn 
 up at nearly right angles with the body. The neigh- 
 bourhood of the joint, in the early stage of the acci- 
 dent, was kept wet with an evaporating lotion ; the 
 regular action of the bowels was elicited by occa- 
 sional aperients, and she generally took at bed-time, 
 for an old chronic cough, an anodyne pill. For some 
 weeks I found that I could extend the limb when I 
 wished, but afterwards I could not accomplish this, 
 1 supposed from the permanent contraction of the 
 muscles of the pelvis; this I presumed was more 
 especially the case, as the opposite thigh was bent 
 at the same angle, and was equally immovable. 
 As she was become perfectly bed-ridden, to which 
 state of imbecility she might be said to be rapidly 
 approaching even before the accident, she had 
 sloughing of the integuments of the parts upon which 
 
168 
 
 FRACTURES OF THE UPPER PART 
 
 she lay, but did not suffer other inconvenience. Her 
 general health appeai-ed nearly as good as before 
 the accident; and she ultimately sunk \vithout any 
 symptom of active disease, about fifteen months 
 from the period at which the fracture took place. 
 
 Inspection, 
 
 The limb was drawn up at right angles with the 
 body, or nearly so. I removed the os innominatum 
 with the thigh-bone, and presented them to Sir 
 Astley Cooper, and the following is the account of 
 (he dissection. 
 
 Dissection, 
 
 The neck of the thigh-bone had been broken at 
 its junction with the body of the bone, and had been 
 forced into the cancellated structure between the 
 trochanter major and trochanter minor, where it 
 had been united with the cancelli. But the most 
 curious circumstance in this dissection was, that in 
 order to give the support which the body required 
 for a limb in such a state, an addition had been made 
 both to the trochanter major and the troclianter 
 minor, by which means they rested against the edge 
 of the acetabulum, and in every slight change of 
 position, would give an opportunity for the weight 
 of the body to be supported by these processes 
 resting on the os innominatum. (See Plate.) 
 
 James Powell. 
 
 My friend, Mr Roux, sent me from Paris a frac- 
 tured thigh-bone, in which the neck of the bone 
 had been broken at the same part, as in Mr Powell's 
 case, and had been united in a similar manner. But 
 it frequently happens in this injury, that the frac- 
 ture of the neck of the thigh-bone is complicated 
 
OF THE THIGH-BONE. 
 
 169 
 
 with an injury of the trochanter major and trochan- 
 ter minor. 
 
 Mr Wray, surgeon, in Fleet Street, was so kind as 
 to present me with a fracture of this description, 
 and the folhnving are the particulars of the case. 
 
 Case, — A man, aged sixty-four, was standing by 
 his bed-side, when he suddenly fell to the ground, 
 as it was supposed in a fit, and on tho attempt to 
 raise him, he was found unable to stand. Mr \¥ray 
 was called to him, and he found his right leg some- 
 what shorter than the other, and the limb everted. 
 Motion of the limb gave him excessive pain; no 
 crepitus could be perceived in the examination which 
 he would permit Mr Wray to make. The limb 
 was placed in a straight position, and a constitutional 
 treatment was pursued, but a high degree of irrita- 
 tive fever succeeded, and on the fourth day from the 
 accident the man died. Upon the examination of 
 the body, great extravasation of blood was found 
 both externally to the muscles and between them; 
 suppuration had commenced near the trochanter 
 major, and a fracture was found at the neck of the 
 thigh-bone and into the trochanter, by which the 
 neck had been received into the cancellated struc- 
 ture of the shaft of the bone. 
 
 Mr Travers has a most valuable specimen of this 
 fracture, which occurred in a patient of his at St 
 Thomas's Hospital, and of which he had the kind- 
 ness to give me the following account. 
 
 Case. — Richard Norton, aged sixty, fell upon the 
 curb-stone of the foot-pavement, and struck the up- 
 per and outer part of his left thigh with great vio- 
 lence. He was admitted into St Thomas's Hospital, 
 on the 24th of January, 1818. The tension was 
 then considerable ; the line of the tensor vagin{e 
 22 
 
170 
 
 FRACTURES OF THE UPPER PART 
 
 femoris formed an arch ; the limb was shortened; 
 the foot inclined outwards; the motion of the limb 
 was free in all directions ; but it was painful, more 
 especially when the knee was carried over the 
 opposite thigh. The crepitus of the trochanter major 
 was distinctly felt in these motions, and the swelling 
 of the parts, with the extensive crepitus, gave an 
 idea that the effect of the accident was a comminut- 
 ed state of the trochanter, and that the base of the 
 cervix femoris was broken ; hence the shortening of 
 the leg, and the eversion of the foot. After the 
 use of evaporating lotions for some days, the tension 
 subsided, so as to allow the application of the long 
 outer splint and two thigh-splints well bedded. On 
 March the 4th, the splints were removed, and union 
 appeared to have taken place, for the limb had re- 
 sumed its natural figure, but was a little shorter than 
 the other. In the course of a month more he began 
 to use his crutches. On April the 15th, he was 
 placed under the physician for defect in his general 
 nealth; and when he was upon the point of quit- 
 ting the hospital, he was seized with spasms in his 
 chest, of which he suddenly expired. 
 
 Upon examination, some old adhesions of the 
 pleura, and water in the chest, and pericardium, 
 were found. The fracture was through the tro- 
 chanter, as had been supposed, extending some way- 
 down the bone, and it apparently had united, with 
 very slight deformity ; but on maceration, the head 
 and neck of the bone became loose in the thigh- 
 bone, and a fracture was found there, which locked 
 the head and cervix in a shell of bone formed 
 aroimd them. B. Travers. 
 
 Mr Travers having sent me the bone, the follow- 
 ing are the appearances of this curious case. The 
 
OF THE THIGH-BONE. 
 
 171 
 
 head and cervix had been separated from the tro- 
 chanter major and body of the bone. The upper 
 part of the thigh-bone was obhquelj split, so as to 
 receive the cervix femoris into the cancelli. Tiiis 
 fracture of the thigh-bone separated the posterior 
 portion of the trochanter major from the body of 
 the thigh-bone, and the trochanter minor was re- 
 moved with it. An union had taken place between 
 the fractured portions of the trochanter, at a slight 
 distance from each other, and thus a hollow was left, 
 into which the cervix femoris was received, and it 
 had not yet become united by ossific deposit, as the 
 man had not lived sufficiently long for firm consoli- 
 dation under his reduced state; for upon maceration, 
 the neck of the bone had free play in the cavity in 
 which it had been received, and from which it could 
 not be removed. 
 
 Mr Oldnow, of Nottingham, who is a very intel- 
 ligent surgeon, sent me two very excellent speci- 
 mens of this fracture, in which the necks of the 
 bones were broken at their junction with the tro- 
 chanter major. The trochanter major itself had 
 been also broken off, and the trochanter minor 
 formed a distinct fracture. The bones had become 
 re-united; the cervix femoris to the shaft of the 
 bone, and the trochanter minor a little higher than 
 its natural attachment. The trochanter major was 
 in one specimen re-united to the body of the bone, 
 but not in the other. Thus the thigh-bone was at 
 its upper part divided into four portions; the head 
 and neck of the bone formed one portion ; the tro- 
 chanter major a second ; the trochanter minor a 
 third; and the body of the bone the fourth. The 
 union was accompanied by very little shortening of 
 the thigh. (See Plate.) 
 
 Since the publication of a former edition of this 
 work, I have inspected, with Mr Key, a fracture of 
 
172 FRACTURES OF THE UPPER PART 
 
 the neck of the thigh-bone. The moment I had 
 examined the patient, I pronounced the case to be 
 a fracture external to the capsule, and was led to 
 believe so from some little diminution in the length 
 of the limb; from the ecchjmosis which attended 
 it; from its distinct crepitus without any rotation; 
 from the diminished motion of the upper part of 
 the thigh ; from the sunken state of the trochanter; 
 and from excitement of great pain by the smallest 
 motion. This man died in a fortnight after the 
 accident. 
 
 When the body was placed upon the table for 
 examination, post mortem, all the limbs were rigid * 
 from the fixed contraction of the muscles, and, con- 
 sequently, the thigh was drawn up to its greatest 
 possible extent ; yet the limb was found to be not 
 quite three-quarters of an inch shorter than the 
 other. The posterior part of the sheath of the 
 vessels, and some branches of blood-vessels, were 
 torn by the bone, which accounted for the ecchy- 
 mosis. The neck of the bone was forced into the 
 cancelli of the trochanter major. 
 
 Before writing this statement, I again inquired of 
 Mr Key, the degree of diminution in the length of 
 the limb, and his answer was, 'If you mention three- 
 quarters of an inch, you will state rather more than 
 its degree of retraction, even when all the muscles 
 were contracted to their utmost rigidity.' 1 shall be 
 happy to show the parts which I removed from the 
 case, with all the surrounding muscles, to any person 
 who wishes to see them, as they at once explain the 
 nature of the accident, and the reason why the limb 
 is so little shortened. 
 
 Although, then, this accident has some of the 
 marks of fracture of the neck of the bone within 
 the ligament, yet it unites by bone, and it will be 
 seen that the union is similar to that of other bones 
 
OP THE THIOH-BONE. 
 
 173 
 
 external to the joints; cartilage is first deposited, 
 and then the matter of bone, because in this case 
 the parts can be brought into apposition, and the 
 ends of the bones are confined together by the sur- 
 rounding nnuscles; one portion is pressed against the 
 other, and the neck of the bone sinks deeply into 
 the cancellated structure of the trochanter; thus di- 
 rect approximation and pressure are preserved when 
 the fracture is at the junction of the cervix with the 
 trochanter, and the nutrition of each extremity of 
 the bone is well supported by the vessels which pro- 
 ceed to it from the surrounding parts. 
 
 Difference of opinion reconciled, — We now see the 
 reason of the difference of opinion respecting the 
 union of fracture of the neck of the thigh-bone. 
 In the internal fracture the bones are not applied 
 to each other, and the nutrition of the head of the 
 bone being imperfect, in general no ossific change is 
 produced ; but in the external fracture the bones 
 are held together by the surrounding parts, easily 
 kept in apposition by external pressure, and there is 
 not only ossific union, but very exuberant callus. 
 Much time is required in these accidents to produce 
 a complete ossific union; and the neck of the bone, 
 received into the cancelli, moves for a long period in 
 its new situation; although it is so far locked in as 
 to prevent its separation. 
 
 Treatment. — In the treatment of this injury, the 
 principle is, to keep the bones in approximation by 
 pressing the trochanter towards the acetabulum ; 
 and the length of the limb is preserved by applying 
 a roller around the foot of the injured leg, and by 
 binding the feet and ankles firmly together, so as to 
 prevent their retraction, and thus cause the uninjur- 
 ed side to serve as the splint to that which is frac- 
 tured, giving it a continued support. A broad 
 
174 
 
 FRACTURES OF THE UPPER PART 
 
 leathern strap should also be buckled around the 
 pelvis, including the trochanter major, to press the 
 fractured portions of the bone firmly together ; and 
 the best position for the limb is, to keep it in a 
 ^straight line with the body. 
 
 The following plan I have also known successful: 
 — The patient being placed on a mattress on his 
 back, the thigh is to be brought over a double in- 
 clined plane composed of three boards, one below, 
 Avhich is to reach from the tuberosity of the ischium 
 to the patient's heel, and the two others having a 
 joint in the middle by which the knee may be raised 
 or depressed ; a few holes should be made in the 
 board, admitting a peg, which prevents any change 
 in the elevation of the limb but that which the sur- 
 geon directs; over these a pillow must be thrown, 
 to place the patient in as easy a position as possible.* 
 (See Plate,) 
 
 Recovery, — When the Vimb has been thus extend- 
 ed, a long splint is placed upon the outer side of the 
 thigh to reach above the trochanter major, and to 
 the upper part of this is fixed a strong leathern 
 strap, which buckles around the pelvis, so as to 
 press one portion of bone upon the other ; and the 
 lower part of the splint is fixed with a strap around 
 the knee to prevent its position from being altered; 
 the limb must be kept as steady as possible for 
 many weeks, and the patient may be permitted to 
 rise from his bed when the attempt does not give 
 him much pain; he is still to retain the strap which 
 I have mentioned round the pelvis; and by this 
 
 * The construction of this inclined plane is so little compli- 
 cated, that it may be made at the instant of two common boards, 
 one of which is to be sawn through nearly at the middle, and if 
 hinges cannot be immediately procured, the boards may be nailed 
 together thus — " ^""^ — — A. C. 
 
OF THE THIGH-BONE* 175^ 
 
 treatment he will ultimately recover, with a useful, 
 though shortened limb. 
 
 FRACTURES THROUGH THE TROCHANTER MAJOR. 
 
 Oblique fractures sometimes happen through the 
 trochanter major, and the cervix ossis femoris does 
 not participate in the injury. This accident occurs 
 at every period of life, and its symptoms are as fol- 
 low: — The leg is very little, and sometimes not at 
 all, shorter than the other, and the foot is benumbed; 
 in some cases the patient is unable to turn in bed 
 without assistance, and the attempt gives him great 
 pain. The broken portion of the trochanter major 
 is, in soaie cases, drawn forward towards the ilium; 
 in others, it falls towards the tuberosity of the ischi- 
 um ; but is, in general, widely separated from that 
 portion which remains connected with the neck of 
 the bone. The foot is greatly everted ; the patient 
 cannot sit, and any attempt to do so produces exces- 
 sive pain. Crepitus is with difficulty discovered if 
 the trochanter is either much fallen, or much drawn 
 forwards. 
 
 The distinguishing marks of this accident are, a 
 fixed state of the upper part of the trochanter, 
 whilst its lower part obeys the motion of the thigh- 
 bone ; eversion of the foot, and the very perceptible 
 altered position of the trochanter major; attended 
 with crepitus under very extended motion of the 
 upper part of the limb, and with little diminution of 
 its length. 
 
 But when the fracture happens below the inser- 
 tion of the principal rotatory muscles, the lower por- 
 tion of bone is much raised by the action of the 
 gluteus maximus, and the limb becomes very much 
 
176 FRACTURES OF THE UPPER PART 
 
 shortened and deformed at the place of union by 
 exuberant callus. 
 
 This fracture unites very firmly, and more quickly, 
 than when the cervix is broken at the root of the 
 trochanter, and the patient recovers with a very 
 good use of the limb. 
 
 The first case of this kind 1 ever saw was in St 
 Thomas's Hospital, about the year 1786. It was 
 supposed to be a fracture of the neck of the thigh- 
 bone within the capsule, and the limb was extended 
 over a pillow rolled under the knee, with splints on 
 each side of the limb, by Mr Cline's direction. An 
 ossific union succeeded, with scarcely any deformity, 
 excepting that the foot was somewhat everted, and 
 the man walked extremely well. When he was to 
 be discharged from the hospital a fever attacked 
 him, of which he died ; and upon dissection, the 
 *fracture was found through the trochanter major, 
 and the bone was united with very little deformity, 
 so that his limb would have been equally useful as 
 before. 
 
 The following case I attended with Mr Harris, 
 surgeon, at Reading, who has been so kind as to 
 communicate the circumstances in detail. 
 
 Case. — On Friday, July 20th, 1821, I was sent 
 
 for to Mr B , a gentleman, living about six miles 
 
 from Reading, who, I understood from the servant, 
 had met with an accident, and put out his hip. I 
 found him placed on a board in his bed room, and on 
 inquiry learnt that his horse had fallen with him 
 when putting him into a trot, and he was thrown, 
 and fell on his left hip on the road. He immediately 
 got on his legs, and walked a few steps, but soon 
 found an inability to bring his left leg forward, and 
 con)plained of [)ain in his left hip. He was placed 
 in a cart, and supporting his left leg by taking the 
 
OF THE THIGH-BONE. 
 
 177 
 
 stirrup and placing his foot in ll, holding it steady by 
 the leather, he was conveyed home, a distance of 
 about four uiilcs. 1 reached him within two hours 
 of tlie accident, and on examining the hmb I imtne- 
 thately perceived that tl)ere was not a dislocation. 
 
 I could not discover any crepitus in rotating the 
 limb; it was of the same length as the other, and 
 neither turned inwards nor outwards; and he had 
 the power of retaining it in any position in which you 
 chose to place it. The integuments in the neigh- 
 bourhood of the trochanter U];ijor wore a good deal 
 swollen; and he complained of pain, but could bear 
 the limb to be moved in any direction, without much, 
 or indeed any inconvenience, excej)t when drawn 
 across the olJier, and then great pain was felt in the 
 situation of the trochanter minor. 1 then gave it as 
 my opinion, that there was neither dislocation nor 
 fracture, and I thought he would be well in a few 
 days. I directed some leeches to be applied over 
 the trochanter major, and an evaporating lotion, and 
 took about twelve ounces of blood from the arm; 
 and as he was in the habit of taking the pil : hydrarg: 
 I directed him. to take a pill at bed-time, and some 
 Cheltenham salts in the morning. 
 
 I should observe, that in making my examination, 
 I discovered that Mr B had formerly experi- 
 
 enced a fracture of the patella of the right knee, 
 which had united by a ligament of near two inches 
 in length ; and on inquiry I learnt, that it had been 
 fractured three times — in 1705, 1790, and 1800. 
 He is of tall stature, and rather thin ; and at the 
 time of the present accident is in the fifty-first year 
 of his ao^e. 
 
 On seeing Mr B the next day, the 21st, I 
 
 found he had had no sleep, and was totally unable to 
 move the limb u^ithout assistance ; his medicine had 
 operated. On the 22nd there was no improvement 
 23 
 
178 FRACTURES OF THE UPPER PART 
 
 in the powers of the limb; the part was still much 
 swollen, although the leeches had drawn a consider- 
 able quantity oi* blood. As there was a disposition 
 to inflammation from the bite of the leeches, I or- 
 dered a poultice of linseed meal and brea'd crumbs, 
 which removed it in a day or two. Mr B in- 
 formed me, that Mr Ring, of Reading, had called on 
 him, had examined the limb very minutely, had 
 measured it and found it to correspond in length 
 with the other; after which he observed, that he was 
 happy to confirm Mr Harris's opinion of the case. 
 
 On the 26th, Mr B was attacked with an 
 
 acute hepatitis, which very nearly proved fatal. 
 From that time to the 28th, he was bled four times 
 from the arm, to the extent of ninety-six ounces of 
 blood, and took a saline purgative draught and cal- 
 omel ; during this period tlie limb remained in much 
 the same state. Dr Taylor saw him about this time. 
 The limb was moved daily, and I began to think 
 that it did not improve so much as it ought ; as it 
 appeared at first to be only a simple contusion, and 
 the antiphlogistic treatment pursued, for the cure of 
 the hepatitis, should also, we thought, have benefit- 
 ed the limb. 
 
 On August the 14th, whilst Mr Ring was moving 
 the leg, he thought he felt a crepitus, which he 
 communicated to me, and I remarked that it was 
 impossible. I did not move the limb on that day, 
 but on the following I rotated it, and distinctly lelt 
 
 and heard the crepitus. Mr B also heard it, 
 
 and said, ' Why, you do not mean to find a fracture 
 now !' I expressed my fears that there was a I'rac- 
 ture, but could not say where, but thought it was 
 through the cervix of the femur; altliough every 
 symptom, savins^ the crepitus, was wanting to such 
 an accident. Having communicated my opinion, it 
 was ini mediately arranged for Mr Brodie to be sent 
 
OF THE THIGH-BONE. 
 
 179 
 
 for, who came the followingdaj at noon (the 18th), and 
 met Dr Taylor, Mr Ring, and niyseU". The partic- 
 ulars of the case were communicated to him, and he 
 proceeded to examine the limb, moving it in every 
 direction ; but could not then discover a crepitus, or 
 anv symptom denoting a fracture, as the limb was 
 still of the same length with the other, and neither 
 turned inwards nor outwards. MrBrodie was in the 
 first instance doubtful as to the existence of iVac- 
 ture. We told him that both Mr Ring and myself 
 had distinctly felt the crepitus, and that it was not 
 discoverable but on certain motions of the limb. Mr 
 Brodie then examined the limb with the greatest at- 
 tention, and in rotating it very extensively he felt the 
 crepitus. Yet when the patient was standing up- 
 right out of bed, supported, and with the right leg 
 elevated from the ground, he bore very considerably 
 on the injured limb, so much so, as to produce from 
 Mr Brodie an exclamation of surprise ; and he gave 
 it as his opinion, that such was the obscurity of the 
 case, that had he seen it a week before, he should 
 decidedly have said that there was not a fracture, 
 as in fact every symptom at that time was complete- 
 ly wanting, except the inability to move the limb; 
 but now he believed a fracture existed in the cervix 
 femoris, or in the superior part of the thigh-bone, 
 where the cervix joins it. 
 
 The treatment recommended by Mr Brodie was, 
 a long splint placed on the outside of the limb, and a 
 bandage from the toes to the hip, which he applied 
 himself, and he ordered it to be worn for one month, 
 and that the limb should be kept entirely free from 
 motion. 
 
 At the expiration of a month Sir A. Cooper was 
 sent for, who arrived September the 11th. After 
 the accident had been stated to him, he proceeded 
 to examine the limb ; he first observed the relative 
 
180 
 
 FRACTURES OF THE UPPER PART 
 
 position of the two limbs (Mr B still lying 
 
 on his back, with ,the llinb resting on the heel), 
 and then passing his hand under the trochanter 
 major, he raised it easily, it having now dropj)ed 
 from its natural position; and he agreed with Mr 
 Brodie and ourselves in declaring the fracture to 
 exist in the trochanter major, where it unites with 
 the cervix femoris. 
 
 The treatment recommended by Sir A. Cooper 
 was, to keep the trochanter in its proper position; 
 the patient to remain in the horizontal posture ; and 
 the most perfect quiet to be observed. 
 
 The means adopted to accomplish these objects 
 were the following. 
 
 A mattress was made of horse-hair about five 
 inches thick, and very smooth, and this was cover- 
 ed with a sheet. A part of the mattress was made 
 to draw out on the side opposite to the fracture, so 
 that when the necessary evacuations took place, 
 there still should be no motion of the body. Be- 
 fore drawing out the piece of mattress, a board of 
 two feet long, and six inches wide, shaped like a 
 wedge, was insinuated under the buttock of the 
 right side, the two ends of the board resting on the 
 mattress; thereby preventing the nates from sink- 
 ing at all into the oj)cning when the piece of mat- 
 tress was removed, and the injured side still rested 
 on the body of the mattress: the board was of 
 course removed after the mattress was replaced. 
 Upon the bedstead w'as first placed a thick smooth 
 board, sufficiently large to cover the bottom of the 
 bed, and on that was placed the mattress, thereby 
 preventing any sinking from pressure of the body. 
 
 The bandage recommended by Sir A. C. was the 
 following: — a broad web, sufficient to go round the 
 body over the hips, was fixed with two buckles and 
 straps, and a piece was added to make it wider 
 
OF THE THIGH-BONE. 
 
 181 
 
 where it passed under the injured troehanter; this 
 was lined with chamois leather, and stuffed : a pa 1 
 of the same leather, about six inches loni^, three 
 broad, and three inches thick, and ending gradually 
 in a point, was placed immediately under the tro- 
 chanter major of the injured side, so that when the 
 bandage was buckled, the pad passed into the hol- 
 low beneath the trochanter, and when the bandage 
 was tightened, it forced the troclianter upwards and 
 forwards into its natural position : another pad made 
 very thick, about eight inches square, in the shaj)e 
 of a w^edge, was placed under the upper part of the 
 thigh, after the bandage was attached. The patient 
 was placed on his back, the limb resiing on the 
 heel ; and to prevent the possibility of any motion 
 of the foot and of the body, a wide board was fixed 
 to the bed-posts at the foot of the bed, with two 
 pieces of wood padded and fastened to it, into which 
 the foot was received, and the least lateral motion 
 prevented. A cushion was placed opposite to the 
 other foot, so that pressure could be made against 
 the board, and the body was thus prevented from 
 slipping down in the bed. 
 
 Sir A. C. gave directions that Mr B should 
 
 not quit the horizontal posture; and ordered him 
 occasional purges, and a generous diet. T' is treat- 
 ment was adopted September the 13th; lie passed 
 a tolerable night, and did not complain of the band- 
 age. Nothing particular occurred during the month, 
 except that the patient suffered occasionally from 
 bilious head-ache and vomiting, which were remov- 
 ed by purging. The bandage was tightened every 
 now and then, but not to any great degree till the 
 expiration of three weeks, when he expressed him- 
 self certain that he still felt the crepitus; upon 
 which I urged the absolute necessity there was for 
 tightening the bandage, and thus by pressure pro- 
 duce a degree of inflammatory action in the bone. 
 
182 
 
 FRACTURES OF THE UPPER PART 
 
 I should j^dge that when Sir A. C. saw Mr 
 
 B , iUe ends of the bone were as much as 
 
 two inches apart^ but that was most certainly not 
 the case when Mr Brodie examined the limb; the 
 separation had taken place during the month. 
 
 From this time the bandage was kept as tight as 
 it could possibly be borne (and it never shifted in 
 the least from the position in which it was first 
 placed), and no feeling of crepitus was afterwards 
 complained of. The swellirig of the thigh and leg 
 was much increased, as if distended with coagulable 
 lymph ; it pitted on pressure, but some degree of 
 force was requisite to produce that effect. Pain 
 was still complained of in the direction of the tro- 
 chanter minor ; the bowels were torpid, and requir- 
 ed opening medicine every other day. 
 
 Sir A. C. visited Mr B a second time, 
 
 October . JGth ; the bandage was not removed, nor 
 was the position changed. He gave it as his opinion 
 that union had begun, and directed the patient to 
 continue in the same position, which he did, without 
 any thing material occurring except bilious attacks, 
 till December the 30th, when Sir A. C. visited him 
 a fourth time : he had seen him in the interval be- 
 tween October the IGth and December the 30th, 
 but nothing particular had occurred. 
 
 On December the 30th, Sir A. C. removed the 
 bandages for two hours; the bone remained in its 
 natural position; and on examination we could feel 
 a great thickening of the [)arts about the trochan- 
 ter.* He ordered him to stand at the side of the 
 bed after the bandage had been removed, and he 
 stood with support a few minutes, when he became 
 faint, and was removed to his bed. Sir A. C. wish- 
 ed the bandage to be re-applied once a day for an 
 hour, and the limb to be rubbed from the foot up- 
 
OF THE THIGH-BONE. 
 
 183 
 
 wards. The thiii;h became much softer during the 
 two hours in which ihe bniidagc was retnoved ; the 
 boards whicli supported the foot were now also re- 
 moved, as well as tlie bandages, and Mr B 
 
 was placed on crutches. From this time he rose 
 every day; and the hrab continuing very much 
 swollen, it was rubbed daily from two to four hours ; 
 still he could not bend the knee ; but when standing 
 on liis crutches he had a most perfect use of the 
 hip-juint. We endeavoured to regain the motion of 
 the knee by friction with oily embrocations. On 
 
 Friday, March 1st, Mr B -— left E in 
 
 his carriage for London. Samuel Harris. 
 
 Since his arrival in London, Mr B — has, 
 
 with great steadiness, employed friction and passive 
 motion for the recovery of the use of the knee with 
 the happiest effect, and the hip-joint is entirely re- 
 stored to its natural powers. A. C. 
 
 Case, — Mr Peggler, of Wanstead, aged*forty-six, 
 on the 13th of November, UUT, fell, while walking, 
 on a glass bottle which he had in his pocket; and 
 when he attempted to raise himself from the ground 
 he found lie was not able to stand. In a quarter 
 of an hour he felt great pain, and could not bear 
 the slightest weight of his body on the injured limb. . 
 Mr Constable, of Woodford, was sent for, and he 
 gave me the following account of the case. The 
 foot, at first, did not appear to turn out; but when 
 the patient was put into bed, and laid on his back, 
 it became everted ; the leg appeared somewhat 
 shorter, but was with little difficully pulled down to 
 its natural length ; the foot was benumbed, and, con- 
 tinued so for twelve months. He was placed in bed, 
 
184 FRACTURES OF THE UPPER PART 
 
 with a bolster under the liip to prevent displace- 
 ment of the bone; and his knees and ankles were 
 tied together. 
 
 In December following, about Christmas, I met 
 Mr Constable, wliilst visiting a patient with a severe 
 injury of the head, and he then requested me to see 
 Mr Peggler, wiiom I found ificapable of turning in 
 his bed without assistance, and the attempt gave him 
 great pain; his injured leg was a little shorter than 
 the other; the trochanter was drawn forward to- 
 wards the spine of the ilium, and could be felt con- 
 siderably separated from tl^at portion of the tro- 
 chanter connected with the neck of the bone; the 
 foot was turned outwards ; he could not sit, and the 
 least attempt to raise himself produced excruciating 
 sufferino^. I broug^ht him to the foot of the bed in 
 an horizontal position, to make as accurate an ex- 
 amination as I could of the nature of tho accident, 
 and had no hesitation in pronouncing it a fracture 
 through the trochanter. In less than a month he 
 began to use his crutches, and continued their use 
 for three months ; he then laid aside one crutch, and 
 employed a stick and crutch, and in a short time 
 needed the support of a stick only ; but it was 
 twelve months before he recovered the entire use 
 of his limb. The leg is still nearly an inch shorter than 
 the other; the portion of .the trochanter connected 
 with the thigh-bone has united with the foi'e part of 
 the trochanter joined to the neck of the bone, and 
 is, consequently, much nearer the spine of the ilium 
 than usual ; the foot Is also slightly everted, but he 
 walks extremely well ; a week ago, he walked ten 
 miles from home, and retin-ned the same day; and 
 this day, July 2inh, 1}U9, he has walked from Wan- 
 stead to my house, and intends to walk back, a dis- 
 tance of near twenty miles. 
 
 This history of Mr Peggler's accident is so similar 
 
OF THE THIGH-BONE* 
 
 to the cases of fracture through the trochanter 
 major which I have had an opportunity of seeing, 
 that a detail of the latter would be superfluous ; the 
 only variations that I have witnessed having been 
 in the distinctness of the crepitus accompanying 
 them, which is less in proportion as the fracture ap- 
 proaches the capsular ligament. I have lately frac- 
 tured through the trochanter major, five diflerent 
 thigh-bones in the living animal; they united, but 
 with great distension, shortening, and exuberant 
 callus. 
 
 In conclusion, I have to observe, that as the dimi- 
 nution of the length of the limb, and its eversion of 
 the knee and foot, are signs common to fractures of 
 the thigh-bone generally, it may be proper to bring 
 into one view the means of distinguishing the three 
 species of fracture which I have described. 
 
 The fracture of the cervix within the capsule is known, 
 with very rare exceptions, by the very advanced age 
 of the patient, — by its greater frequency in female 
 than in male subjects, — by the absence of swelling 
 and ecchymosis, — by the elevation and advance of 
 the trochanter, — by the greater mobility of the 
 joint, allowing flexion and extension, although with 
 some pain, and resistance from muscles, — by a crepi- 
 tus perceptible only on drawing down the limb to the 
 same length with the other, and then rotating it, — 
 by the pain felt at the trochanter minor, — by the 
 small degree of constitutional irritation attending the 
 accident, — by the slight causes which produce it, 
 — and by the little local swelling or change of ap- 
 pearance which ensues. 
 
 Fractures of the cervix into the cancelli of the trochan- 
 ter are known by the effusion of blood amidst the 
 muscles, — by great swelling produced, and by ecchy- 
 mosis, which appears soon after the accident, — by 
 an unnaturally fixed state of the joint, so that flexion 
 24 
 
186 
 
 FRACTURES OF THE UPPER PART 
 
 and extension cannot be performed, — by excessive 
 pain on the least motion of the hip-joint, and upper 
 part of the thigh-bone, — by a crepitus attending the 
 least motion of the thigh-bone without drawing it 
 down to the length of the other, — and by the in- 
 flammation, swelling, and constitutional irritation pro- 
 duced, wliich are frequently fatal. 
 
 The fracture of the trochanter major may be easily 
 known by the separation of the bone at the part, so 
 that the finger may be placed between the fractured 
 portions, — by the distinct crepitus felt in putting the 
 fingers on the trochanter when the knee is advanced, 
 — by inability of the upper portion of the trochanter 
 to obey the motions of the lower, and of the shaft 
 of the bone, — and when at the lower part of the 
 trochanter, by great overlapping, distension, and 
 exuberant callus. 
 
 I have thus stated what dissection and observation 
 have taught me of the three fractures of the upper 
 part of the thigh-bone, and shown it to be a general 
 principle, that fractures within the capsule do not 
 unite by bone. I ought to add, that, in the Museum 
 of Mr Langstaff, there is a preparation of fracture 
 within, and of one external to the ligament; the lat- 
 ter firmly united by bone, whilst the former has 
 scarcely undergone any ossific change. I can have no 
 wish but that these fractures within the capsule 
 should unite by bone, if that result be desirable. I 
 only state what dissection has taught me ; and with 
 respect to contrivances to produce their union, I 
 caiinot extol them until there be some evidence of 
 their value. 
 
OP THE THIGH-BONE. 
 
 187 
 
 FRACTURE OF THE EPIPHYSIS OF THE TROCHANTER 
 MAJOR. 
 
 Mr Key, Surgeon to Guy's Hospital, had the kind- 
 ness to send rne the followino^ account of a peculiar 
 fracture of the trochanter major, in which this pro- 
 cess was broken from the thigh-bone at the part at 
 which it is naturally united by cartilage as an epi- 
 physis in youth. 
 
 Case. — The subject of the accident was a young 
 girl about the age of sixteen, who, in crossing the 
 street with a can in her hand, tripped, and in falling, 
 struck her trochanter violently against the curb- 
 stone. She immediately rose, and without much 
 pain or difficulty walked home. The accident oc- 
 curred on Saturday, March ir)th, 1822; and, in con- 
 sequence of the increase of pain she experienced on 
 the inner side of the thigh, she presented herself at 
 Guy's for admission on the Thursday following. Her 
 constitutional symptoms beirig evidently more violent 
 than those which usually arise from fractured femur, 
 she was placed under the care of the physician, Dr 
 Bright, at whose request I examined the limb. Her 
 right leg, which was the one iiijured, was consider- 
 ably everted, and appeared to be about half an inch 
 longer than the sound limb. It admitted of passive 
 motion in all directions, but in abduction gave her 
 considerable pain. She had perfect command over 
 all the muscles except the rotators inwards. The 
 fact that she had walked both before and since her 
 admission into the hospital, gave rise to some doubts 
 as to the existence of a fracture, and the closest ex- 
 amination of the trochanter and body of the lemur 
 could not detect the slightest crepitus or displace- 
 ment of bone. I repeated the examination of the 
 
188 
 
 FRACTURES OP THE UPPER PART 
 
 limb on the following day, but the result was equally 
 unsatisfactory. 
 
 The fever under which she was labouring, together 
 with general abdominal uneasiness, threatening her 
 life, the limb underwent no further examination. 
 She died on Monday, nine days after the accident. 
 
 Examination after Death,* 
 
 Wishing to ascertain (for I suspected some ob- 
 scure fracture of the os femoris) the exact nature of 
 the injury, previously to removing the soft parts I 
 moved the limb in every direction, fixing the tro- 
 chanter and head of the bone ; but I could perceive 
 no deviation from the usual state of parts, nor could 
 I distinguish ■ the slightest crepitus under all the va- 
 riety of movements. 1 should observe, that there 
 was no tumefaction of the thigh, and therefore the 
 trochanter and head of the os femoris were as 
 readily distinguished and exposed to examination as 
 in the most healthy limb. 
 
 The capsule of the joint being laid bare, a cavity 
 was discovered by the side of the pectinaeus, leading 
 backwards and dow^nwards, towards the troch^ter 
 minor, and containing some pus : it allowed the 
 fingers to pass behind the bone to the greater tro- 
 chanter. The head of the bone was then dislocated 
 by cutting through the ligaments, and not till then 
 was a fracture discovered at the root of the tro^ 
 chanter major. The upper half of the femur being 
 
 * We are very glad to see so great a surgeon as Astley 
 Cooper continue to use the English language as far as possible, 
 instead of adopting the modern fashion of writing ' jargon.' 
 It is now customary to talk of ' post mortem appearances'^ and 
 ' POST mortem examinations^^ as if there were something improper 
 or obscene, in the words 'dissection' or ' Examination after 
 death.' J. D. G. 
 
OF THE THIGH-BONE. 
 
 189 
 
 removed from the body, I discovered the reason why 
 the fracture had eluded our search. 
 
 The fracture had detached the trochanter from 
 the body and neck of the bone, but without tearing 
 through the tendons attached to the outer side of 
 the process. The tendons are those of the two 
 smaller glutasi, and the commencement of that of the 
 vastus externus ; had they been torn, the broken 
 portion of bone would have been drawn upwards by 
 the action of the two former muscles, and, in that 
 case, the injury would readily have been recognised ; 
 but they so effectually prevented all. movement of 
 the fractured portion, that, when dissected from the 
 bodj', not the least motion could be produced except 
 in one direction. It was found that this motion re- 
 sembled that which would be produced by a hinge ; 
 the tendons acting the part of a broad hinge, and al- 
 lowing the portion to be moved only upwards and 
 downwards. It is evident that such motion could 
 not have been produced by any direction given to 
 the limb; hence it is also manifest, that the fracture 
 could not have been detected during the life of the 
 patient. 
 
 FRACTURES BELOW THE TROCHANTER. 
 
 The thigh-bone is sometimes broken just below 
 the trochanter major and minor ; it is a difficult 
 accident to manage, and miserable distortion is the 
 consequence if it be ill-treated. The end of the 
 broken bone is drawn forwards and upwards, so as 
 to form nearly a right angle with the body, and the 
 cause of this position is evidently the contraction of 
 the iliacus internus and psoas muscles, assisted by 
 the pectinalis, and perhaps by the first head of the 
 
190 FRACTURES OF UPPER PART OF THIGH-BONE. 
 
 triceps. A better idea of the effect of this accident 
 may be obtained by a view of the plate, in which 
 the bone will be observed to be united, not only with 
 extreme shortening, but with a hideous projection 
 forwards. If pressure be made upon the projecting 
 bone in the treatment of this case, it only adds to 
 the patient's suffering, and to the degree of irritation 
 of the limb, without preserving the bone in its pro- 
 per situation. It will be seen that this union exceed- 
 ingly overlaps, and that it is very feeble; showing, 
 what I have already mentioned, that a fracture thus 
 circumstanced. has the ossific deposition only on that 
 side where the inflammation was preserved by the 
 pressure of one bone on the other. This prepara- 
 tion may be seen in the Anatomical Museum, St 
 Thomas's Hospital. (^Sce Plate.) 
 
 To prevent this horrid distortion and imperfect 
 union, two circumstances are to be strictly observed: 
 the one is, to elevate the knee very much over the 
 double inclined plane; and, the other, to place the 
 patient in a sitting position, supporting him by pil- 
 lows during the process of union. The degree of 
 elevation of the body which is required will be about 
 forty-five degrees, but it may be readily ascertained 
 by observing the approximation of the fractured ex- 
 tremities of the bones ; and this position is requisite 
 for relaxing the psoas and iliacus muscles, and thus 
 preventing the elevation of the upper part of the 
 bone. In no other manner can the great deformity 
 I have described be prevented. When, by this pos- 
 ture, the extremities of the bones are brought into 
 proper apposition, and all projection of its upper por- 
 tion is removed, either the splints may be applied 
 which are commonly used in fracture of the thighs 
 bone, or, what is better, a strong leathern belt, lined 
 with some soft material, should, by means of several 
 straps, be buckled around the limb, and be confined 
 by means of a strap around the pelvis, 
 
DISLOCATIONS OF THE KNEE. 
 
 The broad surfaces of bone by which the os fe- 
 tnoris rests upon the tibia are calculated to prevent 
 the ready dislocation of this joint, which would be 
 otherwise very liable to happen from the superficial 
 nature of the articulating cavities on the head of the 
 tibia, and also from the great violence to which the 
 knee is frequently exposed. 
 
 Structure of the knee; hone, — The depressions 
 upon the head of the tibia are increased by the 
 addition of the semilunar cartilages which rest upon 
 the bone ; they receive the condyles of the os fe- 
 moris, and are attached by ligaments to the edge of 
 the tibia. The fore part of the joint is defended by 
 the patella, which has two unequal articular surfaces 
 to play upon the condyles of the os femoris. The 
 head of the fibula forms no part of the knee-joint, 
 but is attached to the tibia from one half to three- 
 fourths of an inch below its head. 
 
 Ligaments, — The junction of the os femoris, tibia, 
 and patella, is produced by means of a capsular liga- 
 ment, which proceeds from the os femoris to the 
 head of the tibia, and is attached to the edge of the 
 patella, where it divides into two portions, forms 
 
192 
 
 DISLOCATIONS OF THE KNEE. 
 
 wings to that bone, and takes the name of the alaf 
 ligament. On its outer side the capsular ligament is 
 covered^ and greatly strengthened, by tendinous ex- 
 pansions, which are derived from the vasti muscles, 
 and which proceed to the head of the tibia. In- 
 ternally the ligament has a secreting synovial sur- 
 face, which is folded within the cavities at the ex- 
 tremities of the bones, is reflected to the edge of the 
 articular cartilages, and, it is believed, forms a cover-, 
 ing to those cartilages. Beside the capsular, there 
 are several peculiar ligaments. First: The liga- 
 mentum patellae, which are extended from the lower 
 point of the patella to the tubercle of the tibia. Se- 
 condly : The external lateral or femoro-fibular liga- 
 ment, which passes from the os femoris to the head 
 of the fibula, and which divides into two external 
 lateral ligaments. Thirdly : The internal lateral or 
 femoro-tibial ligament, attached to the os femoris 
 and to the head of the tibia. Fourthly : The ob- 
 lique or popliteal ligament, which proceeds from the 
 external condyle of the os femoris obliquely, to be 
 inserted into the head of the tibia. Fifthly : The 
 crucial ligaments^ which pass from the depression 
 between the condyles of the os femoris behind ; the 
 one to a projection between the articular surfaces 
 of the head of the tibia, and the other to a depres- 
 sion behind that projection, so that these lig^aments 
 cross each other from before backwards. The pa- 
 tella has a muscular connexion with the os femoris 
 by the insertion of the rectus, vasti, and cruralis. 
 By the ligamentum patellae it is united with the 
 tibia, and laterally it is joined to the capsular and 
 alar ligaments. This ligamentous junction of the 
 three bones is very firm, but it allows of free flexion 
 and extension, with some degree of rotatory motion 
 when the knee is bent ; but although great strength 
 is evident in the construction of this joint, still exces- 
 
DISLOCATIONS Of THE KNEE. 
 
 sive violence and extreme relaxation will occasionallj 
 produce its dislocation. 
 
 DISLOCATION OF THE PATELLA. 
 
 Three directions ; symptoms^ Src — The patella 
 is liable to be dislocated in three directions, namely : 
 outwards, inwards, and upwards. In its lateral dis- 
 location, the bone is most frequently thrown on the 
 external condyle of the os femoris, where it produc- 
 es a great projection ; and this circumstance, with 
 an incapacity of bending the knee, is the strong evi- 
 dence of the nature of the injury. The most fre- 
 quent cause of the accident is, that a person in 
 walking or running, falls with his knee turned in- 
 wards, and the foot outwards ; and thus, by the 
 action of the muscles to prevent the fall, the patella 
 is drawn over the external condyle of the os femoris ; 
 and when the person attempts to rise he finds him- 
 self unable to bend his leg, and the muscles and 
 ligaments of the patella are all forcibly on the 
 stretch. This accident generally occurs in those 
 who have some inclination of the knee inwards, 
 which, under the action of the extensor muscles, 
 gives a direction to the patella outwards. 
 
 Internal. — The internal dislocation is much less 
 frequent, and it happens from falls upon a project- 
 ing body, by which the patella is struck upon its 
 outer side, or by the foot being, at the time of the 
 fall, turned inwards. In cither of these cases the 
 ligament will be torn, unless there be some previous 
 disease. 
 
 Mr Harris, getting into a chaise, caught his foot 
 in the carpet at the bottom of it, by which acci- 
 dent the knee was turned in and the leg outwards ; 
 25 
 
194 DISLOCATIONS OF THE KNEE. 
 
 the patella slipped upon the external condyle of the 
 OS femoris, but it returned very soon, by the effort 
 of the muscles, into its natural situation. On ex- 
 amination, I found the internal portion of the capsu- 
 lar ligament torn, and a great accumulation of sy- 
 novia in the joint. 
 
 Mode of reduction, — The mode of reduction in 
 either case consists in pursuing the following plan : 
 — The patient is placed in the recumbent posture, 
 and an assistant raises the leg by lifting it at the 
 heel; the advantage of which is, that it relaxes the 
 extensor muscles on the thigh in the greatest possi- 
 ble degree ; the surgeon then presses down that 
 edge of the patella which is most remote from the 
 joint, be it one luxation or the other ; and this press- 
 ure raises the inner edge of the bone over the con- 
 dyle of the OS femoris, and it is immediately drawn, 
 by the action of the muscles, into its natural 
 situation. 
 
 My friend, Mr George Young, informed me, that 
 he was called to a case of dislocation of the patella 
 outwards, in which the reduction was very difficult. 
 The patient was a female, who, by a fall in walk- 
 ing, had the patella drawn over the external 
 condyle of the os femoris, where it remained. He 
 employed pressure upon the edge of the patella, 
 most perseveringly, without being able to succeed, 
 but at last reduced it in the following manner: — 
 He placed the patient's ankle upon his shoulder, 
 and thus most completely extended the limb and 
 obtained a fixed point of resistance at the knee ; 
 then grasping the patella with the fingers of his 
 right hand, he pressed the outer edge of the pa- 
 tella with the ball of his left thumb, and pushed 
 it into its place. 
 
 When the reduction of this bone has been effect- 
 ed, an evaporating lotion of spirits of wine and wa- 
 
DISLOCATIONS OF THE KNEE. 
 
 195 
 
 ter is to be applied ; in two or three days the limb 
 may be bandaged, and it is soon restored to its na- 
 tural uses, although it is somewhat weaker than 
 before- 
 
 I was informed by Mr Welling, formerly surgeon 
 at Hastings, that he was called to a case in which 
 the patella was dislocated upon its edge. The na- 
 ture of the accident was very obvious, as the edge 
 of the bone forced up the integuments to a consider- 
 able height between the condyles on the fore part 
 of the joint. Mr Welling reduced the dislocation, 
 but with considerable difficulty, by pressing the edges 
 of the bone in opposite directions. 
 
 Dislocation from relaxation, — When the bone is 
 dislocated from relaxation, the patella is drawn upon 
 the external condyle of the os femoris by veny slight 
 accidents, or sudden action of the muscles. My 
 neighbour, Mr Hutchinson, a very intelligent surgeon, 
 informs me he has very frequently seen this accident, 
 and that the tendency to it has arisen, in a large pro- 
 portion of cases, from the relaxation produced by ex- 
 cessive indulgence in onanism. 
 
 The reduction, in these cases, is effected in the 
 manner which has been before described ; and after 
 the reduction, to prevent any recurrence of the ac- 
 cident, and to support the weakened ligament, a 
 laced knee-cap, with a strap and buckle above and 
 below the patella, is to be worn. 
 
 1 once saw the patella drawn over the external 
 condyle of the os femoris from loss of action of the 
 vastus internus, owing to a disease in the thigh- 
 bone. 
 
196 
 
 DISLOCATIONS OF THE KNEE. 
 
 DISLOCATION OF THE PATELLA UPWARDS. 
 
 Upwards; ligament lacerated, 8rc, — In tliis dislo- 
 cation, the ligament of the patella is torn through by 
 the action of the rectus femoris muscle, and the im- 
 mediate effect of the injury is, to draw the patella 
 upwards upon the fore part of the thigh-bone. The 
 appearances which this accident presents are very 
 decisive of its nature ; for in addition to the eleva- 
 tion of the patella, and its easy motion from side to 
 side, a deep depression is felt above the tubercle of 
 the tibia from the absence of the ligament; the pa- 
 tient immediately loses the power of bearing upon 
 that limb, as the knee bends under each attempt, and 
 he would fall if he persisted in throwing the weight 
 of Iiis body upon it. A considerable degree of in- 
 flammation is the consequence. 
 
 Treatment. — In the treatment of this injury, local 
 depletion and evaporating lotions are to be used dur- 
 ing four or seven days from its occui'rence, and then 
 a roller is to be applied around the foot and upon the 
 leg, to prevent its swelling ; the leg is to be kept ex- 
 tended by a splint behind the knee, and a bandage, 
 composed of a leathern strap, is to be buckled around 
 the lower part of the thigh; to this is to be attached 
 another, which is to be carried on each side of the 
 leg, and under the foot, and is to be buckled to the 
 circular strap; thus the bone is gradually drawn 
 down, so as to allow of an union of the ligament. In 
 a month the knee may be slightly bent, and as much 
 passive motion daily given as the patient is able to 
 bear; by these means the ruptured ligament becomes 
 united, and the patella retains its motion. During the 
 time the bandage is worn, the patient is to preserve 
 (he sitting posture, in order to relax the rectus must 
 
DISLOCATIONS OF THE KNEE. 197 
 
 cle and to prevent its action upon the patella. With 
 very great attention the union becomes perfect; for 
 so it happened in a case which I saw with Mr Bur- 
 rowes, in Bishopsgate-sireet. Mr B. paid great at- 
 tention to the case, and the patient recovered with- 
 out any diminution of the natural powers of the part ; 
 the patella being gradually forced down until the 
 ends of the ligament had approximated and coalesced. 
 
 Dislocation downwards. — With respect to dis- 
 locations of the patella downwards^ at which some 
 surgeons have hinted, I have seen no injury which 
 deserved such a title, if I except a rupture of the 
 tendon of the rectus, which 1 have twice witnessed, 
 and which destroyed the attachment of that muscle 
 to the patella. The appearance of this injury was 
 a soft swelling above the patella, upon which, when 
 the hand was placed, it sunk into the joint; the 
 patella fell loose between the condyles of the os 
 femoris and the head of the tibia, but it still retained 
 very much its usual situation, and could not be said 
 to be luxated, as it was not displaced from the joint. 
 
 The treatment which this accident requires is, 
 that the patient be obliged to preserve a sitting 
 posture during the cure; and that a cushion be ap- 
 plied upon the ligamentum patellas, which is to be 
 confined by a roller passed around the head of the 
 tibia.* 
 
 * The following interesting case is given by Mr L. Wheeler 
 in the London Quarterly Journal of F. Medicine, No. xii : 
 
 A coal heaver fell down, and the fore and hinder wheel of an 
 empty wagon, passed over his right knee in a direction from the 
 inner to the outside of the joint. Being immediately taken to 
 St Bartholomew's Hospital, the patella was found resting per- 
 pendicularly on its internal edge, and its external edge was in- 
 clined directly forwards, so that its upper surface was turned 
 inwards, and its under or articulating surface turned outwards. 
 The bone was placed so nearly in a perpendicular direction, 
 that its upper and under surfaces, could only be distinguished by 
 
198 
 
 DISLOCATIONS OP THE KNEE. 
 
 DISLOCATION OF THE TIBIA AT THE KNEE-JOINT. 
 
 In four directions. — These dislocations occur in 
 four different directions; but two of them are in- 
 complete, and lateral, while the others are perfect 
 luxations, the tibia being thrown either backwards or 
 forwards. 
 
 Internal. — The lateral dislocations are but rare. 
 In the dislocation inwards the tibia is thrown from 
 its situation, so that the condyle of the os femoris 
 rests upon the external semilunar cartilage, and the 
 tibia projects on the inner side of the joint, so as at 
 once to disclose the nature of the injury. The first 
 case of this kind w^hich I ever witnessed was brought 
 to St Thomas's Hospital whilst I was an apprentice 
 there, and I remember being struck with three cir- 
 cumstances in it : the first was, the great deformity 
 of the knee from the projection of the tibia ; the 
 second, the ease with which the bone w^as reduced 
 by direct extension ; and the third, the little inflam- 
 mation which followed upon what appeared to be so 
 serious an injury; for the man was discharged from 
 the hospital after a few weeks, having suffered little 
 local or no constitutional irritation. 
 
 External. — The tibia is sometimes thrown upon 
 the outer side of the knee-joint, the condyle of the 
 OS femoris being placed in the situation of the inner 
 semilunar cartilage, or rather behind it, when the 
 
 comparison with the superior surface of the opposite patella. 
 This dislocation was suddenly, but with some difficulty reduced 
 by bending the thigh very much on the pelvis ; drawing the 
 exterior muscles as much as possible, and by forcibly raising 
 the bone at the same time that it was turned in its natural di- 
 rection. J. D. G. 
 
DISLOCATIONS OF THE KNEE. 
 
 199 
 
 same deformity is produced as in the external dis- 
 location. The reduction of the limb is equally easy 
 with the former, and the patient recovers with little 
 diminution of the powers of the part. It seems to me 
 that in both these dislocations the tibia is rather twist- 
 ed upon the os femoris, so that the condyle of the 
 OS femoris, with respect to the tibia, is thrown some- 
 what backwards, as well as outwards or inwards.* 
 
 Case, — One of the aldermen of the City of Lon- 
 don, riding down Highgate-hiil during the night, and 
 not being aware of a rail that was placed across a 
 part of the road, which was undergoing repair, the 
 horse ran against the rail, and, turning quickly, threw 
 his rider over it, whilst his leg was confined between 
 the rail and the horse, so that his body was on one 
 side of the rail, and his leg on the other: the result 
 of this accident was, that he partially dislocated his 
 tibia outwards, throwing the condyle of the os fe- 
 moris inwards. Being immediately taken to a pub- 
 lic-house, the tibia was easily replaced; and on his 
 removal home, some hours afterwards, means were 
 used to reduce the swelling and inflammation, which 
 became considerable. When he attempted to bear 
 upon the limb he found the capsular ligament very 
 feeble, and he was obliged to have a knee-cap made 
 of very strong leather, to support and connect the 
 bones ; by the aid of this bandage he gradually re- 
 covered, and was enabled to walk well, and to do 
 duty on horseback as a light-horse volunteer, before 
 twelve months had expired. 
 
 * I have seen a very interesting- case of dislocated knee- 
 joint in tlie collection of my friend, Dr Bond, of Philadelphia. 
 The leg is turned entirely round, so that the foot is placed di- 
 rectly outwards — the heel presenting to the hollow of the 
 other foot, and the articulation of the knee crossing the natural 
 position at right angles. The history of this case was un- 
 known ; hut from all appearances the limb must have been in 
 this situation for a long time before death. J. D. G. 
 
200 
 
 DISLOCATIONS OF THE KNEE. 
 
 Case of dislocation inwards^ ~ 1 was consulted by 
 Mr Richards respecting Mr Bovill, a gentleman from 
 Barbadoes, who had dislocated his knee. I made a 
 few notes on the case at the moment, which were 
 as follow. The gentleman was thrown from a gig; 
 the tibia was dislocated, and the fibula broken a 
 little below its head. The head of the tibia pro- 
 jected much on the inner side of the condyle of the 
 OS femoris. My friends, Mr Caddell and Mr Rich- 
 ards, surgeons at Barbadoes, saw him a quarter of 
 an hour after the accident ; the leg was extended 
 from the thigh-bone in a bent position of the limb ; 
 the extension was a long time continued, and force 
 was employed by several persons for half an hour 
 before the luxation was reduced. The limb became 
 excessively swollen, and remained so for many weeks, 
 the climate probably being unfavourable to his re- 
 covery ; but at length the inflammation and its con- 
 sequences were subdued by local depletion. When 
 I saw him eighteen months had elapsed from the 
 accident, and he could not then bend the joint at 
 right angles with the thigh ; there was also an un- 
 natural lateral motion of the joint, from the injury 
 which the ligaments had sustained. The fracture 
 of the fibula had injured the peroneal nerve, as w^as 
 evident from the numbness of which he complained 
 in the outer part of the leg and foot. 
 
 Dislocation forwards, — The tibia is now and then 
 dislocated in a direction forwards, [n this accident, 
 when the person is recumbent, the external marks 
 of the injury are these : The tibia is elevated ; the 
 thigh-bone is depressed, and is thrown somewhat to 
 the side as well as backwards; the os femoris makes 
 such pressure on the popliteal artery, as to prevent the 
 pulsation of the anterior tibial artery on the foot ; 
 the patella and tibia are drawn by the rectus muscle 
 forwards. Such were the appearances in a man of 
 
DISLOCATIONS OF THE KNEE. 
 
 201 
 
 the name of Briggs, brought into Guy's Hospital in 
 the year i802, not only with this accident, but with 
 a compound fracture of the tibia of the other leg,- 
 with dislocation of the head of the fibula. Mr Lu- 
 cas was obliged to amputate the compound fracture, 
 and the man is now living at Walworth. The limb 
 in this case was easily reduced by extending the 
 thigh from above the knee, and by drawing the leg 
 from the thigh, and inclining the tibia a little down- 
 wards. As soon as it was reduced, the popliteal 
 artery ceased to be compressed, and the pulsation in 
 the anterior tibial artery was restored. 
 
 Dislocation backwards, — The head of the tibia i& 
 sometimes dislocated backwards, behind the condyles 
 of the OS femoris, producins: the following appear- 
 ances : The limb shortened, the condyles of the 09 
 femoris projecting, the ligament of the patella de- 
 pressed, and the leg bent forwards. 
 
 For the following case I am indebted to my judi- 
 cious friend, Dr Walsh man. 
 
 Case by Dr Walshman. — Mr Luland, residing 
 near the Elephant and Castle, at Newington Butts, 
 a very robust and muscular man, on the 4th of 
 January, 1794, dislocated his shoulder and knee at 
 the same instant. The accident happened in the 
 following manner : It was a severe frost, and the 
 ground very slippery, and he being in his cart, the 
 horse fell. Mr Luland was thrown under the front 
 rail of the cart, and luxated the tibia backwards, 
 whilst his shoulder fell on the saddle, and dislocated 
 the OS humeri into the axilla. The head of the 
 tibia was completely dislocated backwards, reaching 
 behind the condyles of the femur into the ham ; 
 the tendinous connexion of the patella to the rectus 
 muscle was ruptured; the external condyle of the 
 OS femoris was very protuberant; the leg was bent 
 forward and was shortened, and there was a deprea* 
 26 
 
202 
 
 DISLOCATIONS OF THE KNEE. 
 
 sion just above the patella. The patient felt most 
 excruciatiijg pain when the limb was moved, but 
 there was not any considerable degree of suffering 
 when it was at rest. Tiie reduction was effected in 
 the following manner; Two men extended upwards, 
 one from the groin, and the other from the axilla, 
 whilst two others extended the leg from a little 
 above the ankle in the opposite direction ; and they 
 gradually increased the force of their extension till 
 the bone was reduced. The patient was placed on 
 his back, and the head oi* the bone was directed to 
 its natmal situation. A flannel roller was then 
 applied on the knee, the patient placed in bed with 
 his limb upon a pillow, and the part directed to be 
 kept wet with an evaporating lotion. He remained 
 in this state a fortniglit, free from pain : Dr W. 
 slightly moved the part every other day, as far as 
 he could without giving pain. In about a month 
 Mr Luland began to walk on crutches. Ten weeks 
 after the accident he was able to sit at his dinner- 
 table, and in five inonths he had given up the use of 
 his crutches, and appeared perfectly recovered, being 
 able to use that limb as well as the other. He died 
 of dropsy in February, 1819. 
 
 Dr Walsh man's treatment of this case was highly 
 judicious. He suffered the parts, as he observes in 
 his letter, to remain at rest till the adhesive inflam- 
 mation had united the lacerated ligament, and then, 
 and not till then, began with passive motion. 
 
 PARTIAL LUXATION OF THE THIGH-BONE FROM THE 
 SEMILUNAR CARTILAGES. 
 
 From relaxation ; Mr Hetfs idea. — Under ex- 
 treme degrees of relaxation, or in cases in which 
 
DISLOCATIONS OP THE KNEE. 
 
 203 
 
 there has been increased secretion into a joint, the 
 ligaments become so much lengthened, as to allow 
 the cartilages to glide upon the surface of the tibia, 
 and particularly when pressure is made by the thigh- 
 bone on the edge of the cartilage. That excellent 
 practical surgeon, the late Mr Hey, of Leeds, was 
 the first who clearly described the symptoms and 
 cause of these accidents, and suggested a mode of 
 treatment which is ingenious, scientific, and generally 
 successful. The injury most frequently occurs when 
 a person in walking strikes his toe, with the foot 
 everted, against any projection (as the fold of a 
 carpet), after which he immediately feels pain in 
 the knee, which cannot be completely extended. I 
 have seen this accident also happen from a person 
 having suddenly turned in his bed, when the clothes 
 not suffering the foot readily to turn with the body, 
 the thigh-bone has slipped from its semilunar carti- 
 lage. 1 have also known it occur from a sudden 
 twist of the knee inwards when the foot was turned 
 out. 
 
 Explanation of the accident, 8{c, — The explana- 
 tion of this accident is as follows: The semilunar 
 cartilages, which receive the condyles of the os 
 femoris, are united to the tibia by ligaments, and 
 when these ligaments become extremely relaxed 
 and elongated, the cartilages are easily pushed from 
 their situations by the condyles of the os femoris, 
 which are then brought into contact with the head 
 of the tibia; and when the limb is attempted to be 
 extended, the edges of the semilunar cartilages pre- 
 vent it. How then is the bone to be ag^ain brousfht 
 upon the cartilages? Why, as Mr Hey has advis- 
 ed, by bending the limb back as far as is possible, 
 which enables the cartilage to slip into its natural 
 situation; the pressure of the thigh-bone is removed 
 in the bent position, and the leg being brought for- 
 
204 
 
 DFSLOCATIONS OF THE KNEE. 
 
 wards, it can then be completely extended, because 
 the condyles of the os femoris are again received 
 on the semilunar cartilages. This plan is not, how- 
 ever, invariably successful, as the following case will 
 show. A lieutenant in the ai rnv suifered this acci- 
 dent repeatedly, and the limb was as often reduced 
 by the above means; but at length turning in bed, 
 from the pressure of the bed clothes on his foot, 
 the accident recurred. He came to town; but 
 bending the limb had now no effect in enabling him 
 to extend the joint, I therefore advised him to visit 
 Mr Hey, at Leeds; but I learnt that in this case the 
 dislocation was never reduced. 
 
 Different mode of reduction. — I made the follow- 
 ing notes of the case of a gentleman who came to 
 my house. Mr Henry Dobley, aged thirty-seven, 
 has often dislocated his knee, turning the foot in- 
 wards and the thigh-bone outwards, by accidentally 
 slipping on uneven ground, or by sudden exertions 
 of the limb; considerable pain Avas immediately 
 produced, accompanied with a great deal of swelling. 
 His mode of reducing it is as follows: He sits upon 
 the ground, and then bending the thigh Inwards and 
 pulling the foot outwards, the subluxation of the os 
 femoris being external, tlie natural position of the 
 limb becomes restored. A knee-cap laced tightly 
 around the knee, is (he usual preventive of the re- 
 turn of this accident ; but it is not sufficient in Mr 
 Dobley without the addition of straps, and more 
 especially of a very strong one of leather, just below 
 the patella. 
 
 Particular bandage required. A young lady was 
 brought to my house who was frequently the subject 
 of this accident, but in her the cartilages liad been 
 several times easily replaced, and the return of the 
 accident prevented by a bandage composed of a 
 piece of linen with four rollers attached to it, which 
 
DISLOCATIONS OF THE KNEE. 
 
 205 
 
 were tightly bound above and below the patella ; 
 this, she said, answered its intended purpose better 
 than any other contrivance. 
 
 In some of these cases orreat alteration takes 
 place in the form and size of the knees, from a 
 chronic rheumatism occasionally attending them. 1 
 made the following notes of a case of this kind on 
 which I was consulted, and I have seen others of 
 similar character. 
 
 Case, — Lady D., a year and a half ago, fell and 
 twisted her thigh-bone inwards at the knee, produc- 
 ing great pain on the inner side of the joint. Her 
 ladyship immediately restored the parts to their 
 situation by pressing the thigh outwards and the leg 
 inwards, previously to which she could not move 
 the joint. For a fortnight she was scarcely able to 
 bend or straighten the knee, and the muscles felt 
 to her to be in a state of cramp. She then began 
 to stand upon the limb by the aid of crutches, but 
 when she bore upon it considerably, it suddenly 
 bent back, with pain and subsequent swelling, and 
 she felt the condyles at the same time slip from the 
 semilunar cartilages upon the head of the tibia. 
 Any sudden motion produced the same etTect for 
 fifteen months, and each of these accidents retarded 
 her recovery for several weeks; the pain extended 
 from the knee to the toe. For three months pre- 
 vious to her last accident she walked on crutches, 
 and even sometimes with only the aid of a stick ; 
 but about two months since, in endeavouring to 
 raise herself from a sofa, the left knee gave way 
 as if the bone had slipped from its place, the thigh- 
 bone being at the time twisted outwards; pain and 
 swelling succeeded, and she has never been able 
 to stand upright since. Her joints are all of them 
 remarkably flexible, as the elbow may be easily 
 bent backwards to form an angle with the os hu- 
 
206 
 
 DISLOCATIONS OF THE KNEE. 
 
 meri. When a girl, she had frequently the sensa- 
 tion of putting the knees out of joint, but they 
 soon got well. The knees are now swollen, and 
 effusion of a considerable quantity of synovia has 
 taken place into the joints. When she attempts to 
 stand she cannot straighten her knees, but would 
 fall forwards if unsupported. The principal object 
 in the treatment is, to produce absorption of the 
 fluid which is effused, and then give due support 
 to the ligaments. For the first of these she was 
 desired to apply blisters, which were directed to be 
 kept discharging for a considerable time, and after 
 they were healed, she was ordered to make pres- 
 sure upon the joints by a strong bandage, which 
 was to be occasionally removed to give an oppor- 
 tunity of employing friction. But she received ma- 
 terial benefit from a constitutional treatment, con- 
 sisting of pll. hydrargyri submuriatis corop., with 
 decoctum sarsaparillae compositum, and locally from 
 the continued use of friction. I have had lately 
 the pleasure of seeing her perfectly recovered. 
 
 In the dissection of these cases, the ligament is 
 found extremely thickened ; little pendulous liga- 
 mentous and cartilaginous bodies are seen suspend- 
 ed from it ; a thick edge of cartilage projects from 
 the articular cartilage, and a part of the latter is 
 absorbed. When the bone is macerated, a great 
 addition of ossific matter is found to have been 
 made to the edges of the condyles of the os fe- 
 moris, 
 
 DISLOCATION OF THE KNEE-JOINT. 
 
 Cases of dislocation of the knee-joint are so rare, 
 that every instance of this accident is worthy of 
 
DISLOCATIONS OF THE KNEE. 
 
 207 
 
 recital ; and I feel greatly indebted to my friend, 
 Mr Toogood, surgeon at Bridgewater, for the fol- 
 lowing detail of one which occurred under his care. 
 
 Decewher 5th^ 1806. 
 Case, — Francis Newton, a strong athletic man, 
 thirty years old, fell from the fore part of a wagon, 
 heavily laden with coals, and entangling his foot in 
 the frame-work of the shaft, was dragged for a very 
 great distance before he was released. 1 saw him 
 two hours after the accident. The left knee was 
 very much swollen; the tibia, fibula, and patella 
 were driven up in front of the thigh; and the os 
 femoris occupied the upper part of the calf of the 
 leg, the internal condyle being nearly through the 
 skin. It was a complete dislocation, and the ap- 
 pearance of the limb so dreadful, that I despaired of 
 being able to reduce it ; but, to my surprise, it was 
 more easily effected than I imagined. By placing 
 two men to the thigh whilst I extended the leg, the 
 man became directly relieved. The whole limb 
 was placed in splints, and the strictest antiphlogistic 
 treatment observed, with the most perfect quiet. 
 The symptoms were very mild ; and, by carefully 
 watching him, he suffered very little inflammation or 
 pain. At the expiration of a month I allowed him 
 to get up, and on the 29th of January, he came into 
 this town, a distance of four miles, in a cart, and 
 walked from an inn to my house, with his leg but 
 little swollen, and having some motion of the joint. 
 He eventually recovered a very good use of his limb, 
 and walks with so little inconvenience that he has 
 followed his business as a wagoner ever since ; and 
 this day, November 30th, 1822, I have seen him 
 walking by the side of his team Avith very little 
 lameness. 
 
*208 DISLOCATIONS OF THE KNEE. 
 
 COMPOUND DISLOCATION OF THE KNEE-JOINT. 
 
 Having seen only one instance of this dislocation, 
 I conclude it to be a rare occurrence ; and there are 
 scarcely any injuries incident to the body which 
 more imperiously demand immediate amputation 
 than these. 
 
 Case. — On Monday, August 26th, 1819, at eleven, 
 p. m., I was sent for by Mr Oliver, surgeon, at 
 Brentford, to visit Mr Pritt, who had fallen from 
 the box of a mail coach, and most severely injured 
 his knee. 1 met, at the house to which he was 
 carried, Mr Oliver, and Mr Hunter, of Richmond, 
 surgeons, and immediately proceeded to examine the 
 knee. A large opening was found in the integuments, 
 through which the external condyle of the os femoris 
 projected, so as to be on a level with the edges of 
 the skin. The os femoris was thrown behind the 
 tibia on the outer side of the head of the latter, and 
 the external condyle of the thigh-bone was dislo- 
 cated backwards and outwards ; the thigh-bone was 
 twisted outwards, and the internal condyle advanced 
 upon the head of the tibia. I made attempts to re- 
 duce the condyle, but it could only be effected with 
 extreme difficulty; and the bone, directly when the 
 extension was removed, slipped into its former situa- 
 tion. The joint being freely opened by the accident, 
 the bone dislocated, and when reduced easily slipping 
 from its place, and the patient having an extremely 
 irritable constitution, I determined at once to pro- 
 pose the amputation of the limb, which, being acced- 
 ed to, was immediately performed. The symptoms 
 of constitutional irritation which followed the opera- 
 tion became extremely severe, and he being delirious 
 on the 31st, Mr Oliver applied leeches to his tern- 
 
DISLOCATIONS OF THE KNEE. 
 
 209 
 
 pies, a blister under the occiput, and gave the saline 
 medicine with the camphor, and the pulv. ipec. comp. 
 On the following day I was sent for to visit him, but 
 being absent from London, my vahied friend, Mr 
 Cline, visited him, and ordered him tine. opii. gtt. v. 
 — Pulv. castor. gr. x. — Mist, camphor. 3iss. m. — 
 Ft. haustus 4ta quaque hora sumendus. Soon after 
 the second draught w^as administered he fell asleep, 
 and after several hours repose awoke perfectly sen- 
 sible* He gradually recovered, and left Brentford 
 on the 25th of October, with a small wound still re- 
 maining on the stump. 
 
 Dissection. — I brought home the limb, and care- 
 fully dissected it. Under the skin there was great 
 extravasation of blood in the cellular membrane 
 surrounding the knee ; the vastus internus muscle 
 had a large aperture torn in it just above its insertion 
 into the patella ; the tibia projected forwards ; and 
 the patella was drawn to the outer side of the knee, 
 being no longer in a line with the tubercle of the 
 tibia. Looking at the joint posteriorly, both heads 
 of the gastrocnemius externus muscle were lacerat- 
 ed ; the capsular ligament was so completely torn, 
 posteriorly, that both the condyles of the os femoris 
 were seen projecting through the laceration in the 
 gastrocnemius ; neither the sciatic nerve, the pop- 
 liteal artery and vein, the lateral, nor the crucial 
 ligaments, were ruptured. (See Plate,) 
 
 It is probable that all compound dislocations of 
 the knee-joint will require a similar practice, unless 
 the wound be so extremely small as to admit readily 
 of its immediate closure and adhesion^ 
 27 
 
210 
 
 DISLOCATIONS OF THE KNEE. 
 
 DISLOCATION OF THE KNEE FROM ULCERATION. 
 
 Ligament ulcerated, — In the progress of chronic 
 diseases of the joints, inflammation beginning in the 
 synovial membrane, and proceeding to ulcerate the 
 articular cartilages and bone, at length affect the 
 capsular ligament, and sometimes even the peculiar 
 ligaments of the joints; the bones thus becoming 
 unconnected, the muscles irritated by participating 
 in the inflammation, draw the limb into distorted 
 positions, and thus one bone becomes gradually dis- 
 placed from the other. This state is most frequent- 
 ly seen in the hip-joint, from the oblique bearing of 
 the thigh-bone on the pelvis. In the knee it is also 
 not unusual that the thigh-bone shall be placed out 
 of its natural line with the tibia, projecting either on 
 the one side or the other. 
 
 Excessive distortion, — Now and then most re- 
 markable distortions are produced by the irritative 
 and spasmodic action of the muscles succeeding the 
 ulcerative process of the ligaments, of one of which 
 I have given a plate ; Mr Cline removed it by 
 amputation in St Thomas's Hospital. It had been 
 the consequence of what is vulgarly called the 
 white swelling of the knee-joint; the leg was placed 
 forwards at right angles with the thigh, so that when 
 walking on his crutches he had the most grotesque 
 appearance, as the bottom of his foot first met the 
 . eye when he was advancing. Upon inspection of 
 the patella it was found anchylosed to the os femo- 
 ris, and the tibia was also joined by ossific union to 
 the fore part of the condyles of the thigh-bone. 
 {See Plate.) 
 
 How prevented, — This state of parts may be pre- 
 vented by opposing the action of the muscles when 
 their irritability first begins to produce distortion ; 
 
DISLOCATIONS OF THE KNEE. 
 
 21 1 
 
 by the application of splints ; and by the exhibition 
 of the pulvis ipecacuanhas compositus, to diminish 
 the irritabihty of the system. Thus I have seen, 
 in cases of ulceration of the hip-joint, the irritative 
 action of the flexor muscles diminished, and future 
 distortion prevented, by drawing down the limb and 
 keeping it in the extended position ; but as this ex- 
 tension is most painful to the patient, however de- 
 sirable it may be, it should be accomplished very 
 gradually. 
 
FRACTURES OF THE KNEE-JOINT. 
 
 I SHALL now, pursuing my former plan, describe 
 the fractures to which the bones entering into the 
 composition of this part are liable ; and first the 
 
 FRACTURES OF THE PATELLA. 
 
 Transverse or longitudinal. — This bone is gen- 
 erally broken transversely, sometimes, though rarely, 
 longitudinally : it is liable also to simple and com- 
 pound fracture ; but, fortunately, the latter is but 
 of rare occurrence. 
 
 Symptoms. — When the patella is transversely 
 broken, the upper part of the bone is drawn from 
 the lower, its superior portion being elevated by 
 the action of the rectus, vasti, and cruralis muscles, 
 which are inserted into its upper part; whilst the 
 lower portion is still retained in its natural situation 
 by the ligament which passes from it to the tuber- 
 cle of the tibia. 
 
 Degree of separation, — The degree of separation 
 thus produced, depends on the extent of laceration 
 
FRACTURES OF THE KNEE. 
 
 213 
 
 of the ligament; for when the ligament is but lit- 
 tle torn, the separation will be half an inch, but 
 under great extent of injury the bone is drawn five 
 inches upwards, the capsular ligament and tendi- 
 nous aponeurosis covering it being then greatly lac- 
 erated ; and this, with one exception, is the great- 
 est extent of separation which I have seen. The 
 accident may be at once known by the depression 
 between the two portions of bone; the fingers pass- 
 ing readily down to the condyles of the os femoris, 
 into the joint as far as the integuments will permit; 
 and the elevated portion of bone moving readily 
 on the lower and fore part of the thigh. The 
 power of extending the limb is lost immediately af- 
 ter the accident, and likewise that of supporting the 
 weight of the body on that leg, if the person be 
 standing ; for the knee bends forwards from the 
 loss of action in the extensor muscles. The pain 
 of this accident is not very severe, and a simple 
 fracture is not dangerous, for the constitution feels 
 it but little. In a few hours after the accident, a 
 copious extravasation of blood takes place upon the 
 fore part of the joint, so that the appearance is 
 livid from ecchymosis, but this is removed by ab- 
 sorption in a few days. Considerable inflammation 
 and fever succeed, and there is a great degree of 
 swelling in the fore part of the joint, both from 
 the free secretion of synovia, and the effusion aris- 
 ing from inflammation. No crepitus is felt in this 
 fracture, for the bones cannot be sufficiently ap- 
 proximated to evince this general discriminating 
 mark of other fractures. 
 
 The separation of the bones is much increased 
 by bending the knee, as this act removes the lower 
 from the upper portion of bone, pulling down the 
 tibia, the ligamentum patellar, and the lower part 
 of the bone from the upper» 
 
214 
 
 FRACTURES OF THE KNEE. 
 
 Causes, Src. — The accident arises from two caus- 
 es: first, from blows upon the bone produced by 
 falls upon the knee, or received upon the patella 
 in the erect position of the body; and, secondly, 
 from the action of the extensor muscles upon the 
 bone. 
 
 Case. — A gentleman walking in the country, and 
 not used to jumping, leaped a ditch of considerable 
 breadth ; and when he reached the opposite bank, 
 being in danger of falling, he ran forward several 
 steps, and Avith difficulty recovered himself; in this 
 attempt to save himself from a fall, he felt the pa- 
 tella snap. I was sent for to him, and found his 
 patella broken, and the portions of bone consider- 
 ably separated. 
 
 A lady, descending some stairs, placed her heel 
 near the edge of one of the stairs, and was in dan- 
 ger of falling forwards, when, throwing her body 
 somewhat backwards to prevent the fall and to 
 straighten the knee, the patella became broken. 
 
 Explanation. — That a bone should thus break 
 by the action of muscles appears at first sight in- 
 comprehensible, but this circumstance is easily ex- 
 plained. When the knee is bent, the patella is 
 drawn down on the end of the condyles of the os 
 femqris, so as to bring the upper edge of the bone 
 forwards ; and at that moment it is that the patella 
 is broken, by the rectus muscle acting not in a line 
 with the bone, but at right angles with it, or nearly 
 so, and upon its upper edge more particularly. 
 
 Mode of union. — With respect to the union of this 
 bone, whether the separation be great or inconsider- 
 able, it is generally effected by an intervening liga- 
 mentous substance. The bone itself undergoes but 
 little alteration; the lower portion, joined by liga- 
 ment to the patella, has its broken cancellated struc- 
 ture still apparent, although a little smoothed. The 
 
FRACTURES OF THE KNEE. 
 
 215 
 
 upper portion of bone has its broken cancelli covered 
 by a slight ossific deposit, so that there is more ossific 
 action in the upper than in the lower portion of the 
 bone, and certainly much less than in bones which 
 do not form a part of the joints. The internal arti- 
 cular surface of the bone preserves its natural smooth- 
 ness. Blood is immediately deposited in the place 
 of the injured ligament, but this in a few days is ab- 
 sorbed. Inflammation arises and pours out adhesive 
 matter, which extends from one edge of the lacer- 
 ated ligament to the other, and even between the 
 bones, to each of which it is firmly united. (See 
 Plate.) Vessels shoot from the edges of the liga- 
 ment and render the new substance organized, pro- 
 ducing a ligamentous structure similar to that from 
 which the vessels shoot ; this substance is not, how- 
 ever, always perfect, for I have seen apertures in 
 it; but this will greatly depend upon the extent of 
 the laceration of the ligament, and the too early use 
 of the limb. In the dog and in the rabbit, or almost 
 any other quadruped, it is possible by experiment to 
 trace the mode of union of this bone. 
 
 Experiment I. 
 I drew the integuments much aside in a rabbit, 
 and dividing them, placed a knife upon the patella 
 and struck it lightly with a mallet ; the bone was 
 broken and directly drawn up by the action of the 
 muscles. I let the integuments go, and the wound 
 was not opposite to the fracture. In forty-eight 
 hours I killed the animal and examined the part: 
 the bones were separated three-quarters of an inch, 
 and the intervening part filled with coagulated 
 blood. 
 
 Experiment II, 
 I repeated the former experiment, and having 
 
216 
 
 FRACTURES OF THE KNEE. 
 
 killed the animal on the eighth day, found most of 
 the blood absorbed, and adhesive matter occupying 
 the space between the bo^es. 
 
 Experiment III. 
 The former experiment repeated. The animal 
 examined on the fifteenth day. The adhesive mat- 
 ter had acquired a smooth and somewhat hgament- 
 ous character. 
 
 Experiment IV, 
 The same division of the bone being made, it was 
 examined on the twenty-second day, when the new 
 ligament was complete. 
 
 Experiment V. 
 
 The same repeated, and the examination made in 
 five weeks. The part was injected, and vessels 
 were found proceeding from the edge of the ligament 
 into the adhesive matter, now become ligamentous. 
 So that at the end of five weeks the vascularity is 
 complete, and some vessels proceed into the new 
 ligament from the bone, but chiefly from the lacer- 
 ated ligament. Upon the dog these processes may 
 be equally well observed, but they are not quite so 
 rapidly produced in a large dog as in the rabbit. 
 
 The parts were dissected and preserved after 
 these experiments, both in the dog and rabbit, and 
 they are deposited in the collection of St Thomas's 
 Hospital, where they may always be seen. 
 
 Experiment VI. 
 In the rabbit, having dividecj the bone, I sewed 
 the two portions by conveying a needle and thread 
 through the tendinous covering of the bone, but the 
 
FRACTURES OF THE KNEE. 
 
 217 
 
 ligatures separated, and the bones still united by 
 ligament. 
 
 Experiment VII. 
 
 I divided the bone, and cut the rectus muscle 
 across above it, yet the patella united by ligament. 
 
 I could not, either in the dog or rabbit, succeed in 
 producing a bony union in the transverse fracture. 
 Yet in a patient of my kind friend, M. Chopart, at 
 Paris, I once saw a case which appeared to me to be 
 united by bone ; and Mr Fielding, of Hull, has lately 
 published a similar case. 
 
 Liigamentous union as short as possible, — A liga- 
 mentous union of the transverse fracture of the pa- 
 tella is that which generally occurs ; and if there 
 be an exception it is very rare. But still the prin- 
 ciple which is to guide the surgeon's conduct is, to 
 make that ligament as short as possible. If the liga- 
 ment be of great length there is a proportionate 
 weakness; for as soon as the accident has happened, 
 the rectus muscle retracts and draws up the superi- 
 or portion of the patella; and in proportion as the 
 retraction is suffered to continue the muscle is short- 
 ened and its power consequently diminished. Those, 
 therefore, in whom the bones have united after 
 being widely separated, if they walk quickly, do it 
 with a halt, and are very liable to fall, and to break 
 the other patella. Let then the muscle be brought as 
 nearly as it can be to its natural length ; and although 
 complete apposition of the bone may be very rarely 
 effected, yet the ligamentous union will be rendered 
 as short as circumstances will permit, and the patient 
 will recover the power of the limb. 
 
 The notion which was formerly entertained of the 
 danger of squeezing the callus into a projection in the 
 inner side of the bone, so as to destroy the smooth- 
 ness of its internal surface, is not at all tenable, 
 .28 
 
218 
 
 FRACTURES OP THE KNEE. 
 
 Treatment, — When called to this accident, the 
 surgeon places the patient in bed upon a mattress, 
 extends the limb upon a well padded splint placed 
 behind the thigh and leg, to which it is tied, and 
 which should be hollowed. The patient's body 
 should be raised as much as he can bear to the sit- 
 ting posture, to relax the rectus muscle. An evapo- 
 rating lotion is to be then applied upon the knee, 
 consisting of liq. plumbi s. acetat. dilut. 3. v. with 
 spir. vini. 3. i. ; and no bandage should be at first 
 employed. The body should be slightly raised in 
 bed to relax the rectus muscle, and the heel should 
 be raised to bring up the lower portion of the patella. 
 If in a day or two there be much tension or ecchymo- 
 sis, leeches should be applied, and the lotion be con- 
 tinued; after a few days, when the tension has sub- 
 sided, and not till then, should bandages be employed. 
 I have seen the greatest suffering and swelling pro- 
 duced by the early application of bandages in these 
 cases, even so as to threaten sloughing of the skin 
 when there had been much contusion. The means 
 which are most frequently employed in the treat- 
 ment of this case are the following: A roller is ap- 
 plied from the foot to the knee, to prevent the swell- 
 ing of the leg, and the upper portion of bone is 
 pressed downwards, as far as it can be without vio- 
 lence towards the lower, so as to lessen the retrac- 
 tion of the muscles, and produce the approximation 
 of the portions of bone. Then rollers are applied 
 above and below the joint, confining a piece of broad 
 tape next the skin on each side, which crosses the 
 rollers at right angles ; these portions of tape are 
 bent down and tied over the rollers so as to bring 
 them near each other, and thus to keep down the 
 upper portion of bone. Sometimes, instead of the 
 tape on each side, a broad piece of linen is bent over 
 the rollers on the fore part of the joint, and is there 
 
FRACTURES OF THE KNEE. 219 
 
 confined, so as to approximate the pieces of bone, 
 and to bind down the upper portion of the patella, 
 that its lower broken edge may not turn forwards. 
 
 But the mode I prefer is as follows : A leather 
 strap should be buckled around the thigh, above the 
 broken and elevated portion of bone ; and from this 
 circular piece of leather another strap should be 
 passed under the middle of the foot, the leg being 
 extended, and the foot raised as much as possible. 
 This strap is brought upon each side of the tibia 
 and patella, and buckled to that which is fixed around 
 the lower part of the thigh. The strap may be 
 confined to the foot by a tape tied to it, and to the 
 leg at any part in the same manner; this is the most 
 convenient bandage for the fractured patella, and 
 for the patella dislocated upwards by the laceration 
 of its ligament. A roller is to be applied upon the 
 
 In this position, and thus confined, the limb is to 
 be kept for five weeks in the adult, and for six weeks 
 at a more advanced age. Then a slight passive mo- 
 tion is to be begun, and this must be done gently and 
 with so much circumspection that the ligament, if 
 not firmly united, shall not give way, and suffer the 
 bones to recede. If the union be found sufficiently 
 firm to bear it, the passive motion is to be employ- 
 ed, from day to day, until the flexion of the limb be 
 complete. 
 
 State of the muscle, — If passive motion were not 
 used it is to be apprehended that the action of the 
 extensor muscles would never return ; for those who 
 are kept in bed, with the joint at rest, do not in 
 many months acquire any power of bending and ex- 
 tending the limb. When this motion becomes ex- 
 pedient the patient is placed on a high seat, and di- 
 rected to swing the leg, by which motion is given to 
 the rectus; and if the mind be then directed to the 
 
220 
 
 FRACTURES OF THE KNEE. 
 
 contraction of that muscle, its powers will be gra- 
 dually renewed. When the rectus muscle has been 
 shortened, and the upper portion of bone is drawn 
 from the lower, all the disposition to action in that 
 muscle ©eases ; and it does not seem disposed to re- 
 cover its voluntary action until it becomes again 
 elongated, which effect takes place after the union 
 of the ligament by bending the knee ; and from this 
 point of elongation the muscle begins to contract. 
 
 A young woman was brought into my house in her 
 father's arms, and he said, ' I am obliged to carry 
 her, for she has lost the use of her legs, having bro- 
 ken both her knee-pans eight months ago, and she 
 has never been able to use her limbs since.' Pas- 
 sive motion was directed, and she was ordered to 
 try to extend her legs after they had been bent by 
 the surgeon. At first she could effect but little : 
 however, by repeated trials, she gradually recovered 
 the use of her limbs. Mr John Hunter, who raised 
 surgery into a science, and seems to have been the 
 first who attended to the principles on which the 
 practice of surgery ought to be regulated, always 
 dwelt most ably upon this subject in his lectures. 
 Patients, from the pain which passive motion pro- 
 duces, and the slow return of action in the muscles, 
 are indisposed to suffer the one or to make trial of 
 the other; but without them there can be no re- 
 covery. 
 
 Degree of approximation, — The degree of approxi- 
 inflation of the bone is, as I have stated, a matter of 
 great consequence. The bone is rarely brought 
 into contact so as to be united in the transverse 
 fracture by ossific union, but the less the distance 
 between the bones the greater is the power which 
 the muscle re-acquires; for in proportion as the mus- 
 cle is shortened it is weakened; and in ascending 
 there is difficulty in raising the limb, in descending 
 
FRACTURES OF THE KNEE. 
 
 221 
 
 in keeping it extended; the uniting ligament is liable 
 to be torn, and the other patella to be broken by 
 falls ; therefore the surgeon should bring the bones 
 as near together as he can, to render the ligamentous 
 union as short as possible, and consequently to leave 
 the muscle with as much of its original power as the 
 nature of the accident Avill permit.* 
 
 THE PERPENDICULAR FRACTURE OF THE PATELLA. 
 
 There is in the collection at St Thomas's Hospital 
 a patella, one-fourth of which has been broken off; 
 the edge is smooth, and no attempt at ossific union 
 appears to have been made. 
 
 Ligamentous union. — A gentleman consulted me 
 who had about one-third of the patella separated 
 from the other part of the bone ; it had united by 
 ligament, for there was free motion between the 
 fractured piece of bone. and that from which it had 
 been removed. He recovered quickly from this 
 injury, and it affected his power of walking very 
 little. 
 
 During the winter of 1822, a body was dissected 
 
 * From the few, though well attested instances in which frac- 
 ture of the patella has been followed by bony union we cannot 
 doubt but that bone would be produced in every instance if it 
 were possible to keep the fractured pieces accurately in apposi- 
 tion. It has been frequently suggested that the patella and cranium 
 are never consolidated by bone when the one has been broken 
 or a portion of the other removed; lest the irregularity of the 
 callus should destroy the functions of the subjacent parts. But 
 we have now on record instances of the reproduction of bone in 
 both the cases mentioned, and must believe that the distance of 
 the surfaces from each other is the cause of the want of bony 
 union. .T. D. G. 
 
222 
 
 FRACTURES OF THE KNEE. 
 
 at St Thomas's Hospital, in which both the patellas 
 had been broken longitudinally, and although they 
 were in contact, they were both united by ligament. 
 Mr Silvester, one of our pupils, had the kindness to 
 make a drawing of one of these, of which I have 
 given a plate. 
 
 This circumstance surprised me, because I saw no 
 reason why the patella should not be united by bone 
 when broken perpendicularly, as I thought the mus- 
 cles would have a tendency to bring the parts to- 
 gether. I made it therefore a subject of experi- 
 ment. 
 
 Experiment L 
 Union by ligament in experiments. — July 31st, 1818, 
 I broke the patella of a dog by placing a knife upon 
 it in the longitudinal direction, having first drawn the 
 integuments aside; and on the 12th of September 
 following I examined the part, when I found the 
 two portions of bone considerably separated from 
 each other, and united by ligament. The cause was 
 as follows : When I had di\^ided the bone, the knee 
 became bent, the condyles of the os femoris pressed 
 against the inner side of the patella, and thrust the 
 parts asunder, and only a ligamentous union took 
 place. (aScc Plate.) 
 
 Experiment 11. 
 August 2nd, 1818, I broke in the same manner 
 the patella of a rabbit, and examined the parts on 
 September 3rd, when I found the two portions of 
 bone widely separated, and united only by ligament- 
 ous matter. I now began to think it impossible for 
 the patella to unite by bone, but determined to make 
 another experiment to determine this point. 
 
FRACTURES OF THE KNEE. 
 
 223 
 
 Experiment III. 
 Union by hone, — I divided the patella longitudi- 
 nally in a dog, but took care that the division should 
 not extend into the tendon above or to the ligament 
 below it, so that there should be no separation of 
 the two portions. I examined it three weeks after, 
 and found it united ; no separation existing between 
 the two portions.* (^See Plate.) 
 
 Experiment IV. 
 October, 1819. I divided the patella by a crucial 
 fracture into four portions; the two upper portions 
 neither united with each other nor with the bones 
 below, but the two lower portions became united by 
 bone.t 
 
 It appears then that under longitudinal and trans- 
 verse fracture, a ligamentous union is generally pro- 
 duced, and that it arises from the separation produc- 
 ed in the bone; but that if that cannot separate, 
 and its parts remain in contact, ossific union may be 
 produced. In the summer of 1819, Mr Marryat 
 was thrown from his gig as he was passing along the 
 Strand ; by the fall he fractured his patella trans- 
 versely, and the lower portion of the bone was also 
 broken perpendicularly, so that it was divided into 
 
 * The bone was, under maceration, found united in part by 
 bone, and in part by cartilage, not yet completely ossified. It 
 is preserved, and may be seen at any time by tl^ose who are 
 curious to examine it. — A. C. 
 
 t All these experiments tend to prove the correctness of 
 what has been heretofore advanced, relative to the absence of 
 bony union. In all the instances where bony union did not oc- 
 cur, we see that the fragments were liable to separation from 
 the motions of the Umb. J. D. G. 
 
224 
 
 FRACTURES OF THE KNEE. 
 
 three pieces. The transverse fracture united, as 
 usual, by ligament ; but the perpendicular by bone. 
 
 Mr Parrott, of Tooting, who also attended the 
 case, writes in these words: 
 
 'Dear Sir, — I have great pleasure in replying to 
 your letter. The longitudinal fracture of the patel- 
 la of Mr M. has become very firmly consolidated, 
 but there is a line or ridge to be traced upon the 
 surface of the bone, which marks distinctly the place 
 where it had been separated.' 
 
 Treatment, — In the longitudinal or perpendicular 
 fracture of the patella, the best treatment consists 
 in extending the leg, and in using local depletion and 
 evaporating lotions ; in a few days a roller should 
 be applied around the limb, and then a laced knee- 
 cap, with a strap to buckle around the knee above 
 and below the patella, and a pad on each side to 
 bring its parts as nearly as possible into contact. 
 
 COMPOUND FRACTURE OF THE PATELLA. 
 
 From violence or ulceration. — These fractures oc- 
 cur from injury, or from an ulcerative process under 
 peculiar circumstances. 
 
 The cases which I have seen of this accident are 
 as follow : 
 
 Case, — A man was admitted into Guy's Hospital, 
 in the year 1796, under Mr Wc Cooper, surgeon of 
 that hospital, with a compound fracture of this 
 bone; violent inflammation followed; suppuration 
 ensued, with the highest degree of constitutional 
 irritation ; and as no opportunity was given for am- 
 putation, from the great swelling of the thigh, this 
 man died. The bone is in the Museum of St The- 
 
FRACTURES OF THE KNEE. 
 
 225 
 
 mas's Hospital, disunited as at the first moment of 
 the accident. 
 
 Case, — A man was admitted into St Thomas\s 
 Hospital, under the care of Mr Birch, with a frac- 
 ture of the patella, and a small wound extending in- 
 to the joint. The knee was fomented and poultic- 
 ed ; inflammation and suppuration followed ; and 
 this man in a few dajs died with the highest symp- 
 toms of constitutional irritation. 
 
 Case. — Mr Hawker, surgeon, called me to visit 
 a man who had just arrived in Lpndon ; and who, 
 being at Avork in a warehouse up one pair of stairs, 
 on hearing the signal for dinner, seeing the doors 
 of the warehouse open, walked quickly out, and fell 
 into the street. By this fall he had a compound 
 fracture of the patella. The limb was attempted 
 to be saved. The joint suppurated; the discharge 
 became excessively great ; and the symptoms of ir- 
 ritation ran so high, that I thought he would not 
 recover; but he became somewhat better, and I 
 advised him to go into the country. I afterwards 
 heard that he gradually recovered with an anchy- 
 losed joint. 
 
 Case, — Mr Redhead, residing at Kennington 
 Cross, aged thirty-nine years, was thrown from his 
 gig, on June 18th, 18] 9, against a cart-wheel. His 
 knee came violently in contact with the wheel, which 
 fractured his patella and opened the joint. Mr 
 Dixon, of Newington Butts, was sent for, and he 
 found that the knee had bled freely from a wound 
 on its outer side, from which the synovia. freely es- 
 caped, and which readily admitted his finger to the 
 shattered patella. The accident happened at ten 
 o'clock in the morning ; I was sent for by Mr Dix- 
 on, and when 1 met him at four o'clock, I found a 
 wound on the fore part of the knee, through which 
 I readily passed my finger into the joint. The 
 29 
 
226 
 
 FRACTURES OF THE KNEE. 
 
 patella was not broken transversely, but, as I have 
 expressed it, shattered ; that is, broken into several 
 pieces ; and a small piece which was separated from 
 the rest I removed. It was agreed between Mr 
 Dixon and myself, that an attempt should be made 
 to save the limb, for the patient was of a spare 
 habit, and, by his great composure, showed that he 
 was not of an irritable constitution. I passed a su- 
 ture through the integuments, knowing the difficulty 
 of keeping the wound closed on account of the con- 
 tinued escape of synovia, but taking the utmost care 
 that the ligament should not be included in the 
 suture. Adhesive plaster was also applied over the 
 wound, and rollers lightly put on, which were kept 
 constantly wet with spirits of wine and water. The 
 leg was placed in the extended position, and he was 
 ordered not to move it in the slightest degree, and 
 to live on fruit. 
 
 Saturday. He had passed a very good night, and 
 was free from pain or fever. 
 
 Sunday night. He was restless, and was thought 
 delirious. 
 
 Monday morning. He had a dose of ol. ricini, 
 which relieved him from his feverish feelings. 
 
 Tuesday. He stated he had passed a good night, 
 and he afterwards had no bad symptoms. As there 
 was no swelling, no inflammation, and scarcely any 
 pain, the suture was not removed until the 30th of 
 June, when the adhesive plaster was renewed. 
 
 He recovered without any untoward accident. 
 Mr Dixon ordered him from bed in a month, and at 
 the end of five weeks gave the joint slight passive 
 motion. On the 7th of August, the patient walked 
 across his room ; and he entirely recovered the use 
 of his limb. 
 
 If the laceration be extensive, or the contusion 
 
FRACTURES OF THE KNEE. 
 
 227 
 
 very considerable in these cases, amputation will be 
 required; but if the wound be small, and the patient 
 be not irritable, and no sloughing of the integuments 
 or ligament be likely to occur from the nature of 
 the accident, it will be best to try to save the limb; 
 and the treatment of Mr Redhead's case is that 
 which 1 should pursue. The principal object is to 
 produce adhesion immediately ; and every means in 
 our power must be used for that purpose. I know 
 well that sutures are generally objectionable, and I 
 never employ them if 1 can possibly succeed without 
 them ; but in moveable parts, in those w^hich are 
 unsupported, and in those through which a secretion 
 is liable to force its way, they are not only justifiable, 
 but highly necessary. Fomentations and poultices 
 must not be employed in these cases, as they prevent 
 the adhesive process. 
 
 A compound fracture of the patella will be some- 
 times produced by an ulcer, as in the following 
 case. 
 
 Ulceration. — A w^oman was admitted into Guy's 
 Hospital in 1816, with a simple and transverse frac- 
 ture of the patella, which had long been united by 
 a ligament of about three inches in extent. Ulcers 
 were formed upon different parts of the body; and, 
 unfortunately, one of these upon the integuments 
 over the ligamental union of the patella. It became 
 sloughy, and extended through the new ligament to 
 the joint, which it laid open : violent constitutional 
 irritation succeeded; a copious suppuration was pro- 
 duced; and no opportunity was given of amputating 
 the limb, for the inflamed and swollen state of the 
 thigh forbade it. This woman died. 
 
228 
 
 FRACTURES OF THE KNJGE. 
 
 OBLiqUE FRACTURES OF THE CONDYLES OF THE OS 
 FEMORIS INTO THE JOINT. 
 
 Of either condyle. — These cases are of rare occur- 
 rence ; but when thej happen it is difficult to pre- 
 vent deformity, and to restore to the patient a sound 
 and useful limb. Thej are known by the great 
 swelh'ng of the joint which ensues, by the crepitus 
 which is felt in moving the joint, and by the deform- 
 ity consequent upon them. The fracture is some- 
 times of the inner, and sometimes of the outer con- 
 dyle, and the bone is split down into the joint. 
 
 Treatment, — Whether the external or internal con- 
 dyle be'broken, the same treatment is required. The 
 limb is to be placed upon a pillow in the straight 
 position, and evaporating lotions and leeches are to 
 be used to subdue the swelling and inflammation. 
 When this object has been effected, a roller is to be 
 applied around the knee, and a piece of stiff paste- 
 board, about sixteen inches long and sufficiently wide 
 to extend entirely under the joint, and to pass on 
 each side of it, so as to reach to the edge of the 
 patella, is to be dipped in warm water, applied under 
 the knee, and confined by a roller. When this is 
 dry, it will have exactly adapted itself to the form 
 of the joint, and this form it will afterwards retain, 
 so as best to confine the bones. Splints of wood or 
 tin may be used on each side of the joint, but they 
 are apt to cause uneasy pressure. In five weeks 
 passive motion of the limb may be gently begun, to 
 prevent anchylosis. I prefer the straight position in 
 these cases, because the tibia presses the extremity 
 of the broken condyle into a line with that which is 
 not injured. 
 
 Compoundfracture, — Examples of compound frac- 
 
FRACTURES OP THE KNEE. 
 
 229 
 
 tures of the condyles are very unfrequent : the fol- 
 lowing was under the care of Mr Travers, in St 
 Thomas's Hospital, who was so kind as to send me 
 . the history of it. 
 
 Case, — Michael Dixon was admitted into St 
 Thomas's Hospital, September 17th, 1816, for a 
 fracture of the lower extremity of the femur, caus- 
 ed by a carriage wheel in motion, with which his 
 legs became entangled. There was much displace- 
 ment of the fractured bone, and a small wound op- 
 posite the external condyle. Upon examination it 
 was evident that the fracture had extended nearly 
 in the direction of the axis of the bone, and there 
 was a transverse fracture of the shaft of tlie bone 
 above the joint ; the external condyle was move- 
 able, and thrown out of its place during the accident, 
 as if. it had been drawn by the leg, which was twist- 
 ed inwards. The iimb was laid in a fracture box, 
 in a semi-flexed position on the heel ; the constitu- 
 tional disturbance w^as very slight. 
 
 Oct. 5. The external condyle is still moveable : 
 the integuments over it are ulcerated, so as to de- 
 nude the bone. The health remains good. 
 
 Nov. 5. The broken bone protrudes and appears 
 to be dead ; it is surrounded by fungous granula- 
 tions, and there is but little discharge. 
 
 Nov. 18. The protruded bone having been gent- 
 ly twisted off by forceps, proved to be the external 
 condyle, with its articular surface : there still pro- 
 truded a small portion of bone, but this soon healed 
 over. The limb was now placed in an extended 
 position, as anchylosis was considered unavoidable. 
 
 Dec. 1. The boy has recovered almost the per- 
 fect use of his limb, and is enabled to bend and ex- 
 tend it without pain. 
 
 Dec. 6. The boy was discharged from the hos- 
 
0 
 
 230 FRACTURES OF THE KNEE. 
 
 pital. The wound was healed, and he can walk 
 tolerably well with a stick. 
 
 On the February following he called at the hos- 
 pital, walking without any support, and having free • 
 use of the joint.* - 
 
 To aged persons these accidents sometinaes prove 
 fatal, as in the following example; and, indeed, 1 
 have known a simple fracture of the condyles pro- 
 duce the same effect. 
 
 COMPgUND FRACTURE OF THE CONDYLES OF THE 
 FEMUR. 
 
 Vases of compound fracture of condyles. — Bluk- 
 wick, aged seventy-six, on the 1st of January, 1822, 
 slipped accidentally olF the curb-stone, and received 
 the whole weight of the body upon the knee. The 
 patella appears to have acted as a wedge between 
 the two condyles of the os femoris, which were 
 separated by a fracture, running obliquely along the 
 shaft of the bone, the end of which was forced 
 through a wound in the integuments. The patella 
 remained in its place, and was unbroken. The pa- 
 tient at the time of the accident was in a state of 
 inebriety. MrRowe, of Burton Crescent, to whom 
 
 * A case of fracture of the external condyle, complicated 
 with an extensive cut into the joint, occurred in the practice 
 of a surgeon of my acquaintance. The wound was produced 
 by a violent stroke with an axe, which entered the joint at the 
 outer edge of the patella, and sticking into the femur split the 
 external condyle obliquely from the shaft of the bone. The 
 accident happened in very cold weather; the edges of the 
 wound were stitched, and contrary to all expectation the patient 
 entirely recovered, without any loss of bone, under the careful 
 employment of the antiphlogistic regimen. J. D. G. 
 
FRACTURES OF THE KNEE. 23 I 
 
 1 am indebted for the particulars of the case, saw 
 him about three hours after the accident : he had 
 him conveyed to bed, and without much difficulty 
 brought the fractured bones in apposition ; they 
 were retained in their situation by splints and ban- 
 dages, and the limb was placed in the straight posi- 
 tion. A lotion of the liquor plumBi was applied 
 over the part, and an opiate was administered at 
 night. 
 
 The patient passed a tolerable quiet night, and in 
 the morning was pretty free from pain. An aperient 
 draught was administered, which operated freely. 
 On the evening of this day I was called in to him. 
 I directed a leathern cap to be strapped over the 
 fractured part, and the straight position of the limb 
 to be preserved. The patient was ordered a regu- 
 lar diet, and saline draughts, with an occasional 
 opiate. 
 
 This treatment was continued until the twenty- 
 first day from the accident, and the patient remained 
 free from any bad symptom. On the evening of 
 that day, however, he was found much heated, with 
 a very frequent pulse, dry tongue, and a tendency to 
 delirium : these alarming symptoms, it appears, were 
 increased by a glass of brandy and water taken con- 
 trary to the direction of his medical attendant. Mr 
 Rowe ordered him an aperient, but the danger was 
 rapidly increasing : the patient was found next morn- 
 ing in a high degree of fever; pulse one hundred 
 and thirty; countenance exhibiting great depression. 
 These unfavourable symptoms went on increasing, 
 and on the twenty-fourth he died. 
 
 The limb, on examination after death, exhibited 
 great signs of inflammation ; a considerable quantity 
 of matter was found between the muscles of the 
 thigh, part of which was discharged by the external 
 wound. 
 
232 
 
 FRACTURES OF THE KNEE. 
 
 Dissection. 
 
 On examining the thigh-bone its shaft was found 
 broken very obliquely, about seven inches above the 
 knee-joint ; and the bone was split down into the 
 joint, near to the centre, between the condyles, but 
 inclining somewhat to the external condyle : this 
 portion of the bone was loose and detached from 
 the internal condyle : there was also a piece three 
 inches in extent, detached from the shaft of the bone, 
 which however had fallen into the cancelli, where it 
 remained lodged. {See Plate.) 
 
 OBLiqUE FRACTURES OF THE OS FEMORIS JUST ABOVE 
 ITS CONDYLES. 
 
 Oblique fractures of the condyles. — This is a most 
 formidable injury from its consequences on the future 
 form and use of the limb ; for it is liable to termi- 
 nate most unfortunately, by producing deformity, 
 and by preventing the flexion of the knee-joint. 
 
 It is only of late years that I have had an oppor- 
 tunity of investigating this case by dissection ; and, 
 consequently, of obtaining substantial knowledge of 
 the exact nature of the injury. The appearances 
 produced by it are, that the lower and broken ex- 
 tremity of the shaft of the bone projects, and forms 
 a sharp point just above the patella, which pierces 
 the rectus muscle, threatens to tear the skin, and 
 sometimes does tear it : whilst the patella, tibia, and 
 condyles of the os femoris sink into the ham, and 
 are drawn upwards behind the broken extremity of 
 the shaft of the os femoris. 
 
 The accident happens when a person falls from a 
 considerable height upon his feet, or is thrown upon 
 
FRACTURES OF THE KNEE. 
 
 233 
 
 the condyles of the os femorls with the knee bent. 
 In all the cases, the fracture was very oblique 
 through the shaft of the bone; and hence the point- 
 ed appearance of the cxticmity of the fracture, and 
 tlie difficulty of keeping the bones in apposition. 
 
 Case. — A body was brought into the dissecting- 
 room at St Thomas's Hospital, which fell to the lot 
 of Mr Patey, surgeon, of Dorset-street, Portman- 
 square, to dissect, and he kindly permitted me to 
 make a drawing from the limb. It appeared, upon 
 view of the thigh, that the limb had been broken 
 just above the knee-joint, and that the shaft of the 
 bone projected as far as the skin, just above the pa- 
 tella : the union was firm, but the magnitude of the 
 bone was exceedingly increased. When the integu- 
 ments were removed, the end of the superior portion 
 of the shaft of the bone was found to have pierced 
 the rectus muscle, through which it still continued 
 to project (See Plate); and behind this projecting por- 
 tion of bone the rectus muscle was situated, which 
 passed to the patella. The patella, on the attempt 
 to draw it up, was stopped by the projection of the 
 fracture, so that its movement upwards was exceed- 
 ingly limited. The condyles of the os femoris, and 
 the lower portion of the bone, had been drawn by 
 the action of the muscles behind the end of the 
 fracture of the upper portion, and had united by a 
 very firm callus to the body of the bone. 
 
 This union had necessarily produced a great dimi- 
 nution in the power of extending the limb; for the 
 rectus muscle was really hooked down by the frac- 
 tured extremity of the bone : but even if the bone 
 had not piei'ced the muscle, still the elevation of the 
 patella would have been prevented, by that bone 
 being drawn against the fractured end of the thigh- 
 bone in the contraction of the muscle. It appears, 
 then, that in the treatment of this case, a most firm 
 30 
 
234 
 
 FRACTURES OF THE KNEE. 
 
 and continued extension must be supported lo pre- 
 vent the retraction which will otherwise ensue ; but 
 it will be seen by the two following cases, that this 
 defective union is with great difficulty prevented ; 
 and that the complete flexion of the limb afterwards, 
 was not in either instance accomplished. 
 
 COMPOUND FRACTURE JUST ABOVE THE CONDYLES OF 
 THE OS FEMORIS. 
 
 Case. — Mr Kidd, who weighed fifteen stone, fell, 
 on the 9th of November, 1819, from the height of 
 twenty-one feet upon his feet, and broke his thigh- 
 bone just above the knee by the severity of the 
 concussion. The fracture was situated immediately 
 above the condyles, and the broken extremity of 
 the shaft of the bone appeared through the integu- 
 ments and rectus muscle, just above the patella. He 
 was immediately carried home, and I saw him, with 
 Mr Phillips, surgeon to the King's household, a short 
 time after the accident. We agreed that the pro- 
 jecting extremity of the thigh-bone should be imme- 
 diately sawn off, and that the edges of the wound 
 should be approximated so as to render the fracture 
 simple ; and this was immediately done. The limb 
 was placed upon the double inclined plane. The 
 wound healed without difficulty, and our first object 
 was thus accomplished. On the 30th of November, 
 splints were applied, in order to press the bones 
 firmly together. On December 23rd, the leg was 
 straightened, and the inclined plane was lowered, so 
 as to bring the limb gradually into a straight position. 
 On February the 2nd, he sat up in bed. On the 
 7th of February, the knee having been moved, the 
 fractured bones appeared to separate, and on the 
 
FRACTURES OF THE KNEE. 
 
 235 
 
 14th it was clearly ascertained that the bone was 
 not united. On the 16th, a leathern bandage with 
 many straps was tightly buckled around the knee. 
 Having previously tried the position upon his side, 
 which only led to a greater separation of the bone, 
 he was again placed upon his back. On the 3d of 
 May, the bone was found to be united, and on the 
 r2th, the leathern bandage was removed, and the 
 limb placed on a pillow. On the 10th of July, 
 he moved from one side of the bed to the other 
 with difficulty, and on the 16th, was placed on an- 
 other bed, which was obliged to be adjusted to the 
 exact level with the former, before his removal 
 could be accomplished. On July the 19th, he w^as 
 removed from London to Kensington on a litter. 
 On the 8th of August, the thigh was fomented, in 
 order to remove the excessive bulk it had acquired, 
 and to diminish its hardness ; 1 ut the fomentation 
 was discontinued on the 14th, because it was found to 
 increase the swelling. On the 15th, the leg was 
 bathed with the liquor plumbi subacetatis dilutus, 
 and spirits of wine : the skin having been ulcerated 
 from the time that the bandage was buckled tight 
 around the knee. On October the 24th, the leg 
 was placed in a gout cradle. On the 26th, he was 
 on a sofa for two hours, but on the 28th5 was obliged 
 to keep in bed, because irritation and swelling had 
 been produced by moving on the two preceding 
 days. On November the 3rd, he was wheeled into 
 another room on a chair. On January the 29th, 
 1822, he was, for the first time, on crutches; and on 
 February the 24fch, he first walked out of doors. 
 
 His present state, March 1822, is as follows: The 
 bone above the knee is excessively enlarged; the 
 patella is fixed below the broken ex.tremity of the 
 shaft of the bone, the point of which adheres to the 
 skin. 
 
236 
 
 FRACTURES OF THE KNEE. 
 
 Mr Kidd possessed a very fine constitution, for 
 his puise after the accident never exceeded 63 ; and 
 although the rectus muscle was penetrated by tlie 
 bone, he never complained of any spasmodic con- 
 traction of the limb. 
 
 SIMPLE FRACTURE ABOVE THE CONDYLES OF THE OS 
 FEMORIS. 
 
 For the following history 1 am indebted to Mr 
 Welbank, Jun., who attended the case with me. 
 
 Case, — Mr — , of middle age, muscular and tall, 
 
 v^^as driving on the morning of July 20th, 1821, in the 
 neighbourhood of Leicester-fields, and was thrown 
 forward out of his gig, over the horse, which had 
 fallen. It is probable that the external condyle of 
 the right femur received the force and w-eight of 
 his descent upon the pavement. He was brought 
 from Leicester-fields to Chancery-lane in a coach, 
 with his legs out of the door, no surgical assistance 
 having been yet procured. When first seen by his 
 surgical attendant he was lying upon his back on the 
 bed, with the right leg bent and lying across the 
 middle of the left leg at an angle. There was an 
 appearance resembling the lateral dislocation of the 
 knee, from a deep hollow, visible on the external 
 side of the joint, in the situation of the external 
 condyles ; above this hollow close to the joint, and 
 on its external or fibular side, an abrupt and sharp 
 projection of bone was distinctly observable. Slight 
 extension replaced the parts, and it now appeared 
 that the thigh had, previously to the reduction, 
 been bent inwards over the left, upon an oblicjue 
 fracture, situated close to the patella. The patella 
 itself was very obscurely felt through a circumscribed 
 
FRACTURES OF THE KNEE. 
 
 237 
 
 effusion in front of the joint. Just above the situ- 
 ation of its upper edge might still be traced the ridge 
 of the fracture, a sliglit groove intervening: the ap- 
 pearance, indeed, at this and later periods of the 
 accident might have been mistaken, on superficial 
 examination, for the transverse fracture of the pa- 
 tella. Flexion produced great projection of the 
 upper part of the femur, and extension readilj re- 
 stored the natural appearance, except in the swelling 
 on the front of the patella. The crepitus was verj 
 indistinct, if at all observable. 
 
 Little more was done during the first week than 
 steadying the joint in the extended position with 
 short splints, and subduing the inflammation of the 
 capsule which supervened. After this period, a long 
 splint was applied from the trochanter major to the 
 outside of the foot, and an opposing short splint from 
 the middle of the femur to the middle of the inside 
 of the leg, and firmly confined by tapes and buckles. 
 The whole limb was supported upon an inclined 
 plane, and flexion cautiously obviated. To prevent 
 motion of the pelvis the stools were removed in 
 napkins. The posture was not, however, steadily 
 maintained; and it was frequently found that the 
 upper point of bone varied in its degrees of projec- 
 tion, and at different times, more or less, encroached 
 on the situation of the upper edge of the patella. 
 To remedy this, slight permanent extension, with 
 weights appended to the foot, was adopted with 
 advantage ; though 1 believe that the position was 
 by no means rigorously maintained, for I have since 
 understood that the patient, not unfrequently, even 
 had his back washed. The ridge of the upper por- 
 tion of the femur appeared, however, to project so 
 slightly, that it was deemed better to ensure union, 
 than to add to the frequency of disturbance, by beii g 
 too solicitous of exact apposition. 
 
238 
 
 FRACTURES OF THE KNEE. 
 
 About September the 7th, the bone was thought 
 sufficiently united, but flexion was neither attempted 
 by the surgeon, nor permitted to the patient. On 
 September the 10th, the patient was removed to 
 Eastbury, Hertfordshire, in a litter-carriage, as his 
 health was suffering: the limb being steadied with 
 splints, and the position resumed, during the journey. 
 In removing from one bed to another, and in other 
 alterations of posture, it was obvious that flexion 
 produced a greater appearance of projection of the 
 femur than had been anticipated. This might be 
 referred to the drawing down, or rather sinking of 
 the patella in flexion ; and, indeed, it could to ap- 
 pearance be nearly remedied by elevating the leg 
 upon the thigh, as in extension. Under these cir- 
 cumstances, however, rest in the extended posture 
 was again adopted for a fortnight. About Septem- 
 ber 2r)th, a second examination decided the necessity 
 for further rest, as the increase of projection, on 
 flexion of the knee, and a slight lateral motion, in- 
 duced a belief of infirm union. It is worthy of 
 mention, that the immediate vicinity of the joint, the 
 mobility of the patella, and the general thickening, 
 rendered all examinations of extreme difficulty and 
 uncertainty. A circular belt was tightly girded upon 
 the situation of the injury, with a view of compress- 
 ing the fracture, and maintaining the parts in . firm 
 apposition. On October 16th, the union was con- 
 sidered complete, and the patient was allowed to 
 get up. On November 1st, he resumed his pro- 
 fessional duties as an advocate. For a considerable 
 period he suffered pain and swelling of the limb, but 
 has gradually and slowly improved. 
 
 May, 1822. At this date he can walk about his 
 room without assistance either of crutch or stick. 
 He has little power of flexion at the knee-joint. 
 The joint is, however, apparently moveable to a 
 
FKACTURES OF THE KNEE. 
 
 239 
 
 certain extent beneath the pateUa, which bone is 
 fixed beneath the projecting edge of the upper por- 
 tion of the femur, which evidently overlaps and dis- 
 places it. There is visible shortening of the limb, 
 and the contour of the thigh is somewhat bowed out- 
 wards. 
 
 J. Welbank, Jun. 
 
 Chancery Lane, 
 
 To obviate the evils which are produced by this 
 formidable accident, I have had an apparatus construct- 
 ed to preserve the thigh in a constant state of extension. 
 (^See Plate,) The leg is to be first bent, to draw 
 the rectus muscle over the broken extremity of the 
 bone, and then the apparatus is to be applied, and 
 the limb to be preserved constantly on the stretch 
 in the rectilinear position. 
 
 FRACTURE OF THE HEAD OF THE TIBIA. 
 
 Oblique fractures of the tibia into the joint. — The 
 head of the tibia is sometimes obliquely broken ; 
 and if it be fractured into the knee-joint, the treat- 
 ment which it requires is similar to that which is 
 necessary in the oblique fracture of the condyle of 
 the OS femoris; that is, first, to maintain the straight 
 position of the limb, because the femur preserves 
 the proper adaptation of the fractured tibia by serv- 
 ing as a splint to its upper portion, and keeping the 
 articular surfaces in apposkion. Secondly, a roller 
 to press one part of the broken surface against the 
 other. Thirdly, a splint of pasteboard to assist in 
 the preservation of that pressure. And fourthly, 
 early passive motion to prevent anchylosis. 
 
240 
 
 FRACTURES OF THE KNEE. 
 
 Fracture just below the joint, — But if the fracture 
 of the tibia be ol lique, jet not into the joint, then it is 
 best to place the limb upon the double inclined 
 plane : for the cause of deformity being the eleva- 
 tion of the lower portion of the tibia, which is drawn 
 up on the side of the knee-joint, as the fracture is in 
 the inner or outer side of the tibia, the weight of 
 the leg keeps the limb constantly extended as it hangs 
 over the angle of the inclined plane, and thus the 
 bone is brought into as accurate apposition as the na- 
 ture of the fracture permits. 
 
 DISLOCATIONS OF THE HEAD OF THE FIBULA. 
 
 Union with the tibia, — The fibula joins the tibia, 
 three quarters of an inch below the articulation of 
 the knee. Its head is inclosed in a capsular hgament, 
 which unites it to the tibia, to which it is also joined 
 through the greater part of its length by the inter- 
 osseous ligament. 
 
 Produced by violence or relaxation, — This bone is 
 liable to dislocation, both from violence and from 
 relaxation. I have only seen one case of it from vi- 
 olence, and in that instance it was connected with 
 the compound fracture of the tibia. 
 
 Briggs, of whose dislocation of the tibia I 
 
 have given an account, had, at the upper part of the 
 other leg, a compound fracture of the tibia, and dis- 
 location of the head of the fibula. An attempt was 
 made to save the limb, but the constitutional irrita- 
 tion ran so high, that amputation was obliged to be 
 performed ; which was done by my colleague, Mr 
 Lucas, and the man was restored to health. 
 
 Dislocations of the head of the fibula from relax- 
 ation, are more frequent than those which occur 
 
FRACTURES OF THE KNEE. 
 
 241 
 
 from violence ; the head of the bone, in these cases, 
 is thrown backwards, and is easily brought into its 
 natural connexion with the tibia, but it directly 
 again slips from its position. This state produces a 
 considerable degree of weakness and fatigue rn walk- 
 ing, and the person suffers much from exercise. As 
 in these cases there is a superabundant secretion of 
 synovia, and a distension of ligament, repeated blis- 
 tering is required to promote absorption ; and after- 
 wards a strap is to be buckled around the upper 
 part of the leg, to bind the bone firmly in its nat- 
 ural situation ; a cushion may be added behind the 
 head of the bone, to give it support, and at least 
 prevent the increase of the malady. 
 
 31 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 Structure of the joint ; bone, — The bones which 
 enter into the composition of the ankle-joint are the 
 tibia, fibula, and astragalus. The tibia forms an ar- 
 ticulating surface at its lower part, which rests upon 
 the astragalus ; there is a projection on the inner 
 side of the lower portion of this bone, which forms 
 the malleolus internus, and this part is articulated 
 with the side of the astragalus. The fibula projects 
 beyond the tibia at the outer ankle, and forms there 
 the malleolus externus, which has also an articulating 
 surface for the astragalus. The astragalus, which 
 is the superior tarsal bone, rises between the malle- 
 oli and the lower part of the tibia, and moves upon 
 it principally in flexion and extension of the foot. 
 
 Thus nature has strongly protected this part of 
 the body, by the deep socket formed by the two 
 bones of the leg, and by the ball of the astragalus 
 which is received between them. 
 
 Capsular ligament, — A capsular ligament, secret- 
 ing synovia on its internal surface, joins the tibia and 
 fibula to the astragalus. A strong ligament unites 
 the tibia to the fibula, but without any intervening 
 articular cavity, as the ligament proceeds directly 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 24 3 
 
 from one surface of bone and is received into the 
 other. 
 
 Peculiar ligaments. — The peculiar ligaments join- 
 ing the tibia and fibula to the tarsus, consist of a 
 deltoid ligament, which proceeds from the tibia to 
 the astragalus, os calcls, and os naviculare. The 
 fibula is united at its lower end bj three excessively 
 strong ligaments; one anteriorly from the malleolus 
 externus to the astragalus, one inferiorly to the os 
 calcis, and the third to the astragalus posteriorly ; 
 and it is the strong union of this bone which leads 
 to its being more frequently fractured than dislocat- 
 ed ; and even when the tibia is luxated the fibula 
 is fractured in two of the species of dislocation of 
 the ankle, and generally in all ; but when the tibia 
 is thrown outwards I have known the fibula escape 
 a fracture. 
 
 Directions of dislocatio^is, — I have seen the tibia 
 dislocated at the ankle in three different directions: 
 inwards, forwards, and outwards ; and a fourth spe- 
 cies of dislocation is said sometimes to occur, viz, 
 backwards: the foot has also been known to be 
 thrown upwards between the tibia and fibula, by 
 the giving way of the ligament which unites these 
 bones ; but this accident is only an aggravated state 
 of the internal dislocation. 
 
 SIMPLE DISLOCATION OF THE TIBIA INWARDS. 
 
 Dislocation inwards; symptoms, — This is the 
 most frequent of the dislocations of the ankle. The 
 tibia in this accident has its internal malleolus thrown 
 inwards, and so forcibly projecting against the integ- 
 uments as to threaten their bursting. The foot is 
 thrown outwards, and its inner edge rests upon the 
 
244 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 ground. It rotates easily on its axis. There is con- 
 siderable depression above the outer ankle, much 
 pain, some crepitus, often at three inches from the 
 lower joints of the fibula upwards, facility of lateral 
 motion of the foot, and considerable tumefaction. 
 
 Dissection, — Upon dissection, the internal appear- 
 ances are as follow. The end of the tibia rests 
 upon the inner side of the astragalus, instead of rest- 
 ing on its upper artlculatory surface ; and if the ac- 
 cident has been caused from jumping from a con- 
 siderable height, the lower end of the tibia, where 
 it is joined to the fibula by ligament, is split off, and 
 remains connected with the fibula, which is also 
 broken from two to three inches above the joint, 
 and the broken end of the fibula is carried down 
 upon the astragalus, occupying the natural situation 
 of the tibia. The malleolus externus of the fibula 
 remains in its natural situation, with two inches of 
 the fibula and the split portion of the tibia; the 
 capsular ligament attached to the fibula at the 
 malleolus externus, and the three strong fibular 
 tarsal ligaments, remain uninjured. 
 
 This accident generally happens in jumping from 
 a considerable height, or in running violently with 
 the toe turned outwards, when the foot being sud- 
 denly checked in its motion while the body is carried 
 forwards upon it, the ligaments on the inner side of 
 the ankle give way. It may also be caused by a fall 
 on that side, when the foot is fixed. 
 
 To distinguish a fracture of the fibula, the hand 
 must grasp the leg just above the ankle, and the 
 foot must be freely rotated ; when, the motion of 
 the foot being communicated to the fibula, pain will 
 be felt, and a crepitus perceived. 
 
 Mode of reduction. — For the reduction of this 
 dislocation, which cannot be too soon accomplished, 
 the patient is to be placed upon a mattress properly 
 
DISLOCATIONS OF THE ANKLE-JOINT. 245 
 
 prepared, and is to rest on the side on which the 
 injury has been sustained ; the surgeon is then to 
 bend the leg at right angles with the thigh, so as to 
 relax the gastrocnemii muscles as much as possible ; 
 and an assistant grasping the foot, must gradually 
 draw it in a line with the leg. The surgeon then 
 fixes the thigh and presses the tibia downwards, 
 thus forcing it upon the articulating surface of the 
 astragalus. Great force is required if the limb be 
 placed in the extended position, from the resistance 
 of the gastrocnemii; and it is pleasing to observe, 
 ^fter most violent attempts by others, a well-inform- 
 ed surgeon gently bend the limb, and, under a com- 
 paratively slight extension, return the parts to their 
 natural situation. 
 
 Treatment. — When the limb has been reduced 
 it is still to remain upon its outer side in the bent 
 position, with the foot well supported ; a many-tailed 
 bandage is to be placed over the part to prevent it 
 from slipping, and this is to be kept wet with an 
 evaporating lotion. Two splints are then to be ap- 
 plied ; and each is to have a foot-piece, to give sup- 
 port to the foot, prevent its eversion, and preserve 
 it at right angles with the leg. If much inflamma- 
 tion succeeds, leeches are to be applied to the parts, 
 and the constitution will require relief by taking 
 blood from the arm, and by attention to the bowels; 
 but I shall say no more on this subject until I de- 
 scribe compound dislocation of this joint. A person 
 who has sustained this accident may be removed 
 from his bed in five or six weeks, long straps of 
 plaster being passed around the joint to keep the 
 parts together, and he may be suffered to walk on 
 crutches; but from ten to twelve weeks will elapse 
 before he has the perfect motion of the foot ; and 
 much friction and passive motion will be required 
 
246 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 after the eighth week to restore the natural motion 
 of the joint. 
 
 SIMPLE DISLOCATION OF THE TIBIA FORWARDS. 
 
 Symptoms ; dissection^ — Tn this accident the 
 foot appears much shortened and fixed, the heel is 
 proportionably lengthened and firmly fixed, and the 
 toes are pointed downwards. The lower extremity 
 of the tibia forms a hard projection upon the upper 
 part of the middle of the tarsus, under the project- 
 ed tendons, and a depression is situated before the 
 tendon 'Achillis. On dissection the tibia is found to 
 rest upon the upper surface of the os naviculare and 
 OS cuneiforme internum ; quitting all the articulatory 
 surface of the astragalus, excepting a small portion 
 on its fore part, against which the tibia is applied. 
 The fibula is broken, and its fractured end advances 
 with the tibia, and is placed by its side : its malleolus 
 externus remains in its natural situation, but the fibu- 
 la is broken about three inches above it. The cap- 
 sular ligament is torn through on its fore part. The 
 deltoid ligament is only partially lacerated, and the 
 three ligaments of the fibula remain unbroken. 
 This accident arises from a fall of the body back- 
 wards whilst the foot is confined, or from that of a 
 person jumping from a carriage in rapid motion with 
 the toe pointed forwards. 
 
 Reduction ; treatment. — The treatment consists 
 in attending to the following rules. The patient 
 should be placed in bed on his back ; one assistant 
 grasps the thigh at its lower part and draws it to- 
 wards the body, another pulls the foot in a line a lit- 
 tle before the axis of the leg, and the surgeon pushes 
 the tibia back to bring it into its place. The same 
 
DISLOCATIONS OF THE ANKLE-JOINT. 247 
 
 principles are held in view in the mode of reduction 
 as in the former, with respect to the relaxation of 
 the muscles. A many-tailed bandage, dipped in an 
 evaporating lotion, must be lightly applied. The 
 local and constitutional treatment is the same as in 
 the dislocation inwards. 
 
 As to position, it is best to keep the patient with 
 the heel resting on a pillow, and to have a splint, 
 properly guarded, on each side of the leg, having 
 foot-pieces to keep the foot well supported at right 
 angles with the leg, so as to prevent the muscles 
 again drawing it from its place. As in five weeks 
 the fibula will be united, there will then be no danger 
 in taking the patient from his bed, and gentle passive 
 motion may be begun. 
 
 The application of a long splint on each side, with 
 a foot-piece to each splint, and this padded in such 
 a manner as to give the foot a direction inwards, out- 
 wards, or at right angles, according to the direction 
 of the dislocation, answers better than any other 
 mode of securing it. {Seo Plate.) When this is 
 applied, the foot cannot escape from the situation in 
 which the surgeon has placed it. 
 
 M. Dupuytren, of the Hotel Dieu, a very eminent 
 surgeon, has recommended a single splint, well cush- 
 ioned, along the outer or inner part of the leg, ac- 
 cording to the direction of the dislocation, and fast- 
 ened to the leg and foot by bandages. — See a plate 
 in Johnson^ s Medico- Chirurgical Review. 
 
 PARTIAL DISLOCATION OF THE TIBIA FORWARDS. 
 
 Symptoms. — This bone is sometimes partially 
 luxated forwards, so as to rest half on the os navic- 
 ulare, and half on the astragalus. The fibula in this 
 
248 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 accident is broken : the foot appears but little short- 
 ened, nor is there any considerable projection of 
 the heel. The following are the signs of this ac- 
 cident. The foot is pointed downAvards, and a 
 difficuhj is experienced in the attempt to put it flat 
 on the ground ; the heel is drawn up, and the foot 
 is in a great degree immovable. 
 
 Case. — The first case of this kind which 1 saw 
 was in a very stout lady, who resided at Stoke New- 
 ington, who had by a fall, as she said, sprained her 
 ankle. When I examined the limb I found the foot 
 immovably fixed, pointed downwards, and attended 
 with great pain just above the ankle. I attempted 
 to draw the foot forwards and bend it, but could not 
 succeed. Some years afterwards I saw this lady at 
 Bishop Stortford, walking upon crutches; her toe 
 was pointed, and she was unable to bring any other 
 part of the foot to the ground ; the degree of dis- 
 tortion was less than that which occurs in the com- 
 plete luxation of the bone forwards ; but all tension 
 having now been subdued, the nature of the injury 
 was more evident, though I should not have known 
 it decidedly, without an examination of a foot shown 
 to me by ray friend and late apprentice, Mr Tyr- 
 rell, who was so kind as to give me the parts which 
 were taken from a subject dissected at Guy's Hos- 
 pital. The articular surface of the lower part of 
 the titia was divided into two ; the anterior part 
 was seated upon the os naviculare, the posterior 
 upon the astragalus; these two articulatory surfaces, 
 formed at the lower extremity of the bone, had been 
 rendered smooth by friction. The fibula was found 
 fractured. (See Plate.) The result of this disloca- 
 tion clearly proves the necessity which exists in these 
 accidents, however slight they may at first sight ap- 
 pear, of not resting satisfied until the foot be return- 
 ed into its natural position, and restored to its mo- 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 249 
 
 tion; for, if neglected in the commencement, severe 
 inflammation and tension will prevent even a forci- 
 ble extension from being afterwards useful ; and if 
 still longer neglected, the changes in the state of 
 the muscles, and the union of the fractured fibula, 
 will preclude the possibility of a reduction, even 
 under the most violent attempts. The mode of re- 
 duction and after treatment will in no respect differ 
 from that required in the perfect dislocation of the 
 bone forwards, either in regard to the relaxation of 
 the muscles, the bandages, or the local and constitu- 
 tional treatment. 
 
 SIMPLE DISLOCATION OF THE TIBIA OUTWARDS. 
 
 Symptoms, — This luxation is the most dangerous 
 of the three ; for it is produced by greater violence, 
 is attended with more contusion of the integuments, 
 more laceration of ligament, and greater injury to 
 the bone, than ejther of the others. The foot is 
 thrown inwards, and its outer edge rests upon the 
 ground. The malleolus externus projects the integ- 
 uments of the ankle very much outwards, and forms 
 so decided a prominence that the nature of the in- 
 jury cannot be mistaken. The foot and toes are 
 pointed downwards 
 
 Dissection. — In the dissection of this accident, it is 
 found that the malleolus internus of the tibia is 
 obliquely fractured and separated from the shaft of 
 the bone. The fractured portion sometimes consists 
 only of the malleolus; at others, the fracture passes 
 obliquely through the articular surface of the tibia, 
 which is thrown forwards and outwards upon the 
 astragalus, before the malleolus externus. The 
 astragalus is sometimes fractured, and the lower 
 32 
 
250 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 extremity of the fibula is broken into several splint- 
 ers. The deltoid ligament remains unbroken, but 
 the capsular ligament is torn on its outer part. The 
 three fibular tarsal ligaments remain whole in most 
 cases, but when the fibula is not broken they are 
 ruptured. None of the tendons are lacerated, and 
 internal hgemorrhages scarcely ever occur to any 
 extent, as the large arteries generally escape inju- 
 ry. This accident happens either by the passage of 
 a carriage-wheel over the leg, or by a distortion of 
 the foot in jumping or falling. 
 
 Reduction. — The mode of reduction consists in 
 placing the patient upon his back, in bending the 
 thigh at right angles with the body, and the leg at 
 right angles with the thigh; the thigh is then grasp- 
 ed under the ham by one assistant, and the foot by 
 another; and thus an extension is made in the axis 
 of the leg, whilst the surgeon presses the tibia in- 
 wards towards the astragalus. The limb, in the 
 simple dislocation, is to be laid upon its outer side, 
 resting upon splints, with foot-pieces; and a pad is 
 to be placed upon the fibula, just .above the outer 
 ankle, and extending a few inches upwards, so as in 
 some measure to raise that portion of the leg and 
 support it; and to prevent the slipping of the tibia 
 and fibula IVom the astragalus, as well as to lessen 
 the pressure of the malleolus externus upon the 
 integuments where they have sustained injury. 
 
 Treatment. — The local and general treatment will 
 be the same as in the former cases, although more 
 depletion is required, as greater inflammation suc- 
 ceeds ; the greatest care is necessary to prevent the 
 foot from being twisted inwards, or pointed down- 
 wards, as either position prevents the limb from 
 being afterwards useful ; and this precaution is ef- 
 fected by having two splints, with a foot-piece to 
 each, padded and applied to the ankle on the outer 
 
DISLOCATIONS OF THE ANKLE-JOINT. 251 
 
 side of the leg. Passive motion should be given to 
 the joint in six weeks after the accident, when the 
 patient may rise from his bed, and be allowed to 
 walk upon crutches, unless impeded by great swelling 
 of the ankle. In the generality of these cases, from 
 ten to twelve weeks elapse before the cure is com- 
 plete. 
 
 COMPOUND DISLOCATION OF THE ANKLE-JOINT. 
 
 Opening into the joint, — These accidents take place 
 in the same direction as the simple dislocations, and 
 the bones and ligaments suffer in the same manner 
 as in those dislocations. The difference, therefore, 
 in these cases is, that the joint is laid open by a 
 wound in the integuments and ligaments, opposite 
 to the laceration of the skin, by which the synovia 
 escapes, and through which the ends of the bone 
 protrude; this opening in the integuments is gener- 
 ally occasioned by the bone, but sometimes by the 
 pressure of some uneven surface on which the limb 
 may have been thrown. 
 
 Local eff^ects, — The bones being replaced by the 
 means which are employed in the simple dislocation, 
 the effects of this accident upon the parts composing 
 the joint are as follow : The synovia, as 1 have 
 stated, escapes by a large wound through the lace- 
 rated ligament; in a few hours inflammation begins; 
 and when an additional quantity of blood is first de- 
 termined to the part, an abundant secretion issues 
 from this membrane, and is discharged through the 
 Avound; the ligaments participate in the inflammation, 
 as well as the extremities of the bones which enter 
 into the composition of the joint. The inflammation 
 of the internal secreting surface of the ligament, in 
 
252 DISLOCATIONS OF THE ANKLE-JoiNT. 
 
 about five days, proceeds to suppuration ; at first 
 but little matter is discharged, but it continues in- 
 creasing until it becomes very abundant, and the 
 lacerated parts of the ligaments and periosteum also 
 secrete matter. Under this process of suppuration, 
 the cartilages become partially or wholly absorbed, 
 but in general only partially ; for the ulceration of 
 the cartilage is a very slow process, attended with 
 severe constitutional irritation, and often lays the 
 foundation for exfoliation of the extremities of the 
 bones. When the cartilages are absorbed, granula- 
 tions arise from the surface of the bones and from 
 the inner side of the ligament, and these inosculate 
 and fill the cavity between the extremities of the 
 bones. Sometimes we find after accidents to joints, that 
 the adhesive process occurs at one part, and that the 
 cartilage is not absorbed ; whilst granulations are 
 formed at others, where the cartilage was removed 
 by ulceration; and I have seen, after inflammation 
 in joints, the cartilages remain, and their surfaces 
 adhere. 
 
 Neither this inosculation of granulations, noi* the 
 process of adhesion, leads to permanent anchylosis ; 
 for if passive motion be begun as soon as the parts, 
 from cessation of pain and inflammation, will permit, 
 motion will be restored, not always entirely, but with 
 very little diminution ; and the other joints of the 
 tarsus will acquire such an extent of motion as to 
 render the deficiency in the mobility of the ankle- 
 joint but little apparent. The aperture in the liga- 
 ment is filled by granulations ; and with respect to 
 the extremities of the bone, when they are joined 
 by ossific union, this junction is effected by the de- 
 posit of cartilage, and by a secretion of phosphate 
 of lime, in the usual manner in which bones are 
 formed and repaired. 
 
 Thus, then, the compound dislocation of the ankle 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 253 
 
 leads to inflammation over a very extensive secreting 
 surface; it produces an extended suppuration over 
 the lining of the joint, which occasions much con- 
 stitutional derangement : and, further, it hecomes 
 the source of an ulcerative process, more or less ex- 
 tensive according to the treatment pursued; by this 
 the cartilage is partly or wholly removed, and an 
 irritative fever is supported for a great length of 
 time ; and the ulceration sometimes extends over 
 the extremities of the dislocated bones, and leads to a 
 greatly augmented constitutional irritation, and to 
 protracted disease from exfoliation. 
 
 These local effects are accompanied by the common 
 symptoms of constitutional excitement. In two or 
 three days from the accident, or sometimes as early 
 as twenty-four hours, the patient complains of pain 
 in his back and in his head, showing the influence 
 of the accident on the brain and spinal marrow. 
 The tongue is furred: white, if the irritation be 
 slight; yellow, if greater ; and brown, almost to 
 blackness, if it be considerable. The stomach is dis- 
 ordered ; there is loss of appetite, nausea, and some- 
 times vomiting. Secretion ceases in the intestines 
 and in the glands connected with them, as the liver, 
 etc.; costiveness is therefore an attendant symptom. 
 
 The skin has its secretion stopped ; it becomes 
 hot and dry ; the kidneys also have their secretion 
 diminished : the urine is high coloured, and small in 
 quantity. The heart beats more quickly and the 
 pulse becomes hard, which is the pulse of consti- 
 tutional irritation from local inflammation, and in 
 great degrees of this excitement it becomes irregu- 
 lar and intermittent ; the respiration is quicker, in 
 sympathy with the quicker circulation ; the nervous 
 system becomes additionally affected, in high degrees 
 of local irritation ; restlessness, watchfulness, deli- 
 rium, subsultus tendinum, and sometimes tetanus oc- 
 
254 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 cur. These are the usual effects of local irritation 
 upon the constitution, occurring in different degrees, 
 :according to the violence of the injury, the irrita- 
 bility of the system, and the powers of restoration. 
 
 Cause of the symptoms ; principle of cure, — The 
 causes of the violence of these symptoms are, the 
 wound which is made into the joint, and the great 
 efforts required for its repair : for when there is no 
 vround, and the process of adhesion can unite the 
 part, little local inflammation or constitutional irrita- 
 tion can occur ; and if this be the cause of the vio- 
 lence of the symptoms, the principle in the treatment 
 of this accident is easily comprehended ; it consists 
 in closing the wound as completely as possible, to 
 ^issist nature in the adhesive process by which the 
 wound is to be closed, and to render suppuration and 
 granulation less necessary for the union of the opened 
 joint. 
 
 Is amputation required, — The first question which 
 arises upon this subject is the following: Is amputa- 
 tion generally necessary in compound dislocations of the 
 ankle? My answer is, certainly not. Thirty years 
 ago it was the practice to amputate limbs for this 
 accident ; and the operation was then thought abso- 
 lutely necessary for the preservation of life by some 
 of our best surgeons ; but so many limbs have been 
 saved of late years, indeed, I may say, so great a 
 majority of these cases exist, that such advice would 
 now be considered not only injudicious but cruel. It 
 is far from being my intention to state that amputation 
 is never required; I have only to observe, that in 
 the great number of these accidents the operation is 
 unnecessary. 
 
 But before I give the proofs of what I have ad- 
 vanced, I snail state the mode of treatment which is 
 to be pursued in these cases. 
 
 Treatment; artery divided. — When the surgeon 
 
DISLOCATIONS OF THE ANKLE-JOINT. 255 
 
 examines the limb, he finds a wound of greater or 
 less extent, according to the degree of the injury. 
 The extremity of the tibia projects if the dislocation 
 of the tibia be inwards; and the tibia and fibula are 
 protruded, if the dislocation of the former be at the 
 outer ankle. The ends of the bones are often cov- 
 ered with dirt from their having reached the ground. 
 The foot is loosely hanging on the inner or outer 
 side of the leg, according to the direction of the dis- 
 location. Sometimes, though very rarely, a large 
 artery will be divided; and it is surprising that the 
 posterior tibial artery so generally escapes laceration; 
 the anterior tibial being the only vessel I have 
 known to be torn. The arrest of haemorrhage is 
 the first object; and for this purpose, if the anterior 
 tibial artery be Avounded, it must be secured by liga- 
 ture. The extremity of the bone is to be washed 
 with warm water, as the least extraneous matter 
 admitted into the joint will produce and support a 
 suppurative process; and the utmost care should be 
 taken to remove every portion of it adhering to the 
 end of the bone. 
 
 Loose pieces of hone; integuments, — If the bone 
 be shattered, the finger is to be passed into the joint, 
 and the detached pieces are to be removed ; but 
 this is to be done in the most gentle manner possible, 
 so as not to occasion unnecessary irritation. If the 
 wound be so small as to admit the finger with difii- 
 culty, and if small pieces of bone can be felt, the 
 integuments should be divided with a scalpel, to 
 allow of such portions being removed without vio- 
 lence ; the incision should be so made as to leave 
 the joint with as much covering of integument as 
 possible. The integuments are sometimes nipped 
 into the joint by the projecting bone ; and then it 
 cannot be reduced without making an incision, to 
 allow the skin to be drawn from under the bone ; 
 
256 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 and when the edges of the incised wound are after- 
 wards brought together, no additional evil arises 
 from the extension of the wound. 
 
 Reduction, — The mode of reducing the bone is, 
 in other respects, similar to that which I have al- 
 ready described when speaking of simple disloca- 
 tion ; by bending the leg upon the thigh, so as to 
 relax the muscles before the extension is made. 
 When the bone has been reduced, a piece of lint is 
 to be dipped in the patient's blood, and applied wet 
 over the wound, upon which the blood coagulates, 
 and forms the most natural, and, as far as I have 
 seen, the best covering for the wound. A many- 
 tailed bandage i& then applied, the portions of which 
 should not be sewn together, but passed under the 
 leg, so that any one piece may be removed when it 
 becomes stiff ; and by fixing another to its end, the 
 application may always be renewed without any dis- 
 turbance to the limb: this bandage is to be kept 
 constantly wet with spirits of wine and water. A 
 hollow splint, with a foot-piece at right angles, is to 
 be applied on the outer side of the leg, in the dis- 
 location inwards, and the leg is to rest upon its outer 
 side : but in the dislocation outwards, it is best to 
 keep the limb upon the heel, with a splint and foot- 
 piece both upon the outer and the inner side : and 
 an aperture in the splint opposite to the wound. 
 
 Constitutional treatment. — In each dislocation the 
 patient's knee is to be slightly bent, to relax the 
 gastrocnemius muscle. The foot must be carefully 
 prevented from being pointed ; great care being 
 taken to preserve it at right angles with the leg, 
 otherwise the limb will be useless when the wound 
 is healed. The patient is to be placed on a mat- 
 tress, and a pillow is to reach from half way above 
 the knee to beyond tlie foot, and another is to be 
 
DISLOCATIONS OF THE ANKLE-JOINT. 257 
 
 rolled under the hip, to support the upper part of 
 the thigh-bone. 
 
 Blood-letting; purging, — Blood-letting must be 
 adopted J or not, according to the powers of the con- 
 stitution ; as it is necessary to bear in mind that the 
 patient has a great trial of his powers to undergo, 
 and will require throughout the process of restora- 
 tion, all the support which his strength can receive. 
 Purgatives must also be used with the utmost cau- 
 tion ; for there cannot be a worse practice, when a 
 limb has been placed in a good position, and adhe- 
 sion is proceeding, than to disturb the processes of 
 nature by the frequent changes of position which 
 purges produce ; and I am quite sure, that in cases 
 of compound fracture, I have seen patients destroyed 
 by their frequent administration. That which is be 
 done by bleeding, and emptying the bowels, should 
 be effected as soon as is possible after the accident, 
 before the adhesive inflammation arises ; after which 
 the liquor ammoniae acetatis, and tinctura opii, form 
 the patient^s best medicine, with a slight aperient at 
 intervals. 
 
 Secondary treatment. — If the patient complain of 
 considerable pain in the part, in four or five days, 
 the bandage may be raised to examine the wound ; 
 and if there be much inflammation, a corner of the 
 lint should be lifted from the wound, to give vent to 
 any matter which may be formed; but this ought to 
 be done with great circumspection, as there is a 
 danger of disturbing the adhesive process, if that 
 be proceeding without suppuration. By this local 
 treatment, it will every now and then happen that 
 the wound will be closed by adhesion ; but if in 
 a few days it be not, and if suppuration take place, 
 the matter should have an opportunity of escaping; 
 and the lint being removed, simple dressing should 
 be applied. After a week or ten days, if there be 
 33 
 
258 
 
 DISLOCATIONS OF THE ANKLE-JOIKT. 
 
 suppuration with much surrounding inflammation, 
 poultices should be applied upon the wound, leeches 
 in its neighbourhood, and upon the limb at a dis- 
 tance, and the evaporating lotion should be still em- 
 ployed ; but as soon as the inflammation is lessened, 
 the poultices should be discontinued, as they en- 
 courage too much secretion, and relax the blood- 
 vessels of the part, so as to prevent the restorative 
 process. 
 
 Result. — If the cure proceeds favourably, in a 
 few weeks the wound is healed with little suppura- 
 tion ; if less favourably, a copious suppuration takes 
 place, the wound is longer in healing, and exfoliation 
 of portions of the extremity of the bone still fur. her 
 retards the cure. The motion of the joint is not 
 always lost; it is sometimes in a great degree re- 
 stored ; but this depends upon the greater or less 
 extent of suppuration or ulceration. Under the 
 most favourable circumstances, three months gener- 
 ally elapse before the patient can walk with crutches; 
 in many cases, however, a greater length of time is 
 required : he bears upon the foot at different peri- 
 ods of time, according to the degree of injury sus- 
 tained, as in compound fracture, when adhesion is 
 not at first produced. In compound dislocations, of 
 course, the patient is longer in recovering. 
 
 I shall now proceed to state the cases which 
 have induced me to say that amputation, as a gen- 
 eral rule, is improper. 
 
 The circumstances which led me to doubt the 
 soundness of the opinion, which recommended in- 
 discriminate amputation, were these: — 
 
 Case, — I was, many years since, going into the 
 country with a friend of mine, and we met with a 
 surgeon in our journey who put this question : ' How 
 do you act in compound dislocations of the ankle- 
 joint T I do not recollect the reply, but he proceeded 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 259 
 
 to say, ' I have had a case of compound dislocation 
 of the ankle-joint under niy care, in which I told 
 the patient he must lose his limb : not approving 
 this advice, his friends sent for another surgeon, 
 who said he thought he could save it : the patient 
 placed himself under his care, and the man is re- 
 covering.' 
 
 About thirty years ago I received from Mr Lynn, 
 of Woodbridge, now Dr Lynn of Bury St Edmunds, 
 the astragalus of a man broken into two pieces, 
 which he had taken from a dislocated ankle-joint. 
 His letter is as follows: — 
 
 Case. — Dear Sir:— ^J. York, aged thirty-two 
 years, being pursued by some bailiffs, jumped from 
 the height of several feet to avoid them. The ti- 
 bia and a part of the astragalus protruded at the 
 inner ankle. 1 immediately returned the parts into 
 their natural situation. Suppuration ensued ; and in 
 five weeks a portion of the astragalus separated, 
 and another piece a week afterwards, which, when 
 joined, formed the ball of that bone. In three 
 months the joint was filled with granulations : it soon 
 afterwards healed, and the man recovered with a 
 good use of the hmb. 
 
 Your's, etc., 
 
 James Lynn. 
 
 I attended a compound dislocation of the ankle- 
 joint, in the year 1797, with Mr Battley, tlien prac- 
 tising as a surgeon in St Paul's Ghurch-yard, now 
 an eminent chemist and druggist in Fore-street. An 
 account of this case I shall give in the words of Mr 
 Battley. 
 
 (Jase, accompanied with insanity, — In the month 
 of September, 1797, a gentleman lodging in Duke^ 
 
260 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 street, Smithfield, in a fit of insanity threw himself 
 from a two-pair of stairs window into the street, his 
 feet first reaching the ground. He rose without 
 help, knocked violently at the outer door of the 
 house, and ascended the stairs without the least as- 
 sistance, bolted the door after him and got into bed. 
 He refused to open the door, and it was obliged to 
 be forced. A neighbouring surgeon was sent for, 
 who, on viewing the case, proposed an immediate 
 amputation, which was not acceded to by his friends; 
 but Mr Cooper and myself were requested to take 
 charge of the case. On examination there was 
 found a compound dislocation of the ankle-joint. 
 The tibia was thrown on the inner side of the foot ; 
 and when the finger was passed into the wound, the 
 astragalus was discovered to be shattered into a 
 number of pieces. The loose and unconnected por- 
 tions of bone were removed, and the tibia was re- 
 placed ; after which, lint, dipped in the oozing blood, 
 was wrapped around the lacerated parts, and the 
 limb was placed on its outer side, with the knee 
 considerably bent. The parts were ordered to be 
 kept cool by the frequent application of evaporating 
 lotion. 
 
 Mental symptoms improve. — The patient remain- 
 ed as quiet as could be expected from a person in 
 his state of mind until the third or fourth day, when 
 a considerable inflammation appeared in the joint, 
 and greatly increased the previous irritable state of 
 his constitution. Leeches, fomentations and poul^ 
 tices were applied to the limb, blood was taken 
 from the arm, purgative medicines were given, and 
 afterwards saline medicines with sudorifics. Extent 
 sive suppuration ensued, and continued for six weeks 
 pr two months, when it began to lessen, and healthy 
 granulations appeared on the whole wounded sur- 
 faces ; about this time the state of hig mind began 
 
DISLOCATIONS OF THE ANKLE-JOINT. 261 
 
 to improve, and it continued to amend as his leg ad- 
 vanced in recovery. At the end of four or five 
 months the suppurated parts had filled up, the joint 
 healed, and his mind recovered its natural tone. At 
 the end of nine months he returned to his employ- 
 ment, but the ankle-joint was stiff. In two years he 
 had so far recovered as to walk without the aid of 
 a stick; and at the end of three or four years was 
 able to pursue his avocations nearly as well as at any 
 former period of his life. 
 
 COMPOUND DISLOCATION OF THE TIBIA INWARDS, 
 
 Case. — I was sent for on August 11th, 1814, by 
 Mr Richards, of Seale, in Kent, to visit Mr Knowles, 
 a farmer, residing at Tytham Farm, aged forty-eight, 
 who having been thrown from his chaise against the 
 hinder wheel of a wagon, had dislocated the tibia 
 inwards, and fractured both the tibia and fibula. 
 
 Mr Richards, who was immediately called to the 
 case, reduced the dislocation, and endeavoured to 
 heal the wound by adhesion. When I saw Mr 
 Knowles, which was ten days after the accident, 
 the wound wore a favourable aspect. The dis- 
 charge was abundant, but not in a degree to excite 
 alarm ; and all I had to do was to praise the judg- 
 ment which had led to the preservation of the 
 limb, and to direct the continuance of the means 
 which had been employed for that purpose. 
 
 Before I ventured to state the case to the public 
 I wrote to Mr Richards, who informed me that Mr 
 Knowles's wound was perfectly healed, and that he 
 walks without the use of a stick, 
 
262 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 COMPOUND DISLOCATION OF THE TIBIA OUTWARDS. 
 
 For the following details I am obliged to Mr 
 Rowley, apprentice to Mr Chandler, Surgeon at St 
 Thomas's Hospital. 
 
 Case ; integuments confined between the bones, — 
 
 Dear Sir: — In answer to your inquiries, I beg 
 leave to forward jou the particulars of Elizabeth 
 Chisnell's case, who was admitted into St Thomas's 
 Hospital, on Saturday, May 29, 1819, with a com- 
 pound dislocation of the left ankle-joint outwards, 
 occasioned by her slipping from the foot-path into 
 the road-way. The wound communicating with the 
 Joint was situated upon the outer part of the leg, 
 and was about four inches in extent, through which 
 the fibula projected two inches, but it was not frac- 
 tured; the ligaments connecting the malleolus ex- 
 ternus and the astragalus were lacerated. From 
 the inclination of the sole of the foot inwards, the 
 whole articulating surface of the joint was so dis- 
 placed as to allow two fingers to pass readily across; 
 and on examination, I found the extremity of the 
 tibia fractured. The parts were easily returned to 
 their original situation by extending the foot, the 
 leg having been first bent upon the thigh. During 
 the reduction, the integuments became confined be- 
 tween the malleolus externus and the astragalus, so 
 as to require an incision upwards by the side of the 
 fibula, to accomplish the extrication; that being 
 effected, its lips were brought together by four 
 sutures, and straps of adhesive plaster. Splints 
 were applied ; and, to subdue the consequent inflam- 
 mation, the common application was used. 
 
 June 1. The adhesive plasters and sutures were 
 removed, because the wound and adjacent soft parts 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 263 
 
 around the ankle were in a sloughing state. Poultices 
 of linseed meal were ordered to be used daily. 
 
 June 5. The sloughs are separated; the sore is 
 granulating; the discharge profuse. A collection of 
 matter has formed upon the inside of the leg, which 
 was discharged by puncture. The wound Was or- 
 dered to be dressed, and a roller was gently applied. 
 The constitution during this time was but little af- 
 fected. Bark and 'jDorter were ordered by Mr 
 Chandler. 
 
 August 7. The wounds are almost healed. The 
 girl sits up daily, and in a few days she will be al- 
 lowed to walk. 
 
 During the progress of her cure, the constitutional 
 disturbance has been trifling, indeed, not more than 
 in some favourable cases of simple fracture : it may 
 be also well to observe that her bowels were regular 
 during the whole time, so as to preclude the neces- 
 sity of any laxative medicine, nor did she take any 
 other medicine than the bark. 
 
 I remain your's, etc., 
 
 Southwark. R. Rowlev. 
 
 CdMPOUND DISLOCATION OF THE TIBIA INWARDS. 
 
 The following accident I was requested to visit, 
 by Mr Clarke, surgeon, Great Turnstile, Lincoln's 
 Inn Fields, who had the kindness to send me the 
 particulars. 
 
 Case, — ^ Mr George Caruthers, aged tw^enty-two 
 years, had a compound dislocation of the ankle-joint 
 inwards, with frac(ure of the tibia, on October the 
 6th, 1817. The accident was occasioned by the 
 overturning of a stage coach at Kilburn, from whence 
 he was brought to his house at Lambeth. The end 
 
264 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 of the tibia projected through the integuments of 
 the inner ankle, to the extent of from two by three 
 inches, and the bone was tightly embraced by the 
 skin. The tibia was fractured, only a small portion 
 of it remaining attached to the joint ; the bleeding 
 was stated to have been copious, but it had subsided 
 before Mr Clarke saw him. The fibula was badly 
 fractured. 
 
 Reduction; constitutional treatment, — For the re- 
 duction of the protruded parts it became necessary 
 to make an incision in the integuments, to loosen 
 them on the tibia; and when the bone was restored 
 to its place^ simple dressings were spread over the 
 w^ound. Splints and a many-tailed bandage, wetted 
 with an evaporating lotion, were applied, and the 
 limb was placed in the slightly bent position upon 
 a quilted pillow* Bleeding was employed, gentle 
 purgatives given, and saline medicines. Symptoms 
 of great constitutional excitement naturally arose 
 from so severe a local injury. Abscesses formed on 
 the leg, and some exfohations materially retarded 
 the cicatrization of the wound, producing also con* 
 siderable exhaustion of the patient's strength. 
 Openings were made into the abscesses, adhesive 
 straps were placed over the wounds, and lotions 
 were applied on linen, under oiled silk, which pre- 
 served the parts constantly wet. Bark and wine 
 were given with occasional aperients. Mr Caruthers 
 left town on October the 6th, 1818, having then a 
 small opening on each side of the limb, and suffering 
 occasional pain ; but his general health had been 
 good for some months previous. In January last, a 
 considerable portion of bone came away, and the 
 sore immediately healed and has so continued ; he 
 has been ever since free from pain, and is now in 
 better health than before the accident. He employs 
 himself in superintending a farm, around which he 
 
DISLOCATIONS OP THE ANKLE-JOINT. 
 
 265 
 
 walks with one crutch and a stick, but if the ground 
 be level, with a stick only ; and the limb is becoming 
 daily more and more useful.* 
 
 To Mr Somerville, of the Stafford Infirmary, I 
 am indebted for the following letter. 
 
 Cases. — Dear Sir: — I take shame to myself for 
 not having answered your obliging queries sooner, as 
 to the cases of compound dislocation of the ankle 
 which have fallen under my care ; but the fact is, I 
 wished to give you my answer in the most authentic 
 form, by sending you a transcript of the cases from 
 the minute books of the Infirmary; but after having 
 caused the most diligent search to be made for 
 them, I have now the mortification to learn that 
 they are no where to be found ; you will allow me 
 therefore to plead this circumstance as the real 
 cause of my seeming inattention to your wish, and at 
 the same time to offer it as an apology for the want of 
 a more detailed account. I have a distinct recollection 
 of two cases, though not of the manner in which the 
 accidents were produced. The first occurred about 
 fifteen years ago, the other a few. years later: they 
 were both dislocated inwards, and were both dis- 
 charged cured ; the one at the end of the fifth, the 
 latter not till the seventh week. In the first case 
 the wound, which was lacerated so as to form a flap, 
 healed by the first intention ; in the latter it was 
 kept open by the discharge, which was at first puru- 
 lent, afterwards limpid ; but no untoward symptom 
 supervened during the cure. The treatment in both 
 cases was as follows. ^ 
 
 * In June, 1822, I wrote to Mr Caruthers to inquire how he 
 proceeded ; and his answer was, that he could walk three or 
 four miles easily, and eight if required; and that he would not 
 exchange his injured leg for a wooden one for the whole of 
 Europe. — A. C. 
 
 34 
 
266 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 Use of adhesive straps, 8{c, — After the reduction 
 of the bone, the patient was placed upon his side, 
 with the limb in a bent position ; no h'gature was 
 used, but the lips of the wound were nicely approxi- 
 mated, and retained in situ by straps of sticking 
 plaster, of ample length, yet not sufficient to encircle 
 the limb, lest they should, by causing undue pressure 
 on the supervening tension, excite too much inflam- 
 mation, and, in consequence, suppuration. To obvi- 
 ate, however, both tension and inflammation as much 
 as possible, a plaster, spread moderately thick with 
 Kirkland's defensative, was placed round and in easy 
 contact with the ankle, and over the whole a tailed 
 bandage was loosely applied. A brisk purgative 
 was given on the following morning, and low diet 
 was ordered till all danger of inflammation was over. 
 The adhesive plaster was removed on the second or 
 third day, and was not renewed; but a pledget of 
 melilot digestive was placed over the wound, and the 
 defensative bandage applied as before. The subse- 
 quent treatment consisted merely in the daily renewal 
 of the pledget, and the proper adjustment of the 
 plaster and bandage, both of which were gradually 
 drawn tighter round the limb, in proportion as the 
 danger of inflammation became less, and this opera- 
 lion was performed with the view not only to give 
 stability to the joint, but also to facilitate the pro- 
 ofress of cicatrization. 
 
 The use of the plaster after the manner above 
 mentioned, may, at first, appear to you a singular 
 practice, but, by being spread very thick, it seldom 
 requires a renewal during the period of cure, unless 
 the discharge from the wound should be so great as 
 to render a change necessary ; but if it should not, 
 it will appear obvious that there can be no necessity 
 for disturbing or mftving the limb from its original 
 position, the retention of which 1 have ever consid- 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 267 
 
 ered, in cases both of compound dislocations and 
 compound fractures, of the highest importance to 
 facihtate the cure. The plaster is composed of two 
 parts of emp. plumbi, and one each of oil, vinegar, 
 and chalk finely powdered ; and I have ever found 
 it a most powerful repellent in all cases of violent 
 local inflammation. 
 
 I am, dear Sir, 
 Your obliged and most obedient servan 
 Stafford^ Aug, 31, 1819. Henry SomerviLle. 
 
 COMPOUND DISLOCATION OP THE TIBIA OUTWARDS. 
 
 The following case I received from Mr Scarr, 
 surgeon, of Bishop's Stortford. 
 
 Case, — Dear Sir: — John Plumb, the subject of 
 the? following statement, was in the thirty-eighth year 
 of his age when his accident took place, which was 
 about seven years ago. He was in the act of ascend- 
 ing a ladder with a sack of oats on his shoulders, 
 and had mounted ten feet from the ground, when the 
 ladder slipped from under him, and he was precipi- 
 tated to the ground, lighting on his feet, but still sus- 
 taining the sack of oats on his shoulders. I was 
 passing about two hundred yards from the place at 
 the moment when the accident happened, and was, 
 consequently, in immediate attendance. On the re- 
 moval of his stocking, I found that the tibia and fi- 
 bula had penetrated through the integuments at the 
 outer ankle, and were lying on the outside of the 
 foot ; the articulatory surface of the astragalus had 
 penetrated through the integuments of the inner 
 ankle, showing, on a view of the case, the foot nearly 
 reversed, the bottom of the foot being placed where 
 the side of the foot is naturally situated. The 
 
268 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 wounds through which the surfaces of the bone had 
 penetrated being free, soon determined me in the 
 line of conduct 1 should pursue, viz, to immediately 
 reduce the joint to its natural situation with as little 
 violence as possible, and this was effected with much 
 less difficulty than I expected ; the wounds were 
 brought close by adhesive straps, the limb placed 
 on its outer side, and cloths applied constantly 
 moistened with lotion of acetate of lead. The 
 patient was then bled to about sixteen ounces ; 
 a saline diaphoretic mixture was given, and attention 
 was paid to his bowels ; in short, the antiphlogistic 
 plan was persevered in with due regard to his consti- 
 tutional powers: abscesses took place which were 
 opened in the most favourable points, and after five 
 and twenty weeks the man was convalescent ; union 
 of the articulatory surfaces took place, the wounds 
 healed, and the patient became able to walk ; he 
 could not bear much on his foot to work till about 
 twelve months after the accident, from which time 
 he has constantly been labouring in his situation with 
 Mr Starkis, a gentleman of respectability of this 
 town, and continues to do so at this time. 
 
 It is my intention to send this man up to you, that 
 you may have a full confirmation of the accident 
 from him, as well as from Mr Cribb, my present 
 assistant, who was present at the time of my being 
 called to him, being at that time with his father, Mr 
 Cribb, surgeon, of this town, whom I consulted on 
 the case at the time of the accident, as well as during 
 its continuance. Trusting that the statement and 
 result may prove satisfactory to your inquiry, 
 
 I am, dear Sir, 
 
 Your most obedient, 
 j^ugust i6th, 1819. R. T. Scarr. 
 
 This man was sent to town, and I had an oppor* 
 
DISLOCATIONS OP THE ANKLE-JOINT. 
 
 2G9 
 
 tunitj of witnessing the happj result of Mr Scan's 
 skill and attention. — A. C. 
 
 COMPOUND DISLOCATION OF THE TIBIA INWARDS. 
 
 For the following most interesting case I am in- 
 debted to a very excellent surgeon, Mr Abbott, at 
 Needham Market, Suffolk. It is an admirable proof 
 of what may be accomplished in these cases by ex- 
 traordinary skill and attention. 
 
 Case; amputation refused. — April 2.5, 1802, Mr 
 Robert Cutting, a butcher by trade, near seventy 
 years of age, corpulent, very intemperate, and sub- 
 ject to gout from his youth, in a dispute, when in a 
 state of intoxication, was thrown violently to the 
 ground, and suffered a compound dislocation of the 
 tibia at the ankle-joint ; the end of it was forced 
 through the integuments nearly four inches ; the 
 wound was large and semicircular; in the struggle 
 to stand erect, he rested his weight upon the end of 
 the bone, which was covered with sand and dirt ; 
 the cavity of the articulating surface of the joint 
 was filled with blood and sand, the fibula fractured 
 a few inches above the joint, and the foot completely 
 turned outwards ; in this state he was placed in an 
 open cart, full four miles from his residence, Somers- 
 ham, in Suffolk, about seven miles from Ipswich. 
 It was near five hours from the time the accident 
 took place, before surgical assistance arrived, in the 
 middle of a cold night. I attended with a well-in- 
 formed pupil of mine, Mr John Jefferson, who has 
 now^ resided many years at Islington. A case so for- 
 midable, a large wound, the connecting ligaments 
 lacerated, the surfaces of the articulating parts long 
 exposed and much injured, led me to conclude, that 
 
270 DISLOCATIONS OF THE ANKLE-JOINT* 
 
 it would be impossible to save the limb, in a consti- 
 tution so disordered ; however, no persuasion could 
 prevail with a mind obstinate and inflexible ; he 
 would not submit to amputation. The surfaces were, 
 as carefully and expeditiously as possible, made clean 
 with warm water ; the reduction was easily accom- 
 plished, the lacerated parts properly placed, and the 
 edges of the wound nearly brought in apposition, 
 without stitches or adhesive plasters; the limb was 
 laid upon a proper sized thin board, excavated so 
 as to take the form of the leg, with an opening to 
 receive the outer ankle ; this was well padded, the 
 foot-piece raised somewhat higher than the leg ; 
 plaits of lint, wetted, with the tinctura benzoini 
 composita, were placed over the wound, which, in a 
 few hours, formed a hard sealed cap, of a circum- 
 ference that effectually excluded the air ; a folded 
 flannel bandage was applied over the limb from the 
 foot to the knee; and the leg was laid in a flexed 
 position. V. S. 3 xij. A saline purge was given 
 every two hours until his bowels were relieved ; 
 milk broth only was allowed for his support. 
 
 Sixteen hours after the dressing his bowels had 
 been properly evacuated, and he was tranquil. Heat 
 moderate; a moisture was spread over the whole 
 surface ; pulse 8G ; and he had some hours of re- 
 freshing sleep. 
 
 April 27th. A little heat was raised ; sleep in- 
 terrupted; pulse 96; surface moist; darting unea- 
 siness about the ankle and foot; no thirst; bowels 
 kept cool, and the same support continued : common 
 saline medicines were resorted to every three hours. 
 Upon unfolding the flannel some swelling appeared 
 to surround the ankle : a little gleety discharge had 
 escaped from beneath the lower part of the dress- 
 ing. The inflammation did not appear to be more 
 than might be wished. Lint, wetted with the tine- 
 
DISLOCATIONS OP THE ANKLE-JOINT. 271 
 
 ture, was applied so as to prevent the escape of any 
 discharge ; and to seal the covering more securely, 
 six leeches were applied at a small distance from 
 the inflamed part : the wounds bled freely, and 
 afforded ease. 
 
 April 29th. He passed a good night ; heat less- 
 ened; free from thirst; limb easy without tension; 
 and the inflammation about the ankle abated. 
 
 April 30th. A quiet, good night; and every 
 symptom appeared favourable. 
 
 May 2nd. The pulse had regained the natural 
 standard. Upon examining the ankle, a small quan- 
 tity of pus escaped from the lower part of the 
 dressing. Lint, wetted in the same manner, to glue 
 the covering securely, was used. From this time 
 my visits became less frequent. The tincture wa& 
 used whenever the surface of the cap appeared to 
 lose its hold. At the end of ten weeks he was 
 taken from his bed daily, and laid upon a sofa. 
 After the first stage of symptoms, healthy actions 
 were established, and he became perfectly healthy. 
 Between the third and fourth month the cap or 
 dressing was taken from the ankle ; the wound was 
 completely cicatrised; a small abraded surface ap- 
 peared over the cicatrix, occasioned by incrustcd 
 matter. Simple dressings rendered the wound 
 sound and well in a few days. During the time of 
 the curative process the faetor was very trifling. 
 The thickening upon the wound was not more than 
 might have been expected : the form of the joint 
 was natural, and bore the appearance of being per- 
 fect. At the end of five months he was allowed to 
 go on crutches, to place the foot on the ground, and 
 to use such weight or pressure as his feelings could 
 admit. For many months an application of oil, ob- 
 tained from the joints of animals, was made use of 
 night and morning, for an hour each time, by fric- 
 
272 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 tion ; and to please himself, the patient plunged his 
 foot and ankle in the paunch of an ox. With these 
 means an imperfect motion in the joint was recov- 
 ered, and within twelve months he could walk with- 
 out a stick; he pursued his occupation, and lived to 
 the age of eighty-three. The last ten years he 
 was able to walk as well as ever he could. Mr 
 Jefferson will be able to confirm this statement. 
 
 Since the case of Cutting, I have uniformly, in a 
 variety of compound fractures, followed the curative 
 plan of treatment by the first intention. Mr George 
 Lynn, of Woodbridge, my son-in-law, a deserving 
 character in his profession, and the late Launcelot 
 Davie, of Bungay, were pupils of mine, and attended 
 many cases with me of a very formidable nature, 
 successfully treated by the same means. A com- 
 pound fracture of the ihigh, attended with consider- 
 able comminution of the bone, occasioned by a 
 wagon, loaded with twenty-five combs of barley, 
 passing over it, was perfectly restored by the same 
 treatment within six months. 
 
 I have the honour to be. 
 Your very much obliged and faithful servant, 
 
 JYeedham Market^ Robert Abbott. 
 
 SufolL 
 
 COMPOUND DISLOCATION OF THE TIBIA OUTWARDS. 
 
 Mr Ransome, surgeon at Manchester, obliged me 
 with the following case : — 
 
 Case in a strumous habit, — Dear Friend : — In 
 reply to thy letter, requesting to know the result of 
 my experience in cases of compound dislocation of 
 the ankle-joint, I have great pleasure in stating the 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 273 
 
 following case, which has recently occurred. I lake 
 the liberty of briefly describing it, as there were 
 some circumstances connected with it which did not 
 afford the most flattering prospect. 
 
 In the autumn of last year, a female, aged about 
 forty-five years, of a strumous and leucophlegmatlc 
 habit, having a troublesome cough and occasional 
 dyspnoea, fell from a high stool, and pitching upon 
 the left foot, caused a compound dislocation of the 
 ankle-joint. The foot was luxated inwards, the ex- 
 ternal malleolus was fractured, a lacerated wound 
 extended half round the joint and exposed the pro- 
 truding portion of the malleolus, laying the cavity 
 of the joint so open as freely to admit the finger, 
 and through it the synovial fluid escaped. 1 remov- 
 ed a portion of detached bone, reduced the disloca- 
 tion, and brought the integuments together very 
 slightly; the limb was laid upon the side, and kept 
 constantly cool with the saturnine lotion combined 
 with the liq. ammon. acet. A small opiate and a 
 demulcent mixture were given at intervals. From 
 the constitution of my patient I must confess I fear- 
 ed the most serious consequences, but I was happily 
 mistaken. Little inflammation followed, the wound 
 healed without a copious suppuration, and she is now 
 perfectly recovered, and walks to considerable dis- 
 tances. She was confined in a very small room, and 
 in a part of the town not very famous for the purity 
 and salubrity of its atmosphere. 
 
 Manchester, I am, your's respectfully, 
 
 October 227id, 1818. T. A. Ransome. 
 
 35 
 
274 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 COMPOUND DISLOCATION OF THE TIBIA INWARDS, AND 
 FRACTURE OF THE THIGH. 
 
 To Mr Chandler, of Canterbury, Surgeon to the 
 Kent and County Hospitals, I am obliged for the 
 following communication. 
 
 Bengal Street^ Canterbury, 
 My dear Sir: — I take the earliest opportunity of 
 complying with your request, to furnish you with 
 the result of my observations on compound disloca- 
 tion of the ankle-joint. 
 
 You will perhaps think it singular, that this divi- 
 sion of Kent, which our hospital practice embraces, 
 should be so destitute of cases of this nature, that 
 only two have occuried, either in my private prac- 
 tice or at our hospital, or to my coadjutor, Mr Fitch, 
 during the last fifteen years; and as these are the 
 only instances, I fear it would be deemed presump- 
 tuous in me to form an opinion upon the method to 
 be adopted, and the probable termination of the 
 generality of such accidents. The favourable result, 
 however, of these two cases, admitted under my 
 care in the Kent and County Hospitals, was so firmly 
 impressed on my memory, as to confirm unequivo* 
 cally the precepts you early inculcated, to save the 
 limb if possible in compound dislocations of the 
 ankle-joint. In accomplishing so desirable a point, 
 the advantages obtained in a country hospital, will, I 
 apprehend, bear a great proportion in the scale of 
 success, compared with the circumstances ol' a pa- 
 tient placed in a crowded infirmary of a large manu- 
 facturing town, or in the metropolis: the constitution 
 will, in general, be less impaired by excess, poverty, 
 and other evils; whilst purity of air in large venti- 
 
DISLOCATIONS OF THE ANKLE-JOINT. 275 
 
 lated wards will materially contribute towards re- 
 covery, even if the injury to the joint be extensive : 
 we consequently can be permitted to take greater 
 latitude with our curative means upon an injured 
 joint, relying on the powers of nature, without 
 being under the immediate necessity of anticipating 
 the issue resulting from unfavourable habits, and in 
 situations inimical to disease. 
 
 My notes furnish me only with the brief details of 
 one case. 
 
 Cases, — July, 1818. A bricklayer, aged thirty- 
 six, of slender make, but of good constitution and 
 of sober habits, fell from a height of between thirty 
 and forty feet upon loose materials for building, and 
 alighting upon his feet, received a very severe shock, 
 attended with comatos3 symptoms, a fracture of the 
 right thigh, a considerable contusion and laceration 
 of the left ankle-joint, accompanied with a disloca- 
 tion of the bones inwards, the tibia resting upon the 
 inner side of the astragalus; a portion of the lower 
 extremity of that bone was fractured ; the fibula 
 was broken about three inches above the malleolus 
 externus, and the surrounding ligaments of the joint 
 were lacerated; little difficulty was found in reduc- 
 ing the dislocation, and in replacing the fractured 
 bones ; but in consequence of the violent injury done 
 to the joint, a question arose on the propriety of 
 amputation. As the man had enjoyed uninter- 
 rupted health, and was of the constitution and 
 habit least liable to the attack of inflammatory af- 
 fection, I ventured to give him a chance of saving 
 the limb. A union by the first intention of the ex- 
 ternal wound, as far as practicable, was attempted, 
 and the limb was laid in the most convenient, yet 
 relaxed and easy posture. Evaporating lotions were 
 applied, and the strictest antiphlogistic system en- 
 joined. 
 
276 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 Symptoms; disposition to gangrene, S^c, — Consid- 
 erable inflammatory symptoms ensued, with a co- 
 pious discharge of synovial fluid; the limb and 
 joint were niuch swollen, and it became necessary 
 to vary the treatment by applying warm spirituous 
 and opiate fomentations and poultices, which appear- 
 ed more genial to the patient's feeling, and were 
 therefore continued. A disposition of the contused 
 parts to gangrene appearing, muriatic acid was add- 
 ed to the cataplasm, and the medicines were chang- 
 ed according to the eflect produced on the constitu- 
 tion by symptomatic irritation accruing from the dis- 
 charge. The disposition to gangrene ceased soon 
 after the application of the muriatic acid : from 
 this medicine 1 have often derived, in similar cir- 
 cumstances, great advantage. After the first fort- 
 night my hopes of saving the limb were confirmed 
 by the abatement of pain and swelling, and by the 
 mitigation of the constitutional symptoms, the colour 
 of the discharge improving, with less synovia, and 
 granulations arising round the wound. The patient 
 continued gradually to improve till about the tenth 
 week, when the wound was nearly healed. This 
 man was discharged in fourteen weeks quite well, 
 although with rather an unsightly and partially stiff 
 joint. 
 
 The other case, of which I have notes, was also 
 a compound dislocation of the ankle-joint, but with- 
 out the degree of injury sustained in the former: 
 this patient was also discharged cured. 
 
 I have now to apologise for trespassing on your 
 time, in the attempt to give you the details of cases 
 that might have been interesting if not so carelessly 
 drawn up; but as my notes were only penned to 
 furnish me with hints for the future, from the dis- 
 tance of time the minutes have escaped my memory, 
 and [ doubt that they are too inaccurate and too 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 277 
 
 inconclusive to afford you any information; but the 
 occasion serves me as a pretext for assuring you how 
 much 
 
 I remain, dear Sir, 
 Your very faithful and obh'ged servant, 
 
 W, Chandler. 
 
 Royal JYavy Hospital, Plymouth ; 
 - August ]Mh, 1819. 
 
 My dear Sir ; — In answer to your letter inquir- 
 ing of me whether I had had any cases of com- 
 pound dislocation of the ankle-joint, with their 
 treatment and their result, I beg leave to acquaint 
 you, that several of the above nature have fallen 
 under my care and observation during the eight 
 years I served as assistant-surgeon, and tlie six- 
 teen years I have been the first surgeon of this hos- 
 pital ; during nearly the whole of which period the 
 country was engaged in active naval warfare, and, 
 consequently, this hospital was in the constant re- 
 ceipt of important surgical cases ; and I have also 
 witnessed a few more from other causes. The re- 
 sult of my observations has been, that in cases of 
 compound dislocation of the ankle-joint there is not 
 only a chance of saving the limb, but of that limb 
 being at a future time usefuL The dislocated bones 
 should be replaced in their situation with as little 
 violence and injury as possible to the surrounding 
 parts; and should any difficulty arise in returning 
 the bones, from the smallness of the wound,! freely 
 enlarge it with a scalpel. After they are replac- 
 ed, I lay the limb perfectly extended on very soft 
 cushions of lint arranged on three pillows, the centre 
 
278 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 one reaching the length of the leg, the upper one 
 crossing under the ham and inl'erior part of the 
 tliioh, and the lower one crossing under the heel, 
 having previously placed on these pillows a hne 
 sheet, folded so often that when its edges are turned 
 in, it may protect the limb from the pressure of the 
 splints: under this sheet are laid several slips of 
 calico, about eighteen inches long and three broad. 
 When the limb is thus comfortably placed, taking 
 care to fill up every hollow with lint, I draw the 
 edges of the lacerated integuments as near together 
 as they can be brought by the gentlest means, re- 
 taining them with small slips of adhesive plaster, 
 and covering this with pledgets of soft lint; this 
 done, 1 direct the foot to be kept very steady, whilst 
 I ultimately place the slips of calico, already de- 
 scribed, over the whole length of the extremity, 
 draw up the edges of the sheet, and apply on each 
 side of the leg, outside of all, a very broad splint 
 of common deal, of such length as to reach at least 
 three inches below the foot, and as far above the 
 knee-joint ; these splints are well covered with lint, 
 and then so secured as to afford support (but no 
 pressure) to the whole of the leg and foot, the 
 breadth of the splint materially contributing to the 
 latter purpose, and allowing the tape to pass around 
 the limb without injury. The foot ought also to be 
 prevented from diopping, or altering in the least 
 degree its position, by passing a broad tape through 
 a hole in the lower ends of the splints, which tape 
 is to be tied, securing between the sole of the foot, 
 which will effectually keep it up, and securing it 
 further by a stirrup bandage; when every thing is 
 thus accomplished, the foot and leg are directed to 
 be kept constantly wet with cold water, taking care 
 not to sponge it immediately over the wound. The 
 subsequent treatment of the patient must depend 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 279 
 
 upon the symptoms which arise. This is the plan 
 I pursue in those cases where there is a probability 
 of saving the limb. I have seen more than one 
 case, where, after great perseverance and risk, the 
 limb has been saved, but when the wounds were all 
 healed, has been found of little or no use; for ex- 
 ample, a man who had had a compound dislocation 
 of the ankle in the West Indies, from whence he 
 was sent to England as an. invalid, became my pa- 
 tient in this hospital, and when received, after the 
 lapse of thirteen months from the accident, had the 
 whole of the lower head of the tibia (although in 
 its proper situation) exposed, black, and carious, 
 which at the end of a year and a half came away, 
 more than three inches in length ; and at the expir- 
 ation of three years and a half from the injury, he 
 quitted the hospital, with the wound healed, but 
 with a shortened, deformed, and anchylosed leg, 
 liable to break out on the slightest injury. The 
 great question to be decided, however, in these ac- 
 cidents is, in what cases the surgeon is justified in 
 attempting to save the limb, and in what cases im^ 
 mediate amputation is necessary. From all I have 
 seen, I should not hesitate to advise the immediate 
 removal of the limb, where the lower heads of the 
 tibia and fibula are very much shattered; where, 
 together with the compound dislocation of these 
 bones, some of the tarsal bones are displaced and 
 injured; where any large vessels are divided, and 
 cannot be secured without extensive enlargement 
 of the wound and disturbance of the sol't parts; 
 where the common integuments, with the neigh- 
 bouring tendons and muscles, are considerably torn ; 
 where the protruded tibia cannot by any means be 
 reduced ; and where the constitution of the patient, 
 being enfeebled at the time of the accident, is not 
 
280 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 likelj to endure pain, discharge, or long confine- 
 ment. 
 
 I have a fine specimen of injury done to the ti- 
 bia, fibula, and tarsal bones, from a compound dis- 
 location, requiring amputation ten months after the 
 accident, which occurred in the Mediterranean; it 
 is very much at your service to see or copy, but I 
 must beg of you to have the goodness to return it, 
 as it belongs to a collection of bones which I have 
 been forming for the last twenty years. (See Plate?) 
 I am your's, etc., 
 
 Stephen L. Hammick. 
 
 I beg Mr Hammick to accept my thanks for his 
 excellent letter. 
 
 The following case shows that under the most 
 unfavourable circumstances, these injuries are not 
 destructive of life, in persons of good constitutions. 
 
 Winchester, August Isi, 1819. 
 My dear Sir : — In answer to your enquiries con- 
 cerning my practice in compound dislocations of the 
 ankle-joint, I can only say, that in almost every case 
 that I have witnessed, the general injurj^ has been 
 so great as to require amputation. I recollect but 
 one case in which amputation was not necessary ; it 
 was that of a patient at a distance, to whom I was 
 called by a neighbouring practitioner about five 
 weeks after the accident, ' to reduce a dislocation 
 of the ankle, as he had reduced the fracture of the 
 fibula.' I saw the patient, but the fractured fibula 
 was so firmly united, that a reduction could not be 
 attempted ; the compound dislocation gradually got 
 well, if you can call the greatest deformity I ever 
 saw, well; however, no bad symptoms arose, and I 
 
DISLOCATIONS OF THE ANKLE-JOINT. 281 
 
 am persuaded, that had the dislocation been at first 
 reduced, the case would have terminated in a most 
 satisfactory 'manner. 
 
 I had a case of compound fracture of the elbow- 
 joint, in the person of Dr Wool, now head master 
 of Rugby, which did well, without leaving any per- 
 ceptible degree of stiffness. 
 
 Your's very truly, 
 
 W. WiCKHAM* 
 
 28, Park Street, Bristol 
 October 20th, 1818. 
 My dear Sir : — During the twenty-two years I 
 have been surgeon to the Bristol Infirmary, and I 
 believe during my apprenticeship there, making in 
 all nearly thirty years, it has been our invariable 
 practice to endeavour to save the limb in cases of 
 compound dislocation of the ankle, unless where the 
 chance was annihilated by some concomitant injuries 
 or circumstances ; but as a general rule it was al- 
 ways adhered to, which it would not have been un- 
 less the great majority of cases had done well. We 
 save the limb in private practice almost invariably, 
 unless in very bad cases indeed. 
 
 I am, my dear Sir^ 
 
 Your's, etc. 
 R. Smith. 
 
 COMPOUND DISLOCATION OF THE TIBIA INWARDS. 
 
 My friend, Mr Fiske, surgeon at Saffron Walden, 
 stated to me the following case. 
 
 Case, — A man, aged sixty, had ascended a ladder 
 to a considerable height, when, accidentally slipping, 
 36 
 
282 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 he fell to the ground. Mr Fiske being called to 
 him, found the tibia dislocated inwards at the ankle- 
 joint, and the end of the bone, covered by its carti- 
 lage, protruding tlirough the integuments. He im- 
 mediately replaced the bone, brought the integu- 
 ments together by adhesive plaster, applied a ban- 
 dage over the joint, and splints upon the limb, direct- 
 ing him to remain as quiet as possible. The wound 
 healed without any untoward circumstance, and the 
 man not only recovered, but has the advantage of an 
 extremely useful limb. 
 
 COMPOUND- DISLOCATION OF THE TIBIA FORWARDS AND 
 TWO CASES OF THE TIBIA OUTWARDS. 
 
 I have received the following cases of injury to 
 the ankle from Mr Maddocks. 
 
 Cases, — Dear Sir : — These cases are of recent 
 date, and I have a perfect recollection of every im- 
 portant circumstance connected with them. The 
 first happened to a stout healthy young man, who, 
 by a fall from a vicious horse, dislocated his ankle. 
 The accident happened a few miles from Notting- 
 ham. He was immediately brought to his master's 
 house, where I saw him, and found the end of the 
 tibia protruding through a large lacerated and con- 
 tused wound, on the lore part of the ankle. The 
 fibula was broken about four inches ahove the joint, 
 and its lower end was separated from its connexion 
 with the tibia, by a laceration of the ligament con- 
 necting it with that bone, but it did not protrude. 
 Appearances in many respects were unfavourable, as 
 there was much ligamentary and some tendinous 
 laceration ; but as the tibia was sound, and the fibula 
 only transversely fractured, I was encouraged by the 
 
DISLOCATIONS OP THE ANKLE-JOINT. 
 
 283 
 
 resources of a good constitution, and more particu- 
 larly by the sanction of my friend, Mr Wright, a 
 practitioner of much experience, to attempt the pre- 
 servation of the joint. The bones wore reduced 
 with little difficulty, and the limb was placed in a 
 flexed position on ils side on a broad hollow splint ; 
 the supervening symptoms were more favourable 
 than could have been expected frouj the nature of 
 the accident, though some portion of the integuments 
 sloughed away, and two ditrercnt suppuratiofis took 
 place in the joint, followed by two small exfoliations. 
 The patient in three months recovered the use of 
 the joifit, and at this time experiences no inconve- 
 nience from the accident. 
 
 External dislocation, S^^c. — Two cases of external 
 dislocation occurred in boys, both of whom were 
 healthy, and the accidents were occasioned by falls 
 from horses; the malleoli inteini were in both in- 
 stances broken off, and the tibia and fibula protruded 
 two or three inches through the integuments. In 
 one case, the projecting end of the fibula was left, 
 adheriiig by its ligament to the anterior part of the 
 astragalus; in the other it was whole. 1 removed 
 the loose portion of the fibula, the bones easily united, 
 and the limbs were placed in an extended position, 
 supported by long splints. In both cases the inflam- 
 mation was high. In one, a large abscess formed, 
 about the middle of the leg. and a discharge of mat- 
 ter from the joint continued for some weeks, attend- 
 ed with a separation of sloughing ligamentous and 
 membranous parts, The wound gradually healed, 
 the discharge abated, and the boy recovered, with 
 very little impediment to the free motion of the 
 joint. I^he other boy would have been equally for^ 
 tunate, but exfoliations took place on the end of the 
 tibia, which, though small, retarded his recovery for 
 several weeks, and left the joint less perfectj^in its 
 
284 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 motion than in the preceding case, but quite sufficient 
 for the common occupations of life. You have here 
 a plain statement of facts, without comment or em- 
 belh'shment. My mode of treatment has been uni- 
 formly to keep the limb in the most quiescent state, 
 and to meet symptoms as they arise ; and I cannot 
 but attribute the success which attended the treat' 
 ment of these cases in a great measure to that pre- 
 caution. 
 
 I am, dear Sir, 
 
 With great respect, your's, 
 
 B. Maddocks, 
 
 DISLOCATION OP THE TIBIA AND FIBULA OUTWARDS, 
 
 Sir: — Not having the honour of being personally 
 known to you, I trust that the wish you have ex- 
 pressed in your work on dislocations to be informed of 
 the treatment and result of accidents of that nature, 
 will plead my excuse for troubling you with the fol- 
 lowing case of compound dislocation of the ankle. 
 
 Case. — On the 22nd of October last, 1 was called 
 upon to attend Thomas Saxty, a lad about thirteen 
 years of age, whose left foot had got entangled in a 
 strap of the machinery used in the clothing business. 
 On examination, I found a very bad compound dislo- 
 cation of the tibia and fibula outwards ; the bones 
 were protruding four or five inches through the in- 
 teguments, which were dreadfully lacerated; the 
 wound extended from the external malleolus in an 
 oblique direction to the posterior part of the tibia, 
 and within five inches of the head of that bone, which 
 articulates with the femur. On putting my fingers 
 into the cavity of the ankle-joint, 1 found the astra- 
 galus very loose, being torn from its connecting liga- 
 ments. 
 
DISLOCATIONS OP THE ANKLE-JOINT. 
 
 285 
 
 On the first view of so serious an accident, I 
 thought it would be impossible, with safety to my 
 patient, to save the limb; but as he had received so 
 severe a shock, the countenance being pale, and the 
 extremities cold, I determined to defer the amputa-* 
 tion until the constitution should be recovered from 
 the first impression of the accident, and proceeded 
 in reducing the limb to its proper situation, which 
 I accomphshed with but little difficulty; I applied 
 lint to the wound, and covered the limb with a many^ 
 tailed bandage lightly bound on; still I had no idea 
 but that amputation must take place, and the next 
 morning 1 requested Mr Carey, a very intelligent 
 surgeon of this town, to assist me in the operation: 
 owing to professional engagements he could not ac^ 
 company me to the boy before six in the evening, 
 Avhen, on examining the limb, there was considerable 
 inflammation in the leg above the lacerated parts, 
 and gi'eat tenderness in the thigh, which 1 then 
 learnt had received some injury at the time of the 
 accident. Under these circumstances it was deter^ 
 mined to delay the operation for the present. The 
 limb was wrapped in a warm poultice of oatmeal 
 and yest, the boy placed on his left side with the 
 limb in the bent position, and a draught with twenty 
 drops of laudanum ordered to be taken immediately: 
 he passed a restless night. On the following morning, 
 October 24tli, the inflammation of the leg above the 
 injury was considerably increased, with very great 
 tenderness on pressure; and the wound had a dry, 
 dark, sphacelated appearance. I ordered my patient 
 some wine and an opiate at bed-time: he passed a 
 more comfortable night, and the next morning the 
 appearance of the wound had improved. In the 
 course of the 26th, a distinct line, marking the ex--- 
 tent of mortification, could be traced. 
 
286 
 
 DISLOCATIONS OP THE ANKLE-JOINT. 
 
 It would be useless to record the dally progress of 
 the case, as the detail would take up too much of 
 your valuable time; suffice it to say, that in the 
 course of three weeks the whole of the sphacelated 
 parts had separated, leaving a most extensive wound. 
 The poultices were now laid aside, and simple dress- 
 ings substituted ; a many-tailed bandage was applied 
 to give suj:)port to the limb, and a splint attached on 
 each side the leg. The discharge about this time, a 
 month after the accident, was very considerable; but 
 the boy having a good constitution, I began to think 
 there might be some chance of saving the limb, and 
 I determined not to amputate unless the symptoms 
 should imperiously demand that operation. About 
 four inches of the inferior extremity of the fibula 
 Avere expospd to view, and would evidently ex- 
 foliate. 
 
 On November 2tUh, I placed the boy on his back, 
 the limb restin": on the heel. I was induced to 
 make this alteration in his position because my pa- 
 tient had experienced considerable pain every time 
 the limb was dressed, as it was obliged to be moved 
 daily for that purpose. 
 
 The wound at this time did not go on so well as 
 could be wished: it had an unhealthy appearance, 
 with large, flabby, and shining granulations. I tried 
 the effects of stimulants, such as a weak solution of 
 nitrate of silver, a solution of vitriolated zinc, etc., 
 but still without decided benefit. 
 
 On November the 30th, nearly six weeks from 
 the time of (he accident, that part of the fibula 
 wliich forms the external malleolus exfoliated; and 
 three days afterwards I succeeded in bringing away a 
 broad portion of the articulating surface of the tibia. 
 In a few days the discharge lessened, but there 
 seemed no disposition in the wound to heal. 
 
 I had repeatedly witnessed the good eflects of 
 
msLOCATiONS OP THE ANKLE-JOINT. 287 
 
 the adhesive plaster in ulcers of the leg, in the 
 manner recom mended by the late Mr Baynlon ; and^ 
 as in the present case, a stimulant was required, as well 
 as support to the edges of the wound, I considered 
 that this dressing, applied in the form of a raany- 
 tailcd bandage from the ankle to within four inches 
 of the knee (the extent of the wound), would in all 
 probability amend its condition and appearances. I 
 was not disappointed; lor in the course of a few 
 days after the application of the plaster the wound 
 began to heal ; and from that time to the present 
 the rapidity of the cure has been beyond my most 
 sanguine expectations. 
 
 The boy is now, ^fteen weeks from the time 
 when he received the injury, able to walk, with the 
 assistance of crutches, to the factory, a distance of 
 half a mile from his house. To-day I observed 
 tiiat he could put the foot flat on the ground, and 
 walk across the room without the assistance of a 
 stick. 
 
 For the last two months I have daily given pass- 
 ive motion to the ankle-joint; but I fear, from the 
 great extent of injury, that he will never recover 
 the perfect use of it, though it is not so completely 
 anchylosed as to prevent all motion. 
 
 It appears wonderful, that in such a very exten- 
 sive laceration, no artery requiring a ligature should 
 have been wounded. 
 
 I do not claim to myself the merit of having sav- 
 ed the boy's limb, as you will perceive by the pre- 
 ceding statement, that he is more indebted to a 
 fortuitous circumstance. At the time when my 
 friend, Mr Carey, saw it, there was too much inflam- 
 mation above the seat of the injury to warrant us 
 in amputating. 
 
 I have sent you the portions of bone that have 
 exfoliated, as I thought they would give you a clear- 
 
288 DISLOCATIONS OP THE ANKLE-JOtNT* 
 
 er idea of the extent of the injury to the joint than 
 could be afforded in writing. 
 
 I recollect about nine years ago, av hen I was with 
 my father at Wantage, the occurrence of compound 
 dislocation of the ankle inwards, in a woman about 
 fil'ty years of age and of spare habit ; it was attend- 
 ed with but little laceration, was easily reduced, and 
 eventually the patient recovered, but with a com- 
 plete anchylosis of the joint. 
 
 Should any circumstance occur during the further 
 progress of the cure which 1 should think worth 
 communicating to you, I will take the liberty of 
 again addressing you ; or should I have omitted any 
 thing in the preceding statement which you consider 
 of consequence, I shall be very happy in giving you 
 any further information in my power. 
 
 1 remain, 
 Your obedient, humble servant, 
 
 Trowbridge^ Feb, bth, 1822. J. Ormond. 
 
 REMOVING THE ENDS OF THE BONES. 
 
 Sawing off the ends of the bones, S{c, — There 
 is another mode of treatment in these accidents, 
 which consists in sawing off the extremity of the 
 tibia before the bone is returned into its natural 
 situation ; and the reasons which may be assigned 
 for pursuing this practice are as follow. 
 
 Difficult reduction.-^ First, That there is in 
 some cases much difficulty in the reduction of the 
 tibia, and great violence must be employed to ef- 
 fect it. 
 
 Oblique fracture, — Secondly. The extremity of 
 the bone is often broken obliquely, so that when 
 reduced it will not remain upon the astragalus, but 
 
DISLOCATIONS OF THE ANKLE-JOINT. 289 
 
 when the point is removed by the saw, it rests with- 
 out difficulty upon that bone. 
 
 Spasms. — Thirdly. The spasmodic contractions 
 of the muscles are much diminished by shortening 
 the bone, as it throws them all into a state of relax- 
 ation ; whereas, if the bone be reduced by violence 
 when the saw has not been used, the spasm of the 
 limb will be sometimes very violent. 
 
 Local irritation diminished, — Fourthly. The 
 local irritation is much diminished by the greater 
 ease with which adhesion is produced of the sawn 
 extremity of the bone to the parts to which it is 
 applied ; for it is a mistake to suppose that the 
 sawn end of the bone -will not adhere; the contrary 
 is seen in amputation in sawing off a bone in exostosis, 
 and in the union by adhesion of compound fractures; 
 and that adhesive matter can be thrown out upon 
 cartilaginous surfaces is known to every person who 
 has dissected a diseased joint ; it is thus that the 
 end of the tibia adheres to the surface of the astra- 
 galus. 
 
 Suppuration and ulceration lessened. — Fifthly. 
 When suppuration does occur it is much diminished, 
 and a considerable part of the ulcerative process is 
 prevented by the mechanical removal of the carti- 
 lage ; for nearly half the articular surface of the 
 joint no longer remains. Caeteris paribus, therefore 
 the case recovers more rapidly. 
 
 Less constitutional irritation. — Sixthly. The con- 
 stitutional irritation is very much lessened by the 
 diminution of the suppurative and ulcerative pro- 
 cess, and by the ease with which the parts are re- 
 stored. In the cases which I have had an opportu- 
 nity of seeing, there was not more irritative fever 
 than in the mildest cases of compound fracture. 
 
 Bone shattered. — Seventhly. It has been found 
 that in cases in which the extremities of the bones 
 37 
 
290 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 forming the joint have been broken into small pieces, 
 and in which these have been removed by the finger, 
 the patient has suffered less, and has more quickly 
 recovered, than when the bone has been returned 
 whole. 
 
 JVo case of death. — Eighthly. I have known no 
 case of death when the extremities of the bones 
 have been sawn off, although I shall have occasion 
 to mention some in which the cases terminated fa- 
 tally when this was not done. 
 
 Objections; limb shorter. — The objections which 
 may be made to this mode of treatment are, that 
 the limb becomes somewhat shorter by the removal 
 of the cartilaginous extremity of the bone ; but this 
 I do not think an objection of any considerable weight, 
 if the danger of the case be, as I believe, lessened 
 by it ; for the diminished length, which is very slight, 
 is easily supplied by a shoe made a little thicker 
 than usual. 
 
 Anchylosis. — The other objection is, that the 
 joint becomes necessarily anchylosed. I doubt very 
 much the reality of this objection, as in two instances 
 I have seen the motion of the part remain; but 
 even when the joint becomes anchylosed, a conse- 
 quence to which it is liable in either mode of treat- 
 ment, the motion of the tarsal bones becomes so 
 much increased as to compensate for that of the 
 ankle, the patient walks with much less halting 
 than would be anticipated, and has a very useful 
 limb. 
 
 Each mode useful. — My intention, however, is not 
 to advocate either mode of treatment to the exclu- 
 sion of the other, but to state the reasons which 
 may be justly assigned for the occasional adoption of 
 either. It is only by a comparison of the different 
 results of varied practice that a safe conclusion can 
 be drawn ; and from what I have had an opportu- 
 
DISLOCATIONS OP THE ANKLE-JOINT. 
 
 291 
 
 nity of observing in my own practice, and of learning 
 from that of my friends, I feel disposed to recom- 
 mend to those whose minds are not settled upon the 
 subject, not hastily to determine against either treat- 
 ment in the different cases of this injury, as from 
 each mode, under varied circumstances, a strong and 
 useful limb has been saved without any additional 
 risk to the life of the patient. 
 
 Cases in which the one or the other should be em- 
 ployed, — [f the dislocation can be easily reduced 
 without sawing off the end of the bone ; if the bone 
 be not so obliquely broken, but remain firmly placed 
 upon the astragalus when reduced; if the end of the 
 bone be not shattered, for then the small loose pie- 
 ces of bone should be removed, and the surface of 
 the bone be smoothed by the saw; if the patient be 
 not excessively irritable, so as to occasion the mus- 
 cles to be thrown into violent spasmodic actions in 
 the attempt at reduction, which leads to subsequent 
 displacement when the limb has been reduced ; the 
 bones should be at once returned into their places, 
 and the parts should be united by the adhesive in- 
 flammation ; but rather than amputate the limb, if 
 the above circumstances were present, I should cer- 
 tainly saw off the ends of the bones. 
 
 I shall now proceed to state the cases which I 
 have myself had an opportunity of witnessing, and 
 some which have been furnished by my friends, and 
 shall leave the reader to judge of the propriety of 
 the advice I have given. 
 
 COMPOUND DISLOCATION OF THE TIBIA OUTWARDS AT 
 THE ANKLE-JOINT, 
 
 Case, — I was sent for to Guy's Hospital, to see 
 Nathaniel Taylor, aged thirteen years, and was di- 
 
292 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 reeled to bring my amputating instruments with me, 
 being informed that the boy had so bad a dislocation 
 of the ankle that the limb could not be saved. 
 
 Appearances ; removal of the end of the fibula^ ^c. — 
 As soon as I arrived at the hospital, I ordered the 
 patient into the operating theatre ; and making in- 
 quiries into the cause and nature of the accident, I 
 found the particulars to be as follows: The injury 
 had been occasioned by a boat falling upon the leg. 
 A large wound appeared at the outer ankle, through 
 which the tibia and a fractured extremity of the 
 fibula projected ; one inch of the malleolus externus 
 remained attached to the astragalus by its natural 
 hgaments; the foot was turned inwards so as to be 
 capable of being brought in contact wnth the inner 
 side of the leg ; and as the muscles were no longer 
 on the stretch the foot was very loose and pendu- 
 lous. I tried to reduce the limb, but found that the 
 bone could only by great violence be brought on the 
 astragalus, and that it immediately slipped from its 
 place. The case was, therefore, as regarded the 
 state of the parts, the most unfavourable possible, 
 and those around me urged an immediate amputa- 
 tion ; but seeing the character of health which the 
 boy bore, I thought I should not be justified in pro- 
 bably dooming him to a life of mendicity, and I de- 
 termined to try to preserve the limb. Finding that 
 the lower end of the fibula, although still connected 
 by ligament, was very loose and moveable, I sepa- 
 rated it with a scalpel; I then sawed off half an 
 inch of the lower extremity of the tibia. When 
 these operations had been accomplished with the 
 greatest care, I reduced the bones, and they main- 
 tained their situation, as there was no force of mus- 
 cular action upon them, on account of the shortening 
 ef the bones. L»int, dipped in the patient's blood, 
 was then applied, with adhesive plaster over it; and 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 293 
 
 the leg was put in splints, and placed on the heel. 
 Scarcely any constitutional irritation occurred ; the 
 wound and ankle-joint secreted but little matter, and 
 gradually healed. On the seventeenth day an jib- 
 scess showed itself on the tibia, which was suffered 
 to burst, as it had little affected his constitution. In 
 two months he was allowed to sit up and use his 
 crutches. In twelve weeks the wound was healed, 
 and the boy was able to bear on his foot; and at the 
 end of four months he walked Well. I experienced 
 inconceivable pleasure in seeing this boy walk before 
 the students, at my desire, from one end of the ward 
 to the other, four months after the accident, with 
 very little lameness. There seemed to be some 
 motion at the ankle, but the tarsal bones soon ac- 
 quired sufficient mobility to give to the foot so much 
 play as to prevent the appearance of stiffness, which 
 a partially anchylosed state of the ankle would 
 otherwise have produced. 
 
 COMPOUND DISLOCATION OF THE TIBIA INWARDS. 
 
 Case, West, Esq, aged forty, on Decem- 
 ber 11th, 1818, jumped out of his one-horse chaise, 
 alarmed by the horse kicking. He fell, and when 
 he attempted to rise, found his left ankle dislocated, 
 and the bone projecting through the skin. Mr 
 Mackinder, surgeon, brought him to the house of 
 his father-in-law, in London, where Mr Jones, of 
 Mount-street, and myself attended him. 
 
 Integuments pressed between the bones. — Upon ex- 
 amination of the part, I found the tibia projecting 
 at the inner ankle through the integuments, which 
 were nipped under the projecting bone into the 
 joint: the foot was loose and pendulous, and very 
 
294 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 much thrown outwards. Having prepared several 
 pieces of linen to form a manj-tailed bandage, and 
 procured pillows and splints, the patient was placed 
 ort a bed on his left side, and an attempt was 
 made to reduce the bone ; but hearing from Mr 
 Jones that Mr W. was of a most irritable constitu- 
 tion, and finding that most powerful extension must 
 be made, and that the integuments must be divided 
 opposite to the joint, so as to lessen the probability 
 of an easy adhesion to the wound, which was placed 
 one inch and a half above the articulation, 1 sawed 
 off the end of the tibia, and the bone most easily 
 returned into its natural situation, in which it re- 
 mained without difficulty. The edges of the wound 
 were brought together by a fine thread, so as to be 
 very closely adapted to each other ; and lint, dipped 
 in blood, was applied over the wound : the many- 
 tailed bandage was used : the limb was placed on 
 its outer side, with the knee bent nearly at right 
 angles with the thigh, and splints were applied. 
 The leg was ordered to be kept constantly wet with 
 the liq. plumbi, s. acetat. dilutus, 3 v. and spir. vini 
 3i. ; a dose of opium was given to him, and ten 
 ounces of blood were taken from his arm. In the 
 evening more opium was administered, and a dose 
 of infusion of senna and sulphate of magnesia was 
 ordered for the morning. 
 
 December 12. As the limb felt hot, the upper 
 splint was removed, its pressure being somewhat 
 painful, and preventing free evaporation. Opium 
 was ordered at night. 
 
 December 13. The foot was vesicated. He had 
 chilliness succeeded by heat ; slight tension of the 
 leg, and some pain for three hours. His mind was 
 much agitated by seeing his children. 
 
 December 14. The limb was less inflamed, and 
 he had scarcely any constitutional irritation. 
 
DISLOCATIONS OF THE ANKLE-JOINT. 295 
 
 December 15. A slight discharge of serum mixed 
 with red particles from the wound ; some pain in 
 the foot and leg, 'but no irritative fever. 
 
 December 16. There was more discharge, and 
 some air passed from the wound; a poultice was ap- 
 plied, and a generous diet allowed, as his stomach, 
 naturally weak, had become very flatulent. Pulse 
 90. 
 
 December 17. A fomentation and poultice applied. 
 Derangement of the stomach. — December 18. 
 The discharge was becoming purulent; but as his 
 stomach was deranged, he was visited by Dr Pem- 
 berton, who ordered him hyoscyamus with the mix- 
 tura camphor, in the day, and opium at night. 
 
 From this time to the 7th of January, the discharge 
 from the limb was copious, but it then began to 
 lessen; and when the leg was examined on the 12th 
 of January, it had become firm ; a small wound re- 
 mained, on which the granulations were prominent. 
 In the first week in February he was allowed to get 
 upon his sofa, the limb being now firm, and only a 
 small wound remaining, from which an exfoliation 
 will occur, as the bone can be felt bare. 
 
 In August 1 saw him ; the wound still remained 
 open, and the portion of bone had not separated. 
 
 This gentleman, with the worst constitution in re- 
 gard to the state of his stomach, did not suffer so 
 much irritation as a compound fracture usually pro- 
 duces. 
 
 COMPOUND DISLOCATION OF THE TIBIA INWARDS. 
 
 Mr Charles Averill, dresser to Mr Forster, Sur- 
 geon of Guy's Hospital, had the kindness to send me 
 the following particulars of a case, the progress of 
 which I often witnessed with pleasure. 
 
290 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 Case ; use of nitric acid, Src. — John Williams, 
 sailor, aged thirty-eight, a very robust man, was 
 brought into Guy's Hospital, under the care of Mr 
 Forster, August 9th, 1819, at four o'clock in the 
 morning, with a compound dislocation of the right 
 ankle inwards, and considerable injury to the left, 
 occasioned by his falling from a height of about 
 t .venty-six feet, in endeavouring to escape from the 
 Borough Compter, in which he was imprisoned. On 
 examining the injured part, I found the tibia pro- 
 truding three inches through a large transverse 
 wound of four inches in extent, and resting on the 
 inner side of the os calcis ; the cartilaginous surface 
 of the astragalus could be readily felt on passing my 
 finger into the w^ound ; the fibula was broken. I 
 first sawed of!' the whole of the cartilaginous end of 
 the tibia, when the bone was easily replaced ; the 
 edges of the wound were then brought as much in 
 contact as possible ; lint dipped in blood was applied, 
 and over it straps of adhesive plaster ; the foot and 
 leg were wrapped in cloths wet with a lotion of 
 acetate of lead, and the limb was laid on its side. 
 He complained of great pain in the left leg, which 
 was very much swollen all around the ankle ; ten 
 leeches were applied to it, and afterwards the liquor 
 plumbi subacetatis dllutus, which relieved the pain; 
 thirty drops of laudanum were given, and he re- 
 mained easy. On the following day sixteen ounces 
 of blood were taken from him, and five grains of 
 calomel were given. On the 12th, the dressings 
 were removed; the wound looked well. On the 
 17th, suppuration had commenced ; .and the discharge 
 having rather a foeted smell, the nitric acid lotion 
 was applied.* September 2nd, the matter gravitat- 
 
 * The nitric acid lotion, during the sloughing process, is the 
 best application with which I am acquainted. I order it in the 
 proportion of fifty drops of the acid to a quart of distilled water, 
 and apply it by linen covered with oiled silk. — A. C. 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 297 
 
 ing to the outer side of the leg, an opening was 
 made, by which it was discharged, and adhesive 
 plaster applied to the original wound, which was 
 healing fast; the discharge gradually diminished; 
 and on the 21st of September, six weeks from the 
 accident, both wounds w^ere quite healed. He has 
 not yet left his bed. There is motion at the ankle; 
 the toe turns out but very little, and does not point 
 downwards. He wears splints, and the strength of 
 the limb is daily increasing. When the swelling of 
 the left ankle diminished, a fracture of the external 
 malleolus was also there discovered. 
 
 October 4th^ 1819. Charles Averill. 
 
 This man escaped from the hospital on the 24th 
 of October, was retaken two months afterwards, 
 and is now in the Borough Compter. He has free 
 motion of the right ankle, and suffers more from the 
 injury to the left. 
 
 For the following letter I am indebted to Dr Kerr, 
 of Northampton, who, at the age of more than eighty, 
 still continues to practice his profession with all the 
 ardour of youth, and with a strength of intellect 
 which has been seldom surpassed. 
 
 JVorthampton, July 2nth, 1819. 
 My dear Sir : — I have had the honour of your 
 letter this morning respecting compound dislocation 
 of the ankle ; several such cases have fallen under 
 my care, and it has been uniformly my practice to 
 take off the lower extremity of the tibia, and to lay 
 the limb in a state of semiflection upon splints; by 
 this means a great deal of painful extension, and 
 the consequent high degree of inflammation, are avoid- 
 ed. The splints 1 use are excavated wood, and much 
 wider than those in common use, with thick moveable 
 38 
 
298 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 pads stuff'ed with wooL I keep the parts constantly 
 wetted with a solution of h'quor ammonias acetatis, 
 without removing the bandage. In my very early 
 lil'e, upwards of sixty years ago, I saw many attempts 
 to reduce compound dislocation without removing 
 any part of the tibia ; but, to. the best of my re- 
 collection, they all ended unfavourably, or, at least, 
 in amputation. By the method which 1 have pursued, 
 as above mentioned, 1 have generally succeeded in 
 saving the foot, and in preserving a tolerable articu- 
 lation. 
 
 I am, with much esteem, my dear Sir, 
 Your obedient, humble servant, 
 
 William Kerr. 
 
 COMPOUND DISLOCATION OF THE TIBIA OUTWARDS. 
 
 To Dr Rumsey, of Araersham, I am obliged for 
 the following interesting communication. 
 
 Amersham. 
 
 Dear Sir: — I have the pleasure of forwarding 
 to you the case of a compound dislocation of the 
 ankle, which came under my care many years ago, 
 and which had a fortunate termination, as the pa- 
 tient lived many years after the accident. 
 
 Case ; complicated with fracture of the femur, 8^c» 
 — On June the 21st, 1702, Mr Tolson, aged forty 
 years, was thrown from a curricle on Gcrrard's- 
 cross Common, eight miles from this place. The 
 injury he received consisted in a compound disloca- 
 tion of the tibia and fibula at the outer ankle of the 
 left leg, with a fracture of the astragalus (the supe- 
 rior half of which was attached to the dislocated 
 bones of the leg), and likewise a simple fracture of 
 the 08 femoris on the same side. He was conveyed 
 
DISLOCATIONS OF THE ANKLE-JOINT, 
 
 299 
 
 to a friend's house on the Common, where he had 
 the advantage of an airy, healthy situation, with 
 every kind of domestic attention. I saw him about 
 two hours after the accident, and found the bones 
 protruding at the ankle through a very large wound, 
 with the foot turned inwards and upwards, and the 
 integuments beneath the wound exceedingly confined 
 by the dislocated bones which descended nearly to 
 the bottom of the foot. A considerable haemorr- 
 hage had taken place, but was stopped by the 
 spontaneous contraction of the lacerated vessels. 
 
 From such a formidable accident, in so large a 
 joint, there appeared very little probability of the 
 patient's recovery without immediate amputation; 
 I therefore requested that a consultation with some 
 other surgeons might be expeditiously held on the 
 case, and expresses for this purpose were accord- 
 ingly sent to Mr Pearson, surgeon in London, and to 
 my brother, Mr Henry Rumsey, surgeon at Ches- 
 ham, in this county. While 1 was waiting for their 
 arrival, the patient requested me to examine his 
 thigh, when 1 plainly discovered an oblique fracture 
 of the OS femoris at its superior part. This addi- 
 tional evil appeared to me a great obstacle to an 
 amputation. My brother, when he arrived, being of 
 a similar opinion, I attempted to reduce the fractur- 
 ed dislocated joint mto its proper situation. This I. 
 found very difficult without first separating that part 
 of the astragalus which was pendulous to the tibia, 
 having its capsular ligament lacerated half way 
 around the joint. This portion of the astragalus 
 consists of the broad smooth head by which it is 
 articulated to the tibia; of almost the whole of the 
 inner and outer sides of this head, by which it 
 moves on the inner and outer malleoli; and of about 
 the upper half of the posterior cavity on its under 
 surface, by which it is united to the os calcis ; so 
 
300 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 that the bone was divided nearly horizontally, and 
 the part left behind consisted of the lower half of 
 the last mentioned cavity, of the whole of the other 
 or anterior cavity which connects it with the os 
 calcis, and of the anterior portion or process by 
 which it is articulated to the os naviculare : 1 there- 
 fore removed it without hesitation, being per- 
 suaded that if it had been practicable to reduce it 
 into its original situation, so large and moveable a 
 portion of bone would have been a source of pain 
 and irritation, and have rendered the cure more 
 difficult and uncertain. I then divided that portion 
 of the integuments of the foot which was confined 
 by the protruded end of the tibia, and was thus 
 enabled with ease to reduce it and the fibula into 
 their proper situation. I applied some dossils of 
 lint dipped in tincture of opiuna to the wound, and 
 covered the whole with a poultice of stale beer 
 and oatmeal. We now reduced the fractured 
 femur, and placed the limb in a bent position, ex- 
 pecting that our greatest success would be in pro- 
 curing a complete anchylosis, the failure of which I 
 concluded would leave a useless foot. The under 
 splint was a firm excavated piece of deal, of the 
 shape of the leg and foot, with a hole opposite the 
 ankle. Mr Pearson arrived in the evening, and ap- 
 proved of tlic preceding treatment ; giving it as his 
 opinion, that it would be safer to attempt the pre- 
 servation of the limb than to amputate, under such 
 complicated circumstances. The wound was con- 
 cealed as much as possible from the external air, 
 and the cataplasm renewed no oftener than the dis- 
 charge rendered necessary. 
 
 June 22nd. The preceding night had been very 
 painful, with delirium and vomiting; the pulse was 
 full and frequent ; I took away ten ounces of blood, 
 and gave potassse tartras and manna in doses suffi- 
 
DISLOCATIONS OP THE ANKLE-JOINT. 301 
 
 cient to procure stools. A common saline draught, 
 with antimonial wine and tincture of opium, was 
 given every four hours, and a fuller dose of tincture 
 of opium at bed-time. 
 
 23rd. The vomiting continued ; the ankle and 
 thigh had been less painful through the night ; the 
 saline draughts were continued, but without the an- 
 timony, on account of the vomiting; during this 
 period, the antiphlogistic regimen was strictly ad- 
 hered to. 
 
 24th. The night had been tolerable ; the vomit- 
 ing had ceased; the pulse was softer; the saline 
 draughts were continued, with the opiate at bed- 
 time ; this evening the leg was very painful; he 
 passed a pretty goodnight; a discharge from the 
 wound now commenced, and the tension of the 
 muscles of the thigh began to diminish. 
 
 26th and 27th. The same treatment was con- 
 tinued. The discharge increased, and the tension 
 of the thigh still more abated. 
 
 28th. The ankle was much swelled and inflam- 
 ed; I therefore exchanged the beer grounds in the 
 cataplasm for the liquor plumbi subacetatis dilutus. 
 The patient had this day much pain in the bowels 
 from flatulence ; from which circumstance, and that 
 of the discharge being very thin, it was judged ex- 
 pedient to vary his mode of living, and likewise his 
 medicines. 
 
 Change of diet and treatment, Src — 29th. He 
 was allowed a small portion of animal food, some 
 table beer, and some port wine ; and he took the 
 bark liberally, both in substance and in decoction. 
 This change of treatment agreed with him perfect- 
 ly well. At this time I found it necessary to alter 
 the position of the limb, on account of the pressure 
 on the wound, occasioned by its lying in the bent 
 position, and by the pain caused in turning to dress 
 
302 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 it, which, from the copious discharge, now required 
 to be done night and morning. I therefore placed 
 it on the heel, using the common deal flexible splint, 
 of the length of the limb, and confined it in a box, 
 whose sides and lower end let down ; the space 
 between the sides of the box and splint was filled 
 with pieces of flannel. By these means, and the 
 use of the eighteen-tailcd bandage, the dressings 
 were applied with very little disturbance to the leg, 
 and thus the patient escaped much pain. The up- 
 per end of the box under the ham being raised, 
 gave the muscles some degree of flexion, and at the 
 same time was favourable to the discharge. The 
 foot having a tendency to fall inward, and the end 
 of the fibula to protrude through the wound, it re- 
 quired great attention to prevent the deformity 
 which the neglect of these circumstances might 
 have occasioned. The mode of prevention which 
 I adopted, and which proved successful, consisted 
 in employing a number of small deal wedges, about 
 six inches long, two broad, and a quarter of an inch 
 thick ; as many of these as were found sufficient 
 were placed opposite the inside of the foot, between 
 it and the side of the box: others, in the same 
 manner, were placed on the outer side of the calf 
 of the leg; by which means the limb was kept 
 steady; and by retaining the heel in an easy and 
 rather hollow position, none of the usual evils aris- 
 ing from pressure on the heel occurred. 
 
 30th. The bark agreed very well ; the opiate 
 was continued at bed-time; the discharge was great 
 but more purulent; the pulse was become softer and 
 less frequent ; and the urine, which had hitherto 
 been clear and very high coloured, was now turbid; 
 the pain and inflammation being much diminished, 
 the cataplasm was discontinued ; the wound was 
 dressed with dry lint, with a pledget of cerat. plumbi 
 
DISLOCATIONS OP THE ANKLE-JOINT. 
 
 303 
 
 superacetatia over it, and a moderate compression 
 was made by means of a bandage. From this pe- 
 riod the wound progressively mended ; the discharge 
 diminished; granulations formed; and the surround- 
 ing skin began to heal. The use of the bark and 
 of the opiate was continued till the beginning of 
 August. About the end of July, the progress of 
 the cure was retarded by matter collected under the 
 integuments, above the inner ankle, which on pres- 
 sure came out at the wound. After in vain trying 
 the effects of permanent pressure for the prevention 
 of this deposit, I made an incision into the cavity 
 and filled it with dry lint, to produce inflammation 
 on its internal surface, which consolidated it, and 
 the wound became perfectly cicatrised by the mid- 
 dle of September, without any exfoliation of bone 
 larger than the head of a pin having taken place. 
 The fracture of the femur went on very well, ex- 
 cepting that its obliquity, with the impossibility of 
 producing a permanent extension on account of the 
 leg, occasioned a degree of curvature which it 
 otherwise would not have had. The limb gra- 
 dually acquired strength, and the patient is able 
 to walk very well with only the aid of a small 
 stick, and even this assistance he will probably not 
 require long. There is no anchylosis to render 
 the ankle immoveable ; but a sufficient firmness 
 has been produced in the surrounding parts by 
 the long continued inflammation to assist in the 
 formation of an artificial joint, which possesses a 
 degree of motion nearly equal to that of the 
 natural. 
 
304 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 COMPOUND DISLOCATION OF THE TIBIA INWARDS. 
 
 For the following most interesting case 1 am in- 
 debted to Mr Hicks, of Baldock. 
 
 Baldock, Jngust \Oth, 1819. 
 
 My dear Sir : — In the absence of my son, I beg 
 leave to forward you the following account of a case 
 of compound dislocation of the ankle. 
 
 Case. — Case of John Curgan. Early in the morn- 
 ing of November 10, 1812, the Stamford coach, 
 from the carelessness of the guard in neglecting to 
 chain the wheel, ran with great velocity down the 
 hill a mile below Baldock, and fell on its side a little 
 before it reached the foot of the hill ; in its fall, the 
 side of the coach caught the coachman's right leg, 
 and turned the foot upon the outside of the leg, by 
 which the tibia became dislocated on the inner side; 
 the tibia and fibula protruded through the integu- 
 ments about four inches; the oblong end of the 
 fibula was fractured, and several small portions of it 
 remained within the integuments; the end of the 
 tibia had some small portions chipped off, appearing 
 as if it had been ground by the side of the coach ; 
 in this state he was brought to Baldock, with his 
 foot dangling to his leg: the wound was very large; 
 so much so, that the foot appeared almost separated 
 from the leg: the ends of the bone were covered 
 with dirt. 
 
 Removal of the fragments of the fibula, — As there 
 was not the least chance of success in returning the 
 tibia and fibula within the integuments, in this state, 
 and as the patient was anxious for the preservation 
 of his leg, which I likewise was very desirous to save, 
 I judged it prudent to saw off the ends of the tibia 
 and fibula, the foot at the same time lying on a pil- 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 305 
 
 low below the leg; after removing the ends of the 
 tibia and fibula, I searched for the fractured portions 
 of the fibula left within the integuaients, by intro- 
 ducing the fore finger of my right hand into the 
 wound, and found its external malleolus fractured 
 into several small pieces, but still adhering by its 
 ligaments to the astragalus. Being fearful that these 
 shivered portions might be deprived of the proper- 
 ties of life, and that, if so, they might produce much 
 mischief, I resolved to dissect them out by means of 
 a bistoury through the wound. Having thus remov- 
 ed every fragment of the fibula, and rendered the 
 ends of the tibia -and fibula perfectly smooth by 
 means of a saw, not only removing their fractured 
 ends, but making the separation as high up as they 
 were stripped of their periosteum, about one inch 
 and a half in length, measuring from the malleolus 
 internus; I then returned the remaining part of the 
 tibia and fibula that had perforated the integuments, 
 placing it in a straight line with the leg; the lace- 
 rated integuments I brought into contact, and secur- 
 ed them by straps of adhesive plaster; the limb 
 was then placed upon a soft pillow, supported by 
 Mr Pott's long splints placed on the outside of the 
 pillow, and fastened with tapes; compresses of soft 
 linen cloth were applied; the leg was kept con- 
 stantly wet with the diluted solution of the acetate 
 of lead, and the following draught was given for the 
 first few days, every four hours, and afterwards 
 every six or eight, with a regimen strictly antiphlo- 
 gistic. 
 
 R. Pulv. Ipecacuanhae. c. gr. vj. 
 Magnes. Sulphat. 3j. 
 Aquae Purae. 3 ix. 
 
 Menthae. 3 iij. 
 
 Spt. Athens Nitros. 3ss. M. Ft. Haust. 
 
 Through the whole of the cure the man went on 
 39 
 
306 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 remarkably well, and had little symptomatic fever; 
 pulse constantly below the natural standard, between 
 60 and 70 ; skin soft and moist ; the action of the 
 intestines was regularly kept up by the draughts; 
 the integuments united by the first intention, without 
 the least secretion of pus. On the day seven weeks 
 from the accident, the patient was removed from 
 Baldock to his residence at Hewlington, and did not 
 require chirurgical aid afterwards. In a few months 
 afterwards he paid me a visit at Baldock, walked 
 perfectly well, and the leg was very little shorter 
 than the other. The last time 1 saw him was by 
 chance in April, 181. at the Bell New Inn, about three 
 miles below Baldock, where his coach stopped, and 
 he descended and ascended the box with great 
 agility. 
 
 I am, my dear Sir, 
 
 Your's most respectfully, 
 
 George Hicks. 
 
 COMPOUND DISLOCATION OF THE TIBIA OUTWARDS. 
 
 My friend and late dresser, Mr Cooper, of Brent- 
 ford, sent me the following valuable communication. 
 
 Case; longitudinal fradnre of the tibia, — Tho- 
 mas Smith, aged thirty-six, by trade a painter, whilst 
 at work on the 28th of October, 1818, fell with a 
 ladder to the ground, when, his leg getting between 
 two of its steps, the foot was dislocated inwards. 
 The fibula was broken five inches above the joint, 
 the tibia was fractured from the ankle-joint longitu- 
 dinally about three inches ; this small piece of tibia, 
 three inches in length, remained attached to the 
 joint at the inner malleolus, while an inch and a half 
 
DSLOCATIONS OF THE ANKLE-JOINT. 
 
 307 
 
 of the remaining portion of the tibia, with the ex- 
 tremity of the fibula, were thrust through an opening 
 in the integuments, at, and rather anterior to, the 
 outer malleolus. I was passing at the time, and at- 
 tempted by very moderate extension to reduce the 
 dislocation ; this not succeeding, and finding the in- 
 teguments tucked under the protruding portion of 
 bone, with a scalpel I dilated the wound anteriorly 
 and posteriorly about half an inch, and then, by 
 means of a metacarpal saw, removed rather more 
 than an inch of the tibia, and a small portion of the 
 fibula. This dislocation was now reduced without any 
 difficulty. The wound was closed by two ligatures 
 and a few straps of adhesive plaster. The patient 
 was placed on a mattress with the limb on the heel, 
 enveloped in an eighteen-tailed bandage, which was 
 applied just sufficiently tight' to give moderate sup- 
 port, without producing or increasing tension ; on 
 either side was placed a splint, and the limb was 
 kept constantly cool by means of an evaporating lo- 
 tion. 
 
 Subsequent to the operation, and during the 
 whole of the night, there was some haemorrhagy 
 from the articular arteries, but not sufficient to in- 
 duce me to undo the limb in order to secure the 
 bleeding vessels, and I did not open it till the 31st 
 of October, the fourth day, when considerable ad- 
 hesion had taken place, and the parts looked better 
 than I could have expected ; but on the eighth day 
 there was a line of separation formed about five 
 or six inches in circumference ; the wound was now 
 fomented, a linseed meal poultice was applied to it 
 every six hours, and the evaporating lotion was still 
 applied to the limb as far upwards as the knee. 
 On the thirteenth or fourteenth day the slough 
 came away, and healthy granulations were observ- 
 able, both upon the integuments, and also upon 
 
308 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 the extremity of the tibia; when these granula- 
 tions became exuberant, they were kept down by 
 the nitrate of silver, and the wound was slightly 
 dressed either with ungt. cetacei, or equal parts of 
 ungt. rcsinae and cerat. calaminae. In five weeks, 
 the wound was perfectly healed ; the union of the 
 fractured portions of the tibia went on so well, and 
 the ossific deposit at the joint became so firm, that 
 on Christmas day, being fifty-eight days from the 
 time of the accident, I found the man sitting at 
 his table dining with his family, and in three months 
 he was in the street, on crutches. 
 
 This patient had repeatedly suffered much from 
 colica pictonum; his digestive organs were unhealthy, 
 and he was a man of nervous temperament, all 
 which particulars I had to discover after the ac- 
 cident. As early as the third day he was very 
 restless; on the fourth, his sensorium was much 
 affected, and he was constantly vomiting ; by the 
 frequent administration, however, of the saline mix- 
 ture in the act of effervescence, his stomach was 
 quieted. 
 
 I ought to have observed that, on the night of 
 the accident, he took an opiate, and on the follow- 
 ing day I purged him ; but from the state of his 
 pulse, and from the degree of hcemorrhagy, I did 
 not find it requisite to take blood from the arm. 
 On the eighth day, his stomach being tranquil, we 
 were enabled to assist the separation of the slough, 
 by invigorating the powers of the system with bark 
 and port wine ; from half a pint to a pint of which, 
 with eight ounces of the decoction cinchonse and opi- 
 um, the quantity being regulated by his state of irri- 
 tability, enabled him to support the immense sup- 
 puration at the joint, which, from this time to the 
 fourth week, discharged most copiously. 
 
 I may here mention, that I never observed, on 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 309 
 
 the one hand, the stimulating effects of opium, and 
 on the other, its sedative effects, so strikingly 
 exemplified as in this man ; for if he did not take 
 quite enough to produce sleep, he was liter- 
 ally mad, tearing the bed-clothes, swearing, pray- 
 ing, singing, and making the oddest grimaces pos- 
 sible ; but if he had a full dose, which by the 
 third week had been increased to two drachms of 
 laudanum, he slept soundly and awoke refreshed; 
 and I believe his extremely susceptible state to 
 have been such, that, but for opium, which pro- 
 duced a directly sedative effect upon his nervous 
 system, he would have sunk from constitutional ir- 
 ritation. At the end of the second week, his 
 stomach being in a fitter state for digestion, he 
 was allowed a plentiful supply of animal food and 
 good beer, with which, and wine, bark, and opium, 
 continued for a week or two, he perfectly recov- 
 ered, 
 
 I am Sir, your's, etc., 
 
 George Cooper. 
 
 I saw this man on March the 1st, 1820, and I said, 
 * Would you rather have your present or an artificial 
 leg?' — ' Sir,' said he, ' my injured leg is nearly as 
 useful to me as the other; I can go up a ladder, and 
 follow my business as a painter, nearly as well as 
 ever.' A. C. 
 
 COMPOUND DISLOCATION OF THE TIBIA INWARDS. 
 
 Worcester, July 30th, 1819. 
 Dear Sir: — I have had no case of compound dis- 
 location of the ankle-joint under my care since I set- 
 tled in practice ; but my colleague, Mr Sandford, 
 
310 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 gives me the following information, which I do myself 
 the pleasure of transcribing. 
 
 Case, — A boy, fifteen years of age, was admit- 
 ted into the Worcester Infirmary with compound 
 dislocation of the ankle ; the protruding portion of 
 the tibia was sawn off, the anterior tibial artery was 
 taken up, the limb was placed on its outer side, the 
 wound dressed superficially, and the dressings retain- 
 ed with a many-tailed bandage, kept wet with the 
 liq. ammon. acet. Suppuration and granulation 
 came on kindly. The boy wore tin splints for a 
 length of time, and on his recovery had a slight 
 motion of the ankle-joint. 
 
 I am, my dear Sir, 
 
 Your's very respectfully, 
 J. Garden. 
 
 COMPOUND DISLOCATION OF THE TIBIA OUTWARDS. 
 
 Gloucester^ Sept, 1819. 
 
 Case, — My dear Sir : — Some domestic events 
 have delayed my reply to your letter. I remember 
 six cases of compound dislocation of the ankle-joint, 
 four of which underwent immediate amputation. In 
 the two other cases attempts were made to save the 
 limbs, and in one with success. Most of these acci- 
 dents were produced by machinery ; and the injury 
 to the joints and soft parts was so great as to destroy 
 all hopes of saving the limb. 
 
 In the limb that was not saved, though the at- 
 tempt was made, there had been too much mischief 
 done, and, after a trial of seven months, amputation 
 was performed. 
 
 1 was called to a fine young woman, eighteen 
 years of age, who had been consulting me not an 
 
DISLOCATIONS OF THE ANKLE-JOINT. 311 
 
 hour before on the case of her father, and who 
 having fallen from her horse, had suffered a com- 
 pound luxation of the ankle-joint externally. The 
 tibia and broken fibula protruded about an inch and 
 a half through the wound on the outside of the limb. 
 I sent her to the hospital, and in consultation propos- 
 ed that a sufficient quantity of the bones should be 
 removed to admit of restoration ; I advised this at- 
 tempt to save the limb, from observing that the ac- 
 cident took place by a heavy fall with the sole of the 
 foot to the ground, that it was unaccompanied by 
 contusions or violence committed by a blow or 
 wrench, and that the patient was a very healthy 
 country girl. There had been considerable haemorr- 
 hage. 
 
 The extremities of the bones were removed, the 
 reduction accomplished, and the limb supported by 
 a tailed bandage; splints were applied moderately 
 tight, and the bandages were directed to be kept 
 constantly soaked in a cold application. An opiate 
 was given. 
 
 On the following day there had been considerable 
 haemorrhage, but the limb was not disturbed. Great 
 suppuration took place about the joint, spread up 
 the limb, and greatly exhausted the patient, but she 
 recovered. These collections were never opened: 
 I should have opened them early, and thus perhaps 
 have prevented that extent of suppuration which so 
 much reduced the patient. 
 
 I am, very faithfully your's, 
 
 R. Fletcher. 
 
 The following I received from my friend, Dr Lynn. 
 
 Case, — A man on board the Walmer Castle, 
 East Indiaman, in the year 1808, whilst the ship was 
 
312 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 off the Cape of Good Hope, fell between decks, and 
 a cask of water rolllnoj upon his ankle, produced a 
 conjpound dislocation of the end of the tibia inwards. 
 I sawed off the projecting portion of the tibia, 
 brought the parts as closely as possible together, 
 applied evaporating lotions to the linoib, and the man 
 recovered without any dangerous symptoms. 
 
 James Lynn, M.D. 
 
 ADDITIONAL CASES OF COMPOUND DISLOCATION OF 
 THE ANKLE-JOINT. 
 
 Leicester^ June 29th, 1823. 
 
 Dear Sir : — Inclosed I send you the particulars 
 of the case of compound dislocation of the ankle-joint, 
 as extracted from the hospital books by Mr Wilkin- 
 son, the house surgeon, to whom the dressing of the 
 injury belonged. 
 
 Two other cases have occurred to me in private 
 practice, which, although I have taken no particular 
 notes, are valuable in fact, as showing the efficiency 
 of the practice adopted in the detailed case which I 
 have sent you. The wounds in the two cases did 
 not heal by the first intention, and the synovial fluid 
 was discharged for some time, yet they ultimately 
 healed, and did well. One of the cases, as I have 
 since had opportunities of knowing, has completely 
 recovered tlie free use of the ankle. 
 
 Case, — Catherine Paddimore, aged seventy-two, 
 was admitted into the hospital on the afternoon of 
 September 4, 1821, from the country, with compound 
 dislocation of the ankle-joint. She was in the act of 
 picking up pears, when her husband fell from the 
 tree, and lighted on her back, which occasioned the 
 accident. On examination, after removing a consid- 
 
DISLOCATIONS OF THE ANKLE-JOINT. 313 
 
 erable quantity of blood, the inferior extremity of 
 the tibia of the right leg was protruding nearly three 
 inches through a laceration of the integuments; the 
 foot turned completely outward ; • the fibula was 
 fractured in two places. The patient being placed 
 in bed on her right side, and the wound being clean- 
 ed, the knee was flexed, and, with moderate exten- 
 sion, the dislocated tibia was reduced, and the fibula 
 adjusted. The wound was approximated with ad- 
 hesive straps ; M. Dupuytren's splint and bandage, 
 and an evaporating lotion were applied. The patient 
 was retained on the right side, and the limb flexed: 
 she was verv much exhausted. Her bowels were 
 soon acted on by the sulphate of magnesia. 
 
 September 5th. No sleep; tongue furred ; pulse 
 frequent and strong; bowels well opened; no great 
 pain of the ankle, and trifling swelling. Fiat vene- 
 sectio e brachio ad 3 xx. vespere. Pain and swell- 
 ing of the ankle a little increased; pulse frequent 
 and soft. Admoveantur hirudines No. xvi. statim. 
 She takes liq : ant: tart, small doses of the sulphate 
 of magnesia, with a febrile julep, every three hours. 
 
 September 6th. Slept several hours ; pulse fre- 
 quent and soft ; skin comfortable ; bowels not open 
 since yesterday ; tongue furred ; makes no complaint 
 of the leg, which looks remarkably well. She re- 
 peated the sulphate of magnesia. 
 
 September 8th. No pain or swelling about the 
 ankle-joint ; bowels open. 
 
 September 9th. The wound was dressed ; the 
 adhesive process far exceeded expectation ; no pain. 
 
 September 13th. Wound healing. 
 
 September 28th. Wound well. 
 
 October 4tb. Allowed to sit up. 
 
 October 13th. Can walk with crutches, 
 40 
 
314 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 She has now perfect use of the joint, and could 
 walk very well last summer, without crutches. 
 
 Your's very truly, 
 
 John Needham. 
 
 DISLOCATION OF THE ANKLE OUTWARDS. 
 
 Case, — William Thomas, aged eighteen, was ad- 
 mitted into Guy's Hospital, June 28th, 1823, with 
 a compound dislocation of the ankle outwards, caus- 
 ed by a hogshead of tobacco falling upon his leg. 
 
 The foot was doubled inwards, and the malleolus 
 externus broken, which being immediately removed, 
 the limb was placed upon a splint on its inner side, 
 with the knee bent, two sutures were applied to 
 bring the edges of the wound together, and a piece 
 of lint placed over it ; the leg was kept well wetted 
 with the liq : plumb: acet: dil. The patient was 
 ordered to take forty drops tinct : opii:, and not to 
 be disturbed. 
 
 June 29th. Ordered calomel gr. v, and an ape- 
 rient draught to be taken afterwards. 
 
 June 30th. The lint was removed from the 
 wound, and a poultice ordered : no febrile symp- 
 toms appearing, this treatment was continued, with- 
 out medicine, till July 14th. 
 
 July 15th. The opiate lotion was ordered instead 
 of the poultice. 
 
 July 16th, 17th. The same treatment continued. 
 
 July 18th. He passed a restless night, and had a 
 white tongue and quick pulse ; with inflammation 
 and swelling of the leg; complained of great p^in. 
 Ordered the saline draught every three hours. 
 
 July 25th. Matter formed along the tibia ; an 
 opening was made, and a large quantity evacuated ; 
 
DISLOCATIONS OP THE ANKLE-JOINT. 
 
 315 
 
 a poultice was applied over the opening, and the 
 opiate lotion continued to the wound. 
 
 July 28th. It was now judged expedient to 
 change his diet, and his medicines : he was allowed 
 animal food with porter; and bark, with ammonia, 
 was given every six hours. 
 
 August 6th. Matter had again formed; another 
 opening was made, and the same treatment pursued; 
 his diet and m.edicines were continued as before. 
 After this period he rapidly recovered, and at the 
 latter end of the month was able to rise from his 
 bed. The wound always looked healthy. 
 
 DISLOCATION OF THE ANKLE FORWARDS. 
 
 JVew Bridge Street^ Blackfriars ; 
 
 Marck 4th, IH24. 
 
 My dear Sir: — I have much pleasure in sending 
 you an account of the case I mentioned to you last 
 night, together with a sketch by which I have en- 
 deavoured to show the position of the limb at the 
 time when I saw the patient. 
 
 Case, — James Price, aged thirty-nine, a very ro- 
 bust man, was coming to town on iMonday, the ist of 
 March, in a light cart, drawn by one horse. In 
 passing through Clapham the horse ran away, and 
 falling, overturned the cart, and threw Price's legs 
 under one of the shafts ; in endeavouring to extri- 
 cate himself, he received a severe injury to the right 
 ankle. By the direction of Mr Parratt, he was im 
 mediately conveyed to St Thomas's Hospital, where 
 I saw him ; and, on examination, found that the tibia 
 had been dislocated forwards, and a little inwards, 
 its inferior extremity resting on the fore part of the 
 astragalus and os naviculare: the deltoid ligament 
 must have been torn through, as the inner malleolus 
 was not fractured. The heel projected very consid- 
 
316 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 erably, and the foot was turned outwards in a slight 
 degree and downwards, the toes being pointed. The 
 fibula was fractured about two inches above the 
 external malleolus, at which part there was a con- 
 siderable depression. The reduction was very ea- 
 sily accomplished by flexing the leg on the thigh, 
 Avhich was firmly held by my dresser, Mr Campbell, 
 as I drew the foot downwards and forwards, and 
 pressed the tibia backwards. The limb was placed 
 in the flexed position, on the heel; since which time 
 the patient has been perfectly tranquil, and the limb 
 remains in its proper position. 
 
 Believe me, your's most sincerely, 
 
 Frederick Tyrrell. 
 
 Experiment, 
 
 I was anxious to ascertain what steps nature pur- 
 sued in order to restore a oart in which the ex- 
 tremity of a bone, forming a joint, had been sawed 
 off ; and I therefore instituted the following experi- 
 ment. 
 
 I made an incision upon the lower extremity of 
 the tibia, at the inner ankle of a dog, and cutting 
 the inner portion of the ligament of the ankle-joint, 
 I produced a compound dislocation of the bone in- 
 wards. I then sawed off* the whole cartilaginous 
 extremity of the tibia, returned the bone upon the 
 astragalus, closed the integuments by suture, and 
 bandaged the limb to preserve the bone in this situ- 
 ation. Considerable inflammation and suppuration 
 followed ; and in a week the bandage was removed. 
 When the wound had been for several weeks per- 
 fectly healed, I dissected the limb. The ligament 
 of the joint was still defective at the part at which 
 it had been cut. From the sawn surface of the 
 tibia there grew a llgamento-cartilaginous substance, 
 which proceeded to the surface of the cartilage of 
 
DISLOCATIONS OF THE ANKLE-JOINT. 317 
 
 the astragalus, to which it adhered. The cartilage 
 of the astragalus appeared to be absorbed only in 
 one small part ; there was no cavity between the 
 end of the tibia and the cartilaginous surface of the 
 astragalus. A free motion existed between the tibia 
 and astragalus, which was permitted by the length 
 and flexibility of the ligamentous substance above 
 described, so as to give the advantage of a joint 
 where no synovial articulation or cavity was to be 
 found. This experiment not only shows the man- 
 ner in which the parts are restored, but also the 
 advantage of passive motion : for if the part be fre- 
 quently moved, the intervening substance becomes 
 entirely ligamentous ; but if it be left perfectly at 
 rest for a length of time, ossific action proceeds 
 from the extremity of the tibia into the ligamentous 
 substance, and thus produces an ossific anchylosis. 
 
 CASES WHICH RENDER AMPUTATION NECESSARY. 
 
 Cases requiring amputation, 8rc, — But still cases 
 occur in which amputation is found absolutely neces- 
 sary, either to preserve the life of the patient, or to 
 prevent his being doomed to the constant necessity 
 of using crutches on account of the deformity and 
 stiffness of the limb. 
 
 It seems to me, however, to be by much too pre- 
 vailing an opinion, that the amputation of the limb 
 is a sure means of. preserving life ; for when this 
 operation used to be more frequently performed in 
 our hospitals than it now is, for compound disloca- 
 tion of the ankle and compound fracture of the leg, 
 a considerable number of our patients died. Very 
 lately a man at Tring had his foot torn off by a 
 threshing machine, and the limb was obliged to be 
 amputated at the usual place below the knee. The 
 
318 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 operation was performed by Mr Firth, but the man 
 died in the evening of the sixth day; and a case has 
 occurred since the pubHcation of the second edition 
 of my Essays of equally fatal termination. 
 
 The circumstances which 1 have known to create 
 this necessity are, 
 
 (1.) The advanced age of the Patient, 
 Age, — Under great age the powers of the body 
 become so much w^eakened, that the patient is unable 
 to bear the constitutional excitement which the sup- 
 purative inflammation of the joint produces ; and as 
 amputation does not expose him to this process, it is 
 better to have recourse to that operation. How- 
 ever, I ought to observe, that w^hen in my lectures 
 I have stated what I have now advanced, the pupils 
 have flocked around me after lecture, and have told 
 me of cases of recovery, even of very old persons; 
 bu-t in the practice of hospitals in this great metro- 
 polis, very aged persons sink under these accidents, 
 if the limb be not amputated. 
 
 (2. ) A very extensive lacerated Wound will give rise to 
 a necessity Jor this operation. 
 
 Case; laceration, — July 10th, 1806, Mr Dudin^ 
 a gentleman residing in Horsley-down, Borough, 
 jumped out of his one-horse chaise, and dislocated 
 the tibia inwards at the ankle, through a large lace- 
 rated wound, and a portion of the malleolus internus 
 was broken ofl" and remained attached to the astra- 
 galus. The wound bled freely, and the foot was 
 loose and pendulous; I therefore felt myself obliged 
 to amputate the limb. 
 
 Mr D., after this operation, proceeded in every 
 respect favourably; recovering without any unto- 
 w^ard symptom. 
 
 Case, — James Morrise, aged thirty-six, was ad- • 
 
niSLOCATIONS OF THE ANKLE-JOINT. 3l9 
 
 mitted into St Thomas's Hospital, on the 29th of 
 January, 1824, under the care of Mr Green, with a 
 dislocation of the ankle-joint, in consequence of 
 having his leg caught in the coil of a rope, to which 
 a great weight was appended. 
 
 The injury was accompanied with so much loss 
 of integument that immediate amputation was pro- 
 posed, to which the man would not give his consent. 
 Mr Green sawed off the end of the bone and replaced 
 the tibia upon the astragalus ; but the end of the tibia, 
 from deficiency of skin, still remained exposed. 
 The constitutional and local irritation which followed 
 rendered it necessary to amputate the limb, which 
 was done on March the 19th, being seven weeks 
 and one day after the accident. With Mr Green's 
 permission I then dissected it, and the followinfij is the 
 
 Dissection. 
 
 The cellular membrane was loaded with serum; 
 all the muscles remained in a sound state, but the 
 tendon of the tibialis anticus was partially torn, as 
 was that of the peroneus tertius ; 'those of the tibia- 
 lis posticus, and flexor longus digitorum pedis, adher- 
 ed strongly to the posterior portion of the capsular 
 ligament. An abscess extended between the tibia- 
 lis posticus and gastrocnemius muscles from the ankle 
 nearly to the place of amputation. The arteries 
 anvl nerves were undivided, but the anterior tibial 
 artery was greatly diminished by the altered posi- 
 tion and pressure of the tibia. The deltoid liga- 
 ment, the anterior part of the capsular, and the liga- 
 ment of the tendon of the tibialis anticus, were 
 torn through. The fibula was broken four inches 
 from the ankle-joint ; its lower fractured extremity 
 overlapped the upper about an inch, and the latter 
 was situated between the lower portion of the fibula 
 
320 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 and the tibia. The bones were not completely unit- 
 ed, and the fibula was exfoliating at the upper end 
 of the lower portion; a part of the fibula also re- 
 mained detached, which had been broken off at the 
 time of the accident. The lower end of the tibia 
 was dead and exfoliating, and rested but partially 
 upon the astragalus : its periosteum was much thick- 
 ened above the exfoliating part. The outer poste- 
 rior portion of the tibia next the fibula was broken 
 off, and strongly adhered to the fibula. The surface 
 of the astragalus was in parts deprived of its car- 
 tilage by ulceration. 
 
 The exposure and consequent exfoliation of the 
 tibia, the exfoliation of the fibula, and the large 
 abscess, led to the necessity for amputation. 
 
 (3.) A difficulty in reducing the Bones has been con- 
 sidered as a reason jor amputation. 
 Difficult reduction. — This circumstance, however, 
 is rather a motive for removing the extremities of 
 the bones by the saw than for performing amputa- 
 tion ; after which removal the reduction of the 
 tibia is easily effected, and a useful limb is preserv- 
 ed to the patient. 
 
 (4.) The Bones are sometimes extremely shattered. 
 Bones shattered, — If the lower extremity of the 
 tibia be broken into small pieces, the loose portions 
 of bone ought to be removed, and the end of the 
 tibia to be smoothed by a saw ; but if, in addition 
 . to this comminution, the lower extremity of the 
 tibia be obliquely broken, and a large loose portion 
 of bone be felt with the fingers, then it will be 
 roper to amputate : also, if the astragalus be bro- 
 en, the portions of this bone should be removed, 
 otherwise they will separate by ulceration, or occa- 
 sion considerable local irritation. (See Dr Lynn's 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 321 
 
 and Dr Rurasey's cases ) But if the end of the 
 tibia and the tarsal bones, as the astragalus and os 
 tialciS, are broken, then amputation will be requir- 
 ed. The following case clearly shows the necessity 
 of the operation in such a state of parts. 
 
 Case, — I was requested to see a lady, aged thirty- 
 four years, who, on August the Oth, 1819, had, in a 
 fit of insanity, jumped out of a two pair of stairs 
 window, and produced a compound dislocation of the 
 tibia and fibula at the outer ankle. At the lady's 
 residence I met Mr Stephens, a surgeon residing in 
 Hunter- street, Brunswick-square, who had been 
 called immediately after the accident. As she ap- 
 peared almost insensible, and Mr Stephens feared 
 an injury to the brain, he took away twelve ounces 
 of blood. When he examined the ankle, he found 
 the malleolus externus of the fibula projecting 
 through the wound, but unbroken, the tibia dislo- 
 cated and broken, and the foot verj much turned 
 inwards. He extended the foot, and thought that 
 the bones had exactly returned into their natural 
 situation; adhesive plaster was applied upon the 
 wound, and its edges were nicely adjusted. She 
 was placed on a mattress with the limb upon the 
 heel, and with a splint on each side of the leg. 
 For seven days she complained of tittle pain, and 
 had but slight constitutional disturbance. On the 
 day week from the accident I was requested to 
 see her; and finding little local or constitutional 
 irritation, I recommended that the limb should not 
 be disturbed, and the dressings were not removed, 
 
 On the tenth day from the accident, Mr Stephens 
 finding her in more pain examined the wound, and 
 found that it had not adhered. 
 
 On the twelfth day, a considerable discharge issu- 
 ed from the wound. 
 
 On the sixteenth day a slough had separated and 
 
322 DISLOCATIONS OF THE ANKLE-.IOlNt. 
 
 exposed the bones, which appeared shattered and 
 projecting. On this day I again saw her, and upon 
 examining the ankle found the astragalus projecting, 
 and a portion of it broken; and as the surrounding 
 parts were dead I removed the projecting bone. 
 Introducing my finger into the wound as soon as the 
 astragalus had been separated, the tibia was found 
 to be shattered, and the os calcis broken into many 
 pieces. As her pulse was 100 and small, and her 
 strength was failing, I Immediately recommended 
 her to submit to the operation of amputation, to 
 which she consented. 
 
 On the Monday following, the stump was dressed 
 by Mr Stephens, and the greater part was adhering. 
 
 Two of the ligatures separated on the tenth day, 
 and the other came away on the sixteenth day. 
 
 September 29th. The stump was healed, ex- 
 cepting about the size of the section of a pea, and 
 she had no complaint remaining excepting a sore 
 upon her back, and pain in her left foot. 
 
 It is proper to mention that she hurt her spine 
 and kidneys by the fall, so as to discharge urine 
 tinged with blood for three weeks after the acci- 
 dent. 
 
 The other ankle also was most severely injured^ 
 and she suffered exceedingly from pain in it. 
 
 Upon examination of the amputated limb, the 
 tibia was split up from the malleolus internus to 
 the extent of three inches; the fibula was unbrok- 
 en ; the astragalus was broken and detached ; and 
 the OS calcis was fractured into several pieces. 
 
 I have lately had another case of the same kind 
 in which I was obliged to amputate. {See Plate.) 
 
 (5.) The Dislocation of the Tibia at the Outer Ankle ^ 
 Produces much more injury and danger than 
 that at the inner, and amputation will be more fre- 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 323 
 
 quently required for it, because both the bones and 
 soft parts suffer more than in the dislocation inwards. 
 
 (6.) It sometimes happens that when the Bone is 
 replaced^ it will not remain in its Situation, and all 
 the Symptoms of the Injury become renewed. 
 Oblique fracture with dislocation. — This circum- 
 stance arises when the tibia, in the dislocation out- 
 wards, is obliquely broken; and as only a small 
 portion of the articulating surface remains on the 
 dislocated extremity of the tibia, it will not rest on 
 the tibia when it is reduced. 
 
 Mr Andrews, of Stanmore, and Mr Foote, of 
 Edgware, consulted me on the following case. 
 
 Case, — Mr Andrews and Mr Foote were sent 
 for on August the 9th, 1817, to the Hyde, six miles 
 from London, to visit Charles Tomlin, a higgler, 
 forty-eight years of age, who falling in a state of 
 intoxication, the wheel of his cart passed over his left 
 leg, and produced a protrusion of the bones through 
 the integuments at the outer ankle. Mr Andrews 
 reduced the dislocation in the evening of the acci- 
 dent. On the same night Mr Andrews and Mr 
 Foote having visited him again, found his pulse very 
 quick, and spasms in the limb, which had again dis- 
 placed the bone. They gave him a large dose of 
 opium, and succeeded in reducing the bones. 
 
 On the 10th, he had a very quick pulse, accom- 
 panied with strong spasms in the limb, but not suf- 
 ficiently severe to displace the bone. 
 
 On the nth, I was requested by Mr Andrews and 
 Mr Foote, as 1 was going through the village, to stop 
 and see this man ; and as soon as the bandages were 
 removed a violent spasm threw the bones from the 
 astragalus, and all the efforts I could make would not 
 replace them. Seeing, therefore, no hope of the man's 
 recovering without the amputation of the limb 1 im- 
 mediately proposed it, and he readily gave his consent. 
 
324 DISLOCATIONS OF THE ANKLE-JOlNT. 
 
 For three or four days he had a great deal of 
 nervous irritation, which was most etfectuallj^ re- 
 h'eved by occasional doses of opium and gether. 
 
 On the 18th the stump was inflamed and in some 
 parts sloughy ; and on the 22nd it bled profusely. 
 
 On the 23th a poultice was applied; and from 
 this time the appearance of the stump improved, 
 and he proceeded without interruption in his recov- 
 ery. In a month he returned to his home at Bushey, 
 a distance of seven miles. 
 
 Upon examination of the limb I found the cellular 
 membrane around the ankle loaded with extravasat- 
 ed blood ; the ligamentum annulare tarsi was torn. 
 The muscles were all remaining whole, though some 
 of them, as the peronei, were much put upon the 
 stretch. The fibula was broken one inch above the 
 lower extremity of the malleolus externus, which 
 remained in its place, still united by its ligaments to 
 the tarsus. .The tibia was split down from two 
 inches above the joint, leaving the greater part of 
 the articulating surface still resting upon the astra- 
 galus; but the remaining portion of the articulating 
 surface, with the shaft of the tibia and the fibula, 
 passed through the wound at the outer ankle. If, 
 therefore, the bone had been again returned to its 
 situation, it could not have remained there, from the 
 small portion of articulating surface attached to it ; 
 and if the projecting portion had been removed by 
 the saw, it would not have adapted itself to the 
 portion of the tibia which remained attached to the 
 astragalus. 
 
 (7.) The Division of a large Blood-Vessel mighty 
 with an extensive Wound of the Integuments, lead to 
 a necessity for j^mputation. 
 
 Division of an artery. — But I should not, on that 
 account, at once proceed to the operation. The 
 
DISLOCATIONS OF THE ANKLE-JOINT. 
 
 325 
 
 case from Mr Sandford, of Worcester, sent me by Mr 
 Garden, clearly shows that the division of the anteri- 
 or tibial artery does not, if it be well secured, pre- 
 vent the patient's recovery. I also once saw a com- 
 pound fracture close to the ankle-joint, accompanied 
 by a division of that artery ; yet, although the patient 
 was in the hospital, and, being a brewer's servant, 
 possessed the worst constitution to struggle against 
 severe injuries, this man recovered without amputa- 
 tion. 
 
 The posterior tibial artery is a vessel of more im- 
 portance, and is accompanied by a large nerve, which 
 would not be likely to escape injury when the artery 
 was divided by the dislocated bone. Yet the mag- 
 nitude of the anterior tibial artery, and its free anas- 
 tomosis with the posterior, would not entirely pre- 
 clude the hope of preserving the foot under an injury 
 of the posterior tibial artery. 
 
 (8.) Mortification of the Foot 
 
 Sometimes ensues, and becomes a sufficient reason 
 for amputating the limb ; but this must be generally 
 done when limits appear to be set to the extension 
 of the mortification. However, it may be observed, 
 that in the mortification which ensues from the di- 
 vision of a blood-vessel, where the brachial artery 
 had been divided, and the elbow-joint dislocated, I 
 have seen the arm removed above the injured part, 
 while the limb was still dying towards the' seat of 
 the wounded artery, and the patient was restored to 
 health. And I have also known a case of popliteal 
 aneurism, in which the artery and surrounding parts 
 were so compressed by the swelling, that mortifica- 
 tion began at the foot, and was extending to the 
 knee; and, although no limit was yet set to the 
 mortification, the limb was amputated, and the pa- 
 
326 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 tient recovered. So that mortification, when it 
 arises from injury to a blood-vessel, or other local 
 injury, in a healthy constitution, admits of a practice 
 different from that which is pursued in mortification 
 arising from constitutional causes. 
 
 Excessive contusion may he another reason for 
 Jlmputalion ; 
 And therefore in those cases in which hea- 
 vy laden carriages pass over joints, and bruise 
 the integuments so as to occasion the formation 
 of extensive slough, and produce at the same 
 time, generally, the worst examples of compound 
 dislocation, in regard to the state of the bones, I 
 should immediately amputate ; for such cases are 
 very different from those which are caused by jump- 
 ing from a considerable height, from a carriage ra- 
 pidly in motion, or by a fall in walking or running. 
 
 Extensive Suppuration will also be a reason for 
 Amputation. 
 
 Suppuration, — I have known, after an attempt 
 to save the limb, the patient have more extensive 
 suppuration than his constitution could support, fol- 
 lowed by an ulceration of the ligaments, by which 
 the joint became additionally exposed, and the bones 
 were again displaced; hence there arose an absolute 
 necessity to remove the limb for the preservation of 
 his life. 
 
 (9.) A necessity for Amputation may also he produc- 
 ed hy Exfoliations of Portions of Bone, 
 Which, locked in the surrounding parts of 
 the bone, are incapable of becoming separated, 
 and thus keep up a state of continued irrita- 
 tion. My friend, Mr Hammick, had the kindness 
 
DISLOCATIONS OP THE ANKLE-JOINT. 
 
 32t 
 
 to send me a specimen of this kind, which he was 
 obliged to amputate. The loose portion of bone 
 was seated between the lower extremity of the 
 tibia and fibula, and reached to the ankle-joint ; both 
 the bones had been broken and had become reunit- 
 ed, and the uniting medium had inclosed and incar- 
 cerated the dead portion of bone. It is probable, 
 from the appearance of the parts, that this portion 
 of bone never would have been able to escape from 
 the place in which it was locked. (See Plate.) 
 
 (10.) Excessive Deformity of the Foot 
 Will also give rise to a necessity for ampu- 
 tation; and this deformity will take place in 
 three directions. First, when the foot is suffered 
 to turn outwards, whilst the leg is placed upon the 
 heel, in the dislocation inwards. Secondly, when it 
 is turned inwards ; and thirdly, when the foot re- 
 mains pointed. The first is best opposed by placing 
 the leg upon its outer side, when that is compatible 
 with the treatment of the wound ; in the second 
 case it is best to keep the foot on the heel; and in 
 both cases, splints, having a foot-piece both on the 
 inner and outer side of the foot, must be applied : 
 the third requires similar splints, and a (ape, as a 
 stirrup, placed under the foot, and fastened to the 
 splint on the fore and middle part of the leg to keep 
 the foot supported. The splints should be so pad- 
 ded as to preserve it in its proper direction. (See 
 Plate.) 
 
 The following case from Mr Norman, of Bath, 
 shows the necessity for amputation, when great de- 
 formity is permitted to occur. 
 
 Case. — I was sent for to Bradford, some years 
 since, to amputate a leg directly after an accident 
 of this kind. I found the lower extremity of the 
 
328 DISLOCATIONS OF THE ANKLE-JOlNTi 
 
 tibia, with the astragalus loosely ^^attached to it, pro- 
 jecting at the inner ankle. The wound was not 
 large, and the soft parts were little injured. I re- 
 moved the astragalus, and reduced the tibia, leav- 
 ing it to rest upon the os calcis. I did not again 
 ^ee my patient during the healing of the wound; 
 I believe it got well without any severe symptoms, 
 but the OS calcis was drawn up against the poste- 
 rior part of the tibia, to which it firmly united, and 
 the foot became immovable, with the toe pointed 
 downwards. In this state he came to Bath two 
 years afterwards, when I amputated the leg, and 
 the patient did well. 
 
 Bath^ August 2nd, 1819. George Norman. 
 
 (11.) Amputation has been recommended in those 
 cases in which Tetanus occurs after this Injury. 
 Tetanus ; case, — Of tetanus I have seen one 
 case from compound dislocation of the ankle, and 
 have heard of another. That which I saw was in 
 a Mr Yare, stable-keeper, who had a compound 
 dislocation of the tibia inwards, and in whom I re- 
 duced the bones, and placed the limb on its outer 
 side. For a few days he proceeded without any 
 alarming symptoms. The only circumstance in 
 which his case differed from what I expected was 
 in the slight inflammation which succeeded upon 
 the joint, for the restorative process seemed to be 
 scarcely established in him. When I paid him my 
 morning visit, several days after the accident, he 
 said, ' Sir, I believe I have caught cold, for my 
 neck is stiff;' and as he said this with his lower jaw 
 raised and his teeth closed, I begged him to show 
 me his tongue, to ascertain if the jaw was locked ; 
 and he tried to open his mouth, but was unable to 
 do so. I then desired that Dr Relph might see 
 
DISLOCATIONS OF THE ANKLE-JOINT. 329 
 
 him, who did all that his mind could suggest to ar- 
 rest the progress of the symptoms, but unsuccess- 
 fully, as the different muscles of volition became 
 affected in the back, the extremities and the abdo- 
 men, until he was exhausted by irritation. To am- 
 putate under such circumstances would be most un- 
 justifiable, as far as the experience of cases in this 
 climate will enable me to form an opinion. I have 
 not seen amputation performed for compound dislo- 
 cation of the ankle, but I have seen it performed 
 for compound fracture just above the joint, and it 
 seemed to me to precipitate the fatal event. I 
 have also known, in one case, the finger amputated 
 for tetanus arising from injury to it, yet the patient 
 died ; and 1 have also heard of a third case in which 
 it was practised, but still the issue was fatal. There 
 is a species of chronic tetanus, which sometimes even 
 succeeds wounds, and which will occasionally subside, 
 and, apparently, the patient will recover, although 
 little be done by medicine, and nothing by surgery; 
 in such cases it would not be justifiable to amputate. 
 If any medicine be efficacious, submurlas hydrar- 
 gyri, with opium, is that under which I have seen 
 the majority of these cases recover: and opium 
 should also be applied to the wound.* 
 
 * In the year 1819, 1 was called to see a man of 55 years old, 
 who had suffered a compound fracture of the tibia and fibula by 
 the fiilling" of a large log- across his leg. The bones were frac- 
 tured about three inches above the ankle-joint, and the superior 
 fractured portion. of the tibia projected for two inches and a half 
 through the external wound; the substance of the muscles and 
 the fibula were also considerably crushed. The patient being a 
 servant on a farm and his chance of receiving proper diet and 
 attendance being very doubtful, together with his age, the ex- 
 tent of the injury, and the extreme warmth of the weather, de- 
 termined US to amputate the limb, for which immediate pre- 
 parations were made. The owner of the farm accidentally over- 
 hearing the consulting surgeon, (Dr John W. Buckler, now a 
 42 
 
330 
 
 DISLOCATIONS OP THE ANKLE-JOINT. 
 
 (12.) A very irritable State of Constitution 
 Will sometimes render all treatment unavailing to 
 save the limb, and Avill novi^ and then prove destruc- 
 tive, even if the operation be performed. There 
 are some persons originally constituted with so irri- 
 table a system, that the slightest injuries will destroy 
 them. There is a much greater number whose 
 constitutions, originally good, have been so much 
 injured by excess, by want of exercise, by over 
 exertion of mind, by drinking freely of spirits and 
 eating but little, that to them the slightest accidents 
 prove fatal. 
 
 Case, — One of the most curious examples of this 
 kind which I have seen was in a man who worked 
 at Barclay's Brewhouse, in the Borough. The cir- 
 cumstances were these. 
 
 On Saturday he was turning a cask, and a splinter 
 of wood entered his thumb, which he immediately 
 drew out. 
 
 On Sunday night he requested his wife to rise 
 and make him a poultice ; for his thumb, he said, 
 was painful. 
 
 On Monday he sent for Mr John Kent, surgeon in 
 the Borough, who found his thumb inflamed and 
 painful. 
 
 most respectable and distinguished practitioner in Baltimore, 
 Md) speak of the possibility of saving such a limb under more 
 favourable circumstances, overruled our decision and insisted 
 that we should attempt to save the limb. In consequence the 
 fracture was reduced, ihe limb dressed in the usual manner, and 
 the patient carefully attended to during the ensuing fourteen 
 days. On the 15th day from the accident he began to complain 
 of stiffness of the lower jaw, and on the 16th, notwithstanding 
 all the remedies exhibited, he expired under all the agonies of 
 con6rmed tetanus. Had amputation been performed, as pro- 
 posed, I cannot help believing that the life of this man would 
 have been preserved. J. D. G. 
 
DISLOCATIONS OF THE ANKLE-JOINT. 331 
 
 On Tuesday the inflammation had extended to the 
 hand and fingers. 
 
 On Wednesday a swelling appeared at the wrist, 
 above the ligamentum annulare carpi, and the man 
 had a great deal of irritative fever, and was obliged 
 to keep his bed. 
 
 On Thursday, after lecture, Mr Kent came to me, 
 requesting I would see this man, who had been de- 
 lirious during the night ; his arm being much con- 
 vulsed, and his body becoming generally so. I went 
 with Mr Kent, and feeling the thumb, discovered a 
 fluctuation in the theca. I put a lancet into the 
 extremity of the thumb, and a considerable quantity 
 of pus issued. Gratified with the expectation of 
 his being relieved by the discharge of the matter, I 
 was going out of the room to express this feeling to 
 his friends, when I heard a rustling on the bed be- 
 hind me; and upon Mr Kent and myself turning 
 back, we saw him under the influence of a convul- 
 sive fit, which raised him in his bed, and in which 
 he fell back and expired. 
 
 Living as these persons generally do, principally 
 upon porter and spirits, they have constitutions 
 which render them the worst subjects for accident?. 
 
 The following case shows the violent symptoms 
 and quick dissolution which will, from the same 
 cause, occasionally ensue in compound dislocation of 
 the ankle. 
 
 Case, — On the 10th of June, 1809, 1 was request- 
 ed to go immediately to Gracechurch-street, to see 
 a Mr Fenner, who, in walking opposite to the City 
 of London Tavern, had slipped from the foot-way 
 and produced a compound dislocation of the ankle. 
 The tibia projected at the inner ankle ; the fibula 
 was broken ; and the skin was tucked in under the 
 extremity of the tibia. 
 
332 
 
 DISLOCATIONS OF THE ANKLE-JOINT. 
 
 First: — I immediately procured a mattress for 
 him, instead of a feather bed. 
 
 Secondly : — A many-tailed bandage ; /splints lined 
 with wool ; and pillows and tapes. 
 
 Thirdly: — The skin was divided, and the bone 
 reduced ; but it was much opposed by violent spasm 
 of the muscles. 
 
 Fourthly : — The edges of the wound were close- 
 ly adjusted. 
 
 Fifthly: — The bandage and splints were appli- 
 ed; and the limb was placed upon pillows on its 
 outer side, with the knee bent. 
 
 Sixthly: — Bled to 145, and opium given; tinct. 
 opii. gtt. XXX. 
 
 June 11th. His night had been restless; his 
 tongue was white; liis pulse beat 110 strokes in a 
 minute; he had violent pains in the ankle, and had 
 vomited. Ordered oleum ricini, as his bowels had 
 not been relieved. Evening: — He had almost 
 constant spasms of the muscles of the leg; he had 
 not slept, and had no appetite, The oleum ricini 
 had produced four evacuations. 
 
 June 12th. His pulse was 120; his tongue more 
 furred. He had violent and very frequent spasms. 
 He had nausea, but had not vomited since the last 
 report. He had had one evacuation. Blood was 
 extravasated about the ankle ; and a sanious serum 
 was discharged from the wound. Ordered opium, 
 
 June 13th. Had slept three hours. There was 
 some inflammation about the wound, and swelling of 
 the leg, with spasms, but they were less violent than 
 yesterday. A poultice was applied to the ankle, and 
 fomentations ordered. Pulse 120; his tongue was 
 very much furred. Evening: — In most violent 
 pain; he was ordered submurias hydrargyri five 
 grains, with two grains of opium, and the saline medir 
 cine with antimony. 
 
DISLOCATIONS OF THE; ANKLE-JOINT. 333 
 
 June J4th. The spasms continued, but the pain 
 had in a great degree ceased. He had had several 
 evacuations, but had been delirious during the night. 
 The limb was but little swollen; the foot appeared 
 slightly inflamed, but there was no healthy discharge, 
 nor any granulations beginning to form. The former 
 treatment was ordered to be continued. 
 
 June l.Oth. He had passed a bad night, having 
 been delirious through a great part of it. He had a 
 violent spasm in the limb this morning, which pro- 
 duced a slight hasmorrhage, which was stopped by 
 pressure. His leg w^as swollen, and the wound ap- 
 peared to be without action. His pulse was equal- 
 ly quick, and he took no nutriment. 
 
 June 16th. He had spasms in the thigh of the 
 same side, and in the other leg, as much as in the 
 injured limb 5 in other respects he remained the 
 same. 
 
 June 17th. He was delirious during the previous 
 night, and bleeding was again produced by the vio- 
 lence of the spasms. His pulse was considerably 
 quicker than before. 
 
 June 18th. He died at four o'clock in the after- 
 noon. 
 
 Corpulent persons, — Persons who are much load- 
 ed with adeps are generally very irritable, and bear 
 important accidents very ill ; indeed they frequently 
 perish, whatever plan of treatment be pursued : to 
 this statement, however, there are exceptions in those 
 who, though corpulent, are still in the habit of tak- 
 ing much exercise, as they will retain some vigour of 
 constitution ; and in such persons the limb may be 
 attempted to be saved, as in the case described by 
 Mr Abbott, surgeon at Needham Market ; but in 
 those who have become extremely fat, and who have 
 been addicted to habits of indolence, there is but lit- 
 tle chance of preserving life but by amputation. 
 
334 
 
 DISLOCATIONS OP THE ANKLE-JOINT. 
 
 Invitation to correspondence on the subject. — Having 
 thus endeavoured to explain what has fallen under 
 my own observation, and what I have been able to 
 Jearn from others upon this difficult subject, I beg to 
 express a hope, that any of my friends, who may 
 have had cases under their care which would throw 
 further light upon the subject, will have the kind- 
 ness to communicate them to me, whether they make 
 for or against the advice that I have given, as I have 
 no further wish but that all the points respecting 
 this severe accident may be fully elucidated and es- 
 tablished ; and shall only add, that the observations 
 which I have made in favour of saving the limb in 
 compound dislocations of the ankle-joint, will apply 
 much more strongly in country practice than in that 
 of the large hospitals in London, 
 
 The Jlnhle is sometimes dislocated by Ulceration, 
 
 September 23rd, 1823. With Mr Dixon, surgeon 
 of Kennington, I visited Mr P., a patient of his, who 
 had a dislocation of the ankle produced by ulcer- 
 ation. An ulcer existed at the inner ankle, which 
 had discharged synovia. The ankle-joint was red 
 and greatly swollen, the foot drawn outwards by the 
 action of muscles, and the internal malleolus thrown 
 inwards upon the astragalus. The tibial arteries 
 were greatly stretched; and the fibula, by its pres- 
 sure on the malleolus externus, produced consider- 
 able and constant pain. Mr P. is a very old man, 
 and dying of the disease. 
 
FRACTURES OF THE TIBIA AND 
 FIBULA NEAR THE ANKLE-JOINT. 
 
 Fracture of the fibula. — The fibula is frequently 
 broken from two to three inches above the ankle- 
 joint, and the patient instantly becomes conscious of 
 the accident by feeling a snap a little aboVe the 
 outer ankle; by the pain which he suffers in his at- 
 tempt to bear upon the foot ; by his inability to 
 place his foot flat upon the ground, resting it rather 
 on the inner side to throw the bearing of the body 
 upon the tibia; and by pain and a sensation of mo- 
 tion at the injured part when the foot is bent or ex- 
 tended. The surgeon discovers the nature of the 
 accident by rotating the foot with one hand, and by 
 grasping the lower part of the leg with the other ; 
 at each rotation a crepitus is generally felt. There 
 is also frequently an inequality of the bone at the 
 broken part, which assists in pointing out the nature 
 of the injury. 
 
 Its cause, — The cause of this injury is a blow upon 
 the inner side of the foot, or some violence which 
 forces it outwards against the lower extremity of 
 the fibula ; and I have known it broken by distor- 
 tion of the foot inwards. A fall laterally, whilst the 
 foot is confined in a deep cleft, produces this acci- 
 
336 
 
 FRACTURES OF THE ANKLE-JOINT. 
 
 dent. I broke my right fibula by falling on my right 
 side whilst my right foot was confined between two 
 pieces of ice, and 1 could with difficulty support my- 
 self to a neighbouring house by bearing upon the 
 inner side of my foot. I went home in a carriage, 
 and every jolt of it gave me pain at the fractured 
 part as I suspended my leg upon my hand. I knew 
 that the bone was broken by the severe snap which 
 I felt in the part at the moment of the accident. 
 
 Its treatment, — The treatment which this injury 
 requires is, to apply a many-tailed bandage upon the 
 limb, and to keep it wet with a lotion of spir. vini* 
 3 aquoe 3 v ; to apply a splint, with a foot-piece on 
 each side, padded with cushions in such a manner 
 as to preserve the great toe in a line with the pa- 
 tella, an invariable rule on these occasions; and to 
 place the leg upon its side in the semiflexed position, 
 so as io relax the muscles, and render the patient's 
 position as easy as possible. 
 
 Lameness from neglect, — A want of attention to 
 the treatment of this accident leads to permanent 
 lameness. Dr Blair, a naval physician in the Ame- 
 rican war, informed me that he found great difficulty 
 in walking the streets of London on one side of the 
 way, but upon the other he walked better than upon 
 flat ground; and when I remarked his lameness, and 
 inquired into its cause, he informed me it had arisen 
 from a fracture of the fibula, which happened many 
 years ago ; and to which not having applied splints^ 
 the foot became twisted, so that he walked better 
 upon an inclined plane than upon flat ground. 
 
FRACTURES OF THE ANKLE-JOINT. 
 
 337 
 
 FRACTURES OF THE TIBIA AT THE ANKLE-JOINT. 
 
 Fracture of the tibia. — The tibia is often broken 
 into the ankle-joint, or through the bone a little 
 above it; and these fractures pass either obliquely 
 inwards, or obliquely outwards : the first in a line 
 from the usual seat of fracture of the fibula, that 
 is, from one to two inches above the external mal- 
 leolus to the inner ankle : the second from one to 
 two indies of the tibia above the ankle, downwards 
 and outwards into the joint. 
 
 Diagnosis. — Tfie first is distinguished by crepi- 
 tus at the ankle when the foot is rotated, bent, or 
 extended ; and by a slight inclination of the foot 
 outwards. If the fracture does not enter the joint, 
 but obliquely crosses the tibia above it, the lower 
 part of the tibia slightly projects over the malleolus 
 internus. 
 
 Treatment. — The treatment in this case consists 
 in using evaporating lotions ; the many-tailed band- 
 age ; splints with a foot piece to each, padded so as 
 to incline the foot inwards, and to bring the toe into 
 its natural line with the patella, which is easily ef- 
 fected with the splints to which 1 have alluded. 
 
 Obliquefiactures. — The symptoms of the oblique 
 fracture of the tibia downwards and outwards into 
 the joint are, as in the former case, a crepitus upon 
 rotation, flexion and extension; but the foot is slight- 
 ly inclined inwards, and the malleolus externus pro- 
 jects more than it naturally would. The same 
 bandages and splints are to be used as in the former 
 case ; and the position in both these accidents should 
 be as follows. 
 
 Treatment. — The leg should be raised so as to 
 bend and elevate the knee ; and the limb should 
 rest upon the gastrocnemius muscle, and upon the 
 43 
 
338 FRACTURES OF THE ANKLE-JOINT. 
 
 heel. The splints will support the foot on each 
 side, and the leg should be supported hy a pillow, 
 reaching from the knee to beyond the foot, secured 
 by tapes around it. I have seen both these cases 
 do well when the patient and his leg rested upon 
 the outer side; but the advantage of placing the 
 limb upon the heel is, that it gives the surgeon an 
 opportunity of observing the least deviation in the 
 line of the foot, relatively to the axis of the leg; 
 and this is also an easier position to the patient. 
 
 Dislocation npivards from fracture. — The outer 
 portion of the lower extremity of the tibia, at the 
 part at which it joins the fibula, is sometimes frac- 
 tured and split off from the shaft of the bone in 
 juQiping from a considerable height : the foot then 
 rises between the tibia and fibula ; a dislocation of 
 the tibia inwards is produced, and the foot is elevat- 
 ed between the two malleoli. The treatment re- 
 quired in this case is the same as in the dislocation 
 inwards. 
 
 Oblique compound fractures. — Oblique compound 
 fractures into the ankle-joint generally do well if 
 care be taken to produce adhesion of the wound, 
 which is to be effected by applying lint, imbrued in 
 blood, to the lacerated skin, and by leaving it there 
 until it separates spontaneously. The same band- 
 ages and splints are required as in simple fractures, 
 but the position must be varied according to thie sit- 
 uation of the wound. Even if suppuration occurs 
 the patient will generally recover, unless he be much 
 advanced in years. 
 
 But if, with compound fracture into the joint, 
 there be much comminution of bone, and haemorr- 
 hagy from any large vessel, it will be proper to 
 amputate immediately, more especially if the pa- 
 tient be obliged to obtain his bread by his labour; 
 for after recovery, under great comminution, the 
 limb will bear but slight exerlion. 
 
DISLOCATION OF THE TARSAL BONES. 
 
 SIMPLE DISLOCATION OF THE ASTRAGALUS. 
 
 Junction with other hones, — The astragalus is 
 connected above and on each side with the tibia and 
 fibula by its trochlea; below it has articulatory sur- 
 faces for its junction with the os calcis, to which it 
 is united bj means of a capsular and strong interos- 
 seous band of ligament ; and anteriorly to the os 
 naviculare, by a capsular, broad, and internal lateral 
 ligament. A simple dislocation of the astragalus 
 sometimes, though rarely, occurs ; a compound lux- 
 ation is still more rare. 
 
 Simple dislocations. — A simple luxation of the 
 astragalus is a most serious accident, being very 
 difficult to reduce ; and should the reduction not be 
 effected, the patient is ever after doomed to a con- 
 siderable degree of lameness. 
 
 Case. — Being sent for into the country to visit a 
 patient, the surgeon, Mr James, of Croydon, whom 
 I met there, requested me to see a gentleman who 
 had a dislocation of the foot, which had happen- 
 ed several weeks before, but had not proceeded 
 to his satisfaction. Upon examination, I found 
 
340 
 
 DISLOCATIONS OF THE TARSAL BONES. 
 
 the astragalus dislocated outwards, and the tibia 
 broken obliquely at the inner malleolus. Every 
 attempt to reduce it was made which Mr James, 
 who is an extremely well informed man, could adopt ; 
 five persons kept up a continued extension when the 
 accident first happened, but without eifect ; the pa- 
 tient was then taken home, and several persons were 
 employed in extending the foot, and it was thought, 
 after a time, with some success; but the reduction 
 could not, by all their efforts, be rendered complete., 
 as the astragalus still remained projecting upon the 
 upper and outer part of the foot. The extension 
 could not be carried further; the integuments 
 sloughed from that which had been already made ; 
 and the wound was a long time in healing. The limb 
 now deviates much from its natural shape; the toes 
 are turned inwards and pointed downwards ; there is 
 some little motion at the ankle, and only a slight de- 
 gree of it betw^een the projecting and raised astrag- 
 alus and the other bones of the tarsus. 
 
 This accident, then, is of a most serious nature; 
 for the gentleman in question had placed himself 
 under the care of a most intelligent and persevering 
 surgeon, and yet the attempts made at reduction 
 were not successful, merely from the nature of the 
 accident, and not from any fault in the means em- 
 ployed. In these cases the use of pulleys will be 
 required, and the action of the muscles should be 
 lessened by tartarized antimony. (*See Plate,) 
 
 I attended the following cage with my friends, 
 Mr West, surgeon of Hammersmith, and Mr Ireland, 
 surgeon in Hart-street, Bloomsbury. It is highly 
 interesting and instructive ; and shows most clearly 
 the necessity that surgeons should be upon their 
 guard in amputating limbs, and in performing opera- 
 tions, as the resources of nature are sufficient, under 
 very formidable circumstances, to effect restoration. 
 
DISLOCATIONS OF THE TARSAL BONES. 341 
 
 Case. — On July the 24th, 1820, Mr Downes had 
 the misfortnne to dislocate the astragalus by falling 
 from his horse. The accident happened at Kinsal 
 Green, about six miles from London ; and Mr West, 
 surgeon at Hammersmith, who was called in to him, 
 made an attempt to reduce the dislocation, which 
 could not be effected. The patient was largely- 
 bled; the limb was placed in splints; Goulard's lo- 
 tion was applied, and an anodyne given. The pa- 
 tient felt great pain, and a sense of pressure against 
 the skin and ligaments, on the evening of the acci- 
 dent. A purge was directed to be taken, and ano- 
 dynes occasionally in saline draughts. 
 
 On the following day, the 2f)th, Mr Ireland, who 
 had visited Mr Downes the evening before, called 
 upon me and requested me to accompany him to see 
 the patient, and to meet Mr West. When I exam- 
 ined the limb I found the astragalus dislocated for- 
 wards and inwards ; the fibula appeared to be broken 
 a liule above the joint. I made an attempt to re- 
 duce it, but found the bone immovably fixed in its 
 new situation, projecting so as to make the nature 
 of the case perfectly clear, and bearing so strongly 
 against the skiji that a slight incision would have 
 exposed it. My first impression was, that I ought 
 to dissect away the astragalus; but avvare of the 
 resources of nature in accommodating parts under 
 luxations, and in restoring the limb to usefulness, I 
 observed to Mr West, and to Mr Ireland, that I 
 would not operate, and that perhaps the skin might 
 give way, and the bone become exposed, when we 
 should be justified in removing it. The previous 
 treatment was continued. 
 
 On the 2lith he had some irritative fever, when 
 the saline medicine with antimony was given. 
 
 On the 28th there was considerable local irrita- 
 tion, and leeches were applied. 
 
342 
 
 DISLOCATIONS OF THE TARSAL-BONES. 
 
 On the 29th the leeches were repeated and the 
 lotion continued. 
 
 On August the 10th the skin began to be disposed 
 to slough, opposite the projection of the astragalus 
 at the inner ankle. 
 
 On the 14th, fomentations and a vest poultice 
 were directed to be applied, and bark and wine 
 were given. 
 
 On the 16th the skin sloughed. 
 
 On the 20th there was a great discharge of pus, 
 and the astragalus became exposed. The same 
 means were continued; and the inflammation and 
 discharge gradually lessening, the wound was dressed 
 with lint and adhesive plaster. 
 
 The astragalus gradually became dislodged ; the 
 ligament sloughing or ulcerating. In September, 
 the patient was able to be removed to London. 
 
 On October the 5th, 1820, 1 again saw him, and 
 finding the astragalus very loose, removed it with 
 forceps, dividing only some slight ligamentous adhe- 
 sions. The bleeding was trifling, and was suppressed 
 by the application of lint alone. 
 
 In December some slight exfoliations occurred, 
 which produced pain and inflammation ; but at the 
 end of the month he began to walk. 
 
 After the astragalus was removed, soap plaster 
 was applied ; and Mr Downes gradually recovered 
 his strength, and was able to walk without the aid 
 of a stick. 
 
 In October, 1821, he had slight motion at the 
 ankle, which has been gradually increasing. (See 
 Plate.) 
 
DISLOCATIONS OF THE TARSAL BONES. 343 
 
 COMPOUND DISLOCATION OF THE ASTRAGALUS. 
 
 Case. — In the first case of this accident which I 
 had an opportunity of witnessing, the astragalus was 
 thrown inwards and forwards upon the os naviculare; 
 and when I afterwards saw the limb upon the table 
 of the dissecting-room, it having been removed by 
 amputation, I exclaimed, surely that limb might have 
 been saved. 
 
 Case. — In the case of which an account was sent 
 me by Dr Lynn, of Bury St Edmunds, it will be 
 seen that the discharge of the astragalus, in a com- 
 pound dislocation of the ankle-joint, did not prevent 
 the patient's recovery; for he says, 'In five weeks a 
 portion of the astragalus separated, and another 
 piece a week afterwards, which, when joined, formed 
 the ball of that bone.' 
 
 Case. — Mr Trye, of Gloucester, had also under 
 his care a case of compound luxation of the astraga- 
 lus, in which he cut out the luxated bone, and the 
 patient had a good recovery, with a tolerably useful 
 foot. 
 
 The following case was under the care of Mr 
 Henry Cline, in St Thomas's Hospital. 
 
 Case. — Martin Bentley, aged thirty years, was 
 admitted into St Thomas's Hospital at twelve o' clock 
 at noon, on June 21st, 1815. He had just before 
 been overpowered by some stones which he was 
 endeavouring to sling into a ship's hold, by which 
 he was knocked down, and which fell upon him, 
 occasioning a compound fracture of the tibia and 
 fibula of the left leg, near the middle, with a dis- 
 location of the astragalus of the other foot from 
 the other bones of the tarsus. 
 
 As there was much laceration of the skin and 
 
344 DISLOCATIONS OF THE TARSAL BONES. 
 
 muscles, Mr H. Cline thought it right to amputate 
 the limb below the knee, which was done about 
 three hours alter his admission. He complain- 
 ed of much pain during the operation, with fre- 
 quent jerking of the limb : the muscles were ex- 
 tremely rigid : five ligatures were applied, and the 
 wound was dressed as usual. 
 
 The other foot presented the following appear- 
 ance : The protuberance of the os calcis had nearly 
 disappeared; but. this bone projected laterally, and 
 on the outer side mucli beyond the outer malleolus, 
 just under which, however, was a remarkable de- 
 pression. Immediately below the inner malleolus 
 was a remarkable and unnatural projection. The 
 whole foot seemed somewhat displaced outwards, 
 the toes turning out. The astragalus must here 
 have been dislocated from both the navicular bone 
 and OS calcis, and thrown inwards, so as to have its 
 inferior articulatory surfaces for the os calcis resting 
 on the inner edge of that bone. 
 
 After the am[)utation, the dislocation in the other 
 foot was reduced by fixing the knee, having the 
 thigh bent at right angles with the body ; then lay- 
 ing hold of the metatarsus and protuberance of the 
 OS calcis, and drawing the foot gently and directly 
 from the leg. Duririg this exterision, Mr H. Cline 
 put his knee against the outside of the joint, and 
 the foot being pressed against it, the os calcis and 
 navicular bones slipped into the place, carrying with 
 them the rest of the foot, and the deformity disap- 
 peared. He was then carried to bed, and an out- 
 side splint was applied, being well padded, and 
 secured by tapes; and the leg, as far as could be, 
 was placed on the outer side. Goulard's wash was 
 applied. 
 
 June 24, The lead wash was left off, and soap 
 cerate put on the right leg. 
 
DISLOCATIONS OF THE TARSAL BONES. 345 
 
 June 25. The cerate has blistered his leg in 
 several places, and he complains of more pain than 
 yesterday at his ankle. 
 
 June 28. The stump, which is going on well, 
 dressed to-day; one ligature came away. The pain 
 in his ankle has subsided. 
 
 July 1. Complains of uneasiness about the epi- 
 gastrium, and sickness; pulse 112 and hard ;. 3 vviij. 
 blood taken from the arm. 
 
 July 2. All untoward symptoms have disap- 
 
 July 4. Two ligatures came away. A sore, 
 which is the effect of the soap cerate, on the inner 
 malleolus, is dressed with wax and oiL He is now 
 capable of raising his leg, which, however, is be- 
 numbed. 
 
 July 13. The ligatures not appearing disposed 
 to come away, a piece of whale-bone was fixed on 
 the side of the stump, to which they were attached, 
 and so kept constantly tight. Was put on the hos- 
 pital diet to-day; had previously been on milk diet. 
 
 July 19, One of the ligatures was removed with 
 some difficulty by Mr H. Cline ; the other came 
 away easily on the following day. 
 
 August 7. The man walked in the square for 
 the first time since the accident 
 
 August 26. He went out, and was capable of 
 walking tolerably well. 
 
 I conversed with Mr Henry Cline on the subject 
 of these accidents ; and Mr Green, who saw the 
 preceding case in the commencement, sent me the 
 following letter respecting it. 
 
 Lincoln^ Inn Fields ; Jlugust 19th, 1819. 
 My dear Sir: — In the notes of Martin Benlley's 
 case, which I made at the time when he was under 
 44 
 
 peared 
 
346 
 
 DISLOCATIONS OF THE TARSAL BONES. 
 
 Mr Henry Cline's care in St Thomas's Hospital, 1 
 find it stated that the right astragaUis was dislocated 
 inwards; that is, that the os calcis, with the rest of 
 the foot, was thrown outwards : and the description 
 which I have there given ol' the appearance is, that 
 the whole foot seemed to be somewhat displaced 
 outwards ; that the os calcis projected laterally 
 much beyond the outer malleolus, whilst the protu- 
 berance of that bone had nearly disappeared; and 
 that, in consequence of the astragalus retaining its 
 situation, there was a remarkable depression be- 
 neath the outer malleolus, between it and the dis- 
 placed OS calcis; and as remarkable a projection, 
 produced by the astra2:a!u3, below the inner malleo- 
 lus. This accident, which was accompanied with a 
 compound fracture of the opposite leg, had been 
 produced by the fall of several large stones. The 
 reduction of the dislocation was effected without 
 difficulty. First, by fixing the knee; then by mak- 
 ing extension of the foot, gently and directly from 
 the leg, by laying hold of the heel with one hand, 
 and placing the other on the dorsum of the foot ; 
 and, lastly, by pressing the foot inwards, whilst a 
 counter pressure was made with the knee upon the 
 lower extremity of the tibia on the opposite side. 
 The foot was afterwards placed on its outside, and 
 secured upon a well padded splint. 
 
 In the case of compound luxation of the tarsal 
 bones, likewise under the care of Mr Henry Cline, 
 it appears, according to my notes, that the astraga- 
 lus was displaced outwards; that is, that the other 
 tarsal bones were thrown inwards. I find that the 
 appearances are described to have been, that the 
 foot was turned considerably inwards; that the 
 articular surface on the head of the astragalus, 
 which is received into the cup of the navicular bone, 
 was exposed through an extensive, but tolerably 
 
DISLOCATIONS OF THE TARSAL BONES. 
 
 347 
 
 clean cut through the integuments; and that the 
 articulating surface of the os calcis, with the astra- 
 galus, might also be perceived on the outer side. 
 The accident was said to have been occasioned by 
 the fall of a heavy stone, which had struck his heel. 
 
 Reduction of the dislocated parts was accomplish- 
 ed, first, by bending the leg so as to relax the mus- 
 cles, and then by extending the foot in the manner 
 described in the former case, rotating it at the same 
 time outwards. 
 
 The patient was a robust, but not corpulent, la- 
 bouring man, between forty^ and fifty years of age. 
 He stated that he had been in the habit of drinking, 
 and that he was occasionally subject to gout. 
 
 You have already, I believe, been made acquaint- 
 ed with the particulars of the progress of the case, 
 of which the most remarkable features appeared to 
 be, that the primary constitutional irritation was 
 violent, but of short duration ; and that his recovery 
 was retarded by extensive erysipelatous inflamma- 
 tion, which terminated in sloughing, and by the for- 
 mation of matter at the part, accompanied by irri- 
 tative fever and loss of strength; but that his re- 
 covery, although tedious, was complete. 
 
 Joseph Henry Green. 
 
 For the following case I am also indebted to Mr 
 Green, who is an admirable anatomist, and an excel- 
 lent surgeon. 
 
 Case. — Thomas Toms, twenty-three years of age, 
 was admitted into St Thomas's Hospital on July the 
 14th, 1820. He had fallen, whilst engaged in his 
 business, that of a bricklayer, from a three story 
 scaffold ; and his descent had been arrested by his 
 foot catching between the spikes of an iron railing, 
 from which he hung with his head nearly touching 
 
348 
 
 DISLOCATIONS OF THE TARSAL BONES. 
 
 the ground. A wound was found extending beneath 
 the inner malleohis of the left leg; and the head of 
 the astragalus, which was torn from the articulator^ 
 surface of the os naviculare, protruded through the 
 divided integuments. Part of the articulatorj carti- 
 lage of the displaced bone had been separated, and 
 the bone was i^jirt by the edges of the wounded skin, 
 which was puckered under it. The tendons of the 
 tibialis anticus and of the flexor muscles were tightly 
 stretched, and the foot was turned rather upwards 
 and outwards. Further examination showed that 
 the posterior tibial artery was torn through, and that 
 the accompanying nerve was partially lacerated. 
 
 An attempt was made to reduce the luxated as- 
 tragalus by fixing the knee, after having bent the 
 leg upon the thigh, and by making extension of the 
 foot directly from the leg, laying hold of the heel 
 with one hand, and placing the other on the dorsum 
 of the foot. This, however, failed ; and as it ap- 
 peared that the skin, which firmly embraced the 
 bone beneath, prevented the replacement, it was 
 divided, and the extension renewed, but with the 
 same unsuccessful result. This difficulty seemed to 
 arise from the small size of the wound in the capsule 
 of the joint, and from tightness with which the bone 
 was held by the tendons. 
 
 Fearing then that the reduction was impractica- 
 ble, I was led to consider whether the amputation 
 of the leg ought not to be proposed ; but Sir Astley 
 Cooper happening to be in the hospital, I requested 
 him to see the case, and after a careful examination 
 of the injured limb, he suggested that the astragalus 
 might be removed. I concurred, of course, in this 
 proposal, as it attorded a probability of saving the 
 limb, and I proceeded accordingly to perform the 
 operation. I first applied a ligature on the posterior 
 tibial artery, which, however, had not bled, the ori- 
 
DISLOCATIONS OP THE TARSAL BONES. 349 
 
 fice being so contracted that a pin could not hare 
 been introduced. I then cautiously used a scalpel, 
 detached the ligaments by which the astragalus is 
 connected with the bones of the leg and tarsus, and 
 found no considerable difficulty in removing the bone. 
 The parts were then readily brought into apposi- 
 tion, and the wound was closed with straps of adhe- 
 sive plaster. The leg was placed on its outside, 
 resting on a well padded splint, with a foot-piece; 
 the foot was supported above the level of the knee, 
 and the constant use of an evaporating lotion was 
 ordered. 
 
 In the evening of the same day slight fever had 
 come on, but the limb was tolerably easy ; and the 
 patient had an evacuation of the bowels. 
 
 The next day the febrile symptoms had increas- 
 ed. His pulse was fuller and quicker, the skin was 
 hot and dry, the tongue furred, and thirst consider- 
 able ; but he had slept two or three hours during 
 the night, and the injured part was free from pain. 
 I ordered some febrifuge medicine, and directed 
 thait his diet should be low, and that the apartment 
 should be kept well ventilated. 
 
 On the third day the fever was slightly increased. 
 He complained of pain at the ankle, which exhibited 
 marks of inflammation, and he had had no stool. 
 Sulphate of magnesia in the infusion of roses was 
 ordered in repeated doses, until the bowels should 
 be affected. 
 
 At my visit on the fourth day, I learnt that after 
 having taken five doses of the purgative medicine, 
 two copious evacuations had been produced. The 
 fever still continued, but his tongue was cleaner and 
 moister. It was now found necessary to loosen the 
 sphnt-tapes, as the leg had become considerably 
 swollen. Some discharge of pus had taken place 
 
350 DISLOCATIONS OF THE TARSAL BONES. 
 
 from the wound, and the pain complained of the day 
 before had subsided^ 
 
 On the fifth day 1 found that he had passed a 
 good night, and the fever was diminished ; but he 
 complained of a sore throat, and had had a sh'ght 
 
 shivering. 
 
 On the sixth day I learnt that he had passed a 
 sleepless night in consequence of pain in the foot 
 and leg, and that his head had been somewhat af- 
 fected. The pain in the limb had, however, subsid- 
 ed; and there was a copious discharge frorn the 
 wound. 
 
 On the eighth day the fever seemed to be abated; 
 the pulse was tranquil, and was not more than 86, 
 and his bowels were open. The dressings were now 
 removed, and the ligature on the artery came away. 
 The wound had a healthy granulating appearance. 
 He was allowed to take some animal food. 
 
 He continued mending till July the 26th. His 
 sleep had been sound and refreshing; he was free 
 from fever, and from pain at the injured part, and 
 his appetite was improved. But on this day it was 
 found necessary to alter the position of the leg, by 
 lowering the foot, in order to favour the escape of 
 matter which collected in a sinus, extending about 
 a third of the leg upwards, behind the inner mal- 
 leolus. 
 
 On July the 29th he began to complain of pain in 
 the leg, and lie had some symptoms of constitutional 
 disturbance. These unpleasant effects were produced 
 by the formation of an abscess, which was opened 
 on the 1st of August, and from which about six 
 ounces of pus was discharged. He became after 
 this tranquil and easy, and the discharge of matter 
 gradually decreased. 
 
 On August the 10th I ventured to have him re- 
 moved into another bed, but without disturbing the 
 
DISLOCATIONS OP THE TARSAL BONES. 351 
 
 splints or pillows. The wound at the ankle was 
 now filled with granulations, and had in part cica- 
 trized. 
 
 On August the 25th his health had become again 
 •deranged. His skin was hot, his countenance flushed, 
 and he complained of a good deal of pain at the 
 outer ankle, where it rested on the splint. In order 
 to prevent this inconvenience the leg was placed in 
 a fracture box upon the heel, and a poultice was 
 applied to the ankle. On the following day it was 
 evident that matter had formed at the part, and an 
 opening was therefore made, by which about four 
 ounces of pus was discharged. 
 
 During the ensuing week a discharge again took 
 place from the original wound. This flow of matter 
 was copious, a considerable quantity being furnished 
 from a sinus extending to the calf of the leg, and it 
 continued till September the 7th. During this 
 period his leg became cedematous, his appetite de- 
 clined, and he was subject to slight hectic fever. 
 
 Subsequently to this date he rapidly improved: 
 the oedema of the leg subsided, the discharge lessen- 
 ed, and the wound assumed a healthy appearance. 
 He continued to mend till September the 22nd, 
 when we were again troubled with the formation of 
 one small abscess on the inside of the leg, and of 
 another just below the calf of the leg. These were 
 opened, and the discharge of matter gradually sub- 
 sided. 
 
 In the .beginning of October the quantity of pu- 
 rulent discharge was trifling. He was now allowed 
 to sit up, and straps of soap cerate only were applied, 
 with a roller. 
 
 On October the 25th the discharge had entirely 
 ceased. The parts about the joint were quite sound, 
 and pressure produced no inconvenience. He was 
 capable at this time of performing to a considerable 
 
352 
 
 DISLOCATIONS OF THE TARSAL BONES. 
 
 degree the flexion of the foot on the leg, but could 
 not extend it. 
 
 He began now to walk a little with the aid of 
 crutches; and continuing to gain health and strength, 
 he was discharged from the Hospital on November 
 2nd. 
 
 He has since resumed his business, and performs 
 his duties without inconvenience. 
 
 J. H. Green. 
 
 DISLOCATION OP THE OS CALCIS AND ASTRAGALUS. 
 
 The five anterior bones of the tarsus are some- 
 times dislocated from the os calcis and astragalus. 
 There is a joint placed transversely between the os 
 calcis and astragalus, and the os naviculare and os 
 cuboides ; and this joint is sometimes, but rarely, 
 luxated by very heavy weights falling upon the foot, 
 of which the following is an example. 
 
 Simple Dislocation, 
 Case, — A man Avorking at the Southwark Bridge 
 had the misfortune to have a stone of great weight 
 glide gradually on his foot : he was almost irrjmedi- 
 ately brought to Guy's Hospital, and the following 
 were the appearances of the limb. The os calcis 
 and the astragalus remained in their natural situa- 
 tions, but the fore part of the foot was turned in- 
 wards upon the bones. When examined by the 
 students the appearance was so precisely like that of 
 a club foot^ that they could not at first believe that 
 it was not a natural defect of that kind: but upon 
 the assurance of the man that previously to the ac- 
 cident his foot was not distorted, an extension was 
 made by fixing the leg and the heel; the fore part 
 
DISLOCATIONS OF THE TARSAL BONES. 353 
 
 of the foot was then drawn outwards, and thus the 
 reduction was effected. This person was discharged 
 from the hospital in five weeks, having the complete 
 use of his foot. 
 
 Compound Dislocation, 
 
 The following interesting case was under the care 
 of Mr Henrj Cline ; and for the particulars I am 
 indebted to his apprentice, Mr South. 
 
 Case. — Thomas Gilmore, an Irish labourer, aged 
 forty-five years, was admitted, under Mr H. Cline, 
 into St Thomas's Hospital, about eleven o'clock on 
 the morning of March 28th, 1815. Whilst walking 
 at the New Custom House this morning, he received 
 a blow on the heel from the falling of* a stone (said 
 to be half a ton weight), which made a wound on 
 the fore part of the ankle-joint, and dislocated the 
 astragalus. 
 
 The parts were in the following state: — A 
 wound extended from opposite the middle of the 
 base of the tibia, round the upper part of the instep, 
 to the external malleolus, which exposed the articu- 
 lating surface of the astragalus with the navicular 
 bone on the fore part, as well as that with the os 
 calcis on the outside; from both which bones the 
 astragalus was displaced : its connexion with the 
 tibia and fibula, however, was undisturbed. The 
 tuberosity of the os calcis projected outwards, but 
 the rest of the foot turned in, so that the toes point- 
 ed much inwards, towards the opposite foot. 
 
 The reduction was effected by extending the foot, 
 and rotating it outwards ; the wound was brought 
 together with straps of adhesive plaster; the leg 
 was covered with soap plaster and put in a fracture 
 box, on the heel; the partj were kept uncovered, 
 and a slight hasmorrhage supervening, linen rags, 
 dipped in cold water, were applied. 
 45 
 
354 
 
 DISLOCATIONS OF 1 HE TARSAL BONES. 
 
 He was a robust man, had been in the habit of 
 drinking, and sajs he has been subject to the gout. 
 
 March 29. Had not slept much, as, on falling 
 asleejD, spasm was produced ; pulse about 80; skin 
 cool; he has taken the sulphate of magnesia, which 
 has produced two evacuations. The part is not 
 tumefied, but has been painful. 
 
 March 30. Has passed a very restless night, 
 having been delirious. Pulse 120 ; skin hot and dry; 
 fauces parched. Does not now seem quite clear in 
 intellect. This morning he has had more than one 
 rigor. A dose of sulphate of magnesia, with in- 
 fusion of senna, had procured three loose, but 
 healthy stools. The part has become more swollen 
 and painful. Ordered fever mixture, with ten drops 
 of antimonial wine, every six hours. In the afternoon 
 he had three more stools. 
 
 March 31. Is still delirious, and did not sleep last 
 night. Skin very hot and dry ; mouth parched ; 
 pulse about 112. Has had two stools this morning, 
 without medicine. The rigors still continue occa- 
 sionally, and he is also affected with tremors. The 
 inflammation is extending up the leg, and a bruise 
 which he received on the same leg is now ulcerating, 
 to which a dressing of wax and oil is applied. 
 
 April 1. Has been less delirious than on the 
 two former nights. Pulse 122; tongue cleaner ; no 
 stools. 
 
 April 2. Has slept better than on the previous 
 nights. Is not at all delirious. Pulse 96 and soft ; 
 skin moist, and he has perspired freely; no stools; 
 urine in large quantity, but said to be high-coloured. 
 The tremors have in a great measure left him, 
 and he feels altogether comfortable, except that 
 there is a considerable degree of pain in the in- 
 jured part, which he ascribes to a rheumatic affec- 
 tion to which he has been subject. There is a 
 
DISLOCATIONS OF THE TARSAL BONES. 355 
 
 slight erysipelatous inflammation of the leg, with 
 some oedema. 
 
 April 3. Has passed a tolerably good night ; is 
 sensible; pulse 100; bowels costive; the ankle 
 easy. 
 
 April 4. Pulse 96 ; skin moist ; has had two 
 stools. The erysipelatous inflammation has extend- 
 ed rather above the inlernal condyle of the os fe- 
 moris, and small yellow vesicles have formed; this 
 seems to have proceeded from the bruise on the 
 calf of the leg, which has now gone into a state of 
 superficial ulceration. Soap cerate was applied to 
 this wound, and the spirit lotion on the limb, as far 
 as the inflammation extended. The wound on the 
 ankle Avas dressed for the first time today; the liga- 
 ments appear to be sloughing; the strapping was 
 left off, and wax and oil dressing was applied. 
 
 In the afternoon his pulse was 104; seems rest- 
 less, and says his head feels rather light: had an- 
 other stool towards evening. 
 
 April 5. Has been delirious all night ; skin hot 
 and dry; pulse 108, and weak; these symptoms 
 indicate a fever of a different kind from the preced- 
 ing, viz : secondary, and sympathetic, with the ery- 
 sipelas : the wound at the ankle is granulating, and 
 secreting healthy pus; that on the leg is very pain- 
 ful, and has assumed a sloughy appearance. Ordered 
 decoction of bark every four hours, with opium, if 
 diarrhoea is produced. 
 
 April 6. Is delirious; pulse 100 and weak; skin 
 perspirable; has had two stools; the inflammation 
 extends nearly to the groin ; and at one part of the 
 thigh, where the cradle has accidentally pressed the 
 skin, it seems as if it would slough ; takes a grain of 
 opium twice a day, 
 
 April 7. Slept pretty well ; wanders ; pulse 1 10. 
 
35G 
 
 DlSLOCATIOxNS OF THE TARSAL BONES. 
 
 but strong; skin not very hot ; no stool; much pus 
 is discharged from the wound at the ankle. 
 
 April 8. Has been restless during the night; 
 pulse 96, with some power; skin moderately hot; 
 is thirsty; delirious; tongue rather foul; bowels 
 costive ; his urine, of which he still voids a great 
 quantity, scalds him ; pus is forming in different 
 parts of the limb; and the inflammation on the 
 thigh seems now to be stationary. 
 
 April 10. Slept well; is not delirious; pulse 96, 
 not weak; skin not very hot; has appetite; the part 
 is painful, but the inflammation on the thigh is con- 
 siderably diminished, and the sloughs are circum- 
 scribed ; pulse healthy. A few days since he was 
 ordered a pint of porter daily, which is now increas- 
 ed to two pints. 
 
 April 11. Says he occasionally wanders; pulse 
 100, rather weak; appetite tolerably good; skin 
 moist ; has had stools. 
 
 April 12. The inflammation is less ; the opium 
 which he takes procures him good nights ; the wound 
 at the ankle is much the same ; the sloughing sore 
 on the calf of the leg better; to-day he was moved 
 into a clean bed, and the limb was placed on the 
 outer side, as he wishes to lie on his side. 
 
 April 13. Is composed; pulse 98; skin cool; 
 feels weak; has not much appetite, but likes his 
 porter; the sloughs on the leg separate slowly. 
 
 April 14. The limb was returned to its old 
 position on the heel, as he was less comfortable 
 when it was placed on the side. 
 
 April 17. Pulse 92, and weak; has little or no 
 appetite ; the bark and opium were left off to-day, 
 as they seem to affect his head; a poultice was ap- 
 plied to the wound on the calf of the leg, and 
 strapping on that at the ankle : it being hoped, that 
 by the support thus afforded, the discharge would 
 be diminished. 
 
DISLOCATIONS OF THE TARSAL BONES. 
 
 357 
 
 April 22. As his appetite does not improve, and 
 he gets no sleep, the bark and opium were resumed, 
 and an additional pint of porter given, so that he now 
 takes three pints a day. His pulse is not so weak ; 
 spirits good; at times he is in great pain ; strapping 
 is applied to all the wounds ; the sloughs have not 
 separated. 
 
 April 28. Continues much the same. One slough 
 on the leg has separated, that at the ankle not yet ; 
 the part is tolerably easy ; the discharge not great. 
 
 May 15. All the sloughs have separated, and 
 the wounds are gradually healing up, but he is very 
 weak, and his appetite is bad. 
 
 May 20. Oil was ordered to be rubbed on such 
 parts of the leg as would bear it, and then washed 
 off, as it was thought this would promote circulation 
 in the limb, which was cedematous : however, this 
 was soon discontinued, as it occasioned inflammation. 
 About this time his medicines were omitted. 
 
 May 29. An abscess, which had formed on the 
 calf of the leg, was opened. 
 
 July 14. AH the dressings were left off to-day. 
 He is perfectly capable of lifting his leg, and has 
 slight flexion and extension of the foot. 
 
 After this time he rapidly improved : and having 
 left his bed, in a short time was walking about the 
 square on crutches. 
 
 September 12. He went out, being able to walk 
 tolerably well with a stick. 
 
 DISLOCATION OF THE OS CUNEIFORME INTERNUM. 
 
 I have twice seen this bone dislocated ; once in a 
 gentleman who called upon me some weeks after 
 the accident, and a second time in a case which oc- 
 
358 DISLOCATIONS OF THE TARSAL BONES. 
 
 curred in Guy's Hospital very lately. In both 
 these instances the same appearances presented 
 themselves. There was a great projection of the 
 bone inwards, and some degree of elevation, from 
 its being drawn up by the action of the tibialis 
 anticus muscle ; and it no longer remained in a direct 
 line with the metatarsal bone of the great toe. In 
 neither case was the bone reduced. The subject 
 of the first of these accidents walked with but little 
 halting, and I believe would in time recover the use 
 of the foot, so as not to apf ear lame. The cause 
 of the accident was a fall from a considerable 
 height, by which the ligament was ruptured which 
 connects this bone with the os cuneiforme medium, 
 and with the os naviculare. 
 
 The second case, which was in Guy's Hospital, 
 my apprentice, Mr Babington, informs me, happened 
 by the fall of a horse, through which the foot was 
 caught between the horse and the curb-stone. 
 
 The treatment of this injury will consist in con- 
 fining the bone in its place, by at first binding it with 
 a roller dipped in spirits of wine and water, with 
 Avhich it must be constantly kept wet : and when the 
 inflammation is subdued, a leather strap is to be 
 buckled around the foot, to keep the bone in its 
 place till the ligament be united. 
 
 The metatarsal bones I have never known luxated: 
 their union with each other, and their irregular con- 
 nexion with the tarsus, prevent it; and if the luxa- 
 tion ever happens, it must be a very rare occur- 
 rence. 
 
DISLOCATIONS OF THE TARSAL BONES. 
 
 359 
 
 DISLOCATION OF THE TOES FROM THE METATARSAL 
 BONES. 
 
 This is a very uncommon accident: but I had a 
 man under my care at Guy's Hospital, who had such 
 a degree of lameness as to be unable to get his 
 bread by his daily labour, owing to an injury sustain- 
 ed by falling froni a considerable height, and alight- 
 ing upon the extremities of his toes. Upon examina- 
 tion of the bottom of the foot, a considerable pro- 
 jection was found at the roots of all the smaller toes, 
 each of the extremities of the metatarsal bones 
 being placed under the first phalanges of those toes. 
 Several months had elapsed from the time of the 
 accident ; and at first, from the swelling of the foot, 
 it had not been detected. No extension, at the time 
 when I saw him, could answer any purpose, and the 
 only mode of relief was to wear a piece of hollow 
 cork at the bottom of the inner part of the shoe, to 
 prevent the pressure of the metatarsal bones upon 
 the nerves and blood-vessels. 
 
 The toes are sometimes dislocated, but as the 
 mode of their reduction will be the same as that of 
 the fingers, I shall reserve the subject until I de- 
 scribe the dislocation of the fingers. 
 
DISLOCATIONS OP THE LOWER JAW. 
 
 Structure of the articulation^ frc. — An articular 
 cavity is formed behind the root of the zygomatic 
 process of the temporal bone, which receives the 
 condyloid process of the lower jaw at the time 
 when the mouth is shut; and a prominence which 
 is placed before this cavity receives the lower jaw 
 when the teeth are advanced upon the upper: both 
 the cavity and the prominence are covered by ar- 
 ticular cartilage. The condyloid process of the jaw 
 rests in the cavity with an intervening cartilage 
 whilst the mouth is shut, but it advances upon the 
 root of the zygomatic process when the jaw is much 
 opened, or the lower teeth are advanced. Between 
 the condyloid process and the cartilaginous surfaces, 
 an interarticular cartilage is placed, having a double 
 concave surface, Avhich allows of the free motion of 
 the jaw, and of its advance upon the zygomatic 
 articular tubercle; whilst the coronoid or anterior 
 process of the jaw is received between the zygo- 
 matic arch and the surface of the temporal bone. 
 
 Ligaments. — A capsular ligament unites the con- 
 dyloid process to the temporal cavity and to the 
 
DISLOCATIONS OF THE LOWER JAW. 351 
 
 prominence before it, and joins, in its passage from 
 one bone to the other, the edge of the interarticu- 
 lar cartilage ; whilst a strong internal lateral liga- 
 ment passes from the margin of the articular cavity 
 to the inner surface of the angle of the lower jaw. 
 
 Muscles. — The jaw is drawri upwards and down- 
 wards, backwards and forwards, and transvei-sely. 
 Its elevation is produced by the temporal, the mas- 
 seter, and the pterygoideus internus: its depression 
 by the platysma myoidcs, digastrlcus, mylo hyoideu?, 
 genio hyoldeus, and genio hyo glossus. The jaw is 
 drawn backwards by tlie temporal muscle, and by a 
 part of the masseter : and when the os hyoides is 
 fixed by the digastrlcus, the gonlo hyoldeus, and 
 genio hyo glossus, it is pulled forwards by a portion 
 of the masseter, and by the combined action of the 
 pterygoidel externi. 
 
 The lateral motions of the jaw are principally 
 produced by the contractions of the external ptery- 
 goid muscles, which in alteriiate actions pull the jaw 
 from side to side, and give it, with the other mus- 
 cles, its grinding action, in which these muscles are 
 assisted by the oblique motion forwards, given to 
 the jaw by the pterygoideus internus. 
 
 Luxations. — The lower jaw is subject to two 
 species of dislocation, viz: the complete and the 
 partial. When the dislocation is complete, both 
 the condyles of the jaw are advanced into the space 
 between the zygomatic arch and the surface of the 
 temporal bone; but when it Is partial, one condy- 
 loid process only advances, and the other remains 
 in the articular cavity of the temporal bone. 
 
 46 
 
362 DISLOCATIONS OF THE LOWER JAW. 
 
 ., - i 
 
 J 
 
 K 
 
 COMPLETE LUXATION OF THE JAW. 
 
 Co7nplete luxation; symptoms.- — This accident is 
 indicated bj the open state of the mouthy and bj 
 the impossibility of closing it, either by the patient's 
 efforts, or by pressure made upon the chin. The 
 lower jaw may be still in some degree approximated 
 to the upper by muscular efforts, but the lower 
 teeth, if the mouth could be closed, would be in a 
 line anterior to the upper. Some degree of de- 
 pression of the jaw may also still be produced, but to 
 an inconsiderable extent. Thus the appearance of the 
 patient is that of a continued yawning. The cheeks 
 are projected by the advance of the coronoid pro- 
 cesses towards the buccinator muscle, and there is a 
 depression just anterior to the meatus auditorius, 
 from the absence of the condyloid process from its 
 cavity. The saliva is not retained in the mouth, but 
 dribbles over the chin; and a very considerable 
 increase of this secretion follows, in consequence of 
 the irritation of the parotid glands. The pain ac- 
 companying the accident is severe, but I have never 
 seen any dangerous effect produced by it: on the 
 contrary, the jaw becomes more nearly closed by 
 time, and a considerable degree of motion of the 
 jaw is recovered. 
 
 Causes. — This accident may be caused by taking 
 into the mouth too large a body : as I have knoAvn 
 when two boys in play, struggling for an apple, one 
 has forced it into his mouth, and dislocated his jaw. 
 A blow upon the chin, when the mouth is widely 
 opened, produces the same effect. Yawning very 
 deeply is also a frequent cause of the accident. 
 
 A sudden spasmodic action of the muscles will 
 produce this dislocation when the mouth is opened ; 
 
DISLOCATIONS OF THK LOWER JAW. 3tii5 
 
 and it has often hap[)encd in attempts to extract the 
 teetli, where the mouth has been opened too widely. 
 Mr Fox, dentist, whose death we have to deplore as 
 a man of science, informed me that he was called 
 to a lady who had a tooth which required to be ex- 
 tracted, and that in the attempt to do so, a sudden 
 spasm dislocated the jaw. 
 
 In this accident, the jaw must be immediately re- 
 stored to its situation; and the mode of reduction 1 
 shall explain by the following case. 
 
 Case ; reduction, — A madman, confined in one of 
 the houses in Hoxton, during an attempt to give him 
 some food, which the keeper was obliged to force 
 him to receive, had his jaw dislocated. Mr Weston, 
 surgeon in Shoreditch, was sent for ; who, finding the 
 man very powerful and very unmanageable, prefer- 
 red rather to send for some other surgeon, to con- 
 sider with him the best mode of making the attempt 
 at reduction. When I saw the man I thought that' 
 ^ surgeon must be as insane as the patient who 
 would employ the usual means of reduction, and 1 
 therefore desired that the keepers would place the 
 patient on a table upon his back, with a pillow under 
 his head, and that he should be held by several 
 persons. 1 ordered two table forks to be brought 
 me, and wrapped a handkerchief around their points. 
 Placing#iyself behind the patient's head, 1 carried 
 the handles of the forks into the mouth, on each 
 side, behind the molares teeth ; then directed them 
 to be held, and placing my hand under the chin, I 
 forcibly drew it to the upper jaw, and the bone w-as 
 easily and quickly reduced. 
 
 Corks; levers. — In the above mentioned case 
 the handles of the forks were not used as levers, by 
 lifting them ; they only rested upon the jaw, which 
 was used as a lever upon them, depressing the pro- 
 cesses as the jaw was elevated, and thus directing 
 
364 DISLOCATIONS OF THE LOWER JAW. 
 
 the bone backwards into its natural situation. But 
 as wood is liable to injure the gums, it is better to 
 substitute two corks, which are to be placed behind 
 the molares teeth on each side of the mouth, and 
 over these the chin is to be raised. Thej are 
 eqijal!j effectual in reducing the bone, and are less 
 hkely to injure it, or to bruise the soft parts. It 
 has been recommended in these cases, to use a 
 piece of wood as a lever, by introducing it between 
 the molares teeth, first on one side and then on the 
 other, reducing one side first, and then using the 
 same means to the other. Mr Fox, in the case 
 before alluded to, thus succeeded : he placed a 
 piece of wood, a iboi long, upon the molar tooth on 
 one side, and raising it at the part at which he iield 
 it, depressed the point at the jaw on that side, and 
 reduced the jaw. He then performed the same 
 operation on the other side, and thus replaced the 
 bone. But the corks, the recumbent posture, and 
 the elevation of the chin, constitute the mode which 
 I prefer. 
 
 Dislocation liable to occur. — In reducing this dis- 
 location, the surgeon generally wraps a handker- 
 chief round his thumbs, placing them at the roots 
 of the cororioid j)rocesses, and depressing the jaw, 
 forces it backwards as well as downwards, when the 
 bone suddenly shps into its place: but t^'s mode 
 does not so easily succeed as the others, excepting 
 in recent dislocations. When the jaw has been once 
 dislocated, it is very liable to the same accident, and 
 therefore a broad tape, with a hole cut in it to re- 
 ceive the chin, divided into four ends by splitting it 
 on each side some way down, is to be tied over the 
 summit of tlie head and occiput, to confine the jaw 
 until the lacerated parts have healed, by which the 
 tendency to subsequent luxation is diminished. 
 
DISLOCATIONS OF THE LOWER JAW. 
 
 365 
 
 PARTIAL DISLOCATION OF THE JAW. 
 
 Partial dislocation; symptoms. — In this case, the 
 condjlold process advances under the zygomatic arch 
 on one side only, producing an Incapacity to close 
 the mouth; but it is not so widely opened as in the 
 complete dislocation. It is easy to distinguish tills 
 accident, as the chin is thrown to the side oj)posite 
 to the luxation, and the incisores teeth are iiot only 
 advanced upon the upper jaw, but are no longer in 
 a line with the axis of the face. The cause of this 
 accident is a blow on the side of the face when 
 the mouth is opened, and in one case it occurred 
 from vomiting in sea sickness. In this example, the 
 lady, Miss Belfour, daughter of the late Admiral 
 Belfour, of Portsmouth, reduced her jaw by an oys- 
 ter-knife, which she turned half round upon ine 
 side of the jaw between the teeth, and so returned 
 it to its place. 
 
 In this injury, the lever of wood reduces the bone 
 most easily, but the cork may be used on one side, 
 and the chin be elevated, as in those cases in which 
 the dislocation is complete. 
 
 SUBLUXATION OF THE JAW. 
 
 Symptoms, Src — As in the knee, the thigh-bone 
 is sometimes thrown from its semllunur cartilages, 
 so the jaw appears occasionally to quit the inter- 
 articular cartilage of the temporal cavity, slipping 
 before its edge, and locking the jaw, with the mouth 
 slightly opened. It generally happens, that this dis- 
 location is quickly removed by natural efforts alone; 
 but I have seen it continue for a length of time, and 
 
366 DISLOCATIONS OF THE LOWER JAW. 
 
 the motion of the jaw, and the power of closing the 
 mouth have still returned. This state of the jaw 
 happens from extreme relaxation. The patient finds 
 himself suddenly incapable of entirely closing the 
 mouth ; some pain is felt, and the mouth is least 
 closed on that side on which the pain is felt. 
 
 Reduction. — Force for removing these appearances 
 must be applied directly downw^ards, so as to sepa- 
 rate the jaw^ from the temporal bone, and to give an 
 opportunity for the cartilage to replace itself upon 
 the rounded extremity of the condyloid process. 
 
 Relaxation of ligaments. — In extreme degrees of 
 relaxation, a snapping is felt in the maxillary articu- 
 lation just before the ear, with some pain, arising 
 from the sudden relapse of the jaw into its socket, 
 which the relaxation of the ligament had permitted 
 it^to quit, and to advance upon the zygomatic tu- 
 bercle. 
 
 Young women are generally subject to this sensa- 
 tion, and the means which I have found most fre- 
 quently and quickly tending to insure their recovery 
 have been ammonia and steel as medicine; with the 
 shower-bath, and the application of a blister before 
 the ear, when the complaint has continued for a 
 length of time. 
 
DISLOCATIONS OF THE CLAVICLE. 
 
 Dislocations rare. — As the clavicle is the only 
 medium by which the arm is articulated with the 
 bones of the chest, it might be expected that its 
 dislocation would be extremely frequent ; but this 
 bone is so peculiarly and strongly articulated, both 
 with the sternum and scapula, as to render its dislo- 
 cation comparatively rare. 
 
 jirticulation, — In other articulations we find a cap- 
 sular ligament proceeding from the edges of the ar- 
 ticulating surfaces and peculiar ligaments, to give 
 strength to the junction of the bones ; but in the 
 articulation of the clavicle, like that of the lower 
 jaw and knee, we meet with an interarticular car- 
 tilage, composing a part of the articulating appa- 
 ratus. 
 
 JUNCTION OP THE STERNAL EXTREMriY OF THE CL'AVICLE 
 WITH THE STERNUM. 
 
 Bones. — The articulating surfaces, both of the 
 sternum and clavicle, are in part rounded, and in 
 
368 DISLOCATIONS OF THE CLAVICLE. 
 
 part depressed ; and both are covered by an articu- 
 lar cartilage similar to that of the other joints. A 
 capsular ligament proceeds from the end of tlie cla- 
 vicle to the edge of the articulating surfaces of the 
 sternum, and it is strengthened by short ligaments, 
 which pass directly from one bone to the other. . 
 
 Inter articular cartilage^ 8{c, — Within the capsular 
 ligament is situated the interarticular cartilage, joined 
 at the upper part of the joint to the clavicle, and to 
 the caj)sular ligament ; and, below, to the edge of 
 the articular surface of the sternum, and to the cap- 
 sular ligament; it is inclined under the end of the 
 clavicle with ihe capsular ligament, so that the 
 clavicle rests upon its surface, and it is also interpos- 
 ed between that bone and the sternum. Of that 
 portion of this cartilage which is inclined to the 
 clavicle, only about on.e half is smooth, to allow of 
 the motion of that bone, and this is its lower and 
 anterior part. The residue of it adheres to the 
 articular cartilage of the clavicle, forming a flat, 
 rouo^h surface; but on the side towards the sternum 
 the interarticular cartilage forms a smooth and con- 
 cave surface, which allows of its free motion on that 
 bone. The interarticular cartilage is placed not 
 perpendicularly, but obliquely ; its upper end is in- 
 clined inwards, and its lower end outwards, towards 
 the first rib. From the upper point of the clavicle 
 proceeds an interclavicular ligament, which adheres 
 to the capsular ligament, and slightly to the sternum; 
 and traversing the upper and back part of the 
 sternum, it is fixed in the extremity of the opposite 
 clavicle, and unites very strongly one clavicle to the 
 other. 
 
 Clavicular costal ligament. — The clavicle is also 
 joined to the first rib by a clavicular costal, or, as it 
 is called, rhomboid ligament, which proceeds from the 
 inferior edge of the sternal en^ of the clavicle to 
 the cartilage of the first rib. 
 
DISLOCATIONS OF THE CLAVICLE. 
 
 369 
 
 Motion of the clavicle, — The motion of the clavi- 
 cle, as well as that of the sternum, forwards and 
 backwards, is performed upon the smooth surface of 
 the interarticular cartilage, which is applied to the 
 sternum; whilst the motion of the clavicle, upwards 
 and downwards, is produced upon the portion of the 
 smooth surface of the interarticular cartilage, which 
 is applied to the clavicle; and another advantage 
 derived from this mode of articulation is, that it al- 
 lows of the motion of the bone outwards and back- 
 wards to a considerable extent, without occasioning 
 any weakness in the ligament : for, in this view, it 
 may be considered that there are two ligaments; 
 one from the clavicle to the cartilage, and one from 
 the cartilage to the sternum, instead of one loose, 
 long ligament from bone to bone. 
 
 DISLOCATION OF THE STERNAL EXTREMITY OF THE 
 CLAVICLE. 
 
 These are of two kinds, viz : — the dislocation 
 forwards, the clavicle being then thrown upon the 
 Sternum ; or backwards^ when the end of the bone 
 is placed behind the sternum. 
 
 Dislocation Forwards. 
 The circumstances by which this injury is known 
 are, that upon looking at the upper part of the 
 sternum, a rounded projection is seen; and when 
 the fingers are carried upon the surface of the 
 sternum upwards, this projection stops them. If 
 the surgeon places himself behind the patient, puts 
 his knees between the scapulae, grasps the shoulders 
 and draws them back, the projection on the sternum 
 
 47 
 
370 DISLOCATIONS OP THE CLAVICLfi. 
 
 disappears; but directly when the shoulders advance, 
 the projection upon the sternum is renewed. The 
 clavicle may be readily (raced with the finger into 
 the projection on the sternum. If the shoulder be 
 elevated, the projection descends; if it be drawn 
 downwards, the dislocated extremity of the bone 
 becomes elevated to the neck. The motions of the 
 dislocated clavicle are painful, and the patient moves 
 the shoulder with difficulty. The point of the in- 
 jured shoulder is less distant from the central line of 
 the sternum than usual. In a very thin person the 
 nature of the accident can be at once ascertained, 
 because the bone is but little covered ; but in fat 
 persons it is more difficult to detect. When the 
 patient is at rest, very little pain or tenderness is felt 
 from the accident. It sometimes happens that this 
 dislocation is incomplete, the anterior portion of the 
 capsular ligament only being torn, and the bone 
 slightly projecting; but generally all the ligaments 
 are lacerated, and the bone, with its interarticular 
 cartilage, is thrown forwards. 
 
 Its cause. — The cause of this injury is a fall up- 
 on the point of the shoulder, when the force pushes 
 the clavicle inwards and forwards, and projects it on 
 the sternum: but it also frequently happens from a 
 fall upon the elbow at the time when it is separated 
 from the side, by which the clavicle is forced violent- 
 ly inwards and forwards against the anterior part of 
 the capsular ligament. 
 
 Reduction. — With respect to the means of re- 
 duction and the principle upon which the treatment 
 is to be regulated, there is no difficulty in practising 
 the one, or in understanding the other. The clavicle 
 is easily returned to its place by pulling the shoulder 
 backwards, because then it is drawn off the sternum, 
 and its end falls upon the cavity which naturally re- 
 ceived it ; but if pressure in this position of the 
 
DISLOCATIONS OF THE CLAVICLE. 
 
 shoulder be not made upon the fore part of the 
 bone, it will be found still liable to project in some 
 degree. 
 
 Principle, — The principle, therefore, upon which 
 the extension is made, is to draw the scapula as far 
 from the side as is practicable without inconvenience, 
 and by supporting the arm, to prevent its weight 
 from influencing the position of the bone. 
 
 Mode of extension, — The first of these objects is 
 best effected by the use of the clavicle bandage [see 
 Plate), and by the application of two pads or cush- 
 ions affixed to it, which are placed in the axillae. 
 These pads throw the head of the os humeri from 
 the side, and carry the scapula, and the clavicle con- 
 nected with it, outwards and backwards, and thus 
 the clavicle is drawn into its natural articular cavity. 
 The second intention is effected by putting the arm 
 in a sling, which, through the medium of the os hume- 
 ri and scapula, supports it, and prevents the clavicle 
 from being drawn down by the weight of the arm. 
 
 Dislocation Backwards, 
 
 Dislocation backwards, — The dislocation of the 
 extremity of the bone backwards I have never 
 known to occur from violence, yet it might happen 
 from excessive force, as from a blow upon the fore 
 part of the bone, which should tear the capsular and 
 clavicular costal ligament, and allow the bone to glide 
 behind the sternum, occasioning compression of the 
 oesophagus, and rendering deglutition difficult. The 
 trachea would, from its elasticity, elude pressure and 
 escape to the opposite side of the space by which 
 this tube enters the thorax. 
 
 Cause. — The only cause of this dislocation that 
 I have known, was produced by great deformity of 
 the spine, by which the scapula advanced, and suffi- 
 cient space was not left for the clavicle between the 
 
372 DISLOCATIONS OP THE CLAVICLE. 
 
 scapula and sternum ; in consequence of which, the 
 bone gradually glided back behind the sternum, and 
 produced so much inconvenience by its pressure on 
 the oesophagus, as to lead to a necessity for the re- 
 moval of its sternal extremity. 
 
 This case is extremely creditable to the know- 
 ledge, skill, and dexterity of Mr Davie, surgeon at 
 Bungay, in Suifolk ; few would have thought of the 
 mode of relief — very few would have dared to 
 perform the operation — and a still smaller number 
 v/ould have had sufficient knowledge for its accom- 
 plishment. 
 
 The following particulars I in part received in 
 conversation with Mr Davie, who fell a victim to 
 his great professional zeal, and in part from Mr 
 Henchman Crowfoot, surgeon at Beccles. He had 
 the kindness to go over to Dr Camell, of Bungay, to 
 learn from him some of the particulars, and there 
 met with a person who gave him several others, and 
 who knew the patient for some years after the 
 operation. 
 
 Case. — Miss Loffly, of Metfield, Suffolk, had a 
 great deformity, arising from a distorted spine, in- 
 creased by an accident which displaced the sternal 
 extremity of the left clavicle, and threw it behind 
 the sternum. The progressive distortion of the spine 
 gradually advanced the scapula, and occasioned the 
 sternal end of the clavicle to project inwards, behind 
 the sternum, so as to press upon the oesophagus, and 
 occasion extreme difficulty in deglutition. Her de- 
 formity had become excessive, and her emaciation 
 extreme. 
 
 Mr Davie conceived that he should be able to 
 prevent the gradual destruction which the altered 
 position of the clavicle threatened, by removing the 
 sternal extremity of the bone ; and the operation 
 
DISLOCATIONS OF THE CLAVICLE. 373 
 
 which he performed for this purpose was, according 
 to all I can learn, as follows. 
 
 An incision was made of from two to three inches 
 in extent on the sternal extremity of the clavicle, in 
 a line with the axis of that bone ; and its surround- 
 ing ligamentous connexions, as far as he could then 
 reach them, were divided with the saw of Scultetus 
 (often called Hey's) ; he sawed through the end of 
 the bone, one inch from its articular surface from 
 the sternum, and fearful of doing unnecessary injury 
 with the saw, he introduced a piece of well-beaten 
 sole leather under the bone whilst he divided it. 
 When the sawing was completed he tried to detach 
 the bone, but it still remained connected by its inter- 
 clavicular ligament, and he was obliged to tear 
 through that ligament by using the handle of the 
 knife as an elevator, and after some time succeeded 
 in removing the portion of bone which he had sepa- 
 rated. 
 
 The wound healed without any untoward occur- 
 rence, and the patient was enabled to swallow, as 
 the pressure of the clavicle upon the oesophagus 
 was now removed. 
 
 She lived six years after the operation, and re- 
 covered considerably from her former emaciation. 
 ' Of what she ultimately died,' says Mr Crowfoot, 
 ' I have not learnt.' 
 
 JUNCTION OP THE CLAVICLE WITH THE SCAPULA. 
 
 Articulation ; ligaments, S^c. — The clavicle joins 
 with the scapula about three quarters of an inch be- 
 hind the extremity of the acromion. The end of 
 the clavicle is slightly convex, and covered by an ar- 
 ticular cartilage ; the scapula is depressed to receive 
 
374 
 
 DISLOCATIONS OP THE CLAVIOLE. 
 
 it, and this surface is also covered by an articular 
 cartilage. Strong ligamentous fibres pass directly 
 from the clavicle to the scapula, and under these a 
 capsular ligament is extended from the edge of the 
 socket of the scapula, to the extremity of the clavi- 
 cle. The surface of junction is very small, the end 
 of the clavicle not being longer than the end of the 
 little finger of an adult ; and the cavity in the scap- 
 ula which receives it is very superficial, being not 
 larger than is required to receive upon its surface the 
 end of the clavicle. But the junction of the two 
 bones is effected by much stronger means, through 
 the medium of the coracoid process of the scapula, 
 which sends forth two ligaments to the clavicle. The 
 first proceeds from the root of the coracoid process, 
 and is fixed in a small tubercle of the clavicle on its 
 under side, at the insertion of the subclavius muscle, 
 and two inches from the extremity of the bone* 
 This ligament has been called the conoid, from its 
 form, but may be better named the internal coraco- 
 clavicular. The use of this ligament is, to bind 
 down the clavicle to the scapula, and to confine the 
 motion of the clavicle forwards and upwards. 
 
 External coraco-clavicular. — The second ligament 
 of this part is called trapezoid ; it proceeds from the 
 coracoid process, and passes on the under side of the 
 clavicle to near its scapular end, into which it is fix- 
 ed; I call it the external coraco-clavicular. This lig- 
 ament is the chief cause which lessens the tendency 
 to dislocation of the scapular end of the clavicle, for 
 when its capsular ligament is divided, the scapula 
 cannot be forced under the clavicle without lacerating 
 this ligament, so great is its resistance. It allows of 
 very free motion of the scapula backwards and up- 
 wards, but confines its motions forwards. The mo- 
 tions of this extremity of the clavicle are perfomed 
 by the subclavius muscle, although other muscles also 
 move this bone. 
 
DISLOCATIONS OP THE CLAVlCLlEi. 375 
 
 DISLOCATION OF THE SCAPULAR EXTREMITY OP THE 
 
 CLAVICLE. 
 
 This accident is more frequent than the dislocation 
 of the sternal extremity. 
 
 When this extremity of the bone is luxated, the 
 signs by which the surgeon ascertains the nature of 
 the injury are as follow. 
 
 Symptoms. — The shoulder on that side, when 
 compared with the opposite, appears depressed, for 
 the clavicle is formed to give support to the scapu- 
 la, and that support is lost in consequence of the ac- 
 cident. The point of the shoulder approaches near- 
 er to the sternum ; and if the distance of the two 
 shoulders from that bone be measured, this inequali- 
 ty is directly detected; the clavicle being naturally 
 the means of preserving the distance of the scapula 
 from the side, to throw out the shoulders, and to ren- 
 der the motions of the arm extensive. But the 
 easiest mode of detecting this accident is, to place the 
 finger upon the spine of the scapula, and to trace 
 this portion of bone forward to the acromion in which 
 it ends; the finger is stopped by the projection of 
 the clavicle, and so soon as the shoulders are drawn 
 back, the point of the clavicle sinks into its place, 
 but it re-appears when the shoulders are let go. 
 The point of the clavicle projects against the skin 
 upon the superior part of the shoulder, and much 
 pain is felt when it is pressed. 
 
 In this injury, the capsular ligament is necessarily 
 torn through, as well as the external ligament, from 
 the coracoid process to the clavicle, or no dislocation 
 of the sternal extremity could occur. The internal 
 ligament, when the dislocation is complete, must be 
 also lacerated ; but I have seen the clavicle project 
 but slightly on the acromion in some of these acci- 
 
376 
 
 DISLOCATIONS OF THE OLAVICLE. 
 
 dents, denoting that the latter ligament had not 
 given way. 
 
 It is scarcely probable, that the clavicle should be 
 ever dislocated in any other direction than upwards. 
 At least I have never seen an instance of the clavi- 
 cle gliding under the acromion, but I would not deny 
 the possibih'ty of such an accident. 
 
 Cause, — This species of dislocation is caused by 
 a fall upon the shoulders, through which the scapula 
 is forced inward towards the ribs, and the accident 
 which produces it is excessively violent. It has been 
 said, that the action of the trapezius muscle alone 
 could produce this effect, but that is impossible, as 
 this muscle would not influence both the ligaments 
 of the coracoid process, which must be torn through 
 to produce the dislocation. 
 
 Reduction, — In the treatment of this accident, I 
 adopt the following plan : The assistant, standing 
 behind the patient, puts his knee between the shoul- 
 ders, and draws them backwards and upwards, when 
 the clavicle sinks into its socket. A thick cushion is 
 then placed in each axilla, for three purposes : First, 
 to keep the scapula from the side : Secondly, to 
 raise the scapula: Thirdly, to defend the axillae 
 from being hurt by the bandages: on which last ac- 
 count a cushion is employed on each side. Then 
 the clavicle bandage is applied, and its straps should 
 be sufficiently broad to press upon the clavicle, the 
 scapula, and the upper part of the os humeri, to keep 
 the former down, the scapula inwards and backwards 
 (which is the chief object), and the arm backwards 
 and elevated. To secure these objects more effec- 
 tually, the arm is to be suspended in a short sling, by 
 which it is made to support the scapula in its proper 
 situation. 
 
 At the conclusion of my lecture upon this subject 
 I have always given this counsel to the pupils: — 
 
DISLOCATIONS OF THE CLAVICLE. 
 
 377 
 
 'You are not to expect that the parts, after the ut- 
 most care in the treatment, will, in dislocations of 
 either end of the clavicle, be very exactly adjusted; 
 some projection, some slight deformity will remain ; 
 and it is necessary, from the first moment of the 
 treatment, that this should be stated to the patient, 
 as he may otherwise suspect that the fault has arisen 
 from your ignorance or negligence. You may at the 
 same time inform him, that a very good use of the 
 iimb will be recovered, although some deviation from 
 the natural form of the parts may remain, in a slight 
 projection on the sternum, or some elevation of the 
 sternal extremity of the clavicle.' 
 
 DISLOCATION OF THE CLAVICLE WITH FRACTURE OF THE 
 ACROMION. 
 
 We have a preparation of this injury in the Mu- 
 seum at St Thomas's Hospital, and the following ac- 
 count of the case was given me by Mr South. 
 
 Case. — A man, aged sixty years, was admitted 
 into King's Ward, St Thomas's Hospital, October 
 19, 1814, having fallen from a tree two or three days 
 before. The surgeon to whom he applied told him 
 that nothing was injured ; but he himself persisted 
 in saying his shoulder was broken, and walked up 
 from Maidstone to the hospital. On examination, 
 his shoulder appeared fallen as if displaced, but a 
 little attention showed that this was not the case. 
 What, however, the accident was determined to be, 
 I do not recollect ; but the following treatment was 
 adopted. Cushions were put in the axilla9, and a 
 stellate bandage applied, with another just above the 
 elbow to bind it to the side, and the arm was put in 
 a sling, which seemed to keep the parts in their pro- 
 
 48 
 
378 
 
 DISLOCATIONS OF THE CLAVICLE. 
 
 per position; but the next morning the bandages were 
 loose. Supposing that this effect was produced by 
 restlessness, they were again applied, but continued 
 slipping off, day after day, until a week from his ad- 
 mission, when a long splint, placed across the shoul- 
 ders, was bound to them by rollers, and the parts re- 
 sumed their natural situation ; but after a short time, 
 they were also obliged to be removed on account of 
 the extreme irritability of the patient. He was 
 then ordered to lie in bed upon his back without any 
 bandage, but the parts became again displaced. No 
 other attempt at relief was made, and he died on 
 December the 7th following, of some pulmonary 
 disease, after an illness of three weeks. 
 
 Clavicle dislocated; acromion broken, — On exami- 
 nation of his body, the clavicle was found dislocated 
 at its scapular extremity, and projected considerably 
 over the spine of thai bone. The acromion pro- 
 cess, just where the clavicle is united with it, was 
 broken off. 
 
 The splint across the shoulders seemed likely to 
 have succeeded in keeping the parts in apposition, if 
 the man's illness and impatience would have permit- 
 ted him to continue to wear it. 
 
STRUCTURE OF THK SHOULDER-JOINT. 
 
 Shoulder-joint — The shoulder-joint is composed 
 of two portions of bone ; the glenoid cavity of the 
 scapula, and the head of the os humeri. 
 
 Glenoid cavity. — The glenoid cavity is similar in 
 form to a longitudinal section of an egg, with its lar- 
 ger extremity downwards and outwards, and its small- 
 er upwards and inwards; the cavity is so superficial, 
 that the head of the humerus rather rests upon its 
 surface than is received into its hollow ; it is, how- 
 ever, slightly concave, and is covered by an articular 
 cartilage, which is somewhat extended beyond the 
 edge of the bony cavity. 
 
 Coracoid process. — The coracoid process of the 
 scapula is situated at the upper point of the glenoid 
 cavity, and its basis extends from thence to the notch 
 of the superior costa ; it rises and inclines inwards 
 and forwards, terminating in a point, which is situat- 
 ed under the clavicle, one third the length of that 
 bone from its junction with the spine of the scapula, 
 and on the inner side of the head of the os humeri, 
 under the pectoral muscle. It covers and protects 
 the joint on its inner side. 
 
380 
 
 STRUCTURE OF THE SHOULDER-JOINT. 
 
 Cervix scapulce, — The glenoid cavity is united to 
 the body of the scapula by a narrow neck, which is 
 called the cervix scapulas; and its narrowest part is 
 opposite to the notch of the superior costa of the 
 scapula. 
 
 Head of the humerus. — The head of the humerus 
 is divided into three portions. The first is an articu- 
 lar surface forming a small part of a sphere, which 
 rests upon the glenoid cavity of the scapula, and is 
 covered with an articular cartilage ; the second is a 
 process called the larger tubercle, formed for the 
 insertion of three muscles ; it is situated on the outer 
 portion of the head of the bone, under the deltoid 
 muscle ; and the third is a process called the lesser 
 tubercle, which is situated on the inner side of the 
 head of the bone towards the axilla; and in the usu- 
 al position of the arm, nearly in a line with the point 
 of the coracoid process of the scapula. 
 
 Bicipital groove, — Between these two processes 
 is a groove, which lodges the tendon of the long head 
 of the biceps muscle, and is termed the bicipital 
 groove. 
 
 Cervix humeri. — Immediately below the head of 
 the humerus is situated that portion of the bonjB 
 called the cervix humeri. 
 
 Capsular ligament. — The capsular ligament of 
 this joint surrounds the head of the bone, and is at- 
 tached to the whole circumference of the edge of 
 the glenoid cavity, excepting where the tendon of 
 the biceps muscle passes under it; and at that point 
 it arises I'rom a ligament which proceeds from the co- 
 racoid process to the edge of the glenoid cavity. 
 The capsular ligament is also fixed to the two tuber- 
 cles, and towards the axilla, to the neck of the hume- 
 rus, just below its articular surface. This ligament 
 is not of a uniform thickness ; but at those parts 
 where the joint is not defended from injury by the 
 tendinous insertions of muscles, the capsular ligament 
 
STRUCTURE OF THE SHOULDER-JOINT. 
 
 381 
 
 itself is thickened, and is capable of sustaining great 
 violence ; and this difference is remarkably shown in 
 that part of the ligament which is placed in the ax- 
 illa, it being of a strong tendinous nature. 
 
 Muscles of protection to the joint. — Four muscles 
 are destined to move the os humeri, and to strength- 
 en the capsular ligament. The first, the supra-spi- 
 natus, which arises from the fossa supra-spinata, 
 covers the head of the bone^ blends its tendon with 
 the capsular ligament, and is inserted into the larger 
 tubercle; the second, the infra-spinatus muscle, 
 which proceeds from the fossa infra-spinata, adheres 
 to the back part of the capsular ligament, and is also 
 fixed to the greater tubercle ; the third, the teres 
 minor, which arises from the lower edge of the sca- 
 pula, adheres to the back part of the capsular liga- 
 ment, and is inserted into the greater tubercle, and 
 into the cervix humeri ; the fourth is the subscapu-^ 
 laris muscle, which fills up the venter, or inner con- 
 cave surface of the scapula: it passes over the inner 
 side of the head of the bone, and is fixed to the 
 smaller tubercle, firmly adhering to the capsular lig- 
 ament as it passes over its inferior and inner surface* 
 It is between the subscapularis muscle, and the teres 
 minor, that the capsular ligament is found of great 
 strength, as there are no muscles inserted into that 
 part to protect the joint from injury. 
 
 Muscles of motion of the joint, — The deltoid mus- 
 cle, the coraco-brachialis, and the teres major, which 
 are also muscles of this joint, are not united with 
 the capsular ligament as the other muscles, being 
 only destined for the motion, and not particularly for 
 the protection of the shoulder-joint. 
 
 Tendon of the biceps, — The tendon of the lon2: 
 head of the biceps protects the upper part of the 
 joint, where it otherwise Avould be weak ; for this 
 tendon is situated between that of the supra-spinatus 
 
382 
 
 STRUCTURE OF THE SHOULDER-JOINT. 
 
 and subscapularis : it arises from the upper point of 
 the edge of the glenoid cavity of the scapula, and 
 passes over the head of the bone into the groove 
 between the two tubercles and the portion of the 
 capsular ligament. Reflected towards the articular 
 cartilage of the os humeri it adheres to the surface 
 of this tendon, so that the synovia is prevented from 
 escaping. 
 
 Cause of the frequent dislocation of this joint. — The 
 shoulder-joint has a greater extent and variety of 
 motion than any other joint in the body; and its 
 dislocations are, consequently, more frequent than 
 those of all the other joints in the body collective- 
 ly : those of the ankle-joint being next in frequency. 
 
DISLOCATIONS OF THE OS HUMERI. 
 
 Four kinds of dislocation, — This bone is liable ta 
 be thrown from the glenoid cavity of the scapula in 
 four directions ; three of these luxations are com- 
 plete, and one is only partial. 
 
 Downwards and inwards. — The first is downwards 
 and inwards ; it is usually called the dislocation into 
 the axilla, and in this accident the bone rests upon 
 the inner side of the inferior costa of the scapula. 
 
 Forwards. — The second is forwards upon the 
 pectoral muscle, when the head of the os humeri is 
 placed below the middle of the clavicle, and on the 
 sternal side of the coracoid process. 
 
 Backwards. — The third \s {he dislocation back- 
 wards, when the head of the bone can be both felt 
 and distinctly seen, forming a protuberance on the 
 back and outer part of the inferior costa of the sca- 
 pula, and situated upon its dorsum. 
 
 Partial dislocations. — The fourth \s only partial, 
 when the anterior portion of the capsular ligament 
 is torn through, and the head of the bone is found 
 resting against the coracoid process of the scapula, 
 on its outer side. 
 
384 
 
 DISLOCATIONS OF THE OS HUMERI. 
 
 Of the dislocation upwards. — It has been sup- 
 posed that a dislocation of the os humeri upwards 
 might occur, but it is obvious that this could only 
 happen under fracture of the acromion. It is an ac- 
 cident which I have never seen. 
 
 Dislocation in the axilla. — Of the dislocation in 
 the axilla I have seen a multitude of instances; of 
 that forwards on the inner side of the coracoid pro- 
 cess several, although these are much less frequent 
 than that in the axilla ; of the dislocation backwards 
 I have seen only two instances during the practice 
 of my profession for thirty-eight years. 1 do not 
 believe in any change of place after dislocation, 
 when the muscles have once contracted (except 
 from subsequent violence, which is very uncommon), 
 beyond that slight change which pressure, by produc- 
 ing absorption, will sometimes occasion. The bone 
 is generally at once thrown into the situation which 
 it afterwards occupies; so that excepting from cir- 
 cumstances of great violence, the nature and direc- 
 tion of the dislocation are not subsequently changed. 
 
 DISLOCATION IN THE AXILLA. 
 
 Signs of dislocation into the axilla. — The usual 
 sificns of this dislocation are as follow : A hollow is 
 produced below the acromion, by the displacement 
 of the head of the humerus from the glenoid cavi- 
 ty, and the natural roundness of the shoulder is de- 
 stroyed, because the deltoid muscle is flattened and 
 dragged down with the depressed head of the bone. 
 The arm is somewhat longer than the other, as the 
 situation of the bone upon the inferior costa of thesca- 
 pula is below the level of the glenoid cavity. The 
 elbow is with difficulty made to touch the patient's 
 
DISLOCATIONS OP THE OS HUMERI. 
 
 385 
 
 side, from the pain produced in this eiiort by pres- 
 sure of the head of the bone upon the nerves of 
 the axilla; and upon this account it usually happens, 
 that the patient himself supports his arm at the 
 wrist or lore arm with the other hand, to prevent 
 its weight pressing upon these nerves. The head 
 of the 0? humeri can be felt in the axilla, but only 
 if the elbow be considerably removed from the side. 
 I have several times seen surgeons deceived in these 
 accidents, by thrusting the fingers into the axilla 
 when the arm is close to the side, when thej have 
 directly said, ' this is not a dislocation;' but upon 
 raising the elbow, the head of the bone could be 
 distinctly felt in the axilla ; for that movement 
 throws the head of the bone downwards and more 
 into the axilla. 
 
 The motion of the shoulder is in a great degree 
 lost, more especially in the direction upwards and 
 outwards, for the patient can no longer raise his arm 
 by muscular effort, and even the surgeon generally 
 finds some difficulty in overcoming its fixed position; 
 it is usual, therefore, as a first question in detecting 
 dislocation, to ask the patient if he can raise his arm 
 to his head, and if there be dislocation, the answer 
 is invariable that he cannot. The power of rota- 
 tion of the arm is also lost ; but the motion of the 
 limb forwards and backwards, as it hangs by the 
 side, is still preserved. There is, however, great 
 difference in respect to the motion of the limb, and 
 this depends upon the age of the patient ; in old 
 people, the relaxed state of the muscles will not 
 only admit of motion, but allow the surgeon to carry 
 the arm to the upper part of the head. On mov- 
 ing the limb, a slight crepitus will sonaetimes be felt 
 from inflammatory effusion, and from the escape of 
 synovia, but by the continuance of the motion 
 this soon ceases ; the crepitus, however, in these 
 
 49 
 
386 DISLOCATIONS OF THE OS HUMERI. 
 
 cases, is never so strong as that which a fracture 
 produces. The central axis of the arm is changed, 
 for the central h'ne runs into the axilla. 
 
 In this accident, numbness of the fingers frequent- 
 ly occurs, from the pressure of the head of the 
 bone upon a nerve or the nerves of the axillary 
 plexus. 
 
 Circumstances that render the nature of the accident 
 difficult to ascertain, — These are the circumstances 
 of greatest moment ; but it will be seen that the 
 accident can be detected principally by the fall of 
 the shoulder, by the presence of the head of the 
 bone in the axillla, and by the loss of the natural 
 motions of the joint. But a few hours make these 
 appearances much less decisive, from the extravasa- 
 tion of blood, and from the excessive swelling which 
 sometimes ensue ; when, however, the effused blood 
 has become absorbed, and the inflammation has sub- 
 sided, the marks of fhe injury become again deci- 
 sive. At this period it is that surgeons of the me- 
 tropolis are usually consulted; and if we detect a 
 dislocation which has been overlooked, it is our 
 duty, in candour, to state to the patient, that the diffi- 
 culty in the detection of the nature of the accident 
 is exceedingly diminished by the cessation of inflam- 
 mation, and the absence of tumefaction. 
 
 Circumstances that render it easy. — It may be 
 also observed, that there is great difference in 
 the facility with which the accident is discovered 
 in thin persons of advanced age, and in those 
 who are loaded with fat, or who have, by con- 
 stant exertion, rendered their muscles excessively 
 large. 
 
DISLOCATIONS OF THE OS HUMERI. 
 
 387 
 
 Dissection of the Dislocation into the Axilla. 
 
 I have dissected two cases of recent dislocation 
 downwards. A sailor fell from the yard-arm on the 
 ship's deck, injured his skull, ar>d dislocated the arm 
 into the axilla. He was brought into St Thomas's 
 Hospital in a dying state, and expired immediately 
 after he was put into his bed. On the following day I 
 obtained permission to examine his shoulder, which 
 I removed from the body for the purpose of obtain- 
 ing a more minute examination, and the following 
 were the appearances which I found. On removing 
 the integuments, a quantity of extravasated blood 
 presented itself in the cellular membrane, lying im- 
 mediately under the skin, and in that which covers 
 the axillary plexus of nerves, as well as in the inter^ 
 stices of the muscles, extending as far as the cervix 
 of the humerus, below the insertion of the subscapu- 
 laris muscle. 
 
 ^Appearances upon the dissection of the limb. — The 
 axillary artery, and plexus of nerves, were thrown out 
 of their course by the dislocated head of the bone, 
 which was pushed backwards upon the subsca[)ularis 
 muscle. The deltoid muscle was sunken with the 
 head of the bone. The supra and infra spinatus 
 were stretched over the glenoid cavity and inferior 
 costa of the scapula. The teres major and minor 
 had undergone but little change of position; but the 
 latter, near its insertion, was surrounded by extrava- 
 sated blood. The coraco-brachialis was uninjured. 
 In a space between the axillary plexus and coraco- 
 brachialis, the dislocated head of the bone, covered 
 by its smooth articular cartilage and by a thin layer 
 of cellular membrane, appeared. The capsular liga-^ 
 ment was torn on the whole length of the inner side 
 of the glenoid cavity, which would have admitted 
 
388 
 
 DISLOCATIONS OF THE OS HUMERI. 
 
 a much larger body than the head of the os humeri 
 through the opening. The tendon of the-subscapu- 
 laris muscle, which covers the hgament, was also ex- 
 tensively torn. The opening of the ligament, by 
 which the tendon of the long head of the biceps pass- 
 ed, was rendered larger by laceration, but the ten- 
 don itself was not torn. The head of the os humeri 
 was thrown on the inferior costa of the scapula, be- 
 tween it and the ribs; and the axis of its new situa- 
 tion was about an inch and a half below that of the 
 glenoid cavity, from which it had been thrown. 
 
 The second case which I had an opportunity of 
 examining was one in which the dislocation had ex- 
 isted five weeks, and in which very violent attempts 
 had been made to reduce the dislocated bone, but 
 without success. The subject of the accident was a 
 woman fifty years of age. All the appearances 
 were distinctly marked ; the deltoid muscle being 
 flattened, and the acromion pointed ; the head of 
 the hone could also be distinctly felt in the axilla; 
 the skin had been abraded during the attempts at 
 reduction, and the woman apparently died from the 
 violence used in the extension. Upon exposing the 
 muscles, the pectoralis major was found to have been 
 slightly lacerated, and blood effused ; the latissimus 
 dorsi and teres major were not injured ; the supra- 
 spinatus was lacerated in several places ; the infra- 
 spinatus and teres minor w^ere torn, but not to the 
 same extent as the former muscle. Some of the 
 fibres of the deltoid muscle and a few of those of 
 the coraco-brachia.lis had been torn ; but none of the 
 muscles had suffered so much injury as the supra- 
 spinatus. The biceps w^as not injured. 
 
 Having ascertained the injury which the muscles 
 had sustained in the extension, and, in some degree, 
 the resistance which they opposed to it, I proceed- 
 ed to examine the joint. 
 
DISLOCATIONS OP THE OS HUMERI. 
 
 389 
 
 The capsular ligament had given way in the axil- 
 la, between the teres minor and subscapularis mus- 
 cles ; the tendon of the subscapularis was torn 
 through at its insertion into the lesser tubercle of 
 the OS humuri (See Plates) ; the head of the bone 
 rested upon the axillary plexus of nerves and the 
 artery. Having determined these points by dissec- 
 tion, I next endeavoured to reduce the bone, but 
 finding the resistance too great to be overcome by 
 my own efforts, I became very anxious to ascertain 
 its origin. 1 therefore divided one muscle after 
 another, cutting through the coraca-brachialis, teres 
 major and minor, and infra spinatus muscles ; yet 
 still the opposition to my efforts remained, and with 
 but little apparent change. I then conceived that 
 the deltoid must be the chief cause of my failure, 
 and by elevating the arm, I relaxed this muscle; but 
 still could not reduce the dislocation. I next divid- 
 ed the deltoid muscle, and then found the supra- 
 spinatus muscle my great opponent, until I drew the 
 arm directly upwards, when the head of the bone 
 glided into the glenoid cavity. The deltoid and 
 supra-spinatus muscles, are those which most pow- 
 erfully resist reduction in this accident. 
 
 It appears from these dissections, that the best 
 direction in which the arm may be extended for re- 
 duction, is at a right angle with the body, or direct- 
 ly horizontall}^, rather than obliquely downwards; 
 as the deltoid, supra and infra spinati muscles, are, 
 in this position of the limb, thrown into a relaxed 
 state, and these muscles are, as I have explained, 
 the principal sources of the resistance. The biceps 
 is to be relaxed by slightly bending the elbow. 
 The arm may be extended directly outwards, in the 
 line between the pectoralis major on the outer side, 
 and the latissimus dorsi and teres major on the in- 
 ner ; but if there be any deviation from this line, it 
 
390 
 
 DISLOCATIONS OF THE OS HUMERI. 
 
 will be better rather to advance the arm, to lessen 
 the power of the pectoralis major. 
 
 This dissection explains the reason why the arm 
 is sometimes easily reduced soon after the disloca- 
 tion, by raising it suddenly above the horizontal 
 line, and placing the fingers under the head of the 
 bone, so as to raise it towards the glenoid cavity, 
 which, as every tyro knows, will sometimes prove 
 effectual, because, in this position, the muscles of 
 opposition are relaxed so as to oppose no resistance 
 to reduction. 
 
 Dissection of a Dislocation which had been long un- 
 
 reduced. 
 
 Dissection of an old dislocation, — The head of 
 the bone is found altered in its form ; the surface 
 towards the scapula being flattened, a complete cap- 
 sular ligament covers the head of the os humeri. 
 The glenoid cavity is completely filled by ligament- 
 ous matter, infused by a slow inflammatory process; 
 in this ligamentous matter are suspended small por- 
 tions of bone, which appear to be of new formation, 
 as no portion of the scapula or humerus is broken; 
 a new cavity is formed for the head of the os hu- 
 meri on the inferior costa of the scapula, but this 
 is glenoid, like that from which the os humeri had 
 escaped. (See Plate.^ 
 
 Causes of dislocation into the axilla. — The com- 
 mon causes of dislocation of the os humeri into the 
 axilla are, falls upon the hand while the arm is 
 raised above an horizontal line, by which the head 
 of the bone is thrown downwards; also a fall upon 
 the elbow, when the arm is raised from the side; 
 but the most frequent cause is a fall directly upon 
 the shoulder on some uneven surface, by which the 
 
DISLOCATIONS OF THE OS HUMERI. 391 
 
 head of the bone is driven downwards, whilst the 
 muscles are but ill prepared to resist the shock. 
 
 Frequency of its recurrence. — When the arm has 
 been once dislocated, if great care be not taken of 
 the limb after its reduction, it is extremely liable to 
 a recurrence of the accident. I remember, parti- 
 cularly, a carpenter, who used to be a frequent 
 visiter at Guy's Hospital for several years, for the 
 purpose of having his shoulder reduced. Slighter 
 causes than that which originally produced it, will 
 renew the dislocation; I have known it to recur 
 from the act of throwing up the sash of a window. 
 During my apprenticeship at St Thomas's Hospital, 
 in going through the wards early one morning, I 
 was directed to see a man who had just dislocated 
 the shoulder, which he had frequently done before, 
 as he was lying in bed; and upon inquiring how it 
 had happened, the man replied, that it occurred 
 merely in the effort of rubbing his eyes and stretch- 
 ing himself upon waking; but this disposition to the 
 recurrence of dislocation may be prevented, by di- 
 recting that the arm be kept fixed close to the side, 
 and the shoulder rather elevated by a pad in the 
 axilla, for three weeks after its reduction ; during 
 which time the ruptured tendon of the subscapularis, 
 and the capsular ligament will be united: a process 
 which motion greatly impedes, if not wholly pre- 
 vents. 
 
 Reduction of the Dislocation in the Axilla, 
 
 Means employed for reduction, — Various have 
 been the means suggested for the reduction of the 
 head of the humerus, when dislocated downwards 
 into the axilla ; but under the different circumstances 
 attending this accident, different means must be em- 
 
392 
 
 DISLOCATIONS OF THE OS HUMERI. 
 
 ployed ; the first, and that which I usually adopt in 
 my private practice in all recent cases, is 
 
 By the Heel in the Axilla : 
 And the best mode of its application is as follows : 
 The patient should be placed in the recumbent 
 posture, upon a table or a sofa, near to the edge of 
 which he is to be brought ; the surgeon then binds 
 a wetted roller round the arm immediately above 
 the elbow, upon which he ties a handkerchief ; then 
 with one foot resting upon the floor, he separates 
 the patient's elbow from his side, and places the 
 heel of his other foot in the axilla, receiving the 
 head of the os humeri upon it, whilst he is himself 
 in the half sitting posture by the patient's side. He 
 then draws the arm by means of the handkerchief, 
 steadily for three or four minutes, when, under com- 
 mon cfrcumstances, the head of the bone is easily 
 replaced (^see Plate): but if more force be required, 
 the handkerchief may be changed for a long towel, 
 by which several persons may pull, the heel still re- 
 maining in the axilla. I generally bend the fore arm 
 nearly at right angles with the os humeri, because 
 it relaxes the biceps, and consequently diminishes 
 its resistance. I have, in many cases, extended from 
 the wrist, by tying the handkerchief just above the 
 hand, but more force is required in this than in the 
 former mode, although it has this advantage, that 
 the bandage is less liable to slip. In recent cases 
 it very rarely happens that this mode of extension 
 fails, and it is so easily applied in every situation, 
 that I have recommended all our young men to 
 employ it in the first instance, when called to this 
 accident. 
 
 Second Mode. 
 Second mode ; application of the bandage, — But 
 
DISLOCATIONS OF THE OS 11U3IERI. 393 
 
 in those casqs in which (he muscles are of very consid- 
 erable strength, and the dislocation having existed 
 for several days, the muscles have become perma- 
 nently contracted, so that the limb is strongly fixed 
 in its new situation, more force is required, and the 
 following means should be employed. The patient 
 must be placed upon a chair, and the scapula fixed 
 by means of a bandage, which allows the arm to 
 pass through it; that which we use at our hospital 
 is a girt buckled on the top of the acromion, so as to 
 raise the bandage high in the axilla, and thus enable 
 it more completely to fix the scapula, which is the 
 principal object to be attended to, as otherwise all ef- 
 forts will be inefficient. When I first saw the mode 
 of reduction practised thirty-eight years ago, a round 
 towel was used instead of this bandage, which was 
 placed in the axilla, and crossed the chest, but it ap- 
 peared to me that by this means the lower angle of 
 the scapula alone was fixed, and that the glenoid ca- 
 vity was drawn with the arm when extension was 
 made; I directed, therefore, that the towel should 
 be tied over the opposite shoulder with a handker- 
 chief, so that it should be raised in the axilla on the 
 injured side, and thus embrace a larger surface of 
 the scapula; but still I found the scapula drawn from 
 the side with the arm, and therefore had the ban- 
 dage made as described (sec Plate), A wetted j'oller 
 is next to be bound around the u[)per arm just above 
 the elbow, from which situation it cannot slip, and 
 upon this a very strong worsted tape is to be fasten- 
 ed, in a manner to be described, when speaking of 
 the reduction of dislocated fino^ers. The arm should 
 then be raised at right angles with the body, and if 
 there be much difficulty in the reduction, it should be 
 elevated above the horizontal line, more completely 
 to relax the deltoid and supra-spinatus muscles. 
 Two persons should then draw from the bandage 
 
 50 
 
394 
 
 DISLOCATIONS OF THE OS HUMERI. 
 
 affixed to the arm, and two from the scapula band- 
 .agc, with a steady, equal, and conibined force ; jerk- 
 ing should be entirely avoided, and every aim at 
 quick reduction should be discountenanced : 'slowly 
 and steadily'' should be the word of command from 
 the surgeon • who, after the extension has been kept 
 up for a few minutes, sho Id place his knee in the 
 axilla, resting his foot on the chair upon which the 
 patient sits ; he should then raise his knee by extend- 
 ing his foot, and placing his right hand upon the 
 acromion, push it downwards and inwards, when the 
 head of the bone will usually slip into its natural po- 
 sition. Whilst the extension is proceeding I have 
 seen a gentle rotatory motion of the arm diminish op- 
 position of the muscles, and the bone suddenly slip 
 into its place. 
 
 But when a limb has remained a considerable 
 length of time dislocated; when the muscles are so 
 powerfully contracted that the force of men cannot 
 be so steadily exerted as to reduce the limb, after 
 several attempts, the minds and bodies of the assist- 
 ants becoming fatigued, and their efforts violent and 
 unequal^ then we employ the third mode of reduc- 
 tion, 
 
 By means of the Pidleys, 
 Pulleys ; application of the pulley^ 8fc, — And here 
 let it be understood that they are not adopted with 
 a view of employing greater force, for that might 
 be obtained by the aid of more persons ; but they 
 are introduced to enable the surgeon to employ the 
 force gradually and equally ; to avoid jerks and 
 unequal extension, which, in protracted cases, the 
 efforts of men are sure to produce. If, therefore, 
 1 saw a surgeon, as soon as the pulleys were fixed, 
 draw them violently, and endeavour suddenly to re- 
 duce the limb, I should not hesitate at once to say, 
 
DISLOCATIONS OF THE OS HUMERI. 
 
 395 
 
 *that genlleman is ignorant of the principle upon 
 which this mechanical power is employed, and has 
 still this part of his profession to lear n: For the 
 application of the pulley the patient is seated be- 
 tween two staples, which are screwed into the wain- 
 scot on each side of him; the bandages are then 
 applied, precisely as in the former mode, in which 
 the extension is performed by men, and the force 
 is applied in the same direction ; the surgeon should 
 first draw the pulky, as the class of people usually 
 summoned to his assistance, being ignorant of the 
 principle upon which it is employed, would use too 
 great violence ; he should draw gently and steadily, 
 until the patient begins to complain of pain, and 
 then cease, keeping up the degree of extension, and 
 conversing with the patient to direct his mind to 
 other objects. In two or three minutes, more force 
 should be applied, and continued until pain be again 
 complained of, when the surgeon should again cease 
 to increase the force; and thus he should proceed 
 for a quarter of an hour, at intervals slightly rotat- 
 ing the limb. He should, when he has applied all 
 the extension he thinks right, give the string of the 
 pulley to an assistant, desiring the existing degree 
 of extension to be supported; then, putting his knee 
 in the axilla, and resting his foot upon the chair, he 
 should gently raise and push back the head of the 
 bone towards the glenoid cavity, when the bone will 
 pass into its socket; this takes place generally with- 
 out the snap which is heard when other means are 
 employed, yet both the surgeon and the patient are 
 aware of some motion of the head of the bone at 
 the time.* If the |)ulleys be thus employed, the 
 
 * Oae of our pupils, a Mr Bartlett, of Ipswich, has invented 
 n small spring, by means of which the strings are attached to 
 the pulley, and which can certainly detach them whilst the 
 
396 
 
 DISLOCATIONS OF THE OS HUMERI. 
 
 extension will be conducted infinitely more steadily 
 and elfectuaUv tlian when performed by men. In 
 ,my hospital practice I order the patient to be bled, 
 and to be put into a warm bath at the temperature 
 ol* 100 to 110°; and I give him a grain of tartariz- 
 ed antimony every ten minutes until he becomes 
 faint ; then I order him to be removed from the 
 bath, to be wrapped in a blanket, and immediately 
 placed upon the chair for extension, before his mus- 
 cles have had time to recover, which expedient 
 lessens the necessity of employing very considerable 
 force. Mr Henry Cline, Surgeon to St Thomas's 
 Hospital, son to my most excellent master, and who 
 would have made an excellent practical surgeon if 
 the hand of death had not prematurely deprived 
 the world of his useful talents, was in the habit of 
 directing his patients to support a weight for a length 
 of time before the extension was begun, with a view 
 of fatiguing the muscles, and lessening their power 
 of resistance. In apartments where it is not con- 
 venient to place the pulleys in the walls, I have fix- 
 ed them in the floor, on each side the patient, who 
 must, under these circumstances, sit upon the floor. 
 When the reduction has been efl*ected, a small cush- 
 ion should be placed in the axilla, and fixed there 
 by a stellate bandage, to prevent the head of the 
 bone from again slipping out of its situation, which 
 the excessive relaxation of the muscles would readi- 
 ly permit ; but the cushion should not be so large 
 as to separate the arm far from the side. The sling 
 is to be also worn to support the arm. 
 
 There is still a fourth mode of reducing the dis- 
 location into the axilla, which is applicable to recent 
 
 knee is in the axilla. This instrument may sometimes be 
 useful. — A. C. 
 
DISLOCATIONS OF THE OS HUMERI. 
 
 397 
 
 dislocations, to delicate females, and to very old, re- 
 laxed, and emaciated peisons, viz : 
 
 By the Knee in the Axilla. 
 Fourth mode of reduction. — The patient is seat- 
 ed upon a low chair, the surgeon placing himself 
 by him, separates the dislocated arm from the side 
 sufficiently to admit his knee into the axilla, and 
 resting his foot upon the side of the chair, he plac- 
 es one hand upon the os humeri, just above the con- 
 dyles, and the other upon the acromion scapulas; he 
 then pulls down the arm over the knee, and in this 
 manner reduces the dislocation. {See Plate.') Even 
 in persons of powerful muscles, 1 have known this 
 mode succeed, when the patient remained in the 
 state of intoxication in which he was found Avhen 
 the accident happened. 
 
 The use of the Ambe, — The ambe has been re« 
 commended for the reduction of dislocations in the 
 axilla, and this instrument was, in the last century,, 
 improved by the addition of a screw for the pur- 
 pose of rendering its extension more gradual. It 
 may succeed very well in recent cases, and in those 
 persons whose muscles are not very powerful ; but 
 when a continued extension must of necessity be 
 used to reduce the bone, as its fixed point of action 
 is upon the ribs of the patient, it produces too much 
 injury to the side, is too painful to be borne long, 
 and is, therefore, an instrument which cannot be re- 
 commended for general use. 
 
 Mr Kirby, surgeon in Dublin, has lately advised 
 an ingenious mode of applying force in dislocations 
 of the shoulder: the scapula being fixed and the 
 bandage applied to the arm, the patient sits upon a 
 mattress which is laid upon the floor, and the assist- 
 ants, to whose management the extension and coun- 
 ter-extension are consigned, place themselves at his 
 
398 
 
 DISLOCATIONS OF THE OS HUMERI. 
 
 side, sitting opposite to each other, and disposing 
 their legs so that the soles of their feet are oppos- 
 ed to each other, behind and before the patient. 
 If occasion should require a greater force than the 
 power of two men, another assistant or more may 
 be placed at the backs of the first two, sitting close 
 up to them with their faces turned towards the pa- 
 tient;, the extension is now made, with the arm 
 raised nearly to a right angle with the body, and in 
 the direction forwards or backwards, as the circum- 
 stances of the case may require. The force should 
 be maintained until it is perceived that the head of 
 ihe bone (which can be easily felt, and should be 
 pressed upon during the operation), has moved from 
 its new situation ; and when the head of the bone 
 Is found to change its position, the assistants should 
 slowly diminish their force while the surgeon directs 
 it towards the glenoid cavity, by pressing the elbow 
 to the side of the patient and slightly raising it. 
 
 Slight force necessary fir reductions after repeated 
 dislocation.-^ When a person has frequently dislo- 
 cated his shoulder, a very slight effort is sufficient 
 to restore the limb to its place; and I know a gen- 
 tleman in the country who has frequently returned 
 the. dislocated head of the humerus into its situation, 
 by walking up to a gate, reaching over as far as he 
 could, and then holding by one of its lowest bars, 
 the upper bar of the gate being pressed firmly into 
 the axilla; still retaining his hold, he suffers his 
 body to sink on the other side of the gate, and the 
 head of the bone is thus pushed into the glenoid 
 cavity; this mode of reduction is the same in prin- 
 ciple as that of the heel in the axilla, which, as I 
 have already mentioned, in three-fourths of recent 
 dislocations, is the best for effecting the reduction. 
 
DISLOCATIONS OF THE OS HUMERI. 
 
 399 
 
 DISLOCATION FORWARDS, BEHIND THE PECTORAL MUS- 
 CLE, AND BELOW THE MIDDLE OF THE CLAVICLE. 
 
 Symptoms ; situation of the head of the humerus, 
 — This species of dislocation is much more distinct- 
 ly marked than the former. The acromion is more 
 pointed, and the hollow below it, from the depres- 
 sion of the deltoid muscle, is much more consider- 
 able. The head of the os humeri can be readily 
 and distinctly felt, and even seen, in thin persons, 
 just below the clavicle ; and when the arm is rotat- 
 ed from the elbow, the protuberance may be seen 
 to obey the motions of the arm. 
 
 The coracoid process of the scapula is placed oh 
 the outer side of the head of the bone, so that the 
 latter is situated between the scapula and the ster- 
 num, and is covered by the pectoralis major muscle. 
 The arm is somewhat shortened, and the elbow is 
 thrown more from the side, and further back, than 
 in dislocation into the axilla. (See Plate.) The axis 
 of the limb is much altered, being thrown inward 
 towards the middle of the clavicle. 
 
 The degree of pain in this accident, S^c. — The 
 pain attending this accident is slighter than when 
 the head of the os humeri is thrown into the axilla, 
 because the nerves of the axillary plexus are less 
 compressed ; but the motions of the joint are much 
 more materially affected; the head of the bone be- 
 coming fixed by the coracoid process, and neck of 
 the scapula, on the outside, and by the clavicle above ; 
 while the muscles of the scapula, as the supra and 
 infra spinati, and teres minor, being put upon the 
 stretch, confine all its motions inwards and back- 
 wards. If, therefore, the arm be attempted to be 
 brought forwards, the head of the bone strikes 
 against the clavicle; if outwards, from the side, the 
 
400 
 
 DISLOCATIONS OF THE OS HUMERI. 
 
 coracoid process stops it : its motion backwards, 
 however, is confined, not bj bone, but by the resist- 
 ance of muscles. But the strongest diagnostic marks 
 of this dislocation are these : the head of the bone 
 is below the clavicle; the elbow is separated from 
 the side, and thrown backwards ; and the rotation 
 of the arm gives motion to the head of the bone 
 under the clavicle. 
 
 Dissection of the Dislocation Forwards. 
 
 Os humeri; appearances on dissection, — The head 
 of the OS humeri is, in this accident, thrown on the 
 inner side of the neck of the scapula, between it 
 and the second and third ribs. I have had no op- 
 portunity of dissecting a recent accident of this 
 kind; but in the Museum at St Thomas's Hospital 
 there is a beautiful specimen of one in a limb which 
 had been long dislocated, and which was removed 
 from the shoulder of a patient by Mr Green, and 
 dissected by Mr Key,' who gave me the following 
 account of the appearances; — The head of the 
 bone was thrown on the neck and part of the ven- 
 ter of the scapula, near the edge of the glenoid 
 cavity, and immediately under the notch of the su- 
 perior costa : nothing intervened between the head 
 of the humerus and scapula, the subscapularis being 
 partly raised from its attachment to the venter. 
 The head was situated on the inner side of the co- 
 racoid process, and immediately under the edge of 
 the clavicle, without having the slightest connexion 
 with the ribs ; indeed, this must have been prevent- 
 ed, by the situation of the subscapularis and serratus 
 magnus muscles between the thorax and humerus. 
 The tendons of all the muscles attached to the tu- 
 bercles of the humerus were perfect, and are shown 
 
DISLOCATIONS OP THE OS HUMERI. 401 
 
 in the preparation. The tendon of the biceps was 
 not torn; and it adhered to the capsular ligament. 
 The glenoid cavity was completely filled up by liga- 
 mentous structure; still, however, preserving its 
 general form and character. Tiic* tendons of the 
 supra and infra spinatus, and teres minor muscles, 
 adhered by means of bands to the ligamentous struc- 
 ture occupying the glenoid cavity : and to prevent 
 the effects of friction between the tendons and the 
 glenoid cavity in the motions of the arm, a sesamoid 
 bone had been formed in the substance of the ten- 
 dons. The newly formed socket reached from the 
 edge of the glenoid cavity to about one third across 
 the venter. A complete lip was formed around the 
 new cavity, and the surface was irregularly covered 
 with cartilage. The head had undergone consider- 
 able change of form, the cartilage being in many 
 places absorbed. A complete new capsular ligament 
 had been formed. (^See Plate.) 
 
 The pectorah's minor is not mentioned in this dis- 
 section ; but from the natural situation of the cora- 
 coid process, into which this muscle is inserted, it 
 must have passed over the head of the os humeri, 
 as did the pectoralis major. 
 
 Causes of this dislocation. — The usual causes of 
 this dislocation are, either a fall upon the elbow, or 
 a violent blow upon the shoulder, as in the last de- 
 scribed dislocation. If it be a blow upon the elbow 
 which has produced the accident, it must have been 
 inflicted at a time when the elbow was thrown be- 
 hind the central line of the body ; and w'hen the 
 shoulder received the blow, the head of the bone 
 must have been driven forwards and inwards. 
 
402 DISLOCATIONS OF THE OS HUMERI. 
 
 Reduction of the Dislocation Forwards, 
 
 In this, as In the former case, we can usually suc- 
 ceed In effecting reduction by placing the foot in the 
 axilla, and by extending the arm in the same man- 
 ner; excepting that in this dislocation, the foot is 
 required to be brought more forward to press on the 
 head of the bone, and the arm should be drawn 
 obliquely downwards, and a little backwards; but 
 in those cases in which some days have elapsed be- 
 fore reduction has been attempted, continued exten- 
 sion will be necessary ; and, to employ rt steadily 
 and effectually, the pulleys should be used. 
 
 The same bandage is required as in the disloca- ■ 
 tion in the axilla, whether the power used be applied 
 through the medium of pulleys or directly by men. 
 The arm should be bent to relax the biceps mus- 
 cle ; but the principal circumstance to be consider- 
 ed is, the direction in which the bone is to be dravYn, 
 and the best direction is slightly downiwards; for if 
 it be drawn horizontally, the head of the os humeri 
 is pulled against the coracoid process of the scapula, 
 and a difficulty created which may be avoided. The 
 principle upon which the pulley is employed, and 
 the manner in which the extension is supported, is 
 the same as in the dislocation into the axilla, btit the 
 direction is different, the arm being drawn obliquely 
 downwards and backwards. The extension must be 
 kept up longer than in the dislocation downwards, 
 as the resistance is greater : but as soon as the bone 
 is felt to move from its situation, the surgeon should 
 give the strings of the pulley to an assistant, and 
 putting his knee or heel against the head of the 
 bone at the fore part of the shoulder, should push it 
 back towards the glenoid cavity : but this step is not 
 of the smallest utility until the bone has been drawn 
 
DISLOCATIONS OF THE OS HUMERI. 
 
 403 
 
 below the level of the coracoid process: and whilst 
 the surgeon is thus pressing the head of the bone 
 backwards, he should pull the arm forwards from 
 the elbow. This is the plan which I have found by 
 far the most effectual in reducing the dislocation 
 forwards. 
 
 DISLOCATION OF THE OS HUMERI ON THE DORSUM 
 SCAPULiE. 
 
 Diagnostic signs. — In this dislocation, the head 
 of the bone is thrown upon the posterior surface of 
 the inferior costa of the scapula. It is an accident 
 which cannot be mistaken, as there is a protuberance 
 formed by the bone upon the scapula, which imme- 
 diately strikes the eye; and when the elbow is ro- 
 tated, this protuberance rolls also. The dislocated 
 head of the bone may be easily grasped between the 
 fingers, and distinctly felt resting below the spine of 
 -the scapula ; the motions of the arm are impaired, but 
 not to the same extent as in either of the other 
 states of luxation, 
 
 Tke unfrequent occurrence of this accident. — Two 
 cases of this accident have occurred in Guy's Hos- 
 pital in thirty-eight years ; the first during my ap- 
 prenticeship. It happened during the anatomical 
 lecture at St Thomas's Hospital. The surgery-man 
 came to the theatre and announced that there was a 
 dislocation of the shoulder at Guy's Hospital, when Mr 
 Cline went over with the students to see the acci- 
 dent, and met Mr Forster, under whose care the pa- 
 tient was admitted. The nature of the accident 
 was at once obvious, from the projection of the head 
 of the bone on the dorsum scapulte. The bandages 
 
404 
 
 DISLOCATIONS OF THE OS HUMERI. 
 
 were applied in the same manner as if the head of 
 the humerus had been in the axilla, and the exten- 
 sion was made in the same direction as in that acci- 
 dent. During the progress of the adjustment of the 
 apparatus,-some conversation took place between Mr 
 Cline and Mr Forster, as to what variation in 
 direction there should be given to the bone, if the 
 first attempt should not succeed; but in less than 
 five minutes, the bone slipped into the glenoid cavitj 
 with a loud snap. 
 
 Tlie second case, which occurred several years 
 after, was easily reduced by the dressers under the 
 same treatment. 
 
 Mr Toulmin, of Hackney, has had the kindness to 
 send me the following communication upon the sub- 
 ject of this species of dislocation. 
 
 Mr Tonhniri's case. — My dear Sir : — The gen- 
 tleman to whom the dislocation of the head of the 
 humerus upon the dorsum scapulae occurred, was 
 Mr CoHinson, who was about thirty-six years of age, 
 six feet higli, and unusually muscular. The injury 
 was sustained in the neighbourhood of Windsor, in 
 consequence of his horse I'alling with him, by which 
 he was thrown over the animal's head. He applied 
 to a surgeon at Windsor, but the character of the 
 accident was not detected. He returned in a post- 
 chaise to his own liouse, when Mr Hacon and myself 
 saw him. The shoulder had lost its natural round- 
 ness : the arm could be moved considerably, either 
 upwards or downwards; but the motion, either in the 
 anterior or posterior direction, was very limited. On 
 raising the arm to a right angle with the side, the 
 direction of the limb was obviously behind the gle- 
 noid cavity ; and by placing the hand over the 
 dorsum scapultc, and then rotating the arm, the head 
 of the bone was felt to obey the rotating motion. 
 
DISLOCATIONS OF THE OS HUMERI. 
 
 405 
 
 Means employed for its reduction. — In order to 
 reduce this dislocation, a large towel was applied to 
 sustain the necessary force for the reduction, and to 
 fix as much as possible that part of the scapula un- 
 occupied by the head of the bone. A gradual ex- 
 tension of the limb was made directly outwards, and 
 then the arm being slowly moved lor wards, the head 
 of the bone was distinctly heard to snap into its 
 socket. The extension was not continued for more 
 than two or three minutes before the reduction was 
 accomplished. To the best of my recollection, Mr 
 Collinson-3 arm was perfectly restored to all its 
 functions within a month. 
 
 1 am, my dear Sir, 
 
 Very truly your's. 
 Hackney., Jidy 10, 1822. J. Toulmin. 
 
 I have also received the following remarks on the 
 dislocation of the os humeri backwards, from Mr C. 
 M. Coley, of Bridgenorth. 
 
 May Wth, 1822. 
 My dear Sir: — The dislocation of the shoulder 
 backwards is very rare, and I apprehend, imperfect- 
 ly understood and described by surgical writers. 
 The external appearances are a hollow and pucker- 
 ing of the parts just below the acromion; the arm 
 lies close to the side ; the fore arm is turned inwards, 
 and passes obliquely forwards across the body; a 
 protuberance as large as an orange is seen on the 
 dorsum scapula?, close to the spine of that bone. 
 This dislocation is, I suppose, produced by the action 
 of the teres major and latissimus dorsl upon the bone, 
 while its head is forced over the margin of the gle- 
 noid cavity. 
 
 Reduction. — The reduction is effected by elevat- 
 
406 
 
 DISLOCATIONS OF THE OS HUMERI. 
 
 ing the arm and rotating it outwards, so as to roll 
 the head of the humerus towards the axilla; having 
 brought it as much as possible to resemble a disloca- 
 tion into the axilla, the operator must keep it in that 
 situation, and, at the same time, bring down the arm 
 in an horizontal direction, when, an extending force 
 being applied, the bone will be readily reduced. 
 
 Case. — July 17th, 1820. Thomas Aiding, of this 
 town, was pulled down by a calf which he was 
 driving, a cord having been tied to one of the calf's 
 legs, and held fast by the man's hand. The ap- 
 pearances corresponded with the above described 
 general marks of the accident. 
 
 JVleans of reduction employed, — I rotated the fore 
 arm as much as possible outward, carrying the whole 
 arm upwards at the same time, so that the hand 
 was brought nearly in a line wnth the vertebras, and 
 as high as it could be extended above the head. 
 By this expedient I succeeded in rolling the head of 
 the humerus downwards and inwards, until it rested on 
 the inferior costa of the scapula, and was in part to 
 be felt in the axilla. Having thus reduced it as far 
 as possible into the situation resembling the disloca- 
 tion downwards, I brought the arm and fore arm 
 carefully downwards and backwards into the hori- 
 zontal line, keeping the head of the humerus in the 
 same situation all the time. Extension being now 
 made, and my hand being firmly placed on the acro- 
 mion, the bone was easily replaced. The rotatory 
 motion produced considerable pain ; and just as the 
 head of the bone crossed the edge of the glenoid 
 cavity, severe pain was felt, and a noise was heard. 
 My father and Mr Cantin were so kind as to assist 
 me. 
 
 Case, — September 24th, 1820, — Jenkins, aged 
 fourteen, was thrown against a tree by a furious 
 horse, by which accident his shoulder was displaced 
 
DISLOCATIONS OP THE OS HUMERI. 
 
 407 
 
 backwards. The tumour produced by the head of 
 the bone was to be seen in a line with the spine of 
 the scapula, and in part projecting beyond .it. The 
 acromion projected very much, and the integuments 
 below it were puckered and formed a cavity. 
 
 Reduction, — I rotated the arm in an extended 
 direction, still outwards, and raising it as high as I 
 could I brought the head of the displaced bone to- 
 wards the axilla; then retaining the bone in this 
 position, having carefully brought down the limb 
 into a horizontal line, Mr Cantin and I made an ex- 
 tension, and the limb was readily reduced. 
 
 I am, dear Sir, your's respectfullv, 
 
 C. M. COLEY. 
 
 PARTIAL DISLOCATION OF THE OS HUMERI. 
 
 I believe this is not a very rare accident, and it 
 shows itself by the following marks. 
 
 Symptoms, — The head of the bone is drawn for- 
 wards against the coracoid process ; there is a de- 
 pression opposite the back of the shoulder-joint, and 
 the posterior half of the glenoid cavity is percepti- 
 ble, from the advance of the head of the bone ; the 
 axis of the arm is thrown inwards and forwards ; the 
 inferior motions of the limb are still capable of being 
 performed ; but its elevation is prevented by the 
 head of the humerus strikins: a£:ainst the coracoid 
 process ; there is an evident protuberance formed 
 by the head of the bone in its new situation, which 
 is felt readily to roll when the arm is rotated. 
 
 Case. — Mr Brown, aged fifty years, was thrown 
 from his chaise on his shoulder, and, upon examina- 
 tion after the accident, the roundness of the shoul- 
 der was lost, and there was a hollow under the aero- 
 
408 DISLOCATIONS OF THE OS HUMERI. 
 
 mion-; the head of the bone projected forwards and 
 inwards against the coracoid process; the arm could 
 be raised from the side if brought forwards, but- 
 with difficulty raised directly upwards. By exten- 
 sion of the shoulders backwards, 1 at last brought 
 the head of the bone to the glenoid cavity, but it 
 directly again slipped forwards as the extension 
 ceased. This dislocation differs from that forwards 
 under the pectoral muscle, in the head of the os 
 humeri being still on the scapular side of the cora- 
 coid process, while, in the complete dislocation for- 
 wards, it is thrown on its sternal side. 
 
 Dissection. — The only case of dissection of this 
 accident, which I have had an opportunity of seeing, 
 was the following, for which 1 am indebted to Mr 
 Patey, surgeon in Dorset-street, who had the subject 
 brought to him for dissection, at the anatomical 
 room, St Thomas's Hospital. 
 
 Case, — Partial dislocation of the head of the os 
 humeri, found in a subject brought for dissection to 
 St Thomas's Hospital^ during the latter part of the 
 year 1819. 
 
 Jlppearanccs before dissection. — The appearances 
 w^ere as follow : — The head of the os humeri, 
 on the left side, was placed more forward than is 
 natural, and the arm could be drawn no farther 
 from the side than the half way to the horizontal 
 position. 
 
 Jlppearances upon dissection. — The tendons of those 
 muscles which are connected with the joint were not 
 torn, and the capsular ligament was found attached 
 to the coracoid process of the scapula. When this 
 ligament was opened, it was found that the head of 
 the OS humeri was situated under the coracoid pro- 
 cess, which formed the upper part of the new gle- 
 noid cavity; the head of the bone appeared to be 
 thrown upon the anterior part of the neck of the 
 
DISLOCATIONS OF THE OS HUMERI. 
 
 409 
 
 scapula, which was hollowed, and formed the lower 
 portion of the glenoid cavity. The natural rounded 
 form of the head of the bone was much altered, it 
 having become irregularly oviform, with its long 
 axis, from above downwards; a small portion of the 
 original glenoid cavity remained, but this was ren- 
 dered irregular on its surface by the deposition of 
 cartilage ; there were also many particles of carti- 
 laginous matter upon the head of the os humeri, and 
 upon the hollow of the new cavity in the cervix 
 scapulae, which received the head of the bone. At 
 the upper and back part of the joint there was a 
 large piece of the cartilage, which hung loosely 
 into the cavity, being connected with the synovial 
 membrane, at the upper part only, by two or three 
 small membranous bands. The long head of the 
 biceps muscle seemed lo have been ruptured near to 
 its origin at the upper part of the glenoid cavity, 
 for at this part the tendon was very small, and had 
 the appearance of being a new formation. (^See 
 Plate,) 
 
 James Patey. 
 
 Caw^e. — This accident happens from the same 
 causes which produce the dislocation forwards. The 
 anterior part of the ligament is torn, and the head 
 of the bone has an opportunity of escaping forwards 
 to the coracoid process. 
 
 . Means of reduction^ and of preventing the recurrence 
 of the dislocation. — The mode for its l eduction will 
 be the same as that for the dislocation forwards, but 
 it is necessary to draw the shoulders backwards to 
 bring the head of the bone to the glenoid cavity ; 
 and immediately when the reduction is completed, 
 the shoulders should be bound back by a clavicle 
 52 If 
 
410 DISLOCATIONS OF THE OS HUMERI. 
 
 bandage, or the bone will immediately again slip 
 forward against the coracoid process. 
 
 Dislocation of the shoulder complicated with frac- 
 ture. — Dislocations of the shoulder are sometimes 
 complicated with fracture of the head of the os 
 humeri ; and we have a preparation in the Museum 
 at St Thomas's Hospital, in which the greater tu- 
 bercle at the head of the bone had been broken off, 
 and the os humeri thrown into the axilla. This 
 complication of accident does not add to the diffi- 
 culty of reduction, but on the contrary, rather 
 facilitates the return of the bone, as the insertion of 
 the principal opponent muscles, the supra and infra 
 spinati, is removed ; but it increases the difficulty of 
 retaining the bone within the glenoid cavity after 
 the reduction is completed. 
 
 FRACTURE OF THE NECK OF THE OS HUMERI, WITH 
 THE DISLOCATION FORWARDS, UNDER THE PECTO- 
 RAL MUSCLE. 
 
 Case. — Mr John Blackburn fell from his horse, 
 many years ago, at Enfield, and dislocated his shoul- 
 der forwards. Mr Lucas, sen.. Surgeon of Guy's 
 Hospital, was sent for, who said, after he had made 
 considerable extension, that the bone was reduced. 
 Five weeks afterwards Mr B. came to London and 
 showed me his shoulder, when the appearances of 
 dislocation still remaining, I advised a further ex- 
 tension, to which he would not consent. I had fre- 
 quent opportunities of seeing him afterwards, but 
 the shoulder exhibited the same appearances of 
 dislocation. He had, however, the power of using 
 the arm and hand in all directions excepting up- 
 wards, but could not raise his arm parallel with his 
 
DISLOCATIONS OF THE OS HUMERI. 
 
 411 
 
 body ; and he suffered but little pain or inconve- 
 nience. 
 
 In June, 1824, he died ; and as he had always 
 promised me the dissection of his shoulder if I sur- 
 vived him, I removed it in the presence of Mr Ar- 
 not, Surgeon of Greenwich Hospital, examined it 
 with great care, and have the bones preserved. 
 The deltoid teres major and coraco brachialis mus- 
 cles did riot appear to me to be altered ; the supra- 
 spinatus was lessened, as was the teres minor, which 
 had lost considerably of its natural colour : the in- 
 fra-spinatus was stretched ; the subscapularis, di- 
 minished and rounded by the projection of the head 
 of the OS humeri, adhered to its cartilaginous sur- 
 face. The capsular ligament was torn under the 
 subscapularis muscle, but every other part was en- 
 tire. The head of the os humeri had been thrown 
 forwards on the inner side of the coracoid process, 
 and had been united by bone to the scapula ; but 
 its cartilage remained under the tendon of the sub- 
 scapularis. The neck of the os humeri was broken 
 through, and had been covered by a granular liga- 
 mentous substance ; but the parts were kept togeth- 
 er only by the ligament of the joint, and a new and 
 very useful joint had been formed. The outer edge 
 of the glenoid cavity remained; the surface of the 
 glenoid cavity was granulated and ligamentous. The 
 greater tubercle of the os humeri was exceedingly 
 increased, and the tendon of the biceps passed 
 through the bone. The tubercles were separated 
 with the body of the bone, and not with its head. 
 
 This, then, was a case of fracture of the cervix 
 humeri within the capsular ligament, terminating in 
 a ligamentous union. 
 
412 DISLOCATIONS OF THE OS HUMERI. 
 
 COMPOUND DISLOCATION OF THE OS HUMERI. 
 
 An injury of excessive violence will sometimes 
 occasion the head of the bone to be forced through 
 the integuments in the dislocation forwards. It hap- 
 pened in the practice of Mr Saumarez, and Mr 
 Dixon, of Newington; and for the following detail 
 of its circumstances I am indebted to Mr Dixon. 
 
 Mr D'ixon^s case. — My dear Sir : — 1 feel plea- 
 sure in answering the queries you have put. The 
 accident happened to Robert Price, fifty-five years 
 of age, who, on returning in a state of intoxication 
 from the Borough, fell down upon his shoulder. 
 Upon examination, I found that the head of the bone 
 having passed through the integuments in the axilla, 
 lay exposed upon the anterior part of the chest, and 
 situated over the pectoral muscle on the right side. 
 The reduciioii of the dislocation was easy, being 
 perfoi med without the necessity of raising him from 
 the state of stupor and insensibility in which he was 
 lying, by the usual method of extension and counter- 
 extension, taking care only to guide the bone into 
 the glenoid cavity; he was then put to bed and an 
 evaporating lotion applied. On the following morn- 
 ing considerable pain and tension had come on ; he 
 was bled, and purged freely; a large poultice was 
 applied over the joint, and anodynes were given to 
 lessen the pain and procure sleep; leeches were 
 frequently applied in the neighbourhood of the joint 
 for the first ten days or fortnight, after which, a 
 copious discharge of pus issued from the wound in 
 the axilla. The constitution now felt the effects of 
 so important an injury ; he became irritable, restless, 
 and lost flesh. Healthy pus was discharged freely 
 from the joint for ten or twelve weeks, when it 
 somewhat abated. A succession of small abscesses, 
 
DISLOCATIONS OF THE OS HUMERI. 413 
 
 situated in the cellular meaibrane, surrounding the 
 joint, were exceedingly troublesome for several 
 months: some of them formed extensive sinuses, re- 
 quiring to be freely dilated. The discharge of pus 
 from the joint was kept up nearly twelve months, 
 when it finally ceased, leaving the joint anchylosed, 
 and the wound closed. He was quite recovered 
 fourteen months after the accident, when he called 
 on me, and felt gratified, by showing how freely he 
 could make use of the fore arm, and handle his pen 
 for all the purposes of business. He is still living in 
 Paradise-row, Stockwell, and is employed by the 
 parish of Lambeth as a collector of assessed taxes. 
 
 I am, my dear Sir, 
 Your's faithfully, 
 
 P. Dixon, 
 
 Treatment. — Such a case will require an imme- 
 diate reduction, by the means which I have describ- 
 ed for the dislocation of the os humeri forwards; 
 and, in general, the greater the violence done to the 
 injured limb, the more easy is the reduction, from 
 the diminution of the constitutional powers which so 
 great a shock produces. When the bone is replac- 
 ed, lint, dipped in blood, is to be applied to the 
 wound; or, if the wound be large, a suture should 
 be employed, and then the lint applied : adhesive 
 plaster should be used to support approximation, 
 and the limb should be kept close to the side by 
 means of a roller passed round the body, including 
 the arm, and thus preventing the least motion of the 
 head of the bone : by these means the suppurative 
 inflammation may be prevented, and the cure may 
 
414 DISLOCATIONS OF THE OS HUMERI. 
 
 proceed without protracted suffering, or any danger 
 to the patient's life."^ 
 
 * In reducing a dislocation of two months standing at the 
 Philadelphia Alms-Hoiise, professor Gibson states that a rupture 
 of the axillary artery was occasioned, which was speedily fol- 
 lowed hy the death of the patient. The dissection of this case 
 is taken from the 7th volume of the Philadelphia Journal, p. 
 84. 
 
 ^Dissection. — Three incisions were made — one from the 
 acromion process, along the course of the clavicle, as far as the 
 sternum — another perpendicular to the sternum, and about ten 
 inches long — a third nearly at right angles with the lower ex- 
 tremity of the perpendicular one, and running across the chest 
 towards the arm-pit. The integuments and pectoral muscles 
 being elevated along the edge of the sternum, and thrown back- 
 wards towards the shoulder, a considerable quantity of coagu- 
 lated blood was found, filling the cellular membrane, and lying 
 in masses between the interstices of the muscles. In order to 
 ascertain the condition of the large vessels beneath the clavicle, 
 this bone was separated at its juncture with the sternum, and 
 raised. The course of the subclavian artery and vein was then 
 distinctly seen. A small opening was made in the vein, into 
 which a bougie was introduced for several inches, towards the 
 axilla, as a guide during the dissection ; but the vessel was found 
 perfectly sound throughout. Under the vein, as it passes near 
 the glenoid cavity, a large mass of coagulated blood was ob- 
 served, and upon clearing this away, the axillary artery was 
 seen protruding, with its mouth open, having been torn directly 
 across and separated from its connexions. Upon further examin- 
 ation, it was discovered that the head of the bone, at the time 
 of the luxation, had been carried downwards into the axilla, 
 about an inch and a half below the glenoid cavit}', where it 
 formed a white ligamentous cup-like socket, in the subscapulary 
 muscle, and pressing upon the axillary artery, produced such 
 a degree of inflammation as gave rise to a copious effusion of 
 coagulable lymph, which united the artery completely, for some 
 distance, to the capsule of the joint, where it surrounded the 
 neck of the bone. The lower part of the capsule was lorn and 
 separated from the neck of the humerus ; the upper part re- 
 mained entire, and was very much thickened. The head of the 
 bone filled completely the old socket or glenoid cavity. Be- 
 
DISLOCATIONS OP THE OS HUMERI. 415 
 
 PARTIAL DISLOCATION OF THE OS HUMERI FORWARDS. 
 
 Mr Bachelor, of Southville, aged thirty-six, fell 
 from a chaise on the 12th of November, and, as he 
 supposes, pitched on his shoulder. On rising he 
 could not move his right arm for ten minutes, when 
 some sudden spasm gave him the power of moving 
 it underhand. Inflammation succeeded; the shoul- 
 der became much swollen, with pain down the arm 
 to the fingers, and particularly in the direction of the 
 cubital nerve. On looking at the arm the same 
 evening, he found that the os humeri appeared to be 
 advanced. 
 
 It is two months since the injury, and the hand is 
 now benumbed. There is much pain at the inser- 
 tion of the biceps into the fore arm, so that he has 
 been often obliged to rise twice duririg the night to 
 put his hand in warm water. 
 
 The appearances are, a projection of the acro- 
 mion, and a hollow beneath it; the head of the os 
 humeri rests against and under the coracoid process, 
 and the scapular end of the clavicle is opposite to 
 the middle of the head of the bone. The biceps 
 muscle was relaxed and lessened ; the coracoid pro- 
 cess of the scapula was with difficulty felt above, 
 and to the inner side of the head of the os humeri. 
 
 neath the deltoid muscle there was a large hollow filled with 
 blood, and the whole arm, as far as the elbow, had been exten- 
 sively injected with the same fluid. The os humeri was care- 
 fully dissected from the condyles to its head, and the periosteum 
 entirely scraped off, without showing the slightest vestige of a 
 fracture. The long tendon of the biceps was found considerably 
 elongated, but not ruptured.' 
 
 For the whole of the interesting description of Dr Gibson, the 
 reader is referred to the same volume, p. 80. J. D, G 
 
416 DISLOCATIONS OF THE OS HUMERI. 
 
 The principle of treatment in these cases is, to 
 oppose the pectoralis major by a clavicle-bandage, 
 with a broad strap over the head of the os humeri, 
 and by bi'inging the elbow forward to keep the head 
 of the OS humeri back. 
 
 DISLOCATION OF THE OS HUMERI BACKWARDS. 
 
 ^ A man fell from the roof of a coach, and struck 
 the point of his left shoulder against a projecting 
 stone. He suffered little pain from the accident ; 
 but finding himself incapable of using his arm, he 
 came immediately to the hospital. 
 
 Upon examination, I found that the head of the 
 humerus was thrown upon the dorsum of the scapu- 
 la, where it presented a considerable prominence, 
 behind the glenoid cavity, and immediately under 
 the spine of that bone. The vacancy beneath the 
 acromion was not so remarkable as in the axillary 
 dislocation. The arm was closely applied to the side, 
 and slightly inverted, the elbow being directed ra- 
 ther anteriorly. Free motion was practicable for- 
 ward and backward, but the limb could not be raised 
 or carried across the breast without great difficulty. 
 
 Reduction was easily effected in the following 
 manner: — The scapula being fixed, extension was 
 made, by means of a cloth twisted around the elbow, 
 for about three minutes, when finding no disposition 
 in the head of the bone to return to the cavity, al- 
 though it was already in close contact with its lower 
 and back mara^ln, I made a fulcrum of my right 
 hand in the axilla, and grasping the elbow in my left, 
 readily succeeded in lifting it into its socket. 
 
 J. S. Perry. 
 
 Bartholomew's Hospital 
 
DISLOCATIONS OF THE OS HUMERI. 417 
 
 Mr Perry had the kindness to send me the fore- 
 fi^oing case, for which I am much indebted to him. 
 Our large hospitals in London should be made as 
 conducive as possible to the advantage of the public,, 
 by a liberal and reciprocal communication. 
 
 53 
 
-FRACTURES NEAR THE SHOULDER- 
 JOINT, LIABLE TO BE MISTAKEN 
 FOR DISLOCATIONS. 
 
 FRACTURE OF THE ACROMION. 
 
 Diagnostic symptoms, — This point of bone is 
 sometimes broken, in which case, when the shoulders 
 are compared, the roundness of the injured side is 
 lost, and part of the attachment of the deltoid mus- 
 cle being broken off, the head of the os humeri sinks 
 towards the axilla as far as the capsular^ ligament 
 will permit. On tracing the acromion^^from the 
 spine of the scapula to the clavicle, just at their 
 junction, a depression is felt, from the fall of the 
 fractured portion. If the distance be measured from 
 the sternal end of the clavicle to the extremity of 
 the shoulder, it will be found lessened on the injured 
 side. If the surgeon raises the arm from the elbow, 
 so as to put the deltoid muscle in motion, the natural 
 form of the shoulder is directly restored, but the 
 deformity returns immediately when the arm is again 
 suffered to fall. 
 
FRACTURES OF THE SHOULDER-JOINT. 419 
 
 This accident is best detected and distinguished 
 from dislocation by raising the arm at the elbow : 
 having restored the figure of the part, the surgeon 
 places his hand upon the acromion and rotates the 
 arm, when a crepitus can be distinctly perceived at 
 the point of the shoulder, and along the superior 
 portion of the spine of the scapula. The patient, as 
 soon as the accident has happened, feels as if his arm 
 were falling off, the shoulder dropping with a great 
 sense of weight, and there being but little power to 
 raise the limb. 
 
 Treatment, — Fracture of the acromion scapulas 
 will unite by bone, but it generally unites by 
 ligamentous substance, in consequence of the diffi- 
 culty which exists in producing adaptation, and in pre- 
 serving the limb perfectly at rest during the period 
 required for union. In the treatment of this accident, 
 the head of the os humeri is the splint which is em- 
 ployed to keep the acromion in its natural situation ; 
 and with this view the elbow is raised and the arm 
 is fixed ; thus the bone will be elevated to the infe- 
 rior surface of the acromion, and if it be kept stead- 
 ily in that position, it will support and keep in its 
 place the broken process. The deltoid muscle 
 should be also relaxed, and this is best effected by a 
 cushion placed between the elbow and the side ; for 
 if the elbow be brought close to the side, the broken 
 acromion is further separated- The arm should be 
 raised as much as is possible, and the elbow be carri- 
 ed a little backwards, and then bound to the chest 
 by a roller; in this position it should be kept firmly 
 fixed for three weeks, every thing being done to 
 prevent any motion of the bone. Very little inflam- 
 mation succeeds this accident, and the disposition to 
 ossific union is very feeble in the separated portions 
 of bone. 
 
 If a pad be placed in the axilla, the broken portion 
 
420 FRACTURES NEAR THE SHOULDER-JOINT. 
 
 becomes widely separated from the spine of the 
 scapula because it throws out the head of the os 
 humeri. 
 
 ^ FRACTURE OF THE NECK OF THE SCAPULA. 
 
 Symptoms. — But the accident which is much more 
 liable to be mistaken for dislocation, is the frac- 
 ture through the narrow part of tlie cervix scapulas, 
 immediately opposite the notch of the superior costa ; 
 by which the glenoid cavity becomes detached from 
 the scapula, and the head of the bone falls with it 
 into the axilla ; the shoulder in this case falls ; there 
 is a hollow below the acromion from the sinking of 
 the deltoid muscle, and the head of the os humeri 
 can be felt in the axilla. 
 
 Case. — A young lady was thrown from a gig, by 
 the fall of the horse, in the Strand; and being car- 
 ried to her house, a surgeon in the neighbourhood 
 was sent for, who told her the shoulder was dislo- 
 cated ; by extension all the appearances of dis- 
 location were removed, and he bound up the arm. 
 On the following morning he requested me to see 
 the case, as the arm, he said, was again dislocated. 
 On examination I found the head of the bone in the 
 axilla, and the shoulder so fallen and flattened, as to 
 give to the accident many of the characters of dis- 
 location ; however, by elevating the shoulder, in 
 raising the arm at the elbow, and the head of the 
 bone from the axilla, it was immediately replaced ; 
 but when I gave up this support the limb instantly 
 sunk again. I then rotated the elbow, and pressing 
 the coracoid process of the scapula with my fingers, 
 by grasping the top of the shoulder, directly felt a 
 crepitus. Having satisfactorily ascertained the nature 
 
FRACTURES NEAR THE SHOULDER-JOINT. 421 
 
 of the accident, I placed a thick cushion in the axilla, 
 and drawing the shoulder into its natural position, 
 secured it by the application of a clavicle bandage, 
 and in seven weeks it became united without defor- 
 mity. 
 
 The degree of deformity produced by this acci- 
 dent depends upon the extent of laceration of a liga- 
 ment which passes from the under part of the spine 
 of the scapula to the glenoid cavity, and which is not 
 generally described in anatomical books. If this be 
 torn, the glenoid cavity and the head of the os hu- 
 meri fall deeply into the axilla ; but the displacement 
 is much less if this remain whole. 
 
 Diagnostic marks. — The diagnostic marks of this 
 accident are three : the facility with which the 
 
 parts are replaced ; secondly^ the immediate fall of 
 the head of the bone into the axilla, when the ex- 
 tension is removed ; and thirdly^ the crepitus which 
 is felt at the extremity of the coracoid process of the 
 scapula, when the arm is rotated. The best method 
 of discovering the crepitus is, for the surgeon's hand 
 to be placed over the top of the shoulder, and the 
 point of the fore finger to be rested on the coracoid 
 process ; the arm being then rotated, the crepitus is 
 directly perceived, because the coracoid process 
 being attached to the glenoid cavity, and being broken 
 offAvith it, although itself uninjured, the crepitus is 
 communicated through the medium of that process. 
 
 Treatment of this accident. — The treatment of 
 this fracture consists in attention to two principles. 
 The first is to carry the head of the os humeri out- 
 wards ; and the second, to raise the glenoid cavity 
 and arm. The former is effected by a thick cushion 
 placed in the axilla, which presses the head of the 
 bone and glenoid cavity outwards, and this may be 
 confined by the clavicle bandage ; the latter is pro- 
 duced by placing the arm in a short sling, and then 
 
422 
 
 FRACTURES NEAR THE SHOULDER-JOINT. 
 
 the raised head of the os humeri supports the gle- 
 noid cavitj and cervix scapulae, and keeps it steadily 
 in its place until union is produced. The time re- 
 quired for recovery from these accidents in the adult 
 is, from ten to twelve weeks; in the very young, all 
 the motions of the limb are restored in a shorter 
 period, but it is a long time before the limb recovers 
 its strength. 
 
 FRACTURE OF THE NECK OF THE OS HUMERI. 
 
 *^ge ; symptoms, — The humerus is sometimes 
 broken just below its tubercles, through its cervix. 
 I have seen this accident happen both in old and in 
 young persons, but it rarely occurs in middle age. 
 In the young it happens at the junction of the epi- 
 physis, where the cartilage is situated ; and in the old 
 it arises from the greater softness of this part of the 
 bone. In this fracture the head of the bone remains 
 in its place, but the body of the humerus sinks into 
 the axilla, where its extremity can be felt ; and it 
 draws down the deltoid muscle, so as to lessen the 
 roundness of the shoulder. Just as I was writing 
 this account, a child was brought into Guy's Hospital 
 with tiiis accident, on which I made the following 
 notes. 
 
 Its age was ten years. The symptoms of the in- 
 jury were inability of moving the elbow from the 
 side, or of supporting the arm, unless by the aid of 
 the other hand, without great |)aln. The tension 
 which succeeded filled up the hollow which was at 
 first produced by the fall of the deltoid muscle. 
 When the head of the bone was fixed, the fractured 
 extremity of the body of the humerus could be tilt- 
 ed under the deltoid muscle, so as to be felt, and 
 
FRACTURES NEAR THE SHOULDER-JOINT. 423 
 
 even shown, by raising the arm at the elbow. Cre- 
 pitus could be perceived, not by rotating the arm, 
 but by raising the bone and pushing it outwards. 
 The cause of the fracture was a fall upon the shoul- 
 der into a saw-pit of the depth of eight feet. 
 
 It is in old persons that this accident is most liable 
 to be mistaken for dislocation; for in them the flex- 
 ibility of the joint is much diminished by it, and the 
 changes of position of the bone are less easily pro- 
 duced. 
 
 Diagnostic symptoms. — The best diagnostic marks 
 are the following. Embrace the head of the os 
 humeri with the fingers and fix it, then rotate the 
 arm at the elbow, and it will be found that the head 
 of the bone does not obey the rotatory motion, as it 
 is separated from the body of the humerus by the 
 fracture, which is, in this case, external to the cap- 
 sular ligament. The reduced bone in these instances 
 unites in from three to six weeks, according to the 
 age of the patient. 
 
 Treatment, — The treatment consists in applying 
 a roller from the elbow to the shoulder-joint, in 
 placing a splint on the inner and on the outer side of 
 the arm, and in confining these by means of a roller. 
 A cushion is theo to be placed in the axilla, to throw 
 out the head of the bone, and the arm is to be genlly 
 supported by a sling; for if it be much raised, the 
 bones will overlap, and the union will be deformed* 
 
 Case, — William Mills, aged seventy-two, during 
 the severe frost in 1823, fell down upon his shoulder, 
 three days after which he was admitted into Guy's 
 Hospital. The arm and shoulder were much swol- 
 len, there was also acute pain and discoloration of 
 of the integuments. Crepitus could not be felt ; and, 
 from the degree of swelling, it was impossible to as- 
 certain the precise nature of the accident. Leeches 
 and evaporating lotions were applied. The shoulder 
 was again examined on the second day, after the 
 
424 FRACTURES NEAR THE SHOULDER-JOINT. 
 
 swelling had somewhat subsided, and a fracture of 
 the neck of the humerus was discovered. The pain 
 and swelling again became greater, and gradually 
 increased; the integuments inflamed, having the ap- 
 pearance of erysipelas; the skin became discolored 
 and gangrenous. He was feverish and irritable, 
 then delirious, and gradually sunk on the tenth day 
 from the accident. 
 
 Appearances on dissection, — The integuments and 
 cellular membrane, on the inner part of the shoulder 
 over the clavicle, were considerably thickened, hav- 
 ing a sloughy appearance ; and on cutting through 
 the deltoid muscle, a large quantity of bloody matter, 
 mixed with serum, was effused. The capsular liga- 
 ment was extensively lacerated; the humerus was 
 fractured through the cervix, also obliquely through 
 the head ; and a small spicula of bone was separated 
 from the cervix. 
 
 James Mash, 
 
 Jan, 1823. Dresser to Mr Forster. 
 
STRUCTURE OF THE ELBOW-JOINT» 
 
 jBone^.— Tms joint is composed of three bones — - 
 the lower extremity of the humerus, the upper part 
 of the uhia, and the head of the radius. The ex- 
 tremity of the OS humeri is expanded, and presents 
 two lateral eminences, which are called its condyles, 
 the internal of which is the most prominent ; be- 
 tween these condyles the articular surface for the 
 ulna is situated, which is in the form of a pulley ; 
 and above it, both anteriorly and posteriorly, is situ- 
 ated a deep cavity, with a thin partition intervening. 
 On the lower extremity of the external condyle is 
 placed an articular surface, on which the head of 
 the radius is received. The upper extremity of 
 the ulna forms two processes, with an articulatory 
 surface between them, which is adapted to the pul- 
 ley-like articular surface of the os humeri : both 
 these surfaces of the ulna and humerus are covered 
 with cartilage. The superior and posterior process 
 of the ulna is called the olecranon, which forms the 
 point of the elbow, and into which the triceps mus- 
 54 
 
426 
 
 STRUCTURE OF THE ELBOW-JOINT. 
 
 cle is inserted. The anterior and smaller process 
 is called the coronoid, which gives insertion to the 
 brachialis internus. When the arm is extended, the 
 point of the olecranon is received into the posterior 
 cavity, between the condyles of the humerus ; and 
 when it is flexed, the coronoid process passes into 
 the anterior hollow ; so that these cavities are 
 formed for the purpose of allowing free extension 
 and flexion of the arm. The head of the radius is 
 rounded, and rests upon the broad articular surface 
 of the humerus, upon which it bends ; on its inner 
 side it is received into an articular cavity on the ra- 
 dial side of the coronoid process of the ulna, upon 
 which the radius rolls ; and thus all the motions of 
 the fore arm are performed. Immediately below 
 its head the radius becomes smaller, and this part is 
 called its cervix : at the distance of an inch below 
 its head is seated a process which is called its tu- 
 bercle. 
 
 Ligaments; capsular, — The ligaments which bind 
 these bones together are the capsular, Avhich is 
 united with the condyles, and with the portion of 
 bone above the cavities of the os humeri ; it passes 
 over the extremity of the humerus, and is united 
 behind to the olecranon, and to the coronoid process, 
 on the fore part of the ulna : it is also connected to 
 the coronary ligament of the radius. This ligament 
 posteriorly is loose and slender, but on the fore part 
 it is of considerable strength. 
 
 Coronary. — The coronary ligament surrounds the 
 head of this radius : it is connected above with the 
 capsular ligament, and below with the neck of the 
 radius, by a thin ligament of sufficient length to 
 allow of rotation of the head of the bone : it is 
 also attached to the fore and back part of the 
 coronoid process of the ulna, at its lateral articu- 
 latory surface, and thus firmly unites the radius 
 
STRUCTURE OF THE ELBOW-JOINT. 
 
 427 
 
 with the ulna, yet allows of the rotation of the 
 former. 
 
 Brachio cubital. — There are four peculiar liga- 
 ments: — First, the brachio cubital, or internal lat- 
 eral ligament, which passes from the internal con- 
 dyle of the OS humeri into the coronoid process of 
 the ulna. 
 
 Brachio radial — Secondly, the brachio radial, or 
 external lateral ligament, which is fixed to the ex- 
 ternal condyle of the humerus, and to the coronary 
 ligament of the radius ; these ligaments give to the 
 joint a strong lateral support. 
 
 Oblique. — The third llganlent is the oblique, 
 which passes from the coronoid process of the ulna 
 to the radius, just below its tubercle ; and it is this 
 ligament which limits the rotation of the radius. 
 
 A ligament also reaches from the inner side of 
 the coronoid process to the olecranon ; and when 
 this latter process is broken off*, it is this ligament, 
 in some instances, which prevents its extensive sep- 
 aration. 
 
 Muscles. — The muscles of the joint are, first, 
 the brachialis internus, which passes over the an- 
 terior part of the condyles and capsular ligament to 
 which it is attached : it is inserted, in an oblique di- 
 rection, into the coronoid process, and into the body 
 of the ulna just below it. The use of this muscle 
 is to bend the fore arm, and give support to the el- 
 bow-joint, by strengthening the capsular ligament. 
 The next muscle is the triceps, which arises by one 
 of its heads from the inferior costa of the scapula, 
 and by its two others from the os humeri : it de- 
 scends to the capsular ligament, to the loose portion 
 of which it adheres, and is inserted into the point 
 of the olecranon. This muscle extends the arm, 
 and draws up and supports the capsular ligament. 
 Thirdly, the anconeus, which arises from the back 
 
428 
 
 STRUCTURE OF THE ELBOW-JOINT. 
 
 part of the external condyle of the humerus, ad- 
 heres to the capsular ligament, and is inserted to the 
 extent of an inch and a half into the body of the 
 ulna, directly below the olecranon. The course of 
 this muscle is oblique ; and whilst it extends the 
 arm, it supports the capsular ligament. The biceps 
 muscle does not protect the ulna joint, but has great 
 influence in preventing a dislocation of the radius 
 forwards, in the extended state of the arm. It is 
 not connected with the capsular ligament, as the 
 other muscles are ; but arising from the glenoid cav- 
 ity, and coracoid process of the scapula, tendinous, 
 it becomes fleshy in its middle, and again forms a 
 tendon at the elbow-joint, which is fixed into the 
 tubercle of the radius. This muscle bends the fore 
 arm, rotates the radius outwards, that is, supines 
 the hand, and compresses the capsular ligament op- 
 posite the head of the radius. 
 
DISLOCATIONS OF THE ELBOWJOINT. 
 
 There are five species of dislocation of this joint : — 
 First, both bones are dislocated backwards. 
 Secondly, both are dislocated laterally. 
 Thirdly, the ulna is dislocated separately from the 
 
 radius. 
 
 Fourthly, the radius alone is dislocated forwards: and 
 Fifthly, the radius is dislocated backwards* 
 
 DISLOCATION OF BOTH BONES BACKWARDS. 
 
 Symptoms. — This dislocation is strongly marked 
 by the great change which is produced in the form 
 of the joint, and by its partial loss of motion. The 
 shape of the elbow is altered, as there is consider- 
 able projection posteriorly, formed by the ulna and 
 radius, above the natural situation of the olecranon. 
 On each side of the olecranon appears a hollow. A 
 considerable hard swelling is felt at the fore part of 
 the joint, immediately behind the tendon of the 
 biceps muscle, formed by the extremity of the hu- 
 
430 DISLOCATIONS OP THE ELBOW-JOINT. 
 
 merus ; the hand and fore arm are supine, and can- 
 not be rendered entirely prone. The flexion of the 
 joint is also in a great degree lost. 
 
 Dissection of this Dislocation. 
 
 Dissection of the dislocation backwards, — 1 have 
 had an opportunity of dissecting a compound disloca- 
 tion of this joint, where the radius and ulna were 
 thrown backwards, and it is preserved in the Museum 
 at St Thomas's Hospital [see Plate^, The coronoid 
 process of the ulna was thrown into the posterior 
 fossa of the os humeri, and the olecranon projected 
 at the back part of the elbow^, above its- usual situa- 
 tion, an inch and a half; the radius was placed be- 
 hind the external condyle of the os humeri, and the 
 humerus was thrown forwards on the anterior part 
 of the fore arm, where it formed a large projection. 
 The capsular ligament was torn through, anteriorly, 
 to a great extent. The coronary ligament remained 
 entire. The biceps muscle was slightly put upon 
 the stretch, by the radius receding; but the brachi- 
 alis internus was excessively stretched by the altered 
 position of the coronoid process of the ulna. (See 
 Plate,) 
 
 Cause of the accident, — This accident usually 
 happens in a fall when a person puts out his hand to 
 save himself, the arm not being perfectly extended, 
 so that the bones are forced back behind the axis of 
 the OS humeri, by pressure of the whole weight of 
 the body upon them. 
 
 This dislocation is easily reduced by the following 
 means. The patient is made to sit down upon a 
 chair, and the surgeon, placing his knee on the inner 
 side of the elbow-joint, in the bend of the arm, and 
 taking hold of the patient's wrist, bends the arm; at 
 
Dislocations of the elbow- joint. 
 
 431 
 
 the same time he presses on the radius and ulna 
 Avith his knee,^so as to separate them from the os 
 humeri, and thus the coronoid process is tlirownfrom 
 the posterior fossa of the humerus ; whilst this 
 pressure is supported bj the knee, the arm is to be 
 forcibly, but slowly bent, and the reduction is soon 
 effected. It may be also accomplished by placing 
 the arm around the post of a bedstead, and by forc- 
 ibly bending it while it is thus confined. I have also 
 reduced the limb by making the patient, whilst 
 placed upon an elbow-chair, put his arm through the 
 opening in its back, and then, having bent the arm, 
 the body and limb being thus well fixed, the reduc- 
 tion was easily effected. 
 
 This dislocation is sornetimes undiscovered at first, 
 in consequence of the great tumefaction which im- 
 mediately succeeds the injury; but this circumstance 
 does not prevent the reduction, even at the period 
 of several weeks after the accident : for I have 
 known it then eflected by bending the limb over the 
 knee, even without the application of very great 
 force. 
 
 j^Jter 'treatment. — As soon as the reduction has 
 been accomplished, the arm should be bandaged in 
 the bent position; evaporating lotions should be ap- 
 plied, and the limb be supported in a sling; the fore 
 arm should be bent at rather less than a right angle 
 with the upper arm. A splint may be placed in the 
 sling, for the better support of the limb. 
 
 COMPOUND dislocation OF THE OS HUMERI AT THE 
 ELBOW-JOINT. 
 
 Case. — William Dawson, aged thirteen, was ad- 
 mitted into the accident ward of Guy's Hospital on 
 
432 DISLOCATIONS OF THE ELBOW-JOINT. 
 
 the 5th of November, 1822, at twenty minutes past 
 seven o'clock in the evening, with coiji pound disloca- 
 tion of the elbow-joint, occasioned by the overturn- 
 ing of a cart in which he was riding, and which fell 
 with great violence upon the elbow of the left arm. 
 
 The appearances were as follow : The condyles 
 of the humerus were thrown inwards through the 
 skin, the articulating surface receiving the sigmoid 
 cavity of the ulna being completely exposed to view ; 
 the ulna was dislocated backwards, and the radius 
 outwards; the lateral and capsular ligaments were 
 torn asunder, with extensive laceration of the parts 
 about the joint, but the artery and nerve remained 
 perfectly free from injury. 
 
 By the kind assistance of Mr Key the reduction 
 was easily effected in the following manner. The 
 humerus being firmly grasped above its condyles, 
 making that part a fixed point, we gradually extend- 
 ed the fore arm from the position in which it was 
 found (at right angles), and the parts returned to 
 their relative situation; but upon slightly moving 
 the fore arm, they became displaced as before ; but 
 the reduction was effected a second time as above 
 described, and in the semiflexed position the arm 
 was dressed with adhesive plaster, and a paste- 
 board splint put on, previously dipped in warm 
 water, so as to give it pliabihty in order to adapt 
 it to the form of the part ; a roller was then 
 applied, and a sling was attached to the wrist and 
 conveyed round the neck, by which means the pa- 
 tient was prevented from moving the arm from the 
 posture in which it was placed. He was then laid 
 recumbent, with the elbow resting on a pillow ; and 
 the evaporating lotion of our hospital Avas euiployed, 
 to keep the parts constantly moist and cool. I saw 
 him during the night, and found that he was gene- 
 
DISLOCATIONS OF THE ELBOW-JOINT. 433 
 
 rally composed, and had slept. Early the next morn- 
 ing he was free from pain, his pulse 112; he expe- 
 rienced much thiF'st during the day, without any 
 other unpleasant symptoms, except some tension of 
 the parts, hy no means considerable. On the fol- 
 lowing morning, there being some symptoms of in- 
 flammation, accompanied with pain in the head, I 
 drew from the right arm ten ounces of blood, whicfi 
 appeared to relieve him ; in the evening of the same 
 day he was restless, and complained of great thirst; 
 small quantities of barley water were given to him, 
 and in the evening three grains of hydrag : submui'. 
 He slept during the night, and on the following 
 morning the pulse had risen to 121 ; febrile action 
 appearing, the julepum ammon : acet : was given to 
 him every three or four hours, and in the evening 
 his pulse had fallen to 109 ; he complained of dart- 
 ing pains in the shoulder, and his bowels being in a 
 constipated state, I gave him 3 iij. of ol : ricini, and 
 two hours afterwards he had a copious evacuation, 
 from which he felt easier and much relieved, and he 
 passed a good night. On the following day I found 
 him free from pain and much better. The next 
 day (Sunday) he complained of slight pains in the 
 upper arm, accom})anied with a small discharge from 
 the wound. On the following day he was better, 
 pulse 105; and on Tuesday the discharge had in- 
 creased, but on the three following days it decreas- 
 ed, when I ventured to dress the wound : the granu- 
 lations were extremely healthy; the parts appeared 
 to be well adjusted, leaving only a small sinus, by 
 which the discharge escaped. It was again dressed 
 as at first, with the exception of the splint : the 
 lotion was discontinued, the parts being perfectly 
 cool, and the tension much reduced. The bowels 
 being confined, the ol. ricini was repeated, which 
 procured him two stools. On the following day he 
 55 
 
434 DISLOCATIONS OF THE ELBOW-JOINT. 
 
 complained of pains in the slioulder ; tlie discharge 
 was again increasing; but on the four following days 
 he proceeded well, the pulse varying from 98 to 
 109. On the sixth day from the first dressing I pro- 
 ceeded to repeat that operation ; the granulations 
 were rather prominent, but healthy ; and the wound 
 was dressed with straps of soap cerate. During the 
 six following days the patient continued to get better; 
 but on the seventh day from the second dressing of 
 the wound, some inflammation appeared, and the 
 lotion w^as renewed : the discharge at this time was 
 very slight. On examining the part, an abscess had 
 formed upon the external condyle, which 1 relieved 
 in a day or two after by the lancet: the quantity of 
 matter discharged was about sij, but quite healthy. 
 The next day he was much better ; and from this 
 time he continued improving until the 24th of 
 December, on which day he was able to leave his 
 bed, and walk about the ward. By great attention 
 to the use of passive motion, he is now enabled to 
 move the joint to a considerable extent. 
 
 Samuel White, 
 
 Dresser at Guifs Hospital. 
 
 1 frequently witnessed the progress of this case 
 with the greatest pleasure. — A. C. 
 
 LATERAL DISLOCTION OF THE ELBOW. 
 
 JYature of the accident. — In this case the ulna, in- 
 stead of being thrown into the posterior fossa of the 
 OS humeri, has its coronoid process situated on the 
 back part of the external condyle of the humerus. 
 The projection of the ulna backwards is greater in 
 this than in the former dislocation, and the radius forms 
 a protuberance behind and on the outer side of the 
 
DISLOCATIONS OF THE ELBOW-JOINT. 
 
 435 
 
 OS humeri, so as to produce a hollow above it ; the 
 rotation of the head of the radius is distinctly felt by 
 rolling the hand. Sometimes the ulna is thrown 
 upon the internal condyle of the os humeri, so as to 
 produce an apparent hollow above it ; the rotation 
 of the head of the radius is distinctly felt by rolling 
 the hand. Sometimes the uhia is thrown upon the 
 internal condyle of the os humeri, but it still pro- 
 jects posteriorly, as in the external dislocation; and 
 then the head of the radius is placed in the pos- 
 terior fossa of the humerus. The external condyle 
 of the OS humeri in this case projects very much 
 outwards. I have never had an opportunity of dis- 
 secting this injury. 
 
 Causes of the accident. — The manner in which 
 the lateral dislocation is produced is the same as in 
 that directly backwards, hut the direction of the fall 
 is varied ; it is also caused by the wheel of a car- 
 riage passing over the arm whilst it is placed upon 
 uneven ground. The reduction of each may be effect- 
 ed as in the former dislocation, by bending the arm 
 over the knee, even without particularly attending 
 to the direction of it inwards or outwards ; for as 
 soon as the radius and ulna are separated from the 
 OS humeri by the pressure of the knee, the muscles 
 give them the proper direction for reduction. But 
 in a recent injury the bones may be more easily re- 
 duced in the following manner. 
 
 Case. — A lady consulted me respecting a frac- 
 ture of the patella, which had united by a long liga- 
 ment ; and I told her to be careful to wear a band- 
 age, as she was very liable to fall and to break the 
 other patella, which I have frequently known to 
 happen. This was at ten o'clock, in the morning; 
 at two o'clock she came to me at Guy's Hospital, 
 having her elbow dislocated backwards, and also 
 laterally inwards. Finding that the tendon of the 
 biceps, and (as I knew) the brachialis internus, were 
 
436 
 
 DISLOCATIONS OF THE ELBOW-JOINT. 
 
 put upon the stretch, I thought I might make use of 
 ihem to draw the os humei i backwards, as by the 
 string of a pulley, and 1 forcibly extended the arm, 
 when tlie dislocation was immediately reduced. 
 
 The plate of the dislocation backwards will ex- 
 plain the mode in which the reduction was effected. 
 It will be there seen that the tendon of the bra- 
 chialis internus is stretched over the condyles of the 
 humerus, and the biceps is also stretched over that 
 bone ; so that if the fore arm be forcibly extended, 
 these muscles force back the condyles of the humerus 
 into their natural situation. 
 
 DISLOCATION OF THE ULNA BACKWARDS. 
 
 Symptoms of this accident. — The ulna is some- 
 times thrown back upon the os humeri without being 
 followed by the radius. The appearance of the 
 limb is then much deformed by the contortion in- 
 wards of the fore arm and hand. The olecranon 
 projects, and can be felt behind the os humeri. Ex- 
 tension of the arm is impracticable, but by a force 
 which will reduce the dislocation, and it cannot be 
 bent to more than a right angle. It is an accident 
 somewhat difficult to detect; but its distinguishing 
 marks are the projection of the ulna, and the twist 
 of the fore arm inwards. 
 
 Dissection; cause. — We have an excellent speci- 
 men of this accident in the Museum at St Thomas's 
 Hospital. (See Plate.) It had existed a great 
 length of time without reduction ; the coronoid 
 process of the ulna was thrown into the posterior 
 fossa of the humerus; the olecranon is seen project- 
 ing behind the os humeri ; the radius rests upon the 
 external condyle, and has formed a small socket for 
 its head, in which it was able to roll. The coronary 
 
DISLOCATIONS OF THE ELBOW— JOINT. 
 
 437 
 
 and oblique ligaments had been torn through, and 
 also a small part of the interosseus ligament ; the 
 lower extremity of the internal condyle of the hu- 
 merus seems to have had an oblique fracture in it ; 
 but 1 doubt whether it had been broken, or only 
 altered in form, on account of the unnatural position 
 of the ulna. If it had been broken, it was reunited ; 
 the triceps was thrown backwards, and the brachi- 
 alis internus muscle was stretched under the extrem- 
 ity of the humerus. The accident arises from a 
 severe blow on the lower extremity of the ulna, 
 by which it is pushed suddenly upwards and back- 
 wards. 
 
 Mode of reduction. — This d islocation is more easily 
 reduced than that of both bones; and the best method 
 is to bend the arm over the knee, and to draw the 
 fore arm downwards; the reduction will then be 
 easy, as not only the brachial is muscle will act m 
 resistance, but the radius, resting against the exter- 
 nal condyle, will push the os humeri backwards 
 upon the ulna when the arm is bent^ 
 
 DISLOCATION OF THE RADIUS FORWARDS. 
 
 This bone is sometimes separated from the ulna 
 at their junction at the coronoid process, and its head 
 is thrown into the hollow above the external condyle 
 of the OS humeri, and upon the coronoid process of 
 the ulna. (See Plate.) 
 
 Symptoms of this accident. — I have seen six ex- 
 amples of this accident ; its symptoms are as follow: 
 The fore arm is slightly bent, but cannot be brought 
 to a right angle with the upper, nor can it be com- 
 pletely extended. When it is suddenly bent, the 
 
438 DISLOCATIONS OF THE ELBOW-JOINT. 
 
 head of the radius strikes against the fore part of 
 the OS humeri, and produces so sudden a stop to its 
 motion, as at once to convince the surgeon that one 
 bone strikes against the other. The hand is placed 
 in a prone position, but neither its pronation nor 
 supination can be completely performed, although 
 its pronation be nearly complete. If the thumb be 
 carried into the fore and upper part of the elbow- 
 joint, the head of the radius may be there felt; and 
 if rotation of the hand be attempted, the bone will 
 be perceived to roll; this last circumstance, and the 
 sudden stop to the bending of the arm, are the best 
 diagnostic marks of the injury. 
 
 Dissection, — In the dissection of this case, the 
 head of the radius is found resting in the hollow 
 above the external condyle of the os humeri ; the 
 ulna is in its natural situation. The coronary liga- 
 ment of the radius, the oblique ligament, and the 
 fore part of the capsular, as well as a portion of the 
 interosseous ligament, are torn through; the lacera- 
 tion of the latter ligament allows the separation of 
 the two bones. The biceps muscle is shortened ; 
 and those who have not seen an example of this 
 injury, will do well to consult the preparation from 
 which this plate is taken. 
 
 Cause of this accident, — The cause of this acci- 
 dent is a fall upon the hand when the arm is ex- 
 tended; the radius receiving the weight of the body, 
 is forced up by the side of the ulna, and thrown 
 over the condyle, and upon the coronoid process of 
 the ulna. 
 
 Cases, — The first case I saw of this accident was 
 in a woman, who was a patient of Mr Cline's, in 
 St Thomas's Hospital, whilst I was an apprentice to 
 him. The most varied attempts, which his strong 
 judgment could direct, were made to reduce the 
 bone, but they proved ineffectual ; and the woman 
 
DISLOCATIONS OF THE ELUOW-JOIKT. 
 
 439 
 
 was discharged from the hospital with the disloca- 
 tion unreduced. 
 
 The second case was in a lad to whom I was 
 called by Mr Balmanno, of Bishopsgate-street ; and 
 although I made attempts, bj continuiiig and vary- 
 ing the extension in every direction for an hour and 
 a quarter, I could not succeed in effecting the reduc- 
 tion. 
 
 The third case was that of a hair-dresser, who, 
 having been intoxicated in the evening, came to my 
 house on the following morning with his radius dis- 
 located ; during the time of examination the patient 
 became faint, and at last fell upon the floor in a 
 state of syncope ; this I thought afforded me a most 
 favourable opportunity for replacing the bone, and 
 whilst he was still upon the floor 1 rested his ole- 
 cranon upon my foot, so as to prevent the ulna from 
 receding, and then extended the fore arm ; and under 
 these favourable circumstances, the radius returned 
 to its natural situation. 
 
 Case, — The fourth case was that of a gentleman 
 in Old Broad-street, to whom I was called by Mr 
 Gordon, of Oxford-court, in the City; and the man- 
 ner in which we succeeded in the reduction was as 
 follows: — We placed our patient upon the sofa, 
 and bent his arm over the back of it ; then making 
 extension from the hand without including the ulna, 
 the OS humeri being fixed by the sofa, the radius in 
 a few minutes slipped into its place. 
 
 Case, — The fifth case was that from which was 
 made the preparation preserved in our collection at 
 St Thomas's Hospital, and of which I have given a 
 plate. That preparation was one morning lying on 
 my chimney-piece, when a gentleman of high cha- 
 racter at the bar called upon me : he said, ' What 
 have you here?' and when I mentioned the nature 
 of the injury — 'Well, that is very curious,' said 
 
440 
 
 DISLOCATIONS OF THE ELBOW-JOINT. 
 
 he ; ' for I have mjself been the subject of this 
 accident.' He then exposed his arm, and showed 
 me a dislocation of the radius: it had happened 
 many years before, and he told me that numerous 
 and most violent attempts had been made to reduce 
 it without success. 
 
 The observations here stated upon this subject I 
 have usually given in my lectures, carefully explain- 
 ing the difficulty in restoring the bone to its situation. 
 Once, on an occasion of this kind, Mr Williams, one 
 of the most intelligent of my pupils, said to me, ' I 
 have known the radius reduced in these accidents 
 by extending from the hand only.' From a consid- 
 eration of what he said, and from an experiment on 
 the dead body, placing the radius in the situation in 
 which it is thrown by this accident, I was convinced 
 that the mode of extension mentioned by Mr Wil- 
 liams was the best ; as, from the connexion of the 
 hand with the radius, that bone alone is acted upon; 
 and the ulna being excluded from the force applied, 
 the radius sustains the whole extension. It is also 
 right in making the extension to render the hand 
 supine, as this position draws the head of the radius 
 from the upper part of the coronoid process of the 
 ulna, upon which it would otherwise be directed; 
 and then to draw the fore arm, by pulling the hand, 
 and by fixing the os humeri. 
 
 Mr Tyrrel informed me that a sailor^ about thir- 
 ty years of age, came to St Thomas's Hospital, as 
 an out-patient, with a dislocation of the radius for- 
 wards, which had happened between six and seven 
 months before. The head of the radius could be 
 distinctly felt upon the anterior part of the hu- 
 merus, especially when the arm was bent as much 
 as the nature of the accident would allow, and when 
 the hand was bent as much as it could be towards 
 the fore arm. The position of the limb was half 
 
DISLOCATIONS OF THE ELBOW-JOINT. 441 
 
 supine; and when the humerus was fixed, the liand 
 could be rendered neither perfectly supine nor 
 prone. On the attempt to flex the fore arm, a sud- 
 den check to its motion was produced by the head 
 of the radius striking against the humerus. From 
 constant use of the arm alter the accident, consider- 
 able motion had been reacquired,* yet the man was 
 anxious that an attempt should be made to reduce 
 it, from which he was dissuaded, and he went lo 
 Guy's Hospital, where the same advice was given 
 to him. 
 
 DlSLOCA-fioN OF THE RADIUS BACKWARDS. 
 
 appearance of this accident, — This is an acci- 
 dent which I have never seen in the living person; 
 but in the winter of 1821, a man was brought for 
 dissection into the theatre of St Thomas's Hospital, 
 in whom was found this dislocation, which had 
 never been reduced. The head of the radius was 
 thrown behind the external condyle of the os hu- 
 meri, and rather to the outer side of the lower 
 extremity of that bone. Mr Sylvester, from Glou- 
 cester, a very intelligent student, had the kindness 
 to make me a drawing of the parts as they were 
 dissected, and the appearances will be seen in the 
 tw^enty-sixth plate. When the arm was extended, 
 the head of the radius could be seen, as well as 
 felt, behind the external condyle of the os humeri. 
 On dissecting the ligaments, the coronary ligament 
 was found to be torn througli at its fore part, and 
 the oblique also had given way. The capsular 
 h'gament was partially torn, and the head of the 
 
 * He could, although with great difficulty, touch the lips 
 with his hand. 
 
 5(5 
 
442 DISLOCATIONS OF THE ELBOW-JOINT. 
 
 radius would have receded much more, had it 
 not been supported by the fascia which extends 
 over the muscles of the fore arm. 
 
 Of the causes of this accident 1 know nothing, 
 never having seen it in the living subject. 
 
 Mode of reduction. — As to its reduction, it will 
 be easily effected by bending the arm ; but to se- 
 cure the bone from subsequent displacement, the 
 arm must be kept steadily bent at right angles, and 
 secured by splints and a circular bandage in that 
 situation, until the union of the coronary ligament 
 has been effected, which will require the lapse of 
 three or four weeks from the accident. 
 
 LATERAL DISLOCATION OF THE RADIUS. 
 
 Mr Freeman, Surgeon, of Spring-gardens, brought 
 to my house a gentleman of the name of Whaley, 
 aged twenty-five years, whose pony having run away 
 with him, when he was twelve years of age, he had 
 struck his elbow against a tree whilst his arm was 
 bent and advanced before his head. The olecranon 
 was broken, and the radius dislocated upwards and 
 outwards, above the external condyle; and when the 
 arm is bent, the head of the radius passes the os 
 humeri. He has a useful motion of the arm, but 
 neither the flexion nor the extension is complete. 
 
FRACTURES OF THE ELBOW-JOINT. 
 
 FRACTURES ABOVE THE CONDYLES OP THE OS HUMERI. 
 
 The condyles of the os humeri are sometimes 
 obliquely broken off just above the joint, and the 
 appearance produced is so similar to that of the dis- 
 location of the radius and ulna backwards, that this 
 fracture is very liable to be mistaken for that injury. 
 The following case will best exemplify its diagnostic 
 marks. 
 
 Case. — William Law, aged nine years, was ad- 
 mitted into Guy's Hospital on the 3rd of July, 1822, 
 with a fracture of the condyles of the os humeri , 
 above the elbow-joint, which he had sustained in 
 being thrown from a cart, having fallen upon his 
 elbow. At the time of his admission the arm was 
 slightly bent, and the radius and ulna appeared to 
 project considerably backwards; just above the 
 projection there was a hollow in the back of the 
 arm, so that the appearances much resembled those 
 of dislocation. I extended the fore arm, and the 
 appearances of the dislocation ceased; but when the 
 extension was discontinued, those appearances re- 
 
444 
 
 FRACTURES OF THE ELBOW-JOINT. 
 
 turned. At this time Mr Key arrived, who explained 
 the accident to be a fracture above the condyles. 
 The arm was put in splints, which were constantly 
 worn until the 13th of July, when they were occa- 
 sionally removed, and passive motion was employed. 
 D. B. Major, 
 
 Dresser, Guy^s Hospital, 
 
 Diagnostic marks of the nature of this accident, — 
 The appearances of this accident, as will be seen, 
 are like those of dislocation of the radius and ulna 
 backwards; and the mode of distinguishing the two 
 injuries is, by the removal of all the marks of dislo- 
 cation on extension, and by their return so soon as 
 the extension is discontinued ; in general, also, these 
 accidents are detected by rolling the fore arm upon 
 the humerus, when a crepitus may be felt just above 
 the elbow-joint. 
 
 The 'period of life at which the accident happens 
 most yre^?«e72^/?/. — This fracture happens at all pe- 
 riods of life, but much more frequently in children 
 than in persons of advanced age. 
 
 Treatment. — Its treatment consists in bending the 
 arm, and drawing it forwards to effect replacement; 
 then a roller should be applied while it is in the 
 bent position. The best splint for it is one formed 
 at right angles, of which the upper portion should 
 be placed behind the upper arm, and the lower por- 
 tion under the fore arm; a splint must also be plac- 
 ed npon the fore part of the upper arm, and both 
 should be confined by straps; evaporating lotions 
 should be used, and the arm kept in the bent posi- 
 tion by a shng. In a fortnight, if the patient be 
 young, passive motion may be gently begun, to pre- 
 vent the occurrence of anchylosis ; and in the adult, 
 at the end of three weeks, a similar treatment is to 
 
FRACTURES OF THE ELBOW-JOINT. 
 
 415 
 
 b# pursued. But even after the most careful and 
 judicious means which can be adopted, there is some- 
 times considerable Joss of motion ; and when the 
 accident has not been understood or has been care- 
 lessly treated, the deformity and loss of motion be- 
 come very considerable. (See Plate.) 
 
 FRACTURE OF THE CONDYLES OF THE OS HUMERI. 
 
 The following case on this subject was sent me 
 by Mr Ivimy, of Portsea, 
 
 My dear Sir: — Allow me to recommend to you 
 the bearer, Mrs Hewett, of Southsea, who met with 
 a severe accident on the 21st of September last, by 
 a fall from a chaise, which occasioned a compound 
 fracture of the left arm, of the following description : 
 The external and internal condyles were fractured 
 longitudinally ; the intermediate space which re- 
 ceives the olecranon was quite comminuted, and 
 three pieces of bone were extracted soon after the 
 accident from the external wound : there was also 
 a transverse fracture about two inches and a half 
 above the condyles. 
 
 Evaporating lotions were applied during the two 
 first weeks, and the case proceeded favourably. I 
 more particularly call your attention to the wrist of 
 the right arm, which was much injured at the time 
 of the accident ; I recommended friction, which I am 
 afraid has been neglected. 
 
 If time will permit, your opinion of the above 
 case will much oblige 
 
 Your's respectfully, 
 
 Thomas Ivimy. 
 
 Portsea, March 5th, 1823. 
 
446 FRACTURES OF THE ELBOW-JOINT. 
 
 This lady has, in a great degree, reacquired Mie 
 flexion and extension of the left arm. 
 
 A. C. 
 
 FRACTURE OF THE INTERNAL CONDYLE OF THE OS 
 HUMERI. 
 
 The internal condyle of the humerus is frequently 
 broken obUquely from the other condyles and body 
 of the bone ; and the symptoms by which the acci- 
 dent is known are as follow: 
 
 First. The ulna appears dislocated from it and 
 from the broken condyle, projecting behind the hu- 
 merus when the arm is extended. 
 
 Secondly. The ulna resumes its natural situation 
 in bending the arm. 
 
 Thirdly. By grasping the condyles, and bending 
 and extending the fore arm, a crepitus is perceived 
 at the internal condyle. 
 
 Fourthly. When the arm is 'extended, the lower 
 end of the os humeri advances upon the ulna, so as 
 to be felt upon the anterior part of the joint. 
 
 1 saw a girl, a patient of Mr Steel, of Berkhamp- 
 «tead, who, by a fall upon her elbow, had fractured 
 the olecranon, and also broken the internal condyle 
 of the OS humeri, the point of the broken bone hav- 
 ing almost penetrated ' the skin; the cubital nerve 
 had been also injured; for the little finger and half 
 the ring finger were benumbed. 
 
 The cause of this accident is a fall upon the point 
 of the elbow. It usually occurs in youth, before 
 the epiphysis is completely ossified; although I have 
 seen it, but less frequently, in age. It is often mis- 
 taken for dislocation. 
 
FRACTURES OF THE ELBOW-JOINT. 
 
 447 
 
 Treatment, — Its treatment consists in applying a 
 roller round the elbow-joint, to keep the bone in 
 complete apposition ; in wetting it frequently with 
 spirits of wine and water; in bending the limb at a 
 right angle, and supporting it in a sling; and in be- 
 ginning with passire motion, in the child at the ex- 
 piration of three weeks after the accident, and at 
 the end of a month in the adult, to prevent loss of 
 motion in the joint. 
 
 FRACTURE OF THE EXTERNAL CONDYLE OF THE OS 
 HUMERI. 
 
 Diagnostic marks of this accident, — This accident 
 is readily detected by the following symptoms: 
 Swelling upon the external condyle, and pain upon, 
 pressure; the motio'ns of the elbow-joint, both of 
 extension and flexion, are performed with pain ; but 
 the principal diagnostic sign is, the crepitus produced 
 by the rotatory motion of the hand and radius. If 
 the portion of the fractured condyle be large, it is 
 drawn a little backwards, and carries the radius 
 with it ; but if the portion be small, this circum- 
 stance does not occur. We have two excellent pre- 
 parations of this, accident in the Museum at St Tho- 
 mas's Hospital, and in neither case has there been 
 any other than ligamentous union. In one prepara- 
 tion, in which the external condyle is sj)llt obliquely, 
 the bone is somewhat thickened; but although this 
 accident had obviously happened long before death, 
 no union but that by ligament had been produced. 
 The second preparation is a specimen of the trans- 
 verse fracture of the extremity of the condyle, 
 within the capsular ligament, in which not the least 
 
448 
 
 FRACTURES OF THE ELBOW-JOINT. 
 
 attempt at ossific union can be detected. (See 
 Plate.) 
 
 It is obvious, therefore, that this principle of lig- 
 amentous union extends to all detached portions 
 within a capsular ligament; the vitality of the bone 
 being supported merely by the ligament within the 
 joint. ^ ^ 
 
 This accident usually happens in children, by 
 falls upon the elbow; at least in the course of my 
 observation, a very large proportfon of the cases 
 have been in young persons : I have seen it occur 
 in the adult, but very rarely in advanced age. 
 
 Treatment. — The treatment required is the fol- 
 lowing : A roller is applied around the elbow, and 
 above and below the joint. An angular splint is to 
 be adapted, which should admit the elbow, extend 
 behind the upper arm, and receive the fore aim 
 (see Plate), so as to support it ; a roller should then 
 be bound over the whole to keep it firmly fixed. 
 In the child this splint may be made of stiff paste- 
 board, bent to the shape of the elbow ; but the best 
 mode for its application is, to dip it in hot water 
 and apply it wet, so that it may exactly adapt itself 
 to the form of the limb ; it thus becomes the best 
 possible support to the injured arm. Indeed, it may 
 be here observed, that for children this is the best 
 mode of making every support of. this kind. The 
 splint is to be worn for three, weeks, when pas- 
 sive motion is to be begun; it must be very gen- 
 tie at first, and may be gradually increased as the 
 pain and inconvenience attending it subside. 
 
 Result of this injury.- — The result of the case 
 depends upon the seat of the fracture : if the bone 
 be broken very obliquely, a steady and long con- 
 tinued support of the part will occasion it to unite; 
 for in these cases a considerable portion of the 
 fracture is external to the capsular ligament ; but 
 
FRACTURES OF THE ELBOW-JOINT. 
 
 449 
 
 if the whole extent of the fracture be within the 
 ligament, it does not, so far as I have seen, unite by 
 bone, whatever be the means employed. 
 
 FRACTURE OF THE CORONOID PROCESS OF THE ULNA. 
 
 A gentleman came to London for the opinion of 
 different surgeons upon the following case. 
 
 Appearances of the fracture of the coronoid pro- 
 cess of the ulna. — This gentleman had fallen upon 
 his hand whilst in the act of running ; and on rising, 
 he found his elbow incapable of being bent, nor 
 couid he entirely straighten it ; he applied to his 
 surgeon in the country, who, upon examination, 
 found that the ulna projected considerably back- 
 wards; but that so soon as he bent the arm, it re- 
 sumed its natural form. He immediately confined 
 the limb in a splint, and kept it in a sling. When 
 I saw this gentleman in town, several months had 
 elapsed since the accident, yet the same appear- 
 ances, which the surgeon described when he first 
 saw the injury, remained ; namely, the ulna pro- 
 jected backwards whilst the arm was extended, but 
 it was without much difficulty drawn forwards and 
 bent, and the deformity was then removed. It was 
 thought, at the consultation which was held about 
 him in London, that the coronoid process was de- 
 tached from the ulna, and that thus, during exten- 
 sion, the ulna slipped back behind the inner condyle 
 of the humerus. 
 
 Case ; dissection, — I had been several years in 
 the habit of mentioning this case at lecture, when a 
 person was brought to the dissecting room at St 
 Thomas's Hospital, who had been the subject of the 
 same accident, and the joint is preserved in our 
 
 57 
 
450 
 
 FRACTURES OF THE ELBOW-JOINT. 
 
 museum. (See Plate.) The coronoid process, which 
 had been broken off within the joint, had united by 
 ligament only, so as to move readily upon the ulna, 
 and thus alter the sigmoid cavity of the ulna so 
 much as to allow in extension, that bone to glide 
 backwards upon the condyles of the humerus. 
 
 Treatment, — As to the treatment of this accident, 
 I am doubtful whether any mode can completely 
 succeed, as the coronoid process, like the head of 
 the thigh-bone, loses its ossific nourishment, and has 
 no other than a ligamentous support. Its life is pre- 
 served by the vessels of the reflected portions of 
 the capsular ligament upon the end of the bone, 
 which do not appear capable of supporting the least 
 attempt at ossific union; nor is any change on the 
 surface of the bone apparent. It will be proper, 
 however, in this accident, to keep the arm steadily 
 in the bent position for three weeks after the inju- 
 ry, and thus to make the ligamentous union as short 
 as possible, by leaving the bone perfectly at rest* 
 
 FRACTURE OF THE OLECRANON. 
 
 Symptoms of fracture of the olecranon, — This pro- 
 cess of the ulna is not unfrequently broken off, and 
 the accident is followed by symptoms which render 
 the injury so evident, that the nature of the case 
 can scarcely be mistaken. Pain is felt at the back 
 of the elbow, and a soft swelling is soon produced 
 there, through which the surgeon's finger readily 
 sinks into the joint ; the olecranon can be felt in a 
 detached piece, elevated sometimes to half an inch, 
 and sometimes to two inches, above the portion of 
 the ulna, from which it has been broken. This ele- 
 vated portion of bone moves readily from side to 
 
FRACTURES OF THE ELBOW-JOINT. 
 
 451 
 
 side, but is with great difficulty drawn downwards ; 
 if the arm be bent, the separation between the ulna 
 and the olecranon becomes much greater. The pa- 
 tient has scarcely any powe*r to extend the limb, and 
 the attempt produces very considerable pain; but 
 he bends it with facility, and if the limb be undis- 
 turbed, it is prone to remain in the semifle:ied posi- 
 tion. For several days after the injury has been 
 sustained, much swelling of the elbow is produced; 
 there is an appearance of ecchymosis to a consider- 
 able extent, and an effusion of fluid ensues into the 
 joint in a much larger quantity than is natural ; 
 but the extent to which these symptoms proceed, 
 depends upon the violence which produced the ac- 
 cident. The rotation of the radius upon the ulna 
 is still preserved. No crepitus is felt, unless the 
 separation of the bone be extremely slight. 
 
 Dissection of this Accident. 
 
 Appearances of the dissection of this accident. — 
 This fracture is usually i'ound to have happened 
 through the centre of the olecranon; and it is most 
 frequently in the transverse direction; but I have 
 seen the bone broken obliquely, so that the fractured 
 parts presented very thin edges. On that portion 
 of the olecranon attached to the ulna there are some 
 marks of ossific inflammation, and some very slight 
 traces of it on the detached portion. The cancel- 
 lated structure of the fractured olecranon is filled by 
 ossific matter, and is sometimes smoothed by occa- 
 sional friction. The os humeri and radius undergo no 
 change. In the appearances of one case which I 
 dissected, and of which I have given a plate, the 
 olecranon is separated two inches from the ulna; the 
 capsular ligament of the elbow-joint is torn through 
 
452 
 
 FRACTURES OF THE ELBOW-JOINT. 
 
 on each side of the olecranon; and the separated 
 portion is united by a ligamentous band, which is 
 stretched from one broken extremity of the bone to 
 the other. (See Plate,) 
 
 Mode of union. — The nature of this injury then 
 is as follows. So soon as the extremity of the bone 
 is broken off, it is, by the action of the triceps muscle, 
 drawn up from half an inch to two inches from the 
 ulna, and the extent of its separation depends upon 
 the degree of laceration of the capsular ligament, 
 and of that portion of the ligamentous band which 
 proceeds from the side of the coronoid process of 
 the ulna to that of the olecranon. That I might 
 perfectly understand the nature of this accident, and 
 its means of reparation, I tried the following experi- 
 ments on a dog. 
 
 Experiments. 
 
 The integuments having been drawn laterally and 
 firmly over the end of the olecranon, I made a small 
 incision, and placed a knife upon the middle of that 
 process, in a transverse direction; on striking it with 
 a mallet, the bone was readily cut through ; a sepa- 
 ration directly took place by the action of the triceps 
 muscle; adhesive matter was effused; and when I 
 examined the limb a month afterwards, I found the 
 bone united by a strong ligament. I broke the ole- 
 cranon in the same manner in several rabbits: in 
 these experiments blood was first thrown out, and 
 then adhesive matter filled up the space of separa- 
 tion, which subsequently became ligamentous, and 
 firmer and firmer, as the time was protracted be- 
 tween the experiment and the examination. 
 
 Formation of ligament ; union in fractured olecra- 
 non^ Src. — As I found that ligament was formed in 
 each of these experiments, I was anxious to learn 
 whether the olecranon could be made to unite by 
 
FRACTURES OF THE ELBOW-JOINT. 453 
 
 bone, if a longitudinal fracture were produced with 
 but slight obliquity, so that the broken portions might 
 still remain in contact ; and I found that under these 
 circumstances the osseous union readily took place. 
 Therefore this bone, like the extremity of the os 
 calcis when it is broken off, is detached by the 
 action of muscles, and ligamentous union ensues from 
 want of adaptation ; but a different cause exists where 
 bony union fails in fractured bones within joints in 
 the neck of the thigh-bone, in the coronoid process 
 of the ulna, and in the extremity of the external 
 condyle of the os humeri. In these injuries the want 
 of union proceeds from the diminished support which 
 the fractured parts receive, the little that exists 
 being derived through the medium of blood-vessels 
 intended for the nourishment of ligament. The pre- 
 parations made from these experiments may be seen 
 in the Museum at St Thomas's Hospital. I have 
 also seen this bone in the living person united by 
 an ossific process, when the fracture has happened 
 very near to the shaft of the ulna. 
 
 The ligamentous substance, which generally forms 
 the bond of union in these cases, is often incomplete ; 
 having an aperture, and sometimes several apertures 
 in it, when it is of considerable length. The arm is 
 weakened in proportion to the length of the liga- 
 ment ; for if this be very long, extension of the arm 
 is rendered difficult, from the necessarily diminished 
 power of the triceps muscle. 
 
 Causes of this injury. — The causes of this injury 
 are, first, a fall upon the elbow when the joint is 
 bent ; and secondly, fracture by the action of the 
 triceps muscle only, when a great and sudden exer- 
 tion is made during the flexed position of the arm. 
 
 Treatment of fracture of the olecranon. — The treat- 
 ment of this accident is as follows, but it is to be 
 
454 
 
 FRACTURES OF THE ELBOW-JOINT. 
 
 modified according to the degree of injury: — If 
 there be much swelling and contusion, it is right to 
 apply evaporating lotions and leeches for two or 
 three days ; and after the inflammation is reduced, 
 a bandage should be applied ; but in those cases 
 where but little violence is done to the limb, it 
 should be at once secured by bandage. The prin- 
 ciple of the treatment is to preserve the power of 
 the limb, by making the separation of the bones as 
 slight as possible, that their ligamentous union may 
 be shortened ; and secondly, to restore the natural 
 motions of the joint. If the swelling and inflamma- 
 tion do not prevent it, the surgeon is to place the 
 arm in a straight position, and to press down the 
 upper portion of the fractured olecranon until he 
 brings it in contact with the ulna; a piece of linen 
 is then laid longitudinally on each side of the joint, 
 a wetted roller is applied above the elbow, and 
 another below it ; the extremities of the linen are 
 then to be doubled down over the rollers and tightly 
 tied, so as to cause an approximation ; thus the 
 bones are brought and held together : a splint, well 
 padded, is to be applied upon the fore part of the 
 arm, to preserve it in a straight position, and is.to be 
 confined to it by a circular bandage : the whole is 
 to be frequently wetted with spirits of wine and 
 water. 
 
 This is the only injury of the elbow-joint which 
 requires the straight position: those of the condyles 
 and coronoid process demanding that the limb should 
 be kept bent. 
 
 In a month the splint is to be removed, and pas- 
 sive motion is to be begun ; but if it be attempted 
 earlier, the olecranon will separate from the shaft 
 of the bone, and the ligament become lengthened 
 and weakened- All attempts at motion must be 
 made with the greatest gentleness. 
 
FRACTURES OF THE ELBOW-JOINT. 
 
 455 
 
 Fracture of the olecranon an inch from the point 
 of the elbow into the body of the ulna, requires the 
 same treatment as the common fracture of this por- 
 tion of bone. 
 
 Miss , aged thirty, fell from her horse on her 
 
 elbow, and broke the ulna one inch from the point 
 of the olecranon. It was kept bent three months, 
 and no extension could be produced by any effort of 
 herself. I forcibly straightened the arm, and kept 
 it so by a wooden splint. Bony union may, in this 
 case, be readily produced. 
 
 The subjoined plate is intended to show the band 
 of ligamentous fibres, which, if it remains untorn, 
 prevents the olecranon from separating far from the 
 ulna. In general, however, by bending the arm, the 
 fracture of the olecranon is easily discovered. 
 
 A band of ligamentous fibres crosses from the side 
 of the coronoid process to the olecranon ; and upon 
 the radial side of the ulna, the upper portion of the 
 coronary ligament of the radius passes from the 
 side of the olecranon towards the neck of the ra- 
 dius. If the olecranon be broken off, and these 
 ligamentous fibres be left entire, the olecranon will 
 remain still united to the ulna by means of these 
 
456 
 
 FRACTURES OF THE ELBOW-JOINT. 
 
 ligamentous productions, which I should not have 
 noticed, but for their influence on fractures of this 
 bone. 
 
 a. Os humeri. 
 h. Radius. 
 
 c. Ulna. 
 
 d. Olecranon. 
 
 c. External condyle of the os 
 
 humeri. 
 /. Internal condyle. 
 
 g. Coronary ligament, the upper 
 part of which ascends to- 
 wards the olecranon. 
 
 h. Ligamentous fibres from the 
 coronoid process to the ole- 
 cranon. If the olecranon be 
 broken off at the dotted line, 
 and the upper part of the co- 
 ronary hgament, and these 
 ligamentous fibres remain en- 
 tire, the bone moves later- 
 ally, but it separates little 
 from the ulna. 
 
FRACTURES OF THE ELBOW-JOINT. 
 
 457 
 
 COMPOUND FRACTURE OF THE OLECRANON. 
 
 In compound fractures of this bone, the edges of 
 the skin must be brought into exact apposition; h'nt, 
 embued in blood, must be applied on the wound, 
 with adhesive plaster over it, and union by adhesion 
 must be elFected li possible; but in oilier respects 
 the treatment is the same as in simple fracture. 
 
 I have seen two cases of this accident, both of 
 which have been successfully treated. 
 
 FRACTURE OF THE NECK OF THE RADIUS. 
 
 This fracture I have heard mentioned by surgeons 
 as being of frequent occurrence, but there must be 
 some^ mistake in the statement, for it is an accident 
 which I have never seen; and if instances ever 
 present themselves (which I do not mean to deny), 
 they must be very rare. 
 
 Diagnostic marks of this accident. — The injury 
 would be known by fixing the external condyle of 
 the humerus and rolling the radius, when a crepitus 
 would be perceived. 
 
 If such an accident should occur, the treatment 
 which it will require will be the same as that which 
 is demanded for fracture of the external condyle of 
 the OS humeri. 
 
 58 
 
458 
 
 FRACTURES OF THE ELBOW-JOINT. 
 
 COMPOUND FRACTURES AND DISLOCATIONS OF THE ELBOW- 
 JOINT. 
 
 Generally not destructive. — These generally happen 
 through the internal condjles of the os humeri, and 
 the fracture takes an obhque direction into the joint. 
 In the most severe accident of this kind, the consti- 
 tution is generally able to support the injury, if it be 
 judiciously treated ; and the recital of the following 
 cases will evince the happy result that may be ex- 
 pected, if union by adhesion be effected in the treats 
 ment. 
 
 Case, — I was called to Guy's Hospital, to see a 
 brewer's servant, who had a compound fracture of 
 the elbow-joint, caused by his dray passing over 
 the arm, which had considerably comminuted the 
 bones. I could pass my finger readily into the joint, 
 and feel the brachial artery pulsating on its fore^part. 
 Considering the violence done to the part, and the 
 constitution of the patient, who, like most of those 
 in such employment, drank much porter and spirits, 
 and ate but little, I at once told him, I feared 
 there was scarcely any hope of his recovery, un- 
 less he consented to the loss of His limb; the man, 
 however, determined not to submit to the opera- 
 tion, although Dr Hulme, who accompanied me, 
 also endeavoured to convince him of the necessity 
 of amputation; I therefore did all in my power to 
 save both his life and his limb. The bones were 
 easily replaced, and the parts were carefully brought 
 together. The limb was laid upon a splint, lightly 
 bandaged, and placed at right angles. The wound 
 united without any untoward circumstance; and the 
 only check that interrupted his progressive recovery, 
 was the formation of an abscess in the shoulder, 
 
Fractures of the elbow- joint*. 
 
 459 
 
 which was opened, and immediately healed. The 
 elbow-joint was not even completely anchylosed, for 
 he retained sufficient motion in it to allow him to re- 
 sume his former occupation. 
 
 Case, — A gentleman, of the name of Stewart, was 
 thrown from his chaise, and had a fracture of the 
 condyles of the os humeri, with a projection of a 
 portion of its inner condyle through the integuments. 
 The edges of the wound were immediately brought 
 together, and lint, dipped in blood, was laid over 
 them; evaporating lotions were then applied, and 
 the limb was kept in the bent position until the frac- 
 ture was united. He had some use of the joint 
 afterwards, but its motions were much more limited 
 than in the former case. 
 
 Case. — MrL — ^ — , aged seventy-four, who is nearly 
 my opposite neighbour, in New-street,Spring-gardens, 
 fell down some steps on the 20th of April, 1818, and 
 shattered his elbow-joint. The condyles were bro- 
 ken, as well as the olecranon, and the internal con- 
 dyle projected through the skin. Mr Freeman, sur- 
 geon in New-street, was called to him, and he re- 
 quested me to attend him. When I visited Mr L , 
 
 1 found, in addition to the above-mentioned circum- 
 stances, a considerable hasmorrhage from the wound, 
 whilst the comminuted state of the joint allowed it 
 to be twisted in ail directions. 
 
 The treatment which we adopted was, to apply 
 lint to the wound, dipped in the blood which flowed 
 from the arm; recourse was also had to a many- 
 tailed bandage, a pasteboard splint, and an evaporat- 
 ing lotion. As the parts were in a tranquil state, 
 the dressing was not disturbed until the fifteenth of 
 May. Some matter was discharged from the ex- 
 ternal wound, but the joint never manifested any 
 signs of suppuration. The little discharge that ap- 
 peared, did not exceed that which a small superficial 
 
460 FRACTURES OF THE ELBOW-sTOINT. 
 
 wound would produce. The wound was some time 
 in healing, being prevented by the pressure of the 
 splint, on which the arm rested. So soon as it was 
 healed, and the bones united, passive motion was 
 begun; and although the form of the joint was 
 irregular, yet a considerable degree of motion was 
 preserved. 
 
 This case gratified me exceedingly, the subject of 
 the accident being universally respected for his 
 virtues and his talents; his constitution was feeble, 
 his age advanced, and he could not have supported 
 suppuration of the elbow-joint, nor is it probable 
 that he would have survived the loss of his limb. 
 By the simple treatment described, all the dangers 
 which threatened him were averted; and he has, 
 for several years, survived this very severe injury. 
 On the contrary, if poultices be applied in these 
 accidents, the adhesive process is prevented, and 
 suppuration produced, which endangers life, or ren- 
 ders amputation necessary. 
 
 Case, — A woman, between fifty and sixty years 
 of age, was admitted into Guy's Hospital, with a 
 wound of the elbow-joint, and fracture of both the 
 condyles of the os humeri, A poultice was direct- 
 ed to be applied, and fomentation ordered twice a 
 day. On the day following the accident, she had 
 a considerable degree of fever. On the third day 
 the upper arm was exceedingly swollen, and there 
 was an abundant sanious dischargre from the wound. 
 On the fourth day her strength was greatly re- 
 duced, and the wound had almost ceased to dis- 
 charge, but the arm was very much swollen. On 
 the fifth day she died. 
 
 Treatment of compound fractures of the elbow-joint. 
 — In all cases. of this accident, the arm should be 
 kept in the bent position; for as anchylosis, in a 
 greater or lesser degree, is the certain consequence, 
 
FRACTURES OF THE ELBOW-JOINT. 
 
 461 
 
 k is attended with much less inconvenience in this 
 p)sition than in any other. If the bones be much 
 comminuted, and the wound large, all the detached 
 portions of bone should be removed; but in old 
 people, wlien much injury is done, there is often 
 not sufficient strength to support the adhesive pro- 
 cess, and amputation should be recommended. The 
 edges of the wound should be kept together by 
 placing a piece of lint, dipped in blood, over them, 
 supported by adhesive plaster, and a bandage^ 
 lightly applied, wetted with spirits of wine and 
 water. 
 
STRUCTURE OF THE WRIST-JOINT. 
 
 Srucfure of the joint ; bones. — The radius and the 
 three first bones of the carpus, form the articular 
 surfaces of the wrist-joint; the radius having an 
 oval cavity at its lower extremity, which receives 
 the rounded surfaces of the scaphoid, lunar, and 
 cuneiform bones. The articular cartilage which 
 covers this surface of the radius is, at its inner edge, 
 extended beneath the ulna, so as to exclude that 
 bone from the general cavity of the wrist-joint. 
 This articular cartilage is hollow, both above and 
 below ; and at its lower surface it rests upon the os 
 cuneiforme. 
 
 Capsular ligament. — A capsular ligament passes 
 from the edge of the articular cavity of the radius, 
 and from the interarticular cartilage of the ulna, to 
 the three first bones of the carpus, surrounding a 
 large portion of the scaphoid and lunar bones, and 
 but a small surface of the cuneiforme. 
 
 Ulna joint. — The second joint at this part is that 
 formed between the radius and the ulna. On the 
 inner side of the lower extremity of the radius is 
 situated a hollow articulatory surface, which re- 
 ceives an articular surface on the outer side of the 
 ulna, and both are covered by an articular cartilage. 
 
STRUCTURE OF THE WRIST-JOINT. 463 
 
 At the lower part of this joint is placed the inter- 
 articular cartilage of the ulna, the outer edge of 
 which is joined to the articular cartilage of the ra- 
 dius, and its inner edge is united to the ulna bj liga- 
 ment, which sinks into a cavity formed at the lower 
 extremity of this bone, between the styloid process 
 of the ulna and its rounded extremity. 
 
 Sacciform ligament, — The capsular ligament, 
 which unites the ulna to the radius, is called the 
 sacciform ligament: it covers the articular surfaces 
 of the two bones, and is united below to the move- 
 able cartilage of the ulna. This joint of the wrist 
 is formed for the purpose of supporting the rotatory 
 motion of the radius upon the ulna, and of strongly 
 uniting one bone to the other. 
 
 Radio-carpal ; Ulna-carpal. — The wrist is 
 strengthened on each side by peculiar ligaments : 
 one proceeds from the styloid process of the radius, 
 to be fixed to the outer edge of the scaphoid bone, 
 which is ih(y radio-carpnl ligament ; and an ulna-car- 
 pal ligament extends from the styloid process of the 
 ulna, to the os cunelforme, and os orblculare. 
 
DISLOCATIONS OF THE WRISTJOINT. 
 
 The dislocations of this joint are of three kinds : — 
 First, dislocation of both bones. 
 Secondly, dislocation of the radius only* 
 Thirdly, dislocation of the ulna. 
 
 Mode in which these accidents happen. — The first 
 accident, namely, the dislocation of both bones, is 
 not of very frequent occurrence ; but when it does 
 happen, the bones are thrown cither backwards or 
 forwards, according to the direction in which the 
 force is applied. If the person in falling puts out 
 his hand to save himself, and falls upon the palm, 
 a dislocation is produced, the radius and ulna are 
 forced forwards upon the ligamentum carpi annulare, 
 and the carpal bones are thrown backwards. 
 
 Appearance, — The appearances of this disloca- 
 tion are these: — A considerable swelling is produc- 
 ed by the radius and ulna, on the fore part of the 
 wrist, and a similar protuberance upon the back of 
 the wrist by the carpus, with a depression above it ; 
 the hand is bent back, being no longer in the line 
 with the fore arm. 
 
DISLOCATIONS OF THE WRIST-JOINT. 465 
 
 In the dislocation of the radius and ulna back- 
 wards, the person falls upon the back of the hand, 
 the radius and ulna are thrown upon tiie posterior 
 part of the carpus, and the carpus itself is forced 
 under the flexor tendons, which pass behind the li- 
 garaentum carpi annulare ; but in each ol" these cases 
 two swellings are produced, one b>; the radius and 
 ulna, and the other by the bones of the carpus, ac- 
 cording to the direction in which thej are thrown : 
 and these become the diagnostic signs of the acci- 
 dent. 
 
 Sprains. — Severe falls upon the palm of the hand 
 will produce sprains of the tendons on the fore part 
 of the wrist, and occasion a very considerable swell- « 
 ing of the flexor tendons, opposite the wrist-joint. 
 This accident assumes the appearance of dislocation, 
 but may alw^ays be distinguished from it by the exist- 
 ence of one swelling only, which does not appear 
 immediately after the injury is received, but suc- 
 ceeds it gradually. And further, if the surgeon be 
 called directly after the dislocation has happened, 
 there is then a great flexibility of the hand, as well 
 as distortion, and the extremities of the radius and 
 ulna on one side, and of the carpal bones on the 
 other, are easily detected. 
 
 Reduction, — The reduction of this dislocation, in 
 whatever form it may have occurred, is by no means 
 difficult. The surgeon grasps the patient's hand 
 with his right hand, supporting the fore arm with 
 his left, whilst an assistant places his hands around 
 the upper arm, just above the elbow ; they then 
 pull in different directions, and the bones become 
 easily replaced. The reduction is in both cases the 
 same, for the muscles draw the bones towards their 
 natural position as soon as they are separated from 
 the carpus by extension. 
 
 When the hand recovers its natural situation, a 
 59 
 
466 DISLOCATIONS OF THE WRIST-JOINT. 
 
 roller, wetted in spirits of wine and water, is to be 
 lightly applied around the wrist, and the whole is 
 to be supported by splints placed before and behind 
 the fore arm, reaching as far as the extremities of 
 the metacarpal bones, for the more perfect security 
 of the limb. 
 
 DISLOCATION OF THE RADIUS AT THE WRIST. 
 
 Diagnostic marks of this accident, — This bone is 
 sometimes separately thrown upon the fore part of 
 the carpus, and lodged upon the scaphoid bone and 
 the OS trapezium. The outer side of the hand isj 
 in this case, twisted backwards, and the inner for- 
 wards: the extremity of the radius can be felt and 
 seen, forming a protuberance on the fore part of the 
 wrist. The styloid process of the radius is no longer 
 situated opposite to the os trapezium. 
 
 Cause of the accident.— This accident usually hap- 
 pens from a fall when the hand is bent back; and I 
 have also known it arise from a fall upon the hand, 
 by which the condyles of the os humeri were bro- 
 ken obliquely, and the radius dislocated at the wrist, 
 being thrown upon the fore part of the scaphoid 
 bone, where it could be distinctly felt: this was the 
 case of the lad whom I mentioned when speaking 
 of fractures of the os humeri ; his hand was hang- 
 ing backwards, and he felt great pain upon its being 
 moved. 
 
 The extension necessary to reduce a dislocation 
 of the radius, and the treatment which it demands, 
 are the same which are required for the luxation of 
 both bones; and there is no difficulty in the opera- 
 tion, the hand being extended whilst the fore arm is 
 fixed. 
 
DISLOCATIONS OF THE WRIST-JOINT, 
 
 467 
 
 DISLOCATION OF THE ULNA. 
 
 As this bone does not form a part of the wrist- 
 joint, but is received into a capsular ligament of its 
 own, and is separated from the wrist by a moveable 
 cartilage, it is more frequently dislocated, separately, 
 than the radius. 
 
 Symptoms. — When this accident occurs, the sac- 
 ciform ligament is torn through, and the bone gener- 
 ally projects backwards, without any accompanying 
 fracture of the radius. It rises and forms a protu- 
 berance at the back of the wrist; and although it 
 is easily pressed down into its natural position, yet 
 so soon as the pressure is removed the deformity re- 
 turns, as the lacerated ligament has no longer the 
 power to retain it in its place. 
 
 Diagnostic marks. — The diagnostic marks of the 
 injury are the projection of the ulna, much above 
 the level of the os cunelformc, and altered position 
 of the styloid process, which is no longer in a line 
 with the metacarpal bone of the little finger. 
 
 Mode of reduction, — The reduction is accom- 
 plished by pressure of the bone forwards, which 
 brings the ulna into its natural articular cavity by 
 the side of the radius ; and to retain it in this situa- 
 tion, splints must be placed along the fore arm, in a 
 line with the back and palm of the hand; the splints 
 should be padded throughout; but upon the ex- 
 tremity of the ulna a compress of leather should be 
 placed, to keep it in a line with the radius; a roller 
 should then be applied over the splints to confine 
 them with sufficient firmness. 
 
463 I>ISLOCATION& OF THE WRIST-JOINT. 
 
 COMPOUND^ DISLOCATION OF THE WRIST, ULNA PROJECTED, 
 AND FRACTURE OF THE RADIUS. 
 
 June 2\st, 1818. 
 John Winter fell from a ladder on his hand and 
 knee ; the hand was bent back, and the ulna pro- 
 truded at the inner part of the wrist. Mr Steel, of 
 Berkhampstead, attended ; the bone was reduced, a 
 roller was put around the wrist, and the wound 
 healed very soon by adhesion. In seven weeks he 
 was well, excepting that a slight swelling of the ten- 
 dons renaained for a few weeks longer. 
 
 SIMPLE FRACTURE OF THE RADIUS, AND DISLOCATION 
 OF THE ULNA. 
 
 */? Jrequent accident, — The radius is frequently 
 broken, and the ulna at the same time dislocated ; 
 the fracture usually happens one inch above the 
 articulation. If it occurs in a very oblique direc- 
 tion, so great a displacement of the radius ensues, 
 that dislocation of the ulna forwards is also pro- 
 duced. 
 
 Dissection.-— I have given a plate of this accident 
 from a preparation of it in the Museum at St Tho- 
 mas's Hospital. (See Plate,) The lower end of 
 the radius is seen in its natural situation, articulated 
 with the carpal bones. An inch above the liga- 
 mentum annulare carpi, the broken extremity of the 
 radius is seen projecting under the flexor tendons of 
 the wrist, which have been removed to show its 
 situation ; the ulna is dislocated forwards, and rests 
 upon the os orbiculare. 
 
PSLOCATIONS OF THE WRIST-JOINT. 460 
 
 Diagnostic marks of this accident, — The signs of 
 this injury are, that the hand is thrown back upon 
 the fore arm, so as at first sight to exhibit the 
 appearance of a dislocation of the hand backwards ; 
 and a projection of the ulna is felt under the tendon 
 of the flexor carpi uhiaris muscle, just above the os 
 orbiculare ; and thirdly, the fractured extremity of 
 the radius is easily detected, under the flexor ten- 
 dons of the hand. I have seen this accident fre- 
 quently, and at first did not exactly understand the 
 nature of the injury ; indeed, dissection alone taught 
 me its real character. 
 
 Mode of reduction, and its difficulties, — A very 
 powerful extension is required to bring the broken 
 ends of the radius into apposition, and great difficulty 
 exists in confining them when this is effected. The 
 hand is to be extended by the surgeon, and the fore 
 and upper arm are to be drawn back by an assistant ; 
 then a cushion is to be placed upon the inner part of 
 the wrist, and another to the back of the hand, 
 firmly bound down by a roller, for the purpose of 
 keeping the ulna and broken end of the radius in 
 situ ; a splint, well padded, is then lo be applied to 
 the back part and inner side of the fore arm, which 
 is to extend to the extremities of the metacarpal 
 bones ; these splints are to be confined by a roller, 
 reaching from the upper part of the fore arm to the 
 wrist, and no farther. The arm should be then 
 placed in a sling : this position is to be preserved 
 for three weeks in young persons, and for four or 
 five in the aged, before passive motion be attempted. 
 The recovery in these cases is slow, and six months 
 will sometimes elapse before motion of the fingers is 
 completely restored. (See Plate,') 
 
470 DISLOCATIONS OF THE WRIST-JOINT. 
 
 FRACTURE OF THE LOWER END OF THE RADIUS 
 WITHOUT DISLOCATION OF THE ULNA. 
 
 Symptoms of this accident ; treatment. — This frac- 
 ture generally happens about an inch above the sty- 
 loid process. The cure is difficult, (he lower ex- 
 tremity of the broken bone being drawn by the ac- 
 tion of the pronator quadratus amongst the flexor 
 tendons, where it may be distinctly felt : in this situ- 
 ation it interferes very considerably with the mo- 
 tions of the fingers, by confining the action of the 
 flexor profundus perforans. Mr Cline, in his lec- 
 tures on this subject, used, nearly in these terms, to 
 recommend the following treatment: — 'When a 
 fracture of the radius happens just above the wrist- 
 joint, you must be very careful in your treatment of 
 it, to prevent the injury from leading to the perma- 
 nent loss of the use of the fingers ; for so soon as the 
 injury has happened, the pronator quadratus muscle 
 draws the fractured end of the bone obliquely across 
 the fore arm, amidst the flexor tendons ; your object, 
 therefore, in the treatment of this accident is, to 
 prevent the action of the pronator from producing 
 that eflfect ; and the mode of treatment which you 
 are to adopt is, to make the hand, by its weight, 
 oppose the action of that muscle. For this purpose, 
 when the bone has been placed in its right position, 
 by drawing the hand in a line with the fore arm, 
 apply a roller around the fore arm to the wrist; 
 then a splint upon the fore and back part of the 
 arm to reach to the palm and back of the hand, so 
 as to preserve it in a half supine position ; and con- 
 fine the splints by means of a roller, which should 
 reach only to the wrist. The arm is then to be 
 placed in a sling, which is also to support it no fur- 
 ther than to the wrist. Thus the hand, being allow- 
 
DISLOCATIONS OF THE WRIST-JOINT. 
 
 471 
 
 ed to han^ between tlie ends of the splints, draws 
 tlie end of the radius, so as to maintain a constant 
 extension upon if, opposing the action of the prona- 
 tor quadratus muscle, and keeping the broken end 
 of the bone constantly in its place.' 
 
 COMPOUND DISLOCATION OF THE ULNA, WITH FRACTURE 
 OF THE RADIUS. 
 
 Often a very serious accident. — This is a very se- 
 rious accident when the radius is much comminuted 
 (see Plate) ; but recovery proceeds very well, when 
 the radius is broken without being shattered. I saw 
 a case of this injury in Hertfordshire, in which the 
 man met with the accident by falling upon the back 
 of his hand, and the ulna protruded an inch and a 
 half through the integuments. The bone was imme- 
 diately reduced and bandaged ; the wound healed 
 by the adhesive process, and the man recovered the 
 perfect use of his limb. 
 
 Case. — Susannah Griffith, a woman from Rother- 
 hithe Poorhouse, aged seventy-two, was admitted 
 into Guy's Hospital, on the 10th of April, 1822. 
 Whilst walking on the pavement, her foot had acci- 
 dentally slipped, and she fell with her right hand 
 under her, in such a manner, that the palmar surface 
 was forcibly bent against the inner side of the fore 
 arm; the carpal extremity of the ulna was, conse- 
 quently, thrown violently outwards through the in- 
 teguments, and the lower end of the radius was ob- 
 liquely fractured. 
 
 The parts were reduced, and the edges of the 
 wound brought as closely into contact as the lacerat- 
 ed condition of it would admit ; a pledget of lint, 
 
DISLOCATIONS OF THE WRIST-JOINT. 
 
 dipped in blood, was applied to the part, and a band 
 age over it. 
 
 On the third day the arm became tumefied and 
 inflamed, and poultices were apphed. By the 21st 
 of May the fracture of the radius had united, and 
 the patient recovered the use of the thumb and two 
 first fingers ; the whole of the articular cartilage 
 had come off in the form of black sloughs, intermix- 
 ed with spiculoe of the adjacent bone, and the gra- 
 nulations were so prominent, as to lead to the appli- 
 cation of adhesive straps : the healing process, how- 
 ever, was greatly retarded by a frequent displace-* 
 ment of the extremity of the ulna, owing to the 
 constitutional irritability of the patient, and to the 
 cedematous state of the arm, which did not allow 
 the bandages to be applied with the tightness requi- 
 site for its due confinement. 
 
 On the 18th of June, the wound was nearly heal- 
 ed; but still a small portion of the end of the ulna 
 will exfoliate, and she applies the lotion acidi nitrici, 
 to hasten its exfoliation. 
 
 Peploe Cartwright, 
 
 j^Kgust Idth, 1822, Dresser, Guy^s Hospital. 
 
 Case. — A man was admitted into St Thomas's 
 Hospital, under the care of Mr Chandler. I now 
 forget in what manner the accident had happened, 
 but the ulna projected through the integuments at 
 the back of the carpus: and a compound fracture 
 of the radius, with great comminution of the bone, 
 was produced. The ulna was at first replaced, but 
 immediately resumed its dislocated position on the 
 back of the wrist, although it did not again protrude 
 through the skin. The hand and fore arm were 
 placed in a poultice, and were ordered to be foment- 
 ed twice a day. A copious suppuration ensued, at- 
 
DISLOCATIONS OF THE WRiST-JpINT. 473 
 
 tended with violent constitutional irritation ; and Mr 
 Chandler, in order to save the patient's life, after a 
 lapse of five weeks, amputated the limb. 
 
 Dissection. — On dissection, I found the ulna dis- 
 located backwards, and its extremity just drawn with- 
 in the opening of the integuments, through which it 
 had protruded. The radius was broken into several 
 pieces, some of which being loose, were necessarily 
 a great source of irritation ; the tendons and muscles 
 were some of them lacerated, as the extensor carpi 
 radialis longior, and the extensors of the thumb. 
 
 Treatment. — In a similar case it would be proper, 
 when loose pieces of bone can be felt at the extre- 
 mity of the radius, that the wound should be en- 
 larged for their removal ; and instead of fomenta- 
 tion£^ and poultices, a quantity of lint, dipped in the 
 patient's blood, should be applied round the wrist, 
 lightly bound with a roller. The arm should be 
 supported upon a splint, so as to be kept perfectly 
 free from motion; evaporating lotions .should be ap- 
 plied ; and the limb should not be disturbed, unless 
 the patient has symptoms of a suppurative process, 
 when a small opening should be made in the bandage 
 to allow of the escape of pus, but still the bandages 
 should be suffered to remain. The patient should be 
 bled from the arm if the inflammation and constitution- 
 al irritation be considerable, and under these circum- 
 stances leeches should be occasionally applied. The 
 bowels should be kept gently open, but all active 
 purging avoided. 
 
DISLOCATIONS OF THE CARPAL BONES. 
 
 Carpal joint. — The eight bones of the carpus 
 are joined to each other by short ligaments, which 
 pass from bone to bone, allowing but a very slight 
 degree of motion of one bone upon another; but 
 besides this mode of articulation, there is a transverse 
 joint between the first and second row of carpal 
 bones, forming a complete ball and socket. The 
 ball is produced by the rounded extremities of the 
 OS magnum and os cuneiforme : the cup, by the sca- 
 phoid, lunar, and cuneiform bones. A ligament 
 passes from one row of bones to the other, including 
 this articulation. 
 
 The dislocation of a carpal bone is but of rare 
 occurrence ; the following is an example of the ac- 
 cident. 
 
 Case, — Mary Nichols, aged sixty, slipped down, 
 and, trying to save herself, fell upon the back of 
 her hand and fractured the radius obliquely outwards, 
 through the lower articulating surface. The frac- 
 tured portion, with the os scaphoides, was thrown 
 
DISLOCATIONS OF THE CARPAL BONES. 
 
 475 
 
 backwards upon the carpus. The wrist was slightly 
 bent, and there was an evident projection at the 
 back of the carpus. The fingers could be com- 
 pletely extended, but only semiflexed. A crepitus 
 might be distinctly felt, either by moving the hand, 
 or the styloid process of the radius backwards or 
 forwards. By slight extension, and steady pressure 
 upon the displaced part, the fracture was easily re- 
 duced. There was much extravasation and pain 5 
 six leeches were applied, afterwards evaporating lo- 
 tions, and two long splints ; and as soon as the swell- 
 ing had in some measure subsided, strips of soap 
 plaster. At the end of six weeks the fracture was 
 firmly united, but the motions of the wrist are still 
 imperfect, and she cannot grasp any thing. 
 
 F. R. Elkington, 
 August \3thy 1822. Dresser, Guyh Hospital 
 
 Ganglia are sometimes mistaken for this accident; 
 but in such cases a smart blow with a book will dis- 
 perse the swelling, and dispel the cloud of doubt 
 which enveloped the mind of the surgeon. 
 
 Relaxation of the carpal joint. — The os magnum 
 and the cuneiform bones, from relaxation of their 
 ligaments, are occasionally thrown somewhat out of 
 their natural situation, so that when the hand is bent, 
 they form protuberances at the back of the wrist. 
 This state is productive of so great a degree of 
 weakness, as to render the hand useless unless the 
 wrist be supported. 1 was consulted by a young 
 lady, a patient of Mr Gumming, of Chelsea, who had 
 such a projection of the os magnum, that she was, 
 in consequence, obliged to give up her music and 
 other accomplishments, on account of the attendant 
 weakness ; for when she wished to. use her hand, 
 she was compelled to wear two short splints, which 
 
476 
 
 DISLOCATIONS OP THE CARPAL BONES. 
 
 were adjusted to the wrist, and bound upon the back 
 and fore part of the hand and fore arm. Another 
 lady, who had a weakened state of limb, arising 
 from a similar cause, wore, for the purpose of giving 
 it strength, a strong bracelet of steel chain, clasped 
 very tightly around the wrist. But the supports 
 generally directed to be worn in these cases are 
 straps of adhesive plaster, and a bandage over the 
 wrist to confine and strengthen it. The effusion of 
 cold water upon the hand from a considerable height 
 is also employed, and the part is afterwards rubbed 
 with a coarse towel, to give vigour to the circula- 
 tion, and strength to the joints. 
 
 COMPOUND DISLOCATION OF THE CARPAL BONES. 
 
 These accidents are of frequent occurrence, and 
 they are generally caused by guns bursting in the 
 hand ; portions of the instrument being forced 
 through the carpus, and between the metacarpal 
 bones. 
 
 Recovery. — In these cases a carpal bone may be 
 removed by dissection, and the patient may recover; 
 not only saving his hand, but, in a considerable de- 
 gree, preserving its motions; of which the following 
 is an example. 
 
 Case, — Richard Mitchell, aged twenty-two, was 
 admitted into Guy's Hospital, under Mr Forster, on 
 the 17th of October, 1822, for an extensive wound 
 in the wrist-joint, inflicted by wliat is called a wool- 
 comber's devil. On examination it was found that 
 the wound extended through two-thirds of the cir- 
 cumference of the joint, and was attended with a 
 great deal of contusion ; the scaphoid bone projected 
 at the back part, being attached only on the side 
 
DISLOCATIONS OP THE CARPAL BONES. 477 
 
 towards the joint ; in consequence of this, the joints 
 into which it enters were laid open ; the extensor 
 tendons of the thumb, and of the middle and fore 
 fingers, were torn through; the radial artery was 
 also torn, but did not afford any considerable hae- 
 morrhage. The scaphoid bone was removed with 
 a scalpel ; the edges of the wound were brought 
 together by sutures, and lint, dipped in blood, was 
 applied to it and confined by adhesive straps; the 
 fore arm and hand were laid on a splint, so as to 
 keep the joint perfectly at rest ; the patient was 
 bled to twelve ounces, and an evaporating lotion or- 
 dered. In two or three days the dressings were 
 removed, in consequence of the pain, when a good 
 deal of surrounding inflammation was found, and in 
 one spot a slough ; the sutures were removed, and 
 a poultice ordered ; two or three days after this, 
 abscesses formed along the thecae of 'the tendons, 
 which were opened. The slough quickly separated, 
 and the inflammation subsided, as the suppurative 
 process became established. In two or three weeks, 
 the wound was so well filled, as to allow the applica- 
 tion of adhesive straps, under which treatment it 
 gradually healed. The only constitutional symptoms 
 which occurred during the progress of the case 
 were those of common irritative fever, which were 
 relieved by the exhibition of antimony, with opium 
 and the liq. ammon. acet. with the tinct. opii. and 
 the use of mild cathartics. A pulmonic affection, 
 which threatened phthisis, was also relieved by the 
 use of leeches and diaphoretics, which, however, 
 considerably retarded his recovery. 
 
 Whilst his wound was in the progress of 'healing, 
 passive motion was early and regularly practised : 
 and after it had healed, friction, with the soap lini- 
 ment: but he hftd only a limited power of moving 
 his fingers when he left the hospital. 
 
478 DISLOCATIONS OP THE CARPAL BONES. 
 
 All the intelligence I can now gain of him is, that 
 he has lately gone to work, under the hope that the 
 constant habit of grasping bodies (which indeed I 
 strenuously recommended to him previously), will 
 restore the motion of his fingers. 
 
 Charles Fagg, 
 
 Aug, '\2th, 1822. Dresser, Gwifs Hospital. 
 
 When only one or two of the carpal bones are 
 displaced by guns bursting in the hand, they may 
 be dissected away; but if more considerable injury 
 be done, amputation will be necessary. 
 
DISLOCATIONS OF THE METACARPAL 
 BONES. 
 
 Arrfputation often necessary. — These bones are so 
 firmly articulated with the bones of the carpus, that 
 I have never seen them dislocated but by the burst- 
 ing of guns, or by the passage of heavy laden car- 
 riages over the hand; and in each of these eases 
 there is generally so much injury produced, as to 
 render amputation necessary. In the former of 
 these accidents, a bone, and sometimes two, are ca- 
 pable of being removed; and if it be necessary to 
 amputate the middle and ring finger, the fore and 
 little finger may be brought so nicely together, and 
 secured in such exact adhesion, as to produce little 
 deformity. 
 
 Case. — I was called by Mr Hood, surgeon at 
 Vauxhall, to a Mr Waddle, of Bow-lane, Cheapside, 
 who, whilst shooting, had his gun burst, and his hand 
 lacerated by a portion of the barrel passing through 
 its centre. The metacarpal bones of the middle and 
 ring fingers were fractured, and also much commi- 
 nuted by the violence of the injury, but the integu- 
 
480 DISLOCATIONS OF THE METACARPAL BONES. 
 
 ments were only lacerated, and not completely re- 
 moved. I dissected out the two fingers, with the 
 metacarpal bones which supported them, and brought 
 the edges of the skin together by suture, approxi- 
 mating the fore and little finger, and applying a 
 roller, so as to bind them together ; the parts united 
 perfectly, and the maimed hand was afterwards ex- 
 tremely useful to him : the case, indeed, is highly 
 worthy of inspection. 
 
 Case. — A boy of twelve years of age was brought 
 into Guy's Hospital, who, by the bursting of a gun, 
 had his thumb anJ all the fingers, excepting the fore 
 finger, blown to pieces; the whole hand was exceed- 
 ingly shattered, and the metacarpal bones were se- 
 parated from the carpus. Upon examination of the 
 hand, I found that the tendon of the fore finger was 
 uninjured, so that its use remained perfect ; and as 
 the integument could be still saved, so as to cover 
 its metacarpal bone, I dissected out the trapezium 
 (the thumb had been entirely carried away by the 
 concussion), and the metacarpal bones of all the fin- 
 gers, excepting that of the fore finger, which was 
 afterwards of the greatest use to him. 1 kept him 
 for some time at the. hospital, to show to the stu- 
 dents the restorative powers of nature, and the utility 
 of this finger, saved out of the wreck of his hand ; 
 he used it as a hook with the greatest facility. 
 
 FRACTURE OF THE HEAD OF THE METACARPAL BONE. 
 
 Fracture, — The extremity of the metacarpal 
 bone towards the fingers, which is called its head, is 
 sometimes broken off, and it gives the appearance of 
 dislocation of the finger, as the head of the bone 
 sinks towards the palm of the hand. In the treat- 
 
DISLOCATIONS OF THE METACARPAL BONES. 481 
 
 ment of this case, a large ball is to placed in the 
 hand, grasped by it, and bound over it by a roller; 
 and thus the depressed extremity of the bone is raised 
 to its natural situation. 
 
 6t 
 
DISLOCATIOxNS OF THE FINGERS AND 
 
 TOES. 
 
 Structure. — The phalanges of the fingers and of the 
 toes are united bjr capsular ligaments to the metacar- 
 pal and metatarsal bones, and to each other; and their 
 union is further strengthened bj lateral ligaments, 
 proceeding from the side of one phalanx to the other. 
 Posteriorly, they are defended by the tendon of the 
 extensor muscle of the fingers; and anteriorly, by 
 the thecse and flexor tendons. Dislocation of the 
 phalanges, therefore, is but rare; but Avhen this ac- 
 cident does occur, it more frequently happens between 
 the first and second phalanges than between the 
 second and third. 
 
 In the twenty-eighth plate this dislocation will be 
 seen; the second phalanx being thrown' forwards 
 towards the ffiecae, and the first backwards. I could 
 not learn if the ligaments had been torn,' as the dis- 
 location had existed for a length of time, and the 
 ligament, if it had ever been lacerated, was then 
 united ; the extensor tendon was very much stretched 
 over the end of the first phalanx. 
 
DISLOCATIONS OF THE FINGERS AND TOES. 483 
 
 Diagnostic marks of this accident. — This accident 
 may be readily distinguished by the projection of the 
 first phalanx backwards, while the head of the se- 
 cond may be, although less distinctly, felt under the 
 thecae. 
 
 Reduction, — The reduction may be effected by 
 making extension with a slight inclination forwards 
 to relax the flexor muscles. If the bone has not 
 been dislocated many hours, it is easily reduced ; but 
 if neglected at first, this can only be accomplished 
 by a long continued extension, very steadily applied. 
 1 have seen too much mischief arise from injury to 
 the tendons and ligaments of these joints ever to 
 recommend the division of them (which some have 
 advised) to facilitate reduction, when extension will 
 not succeed. The observations which I have made 
 respecting the dislocation of the fingers, also apply 
 to the toes; of which, however, the dislocations are 
 more difficult to reduce, from their greater shortness, 
 and the less pliability of the joints. 
 
 DISLOCATION FROM CONTRACTION OF THE TENDON. 
 
 Contraction of tendon, — A toe or finger is some- 
 times gradually thrown out of its natural direction 
 by a contraction of the flexor tendon and thecse, and 
 the first and second phalanges are consequently 
 drawn up and projected against the shoe, so as to 
 prevent the patient from being able to take his 
 usual exercise. 
 
 Amputation required. — I have frequently seen 
 young ladies subject to this inconvenience in the 
 toe, and attribute it to the tightness of their shoes ; 
 it appears an extremely harsh measure on the part 
 of the surgeon to amputate a toe under such circura- 
 
 « 
 
484 DISLOCATIONS OF THE FINGERS AND TOES. 
 
 stances, yet it is sometimes absolutely necessary, as 
 the contraction deprives the person of exercise, and 
 of many of the enjoyments of life. In the first per- 
 son whom I saw w^ith this state of the toe \ refused 
 to amputate, fearful of tetanus being produced by 
 the operation; but the lady went to another sur- 
 geon, who complied with her request, and she did 
 very well. In consequence of the perfect recovery 
 of this lady, and the comfort which she derived 
 from the loss of the annoyance, I was induced, at 
 the request, of Mr Toulmin, of Hackney, to remove 
 one of the toes from a patient of his, which was 
 constantly irritated by the pressure of her shoe in 
 walking, and prevented her from taking the exer- 
 cise necessary to the preservation of her health; 
 she did very well, perfectly recovering the use of 
 her foot. 
 
 Contraction of fingers, 8{c. — The fingers are some- 
 times contracted in a similar manner by a chronic 
 inflammation of the thecas and aponeurosis of the 
 palm of the hand, from excessive motion of the 
 hand, in the use of the hammer, the oar, ploughing, 
 etc. etc. When the thecae are contracted, nothing 
 should be attempted for the patient's relief, as no 
 operation or other means will succeed ; but when 
 the aponeurosis is the cause of the contraction, and 
 the contracted band is narrow, it may with advantage 
 be divided by a pointed bistoury, introduced through 
 a very small wound in the integument. The finger 
 is then extended, and a splint is applied to preserve 
 it in the straight position. 
 
 Some time since, my nephew, Mr Bransby Cooper, 
 who was transacting my business during my absence 
 from town, performed this operation for a Lincoln- 
 shire farmer, who, by this impediment, had been pre- 
 vented following his avocations ; and he perfectly 
 recovered the use of his foot. 
 
DISLOCATIONS OF THE FINGERS AND TOES. 485 
 
 DISLOCATION OF THE THUMB. 
 
 These accidents are very difficult to reduce, on 
 account of the numerous strong muscles which are 
 inserted into the part. 
 
 Structure, — The thumb consists of three bones : 
 — its metacarpal bone, and two. phalanges. The 
 metacarpal bone of the thumb is articulated with 
 the OS trapezium by means of a double pulley; that 
 of the 4rapezium directing the thumb towards the 
 palm of the hand, and that of the metacarpal bone 
 direcling it laterally. The metacarpal bone is con- 
 nected with the trapezium by a capsular ligament, 
 and a very strong ligament joins the first phalanx to 
 the palmar part of the trapezium, at its lower ex- 
 tremity. The metacarpal bone forms a rounded 
 pojecting articulatory surface, upon which the hol- 
 low of the first phalanx rests, both being surround- 
 ed by a capsular ligament, arid strengthened by two 
 strong lateral ligaments. There are eight muscles 
 inserted into the thumb: two into the metacarpal 
 bone, as the extensor and flexor ossis metacarpi ; 
 two into the first phalanx, the flexor brevis pollicis^ 
 and the extensor prlmi internodli; the abductor and 
 adductor pollicis are also inserted into the first pha- 
 lanx, through the medium of the sesamoid bones; 
 the extensor secundi' internodil and flexor longus 
 pollicis are inserted into the second phalanx. Thes.e 
 muscles necessarily offer great resistance to the re- 
 duction of dislocations, and therefore those of the 
 thumb are amongst the most difficult to reduce, if 
 any considerable time be allowed to elapse before 
 the attempt be made^ 
 
486 DISLOCATIONS OF THE FINGERS AND TOES. 
 
 DISLOCATION OF THE METACARPAL BONE FROM THE 
 OS. TRAPEZIUM. 
 
 Symptoms, — In the cases which I have seen of 
 this accident, the metacarpal bone has been thrown 
 inwards, between the trapezium, and the root of 
 the metacarpal bone supporting the fore finger; it 
 forms a protuberance towards the palm of the hand; 
 the thumb is bent backwards, and cannot be brought 
 towards the little finger. Considerable pain, with 
 swelling, is produced with this accident. 
 
 Mode adopted for reduction. — For the facility of 
 reduction, as the flexor muscles are much stronger 
 than the extensors, it is best to incline the thumb 
 towards the palm of the hand during extension, and 
 thus the flexors become relaxed, and their resistance 
 diminished. The extension must be steadily, and 
 for a considerable time, supported, as no sudden vio- 
 lence will effect the reduction. If the bone cannot 
 be reduced by simple extension, it is best to leave 
 the case to the degree of recovery which nature 
 will in time produce, rather than divide the muscles, 
 or run any risk of injuring the nerves and blood- 
 vessels. 
 
 Compound luxation, — This bone is sometimes dis- 
 located by the bursting of a gun, which produces 
 compound luxation ; it can, in these cases, usually be 
 with ease returned to its natural situation : the in- 
 teguments being brought and confined over it by 
 suture, a poultice is applied ; and under common 
 circumstances, where the degree of bruise has not 
 been very considerable, a cure is perfected. Some- 
 times, however, the metacarpal bone becomes so 
 much detached from the trapezium, and the muscles 
 are so severely torn, that it is necessary to remove 
 the thumb, in which case it is best to saw off the 
 
DISLOCATIONS OF THE FINGERS AND TOES. 487 
 
 articular surface of the trapezium. Such a case 
 happened lately to a servant of Mr G rover, of 
 Hemel Hempstead ; the metacarpal bone of the 
 thumb was dislocated, and the muscles were so 
 much lacerated that it became necessary to remove 
 the thumb at the os trapezium ; but the articular 
 surface of the trapezium projected so far that the 
 integuments could not be brought over it, 1 there- 
 fore directed this surface to be sawn off, through 
 the OS trapezium ; and a poultice being applied, the 
 man recovered by the granulating process. 
 
 The following case was kindly sent me by Mr G. 
 Cooper. 
 
 Brentford, April 6^/^, 1820. 
 
 Dear Sir:~I some time since promised to send 
 you an account of a compound dislocation of the 
 thumb, which came under my care during the last 
 year; but really I have been in such a whirl of 
 engagements, that I have not until this evening had 
 leisure to look at my notes of the case. 
 
 Case, — Master Arthur Trimmer, aged thirteen 
 years, on the 2nd of February, 1819, whilst a wild 
 fire was gradually consuming, was in the act of 
 adding, from a copper flask, dry powder, of which it 
 contained about half a pound, when explosion took 
 place, and the flask bursting in his hand, caused se- 
 vere laceration of the palm, and a compound dislo- 
 cation of the thumb. The Avhole mass of muscle, 
 connecting the thumb with the hand was completely 
 torn through ; and observing the thumb lying upon 
 the carpus, dislocated from its articulation with the 
 trapezium, I was about to have removed it by a 
 scalpel, when I saw the tendon of the flexor longus 
 pollicis glisten in its sheath, uninjured, as well as the 
 tendon of the extensor longus ; I therefore put the 
 
48B DISLOCATIONS OF THE FINGERS AND T0E9. 
 
 parts in something like a natural position, and took 
 ten minutes to reflect upon the best mode of pro- 
 ceeding. The haemorrhage was great at the mo- 
 ment, but the wound being contused and lacerated, 
 it ceased on slight pressure. 
 
 Considering the thumb of the right hand to be a 
 very important part, 1 resolved, if possible, that it 
 should be preserved, assuring the friends of the 
 young gentleman, who were under great apprehen- 
 sion lest tetanus should ensue, that the probability 
 of trismus supervening, would not be increased by 
 the attempt to save the thumb. 
 
 That intelligent surgeon, Mr Brodie, having been 
 also sent for at the time of the accident, arrived in 
 about three hours, when being of opinion with my- 
 self that there was a chance that the limb might 
 be saved, I brought the parts together with three 
 ligatures, two towards the palm, and one on the 
 posterior part of the hand, put on adhesive straps, 
 allowing sufficient room for extension, and to the 
 hand and fore arm applied an evaporating lotion. 
 Gave him at bed-time a pill, containing three grains 
 of calomel and one of opium, and in the morning a 
 cathartic mixture. 
 
 February 3rd. Had a restless night, but the part 
 not very painful. 
 
 February 4th. His pulse running 120, and hard, 
 I took away about eight ounces of blood, and order- 
 ed him the effervescing mixture, paying attention to 
 the state of his bowels. Continued the antiphlogis- 
 tic plan. 
 
 February 7th. Removed the dressings and liga- 
 tures, and had the pleasure to find that considerable 
 adhesion had taken place ; that no tetantic symptoms 
 made their appearance, and that every day he suf- 
 fered less from constitutional irritation. 
 
 February 9th. Again removed the dressings. 
 
DISLOCATIONS OF THE FINGERS AND TOES. 489 
 
 wound looking healthy, and suppuration not consid- 
 erable ; I therefore continued to dress with adhesive 
 plaster, small quantities of lint, and over that a 
 bandage about an inch wide and two yards long, by 
 means of which sufficiently equable pressure could 
 be made to promote the inosculation of granulating 
 surfaces, as well as to produce a tolerable even ex- 
 ternal state of the parts during the advance of the 
 adhesive process. 
 
 From this time it was dressed every second day, 
 and on the sixteenth I began to give it passive motion, 
 at first, by simply bending the first phalanx of the 
 thumb^ so as to break down any adhesions that might 
 have taken place between the tendons and their 
 thecae. By the twenty-third 1 gave trifling motion 
 to the second phalanx, and towards the end of the 
 month the wound was healed. Through the month 
 of March I gradually increased the motion, and on 
 the first of April my little patient left Brentford on 
 a visit to the Isle of Wight, with injunctions to give 
 daily motion to the joint; and I am happy to add, he 
 now makes use of it in writing as well as ever, and 
 €rids the thumb perfectly useful for all the ordinary 
 purposes of life. 
 
 I am, dear Sir, 
 
 Most truly yours, 
 
 George Cooper. 
 
 DISLOCATION OP THE FIRST PHALANX. 
 
 Diagnostic marks of simple dislocation of the first 
 phalanx. — This accident may be either simple or 
 compound. I shall first describe the simple disloca- 
 tion. In this accident the first phalanx is thrown 
 back upon the metacarpal bone ; the lower extremi- 
 62 
 
490 DISLOCATIONS OF THE FINGERS AND TOES. 
 
 ty of the latter projects very much inward towards 
 the palm of the hand, and the extremity of the 
 phalanx projects backwards. The motion of that 
 joint is lost, but that of the thumb, through the 
 medium of the metacarpal bone and trapezium, 
 remains free ; so that, as an opponent to the fingers, 
 its power of action continues; but with respect to 
 flexion and extension, which are performed between 
 the metacarpal bone and the first phalanx, they are 
 destroyed by the dislocation. 
 
 Mode of reduction. — The extension is to be made 
 by bending the thumb towards the palm of the hand, 
 to relax the flexor muscles as much as possible; and 
 the following is the mode of applying the extending 
 force, which may be considered as the general mode 
 to be adopted in dislocations of the toes, thumb, and 
 fingers. The hand is to be first steeped in warm 
 water for a considerable time, to relax the parts as 
 much as possible ; then a piece of thin wetted leather, 
 wash-leather for instance, is to be put around the 
 first phalanx, and as closely adapted to the thumb as 
 possible ; a portion of tape, about two yards in length, 
 is then to be applied upon the surface of the leather, 
 in the knot which is called by sailors the clove hitch 
 (see Plate), {or this becomes tighter as the extension 
 proceeds. An assistant places his middle and fore 
 finger between the thumb and fore finger of the 
 patient, and makes the counter extension, whilst the 
 surgeon, assisted by others, draws the first phalanx 
 from the metacarpal bone, directing it a little inward 
 towards the palm of the hand. 
 
 The extension should be supported for a consider- 
 able length of time, and if success does not attend 
 the surgeon's efforts, it is right to adopt the follow- 
 ing plan. The leather and sailor's knot are to be 
 applied as above, and a strong worsted tape is to be 
 carried between the metacarpal bone of the thumb 
 and the fore finger; the arm is then to be bent 
 
DISLOCATIONS OF THE FINGERS AND TOES. 491 
 
 around a bed-post, and the worsted tape fixed to it; 
 a pulley is then to be hooked to the tape which sur- 
 rounds the first phalanx, and extension is to be made : 
 this mode is ahnost sure to succeed. If, however, 
 under the steadiest, best directed, and most perse- 
 vering attention, the bone be not reduced, a disap- 
 pointment w^iich will sometimes happen in disloca- 
 tions which have been neglected, then the surgeon's 
 efforts must cease ; no operation for the division of 
 parts should be made, as the patient will have a 
 very useful thumb after a time, even without re- 
 duction. 
 
 Treatment of compound dislocation of the thumb, — 
 In compound dislocations of the first phalanx of the 
 thumb, if there be much difficulty in its reduction, 
 and the wound be large, it is best to saw off the ex- 
 tremity of the bone, rather than to bruise the parts 
 by. long continued extension: they are to be healed 
 by adhesion; and if passive motion be begun early, 
 a joint will soon be formed, and a very useful mem- 
 ber remain. In this case, lint, dipped in blood, is to 
 be applied to the wound : a roller must be bound 
 round, and the part kept cool by evaporating lotions 
 for several days, until the wound be healed. 
 
 I very recently saw the following case of compound 
 dislocation of this bone. 
 
 Case, — A gentleman came to my house, whose 
 first phalanx had been thrown upon the back of the 
 metacarpal bone of the thumb by the bursting of a 
 gun. The flexor muscles and the abductor were 
 much lacerated just below the os trapezium ; the 
 extensors were not injured. I applied the tape to 
 the first phalanx, and extending, easily reduced it; 
 I then brought the edges of the integuments toge- 
 ther by suture, directing a poultice to be applied, on 
 account of the great contusion of the parts ; and 
 the recovery was very complete. 
 
492 DISLOCATIONS OF THE FINGERS AND TOES, 
 
 DISLOCATION OP THE SECOND PHALANX. 
 
 Simple, — If this be a sim|3le dislocation the best 
 mode of reducing it is, that the surgeon should grasp 
 the back of the first phalanx with his fingers, apply 
 his thumb upon the fore part of the dislocated pha- 
 lanx, and then bend it upon the first as much as he 
 possibly can. 
 
 Compound. — In compound dislocations of this 
 joint (of which I have given a plate), it is best to 
 saw off the extremity of the second phalanx, taking 
 care not to injure the tendon which is torn through; 
 for when the bone is removed, the ends of the ten- 
 don may be readily approximated, and adapted to 
 each other. The extremity of the tendon should 
 be smoothed by a knife, and the part be then bound 
 up in hnt, dipped iri blood, confined by a roller ; and 
 it should be kept quiet for a fortnight or three 
 "weeks, when passive motion may be begun^ 
 
DISLOCATION OF THE RIBS. 
 
 Authors describe different species of dislocations 
 of the ribs : their heads are said to be thrown from 
 their articulation with the vertebrge forwards upon 
 the spine. If this accident ever does occur, it is 
 certainly extremely rare, and must be very difficult 
 of detection. 
 
 Heads of ribs, — A person, by falling on his back 
 upon some pointed body, may, however, receive a 
 blow upon his ribs, by which they may be driven 
 from their articulations. 
 
 Symptoms. — Such an injury would produce the 
 usual symptoms of fracture of these bones : their 
 motions v^^ould be painful, and respiration necessarily 
 difficult. 
 
 Treatment — The treatment which would be re- 
 quired, would also be the same as that which is 
 pursued in fracture of the ribs : viz, the abstraction 
 of blood, and the application of a circular bandage : 
 the former to prevent inflammation of the pleura 
 and lungs; the latter to lessen the motion of the 
 ribs. Any attempt made to effect their reduction 
 would be entirely fruitless. 
 
494 
 
 DISLOCATION OF THE RIBS. 
 
 Cartilages, — The cartilages connecting the ribs 
 with the sternum, frequently appear to have been 
 dislocated from the extremities of the ribs, and 
 sometimes from the sternum. Mothers have sever- 
 al times brought their children to me, saying, ' My 
 child has sometime since had a fall, and see how the 
 form of its breast is altered.' The sixth, seventh, 
 and eighth cartilages of the ribs are most frequent- 
 ly the subjects of this alteration of form: and when 
 the ribs are carefully examined, it is found that their 
 natural arch is diminished, their sides flattened, and, 
 consequently, the extremities of the ribs, with their 
 cartilages, thrust forward. The appearance which 
 is thus produced is the result of constitutional weak- 
 ness, and not of the accident to which it is attributed. 
 
 Termination of cartilage ; forcibly separated^ frc. 
 — The termination of the cartilages at the sternum 
 sometimes projects from a similar cause, giving rise 
 to the same false impression upon the minds of the 
 parents, that the circumstance must have arisen from 
 accident, and not from disease. Sometimes, how- 
 ever, but very rarely, a cartilage is torn from the 
 extremity of the rib, and projects over its surface ; 
 when this happens, a similar treatment is required 
 as in fracture of the ribs. The patient is to be 
 directed to make a deep inspiration, and then the 
 projecting cartilage is to be pressed into its natural 
 situation ; a long piece of wetted pasteboard should 
 be placed in the course of three of the ribs and 
 their cartilages, the injured rib being in the centre : 
 this dries upon the chest, takes the exact form of 
 the parts, prevents motion, and affords the same 
 support as a sphnt upon a fractured limb. A flannel 
 roller is to be applied over this splint,' and a system 
 of depletion pursued, to prevent inflammation of the 
 thoracic viscera. 
 
INJURIES OF THE SPINE. 
 
 Dislocations very rare It has been generally 
 
 stated by surgeons that dislocations of the spinal 
 column frequently occur; but if luxation of the spine 
 ever does happen, it is extremely rare; as in the 
 numerous instances which I have seen of violence 
 done to the spine, I have never witnessed a separa- 
 tion of one vertebra from another through the in- 
 tervertebral substance, without fracture of the ar- 
 ticular processes; or, if those processes remain un- 
 broken, without a fracture through the bodies of the 
 vertebrae. Still I would not be understood to deny 
 the possibility of dislocation of the cervical verte- 
 brae, as their arliculatory processes are placed more 
 obliquely than those of the other vertebrae. I must, 
 however, observe, that from the vicinity of our hos- 
 pitals to the river, sailors are often brought into 
 them with injuries of the spine, by falls from the 
 yard-arm to the deck ; and as there is almost always 
 an opportunity of inspection in these cases, a dislo- 
 cation must be very unusual,, since I have never met 
 with a single instance of it, those injuries having all 
 proved to be fractures with displacement. 
 
496 
 
 INJURIES OF THE SPINE. 
 
 I am well aware that respectable surgeons have 
 described dislocations as- occurring in tlie cervical 
 vertebrae, but I wish to state my own experience, 
 with no further reference to that of others. 
 
 The following short account of the structure of 
 the spine, is given merely to revive the ideas which 
 may have faded from the memory. 
 
 Structure; bones. — The spinal column is composed 
 of twenty-four vertebrae, which are divided into 
 three classes; namely, the cervical, dorsal, and the 
 lumbar; they are very strongly connected by four 
 articular processes, and are firmly joined by an elas- 
 tic substance, which proceeds from the broad surface 
 of the body of one vertebra to that of the other. 
 The spinous processes of many of the vertebrae, 
 and particularly those nearest to the centre of the 
 column are locked together, one being admitted into 
 a depression of the other. 
 
 Invertebral substance ; ligaments, S^c, — The bodies 
 of the vertebrae are united by a ligamento cartilagi- 
 nous substance, extremely elastic, and composed of 
 concentric lamellae, connected by oblique fibres, 
 which decussate each other, but in the centre be- 
 come mucous, so as to form a pivot, which supports 
 the central line of the vertebrae ; whilst the elasti- 
 city and compressibility of the outer edge of this 
 uniting medium, allows the vertebrae to move upon 
 this centre in all directions. The column is also 
 farther connected by an anterior spinal ligamejit, 
 which proceeds from the second vertebrae of the 
 neck to the sacrum, and is united to all the bodies 
 of the vertebrae, excepting the first. There is also 
 a posterior spinal ligament, situated within the canal 
 of the spinal column, and proceeding from the se- 
 cond vertebra ; but it is also intermixed with the 
 perpendicular ligament ; and descending to the sa- 
 crum, it sends out lateral processes to the superior 
 
INJURIES OF THE SPINE. 
 
 491 
 
 and inferior edges of the bodies of the vertebrae. 
 Intervertebral ligaments also pass in a crucial direc- 
 tion from vertebra to vertebra. The articular pro- 
 cesses are united by capsular ligaments, and the 
 transverse processes have ligaments passing from 
 the one to the other. Between the arches of the 
 roots of the spinous processes is placed an elastic 
 ligament, called the ligamentum subjlamm^ which al- 
 lows of considerable separation of the spinous pro- 
 cesses; and, by its elasticity, approximates them, 
 rendering muscular support for the erect position of 
 the body less necessary. The vertebrse of the neck 
 are united at their spinous processes by an elastic 
 ligamentous substance, which is termed the ligamen- 
 tum nuchcB. 
 
 Capsular. — The head is connected to the spinal 
 column by capsular ligaments, enclosing the condyles 
 of the OS occipitis and the articular processes of the 
 atlas, or the first vertebra. 
 
 Circular. — circular ligament proceeds from the 
 foramen magnum to the edge of the aperture of 
 the first vertebra. 
 
 Perpendicular, — ^ perpendicular ligament passes 
 from the anterior part of the foramen magnum 
 to the dentiform process of the second vertebra. 
 
 Lateral. — Lateral ligaments proceed from the 
 edge of the foramen magnum and first vertebra on 
 each side, and are united to the dentiform process 
 of the second vertebra : these ligaments limit the 
 lateral motions of the head. 
 
 Transverse. — The first vertebra of the neck is 
 united to the second by means of a transverse liga- 
 ment, which is also fixed to the first vertebra on 
 each side, and passes behind the dentifofm process 
 of the second vertebra. 
 
 The spinal column, from the two important pur- 
 poses which it serves, namely, that of supporting 
 
 63 
 
498 
 
 INJURIES OP THE SPINE. 
 
 the head and all that part of the body situated 
 above the pelvis, and also from its containing and 
 protecting the spinal marrow, upon which the voli- 
 tion and sensation of the extremities depend, is, by 
 the number of its bones, the strength of its joints, 
 and its connexion with the bones of the chest, most 
 carefully protected from external injury. 
 
 Effects of injuries, — The etfects which are pro- 
 duced by violence done to the spinal cord are very 
 similar to those which are produced by injuries to 
 the brain; for example: — 
 
 Concussion, 
 
 Extravasation, 
 
 Fracture, 
 
 Fracture with depression, 
 Suppuration and ulceration. 
 
 CONCUSSION OF THE SPINAL MARROW- 
 
 Concussion, — When a person receives a very se- 
 vere blow upon the spine, or, from any great force, 
 has it very suddenly bent, a paralysis of the parts 
 beneath will frequently succeed, in a degree propor- 
 tionable to the violence of the injury ; but after such 
 an effect, the person, in general, gradually recovers 
 the motion and sensation of the parts. 
 
 Case, — A man was admitted into Guy's Hospital 
 under the care of Dr Curry, who had received a 
 severe blow from a piece of wood, which, falling 
 upon his loins, knocked him down ; and as he came 
 to the hospital on the regular day of admission, and 
 not immediately after he had received the injury, 
 he was placed amongst the physicians' patients. 
 His lower extremities were in a great degree de- 
 prived of motion, and their sensibility was much 
 
INJURIES OF THE SPINE. 
 
 499 
 
 diminished. Wh'en resting upon his back in bed he 
 could slightly draw up his legs, but could not bend 
 them to a right angle with the thigh ; and a con- 
 siderable time elapsed before he could make the 
 muscles of the lower extremities obey the effort of 
 his will. As there was still the appearance of se- 
 vere contusion and much deep seated tenderness in 
 the situation of the blow upon the loins, Dr Curry 
 ordered blood to be repeatedly drawn away by cup- 
 ping, and the bowels to be acted upon by calomel; 
 and when the pain and tenderness, in consequence 
 of the contusion, had been removed, a blister was 
 applied to the loins, and a discharge supported for 
 three weeks by the application of the unguentum 
 sabinae. The liniment ammonias was ordered to be 
 daily rubbed upon the lower extremities. In six 
 weeks the motion and sensation of his legs had almost 
 entirely returned, and he was then directed to be 
 submitted to the influence of electricity. By this 
 treatment, in ten weeks he completely recovered. 
 
 I lately attended a gentleman, who, by a fall from 
 his gig, had received a severe blow upon his loins, 
 and who had, at first, great difficulty in discharging 
 both his urine and fasces ; but he was relieved by 
 fomentation and cupping. 
 
 EXTRAVASATION IN THE SPINAL CANAL. 
 
 Extravasation ; spinal morrow examined in dissec^ 
 tion. — A very severe blow upon the vertebrae will 
 sometimes produce extravasation upon the spinal 
 chord, but more frequently upon the sheath upon 
 which it is contained. Of late years it has been our 
 custom, in examining dead bodies, to saw off the 
 spinous processes of the vertebrae, the more accu- 
 
500 
 
 INJURIES OF THE SPINE. 
 
 rately to examine the spinal marrow ; and under 
 such circumstances, in cases of severe injury, blood 
 has been several times found on the outer side of 
 the spinal sheath ; and, in one instance, it occurred 
 upon the spinal marrow, just above thecauda equina. 
 
 The case which best illustrates this subject is one 
 which I visited with Dr Baillie, and Mr Heaviside, 
 and the particulars of which I have obtained from 
 Mr Heaviside, whom 1 have ever found ready to 
 make his beautiful anatomical collection useful to 
 the profession. 
 
 Case. — Master — , a fine youth, aged twelve 
 
 years, in June, 1814, was swinging in a heavy wooden 
 swing, and in just commencing the motion forward, 
 was caught by a line which had got under his chin, 
 by which accident his bead and the whole of the 
 cervical vertebra} were violently strained ; as, how- 
 ever, the line slipt immediately off, he thought no 
 more of it. Subsequently to the accident, for some 
 months, he was not aware of any pain or inconve- 
 nience, but his school-fellows observed that he was 
 less active than usual : instead of filling up his time 
 by play, he would be lying on the school forms, or 
 leaning on a stile or gate when in the fields. They 
 were always teasing him on this account; and at 
 last he was persuaded that he was weaker than he 
 used to be. From this time he continued to decline 
 both in strengtli and power. About the middle of 
 May following he came to London. His complaints 
 were occasional pains in the head, which were more 
 severe and frequent about the back of his neck 
 (where a blister had been applied without relief) 
 and down his back. The muscles at the back of 
 the head and neck were stiff, indurated, and very 
 tender to external pressure. He felt pain in moving 
 his head or neck in any direction : added to these 
 
INJURIES OF THE SPINE. 
 
 501 
 
 symptoms, there was a great deficiency in the volun- 
 tary powers of motion, especially in the limbs. 
 
 May 18th. Two setons were made in the neck, 
 and he was ordered various medicines, none of which 
 proved useful. 
 
 May 29th. His complaints and the paralytic 
 affection of his limbs were getting much worse, added 
 to which he felt a most vehement hot burning pain 
 in the small of his back. This, by the next day, 
 was succeeded by a sense of extrenje coldness in the 
 same part. Some time after, the same pain occur- 
 red higher up in the back, and then disappeared. 
 Pulse and heat natural. 
 
 June 3d. A consultation of Dr Baillie, Dr Pem- 
 berton, Mr A. Cooper and Mr Heaviside was held, 
 and the application of mercury was determined on. 
 The pil. hydr. was taken for a few days; but, as it 
 ran off by the bowels, mercurial frictions were con- 
 sequently preferred. He felt his limbs getting every 
 day weaker, but his neck was more free from pain 
 when moved, and he was more capable of moving 
 it by his own natural efforts. 
 
 June 7th. His respiration became laborious ; he 
 passed a bad night ; on the following day all his 
 symptoms increased, and at five in the afternoon he 
 expired. 
 
 Examination. 
 Dissection. — The whole contents of the head were 
 carefully examined and found perfectly healthy; but 
 upon sawing out the posterior parts of the cervical 
 vertebree, the theca vertebralis was found over- 
 flowed with blood, which was effused between the 
 theca and the enclosing canals of bone. The dis- 
 section being farther prosecuted, this effusion ex- 
 tended from the first vertebra of the neck to the 
 second vertebra of the back, both included. 
 
502 
 
 INJURIES OP THE SPINE. 
 
 The preparation only shows a small proportion of 
 the effused blood which had become coagulated on 
 the theca, because much of it, being fluid, escaped 
 in the act of removal. 
 
 FRACTURE OF THE SPINE. 
 
 Produce symptoms of irritation on pressure, — These 
 accidents, even when the bones retain their situation, 
 produce, by admitting unnatural variations in the 
 positions of the spinal column, very extraordinary 
 symptoms, and sometimes sudden death. Mr Else, 
 who preceded Mr Cline as teacher of anatomy at 
 St Thomas's Hospital, used to mention the following 
 case in his lectures. 
 
 Case. — A woman, who was in the venereal ward 
 at St Thomas's Hospital, and who was then under a 
 mercurial course, while sitting in bed, eating her 
 dinner, was observed to fall suddenly forward; and 
 the patients hastening to her, found that she was 
 dead. Upon examination of her body, the dentiform 
 process of the second vertebra had been broken off : 
 the head, in falling forwards, had forced the root of 
 the process back upon the spinal marrow, which occa- 
 sioned her instant dissolution. 
 
 At the time I lived with Mr Cline, as his appren- 
 tice, the following case occurred in his practice. 
 
 Case ; fracture of the atlas. — A boy, about three 
 years of age, from a severe fall, injured his neck ; 
 and the following symptoms succeeding the accident, 
 Mr Cline was consulted. 
 
 Symptoms. — He was obliged to walk carefully up- 
 right, as persons do when carrying a weight on the 
 head ; and when he wished to examine any object 
 beneath him, he supported his chin upon his hands 
 
INJURIES OF THE SPINE. 
 
 503 
 
 and gradually lowered his head, (o enable him to 
 direct his eyes downwards ; but if the object was 
 above him, he placed both his hands upon the back 
 of his head, and very gradually raised it until his 
 eyes caught the point he wished to see. 
 
 If, in playing with other children, they ran against 
 him, it produced a shock which caused great pain, 
 and he was obliged to support his chin with his 
 hand, and to go immediately to a table, upon which 
 he placed his elbows, and thus supporting his head 
 he remained a considerable time, until the effects of 
 concussion had ceased. He died about twelve months 
 after the accident; and upon the inspection of his 
 body, which was conducted by Mr Cline, the first 
 vertebra of the neck was found broken across, so 
 that the dentiform process of the second vertebra 
 had so far lost its support, that under different incli- 
 nations of the head, it required great care to prevent 
 the spinal marrow from being compressed by it; and 
 as the patient could not depend upon the action of 
 the muscles of the neck, he therefore used his hands 
 to support the head during different motions and 
 positions. 
 
 Spinous process, — Portions of the spinous process- 
 es are sometimes broken off, but these accidents do 
 not usually affect the spinal marrow, unless when 
 attended with considerable concussion. Mr Ashton 
 Key, in dissecting a subject at St Thomas's Hospi- 
 tal, found a spinous process loose, which he kindly 
 brought to me, with the following account : ' The 
 fractured vertebra was the third dorsal ; the cause 
 of the accident I could not ascertain, as it occurred 
 iri a subject brought into the dissecting-room. There 
 was a complete articulation formed between the 
 broken surfaces, which had become covered with a 
 thin layer of cartilage. The synovial membrane 
 and capsular ligaments resembled those of other 
 
504 
 
 INJURIES OF THE SPINE. 
 
 joints, excepting that the former was more vascular. 
 The fluid within the joint had the hibricating feel 
 characterizing synovia.' 
 
 Case. — A boy was admitted into Guy's Hospital, 
 who had been endeavouring to support a heavy 
 wheel, by putting his head between the spokes, and 
 receiving its weight upon his shoulders. The wheel 
 overbalanced him, and he fell, bent double. When 
 he was brought into Guy's Hospital, although he 
 had been perfectly straight before, he had the ap- 
 pearance of one who had long suffered from distort- 
 ed spine, yet this injury had not produced paralysis 
 of the lower extremities. Three or four of the 
 spinous processes had been broken off, and the mus- 
 cles torn on one side, so as to give an obliquity to 
 the situations of the fractured portions. The boy 
 quickly recovered without any particular attention, 
 and was discharged with the free use of his body 
 and limbs, but he still remained deformed. 
 
 FRACTURES OF THE BODIES OF THE VERTEBRAE, WITH 
 DISPLACEMENT. 
 
 Displacement of the vertehrce. — These fractures 
 frequently come under our observation, producing 
 displacement of the vertebrae. As the syojptoms 
 and result of the accident differ according- to the 
 situation of the fractured bones, these injuries may 
 be divided into two classes; firsts those which occur 
 above the third cervicle vertebra; and, secondly^ 
 those which occur below that bone. 
 
 These accidents fatal, — In the first class, the ac- 
 cident is almost always immediately fatal, if the dis- 
 placement be to the usual extent. Death, in the 
 
INJURIES OF THE SPINE. 
 
 505 
 
 second class, occurs at various periods after the inju- 
 ry. The origin of the phrenic nerve, from the third 
 and fourth cervical pair, is the reason of this differ- 
 ence ; for as the parts below are paralyzed by the 
 pressure upon the spinal chord, if the accident be 
 below the fourth cervical vertebra, the phrenic 
 nerve retains its functions, and the diaphragm sup- 
 ports respiration; but if, on the contrary, the frac- 
 ture be situated above the origin of this nerve, death 
 immediately ensues. It is true, that a small filament 
 of the second cervical nerve contributes to the Ibr- 
 mation of the phrenic, but is in itself insufficient to 
 support respiration under fracture of the third 
 vertebra. 
 
 Displacement below the phrenic nerve, 8^c, — The 
 effects which arise from fracture and displacement 
 of the spine, below the origin of the phrenic nerve, 
 depend upon the proximity of the accident to the 
 head. If the lumbar vertebrae be displaced, the 
 lower extremities are rendered so completely insen- 
 sible, that no injury inflicted upon them can be per- 
 ceived by the patient. Pinching, burning with caus- 
 tic, or the application of a blister, are alike unfell. 
 The power of volition is completely destroyed, not 
 the smallest influence over the muscles remaining. 
 The sphincter ani loses its power of resistance to the 
 peristaltic motion of the intestines, and the faeces 
 pass off involuntarily. The bladder is no longer able 
 to contract, and the urine is retained until drawn off 
 by a catheter, and yet the involuntary powers of the 
 limbs remain nearly the same as before. The circu- 
 lation proceeds, although perhaps somewhat more 
 languidly, but sufficiently to preserve their heat; and 
 local inflammation can be excited in them. A blister 
 applied upon the inner side of the thigh or leg, of 
 which the patient is wholly unconscious, will still in- 
 flame, vesicate, and heal ; showing that the involun- 
 tary functions may proceed in parts which are cut 
 
 64 
 
506 
 
 INJURIES OF THE SPINE. 
 
 off from their connexion with the brain and spinal 
 marrow.* The penis, under these circumstances, is 
 generally erect. Patients die from this injury at 
 various periods, according to the degree of displace- 
 ment of the vertebrae. In general, in fractures of 
 the lumbar vertebrae, the patient dies within the 
 space of a month or six weeks after the injury; and 
 usually for some time before death, the urine passes 
 off involuntarily, from extreme debility. I remem- 
 ber a patient of Mr Birch, in St Thomas's Hospital, 
 who lived more than two years after this accident, 
 and then died of gangrene of the nates. 
 
 Displacement of the dorsal vertebrce, — in fractures 
 and displacement of the dorsal vertebrae, the symp- 
 toms are very similar to those described in fractures 
 of the lumbar ; but the paralysis extends higher, 
 and the abdomen becomes excessively inflated. I 
 remember one of our pupils saying, when a patient 
 was brought into Guy's Hospital who had suffered 
 from injury to the dorsal vertebrae, * Surely this man 
 has ruptured his intestines, for observe how his ab- 
 domen is distended.' But the first faecal evacuation 
 relieved this state, and proved that it had merely 
 arisen from excessive flatulency. This symptom 
 proceeds from diminished nervous influence in the 
 intestines ;t for although their peristaltic motion can 
 proceed independently of the brain and spinal mar- 
 row, yet it is quite certain that the involuntary func- 
 tions of the intestines, like those of the heart, can 
 be influenced by the brain and spinal marrow ; for 
 we see even states of the mind producing affections 
 
 * 1 have always thought that although sensation and volition 
 depend upon the brain, the spinal marrow, and the nerves, yet 
 the involuntary functions depend principally upon the nerves. — 
 A. C. 
 
 t Preceding dissolution, in almost all diseases, a great evolu- 
 tion of air into the intestines is observed, and from the same 
 cause. — A. C, 
 
INJURIES OF THE SPINE. 
 
 507 
 
 of the intestines ; one state rendering them torpid, 
 and another irritable ; as we see the heart leaping 
 with joy, and depressed by disappointment. We 
 also observe pressure on the brain rendering the 
 intestines very difficult of excitement, even through 
 the influence of the strongest aperients. From dis- 
 placement of the dorsal vertebrae, death sooner suc- 
 ceeds than in similar injuries to the lumbar, the 
 patient usually surviving the accident not more than 
 a fortnight or three weeks ; but still I knew a case 
 of a gentleman in the city, who met with this acci- 
 dent, and who lived rather more than nine months. 
 The period of existence is short or protracted, as 
 the injury is near or distant from the cervical verte- 
 brae, and as the displacement is slight or considerable ; 
 it depends also upon the degree of injury which the 
 spinal marrow has sustained. 
 
 Fractures of the cervical vertebrce, — Fractures of 
 the cervical vertebrae, below the origin of the 
 phrenic nerve, produce paralysis of the arms, as well 
 as of the lower parts of the body ; but this paraly- 
 sis is seldom complete. If it occurs at the sixth or 
 seventh vertebra, the patient has some feeling and 
 powers of motion ; but if at the fifth, little or none. 
 Sometimes one arm is much more afiected than the 
 other, when the fracture is oblique, and the axillary 
 plexus of nerves is, in consequence, partially influ- 
 enced. Respiration, in these cases, is difficult, and 
 is performed wholly by the diaphragm, the power 
 of the intercostal muscles being destroyed by the 
 accident. The abdomen is also tumid from flatulen- 
 cy, as when the dorsal vertebrae have sustained in- 
 jury. The other symptoms, in regard to the lower 
 extremities, the bladder, and the sphincter ani, are 
 the same as in fractures of the vertebrae below the 
 cervical. Death ensues in these cases in from three 
 to seven days, as the disease happens to be seated 
 
508 
 
 INJURIES OP THE SPINE. 
 
 in the fifth, sixth, or seventh vertebra. I have 
 scarcely known the subject of this injury to live 
 beyond a week, and but rarely to die on the second 
 day, although they sometimes die so early, if the 
 fifth cervical vertebra has sustained the injury. I 
 have already stated, that in fractures and displace- 
 ments above the fourth cervical vertebra, death al- 
 most instantaneously follows. The longest life I 
 have known after such an accident has been ten 
 months. 
 
 Dissection. — In the dissection of these cases the 
 following appearances are found : the spinous pro- 
 cess of the displaced vertebra is depressed ; the 
 articular processes are fractured ; the body of the 
 vertebra is broken throiigh ; for it but rarely hap- 
 pens that the separation and displacement occur at 
 the intervertebral substance. The body of the 
 vertebra is usually advanced from half an inch to an 
 inch. Between the vertebrne and the sheath of the 
 spinal marrow, blood is extravasated ; and frequently 
 there is extravasation of blood on the spinal chord 
 itself. The spinal marrow is compressed and bruis- 
 ed in slight displacements, and is torn through when 
 the injury has been very extensive ; but the dura 
 mater remains whole. A bulb is formed at each 
 end of the lacerated spinal marrow, which lacera- 
 tion is usually produced by the bony arch of the 
 spinous process. 
 
 A most interesting case of this accident has been 
 published by Mr Harrold, an intelligent surgeon at 
 Cheshunt ; and a preparation made from the case is 
 preserved in the Museum at the Royal College of 
 Surgeons. 
 
 The outline of the case is as follows : 
 
 Case, — A man, twenty-eight years of age, was 
 
INJURIES OF THE SPINE. 
 
 509 
 
 knocked down by a quantity of chalk, which, falling 
 upon him, broke his spine at tlie lower part of the 
 dorsal, or the beginning of the lumbar vertebra. 
 
 The principle upon which Mr Harrold proceeded 
 Avas, to produce union of the bones, by preserving 
 the spine perfectly at rest ; and to effect this object 
 the patient was placed in a fracture-bed, which per- 
 mitted him to evacuate his bowels without disturb- 
 ance. The urine was drawn off daily by the cathe- 
 ter for several weeks; after which time he was 
 able to retain from a pint to a pint and a half, and 
 to discharge it when he pleased. A wound was 
 produced upon the sacrum, from the constant press- 
 ure of his body upon the bed ; and although he was 
 insensible of it, the sore gradually healed. 
 
 Symptoms. — At the end of six months his state 
 was as follows : His back was straight, flexible, and 
 apparently as strong as ever. He retained and 
 passed his urine, but probably he discharged it more 
 by the action of the abdominal muscles than by any 
 contraction of the bladder. He had a stool once 
 ip three or four days. His health and spirits were 
 good, but he had neither sensation nor volition in the 
 lower extremities. He dressed himself entirely; he 
 let himself down stairs step by step. He died after 
 the lapse of twelve months, wanting nine days, from 
 the accident, owing to a sore on the tuberosity of 
 the ischium, and to disease of the bone. 
 
 Emmination. — I carefully examined the prepara- 
 tion, which is preserved in the Museum of the Col- 
 lege, and found the following circumstances: 
 
 The bodies of the first and second lumbar verte- 
 brae had been fractured; the first had advanced, and 
 the second had been forced backwards. 
 
 The fracture had united by ossific matter, which 
 had been spread over the fore part of both verte- 
 
510 
 
 INJURIES OP THE SPINE. 
 
 brae to a considerable extent, and a little had been 
 deposited upon the dorsal vertebrae. 
 
 The spinal canal had been much diminished by a 
 portion of bone forced into it from the first vertebra 
 of the loins ; this portion of bone had split the theca 
 vertebralis into two, and divided the spinal marrow 
 almost entirely ; a bulbous projection of the spinal 
 marrow appeared above and below the bone, formed 
 by its divided extremities, which were separated 
 nearly an inch from each other. 
 
 Formation of ossific matter, — Mr Brookes also 
 had a preparation in his late excellent anatomical 
 collection, of fracture of the spine at the seventh 
 and eighth dorsal vertebra?. The person had lived 
 sufficiently long for a great deposit of ossific matter 
 to have formed upon the anterior and lateral part of 
 the fractured vertebi'se. The spinal marrow was 
 almost entirely torn through, but the spinal sheath 
 remained. Mr Brookes could not learn how long 
 the person had survived the accident. j- 
 
 As to the treatment of these cases, I fear that 
 whatever maj be done, the majority of them will 
 prove fatal. 
 
 To bring the spine into its natural form by exten- 
 sion would be impossible, if it were attempted; and 
 even if that object were attained, it would scarcely 
 be practicable to preserve it in its situation, as the 
 least motion would again displace it. Rest will be 
 essential to ossific union; but ossific union will not 
 save the patient if the pressure upon the spinal 
 marrow be not removed. 
 
 Operation by Mr H. Cline. — Mr Henry Cline was 
 the only person who took a scientific view of this ac- 
 cident. He considered it to be similar to fracture 
 with depression of the cranium, and to require that 
 
INJURIES OF THE SPINE. 
 
 511 
 
 the pressure should be removed ; and as the cases 
 had proved so uniformly fatal, he thought himself 
 justified in stepping out of the usual course, with 
 the hope of preserving life. He made an incision 
 upon the depressed bone, as the patient was Ijing 
 upon his breast, raised the muscles covering the spi- 
 nal arch, applied a small trephine to the arch, and 
 cut it through on each side, so as to remove the spi- 
 nous process and the arch of bone which pressed 
 upon the spinal marrow. The only case in wdiich 
 he tried it did not succeed ; and unfortunately he 
 did not live to bring his opinion sufficiently to the 
 test of experiment, to warrant a decided judgment. 
 He was blamed for making this trial. I am not 
 sure that he would have been ultimately successful; 
 but in a case otherwise without hope, I am certain 
 that such an attempt was laudable.* 
 
 In those cases in which the first and second cervi- 
 cal vertebrae have been broken and displaced, death, 
 from obstructed respiration, is too sudden to allow 
 time for any surgical relief. 
 
 INFLAMMATION AND ULCERATION OF THE SPINAL 
 MARROW. 
 
 The only one which I could determine to be of 
 this nature by dissection was the following: — 
 
 Case, — A gentleman who resided about eight 
 miles from London, had, by a fall, received a severe 
 blow upon his spine ; but as it produced no immedi- 
 
 * I beg the reader to observe that this operation is not mine ; 
 that I have expressed some doubts of its ultimate success ; but 
 I wish the trial to be made, as the only means of deciding posi- 
 tively on its utility ; and if it saves only one life in an hundred, 
 it is more than I have yet seen accomplished by surgery. — A.C. 
 
512 
 
 INJURIES OP THE SPINE. 
 
 ate ill effect, he thought very lightly of it. Ingoing 
 down to his country house he was exposed to the in- 
 clemencies of the weather, and he was on a sudden 
 seized with pain in his hack, and paralysis of the 
 lower extremities, retention of urine, and an involun- 
 tary discharge of fasces. I was requested to see him 
 on account of the retention of urine, and went daily 
 for a length of time to Wimbledon Common, >vhere 
 he resided, to make use of the catheter. For sever- 
 al weeks his symptoms remained unchanged, except- 
 ing that now and then the integuments of the sacrum 
 gave way, and required great attention to prevent a 
 dangerous sore. Towards the close of his existence 
 he complained of a sense of uneasiness and disten- 
 tion at the upper part of his abdomen. His appe- 
 tite failed him ; he rejected his food, and had a great 
 deal of fever, with quick pulse and profuse perspira- 
 tion. He sunk gradually, worn out by irritation. 
 
 I removed the spinal marrow, and have it preserv- 
 ed in the collection at St Thomas's Hospital. Upon 
 opening the spinal sheath, a milky fluid was found 
 within it, just above the cauda equina; and higher 
 than this, for the space of three inches, the spinal 
 marrow^ was ulcerated to a considerable depth, and 
 was in the softened state which the brain assumes 
 when it is rendered semi-fluid by putrefaction. All 
 the other parts of the body were healthy, excepting 
 the bladder, which was considerably inflamed, and 
 exceedingly extended by the long continued reten- 
 tion of the urine. 
 
 In a case similar to this, it will be necessary to 
 make use of precautions to prevent inflammation, 
 by cupping or by leeches. Blisters should be applied ; 
 and if the fever still continues, a seton should be 
 made, or issues be opened, to prevent the continu- 
 ance of inflammation, by producing and supporting 
 external irritation. 
 
f 
 
 NOTES. 
 
 Fracture and displacement of the vertebrae. — We have been 
 enabled by the politeness of Dr J. R. Barton, to give an ac- 
 count of his operation on the Spine. 
 
 His views relative to this operation are very ingenious and 
 deserving of consideration. His object in cutting down to the 
 vertebras is not the mere elevation or removal of a depressed 
 or fractured portion of the bone, but the excision of as many of 
 the spinous processes as are exterior to the angle formed by the 
 dislocation of the vertebras. This he thinks will allow the spi- 
 nal marrow to curve outwards so as to free it fi cm pressure, 
 and also allow matter or effused blood to be readily discharged. 
 
 J. P. was received into the Pennsylvania Hospital, Aug. 18, 
 1824, with a fracture of the spine, caused by a fall from the 
 mast head of a brig. The lower part of the trunk, and the in- 
 ferior extremities were totally paralysed. He continued in this 
 state discharging his faeces and urine involuntarily until the 
 30th of Aug , when Dr Barton performed the following opera- 
 tion. An incision was made about eight inches in length im- 
 mediately over the injured vertebrae. He found the spinous 
 process and arched portion of the seventh dorsal broken off and 
 depressed on the spinal marrow. When this was done it was 
 ascertained that the bodies of the 7th and 8th dorsal vertebrse 
 were dislocated from each other, without any fracture but that 
 above mentioned. Lint was laid over the wound. The para- 
 lysis not being immediately relieved, it was inferred that com- 
 pression was kept up by blood effused within the spinal canal, 
 which would possibly escape with the suppuration from the 
 wound. 
 
 About forty-eight hours from the time of operation sensi- 
 bility began to return below the injured vertebrae, and gradu- 
 ally extended towards the toes until the third day, when he was 
 attacked with a violent chill, which continued notwithstanding 
 65 
 
514 
 
 NOTES. 
 
 all the stimulating medicines given, until his death, which.oc- 
 curred in twelve hours from its commencement. 
 
 An examination was made next day to ascertain the real state 
 of the spinal column. On opening the thorax, the posterior 
 mediastinum was found filled by about half a gallon of coagula- 
 ted blood, which accounts for the difficulty of respiration espe- 
 cially when he lay on his back. This being cleared away, the 
 condition of the vertebral column was seen. The 7th and 8lh 
 dorsal were injured as before stated, the body of the 9th was 
 fractured, and blood was effused throughout the spinal canal. 
 
 Fractures not united — Where the extremities of fractured 
 bones have not been brought into proper apposition, have been 
 frequently moved, or the constitution of the patient is very deli- 
 cate, we find after the lapse of a very considerable time, no 
 bony union formed. Instead of this there is a ligamentous 
 substance joining the pieces of bone to each other, yet as 
 this allows of motion, the usefulness of the limb is almost en- 
 tirely lost. This is a circumstance attended with much diffi- 
 culty, and frequently is considered beyond the reach of surgery. 
 The method adopted to induce a renewal of the ossific action, 
 is by making an irritation directly on the fractured portions. 
 This has sometimes been done by rubbing them together with 
 considerable violence, sometimes by cutting down and sawing 
 off the ends of the bone. The passage of a seton through the 
 limb, between the ends of the fracture, has been very successful 
 in the hands of Dr Physick and others. Dr J. R. Barton, 
 lately informed me of a case in which he had succeeded per- 
 fectly in restoring the limb of a gentleman whose tibia had been 
 broken and not united by bone. He applied caustic alkali di- 
 rectly over the ligamentous union and continued it until this 
 substance was destroyed. The ossific action immediately en- 
 sued and the limb became as useful as before the Fracture. 1 
 have recently dissected the arm of a very robust black man who 
 died very suddenly. At about two inches below the wrist there 
 was a tumor of considerable size, that, from its hardness, and 
 general appearance, was supposed to be an irregular callus, 
 formed where there had been a fracture. The skin was not 
 diseased, nor were the extensors of the thumb which crossed 
 the tumor. But when the extensors were removed, and the 
 tendons of the longer and shorter radial extensors of the car- 
 pus and supinator longus were removed, a number of black 
 holes were seen passing into the bony tumor of the radius, 
 and containing a quantity of thick and foul black matter. 
 The periosteum surrounding was thickened and in some places 
 sloughy. The radius had been obliquely fractured, the inju- 
 ry beginning at an inch and a half below the carpal extremity 
 of the radius, and crossing the radius obliquely, so as to ter- 
 
NOTES. 
 
 515 
 
 minate about two inches and a half below, on the inner side, 
 and a free motion was allowed, as the extremities were merely 
 united by ligament. 
 
 This injury I suppose was, during the life of the patient, 
 mistaken for a sprain or some not very serious mischief; in 
 consequence of which the limb was frequently moved, and the 
 ossific union prevented: otherwise, in a system appearing so 
 robust and healthy, a fracture, properly treated, would have 
 been solidly united in a short time. J. D. G. 
 
 ON THE FORMATION OF THE CAPSULAR LIGAMENTS 
 OF THE JOINTS. 
 
 Anatomists hitherto have uniformly cosidered the capsular 
 and proper ligaments of the joints as similar in character, and, 
 like the latter, being merely continued from a point of origin 
 on the extremity of one bone to an insertion near the extremi- 
 ty of another. By the proper ligaments 1 mean those which 
 are solid, fibrous and mostly perpendicular, resembling the 
 lateral ligaments of the knee joint and those from the fibula 
 and tibia to the tarsal bones. 
 
 The capsular ligaments, however, must be separated from 
 the proper ligaments, inasmuch as they are immediately re- 
 lated to the muscular system, being formed by the layers of 
 the fasciae which sheathe all the muscles, or fairly encircle 
 them. 
 
 The muscles of the upper part of the body and all the 
 trunkj not excepting the heart, are contained within duplica- 
 tures of the fascia superficialis. The same fascia forms the 
 capsular ligament of the shoulder joint, by the succession of 
 the layers forming the sheaths for all the muscles about the 
 scapula going to be laid out over the joint, and by their aggre- 
 gation constituting the thickness of this capsule. 
 
 The fascia lata femoris sheathes all the muscles of the in- 
 ferior extremities, and the duplicatures, enclosing the mus- 
 cles of the thigh, form the great capsule of the hip joint, 
 as minutely described in my Anatomical Investigations re- 
 cently published. On the same principle the capsular liga- 
 ments throughout the body appear to be formed from the 
 fasciae sheathing the muscles. For the details I must refer 
 to the work above named, and the 18th No. of the Philadel- 
 phia Medical and Physical Journal, in which the details of the 
 
 4 
 
516 
 
 NOTES. 
 
 formation of the capsular ligament of the shoulder joint will 
 be given. 
 
 The muscles within the belly and pelvis derive their sheaths 
 from the fascia interna abdominis, heretofore called fascia 
 transversalis^ which also forms the ligaments of the liver, and 
 bladder, the prostrate fascia, &c. 
 
 Some persons in speaking of the fascia sttperfcialis state 
 that it is composed of condensed cellular membrane. This is 
 correct as applied to its ultimate analysis, but not when we ex- 
 amine it in the recent subject. It is equally true that skin, ten- 
 don and bone, are composed of cellular texture, but we only 
 arrive at this conclusion by a long and careful series of expe- 
 riments. 
 
 The discovery of the formation of the capsular ligaments 
 by a thorough analysis of the fasciae, leads to a variety of im- 
 portant conclusions relative to their physiology and pathology, 
 and gives us a better idea of their relation to the strength of 
 the muscles, whose actions are all moditied by the manner in 
 which they are sheathed by these fasciae. See 18th No. of 
 Philadelphia Medical Journal. 
 
 Diagnosis of Fractures. — M Lisfranc has proposed the use 
 of the stethoscope for determining the presence of fractures, 
 which will be attended with considerable advantage: especi- 
 ally in such cases of fracture as are not marked by any very 
 striking displacement of the limb, and where nothing but the 
 crepitus could enable us to say that the limb was not dislocat- 
 ed. He has given very full directions for the use of the in- 
 strument, which have been republished in various periodical 
 journals in this country. They may be found in the Archives 
 Generales de Medicine, at l^uU length. 
 
 Bones of Children. — Dr J. Rhea Barton has given a very 
 interesting paper in the 4th volume of the American Medical 
 Recorder on certain injuries of the bones of children by which 
 the figure of the limb is much altered from the bending of the 
 bones without the production of fracture. Several cases are 
 related and a plate delineating the appearance of the limb and 
 of the deformity of the bones accompanies the description. 
 
 J. D. G. 
 
JPJLolo 
 
PLATE I 
 
 Shows the positions of the limb in the different dislocations 
 of the thigh-bone, and in the fracture of the cervix femoris. 
 
 Fig. 1. 
 
 The thigh-bone dislocated vpwards^ upon the dorsum ilii. 
 
 The leg shorter, the hip projecting, the knee turned inwards, 
 and the patella at least two inches higher than the other; the 
 foot turned inwards, and the toes resting upon the metatarsal 
 bones of the other foot ; the head of the bone is thrown back, 
 and the trochanter major forwards. 
 
 Fig. 2, 
 
 The dislocation downwards^ in the foramen ovale. 
 
 The leg is longer than the other ; the knee is advanced and 
 separated from that on the sound side ; the toe is pointed down j 
 the heel does not touch the ground ; the body is bent forwards. 
 
 This is the only accident of this joint in which the leg is longer. 
 
 Fig. 3. 
 
 Dislocation in the ischiatic notch. 
 
 The leg is shorter ; the patella from half an inch to an inch 
 above the other ; the foot slightly turned inwards ; the great toe 
 rests against the ball of the great toe of the other foot ; the leg 
 is with difficulty separated from the other. 
 
 In thin persons, the head of the os femoris may be felt a lit- 
 tle above and behind the acetabulum; more especially if the 
 surgeon rolls the knee inwards. 
 
 Fig. 4. 
 
 Dislocation of the os femoris upon the pubes. 
 
 Prominence at Poupart's ligament, from the head of >the 
 bone; the knee turned out, and widely separated from the oth- 
 er ; leg a little shorter, the one patella being about an inch high- 
 er than the other; the toe touches the ground, but the heel 
 does not reach it ; the knee and foot turned out. 
 
 Fig. 5. 
 
 Fracture of the neck of the thigh-bone. 
 
 The leg shorter; the knee turned out; the patella from one 
 to two inches above the other, and sometimes more; the foot 
 is generally everted, and does not reach the ground when the 
 other leg is straight ; the leg is easily drawn to the same length 
 with the other, and then, if rotated, a crepitus is felt. 
 
PLATE II. 
 
 Shows a dislocation into the foramen ovale which had never 
 been reduced, and beautifully exhibits the resources of nature, 
 in forming a new socket for the head of the bone, and allowing 
 of the restoration of a considerable degree of motion^ 
 
 A. Right and left ilium 
 
 B. Ischium 
 
 C. Pubes 
 
 D. Foramen ovale 
 
 E. The left acetabulum 
 
 F. Sacrum 
 
 G. Os femoris 
 
 H. The new acetabulum, formed in the foramen ovale, in which 
 
 the head of the thigh-bone was contained, and in which it 
 was so completely enclosed, that it became impossible to 
 remove it, unless a portion of the new socket was broken 
 away. It was lined by a ligamentous substance, on which 
 the head of the bone moved to a considerable extent 
 
 I. The original acetabulum, situated above the level, and to the 
 
 outer side of the new cavity. 
 
 Museum, St Thomas'^s Hospital. 
 
Piiih^^7i,:d hy £tny&Wait.l832. 
 
 J.Brayton Sc. 
 
PLATE III. 
 
 Exhibits another view of the same preparation, showing the 
 relative situation and appearance of the new and original aceta- 
 bulum. 
 
 AA. Ilia 
 
 B. The original acetabulum, little more than half its natural 
 
 size, the edge of the new acetabulum occupying its lower 
 and anterior part 
 
 C. The new acetabulum formed in the foramen ovale, a deep 
 
 ossific edge surrounding it ; its internal surface is extremely 
 smooth. The ligament of the foramen ovale has disappear- 
 ed, and ossific matter has been deposited in its stead 
 
 D. The thigh-bone removed, and the portion of the new aceta- 
 
 bulum is shown, which was obliged to be broken off to se- 
 parate the thigh-bone from its new socket 
 E« Head and neck of the thigh-bone; the former a little changed 
 by absorption, and the latter by ossific deposit. 
 
PLATE IV. 
 
 Shows a dislocation in the ischiatic notch. This is a side view 
 of the exterior surface of the osinnorainatum. 
 
 A. Ilium 
 
 B. Ischium 
 
 C. Pubes 
 
 D. Trochanter mnjor, covering and concealing the acetahulum' 
 
 F. Head of the os femoris thrown into the ischiatic notch, and 
 
 situated between the posterior and inferior spinous process 
 of the ilium, and the spinous process of the ischium 
 
 G. A new capsular ligament, formed around the head of the hone, 
 
 and composed of cellular membrane, condensed by inflamma- 
 tion 
 
 H. Ligamentum teres, which had been torn through in the dis- 
 location, as well as the original capsular ligament. 
 
 Museum^ St Thomases Hospital, 
 
ipt-.:jt. 
 
 i-uKlished bv LiUj il Wilt Eciu.n 1832 
 
PLATE V. 
 
 Exhibits a view of the dislocation of the os femoris upon the 
 pubes, or forwards and upwards. This preparation bejiutifuily 
 shows the power of nature in accommodating itself to new cir- 
 cumstances. 
 
 AA. Ilia 
 
 B. Pubes 
 
 C. Ischia 
 
 D. Os femoris 
 
 E. Trochanter major, occupying the original acetabulum 
 
 F. Head and neck of the os femoris, upon the junction of the 
 pubes and ilium 
 
 G. The new cup formed for the neck of the os femoris 
 
 H. The femoral artery and vein, passed upon the smooth sur 
 face of the pubes, on the inner side of the new acetabulum. 
 
 Museum^ St Thomases Hospital. 
 
 66 
 
PLATE VI. 
 
 Shows the same pelvis, with the thigh-bone removed from it, 
 to expose the new acetabulum formed by ossific inflammation 
 on the junction of the pubes and ilium. 
 
 AA. Ilia 
 BB. Pubes 
 CC. Ischia 
 
 D. Acetabulum which was occupied by the trochanter major 
 EF. The new acetabulum. 
 
 Under the line E. the femoral artery and vein took their 
 jcourse. 
 
■JFIL.:VILo 
 
 Publibhod bj- J.illj i \Vait.llos(on.li!32 
 
PLATE VII 
 
 Dislocation and fracture of the pelvis. 
 
 A. Fracture of the puhes on the left side 
 
 B. Fracture of the ischium on the same side 
 
 C. Dislocation of the right ilium 
 
 D. Laceration of the ilio sacral ligament, and separation of the 
 
 ilium from the sacrum. 
 
PLATE VIII. 
 
 Fig. 1. 
 
 Shows the mode of reducing the dislocation upwards^ on the 
 dorsum ilii. 
 
 A. The band passed between the thighs to fix the pelvis 
 
 B. The pulley fixed above the knee, and the direction shown in 
 
 which the thigh is to be drawn; viz, obliquely across the 
 sound thigh, two-thirds of its length downwards 
 
 C. Head of the bone upon the dorsum ilii 
 
 D. Acetabulum. 
 
 Fig. 2. 
 
 Dislocation in the foramen ovale. 
 
 A. Bandage to fix the pelvis 
 
 B. The pulley to draw the head of the os femoris outwards and 
 
 upwards 
 
 C. The surgeon''s hand grasping the ankle to draw the one leg 
 
 across the other, and to throw the head of the bone outwards 
 
 D. Head of the bone in the foramen ovale 
 
 E. Acetabulum, into which the head of the bone is to be brought. 
 
\3 
 
 K 
 
PLATE IX. 
 
 Fig. 3. 
 
 This is a view of the mode of reducing the dislocation into 
 the ischiatic notch. 
 
 A. The bandage which fixes the pelvis, and which passes be- 
 
 tween the thighs 
 
 B. The pulleys fixed above the knee, and extending in a direc- 
 
 tion across the middle of the sound thigh 
 
 C. A band surrounding the thigh, by which the surgeon is to 
 
 elevate the bone when the extension has been for some 
 time continued 
 
 D. The acetabulum 
 
 E. The head of the bone in the ischiatic notch. 
 
 Fig. 4. 
 
 This figure shows the best mode of reducing the dislocation 
 of the OS femoris upon the pubes. 
 
 A. The bandage to fix the pelvis, passing upwards and forwards 
 
 B. The pulleys which draw the bone downwards and backwards 
 
 C. A band passed around the thigh, to enable the surgeon to 
 
 raise the head of the bone during the extension 
 
 D. Head of the os femoris on the pubes 
 
 E. The acetabulum, above and before which the head of the 
 
 bone rests upon the junction of the pubes and ilium. 
 
 V 
 
PLATE X. 
 
 Shows fractures of the neck of the thigh-bone in man, and in 
 other animals, as they usually appear on dissection. 
 
 Fig. 1. 
 
 Ligamentous union shown. 
 
 A. Ilium 
 
 B. Pubes 
 
 C. Ischium 
 
 D. Foramen ovale 
 
 E. Os femoris 
 
 F. Trochanter major 
 
 G. Trochanter minor 
 
 H. Neck of the thigh-bone broken within the capsular liga- 
 
 ment, and in a great degree absorbed, as it generally is 
 soon after the accident: its surfiice smooth from friction, 
 and rounded to roll upon the hollow of the head of the bone 
 
 I. Head of the bone, hanging in the acetabulum by the ligamen- 
 
 tum teres only, smoothed by one bone rubbing against the 
 other : a portion of its surface having ligament secreted 
 upon it 
 
 K. The capsular ligament exceedingly thickened ; more espe- 
 cially on that part of the joint which is opposite to the fo- 
 ramen ovale. 
 
 Fig. 2. 
 
 A. Ilium 
 
 B. Pubes 
 
 C. Ischium 
 
 D. Foramen ovale 
 
 E. Os femoris 
 
 F. Broken cervix femoris, in a great degree absorbed 
 
 G. The head of the bone, supported by the ligamentum teres, 
 
 and having no other connexion with the body : its surface 
 smoothed by friction when the person begins to walk. 
 In each of these preparations the head and neck of the bone 
 conjointly, would not form more than one-third the natural 
 length of those parts. 
 
 Fig. 3. 
 
 The neck of the bone broken in a dog, and no union produc- 
 ed but by ligament. 
 
 Fig. 4. 
 
 The neck of the thigh-bone broken and ununited but by liga- 
 ment. The ligament in this experiment was not injured in 
 breaking the bone. 
 
FiMMH Uayi^ If ait. 1832. 
 
/ 
 
 I 
 
PLATE XI. 
 
 Fig. 1. 
 
 Shows a preparation of Mr Langstaff 'a. A fracture of the 
 thigh-bone united, as it usually is, by ligament. 
 
 A. Head of the thigh-bone 
 
 B. Trochanter major 
 
 C. Trochanter minor 
 
 D. Shaft of the os femoris 
 
 E. Capsular ligament excessively thickened 
 
 F. Ligamentous productions uniting the neck to the head of the 
 bone 
 
 G. A fork formed in the trochanter minor, which received the 
 head of the bone, and prevented its further descent. 
 
 Fig. 2. 
 
 Shows a preparation of Mr Langstaflf's. The upper part of 
 the thigh-bone broken within the capsule and external to it. 
 That external to the capsule firmly united by bone, and that 
 within it not united. 
 
 A. Head of the thigh-bone 
 
 B. Trochanter major 
 
 C. Trochanter minor » . 
 
 D. Shaft of the bone 
 
 E. Ligamentum teres, in its usual situation as regards the head 
 of the bone, and, as will be seen, not at its centre. 
 
 F. Fracture of the thigh-bone external to the capsule, firmly 
 and well united by bone 
 
 G. Fractured cervix within the capsule, still remaining ununited, 
 even by ligament. 
 
PubLUhfd by LW-i/ & n'ait.IS^Z. 
 
Fzg.2 
 
 'lucka-.Aifuii'Jm,. 
 
 Jfuhlislz,:d bif Lilly S.NaiL 1832. 
 
 Sced.Sculp. 
 
L 
 
 PLATE XII. ^^Im 
 
 Contains views of the altered state of the neck of the thigh- 
 bone, by which it is rendered incapable of supporting the super- 
 incumbent weight of the body, gradually becoming absorbed, and 
 the head of the bone descending to the trochanter minor. 
 
 Fig. 1. 
 
 Is a diagram of the upper part of the thigh-bone, to show the 
 change in figure it undergoes from a softened and absorbed state 
 of its cervix. 
 
 A. Natural position of the h ad of the bone 
 
 B. Head of the bone fallen to the trochanter minor 
 
 C. Shaft of the thigh-bone. 
 
 Fig. 2. 
 
 Head of the thigh-bone fallen, — neck of the bone absorbed 
 and shortened, so that the head and trochanter are brought 
 together. 
 
 A. Head of the bone 
 
 B. Trochanter major 
 
 C. Shaft of the bone 
 
 D. Ligament attached to the remains of the cervix. 
 
 Fig. 3. 
 
 Shows in a section the internal view of fig. 2. The cervix 
 femoris in a great degree absorbed, the head of the bone and 
 trochanter major in contact. 
 
 A. Head of the thigh-bone 
 
 B. Trochanter major 
 
 C. Shaft of the bone 
 
 D. Ligament entering between the head and cervix 
 
 E. Cervix femoris in a great degree absorbed. This disease 
 
 occurred on both sides in the same subject. 
 
 Fig. 4. 
 
 Section of the head and neck of the thigh-bone, the neck in 
 a great degree absorbed. 
 
 A. Head of the os femoris 
 
 B. Trochanter major 
 
 CC. Remains of the cervix and ligament. 
 
 Fig. 5. 
 
 Head and neck of the thigh-bone sunken down an inch and a 
 quarter towards the trochanter minor — neck of the bone ab- 
 sorbed, shortened, and a line formed at the part at which it yields 
 to the superincumbent weight, which gives it the appearance of 
 having been fractured; wholly, in some sections of it, — partially, 
 in others. 
 
 A. Head of the thigh-bone 
 
 B. Trochanter major 
 
 C. Shaft of the bone 
 
 67 
 
 % 
 
DD. Line of absorption of the phosphate of lime ; in the recent 
 state a ligamento cartilaginous substance is found. 
 I have several sections of this state of the bone ; two in which 
 the line of absorption extends quite through ; two in which it 
 extends partially through; and one in which the line of absorp- 
 tion has taken quite a different direction. 
 
 Fig. 6. 
 
 Shows the greatest descent of the head of the thigh-bone which 
 I have seen. — Let this section be brought in comparison with 
 fig. 1, and the great alteration which it has undergone will be at 
 once obvious ; the head of the bone, instead of being at A, is at B 
 of fig. 1, pressed down by the superincumbent weight of the body. 
 
 A. Head of the bone 
 
 B. Trochanter major 
 
 C. Shaft of the bone. 
 
 Thus the neck of the thigh-bone undergoes great changes in 
 form, length, and direction. 
 
 Fig. 7. 
 
 Shows the changes which are sometimes found in old and bed- 
 ridden persons. 
 
 A. Head of the thigh-bone 
 
 B. Trochanter major 
 
 C. Cancelli of the neck of the bone increased in coarseness by 
 
 absorption, so as to render the bone weaker, and, when dried, 
 diaphanous 
 
 D. Piece of bone added to the upper part of the cervix 
 
 EE. A larger piece of bone added to the lower part of the cer- 
 vix, to support the weakened neck of the bone. 
 
 If sections are made transversely of the neck of the thigh- 
 bone in old persons, the neck of the bone is found so exceedingly 
 spongy, as to be unable to bear even slight concussion. 
 
 Fig. 8. 
 
 Is a fracture of the neck of the thigh-bone in a person be- 
 tween thirty and forty years of age. The preparation was lent 
 me by Mr Herbert Mayo. 
 
 The bone was siiortened an inch only, because a fork in the 
 trochanter minor had caught the neck of the bone, and prevented 
 its further descent. The person lived nine months after the 
 accident ; and although the age was ftn'ourable, and the bones 
 were nearly in apposition, ligamentous union only was produced. 
 
 A. Head of the bone 
 
 B. Trochanter major 
 
 C. Shaft of the bone 
 
 D. Fork in the trochanter minor 
 
 E. Fracture united oy ligament only. 
 
 It is curious to observe how little the head of the bone is 
 changed in this fracture after nine months. Any other bones in 
 the body but those forming parts of articulations would be loaded 
 with ossific matter. 
 
Sud.Sriilp. 
 
PLATE XIII. 
 
 Fig. 1. 
 
 Fracture of the cervix femoris, sent me By Mr Powell, sur- 
 geon of Coram-street, Brunswick-square, in which the neck of 
 the thigh-bone has been forced into the cancellated structure. 
 
 A. AcetabuluDf) 
 
 B. Head of the thigh-bone 
 
 C. Trochanter major 
 
 D. Trochanter minor 
 
 E. Shaft of the thigh-bone 
 
 F. Neck of the thigh-bone united to the cancelli, into which it 
 
 had been forced 
 
 G. Addition to the trochanter major, which occasionally rested 
 
 on the ilium 
 
 H. Addition to the trochanter minor, which occasionally rested 
 
 on the left of the acetabulum ; and thus the bone became 
 supported by these processes under the weakened state of 
 the cervix. 
 
 Fig. 2. 
 
 Anatomical view of the head of the thigh-bone and capsular 
 ligament. 
 
 A. Head of the thigh-bone 
 
 B. Thigh-bone 
 
 C. Reflected synovial surface, vessels seen under it 
 
 D. Depression for the ligamentum teres 
 
 EE. Capsular ligament, and synovial secreting surface 
 
 F. Place of reflection of the synovial surface 
 
 G. Reflected ligament upon the neck of the bone, which sinks 
 
 into its pores and envelopes the neck of the bone as a 
 periosteum ; conveying vessels, but differing from perios- 
 teum in the strength, arrangement, and appearance of its 
 fibrous structure. 
 
 Fig. 3. 
 
 A. Head of the bone 
 
 B. Ligamentum teres 
 
 C. Thigh-bone 
 
 D. Trochanter major 
 
 E. Trochanter minor 
 
 F. Capsular ligament 
 
 GG. Insertion of the capsular ligament into the bone 
 
H. A band of reflected ligament and synovial secreting^ surface 
 with its vessels opposite the trochanter minor. Nearer to 
 the bone the reflection of the ligamentous periosteum is 
 seen 
 
 H. Another band opposite the trochanter major, the blood- 
 
 vessels in it 
 
 I. The reflected ligament forming a sheath to the bone is seen 
 
 upon the cervix femoris. 
 
 In reviewing what 1 have written on the structure of the 
 head and neck of the thigh-bone, I fear that some misconcep- 
 tion may be formed of the passage in which I say that the head 
 and neck of the bone are supplied with vessels from the re- 
 flected ligament and ligamentum teres. I would not be under- 
 stood to mean that this is the only supply, for it is well known 
 that vessels pass through the interior of the neck of the bone ; 
 but as these are torn through by the fracture, only those of the 
 untorn reflected ligament and ligamentum teres remain, and it 
 is principally those of which I have given a view in this plate. 
 In the fastal bone, in this plate, the interior vessels are slightly 
 tinted. 
 
 Fig, 4. 
 
 Faetal thigh-bone. 
 
 A. Head of the bone 
 
 B. Trochanter major 
 
 C. Shaft of the bone 
 
 D. Ligamentum teres, with its vessels 
 
 E. Ossific vessels of the head of the bone. 
 
 Fig. 5. 
 
 Extremity of the os calcis, cut ofi" and drawn up by the ac- 
 tion of the gastrocnemius muscle, in the rabbit. 
 
 A. Os calcis 
 
 B. Portion of bone detached from it 
 
 C. Union by ligament. 
 
 Fig. 6. 
 
 Longitudinal section of the head of the thigh-bone in a dog, 
 partly within and partly external to the ligament. 
 
 A. Head of the bone 
 
 B. Portion of the head of the bone broken off longitudinally, 
 
 and re-united by an ossific process. In this experiment, 
 both the capsular ligament and periosteum afforded nour- 
 ishment to the bone. 
 
PLATE XIV. 
 
 Fig. 1. 
 
 Shows the seat of fracture of the cervix femoris within the 
 capsular Hgament. 
 
 A. Head of the bone 
 
 B. Cervix femoris 
 
 C. Capsular ligament. 
 
 ^ Fig^. 2. 
 
 Exhibits the seat of fracture of the trochanter major, often 
 mistaken for fractured cervix femoris. This fracture unites by 
 bone. 
 
 A. Head of the bone 
 
 B. Shaft of the os femoris 
 
 C. Fracture through the trochanter. 
 
 Fig. 3. 
 
 Fracture of the trochanter, sent me by Mr Oldknow, of Not- 
 tingham. 
 
 A. Head of the bone 
 
 B. Broken trochanter major 
 
 C. Broken trochanter minor 
 
 D. Neck of the thigh-bone 
 
 E. Shaft of the bone. 
 
 Fig, 4. 
 
 Shows the bone sent me by Mr Roux, in which the neck of 
 the OS femoris is driven into the cancellated structure of the 
 shaft of the bone, where it unites by means of bone, as in Mr 
 Powell's case. 
 
 Fig. 5. 
 
 The inclined plane for simple fracture of the thigh and tro- 
 chanter major. 
 
 A. Frame to rest upon the bed 
 
 B. Two lateral supporters to A 
 
 C. The plane for the thigh 
 
 D. The plane for the leg 
 
 E. The joint. 
 
 Two boards nailed together, with the inclination as described 
 in the plate, answer nearly the same purpose. 
 
Fig. 6. 
 
 The thigh-bone fractured below the trochanter nninor, and 
 drawn into a most deformed union by the action of the psoas and 
 iliacus internus muscles. 
 
 Museum, St Thomas's Hospital. 
 Fig. 7. 
 
 Dislocation of the knee from ulceration of the ligament, with 
 subsequent anchylosis of the tibia forwards, at right angles with 
 the thigh-bone, and of the patella to the thigh-bone. 
 
 A. Shaft of the bone 
 
 BC. Tibia projecting forwards, and anchylosed to the os femoris. 
 
 D. Patella anchylosed 
 
 E. Ligamentum patellar. 
 
 Amputated by Mr Cline. 
 
 Museum, St Thomash Hospital. 
 Fig. 8. 
 
 Fracture of the human thigh-bone through the trochanter 
 major, in which ossific union has taken place, the fracture being 
 external to the ligament. 
 
 A. Fracture. 
 
 This case shows the tendency to eversion of the knee and foot 
 in this injury, and the necessity for guarding against it by atten- 
 tion to the position of the foot during the union. 
 
PLATE XV. 
 
 The thigh-bone broken just above its condyles and united. 
 Laceration of the rectus muscle, and great overlapping of the 
 bone. 
 
 A. Os femoris 
 
 B. Tibia 
 
 C. Patella 
 
 D. Rectus muscle lacerated 
 
 EE. Os femoris broken and overlapping but united 
 
 F. Point of the os femoris projecting through the rectus muscle, 
 
 preventing complete extension, and exceedingly limiting the 
 
 flexion of the joint. 
 
 In Mr Patey's possession. 
 
PLATE XVI. 
 
 Fig. 1. 
 
 Shows an anterior view of a dislocation of the thigh at the 
 knee-joint outwards. 
 
 A. Muscles of the thigh 
 
 B. Patella 
 
 C. External condyle of the os femoris, which had pushed through 
 
 the ligaments and skin 
 
 D. One semilunar cartilage 
 
 E. The other semilunar cartilage 
 
 F. Head of the tibia 
 
 G. Leg 
 
 HH. Capsular ligament. 
 
 Fig. 2. 
 
 Posterior view of the same knee. 
 
 A. Muscles of the thigh 
 
 B. Gastrocnemius 
 
 C. Sciatic nerve 
 
 D. Popliteal vein 
 
 E. Popliteal artery 
 
 F. External condyle, which had torn the capsular ligament and 
 
 muscles posteriorly 
 O. Internal condyle, which had also torn the ligament and 
 muscles 
 
 H. Torn ligaments 
 
 From Mr Oliver^ of Brentford. 
 Fig. 3. 
 
 Shows the thigh-bone in a compound fracture at its condyles 
 into the knee-joint. 
 
 Museum^ St Thomases Hospital. 
 Fig. 4. 
 
 Longitudinal fracture of the patella, in which the separation 
 of the bone is very slight, yet it is united by ligament only. 
 
 A. Tendon of the rectus femoris 
 
 B. Ligamentum patellae 
 
 C. Patella 
 
 D. Ligamentous union. 
 
 Drawn by Mr Sylvester. 
 
 Museum^ 
 
 St Thomas'' s Hospital. 
 
Picblished hj Lilli/.^lfaitJSiZ. 
 
PLATE XVII. 
 
 Diflferent views of fracture of the patella. 
 
 Fig. 1. 
 
 Fracture of the patella, with ligamentous union and great 
 separation of the bone. 
 
 The extent of separation depends upon the degree of lacera- 
 tion of the capsular ligament, and of the tendons of the vasti 
 muscles which are spread over it. 
 
 A. Upper portion of the patella drawn up by the action of the 
 
 rectus and vasti 
 
 B. Lower portion of the bone 
 
 C. to A. Original ligament 
 
 C. to B. New ligament, which, from its length, excessively 
 diminished the power of the extensor muscles. 
 
 Fig, 2. 
 
 Patella of a dog broken and united by ligament. 
 
 Fig. 3. 
 Patella of a rabbit broken. 
 A. Coagulated blood between the bones. 
 
 Fig. 4. 
 Patella of a rabbit broken. 
 A. The blood absorbed, and adhesive matter in its stead. 
 
 Fig. 5. 
 
 Patella of the rabbit broken and united by ligament ; from 
 A. to B. • 
 
 Fig. 6. 
 
 Longitudinal fracture of the patella in the dog. 
 
 A. One portion 
 
 B. The other. 
 
 Ligament seen between the two. 
 
 Fig. 7. 
 
 Patella broken longitudinally, so that there is no separation, 
 and it is united by bone. 
 
 A. Rectus muscle 
 
 B. Ligamentum patellae 
 
 C. Longitudinal fracture united. 
 
 By its side is seen the patella separated and macerated, and 
 there was slight ossific union. 
 
 All in the Museum, St Thomas'^s Hospital. 
 
 68 
 
PLATE XVIIL 
 
 Fig, 1. 
 
 Shows the dislocation of the tibia inwards at the ankle-joint. 
 
 A. Malleolus internus of the tibia thrown on the inner side of 
 
 the astragalus 
 
 B. A portion of the tibia split off 
 
 C. Fibula broken 
 
 D. Broken portion of the tibia adhering by ligament to the 
 
 fibula 
 
 E. Malleolus externus of the fibula, with the broken portion of 
 
 the tibia adhering to it 
 
 F. Astragalus thrown outwards. 
 
 Museum^ St Thomases Hospital 
 Fig. 2, 
 
 Shows the dislocation of the tibia outwards at the ankle-joint. 
 
 A. Tibia 
 
 B. Fibula 
 
 C. Os Calcis 
 
 D. Fracture of the tibia at the malleolus internus, which has 
 
 become reunited 
 
 E. Extremity of the fibula broken 
 
 F. Tibia thrown on the outer side of the articulatory surface of 
 
 the astragalus, to which it is anchylosed. 
 
 Museum^ St Thomas'' s Hospital. 
 Fig. 3. 
 
 Shows a fracture of the tibia and fibula at the ankle-joint, sent 
 to me by my friend, Mr Hammick, Surgeon of the Plymouth 
 Naval Hospital. 
 
 A. Tibia fractured 
 
 B- Fracture of the fibula 
 
 C. Astragalus 
 
 E, Shell of the bone surrounding a fragment of bone, and so 
 completely enclosing it that it could not be removed, and 
 amputation became necessary. 
 
 Fig. 4. 
 
 The fragment of bone seen separately. 
 
PLATE XIX. 
 Partial dislocation of the tibia forwards, at the ankle-joint. 
 Fig. 1. 
 
 A. The tibia thrown forward over the os naviculare 
 
 B. The astragalus 
 
 C. New articulatory surface of the tibia 
 
 D. The portion of the astragalus behind the tibia. 
 
 Fig. 2. 
 
 Opposite view of fig. 1. 
 
 A. The tibia thrown forwards 
 
 B. New articulatory surface of the tibia 
 
 C. Astragalus 
 
 D. Fibula broken and reunited 
 
 E. Malleolus externus of the fibula 
 
 F. Astragalus behind the tibia. 
 
 Fig. 3. 
 
 Comminuted fracture of the tibia at the ankle-joint, which 
 rendered amputation necessary. 
 
 A. Astragalus 
 
 BB. Fibula fractured 
 
 CC. Tibia shattered into the joint. 
 
PLATE XX. 
 
 Two views of dislocation of the astragalus, in the case of 
 Mr Downes, in whom the astragalus sloughed away. The 
 drawing was made when the bone began to loosen. 
 
PJL.XX . 
 
 Publish..!, l.y Lilly W ait B<.sion Ib.l-J 
 
PLATE XXI. 
 
 Dislocation of the os humeri in the axilla, as it appears in the 
 first dissection of the parts. 
 
 A. Clavicle 
 
 B. Scapula 
 
 C. Os humeri, with the biceps before, and triceps behind the bone 
 
 D. Subscapularis 
 
 E. Teres major 
 
 F. Latissimus dorsi 
 
 G. Pectoralis major 
 
 H. Nerves of the axillary plexus and axillary artery and vein 
 
 which are seen cut across at the lower part of the plexus; 
 the cutaneous nerve seen passing through the coraco brachi- 
 alis muscle 
 
 I. Coracoid process 
 
 K. Head of the bone dislocated in the axilla 
 
 L. Capsular ligament and tendon of the subscapularis muscle 
 torn, through which laceration the head of the bone escap- 
 ed from the glenoid cavity. 
 
PLATE XXII. 
 
 Fig. 1. 
 
 Shows the^ew socket which has been formed on the inner 
 side of the inferior costa of the scapula, in a dislocation of the 
 OS humeri into the axilla. 
 
 A. The scapula 
 
 B. The coracoid process of the scapula 
 
 C. The glenoid cavity, with the acromion above it 
 
 D. The new socket for the head of the os humeri. 
 
 Fig. 2. 
 
 Partial dislocation of the os humeri forwards. This drawing 
 was made from the dissection of Mr Patey, Dorset-street. 
 
 A. Clavicle 
 
 B. Acromion 
 
 C. Coracoid process 
 
 D. Scapula 
 
 EE. Os humeri — head of the bone somewhat altered 
 
 F. Glenoid cavity. 
 
 G. New smooth cavity for the head of the os humeri, which 
 
 extended from the edge of the glenoid cavity to the cora- 
 coid process of the scapula. 
 
JPI..XX11,. 
 
 wm ."1 
 
 Published by Lilly k W-iit. tiosiou ISii 
 
I'iih/islu-d by LiUy,(-Kaa. Vm. 
 
PLATE XXIII. 
 
 Fig. 1. 
 
 Dislocation of the os humeri forwards, under the clavicle, and 
 behind the pectoral muscle. 
 
 A. Clavicle 
 
 B. Scapula 
 
 C. Acromion 
 
 D. Glenoid cavity of the scapula, from which the os humeri 
 
 had been thrown ; and on the inner side of this cavity is 
 seen the coracoid process 
 
 E. The head of the os humeri, with the tendon of the biceps 
 
 passing over it ; the head of the bone under the middle of 
 the clavicle, in the centre of the scapula, and on the inner 
 side of the coronoid process 
 
 F. Portions of the new ligament, which enclosed the head of 
 
 the bone. 
 
 Removed from a patient in St Thomas's Hospital, by Mr 
 Coleby. 
 
 Museum^ St Thomases Hospital. 
 
PLATE XXIV. 
 
 Fig. 1. 
 
 Shows a dislocation of the os humeri in the axilla. 
 
 A. The clavicle 
 BB. The scapula 
 
 C. The OS humeri 
 
 D. The biceps flexor cubiti 
 EE. Subscapularis muscle 
 
 F. Laceration of the capsular ligament, and of the tendon of the 
 
 subscapularis 
 
 G. Head of the bone thrown on the inner side of the inferior 
 
 costa of the scapula. 
 
 Fig. 2. 
 
 Dislocation of the ulna and radius backwards. 
 
 A. Os humeri 
 
 B. Ulna 
 
 C. Radius 
 
 D. Biceps flexor cubiti, inserted into the tubercle of the radius 
 
 E. Brachialis internus, inserted into the coronoid process of the 
 
 ulna 
 
 F. Triceps extensor cubiti, inserted into the olecranon 
 
 G. Internal condyle of the os humeri 
 
 H. Olecranon and coronoid process, thrown behind the articu- 
 
 latory surface of the os humeri ; the coronoid process is 
 received into the posterior cavity of the humerus. 
 
 Museum^ St Thomas's Hospital. 
 
FullUhed iy LiUi/, & Wait. 1332. 
 
J.Braytcrn S. 
 
PLATE XXV. 
 
 Fig. 1. 
 
 A dislocation of the ulna backwards. 
 
 A. Os humeri 
 
 B. Ulna 
 
 C. Radius 
 
 D. Insertion of the biceps flexor cubiti into the tubercle of the 
 
 radius 
 
 E. Olecranon thrown behind the os humeri 
 
 F. Some appearance of injury to the internal condyle of the os 
 
 humeri. 
 
 Museum^ St Thomas''s Hospital. 
 Fig. 2. 
 
 Opposite view of the same preparation. 
 
 A. Os humeri 
 
 B. Ulna 
 
 C. Radius 
 
 D. Insertion of the biceps into the tubercle of the radius 
 
 E. Olecranon thrown backwards 
 
 F. Head of the radius, which, by its pressure against the exter- 
 
 nal condyle of the os humeri, has produced a socket there 
 for itself. 
 
 Fig. 3. 
 
 Dislocatio7i of the Radius. The bone is thrown upon the ex- 
 ternal condyle, and upon the coronoid process of the ulna. 
 
 A. Os humeri 
 
 B. Ulna 
 
 C. Radius 
 
 D. Olecranon 
 
 E. Head of the radius. The coronary ligament and a part of 
 
 the interosseous ligament is torn through, and the head of 
 the bone is thrown upon the coronoid process of the ulna, 
 and external condyle of the os humeri. 
 
 Museum^ St Thomas'' s Hospital. 
 
 69 
 
PLATE XXVI. 
 
 Shows a dislocation of the radius backwards, behind, and to 
 the outer side of the external condyle of the os humeri. 
 
 A. Os humeri 
 
 B. Radius 
 
 C. Ulna 
 
 D. Internal condyle of the os humeri 
 
 E. Coronoid process of the ulna; the capsular ligament being 
 
 opened to show D and E 
 
 F. The head of the radius dislocated backwards and outwards 
 
 G. The coronary ligament torn through. 
 
 Given by Mr Poingdestre. Drawn by Mr Sylvester. 
 
 Museum^ St Thomas's Hospital. 
 
f'ld'lish^d ?^?^Iiat/ ^ [Tart IS^-ii. jDrayton S^. 
 
JJLNesinitk .V,- 
 
PLATE XXVII. 
 
 Fig. 1. 
 
 Shows a fracture of the external condyle of the os humeri, 
 still disunited. 
 
 A. Os humeri 
 
 B. Ulna 
 
 C. Radius 
 
 D. Fractured external condyle within the ligament; no attempt 
 made to unite it; the broken portion unaltered 
 
 E. Head of the radius. 
 
 Museum., St Thomas's Hospital 
 Fig, 2. 
 
 Fracture of the external condyle of the os humeri, and of the 
 coronoid process of the ulna. 
 
 A. Os humeri 
 
 B. Ulna 
 
 C. Radius 
 
 D. Head of the radius 
 
 E. External condyle fractured externally to the capsular liga- 
 ments; great attempts mnde by nature to unite it, and the 
 form of I he bone changed 
 
 F. Coronoid process of the ulna broken off, and united by liga- 
 ment only to the ulna; no attempt made to produce os;sitic 
 union. This portion of the coronoid process was seated 
 within the capsular ligament. 
 
 Museum^ St Thomas''s Hospital. 
 
 Fig. 3. 
 
 Fractured olecranon. 
 
 A. Os humeri 
 
 B. Ulna 
 
 C. Radius 
 
 D. A portion of the triceps extensor cubiti 
 
 E. Olecranon broken and drawn up by the triceps 
 
 F. Shaft of the ulna where the olecranon is broken from it 
 
 G. The new ligament, which has joined the olecranon lo the 
 ulna. 
 
 Museum^ St Thomas's Hospital. 
 
PLATE XXVIIL 
 
 Shows a fracture ot the inferior extremity of the radius, and 
 dislocation of the ulna forwards. 
 
 A. Radius 
 
 B. Ulna 
 
 C. Ligamentum annulare carpi 
 
 D. Ulna thrown forwards upon the os crbiculare 
 
 E. Broken extremity of the radius: the shaft of the bone 
 thrown forwards, and the lower extremity of the bone re- 
 maining in its natural situation. On the shaft of the bone, 
 just above the fracture, is seen the attachment of the pro- 
 nator quadratus. 
 
 Museum, St Thomas's Hospital. 
 Fig. 2. 
 
 Shows a compound dislocation of the ulna backwards, with a 
 compound and comminuted fracture of the radius. 
 
 A. Radius 
 
 B. Ulna 
 
 C. Carpus 
 
 D. Ulna dislocated backwards, being thrown behind the extre- 
 mity of the radius 
 
 E. Fragments of the broken radius extremely comminuted : the 
 tendon of the extensor carpi radialis brevior torn through. 
 
 Museum, St Thomases Hospital. 
 
 Fig. 3. 
 
 Dislocation of the second phalanx of the finger forwards, and 
 of the first backwards. 
 
 A. First phalanx 
 
 B. Second phalanx 
 
 C. Third phalanx 
 
 D. Dislocated extremity of the first phalanx 
 
 E. Dislocated second phalanx 
 
 F. New capsular ligament covering the ends of the dislocated 
 bones. 
 
 Fig. 4. 
 
 Compound dislocation of the first phalanx of the thumb. 
 
 A. Metacarpal bone 
 
 B. First phalanx thrown backwards 
 
 C. Second phalanx 
 
 D. First phalanx dislocated 
 
 E. Tendon of the flexor longus pollicis torn through. 
 
 In the treatment of this accident, the end of the bone is to 
 be sawn away. 
 
 Museum^ St Thomas''s Hospital. 
 
TTCr. 3. 
 
 FI& . 2 
 
 FIG-.l 
 
 ■ IDraytim 
 
f 
 
PutlisKed by Lilly H WalLBosbn.ieS?. . 
 
PLATE XXIX. 
 
 Fig, 1. 
 
 Shows a view of a dislocation of the os humeri into the axilla 
 on the right side. 
 
 Fig. 2. 
 
 Is a view of the dislocation of the os humeri forwards, behind 
 the pectoralis major, and under the clavicle. 
 
 Fig. 3. 
 
 The bones of the trunk, showing the seats of dislocation of 
 the clavicle and os humeri. 
 
 A. Sternal end of the clavicle thrown upon the sternum 
 
 B. Scapular end of the clavicle thrown upon the spine of the 
 scapula 
 
 C. Spine of the scapula 
 
 D. The glenoid cavity 
 
 E. Coracoid process 
 
 F. Head of the os humeri thrown into the axilla 
 
 G. Head of the os humeri thrown forwards upon the second rib 
 under the clavicle, and upon the inner side of the coracoid 
 process in the dislocation forwards. 
 
 Fig. 4. 
 
 Shows the situation of the head of the os humeri, when dis- 
 located backwards upon the scapulae. 
 
 A. Dorsum scapulae 
 
 B. Os humeri 
 
 C. Head of the os humeri on the dorsum scapulae. 
 
 Fig. 5. 
 
 Shows a dislocation of the astragalus outwards. 
 
 A. Malleolus externus 
 
 B. Astragalus thrown outwards : the foot resting upon its outer 
 edge. 
 
 Fig. 6. 
 
 A. Ulna thrown back 
 
 B. Radius thrown with the ulna 
 
 C. Hollow above the elbow. 
 
PLATE XXX, 
 
 Fig. 1. 
 
 Shows the mode which I almost constantly pursne of reducing 
 recent dislocations of the os humeri, by placing the heel in the 
 axilla, and by extending the arm either from above the elbow 
 or from the wrist. 
 
 Fig. 2. 
 
 Mode of reduction by the pulley; showing the manne** iq 
 which the scapula is fixed by a bandage which receives the arm, 
 and the pulleys af)plied above the elbow ; as well as the direc- 
 tion in which extension is to be made in dislocation in the axilla. 
 If the dislocation be forwards under the clavicle^ the arm must 
 be somewhat lowered to avoid the coracoid process. 
 
 Fig. 3. 
 
 Shows the mode of reducing the dislocation downwards, by 
 the knee in the axilla. 
 
PLATE XXXI, 
 
 Fig. 1. Shows an altered state of the neck of the thigh-bone 
 frona disease, which might be mistaken for fracture and union. 
 The same appearance in a less degree, is sometimes seen in the 
 tipper part of the thigh-bone in very old persons; the head and 
 neck of the bone falling down upon its shaft at the trochanter 
 minor, and the neck of the bone absorbed. 
 
 Fig. 2. Fracture of the cervix scapulse. 
 
 A. Spine of the scapula 
 
 B. Coracoid process 
 
 C. Glenoid cavity broken off by a fracture through the neck of 
 
 the scapula. 
 
 Fig. 3. Fracture of the acromion. 
 
 4. Fracture of the cervix humeri. 
 
 5. Fracture of the internal condyle of the os humeri. 
 
 6. Fracture of the external condyle of the os humeri. 
 
 7. Fracture of the olecranon. 
 
 8. Fracture of the coronoid process of the ulna. 
 
 9. Clavicle bandage, with the pads under the axilla, to 
 
 throw the head of the os humeri from the side ; used 
 
 in fractured clavicle ; in dislocations of that bone ; and 
 
 in fracture of the cervix scapulae. 
 
 10. Lateral splints for fractures of the elbow-joint. 
 
 11. Back splint for the arm, with the hinge at the elbow, 
 
 for fractures of the condyles when requiring motion. 
 12. Mode of reduction of the thumb. 
 
 13. Loop used for the foregoing purpose, called by sailors 
 
 the clove hitch, composed of two circles, with the ends 
 between them. 
 
 14. Bandage for the fracture of the olecranon. 
 
 15. Common mode of bandaging for the fractured patella. 
 
 16. Leather strap buckled above the patella, with another 
 
 strap passing under the foot, which I employ for frac- 
 tured patella. 
 
 17. Long splint for fractured thighs. Its upper part rests 
 
 against the pubes, and is buckled around the upper part 
 of the thigh. The splint passing down on the inner side 
 of the thigh and leg, with a screw to add to its length, and 
 a boot attached to it to confine the splint to the loot. 
 
 18. Splint, with a foot-piece on each side, for dislocations 
 
 and fractures at and near to the ankle-joint. 
 
 19. Bandage used in the case related by Mr Harris, of 
 
 Reading, of injury to the upper part of the thigh-bone. 
 
 A. A pad buckled around the pelvis, to support the trochanter 
 
 B. Wedge to support the thigh-bone 
 
 C. Foot supporter 
 
 D. Portion of the mattress which drew out to slide a bed-pan 
 
 under the patient. 
 
PLATE XXXII. 
 
 Fig. 1. 
 
 Shows the union of the radius after fracture, and a ligament- 
 ous union of the ulna. Mr Cline used to attribute the want of 
 union in such cases, to the muscles drawing the bones from each 
 other, hence the pronator quadratus would produce this effect j 
 in the os humeri, the coraco brachialis would, in a similar man- 
 ner, prevent union. Whatever prevents pressure of one bone 
 against the other, will have a tendency to produce that etfect. 
 VVant of pressure is one principle of non-union. 
 
 A. Radius 
 
 BB. Section of the ulna 
 
 C. Interosseous ligament 
 
 D. Pronator quadratus muscle 
 
 E. United radius 
 
 F. Ulna united bj ligament. 
 
 Fig. 2. 
 
 Fracture of the cranium, and a portion of bone removed by 
 the trephine, 
 
 A. Os frontis 
 
 B. Parietal bone 
 
 C. Large aperture in the skull remaining unfilled except at its 
 
 edges, although it had the appearance of being an acci- 
 dent of ancient date 
 
 D. Fracture not united. 
 
 In examining these cases, I have found that the pericranium 
 has been much thickened at the aperture. The dura mater 
 greatly thickened beneath the openings, and a ligamentous sub- 
 stance unites the dura mater to the pericranium. Some ossific 
 matter is added to the edge of the opening in the bone, but un- 
 less the opening be small, it is rarely filled by bone. 
 
 Fig. 3. 
 
 Tibia united after fracture ; yet in these cases the person 
 walks with a much less halt than would be expected by the sur- 
 geon who had not witnessed similar examples. 
 AA. Tibia 
 
 B. Non-union of the tibia 
 
 CCC. Fibula enormously enlarged and curved, so as to bring 
 the foot near to the axis of the body. The upper part 
 of the fibula little less than the tibia 
 
 D. Interosseous ligament. 
 
 A lady from Salisbury, whom I lately saw, walked extremely 
 well across my room, although her tibia was not united after 
 fracture. 
 
-fuHis/u'd hy Lilly. & If a it. 183Z 
 
 J.Drayton Sc 
 
P1L »m3iii» 
 
 V 
 
 b 
 
 Pubiii-hed by W,iil:..Hoslon..l83'2, 
 
PLATE XXXIII 
 
 Fig. 1. 
 
 Shows the radius of a dog, from which half an inch of bone 
 had been removed, it had not united, but, from the appearance 
 of the callus, probably would have united had the animal lived 
 longer than two months. 
 
 AA. Space produced by the removal of the bone. 
 
 Fig. 2. 
 
 Portion of the radius removed, an inch in length. Mode of 
 union shown. 
 
 AA. Each end of the radius united with the ulna only. 
 
 Fig, 3. 
 
 Two inches of the radius removed. A ligamentous union of 
 the radius to the ulna was produced, an.d the ulna was enlarged 
 opposite to the space produced by the removal of the radius. 
 
 Fig. 4. 
 
 Is a curious result of an experiment, in which an inch of bone 
 was removed from the radius, and the ulna was accidentally 
 broken at the time. The radius produced callus, which did not 
 reach from bone to bone, but the ulna, at its fractured part, sent 
 in two portions of bone to fill the space between the ends of 
 the radius. 
 
 AA. Space between the ends of the radius 
 
 BB. Fracture of the ulna, with two portions of bone proceeding 
 into the interspace of the radius. 
 
 This experiment explains the cases of apparent union between 
 remote portions of bone, when a piece of the tibia has been re- 
 moved, and the fibula at the same time fractured ; this is fully 
 exemplified in the case published by Mr Dunn, a very intelligent 
 surgeon at Scarborough, who has had the kindness to send me a 
 cast of the leg of his patient. 
 
 70 
 
PLATE XXXIV 
 
 Fig. 1. 
 
 Shows a dislocation of the scapular end of the clavicle upon 
 the acromion ; the clavicle is seen projecting over the spine ©f 
 the scapula. 
 
 AA. Clavicle 
 
 B. Scapula 
 
 C. Spine of the scapula 
 
 D. Acromion 
 
 E. Scapular end of the chwicle thrown over the acromion 
 
 F. The coronoid ligament almost entirely converted into bone, 
 
 and anchylosing the clavicle to the scapula. 
 
 Fig. 2. 
 
 Shows a fracture of the acromion united by ligament. 
 
 A. Portion of the scapula 
 
 B. Spine of the scapula 
 
 C. Glenoid 
 
 T). Coracoid process 
 
 E. Acromion 
 
 F. The fracture of the acromion united at its edge by the liga- 
 
 ment 
 
 G. Which has been turned aside to show ligamentous granula- 
 
 tions upon the broken surfaces. 
 
 Fig. 3. 
 
 Is a very curious preparation of dislocation of the os humeri in 
 the axilla, and fracture of the cervix within the capsular liga- 
 ment, forming there a new joint, the fracture not having united. 
 
 AA. The scapula 
 
 B. Portion of the clavicle 
 
 C. Acromion 
 
 D. Coracoid process of the scapula 
 
 E. Acromio-coracoid ligament 
 
 F. Head of the os humeri dislocated 
 
 G. Tubercles of the os humeri 
 
 H. Os humeri 
 
 I. Tendon of the biceps 
 
 K. The new joint from the fracture. 
 
 Fig. 4. 
 
 Fracture of the os humeri below the capsular ligament united. 
 
 A. Head of the os humeri 
 
 B. Os humeri 
 
 CC. Fracture united.