{"1": {"fulltext": "", "height": "4617", "width": "2821", "jp2-path": "practicaltreati00stim_0001.jp2"}, "2": {"fulltext": "LIBRARY OF CONGRESS.\\nChap. _*____ Copyright No.\\nUNITED STATES OF AMERICA.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0002.jp2"}, "3": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0003.jp2"}, "4": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0004.jp2"}, "5": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0005.jp2"}, "6": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0006.jp2"}, "7": {"fulltext": "A PRACTICAL TREATISE\\nFRACTURES AND DISLOCATIONS.\\nBY\\nLEWIS A. STIMSON, B.A., M.D., LL.D. (Yalen),\\nPROFESSOR OF SURGERY IN CORNELL UNIVERSITY MEDICAL COLLEGE, NEW YORK J SURGEON TO\\nTHE NEW YORK AND HUDSON ST. HOSPITALS J CONSULTING SURGEON TO BKLLEVUE,\\nST. JOHNS, AND CHRIST HOSPITALS; CORRESPONDING MEMBER OF THE\\nSOCIETE DE CHIRURGIE OF PARIS.\\nTHIRD EDITION, REVISED AND ENLARGED.\\nWITH 336 ILLUSTRATIONS AND 32 PLATES IN MONOTINT.\\nLEA BROTHERS CO.,\\nNEW YORK AND PHILADELPHIA,\\n1900.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0007.jp2"}, "8": {"fulltext": "b\\ng 3\\n37799\\nLiorfctry of Con^j\\nwo Copies Received\\nAUG 23 1900\\nCopyrigfct \u00c2\u00abftry\\nMQM\\nSECOND COPY.\\nDelivered to\\n0R0\u00c2\u00a38 DIVISION,\\nSEP 6 1900\\nEntered according to Act of Congress in the year 1900, by\\nLEA BROTHERS CO.,\\nin the Office of the Librarian of Congress, at Washington. All rights reserved.\\n^,:;::d\\nWESTCOTT THOMSON,\\nElectrotypers, Phila.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0008.jp2"}, "9": {"fulltext": "PREFACE TO THE THIRD EDITION.\\nThe two volumes in which this work originally appeared were so\\nextensively rewritten for the edition in one volume, published in 1899,\\nthat it was then practically a new book. The author gratefully\\nacknowledges the favor which exhausted that edition in about a year,\\nand he has endeavored to respond by again revising it to the latest\\ndate. It continues to embody the experience gained in the House of\\nRelief (Hudson Street Hospital), where traumatic cases are so numer-\\nous as to include all the ordinary forms of injury, and most of those\\nwhich are rare. So wide indeed is this clinical field that a number of\\nlesions were first observed there and described in this work. These\\nfacts gave the opportunity for and seemed to justify a personal form\\nfor the book, with a reduction in the number of quotations of histories\\nand of opinions based upon single cases. This enabled the author\\nnot only to introduce such additions as have been made to our\\nknowledge of the subject in the interval, but also to adapt the work\\nmore specifically to the needs of the practitioner, especially in regard\\nto diagnosis and treatment, while the requirements of the student of\\nspecial subjects were heeded in the bibliographical references, which\\nwere largely added to.\\nThe portion treating of Fractures was almost wholly rewritten\\nin the edition of 1899, the most marked change in classification and\\narrangement being that made in the chapter on Fractures of the Skull.\\nIn the portion treating of Dislocations, the most notable changes,\\nin addition to those above referred to, were those dealing with\\noperative reduction of both old and recent injuries.\\nThe additions made in the present edition, notwithstanding the\\nshortness of the interval, have been numerous and important. Promi-\\nnent among them is that representing the advance in our knowledge\\nof traumatic hsematomyelia and the light it has thrown upon the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0009.jp2"}, "10": {"fulltext": "VI PREFACE TO THE THIRD EDITION.\\nprognosis and treatment of injuries of the spinal cord, and the judg-\\nment it permits concerning the supposed efficacy of surgical interference\\nin such cases.\\nSpace for these additions has been gained so far as practicable by\\nomitting old material but nevertheless the size of the book has been\\nincreased. Twenty new illustrations have been substituted or added,\\nand the number of plates has been increased from twenty to thirty-\\ntwo, with nineteen new figures, all but one being reproductions of\\nskiagrams.\\nLewis A. Stimson.\\n34 East Thirty-third Street, New York,\\nAugust, 1900.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0010.jp2"}, "11": {"fulltext": "CONTENTS\\nFRACTURES\\nCHAPTEE I.\\nINTRODUCTION.\\nPAGE\\nDefinitions, statistics, influences of sex, age, and season 19\\nCHAPTER II.\\nPATHOLOGY.\\nA. The bone varieties of fracture 22\\n1. Incomplete fractures 23\\n(a) Fissures 23\\n(6) True incomplete, green-stick infraction 23\\n(c) Depressions 24\\n(d) Separation of a splinter or apophysis 24\\n2. Complete fractures subdivided according to 25\\n(a) Direction and character of the line of fracture 25\\n(6) The seat of fracture 28\\nSeparation of epiphysis 28\\n(c) Intra-articular 29\\n3. Multiple fractures 30\\n4. Compound fractures 30\\n5. Gunshot fractures 32\\nDisplacements 34\\nB. The soft parts 36\\nCHAPTER III.\\nETIOLOGY.\\nPredisposing causes 38\\nExternal, normal, interstitial atrophy, inherited liability 38\\nDetermining causes 39\\nExternal violence, direct or indirect 39\\nMuscular action 40\\nSpontaneous and pathological fractures 43\\nGeneral diseases 43\\nDiseases of nerve centres 45\\nRhachitis, syphilis, rheumatism 45\\nCancer and sarcoma t 46\\nCysts, osteomyelitis 47\\nIntra-uterine, and during delivery 47\\nCHAPTER IV.\\nEARLY SYMPTOMS AND DIAGNOSIS.\\nObjective signs 49\\nDeformity (normal asymmetry) 49\\nAbnormal mobility 50\\nCrepitus 51\\nSubjective or rational symptoms 52\\nLoss of function pain 52\\nHistory 53\\nvii", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0011.jp2"}, "12": {"fulltext": "Vin CONTENTS.\\nCHAPTER V.\\nREPATR OF FRACTURES AND CLINICAL. COURSE.\\nPAGE\\nAnatomo-pathological processes. The callus 55\\nIn compound fracture 59\\nIn short and flat bones GO\\nAt the epiphyseal line 61\\nClinical course 02\\nCHAPTER VI.\\nCOMPLICATIONS AND REMOTE CONSEQUENCES.\\nEarly local complications 66\\nSkin. Bloodvessels 66, 67\\nGangrene. Degeneration of muscles 68\\nSuppuration 69\\nEarly general complications 69\\nSepticaemia 69\\nFat embolism 70\\nDelirium tremens, tetanus, pneumonia 71\\nLate local complications 71\\nExcessive or painful callus 71\\nDevelopment of a tumor 73\\nInjury of a nerve 73\\nWeakness of callus 75\\nArrest or exaggeration of growth 75\\nStiffness of the joints 75\\nAtrophy. Thrombosis and embolism 76\\nCHAPTER VII.\\nTREATMENT.\\nReduction 79\\nRetention 84\\nTemporary and removable dressings 86\\nWooden and metal splints 87\\nAnterior suspended splints 89\\nMoulded splints 90\\nPermanent or hnal dressings 92\\nEncasement in plaster 92\\nTraction, Buck s extension 94\\nHodgen s splint, long side splint 96\\nVertical suspension. Double inclined plane 97\\nDirect fixation 98\\nMassage 99\\nAmbulatory treatment 100\\nManagement of the joints 102\\nCompound fractures 1 03\\nBy indirect violence 104\\nBy direct violence 104\\nGunshot fractures 106\\nAmputation 106\\nCompound articular fractures 107\\nGeneral treatment 108\\nCHAPTER VIII.\\nDELAYED UNION, FAILURE OF UNION, FAULTY UNION.\\nDelaved union failure of union 109\\nPathology 109\\nEtiology 110\\nSymptoms 112\\nTreatment 113\\nFaulty or vicious union 114", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0012.jp2"}, "13": {"fulltext": "CONTENTS ix\\nCHATTER IX.\\nPAGE\\nGENERAL PROGNOSIS 117\\nCHAPTEE X.\\nFRACTURES OF THE SKULL.\\nMechanism and pathology 121\\nExceptional forms 126\\nInternal table 127\\nInjuries of brain 128\\nPathological and reparative processes 129\\nSymptoms, diagnosis, and treatment 130\\nCircumscribed fractures of the vault 130\\nFissured fractures with generalized brain injury 133\\nInternal table 135\\nRupture of the middle meningeal artery 135\\nPerforating fractures of the base 137\\nSummary 137\\nCHAPTER XI.\\nFRACTURES OF THE VERTEBRA.\\nPathology 140\\nHaematomyelia 143\\nEtiology 144\\nSymptoms and diagnosis 144\\nAtlas and axis 146\\nLower five cervical and first two dorsal 147\\nLower dorsal and first two lumbar 149\\nLower three lumbar 150\\nCourse and termination 150\\nTreatment 153\\nCHAPTER XII.\\nFRACTURES OF THE BONES OF THE FACE.\\n1. Nose 157\\n2. Malar bone and zygoma 160\\n3. Superior maxilla 161\\n4. Inferior maxilla 164\\nCHAPTER XIII.\\nFRACTURES OF THE HYOID BONE 171\\nCHAPTER XIV.\\nFRACTURES OF THE LARYNX AND TRACHEA 173\\nCHAPTER XV.\\nFRACTURES OF THE STERNUM 175\\nCHAPTER XVI.\\nFRACTURES OF THE RIBS AND THEIR CARTILAGES 180\\nCHAPTER XVII.\\nFRACTURES OF THE CLAVICLE.\\nPathology 189\\n1. Middle third 190\\n2. Outer third 191\\n3. Inner third 192\\nMultiple fractures. Complications 193", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0013.jp2"}, "14": {"fulltext": "x COS TENTS.\\nPAGE\\nEtiology 195\\nSymptoms and course 196\\nSimultaneous fractures of both clavicles 198\\nTreatment 199\\nCHAPTER XVIII.\\nFRACTURE? OF THE SCAPULA.\\n1. Of the body of the scapula 206\\n2. Of the inferior angle 208\\n3. Of the upper angle 209\\n4. Of the spine 209\\n5. Of the acromion 209\\n6. Of the coracoid process 211\\n7. Of the neck 212\\n8. Of the glenoid cavity 213\\nCHAPTER XIX.\\nFRACTURES OF THE HUMERUS.\\n1. Fractures of the upper end of the humerus 215\\nA. Fractures of the head 216\\nB. Fractures of the anatomical neck and fracture through the tuberosities 216\\nC. Fractures of the tuberosities 221\\nD. Separation of the epiphysis 223\\nE. Fracture of the surgical neck 226\\nSymptoms, diagnosis, prognosis, treatment 229\\n2. Fractures of the shaft of the humerus 233\\n3. Fractures of the lower end of the humerus 237\\nA. Fractures above the condyles supracondyloid 239\\nB. Fractures of the internal epicondyle 244\\nC. Fractures of the external epicondyle 246\\nD. Fractures of the internal condyle 246\\nE. Fractures of the external condyle 248\\nF. Intercondyloid, T-shaped fractures 251\\nG. Separation of the epiphysis 253\\nH. Fractures of the articular process 255\\nOf the capitellum. Of the trochlea 256\\nDiagnosis 257\\nTreatment 258\\nCHAPTER XX.\\nFRACTURES OF THE BONES OF THE FOREARM.\\n1. In the vicinity of the elbow-joint 259\\nA. Olecranon 259\\nB. Coronoid process 266\\nC. Of the head and neck of the radius 268\\n2. Fractures of the shaft 271\\nFractures of the shafts of both bones 271\\nB. Of the shaft of the ulna 276\\nC. Of the shaft of the radius 278\\n3. Fractures in the vicinity of the wrist 279\\nA. Fractures of the radius. Colles s fracture 279\\nCause 283\\nSymptoms 285\\nTreatment 287\\nB. Fractures at the wrist other than Colles s 289\\nCHAPTER XXI.\\nFRACTURES OF THE CARPUS AND HAND.\\n1. Fractures of the carpal bones 293\\n2. Fractures of the metacarpal bones 293\\n3. Fractures of the phalanges 295", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0014.jp2"}, "15": {"fulltext": "COXTENTS. xi\\nCHAPTEE XXII.\\nFRACTURES OF THE PELVIS.\\nPAGE\\n1. Fractures of the ring of the pelvis 297\\nSeparation of the symphysis pubis 298\\nSeparation in front and behind 299\\nSeparation of the sacro-iliac synchondrosis 299\\nSeparation of all three joints 299\\nFracture of the pubic portion of the pelvic ring 300\\nFracture of the lateral portion 300\\nCourse, diagnosis, treatment 303\\n2. Transverse fracture of the sacrum 304\\n3. Fracture of the coccyx 305\\n4. Fracture of the ilium 306\\n5. Fracture of the ischium 307\\n6. Fracture of the pubis 307\\n7. Fracture of the rim of the acetabulum 308\\nCHAPTER XXIII.\\nFRACTURES OF THE FEMUR.\\n1. Fractures at the upper end of the femur 309\\nA. Fractures of the head of the femur 310\\nB. Fracture of the neck of the femur 310\\nCauses 313\\nPathology 314\\n(a) Fractures through the neck 314\\n(6) Separation of the epiphysis 316\\n(c) Fractures at the base of the neck 318\\nRepair 320\\nSymptoms and diagnosis 325\\nPrognosis 331\\nTreatment 334\\nC. Fractures through the trochanter and neck 339\\nD. Fracture of the great trochanter 340\\nE. Fracture of the trochanter minor 340\\n2. Fractures of the shaft of the femur 341\\n3. Fractures of the lower end of the femur 350\\nA. Intercondyloid fractures 350\\nB. Separation of the epiphysis 353\\nC. Fracture of either condyle 355\\nCHAPTER XXIV.\\nFRACTURES OF THE PATELLA.\\nCause 358\\nPathology 359\\nSymptoms 361\\nTreatment 364\\nNon-operative 365\\nOperative 368\\nFor relief of disability 372\\nFor refracture 373\\nCHAPTER XXV.\\nFRACTURES OF THE BONES OF THE LEG.\\n1. Fractures of the upper end 374\\nSeparation of the epiphysis 376\\nAvulsion of the spine of the tibia 376\\nAvulsion of the tubercle of the tibia 376\\n2. Fractures of the shaft 377", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0015.jp2"}, "16": {"fulltext": "x CONTENTS.\\nPAGE\\nEtiology 195\\nSymptoms and course 196\\nSimultaneous fractures of both clavicles 198\\nTreatment 199\\nCHAPTER XVIII.\\nFRACTURES OF THE SCAPULA.\\n1. Of the body of the scapula 206\\n2. Of the inferior angle 208\\n3. Of the upper angle 209\\n4. Of the spine 209\\n5. Of the acromion 209\\n6. Of the coracoid process 211\\n7. Of the neck 212\\n8. Of the glenoid cavity 213\\nCHAPTER XIX.\\nFRACTURES OF THE HUMERUS.\\n1. Fractures of the upper end of the humerus 215\\nA. Fractures of the head 216\\nB. Fractures of the anatomical neck and fracture through the tuberosities 216\\nC. Fractures of the tuberosities 221\\nD. Separation of the epiphysis 223\\nE. Fracture of the surgical neck 226\\nSymptoms, diagnosis, prognosis, treatment 229\\n2. Fractures of the shaft of the humerus 233\\n3. Fractures of the lower end of the humerus 237\\nA. Fractures above the condyles supracondyloid 239\\nB. Fractures of the internal epicondyle 244\\nC. Fractures of the external epicondyle 246\\nD. Fractures of the internal condyle 246\\nE. Fractures of the external condyle 248\\nF. Intercondyloid, T-shaped fractures 251\\nG. Separation of the epiphysis 253\\nH. Fractures of the articular process 255\\nOf the capitellum. Of the trochlea 256\\nDiagnosis 257\\nTreatment 258\\nCHAPTER XX.\\nFRACTURES OF THE BONES OF THE FOREARM.\\n1. In the vicinity of the elbow-joint 259\\nA. Olecranon 259\\nB. Coronoid process 266\\nC. Of the head and neck of the radius 268\\n2. Fractures of the shaft 271\\nFractures of the shafts of both bones 271\\nB. Of the shaft of the ulna 276\\nC. Of the shaft of the radius 278\\n3. Fractures in the vicinity of the wrist 279\\nA. Fractures of the radius. Colles s fracture 279\\nCause 283\\nSymptoms 285\\nTreatment 287\\nB. Fractures at the wrist other than Colles s 289\\nCHAPTER XXI.\\nFRACTURES OF THE CARPUS AND HAND.\\n1. Fractures of the carpal bones 293\\n2. Fractures of the metacarpal bones 293\\n3. Fractures of the phalanges 295", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0018.jp2"}, "17": {"fulltext": "CONTENTS. xi\\nCHAPTER XXII.\\nFRACTURES OF THE PELVIS.\\nPAGE\\n1. Fractures of the ring of the pelvis 297\\nSeparation of the symphysis pubis 298\\nSeparation in front and behind 299\\nSeparation of the sacro-iliac synchondrosis 299\\nSeparation of all three joints 299\\nFracture of the pubic portion of the pelvic ring 300\\nFracture of the lateral portion 300\\nCourse, diagnosis, treatment 303\\n2. Transverse fracture of the sacrum 304\\n3. Fracture of the coccyx 305\\n4. Fracture of the ilium 306\\n5. Fracture of the ischium 307\\n6. Fracture of the pubis 307\\n7. Fracture of the rim of the acetabulum 308\\nCHAPTER XXIII.\\nFRACTURES OF THE FEMUR.\\n1. Fractures at the upper end of the femur 309\\nA. Fractures of the head of the femur 310\\nB. Fracture of the neck of the femur 310\\nCauses 313\\nPathology 314\\n(a) Fractures through the neck 314\\n(b) Separation of the epiphysis 316\\n(c) Fractures at the base of the neck 318\\nRepair 320\\nSymptoms and diagnosis 325\\nPrognosis 331\\nTreatment 334\\nC. Fractures through the trochanter and neck 339\\nD. Fracture of the great trochanter 340\\nE. Fracture of the trochanter minor 340\\n2. Fractures of the shaft of the femur 341\\n3. Fractures of the lower end of the femur 350\\nA. Intercondyloid fractures 350\\nB. Separation of the epiphysis 353\\nC. Fracture of either condyle 355\\nCHAPTER XXIV.\\nFRACTURES OF THE PATELLA.\\nCause 358\\nPathology 359\\nSymptoms 361\\nTreatment 364\\nXon-operative 365\\nOperative 368\\nFor relief of disability 372\\nFor refracture 373\\nCHAPTER XXV.\\nFRACTURES OF THE BONES OF THE LEG.\\n1. Fractures of the upper end 374\\nwSeparation of the epiphysis 376\\nAvulsion of the spine of the tibia 376\\nAvulsion of the tubercle of the tibia 376\\n2. Fractures of the shaft 377", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0019.jp2"}, "18": {"fulltext": "xii CONTENTS.\\nPAGE\\n3. Fractures at the lower end of the leg 381\\nA. Comminuted fracture of the tibia 382\\nB. Supramalleolar fracture 382\\nC. Separation of the epiphysis of the tibia 383\\nD. Fractures by eversion and abduction, Pott s 383\\nE. Fractures of the malleoli by inversion 391\\nF. Of the posterior portion of articular surface 392\\n4. Fractures of the fibula 394\\nA. Of the upper end 394\\nB. Of the shaft 394\\nC. Separation of epiphysis 395\\nCHAPTER XXVI.\\nFRACTURES OF THE BONES OF THE FOOT.\\n1. Of the astragalus 395\\n2. Of the calcaueum 396\\nOf the sustentaculum 398\\nBy muscular action 399\\n3. Fractures of the metatarsal bones 400\\n4. Fractures of the phalanges 400\\nDISLOCATIONS.\\nCHAPTER XXVII.\\nGENERALITIES.\\nDefinitions 405\\nStatistics 407\\nCHAPTER XXVIII.\\nETIOLOGY AND MECHANISM.\\nA. Predisposing causes 410\\nB. Immediate or determining causes 411\\nRecurrent or habitual dislocations 412\\nCHAPTER XXIX.\\nPATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS COMPLICATIONS J PROCESS OF\\nREPAIR AFTER REDUCTION.\\nPathological anatomy 414\\nComplications 415\\nBones 415\\nBloodvessels 416\\nNerves 418\\nViscera 421\\nSoft parts and integument 42]\\nRepair 422\\nCHAPTER XXX.\\nPATHOLOGY OF UNREDUCED (ANCIENT) DISLOCATIONS 425", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0020.jp2"}, "19": {"fulltext": "CONTENTS. xni\\nCHAPTER XXXI.\\nSYMPTOMS AND DIAGNOSIS.\\nPAGE\\nObjective signs 430\\nDeformity 430\\nLoss of mobility 432\\nCrepitus 433\\nSubjective symptoms 433\\nPain 433\\nLoss of function history 433\\nCHAPTER XXXII.\\nCOURSE AND PROGNOSIS 435\\nCHAPTER XXXIII.\\nTREATMENT.\\nSpontaneous reduction 437\\nObstacles to reduction 437\\nAnaesthesia 439\\nMethods of reduction 440\\nOld dislocations 445\\nAfter-treatment 447\\nHabitual dislocation 448\\nCHAPTER XXXIV.\\nACCIDENTS THAT MAY BE CAUSED BY ATTEMPTS TO REDUCE A DISLOCATION 449\\nIntegument 450\\nEmphysema of the cellular tissue 450\\nRupture of the muscles 451\\nAvulsion of a portion of a limb 451\\nInjuries of the main bloodvessels 451\\nInjuries to nerves 457\\nFracture 459\\nInflammation, suppuration, gangrene 460\\nPersistent oedema 461\\nSyncope and sudden or early death fat embolism 461\\nCHAPTER XXXV.\\nCONGENITAL DISLOCATIONS.\\nStatistics 463\\nEtiology 464\\nPathology (hip) 468\\nSymptoms and diagnosis 471\\nPrognosis 473\\nTreatment 473\\nCHAPTER XXXVI.\\nSPONTANEOUS DISLOCATIONS 475\\nBy distention 476\\nParalytic 477\\nVoluntary 477\\nBy destruction by deformity 477\\nCHAPTER XXXVII.\\nDISLOCATIONS OF THE LOWER JAW.\\nBackward with fracture 479\\nUpward 479\\nOutward 480", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0021.jp2"}, "20": {"fulltext": "xiv CONTENTS.\\nPAGE\\nForward 480\\nPathology 481\\nSymptoms 483\\nPrognosis 483\\nTreatment 483\\nPathological 485\\nCongenital 486\\nCHAPTER XXXVIII.\\nDISLOCATIONS OF THE VERTEBRAE AND OF THE OCCIPUT FROM THE ATLAS.\\nClassification and pathology 488\\nSecondary changes -193\\nEtiology 494\\nSymptoms and diagnosis 494\\nPrognosis 496\\nTreatment 497\\nDislocations of the occiput 498\\nDislocations of the atlas 500\\nDislocations of the lower six cervical vertebrae 503\\nDislocations of the dorsal vertebra? 509\\nDislocations of the lumbar vertebra? 511\\nCHAPTER XXXIX.\\nDISLOCATIONS OF THE STERNUM.\\nOf the body from the manubrium 513\\nOf the ensiform process 517\\nCHAPTER XL.\\nDISLOCATIONS OF THE RIBS AND COSTAL CARTILAGES.\\nOf the head of the rib 518\\nOf the ribs from the costal cartilages 519\\nOf the costal cartilages from the sternum 520\\nOf one cartilage from another 522\\nCHAPTER XLI.\\nDISLOCATIONS OF THE CLAVICLE.\\n1 Of the sternal end 523\\nForward 524\\nBackward 527\\nUpward m 529\\n2. Of the acromial end 531\\nSupra-acromial 532\\nSubacromial 537\\nSubcoracoid 540\\n3. Simultaneous of both ends 540\\nCHAPTER XLII.\\nDISLOCATIONS OF THE SHOULDER.\\nAnatomy 542\\nStatistics 546\\nClassification 547\\nAnterior (and downward) dislocations 552\\n1. Subcoracoid 553\\nPathology 555\\nSymptoms and diagnosis 559\\n2. Intracoracoid 560", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0022.jp2"}, "21": {"fulltext": "CONTENTS. xv\\nPAGE\\nTreatment of anterior dislocations 563\\nDirect reposition traction downward and outward 564\\nTraction upward 566\\nTraction with leverage 567\\nHeel in the axilla 567\\nForcible traction 568\\nManipulation 569\\nAfter-treatment 573\\nCHAPTEK XLIII.\\ndislocations or the shoulder Continued.\\nDownward dislocations 574\\n1. Subglenoid 574\\nSymptoms treatment 577\\n2. Luxatio erecta 577\\n3. Subtricipital dislocation 578\\nPosterior dislocations (subacromial, subspinous) 579\\nSymptoms 583\\nDiagnosis and treatment 584\\nUpward dislocations (supraglenoid, supracoracoid) 585\\nCHAPTER XLIV.\\ndislocations or the shoulder Continued.\\nAssociated injuries and complications 590\\nLaceration of muscles 590\\nFractures 591\\nNerves 594\\nVessels. Chest. Compound 595\\nSimultaneous of both shoulders 595\\nPrognosis and after-treatment 596\\nHabitual dislocation 598\\nTreatment of old dislocations 601\\nSubcutaneous section 601\\nArthrotomy 602\\nExcision of the head of the humerus 603\\nFracture of the surgical neck 603\\nCongenital dislocations 603\\nPathological dislocations and subluxations 608\\nDislocations due to paralysis 609\\nCHAPTER XLV.\\nDISLOCATIONS OF THE ELBOW.\\nAnatomy 611\\nFrequency. Classification 613\\nDislocations of the forearm backward 614\\nMechanism 614\\nPathology 616\\nComplications .617\\nSymptoms 618\\nDiagnosis 619\\nPrognosis 620\\nTreatment 621\\nLateral dislocations 624\\nIncomplete lateral 625\\nA. Inward 626\\nB. Outward 627\\nComplete outward 631\\nForward dislocations 635\\nDivergent dislocations of the radius and ulna 639\\nA. Antero-posterior 640\\nB. Transverse 642", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0023.jp2"}, "22": {"fulltext": "xvi CONTENTS.\\nCHAPTER XLVI.\\ndislocations of the elbow Continued.\\nPAGE\\nDislocation of the ulna alone 643\\n1. Backward 644\\n2. Inward 647\\n3. Forward 647\\nDislocation of the radius alone 647\\n1. Backward 648\\n2. Outward 651\\n3. Forward 654\\n4. By elongation, or subluxation in children 657\\nDislocation of the head of the radius with fracture of the ulna 662\\nCHAPTER XLVII.\\ndislocations of the elbow Continued.\\nTreatment of old dislocations 664\\nCongenital and pathological dislocations 669\\nCHAPTER XLVIII.\\ndislocations at the wrist.\\nDislocations of the lower radio-ulnar joint 672\\nBackward 672\\nForward 673\\nInward and downward 674\\nDislocations of the radio-carpal joint 674\\nBackward 676\\nForward 678\\nOutward 680\\nPathological subluxation forward 680\\nCongenital 684\\nDislocations of the carpal bones 685\\nMedio-carpal 685\\nIsolated dislocations of the carpal bones 686\\nScaphoid 687\\nSemilunar 687\\nUnciform pisiform os magnum 688\\nTrapezoid _ 689\\nTrapezium os magnum and trapezoid 690\\nCarpo-metacarpal dislocations 690\\nCHAPTER XLIX.\\ndislocations of the thumb and fingers.\\nProximal phalanx of thumb 696\\nAnatomy 696\\nBackward 697\\nForward 700\\nLateral 701\\nMetacarpophalangeal of the fingers 702\\nBackward 702\\nForward 703\\nDislocations of the middle phalanges 703\\nBackward 703\\nForward 704\\nLateral 704\\nDislocations of the distal phalanges 704\\nBackward 705\\nForward 705\\nLateral 705", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0024.jp2"}, "23": {"fulltext": "CONTENTS. xv ll\\nCHAPTER L.\\nDISLOCATIONS OF THE PELVIS AND OF THE COCCYX.\\nPAGE\\nDislocations of the pelvis 707\\nDislocations of the coccyx 707\\nForward 708\\nBackward 709\\nLateral 709\\nCHAPTER LI.\\nDISLOCATIONS OF THE HIP.\\nAnatomy 710\\nStatistics ...713\\nSimultaneous dislocation of both hips 714\\nCompound dislocations 714\\nClassification 716\\nBackward dislocations 720\\n1. Dorsal dislocations 721\\nCauses 721\\nPathology 722\\nSymptoms 725\\nDiagnosis 727\\n2. Everted dorsal dislocations 728\\nPathology 729\\nAnterior oblique 730\\nSymptoms 730\\nTreatment of backward dislocations 731\\nCHAPTER LII.\\ndislocations of the hip Continued.\\nDislocations downward and inward 736\\nObturator or thyroid dislocations 736\\nCause 736\\nPathology 737\\nSymptoms 738\\nTreatment 739\\nPerineal dislocations 741\\nDislocations upward and forward, and inward and forward (suprapubic) 742\\nIliopectineal pubic intrapelvic 742\\nPathology 743\\nSymptoms 745\\nTreatment 746\\nDislocations directly upward (subspinous supracotyloid) 747\\nDislocations directly downward (infracotyloid) 751\\nCHAPTER LIII.\\ndislocations of the hip Continued.\\nComplications 754\\nMuscles. Bloodvessels 754\\nNerves. Fractures 755\\nSimultaneous dislocation of both hips 757\\nAccidents caused by attempts to reduce 758\\nPrognosis and after-treatment 759\\nHabitual dislocations 759\\nTreatment of old unreduced dislocations 760\\nCongenital dislocations 762\\nSpontaneous or pathological dislocations 762", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0025.jp2"}, "24": {"fulltext": "xvin CONTENTS.\\nCHAPTER LIV.\\nDISLOCATIONS OF THE KNEE.\\nPAGE\\nAnatomy 765\\nStatistics 766\\nDislocations forward 767\\nDislocations backward 771\\nLateral dislocations 773\\n1. Outward dislocations 773\\n2. Inward dislocations 776\\nAnterolateral dislocations 777\\nDislocations by rotation 777\\nOutward 777\\nInward 779\\nDislocation of the semilunar cartilages 780\\nCongenital dislocations 783\\nSpontaneous or pathological dislocations 785\\nCHAPTER LV.\\nDISLOCATIONS OF THE PATELLA.\\nGeneral considerations 786\\nOutward dislocations 789\\n1. Complete 789\\n2. Incomplete 792\\n3. Outward edgewise, or vertical 793\\nInward dislocations 794\\nInward edgewise, or vertical 795\\nComplete reversal 795\\nCongenital dislocations 796\\nHabitual or pathological dislocations 797\\nCHAPTER LVI.\\nDISLOCATIONS OF THE FIBULA.\\nDislocations of the upper end 799\\n1. Forward 799\\n2. Backward 800\\n3. Upward 800\\nDislocations of the lower end 801\\nSpontaneous or pathological dislocations 801\\nCHAPTER LVII.\\nDISLOCATIONS AT OR NEAR THE ANKLE.\\nAnatomy 803\\nDislocations of the foot. Tibio-tarsal dislocations 804\\n1. Dislocations backward 804\\n2. Dislocations forward 806\\n3. Dislocations inward 807\\n4. Dislocations outward 808\\n5. Compound and complicated dislocations 809\\nSubastragaloid dislocations 809\\n1. Dislocations inward or inward and backward 810\\n2. Dislocations outward 811\\n3. Dislocations backward 812\\n4. Dislocations forward 813\\nDiagnosis 814\\nTreatment 814", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0026.jp2"}, "25": {"fulltext": "CONTENTS. xix\\nPAGE\\nTotal dislocations of the astragalus 816\\n1. Forward 816\\n2. Outward and forward 816\\n3. Inward and forward 817\\n4. Inward 817\\n5. Backward 817\\n6. Bv rotation 818\\nTreatment 822\\nMedio-tarsal dislocation 823\\nCongenital dislocations of the ankle-joint 824\\nCHAPTER LVIII.\\nDISLOCATIONS OF THE TARSAL AND METATARSAL BONES AND OF THE TOES.\\nCalcaneum 825\\nScaphoid 825\\nCuboid 825\\nCuneiform bones 826\\nOf the metatarsal bones from the tarsus and from one another 826\\nSubluxation of the head of a metatarsal bone 828\\nDislocations of the toes 828\\n1. Metatarso-phalangeal dislocations 828\\nOf the great toe 828\\nOf the other toes .829\\n2. Dislocations of the phalanges 829", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0027.jp2"}, "26": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0028.jp2"}, "27": {"fulltext": "LIST OF PLATES.\\nPLATE\\nPAGE\\nI. Recent gunshot fracture of carpus and radius 32\\nII. Same as Plate I., after repair 32\\nIII., A.\u00e2\u0080\u0094 Fig. 1. Periosteal bridge; fracture of forearm. Fig. 2. Periosteal\\nbridge humerus two years after injury 36\\nIII., B\u00e2\u0080\u0094 Same as Plate III., A, fig. 2; injury recent 36\\nIV. Fracture of surgical neck of humerus in a child 227\\nV. Fig. 1. Gunshot fracture of humerus by small ball. Fig. 2. Fracture\\nof lower third of forearm 234\\nVI.\u00e2\u0080\u0094 Figs. 1 and 2. Cubitus varus; front and rear views. Fig. 3. Frontal\\nsections of same 242\\nVII. Fig. 1. Old supra-condyloid fracture of humerus cubitus varus. Fig.\\n2. Same; followed by fracture of external condyle 242\\nVIII. Fig. 1. Fracture of head and neck of radius. Fig. 2. Cubitus varus,\\nthree years after a low partial supra-condyloid fracture or sepa-\\nration of the epiphysis 242\\nIX. Fig. 1. Fracture of olecranon dislocation forward of radius and ulna.\\nFig. 2. Fracture of forearm angular displacement 242\\nX. Fig. 1. Fracture of radius; marked angular displacement. Fig. 2.\\nRecent Colles s fracture in a boy 12 years old 282\\nXL Fig. 1. Recent Colles s fracture male, 22 years old (Plate XV., fig.\\n1). Fig. 2. Old Colles s fracture 288\\nXII. Fig. 1. Recent Colles s fracture, comminuted; male, 45 years old.\\nFig. 2. Recent Colles s fracture, comminuted male, 40 years\\nold (Plate XV., fig. 2) 288\\nXIII. Fig. 1. Recent Colles s fracture male, 26 years old Fig. 2. Same as\\nFig. 1, side view 288\\nXIV.\u00e2\u0080\u0094 Fig. 1. Same as Plate XIII., after reduction. Fig. 2. Recent Colles s\\nfracture male, 56 years old 288\\nXV.\u00e2\u0080\u0094 Fig. 1. Recent Colles s fracture; male, 22 years old (Plate XL, fig. 1).\\nFig. 2. Recent Colles s fracture; male, 40 years old (Plate\\nXIL, fig. 2) 288\\nXVI. Recent Colles s fracture female, both wrists 288\\nXVII. Fig. 1. Colles s fracture at 12 years; arrest of growth. Fig. 2. Sepa-\\nration of radial epiphysis boy 1 5 years old 288\\nXVIII. Fig. 1. Normal wrist; adult male. Fig. 2. Normal wrist; adult\\nfemale, fracture of third metacarpal 28S\\nXIX. Fig. 1. Fracture of carpal scaphoid. Fig. 2. Separation of lower\\nepiphysis of femur 293\\nxxi", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0029.jp2"}, "28": {"fulltext": "xxn LIST OF PLATES.\\nPLATE PAGE\\nXX. Fig. 1. Fracture of patella, three months later non-operative treat-\\nment. Fig. 2. Fracture of patella, two months after mediate\\nsuture 360\\nXXI. Fig. 1. Fracture of patella, three years after periosteal suture. Fig.\\n2. Fracture of patella, three months after periosteal suture 364\\nXXII. Fig. 1. Pott s fracture by eversion in a youth. Fig. 2. Fracture of\\nthe posterior portion of the lower end of tibia 368\\nXXIII. Fig. 1. Pott s fracture by abduction. Fig. 2. Pott s fracture, two\\nmonths old backward displacement (Plate XXIV., fig. 1) 384\\nXXIV.\u00e2\u0080\u0094 Fig. 1. Pott s fracture by abduction; same as Plate XXIII., fig. 2).\\nFig. 2. Bimalleolar fracture by inversion 384\\nXXV. Fig. 1. Bimalleolar fracture by inversion in youth. Fig. 2. Fract-\\nure of femur remaining ununited a year after wiring 392\\nXXVI. Fracture of upper posterior angle of os calcis 400\\nXXVII. Fig. 1. Congenital dislocation of the hip. Fig. 2. Dislocation of\\nsemilunar bone 470\\nXXVIII. Congenital dislocation of the shoulder 606\\nXXIX. Fig. 1. Old dislocation backward of os magnum, side view. Fig. 2.\\nOld dislocation backward of os magnum, antero-posterior 688\\nXXX.\u00e2\u0080\u0094 Fresh dorsal dislocation of the thumb 696\\nXXXI. Fig. 1. Anterior dislocation of the knee. Fig. 2. Posterior disloca-\\ntion of the knee 768", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0030.jp2"}, "29": {"fulltext": "FRACTURES.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0031.jp2"}, "30": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0032.jp2"}, "31": {"fulltext": "A TREATISE\\nFRACTURES AND DISLOCATIONS.\\nCHAPTER I\\nINTRODUCTION.\\nBy Fracture, in the surgical sense of the term, is meant the breaking\\nof a bone or cartilage.\\nThe liability to fracture of the different bones of the body varies\\ngreatly, in consequence of their differences in size, shape, and degree of\\nexposure to external violence or extreme muscular action. Hospital\\nrecords covering periods varying in length from five to eighty-seven\\nyears have been tabulated by different writers, with the object of deter-\\nmining the relative degree of this liability but it is evident that such\\nstatistics cannot contain all the needed facts, for the reason that patients\\nwith fractures which do not necessitate confinement to the bed do not so\\ngenerally seek hospital care as those with fractures which do. Com-\\nbined hospital and dispensary statistics are more nearly correct, but\\neven they differ considerably from one another in their percentages,\\npossibly because of differences in the occupations and mode of life of\\nthe communities which furnished them. During the past six years I\\nhave had the records of the House of Relief Hudson Street Hos-\\npital of which I am the attending surgeon, kept with a view to\\nthis tabulation, and the results are given in the following table. The\\nhospital is the only one in New York City below Canal Street, a region\\nlargely given over to trade, transportation, and manufacturing, with\\nfrequent construction of large buildings, and in which there is only a\\nlaboring resident population. The ambulance cases number about\\n3500 yearly, the surgical dispensary cases about 30,000.\\nHudson Street Hospital, New York: Statistics of Fractures Treated\\nin Hospital and Dispensary, 1894-1899.\\nCases. Cases. Per cent.\\nCranium 360 Head 360 5.21\\nMalar bone 11\\nNasal bones 323\\nSuperior maxilla 20\\nInferior maxilla .193\\nZygoma 10\\nFace 557 8.07\\n19", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0033.jp2"}, "32": {"fulltext": "20\\nFRACTUEES.\\nSpine 31\\nPelvis 29\\nCoccyx 3\\nSternum 3\\nKibs 774\\nUpper extremity 132\\nClavicle 310\\nScapula 29\\nHumerus, shaft and neck 168\\ninternal condyle 32\\nexternal condyle 24\\nlower end 36\\ninternal epicondyle 6\\nEadius and ulna 102\\nEadius, shaft 183\\nColles s 547\\nUlna, shaft 164\\nolecranon 49\\nCarpus 4\\nMetacarpus 511\\nPhalanges 1184\\n1\\nI\\nTrunk\\nI\\nJ\\nFemur\\nPatella\\nTibia, or tibia and fibula\\nAbduction and adduction\\nfractures at ankle\\nFibula\\nExternal malleolus\\nInternal malleolus\\nTarsus\\nMetatarsus 121\\nToes 135 J\\n232 1\\n86\\n447\\n453\\n78\\n15\\n9\\n90\\nCases.\\n840\\nPer cent.\\n12.17\\nUpper extremity\\n3481\\n50.37\\nLower extremity\\n1666\\n24.14\\nTotal\\n6904\\nDuring the same period 705 dislocations were treated.\\nSex. Fractures are more numerous in men than in women, in the\\nproportion of about three to one but this proportion varies greatly at\\ndifferent ages. In infancy the difference is slight; in middle life frac-\\ntures are ten times as frequent in men as in women between the ages\\nof fifty and seventy years the difference again becomes slight, and after\\nthe age of seventy years fractures are much more common in women\\nthan in men, a reversal of conditions due to a disproportionate increase\\nin the number of fractures of the neck of the femur.\\nAge. Gurlt l tabulated 1383 cases (hospital and dispensary) with ref-\\nerence to the ages of the patients, and found in the first decade, 265\\nin the second, 193 in the third, 274 in the fourth, 224 in the fifth,\\n154 in the sixth, 155 in the seventh, 72 in the eighth, 38, and in\\nthe ninth, 8. Combining these with statistics showing the relative\\nnumber of people living at the different ages, he found the highest\\nproportion of fractures in the period above the age of sixty years.\\nMalgaigne 2 made a similar tabulation, using only hospital cases, and\\ngrouping in periods of five years he found that the periods between\\nfifty -five and eighty were practically equal to one another, and gave the\\nhighest proportion according to population.\\n1 Gurlt Handbuch der Lehre von den Knochenbruchen, 1862.\\n2 Malgaigne Traite des Fractures et des Luxations, 1847.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0034.jp2"}, "33": {"fulltext": "INTRODUCTION.\\n21\\nSeason affects the frequency of fracture only by increasing or dimin-\\nishing- the exposure to the accidents which occasion them. Falls due\\nto ice and snow in winter are more than offset as a cause by the more\\nvaried and active occupations of the milder months, and fractures are,\\ntherefore, less frequent in winter than in summer. This is shown by\\nthe following tabulation of the fractures treated in the Hudson Street\\nHospital, according to months\\nHudson Street Hospital: Fractures in 1896, Wards and Dispensary.\\nJanuary, 77 March, 130 June, 82 September, 105\\nFebruary,\\nDecember,\\nOmitting hand)\\nand toes, J\\n88\\n119\\n284\\n57\\n227\\nApril,\\nMay,\\n130\\n103\\n97\\n330\\n84\\n246\\nJuly,\\nAugust,\\n148\\n150\\n380\\n104\\n276\\nOctober, 107\\nNovember, 116\\n328\\n92\\n236\\nThe maximum is found in the summer months, the minimum in the\\nwinter. It is only in fractures of the leg that the winter season heads\\nthe list, and yet even in these, as the following table shows, a decided\\nmonthly maximum is found in March, a month in which there is but\\nlittle snow and ice in New York\\nFractures of the Leg, of either Bone, and Pott s Fracture.\\nJanuary,\\n19\\nMarch,\\n29\\nJune,\\n9\\nSeptember,\\n8\\nFebruary,\\n20\\nApril,\\n9\\nJuly,\\n11\\nOctober,\\n6\\nDecember,\\n21\\nMay,\\n12\\nAugust,\\n25\\nNovember,\\n20\\n60\\n50\\n45\\n34\\nFractures of the femur (shaft and neck) give the following totals\\nWinter 16, spring 17, summer 8, autumn 12 those of the upper ex-\\ntremity (clavicle, humerus, and either or both bones of the forearm)\\ngive Winter 67, spring 63, summer 107, autumn 72.\\nNote. For other statistics see Malgaigne, Gurlt, and the first edi-\\ntion of this work also Wallace, American Journal of the Medical\\nSciences, 1839 Norris, Ibid., 1841 Lente, New York Medical Journal,\\n1851, and Lonsdale, Fractures, 1838.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0035.jp2"}, "34": {"fulltext": "CHAPTER II.\\nPATHOLOGY.\\nThe Bone Varieties Incomplete, Complete, Multiple, Compound, Gunshot.\\nDisplacements. The soft parts.\\n(A) THE BONE\u00e2\u0080\u0094 VARIETIES OF FRACTURE.\\nThe varieties of fracture are numerous and are constituted by\\ndifferences in the extent of the injury to the bone or to the surrounding\\nsoft parts, in the seat, shape, and direction of the fracture, in the rela-\\ntion of the fragments to each other, and in the number of bones\\ninvolved. These varieties may be grouped in five divisions, marked\\nby important clinical differences and containing many subdivisions, as\\nfollows\\n1. Incomplete fractures,\\n(a) Fissures.\\n(6) True incomplete, green -stick; bent bone.\\n(c) Depressions.\\n(d) Separation of a splinter or of an apophysis.\\n2. Complete fractures, subdivided, according to\\n(a) Direction and character of the line of fracture, into transverse,\\noblique, longitudinal, spiral, toothed or dentate, Y-, Y-, or T-shaped,\\nand comminuted\\n(b) Seat of the fracture, into fracture of the shaft, of the neck, of the\\nupper, middle, or lower third, intercondyloid, separation of epiphysis\\nand\\n(c) If extending into a joint, intra-articular.\\n3. Multiple fractures, comprising fractures of two or more non-\\nadjacent bones and two or more fractures of the same bone.\\n4. Compound fractures.\\n5. Gunshot fractures.\\nThe term simple fracture is commonly used, in contradistinction to\\nthe term compound, to indicate that there is no associated wound of the\\nsoft parts which establishes communication between the fracture and\\nthe exterior. Some writers make also a class of complicated fractures\\nto include cases in which some important injury coexists and there are\\nstill other terms in use to indicate peculiarities which do not lend them-\\nselves easily to the above classification. Such are Spontaneous frac-\\nture, one produced by the minimum of violence pcdholor/ical fracture,\\none favored by weakening or partial destruction of the bone by disease\\ndirect fracture, one occurring at the point where the causative external\\nviolence is received indirect fracture, one occurring at a distance from\\nthat point recent and old, or ununited, fracture. This classification is\\nnot claimed to be absolutely correct in the scientific or even in an ana-\\n22", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0036.jp2"}, "35": {"fulltext": "PATHOLOGY.\\n23\\ntomical sense, but it is a serviceable and, with some variations, a com-\\nmon one.\\nFig. 1.\\n1. Incomplete Fractures.\\nUnder this head will be considered fractures in which the continuity\\nof the bone has not been completely lost or a fragment has not been\\ncompletely detached.\\n(a) Fissures. This variety is characterized by the existence of a\\nsplit or crack in the bone, one which does not entirely circumscribe a\\nfragment and separate it from the rest of the bone. It is of common\\noccurrence in the bones of the cranium, and very rare in the long bones\\nexcept when associated with other varieties. It is almost unknown in\\nthe short or spongy bones.\\nThe examples of isolated fissure of long bones are very rare. Fig.\\n1, copied by Gurlt from Froriep, represents one extending from the\\ngreater tuberosity of the humerus to the lower fourth of the shaft, pro-\\nduced in a boy by a fall upon the elbow. Fissures connected with\\ncomplete fracture are common are sometimes very long, and may\\nextend into a neighboring joint. A very long fissure is sometimes\\ntermed a longitudinal fracture.\\nThe mechanism by which a long\\nisolated fissure is produced in a long\\nbone is probably the forcible bend-\\ning of the bone. This is plainly\\nindicated in a case reported by De-\\nbrou in 1843, and quoted by Gurlt as\\na case of infraction. The patient, a\\nman sixty-two years old, fell while\\nwalking, and injured his thigh. Ery-\\nsipelas set in and caused his death.\\nAt the autopsy a fissure was found\\nunder the untorn periosteum, extend-\\ning six inches downward from the tro-\\nchanter minor, and this fissure could\\nbe made to widen by pressure upon\\nthe ends of the bone.\\nThe diagnosis cannot be made with\\ncertainty, except when the bone is ex-\\nposed to direct examination but it\\ncan be inferred with much proba-\\nbility in some forms of fracture with\\nwhich it is usually associated, such as\\nY-shaped fractures of the tibia.\\nExcept when it extends into a joint\\nthe importance of a fissure is probably slight, and is dominated by\\nthat of the associated lesions. In some cases the injury has been\\npromptly or tardily followed by suppuration beneath the periosteum\\nor within the bone.\\n(6) True Incomplete, Green-stick Fracture Infraction Bent Bone,\\nFissure of\\nthe humerus.\\n(Gurlt.)\\nPartial fracture of the\\nfibula, a, the head; b,\\nthe malleolus.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0037.jp2"}, "36": {"fulltext": "24 FRACTURES.\\nor Curvature Without Fracture. This variety is characterized by a frac-\\nture involving only a portion of the thickness of a long bone, and\\ncombined with a bending of the bone at the seat of fracture. In its\\nconsideration is included also that of the rare cases of curvature with-\\nout recognizable fracture, a variety which has only an academical\\ninterest, for it cannot be recognized clinically. Its possibility has been\\ndemonstrated experimentally upon young animals and by a single\\nspecimen belonging to Prof. Uhde, the ulna of an adult much bent by\\na machinery accident, and showing no trace of fracture.\\nThe injury appears ordinarily as a short transverse fracture, continu-\\nous with one or more longitudinal ones of variable length sometimes\\nthere is no transverse line, but only oblique ones running from the\\nangle upward or downward. The appearance can be closely imitated\\nby over-bending a green or tough stick, a fact that has given this form\\nof fracture a name by which it is very commonly known.\\nA few instances are recorded of supposed incomplete fracture of the\\nneck of the femur, but the conditions are quite different, because of the\\nspongy character of this portion of the bone. The lesion is on the\\nconcave side and is a crush, not a crack.\\nThis fracture is seen most frequently in the bones of the forearm,\\nthen in the clavicle, and very rarely in the bones of the arm, leg, and\\nthigh. The great majority of cases occur in those under the age of\\nfifteen years. In the forearm it may be found in only one bone, the\\nother being completely broken. The usual cause is a fall, but I have\\nseen several cases in which the cause was the forcible bending of the\\nforearm over a rigid body, as when the limb is caught between a shaft\\nand its belting.\\nThe chief symptoms are deformity, consisting in an angular devia-\\ntion of a portion of the limb or bone, and localized pain on pressure at\\nthe angle. The deviation can be more or less completely corrected by\\nthe use of force, and the correction may be accompanied by crepitus and\\nfollowed by abnormal mobility, the fracture having been made complete.\\nThe prognosis is favorable as regards correction of the deformity and\\nrepair. Ordinarily, the limb can be straightened by the surgeon s\\nhands alone, aided, perhaps, by the pressure of his knee against the\\nangle and the surgeon should not be deterred, by the fear of making\\nthe fracture complete, from using all the force that is necessary.\\n(c) Depressions. I limit the use of this term to those cases in which\\na portion of the outer layer of a flat bone or the spongy portion of a\\nlong bone is driven inward by direct violence, usually a blow with a\\npointed instrument. The injury is most frequently seen in the vault\\nof the skull, and is there generally termed a fracture of the outer table.\\nIt is occasionally seen in the limbs in connection with complete fracture.\\n(c?) Separation of a Splinter or of an Apophysis. In this variety are\\nincluded two classes of fractures which diifer widely in their mode of\\nproduction, but have this in common that the fragment does not com-\\nprise the entire breadth or thickness of the bone, and that consequently\\nthe continuity of the latter is not destroyed. In the first class a\\nsplinter or fragment of bone is broken off by direct violence as by a\\ncutting instrument in the second class a bony prominence is torn off", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0038.jp2"}, "37": {"fulltext": "PATHOLOGY.\\n25\\nby the violent contraction of the muscle attached to it, or by traction\\nthrough a ligament.\\nThe separation of a splinter or scale of bone by a sword-cut or bullet\\nis not uncommon in the spongy bones or the spongy extremities of long\\nbones, and has also been known to occur in the shaft of the tibia. It\\nis an injury which should be classed rather among wounds of bones\\nthan among fractures. The separation of a splinter by direct violence,\\nunaccompanied by a wound of the soft parts, occurs in the bones of the\\nface, at the crest of the ilium, and at exposed points upon the extremi-\\nties of the long bones.\\nAvulsion of an apophysis, or of a scale of bone, by muscular action\\nis a far more common accident than the one just described. The lesion\\nconsists in the fracture of an apophysis at its base or in the tearing\\noff of a portion of bone to which a muscle or tendon is attached. The\\nfragment may consist of a thin layer of bone corresponding in extent\\nto the muscular attachment and composed almost exclusively of the\\ncortical substance, or it may comprise the entire thickness of an apoph-\\nysis, as in fracture of the olecranon or of the coracoid process of the\\nscapula. The internal malleolus may be torn off by forcibly bending\\nthe foot to the opposite side, or the epicondyle at the elbow by forced\\nlateral flexion of the forearm.\\n2. Complete Fractures.\\nThe term complete, when applied to a fracture of a long bone indi-\\ncates that the bone is divided into two or more distinct fragments by a\\nline of fracture crossing its long axis.\\n(a) Subdivision According to the Direction of the Fig. 3.\\nLine of Fracture. Such terms in use are transverse,\\noblique, splintered, spiral V-shaped, T- or Y-shaped,\\ndentate, and longitudinal. Apparently as a result\\nof physical conditions, fractures by direct or in-\\ndirect violence which bend a long bone are either\\npractically transverse or markedly oblique, with or\\nwithout splintering.\\nThe line of a transverse fracture does not de-\\nviate more than about 15 or 20 degrees from that\\nof the transverse axis that of an oblique fracture\\nlies near an angle of 50 degrees, but is usually\\nsomewhat curved, so that its point is sharper. A\\ntransverse fracture may be, but rarely is, exactly\\ntransverse and smooth (Fig. 3) clinically such\\ndetails cannot be recognized unless the fracture is\\ncompound, and the diagnosis of the variety is\\nmade on the fact that the end of the fragment can\\nbe felt through the overlying soft parts to be ap-\\nproximately square and smooth. In the oblique\\nvariety the line of fracture may be single (Fig. 5)\\nor multiple (Fig. 4), circumscribing in the latter m\\nx -l j i -i r\u00c2\u00bb t i Transverse fracture of the\\ncase one or more detached fragments which ap- less f emU r. (Gurlt.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0039.jp2"}, "38": {"fulltext": "26\\nFRACTURES.\\nparently are formed on the side of the concavity created by the\\nbending of the bone {splintered). The line of fracture in either\\nform may be markedly irregular on either or both fragments. When\\nthis irregularity is found on both fragments the term toothed or dentate\\nis applied when it is found only on one side the absence of a corre-\\nsponding line on the other is due to the crushing of the bone or to the\\nsplitting off of one or more large fragments.\\nSpiral fractures, which are rare, are produced by torsion of the bone,\\nand are found in the femur, humerus, and tibia. In the latter they\\nare better known as Y-shaped (Fig. 6), and can be readily recognized\\nFig. 4.\\nFig. 5.\\nOblique fracture by direct pressure.\\n(Kocher.)\\nSpiral fracture by outward rotation of\\nlower end. (Kocher.)\\nby the sharp point of the upper fragment, which can be felt midway\\nbetween the crest and the internal border of the bone. From the\\nre-entrant angle corresponding to this point a fissure runs down to the\\nankle-joint.\\nUnder the term longitudinal are included very oblique fractures run-\\nning from one side of the bone to the other, fractures running from\\none end of the bone to or nearly to the other, and fractures which split", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0040.jp2"}, "39": {"fulltext": "PATHOLOGY.\\n27\\nFig. 6.\\nlengthwise a long fragment intermediate between two transverse frac-\\ntures. The last-named form is produced only by great crushing\\nviolence, and the prognosis is very bad. In the other\\nforms the violence is indirect, apparently a bend or twist\\nof the bone or a blow received at one end the ill re-\\nsults which have so commonly followed appear to be due\\nin some to the implication of one or both joints or to a\\nfailure to recognize the injury and maintain immobility.\\nThe most marked cases are one reported by Kronlein, 1\\na fracture of the humerus from the shoulder to the\\nelbow-joint, in a man twenty-seven years old, by an\\nattempt to raise a heavy ladder, and one by Cloquet, in\\n1831, a fracture of the femur from the intercondyloid\\nnotch to a point just below the trochanter minor, by a\\nfall from a roof.\\nA comminuted fracture of the shaft of a long bone is\\none in which, in addition to the complete division of the\\nbone into two fragments, there is also extensive splinter-\\ning of the portion of bone adjoining the fracture or of\\none of the fragments (Figs. 7 and 8). In a comminuted\\nfracture of a flat bone the bone or a portion thereof is\\nbroken into several rather large fragments, with or\\nwithout additional small ones in this use of the term\\nfractures showing only two or three fragments, and\\nthose rather small, are excluded, the line of distinction\\nbeing of necessity vague and arbitrary. In the short\\nbones and the spongy ends of the long bones comminu-\\ntion is frequently associated with crushing of the spongy tissue, or the\\nFig. 7. Fig. 8.\\nV-shaped fracture.\\nComminuted fracture of the femur, Comminuted fracture of the lower\\nwith splitting of the condyles. end of the radius. Palmar aspect.\\n1 Kronlein Deutsche Zeitsch. f. Chir., 1873, p. 132.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0041.jp2"}, "40": {"fulltext": "28\\nFRACTURES.\\nend of the diaphyseal fragment may be driven into the expanded,\\nspongy end, crushing it or splitting it if the two main fragments are\\nrather firmly held together in their new relations the condition is\\ntermed impaction or impacted fracture (Fig. 9). If the crushing of the\\nspongy tissue has taken place without much splintering of the cortical\\nlayer the term fracture with crushing is used (Fig. 10). This crush-\\ning of spongy tissue is effected by breaking down the innumerable\\nfine lamellse of bone and forcing out the fat within the meshes, as a\\nhandful of snow or a wet sponge is compressed, and the result is\\nequivalent to an actual loss of tissue that is, if the main fragments\\nare replaced in their original positions a gap is left between them cor-\\nresponding to the position and extent of the crushing. This gap is\\noften too large to be filled by new bone formed during repair conse-\\nquently, a full correction of the displacement is inadvisable, even when\\npossible, lest failure of union should result, and the surgeon must be\\ncontent to obtain union with some deformity.\\nFig. 9.\\nFig. 10.\\nIntra-articular fracture of the head\\nof the tibia, with impaction and sepa-\\nration of the upper fragments.\\nFracture of the calcaneum, with crushing.\\n(b) Varieties Dependent Upon the Seat of the Fracture. A fracture\\nmay occupy any portion of the bone and be known by its name for\\nexample, fracture of the neck of the femur, of the lower third of the\\ntibia, of the head, of the shaft, of the inner condyle, of the acromion\\nintercondyloid fracture, when it passes across the shaft and also down-\\nward between the condyles separation of the epiphysis.\\nSeparation of the Epiphysis. 1 This term is limited to separation of\\nepiphyses which have not yet become united by bone with the shaft.\\nThis union takes place in the different bones at different ages, but is\\nusually complete in all in the female at the age of twenty-two years,\\nand in the male at twenty-five years. Bruns 2 collected 81 cases, with\\n101 separations, in which direct examination of the seat of injury was\\n1 The first work upon this subject is by G. C. Beichel, De Epiphysium ab Ossium\\nDiaphysi Diductione, published at Leipsic in 1794. Manquat s thesis, in 1877, and\\nBruns article, in 1878, were the first in which any considerable number of cases was\\ncollected. Later articles will be referred to in connection with the different epiphyses.\\nQuite recently, 1898, a large work upon the subject has been published by John Poland.\\n2 Bruns: Arch. f. klin. Chir., 1878, vol. xxii. p. 343.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0042.jp2"}, "41": {"fulltext": "PATHOLOGY. 29\\npossible the points of greatest frequency were the lower end of the\\nfemur 28, lower end of the radius 25, and upper end of the humerus\\n11. Of the 52 cases in which the age was given, 44 were between\\nten and nineteen years old, 8 between one and nine years. Of 61 in\\nwhich the line was exactly described, the line in 23 ran exactly along\\nthe face of the conjugal cartilage, in 5 it ran through the cartilage,\\nand in 33 partly along the cartilage and partly through the adjoining\\nchondroid tissue on its diaphyseal side. An important feature is\\nthe fact that the periosteum of the adjoining portion of the shaft is\\nfreely stripped off, preserving its continuity to a large extent with the\\nepiphysis.\\nThe mode of production appears usually to be by cross-strain, the\\nlimb being bent beyond the limit of normal motion in the correspond-\\ning joint or in a direction in which there is normally no motion; for\\nexample, lateral bending at the knee.\\nThe displacement may be very slight or so great as wholly to sepa-\\nrate the fractured surfaces from each other. Colles s fracture at the\\nlower end of the radius in the young is occasionally a separation of\\nthe epiphysis with slight displacement (see Plate XVII., fig. 2); at\\nthe upper end of the humerus the displacement is usually equal to\\nabout half the thickness of the bone; complete displacement I have\\nseen only at the lower end of the femur three times, and once each\\nat the upper end of the fibula and at the head of the femur.\\nThe diagnosis is made in the cases of slight displacement on the\\nhistory of the injury and tenderness on pressure limited to the line of\\njunction of the epiphysis and shaft; in the others by recognition of the\\ndeformity and of the size and shape of the fragment. When the dis-\\nplacement is great reduction may be seriously opposed by the interpo-\\nsition of the loosened periosteum.\\nThe prognosis is affected by the possibility of arrest of growth due\\nto an uncorrected displacement or to premature ossification of the con-\\njugal cartilage. A few such cases have been reported. This defi-\\nciency of growth is, of course, most marked in those who receive their\\ninjury at an early age, and secondly in those cases in which the\\naffected epiphysis normally takes the larger part in the growth of the\\nbone in length, namely, the upper end of the humerus and tibia and\\nthe lower end of the femur and radius. I have seen two cases in\\nwhich this injury at the lower end of the radius at the age of fourteen\\nyears produced a late deformitv exactly resembling that of a very bad\\nColles s fracture. (See Plate XVIL, fig. 1.)\\n(c) Intra-articular or articular fractures are those in which the main\\nline of fracture, or a subsidiary one, extends into a joint. Common\\nexamples are fractures of either condyle of the femur or humerus,\\nintercondyloid fractures of the same bones, fractures of the patella\\nand olecranon. The special importance of the variety arises partly\\nfrom the implication of the joint in the inflammatory reaction follow-\\ning the trauma, but mainly from the change in the mechanical condi-\\ntions produced by the displacement of the fragment and the formation\\nof adhesions or of callus. Thus, the result after a fracture of the\\npatella in which the permanent displacement is slight is usually very", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0043.jp2"}, "42": {"fulltext": "30 FRACTURES.\\ngood, while that following a fracture of a condyle of the humerus or\\nof the head of the tibia may be great limitation of the motions of the\\njoint. In the young excessive formation of bone outside of, but near\\nto, the joint as the result of the traumatic irritation of the periosteum\\nmay also mechanically limit the motions of the joint. An important\\nfactor in producing the bad result is found in the difficulty or impos-\\nsibility of properly reducing the displacement or maintaining the\\nreduction because of the small size of the fragment and the lack of\\nefficient means of acting upon it. Among other causes are the hemor-,\\nrhage into the joint, the inflammation of the synovial membrane and\\nadhesions of its opposing surfaces, and the inflammatory thickening,\\nretraction, and loss of pliability of the peri-articular tissues. The\\ndegree of these changes varies with that of the inflammatory reaction.\\n3. Multiple Fractures.\\nThis term is applied to the simultaneous fracture of two or more\\nnon-adjacent bones and two or more fractures of the same bone whose\\nlines are not continuous with one another. The term double is also\\nused when there are only two fractures. This definition is intended\\nto exclude simultaneous fracture of both bones of the leg or forearm\\nand fractures which involve two or more adjacent bones of the skull\\nor pelvis. The term is frequently applied to fracture of two or more\\nadjacent ribs, and sometimes to cases of extensive splintering of the\\nflat bones.\\nMultiple fractures of a single bone are caused by violence, usually\\ngreat, acting in part directly against the shaft, as the fall of a heavy\\nweight or, as in one of my own cases, by the striking of the thigh\\nagainst a tree when the patient was thrown from a carriage. The\\ncondition may be serious as to life, because of the shock of the injury,\\nand in respect of restoration of form and function, because of the diffi-\\nculty of controlling the position of the intermediate fragment. There\\nis also the chance of overlooking one of the fractures.\\nMultiple fractures of different bones are also usually caused by\\ngreat violence the prognosis is affected much more by the associated\\ninjuries and shock than by the multiplicity of the fractures. If the\\npatient survives the primary effects of the accident the fractures heal\\nin the ordinary manner.\\n4. Compound Fractures.\\nA compound fracture is one in which communication between the\\nfracture and the external air is established through a wound of the\\nsoft parts. The importance of this communication arises through the\\npossibility of infection of the wound from without, with all the risks\\ninvolved in the consequent suppuration of the bone and the lacerated\\nsoft parts. In addition, a large proportion of compound fractures are\\ncaused by direct violence, and the consequent laceration of the over-\\nlying soft parts is such as to be a serious addition to the fact of fracture.\\nIn other cases the external wound may be merely a puncture made by", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0044.jp2"}, "43": {"fulltext": "PATHOLOGY. 31\\nthe broken end of the bone, which, under suitable treatment, heals in\\na few days, making the fracture thenceforth a simple one.\\nA fracture that is simple at first may be made compound by the\\nsloughing of the overlying skin in consequence of its injury by the\\nprimarv violence or of pressure upon it by a displaced fragment, or\\nbv the later forcing of the sharp end of a fragment through the skin\\nin the agitation of delirium or in an attempt to use the limb while in\\nignorance of the character of the injury that has been received.\\nCompound fractures are most frequent in the lower limbs, and com-\\nprise, according to Gurlt, 16 per cent, of all fractures of the limbs.\\nExcluding those of the hand and foot, the relative frequency of the\\nmore common ones is as follows Leg, 17.96 per cent. forearm,\\n11.68 per cent. femur, 7.05 per cent. humerus, 6.76 per cent.\\nIn determining the compound character of a fracture it is sufficient\\nto establish the fact that the wound of the soft parts extends through\\nthe enveloping fascia and to the immediate neighborhood of the seat\\nof fracture, for even if the gross lesion should not extend to the\\nbroken surface of the bone, yet the minuter lacerations and the\\nextra vasa ted blood create a path for the spread of infection that brings\\nthe condition fully within the definition and the special dangers.\\nThe prognosis varies so greatly with the extent and character of the\\ninjury to the soft parts that statistics which take no account of these\\nvariations have but little value. A fracture produced by indirect\\nviolence and made compound by a puncture of the skin by the end of\\na subcutaneous bone, such as the ulna or tibia, may be confidently\\nexpected to heal under appropriate treatment as kindly and promptly\\nas a simple fracture while one produced by direct violence and\\naccompanied by destruction of the skin and muscles can heal only by\\ngranulation, and will probably suppurate, notwithstanding all the care\\nthat may be given it or, the associated damage to the soft parts may\\nbe such that the limb would be useless even if the wound should heal.\\nThe shock of the injury is usually much greater than that of simple\\nfracture, and may cause death in a few hours, and the probability of\\nthe existence of serious associated lesions is also greater because of the\\nusually greater violence that has produced the fracture. This is shown\\nby the following statistics: During two years, February, 1895, to\\nFebruary, 1897, there were received at the Hudson Street Hospital\\n70 compound fractures of the limbs, exclusive of those of the hand.\\nEleven of these patients died within twenty-four hours after the acci-\\ndent, 3 of the 11 having also a fracture of the base of the skull 4\\nmore died within three days after the accident, making in all 15\\ndeaths (or 12, if the fractures of the skull are excluded) directly due\\nto the shock of the injury, a mortality of 21 per cent. This is largely\\nin excess of that following simple fractures, although they, too, may\\nbe accompanied by other grave lesions or by severe shock, or may\\nlead to a fatal pneumonia or attack of delirium tremens. I cannot\\ngive the final result in the remaining 55 cases of my list, because\\nmany of them were transferred to their homes or to other hospitals\\nafter they had recovered from the primary effects of their injuries.\\nAt least three of them underwent amputation.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0045.jp2"}, "44": {"fulltext": "32\\nFRACTURES.\\nMumford, 1 collating 300 cases (excluding those that died within the\\nfirst twelve hours and those treated by primary amputation) received\\nat the Massachusetts General Hospital during the preceding eight\\nyears, found a mortality of 30, or 10 per cent., the causes of death\\nbeing sepsis, 10; shock, 7; delirium tremens, 6; fat embolism, 3;\\ngangrene, 3 nephritis, 1. The highest mortality was in fractures of\\nthe femur 25 cases with 7 deaths, 28 per cent.\\nThe principles of treatment are to transform the fracture into a\\nsimple one as promptly as possible, to minimize suppuration and keep\\nit superficial when it is inevitable, and to protect against other infec-\\ntion while the wound is open, meanwhile immobilizing the fragments\\nby suitable splints. For details, see chapter on Treatment. Under\\nthe protection of strict asepsis the question of the need of amputation\\nmay often be postponed until after the progress of the case shall have\\nclearly shown whether or not the limb can be saved.\\n5. Gunshot Fractures.\\nThe call for separate consideration of this variety of compound frac-\\ntures comes through peculiarities of the lesions and dangers consequent\\nFig. 11.\\nFig. 12.\\nContusion of side of femur by pistol-ball symmetrical\\nfissure of the opposite side. (Pox let and Bousqt t et.)\\nTransverse fracture of the clavicle\\nby a spent ball. (Ricard.)\\nupon the small size and the velocity of the projectile. The subject,\\nconsequently, is rather more limited than its title might suggest, and\\ndoes not include fractures by large balls or pieces of shell, in which\\n1 Mumford Boston Medical and Surgical Journal, May 10, 1894.", "height": "4343", "width": "2506", "jp2-path": "practicaltreati00stim_0046.jp2"}, "45": {"fulltext": "PLATE I.\\nFracture of Radius by Small Bullet of High Velocity enter-\\ning at the Hand and emerging at the Elbow.", "height": "4343", "width": "2506", "jp2-path": "practicaltreati00stim_0047.jp2"}, "46": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0048.jp2"}, "47": {"fulltext": "PLATE II.\\nSame Case as Plate I., after repair.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0049.jp2"}, "48": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0050.jp2"}, "49": {"fulltext": "PATHOLOGY.\\n33\\nthe extensive laceration of the soft parts is even more important than\\nthe fracture.\\nThe special features are the usually extensive splintering and As-\\nsuring of the bone and the bruising of the tissues along the track of\\nthe bullet which may prevent prompt healing of the wound. These\\nfeatures are found in varying degrees, corresponding to the velocity of\\nthe ball and to its size. A ball whose force is nearly spent may, on\\nstriking the shaft of a long bone, do no injury at the point of impact,\\nbut may yet cause a curved fissure nearly circumscribing a cortical frag-\\nment on the opposite side (Delorme, Fig. 11); if its speed is slightly\\ngreater, and especially if it strikes the spongy end of the bone, it\\ncauses a depression of the surface only if the ball is large and its\\nvelocity low, and the point struck is near the centre of the shaft, a trans-\\nverse fracture (Fig. 12), or an oblique one (Plate VI.) may be produced.\\nAt higher velocities the bone is perforated, with more or less splinter-\\ning and Assuring (Fig. 13), or the entire cylinder for a length of one\\nor two inches is split into small fragments which are driven far into\\nthe surrounding tissues (Fig. 14). See also Plate I. With the latter\\nFig. 13.\\nFig. 14.\\nPerforatim\\nshot-wound of tibia.\\n(RlCARD.)\\na, entrance b, exit.\\nmay be associated extensive laceration of the soft\\nparts on the distal side. In other cases the bone\\nis fissured or split into large fragments on each\\nside. Occasionally the bone may be simply per-\\nforated or notched, and then broken by the sub-\\nsequent use of the limb. I have seen two such\\ncases in one the patient was shot by a policeman,\\nand as he ran away the femur broke at the point\\nwhere it had been perforated he died of tetanus.\\nIn the other, fracture of the leg, the same sequence was observed, but\\nthe patient survived, and the exact character of the injury caused by\\nthe bullet remained unknown.\\nIn the case shown in Plate I., in which the ball entered between the\\nfingers and emerged above the elbow after extensively splintering the\\nlower half of the radius, the skin of the forearm was torn longitudi-\\nnally in several places, apparently by the distending effect of the ball.\\nFracture of femur by-\\nball from a Lobel rifle;\\nsmall calibre high ve-\\nlocity. (Chauvel and\\nNimier.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0051.jp2"}, "50": {"fulltext": "34 FRACTURES.\\nIn fractures by a charge of small shot at close range the laceration\\nof the soft parts is the predominant feature. In those of the cranium,\\nchest, and pelvis the associated visceral injuries are the most impor-\\ntant thus, one of my patients died from the injury done to his brain\\nby a single bird shot, size No. 7, which entered through a very thin\\npart of the frontal bone just below the inner end of the eyebrow. The\\nremoval of the bullet, even from the brain, is not essential to recovery,\\nand a search for it may easily be harmful.\\nThe great mortality which formerly characterized these injuries has\\nbeen greatly reduced by antiseptic treatment. There have been no\\nimportant military statistics since the Turco-Russian war of 1878, but\\nthe current reports from those wounded in Cuba during the war in\\n1898, and from South Africa, show easy recovery after injuries which in\\nearlier days would probably have been fatal. In civil practice, which\\ndeals mainly with pistol-shot wounds, the results now obtained are good.\\nA pistol-shot wound is usually surgically clean, and if not officiously\\ntreated may be confidently expected to heal kindly a piece of the\\nclothing is rarely carried in by the bullet, and in most cases all that is\\nnecessary is to clean the surface and the orifice of the wound and apply\\na dressing. The bullet may be left to heal in unless the wound is large\\nand ragged. Late hemorrhages, due to the sloughing of bruised ves-\\nsels, sometimes occur.\\nDisplacements.\\nThe relations of the two principal fragments produced by fracture\\nof a bone may be altered in various ways, which Malgaigne classified\\nunder six heads. The classification has been generally adopted, with\\nthe understanding, however, that a fracture usually presents a combi-\\nnation of two or more of them, and that there is an additional group\\nof cases in which the peculiarities of the displacement defy classification.\\nThe six classes group displacements according to\\n1. The transverse axis of the bone, transverse or lateral displacement.\\n2. The long axis of the bone, angular displacement.\\n3. The circumference of the bone, rotatory displacement.\\n4. The length of the bone, overriding.\\n5. Penetration of one fragment by the other, impaction or crushing.\\n6. Direct longitudinal separation.\\n1. Transverse or lateral displacement may take place forward, back-\\nward, or toward either side, and may be partial or complete. Pure\\ntransverse displacement is rare it is usually associated with over-\\nriding or angular displacement, or both (Plate III., fig. 1).\\n2. Angular displacement may vary in degree from a slight deviation\\nto a right angle, or even more, and mav be associated with so com-\\nplete and distant separation of the broken surfaces that the fragments\\nform a T (Fig. 15). It may be produced by the fracturing violence,\\nthe action of the gravity, or the contraction of the muscles.\\n3. In rotatory displacement one fragment, usually the lower, turns\\nabout its long axis, while the other fragment remains in position.\\n4. Overriding is most common after oblique fracture of the shaft,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0052.jp2"}, "51": {"fulltext": "PATHOLOGY.\\n35\\nand is produced by various causes, such as a continuation for a moment\\nafter rhe fracture of the force that has produced it, the tonicity of the\\nmuscles, or the swelling of the limb due to inflammatory reaction and\\nextravasation of blood beneath the deep fascia, which, by increasing\\nthe transverse diameters, shortens the longitudinal one.\\nFig\\nFracture of the clavicle.\\n5. Displacement by penetration or crushing has been already men-\\ntioned as the impacted variety of fracture. Penetration rarely takes\\nplace without a change in the direction of the axes of the fragments,\\nbecause of differences in the resistance or of the direction of the\\nfracture.\\nFig. 16.\\nFtg. 17.\\nFig. 18.\\nFracture of the lower end of\\nthe radius. Angular displace-\\nRotatory displacement after frac- Fracture of both bones of the ment of the lower fragment\\nture of the neck of the femur. leg, with overriding. backward. (E. W. Smith.)\\nThe callus found after consolidation of the fracture may give the ap-\\npearance of a much deeper penetration than has actually taken place\\nthus, in Fig. 18 the triangular mass of spongy tissue on the side is", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0053.jp2"}, "52": {"fulltext": "36\\nFRACTURES.\\nnot the penetrated epiphysis, but is mainly composed of callus formed\\nby the stripped-up periosteum.\\n6. Direct longitudinal separation is seen most frequently after fracture\\nof the patella, and is then due partly to the retraction of the quadri-\\nceps and partly to the distention of the joint by blood and exudate.\\nAmong the irregular displacements, those which do not fall entirely\\nwithin the above classification, may be mentioned rotation of one frag-\\nment about its transverse axis, as in some fractures of the neck of the\\nhumerus, crossing of the fragments in the form of an X, and the inter-\\nposition of a bone between two fractured ones, or of the end of the\\nshaft between its separated condyles.\\n(B) THE SOFT PARTS.\\nThe periosteum may be simply loosened from the surface of bone\\nadjoining the fracture, or it may be torn across throughout the whole\\nor only a portion of its extent at or near the line of fracture. The\\nfirst form (excluding fractures of the flat bones) is found only in frac-\\ntures with slight displacement, and especially in the young, in whom\\nthe periosteum is thick and resistant. Such fractures are known as\\nsubperiosteal. They may be recognized or inferred from the youth of\\nthe patient and the slight displacement and abnormal mobility of the\\nfragments. Their prognosis is exceptionally good.\\nComplete rupture of the periosteum all around the bone is probably\\ninfrequent and to be found only in fractures with great displacement.\\nExamination of fresh specimens and of the position and shape of the\\ncallus in those that have united indicates that in most cases the conti-\\nnuity of the periosteum is preserved on one side, the continuous portion\\nbeing stripped off one of the fragments for some distance and forming\\na periosteal bridge (Oilier), which unites the two fragments and\\ntakes an important part in the subsequent repair. (Plate III. and\\nFig. 19.)\\nFig. 19.\\nPeriosteal bridge after fracture of a rib.\\nThe muscles may escape injury or may be extensively torn. The\\nneighboring connective tissue is torn and infiltrated with blood from its\\nown vessels or from those of the broken bone. Injury to important\\nvessels and nerves is rare it will be described under Complications,\\nChapter VI.", "height": "4383", "width": "2530", "jp2-path": "practicaltreati00stim_0054.jp2"}, "53": {"fulltext": "PLATE III.\\nFig. 1\u00e2\u0080\u0094 Fracture of Forearm, six weeks old, showing Ossification\\nalong Periosteal Bridge.\\nFig. 2. Humerus, two years after Fracture Growth of Bone along\\nPeriosteal Bridge.", "height": "4383", "width": "2530", "jp2-path": "practicaltreati00stim_0055.jp2"}, "54": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0056.jp2"}, "55": {"fulltext": "PLATE III. B\\nSame as Plate III., Fig. 2. Injury Recent.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0057.jp2"}, "56": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0058.jp2"}, "57": {"fulltext": "PATHOLOGY. 37\\nThe skin may be torn by the original violence or by the sharp end\\nof a fragment, or it may be so bruised by the original violence or so\\npressed upon by a displaced fragment that it subsequently sloughs.\\nThese lesions of the skin may communicate with the seat of fracture\\n(compound fracture), or may be at a distance therefrom and without\\ninfluence upon its course, except so far as they may interfere with the\\napplication of splints. Discoloration of the skin due to extravasated\\nblood beneath almost invariably appears after a day or two, and may\\nbe widespread. Large blebs filled with dark, blood-stained serum fre-\\nquently appear upon the limb near the fracture by the second or third\\nday.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0059.jp2"}, "58": {"fulltext": "CHAPTER III.\\nETIOLOGY.\\nPredisposing Causes Determining Causes Spontaneous and Pathological\\nFractures Intra-uterine Fractures and Fractures During Delivery.\\nThe causes of fracture may be grouped under two heads A. The\\npredisposing causes; B. The immediate or determining causes.\\nThe Predisposing Causes\\nare of three kinds (1) the external, (2) the normal or physiological,\\nand (3) the pathological. Most of the latter, which consist in a local\\nor, more rarely, a general diminution of the strength or an actual de-\\nstruction of the bone by a local or general disease, will be considered\\nunder the head of Spontaneous or Pathological Fractures.\\nThe external predisposing causes are those incidental to various occu-\\npations and modes of life which involve greater exposure to deter-\\nmining causes they account for the great excess of fractures in males\\nover those in females between youth and old age, and for their rarity\\nin young children.\\nThe normal or physiological causes are those which have their\\norigin in the position and functions of the different bones. The\\nbones of the skull and chest are broken when the violence against\\nwhich they are designed to protect the enclosed viscera is too great for\\ntheir power of resistance the use of the arms in many occupations\\nexposes them to fracturing violence, and they and the lower limbs are\\nbroken in falls all the more easily because of the contraction of the\\nmuscles by which they are stiffened to protect the body against the\\nshock. In like manner the normal curves in single or associated bones\\ne. g., the clavicle and spinal column which supply an elasticity\\nthat is protective of the viscera increase their liability to fracture.\\nInterstitial atrophy of the bones, which is so common a senile change,\\nis undoubtedly the cause of the greater relative frequency of fractures\\nin the old and its agency becomes all the more apparent when the\\nusual withdrawal of the aged from the occupations which most expose\\nto fracture is taken into account. This atrophy consists in thinning of\\nthe cortex of the shafts and of the trabecule of the spongy portions\\nand of the short bones, not in a relative increase of the lime salts in\\nthe bone tissue itself, as was long supposed. It is an actual diminution\\nof the bone substance and a corresponding increase of the fat and other\\nsoft parts contained in it. In the old, and when not extreme, it may\\nbe classed as a normal predisposition to fracture, but when it appears\\nprematurely or reaches an extreme degree it must be deemed patholog-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0060.jp2"}, "59": {"fulltext": "ETIOLOGY. 39\\nical and classed with other similar atrophies whose nature and causes\\nare not well understood.\\nThe inherited or early developed liability to fracture which has been\\nobserved in certain individuals and families who were in other respects\\nnormal is probably the result of a similar scantiness of the bone tissue.\\nOf this inherited* liability Gurlt gives three examples, extending in\\none over four generations, in the others over three. One of the patients\\nsuffered fourteen fractures, and another thirteen, before either reached\\nthe a\u00c2\u00ab;e of thirteen years. All united promptly. He gives also three\\ncases of a congenital but not inherited liability to fracture in families.\\nOne girl suffered thirty-one fractures of the thigh, leg, and arm between\\nthe ages of three and fourteen years her sister had nine before she was\\nsix years old. Not infrequently individuals have developed in early\\nor middle life a noticeable fragility of the bones without any other\\nchange that would indicate a general deterioration or disease.\\nImmediate or Determining Causes of Fractures.\\nThese are of two kinds (1) External violence, and (2) muscular\\naction, the latter exerted by muscles connected more or less directly\\nwith the bone that is broken.\\n1. Fractures by External Violence. The division of these into two\\nclasses, of which one is called fractures by direct, the other fractures\\nby indirect, violence is based upon clinical differences often of ex-\\ntreme importance, and not simply upon mechanical differences in the\\nmode of transmission and in the effect of the applied force. This\\nrelieves us, therefore, from the necessity of examining the latter ques-\\ntions with their many obscure factors and complex relations, and makes\\nthe definitions simple. A fracture by direct violence is one in which\\nthe bone is broken immediately under the point upon the surface where\\nthe fracturing force is received and a fracture by indirect violence is\\none in which the fracture takes place at a distance from that point.\\nThe most important clinical difference between the two varieties de-\\npends upon the injury to the overlying soft parts in the one case and\\nthe absence of such injury in the other.\\nThe skin is not always broken in fractures by direct violence, even\\nwhen the vulnerant force has been great and the injury to the soft parts\\nunder the skin extensive, but it may have been so injured, even if it\\nshows no marks of violence, that it will slough. On the other hand,\\nthe blow may break the skin at the point where it is received and pro-\\nduce fracture indirectly at a greater or less distance, the bone yielding\\nat its point of least resistance and not at that where the force is directly\\nexerted.\\nThe fracturing force may be applied directly or indirectly to the bone,\\nto crush or break it, or obliquely to its long axis, or as torsion, or as\\navulsion. Examples of the first are furnished by falls upon the feet\\nwith fracture of the calcaneum, gunshot wounds, and crushing of the\\nlower end of the radius in a fall upon the hand; of the second by most\\nfractures of the shafts of long bones of the third by some fractures\\nof the leg when the foot is fixed and the body turned forcibly about it", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0061.jp2"}, "60": {"fulltext": "40 FRACTURES.\\nand of the fourth by some fractures of the internal condyle of the\\nfemur by forced abduction of the leg, by some of the internal malleolus\\nin eversion of the foot, and by some of the patella in forced flexion of the\\nknee when its normal range of motion has been limited by previous\\ninjury.\\nIndirect fractures are by far more common in long bones than in the\\nshort spongy ones, because of their proportions and functions. The\\nprinciple of their production is that of the transmission of a force\\nalong a bone or set of bones made rigid by ligamentary attachments\\nor muscular contraction in such manner that it is resolved into forces\\nacting in two or more directions, one of which crosses the long axis\\nof the bone and acts as if it had been applied directly at the point of\\nleast resistance in a transverse direction. The effect is greatly modi-\\nfied by the anatomical structure and form of the bone, the attitude of\\nthe limb, the contraction of the muscles, and the direction of the blow.\\nThus, a fall upon the hand may break the bones of the forearm, the\\nhumerus, or the clavicle; a fall upon the foot may fracture the calca-\\nneum by direct violence, or the bones of the leg, the thigh, or even\\nthe vertebral column or skull by indirect violence.\\nThe best example of the fracture of short bones by indirect violence\\nis furnished by the spinal column, the bones of which, considered as a\\ngroup, constitute a long bone with several curves, the forcible exag-\\ngeration of which produces fracture.\\n2. Fractures by Muscular Action. Under this head are included\\nonly those fractures in which the rupturing force is exerted by the\\nmuscles alone, without the aid of any external violence. It is, of\\ncourse, evident that, if an individual breaks his skull or a limb by\\nrunning or striking against a solid object, the force that causes the\\nfracture is developed by the action of his muscles; but the mechanism\\nis the same as if he had fallen from a height, or as if his body was at\\nrest and the object with which he has come into contact was in motion.\\nOnly those cases are considered to be fractures by muscular action in\\nwhich the action is exerted directly by the muscles upon the bones to\\nwhich they are attached (mediately or immediately), either as direct\\ntraction, as in fracture of the patella or of the olecranon, or obliquely,\\nor in torsion against resistance, or by exaggerating the normal curve\\nof the bone, or by sudden muscular arrest of the rapidly moving limb,\\nas in throwing, or in striking or kicking at an object and missing it-\\nSome authors have expressed the opinion that no bone can be broken\\nby simple muscular contraction unless it has previously undergone\\nsome change that has diminished its strength but this opinion must\\nbe looked upon as an attempt to explain away by an unfounded, or at\\nleast an unproved, assumption a difficulty which does not really exist.\\nIt is no more logical to claim that such a change has preceded every\\nfracture by muscular action than it would be to make the same claim\\nfor fractures by external violence it can rest only upon the assump-\\ntion that the power of resistance of a normal bone is superior to any\\nforce that a muscle or group of muscles can exert upon it, even under\\nextreme and unusual circumstances; whereas, on the contrary, nature s\\nprecautions and adaptations are, as a rule, calculated upon the basis of", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0062.jp2"}, "61": {"fulltext": "ETIOLOGY. 41\\nthe probable, not of the exceptional. Such a position may be taken\\nwith propriety concerning all fractures produced by slight causes in\\nthe old, the diseased, the cachectic, or in those who have suffered pain\\nat the point of fracture for some time previous to the accident; but\\nit is entirely unsupported by proof in the rarer, but still sufficiently\\nnumerous, cases of the fracture of the shaft of a long bone produced\\nbv a violent effort in a healthy athletic man, and in the common ones\\nof fracture of the patella.\\nThe effect of muscular action is manifested in all the degrees of\\nvarying importance between its relatively unimportant additions to\\nthe effects of external violence and those cases in which it is the sole\\nagent of the fracture of a healthy bone. The intermediate degrees\\nare presented by those fractures, usually of weakened bones, in which\\nmoderate muscular action has acted either alone or combined with\\nslight external violence. In the first case, when the power of the\\nmuscle is exerted in the same direction as the external violence, it\\nincreases the fracturing force by just so much; and, by prolonging its\\neffect after the fracture has been made, it also increases the displace-\\nment of the fragments and the laceration of the soft parts. The prin-\\ncipal interest of the intermediate cases is connected with the cause of\\nthe exceptional fragility of the bone, and is considered in the following\\nsection Spontaneous and Pathological Fractures.\\nThe commonest examples of fracture by muscular action alone are\\nfurnished by the patella other apophyses and tuberosities to which\\npowerful muscles are attached the olecranon, greater tuberosity of\\nthe humerus, coracoid, acromion furnish them much more rarely.\\nOf the long bones the humerus is the one most frequently broken\\nin this manner; out of 85 cases of fracture of the limbs by muscular\\naction collected by Gurlt, 1 57 were fractures of the humerus, 15 of the\\nthigh, 8 of the leg, and 5 of the forearm. The mechanism seems in\\nmost cases to be the same as in indirect fracture in some the fracture\\ntakes place at the insertion of the muscle, and in others the elements\\nare too complex and too uncertain to be explained theoretically. In a\\ncomparatively small number of cases the fracture has been caused by\\nreflex spasms in limbs that had long been paralyzed or by the convul-\\nsions of epilepsy or tetanus, but usually the cause is a violent volun-\\ntary muscular effort to avoid a fall, to throw a stone, or to lift a heavy\\nobject. The following cases taken from Gurlt illustrate the different\\nforms and the methods by which they may be produced. It must be\\nremembered that fractures produced during convulsions need to be\\nclosely examined in order not to overlook the possible addition of\\nexternal violence by a fall from the bed or by a blow.\\nIn a negro boy, twelve or thirteen years of age, affected with teta^\\nnus, both thigh bones were broken at the neck, probably just below\\nthe t trochanter, by the contraction of the muscles, and the fragments\\nforced through the skin on the outer side of the limb.\\nAn athletic man, thirty-four years old, accustomed to lift heavy\\nweights, broke his humerus with an audible snap, just below the inser-\\ntion of the deltoid, by the effort made, on a wager, to throw a stone\\n1 Loc. cit., vol. i. p. 232.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0063.jp2"}, "62": {"fulltext": "42 FRACTURES.\\nweighing about two ounces the distance of a hundred yards. Recovery\\nin six weeks.\\nGurlt gives also eleven cases in which the humerus was broken\\nduring that trial of strength in which two men place their elbows upon\\na table, clasp bauds with the forearms parallel and vertical, and strive\\nto force each other s hand backward.\\nFractures of the femur may occur at any point of the shaft, and in\\nthe recorded cases have been the result of an attempt to kick, to avoid\\na fall, or to rise from the ground on one foot, or of cramps, excited\\nin one case by drawing on a tight boot and in another by turning\\nin bed.\\nA colonel of cavalry, thirty-six to thirty-eight years old, of middle\\nsize and great muscular power, broke his thigh at the junction of its\\nupper and middle thirds by kicking at and missing his servant.\\nVan Oven described before the Royal Medical and Surgical Society\\na fracture of the thigh sustained by himself. He was fifty- six years\\nold, healthy and strong, and free from taint of cancer, scrofula, syph-\\nilis, etc. He was awakened by a sharp, cramp-like pain above the\\nknee, and as he felt the part with his hand, and noticed that the muscle\\nwas tense, he heard a snap, followed by relaxation of the muscle, crepi-\\ntus, and diminution of the pain. Examination showed a transverse\\nfracture of the femur three inches above the knee. Complete recovery\\nin four months.\\nA cavalryman, twenty-nine years old, while trying to rise from a\\nsitting posture on the ground without the aid of his hands, broke his\\nright thigh at its middle.\\nGurlt s eight cases of fracture of the leg comprise four of both bones,\\none of the tibia, and three of the fibula alone, the latter being fractures\\nat the upper end of the bone by the contraction of the biceps.\\nA small, rather corpulent woman, forty-five years old, slipped on\\nthe left foot while descending some steps, made a violent effort with\\nthe right leg to avoid a fall, felt at once a severe pain in the latter, and\\nfell in a sitting posture. An immediate examination showed a fracture\\nof both bones at the middle of the leg.\\nA woman, fifty-two years old, mistook a door leading into the cellar\\nfor one opening into a closet, and, recognizing the mistake as she put\\nher right foot forward, drew herself instinctively backward, and felt\\nat the same moment something snap in her left leg, upon which the\\nweight of her body rested. She fell and rolled down the steps. A\\nfracture of the left fibula just below its head was found.\\nFracture of either or both bones of the forearm has been caused by\\nthe wringing of wet clothes and in shovelling. A healthy girl, eighteen\\nyears old, while wringing clothes, felt a sudden sharp pain on the inner\\nside of the forearm above the wrist. Three days afterward a fracture\\nof the ulna, two and one-half inches above the wrist, was recognized.\\nA woman, thirty years old, broke the radius in its lower third with\\nsevere pain while wringing two heavy towels.\\nFractures of the clavicle have been caused by the effort of raising a\\nheavy object, shovelling, and striking backward or with a whip.\\nFractures of one or more ribs are not infrequently caused by violent", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0064.jp2"}, "63": {"fulltext": "ETIOLOGY. 43\\ncoughing. The sternum has been broken in four recorded cases by the\\nviolent straining and bending backward of the body during the expul-\\nsive efforts of parturition, and there are several cases of fracture of the\\nvertebral column by muscular action alone, and of the scapula.\\nHilton reports the case of a man who had broken a rib by muscular\\naction while trying to mount a spirited horse.\\nA primipara, twenty-four years old, taken in labor, sought to hasten\\ndelivery by forcible expulsive efforts, bending backward and resting\\non her elbows and heels she felt a sudden sharp pain and a snap in the\\nmiddle of the breast, and said at once that something had broken there.\\nShe died of peritonitis, and at the autopsy a transverse fracture of the\\nsternum was found, one and one-half lines above the junction of its\\nbody and the manubrium.\\nA soldier dived into a river, and, not reappearing, was sought for\\nand brought out. His body showed no trace of external violence, but\\nthere was paralysis of all the limbs, loss of sensation, pain at the pos-\\nterior and lower parts of the neck, priapism, frequent desire to urinate.\\nHe said that as he dived he saw the water was too shallow, and in the\\neffort to avoid striking against the bottom he jerked his head sharply\\nbackward and at once lost consciousness. He died the same night, and\\nthe autopsy showed a transverse fracture of the body of the fifth cer-\\nvical vertebra a little below its centre.\\nA servant engaged in preparing a lamp raised his arm quickly to\\narrest the action of an escaping spring and felt something give way in\\nit. The arm fell powerless by his side, and the greater portion of the\\nacromion was found to have been broken off.\\nI have seen two fractures of the coracoid process by forcible con-\\ntraction of the muscles of the arm.\\nSpontaneous and Pathological Fractures.\\nThe term spontaneous is used to indicate that the violence, external\\nor muscular, which has produced the fracture is much less than that\\ncommonly observed in that form and the term pathological to indi-\\ncate a preceding abnormal change in the fractured bone by which\\nits strength has been diminished. It has become common to use the\\nterms interchangeably, because the slight violence indicated by the\\nfirst is efficient to fracture only when the change indicated by the\\nsecond is present.\\nIt is noteworthy that the pain accompanying or following the frac-\\nture is often very slight fractures of ribs, and even some of the limbs,\\nhave passed unrecognized until the autopsy. The pathological condi-\\ntion known as general atrophy or rarefaction of the bone, or osteopo-\\nrosis, and which has been referred to as senile atrophy, may appear\\nprematurely or may have its origin in other causes than senility, such\\nas paralysis, locomotor ataxia, diabetes, pregnancy, and osteomalacia.\\nIt is w T orthy of note that in not a small proportion of cases union takes\\nplace promptly. In most of the cases which furnish autopsies the bones\\nare found softened and reduced to a shell by absorption from within,\\nand in some of the cases suppuration has taken place at the fracture.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0065.jp2"}, "64": {"fulltext": "44 FRACTURES.\\nIt has been noted by Bouchard and by Verneuil and Verchere that\\nspontaneous fracture occasionally happens in the diabetic, and that the\\nurine shows the presence not only of sugar but also of phosphoric acid\\nin quantities that suggest its origin in a decalcification of the bones.\\nThese observations have been confirmed by Isch-Wall (quoted by\\nRicard), who also found the phosphoric acid present in some patients\\naffected with cancer. In nine cases of spontaneous fracture in the\\ndiabetic reported by Verchere union was greatly delayed.\\nThe following cases represent different varieties\\nA woman, seventy-two years old, had both thighs broken by kneel-\\ning in church, and the humerus by the efforts of bystanders to lift her\\nup. Another broke her clavicle by putting her arm about the nurse s\\nneck and trying to turn herself in bed (Gurlt).\\nA woman, forty-five years old, the mother of two children, suffered\\na great deal of pain in her bones after the birth of her second child,\\nand became so helpless that she could not get into or out of bed with-\\nout aid. She broke each thigh below the trochanter by stumbling\\nagainst the bedpost in one case and by turning in bed in the other.\\nBoth united with marked angular displacement, and at the autopsy the\\nbones of the thigh and pelvis were found to be so light that they floated\\nin water and could be crushed by pressure with the finger. The cor-\\ntical layer of the femur was as thin as an egg-shell, the medullary\\ncanal enlarged, traversed here and there by delicate plates of bone, and\\nfilled with a grumous, semifluid mixture of blood and marrow (Gurlt).\\nA man, sixty years old, broke his femur in the middle third by\\nstumbling, without falling. He died a fortnight later, and I found an\\nenormous calculus in each kidney.\\nSaviard saw in 1 690 a woman, about thirty years old, who had suf-\\nfered for four months with severe pains throughout the body, increased\\nby movements, and without fever. Three months later she had become\\nbedridden, and her bones had become so friable that most of them were\\nbroken, and she could not be moved without causing a new fracture.\\nShe lived ten months in this condition, and the autopsy showed frac-\\ntures of almost every bone in her body. The structure of the bones\\nwas so delicate that they could not be pressed between the fingers with-\\nout breaking into small pieces the marrow was red, the muscles pale,\\nthe joints and cartilages unchanged.\\nIn a case under my care the tibia appeared to have been weakened\\nby an osteitis set up by a blow and a wound of the soft parts. The\\nwound healed in three weeks a fortnight later the patient returned\\nwith a compound fracture of the leg at the scar, caused by stepping\\ndown a distance of two feet. The bone could be plainly seen and was\\nrarefied. Prompt recovery.\\nA similar friability is also found in some cases of old unreduced\\ndislocation, due, it is supposed, to lack of use. The condition was\\nshown by direct examination in a case of subcoracoid dislocation of six\\nweeks standing, in which Guerin l tore off the forearm in an attempt\\nto reduce. The ends of the bones were rarefied and soft, and the mus-\\n1 Guerin: Ball, de la Soc. de Chir., 1864, vol. v. pp. 121 and 131.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0066.jp2"}, "65": {"fulltext": "ETIOLOGY. 45\\ncles softened and brown. The autopsy showed no change in the other\\nportions of the body.\\nIt seems probable, however, that in most cases in which fracture has\\noccurred during an attempt to reduce a dislocation, and in which un-\\nusual fragility has been alleged in explanation, the force exerted upon\\nthe bone has been greater than the surgeon supposed, because of the\\nleverage employed, especially in rotation of the limb.\\nDisease of the Nerve-centres. In 1842 Davey called attention to the\\nfacility with which fracture sometimes occurred in lunatics, especially\\nin those who were also paralytic, and the observation has been abun-\\ndantly confirmed, Brims having collected more than sixty reported cases.\\nWeir Mitchell 1 was the first to call attention to the frequency of frac-\\nture in those affected with locomotor ataxia, and suggested that the\\ncause might lie in an impairment of the nutrition, and consequently of\\nthe strength, of the bone dependent upon the disease of the cord.\\nShortly afterward Charcot 2 published a remarkable case of multiple\\nfractures and dislocations in an ataxic woman, and Brims 3 followed\\nwith a paper upon the subject, based upon thirty cases reported within\\na few years. He finds that the fractures are usually multiple, from\\ntwo to six in number, and are most common in the lower limb, espe-\\ncially in the femur the frequency is equal in the different bones of the\\nupper extremity clavicle, humerus, and forearm. Repair takes place\\nin the usual time.\\nThe accident seems to occur more frequently in the earlier than in\\nthe later stages of the nervous disease, and the predisposing condition\\nis a rarefaction of the bone marked by great absorption of the compact\\ntissue, increase of fat, and loss of inorganic matter. A very remark-\\nable instance of the earliness of this change is given by Tillmann 4 in\\nthe report of three cases of spiral fracture of the shaft of the femur\\ncaused by the effort made in drawing off a shoe. The patients showed\\nnothing abnormal at the time, but when examined three and half, five,\\nand eight years later, respectively, locomotor ataxia existed.\\nRachitis. Friability due to rachitis is found only in childhood, for\\nthe disease is one which involves the bones only during their period of\\ngrowth, and consists essentially in the prolongation and exaggeration\\nof the embryonal or developmental condition of the shaft, in conse-\\nquence of which its strength and the firmness of its union with the\\nepiphyses are diminished.\\nUnion after fracture takes place rather more slowly than in normal\\nbone, and sometimes fails entirely. The callus is usually large, but,\\nas it is composed of the same soft embryonal tissue whose excess is the\\npathological feature of the disease, it is lacking in firmness.\\nSyphilis, Mercurialism, and Rheumatism. Syphilis affects the organ-\\nism in so many and so varied forms, and causes such serious bone\\nlesions in its later stages, that it is not strange that both physicians and\\npatients have been inclined to attribute to it fractures produced by\\nslight causes whenever the patient was or had been affected by it.\\n1 Weir Mitchell American Journal of the Medical Sciences, July, 1873, p. 113.\\n2 Charcot Arch, de Phvs., 1874, p. 166.\\n3 Bruns: Berlin, klin. Wochenschrift, 1882, p. 164.\\n4 Tillmann: Berlin, klin. Wochenschrift, 1896, No. 35.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0067.jp2"}, "66": {"fulltext": "46 FRACTURES.\\nAnd in like manner those who saw in mercury the cause of the bone\\nlesions of syphilis attributed the fractures to the use of that drug.\\nWhen we remember what multitudes of people have contracted\\nsyphilis, how numerous those in whom it has caused grave lesions of\\nthe bones, and on the other hand how few are the cases, excluding sep-\\naration of the epiphyses in the new-born, in which it can even be sus-\\npected as a predisposing cause of fracture, it is evident that it can have\\nbut little influence in this direction and an examination of the alleged\\ncases shows very frequently a coexisting constitutional weakness or a\\ncachexia not always to be attributed to the specific disease which\\ncreates a close resemblance between these cases and those in which the\\nfriability of the bone is due to a premature or exaggerated senile\\natrophy. Yet it seems strange that the development of a gumma in\\nthe shaft of a long bone, with the consequent destruction of tissue,\\ndoes not more often lead to fracture.\\nGurlt s fifteen syphilitic cases include five in which the fracture was\\npreceded by severe pain, more or less prolonged, in the broken bone,\\nand these might be deemed demonstrative of the influence of syphilis\\ndid we not possess other similar cases in which the syphilitic complica-\\ntion does not exist. Malgaigne, 1 indeed, speaks of local inflammation\\nof the bone as a frequent and too much neglected predisposing cause of\\nfracture, adding I give this name, conjecturally, to an affection\\nwhich manifests itself by dull pains attributed by the patient to some\\ncontusion or to rheumatism, rarely sufficient to cause a general reaction,\\nand attracting but little attention until some slight cause produces frac-\\nture at the point it occupies. There is a striking similarity between\\nthe cases he cites and Gurlt s syphilitic cases.\\nThere seems to be no reason to suppose that mercury has any direct\\naction upon the bones rendering them more liable to fracture, and the\\nmost that can be claimed is that its excessive, unskilful use will cause\\na deterioration of the health, which may result in an atrophy of the\\nbones similar to that found in old age.\\nCancer and Sarcoma. There are two ways, apparently, in which the\\ndevelopment of a malignant tumor may lead to fracture either the\\ntumor may occupy the bone itself, primarily or secondarily, and destroy\\nit to such an extent that the slightest force is sufficient to fracture it,\\nor the presence of the tumor elsewhere may induce a cachexia which\\nresults in atrophy of the bones. The following cases are quoted in\\nillustration\\nLouis 2 was called to see a nun, sixty years old, Avhose arm had been\\nbroken by the efforts of a coachman to help her into a carriage. Union\\ndid not take place, and six months later, while seated in a chair, she\\nbroke her femur by letting her hand fall upon it. Louis, seeking the\\ncause of this fragility, then learned that the patient had an ulcerated\\ncancer of the breast.\\nA woman, 3 forty years old, who had a cancer of the breast for some\\ntime, with well-marked cachexia, broke her right femur in the lower\\nthird by rising from a chair. She was taken to the hospital, and there\\n1 Malgaigne Loc. eit., p. 22. 2 Malgaigne: Loc. cit., vol. i. p. 14-\\n3 Cruveilhier Anat. Path., Livraison xx, PL 1, Fig. 4.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0068.jp2"}, "67": {"fulltext": "ETIOLOGY. 47\\nthe other femur was broken by the interne as he was preparing to\\napply a bandage to the first. She died the same night, and at the\\nautopsy cancerous masses were found in the spongy tissue and in the\\nmedullary canal at the points of fracture and elsewhere, also in the\\nvertebrae and cranial bones.\\nI have now under treatment a woman thirty-one years old who broke\\nher left femur in the upper third by stumbling, without falling. For\\ntwo years she has had a carcinoma of the left breast, unulcerated but\\ninvolving the skin. Two months later there was a large mass at the\\nseat of fracture, and on moving the limb crackling (apparently the\\nbreaking of small pieces of bone) could be plainly felt. Now, a month\\nlater, there seems to be fairly firm union.\\nIn thirty-two cases collected by Gurlt in which the position of the\\nprimary tumor is noted, it occupied the mammary gland twenty-six\\ntimes (once in a man); and of the entire thirty-eight cases thirty-five\\nwere women. As a rule, too, the aifection was of long standing; in\\nmany of the cases the tumor had returned after removal, and in nine\\nit had ulcerated. The humerus and femur were almost exclusively\\naffected, but very unequally twenty-six fractures of the femur and\\nseven of the humerus. Severe localized pain in the bone preceded the\\nfracture in a number of cases.\\n.Reunion took place in one-fourth of the cases, and in at least three\\nof these there was cancerous degeneration of the bone at the seat of\\nfracture. In most of the remaining twenty-eight cases death, due to\\nthe progress of the disease, followed so soon after the fracture that the\\nbones had not time to unite, even if they were capable of doing so.\\nHydatid and Other Cysts. There are a few instances on record in\\nwhich the unsuspected development of a hydatid cyst within a bone\\nhas resulted in its fracture by slight violence at the point occupied by\\nthe cyst; and others in which a similar result has been produced by\\nthe occurrence of a cystic degeneration of unspecified character within\\nthe bone. These causes act by direct absorption of the cortical layer\\nof the bone, and their action is purely local.\\nOsteomyelitis favors fracture by partial destruction of the bone, but\\nas this effect is accompanied by a rapid and often very bulky new-\\nformation which makes good the loss, fractures are but infrequently\\nobserved except in the course of operations undertaken for the cure of\\nthe disease which require much cutting away of the new bone. I\\nhave seen several such their importance is slight, for there is usually\\nbut little displacement, and repair takes place within the usual time.\\nI have met with the report of one case in which fracture was due to a\\nsuppurative osteomyelitis mistaken for sarcoma the error, of course,\\nwas due to the enlargement of the bone and to the fact that the pus\\nhad not yet reached the surface.\\nIntra-uterine Fractures and Fractures During Delivery.\\nFracture of a limb of the child during its delivery through the natural\\npassages of the mother is not very infrequent and is usually the result\\nof manual or instrumental interference. Such fractures belong to the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0069.jp2"}, "68": {"fulltext": "48 FRACTURES.\\nclass of fractures by external violence, and present no features of\\nspecial interest but there are others in which the fracture is caused\\nby the expulsive efforts of the mother alone. An arm or a leg is\\nengaged between the body of the child and the rigid parts of the\\nmother, and the humerus or the femur is broken, sometimes with an\\naudible snap, as the child is forced through the passage.\\nFractures within the uterus have been caused in a few cases by a\\nbullet or sharp instrument that has at the same time perforated the\\nabdominal wall of the mother.\\nThe possibility of the occurrence of fracture within the uterus as\\nthe result of external violence without perforation of the abdomen of\\nthe mother, or, in some cases, of unknown causes, has been proved by\\nthe birth of children presenting fractures of different bones in various\\nstages of repair. It is not always easy to say, when a child is born\\nwith a fracture, whether it was caused during delivery or at an earlier\\nperiod, or whether it was due to external violence or to the contractions\\nof the uterus. And, further, it is not always possible to say whether\\nan apparent fracture is actually one or only a malformation, a defect\\nof ossification or of development, or a separation of the epiphysis due\\nto syphilis. Gurlt collected eight cases in which the causal relation\\nbetween an injury received by the mother during pregnancy and the\\nfracture observed in the child seemed to him to be clearly demon-\\nstrated, and twenty-five others in which more or less doubt existed as\\nto the cause of the fracture or the character of the lesion. The injury\\nin the first eight cases was either a fall from a height or a violent blow\\nupon the abdomen and the bones broken were those of the thigh, leg,\\narm, and forearm, and the clavicle.\\nThe other group includes some in which an undoubted fracture\\nexisted, but with no history of external violence, and some in which\\nthe coexistence of malformations threw r some doubt upon the character\\nof the supposed fracture, and others in which the fractures were so\\nnumerous and so symmetrical that they must have depended upon some\\ngeneral cause, syphilis or rachitis, acting possibly upon the epiphyseal\\ncartilages.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0070.jp2"}, "69": {"fulltext": "CHAPTER IV.\\nEAKLY SYMPTOMS AND DIAGNOSIS.\\nThe symptoms produced by a fracture are divided into two groups\\nthe objective or positive, those which can be directly observed by the\\nsurgeon, and the subjective or rational, those for his knowledge of which\\nhe has to depend more or less completely upon the statements of the\\npatient. The former are the most important, the only ones that are\\nreally pathognomonic they include, first, deformity of the limb or part\\nsecond, abnormal mobility at the point of fracture; third, crepitus.\\nThe second group includes, first, loss of function second, pain third,\\nhistory of the case and of the patient.\\nObjective Signs.\\nDeformity. This term is here employed in its widest sense, to include\\nchanges in the relations of the fragments of the bones to each other\\nand the modifications in the appearance of the limb or part of the body\\nproduced by those changes, by the effusion of blood, and by the later\\ninflammatory processes.\\nThe changes in the relations of the fragments to each other have\\nbeen described in detail under Displacements. Many of them are so\\nmarked that they are recognizable by simple inspection of the part,\\nwhile others are brought to light only by careful palpation and by meas-\\nurements compared with those of the opposite limb. These measure-\\nments are used in practice only to recognize displacements by which a\\nlimb is shortened or the diameters of an articular extremity modified.\\nIn a few places normal relations exist which may take the place\\nof comparison with the opposite limb such are those of the great\\ntrochanter of the femur to a line drawn from the tuberosity of the\\nischium to the anterior superior spine of the ilium, and those of the\\nstyloid process of the radius to that of the ulna, both of which may\\nbe used with confidence in cases of fracture of the neck of the femur\\nor of the lower extremity of the radius respectively.\\nThe chief difficulty in employing mensuration is that of finding\\nwell-defined points upon the skeleton between which the measurements\\ncan be made. Those employed in fractures are bony prominences or\\nedges sufficiently near the surface to be clearly felt, but as they are all\\nmore or less rounded, absolute accuracy in measuring the distance is\\nimpossible.\\nAnother cause of uncertainty or of error lies in the normal asym-\\nmetry, the difference not due to traumatism or disease, w T hich has been\\nfound occasionally to exist, and which sometimes is very notable, as\\nmuch as an inch and a half in the lower limbs.\\n4 49", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0071.jp2"}, "70": {"fulltext": "50 FRACTURES.\\nOther sources of difficulty and error are found in the swelling of the\\nsoft parts, which may prevent the tape from being drawn straight, and\\nin the varying angles between the axis of the limb and the line of\\nmeasurement. The first is not likely to be great or to be overlooked\\nbut the latter is a frequent source of error. It is rare that the two\\nfixed points between which the measurement is made are both upon\\nthe limb or the bone whose length is in question one of them is usually\\nupon the trunk, and lies at a certain distance from the centre of motion\\nof the limb. Consequently, any change in the position of the limb\\nchanges the distance between the two points that have been chosen.\\nFor example, in measuring the length of the lower limb the points\\ntaken are the anterior superior spine of the ilium and the tip of the\\nmalleolus the former lies several inches above the centre of the hip-\\njoint, and, therefore, when the limb is in abduction, the distance be-\\ntween the chosen points is less than when the limb is parallel to the\\nlong axis of the body. If a comparison is to be made between the\\ntwo limbs, it is essential that their position with reference to the pelvis\\nshould be the same, and, therefore, care must be taken that the ankles\\nare equidistant from a line drawn between them at right angles to and\\nat the centre of another connecting the two anterior iliac spines.\\nSimilar difficulties and uncertainties exist in transverse and periph-\\neral measurements. The swelling of the soft parts not only increases\\nthe bulk of the limb, but it also obscures the bony prominences and\\nplaces them at a greater distance below the surface, so that an accurate\\nmeasurement of the distance between points on the opposite sides of a\\nbone is practically impossible. For this and for rotatory and angular\\ndisplacements the trained eye, aided by careful and minute considera-\\ntion and palpation of the anatomical landmarks and comparison with\\nthe opposite limb, is the best guide.\\nThe appearance of the limb will be still further modified by swell-\\ning due to extravasated blood and inflammatory exudate, and some-\\ntimes to the shortening of the limb, which increases its transverse\\ndiameters.\\nEcchymosis is a symptom that is rarely absent, although its appear-\\nance may be delayed for several days. It is most marked and most\\nextensive in the old. The blood which escapes from the broken bone\\nand the adjoining parts makes its way along the muscular planes, and\\nfirst appears under the surface at some distance from the fracture. Its\\nappearance at certain points creates a strong presumption of fracture\\ne. g., beneath the malleoli in Pott s fracture and the same interfer-\\nence is measurably justified whenever an ecchymosis appears upon a\\nlimb that has not been directly contused.\\nLarge blebs, the serum of which is often dark, frequently appear\\nupon the leg a day or two after its fracture less frequently upon\\nother limbs. The cause of their production is not known.\\nIn fractures communicating with joints a characteristic deformity is\\ncaused by the filling of the cavity of the joint with blood or an inflam-\\nmatory effusion, the situation of which is shown by its limitation\\nwithin the boundaries of the articular capsule.\\nAbnormal Mobility. Mobility appearing after injury at a point in a", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0072.jp2"}, "71": {"fulltext": "EARLY SYMPTOMS AND DIAGNOSIS. 51\\nbone where it did not previously exist, and permitting the bone to be\\nbent at an angle, or a portion of it to be moved while the other por-\\ntion remains at rest, is pathognomonic of fracture, but it is not always\\npresent or recognizable, for the fracture may be incomplete or too near\\na joint, or one of the fragments may be too small or too deeply placed\\nto* be grasped. In fracture of the ribs, sternum, or fibula the elasticity\\nof the bone may deceive if not taken into consideration, or raise a\\ndoubt if it is.\\nThe manipulations employed for the detection of abnormal mobility\\nvary with the seat of fracture and the kind of mobility which is sought\\nto be produced. In fracture of the shaft of a long bone the surgeon\\nseeks first to produce an angular displacement by passing his hand\\nunder the limb at the supposed seat of fracture and gently raising it,\\nor by grasping the two extremities of the bone firmly and moving the\\nlower one slightly from side to side while the upper one is held sta-\\ntionarv. Or he may grasp the limb with both hands close to the\\nfracture, and produce transverse displacement by moving the fragments\\nbodilv in opposite directions. la fracture of the shaft of the fibula,\\nradius, or ulna lateral mobility may be detected by grasping the limb\\nwith both hands above and below the fracture, and then making press-\\nure alternately against the bone.\\nIn fracture of the upper portion of the shaft of the femur or of the\\nneck of the humerus or of the upper end of the tibia, where a lateral\\nor angular mobility cannot be easily recognized, recourse may be had\\nto slight rotatory movements of the lower portions of the limb, while\\nthe upper portion is so held that its bony prominences can be distinctly\\nfelt by the fingers. Abnormal mobility is then recognized by the\\nfailure of the manipulation to transmit the rotatory movements to the\\nupper fragment. It is essential that the communicated movements\\nshould be slight, for otherwise the attachments of the soft parts or the\\ninterlocking of the fragments may prevent the success of the manoeuvre,\\nwhich, moreover, for obvious reasons, must fail in partial or impacted\\nfractures.\\nIn fracture of either condyle of the femur or humerus, or in frac-\\nture of an apophysis, the surgeon must try to grasp the fragment\\nfirmly and move it in the direction of the plane of fracture.\\nIt is sometimes possible to give a fragment a tipping or see-saw\\nmotion; thus, by pressing the tip of the external malleolus inward,\\nwhen the fibula has been broken just above the ankle, the upper end\\nof the lower fragment may sometimes be felt to move outward. In\\nthis manipulation the sliding of the skin is liable to be mistaken for\\nmovement of the bone, and should be guarded against by pressing the\\nfingers toward each other so as to relax the skin between them.\\nCrepitus. This is the sound produced, or the sensation communi-\\ncated to the hand of the surgeon, by the friction of the fragments of a\\nbroken bone against each other. It is as pathognomonic of fracture\\nas is abnormal mobility, and these two signs usually coexist. The\\nsensation is not the same in all cases it may be the sharp click of two\\nhard points or edges, or a dull, muffled contact, or the crackling and\\ngrating of multiple fragments and broad surfaces. Some of its forms", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0073.jp2"}, "72": {"fulltext": "52 FRACTURES.\\nare practically identical with the friction sounds obtained by the move-\\nment of joints whose surfaces are altered by disease, and although it\\nis usual to speak of a recognizable difference in the quality of these sen-\\nsations, the one being called hard or rough, the other soft or smooth,\\nthe diagnosis in cases of doubt must depend upon circumstances other\\nthan this difference.\\nCrepitus is perceived through the hand rather than the ear, although\\nsometimes it is audible to bystanders not in contact with the patient.\\nIt is to be sought by the same methods as abnormal mobility, and also\\nin the ribs and flat bones by placing the palm of the hand over the\\nsupposed seat of fracture and pressing gently in various directions.\\nDirect auscultation is sometimes employed, especially in fracture of\\nthe ribs or sternum.\\nCrepitus cannot always be produced when there is a fracture, for\\nits production is conditioned upon the contact and, in a measure, the\\ncharacter, of the broken surfaces. If the fragments are completely\\nseparated, if a piece of muscle or fascia is interposed between them, or\\nif they have become covered with granulations, their movements may\\nnot cause crepitus, and it is a common experience that the manipula-\\ntion which produces it at one moment fails to produce it at the next.\\nAuscultatory percussion, the stethoscope being moved from one frag-\\nment to the other while percussion is made upon the first, will some-\\ntimes give a marked change in the sound as the line of fracture is\\ncrossed but it is rarely significant, except in cases in which the diag-\\nnosis can be made by other means.\\nConditions giving rise to sensations that may be mistaken for crep-\\nitus are Roughness of neighboring joints, inflammation of the sheaths\\nof tendons or of bursse, and the crackling of coagulated blood.\\nBy the use of the x-rays, aided by the fl Horoscope or photography,\\nmany fractures can be recognized in detail. Thus far, in my expedi-\\nence, the rays have rarely given practically important information in.\\nfractures which could not be obtained without their aid; but there is\\nreason to anticipate that with increasing knowledge and experience\\nmuch good will yet come from their use.\\nSubjective or Rational Symptoms.\\nLoss of function of the limb or part involved is a common result of\\nfracture, and is due either to mechanical causes, such as the breaking\\nof the lever through which the muscles act, or to the inhibitory effect\\nof pain or the fear of pain. As pain due to other causes may have\\nthe same effect, and as the loss after some fractures, even of the main\\nbone of a limb, may be at first slight, the presence or the absence of\\nthe symptom is only suggestive, not indicative, of the presence or\\nabsence of fracture. In most cases of fracture of a long bone the limb\\nis practically helpless, but from time to time we meet with patients\\nwho can move it with some freedom or who can walk with a broken\\nankle, leg, or even thigh.\\nPain, spontaneous or on pressure upon, or movement of, the broken\\nbone, is a constant accompaniment of fracture. Spontaneous pain", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0074.jp2"}, "73": {"fulltext": "EARLY SYMPTOMS AND DIAGNOSIS 53\\nwhen the part is at rest is usually slight, not distinetly limited to the\\nseat of injury, and not significant but localized pain on pressure, on\\nmovement of the bone, and on pressing the fragments together is a\\nyaluable symptom, and in some cases the most positive one that can be\\nobtained, and sufficient in itself for a diagnosis. It is to be sought for\\nby pressure with the tip of the finger along the line of the bone, by\\npressing one end of the bone toward the other, or, more rarely, by\\ngentle lateral or rotatory movements communicated to the lower por-\\ntion of the limb while the upper is fixed, or by making the patient\\ncontract a muscle attached to the bone while its movement is opposed,\\nas in fracture of the calcaneum or olecranon. It is of great diagnostic\\nimportance in absence of the positive signs, and is therefore specially\\nvaluable in many fractures near the end of a bone and in those of the\\nmetacarpals and metatarsals and ribs, and its absence is often a positive\\nmeans of excluding fracture.\\nThe absence of pain on handling an important fracture, such as one\\nof the leg or thigh, deserves attention as possibly indicative of central\\nnervous disease or of commencing delirium tremens.\\nThe history, with reference to diagnosis, includes earlier injuries which\\nmay have modified the form of the limb, the nature of the accident,\\nand the manner in which the force was applied, the interference with\\nfunction, and occasionally the snap heard at the time and the distortion\\nof the limb observed. A knowledge of the manner in which the vio-\\nlence was applied is sometimes of value in determining obscure points,\\nand, in the absence of positive information, indications may be gathered\\nfrom the position of contusions or of stains made by contact with the\\nground. The account given by the patient must always be received\\nwith distrust, because of his preoccupation by other circumstances at\\nthe moment of the accident and of the tendency to substitute inference\\nfor observation.\\nSuch are the facts upon which the diagnosis is made. They are not\\nall present in every case, and it is never necessary to seek for them\\nall deformity, abnormal mobility, and crepitus are alone absolutely\\npathognomonic, but in not a few fractures none of these can be recog-\\nnized by manipulations that are not unduly severe, and the diagnosis\\nmust be made upon the history and localized pain. It is important\\nthat this should be borne in mind, for many a fracture has been over-\\nlooked because crepitus could not be got. The character of the injury\\nis sometimes so apparent that it can be recognized at a glance in\\nothers so obscure that even the most careful and experienced observer\\nmay remain in doubt. In most cases the examination should be made\\nsystematically and thoroughly, beginning with the history and follow-\\ning with an investigation of the interference with function, the pain,\\nthe deformity, and the abnormal mobility and crepitus in that order.\\nThe clothing should be removed from the injured part, and in doubt-\\nful cases also from the opposite limb. After having noted such changes\\nin appearance as are easily recognizable, the surgeon makes gentle press-\\nure with his fingers along the limb in search of the point of maximum\\ntenderness and of irregularity of outline if the bone is subcutaneous,\\nand when that has been found he seeks evidence of abnormal mobility", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0075.jp2"}, "74": {"fulltext": "54 FRACTURES.\\nat that point by one of the manipulations above mentioned. If the\\nsearch is successful the diagnosis is made. If not, or if the injury is\\nat a point where abnormal mobility is not recognizable, the surgeon\\nseeks for such deformity as is likely to exist after such a fracture as is\\nsuspected, first inquiring whether the region has been previously\\ninjured, in order that he may not mistake an old deformity for a fresh\\none, and the pain of a sprain for that of a fracture.\\nIf neither abnormal mobility nor deformity can be recognized he\\ntests for local pain by pressure in the long axis of the bone or by the\\naction of attached muscles, and accepts pain thus aroused as indicative\\nof the presence of a variety of fracture which may not give the signs\\nthat are lacking.\\nIf doubt still remains as to the existence of a fracture, and if the\\nsearch for signs is hampered by the pain that the necessary manipula-\\ntions cause, or if, a fracture having been proved, it is necessary to\\ndetermine its details, he employs an anaesthetic after having made his\\npreparations to utilize the anaesthesia for the reduction of displacements\\nand the application of a dressing.\\nThe compound character of a fracture is easily determined. In\\nfractures by indirect violence the wound in the skin, close to the seat\\nof fracture, is usually small and bleeds much more freely than a simple\\nwound of the skin would in fractures by direct violence the tegu-\\nmentary wound is usually large and ragged, and the broken ends of\\nthe bones can be seen or felt through it. It is not necessary positively\\nto determine the existence of direct communication between the frac-\\nture and the external wound; the coexistence of the two is sufficient\\nto make imperative the employment of every precaution against infec-\\ntion that would be called for if such communication were known to\\nexist. If the wound is explored at all, it should be done only as a\\npart of the treatment, and with strict asepsis, not merely as a diagnos-\\ntic measure.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0076.jp2"}, "75": {"fulltext": "CHAPTER V.\\nTHE EEPAIE OF FEACTUEES AND THE CLINICAL COITESE.\\nAnatomo- pathological Processes.\\nThe Callus. Bone is one of those tissues whose cicatrices are com-\\nposed of a substance closely resembling, or identical with, the original\\ntissue. The process of repair after fracture is fundamentally the same\\nas that after other forms of injury, and its histological phenomena,\\nlike those of repair of other tissues, are those of normal growth and\\nexaggerated nutrition. It begins with the enlargement and multipli-\\ncation of the cells of the periosteum, marrow, Haversian canals, and\\nlacunae; this multiplication produces a mass of granulations which fill\\nthe gap between the fragments and are transformed into bone, some-\\ntimes directly, sometimes after having passed through a cartilaginous\\nstage. This mass of new bone, at first spongy in its structure that\\nis, composed of irregular lamellae or plates circumscribing relatively\\nlarge lacunae filled with bloodvessels and medullary elements becomes\\nfirmer and more compact in some portions by increase in thickness of\\nthe lamellae and consequent reduction in size of the lacunae the pro-\\ncess known as condensing osteitis, and observed constantly in the\\nfoetus as well as in many pathological conditions and becomes thinner\\nand weaker in other portions until it finally disappears by the con-\\nverse process, diminution of the lamellae through their absorption by\\nthe medullary elements of the lacunae, rarefying osteitis, another\\nstage of productive or simple osteitis and also found in the normal\\ndevelopment of bone and in pathological conditions. The variations\\ndepend upon differences in the degree of the injury or in the position\\nof the fragments^ which require disproportionate amounts of work to\\nbe done by the different parts. The details of the process will appear\\nupon examination of the manner in which it is carried on after simple\\nfracture of the shaft of a long bone, an example which has the advan-\\ntage of illustrating the behavior of all the different elements and of\\nbeing both more complete and more open to experimental study than\\nfractures of short bones or of the spongy extremities of long ones.\\nWhen a fracture takes place the cylindrical shell is broken along an\\nirregular line and probably always with the production of splinters of\\ngreater or less size. The periosteum is usually torn, but the extent of\\nits rupture has probably been largely overestimated even when there\\nis much displacement of the fragments. Oilier l was the first to call\\nespecial attention to the preservation of its continuity at some part of\\nthe periphery of the bone and to the fact that when a lateral or longi-\\ntudinal displacement has occurred the membrane is stripped partly\\n1 Oilier Traite de la Eegeneration des Os.\\n55", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0077.jp2"}, "76": {"fulltext": "56 FRACTURES.\\noff one fragment, but without having its continuity broken, and thus\\nforms a band uniting the two fragments. To this band he gave the\\nname of periosteal bridge. Other portions, also, which do not pre-\\nserve their continuity with one another, are doubtless stripped off the\\ntwo fragments, as can be seen in compound fractures, and as they are\\nstructurally continuous with the overlying soft parts they probably\\ncome quite accurately into place when the displacement is corrected,\\nand thus form a fairly complete tubular sheath connecting the ends\\nof the fragments and all splinters except those which are entirely\\nloose, guiding and limiting the formation of the new tissue that is to\\nestablish the ultimate union. When this sheath is not complete,\\nbecause of persisting displacement, the existence of the periosteal\\nbridge is of extreme importance, because it maintains the connection\\nbetween the fragments by means of a tissue whose activity in the pro-\\nduction of bone is marked. The position and form of the callus in\\nspecimens of union with displacement indicate clearly the position and\\nagency of the bridge, and Plate III. shows the ossification on the\\ninner surface of the bridge, but not complete throughout the interval\\nbetween it and the surface of the bone.\\nAt the same time blood is poured out from the torn vessels of the\\nbone into the gap between the fragments and from the vessels of the\\nsoft parts into the interstices among the muscles. This blood is grad-\\nually absorbed during the first few days following the receipt of the\\ninjury, and at the same time the effects of the traumatism are mani-\\nfested in the inflammatory oedema of the limb and the infiltration of\\na thick viscid liquid into the soft tissues immediately adjoining the\\nseat of the fracture, the beginning of the firm ovoid mass which can\\nalways be felt at this point. The periosteum becomes much thicker,\\nsofter, and more vascular a thin layer of gelatinous or viscid liquid\\nis found between it and the bone for a distance of a few lines from\\nthe edge of the fracture or from the point to which the membrane has\\nbeen stripped up, and at the more distant limit of this layer the sur-\\nface of the bone promptly become roughened by the formation of\\npatches of new bone. The portions of the periosteum which have\\nbeen stripped off, those which form complete or incomplete bridges,\\nand the lacerated tissues which form the wall of the cavity in which\\nthe ends of the bone lie, granulate and pour out an exudate to mingle\\nwith the remaining blood.\\nThe marrow shares in this production of granulations, and the cells\\nof the connective tissue external to the periosteum share for a greater\\nor less distance in the irritation, and by their proliferation bind to-\\ngether all the adjoining parts in one firm, compact mass. The com-\\npact layer of bone, the cylindrical shell of the shaft, feels the same\\ninfluence and reacts in the same manner, but much more slowly in\\nconsequence of the scantiness of its cellular elements. Its outer and\\nbroken surfaces soon show pink points which enlarge and send out\\ngranulations to join those already produced by the periosteum and\\nmarrow, and thus there is formed between the separated fragments a\\nbond of union which is actually continuous, almost from the beginning,\\nwith all their constituent parts. The size and character of this bond vary", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0078.jp2"}, "77": {"fulltext": "THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 57\\nFig. 20.\\nwith the degree of displacement if the fragments remain nearly in\\ntheir original relations to each other, the bond is short and symmetrical,\\nthe granulations springing from the marrow meet and unite in the\\ncentre of the gap, while the thickened periosteum passes from one\\nfragment directly to the other, remaining adherent to them or sepa-\\nrated only by a layer of effused blood. If longitudinal and lateral\\ndisplacement occurs and persists, the bond passes obliquely from the\\nouter surface of one fragment to that of the other, and is much more\\ncomplete at some points of the periphery than at others. Thus, in\\nFig. 20, which represents the condition on the seventh day, the firmest\\nunion is by the cartilaginous band crossing the\\nangle at b and formed apparently by the thick-\\nening of a periosteal bridge. On the opposite\\nside of the lower fragment the beginning of\\nan incomplete band of similar structure is seen.\\nThe formative action thus begun is rapidly\\ncarried on, and principally by the periosteum\\nand marrow. When the fragments are kept\\nend to .end an ovoid mass of tissue, having the\\nconsistency of jelly and a pearly white appear-\\nance, and continuous above and below with the\\nperiosteum, envelops them, the so-called pro-\\nvisional or ensheathing callus. This mass\\nis formed not solely by granulations springing\\nfrom the under side of the periosteum, but also\\nbv the thickening of that membrane and of the\\nconnective tissue on the outer side, including\\neven that which surrounds the adjoining mus-\\ncular bundles. Composed at first of embryonal\\nelements, it soon becomes cartilaginous in the\\nportions formed by the periosteum then lime\\nsalts are deposited at different points within it,\\nand finally it is transformed into bone.\\nThe granulations that spring from the marrow ossify without passing\\nthrough the cartilaginous stage, and the process here apparently begins\\nat the fine lamella? which lie upon the inner side of the compact shell.\\nThe new lamellae extend across the canal, soon occluding it entirely,\\nand also out into the interval to meet those coming from the other\\nfragment. Thus is formed the internal or medullary plug.\\nThe granulations occupying the annular interval between the cortical\\nlayers of the two fragments (when the reduction is complete) apparently\\ncome mainly from the periosteum and pass through a cartilaginous\\nstage before becoming bone, as do the others that have the same origin.\\nThey unite promptly with those of the medullary plug and ultimately\\n(sometimes after a long delay) with the cortical layer. It was to this\\npart of the callus that Dupuytren gave the name of definitive callus.\\nThe cause of the delay in union with the cortical layer lies in the slow-\\nness with which the latter forms the granulations necessary to unite\\nwith the others, and doubtless to the occasional long persistence of a\\nnecrotic scale of bone on its broken surface, which has to be slowly\\nTibia of rabbit. Seventh\\nday: a, blood; b, cartilag-\\ninous callus c, muscles.\\n(Gurlt.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0079.jp2"}, "78": {"fulltext": "58 FRACTURES.\\npenetrated and absorbed by the granulations. The cellular elements\\nof the cortex, which have to do the work of enlarging the Haversian\\ncanals and forming the granulations, are scanty, and those immediately\\nadjoining the broken surface cannot share in the work because their\\nblood-supply is cut off by the clotting of the blood in the torn capil-\\nlaries. The cells situated a little more deeply have to carry on the\\nwork and slowly break through the intermediate necrotic scale before\\nthey can meet and unite with the other granulations that have spread\\ninto the interval from without and within. This process in the com-\\npact tissue is the usual rarefying osteitis, characterized by an enlarge-\\nment of the Haversian canals and a corresponding loss of the bone\\ntissue, a change, in short, which transforms the cortex for a certain\\ndistance into spongy tissue like that of the ossifying callus. Ulti-\\nmately the rarefaction ceases and a productive or condensing\\nosteitis follows, by which the lamellae are thickened and the interme-\\ndiate spaces and canals contracted until the former proportions between\\nthem are measurably restored. Occasionally the ossification spreads\\ninto ligaments and tendons attached to the bone close by the fracture.\\nWhile the callus is thus forming and ossifying, the irritation in the\\nadjoining soft parts subsides, and they regain their original condition\\nand functions more or less completely. Occasionally the associated\\ninjuries of muscles or tendons or the sheaths of the latter lead to per-\\nmanent disabling adhesions.\\nAfter the ossification of the callus has been completed the excess on\\nits exterior and even projecting portions of fragments slowly disap-\\npear, and in cases in which the reduction of the displacements has\\nbeen exact this disappearance of the exterior callus may go so far as\\nto leave little or no trace on the surface of its previous existence. In\\nlike manner the central plug diminishes and the medullary canal may\\nbe restored.\\nFragments of the cortical layer broken off at the time of the injury\\nmay remain attached to the periosteum, preserve their vitality, share\\nin the same processes, and form a part, often an important one, of the\\ncallus. There is reason to believe also that even after they have been\\nentirely detached they may form new connections with the soft parts\\nand granulations, and preserve (or renew) their life. Such fragments\\nhave been found embedded so deeply in a callus that no other expla-\\nnation than that of complete detachment can well be accepted. How-\\nship describes and figures one, and Gurlt another and remarkable one\\n(Fig. 21). The possibility of this preservation has also been estab-\\nlished by experiment upon animals. Portions of the shaft have been\\nchiselled off, separated entirely from the soft parts, and replaced in\\ncontact with the bone examination after the lapse of some weeks\\nshowed re-establishment of vascular connection.\\nIt is also known that fragments may long remain without vascular\\nconnection embedded in a callus as well-tolerated foreign bodies. After\\nthe lapse of months, or even years, and from unknown causes, they\\nmay cause irritation an abscess forms, the bone softens about them,\\nand either they are cast out spontaneously or they remain, provoking\\nan interminable suppuration, until removed.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0080.jp2"}, "79": {"fulltext": "THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 59\\nFig. 21.\\nIt occasionally happens that the callus does not ossify, and in some\\nvery exceptional cases the bone is entirely absorbed for a considerable\\ndistance on each side of the seat of fracture. The causes are not fully\\nunderstood. The difference in the process consists in an entire or\\npartial absence of productive osteitis and in an\\nexcess of the rarefying osteitis. The latter, I\\nam convinced, is favored by the presence of a\\nmetallic suture in the bone.\\nWhen the fracture is compound, and remains\\nso, the details of the reparative process are dif-\\nferent to this extent: that the callus does not\\npass through the preliminary cartilaginous stage\\nat any point where suppuration has occurred.\\nThe formation of the medullary plug is not\\naffected, the granulations there being transformed\\ndirectly into bone as they are in simple fractures;\\nthe difference is in the external or ensheathing\\ncallus. The reason of this difference, as shown\\nby experiment, 1 lies in the destruction of the\\nperiosteum by the suppurative process, in the\\ndestruction, that is, of the only tissue whose\\ngranulations pass through the cartilaginous stage\\nin forming the callus.\\nThe process is slower than after a simple frac-\\nture because the suppuration of the wound delays\\nor prevents the formation of much of the exter-\\nnal callus and throws most of the labor upon the\\nbone itself, which, as has been shown, is the least\\nable to do it. It is easy to watch the process.\\nThe ends of the bone are seen lying bare and\\nwhite in the wound; a mass of pink granulations\\nforms at the limit of the denudation and ad-\\nvances slowly across the bared surface; the\\nbroken surface remains for a time quiescent, then\\ngranulations spring from it, beginning at the\\npoints nearest the medullary canal and spreading come united, with its orig\\nslowly toward the outer edge the wound gradu-\\nally fills up with these granulations, the bone is\\ncovered in, and cicatrization follows.\\nIn less fortunate cases a portion of the bared\\nbone dies and is cast off by the formation of a\\nline of demarcation which can sometimes be seen at the edge of the\\ngranulations, but which more commonly is hidden by them. It must\\nnot be thought that all the bare white bone seen in such a wound is\\ndead, even after it has remained unchanged in appearance for several\\nweeks. Its surface may, indeed, be dead, but the interior is often\\nalive and able to cast off the dead superficial scale without aid. The\\ngranulations which form between the living and the dead parts seem\\n1 Eigal and Vignal: Comptes-Rendus de l Academie des Sciences, 1880, vol. xc. p. 1218.\\nFracture of the neck of\\nthe femur and of the shaft.\\nA splinter 5 inches long and\\nnearly 1 inch wide, com-\\nposed of the cortical layer,\\nhas been turned completely\\nabout its long axis and be-\\ncontact with the other frag-\\nments. (Figured by Gurlt\\nfrom the Museum of the\\nRoyal College of Surgeons,\\nEngland, No. 454.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0081.jp2"}, "80": {"fulltext": "60 FRACTURES.\\nsometimes to dissolve and absorb the latter if they are small and thin,\\nor, if not, slowly to bear them to the surface and cast them out.\\nThe callus thus formed is larger and more irregular than after\\nsimple fracture it remains tender and sensitive for a long time, and\\nis covered by an adherent scar at the seat of the wound. Fragments\\nformed at the time of the accident and remaining attached to the peri-\\nosteum usually preserve their vitality if not, they become detached\\nafter a time and are found loose in the wound, or become shut in by\\nthe callus and prolong the suppuration indefinitely. In this latter case\\nthe constant irritation due to the presence of the foreign body, the exist-\\nence of sinuses, and the burrowing of the pus interfere with the evolu-\\ntion of the callus. Instead of undergoing a gradual and uniform\\ndiminution and condensation, it becomes eburnated at some points and\\nentirely absorbed at others, irregular prominences appear on its surface\\nor follow the lines of attached tendons and fascia?, and its interior is\\noccupied by cavities of various sizes usually suppurating and in com-\\nmunication with the exterior.\\nIn the spongy bones and the spongy ends of the long bones less of\\nthe work of repair is done by the periosteum and more by the bone\\nitself, for the periosteum is so interrupted by attached tendons and\\nligaments that it is less freely stripped up, and the bone surfaces are\\nbroadly in contact and, being spongy, are ready at once to form gran-\\nulations without preliminary rarefaction.\\nIn fractures involving joint-surfaces the absence of periosteum and\\nother soft tissues on the articular surface prevents the formation of an\\nexternal callus on that side, and union takes place by granulations\\narising directly from the fractured surfaces and by an external callus\\nat the extra-articular parts of the fracture. The line of the fracture\\non the articular surface is marked by the absence of cartilage over it,\\nand usually by a groove. The fracture of the cartilage does not heal\\nby the formation of new cartilage usually the callus is covered at this\\npoint by a firm white layer of fibrous tissue, but sometimes the bone\\nis bare. In exceptional cases the callus is exuberant and groAvs out\\nbeyond the level of the cartilage, forming an irregular mass in place\\nof the usual groove.\\nFracture of cartilage (costal cartilage, larynx, etc.) is repaired partly\\nby a fibrous, rarely a cartilaginous, band between the fragments, and\\npartly by a bony peripheral callus. (See Chapter XVI.)\\nExuberance of the callus, both external and intermediate, is a fre-\\nquent cause of diminution of the functions of the joint by destroying\\nthe normal relations of the articular surfaces, by filling up normal\\ndepressions, and by creating abnormal prominences. These results are\\nusually beyond the control of the surgeon, and the latter are most\\ncommon in the young, whose power of producing bone is greatest.\\nOccasionally the productive process excited by the fracture extends far\\nbeyond the limits of the latter, and not only may the joint itself be\\nobliterated by fusion of the bones which constitute it, but the process\\nmay also spread to and produce the same result in neighboring joints\\nas in the case represented in Fig. 22.\\nBones which lie parallel and close to each other, as those of the fore-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0082.jp2"}, "81": {"fulltext": "THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 61\\narm and leg and the ribs, may become united by an exuberant callus\\nwhen either one or both are broken. This consolidation is most likely\\nto occur when both bones are broken at the same level, and when dis-\\nplacement of one or more of the fragments diminishes the normal inter-\\nval between them. The mass of granulations developed about one\\nfracture becomes continuous with that developed about the other, and\\nossification follows. The presence of an interosseous membrane favors\\nthis result, for this tissue has the same tendency to ossify that is shown\\nFig. 23.\\nBony anchylosis of the foot and ankle\\nafter fracture of the leg. (Gurlt.)\\nAbsorption of the neck of the femur after fracture.\\nby other white fibrous tissue in the presence of a productive osteitis. The\\neffect of this consolidation is, of course, to prevent independent motion\\nof the two bones, and while of no importance in the leg and of little, if\\nany, in the ribs, it produces a very serious disability in the forearm by\\nabolishing pronation and supination. It occasionally happens, when two\\nbones are broken at the same level, that the calluses grow into contact\\nw T ith each other but do not unite. Their adjoining surfaces are smooth\\nand together form a sort of lateral joint which may allow movement\\nof one upon the other.\\nWhen the line of fracture follows that of a still existing epiphyseal\\ncartilage, either wholly or in part, and the fragments are not displaced,\\nunion apparently takes place as readily as after simple fracture, but\\nnothing positive is known of the details of the process. The injury\\ndoes not necessarily interfere with the subsequent growth of the bone\\nthe layer of cartilage may remain unossified and perform its functions", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0083.jp2"}, "82": {"fulltext": "62 FRACTURES.\\nas before but it is known from the results of experiments upon ani-\\nmals, and from cases of inflammatory disease and from some of trau-\\nmatic separation without displacement, that the effect of irritation of\\nthe epiphyseal cartilage is sometimes to hasten its ossification, and thus\\narrest the growth of the limb. This last result must certainly be pro-\\nduced when the epiphysis is dislocated by the fracture and is not\\nrestored to its place. Probably there is less likelihood of interference\\nwith growth if the line of fracture lies mainly in the chondroid tis-\\nsue on the diaphyseal side of the cartilage. Gurlt quotes a case of sepa-\\nration of the upper epiphysis of the humerus which showed on dissec-\\ntion three years later a false joint between the fragments. The head\\nof the bone was united to the scapula, and the movements of the limb\\nwere free. Poland thinks the case was probably one of disease.\\nFinally, failure of union after fracture may be due to arrest of the\\nreparative process in the granulation stage, ossification not taking\\nplace and the bond between the fragments remaining fibrous, or to the\\nwide separation of the fragments, or to the interposition of a bundle\\nof muscular tissue, or to the insufficiency of the blood-supply of one\\nof the fragments. This condition, especially as seen after fracture of\\nFig. 24.\\nFracture of the olecranon fibrous union. (Malgaigne.\\nthe shaft of a long bone, is considered in detail in Chapter VIII.,\\nPseudarthrosis. Examples at other points than the shaft are furnished\\nespecially by the patella and olecranon (direct longitudinal separation),\\nand by some fractures of the neck of the femur where the cause lies\\nin an excess of the rarefying process, by which the neck is destroyed,\\nor in the cutting off of the blood-supply by complete rupture of the\\nperiosteum of the neck which carries vessels to the head.\\nClinical Course.\\nThis varies with the position and character of the fracture and espe-\\ncially with the complications arising from the peculiarties of the\\nfracture and the health and age of the patient. Ordinarily, in simple\\ncases, after the primary reaction of the injury has subsided and an\\nappropriate treatment has been established, the patient goes on to\\nrecovery without pain, fever, or other disturbance of his general\\nhealth, and incommoded only by the disability of the limb and the\\nconfinement to which he is subjected. But in the alcoholic this tran-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0084.jp2"}, "83": {"fulltext": "THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 63\\nquil course may be promptly interrupted by the onset of a pneumonia\\nor an attack of delirium tremens; and in the old, confined to bed by a\\nbroken thigh or leg, the primary shock may be sufficient to cause\\ndeath in the first few days, or the general health may begin to suffer\\nabout the third week, and death follow after a short interval marked\\nby symptoms of hypostatic pneumonia or mild delirium and gradual\\nfailing of the strength. And very, very rarely, even in simple cases\\nand without the slightest warning, death may come suddenly in the first\\nfew days by fat embolism of the lungs, or at a later period by a car-\\ndiac pulmonary embolus detached from a thrombus in some large vein.\\nFor the first day or two the patient may suffer pain at and near the\\nfracture, augmented by muscular twitchings, and considerable discom-\\nfort from the weight and tension of the swollen limb and if the bone\\nis a large one (thigh, leg, arm) and the fright and emotion at the time\\nof the accident extreme, the symptoms of shock may be well marked.\\nThe temperature usually shows a rise of from one to two degrees\\nFahrenheit, aseptic fever, which promptly diminishes, and disap-\\npears within a few days. At the same time the urine may contain a\\nsmall amount of albumin and free fat and hyaline casts enclosing\\nbrown granules. The fat, which is sometimes sufficient to form a dis-\\ntinct layer on the surface after standing, is thought to come from the\\ncrushed marrow of the bone, and the variations in its quality and the\\ntime of appearance to depend upon its temporary arrest in the pulmo-\\nnary capillaries (fat embolism, q. v.). The brown casts are sometimes\\nvery numerous, but more often are wholly lacking.\\nThe limb swells, partly because of extravasated blood and shorten-\\ning, but mainly by oedema; the swelling reaches its maximum on the\\nsecond or third day and then slowly subsides. The skin of the involved\\nregion shows a yellowish tinge, the result of staining with the coloring\\nmatter of the extravasated blood, and ecchymoses appear at points\\nbelow and sometimes above the fracture. Larger or smaller blebs\\nappear, especially on the legs, by the second or third day, and may\\ninterfere with the early application of a fixed dressing.\\nAs the swelling subsides a firm ovoid mass becomes recognizable,\\nextending above and below the fracture, and the sensitiveness on\\npressure diminishes; this mass diminishes in size and increases in firm-\\nness as time passes, the abnormal mobility diminishes, and finally,\\nafter a length of time which varies greatly in different cases, ceases,\\nand union is then effected, although not so firm as it will ultimately\\nbecome after ossification shall have been completed. A small, hard\\nmass can still be felt at the seat of fracture which will slowly diminish\\nfor months, perhaps for years.\\nOther things being equal, and bone for bone, less time is required\\nto complete repair in children than in adults and fractures heal as\\nrapidly in one sex as in the other, and in the old as rapidly as in the\\nmiddle-aged. As a general rule, too, the larger the bone the longer\\nthe time required, and fractures of the shaft require more time than\\nthose of the spongy ends, and those with uncorrected displacement\\nmore than those in which the normal relations have been maintained\\nor restored. The average for fractures of the shaft of the long bones", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0085.jp2"}, "84": {"fulltext": "64 FRACTURES.\\nin adults varies from four weeks for the clavicle or forearm to eight or\\nnine weeks for the thigh.\\nBut with the union of the fracture the recovery of the patient, espe-\\ncially after fractures of the limbs, is not yet complete. The circula-\\ntion of the part, the skin, the muscles, and the neighboring joints have\\nyet to recover from the disabilities imposed upon them by the primary\\ninjury or by the prolonged disuse of the limb. The skin is harsh and\\ndry; the limb swells and shows venous congestion when used, and\\nespecially when dependent, presumably because of plugging of the\\nveins and possibly because of rupture of lymphatic channels; the\\njoints are swollen, stiff, and sensitive. As a rule, all these features\\ndisappear under use, and more rapidly in the young than in the old,\\nbut occasionally some of them persist for a long time. (See Chapter\\nX., Prognosis.) Their duration can usually be shortened by appro-\\npriate treatment, especially by massage and mobilization of the joints.\\nThe course of the case, as thus sketched, may be greatly modified by\\nexceptional severity of the injury, by associated lesions, or by a wound\\nor contusion which makes the fracture compound either immediately\\nor after the lapse of a few 7 days. In the severe cases, with more splin-\\ntering of the bone and laceration of the soft parts, the pain, swelling,\\nand general and local reaction are greater and more prolonged, but\\nvery rarely end in suppuration.\\nThe direct implication of a joint in a fracture, or the spread to it of\\nthe neighboring reaction, or the presence of a concomitant sprain, as\\nis so often seen at the knee in fractures of the thigh, adds an arthritis\\nwhich increases the pain and discomfort, and may delay recovery or\\ndiminish its completeness.\\nIn compound fractures with a small, clean wound in unbruised skin\\nthe local and general reaction is even less than in simple fracture, pre-\\nsumably because the extravasated blood escapes through the wound,\\nwith consequently less tension and less absorption of fibrin-ferments to\\ncause fever. Under appropriate treatment such a wound heals in a\\nfew days, and the course is thenceforth that of a simple fracture.\\nIn compound fractures with bruising of the skin that prevents pri-\\nmary union of the wound, and in those made compound by the slough-\\ning of the bruised skin, the course may be very different. It is that\\nof a deep, lacerated wound, from whose walls sloughs must be cast off,\\nand in which suppuration is inevitable and serious infection possible.\\nIn the milder forms the suppuration is slight and limited to the super-\\nficial portions of the w T ound, and the course is practically that of a\\nsimple fracture with only the delay due to tardier union of the bone\\nand cicatrization of the wound. But in the severer forms all the local\\nand general symptoms are more marked, the swelling is greater, the\\nfever higher and persistent. If treatment fails to overcome the infec-\\ntion the pus burrows amid the muscles, neighboring abscesses form,\\nwith chills and exacerbation of the fever, and amputation may be indi-\\ncated to save the imperiled life. Or, by counter-openings, drainage,\\nand the free use of antiseptics, the suppuration may be brought under\\ncontrol, and then the patient pursues his weary course toward conva-\\nlescence through the pains and perils of the slow casting off of necrotic", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0086.jp2"}, "85": {"fulltext": "THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 65\\nfragments of the bone and the tardy formation and ossification of the\\ngranulations that must take their place. Such cases are often despair-\\ninglv slow in reaching solid union and closure of the sinuses, and still\\nlonger in regaining use of the limb. The callus is large, the cicatrix\\nadherent and sensitive, the adjoining muscles hampered by adhesions.\\nThe condensation of the callus is liable to become extreme in portions,\\nbecause of the prolongation of the irritation, and thereby to cause par-\\ntial necroses which prolong or renew the suppuration in the efforts to\\ncast them out, so that the sinuses may persist for years with longer or\\nshorter interruptions.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0087.jp2"}, "86": {"fulltext": "CHAPTEE VI.\\nCOMPLICATIONS AND REMOTE CONSEQUENCES.\\nEarly Local Complications Skin, bloodvessels, gangrene, degeneration of mus-\\ncles, suppuration. Early General Complications Septicaemia, fat embolism,\\ndelirium tremens, tetanus, pneumonia. Late Local Complications Excess-\\nive painful callus, tumor, injury of nerve, weak callus, arrest or exaggeration\\nof growth, stiffness of joints, atrophy, thrombosis, and embolism.\\nThese may be local or general, and the complications may be the\\ndirect and immediate result of the primary violence or the later result\\nof the primary lesions, of infection, or of constitutional conditions.\\nSome are peculiar to fractures, others may arise also in connection with\\nother forms of injury.\\nEarly Local Complications.\\nSkin. The sharp point of the upper main fragment may be forced\\nthrough the overlying muscles and fascia and perforate the skin or\\nbecome engaged in its deeper layers in such a way that its reduction is\\ndifficult, or it may make such pressure upon the unbroken skin that\\nthe latter will slough at the point of pressure in the course of a few\\ndays. The first condition may sometimes be corrected by traction upon\\nthe lower segment of the limb, but usually an incision will be neces-\\nsary to effect a complete reduction of the displacement. If perforation\\nhas taken place the opening should be at once enlarged, for this does\\nnot add to the chance of infection, and greatly simplifies reduction.\\nPressure upon the unbroken skin must be relieved by reduction, or\\nat least by diminution of the displacement and if this is not possible\\nthe bone should be exposed by incision and the projecting portion cut\\naway, for such a wound can be so protected that it will heal promptly,\\nwhile one made by sloughing will surely suppurate, and even if danger-\\nous infection thereby of the seat of fracture is avoided, yet the wound\\nwill be slow to heal, and will leave an adherent and possibly sensitive\\nscar.\\nThe sloughing of the skin contused by the primary violence is rare\\nexcept in connection with compound fracture that is, violence which\\nis sufficient to kill the skin generally breaks it. Theoretically, it\\nwould be well immediately to remove all skin and other tissues that\\nhave been thus killed, in order more surely to avoid infection but the\\nlimits of such destruction cannot be determined with sufficient accu-\\nracy. A fairly accurate estimate of the probability of sloughing and\\nits extent can be made by applying a rubber bandage tightly to the\\nlimb for a few minutes, as in producing artificial ischsemia for opera-\\ntion, and noting the areas which do not share in the blush following", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0088.jp2"}, "87": {"fulltext": "COMPLICATIONS AND REMOTE CONSEQUENCES. 67\\nits removal. This test is fairly accurate except for areas of skin on the\\ndistal side of long transverse wounds such generally remain pale, even\\nif viable. It is important promptly to remove the dead skin in order\\nto check the spread of infection. After its removal the raw surfaces\\nmust be protected with sterile or antiseptic dressings.\\nBloodvessels. Rupture or serious bruising of the main vessels of a\\nlimb is a serious but infrequent complication. Among the more impor-\\ntant vessels that have been thus injured in simple fracture are the\\nmiddle meningeal and carotid arteries in fractures of the skull, the\\nsubclavian vein and the acromial branch of the acromio-thoracio\\nartery in fractures of the clavicle, the brachial and axillary artery in\\nfractures of the humerus, the popliteal artery and vein in those of the\\nlower end of the femur, and the anterior tibial in those of the leg.\\nIn compound fractures the same vessels and also those lying at a\\ngreater distance from the bone may be injured.\\nThe rupture of an artery in a simple fracture may lead to fatal\\nhemorrhage, even if the vessel is a small one, in case the blood can\\nescape into a large natural cavity, as in a unique case of fatal hemor-\\nrhage following rupture of a small branch of an intercostal artery after\\nfracture of a rib l but in a limb it leads either to the formation of a\\ntraumatic aneurism or to gangrene. The rupture may be immediate\\nor it may occur after a few days by sloughing of the bruised vessel.\\nThe symptoms are a rapidly increasing local swelling, which pulsates\\nafter it has ceased to increase, and (in the case of the main artery)\\nabsence of the pulse in its distal branches. Gangrene is more directly\\ndue to interference with the venous flow by the pressure of the swelling\\nthan to loss of arterial supply, and consequently appears in the moist\\nform, characterized by swelling, duskiness, and coolness of the limb.\\nThe object of early treatment is to check the hemorrhage and favor\\nthe venous flow by elevation of the limb, possibly combined with\\ndigital pressure upon the main trunk or with snug bandaging from the\\nlower end of the limb to a point well above the injury. If a w r ell-\\ndefined aneurism forms it may be treated, after union of the fracture\\nhas taken place or is well advanced, by proximal or local ligature of\\nthe artery. Possibly, if gangrene threatened, the limb might be saved\\nby a free incision through which the escaped blood could be turned\\nout, thus relieving the pressure on the veins, and by tying the artery.\\nIn compound fractures the diagnosis is made by the profuseness and\\narterial character of the bleeding and the treatment is to tie the artery\\nat the point of injury.\\nRupture of a large vein cannot be certainly recognized in a simple\\nfracture, and its treatment is controlled by that of the gangrene which\\nit may cause. In compound fractures the vessels may sometimes be\\nseen and tied, but probably the associated lesions will be such that\\namputation will be indicated.\\nThrombosis of an artery, and doubtless also of a vein, may be caused\\nby the direct violence Avhich causes a fracture. I have seen examples\\nin the arteries of the arm and leg broken by the passage of a wheel,\\nthe condition being found on examination of the limb after amputation\\n1 Loudon Medical Times and Gazette, 1860, ii., p. 607-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0089.jp2"}, "88": {"fulltext": "68 FRACTURES.\\nbecause of gangrene, and others have been reported. Thrombosis of\\na vein may be caused by the pressure of a displaced fragment. A\\ncase involving the femoral vein and ending in gangrene and amputa-\\ntion is reported in the Deutsche med. Wochenschrift, June 8, 1892, p.\\n549.\\nGangrene may be local or general the former the result of crushing\\nof the skin and other soft parts in direct fracture, the latter the result\\nof injury to or compression of the vessels or of tight bandaging.\\nLocal gangrene is manifested by the darkening and hardening of an\\narea of skin surrounded by an inflammatory zone the swelling and\\nfever are more marked and persistent, and when the dry patch is split\\nor cut away an abundant thin, pink or dark, and offensive exudate\\nescapes from beneath it and from the adjoining subcutaneous and inter-\\nmuscular planes. The infection must be combatted by free removal of\\nthe dead and dying tissues, irrigation, and drainage. The danger of\\ngeneral infection is great, and amputation is often required to save life.\\nGangrene of the limbs is usually of the moist form and begins with\\ncoolness and discoloration of the toes or fingers, the latter beginning\\nas a deep-red color, and soon changing to purple and grayish-black.\\nDark blebs may appear on the surface, or the epidermis may be exten-\\nsively but slightly raised by a thin, dark serum. If taken in time,\\nand if the cause can be removed, as in tight bandaging, the life of the\\npart may be preserved, and I have thought that keeping the limb in\\nhot water (100\u00c2\u00b0 to 102\u00c2\u00b0 F.) was helpful; but the vitality of the skin\\nis greater than that of the muscles, so that even if the circulation\\nreturns in the former the muscles may yet disintegrate and the limb\\nbe lost. I saw this result in a case of fracture of the olecranon which\\nhad been treated by the immediate application of a plaster- of-Paris\\ndressing. The patient entered the hospital on the fifth day, with the\\nuncovered hand black and swollen the dressing was removed, and the\\nlimb placed in a hot bath. Two days later circulation was re-estab-\\nlished in the skin of the hand and forearm, but a week later incisions\\nhad to be made in the forearm, through which the muscles appeared\\nwholly disorganized and pulpy.\\nIt must be borne in mind that even a narrow circular constriction,\\nas by a band of adhesive plaster, is sufficient to produce this disastrous\\nresult, and is, perhaps, even more likely to do so than an equally tight\\nbandage covering the limb. Consequently the longitudinal strips of\\nplaster used in making traction should not be reinforced by the circular\\nstrips which are sometimes applied with the idea of keeping the former\\nmore securely in place.\\nDegeneration and contraction of the muscles, the result of arrested\\nblood-supply by bandaging, is occasionally seen it is a lower grade of\\nthe change mentioned in the preceding section. Volkmann, who first\\ndescribed it, give it the name ischemic contraction/ It is most\\nfrequently seen in the forearm and is marked by atrophy and shorten-\\ning of the muscles, the fingers being permanently flexed. This change\\nis brought about by rapid degeneration of the muscular fibres and\\nsubsequent reactive increase and contraction of the connective tissue.\\nIt is to be distinguished from similar contractures due to nerve injury", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0090.jp2"}, "89": {"fulltext": "COMPLICATIONS AND REMOTE CONSEQUENCES. 69\\nor disease by its prompt appearance. In the less severe cases some-\\nthing may be gained by massage, electricity., and persistent efforts to\\nstraighten the lingers.\\nSuppuration in simple fractures is very rare, and when it occurs it\\nappears to be due to auto-infection, by germs carried by the blood and\\npossibly brought from some suppurating focus in a distant portion of\\nthe body, as a furuncle; rough handling of the broken limb and\\nneglect of proper care apparently favor its occurrence. It promptly\\nmakes the fracture compound by spontaneous or surgical opening, and\\nthe course and prognosis are then those of an open infected fracture.\\nSuppuration in compound fractures can generally be prevented or\\nrestricted to the superficial layers when the wound is small and its\\nedges not contused, as is ordinarily the case in fractures by indirect\\nviolence. The later its appearance, the less likely is it to spread widely\\namong the muscles and endanger life.\\nIn compound fracture with bruising and extensive laceration, sup-\\npuration may remain as a local complication, the pus escaping freely\\nto the exterior and the infection not spreading the graver cases will\\nbe considered in the following section.\\nEarly General Complications.\\nSepticemia. This grave complication occurs in compound fractures\\nand in simple ones followed by gangrene of the limb or suppuration at\\nthe seat of fracture. The most prompt, rapid, and fatal forms are\\nseen in compound fractures accompanied by much bruising and lacera-\\ntion of the soft parts and in those patients whose vitality has been\\nlowered by alcoholism, constitutional disease, or age.\\nA dusky-brown tinge discolors the skin about the wound and spreads\\nrapidly upward, especially on the sides and back of the limb the torn\\nmuscles become gray and less moist, an offensive odor appears and\\ngrows rapidly more marked, and a thin offensive discharge escapes at\\nthe surface of the wound and can be pressed out from its recesses.\\nThe limb swells far above the fracture, the temperature rises, the\\npatient becomes apathetic and slightly delirious. Occasionally pressure\\nwith the fingers upon the discolored skin provokes the slight crackle\\nof emphysema, evidence of decomposition with production of gas, and,\\nif well marked, strongly suggestive of the presence of one of the most\\nrapidly fatal infections known, that of the vibrion septique of\\nPasteur, or the bacillus capsulatus aerogenes (Welch), the germ of\\nacute gangrenous septicaemia.\\nAmputation alone, with vigorous disinfection of the stump and of\\nthe subcutaneous tissue throughout the discolored area, can save life,\\nand that only in so small a proportion of the cases that no one can be\\nblamed for declining to resort to it. The peroxide of hydrogen appears\\nto be a valuable antiseptic in these cases it can be forced under the\\nskin with a syringe or through incisions which will serve also for\\ndrainage. I have never known a case in which the septic vibrio was\\npresent to recover, although I have heard of one or two in a few cases\\nin which the early symptoms indicated its presence I have changed\\nthe diagnosis because the patient did not fail so rapidly as I anticipated,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0091.jp2"}, "90": {"fulltext": "70 FRA CTURES.\\nand in every such case culture tests have shown its absence. Air which\\noccasionally makes its way through the wound into the adjoining cel-\\nlular tissue must not be mistaken for the gas of this decomposition.\\nIn the less acute cases septic infection follows the establishment of\\nsuppuration and is less marked locally and generally. The limb swells\\nand becomes discolored, but the color is a dusky red and its area is\\nlimited the swelling is more like the common inflammatory bogginess.\\nand incisions into it give exit to pus or inflammatory serum which has\\nnot the odor of decomposition. Such processes may be arrested by\\nfree incisions, drainage, and antiseptics but complete recovery is long\\ndelayed by necrosis of the ends of the fragments.\\nFat Embolism. As has been stated in Chapter III., free fat can fre-\\nquently be found in the urine during the first two or three days after\\nfracture. It is reasonable to suppose that it comes from the lacerated\\nmarrow, entering the circulation either directly through the torn and\\ngaping veins of the bone or through the lymphatics. When thus\\ntaken up in considerable quantities it may be arrested in the pul-\\nmonary capillaries or, after having passed through those, in the capil-\\nlaries of the systemic circulation, and occasion serious symptoms or\\neven death. Although the subject has been studied by several, by\\nobservation and experiment, since Von Recklinghausen first noted it\\nin 1884 as a cause of death by plugging the pulmonary capillaries, its\\nsymptomatology is not at all clear, presumably because it is masked\\nby the functional disturbances created by its interference with the\\ncirculation in various organs, notably the brain. There is even reason\\nto think that it has something, perhaps much, to do in some cases\\nwith the phenomena classed as shock, with delirium tremens, which is\\nso much more common after fractures than after other injuries, and\\nwith the pulmonary oedema and early pneumonias of the alcoholic\\nand aged.\\nThe pathological conditions revealed on autopsy are oedema of the\\nlungs and extensive plugging of the pulmonary capillaries, and\\nsometimes even of the arterioles, with free fat, similar but less ex-\\ntensive plugging of the systemic capillaries, often marked by small\\nhemorrhages, and sometimes extensive filling of the renal glomeruli.\\nThe local reaction is that of the beginning of infarction, and probably\\nin the cases which survive it is arrested by the prompt forcing of the\\nfat through the capillaries and the re-establishment of the circulation.\\nSince the emboli are not septic the element of infection does not enter\\ninto the case, and death is due to the mechanical interference with\\nthe nutrition and functions of the parts involved.\\nThe symptoms in well-defined cases confirmed by autopsy have\\nbegun within twenty-four hours after the injury, rarely after two or\\nthree days, and usually with quickening of the respiration that some-\\ntimes became marked dyspnsea undiminished resonance of the chest\\nand abundant, coarse rales little or no fever face at first pale, then\\ncyanotic unconsciousness followed, and death within a few hours.\\nIn other cases the central nervous symptoms have been the most\\nprominent unconsciousness, noisy and slow breathing, muscular\\ntwitching, and even convulsions, and sometimes paralyses. Most", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0092.jp2"}, "91": {"fulltext": "COMPLICATIONS AND REMOTE CONSEQUENCES. 71\\ntragical are those cases, fortunately very rare, in which the complica-\\ntion proves rapidly fatal in a young and healthy patient after a simple,\\ncomparatively unimportant fracture, such as a Pott s at the ankle,\\nwith which the idea of danger to life is never associated.\\nTreatment is apparently almost powerless to help the indications\\nare to prevent further crushing of the marrow by immobilization of\\nthe limb, to stimulate the heart, and to aid the respiration by inhala-\\ntions of oxygen when dyspnoea is present.\\nDelirium tremens is a not infrequent complication of fracture in hos-\\npital cases. The course is less severe and the prognosis better than\\nin cases not excited by traumatism. Its occurrence appears to be\\nfavored not only by the traumatism, but also by the withdrawal of\\nthe customary stimulant which usually follows admission to a hospital,\\nand I have found it advisable, therefore, as routine practice to give\\nalcohol in moderate quantities during the first week to those injured\\nwho are habitual, even if not excessive, drinkers. The attack begins\\nwith restlessness and sleeplessness, and when fully developed presents\\nthe usual symptoms. In addition to alcohol, sedatives are indicated,\\ntogether with cathartics and a light, nutritious diet. Usually the attack\\nsubsides after one good night s rest has been obtained. Care must\\nbe taken not to give alcohol too freely, lest it should provoke an attack.\\nTetanus is a rare complication, almost unknown in simple fractures\\nand much more frequent in compound fractures of the hand and\\nfingers than in those of other bones. Excluding those of the hand\\nand fingers, I have seen it only in one fracture of the femur (gunshot)\\nand in two of the forearm (compound). Although the microbic nature\\nof the disease has been established, it is noteworthy that many of the\\nattacks are preceded by a sudden fall in the temperature of the air.\\nOne of my cases developed after such a fall, and on the same day two\\ncases occurred in two other hospitals in the city.\\nPneumonia, developing on the second or third day, is a rather fre-\\nquent and dangerous complication. Reference has been made to its\\npossible origin in fat embolism of the lungs. It begins more fre-\\nquently without a chill than with one, and, in our hospital cases at\\nleast, is likely to run a rapid, severe course, with high fever and\\ndelirium, often terminating fatally in three or four days.\\nPneumonia appears also as a late complication in the old and feeble,\\nbeginning insidiously, and pursuing an asthenic course, with moderate\\nfever and mild delirium, and ending usually in unconsciousness and\\ndeath. Prolonged recumbency is thought to favor its occurrence by\\npromoting venous congestion of the lungs, but it appears to me to be\\nrather a relatively unimportant incident in a general failing of the\\nstrength which is usually manifest a few days before the signs of con-\\nsolidation appear, and to which the death appears to be due quite as\\nmuch as to the pneumonia. I have learned to look for this change\\nespecially in fractures of the neck of the femur in the old and feeble.\\nLate Local Complications.\\nThe callus may be excessive, painful, or iveak, or may become the\\nseat of a sarcoma. A callus may be unusually large, exuberant,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0093.jp2"}, "92": {"fulltext": "72\\nFRACTURES.\\neither because the fragments remain widely displaced during repair,\\nor because ossification extends far beyond the usual limits, or* because\\nthe presence of a necrotic fragment maintains irritation and delays the\\ntermination of the productive process. The first variety is not prop-\\nerly to be termed a complication, for the size of the callus is necessary\\nto firm union. The second is seen especiallv in the neighborhood of\\njoints, as the result of the persistent displacement of a fragment, or of\\nossification of muscular attachments, ligaments, or capsule in the old,\\nor of exaggerated productive activity of the periosteum in the young!\\nThe third is rather common after compound fractures that have sup-\\npurated.\\nFig. 25.\\nFig. 26.\\n\u00e2\u0096\u00a0v.\\nIntra-articular fracture of the lower end\\nof the humerus, with exuberant callus,\\nespecially in front.\\nExuberant callus fracture of lower end\\nof humerus.\\nEnlargement near a joint may mechanically restrict its range of\\nmotion, and at other points it may, in like manner, interfere with the\\naction of a muscle or make disabling pressure upon a nerve or inter-\\nfere with the venous circulation in the limb.\\nVirchow has suggested that a callus may continue to increase for a\\nlong time by the progressive ossification of ligaments and tendons in-\\ncluded in it, just as those tissues ossify under other irritating condi-\\ntions. A sudden increase may take place in consequence of premature\\nuse of the limb by which the union is loosened and the irritation\\nrenewed, but such increase is temporary and is due to a renewal of\\nthe irritative reaction in the soft parts which is manifest in the early\\ndays of a fracture and then produces the swelling about the injury.\\nAn exuberant callus may, and usually does, diminish in size, but\\nnot sufficiently to remove marked obstacles to function. Such removal\\ncan be effected only by surgical measures, the cutting away of the\\nexuberant mass local applications made to the surface with the object", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0094.jp2"}, "93": {"fulltext": "COMPLICATIONS AND REMOTE CONSEQUENCES. 73\\nof promoting its absorption are useless. The same pressure-effects\\ncan be produced by persistent displacement of the fragments, and it\\nis not always possible to determine, previous to operation, whether\\nthe offending mass is a fragment or the callus.\\nPainfulness of the callus may begin early in the course of repair\\nand persist long after union has become complete, or it may begin\\nafter an interval, sometimes a very long one. Many patients com-\\nplain of dull pain in the limb for months, even for years, after the\\ninjury, especially after prolonged use and in connection with changes\\nin the weather, but the cases in which the pain is limited to the callus\\nare rare. The late form, that in which the pain begins after an in-\\nterval, is clearly inflammatory, the inflammation being generally a\\nrecurrence in an old suppurative focus, manifesting itself by fever,\\nswelling, and tenderness, and relieved by spontaneous or surgical\\nevacuation of the pus.\\nThe early continuous form is not inflammatory, but the causes are\\nnot always clear. The pain has been attributed to pressure upon a\\nnerve either without or within the callus, to a neuritis set up by in-\\njury of a nerve at the time of the accident, as is seen also after wounds\\ninvolving only the soft parts, and to a supposed persistent osteitis or\\nan osteo-neuralgia (Gosselin), the cause of which is equally hypothet-\\nical. The pain may begin early in the formation of the callus, or\\nnot until after union has become complete it may be continuous or\\nintermittent, and exacerbated at night or by change in the weather.\\nIt must be distinguished from pain due to injury of, or pressure upon,\\na nerve.\\nCounter-irritation on the surface has given relief, and I should sup-\\npose that in the rebellious cases it would be advisable to incise the\\nperiosteum or to cut into or chisel away the bone.\\nThe development of a tumor, sarcoma, at the site of a healed frac-\\nture, within a few weeks or after an interval of several years, has been\\noccasionally observed, and apparently belongs in the same etiological\\ngroup as that of sarcomata following other injuries of bone or soft\\ntissues. Still rarer is the development of carcinoma after fracture in\\nthose who have or have had a carcinoma at another point. Pearce\\nGould (Lancet, April 25, 1896) refers to one such case, fracture of the\\nhumerus in a lady whose breast had been removed for carcinoma five\\nyears previously he explored very carefully by operation, without\\nfinding any sign of tumor two months later an extensive growth\\nhad appeared at the seat of fracture.\\nAssociated Injury of a Nerve. A nerve may be bruised or completely\\nruptured at the time of the accident, or it may become stretched over\\nthe edge of a fragment or by the growing callus, or compressed within\\na more or less complete canal formed about it by the callus or by cica-\\ntricial tissue developed in the soft parts. Primary rupture of a motor\\nnerve is liable to be overlooked at first, because of the withdrawal of\\nthe limb from use in consequence of the fracture, but it is not prob-\\nable that the resultant delay diminishes the chance of successfully\\nuniting the divided portions by operation, and on some accounts the\\noperation is more free from risk if not undertaken until after the frac-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0095.jp2"}, "94": {"fulltext": "74\\nFRACTURES.\\nture has become united. The diagnosis of rupture cannot always be\\nsafely made on immediate paralysis of the muscles supplied by the\\nnerve. I once operated upon a case of supposed rupture of the\\nmusculo-spiral nerve in connection with fracture of the shaft of the\\nhumerus, and found the nerve untorn and apparently uninjured for\\nsome distance above and below the fracture. It must also not be\\nhastily assumed that an operation to reunite the nerve has failed in\\ntwo cases (musculo-spiral nerve) I have seen function return after\\nnearly a year had elapsed since the operation.\\nFig. 27.\\nInclusion and compression of the musculo-spiral nerve in a callus. A in 2 shows a bony bridge\\ncrossing the nerve, and in 1 shows the surface left by its removal. The dotted area shows the\\nsurface left after the cutting away of the sides of the bony gutter.\\nThe compression of a nerve by a displaced fragment may abolish its\\nfunctions or may excite a neuritis manifested by modifications of sensi-\\nbility and sometimes by great pain similar effects may be produced\\nby a coincident contusion of the nerve. The most frequent examples\\nare in fractures above the elbow and above and below the knee occa-\\nsionally it is seen in fractures of the clavicle, upper end of the humerus,\\nand pelvis.\\nSimilar compression may be made by the callus upon a nerve which\\ncrosses or passes through it. Of late years a number of such cases\\nhave been operated upon, and various gross changes noted in the nerve,\\nwhich is usually reduced in size for a greater or less distance below and\\nshows a notable enlargement just above the point of pressure.\\nThe treatment consists in the removal of the corresponding portion\\nof the bone or callus, and this should be done freely. I have thought\\nit advisable in some cases to interpose a strip of periosteum or other\\nsoft tissue between the nerve and the cut surface of the bone in order", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0096.jp2"}, "95": {"fulltext": "COMPLICATIONS AND REMOTE CONSEQUENCES. 75\\nto diminish the probability of the nerve becoming included in a firm\\nadherent and possibly compressing cicatrix.\\nWeakness of the callus, which should not be confounded with delay\\nin consolidation, is manifested in two ways by its yielding under use\\nof the limb after union, as judged by the usual tests, has appeared to\\nbe complete, and by a later loss of its strength under the influence of\\nintercurrent local or general causes the latter is also termed softening\\nor absorption of the callus, and in either case, if fracture occurs, it\\nis termed secondary fracture. The weakness may be due to insuffi-\\nciency in the amount of the callus, as when a gap has been created\\nbetween the principal fragments by their displacement or by loss of\\nbone, or in the ossification of the bond uniting the fragments. In\\neither case the bony bridge uniting the fragments is not strong enough\\nto bear the strain of use, and it either breaks completely or yields\\nenough to permit an angular displacement.\\nSoftening of the callus under the influence of a general disease\\ne. g., scurvy, typhoid fever, erysipelas has been observed in a few\\ncases, sometimes after the lapse of many months. Clarke, quoted in\\nthe Traite de Chirurgie, reported a case in which the softening ap-\\npeared to be the result of overwork in school. The callus has been\\nfelt to diminish in size, and abnormal mobility to reappear without the\\nintervention of any violence.\\nSecondary, or u iterative, fracture without apparent defect or\\nchange in the callus is a not infrequent accident due to premature use\\nof the limb or to slight external violence. Gosselin tells of a man\\ntwenty-five years old who broke his femur six times in twenty\\nmonths the fractures occurred in the second week after he began to\\nwalk and in consequence of a slight effort, as in dancing, running,\\nand trying to avoid a fall each time the patient had left his bed on\\nthe forty-fifth day. The symptoms are those of primary fracture,\\nbut usually less marked.\\nArrest of growth of the bone is occasionally observed in the young\\nafter fracture at or near the epiphyseal cartilage. (See Separation of\\nthe Epiphyses, Chapter II.)\\nExaggeration of growth of the bone after fracture has been observed\\nin a very few cases, in consequence either of stimulation of the epi-\\nphyseal cartilage to greater activity or of exaggerated production of\\nbone at the fracture. Cases have been reported in which a consider-\\nable shortening noted immediately after recovery has disappeared in\\nthe course of a year or two. There is usually room in such cases for\\nsome doubt of the accuracy of the observation.\\nStiffness of the joints of the injured limb is habitually seen after\\nfracture, and involves not only those of which the broken bone forms\\npart but also those at a distance from it, especially on the distal side.\\nIt is most marked in the old and rheumatic and in joints directly in-\\nvolved in the fracture or coincidently sprained. It appears promptly\\nafter the accident, is most marked when the splints are removed\\n(unless measures have meanwhile been taken to relieve it), and in\\nmost cases disappears slowly under use of the limb. If a joint is\\ninvolved in the fracture, or otherwise injured at the moment of the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0097.jp2"}, "96": {"fulltext": "76 FRACTURES.\\naccident, a traumatic arthritis may follow and the resultant stiffness\\nmay be permanent; and in the old and rheumatic more or less limita-\\ntion of motion may remain even when the joint has not been directly\\ninjured.\\nThe causes of the stiffness, exclusive of direct injury of the joint,\\nare to be found in injury of the muscles, oedema, and shortening and\\nloss of elasticity in the peri-articular tissues, sometimes because of\\ntheir implication in the irritative reaction following the injury, and\\nsometimes because of the enforced quiet. Stiffness of the knee and\\nankle after fracture of the thigh, of the elbow after fracture of the\\narm, and of the wrist and fingers after fracture of the forearm is con-\\nstant and often very persistent. It is relieved by measures which\\ndiminish the oedema and improve the circulation, and these may some-\\ntimes be employed before consolidation of the fracture is complete\\nsuch are massage, passive motion, and position. The fingers stiffen,\\nand sometimes very rebelliously, under immobilization, and especially\\nwhen kept fully extended. The rule should therefore be, in all\\ninjuries of the upper extremities, to leave them free of the dressings\\nwhenever that is possible and to instruct the patient to move them\\nfrequently when they must be confined the position of flexion for\\nthe fingers and abduction for the thumb is to be preferred.\\nPersistent active and passive motion of the joints within their ex-\\nisting range, massage and hot and cold douching will usually increase\\nthe range and freedom rapidly in the young and young adults little\\ntime will be lost by simply trusting to the natural use of the limb to\\nrestore its functions. Patients should be encouraged to disregard\\npain following use which does not leave the joint tender the next day.\\nLimitation of motion due to displaced fragments or overgrowth of\\ncallus can be relieved, if at all, only by operation.\\nAtrophy of the Muscles. A limb that has long been withdrawn\\nfrom use because of fracture appears smaller above the seat of the\\ninjury, and also below it if the oedema has disappeared. Advantage\\nhas been taken of the death of a few patients at this perio:! to weigh\\ntheir muscles, and they have been found distinctly, and in some cases\\nnotably, smaller than those of the opposite limb, the loss involving\\nall and not merely those of some group supplied by a nerve that might\\nhave been injured. In the young and in young adults the loss is\\nsoon made good, but in others and in cases of long duration the\\natrophy may persist for months or even be permanent. Various\\nexplanations have been offered, such as lack of use, occlusion in fixed\\ndressings, diversion of nutritive materials to form the callus, and reflex\\ntrophic disturbances from injured nerve branches, but none is free from\\nserious objections. Massage, electricity, and systematic exercise are the\\nmeasures employed to hasten or effect recovery.\\nThrombosis of the Veins and Embolism. Thrombosis of some of the\\nlarger veins in the neighborhood of a fracture is thought to be rather\\ncommon and to be the cause of the oedema and venous congestion\\nwhich are so constant and troublesome after fracture of the lower\\nlimb when the patient begins to walk. Occasionally, but very rarely,\\nthe process occupies or extends into a vein sufficiently large to furnish an", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0098.jp2"}, "97": {"fulltext": "COMPLICATIONS AND REMOTE CONSEQUENCES. 77\\nembolus which is carried to the heart or, more commonly, through it\\ninto the pulmonary artery, and causes death. Virchow published in\\n1846 such a case following fracture of the neck of the femur, and\\nDurodie l collected eight other cases in which the deaths occurred be-\\ntween the sixteenth and fifty-seventh days. One fracture was of the\\nfemur, the others of the leg.\\nThe symptoms are the usual ones of pulmonary embolism sudden\\nonset, with lividity or pallor, dyspnoea, precordial distress, and death\\nin a few minutes.\\n1 Durodie Etude sur les Thromboses et l Embolie veiueuses dans les Contusions et les\\nFractures, These de Paris, 1874, No. 326.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0099.jp2"}, "98": {"fulltext": "CHAPTER VII.\\nTREATMENT.\\nReduction. Retention Removable Dressings, Permanent Dressings, Direct Fix-\\nation. Massage. Ambulatory Treatment. Management of Joints. Com-\\npound Fractures. Amputation. Compound Articular Fractures. General\\nTreatment.\\nGenerally speaking, the treatment of a fracture should begin\\nwhen the patient is first seen, but by this it is not meant that every\\nindication should at once be met by appropriate measures even the\\ncorrection of the displacement, the setting of the fracture, and the\\nimmobilization of the fragments may have to be left undone or in-\\ncomplete because of conflicting and dominating conditions, such as\\nextreme swelling, muscular spasm, or associated lesions. A delay of\\neven several days is usually, in respect of these indications, of small\\nimportance, for the preparatory work in the bone and soft parts goes\\non notwithstanding it, and when finally the adjustment is made the\\ncondition differs but little from that which would have existed had it\\nbeen made at the first.\\nA much more important indication in most cases is to prevent addi-\\ntional injury while the patient is being taken home or to hospital.\\nThe danger at this time is that by incautious handling, disordered\\nmovements, or injudicious attempts to use an injured limb a simple\\nfracture may be made compound or additional laceration caused.\\nThis risk exists especially after fracture of the middle or lower third\\nof the leg because a large extent of the surface of the tibia lies im-\\nmediately beneath the skin and the end of a fragment can easily be\\nforced through it. The surgeon therefore will protect the limb by a\\ntemporary splint, when such protection is needed, and the judicious\\nlayman will leave the patient undisturbed or will transport him re-\\ncumbent.\\nIf the fracture is one which necessitates confinement to the bed, the\\nbed should be narrow and high, and the mattress firm. A long, broad\\nboard may be placed beneath the latter if the spring mattress is soft.\\nSpecially constructed fracture-beds, some of which are very ingen-\\niously arranged, are convenient, but not at all essential. A water-bed\\nor air-bed is of the greatest value in the treatment of fractures of the\\nspine in minimizing the formation and duration of bed-sores.\\nThe points to be considered and the indications to be followed by the\\nsurgeon called to treat a fracture vary greatly in different cases accord-\\ning to the bone or portion of bone involved, the complications that\\nexist or are to be feared, and the age, the health, the habits, and\\neven the social status of the patient. At one end of the long and\\nvaried series of problems which present themselves he has only to", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0100.jp2"}, "99": {"fulltext": "TREATMENT. 79\\nprovide the simplest means to protect the patient from additinal in-\\njury or pain during the few days or weeks that are needed for repair;\\nat the other the highest resources of his art are required to save life\\nor limb or to preserve function. On the one hand, the fracture may\\nbe the sole thing to be considered, his attention must be unremittingly\\ngiven to the position of the fragments and their maintenance in proper\\nrelations, and his skill and care Avill determine the character of the\\nresult on the other, his best endeavor may be powerless to affect the\\nposition of the fragments or modify the result, or the fracture, as\\nin many of the base of the skull, may be a wholly unimportant and\\nnegligible incident beside the associated lesion.\\nThe indications for treatment arise, therefore, in varying degrees\\nfrom the fracture itself, the associated lesions, and the immediate or\\nlate local or general effects upon the patient. Occasionally they con-\\nflict, and the surgeon must then temporarily disregard some or he must\\neven be content with a defective local result because an attempt to\\nsecure a better one would involve risks disproportionate to the advan-\\ntage sought. Those directly concerned with the fracture are to cor-\\nrect displacement of the fragments, if such displacement exists and if\\nits correction is possible and advisable, and to oppose by appropriate\\nmeans the action of those forces which might reproduce it, such as\\nmuscular action, swelling, and gravity. This correction of the dis-\\nplacement is termed the reduction or setting of the fracture.\\nReduction.\\nNot every fresh fracture is accompanied by a displacement that needs\\nto be corrected; and of those in which such displacement exists, in\\nnot every one is reduction possible or advisable; and sometimes when\\nreduction is both possible and advisable circumstances require that it\\nshould be delayed.\\nFractures without a displacement that needs to be corrected are\\nmany and varied, such as most simple fractures of the cranium, of the\\nscapula, of the ribs, the ilium, the shaft of the fibula or ulna alone,\\nand many of the metacarpal and metatarsal bones.\\nReduction is said to be impossible (although in most cases the better\\nterm would be inadvisable) when the opposing conditions are such that\\nthey cannot be overcome by the methods ordinarily in use, and when\\nmore efficient ones would involve overbalancing disadvantages or\\nrisks. The causes of this condition are varied among them may be\\nmentioned the interlocking of the irregular ends of the main frag-\\nments, the interposition of soft parts or small fragments, and the small\\nsize and inaccessible position of a fragment, as in some articular frac-\\ntures. When the fracture is of the shaft or subcutaneous end of a\\nlong bone the existence and character of the displacement are usually\\nrecognizable, but when one of the principal fragments is a part of the\\narticular end of a long bone and is thickly covered by muscle or\\nmasked by swelling, not only the character but even the existence of\\nthe displacement may be in doubt and remain so until after repair is\\nfar advanced. In such cases an exact diagnosis can be made and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0101.jp2"}, "100": {"fulltext": "80 FRACTURES.\\nreduction can generally be effected by the aid of an incision which\\nexposes the seat of fracture, but although the probability that such an\\noperation in experienced hands and under proper precautions would\\nbe followed by disaster is small, yet the evils of such a result, if it\\nshould follow, are so greatly in excess of those resulting from the\\npersistence of the displacement that the operation is rarely undertaken\\nwhile the injury is recent, and then only because of the presence of\\nsome controlling condition or danger, such as pressure upon the skin\\nor a main vessel or nerve that cannot otherwise be removed. In cases\\nnot thus complicated the w 7 orst that can follow after fracture of the\\nshaft is failure of union or union with a disabling deformity, and both\\nof these conditions may be relieved by a late operation. Nevertheless,\\ndisplacements unrelievable by manipulation and likely to involve\\nserious loss of function if not corrected, can occasionally be recog-\\nnized, and in such cases reduction by open operation is called for.\\nThey are generally cases in which the limb has been greatly distorted\\nat the time of the accident so that the sharp end of a fragment has\\nbeen driven into an adjoining muscle, or an obliquely broken frag-\\nment has been forced around to the opposite side of the other from\\nwhich it has been broken. The first form is not uncommon in frac-\\ntures of the lower end of the femur, and I have seen the second in\\nfractures of the forearm. From the admitted propriety of operative\\ninterference in such cases it is a long step to similar interference in\\nall, as has been urged and such generalization, if accepted, would, in\\nmy judgment, lead to disasters far more serious and numerous than\\nthe disadvantages that would follow failure to reduce the displace-\\nments.\\nIn articular fractures the conditions are different the displacement\\nif uncorrected may seriously compromise the usefulness of the joint,\\nand but little if any relief is to be expected from a late operation.\\nIf anything is to be done it must be while the injury is still recent,\\nI haye taken this course in a considerable number of cases, and with-\\nout ill result in any, but I am convinced it should be resorted to only\\nafter thorough study of the conditions and careful weighing of the\\nprobabilities. The risk of such primary interference by operation is,\\nI think, less the more promptly it follows upon the receipt of the\\ninjury: if it is done within the first twenty-four hours the condition\\nis practically that of an operation upon previously uninjured tissues,\\nand the same confidence may be felt that primary union will be\\nobtained, but if the third or fourth day has been reached and the tis-\\nsues are swollen and infiltrated with extra vasated blood the same con-\\nfidence cannot be felt, and it is, I think, better to wait for the subsi-\\ndence of the swelling and the absorption of the blood. It is a matter\\nof common observation that compound fractures which heal primarily,\\nand simple fractures which have been exposed by early incision, run\\ntheir course with less swelling and possibly with less general reaction\\nthan simple fractures treated solely by immobilization their course is\\nessentially that of an ordinary osteotomy for deformity but neverthe-\\nless the difference, in my opinion, is too slight to justify routine resort\\nto operation, as has been suggested, in order to obtain it, even with", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0102.jp2"}, "101": {"fulltext": "TREATMENT. 81\\nthe added advantage of an accurate adjustment of the fragments. The\\ndifference is apparently due to the prompt removal of the extravasated\\nblood and the drainage of the primary serous exudate and the advan-\\ntage, except in a few selected cases, is limited to some diminution of\\nthe discomfort of the first few days, and does not extend either to the\\ncharacter of the final result or to the time within which it is obtained.\\nOther conditions which make exact and immediate reduction inad-\\nvisable are crushing of the spongy tissue of the bone, extreme sub-\\nfascial swelling of the broken limb, muscular spasm, and coincident\\ninjuries or other conditions which prevent the application of a dress-\\ning efficient to maintain the reduction when effected. Crushing of the\\nspongy tissue is seen mainly in the old, at the upper end of the femur\\nand at the lower end of the radius. It is seen also at the upper end\\nof the humerus, but there reduction is mechanically impossible, and\\nin the bodies of the vertebrae. The effect of this crushing is the same\\nas the removal of a piece of the bone if the fragments are restored\\nto their original positions a gap corresponding to the amount of the\\ncrushing is created between them, which, if the position is maintained,\\nmust be filled by the production of new bone, a task that may be\\nbevond the power of the organism, and failure in which would lead\\nto failure of union, a result much more disabling than the persistence\\nof the deformity. In fractures at the lower end of the radius it would\\nbe easy to expose the seat of fracture, force the lower fragment\\ndownward, and fill the gap with fresh, decalcified, or calcined bone,\\nbut the deformity which remains after such reduction as can be made\\nwithout operation has no functional importance, and the cases in which\\ncosmetic considerations would justify such interference must be rare.\\nIn fractures at the base of the neck of the femur an open operation\\nwould be wholly unjustifiable; the only other means of overcoming\\nthe shortening and rotation of the limb is by forcible manipulation\\nunder an anaesthetic and the prolonged use of forcible traction and\\nfixed dressings, both of which are badly borne by the elderly patients\\nwho furnish the majority of these cases.\\nExtreme subfascial swelling of an injured limb shortens it and in-\\ncreases its transverse diameter, because the capacity of the fascial\\nsheath is greater the more nearly it approaches the globular form\\nconsequently forcible elongation of the limb with the object of cor-\\nrecting the shortening diminishes the capacity of the fascial sheath\\nand increases its tension and the pressure upon its contents this\\nresistance may be sufficient to maintain the shortening against any\\nreasonable effort to overcome it, or to endanger the vitality of the\\nlimb by interference with the circulation. It is therefore necessary\\nto await the subsidence of the swelling.\\nMuscular spasm, excited by the trauma or by pain or the fear of\\npain, acts powerfully at first to fix the fragments in their faulty\\npositions and especially to produce and maintain shortening of the\\nlimb. It usually disappears within a day or two, and can be tempo-\\nrarily annulled by anaesthesia or a full dose of opium or even, as was\\npointed out by Broca, by compression of the main artery of the limb.\\nAssociated injuries or conditions which prevent or delay reduction", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0103.jp2"}, "102": {"fulltext": "82 FRACTURES.\\nmay be general or local, such as profound shock due to the fracture\\nor to other injuries, damage to the main vessels of the limb threaten-\\ning gangrene, and extensive wounds of the skin which would prevent\\nthe use of dressings to maintain reduction.\\nIn the absence of any of these contraindications the -sooner the\\nfracture is set, the sooner the fragments are brought to and fixed\\nin the positions they are expected to keep during repair, the better;\\nfor although the preparatory changes in the bone itself require several\\ndays, and in places even weeks, for their completion, yet the accessory\\nprocesses in the soft parts begin immediately, and it is desirable that\\nthey should not be interrupted or undone by changes of place and\\nrelations which are, moreover, likely to produce additional, though\\nslight, lacerations. The thickening and infiltration of the parts ad-\\njoining the bone which appear so promptly give a steadily increasing\\nfixity to the position of the fragments, and it is desirable that that\\nposition should as early as possible be made the permanent and final\\none, for although it can be changed without much difficulty and to a\\nconsiderable extent in many fractures even two or three weeks after\\nthe receipt of the injury, yet the shift is necessarily accompanied by\\nsome loss of security and time.\\nThe actual reduction or setting of the fracture is in many cases a\\nprocedure guided only by general ideas, not by an exact and detailed\\nknowledge of the peculiarities of the displacement to be overcome or\\neven of the lines of fracture, and the extent to which the effort has\\nbeen successful can only be surmised, not positively known. Such is\\nnotably the case in fracture of the shaft of a long bone thickly covered\\nwith muscle, as the femur. By eye, touch, and measurements the\\nsurgeon can recognize shortening, angular, rotatory, and perhaps even\\nlateral displacement, and by traction and pressure he can straighten\\nand lengthen the limb, but he cannot know whether or not the adjust-\\nment of the fragments is accurate and close. The same is measurably\\ntrue even of many fractures of bones that are more or less subcuta-\\nneous and palpable or if palpation shows some remaining irregularity\\nof outline the best effort may be unavailing to correct it. This,\\nhowever, does not make the result so much a matter of chance as the\\nstatement may seem to indicate the main factors of displacement at\\nthe different points are known, and the surgeon is safely guided by\\nthis knowledge in his choice and use of methods to make and main-\\ntain reduction and of the attitude and support given to the limb while\\nthe fracture is healing, and is justified in awaiting the outcome with\\na confidence that is limited only by knowledge of the fact that in a\\ncertain proportion of cases, fortunately small, unknown and unknow-\\nable factors may defeat efforts wisely conceived and faithfully ex-\\necuted. The ideal is the complete restoration of form and function,\\nbut he must often be content to obtain, or even to seek, much less.\\nThese more or less necessary limitations will be mentioned in connec-\\ntion with the results of the individual varieties of fracture.\\nSince the principal causes of displacement after fracture of the shaft\\nof a long bone are the tonic contraction of the attached muscles and\\nthe unsupported weight of the lower segment of the limb, reduction", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0104.jp2"}, "103": {"fulltext": "TREATMENT. 83\\nis commonly effected by bringing this lower segment into line with\\nthe upper one and making steady traction upon it in the direction of\\nits long axis, the different joints being usually held in partial flexion\\nin order that the attached muscles on either side may be correspond-\\ningly relaxed. Xote must be taken, in fractures at certain points, of\\nthe known tendency of the upper segment to assume a certain attitude\\nbecause of the unopposed action of the muscles attached to it, an atti-\\ntude which is often but faintly indicated by the form of the limb if\\nthe fragment is short and thickly covered by muscle. Common ex-\\namples are furnished by fractures of the upper third of the femur and\\nof the surgical neck of the humerus, in both of which the upper\\nfragment may be markedly abducted, flexed, and rotated outward.\\nThe surgeon confidently places the lower segment in the corresponding\\nattitude, even if he cannot detect the deviation of the upper one, for\\nhe knows that even if it does not exist the upper fragment will follow\\nthe movement he gives to the lower one, and the two pieces will be\\nin line when he makes the traction designed to give the limb its proper\\nlength.\\nWhile traction (and, if necessary, rotation of the lower segment)\\nis made the surgeon makes lateral pressure to correct such lateral dis-\\nplacement as may remain, and seeks to discover and take advantage\\nof such peculiarities of the line of fracture as may aid him to main-\\ntain the position he gives the fragments. Thus, in a transverse frac-\\nture or in one with marked irregularities of outline the opposing ends\\nmay be so engaged with each other that the lower fragment will be\\nheld in place and kept from overriding, notwithstanding the pull of\\nthe muscles. If there is only an angular displacement, as in partial,\\nsubperiosteal, and some transverse fractures, traction is not needed,\\nand the surgeon has only to correct the deviation by lateral pressure.\\nIn the partial fractures of adolescence this sometimes requires con-\\nsiderable force the knee must be placed against the projecting angle\\nand the ends drawn into line, but usually this can be accomplished\\nby the hands alone, the thumbs being placed against the angle while\\nthe fingers grasp the limb above and below it.\\nA serious obstacle to reduction occasionally arises from the penetra-\\ntion of the overlying muscle and fascia by the sharp end of one of the\\nfragments, usually the upper one. This occurs most frequently in\\noblique fracture of the lower third of the femur, and can there be\\ntreated most effectively by flexing the hip and the knee to a right\\nangle, thus drawing the relaxed quadriceps (which is the muscle com-\\nmonly penetrated) downward past the engaged end of the upper frag-\\nment, and, if necessary, completing the act by traction at the knee.\\nThis exemplifies the principles of treatment in all cases relaxation\\nof the muscle, if it crosses the proximal joint, and also the fascia by\\nmoving the limb toward the corresponding side drawing the muscle\\ndownward by bending the distal joint in the opposite direction and\\nthen lifting the lower segment of the limb bodily away from the upper\\nfragment. If this or other appropriate manipulations fail, the frag-\\nment must be exposed by an incision and freed by direct means. If\\nthe fragment has perforated the skin also the opening should be at", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0105.jp2"}, "104": {"fulltext": "84 FRACTURES.\\nonce enlarged and reduction made through it as the external wound\\nexists, nothing is lost and much may be gained by freely using it for\\nreduction, cleaning, and drainage.\\nWhenever an anaesthetic is given it is prudent to protect the broken\\nlimb during its administration by temporary splints or the hands of\\nan assistant in order that the lacerations may not be increased by the\\nunconscious struggles of the patient.\\nIn some cases in which the fragments are firmly interlocked or im-\\npacted, notably in some Colles s fractures at the lower end of the radius,\\nit is advisable to increase the angular displacement as a first step, and\\nforcibly to move the lower fragment backward and forward in order\\nto break up the impaction and thus facilitate reduction.\\nWhen the line of fracture runs through or close above the articular\\nend of a bone it is at most points impracticable to control the position\\nof the small articular fragment by manipulation, because it is too\\nsmall or too deeply covered to be grasped under such circumstances\\nit can sometimes be brought into place by so changing the attitude at\\nthe corresponding point as to make tense a portion of the capsule\\nwhich is attached to it and then by continuing the movement to cor-\\nrect the displacement, or by making direct traction upon it through its\\nligaments. In some injuries e. g., separation of the upper epiphysis\\nof the humerus and Pott s fracture at the ankle the character of the\\ndisplacement is so constant that a formula of treatment is based upon\\nthese facts similar formula? have been made for injuries at other\\npoints, as the elbow r and knee, but the lesions and displacements are\\nthere too varied to make routine treatment safe. At the shoulder the\\nseparated epiphysis is in anterior flexion and abduction although the\\narm hangs by the side on raising and abducting the elbow the move-\\nment of the already flexed and abducted epiphysis is promptly arrested\\nat the normal limit by the posterior portion of the capsule, and then\\nthe lower portion of the humerus is brought into line with it by con-\\ntinuing its movement in the same direction, and thus the angular dis-\\nplacement is corrected. At the elbow, after fracture of the internal\\ncondyle, the small fragment can be drawn down into place by full\\nextension of the joint and abduction of the forearm and after supra\\ncondyloid fracture of the humerus full flexion of the elbow, by making\\ntense the posterior portion of the capsule, enables the surgeon to cor-\\nrect an angular displacement of the lower fragment in which the apex\\nof the anor-le is directed forward.\\nRetention.\\nThe objects of retention are to prevent displacement of the frag-\\nments by the various agents that are competent to produce it, notably\\ngravity and muscular contraction, to protect the limb from external\\nviolence during the progress of repair, and to prevent the pain that\\nwould be caused by movement of the fragments. The relative im-\\nportance or urgency of these needs varies greatly in different cases,\\nand this, together with the mechanical conditions, measurably deter-\\nmines the choice of the method of treatment. Thus, in the fracture", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0106.jp2"}, "105": {"fulltext": "TREATMENT. 85\\nof a single long bone, such as the femur, where the weight of the\\nlimb and the action of the muscles are efficient and always ready to\\nproduce displacement, support equivalent to that destroyed by the\\ninjury must be supplied by apparatus while in fractures of only one\\nof two or more parallel bones, as of the fibula or of a rib, or in those\\nof the flat or small spongy bones, or of an apophysis or condyle, only\\nsuch a dressing is required as will moderate or prevent voluntary or\\ninvoluntary contraction of attached muscles.\\nThe swelling of a limb which so promptly follows its fracture is an\\nelement of much importance because its variations affect the adjust-\\nment and fit of most dressings and because its appearance after the\\napplication of a dressing that envelops a limb may so interfere with the\\ncirculation as to cause gangrene of the limb or ischsemic degeneration\\nand contracture of the muscles. For these reasons it is frequently\\nadvisable to delay the application of an em 7 eloping permanent dressing\\nuntil after the swelling shall have notably subsided, and it should be the\\nrule to make frequent examination of the fingers and toes during the\\nfirst two or three days after the application of such a dressing, and to\\nleave them uncovered by the dressing for the purpose of such exami-\\nnation.\\nThe possibility of dangerous constriction is specially to be borne in\\nmind in dressings which completely and closely encircle a limb and\\nwhich are inelastic, such as pi aster-of- Paris encasement or even a\\nmuslin roller-bandage applied directly to the surface without an inter-\\nvening layer of cotton. Such a dressing snugly applied while the\\ninjury is recent will almost always become too tight and will have to\\nbe removed in a few hours either because of the pain which it causes\\nor of the threatening strangulation of the tissues. This is true even\\nwhen the injury is a comparatively slight one. I have seen gangrene\\nof the hand and forearm follow the application of a gypsum dressing\\nfor fracture of the olecranon. A roller-bandage may be applied to\\nthe limb below the fracture to restrain its swelling, but should not be\\ncarried as high as the fracture beneath the splints and when splints\\nare used they should be broad enough to prevent circular constriction\\nby the bandage which binds them in place. If plaster of Paris is\\nused it should preferably be in the form of moulded splints, not com-\\nplete encasement, or at least in a form which will permit the dressing\\nto be loosened.\\nIt is a good rule also to remove a permanent dressing after ten or\\ntwelve days in order to detect and correct any displacement that may\\nhave taken place under it and to tighten or renew it to meet the\\nshrinking of the limb.\\nIt is specially important that the possibility of constriction by the\\ndressing should be guarded against whenever the injury is such\\nthat it may itself cause gangrene of the limb. A limb whose vitality\\nhas thus, been put in doubt by the injury should be treated for the\\nfirst few days with the primary object of favoring the- impaired cir-\\nculation and especially of avoiding the creation of any additional ob-\\nstacle to the venous flow, and this not only for the advantage of the\\npatient, but also for the protection of the surgeon against the suspicion", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0107.jp2"}, "106": {"fulltext": "86 FRACTURES.\\nor the charge that his dressings may have caused the gangrene. This\\ndisastrous result of injury is a fruitful source of suits for malpractice,\\nand the defence that it was due to the injury and not to the treatment\\nis usually viewed with so much suspicion that the surgeon should be\\nwatchful from the beginning of the case that the real cause should be\\nclear. It must be remembered that in the great majority of cases\\nthe gangrene is of the moist form and due to interference with, the\\nvenous flow, and that this interference may easily and rapidly be\\nraised to a dangerous degree by circular constriction at even a single\\npoint.\\nCases differ far too widely in severity and local conditions to permit\\nof a general rule of practice applicable to all. Many, in which the\\ntendency to displacement is slight or easily controlled, may be treated\\nin a permanent dressing from the beginning, one which gives the nec-\\nessary support without danger of constriction, and can be left in place\\n(or removed temporarily for inspection) for one, two, or three weeks.\\nOthers, more severe, such as most fractures of the femur, also receive\\na permanent dressing at the beginning because this dressing is mainly\\napplied below the seat of fracture and does not expose to constriction\\nby swelling. Others, such as most fractures of the leg, should rest in\\na temporary dressing, such as a Volkmann splint, for from live to\\nten days, unless permanent moulded splints that can be loosened are\\nused.\\nSo, too, when the surface of the limb has been so torn or bruised\\nthat the wounds cannot be properly treated through an opening made\\nfor the purpose in a permanent dressing, and when damage to the\\ndeeper parts forbids the use of any constriction or pressure. Under\\nsuch circumstances the surgeon must be content to make such dressings\\nas the associated injuries require and to leave the limb simply sup-\\nported upon the bed by pads or in splints loosely applied over the\\nother dressings. Although the use of these temporary dressings may\\nbe necessarily prolonged for several weeks, it will be convenient and\\nproper to describe them under that title.\\nThe presence of large blebs is sometimes an additional reason for\\ndelay, although they usually heal promptly under a protective dress-\\ning after puncture. If it is desired to leave the limb as undisturbed\\nas possible, it is advisable thoroughly to clean and disinfect the ad-\\njoining skin, cut away all the raised epidermis, cover the exposed sur-\\nface with sterile rubber tissue, and apply a gauze dressing.\\nTemporary and Removable Dressings.\\nThe object of a temporary dressing is mainly to protect the patient\\nagainst pain and additional injury by movement of the fragments\\nduring transport to his home or hospital, or to prevent displacement\\nby the unsupported weight of the lower segment of the limb it is\\nrarely efficient to prevent displacement by the action of the muscles\\nwhen the character of the fracture is such that such displacement is\\npossible.\\nSide Splints. These are usually made of wood, but in case of need", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0108.jp2"}, "107": {"fulltext": "TREATMENT.\\n87\\nmany other materials are available, such as card-board, stiff leather,\\niron, zinc, tin, even bundles of tightly-rolled straw.\\nThe wooden splint in ite simplest form is a piece of soft wood of a\\nlength and breadth corresponding to those of the injured limb and\\nthick enough not to bend under firm pressure. A thick layer of\\ncotton or other soft material should be bound along the side which is\\nto rest against the limb, and should be reinforced at needed points in\\norder to fill depressions of the surface of the limb. Projecting points\\nof bone should be protected by cotton placed around them, not upon\\nthem. While an assistant makes traction upon the lower segment of\\nthe limb the surgeon places the splints, one on each side, and binds\\nthem on with a roller-bandage, taking care that the turns support the\\nlimb throughout its entire length, but do not make circular compres-\\nsion. The splints should be long enough to support the hand and\\nfoot respectively. A form in common hospital use is the thin bass-\\nwood splint, the necessary rigidity being obtained by binding several\\ntogether.\\nGooch s flexible wooden splint (Fig. 28), which is made of narrow\\nstrips pasted together upon cloth on one side, is designed to adapt\\nFig. 28.\\nGooch s flexible wooden splint\\nitself to the curve of the limb and thus give a more uniform support.\\nIt is rarely used.\\nFig. 29.\\nWire splint.\\nThe carved splints sold in packages of assorted sizes have few if\\nany points of superiority over those improvised for the occasion, for\\nthey also need to be fitted and padded. If it is desired to have a\\nsplint that more nearly follows the contour of the limb an excellent\\none can be made with plaster of Paris (see below) or card-board or", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0109.jp2"}, "108": {"fulltext": "88\\nFRACTURES.\\nleather softened in water, and similar ones can also be used with ad-\\nvantage over the dressings that are needed for associated wounds of the\\nskin or compound fractures.\\nSplints of wire (Fig. 29) that can be measurably modelled to the\\nlimb are convenient they can be had from the instrument makers.\\nThe fracture-box (Fig. 30) is a form of wooden splint once much\\nFig. 30.\\nPetit s fracture-box.\\nused in fractures of the leg, but now almost wholly discarded for the\\nfollowing\\nVolkmann s splint (Fig. 31) is a shallow gutter and foot-piece, made\\nin several lengths, and fitted with a movable support by which the\\nfoot can be raised from the bed. For use it is thickly padded with\\ncotton, and the leg is bound in it with a roller-bandage. Care must\\nbe taken that undue pressure is not made on the skin covering the\\nfront of the tibia by the bandage or on the heel or the tendo Achillis\\nthe latter pressure is best avoided by slinging the foot by means of a\\nbroad strip of adhesive plaster extending from the middle of the calf,\\nFig. 31.\\nVolkmann s splint.\\nunder the heel and along the sole, to the top of the foot-piece, where\\nit is made fast by a reversed piece attached to it and then to the lower\\nsurface of the metal.\\nGutters of galvanized wire or tin (Fig. 32) are much used for frac-\\ntures of the humerus they give more protection than short splints\\nbecause they include the forearm. They can be readily made from", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0110.jp2"}, "109": {"fulltext": "TREATMENT.\\n89\\nFig. 32.\\nWire gutter for the arm and forearm.\\nsheets of wire gauze by taking a strip of suitable size and cutting it\\npartly through at the angle, and tying together the meshes which over-\\nlap where it is bent.\\nWhen it is desired to cover the limb with dressings because of the\\npresence of a wound of the skin or to make moderate uniform com-\\npression, or while waiting to\\nlearn the effect of the injury\\nupon the vitality of the skin or\\nthe limb, a convenient method\\nof applying them so that they\\ncan be readily and painlessly\\nremoved for adjustment or in-\\nspection is in the form of the\\nScultetus bandage, a dressing\\nwhich was formerly in wide use\\nfor retention. The dressings\\nare cut in thick strips one-half\\nlonger than the circumference\\nof the limb and three or four\\ninches wide, and then arranged\\nupon a piece of muslin a little\\nlonger than the part to be\\ndressed in such a w r ay that each overlaps its adjoining upper one by\\nabout an inch. The limb is then placed along the centre of the band-\\nages and each end of each of the latter, beginning with the lowest,\\nturned over the front of the limb until it is entirely enveloped lateral\\nsupport is given by splints rolled into the sides of the underlying strip\\nof muslin and bound fast, or by other splints, or by placing the limb in\\na Yolkmann splint or a gutter. The front and sides of the limb can then\\nbe readily exposed by turning back the ends of the pieces of dressing.\\nInstead of lateral, anterior or posterior splints may be used, either\\nthat they may be combined w T ith suspension or that portions of the\\nlimb may be more conveniently exposed and dressed. Because of\\nthe importance of equally distributing the pressure, a posterior splint\\nto be used with suspension should be accurately fitted to the limb\\nconsequently the moulded splints (plaster of Paris, gutta-percha, etc.,\\nsee below) are to be preferred. When they are sufficiently rigid the\\nlimb can be suspended by two or three bandages passed beneath and\\nattached above to a suitable support.\\nLate in the treatment of fracture of the femur one of the forms of\\nhip-splints may be conveniently used.\\nAnterior suspended splints may also be of the moulded kind, with\\nincluded metal rings or loops for the attachment of the supporting\\ncords, or some modification of Nathan R. Smith s anterior splint\\nspecially designed for the treatment of fractures of the femur. This\\nsplint (Fig. 33) is made of two parallel iron rods, joined at the ends\\nand by two or three intermediate rods, bent slightly at the knee and\\nsharply upward at each end to fit the foot and pelvis. It is placed\\nalong the anterior surface of the limb, which is attached to it by a\\nroller or by straps, and is suspended by cords. Hodgen s splint has", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0111.jp2"}, "110": {"fulltext": "90 FRACTURES.\\ntaken its place for fractures of the thigh because of the additional\\ntraction which it supplies, but Smith s is useful in those and, in suit-\\nably modified forms, in others when suspension alone is desired.\\nMoulded splints are constructed of any material that can be made\\ntemporarily soft enough accurately to take the shape of the part to\\nwhich it is fitted and which then becomes hard enough to retain the\\nshape thus given to it. The materials most frequently used are\\nplaster of Paris, pasteboard, leather, felt, and gutta-percha.\\nPasteboard is used by softening one or two strips of suitable size bv\\nimmersion in hot water, and then moulding them to the limb bv\\nbinding them on snugly with a roller-bandage. Temporary support\\nmust usually be given by other splints until the pasteboard has be-\\ncome hard by drying. When it is necessary to bend the pasteboard\\nFig. 33.\\nNathan R. Smith s anterior splint.\\nat a sharp angle cuts should be made in it in suitable directions and\\nplaces and the overlapping portions stitched together.\\nLeather and felt are prepared in the same manner. A material is\\nmade for this purpose of woven tissue soaked in shellac which can be\\nsoftened by dry heat and hardens more rapidly than the others.\\nGutta-percha is used in strips one-sixteenth to one-eighth inch thick\\nand is softened by immersion in hot water. The stickiness of the\\nsurface can be mitigated by covering it with muslin.\\nPlaster-of-Paris, or gypsum, splints can be made of the prepared\\nbandages or of some loose-meshed material soaked in plaster cream.\\nIf the prepared bandages are used they should be thoroughly wet in\\nthe usual way, squeezed out, and then rapidly unrolled back and forth\\nto make a splint of the desired dimensions. From eight to fifteen\\nlayers are required to give the needed solidity. Plaster cream is pre-\\npared by sifting the dry plaster into water and then spreading the\\nplaster thus moistened upon the selected material previously cut to\\nsuitable shape and wrung out in water. The number of layers\\nneeded will depend upon the thickness of the material, and care must\\nbe taken thoroughly to work the plaster into them. The use of hot\\nwater or the addition of salt or zinc oxide to the water will hasten\\nthe setting. If the plaster has been long exposed to the air before", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0112.jp2"}, "111": {"fulltext": "TREATMENT.\\n91\\nuse it should be dried in an oven otherwise the setting may be long\\ndelayed or even fail. Splints thus prepared can be made impervious\\nto water by varnishing them or by pouring melted paraffin upon\\nthem. A strip of rubber tissue or oiled-silk carefully packed in at\\nthe exposed point will protect satisfactorily for several days from the\\ndischarge of a wound. Weight can be reduced, while preserving the\\nstrength, by inserting thin strips of metal or wood at places where\\nthe splint will not require much modelling to fit the limb. Splints of\\nthis kind are specially useful in fractures at the ankle, wrist, elbow,\\nand arm, and not infrequently such a temporary splint will remain\\nefficient for two or three weeks. For fractures of the leg one of the\\nsplints should be posterior and broad enough to cover nearly half of\\nthe circumference of the limb a narrower anterior one may be used\\nFig. 34.\\nPosterior gypsum splint or gutter.\\nwith it, or a lateral one the lower end of FlG 35\\nwhich encircles the instep, or a bilateral one\\ncrossing below the instep like a stirrup.\\nThe posterior splint should pass along the\\nsole and project about an inch beyond the\\ntoes so as to take the weight of the bed-\\nclothing (Fig. 34).\\nA form of bilateral moulded splint which\\nI have found convenient in fractures of\\nthe leg as a substitute for the Volkmann\\nsplint during the first week, and, because\\nof the ease with which it can be removed,\\neven for the complete encasement in plas-\\nter of Paris which usually follows, is the\\nfollowing Two pieces of muslin are cut\\nto the shape shown in Fig. 35, and of a\\nsize to fit the limb, and stitched together\\nalong the median line. Then twelve or\\nP n Stocking or bivalve plaster splint.\\nniteen pieces ot crinoline, or three or four\\nof canton-flannel, each a little smaller than a lateral half of the first,\\nare soaked in plaster cream and laid in each half of the first between", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0113.jp2"}, "112": {"fulltext": "92\\nFRACTURES.\\nits two layers, and the whole then bound smoothly to the limb with a\\nroller-bandage. Swelling of the limb is met by loosening the band-\\nage, and inspection is easy by turning down either lateral half, the\\nline of stitching acting as a hinge. The additional trouble entailed in\\nits preparation, as compared with the Volkmann splint and later encase-\\nment in plaster, is offset by the greater security and ease with which the\\npatient can be moved during the first week, and the ease with which\\nthe dressing can be removed and the seat of fracture inspected so long\\nas intercurrent displacement is possible and corrigible.\\nPermanent or Final Dressings.\\nThe dressings included under this title are those designed to main-\\ntain the fragments in the relative positions given them until union is\\ncomplete or, at least, far advanced. They are expected to give the pro-\\ntection and quiet of the temporary dressings, and in addition to oppose,\\nwith as much efficiency as possible, shortening of the limb or angular\\ndisplacement by muscular contraction or gravity. As has been said,\\nthe temporary dressings may sometimes be used equally well for the\\nsame purpose, and some of the permanent dressings, especially those\\nmaking continuous traction, may be used from the beginning. A\\nrule of practice which will save the surgeon an occasional and very\\ndisagreeable surprise and disappointment should be to examine about\\nthe end of the second week, and again later if the fragments are still\\nmovable, every fracture that has been covered by the dressing in order\\nto detect and correct such displacement as may have occurred beneath\\nit. This applies especially to fractures of the shaft of the long bones\\nand to some articular fractures in which displacement is easy.\\nFig. 36.\\nEncasement of leg in plaster of Paris.\\nComplete encasement in plaster of Paris (Fig. 36), occasionally advis-\\nable, if carefully watched, even as a primary dressing, is most useful\\nand efficient when applied after the swelling has subsided, and at still\\nlater stages in cases in which continuous traction has been used until\\nunion has become well advanced. Its mode of application is as fol-\\nlows The limb is raised by one or two assistants who make steady\\ntraction upon it in order to keep it straight and of full length, the sur-\\ngeon wraps it in a thin layer of cotton batting, preferably prepared in\\nthree-inch rollers, and then applies the plaster roller-bandages, thor-\\noughly wetted and wrung out in hot water, from below upward. The\\nturns of the first layer should be drawn just tight enough to keep their\\nplace, and the subsequent turns simply rolled over the first without", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0114.jp2"}, "113": {"fulltext": "TREATMENT.\\n93\\nFig. 37.\\nincreasing the pressure, taking care to model the dressings accurately\\nto the prominences and depressions of the limb. When the dressing\\nis complete the limb is lowered to rest, and proper support given it\\nuntil the plaster is hardened. The dressing should extend far enough\\nabove and below the fracture to rest against such prominences of the\\nskeleton or muscles as may be present and will act, after the plaster\\nshall have set, to prevent movement of the limb within its case. When\\nsuch fixed points do not exist, as at the shoulder and hip, other means\\nto prevent shortening must be used, usually some form of traction.\\nThe upper and lower ends should be so placed that their edges will not\\nmake irritating pressure directly against a diverging surface thus, for\\nthe forearm it should stop well short of the flexure of the elbow or\\nshould pass a short distance up the arm at the ankle it should stop\\nshort of or pass well forward on the dorsum of the foot on the inner\\nside of the thigh it should not reach the perineum.\\nThe finger or toes should always be left uncovered and should be\\nrepeatedly inspected during the first two or three days in order to detect\\nany interference with the circulation.\\nIn the lack of plaster rollers the dressing can be made of any\\ncoarse material cut in suitable strips and soaked in plaster cream\\n(Fig. 37).\\nIf it is desired to have a small por-\\ntion of the limb exposed, as for the\\ndressing of a wound, a fenestra can be\\ncut, and its edges protected with adhe-\\nsive plaster, rubber tissue, or oiled-silk.\\nIf a larger opening is required the\\nsplint must be reinforced by one or two\\ncurved iron bands incorporated in the\\ndressing or, better, fastened to it by\\nadditional turns of a plaster roller after\\nthe main portion of the dressing has\\nhardened. These are termed fenes-\\ntrated or interrupted splints (Fig.\\n38).\\nSimilar dressings can be made with\\nsilicate of soda or potash, starch, dex-\\ntrin, or glue. The silicate and dextrin\\nare used by thoroughly saturating\\nroller-bandages with the material and\\napplying them in the same manner as\\nplaster bandages. They do not dry so\\nrapidly as plaster, but are lighter and\\ncleaner and not so liable to crumble at\\nthe edges. Silicate is frequently used\\nfor dressings of the hand and forearm.\\nThe edges of both silicate and plaster\\ndressings can be advantageously pro-\\ntected against crumbling by covering them with adhesive plaster.\\nThe removal of one of these dressings is a tedious and troublesome\\nPlaster-of-Paris dressing made of coarse\\nsackcloth. (Esmarch.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0115.jp2"}, "114": {"fulltext": "94\\nFRACTURES.\\ntask it can best be done by cutting lengthwise with a short, stout-\\nbladed knife, aided in the case of plaster by moistening the dressing\\nalong the line of the division. The diminished resistance to the knife\\ngives warning of the proximity of the skin, and the deepest layer and\\nthe underlying cotton should be cut with strong bandage scissors. The\\nFig. 38.\\nFenestrated plaster dressing.\\nprincipal difficulty is in turning re-entrant angles, as at the front of the\\nankle or elbow. After the division has been completed the sides can\\nbe forcibly drawn back and the limb lifted out.\\nIn cases in which the absence of firm points of support makes a\\nfixed dressing inefficient effectually to oppose the contraction of the\\nmuscles, as in most fractures of the thigh and many of the humerus,\\npermanent moderate traction is employed to tire the muscles and\\nobtain and maintain the desired length of the limb. For this purpose\\nthe partially unsupported weight of one segment of the limb may be\\nutilized or a weight attached to the lower segment.\\nTraction by Weight and Pulley, or Elastic Traction. This method is\\nemployed almost exclusively in the treatment of fractures of the\\nthigh. Methods of treatment by continuous traction have long been\\nin use, but the efficiency and comfort which now make the method so\\nFig. 39.\\n^7\\nTX\\nAdhesive plaster and spreader for Buck s extension.\\npopular date from the introduction about the year 1850 by the Ameri-\\ncan surgeons Sargent, Josiah Crosby, and Gordon Buck of the use of\\nadhesive plaster to attach the weight or screw to the limb. Previously\\nthe attachment was by bandages about the foot and ankle, and the\\npain and damage to the skin occasioned thereby were such that efficient\\ntraction could not be maintained.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0116.jp2"}, "115": {"fulltext": "TREATMENT.\\n95\\nBuck s Extension. (As for a fracture of the thigh.) Two strips\\nof stout adhesive plaster, each four inches wide and long enough to\\nreach from well above the knee to a little beyond the sole, are notched\\non each side at the junction of the lower and middle thirds for one-\\nthird their width, and the sides turned in, as shown in Fig. 39, so as\\ncompletely to cover the adhesive surface of that portion. The sides\\nof the remaining portion are obliquely notched at several points. A\\npiece of wood, 5X3 inches, with a central hole, is then covered with\\nadhesive plaster folded beyond the ends, as shown in Fig. 39.\\nA third piece of adhesive plaster a yard long and 2 inches wide is\\ncut in two and the halves fastened together end to end by facing their\\nterminal four or five inches; it is attached to the back of the calf, and\\nbrought along and well beyond the sole of the foot; a roller-bandage\\nis applied to the foot and lower third of the leg, the first two strips\\nof plaster placed one on each side above it so that their folded por-\\ntions extend below the ankle, aiid the roller carried over them. Unless\\nthe fracture is too low the roller and strips of plaster should be car-\\nried well above the knee. The ends of the plaster on the wooden\\nspreader are then attached by pins or clamps to the free ends of the\\nlateral plasters so that it lies squarely across the sole a few inches\\nbelow it. A cord is then passed through the hole in the spreader\\nand secured by a knot.\\nA Yolkmann s slidiug-rest (Fig. 40) is then placed under the leg,\\nthe foot lightly swung from it by carrying the free end of the third\\nFig. 40.\\nVolkmann s sliding rest for fractures of the thigh.\\nstrip of plaster over its top and sticking it to its lower surface, and the\\nleg secured to it by a roller. The cord is then carried over a pulley", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0117.jp2"}, "116": {"fulltext": "96\\nFRACTURES.\\nat the foot of the bed, and a weight of from ten to twenty pounds\\nattached. Counter-extension is made by raising the foot of the bed\\nabout four inches. Coaptation splints about a foot long are bound\\nabout the thigh to give lateral support.\\nHodgen s suspended splint (Fig. 41) is a modification which gives\\nmore freedom of motion and consequently more comfort to the patient.\\nIt consists of two parallel iron bars, slightly bent at the point corre-\\nsponding to the knee and connected at the lower end by a straight bar\\nand at the upper end by a curved one. The leg and thigh are placed\\nbetween these bars and suspended from them by half a dozen bands,\\nand the ends of the lateral pieces of plaster are attached to the lower\\ncross-bar, care being taken that they do not press against the malleoli,\\nor by the cord of the spreader of Buck s extension. Then the limb is\\nraised from the bed by a cord, as shown in the figure, which should be\\nattached to a support at least four feet (better more) above the bed and\\nso placed that the cord is inclined fifteen to thirty degrees from the\\nvertical, and shall thus tend constantly to draw the leg downward\\nthis furnishes the traction, and by moving the point of support to the\\nouter side the position of abduction of the thigh, which is usually\\ndesirable, can be readily obtained.\\nFig. 41.\\nHodgen s suspended splint.\\nThe same method of traction is sometimes used in fractures of the\\nthigh in connection with a long side splint, either with a weight and\\npulley or with an elastic cord on the side of the splint (Fig. 42), and\\nalso with one of the forms of hip-splints. A splint devised by Dr.\\nWeed (Fig. 43) uses a steel spring to make traction, and contains many", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0118.jp2"}, "117": {"fulltext": "TREATMENT.\\n97\\ningenious devices to modify the amount of traction and to adapt the\\nsplint to limbs of different sizes.\\nVertical suspension, for fractures of the thigh in infants and for some\\nfractures of the arm, can be obtained in like manner by the use of the\\nFig. 42.\\nDouble pulley\\nLons\\nInd. -rubber accumulator\\nside splint with traction.\\nplaster strips and a cord carried to a point of support directly above\\nthe bed. (See Fig. 194.)\\nIn the double inclined plane (Fig. 44) traction is made by the weight\\nof the upper segment of the thigh and pelvis. It consists of two pos-\\nterior splints, for the leg and thigh respectively, hinged at the knee and\\nFig. 43.\\nWeed s splint.\\nkept at the desired angle by a plank upon which they rest and to which\\nthe upper end of the short femoral splint is hinged. As shown in the\\nfigure the femoral splint is too long it must be so short that the upper\\npart of the thigh is wholly unsupported by it, and the mattress must\\nFig. 44.\\nEsmarch s double inclined plane.\\nbe so soft that the pelvis can sink into it, for it is by this sinking of\\nthe pelvis that the upper fragment of the broken thigh is drawn away\\nfrom the lower one. It cannot be depended upon to give a good result\\nin respect of shortening, but it is very convenient in some compound\\nfractures.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0119.jp2"}, "118": {"fulltext": "98 FRACTURES.\\nDirect Fixation of the Fragments.\\nThis can be effected in a variety of ways, the types being the suture,\\nligature, pin, and central or external brace. Even the plan of baring\\nthe ends and engaging them in a ferrule of bone has been employed\\nin a few cases. It is rarely resorted to except in compound fractures,\\nsome special ones such as fractures of the patella, and in operations\\nafter failure of union.\\nIn determining the advisability of resort to it in any case or in\\nmaking choice of a method, consideration should be given to the fol-\\nlowing facts The cases of fracture of the shaft of a long bone in\\nwhich reduction cannot be maintained by a suitable external dressing\\nare very rare. The cases are more frequent in which it cannot be com-\\npletely made, or in which it cannot be certainly maintained during the\\napplication of the dressing. To make complete reduction exposure of\\nthe seat of fracture may be necessary, and in some fractures thus\\nexposed and in some compound ones temporary direct fixation of the\\nfragments may be advisable. In fractures of articular extremities the\\ndifficulty is in making reduction (or in being certain that it has been\\nmade) rather than in maintaining it, the exceptions being cases of\\nextensive splintering. In fracture of apophyses to which powerful\\nmuscles are attached, such as the olecranon, the coracoid process, the\\ngreater tuberosity of the humerus, the tuberosity of the os calcis, it\\nmay be impracticable to maintain a position of the limb in which the\\nmuscle is so fully relaxed that it will not renew the displacement even\\nif it can be corrected, and in such the proper relations of the fragments\\ncan be secured only by direct fixation but in most of such cases the\\ncontinuity is maintained by periosteal or fascial attachments which\\nensure a union, bony or fibrinous, sufficient for satisfactory function.\\nAnother fact, to which I think far too little attention has been given,\\nbut of which I have been convinced by many observations, is that the\\npresence of a foreign body, even if sterile and unconnected with sup-\\npuration, in bone at or near the line of fracture notably exaggerates\\nand prolongs the preliminary rarefaction of the bone. I believe this\\ninfluence may even cause failure of union by transformation of a con-\\nsiderable portion of the bone into fibrous tissue, for in several cases in\\nwhich I have operated for failure of union several weeks or months\\nafter a wire suture has been applied to the fracture I have found the\\nsuture lying free, and the ends of the fragments thinned and pointed\\nand separated by a considerable intermediate mass of fibrous tissue.\\nThat the holes pierced for such sutures enlarge, and that the bone\\nincluded in the loop wholly disappears is a common observation, and I\\nbelieve the same change is promoted for a considerable distance round\\nabout, and although this ill effect is not to be expected always to fol-\\nlow, vet its possibility should be seriously considered. 1 (See Plate\\nXXV., fig. 2.)\\nIn my judgment, direct fixation by suture or pins should therefore\\n1 Mumford (Boston Medical and Surgical Journal, May 10, 1S94), in a report on 300\\ncases of compound fracture, noted that in twenty-seven primary wiring of the fragment\\nwas done, and that in seven of these necrosis followed.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0120.jp2"}, "119": {"fulltext": "TREATMENT. 99\\nbe only temporary, with the view merely of holding the fragments\\ntogether during the application of a dressing and for a few days there-\\nafter, and that the loop of a suture should include only a small portion\\nof the cortical layer. Possibly silk and silkworm-gut are less injurious\\nthan wire, although I have known both wholly to free themselves in\\nthe same manner as wire, and I am not willing to advise against their\\nuse as absolutely as I do against that of wire, but I believe that with\\ncare in handling strong catgut will give all we ought to seek to obtain\\nfrom a suture. I devised and have used in two cases a simple means\\nof freeing a silk suture which also serves as a drain a metal cylinder\\none-eighth inch in diameter and one or two inches long according to\\ncircumstances, with a broad, flat, transversely notched head. After\\nthe suture has been drawn through the holes drilled in the bone its\\nends are passed through the cylinder, which is then pressed down to\\nthe bone, and are tied tight about its head. After untying or cutting\\nthe thread all can be easily withdrawn. That the loop cannot be so\\ntightly drawn as by a knot is no objection, for it should always be\\nrather loose so as to diminish the chance of breaking by a bend or twist\\nof the limb.\\nTemporary fastening by nails or pins is applicable only to spongy\\nportions of bone it has been suggested for fractures of the shaft in the\\nform of a long pin passed through the pieces, which are further secured\\nby a thread thrown several times over the point and the shaft by with-\\ndrawing the pin the thread is freed.\\nA ligature thrown circularly, or better obliquely in notches, about\\nthe bone has been employed.\\nFixation by a bone pin inserted lengthwise into the medullary canal,\\nby an external metal plate screwed to the two fragments, or by pinning\\nor screwing the notched and fitted fragments together has been prac-\\ntised, but mainly, I think, in operations after failure of union.\\nIn fracture of the patella, in which a special indication for fixation\\nexists, it has been my practice for several years to use a silk suture\\npassed through the tendon of the quadriceps and the ligamentum\\npatellae and crossing the front of the bone, or simply two or three\\npoints of catgut suture in the fibro-periosteum at the edge of the frac-\\nture. In fracture of the olecranon I have once or twice used a suture\\nsimilarly passed through the tendon of the triceps and the firm fibrous\\nlayers overlying the ulna or through a hole drilled transversely in the\\nulna a short distance below the fracture.\\nTo sum it up, direct fixation is very rarely necessary when it is\\nmade convenient by an existing wound it should be temporary, by the\\nuse either of an absorbable suture or of one that can be easily removed\\nafter a few days.\\nMassage.\\nMassage has shown itself after fracture, as after other injuries, so\\nefficient to overcome the early and later swellings, stiffness of contigu-\\nous joints, and dryness and coldness of the surface, the conditions which\\ndelay convalescence and apparently prolong the period of repair, that\\na somewhat exaggerated impression of its value has found expression", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0121.jp2"}, "120": {"fulltext": "100 FRACTURES.\\nin some quarters, and it has even been proposed as a sole method of\\ntreatment to the exclusion of all retentive dressings. To these exces-\\nsive claims has succeeded a calmer and more judicial appreciation of\\nits merits and limitations, largely through the experience and writings\\nof Lucas-Championniere. 1 It appears to be beyond question that by its\\nsystematic and skilful use in suitable cases the primary swelling is\\nlessened and disappears more promptly, the circulation and skin more\\nrapidly regain their normal condition, the atrophy of the muscles is\\nless and more promptly disappears, and the joints more quickly lose\\ntheir sensitiveness and regain the range of motion which is possible\\nunder the changed skeletal conditions possibly that range after frac-\\nture at or near a joint may be increased by massage over what it would\\nbe without it, but if so the fact can hardly be demonstrable.\\nThe claim that repair of the fracture takes place more promptly has\\nnot, I think, been substantiated and seems to me, moreover, possibly\\ninconsistent with certain observations which indicate that repair may\\nbe delayed by insufficiency of reaction.\\nWhether these gains, which amount to a little more than a shortening\\nof the period of after-affects, are worth the trouble and expense of\\nobtaining them is an economic rather than a surgical question, and it\\nis clear that they should be sought for only when there is no danger of\\nmaking greater losses thereby that is, in cases in which the tendency\\nto displacement is slight and can be satisfactorily guarded against.\\nThis is the case with many fractures at the ankle, wrist and elbow, and\\nof the fibula alone and in some of the leg, forearm, and arm protected\\nby moulded splints one splint will give sufficient protection while mas-\\nsage is made after removal of the other.\\nMassage is made by light rubbing toward the trunk with the fingers\\nand then the whole hand, first beside the fracture and then, as tolerance\\nis established, over it. The sittings should last for twenty or thirty\\nminutes and be repeated daily. It has seemed to me that the repeated\\napplication of the elastic bandage was equally advantageous.\\nAmbulatory Treatment.\\nThe suggestions made a few years ago by an instrument maker in\\nGermany that in fractures of the lower extremity splints should be\\nused which would enable the patient to walk during treatment has led\\nto considerable experimentation, the ultimate result of which seems\\nlikely to be of some benefit to the patient, although far less than is\\nclaimed by some who have sought to generalize the method. In esti-\\nmating the value of the suggestion and determining the extent to which\\nthe previous use of the method can be broadened, we must discriminate\\nsharply between the different forms of fracture. A man with a frac-\\nture of the fibula, of the external malleolus, even with a Pott s fracture,\\ncan often walk with comparative ease and security under the protection\\nof a plaster-of-Paris dressing which limits the motion of the ankle-\\njoint and prevents lateral strain upon it. And so too with fracture of\\nthe patella. To that extent there is nothing new in the idea, so far at\\n1 Lucas-Championniere Du massage dans le traitement des fractures, Paris, 1895.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0122.jp2"}, "121": {"fulltext": "TREATMENT. 101\\nleast as the freedom from confinement is concerned. The claim now\\nis that the method can be extended to fractures of both bones of the\\nleg and even of the femur, that the loss of time and earning capacity\\nis thereby lessened, that union takes place more rapidly, and that the\\njoints more promptly regain their freedom of motion and the whole\\nlimb its normal condition. The comparison in respect of the last three\\npoints is one that is notoriously difficult to make with accuracy, and it\\nhas not been helped by the statistics that have been published, for they\\nhave included a large proportion of the slighter cases, and I think it\\nmust still be held that the claim has not been substantiated. As for\\nthe pecuniary value of ambulation on the splint, the advantage seems\\nto me to be illusory the splint is in that respect no better than a\\ncrutch, and although it may perhaps be at times more convenient it is\\nat others less so.\\nOn the other hand, the method exposes to risks of displacement and\\nof healing with deformity which, in my judgment, outweigh even the\\nclaimed advantages, and the statistics show that the risk is a real one\\nand that damage results in a considerable proportion of cases.\\nThe principle of construction of an ambulatory splint for a fracture\\nof the leg is to make it of plaster of Paris in a way to combine reten-\\ntion in the ordinary manner with a support on each side which extends\\nwell below the sole and takes the weight of the body through its attach-\\nment to the splint well above the fracture, the lower segment of the\\nlimb hanging between these supports and receiving none of the weight.\\nFor a fracture of the thigh the dressing is a combination of a fixed\\ndressing and a hip-splint which receives the weight of the body at the\\npelvis.\\nIt is admitted^ I think, by all supporters of the method that it\\nshould not be employed until after the primary swelling has subsided\\nand the early hardening of the soft parts about the fracture has\\nappeared, say after a fortnight in a fracture of both bones of the leg.\\nThe limb is then covered with a plaster dressing applied directly over\\nthe skin except along the sole, where it is separated from it by a layer\\nof cotton about two inches thick. Along the sole and on the sides of\\nthe limb the dressing is made very thick and strong and is sometimes\\nreinforced by lateral strips of wood or metal. The other foot must be\\ncorrespondingly raised by a thick sole. It is beyond question that if\\nthe method is employed the patient should be kept under observation\\nand the same precautions as regards removal for inspection should be\\ntaken as have been shown to be necessary with other splints.\\nA safer plan, if it is essential that the patient should walk, is to use\\nan ordinary hip-splint for ambulation, the broken leg being separately\\nencased in plaster. The same plan can be employed in the later stages\\nof fracture of the femur.\\nI have found that patients can sometimes walk about with the aid\\nof two lateral strips of wood placed outside of an ordinary plaster\\ndressing after it has hardened and supported by a shoulder or collar of\\nplaster at its upper part, or by a light apparatus of two iron side-pieces\\nfastened over a plaster dressing with straps and buckles.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0123.jp2"}, "122": {"fulltext": "102 FRACTURES.\\nManagement of the Joints.\\nThe joints in the formation of which the broken bone takes part,\\nand often more distant ones, become stiff and sensitive during the\\nperiod of repair and remain so for a longer or shorter time thereafter.\\nThis disability is specially marked and may become permanent in the\\nold and rheumatic when the fracture has involved the joint, when the\\njoint has been coincidently sprained, and in the joints of the hand even\\nwhen the fracture is of the arm or forearm. The causes are varied\\nand numerous, usually unavoidable, and sometimes irremovable. The\\nmore important and permanent are those arising from change in the\\nshape of the articular end of the bone by uncorrected displacement of\\na fragment or by excessive formation of callus, and, in less degree,\\nfrom thickening and retraction of the periarticular tissues and the\\nformation of adhesions within the joint following its sprain or its share\\nin the fracture. These are all the result of the primary injury and\\nof the inflammatory reaction, overgrowth of callus being most com-\\nmon in the young because of the activity of the periosteum in bone\\nformation at that period. Anything which diminishes that reaction\\nand shortens its duration will, therefore, tend to diminish these ham-\\npering consequences anything which augments it will add to them.\\nThis gives us a standard by which to measure the value and appropri-\\nateness of any method of treatment. Rest, massage, elastic compres-\\nsion have long since proved their value to reduce inflammation in\\njoints and to remove exudates from within them and from the peri-\\narticular tissues; and moderate use, active or passive, to increase the\\nrange of motion after the inflammatory reaction has ceased. The\\nimportance, and especially the respective timeliness, of these two\\nopposing methods need to be fully grasped. The surgeon s dread of\\nanchylosis, his anchylophobia, as it has been termed, too often leads\\nhim to move and even to force a joint while such motion will still be\\npainful and will be followed by an increase in the reaction and a reduc-\\ntion of the range of motion, and, on the other hand, if he has well\\ngrasped the corresponding principle he is in danger of unduly prolong-\\ning confinement and thereby postponing and perhaps restricting the\\nrestoration of function. The criterion is a plain one so long as the\\njoint is swollen and hot, so long as its use is followed by an increase of\\nswelling and heat and by persistent pain, so long must it be kept at\\nrest and so long must active treatment be limited to massage or elastic\\ncompression and, as a rule, this attitude of non-interference may be\\nmaintained without harm until after union of the fracture has become\\ncomplete. Then he may resort to passive motion or may encourage the\\npatient to gradually increasing use of the limb, and he will see the stiff\\njoint rapidly regain its functions.\\nForcible passive motion, with or without anaesthesia, is always harm-\\nful before the second month, and even after that time it is far more\\nlikely to do harm than good. About the only condition in which it\\ncan really help is that of isolated cord-like adhesions within the joint\\nwhich can thus be broken without the probability of their reunion.\\nSuch a condition we have every reason to believe to be very rare.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0124.jp2"}, "123": {"fulltext": "TREATMENT. 103\\nWhen the method is employed to increase a range of motion that has\\nbeen restricted bv the common causes, such as broad adhesions, retrac-\\ntion of the capsule with periarticular thickening, and bony irregulari-\\nties it accomplishes its object only by creating lacerations which\\nnecessitate immediate immobilization in order to check inflammatory\\nreaction and which in healing re-create the original or similar conditions\\nand even increase them. The procedure should, I think, be almost\\nwholly abandoned, and in its place we should resort to massage, con-\\nstant use within existing limits, and possibly to the recently intro-\\nduced method of prolonged exposure to high dry temperatures, and\\nthese failing, I should prefer to expose the joint by incision in order to\\nremove such intra-articular obstacles as might exist and be removable\\nrather than blindly to seek to break and tear them without knowing\\nwhat and where they are.\\nThis general rule of immobilization needs one important addition\\nwith respect to the fingers. Prolonged immobilization of the larger\\njoints does not stiffen them, but immobilization for even two or three\\nweeks, especially in the extended position, will cause stiffness of the\\nfingers which in the old and rheumatic may be permanent, even if the\\nhand and fingers have been previously uninjured. For this reason, in\\nthe treatment of all fractures of the arm and forearm the fingers and\\nthumb should be left free and the patient should be enjoined constantly\\nto move them in addition, if the dressing must include a portion of\\nthe hand it should be so arranged that the wrist will be in slight dorsal\\nflexion, the fingers flexed but free to be extended, and the thumb\\nabducted, because these attitudes tend to retard and diminish the ill\\neffects of confinement and lack of use. If the fingers must be confined\\nit should be in flexion.\\nCOMPOUND FRACTURES.\\nThe points here to be considered are those connected with the man-\\nagement of the wound of the soft parts and the modifications imposed\\nby its presence and character upon the details of reduction and reten-\\ntion of the fracture.\\nA fracture may be compound from the beginning or it may become\\nso by suppuration, by the extension in depth of a coexisting superficial\\nwound, or by the formation and fall of an eschar. A very important\\ndifference is that between fractures by direct and fractures by indirect\\nviolence, because in the former the wound is usually large and so con-\\ntused that its prompt uncomplicated healing cannot be expected, while\\nin the latter it is usually made from within outward by the sharp end\\nof a fragment, is small and clean, and may confidently be expected to\\nheal within a few days under proper care, thus transforming the frac-\\nture into a simple one and putting an end to the special dangers which\\nmake the injury so redoubtable. These two varieties differ so greatly\\nin prognosis and treatment that I shall seek to emphasize the distinc-\\ntion between them by a separate description, although it must be\\nadmitted that the special difficulties and dangers which characterize\\nthose by direct violence may also exist in those by indirect violence in", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0125.jp2"}, "124": {"fulltext": "104 FRACTURES.\\nconsequence of unusual associated conditions more or less independent\\nof the mode of production. The essential difference is in the condi-\\ntion of the wounded tissue in the one, a lacerated contused wound,\\nsome of the skin about which, even if apparently uninjured, is almost\\ncertain to slough; in the other, a small clean wound almost as fit to\\nheal as if it had been made on the operating-table.\\nCompound Fracture by Indirect Violence, or with a Small,\\nClean Wound.\\nThe patient is anaesthetized and the skin about the wound is cleaned\\nas for an operation. If the point of a fragment projects through the\\nskin and is rather tightly grasped by it the wound must be freely\\nenlarged, and it and the bone irrigated with an antiseptic solution,\\nsuch as the 1-1000 bichloride reduction is then made, the limb\\npressed to force out the escaped blood, the w r ound closed with inter-\\nrupted sutures at half-inch intervals, and a sterile or antiseptic dress-\\ning applied, with temporary splints. Exceptionally it may be advis-\\nable to insert a drain of gauze or tubing, or to explore the wound to\\naid the reduction or to remove fragments, or to secure a torn vessel,\\nbut the less the wound is handled the better, because of the risk of\\ncontamination by the fingers.\\nAbout a week later the dressing is removed and if all has gone\\nwell the fracture is thenceforth treated as a simple one; but if infec-\\ntion has occurred the measures described in the next section must be\\nemployed.\\nCompound Fracture by Direct Violence, or with a Contused or\\nInfected Wound.\\nThe patient is anaesthetized, the skin cleaned, and the wound thor-\\noughly washed out with an antiseptic solution; loose fragments are\\nremoved, the ends of the bones regularized if necessary, and the deeper\\nlayers of muscle and fascia fastened together by sutures so as to give\\nsupport to the fragments; if deemed necessary a catgut or temporary\\nsuture may be placed in the bone to hold the fragments together.\\nThen the enveloping fascia is sutured at a few points, not too closely,\\nand the skin sutured so far as its condition permits. Drains of rubber\\nor gauze are inserted, and a dressing placed over all. The limb is\\nthen placed in splints that will permit a change of dressing with the\\nleast disturbance of the fragments for the leg Volkmann s splint is\\nconvenient, or the plaster stocking (page 91), or moulded anterior\\nand posterior splints, one of which is placed if possible next the skin\\nand protected by rubber tissue or oiled silk from being softened by the\\ndischarge (Fig. 45). Later in the course, if the case does well, an\\ninterrupted or fenestrated splint may be used, but the dressing occu-\\npying the fenestra or interval must be bound on very snugly or the\\ntissues under it will become oedematous and project through the open-\\ning. Suspension adds to the comfort of the patient and often to the\\nconvenience of the surgeon.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0126.jp2"}, "125": {"fulltext": "TREATMENT. 105\\nFor the thigh Hodgen s splint is usually the most convenient, but\\nthe double inclined plane is sometimes better. For the arm, especially\\nin fractures near the elbow, I like vertical suspension; it seems to\\nkeep down the reaction very efficiently, but moulded splints are very\\nconvenient, as they also are for the forearm.\\nThe condition of the skin about the wound in these fractures\\ndemands close inspection, for it is usually much more seriously and\\nextensively affected than its appearance indicates. It is almost in va-\\nriably stripped up from the underlying parts for a considerable dis-\\ntance and certain to slough, often over a large area, although it may\\nshow no sign of the injury received. I have found a brief application\\nof the elastic bandage, as in producing artificial ischsemia for opera-\\ntion, of value in determining the extent of this injury, for the killed\\nFig. 45.\\nCompound fracture. Dressing and plaster splint.\\nportions of skin do not share in the blush which follows its removal\\nit must be remembered that skin on the distal side of a long transverse\\nwound sometimes remains pale under this test although still viable.\\nThe absence of bleeding on puncture is also a fairly good sign of loss\\nof vitality.\\nI have experimented somewhat on the possible advisability of cut-\\nting away at once all skin that is clearly certain to slough in order to\\ndiminish infection and favor drainage from beneath it, but have not\\nbeen able to satisfy myself that it is best to do so. If the infection is\\nslight the skin mummifies and but little exudate forms under it, and it\\nserves, by the sutures placed in it, to prevent retraction of the adjoin-\\ning portions it can be cut away later, in the second or third week. If,\\non the other hand, the case does less well the dying or dead skin can be\\nremoved at the second or third dressing with, I think, no serious loss\\nfrom the attempt to utilize and save it.\\nLacerated and divided muscles should be adjusted as nearly as possi-\\nble in their normal relations and may be secured there by a few catgut\\nsutures, but the main reliance upon their proper reunion is in the closing\\nof the enveloping fascia over them, with intervals for drainage. Divided\\nnerves and tendons are, of course, to be sutured, and torn vessels tied.\\nThe proper management of fragments of bone is often a matter of\\nanxious doubt and the surgeon must be guided somewhat by the prob-\\nability of avoiding extensive suppuration, for fragments may safely be\\nleft in wounds that are to heal kindly which must certainly be removed\\nsooner or later if suppuration takes place about them. It has been", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0127.jp2"}, "126": {"fulltext": "106 FRACTURES.\\nabundantly demonstrated that even wholly detached fragments can\\nmaintain or regain their vitality and be an important aid in establish-\\ning union betAveen the main fragments if infection is avoided. If the\\nloss of bone is considerable it is advisable to square the ends of the\\nmain fragments and bring them close together in the leg this loss is\\nusually at the expense of the tibia, and the fibula must then be corre-\\nspondingly shortened.\\nIf the laceration of the muscles is great, and persistent infection\\nprobable, abundant provision for drainage and irrigation should be\\nmade. Long fenestrated rubber tubes should be run through the limb,\\nby counter-openings, and should project through the dressings so that\\nan antiseptic solution can be frequently injected during the first few\\ndays or until the infection is under control. If suppuration becomes\\nfully established it must be treated according to general principles, or\\namputation must be done.\\nGunshot Fractures.\\nGunshot fractures, when the missile is a pistol bullet, can generally\\nbe successfully treated by a single irrigation of the wound and an anti-\\nseptic dressing without removal of the bullet. It is very rare for a\\npiece of the clothing to be carried in beyond the skin. When the\\nmissile is a large rifle ball or a charge of shot at close range the destruc-\\ntion of the soft parts is such that prompt closure of the wound cannot\\nbe expected, and the case must be treated as one of the second class just\\ndescribed. I have recently, 1898, seen two cases of fracture of the\\nupper end of the femur, one of the carpus and radius, and one of the\\nhumerus, by Mauser balls, which healed without suppuration.\\nAmputation.\\nThere is a class of cases, fortunately not a large one, in which pri-\\nmary amputation is clearly indicated, cases in which the fracture is\\nonly one, and sometimes not the most important, of the injuries\\nreceived. The extensive destruction of the soft parts, sometimes also\\nof the bone, makes it evident that the limb cannot be saved or that if\\nsaved it would be useless. The only question is as to the time and\\nplace of amputation. I am confident that in some of these cases a\\nformal amputation well above the injury should be rejected in favor of\\ndivision of the remaining soft parts at the upper limit of the laceration\\nand the removal of only so much of the upper fragment as can be\\nconveniently reached from the surface of section. These are the cases\\nin which the soft parts have not been torn and bruised above the line\\nof their division, and in which it is important to save as much as pos-\\nsible of the length of the limb, or in which a formal amputation would\\nsacrifice a contiguous joint, especially the knee or elbow. Eecovery of\\ncourse would be slower, but under the protection of asepsis the stump\\nwould be more serviceable than those which were formerly obtained\\nafter suppuration and whose defects led to the rule of practice which\\nnow, I think, needs revision. Such limited experience as I have gained\\nin the matter encourages me to invite consideration of it.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0128.jp2"}, "127": {"fulltext": "TREATMENT. 107\\nDoubt as to the advisability of amputation and anxiety as to the\\nresult if amputation is not done arise in those cases in which the injury\\nis not clearly destructive of the limb or its usefulness, but in which\\nthe attempt to save it will imperil life by the progress of an infection\\nalready present or certain to result from the sloughing of the bruised\\ntissues. It is a peculiarly anxious question for the surgeon, for it\\ninvolves his reputation for sound judgment as well as the welfare of\\nthe patient. Weighing the probabilities he may wisely decide that the\\nchance of saving the limb or of its usefulness if saved is not such as\\nto justify the taking of the risks involved in the attempt to save it, and\\nyet if the patient refuses amputation and happily saves both life and\\nlimb the advice to amputate is likely often to be recalled as a reproach\\nor an error of judgment. In some cases it is probable that under the\\nprotection of antiseptics the decision can be delayed until time shall\\nhave shown the full extent of the injury and the ability or inability\\nto control the infection, with a reasonable expectation that a later am-\\nputation, if necessary, will still be in time to save life but in other\\ncases, particularly in the middle-aged and alcoholic and in those with\\ndiseased organs and tissues, the infection is so superior to the organ-\\nism s power of resistance that if it is allowed to become fairly estab-\\nlished death is inevitable. In the first set of cases the surgeon may\\nfairly place the responsibility of delay, of taking the chances, upon the\\npatient or his friends in the latter he must throw the whole weight of\\nhis opinion unreservedly in favor of immediate amputation unless he\\nis forced to believe that even that will be unavailing. An infection in\\na middle-aged patient which in a few hours has produced a condition\\nof apathy or subdelirium, with brownish discoloration of the skin\\nextending rapidly upward and a dark offensive discharge from the\\nwound, cannot be arrested by amputation, except perhaps when it has\\nnot got above the knee or elbow but one which is marked rather by\\nabundant suppuration, even with high fever, by less implication of the\\nsensorium, and by a slower, reddish, boggy oedema of the parts about\\nand above the wound can often be saved by amputation.\\nCompound Articular Fracture.\\nIn these cases also conservative treatment has gained much additional\\nground the outlook and details vary, as in fracture of the shaft, with\\nthe character and extent of the injury to the soft parts. In addition\\nto the principles governing the treatment of similar fractures of the\\nshaft the surgeon has also to consider the conditions arising from the\\nimplication of the joint, especially the probability of the extension\\nof suppuration to it and the effect upon its functions of such sup-\\npuration or of the injury itself. If the wound is small and clean\\nits communication with the joint may be disregarded, or, at the most,\\ndrainage of the joint made and maintained for twenty-four to forty-\\neight hours. The principle in any case of moderate or extensive lacera-\\ntion and contusion of the soft part, in which the attempt is made to\\npreserve all the articular portions of the bone and the functions of the\\njoint, is to protect the joint by drainage against the consequences of", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0129.jp2"}, "128": {"fulltext": "108 FRACTURES.\\nprimary infection and against later infection from the wound itself by\\nassuring the early escape of the exudates of the latter. In the more\\nsevere cases laceration, splintering of the articular end, free commu-\\nnication between the wound and joint drainage may be made directly\\nthrough the wound and even partial excision of the joint may be done\\nto insure its thoroughness.\\nThe probable effect of the injury to destroy the functions of the joint\\nraises the question of resection with a view to restrict the loss. The\\nanswer varies with the joint and to some extent with the vocation of\\nthe patient, for at some joints and in some occupations solidity is more\\nuseful than mobility with insufficient control. Thus, at the knee anchy-\\nlosis is preferable, at the ankles the removal of the astragalus may leave\\na useful limb but anchylosis is better than removal of the lower portion\\nof the tibia, at the elbow a stiff joint in a good position is more useful\\nthan one that is very loose for a man who has to do heavy work, while\\nfor one who does light work, using mainly his fingers and wrist, even\\na loose elbow would be better than a stiff one. We have learned too\\nthat partial resections under the protection of the antiseptic method\\ngive much better results in respect of mobility than they formerly did\\nthus, removal of the lower end of the humerus with conservation of\\nthe olecranon gives usually a more useful joint than total resection\\ndoes.\\nGENERAL TREATMENT.\\nThe vital indications in simple fracture of the limbs rarely arise\\nexcept in the aged and the alcoholic. In the former the shock of the\\ninjury, frequently a fracture of the neck of the femur, occasionally\\nproves fatal within a day or two, or the strength gradually fails and\\nthe patient dies about the third week, often with symptoms of localized\\npneumonia at the end. Against this there is little that can be done\\nexcept to avoid dressings which give pain and increase discomfort. I\\ndo not believe that the recumbent posture increases the latter danger\\nor can be safely discarded during the first three weeks. At a still\\nlater period it may sometimes be advisable, because of the general con-\\ndition, to take the patient out of bed even at the risk of failure of union.\\nIn the alcoholic, it is important to maintain nutrition and secure sleep\\nduring the first week, and to give alcohol regularly in moderate quan-\\ntities it is claimed that the chance of an alcoholic outbreak delirium\\ntremens is less if the patient is not kept in bed,- and for that reason\\nan early application of a fixed dressing is advised.\\nNo medication, except tonics, appears to have any value in hastening\\nor assuring union of the fracture except when some specific poisoning\\nis present, such as syphilis or paludism, when mercurials and quinine\\nare respectively indicated.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0130.jp2"}, "129": {"fulltext": "CHAPTEK VIII.\\nDELAYED UNION, FAILURE OF UNION, PSEUDABTHROSIS,\\nFAULTY UNION. 1\\nDelayed Union Failure of Union.\\nIn the use of the terms delayed union, fibrous union, and failure of\\nunion or jiseudarthrosis, a certain vagueness of differentiation is inevi-\\ntable because of the frequent lack of knowledge of the exact anatomical\\nconditions and because the time requisite for the complete repair of\\na fracture varies so much in different cases that it may not be pos-\\nsible to say whether in a given case the process has come to a standstill\\nor is still slowly but surely continuing. This vagueness, moreover, is\\nnot simply clinical but extends also to the anatomical conditions, for\\nin most cases this represents a stage through which the process of\\nrepair commonly passes, that of union of the fragments by a bond of\\nfibrous tissue, and the abnormality consists in the delay or failure of\\nthat bond to ossify. Furthermore, as this final step, ossification, is\\noften still possible after a delay of many months, a case which fully\\ndeserves, clinically, to be termed failure of union/ one in which\\nspecial measures are required to excite ossification, is yet identical,\\nanatomically, with another in which ossification will follow without\\nother aid than the prolongation of the usual immobilization. The\\nterm pseudarthrosis, literally false joint, is not restricted to those rare\\ncases in which some of the characteristic anatomical elements of a\\njoint are present, but is used as a synonym of failure of union. In\\ncases in which bony union is from the first unlookecl for, or has been\\ndeemed unlikely, as in most fractures of the patella without operative\\ntreatment and in some of the neck of the femur, the term fibrous\\nunion is habitually used instead of failure of union.\\nWhile delay in union is not infrequent, failure of union is rare.\\nThe published statistics of failure differ so widely that it is evident\\nthe same basis of classification has not been followed, and probably\\nthose which give the large proportions include cases of delayed union\\nand possibly even fractures of apophyses which are habitually so dis-\\nplaced by attached muscles that only fibrous union is probable. Fail-\\nure is more frequent, actually and relatively, in the shaft of the humerus\\nthan in that of any other bone, and in the prime of life than at any\\nother age. It must be remembered that these statements and most of\\nwhat follows relate only to the shafts of the long bones, and do not\\ninclude fractures of the short bones, of apophyses, or even of the neck\\nof the femur.\\nPathology. Although the anatomical conditions differ greatly in\\n1 For statistics see Norris, American Journal of the Medical Sciences, 1S42, vol, xxix.\\nAgnew s Surgery, vol. i. Gurlt, die Knochenbriiche. Berenger-Feraud, Traite des frac-\\ntures non-consolidees ou pseudarthroses, 1871.\\n109", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0131.jp2"}, "130": {"fulltext": "110 FRACTURES.\\ndetail they may be conveniently classified in two groups, one, contain-\\ning most of the cases, in which the fragments are united end to end or\\nlaterally and more or less closely by fibrous tissue, and another, very\\nrare, in which a distinct joint has formed between them. The varie-\\nties of the first form are very numerous, the variations depending upon\\nthe relative positions of the fragments, the extent of the preliminary\\nrarefaction, the amount of fibrous tissue, and the presence or absence\\nof a productive osteitis or partial ossification of the bond. In short,\\nthe process of repair in any of the widely different forms imposed\\nupon it by the character of the fracture and the displacement may be\\narrested at any period or may be continued unevenly but still incom-\\npletely at different points. Thus, the fragments may be in close ap-\\nposition and united by a short firm bond with only slight motion\\nbetween them, or they may overlap in such a way that the surfaces of\\nfracture are not apposed and the union is only by the thickened inter-\\nposed connective tissue or the displaced end may be enlarged, with\\nosteophytes extending into the fibrous bond and separate nodules of\\nbone developed within it, needing only a slight additional ossification\\nfor complete bony union or the effect of the preliminary rarefaction\\nof one or both fragments may not have been corrected by subsequent\\nossification, and they remain soft and spongy, or atrophied and pointed,\\nand even this process of rarefaction may be so exaggerated as to create\\nas distinct a gap between the fragments as if a piece had been removed\\nor even to transform the entire shaft of the bone into a fibrous cord.\\nOf the second form, the creation of a joint between the fragments,\\nonly a few examples have been recorded. They show, in more or less\\ncomplete and distorted forms, joints with a fibrous capsule embedding\\ncartilaginous or bony nodules, a cavity containing a synovia-like\\nliquid, and the ends of the fragments rounded, eburnated, usually\\nenlarged, sometimes smooth and polished and sometimes covered with\\na fibrous or even a cartilaginous lining.\\nEtiology. Certain general conditions have been deemed a cause of\\ndelay or failure of union either through a specific poison, as in syphilis,\\nor through a deterioration of the health or a lowering of the vitality\\ninduced by them, as pregnancy, lactation, defective nourishment, and\\nacute diseases but it is beyond question that the causes are usually\\nlocal and that the most common one is a faulty relation of the frag-\\nments to each other, including therein the interposition between them\\nof muscular tissue. Others are defective innervation, disease of the\\nbone, inflammation on the surface, and defective treatment. But it is\\nalso true that delay and even failure may occur when no legal or gen-\\neral cause can be found, when the fragments are in exact apposition,\\nand when the general condition is good. We know that the less the\\nprimary displacement, the more exact the reposition, and the more\\ncomplete the immobilization, the less is the local reaction and the\\nsmaller the callus. It is possible, therefore, that the reaction the\\nhyperemia and the exaggeration of the local nutritive processes may\\nbe too slight or too brief to complete repair, but this only throws the\\nquestion further back, and we have yet to learn why the reaction is\\ninsufficient in one case and sufficient in others which are apparently", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0134.jp2"}, "131": {"fulltext": "DELATED, FAILURE, OB FAULTY UNION. Ill\\nidentical. Id the leg and in the forearm a condition occasionally exists\\nwhich is not found where there is only a single bone. For example,\\nthe fibula unites, but the rarefactive process in the tibia is exaggerated\\nand leaves the fragments separated by quite an interval occupied by\\ngranulations, and the ossification which follows is not active enough to\\nextend entirely across it. If the bone were single it seems not unrea-\\nsonable to suppose that the fragments would be brought nearer together\\nand the intermediate granulations stimulated by the pressure caused by\\nthe contraction of the muscles, but here the fibula holds the fragments\\napart. This exaggerated rarefaction can sometimes be directly observed\\nin compound fractures, especially in the spongy tissue near the epiphy-\\nses. The delay commonly observed after resection for the relief of\\npseudarthrosis I attribute to the absence of a periosteal bridge.\\nThe defective relations of the fragments consist mainly in a dis-\\nplacement by which the fractured surfaces are more or less widely sep-\\narated and which is maintained perhaps by the interposition of muscle.\\nThis interposition, which has occasionally been demonstrated by opera-\\ntion, is thought by some to be by far the most common cause of failure\\nof union, but in the present lack of observations the opinion must be\\ndeemed too exclusive. It is probable that when interposition occurs it\\nis by penetration of the sharp point of one fragment into the overlying\\nmuscle. Another form of defective relations is constituted by the inter-\\nposition of a fragment wholly or partially detached or by the loss, in a\\ncompound fracture, of one or more fragments and the consequent crea-\\ntion of a considerable gap.\\nFailure by defective innervation, as shown by Bognaud, 1 occurs\\nwhen the trophic nerves or nerve centers of the limb are injured.\\nMotor or sensory paralysis without injury of the trophic apparatus\\ndoes not delay union. Bognaud collected six cases of failure of union\\nof fracture of the leg with paraplegia due to injury of the spinal cord\\nat or below the last dorsal vertebra, while in others in which the paral-\\nysis was incomplete or the spine was injured at a higher point union\\ntook place.\\nLocal diseases, syphilis, cancer, etc., which by destroying or soften-\\ning the bone lead to spontaneous or pathological fracture, act\\nin like manner to prevent repair, and the inflammation which accom-\\npanies deep suppuration in compound fracture and is usually associated\\nwith necrosis is a frequent cause of delay or failure.\\nThe presence of an open wound exposing a fracture, even when sup-\\npuration is slight and superficial, I have observed in several cases to\\nbe accompanied by marked hyperemia and softening of the bone and\\nby great delay in union of the fracture even when the fragments were\\nin exact apposition.\\nDefective treatment includes the failure to correct the displacements\\nwhich make union difficult and which might be corrected, to secure\\nimmobility and maintain it for a sufficient length of time, and possibly\\ncertain errors of commission, such as the excessive use of cold upon\\nthe limb. Of these, frequent movement of the fragments upon each\\n1 Bognaud Sur l influence de quelques lesions du systenie nerveux sur la formation\\ndu cal, These de Paris, 1878.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0135.jp2"}, "132": {"fulltext": "112 FRACTURES.\\nother has long been recognized as a potent factor in delaying union.\\nIt may be due to insufficient retention by the splints or to the indo-\\ncility of the patient or to the manipulation of the surgeon in making\\nearly passive motion of a neighboring joint. There is reason to think\\nthat the exceptional freqency of failure of union in the humerus is\\ndue in part to this latter cause, for, such fractures being commonly\\ntreated with the elbow flexed, movements of the forearm are liable to\\ntake place about a low fracture of the arm as a centre instead of in\\nthe elbow, especially if the splint does not rest against the front or\\nback of the shoulder.\\nThe return of mobility after union has become apparently complete,\\nand even after the patient has used the limb for some time, is occasion-\\nally observed. In most of the cases probably the union has only been\\nfibrous, although close and firm, and has slowly yielded under use but\\nin others, in which there is no reason to doubt the solidity of the union,\\nthe cause has been a local inflammation, such as erysipelas, or an ulcer,\\nan acute febrile disease, or scurvy.\\nSymptoms. The persistence of abnormal mobility after a lapse of\\na period that is usually largely sufficient for union constitutes de-\\nlayed union the merger into failure of union is a matter of\\nopinion rather than of exact definition. If the position of the frag-\\nments is good and the mobility slight the condition should be deemed\\nmerely one of delay for a much longer period than when the local\\nrelations are less favorable, and the usual treatment of a fracture\\nshould be continued the instances are numerous in which union has\\nfinally become complete after the lapse of several months and without\\nexceptional measures. On the other hand, failure may be predicated\\neven before the usual time has passed if the position of the fragments\\nis very unfavorable and the mobility still great.\\nThe persistence of abnormal mobility is the pathognomonic sign,\\nbut it is occasionally difficult or even impossible of recognition either\\nbecause it is very slight or because the fracture is so close to the articular\\nend of the bone that the mobility is masked by the movements at the\\njoint under such circumstances the functional disturbance and pain\\nmay be the only symptoms. The abnormal mobility may be slight or\\nvery free, and is usually painless until its limits are approached or\\nreached. With it may be associated a recognizable position and shape\\nof the fragments under which union is plainly impossible without\\nthe aid of exceptional measures.\\nFunctional disturbances vary with the extent of mobility, the limb,\\nand the amount of the associated muscular degeneration it ranges\\nfrom complete disability to interference so slight as scarcely to be\\nnoticeable in one of my own cases, a compound fracture, the patient\\npreferred amputation of the leg to longer delay, and others have sought\\nin amputation relief from the pain of the movements of the limb.\\nOthers, again, are able to use the limb with the aid of a brace, and\\nsome even without it. In the shaft of the femur the disability is\\nusually the greatest and is practically complete, but when at its neck\\nthe limb may be still quite useful I have one such specimen taken\\nfrom a man who was able to walk freely, and others have been reported.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0136.jp2"}, "133": {"fulltext": "DELAYED, FAILURE, OB FAULTY UNION. 113\\nTreatment. When delay has occurred and the local conditions are\\nsuch that union may reasonably be hoped for, the surgeon s first duty\\nis to seek for and combat any general condition that may be at fault,\\nsuch as syphilitic or malarial poisoning or defective nourishment, using\\nthe respective remedies and tonics, and perhaps giving preference among\\nthe latter to phosphorus or phosphate of lime. 1 Then he continues the\\nimmobilization, aiding it then or a little later by massage this still\\nfailing, he has choice of a number of mild measures to hasten the pro-\\ncess, such as the application for a few hours, once or twice repeated, of\\na bandage about the limb above the fracture tight enough to cause\\nvenous congestion and swelling, the painting of the skin with iodine,\\nor the injection of a few drops of tincture of iodine or of a 10 per\\ncent, solution of the chloride of zinc into the periosteum and the fibrous\\nbond at the fracture or, in the case of the leg, if the mobility is slight\\nand the fragment in good position, he applies a splint or brace by the\\naid of which the limb can be used in walking without too much risk\\nof causing displacement, in the hope that the irritation thereby pro-\\nduced at the fracture may stimulate the process.\\nIf these also fail or if the condition calls for more pronounced meas-\\nures, he seeks to produce a sharp reaction by forcibly and widely bend-\\ning the limb at the fracture, under an anaesthetic, so as to tear the bond\\nand measurably produce the conditions of a fresh fracture, or he passes\\na drill down to the bone, with or without incision, and perforates the\\nends of the fragments at several points. Bone and ivory pegs have\\nbeen inserted into holes thus made and withdrawn after a few days or\\nweeks, but apparently with no advantage over simple drilling.\\nElectrolysis has also been used with advantage, the needle being\\npassed into the bond between the fragments.\\nFinally, the surgeon may freely expose the fracture by incision, resect\\nthe ends of the fragments, bring them into close and exact apposition,\\nand secure them there by external dressing with or without the aid of\\na suture or other fastening applied directly to the bone. In the pre-\\nceding chapter. I have given reasons for thinking that the presence\\nof a permanent metallic suture or pin interferes with the processes\\nby which alone union can be accomplished, and I must repeat my\\nbelief that sufficient security can be given by an external dressing,\\nand that the usefulness of a suture is limited to keeping the fragments\\nin position during the application of that dressing. No suture that\\ncan properly be used is strong enough to relieve the surgeon from the\\nnecessity of great care in handling the limb during the application of\\nthe dressing, not because the fragments have a great tendency to slip\\napart laterally, but because the angular deviations wdiich are certain to\\ntake place bring a great breaking strain upon the suture. For this\\nreason I believe that if any suture is used it should be of catgut or\\nsilk, and tied loosely so as to permit angular deviation within a mod-\\nerate range. The best security, I believe, lies in making the ends of\\n1 Gauthier Lyon Medical, June aud July, 1897, reports the successful use in two cases\\nof the thyroid extract to cause consolidation after delay of about three months the\\nremedy was used for between three and four weeks and union was then established. I\\nhave employed it in two cases without recognizable benefit.\\n8", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0137.jp2"}, "134": {"fulltext": "114 FRACTURES.\\nthe bone square and then having an assistant press the lower segment\\nof the limb forcibly against the upper one until the dressing has been\\ncompleted. I have successfully operated upon at least six cases of\\nfailure of union of the femur in this way and without suture. I may\\nadd that I have seen as many cases of pseudarthrosis of the leg that\\nhad been unsuccessfully sutured with silver wire, and in all them I\\nhave found at the second operation the wire lying loose and sometimes\\nbroken. (See also Plate XXV., fig. 2.)\\nIf on resection the end of the bone is found thickened and dense I\\ndrill it in several places in order to promote its rarefaction by increas-\\ning the area of irritation, and under such circumstances the use for\\ntwo or three weeks of a silk or other removable suture might further\\nthe same aim and thereby be advantageous. In the humerus and in the\\nbones of the forearm, where retention is not so easy as in the thigh and\\nleg, I- have used both absorbable and temporary silk ligatures.\\nA pin of bone has sometimes been inserted into the medullary canal\\nto hold the fragments together if asepsis is preserved it may heal in,\\nbut it usually needs to be removed.\\nWhen failure of union has been due to loss of bone the gap has\\nsometimes been filled and union obtained by pieces of fresh or decalci-\\nfied bone over which the soft parts are closed by primary healing.\\nAbsolute asepsis is necessary to success. Apparently the pieces act\\nonly mechanically by furnishing a framework within and around which\\nthe granulations grow and by filling the space which if left to be filled\\nby the slowly forming granulations would collect the exudates and thus\\nfavor the spread of chance infection. It has also been proposed to fill\\nthe gap with powdered calcined bone on the theory that it would equally\\nwell fill the space and serve as a framework, and would also supply the\\nlime salts needed for the formation of bone. The plan commends itself\\nby its simplicity and cleanliness, for the powder can be perfectly ster-\\nilized by fire, and I have thought it might also be useful in delayed\\ncompound and even simple fractures, the powder being poured in\\namong the granulations or introduced through a hypodermic needle\\nmixed with water.\\nWhen loss of substance has occurred in one of two parallel bones, as\\nin the leg or forearm, it is usually advisable, if the gap is not too large,\\nto excise a corresponding piece from the other bone so that the frag-\\nments of the first can be brought into contact. When the gap has been\\nlarger in the tibia a solid limb has been obtained by dividing the fibula\\nand uniting its lower segment with the upper segment of the tibia. In\\ntime the bone enlarges sufficieutly to make the limb strong and useful.\\nFaulty or Vicious Union Union with Deformity.\\nThe use of these terms is restricted to cases in which the deformity\\nor persistent displacement differs notably from the result usually\\nobtained after that form of fracture the term is not applied when the\\nirregularity is slight or common. Thus it is not applied to moderate\\nshortening by overriding in oblique fractures, to the shortening and out-\\nward rotation commonlv seen after fracture of the neck of the femur,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0138.jp2"}, "135": {"fulltext": "DELAYED, FAILURE, OR FAULTY UNION. 115\\nor to the deformity of the wrist so frequently seen after Colles s fracture.\\nIn short, its use implies a condition that might have been avoided.\\nAny of the possible displacements after fracture may remain uncor-\\nrected and produce this condition, but the most common are marked\\nangular displacement or rotation after fracture of the shaft and trans-\\nverse displacement with overriding. Excessive size of the callus is\\nsometimes included in this group and so is the inclusion in the callus\\nof muscle, tendon, or nerve. The ill results are not limited to the\\nchange in the appearance of the limb, which is often marked and\\noffensive, but include also an interference with function, which may\\namount to complete disability by shortening of the limb, by the devia-\\ntion of its lower segment, or by restricting the movements of a neigh-\\nboring joint either directly or indirectly by implication of its muscles.\\nThus angular displacement, with or without overriding, after fracture\\nof the thigh near the middle may produce a shortening of several\\ninches angular displacement after fracture of the leg may so raise the\\nheel or toes or invert or evert the foot as to make it difficult or impos-\\nsible to place the sole squarely on the ground in walking transverse\\ndisplacement backward or forward close above the elbow may limit\\nflexion or extension respectively, more, I think, by cicatricial implica-\\ntion of the muscle than by contact with the bones of the forearm.\\nExcessive callus in the neighborhood of a joint may diminish its\\nrange of motion mechanically this is seen most frequently at the hip\\nafter fracture of the neck of the femur at its base and at the shoulder\\nand elbow. The inclusion of muscles and tendons in a callus is rare\\nthat of a nerve, or, rather, pressure upon a nerve by a callus, is seen\\nmost frequently in the musculo-spiral nerve after fracture of the lower\\nhalf of the humerus.\\nTreatment. The method of treatment varies with the solidity of\\nunion, and therefore to some extent with the length of time that has\\nelapsed. As persistent displacement is often a cause of delay of union\\nand of early weakness of the callus, it is possible to correct the posi-\\ntion by the hands alone at a much later period than under better con-\\nditions that is, an angular displacement can thus be corrected by\\nforcibly straightening the limb with the hands or with the knee pressed\\nagainst the projecting angle. But little improvement in overriding is\\nto be expected from such means because the cicatricial condition of the\\nsoft parts which maintains it cannot often thus be modified. A few\\ncases have been reported in which continuous traction has been quite\\nefficient. Gradual straightening has occasionally been effected by a\\nlateral brace with transverse elastic pressure at the angle.\\nRefracture by specially devised osteoclasts has been much employed\\nin the past for the correction of angular deformity, but has largely\\ngiven place of late to open operation. Some of the instruments are\\nvery powerful and accurate in the application of the force. Union\\nafter early refracture may be confidently expected to require less time\\nthan after primary fracture. A serious obstacle to success may exist\\nin the permanent retraction of the soft parts on the concave side when\\nthe deformity has long existed. The condition then resembles that of\\na bent bow, and as the length of the soft parts determines that of the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0139.jp2"}, "136": {"fulltext": "116 FRACTURES.\\nlimb the latter cannot be increased, and the bone can be straightened\\nafter breaking it only by forcing the ends of the fragments past each\\nother, overriding.\\nOsteotomy meets the indications in the same manner as osteoclasis,\\nbut more widely and precisely, for it not only insures division at the\\nchosen point, but it also permits the correction of lateral displacement\\nand the removal of a V-shaped or longer piece if the condition is\\nthat mentioned at the close of the preceding paragraph. With strict\\nattention to asepsis recovery is likely to be as uneventful as after\\nosteoclasis, but it will be notably slower if bone is excised. Unless\\nanatomical reasons to the contrary exist the incision should be made\\nlongitudinally at or near the most projecting part of the bone, and\\nshould be long enough to permit free exposure and easy access to it\\nthe management of the bone will be determined by the relations of\\nthe fragments and by the end in view, but in case of excision every\\neffort should be made to maintain the continuity of the periosteum on\\none side and to restore it by suture on the other at the end of the\\noperation.\\nIn articular fracture with displacement, such as Pott s fracture\\nabove mentioned, the bone can sometimes be restored to place by open\\noperation with considerable improvement in function. I have im-\\nproved the condition in a number of Pott s fractures in this way and\\nin one of accidental refracture of the outer condyle of the humerus\\nin which the primary fracture (two years previous) had resulted in\\nconsiderable limitation of motion, I exposed the fracture by incision\\nbecause of non-reducible displacement of the fragment, and was able\\nso to place it that the range of motion was subsequently increased.\\nPossibly a like advantage could be gained by a deliberate osteotomy\\nand shifting of the fragments.\\nAn excessive portion of callus or a projecting fragment which causes\\npain or ulceration of the skin by pressure can be removed by the chisel\\nor rongeur.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0140.jp2"}, "137": {"fulltext": "CHAPTEE IX.\\nGENERAL PEOGNOSIS.\\nThe prognosis after fracture involves consideration of the effects of\\nthe injury in respect of the prolongation of life, the preservation of the\\nlimb, its usefulness if preserved, and the time required for recovery.\\nThe factors in the prognosis have been considered in detail in the pre-\\nceding chapters and will only be grouped here for a more convenient\\ngeneral review.\\nThe prognosis varies with the age and condition of the patient, the\\nposition and character of the fracture, and the complications present or\\npossible.\\nThe Patient. Sex does not affect the prognosis. Age has a con-\\nsiderable influence the younger the patient the better the prognosis,\\nbecause in the young fractures unite more easily and promptly than\\nin the adult, and advancing years increase the probability of dimin-\\nished vitality and of the presence of constitutional dyscrasise. But in\\nfractures involving or in close proximity to joints the prognosis in\\nrespect of function is unfavorably affected by the greater tendency in\\nyouth to excessive formation of callus when the displacement is not\\nentirely corrected or the periosteal irritation is extensive and long\\nmaintained. In the old the prognosis is worse in respect of life because\\nof their diminished ability to withstand the shock and to bear prolonged\\nconfinement to bed and pain, and worse in respect of function because\\nof the greater difficulty with which the affected soft parts and joints\\nregain their original conditions. The reduction of vitality by degen-\\neration or disease of various organs may have a similar effect. Chronic\\nalcoholism exposes to an outbreak of delirium tremens and, as does\\nalso advanced age, to the so-called hypostatic pneumonias.\\nSudden death by fat or pulmonary embolism is possible, but very rare,\\nat any age and with almost any form of fracture.\\nThe Fracture. In compound fracture the prognosis is worse in every\\nrespect than in simple fracture, and worse when by direct violence than\\nby indirect violence because of the usually greater extent and severity\\nof the associated lesions of the soft parts. In gunshot fractures the\\nprognosis is usually bad, the laceration of the soft parts and the shat-\\ntering of the bone being often such as to necessitate amputation or\\ngreatly to limit the usefulness of the limb if it is preserved.\\nThe fracture of the shaft of a long bone generally heals with some\\nshortening, the chief exceptions being the incomplete and subperiosteal\\nfractures of the young and transverse fractures in which lateral and\\nangular displacements can be reduced or prevented.\\nFractures of the short or spongy bones heal promptly, but the dis-\\nplacement, with or without crushing, cannot usually be corrected.\\n117", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0141.jp2"}, "138": {"fulltext": "118 FRACTURES.\\nFracture of the spongy end of a long bone usually heals more quickly\\nthan fracture of the shaft, but occasionally delay is occasioned, or even\\nfailure of union, by exaggeration of the preliminary rarefactive pro-\\ncess. Fracture of a flat bone is rather frequently followed by\\nexaggerated formation of callus.\\nFracture of one of two parallel and connected bones (leg, forearm)\\nis more easily managed and has a better prognosis than fracture of both\\nor of a single bone, because the unbroken one acts as a splint an\\nexception to this is found when the fracture is accompanied by a loss\\nof substance which creates a gap between the fragments.\\nArticular fractures and fractures near the joints are especially liable\\nto be followed by limitation of motion in the joint at the knee and\\nelbow, and to a less extent the shoulder and hip, this is the rule.\\nNo general statement of value can be made as to the time required\\nto reach the final result after fracture or as to the completeness of resto-\\nration of function, and the statistics that have been collected are prac-\\ntically valueless because they do not completely discriminate between\\nthe different forms and ages of the patients. Each fracture or at least\\neach class of fracture must be judged by itself, and in many a given\\ncase there can be no great certainty that it will not vary widely from\\nthe average. As I write this paragraph, I have just visited a patient\\nwho broke the outer portion of the head of the tibia seven months ago\\nI predicted great loss of motion and was gratified when at the end of\\nabout four months a range of 45\u00c2\u00b0 had been obtained, and yet within\\nthe last two months that range has been increased to 90\u00c2\u00b0 under natural\\nuse of the limb. I think it can properly be said that an uncompli-\\ncated fracture of the shaft of the long bone of the arm, forearm, or\\nleg will, in the great majority of cases, heal without any diminution of\\nthe earning capacity of the patient after six months, and that almost\\nall the remainder will have reached the same condition in a year. In\\nfractures of the shaft of the femur more time is required, and the\\nnumber of those who will remain more or less disabled is greater. As\\nmiddle life is passed, the ability of the patient to adapt himself to\\nchanged conditions is less, the joints are more likely to be stiffened,\\nand pain in the limb after fatigue or when the weather is cold and\\ndamp is more common. The latest statistics I have seen are those of\\nLoew l and Ramsperger, 2 collected from the records of Aid Societies.\\nLoew s were of 167 simple fractures of the leg; only one was perma-\\nnently disabled, the others regained their earning capacity in an average\\nof 101 days, 70 per cent, in 91 days each.\\nKamsperger s, of 145 fractures of the leg, given in more detail,\\nshow complete earning capacity, after simple fracture of the shaft\\nof both bones healed without deformity, restored in most during the\\nfirst six months, in a few not until the third or fourth year in those\\nthat healed with deformity (36 per cent.) the restoration was complete\\nin 29 per cent., in the remainder the loss was generally less than 25\\nper cent. Of the compound fractures of the shaft complete restora-\\n1 Loew Deutsche, Zeitschrift f. Chir. vol. xliv. Abstr. in Centralb. f. Chir., 1897. p. 855.\\n2 Ramsperger: Korresp. des Wiirtemb. arzt. Landesvereins. Abstr. in Centralb., 1897,\\np. 735.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0142.jp2"}, "139": {"fulltext": "GENERAL PROGNOSIS. 119\\ntion followed in 32 per cent., the loss in the remainder was usually less\\nthan 25 per cent.\\nOf the simple fractures of the malleoli there was recovery without\\ndeformity in 61 per cent,, with deformity in 39 per cent. of the\\nformer, restoration was complete in 75 per cent., of the latter, in 23 per\\ncent. Two-thirds of all resumed work during the first six months,\\none-third during the second six months. After compound fracture\\nthere was always some loss.\\nAfter fracture of the fibula restoration was always complete, but\\nsometimes much delayed.\\nThe more unfavorable estimates of results in respect of earning\\ncapacity, notably those of Lane, are entirely out of accord with my\\nown experience and observation. I recently sent letters to all the\\npatients who had been treated in the New York Hospital for fracture\\nof the lower limb during the previous year and received answers from\\ntwenty-six as follows Neck of femur, 3 limb nearly useless. Shaft\\nof the femur, 4 limb as useful as before the injury. Leg, 10 in 7\\nas good as ever, in 3 good but with some pain. Pott s fracture, 9 in\\n6 as good as ever, in 2 fairly good, in 1 bad.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0143.jp2"}, "140": {"fulltext": "CHAPTER X.\\nFRACTURES OF THE SKULL.\\nThe function of the cranium is so largely limited to mechanical\\nprotection of the brain and its annexa from external violence, its frac-\\nture in a great majority of cases involves after recovery so slight an\\ninterference with this function, and treatment can do so little to dimin-\\nish this interference, that the importance of the injury lies almost\\nwholly in the associated injury of the brain and in the later inflam-\\nmatory or degenerative processes therein to which that injury or that\\nof the overlying soft parts may give rise, and its consideration falls in\\nthe majority of cases rather under the rubric of injury of the brain\\nthan under that of fractures. It is unfortunate that these injuries\\nshould be so universally classed as fractures, for this leads to an\\nundue fixing of the attention upon the lesion of the bone to the exclu-\\nsion or minimizing of that of the brain and to undeserved reproach for\\noccasional failure to recognize the presence of fracture. It should be\\nremembered that the violence which causes fatal injury of the brain\\ntogether with fracture of the skull may, under slightly changed con-\\nditions, cause the former without the latter, and that in a large propor-\\ntion of fatal cases the fracture is merely an incident without any direct\\nrelation to the fatal result or only with that of having made the causa-\\ntive lesion possible. On the other hand, there is a class of fractures\\nin which the lesions are entirely local and limited to the bone and the\\noverlying soft parts, or in which, if the contents of the cranium are at\\nall injured, the injury is limited to the immediate neighborhood of the\\nfracture. In these the fracture is the essential lesion, and the treatment\\nis almost wholly directed to it. Between these two forms generalized\\ncontusion of the brain and its envelopes, with or without fracture, and\\ncircumscribed fracture with or without localized injury of the brain or\\nmeninges there are others in which the character of the fracture and\\nits mode of production are exaggerations of those of the second group,\\nand the effect upon the contents of the cranium those of the first group.\\nIn the first group the fracture is usually fissured and almost always\\noccupies or extends to the base of the skull, and hemorrhages covering\\na large area though limited in amount of extravasated blood are found\\nupon the surface of the brain and sometimes within it and the medulla,\\nindicating contusion in the second the type is a compound circum-\\nscribed depressed fracture, possibly with a rent in the underlying dura\\nin the intermediate class there are the comminution of the second (but\\nmore extensive and associated with fissure) and the hemorrhages and\\nthe contusion of the first. In the production of the first the causative\\nviolence acts broadly upon the skull, modifying its shape through its\\nelasticity and perhaps splitting it by exceeding the limits of that elas-\\n120", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0144.jp2"}, "141": {"fulltext": "FRACTURES OF THE SKULL. 121\\nticitv, and bruising its contents by that modification of the shape and\\nby the jar, as in a fall in the second, as in a blow of a hammer, the\\nforce is consumed in breaking the bone at the point of impact, there is\\nno general change in the shape of the skull, no diffused effect upon\\nthe brain as a whole. Because of the mode of production fractures of\\nthe second group are usually compound. In the intermediate group\\nthe violence is greater than in the others, it breaks a larger area of\\nbone and is not exhausted in producing the fracture. This difference\\nin the mode of production and in the effects of the violence dominates\\nthe whole subject and determines the treatment and the prognosis.\\nAll this appears plainly in study of the mechanism, pathology, and\\ncause of the injury in the various forms.\\nMechanism and Pathology.\\nIn studying the mechanism of fracture certain anatomical features\\nof the cranium must be borne in mind. Of the vault and base of\\nwhich it is composed in unequal parts, the former is globular, thick,\\nand elastic the latter is flattened, irregular, thick in places, thin in\\nothers, and perforated at many points for the passage of nerves and\\nvessels. From the occipital condyles, by which it rests upon the\\nspinal column, pass outward, backward, and forward various thick\\nportions or ridges constituting a strong framework to connect them\\nwith the vault the basilar process and body of the sphenoid, the\\noccipital crest, and the petrous portions of the temporal bones further\\nforward are the thicker portions of the greater and lesser wings of the\\nsphenoid and the frontal crest. To a certain extent these ridges direct\\nlines of fracture of the base to the thinner intermediate segments, but\\nFig. 46.\\nSword cut fissured fracture. (Konig.)\\nall can be crossed by them. The vault, which varies greatly in thick-\\nness at different points and in different individuals, has a thick outer\\nand a thin inner table of dense bone separated by the spongy diploe.\\nThe physical characteristic of the vault which most concerns us is its", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0145.jp2"}, "142": {"fulltext": "122\\nFRACTURES.\\nFig. 4^\\nelasticity, which is sufficient to permit a considerable change of shape\\nwithout fracture that is, a diameter of the skull can be shortened and\\nthose at right angles to it lengthened by compressing it in a vise, or a\\nportion of its surface can be momentarily flattened by a blow.\\nThe effect of violence acting upon the skull varies with its character\\nand the size and shape of the vulnerant body, and appears in all the\\ngradations between a slight crush or cut of the outer table or of the\\nentire thickness of the bone, through circumscribed depressed areas\\nto single or multiple fissures running completely around. A cutting\\ninstrument, as a chisel or sword, cuts partly or entirely through the\\nbone and by its wedge-action may produce long fissures running from\\neach end of the cut if the weapon is heavy and the blow powerful\\n(Fig. 46), or, if the instrument changes its direction, it may break off\\na piece of the bone and raise it above the level.\\nA moderate blow with a pointed or edged weapon may simply break\\nthe outer table, where the bone is thick, and depress it by crushing the\\nunderlying diploe, or, if the bone is thin, it may make a small rounded\\nhole in it without splintering or Assuring of the side. If the instru-\\nment is not sharp or edged the bone is bent inward and the effect varies\\nwith the force of the blow and the prolongation of its action. In the\\nslightest form the elasticity of the skull takes up and distributes the\\nforce without recognizable injury to the bone. If the force is a little\\ngreater the inner table, which is overbent in the movement, splits away\\nfrom the diploe and is broken (frac-\\nture of the inner table alone), the\\nunbroken portion springing back to\\nits original position and leaving the\\nfragment more or less removed and\\nchanged in position. The same effect\\nhas been produced in the outer table\\nby a blow from within, as by a bullet\\nthat has traversed the skull from the\\nopposite side.\\nIf the force is still greater the\\nbone is broken entirely through to\\nan extent and in directions that vary\\nwidely, and the circumscribed por-\\ntion remains more or less depressed.\\nIf the lines of fracture do not en-\\ntirely circumscribe the affected area the elasticity of the unbroken\\nportion brings back the depressed piece toward or to its place (Fig.\\n48), sometimes imprisoning in the fissure a few hairs or a portion of\\nthe head covering. If the circle of fracture is complete the enclosed\\nportion remains depressed, either bodily or, more commonly, with\\nsloping sides (Fig. 49). From the edge of the opening, small fissures\\nor circumscribed lines of fracture frequently run. The inner table is\\nalways more extensively broken than the outer one, and the two are\\nlargely separated from each other by planes of fractures through the\\ndiploe (Fig. 50). These fractures are almost always compound\\nbecause of the character of the causative violence, the skin yielding\\nMechanism of fracture of the internal table\\nby bending of the bone.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0146.jp2"}, "143": {"fulltext": "FBACTUBES OF THE SKULL. 123\\nunder it a? the bone does. They are part of the so-called compound\\ncomminuted depressed fractures of the skull.\\nAll of the injuries thus far described belong in what are termed the\\nsecond group in the opening paragraph of this chapter, those in which\\nFig. 48.\\nCircumscribed fracture with inclusion of hair. (Konig.)\\nthe dominant feature is the fracture and in which injury to the brain\\nis usually absent or strictly localized. This feature is of so great prac-\\ntical importance that I wish it might be indicated in the classifying\\nFig. 49.\\nCircumscribed depressed fracture. (Konig.)\\nnomenclature, to the exclusion, or at least the great subordination, of\\ndepression, which has long held the attention of the surgeon, to the\\nhopeless confounding of radically different cases and the useless or", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0147.jp2"}, "144": {"fulltext": "124\\nFRACTURES.\\nharmful generalization of therapeutic measures the value of which is\\nstrictly limited. I have long sought such a name that would be dis-\\ntinctive and short; possibly circumscribed fracture of the vault\\nwould serve the purpose, although it is far from meeting all the indi-\\ncations.\\nThe vast majority of fractures of this class involve the vault, but\\nthey occasionally occur at the base, the vulnerant body reaching it\\nthrough the mouth or orbit, and in a very few cases even the condvle\\nof the lower jaw has been driven through the roof of its socket,* or\\nthe ethmoid driven in by a blow on the nose. The prognosis is worse\\nin these basal cases because important parts of the bram are usually\\ninjured, efficient treatment is impracticable, and infection is more\\nlikely to occur.\\nFig. 50.\\nFig. 51.\\nCircumscribed depressed fracture, inner side\\nhealed. (Konig.)\\nFracture of internal table.\\n(Bergmaxn.)\\nThe other group of fractures, those produced by a force acting\\nbroadly upon the cranium to modify its shape as a whole, include\\nalmost all fractures of the base, and all so-called indirect fractures\\nand fractures by contrecoup which have had so large a part in the\\ndiscussion of this subject. In these, I repeat, the important lesion is\\nthat produced in the brain the fracture is an incident, it usually has\\nno influence upon the progress of the case and gives rise to no thera-\\npeutic indications. Similar brain lesions can be produced without\\nfracture, and these cases belong among injuries of the brain rather\\nthan among fractures. This makes a detailed account of the many\\nforms, their relative frequency, and their more or less hypothetical", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0148.jp2"}, "145": {"fulltext": "FRACTURES OF THE SKULL. 125\\nrelations to different forms of violence unnecessary in a work of the\\nscope of this one.\\nThe mode of production of these fractures has been the subject of\\nclose observation, experiment, and study by many, among whom I\\nshall mention only Aran, Felizet, Messemer, and Yon Wahl. Another,\\nBuret, 1 deserves to be remembered, perhaps above all others, for his\\nremarkable investigations and his theory of mechanism by which the\\nchanges of shape of the cranium produce the often distant lesions of\\nthe brain and meninges, a theory which, even if carried in its details\\nsomewhat further than it can readily be followed, and possibly even\\nincorrect, has yet been most valuable in fixing the attention upon the\\nintracranial lesions and clearing away a large amount of nebulous\\ntheories concerning distant effects and their hypothetical causes.\\nThe theory of these fractures as now apprehended is based in part\\nupon the shortening of the diameter in the direction of the violence\\nand the consequent lengthening of those at right angles to it, and in\\npart upon the overbending of the bone under a like strain. In a\\nglobular body of uniform elasticity the shortening of one diameter\\nunder pressure is necessarily accompanied by the enlargement of the\\nmass in the line of the equator and in the corresponding separation\\nof the meridians. If the limit of cohesion is passed, separation (frac-\\nture) necessarily takes place between two or more meridians, and the\\nline of fracture runs approximately from pole to pole that is, from\\nthe point struck to one diametrically opposite along a meridian. To\\nthese Messemer gave the name of bursting fracture. Thus, in the\\nskull, a blow received in the centre of the frontal bone and directed\\nbackward w T ould shorten the antero-posterior diameter and enlarge the\\nskull in the central transverse plane at right angles to the line of force,\\nand, if strong enough, produce one or more fissured fractures running\\nfrom before backward along the summit or side of the cranium. If\\nthe blow were received upon the side the lines of fracture would be\\ntransverse through the vault or base or both.\\nUnder other circumstances not fully understood, but probably de-\\npendent upon lack of uniformity in or differing degrees of elasticity, the\\nyielding along the line of impact is not so fully or so promptly met by\\nexpansion in the other plane, and the bone breaks at the point of maxi-\\nmum curvature at the periphery of the depressed area and along what\\nmay be termed a parallel of latitude, at right angles to the line of force,\\nproducing what Von Wahl names a bending fracture. Thus, a force\\nacting from before backward upon the centre of the frontal bone would\\nproduce this form of fracture along a line crossing the cranium from\\nside to side.\\nThe lines of fracture produced in these two ways are modified by\\nlack of uniformity in the shape and structure of the cranium and by\\nthe degree of the fracturing force the majority of those involving the\\nbase and limited to a single zone occupy the middle fossa, and in those\\nnot limited to a single zone the violence appears to have been greater,\\nand the portion of the vault which has received the blow shows ex-\\n1 Buret: Etudes Experimen tales et Cliniques sur les Trauniatisiues Cerebraux, Paris,\\n1878.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0149.jp2"}, "146": {"fulltext": "126 FRACTURES.\\ntensive splintering (Von Bergmann). The direction of fissures lim-\\nited to the middle fossa is in the great majority of cases transverse,\\nfollowing one of two paths, either in the anterior part of the petrous\\nportion of the temporal bone, parallel to its long axis and opening into\\nthe middle ear, or further forward in the great wing of the sphenoid.\\nThe cause is a blow T upon the vertex or the side of the skull, and the\\nfracture ends in the foramen lacerum anterius or in the sphenoidal\\nfissure. If the force is greater the fracture may extend across the\\nsella turcica into the opposite middle fossa, or obliquely through the\\nsphenoid into the opposite anterior fossa, or into the anterior fossa of\\nthe same side. Fractures of the posterior fossa, caused by a blow on\\nthe occiput, are rarely limited to it, but cross the petrous portion to\\nthe middle fossa, but never cross the occipital ridge and those of the\\nanterior fossa usually pass through the upper margin of the orbit and\\nrun back to the optic or sphenoidal foramen, extending sometimes across\\nthe middle into the posterior fossa, sometimes also across the cribriform\\nplate to the other orbit (Konig). In crushing fracture of the bones of\\nthe face longitudinal fracture of the base along the body of the sphe-\\nnoid appears to be frequent.\\nThat most of the fractures produced in this manner occupy the base\\nwith but little or no extension to the vault is to be explained by the\\nless resistance of the base due to its relative thinness and its irregu-\\nlarity of shape and also, possibly, in part to the impinging force or the\\nresistance of the body exerted upon the base by the spinal column\\nthrough the occipital condyles. When the vault is more extensively\\ninvolved the line of fracture may cross it completely in any direction\\neither as a long fissure with little change of place or with a separation\\nso free that the two halves of the skull can be freely moved upon each\\nother. The internal table shows no splintering. The short isolated\\nfissures distant from the point struck, which are seen not infrequently\\nin the base and occasionally, but very rarely, in the vault, are produced\\nin a variety of ways and will be considered in the following paragraph\\namong the exceptional forms. Most of the extensive fissures of the\\nvault belong in what was spoken of in the opening paragraph of this\\nchapter as the group of fractures intermediate between the two main\\ngroups, those in which the causative violence is great and produces\\nextensive crushing fracture at the point struck, with radiating fissures\\nand generalized lesion of the brain. They are sometimes, but not\\nalways, compound.\\nExceptional forms of fracture, the mode of production of some of which\\nis very obscure, are found at many points. The small isolated fissures\\nat a distance from, or even directly opposite, the point struck, to which\\nthe name fracture by contrecoup was given, belong almost all\\namong the bursting or bending fractures, those of the base\\n(when the blow has been received upon the vertex) being due to the\\nresistance of the spinal column acting through the occipital condyles.\\nThe cases in which the fracture is directly opposite the point struck\\nare so few and so doubtful that their existence has been denied, yet\\nPerrin produced experimentally a fracture of the frontal bone by\\nthrowing a skull upon its occiput, and therefore the possibility must", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0150.jp2"}, "147": {"fulltext": "FRACTURES OF THE SKULL. 127\\nbe admitted. Inclusion in this group of fractures at such a point pro-\\nduced by a second blow directly upon it, as when a fracture of the\\nocciput is caused by a fall upon the back of the head following a blow\\nupon the forehead, is, of course, unjustifiable. A special group of\\nnine cases collected by Yon Bergmann 1 in which the orbital plate was\\nbroken is of great interest. In four cases the primary violence was\\nby a glancing bullet, in the others a bullet penetrating the temporal\\n(3), the occipital (1), and the parietal (1). In some only one orbital\\nplate was broken, in others both the fracture was either a straight\\nfissure or circular; in President Lincoln s case 2 (perforation of the\\noccipital by a bullet) both plates were broken and the fragments\\npushed up toward the brain; 7 in two the fragments were depressed\\na few millimetres into the orbit. In an allied case a perforating bullet\\nwound of the right parietal was accompanied by a fissure extending\\nfrom the sella turcica through the great wing of the sphenoid. The\\nexplanation offered by Longmore 3 and Von Bergmann is by moment-\\nary excessive intracranial pressure produced by the penetration of the\\nball or the bending inward of the vault.\\nFracture of the posterior clinoid processes is occasionally observed,\\nevidently produced by traction upon them by the attached tentorium\\nduring elongation of the antero-posterior diameter of the skull.\\nThe so-called ring fractures about the foramen magnum caused\\nby a fall upon the feet or buttocks are due to the impact of the skull,\\nthrough the occipital condyles, upon the upper end of the spinal col-\\numn, just as, to use Felizet s comparison, the head of a hammer is\\ndriven firmly down upon its handle by striking the other end of the\\nlatter against the ground.\\nExceptional isolated fractures of the base by direct violence have\\nbeen referred to, such as those produced by the passage of a bullet, a\\nstick, or a knife through the orbit or the mouth, fracture of the\\nethmoid by a blow upon the nose, or fracture of the temporal by the\\npressure of the condyle of the inferior maxilla in a blow upon the\\nchin. Fracture of the anterior wall of the auditory canal by the same\\ncause deserves mention because of the bleeding from the ear which it\\noccasions and which may be mistaken for that following fracture of the\\npetrous portion of the temporal bone. These fractures owe their impor-\\ntance to the associated injuries of the contents of the cranium, espe-\\ncially of the carotid artery and cavernous sinus in wounds through the\\norbit, and to the possibility of the spread of infection from the outside\\nto the interior.\\nFractures of the Internal Table. These are apparently extremely rare.\\nIn the Medical and Surgical History of the War of the Rebellion twenty\\ncases observed during the war are recorded and brief notes are given\\nof twenty-nine cases reported during the preceding two hundred years.\\nVon Bergmann describes three additional specimens. In the great\\nmajority of the reported cases the cause was a blow by a glancing\\nbullet which exposed the bone but left the outer table uninjured or\\nonly grooved or contused among the other causes are blows with small\\n1 Von Bergmann Deutsche Chirurgie, Lief. 30, p. 211.\\n2 Surg. Hist. War of the Eebellion, vol. i. p. 305. 3 Lancet, 1865, vol. ii. p. 649.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0151.jp2"}, "148": {"fulltext": "128 FRACTURES.\\nround objects, such as a hammer, a cricket-ball, a beer glass in only\\none case was the cause a fall upon the head. The alleged greater\\nbrittleness of the internal table appears to be entirely foreign to this\\nlimitation of the effect of the blow, the cause of which is the over-\\nbending of the table as described above.\\nThe fracture may be a simple fissure, one side of which is slightly\\ndepressed, or circumscribing and detaching a scale of bone, or, more\\ncommonly, a comminuted one with a marked central depression (Fig.\\n53). The dura may be torn or the small fragment may be forced\\nentirely through it. In one case the middle meningeal artery was torn.\\nIn some of the cases close examination after death has shown a slight\\nfissure of the outer table and diploe. As almost all the reported cases\\nhave ended fatally, usually in consequence of suppuration of the super-\\nficial wound and extension of the infection to the interior of the cra-\\nnium, it is possible that many other cases not thus complicated have\\nended in recovery and passed unrecognized the inference then would\\nbe that the danger to life lay not in the fracture or in the displacement\\nof a fragment but in the coexisting wound and the spread of infection\\nfrom it.\\nThe coincident injuries of the contents of the cranium are rupture of\\nthe dura and pia, laceration and contusion of the brain, rupture of\\narteries, venous sinuses, and cranial nerves, and multiple extravasations\\nof blood from the smaller vessels on the surface of the brain and ven-\\ntricles and less frequently in its substance.\\nThe dura is rarely torn except when the fragments are notably driven\\ninward, and then only to a moderate extent. Direct contusion and\\nlaceration of the brain, recognizable macroscopically, is found only\\nunder the same circumstances, but there is reason to believe that even\\nin the slighter cases it receives a contusion which makes it peculiarly\\nliable to be secondarily affected by infection proceeding from suppura-\\ntion of the adjoining scalp that is, central abscesses and cysts which\\nare probably not the remains of hemorrhages are occasionally observed,\\nthe former after suppuration of the scalp, the latter after even simple\\nfracture.\\nThe hemorrhages from the vessels of the pia which are constant in\\nthe bursting and bending fractures are attributed by Duret to\\nrupture of the smaller vessels by the sudden forced shifting of the\\ncerebro-spinal liquid under the influence of the blow and the change\\nin the shape of the skull thereby produced, by which certain portions\\nof the space in which it is contained are sharply distended and the\\nconnected vessels torn. The effects are seen not only on the surface\\nof the brain or in the subarachnoid space but also within the cortex\\nand in the ventricles, especially the fourth, and it is to these that many\\nof the cerebral symptoms are to be attributed. This also is the expla-\\nnation of the presence of the hemorrhages found at points distant from\\nthe one struck.\\nRupture of the middle meningeal artery is followed by increasing\\nextravasation of blood, usually between the dura and the skull, with\\nquite characteristic symptoms and the possibility of relief by operation.\\nRupture of the cavernous sinus, and more rarely of the carotid artery", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0152.jp2"}, "149": {"fulltext": "FRACTURES OF THE SKULL. 129\\nwhere it lies within it, is seen in some fractures of the base and espe-\\ncially in those due to the entrance of the vulnerant body through the\\norbit. Occasionally an arterio-venous aneurysm results. The other\\nsinuses may also be torn when the line of fracture crosses them, but\\nthe complication seems rarely to be important.\\nLaceration of a cranial nerve is rare the facial most frequently.\\nBut interference with function by hemorrhage into the sheath of a\\nnerve is more common.\\nPathological and Reparative Processes following Fracture.\\nThese differ radically according as infection is present or absent, and\\nwhile this difference does not exactly coincide with that of simple and\\ncompound fractures, yet the existence of an open wound in communi-\\ncation with or even near the fracture creates dangers which are almost\\nwholly absent from simple fractures.\\nRepair of the fracture is effected largely by the diploe, and although\\nthe pericranium and dura can each produce bone they usually do so to\\nonly a slight extent, and consequently an overgrown callus is rare.\\nMoreover, the osteogenetic action is rarely sufficient to close even a\\nsmall gap in the bone, so that gaps created by the removal of frag-\\nments or trephining are habitually closed only by fibrous tissue with\\nat the most a small margin of new bone along the edge of the opening.\\nDepressed fragments heal in the position in which they are left (Fig.\\n52), and large broad depressions in infants will often be diminished\\nby intracranial pressure.\\nPersistent depression in the motor area may maintain a correspond-\\ning paralysis by its local pressure upon the cortex, but the weight of\\nsurgical opinion at the present time is opposed to the belief that it has\\nany marked influence in producing irritation or other functional dis-\\nturbances, such as epilepsy. 1 It has been abundantly shown clinically\\nand by experiment that the brain readily accommodates itself to a\\nmarked diminution of the cranial capacity, and that even a sudden\\ndiminution must amount to about two cubic inches in the adult skull\\nbefore it can of itself produce permanent symptoms of general com-\\npression. In very few fractures is the depression as great as that, and\\nthe symptoms which accompany it rarely differ from those of other\\nfractures with little or no depression. That cerebral symptoms have\\nbeen promptly relieved by the removal of a depressed portion of bone\\ndoes not prove that the depression was their cause, for similar relief\\nhas often been given by the removal of portions that were not depressed\\nor in any way altered, and even by operations on distant parts of the\\nbody. The clinical grounds for the belief that the scar following\\nremoval of a portion of the skull is able to cause functional disorders\\nare as good as those that a persistent depression can do so. It seems\\nprobable that if the dura is torn, and intrameningeal adhesions thereby\\nproduced, the chances of chronic irritation and functional derangement\\nare greater than if such adhesions do not exist.\\n1 See Von Bergmann, Konig, Hutchinson, in London Hospital Keports, vol. vi. Eche-\\nverria, Arch. Gen. de Med., 1878.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0153.jp2"}, "150": {"fulltext": "130 FRACTURES.\\nContusion of the brain and laceration of its vessels and of those of\\nthe pia, in uncomplicated cases in which the patient survives the pri-\\nmary injury, heal kindly, and the cases in which they give rise to a\\nmeningitis of any extent or importance are very exceptional. The\\nextravasated blood is absorbed, or occasionally remains as a cyst.\\nOccasionally, but very rarely, suppuration takes place beneath a simple\\nfracture, just as it does in closed injuries in other parts of the body.\\nGeneralized contusion of the brain, as seen in the bursting and\\nbending fractures and in those of the intermediary group, is gen-\\nerally fatal, but not through meningitis. The lesions are more exten-\\nsive than those of most apoplexies and apparently they kill in like\\nmanner. Even in fractures of the base with rupture into the middle\\near the cases in which an intracranial infection has originated through\\nthis communication with the exterior are, in my experience, very rare.\\nIt is the cerebral lesion that kills, not the fracture or any secondary\\nresult of the fracture.\\nIn compound fractures when infection is avoided repair goes on in\\nthe same manner but if the wound suppurates the infection may spread\\nnot only to the bone but also, as in cases of phlegmon without fracture,\\nto the interior of the cranium by lymph channels, connective tissue,\\nand thrombi in the veins, and thus give rise to suppurative meningitis\\nand pyaemia. In short, the progress of a case is determined mainly\\nby the character and extent of the intracranial lesions and the pres-\\nence or absence of infection, and the fracture, as such, usually has but\\nlittle influence upon it.\\nSymptoms, Diagnosis, and Treatment.\\nThe distinction which has been made between those cases in which\\nthe fracture is an important, perhaps the principal, lesion and those in\\nwhich it is only a comparatively unimportant accompaniment of grave\\nlesions of the brain and its annexa must here be kept constantly in\\nmind. Fortunately, in the former, in which the recognition of the\\nfracture is important because of the therapeutic indications which arise\\nfrom it, the diagnosis is usually easy and in the latter, in which the\\nfracture seldom demands or can receive any direct treatment or affects\\nin any way the prognosis, and in which the practical interest is limited\\nto the intracranial injuries, the fact that the existence of a fracture can\\nonly be inferred, and not be demonstrated, does not leave us less able\\nto do all that can be done for the patient. Instead, therefore, of fol-\\nlowing the usual division of the subject fractures of the vault and\\nfractures of the base I shall use that of circumscribed fractures of the\\nvault and fissured fractures with generalized brain injury, with separate\\nconsideration of the rarer forms which lie outside of this grouping.\\nFurthermore, as diagnostic and therapeutic measures in many cases\\nrun closely together or even coincide, I shall at the same time consider\\nthe treatment.\\nCircumscribed Fractures of the Vault.\\nAs these fractures are produced by a blow from a relatively small\\nbody or from one having an edge or corner, the fracture is often com", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0154.jp2"}, "151": {"fulltext": "FRACTURES OF THE SKULL. 131\\npound and the diagnosis is made by direct inspection and palpation of\\nthe bone. In most cases there is no difficulty the fragments can be\\nseen and felt at the bottom of the wound, and it remains only to deter-\\nmine the extent of the fracture and apply the appropriate treatment.\\nIn the doubtful cases the bone has to be carefully examined in search\\nof a fissure, or its condition and the character of the violence con-\\nsidered as bearing upon the probability of a fracture of the internal\\ntable.\\nIn respect of a fissure the edge of the torn periosteum can easily be\\nmistaken for one by touch, or a cranial suture by the eye. The error\\nin the first case is so easily made, even when one is on his guard against\\nit, that the finger should not be trusted in the second the fissure can\\ngenerally be recognized by its bleeding, when fresh or when rubbed.\\nThe importance of its recognition comes from its possible indication of\\nmore extensive fracture beneath and from the frequent advisability of\\nenlarging it for thorough disinfection.\\nWhen the bone is distinctly broken and depressed, even when the\\narea is small, the depressed portion should be raised. If it proves to\\nbe only a fracture and depression of the outer table the operation needs\\nto be carried no further the wound is washed and closed. If the\\nentire thickness of the bone is broken the deeper as well as the super-\\nficial fragments must be removed. It is rarely necessary to use a\\ntrephine for this purpose, for the corner of a chisel or elevator can be\\nengaged under the edge of a fragment and thus raise it, and after one\\npiece has been removed the removal of the deeper ones is easy, for they\\ncan be grasped with forceps and withdrawn by careful traction the\\namount of internal table removed is usually greater than that of the\\nouter table. If the dura is torn, and there is no bleeding from the pia, the\\nopening in the dura should be closed with catgut sutures if there is\\nfree bleeding from the pia the wound should be packed with gauze for\\na few hours, after which the opening in the dura may be closed. The\\noverlying soft parts, including the pericranium as far as possible, should\\nbe closed with sutures, a small gauze drain being inserted and main-\\ntained for a day or two. The scalp should be shaved for some distance\\nabout the w T ound and thoroughly disinfected by scrubbing and washing\\nwith bichloride before anything is done to the bone.\\nWhen the gap left by the removal of bone is large and the wound\\nis clean a thin sheet of aluminum, celluloid, rubber tissue, or foil cut\\nto fit it may be inserted in it. The softer materials seem to answer as\\nwell as the firmer ones by leading to the formation of a thick and\\ntough cicatrix. Gold foil or rubber tissue has sometimes been placed\\nbeneath the torn dura to prevent meningeal adhesions, but either is\\nliable to induce exaggerated cicatricial formation. Freeman has lately\\nrecommended the use of the lining membrane of an egg.\\nIn small perforations, as by a nail or even by the end of a small\\nstick (the handle of a paint-brush in one of my own cases), the open-\\ning must be enlarged by the chisel or trephine for the better cleaning\\nof the deeper parts of the wound and in pistol-shot fractures this is\\nalso necessary, but only for the same purpose and for the removal of\\nthe ball, if it is within easy reach, and of small fragments. Bullets", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0155.jp2"}, "152": {"fulltext": "132 FRACTURES.\\ncan heal in, and without giving rise to late consequences and I think\\nthe risks of attempts to remove a bullet are greater than those of leav-\\ning it in place if the orifice of entry is the only communication with\\nthe exterior and can be thoroughly cleaned. If the bullet in its pas-\\nsage has opened the ethmoid cells or the frontal sinus infection from\\nthat side is probable and the bullet should be removed if possible, but\\nwhether it is removable or not the prognosis is thoroughly bad.\\nIn any of these cases there may be free hemorrhage from within the\\ncranium and escape of brain tissue, or, very rarely, a flow of cerebro-\\nspinal liquid coming from the subarachnoid space or even from the\\nlateral ventricle. Bleeding from a wounded sinus can be arrested by\\nlateral ligature or suture or by packing.\\nCircumscribed depression without wound of the soft parts may be recog-\\nnized by the finger, which when carried firmly along from the adjoining\\nbone appreciates the change in level, but a very similar sensation is\\ngiven by the swollen circular margin of a deep contusion that is, the\\nfinger passes over a firm rim to a soft central area which suggests\\ndepression. Error can be avoided by making firm pressure on the\\nhard margin and then passing slowly toward the centre the margin\\nyields under the pressure and the finger recognizes the level resistance\\nof the bone throughout.\\nIn these cases, as in the preceding, general symptoms cerebral shock\\nor contusion may be slight, transient, or absent the stunning, the\\npartial or complete unconsciousness passes and is perhaps followed by\\nnausea and headache if they are more than this they indicate gener-\\nalized lesions that bring the case into the intermediate group, to be\\nsubsequently considered. If the depression is immediately over a por-\\ntion of the motor area or a special centre there may be a corresponding\\nparalysis or abolition of function. Very rarely a fluctuating tumor\\nmay form under the skin which on puncture proves to contain cerebro-\\nspinal liquid that has escaped through the torn dura. This has been\\nobserved only in young children.\\nIn the treatment of these simple circumscribed fractures with depres-\\nsion there are two things to be considered the effect upon the brain and\\nmeninges if the depression persists, and the risks involved in relieving\\nit. The reasons have been given above for the belief that persistent\\ndepression is not often responsible for the late functional disturbances\\nthat have been attributed to it, and that consequently it does not, in\\nthe absence of special indications, imperatively require relief. But,\\non the other hand, although it is properly urged that the unbroken\\nskin is a safer protection against infection than the strictest asepsis\\n(Konig), yet the danger incurred in making an opening in the vault of\\nthe cranium, especially if the dura is not wounded, is so slight that I\\ncannot criticise those who act upon the conviction that it is less than\\nthose of persistent displacement even when the disadvantages of the\\nresultant gap are taken into account. This applies only to small areas\\nof depression and the removal of only a small portion of bone. The\\nspecial indications referred to, which call for operation, are found in\\nthe evidences of localized pressure or of hemorrhage from a branch of\\nthe middle meningeal artery. (See below.) The value of a localized", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0156.jp2"}, "153": {"fulltext": "FRACTURES OF THE SKULL. 133\\nsvmptom (monoplegia, etc.) is much greater in a fresh injury than\\nwhen it occurs after the lapse of a few days, for in the latter case it\\nmav be due to the spread of inflammation from a primary focus at\\nsome little distance from the centre which corresponds to the paralysis.\\nFissured Fractures with Generalized Brain Injury.\\nThese, let me repeat, are the bending and bursting fractures\\nproduced by violence acting broadly upon the skull, changing its shape\\ntemporarily beyond the limits of its elasticity, and causing contusion\\nof the brain with larger or smaller hemorrhages especially upon its\\nsurface. In the great majority the fracture occupies or extends to the\\nbase of the skull, and the injury is hence generally spoken of as fracture\\nof the base. The principal injury is the lesion of the brain, and the\\nassociated fracture is mainly of importance as indicating that the injury\\nto the brain is probably extensive and grave. The opinion long held\\nthat fractures of the base were necessarily fatal has been shown to be\\nexaggerated, but yet the percentage of mortality is high, and similarly\\nproduced fractures of the vault have a like gravity. The chief symp-\\ntom of the brain injury is unconsciousness, more or less complete, with\\nthe history of a blow, irregularity of the pupils, and a moderate rise\\nof temperature. The high temperatures which have been spoken of\\nas constant, 105\u00c2\u00b0 to 107\u00c2\u00b0 F. (Phelps), I have seen only in the few hours\\nbefore death. Paralytic symptoms and symptoms connected with the\\ncirculation and respiration depend upon the portions of the brain and\\nmedulla involved in the injury.\\nThe differentiation is with other forms of coma, especially the alco-\\nholic, and is often extremely difficult or even impossible, as when\\nalcoholism coincides with trauma. The points of difference (with\\nmany exceptions) are that in alcoholic coma the temperature is not\\nraised, the unconsciousness is less deep, the pupils are equal and respon-\\nsive. It must always be remembered that the two conditions may\\ncoexist.\\nThe symptoms belonging to the fracture itself are hemorrhages,\\necchymoses, occasionally a watery discharge from the ear or nose, and\\ndeafness of the ear of the affected side.\\nHemorrhage from the ear, nose, or mouth is frequent, that from the\\near being almost pathognomonic of a fracture through the petrous por-\\ntion of the temporal bone it is usually slight but may be profuse.\\nKonig refers to a case in which the flow from the middle ear through\\nthe Eustachian tube into the mouth was so abundant that he felt obliged\\nto do tracheotomy to prevent suffocation. Bleeding from the ear which\\nmay be mistaken for that of a fracture of the base may be due to rup-\\nture of the membrana tympani or to injury of the external auditory\\ncanal by a blow upon the chin which has forced the condyle of the jaw\\nbackward, or even to a fissure of the vault extending to the mastoid\\nprocess.\\nEcchymosis at certain points, not due to direct contusion, is signifi-\\ncant of fracture. The most common is that beneath the ocular con-\\njunctiva, spreading to that of the lids and then to the skin of the latter", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0157.jp2"}, "154": {"fulltext": "134 FRACTURES.\\nit is most constant and marked in fractures of the orbital plate and\\nsphenoid. A slight ecchymosis behind the ear is often found after a\\nday or two.\\nA watery discharge from the ear after fracture of the base is not\\ninfrequent and is sometimes very profuse (in one case 63 ounces in\\nfour and one-half days). Four varieties differing in the amount and\\ncharacter of the discharge have been observed (1) The flow is abun-\\ndant and prolonged, the liquid contains a large proportion of chloride of\\nsodium and but little albumin, and is then doubtless the cerebro-spinal\\nliquid of the subarachnoid space and sinuses escaping through frac-\\nture of the internal auditory canal and rupture of the tympanum. (2)\\nThe flow is similar, but the liquid is highly albuminous and without chlo-\\nride of sodium autopsy in some cases has shown a fracture through the\\nmiddle and internal ear but not through the internal auditory canal\\nthe liquid is probably lymph coming from the large arachnoid lymph-\\nspace which normally communicates with that occupied by the peri-\\nlymph of the labyrinth or liquid Cotunnii. (3) The flow is abundant\\nand albuminous, becoming scanty and purulent probably an inflam-\\nmatory discharge from the surface of the cavity of the tympanum.\\n(4) The flow is scanty, appears late, is albuminous and reddish, and is\\nprobably the serum of extra vasated blood. 1\\nDeafness of the ear of the affected side is due to injury of the middle\\nor internal ear or of the acoustic nerve in its passage through the bone.\\nParalysis of other cranial nerves is occasionally observed, the result\\nof direct injury of the nerve or of pressure upon it by extra vasated\\nblood. Paralysis of the limbs is caused by intracranial hemorrhage.\\nSlowing of the pulse and irregularity of the respiration indicate hem-\\norrhage in the medulla.\\nFissured fractures of the vault are sometimes recognizable by a differ-\\nence in the level of the two sides and even in rare cases by the inde-\\npendent mobility of the two parts of the cranium. Auscultatory\\npercussion has been alleged to be a means of recognition of a fissure,\\nbut I have found it wholly untrustworthy. The general symptoms are\\nthe same as when the fracture occupies the base and are dependent upon\\nsimilar lesions of the brain.\\nEmphysema of the scalp is a rare symptom and is due to the escape\\nof air into it after fracture opening the mastoid, frontal, or ethmoid\\nsinuses.\\nThe treatment of these fractures is medicinal and expectant absolute\\nquiet, light diet, laxatives, and cold to the head if indicated by rest-\\nlessness, headache, or other symptoms of cerebral irritation. In frac-\\ntures of the base with bleeding from the ear a light plug of iodoform\\ngauze may be placed in the external meatus, but more active measures\\nto disinfect this region seem to me wholly uncalled for in view of the\\nfact that a route for infection from the mouth through the Eustachian\\ntube remains and cannot be protected.\\nWhen the fracture involves the vault and is compound the wound\\nshould be thoroughly cleansed, and to this end it is proper to chisel\\n1 For interesting details of these symptoms the reader is referred to Hewett, in Holmes s\\nSystem, vol. i. Von Bergmann, in Deutsche Chirurgie, Lief. 30, and Eoswell Park.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0158.jp2"}, "155": {"fulltext": "FRACTURES OF THE SKULL. 135\\naway the sides of the fissure, but I do not think it judicious to enlarge\\nthe wound in the scalp in order to follow up the fissure and treat it\\nthus throughout its entire length. The interference is solely for disin-\\nfection, and in fresh cases we may be confident that infection has not\\npassed much beyond the limits of the external wound. Depression of\\none side of a fissure of the vault is not a justification for making an\\nincision through the unbroken skin.\\nThe same principles apply to the treatment of the intermediary\\ngroup extensive comminuted fractures with marked general cerebral\\nsymptoms. The important lesion is that of the brain, and it is not\\nprobable that good can be got by removal of fragments or relief of\\ndepression that will compensate for the risk incurred in dividing the\\nunbroken scalp. Possibly the relief of tension by draining away the\\nexudate through an incision may be an important advantage, but this\\nhas not been demonstrated. If the fracture is compound the wound\\nmust be cleaned and protected, and advantage may be taken of it to\\ndo whatever the condition of the bone requires, but this cannot be\\nexpected to have any important influence upon the progress and out-\\ncome of the injury.\\nCertain exceptional forms of injury require separate description.\\nPossible Fracture of the Internal Table.\\nWhen the skull has been contused (compound) by a blow of the\\nkind known sometimes to produce fracture of the internal table, such\\nas a glancing bullet or a sharp blow by some small object, there can be\\nno serious objection to trephining in order to insure cleanliness and\\ndetermine the condition of the internal table, if care is taken not to\\nopen the dura and even when the skin is not broken, if well-marked\\nsymptoms of localized cerebral injury are present, a similar interference\\nwould, I think, be justifiable as an attempt to relieve a local and\\nlimited injury. But, I repeat, the known instances of fracture of the\\ninternal table alone are very few, and almost all of them compound\\nand fatal by infection through the scalp wound. If it is claimed that\\nthere are many simple (not compound) ones which pass unrecognized\\nbecause the patient recovers, it must be added that that then is proof\\nthat an operation is not always necessary. The diagnosis of probable\\nfracture of the internal table has been not infrequently made for no\\nbetter reason than that no other could be positively made. Such mis-\\ntakes would be less frequent and officious treatment Avould be rarer if\\nthe fact was fully appreciated that early general cerebral symptoms\\nmean generalized cerebral lesions, and that such cannot be relieved by\\nlocal measures. For the latter there must be local indications.\\nRupture of the Middle Meningeal Artery.\\nRupture of the middle meningeal artery or of one of its branches by\\na fracture crossing its course, or even without fracture, is a not infre-\\nquent injury of great importance and requiring immediate operative\\nrelief. As the vessel lies in a groove on the inner surface of the bone", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0159.jp2"}, "156": {"fulltext": "136 FRACTURES.\\nand is covered by the dura, the hemorrhage commonly takes place\\nbetween the dura and the bone, stripping up the former sometimes for\\na considerable distance and causing symptoms of local and sometimes\\nof general compression. Usually there is an interval, half an hour to\\nthree hours (occasionally very much longer, even eight days in one of\\nKonig s cases), between the blow and the development of the symp-\\ntoms, an interval during which the patient may seem entirely well but\\nwhich in other cases may be masked by the symptoms of cerebral shock\\noccasioned by the primary violence the recognition in the latter case\\nmust then come through the steady increase in the symptoms and fre-\\nquently the limited paralyses caused by pressure upon portions of the\\nmotor area. The pulse becomes slow (pulse of pressure), and the\\npupils unequal, that on the side of the injury being usually dilated.\\nThe paralyses, of course, are on the opposite side of the body if lim-\\nited they indicate a hemorrhage between the dura and the bone if\\ndiffuse, a hemorrhage into the arachnoid space.\\nLeft to itself the injury terminates fatally in the great majority of\\ncases. Relief must be given by removal of the extravasated blood\\nand arrest of the bleeding. The difficulty may be to determine the\\npoint at which the trephine is to be applied to meet the indications; the\\nguides thereto are furnished by external evidences of injury, the seat\\nof the fracture, the situation of the centres corresponding to the paral-\\nyses, the anatomical relations of the artery, and the relative frequency\\nof hemorrhage at different points. The artery runs from the foramen\\nspinosum across the middle fossa and upward along the greater wing\\nof the sphenoid and divides into two branches, of which the anterior\\nruns forward near the outer part of the lesser wing of the sphenoid to\\nbe distributed under the frontal and anterior portion of the parietal\\nthe posterior runs horizontally backward across the base of the petrous\\nportion of the temporal to the posterior inferior angle of the parietal\\nand the occiput. The most frequent seat of rupture and hemorrhage\\ncorresponds to the lower anterior portion of the parietal bone (anterior\\nbranch of the artery) the next, but much less frequent, corresponds\\nto the lower posterior portion of the parietal and the adjoining por-\\ntion of the occipital (posterior branch).\\nThe size of the extravasation varies greatly I have seen one of less\\nthan an ounce directly above the ear in which the symptoms -stupor\\nand limited paralysis were well marked and which was cured by\\noperation.\\nIf the exact position of the extravasation cannot be determined and\\nif no indication is furnished by a line of fracture, an opening made near\\nthe point where the frontal, parietal, and temporal bones meet, say two\\nfinger-breadths above the zygoma and an inch behind the external\\nangular process of the frontal, will expose the most frequent seat and\\nalso the anterior branches of the artery. An opening about three inches\\ndirectly behind this will expose the posterior region.\\nThe opening should be made with the trephine or by removing a\\nbroken fragment, and if the extravasation is not at once encountered\\nthe dura should be carefully separated from the bone in different direc-\\ntions in search of it. When found the blood should be picked or", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0160.jp2"}, "157": {"fulltext": "FRACTURES OF THE SKULL. 137\\nwashed out if clotted, and bleeding points should be secured if possi-\\nble, or, failing that, the wound should be packed in their neighborhood.\\nThe artery is often difficult to secure, especially when its point of rup-\\nture is not within the opening made by the trephine. Temporary\\npressure with the linger, an artery clamp, or even a pad of gauze has\\nbeen successfully employed. In all my own cases the bleeding has\\nstopped spontaneously before the removal of the clot.\\nPerforating Fractures of the Base through the Orbit.\\nPerforating fractures of the base through the orbit are extremely grave\\nand rarely accessible to treatment, the important lesion being usually\\nthat of the brain. In the extent of these lesions and their consequences\\nthe variations are very great. I have seen the breech-piece of a shot\\ngun, about six inches long, driven into the brain through the nose and\\norbit and carried there, unrecognized, for more than two months, the\\npatient recovering sufficiently to take a railway trip to the city in order\\nto have the deformity of his face relieved and in another a single bird-\\nshot (No. 7) which entered just above the tendo oculi and passed\\nthrough the lower part of the frontal lobe directly back nearly to the\\nSylvian fissure caused death in a week without any evidence of inflam-\\nmation and with only a minute intracranial hemorrhage. Sometimes\\nan important feature is the wounding of the cavernous sinus or of a\\nlarge artery. Another, and frequent one, is the infection of the deeper\\nportion of the wound by the vulnerant body even if the superficial\\nportion of the wound is small and heals kindly. The common cause\\nis the passage of a small body a bullet, cane, pencil through or even\\nbetween the eyelids. I have seen two cases in which a slender stick\\n(the end of an umbrella in one) had thus penetrated and had broken\\noff; both patients died, one after removal to another hospital and opera-\\ntion there by the large omega-flap to expose the base of the brain, pro-\\nfuse venous bleeding which could not be arrested was encountered and\\nthe patient died shortly after removal from the table.\\nSimilar wounds through the nose and mouth are even more exposed\\nto infection.\\nSummary.\\nThe principles of treatment may be thus summarized Danger to life\\nand function comes mainly from generalized contusion of the brain,\\nlarge or small intracranial hemorrhages, and intracranial infection\\nthrough an open wound the fracture itself, as such, even when asso-\\nciated with depression, is rarely a factor in the fatal result,\\nAgainst generalized cerebral injury the only treatment is medical\\nrest, sedatives, laxatives, cold to the head. Against infection we have\\nprevention and disinfection after it is fairly established disinfection\\nand drainage have a restricted availability. Consequently, fractures\\nof the base and fissured fractures of the vault not compound do not\\nrequire operation. When compound, the wound may be enlarged suf-\\nficiently to permit disinfection of the area already exposed to infec-\\ntion; and for the purpose of this disinfection a fissure may be enlarged,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0161.jp2"}, "158": {"fulltext": "138 FRACTURES.\\nbut this enlargement should not be carried much beyond the limits of\\nthe original wound.\\nDepression of a portion of the skull below its normal level is not a\\ncondition which always needs to be corrected. The associated condi-\\ntions which indicate its correction are limited paralyses due to pressure\\nof the depressed portion upon the underlying portion of the brain.\\nConditions which justify its correction are an associated wound of the\\nscalp and, in simple fractures with a well-defined small area of depres-\\nsion, the absence of symptoms of generalized injury of the brain and\\nconsequently of fissures radiating from the depressed area which\\nwould favor the extension of infection if it should occur in the wound\\nmade for the relief of the depression.\\nEpidural hemorrhage (rupture of the middle meningeal artery)\\nrequires operation for the removal of the extravasated blood and the\\narrest of hemorrhage.\\nA monoplegia promptly following a blow upon the head is an indi-\\ncation for the application of the trephine over the corresponding cor-\\ntical centre, with the expectation of thereby removing a clot or a\\nfragment which is making pressure on that portion of the brain.\\nLate functional cerebral disturbances (epilepsy, etc.) appear to be\\nso much more closely connected with injury of the brain and meninges\\nwhich cannot be corrected by a primary operation than with traumatic\\nirregularities on the inner surface of the skull which can be thus cor-\\nrected, that an early operation for their prevention is not indicated.\\nSevere meningeal or cortical inflammation, not connected with an\\nexternal wound, is so rare that operation for its prevention is not indi-\\ncated, and is, indeed, more likely to produce it than to prevent it.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0162.jp2"}, "159": {"fulltext": "CHAPTEE XL\\nFKACTUEES OF THE VERTEBRAE.\\nFractures of the vertebrae have this in common with fractures of\\nthe skull, that most of their importance depends upon the associated\\ninjury of the nerve-centres and trunks contained within their canal,\\nbut they have in addition the importance due to the function of the\\nspine as a support for the head and trunk. Upon the integrity of this\\nsupport depend not only the power of locomotion, but also grace of\\ncarriage and dexterity in the use of the limbs.\\nThe spinal cord, occupying the centre of the vertebral column, is\\nefficiently protected against any external violence that is not sufficient\\nto break the bones that constitute the latter, or the ligaments and mus-\\ncles that bind those bones together and the column itself is constituted\\nin a manner that combines elasticity and mobility with the necessary\\nfirmness and rigidity. The bodies of the vertebrae, increasing in size\\nfrom above downward in correspondence with the variations in the\\nweight and strain which the different ones are called upon to bear, are\\ncomposed of spongy tissue and separated from each other by the elastic\\nintervertebral cartilages, and prevented from changing their positions\\nby the interlocking of the articular processes upon the sides. The\\ngeneral form of the column is that of a long slender cone with a double\\nantero-posterior curve, and its component parts are strongly bound\\ntogether by ligaments and muscles allowing a range of motion which,\\nwhile small between each pair of vertebrae, is in the aggregate consid-\\nerable. Mechanically, therefore, the spine is exposed to fracture by\\ndirect violence, like other bones, and by indirect violence through\\nexaggeration or straightening of its normal curves.\\nIn the displacements following fracture the corresponding joints may\\nbe dislocated, and as in dislocation there may be associated fracture, and\\nas the symptoms in the two forms of injury are in many respects the same,\\nthey are sometimes grouped as fracture-dislocations of the spine.\\nFractures of the vertebrae are relatively rare, 0.5 per cent, in my\\nstatistics (Chapter I.). Gurlt collected 270 cases, with 444 fractures,\\nand found that fractures of the cervical aud dorsal vertebrae are about\\nequally frequent, 178 and 184 respectively, while those of the lumbar\\nvertebrae, 82, are much less common that the fatal cases of fracture\\nof the cervical vertebrae are, however, considerably more numerous,\\nactually and relatively, than those of the two other regions that the\\nfifth and sixth cervical, the last dorsal, and the first lumbar are more\\nfrequently broken than any of the others and that it is common in\\nfractures of the cervical and dorsal regions for more than one vertebra\\nto be broken at the same time. They are extremely rare in childhood\\nand old age, and relatively infrequent in women.\\n139", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0163.jp2"}, "160": {"fulltext": "140\\nFRACTURES.\\nThe part most frequently fractured is the body of the vertebrae\\nthat is, in about two-thirds of all cases, or in more than half of the\\nfractures of the cervical vertebrae, in about seven-eighths of those of\\nthe dorsal vertebrae, and in about all those of the lumbar vertebrae.\\nOr, in general terms, fractures of the bodies of the vertebrae begin at\\nabout the middle of the cervical region and increase in frequency down-\\nward. Simultaneous fracture of two or more vertebrae is common in\\nthe cervical and upper dorsal regions, less common in the lower dorsal,\\nand rare in the lumbar region. Fracture of one or more of the ver-\\ntebral processes either of the same or of adjoining vertebrae is common.\\nPathology.\\nThe fracture of the body of a vertebra may be complete or incom-\\nplete the line of fracture may extend only partly through it or en-\\ntirely across it, or it may be broken into several fragments, or com-\\npressed, or impacted. The line of fracture, if single, may be vertical,\\nhorizontal, or oblique in any direction the first being found almost\\nexclusively in the cervical and upper dorsal regions, the two latter\\nand multiple fractures occurring everywhere. The transverse and\\noblique fractures lie, as a rule, nearer the upper than the lower\\nFig. 52.\\nFig. 53.\\nTransverse fracture of vertebra.\\nDisplacement of the vertebrae causing compression\\nof the spinal cord.\\nborder of the bone, and may pass from the upper to the anterior sur-\\nface, leaving the posterior and lower surfaces unbroken, and in these\\ncases the upper fragment preserves its relations to the overlying ver-\\ntebra and is displaced with it forward and downward, producing a\\nchange in the long axis of the spine characterized by an angle having\\nits apex directed backward at the seat of fracture. This displacement\\nnarrows the antero-posterior diameter of the spinal canal and lacerates", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0164.jp2"}, "161": {"fulltext": "FRACTURES OF THE VERTEBRA.\\n141\\nFig. 54.\\nor compresses the spinal cord within it. If the line of fracture is\\noblique, and if fracture or dislocation of the articular processes is asso-\\nciated with it, the displacement is inclined to the corresponding side\\neither directly or by rotation.\\nCompression of the body of a vertebra is found either in combina-\\ntion with comminuted fracture or alone, and involving one or several\\nvertebrae. It is apparently caused by\\nforcible forward flexion, in which either\\nthe posterior portions of the vertebrae\\nmust separate from each other or the\\nanterior portions must approximate by\\ncondensation of the intervertebral disks\\nor of the bone.\\nThe compression may be so extreme\\nthat the intervertebral disks above and\\nbelow the affected vertebra are brought\\ninto contact with each other in front,\\nthe substance of the bone being partly\\ncompressed and partly forced out upon\\nthe sides or behind into the spinal canal\\n(Figs. 55 and 56), compressing the cord.\\nWith this compression may be associ-\\nated fracture or fissure of the body, and\\nespecially fracture of the processes of\\nthe same or the adjoining vertebra.\\nanterior portion of the body may be produced by splintering of part\\nof the bone or by impaction of one fragment into another lying above\\nCompression of the last dorsal vertebra.\\nThe same shortening of the\\nFig. 55.\\nFig. 56.\\nFracture with compression of the third and fourth lumbar vertebras.\\nor below it. This latter condition was found in four of Gurlt s cases,\\nthree times in the twelfth dorsal and once in the first lumbar vertebra.\\nFracture of the vertebral arches, according to Gurlt, is found in about\\nhalf the cases of fracture of the cervical vertebrae, and only in one-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0165.jp2"}, "162": {"fulltext": "142 FRACTURES.\\nseventh of those of the dorsal, and one-eighth of those of the lumbar. 1\\nHe attributes the frequency of this form of fracture in the cervical\\nspine to the comparatively greater breadth and less height of the arch\\nand to the absence of that protection which is furnished in the dorsal\\nand lumbar regions by the larger and stronger spinous, transverse, and\\noblique processes. When the arch is broken on each side the interme-\\ndiate portion bearing the spinous process may be driven into the spinal\\ncanal and cause fatal laceration or compression of the cord. Gurlt s\\nstatistics contain six such cases, aifecting the fifth, sixth, and seventh\\ncervical vertebrae.\\nThe spinous processes are broken most frequently at those points\\nwhere they are longest and thinnest, nearly one-fourth of the cases\\noccurring in the cervical spine, more than half in the dorsal, and\\nabout one-eighth in the lumbar and often several adjoining ones\\nare broken at the same time. In the dorsal region this fracture is\\nusually found only in combination with fracture of the body of one\\nof the vertebrae above or below it. Isolated fracture of a spinous\\nprocess may occur as the result of direct violence, or of muscular\\naction, and the displacement is either directly downward or to one\\nside.\\nFracture of the transverse or articular processes occurs in combina-\\ntion with other fractures in about one-sixth of all cases, but is rare\\nexcept in such combination. In the few instances in which it has\\noccurred alone it was the result of gunshot injury. As a complication\\nof other fractures the proportion of its occurrence for the transverse\\nprocess is greatest in the cervical and next in the lumbar and dorsal\\nregions for the articular processes it is greatest in the cervical and\\nsmallest in the lumbar. Fracture of a transverse process of a dorsal\\nvertebra may lead to fracture of the rib which articulates with it, and\\nfracture of the transverse process of a cervical vertebra may seriously\\ninjure the vessels contained in the vertebral canal. Fracture of an\\narticular process exposes to dislocation of the vertebra with all its\\naccompanying dangers.\\nThe ligaments which bind the different vertebrae together are torn\\nin fracture to an extent which varies with the severity of the injury\\nand the degree of the displacement, and the intervertebral disks may\\nbe torn, displaced, or compressed. In rare cases the injury may be\\nconfined to the ligaments and disks real dislocation or diastasis with-\\nout fracture although the distinction cannot be made during life.\\nThe muscles and tendons, too, are usually torn, especially those lying\\nnearest the bones and ligaments and extravasations of blood form as\\nafter other fractures and extend along the cellular interspaces between\\nthe muscles and in front of the spine, sometimes into the posterior medi-\\nastinum, and sometimes into the retroperitoneal tissues surrounding\\nthe kidneys and the iliacus and psoas muscles. Ecchymoses may appear\\non the face or chin after fracture of the cervical vertebra?, and as low\\neven as the loins in other cases.\\nThe spinal cord, the diameter of which is considerably less than that\\n1 For cases of doubtful character in the lumbar vertebrae, see section on Course and Ter-\\nminations.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0166.jp2"}, "163": {"fulltext": "FRACTURES OF THE VERTEBRAE. 143\\nof the canal in which it lies, is suspended within the dura mater, which\\nis itself loosely connected with the bones and separated from direct con-\\ntact with them in most places by a rich venous plexus. The medul-\\nlarv portion of the cord ends at the first or second lumbar vertebra, and\\nits lower portion is enveloped by the numerous nerve trunks which\\npass downward to form the cauda equina and the lumbar and sacral\\nplexuses. The cord is injured directly only when the lumen of the\\ncanal is considerably encroached upon by the displacement of a frag-\\nment or of a vertebra, but it can be compressed by extravasated blood\\nor by inflammatory exudations, or torn by elongation. I have seen\\nit so injured in fracture of both laminae of the sixth cervical without\\ndisplacement, by anterior flexion of the neck, as to cause immediate\\nparaplegia and death in a week. Occasionally the cord is penetrated\\nby a sharp fragment, but usually the dura mater is untorn and the cord\\nis crushed between the anterior portion of one fragment or vertebra,\\nusually the lower, and the posterior portion of another, usually the\\nupper. This crushing presents all degrees, from a slight flattening to\\ncomplete disorganization, and apparently the medullary portion is more\\neasily and permanently injured and destroyed than the nerve-fibres in\\nthe columns beside it.\\nHemorrhage, Hsematomyelia. Hemorrhage, without division of the\\ncord, mav be extra- or intra-dural, or within the substance of the cord\\n(hsematomyelia). Hemorrhage outside the cord spreads upward and\\ndownward within the canal and produces changes and symptoms by\\npressure upon the cord.\\nHaematomyelia is apparently caused by forcible elongation of the\\ncord in hyperflexion or extension of the column, with or without recog-\\nnizable lesion of the ligaments or bones it is seen almost exclusively\\nin the lower cervical and upper dorsal region, but sometimes near the\\njunction of the lower dorsal and lumbar regions. The condition, first\\npointed out by Thorburn and Minor, of Moscow, about 1890, has\\nbeen recently studied in detail by Bailey l and Bolton. 2 The hemor-\\nrhage takes place in the gray matter of the cord and may be very\\nclosely limited to it, spreading upward and downward in it through\\ntwo, three, or even more segments. If the lesion is more severe the\\nhemorrhage may extend into the white columns as a clot, or appear\\nthere as punctate extravasations. If the patient survives the blood\\nis absorbed, leaving cavities within the cord which contain a viscid\\nliquid and tend toward obliteration by formation of connective tissue.\\nThe elements of the gray matter, cells and fibres, which are injured by\\nthe hemorrhage appear to be incapable of repair with restoration of\\nfunction, but pressure-effects upon adjoining parts may be, and ap-\\nparently frequently are, recovered from. Consequently, the recogni-\\ntion of the condition is of great importance in prognosis and in deter-\\nring from active surgical interference. Apparently most of the cases\\nof injury to the neck which recover after having presented symptoms\\nof severe injury to the cord are cases of hsematomyelia. In a notable\\nnumber of them the injury has been caused by diving into shallow\\n1 Bailey Med. Eecord, Nov. 19, 1898. 2 Bolton Annals of Surg., Aug., 1899.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0167.jp2"}, "164": {"fulltext": "144 FRACTURES.\\nwater, the head being thrown forcibly back to avoid contact with the\\nbottom.\\nEtiology.\\nThe immediate causes are muscular action and external violence.\\nThe former is very rare and acts either by a direct pull of the muscle\\nupon the process to which it is attached or by the momentum given\\nby the head in sudden dorsal flexion of the neck or rotation of the\\nhead. The most frequent examples of the latter (producing either\\nfracture or dislocation of the cervical spine) have been in cases in\\nwhich the patient has dived into shallow water and has thrown his\\nhead backward to escape contact with the bottom.\\nThe commonest cause is the forcible bending of the spine in a fall\\nor, less frequently, by the weight of a falling object or by the com-\\npression of the body in a narrow space, as in driving under an archway\\n(indirect fracture). The relative frequency of the injury at the lower\\npart of the cervical spine and at the junction of the dorsal and lumbar\\nsegment seems to be associated with the fact that at these points the\\nmore flexible and the more rigid portions of the column meet, such\\nmeeting points being specially liable to break in all combinations of\\nflexible and rigid bodies.\\nFractures by direct violence are infrequent and are usually found in\\nthe posterior portion of the vertebra.\\nSymptoms and Diagnosis.\\n(See also Dislocations of the Vertebra.)\\nThe symptoms of fracture of the spine vary with the position and the\\nportion of the vertebra involved, and therefore need a separate and\\ndetailed consideration in connection with the different groups of frac-\\ntures. But there are certain general symptoms common to most which\\nmay first be mentioned. After the first shock of the injury, which usually\\npasses off without permanent impairment of the intelligence, the patient\\ncomplains of a localized pain at the seat of fracture increased by manip-\\nulation or movements. There is usually a recognizable deformity con-\\nsisting of a change in the direction of the spine, a more or less marked\\nangular projection backward with or without swelling of the surround-\\ning soft parts crepitus can sometimes be made out by the surgeon, but\\nmore commonly it is appreciable, if at all, only by the patient himself\\nwhen his body is moved. The most important and constant symptom\\nis paralysis, motor and sensory, more or less complete, of the limbs and\\nthe portion of the body lying below the fracture. If complete its\\nupper limit is usually sharply defined by a line crossing the trunk and\\ncorresponding to the adjoining limits of the regions supplied by the\\nnerves that leave the column immediately above and below the point\\nat which the cord has been injured. The consequences of this paralysis,\\nif it involves the abdominal muscles, bladder, and rectum, are reten-\\ntion of urine and feces, followed by incontinence of one or both, by\\nalkaline fermentation of the former, and cystitis. Respiratory diffi-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0168.jp2"}, "165": {"fulltext": "FEACTURES OF THE VERTEBRAE. 145\\nculties, sometimes severe enough to cause death, appear when the frac-\\nture involves the upper portion of the spine, the result of the paralysis\\neither of the abdominal muscles or of the diaphragm, or of vasomotor\\ninjury. There is also a great tendency to sloughing at all points of\\npressure within the paralyzed region, especially over the sacrum and\\ntrochanters and along the back. The sloughs appear promptly, some-\\ntimes within two or three days, are usually symmetrical, and often\\nhasten death even if they are not its immediate cause.\\nParalysis is, of course, only a symptom of injury to the cord and\\nmav follow violence that has caused neither fracture nor dislocation.\\nThus, a diastasis of two vertebrae, followed by immediate return to\\ntheir normal relations, may cause hemorrhage into the canal or may\\neven injure the cord by elongation and thus cause paralysis. A paral-\\nysis appearing shortly after an injury, and increasing, generally indi-\\ncates hemorrhage into the canal, but I have seen it caused by displace-\\nment, with pressure, occurring during the transfer of the patient to\\nhospital, the condition being shown by autopsy.\\nExtension of paralysis indicates hemorrhage or an ascending mve-\\nlitis.\\nIn haematomyelia there is immediate motor paralysis (usually para-\\nplegia, but occasionally hemiplegia, when only one gray column is\\naffected) which is transient except for those muscles whose spinal\\nnuclei in the gray matter have been destroyed by the hemorrhage.\\nThus, when the lesion is situated in the lower cervical region the paral-\\nysis of the lower limbs and the sphincters promptly disappears, but\\nthat of the muscles of the forearm and hand remains in part. The\\ninterference with sensation is constant and characteristic there is loss\\nof sensibility to heat and cold (thermo-anaesthesia) and usually insensi-\\nbility to pain (analgesia) also, but tactile sensibility is not affected.\\nBailey says the distribution of these disturbances is the same as that\\nof the anaesthesia of a corresponding transverse lesion of the cord, but\\nthat it may present the Brown-Sequard type, namely, motor paralysis\\nof one arm and leg with loss of pain-sense and temperature-sense in\\nthe arm and leg of the opposite side. The tendency is toward\\nimprovement, and sometimes recovery is complete. The reflexes are at\\nfirst lost, then slowly regained.\\nIn complete transverse injury there is permanent complete paraplegia\\nand loss of all kinds of sensation and of the reflexes.\\nIn incomplete transverse injury there is irregular paraplegia, the\\nsensibility to pain, touch, and temperature may persist or be regained\\nin limited areas below the lesion, and the reflexes return and become\\nexaggerated.\\nPriapism, more or less complete, was observed, according to Gurlt,\\nin 31 of 96 cases of fracture of the cervical and two upper dorsal ver-\\ntebrae, 16 times in 133 cases of fracture between the third dorsal and\\nsecond lumbar vertebrae, and never in fracture below the latter. It\\nappears promptly, usually on the first or second day, and seldom lasts\\nlonger than a fortnight. Notwithstanding the insensitiveness of the\\npenis it may be caused or increased by the use of the catheter. On the\\nother hand, in one case the erect organ became relaxed as soon as the\\n10", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0169.jp2"}, "166": {"fulltext": "146 FRACTURES.\\ncatheter had passed over half the length of the urethra. Ejaculations\\nare very exceptional, there being only four instances in Gurlt s collec-\\ntion, all of them in cases of fracture of the cervical spine.\\nFracture of Atlas and Axis.\\nThe intimate relations existing between these two bones and the\\nmedulla oblongata, and their position above the roots of the phrenic\\nnerve as well as above those of the other nerves supplying other\\nmuscles which aid in respiration, make their injury especially danger-\\nous, and have probably led to the generally received opinion that their\\nfracture is, as a rule, immediately fatal. Gurlt s cases show, however,\\nthat this opinion is not correct, for in the eleven in which the nature\\nof the injury was demonstrated by the autopsy, death occurred imme-\\ndiately in only two, and in only two others within an hour after the\\ninjury was received. In the other cases the patients survived for a\\nconsiderable length of time, thirteen days in one, although some of\\nthem at the last died suddenly, apparently by displacement of the ver-\\ntebrae due to incautious movements. The fractures were all caused by\\nexternal violence, sometimes slight, as a fall from the bed while trying\\nto reach down to the floor.\\nThe parts broken in ten of these eleven cases were the odontoid\\nprocess alone once the odontoid process and posterior arch of the atlas\\nthree times the posterior arches of the\\nFig. 57. atlas and axis three times the poste-\\nrior arch of the axis alone once the\\nspinous process of the axis twice. In\\nsix of the cases there was associated\\nfracture of other cervical or dorsal ver-\\ntebrae, and in no case was the trans-\\nverse ligament torn. Figure 57, taken\\nfrom a specimen in the museum at\\nBraunschweig, shows a fracture of the\\nsuperior articular surface of the axis.\\nThe patient was twenty-four years old,\\nand died in a few hours after falling\\nout of a wagon upon his head.\\nThe symptoms of this fracture are\\nso variable and so indefinite and have\\nFracture through the superior articular j.\\nsurfaces of the axis. (Gttblt.) so much in common with simple dis-\\nlocation of one bone upon the other,\\nor of the atlas upon the skull, that the diagnosis is extremely diffi-\\ncult, On the one hand, the patient may die instantly on the other,\\nhe may survive a longer or shorter time, either completely paralyzed\\nor presenting no important symptoms, and then die suddenly by dis-\\nplacement of the fragments or gradually by extension of the symp-\\ntoms, or in consequence of other injuries, or, if the diagnosis in some\\nsuch cases may be accepted, may even get well. The symptoms of\\nlocal pain and stiffness of the neck are too indefinite to be of any ser-\\nvice, and paralytic symptoms may be entirely absent, as in Gurlt s", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0170.jp2"}, "167": {"fulltext": "FRACTURES OF THE VERTEBRA. 147\\nsecond case, where the patient walked for two hours after the accident to\\nreach home and developed no paralysis until the following day. Death\\ntook place suddenly on the eighth day, and the autopsy showed fracture\\nof both arches of the atlas and of the odontoid process.\\nThe symptoms in those of Gurlt s eleven cases which survived long\\nenough to present any, or in which any are recorded, were complete\\nparalvsis of all the parts below the fracture in some, partial paralysis\\nin others, only a slight diminution of sensibility in the left arm in one,\\npain in the neck or occiput in six, rigidity of the neck in most, absence\\nof recognizable deformity in all, distinct crepitus in one, and falling\\nforward of the head upon the breast in one. All of these symptoms\\npain, rigidity, paralysis, sudden death may be the result of dislo-\\ncation as well as of fracture, and, as dislocation has in addition no\\ngeneral or local characteristic symptoms which serve to distinguish it,\\nthe differential diagnosis must usually remain in doubt.\\nFractures of the Lower Five Cervical and First Two Dorsal Vertebrae.\\nThe special characteristics of fractures of this region are due to the\\ninclusion within it of the roots of thephrenic nerve and brachial plexus.\\nThe former passes out through the intervertebral foramen between the\\nthird and fourth cervical vertebrae, either coming from the fourth cer-\\nvical pair alone, or receiving branches also from the third and fifth\\npairs. The brachial plexus is formed by the four lower cervical and\\nthe first dorsal pairs. Consequently, if the fracture is accompanied by\\ndisplacement of the fragments and injury to the spinal cord, paralysis\\nof the upper limbs also is caused, and if the fracture is high enough\\nin the region to involve the phrenic nerve directly or by extension\\ndeath follows promptly, preceded by the respiratory symptoms peculiar\\nto lesion of this nerve.\\nHere, too, as after fracture of the altas and axis, are found cases in\\nwhich the patients present only symptoms of paralysis for a longer or\\nshorter time, and then die suddenly of asphyxia in consequence of some\\naccidental or intentional movement of the head, which probably causes\\ncompression of the phrenic nerves by displacement of the fragments.\\nThe paralysis in fractures of the portion of this region below the\\nfourth cervical vertebra shows many variations. From the relations\\nof this part to the brachial plexus it might be expected that paralysis\\nof the upper limbs would be a constant symptom, excluding those cases\\nin which there is no displacement, but Gurlt s tables show this paral-\\nysis to have been present in less than one-fourth of the cases, that in\\nthe majority complete paralysis of the lower portion of the body\\nextended upward at first only to the middle of the breast, the second\\nrib, rarely to the neck, clavicle, or shoulders, and sometimes not even\\nto the umbilicus, although it often advanced to a higher point later in\\nthe progress of the case. Paralytic symptoms appeared in the arms,\\nas a rule, either later on the day of the accident or on the following\\nday. The paralysis may be complete in one arm and partial or absent\\nin the other it may be complete of motion and incomplete of sensa-\\ntion, or the reverse it may be limited to the arm or to the forearm", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0171.jp2"}, "168": {"fulltext": "148 FRACTURES.\\nor the injury to the nerves may be evidenced by abnormal sensations,\\nsuch as numbness or prickling in the limb. Probably incompleteness\\nof paralysis is due in most cases to the conservation of some of the\\nnerve fibres, although the medullary position of the cord is completely\\ndestroyed by crushing. Hyperesthesia affecting the whole or part\\nof the limb is occasionally observed, and is sometimes associated with\\nsharp, lancinating, continuous or intermittent pain, which may be\\nspontaneous or may be excited or increased by the slightest touch of\\nthe surface. Tonic or clonic spasms are seen somewhat more\\nfrequently than hyperesthesia, sometimes limited to the arms alone,\\nsometimes involving other muscles also.\\nAn important consequence of the paralysis is the change in the\\nrespiratory act due to the withdrawal of the aid of the accessory mus-\\ncles when the phrenic nerve is uninjured. As a consequence of the\\nparalysis of the intercostal and abdominal muscles, inspiration is\\neffected by the diaphragm alone, and expiration by the weight of the\\nabdominal walls and viscera which sink back to the positions from\\nwhich they have been displaced by the contraction of the diaphragm.\\nAs the expiration is thus purely passive the patient cannot sneeze or\\ncough strongly, and as he is thus prevented from clearing his lungs\\nof the mucus which collects in them it gives rise to plentiful moist\\nrales. If the phrenic nerve shares in the injury the diaphragm acts\\nvery slowly, perhaps not oftener than twice or thrice in the minute,\\nthe breathing is noisy or sighing, and the shoulders may be slightly\\nraised at each inspiration. Sometimes a change in the position\\nincreases or diminishes the difficulty by modifying the pressure upon\\nthe cord. A noticeable slowing of the pulse accompanies this defec-\\ntive respiration.\\nThe local symptoms are usually few and obscure, often nothing\\nmore than the pain that is felt at the seat of fracture and is increased\\nby pressure or motion. Sometimes there are positive objective signs:\\nan abnormal projection or depression of one or more spinous pro-\\ncesses, an irregularity on the posterior wall of the pharynx produced\\nby the displaced body of a vertebra, lateral displacement of one or\\nmore spinous processes, irregularity in the line of the transverse pro-\\ncesses, and possibly crepitus or abnormal mobility.\\nThe position and mobility of the head vary greatly in different\\ncases. In some cases they show nothing abnormal, in others the head\\ncan be moved freely to either side, but not forward or backward, and\\nin others it is held firmly fixed in some one position and any attempt\\nto change that position causes pain. This rigidity is due not to change\\nin the relations of the articular surfaces, but to the involuntary\\nspasmodic contraction of the muscles which is nature s method of pre-\\nventing the infliction of pain by movement of the parts.\\nIt is to be borne in mind that, as stated above, this is the region in\\nwhich traumatic hamiatomvelia almost exclusively occurs, and that\\nexamination of the sensibility to heat, cold, and pain should be made\\nwhenever, in connection with more or less motor paralysis, there is\\npreservation of the touch-sense.\\nIt is apparent that the diagnosis of fracture of this region may be", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0172.jp2"}, "169": {"fulltext": "FRACTURES OF THE VERTEBRA. 149\\ndifficult or impossible. The most that can be done in many cases is to\\nrecognize approximately the seat of the injury. Thus, paralysis or\\nsymptoms of irritation in the arms, even if they first appear after\\nsome delay, indicate a lesion above the second dorsal vertebra, although\\nin a few exceptional cases this symptom has existed when the injury\\nwas lower on the spine, and was then due probably to an associated\\nbrain lesion or a large collection of blood within the spinal canal. If\\nall local and functional signs are absent the diagnosis is, of course,\\nimpossible, and the real nature of the injury may be entirely over-\\nlooked until the progress of the inflammation or a chance displace-\\nment of the fragments brings it to light.\\nThe prognosis is extremely unfavorable. Gurlt s tables contain 96\\nfatal cases, and only 8 which ended in recovery, and in one of these\\nthe symptoms reappeared after a fall and the patient died in conse-\\nquence. In one-third of the cases death took place within the first\\nfour days; in 20 between the fifth and twelfth; in 11 between the\\nthirteenth and thirty-sixth and in one case the patient survived five\\nmonths. I have known two cases in which life was prolonged more\\nthan a year, without change in the paralysis. In hsematomyelia the\\nprognosis is much more favorable.\\nFractures of the Lower Ten Dorsal and First Two Lumbar Vertebrae.\\nThis region includes another point at which fractures are very\\ncommon, the lower dorsal and the first lumbar vertebrae. Its position\\nbelow the origin of the brachial plexus prevents the involvement of\\nthe arms in the paralysis except in rare cases where this unusual exten-\\nsion is due apparently to the spread of inflammatory softening of the\\ncord or to the pressure of extravasated blood. Paralysis of the lower\\nlimbs, the bladder, and rectum, which is one of the common results of\\nfracture in this division as well as in the higher ones, may be entirely\\nabsent at the beginning, especially after fracture of the second lumbar\\nvertebra, or, more frequently, may be incomplete, the motor paralysis\\nbeing, as a rule, more marked than the paralysis of sensation. The\\nlatter may extend as high as the lower part of the heart, or may stop\\nat the groin, and sometimes even does not reach above the lower part\\nof the thigh. A common result of the paralysis is the immediate\\nretention of urine and feces, followed, as before mentioned, by incon-\\ntinence and by alkaline decomposition of the urine and cystitis. This\\nincontinence persists until death takes place or improvement begins.\\nThe disturbance in the function of the bowels aided by the flaccid ity\\nof the abdominal muscles produces tympanites, which makes its\\nappearance usually within a day or two and may be sufficiently marked\\nto interfere with respiration by crowding the diaphragm upward and\\nopposing its contraction. In other cases, even of apparently severe\\ninjury to the body of a vertebra, there may be an entire absence of\\nparalytic symptoms and even of those of meningeal irritation.\\nThe diagnosis is aided by objective symptoms, which are more\\nmarked and distinctive than those found after fractures of the upper\\nportion of the column, because as the fracture in the great majority of", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0173.jp2"}, "170": {"fulltext": "150 FRACTURES.\\nthe cases involves the body of the vertebra, and is comminuted or\\naccompanied by displacement, there is usually a recognizable deformity\\nconsisting in an angular change in the long axis of the spine, with\\nprojection of the spinous process of the broken vertebra or of the one\\nimmediately above it. This change in the position of the spinous\\nprocess is sometimes so marked that the finger can be pressed deeply\\nin between it and the next lower one.\\nThe possibility of traumatic hsematomyelia in the lower part of this\\nregion must not be overlooked.\\nThe prognosis, as regards both life and recovery of function, is\\nmore favorable than after fracture at a higher point. Gurlt s statistics\\ncontain 145 cases, of which 39 recovered more or less completely; in\\n18 additional ones the patient survived more than three months, with\\na fair prospect of recovery, but died in consequence of some compli-\\ncation that had no necessary connection with the fracture. In 23 of\\nthe fatal cases other severe injuries or complications were present, and\\napparently caused death. Of the 83 fatal cases which remain after\\nexcluding these 23, one died in the first twenty-four hours, 33 in the\\nfirst month, 23 in the second, 8 in the third, and 2 in the fourth in\\n16 the patients survived for periods varying between four and fifteen\\nmonths.\\nFractures of the Lower Three Lumbar Vertebrae.\\nFractures of this portion of the spine appear to be exceedingly\\nrare. 1 The absence of paralytic symptoms and recognizable displace-\\nment would make the diagnosis during life practically impossible.\\nAs this portion of the spinal canal contains only nerve trunks, which\\nare better fitted by their texture and comparative independence of each\\nother to resist or escape damaging pressure by displaced fragments than\\nthe spinal cord itself is, paralysis may be absent even when the dis-\\nplacement is marked in some cases it has been complete, both of\\nmotion and sensation, over the limbs and abdomen. The patient may,\\nhowever, be unable to walk in consequence of the loss of support occa-\\nsioned by the fracture, or he may walk only feebly and in a bent pos-\\nture. But if union takes place, even if the deformity persists, he may\\nbe as strong and capable as before. In short, the prognosis is favor-\\nable as regards both life and function.\\nCourse and Terminations.\\nThe course and terminations of fracture of the spine, with their\\nmany variations as regards both the life and principal functions of\\nthe patient, have been indicated in the preceding section we have\\nnow to consider the changes effected in the broken bone by the process\\nof repair, and to describe some of the later symptoms with more\\ndetail.\\n1 If the specimens of supposed ununited fracture of the arch of these bones, which have\\nbeen found upon the dissecting-tabie, in museums, and in old Indian graves, are accepted\\nas such, they raise the question whether similar fractures are not more common than has\\nbeen supposed, and whether they may not be present, without displacement, in some of\\nthe severe, so-called strains of this region.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0174.jp2"}, "171": {"fulltext": "FRACTURES OF THE VERTEBRAE. 151\\nRepair takes place as after fracture of other spongy bones that is,\\nbv a callus which may remain fibrous or become bony, and may be\\nlarger or smaller according to circumstances. As the displacement\\ncannot be reduced the fragments must unite, if at all, in the positions\\nin which they are left by the accident, and although the normal rela-\\ntions may thus be notably altered and the union remain fibrous the\\nsolidity is quite sufficient. In fractures that have been healed for a\\nlong time is found the same absorption of projecting angles and sur-\\nfaces which has been noticed in connection with other fractures, and\\nthis absorption is especially marked in the bodies of the vertebrae.\\nIf several adjoining vertebrae are broken at the same time the inter-\\nvertebral disks disappear in part by absorption, and the remaining\\nportions undergo partial or complete ossification, uniting structurally\\nwith the vertebra?, and thus forming a more or less extensive, rigid,\\nbony mass. The length of time required for consolidation appears to\\nbe greater than for that of other spongy bones.\\n\u00e2\u0096\u00a0A number of instances of complete pseudarthrosis have been recorded,\\nand their origin differently interpreted. Gurlt has collected 21 such\\ncases 1 of the odontoid process, 4 of the spinous processes of the\\ncervical, dorsal, and lumbar vertebras, and of the sacrum, 3 of the\\ntransverse processes of lumbar vertebrae, 11 of the arches of lumbar\\nvertebrae, and 2 of the side of the upper false vertebra of the sacrum.\\nMeckel considered the 11 cases involving the arches of lumbar ver-\\ntebrae as instances of arrest of development, comparing them to the\\nvertebrae of some reptiles, which consist normally of a separate body\\nand arch, and in which many of the processes also remain ununited.\\nOtto opposed this view, because the position of the false joint does not\\ncorrespond to that of the line between the diaphysis and epiphysis, and\\nWyman/ who reported eleven additional cases and did not know of\\nthese earlier ones, held the same opinion for the same reason. Gurlt\\naccepted Meckel s opinion concerning the arches of the lumbar verte-\\nbrae, and claims that it is probably true also of the other cases. His\\nreasons are that there is no trace of injury to other parts, and that it\\nis known that fracture limited to a vertebral arch, a spinous, or a trans-\\nverse process is exceedingly rare that most of the cases relate to the\\nlowest lumbar vertebrae, fractures of which, of any kind, are rare, and\\nin the case of the fifth unknown and that the identity of the position\\nof the joint in all corresponding cases, and its perfect structure, point\\nstrongly to an arrest of development, and are incompatible with a frac-\\nture by external violence. Shepherd 2 reports another of the fifth\\nlumbar vertebra found in the dissecting-room.\\nSuppuration at the seat of fracture, which is very rare in other bones,\\nseems to be more common after simple fracture of the spine, and is\\nattributed by Gurlt to the greater complexity of the anatomical condi-\\ntions and to the less perfect immobility maintained during the progress\\nof the case. His statistics contain eight cases in which, excluding\\ninstances of suppurative meningitis, more or less pus was found after\\ndeath at the seat of fracture in four of the cases the abscess was large,\\n1 Wyman: Boston Medical and Surgical Journal, August 14, 1S69.\\n2 Shepherd: Montreal Medical Journal, June, 1892.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0175.jp2"}, "172": {"fulltext": "152 FRACTURES.\\nand its walls were formed in part by the unbroken ligaments in one of\\nthem the wall of the abscess had ossified. Usually the intervertebral\\ndisks are partly destroyed, the articular surfaces eroded, and some-\\ntimes the bone carious. In most cases the suppuration was limited\\nto the fracture, but in one the pus had made its way out by several\\nchannels through to the muscles and tendons, and had collected in the\\nback.\\nAs to the recovery of the cord after injury, with restoration of func-\\ntion, nothing definite is known beyond the fact that a number of autop-\\nsies made at various periods after injury have shown the cord more or\\nless completely divided, or reduced to pulp at the compressed part, or\\nreplaced by fibrous tissue. There is nothing to prove that a disinte-\\ngrated portion can be restored, or that divided cords can be reunited,\\nand it is not easy to see how proof of such a fact could be furnished\\nexcept by experiment. In those cases in which paralysis has disap-\\npeared after a time, it is impossible to know exactly what was the\\nnature of the lesion of the cord that caused it, but probably most of\\nthem are cases of moderate hsematomyelia.\\nThe troubles created by paralysis of the bladder are very serious,\\nand often hasten a fatal termination. They begin, usually promptly,\\nwith retention, which if not looked for by the surgeon may pass unno-\\nticed, since it gives the patient no pain, until the distention of the\\nbladder has become so great that the urine begins to dribble away\\nthrough the urethra. This distention is of itself sufficient to cause\\ncystitis. If the retention is noticed and the catheter used regularly\\nthe appearance of the cystitis will be delayed the urine gradually\\nbecomes turbid, ammoniacal, and charged with mucus, and remains so\\nuntil death or until improvement has taken place in the paralysis.\\nAfter a period that is usually short, the retention passes into inconti-\\nnence, either complete or by overflow. The symptoms and usual con-\\nsequences of the cystitis are such as are commonly observed when the\\nsame affection is excited by other causes, and do not require a detailed\\ndescription here but in addition to these common ones there are occa-\\nsionally observed others of great gravity, such as sloughing of the Avail\\nof the bladder, and pericystitis with formation of abscesses.\\nEvery effort should be made to delay the appearance of this compli-\\ncation and to diminish its severity, and with this object the water must\\nbe regularly drawn as soon as the first signs of retention appear. It\\nis usually sufficient to use the catheter twice a day it must be steril-\\nized and passed with even more than the usual precautions and gentle-\\nness because the patient s insensitiveness creates an additional risk of\\ndoing damage unwittingly to the urethral wall. After cystitis has\\nappeared and the urine has become turbid, the bladder should be\\nwashed once or twice a day. Permanent drainage of the bladder\\nthrough a perineal or suprapubic incision has been employed with\\nadvantage.\\nBed-sores appear promptly after any fracture that has caused para-\\nplegia by a complete transverse lesion of the cord, but are absent in\\nhsematomyelia. The skin at first becomes white, then mottled, and\\nthen separates as after blistering then the deeper part sloughs, and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0176.jp2"}, "173": {"fulltext": "FRACTURES OF THE VERTEBRJE. 153\\nthe slough spreads peripherally and in depth. The commonest seat is\\nthe skin covering the convexity of the sacrum, then other prominent\\npoints upon the back and legs. Not infrequently when the slough\\nover the sacrum separates the bone underneath is found necrosed. The\\ncause of this early sloughing has been thought to lie in injury to nerves\\nor nerve centres presiding over the nutrition of the parts but Mr.\\nShaw explains it by the pressure which is continued for a length of\\ntime and with an absence of interruption unknown except in connec-\\ntion with paralysis. Not only is the patient unable to move, but he is\\ninsensitive to the prolonged pressure, and does not seek to change his\\nposition or to have it changed. He lies absolutely motionless in one\\nsettled position the pressure interrupts the circulation at certain\\npoints, and, if this interruption continues unrelieved, the part dies.\\nThe presence of urine or liquid feces may prove an additional source\\nof irritation, as may also creases or irregularities in the bed-clothing,\\nand lack of attention and scrupulous cleanliness. The rapid improve-\\nment which sometimes takes place in these sloughs, even when the\\nparalysis remains complete, as soon as the consolidation of the fracture\\nis sufficiently advanced to allow the patient to be readily moved, is an\\nadditional demonstration that they are due to the pressure and not to\\nthe paralysis. Some cases which have recovered with permanent para-\\nplegia have shown, on the other hand, a very marked tendency to the\\nformation of sloughs on slight provocation, and in one case 2 the tarsal\\nbones of both feet became necrotic.\\nIn those cases in which the patients survive the injury and its more\\nimmediate consequences, it is sometimes found that the paralysis grad-\\nually diminishes and may even disappear entirely. The beginning of\\nthe improvement is sometimes marked by the appearance of sharp\\ndarting pains in the limbs and of muscular twitchings excited by slight\\ncauses, such as pinching or touching the skin then the power of vol-\\nuntary motion returns, first in one muscle, then in another. Sensation\\nreturns usually before motion the bladder is found to be again able to\\nretain a certain quantity of urine and to expel it with some force and\\na similar improvement is presented by the rectum, although, as a rule,\\neven in the best cases, the functions of the rectum and bladder remain\\npartially and permanently disabled. The improvement in the paralysis\\nmay be very slight, or it may go on to complete restoration of function,\\nor it may be arrested at any intermediate stage. Cases have been\\nreferred to in which a permanent deformity existed, but the functions\\nof the body and limbs were in no manner disturbed by it. Finally,\\nafter a short period of apparent recovery, symptoms of progressive\\ndegeneration of the cord or of pachymeningitis may appear.\\nTreatment.\\nThe indications, as in other fractures, are to reduce displacement\\nand to immobilize until repair shall have taken place, but the limita-\\ntions which exist in so many other fractures exist here to an even\\n1 Shaw Holmes s System of Surgery, Am. ed., vol. i. p. 810.\\n2 Courier Medical, November 11, 1882.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0177.jp2"}, "174": {"fulltext": "154 FRACTURES.\\ngreater extent because of the uncertainty as to the character of the\\ndisplacement, the difficulty in modifying it as desired, and the fre-\\nquent association of dominant lesions of the cord which cannot possibly\\nbe remedied. The condition of the cord, as indicated by the symp-\\ntoms, should usually determine the measure of benefit to be expected\\nfrom treatment, but unfortunately we cannot distinguish with certainty\\nbetween a complete division or crush of the cord which cannot be\\nrepaired and compression by bone or extravasated blood which will be\\nrecovered from if the pressure is relieved, although we know that in\\nthe great majority of cases, a majority which is greater the higher the\\ninjury is situated in the vertebral column, the condition of the cord is\\nhopeless or at the most can only be mitigated.\\nIn the first care of the patient transport, undressing, examination\\nhe must be handled with constant watchfulness to avoid producing\\nor increasing displacement. Then, if the fracture is of a spinous pro-\\ncess alone or of the column without recognizable displacement and\\nwithout symptoms of injury of the cord, confinement to the bed, pref-\\nerably aided by a plaster-of-Paris corset, is all that is required.\\nIf there is recognizable displacement gibbosity of the spine with-\\nout cord symptoms immobilization in the plaster corset is indicated,\\nwith or without an attempt to correct the displacement.\\nIf symptoms of pressure on or injury of the cord coexist an attempt\\nshould be made to relieve the condition by correcting the displacement.\\nThe means of accomplishing this are traction upon the trunk to\\nstraighten it by elongation, direct pressure forward upon the project-\\ning angle, and open operation.\\nWhen the injury is in the cervical or upper dorsal region traction\\ncan be made by turning the patient upon his side and pulling by the\\nchin and occiput; and by gradually changing the direction of the\\ntraction by moving the head backward while pressure is made against\\nthe spine below the fracture the angular displacement can sometimes\\nbe completely corrected. But when the injury is at a lower point, and\\nespecially if the patient is large and heavy, traction thus made is not\\nsufficient even with the aid of anaesthesia and even pressure with the\\nknee or hand against the angle (the patient being on his side) while\\nthe hips and shoulders are pressed backward may fail to make any\\nchange in the condition.\\nSuspension by the apparatus used in disease of the spine has been\\nemployed by some with advantage, but I have not ventured to try it.\\nInstead, I have used a long plank, placing the patient upon it, secur-\\ning his shoulders to one end, and then gradually raising that end so\\nthat the lower limbs would make the desired traction by their weight.\\nAVhile the patient is thus supported pressure forward upon the angle\\ncan be made by a bandage or stick passed between it and the plank.\\nIf the materials for a plaster corset have been previously prepared, in\\nthe form of broad strips of muslin or canton -flannel soaked in plaster\\ncream, and placed at the proper point upon the plank before the\\npatient has been laid upon it, the dressing can be easily and rapidly\\ncompleted while the patient remains suspended by bringing forward\\nthe ends of the strips around the body on each side.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0178.jp2"}, "175": {"fulltext": "FRACTURES OF THE VERTEBRAE. 155\\nDandridge recommends horizontal suspension on a narrow strip of\\nstout muslin, like a hammock, which is then included in the plaster\\njacket. The method is praised by those who have employed it in\\nPott s disease of the spine.\\nIn a few cases an existing paraplegia has immediately disappeared\\ndurino* suspension, and although in others the symptoms have been\\ntemporarilv aggravated I think we are justified in deeming the method\\nsafe and probably efficient to correct an angular displacement due to\\nfracture or crushing of the body of a vertebra or of the pedicles or\\narticular processes and also, though less certainly, a forward displace-\\nment of one segment. It cannot correct the much less common dis-\\nplacement forward into the canal of the posterior portion of the ver-\\ntebral arch, the spinous process with one or both laminae, or probably\\na fracture-dislocation in which one or both inferior articular processes\\nof an upper vertebra have lodged in front of the corresponding supe-\\nrior processes of the next lower one.\\nIn reduction by open operation a longitudinal incision is made along\\nthe median line with its centre at the apex of the angle of the frac-\\nture, and the soft parts separated on each side from the spinous process\\nand laminae of the vertebra forming the upper part of the angle, cut-\\nting through both laminae, if unbroken, and removing them with the\\nspinous process. If indicated the opening in the spinal canal is\\nenlarged upward or downward by removal of the adjoining spinous\\nprocess and laminae, and the displacement of the body of the vertebra\\nis corrected by manipulation guided by the eye and perhaps aided by\\ntraction with a blunt hook passed into the spinal canal. Hemorrhage\\nbeneath the dura is relieved by evacuation through an incision.\\nA large number of cases have been thus operated upon during the\\nlast few years, and apparently with marked benefit in some, but it is\\nstill too early to formulate a rule of practice. It is admitted by all\\nthat the operation can do good in only a small proportion of cases,\\nand it is probable even that that proportion is less than is indicated by\\nthe statistics because it is not clear that the improvement which has\\nsometimes followed was the result of the operation similar improve-\\nment has been noted in apparently identical cases not operated upon,\\nsome of them probably cases of haematomyelia. It must also be\\nadmitted, I think, that the operation is not likely to do harm and that\\noccasionally it discloses an important condition which could not other-\\nwise be recognized and corrected. My own inclination is strongly\\ntoward reliance upon traction and the plaster jacket, systematic use of\\nwhich might show a gain as great as that which Burrell 1 found in the\\nBoston City Hospital: 33 per cent, of recoveries as against 22 per\\ncent, under expectant treatment. I believe, for reasons above given,\\nthat in the common form of injury with angular displacement gib-\\nbosity reduction can almost always be accomplished as well in this\\nway as by operation, and that the latter may find its special indica-\\ntions in cases of intraspinal hemorrhage and those rare ones in which\\nthe posterior portion of the arch is driven into the canal and presses\\nupon the cord. Thorburn, 2 after a personal experience of seven cases\\n1 Burrell Annals of Surgery, February, 1895. 2 Thorburn Lancet, August 11, 1894.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0179.jp2"}, "176": {"fulltext": "156 FRACTURES.\\nof operation and study of about 200 published cases, says he has\\nfound no clear evidence of benefit from it. Nevertheless, he deems\\nlaminectomy justifiable (1) in compound fracture; (2) in injuries of\\nthe laminse and spinous processes with lesion of the cord when the\\ncrush is probably incomplete; (3) when the symptoms are mainly or\\nentirely due to thecal or perithecal hemorrhage; (4) in pachymenin-\\ngitis or peripachymeningitis, which may follow an injury after a very\\nlong period and (5) in cases of compression of the cauda equina.\\nOf the great value of the plaster jacket, applied during suspension,\\nin aiding consolidation of the fracture in cases in which the disability\\nis due to the fracture rather than to injury of the cord, there can be no\\nquestion. 1\\nThe general treatment, when paraplegia is present, is to place the\\npatient upon a water-bed, carefully prevent irritation of the skin by\\nmoisture or creases in the sheets, and regularly empty the bladder and\\nbowels. Later in the case electricity may render some service.\\n1 See Papail, De l emloi du corset platre dans les lesions de la colonne vertebrale,\\nParis, 1887.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0180.jp2"}, "177": {"fulltext": "CHAPTER XII.\\nFRACTURES OF THE BONES OF THE FACE.\\n1. Fractures of the Nose.\\nUnder this term we include not only the two nasal bones, but also\\nthose upon which they rest, the septum, the nasal process of the supe-\\nrior maxillary, and the nasal spine of the frontal. The fracture may\\ninvolve one or both nasal bones or adjoining processes it may be simple\\nor compound, multiple or comminuted and it may be associated with\\nother fractures of neighboring bones, the most important of which is\\nfracture of the cribriform plate of the ethmoid. In the great majority\\nof cases the fracture is a more or less comminuted one, occupying the\\nlower half of the nasal bones, the main line of fracture running trans-\\nversely or obliquely, and the fragments are displaced backward or back-\\nward and to one side, according to the direction of the force that has\\nproduced the injury. In rare cases the fracture involves only one\\nnasal bone, or there may be dislocation of one or both bones. The\\ncartilages which form the alse may be broken or torn from their attach-\\nments to the bone, and that which forms the septum is frequently\\nbroken in connection with fractures of the bones themselves, or sepa-\\nrated from the vomer.\\nThe symptoms by which fracture may be recognized are deformity,\\nmobility, and crepitus. If the nose is grasped by the thumb and finger\\nlateral mobility with crepitus can usually be recognized, and displace-\\nments may at the same time be appreciated. The separation of the\\nseptum is recognized by exploration within the nostrils. The swelling\\nof the soft parts, which appears promptly, will mask any but an\\nextreme displacement.\\nOther symptoms which may be present, but which are by no means\\npathognomonic, are free bleeding from the nose, and occasionally\\nemphysema of the eyelids and face. Bleeding is often severe and\\nsometimes recurrent and difficult to arrest, but rarely endangers life.\\nEmphysema generally has its origin in an effort of the patient to blow\\nhis nose the air is forced into the subcutaneous cellular tissue through\\na rent in the mucous membrane and periosteum and spreads promptly\\nto the eyelids and sometimes over the rest of the face.\\nAn occasional symptom, when the fracture has extended into the\\nadjoining portion of the superior maxillary bone, is obstruction to the\\nflow through the lachrymal duct in consequence of its inclusion in the\\nline of fracture. Another and more common one is the difficulty or\\nimpossibility of breathing through the nose, the result of inflammatory\\nswelling of the mucous membrane and, finally, in the comminuted\\nfractures that are or have become compound, suppuration may be\\n157", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0181.jp2"}, "178": {"fulltext": "158 FRACTURES.\\nmaintained for weeks or months until all the necrosed fragments have\\nworked their way oat or have been removed. It occasionally happens,\\ntoo, that after a simple fracture a tendency is manifested toward inflam-\\nmatory complications in the neighborhood, abscesses form in and about\\nthe nose, portions of bone or cartilage become necrosed and are exfoli-\\nated, and a constant purulent discharge from the nostrils is maintained.\\nIt is so important that displacement should be corrected that an\\nanaesthetic should be used if a thorough exploration cannot be made\\nwithout its aid, and the surgeon should spare no pains to satisfy him-\\nself as to the condition and position of the bones. The examination\\ncannot prudently be long postponed, for the bones of the face unite\\npromptly, and more than once it has been found impossible to correct\\na displacement after eight or ten days had elapsed firm union may be\\nexpected within a fortnight or three weeks.\\nThe prognosis as regards life is favorable, except in those cases in\\nw T hich the skull is at the same time broken, and in those few others in\\nwhich recurrent hemorrhages, of which no satisfactory explanation is\\ngiven, show themselves. But as regards the avoidance of deformity\\nthe outlook is not so favorable, because it is not always easy to recog-\\nnize or correct a displacement through the swollen tissues and the\\npersistence of even a slight one is likely to be a noticeable blemish.\\nThe treatment consists mainly in the reduction of the displacement,\\nfor it is seldom possible to apply any apparatus or dressing that will\\nprevent a recurrence of the displacement if there is any tendency\\ntoward it. The reduction when there is depression is accomplished by\\npressure made from within the nostril, aided by manipulation or mod-\\nelling of the fragments on the outside. The interval between the sep-\\ntum and the side of the nose at the part of the nostril corresponding\\nto the nasal bone is so small that a small strong instrument, such as\\na steel director, must be used, one that is small enough to work within\\nthe narrow space next the nasal bone, and strong enough to transmit\\nconsiderable pressure. The fingers of the left hand placed upon the\\nnose serve to guide the instrument and to recognize the degree of reduc-\\ntion that has been obtained. Cocaine may be used to diminish the sen-\\nsitiveness of the mucosa. Ordinarily there is but little tendency to\\nrecurrence of the displacement, except when the fracture is comminuted\\nand the septum badly broken the only forces that tend to change the\\nposition of the fragments are the swelling of the external soft parts\\nand the pressure of the air when the patient seeks to clear his nose by\\nsnuffing or blowing.\\nThe idea of supporting the fragments by pressure from within the\\nnostrils suggests itself so readily that it is not surprising to find recorded\\nmany instances and several varieties in the methods of its use. The\\nsimpler ones consist of plugs of lint crowded into the nostrils, with or\\nwithout tubes to permit breathing the more elaborate ones are arrange-\\nments of rods supported by straps crossing the upper lip, and capable\\nof adjustment in length and direction within the nostril so as to hold\\nthe fragments in place they are said to have been efficient in some\\ndifficult cases. On the other hand, I can find no evidence that the\\nplugs of lint serve any useful purpose.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0182.jp2"}, "179": {"fulltext": "FRACTURES OF THE BONES OF THE FACE.\\n159\\nThe use of plaster or gutta-percha splints moulded upon the outside\\nseems to me to be entirely illusory if swelling takes place under them\\nit will tend to reproduce the displacement by pressure, if it is present\\nwhen the mould is applied its subsidence soon creates a gap between\\nthe splint and the skin. The best plan appears to be repetition of the\\nreduction as often as the displacement recurs. Occasionally the bridge\\nhas been held up by transfixion with a pin which rests upon the solid\\nbone on each side. Recurrence of a lateral displacement may be\\nopposed by a pad of gauze secured against the side of the nose by a\\nstrip of adhesive plaster crossing both cheeks.\\nSeparation of the cartilaginous septum from the vomer can be treated\\nwith a pair of forceps, one branch of which is passed into each nostril,\\nFig. 58.\\nCorrection of saddle nose.\\nlapping and grasping the bone and cartilage so as to hold them in line.\\nThe depression of the bridge, the saddle nose/ which so often is seen\\nafter this fracture, constitutes so marked a disfigurement that many\\nattempts have been made to correct it. Operations upon the bone,\\ndesigned to detach and raise the bridge, have, as a rule, failed so com-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0183.jp2"}, "180": {"fulltext": "160 FRACTURES.\\npletely that I was led to try to meet the indication by introducing a\\nsuitably shaped foreign body between the skin and the bone. It proved\\nentirely successful in restoring the profile, and the pieces of aluminum\\nand gutta-percha have remained in place for several years without\\ncausing irritation. I have always introduced them through a small\\ncut on the side of the ala of the nose and prepared a place for them\\nby subcutaneously freeing the skin with a knife introduced through the\\nsmall cut and swept freely across the bridge. Fig. 58 shows the pro-\\nfile after introduction of a piece of gutta-percha one and a quarter\\ninches long and one-quarter inch wide. A year later I removed it at\\nthe patient s request and inserted a piece, one and three-quarters inches\\nlong in order to lessen the notch at the root of the nose. (See Annals\\nof Surgery, June, 1896.)\\n2. Fractures of the Malar Bone and Zygoma.\\nIsolated fractures of this bone are rare, and, so far as can be inferred\\nfrom the small number of cases in which a direct examination has been\\npossible, single fractures are rarer than multiple ones, and the rarest is\\nthat which is almost a simple diastasis, a separation at the sutures with\\nsome splintering. Partial fractures involving the lower and outer por-\\ntion of the bone or the margin of the orbit have been observed, and\\nalso single fractures of the frontal and zygomatic processes, extending\\npossibly into the bones with which they articulate. In most cases there\\nis depression of the entire bone with fracture of the malar process of\\nthe superior maxilla and crushing of the anterior wall of the antrum,\\nthe malar bone being displaced inward toward the antrum or sometimes\\nbackward into the zygomatic fossa. Pure diastasis of the malar bone\\nprobably does not exist it has never been demonstrated by autopsy,\\nand attempts to produce it upon the cadaver have always resulted in\\nmore or less fracturing.\\nFractures of the zygomatic arch alone have been caused by external\\nviolence acting from without inward, and in two cases from within\\noutward, the patient having fallen forward upon a stick held in the\\nmouth. In some of those I have seen a portion of the arch has been\\nseparated by two lines of fracture and depressed in one of them one\\nof the lines of fracture extended into the temporo-maxillary joint.\\nThe displacement follows the direction of the fracturing force.\\nThe symptoms upon which the diagnosis must be made are deformity,\\nmobility, and crepitus. Unless there is much inflammatory swelling\\nthe deformity, which consists usually in a depression or flattening of the\\ncheek just below the outer half of the eye, can be recognized by sight\\nand touch, and the irregularity of the line of fracture can be readily\\nfelt on the margin of the orbit, or. if it extends to the malar process\\nof the superior maxillary bone, on the under and anterior surface of\\nthis process by the finger within the mouth. Mobility and crepitus\\nare perceived more rarely the latter can be sometimes produced by the\\nmovement of the jaw.\\nAnsesthesia or a sense of formication in the cheek, nose, upper lip,\\nand gum of the corresponding side is sometimes observed, and is due", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0184.jp2"}, "181": {"fulltext": "FRACTURES OF THE BONES OF THE FACE. 161\\nto an extension of the fracture along the floor of the orbit, involving\\nthe infra-orbital canal and tearing or bruising the superior maxillary\\nnerve. This symptom may be associated with an extravasation of\\nblood in the posterior part of the orbit sufficient to force the eye for-\\nward and showing itself also under the conjunctiva and in the eyelids.\\nBleeding from the mouth or nose is occasionally seen as the result of\\nthe extension of the fracture through the mucous membrane of the\\nmouth or antrum.\\nWhen the fracture involves the zygomatic arch, and the fragments,\\nas is usually the case, are driven inward, movement of the jaw may be\\ndifficult or impossible, either because the masseter has been injured, or\\nbecause the depressed fragments of the arch are forced against the\\ncoronoid process of the inferior maxilla, or into the tendon of the tem-\\nporal muscle. In one case the tip of the coronoid process was broken\\noff by the same blow that fractured the arch. Swelling, discoloration,\\nand pain are the natural and constant results of the fracture and the\\nbruising of the soft parts.\\nThe natural course of these fractures is toward rapid repair without\\nexcessive callus, and with gradual disappearance of any difficulty that\\nmay exist at first in the movement of the jaws. It is seldom possible\\nto reduce the displacement completely, because, as has been said, it is\\ngenerally inward, and there is no way of acting very efficiently upon\\nthe bone, except through a wound of the skin. The attempt must be\\nmade to move the bone in the desired direction by engaging the end\\nof the thumb or finger under it in the zygomatic fossa, introducing it\\nthrough the mouth if the cheek is swollen. It has been proposed, and\\noccasionally practised, to cut down upon the bone opposite the zygo-\\nmatic process, divide the fascia overlying the masseter muscle, pass a\\nstout hook under the process, and raise the bone by drawing upon it,\\nor to make a smaller incision over the body of the bone and screw an\\nelevator into it, by which it could then be raised.\\nInward displacement of the zygomatic arch cannot be directly acted\\nupon except by a hook introduced through the skin or an incision. In\\nonly one of the recorded cases has the displacement interfered seriously\\nand for any length of time with the movement of the jaws in this\\none the difficulty increased steadily for some time until the patient\\ncould barely separate the teeth, and then one morning while yawning\\nhe felt something snap, and the motion of the jaw at once became and\\nremained free.\\n3. Fractures of the Superior Maxilla.\\nWhile the body of this bone, protected as it is by outlying processes\\nand other bones, is rarely fractured, its own processes are not infre-\\nquently broken or involved in the fractures of those bones with which\\nthey are continuous. Thus, a blow upon the nose breaks not only the\\nnasal bones but also the nasal process of the superior maxilla, and a\\nblow upon the malar bone may force in the anterior wall of the antrum\\non which it rests. The fractures are always produced by direct vio-\\nlence, and present, consequently, considerable variety in their extent\\n11", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0185.jp2"}, "182": {"fulltext": "162 FRACTURES.\\nand the parts involved, but a fissure roay extend to this bone from a\\nfracture of the cranium. The alveolar process may be broken off in\\npart or entirely by a blow received on it or on the teeth. A blow\\nreceived in front, at or below the level of the nostrils, may produce a\\nhorizontal line of fracture separating the alveolar and palatal processes\\nfrom the body of the bone, and including also the pterygoid plates.\\nFalls from a height have caused a vertical line of fracture or diastasis\\nbetween the two bones along the median line of the mouth, extending\\neven through the soft palate, and associated with fracture of the malar\\nor nasal bones. In a very few cases a line of fracture on each side at the\\ncanine tooth has separated the intermediate portion, with marked dis-\\nplacement and mobility. Fractures of the alveolar process, even with\\nmuch displacement and mobility, present but little gravity, for thev\\nheal rapidly and without necrosis except of small pieces of the sockets\\nof teeth displaced at the same time.\\nIt occasionally happens that one or both bones are driven in with\\nmultiple and comminuted fracturing of them and of the adjoining\\nones. The earliest known case of the kind was reported by Wiseman,\\nand has been extensively quoted. The upper jaw was driven in so\\nfar that the finger could not be introduced between the palate and the\\nposterior wall of the pharynx. AViseman inserted a blunt hook through\\nthe mouth and easily drew the bone forward into place; as, however,\\nthe displacement recurred very easily, he left the hook behind the\\npalate and had it drawn upon constantly by the patient or his friends\\nuntil consolidation had taken place. Quite a number of similar cases\\n(Gurlt collected upward of twenty) have been reported, all the\\nresult of great violence, either by falls from a height or the passage\\nacross the face of a heavy wagon, or a violent blow. In one of my own,\\na blow by a descending elevator upon an upturned face, the nasal bones\\nwere separated from the frontal along the sutnre line, the right malar\\nand zygoma broken, and both superior maxillae displaced downward and\\nbackward and separated from each other along the median line of the\\nhard palate. In one case the bones of the face were so movable that\\nthey moved up and down when the patient swallowed, as if they were\\nrestrained only by the skin. In most of them the patients recovered,\\nand it is worthy of remark that, notwithstanding the degree of the vio-\\nlence and the extent of the injury, it seldom happens that the fracture\\ninvolves the cranium. The reason lies apparently in the direction in\\nwhich the fracturing force is applied, a direction outside of and more\\nor less parallel to the surface of the cranium and not in the line of one\\nof its diameters. The bones of the face are, as it were, torn off the\\ncranium rather than driven back upon it.\\nVery extensive mutilation of the face has been caused by gunshot\\nwounds, especially in attempts at suicide when the muzzle of the gun\\nhas been placed within the mouth, but it is rare for ordinary violence\\nto lead to much loss of tissue. Malgaigne speaks of the following case\\nas unique in this respect in his experience A boy was kicked in the\\nface by a horse the superior maxillary, nasal, and palatal bones were\\nextensively comminuted, and the skin torn and bruised. Recovery\\ntook place, but with much deformity. The nasal bones, the anterior", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0186.jp2"}, "183": {"fulltext": "FRACTURES OF THE BONES OF THE FACE.\\n163\\nportion of the alveolar arch, and the greater part, if not all, of the\\nhard palate had disappeared. There was no longer either nose or\\nmouth the lips were united by a firm cicatrix, and the mouth and\\nnostrils were represented by an oval opening between the nasal pro-\\ncesses of the superior maxilla?. Through this opening the patient\\nbreathed, spoke, drank, and ate.\\nThe diagnosis of fracture is ordinarily made without any difficulty,\\nsince large portions of the bone are open to direct examination with\\nthe finger through the mouth and on the cheek. Irregularity of out-\\nline, mobility, displacements, and crepitus can be readily recognized.\\nIn some few cases where there w T as no displacement the diagnosis has\\nbeen in doubt, and Guerin has pointed out a symptom which might\\nbe useful under such circumstances. It has been said that the ptery-\\ngoid apophysis is always broken when the line of fracture crosses the\\njaw horizontally between the alveolar process and the malar bone, and\\nGuerin found that pressure with the finger upon the inner plate of this\\nprocess caused pain and sometimes showed mobility when there was no\\nother sign of fracture. Ecchymosis of the hard or soft palate indicates\\nfracture.\\nRepair in cases of average severity takes place in from thirty to\\nforty days with a scanty formation of callus, and not infrequently in\\nless time. The vitality of the bone is exceptionally great, hence the\\nrule laid down by Malgaigne and some of his predecessors, and\\nrepeated by all subsequent writers, to leave every fragment that is not\\nabsolutely and entirely detached. Although the rule is a sound one,\\nit occasionally happens that fragments become necrosed and have to be\\nremoved. This is thought to happen more frequently with fragments\\nof the alveolar border than with any others.\\nDisplacement is seldom noticeable after repair is completed, except\\nin the nose, but it usually exists to a greater or less degree, and the\\ningenuity and the patience of the surgeon are\\noften severely taxed to overcome the constant\\ntendency to the recurrence of the displacement.\\nSalivation is often profuse, and the discharge\\noffensive. Division of the lachrymal canal by\\nthe fracture may lead to its obliteration.\\nDisplacement of the entire bone may be treated\\nas in Wiseman s case, or the retention may be\\naided by securing the lower jaw against the upper\\none, with or without the intervention of inter-\\ndental splints or moulds of gutta-percha or metal\\nshaped to fit the teeth and alveolar arch. Lateral\\npressure cannot well be made upon the cheeks to\\novercome separation along the median line of the\\npalate, but fortunately it is not always necessary.\\nquoted by Malgaigne, the gap began to contract spontaneously by the\\ntenth day, and was completely closed by the thirty-third, with no other\\ndisplacement than a slight difference in level between the two halves.\\nIn another case, quoted by Hamilton, the gap was large enough to\\n1 Guerin: Archives Generates de Medecine, July, 1866, vol. ii. p. 5.\\nFig\\nIntrathecal splint for frac-\\nture of the upper jaw.\\nIn Simon in s case,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0187.jp2"}, "184": {"fulltext": "164 FRACTURES.\\nadmit the little finger, and was still open six weeks after the receipt of\\nthe injury.\\nAfter fracture of the alveolar process the fragment should be care-\\nfully readjusted and fixed by wiring the teeth to the adjoining ones, or\\nby a splint of gutta-percha or metal. Agnew says he has used for this\\npurpose with great advantage a piece of cork with grooves cut in its\\nupper and lower surfaces to receive the teeth of both jaws. The reduc-\\ntion is made, the cork inserted, and the jaws firmly bound together.\\nNo attempt should be made to remove the corresponding teeth, for not\\nonly are the chances in favor of their becoming firm again in their\\nsockets, but the attempt to draw them, even if they are loose, may\\nbring away an important piece of the bone.\\nThe gutta-percha or metal mould may be held in place by binding\\nthe lower jaw against it after it has been fitted to the upper one, or by\\nan apparatus similar to one devised by Graefe for the purpose, and\\nshown in Fig. 59. If the splint is to be supported by the lower jaw\\nit should be so constructed that an interval will be left through which\\nfood can be given and the mouth cleaned.\\n4. Fractures of the Inferior Maxilla.\\nFracture of the inferior maxilla occurs more frequently than that of\\nany other of the bones of the face. It is rare in childhood and old\\nage, most frequent between the ages of twenty and thirty, and is appar-\\nently more than ten times as common in males as in females.\\nGurlt collected 143 published cases in which the character and posi-\\ntion of the fracture were described with sufficient accuracy to allow of\\ntheir use as statistics of these 80 were single, 49 double, and in 14\\nthere were three or more lines of fracture. Of 75 single ones (exclud-\\ning 5 in which the fracture was limited to the alveolar process) the\\nfracture occupied the median line in 25, the region of the incisor teeth\\nin 22, that of the back teeth in 15, behind the teeth in 8, and the con-\\ndyloid process in 5. In 35 double fractures both halves of the bone\\nwere broken 20 times, and at points on the two halves corresponding\\nclosely with each other one side alone 8 times, and the median line\\nby one of the fractures 7 times. One or both of the condyloid pro-\\ncesses were broken in several of the multiple fractures. These figures\\nshow that, exclusive of partial fractures of the alveolar border, which\\nare very common, and often caused by the drawing of a tooth, the most\\nfrequent seat of fracture is at or near the median line, and that single\\nfracture of the ramus, or of the alveolar or condyloid process is com-\\nparatively rare. They differ materially from the estimates made by\\nvarious writers, but as the latter differ quite as much among them-\\nselves, and appear to have spoken in most cases from general impres-\\nsions rather than from figures, the preference should be given, I think,\\nto Gurlt,\\nDouble fractures of the lower jaw are relatively more common than\\nthose of other bones, while multiple and comminuted ones are rare.\\nCompound fractures are common, both because the gum overlying the\\nfracture is frequently torn and because the lip and skin are often", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0188.jp2"}, "185": {"fulltext": "FRACTURES OF THE BONES OF THE FACE. 165\\ninvolved in the direct injury that has caused the fracture. The frac-\\nture is complete or incomplete, the latter rarely except when the alve-\\nolar border alone is involved. A portion of the lower border of the\\nbone may be broken off by a blow.\\nThe line of fracture in the body of the bone is usually vertical or\\nnearly vertical at the angle or in the ramus it is oblique or transverse.\\nAt the median line there is but little displacement, if any but, when\\npresent, it may be in either of three directions a difference in the hori-\\nzontal level of the edge of the teeth, a displacement forward and back-\\nward of the fragments upon each other with lateral overriding, or a\\nlateral separation of the two. In the fractures between the median\\nline and the canine tooth the line is still much more frequently vertical\\nthan oblique but displacement is the rule, although no one form of it\\nseems to be more common than the others. Between the canine tooth\\nand the angle of the jaw it is either vertical or inclined backward and\\ndownward, and usually, instead of crossing the bone from without\\ninward at a right angle to the surface, it is inclined backward and\\ninward, so that the anterior fragment is lengthened on the inner side\\nand the posterior fragment on the outer side. The inferior dental\\nnerve is crossed by this fracture, and is sometimes torn or bruised.\\nFracture behind the teeth is comparatively rare, only eighteen cases\\nbeing contained in Gurlt s statistics, and it is frequently double or\\nmultiple or associated with other fractures.\\nAVhen the fracture lies at the junction of the\\nbody of the jaw and the ascending ramus, it\\nis usually oblique, running from behind the\\nlast tooth backward and downward toward the\\nangle of the jaw but it may be vertical.\\nDisplacement is usually slight or lacking, the\\nparts being kept well together by the masseter\\nand internal pterygoid muscles (Fig. 60).\\nFracture of the condyloid process is usually\\naccompanied by other fractures of the same\\nor other bones of the face, and may be pro-\\nduced by a blow; either upon the chin or upon Fracture of lower jaw beMnd\\nthe side of the jaw near the joint. The line the teeth,\\nof fracture passes through the neck, and the\\nfew specimens furnished by autopsies and museums do not show a\\ngreater frequency at any point or in any direction than at any other.\\nFracture of the coronoid process is exceedingly rare and has been seen\\nonly in association with, other fractures of the same or adjoining bones.\\nA portion of the alveolar process with the teeth in place is some-\\ntimes broken off. The size of the piece varies within wide limits, and\\nthe displacement is habitually inward. In one or two entirely excep-\\ntional cases a similar piece, including a portion of the body of the\\nbone, has been broken off.\\nComminuted fractures, except as the result of gunshot wounds, are\\ncomparatively rare double and treble fractures are less so and one\\ncase is on record in which there were five distinct and separate lines of\\nfracture.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0189.jp2"}, "186": {"fulltext": "166 FRACTURES.\\nThe most frequent cause of fracture,, exclusive of partial fractures\\nproduced by attempts to draw a tooth, is violence received upon the\\nchin fracture by pressure upon the sides is much less common, the\\nother occurring thrice as frequently. Fracture of the condyloid pro-\\ncess may be produced in either of the same two ways a blow upon\\nthe chin or upon the cheek.\\nThe objective symptoms of fracture of the lower jaw are the same\\nas those of other fractures abnormal mobility, crepitus, displace-\\nment, pain. The bone is so accessible to the touch both within and\\nwithout the mouth that irregularities in the outline of its body can be\\neasily recognized by the fingers and sometimes by sight. The teeth\\nshow differences in level, vertically or antero-posteriorly those which\\nadjoin the fracture are usually loosened and may be entirely dis-\\nlodged. Mobility and crepitus are detected by manipulation. When\\nthe fracture is situated at or above the angle of the jaw its recognition\\nis by no means so easy by passing the finger within the mouth along\\nthe inner and outer surfaces of the ramus irregularities of outline and\\nlocalized points of pain may be recognized, and pain at a fixed point\\nis caused by biting.\\nThe degree and direction of the displacement vary much. As a\\nrule, when the fracture is single and lateral, the anterior fragment\\ntends toward the inside of the mouth. In double fractures, the inter-\\nmediate piece is almost invariably drawn downward and backward by\\nthe unopposed action of the muscles of the neck which are attached\\nto it.\\nFracture of the condyloid process was first studied by Desault and\\nBichat, and but little if anything has been added to our knowledge of\\nthe subject since their time. The symptoms are pain, increased by\\nmotion, diminished mobility of the jaw, often crepitus on manipulation,\\nirregularities in the region of the condyle, the ease with which the con-\\ndyle can be pushed forward into the zygomatic fossa, its failure to share\\nin the movements of the jaw, and its almost constant displacement\\nupward and forward by the contraction of the external pterygoid.\\nRibes pointed out an additional symptom which is sometimes present,\\ndeviation of the chin toward the affected side. This is effected by the\\ndisplacement of the ramus upward and backward on the outer side of\\nthe condyle and neck, and the more easily if the fracture is a double\\nor multiple one. Gurlt quotes the description of a specimen of this\\nkind from a work by Bonn, published in 1785. The condyle was\\nunited by a bony callus to the ramus just above the orifice of the dental\\ncanal.\\nSwelling of the gums, face, and glands follows promptly upon the\\ninjury, and is often increased by the direct bruising of the soft parts\\nthemselves the secretions of the mouth, increased in quantity by the\\nirritation, mingle with the pus that comes from the fracture if com-\\npound or from the ulcers produced by the stomatitis, decompose, and\\ncause an offensive odor that can scarcely be kept under control even by\\nthe most careful attention. Abscesses may form and open within the\\nmouth or upon the sides of the jaw or the neck below it they are\\nalmost invariably associated with the presence of detached splinters or", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0190.jp2"}, "187": {"fulltext": "FRACTURES OF THE BOXES OF THE FACE. 167\\nthe exfoliation of portions of the jaw, which require, of course, to be\\nremoved before a permanent cure can be obtained. Small fragments\\nmay long escape recognition, and the only indication of their presence\\nmay be a sinus larger fragments force themselves promptly upon the\\nsurgeon s attention by the profuseness of the discharge and the amount\\nof local reaction. A few cases of extensive necrosis have been reported.\\nSimple fractures unite in from thirty to forty days, and, even when\\nthere has been a considerable loss of bone by splintering or necrosis,\\nthe final result may be a very good one, in this sense, that the jaw is\\nstrong enough to support artificial teeth in the place of those that\\nhave been lost by the accident, is sufficiently regular in form to avoid\\ndeformity, and is free in its movements.\\nFailure of union, pseudarthrosis, is rare. Gurlt s statistics contain\\nonly two cases which can be properly considered as such, and they were\\nboth cured by operation. It is more common after gunshot fracture\\nwith much loss of substance by elimination of splinters, and may inter-\\nfere with mastication. In a few cases union in a faulty position has\\nrequired an operation to correct the deformity or relieve the functional\\ndisability.\\nThe prognosis is a relatively favorable one the probabilities are that\\nunion will take place promptly, that no serious complications will arise,\\nand that no important deformity or disability will remain. Danger to\\nlife may come from two quarters the proximity of the bone to the\\ncranium carries with it the possibility of associated injury to the brain\\nor to its case retention of pus in a compound fracture in communica-\\ntion with the cavity of the mouth exposes to the grave danger of absorp-\\ntion of the decomposed secretions and, though rarely, to the burrowing\\nof the decomposed pus along the deeper planes of the neck into the\\nanterior mediastinum.\\nTreatment. Displacement following fracture of the body of the jaw\\ncan usually be readily overcome by the pressure of the thumb and\\nfingers upon the teeth and the lower border of the bone in some\\ncases the interlocking or wedging of the smaller pieces or of displaced\\nteeth may render the reduction impossible until after they shall have\\nbeen removed.\\nIn simple cases where the tendency to displacement is slight it is\\nsufficient to immobilize the lower jaw by binding it against the upper\\none with a four- tailed bandage, the centre of which is at the chin, as\\nshown in Fig. 61.\\nSplints are applied either to the front and under surface of the jaw\\noutside the mouth, or to the teeth, or the inner surface of the jaw, and\\ntwo kinds are sometimes used in combination. Outside splints are\\navailable only in cases in which there is not much tendency to displace-\\nment and in which the lateral pressure of a simple bandage would\\ncause the fragments to override in one direction or another. They\\nmay be made of leather, pasteboard, gutta-percha, or plaster of Paris,\\nand consist essentially of a cup-shaped piece embracing the chin and\\nextending nearly to the angle of the jaw on each side, and to the fold\\nof the neck below.\\nInterdental splints are made of metal, gutta-percha, or vulcanized", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0191.jp2"}, "188": {"fulltext": "168\\nFRACTURES.\\nrubber they are fitted to the crowns of the teeth of both fragments\\nafter reduction of the displacement, and are held in place either by\\nbinding the jaws together with an outside bandage, or by braces con-\\nnecting the splint with a pad under the jaw, or by a special arrange-\\nment of lateral braces as in Kingsley s apparatus (Fig. 62), or by\\nfastening them to the teeth with wires. Some are fitted only to the\\nbroken jaw and are intended only to immobilize the fragments on each\\nother others are fitted to both jaws and enable the upper one to be\\nused as a splint for the lower. Ackland l describes one capable of ready\\nadjustment to almost any fracture of the body a metal gutter partly\\nfilled with softened gutta-percha, pressed down upon the teeth, and\\nsecured to a plate beneath the chin by two adjustable clamps.\\nFig. 61.\\nFig. 62.\\nFour-tailed bandage for fracture of the\\nlower jaw.\\nKingsley s splint applied.\\nIn one difficult case I used a carpenter s small wooden yise, one end\\nof which lay on the edge of the teeth, the other under the chin after\\na few day s use the displacement ceased to recur.\\nGutta-percha splints may be made either of thin strips or of thick\\nlumps or wedges. The former haye a length of three or four inches,\\nand a breadth sufficient to overlap the crowns of the teeth from gum to\\ngum they are softened by immersion in hot water, moulded to the teeth,\\ncooled as rapidly as possible, taken off, and trimmed suitably. Then\\nthe splint is reapplied and the jaw T s bound together. If the tendency\\nto displacement is slight the bandage may be loosened during the day\\nto allow the introduction of liquid food, or a wedge may be kept\\nbetween the jaws so as to create an interval to be used for this purpose,\\nor advantage may be taken of the absence of teeth, especially from the\\nupper jaw. In a case quoted by Gurlt 2 two fragments of the alveolar\\n1 Ackland British Medical Journal, April 1, 1893.\\n2 Gurlt Loc. cit., vol. ii. p. 393.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0192.jp2"}, "189": {"fulltext": "TREATMENT.\\n169\\nborder carrying eight teeth were secured by a splint of sheet lead\\nmoulded to the teeth and fastened down by silver wire, the ends of\\nwhich were brought out under the chin by means of a needle and tied\\nover a roll of plaster. The wire caused no irritation and was left in\\nplace forty-seven days.\\nGutta-percha wedges were introduced by Dr. Hamilton to meet a\\ndouble indication, that of fixing the fragments securely and of allow-\\ning the easy introduction of food. Two pieces of gutta-percha of suit-\\nable size are softened and formed into wedges and introduced between\\nthe jaws, the edge of the wedge directed backward. The jaws are\\nclosed upon them, the fragments pressed up until the line of the teeth\\nis straight, and the wedges moulded to the sides of the teeth above and\\nbelow. As soon as the gutta-percha has hardened it is removed, trimmed\\nsuitably, and reapplied, and the jaws are bound together with a bandage.\\nFig. 63.\\nKingsley s interdental splint.\\nVulcanized rubber is a valuable substitute for gutta-percha in some\\ndifficult cases, but its employment requires special skill and experience\\nwdiich are found usually only among the dentists. Casts of one or both\\njaws are first taken in wax from these plaster models are made, and\\nupon these latter the splint. Figs. 62 and 63 show the splint as made\\nby Dr. Kingsley, of New York,\\nwith attached bars by which the FlG 64\\nsplint and jaw can be bound firmly\\ntogether, the bandage passing from\\none bar to the other underneath the\\nchin.\\nAnother method, which dates back\\nto Hippocrates, is to fasten together\\nthe teeth on opposite sides of the frac-\\nture by thread. In some cases I have\\nfound this to answer perfectly, in\\nothers to fail entirely. The liga-\\nture should be attached to the second\\nor third tooth from the fracture on\\neach side, and should be drawn very\\ntight,\\nA wire loop exactly moulded to\\nthe sides of the teeth and secured to them at several points by en-\\nHammond s wire splint for fracture of\\nthe jaw.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0193.jp2"}, "190": {"fulltext": "170 FRACTURES.\\ncircling loops (Fig. 64) has been found efficient also Angle s anchor\\nsplint/ in which the wire is attached to the teeth by metal collars\\ncemented on. In a few cases it has been found effectual to bind the\\njaws together by ligatures applied to opposing teeth.\\nDirect suture of the fragments by stout wire passed through holes\\ndrilled well below the alveolar border is said by Konig to be the\\nmethod which he has employed exclusively for several years.\\nRepair takes place so rapidly that, except in compound fracture with\\nmuch suppuration, there is rarely any tendency to displacement after\\nthe tenth day, and, therefore, the discomforts incidental to the contin-\\nuous closure of the jaws do not need to be borne for any great length\\nof time. If the importance of the case warrants it, if the displacement\\ncan be prevented only by keeping the jaws constantly in contact with\\neach other, the patient can be fed through a tube passed behind the last\\nmolar tooth, or through the nose, or by the rectum.\\nCleansing and disinfecting washes containing chlorate of potash,\\nborax, or alum will be found to add much to the comfort of the patient\\nwhenever they can be used.\\nAfter fracture of the neck of the condyle the tendency is to the dis-\\nplacement of the condyle forward by the traction of the external ptery-\\ngoid muscle, and as the fragment is too small to be acted upon directly\\nby any dressing this tendency, if manifested, cannot well be overcome.\\nThe treatment, therefore, is to reduce the displacement if it exists, and\\nthen to immobilize the jaw after having pressed it upward to inter-\\nlock the fragments. Ribes reduced the displacement by passing his\\nforefinger into the mouth and along the inner side of the ascending\\nramus until be reached the condyle and was able to press it back into\\nplace. Fountain obtained a good result by drawing the jaw well for-\\nward and wiring the teeth together, so as to maintain the position.\\nFracture of the coronoid process is not open to any treatment except\\nimmobilization.\\nFractures of the alveolar border are best treated, like fractures of\\nthe body, by immobilization after careful reduction of the displace-\\nment, and it is advisable not to make haste to remove loose or semi-\\ndetached teeth. They may become firmly adherent again, or, if this\\nshould fail, they may be removed subsequently without having caused\\nany serious trouble or delay.\\nDelayed union and pseudarthrosis are to be treated by the removal\\nof the cause, if any definite local one exist, or by operative interference,\\nfreshening of the surfaces of fracture, and w T iring of the fragments.\\n1 Angle Medical Eecord, August, 1890.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0194.jp2"}, "191": {"fulltext": "CHAPTEE XIII.\\nFKACTURES OF THE HYOID BONE.\\nThis comparatively rare lesion has received the attention of writers\\nonly within the present century. Malgaigne collected 8 cases, Hamil-\\nton added 2, and Gibb 3; in 1864 Gurlt collected 27 cases, 21 being\\nof the bone alone, while in 6 there was associated fracture of the thy-\\nroid or cricoid cartilage or of the trachea. I have seen 3 of the\\ngreater cornu. In 3 of Malgaigne s cases and in 5 additional of\\nGurlt s the fracture was caused by hanging, judicial or suicidal, one of\\nthe latter surviving; in 6 of these one of the greater cornua was\\nbroken, in the remaining 2 the body. In the other cases of the list\\nthe cause was violent grasping of the neck, or a blow, or fall, and in\\ntwo cases apparently muscular action, general muscular contraction\\nduring a fall. Valsalva reports a case of dislocation of one of the\\ngreater horns from the body/ caused by the effort to swallow a large\\npiece of food.\\nIn the great majority of the cases the fracture was of one of the\\ngreater cornua, and usually at or near its junction with the body. In\\nonly three cases was the body of the bone broken, and in none the\\nlesser horn.\\nSymptoms. The symptoms of fracture of one of the larger cornua,\\nwithout accompanying injury to the larynx or trachea, are, according\\nto the records, quite well denned and characteristic sharp pain at the\\nseat of fracture increased by pressure, speaking, or swallowing swell-\\ning in the same region appearing soon after the accident and due in\\npart to extravasated blood recognizable displacement or mobility of\\nthe fragment crepitus and sometimes free bleeding into the mouth,\\nthe result of perforation of the mucous membrane of the pharynx by\\nthe bone. Exploration of the pharynx will enable the surgeon to\\nrecognize displacement of the horn inward and perforation of the\\nmucous membrane if they exist. The patient is seldom able to move\\nthe tongue freely or without pain, and in some cases attempts to\\ndepress it or put it out have caused paroxysms of suffocation. In all\\nthe cases it has been difficult to swallow, even a drop of water some-\\ntimes causing the patient to cough and choke, and in many of them it\\nwas necessary to give food through an oesophageal tube, in one case\\nfor twenty days. In my own cases there was localized pain on press-\\nure, and the mobility of the cornu could be recognized by grasping the\\nbone with the thumb and finger on either side of the neck. The sub-\\njective symptoms were not urgent except when fracture of the larynx\\nwas associated one such died by suffocation while tracheotomy was\\nbeing done.\\nIn the single case in which a fracture of the body of the hyoid bone\\nin", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0195.jp2"}, "192": {"fulltext": "172\\nFRACTURES.\\nFig. 65.\\nwas observed during life the symptoms were severe paroxysms of\\ncoughing, dyspnoea, lividity of the face, and abundant bloody sputa,\\nand were relieved by the reduction of the displacement.\\nThe local and general reaction after the injury has been quite\\nmarked and although the bone appears to have united promptly con-\\nvalescence has been delayed by the persistence of the dysphagia and\\nof the change in the voice. In two cases an abscess formed at the seat\\nof fracture, and three months afterward the necrosed posterior frag-\\nment was cast out. In an unreported case of which I have heard a\\nsluggish abscess without necrosis formed, and the diagnosis was made\\nwhen the pus was evacuated.\\nThe possibility of repair by a bony callus is shown by three speci-\\nmens one, taken from the body of an adult man without a history\\nand presented to the London Patho-\\nlogical Society by Gibb, showing a\\nfracture of the right greater horn which\\nhad united with overriding to the ex-\\ntent of one-quarter of an inch, and dis-\\nplacement inward another (Fig. 65)\\nin the pathological collection of the\\ncollege at Brunswick, showing a frac-\\nture of the right greater horn united\\nwith some shortening and displacement\\ndownward the third, 1 found in the\\ndissecting-room, a fracture at the junc-\\ntion of the left cornu and body, united\\nw T ith angular displacement.\\nPrognosis. The prognosis, so far as\\nlife is endangered by the injury to the\\nbone, is favorable, but the associated injuries in the recorded cases\\nhave often been such as to cause death. Among these associated inju-\\nries fracture of the larynx is prominent.\\nTreatment. The treatment requires the reduction of displacement,\\nif possible and this might be facilitated by the introduction of the\\nfinger into the pharynx. It is unlikely that a bandage would be of\\nany service in opposing a tendency to the recurrence of displacement.\\nThe dysphagia may render nourishment through an oesophageal tube\\nnecessary, and associated injury of the larynx may require tracheotomy.\\n1 Scriber Medical Age, Detroit, January, 1892.\\nUnited fracture of the hyoid bone.\\n(Gtjrlt.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0196.jp2"}, "193": {"fulltext": "CHAPTER XIV.\\nFEACTUEES OF THE CAETILAGES OF THE LAEYNX AND\\nTEACHEA.\\nThis injury, although actually rare, is more frequent and much more\\ndangerous than fracture of the hyoid bone and has received more atten-\\ntion from writers. Gurlt s collection published in 1864 contained 47\\ncases, Dr. Hunt 1 collected and analyzed 27 cases but did not give the\\ndetails, andHenoque 2 collected 52 cases, to which Mr. Durham 3 added\\n10, making 62 in all, or including 4 of Gurlt s in which the trachea\\nalone was injured, 66. Piatt 4 reports one terminating fatally by\\nbroncho-pneumonia in three days.\\nThe following table shows the relative frequency with which the\\ndifferent parts are affected\\nCartilage broken.\\nCases.\\nDeaths.\\nRecoveries.\\nThyroid alone\\n24\\n18\\n6\\nCricoid alone\\n11\\n11\\nThyroid and hyoid bone\\n5\\n3\\n2\\ncricoid\\n9\\n9\\nand hyoid bone\\n2\\n2\\ntrachea\\n2\\n2\\nCricoid and trachea\\n2\\n2\\nand hyoid bone\\n1\\n1\\nLarynx\\n7\\n3\\n4\\nTrachea alone\\n4\\n1\\n67 54 13\\nThe causes are blows, falls, hanging, and the grasp of the hand in\\na fight, or in an attempt to strangle. The injury is seen more fre-\\nquently in males than in females, and in middle life than at any other\\nperiod, but youth and old age are not exempt. The mechanism of the\\nfracture of the thyroid or cricoid is usually either lateral compression on\\nboth sides or pressure backward against the vertebral column the first\\ncauses commonly longitudinal fracture of the thyroid cartilage near its\\nmiddle, together with flattening or depression of its sides, and either a\\ndouble lateral fracture of the cricoid cartilage or a single fracture in the\\nanterior median line the second causes irregular and multiple lines of\\nfracture. The mucous membrane of the larynx is frequently torn, and\\nextravasations of blood take place under the skin and mucous mem-\\nbrane or among the muscles.\\nSymptoms. The symptoms of fracture of the larynx are frothy\\nbloody expectoration with convulsive coughing and usually much\\n1 Hunt American Journal of the Medical Sciences, April, 1S66, p. 378.\\n2 Henoque Gazette Hebdomadaire, Sept. 26 and Oct. 2, 1868.\\n3 Holmes s System of Surgery, American edition, vol. i. p. 697.\\n4 Piatt Med. Chronicle, Dec, 1899.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0197.jp2"}, "194": {"fulltext": "174 FRACTURES.\\ndyspnoea and its attendant symptoms. The voice is affected or lost,\\nand swallowing often difficult and painful, although not so much so as\\nafter fracture of the hyoid bone and in all severe cases, when there\\nis laceration of the mucous membrane, emphysema appears promptly\\nand spreads steadily over the neck, face, trunk, the extremities, and\\nmediastinum, being sometimes more marked in the intermuscular than\\nin the subcutaneous connective tissue and sometimes causing pneumo-\\nthorax without wound of the lung.\\nThe additional objective symptoms are deformity of the region and\\nabnormal mobility of parts of the larynx upon each other, but both\\nthese signs may be unrecognizable on account of the swelling. I have\\nseen one case in which the only symptom was the mobility with crep-\\nitus of a small fragment at the upper posterior angle of the larynx\\nthere was also slight hoarseness.\\nIn some cases there have been no marked symptoms beyond a change\\nin the voice, although the character of the injury was made clear by\\ncareful examination, and the difference seems to be due to the absence\\nin these cases of any obstruction or narrowing of the air-passages by\\ndisplacement or swelling.\\nThe course in the severe cases is toward prompt death by suffocation,\\neither by gradual increase of the dyspnoea or by the sudden intercur-\\nrence of oedema of the glottis. Occasionally the dyspnoea does not\\nmake its appearance until some days after the injury. In the mild\\ncases the symptoms gradually subside, and recovery follows.\\nIt seems probable that repair is by a bony, or at least by a calcified,\\ncallus.\\nTreatment. The treatment in the milder cases consists of local anti-\\nphlogistics and quiet in the severer ones, of tracheotomy whenever\\nthe dyspnoea is great or increasing. It is not safe to wait until it has\\nbecome extreme, for its increase at the last is often so rapid and sudden\\nthat death takes place before relief can be given. It is, therefore, the\\npart of prudence to interfere early and before the interference is made\\nactually necessary by the defective breathing. Advantage should be\\ntaken of the opportunity afforded by the operation to reduce any dis-\\nplacement that may exist and that can be overcome by manipulation\\nthrough the wound.\\nTrachea. The symptoms of fracture of the trachea are similar to\\nthose of fracture of the larynx, except the local ones due to the dis-\\nplacements the diagnosis is difficult because of the lack of symptoms\\ndistinctive of the seat and character of the lesion. The prognosis is\\nunfavorable, and the treatment has usually been insufficient to avert\\nthe fatal termination or relieve the suffering, because in the few\\nrecorded cases the seat of injury has been beyond reach by operation.\\nThe indication for treatment is to insert a tube into the trachea past\\nthe point of fracture so as to insure free breathing.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0198.jp2"}, "195": {"fulltext": "CHAPTER XV.\\nFRACTURES OF THE STERNUM.\\nThe sternum, formed originally of several pieces, has an irregular\\nand uncertain development, only one feature of which needs here to\\nbe mentioned. The upper portion, the manubrium, may unite by\\nossification with the central portion, the body, at some time during\\nadult life, and in such case a traumatic separation of the two portions\\nis a fracture, not a dislocation.\\nFracture is rare, almost unknown, before the age of twenty years,\\nand is frequently associated with other fractures, especially of the ribs\\nand vertebrae. The fracture may be incomplete, multiple, transverse,\\noblique, or longitudinal. Of the first form there are but two recorded\\ninstances in both the infraction occupied the posterior surface of the\\nbone at or near the junction of the lower and middle thirds and was\\naccompanied by an abundant extravasation of blood into the anterior\\nmediastinum.\\nOf compound fractures, except such as were gunshot or stab wounds,\\nthere is but one example, reported by Duverney in 1751. A quarry-\\nman, while at work lying upon his side, was caught under a heavy\\nstone about five feet long which compressed his chest laterally with\\nsuch force as to separate the middle portion of the sternum from the\\nupper portion and force it through the skin. Death was immediate,\\nby rupture of the heart and lungs.\\nOf pure longitudinal fracture there is but one certain example, but\\nthere are two other cases in one of which there was a longitudinal frac-\\nture of the manubrium, and in the other of the body of the sternum\\nassociated with a transverse fracture at its upper end. The first case\\nwas that of a man who was overthrown and crushed by a falling wall\\nin addition to numerous contusions, the sternum was broken longitu-\\ndinally through its entire length, the right half being depressed\\nfrom eight to ten lines below the level of the left half. There was\\nprofuse bloody expectoration and difficult breathing. Reduction was\\naccomplished by drawing the right arm back and making forcible press-\\nure upon the middle of the sternal ribs of the right side and gentle\\npressure upon the left side. The patient recovered in six weeks.\\nCases of congenital fissure of the sternum have been mistaken for\\nlongitudinal fracture.\\nSimple transverse fractures form the great majority of fractures of\\nthe sternum, and occupy most frequently the junction between the\\nmanubrium and the body of the bone or its immediate neighborhood\\nthat is, the region of the second intercostal space next in frequency\\nare fractures at or near the middle of the bone, corresponding to the\\nthird rib and the third intercostal space they are rarely high in the\\n175", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0199.jp2"}, "196": {"fulltext": "176\\nFRACTURES.\\nmanubrium and below the middle of the body, and very uncommon as\\nseparations of the ensiform appendix from the body.\\nFractures of the manubrium occur most commonly a short distance,\\ntwo or three lines, above its lower border the periosteum sometimes\\nremains untorn upon either the anterior or the posterior surface in\\nsome cases there has been no displacement, in others either the upper or\\nthe lower fragment has been displaced forward, and in one case there was\\nangular displacement, the apex of the angle being directed backward.\\nIn several of the cases the fracture was produced by muscular action,\\nby straining during childbirth, or by the effort to raise a heavy weight\\nwith the teeth, the back being bent far back. In a large proportion\\nof cases in which the lesion was produced by external violence there\\nwas also fracture of the ribs, clavicle, or vertebra?.\\nFractures of the border have been observed in three instances, once\\nin connection with fracture of the ribs, a scale of bone corresponding\\nto the articulation with the first rib being broken off; a second time in\\nconnection with dislocation of the sternal end of the clavicle, the por-\\ntion to which the sterno-cleido-mastoid was attached being torn off and\\ndrawn upward nearly half an inch and in a third case in connection\\nwith a transverse fracture lower down.\\nTransverse fracture at or near the junction of the manubrium and\\nbody of the bone, and diastasis at this point, which is not always to be\\ndistinguished from fracture, are the commonest\\nforms of injury. In the great majority of cases the\\nlower fragment is displaced so as to lie in front of\\nthe upper one, and sometimes to override it is ex-\\nceptional for displacement to be absent or for the\\nupper fragment to lie in front of the lower one.\\nThere is reason to think that the periosteum is\\nalmost invariably torn upon the anterior surface,\\nbut that it sometimes remains untorn behind, a\\nfact which derives considerable importance from\\nits bearing upon the escape of blood into the ante-\\nrior mediastinum. One or both of the second pair\\nof ribs usually remain attached to the manubrium.\\nOut of a total of 105 cases of fracture of the\\nsternum collected by Gurlt, 27 are described as\\npartial or complete diastasis at the junction of the\\nfirst and second portions, the character of the lesion\\nhaving been determined by post-mortem examina-\\ntion in fourteen of them.\\nFractures of the body of the sternum (Fig. 66)\\noccur most frequently between the second and\\nfourth costal cartilages, are usually transverse, but\\nsometimes oblique laterally or from before back-\\nward. The displacements are the same as after\\nfracture at the junction of the manubrium and\\nsternum, and there is the same relative frequency of the projection of\\nthe lower fragment.\\nComminuted fracture of the bodv of the sternum has been rarely\\nTransverse fracture\\nof the body of the\\nsternum.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0200.jp2"}, "197": {"fulltext": "FRACTURES OF THE STERNUM. Ill\\nseen except in connection with gunshot and punctured wounds. Of\\ntriple fractures Gurlt found only two cases, and of double fractures\\nonly six, all of them associated with fracture of other bones, usually\\nthe ribs or vertebrae.\\nOf fracture or diastasis of the ensiform appendix, Gurlt collected\\nonly four examples, and the list does not appear to have been increased\\nby subsequent writers one was a fracture, the other three diastases.\\nThe fracture was produced in a man sixty years old by a fall upon the\\nsharp edge of a grain measure, and, when last examined, nine months\\nafter the accident, was still ununited, and crepitated on pressure, but\\ncaused no inconvenience. In the other three cases the prominent symp-\\ntom was persistent vomiting, which in one lasted for two years, recurring\\nevery five or six days, and then ceased spontaneously in another it\\nwas cured by grasping the process between two fingers and bending it\\nback into place and in the third, after it had lasted a month and\\ndeath by exhaustion seemed imminent, it was instantly relieved by\\nthe reduction of the displacement, which was accomplished by in-\\nserting a blunt hook into the abdominal cavity through an incision,\\nand drawing the process forward. The patients were aged respectively\\ntwenty-eight, eighteen, and nineteen years.\\nThe effusion of blood, which is observed after all fractures, may\\nattain an especial importance after fracture of the sternum, by the\\npressure which it may exert upon the underlying heart. The blood,\\ncoming from the torn vessels of the bone and periosteum, makes its\\nway forward into a region where it can do no harm if the periosteum\\non the posterior surface remains untorn but if this membrane shares\\nin the injury, and especially if one of the internal mammary veins or\\narteries is ruptured, the blood makes its way into the anterior medias-\\ntinum, and sometimes in sufficient amount to cause death promptly.\\nRupture of the pericardium, or of the heart, has been observed in a\\nfew cases; as has also probable laceration of the lung, evidenced by\\nthe appearance of subcutaneous emphysema or pneumothorax.\\nEtiology. Fracture of the sternum may be produced either by mus-\\ncular action or by external violence.\\nThere are four recorded cases in which the bone has been broken by\\nstraining during labor, and three in which the fracture has occurred\\nduring an effort to lift a heavy object.\\nExternal violence acts either directly by a blow upon the breast, or\\nindirectly by forcibly bending the body forward or backward, or pos-\\nsibly by a combination of the two forms in the fall upon the body of\\na heavy object, or the passage across it of a loaded wagon, or, according\\nto Lane, by depression of the shoulder acting through the clavicle and\\nthe upper ribs. It is not necessary that the force which acts directly\\nshould be very great to produce fracture it is sufficient for it to act\\nupon a limited area, as in a fall upon a stone, or stick, or the edge or\\ncorner of a box.\\nThe violence which produces indirect fracture is, in most cases, a fall\\neither upon the shoulders or buttocks, or with the back or breast across\\nsome fixed object, so that the trunk is bent sharply forward or back-\\nward in the one case the bone is broken by being bent forward, in the\\n12", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0201.jp2"}, "198": {"fulltext": "178 FRACTURES.\\nother by traction exerted through the muscular attachments at either\\nend.\\nDiagnosis. The diagnosis is readily made by the objective symp-\\ntoms the displacement, mobility, and crepitus and by the localized\\narea of pain excited by pressure, change of position, and the more\\nforcible respiratory acts. I have seen a few cases in which the only\\nsymptom was pain on pressure, with late ecchymosis. The examination\\nof the bone must be made carefully in order, on the one hand, to avoid\\nmistaking some irregularity of development for a traumatic displace-\\nment, and, on the other, not to overlook a second or third fracture, or\\neven a single one in case there should be no displacement. In cases\\nof supposed injury to the ensiform appendix the frequent irregularities\\nin the shape, position, and mobility of that part must be borne in mind.\\nThe importance of the injury is by no means so great as the mor-\\ntality of the recorded cases would indicate, for this mortality is largely\\ndue to associated lesions. Gurlt tabulated 98 cases with reference to\\nthis point, among others, and found that of 54 simple cases 46 recov-\\nered and 8 died, while of 44 complicated cases, cases, that is, in which\\nthere was some severe associated injury, only 1 recovered and 43 died.\\nOf 20 cases in which the fracture was certainly caused by direct vio-\\nlence, 15 recovered and 5 died, 3 of the latter being complicated cases.\\nCourse. The course in the uncomplicated cases is uneventful if pain\\nand oppression are marked at first they soon diminish and disappear, as\\ndo also expectoration of blood, dyspnoea, and orthopnea. The principal\\ndanger is from pulmonary complications, especially in the old and\\nalcoholic. In exceptional cases the local reaction may be great and\\nmay lead even to the formation of an abscess about the fracture. The\\npus may make its way to the surface betAveen the fragments or on the\\nsides, and if it collects upon the posterior surface and is discharged\\nimperfectly through a small opening, the sinus may persist indefi-\\nnitely, or the unnatural conditions may lead to extensive caries of the\\nbone. Both conditions require treatment by active operative inter-\\nference.\\nUsually repair takes place in from four to eight weeks, and by a\\nbony callus. The persistence of a certain degree of displacement is\\nnot uncommon, and in some cases the deformity has been extreme.\\nFailure of bony union has been observed in a few cases, but does\\nnot appear to have caused any disability beyond a temporary difficulty\\nin abduction and adduction of the arms.\\nGunshot fractures may be penetrating or non-penetrating. A num-\\nber of illustrative cases of each kind are given in the Surgical History\\nof the War of the Rebellion. The latter do not differ materially from\\ncompound fractures due to any other cause, but in the former the prog-\\nnosis is rendered very grave by the associated lesions.\\nTreatment. The first indication is to reduce such displacement as\\nmay exist. This is not always possible the most intelligently directed\\nand persistently conducted efforts have sometimes failed. The usual\\nmethod is direct pressure upon the projecting fragment, aided, espe-\\ncially when there is overriding, by traction upon the two pieces. The\\ntraction must be made, in part at least, through the muscles attached", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0202.jp2"}, "199": {"fulltext": "FR ACTUBES OF THE STERNUM. 179\\nto the ends of the bone, and is accomplished sometimes by resting the\\nback upon some rather firm object, as a cushion or box, and bending\\nthe head and shoulders forcibly backward. At the same time the\\npatient may be directed to take a full inspiration, and the surgeon\\npresses downward against the upper edge of the lower fragment if that\\none, as is usual, projects, or he draws this fragment downward by\\ntaking hold of the projecting ribs that are attached to it. Various\\nmodifications of the plan have been employed, but all have the same\\nfundamental idea, that of traction in opposite directions upon the frag-\\nments by forcible bending of the body backward.\\nA number of operative methods have been proposed for use in those\\ncases in which the displacement cannot be reduced by manipulation,\\nsuch as to raise the depressed fragment by a sort of gimlet screwed\\ninto it, or by an elevator or blunt hook passed under it through an\\nincision, or to cut away the projecting portion with a knife or trephine,\\nor to press it back with a rod carried directly down to it through an\\nincision. Most of these remain as suggestions that have not been put\\nto the test. One case has been already mentioned in which the ensi-\\nform appendix was drawn forward successfully by means of a blunt\\nhook passed into the peritoneal cavity in another, of fracture at the\\nupper part of the sternum with depression of the lower fragment, an\\nincision was made with the intention of introducing a hook, but the\\npleural cavity was opened and the surgeon felt it necessary to close the\\nwound immediately. In another the upper fragment was raised to the\\nproper level by screwing a sort of gimlet into it and drawing it for-\\nward, but it afterward sank partly back again, and a second attempt to\\nraise it was defeated by the tearing of the screw.\\nUnless the displacement is actually causing dangerous or distressing\\nsymptoms these methods of removing it by operation are hardly justi-\\nfiable, because they carry with them risks that should not be lightly\\nrun.\\nThe subsequent treatment consists in immobilization of the chest,\\nand, if necessary, in the use of measures to allay local inflammation\\nand to prevent coughing. A convenient dressing is a broad flannel\\nbandage pinned tightly about the chest after forced expiration, or bands\\nof adhesive plaster extending from side to side across the front of the\\nchest and covering the entire length of the sternum.\\nIf the formation of pus behind the bone is recognized or suspected\\nit should be promptly sought for and evacuated by cutting through the\\nbone at the seat of fracture.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0203.jp2"}, "200": {"fulltext": "CHAPTER XVI.\\nFRACTURES OF THE RIBS AND THEIR CARTILAGES.\\nFractures of the Ribs.\\nThese are among the commonest of all fractures, more common in\\nmen than in women, and almost unknown (or unrecognized) in infancy\\nand childhood probably many cases pass unrecognized, and the fre-\\nquency is even greater than the statistics show.\\nPathology. The fracture may be partial or complete, simple or com-\\npound, single or multiple. Partial fractures may be constituted either\\nby a fissure involving only one of the borders of the rib and, perhaps,\\nseparating entirely a longer or shorter fragment of that border, or by\\nan infraction. The former is very uncommon.\\nComplete fractures may be transverse, oblique, irregular, or multiple,\\nand may be limited to a single rib, or may involve all the true ones on\\none side, and in some cases even many on both sides. The central\\nribs are the ones most frequently broken. Fracture of the twelfth is\\nvery rare Gurlt could find only two recorded cases, the causes being\\na fall against the edge of a step and a table respectively. I saw one\\nat the Hudson Street Hospital in 1896, in a man, fifty years old, who\\nhad been caught about the waist in the loop of a hawser. He died a\\nfew days later of coincident rupture of the large intestine the twelfth\\nrib was broken obliquely at its centre.\\nFracture of the first rib was formerly thought to be almost equally\\nrare, but the observations of Lane l and Marsh 2 indicate that fracture\\nof it or its cartilage may be rather common. Lane found four speci-\\nmens in a series of 200 bodies in the dissecting-room, and Marsh saw\\nfour cases in six months hospital service. According to Lane this rib\\nis easily broken by forcible depression of the shoulder acting by direct\\npressure of the clavicle. The symptom is said to be pain behind the\\nupper part of the sternum on lifting with the corresponding hand.\\nThe fracture of a rib may occupy any part of it, but is most fre-\\nquent on the side and anterior half. The periosteum may remain\\nuntorn, and the fragments preserve their relations to each other, or\\nthey may form a re-entrant or a salient angle, or override each other.\\nIf several ribs are broken at the same time and forced inward the\\ndepression may remain both broad and deep. Overriding of the frag-\\nments is impossible unless several ribs are broken at the same time,\\nfor the muscular and fibrous attachments of the adjoining ones hold the\\nfragments in place, and the ribs above and below act as splints to pre-\\nvent shortening. In double or multiple fracture of one or several ribs\\n1 Lane British Medical Journal, 1S87, vol. ii. p. 119. and Guy s Hospital Keports, 1886,\\np. 429. 2 Marsh Lancet, June 30, 1888.\\nISO", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0204.jp2"}, "201": {"fulltext": "FRACTURES OF THE RIBS AND THEIR CARTILAGES. 181\\nthe intermediate piece or pieces may be so loosened that they move in\\nand out with every inspiration.\\nIn compound fractures the wound of the soft parts is rarely, if ever,\\ncaused by the projection of the broken end of the rib, but always by\\nthe object which produced the fracture.\\nThe complications include injuries to the muscles, which are rarely\\nimportant, to the intercostal arteries, and to the thoracic and abdom-\\ninal viscera. The intercostal arteries are rarely seriously injured,\\nalthough moderate hemothorax is not uncommon after fracture of the\\nmiddle third, especially of the sixth to the ninth ribs. Fatal hemor-\\nrhage into the pleural cavity has occurred in a few cases, even after\\nfracture of a single rib and by slight violence.\\nA wound of the pleura and of the lungs is a rather common com-\\nplication, and is generally caused by the sharp end of a fragment, but\\nin some cases fatal injury of the lung has been caused by the crushing\\neffect of the external violence acting through the, perhaps unbroken,\\nribs; the thorax is compressed by the force, and the lung is put upon\\nthe stretch in such a manner that it is actually torn, not perforated by\\nthe bone. The consequences of the wound vary with its size and with\\nthe relations existing between the lung and the thoracic wall. If these\\nlatter are normal that is, if the lung is not adherent at the wounded\\npart air and blood escape more or less freely into the pleural cavity,\\nand the lung collapses if, on the other hand, the lung is adherent,\\nthe escaping air makes its way into the meshes of the connective tis-\\nsue, and may spread through the mediastinum, under the pericardium\\nand pleura, and into the interlobular tissue of the lung itself and the\\nsubcutaneous tissue on the surface of the body. Emphysema of the\\nsurface may be produced also when the lung is not adherent the air\\nwhich has escaped into and filled the pleural cavity is forced by the\\ncontraction of the chest during expiration out through the opening at\\nthe fracture, and its place is supplied at the next inspiration by fresh\\nair drawn in through the wound of the lung, and thus a small quan-\\ntity is pumped into the outer cellular tissue at each respiration, and\\nthis will continue until one or the other opening is closed by a clot or\\nexudation or a change in the relations of its walls.\\nWounds of the heart are much rarer, and even more dangerous.\\nGurlt collected six cases, in only four of which the wound of the heart\\nappears to have been caused by the broken rib in the other two it\\nappears to have been caused by the compression of the heart between\\nthe anterior chest-wall and the vertebral column, for the pericardium\\nwas untorn.\\nEtiology, Fractures of the ribs may be caused by muscular action\\nor by external violence. Of muscular action the most common form\\nby far is coughing; others are sneezing, lifting a heavy object, even\\nturning in bed. The lower ribs, especially the eleventh, are the ones\\nmost frequently broken in this way, but it has happened to the second,\\nfourth, fifth, and sixth. It is much more common on the left than on\\nthe right side. (See forty cases collected by Tunis in University Med-\\nical Magazine, November, 1890.)\\nBy far the most common cause of fracture is external violence, by", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0205.jp2"}, "202": {"fulltext": "182 FRACTURES.\\na blow, fall, or excessive pressure. The fracture may be direct or\\nindirect, but it is not often easy to distinguish between these two\\nvarieties. It has been claimed on theoretical grounds that in indirect\\nfractures caused by pressure upon or near the sternal ends of the ribs\\nthe bone would yield near its centre, at its point of greatest curvature\\nbut this view is not supported by clinical or experimental facts. On\\nthe contrary, the fracture is found much more frequently in either the\\nanterior or the posterior third, and, indeed, the point of greatest fre-\\nquency seems to be very near that at which the force is received, an\\ninch or two on the outer side of the sternal end of the bone.\\nSymptoms. The symptoms of fracture of a rib in the less severe\\ncases are likely to be obscure. The breathing is shallow and some-\\ntimes catching through pain or fear of pain, and occasionally there is\\nvery troublesome reflex cough. Pain is provoked by pressure, inspi-\\nration, coughing, sneezing, and certain movements of the body its\\ndiagnostic value comes from its limitation to one point under the dif-\\nferent causes and especially when pressure is made on the affected rib\\nat a distance.\\nAbnormal mobility is sometimes present, but the elasticity and\\nmobility of the ribs make its recognition uncertain. It may sometimes\\nbe made out by placing a finger on each side of the suspected fracture,\\nand pressing alternately with one and the other. The same manipula-\\ntion may produce crepitus, but usually this is more readily recognized\\nby placing the hand flat upon the chest, and pressing slightly at dif-\\nferent points, or asking the patient to cough or draw a long breath.\\nIt may also be heard sometimes on auscultation of the chest in the\\nusual manner, and may be accompanied after a day or two by a pleu-\\nritic friction sound, the result of a pleurisy excited by the trauma-\\ntism, and usually limited in area to its immediate neighborhood. It\\nis not uncommon for the patient himself to recognize the crepitus.\\nEmphysema is, in itself, a very positive sign of injury to the lung and\\nof fracture of a rib if there is no penetrating wound to account for it\\notherwise. Pneumothorax, or hemorrhage into the pleural cavity from\\na lacerated lung or an intercostal artery may be present in any of the\\nseverer cases and bloody expectoration, which also points toward\\nfracture, is often present even in slight cases, and is not infrequently\\nabsent in grave ones.\\nThe symptoms of partial fracture or infraction are seldom definite\\nenough to permit a positive diagnosis.\\nThe course of a simple uncomplicated fracture is usually quite\\nuneventful; the patient remains quiet, sometimes keeping his bed, and\\nbreathes carefully and superficially to avoid pain after two or three\\nweeks he finds these precautions unnecessary, and the surgeon finds on\\nexamination that the local tenderness has disappeared, and that crep-\\nitus and mobility can no longer be detected. Union by a bony callus\\ntakes place almost invariably, notwithstanding the defective immobili-\\nzation of the parts, but, as a consequence of the latter, the callus is\\nlikely to be large, and, when two or more ribs have been broken, to\\nunite the adjoining ones by a bridge of new formation. Solidity is\\ngiven at first by an ensheathing callus, and the union between the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0206.jp2"}, "203": {"fulltext": "FBACTUBES OF THE BIBS AND THEIB CABTILAGES. 183\\nfractured surfaces, even when they are in apposition, may remain\\nfibrous for several months. Failure of union is rare.\\nDisplacement upward or downward of one or more of the fragments\\nmay lead to its union with the adjoining rib, or to the formation of a\\nlateral joint between them, as in the next following case; or, if adjoin-\\ning ribs are displaced in opposite directions, a gap may be left between\\nthem which may lead to hernia of the lung, as in the following case\\nwhich is recorded in the Gazette Medicalc de Paris, 1832, p. 465, and\\npictured in Cruveilhier s Atlas d Anatomie Pathologique.\\nThe patient died at the age of 62 years in his youth he had sus-\\ntained a fracture of the ribs by being crushed between the pole of a\\nwagon and a wall. Between the third and fourth ribs on the right side\\nnear the sternum was a reducible tumor composed of normal lung and\\ncontained in a real hernial sac. The first rib was intact, the second and\\nthird were broken about three inches from their cartilages with dis-\\nplacement inward of the anterior fragment, overriding, and a vertical\\ndisplacement that brought the posterior fragments into contact and led\\nto the formation of a false joint between them. The fourth rib was bent\\nsharply downward, forming the lower limit of a gap that was four\\ninches long and two and a half inches wide at the widest part, and\\nthat was bounded above by a small strip of bone extending from the\\nfourth costal cartilage along the lower border of the third rib, and\\nbecoming attached to the latter near its middle.\\nThe course and symptoms in the severer cases vary with the degree\\nand character of the complications which give them their gravity.\\nEmphysema may be slight and transitory, or it may continue for days\\nand spread over a large portion of the surface of the body. If the air\\nescapes into the cavity of the chest, or if the fracture is compound with\\na penetrating wound, the resultant dyspnoea and oppression may be\\nextreme, and the physical signs of pneumothorax will be found upon\\nexamination. If, in addition to the escape of air, there is also free\\nhemorrhage into the chest from the torn lung or an intercostal artery,\\nthe physical signs will be correspondingly modified. Extreme dysp-\\nnoea, due to congestion of the lung following promptly upon the injury,\\nis not uncommon, and pneumonia occasionally results and leads to a\\nfatal termination in the old and feeble.\\nI have observed in half a dozen cases of severe compression of the\\nchest with fracture or dislocation of ribs or, more commonly, costal\\ncartilages, a peculiar dusky discoloration of the skin of the face, neck,\\nand upper part of the chest, together with marked subconjunctival\\necchymosis nearly limited to the interpalpebral space. The discolora-\\ntion does not disappear on pressure and is apparently due to the color-\\ning matter of the blood, possibly through innumerable minute capillary\\nextravasations. It appears immediately, is evidently due to the com-\\npression of the chest, and disappears slowly, usually taking several\\nweeks. 1\\nLegros Clark 2 claims that serious functional derangement, without\\norganic lesion of the lung, may result from contusion or concussion of\\n1 New York Medical Journal, March 1, 1890.\\n2 Clark Diagnosis of Visceral Lesions, p. 213.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0207.jp2"}, "204": {"fulltext": "184 FRACTURES.\\nthe chest, that it may be transient or may be followed by inflammation,\\nlocal or general, of the affected lung, and that it is sometimes observed\\nin the lung on the side opposite that which has sustained the injury.\\nPrognosis. The prognosis depends largely upon the complications.\\nSimple fractures without important complications do well, as a rule;\\nthe exceptions are found mainly in the old and feeble, w r hose lives may\\nbe endangered by congestion of the lungs, pneumonia, or pleurisy.\\nCases complicated by wound of the heart or pericardium are usually\\npromptly fatal. Wounds of the lungs are serious, but there are many\\ninstances of recovery even in cases where the laceration of the lung\\nwas probably extensive and accompanied a fracture that w T as in itself\\nsevere.\\nTreatment. The indications for treatment are to reduce any displace-\\nment that threatens to produce a complication or that causes pain, to\\nimmobilize the chest-wall, and to relieve or prevent pulmonary inflam-\\nmation or congestion.\\nOutward angular displacemont may be corrected by pressure upon\\nthe projecting angle, and inward angular displacement may sometimes\\nbe corrected, when the broken surfaces are still in contact and the frac-\\nture is situated near the middle of the rib, by pressing the sternum\\nbackward and thus springing the bone out. If the fragments have\\noverriden this manoeuvre is worse than useless, for it can only increase\\nthe displacement. Malgaigne says the method was proposed by Lionet\\nfor use in those cases in which the pain is severe although the displace-\\nment is slight. Relief may also be obtained by making the patient\\nstrain or draw full deep breaths. Ravaton relieved the pain and cor-\\nrected the displacement in one case by suspending the patient upon two\\nrods passed under his axilla?.\\nWhen the displacement was greater and one of the fragments was\\npressed inward Malgaigne ingeniously made use of the other to elevate\\nit, pressing it in until the ends met and became locked together by the\\nirregularities of their broken surfaces so that the elasticity of the second\\nshould serve to raise the first.\\nFor this elevation or removal of a depressed fragment by operation\\na number of methods have been proposed, but very few instances are\\nknown of the use of any of them. If such elevation should seem\\nnecessary, and if approach through an incision were deemed inadvisable\\nbecause of the risk of the admission of air to the pleural cavity, the\\nold suggestion of raising the bone by means of a hook passed through\\nthe skin and behind the upper border of the bone might be used.\\nImmobilization of the chest is best effected by surrounding it with\\na broad, snugly drawn piece of adhesive plaster, or with two or three\\nnarrower strips. The guide to the amount of pressure is the comfort\\nof the patient. Malgaigne preferred a bandage three or four inches\\nwide and long enough to pass once and a half around the chest, and\\nhe did not place it lower than the ensiform appendix, believing it to\\nbe sufficient, whichever ribs might be broken, to restrain the move-\\nments of the middle ones. When a circular bandage cannot be borne\\nhe recommends that a long narrow strip of plaster should be carried\\nfrom the anterior end of the seventh rib on the right side, for example,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0208.jp2"}, "205": {"fulltext": "FBACTUBES OF THE BIBS AND THEIB CABTILAGES. 185\\nacross the front of the chest, under the left arm and across the back to\\nand over the right shoulder, thence again across the chest in front and\\naround the left side and back to end at the crest of the right ilium.\\nThis immobilizes the left side of the chest very effectually and leaves\\nthe right side free. He suggests that in addition the arm should be\\nfixed to the side.\\nThe pressure of a bandage is useful also to prevent the spread of\\nemphysema. This complication seldom requires any more active treat-\\nment, although scarifications have been made or the air drawn off through\\na trocar. If either method is used the instrument must be applied at\\na distance from the fracture, so as not to incur the risk of making it a\\ncompound one. The more dangerous variety of emphysema, that in\\nwhich the air makes its way into the mediastinum and the interlobular\\ntissue of the lung, is not amenable to operative treatment.\\nIn pneumothorax it may be desirable to draw off the air through an\\naspirating needle or a canula in order to relieve the pressure, and if\\nblood accumulates within the pleural cavity in quantities sufficiently\\nlarge to endanger life by interference with the action of the heart and\\neither or both lungs, it may become necessary to remove it by aspiration\\nor incision, but the indications should be very plain before the surgeon\\ndecides to interfere in this manner, since the removal of the clotted\\nblood and the relief of pressure may only lead to a return of the bleed-\\ning. Persistent internal hemorrhage can be treated only by indirect\\nmeasures, because its source cannot be recognized, and, if recognized,\\nprobably could not be reached, It has been found useful to constrict\\nthe thighs circularly at the groin with rubber tubing or a roller-bandage\\njust sufficiently to arrest the venous current this withdraws a consid-\\nerable amount of blood temporarily from circulation and acts as a\\nvenesection. It sometimes arrests bleeding instantly.\\nWhen life is threatened by pulmonary engorgement with extreme\\ndyspnoea, blood should be taken from the arm immediately and freely,\\nand the bleeding should be repeated if the symptoms reappear. The\\nolder records are full of cases showing the benefit of this practice, and,\\namong modern surgeons, Mr. Bryant recommends it unhesitatingly and\\nforcibly. He says Bleed with no sparing hand. When relief\\nhas been obtained arrest the flow immediately, as syncope can only\\ndo harm, then follow with antimony.\\nFractures of the Costal Cartilages.\\nThe first mention made of this lesion appears to have been by\\nZwinger in 1698, and it is not again referred to in medical literature\\nuntil 1805, when Lobstein, at Strasburg, and in 1806 Magendie, at\\nParis, each described it with cases. Additional observations were made\\nby Delpech, Sir Astley Cooper, and Velpeau, and in 1841 Malgaigne 1\\npublished a paper upon the subject which, six years afterward, he\\nreproduced in part in his book on fractures. Since then but little\\nwork has been done upon the subject, most writers contenting them-\\nselves with reproducing in substance Malgaigne s chapter. Gurlt col-\\n1 Malgaigne Bulletins de Therapeutique, 1841, p. 227.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0209.jp2"}, "206": {"fulltext": "186 FRACTURES.\\nlected more than thirty cases for the chapter upon it in his book on\\nfractures, and Paulet, 1 who appears not to have known of Gurlt s\\nwork, gives fourteen cases which he obtained by a partial search through\\nFrench periodical literature, only four of which are mentioned bv\\nGurit, Bourneville 2 (1880) and Pozzi 3 (1888) raised the list to seventy-\\nnine cases. I have seen two or three.\\nFractures occur much more frequently at or near the junction of the\\ncartilage and rib than at any other point, and more frequently in the\\nseventh and eighth ribs than in any other. The fracture may be double,\\nand may involve several cartilages on one side or on both. All the\\nrecorded fractures have been complete with the exception of one case\\nthey have been perpendicular to the long axis of the cartilage, or very\\nslightly oblique, and the surface has always been smooth, without ser-\\nrations or splinters.\\nIt is probable that persons advanced in life are more liable to this\\nfracture than the young, because of the calcification or ossification of\\nthe cartilages, but it has occurred in young men (seventeen years) and\\neven in a child seven years old.\\nDisplacement has been absent in a very few cases in most it takes\\nplace in the antero-posterior direction, and in some the fragments have\\noverriden in the direction of the long axis of the rib. This latter\\nform, probably, is possible only in the longer and more curved ribs, or\\nwhen several adjoining ones are broken. The separation in either of\\nthese two directions may amount to as much as an inch, but is rarely\\nso great. Either fragment may lie in front of the other, although the\\ncostal fragment projects more frequently than the sternal one the dis-\\nplacement, however, appears to depend entirely upon the direction of\\nthe fracturing force and upon the position occupied by the patient, and\\nconsequently to follow no definite laws.\\nJSTo instance of a compound fracture of a costal cartilage is on record,\\nand the complications are less frequent and, as a rule, less serious than\\nthose accompanying fractures of the ribs. In some cases where the\\nviolence has been extreme and many cartilages have been broken fatal\\ninjury has been done at the same time to the heart or great vessels, but\\nnot by the penetration of one of the fragments the viscera are crushed\\nor torn by the continued action of the force after the wall of the chest\\nhas yielded under it.\\nHernia of the lung has been observed in three cases, one after frac-\\nture of the third and fourth cartilages and rupture of the intercostal\\nmuscles by the fall of a heavy weight, the second, a double one, after\\nfracture or diastasis due to paroxysms of coughing, and the third,\\nobserved by Legros Clark 4 after a blow received from the shaft of some\\nvehicle. In this one the cartilage of the second rib was driven in,\\ncreating a gap through which a tumor as large as the fist appeared at\\neach inspiration and disappeared at each expiration, leaving a depres-\\nsion capable of containing at least two ounces of liquid. Recovery in\\n1 Paulet Diet. Encvclopedique, First Series, vol. xxi., art. Cotes, 1878.\\n2 Bourneville Progres Med., 1880. 3 Pozzi Ibid., October 20, 1888.\\n4 Legros Clark Loc. cit., p. 206.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0210.jp2"}, "207": {"fulltext": "FRACTURES OF THE RIBS AND THEIR CARTILAGES. 187\\nthree weeks, the gap persisting but evidently occupied by some\\nplastic deposit.\\nIn seven cases the fracture has been produced by muscular action,\\neither an excessive effort, as to avoid a fall or to throw a heavy object,\\nor coughing or sneezing. Thus Broca l reported the case of a porter\\nat the market who having placed a sack of peas upon his shoulder\\nasked a comrade to add another to it. The latter threw the second sac\\nheavily upon him, and in the effort to avoid a fall under the weight he\\nfractured the cartilages of the sixth, seventh, and eighth ribs on the\\nright side at points seven or eight centimetres from the median line.\\nFractures by external violence may be direct or indirect. Gurlt,\\nthinks the indirect fractures take place at or near the costo-chondral\\njunction, the force acting upon the rib itself in such manner as to spring\\nits anterior end outward, while in the direct fractures the force is\\nexerted upon a restricted area of the cartilage itself, as in a fall upon\\nthe edge of a tub or step, the blow of a fist, the kick of a horse.\\nThe symptoms are local pain and deformity. Crepitus and abnormal\\nmobility are not often recognizable, but if displacement is present it can\\nusually be made out by following the outline of the rib and cartilage\\nwith the finger and by observing that it can be increased or diminished\\nby pressure upon one or the other fragment. It may not be easy in\\nsome cases to say whether the fracture involves the rib or the cartilage\\nand in others whether it is a fracture of the cartilage or a dislocation\\nof its sternal or costal end, but the question has no practical impor-\\ntance.\\nThe prognosis, independent of complications, is favorable, and the\\nfracture may be expected to unite in three or four weeks. Our knowl-\\nedge of the mode of repair has been obtained partly by experimentation\\nand partly by examination of specimens. When the fragments remain\\nend to end and the fractured surfaces are more or less completely in con-\\ntact, a fibrous band unites them, and the union is strengthened by an\\nexternal ring of spongy bone. In a specimen obtained by Basserau 2\\nand examined microscopically by Malassez, and in one reported by\\nPozzi, 3 it was found that the central band was partly cartilaginous,\\nand it is asserted that in other specimens points of ossification have\\nbeen found.\\nFig. 67. Fig. 68.\\nRepair of fracture of a costal cartilage. (Gurlt.) Repair of fracture of a costal cartilage.\\nWhen the fragments override, they take, so far at least as the broken\\nends are concerned, little or no part in the repair. Union is accom-\\n1 Broca Quoted by Paulet, loc. cit., p. 83. 2 Basserau Paulet, loc. cit., p. 88.\\n3 Pozzi Loc. cit.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0211.jp2"}, "208": {"fulltext": "188 FRACTURES.\\nplished by an intermediate band which is at first fibrous or cartilaginous\\nand may become bony (Fig. 67), or if the fragments are in contact\\nthe new bone forms on the sides and the ends (Fig. 68), and in both\\ncases it envelopes the pieces more or less completely like a ring. This\\nring originates apparently in the perichondrium, and its ossification is\\nthe final result of the formative irritation created by the traumatism,\\nand is analogous to the ossification seen so constantly not only in carti-\\nlage which would normally be transformed into bone, but also in others,\\nsuch as that of the larynx, whose normal evolution does not include\\nthat change.\\nTreatment. The treatment is similar to that of fracture of the ribs\\nreduction of a displacement if necessary and possible, and immobiliza-\\ntion. The former must be accomplished, if at all, by placing the\\npatient upon the opposite side or upon his back, by drawing the shoul-\\nders back, or by deep inspirations the latter by a body bandage, strips\\nof adhesive plaster, or, following Malgaigne s example, by a hernial\\ntruss so placed as to restrain the fragment that tends to project.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0212.jp2"}, "209": {"fulltext": "CHAPTER XVII.\\nFRACTURES OF THE CLAVICLE.\\nFeacture of the clavicle is a common injury and is especially\\nfrequent in childhood, taking the place at that age, as was pointed out\\nby Kronlein, of dislocation of the shoulder by direct violence later in\\nlife. That is, a fall upon the shoulder breaks the clavicle of a child\\nbut dislocates the shoulder of an adult.\\nPathology.\\nIt has been found convenient by most modern authors for the pur-\\nposes of study and description to divide the fractures into three groups,\\naccording as they occupy the inner, middle, or outer thirds of the bone.\\nThe average length of the clavicle is six inches, and this division into\\nthirds of about two inches each corresponds to anatomical differences\\nof considerable clinical importance. To the flattened outer third are\\nattached the trapezius and deltoid muscles and the strong coraco-clavic-\\nular ligament binding it to the coracoid process, the inner fasciculus of\\nwhich, known as the coracoid ligament, marks the inner limit of this\\nportion, and can sometimes be readily felt upon the living body. The\\ndividing line between the inner and middle thirds is not so definitely\\nmarked anatomically, it corresponds approximately to the point where\\nthe clavicle crosses the lower or outer edge of the first rib. The inner\\nthird is attached to the sternum by the sterno-clavicular ligaments, and\\nto the cartilage of the first rib by the costo-clavicular or rhomboid\\nligament. To its upper border is attached the sterno-cleido-mastoid\\nmuscle, to its lower the pectoralis major.\\nSince the outer third is broadly attached by ligaments to the scapula\\nit is apparent that after fracture of the bone in the inner or middle\\nthird the outer fragment will not be able to change its relations to the\\nscapula materially, and that its displacement, therefore, will be gov-\\nerned by the change of position of the latter, by its sinking inward\\nand forward to the side of the chest in consequence of the loss of its\\nanterior support.\\nThe outer portion of the middle third is by far the most common\\nseat of fractures observed clinically, but Lane s 1 observations in the\\ndissecting-room and his experiments indicate that fractures of the outer\\nthird may be very frequent and usually unrecognized.\\nThe fracture may be partial or complete, single or multiple, simple\\nor compound the most frequent form is simple complete fracture.\\nCompound fracture is so rare that Gurlt says he could find only four\\nexamples of it, and Hamilton, who gives the same four cases, says he\\n1 Lane: Guy s Hospital Eeports, 1886, vol. xliii.\\n189", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0213.jp2"}, "210": {"fulltext": "190 FRACTURES.\\nhad never met with an example. I have seen one An Italian laborer\\nwas struck by a falling stone upon the shoulder and sustained a\\nfracture of the right clavicle at a point nearly two inches from the\\nsternal end of the bone. The line of fracture was oblique from above\\ndownward and inward. A large ragged wound extended backward\\nacross the clavicle and shoulder, in which some of the divided fibres\\nof the trapezius could be seen. The outer end of the inner fragment\\nwas directed sharply upward, the outer fragment lying below and a\\nlittle distance from it. The wound healed almost entirely in about six\\nw r eeks, but when last seen there was still a sinus over the end of the\\ninner fragment from which pus flowed freely and through which a\\nprobe could be passed to the bone.\\nIncomplete or partial fracture is, according to Hamilton, who has\\ngiven much attention to this variety, very common. He thinks that\\n34 of the 157 fractures of the clavicle recorded by him 1 were partial\\nfractures, and says that at least eleven of these were immediately and\\nspontaneously restored to their natural axes. The symptoms accepted\\nfor this diagnosis are the history of a fall upon the shoulder, or at least\\nindirect violence, the youth of the patient, a swelling upon the upper\\nsurface and front or rear border of the middle third of the bone appear-\\ning within two or three days after the accident, possibly a change in\\nthe axis of the bone, and possibly ability to straighten it with slight\\ncrepitus.\\n1. Complete fracture of the middle third may be oblique or transverse,\\nthe former variety being found most commonly in adults, the latter in\\nchildren. The line of an oblique fracture usually runs inward and\\ndownward or backward, but may take any other direction and may be\\nnearly transverse, or extremely oblique (Fig. 69), or practically longi-\\nFig. 69.\\nOblique fracture of the clavicle.\\ntudinal, as in a case observed by Chassaignac and mentioned by Polail-\\nlon, 2 in which the fracture ran from the centre of the acromial end to a\\npoint just external to the sterno-clavicular articulation, dividing the\\nbone into two longitudinal halves. Multiple and comminuted fractures\\nare rare. When the fracture is multiple or double, the intermediate\\nfragment is likely to occupy a very irregular position.\\nThe most common displacements are produced by the falling for-\\nward, downward, and inward of the shoulder, the consequences of the\\nloss of support normally furnished by the clavicle, and depend some-\\nwhat upon the direction of the line of fracture. The commonest form\\n1 Hamilton Fractures and Dislocations, 6th ed., p. 90.\\n2 Polaillon Diet. Encyclopedique, art. Clavicule, p. 682.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0214.jp2"}, "211": {"fulltext": "FRACTURES OF THE CLAVICLE. 191\\nis that in which the sternal fragment is drawn upward by the sterno-\\ncleidomastoid muscle or pushed upward by the outer fragment, which\\nis displaced inward along the under or anterior surface of the other\\nand has at the same time changed its direction somewhat by the sink-\\ning of its acromial end. The shortening may be very notable, nearly\\none- third of the entire length of the bone in a specimen mentioned by\\nMalgaigne. Another form is found where the line of fracture is such\\nthat the fragments do not readily leave each other, and the broken\\nends are displaced together upward and backAvard by the falling in\\nof the shoulders so that the bone forms an angle at the seat of fracture.\\nIn some exceptional cases the outer fragment has lain upon the upper\\nor posterior surface of the inner fragment. Malgaigne 1 says this\\nvariety was mentioned by Hippocrates, and that he himself saw one,\\nbut only one, example of it. Under these circumstances the sternal\\nfragment is held down instead of being pushed up by the other one,\\nand the displacement is mainly in the direction of the latter, the inner\\nend of which is turned upward, forming a projection at the seat of\\nfracture.\\nFig. 70.\\nFracture of the clavicle. Union with extreme displacement.\\nFig. 71.\\nFracture of the clavicle.\\nIn transverse fractures the broken surfaces seldom leave each other,\\nand the only displacements possible are in thickness and direction, the\\nlateral and angular. The latter is the one usually seen, the angle\\nbeing directed, for reasons that have been already stated, upward and\\nbackward.\\nThe most common and persistent cause of these displacements is\\nundoubtedly the tendency of the scapula and shoulder to fall forward\\nand inward upon the chest, but it is aided largely in the first place by\\nthe fracturing force which continues to act after the bone has yielded\\nto it. Thus, in a fall upon the shoulder or the outstretched hand, the\\nclavicle breaks by the exaggeration of its normal curves, and as the\\ndirection of the line of fracture is usually downward and inward the\\nouter fragment is forced inward on the under side of the other and\\nnecessarily turns the outer end of the latter upward.\\n2. Fracture of the Outer Third. This variety is next in frequency to\\n1 Malgaigne Loc. cit., p. 468.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0215.jp2"}, "212": {"fulltext": "192 FRACTURES.\\nthe preceding, and may be produced by direct or indirect violence.\\nThe direction of the line of fracture is more commonly transverse than\\noblique. The degree of displacement varies greatly in different cases,\\nbeing very notable in some and slight or entirely absent in others.\\nWhen displacement exists it is usually an angular one, the apex of\\nthe angle being directed backward. In some specimens 1 bony union\\nhas taken place between the clavicle and the scapula, presumably by\\nossification of the coraco-clavicular ligament. It is in the form of a\\nprop extending from the under side of the clavicle to the base of the\\ncoracoid process, and sometimes to the notch of the scapula, and\\nusually convex posteriorly.\\nFig. 72.\\nFracture of the clavicle, outer third. Extreme angular displacement. (R. W. Smith.)\\nWhen the fracture is external to the trapezoid ligament that is,\\nwhen it lies within the outer inch of the bone angular displacement is\\nthe rule, the outer fragment turning forward and inward until its axis\\nis at right angles with that of the inner fragment sometimes its broken\\nsurface lies against the anterior border of the inner one, and sometimes\\nthe outer fragment lies under the inner one. Malgaigne describes a\\ncase in which, after fracture within half an inch of the articular sur-\\nface, the inner fragment was elevated an inch above the other, and\\nthere was shortening of nearly half an inch the appearance, in short,\\nwas that of a dislocation upward of the acromial end of the clavicle.\\n3. Fracture of the Inner Third. The older division, which was into\\nfractures of the body and fractures of the outer end, took no special\\nnotice of this variety which received its first separate description from\\nMalgaigne. It is the least common of the three Delens, 2 who wrote\\nthe first formal article upon the subject, collected twenty-eight cases, to\\nwhich Polaillon two years later added three. I have seen one caused\\nby a direct blow with a baseball. The fracture may occupy any point\\nin the division, and is more often oblique than transverse. It was\\nasserted at first that the displacement did not occur if the fracture was\\nwithin the region of the attachment of the costo-clavicular ligament,\\nbut the contrary has since been proved displacement may take place\\nin any direction, but the commonest one is downward and forward of\\nthe inner end of the outer fragment, or of the adjoining ends of both\\n1 Smith Dublin Journ. Med. Sci., 1842, p. 478, and Fractures in the Vicinity of Joints, p.\\n212.\\n2 Delens Archives Generates de Med., 1873, vol. i., p. 529.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0216.jp2"}, "213": {"fulltext": "FBACTUBES OF THE CLAVICLE. 193\\nfragments if they do not separate from each other. Polaillon attributes\\nthe principal part in the production of this displacement to the action\\nof the pectoral and deltoid muscles upon the outer fragment, and finds\\nsupport for his opinion in the fact that this displacement has always\\nbeen observed after fracture by muscular action and as in this variety\\nthe fracture is usually near the inner articular surface, in a region,\\nthat is, where displacement after fracture by other causes is slight or\\nabsent, the argument is not without weight, although the obliquity of\\nthe line of fracture in such cases as that represented in Fig. 73 cannot\\nbe entirely foreign to the direction and degree of the displacement.\\nWhen the fracture is transverse the lateral displacement may be slight\\nor entirely absent and the periosteum may remain untorn. Longitu-\\ndinal fracture with comminution was seen in one case, and Hamilton\\nreports another in which the line ran from the articulation upward and\\noutward for one and a half inches. The fragments overlapped three-\\nfourths of an inch and were firmly united. In two cases the end of\\nthe outer fragment lav underneath the inner one and both were directed\\nupward and backward. The outer end of the inner fragment is acted\\nupon more strongly by the sterno-cleido-mastoid muscle than by any\\nother, the effect of which is to draw it upward, and this effect is\\nincreased by the pressure of the outer fragment when that is forced in\\nfront of and below the other, so that whenever the two fractured sur-\\nfaces leave each other the inner fragment is likely to incline upward.\\nFig. 73.\\nFracture of the clavicle, inner third. (Gurlt.)\\nMultiple Fractures. But few cases are recorded in which the bone\\nhas been broken in two or more places in some the fracture was by\\ndirect, in others by indirect, violence. Both fractures have been found\\nin the middle third, but more commonly they occupy different thirds.\\nWhen one fracture has been in the acromial, and the other in the inner\\nor middle third, the intermediate piece has not shown much displace-\\nment, and each fracture has followed the usual course of a single one\\nbut when the fractures have been within or close to the limits of the\\nmiddle third, the displacement has been very notable.\\nComplications. Complications of fracture of the clavicle consist in\\ninjuries to the vessels, nerves, and lungs, and are exceedinglv rare,\\nexcluding gunshot wounds in which the complications are produced by\\nthe ball and not by the fractured bone. Although the subclavian artery\\nis in intimate relations with the clavicle, I find no recorded case of its\\ninjury as a complication of the fracture of this bone. Dupuytren speaks\\nin a lecture of having seen two or three cases of aneurism following\\n13", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0217.jp2"}, "214": {"fulltext": "194 FRACTURES.\\nfracture of the clavicle, and Jacquemier 1 gives a case observed by\\nBlandin, of an aneurism of the acromial branch of the acromio-thoracic\\nartery following fracture by direct violence.\\nA few cases are reported of injury to the subclavian or internal jug-\\nular vein, in some of which the diagnosis was verified by autopsy.\\nIn the museum of St. George s Hospital 2 is a specimen in which the\\nfractured end of the bone was driven through the internal jugular vein.\\nThe patient, a youth of twenty-three years, while standing under a tree\\nduring a thunder-storm was struck by a falling branch and died imme-\\ndiately.\\nIn one case the patient, 3 a man fifty-nine years old, broke the right\\nclavicle in the middle third by a fall upon the shoulder. A large\\nswelling appeared promptly in the supraclavicular region and extended\\nto the parotid it did not pulsate, and had a slight intermittent murmur\\nisochronous with the pulse. The arm was paralyzed, and the radial\\npulse lost. On the following day the pain was less, and the pulse had\\nreappeared. An incision was made, an enormous quantity of blood\\nescaped, and the patient died at once in consequence of the entrance of\\nair into the vein. The fracture was very oblique from without inward\\nand backward, and the vein was torn completely across by the outer\\nfragment. The artery and nerves were not injured.\\nIn a very few reported cases symptoms indicating injury to the\\nbrachial plexus have appeared immediately or after an interval. In\\none 4 sharp pains extending throughout the arm with swelling and dis-\\ncoloration followed every attempt to work after the fracture had united\\ncomplete relief was obtained by resection of the callus. In another, 5\\na fracture of the clavicle, scapula, and two ribs by crushing, the arm\\nwas paralyzed from the first, and sharp pain appeared ten days later,\\nextending to various portions of the arm and hand. Relief by opera-\\ntive correction of the marked displacement at the junction of the outer\\nand middle thirds. In a third, 6 complete loss of function persisting three\\nweeks after the injury, an operation was done to remove a splinter and\\nimprove the position of the fragments recovery. In a fourth, 7 a\\ncomminuted fracture by direct violence, the pain was so great, in addi-\\ntion to the paralysis, that the limb was amputated at the shoulder. In\\na fifth case, my own, 8 extensive motor and sensory paralysis of the\\nlimb existed from the first, although the fracture was without recog-\\nnizable displacement six weeks later there had been no improvement.\\nOf the three earlier cases in which paralysis of the arm immediately\\nfollowed the accident (Earle, Gibson, Mercier), displacement of the\\nfragment is noted in two and not mentioned in the third. A notice-\\nable incident in two (Earle, Stimson) was the paralysis of the scapular\\nmuscles supplied by the suprascapular nerve which leaves the plexus\\n1 Jacquemier: Fractures de la Clavicule, These de Aggregation, Paris, 1844.\\n2 British Medical Journal, 1873, vol. ii. p. 82.\\n3 Progres Medical, 1882, No. 16.\\nHassler: Lyon Medical, January 12, 1896.\\n5 Davis Annals of Surgery, February, 1895.\\n6 Mauclaire: La Semaine Medicale, October 17, 1894.\\n7 Poirier: La Semaine Medicale, September 2, 1891.\\n8 Stimson: New York Medical Journal, June 11, 1887.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0218.jp2"}, "215": {"fulltext": "FRACTURES OF THE CLAVICLE. 195\\nabove the clavicle. Direct injury or compression of the nerve by the\\nfragments or callus can fairly be assumed as the cause in some of the\\ncases in the others the cause remains unknown. In a few the press-\\nure of an axillary pad in the dressing appears to be responsible for\\ntemporary disability. Two cases of pressure by an exuberant callus\\nare given below in the section on Symptoms and Course.\\nInjury to the lung, as evidenced by emphysema, has been recorded\\nin live cases where this symptom seemed to be demonstrative, and in\\ntwo others in which it is much more likely that the emphysema was\\ndue to the introduction of air through a wound of the soft parts.\\nThe first five cases are those of Vigarous, Velpeau, Huguier,\\nRuble, and Mercier. All except the fourth are described with all the\\ndetails obtainable in a thesis by Mercier. 1 (See First Edition.)\\nThe anatomical demonstration of the immediate agency is lacking\\nin all these cases, but the notes in all but one show that the surgeons\\nwere mindful of the possibility that a fracture of a rib might coexist\\nand might have been the cause of the wound in the lung, and that\\nthey were unable to detect such a complication. In most of them,\\ntoo, mention is made of the depression of the outer fragment, and as\\nthe relations of the clavicle to the upper portion of the thoracic cavity\\nare such that it is not difficult to admit the possibility of a wound of\\nthe apex of the lung by the broken bone, I think the clinical evidence\\nmay be accepted as sufficient.\\nEtiology.\\nThe clavicle may be broken by muscular action, by direct violence,\\nor by indirect violence.\\nGurlt 2 and Delens 3 collected and analyzed a number of reported\\ncases of fracture by muscular action. The efforts by which the frac-\\ntures were caused were various lifting a heavy weight striking with\\nthe hand, a whip, or racket making a vigorous effort that involved\\nthe contraction of many muscles, as in Legros Clark s case of a lad\\nwho, while swinging by the feet from a trapeze, tried to raise himself\\nso as to seize the bar with his hands the clavicle broke in its inner\\nthird during the effort. It is probable that the clavicular fibres of\\nthe deltoid and pectoralis major are the most efficient agents in pro-\\nducing this fracture, since their contraction tends to draw the unsup-\\nported central portion of the clavicle downward and outward toward\\nthe humerus when the arm is fixed.\\nClosely allied to these cases are those in which the fracture has been\\nproduced by a blow or other force acting at the hand thus, an old\\nwoman broke her clavicle by closing the door of a wardrobe forcibly,\\nand a lunatic at Bicetre broke his by striking violently with a heavy\\nstick against some iron bars.\\nIn a very few of the cases the fracture has been produced by two\\nefforts, or a blow and an effort, separated by a longer or shorter inter-\\nval the patient feels pain at some point in the clavicle after a fall or\\n1 Mercier Des Complications des Fractures de la Clavicule, These de Paris, 1.881.\\n2 Gurlt: Loc. cit 3 Delens Loc. cit., and Arch. Gen., 1875, vol. i. p. 257.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0219.jp2"}, "216": {"fulltext": "196 FRACTURES.\\na blow or an effort, which persists, perhaps, but is not severe and does\\nnot interfere with the use of the arm and then in a few days, after\\nanother violence or effort, the bone breaks. If the second violence\\nwere sufficient in itself to account for the fracture, the first one might\\nbe regarded as a mere coincidence, but it has generally been less than\\nthe first.\\nDirect fractures are produced by varied causes, and may occur at\\nany part of the bone, but most frequently in the middle and outer\\nthirds. The commonest form of violence is a blow falling upon the\\ncentre of the bone in a direction that is backward and downward.\\nIndirect fractures, which constitute the great majority, are most\\nfrequently produced by a fall upon the shoulder or upon the hand or\\nelbow, the arm being extended and the muscles rigid. In a few cases\\nthe fracture has been caused by the sudden depression of the shoulder,\\nby which the clavicle was bent over the first rib. Malgaigne l reports\\none an incomplete fracture at the middle of the bone due to the slip-\\nping of a burden from the shoulder to the arm and Polaillon 2\\nanother a man who held the end of a lever which was to receive part\\nof the weight of a heavy stone, the stone slipped suddenly upon the\\nlever and drew the arm which held it downward. The man heard a\\nsnap and felt pain in the shoulder the clavicle was broken in its\\nmiddle third.\\nThe clavicle has been broken in a number of cases during intra-\\nuterine life by external violence, and occasionally by the midwife or\\nobstetrician during parturition.\\nSymptoms and Course.\\nThe rational and physical signs common to most fractures are found\\nin those of the clavicle. These are the deformity, mobility, and crepitus,\\nthe localized pain, and the diminution of function. Besides the\\ndeformity due to the displacement of the fragments, there is also that\\nwhich is produced by the falling inward of the shoulder and which is\\nmost apparent when viewed from behind, and with it goes a very\\nnoticeable projection of the posterior border and inferior angle of the\\nscapula. These signs are, of course, most marked in cases of complete\\nfracture with overriding of the fragment in fractures of the inner\\nand outer thirds they are usually less marked, or even absent, because\\nthe average displacement is less.\\nIn fractures of the middle third there is usually displacement of such\\na character and extent that there is no difficulty in recognizing it and\\nits cause; the fragments can be separately grasped and moved upon\\neach other. Crepitus, however, is not always produced by this manoeu-\\nvre, for the broken surfaces may not be in contact, and in order to get\\nthis symptom it may be necessary to have the shoulder drawn back-\\nward and outward, so as to reduce the displacement.\\nLocalized pain on direct pressure or when the shoulder is pressed\\ninward is a valuable sign in partial fractures and in fractures without\\ndisplacement, and it may be the only one that is present immediately\\n1 Malgaigne Loc. cit., p. 463. Polaillon: Loc. cit., p. 679.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0220.jp2"}, "217": {"fulltext": "FBACTUEES OF THE CLAVICLE. 197\\nafter the injury the appearance within a week of a firm oval mass at\\nthe point where pain was felt confirms the diagnosis of fracture.\\nThe interference with function seems to be largely the consequence\\nof the pain which makes the patient unwilling to move the arm, rather\\nthan of any mechanical defect produced by the fracture. The patient\\ncan usually move the arm quite freely backward and forward, but\\ncannot raise it or adduct it without pain, and if asked to put his hand\\non his head, will usually flex the forearm, incline the body, and bend\\ndown his head to accomplish it. The fracture and displacement are\\nnot entirely without influence in this limitation of the movements, but\\nthey are not wholly responsible for it. Hurel, 1 who profited by his\\ninternat at the hospital for convalescents at Paris, to examine the later\\ncondition of patients with this fracture, found the movement of cir-\\ncumduction of the arm the last to be regained, and that a shortening\\nof half an inch or more delayed complete recovery considerably beyond\\nthe time that was sufficient for it when the shortening was less or\\nabsent.\\nThe patient s appearance is often quite characteristic he sits with\\nhis body and head inclined toward the injured side and supports the\\nelbow with the other hand. The only cases in which the diagnosis can\\nwell remain in doubt after even a brief examination are those of incom-\\nplete fracture, and some of fracture close to either end of the bone\\nwhich may be mistaken for dislocation. On the other hand, the crep-\\nitus which is so frequently present in dislocation of the acromial end\\nof the clavicle, because of the chipping of the edge of the joint, may\\nlead to a diagnosis of fracture. Either error may be avoided if the\\noutline of the bone can be accurately traced.\\nThe progress of the fracture is simple and is rarely disturbed by\\ncomplications or dangers. Union is usually firm by the end of the\\nfourth week, sometimes much earlier, and failure of union is rare.\\nDisplacement and shortening, however, are the rule only those cases,\\napparently, are exempt in which the line of fracture is transverse\\nand there is no displacement at first. The amount of the shortening\\nmay vary from a fraction of an inch to one and even two inches, and\\nit may be produced by angular displacement, or by overriding, or by\\nboth.\\nThe complications that may occur in the course of the repair are the\\nordinary inflammatory ones that may arise at the seat of fracture in\\nconsequence of the bruising of the surrounding parts, or of the failure\\nto immobilize the fragments, or special ones due to the pressure of the\\nfragments or callus upon the vessels and nerves. Hassler s case quoted\\nabove is an instance of pressure upon the nerves by the callus during\\nforcible use of the arm, and two others have been reported by Delens 2\\nand Polaillon. 3 Delens s case is very satisfactory. The patient was\\nbrought to the hospital January 1, 1881, with fracture of the left\\nclavicle and two ribs. The arm was placed in a Mayor s sling, and\\n1 Hurel Les Fractures de la Clavicule, These de Paris, 1867.\\n2 Delens De la resection d un cal de la Clavicule comprimant les vaisseaux et les nerfs\\nsousclaviers, in Archives de Medecine, August, 1881, p. 170.\\n3 Polaillon Loc. cit., p. 696.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0221.jp2"}, "218": {"fulltext": "198 FRACTURES.\\nunion was complete by the end of the month. The patient returned\\non March 19th, complaining of great loss of power in the left arm\\nexamination showed marked overriding of the fragments, the outer\\nlying in front of the inner one, with a hard, firm callus two inches\\nthick, atrophy of all the muscles of the left arm, and passive conges-\\ntion of the skin of the hand the pulsations of the left radial artery\\nwere much weaker than those of the right. The posterior and lower\\nportion of the callus was removed by operation, the pulsations of the\\nradial artery and the appearance of the hand at once became normal,\\nand the patient gradually recovered the use of the limb.\\nIn another case Gosselin removed a portion of callus which had\\ncaused persistent ulceration of the soft parts covering it. A prompt\\ncure followed.\\nOssification of the coraco-clavicular ligament has been observed in\\nseveral cases after fracture in the outer third. No description is given\\nof the modifications, if any, of the functions of the part produced by\\nthis anchylosis.\\nFailure of union is rare, and in the few cases which have been\\nrecorded it does not appear to have resulted in any diminution of func-\\ntion in one case carefully examined by Hamilton where there was\\nligamentous union and overriding to the extent of half an inch the arm\\non the affected side was in every way as strong and as fit for use as the\\nother.\\nSimultaneous fracture of both clavicles is a relatively rare accident.\\nWriting in 1881, I found twenty-eight cases collected by five authors,\\nbut a year seldom passes now without the report of one or more cases.\\nIn position, symptoms, and mode of production these double fractures\\ndo not differ materially from single ones. Sometimes they are pro-\\nduced simultaneously by lateral pressure upon the shoulders, some-\\ntimes successively by two different blows, and once simultaneously by\\na kick by a horse, each hoof breaking a clavicle.\\nIn three of the six cases collected by Malgaigne, union failed in\\nboth bones, and he has left a very complete account of the resultant\\ndisability in one of them which was under his own care. In the\\nothers there was apparently but little permanent interference with the\\nfunctions of the arms. In none of the recently reported cases has\\nfailure of union been noted. In recent cases there is sometimes con-\\nsiderable dyspnoea, which Hurel thinks is due to the weight of the\\narms and shoulders upon the thorax, aided perhaps by the loss of\\npower of the accessory muscles of respiration, those which pass from\\nthe neck or thorax to the clavicle and scapula. This dyspnoea is relieved\\nby the dorsal decubitus if the shoulders rest upon a firm support.\\nThe condition of Malgaigne s patient on examination three years after\\nthe accident was as follows the shoulders appeared to be below, in\\nfront of, and on the inner side of their normal positions, the shoulder-\\nblades stood out posteriorly three or four inches from the chest-wall\\nand were inclined forward and outward, and the upper part of the\\nchest seemed much contracted. The clavicles were broken at the\\ncentre, and the outer fragments were below and behind the inner ones.\\nThe shoulders could be drawn back slightly, but not enough to over-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0222.jp2"}, "219": {"fulltext": "FRACTURES OF THE CLAVICLE. 199\\ncome the displacement forward, and they could be drawn forward so\\nfar that they were separated by an interval of only three inches, meas-\\nuring across the chest. The arms could be raised to the horizontal\\nline in front and on the side, but not behind.\\nTreatment.\\nThe indications for treatment are to reduce the displacement and\\nto prevent its recurrence. The means by which they are to be met\\ndo not differ materially in the different fractures, but in describing\\nthem I shall have mainly in mind fractures of the middle third.\\nAs has been already said, the FlG 74\\nshoulder and outer fragment are A\\nusually displaced inward, forward, /^V\\nand downward, and the outer end f^ 1\\nof the inner fragment is displaced 1 11 __\\nupward. The force which pro- ^^^S^\\nduces the first displacement is the 77/ ^V^\\nweight of the shoulder. It must If\\nbe remembered that the shoulder A r^^^^\\nhangs out from the chest as a sign \\\\f W^^\\nhangs out from the side of a house ^g-gf\\nthe scapula and clavicle are two Mechanism of displacement after fracture of\\nlateral supports, and the trapezius the clavicle: a, acromions, clavicle ;s, S ca P:\\nrr r u a A position of the acromion after the\\nmuscle is a suspensory one. A f rac ture.\\nglance at Fig. 74 shows how the\\nfracture of the clavicle removes one lateral support, and how the\\nweight of the shoulder, being no longer supported upon that side,\\nswings forward and inward until a new equilibrium is found. This\\nmovement of rotation carries the posterior portion of the scapula\\naway from the back at the same time that it brings the anterior portion\\nnearer the front, and as the upper part of the chest is dome-like and\\nnot simply cylindrical, and as the movement, the change of position,\\ntakes place therefore in a vertical as well as in a horizontal plane, the\\nshoulder drops and the inferior angle of the scapula rises, by compari-\\nson at least, if not actually. Reduction, therefore, is to be accomplished\\nby carrying the shoulder back to its former position, and retention by\\nsupplying the support previously given by the clavicle. These indi-\\ncations have been clearly understood since the time of the earliest\\nwriters, but it has been found very difficult to embody them in practice,\\nbecause there is no means of acting in the desired manner upon the\\nshoulder that does not involve an amount of discomfort that patients\\nwill not ordinarily submit to. Moreover, in some cases surgeons have\\nlost sight of the fact that the position of the arm is a secondary one,\\nits importance being due solely to its use as a means of acting upon\\nthe outer end of the scapula, and that it is useless to press the elbow\\nupward unless the scapula is left free to be raised by that pressure. It\\nis entirely useless to bind the elbow to the shoulder on the same side\\nsuch dressings do not raise the scapula.\\nOne of the methods of reduction employed by Hippocrates resembles", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0223.jp2"}, "220": {"fulltext": "200 FRACTURES.\\nin principle very closely the dressing suggested by Velpeau and em-\\nployed with much success by him and others. He placed the hand of\\nthe affected side upon the opposite shoulder and then pressed the elbow\\nforcibly upward and outward. As the arm lies thus across the chest\\nits long axis is exactly in the direction in which pressure should be\\nmade to overcome the usual displacement. Another method employed\\nby Hippocrates was to place the patient upon his back with a small,\\nhard cushion between his shoulders, and then to press backward upon\\nthe acromion or the head of the humerus while the elbow was pushed\\nup by an assistant. Paulus iEgineta made extension by drawing the\\narm upward and outward, and counter-extension by the neck or other\\narm, and he also recommended the axillary pad with the elbow brought\\nclose to the side. Guy de Chauliac placed his knee between the\\npatient s shoulders and drew them backward. These methods are the\\ntypes of all that have since been used or that are now in use.\\nReduction, in short, is to be sought by carrying the shoulder upward,\\noutward, and backward, acting either directly upon it or indirectly\\nthrough the elbow, or using the arm as a lever. Polaillon recommends\\nstrongly a method based upon the latter principle standing behind the\\npatient he passes the hand or forearm into the axilla, and draws upward\\nand backward with it, while with the other hand he presses the elbow\\nagainst the side and thus forces the shoulder outward.\\nIn some cases it is necessary to have these efforts made by an assist-\\nant in order that the surgeon himself may be at liberty to make such\\nmovements of coaptation as may be needed to overcome the obstacles\\noffered by points or irregularities upon the surface when the line of\\nfracture is transverse or nearly so. In transverse fractures with only\\nangular displacement upward and forward it is sometimes sufficient to\\nmake pressure upon the angle.\\nThe physical obstacles that need to be overcome in the treatment are\\nso great and the success that has attended the different methods has\\noften been so moderate that the number of plans that have been pro-\\nposed and employed is very great, and the history of the treatment\\nshows mainly a recurrence of periods marked at first by elaboration\\nand multiplication of details and precautions and then by the abandon-\\nment of them all and the substitution of something very simple. The\\nresults obtained by the simple scarf or sling are often as good as those\\nfurnished by the most elaborate bandaging, and the discomfort to the\\npatient during treatment is much less.\\nThe differences in the methods depend in great part upon the indi-\\ncation which each surgeon has had more particularly in mind, upon the\\ndisplacement which he sought to prevent. Thus, in some, the special\\nobject of the dressing is to maintain the shoulder elevated, in others to\\nhold it back, and in others again to draw it outward. The type of the\\nfirst class is a band passing under the elbow and forearm and around the\\nneck, the forearm lying across the chest. That of the second is a pos-\\nterior transverse splint to the ends of which the shoulders are made\\nfast, or an anterior transverse splint pressing the shoulder back. That\\nof the third is the axillary pad used as a fulcrum to force the shoulder\\nout by pressing the elbow in.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0224.jp2"}, "221": {"fulltext": "FBACTL r BES OF THE CLAVICLE.\\n201\\nWhen the patient is sufficiently desirous to avoid any visible irreg-\\nularity in the outline of the clavicle to bear the discomforts of a\\nprolonged rest in bed without change of position, and when the dis-\\nplacement can be reduced, treatment in the recumbent position holds\\nout the best prospect of recovery without deformity. The patient should\\nbe placed upon his back (or rather upon her back, for it is not probable\\nthat any one but a lady whose social position requires her neck to be\\nleft at times uncovered will submit to this confinement), upon a firm\\nmattress with the neck bent so as to relax the sterno-cleido-mastoid upon\\nthe injured side, and the elbow fastened to the side or chest or raised\\nupon a cushion so that the weight of the arm may tend somewhat to\\nforce the shoulder upward and backward, anatomically speaking. It\\nhas been recommended also that a firm narrow cushion be placed along\\nthe spine between the shoulder-blades, and Eobert preferred to have the\\npatient lie not entirely flat upon the back, but inclined slightly toward\\nthe uninjured side. In one case digital pressure was made upon the\\nfragments throughout the treatment to insure accurate coaptation.\\nMalgaigne suggested that blunt hooks with a strap fastening them to\\nthe elbow or double hooks like those he used in fracture of the patella\\nmight perhaps be substituted for the fingers of the assistant. The\\nposition must be kept practically unchanged for at least two, and prob-\\nably for three, weeks.\\nMayor s scarf or sling (Fig. 75) is made of a square of muslin\\nthe diagonal of which is long enough to extend easily around the body.\\nFig. 75.\\nFig. 76.\\nFracture of the clavicle. Mayor s\\nscarf.\\nVelpeau s dressing for fracture\\nof the clavicle.\\nThe forearm is flexed at a right angle and laid across the breast the\\ncloth, folded diagonally, is laid over it and tied around the body so\\nthat its folded border runs horizontally around an inch or two above\\nthe forearm, in front of which the cloth hangs down. The free point\\nof the triangle is then brought up between the forearm and the body,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0225.jp2"}, "222": {"fulltext": "202\\nFRACTURES.\\nand the two folds of which it is composed are secured, one on either\\nside of the neck, by bands attached to the scarf behind and brought\\nforward over the shoulder or the forearm is placed between the folds\\nof the triangle, the folded diagonal of which thus forms the lowest part\\nof the dressing, while its ends are tied around the body as before. The\\nfolds that form the third point are tied together about the neck.\\nThis method is suitable for fractures without much displacement,\\nespecially for those in children with untorn periosteum.\\nVelpeau s dressing (Fig. 76) is more secure. It is made with a\\nlong roller-bandage. The elbow is brought well in front of the chest\\nand the hand placed on the opposite shoulder, and the limb is drawn\\nsnugly up toward the neck by successive turns of the roller which,\\nbeginning at the opposite axilla, pass obliquely across the back, over\\nthe shoulder, in front of the arm, under the elbow, and back to the\\naxilla after three or four such turns have been placed the bandage is\\ncarried circularly around the body covering in the arm from below\\nupward. The turns should be secured by stitching or by soaking in\\ndextrine or plaster.\\nSayre s Dressing (Figs. 77 and 78). A very convenient and\\npopular dressing is the one introduced by Prof. Sayre. It is made of\\nFig. 77.\\nFro. 78.\\nSayre s adhesive plaster dressing for fracture\\nof the clavicle. First piece.\\nThe same. Second piece.\\ntwo strips of adhesive plaster, each about three inches wide and long\\nenough to go once and a half around the body; one end of the first\\nstrap is stitched closely about the arm just below the axilla, and the\\nother carried around the chest from behind forward, as shown in Fig.\\n77. The second strap is then carried from the top of the shoulder on\\nthe uninjured side across the back, under the elbow, and along the fore-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0226.jp2"}, "223": {"fulltext": "FRACTURES OF THE CLAVICLE.\\n203\\narm to the shoulder again (Fig. 78). The elbow should be drawn back\\nwhile the first strap is applied, and well forward while the second is.\\nIt is a convenience to the patient to have the plaster carried past the\\nulnar side of the hand so as to leave the latter uncovered. The action\\nof the dressing is simply to press the shoulder upward and backward,\\nand its principal advantage lies in the solidity which the use of the\\nadhesive plaster gives. A thin pad of absorbent cotton may be placed\\nin the axilla to absorb perspiration.\\nThe axillary pad, designed especially to prevent shortening by\\nforcing the shoulder outward, has been in use for many centuries, and\\nreached its highest development at the hands of Desault, of whose\\ncomplicated dressing it forms the essential part. I believe that when-\\never it is large and firm enough to accomplish its object it is dangerous,\\nand whenever small enough to be free from danger it is useless.\\nThe dressings which are intended mainly to draw the shoulder back-\\nward are modifications of the figure-of-eight bandage and the posterior\\nFig. 79.\\nFig. 80.\\nMoore s dressing for fractured clavicle.\\nMoore s dressing for fractured clavicle.\\nand anterior splints. The simple figure-of-eight carried across the back\\nfrom one shoulder to the other, either in muslin or plaster of Paris, I\\nhave found to interfere too much with the circulation in the arms if effi-\\nciently applied. In two cases of marked displacement which could be\\nreduced by drawing the shoulders back, but which recurred under the\\nusual dressings, I obtained a satisfactory result by the use of a breast-\\nplate made of crinoline soaked in plaster cream and covering the front\\nof the chest and shoulders. The shoulders were held back and reduc-\\ntion maintained until the plaster had set, and then the position was", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0227.jp2"}, "224": {"fulltext": "204 FRACTURES.\\nmaintained by a figure-of-eight bandage. The heavy ends of the\\nbreast-plate in front of the shoulder prevented compression of the\\naxillary vessels by the bandage, and the dressing was worn with com-\\nfort for three or four weeks.\\nA modification of the figure-of-eight suggested by Recamier amounts\\nalmost to a posterior splint. He placed a large, hard square cushion\\nbetween the shoulders behind and carried a bandage from each upper\\ncorner over the shoulder and under the axilla back to the lower corner.\\nMoore, of Rochester, applied the bandage so as to include the elbow as\\nwell as the shoulder of the affected side, seeking to make the fibres of\\nthe pectoralis major tense by drawing the elbow backward. The ban-\\ndage in his dressing (Figs. 79 and 80) should be about two yards long,\\nits centre is placed under the olecranon, the forearm being flexed at a\\nright angle, the end that is next the body is carried up between the arm\\nand the side, in front of and over the shoulder, across the back and\\nunder the opposite axilla the other end is carried around the outer\\nside and front of the elbow, then between it and the side to the back,\\nand across the back to the opposite shoulder, where it is made fast to\\nthe first end. The elbow must be drawn backward and pressed up-\\nward.\\nPosterior splints have been made in the form of a cross, against\\nthe arms of which the shoulders were drawn back, and as iron, wooden,\\nand pasteboard splints crossing the back and extending usually beyond\\nthe shoulders, so that the traction of the bandages by which the shoul-\\nders were made fast should be exerted in an outward direction as well\\nas backAvard.\\nA fixed support shaped like the upper end of a crutch and fastened\\nto the side of the chest by adhesive plaster has been occasionally sug-\\ngested and even used. Like the axillary pad it is probably intolerable\\nor dangerous if applied efficiently.\\nIt is apparent that while many different dressings may give good\\nresults in certain cases, none can be depended upon to do so in all, and\\nthat the displacement, the shortening, which is the rule in the adult, is\\nthe result in some cases of forces which cannot be effectually controlled,\\nof the obliquity of the fracture, and not infrequently of the indocility\\nof the patient, who, finding himself incommoded by the dressing, shifts\\nit slightly, but often, until he obtains ease at the sacrifice of the object\\nit was applied to secure.\\nIf the fracture is without displacement, especially the subperiosteal\\nfracture of children, or if the displacement shows but little tendency\\nto recur after reduction, the simple scarf or sling or Sayre s dressing\\nwill answer every purpose.\\nIf, on the other hand, the tendency to displacement is great, the\\nchoice of a method of treatment will depend largely upon the character\\nand wishes of the patient. If he is indifferent to the deformity or\\nintolerant of restraint, it is useless to attempt more than a simple\\ndressing but if he is Avilling to submit to the confinement, the fracture\\nmay be treated by dorsal decubitus and digital pressure with a fair\\nprospect of success, or by the plaster-of- Paris breast-plate and figure-\\nof-eight bandage.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0228.jp2"}, "225": {"fulltext": "FRACTURES OF THE CLAVICLE. 205\\nIn simultaneous fracture of the two clavicles, the dorsal position is\\nstrongly to be recommended.\\nIt is well to place in the axilla a pad of cotton wrapped in a com-\\npress to absorb the moisture and keep the opposing surfaces from con-\\ntact with eacli other and for the same reason a compress should be\\nplaced between the arm and the body, wherever the two would other-\\nwise be in contact.\\nThe dressing should be worn for from fifteen to twenty days by\\nchildren, and twenty to thirty days by adults.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0229.jp2"}, "226": {"fulltext": "CHAPTER XVIII.\\nFig. 81.\\nFRACTUKES OF THE SCAPULA.\\nFractures of the scapula clinically recognized are comparatively\\nrare, about 1 per cent, of all fractures according to the best statistics at\\nour command, but Lane s l observa-\\ntions in the dissecting-room indicate\\nthat fractures of the acromion are\\nvery common and must, therefore,\\nusually pass unrecognized. They\\nare six times as common in men as\\nin women, and in the great majority\\nof cases the patients have been be-\\ntween twenty and fifty years of age.\\nThe size and shape of the bone,\\nand the presence of three irregular\\nand prominent apophyses permit a\\ndiversity of fractures differing so\\ngreatly in their mode of production\\nand symptoms that it becomes\\nnecessary to consider them sepa-\\nrately. Most writers in the last\\nhundred years have made from six to\\neight groups as follows 1st, frac-\\ntures of the body 2d, fractures of\\nthe inferior angle 3d, fractures of\\nthe upper angle and supra-spinous\\nfossa 4th, fractures of the spine\\n5th, fractures of the acromion 6th,\\nhespine a* fractures of the coracoid process\\n7th, fractures through the surgical\\nneck; 8th, fractures of the glenoid cavity. Of these varieties the 1st,\\n4th, and 5th are bv far the most common the others are extremely\\nFracture across body of the\\nseparation of a long piece of the spine\\nrare.\\n1. Fractures of the Body of the Scapula.\\nFractures of the body of the scapula are single or multiple. The\\nformer are confined to the subspinous fossa, and the direction of the\\nline of fracture is transverse or oblique. The fragments may preserve\\ntheir normal relations to each other or there may be displacement, the\\nlower fragment shifting to either side of the upper one and overriding\\nfor a greater or less distance. This overriding is most marked on the\\naxillary side and is due apparently to contraction of the teres major\\n1 Lane Guy s Hospital Reports, 1886, vol. xliii. p. 418.\\n206", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0230.jp2"}, "227": {"fulltext": "FRACTURES OF THE SCAPULA.\\n207\\nand serratus, -while the lateral displacement is the result of the continued\\naction of the fracturing force. In some cases the fragments have\\nunited after transverse or oblique fracture in such a position that they\\ntouch or override at one side and\\nare separated at the other. FlG 82\\nIn multiple fractures the lesion\\nis extremely variable, the fracture\\nmav be starred/ or comminuted,\\nsome of the lines may be incom-\\nplete, and the main one may be longi-\\ntudinal the only condition, appar-\\nently, under which longitudinal\\nfracture is met with (Fig. 82).\\nThe fracture may be partial, in\\nthe form of a fissure running from\\none border, or circumscribed, a cen-\\ntral piece being broken out.\\nThe cause of the fracture has\\nalmost always been direct violence,\\nusually a blow or a fall upon some\\nangular object, but in three reported\\ncases it appears to have been caused\\nby muscular action, as in similar\\nfractures of the inferior angle (q. v.),\\nthe line of fracture being somewhat\\nhigher than in the latter. The cases are those of Dobson, 1 Leidy, 2\\nand Hoover. 3\\nThe objective symptoms which may be met with are irregularity in\\noutline, abnormal mobility, crepitus, and ecchymosis. The posterior\\nborder and inferior angle of the bone can be made prominent by carry-\\ning the elbow forward and inward, and then if the finger is passed\\nalong it a transverse or oblique fracture with displacement will be cer-\\ntainly recognized. Abnormal mobility and crepitus can be recognized\\nby grasping the inferior angle and moving it while the upper portion\\nis steadied by the other hand. In multiple or partial fractures with\\ndepression the adjoining edge of bone may be felt if the patient is not\\ntoo fat or muscular. The precaution should always be taken to make\\na comparison with the other scapula, and the normal ridges along the\\nborders and at the base of the spine should be borne in mind. Ecchy-\\nmosis, unless due to the action of the violence upon the soft parts,\\nseldom appears until after the lapse of a few days.\\nLocalized pain on pressure and on movement of the arm is a con-\\nstant symptom, and may make it impossible for the patient to ex-\\ntend his arm horizontally and directly forward because it is so much in-\\ncreased by the contraction of the muscles concerned in this movement.\\nThe course in the simpler cases ends in recovery in four or five weeks,\\nusually with preservation of function even if union has taken place\\nMultiple (longitudinal) fracture of the\\nscapula.\\n1 Dobson Lancet, November 27, 1886.\\n2 Leidy University Medical Magazine, March, 1891.\\n3 Hoover Medical and Surgical Eeporter, 1893, p. 848.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0231.jp2"}, "228": {"fulltext": "208 FRACTURES.\\nwith some unreduced displacement. Multiple fractures are more dan-\\ngerous because of the greater probability of suppuration at or in the\\nneighborhood of the fracture, and of course if the fracture is a com-\\npound one the danger is still greater. In a very few instances there\\nhas been much disability due to failure of union or to union with dis-\\nplacement and exuberant callus. Gurlt quotes an example of the\\nformer in which the patient was unable to raise his hand to the back\\nof his neck, and one of the latter in which the disability was almost\\ncomplete and all communicated movements of the arm and shoulder\\nwere painful.\\nTreatment. In simple fracture without displacement no other treat-\\nment is needed than immobilization of the arm and shoulder during\\nthe length of time necessary for consolidation. If displacement exist\\nit must be corrected, if possible, by placing the arm and shoulder in\\nvarious positions and pressing upon the fragments with the hands\\nin the directions indicated by the displacement. When the latter is\\nreduced as far as possible the arm and shoulder must be immobilized\\nby binding the arm to the side or merely supporting it in a sling, and\\na broad strip of adhesive plaster may be laid across the scapula to aid\\nits immobilization.\\nIn comminuted fractures the principal indication is to prevent the\\nsevere inflammatory reaction w r hich is so likely to follow the bruising\\nand laceration produced at the same time by the extreme violence that\\nhas caused the fracture. If the fracture is compound it must be\\nexplored through the wound and treated in accordance with the prin-\\nciples elsewhere laid down, and it is prudent in such cases to remove\\npartly adherent fragments which could be safely left after fracture of\\nother bones, whenever by such removal a free outlet that would other-\\nwise be lacking is supplied to matter that may accumulate on the under\\n(costal) surface of the bone. In a few cases of simple fracture pus has\\nformed and caused much trouble by burrowing down the side of the\\nbody, confirming the experience furnished by some simple fractures of\\nother bones, in which pus has formed apparently in consequence of\\nimperfect immobilization.\\n2. Fractures of the Inferior Angle.\\nThese are included by some writers in the group of fractures of the\\nbody of the scapula, from which they differ merely by the proximity\\nof the line of fracture to the lowest part of the bone, but as they pre-\\nsent a more constant and well-defined displacement which cannot be\\nreadily overcome or prevented they deserve separate mention. The\\nrecorded instances of separate fracture are not very numerous. Gen-\\nsoul reported one produced by muscular action the patient saved him-\\nself from falling to the ground while descending a sharp incline, either\\nby catching hold of some support or by falling backward upon his\\noutstretched hand the abstracts of the report are not clear upon\\nthis point. A triangular piece corresponding to the inferior angle was\\ndetached from the scapula and displaced forward and upward, and could\\nbe moved independently and with crepitus. Gensoul attributed the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0232.jp2"}, "229": {"fulltext": "FBACTURES OF THE SCAPULA. 209\\nfracture to the sharp contraction of the teres major. Gurnard l reports\\na second case and quotes a third, 3 the only one he could find. He\\nadds a detailed study of fractures of the body and inferior angle by\\nmuscular action and quotes the reports of all the known cases. The\\nhistories of these cases and of those of fracture of the body suggest the\\npossibility, even the probability, that muscular contraction was the\\ncause in many others in which the history of a fall upon the back led\\nto the easy assumption of fracture by direct violence.\\nSymptoms. The symptoms are clear and unmistakable displace-\\nment of the fragment forward and upward by the combined action of\\nthe serratus magnus and teres major abnormal mobility recognized by\\ngrasping the fragment with one hand and moving it, or by fixing it\\nwith one hand and moving the scapula with the other and crepitus.\\nIn one case 3 the displacement was said to have been downward.\\nThe displacement is difficult to maintain reduced, because the small-\\nness of the fragment prevents efficient control of it, and the tonicity of\\nthe muscles tends constantly to draw it away but while this ensures\\nsome deformity it is slight and does not add seriousness to the prognosis.\\n3. Fractures of the Upper Angle.\\nThese are very rare. Gurlt gives a figure of a specimen preserved\\nin Dresden, and Hamilton of one in Philadelphia. In the latter a\\nfissure extends well into the subspinous fossa. In both repair has\\ntaken place without much displacement. Gurlt records two cases\\nobserved during life in each the injury was the result of a fall upon\\nthe back in one there was no displacement, in the other the fragment\\nwas drawn upward and inward by the levator anguli scapula?. Texier 4\\nreports a case the cause was direct violence prompt recovery.\\nTreatment. The treatment is to immobilize the arm and shoulder in\\nthe position that is most comfortable, securing the scapula with a body\\nbandage or strips of adhesive plaster, and the arm by binding it to the\\nbody with the forearm flexed across the chest.\\n4. Fractures of the Spine of the Scapula.\\nThere are no known specimens of isolated fracture of the spine of\\nthe scapula, and our only knowledge of them is clinical. In those\\nI have seen the diagnosis was readily made by recognition of the\\nabnormal mobility, with crepitus, of the fragment, and sometimes of an\\nirregularity in the outline of the spine.\\nTreatment. The treatment is as before immobilization of the arm\\nin a suitable position, and local antiphlogistic remedies if required.\\n5. Fracture of the Acromion.\\nThe alleged frequency of this fracture has been called in question by\\nthose who deem most of the museum specimens examples either of\\n1 Gurnard: Archives generales de Med., April, 1896.\\n2 Sabatier Union Medicale, 1857, p. 397.\\n3 Denuce Journ. de Med. de Bordeaux, 1892, vol. i. p. 571.\\n4 Texier Journ. de Med. de Bordeaux, April 5, 1896.\\n14", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0233.jp2"}, "230": {"fulltext": "210 FRACTURES.\\na traumatic separation of the epiphysis or of non-ossification. The\\nformer would still belong under the head of fractures, and, even if we\\nexclude the others, there are still clinical instances in sufficient number\\nto make the lesion one of the most common.\\nThe acromion is exposed to fracture by blows received directly upon\\nit, and also through the humerus, as in a fall upon the elbow, and occa-\\nsionally by muscular action. The line of fracture is usually perpen-\\ndicular to the axis of the apophysis, but is sometimes oblique. It lies\\nmost frequently either in front of the acromioclavicular joint or at\\nthe root of the acromion, rarely at an intermediate point.\\nThe symptoms are those of fracture, and of the contusion if the\\nagency has been direct violence and as the latter are prominent and\\nmay obscure the former, a fracture may be mistaken for a simple con-\\ntusion. The signs common to both are ecchymosis, local or extending\\ndown the arm, swelling, and pain. The additional signs of fracture\\nare increase of the local pain on pressure and on moving the arm,\\nusually complete inability to abduct the arm, displacement, abnormal\\nmobility, and crepitus.\\nThe displacement varies with the position and extent of the fracture.\\nIf the latter involves only the outer end of the apophysis, the displace-\\nment is slight and downward by the contraction of the attached fibres\\nof the deltoid, the shoulder loses a little of its roundness in consequence,\\nbut the head of the humerus retains its place. If the fracture is near\\nthe base of the apophysis, the weight of the arm tends to draw the\\nfragment downward and inward, turning it upon the outer end of the\\nclavicle as a centre, and the shoulder is flattened. The finger passed\\nalong the spine recognizes an irregularity in the outline, usually a\\ndepression of the outer fragment, but sometimes an elevation or a\\ntransverse groove or gap in which the end of the finger can rest.\\nCrepitus can often be got by lifting the elbow directly upward, so\\nas to push up the acromion, or by abducting the arm and abnormal\\nmobility must be sought by varied manipulations of the apophysis and\\nby moving the arm.\\nThe commonest functional disturbance is the inability to raise the\\narm, although this is not a constant symptom, while the power of rota-\\ntion is preserved unaltered, even if somewhat painful.\\nBony union appears to be the exception, the fragments uniting by a\\nfibrous bond of greater or less length and solidity the rupture or the\\npreservation of the periosteum must be of almost controlling impor-\\ntance in determining the character of the union. Apparently, bony\\nunion takes place only when the fragments remain in close contact.\\nIn one case the distal fragment became necrosed and was cast out,\\napparently in consequence of the excessive inflammation of the over-\\nlying soft parts.\\nTreatment. The treatment consists in reduction of the displacement\\nby pressing the head of the humerus upward against the acromion,\\nand in securing it in this position by a bandage passing about the\\nbody and the shoulder. The dressing should be worn for about three\\nweeks.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0234.jp2"}, "231": {"fulltext": "FRACTURES OF THE SCAPULA. 21 1\\n6. Fracture of the Coracoid Process.\\nThis may be caused by muscular action or by direct or indirect vio-\\nlence in the former the causative effort is sometimes comparatively\\nslight wringing wet clothes in one case but more often is a powerful\\neffort made with the arm. In fractures by direct violence other bones\\nribs, arm, clavicle\u00e2\u0080\u0094 are usually coincidently broken those by indi-\\nrect violence appear, according to the observations of Lane, 1 to be most\\ncommonly produced by pressure of the tip of the process against the\\nclavicle in forced flexion of the shoulder other instances are those in\\nwhich the fracture is produced by the impact of the dislocated head\\nof the humerus.\\nThe line of fracture is usually about an inch behind the beak of the\\nprocess, but sometimes is further back, passing close to the upper edge\\nof the glenoid cavity in a line that corresponds so nearly to the position\\nof the epiphyseal cartilage that some\\nobservers consider some specimens to FlG 83\\nbe examples of separation of the epi-\\nphysis, or even simply of delay in\\nossification. Normally this conjugal\\ncartilage ossifies at about the fourteenth\\nyear. Bennett 2 published a case of\\nseparation of the epiphysis, verified by\\nautopsy, in a child six years old. In\\none of Malgaigne s and in two of\\nGurlt s cases the end of the process\\nwas also split longitudinally into two\\npieces, one remaining attached to the Fracture of the coracoid process.\\ntendon of the biceps, the other to that\\nof the pectoralis minor. The displacement is seldom great, because\\nthe fragment is prevented from yielding to the action of the attached\\nmuscles by the coraco-clavicular ligament still, in one of the last-\\nmentioned cases the fragments were displaced more than half an inch\\ndownward.\\nSymptoms. The symptoms are abnormal mobility and crepitus, but\\nare not easily recognized, especially if the soft parts be much bruised\\nand swollen the depth at which the process is placed, and the thick-\\nness of the overlying muscles, make it difficult to grasp the process\\nbetween the fingers or to appreciate its independent mobility. I have\\nalso noticed localized pain on forcible voluntary adduction and flexion\\nof the arm.\\nThe fracture in itself involves no danger to life, and no probable\\ndisability, although the union is seldom bony. Of six specimens exam-\\nined by Gurlt bony union was found in only one in four cases men-\\ntioned by him of which our knowledge is only clinical, mobility\\npersisted in two. This failure of union does not seem to cause any\\nloss of function. In Hulme s case the union was firm but the frag-\\nment somewhat displaced downward.\\n1 Lane: British Medical Journal, May 19, 1888.\\n2 Bennett: Dublin Journ. Med. Sciences, August, 1888.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0235.jp2"}, "232": {"fulltext": "212 FRACTURES.\\nTreatment. The treatment must be directed to immobilizing the\\narm in a position which will relax, as well as may be, the muscles\\nattached to the process. Theoretically, the best position is that in\\nwhich the forearm is flexed and the elbow carried across the front of\\nthe chest, but this cannot be carried out thoroughly without causing\\nmore discomfort than the benefit to be obtained by it will warrant\\nand it is best, therefore, simply to fix the arm against the side with\\nthe forearm comfortably flexed.\\n7. Fractures of the Neck of the Scapula.\\nUnder this term, following Gurlt, I include not only fractures\\nwhich pass from the suprascapular notch to the axillary border of the\\nscapula in a direction parallel to the surface of the glenoid cavity,\\nbut also those which begin in front of the base of the coracoid process\\n(sometimes even within the articular border) and pass obliquely down-\\nward and backward to the axillary border. There is no known exam-\\nple of fracture running close behind and parallel to the glenoid fossa\\nalong what is sometimes termed the anatomical neck.\\nThe small anterior fragment always carries with it the attachment\\nof the triceps and usually the entire coracoid process but the liga-\\nments which bind the coracoid process to\\n84, the clavicle and acromion remain untorn,\\nas does also a ligament extending from\\nthe under surface of the spine of the\\nscapula to the edge of the glenoid cavity,\\nand they limit the displacement.\\nThe cases in which this fracture has\\nbeen verified by dissection are six in num-\\n%iE fBI 1 er ne cases \u00c2\u00b0f Luverney, Xeill, and\\n^^f i||| Spence, a specimen in the museum of\\nlira Guy s Hospital and another in that of the\\nRoyal College of Surgeons at London,\\nand one found by Lane. 1 Gurlt describes\\nthe first three, and Flower 2 mentions the\\nFracture of the neck of the scapula. next The exact character of Weill s 3\\nSpence s case. (Gurlt.) _.\\ncase is uncertain; in hpenee s (x ig. o4)\\nthe fracture passed in front of the coracoid process in the others it\\nappears to have passed through the suprascapular notch.\\nCause. The cause has been a fall or blow upon the shoulder; May 5\\nreported a case caused in a girl by the effort of placing a handker-\\nchief about her neck, but it seems more probable from the description\\nthat the injury was a fracture of the coracoid.\\nFarabeuf found that if the anterior portion of the capsule was\\nmade tense by outward rotation of the arm the neck could be broken\\n3 Lane Loc. cit., p. 415.\\n2 Flower: Holmes s System of Surgery, Am. ed., vol. i. p. 851.\\n3 Neill: American Journ. Med. Sciences, new ser., 1858, vol. xxxvi. p. 105.\\n4 Spence: Edinburgh Medical Journal, June, 1863, p. 1082.\\n5 May London Medical Gazette, 1842-43, p. 49.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0236.jp2"}, "233": {"fulltext": "FBACTUBES OF THE SCAPULA. 213\\nbv a blow on the back of the head of the humerus or by one upon\\nthe elbow if the arm was also directed backward.\\nSymptoms. The symptoms of the fracture are the flattening of the\\nshoulder, the prominence of the acromion, the absence of the head of\\nthe humerus from the axilla (where it would be found if the injury\\nwere a dislocation), the easy reduction of the displacement by raising\\nthe elbow, its immediate return when the support is withdrawn from\\nthe elbow, and the crepitus which accompanies these movements. In\\ntwo of Gurlt s cases the fragment could be felt in the axilla. The\\npower of voluntary motion of the arm is lost, but passive movements\\nare free, and, within certain limits, painless. On the other hand,\\nmanipulations which reduce the displacement or bring out crepitus\\ncause much pain. Sometimes the lower edge of the fragment can be\\nfelt in the posterior and outer part of the axilla as a hard movable\\nbody which can be pushed upward, with pain and crepitus, but falls\\nback as soon as the pressure is removed. In a case reported by Ash-\\nhurst, 1 crepitus was obtained by grasping the parts between the fingers\\non the shoulder and the thumb deep in the axilla and rotating the\\narm. There was very slight displacement. In a personal case a point\\nof pain on pressure could be found by passing the finger high up along\\nthe axillary border of the scapula.\\nThe most characteristic symptom is the easy reduction and the imme-\\ndiate return of the displacement, and it is this which distinguishes it\\nmost sharply from dislocation of the humerus, the prominent symp-\\ntoms of which are so similar.\\nPrognosis. According to Gurlt, bony union is the rule, fibrous union\\nthe exception, but in both cases with slight displacement of the frag-\\nment forward and downward. His collection contains only two cases\\nof fibrous union in one the patient had fair use of the arm, in the\\nother the limb was entirely useless. In the cases where bony union\\nwas secured, repair was complete in from four to seven weeks in\\nsome there was slight diminution of the usefulness of the limb, but in\\nthe majority its use was fully regained.\\nTreatment. It is doubtful if the parts can be supported by any\\ndressing so perfectly that union without any displacement can be\\nsecured. The indications of treatment are to oppose the constant dis-\\nplacement downward and forward or inward by supporting the elbow\\nprobably the dressing which I have found so efficient in dislocation of\\nthe acromial end of the clavicle (q. v.) would answer the purpose if the\\nends of the plaster strip were carried further inward on the shoulder.\\n8. Fracture of the Glenoid Cavity.\\nIn almost all the instances that are on record this fracture has been\\ndiscovered jiost mortem or during operation after dislocation of the\\nshoulder. It is thought to be not uncommon, but as the diagnosis is\\nvery difficult its frequency cannot be determined. Usually the frac-\\nture is of the inner border of the articular surface, but sometimes the\\n1 Ashhurst: Trans. Coll. of Physicians, Phila., 1875, 3d ser., vol. i. p. 69.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0237.jp2"}, "234": {"fulltext": "214 FRACTURES.\\nouter or lower border has beeu broken off; and Flower says that frac-\\ntures have been found running across the glenoid fossa and even split-\\nting it into several portions. Poland l showed a specimen of stellate\\nfracture of the fossa with three lines radiating thence to the bodv\\nthere was also fracture of the acromion, but no dislocation. Agnew\\ngives a similar figure, but does not state the source from which it was\\nderived.\\nSymptoms. The symptoms cannot be described because no case\\nappears to have been recognized during life and it seems unlikely\\nthat a diagnosis could be made with any positiveness. The fragment\\nis small and not accessible to direct manipulation, so that the only\\nsymptoms w r ould be those of a dislocation together with crepitus on\\nreduction, and perhaps a ready recurrence of the dislocation signs\\nthat may be present under a variety of circumstances.\\nTreatment. Treatment must be limited to reduction and immobili-\\nzation, and the latter should be more complete and better guarded than\\nafter a simple dislocation, because of the greater ease with which the\\nhead of the humerus can escape from the glenoid cavity when the rim\\nof the latter is broken.\\n1 Poland British Medical Journal, January 23, 1892.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0238.jp2"}, "235": {"fulltext": "CHAPTEE XIX.\\nFRACTURES OF THE HUMERUS.\\nThe tables in Chapter I. show that, while fractures of the upper\\nextremity (including the clavicle) constitute more than half of all\\nfractures, those of the humerus are less than 4 per cent, of all, and\\nthis bone is less frequently broken than either the clavicle, radius, or\\nulna. Different tables of statistics show great variations in the rela-\\ntive frequency of the fractures of the different portions of the bone,\\nsome giving the greatest number to the shaft, others to the lower end,\\nbut all agree in giving the greatest frequency to the first twenty years\\nof life.\\nThe different varieties of fracture may be most conveniently studied\\nby arranging them in three groups fractures of the upper end, frac-\\ntures of the shaft, and fractures of the lower end, although the first\\nand third groups severally contain varieties which differ materially\\nfrom one another.\\nFor a remarkable case of longitudinal fracture extending the entire\\nlength of the bone which cannot be placed in any one of these groups,\\nthe reader is referred to page 27.\\n1. FRACTURES OF THE UPPER END OF THE HUMERUS.\\nThe fractures of this region include fissures and chippings of the\\narticular head, fractures of the tuberosities, of the anatomical neck, and\\nalong the epiphyseal line, and a group comprising the great majority\\nof fractures in this region in which the line of fracture crosses the bone\\nin a variety of ways between the anatomical neck and the lower bor-\\nder of the surgical neck, which is commonly drawn at the insertions\\nof the teres major and pectoralis, and which includes fractures pro-\\nduced by compression, so-called, cross-strain, and torsion. Above,\\nthis group unites with or closely approaches fractures of the anatomical\\nneck, and below with oblique and comminuted fractures of the adjoin-\\ning portions of the shaft. Its upper limit may be placed at those frac-\\ntures which pass along or very close to the lower (inner and posterior)\\nportion of the anatomical neck and then reach the outer side through\\nthe greater tuberosity; the lower limit may, for clinical reasons, be\\nconveniently placed low enough to include even quite oblique fractures\\nin which one end of the line rises to the surgical neck. Between those\\nat the upper limit and fractures of the anatomical neck are some in\\nwhich the line is doubled on the outer side a fracture of the anatomical\\nneck with a second line passing through the tuberosities from about the\\nmiddle of the first. As these, like pure fractures of the anatomical\\n215", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0239.jp2"}, "236": {"fulltext": "216 FRACTURES.\\nneck, are frequently associated with anterior dislocation of the shoulder,\\nand as they lack the clinical characteristics of the lower fractures, I\\nshall describe them in the same section with fractures of the anatomical\\nneck, but under a separate title -fractures through the tuberosities their\\nlower line is the same as that of the highest of the main group (frac-\\ntures of the surgical neck), the distinction lying in the addition of a\\nline along the anatomical neck detaching the head. The lower main\\ngroup is characterized clinically by the fact that the upper fragment is\\npeculiarly subject to the unopposed action of the scapular muscles a\\nseparate class is made of separation of the epiphysis in the young, but\\nfractures in the adult which follow in the main the former line of the\\nconjugal cartilage are not separated from the main group.\\nIn this section, then, will be considered fractures of the head, of the\\nanatomical neck, through the tuberosities, of the tuberosities, and of\\nthe surgical neck, and separation of the epiphysis.\\nA. Fractures of the Head.\\nSimple fissures or partial fractures of the head of the humerus with-\\nout associated fracture of the tuberosities or surgical neck are very rare.\\nTo the two instances which Gurlt quotes from Gosselin and Gross l\\nmay be added, I think, three others, one described by Malgaigne, 2 the\\nother two by Houel.\\nHouel s first case is a specimen in the Musee Dupuytren about one-\\nthird of the head of the humerus has been broken off and has reunited.\\nHis second case, also in the same museum, is a specimen of fracture\\nthrough the head separating a thin fragment entirely covered with\\narticular cartilage. The fragment was turned completely over and not\\nunited. The patient was an old woman and died seven or eight months\\nafter the receipt of the injury.\\nThe cases are much more numerous in which the articular surface is\\nfractured in connection with fracture of adjoining parts and in ante-\\nrior dislocation of the shoulder (q. v.) deep indentation or bruising of\\nthe surface of the head by the edge of the glenoid fossa is apparently\\nnot infrequent.\\nB. Fracture of the Anatomical Neck, and Fracture Through the\\nTuberosities. 3\\nFracture of the anatomical neck, without an additional line of frac-\\nture through the tuberosities, is apparently a very rare, and also a very\\nobscure, injury, except in association with anterior dislocation of the\\nshoulder. Although it is described, and the means of diagnosis given,\\nin all systematic works upon the subject, it must be admitted, I think,\\nthat our knowledge of it is extremely scanty and uncertain, being\\nlimited to a few specimens and to a few cases clinically observed in\\nwhich the diagnosis remains more or less doubtful. The reported\\nspecimens of fresh fracture, without dislocation or additional fracture\\n1 Gross Surgery, fifth ed., vol. i. p. 985. 2 Malgaigne s Atlas, Plate iv. Fig. 2.\\n3 It is to be noted that some writers include both forms under the title Fracture of the\\nAnatomical Xeck.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0240.jp2"}, "237": {"fulltext": "FRACTURES OF THE HUMERUS.\\n217\\nFig. 85.\\nFig. 86.\\nthrough the tuberosities, are those of Boyer 1 and Spence; 2 both patients\\nwere aged, and in each the injury was caused by a fall upon the shoul-\\nder. The reported specimens from cases in which the fracture was\\nassociated with dislocation are more numerous, but in so many of such\\ncases associated fracture of the tuberosities, generally without displace-\\nment, is mentioned that it seems probable it may have been overlooked\\nor passed without comment in many of the others. These specimens\\nhave been obtained in the course of operations undertaken for the\\nremoval of the dislocated head or for the reduction of the dislocation.\\nUsually the head remains attached to the shaft by a strip of perios-\\nteum or capsule, and in one case (McBurney) the line of fracture\\ndiverged from the neck and split off a thin piece of the shaft adjoining\\nthe lowest portion of the head.\\nThe clinical cases are obscure, even uncertain. Kocher 3 reports three\\ncases in which he thought this diagnosis could be made. The first was\\na man seventy-nine years old who fell from a height upon his side\\nthe shoulder was swollen no deviation of the axis of the arm short-\\nening half a centimetre active motion lost, passive motion gave dis-\\ntiuctTcrepitus. The head projected in front below the acromion and\\ncould be drawn downward away from it so that the finger could be\\npassed in beneath the acromion and\\ncould there feel behind the fulness\\nof the head [tuberosity] in the region\\nof the anatomical neck the edge of\\nthe lower fragment directed back-\\nward. In the second case, also a fall\\nupon the side, the patient was nine-\\nteen years old, and the edge could\\nbe similarly felt movements were\\nvery paiuful. The third patient was\\na woman sixty-one years old the\\ncause a fall upon the front of the\\nshoulder. Slight swelling, pain, loss\\nof function, crepitus on rotation of\\nthe arm displacement of the upper\\nfragment upward could be felt. Figs.\\n85 and 86 represent his conception of the fracture and the displace-\\nments.\\nI have seen only one case in which the diagnosis seemed probable.\\nThe patient, whom I presented to the New York Surgical Society, 4\\nwas a man about thirty-five years old, who had fallen on his back in\\nfront of a horse-car in such a way that, as the car passed over him, the\\nedge of the front platform caught against his right elbow and pressed\\nthe humerus with great force against the scapula. Swelling and pain\\nat the shoulder, complete loss of function the tuberosities rotated with\\nthe shaft the acromion, coracoid, and neck of the scapula were unin-\\nSupposed displacement and line of frac-\\nture of anatomical neck of the humerus.\\n(Kocher.)\\n1 Boyer: Traite des Maladies Chirurgicales, 1831, vol. iii. p. 199.\\n2 Spence Edinburgh Medical Journal, 1860, vol. v. p. 1140.\\n3 Kocher Praktisch wichtiger Frakturformen, 1896.\\n4 Stimson New York Medical Journal, March 19, 1891, p. 310.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0241.jp2"}, "238": {"fulltext": "218\\nFRACTURES.\\nFig.\\njured; pressing the arm upward against the acromion gave pain and\\nwas accompanied by crepitus. He was treated in the recumbent posi-\\ntion with moderate continuous traction for five weeks, and made a\\ncomplete recovery.\\nOn another occasion I had an opportunity to examine an undoubted\\ncase. The patient had suffered the fracture with dislocation, and I\\nwas able clearly to recognize the small, movable upper fragment in the\\naxilla. Under anaesthesia I was, fortunately, able to reduce the dis-\\nlocation, and then, being in presence of a fracture of the anatomical\\nneck without dislocation, I examined it carefully in order to ascertain,\\nif possible, a means of diagnosis but I could detect nothing abnormal,\\nno deformity, no crepitus after the anaesthesia had ended, pressure\\nupward at the elbow or backward at the front of the shoulder caused\\npain.\\nThis shows that the fracture can exist without other symptom than\\npain on pressing the fragments together, and that crepitus on moderate\\nmovements of the limb may be absent which, indeed, is not surprising\\nwhen it is remembered how easily the head can move in its socket and,\\nconsequently, how likely it is to share in the movement of the lower\\nfragment if it is at all closely connected with it by irregularities of the\\nline of fracture. Probably the most that can\\nbe said in any case is that there is a fracture\\nabove the surgical neck, but whether it is purely\\nof the anatomical neck or combined with frac-\\nture through the tuberosities or even partly of\\nthe neck and partly through the tuberosities is\\nlikely to remain uncertain, because the deter-\\nmining fact the relations of the upper part of\\nthe greater tuberosity with the shaft, its move-\\nment with it or its independence of it may\\neasily be beyond exact determination.\\nOf fracture through the tuberosities the ex-\\namples are much more numerous. To a frac-\\nture of the anatomical neck may be added one\\nor more lines of fracture passing from the first\\nthrough the tuberosities, or the line may pass\\nFracture of the anatomical along the lower (posterior and internal) portion\\nneck of the humerus, with f the neck and then diverge through the tuber-\\nig and frac- ogities The fresh specimens have almost all\\nbeen obtained from cases of combined fracture\\nand dislocation, and our periodical literature\\nnow contains almost every year one or more instances. I have had\\none such, fracture of the anatomical neck with Assuring of the greater\\ntuberositv, in which I removed the head, and have seen two others\\nunder the care of colleagues.\\nThe distinction between this variety and the higher form of fractures\\nof the surgical neck (as I have here defined the latter) is arbitrarily\\ndrawn and I doubt, for the reasons given, if it can often be recognized\\nclinically. Because of its mode of production violence acting directly\\nagainst the upper end of the bone from the outer side or in front it\\nture of both tuberosities\\n(Gtjrlt.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0242.jp2"}, "239": {"fulltext": "FRACTURES OF THE HUMERUS.\\n219\\nis, I think, much more frequently associated with dislocation of the\\nupper fragment than are fractures at a somewhat lower level which\\nseem more commonly to be caused by cross-strain. Independent mo-\\nbility of only the upper part of the tuberosity would at least show that\\nthe fracture was high.\\nTwo specimens described and pictured by R. W. Smith 1 (Figs. 88\\nand 89) show healing with marked impaction in one case and with\\ncomplete reversal of the head in the other. In the one shown in Fig.\\n88, examined five years after the accident, the head of the humerus\\nwas found to have been drawn into the cancellated tissue of the shaft\\nbetween the tuberosities so deeply as to be below the summit of the\\nFig. 88.\\nFig. 89.\\nFracture through the tuberosities of the\\nhumerus. Reversal of the head. (R. W.\\nSmith.)\\ngreater tubercle this process had\\nbeen split off and displaced out-\\nward it formed an obtuse angle\\nwith the outer surface of the shaft\\nof the bone. Osseous union\\nhad taken place along the line of\\neach fracture.\\nThe specimen illustrated in Fig.\\n89 is described by the same author\\nas impacted fracture of the neck of the humerus, accompanied by\\nfracture of both tubercles. It was removed from the body of a\\nwoman forty years old who had fallen down a flight of stairs many\\nyears before and had struck the shoulder violently against one of the\\nsteps. The appearances (at the time of death) were those of disloca-\\ntion into the axilla, the acromion being prominent and the region of\\nthe deltoid flattened but the arm was shortened, the glenoid cavity\\ncould not be felt, and the shaft of the humerus was drawn upward and\\ninward so as to be almost in contact with the coracoid process the\\n1 E. W. Smith Fractures in the Vicinity of Joints, 1854, p. 192.\\nImpaction of the head of the humerus into\\nthe shaft, with splitting off of .the tuberosi-\\nties. (R. W. Smith.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0243.jp2"}, "240": {"fulltext": "220 FRACTURES.\\nmotions of the joint were extremely limited and the scapular muscles\\natrophied. The head of the bone was found to have been separated\\nfrom the shaft by a fracture which traversed the anatomical neck of\\nthe humerus. It was reversed in the articulation, so that the fractured\\nsurface was directed upward toward the glenoid cavity, and the car-\\ntilaginous articulating surface thrown downward toward the shaft, and\\nhaving assumed this position it was -driven to a considerable distance\\ninto the cancellated structure between the tubercles. From this vio-\\nlent impaction of the head of the bone into the lower fragment a\\nsecond fracture resulted which split off the lesser tubercle along with\\nabout two-thirds of the greater, and a small portion of the shaft\\nof the humerus, corresponding to the upper part of the bicipital\\ngroove.\\nThe outer part of the cartilaginous surface of the head was buried\\nto a depth of nearly an inch, but the inner part was free the cartilage\\nremained perfect, and was not united to the cancellated tissue of the\\ntubercles the rest of the fragment was firmly united with the tissue\\nof the tubercles, and their union also was complete. A similar case is\\nreported by Kronlein 1 and one bv Korte. 2 (See also Gurlt, vol. ii. p.\\n693.)\\nDoubtless, also, the upper fragment may undergo that displacement\\ninward and downward by the rising of the shaft under the action of\\nthe deltoid which was pointed out by Jonathan Hutchinson as occurring\\nin those cases which I here classify as high fractures of the surgical\\nneck, and which at a later period may easily be mistaken for unre-\\nduced dislocation.\\nRepair is largely carried on by the distal portion of the bone, and is\\nmarked by an exuberant production of callus and osteophyte growths\\non the surface and sometimes by ossification of the adjoining portion\\nof the capsule.\\nOf the fate of the small upper fragment after fracture of the anatom-\\nical neck we have little positive knowledge. Boyer s statement that\\nin his case the fragment had been diminished by absorption has been\\nextensively quoted, but as the patient died only seven days after the\\ninjury was received the accuracy of the observation is doubtful.\\nKocher does not state the result in his cases, but in McBurney s in\\nwhich the fragment was restored to its place by operation, and in mine\\nin which a presumably similar fragment was restored to its place by\\nmanipulation, and in my other in which the fragment was not dislo-\\ncated and the diagnosis is not certain, recovery with good function fol-\\nlowed. Probably the head in most cases retains some vital connection\\nthrough untorn portions of the capsule, and experience at other joints\\nshows that similar fragments can reunite or can remain as unirritating\\nloose bodies in the joint.\\nTreatment. Treatment is clearly limited to immobilization of the\\njoint, possibly aided by some traction to oppose the tendency of the\\nmuscles to draw the shaft upward and thus displace the head.\\n1 Kronlein Deutsche Zeitschrift f. Chirurgie, 1874, -p. 1.\\n2 Korte Langenbeck s Archives, 1882, vol. xxvii. p. 749.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0244.jp2"}, "241": {"fulltext": "FEACTUEES OF THE HUMERUS. 221\\nC. Fractures of the Tuberosities.\\nIsolated fracture of either tuberosity is so rare an accident, except\\nin connection with dislocation of the shoulder, that very few cases are\\non record, and none that have been verified by direct examination while\\nfresh. Partial fracture of the greater tuberosity, that is, the fracture\\nof a larger or smaller portion comprising some or all of the facets to\\nwhich the supraspinatus, infraspinatus, and teres minor muscles are\\nattached, is a not infrequent accompaniment of anterior dislocation of\\nthe humerus, and has also been seen by Malgaigne l in a case of dislo-\\ncation backward under the acromion. (See Anterior Dislocations of\\nthe Shoulder.) Fracture of the lesser tuberosity is .much more rare.\\nA number of cases have been reported of fracture of the greater\\ntuberosity with symptoms so closely resembling those of dislocation\\nthat the diagnosis of the latter lesion was at first made in each case,\\nand a study of the reports makes it seem probable that this diagnosis\\nwas correct, the dislocation having then been unwittingly reduced\\nduring the manipulations most of the specimens found at autopsies\\nprobably belong in the same class.\\nGurlt quotes a case of supposed fracture of the tuberosity by mus-\\ncular action, in which the symptoms were extreme passive mobility at\\nthe shoulder, complete loss of voluntary outward rotation, and partial\\nloss of voluntary elevation of the arm. If the arm was rotated vigor-\\nously and the ear laid upon the patient s shoulder, crepitus could be\\nheard. Four weeks later the corresponding muscles were still power-\\nless and atrophied. The patient was a muscular youth of twenty years,\\nand the lesion was produced by an eifort to throw a snow-ball with\\nforce something was heard to crack and the arm fell powerless. The\\nonly mention of displacement in the case is that the patient s brother,\\na physician, thought the arm was dislocated and made a sort of\\nreduction.\\nIn 1881 I saw at the Presbyterian Hospital a youth of nineteen\\nyears who had been injured the preceding day. He said that while\\nholding the bridle of a horse in his right hand the animal reared, and\\nas he came down his breast struck against the patient s left forearm\\nwhich was held before his face in protection, and threw him to the\\nground. The left shoulder was somewhat swollen there was an\\necchymosis at the lower border of the tendon of the pectoralis major\\nvoluntary abduction possible voluntary external rotation impossible\\nfirm pressure upward at the elbow painless. The lesser tuberosity\\nmoved with the shaft on rotation crepitus observed high up in the\\nshoulder when the head of the bone was grasped between the thumb\\nand fingers and they were moved pain on pressure upon the greater\\ntuberosity. I inserted an insect-pin in front at the bicipital groove\\nand passed it backward its full length, evidently between two bony\\nsurfaces, and by pressing its point against the inner one and rotating\\nthe arm the continuity of this surface with the shaft was shown. My\\ndiagnosis was fracture of the greater tuberosity by muscular action,\\n1 Malgaigne Atlas, Plate xxii. Figs. 5 and 6.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0245.jp2"}, "242": {"fulltext": "222\\nFRACTURES.\\nby outward rotation of the arm in the effort to ward off the descending\\nbody of the horse.\\nI have seen a few cases of pain at the greater tuberosity on pressure\\nand on voluntary outward rotation, but without crepitus or abnormal\\nmobility, which I have regarded as minor effects of similar muscular\\naction, the partial rupture or detachment of the tendon or possibly the\\navulsion of a small piece of the bone.\\nThe line of fracture usually runs along the sulcus marking the\\nanatomical neck at the part where it adjoins the tuberosity and down\\nthe bicipital groove, sometimes liberating the long tendon of the biceps\\nfrom its sheath and allowing it to slip in between the fractured sur-\\nfaces. If the separation is complete the fragment is drawn upward\\nand backward; if incomplete, that is, if the periosteum remains untorn\\non the side of the fragment adjoining the shaft, new bone fills up the\\nlower part of the gap, and the upper part of the fragment stands out\\nfrom the surface from which it has been\\ntorn, as in Fig. 90. When union takes\\nplace it is almost always bony.\\nI believe that in all cases in which the\\nfracture is not an incident of a dislocation\\nthe cause is the direct action of the at-\\ntached muscles. Some w r riters ascribe it\\nalmost without exception to direct external\\nviolence, but I know of no cases to support\\nthe opinion. The diagnosis must be made\\nby localized pain on pressure and on at-\\ntempted voluntary outward rotation of the\\narm, and by the abnormal mobility of the\\nfragment, possibly with crepitus.\\nTreatment. The treatment is immobiliza-\\ntion with as much outward rotation of the\\narm as is practicable in order to diminish\\nthe pull of the attached muscles. Any ten-\\ndency to inward displacement, such as was\\nnoted by Smith, should be opposed by a pad\\nin or below the axilla.\\nFractures of the lesser tuberosity are extremely rare. Gurlt collected\\nonly three cases, two of them accompanying dislocation of the shoul-\\nder, the third a specimen in the museum at Giessen. In each of the\\nfirst two a small hard lump could be felt on the inner side of the head\\nof the humerus, not moving with it.\\nBardenheuer 1 says he has seen two cases. In the first the patient\\nfell down stairs and tried in vain to check his fall with his elevated\\narm in the second, a man while descending a winding staircase with\\nhis left arm upon the rail fell over it. Bardenheuer supposes that in\\nthe fall the arm was forcibly rotated inward and that the tubercle was\\nbroken off by pressure against the edge of the glenoid fossa he says\\nthe appearance of the shoulder was that of a dislocation, the arm was\\nin outward rotation, and a tumor as wide as the finger and movable\\n1 Bardenheuer Deutsche Chirurgie, Lief. 63 a, p. 168.\\nFracture of the greater tuberosity\\nof the humerus united.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0246.jp2"}, "243": {"fulltext": "FBACTUBES OF THE HUMERUS. 223\\nwith crepitus could be felt in the region of the lesser tuberosity and\\nwas painful on pressure.\\nJossel 1 reports two cases accompanying backward dislocation of the\\nshoulder (q. v.) in both the tuberosity remained attached to the sub-\\nscapulars, and in one it was broken into two pieces.\\nTreatment. The treatment would be immobilization in inward rota-\\ntion, possibly aided by pressure on the outer aspect of the shoulder to\\noppose a tendency to outward displacement.\\nD. Separation of the Epiphysis.\\nThe upper epiphysis of the humerus comprises the head and the\\ntuberosities. The epiphyseal line runs upward and outward along the\\nlower and inner half of the anatomical neck and then transversely\\nunder or through the tuberosities to the outer edge, its level rising as\\nthe individual grows older, and passing above part of the insertion of\\nthe teres minor. Its centre is higher than its edge, so that the shaft\\nterminates in a low cone or wedge, with, of course, a corresponding\\nhollow on the under surface of the epiphysis. This cone is very low\\nin early life and its height increases as the individual grows older,\\nuntil ossification of the conjugal cartilage takes place, usually by the\\ntwentieth year, but sometimes as late as the twenty-fifth.\\nThis lesion has been observed at all ages between the moment of\\nbirth and the age of nineteen years. Jetter, 2 in an account of sixteen\\ncases operated upon by Burns, mentions two cases aged twenty-three\\nand twenty-four years, but no mention is made of the presence of the\\nconjugal cartilage in either, and in one the line of fracture followed\\nthat of the epiphyseal junction for only half an inch. Both, I think,\\nbelong in the class of fractures after ossification of the cartilage, and\\nare examples of the rather common high fractures of the surgical neck\\nin which the line of fracture frequently follows the former epiphyseal\\nlines quite closely. In 66 cases collected by J. Hutchinson, Jr., 3 6\\noccurred at birth, 4 during the first year, and 17 at or above the age of\\nfifteen years. In a considerable number of the recorded cases it was\\nproduced by the efforts of the midwife or physician to hasten delivery\\nby drawing upon the presenting arm, or with the finger hooked into\\nthe axilla, or to bring down the arm from the side of the head when\\nthe legs and body were already delivered. In others it has been caused\\nby falls, by forcibly drawing the arm upward and outward, and by a\\nfall upon the elbow when it was held behind the axillary line.\\nConsidering how easily the epiphyses can be separated by the\\ncross-strain produced in forcibly carrying the limb beyond the normal\\nlimit of motion in the corresponding joint established by the capsule,\\nligaments, and muscles attached to it, it seems probable that this is\\nthe mechanism in most cases, and in this may probably be included\\nforced rotation of the arm.\\nThe opportunities for direct examination of the seat of injury have\\n1 Jossel Deutsche Zeitschrift f. Chir., 1874, vol. iv. p. 125.\\n2 Jetter Beitrage zur klin. Chir., 1892, vol. ix. p. 361.\\n3 J. Hutchinson, Jr., British Medical Journal, July 8, 1893.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0247.jp2"}, "244": {"fulltext": "224\\nFRACTURES.\\nbeen largely increased of late by operations undertaken for the correc-\\ntion of the displacement, often while recent. They show that the line\\nof fracture almost always follows the epiphyseal line closely and that\\nthe periosteum remains untorn to a considerable extent, especially pos-\\nteriorly, and that where torn its separation often takes place at some\\ndistance below the line of fracture, the portion between the rent and\\nthe line of fracture being stripped from the shaft and remaining\\nattached to the epiphysis as an irregular sleeve. The younger the\\npatient the more marked apparently is this sleeve formation.\\nThe displacement is habitually forward, and sometimes to the outer\\nor to the inner side, the posterior portion of the end of the shaft\\nusually lodging in the saucer-shaped lower surface of the epiphysis,\\nthe latter being flexed and abducted (Fig. 91). Exceptionally the dis-\\nFig. 91.\\nFtg. 92.\\nSeparation of the upper epiphysis of the humerus dis-\\nplacement forward of the lower fragment. (Moore.)\\nUpper epiphysis of the humerus at\\n10 years separated by maceration.\\nOuter side. (Moore.)\\nplacement inward of the upper end of the shaft may be such as com-\\npletely to separate the fractured surfaces and lodge the end of the shaft\\nbeneath the coracoid process. There is reason to think that in some\\ncases there is no displacement.\\nSymptoms. The symptoms are so characteristic that it is difficult to\\nunderstand why the mistake of supposing the injury to be a disloca-\\ntion should have been made so frequently. The anterior edge of the\\nupper end of the shaft can be distinctly felt at the front of the shoulder\\nan inch or more below the acromion, and often so raises the skin that\\nits presence can be seen as well as felt. The arm usually hangs\\nstraight with the elbow directed a little backward, or it may be\\nabducted, but the suggestion of a dislocation which the latter attitude\\ngives is at once removed by palpation of the shoulder which shows the\\nhead of the humerus to be in its place, and if the head is grasped\\nbetween the thumb and fingers and the arm gently rotated the inde-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0248.jp2"}, "245": {"fulltext": "FRACTURES OF THE HUMERUS.\\n225\\npendent mobility of the two will be recognized, perhaps with crepitus.\\nThe anterior displacement of the upper end of the shaft is well shown\\nin Fig. 93.\\nIn cases without displacement the diagnosis could be made only by\\nthe localized pain on pressure, on pressing the elbow upward, and on\\nattempting to use the limb.\\nFig. 93.\\nFig. 94.\\nSeparation of upper epiphysis of humerus.\\nIf displacement is absent or has been corrected repair takes place\\nhabitually without incident, although occasionally the trauma has led\\nto premature ossification of the conjugal cartilage and consequent\\narrest of growth, a matter of special importance here because the\\ngreater part of the growth of the humerus in length takes place at its\\nupper end.\\nWhen the displacement persists various results are possible union\\nmay take place (Fig. 95), and the subsequent range of motion be\\nrestricted by the deformity as the epiphysis is already flexed and\\nabducted motion of the arm in those directions is restricted, and\\nmotion in other directions may be interfered with either by the faulty\\nposition in some respects (e. g., inward rotation) of the lower fragment\\nor by the contact of projecting portions with adjoining apophyses. Or\\nsuppuration may follow in the reported cases it is not entirely clear\\nthat the suppuration was not provoked by injudicious attempts to\\nreduce a supposed dislocation, or that it may not have been a sponta-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0249.jp2"}, "246": {"fulltext": "226\\nFRACTURES.\\nneous osteomyelitis preceding the separation of the epiphysis, the latter\\nbeing the result, not the cause, of the suppuration. Or, very rarely,\\nreunion may fail.\\nIn respect of treatment the first effort must be to correct the dis-\\nplacement this can sometimes be effected by traction upon the arm\\naided by direct pressure upon the projecting fragment, but in other\\ncases it is advisable to use the plan suggested by Dr. E. M. Moore,\\nthat of forcibly raising the elbow beside the head so as to bring the\\nFig. 96.\\nUnion after separation of the upper\\nepiphysis of the humerus with displace-\\nment. (R. W. Smith.)\\nSeparation of upper epiphysis of humerus. Excision\\nof projecting end of shaft. (Kocher.)\\nshaft into a position corresponding with\\nthat taken by the epiphysis as the latter\\nis prevented by the posterior portion of\\nthe capsule from moving further in this\\ndirection, the forced movement of the\\narm throws the upper end of the shaft\\nbackward into place. Interposition of\\nthe torn and loosened periosteal sleeve\\nmay create so serious an obstacle that\\nreduction cannot be effected without the\\naid of an incision exposing the seat of\\nfracture. In the older cases ossification of the untorn periosteum\\nrapidly produces a bony bridge between the fragments which pre-\\nvents reduction. In two such cases Kocher cut away the projecting\\nportion of the shaft (Fig. 96) and increased the range thereby others\\nhave resected the callus and a portion of the diaphysis and then made\\nreduction.\\nAfter reduction immobilization of the limb for three or four weeks\\nis necessary. It is only in cases in which reduction is incomplete that\\nmeasures are required to oppose a tendency to recurrence of the dis-\\nplacement.\\nE. Fracture of the Surgical Neck.\\nUnder this rubric are here included fractures of the portion of the\\nbone lying between the site of the epiphyseal cartilage and the insertion\\nof the pectoralis and teres major, the great majority of all fractures of", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0250.jp2"}, "247": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0251.jp2"}, "248": {"fulltext": "Oh\\nO\\no\\nB\\nw", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0252.jp2"}, "249": {"fulltext": "FRACTURES OF THE HUMERUS.\\n227\\nthe upper end of the bone. The line of fracture in separation of the\\nepiphysis in the young marks the upper limit of this group in adults\\nits lower limit is an arbitrary and ill-defined one and, moreover, is not\\ninfrequently crossed by fractures which lie partly above and partly\\nbelow it. The higher fractures of the group are separately described\\nbv some as fracture through the tuberosities, fractura pertubercularis,\\nbut the distinction does not seem worth preserving.\\nThe common cause is external violence, a fall or a blow upon the\\narm, but occasionally is muscular action. The mode of action is rarely\\nclear in the history of a given case, but experiment has thrown light\\nupon it. The higher fractures may be caused by a blow or fall upon\\nthe upper part of the arm or upon the elbow, presumably aided by the\\nresistance of the glenoid fossa or the acromion, the so-called com-\\npression fractures, but much more frequently, I think, by a cross-\\nstrain in which the upper end is fixed by the resistance of the capsule\\nand ligaments and possibly the muscles, and either the elbow is forced\\noutward or forward or is fixed in abduction while the blow is received\\non the outer part of the shoulder, abduction fractures; adduction\\nfractures, by violence acting in the opposite direction, are much rarer.\\nFig. 97.\\nFig. 98.\\nF\\nUpper and lower limits of fracture\\nof the surgical neck of the humerus\\nwith spiral fracture of shaft extend-\\ning into the area.\\nThe\\nImpacted fracture of the surgical neck of the humerus.\\n(R. W. Smith.)\\nlower fractures may be caused by violence acting on the side of\\nthe shaft at or below the point of fracture, or by cross-strain in a fall\\non the elbow or hand, or by torsion of the limb.\\nIn the higher and some of the lower fractures the line is essentially", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0253.jp2"}, "250": {"fulltext": "228\\nFRACTURES.\\ntransverse, usually with splintering or even comminution, sometimes with\\nfissures extending through the head and sometimes with notable impac-\\ntion. Many of the lower fractures are oblique, often markedly so.\\nThe upper fragment, since opposition to the action of the muscles\\nattached to it is diminished or annulled by the fracture, often takes the\\nattitude of flexion, abduction, and outward rotation, being sometimes\\naided therein by the impaction into it of the lower fragment (Plate IV.)\\nthe latter is usually displaced inward, partly by the momentary con-\\ntinuation of the fracturing force in some cases and partly by the action\\nof the pectoralis and teres major. Exceptionally the displacement is\\nequal to the thickness of the shaft, and may be outward or posterior, as\\nshown in some of the figures but in the great majority of cases the\\ndisplacement is too slight to be clinically recognizable.\\nAn important form of impaction is that in which the shaft passes to\\nthe front and outer side of the head and the latter is thereby brought\\nFig. 99.\\nFig. 100.\\nh\\nFracture of the surgical neck of the\\nhumerus. The dark spot is an ecchy-\\nmosis.\\nFracture of the surgical neck displacement\\ninward of the lower fragment, resembling dis-\\nlocation.\\nto a lower point on its inner side (Fig. 98). It is claimed by Hutch-\\ninson that the rising of the shaft under the pull of the deltoid may\\npress the head so far inward and downward that the final position may\\nresemble that of a dislocation below the coracoid.\\nThe tendon of the long head of the biceps may be torn in these\\nextreme displacements. Injury of the axillary vessels and nerves is", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0254.jp2"}, "251": {"fulltext": "FRACTURES OF THE HUMERUS. 229\\nextremely rare thrombosis of the artery in consequence of bruising\\nhas been seen, the axillary vein has been torn in a compound fracture,\\nand the musculo-spiral nerve has been so compressed as to cause paral-\\nysis of motion and sensation in its area of distribution.\\nIn an oblique fracture the sharp end of the lower fragment may\\napproach or become engaged or even perforate the skin, usually on\\nthe inner side, and even in the higher fractures this has been observed\\nin front close below the acromion.\\nFor the combination of fracture with dislocation see Dislocation of\\nthe Shoulder, Chapter XLIY.\\nSymptoms. The symptoms vary with the form of fracture and the\\ndisplacement usually the arm hangs by the side or the elbow is slightly\\nabducted, but if the displacement inward of the upper end of the shaft\\nis marked the abduction of the arm resembles that of an anterior dis-\\nlocation (Fig. 100) the distinction is easily made by recognition of\\nthe presence of the head of the glenoid fossa, maintaining the fulness\\nof the shoulder. Loss of function is usually complete, swelling\\nmarked, and ecchymoses very extensive, especially in the old, often\\nspreading to the elbow and across the front of the chest.\\nIf the elbow is pressed upward pain is felt at the fracture, and dis-\\ntinctly localized pain can often be caused by pressure with the linger\\nalong the line of fracture.\\nThen if the upper fragment is grasped between the thumb and fingers\\nin such a way that the notch between the tuberosities at the bicipital\\ngroove can be felt, and the elbow is gently rotated, the failure of the\\nformer to share in the movement will be recognized and usually crepi-\\ntus will be perceived. In the cases with more marked displacement the\\nrelations of the fragments can be determined by palpation if the patient\\nis not too fat or the region too swollen, or by noting the direction of the\\naxis of the shaft.\\nDiagnosis. In the great majority of cases the diagnosis is made upon\\nthe localized pain, especially on pressing the elbow upward, and on the\\nfailure of the tuberosities to share in slight rotatory movements com-\\nmunicated to the elbow, for the displacement is usually too slight to be\\nrecognized through the swollen tissues. When marked displacement\\nexists the position of the upper end of the lower fragment is indicated\\nby the direction of the axis of the shaft, generally upward and inward,\\nand is demonstrated by abnormal resistance to pressure and pain at the\\nindicated point, usually corresponding to the groove between the pec-\\ntoralis and deltoid near the coracoid. Dislocation of the shoulder is\\nexcluded by recognition of the head in its place. The lower end of\\nthe upper fragment can be traced only in those oblique fractures wliere\\nthe line of fracture descends upon the shaft.\\nPrognosis. When no important displacement persists and no compli-\\ncations are present, the course is uneventful and the result good union\\ntakes place in from thirty to forty days, and the restoration of function\\nis complete after a few more weeks. Exceptionally, function may be\\ndiminished by an associated arthritis, especially in the old, or by exces-\\nsive formation of callus in the higher forms. Failure of union has\\nbeen noted in only a very few cases with uncorrected displacement;", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0255.jp2"}, "252": {"fulltext": "230 FRACTURES.\\nand once or twice the displaced end of the shaft has become firmly\\nadherent to the coracoid process.\\nTreatment. Reduction of the displacement is made by traction upon\\nthe arm aided by appropriate pressure on the end of the lower frag-\\nment. In most cases, because of the usual abduction of the upper\\nfragment, it is necessary to make traction with the arm widely abducted\\nso as to bring the shaft into line with the attitude of the upper frag-\\nment, and after the displacement has thus been reduced the arm is\\nlowered to the side and there maintained by suitable dressings unless\\nthis position too greatly favors recurrence of the displacement, in which\\ncase the abducted position must be maintained for a week or two.\\nExceptionally, another attitude may be made necessary by another\\nform of displacement.\\nThe chief disturbing influence which the retentive dressing has to\\noppose is the action of the muscles, which tends to draw the lower frag-\\nment upward and inward and to flex, abduct, and sometimes outwardly\\nrotate the upper fragment, and the great difficulties in the preparation\\nof an always effective dressing are to find a fixed support for its upper\\nend which will furnish the counter-extension for traction upon the\\nlower segment and to oppose the tendency to displacement inward with-\\nout making undue pressure upon the vessels and nerves of the axilla\\nand inner aspect of the arm. The upper fragment is too small to be\\nacted upon directly by any splint, and its position and movements can\\nbe controlled only through its interlocking with the lower fragment\\nin default of such control the lower fragment must be brought into line\\nwith the upper in the position given to the latter by its attached mus-\\ncles. Counter-extension against the folds of the axilla is ineffective\\nboth because they are yielding and because they rest upon muscles, the\\npectoralis and latissimus dorsi, which are attached to the humerus\\nbelow the seat of fracture, so that the force is applied to the two ends\\nof the lower segment and is, therefore, ineffectual to control its rela-\\ntions to the upper one. The desired fixation can be got by a heavy\\nplaster-of-Paris dressing enveloping the chest and shoulder, but this is\\ntoo irksome to be used except in cases of extreme need. I have used\\nit with advantage in some compound fractures. Fortunately the ten-\\ndency to displacement can usually be controlled by simple measures\\nwhich are sufficiently effective in practice even if not in theory, but\\nwhen it is great continuous traction must be used, either by weight and\\npulley with the patient in bed, or by a weight attached to the dependent\\narm when the patient is seated or standing.\\nLateral displacement inward of the upper end of the shaft can be\\neffectively opposed when the patient is in bed by moderate traction\\noutward applied by a band about the upper part of the arm. JN o fixed\\ndressing or splint can alone do it. when the tendency is marked, because\\nof the presence of the main vessels and nerves on the inner side of the\\narm where they might be dangerously compressed between the bone\\nand the upper part of the splint. Fixed dressings consist essentially\\nof a stiff piece on the outer side of the limb, resting against the shoul-\\nder and elbow, to which the arm is made fast by a bandage this meas-\\nurably controls inward displacement but not shortening. If the latter", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0256.jp2"}, "253": {"fulltext": "FRACTURES OF THE HUMERUS.\\n231\\nthreatens it must be opposed by traction, although that supplied by the\\nweight of the limb is usually sufficient. Occasionally the fixed dress-\\ning is a simple support between the arm and the body, by which the\\nlimb is immobilized in abduction and not infrequently it is sufficient\\nsimply to bind the arm to the side of the body.\\nContinuous traction by weight and pulley is made through a cord\\nattached to the arm above the elbow by two strips of adhesive plaster\\nbound to it by a roller bandage as in the similar treatment of fractures\\nof the thigh (page 95). The hand and forearm should be bandaged\\nto prevent swelling. The patient should be in bed, the arm somewhat\\nabducted and resting on pillows or a sliding support weight about five\\npounds. It is rarely necessary to maintain it for more than two weeks.\\nTraction with the patient out of bed can be made by a weight simi-\\nlarly attached to the arm or hanging from a plaster-of-Paris dressing\\nFig. 101,\\nFig. 102.\\nr^\\nHennequin s plaster splint for fracture of the humerus.\\nas described below the elbow is flexed at a right angle, and the fore-\\narm supported at the wrist by a sling.\\nThe common shoulder-cap of leather or cardboard, capping the shoul-\\nder and covering the outer aspect of the arm, or even extending to the\\nelbow, is wholly inefficient against inward displacement or overriding\\nand serves only to give support and to protect against chance violence.\\nIf more is needed it must be combined with an internal lateral splint\\nto give it more control over the lower fragment and with traction to\\nprevent overriding.\\nA similar dressing of plaster of Paris enveloping the arm and fore-\\narm and overlapping the shoulder has the same defects, although they\\nare diminished by the better control of the limb and by the weight\\nof the dressings which makes efficient traction when tlie patient is", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0257.jp2"}, "254": {"fulltext": "232\\nFRACTURES.\\nerect. It can safely be used when the tendency to displacement is\\nslight, especially after the second week. It can be readily made with\\nthe usual plaster roller-bandage, applied lightly over the forearm and\\nmore thickly on the arm as high as the axilla, and combined with a\\ncap over the shoulder made by carrying the bandage up and down over\\nit from the outer side of the arm. Overriding taking place under it can\\nbe detected by noticing that the cap rises above the shoulder, admitting\\nthe finger, or even two, beneath it this must be met by attaching a\\nweight to the elbow, and in all cases the forearm should be supported\\nacross the chest only at the wrist, in order that the weight of the arm\\nmay constantly draw the lower fragment down when the patient is erect.\\nA convenient method of making a similar plaster dressing is that\\ndevised by Hennequin L a dozen thicknesses of crinoline, or three or\\nfour of muslin or canton-flannel, cut as shown in Fig. 101, the width\\nbeing equal to the circumference of the arm, and the length of the\\ncentral portion equal to the distance from the fold of the axilla to the\\nelbow, are soaked in plaster cream and applied as shown in Fig. 102,\\nthe limb having previously been bandaged from the wrist to the elbow\\nto prevent swelling. If overriding is present or anticipated traction\\nmust be made while the plaster is hardening, either by the hands or by\\na weight made fast at the elbow by a bandage under the splint. Hen-\\nnequin makes temporary counter-extension by a bandage under the\\naxilla, but I doubt its value or safety it seems liable to lead to making\\nthe splint too high on the inner side and thus chafing the axillary folds.\\nFor cases in which the attitude and fixation of the upper fragment\\nare such that the limb must be kept abducted so as to be in line with\\nit, and in which confinement to\\nbed must be avoided, a support\\nbraced against the body may be\\nused. Middeldorpf s triangle (Fig.\\n103) is a type of such dressing\\nthe objection to them is in the in-\\nternal rotation which they give to\\nthe arm and which may not coin-\\ncide with the position of the upper\\nfragment. A lighter pattern is\\nmade of a bent rod or piece of\\nstout leather strapped to the arm\\nand trunk.\\nThe choice of these different\\nmethods in varying cases may be\\nsummarized as follows In the\\nhigh fractures with little displace-\\nment or tendency thereto moderate\\nimmobilization, support, and pro-\\ntection are sufficient, and these\\nmay often be got by binding the\\narm to the side, especially if the\\npatient is fat. If the patient is robust, and especially if the fracture\\n1 Heunequin Eevue de Chirurgie, 1887.\\nMiddeldorpf s triangle for fracture of the\\nhumerus.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0258.jp2"}, "255": {"fulltext": "FRACTURES OF THE HUMERUS.\\n233\\nFig. 104.\\nis oblique, so that shortening by the traction of the muscles is prob-\\nable, a plaster-of-Paris dressing with traction by a weight at the elbow\\nis required. If the upper fragment is abducted and its position can-\\nnot be controlled by interlocking of the broken surfaces, the abducted\\nposition of the arm is necessary, and the patient should be treated in\\nbed with traction in that position for a fortnight, when the upper frag-\\nment will generally be found to accompany the lower one when it is\\nadducted, or out of bed with a dressing like the Middeldorpf triangle.\\nCases with marked tendency to displacement inward of the upper\\nend of the lower fragment should be treated in bed with traction in\\nabduction aided by moderate outward traction upon the upper part of\\nthe lower fragment.\\nCompound fractures which suppurate need a strong fixed support\\nwhich can be maintained during the changes of dressing, such as a\\nplaster-of-Paris jacket with iron braces extending across to a plaster\\ncase enveloping the lower two-thirds of the arm or with a strong broad\\nplaster bridge uniting the two over the top and outer aspect of the\\nshoulder. In compound fractures with splintering of the upper frag-\\nment and implication of the joint, usually gunshot, excision of the head\\nfavors repair and the subsequent usefulness of the limb.\\nIn all cases the patient should be directed to move his wrist and\\nfingers freely and fixed dressings should be removed as early as pos-\\nsible, and the limb supported only in a sling and protected by a\\nremovable shoulder-cap extending to the elbow, in\\norder that massage may be used to hasten the restora-\\ntion of function.\\nFor the treatment of fracture combined with dislo-\\ncation see Dislocation of the Shoulder.\\n2. FRACTURES OF THE SHAFT OF THE\\nHUMERUS.\\nThe region is that included between the insertion\\nof the pectoralis major and the upper portion of the\\nsupracondyloid ridges.\\nAll the varieties of fracture which may occur in long\\nbones are contained among those of the shaft of the\\nhumerus. A remarkable and unique example of longi-\\ntudinal fracture extending the entire length of the bone\\nis quoted in Chapter II. (p. 27), and Gurlt gives two\\nof exceptionally long fissures, beginning in the one\\ncase at the condyles and ending at the insertion of the\\ndeltoid, and extending in the other from the upper\\nborder of the greater tuberosity to the lower fourth\\nof the shaft. Incomplete or partial fractures are ex-\\ntremely rare.\\nAll the forms of displacement common to fractures\\nof the long bones are also found here, and no one deserves mention\\nas of exceptional frequency and importance. The character of the\\nLongitudinal frac-\\nture of the humerus.\\n(Gurlt.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0259.jp2"}, "256": {"fulltext": "234 FRACTURES.\\nprimary displacement depends largely upon the fracturing force that\\nof later displacement upon the unsupported weight of the limb and\\nupon muscular action.\\nDouble fractures of the same bone are very rare. Simultaneous frac-\\nture of both humeri has been caused by epileptic convulsions and by\\nexternal violence.\\nAmong the injuries which may be associated with the fracture are\\ndislocation of the shoulder, laceration of the soft parts, and contusion\\nor rupture of bloodvessels or nerves. The latter deserve special atten-\\ntion because of the gangrene of the limb or the paralysis which mav\\nresult and may be attributed to negligence in the treatment. The\\nbrachial artery or vein may be so crushed or bruised by direct violence\\nthat a thrombus forms within it and arrests the circulation or, more\\nrarely, it may be torn by the sharp edge of a displaced fragment, or\\nthe vessel may be stretched across the fragment in such a way as to be\\noccluded by pressure. Occasionally the injury to the artery has resulted\\nin the formation of an aneurism. The musculo-spiral nerve is par-\\nticularly exposed to injury because of its close relations to the bone\\nthroughout so large a part of its course. (See p. 73.)\\nCauses. The causes of fracture are external violence and muscular\\naction the latter causes fracture in the humerus more frequently than\\nin any other bone, and the causative eifort has not always been very\\ngreat. The two most common efforts which have caused it are throw-\\ning a stone and that trial of strength in which two men clasp hands\\nwith elbows resting on a table and strive each to force the other s hand\\naside the latter produces a spiral fracture.\\nCompound fractures have no anatomical peculiarities that require\\nmention. Gurlt collected five cases of almost complete severance of\\nthe arm by a blow with an axe or sabre, all of which recovered with\\npreservation of the limb in all the wound was on the outer and ante-\\nrior aspect of the limb.\\nSymptoms. The symptoms are the usual ones abnormal mobility,\\ncrepitus, loss of function, pain, and more or less deformity. Impor-\\ntant complications, such as dislocation of the shoulder or injury of the\\nartery or a nerve, have their special symptoms the principal danger is\\nthat they may be overlooked because the attention is concentrated on\\nthe fracture. Injury to the artery is indicated by absence or weakness\\nof the radial pulse, either immediately or after the lapse of a few\\nhours sometimes the symptoms have appeared gradually, the pulse\\nbecoming weak, and finally disappearing, the hand numb and cold, the\\nsurface bluish, and after death or amputation a clot, sometimes firm,\\npale, and adherent, sometimes dark and soft, has been found in the\\nartery. Injury of a nerve, usually the musculo-spiral, is shown by\\nparalysis and loss of sensation or hyperesthesia in the region supplied\\nby it; paralysis or loss of sensation indicates division or destruction of\\nthe nerve hyperesthesia indicates irritation, usually by pressure.\\nParalysis of motion is often overlooked at first.\\nA simple fracture in an adult, running its course without complica-\\ntions, will be solidly united in from four to six weeks, and in three or\\nfour weeks in children. The possible complications are inflammation", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0260.jp2"}, "257": {"fulltext": "PLATE V.\\nFig. 1. Fracture of Humerus by Small Bullet.\\nFig. 2. Fracture of Forearm.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0261.jp2"}, "258": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0262.jp2"}, "259": {"fulltext": "FEACTUBES OF THE HUMERUS.\\n235\\nFig. 105.\\nand delayed union the former is sometimes quite marked, and the\\nlatter is of much more frequent occurrence in the humerus than in any\\nother bone. The general and local causes which lead to delay in or\\nfailure of union have been discussed in Chapter VIII. It has been\\nthought that the special cause in the case of the humerus is defective\\nimmobilization of the fragments, for when the elbow is kept at a right\\nangle any vertical movement of the hand or forearm is likely to cause\\nhorizontal movement of the lower fragment on the upper one, and\\nlateral splints cannot be fitted accurately or snugly\\nenough to prevent it. It has been proposed, there-\\nfore, to treat the fracture with the elbow in full exten-\\nsion, but this position is very irksome and equal im-\\nmobilization can be obtained by the use of a posterior\\nsplint the upper end of which overlaps and is secured\\nto the shoulder. The supposed interposition of mus-\\ncle which has been so frequently alleged as the cause\\nhas existed in none of the cases upon which I have\\noperated because of failure of union.\\nTreatment. Reduction is made by traction upon\\nthe condyles or the flexed forearm. The treatment in\\nfractures of the upper third is essentially the same as\\nin fractures of the surgical neck rest in bed, with\\ncontinuous traction and the limb supported upon\\ncushions, may be required at first. For the lower\\nfractures abduction of the limb is not so often needed.\\nThe plaster-of-Paris bandage is in common use, is\\nmore secure than lateral splints, and gives good re-\\nsults, but it needs careful watching at first, both to\\ndetect displacement and to prevent strangulation of\\nthe limb. It should be carried from the wrist to the\\nshoulder, and may include a few spica turns over\\nthe shoulder and about the chest to aid immobiliza-\\ntion and oppose overriding. The forearm should be\\nflexed and supported by a sling at the wrist. Snug\\nsupport under the elbow in low fractures can produce\\nan angular deviation inward of the lower fragment\\n(Fig. 105), which greatly disfigures the limb, espe-\\ncially when the forearm is extended this deformity\\nis considered in detail in the subsequent section on\\nSupra-condyloid Fractures. A posterior moulded\\nplaster or wire splint extending under the forearm\\nand over the back of the shoulder (Fig. 106), is\\nconvenient and efficient. A weight attached to the\\nelbow is sometimes useful to prevent shortening or\\nto overcome that which is already present it will\\nlengthen a limb even after the lapse of two or three\\nl L Fracture of lower por-\\nWG t i j- tion of shaft angular\\nI have found it advantageous in cases of fracture displacement; cubitus\\nby direct violence, especially in women and the vams\\nalcoholic, to keep the patient in bed for about a week, or until the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0263.jp2"}, "260": {"fulltext": "236\\nFRACTURES.\\ndanger of acute inflammatory complications had passed. Stromeyer s\\ncushion, designed particularly for the treatment of compound fractures,\\nFig. 106.\\nPlaster-of-Paris splints for fracture of the shaft of the humerus.\\nis useful as a support. It has the form of a triangular pyramid (Fig.\\n107), the long lines of which are twelve or fifteen inches long. It\\nshould be firm enough to keep its shape under pressure, and its upper\\nend should be blunter than shown in the figure. It is secured in place\\n(Fig. 108) by tying the upper pair of straps about the opposite shoulder\\nand the lower pair about the waist.\\nIn the treatment of compound fractures the general principles laid\\ndown in Chapter VII. are to be followed. I habitually treat them in\\nbed for the first fortnight with the limb on a pillow, trusting to the\\nposition and the support of a bulky dressing of the wound, for the\\ndesired immobilization. If prompt union of the wound is not ob-\\ntained moulded splints can be applied outside the dressing. Resec-\\ntion of the ends of the fragments or their direct suturing is rarely\\nindicated.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0264.jp2"}, "261": {"fulltext": "FRACTURES OF THE HUMERUS.\\n237\\nWhen there is reason to fear serious injury to bloodvessels or nerves\\nfixed dressings and bandages should be avoided until after the extent\\nof the injury shall have become apparent. Reduction should be made\\nas completely as possible and the limb supported upon cushions.\\nIf there is reason to believe that the musculo-spinal nerve has been\\nFig. 10/\\nFig. 108.\\nStromeyer s cushion applied.\\nruptured it should be sought in\\nthe groove between the supi-\\nnator and brachalis anticus and\\ntraced to the point of injury, and\\nsutured. Or the operation may\\nbe delayed two or three weeks in\\nstromeyer s axillary cushion. order that repair may be well ad-\\nvanced and the dangers of infec-\\ntion thereby lessened. If the paralysis appears only after the lapse of\\na few weeks it is probably due to inclusion of this nerve in callus or\\ncicatricial tissue, which must then be relieved by open operation. (See\\nChapter VI., p. 74.)\\n3. FRACTURES OF THE LOWER END OF THE HUMERUS.\\nThis group, like that of fractures at the upper end of the humerus,\\nincludes a number of varieties differing materially in character and\\nimportance, and having in common only their position near the elbow,\\nand the frequent necessity and difficulty of making a differential diag-\\nnosis between each and the others and dislocation. A certain lack of\\nagreement among writers, as to the sense in which some of the distin-\\nguishing terms are used, makes it desirable to define those that are to\\nbe here employed at the same time that the limits of the divisons of\\nthe main group are traced. These divisions are\\nA. Fractures Above the Condyles Supracondyloid. The line of\\nfracture crosses the expanded part of the bone above the articular\\nsurface transversely or obliquely, and may or may not open the articu-\\nlation.\\nB. Fractures of the Internal Epicondyle or Epitrochlea. The line of\\nfracture is entirely extra-articular, and the piece broken off consists\\nof the whole or part of the epicondyle. And by the internal epicon-\\ndyle or epitrochlea is meant the whole of the projecting tuberosity that\\nlies above and on the inner side of the trochlea, and part of which is\\ndeveloped about a separate centre of ossification.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0265.jp2"}, "262": {"fulltext": "238 FRACTURES.\\nC. Fractures of the External Epicondyle. The line of fracture is\\nprobably extra-articular; the fragment is very small, consisting of the\\nepicondyle proper, either alone or with some of the adjoining bone.\\nD. Fractures of the Internal Condyle. In these the line of fracture\\npasses from a point on the inner border of the bone above the tip of\\nthe epicondyle obliquely downward and outward to the articular sur-\\nface.\\nE. Fractures of the External Condyle. Similar to the preceding\\nvariety, except that the line of fracture begins upon the outer side and\\npasses downward and inward.\\nF. Intercondyloid or T-shaped Fractures. These are a combination\\nof the first, fourth, and fifth, the extremity being separated from the\\nshaft and split into two or more pieces.\\nG. Separation of the Epiphysis. The fracture follows the line of\\nthe conjugal cartilage.\\nH. Fracture of the Articular Process. In this more or less of the\\nportion of bone covered by articular cartilage is broken off; the most\\ncommon form is fracture of the capitellum.\\nThese fractures are much more common than those of either the\\nupper end or shaft. The relative frequency of the varieties mentioned\\nin the preceding list has not been satisfactorily determined published\\nstatistics differ quite widely, and the differential diagnosis is often so\\ndifficult (partly because of the extreme youth of many of the patients)\\nthat doubt must sometimes remain whether a case has been properly\\nassigned to its class. In the Out-patient Department of the House\\nof Relief between January 1, 1895, and October 1, 1897, forty-eight\\nof these fractures were received, divided as follows Supracondyloid\\n8, intercondyloid 7, external condyle 15, internal condyle 10, internal\\nepicondyle 8. 1\\nThe great relative frequency of these fractures in children makes\\nnecessary a brief account of the somewhat complex development of this\\nend of the bone. According to Henle, the epiphysis at birth is wholly\\ncartilaginous below a transverse line passing through the lower part\\nof the olecranon fossa in a month or two this line descends centrally\\nto the lower edge of the fossa, becoming convex, and during the first\\nor second year a centre of ossification appears in the capitellum.\\nBetween the eighth and twelfth years this nodule enlarges, nearly or\\nquite reaching the trochlear groove, a nodule appears in each epicon-\\ndyle, and the diaphysis sends a prolongation down into the inner por-\\ntion of the trochlea. Between the twelfth and fifteenth years the\\nnodule of the capitellum unites with that of its epicondyle, and after\\nthat the final point of ossification, that of the trochlea, appears it is\\na thin concave cap or shell, closely applied to the downward projection\\n1 Excluding cases associated with dislocation of the elbow. Examination of the record\\nsuggests that two or three of those classed as fractures of the internal condyle were\\nsupracondyloid. Thirty of the patients were under eleven years of age, and 7 others\\nwere less than twenty years old 8 were more than twenty years old, and in 3 the age\\nwas not noted. Of the 8 fractures in adults 3 were of the epicondyle, 2 of the external\\ncondyle, 1 of the internal condyle, 1 supracondyloid, and 1 intercondyloid. Counting\\nthe intercondyloid as a variety of the supracondyloid and adding to the latter the\\ndoubtful ones classed as of the internal condyle, the order of frequency would be 1.\\nSupracondyloid. 2. External condyle. 3. Internal condyle. 4. Epicondyle.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0266.jp2"}, "263": {"fulltext": "FRACTURES OF THE HUMERUS.\\n239\\nof the corresponding portion of the diaphysis, and unites with the\\nnodule of the capitellum about the fifteenth year soon afterward the\\nnodule formed by the union of the trochlea, capitellum, and external\\nepicondyle unites with the diaphysis, and subsequently the nodule of\\nFig. 109.\\nTwelfth to fifteenth year. Eighth to twelfth year. First to second year.\\nOssification of the lower epiphysis of the humerus.\\nthe internal epicondyle unites. Kocher s statement, following Fara-\\nbeuf, that the trochlear nodule is the first to unite with the diaphysis\\nseems to be an error due to misinterpretation of the peculiar descent\\nof the diaphysis into the trochlea, probably through ignorance of the late\\nappearance of the trochlear nodule. It\\nthus apears that the epiphysis after about Fig. 110.\\nthe fifth year is an irregular strip of carti-\\nlage containing one, or two, bony nodules\\nin its thicker outer portion, and none in its\\nthin saucer-like trochlear portion, which\\nlatter is continuous by a sort of neck with\\nthe cartilaginous and bony internal epicon-\\ndyle.\\nA. Fractures above the Condyles\\nSupracondyloid.\\nThese fractures are those which come\\nnext in order of position after fractures of\\nthe lower third of the shaft, and require\\nseparate mention because of the special\\nquestions involved in the differential diag-\\nnosis by reason of the proximity of the\\nelbow-joint and by the possible extension\\nof the fracture into the joint. The line of\\nfracture may be transverse or oblique, and oblique either from side to\\nside or from before backward, and it may open the joint by crossing\\nthe olecranon or coronoid fossa or by the extension into it of a fissure\\nbetween the condyles.\\nThe cause is violence acting upon the front or back of the lower\\nend of the bone, usually through the bones of the forearm, as in a mil\\nupon the outstretched hand, or, as indicated by Kocher s experiments,\\nby torsion. The commonest cause appears to* be a fall upon the hand\\nSupracondyloid fracture of the\\nhumerus.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0267.jp2"}, "264": {"fulltext": "240\\nFRACTURES.\\nin which the end of the humerus is pressed backward extension\\nfracture either directly by the partly flexed forearm or possibly by\\nhyperextension of the joint. In this case the line of fracture is\\noblique from behind downward and forward, the lower end of the\\nupper fragment often ending in a sharp point on its anterior aspect.\\nFig. 111.\\nFig. 112.\\nExtension and flexion fractures of lower end of the humerus.\\nFig. 113. Fig. 114.\\nSupracondyloid fracture. A. Front. B. Rear view.\\nWhen the force acts in the opposite direction, against the back of the\\nelbow, a much more rare occurrence, and the lower end of the humerus\\nis forced forward flexion fracture the line of fracture runs from\\nin front downward and backward, and the sharp point is found at the\\nupper end of the lower fragment in front (Figs. Ill and- 112). Figs.\\n113 and 114 represent a specimen of this kind which I obtained from", "height": "4461", "width": "2577", "jp2-path": "practicaltreati00stim_0268.jp2"}, "265": {"fulltext": "PLATE Vf.\\nFia. 1.\\nFig- 2.\\n\u00e2\u0080\u00a2mmW^\\nmm\\n1\\n\u00c2\u00abv,j^^\\nMil\\n^BJRiSJto -fofc JF\\nV\\nFig. 3.\\nCubitus Varus after Low Partial Supra-eondyloid Fracture in Youth.\\nor Separation of Epiphysis.\\nFig. 1, front. Fig. 2, rear. Fig. 3, sections, ending above on posterior surface.", "height": "4461", "width": "2577", "jp2-path": "practicaltreati00stim_0269.jp2"}, "266": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0270.jp2"}, "267": {"fulltext": "PLATE VII.\\nFig. 1.\u00e2\u0080\u0094 Old Supra-eondyloid Fracture of the Humerus. Cubitus Varus.\\nFig. 2.\u00e2\u0080\u0094 Old Supra-eondyloid Fracture of Humerus, followed by Frac-\\nture (ununited) of external condyle.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0271.jp2"}, "268": {"fulltext": "", "height": "4351", "width": "2522", "jp2-path": "practicaltreati00stim_0272.jp2"}, "269": {"fulltext": "PLATE VIII.\\nFig. 1. Fracture of Head and Neck of Radius.\\nFig. 2.\u00e2\u0080\u0094 Cubitus Varus; three years after a low partial Supra-eondyloid\\nFracture or Separation of the Epiphysis. The lower part\\nof the Supinator Ridge has been cut away.\\n(Case on page 2SS.)", "height": "4351", "width": "2522", "jp2-path": "practicaltreati00stim_0273.jp2"}, "270": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0274.jp2"}, "271": {"fulltext": "PLATE IX.\\nFig. I. Fracture of Olecranon; Dislocation forward of Radius\\nand Remainder of Ulna.\\nFig. 2.\u00e2\u0080\u0094 Fracture of Forearm Angular Displacement.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0275.jp2"}, "272": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0276.jp2"}, "273": {"fulltext": "FRACTURES OF THE HU3IERUS.\\n241\\na patient who died of delirium tremens shortly after the accident.\\nWhile carrying a flagstone he fell upon the elbow, flexed at a right\\nangle, with the edge of the stone resting in the flexure of the joint\\nthe fracture was almost exactly in the frontal plane, as if the condyles\\nhad been cut off by an axe descending along the anterior surface of\\nthe humerus. The lower fragment was slightly displaced forward and\\nupward. In both forms the higher the fracture the less, apparently,\\nis the obliquity. An adduction fracture in the young may be classed\\nas a low form of this the fracture starts close above the epicondyle\\nFig. 115. Fig. 116.\\nSupracondyloid fracture with angular dis-\\nplacement marked cubitus varus.\\nSupracondyloid fracture with angular displace-\\nment marked cubitus varus. Front view.\\nand runs along or close above the epiphyseal line toward or to\\nthe epitrochlea the displacement is angular, pivoting on the inner\\nside, and if it remains uncorrected or recurs, marked cubitus varus\\nresults.\\nThe character and extent of displacement vary with the direction of\\nthe line of fracture as the latter is so often oblique downward and\\nforward, the lower fragment is commonly displaced backward and\\nupward, and not infrequently the sharp end of the upper fragment is\\n16", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0277.jp2"}, "274": {"fulltext": "242 FRACTURES.\\nforced through the overlying muscles and even the skin on the antero-\\ninternal aspect. To this displacement backward may be added, or for\\nit may be substituted, an angular displacement, the apex directed for-\\nward, which accentuates the prominence of the back of the elbow. In\\nthe less common cases in which the obliquity is downward and back-\\nward the displacement of the fragment is forward and upward, but is\\nmuch less marked than in the other form, although occasionally the\\nupper fragment has been forced through the triceps and the skin.\\nIf displacement persists the range of motion in the elbow may be\\nrestricted by direct bony contact or by fibrous bands attaching the torn\\nand bruised muscles to the bone.\\nAn important displacement, apparently due in part to the dressing,\\nto the support of the limb by a sling under the elbow, aided perhaps\\nby muscular contraction or primary displacement in a fracture by\\nadduction, is the angular lateral deviation of the lower fragment with\\nthe apex directly outward, which is shown in Figs. 115 and 116 and in\\nPlate VI. The deformity of the elbow which results is very noticeable\\nin extension and has usually been attributed solely to the ascent of the\\ninternal condyle after its fracture, but there is good reason to believe, I\\nthink, that it is much more frequently the result of a supracondyloid\\nfracture followed by this angular displacement. A number of specimens\\nhave been described, and I possess three (Figs. 105, 115, and 116, and\\nPlate YI.) those represented in Fig. 116 and Plate YI. correspond\\nFig. 117.\\nf\\nSupracondyloid fracture cubitus varus.\\nalmost exactlv with the condition of the bones shown in the skiagram\\n(Plate VIL, fig. 1) of the limb shown in Fig. 117.\\nTwo frontal sections of the specimen shown in Plate YI. show no\\ntrace of fracture, no change in the cortex of the juxta-epiphysary\\nregion, and the outline of the inner supracondyloid ridge is unbroken,\\nbut more sharply curved. The appearance is rather that of elongation\\non the outer side than of shortening on the inner, and suggests a frac-\\nture along or close above the epiphysary line, incomplete on the inner\\nside, with angular displacement upon the inner portion of the internal\\ncondvle as a centre. Presumably the mass between the outer condyle\\nand the shaft is new bone formed by the untorn periosteum. Ex-\\nperiment on the cadaver shows that the posterior part of the periosteum\\nmay remain untorn even w T hen the displacement downward of the outer", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0278.jp2"}, "275": {"fulltext": "FRACTURES OF THE HUMERUS.\\n243\\npart of the fragment is considerable, and its preservation is even greater\\nwhen the fracture is along or close to the epiphyseal line.\\nThe artery or the median or musculo-spiral nerve may be torn or\\ncompressed, but this injury is much less frequent than might be antici-\\npated from the extent and direction of the displacement.\\nSymptoms. The symptoms are deformity, loss of function, abnormal\\nmobility, and pain. The deformity may be marked or slight, the\\nformer especially when the line of fracture is oblique from behind\\ndownward and forward and the lower fragment is displaced and tilted\\nbackward this causes a prominence of the back of the elbow which\\nin some stages resembles that of a dislocation, but is readily distin-\\nguished from it by noting that the relations of the olecranon and epi-\\ncondyles are normal and that the head of the radius is in place.\\nThe determination of these relations is the first step to be taken in\\nthe examination of most injuries of the elbow it is conveniently done\\nby placing the tips of the thumb and middle finger on the two epicon-\\ndyles respectively and that of the index-finger upon the point of the\\nolecranon, and noting their correspondence or lack of correspondence\\nwith the normal in the positions of extension and of flexion at a right\\nangle, ordinarily using the other elbow in comparison. The head of\\nthe radius can be felt from one-half to three-fourths of an inch distant\\nfrom the external epicondyle in the direction of the wrist. Fig. 118\\nshows these relations.\\nSwelling is marked and uniform ecchymosis is usually present after\\na few hours voluntary motion is inhibited by pain, passive motion\\nrestricted. Abnormal lateral mobility adduction and abduction of\\nthe forearm exists and is most surely recognized if the test is made\\nwhile the elbow is extended. If the condyles are firmly grasped with\\none hand and the shaft with\\nthe other, free mobility of one Fig. 118.\\nupon the other, usually with\\ncrepitus, is found. Pressure\\nupward with the hand under\\nthe flexed elbow causes pain.\\nPressing the condyles together\\ndoes not cause pain unless the\\nline of fracture also runs be-\\ntween them (T-fracture), nor\\ncan the condyles be moved\\nindependently of each other.\\nPressure with the tip of the\\nfinger along the supracondy-\\nloid ridges may detect irregu-\\nlarity and cause pain at the\\npoint of fracture if the displacement is slight if it is marked the\\nlower end of the upper fragment can be readily recognized, usually\\nin front, at or close above the flexure of the elbow.\\nTreatment. In view of the proximity of the joint the important indi-\\ncation is to secure repair without displacement and the displacements\\nwhich threaten are the primary overriding and the late lateral angular\\nLeft arm from (a) outer side, (b) behind to show\\nrelations of the olecranon and epicondyles in (a) flex-\\nion and (6) extension.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0279.jp2"}, "276": {"fulltext": "244 FRACTURES.\\ndeviation (Fig. 115). The overriding can be corrected by traction,\\npreferably with the elbow at a right angle, and its recurrence effectively\\nopposed by anterior and posterior moulded splints, or a plaster encase-\\nment, aided sometimes by a weight attached to the forearm close by\\nthe elbow, with the wrist supported by a sling. In children with\\nmarked displacement and swelling I use a long posterior moulded splint,\\nsuspended by its lower end with the forearm vertical, the patient kept\\non his back. Lateral angular displacement is unlikely to occur if the\\nlimb is not supported at the elbow it should be further opposed by\\ntaking care that the inner upper portion of the forearm (with the attached\\nlower fragment) is kept well down, pronated, while the moulded splint is\\nhardening. Fixation in the position of full extension, which has been\\nrecommended more particularly in fracture of the internal condyle\\nwith the object of maintaining the normal outward deviation (abduc-\\ntion) of the forearm, is, I think, undesirable. I have used it in the\\nform of vertical suspension in compound fractures with great advan-\\ntage during the first fortnight, but the advantage comes from the\\nsuspension, in controlling the reaction, not from its effect upon the\\nposition of the lower fragment that, I think, is likely to tilt back-\\nward in the extended position, producing an angular displacement,\\napex forward.\\nIn a few cases after union has taken place the deformity produced\\nby angular inward displacement has been relieved by excision of a\\nwedge-shaped piece from the outer side of the humerus just above the\\nepicondyle, thus bringing the lower fragment into line with the shaft.\\nThe same could be done in case of angular displacement, apex forward,\\nand thereby the hand would be brought nearer the shoulder in full\\nflexion of the joint.\\nB. Fractures of the Internal Epicondyle (Epitrochlea).\\nBy the epitrochlea is meant the projecting spur of bone on the side\\nof the trochlea its lower limit is sharply defined, but above it is con-\\ntinuous with the condyloid ridge.\\nThe first author who called attention to this fracture was Granger, 1\\nin 1818. It is more common in children than in adults; of the ten\\ncases above mentioned, not associated with dislocation of the elbow,\\ntreated in the House of Relief in two and a half years, the ages were\\none, five, ten, ten, fourteen, seventeen, twenty-eight, thirty-four, and\\nforty-three years. The fracture frequently accompanies dislocation of\\nthe elbow, being produced, I think, by the pull of the flexor muscles\\nof the forearm which are attached to it and which are put upon the\\nstretch by the forcible abduction of the forearm which is so common a\\nfirst step in the production of a backward or outward dislocation. In\\ncases not thus complicated the cause appears commonly to be external\\nviolence acting directly upon the back of the epitrochlea.\\nSymptoms. The symptoms vary somewhat with the size of the frag-\\nment, for when the latter is small it is held in place by the untorn por-\\ntion of the muscular attachments upon it and the adjoining bone, but\\n1 Granger Edinburgh Medical and Surgical Journal, vol. xiv. p. 196.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0280.jp2"}, "277": {"fulltext": "FBACTUBES OF THE HUMERUS.\\n245\\nFracture of the\\ninternal epicon-\\ndyle of the hume-\\nrus (epitrochlea).\\n(GURLT.)\\nwhen it is large enough to include the greater part of the attachment\\ndisplacement takes place downward and forward in the direction of the\\nmuscles. If the swelling is not too great the fragment can be seized\\nbetween the thumb and finger and moved, usually with IG ^9\\ncrepitus. Ecchymosis is common, and the functions of\\nthe joint may be diminished by pain or the fear of it.\\nIn a few cases the ulnar nerve has been injured by\\nthe original violence or irritated by pressure of the dis-\\nplaced fragment or a portion of callus. In three of\\nGranger s cases there was partial paralysis of motion\\nand sensation in the region supplied by the ulnar nerve,\\nand repeated crops of vesicles formed upon the corre-\\nsponding part of the hand during the two or three\\nmonths following the injury. All the symptoms dis-\\nappeared after a time. Bichet 1 observed a case of frac-\\nture of the epitrochlea with dislocation of the elbow\\ninward due to a fall upon the ice. After reduction of\\nthe dislocation the ulnar nerve was found to be com-\\npletely paralyzed. A month later the little finger was\\nso insensitive that the patient amused himself and\\namazed his play-fellows by holding it more than a\\nminute in the flame of a candle. The deep burn which was the\\nresult took several weeks to heal; afterward sensibility returned\\ngradually and became complete.\\nDenuce 2 was consulted by a man suffering with an intense neuralgia\\nof the ulnar nerve following a fall upon the elbow three months before.\\nHe recognized deformity of the epitrochlea, made an incision, and\\nfound the nerve hypertrophied and resting upon a bony prominence\\nformed by the epitrochlea displaced and united in its false position.\\nThe projecting part of the bone was excised, and the neuralgia ceased.\\nTreatment. The treatment is simple immobilization of the elbow\\nin the flexed position so as to relax the muscles that arise from the epi-\\ntrochlea and thus diminish the force that tends to draw it forward and\\ndownward. It is futile to attempt to keep the fragment in place by\\npressure upon it from the outside. Even if it remains displaced down-\\nward and forward the deformity is slight and entails no loss of function.\\nImmobilization should be maintained until consolidation has taken\\nplace, the length of time necessary for which varies with the age of the\\npatient and the extent of the unreduced displacement. In children,\\nand without displacement, union is sufficiently firm at the end of ten\\ndays or a fortnight to allow splints to be laid aside and the arm to be\\ncarried in a sling, and in three weeks the arm may be left unsupported\\nand free.\\nIn a few cases the fragment has been excised because of pain or fear\\nlest it should interfere with function it has also been proposed to\\nsecure it in place by transfixion with a pin or by incision and suture,\\nbut the measure seems wholly unnecessary.\\n1 Eichet Anatomie Medico-Chirurgicale, 4th ed., p. 672, note.\\n2 Denuce Diet, de Med. et Chir. Pratiques, art. Coude, p. 721.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0281.jp2"}, "278": {"fulltext": "246 FRACTURES.\\nC. Fractures of the External Epicondyle.\\nThis is a much rarer accident than the preceding, and as the frag-\\nment that is broken off is small, and as the cause appears to be always\\ndirect violence, which is usually accompanied by bruising and swelling,\\nthe exact nature of the injury may easily pass unrecognized. An\\nanatomical demonstration of the fracture has never\\nFig. 120. been made, except in connection with more exten-\\nsive fractures of the elbow.\\nIn the sense in which the term is here used the\\nepicondyle is the small prominence above and on\\nthe outer side of the capitellum, composed in part of\\nbone formed about a separate centre of ossification,\\nand in part of the projecting portion of the shaft or\\ncondyle itself. To it are attached the external\\nlateral ligament of the joint and part of the ex-\\ntensor muscles of the forearm.\\nMost surgeons deny the possibility of an extra-\\narticular fracture of this part, and group all frac-\\ntures of the region as of the external condyle.\\nFracture of the external Anatomically speaking it is certainly possible for\\nepicondyle of the hume- sucn a f rac t U re to occur the epicondyle, though\\nsmall, is still large enough to be broken in such a\\nway that the line of fracture may lie entirely outside the joint.\\nGurlt describes as extra-articular fractures of the external epicon-\\ndyle two specimens preserved, the one at Giessen, the other at Berlin.\\nIn each the fracture has united with considerable displacement down-\\nward of the fragment, which appears in the description and figure (Fig.\\n120) too large to have been entirely extra-articular. Still, his personal\\nexamination of the specimens was more likely to lead to a correct\\nopinion of them than a verbal description or a figure is.\\nThere is little to be added. The cause must be direct violence, or\\npossibly forcible adduction of the forearm acting through the lateral\\nligament; the displacement must be slight and unimportant; the\\ntreatment, rest.\\nD. Fractures of the Internal Condyle.\\nThe line of fracture runs from a point on the inner border of the\\nepitrochlea or of the ridge above it downward and outward, ending on\\nthe outer half of the lower part of the trochlea or at, or even a little\\nbeyoud, its junction with the capitellum (Fig. 121).\\nThe common cause appears to be violence acting from below upward\\nupon the trochlea, as in a fall upon the flexed elbow or by forced adduc-\\ntion or abduction of the forearm, turning upon the head of the radius\\nas a centre, and breaking off the condyle by forcing it upward or back-\\nward or drawing it downward or forward.\\nThe fragment may be displaced in any of these directions, and may\\nalso be rotated. As the ulna remains attached to the fragment and is\\nitself held in place by its attachments to the radius, the displacement of\\nthe fragment cannot be great unless there is associated dislocation of the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0282.jp2"}, "279": {"fulltext": "FRACTURES OF THE HUMERUS.\\n247\\nFig. 121.\\nUpper and lower limits of fracture\\nof the internal condyle.\\nradius from the capitellurn, as occasionally observed. A late displace-\\nment, similar in cause and effect to that observed after supracondyloid\\nfracture, occurs here also pressure upward against the flexed elbow,\\nas bv a snug sling, is transmitted through the olecranon to the frag-\\nment and raises it above its proper place,\\nthus changing the direction of the trans-\\nverse axis of the joint and substituting ad-\\nduction of the forearm cubitus varus\\nfor the slight normal abduction. Possibly\\nthe contraction of the triceps and brachialis\\namicus may aid in producing this result. I\\nbelieve, however, this is a much less fre-\\nquent cause of the deformity than displace-\\nment after supracondyloid fracture. There\\nis also reason, I think, for the suspicion that\\nthe elevation of the condyle found in some\\ncases is the result not of displacement be-\\nfore union, but of arrested growth by the\\ninterference of the fracture with the con-\\njugal cartilage on that side. This is sug-\\ngested by the perfect outline of the supra-\\ncondyloid ridge and the absence of marked\\nirregularity on the anterior and posterior surfaces. The fact, if it is\\none, could be determined by observing the gradual increase of the\\ndeformity, adduction of the forearm, during the years following frac-\\nture in a young person.\\nThe swelling, as in most of these fractures at the elbow, is uniform,\\nrarely more marked on the side of the injury except at first loss of\\nfunction is marked, the arm generally being held at an angle of about\\n125 degrees, and the range even of passive motion without anaesthesia\\nis restricted. The characteristic symptoms are independent mobility\\nof the condyle, usually with crepitus, pain on pressing the condyles\\ntogether and on pressure with the tip of the finger at the point where\\nthe line of fracture crosses the supracondyloid ridge, and sometimes\\nan irregularity in the line of the ridge at that point. The independent\\nmobility is recognized by grasping the fragment between the thumb\\nand fingers and moving it slightly backward and forward while the\\nother condyle and the shaft are held with the other hand. Pain can\\nalso be caused by pressure upward against the olecranon or backward\\nthrough the forearm while the elbow is partly flexed. If the limb can\\nbe fully extended abnormal lateral mobility of the forearm adduction\\nand abduction is found, especially abduction. The same mobility\\nexists when the joint is more or less flexed, but the observation cannot\\nbe safely made, at least in the young, because of the difficulty of dis-\\ntinguishing between it and rotation of the humerus full extension is\\nnecessary for the test, and this can rarely be had except with the aid\\nof general anaesthesia. The relations of the epitrochlea and tip of the\\nolecranon are preserved, and their elevation or displacement backward\\nwith reference to the external epicondyle is generally too slight to be\\nrecognized through the swelling.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0283.jp2"}, "280": {"fulltext": "248\\nFRACTURES.\\nAssociated dislocation of the radius from the capitellum is recognized\\nby the presence of its head below and behind the outer condyle and by\\nthe marked displacement backward of the internal condyle and olecra-\\nnon which leaves the outer condyle and lower end of the shaft as an\\neasily recognizable prominence in the flexure of the joint.\\nThe main point to be considered in the treatment is the correction or\\nprevention of such displacement as would seriously interfere with the\\nfunctions of the joint or the appearance of the limb, notably the ascent\\nof the condyle by which the axis of the forearm would be directed\\ninward (adduction). The fragment is too small to be acted upon\\ndirectly by any dressing, and its position must, therefore, be controlled\\nthrough the ulna to which it is attached. Ordinarily this can be satis-\\nfactorily done by a fixed dressing with the elbow at a right angle, either\\na tin posterior splint or, preferably, a moulded one or a plaster encase-\\nment. The essential points are that the fragment should be kept well\\ndown in place while the dressing is hardening, if a moulded one is used,\\nand that it should not be pressed upward during repair by the bandage\\nwhich supports the forearm this should lie near the wrist, not under\\nthe elbow. Full flexion and full extension of the joint, which meas-\\nurably control the position of the fragment by the tension of the pos-\\nterior and anterior portions of the capsule respectively, have been\\nrecommended in each position tilting of the fragment sometimes\\noccurs. Full flexion is a much more convenient attitude than full\\nextension, unless the patient is kept in bed; but it is no more con-\\nvenient than rectangular flexion and, I think, gives no more security\\nagainst displacement. It is usually desirable in fracture complicated\\nby dislocation of the radius, in order to oppose recurrence.\\nIf the fragment is rotated or tilted and cannot otherwise be brought\\ninto place it should be exposed by an incision advantage may be taken\\nof this to fix the fragment in place by\\nperiosteal sutures or even by transfixion\\nwith a pin.\\nImmobilization is required for about\\nthree weeks, a sling for another week, and\\nthen the limb abandoned to natural use\\nwithout forced passive motion the latter,\\nfor reasons given in Chapter VII., is more\\nlikely to do harm than good, for it may\\nincrease the irritation which provokes\\novergrowth of callus. Even with satis-\\nfactory reduction the range of motion may\\nbe diminished by callus obstructing the\\nolecranon or coronoid fossa.\\nE. Fractures of the External Condyle.\\nFig. 122.\\nLines of fracture of external\\ncondyle.\\ncause is a fall upon the\\nThese are more common than fractures\\nof the internal condyle, and much more\\nfrequent in the young than in adults. The\\nhand while the elbow is flexed or upon the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0284.jp2"}, "281": {"fulltext": "FRACTURES OF THE HUMERUS.\\n249\\ninner and posterior portion of the flexed elbow, or forcible adduction of\\nforearm in the first the force is transmitted through the radius to the\\ncapitellum in a backward or backward and upward direction, in the\\nsecond through the olecranon upward and outward against the outer\\nslope of the trochlea, and in the third it acts by avulsion through the\\nexternal lateral ligament and the muscles attached to the condyle. I\\nhave found it easy to produce the fracture by adduction of the ex-\\ntended forearm in bodies of the young. In one or two cases I have\\nthought the cause was a blow upon the back of the condyle.\\nThe line of fracture runs obliquely from the outer ridge of the\\nhumerus above the epicondyle downward and inward into the joint,\\nFig. 123.\\nOld fracture of external condyle of humerus with displacement downward and inward and\\nincomplete dislocation inward of ulna.\\nending usually in the groove of the trochlea, coinciding in part at least\\nwith the epiphyseal line, so that the fragment comprises the epicondyle,\\nthe capitellum, and the outer portion of the trochlea. As the fragment\\nremains attached to the radius and ulna by the lateral ligament and\\ncapsule, the displacement is usually slight when the forearm is in its\\nproper position, but there is tendency to tilting (flexion) of the frag-\\nment, and sometimes it is markedly rotated about one or another axis,\\nso far in one of Kocher s cases and one of mine that the fractured sur-\\nface looked outward, and in two of mine upward. If the forearm is\\nabducted the fragment is displaced backward or upward and outward\\nif adducted, forward or downward. If the elbow is simultaneously\\ndislocated backward or outward the fragment accompanies the radius.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0285.jp2"}, "282": {"fulltext": "250\\nFRACTURES.\\nA late condition sometimes found, such as those shown in Figs.\\n124 and 125, and usually attributed to a primary displacement left\\nuncorrected, appears to me to be due more probably to arrest of devel-\\nopment at the base of the capitellum. Displacement upward must take\\nplace along the line of fracture, and consequently it must also be out-\\nward, as is not sufficiently the case in those specimens. The position\\nof the head of the radius could be more plausibly explained by the\\nelongation which follows the removal of pressure than by forcible\\nascent of the entire bone beside the ulna. Usually this condition leads\\nto marked abduction of the forearm cubitus valgus.\\nSwelling appears first on the outer side and then becomes uniform\\necchymosis appears below the condyle, or on the inner side if the patient\\nhas remained in bed with the arm abducted. Loss of function is not\\nso marked as in fracture of the internal condyle pain is felt on press-\\ning the broken condyle against the shaft, inward, upward, or forward;\\nalso on pressure with the tip of the finger on the ridge close above the\\nepicondyle. Abnormal mobility appears as adduction of the forearm\\nFig. 124.\\nFig. 125.\\nFracture of external condyle late result. Old fracture of external condyle.\\nCubitus valgus. (Helferich.)\\n(also painful), with less or no abduction, and can sometimes be recog-\\nnized by grasping the fragment between the thumb and finger and\\nmoving it backward and forward while the shaft is firmly held crepi-\\ntus may be perceived at the same time. If the fragment is notably\\ndisplaced the irregularity may be recognized by palpation and if the\\nulna is at the same time dislocated backward from the trochlea the con-\\ndition is recognized by noting the common signs of dislocation on the\\ninner side backward projection of the olecranon, prominence of the\\ntrochlea in the flexure of the elbow and the position of the fragment", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0286.jp2"}, "283": {"fulltext": "FRACTURES OF THE HUMERUS.\\n251\\nin close relations with the head of the radius behind and above its\\nproper position. The much rarer dislocation outward could be recog-\\nnized in like manner.\\nThe difficulty in treatment lies more in the reduction of displacement,\\nif it is marked, than in the maintenance of the proper position if that\\nis secured. In most cases, those without much displacement, immobil-\\nization for three weeks at a right angle by a posterior moulded splint\\nis sufficient, although, of course, pains must be taken to make reduc-\\ntion as complete as possible.\\nWhen the fragment has suffered one of the rarer displacements by\\nrotation it is generally impossible to restore it to place without an\\noperation. In three such cases I opened the joint by an incision on the\\nouter side and, with considerable difficulty in two, turned the fragment\\nback into place and obtained a good result. Kocher twice excised the\\nfragment under such circumstances, and reports a satisfactory result\\nboth were old cases, and one of mine was two months old.\\nIn two old cases, one of them with displacement of the fragment\\ndownward and inward and partial dislocation of the ulna inward (Fig.\\n123), the other with displacement upward and backward, I detached\\nthe fragment with a chisel and brought it back into place. Primary\\nunion considerable improvement in function.\\nF. Intercondyloid, T-shaped, or Y-shaped Fractures.\\nThese fractures are commonly caused by great violence, and conse-\\nquently are often compound either by the direct action of the violence\\nFig. 126.\\nFig. 127.\\n1\u00c2\u00ab; I\\nIntercondyloid fracture of the humerus.\\n(Gurlt.)\\nIntercondyloid fracture of the humerus.\\nFront view. (Gurlt.)\\nupon the skin or from within outward by the sharp end of one of the\\nfragments.\\nIn many the main line of fracture is the same as in supracondyloid\\nfracture, with an additional line passing down into the joint between", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0287.jp2"}, "284": {"fulltext": "252 FRACTURES.\\nthe condyles in the others the variations in the form and extent of the\\nfracture and the degree of displacement are very great, the essential\\nfeatures being the separation of both condyles from the shaft and from\\neach other, the variations appearing in the number and position of the\\nfragments and lines of fracture. When the fracture between the con-\\ndyles is a mere fissure the condyles remain together, and the displace-\\nments are those of supracondyloid fracture in the other cases the\\ndisplacements are too varied and irregular for classification and the\\ncondyles may be widely separated from each other, the olecranon pass-\\ning up between them.\\nOccasionally the nerves or vessels crossing the front of the joint are\\ntorn or compressed.\\nSymptoms. The symptoms in many cases are those of supracondy-\\nloid fracture with, in addition, independent mobility of the condyles\\nupon each other and pain when they are pressed together. In cases\\nwith the more varied displacements the deformity is great and the inde-\\npendent mobility of the condyles upon each other and the shaft is\\nreadily recognized if they can be grasped through the swollen tissues.\\nFig. 128. Fig. 129.\\nIntercondyloid fracture of the humerus. Comminuted intercondyloid fracture of the\\nRear view. (Gtjrlt.) humerus. (Gtjrlt.)\\nIn respect of treatment much that has been said of that of supra-\\ncondyloid fracture can be repeated. Cases with comminution and much\\ndisplacement are quite certain to result in marked limitation of motion\\nin the joint. Reduction by manipulation through the unbroken skin\\nis largely problematical, and the limb should, therefore, be kept in the\\nattitude which will be most useful if stiffness results. In maintaining\\nreduction I have been best satisfied with plaster splints, anterior and\\nposterior, held snugly at and above the condyles while they were hard-\\nening. Vertical suspension occasionally does well, especially in com-\\npound fractures, but I have never continued its use for more than about\\nten days, resorting then to moulded splints with the elbow flexed, and\\nwith fresh reduction if necessary.\\nIn compound fractures it may sometimes be advisable to remove some", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0288.jp2"}, "285": {"fulltext": "FEACTURES OF THE HUMERUS.\\n253\\nof the smaller fragments or cut off sharp ends and in one case in\\nwhich the fragments could not otherwise be held together I transfixed\\nthem with a long drill which was left in place for a fortnight. Kocher\\nrecommends the removal of the external condyle, on the ground that it\\nfacilitates drainage and ensures a greater range of motion without seri-\\nously diminishing the stability of the joint. Occasionally it has seemed\\nFig. 130.\\nInterrupted plaster splint.\\nadvisable to remove both condyles the resulting joint is likely to be\\ntroublesomely loose, although not so much so as when the olecranon\\nalso has been removed.\\nInterrupted splints add to the facility of change of dressing of the\\nwound. One form is shown in Fig. 130.\\nG. Separation of the Epiphysis.\\nTo the account of the development of the epiphysis previously given\\n(p. 238) must be added that the views of others differ therefrom in\\nsome important details, and that some of the appearances shown on\\nsection can be explained only on the supposition that the development\\n(especially of the trochlea) differs widely in individuals, or (which seems\\nto me more probable) that the sections have been made in different\\nplanes. The accounts which seem most trustworthy represent the\\ntrochlear portion of the epiphysis as remaining wholly cartilaginous\\nmuch longer than the other portions, and as having a concave upper\\nsurface which steadily deepens so that before its union with the diaph-\\nysis it has become a relatively thin saucer-like scale capping a project-\\ning portion of the shaft, and is connected with the capitellum on one\\nside and with the epitrochlea on the other only by a thin neck. Tins\\nseems to make the separation of the entire epiphysis, with or without\\nthe epitrochlea, in one piece from the shaft very improbable except at\\nan early age that it has thus been separated is demonstrated by a few\\nspecimens, but the diagnosis in the great majority of supposed cases\\nrests only upon doubtful clinical evidence. Moreover, some writers\\nand reporters of cases describe under this title fractures in which the\\nline diverges widely into the shaft on the inner side. As was explained\\nin Section E of this chapter, it is probable that some, perhaps many, of\\nthe fractures of the external condyle in the young are separations of\\nthat portion of the epiphysis which is constituted by the external epi-\\ncondyle and capitellum.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0289.jp2"}, "286": {"fulltext": "254 FRACTURES.\\nAmong the specimens described are those of Little, 1 Reeve, 2 Lange, 3\\ntwo of Bardenheuer s, 4 and two figured and described by Poland 5\\nfrom the museums of St Mary s and St. Thomas s hospitals in the first\\ntwo a portion of the shaft adhered to the epiphysis in Lange s the\\npatient was ten years old, the separation (compound) was wholly through\\ncartilage, and the epicondyles were separated from the fragment and\\nalso from the shaft the fragment was widely displaced from the shaft\\nand the bones of the forearm, but was still attached to the shaft by the\\nloosened periosteum. In one of Bardenheuer s the separation appears to\\nhave been below both epicondyles, and the fragment was displaced back-\\nward and inward with the forearm in the second the fragment, which\\nis not described in detail, was displaced backward, also preserving its\\nrelations with the bones of the forearm. In both of Poland s the separa-\\ntion was wholly along cartilage, the epicondyles remaining attached to\\nthe trochlea and capitellum. A specimen apparently of pure cartilag-\\ninous separation was in the Bellevue Hospital Museum, but has now\\nbeen lost.\\nThe cause appears usually to have been a fall upon the elbow or the\\noutstretched hand in Lange s the elbow was caught between an eleva-\\ntor and a beam, and in one of Poland s it was jammed in a gate.\\nThe displacement in all the certain cases has been great, and in all\\nbut Bardenheuer s the injury was compound. In the cases diagnosti-\\ncated without direct examination of the fragment the displacement has\\nbeen sometimes marked, sometimes slight, the diagnosis in the former\\nbeing made by palpation of the fragment, in the others upon the abnor-\\nmal lateral and antero-posterior mobility of the upper end of the fore-\\narm with fine crepitus and on the exclusion of other forms of fracture.\\nSchuller and Brims think the injury more frequent than the paucity\\nof reported cases indicates.\\nIn respect of the symptoms and diagnosis it is not easy to do more\\nthan indicate what the symptoms are likely to be. The only case in\\nmy own experience in which the diagnosis seemed to be certain, or at\\nleast highly probable, was a boy ten years old who had fallen backward\\nupon his hand after a jump. He was brought to me a week later by\\nDr. MeAuliffe. The elbow was held at an angle of 110 degrees and\\ncould not be flexed within a right angle. Marked abnormal lateral\\nmobility of the forearm, especially adduction. The olecranon was dis-\\nplaced slightly backward from the plane of the internal epicondyle\\nthe head of the radius rested normally against the external condyle.\\nClose above the external epicondyle the line of fracture could be dis-\\ntinctly felt, the lower fragment projecting plainly backward. The\\ninternal epicondyle was continuous with and immovable upon the shaft.\\nTraction upon the forearm, aided by pressure of the thumb against the\\nolecranon and external condyle while the fingers made counter-pressure\\nagainst the shaft, easily brought the bones into place with a slight snap\\nand cartilaginous crepitus, and nearly full flexion was then possible.\\n1 Little: New York Medical Journal. November. 1865, p. 133.\\n2 Eeeve Quoted by Hamilton. Fractures and Dislocations. 6th ed., p. 272.\\n3 Lange Medical Record, July, 1880, p. 48.\\n4 Bardenheuer Deutsche Chirurgie, Lief. 63a, p. 736.\\n5 Poland: Traumatic Separation of the Epiphyses, London, 1898.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0290.jp2"}, "287": {"fulltext": "FRACTURES OF THE HUMERUS. 255\\nAnother case which apparently had a claim to inclusion in the class\\nwas one which I did not see until two months after the injury had been\\nreceived. The articular portion of the humerus was then so far dis-\\nplaced inward that the external epicondyle or the adjoining ridge had\\nulcerated through the skin. Two years after the accident the case\\nshowed marked cubitus varus (Plate VIII., fig. 2). The injury when\\nrecent had been mistaken by an experienced surgeon for a backward dis-\\nlocation, and this indicates what has been a prominent feature in several\\nof the reported cases, namely, the backward displacement of the fore-\\narm and its easy restoration to place. Kocher, analyzing five personal\\ncases of what he terms fractura diacondylica, in which this form is\\nplainly included, speaks of pain on pressing the extended or flexed\\nforearm against the arm, and it would seem that that, together with\\nabnormal mobility and cartilaginous crepitus, would have to furnish\\nthe basis of the diagnosis.\\nThe treatment is reduction of the displacement and immobilization\\nat a right angle, with special precautions against displacement inward.\\nH. Fractures of the Articular Process, in Whole or in Part.\\nThese include fractures of the whole or part of the capitellum, of the\\ninner portion of the trochlea, and of the capitellum and trochlea together.\\nA few specimens of fracture in adults passing wholly or mainly\\nbelow the epicondyles are known, and Kocher, who includes them with\\nseparation of the epiphysis under the title fractura diacondylica,\\nfound that the lesion could be produced experimentally by a blow upon\\nthe lower surface of the bone in the direction of its long axis. In a\\nspecimen in the museum of Bellevue Hospital, New York, the line of\\nfracture passes between the capitellum and the shaft into the olecranon\\nand coronoid fossae and then upward and inward to end on the ridge\\nabove the epitrochlea repair has taken place with displacement for-\\nward of the capitellum, excessive callus on the inner half, and bony\\nunion between the olecranon and humerus (Fig. 131) it is an inter-\\nmediate form between the very low supracondyloid fractures and those\\nthat are below the epicondyles.\\nThe direction and character of the violence apparently concerned in\\nthe production of these fractures suggest a well-marked displacement\\nof the fragment forward and upward in combination with the radius\\nand ulna which probably could be recognized by palpation and the\\nabnormal mobility. The indications for treatment would be to press\\nthe fragment downward and backward into place and keep it there by\\npressure or traction upon the upper part of the forearm. The prog-\\nnosis, in respect of the preservation of function, seems bad because\\nof the intra-articular position of the line of fracture.\\nFracture of the capitellum alone, in whole or in part, has been ob-\\nserved in a number of cases. Hahn 1 reports an old specimen in\\nwhich the capitellum had united Avith the front of the humerus after\\ndisplacement upward and rotation. Kocher figures four specimens\\nrepresenting larger or smaller portions of the capitellum removed by\\n1 Hahn Quoted by Gurlt, loc. cit., p. 801.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0291.jp2"}, "288": {"fulltext": "256\\nFRACTURES.\\noperation in fresh cases; Figs. 132 and 133 represent the largest and\\nsmallest. Steinthal l reports a case similar to Halm s. The capitellum\\nwas removed by operation, with improvement of function.\\nFltt. 1 31\\nAnchylosis after fracture below the epicondyle.\\nIn two of Kocher s cases the cause was violence exerted through\\nthe radius, the elbow being flexed, once in a fall upon the palm of the\\nhand, and once by pressure against the palm while the back of the\\nelbow rested against a wall in the other two the injury was received\\nin an effort to raise or hold a heavy object, apparently with the elbow\\npartly flexed. The mechanism in the latter cases seems to me to be\\npressure by the head of the radius upward against the lower anterior\\nportion of the capitellum under the pull of the biceps.\\nIn a personal case the capitellum was broken off and the upper pos-\\nterior angle of the olecranon broken (extra-articular) by the fall of a\\nheavy stone. The injury was compound and the skin so contused that\\nit sloughed the ensuing suppuration led to later excision of the end of\\nthe humerus. Recovery with preservation of rotation of the forearm.\\nThe local reaction, as evidenced by pain, swelling, and loss of func-\\n1 Steinthal: Centralb. f. Chir., 1898, p. 17.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0292.jp2"}, "289": {"fulltext": "FRACTURES OF THE HUMERUS.\\n257\\nFig. 132.\\n133.\\ntion, is comparatively slight or tardy in appearing in three of six\\nreported cases the fragment was displaced upward within the capsule of\\nthe joint, in the other three (all Kocher s) backward,\\nlying between the head of the radius and the olecranon,\\nwhere it could be easily felt. Kocher removed the frag-\\nment in all his cases and secured a good result.\\nFracture of the trochlea alone is very rare. Lau-\\ngier first called attention to it in 1853 in the report of\\na case in which the diagnosis rested only on scanty\\nclinical evidence. I have had a case in which a frag-\\nment of the lower part of the inner rim of the trochlea,\\nabout three-fourths of an inch long, had been broken\\noif and could be easily felt beneath the epitrochlea.\\nThe displacement was slight, so I did not excise the\\nfragment, but simply immobilized the joint. The result\\nwas good.\\nDiagnosis.\\nThere is so much in common in these injuries of the\\nlower end of the humerus that it is well to summarize\\nthe methods of examination and the principles of treat-\\nment.\\nIn most cases of injury the diagnosis at first sight\\nrests between fracture, dislocation, and sprain the first\\ntwo have positive signs by which they can be affirm-\\natively recognized, the latter has its own signs, but its\\ndiagnosis must be confirmed by exclusion of the other\\ninjuries.\\nIf the case is seen early the absence of swelling\\ngreatly facilitates examination if excessive swelling is\\npresent it may be diminished by vertical suspension of the limb or by\\nthe use of the elastic bandage, and the fluoroscope or the skiagram may\\ngive information that cannot be got at the time by palpation. The\\nregion in which swelling begins, or to which it remains limited, is the\\none which specially requires close examination.\\nAfter the history of the accident has been obtained usually too\\nvague or uncertain to be of much value and in the absence of indi-\\ncations pointing clearly to one or another portion of the bone or one or\\nanother kind of injury, the surgeon seeks to place the ends of his\\nthumb, index-, and middle finger on the two epicondyles and the tip of\\nthe olecranon in order to determine their relative positions and to note\\nif their relations are normal in such attitudes as he can give to the\\njoint. This examination, if it can be satisfactorily made, should at\\nonce determine the presence or absence of a dislocation of the ulna,\\nand of the radius if the head of that bone is next found.\\nIf dislocation has thus been excluded and if the patient is not too\\nyoung, he next seeks the indications given by pain, grasping the elbow\\nwith one hand and the shaft of the humerus with the other and press-\\ning the two together and then sideways, with thumb and fingers on the\\nepicondyles, determining also by the latter movement the presence\\n17\\nFracture of capi-\\ntellum.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0293.jp2"}, "290": {"fulltext": "258 FRACTURES.\\nor absence of abnormal mobility of the lower end upon the shaft if\\nthe results suggest supracondyloid fracture confirmation is sought by\\nexploration of the condyloid ridge for points of pain and irregularity\\nof outline, and the shaft is traced downward to determine its relations\\nto the condyles. The condyles are also pressed together to note the\\npain of a fissure running down between them, or each is grasped between\\nthe thumb and fingers and the effort made to move them on each other.\\nThe positive sign of fracture of either condyle is its independent\\nmobility, recognized by grasping it between the thumb and fingers and\\nmoving it backward and forward. Corroborative evidence, or evidence\\nthat may be deemed sufficient in absence of independent mobility, is\\npain on point pressure on the condyloid ridge and abnormal abduction\\nor adduction of the forearm, adduction in fracture of the external,\\nadduction in that of the internal condyle, and pain, especially on move-\\nment in the opposite direction.\\nFracture of the internal epicondyle is shown by its abnormal mobility.\\nThe positive evidence in every case is the independent mobility of\\nthe fragment, usually with crepitus, and only when that is unrecog-\\nnizable because of the impossibility of properly grasping the fragment\\nshould the surgeon rest his diagnosis upon other symptoms. If this\\nrule and that of always determining the relative positions of the ends\\nof the bone constituting the joint were followed, the disastrous con-\\nfounding of fractures and dislocations would be much less frequent.\\nTreatment.\\nThe tendency to displacement except by the unsupported or im-\\nproperly supported weight of the limb is so slight that if reduction\\ncan be made a satisfactory result should be obtained in most cases,\\nthe exceptions being those in which the functions of the joint are dimin-\\nished by obstructive callus or by peri-articular thickening. Consequently\\nevery effort should be made to effect complete reduction, especially when\\nthe fracture extends into the joint, even, if necessary, by exposure\\nthrough an incision, and then to prevent its recurrence by so support-\\ning the limb that this cause of displacement may not become operative.\\nThe most important point in most cases is that the flexed forearm should\\nnot be supported at the elbow. If a sling, with or without a splint,\\nis drawn snugly about the neck and under the elbow the weight of the\\nlimb is borne in great part by the olecranon and this pressure being\\ntransmitted through it to the internal condyle, or to both in supra-\\ncondvloid fracture, inevitably forces the fragment upward and produces\\nthe disfiguring deformity of cubitus varus. The corresponding dis-\\nplacement in fracture of the external condyle, cubitus valgus, is much\\nless easily produced. Consequently the flexed forearm should be sup-\\nported at the wrist, and the limb protected by a splint, preferably one\\nof plaster of Paris extending along the posterior aspect from the wrist\\nto the shoulder. For the details of special cases which cannot well be\\nsummarized the reader is referred to the preceding sections, and for\\nfracture of the adjoining portions of the radius and ulna to the follow-\\ning chapter.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0294.jp2"}, "291": {"fulltext": "CHAPTER XX.\\nFRACTURES OF THE BOXES OF THE FOREARM.\\nIn the Vicinity of the Elbow-joint: Olecranon, coronoid process, head and neck\\nof radius Fractures of the Shaft Both bones, ulna, radius In the Vicin-\\nity of the Wrist Of the radius, Colles s, other than Colles s.\\n1. IN THE VICINITY OF THE ELBOW- JOINT.\\nA. Fractures of the Olecranon.\\nThe frequency of fractures of the olecranon has been very differently\\nestimated by different writers, Malgaigne placing it among the rarest,\\nonly nine cases in a total of more than 2300 fractures treated during\\neleven years at the Hotel-Dieu. The table in Chapter I. gives 49\\ncases in a total of 6899.\\nThe line of fracture may lie close to and parallel with the upper end\\nof the process, or at any intermediate point above the base of the coro-\\nnoid process, crossing the bone transversely or obliquely or along a\\nV-shaped line corresponding somewhat to the borders of the triangular\\nsubcutaneous surface of the olecranon. In rare cases it is comminuted,\\nand sometimes is compound. In a very few cases the epiphysis has\\nbeen broken off along the line of the conjugal cartilage.\\nThe commonest cause by far 36 out of 45 cases collected by one\\nwriter is a fall upon the elbow. The mechanism, however, is appar-\\nently not simply that of fracture by direct violence, the bone is not\\nbroken solely by a force acting directly upon the end of the apophysis,\\nbut the contraction of the triceps must play an important part in it.\\nAmong the reasons for this belief are the usual absence of the signs of\\ndirect violence upon the surface of the region sufficient to have caused\\nthe fracture, and the impossibility of producing similar fractures upon\\nthe cadaver by this means. When the fracture is produced experi-\\nmentally by direct violence, by a blow with a blunt object, the bone is\\nnot broken cleanly and transversely at its narrowest part, as is the case\\nin most fractures observed clinically, but it is crushed and split into\\nseveral pieces. The explanation that seems most plausible is that a\\nsudden change is effected in the position of the forearm by the fall\\nwhen the muscles are all tense. The man falls with his elbow partly\\nbent, and all his muscles rigid with the effort to save himself; his out-\\nstretched hand or the back of his forearm encounters some solid object,\\nand the flexion of the limb is suddenly and violently increased, while\\nthe olecranon is held immovable by the triceps. The consequence is\\nthat the ulna is bent about the elbow, and breaks at the weakest part\\nof the olecranon if the violence is received near the elbow, or, perhaps,\\n259", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0295.jp2"}, "292": {"fulltext": "260 FRACTURES.\\nat some part of its much thinner shaft if the violence is received upon\\nthe hand in short, the bone is broken across the elbow as a stick is\\nbroken across the knee.\\nOccasionally the olecranon has been broken in an attempt to reduce\\nan old dislocation or to mobilize a stiff elbow and it has been alleged\\nthat a blow upon the back of the ulna near the elbow can break or\\ncrack the olecranon from the articular surface outward.\\nMuscular action, contraction of the triceps, appears to be an occa-\\nsional cause, as in throwing a ball or vigorously pushing with the elbow\\npartly flexed. In such fractures the fragment torn off is small, little\\nmore than the cortical layer of the summit of the process to which the\\ntriceps is principally attached in other cases the line of fracture lies\\nusually at the narrowest part of the process, directly under the centre\\nof the sigmoid fossa, that which is called by some the centre, by others\\nthe base, of the olecranon.\\nAnother variety of fracture, partial or complete, and produced from\\nwithin outward, has been spoken of by different writers as theoretically\\npossible, but has only recently been observed and described clinically.\\nPingaud produced it experimentally in the effort to dislocate the ulna\\nbackward by over-extension (extension beyond the straight line) of the\\nforearm. The end of the olecranon is pressed againt the humerus,\\nthe lateral ligaments resist the movement, and the prolongation of the\\neffort results in fracture of the olecranon or, much more commonly, of\\nthe thinner and weaker shaft of the ulna. Quintin 2 reports three\\ncases of incomplete fracture of the olecranon the surface articulating\\nwith the humerus was broken, the dorsal portion was unbroken in all\\nthe swelling was moderate, the pain severe, flexion and extension com-\\nplete but slow. In the first case, seen a week after the accident, a small\\nprominence could be felt on the side of the olecranon, and behind it\\nwas a notch the upper end could be sprung back a little. In the\\nsecond case a short shallow groove could be felt on the outer side of\\nthe olecranon, at its base and in the third the olecranon could also be\\nsprung. Quintin thinks this fracture is frequently overlooked and\\ntreated as a simple contusion. The symptoms in the three cases\\ndescribed will, perhaps, hardly be considered entirely demonstrative, in\\nthe absence of corroborative testimony of direct examination, of a\\nrecent fracture and, indeed, it is only by admitting that the injury is\\na common one and has heretofore always been overlooked that its\\noccurrence three times .during a short period in the experience of one\\nobserver can seem probable.\\nSymptoms. The symptoms of the fracture are pain, swelling, dis-\\nplacement, and mobility of the upper fragment, sometimes crepitus,\\nand loss of power, especially of active extension.\\nAs the result, apparently, of theoretical considerations, and of what\\nhas been observed in exceptional cases, the tendency to displacement\\nupward of the fragment by the contraction of the triceps has been\\nsomewhat overstated. This action of the muscle is greatly restricted\\n1 Pingaud Diet. Encylopedique, art. Coude, pp. 517 and 631.\\n2 Quintin Beitrag zur Lehre von den Briicken des Olekranon, Bonn, 1881, Abstract in\\nCentralblatt fur Ckirurgie, 1881,. p. 763.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0296.jp2"}, "293": {"fulltext": "FRACTURES OF THE BONES OF THE FOREARM. 261\\nby the lateral aponeurotic attachments and ligaments, and by the exten-\\nsion of the insertion of the triceps along the lateral and posterior aspects\\nof the olecranon, all of which must be ruptured before the fragments\\ncan be widely separated and the upper one drawn high up. In a dis-\\ncussion in the Societe de Chirurgie which followed the presentation by\\nBardinet of a paper upon this subject, Robert, Richert, and Gosselin\\ntestified to the usual absence of separation in their experience, and\\nsimilar testimony has since been furnished in abundance.\\nIf the thick periosteum and tendinous attachments on the sides and\\nback of the olecranon are torn, nothing remains to hold the fragments\\ntogether, and separation may be effected either by the contraction of\\nthe triceps, drawing the upper fragment away from the shaft of the\\nbone, or by flexion of the forearm, drawing the bone away from the\\nfragment. In either case coaptation is effected by extending, straight-\\nening, the forearm upon the arm, because the triceps cannot draw the\\nfragment above the position which it takes in complete extension\\nunless the ligaments which bind it to the humerus are torn, and this is\\na complication which apparently happens very rarely.\\nIn old ununited cases the gradual retraction of the triceps draws\\nthe fragment upward, but not even in such has it risen above the ole-\\ncranon fossa.\\nAnother displacement, one that is important because of the danger\\nthat the skin may be broken by the pressure to which it leads, is an\\nangular one observed in a few cases when the line of fracture has been\\nnear the base of the coronoid process, and especially when its direction\\nhas been obliquely downward and backward and the upper fragment\\nhas ended in a sharp lower edge or point.\\nCoincident dislocation of the radius and ulna forward is occasionally\\nseen. (See Chapter XLV., and Plate IX.)\\nMobility of the fragment is recognized by grasping it between the\\nthumb and finger and moving it laterally, or by flexing the forearm\\ngently while the finger is pressed against the groove or crack left by\\nthe separation when it is slight. If the fragments are brought together\\nby extending the forearm or drawing the upper fragment down, crepi-\\ntus can be felt.\\nIf the swelling is sufficient to prevent recognition of these objective\\nsigns, the fracture may be suspected from the history of the case and\\nthe loss or marked diminution of the power of active extension.\\nRepair. It is very important, with reference both to the treatment\\nand prognosis, that the character and extent of the displacement\\nshould be known. As a rule, union takes place, but it is fibrous, not\\nbony and the restoration of function depends in a measure upon the\\nlength of the fibrous band. I say in a measure/ for experience\\nhas shown in not a few cases that there may be excellent control over\\nthe limb even with a long fibrous band between the two fragments.\\nThe disability sometimes observed under the opposing conditions,\\nlimitation of motion when the band is short, is due to adhesions\\nbetween the fragment and the humerus, or to change in the flexibility\\nand length of the capsular bands. The process of repair involves two\\ndangers defective union or failure of union between the fragments,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0297.jp2"}, "294": {"fulltext": "262\\nFRACTURES.\\nFig. 134.\\nand the formation of the intra-articular bands or changes in the artic-\\nular and peri-articular tissues.\\nInstances of bony union do exist. Malgaigne figures and describes\\none in his Atlas (Plate XXIV., fig. 2), which, however, differs\\nnotably from the ordinary fracture, the line having run so obliquely\\nas to bring away with the olecranon a lateral half of the coronoid pro-\\ncess. Many instances of union with very slight separation, if any,\\nand apparently bony, have been reported, but in only a few has the\\ncharacter of the union been established by autopsy. Gurlt l describes\\nand pictures two one, a fracture half an inch from the apex of the\\nprocess, united with slight displacement of the fragment upward and\\nonly a small amount of callus on the outer side the line of fracture\\nis partly visible upon the surface\\nof section, and complete extension\\nof the joint is prevented by an over-\\ngrowth of bone at the apex. The\\nother is an oblique fracture (Fig.\\n134), and has united so completely\\nthat the only sign of it is a shal-\\nlow groove on the under surface of\\nthe olecranon running obliquely\\nbackward from the radial to the\\nulnar side. The articular cartilage is lacking in part, and the callus\\nconsequently visible. Apparently bony union is more probable when\\nthe fracture is oblique.\\nThe length of the fibrous band varies within very wide limits. Fig.\\n135, taken from Malgaigne, represents a comparatively short band\\nand one that presents another peculiarity in that it consists of two\\nlateral bands with a central interval or gap. This is by far the most\\ncommon mode of reunion, and although several cases have been\\nreported in which the patient appeared to have regained full use of the\\nFig. 135.\\nFracture of olecranon bony union. (Gurlt.)\\nFracture of the olecranon fibrous union. (Malgaigne.)\\narm, notwithstanding fibrous union with separation to the extent of\\nhalf an inch more, yet actual deficiency in the power of active exten-\\nsion of the forearm is to be regarded as a frequent result of fibrous\\nunion, and its degree will vary directly with the length of the band.\\nThe disability may be unnoticed by others, and its consequences may\\nbe avoided or diminished by care in the use of the arm, by avoidance\\n1 Gurlt: Loc. cit,, vol. i. p. 41, Fig. 9, and p. 310, Fig. 121.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0298.jp2"}, "295": {"fulltext": "FRACTURES OF THE BONES OF THE FOREARM. 263\\nof positions and movements which require the especial action of the\\ntriceps, but it exists and can be readily demonstrated. Malgaigne\\ndescribes a case in which the fragment apparently had not reunited\\nwith the shaft, and yet the patient could use the limb actively, and\\neven handle a sword or a foil. On examination it was found, how-\\never, that the vigor and strength of the arm depended largely upon its\\nposition, being greatest when the hand was supinated and the arm\\ndependent, and disappearing almost entirely when the arm was raised\\nabove the horizontal line.\\nFailure of union, as in the case just mentioned, is not very uncom-\\nmon the upper fragment may remain freely movable, or it may become\\nadherent to the humerus. An example of the latter condition came\\nunder my observation in Bellevue Hospital. The patient, John A.,\\nfifty-six years old, was admitted in August, 1880, for some slight affec-\\ntion, and while examining him I noticed the defect in the right elbow.\\nHe said that when about twenty years old he fell from a truck, striking\\nupon the elbow. The limb was treated in a rectangular splint. The\\nupper fragment, as shown in Fig. 136, was slightly drawn up and some-\\nwhat tilted, and was firmly adherent to the humerus. The forearm\\ncould be completely flexed and could be extended to 135 degrees, the\\nforce of extension being very feeble.\\nFig. 136.\\nA\\nUnunited fracture of the olecranon, a, the upper fragment; b, the external condyle.\\nIn the majority of cases union takes place with but little separation\\nand with full restoration of function, so far at least as power is con-\\ncerned, although extension is often incomplete.\\nA still more unfortunate result, anchylosis of the joint, has followed\\nin a small number of cases. Malgaigne quotes from Camper and\\nTrioen an anatomical specimen of bony fusion, and although it is not\\nspecifically asserted that the union was between the ulna and the\\nhumerus, this seems probable from the context. Thierry, according\\nto Pingaud, reported two cases of articular rigidity that had lasted, the\\none for six months, the other for a year, in spite of the most persistent\\nefforts to overcome it. I have seen a case in which the joint was stiff\\nin full extension after wiring of the fragments, although the operation-\\nwound had healed without suppuration.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0299.jp2"}, "296": {"fulltext": "264 FRACTURES.\\nThe course of the fracture is ordinarily very simple and uncompli-\\ncated the swelling subsides promptly and union takes place in from\\nthree to four weeks.\\nTreatment. Discussion concerning the proper treatment of fracture\\nof the olecranon has turned mainly upon the position to be given to\\nthe limb, some favoring the extended position in order to secure closer\\nunion of the ligaments, others recommending flexion, either because\\nthey did not fear separation of the fragments and sought the position\\nthat could be kept with the least discomfort, or because they feared\\nanchylosis and wished to have the limb in the most favorable position\\nif it should occur. It is evident from the facts that have been already\\nstated that neither the first nor the third reason is sufficient to establish\\na rule of practice to be followed in all cases. The probability of the\\noccurrence of anchylosis after simple fracture is very small, so small\\nthat it ought not to be weighed against that of non-union when the\\nfragments are separated rather widely. On the other hand, the sepa-\\nration at first is so slight in many cases and the extended position so\\nunnecessary to overcome it that if partial flexion is more comfortable\\nto the patient, if it makes the restraint less irksome, it should not be\\ndenied him. Furthermore, there appears to be danger of two displace-\\nments in complete extension if the fracture is at or near the base of\\nthe process the ulna can be readily dislocated forward and secondly,\\neffusion into the joint or swelling of the capsule may prevent the tip of\\nthe olecranon from sinking into the olecranon fossa to the usual depth,\\nand under such circumstances complete extension of the forearm would\\ncause a tilting, an angular displacement of this fragment. This latter\\npoint has been made by several writers upon theoretical grounds alone,\\nbut, although it seems plausible, no confirmatory observation has been\\nmade, so far as I know.\\nThe aim of treatment should be to secure bony union if possible, and,\\nfailing that, close fibrous union, and this consideration will regulate the\\nposition to be given to the arm. If there is wide separation which\\nincreases as the elbow is flexed, if the fragments cannot be brought\\nwell together except by extending the forearm, that position must\\nbe taken and kept until consolidation is well advanced. If, on\\nthe other hand, the separation is slight and the upper fragment\\nfollows the movements of the lower, if they can be easily brought to-\\ngether and kept so by moderate traction upon the upper one, the\\npatient may be safely allowed the comfort of the partly flexed posi-\\ntion.\\nApparently it is not often necessary to take especial measures to draw\\nthe upper fragment down to the lower one, and even when there is con-\\nsiderable separation between them in the flexed position it is usually\\nsufficient simply to extend the elbow. Some methods of treatment,\\nhowever, have been designed with the especial intention of drawing\\nthe fragment down, and it has been sought to accomplish this by figure-\\nof-eight bandages passing above and below the fragment and crossing in\\nfront of the elbow, or by circular bands about the arm drawn together\\nby longitudinal ones. In others, strips of adhesive plaster have been\\napplied to the skin above the olecranon, drawn down snugly, and fast-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0300.jp2"}, "297": {"fulltext": "FRACTURES OF THE BONES OF THE FOREARM. 265\\nened to the skin of the forearm or to the splints sometimes the plaster\\nis cut in the form of a U, the olecranon lying in the angle and the two\\nsides passing along the forearm.\\nMetal hooks similar to those used in fracture of the patella have\\nalso been used here successfully, although not frequently. I do not\\nknow when or by whom they were first employed, but Busch recom-\\nmended them in 1864, and Pingaud 1 speaks of the use of a similar\\nmethod a very long time ago by Prof. Rigaud, of Strasburg. It\\nis sufficient that the nook should have but a single point at the upper\\nend, and* at the other end should be made fast to a gypsum bandage\\ncovering the arm and forearm and provided with a large fenestra\\nbehind the elbow.\\nThe best splint is an anterior one made fast to the limb by a roller\\nbandage or a fenestrated gypsum bandage. It is not worth while, I\\nthink, to try to force the upper fragment down by turns of a roller\\nbandage, because this can be done much more eifectively when necessary\\nby adhesive plaster or hooks. In short, the treatment to be recom-\\nmended is as follows If the separation is slight and is not increased\\nbv the Hexed position it is only necessary to immobilize the limb with\\nthe forearm slightly flexed, about midway between complete extension\\nand flexion at a right angle, and for this purpose an anterior splint of\\nwood or of plaster of Paris is sufficient and convenient. If the frag-\\nment shows any tendency to be drawn up it should be secured with\\nadhesive piaster. If, on the other hand, there is notable separation,\\nand if the separation is increased by flexion of the forearm, the exten-\\nsion should be complete enough to bring the fragments together, and it\\nshould be aided by adhesive plaster or hooks. The fenestrated gypsum\\nbandage seems to be the one best fitted for this purpose, and the fenes-\\ntra should be large enough and so placed as to permit inspection of the\\nseat of fracture. If Malgaigne s hooks are used in connection with it\\none hook or pair of hooks should be forced through the tendon of the\\ntriceps down to the bone, and the other pair fixed to the gypsum\\nbandage below the fenestra. In one of three cases recorded by Quin-\\ntin, 2 the hooks remained in place four weeks without causing any\\ninflammatory symptoms.\\nIf the patient is rheumatic, or if the reaction has been severe and\\nprolonged and anchylosis is feared, it is well to change the degree of\\nflexion slightly from time to time after the pain and inflammation have\\ndisappeared and if the tendency to separation is slight this change of\\nposition may be begun quite early. It must be done very gently and\\ncautiously, and the upper fragment must be supported by the finger in\\norder that the adhesions may not be ruptured. In a case reported by\\nPingaud, 3 the callus was broken by this attempt at passive motion\\nand as the surgeon did not dare to immobilize the joint again for three\\nor four weeks he applied a plaster bandage to the forearm, and used it\\nas the support for a pair of Malgaigne s hooks by which he was enabled\\n1 Pingaud Diet. Encyclopedique, art. Coude, p. 639 (1878).\\n2 Quintin Centralblatt fur Chirurgie, 1881, p. 764.\\n3 Pingaud Gazette Hebdomadaire, May 21, 1875.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0301.jp2"}, "298": {"fulltext": "266 FRACTURES.\\nto keep the fragment perfectly in place, and at the same time to move\\nthe elbow as much as he wished.\\nLauenstein l used in one case a method of preliminary treatment\\nrecommended by Volkmann in fracture of the patella aspiration of\\nthe joint to remove the blood and synovia. There was separation to\\nthe extent of half an inch and the joint was distended he removed 50\\nc.c. (about 1J ounces), dressed the limb in the extended position upon\\nan anterior splint, and drew down the fragment by means of longitu-\\ndinal strips of adhesive plaster renewed about once a week. Recovery\\nfollowed without displacement and with full use of the joint. Another\\ncase is reported in the Cent ralblatt fur Chirurgie, 1885, p. 570.\\nIn a few cases the fragments have been wired together when resort\\nto such a measure was deemed necessary I have preferred sutures\\nthrough the fibro-periosteum adjoining the fracture, or a suture through\\nthe tendon of the triceps and a hole drilled transversely in the ulna\\nbelow the fracture.\\nIn a few cases of fibrous union with much separation and consequent\\ndisability operative measures, according to some of the various plans\\nmentioned in Chapter VIII., have been undertaken to obtain closer\\nunion and since the introduction of the antiseptic method some sur-\\ngeons have obtained good results by excising the fibrous band and\\nwiring the fragments together.\\nB. Fractures of the Coronoid Process. 2\\nThis fracture, the frequency of which has been much disputed, is\\nunquestionably very rare except as a complication of dislocation of the\\nulna backward.\\nFig. 137. Fig. 138.\\nFracture of the coronoid process of the right ulna.\\nUnited with exuberant callus on the anterior surface,\\nline of fracture still visible on the articular surface.\\na, a small fragment broken from the articular border Fracture of the coronoid process and\\nof the olecranon and reunited. (Gurlt.) the head of the radius. (Bryant.)\\nSo far as can be inferred from the few detailed descriptions of speci-\\nmens the line of fracture crosses the process transversely or somewhat\\n1 Lauenstein: Centralblatt fur Chirurgie, 1881, p. 172.\\n2 The references to the specimens in the first edition are: Cooper. Fractures and Dis-\\nlocations, p. 411 S. Cooper and Gibson, quoted bv Hamilton Velpeau, Annales de la\\nChir., 1843, vol. ix. p. 98; Berard, Diet, de Med., en 30 vols., art. Coude, p. 228: Gurlt,\\nvol. i. p. 41 Bryant s Surg., 3d Am. ed., vol. i. p. 837: two in Holmes s System, Am. ed.,\\nvol. i. pp. 859, 860; Annandale, Medical Times and Gazette. 1875, vol. i. p. 576, and\\nEdinburgh Medical Journal, February. 1885, p. 681. For a personal case seethe following\\nsection, Fractures of the Head and Xeck of the Badius.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0302.jp2"}, "299": {"fulltext": "FRACTURES OF THE BONES OF THE FOREARM. 267\\nobliquely at about one-fourth of an inch below its apex, and may\\nreunite with a close bony union or by a fibrous band. When the\\nunion is close and bony there may be a somewhat exuberant callus\\nupon the anterior aspect of the process, due probably to the stripping\\nup of the periosteum or tendon.\\nIn Annandale s three cases the fracture was associated with an old\\nunreduced dislocation of the elbow backward, and the process had\\nunited with the back of the humerus.\\nThe mechanism in the great majority of cases is by indirect violence\\nexerted in such a Avay as to cause dislocation of the joint backward and\\nto break off the point of the process as it is forced past the trochlea,\\nand in such cases there is also sometimes fracture of the anterior por-\\ntion of the head of the radius. In one case mentioned by Lotzbeck l\\nthe process appeared to have been broken off by direct violence a\\nsoldier was struck in the elbow by a piece of a shell which caused a\\nsevere contusion but no open wound. Two months afterward the coro-\\nnoid process could be felt as a movable body, and by pressing it down\\nit could be made to rub against the ulna with a creaking sound. Acu-\\npuncture proved the supposed fragment to be a hard solid body. In\\nanother case, that of a boy fourteen years old, the process was broken off\\nby extreme flexion of the elbow. A somewhat similar personal expe-\\nrience may be mentioned as corroborative of this mechanism to a cer-\\ntain extent. I excised an elbow for suppurative disease of the joint,\\nusing Ollier s postero-lateral incision. In order to facilitate the clean-\\ning of the external condyle, and before the olecranon had been touched,\\nI asked the assistant to flex the elbow he did so with some force, and\\nfelt something snap. About half an inch of the coronoid process was\\nfound to have been broken off. It seemed, however, to be unusually\\nlong and prominent, possibly by ossification of the attached capsule in\\nconsequence of the prolonged inflammation.\\nAs regards experiment upon the cadaver we have the assertion of\\nMalgaigne, 2 that in producing dislocations backward he broke off the\\nend of the coronoid process quite frequently, and the more detailed\\nresults of Lotzbeck who fixed the elbow in a slightly flexed position by\\nmeans of a gypsum bandage and then by striking upon the palm of\\nthe hand broke the coronoid process five times in ten attempts. Vary-\\ning the experiment by extending the elbow completely he succeeded in\\nproducing the fracture only once.\\nThe mechanism of this production and the anatomical relations of\\nthe process explain the union with slight displacement shown in some\\nof the specimens and the difficulty of diagnosis during life. The ten-\\ndon of the brachialis anticus is inserted not upon the top of the process\\nbut upon its anterior aspect and base, and the articular capsule is\\nattached all along its edge. When it is broken off by being forced\\nbackward against the trochlea its connection with the ulna is preserved\\nin front by the tough attachments of the tendon, and therefore instead\\nof being displaced bodily along the anterior aspect of the bone it is\\nprobably only tilted forward. Its vitality is assured in any case by\\n1 Lotzbeck Schmidt s Jahrbuch, 1866, vol. cxxix. p. 134.\\n2 Malgaigne Luxations, p. 634.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0303.jp2"}, "300": {"fulltext": "268 FRACTURES.\\nits connection with the capsule, and when the dislocation is reduced\\nthe fragment is held exactly in place by the tendon of the brachialis\\nanticus in front and the humerus behind.\\nThe symptoms and the means of diagnosis, in view of the uncer-\\ntainty of the diagnosis in the supposed cases, cannot be positively\\ndescribed those which have been deemed sufficient are dislocation\\nbackward, easy reduction, great tendency to recurrence, possibly crepi-\\ntus, and the presence of a hard movable body in front of the elbow in\\nthe line of the tendon of the brachialis anticus. In a personal case\\nthe supposed fragment could be readily grasped between the thumb\\nand finger and moved freely to and fro.\\nTreatment. The treatment consists in immobilization of the joint\\nflexed to a right angle or beyond. The degree of flexion and the com-\\npleteness of the immobilization may vary with the tendency to dis-\\nplacement. If the latter is great, experience has shown that it is best\\nopposed by increasing the flexion and, of course, complete immobil-\\nization gives additional security. The immobilization should be main-\\ntained as long as the tendency to dislocation exists when that ceases\\nthe splint becomes unnecessary, and the only indication then is to main-\\ntain sufficient flexion to favor prompt and close union. The slight\\nmotion in the joint permitted by a sling, if it is painless, diminishes\\nthe resulting stiffness.\\nC. Fractures of the Head and Neck of the Radius.\\nOur knowledge of this variety of fracture is drawn from about a\\nscore of specimens, old or recent, and a few more or less doubtful clin-\\nical cases. 1 The line of fracture may separate a small portion of the\\nhead, about one-third, or a much larger portion, passing down through\\nthe neck, or may split the head into two or more pieces and separate\\nall of them from the shaft. I know of only one specimen (Mutter) of\\nfracture of the neck without splitting of the head, but two specimens\\nof separation of the epiphysis have been reported.\\nCause. The cause may be a blow upon the head of the bone i Stim-\\nson, Cheyne, Delorme), or a wrench of the forearm, probably forced\\nabduction (Stimson), or the injury may occur as an incident of a back-\\nward dislocation of both bones of the forearm the latter seems to be\\nby far the most frequent cause. The form of the fracture varies with\\nthe cause fracture of a small portion of the head is the form seen in\\ndislocation and in fracture by direct violence the more extensive frac-\\ntures splitting of the head and complete separation from the shaft\\nare rarer and are seen when the limb has been violently wrenched. I\\nhave seen three of the former two in dislocation and one by direct\\nviolence and three of the latter verified by arthrotomy and three prob-\\nable cases observed clinically.\\n1 See the last five of the references quoted in the preceding section Hodges, Boston\\nMedical and Surgical Journal, 1S66, p. 383, and 1S77, p. 65: seven cases or specimens\\nquoted or described in the first edition Cheyne. British Medical Journal, March 7. 1S91\\nDelorme, Gaz. des Hop., March 17, 1891; Stimson. Xew York Medical Journal. Xov. 24,\\n1888, and Jan. 30. 1892, and Annals of Surgery, March and April. 1898: Helferich, Frac-\\ntures and Dislocations, p. 172: Javle. Bull/de le Soc. Anat., January, 1893; Pinner,\\nDeutsche Zeitschr. fiir Chir., 1883, p. 631.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0304.jp2"}, "301": {"fulltext": "FRACTURES OF THE BOXES OF THE FOREARM.\\n269\\nIn the cases accompanying dislocation a small piece, comprising\\nabout one-third of the periphery, is broken off, probably the portion\\nthat is anterior when the head is forced past the capitellum. I have\\nfound it lying, after reduction of the dislocation, beneath the external\\nepieondyle between the radius and the olecranon, and the portion of\\nthe head of the radius accessible to palpation did not comprise the gap\\nleft by the fracture.\\nIn a case of fracture by direct violence (kick by a horse) Cheyne\\nfound the fragment in the same place and removed it, as he did also\\nin another supposed to be by direct violence in another Delorme\\nrecognized abnormal mobility of the undisplaced fragment and treated\\nit by immobilization, obtaining complete restoration of function. In\\nmine the patient did not come under observation until after suppura-\\ntion of the joint had occurred resection was done.\\nMy three certain cases of fracture by violence acting through the\\nforearm resemble one another closely. In each the cause was a fall\\nfrom a height, the arm being caught under the body. I imagine that\\nthe immediate cause was violent abduction of the forearm. Fig. 139\\nshows the lines of fracture. In the first, one of the two smaller frag-\\nments was displaced outward and backward, and a primary excision of\\nthe head and neck was done, with a good functional result. It was\\nthought that the coronoid process also was broken. In the second\\nthere was no recognizable displacement at first, and I was not entirely\\ncertain of the character of the injury after immobilization for four\\nweeks the functional result seemed so likely to be bad that I opened\\nthe joint and removed the head and neck, finding the larger fragment\\ndisplaced angularly outward and backward and reunited with the shaft.\\nIn the third case there were two large pieces and a crush of the inter-\\nFig. 139.\\nA B\\nFracture of head and neck of radius, a, first case b, second case c, third case the portion\\ncorresponding to the gap was crushed.\\nmediate portion, also fracture of the coronoid process and slight dis-\\nplacement backward of the ulna. I saw the patient a month after the\\naccident and removed the head of the radius. The cases are reported\\nin detail in the references given above. In one case observed clinically\\n(details in first edition) reunion followed, with a good functional result,\\nnotwithstanding a notable enlargement of the upper end of the radius\\nin the other rotation of the forearm was lost. I have also had a case\\nin which the head of the radius was broken by a pistol -bullet entering\\nfrom the outer side and above. I excised the head, and the functional\\nresult was good.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0305.jp2"}, "302": {"fulltext": "270 FRACTURES.\\nTwo of Mutter s specimens and Helferich s show a small portion of\\nthe head broken off and reunited with displacement. Mutter s third\\nspecimen shows union with marked angular displacement after fracture\\nof the neck at the upper margin of the bicipital tuberosity. In Pin-\\nner s the small fragment was eburnated but not reunited, and in\\nDelorme s the fragment reunited with conservation of function.\\nThese cases show that union is possible, even probable, after fracture\\nof the neck or of the head in my case in which suppuration followed\\nthe patient was a delicate strumous lad in whom any serious joint lesion\\nwould have been likely to have that result.\\nMutter s specimen of fracture of the neck alone is without history\\nof the cause or symptoms in Annandale s the patient, a man forty\\nyears old, received a severe jar of the elbow by striking his wrist\\nagainst his knee while shovelling. He did not seek treatment until\\nsix weeks later. After a month s immobilization the joint was opened\\nthe head was found loose and the neck atrophied.\\nDiagnosis. The diagnosis after fracture of a small portion accom-\\npanying a dislocation or by direct violence is easy if the fragment is\\ndisplaced to the position beside the olecranon which it has occupied in\\nmost of the reported cases, for it can then be readily palpated. Its\\nremoval is easy, and its loss appears to entail no disability. The loss\\nof rotation observed in one case after removal was probably due to\\nadhesions between the surface of fracture and the capsule.\\nIn the cases of more extensive breaking the diagnosis is easy if there\\nis enough displacement of the head to be recognized by palpation and\\nif its separation from the shaft is shown by its failure to share in rota-\\ntory movements of the forearm. In my second case the head rotated\\nwith the shaft, and the only sign pointing to its fracture was an occa-\\nsional click perceived during rotation of the forearm there was also\\nmarked abnormal lateral mobility, especially adduction of the forearm,\\nand sharp pain on abduction.\\nThe proper treatment of this condition is not so clear one of my\\ncases regained good use of the joint without operation another did the\\nsame after a primary excision the third and fourth had completely\\nlost rotation and preserved only 20 to 40 degrees of flexion and exten-\\nsion at the end of four and five weeks when I removed the reuniting\\nfragments the removal considerably improved the condition.\\nFracture through the neck alone should theoretically show failure of\\nthe head to share in the rotation of the forearm, with crepitus, if it is\\nheld firmly against the ulna by the pressure of the thumb during the\\nmanipulation. In the treatment the possibility of angular displace-\\nment shown in Mutter s specimen and observed by Hamilton in three\\ncases supposed to be of this character should be borne in mind. It\\nhas been attributed to the pull of the biceps upon the lower fragment,\\nbut considering that injuries of the elbow are commonly treated in the\\nflexed position which would prevent that pull I doubt that agency,\\nalthough unable to suggest a satisfactory one. Possibly the pressure\\nof the soft parts in the flexure of the joint when it is flexed, or abduc-\\ntion of the forearm by the weight of the arm when the wrist rests upon", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0306.jp2"}, "303": {"fulltext": "FRACTURES OF THE BOXES OF THE FOREARM. 271\\nthe front of the body may be a factor. If the pull of the biceps is\\nthe cause it could be met by full flexion of the joint.\\n2. FRACTURES OF THE SHAFT.\\nA. Fractures of the Shafts of Both Bones.\\n(Plates III., V., IX.)\\nThe relative frequency of fracture of both bones may be seen by\\nreference to the table in Chapter I. It occurs rarely in the upper third\\nand with about equal frequency in the middle and lower thirds. Usu-\\nally the radius is broken nearer the elbow than the ulna.\\nCause. The cause may be direct or indirect violence or muscular\\naction, a fall upon the hand, or the bending of the forearm across some\\nobject, or by a transverse blow.\\nOnly a few instances of fracture by muscular action have been\\nrecorded, and even in those there was a contributing external force,\\nsuch as shovelling or rising upon the hand in bed.\\nPartial or incomplete fractures green- stick fractures are,\\naccording to Malgaigne, more common in the forearm than elsewhere,\\nand are usually due to a fall upon the hand.\\nDisplacements. The displacements are of the usual kinds overrid-\\ning in oblique fractures, lateral with or without overriding in the\\ntransverse fractures, and angular displacement of one or both bones in\\nboth forms. Rotatory displacement of the radius alone, especially\\nwhen it is broken above the insertion of the pronator teres, was first\\npointed out apparently by Lonsdale. He suggested that the upper\\nfragment might be strongly supinated by the biceps, while the lower\\nfragment was kept in the usual semi-prone position, and he thought\\nthis might be a cause of the inability to supinate the hand completely\\nsometimes observed after fracture. Flower and Hulke 1 say they have\\nfound proof of the correctness of this conjecture in the examination\\nof numerous specimens of united fracture of the radius, in a great\\nnumber of which the lower fragment was much less supinated than\\nthe upper, and Agnew says there are similar specimens in the collec-\\ntions of the College of Physicians and the University of Pennsylva-\\nnia. Mr. Callender 2 examined eighteen specimens of united fracture\\nof the shaft of the radius in the London museums, and found in fifteen\\nof them rotatory displacement averaging 36 degrees, the extremes\\nbeing 6 degrees and 64 degrees. The displacement in every case was\\nthat pointed out by Lonsdale, supination of the upper fragment. The\\nagency of this rotatory displacement supination of the upper frag-\\nment in preventing full supination of the lower segment after heal-\\ning appears much more likely to be efficient in fractures below the\\ninsertion of the pronator radii teres, for that muscle is the main oppo-\\nnent of the exaggerated supination of the upper fragment which would\\nthen be necessary to the full supination of the lower.\\nIn angular displacement one bone may be bent while the other\\n1 Hulke: Holmes s System of Surgery, Am. eo\\\\, vol. i. p. 860.\\n2 Callender St. Bartholomew s Hospital Reports, vol. i., 1865, p. 297.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0307.jp2"}, "304": {"fulltext": "272 FRACTURES.\\nremains nearly straight, possibly with overriding, or the fragments of\\nboth bones may be inclined in the same direction, forward, backward,\\nor to either side, or there may be lateral inclination in opposite direc-\\ntions, each bone being inclined toward the other and if the fractures\\nare at the same level the four ends may thus be brought into contact,\\nand the possibility created of a union that will abolish the power of\\nrotation of the limb. In a case seen by Malgaigne the ends of the\\nupper fragments were brought together and interposed between the\\nends of the lower fragments, and in addition there was a displacement\\nproduced by supination of the lower segment of the limb, one which\\nbrought the lower fragment of the radius behind the upper one, and\\nthat of the ulna in front of its upper one. A displacement, the direct\\nopposite of the latter, has also been observed and described by Mal-\\ngaigne, the lower segment of the limb being more pronated than the\\nupper one. Overriding of the fragments has been observed to a dis-\\ntance of more than three inches (eight centimetres).\\nSymptoms. The symptoms are the usual ones of fracture pain,\\ndeformity, abnormal mobility, crepitus, and loss of power.\\nThe course is usually simple and the prognosis favorable, but both\\nmay be gravely modified by laceration or bruising of the soft j arts or\\nby the occurrence of acute inflammatory reaction or of gangrene, and\\nin addition the prognosis may be made unfavorable by an irreducible\\ndisplacement or comminution or loss of substance of one of the bones.\\nDisplacement affects the prognosis when it increases the chances that\\nunion may take place between the two bones, and comminution or loss\\nof substance by favoring the occurrence of pseudarthrosis.\\nIn simple cases without marked displacement or complication com-\\nplete union may be expected in a month, but in no other limb do\\ninflammatory complications and gangrene occur so frequently, even\\nunder prudent treatment. The gangrene may be limited to points\\nwhere the splints have made pressure or to portions of the hand and\\nfingers, but it is very likely to involve the entire member if it is over-\\nlooked at the beginning or not effectively combated. Diffuse phleg-\\nmonous inflammation of the forearm may follow severe bruising of the\\nsoft parts or may even take its rise in the fracture. Its importance\\nlies in the danger to the life and limb which follows the burrowing of\\nthe pus, the opening which it necessitates, and the matting together\\nof the tendons and their sheaths.\\nIschemic contraction of the muscles (p. 68) is of especial import-\\nance because of its marked interference with the usefulness of the\\nhand.\\nThe cause of gangrene in many cases and of ischemic contraction\\nhas been pressure exerted by splints or bandages, and the necessity\\nfor caution and watchfulness to avoid this accident cannot be urged\\ntoo strongly. The practice of applying a roller bandage to the limb\\nunder the splints is extremely dangerous, and so also is the use of\\nsplints of soft material, pasteboard and the like, which take the shape\\nof the limb and are fastened to it with a roller bandage. There is the\\nsame compression, the same chance of strangulation in this case as\\nwhen the roller is applied directly to the skin. It is not safe to depend", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0308.jp2"}, "305": {"fulltext": "FRACTURES OF THE BONES OF THE FOREARM. 273\\nupon the sensations of the patient, upon pain, to give warning of\\nthreatening strangulation cases, in both old and young, have been\\nreported in which total gangrene of the distal portion of the limb has\\noccurred without attracting the attention of the patient or his attend-\\nants by any symptoms except the final change in the color of the\\nexposed fingers.\\nThe persistence of angular displacement of both bones, or, to a less\\ndegree, of the radius alone, seriously affects the prognosis by its inter-\\nference with rotation. In rotation only the radius moves, and its\\nmovement is about an axis running from its upper end to the lower\\nen;l of the ulna, so that in full pronation the radius crosses the ulna\\nobliquely, and in supination is parallel to it and at its maximum dis-\\ntance from it at the centre. If now the bones are bent, say in the\\nmiddle third, the radius of rotation of the radius at the apex of the\\nangle is correspondingly increased, and this angle must, therefore,\\nmove to a greater distance from the ulna than normal in supination\\nsuch a movement is prevented by the interosseous membrane, and rota-\\ntion is correspondingly diminished. This is the most frequent cause\\nof diminution or loss of rotation after fracture. The marked dis-\\nplacement of the radius in the case represented in Plate X., fig. 1,\\ncaused the loss of only half of the rotation.\\nThe possibility of union between the bones as well as the fragments\\nshould also be borne in mind. Its occurrence is more likely when the\\nnatural interval between them is destroyed or diminished by displace-\\nment, but this approximation is not essential. Excessive formation of\\ncallus, in consequence of laceration of the intermediate tissues and irrita-\\ntion especially of the interosseous membrane, is sufficient in itself to\\nproduce this result so destructive of the usefulness of the limb. The\\noccurrence is favored also by correspondence in the position of the frac-\\ntures, for the fragments are more likely to fall into abnormal contact\\nwith each other, and the granulations which form the callus about each\\nfracture may easily unite if each spreads over only half the intermediate\\nspace (Fig. 140). It has occasionally happened that the two calluses\\nhave come into contact and formed a lateral joint (Fig. 141), instead\\nof uniting. Slight inclination of the hand to one side or the other is a\\nnot infrequent result and may be due to the position of the sling in\\nwhich the arm is supported; thus, if the weight of the arm is borne\\nupon the sling at or above the point of fracture the unsupported hand\\ndrops downward and the lower fragment deviates toward the ulnar\\nside, as in the figures while if the sling passes under the hand or wrist\\nand leaves the forearm unsupported the latter sinks down between the\\nwrist and elbow and the lower fragment deviates in the opposite direc-\\ntion toward the radial side.\\nDelay or failure of union of either or both bones is not very uncom-\\nmon, especially of the radius, and cases are reported in which the union\\nof one of the bones has been delayed four or five months, and has then\\ntaken place without operative aid. Failure of union entails a disability\\nthat is often practically complete, and Agnew s tables do not indicate\\nthat the prospects of relieving it by operation are very great, since out\\nof thirty-seven cases a cure was obtained in only nineteen.\\n18", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0309.jp2"}, "306": {"fulltext": "274\\nFRACTURES.\\nTreatment. Reduction must be effected, when necessary, by exten-\\nsion and counter-extension aided by cautious pressure upon the bones\\nnear the seat of fracture. The importance of reduction is exception-\\nally great, because of the special function of rotation of the forearm\\nwhich may be so easily destroyed by displacement or failure of union.\\nI have once or twice found it necessary to cut clown upon the fracture\\nbecause I could not otherwise correct the displacement, the fragments\\nbeing so placed after oblique fracture that the surfaces of fracture were\\nseparated from each other by the entire thickness of the bone and the\\nfragments were in contact only by surfaces covered with periosteum.\\nOverriding is to be overcome by traction the forearm and fingers are\\nflexed, counter-extension is made by an assistant who grasps the arm\\nFig. 140.\\nFig. 141.\\nFracture of the forearm angular displacement,\\nand union between the bones.\\nFracture of the forearm, with formation\\nof a lateral joint.\\nclose above the elbow r and traction by the surgeon himself or another\\nassistant grasping the hand. If there is angular displacement the\\ntraction should be first made in the direction of the lower fragment,\\nand when this is thought to be sufficient, and while it is still main-\\ntained, the lower segment of the limb is brought into line with the up-\\nper one, the latter being steadied by the hand of the surgeon or press-\\nure being made upon the projecting angle with the thumbs. This\\npressure may be safely made if the angle is directed forward or back-\\nward, but it must be used with great caution w T hen the angle is lateral,\\nfor there is danger that it may force the bone upon which it is made\\ntoo near its fellow, and that when the manoeuvre is completed the posi-\\ntion of the fragments may resemble that of the arms of an X, each pair", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0310.jp2"}, "307": {"fulltext": "FRACTURES OF THE BONES OF THE FOREARM. 275\\nbeing displaced angularly toward the other. To avoid this result the\\nhand should be supinated while the reduction is making, because in\\nthis position the interval between the bones at the centre of the limb is\\ngreatest and most accessible, and the surgeon should seek to force or\\nkeep the fragments apart by pressing his thumbs in between them in\\nfront and his lingers behind.\\nThe position in which the forearm is usually kept during treatment\\nis that which is midway between pronation and supination. It is the\\none which the limb naturally assumes when it is suspended beside the\\nbodv with the elbow bent at a right angle and is the one which is\\nborne with the least fatigue and discomfort. But while this position\\nmeets the indications sufficiently in the simple and, indeed, in most\\ncases, it was long since recognized by some surgeons that the bones of\\nthe forearm are normally separated most widely from each other at the\\ncentre when the limb is supinated, and that consequently this position\\nis the one in which the arm should be kept whenever there appears to\\nbe danger of the bones uniting with each other. According to Mal-\\ngaigne, fractures of the forearm were treated in the supine position by\\nthe contemporaries of Hippocrates, but the practice was condemned by\\nthat writer it was reinvented by Pare, and abandoned by him when he\\nlearned that Hippocrates had disapproved of it, a yielding to authority\\nthat seems to have been unusual with that vigorous-minded surgeon,\\nand again reinvented by Malgaigne, who afterward learned that\\nLonsdale had preceded him by a few years. Lonsdale l recom-\\nmended the position for a reason mentioned above, the difference\\nbetween the degree of supination of the upper fragment of the radius\\nand that of its lower fragment Malgaigne recommended it because\\nof the greater distance between the centres of the bones when they\\nare in this position.\\nThe difficulty which Lonsdale sought to avoid, supination of the\\nupper fragment, appears not to have much importance when the frac-\\nture of the radius is above the insertion of the pronator radii teres and\\nto be rare when it is below it that which Malgaigne had in mind\\npossible union of the two bones is rare even when the two bones are\\nbroken at the same level. The principal faults to be avoided are angu-\\nlar displacement and overriding, and so far as these are concerned the\\nattitude of pronation or supination seems to be indifferent. The objec-\\ntion to the attitude of supination is its greater constraint and incon-\\nvenience if the attitude is desirable the discomfort can be avoided by\\nconfinement to bed with the arm abducted and the elbow flexed at a\\nright angle, in which position the forearm rests easily in full supination\\non its ulnar side.\\nA common method of treatment is to fix the limb between two light\\nwooden splints broad enough to overlap it slightly when applied to the\\npalmar and dorsal surfaces. The palmar splint should extend from the\\nfold of the elbow to the roots of the fingers, the dorsal one should be\\nshorter and not reach beyond the wrist. Each splint should be padded\\nwith cotton, and patients usually find it agreeable to have the end\\ncorresponding to the palm of the hand very thickly padded, or a small\\n1 Lonsdale London Medical Gazette, 1832, vol. ix. p. 910.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0311.jp2"}, "308": {"fulltext": "276 FRACTURES.\\nroll of bandage fastened obliquely to it so that the fingers can close\\neasily over it.\\nIn simple cases uncomplicated by threatening displacement, the\\nsplints are applied to the semi-pronated limb and fastened by two\\nstrips of adhesive plaster wrapped about them, one near the elbow, the\\nother at the wrist, the hand is made fast to the palmar splint by a few\\nturns of a bandage, and the limb is placed in a sling that supports both\\nthe elbow and hand.\\nThe limb should be frequently inspected at first in order to guard\\nagainst excessive pressure either by bandages too tightly applied at first,\\nor made too tight by the swelling of the parts, and the splints should be\\nremoved in the second week to detect and remedy any new displacement.\\nA roller bandage should not be applied to the limb under the splints\\nit exposes to displacement by pressing the bones toward each other,\\nand to gangrene or ischemic contraction by constriction. The com-\\nplete plaster-of-Paris dressing is objectionable for the same reasons\\nduring the first few days, but it or moulded plaster splints including\\nthe lower portion of the arm may be used after the first week if care\\nis taken not to make lateral pressure.\\nAnterior and posterior splints immobilize the limb sufficiently to\\nmeet every indication except that of opposing the tonicity of the mus-\\ncles and the occurrence of overriding. When the lines of fracture are\\ntransverse or toothed the bones themselves afford sufficient protection,\\nand in any case flexion of the elbow relaxes many of the muscles and\\ndiminishes the risk, which, moreover, is not a great one.\\nIn compound fractures great caution should be used in removing\\nfragments or excising portions of bone, lest failure of union should\\nfollow. If the extent and position of the wound are such that efficient\\nsplints cannot be used at first, the patient should be kept in bed with\\nthe arm abducted and the elbow flexed, and traction, elastic or by\\nweight, made by means of adhesive plaster attached to the hand and\\nwrist. Counter-extension can be made from the lower part of the arm\\nby a broad bandage, the limb being meanwhile supported upon cushions\\nor suspended, and preferably steadied by a splint placed outside the\\ndressings of the wound.\\nB. Fracture of the Shaft of the Ulna.\\nFractures of the shaft of the ulna alone are almost invariably the\\nresult of direct violence, of a blow received upon the arm while it is\\nraised to protect the head, or of a fall upon the ulnar side of the fore-\\narm.\\nDisplacement. Displacement may be entirely absent, and when pres-\\nent may be in any direction. Its extent and direction seem to depend\\nalmost entirely upon the fracturing force. Most recent writers, follow-\\ning the example of Pouteau, 1 have alleged that the broad articulation\\nof the ulna with the humerus prevented lateral displacement of the\\nupper fragment, and that the lower fragment was therefore the only\\none that could be displaced toward the radius. Even if the articula-\\ntion was absolutely free from lateral mobility, the inference that has\\n1 Pouteau CEuvres posthumes, 1783, vol. ii. p. 258.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0312.jp2"}, "309": {"fulltext": "FRACTURES OF THE BONES OF THE FOREARM. 277\\nbeen thus drawn would not be correct, because the radius can be\\nmoved toward the ulna after fracture of the latter and thus the exact\\nequivalent of the displacement of the ulna toward the radius produced.\\nThe only muscle which acts directly upon the lower fragment is the\\npronator quadratus, the tendency of which is to draw it toward the\\nradius.\\nSymptoms. The symptoms may be limited to pain and swelling at\\nthe seat of fracture, and their significance may be rendered obscure by\\nthe history and the effect upon the soft parts of the direct violence\\nwhich has caused the fracture. If the radius remains entire and is\\nnot dislocated at either end, there can be no shortening of the limb, no\\noverriding of the fragments, and displacement, if present, must be\\nrecognized bv following the outline of the bone with the finger. For-\\ntunately this exploration is made easy by the subcutaneous position of\\nthe ulna. Crepitus and abnormal mobility may be obtained by grasp-\\ning the limb above and below the fracture and making pressure alter-\\nnately upon the fragments with the ringers, or by seizing the fragments\\nbetween the thumb and fingers and moving them forward and back-\\nward upon each other.\\nAn important and not infrequent complication is dislocation of the\\nhead of the radius forward it should always be suspected when there\\nis marked displacement of the fragments of the ulna or unusual swell-\\ning at the elbow.\\nFig. 142.\\nFracture of the ulna with dislocation of the head of the radius forward.\\nThe prognosis is good as regards repair and preservation of function.\\nReduction. Reduction can be made only by appropriate pressure upon\\nthe displaced fragments, traction being practically without value. The\\ndisplacement which it is most important to overcome is the lateral one\\ntoward the radius, and that should be met in the same way as after\\nfracture of both bones, that is, by pressing the thumb and fingers in\\nbetween the bones.\\nAs the radius acts as a splint to prevent overriding of the fragments\\nthe surgeon s chief care is to secure immobility and prevent lateral or\\nangular displacement. This can be done by the anterior and posterior\\nsplints used in fracture of both bones, or by a rectangular splint fast-\\nened against the inner side of the arm and semi-pronated forearm, or\\nby a moulded plaster splint, In some cases it may be necessarv to\\nkeep the forearm supinated, and in others the bruising of the soft parts\\nmay be so severe as to forbid the use of splints at first. The arm", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0313.jp2"}, "310": {"fulltext": "278\\nFRACTURES.\\nshould be kept in a sling and the same precautions should be taken to\\navoid undue pressure by the sling upon the ulna as when both bones have\\nbeen broken. Many surgeons place the limb in a pasteboard, felt, or\\nplaster gutter in order to avoid this danger.\\nC. Fracture of the Shaft of the Radius.\\nAs far as can be judged from general impressions and statistics that\\nare somewhat scanty, isolated fracture of the shaft of the radius is less\\nfrequent than that of the ulna, and appears also to be generally caused\\nby direct violence, sometimes by a fall upon the hand. In three cases\\nreported by Falkson 1 fracture in the middle third with angular dis-\\nplacement forward was caused by pressure along its longitudinal axis,\\nthe palm of the hand in dorsal flexion and the back of the elbow\\nhaving been caught between heavy objects which were approaching\\neach other. Occasionally it has been broken by muscular action\\nforcible rotation.\\nDisplacements. The displacements vary somewhat with the seat of\\nfracture, the causes being the fracturing force and the action of the\\nbiceps and pronator muscles. The more common displacement appears\\nto be an angular one, the apex of the angle directed forward and inward.\\nPlate X. represents an extreme form. If the fracture is in the\\nlower third and the displacement inward, as in Fig. 143, the styloid\\nprocess is raised and the hand inclined toward\\nFig. 143. the radial side, so that the deformity resembles\\nthat of a Colles s fracture.\\nThe possible loss of supination in consequence\\nof union with a rotatory displacement, the upper\\nfragment being completely supinated by the\\nbiceps while the lower is kept partly pronated\\nby the dressings, which was pointed out by\\nLonsdale, and has been spoken of in the sec-\\ntion on fracture of both bones, is also to be\\nborne in mind after fracture of the radius alone,\\nespecially if the seat of fracture is above the in-\\nsertion of the pronator teres, and is to be met,\\nif at all, in the same manner, that is, by keep-\\ning the forearm supinated, but it does not appear\\nto interfere noticeably with function.\\nIf the fracture is at or below the middle of\\nthe bone the tendency of the biceps and pronator\\nteres is to draw the lower end of the upper frag-\\nment forward and inward, and that of the pro-\\nnator quadratus and supinator longus is to draw\\nthe upper end of the lower fragment toward the\\nulna.\\nOverriding has been observed only when dis-\\nlocation of the lower end of the ulna is asso-\\nciated with the fracture.\\nDiagnosis. The diagnosis is made by recognition of the displacement,\\nFracUire of the shaft of the\\nradius. (Malgaigxe.)\\nFalkson Centralblatt fur Chirurgie, 1885, p. 913.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0314.jp2"}, "311": {"fulltext": "FRACTURES OF THE BONES OF THE FOREARM. 279\\nif it exists, of crepitus and abnormal mobility obtained by grasping\\nthe fragments with either hand and moving them upon each other or\\nbv placing a thumb upon the head of the radius and rotating the wrist\\ngently.\\nTreatment. The indications for treatment are the same as after frac-\\nture of both bones, except so far as the uninjured ulna may be utilized\\nas a splint or as its dislocation may require more or less prolonged\\ntraction. If displacement exists the fragments should be pressed\\nback into place as before described, and if the fracture is low down\\nand the lower fragment is inclined toward the ulna it will perhaps be\\nfound easier to bring it back into line by drawing the hand forcibly\\ndownward and toward the ulnar side than by pressing the fingers in\\nbetween the bones. Traction at the wrist and elbow may be required\\nto overcome dislocation of the lower fragment upward from the ulna.\\nThe arm should be secured upon well-padded anterior and posterior\\nwooden or moulded splints in the semi-pronated position. Dislocation\\nat the lower radio-ulnar articulation or change in the direction of the\\nlower articular surface of the radius may make it desirable to use a\\nmoulded splint that will include the hand and perhaps the lower part\\nof the arm, or a long rectangular one for the purpose of extension and\\ncounter-extension, or to keep the hand inclined toward the ulnar side.\\n3. FRACTURES IN THE VICINITY OF THE WRIST.\\nA. Fractures of the Radius. Colles s Fracture.\\nUnder this term are included fractures of the radius near the wrist,\\nwhich, while differing from each other in many respects, have in com-\\nmon a characteristic deformity, and often a certain difficulty in making\\nreduction.\\nNext after the ribs the lower end of the radius is the part of the\\nskeleton most frequently broken. While the fracture occurs at all\\nages, it is most frequent in the elderly. It is very remarkable, and\\nworthy of mention as a proof of the difficulty of diagnosis in fractures\\nnear a joint, as well as of the force of authority and tradition, that the\\nreal nature of this common injury which comes so frequently under\\nthe notice of all surgeons should not have been recognized, and that it\\nshould have been taken almost always for a dislocation of the wrist\\nbackward, until about one hundred years ago. The first mention of\\nthe injury as a fracture is generally attributed to J. L. Petit, but, I\\nthink, incorrectly, for I find no reference to it in his chapter on frac\\ntures, while the chapter on dislocation of the wrist contains a very good\\nclinical description of it.\\nPouteau 1 is the first author to describe it as a fracture and to point\\nout the previous universal error in diagnosis. He describes its pathol-\\nogy, attributes its production to the violent contraction of the prona-\\ntors, and gives its symptoms and treatment, adding that there is, per-\\nhaps, no fracture so easy to recognize at a glance. The fact that he\\nincludes in his description fractures of both bones does not, I think,\\n1 Pouteau (Euvres postliumes, 1783, vol. ii. p. 251.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0315.jp2"}, "312": {"fulltext": "280 FRACTURES.\\ndiminish the credit due him for his recognition of the error of his pred-\\necessors and contemporaries. His view of the subject does not appear\\nto have commended itself to his immediate successors, and, during the\\nthirty years following its publication, only an occasional mention is\\nmade of even the possibility of such a lesion, and the common injury\\nwas still deemed a dislocation.\\nThe next writer upon the subject failed in like manner to impress\\nhis opinion upon his immediate contemporaries, and although justice\\nwas ultimately done him, and the fracture is now known widely by his\\nname, the recognition did not come until after his death. Mr. Colles\\npublished his brief but accurate account of the fracture in 1814/ but\\nDr. E. W. Smith, writing in 1847 2 says: Subsequent authors have\\nrepeated what Mr. Colles had said upward of thirty years since, but\\nno writer (as far as I have been able to ascertain), not even the distin-\\nguished author of the Surgical Dictionary, has alluded to his account\\nof the injury.\\nSir Astley Cooper, in the second edition of his Dislocations and Frac-\\ntures of the Joints, published in 1 823, describes fracture of the lower\\nend of the radius, and adds that he had seen this injury frequently,\\nbut did not understand its nature until taught by dissection but he\\ndescribes at the same time dislocation of the wrist, and evidently did\\nnot appreciate the full character and frequency of the fracture. In a\\nsubsequent edition he describes experiments made by himself upon the\\ncadaver in 1833, in which he produced the fracture by hyperextension\\n(extreme dorsal flexion) of the hand. The same failure to appreciate\\nthe character of the common injury which was coming so frequently\\nunder the care of every surgeon persisted, notwithstanding the publi-\\ncations of Pouteau and Colles, that of the former being entirely over-\\nlooked apparently, and that of the latter remembered only by the\\nDublin surgeons, who believed in the fracture and gave his name to it.\\nBut the misapprehension was not destined to last long the great change\\nwhich took place in the science of medicine at the beginning of the\\npresent century under the inspiration and guidance of the French\\nphysicians, the substitution of objective knowledge for dogma, of clinical\\nand dead-house observation for pure speculation, made short work of\\nthis error. Dupuytren was the first to call attention to it and to impress\\nit upon the profession; a post-mortem examination in 1820 showed\\nhim the real character of the injury, and his hospital service gave\\nhim the clinical opportunities that were needed for study and demon-\\nstration. A short period of doubt followed, and then, about 1830,\\nthe fact Avas universally accepted, and the second stage that of dis-\\ncussion of details, which has lasted until the present time\u00e2\u0080\u0094 was\\nentered upon.\\nMr. Colles, who had never had an opportunity to dissect a specimen\\nof the fracture, speaks only of the symptoms and treatment. His only\\nstatement concerning the fracture itself is an incorrect one This\\nfracture takes place at about an inch and a half above the carpal\\nextremity of the radius. We now know that, while the line of frac-\\n1 Colles Edinburgh Med. and Surg. Journal, April, 1814, vol. x. p. 182.\\n2 E. W. Smith Fractures in the Vicinity of Joints, Ani. ed.. p. 129.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0316.jp2"}, "313": {"fulltext": "FRACTURES OF THE BOXES OF THE FOREARM.\\n281\\nture may lie at the point he mentioned, it is usually much lower, and is\\noften associated with comminution of the lower fragment. The aver-\\nage distance is differently estimated, possibly because some have meas-\\nured from the articular edge of the bone and others from the styloid\\nprocess but the weight of testimony places it at from one-third to\\nthree-fourths of an inch above the articular border. In the young it\\nsometimes follows the epiphyseal line. Its direction is Usually trans-\\nverse, but it may be oblique laterally or antero-posteriorly, and the\\nlower fragment is often comminuted. The lower fragment is some-\\ntimes displaced bodily backward without crushing, as in Figs. 144 and\\n145, but the displacement appears more often to be almost entirely\\nangular, the lower fragment turning upon its anterior edge as upon a\\nFig. 144.\\nFig. 145.\\nFig. 146.\\nFracture of the lower end of the\\nradius. Displacement backward.\\n(R. W. Smith.)\\nFracture of the lower end\\nof the radius. Displacement\\nof lower fragment backward.\\n(R. W. Smith.)\\nFracture of the lower\\nend of the radius. Angu-\\nlar displacement of the\\nlower fragment back-\\nward with impaction.\\n(R. W. Smith.)\\nhinge, crushing or penetration with impaction taking place posteriorly\\nand outwardly, and the articulating surface looking downward and\\nbackward instead of downward and forward as it does normally\\nat the same time the styloid process rises to a higher level. An\\nextreme example of this displacement, with union, is shown in\\nFig. 146. Sometimes the styloid process of the ulna is broken off,\\napparently by avulsion through the lateral ligament or possibly the\\nfibro-cartilage.\\nSpecimens of recent fracture are not very common, and many of\\nthose we possess are open to the objection that the fractures have been\\ncaused by violence far in excess of that which causes the great majority\\nof the fractures met with clinically, the patients having falling from\\na considerable height, and having received also injuries that caused\\ndeath within a short time thereafter. Others are obtained from elderly\\npatients who have received the fracture in the usual manner, that is,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0317.jp2"}, "314": {"fulltext": "282\\nFRACTURES.\\nby a fall upon the ground while walking, and have then died in a few\\ndays of an intercurrent affection, usually pneumonia.\\nThe Rontgen rays have recently added to our knowledge of the\\ndetails, showing that the surface of fracture is rarely flat and trans-\\nverse, that comminution or splitting of the lower fragment is frequent\\neven in early adult life, that the displacement backward of the frag-\\nment is not commonly so marked as has been supposed from the appear-\\nance of the limb, and that the styloid process of the ulna is rarely\\nbroken. They confirm the opinion that the radial side of the bone is\\nshortened and show that the carpus preserves its relations with the\\narticular surface of the radius, passing slightly upward toward the\\nradial side of the ulna and thus making the latter prominent. In\\nmarked backward displacement the ulna accompanies the fragment.\\nFig. 147\\nFig. 148.\\nUnited fracture of the radius.\\nSmith.)\\n(R. W\\nRecently united fracture of the lower end\\nof the radius. (R. W. Smith.)\\nThe figures of Plates X.-XYI. show the different levels at which\\nthe fracture occurs, the frequency and character of the comminution,\\nthe differences in dorsal displacement, and the marked dorsal pro-\\njection of the first row of the carpus in one. Plate XVII., fig. 1, shows\\narrest of growth after fracture at the age of twelve years, the patient\\nbeing nineteen years old when the picture was taken. Plate XVIII.\\nshows the normal wrist in the adult male and female the notably\\nlower position of the articular surface of the radius as compared with\\nthat of the ulna in the female was found in most of the female cases\\nexamined.\\nIn specimens obtained after repair has taken place without reduction\\nof the displacement the penetration of the posterior portion appears very\\nmarked (Fig. 147), often more so than it really is. The appearance is\\ndue in part to the formation of callus upon the posterior face of the\\nupper fragment under the periosteum which is stripped up, the peri-\\nosteal bridge which is so often found at one side of a fracture, and\\nin part to condensation of the spongy tissues during repair.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0318.jp2"}, "315": {"fulltext": "FBACTUBES OF THE BONES OF THE FOBEABM. 283\\nAmong the lesions that may be associated with the principal fracture\\nare fracture of the ulna near its lower end, fracture of the styloid\\nprocess of the ulna, rupture of the radio-ulnar and intra-articular liga-\\nments, and perforation of the skin by the ulna, The first is rare, and\\nall the others are the consequence of the momentary prolongation of\\nthe action or variation in the degree of the fracturing force. The\\nRontgen rays show the fracture only occasionally, and then only\\nas the breaking off of the tip of the process, so that I think it probable\\nthat the more extensive injuries heretofore noted were in cases charac-\\nterized by greater causative violence and wider displacement. The\\nmechanism appears to be avulsion through the cord-like lateral liga-\\nment which is attached to its tip.\\nConcerning the condition of the intra-articular fibro-cartilage I can\\nfind but little that is positive, since the only sources of information are\\nthe autopsies of recent fractures. The Rontgen rays give no direct\\ninformation on this point, for the cartilage is transparent to them its\\navulsion from the ulna or radius seems inevitable when the lower end\\nof the radius is markedly displaced.\\nAlthough much stress has been laid by some upon the supposed\\nrupture of the internal lateral ligament, fresh specimens and experiment\\nupon the cadaver give no ground for the belief that it occurs except in\\ncases with marked displacement. The fact that the end of the ulna is\\nprominent and that the finger can be pressed in on the side below it\\nmuch more deeply than in a normal joint can be explained by the\\nascent of the carpus, which would draw the ligament to a more trans-\\nverse position.\\nI believe that in the severer cases the tendon of the extensor carpi\\nulnaris is torn out of its sheath and displaced outwardly from the ulna,\\nfor I have noted in such cases the absence of the resistance which the\\ntendon normally offers to the finger close below the joint.\\nI have not met with the record of any case in which the radius pro-\\njected through the skin, except after separation of the epiphysis, but I\\nhave seen fractures compound on the radial side.\\nAssociated fracture of the scaphoid (Rutherford) and of the semi-\\nlunar (Hunt) and dislocation of the semilunar (Cameron) have been\\nreported. (See Fractures of the Carpus for similar injuries produced\\nexperimentally.)\\nCause. The cause of Colles s fracture is usually a fall upon the palm\\nof the hand, and in the great majority of cases the fall is only to the\\nground while walking. This is true of almost all cases in which the\\npatients are somewhat advanced in life in the younger ones the vio-\\nlence is usually greater, as a fall from a height.\\nThe mechanism by which the fracture is produced has been almost\\nfrom the very beginning and still is the subject of much discussion.\\nThree theories have been advanced: 1. Fracture by splitting or crush-\\ning the cancellous tissue is crushed or comminuted between the carpus\\nand the diaphysis. 2. Fracture as in other bones by decomposition of\\nthe force and yielding at the weakest point. 3. Fracture by cross-\\nstrain exerted through the anterior ligament in exaggerated and forced\\ndorsal flexion (hyperextension) of the hand. I believe that almost all", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0319.jp2"}, "316": {"fulltext": "284 FRACTURES.\\nthese fractures are produced according to one or the other of the first\\ntwo ways, and that the third is rarely seen.\\nIn the first the weight of the body is received upon the ball of the\\nhand the carpus directly in the line of the long axis of the radius,\\nand the inner end of the scaphoid or the semilunar splits the end of\\nthe radius like a wedge. This is shown by many specimens and appears\\nto be especially frequent in the elderly.\\nIn the second the line of the force is slightly inclined from the long\\naxis of the radius, making an angle open anteriorly. The arm is out-\\nstretched and not directly in the line of the fall. The force is decom-\\nposed as usual, part being taken up by the resistance of the shaft in the\\nlong axis, and part acting transversely to break the. bone. The back-\\nward displacement and tilting of the lower fragment indicate the direc-\\ntion of this component. The objection sometimes urged that under\\nsuch circumstances the bone should always break (as it sometimes does)\\nat a higher point where it is smaller and the leverage presumably\\ngreater can only be met at present by throwing the burden of proof\\nupon the objectors. It seems certain that this is the way in which the\\nviolence is received in a large proportion of the cases. Hennequin\\nfinds an explanation of the seat of fracture in the position and arrange-\\nment of the interosseous ligament the fibres of which run obliquely\\ndownward from the radius to the ulna, the lowest ones leaving the\\nradius a short distance above its lower end consequently a force\\nreceived upon the lower end of the radius (through the carpus) is\\ntransmitted not directly through its shaft and head to the humerus,\\nbut through the fibres of the interosseous ligament to the ulna and\\nthence to the humerus. This, he thinks, makes the lower end of the\\nradius the weakest part of the intermediate segment, and therefore the\\npart most easily broken.\\nAccording to the third theory a cross-strain is exerted upon the end\\nof the bone through the anterior ligament of the wrist the force is\\nthought to be received upon the palm of the extended hand at a point\\nthat lies posterior to the posterior border of the end of the radius, the\\nhand is bent back, the ligament is put upon the stretch, and the bone\\nis broken by avulsion. The theory seems to have originated in experi-\\nments upon the cadaver. The earliest recorded experiments in this\\ndirection were those already alluded to which were made by Sir Astley\\nCooper in 1833, but not published until several years afterward the\\nearliest publication appears to have been by Bouchet 2 in 1834. The\\nexperiment may produce a transverse fracture within a short distance of\\nthe articular surface of the radius, but quite as often it causes rupture\\nof the anterior ligament and even dislocation or fracture of one or\\nmore of the carpal bones. There is no doubt, therefore, that the frac-\\nture can be produced in this way, and there are a few clinical cases in\\nwhich this was apparently the mode of production. But, with the\\nexception of these few cases, in which the mode of action of the vio-\\nlence was distinctly exceptional, there is nothing but the experiments\\nto support the theory. In other clinical cases the same movement has\\n1 Hennequin Bevue de Ckirurgie, July, 1S94.\\n2 Bouchet These sur les Luxations du Poignet. Quoted by Malgaigne.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0320.jp2"}, "317": {"fulltext": "FEACTUEES OF THE BONES OF THE FOREARM.\\n285\\nproduced dislocation of the semilunar or fracture of the scaphoid or\\nsemilunar.\\nThe violence in a fall is not usually received at a point on the palm\\nof the hand posterior to the line of the radius it is received at the\\nbase of the thumb, at a point corresponding to the trapezium. When\\nthe hand is bent backward the motion takes place between the first and\\nsecond rows of the carpus the first row remains in place and the\\nsecond row swings around until it comes almost into contact with the\\nradius, as shown in Fig. 149. This figure represents a section made\\nthrough the radius and the second metacarpal bone and traversing the\\npoint upon the palm which receives the blow in a fall, and as the posi-\\ntion is that of extreme physiological dorsal flexion it is evident from\\nit that no cross-strain can be exerted until after this limit has been\\npassed and the second row of carpal bones have obtained a bearing upon\\nthe radius. Before this can take place the flexor muscles must be\\noverpowered, and that is a fact which I think has not been taken prop-\\nerly into account in reasoning from the results of experiments. The\\nstrain does not come upon the ligament unless the hand is caught under\\nthe body in the fall and bent far back. Ordinarily the hand is not\\nbent back even to a right angle, not even far enough to make the ante-\\nrior ligament of the wrist tense, much less to exert a fracturing strain\\nFig. 149.\\nSection of the long axis of the radius the hand in dorsal flexion. Tr-m, trapezium\\nTr-d, trapezoid.\\nthrough it. Moreover the theory fails to explain the comminution so\\nfrequently seen and fractures above the conjugal cartilage in the young.\\nSymptoms. The symptoms are marked and characteristic, but crep-\\nitus and abnormal mobility, so common in other fractures, are not\\nalways easily recognizable in this. The most striking features of the\\ndeformity are the prominence of the dorsum over the lower fragment\\nand that of the end of the ulna. The former so changes the outline\\nof the forearm and wrist that when viewed from the radial side its\\nappearance is like that represented in Fig. 150, and was aptly com-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0321.jp2"}, "318": {"fulltext": "286\\nFRACTURES.\\npared by Velpeau to the outline of a silver fork, a comparison which\\nhas survived in the name silver-fork fracture, by which it is some-\\ntimes known. The cause of this change in the outline, so far as it is\\ndue to the position of the fragments, is shown in some of the radio-\\ngraphs swelling of the soft parts and even projection of the first row\\nof the carpus accounts for some of it that of the palmar aspect is\\ndue mainly to swelling of the soft parts.\\nThe radiographs show that the characteristic deformity is present\\neven when the displacement of the fragment is slight, and that in\\nFig. 150,\\nDeformity in Colles s fracture.\\ngeneral this displacement is much less than has heretofore been sup-\\nposed.\\nThe prominence of the end of the ulna appears to be due to the\\ndisplacement of the carpus and the fragment of the radius upward\\nand somewhat to the radial side, aided sometimes by avulsion of the\\nstyloid process of the ulna, or, possibly, the equivalent rupture of the\\ninternal lateral ligament. That ascent of the end of the radius is\\nsufficient to produce this prominence is shown by its gradual appear-\\nance in cases of arrest of growth at the lower end of that bone. (See\\nPlate XVII.)\\nIf the surgeon marks the positions of the styloid processes by press-\\ning the end of a linger into the side of the joint below and against the\\nend of each, he will see that that of the radius has risen, so that\\ninstead of being about a quarter of an inch lower (nearer the hand)\\nthan that of the ulna, as it usually is, it has risen to the same level, or\\neven above it.\\nThe swelling upon the anterior surface of the forearm is quite\\nmarked, and is sharply rounded off toward the wrist with deepening\\nof the transverse creases.\\nCrepitus and abnormal mobility can sometimes be obtained by\\ngrasping the lower fragment between the thumb and fingers and mov-\\ning it backward and forward while the forearm is steadied by the\\nother hand.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0322.jp2"}, "319": {"fulltext": "FRACTURES OF THE BONES OF THE FOREARM. 287\\nPressure along the line of fracture on the dorsum of the radius or\\nof the hand upward against the forearm is painful.\\nDiagnosis. The diagnosis is made by recognition of the above signs\\nand symptoms. In difficult cases, fat people and children without\\ndisplacement, it may be made upon the existence of a well-defined\\ntransverse line of tenderness on pressure on the dorsum of the radius,\\ndeepening of the transverse folds on the palmar aspect of the wrist,\\nloss of power in the limb, and history of the case.\\nA sprain or contusion may be mistaken for a fracture if the limb\\nhas been broken previously and has united with deformity, for it will\\npresent many of the physical and functional signs. The question\\ntherefore should always be asked whether the wrist has suffered a pre-\\nvious injury.\\nCourse and Prognosis. Firm union between the fragments may be\\nexpected within a month. The prognosis with reference to deformity\\ndepends, of course, upon the completeness of the reduction and reten-\\ntion. As a rule, permanent deformity after fracture in youth is slight\\nor entirely absent but in adults the case is different, either because\\nthe original displacement is greater, or because crushing and comminu-\\ntion make complete reduction and retention practically impossible.\\nThe prognosis with reference to function is somewhat better, since\\nthe persistence of even marked displacement does not necessarily\\nentail disability. The range of motion at the wrist may be somewhat\\nrestricted, and yet may be wide enough to answer all .purposes, and a\\nchange in the direction of the articular surface is still compatible with\\nfree and painless motion. Rigidity of the wrist and fingers usually\\npersists for some weeks, or even months, and in exceptional cases, in\\nthe old and rheumatic and in those where there has been much inflam-\\nmation of the sheaths of the tendons and of the wrist-joint, it may\\npersist for years. I have seen two cases in which the hand was prac-\\ntically useless a year or two after the receipt of the injury. There\\nwas much deformity in one of them. This rigidity of the fingers is\\ndue in part to their prolonged immobilization and in part possibly to\\ninflammation within the sheaths of their tendons in the forearm.\\nThe possible arrest of the growth of the bone after separation of the\\nepiphysis in the young deserves mention, although it is an exceptional\\nconsequence of the injury. I have seen two such cases. (Plate XVII.)\\nTreatment. Complete reduction of the displacement is, of course,\\nessential to prevent permanent deformity. The ease with which it can\\nbe accomplished varies greatly in different cases. Traction upon the\\nhand with direct pressure upon the fragment is sometimes sufficient to\\ncorrect the dorsal displacement in other cases forcible pressure must\\nbe made, the forearm is grasped with the fingers upon the palmar\\nprominence and the thumbs upon the dorsal one, and the pieces pressed\\ninto line. Occasionally an anaesthetic must be given and the fragment\\nmobilized by moving it forcibly backward and forward and then press-\\ning it into place.\\nIn order to meet the two indications the prevention of posterior\\ndisplacement of the lower fragment and of projection of the end of the\\nulna a great variety of splints have been devised, most of them upon", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0323.jp2"}, "320": {"fulltext": "288\\nFRACTURES.\\nthe theory that the position of the fragment can be controlled by the\\nattitude given to the hand. Thus, palmar flexion of the wrist has\\nbeen employed to prevent backward displacement of the fragment of\\nthe radius, and ulnar flexion to prevent the prominence of the ulna.\\nThe theory is wrong and the results have disappointed. If the dorsal\\ndisplacement has been corrected it has little tendency to recur, and the\\nattitude of the hand is without influence upon it the projection of the\\nend of the ulna cannot be prevented by ulnar flexion of the wrist, for\\nthis movement does not bring back the carpus and the radial fragment\\nto their normal positions.\\nThe facts to be borne in mind are 1. That dorsal prominence of the\\nfragment is to be prevented by correction of the displacement before\\nthe application of a dressing, and its recurrence prevented by direct\\naction upon the fragment, not by indirect action through the hand.\\n2. That some permanent shortening of the radius, especially on its\\nouter side, if its cancellous tissue has been crushed, as is the rule in\\nthe old and frequent in others, is inevitable. 3. That the prominence\\nof the ulna can be prevented only by bringing the fragment of the\\nradius (and thus the carpus) fully back to its normal position a prac-\\ntical impossibility in many cases. Direct lateral pressure upon the\\nsides of the wrist may diminish the prominence in some cases. 4.\\nThat the fingers must be left free in order to avoid the stiffening caused\\nby their confinement.\\nA suitable dressing, therefore, is one which immobilizes the fragment\\nand the carpus in the position given to them and leaves the fingers free\\nto be flexed and extended at will and as the tendency to recurrence of\\nthe dorsal displacement is slight special precautions against it are rarely\\nneeded.\\nSuch a dressing may be made of plaster-of-Paris or wooden splints.\\nThe most convenient attitude is that of partial pronation with the wrist\\nin slight dorsal flexion and the fingers flexed. There should be two\\nsplints, palmar and dorsal, the former extending from a little below\\nthe elbow to the metacarpophalangeal joints, the latter from the same\\nheight to the carpo-metacarpal joints.\\nFig. 151.\\nWooden splints for Colles s fracture.\\nWooden splints (Fig. 151) should be three inches broad and padded,\\nthe padding being a little thicker on the palmar splint at the point cor-\\nresponding to the lower end of the upper fragment, and on the dorsal\\nsplint at the point corresponding to the lower fragment. A roller-\\nbandage placed obliquely at the lower end of the palmar splint makes", "height": "4359", "width": "2514", "jp2-path": "practicaltreati00stim_0324.jp2"}, "321": {"fulltext": "PLATE X.\\nFig. 1. Fracture of Radius; marked Angular Displacement,\\nFig. 2. Recent Colles s Fracture in a Boy 12 years old showing\\nEpiphyses.", "height": "4359", "width": "2514", "jp2-path": "practicaltreati00stim_0325.jp2"}, "322": {"fulltext": "", "height": "4367", "width": "2546", "jp2-path": "practicaltreati00stim_0326.jp2"}, "323": {"fulltext": "PLATE XI.\\nFig. 1. Recent Colles s Fracture; Male, 22 years.\\nSee also Plate XV., Fig. 1.", "height": "4367", "width": "2546", "jp2-path": "practicaltreati00stim_0327.jp2"}, "324": {"fulltext": "", "height": "4390", "width": "2648", "jp2-path": "practicaltreati00stim_0328.jp2"}, "325": {"fulltext": "PLATE XII.\\nFig. 1.\u00e2\u0080\u0094 Recent Colles s Fracture; Comminution; Male, 45 years.\\nFig. 2.\\n\u00e2\u0096\u00a0Recent Colles s Fracture; Comminution\\nSee also Plate XV., Fig. 2.\\nMale, 40 years.", "height": "4390", "width": "2648", "jp2-path": "practicaltreati00stim_0329.jp2"}, "326": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0330.jp2"}, "327": {"fulltext": "PLATE XIII.\\nFig. 1. Recent Colles s Fracture Male, 26 years. Fall from\\nheight of four feet.\\nFig. 2.\u00e2\u0080\u0094 Same as Fig. 1. Side view.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0331.jp2"}, "328": {"fulltext": "", "height": "4335", "width": "2491", "jp2-path": "practicaltreati00stim_0332.jp2"}, "329": {"fulltext": "PLATE XIV.\\nFig. 2.\u00e2\u0080\u0094 Recent Colles s Fracture Male, 56 years.\\nFall from a height.", "height": "4335", "width": "2491", "jp2-path": "practicaltreati00stim_0333.jp2"}, "330": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0334.jp2"}, "331": {"fulltext": "PLATE XV.\\nFig.\\n1. Recent Colles s Fracture; Male, 22 years.\\nSame as Plate XI., Fig. 1.\\nRecent Colles s Fracture Male, 40 years.\\nSame as Plate XII., Fig. 2.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0335.jp2"}, "332": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0336.jp2"}, "333": {"fulltext": "w\\nh\\nPLh", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0337.jp2"}, "334": {"fulltext": "", "height": "4343", "width": "2530", "jp2-path": "practicaltreati00stim_0338.jp2"}, "335": {"fulltext": "PLATE XVII.\\nFig. 1.\u00e2\u0080\u0094 Arrest of Growth of Radius after Colles s Fracture at age of\\n12 years. Present age, 19 years.\\nFig. 2.\u00e2\u0080\u0094 Separation of Radial Epiphysis; Boy, 15 years.", "height": "4343", "width": "2530", "jp2-path": "practicaltreati00stim_0339.jp2"}, "336": {"fulltext": "", "height": "4374", "width": "2545", "jp2-path": "practicaltreati00stim_0340.jp2"}, "337": {"fulltext": "PLATE XVIII.\\nFig. 1.\u00e2\u0080\u0094 Normal Wrist; Adult Male.\\nFig. 2. Normal Wrist; Adult Female. Fracture of Third Metacarpal.", "height": "4374", "width": "2545", "jp2-path": "practicaltreati00stim_0341.jp2"}, "338": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0342.jp2"}, "339": {"fulltext": "FRACTURES OF THE BONES OF THE FOREARM.\\n289\\na convenient rest for the hand, maintains dorsal flexion of the wrist,\\nand permits the fingers to be clasped over it. The splints are secured\\nin place by two adhesive bands, one at each end, and by a roller-\\nbandage.\\nPlaster-of- Paris splints (Fig. 1 52) should be wide enough to cover\\nin the wrist, and the lower end of the palmar one may be conveniently\\nmade into a roll to fill the palm of the hand. The dorsal one may\\nFig. 152.\\nPlaster-of-Paris splints for Colles s fracture.\\nextend upon the back of the hand. They should be secured in place\\nby a roller-bandage, and while the plaster is setting it may be held\\nsnugly against the sides of the wrist so as to keep the ends of the\\nradius and ulna close together. They are especially advantageous in per-\\nmitting daily massage of the parts the dorsal splint is removed and\\nmassage made on the uncovered portion from the beginning, and the\\npalmar one can be removed for the same purpose (the dorsal one being\\nkept in place) after the first week. The patient must be instructed to\\nkeep the fingers flexed when at rest, and to move them frequently.\\nIt is well also to keep the thumb abducted.\\nA strip of adhesive plaster drawn snugly about the limb at the level\\nof the fracture may be used in addition to diminish the ulnar promi-\\nnence in cases with comminution. It has even been employed as the\\nsole dressing.\\nThe question sometimes arises whether the deformity, persisting for\\nsome time after the injury and the result of an error in diagnosis or of\\nfailure of treatment, can be corrected. Among Dupuytren s earliest\\ncases were three of this kind, and he succeeded in overcoming the\\ndeformity by steady forcible traction and pressure upon the fragments\\non the twentieth, twenty-ninth, and thirtieth days after the receipt of\\nthe injury, the patients being respectively sixty-nine, ten, and thirteen\\nyears old. A few cases have been treated by refracture or by incision\\nand osteotomy. I doubt if anything more than an improvement in\\nappearance can be gained thereby the causes of loss of function can-\\nnot be thus removed.\\nB. Fractures at the Wrist Other than Colles s.\\nDr. Rhea Barton, 1 of Philadelphia, described clinically a fracture\\nwhich he said was very common, and which he supposed to be the\\ndetachment of the posterior border of the articular surface of the\\nradius. It does not appear from his paper that he had ever had an\\n1 Barton Medical Examiner, 1838, p. 365.\\n19", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0343.jp2"}, "340": {"fulltext": "290 FRACTURES.\\nopportunity to verify the diagnosis by examination. A few specimens\\nof such a fracture, most of them, I believe, found in the dissecting-\\nroom and without history, are in existence, and the injury is known in\\nAmerica as Barton s fracture. Dr. Agnew 1 figures a specimen in which\\nthe fragment is much larger. It is perhaps hardly worth while to try\\nnow to change this name, but there are three good reasons why the\\ninjury should not be known as Barton s fracture 1st, as a reference to\\nthe original article shows, the injury which Barton described clinically\\nwas not what he supposed it to be anatomically, but was the ordinary\\nColles s fracture 2d, the lesion as he supposed it to be, had been\\nobserved some years before his paper was published, and the specimen\\nwas presented by Lenoir 2 to one of the Paris societies; and, 3d, it\\ndeserves to be classed not as a variety of fracture, but as a complica-\\ntion of dislocation of the carpus backward. In Lenoir s case, which is\\ndescribed as a dislocation by Voillemier and Maigaigne, a narrow frag-\\nment of the posterior articular border had been broken off, remained\\nattached to the capsule, and was displaced backward with the bones of\\nthe wrist. I have seen two such cases.\\nAn analogous case, dislocation of the carpus forward with detachment\\nof the anterior border of the articular end of the radius and fracture\\nof the styloid process, was reported, with the specimen, to the Society\\nAnatomique, by Letenneur. 8 The patient was brought to the Hotel-\\nDieu May 7, 1838, having received this injury and also a fracture of\\nthe scaphoid bone of the other wrist, by falling into a ditch while\\nintoxicated. Mr. Callender 4 refers to a somewhat similar specimen,\\nbut one in which the fragment is much larger, in the following words\\nThe line of fracture is four-tenths of an inch from the end of the\\nradius on the palmar surface, but on the dorsal passed into along the\\nedge of the articular facets.\\nOther irregular fractures, too rare to be classified or systematically\\ndescribed, may be conveniently mentioned here. 1. An oblique frac-\\nture running downward and inward and detaching the styloid process\\nof the radius with more or less of the articular portion the larger the\\nfragment the more closely will the symptoms resemble those of Colles s\\nfracture.\\n2. A condition which is the direct opposite of that constituting\\nColles s fracture the lower fragment is inclined toward the palmar\\nside, and the crushing is also on that side. Mr. Callender 5 reports\\nsuch a case caused by forced flexion of the hand in a fall upon it\\nthere was a well-marked prominence on the dorsum of the forearm\\nabout three-fourths of an inch above the wrist-joint, and opposite it\\non the palmar surface was a considerable depression. The lower frag-\\nment of the radius was inclined at an oblique angle to the palmar sur-\\nface, and projected at the wrist. No crepitus. Reduction could not\\nbe effected. Ten months later the deformity persisted, with good rota-\\n1 Agnew Loc. cit., vol. i. p. 905.\\n2 Lenoir This fact is mentioned by Voillemier, in the Archives Generales deMedecine,\\n1839, vol. vi. p. 402, and by Maigaigne. The Society referred to is probably the Societe\\nAnatomique, but I have failed to find mention of the specimen in its Bulletins.\\n3 Letenneur Bulletins, vol. xiv. p. 162. 4 Callender Loc. cit., p. 291.\\n5 Callender Loc. cit., p. 289.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0344.jp2"}, "341": {"fulltext": "FBACTUBES OF THE BONES OF THE FOBEABM. 291\\ntion, exaggerated flexion, and inability to extend the hand beyond a\\nstraight line with the forearm.\\nCallender mentions also two specimens, one in the museum of West-\\nminster Hospital, the other at St. Bartholomew s, which show the cor-\\nresponding displacement with union. In one the styloid process of\\nthe ulna was broken and the lower fragment of the radius displaced\\nforward and outward, especially in the latter direction, with penetra-\\ntion on the palmar surface, to the depth of more than three-tenths of\\nan inch. In the other the line of fracture is rather more than an inch\\nabove the end of the bone there is a prominent angle on the dorsal\\naspect in the line of the fracture and an elevation of new bone on the\\ncorresponding part of the palmar surface the triangular fibro-cartilage\\nwas almost completely separated from the radius.\\nR. W. Smith 1 describes and figures a similar case, in which also the\\nfracture was caused by a fall upon the back of the hand, and Dr.\\nHamilton thought he also had seen one.\\n3. Longitudinal fracture or fissure of the end of the bone. Dr.\\nBigelow 2 reported one case and referred to a second. There was a star-\\nshaped crack on the articular surface without displacement and slight\\ncorresponding cracks in the shaft for more than an inch above. At\\nfirst there was only lameness at the wrist, but after several days there\\nwere swelling and tenderness, the persistence of which led Dr. Bigelow\\nto make the diagnosis. He had had a similar case two years before,\\nwith the same symptoms, but less extensive injury to the bone.\\nProbably this represents an incomplete Colles s if the violence had\\nbeen greater the fracture would have been the usual one.\\nFracture of the styloid process of the radius alone is rare. In the few\\nI have seen and in reported cases the fragment has been quite large,\\ncomprising also the adjoining part of the bone. Usually the displace-\\nment is slight, but in one case the fragment was drawn upward one\\nand a half inches. Immobilization of the wrist appears to be all that\\nis necessary.\\nOf transverse fracture of the radius just above its carpal surface with\\ndisplacement of the fragment forward, which has already been spoken of\\nas sometimes produced by a fall upon the back of the hand, it needs\\nonly to be said that the diagnosis is made by attention to the position\\nof the styloid process with reference to the carpus and the ulna and by\\nrecognition of the line of limited tenderness if mobility and crepitus\\ncannot be obtained. The treatment should be the same as in Colles s\\nfracture, except that the position of the pads should be changed to\\nmeet the different displacements. The subject has been treated in detail\\nby Dr. J. B. Roberts in Annals of Surgery, January, 1897.\\nFracture of the styloid process of the ulna is sometimes observed sepa-\\nrately as the result of direct violence. In addition to the usual symp-\\ntoms of pain and swelling, mobility of the process could probably be\\nrecognized by direct manipulation or by abduction of the hand. Dr.\\nAgnew says some deformity is likely to remain, and that in the only\\ncase he has seen the union was fibrous. He advises treatment upon an\\n1 E. W. Smith Loc. cit., p. 162.\\n2 Bigelow Boston Med. and Suvg. Journal, 1858, vol. lviii. p. 99.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0345.jp2"}, "342": {"fulltext": "292 FRACTURES.\\nanterior splint with the hand inclined toward the ulnar side and in\\ndorsal flexion, so as to relax the extensor carpi ulnaris.\\nFracture of both bones near the wrist is occasionally seen. The diag-\\nnosis is made by recognition of the abnormal mobility of the fragments.\\nTreatment as in Colles s fracture.\\nIn compound fractures every effort should be made to avoid ampu-\\ntation. Good results have been obtained even by excision of the lower\\nend of the ulna alone or of both bones.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0346.jp2"}, "343": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0347.jp2"}, "344": {"fulltext": "PLATE XIX.\\nFig. 1. Fracture of Carpal Scaphoid.\\nFig. 2. Separation of Lower Epiphysis of Femur; Displacement forward\\nwith Rotation about the Transverse Axis.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0348.jp2"}, "345": {"fulltext": "CHAPTEK XXI.\\nFRACTURES OF THE CARPUS AND HAND.\\nFractures of the Carpus, of the Metacarpal Bones, of the Phalanges.\\n1. FRACTURES OF THE CARPAL BONES. 1\\nSimple fractures of the carpal bones appear to be very rare. Only\\na few cases have been reported in which the nature of the injury was\\nshown by direct examination, and I have met with only one case in\\nwhich the diagnosis was made during life. A few compound fractures\\nhave been reported. As the symptoms are very obscure it is possible\\nthat the injury may be more common than is supposed, and may fre-\\nquently pass unrecognized. The number, size, and relations of the bones\\nare such that they can be broken only by direct violence, as a blow, the\\npassage of a wheel, or a fall upon the hand, or by traction (avulsion)\\nin forced dorsal flexion or displacement. I presented to the New York\\nSurgical Society in 1891 a case of fracture of the scaphoid by dorsal\\nflexion associated with compound laceration of the anterior carpo-radial\\nligament and backward dislocation of the carpus. It occasionally hap-\\npens in experimental fracture of the lower end of the radius that the\\nscaphoid or semilunar is broken, and the same complication has been\\nobserved clinically. I have seen two cases, several weeks after the\\nreceipt of the injury one is shown in Plate XIX., fig. 1. In each\\nthe region of the scaphoid was thickened, and the motions of the wrist\\ndiminished. One had been supposed to be a Colles s fracture.\\nThe only symptom which could make the diagnosis possible is crepi-\\ntus, and it might be difficult to determine whether this has its origin\\nin the carpus or in one of the adjoining bones.\\nTreatment. The treatment would consist in immobilization of the\\nwrist for two or three weeks, and it is probable that some stiffness of\\nthe joint would result. In compound cases it seems probable that\\nextirpation of the broken bone would give a better functional result\\nthan its conservation would even if suppuration was avoided.\\n2. FRACTURES OF THE METACARPAL BONES.\\nWhile simple fracture of a metacarpal bone is not a very common\\naccident, still it is not so rare as some authors have inferred from hos-\\npital statistics. Malgaigne found 16 cases in a total of 2377 fractures\\nof all kinds treated at the Hotel-Dieu, a percentage of 0.67 Polaillon\\n1 See experiments by Daillez, Journ. des Sc. Med. de Lille, February 13, 1891, and cases\\nby Berard, Diet, en 30 Vols., art. Main, p. 524 Malgaigne Letenneur, Bull, de la Soc.\\nAnatomique, vol. xiv. p. 162 Polaillon, Diet. Encyclopedique, art. Main, p. 50 Hunt.\\nAnnals of Anatomy and Surgery, Marcb, 1881, p. 110; Butherford, Glasgow Medical\\nJournal, April, 1891 Fortunet, Lyon Medical, July 1, 1888.\\n293", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0349.jp2"}, "346": {"fulltext": "294 FRACTURES.\\n64 oases in a total of 5517 fractures treated in the Paris hospitals during\\nthe years 1861-63, a percentage of 1.16. Of Polaillon s 64 cases,\\n57 were men, only two were old, and none were infants.\\nThe third and fourth are most frequently broken, the first and fifth\\nleast. Simultaneous fracture of two or more is frequent when the\\ninjury is compound.\\nA very few cases of probable separation of the distal epiphysis have\\nbeen recorded, one by Malgaigne, one by Hamilton, and one quoted\\nby Polaillon from a thesis by Pichon, the ages being nine, eight, and\\ntwelve years respectively. There was failure of union in Malgaigne s\\ncase, but without disturbance of function when last seen, thirteen years\\nafter the injury. Bennett 1 has described a variety of fracture of the\\nbase of the first metacarpal, an oblique fracture by which the palmar\\nhalf of this end is separated and the remainder is displaced more or\\nless backward, so that at first sight the injury appears to be a subluxa-\\ntion. He collected nine examples. The usual displacement is angu-\\nlar, the apex of the angle being directed backward or forward, and at\\nthe same time the fragments may override longitudinally.\\nCause. The cause may be direct or indirect violence. When direct\\nit is a blow upon the back or even the palm of the hand, a fall or\\nblow upon its side, or a crushing force, the hand being caught between\\ntwo solid bodies. The first, second, and fifth metacarpals are the ones\\nmost frequently broken by direct violence.\\nThe commonest indirect cause is violence received upon the distal\\nend of the bone in the direction of its long axis, by which its normal\\ncurve is exaggerated and fracture produced, as in a fall upon the\\nknuckles or a blow with the fist. Lonsdale reported a case in which\\nfracture of the third metacarpal was caused by a fall upon the end of\\nthe outstretched middle finger. In a case reported by Dupuytren, the\\nthird metacarpal bone was broken by being bent backward in a trial\\nof strength, the contestants trying to force each other s wrist back\\nwith their fingers interlocked. Velpeau saw the same bone broken by\\ntraction upon the index- and middle fingers with some twisting.\\nSymptoms. The symptoms are the deformity due to the displace-\\nment of the distal fragment, abnormal mobility, crepitus, pain, and\\ninability to use the fingers. The deformity is usually slight and may\\nbe wholly masked by the swelling abnormal mobility and crepitus\\nmay be found by flexing and extending the corresponding finger and\\nat the same time making pressure upon the palm at the supposed seat\\nof fracture, so as to make the fragments prominent behind. The pain\\ncan be suddenly and sharply increased by pressing the finger toward\\nthe carpus.\\nThe course of the fracture is usually simple, and ends in consolida-\\ntion in the course of three or four weeks. The complications which\\noccurred in the eighty-one cases collected by Polaillon were inflamma-\\ntion of the carpo-metacarpal joint, union with marked displacement,\\nfusion of adjoining bones when both were broken, and deviation of\\nthe extensor tendons by a voluminous callus in one each, and failure\\nof union in three. In neglected cases of fracture at or near the knuckle\\n1 Bennett British Medical Journal. July, 1886, p. 13.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0350.jp2"}, "347": {"fulltext": "FRACTURES OF THE CARPUS AND HAND. 295\\nsuppuration is not infrequent and may so extend as to cause marked\\ndisability.\\nTreatment. The first indication is to prevent a too severe inflam-\\nmatory reaction if it threatens, and with this object the hand should\\nbe kept at rest in an elevated position.\\nIf there is no displacement or tendency thereto, a simple immobil-\\nizing dressing of cotton, bound on snugly with a roller-bandage, is suf-\\nficient, the fingers being left free to prevent their stiffening.\\nA method that has long found favor is to fill the palm with a mass\\nof tightly packed cotton or some similar substance, or a ball, over\\nwhich the fingers are closed and fastened down with a bandage or\\nadhesive plaster. The flexion of the finger over the firm mass tends\\nto draw the knuckle downward, and thus prevent shortening. The\\nsupport furnished by the adjoining bones is an additional aid against\\ndisplacement, and the back of the hand can be left partly uncovered\\nfor inspection.\\nIn fracture of the third and fourth metacarpals the hand may be\\nbound upon a dorsal or palmar longitudinal splint suitably padded and\\nfastened with a roller, but this plan is unsuited to fractures of the\\nsecond or fifth because the circular compression exerted by the bandage\\ntends to cause lateral displacement.\\nIf continuous traction seems necessary to overcome a tendency to\\ndisplacement the finger may be bound to the adjoining ones for a few\\ndays, but it is important that immobilization of the fingers, especially\\nin the extended position, should be avoided or made as brief as pos-\\nsible.\\n3. FRACTURES OF THE PHALANGES.\\nThese fractures are usually due to direct violence, and in conse-\\nquence are frequently compound or at least accompanied by laceration\\nor bruising of the soft parts. A few cases have been reported of frac-\\nture by indirect violence, as in a fall or blow upon the end of the\\nfinger, or by having the finger caught and fixed while the hand con-\\ntinued to move.\\nThe proximal phalanx is the one most frequently broken, the ter-\\nminal phalanx most rarely.\\nThe symptoms upon which the diagnosis is made in simple fractures\\nare mobility and crepitus.\\nThe progress of the case in simple fracture is toward prompt repair\\nin compound fractures the suppuration is apt to be prolonged, and\\nnecrosis of splinters and even of one of the principal fragments is not\\nuncommon.\\nA well-established rule of treatment of injuries of the hand is to\\nsave everything that can be saved, but it needs limitation in compound\\nfractures of the fingers. While it is desirable to save the thumb or\\nany part of it, even at the price of anchylosis of both the joints, the\\nsame value does not attach to the fingers, and a rigid deformed finger\\nthat has been saved with much difficulty is often a source of so much\\ninconvenience that the patient subsequently seeks relief in amputation.\\nIt is better that members so injured that rigidity will probably result", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0351.jp2"}, "348": {"fulltext": "296 FRACTURES.\\nshould be removed at first, for the attempt to save them cannot be\\nmade without incurring certain risks, prolonged suppuration, phlegmon\\nof the forearm, tetanus, which, although somewhat remote, should not\\nbe lost sight of.\\nIn the treatment of simple fracture the usual indication to prevent\\ndisplacement is habitually met by means of a moulded palmar splint\\nmade of pasteboard, felt, or gutta-percha to which the finger, slightly\\nflexed, is made fast. This answers very well for the terminal and\\nmiddle phalanges, but it does not support the proximal one sufficiently.\\nSometimes a straight splint is used, sometimes a plaster-of-Paris\\nbandage.\\nA common displacement, important to be guarded against, is an\\nangular one with the apex directed forward and caused, I think, by\\nthe action of the interosseous muscles. The persistence of this dis-\\nplacement constitutes a serious inconvenience, for it limits flexion of\\nthe metacarpo-phalangeal joint and creates a prominence upon the\\npalmar aspect of the phalanx, the skin covering which may become so\\nsensitive that a firm grasp cannot be taken of any hard object.\\nAs a palmar splint does not entirely prevent this displacement I\\nprefer to close the hand upon some firm cylindrical body, a roller-ban-\\ndage for example, and fasten the fingers down with strips of adhesive\\nplaster applied longitudinally along the back of the hand, the fingers,\\nand the front of the forearm, and additionally secured with a few turns\\nof a bandage. The roll must be large enough to give ample support,\\nand by passing the finger along the dorsum of the phalanx the occur-\\nrence of displacement can be recognized. It will be remembered that\\nthe tendon of each extensor muscle is attached to the base of the prox-\\nimal phalanx by a short band which limits the action of the muscle to\\nthat phalanx, and that the extension of the middle and distal pha-\\nlanges is accomplished by the interossei, which also flex the metacarpo-\\nphalangeal joint and are relaxed when the fingers are closed. The\\ntendency to overriding is thus effectively opposed by this position, and\\nthe displacement which then most needs to be guarded against is the\\none also that is most readily detected, angular displacement with the\\nangle directed backward.\\nSupport that may be sufficient in some cases can be readily obtained\\nby binding the broken finger to the adjoining ones and supporting both\\nor all three upon a common splint.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0352.jp2"}, "349": {"fulltext": "CHAPTER XXII.\\nFRACTURES OF THE PELVIS.\\nFractures of the Ring of the Pelvis, Sacrum, Coccyx, Ilium, Ischium, Pubis,\\nRim of the Acetabulum.\\nFollowing well-founded custom I group in one section all fractures\\nwhich break the continuity of the ring of the pelvis and consider sepa-\\nrately fractures of the individual bones which do not break the con-\\ntinuity of the ring.\\n1. FRACTURES OF THE RING OF THE PELVIS.\\nThe most frequent cause of this lesion is the passage of the wheel of\\na heavily laden wagon across the thigh and hypogastrium among the\\nothers are falls upon the feet or the buttocks, the caving in of an\\nembankment, and crushing between the buffers of railway cars or\\nother heavy moving objects. The position and the number of the frac-\\ntures vary with the degree of the violence and the portion of the ring\\nupon which it is received. When it falls upon the symphysis and is\\ndirected backward the arch yields at its weakest point, and the line of\\nfracture passes through the horizontal and descending branches of the\\npubis, sometimes on one side alone, sometimes on both sides. If the\\nforce then continues to act it presses the sides apart, and either breaks\\nthe sacrum vertically (by avulsion) or ruptures the ligaments of the\\nsacro-iliac synchondrosis, or breaks the ilium into the synchondrosis or\\ninto the sacro-sciatic notch and it does this sometimes also on one side\\nalone, and sometimes on both.\\nWhen the violence is received upon the side of the pelvis, or the\\ngreat trochanter, or even upon the foot, it may cause what Malgaigne\\ndescribed as double vertical fracture of the pelvis, or fracture of the\\nacetabulum to a variable extent, and in one case a fall upon the foot\\ncaused dislocation of the entire os innominatum, separating it cleanly\\nat the symphysis pubis and sacro-iliac joint and forcing it upward. In\\ndouble vertical fracture the anterior fracture occupies the same position\\nas when the force has been received upon the symphysis, it crosses the\\npubis the posterior one is usually entirely within the ilium and behind\\nthe acetabulum. In fracture of the acetabulum, which can be caused\\nonly by violence transmitted through the femur, the bone may be simply\\nfissured, or the head of the femur may be driven entirely through into\\nthe cavity of the pelvis. In the slighter cases the continuity of the\\npelvic ring is not broken, but in the more extensive ones it is. In\\nyoung people the lines of fracture may follow those of the develop-\\nmental division of the bone into three.\\n297", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0353.jp2"}, "350": {"fulltext": "298 FRACTURES.\\nThe displacements are seldom great, but complications are numerous\\nand serious. The most frequent is rupture of the urethra, usually in\\nits membranous portion among the others are rupture of the bladder\\nand laceration of the iliac veins or the external iliac artery. Rupture\\nof the bladder may be intra- or extra-peritoneal; in some cases it-\\nappears to have been caused by the direct pressure upon the bladder of\\nthe object which caused the fracture, in others by a splinter or the dis-\\nplaced fragment. The other two lesions mentioned are due to the\\ndisplacements. The separation of the pubes tears the urethra across\\nat or near the triangular ligament, and the projecting edge of the pos-\\nterior line of fracture lacerates one of the iliac veins, or the edge of\\nthe anterior one tears the external iliac vein or artery.\\nIn a case referred to briefly by Legros Clark l there were several\\nfractures, and separation of the sacro-iliac synchondrosis on each side\\nand of the pubic symphysis to the extent of four inches. The rectum\\nwas ruptured and feces were extravasated into the pelvis the bladder\\nwas ruptured and the urethra torn completely from the prostate gland.\\nThe varieties and the symptoms, which vary notably with them,\\nrequire separate mention.\\nSeparation of the symphysis pubis may be produced by external vio-\\nlence acting directly upon the pubic arch or through forced abduction\\nof the thighs, or by the descent of the foetus through the superior\\nstrait in parturition. Malgaigne collected seventeen cases of the latter,\\nmost of them occurring in primiparse, and most by the unaided action\\nof the patient s muscles in a few cases the forceps was used. Usually\\nthe separation takes place with a distinct cracking sound, and the gap\\ncan be felt with the finger, and in one or two cases the fracture has\\nbeen made compound by simultaneous laceration of the soft parts.\\nThe gap is the chief diagnostic symptom. The scanty information\\npossessed upon the subject indicates that, in the traumatic cases at\\nleast, the separation takes place not through the cartilage, but between\\nthe cartilage and the bone.\\nThe traumatic cases are no less numerous and more varied in their\\ndetails, although in a large proportion of them the force seems to have\\nbeen exerted through the adductor muscles of the thighs. In two cases\\nquoted by Malgaigne, in a third reported by Weber, 2 and in a fourth\\nby Earle, 3 the patient was on horseback and received the injury either\\nby being thrown forward upon the withers, or first to one side and then\\nto the other, or by the muscular effort made to keep his seat. In one\\nof Malgaigne s cases the results were an immediate hernia, rupture of\\nthe perineum with a separation at the symphysis that would admit the\\nhand, and pain at each sacro-iliac synchondrosis. The patient recov-\\nered in three and a half months, the treatment consisting of a bandage\\ndrawn tightly about the pelvis, with the limbs resting upon a double\\ninclined plane.\\nIn Earle s case there were collapse, severe pain, flattening of the\\npubes, and free bleeding from the anus. An incision in the perineum\\n1 Legros Clark Diagnosis of Visceral Lesions, p. 339.\\n2 Weber Gaz. Med. de Strasbourg, 1872.\\n3 Earle Med. Chir. Trans., 1835, vol. xix. p. 257.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0354.jp2"}, "351": {"fulltext": "FBACTUBES OF THE PELVIS. 299\\ngave exit to blood and urine. The patient survived for only forty\\nhours, and the autopsy showed a separation of three inches at the\\nsymphysis, the left sacro-iliac synchondrosis gaping one inch, and the\\nprostate torn completely away from the bladder and hanging down in\\na cavity filled with clot. The patient was between sixty and seventy\\nyears of age.\\nIn another singular case quoted by Malgaigne the patient, a lad\\neighteen years old, was learning to be a dancer. His teacher made him\\nlie upon his back on the floor with his thighs flexed, and then stand-\\ning upon him with one foot on each knee, sought to force the thighs\\noutward. It caused the bones to separate at the symphysis to the\\nextent of half a finger-breadth.\\nSeparation in Front and Behind. In one of Mr. Earle s l cases there\\nwas complete separation of the left os innominatum, both in front and\\nbehind the bone was forced up to a considerable extent, and the com-\\nmon iliac vein torn across. The patient was a young man, and received\\nthe injury by jumping from a third story he landed upon the left foot,\\ncausing also a compound comminuted fracture of the calcaneum and\\nastragalus.\\nSimilar cases were collected by Malgaigne, and two have been pub-\\nlished by Salleron. 2 The injury has been caused by a fall upon one\\nfoot or upon the side of the pelvis, or by the pressure of a heavy\\nweight upon the front of the pelvis. The characteristic symptom is\\nthe elevation of the corresponding half of the pelvis with absence of\\nthe crepitus which is usually present in double vertical fracture. Sal-\\nleron was able to reduce the dislocation in his cases, and both recovered,\\nbut, as a rule, the prognosis is extremely grave.\\nSeparation of the Sacro-iliac Synchondrosis. Simple separation of this\\njoint is very rare. Malgaigne 3 quotes one case of it, and four others\\nin which there was in addition fracture of the ilium. I have seen one\\nwell-marked case. The lesion is said also to have been produced during\\nlabor.\\nThe diagnosis is made by recognition of the displacement, which is\\nbackward and outward.\\nSeparation of all Three Joints. A few cases have been reported as\\nsuch, but in most there has been also fracture at one or more points,\\nand the separation of one or both of the sacro-iliac synchondroses has\\nbeen only the gaping of the joint due to the lateral separation of the\\ntwo halves of the pelvis and not a real displacement. Malgaigne\\nquotes briefly five cases, in four of which there were associated frac-\\ntures of the pelvic bones. Dolbeau, 4 Dubrueil, 5 and Pollock 6 have\\nsince reported others. DubrueiPs is the only one in which there seems\\nto have been actual displacement at all three points, and even in it\\nthere was also a slight fracture. The patient was run over by a w T agon.\\nThere was separation of two and a half inches at the symphysis pubis\\nand gaping of both sacro-iliac synchondroses. The sacrum was dis-\\n1 Earle: Loc. cit., p. 261, Case 5.\\n2 Salleron Archives Gen. de Med. 1871, vol. ii. p. 34, Cases 1 and 2.\\n3 Malgaigne Loc. cit., vol. ii. p. 777.\\n4 Dolbeau Gazette des Hopitaux, 1868. p. 194. 5 Dubrueil Id., 1871, p. 413.\\n6 Pollock The Lancet, 1872, vol. ii. p. 409.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0355.jp2"}, "352": {"fulltext": "300 FRACTURES.\\nplaced forward, projecting at the level of the superior strait two centi-\\nmetres in front of the right ilium and one and a half in front of the\\nleft. There was a fracture at the junction of the right ischium and\\npubis, and partial fracture of the body of the right pubis.\\nIn each case the injury was caused by extreme violence acting\\ndirectly upon the pelvis, the passage of a heavy wagon, the fall of a\\nheavy object. All terminated fatally.\\nFracture of the pubic portion of the pelvic ring, which is the most com-\\nmon of all, passes usually through the horizontal ramus just in front\\nof the ilio-pectineal eminence and through the descending ramus near\\nits junction with the ischium. The fracture may be oblique or trans-\\nverse, may be double (of one or both pubic bones), or may be associated\\nwith separation of the symphysis or with other fractures of the lateral\\nor posterior portions of the pelvis. As has been already mentioned,\\nrupture of the ligaments of one or both sacro-iliac synchondroses with\\ngaping of the joint is a frequent accompaniment when the action of\\nthe fracturing force is momentarily prolonged.\\nThe displacement is sometimes so marked that it can be easily recog-\\nnized by the eye in other cases the diagnosis can only be made after\\npalpation of the outline of the bone, which is quite accessible to the\\ntouch.\\nInterference w 7 ith the voiding of the urine, either by rupture of the\\nurethra or by pressure upon it, is a frequent complication. Injury to\\nthe urethra takes place usually in the membranous portion. The\\nbladder, too, has been sometimes torn by a fragment or ruptured by\\npressure.\\nThe following are the more noteworthy complications and varieties\\nthat have been recorded. A man, twenty years old, was run over by\\na railway train and received a fracture of the crest of the right ilium,\\nthe ramus of the left pubis, and of the right pubis close to its junc-\\ntion with the iliac portion of the bone, the sharp end of this fracture\\nhad entirely divided the external iliac artery. A man, forty-three\\nyears old, w^as run over by a wagon, w r as brought to the hospital insen-\\nsible, and died in three hours. There was fracture of the ramus and\\nbody of the pubis on both sides, and separation of the sacrum from the\\nleft os innominatum. Fracture of the left ilium, the fracture extend-\\ning across the pectineal line and causing laceration of the left external\\niliac vein. 7 2\\nFracture of the lateral portion of the ring occurs in two principal\\nforms, one in connection with fracture of the pubic portion, the other\\na fracture radiating from the cavity of the acetabulum. The former\\nis the one to which attention w r as first called by Malgaigne under the\\ntitle of double vertical fr acture of the pelvis (multiple fractures, Duplay),\\nand a variety which has been described at much length by Voillemier 3\\nas vertical fracture of the sacrum. The posterior line of fracture lies\\neither in the ilium entirely behind the acetabulum, or in the sacrum,\\nor partly in the ilium or sacrum and partly in the sacro-iliac synchon-\\ndrosis, and sometimes the sacrum is crushed rather than fractured.\\n1 Lancet, 1878, vol. i. p. 347, Case 2. 2 Lancet, Idem, Case 3.\\n3 Voillemier Clinique Ckirurgicale, 1862, p. 77.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0356.jp2"}, "353": {"fulltext": "FBACTUBES OF THE PELVIS.\\n301\\nThe cause apparently may be a force acting in either the antero-\\nposterior or transverse diameter of the pelvis or upward against the\\nDouble vertical fracture of the pelvis united.\\ntuberosity of the ischium. The most prominent symptoms in these\\ncases are in the position of the leg and in the extent to which it can be\\nFig. 154.\\nDouble vertical fracture of the pelvis vertical of sacrum, double of pelvis.\\nmoved. The femur is attached to the portion of bone which is inter-\\nmediate between the two lines of fracture, and as this piece is usually", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0357.jp2"}, "354": {"fulltext": "302 FRACTURES.\\ndisplaced upward and inward there is apparent shortening of the\\nlimb. At the same time the piece is commonly rotated about an\\nantero-posterior axis so that the upper part of the pelvis is broadened\\nand the lower part narrowed. The inability to move the limb is due\\nin part to the lack of a solid support and the fear of pain, and in part\\nperhaps to laceration of the muscles of the iliac fossa. Pain in the\\ndistribution of the obturator nerve is not uncommon. The prognosis\\nis unfavorable (35 deaths in 106 cases, Dreschler) because of the prob-\\nability of associated injuries. It may result in lameness or in a per-\\nmanent change in the shape of the pelvis, which in a woman may have\\nserious consequences if pregnancy should follow.\\nWalther l describes a variation in which the anterior fracture occu-\\npied the body and descending ramus of the pubis, and the second frac-\\nture ran below the anterior superior spine of the ilium to the sacro-\\nsciatic notch in addition the upper fragment of the ilium was split\\nvertically, and the fifth sacral vertebra was broken. The fragment\\nbetween the two principal lines of fracture was displaced inward and\\nhad reunited.\\nThe second form of lateral fracture of the pelvis, radiating fracture\\nof the acetabulum, is produced by violence acting through the femur,\\nand is quite rare, although Dupuytren said he had met with it a num-\\nber of times. The fracture may be no\\nFig. 155. more than a simple fissure, or the head of\\nthe femur may be driven entirely through\\ninto the pelvis. Dr. Agnew refers to a\\npreparation in the collection of Dr. Neill\\nin which the lines of fracture follow those\\nof the embryonal division of the bone\\nthe union is complete, and there is very\\nlittle callus on the articular surface.\\nThe symptoms of the more severe va-\\nriety, that in which the head of the femur\\nis driven more or less completely through\\ninto the pelvis, have varied considerably\\nHead of the femur driven through in the different cases, and the diagnosis has\\nthe acetabulum. not always been made during life. Some-\\ntimes there are outward rotation, fixation,\\nand extreme pain on motion in other cases the movements of the limb\\nare quite free and painless within certain limits. Shortening is slight\\nor absent, the trochanter is sunk, and there is absence of crepitus.\\nInteresting fatal cases have been reported by Drs. Neill, 2 Sands, 3 Law-\\nson, 4 and Holmes. 5\\nA remarkable case, which will serve to illustrate the possibilities of\\nrepair, is one reported by Mr. Moore. 6 A man received a severe injury\\nof the hip, thought to be fracture of the neck of the femur he recov-\\n1 Walther Soc. Anat., October, 1891.\\n2 Neill Transactions of the College of Physicians, Philadelphia, vol. ii. p. 267.\\n3 Sands: New York Medical Eecord, 1877, p. 93.\\n4 Lawson Lancet, 1878, vol. i. p. 382.\\n5 Holmes: British Medical Journal, December 24, 1887.\\n6 Moore Medico-Chirurgical Transactions, vol. xxxiv. p. 107.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0358.jp2"}, "355": {"fulltext": "FRACTURES OF THE PELVIS. 303\\nered and was able to walk with only a slight limp. At the autopsy\\nseveral years afterward the injury was found to have been a fracture\\nof the pubis, ilium, and acetabulum, which allowed the head of the\\nfemur to pass through into the pelvis, the trochanter resting against the\\nacetabulum (Fig. 155).\\nSimilar cases are reported by Lendrick and Morel-Lavellee.\\nVertical fractures of the sacrum are not known except in connection\\nwith fractures of the pelvic ring at other points, as already mentioned.\\nA few cases of very extensive injury have been recorded, extensive\\ncrushing and multiple fractures. All proved fatal.\\nCourse and Prognosis. The course and prognosis in all these cases\\ndepend mainly upon the lesions associated with the fracture. The only\\nadditional point which requires mention is one referred to by Legros\\nClark, the tendency to suppuration in the loose connective tissue\\nbetween the pubes and the bladder, especially after fracture of the\\npubis or separation of the epiphysis. The uncomplicated and simpler\\nforms of fracture tend to easy repair, and even fractures that are very\\nextensive are by no means necessarily fatal, as is proved by many\\nspecimens.\\nDiagnosis. The diagnosis is usually easy, but may be very obscure if\\nthe fracture is limited and without much displacement. The outline\\nof the pubis should be carefully followed with the finger to detect irreg-\\nularity or localized pain, and pressure should be made backward alter-\\nnately with either hand upon the anterior portion of each ilium in the\\nsearch for abnormal mobility and crepitus. In vertical fracture of the\\nsacrum or in separation of the sacro-iliac synchondrosis displacement\\nwill change the position of the posterior spine of the ilium. In double\\nvertical fracture the intermediate portion, which bears the anterior\\nsuperior spine, is usually displaced upward, and the displacement is\\neasy of recognition and can be diminished or perhaps reduced by trac-\\ntion upon the leg. Fissured fracture of the acetabulum would prob-\\nably pass unrecognized, or at the most, be only suspected from the\\nhistory of a fall upon the trochanter, knee, or foot with pain in the\\njoint and the absence of dislocation or of fracture of the femur. Frac-\\nture of the acetabulum with displacement of the head of the femur\\ninto the cavity of the pelvis will probably be recognizable by palpa-\\ntion of the iliac fossa through the anterior abdominal wall or by digital\\nor manual exploration through the rectum, and by the depression of\\nthe trochanter.\\nTreatment. In cases without much displacement rest in bed on the\\nback is all that is required, aided in the multiple forms or in separa-\\ntion at or near the symphysis pubis by a stout girdle drawn snugly\\nabout the pelvis. Reduction of a fragment of the pubis may some-\\ntimes be made by digital pressure, and that of the intermediate frag-\\nment in double fracture by traction upon the limb aided by pressure\\nwith the finger from the vagina or rectum. In compound fractures\\nloose fragments should be removed. Displacement of the head of the\\nfemur through the acetabulum may be corrected by traction upon the limb.\\nTreatment of the complications belongs more properly to the subject\\nof general surgery, but the frequency of laceration of the urethra and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0359.jp2"}, "356": {"fulltext": "304 FRACTURES.\\nthe advantages of its early recognition and treatment are so great that\\nit deserves mention. On the first indication of probable injury to the\\nurethra the catheter should be introduced, and if its passage is pre-\\nvented or even rendered difficult by injury to the urethra, an incision\\nshould be made through the perineum to the injured part cutting upon\\nthe end of the catheter as a guide. I have almost always found the\\nmembranous urethra not only torn across but also so freely separated\\nby laceration of the soft parts amid which it lies that its recognition\\nwas difficult. It is so thin and collapsed and its torn end so shreddy\\nthat it can hardly be distinguished. For this reason it is desirable to\\nmake the incision with the aid only of local anaesthesia cocaine or\\nfreezing in order that the patient may aid the recognition by passing\\nurine. If possible the two torn ends of the urethra should be united\\nby one or two sutures along its roof so as to aid the permanent resto-\\nration of the continuity of the canal and each torn end should be split\\nfor half an inch along the floor so as to avoid the cicatricial narrowing\\nwhich follows circular division.\\nIf the bladder has been ruptured, intra- or extra-peritoneally, supra-\\npubic cystotomy may be needed to evacuate the escaped urine and close\\nthe opening or for drainage of the bladder. Permanent catheteriza-\\ntion through the perineal opening may sometimes take the place of\\nsuprapubic drainage; it is not needed if the bladder is uninjured.\\n2. TRANSVERSE FRACTURE OF THE SACRUM.\\nThis rare injury is produced by blows or falls upon the correspond-\\ning region, and appears in all cases to have occupied the lower half of\\nthe bone and to have been produced by the forcible bending inward of\\nits apex. Its direction is practically transverse. Malgaigne has\\nreported one case of oblique fracture in it the violence was received\\nupon the side of the bone, and there were also two incomplete trans-\\nverse fractures.\\nThe usual displacement is an angular one, the coccyx and lower frag-\\nment being drawn forward so that the apex of the angle is directed\\nbackward at the seat of fracture. The displacement is due in part to\\nthe fracturing force and in part to the action of the attached muscles.\\nIn a case that came under my observation at Belle vue Hospital there\\nwas extensive sloughing over the sacrum and denudation of the bone,\\napparently due to the direct violence that caused the fracture. The\\nsame complication is mentioned in two of the five cases collected by\\nMalgaigne, both terminating fatally.\\nThe symptoms are pain at the seat of fracture, both spontaneous and\\nprovoked by pressure or movements of the trunk, or by the act of defe-\\ncation, or perhaps by the act of coughing the displacement if present\\nand abnormal mobility and crepitus recognized by grasping the lower\\nfragment between the thumb and a finger introduced into the rectum.\\nAgnew l says there will probably be present paralysis of the blad-\\nder and rectum, both of these organs receiving nerves from the sacral\\nplexus, and Lossen 2 says that when there is complete displacement of\\n1 Agnew Surgery, p. 922. 2 Lossen Deutsche Chirurgie, Lief. 65, p. 7.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0360.jp2"}, "357": {"fulltext": "FRACTURES OF THE PELVIS. 305\\nthe fragment paralysis of the lower extremities, bladder, and rectum\\nis never absent, but neither author quotes any cases in support of the\\nstatement. In the one case that has come under my own observation,\\nthere was almost complete paralysis of the lower limbs, bladder, and\\nrectum, which nine months after the accident had been recovered from\\nin great part.\\nIn Bermond s case, quoted by Malgaigne, the fracture was near the\\ncoccyx, and the lower fragment was displaced so far forward that the\\nfinger could not be passed into the rectum until after a female catheter\\nhad been introduced as a guide. The pain was extreme, was relieved\\nby the reduction of the displacement, and returned as soon as the finger\\nwas withdrawn.\\nTreatment. Unless there is marked displacement, no treatment is\\nrequired beyond the use of pads or rings to relieve the lower fragment\\nfrom pressure. In some cases the surgeons have sought to diminish\\nthe pressure by flexing the thighs and supporting them upon pillows\\npiled up under the knees.\\nIn two cases the surgeon has tried to make direct pressure upon the\\nlower fragment by dressings introduced into the rectum. Judes, quoted\\nby Malgaigne, used a cylinder of wood five inches long and one inch in\\ndiameter with graduated compresses outside and a T-bandage to sup-\\nport the whole. Bermond filled the rectum with a bag of lint, which\\nsoothed the patient s pain but had to be removed on the following day\\nto allow the bowels to be emptied. He then used a shirted canula\\nthrough which the gas and feces could be passed at will while the rec-\\ntum was kept distended by the tampon. It was removed temporarily\\non the seventh day, and finally on the nineteenth, when abnormal\\nmobility could no longer be detected.\\n3. FRACTURE OF THE COCCYX.\\nThere is but little definite knowledge concerning this lesion. The\\nfirst mention of it appears to be that of Cloquet in the statement that\\nwhen in old people union has taken place between the different por-\\ntions of the coccyx, and between it and the sacrum, the coccyx might\\nbe broken by a fall upon the buttocks or, as in a case which he had\\nseen, by a kick upon the same part. He refers also to another case in\\nwhich caries of the coccyx followed its fracture, but, as Malgaigne\\nsays, it does not appear that Cloquet verified the fracture. Within a\\nfew years several cases have been published, and it is furthermore pos-\\nsible that some of the cases described as dislocations of the coccyx or\\ncoccygodynia may have been fractures. None of the cases of fracture\\nmentioned have been described with any details, and there is, there-\\nfore, nothing to be said except that the diagnosis must be made as\\nafter fracture of the sacrum, and that probably no treatment would be re-\\nquired except to reduce displacement. (See Dislocations of the Coccyx.)\\nJolly 1 reported a unique case of escape of the lower segment of the\\ncoccyx through the anus ten days after delivery, the bone apparently\\nhaving been broken at that time.\\n1 Jolly Medical Eecord, Dec. 17, 1887.\\n20", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0361.jp2"}, "358": {"fulltext": "306 FRACTURES.\\n4. FRACTURE OF THE ILIUM.\\nFractures of the expanded upper portion of the ilium are compara-\\ntively frequent and vary widely in their position and extent; the\\nmore extensive ones pass transversely or obliquely from before back-\\nward at some distance below the crest and are associated sometimes\\nwith vertical lines which divide the upper fragment into two or more\\nportions. Malgaigne says that when the fracture lies near the crest it\\nbegins commonly at a triangular prominence on the crest near its\\nmiddle, and runs thence backward or forward, or in both directions,\\nfollowing a curved line the concavity of which is directed upward.\\nThe fracture may be limited to a small portion of the rim of the bone,\\nas the anterior superior spinous process or the outer lip of the crest.\\nIn a unique case observed by Hamilton, the posterior superior spinous\\nprocess was broken off by a fall upon the back and Eiedinger and\\nLinhart 1 have shown experimentally that the anterior inferior spinous\\nprocess can be torn off by putting the Y-ligament of the hip-joint\\nupon the stretch. In a case reported in the Bulletins de la Societe\\nAnatomique, 1867, p. 283, the anterior superior and inferior spinous\\nprocesses were broken off while still in the condition of epiphyses by\\nthe passage of a wagon. The patient was fifteen years old.\\nThe displacement is usually slightly outward, and forward when the\\nline of fracture is below the anterior superior spine. Fragments of\\nthe crest alone may be markedly displaced upward, and after fracture of\\nthe anterior superior spine the fragment may be displaced downward.\\nCause. The cause has heretofore been thought to be direct violence\\nexclusively, but Hamilton reported a case of fracture by muscular\\naction separating a piece of the crest three inches long and including\\nthe anterior superior spinous process. Nickerson 2 has reported\\nanother of the anterior superior spine with abstracts of four additional\\ncases, and Whitelocke 3 two others in lads eighteen and nineteen years\\nold while running, and Albertin 4 and Reverdin 5 similar ones.\\nSymptoms. The usual signs of pain and swelling are increased by\\nthe associated bruising of the overlying soft parts abnormal mobility\\nand crepitus can be felt on manipulation at times, but their manifesta-\\ntion depends upon the position of the fragment, the posture of the\\npatient, and the contraction or relaxation of the muscles. In a case\\nunder my care where a large fragment composed of the anterior half\\nof the crest and the adjoining bone had been broken off by a fall,\\nmobility and crepitus would at times disappear entirely, apparently in\\nconsequence of slight changes in the position of the fragment. In\\nseeking for mobility and crepitus the abdominal muscles should be\\nrelaxed by bending the body forward and to one side, and the thighs\\nshould be flexed on the pelvis.\\nThe patient is usually unable to walk, because of pain or of the\\nsense of a lack of support.\\n1 Linhart Langenbeck s Archiv, vol. xx. p. 451.\\n2 Nickerson Deutsche med. Wochenschrift, March 6, 1890.\\n3 Whitelocke Lancet, November 25, 1893.\\nAlbertin La Province Medicale, 1887, p. 741.\\n5 Keverdin Centralblatt fur Chirurgie, 1900, p. 352.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0362.jp2"}, "359": {"fulltext": "FRACTURES OF THE PELVIS. 307\\nCourse. The course is usually a simple one, and the patients are\\nsometimes able to leave their beds in two or three weeks. In some\\nvery exceptional cases where the violence has been extreme fatal\\ninjury has been done to the viscera, such as perforation of the intes-\\ntines by a splinter or laceration of the iliac veins and suppuration\\nhas sometimes taken place.\\nTreatment. The treatment is simple, rest in bed in the position\\nwhich gives most ease and is most favorable to the relaxation of the\\nmuscles which would be likely to cause displacement. The attempts\\nthat have been made in the few recorded cases of fracture of the\\nspinous processes to keep them in place by pressure with pads and\\nbandages have been entirely unsuccessful.\\n5. FRACTURE OF THE ISCHIUM.\\nThis is one of the rarest of the fractures of the pelvis. Malgaigne\\ncollected only six cases, and the list has not been since increased by\\nany reported in detail. In some of the cases almost the entire ischium\\nwas broken off, in others only the tuberosity. Experiment indicates\\nthat the fracture may pass into the cotyloid cavity. In three of Mal-\\ngaigne s cases the cause was a fall upon the buttocks, the fourth was a\\ngunshot fracture, the fifth was caused by an explosion, and the sixth\\nwas in a woman who had recovered from a double vertical fracture\\nof the pelvic ring with a displacement that narrowed the inferior strait\\nso much that two years afterward delivery could be effected only with\\nthe aid of forceps, and the ischium was broken in the effort. In two\\nof the cases the fracture was comminuted, and in one of them also\\ncompound, in the other the scrotum was lacerated and the urethra\\ntorn, presumably by violence received at the same time upon the peri-\\nneum and not by displacement of the bone. In the simple cases\\nthere was little or no displacement in the gunshot fracture the frag-\\nment was displaced downward more than two inches by the contraction\\nof the hamstring muscles. The displacement persisted, but does not\\nappear to have interfered materially with the movements of the limb.\\nAll except the sixth recovered.\\nMobility and crepitus can be recognized by manipulation of the\\nbone, preferably with the ringer in the rectum or vagina. The severity\\nof the pain depends upon the violence and the associated injuries and\\nmakes it difficult for the patient to walk.\\nNo treatment is required except rest in bed with pillows or air-\\ncushions so arranged as to prevent pressure upon the broken bone. If\\nthe patient lies upon the side the knees may be kept flexed to relax\\nthe muscles which are attached to the ischium.\\n6. FRACTURE OF THE PUBIS.\\nIn almost all cases of its fracture the pubis is so broken that the\\ncontinuity of the pelvic ring is destroyed the cases in which only one\\nramus has been broken or in which a lateral fragment has been broken\\noff are extremely rare, and consequently there is but little to be added", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0363.jp2"}, "360": {"fulltext": "308 FRACTURES.\\nto what has been already said in the first portion of this chapter. The\\nonly cases of this limited fracture of which I have any knowledge are\\none reported by Nivet and one by Cappelletti. In Nivet s l case, the\\naccount of which is not quite clear, there appears to have been a double\\nfracture of the descending ramus, the intermediate piece was displaced\\nforward and had torn the skin of the groin. In Cappelletti s 2 case a\\nman jumped from a carriage, alighting upon his feet with one limb\\nwidely abducted. Six months afterward there was still some swelling\\nat the anterior superior part of the right thigh, and a fragment of bone\\nabout two and a half inches long, and as large as the finger could be\\nfelt there. Cappelletti was convinced that this fragment was a portion\\nof the descending branch of the pubis and the ascending branch of the\\nischium detached by muscular action. The pelvis appeared to be defec-\\ntive anteriorly at the point corresponding to the supposed original seat\\nof the fragment, there was acute pain on pressure at the swelling and\\nat the tuberosity of the ischium, the patient walked limping and with\\npain, and the pain was increased by abduction of the limb.\\n7. FRACTURE OF THE RIM OF THE ACETABULUM.\\nThis is a lesion which sometimes accompanies partial or complete\\ndislocation of the femur upon the pelvis.\\nThe upper and posterior portion of the rim is the part most fre-\\nquently broken, and the accompanying dislocation is commonly back-\\nward. In one of JVFTyer s cases 3 there were two fragments, and in\\nMaisonneuve s case three, but in this latter the fracture was much\\nmore extensive. In another case (M Tyer) the fracture had united\\nwith but slight displacement, and the ligamentum teres was untorn.\\nThe symptoms, Avhen the case first comes under observation, are those\\nof simple dislocation backward, and the complication of fracture is\\nrecognizable only by slight crepitus felt on manipulation or during\\nreduction and by the easy recurrence of the dislocation after reduction.\\nSometimes the head of the bone slips out of its socket again as soon as\\nthe traction ceases, in other cases only after the lapse of a few hours or\\non movement of the limb or body.\\nMalgaigne calls attention to the necessity of making sure of the\\nexistence of a dislocation, and of not depending for the diagnosis solely\\nupon crepitus and easy recurrence of the displacement, signs which\\nmay accompany fracture of the neck of the femur. The prominent\\ndistinction between dislocation backward and fracture of the neck of\\nthe femur is in the position of the limb, which is flexed upon the\\npelvis and rotated inward in the former, and usually straight and\\nrotated outward in the latter, but this alone should not be depended\\nupon, the position of the head of the bone should be made out.\\nThe treatment should be directed to the prevention of a recurrence\\nof the dislocation after its reduction. Continuous traction gave me a\\ngood result in one case, but theoretically abduction and extension of the\\nlimb should be maintained, as the attitude most opposed to recurrence.\\n1 Nivet Bull, de la Societe Anatomique, 1837, p. 194.\\n2 Cappelletti Banking s Abstract, 1848, vol. viii. p. 91.\\n3 M Tyer Glasgow Medical Journal, 1830.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0364.jp2"}, "361": {"fulltext": "CHAPTER XXIII.\\nFRACTURES OF THE FEMUR.\\nFractures of the upper end Head, neck, separation of epiphysis, through the\\ntrochanter and neck, great trochanter, trochanter minor. Of the shaft. Of\\nthe lower end Intercondyloid, separation of epiphysis, either condyle.\\nThe table in Chapter I. shows 232 fractures of the femur in a total\\nof 6899 cases, 3.36 per cent. Those of the London Hospital for\\ntwenty-six years show 3243 in a total of 51,938, about 6 per cent.\\nThe Berlin and Halle records, quoted by Gurlt, show in totals of 232\\nand 97 fractures of the thigh, 76 and 21 of the neck of the bone respec-\\ntively. The records of Belle vue Hospital for nine years, collated by\\nDr. F. E. Hyde, 1 contained 302 cases of fracture of the thigh, in which\\nthe position of the fracture was stated, divided as follows: neck 61,\\nupper third (exclusive of neck) 34, middle third 169, lower third 31,\\nof which 7 were of the condyles. Of 236 fractures of the thigh recorded\\nby Hamilton, 84 were of the neck, 30 of the upper third, 86 of the\\nmiddle third, and 36 of the lower third.\\nMalgaigne s analysis of 311 fractures (104 of the neck, 207 of the\\nshaft) according to age and sex is as follows\\nFractures of the Shaft.\\nAge. Male. Female.\\n2 to 20 years 35 12\\n20 40 47 6\\n40 60 43 15\\n60 80 20 29\\n145\\n62 207\\nFractures of the Neck.\\nAge. Male. Female.\\n4 to 50 years 9 5\\n50 60 9 10\\nAbove 60 30 41\\n48 56 104\\n1. FRACTURES AT THE UPPER END OF THE FEMUR.\\nIn this class are included fractures of the head, of the neck of the\\nfemur, separation of the epiphysis, fractures of the great trochanter\\nand separation of its epiphysis, fractures through the trochanter, and\\nfracture of the trochanter minor.\\n1 Hyde New York Medical Eecord, 1875.\\n309", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0365.jp2"}, "362": {"fulltext": "310 FRACTURES.\\nA. Fractures of the Head of the Femur.\\nThe only reported instances of this very rare injury have been\\nobtained in cases in which there was also dislocation backward of the\\nhead of the bone. Riedel (quoted by Hoffa) reported one, a boy fifteen\\nyears old who had been run over by a heavy wagon. The dislocated\\nhead was split by a line of fracture which also traversed the neck lon-\\ngitudinally, and the posterior portion of the rim of the acetabulum was\\ncrushed. The upper outer fragment and the trochanter were removed\\nthe rest of the head was returned to the socket. Healing with anchy-\\nlosis.\\nBraun 1 reported a similar case, the line of fracture running from the\\ninsertion of the ligamentum teres to the attachment of the capsule.\\nI showed to the New York Surgical Society 2 a specimen showing a\\ncrush of the anterior portion of the head one inch long, half an inch\\nwide, and one-eighth inch deep, caused evidently by impact against an\\nexostosis situated close behind the rim of the acetabulum; the injury\\nclosely resembled that occasionally produced in the head of the humerus\\nin an anterior dislocation by impact against the edge of the glenoid\\nfossa.\\nB. Fracture of the Neck of the Femur.\\nThis is essentially a lesion of advanced middle life and old age, and,\\nas the table given above shows, is more common in old women than in\\nold men. Whitman 3 has recently shown that it is more frequent in\\nchildhood than has heretofore been supposed, though still relatively\\nrare. It is often produced, too, by slight causes, such as a misstep, a\\nstumble, a fall upon the knee or hip, and these two facts taken together\\nindicate senile change in the bone as a markedly predisposing cause.\\nExamination of the thigh bones of old people, those that have been\\nbroken and those that have not, bears out this indication, for it shows\\nall the parts of the bone much rarefied, with thinning of the cortical\\nshell and enlargement of the meshes of the spongy tissue.\\nAnother reason for the greater frequency of these fractures in the\\nold has been sought in a change alleged to take place in the angle at\\nwhich the neck joins the shaft. It has been asserted that as the indi-\\nvidual grows older this angle approaches a right angle, a position that\\nwould favor fracture, but examination has proved this not to be the\\nrule. Rodet 4 found the average angle in the child and adult 131\\ndegrees, and in the old 128 degrees, a difference too small to deserve\\nattention, especially since the limits between which the angle ranges\\nnormally are wide, 121 degrees and 144 degrees according to the same\\nauthor. Similar findings have been published by others on the other\\nhand, Lauenstein found the angle changed.\\nOther points in the connection between the neck and the shaft require\\nmention because of their influence in the production of the fracture and\\nin the character of the displacement. The antero-posterior diameter\\n1 Braun Arch, fur klin. Chir., July 15, 1892.\\n2 Stimson New York Medical Journal, August, 1889, p. 163.\\n3 Whitman Annals of Surgery, June, 1897, and February, 1900.\\n4 Eodet These de Paris, 1844. quoted by Tillaux and others.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0366.jp2"}, "363": {"fulltext": "FBACTURES OF THE FEMUR.\\n311\\nFig. 156.\\nof the neck is much smaller than that of the shaft, and the two are so\\njoined that a large part of the great trochanter lies behind the posterior\\nwall of the neck, and, as shown by Prof. Bigelow, 1 it is traversed in\\npart by a prolongation of the posterior wall of the neck (Fig. 156).\\nThis prolongation which Bigelow calls the true neck constitutes a ver-\\ntical septum, a thin dense plate of bone continuous with the back of\\nthe neck, and reinforcing it, plunging beneath the intertrochanteric\\nridge in an endeavor to reach the opposite and outer side of the shaft.\\nAt its lower extremity it curves a little\\nforward so as to take its origin, when on\\na level with the lesser trochanter, from\\nthe centre instead of the back of the\\ncylindrical cavity. The posterior part\\nof the trochanter is therefore only an\\napophysis attached to the shaft for the\\ninsertion of the rotator muscles, and the\\nmechanical function of the shaft and\\nneck with reference to the resistance to\\nstrain is practically independent of it.\\nThe rarefying senile change affects this\\nseptum and may remove it so completely\\nthat it cannot be distinguished from the\\nsurrounding cancellous tissue.\\nThe capsule is usually attached to the\\nfemur in front along the spiral line, above\\nto the neck a little short of its junction\\nwith the trochanter, behind to the neck\\nitself about half an inch from the inter-\\ntrochanteric line, and below to the upper\\npart of the lesser trochanter. In front\\nand below, therefore, the neck lies en-\\ntirely within the capsule, while above\\nand behind its outer third or fourth part\\nis external to it. These limits vary some-\\nwhat in different individuals. The\\nsynovial membrane does not follow the\\ncapsule closely to its insertion, but is\\nreflected early from it to the neck, leav-\\ning a strip of the latter between the\\npoints where it joins the capsule and the synovial membrane which\\nalthough intracapsular is yet extra-articular. The periosteum is thick,\\nand contains, especially in its upper portion, numerous bloodvessels\\nwhich enter the head and neck by the large foramina found there. Of\\nthese vessels, one in particular, a branch of the internal circumflex\\nartery, is of considerable size, runs along the upper portion of the neck\\nand enters the head. Wilkinson Kins; 2 long ago called attention to\\nthe fact that this portion of the periosteum is frequently left untorn in\\nfracture of the narrow part of the neck, and suggested that this arte-\\nrial branch might preserve the vitality of the head of the bone under\\n1 Bigelow The Hip, p. 121. 2 King Guy s Hospital Eeports, 1S44, p. 347.\\nNeck of lemur. (Big e lew", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0367.jp2"}, "364": {"fulltext": "312 FRACTURES.\\nsuch circumstances. Later observations indicate that the vitality is\\npreserved, and presumably by this agency, much more frequently than\\nhas long been supposed.\\nThe division into intracapsular and extracapsular fractures, so long\\ncurrent and still so widely used, had its origin in important pathological\\ndifferences, but it has proved unsatisfactory and misleading, partly\\nbecause the two terms do not properly express these differences and,\\nconsequently, leave a large group the mixed fractures, those in\\nwhich the line of fracture lies partly within and partly without the\\ncapsule to be classed sometimes with one and sometimes with the\\nother, and partly because the associated theory that repair was impos-\\nsible after intracapsular fracture, although subsequently abandoned by\\nits author, Sir Astley Cooper, and many times disproved, has clung to\\nit in many minds until the present time. The breaking away from\\nthis classification Avhich has appeared in so many of the systematic\\nwritings of the last thirty years is largely due to the late Professor\\nBigelow who suggested the terms fracture at the narrow part of the neck\\nand fracture at the base of the neck. These have the disadvantage of\\nbeing rather cumbrous and of unduly limiting the seat of fracture in\\nthe former, for which, therefore, it seems to me advisable to substitute\\nthe term fracture through the neck. An alternative measure recom-\\nmended by some (most recently Sir William Stokes of fracture of the\\nneck for the former and at the base of the neck for the latter, is open to\\nthe objection that the first is also habitually used for the injury as a\\nwhole and is, therefore, liable to be misunderstood when used as mean-\\ning either more or less than was intended. Kocher s 2 recently proposed\\nfractura subcapitalis for the first, and fractura intertrochanterica and\\nfractura pertrochanterica for the latter, do not seem likely to be\\nacceptable.\\nThe importance of the distinction in prognosis and treatment is cer-\\ntainly not so great as has been alleged, nor is the presence or absence\\nof so-called impaction. The capital point in prognosis the degree of\\nvitality of the upper fragment depends not upon impaction nor upon\\nthe situation of the fracture, but upon the preservation of the vascular\\nsupply furnished by the vessels which approach the bone near the inser-\\ntion of the capsule and run toward and to the head in the thick peri-\\nosteum of the neck. In fractures at the base of the neck these vessels\\nare not much injured, and in fractures at the narrow part of the neck\\nthe continuity of the periosteum and the included vessels appears to be\\nsufficiently preserved in many, perhaps most, cases to maintain the\\nvitality of the fragment. The number of specimens of bony union\\nafter undoubted fracture at the narrow part of the neck is not only\\nlarge enough amply to demonstrate the possibility of such repair, but\\nalso, in comparison with those of failure of union and in connection\\nwith clinical results, to indicate that such union is probably common\\nunder appropriate treatment and in the absence of injudicious move-\\nments at first which may destroy the connection left by the fracture.\\nMoreover, it is clinically impossible positively to distinguish between\\n1 Stokes British Medical Journal, October 12, 1895.\\n2 Kocher Praktisch wiclitiger Frakturformen, 1896.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0368.jp2"}, "365": {"fulltext": "FBACTUEES OF THE FEMUR. 313\\nmanv of these fractures at the narrow part of the neck and those at\\nthe base in which there is little or no injury to the adjoining part of\\nthe shaft and its periosteum.\\nIt therefore seems to me unwise to make a sharp distinction between\\nthe two forms and to urge as some do, most recently Kocher, that frac-\\ntures of the narrow part of the neck, or intracapsular, should be\\ndeemed from the first incapable of union and treated accordingly. I\\nthink, on the contrary, that union should be sought in all cases and\\nalmost always by the same methods, and that the diagnostic differ-\\nentiation at the outset therefore is rarely of practical importance.\\nAlthough the distinction must be preserved in the description of the\\nforms of fracture (I shall use the names fracture through the neck and\\nfracture* at the base of the neck), the sections on symptoms and treat-\\nment will treat of them jointly.\\nCauses.\\nAn important predisposing cause has been mentioned, the senile\\nrarefaction which begins usually after the fiftieth year and is more\\nmarked in females than in males.\\nThe common cause in the old is a fall to the ground while walking\\noccasionally a stumble or a misstep with an effort to avoid a fall, or the\\njar occasioned by stepping down to a slightly lower level than was\\nanticipated thus, I have known the fracture to be caused by stepping\\nout of a carriage into a shallow hole in the sidewalk. In the young\\nand young adults the cause is usually much greater violence, as in a\\nfall from a height.\\nIt is probable that the strain exerted through the ligaments in ex-\\ntreme positions of the limb is a more frequent cause of fracture than\\nis generally supposed, and that the fall is sometimes the consequence\\nrather than the cause. A number of cases are on record in which the\\nbone has been broken in this manner, and by efforts so slight in some\\nof them that they might easily have been overlooked if a fall had been\\nassociated with them, and experiment upon the cadaver confirms the\\nopinion. The efforts which have been made to explain different varie-\\nties of fracture by differences in the direction of the blow or in the\\npoint at which it has been received have not been satisfactory either as\\na demonstration or as an aid in diagnosis. Few patients are able to\\ntell exactly how they have fallen, and even if they could do so there\\nwould still be enough uncertainty concerning the extent to which the\\nposition of the limb had intervened to vitiate the conclusions that\\nmight otherwise be drawn from the circumstances of the fall. At the\\nsame time it should be said that attempts to produce the fracture in\\ncadavers by blows upon the knees have always failed, although blows\\ndirectly downward upon the head sometimes do it, while blows upon\\nthe trochanter usually succeed, the fracture being then invariably at\\nthe junction of the neck and shaft if the body is that of an old person. 1\\nIt is, however, comparatively easy to break the bone in the old,\\neither at the base or at the narrow part of the neck, by abduction,\\nadduction, or rotation.\\n1 Heunequiu Des Fractures du Femur, p. 627.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0369.jp2"}, "366": {"fulltext": "314 FRACTURES.\\nSir Astley Cooper 1 tells of a woman who turned suddenly while\\nstanding an irregularity in the floor kept the foot from following the\\nmovement of the body, and this was sufficient to break the neck of the\\nfemur. He tells also of a woman, eighty-three and one-half years\\nold, who, while walking across the room, accidentally placed her cane\\nin a hole in the floor and lost her balance she tottered, but was saved\\nfrom falling by those standing near her, and found she had broken her\\nthigh. At her death, fifteen months afterward, the fracture was found\\nto have taken place at the junction of the neck and shaft, with deep\\npenetration of the former into the latter. 2\\nEarle s mentions a case in which the neck gave way within the cap-\\nsule from a mere muscular effort in emptying a pail of w T ater, and twist-\\ning the body and pelvis at the same moment, while the lower extremi-\\nties remained fixed.\\nMalgaigne 4 produced a fracture by forced abduction of the thigh in\\nan attempt to dislocate the head of the bone forward and downward.\\nThe cadaver was that of an individual eighty-one years old. He also\\nsaw a fracture caused in an old man in an effort to save himself from\\nfalling by leaning to the opposite side.\\nLinhart 5 was able to break the neck of the femur by abducting the\\nthigh and then forcing the body backward so as to put the ilio-femoral,\\nor Y-ligament, upon the stretch and Riedinger 6 and Stetter 7 have pub-\\nlished cases in which the injury occurred in like manner, the patients\\nhaving bent suddenly backward to save themselves from falling. One\\nwas sixty, the other fourteen years old.\\nMuscular action may be a cause by producing a forced position of the\\nlimb in which the capsule, and especially the Y-ligament, is put upon\\nthe stretch, the mechanism then being the same as when the corre-\\nsponding position is given by an external force.\\nPathology.\\nThe line of fracture may lie at any point between the junction\\nof the head and neck and the base of the neck, and in the latter\\ncase it may be associated with more or less splitting of the trochanter\\nand adjoining shaft, or it may pass (rarely) from the lower part of\\nthe junction of the neck and shaft transversely to the outer side.\\nFractures at a somewhat lower level, below the trochanter minor, will\\nbe considered among fractures of the shaft. There are, therefore, to be\\nconsidered here fractures through the neck, fractures at the base of the\\nneck with or without splitting of the trochanter, separation of the\\nepiphysis, and fracture through the trochanter.\\n(a) Fractures Through the Neck. Syn. Intracapsular Fracture.) The\\ninjury is rarely seen in the young, and its frequency has been thought\\n1 Cooper: Loc. cit., p. 155.\\n2 Cooper Loc. cit., p. 177, Case 90.\\n3 Earle Practical Observations on Surgery, 1822, p. 20.\\n4 Malgaigne Loc. cit., vol. i. p. 666.\\n5 Linhart Deutsche Gesellschaft fur Chirurgie, 1875.\\n6 Eiedinger Centralblatt fur Chirurgie, 1875, p. 817.\\n7 Stetter Idem, 1877, p. 561.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0370.jp2"}, "367": {"fulltext": "FRACTURES OF THE FEMUR.\\n315\\nto increase with advancing age after sixty years, but the facts upon\\nwhich the opinion rests are mainly clinical and, therefore, hot entirely\\ntrustworthy.\\nThe line of fracture may be transverse, oblique, or irregular it may\\nlie close to the head or at some distance from it, or may (rarely) pass\\nslightly into the head itself. In a few old specimens the appearance\\nsuggests that the line of fracture was incomplete on one side, but as\\nthe head in such cases shows a well-marked angular displacement it is\\nprobable that the fracture was complete with bending but no other\\ndisplacement at the apparently continuous portion and crushing else-\\nwhere. The surface of fracture is frequently irregular, but sometimes\\nFig. 15/\\nFig. 158.\\nFracture through the neck of the femur.\\ncapitalis.) (Kocher.)\\n(F. sub-\\nSo-called incomplete fracture of the\\nneck of the femur. (Konig.)\\nuniform and sometimes smooth or irregular on the side of the head\\nwhile the neck on the other side is crushed or comminuted (Fig. 157).\\nAngular deviation at the fracture is the rule, the apex of the angle\\nbeing usually directed forward and upward, and is habitually effected\\nby crushing of the bone or by penetration of one fragment into the\\nother. This penetration or impaction is rarely more than a simple\\ninterlocking of the irregularities of the surface, although Bigelow 1\\nreported one in which considerable force was required to separate the\\nfragments possibly the fixation was due to incompleteness of the\\nprimary separation at some point on the periphery, as in the so-called\\nincomplete fractures (Fig. 158).\\nThe periosteum of the neck appears usually to remain untorn over\\na portion of the periphery, and may even be complete, as in cases\\n1 Bigelow Loc. cit., p. 131.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0371.jp2"}, "368": {"fulltext": "316\\nFRACTURES.\\nFig. 159.\\nreported by Mayor l and Stanley. 2 In one of my specimens the\\nuntorn portion is nearly an inch wide and is situated at the lower and\\nposterior portion of the neck in another\\nit was broadly preserved in three bands\\nin other reported cases it has been behind,\\nbehind and above, and above and in front.\\nIf the primary displacement is great, or\\nif it is increased by an attempt to bear\\nthe weight upon the limb, the rupture\\nmay be or may become complete and the\\nfragments may be widely separated, both\\nof which circumstances would seriously\\naffect the prognosis under similar cir-\\ncumstances the capsule may be torn.\\n(b) Separation of the epiphysis has been\\ndemonstrated by specimen in a few cases\\nand suspected in a number in which frac-\\nture of the neck has occurred in the\\nyoung, but there is reason to believe that\\nit is much rarer even than fracture at the\\ncorresponding age. The conjugal carti-\\nlage immediately adjoins the head, and\\nbony union takes place between the seven-\\nteenth and twenty-first years. The first\\ncase verified by direct examination was\\nreported by Bousseau. 3 The patient was\\nfifteen years old, and was run over by a\\nwagon. The symptoms were shortening,\\neversion, and inability to move the limb.\\nThe patient died in a few hours. The separation was complete along\\nthe epiphyseal line, and the head\\nwas attached to the neck only by\\na strip of periosteum two milli-\\nmetres wide. The periosteum was\\nstripped up on the inner and lower\\npart of the neck, and the capsule\\nwas torn at its inner portion.\\nKocher 4 reports two. The first\\nis that of a girl sixteen years old,\\nwho fell while walking and struck\\nupon her right trochanter. On\\nthe theory that if the injury, as\\nsupposed, was a fracture through\\nthe neck (or separation of the\\nepiphysis) repair was impossible,\\nan operation was done three weeks\\nlater for the removal of the upper fragment. A fracture, hidden by\\n1 Mayor Gazette Medicale, 1834, p. 612.\\n2 Stanley: Medico-Chirurgical Transactions, 1825, vol. xiii. p. 511.\\n3 Bousseau Bulletins de la Societe Anatomique, 1867, p. 283.\\n4 Kocher Praktisch wichtiger Frakturfornien, 1896, pp. 238 and 243.\\nFracture through the neck in a boy\\neight years old. (Bolton.)\\nFig.\\nSeparation of the epiphysis\\n(Kocher.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0372.jp2"}, "369": {"fulltext": "FRACTURES OF THE FEMUR. 317\\nthe untorn periosteum, was found along the epiphyseal line, with pene-\\ntration of the posterior part of the neck into the head the latter was\\nremoved; recovery with anchylosis.\\nThe second case was that of a girl, who, when ten years old, fell\\nfrom a height she rose and walked a short distance, was then unable\\nto use the limb because of pain, and was taken to a hospital. After appa-\\nrent recovery she walked with a limp which increased as time passed.\\nFour years after the accident Kocher found shortening of three centime-\\ntres, outward rotation, and marked diminution, active and passive, of\\nmotion in the hip-joint. The condition found at the operation is shown\\nin Fig. 160; the head was so tightly fixed in the acetabulum that it\\nwas removed with difficulty the neck was bent sharply downward\\nwith an irregular, knobbed end covered with fibro-cartilage the end\\nwas placed in the acetabulum and the limb fixed in abduction and\\nFig. 161.\\nImpacted fracture at the base of the cervix femoris, with bending of the head backward.\\n(Bigelow.)\\ninward rotation. The history ends with the recovery from the opera-\\ntion.\\nPoland l reports a personal case verified by operation and quotes\\ntwo others, and Whitman 2 reports one in which the injury was\\ncaused by forcible abduction of the thigh in a lad sixteen years old,\\n1 Poland: Traumatic Separation of the Epiphyses, p. 628.\\n2 Whitmau Annals of Surgery, Feb., 1900, p. 151.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0373.jp2"}, "370": {"fulltext": "318\\nFRACTURES.\\nthe diagnosis being confirmed by a skiagram taken three weeks after\\nthe accident.\\n(c) Fractures at the Base of the Neck. (Extracapsular and mixed\\nfractures.) The line of fracture follows ordinarily the junction of the\\nneck and shaft quite closely that is, it coincides with the spiral line in\\nfront and the intertrochanteric line behind as they pass between the\\ngreat and lesser trochanters. It may extend downward and detach the\\nlesser trochanter from the shaft, leaving it attached to the neck, or go\\neven lower and separate a part of the shaft. At its upper part it may\\ndeflect to either side, crossing the outer part of the neck or traversing\\nFig. 162.\\nFig. 163.\\nImpacted fracture of the neck of the femur\\nwithout splintering. Vertical section.\\nRepair after fracture of the neck of the femur.\\n(Lossen.)\\nthe great trochanter, in the latter case passing quite beyond the limits\\nof the neck.\\nIn the majority of cases other lines of fracture traverse one or both\\ntrochanters, splitting off one or two pieces, usually from the posterior\\nsurface of the great trochanter, or comminuting it completely. Mal-\\ngaigne thought that simple fracture, division into only two fragments,\\nwas exceedingly rare the only case of which he knew, excluding two\\nin which the fracture crossed the trochanter horizontally, was one\\ndescribed by R. W. Smith, 1 and, as even in this two fragments are\\nbroken off the trochanter behind, it is evident that he believed consid-\\nerable comminution to be the rule. Hamilton refers to two similar\\nspecimens, one in Dr. Mutter s, the other in Dr. Neill s collection in\\none of my own specimens there was no splintering, and in another the\\n1 E. W. Smith Loc. cit., Case 34.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0374.jp2"}, "371": {"fulltext": "FRACTUEES OF THE FEMUR.\\n319\\nfracture was almost identical with the one quoted by Malgaigne from\\nSmith.\\nThe common fracture is that in which the neck is bent backward\\nwith crushing of the posterior part or penetration of the neck\\ninto the trochanter. Prof. Bigelow l directed especial attention to this\\nbending backward and impaction (Fig. 161) as the important features\\nof the most common form of fracture in this region, the symptoms of\\nwhich are pain and tenderness, disability, shortening and eversion, how-\\never slight, absence of crepitus, and rotation of the trochanter about\\nthe head of the bone as a centre, and he described the displacement as\\na rotation of the head and neck backward and downward upon the\\nFig. 164.\\nFig. 165.\\nComminuted fracture of the neck of the femur.\\nAnterior aspect.\\nFracture of the neck of the femur with\\nsplitting of the great trochanter.\\nportion of the anterior wall corresponding to the spiral line uniting the\\ntrochanters as upon a hinge. This displacement accounts for the ever-\\nsion and slight shortening.\\nA certain amount of misapprehension has resulted from the use of\\nthe word impaction. Impaction, in the sense of penetration and fixa-\\ntion, is, I think, uncommon while crushing, with or without penetra-\\ntion or much splitting of the trochanter, is the rule. The penetration\\nor crushing may be limited to the posterior part (this, as has been said,\\nis the most common condition), or the neck may turn upon its upper\\nportion, making that the hinge, and sink its anterior, posterior, and\\nlower walls into the substance of the trochanter, or the neck may be\\ndriven bodily into the trochanter without much change of direction,\\nand may even penetrate to the opposite wall. In exceptional cases the\\nlower fragment may penetrate the upper one.\\nThe splitting of the trochanter may be limited to one or two pieces\\n1 Bigelow: The Hip, p. 118, and Boston Medical and Surgical Journal, 1875, vol. xcii.\\npp. 1, 29.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0375.jp2"}, "372": {"fulltext": "320\\nFRACTURES.\\nFig. 166.\\nbroken off its posterior border (Fig. 165), or it may be very general\\n(Fig. 166). The extent of the splitting seems to be independent of\\nthe force that caused the fracture, extensive\\ncomminution being sometimes produced by\\na simple fall while walking, as in Fig.\\n164, which is drawn from one of my own\\nspecimens.\\nIn a few cases the angular displacement\\nof the neck has been in the opposite direc-\\ntion, so that the limb has been rotated in-\\nward instead of outward. R. W. Smith 1\\ndescribes one such specimen, and Bigelow 2\\nanother. In a number of cases inversion\\nhas existed when the fragments were not\\ninterlocked.\\nThe angular displacement of the neck\\nand the form of the fracture appear to be\\nconnected with the mode of production of\\nthe fracture and the attitude of the limb\\nat the moment of fracture thus, if the\\nlimb is extended and rotated outward or\\nabducted the anterior portion of the capsule\\nis tense and the posterior portion of the\\nneck is driven into the trochanter (Fig.\\n167); if the limb is strongly adducted the deep penetration is found\\nespecially at the inferior portion of the neck (Fig. 168).\\nThe capsule is sometimes torn so that the cavity of the joint is\\nopened the laceration of the periosteum and adjoining soft parts varies\\nwith the extent of the comminution and crushing.\\nComminuted fracture of the neck\\nof the femur. (Gurlt.)\\nRepair.\\nThe question of the extent to which repair is possible or probable\\nafter fracture through the neck is important because of its bearing\\nupon treatment. If reunion is possible an effort to obtain it should\\nbe made, in the absence of controlling contraindications if it is im-\\npossible or even improbable, treatment must be directed to obtaining\\nthe best functional result compatible with such failure.\\nThat repair is possible is abundantly proved by specimens, even\\nif we disregard those in which any question can be raised as to the\\ncharacter of the injury or the exact situation of the fracture. Such\\nillustrative specimens are those of Stanley, 3 Swan, 4 Gurlt 5 (Figs. 169\\nand 170), Brulatour, 6 Cushing, 7 Humphry, 8 Raven, 9 and Kocher 10\\n1 R. W. Smith Loc. cit., p. 128. 2 Bigelow Loc. cit., p. 128.\\n3 Stanley: Medico-Chirurgical Transactions, 1833, vol. xviii. p. 256.\\n4 Swan Quoted by R. W. Smith, Fractures in the Vicinity of Joints, p. 59.\\n5 Gurlt: Knochenbruchen, vol. i. p. 308.\\n6 Brulatour: Medico-Chirurgical Transactions, 1825, vol. xiii. p. 513.\\n7 Cushing Quoted by Bigelow, The Hip, p. 133.\\n8 Humphrv Lancet, August 2, 1890.\\n9 Raven Ibid., 1887. 10 Kocher LoC. cit., p. 206.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0376.jp2"}, "373": {"fulltext": "FEACTUBES OF THE FEMUR.\\n321\\n(Fig. 171). 1 They include patients of ages varying from eighteen to\\neighty-one years.\\nFig. 167.\\nFig. 168.\\nFracture of the neck of the femur in\\nabduction. (Kocher.)\\nFracture of the neck of the femur in adduction.\\n(Kocher.)\\nFig. 169.\\nFig. 170.\\nPure intracapsular fracture of the neck of the\\nfemur. Bony union. (Gurlt.)\\nOblique section of the specimen shown\\nin Fig. 169. (Gurlt.)\\nOther specimens show close fibrous union (Figs. 172 and 173) and\\n1 For other cases and details the reader is referred to the first edition and the bibliog-\\nraphy in it, page 499.\\n21", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0377.jp2"}, "374": {"fulltext": "322\\nFRACTURES.\\nothers in which no form of union had taken place show eburnation of\\nthe head and other changes which\\ndemonstrate the preservation of its\\nvitality. After fibrous union or\\nfailure of union the capsule usually\\nthickens and sometimes becomes\\nclosely adherent to the periosteum\\nlining the neck, thus obliterating\\nall the outer portion of the original\\ncavity of the joint. This was the\\ncondition in two cases reported by\\nColles, 1 and there was actually a\\nfalse joint between the fragments,\\nthe surface of the lower one being\\nhollowed out to receive the upper.\\nSometimes the capsule ossifies in\\npart. The two following cases are\\nquoted to show the ability of the\\nupper fragment to produce gran-\\nulations and to illustrate close\\nfibrous union without absorption\\nof the neck. They are both taken\\nfrom R. W. Smith, Cases 58 and\\n59. See also his Cases 11 and 16\\nfor examples of eburnation.\\nA man, fifty -two years old, was\\nadmitted to the City of Dublin\\nHospital with an intracapsular\\nand died of bronchitis on the six-\\nBony union after fracture through the neck.\\n(F. subcapital is.) (Kocher.)\\nfracture of the neck of the femur.\\nFig. 172.\\nFig. 173.\\nFracture within the capsule fibrous union,\\n(Smith.)\\nFracture within the capsule. Close fibrous union.\\nteenth day. Very little synovia was found in the hip-joint a layer\\n1 Colles Dublin Hospital Eeports, vol. ii. p. 334.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0378.jp2"}, "375": {"fulltext": "FRACTURES OF THE FEMUR.\\n323\\nof lymph covered the entire inner surface of the capsule, was closely\\nadherent to it, and vascular at several points it adhered to the head\\nand neck of the femur.\\nThe fracture was entirely within the capsule. The cer-\\nvical ligament [periosteum] torn in front was perfect behind and\\nbelow the surface of each fragment was highly vascular, and several\\nshreds of lymph connected them; in fact, a thin layer of lymph was\\neffused between the opposed surfaces of the fracture, on separating\\nwhich it was drawn out into the thin and delicate bands above men-\\ntioned.\\nThe fracture in this case was caused by a fall directly on the\\nmost prominent external part of the trochanter major, and the patient\\nwalked a few yards after the receipt of the injury. The foot was\\neverted and the limb shortened exactly half an inch.\\nA woman, eighty years old, fell upon her left hip while walking\\nacross her room^and was unable to rise. She died eight weeks after-\\nward, having regained some\\ncontrol over the limb, which FlG 174\\nremained inverted.\\nThe fracture was close to\\nthe head of the bone above,\\npassed thence downward and\\ninward, leaving a portion\\nabout half an inch in length\\nof the under part of the neck\\nattached to the head. The\\nhead was displaced down-\\nward, overlapping the neck\\nbelow and behind, and being\\noverlapped by it above and\\nin front (see Fig. 172).\\nThere was thus a mutual\\nimpaction of the two frag-\\nments, and they were further\\nmaintained in contact by a\\ndense, fibrous tissue, which\\nadhered closely to the broken\\nsurfaces.\\nSome specimens of failure\\nof union show entire disap-\\npearance of the neck, the\\nhead remaining in the acetabulum and presenting a smooth uniform\\nsurface there is a similar smooth surface on the mesial aspect of the\\nshaft at the place corresponding to the base of the neck (Fig. 174).\\nThe situation of the fracture in such cases cannot be positively\\nknown the neck has disappeared by crushing and rarefaction, and this\\npresumably can happen after either form of fracture considering the\\ngreater interference with the vascular supply of the head I am disposed\\nto think it more likely to happen on that side of a fracture than on the\\nother.\\nFracture with absorption of the neck.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0379.jp2"}, "376": {"fulltext": "324 FRACTURES.\\nSome specimens with union show an almost equal absence of the\\nneck in some, as shown in Fig. 163, the neck still exists but has been\\ndriven into the trochanter in others it has disappeared in great part,\\npresumably by crushing and rarefactive osteitis, and it is difficult or\\nimpossible exactly to determine the primary position of the fracture.\\nThese latter specimens are of special interest because they have been\\nused to support the theory that interstitial absorption of the neck may\\nbe caused by a contusion, without fracture, and that thus may be grad-\\nually produced a deformity clinically identical with that following frac-\\nture. I have given elsewhere l reasons for deeming this theory incorrect\\nand for believing all such alleged cases to be cases of unrecognized\\nfracture.\\nOther specimens, and they are numerous, show an abundant produc-\\ntion all about the trochanter and upper end of the shaft. In part this\\nenlargement is due to splitting and displacement of the fragments, but\\nFig. 175.\\nFracture of the base of the neck. Exuberant callus and interlocking of the fragments that per-\\nmitted fair use of the limb, notwithstanding failure of union.\\nthe greater part of it is new bone produced subperiosteally, or, more\\nprobably, by ossification of the attached fibrous and tendinous tissues.\\nThis is especially common at the back, along the intertrochanteric line.\\nSometimes these masses so embrace the end of the ununited upper\\nfragment (neck) that the patient can walk well without the aid of cane\\nor crutch (Fig. 175).\\nIt is alleged by Whitman that after repair in the child, especially in\\nthe first few months, the angle between the neck and shaft may dimin-\\nish (adduction) and the shortening be thereby notably increased.\\nThe cavity of the joint is sometimes diminished by an adhesive\\n1 Stimson Doubtful Fractures of the Neck of the Femur and their Identity with an\\nAlleged Form of Arthritis Deformans. New York Medical Journal, April 14, 1888.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0380.jp2"}, "377": {"fulltext": "FEACTUEES OF THE FEMUE. 325\\nsynovitis which, aided by peri-articular thickening and retraction and\\nby the above-mentioned osteophytic growths, greatly restricts its mo-\\nbility.\\nOccasionally the limb, after either form of fracture, remains useless,\\nand much pain is felt, especially if union has failed and there are a\\nfew recorded cases in which suppuration has occurred within or without\\nthe joint.\\nThe degree of probability of bony union after fracture through the\\nneck could be determined only by the statistics of a series of continuous\\ncases. The collation of reported cases is not sufficient because it is\\ncertain that the proportion of failures of union therein would be dis-\\nproportionately large the examination post mortem of the part is more\\nlikely to be made if the patient remains disabled until death than if\\nhe has regained use of the limb. Most of the specimens we possess\\nof bony union have been obtained from patients who died from some\\nintercurrent cause within a comparatively short time after the accident,\\nwhile its memory was still fresh.\\nClinical statistics are untrustworthy because of uncertainty as to the\\nexact situation of the fracture and as to the extent and character of the\\nrepair. In respect of the latter it is to be borne in mind that some\\npatients have been able to make fair use of the limb even when union\\nhad entirely failed, and that others (after fracture at the base of the\\nneck) have been able to make even less use although bony union had\\ntaken place.\\nThe facts in our possession are (1) that bony or close fibrous union\\nis possible (2) that the preservation of enough of the periosteum of\\nthe neck to make a vigorous vitality of the head probable is probably\\ncommon and (3) that the primary displacement usually does not sepa-\\nrate the fractured surfaces, so that if it is not increased by early\\nattempts to use the limb or, more rarely, by the action of the muscles\\nin the absence of proper retention, the conditions for reunion are favor-\\nable. We also know that fair usefulness of the limb, even after union\\nhas failed, is possible and it has not been proved that this usefulness\\nis greater or more probable if the attempt to secure union has not been\\nmade.\\nSymptoms and Diagnosis.\\nThe symptoms of the fracture and the signs upon which the diag-\\nnosis must be made include not only the usual objective and subjective\\nsymptoms of fracture but also the history of the case, the nature of\\nthe violence, and especially its slight degree, which so often char-\\nacterizes this injury.\\nInterference with Function. As a rule the patient is unable to use the\\nlimb, and he is not merely unable to bear his weight upon it, but he\\ncannot even move it in bed. Exceptions to this have been already\\nmentioned, and it is not particularly uncommon to see patients who,\\nwhile lying on the back, can slowly flex the thigh upon the pelvis\\neither by its muscles alone or with the aid of the hands, but they can-\\nnot raise the foot from the bed, the knee bends at the same time and\\nthe foot is drawn up toward the body. Most authors have mentioned", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0381.jp2"}, "378": {"fulltext": "326 FRACTURES.\\ncases in which the patients have walked for longer or shorter distances\\nimmediately after the injury, and in which the existence of a fracture\\nhas subsequently become very clear. This is very exceptional, and it is\\nsufficient to bear the possibility in mind to avoid the error of inferring\\nthat a fracture cannot be present because the patient is or has been able\\nto use the limb.\\nThe opposite error, that of supposing a fracture to exist because the\\nlimb has been disabled by a fall, can be easily made, because a simple\\ncontusion may cause eversion of the limb as well as ecchymosis and\\nswelling, and in some cases fracture causes no other symptoms than\\nthese. Observation of the case for a few days will make the diagnosis\\nclear. Whitman (loc. cit.) claims that in the young the disability is\\nusually much less than in the old, and that in many instances the pa-\\ntients are able to walk after a few days.\\nPain is always present. It is usually slight, or even absent, when\\nthe patient is at rest, but is readily excited by even slight communi-\\ncated or voluntary movements. It is referred sometimes to the region\\nof the trochanter, sometimes to the groin or inner and upper portion\\nof the thigh. Sometimes pressure with the end of the finger detects\\na particularly sensitive point in the line of the neck in front just out-\\nside the great vessels, or at the corresponding point behind. Forcible\\npressure upward against the foot or inward against the trochanter fre-\\nquently fails to cause pain.\\nThe posture and appearance of the limb are so characteristic that it\\nis sometimes almost safe to make the diagnosis by simple inspection.\\nAs the patient lies upon his back the affected limb appears shorter than\\nthe other, everted, and slightly flexed and abducted, and conveys an\\nimpression of helplessness that is often very striking. The upper por-\\ntion of the thigh is swollen in front and on the outer side, and ecchy-\\nmosis sometimes appears after a day or two. The greater the shortening\\nthe more marked is this swelling.\\nEversion may be so marked that the foot rests entirely upon its\\nouter border as the patient lies upon the back. In other cases it is so\\nslight that, as Prof. Bigelow has pointed out, it is best recognized by\\ncomparing the extent to which the two feet can be inverted.\\nIn exceptional cases the limb is inverted it is either found so on\\nthe first examination or it becomes so after a day or two. In 60 cases\\ntabulated by Smith eversion is noted 33 times, and inversion 7 times,\\nin one it is said there was no rotation to either side, and in the remain-\\ning 1 9 the symptom is not mentioned.\\nThe cause of the eversion is probably almost always mechanical it\\nis largely the effect of gravity acting upon the limb under changed\\nconditions of support. It is favored by angular displacement at the\\nfracture. On the other hand, eversion has been observed in cases of\\nsimple contusion, and in others of fracture in which there was no dis-\\nplacement of the fragments, no rupture of the periosteum even, and\\nconsequently no loss of support. When one lies upon his back a dis-\\ntinct, although slight, effort is required to keep the toes upright the\\nnatural tendency of the limb is toward eversion, particularly if the\\nknee is slightly flexed, and this tendency which is increased by any-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0382.jp2"}, "379": {"fulltext": "FRACTURES OF THE FEMUR. 327\\nthing that diminishes the activity of the muscles must be taken into\\naccount in those obscure cases where the diagnosis lies between a con-\\ntusion and a fracture.\\nThe cause of inversion is not so clear. Smith attributes it to the\\nposition of the fragments relative to each other, and says that in all\\nthe cases of inversion which he was able to examine post mortem he\\nfound the lower fragment in front of the upper one. This, however,\\ndoes not always explain the symptom when the fracture is of the nar-\\nrow part of the neck, intracapsular, although it may do so in some,\\nas in the case observed by Goyrand l where the neck had slipped behind\\nthe head and was fixed between it and the capsule.\\nThe diagnostic value of the posture of the limb, as regards eversion\\nor inversion, is not very great, for inversion is a symptom that needs,\\nas it were, to be explained aw r ay, and eversion may be due to a simple\\ncontusion. In order to estimate the degree and persistence of the ever-\\nsion the patient should be placed flat upon his back with the thigh and\\nleg extended. A comparison with the other foot will then show the\\ndegree of the eversion, and gentle efforts to rotate the limb will show\\nto what extent and in Avhat manner the movements are restricted.\\nShortening of the limb is produced either by alteration of the angle\\nbetween the shaft and the neck or by overriding, and may vary in\\nextent from a small fraction of an inch to two or three inches. It\\nmay be present at its maximum immediately after the accident, or it\\nmay be absent at first and appear gradually or suddenly after the lapse\\nof a few hours or days, or may increase gradually or suddenly. It is\\nusually held that when the fracture is of the narrow part of the neck\\n(intracapsular) the shortening is absent or slight at first, increases\\nmore or less gradually, and never exceeds one and a quarter inches\\nand gradual increase in the amount of shortening is claimed by some\\nto be pathognomonic of this variety of fracture. These statements are\\ntrue only as an expression of the average condition in exceptional\\nintracapsular cases the shortening may exceed this amount, and in\\nfractures at the base of the neck it may increase gradually in the same\\nmanner.\\nIn measuring the limbs care must be taken to have them form the\\nsame angle with the pelvis, that each is in the same position of exten-\\nsion and abduction. If the injured limb cannot be brought parallel\\nto the median line of the body the other must be abducted to the same\\ndegree. To insure this symmetry it is well to stretch a cord downward\\nat right angles to and from the centre of another cord stretched between\\nthe two anterior superior iliac spines, and then to place the ankles at\\nequal distances from it and as near to it as is convenient. The meas-\\nurements are usually made between the anterior superior spine of the\\nilium and the external malleolus.\\nAnother method of recognizing shortening and of measuring its\\nextent is one recommended by Mr. Bryant, measuring to the trans-\\nverse vertical plane passing through the anterior superior spinous pro-\\ncesses. Thus, in Fig. 176 a c represents the vertical plane passing\\nthrough these processes, and b is the top of the great trochanter. In\\n1 Goyrand Diet. Eucyclopedique, art. Cuisse, p. 239.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0383.jp2"}, "380": {"fulltext": "328\\nFRACTURES.\\nfracture of the neck with shortening b is brought nearer to c. The\\nsame care must be taken to have the limbs in symmetrical positions,\\nand I have found it convenient to mark the vertical plane by placing\\na small stick or pencil upright beside the pelvis and in line with the\\nprocesses, and then to measure the distance between it and the tro-\\nchanter. The same measurement can be made, roughly but usually\\nwith sufficient accuracy, by placing the thumbs on the superior iliac\\nspinous processes and the tips of the fingers on the trochanters, and\\nthus estimating the comparative levels.\\nAnother but less accurate method of recognizing the elevation of\\nthe trochanter is to find its position with reference to Nekton s line\\nthe line taken by a cord stretched between the tuberosity of the ischium\\nFig. 176.\\nBryant s iliofemoral triangle, for diagnosis of fracture of the neck of the femur.\\nand the anterior superior spine of the ilium. Under normal conditions\\nthis line crosses the top of the trochanter when the thigh is slightly\\nflexed on the pelvis.\\nAttention has been called by Dr. Allis to an effect of this shortening\\nwhich can be easily recognized the relaxation of the fascia lata between\\nthe ilium and the trochanter and just above the knee on the outer\\nside.\\nThe shortening can sometimes be overcome, entirely or in great part,\\nby gentle traction upon the limb combined with enough rotation inward\\nto correct such eversion as may exist. I think the dread of separating\\nimpacted fragments by traction has been exaggerated. The penetra-\\ntion is transverse, and longitudinal traction that is not violent enough\\nto cause much pain cannot do more than change the angle at the junc-\\ntion of the neck and shaft, it does not separate the fragments from each\\nother. Rotatory movements communicated to the limb are more likely\\nto do harm, as is also such lack of support as will allow the eversion\\nand shortening to be increased.\\nCrepitus is occasionally perceived during the manipulation of the\\nlimb while making either traction or rotation, in the latter especially\\nif the limb is at the same time flexed but it is far from being a con-\\nstant sign, either because of impaction or of splintering that leaves the\\npieces too closely connected to produce it. The sign is one that should\\nnot be repeatedly sought for in the cases that are really obscure it is\\nhighly improbable that it can be obtained, and in the others it is not\\nneeded.\\nAmong other signs which may be present are enlargement of the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0384.jp2"}, "381": {"fulltext": "FRACTURES OF THE FEMUR. 329\\ngreat trochanter when it has been split or comminuted, change in its\\ndistance from the median line of the body, change in the centre of\\nrotation of the limb, and change in the depressibility of the outer\\nportion of Scarpa s space.\\nThe enlargement of the trochanter in consequence of its having been\\nsplit by the outer end of the neck is sometimes very marked and easily\\nrecognized when the soft parts are not swollen by grasping it between\\nthe thumb and fingers.\\nThe distance between the outer face of the trochanter and the median\\nline of the body may be increased or diminished, but the change is\\nseldom very marked and is difficult of accurate determination. It is\\neasier to prove that it ought to exist on theoretical grounds than to\\nrecognize it if actually present. If the neck is driven into the tro-\\nchanter the distance of the trochanter from the cotyloid cavity is dimin-\\nished by the amount of the penetration if, on the other hand, there is\\nno penetration or crushing and the displacement is an angular one in\\nthe frontal plane, the bone being pushed up until the angle at the\\njunction of the neck and shaft becomes a right angle, the distance is\\nincreased because the neck then stands directly out from the body\\ninstead of being inclined downward and thirdly, in combinations of\\npenetration and this angular displacement the two changes may neu-\\ntralize each other in whole or in part.\\nRotation of the trochanter upon a shorter radius than usual is\\nanother symptom found in the text-books but not often at the bed-\\nside. Theoretically, if the lever upon which rotation is made is broken\\na new centre is formed at the seat of fracture or the radius is shortened\\nby impaction. Nothing could be simpler or more accurate in theory,\\nbut in practice it is beset with difficulties that make it worthless as a sign,\\nfor it is recognizable only in cases where the diagnosis cannot be in doubt.\\nIt is practically impossible to tell by pressing the finger against the\\nouter face of the trochanter whether it rotates upon a long or a short\\naxis, for the range of permissible motion is too limited to make it pos-\\nsible to recognize the sharpness of its curve. In cases of fracture with\\ncrushing of the neck and when the shaft lies unconnected with the\\nremainder of the neck and the head, rotation of the limb may take\\nplace about the longitudinal axis of the femur, and the centre of motion\\nlie within the shaft, not outside of it in the cotyloid cavity, and this\\ncan sometimes be recognized by pressing the finger against the posterior\\nface of the trochanter and rotating the limb gently. Instead of rising\\nfrom the finger the bone may be felt to slide over it. Or pressure\\nagainst the back of the trochanter may simply raise it, instead of\\ninverting the foot.\\nThe change in the depressibility of Scarpa s space signalized by\\nHennequin 1 is a valuable diagnostic symptom. Under normal condi-\\ntions the fingers can be pressed deeply into the limb in the outer por-\\ntion of Scarpa s space, but when the neck of the femur is broken this\\ndepressibility is reduced in varying degrees, apparently by the angular\\ndisplacement (with the apex directed forward) which takes place so\\ncommonly at the junction of the neck and shaft. The same condition\\n1 Hennequin Des Fractures du Femur, p. 700.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0385.jp2"}, "382": {"fulltext": "330 FRACTURES.\\nwas described by Laugier 1 as a sort of bony tumor to be felt on the\\nouter side of the great vessels an inch or two below Poupart s ligament,\\nslight pressure upon which was painful.\\nDiagnosis.\\nIn most cases the existence of a fracture of the neck of the femur\\ncan be readily determined and sometimes its variety can also be easily\\nrecognized, but in others the main character of the injury is very\\nobscure, and in a large proportion of cases it is simply impossible\\nto say whether the fracture is intracapsular or extracapsular, of the\\nnarrow part of the neck or of the base of the neck. This difficulty\\nis recognized by all practical surgeons and finds expression in many\\nsurgical works, although others still preserve the distinction between\\nthe two forms, and lay down rules for their recognition. Gosselin 2 says\\na rigorous diagnosis between extracapsular and intracapsular fractures\\nis both impossible and useless. Mr. Bryant 3 says the old division\\nof intracapsular and extracapsular fractures is as unscientific as it is\\nimpracticable and Agnew, 4 to recognize clearly a fracture through\\nthe neck of the femur or to assert with positiveness that such a fracture\\nis present is often a matter of no small difficulty, and occasionally one\\nof impossibility; and Hamilton, 5 the diagnosis between these two\\nvarieties of fracture is often impossible during the life of the patient\\nand Bigelow, 6 the importance of distinguishing between the different\\nfractures of the neck of the femur is not so great as to justify any\\nprotracted or considerable examination.\\n\\\\Yhen the symptoms described above are clearly marked, when there\\nis the history of a fall followed by complete loss of power in the limb,\\nwith shortening, eversion, crepitus, pain at the hip, and elevation of\\nthe trochanter, there can, of course, be no doubt the neck of the\\nfemur is broken. But when the limb is not entirely powerless, when\\nthe shortening and eversion are slight, perhaps even doubtful, when\\ncrepitus is not felt, when, in short, there is no single positive sign, the\\ntemptation to conclude that there is no fracture is great, and although\\nthe warning uttered by Hodgson nearly a century ago, that inability\\nin an elderly patient to use the limb after a fall upon the hip should\\nbe deemed evidence of probable fracture of the neck of the femur, has\\nbeen repeated many times since, it is still very often disregarded to the\\ngreat damage of the patient and sometimes also of the surgeon. The\\nrule should be firmly established in practice that every doubtful case,\\nespecially in the elderly, should be treated at first as a fracture, and all\\nthe more so if the violence has been comparatively slight, such as a\\nstumble or a fall while walking. It has been said that the pain of a\\ncontusion or sprain is most marked on moving the limb, that of a frac-\\nture on trying to bear the weight of the body upon it but even if the\\nstatement is accurate, which I doubt, it would be very injudicious to\\nmake the test, for if fracture is present the effort to bear the weight\\n1 Laugier Diet. Encyclopedique, art. Cuisse, p. 507.\\n2 Gosselin Cliuique de la Charite, vol. i. p. 346.\\nBryant Loc. cit., p. 841. 4 Agnew Loc. cit. vol. i. p. 941.\\n5 Hamilton Loc. cit., p. 425. 6 Bigelow Loc. cit., p. 127.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0386.jp2"}, "383": {"fulltext": "FEACTUEES OF THE FEMUE. 331\\nupon the limb would be likely to separate the fractured surfaces and\\nincrease the displacement and the chances of failure of union. If the\\ninjury is not a fracture the rest and even the confinement to bed can\\ndo no harm and are but a small price to pay for the avoidance of the\\ngrave risks involved in the neglect of the precaution so long as it is\\npossible that the injury is a fracture.\\nThe examination should be directed first to the history of the case,\\nthen to the functions of the limb and the pain, then to its attitude and\\nlength, the condition and height of the trochanter, and the depressi-\\nbility of Scarpa s space. If any doubt then remains the limb may be\\ngently rotated, in order to judge of the degree of eversion and of its\\nmobility, to elicit crepitus, and, if desired, to estimate the radius of\\nrotation.\\nA possible source of error in the existence of a former fracture, or\\nof a deforming or dry arthritis, to which a fresh contusion has just\\nbeen superadded, must be borne in mind when the history of the case\\nis inquired into.\\nDislocation is eliminated in case of eversion by noting the absence\\nof the head of the femur from the pubic region. The exclusion of\\ndislocation backward upon the ilium in case of fracture with inversion\\nof the limb may be more difficult. In dislocation the limb is more fixed,\\nit is adducted and flexed, the head of the femur may be felt posteriorly,\\nmid its absence from the cotyloid cavity may be recognized by palpa-\\ntion. In fracture the inversion may give place to eversion after trac-\\ntion upon the limb.\\nFracture at a lower level is recognized by the seat of pain on direct\\npressure and usually by the failure of the trochanter to share in rota-\\ntory movements communicated to the lower portion of the limb.\\nFracture of the acetabulum with penetration of the head of the\\nfemur into the pelvis has usually been mistaken for fracture of the\\nneck of the femur. The means of diagnosis has been mentioned in\\nthe preceding chapter.\\nIn regard to the differential diagnosis between fractures through the\\nneck (intracapsular) and those at the base (extracapsular) it can only\\nbe said that some of the latter can be positively recognized, as when\\nthe trochanter is split or the immediate shortening is great, and some of\\nthe former almost as positively by exclusion aided by the age of the\\npatient, the slight violence, the great disability, and the absence or the\\nslight amount of the shortening, but in many cases the distinction can-\\nnot be made. Later in the course thickening about the trochanter may\\nappear and prove that the fracture was at the base. Anaesthesia makes\\nthe recognition of some of the signs easier, but is likely to lead to\\nunnecessary handling and to increase the displacement.\\nPrognosis.\\nIn this must be considered the immediate danger to the life of the\\npatient created by the accident, and the remoter influence upon the\\nfunctions of the limb. Of the 60 cases collected by K. W. Smith\\n26 terminated fatally within the first month and 4 within the second", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0387.jp2"}, "384": {"fulltext": "332\\nFRACTURES.\\nmonth. It must not be thought that these figures represent the\\naverage mortality of the injury, for his collection is only of cases that\\nhad furnished specimens, but they will serve to call attention to the\\nactual danger that does exist, and to the probability that death will be\\ncaused promptly if at all.\\nThe promptly fatal cases present three principal forms in one the\\nprimary inflammatory reaction is sharp, a high fever sets in, the patient\\nbecomes delirious and dies within a few days, or pneumonia is devel-\\noped soon after the accident and proves fatal. In another the patient,\\nold and feeble, seems overwhelmed by the mental and physical shock\\nand dies within two or three days. In the third form the patient s\\nstrength fails rapidly without much inflammatory reaction from the\\ninjury, and he dies cachectic, usually with an intercurrent pneumonia.\\nIt is possible that fat embolism, especially of the lungs, may be an\\nimportant factor in producing this result. In other cases death is the\\napparent result of marasmus due to prolonged confinement to the bed\\nand constant pain. I have come to regard the third week as the time\\nwhen the condition is most likely to change for the worse that passed,\\ncases usually do well. The influence of age upon the prognosis is very\\nwell marked, the older the\\nFig. 177. patient the greater the\\nprobability of a fatal ter-\\nmination within a few\\nweeks.\\nThe influence of the seat\\nof the fracture upon the\\nprognosis in respect of re-\\npair has been discussed\\nabove. Speaking gener-\\nally, union may be confi-\\ndently expected in frac-\\ntures at the base of the\\nneck, and I believe that it\\nis much more common\\nafter fractures through the\\nneck than has been sup-\\nposed, and that this fre-\\nquency can be increased\\nby appropriate treatment.\\nBut, on the other hand,\\nunion takes place almost\\ninevitably with some de-\\nformity and with some\\nlimitation of motion at the\\nhip the limb is shortened\\nand everted, and abduc-\\ntion is diminished by the\\nchange in the angle of the\\nneck with the shaft. This shortening may be slight, but it causes\\nmore of a limp than an equal amount in the line of the shaft does,\\nUnunited fracture of the neck of the femur, showing the\\nhypertrophied outer fasciculus of the Y-ligarnent support-\\ning the weight of the body in walking. (Bigelow.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0388.jp2"}, "385": {"fulltext": "FEACTUBES OF THE FEMUR.\\n333\\nFtg. 178.\\nbecause a compensatory abduction of the limb is not so easily made.\\nThe limitation of motion is seldom enough to cause much inconven-\\nience, but the joint may be sensitive to fatigue and weather and may\\neven be persistently painful. Very satisfactory usefulness is possible\\neven in advanced age.\\nFailure of union bony or fibrous does not necessarily cause com-\\nplete disability. There are a number of specimens of complete failure\\nof union obtained from patients who have made considerable use of the\\nlimb for several years after\\nthe fracture they show\\nusually complete disap-\\npearance of the neck and\\nsmooth opposing surfaces\\non the head and side of\\nthe shaft. One of Bige-\\nlow s specimens shows a\\nsimilar condition with\\nmarked displacement up-\\nward of the shaft, the\\nweight of the body hav-\\ning apparently been borne\\nupon it by suspension\\nthrough the Y-ligament\\nand the obturator and in-\\nferior gemellus. Among\\nlater specimens reported\\nwith interesting details are\\ntwo by Reboul l and one by\\nBryce. 2 In such cases that\\nhave come under my ob-\\nservation the usefulness of\\nthe limb has been slight,\\nalthough there were good\\nmotion and little or no\\npain the patient walks\\nwith a marked limp, only\\nwith the aid of a cane or\\nmomentarily upon the limb\\nThe same, seen from, behind, showing the tense obtu-\\nrator tendon and the hypertrophied inferior gemellus.\\n(Bigelow.)\\ncrutch, and bearing the weight only\\nTn the case represented in Fig. 175\\nthe patient walked without a cane. In other cases the pain has been\\nso great and constant that excision of the upper fragment has been\\ndone for its relief.\\nOccasionally, especially in the old and rheumatic, the joint remains\\nstiff and painful even after union has taken place, and sometimes the\\nnew formation of bone upon and about the trochanter is so great that\\nit notably restricts motion in the joint.\\nMr. Bryant s 3 statement that all his hospital cases for many years\\n(forty-two cases, average age seventy) went out with good and useful\\n1 Reboul Bull, de la Soc. Anat., May 25, 1888.\\n2 Bryce Glasgow Medical Journal, July, 1892.\\n3 Bryant Lancet, 1880, vol. i. p. 160, and British Medical Journal, Oct, 12, 1895, p. 889.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0389.jp2"}, "386": {"fulltext": "334 FRACTURES.\\nlimbs indicates results much better than any others I have knowledge\\nof, even if his standard of good and useful is only that the patient\\nTreatment.\\nThe attainment of the ideal object of treatment\u00e2\u0080\u0094 restoration of\\nform and function is rarely to be expected or even sought the\\nlack of control of the upper fragment and the destruction of tissue\\nby crushing prevent the restoration of form, while the proximity or\\ninvolvement of the joint, combined as it usually is with advanced age,\\ninsures limitation of function. In addition, the danger to life in weak\\nand aged patients from measures which cause pain and insure rigid\\nconfinement is such as to forbid in such cases the use of means by\\nwhich alone the displacements could be corrected and sometimes even\\nof those by which union is to be sought. The first indication is to\\nsave life, the second to get union, the third to correct or diminish dis-\\nplacements.\\nThe vital indication often forbids the use of an anaesthetic to complete\\nthe diagnosis or to correct the displacement, even if either should be\\ndeemed very desirable, and sometimes, as when pulmonary or heart\\ndisease is present, even prevents the recumbent position and conse-\\nquently the use of means of retention which otherwise would be chosen.\\nReduction of the displacement, which is not only desirable and proper\\nbut also essential to repair in many fractures of the neck, may be dis-\\nadvantageous in others, and especially in fractures at the base with\\ncrushing, because it would increase the difficulty of repair by creating\\na gap between the fragments. Thus, if the angle of the neck with the\\nshaft has been diminished by crushing at the lower part of the neck\\n(Fig. 168), or if the posterior portion has been similarly crushed (Fig.\\n161), the correction of the displacement (shortening in the first, eversion\\nin the second) would separate the fractured surfaces so far as to endan-\\nger union. And the forcible breaking up of a tight impaction may also\\nendanger repair by creating a mobility between the fragments which\\nit may be difficult to control by apparatus. As the presence or absence\\nof tight impaction or of crushing cannot often be recognized with cer-\\ntainty, and as the consequences of an uncorrected displacement are not\\nserious, it has long been the rule of practice to make no attempt to\\ncorrect eversion or slight shortening and to seek only to prevent their\\nincrease. In marked shortening and in most fractures through the\\nneck the limb can usually be drawn down easily to or nearly to its full\\nlength, and this much at least is certainly permissible. Forcible cor-\\nrection under ether, recommended by Senn and recently again by\\nSoutham, should be limited, in my opinion, to the relatively young\\nand robust patients.\\nRetention has for its object to maintain the position of the limb\\nagainst the displacing action of the muscles and gravity, to keep the\\nfractured surfaces in contact, and at the same time to permit a certain\\ngeneral freedom of motion to the patient which will facilitate the atten-\\ntions necessary to meet his wants, preserve cleanliness, avoid bed-sores,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0390.jp2"}, "387": {"fulltext": "FRACTURES OF THE FEMUR.\\n335\\nand diminish the general ill effects of restraint. The means employed,\\nin their order of frequency, are continuous traction, immobilization by\\nsplints with or without direct pressure upon the trochanter, and fixation\\nof the fragments by nails or sutures.\\nIt has long been noted that satisfactory functional results can some-\\ntimes be obtained by simple rest in bed for a few weeks with only such\\nsupport for the limb as can be given by cushions or a long side-splint\\nwithout traction or a double inclined plane, but it is always advisable\\nand sometimes absolutely necessary to use means which will more surely\\ngive the necessary immobilization in the proper position.\\nContinuous traction can be made by weight and pulley (Buck s\\nextension), or by Hodgen s suspended splint, or in combination with a\\nlong side-splint or hip-splint. The details of their application are\\ngiven in Chapter VII. If Buck s extension is used the foot and leg\\nshould lie upon a Volkmann s sliding-rest (Fig. 40) to promote com-\\nfort and oppose e version of the limb. Direct pressure upon the outer\\naspect of the trochanter to press the fragments together can be made\\nFig. 179.\\nHodgen s suspended splint\\nby a padded band about the pelvis. The weight varies from five or\\nten pounds in the old to fifteen or twenty in the young adult. If\\nHodgen s splint (Fig. 179) is used, the traction can be made greater\\nor less by changing the angle of the supporting cord thus, in the old\\nits upper attachment should be eight or ten inches beyond the vertical\\n(at a height of about five feet), and when more traction is desired,\\nfifteen or twenty inches. The limb should swing just free of the bed,\\nand somewhat abducted. The Hodgen splint greatly promotes the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0391.jp2"}, "388": {"fulltext": "336\\nFRACTURES.\\npatient s comfort and is generally to be preferred, I think, to the other\\nmethods of traction.\\nThe combination of continuous traction and immobilization by a\\nsplint is effected in various ways. The older method was the long\\nsingle or double side-splint with elastic traction, as shown in Fig. 44.\\nIts objectionable feature is the general restraint and immobility which\\nit imposes and which the aged do not bear well. Lighter and shorter\\nsplints with a perineal band for counter-extension, and with traction\\nby screws and springs, such as that shown in Fig. 45, are freer from\\nthis objection.\\nFig. 180.\\nFig. 181.\\nSayre s traction hip-splint.\\nPhelps s hip-splint.\\nThe various metal splints designed for use in hip-joint disease have\\nof late come into some use in the treatment of these fractures, and this\\nuse might, I think, be advantageously extended, certainly in the\\nyounger cases. Such an apparatus can be used simply for immobili-\\nzation, as in the Thomas splint, or combined with traction in the usual\\nmanner. AVith its aid, especially if supplemented by a pelvic band\\nor a pad to press upon the trochanter, the patient, if not too old and\\nfeeble, can leave the bed by the fourth or fifth week, sometimes even\\nearlier, and go about on crutches. Shaffer 1 has reported two very inter-\\nesting and suggestive cases in which by the aid of such a splint with\\ntraction and trochanteric pressure he obtained good union, although\\ntreatment was begun in one three months, in the other nine months,\\n1 Shaffer New York Medical Journal, October 23, 1897, p. 557.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0394.jp2"}, "389": {"fulltext": "FRACTURES OF THE FEMUR.\\n337\\nFig. 182.\\nafter the receipt of the injury. In his first case the trochanteric press-\\nure was made by a pelvic band, in the second by a tourniquet it could\\nbe increased and diminished at will and was borne without discomfort.\\nIn both cases the fracture was thought to be through the neck (intra-\\ncapsular), and the patients were young men. They mark an important\\nadvance in the treatment of failure of union and suggest the more gen-\\neral use of trochanteric pressure, especially in fractures through the\\nneck.\\nEncasement of the limb and pelvis in plaster of Paris is occasionally\\nused, but the discomfort and inconvenience of the method are great and\\nadd to the danger to life in the aged. Senn applied the plaster to both\\nlimbs and the pelvis and made pressure by a steel pin passed through\\nthe soft parts to the outer aspect of the trochanter, but the plan has not\\nmet with favor and appears to be distinctly inferior to the long traction-\\nsplint and pressure by a girdle.\\nThe apparent advantage of a dressing that permits the patient\\npromptly to leave the bed is\\nillusory in most cases, for the\\npatients are too old and feeble\\nto profit by it those that may\\nseem to need the change most\\nare the least able to make\\nit, in the others the gain does\\nnot seem to me to compensate\\nfor the risk. In fractures\\nthrough the neck, and in\\nothers in which the transfor-\\nmation of the bond of union\\ninto bone is delayed such a\\ndrcsJ ig has great advan-\\ntages, for it permits the pa-\\ntient to leave the bed, say in\\nthe second or third month,\\nwithout interruption of the\\nimmobilization.\\nExceptionally, Henne-\\nquin s modification of the\\nwire cuirass, shown in Fig.\\n182, may be of advantage.\\nThe thigh rests in the\\ngrooved splint, the leg and\\nfoot are wrapped in cotton\\nand rest on a chair beside the\\nbed, the knee being partly\\nflexed, and traction is made\\nby a weight attached to a\\nbandage about the upper\\nportion of the leg.\\nDirect fixation of the fragments by metal or bone pins was first\\nemployed (unsuccessfully) by Langenbeck, and then successfully by\\n22\\nHennequin s splint for fracture of the neck of the\\nfemur.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0395.jp2"}, "390": {"fulltext": "338\\nFRACTURES.\\nKonig in 1875. Lately several cases have been reported Cheyne, 1\\nDollinger, 2 Meyer, 3 and Kocher. 4 Kocher 5 says direct fixation cannot\\nbecome a general method, because it is unnecessary in most fractures\\nat the base and because the bone is so soft that the pin has no secure\\nhold.\\nFig. 183.\\nFig. 184.\\nPertrochanteric fracture. (Kocher.)\\nLoretta, 6 in a case of ununited intracapsular\\nfracture in a man thirty-six years old, which\\nhad remained ununited nineteen months, ex-\\nposed it by a posterior incision, freshened the\\nends, which were still in contact with each\\nother, and placed between them a bundle of\\nwires which was withdrawn five days later.\\nTwo months later the pain had ceased and the\\npatient- was able to walk a little.\\nExcision of the upper fragment for the re-\\nlief of pain or disability after failure of union\\nhas been done by Howe, 7 Konig, Lejars, 8 and\\nBolton. 9 In Howe s case the limb remained\\nuseless Lejars reported a good functional re-\\nsult, and Konig says his patient was extra-\\nordinarily content with the result.\\nPertrochanteric fracture.\\n(Kocher.)\\nKocher Loc. cit., p. 303.\\n1 Cheyne British Medical Journal, March 7, 1892.\\n2 Dollinger Centralblatt fur Chir., June 6, 1892.\\n3 Meyer Annals of Surgery, July. 1S93.\\n5 Kocher Loc. cit., pp. 304 and 305.\\n6 Loretta British Medical Journal, August 25, 1888.\\n7 Howe Medical Eecord, vol. xiv. p. 394. 8 Lejars Semaine Med., October 17, 1894.\\n9 Quoted by Whitman, Annals of Surgery, Feb., 1900, p. 149.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0396.jp2"}, "391": {"fulltext": "FRACTURES OF THE FEMUR. 339\\nWhitman lias obtained good results in the young by cuneiform\\nosteotomy at the level of the trochanter minor followed by immobili-\\nzation in wide abduction.\\nC. Fractures Through the Great Trochanter and Neck.\\n(Fractura Pertrochanterica, Kocher.)\\nThis class may be defined as composed of those cases in which the\\nline of fracture begins at or near the lower part of the junction of the\\nneck and shaft and passes through or close below the great trochanter,\\ndividing the bone into two parts, of which the upper is formed by the\\nhead, neck, and upper part of the trochanter. The line of fracture\\nmay be oblique from within outward and upward, or from behind\\nupward and forward. The line of division between these and the\\nsubtrochanteric fractures, the highest of the fractures of the shaft, is\\nmarked by the trochanter minor, which also establishes an important\\nclinical diiference depending upon the action of the psoas-iliacus which\\nis attached thereto. Its action in fractures below that point is to flex\\nthe upper fragment.\\nThe injury is not a common one, and the recorded specimens are\\nfew. To those described in the first edition may be added three from\\nthe museum of Trinity College, Dublin, shown by Bennett 1 to the\\nBritish Medical Association, and five described and figured by Kocher.\\nThe illustrations of Bennett s are so indistinctly printed that the details\\nare not recognizable in two of them the fracture appears to have ex-\\ntended down the outer part of the shaft. Kocher s 2 specimens show\\nmarked angular deformity, apex forward, and some diminution of the\\nangle of the neck, adduction of the shaft (Figs. 183 and 184).\\nThe only one I have seen differed notably from the type-form in\\nthat the line of fracture was very long and oblique, extending from the\\ntop of the trochanter downward and inward to a point which I thought\\nwas well below the lesser trochanter. Because of persistent displace-\\nment and some uncertainty of diagnosis I exposed the fracture by an\\nanterior incision, but did not uncover its lower end. The patient was\\nfifty years old, and recovered with little, if any, shortening.\\nThe mechanism appears to be forcible extension (possibly abduction)\\nof the limb, in which movement the neck and trochanter are arrested\\nby the Y-ligament and the fracture takes place below or through its\\nlower attachment.\\nThe characteristic symptom appears to be the prominence of the\\nangle in front, with pain on pressure at this point and possibly with\\nimmobility of the trochanter and crepitus when the limb is gently\\nrotated. Shortening and eversion are present, the latter due to mus-\\ncular relaxation and loss of control of the lower fragment. In my case\\nthe trochanter was prominent and eversion marked.\\nTreatment. The treatment is immobilization with traction, but pref-\\nerably with more flexion of the hip than is usual in fracture of the\\nneck.\\n1 Bennett British Medical Journal, October 12, 1895, p. 893.\\n2 Kocher Loc. cit., Figs. 140 and 151 to 157.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0397.jp2"}, "392": {"fulltext": "340 FRACTURES.\\nD. Fracture of the Great Trochanter. Separation of the\\nApophysis.\\nOnly a few specimens, not more than a dozen, of this injury, inde-\\npendent of associated fracture of the neck, have been reported. The\\ncause appears commonly to be a blow upon the outer posterior portion\\nof the trochanter occasionally muscular action.\\nThe fragment usually remains attached to the femur by tendinous\\nand periosteal fibres, and is sometimes broken into two or more pieces\\nit is freely movable upon the shaft, but rarely is completely separated\\nfrom it and displaced upward or backward by the attached muscles.\\nPotherat 1 reported a specimen, found in the dissecting-room, with dis-\\nplacement upward of four centimetres.\\nThe specimens of the separation of the apophysis are one in Guy s\\nHospital museum, Key s case (Fig. 185), one in Steevens s Hospital/\\nDublin, Hilton s, 3 Ashton s, 4 Adami s 5 and Daniels s. 6 The last four\\nare quoted from Poland. Two of these (Adami s and Steevens Hosp.)\\nwere obtained in the dissecting-room without history. In the others\\ndeath followed within a few weeks after the violence that was thought\\nto have caused the separation, and was preceded by fever and suppura-\\ntion about the upper part of the bone. In\\nFig. 185. all but one (Daniels) the separation was\\nexactly along the epiphyseal line, and the\\nfragment was not displaced it seems to me\\nhighly probable that they were cases of\\nosteomyelitis, possibly originating in the-\\ntrauma.\\nMcCarthy s case seems to me clearly to\\nbe osteomyelitis rather than fracture.\\nSymptoms. The symptoms are local pain\\non pressure, and mobility of the fragment\\nFracture or diastasis of the great x\\ntrochanter. (Bryant.) recognizable if the swelling is not too great.\\nMost of the patients have been able to walk,\\nthough with pain and rotation of the hip was painful.\\nTreatment. The treatment is immobilization, preferably with the\\nlimb abducted and rotated outward to diminish the displacing action of\\nthe attached muscles. Local pressure by a bandage about the hips has\\nbeen used, but is probably unimportant.\\nE. Fracture of the Trochanter Minor.\\nBennett 7 reports a specimen of this fracture in the museum of Trinity\\nCollege, Dublin, associated with a united intracapsular fracture of the\\nneck. The accompanying illustration shows the trochanter detached\\nwith a small portion of the shaft. He adds that he has recognized the\\nfracture in the living, but gives no details.\\n1 Potherat Bull, de la Soc. Anat., February, 1888.\\n2 Transactions Pathological Society of Dublin, vol. vii., n. s., quoted by Bennett.\\n3 Hilton Guy s Hosp. Bep., 1865, p. 342. 4 Ashton Lancet, Feb., 1875, p. 231.\\n5 Poland Traumatic Sep. of Epiphyses, p. 666.\\n6 Trans. London Path. Soc, vol. xlvii.. p. 174.\\n7 Bennett British Medical Journal, October 12, 1S95, p. 893.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0398.jp2"}, "393": {"fulltext": "FRACTURES OF THE FEMUR. 341\\nThe only other specimens or cases that I know of are Fenwick s and\\nJulliard s. Fenwick s is reported by J. Hutchinson, Jr./: a boy,\\nseventeen years old, leaped upon a fence and fell backward, breaking\\noff the lesser trochanter, apparently by the pull of the psoas-iliacus.\\nThis was verified by incision. He died of septicaemia on the seven-\\nteenth day. The specimen is in the museum of McGill College,\\nMontreal.\\nJulliard s 2 patient was a man eighty-two years old and was injured\\nby foiling as he rose from bed. Severe pain in the hip and marked\\neversion and disability which persisted until his death, a fortnight\\nlater. Diagnosis, fracture of the neck of the femur. The autopsy showed\\na large extravasation of blood in the muscles, the joint and neck of the\\nfemur intact, the lesser trochanter broken off and adherent only by a\\nstrip of periosteum. The upper extremity of the femur shows a cavity\\nas large as a small nut and presents a sarcomatous degeneration.\\n2. FRACTURES OF THE SHAFT OF THE FEMUR.\\nThe highest of the fractures considered in this section are the sub-\\ntrochanteric, the lowest the supracondyloid intercondyloid or T-frac-\\ntures will be described in the following section. Exceptional and\\nirregular forms are occasionally seen, spiral and oblique fractures in\\nwhich the main line or a fissure passes from the upper part of the shaft\\nto the neck and the trochanter, and even in which the upper fragment\\nhas been split longitudinally through the trochanter.\\nCauses. The causes of fracture are direct and indirect violence and\\nmuscular action see Chapter III.\\nPathology. All the varieties of fracture that may occur in long bones\\nare met with in the femur, but in the great majority of cases the frac-\\nture is oblique and often extremely so, the obliquity usually correspond-\\ning to the normal curves of the bone that is, in the middle part of the\\nbone it runs from behind forward and downward, and in the upper\\nthird forward and outward. Transverse fracture is rare in adults, but\\nmore common in children.\\nThe displacement is marked, and is the effect of the fracturing cause,\\nof the contraction of the powerful muscles of the thigh, and of the\\nswelling of the limb beneath the fascia by which it is broadened and\\nshortened. The lower fragment usually passes behind and to the inner\\nside of the upper one and is sometimes rotated outwardly in addition\\nthere is angular displacement, the angle usually being directed forward\\nor forward and outward, but sometimes backward or inward.\\nInclination forward and outward of the lower end of the upper frag-\\nment after fracture in the upper third is the rule and is mainly due\\nto muscular action, the contraction of the gluteal muscles and the\\npsoas upon the upper fragment and of the adductors and the flexors of\\nthe leg upon the lower one. The tendency of the former is to tilt the\\nupper fragment forward, outward, or in both directions that of the\\nlatter is to draw the lower fragment up against the upper one, and this\\n1 Hutchinson British Medical Journal, December 30, 1S93, p. 671.\\n2 Julliard Progres Med., 1879, vii., p. 825.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0399.jp2"}, "394": {"fulltext": "342\\nFRACTURES.\\nwill produce an angular displacement in any direction that is favored\\nby the line of fracture. The fact that the displacement is sometimes\\nbackward or inward does not disprove the influence of the muscles\\nattached to the upper fragment, as has been argued the principal\\nagency is the drawing upward of the lower fragment, and if the frag-\\nments are so related at the seat of fracture that the upper one is pushed\\nin a different direction from that in which its muscles would draw it the\\nlatter must yield. In the extreme case figured by Sir Astley Cooper\\n(Fig. 186) it can be seen how great the angular displacement and at\\nthe same time the overriding can be under these circumstances. The\\nangular displacement necessarily produces shortening, and this short-\\nening varies according to the angle and, the angle being the same,\\nFig. 186.\\nFig. 187.\\nFracture of the upper third of the femur; union\\nwith great displacement. (A. Cooper.) Transverse fracture of the femur. (Gurlt.)\\naccording to the distance of the fracture below the neck of the bone.\\nIn the same specimen outward rotation of the lower fragment is also\\nvery marked. In transverse and toothed fractures the displacement\\nmay be lateral or angular or both, and if the lateral displacement is\\nsufficient to free the fragments they may override, as in Fig. 187.\\nExtreme obliquity of the fracture, which is not uncommon, leads\\noccasionally to a complication which may be very troublesome and may\\ntransform a simple fracture into a compound one, the penetration of\\nthe muscle and sometimes of the skin by the sharp end of the upper\\nfragment. This is specially likely to occur in fractures of the lower\\nthird, the sharp lower end of the upper fragment perforating the quad-\\nriceps or even the skin. The perforation of the muscle is directed\\ndownward as well as forward, probably because the knee is flexed at", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0400.jp2"}, "395": {"fulltext": "FRACTURES OF THE FEMUR. 343\\nthe moment when it occurs, and then when the joint is straightened\\nthe muscle retracts upward along the spike of bone this makes it neces-\\nsary to ilex the knee again in order to free the bone, thus drawing the\\nmuscle down past its end. In these fractures of the lower third the\\nlower fragment is sometimes tilted (presumably by the action of the\\ngastrocnemius) so that its upper end is directed obliquely backward,\\nFig. 188.\\nFracture of left femur close below the trochanters.\\nand it is sometimes split by a line of fracture running between the\\ncondyles. See Intercondyloid Fractures.\\nOther complications are rare, the vessels and nerves not lying in\\nsufficiently close relations with the bone to be often injured. Muller\\nreported a case of rupture of the inner and middle coats of the femoral\\nartery in a fracture at the junction of the middle and lower thirds;\\ngangrene threatening^ amputation was done death. And Selenkow 2\\nreported one of laceration of the femoral vein death followed, appar-\\nently the result of officious treatment. The danger is greater in the\\nlower third than elsewhere, and pressure upon the vessels when they\\n1 Muller Deutsche med. Wochenschrift. October 11, 1S88.\\n2 Selenkow St. Petersburg med. Woch., October 8, 1888.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0401.jp2"}, "396": {"fulltext": "344\\nFRACTURES.\\nare not torn may cause gangrene of the leg either by its continuance\\nor by the formation of a thrombus in consequence of the bruising.\\nFissures extending upward and downward from the seat of fracture\\nare probably not infrequent, especially in gunshot fractures.\\nDouble fractures have been observed, and, according to Malgaigne,\\nthere is a specimen of triple fracture in the Musee Dupuytren. Double\\nfracture should always be looked for when the\\ncausative violence has been great. Comminuted\\nor splintered fractures are not uncommon, espe-\\nciallv among fracture:\\nbv direct violence, and\\nthe splinters may be large.\\nThe effusion into the knee-joint which is ob-\\nserved so frequently in the course of fractures\\nof the thigh has received particular attention\\nsince 1870, when Kouge, of Lausanne, first\\nwrote concerning it. Among those who have\\nstudied it most carefully are Gosselin, 1 Berger, 2\\nMarjolin, Alison, 3 and Hennequin, 4 the two\\nformer attributing it to the passage of extra-\\nvasated blood into the joint, the third and\\nfourth to interference with the return venous\\ncirculation, and the last, in common with Ver-\\nneuil and others, to an associated sprain.\\nOthers again have sought the cause of the\\neffusions noted in the later periods of the case\\nin the prolonged immobility and the extended\\nposition. An appreciable effusion makes its\\nappearance in a majority of the cases within\\nthe first three days following the injury; it is\\nmost prompt in children and when the frac-\\nture is in the lower third, and is more common\\nafter fracture by indirect than after fracture\\nby direct violence. It disappears promptly in\\nchildren, more slowly in adults, and may per-\\nsist for years.\\nSymptoms. The symptoms are pain, loss of\\nfunction, abnormal mobility, deformity, and\\ncrepitus. As the bone is deeply placed under\\nthick muscles, irregularity in its outline can-\\nnot be recognized by the touch angular dis-\\nplacement can often be readily recognized in\\nthin patients by the eye, but the method of\\nexamination which renders the best service in\\nthis respect is the comparative measurement of the two limbs. The\\nfixed points commonly used for this purpose are the anterior superior\\nspinous process of the ilium and the tip of the external malleolus the\\nFracture of the neck of the\\nfemur and of the shaft. A\\nsplinter, 5 inches long and\\nnearly 1 inch wide, composed\\nof the cortical layer, has been\\nturned completely about its\\nlong axis and become united,\\nwith its original periosteal\\nsurface in contact with the\\nother fragments. (Figured by\\nGurlt from the Museum of\\nthe Royal College of Surgeons,\\nEngland, Xo. 454.)\\n1 Gosselin Clinique de 1 Hopital de la Charite. 2 Berger These de Paris, 1873.\\n3 Alison These de Paris.\\n4 Hennequin Loc. cit.. p. 78. (See also the discussions in the Bulletins de la Societe\\nde Chirurgie. 1878, pp. 6 and 336.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0402.jp2"}, "397": {"fulltext": "FRACTURES OF THE FEMUR. 345\\nrules for making these measurements and the precautions to be taken\\nto guard against error have been given in Chapter IV. and in the\\npreceding section of this chapter, page 327 the capital point is to\\nmake sure that the two limbs form the same angle with the pelvis,\\nand the best method of doing this is to stretch a tape across the abdo-\\nmen from one anterior superior iliac spine to the other, and a second\\none at right angles to the first from its centre downward, and then to\\nplace the ankles at equal distances from the second line. The shorten-\\ning may vary from a small fraction of an inch to two, four, or even\\nsix inches.\\nAbnormal mobility may be recognized by placing the hand under\\nthe thigh at the suspected seat of fracture and gently lifting it, or\\nby holding the upper portion of the thigh down with one hand and\\ngently lifting the leg or moving it from side to side with the other, or\\nby observing whether the great trochanter moves with the leg when\\nthe latter is gently rotated. The examination for abnormal mobility\\nand crepitus should be made very gently, and should not be prolonged\\nif the latter is not promptly obtained.\\nPrognosis. Any fracture of the femur is a serious injury to this\\nextent, that its proper treatment makes confinement to the bed for\\nseveral weeks desirable, that it will make it difficult for a long time\\nfor the patient to get about even with crutches, and that it may lead\\nto shortening of the limb, even if not to a persistent limp. It also\\nFig. 190.\\nFracture of the shaft of the femur.\\nexposes to the possibility of a fatal result, especially in the aged and\\nalcoholic, and to that of gangrene of the limb by rupture or bruising\\nof the main vessels or by pressure upon them.\\nA simple fracture without displacement, or suitably reduced, will\\nusually consolidate in six or seven weeks sufficiently to allow the\\npatient to get about on crutches, and he will be able to bear his weight\\nsafely upon the limb, and to discard the crutches in three or four weeks\\nmore. In exceptional cases the consolidation may be delayed, and it\\nhappens occasionally that a secondary fracture occurs soon after the\\npatient first leaves his bed, usually in consequence of a fall.\\nMost authorities assert that an oblique fracture of the shaft of the\\nfemur cannot be cured without some permanent shortening. Since the\\ntime of Desault the possibility of a better result has been claimed by", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0403.jp2"}, "398": {"fulltext": "346 FRACTURES.\\ndifferent surgeons, and for different dressings, but no method has yet\\nwon a general acceptance of its claim. While there is no reason to\\ndoubt the possibility of a union without shortening, and while I believe\\nsuch union has been obtained in some cases, I do not believe there is\\nany method of treatment which can be depended upon to secure it in\\nany given case, for it can never be known in advance whether or not\\nthe patient will be able to support the traction and pressure necessary\\nto success. Some surgeons have claimed an actual elongation of the\\nlimb by the use of continuous traction. Although a certain doubt\\nis thrown over such assertions by the acknowledged difficulty of making\\naccurate measurements, and by the possibility of a previously existing\\ninequality in the length of the limbs, the occurrence is not impossible,\\nhowever improbable it may be.\\nThe persistence of some shortening, even an inch, does not necessarily\\ncause the patient to limp, since it may be compensated for by an inclina-\\ntion of the pelvis. The rigidity in the knee is likely to persist for a length\\nof time that is greater if the patient is older and of a rheumatic habit.\\nThe prognosis in compound fractures is particularly grave when the\\ninjury has, been produced by direct violence and in a fracture of both\\nthighs, particularly if either is compound, the shock is usually so great\\nas to put the patient s life in serious danger.\\nTreatment. The dressings now in use for the treatment of fracture\\nof the shaft of the femur are Buck s extension, Hodgen s suspended\\nsplint, the long side-splint or the hip-splint, usually with traction,\\nencasement in plaster of Paris, and the double inclined plane. All\\nhave been described in detail in Chapter VII. It remains only to\\nnote their special advantages and indications.\\nThe long side-splint without traction should be used only as\\na temporary dressing during transport or for a few days at first w T hen\\nthe condition of the patient delirium, shock, associated injuries con-\\ntraindicates one which would not be sufficiently restraining, or the\\napplication of which would be too exhausting.\\nThe long side-splint with traction may be used temporarily\\nlater in the case if the patient is to be transported to a distance it is\\ncheaper than a hip-splint, can be readily improvised, and as it extends\\nalmost to the axilla it insures greater immobilization. Indeed, the\\nimmobilization of the trunk, and the consequent restraint, is the objec-\\ntion to its general use. In a somewhat shorter form (Fig. 42), extend-\\ning only to the waist, it is widely used in England throughout the\\ncourse of the case. Weed s splint (Fig. 43) represents a highly\\ndeveloped form, adjustable to limbs of different lengths and making\\ntraction by a spring.\\nBuck s extension (Fig. 40) is the method in general use in\\nthe United States and very largely in Europe. It is suitable for the\\ngreat majority of cases, except the subtrochanteric, is easily borne, and,\\nas it permits a certain freedom of motion, promotes the comfort and\\nwell-being of the patient. It also permits constant supervision of the\\nfracture and easy recognition of shortening or angular displacement.\\nAn objection to it is that the patient tends to turn on the injured side\\nand thus rotate the upper fragment outward while the lower one and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0404.jp2"}, "399": {"fulltext": "FRACTUBES OF THE FEMUR.\\n347\\nthe foot are kept upright. This can be measurably met by a small\\nfirm cushion behind the trochanter, as can also the occasional outward\\nrotation of the upper fragment by gravity. In the higher fractures,\\ntoo, it is not always easy to maintain as much abduction of the limb\\nas may be desirable. Sagging of the fragments, with production of a\\nbackward or outward angular displacement, can be prevented by cush-\\nions or a long posterior plaster gutter.\\nHodg-en s suspended splint (Fig. 179) gives even greater comfort\\nand freedom, permits greater variety in the attitude given to the limb\\nabduction and flexion for the higher fractures and allows the knee\\nto be kept partly flexed, an easier position. It is specially advan-\\ntageous in the older and feebler patients. I do not think it immobilizes\\nthe fractures quite so well as Buck s extension does, but I have found\\nFig. 191.\\nFig. 192.\\nSayre s traction hip-splint.\\nPhelps s hip-splint.\\nno serious inconvenience from this and I use the splint more and\\nmore in preference even to Buck s, and always in high fractures and\\nin those of the lower third in the latter because of the flexion of\\nthe knee.\\nEncasement in plaster of Paris, including the pelvis, after\\nhaving been widely used as the preferred treatment for some years\\nafter 1870, has now largely given place to continuous traction during\\nthe first month or six weeks, but is still much used in the later stages\\nwhen displacements are no longer to be much feared and the patient", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0405.jp2"}, "400": {"fulltext": "348\\nFRACTURES.\\nDeeds only to be protected against accident while he goes about on\\ncrutches and awaits complete consolidation. In cases of delayed union\\nit may even permit the patient to bear part of his weight upon the\\nlimb and thus hasten ossification of the bond. It is still sometimes\\nused from the beginning, and the patient allowed to go about on\\ncrutches., but marked displacement can occur under such circumstances\\nand the chance, in my opinion, should not be taken. The absence of\\na fixed upper point of support makes it easy for overriding and angular\\ndisplacement to occur.\\nThe hip-splixt, in any of its various forms (Figs. 191 and 192),\\nmeets the same indications more conveniently, though more expen-\\nsively, and as it can be combined with traction (as in hip-joint disease)\\nit can be safely used at an earlier period in the case. It is especially\\nconvenient in cases of delayed union, for it relieves the patient from\\nconfinement to bed.\\nThe double ixclixed plaxe (Fig. 44) is occasionally useful as a\\ntemporary dressing in very severe injuries when the swelling is great\\nor the circulation embarrassed also in compound fractures with so\\nFig. 193.\\nAnterior suspended splint, without traction, in compound fracture.\\nmuch loss of bone that traction is not required to prevent overriding\\nI have recently brought a very severe case of the latter kind to a\\nsuccessful result by its aid at the Xew York Hospital.\\nThe same indications can be met by a long anterior splint flexed at\\nthe knee and suspended from a horizontal bar placed a short distance\\nabove it (Fig. 193). Such a splint can be conveniently made of a\\nstout iron rod, like Smith s splint (Fig. 33), but it is better to have\\nthe leg horizontal it permits an easy change of the dressings of the\\nwound without disturbing the fragments but, like the inclined plane,\\nit cannot be trusted when traction is needed to keep the fragments in\\nposition.\\nIn fractures of the upper third the thigh should be flexed and\\nabducted in order that the lower fragment shall be in line with the\\nupper one which usually assumes this attitude, and for this the Hodgen\\nsplint is the most convenient.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0406.jp2"}, "401": {"fulltext": "FRACTURES OF THE FEMUR. 349\\nAfter five or six weeks, in most cases, abnormal mobility will have\\ndisappeared or so far diminished that traction is no longer needed\\nangular displacement is then the only one that is likely to take place,\\nand this can be prevented by plaster-of-Paris encasement. If the\\nabnormal mobility has wholly disappeared I usually remove the appa-\\nratus and keep the patient in bed for a few days without any dressing\\nthen I apply a plaster dressing, including the pelvis if the fracture is\\nabove the lower third, and allow him to go about on crutches. After\\nanother fortnight the plaster is removed.\\nIn young children vertical suspension is by far the most convenient\\nand satisfactory method of treatment. Strips of adhesive plaster are\\napplied, as in Buck s extension, to both legs and attached by cords to\\na support immediately above the child so that the pelvis rests lightly\\nupon the bed (Fig. 194). I have sometimes made this attachment\\nelastic by introducing a rubber cord or by using a support with a flex-\\nible arm, but have found no great advantage in it and some disadvan-\\ntage because of the gradual yielding. The fixed support is also better\\nthan the weight and pulley which are sometimes used. The position is\\nwell borne and makes it easy to keep the child dry and clean. The\\ncontact with the bed should be so light that the hand can be passed\\neasily under the pelvis.\\nIn older children over ten years I have found Buck s extension\\nthe best, and decidedly preferable to the double side-splint, with which\\nit is difficult to prevent shortening and angular displacement. Fairly\\nfirm union may usually be expected in three weeks.\\nIn fractures of the lower third the engagement of the lower end of\\nthe upper fragment in the quadriceps, or even in the overlying skin,\\nadds greatly to the difficulty of reduction. This can sometimes be\\nmade by flexing the hip and the knee to a right angle, thus drawing\\nthe muscles downward along the penetrating fragment, and then com-\\npleting the disengagement by strong traction in the axis of the shaft,\\nthe flexion being maintained. If this fails the skin and fascia must\\nbe freely incised over the end of the fragment and the bone disengaged\\nby direct manipulation. If the point of the bone has perforated the\\nskin the opening should be enlarged, both to facilitate the disengage-\\nment and to evacuate the extra vasated blood. The Hodgen splint\\nshould be preferred in the treatment of these fractures, for it permits\\nmoderate flexion of the knee and thus tends to avoid the tilting of the\\nlower fragment which is so common when the knee is kept extended.\\nIf the artery is torn it may be tied in the wound if the vein alone\\nis torn it may be tied, or, if not torn entirely across, the deep soft parts\\nmay be sutured over it so as to oppose escape of the blood, and the\\nattempt made to save the limb, but if gangrene appears amputation\\nmust be done at once. Division of both artery and vein justifies im-\\nmediate amputation.\\nDelayed union, if the fragments are in a fairly good position and\\ntheir mobility is not great, is best treated ordinarily by plaster-of-Paris\\nencasement, including the pelvis, and by bearing some weight upon the\\nlimb with the support of crutches. I have seen union become solid as\\nlate as the sixth month.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0407.jp2"}, "402": {"fulltext": "350 FRACTURES.\\nIn failure of union, when the position of the fragments is bad and\\nthe mobility marked after three or four months, resection of the ends\\nand readjustment are required. I have always made the incision on\\nthe outer side, cut the ends square, and kept them in contact by a\\nFig. 194.\\nFracture of the thigh; vertical suspension. The fracture is compound in the patient on the\\nright.\\nsuspended splint or by resting the limb upon an inclined support so\\nthat the leg and lower fragment would constantly press downward\\ntoward the upper one. Occasionally I have used plaster of Paris over\\nthe primary dressing of the wound. For other details see Chapter\\nVIII.\\n3. FRACTURES AT THE LOWER END OF THE FEMUR.\\nIn this group are here included intercondyloid fractures, separation\\nof the lower epiphysis, and fracture of either condyle.\\nA. Intercondyloid Fractures.\\nIn these fractures both condyles are separated from the shaft and\\nfrom each other, the line being T-shaped or Y-shaped. The fracture\\nis sometimes classed as a supracondyloid fracture with splitting of the\\nlower fragment, since that is thought to be the mode of production in\\nmost cases the shaft is first broken and then the upper fragment pene-\\ntrates and splits the lower (Fig. 196). The claim that the fracture is\\ncaused by a violence transmitted through the patella which acts as a\\nwedge and splits off the condyles does not bear the test of experiment\\nor harmonize with the fact that in a fall the blow is rarely received\\nupon the patella. Trelat, 1 in an elaborate article in which it was first\\n1 Trelat Archives Generales de Med., 1854, vol. ii. p. 59.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0408.jp2"}, "403": {"fulltext": "FRACTURES OF THE FEMUR.\\n351\\nsought to give a detailed and full account of fracture of the lower end\\nof the femur, points out that in six cases of supracondyloid fracture\\nthe average age was twenty-seven and a half years, while in thirteen\\ncases of intercondyloid fracture it was forty-eight and a half years.\\nFig. 195.\\nFig. 196.\\nIntercondyloid fracture of the femur.\\n(Bryant.)\\nComminuted fracture of the femur, with\\nsplitting of the condyles. (Gurlt.)\\nThe number of cases seems to me too small to warrant the inference\\nthat the difference is an essential and constant one.\\nThe main line of fracture across the shaft may be very oblique, as\\nin the common fracture of the lower third, but is usually more nearly\\ntransverse in its general direction with splintering which makes the\\nsurface irregular, and lies close to the base of the condyles.\\nThe line between the condyles follows the intercondyloid notch, and\\nis vertical and antero-posterior. In a case observed by Nelaton and\\nreported by Trelat, 1 the mechanism of the separation of the condyles\\nis shown plainly, the upper fragment being impacted into the lower\\none, but mainly on the inner side, and the separation of the condyles\\nmerely a fissure (Fig. 197). Usually, however, the condyles are com-\\npletely detached from each other and sometimes separated far enough\\nto allow the patella to sink in between them, and either may be further\\ndisplaced backward than the other, with a corresponding rotation of the\\nleg since the tibia retains its connection with them. The crucial liga-\\nments may be torn longitudinally or transversely, and then the attach-\\nment of the tibia is less close.\\nThe injury is frequently compound, from within outward by the end\\nof the upper fragment, especially when the fracture is oblique danger-\\nous pressure by one or the other fragment upon the popliteal vessels is\\nnot uncommon, and the vein and artery have been torn, the vein the\\n1 Trelat Loc. cit., p. 73.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0409.jp2"}, "404": {"fulltext": "352\\nFRACTURES.\\nFig. 197.\\nmore frequently. In one of my cases fracture of both femurs by a\\nfall of forty feet, the patient dying in thirty-six hours one fracture\\nwas compound by perforation of the muscle and skin in front by the\\nupper fragment, the other was simple, but the popliteal vein was torn,\\nand there was a large extravasation of the blood in\\nthe thigh. In each the lower end of the upper frag-\\nment was very irregular but not broken obliquely,\\nand there was much comminution between it and\\nthe condyles the compact layer on the posterior\\nface of the bone was pressed in toward the centre\\nas if the lower fragment had been bent violently\\nbackward upon the other.\\nThe recognition of the main line of fracture is\\neasy by attention to the usual signs that of the\\nline between the condyles is made by noting the in-\\ndependent mobility of the two condyles on each\\nother when they are grasped and moved backward\\nand forward, and pain when they are pressed to-\\ngether laterally.\\nShortening of the limb is common, but the sign\\nis one that is seldom needed for the diagnosis in an impacted fracture\\nit might be useful in distinguishing the lesion from fracture of one con-\\ndyle alone.\\nEnlargement of the knee by separation of the condyles is rare, or\\nat least is difficult of recognition on the other hand, enlargement by\\neffusion or hemorrhage into the joint is constant.\\nInterconclyloid fracture\\nof femur.\\nFig. 198.\\nPlaster splints. A is a wire bent into loops for the purpose of suspension.\\nPrognosis. The prognosis is serious as regards both the life of the\\npatient and the integrity of the joint. Of 26 cases collected by Hen-\\nnequin 7 died, 3 were amputated, and 16 recovered. The gravity of", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0410.jp2"}, "405": {"fulltext": "FRACTURES OF THE FEMUR. 353\\nthe injury depends mainly upon the implication of the joint and the\\ntraumatic arthritis excited thereby, which may easily end in suppura-\\ntion and which in any case is very likely to result in more or less stiff-\\nness.\\nTreatment. As the tendency to overriding and angular displacement\\n(except when the main fracture is oblique) is not so marked as in the\\nhigher fractures, continuous traction need not be so vigorous or so pro-\\nlonged. I prefer the position of slight flexion of the knee and there-\\nfore habitually use the Hodgen splint. Or the limb may be simply\\nkept on a double inclined plane, or suspended by an anterior splint or\\na wire gutter, or encased in plaster or in plaster splints (Fig. 198).\\nBecause of the length of the limb above the fracture, and the more\\nsecure hold thereby given to a splint, the limb may be put in plaster or\\nin splints and the patient allowed to leave the bed earlier than in other\\nfractures of the shaft.\\nInjury to the popliteal vessels may necessitate amputation. The\\nindication is given by the appearance of gangrene of the leg or by\\ndirect recognition of the injury to the vessels. It may be proper at\\nthe beginning in a compound case to try to save the limb by ligature\\nof the torn artery or by suturing the deep soft parts over the vein if\\nthat is only partly torn across if both are torn immediate amputation\\nis justifiable.\\nB. Separation of the Epiphysis.\\nTraumatic separation of the lower epiphysis of the femur is far more\\nfrequent than that of any other, and nearly a hundred cases have been\\nreported and collected by various surgeons. The first paper dealing\\nspecifically with separation of this epiphysis was a very complete one\\nby Delens. 1 Later ones are by J. H. Packard, 2 J. Hutchinson, Jr., 3\\nK. H. Harte/ A. H. Meisenbach, 5 and Charles McBurney. 6\\nAlthough the epiphysis may not unite with the shaft before the\\ntwenty-fifth year, in none of the reported cases has the patient been\\nmore than twenty years of age.\\nCause. The cause in almost all cases has been great violence, extend-\\ning or abducting the knee, and in a singularly large proportion of cases\\nit has been the engagement of the leg between the spokes of a revolving\\nwheel. In one or two cases the injury has been inflicted upon the\\ninfant during delivery by the feet and has then been attributed, but\\nprobably incorrectly, to direct traction. In a few cases the injury has\\nbeen caused in attempts to straighten a stiff knee or in osteoclasis for\\ndeformity.\\nPathology. The separation, as is the rule also at other points, takes\\nplace between the conjugal cartilage and the diaphysis, is usually com-\\nplete and clean, but sometimes leaves attached to the epiphysis one or\\nmore scales broken from the diaphysis or diverges to pass through a\\n1 Delens Archives Generales de Medecine, 1884, vol. xiii. p. 272.\\n2 Packard Annals of Gynecology and Pediatry, November, 1890.\\n3 Hutchinson British Medical Journal, December, 1894, p. 671.\\n4 Harte: Transactions American Surgical Association, 1895.\\n5 Meisenbach Medical Eecord, October 5, 1895.\\n6 McBurney Annals of Surgery, March, 1S96.\\n23", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0411.jp2"}, "406": {"fulltext": "354\\nFRACTURES.\\nFig. 199.\\nportion of the diaphysis. The periosteum is always freely stripped from\\nthe shaft, often for several inches, remaining attached to the epiphysis\\nas an irregular sleeve. In a few cases the epiphysis has in addition\\nbeen split longitudinally between the condyles.\\nThe common displacement is of the epiphysis forward and to one\\nside, usually the inner, corresponding apparently to production by\\nhyper-extension of the knee in other cases it has been to the inner or\\nthe outer side, doubtless when produced by abduction or adduction.\\nWhen displaced forward it has also passed upward upon the anterior\\nsurface of the shaft with or without rotation (Plate XIX.). In a few\\ncases it has been rotated about the vertical\\naxis so that one condyle presented in the\\npopliteal space, in others about a transverse\\naxis so that the surface of separation was\\ndirected backward.\\nThe knee-joint is not often involved, but\\nsometimes the capsule is torn and the joint\\nfilled with blood and exudate.\\nIn a large proportion of cases the injury\\nhas been compound, the lower end of the\\nshaft projecting through the skin on the\\nside or in the popliteal space. The pop-\\nliteal vessels have been torn or, more fre-\\nquently, so pressed upon that circulation\\nwas interrupted or seriously diminished.\\nIn one case a popliteal aneurism appeared\\nseveral years later and was attributed to\\nthe accident.\\nIn some, even of the cases which were\\nnot compound, suppuration has ensued in\\nothers the pressure of the end of the frag-\\nment has caused the skin to slough, and in\\nothers gangrene of the leg followed.\\nIn a few cases of recovery without displacement arrest or diminution\\nof growth has been observed. Puzey l noted in a lad sixteen years old\\nat the time of the accident shortening of one inch three years later.\\nIn other cases examined with reference to this point growth has not\\nbeen interfered with.\\nSymptoms. Examination under anaesthesia should make it possible,\\nunless the swelling is too great, to establish the identity of the two\\nfragments and their relations to each other, to recognize that one is the\\nlower end of the shaft and the other the epiphysis in normal relations\\nwith the tibia. This excludes dislocation and then the distinction,\\nnot a practically important one, between low fracture through the shaft\\nand separation of the epiphysis is made by the character of the crepitus\\nbony in one case, cartilaginous in the other the age of the patient,\\nand the relations of the line of fracture to the adductor tubercle which\\nlies immediately above the conjugal cartilage.\\nWhen the injury is compound the denudation of the shaft and\\n1 Puzey: Liverpool Medico-Chirurgical Journal, January, 1885, p. 41.\\nSeparation of the lower epiphysis\\nof the femur. Incomplete displace-\\nment forward. (St. Bartholomew s\\nHospital, Poland.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0412.jp2"}, "407": {"fulltext": "FRACTUBES OF THE FEMUR. 355\\nthe regular, slightly curved surface of its end demonstrate its char-\\nacter.\\nRupture of, or pressure upon, the artery is shown by the absence of\\npulsation in the vessels below rupture of the vein might be suspected\\nif the bleeding was profuse and venous, but could be demonstrated only\\nbv direct inspection.\\nTreatment. The recorded cases show a very large proportion of am-\\nputations, primary or secondary, and of deaths from shock, infection,\\nand operation, but it seems reasonable to believe, especially in view of\\nsome of the later cases, that the future will show much, better results.\\nPatients have suffered in the past both from infection, which can now\\nbe more generally avoided, and from a consequent reluctance to take\\nthe chances of conservative treatment in compound injuries or to make\\nan incision in the simple ones in order to effect reduction. Some of\\nthe amputations have clearly been justified, and will still be justified\\nin similar cases, by the extent of the injury to the soft parts, but I\\nfeel sure that a much larger proportion of the compound injuries will\\nbe successfully treated with preservation of the limb, and of the simple\\nones with restoration of form and function. Dr. McBurney s two\\ncases are particularly encouraging.\\nIf, in a simple case uncomplicated by injury to the vessels, complete\\nreduction of the displacement cannot be made by traction and manip-\\nulation, it would be not only proper, but, I think, imperative, to expose\\nthe fracture by a longitudinal incision, preferably on the outer side in\\nfront of the tendon of the biceps, in order to overcome the obstacle,\\nwhich would doubtless be the interposed periosteum and perhaps some\\nmuscular bundles.\\nIn a compound case free enlargement of the wound in the skin and\\nfascia would probably make reduction possible without the aid of resec-\\ntion of the end of the shaft. If the injury to the vessels is such that\\nthe vitality of the limb cannot be preserved, amputation must be done,\\nand it should be as low as the condition of the soft parts will permit,\\nthat is, through or a short distance above the fracture. It seems even\\npossible that in some cases the amputation might be done a short dis-\\ntance below the knee so as to preserve that joint to the patient.\\nHutchinson advises that the limb should be immobilized in full\\nflexion after reduction, on the theory that the pressure of the quad-\\nriceps in that position would keep the fragment securely in place. I\\ndoubt if there is enough tendency to displacement to justify so irksome\\nan attitude.\\nC. Fracture of Either Condyle.\\nFracture of a single condyle may be caused by direct violence, as in\\na fall upon the bent knee, or by avulsion, the force being exerted\\nthrough one of the lateral ligaments to tear off one condyle by\\nbending the leg toward the opposite side, or by the direct pressure of\\nthe head of the tibia against the condyle on the side toward which the\\nleg is bent. In a case reported by A. H. Crosby 1 the fracture was\\n1 Crosby New Hampshire Journal of Medicine, 1857.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0413.jp2"}, "408": {"fulltext": "356\\nFRACTURES.\\nFig. 200.\\ncaused by a twist of the leg while the patient, a youth of twenty-one\\nyears, was resting his entire weight upon it.\\nThe specimens of fracture of a single condyle are not numerous, but\\nthey show that the line may run for a considerable distance upward\\nfrom the intercondyloid notch so that the fragment terminates above in\\na long point, or it may turn abruptly above the edge of the articular\\ncartilage toward the side of the bone, as in Fig. 200, which represents\\na specimen given to the Dupuytren Museum by Yerneuil in this case\\nthe periosteum on the inner side and the crucial ligaments were untorn\\nand the fragment was not displaced. 1\\nThe fragment may be displaced upward, or to one side, or it may be\\nswung around so as to lie partly behind or partly in front of the femur,\\nusually the former. As it remains attached to\\nthe tibia the first and third displacements are\\nindicated by the posture of the leg, the second,\\nwhich is very rare, by the greater breadth of the\\nknee.\\nAs the displacement is usually slight, and the\\nconnections untorn, the injury may easily be over-\\nlooked, or, if suspected, not recognized with cer-\\ntainty. In a case under the care of Gosselin\\n(quoted by Trelat) the patient was treated for\\nmore than a month for a supposed arthritis of the\\nknee he grew weaker daily and died of exhaus-\\ntion. At the autopsy the joint was found full of\\npus and one of the condyles broken. The frag-\\nments were in exact apposition, but there was no\\nsign of repair. The diagnosis must be made upon\\nthe localized pain, ecchymosis, loss of function,\\nand abnormal mobility and crepitus, recognized\\nby direct manipulation of the condyle or by\\nmoving the leg laterally or in the direction of\\nflexion and extension.\\nThe reported cases show a remarkable variety in their course and\\nterminations. Some patients have recovered without greater reaction\\nthan would be expected after a simple non-articular fracture in others\\nthe joint has suppurated, and the case has terminated fatally in Dr.\\nCrosby s case the fragment was removed six months afterward, by\\noperation, and the patient made a complete recovery and in a case\\nfirst seen by Hamilton three months after the injury, the fragment\\nremained ununited and could be moved upward half an inch with dis-\\ntinct crepitus and pain by flexing the knee. During the next two years\\nthe usefulness of the limb increased steadily.\\nTreatment. The treatment consists in reduction of such displacement\\nas may exist by acting upon the fragment through the lateral ligament\\nand the leg, and prevention of its recurrence by keeping the leg fixed\\nin the position to which it has been brought in making the reduction.\\nAs the lateral ligaments are tense when the knee is extended, and relaxed\\nwhen it is flexed, the extended position is the one which gives most\\n1 Trelat Loc. cit., p. 69.\\nFracture of the internal\\ncondyle of the femur.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0414.jp2"}, "409": {"fulltext": "FBACTURES OF THE FEMUR. 357\\nsecurity. The objection urged by Malgaigne, that it favors anchylosis,\\nis, I think, unfounded we know that the common cause of anchylosis\\nlies in the severity or the prolongation of an arthritis, not in the posi-\\ntion in which the joint is kept. In the flexed position of the knee a\\nslight displacement upward of the fragment could occur easily, and it\\nwould certainly pass unrecognized so long as the position was kept,\\nand would show itself in abduction or adduction of the leg as soon as\\nit was extended. I prefer, therefore, to treat a case in the extended\\nposition upon a posterior splint or in a plaster bandage. After three\\nor four weeks the knee may be partly flexed if the fragment has lost\\nits mobility.\\nMassage is useful to shorten the period of convalescence and hasten\\nthe restoration of function. Incision of the joint for the removal of\\na large amount of blood from it could probably be safely done and\\nwould diminish the chance of limitation of motion.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0415.jp2"}, "410": {"fulltext": "CHAPTEK XXIV.\\nFRACTURES OF THE PATELLA.\\nAccording to published records fractures of the patella represent\\nfrom one to two per cent, of all fractures. They are much more fre-\\nquent in men than in women, and in middle life than in childhood or\\nold age. The youngest of Malgaigne s patients was eleven years old,\\nand he knew of no other younger than seventeen years. The youngest\\npatient in the 127 cases collected by Hamilton was five years old, and\\nthe fracture was very different from the usual one since only a small\\npiece was broken from the margin of the bone by a direct blow his\\nnext youngest case was sixteen years old, and in this also the fracture\\nwas by direct violence. Dittmer 1 reports one in a boy nine years old.\\nCauses.\\nThe cause may be direct or indirect, a blow or fall upon the patella\\nor the sudden vigorous contraction of the quadriceps femoris, or\\nthe sudden flexing of the knee against the opposition of the quadri-\\nceps. The statistics that have been collected to show the relative fre-\\nquency of these varieties vary widely and are, I think, untrustworthy\\nbecause of the difficulty, or rather the impossibility, in many cases of\\nrecognizing the mode in which the fracture has been produced. The\\npatient slips or stumbles, makes an effort to save himself, falls, and\\nthe patella is found to be broken. He is unable to say whether he\\nstruck upon the patella or upon the tuberosity of the tibia, whether\\ndirectly in front or upon the side, or, and this I have often met with,\\nhe asserts that he fell upon the patella because he knows it is broken,\\nand cannot understand that the lesion could have been produced in any\\nother way. If the examination is pushed, and the question asked,\\nHow do you know it the answer is often, Why, it must have\\nbeen so.\\nMy own conviction is that the efficient agent in the great majority\\nof cases is the contraction of the quadriceps, either directly or by the\\nopposed flexion of the knee, and the grounds for this belief are the\\nnumerous cases in which this mode of production can be clearly demon-\\nstrated, the practical impossibility of producing any but a comminuted\\nfracture experimentally by direct violence, and the position of the\\npatella, w T hich is such that the blow is rarely received upon it in a fall.\\nThe question whether muscular contraction breaks it by direct trac-\\ntion or by bending it over the convexity of the condyles is of purely\\nacademical interest, and in most cases it cannot be answered positively\\nbecause the position of the bone at the moment of fracture with refer-\\nence to the condyles cannot be known. In a few cases the fracture has\\n1 Dittmer Laiigenbeck s Archives, vol. lii.\\n358", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0416.jp2"}, "411": {"fulltext": "FBACTUBES OF THE PATELLA.\\n359\\nbeen caused, beyond question, by simple traction without bending or\\ncross-strain, as in a case reported by Garreau l in which a second frac-\\nture by muscular action occurred in the upper fragment twelve years\\nafter the first fracture had healed with a separation of four centimetres\\n(If inches). In others it is equally certain that the traction of the liga-\\nmentum patella? was inclined somewhat backward from the vertical axis\\nof the patella, the fracture taking place when the limb was partly\\nflexed.\\nThe common clinical form is a vigorous contraction of the quadri-\\nceps, either simply in voluntary use of the limb or aided by forced\\nflexion of the knee by forces which overcome the opposition of the\\nmuscles. Thus, a man jumps and breaks the patella, or he fails in an\\neffort to avoid a fall and the leg is bent under him, or, as in a case of\\nmy own, he seeks to push a heavy box with his foot resting against its\\nside and the knee partly flexed, the foot slips down, the flexion of the\\nknee is sharply increased thereby, and the bone is broken. This forcible\\nflexion is a frequent cause of early refracture while motion is still\\nlimited and the descent of the upper fragment prevented by adhesions\\nor peri-articular thickening.\\nIn a few cases there is reason to think that a blow upon the bone\\nhas cracked it or originated some process in it by which its complete\\nfracture by muscular action shortly afterward was made easy.\\nPathology.\\nIn the great majority of cases by indirect violence the fracture is\\ntransverse or slightly oblique, and usually at or just below the middle\\nFig. 201. Fig. 202.\\nUnusual form of fracture of patella.\\nB, mesial section.\\na, anterior surface\\nComminuted fracture of the\\npatella. Bony union. Exuber-\\nant callus at several points.\\n(GURLT.)\\nof the bone sometimes it lies very near one end of the bone, espe-\\ncially the lower, and once or twice I have seen it crossing and separating\\nonly the upper inner corner. I have occasionally seen the lower frag-\\nment split longitudinally, and I have seen one case (Fig. 201) in which\\non inspection through an incision the surface of fracture w T as found\\nto be very oblique downward and backward and was also curved down-\\nward on the anterior aspect. Parke 2 reports a somewhat similar one\\n1 Garreau Revue Medico-Chirurg., 1S53, p. 375.\\n2 Parke New York Medical Journal, March 1S93,\\n303.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0417.jp2"}, "412": {"fulltext": "360 FRACTURES.\\nseen two months after the accident the injury was apparently caused\\nby direct lateral pressure, and the upper and posterior fragment, com-\\nprising nearly half the bone, lay wholly above the other.\\nVertical, comminuted, and some oblique fractures are due to direct\\nviolence, and rarely show much displacement.\\nThe displacement after transverse fracture is ordinarily well marked,\\nits degree being modified by the extent to which the periosteum and\\nlateral expansions are torn. Occasionally there is none. The separa-\\ntion, which may be an inch or more, is due in part to the retraction\\nof the quadriceps and the tension of the fascia lata and in part to dis-\\ntention of the joint by blood and exudate. While the injury is fresh\\nthe quadriceps, even when actively contracted, can rarely separate the\\nfragments for more than a short distance when the knee is fully ex-\\ntended and the hip somewhat flexed. Later, if the fragments remain\\nununited, the gradual shortening of the muscles increases the interval.\\nA third cause, which acts less promptly, is the gradual retraction\\nof the ligamentum patellae in one of Malgaigne s l old cases it was\\nshortened one-half, measuring only three centimetres, and in one\\nreported by Brunner 2 it was shortened from five and a half to one and\\na half centimetres.\\nOccasionally the lower fragment is so rotated that its fractured sur-\\nface is directed forward.\\nThe other displacements are more readily recognizable later. They\\nare lateral displacement and angular displacement, the angle pointing\\nforward, backward, or to one side. Lateral angular displacement\\nappears to be commonly the result of uneven stretching of the fibrous\\nunion after the patient begins to use the limb; anterior angular dis-\\nplacement is not only produced by the pressure of pads or bandages\\nabove and below the fragments when the latter are in contact, or\\nnearly so, but it is also the inevitable effect of separation by distention\\nof the joint, and may apparently be caused by cicatricial retraction of\\nthe lateral soft parts. I have seen in skiagrams the upper fragment\\nturned so that its fractured surface was directed backward. (Plate\\nXX., fig. 1.)\\nThe associated injuries to the soft parts have become well known\\nthrough the opportunities for direct inspection furnished by frequent\\nresort of late to open arthrotomy in treatment. They involve the\\nfibro-periosteal envelope of the front of the bone, the lateral expan-\\nsions and capsule on the sides, and the fascial expansions downward.\\nThe fibro-periosteal layer on the front of the bone is usually torn\\nat a level different in part from that of the fracture and rather irregu-\\nlarly, so that it projects from the edge of one or the other fragment,\\nusually the upper, as a ragged fringe, sometimes fully half an inch\\nwide, which drops over the fractured surface and is thus interposed\\nbetween the fragments when they are brought together. Macewen was\\nthe first to call special attention to this fringe and to suggest that it\\nmight be a bar to close, firm union. It is sometimes notably supple-\\nmented by one or more long strips of fascia (I have seen them more\\n1 Malgaigne: Atlas, Plate xiv., Fig. 4, and p. 17.\\n2 Brunner Deutsche med. Wochenschrift, May 17, 1888.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0418.jp2"}, "413": {"fulltext": "PLATE XX.\\nFig. 1. Fracture of Patella, S months old; after treatment by Straight Splint.\\nActive Extension almost complete.\\nFig. 2. Fracture of Patella two years after Mediate Suture.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0419.jp2"}, "414": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0420.jp2"}, "415": {"fulltext": "FEACTUEES OF THE FATELLA.\\n361\\nthan four inches long) attached to the upper fragment and drawn up\\nfrom the region immediately below, lying curled up in the joint between\\nthe fragments. The lateral expansions and the capsule are freely torn\\non each side transversely, except in the rare cases without separation.\\nThe fracture may be made compound by direct violence or by tear-\\ning of the skin in the separation of the fragments when it has become\\nadherent to the patella by an inflammatory or cicatricial process. The\\ncommon instances of the latter are in refracture, especially after opera-\\ntive treatment of the first fracture; much more rarely in a primary\\nfracture after a wound of the skin which has not entirely healed.\\nSymptoms.\\nIn fractures by muscular action, with or without a fall, a sharp\\ncrack may be heard and the patient is usually unable to use his limb.\\nIn a few cases he has walked, and, indeed, in most it is possible to\\nwalk backward, keeping the knee extended by the pressure of the heel\\non the ground, or even to walk forward if the uninjured limb is\\nadvanced and the other swung up to it but not beyond it.\\nThe knee becomes promptly swollen by an effusion of blood or\\nsynovia into it and by tumefaction of the soft parts, especially if a blow\\nhas been received upon it, and the two fragments, separated usually\\nby a well-marked interval, can be made out and their independent\\nmobility recognized. This mobility may be very slight if the frag-\\nments are close together. Crepitus can often be felt when the frag-\\nments are pressed together.\\nThe subjective symptoms are moderate pain when the limb is at\\nrest, increased by movement and by pressing the fragments together\\nand by pressure along the edge of a fragment, and\\ninability actively to extend the leg or to raise the\\nheel from the bed. It must be remembered that\\nin rare, entirely exceptional, cases the fibrous cov-\\nering of the bone may remain untorn and consti-\\ntute a sufficient connection between the fragments\\nto make a limited use of the limb possible.\\nIn vertical or comminuted fractures the signs\\nrecognized by palpation will vary in accordance\\nwith the differences in the lines of the fracture,\\nand in the former active extension will be pre-\\nvented only by the pain attending the effort.\\nCourse and Termination.\\nFig. 203.\\nThe region swells promptly, partly by reaction\\nof the overlying soft parts, partly by the disten-\\ntion of the joint by blood and synovia; the\\nswelling can be largely prevented or rapidly re-\\nduced by methodical pressure, preferably by an\\nelastic bandage.\\nIf the fragments are kept fairly well together and if neither is tilted\\na fibrous bond forms between them which may ossify wholly or in\\nBony union after frac-\\nture of the patella. (Spec-\\nimen 201 of the Musee\\nDupuytren.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0421.jp2"}, "416": {"fulltext": "362\\nFBACTUBES.\\npart if the contact is very exact (Fig. 203 and Plates XX. and\\nXXI.), bnt which in cases not treated by operation almost always\\nremains fibrous and usually lengthens somewhat under use during the\\nfirst few months. Even in some operative cases which have again\\ncome to direct inspection after many months the union which was so\\nclose that no independent mobility could be recognized has been found\\nto be fibrous. Most of the skiagrams I have taken have shown bony\\nunion only in the posterior half or three-fourths. They also show an\\nangular displacement producing a slight concavity of the articular\\nsurface which, according to Chaput, 1 favors full restoration of func-\\ntion. If the fragments are not kept together, or if one is turned so\\nthat its fractured surface is directed\\nFig. 204. Fig. 205. forward or backward, the union\\nbetween them is by a bond formed\\nmainly by the overlying soft parts\\n(Fig. 204), but sometimes by a\\nthicker one apparently of new\\nformation (Fig. 205) it seems\\nprobable that the latter form is\\nproduced by the elongation of a\\nshorter bond formed under favor-\\nable conditions of proximity and\\nposition.\\nHypertrophy of the fragments\\nis frequently noticed and some-\\ntimes appears mechanically to limit\\nflexion of the knee occasionally\\nalso bony nodules, sometimes quite\\nlarge, form within the connecting\\nband.\\nOn the first attempts to use\\nthe limb, whether these are made\\npromptly or only after a month or\\ntwo, the joint is found to be very\\nstiff, but usually the range in-\\ncreases quite rapidly and full act-\\nive flexion and extension are ulti-\\nmately re-established. In a certain,\\nnot large, proportion of cases there\\nis notable loss of function either inability fully to flex, or almost com-\\nplete loss of active extension although the joint is freely movable, or\\ninability to make complete active extension, the limb remaining\\nslightly flexed.\\nThese disabilities coincide with and presumably depend upon the\\nvarying conditions of the fragments and uniting bond which have been\\ndescribed.\\nInability to flex appears to be largely due to retraction of the portion\\nof the capsule attached to the upper fragment and of the fascia lata on\\nthe outer side, especially of the upper side of the rent in the lateral\\n1 Chaput These de Paris. 18S5, and Bull, de la Soc. Anat., April, 1SS3, p. 459.\\nFibrcms union -with great\\nseparation, after fracture\\nof the patella. The band\\nadheres to the broken sur-\\nface of the lo wer fragment.\\n(Holrnes s System.)\\nLong fibrous\\nunion.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0422.jp2"}, "417": {"fulltext": "FRACTURES OF THE PATELLA.\\n363\\nexpansion, and sometimes to enlargement of the patella, itself the\\nresult of hypertrophy of the fragments or of a short stiff bond between\\nthem which makes the bone too long to turn over the curve of the\\ncondyles. Retraction of the quadriceps seems not to be an important\\nfactor in this disability. (See also the section on Disability After\\nFracture.)\\nLoss of active extension, when marked and when combined with\\nfree flexion, is due to insufficient union between the fragments and the\\nabsence of complementary fascial connections between the quadriceps\\nand the leg, such as are found in some cases. It is remarkable that\\nthis loss interferes so slightly with ordinary use of the limb in most\\ncases the patients often walk easily and securely, although they are\\nexposed to fall whenever their weight rests only on the partly flexed\\nlimb. They seem instinctively to depend upon the sound limb when-\\never the use of the damaged one would be unsafe. There is difficulty\\nin going up and down stairs and in rising from a seat. In the case\\nFig. 206.\\nExtreme separation of the fragments after fracture of the patella.\\nrepresented in Fig. 206 the patient claimed not to be aware of any\\nnoteworthy defect in the limb although active extension was almost\\nentirely absent.\\nThe common defect is slight limitation of active extension, the\\npatient being unable to raise the heel from the bed without first\\nslightly flexing the knee.\\nDegeneration of the quadriceps in direct consequence of the trauma\\nhas been alleged as a cause of diminution of the power of active exten-\\nsion, and has been used as an argument for early resort to massage.\\nRupture of the uniting band or bone refracture is not infrequent\\nin the first few months, or even much later when flexion has remained\\nlimited. The cause is always forcible flexion of the knee beyond the\\nrange that has been acquired, as in a fall it has occasionally been\\ncaused by the surgeon in an attempt to increase the range by passive\\nmotion. The mechanism is the pulling away of the lower fragment,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0423.jp2"}, "418": {"fulltext": "364 FRACTURES.\\nthe corresponding descent of the upper being prevented by the pre-\\nviously mentioned conditions. Occasionally the soft parts, including\\nthe skin, have been so adherent that the rupture has involved them\\nalso, thus freely opening the joint. In the past such an accident was\\nfrequently followed by suppuration of the joint and the consequent\\nloss of limb or life. This complication is more likely to happen when\\nthe skin over the fracture has been incised in operative treatment.\\nFracture of a fragment has occurred in a few cases.\\nThe course of a compound fracture depends on the occurrence or\\navoidance of infection if it is avoided the course and termination are\\npractically those of simple fracture if it occurs it creates serious risk\\nto life and limb, leading to anchylosis or amputation.\\nTreatment.\\nThe obstacles to apposition of the fragments and their close reunion\\nare the pull of the quadriceps, the distention of the joint, and the inter-\\nposition of the fibro-periosteal fringe or aponeurotic shreds. Later\\ncauses of limitation of function are adhesions and retraction of the soft\\nparts of the joint, hypertrophy of the fragments, and possibly degene-\\nration of the quadriceps.\\nThe numerous methods of treatment, which respectively seek more\\nor less specifically to remove one or another obstacle or late conse-\\nquence, may be grouped as operative, and non-operative, including in the\\nformer those in which the fragments are mechanically fastened together\\neither after open arthrotomy or by means introduced subcutaneously or\\nacting temporarily or permanently through the punctured skin in\\nshort, those which distinctly involve the chance of infection of the joint.\\nThe points to be considered in choosing between these two main\\nmethods are that a long experience has shown that non-operative\\nmethods furnish in the great majority of cases in which they are prop-\\nerly used a result which is functionally satisfactory even if the union\\nof the fragments is not close, that most of the failures are apparently\\ndue to unfitness of the method chosen or its faulty use, that only in a\\nsmall proportion of cases are the conditions such as to make a bad\\nresult inevitable without resort to operative methods, and that most of\\nthe later causes of limitation of function are equally active after either\\nmethod of treatment. That direct mechanical approximation and\\nmaintenance of the fragments, if the dangers of the operation are\\nescaped, practically annuls or ensures the removal of the primary\\nobstacles in all cases, notably hastens the restoration of function, and\\nprobably makes that restoration more complete in some cases, besides\\nmaking it possible in those in which otherwise it would certainly fail\\nto be obtained, cannot be denied. On the other hand, operation exposes\\nto infection and if infection occurs the result is almost certain to be a\\nstiff joint, amputation, or death. In short, it takes less time and makes\\na good result more certain, but some of its failures are disastrous to an\\nextent for beyond that of non-operative failures.\\nIf there was no risk in an open operation it w T ould deserve selection\\nin almost every case, if only because it makes possible the removal of", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0424.jp2"}, "419": {"fulltext": "r\\nH\\nX", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0425.jp2"}, "420": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0426.jp2"}, "421": {"fulltext": "FBACTUBES OF THE PATELLA.\\n365\\nthose certain causes of failure which are sometimes present and cannot\\notherwise be recognized and removed, such as tilting of the fragments\\nand the interposition of bundles of fascia. The propriety of resort to\\noperation turns, therefore, in the absence of special reasons, upon the\\nmeasure of safety with which it can be done, and while I believe that\\ncertain methods* when surrounded by every precaution, can be em-\\nployed with an assurance of success that justifies resort to them, and\\nwhile I habitually use them, yet I have never taught them as routine\\npractice, but on the contrary have strongly advised against their use\\nexcept by those who can bring to them not merely experience in oper-\\nating but also the habit of taking surgical precautions and the aid of\\ntrained assistants who have the same habit, who are practising those\\nprecautions daily in short, the personnel of an active surgical hospital\\nservice. I do not mean that any one of the many operative methods\\nproposed and used can be done with this assurance of success, but only\\nthat the one with which I am familiar, and which now (February,\\n1900) I have used in more than a hundred cases without accident, can\\nbe so done, and that only because it is freer than most operations from\\nthose more or less unavoidable causes to which we attribute our disasters.\\nI refer especially to the difficulty of making the hands clean. The gen-\\nFig. 207.\\nDressing for fracture of the patella\\nThe final turns of the roller in front of the knee are not\\nshown in the cut.\\neral practitioner, and even the occasional surgeon, is not only fully\\njustified in using a non-operative method but ought to do so and he\\ncan feel assured that the methods at his command justify the expecta-\\ntion of a satisfactory, even if not perfect, result.\\n1. Non-operative Treatment. The opposing factors specially sought\\nto be controlled by most of the methods are the effusion in the joint\\nand the action of the quadriceps to create or maintain separation.\\nThe production of the effusion may be opposed by systematic press-\\nure or cold its absorption may be hastened by pressure or massage, or\\nit may be immediately removed by puncture or aspiration. I prefer\\npressure with a light rubber bandage this will remove the effusion\\nrapidly or, if the case is seen early, will notably limit its production.\\nIt should be aided by immobilization of the joint.\\nImmediate removal of the effusion by aspiration or puncture, with\\nor without washing of the joint, is occasionally practised, but, except\\nin rare conditions such as a large intra-articular hematoma, has no", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0427.jp2"}, "422": {"fulltext": "366 FRACTURES.\\nmarked superiority over the slower removal by pressure. If washing\\nis done it should be with a hot sterile salt solution, not with carbolic\\nacid.\\nAfter removal, immediate or gradual, recurrence must be opposed\\nby bandaging the application of strips of adhesive plaster so as\\nentirely to cover the front and sides of the joint has been recom-\\nmended, but a well-applied roller is probably equally efficient.\\nApproximation of the fragments is effected by the hands, and its\\nmaintenance by a great variety of devices from a simple circular\\nbandage to complex apparatus. All are combined with a posterior\\nsplint for immobilization and usually with confinement to the bed with\\nthe foot raised for at least a month. As for active separation of the\\nfragments by the quadriceps, full extension of the knee with elevation\\nof the foot (flexion of the hip) prevents it.\\nThe simplest form is a roller-bandage applied over a long straight\\nor, better, a moulded posterior splint, the turns immediately above and\\nbelow the fragments being placed obliquely, as shown in Fig. 207.\\nFixation has been sought in encasement in plaster of Paris by pressing\\nthe still soft dressing snugly down above and below the fragments and\\nmaintaining the pressure until the dressing has hardened, but an irre-\\nmovable dressing which prevents inspection exposes to rude disappoint-\\nment on its removal, for as the limb grows loose within the control of\\nthe fragments is lost and separation may occur and remain unrecog-\\nnized until it is too late to remedy it.\\nMore exact fixation of the upper fragment has been sought by fixed\\nor elastic traction on the skin close above it, so applied that its pressure\\nwill be downward and backward and thus act upon the fragment.\\nThus, a strip of adhesive plaster an inch or two wide is laid across\\nclose above the fragment and its ends carried downward on either side\\nto the sides or back of the splint at the calf, as in Fig. 208. For\\nFig. 208.\\nFracture of the patella. (Lal gier.)\\na number of years I used this plan with a piece of rubber tubing\\ninterposed on each side to make the traction elastic, and was well satis-\\nfied with the results. Sometimes the plaster is cut in a broad U-shape\\nthat it may fit better.\\nMassage has been strongly recommended to reduce the swelling, pre-\\nvent adhesions, diminish retraction of the capsule, regenerate the quad-\\nriceps, and hasten convalescence. It has even been claimed that it\\ncould be trusted to secure a good result without immobilization of the\\njoint or confinement to bed, but even its most ardent recent advocates", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0428.jp2"}, "423": {"fulltext": "FEACTUEES OF THE PATELLA. 367\\nhave not repeated the claim. I do not think it removes the effusion as\\nrapidly and conveniently as elastic pressure does after the second or\\nthird week it hastens absorption of the exudate and improves the\\ncirculation as after other injuries, but I doubt if it does more than\\nsomewhat shorten the period of convalescence.\\nIn most fractures by direct violence the preservation of much of the\\nperiosteal envelope prevents separation, and no special measures are\\nrequired to keep the fragments together.\\nThomas l reports eleven cases to prove that an excellent result can be\\neasily obtained without confinement to bed. He simply immobilizes\\nthe joint by the splint which he uses in disease of the knee, two metal\\nrods lying on either side, attached to the heel of the shoe, and fitted\\nwith a perineal band and three straps, one each behind the knee and\\nacross the front of the thigh and leg. It is worn for four or five months.\\nTo summarize an elastic bandage covering the patella and six inches\\nabove and below may be applied for a few days to reduce or prevent\\nswelling, and if it keeps the fragments well together it may be con-\\ntinued for a fortnight. Then the limb is placed in a long posterior\\nplaster gutter or on a straight posterior splint and bandaged from the\\nfoot to the upper part of the thigh, the turns immediately above and\\nbelow the fragments being placed obliquely as above shown, and the\\npatient is kept in bed on his back with his foot well raised. A month\\nor six weeks after the accident the limb is encased in plaster and the\\npatient allowed to go about on crutches. If the attention can be given,\\nthe splint may be cut open in front and removed daily for massage, and\\nafter a month it may be left off at night and then in the house during\\nthe day, and the patient encouraged to move the joint. The danger to\\nbe avoided is premature forcible flexion of the knee, which is most\\nlikely to happen by accident, as in a fall, and the prolonged use of the\\nsplint is mainly as a protection against this accident. The closer the\\nunion the shorter the time it needs to be worn, but certainly no great\\nstrain should be put upon the bond until after the second month.\\nA few methods, which may be termed intermediate between the\\noperative and non-operative, have been devised to act directly upon\\nthe fragments without the necessity of opening the joint, but as they\\nrequire multiple punctures of the skin which must be kept open for\\nseveral weeks, and as these punctures\\nmay communicate with the seat of Fig. 209.\\nfracture through the spaces created\\nby the extravasated blood, the chance\\nof infection exists as in open opera-\\ntion, while the work is done less\\neasily and effectively.\\nMalgaigne s hooks (Fig. 209), the\\nearliest of these, may be taken as the\\ntype. The points of the hooks are Malgaigne s hooks.\\npassed through the skin and engaged\\nrespectively in the upper and lower ends of the patella, and then\\nbrought together by the screw until the fragments are coaptated. It\\n1 Thomas Pro vine. Medical Journal, August 1, 1SS9.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0429.jp2"}, "424": {"fulltext": "368 FRACTURES.\\nis an efficient method and is usually well borne, but the presence of\\nswelling may make the application difficult or impossible. They must\\nbe worn three or four weeks. The danger is of suppuration about the\\npoints and of its possible extension to the joint. The instrument has\\nbeen modified by Levis two separate pairs instead of a double one\\nby W. K. Otis, who made the individual parts adjustable, and by\\nDuplay, who made it stronger and firmer. It has furnished many good\\nresults, and the accidents following its use have been few. Of course\\nthe punctures must be carefully protected. To avoid making punctures\\nin the skin Trelat used two gutta-percha plates moulded to the surface\\nabove and below and engaged the hooks in them.\\nI devised and tried in a few cases l a modification consisting of a\\ntwo-pronged fork bent on the flat, which was engaged in the upper\\nfragment with its shank resting on the thigh above, and was drawn\\ndownward by an elastic cord. It is easier of adjustment than Mal-\\ngaigne s hooks and did the work equally well, but suppuration about\\nthe points was occasionally free. I long ago abandoned it for the\\nsuture.\\nMayo Robson 2 passed a steel pin transversely through the tendon of\\nthe quadriceps close to the upper edge of the patella, and another\\nthrough the ligamentum patellae close to the lower edge, and then drew\\nthe fragments together and maintained them by a ligature about the\\nprojecting portions of the pins on each side. I should think it an\\neasier method than Malgaigne s. Dieffenbach had long before driven\\npegs into the fragments and tied them together.\\nAnderson 3 modified Robson s method by passing the pins through the\\nfibro-periosteal covering of the fragments, a disadvantageous change,\\nI should think, because it brings the punctures nearer the fracture and\\nthereby increases the chance of infection of the joint in case suppura-\\ntion should take place about the pins, as it did in one of his four cases.\\nCertain other methods of subcutaneous or temporary fixation which\\nresemble the above in some respects will be mentioned in the next\\nsection because in all the joint is opened, directly or indirectly, through\\nthe gap made by the fracture, and as therefore direct and early infec-\\ntion is possible they should be compared with others carrying the same\\nrisk.\\n2. Operative Treatment. This, which began, 4 in the antiseptic\\nperiod, with Lister s exposure of the fracture and wiring of the frag-\\nments, presents a great number of methods and procedures, some of\\nwhich are a natural evolution from their predecessors in the direction\\nof simplicity, efficiency, or safety, while others are merely novelties\\nobtained at the price of some disadvantage or based upon the exag-\\ngeration of the importance of some indication. The fundamental idea\\nis the mechanical fixation of the fragments by some form of suture,\\nand the associated one is either the removal of the effusion or of the\\ninterposed periosteal fringe, or the reduction of the risk by the use of\\n1 Stimson New York Medical Journal, January 3, 1885, p. 23.\\n2 Kobson British Medical Journal, March 30, 1889.\\n3 Anderson Lancet, July 2, 1892.\\n4 In 1834 Dr. Barton, of Philadelphia, fastened the fragments together by a wire passed\\nthrough them and knotted outside the skin the patient died.", "height": "4351", "width": "2506", "jp2-path": "practicaltreati00stim_0430.jp2"}, "425": {"fulltext": "PLATE XXII,\\nFig. 1.\u00e2\u0080\u0094 Potts Fracture by Eversion in a Youth; showing also\\nEpiphyseal Line; Internal Malleolus broken at its Base.\\nFig. 2\u00e2\u0080\u0094 Fracture of the Posterior Portion of the Lower End of the\\nTibia, with Fracture of Fibula and Internal Malleolus.", "height": "4351", "width": "2506", "jp2-path": "practicaltreati00stim_0431.jp2"}, "426": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0432.jp2"}, "427": {"fulltext": "FBACTUEES OF THE PATELLA. 369\\npunctures instead of a free incision. Their comparison will be made\\neasier by first considering certain facts and general principles.\\nThe pull of the quadriceps when the knee is fully extended and the\\nhip slightly flexed is so weak that even when the muscle is actively\\ncontracted it will not separate the fragments more than half an inch.\\nI have repeatedly observed this during an open arthrotomy, and I\\nhave seen several patients pass through an attack of delirium tremens\\nin the first week without tearing apart the fragments although they\\nwere fastened together only by catgut or light silk sutures. It is plain,\\ntherefore, that a strong suture, one of metal or heavy silk, is not neces-\\nsary to the proper approximation of the fragments if the joint is not\\ndistended and if the foot is kept elevated. Consequently, any addi-\\ntional risk or complexity of procedure involved in the use of a strong\\nsuture is not justified. This, in my opinion, is sufficient for the rejec-\\ntion of all methods of suturing which require drilling of the bone,\\neven without consideration of the other disadvantages of a permanent\\nsuture through it which have been described in Chapter VII.\\nThe removal of the effusion facilitates approximation, reduces ten-\\nsion, and probably diminishes the chance of the formation of adhesions\\nand peri-articular thickening and retraction. Other things being equal,\\ntherefore, methods which include such removal are preferable to those\\nwhich do not, and if they also permit the adjustment of an interposed\\nperiosteal fringe or aponeurotic shred they have an additional advan-\\ntage.\\nThe periosteal fringe, long charged with much of the responsibility\\nfor failure of bony or close fibrous union, has been shown by large\\nexperience with operative methods in which it was disregarded to be\\nusually a negligible factor that is, long series of cases treated by sub-\\ncutaneous suture have given close union in almost all, and yet it must\\nbe believed that a fringe of some size was present in most of them.\\nOn the other hand, I think the large aponeurotic shreds which I have\\nseen several times Avould probably have been a serious obstacle if they\\nhad been left, and possibly similar ones have been responsible for sonie\\nof the failures noted under methods of treatment usually efficient. It\\nis, therefore, not necessary to choose an open method of operating in\\norder to adjust the fringe, but probably in a small proportion of cases\\nthere is present a fringe or shred of such size that it will diminish the\\nsuccess of any operation which does not effect its removal. Again,\\nother things being equal, an open method better protects against this\\nobstacle to success.\\nInfection may occur in any operation which wounds the skin, and\\nthe chance of its spread to the joint the great danger is greater if\\nthat wound communicates with the joint or the seat of fracture. The\\nbriefer the existence of that wound or of that connection, the less the\\ndanger. All the so-called subcutaneous methods require two or more\\nsmall incisions, and in all a suture of silk or wire is passed either\\ndirectly into the joint or through the line of fracture or its immediate\\nneighborhood. If suppuration occurs at a puncture the suture opens\\na direct road for its spread to the joint. The size of the wound is not\\na measure of the chance of infection that comes, if the common pre-\\n24", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0433.jp2"}, "428": {"fulltext": "370 FRACTURES.\\ncautions are taken, mainly from the hands of the operator and his\\nassistants.\\nFinally, the permanent presence in the tissues of a foreign body is\\nnot, according to general experience, a matter of indifference occasion-\\nally suppuration takes place about it after a long interval, and not\\ninfrequently its removal has been required because of pain and irrita-\\ntion.\\nThe operative methods are (1) by open incision direct suture of\\nthe fragments through holes drilled in them, suture of the fibro-perios-\\nteal layer, and mediate suture through the tendon of the quadriceps\\nand ligamentum patella? (2) subcutaneous suture by wire through\\nthe whole length of the fragments, or by silk through the tendons and\\ncrossing the front of the bone (3) subcutaneous permanent ligature\\nsurrounding the fragments in the sagittal plane and lying partly in the\\njoint (4) temporary ligatures passing through the joint as in (3), or\\nthrough the tendons as in (2), or through the bone, and tied outside\\nthe skin.\\nThe methods are far too numerous to permit a detailed description\\nand criticism, even if it were not probable that most of them will be\\nabandoned in favor of the simpler and safer ones. Many of them, too,\\ncan be judged in classes. Thus, for reasons given above, I would reject\\nall in which a permanent suture is placed in the bone itself.\\nTemporary ligature through the tendons (one of the earliest methods\\nproposed), or through the bone, or around it through the joint seems\\nto me to be more dangerous, because of the prolonged communication\\nwith the exterior, and less efficient than the similar subcutaneous\\nmethods.\\nThe subcutaneous methods which can be done equally well by an\\nopen incision appear to have an equal risk with and to lack the advan-\\ntages which belong to the latter.\\nBarker s subcutaneous ligature about the fragments (silver or silk\\npassing through the joint) opens a direct road for the spread to the\\njoint of infection occurring at either puncture or small incision, and as\\nit also fails to provide for satisfactory evacuation of the joint and\\nadjustment of the periosteal fringe I should reject it. It appears to\\nhave met with considerable favor and success since its introduction in\\n1894 and has been warmly commended by several.\\nMy personal experience is limited to the subcutaneous mediate silk\\nsuture through the tendon and the ligamentum patella? (1889-1892,\\nabout forty cases) and open incision with the same or the fibro-perios-\\nteal suture (1892-1900, about one hundred cases). In the first series\\ninfection occurred twice and resulted in a stiff joint, suppuration ap-\\npearing in one of them after the patient had left the hospital, appar-\\nently well, in the second week. In the second series all the cases have\\nrecovered without accident and with close union all that I have seen\\nafter the third month have had good use of the joint except one very\\nstout nervous woman who could not be persuaded to abandon\\ncrutches her patella was freely movable laterally and union was close,\\nbut flexion was limited to 30 degrees three months after the accident.\\nI began with the subcutaneous method because I thought its risks", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0436.jp2"}, "429": {"fulltext": "FRACTURES OF THE PATELLA. 371\\nless than those of free incision, but when I found that the extrava-\\nsated blood often escaped freely through some of the four small incis-\\nions and that consequently the suture lay free within the area of\\nfracture and laceration I abandoned it for the single free incision and\\nwas soon convinced that the patient was equally, perhaps better, pro-\\ntected. A special advantage of the latter method is that the operation\\ncan be done without once touching the cut tissues with the fingers, and\\nto that I attribute the complete freedom from infection. I have\\nfrequently done the operation under local anaesthesia cocaine or\\nfreezing.\\nThe method is as follows The surface having been prepared, an\\nincision is made in the median line slightly overlapping the two frag-\\nments the sides are drawn apart, the fragments lifted in turn with a\\nsharp retractor, and their surfaces freed from clot or fringe while\\nthey are held up the joint is thoroughly washed with a hot sterile salt\\nsolution. Then the fragments are drawn snugly together w T ith hooks,\\nthe fringe adjusted, and two or three catgut sutures placed in the peri-\\nosteum along the edge of the fracture, or a single silk or stout catgut\\nsuture passed through the tendon and ligameutum patella so that its\\ntwo strands lie on the front of the bone. Sometimes additional sutures\\nare placed in the rents in the lateral expansions. The incision is closed\\nwithout drainage with an uninterrupted silk suture, the dressing ap-\\nplied, and the limb bound upon a posterior splint. The patient is kept\\nin bed with the foot elevated for a week, the silk suture of the incision\\nis then removed, and a light plaster-of-Paris encasement applied.\\nAfter a few days the patient leaves the hospital on crutches, and after\\na month the dressing is cut down the middle in front, and he is directed\\nto wear it only in the daytime. Usually the joint can be flexed at least\\n90 degrees by the end of the third month, often earlier, and the patient\\nusually discards the splint entirely before that time, since he is told it\\nserves only as a protection against damage by a fall. In no case have\\nI seen the fragments separate under use, but several have come back\\nin the third or fourth month with refracture caused by a fall.\\nI have thrice used a transverse incision it permits more exact suturing\\nof the rents in the lateral expansions, but I prefer the median incision.\\nI have treated a few cases without immobilization after the tenth\\nday, but the gain in rapidity of restoration of function has not been\\nsufficient to justify the risk of accident.\\nFor Cecils l method, first subcutaneous wire suture through bone\\nAiken s 2 modification, the wire passing only once through the bone and\\nthen back under the skin Barker s 3 method, subcutaneous ligature\\nthrough the joint about the patella my earlier method, 4 subcutaneous\\nmediate suture through the tendon and ligamentum, the reader is re-\\nferred to the original accounts. Other plans not above mentioned are\\nthose of Wolff, 5 open incision, two metal rivets driven into each frag-\\n1 Ceci Deutsche Zeitschrift fiir Chirurgie, February, 1888.\\n2 Aiken British Medical Journal, July 23, 1892.\\n3 Barker Lancet, April 18, 1896, and American Text-book of Surgery, 1897.\\n4 Stimson: New York Medical Journal, May 10, 1890, p. 531, and American Text-\\nbook of Surgery, 1892.\\n5 Wolff: Deutsche med. Wochenschrift, May 14, 1891.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0437.jp2"}, "430": {"fulltext": "372 FRACTURES.\\nment to receive silver wires by which the fragments are fastened\\ntogether Kittredge, 1 two similar rivets placed astride the line of frac-\\nture and Axford, 2 temporary wire suture through the bone and back\\noutside the skin. Other older temporary measures are Barton s (1834,\\nthe same as Axford s), Volkmann s silk loops transversely through the\\ntendon and ligamentum patellae and tied together over the skin, and\\nIvocher s (1880) surrounding wire ligature, passing like Barker s through\\nthe joint beneath the patella but, unlike his, including the skin in its\\nloop.\\nCompound fractures specially need protection from infection be-\\ncause of the importance of the joint and the danger to life or limb\\ninvolved in its suppuration. If infection has already occurred the\\njoint must be cleaned as thoroughly as possible and drainage provided\\non each side. The fragments must be sutured together.\\nDisability After Fracture. This may be due to stiffness of the\\njoint or, much less frequently, to the loss of active extension. The\\ncauses of the former are varied, and but few of those which are per-\\nmanent, which do not gradually diminish under use, can be removed\\nby operation. Many attempts to relieve have been made upon the\\ntheory that the fault lay in separation of the fragments or in the\\nabsence of a firm bond between them, the usual plan being to open\\nthe joint and bring the fragments together. Failures have been numer-\\nous, either through inability to close the gap, or through infection, or\\nthrough persistence of the disability after an operative success. Even\\nin many of the cases in which improvement has followed the operation\\nit seems probable that an equal improvement would have come in time\\nwithout the aid of the interference. Chaput, 3 who has thoroughly\\nstudied the conditions, attributes the loss of flexion to hypertrophy or\\nrigid elongation of the united patella by which it is made too long i:o\\npass around the condyles, or, much more frequently, to the ascent of\\nthe upper fragment (with a separation of two to five centimetres), in\\nconsequence of which the upper portion of the capsule and the lateral\\nexpansions become so shortened that the descent of the fragment is\\nimpossible, and it cannot be sufficiently mobilized without a division\\nof its attachments too extensive to be practicable or possibly compatible\\nwith its vitality and even if the lower fragment is brought up to the\\nupper one by detachment of the ligamentum patellae from the tibia\\n(Von Bergmann, 1887) and is united with it flexion would still be lost.\\nThis being so, what is required is not the approximation or reunion of\\nthe fragments but the removal of the obstacle to the descent of the\\nupper one. Chaput did this in one case by excising the upper fragment\\nand obtained a good result, the patient being able to walk up and down\\nstairs and carry a burden of 200 pounds the range of motion is not\\nstated. His grouping of the different forms and their respective treat-\\nment is as follows\\n1. Close union. Medical treatment and exercise.\\n1 Kittredge: Boston Medical and Surgical Journal, November 19, 1891.\\n2 Axford Annals of Surgery, July, 1898.\\n3 Chaput: Fractures anciennes de la Eotule. These de Paris, 1885, and La Semaine\\nMedicale, June 17, 1891.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0438.jp2"}, "431": {"fulltext": "FRACTURES OF THE PATELLA. 373\\n2. Elongation of the patella b) T hypertrophy or a stiff bond with loss\\nof flexion. Extirpation of the patella.\\n3. Short flexible bond. Massage.\\n4. Bond two to five centimetres long with loss of flexion. Extir-\\npation of upper fragment.\\n5. Bonds more than five centimetres long, and those cases of class\\n4 in which active extension is lost. Suture of the fragments after free\\nseparation of the lower portion of the quadriceps and upper part of the\\ncapsule from the femur. This denudation of the femur he proposes to\\neffect through a curved transverse incision at the level of the lower\\nfragment or, if the gap is long, through a longitudinal one for the\\ndenudation he would use the elevator or knife and would suture the\\nfragments with wire because the strain might be too great for periosteal\\nsutures.\\nRupture of Bond Refracture This has rarely seemed to me to\\nrequire more than rest in bed with the foot elevated. As it is\\ncaused by the tearing away of the lower fragment from the upper one\\nin forcible flexion, full extension of the joint brings the torn surfaces\\ninto contact, and we have only to wait for them to reunite, opposing\\nswelling, if necessary, by appropriate measures. Once or twice I have\\nreopened the joint and again sutured the fragments, and, of course,\\nthis would be done if the fracture is compound. The prognosis is\\nmade worse by the prolongation of the confinement and the repetition\\nof the trauma and its consequences.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0439.jp2"}, "432": {"fulltext": "CHAPTEK XXV.\\nFEACTUEES OF THE BONES OF THE LEG.\\nOf the upper end of tibia or both, separation of epiphysis of the tibia, avulsion\\nof the spine, avulsion of the tubercle Of the shaft of the tibia or both\\nAt the lower end Comminuted, supramalleolar, separation of epiphysis of\\ntibia, by eversion and abduction (Potts), by inversion, of the posterior portion\\nof the tibia Of the fibula Upper end, shaft, separation of epiphysis.\\nAccording to the table in Chapter I. fractures of the shaft of the\\ntibia or of both bones constitute one-fourth of those of the lower ex-\\ntremity, and more than 6 per cent, of all fractures. The more fre-\\nquent seat is at or near the junction of the lower and middle thirds.\\nWhen both bones are broken the fibula is usually broken at a higher\\nlevel than the tibia.\\nStatistics show that infancy and childhood are almost exempt, and\\nthat the maximum of frequency is found between the ages of thirty\\nand sixty years, those three decades, according to Malgaigne, furnish-\\ning equal numbers.\\n1. FRACTURES OF THE UPPER END OF THE TIBIA AND FIBULA\\nOR OF THE TIBIA ALONE. 1\\nThe causes of these fractures are direct and indirect violence in the\\nformer a blow received directly upon the part, as the fall of a heavy\\nbody or the kick of a horse in the latter a fall from a height or a\\ntwist of the limb, especially abduction.\\nThe line of fracture may be transverse, oblique, or longitudinal, in\\nthe latter case passing into the joint and separating only a portion of\\nthe articular end from the shaft, or there may be a crush of the internal\\ncondyle of the tibia with rupture of the external lateral ligament.\\nTransverse fractures by direct violence, the fall of a stone, the kick of\\na horse, have been observed at four and seven centimetres from the\\narticular edge. Comminuted fractures have been caused by direct\\nviolence and by falls upon the feet, the shaft penetrating and splitting\\nthe head. Oblique fracture, the line running into the joint and sepa-\\nrating the whole or part of either condyle, appears to be caused by\\nabduction or adduction of the leg, the fracture taking place on the side\\ntoward which the leg is bent.\\nOf longitudinal fracture I have seen one case, a man of twenty-five\\nyears. The line of fracture ran from the inner part of the outer artic-\\nular surface directly downward in a sagittal plane. The separation at\\n1 Including separation of the upper tibial epiphysis and avulsion of the tubercle of the\\ntibia.\\n374", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0440.jp2"}, "433": {"fulltext": "FJRACTUBES OF THE BOXES OF THE LEG.\\n375\\nthe upper end was about half an inch and was maintained partly by a\\nsmall fragment lodged deeply in the cleft, but even after removal of\\nthe latter the displacement could not be wholly reduced. The cause\\nwas a fall from a ladder, but the mechanism was not known. The\\njoint was so loosened that the tibia could be moved outward nearly half\\nan inch. Recovery took place with active flexion nearly to a right\\nangle and marked genu valgum.\\nThe displacement varies with the character of the fracture and the\\nfracturing force in a transverse fracture without comminution it is\\nusually slight in comminution of the upper end and in oblique frac-\\nFig. 210.\\nFig. 211.\\nFig. 212.\\nFracture of the head of the tibia with\\nimpaction and separation of the upper\\nfragments.\\nFracture of the head\\nof the tibia.\\nFracture of upper ends\\nof both bones.\\nture of either tuberosity the fragment may be\\nnotably displaced or tilted. The direct or indirect\\nimplication of the joint ensures an effusion within\\nit, and the proximity of the main vessels makes\\ntheir injury more likely than in fracture at most\\nother points. Both tibial arteries and the pop-\\nliteal vein have been torn, the injury in every case\\nleading to amputation or death.\\nDiagnosis. The diagnosis, in reaching which the aid of an anaesthetic\\nmay be required, is made by recognition of the irregularity of outline,\\npain on local pressure and on pressing the leg upward, and possibly\\nabnormal mobility and crepitus. In high transverse fractures care\\nmust be taken not to mistake the injury for a subluxation of the knee.\\nPrognosis. The prognosis of this injury is exceptionally serious,\\nbecause of the proximity of the joint and the possibility of inflamma-\\ntory complications and the more or less complete loss of the functions\\nof the knee which that and the derangement of the articular surface in\\noblique and comminuted fractures involve, and also because of the\\nexceptionally long period that is necessary for consolidation. The\\naverage period in seven cases collected by Poncet was about four", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0441.jp2"}, "434": {"fulltext": "376 FRACTURES.\\nmonths. Xo satisfactory explanation has been given of this peculi-\\narity.\\nTreatment. Displacement must be corrected by traction and direct\\npressure according, to its character, and retention effected either by\\npermanent traction or by a suspended posterior splint with the knee\\npartly flexed or by encasement of the entire limb in plaster. The\\nindications vary so much with the position, direction, and extent of\\nthe fracture that general rules cannot well be made. Complete encase-\\nment is valuable to prevent bowing of the knee when the fracture\\nextends into the joint.\\nWhen the fracture extends into the joint function may be so limited\\nby an irregular position of the articular fragments that I have thought\\nit might be wise to expose them by incision for more accurate adjust-\\nment. With proper precautions it would be justifiable if the irregu-\\nlarity was great and not otherwise remediable, but I have met with\\nonly one case that seemed to require it.\\nIf the fracture is compound and if suppuration of the joint occurs\\na free outlet for the pus must be promptly provided by special open-\\nings at the sides rather than through the wound which can hardly fail\\nto be unsuitably placed for effective drainage.\\nSeparation of the Epiphysis\\nhas been noted in a few cases. Bruns collected four, Hutchinson 1 says\\nhe has records of ten, including three unpublished cases, and Poland 2\\ncollected twenty-four. The recently reported cases that I have seen\\nare those of Heuston and Manly. 3 In Hutchinson s list the extremes\\nof age were one and sixteen years. The common cause appears to be\\na wrench of the leg, abduction or adduction, by which a transverse\\nstrain is made, but Poland thinks it is direct pressure against the epiph-\\nysis. One of Poland s was compound the patient recovered. In\\ntwelve the patient died or the limb was amputated. The ages ranged\\nfrom three to twenty years. In all but one case the process bearing the\\ntubercle of the tibia accompanied the epiphysis. The displacement was\\nforward, forward and outward, or lateral, and usually slight. In a num-\\nber the diaphysis was also broken, and sometimes extensively. In\\nseveral of the cases which recovered no trace remained of the injury.\\nAvulsion of the Spine of the Tibia\\nby traction through the crucial ligament, which has been noted a few\\ntimes, is to be classed as a complication of dislocation of the knee\\nrather than as a form of fracture.\\nAvulsion of the Tubercle of the Tibia.\\nTo the tubercle is attached the ligamentum patellae, and all the cases\\nof its fracture which have been reported have been caused by the action\\n1 Hutchinson British Medical Journal, March 31, 1894.\\n2 Poland: Traumatic Separation of the Epiphyses, p. 802.\\n3 Heuston and Manly British Medical Journal, July 21 and September 22, 1888.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0442.jp2"}, "435": {"fulltext": "FRACTURES OF THE BONES OF THE LEG. 377\\nof the quadriceps in some violent effort, usually jumping, and most of\\nthem in youths between sixteen and eighteen years of age. The fre-\\nquency in youth is to be accounted for by the fact that the tuberosity\\nis a downward prolongation of the epiphysis and remains separated\\nfrom the shaft by conjugal cartilage until growth is completed.\\nMuller, 1 who has written the only special article upon the subject, col-\\nlected seven cases and added one of his own. To these may be added\\none by Keyser 2 and one by Landsberg. 3 The size of the fragment has\\nvaried in length from two to five centimetres, and in one exceptional\\ncase (Bichet) the rupture ran partly through the tubercles (both legs)\\nand partly through the ligamentum patellae.\\nSymptoms. The symptoms are inability to use the limb immediately\\nfollowing the effort, which sometimes is accompanied by a cracking\\nsound, and the recognition of a movable lump of bone about two inches\\nbelow the patella. On pressing this lump downward and backward\\nagainst the tibia crepitus is felt. The knee-joint is more or less dis-\\ntended by an effusion.\\nTreatment. The treatment is to press the fragment into place and\\nmaintain it there by a bandage or strips of adhesive plaster while the\\nlimb is kept extended upon a splint for four or five weeks. Will, who\\nopened the joint under the impression that he was dealing with a frac-\\nture of the patella, utilized his incision to pin the fragment in place\\nwith a steel drill, and obtained a good result.\\nThe ultimate result has been good in all the cases, but in one the\\nrestoration of motion was not complete until after a year.\\n2. FRACTURES OF THE SHAFT.\\nFractures by direct violence may occur at any point those by indi-\\nrect violence are much more frequent at or near the junction of the\\nlower and middle thirds than at any other point. It seems probable,\\nas taught more especially by Grosselin, that torsion of the limb is an\\nimportant factor in the production of the fracture, the twist being clue\\neither to the forcible contraction of the muscles or to the propulsion\\nof the upper portion while the lower one is fixed by the pressure of the\\nfoot upon the ground.\\nThe varieties of fracture common to other long bones are found here,\\nand in addition a special variety, the V-shaped fracture, first pointed\\nout by Gosselin, which although occasionally found elsewhere is much\\nmore frequent in the leg. In these, which are especially frequent\\nbelow the middle of the bone, the upper fragment terminates in front\\nand on the inner side in a more or less sharp triangular point, the\\nlower fragment presents a similar point posteriorly, and from the bottom\\nof the depression in the lower fragment which corresponds to the first\\npoint a fissure passes spirally downward and usually runs into the ankle-\\njoint, sometimes splitting off a superficial fragment on the posterior\\naspect as shown in Fig. 213. The extent of the fissures and the im-\\n1 Muller Beitrage zur klin. Chir., iNToveniber, 1887, p. 257.\\n2 Keyser: Reported in Sajous s Annual, 1888, vol. ii. p. 267.\\n3 Landsberg; Centralblatt fur Cbir., September 28, 1889.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0443.jp2"}, "436": {"fulltext": "378\\nFRACTURES.\\nFig. 213.\\nplication of the ankle-joint give this variety of fracture an especial\\nimportance.\\nIt is quite rare for the tibia alone to be broken when the fracture is\\nby indirect violence, for the force continues to act, if only for a mo-\\nment, and breaks the weaker fibula all the more easily, and usually at a\\nhigher point than the tibia.\\nThe subcutaneous position of the tibia throughout its entire length\\ngreatly exposes its fractures to the chance of becoming compound\\neither by the direct action of the causative violence when the fracture\\nis direct, or by the perforation of the skin by the end of one of the\\nfragments, usually the upper one, when the fracture is indirect.\\nThe displacements show the usual varieties, but the\\nmost common and important is the projection of the\\nlower end of the upper fragment when it terminates in an\\nanterior point, as it usually does, the contraction of the\\npredominant muscles of the calf aiding it by creating\\nan anterior angular displacement.\\nIn addition to the usual symptoms of crepitus, ab-\\nnormal mobility, pain, and loss of function, there is\\nalso the irregularity in the outline of the subcutaneous\\nportion of the tibia which may often be recognized by\\npassing the finger along it. It is not always possible\\nto say whether or not the fibula is broken as well as\\nthe tibia without making a more severe and painful\\nexamination than the need of the information will\\njustify. When both bones are broken the mobility is\\nusually much greater than when the tibia alone is\\nbroken, and by making gentle pressure with the finger\\nalong the line of the fibula the point of fracture can\\nusually be determined.\\nBeside the frequent complication of a communicat-\\ning wound of the skin, and the comminution which is so\\noften the result of direct violence, injury to the prin-\\ncipal vessels is occasionally met with. Xepveu, 1 in a\\nv-shaped fracture, very complete and elaborate paper read before the\\nSurgical Society of Paris, collected more than fifty\\ncases, among which are found examples of injury to both tibials, the\\nperoneal, and the nutrient artery of the tibia. Injury to the tibial or\\nperoneal nerves seems to be much more rare. Mourret collected\\ntwenty-seven cases of aneurism complicating fracture, five of which\\nwere mistaken for abscess and opened.\\nI have seen hemorrhage occur from the anterior tibial on the eighth\\nday after fracture by direct violence without displacement the rupture\\nwas one and a quarter inches above the fracture and was evidently due\\nto bruising of the artery by the wheel which caused the fracture.\\nA simple fracture without persistent displacement will usually become\\nfirmly consolidated in six weeks but in the comminuted ones and in\\nthose that are oblique with persistent displacement the callus remains\\nweak much longer. Complete recovery is long delayed by rigidity at\\n1 Xepveu Bulletins de la Societe de Chirurgie. 1875, p. 365.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0444.jp2"}, "437": {"fulltext": "FRACTURES OF THE BONES OF THE LEG. 379\\nthe ankle, tenderness of the skin, feebleness of the circulation, and\\nneuralgic pains which are more common after fractures of the leg than\\nafter those of other long bones. In the old and rheumatic this delay\\nis especially prolonged.\\nIf the suppuration becomes free after a compound fracture it is prob-\\nable that complete recovery will be postponed for even a much longer\\ntime, and that sinuses leading down to bare or necrosed bone will re-\\nmain open for many months or will reopen at intervals.^ On the other\\nhand, the subcutaneous position of the tibia makes it easier to drain the\\ncavity of the fracture thoroughly and to remove splinters, and thus\\nmakes the danger to life less than after compound fracture of bones that\\nare more deeplv placed.\\nTreatment. Reduction of the displacement can generally be made\\nby traction at the foot and counter-extension at the knee, this joint\\nFig. 214.\\nVolkmann s splint for leg.\\nbeing slightly flexed to relax the muscles of the calf. In the more\\ndifficult cases in which spasm of the muscles opposes reduction com-\\npression of the femoral artery for a few minutes, as suggested by Broca,\\nhas sometimes seemed to be useful in my experience. In a small pro-\\nportion of cases complete reduction is impossible, probably because of\\nthe interposition of a small piece of bone or of a muscular bundle\\nbetween the fragments.\\nMaintenance of the reduction depends largely upon the character of\\nthe fracture when this is nearly transverse and toothed, the displace-\\nment is unlikely to recur but when it is oblique the difficulties of\\ncomplete retention may be great. The segment of the limb below the\\nfracture is too short to permit traction by strips of adhesive plaster, as\\nin fracture of the thigh, and the surgeon has to depend upon some form\\nof splint or an immovable dressing, neither of which will certainly", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0445.jp2"}, "438": {"fulltext": "380\\nFEACTUEES.\\npreveot shortening, although the amount may be so slight as to be\\nwithout practical importance.\\nThe usual routine of treatment in simple fractures without marked\\ndisplacement is to put the patient in bed with the limb in a Yolkmann\\nsplint (Figs. 31 and 214) for about a week or until the swelling\\nhas subsided, and then to encase it in plaster of Paris. Immediate\\napplication of plaster is objectionable because either the swelling is\\nlikely to increase and make the dressing too tight, or it will diminish\\nand leave it too loose. The stocking bivalve plaster splint (Fig. 215)\\nis a convenient means of combining the advantages of the primary\\nYolkmann splint and the later encasement. The details of its con-\\nstruction are given on page 91. Care must be taken to maintain full\\nFig. 215.\\nBivalve or stocking splint.\\nPosterior gypsum splint or gutter.\\nlength of the leg and to avoid angular or rotatory displacement during\\nthe hardening of the plaster. It can be applied while the injury is\\nrecent, and loosened or tightened as the need arises, and it permits\\neasy inspection to detect and correct such displacements as may occur\\nbeneath it. It also permits massage and the application and change\\nof such dressings as may be needed for associated wounds of the skin\\nor for blisters.\\nIt may become so loose after a week or two that it does not properly\\nsupport the fragments, and should then be renewed. It should be\\nworn until mobility can no longer be recognized, usually five to seven\\nweeks, and the patient can go about on crutches during most of that\\ntime. If union is delayed beyond that time it is well to let the patient\\nbear part of his weight upon the foot in walking, angular displacement\\nthereby being prevented by a strong plaster encasement.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0446.jp2"}, "439": {"fulltext": "FRACTURES OF THE BONES OF THE LEG.\\n381\\nInstead of a Volkmann splint during the first week side splints of\\nwood or wire or a posterior plaster moulded splint (Fig. 216) may be\\nused, and they may also, especially the latter, be serviceable during the\\nlater stages if wounds of the anterior soft parts require dressing.\\nA number of devices for maintaining continuous traction have been\\nsuggested, but their inherent defects are such that they have never come\\ninto general use. Figs. 217 and 218 show two such.\\nFig. 217.\\nDr. Neill s dressing for continuous traction.\\nDirect pressure by a metal pin or a pad controlled by a screw was\\noccasionally used when the projecting end of the upper fragment could\\nnot otherwise be controlled and especially if it threatened to perforate\\nthe skin. It is now generally deemed better to expose the fracture by\\nincision and remove the cause.\\nIn compound fractures the bivalve or fenestrated or interrupted splint\\nmay be used, or anterior and posterior moulded splints one of which\\nholds the fragments in place while the other is removed that the dress-\\nFig. 218.\\nContinuous traction in fracture of the leg.\\ning may be changed. The details of treatment of the wound are here\\nof special importance, and particularly the distinction to be made\\nbetween fractures that are compound by direct violence and those by\\nindirect violence. For these and for ambulatory treatment the reader\\nis referred to Chapter VII.\\nSuspension may be employed with any of these splints and often\\npromotes comfort notably.\\n3. FRACTURES AT THE LOWER END OF THE LEG.\\nIn this group I place the rare fractures of both bones in which the\\nlower end of the tibia is crushed or splintered, separation of the lower\\nepiphysis of the tibia and the allied supramalleolar fracture, the numer-\\nous and varied fractures of one or both bones at or near the joint caused\\nbv forcible inversion or eversion of the foot, sometimes aided bv the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0447.jp2"}, "440": {"fulltext": "382\\nFRACTURES.\\nFig. 219.\\nweight of the body, of which the most common is known as Pott s\\nfracture, and the much rarer fracture of the posterior articular portion\\nof the tibia. The feature which almost all have in common is the\\naction of the causative violence through the foot.\\nA. Comminuted Fracture of the Lower End of the Tibia with Frac-\\nture of the Fibula.\\nThe fractures which constitute this group are too rare and varied to\\npermit a systematic description. The tibia is broken either by direct\\nviolence acting upon its side to crush it, or, more frequently appar-\\nently, by a fall from a height in which the bone is broken by a trans-\\nverse strain and then its lower portion split by the penetration into it\\nof the other. Thus, in a case reported by Chassaignac the tibia was\\nbroken four finger-breadths above the joint and the lower fragment\\nsplit into four pieces the fibula was broken at two places in its lower\\nthird. A specimen in the museum at Val de Grace is shown in Fig.\\n219 the lower end of the tibia was broken into six fragments.\\nDiagnosis. The diagnosis must be made by recognition of the abnor-\\nmal mobility and the mobility of the fragments probably the aid of\\nanaesthesia would always be necessary to appreciation of the details.\\nTreatment. The treatment must aim to effect and maintain as com-\\nplete reduction as possible, acting upon the fragments by traction\\nthrough the foot and by direct pressure. The\\nimplication of the joint and the frequent derange-\\nment of the articular surface by fragmentation\\nmake loss of function in the ankle-joint inevit-\\nII j able, and therefore the foot must be maintained\\n1 I at right angles to the leg and without eversion or\\nJ J inversion of the sole in order that its usefulness\\nI jjj Y% may not be further diminished by a fixed faulty\\nposition. If the injury is compound by direct\\nviolence amputation may be expected to give a\\nbetter functional result than conservative treat-\\nment in most cases.\\nB. Supramalleolar Fracture.\\nThis term was created by Malgaigne and ap-\\nplied to fractures which for the most part were\\nlow or partial forms of the preceding class, the\\nline of fracture always running into the joint\\nand usually comminuting the end of the bone,\\nbut there are cases in which the tibia is broken\\nacross within an inch or two of its lower surface\\nand with fracture of the fibula at or above the\\nsame level. I have seen one in which the tibia was broken squarely\\nacross, one inch above its lower end, the fibula was broken at the\\njunction of the upper and middle thirds, and the tip of the external\\nmalleolus was broken off. Tillaux l was able to produce this form\\n1 Tillaux Anatomie topographique, p. 1174.\\nComminuted fracture\\nof the lower portion of the\\nleer.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0448.jp2"}, "441": {"fulltext": "FRACTURES OF THE BONES OF THE LEG.\\n383\\nexperimentally by inversion of the foot, and says the fracture then\\ntakes place first in the fibula, and only in the tibia if the force con-\\ntinues to act he reports one case in which dislocation of the upper\\nend of the fibula took the place of fracture of that bone, the line of\\nfracture of the tibia lying three finger-breadths above its lower sur-\\nface. In the few cases I have seen the mechanism could not be\\nlearned, but I see no reason to doubt that it can be effected also by\\neversion of the foot in the case above quoted the lower fragment\\ncould be easily displaced outward, but not inward.\\nDiagnosis. The diagnosis is made by pain on pressure along the\\nline of fracture and on pressing the foot up against the leg, and pos-\\nsibly by recognition of abnormal mobility and crepitus.\\nTreatment. The treatment is immobilization, preferably in a fixed\\ndressing, using the foot to control the position of the lower fragment.\\nC. Separation of the Epiphysis of the Tibia.\\nFig. 220.\\nThis is more frequent than that of the upper epiphysis, 11 to 4 in\\nBruns s 100 cases of all kinds. The cause\\nappears to be a cross-strain in eversion and\\nperhaps in inversion of the foot, sometimes the\\nresult of great violence as in a fall from a height,\\nsometimes a simple twisting of the foot in a\\nmisstep. Experiments indicate that it may be\\nproduced by forcible dorsal flexion of the foot\\ncombined with pressure against the sole.\\nIn some cases, as in Fig. 220, the outer por-\\ntion of the shaft is broken off, evidently during\\neversion and in some the injury is compound\\nwith marked protrusion of the shaft through\\nthe wound on the inner side. The fibula is\\nalmost always broken at a higher point, and\\nalthough the upper limit of its own epiphysis\\nis situated well below that of the tibia its sepa-\\nration occasionally takes the place of fracture\\nof the shaft.\\nHutchinson collected eight reported cases of\\narrest of growth after the injury, with overgrowth of the fibula and\\ninversion of the foot.\\nThe principle of treatment is the same as in supramalleolar fracture.\\nSeparation of the lower\\nepiphysis of the tibia.\\n(Bruns.)\\nI). Fractures by Eversion and Abduction of the Foot. Pott s Fracture.\\nBeside being a very common injury this gains special importance\\nfrom the frequency with which the cardinal principles of its treatment\\nare overlooked and the occasional great disability which results. The\\nlesions vary much in extent and detail indeed, occasionally fracture\\nis wholly absent and some of the forms have been classed with dislo-\\ncations. But these differences are due either to alternative lesions or\\nto the early cessation of the force before the typical form has been", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0449.jp2"}, "442": {"fulltext": "384\\nFRACTURES.\\nreached, and the mode of production in its two forms is constant, so\\nthat all the variations are parts of a single nosological entity. The\\ndifferences make a name anatomically descriptive of the group almost\\nimpossible; the one above given, based on the mode of production, is\\nuseful to distinguish the group from the following one which has cer-\\ntain points of resemblance, and correctly includes all the forms, but it\\nis not suitable for current use the alternative title, Pott s fracture,\\nhas not only the advantage of convenience but also that of long asso-\\nciation with the injury. It deserves, I think, to be retained as the\\nprincipal name.\\nCause and Pathology. The cause is a twist of the foot eversion\\nand abduction aided somewhat by the weight of the body. Accord-\\nFig. 221.\\nPott s fracture, right side showing outward displacement and absence of eversion.\\ning as the eversion or the abduction predominates the lesions take one\\nor the other of two easily distinguishable forms, as follows\\nIf eversion is the sole, or main, movement the force is exerted\\nthrough the internal lateral ligament and breaks the internal malleolus\\nsquarely off at its base then it presses the external malleolus out-\\nward, rupturing the tibio-fibular ligament, and breaks the fibula close\\nabove the malleolus. Sometimes, instead of pure rupture of the tibio-\\nfibular ligament, there is avulsion of the portion of the tibia to which\\nit is attached, in front or behind or both, but I believe this to be rare.\\nThese lesions can be easily produced experimentally by fixing the foot\\nin a vise and pressing the upper part of the leg outward.\\nIf, on the other hand, abduction of the front of the foot is the\\nprincipal movement the first and last of these three lesions vary", "height": "4477", "width": "2514", "jp2-path": "practicaltreati00stim_0450.jp2"}, "443": {"fulltext": "PLATE XXIII.\\nFig. 1.\u00e2\u0080\u0094 Potts Fracture by Abduction; Male, 40 years\\nInternal Malleolus Unbroken.\\nFig. 2. Potts Fracture, 2 months old; Backward Displacement.\\nSee also Plate XXIV., Fig. 1.", "height": "4477", "width": "2514", "jp2-path": "practicaltreati00stim_0451.jp2"}, "444": {"fulltext": "", "height": "4453", "width": "2498", "jp2-path": "practicaltreati00stim_0452.jp2"}, "445": {"fulltext": "PLATE XXIV.\\nFig. 1. Potts Fracture by Abduction same as Plate XXIII., Fig. 2.\\nFig. 2. Bimalleolar Fracture by Eversion Boy, 14 years External\\nMalleolus separated at Epiphyseal Line; Fracture of Internal\\nMalleolus does not show, but was recognized clinically.", "height": "4453", "width": "2498", "jp2-path": "practicaltreati00stim_0453.jp2"}, "446": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0454.jp2"}, "447": {"fulltext": "FRACTURES OF THE BONES OF THE LEG.\\n385\\ninstead of a square break of the internal malleolus at its base, there\\nis an oblique, almost marginal, fracture of its anterior portion, or,\\nmore commonly, there is rupture of the anterior portion of the internal\\nlateral ligament then follows rupture of the tibio-fibular ligament,\\nand, as the movement continues, the torsion of the fibula produces an\\noblique fracture the upper end of which is found three or four inches\\nabove the tip of the malleolus. If the movement is arrested in time\\nfracture of the fibula may occur. Experimentally this can be easily\\nproduced and the sequence of events accurately observed. Clinically\\nit cannot be demonstrated so easily, for the patient can rarely give a\\nFig. 222.\\nThe same showing backward displacement.\\ndetailed account of the manner in which the injury was received, but\\nin one of my cases the mechanism was evident while the patient was\\nkneeling on one knee, the foot resting on the hyper-extended toes, he\\nwas pressed backward so that his buttocks rested on and forced the\\nankle inward, causing abduction of the front of the foot. The essen-\\ntial lesion is the tibio-fibular diastasis, the rupture of those ligaments,\\nand the consequent widening of the mortise within which the astrag-\\nalus is held.\\nTwo complications which may appear in the first variety were, so\\nfar as I know, first observed and reported by me l I have seen two\\n1 Stimson Transactions of the New York Surgical Society, in New York Medical Jour-\\nnal, Jan. 26, 1889, p. 108, and Pott s Fracture, New York Medical Journal, June 25. 1892.\\n25", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0455.jp2"}, "448": {"fulltext": "386 FRACTURES.\\ncases of each. One is the rotation of the internal malleolus about an\\nantero-posterior axis so that its fractured surface lies parallel to and\\njust beneath the skin, the fragment being exceptionally prominent and\\nmovable. The other is the interposition between the malleolus and the\\ntibia of a large strip of periosteum torn from the tibia in this condi-\\ntion also the malleolus is exceptionally prominent and movable. In\\nall my four cases the fracture was exposed and readjustment made\\nthrough an incision recovery followed with full restoration of func-\\ntion.\\nAnother occasional complication is the breaking of the posterior lip\\nof the articular surface of the tibia. (See Section D.)\\nAnother, not very uncommon, complication of the first variety is\\nlaceration of the skin on the inner side by the end of the tibia, which\\nmay project through the wound this is due to the prolongation of the\\naction after fracture, by which the foot is forced outward and everted\\nand the skin torn across the broken edge of the tibia. The displace-\\nment is of the foot (astragalus) and outer malleolus outward and back-\\nward. This displacement is usually slight, a quarter of an inch, but\\nit may be much more, and the backward displacement is sometimes so\\ngreat that the body of the astragalus lies almost wholly behind the\\ntibia.\\nSymptoms. The appearance of the region is usually so characteristic\\nthat the diagnosis can be made at a glance, the characteristic feature\\nbeing the outward displacement of the foot and the corresponding prom-\\ninence of the internal malleolus or the adjoining portion of the tibia\\n(Fig. 221) in the marked cases the backward displacement is also\\nplainly to be seen (Fig. 222). The former is most apparent when the\\nmuscles are relaxed, as by anaesthesia, or when swelling is absent.\\nThe pathognomonic signs are abnormal lateral mobility at the ankle,\\nwhich can be shown by grasping the foot with one hand so that the\\nposterior portion of the sole rests in the palm, with the thumb close\\nbelow the external malleolus, and the index-finger below the internal\\nmalleolus, and moving it bodily inward and outward w r hile the other\\nhand grasps the leg above the ankle and steadies it (Figs. 223 and\\n224). This manipulation sometimes produces a distinct click by the\\nimpact of the astragalus against the internal malleolus or of the exter-\\nnal malleolus against the tibia.\\nIn like manner abnormal mobility backward and forward can some-\\ntimes be shown by clasping the back of the heel with the fingers of\\nboth hands, placing the thumbs on the front of the lower part of the\\ntibia, and then alternately lifting the foot and allowing it to drop back,\\nthe patient being recumbent.\\nThree points of tenderness on pressure are constant and character-\\nistic one in front of the position of the tibio-fibular ligament, that is,\\nin the groove between the tibia and the external malleolus, showing\\nthe rupture of this ligament one at the base of the internal malleolus\\nor near its anterior border or just in front of it, marking the fracture\\nof the malleolus or the rupture of the anterior portion of the lateral\\nligament the third over the outer aspect of the fibula, close above the\\nmalleolus in the first variety, an inch or so higher in the second, mark-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0456.jp2"}, "449": {"fulltext": "FBACTUBES OF THE BONES OF THE LEG.\\n387\\ning the fracture of the fibula. Abnormal mobility of the two frag-\\nments may sometimes be recognizable.\\nMarked ecehymosis appears beneath the external malleolus and\\nusually also beneath the internal.\\nPressure upward against the heel is not painful, and the patient can\\nsometimes walk if he steps carefully and without much movement in\\nthe ankle-joint.\\nPrognosis. If reduction is made and maintained the prognosis is\\nFig. 223.\\nFig. 224.\\nX\\nPott s fracture method of recognizing abnormal lateral mobility.\\ngood, the patient almost always regaining full use of the joint, but if\\neither backward or outward displacement persists (Figs. 225 and 226)\\nthe disability is likely to be marked. Backward displacement limits\\ndorsal flexion at the ankle, and the patient is, therefore, obliged to turn\\nthe toes well outward in walking outward displacement brings the\\nweight of the body too far to the inner side of the foot and thus pro-\\nduces a strain upon the internal lateral ligament which promptly causes\\nfatigue and pain.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0457.jp2"}, "450": {"fulltext": "388\\nFRACTURES.\\nTreatment. Reduction, to facilitate which anaesthesia is sometimes\\nadvisable, is made by pressing the calcaneum forward and inward; the\\nhand is placed against the back and outer side of the heel and pressed\\nforward and then forcibly inward. It is best maintained by a poste-\\nrior and a lateral plaster splint, such as those shown in Figs. 227 and\\n228. They are preferable to complete encasement in plaster because\\nthey permit inspection of the inner side of the ankle and the immediate\\nFig. 225.\\nFig. 226.\\nOld Pott s fracture outward\\ndisplacement.\\nThe same backward displacement.\\ndetection of recurrence, and to wooden splints (Fig. 229) because they\\nare more secure. They can be conveniently made of a four-inch plaster\\nroller by soaking it and running it back and forth on a table until\\ntwelve or fifteen layers of suitable length have been put together. The\\nposterior splint should extend from the toes, along the sole, and up the\\ncalf nearly to the knee. The lateral one should begin just in front of\\nthe external malleolus, pass over the dorsum of the foot to the inner", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0458.jp2"}, "451": {"fulltext": "FBACTUBES OF THE BONES OF THE LEG.\\n389\\nside, under the sole, and up along the outer side of the leg to the same\\nheight. They are snugly moulded and bound to the limb while still\\nFig. 227.\\nBK1\\n^^^^H^BL\\nKL\\n-4^8\\n^^^1^,\\n\u00c2\u00a33aMBHta*a(\\nisitt^\\ntS*\\nl m\\nm 1\\nPott s fracture posterior plaster splint.\\nwet with a roller-bandage which may be removed after the plaster\\nhas set, its place being taken by a few turns of a bandage just above\\nFig. 228.\\nPott s fracture lateral plaster splint.\\nthe ankle and at the upper end of the splint. While the plaster is\\nsetting reduction must be maintained by an assistant or by resting the\\nFig. 229.\\nDupuytren s splint.\\nheel on a sand-bag with the limb in outward rotation so that the foot\\nwill be pressed forward and inward. I have sometimes placed the\\nlateral splint on the inner side.\\nSuch a splint may be conveniently and safely applied immediately\\nafter the accident, for if strangulation should threaten the circular\\nbandages can be loosened sufficiently to relieve the constriction without", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0459.jp2"}, "452": {"fulltext": "390\\nFRACTURES.\\ndisturbing the position of the foot. If applied while the limb is swol-\\nlen the shrinking can be met by tightening the circular bands, but it\\nis better to apply a new one after a few days.\\nIn compound fracture with a small wound infection can generally be\\navoided by the usual measures, and a good result obtained. If the\\nwound is or should become infected drainage must be made on both\\nFig. 230.\\nFig. 231.\\nPott s fracture; same case as in Figs. 225 and 226 showing result of operation.\\nsides, and the foot kept square upon the leg that its usefulness may be\\nas great as possible after the probable result of anchylosis.\\nIn the rare cases of rotation of the internal malleolus or interposition\\nof a strip of periosteum the condition should be corrected through an\\nopen incision.\\nIn old fractures with unreduced displacement relief can be had only by\\noperation. Supramalleolar osteotomy enables the foot to be brought\\nback into line with the leg, but does not correct the backward displace-\\nment which almost always coexists. I have never employed it, but\\nhave always resorted to a formal attempt to bring the astragalus and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0460.jp2"}, "453": {"fulltext": "FRACTURES OF THE BONES OF THE LEG. 391\\nexternal malleolus back to their places, using two lateral incisions, as\\nfollows (Figs. 230, 231):\\nOne incision begins at the front of the fibula three inches above the\\nankle, is carried downward, passing in front of the malleolus, and then\\ncurved forward on the side of the foot the fracture is exposed and the\\nlower fragment again detached. The second incision begins on the\\ninner side of the tibia at the same level as the first and passes down to\\nthe front of the malleolus and thence forward to or beyond the tubercle\\nof the scaphoid. Through it the internal malleolus, if it was broken\\noff in the original injury, is again detached from the tibia with a chisel,\\nand the end of the tibia protruded so that it is easy to liberate the\\nastragalus and cut awav any new growth of bone that may have formed\\non the back of the tibia. The foot is then easily restored to place, the\\nincisions closed, and a bulky dressing applied and covered with plaster\\nof Paris. In the nine or ten cases in which I have done this the res-\\ntoration of form has been complete, and that of function always\\nan improvement upon the previous condition and sometimes a -very\\nmarked one.\\nE. Fractures of the Malleoli by Inversion of the Foot.\\nThis injury, which also is a common one, presents several varieties\\ndiffering notably in the extent of the lesions, the immediate disability,\\nand the prognosis. The fibula may be alone broken at or close above\\nthe base of the malleolus or at the epiphyseal line in the young, or\\nwith its fracture may be associated that of the tip of the internal mal-\\nleolus or one passing obliquely upward and inward through the tibia\\nand separating a fragment composed of the internal malleolus and a con-\\nsiderable portion of the adjoining bone (Plates XXIV., XXV.). The\\nvariations appear to be due to differences in the amount or force of the\\ninversion and to the extent to which the weight of the body acts as a fac-\\ntor. Thus, the first effect of inversion is to break the fibula if the move-\\nment is continued, or possibly if its direction is somewhat different,\\nthe astragalus presses against and breaks off the tip of the internal\\nmalleolus but if the weight of the body is added, as in a fall upon\\nthe inverted foot, the astragalus presses upward and inward against\\nthe inner portion of the tibia and breaks off the larger fragment.\\nThe first form of the injury, fracture of the external malleolus or\\nfibula alone, is of slight importance, producing no displacement of the\\nastragalus and getting w r ell under a simple protective dressing. The\\nsame is nearly equally true of the second form, added fracture of the\\ntip of the internal malleolus, but more time is required before the limb\\ncan be freely used. The third form is much more serious and usually\\nresults in considerable restriction of motion at the joint.\\nDiagnosis. The diagnosis is made in the first two varieties by recog-\\nnition of tenderness on pressure at the lines of fracture and of inde-\\npendent mobility of the external malleolus by pressing its tip inward\\nwhile another finger is placed at the seat of fracture to feel the tilting\\nof the upper end of the fragment. In the third variety the line of\\nfracture of the tibia can be recognized by tenderness on pressure and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0461.jp2"}, "454": {"fulltext": "392\\nFRACTURES.\\nby the irregularity produced by the displacement upward and inward\\nof the fragment.\\nTreatment. For the first two varieties it is sufficient to immobilize\\nthe part by plaster of Paris, taking care to keep the foot well pressed\\ninward while the plaster is setting in order that the malleolar mortise\\nshall not be widened. In the third variety the effort must be made to\\ncorrect the displacement of the tibial fragment by pressing it down-\\nward and outward, and to immobilize with the foot well forward,\\nguarding against backward displacement, and the external malleolus\\npressed snugly against the tibia, guarding against outward displacement.\\nF. Fracture of the Posterior Portion of the Articular Surface of the\\nTibia. 1\\nThis may be a complication of Pott s fracture, the fragment being\\nrather small, or the crush may be so extensive that the symptoms and\\nFig. 232.\\nFracture and displacement of the posterior portion of the lower articular surface of the tibia\\nand of the fibula and internal malleolus. (See also Plate XXII., fig. 2.)\\ntreatment are very different. In the slighter form the breaking of the\\ntibia is apparently produced by the weight of the body pressing the\\nposterior and outer part of the articular surface against the displaced\\nastragalus, and yet I have known it to be caused by the comparatively\\n1 See also Backward Dislocation of the Foot.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0462.jp2"}, "455": {"fulltext": "PLATE XXV.\\nFig. 1.\u00e2\u0080\u0094 Bimalleolar Fracture by Eversion in a Youth Line of Fracture\\npassing above the Base of the Internal Malleolus; External Malleolus\\nseparated at Epiphyseal Line.\\nFig. 2.\\nFracture of Femur remaining ununited a year after wiring.\\nNote detachment of the wire.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0463.jp2"}, "456": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0464.jp2"}, "457": {"fulltext": "FRACTURES OF THE BONES OF THE LEG.\\n393\\nslight violence of a fall from an almost stationary bicycle. I have\\nnever seen it in a fresh injury and do not know whether it could be\\nrecognized the signs of Pott s fracture would be recognizable, of\\ncourse, and possibly the additional fracture might be shown by dis-\\nplacement of the foot (astragalus) slightly upward as well as backwad\\nand outward.\\nThe treatment is that of Pott s fracture with special care to bring the\\nfoot well forward.\\nThe more severe form is rare and apparently the result of a fall from\\na height upon the foot. I have one old specimen of extensive crushing\\nwith fracture of the external malleolus and its displacement backward,\\nbut repair has obliterated most of the details. I have seen another\\nin the collection of Dr. Dandridge, of Cincinnati, in which the poste-\\nrior half of the tibial plateau is broken off and has united with the\\nback of the tibia after displacement of more than half an inch upward.\\nThe fibular fragment is rather short and is displaced angularly, the\\nFig. 233.\\nSame case as Figure 232.\\nastragalus having slipped outward between it and the tibia the inter-\\nnal malleolus is broken off at its base and has accompanied the astrag-\\nalus. In two old cases treated by operation (Figs. 232 and 233) I have\\nfound similar lesions and displacements.\\nProbably under an anaesthetic the general condition, if not the\\ndetails, could be recognized by palpation. The treatment would be", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0465.jp2"}, "458": {"fulltext": "394 FRACTURES.\\nto make such reduction as was possible and to immobilize in plaster\\nsplints.\\nIn two old cases I have removed the posterior fragment of the tibia,\\ncorrected the displacement, and obtained a useful limb with obliteration\\nof the ankle-joint.\\n4. FRACTURES OF THE FIBULA.\\nA. Fracture of the Upper End. 1\\nThis may be caused by direct violence, by muscular action (contrac-\\ntion of the biceps), or more commonly by forcible adduction of the leg\\nacting through the external lateral ligament attached to the head of\\nthe fibula. In two of the reported cases (Stimson, Weir) the lesion\\nwas a separation of the epiphysis. In a number of the cases paralysis\\nof the extensor and peroneal muscles and loss of sensation in the region\\nsupplied by the musculo-cutaneous branch of the peroneal nerve were\\nnoticed shortly after the accident, and in some persisted until the\\npatients passed from observation. Weir and Marchant exposed the\\nnerve in their cases and found it unbroken but apparently compressed\\nby the edge of the fragment the patients recovered almost completely\\nfrom the paralysis.\\nThe upper fragment has been widely displaced upward in most of\\nthe cases, and it has usually been impossible to bring it fully back to\\nits place, but it does not appear that any disability has resulted there-\\nfrom.\\nTreatment. The treatment consists in approximation of the frag-\\nments by bandaging aided by flexion of the knee to relax the biceps and\\nplaster of Paris to prevent adduction of the leg. If peroneal paralysis\\nexists it would probably be well to expose the nerve for some little\\ndistance above and below the fracture in order to reunite it if it is torn\\nor to relieve pressure upon it.\\nB. Fractures of the Shaft.\\nThese fractures are produced by direct violence. The displacement\\nis slight because of the support given by the tibia, and the diagnosis\\nis made upon the localized pain and possibly crepitus and recognizable\\nmobility or irregularity of outline. Occasionally symptoms indicative\\nof injury to the cutaneous branch of the peroneal nerve are present,\\npresumably by the violence which caused the fracture.\\nTreatment. The only treatment needed is protection against external\\nviolence and movement of the lower fragment by twisting the foot\\nthis is conveniently given by a plaster or silicate dressing extending\\nfrom the toes to the knee. It should be worn for about three weeks,\\n1 For reported cases, which are riot numerous, see the firs* edition of this work and\\nGurlt s Knochenbriichen, vol. i. p. 243 Duplay, Bull, de la Soc. de Chirurgie, 1880, p.\\n218 Terrier, Idem, p. 222 Leggatt, Lancet^ March 31, 1888 Hirschberg, Arch, fur\\nklin. Chir., vol. xxxvii. p. 199 Weir, New York Medical Journal, May 26, 1888 Mar-\\nchant, La France Med., February 21, 1889 and Chapin, New York Medical Journal,\\nSeptember, 1891, p. 12.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0466.jp2"}, "459": {"fulltext": "FBACTUBES OF THE BONES OF THE LEG. 395\\nand care should be taken for a fortnight longer to avoid muscular strain\\nand lateral pressure by the foot at the ankle.\\nC. Separation of the Lower Epiphysis.\\nPoland 1 has collected four cases of this injury uncomplicated by\\nfracture of the tibia. In three the injury was compound. One patient\\n(Allis) died of tetanus, in one (Wright) the lower fragment became\\nnecrosed, and in the third (Poland) gangrene occurred on the third day\\nafter the application of a plaster dressing. In two other cases (speci-\\nmens in the Middlesex and London Hospitals) there were extensive\\nassociated injuries amounting to dislocation of the ankle and requiring\\namputation. (See also Plate XXIV., fig. 2.)\\n1 Poland Loc. cit., p. 860.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0467.jp2"}, "460": {"fulltext": "CHAPTEK XXVI.\\nFRACTUEES OF THE BONES OF THE FOOT.\\n1. FRACTURES OF THE ASTRAGALUS.\\nThese are commonly the result of falls from a height, the bone\\nbeing broken between the calcanenm and the tibia, and the lesion being\\nfrequently associated with fracture of the calcaneum and with disloca-\\ntion at the ankle and fracture of the fibula in other cases the force\\nacts transversely.\\nThe direction and extent of the line of fracture vary greatly the\\nbone may be divided transversely, or longitudinally, or horizontally,\\nor obliquely, or into several pieces, and the fragments may be widely\\nseparated and dislocated.\\nAVhen there is no displacement or external wound the diagnosis may\\nbe very difficult, because the symptoms are not distinctive and indicate\\nonly severe injury to the foot, pain, swelling, inability to bear the weight\\nof the body on it, and perhaps crepitus on handling or flexing and\\nextending it. The diagnosis must be made by exclusion of other\\ninjuries, by localized pain, and possibly by recognition of a displaced\\nfragment, or of independent mobility of the head of the bone. I have\\nonce found it by the tf-rays, in combination with fracture of the os\\ncalcis and without displacement, when unable to recognize it clinically.\\nWhen there is no displacement treatment is directed simply to immo-\\nbilize the joint and control the inflammation a plaster bandage should\\nbe applied, especial attention being given to the position of the foot,\\nwhich should be at right angles to the leg in the antero-posterior plane\\nand without inversion or e version.\\nIf a fragment is broken from the upper articular surface of the body\\nit should be removed. If the neck has been broken and the head dis-\\nplaced it should be restored to its place, by an incision if necessary, or\\nremoved if it is found to be completely detached. If the body should\\nprove to be crushed or comminuted its total excision, with or without\\nthe head and neck, will probably yield a much better functional result\\nthan conservative treatment.\\nIn compound fractures by direct violence removal of the astragalus\\nis indicated because the functional result is likely to be better than\\nafter even successful conservative treatment.\\n2. FRACTURE OF THE CALCANEUM.\\nThis bone may be broken by a fall upon the foot from a height, by\\ncontraction of the muscles attached to the tendo Achillis, and by\\nforcible inversion of the sole of the foot. The extent and position of\\nthe fracture vary with the causes.\\n396", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0468.jp2"}, "461": {"fulltext": "FBACTUBES OF THE BONES OF THE FOOT. 397\\nIn a fall directly upon the sole the bone is splintered or crushed, and\\nespecially so in its anterior half, and its vertical diameter is diminished\\nbv the crushing and its transverse diameter increased (Fig. 234).\\nSometimes the bone is also split longitudinally. There is some reason\\nto think that forcible pressure upon the ball of the foot, dorsal flexion,\\nresisted bv the contraction of the muscles of the calf, may produce the\\nsame result by the following mechanism the arch of the foot is ex-\\ntended, the thick, strong inferior calcaneo-scaphoid ligament made\\ntense, and the calcaneum broken behind the insertion of this ligament\\nthen, the force continuing to act, the broken bone is further crushed\\nby the astragalus.\\nSymptoms. The symptoms of a vertical or crushing fracture are\\nsomewhat indefinite, and the diagnosis is not always easy, as is shown\\nbv the fact that surgeons so experienced as Malgaigne, Bonnet, Huguier,\\nand Legouest have mistaken the injury for fracture of the fibula or\\nankle. The symptoms are increase of its transverse diameter, which,\\nhowever, may be completely masked by the swelling below and about\\nFig. 234.\\nFracture of the calcaneum, witn crushing.\\nthe malleoli, flatness of the sole and approximation to it of the mal-\\nleoli, especially of the internal one, pain, and loss of function. Crepi-\\ntus is either absent or obscure abnormal mobility may be recognized\\nby moving the posterior portion laterally. Pain is caused by direct\\npressure and by a voluntary effort to make plantar flexion against\\nresistance at the toes. The tendo Achillis feels less tense when pressed\\nupon, and the depression on each side of it is obliterated by swelling.\\nThe deformity of the heel is best recognized when compared with its\\nfellow from behind while the patient is kneeling.\\nTreatment. The treatment is immobilization, preferably with mas-\\nsage, for about three weeks use of the limb to be renewed as soon\\nas the patient can bear his weight upon it.\\nWhen the direction of the violence with reference to the axis of the\\nleg is such that the foot is adducted or inverted by it, the strain is\\nbrought upon the external lateral ligament and the sustentaculum tali,\\nwith the result of producing fracture of the fibula as described on page\\n391, or rupture of the external lateral ligament, or avulsion of a scale\\nof bone from the side of the calcaneum where the ligament is inserted,\\nor fracture of the sustentaculum tali.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0469.jp2"}, "462": {"fulltext": "398 FRACTURES.\\nWith the first of these we have not here to deal. A case of avulsion\\nof a scale of bone came under my observation at the Presbyterian Hos-\\npital in 1880 the patient had fallen from a height of ten feet, striking\\nupon his left foot. I saw him on the following day and found the foot\\nand ankle much swollen, with obscure crepitus and pain on manipulation\\nof the side of the heel below the outer malleolus. The swelling sub-\\nsided under lead and opium lotions, and in a few days I could distinctly\\nmake out a movable flat fragment evidently detached from the outer\\nside of the calcaneum below the malleolus. The movements of the\\nfoot and ankle were normal and painless except when the peroneal\\nmuscles were made to contract, then pain was felt below the external\\nmalleolus. The sheath of the tendons of these muscles was swollen\\nbelow and behind the malleolus.\\nFracture of the sustentaculum tali was first described by Abel. 1\\nIn his first case the injury was thought to be a Pott s fracture of the\\nankle, and its real character was disclosed at the autopsy. The patient\\nwas a young man who in dismounting from a horse slipped on a stone\\nand turned his foot forcibly inward. He attempted to walk, and the\\nposition of the foot then changed instantly to marked valgus. A lon-\\ngitudinal wound three inches long below the external malleolus opened\\nthe ankle-joint and the joint between the astragalus and calcaneum.\\nThere was tenderness on pressure below the internal malleolus, and on\\nthe fibula above the external malleolus. These symptoms together\\nwith the apparent broadening of the ankle and eversion of the foot led\\nto the erroneous diagnosis mentioned. Erysipelas set in and the patient\\ndied on the fifteenth day.\\nThe fibula and tibia were found uninjured, the sustentaculum tali\\nbroken off, and the external lateral ligament divided in the line of the\\nwound.\\nAbel afterward saw two cases in which he thought this injury had\\nbeen received some time before. In both the foot had been violently\\ninverted, and in one the sustentaculum tali seemed to be doubled in\\nsize. The symptoms, primary and ultimate, corresponded to the fol-\\nlowing, which he gives as diagnostic of the injury.\\n1. The mode of production forcible inversion of the sole of the foot.\\n2. The immediate change in the position of the foot, from inversion\\nto eversion, and the permanent sinking of the inner border of the foot\\nand internal malleolus (valgus).\\n3. Shortening of the heel by slight displacement of the calcaneum\\nforward this can be best recognized by measuring from one malleolus\\nto the other around the heel, and was verified by experiment.\\n4. Pain and disability.\\n1 2 presented to the New York Surgical Society a specimen of this\\nfracture combined with that of the anterior portion of theos calcis and\\nthe inner part of the scaphoid. The patient, a man thirty years of\\nage, was injured by jumping from a height of thirty feet during a\\nparoxysm of delirium tremens, and died soon after he was brought to\\nthe hospital. The appearance of the left foot closely resembled that\\n1 Abel Archiv fur klin. Chirurgie, 1878, vol. xxii. p. 396.\\n2 Stirnson New York Medical Journal, January 21, 1888.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0470.jp2"}, "463": {"fulltext": "FRACTURES OF THE BONES OF THE FOOT 399\\nof splay-footed valgus the internal border in front of the ankle was\\nlowered, and the front of the foot was somewhat abducted. The head\\nof the astragalus was prominent on the internal border. The region of\\nthe internal malleolus was apparently normal, except so far as it was\\ninvolved in the general swelling the external malleolus was promi-\\nnent, and its appearance suggested that the fibula had been broken\\nabove the ankle. A piece of bone, freely movable with crepitus, could\\nbe felt in front of the astragalus on the inner border, and there was\\nmarked crepitus just in front of the external malleolus. On dissection,\\nthe astragalus was found to be displaced forward upon the tibia about\\na quarter of an inch, its head being somewhat adducted, projecting\\ninternally beyond the scaphoid. A fragment of the scaphoid, includ-\\ning the entire height of its inner border and having an average thick-\\nness of an eighth of an inch, was broken off. The sustentaculum tali\\nwas detached and the anterior portion of the calcaneum was fractured\\ntransversely and crushed its anterior articular surface was fissured,\\nbut the fragments were not separated. It seemed as if the fracture\\nmust have occurred during abduction of the front of the foot, by the\\nviolent propulsion of the astragalus downward, forward, and inward,\\nduring which movement the prominent wedge-shaped angle below the\\nexternal articular surface was driven into, and thus crushed, the ante-\\nrior part of the calcaneum. The fracture of the scaphoid was appar-\\nently effected by the pressure of the head of the astragalus, possibly\\naided by the tension of the tibialis posticus and the anterior portion of\\nthe internal lateral ligament. The mechanism of the fracture of the\\nsustentaculum tali was not easily comprehended. An explanation that\\nseemed plausible was that the fracture was effected by avulsion through\\nthe internal lateral ligament, made tense by e version, the fracture of\\nthe process being aided by that of the adjoining portion of the calca-\\nneum.\\nThe foot should be immobilized in a plaster bandage or splints with\\nthe sole sufficiently inverted to favor reunion of the fragments, but\\nwithout lengthening of the external lateral ligaments if they have been\\ntorn.\\nFracture by muscular action, contraction of the soleus and gastroc-\\nnemii, has been observed a number of times. Malgaigne collected\\neight cases, rather briefly reported in two the fracture was caused by\\na misstep, and in five by a fall upon the feet, in two of which it is\\nnoted that the patient alighted upon the ball of the foot. The fracture\\nseems to take place always behind the astragalus and sometimes to\\nseparate only a portion corresponding to the insertion of the tenclo\\nAchillis. The displacement in some cases was slight, in others extreme,\\nfour and one-half inches from the lower edge of the fragment to the\\nbottom of the heel in Constance s 1 case, in which, nevertheless, the\\npatient made a good recovery with perfect use of the limb, although\\nthe displacement persisted.\\nIn a case reported by Anningson 2 the mechanism of the fracture\\n1 Constance American Journal of the Medical Sciences, 1892, p. 222, quoting from an\\nEnglish journal.\\n2 Anningson British Medical Journal, 1878, vol. i. p. 128.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0471.jp2"}, "464": {"fulltext": "400 FRACTURES.\\nseems very clear. A woman, forty-two years old, after stepping down\\nfrom a doorway to the sidewalk, a distance of about six inches, cried\\nout that she had put out her ankle. She walked home slowly, a\\ndistance of one hundred yards. A fragment of bone was found two\\nand a half inches above the heel in the line of the tendo Achillis which\\nwas lacking below it its lower edge was a little above the level of the\\nlower end of the internal malleolus it measured one inch transversely\\nand had been torn off the posterior surface of the os calcis where a\\ncavity could be felt. The whole depth of the bone had not been torn\\naway, but only the upper three-fourths, and the inferior edge of the\\nfragment was tilted backward. The usual treatment of ruptured tendo\\nAchillis was adopted, and eight weeks afterward the patient was able\\nto walk without limping and complained only of some loss of spring.\\nI have seen a similar fracture, but with less displacement of the frag-\\nment, caused by jumping from a boat, the fracture apparently occurring\\nas the patient alighted on his toes. In another the patient while bend-\\ning forward was struck upon the back of the leg by a falling beam\\nthe posterior part of the fragment, as shown by a skiagram, was dis-\\nplaced upward three centimetres, but its anterior portion remained in\\ncontact with the os calcis. Plate XXVI.\\nThe foot should be maintained in the position of complete plantar\\nflexion, and it is sometimes advisable to flex the knee also. This can\\nbe done by a plaster dressing, or an anterior splint, or a shoe with a\\ncord extending from its heel to a band about the upper part of the leg\\nor the lower part of the thigh. Gussenbauer l successfully treated a\\ncase by nailing the fragment in place.\\n3. FRACTURES OF THE METATARSAL BONES.\\nThese are usually the result of direct violence, and consequently are\\noften associated with contusion or laceration of the skin even when the\\nfracture is not compound. The first is the one most frequently broken,\\nthe fifth is next in order of frequency.\\nThere is but little tendency to displacement except when several\\nbones are broken at the same time, and the usual displacement is of the\\nbroken end of either fragment toward the dorsum of the foot.\\nThe diagnosis is made by localized pain, abnormal mobility and\\ncrepitus when the first or fifth is broken, and pain when the corre-\\nsponding toe is pressed bodily backward against the metatarsus.\\nA simple fracture is not a serious injury, its course is uncomplicated,\\nits result favorable but a compound fracture may lead to much bur-\\nrowing of pus, necrosis of the fragments, and grave inflammatory com-\\nplications, and the treatment should be directed actively to their\\nprevention if suppuration becomes profuse the freest possible drainage\\nshould be provided and counter-openings made on the sole or dorsum\\nas the case may require.\\nThe limb and foot may be supported upon a moulded splint of plas-\\nter, felt, or pasteboard, and secured to it with a roller-bandage. In\\ncompound fracture the gauze dressings will immobilize the fragments\\nsufficiently.\\n1 Gussenbauer Ceutralblatt fur gesarurute Therapie, June, 1888.", "height": "4359", "width": "2782", "jp2-path": "practicaltreati00stim_0472.jp2"}, "465": {"fulltext": "", "height": "4359", "width": "2782", "jp2-path": "practicaltreati00stim_0473.jp2"}, "466": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0474.jp2"}, "467": {"fulltext": "FEACTUEES OF THE BONES OF THE FOOT. 401\\n4. FRACTURES OF THE PHALANGES.\\nThese are caused by direct violence and are usually compound, and,\\nas in similar injuries of the hand, may be the starting-point of very\\nserious inflammatory complications. Immersion of the foot in a bath\\ncontaining 1 or 2 per cent, of carbolic acid once or twice daily for an\\nhour each time is a valuable means of arresting commencing inflam-\\nmation.\\nThe dressings of a compound fracture will immobilize the toe suffi-\\nciently, and in a simple fracture it is usually sufficient to place the foot\\non a splint. If it is thought desirable the toe itself may be steadied\\nby strips of adhesive plaster applied longitudinally to its dorsum and\\nsides, or it may be made fast to the adjoining ones.\\n26", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0475.jp2"}, "468": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0476.jp2"}, "469": {"fulltext": "DISLOCATIONS", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0477.jp2"}, "470": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0478.jp2"}, "471": {"fulltext": "CHAPTEB XXVII.\\nGENERALITIES.\\nA dislocation is a permanent, abnormal, total or partial displace-\\nment from each other of the articular portions of the bones entering\\ninto the formation of a joint.\\nThe term diastasis is employed to indicate a direct separation, tem-\\nporary or permanent, of articular surfaces, without lateral gliding of\\none upon the other, as when the pubic bones separate at the symphysis,\\nor the tibia and fibula are torn apart, or in some injuries of the spinal\\ncolumn.\\nIf the displacement is only momentary, the parts immediately return-\\ning to their normal relations, the injury is classed as a sprain.\\nWhen a coexisting wound of the soft parts establishes communication\\nbetween the outer air and the cavity of the joint, the dislocation is said\\nto be compound; and when there exist associated lesions of the joint or\\nneighboring tissues so extensive or peculiar as to present special indi-\\ncations or create special difficulties in treatment, such as fracture or\\nlaceration of vessels, nerves, or integuments, it is said to be complicated\\nunder other circumstances it is described as simple.\\nWhen the articular surfaces are so far displaced that they no longer\\ntouch each other, or that they touch only by their edges, the dislocation\\nis said to be complete if the displacement is less, it is called an incom-\\nplete dislocation or subluxation. Incomplete dislocations are frequent\\nin the ginglymoid and arthrodial joints, and the controversy as to their\\nfrequency or infrequency in the enarthroses has arisen not from any\\ndoubt as to the nature of the new relations of the articular surfaces to\\neach other or of the extent of the displacement, but solely from differ-\\nences in definition, some authors maintaining that only those dislocations\\nshould be deemed complete in which the head of the bone has entirely\\nleft its bony socket, and all those incomplete in which any portion of\\nthe head remains within the area bounded by the rim of the socket,\\nwhether portions of the articular surfaces are in contact with each other\\nor not. Under that definition many dislocations of the shoulder and\\nof the hip would probably have to be classed as incomplete, if the exact\\nrelations of the bones could be determined and as such accuracy of\\ndiagnosis would rarely be attainable, and the doubtful cases would not\\ndiffer clinically from those in which the displacement is greater, the\\nadoption of such a classification would serve only to embarrass and\\nobscure. It seems to me much simpler and more practical, even if\\nsomewhat arbitrary, to call all traumatic dislocations of the hip and\\nshoulder complete in which the centre of the head of the bone has\\npassed beyond the rim of the socket. The incomplete dislocations\\nwould then be exceptional, practically only those in which a portion of\\n405", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0479.jp2"}, "472": {"fulltext": "406 DISLOCATIONS.\\nthe rim of the socket is broken off and pushed aside by the displaced\\nhead, as in a case mentioned by Robert l in an animated discussion of\\nthis subject before the Societe de Chirurgie.\\nIn the great majority of cases the dislocation is of a single joint only,\\nbut occasionally two or more joints may be simultaneously dislocated,\\nand the injury is then said, according to circumstances, to be bilateral,\\ndouble, or multiple. When a symmetrical bone, having joints on both\\nsides of the median line of the body, as the lower jaw or a vertebra,\\nsuffers dislocation of these joints, the injury is called bilateral or double.\\nWhen both ends of a bone are dislocated, as has been observed in the\\nclavicle, ulna, and fibula, the dislocation is said to be double or total.\\nthe same term is also applied to symmetrical dislocations on opposite\\nsides of the body, as of both shoulders or both hips.\\nMultiple dislocations are those in which two or more bones are simul-\\ntaneously dislocated, as two fingers, a shoulder and a hip. Some\\nauthors include under this term those dislocations which others term\\ntotal.\\nA method of nomenclature accurately descriptive of the different\\nvarieties of dislocation has not been established. As a general rule,\\nsubject, however, to some exceptions, the bone which is more distant\\nfrom the trunk or median line of the body, the one that is generally\\nmoved upon the other, is said to be dislocated thus a dislocation at the\\nhip, at the shoulder, is called a dislocation of the femur, of the humerus.\\nOr the joint alone is named, as a dislocation of the elbow, of the hip,\\nof the shoulder. As an example of the exceptions may be mentioned\\ndislocation of the outer end of the clavicle, a term universally preferred\\nto dislocation of the acromion.\\nThe same lack of uniformity appears in the names given to the vari-\\nous dislocations that may occur at the individual joints, and the prac-\\ntice has grown up of using in each case such a name as may most\\nreadily and accurately indicate either the general character of the dis-\\nplacement or some important special feature connected with it. When\\nthe name of the joint is used, and a term indicating direction is added,\\nas dislocation of the elbow backward, forward, to the inner or to the\\nouter side, the latter denotes the direction in which the distal member\\nof the joint has been displaced. Whenever the use of the name of the\\njoint would give rise to ambiguity, it is common to prefer the name of\\none of the bones constituting it, as a dislocation of the radius and ulna\\nbackward, instead of dislocation of the elbow backward. Strictly speak-\\ning, it is true that this might be mistaken for a dislocation at the wrist,\\nand that, therefore, it would be well to add at the elbow, but cus-\\ntom has so well established the meaning of the different terms now in\\nuse that in practice such a mistake would hardly be made. Other dis-\\nlocations, again, have received names denoting the relations of the dislo-\\ncated bone to certain muscles or bones, as subcoracoid or subpectoral\\ndislocation of the humerus, and dislocation of the (head of the) femur\\nupon the dorsum of the ilium or into the obturator foramen.\\nThe prim it ire or primary displacement is the one immediately effected\\nby the causative violence which produces the dislocation if the dislo-\\n1 Robert Bull, de la Societe de Chirurgie, January 19, 1853, p. 389.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0480.jp2"}, "473": {"fulltext": "GENERALITIES.\\n407\\ncated bone afterward shifts to another position, the displacement is said\\nto be consecutive or secondary. This shifting of the position of the\\ndislocated end sometimes has very important consequences as regards\\ntreatment, because the end of the bone may thereby be removed from\\nits position opposite the rent in the capsule through which it escaped\\nfrom the cavity of the joint, and it may need to be brought back to\\nthat position before it can be replaced in the joint.\\nIn the great majority of cases a dislocation is produced suddenly by\\nexternal violence or by muscular action, or by the two acting together\\nupon a healthy joint, and when thus produced it is called traumatic.\\nIn other cases the joint has been altered by disease previous to the\\noccurrence of the dislocation, and this latter is effected by the gradual\\naction of the muscles or even by gravity these are known as sponta-\\nneous, and present many varieties. (See Chapter XXXVI.) A third\\nclass, congenital dislocations, is composed of those in which the dislo-\\ncation occurs during intra-uterine life, presumably as the result of a\\nmalformation or defective development. Dislocations produced during\\ndelivery are traumatic. The second and third classes will be sepa-\\nrately considered. (See Chapters XXXV. and XXXVI.)\\nStatistics. Compared with other surgical injuries, dislocations are\\ninfrequent the proportion to fractures is about 1 to 10.\\nDislocations at the Hudson Street Hospital, New York, 3894-1899.\\nHospital and Dispensary.\\nHip, dorsal\\nthyroid\\nKnee\\nPatella, outward\\nHead of fibula\\nAnkle\\nAstragalus\\nMetatarsus\\nn\\n2 I\\n8\\n2 S\\n1 f\\n1\\n3\\n3J\\nLower extremity, 27 3.84 per cent.\\nClavicle, outer end 28\\nsternal end 8\\nShoulder 287\\nElbow 67\\nHead of radius l 10\\nUlna, upper end l 6\\nlower end 1\\nCarpus 3\\ntrapezium 1\\nsemilunar 2\\nscaphoid 1\\nos magnum 1\\nMetacarpal 43\\nMetacarpo phalangeal and\\nphalangeal 175\\nUpper extremity, 633 89.75 per cent.\\nLower jaw 41\\nVertebrae\\nChondro-sternal\\nHead and trunk, 45 6.40 per cent.\\n705\\nIncluding cases with associated fracture.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0481.jp2"}, "474": {"fulltext": "408\\nDISLOCATIOXS.\\nTable of 400 Kecent Traumatic Dislocations (Keonlein). 1\\nHospital and Polyclinic.\\nJoints.\\nHip\\nKnee\\nFoot\\nMetatarsophalangeal\\nShoulder\\nElbow\\nWrist\\nMetacarpo-phalangeal\\nInterphalangeal\\nSterno-elavicular\\nAcromioclavicular\\nLower jaw -j\\nCervical vertebrae\\nKind.\\nSex.\\nIliac\\nObturator\\nPubic\\nLateral\\nPatella out-\\nward j\\nbackward\\nSubcoracoid I\\nand axillary\\nErecta\\nInfraspinous\\nOf forearm\\nbackward/\\nOf radius\\nDorsal of ulna\\nUnilateral\\nBilateral\\n180\\n3\\n1\\n23\\n7\\nA\\n2\\nF.\\n23\\n400\\nAge.\\n2\\n2\\nZ\\n22\\n9\\nis\\n1\\n1\\nl\\n*4\\nI\\nl\\n2\\ni\\n2\\n44\\n5\\ns\\n3\\n1\\n1\\n1\\nl\\n1\\n53\\n14\\n1\\n1\\n4\\n5\\n2\\nl\\n3\\nT\\nM\\n1\\ni\\n1\\n44\\n1\\n5\\n8\\n1\\n2\\ni\\n48\\n4\\ni\\n1\\n4\\nI\\n1\\nl\\n1\\n2\\n35\\nl\\n3\\n1\\n\u00e2\u0080\u00a23\\nl\\n1\\n19\\n1\\nl\\n9.\\n2\\n1\\n69\\n88\\n65\\n60\\n48\\n23\\n3\\n4\\n)0\\nTotals.\\nPercentages of\\nfrequency=\\n1.7\\n2 0.5\\n3 0.7\\nLower\\nextremity,\\n20 5\\n203)\\n3 20:\\n1)\\n94\\n15)\\n\u00e2\u0096\u00a0109 27.2\\n1 0.2\\n7 6.7\\n5 2\\n6 1.5\\n2.7\\n400\\n2.5\\n0.2\\nUpper\\nextremity,\\n369 92.2\\nTrunk,\\n11 2.8\\nThe following table summarizes the other two with Malgaigne s\\nstatistics of the Hotel-Dieu\\nCases.\\nUpper extremity.\\nLower extremity.\\nTrunk.\\nMalgaigne, hospital 491\\nKronlein, hospital and polyclinic 400\\nStimson, hospital and dispensary 705\\n85.7 per cent.\\n92.2\\n89.75\\n12.6 per cent.\\n5\\n3.84\\n1.6 per cent.\\n2.8\\n6.40\\nThese tables show the great. relative frequency of dislocations of the\\nupper extremity as compared with those of the lower. Each set of\\nstatistics shows that dislocation of the shoulder is far more common\\nthan that of any other joint, and that next in frequency come disloca-\\ntions of the elbow. These two dislocations may be estimated as\\ntogether comprising from two-thirds to three-fourths of all cases,\\nexcluding the phalanges.\\nAs between males and females, Malgaigne and Gurlt found the\\ninjury three times as frequent in the former as in the latter Kronlein\\nfound it five times as great. Dislocations of the lower jaw are an ex-\\nception, being four times (Kronlein) as frequent in women as in men.\\nAge. Xo age is exempt dislocations have occurred as early as the\\nmoment of birth and as late as the age of ninety years. The relative\\nliability to the injury at different ages is not shown by simply com-\\nKronlein Deutsche Chirurgie, Lief. 26, p. 5.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0482.jp2"}, "475": {"fulltext": "GENERALITIES.\\n409\\nparing the number of cases observed at those ages, but by also com-\\nparing these numbers with the number of people at those ages living\\nin the community where the observation is made. This comparison\\nhas been made by Kronlein for Berlin, with the following results\\nFrequency of Dislocations at Different Ages.\\nAbsolute frequency\\nRelative number of people living\\nRelative frequency as computed for equal)\\nnumbers of people j\\n1-10\\n11-20\\n21-30\\n31-40\\n41-50\\n51-60\\n61-70\\n41\\n69\\n88\\n65\\n60\\n48\\n23\\n1872\\n1620\\n2529\\n1679\\n940\\n599\\n282\\n10\\n18\\n15\\n16\\n27\\n35\\n35\\n3\\n117\\n10+\\nFrom this it appears that a smaller proportion of individuals\\nbetween the ages of one and ten, and seventy-one and eighty years\\nreceive dislocations than in any other decade of life and the highest\\nproportions are found between the ages of fifty-one and sixty and\\nsixty-one and seventy. It is further to be noticed that dislocation of\\nthe shoulder is very rare, and that of the elbow very common, before\\nthe age of twenty-one years. Kronlein s table shows that of 207 cases\\nof the shoulder, in only two were the patients less than twenty-one\\nyears old, and that of 109 cases of the elbow 80 were no older, the age\\nin 31 being between one and ten years, and in 49 between eleven and\\ntwenty years. Compared with fractures, it appears that the liability\\nto dislocation is least during those periods of life in which the liability\\nto fracture is greatest that is, in infancy and youth and in old age\\nthe latter part of this statement may need some modification, for while\\ndislocations are rare after the age of seventy, they are relatively fre-\\nquent in the preceding decade. The liability to each increases from\\nadolescence through middle life.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0483.jp2"}, "476": {"fulltext": "CHAPTER XXVIII.\\nETIOLOGY AND MECHANISM.\\nPredisposing Causes Immediate Causes Recurrent or Habitual Dislocations.\\nThe causes of dislocation may be grouped in two classes a. Pre-\\ndisposing b. Immediate or determining.\\nA. Predisposing Causes.\\nThese are found in certain normal differences of form and function\\ncharacterizing certain joints, and in accidental or pathological conditions\\nthat sometimes arise.\\nThe joint which is most frequently dislocated is the shoulder-joint,\\nand it differs normally from others in the Avide range and variety of\\nmotion made possible by its form, the laxity of its capsule, and the\\nabsence of any firm ligament to hold the bones closely together. A\\nwide range of motion in one direction is not necessarily a circumstance\\nfavoring dislocation on the* contrary, it may protect against it by\\nmaking it difficult to bring into action the fulcrum which is furnished\\nby the edge of the bone when it arrests the motion. In a young\\nhealthy person the elbow or knee cannot be dislocated by flexion,\\nbecause the motion is finally arrested by broad contact of the soft parts,\\nnot by the edge of the joint while, on the other hand, in each case\\nextension is limited by the structures of the joint itself, and hyper-\\nextension at once favors dislocation by rupturing those structures. A\\nlong range of motion in one plane does not make the joint insecure so\\nlong as the two bony surfaces rest squarely against each other, as they\\ndo in the hinge-joints but when the change of position makes this\\ncontact oblique, as in abduction of the arm, a displacing force exerted\\nin the direction of the long axis of the bone is resisted only by the\\ncapsule. Under certain conditions, therefore, it may be said that free-\\ndom of motion in a joint diminishes, and limitation of motion increases,\\nthe liability to dislocation.\\nDropsy of some joints favors dislocation by removing the obstacle\\nwhich the necessity of creating a vacuum between the articular surfaces\\nwould otherwise interpose. (See Chapter XXXYL, Dislocations by\\nDistention.)\\nThe destruction of the ligaments by violence or disease, and frac-\\nture or disease of the bony constituents of the joint, favor dislocation,\\nand the fracture of an associated or parallel bone may have the same\\n410", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0484.jp2"}, "477": {"fulltext": "ETIOLOGY AND MECHANISM. 411\\neffect, as fracture of the ulna favors dislocation of the head of the\\nradius.\\nB. Immediate or Determining Causes.\\nA bone may be dislocated by (1) external violence applied (a) directly\\nto it at or near its end, or (6) indirectly and at a distance from its end\\n(2) by muscular action.\\n1. External Violence. Dislocations by direct violence are rare, espe-\\ncially if the class is restricted to those cases in which the violence falls\\nupon only one of the bones forming the joint and forces it directly\\naway from the other. Thus, the head of the humerus has been driven\\nbackward (subspinous dislocation) by a blow of the fist (Busch) or by\\na fall in which the front of the shoulder struck against the corner of\\na table (Kronlein), or inward by a fall upon the outer side of the\\nshoulder, or even downward into the axilla by a force received upon\\nand first breaking the acromion (Krdnlein, Stimson).\\nIn dislocations by indirect violence the mechanism may vary greatly.\\nThe force in some cases is exerted directly along the long axis of the\\nbone while the limb is in a position in which the articular surfaces do\\nnot rest squarely upon each other, and the head of the bone is driven\\nout of its socket, as in some dislocations of the shoulder by a fall upon\\nthe outstretched (abducted) arm or by muscular action, or in disloca-\\ntion of the outer end of the clavicle by a fall upon the shoulder. The\\nmechanism is similar to that of the first form of dislocation by direct\\nviolence mentioned above. Or a much slighter force, favored by\\nconditions of leverage established at the joint, tears the capsule or\\na ligament and produces a dislocation. This is the most common\\nmechanism. The conditions of leverage are found at all points where\\nnormal movements are arrested or no movement permitted. The head\\nor neck of a moving bone is arrested by the edge of the corresponding\\narticular cavity, or by a projecting point of bone, or by a tense liga-\\nment or portion of capsule this at once becomes a new centre of\\nmotion, a fulcrum, and, the force continuing to act at the end of the\\nbone or limb (the long arm of the lever), the head of the bone (or short\\nend of the lever) is forced away abnormally.\\nWhen the force is exerted in a direction in which normally no motion\\nis permitted, as laterally at the elbow, ankle, or knee, it meets at once\\nwith greater resistance than that habitually found at the extremes of\\nnormal ranges of motion, and if it is great enough to overcome this\\nresistance it is more likely to cause in addition other and perhaps\\nextensive injuries of the soft parts or of the bones.\\nViolence, then, acting in a given manner, may cause a fracture, a\\ndislocation, or a sprain according to its force, the strength of the resist-\\nance offered by the ligaments and the bones to which they are attached,\\nand the prolongation of its action.\\n2. Muscular Action. Contraction of the corresponding muscles can\\ncause the dislocation of a sound joint in either of two ways it can. by\\nrapidly moving the limb, communicate to it a momentum which acts\\nin the same manner as external violence and produces a dislocation", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0485.jp2"}, "478": {"fulltext": "412 DISL CA TIONS.\\nwhen the normal limit of the range of motion is reached and condi-\\ntions of leverage are established. A case, probably of this kind, was\\nobserved by Sedillot l a woman, forty-six years old, who dislocated her\\nshoulder by raising her arm to strike a blow. Or, secondly, the mus-\\ncular contraction acts like external violence received at or near the end\\nof the bone, or transmitted along its longitudinal axis, and draws the\\nbone out of its socket. For this it is essential that one or two muscles\\nshould contract violently while the others that normally act upon the\\njoint remain passive, or that the limb should be in such a position that\\nthe line of traction of the muscles is nearly parallel to the opposing\\narticular surface. Instances of this kind are common at some joints\\ndislocation of the lower jaw is commonly caused by muscular action\\nin yawning, laughing, or vomiting, and others have been caused in like\\nmanner at the shoulder and hip, and, very exceptionally, at other\\njoints. As illustrative examples may be mentioned the following\\nA man, fifty-one years old, dislocated both shoulders (subcoracoid)\\nby drawing himself up with his hands a painter dislocated his shoul-\\nder while painting a ceiling a woman, by trying to lift a heavy object\\nfrom a shelf; a man, by trying to lift at arm s length a heavy book\\nfrom the floor and a woman, by carrying a heavy load upon her head\\nwith both arms uplifted.\\nMany cases have been reported in which dislocation has been caused\\nby the convulsive contractions of individuals affected with epilepsy,\\ntetanus, or uraemia, or poisoned with strychnine. In many of the\\ncases reported as such the dislocation may have been caused by vio-\\nlence received in falling during a fit or by striking the limb against\\nsome object, but in a number of them the history positively establishes\\nthe absence of any other cause than the contraction of the muscles.\\nIn these cases, as in fractures by muscular action, it is unnecessary\\nto suppose, and unwarranted to claim, that the strength of the capsule\\nor ligaments is less than usual, or that the structure of the joint varies\\nfrom the normal in such a way as to facilitate the production of the\\ndislocation.\\nThe power of voluntary dislocation of one or several joints has been\\noccasionally observed. In a large proportion of the cases its appear-\\nance has followed the occurrence of a traumatic dislocation of the same\\njoint, but in a few instances the history of the individual contained the\\nrecord of no traumatism or diseased condition to which the peculiarity\\ncould be referred.\\nC. Recurrent or Habitual Dislocations.\\nIndividuals are occasionally observed in whom dislocation of some\\none joint, commonly the shoulder, but also the hip, jaw, and clavicle,\\nfrequently recurs under the influence of some slight cause, and who\\nhave acquired this liability as the result of an ordinary traumatic dis-\\nlocation, or of paralysis of one or more of the muscles of the joint, or\\nof fracture. The first class will be considered in Chapter XXIX. of\\n1 Sedillot Diet. Encyclopedique, art. Luxations, p. 23.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0486.jp2"}, "479": {"fulltext": "ETIOLOGY AND MECHANISM. 413\\nthe others the following case, reported by Sir Astley Cooper, 1 will\\nserve as an illustration A gentleman happened, as a junior officer\\non board his ship, to be placed under the orders of one of the mates\\nwhen the captain was on shore, and for some trifling offence was\\npunished in the following manner his foot was placed upon a small\\nprojection on the deck, and his arm was lashed tightly toward the yard\\nof the ship, and thus kept extended for an hour. When he returned\\nto England he had the power of readily throwing that arm from its\\nsocket merely by raising it toward his head, but a very slight extension\\nreduced it the muscles were also wasted, as in a case of paralysis. 7\\nThe explanation is to be found in the loss of support occasioned by\\nthe diminution of the tonicity of the muscles which in such joints as\\nthe shoulder, take the place of short, firm ligaments and hold the\\narticular surfaces in contact with each other, a loss which allows the\\nbones to be separated by the action of gravity, or by an effusion into\\nthe joint, until the separation is arrested by the capsule. When thus\\nseparated, a slight force is sufficient to throw the head of the humerus\\npast the edge of the glenoid cavity and produce a dislocation without\\nrupture of the capsule.\\nThe cases of dislocation due to limited paralysis of peripheral origin\\nmust not be confounded with those sometimes accompanying the\\narthropathies that complicate some paralyses of central origin and\\nsome cases of central nervous disease without paralysis. In the latter\\nthe articular portions of the bones are absorbed in the progress of the\\ndisease, and thus even a joint the bones of which are normally held\\nclose together by ligaments becomes a loose one by loss of bone sub-\\nstance. Strictly speaking, such cases in which the articular end of the\\nbone has been entirely absorbed do not come within the definition of\\ndislocation, but clinicallv it is proper and convenient so to designate\\nthem. (See Chapter XXXVI.)\\nThe unequal growth of parallel and associated bones, tibia and fibula,\\nor radius and ulna, may cause dislocation at one or the other end.\\n1 Cooper Dislocations and Fractures, Am. ed., 1844, p. 9.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0487.jp2"}, "480": {"fulltext": "CHAPTER XXIX.\\nPATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS COMPLI-\\nCATIONS AND THE PROCESS OF REPAIR AFTER REDUCTION.\\nPATHOLOGICAL ANATOMY.\\nAs a traumatic dislocation consists in the forcible overcoming of the\\nnormal restraints upon the motion of the joint in one or more direc-\\ntions, restraints offered by the ligaments and capsule of the joint, it is\\nalmost invariably accompanied by rupture of a ligament or of the cap-\\nsule. There is some reason to think that dislocation of the inferior\\nmaxilla may be an exception to this rule, but the lack of opportunities\\ndirectly to examine such cases leaves the question in doubt. In enar-\\nthrodial joints, especially the shoulder, where the ligaments are loose\\nand where the bones are held together by the tonicity of the muscles\\nand the atmospheric pressure, such a change as dropsy of the joint may\\nso annul the effect of the latter agent and overcome the former by filling\\nthe capsule with liquid that insinuates itself between the contiguous\\narticular surfaces, that the head of the bone falls away from its socket\\nand the joint becomes loose like that of a flail under such circum-\\nstances dislocation may occur without rupture or laceration.\\nThe capsule of an enarthrodial joint is torn upon the side toward\\nwhich the distal bone is displaced in joints of other forms the liga-\\nments may be broken on either or both sides, the extent and character\\nof the injury varying with the character of the force. The rent in the\\ncapsule may be limited in extent and simple in form, merely a longi-\\ntudinal or transverse slit, or it may be irregular or may even involve\\nthe entire periphery. Instead of suffering a rent, the capsule may be\\ntorn away from the bone, sometimes bringing with it portions of the\\nbone itself or remaining continuous with the periosteum stripped up\\nfrom the shaft. Under similar conditions the position of the rent in\\nthe capsule is very constant, for it is determined by the posture of the\\nhead and the direction of the force. In addition to the laceration of\\nthe capsule and ligaments produced by the pressure of the bone, others\\nmay be caused by the tearing off of attached muscles that are put upon\\nthe stretch by the displacement. This may be effected by the avulsion\\nof the tuberosities upon which the muscles are inserted the bone yields,\\nand the laceration, starting from the broken surface, extends across and\\nthrough the adjoining soft parts. This is a frequent accompaniment\\nof dislocation forward and downward of the shoulder the supra-\\nspinatus and infraspinatus muscles, inserted respectively upon the\\nupper and middle facets of the greater tuberosity of the humerus, are\\nput upon the stretch and one or both are torn away from the bone.\\n414", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0488.jp2"}, "481": {"fulltext": "COMPLICATIONS OF RECENT DISLOCATIONS. 415\\nThe soft parts overlying the capsule may be torn by extension of the\\nrent in the capsule if they are closely adherent to the latter, or by the\\nforcible passage through them of the displaced bone. The surrounding\\nmuscles on the side toward which the displacement takes place may be\\ncontused or torn by the passage of the bone, and those upon the oppo-\\nsite side by being put upon the stretch. Blood is freely extravasated\\ninto the cellular tissue from the ruptured vessels.\\nThe cartilages of incrustation may be bruised and sometimes chipped\\nin the passage of the surfaces across each other, and projecting portions\\nof bone, apophyses, or the rim of an orbicular cavity may be broken off\\nThe bone itself seldom passes to any great distance from its normal\\nposition its progress is arrested by the ligaments and muscles that\\nremain untorn and the resistance of the soft parts that it presses upon,\\nand it comes to rest lying directly upon the adjoining bone or with some\\nsoft parts interposed. Its position, as taken in the primary displace-\\nment, may be changed by the renewal of external violence, by gravity,\\nby a change in the position of the limb, or by the spasmodic contrac-\\ntion of attached muscles, but the secondary position consecutive\\ndisplacement is habitually determined by the resistance of untorn\\nligaments which constitute the fulcrum or pivot about which the bone\\nturns.\\nCOMPLICATIONS.\\nOther injuries, and severer or more extensive forms of those\\nalready mentioned, may coexist with a dislocation as complications.\\nThey include fracture of the bone, partial or complete rupture of\\nlarge bloodvessels or nerves, and extensive laceration of the soft\\nparts. To constitute a complication of the dislocation the associ-\\nated injury should be the direct or consecutive result of the original\\nviolence upon adjoining tissues, and should create special indications\\nfor, or difficulties in, treatment. A fracture of the leg caused by the\\nsame fall that dislocates the shoulder is not, in this sense, a compli-\\ncation of the dislocation but a fracture of the ulna accompanying\\ndislocation of the radius, or a fracture of the neck of the humerus\\naccompanying dislocation of the shoulder is a complication, for the two\\ninjuries are associated in their origin and in their treatment.\\nBones. ]N~ot all fractures that coexist with dislocation of even the\\nsame bone are necessarily to be deemed complications, since some habit-\\nually accompany certain dislocations, may even not be recognizable\\nclinically, and neither receive nor require special treatment. Such are\\nfractures of apophyses or tubercles to which muscles are attached, and\\nsome fractures of a portion of the articular end of the bone or of the rim\\nof an orbicular cavity. In others the dislocation is rather to be deemed\\na complication or incident of the fracture, since it is made possible by\\nit, as in some fractures of the vertebrae and in fracture of the olecranon\\nw T ith displacement forward (or upward) of the radius and ulna.\\nRelatively common are those in which the force is exerted through\\nthe head of the bone upon the margin of the opposing articular sur-\\nface, breaking off the latter the dislocated bone leaves the joint through\\nthe gap thus created, driving the fragment before it, or else tears the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0489.jp2"}, "482": {"fulltext": "416 DISLOCATIONS.\\ncapsule and escapes in the usual manner. The commonest examples\\nof this kind are found in fractures of portions of the rim of the glenoid\\nand cotyloid cavities, and some fractures at the ankle with dis-\\nplacement of the astragalus. Others, that are closely analogous, are\\nfractures of the coronoid process of the ulna or of the head of the\\nradius, or of both, in dislocation backward of both bones.\\nBruising or deep indentation of the head of the bone by impact upon\\nthe edge of the socket has been noted several times at the shoulder and\\nonce by myself at the hip. It cannot be recognized clinically and is\\nnot known to have important consequences, but when the impact is\\nalong the anatomical neck of the humerus it may detach the head, and\\nin two cases l the head of the femur has been split vertically in a third 2\\nthe head and neck were split longitudinally, apparently after disloca-\\ntion had taken place.\\nA very rare complicating fracture is that of the central part of the\\nacetabulum when the head of the femur is driven through it into the\\ncavity of the pelvis by great violence.\\nMuch more common, but seldom deserving to be classed as compli-\\ncations, are those fractures by avulsion, already referred to, in which,\\nligaments or muscles being put upon the stretch, the bony prominences\\nto which they are attached are torn off. Some of them may be looked\\nupon as habitual, or at least frequent, accompaniments of certain dis-\\nlocations, for example, fracture of the greater tuberosity of the humerus\\nin dislocation of the shoulder forward and downward, and fracture of\\nthe internal epicondyle in dislocation of the elbow.\\nThe form in which the complication most seriously affects the treat-\\nment and prognosis is that in which the bone is broken completely\\nacross near the dislocated end. The commonest examples are found\\nat the shoulder, where the line of fracture follows either the anatomical\\nor the surgical neck, and the special difficulty in treatment arises from\\nthe smallness of the upper fragment, whereby it is made difficult or\\nimpossible so to act upon it as to return it to its normal position in the\\njoint, In 68 cases of this kind collected by Thamhayn 3 14 were of the\\nanatomical neck of the humerus, and of these in only 2 was the dislo-\\ncation reduced while of the 46 cases in which the fracture occupied\\nthe surgical neck 20 were reduced. McBurney s recent (1893) method\\nof reducing with the aid of a hook inserted into the fragment has\\ngreatly diminished the difficulty. The mechanism of the combined\\nlesions is sometimes obscure, as regards its details, and varies in the\\ndifferent cases, the dislocation sometimes preceding and sometimes fol-\\nlowing the fracture, and perhaps sometimes occurring simultaneously.\\nIn a specimen figured by Kr5nlein the head of the humerus, after\\nfracture of the anatomical neck, has been completely reversed and lies\\nwedged between the tuberosities.\\nBloodvessels. Injury of a large bloodvessel adjoining a dislocated\\njoint (the dislocation not being compound) is a comparatively rare acci-\\n1 Birkett Medico-Chirurgical Transactions, 1869, vol. Hi. p. 133. Moxon Medical\\nTimes and Gazette, 1872, vol. i. p. 96.\\n2 Riedel Beilage zum Centralb. fur Chir., 1885, p. 92.\\n3 Thamhayn Schmidt s Jahrbuch, 1868, vol. cxl.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0490.jp2"}, "483": {"fulltext": "COMPLICATIONS OF RECENT DISLOCATIONS. 417\\ndent, and one that depends either upon the close relations of the vessels\\nand the bones, as at the shoulder and knee, or upon violence so great\\nas to displace the bone to a greater distance than usual, or in an\\nunwonted direction.\\nIn most of the recorded cases the dislocation has been of the shoul-\\nder, inward and forward, and the lesion has consisted either in the\\nrupture of a large arterial branch, the anterior circumflex or the sub-\\nscapular, at or near its origin, or in such stretching of the axillary\\nartery that its inner and middle coats have been torn across, the outer\\none remaining undivided, or, more rarely, in rupture of the main vein.\\nThe injury may result in the immediate formation of a traumatic aneu-\\nrism or in the gradual formation of an encysted one, or in gangrene of\\nthe distal portion of the limb. In some of the recorded cases it is not\\npossible to determine whether the injury to the vessel was the imme-\\ndiate result of the dislocation or of the efforts to reduce it.\\nThe symptoms vary greatly, but, except at the shoulder, are not\\nlikely to leave any doubt concerning the nature and details of the\\ninjury. Injury to the inner and middle coats alone may in some cases\\nbe recognized by the immediate cessation of the brachial and radial\\npulse, in others only by the subsequent gradual formation of an aneu-\\nrism. In other cases the prompt appearance and rapid growth of a\\nfluctuating swelling in the axilla, perhaps accompanied by extensive\\nccchymosis and alarming symptoms of collapse or shock, sufficiently\\nprove the fact of an internal hemorrhage but the source of the bleed-\\ning, whether from an arterial branch, the main artery, or the vein, may\\nremain in doubt, for the radial pulse may persist even when the hem-\\norrhage comes directly from the axillary artery. The subject will be\\nmore fully discussed in Chapter XXXIV.\\nIn a case observed by Korte, 1 this complication accompanied a dis-\\nlocation of the shoulder caused by a blow received upon its upper sur-\\nface while the arm was abducted the dislocation was spontaneously\\nreduced before the arrival of the surgeon, and probably the displace-\\nment was only slight. An aneurism formed, and was opened under the\\nimpression that it was an enlarged lymphatic gland. The autopsy indi-\\ncated that the lesion was avulsion of the anterior circumflex artery at\\nits origin, and showed also that the inner and middle coats of the\\naxillary artery were torn transversely at a higher point, but the calibre\\nof the vessel was not thereby obstructed.\\nThe following cases illustrate other varieties\\nMr. J. W. Turner 2 reported two cases of rupture of the popliteal\\nartery complicating dislocation of the knee. In the first a man, twenty-\\nfour years old, fell from a height of thirty feet and sustained a com-\\npound dislocation of the knee, the condyles of the femur projecting\\nthrough the integument of the ham. The limb was immediately ampu-\\ntated, and the two inner coats of the popliteal artery were found to be\\nruptured, the outer coat remaining untorn.\\nIn the second case a middle-aged woman fell while carrying a heavy\\nburden on her back. When she was brought to the hospital there was\\n1 Korte Archiv fur klinische Chirurgie, 1882, p. 636.\\n2 Turner: Trausactious of the Edinburgh Medico-Chirurgical Society, vol. iii. p. 30S.\\n27", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0491.jp2"}, "484": {"fulltext": "418 DISLOCATIONS.\\nfound a dislocation of the knee together with a wound in the ham\\nthrough which, it was said, the condyles of the femur had projected.\\nThere was no bleeding the limb became greatly swollen, and the\\npatient died on the tenth day. The artery and vein were found to\\nhave been torn completely across.\\nDr. M. Goldsmith l reported the case of a man, forty years old, who\\nsuffered a dislocation of the left femur the head of the bone being\\nthrust under Poupart s ligament overrode the margin of the pelvis in\\nsuch a manner as to underlie the femoral artery it remained unreduced\\nfor two months, when he came under observation with a diffused swell-\\ning occupying the groin, filling the iliac fossa, and extending to the\\nmiddle of the thigh feeble pulsation tumor appeared a few days after\\nthe accident pain severe diagnosis, aneurism treatment, ligature of\\nthe common iliac artery death on fifth day. The femoral and exter-\\nnal iliac arteries were perforated to the extent of an inch on the pos-\\ntero-external aspect the head of the femur lay in the cavity of the\\naneurism.\\nCases also have been reported of rupture of the anterior and poste-\\nrior tibial arteries in dislocation of the ankle and Sedillot 2 published\\none in which the brachial artery was ruptured at the elbow by being\\nstretched over the end of the humerus in a dislocation of the radius\\nand ulna backward.\\nNerves. Injuries of the nerves may be demonstrated by direct exami-\\nnation or inferred from the symptoms. Examples of the former are\\nuncommon, and in some of the latter it may remain in doubt whether\\nthe nerves were injured by the displacement of the bone, or by the\\nefforts to reduce the dislocation, or by the independent action of the\\nviolence upon them. It is asserted 3 that a fall upon the hand or\\nshoulder, without lesion of the skeleton, is competent to cause palsy of\\nthe arm hence, it is not always to be inferred that a palsy following\\na dislocation has been caused by the pressure of the head of the bone\\nupon the nerves, and this is especially true of those cases in which a\\nblow has been received directly upon the shoulder, and the deltoid\\nalone is paralyzed.\\nThe injury may be a complete rupture or laceration of one or more\\nnerve trunks, or a contusion with extravasation of blood about the nerve\\nand amid its fibres, or a neuritis originating in an injury of some lesser\\nnerve and extending thence to the main trunk, or an inflammatory pro-\\ncess extending to the nerve and causing its compression by newly\\nformed connective tissue, or simple compression by the displaced bone.\\nRupture or laceration of the nerve is caused by violent pressure\\nagainst it of the displaced end of the bone, and, in the case at least of\\nthe larger trunks, it appears commonly to be associated with extensive\\nlaceration of the other soft parts, including even the overlying skin.\\nContusion of the nerve may be produced in the same manner, and then\\nrepresents a less degree of the same injury, or by compression of the\\n1 Goldsmith American Journal of the Medical Sciences, July, 1860, p. 30 abstract\\nfrom the Louisville Medical Journal, February, 1S60.\\n2 Sedillot: Diet. Encyclopedique, art. Luxations, p. 261.\\n3 Weir Mitchell Injuries of Nerves, p. 99.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0492.jp2"}, "485": {"fulltext": "COMPLICATIONS OF RECENT DISLOCATIONS. 419\\nnerve between the displaced bone and an adjoining portion of the\\nskeleton, as between the head of the humerus and the wall of the\\nthorax.\\nThe symptoms vary with the character of the injury laceration is\\nimmediately followed by motor paralysis and loss of sensation in the\\nregion supplied by the nerve, which are permanent or persist until the\\nintegrity of the nerve is restored in other forms of injury there are\\nvarying degrees of paralysis and loss of sensation, numbness, pain,\\nalteration of local nutrition, and other symptoms of neuritis, limited\\nat first to the nerve directly injured, and afterward perhaps extending\\nto others. In many of the recorded cases a cure has followed the\\nsystematic use of electricity.\\nThe statistics of the FriedriciYs Hospital collected by Holm 1 show\\nthat of 112 cases of dislocation of the shoulder there was general paral-\\nysis of the arm in 7, and paralysis of the deltoid alone in 10. In one\\nof them all the muscles supplied by the median nerve were paralyzed,\\nwhile those supplied by the musculo-spiral w T ere unaffected. This is a\\nmuch larger proportion than I have observed.\\nThe recorded cases of rupture of a nerve verified by direct exami-\\nnation are few the following are examples of different forms\\nHilton 2 examined the body of a man who died thirteen weeks after\\nhaving received a dislocation of the shoulder into the axilla the del-\\ntoid was much atrophied, the circumflex nerve was small and w T as\\ndistinctly lacerated, but its actual condition was changed by some\\nstrong cellular adhesions, fixing it with the radio-spinal nerve and the\\naxillary artery to the inner surface of the subscapularis muscle.\\nBouley 3 presented to the Society Anatomique a specimen of complete\\ndislocation outward of both bones of the forearm at the elbow, with\\nfracture of the outer condyle of the humerus, caused by a fall upon\\nthe elbow from a height of tw T enty-four feet. The patient refused\\namputation and died twenty days after the receipt of the injury.\\nThe lateral ligaments of the elbow were entirely ruptured, both\\nbones of the forearm were situated external to the lower end of the\\nhumerus, and the ulnar nerve was lacerated at the level of the articular\\nsurface.\\nHoll 4 found in the dissecting-room a cadaver with a marked deformity\\nof the elbow, and on examination it appeared that the individual had\\nsuffered fracture of the upper end of the ulna and dislocation of the\\nhead of the radius upward and inward, and that the ulna artery and\\nulnar and median nerves had been completely divided and had not\\nreunited.\\nMuller, 5 seven months after dislocation of the shoulder which had\\nbeen easily reduced and which had been followed by gradual paralysis\\nof motion and sensation in the arm, found, by an axillary incision, the\\nartery and main nerves tightly compressed by a cicatricial band about\\na quarter of an inch wide. On division of the band pulsation at once\\n1 Holm Schmidt s Jahrbuch, vol. cxxi. p. 82.\\n2 Hilton Guy s Hospital Reports, 1847, vol. v. p. 93.\\n3 Bouley: Bull, de la Soc. Anatomique, 1837, p. 101.\\n4 Holl: Medicin. Jahrbuch, Wien, 1880, p. 151.\\n5 Muller: Centralb. fur Chir., 1892, p. 611.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0493.jp2"}, "486": {"fulltext": "420 DISLOCATIONS.\\nreappeared in the brachial and radial arteries sensation and muscular\\nfunction reappeared gradually.\\nOf the cases that have been observed clinically the injury in most\\nhas been attributed to the reduction, as a consequence of too forcible\\ntraction, extreme abduction of the limb (arm), or to the presence of\\nadhesions between the nerve and the parts with which it has been tem-\\nporarily brought into contact. In some of these cases the correctness\\nof this view cannot be questioned in others the necessary data for an\\nopinion are lacking.\\nA man x fifty-four years old was seized by the right arm and shaken\\nso violently as to dislocate the humerus into the axilla, causing pain in\\nthe shoulder and instant loss of feeling and motion in the hand.\\nReduction on the third day. Six weeks afterward the whole hand\\nand lower side of the forearm were oedematous, and the former also\\nhard and brawn-like, resisting pressure. The fingers were in the same\\nstate, and the whole hand was dark and congested, but not shiny or\\nsmooth. The joints from the wrist to the finger ends were sore, swol-\\nlen, and very stiff. The whole palm was the seat of pretty severe\\nburning, with no darting or other pain. Partial loss of touch and\\npain-sense in the median and radial distribution. The elbow motions\\nwere perfect, wrist flexion good, extension lost flexion of the fingers\\ngood, extension and lateral motions lost from palsy of the extensors\\nand interossei.\\nA soldier 2 fell from a tree, striking upon and dislocating his left\\nshoulder the dislocation was reduced within twenty-four hours, and,\\nthe previous pain and numbness disappearing, he remained well for\\nfour weeks, when the arm began to waste, with loss of power which\\nbecame complete in a few months. Sensation was much less altered.\\nAt the close of a year there was only partial ability to flex the arm,\\nand slight use of the flexors and extensors of the fingers. Marked\\natrophy contraction of the pronators. Rapid relief and final cure\\nwere obtained by electricity.\\nA man 3 twenty-five years old was admitted to the Hotel -Dieu with\\nan intracoracoid dislocation of the left shoulder, caused shortly before\\nby a fall. Any motion communicated to the limb caused great pain\\nand violent involuntary contraction of all its muscles. The next morn-\\ning the dislocation was found to have become subglenoid, the limb was\\ncompletely paralyzed, but without loss of sensation, and although com-\\nmunicated motion was still painful, it did not cause reflex contractions\\nof the muscles. Reduction was readily effected with the aid of anaes-\\nthesia. The muscles of the shoulder reacted to the faradic current;\\nthose of the arm and forearm did not. The limb wasted rapidly\\nunder electrical treatment an almost complete cure was obtained in\\nabout two years.\\nKronlein 4 quotes Hutchinson as having seen paralysis of the sciatic\\nnerve follow an ischiatic dislocation of the femur and Sir Astley\\nCooper 5 quotes a case in which numbness of the limb accompanied the\\n1 Weir Mitchell Injuries of Nerves, p. 103. 2 Weir Mitchell Loc. cit., p. 101.\\n3 Duchenne De l Electrisation localisee, 2d ed\\\\, p. 179.\\n4 Kronlein Loc. cit., p. 34. 6 Cooper Loc. cit., p. 67.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0494.jp2"}, "487": {"fulltext": "COMPLICATIONS OF RECENT DISLOCATIONS. 421\\nsame injury. Cooper 1 also quotes a case of suprapubic dislocation in\\nwhich the pressure of the head of the femur upon the anterior crural\\nnerve caused numbness of the thigh.\\nViscera. Excluding the common implication of the spinal cord in\\ndislocations of the vertebrae, there are few recorded cases of injury to\\nparts lying within the body or neck by dislocated bones. Such injuries\\nmust, to a greater or less extent, accompany dislocation of the head of\\nthe femur through the floor of the acetabulum into the pelvis, and\\ncomplete dislocation backward of the sternal end of the clavicle has\\nin some cases been accompanied by symptoms indicating pressure on\\nthe trachea or o?sophagus.\\nA case that is entirely unique, and interesting not only because of\\nthe distance to which the bone Was displaced, but also because of the\\nchanges subsequently undergone by the bone, and of the ease with\\nwhich the deformity was borne, is reported by Prochaska 2 and by\\nLarrey, 3 who had examined the specimen. A lad, sixteen or seven-\\nteen years old, dislocated his right humerus by a fall upon the abducted\\nelbow, and the head of the bone was driven between the second and\\nthird ribs (Prochaska says the third rib was fractured) into the chest,\\nstripping up the pleura, but not perforating it. All attempts to reduce\\nit were unavailing, and the subsequent treatment was limited to vene-\\nsection, warm baths, and antiphlogistic measures for the relief of urgent\\nsvmutoms. The patient survived until the age of thirty-one (forty,\\nProchaska), and, although the arm remained abducted, gained his live-\\nlihood by woodchopping. At the autopsy the head of the humerus\\nwas found within the thorax, covered by the pleura, and its neck firmly\\nplaced between the second and third ribs. The head was so soft that\\nit yielded to the slightest pressure of the finger the articular cartilage\\nand bony texture of all the portion that lay within the chest had\\nentirely disappeared, leaving only a few membranous remains of the\\nhumerus, of w T hich the greater part seemed to belong to the costal\\npleura. Prochaska describes it as u naked, soft, yielding to the softest\\npressure, presenting only a thin envelope, and almost empty within,\\nsince it had lost more than half of its internal bony substance.\\nSoft Parts and Integument (Compound Dislocations). Although\\ninstances of this complication have been recorded for almost every\\njoint, they are yet of rare occurrence, and mainly restricted to the\\nelbow, knee, ankle, and phalanges. Except in the latter case, they\\nare commonly the result of extreme violence, and the wound of the\\nskin is produced either by the direct action of this violence, or from\\nwithin outward by the projecting end of the bone.\\nThe complication in the case of the larger joints is very grave,\\nbecause of the extent of the injury, which is usually great and marked\\nby much laceration and bruising of the tissues, and also because of the\\nspecial dangers due to the probable infection of the wound.\\nThe treatment may require, in addition to the most rigorous anti-\\n1 Cooper: Loc. cit., p. 74.\\n2 Prochaska Disquisito Anatoniico-physiol. Org. Humani. Wien, 1812, quoted by\\nMalsjaigne.\\n3 Larrey Mem. de Chir. Militaire, vol. ii. pp. 405-407.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0495.jp2"}, "488": {"fulltext": "4*22 DISLOCATIONS.\\nseptic measures, the partial excision of the joint, because of the diffi-\\nculty of otherwise providing efficient drainage of all the recesses and\\npouches of the synovial sac. To what extent the results of former\\nexperience will be improved upon by those of modern methods,\\nremains to be determined it can only be said that the promise is good,\\nand that it is sustained by some excellent cures already obtained.\\nCompound dislocations of the shoulder and hip are rare, those of the\\nelbow and knee less so, and those of the smaller joints much more\\nfrequent.\\nREPAIR.\\nOnly a few observations have been made of simple dislocations\\nundergoing, or that have undergone, repair. Clinically it is known\\nthat after a period of a few days or weeks marked by gradually\\ndiminishing tenderness and swelling, the joint can be freely used with-\\nout pain, but that sometimes the range of motion remains limited for\\na much longer period, and that in some cases there is a marked ten-\\ndency to recurrence of the dislocation. In a few cases, in which\\npatients have died within a few days after having suffered a disloca-\\ntion, the surrounding tissues have shown the remains of the extrava-\\nsation of blood that had taken place amid them, and the rent in the\\ncapsule has either been occupied by a clot or has been empty and\\nwithout evidence of repair. It is to be presumed, however, that repair\\nusually takes place after dislocation as it does after many other sub-\\ncutaneous injuries, without suppuration or even much inflammatory\\nreaction, that the ruptured capsule reunites or that the gap in it is\\ntilled by condensation and adhesion of the adjoining connective tissue,\\nthat the lacerated muscles and ligaments are repaired in like manner,\\nand that these cicatrices pursue the evolution common to their class.\\nThis process may, however, be disturbed by various complications.\\nIf the injury has been exceptionally severe, if the bone has been widely\\ndisplaced, and the surrounding tissues much lacerated, if the efforts to\\nreduce have been violent and long continued, if the joint has not been\\nproperly immobilized, if passive motion has been injudiciously begun\\nand maintained, or, finally, if the general condition of the patient is\\nunfavorable for repair, the inflammatory reaction may become exces-\\nsive, and even end in suppuration and pyaemia. If it stops short of\\nthis disastrous result, it may yet lead to partial or complete anchylosis\\nthrough the formation of adhesions between the opposed articular sur-\\nface s or the thickening and retraction of the capsule and peri-articular\\ntissues. The older records contain numerous instances in which sup-\\npuration appears to have been caused by the efforts to reduce, but this\\naccident has become much less common since the introduction of ana?s-\\nthesia and the substitution of the so-called mild methods by manip-\\nulation for the forcible traction by pulleys which was formerly so much\\nin vogue.\\nFractures of apophyses, or portions of bone to which muscles or liga-\\nments are attached, are repaired either by bony callus or by a fibrous\\nband, the difference depending on the extent of the separation and the\\nindependent motion of the fragment. The fragment may be withdrawn", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0496.jp2"}, "489": {"fulltext": "REPAIR OF RECENT DISLOCATIONS.\\n423\\nFig. 235.\\nto such a distance that the attached muscle or muscles permanently\\ncease to exercise any control over the main bone, which, in conse-\\nquence, is exposed to frequent and easy recurrence of the dislocation.\\nThe same infirmity may result from defective repair of fracture of\\nthe rim of an orbicular cavity. Instances of the former variety are\\nmost common at the shoulder-joint, those of the latter are found at the\\nhip and shoulder. Another cause of the liability to recurrence at the\\nshoulder laxity of the capsule has been indicated by Jossel, 1 who\\nhad the opportunity to examine four such cases after death he found\\nin all that the supraspinatus and infraspinatus muscles had been torn\\nloose from their attachment to the greater tuberosity, had retracted\\nbehind the acromion, and had un-\\ndergone atrophy and fatty degenera-\\ntion. The relations of the tendons\\nof these muscles with the articular\\ncapsule are so close that the rupture\\nof the former involves also that of\\nthe latter, and the retraction of the\\nformer creates, bv drawing back one\\nside of the rent, a large gap in the\\nupper part of the capsule opening\\ninto the subacromial bursa. In the\\nprocess of cicatrization the front part\\nof the capsule, that lying between\\nits attachment to the humerus and\\nthe rent, becomes adherent at the\\nedge of the rent to the under sur-\\nface of the deltoid close bv its at-\\ntachment to the acromion, while the\\nposterior lip of the rent, after retrac-\\ntion with the tendon, becomes per-\\nmanently fixed at the posterior part\\nof the acromion. The under surface\\nof the acromion is thus left to fill\\nthe gap between the two lips, to\\nform the upper limit of the articular cavity, and to be in direct con-\\ntact with the head of the humerus. In none of Jossel s four cases\\nwas the normal communication between the cavity of the joint and\\nthe subscapular bursa- found to be enlarged in one the subcoracoid\\nbursa communicated with the joint, and in one the tendon of the\\nlong head of the biceps was ruptured, and its torn end had become\\nfixed in the bicipital groove. In two of the cases a small defect with\\nsmooth edges was found in the capsule below the tendon of the sub-\\nscapularis, and in the others the capsule appeared thinned at the same\\npoint. Apparently this indicated the place at which the head of the\\nhumerus escaped through the capsule at the time of the first dislo-\\ncation.\\nThe cavity of the joint was greatly enlarged by the changes in the\\ncapsule in the first its capacity was 90 cubic centimetres, as against\\n1 Jossel Deutsche Zeitschrift fur Chirurgie, 1880, vol. xiii. p. 167.\\nRecurrent or habitual dislocation of the\\nshoulder, showing the opening into the sub-\\nacromial bursa. (Jossel.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0497.jp2"}, "490": {"fulltext": "424 DISLOCATIONS.\\n28 in a normal joint, and its length along the upper portion was 10\\ncentimetres instead of the normal 3f.\\nThis condition of the capsule, aided by the withdrawal of the con-\\ntrol and support normally supplied by the supraspinatus and infra-\\nspinatus muscles, seems entirely adequate to explain the easy recur-\\nrence of the dislocation, and the recent cases of relief by operative\\nshortening of the anterior portion of the capsule are confirmative of\\nthe opinion.\\nGangrene of the limb may ensue upon the rupture of the principal\\nvessels, or even upon extensive laceration and violent inflammatory\\nreaction and paralysis of one or several muscles may manifest itself\\nimmediately or only after the limb is again brought into use, the result\\nof injury to nerve trunks or of contusion of the muscle itself, or of\\ncompression of the nerve by a cicatricial band as in Midler s case\\nquoted above, p. 419.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0498.jp2"}, "491": {"fulltext": "CHAPTER XXX.\\nTHE PATHOLOGY OF UNEEDUCED ANCIENT, INVETERATE\\nDISLOCATIONS.\\nThe changes that take place about joints that have long remained\\ndislocated are well understood, through direct observations of many\\nspecimens in man and through experiment upon animals. These\\nchanges are partly the direct result of purely inflammatory processes\\nexcited by the traumatism and the changed relations of the parts,\\npartly that of disease, and partly that of a seeming effort of nature to\\ncreate a new and serviceable joint. The changes consist, in general\\nterms, in the condensation and thickening of connective tissue about\\nthe displaced bone in such a manner as to protect it against further\\ndisplacement, and in the change of the bones at the new points of con-\\ntact partly by absorption and partly by the formation of new bony\\noutgrowths through continued slight irritation of the bone itself, the\\nperiosteum, and the adjoining fibrous and ligamental tissues. The\\nirritation which leads to these changes is furnished by motion, use, of\\nthe limbs hence the most striking examples are found at the shoulder\\nand the hip, and these will be used as the basis of the following\\ndescription.\\nThe first changes, in point of time, are those in the bruised and torn\\nsoft parts amid which the end of the bone has lodged after its escape\\nthrough the rent in the capsule. The loose connective tissue lying\\nabout the vessels, nerves, and muscular bundles, bruised and pressed\\nback by the head of the bone and infiltrated with extravasated blood,\\nreacts in the usual manner under the traumatism by becoming the seat\\nof an exudation and by multiplication of its cellular elements. The\\nlatter follow their natural evolution into fibrous tissue, and thus is\\nformed about the bone a continuous fibrous envelope enclosing a cavity\\nwithin Avhich the end of the bone lies, more or less free, and continuous\\nstructurally on its outside with the adjoining tissues, some of which\\nvessels, nerves, and muscular fibres may be firmly imbedded in it.\\nIts inner surface is smooth and lined with flat cells resembling those\\nfound on the surface of normal or accidental bursa?, and it is moistened\\nby a small amount of liquid which, in some cases, closely resembles\\nsynovia. It seems probable that when real synovia is present it is\\nfurnished by portions of the original capsule which have remained\\nadherent to the bone and have formed part of the new cavity. Indeed,\\nthe new cavity is usually only an enlargement of, or addition to, the\\noriginal one, its connection with, or its entire independence of, the old\\none being determined by the character and extent of the rent in the\\ncapsule and the distance to which the head of the bone has passed\\nthrough it but the capsule may be torn away from the humerus, for\\n425", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0499.jp2"}, "492": {"fulltext": "426\\nDISLOCATIONS.\\nexample, so completely that it falls together behind it and its cavity is\\nobliterated by adhesion of the opposing surfaces or is shut oif by union\\nof the torn edges. The new capsule is so small and close and the\\nbands formed between the bones by the condensation and increase of\\nthe surrounding tissues are so firm that motion is greatly restricted or\\nwholly lost, and restoration of the original relations can be effected only\\nafter a division or laceration of those tissues far more extensive than\\nthat which accompanied the dislocation.\\nBut while these changes in the soft parts tend permanently to fix the\\nbone in its new position, other changes take place in the periosteum\\nand the bone itself upon which the displaced articular end rests and\\nmoves, which, on the other hand, tend to make this new position a\\nFig. 236.\\nFig. 237.\\nOld supracotyloid dislocation of the femur, with\\nvery complete new acetabulum. From the collec-\\ntion at Bonn. (Kronlein.)\\nScapula showing new socket found in\\nan old unreduced subcoracoid disloca-\\ntion. (Cooper.)\\nmore suitable resting-place and to give it a form and character like\\nthose of the part it is to replace. Thus, a new cotyloid cavity may be\\nformed upon the ilium, or a new glenoid cavity on the inner side of\\nthe scapula adjoining the old one. In this new formation of bone two\\nprocesses may take part production of bone by the periosteum, and\\nossification of the old ligaments and new fibrous tissue. The perios-\\nteum may produce bone either after it has been stripped up or while it\\nis still in place. If, in the dislocation of the head of the bone, a por-\\ntion of the rim of the corresponding articular cavity is broken off and\\npushed away, carrying with it a strip of periosteum torn from the\\nadjoining surface, but preserving its connection with both pieces, or if", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0500.jp2"}, "493": {"fulltext": "PATHOLOGY OF UNREDUCED DISLOCATIONS. 427\\nthe periosteum is stripped up by the attached capsule or a ligament, as\\noccurs so frequently at the elbow, this loosened strip forms on its side\\nthe limit of the new cavity, and produces on its under surface new\\nbone which is continuous with the old and with the fragment of the\\nrim, if such has been broken off, constituting a bridge between them.\\nIf the periosteum is not stripped up, but the head of the bone escapes\\nentirely from the cavity and comes to rest upon the outside of a layer\\nof periosteum still adherent to its bone, this periosteum, irritated by\\nthe pressure and movements, produces new bone between itself and the\\nold, and this production is greatest in the zone just around the point of\\ngreatest pressure. The portion of periosteum directly pressed upon dis-\\nappears under the pressure, leaving a bare surface of bone in contact\\nwith the displaced head, or becomes fibrous or fibro-cartilaginous in\\nstructure while in the immediately adjoining portion the osteogenetic\\nproperty is called into play and a ridge of bone is built up around the\\ncentral denuded area. This may be a sharply defined rim rising to a\\nconsiderable height and closely resembling that for which it is a sub-\\nstitute, or it may be a mass of irregular height and outline, having little\\nor no resemblance to either the glenoid or cotyloid cavity.\\nThe details of this formation, as observed by Baiardi l at the hip in\\nanimals, consist, first, in the appearance of a circular cartilaginous wall\\nwhose free border is continuous with the new-formed fibrous capsule,\\nits base resting upon the ilium and its inner surface in contact with the\\nhead of the femur its ossification (in rabbits) is complete by the thir-\\ntieth day, except along its concave surface, where it remains soft,\\nshading off toward the centre of the new acetabulum into a whitish,\\ncartilaginous like tissue, Avhich takes the place of the destroyed perios-\\nteum. On its free border it has the structure of fibro-cartilage on the\\nconcave surface it closely approximates that of hyaline articular car-\\ntilage. At the very centre the underlying bone is left bare or is\\ncovered by fibrous tissue and fibro-cartilage, and becomes denser in\\nstructure. Grinewetsky, 2 who experimented on dogs, says he never\\nfound a lining of periosteum or cartilage inside the new acetabulum\\nthe bone was always sclerosed. He also notes the absence of endothe-\\nlium on the inner surface of the new capsule.\\nThe ossification, may pass beyond the usual limits and include por-\\ntions of the capsule, 3 forming bony stalactites, or even a complete\\nbony case enveloping, and perhaps united with, the head of the bone 4\\nand in a specimen presented by Moreau, 5 a dislocation of the femur\\ninto the obturator foramen, the membrane filling the foramen had been\\ntransformed into a bony plate throughout, except in a strip along its\\nanterior margin.\\nSome of these experimental observations have been repeated upon\\nspecimens of ancient dislocations in man, in some of which the new\\ncavity has been found to be lined with fibro-cartilage, 6 in others\\n1 Baiardi: Arch, per le Scienze medicke, 1880, vol. iv., quoted by Kronlein.\\n2 Grinewetsky Centralblatt fur Ckirurgie, 1879, p. 279.\\n3 Tkore Bull, de la Soc. Anatomique, 1839, p. 33.\\n4 Cooper Loc. cit., p. 50; and Cruveilkier Anat. patkok, vol. i. p. 425.\\n5 Moreau Mem. de l Acad. royale de Ckirurgie, 1769, vol. ii, p. 153.\\n6 Lepine and Desormeaux Bull, de la Soc. Anat., 1844, p. 167.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0501.jp2"}, "494": {"fulltext": "428 DISLOCA TIOXS.\\nwith a granular fibroid tissue without apparent cartilage of incrus-\\ntation. 1\\nThe displaced head shows changes varying in extent and consisting\\nin loss of its cartilage, erosion of the bone in places and its increase in\\nothers, and occasionally in profound changes of structure throughout.\\nThus in the case just referred to, reported by Duguet, a dislocation\\ninward of the shoulder of six months standing, the head of the\\nhumerus was worn away behind at the point where it rested against\\nthe rim of the glenoid cavity, which also had in great part disappeared\\nits anterior portion had preserved its cartilage at almost all points,\\nwhile its posterior portion had none, it being there replaced by rather\\ntight, short fibrous bands uniting the head to the old glenoid cavity.\\nIn a specimen presented by Walsh 2 to the Royal Surgical Society of\\nIreland, April 25, 1840, of an old dislocation of the shoulder forward,\\nthe subscapulars muscle was raised from the scapula by the head of\\nthe humerus, the new glenoid cavity was covered by fibro-cartilage,\\nthe synovial sac was complete, and the cartilage of the humerus perfect.\\nThe empty glenoid or cotyloid cavity diminishes gradually in size\\neither by absorption of that portion against which the head of the bone\\nrests or by a general atrophy, presumably due to its disuse, similar to\\nthat observed in the alveolar process after removal of the teeth, and\\nits cavity fills up with fibrous tissue that springs from and replaces its\\nlining cartilage. The glenoid cavity has in some cases been still further\\nrendered unfit for use and inaccessible by union with the outer portion\\nof the original capsule, when that has been drawn across its face as the\\nhumerus was displaced inward. And yet, occasionally the acetabulum\\nhas remained empty and its cartilage unchanged for many years (Dreh-\\nmann). 3\\nWhen the use made of the limb is very slight and the head of the\\nbone is immovably fixed in its new position, the development of artic-\\nular characteristics is slighter and the bone may even diminish nota-\\nbly in size or consistency, as in the case quoted on page 421, in\\nwhich the head of the humerus passed into the chest and remained\\nfixed there. This atrophy of disused parts is a general rule, and\\nalthough observed in bone is more marked in other tissues whose nutri-\\ntive changes and functional activity are greater. In accordance with\\nthis general law the muscles which are rendered inactive by the greater\\nor less fixation of the dislocated bone diminish in size, and if their\\ninactivity is complete, or even nearly so, their fibres undergo an actual\\ndegeneration and their fibrous tissue predominates to such an extent\\nthat they are hardly more than ligaments. The bone, too, is similarly\\naffected throughout its entire length it becomes smaller, or, if the\\ndislocation has occurred during youth, before development is complete,\\nit fails to develop to the same extent as its fellow on the opposite side,\\nand even its normal curves disappear.\\nThese facts show both the danger and the futility of attempts to\\nreduce dislocations that have long existed they show that reduction\\n1 Duguet Bull, de la Soc. Anat., 1863, p. 144.\\n2 Walsh Gazette des Hopitaux, 1840, p. 330.\\n3 Drehmauu Beitrage zur klin. Chir., 1897, vol. xvii.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0502.jp2"}, "495": {"fulltext": "PATHOLOGY OF UNREDUCED DISLOCATIONS. 429\\ncan be accomplished only at the cost of lacerations far more extensive\\nthan those involved in the original injury, that among these lacera-\\ntions may be included rupture of important vessels or nerves that have\\nbecome adherent to or included in the fibrous bands of new formation,\\nand that even if the bone can be successfully liberated from its attach-\\nments and brought back to the cavity from which it was displaced the\\nlatter may have become entirely unfit for its reception and for a resump-\\ntion of its own original functions.\\nImportant changes in the condition of the limb may be caused by\\npressure upon the bloodvessels or nerves by the displaced bone or by\\ninjury done them during attempts at reduction. Instances of the latter\\nare given in Chapter XXXIV.\\nPersistent oedema, resulting in a condition resembling elephantiasis,\\nwas observed by Bartels in a patient whose shoulder had been dislo-\\ncated for more than a year. There was also rigidity of the fingers in\\na position indicating ulnar paralysis, which was relieved by increasing\\nthe mobility of the shoulder, but the oedema persisted.\\n1 Bartels Arch, fur kliii. Chir., 1874, vol. xvi. p. 638.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0503.jp2"}, "496": {"fulltext": "CHAPTEE XXXI.\\nSYMPTOMS AND DIAGNOSIS.\\nThe symptoms of a dislocation those changes in the form, functions,\\nand sensibility of the part by which the presence of a dislocation is recog-\\nnized are classed as objective and subjective or rational. The former,\\nwhich alone are deemed demonstrative, are those which can be recog-\\nnized by the surgeon on examination the latter are those for his knowl-\\nedge of which he must depend, to a greater or less extent, upon the\\nstatements of the patient.\\nThe examination of the patient should always be conducted sys-\\ntematically, with the view to learn not merely the existence of the\\ndislocation, but also such details and complications as may be present\\nand may affect the treatment and prognosis and it should include an\\nexamination of the condition of such bloodvessels and nerves as may\\nhave been injured at the same time, in order that such injuries, if their\\nlater consequences should become manifest, may not be attributed to\\nthe treatment. If swelling, a large amount of subcutaneous fat, or\\npain should prevent a satisfactory examination, anaesthesia should be\\nemployed. The character and direction of the force that produced the\\ndislocation should be learned, and also, if possible, the position of the\\nlimb at the moment of its dislocation, and whether a consecutive\\nhas been substituted for a primary displacement, or, as evidence of\\nthe latter fact, whether one fixed position of the limb has been sub-\\nstituted for another. In doubtful cases the uninjured limb should be\\nused for comparison, and the question should be asked whether or not\\nthe suspected joint has been previously the seat of disease or injury the\\nconsequences of which may affect the conclusions to be drawn from\\nthe examination. The essential point in the examination is to deter-\\nmine the position of the end of the bone, its relations to that one from\\nwhich it is thought to have been violently separated, and the best\\nevidence of this fact is furnished by feeling the end of the bone with\\nthe fingers, by tracing its outline, by feeling it move when the lower\\npart of the limb is moved.\\nObjective Signs.\\nDeformity. Beside the attitude of the patient or of the limb, which\\nis often strikingly characteristic, the aspect of the region of the affected\\njoint is changed by the inflammatory swelling, which may appear\\npromptly or tardily and be accompanied by ecchymosis and by altera-\\ntions in the depth or position of the fold of its flexure and in its normal\\ndepressions and prominences. The swelling varies with the length of\\ntime that has elapsed since the injury was received, increasing for a day\\n430", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0504.jp2"}, "497": {"fulltext": "SYMPTOMS AND DIAGNOSIS. 431\\nor two, remaining stationary for a variable time, and then diminishing\\nin old cases the region is atrophied. If the dislocation has been caused\\nby external violence acting directly upon the region of the joint, the\\nswelling is increased by the effects of the contusion, and ecchymoses\\nappear more promptly than in other cases.\\nThe position, with reference to each other, of the articular surfaces\\nor ends which constitute the joint can often be determined by palpation,\\nand this furnishes the most exact and positive evidence of the character\\nof the injury. In joints that are not thickly overlain by soft parts or\\nmasked by swelling or extravasated blood, this position can be readily\\nmade out, as at the knee, fingers, elbow, or even the shoulder at the\\nhip it is easy in some dislocations e. g., suprapubic to recognize the\\nhead of the femur, in others it .is much more difficult.\\nIf the head of the bone cannot be felt, its position (if there is no\\nfracture) can be determined from that of its shaft and recognizable\\nprominences or apophyses. Thus, if the great trochanter can be recog-\\nnized, the position of the head of the femur can be readily inferred by\\nFig. 238. Fig. 239.\\nDiagram to show the effect of position upon the appar- Diagram to show the action of a Iiga-\\nent length of the arm in dislocation of the shoulder. A, ment in limiting the range of motion\\nacromion B, lower end of humerus C, head of humerus, in a dislocation.\\nprolonging from it in imagination the neck of the femur in the line\\nindicated by the position of the shaft. In like manner prolongation\\nupward of the line of the lower portion of the humerus indicates the\\nposition of the head of the bone, and if it passes to the inner side of\\nthe acromion the shoulder must be dislocated or the bone broken.\\nThe continuity of the supposed head with the shaft is determined by\\nrecognizing that it participates in slight movements communicated to\\nthe lower segment of the limb. The aid of needles passed down\\nthrough the soft parts to the head of the bone is sometimes resorted to\\nwhen the thickness of the soft parts makes examination with the\\nfingers difficult or uncertain. By prolonged firm pressure with the\\nfingers an inflammatory swelling may sometimes be pushed aside and\\nthe bone distinctly felt.\\nThe limb may appear to be, or may actually be, shortened or length-\\nened, but this sign is not of so much value as it is in cases of fracture,\\nboth because it varies greatly with varying positions of the limbs and\\nbecause the limbs cannot ahvays be placed symmetrically. The reason\\nwhy the length of the measured distance varies in different positions", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0505.jp2"}, "498": {"fulltext": "432 DISLOCATIONS.\\nof the limb can be made clear by taking an example, as the shoulder.\\nHere the distance usually measured is that from the edge of the acro-\\nmion to the external epicondyle of the humerus. Now, this distance\\ndiminishes as the arm is abducted, for (Fig. 238) when the arm hangs\\nby the side, the line A B is almost exactly equal to C B plus the dis-\\ntance that C lies below the level of A; while, on the other hand, when\\nthe arm is abducted the distance A B is equal to C B minus the dis-\\ntance of C beyond the line of A.\\nThe methods of measuring and the precautions to be taken are the\\nsame as in the case of fracture and have been elsewhere considered and\\nthe possibility of the previous existence of asymmetry of the limbs, of a\\ndhTerence in their length, has also been described. (Fractures, p. 49.)\\nLoss of Mobility. In almost every dislocation there is a position\\nwhich is characteristic of it and which the limb tends spontaneously\\nto assume and retain, even under anaesthesia. This position depends\\nrather upon the tenseness of ligaments and untorn portions of the cap-\\nsule than upon the muscles, although the latter by being already over-\\nstretched may aid in limiting motion or change of position in certain\\ndirections. The head of the bone takes up a new position at some\\ndistance from its normal one and there establishes a new centre of\\nmotion for the limb consequently the ligaments on the side opposite\\nthat toward which the head has been displaced are put upon the stretch\\nif the attempt is made to move the lower part of the bone in the\\nsame direction, and, unless torn, fix it at an angle with the other\\nbone to which they are attached (Fig. 239). The bone can be moved\\ntoward the attachment of the untorn ligament but not further away\\nfrom it.\\nSince the limitation of motion has its principal cause in the non-\\nmuscular structures, it cannot be entirely removed by anaesthesia, but\\nsuch additional limitation as may be due to contraction of the muscles\\nexcited by the fear of pain can be thus removed, and whenever the\\nfixity of a limb is used as an element in making the diagnosis the part\\ntaken by the muscles in its production should be determined. The\\ndiagnostic formula sometimes given that abnormal fixation is charac-\\nteristic of dislocations, and abnormal mobility of fractures, is a partial\\nstatement that may be misleading, for in fracture, or even in contusion,\\nnear a joint complete fixation may be effected by the muscles, and in\\ndislocation with extensive laceration of the capsule and ligaments the\\nrange of motion may be very wide, and in all it is generally free in\\nsome direction.\\nA therapeutical fact that may often be of importance is to be deduced\\nfrom the fact that the dislocation must, in most cases, have taken place\\nwhen the limb was in one of the positions in which, while still dislo-\\ncated, it is shortened that is, one in which the distance from its normal\\noj^posing articular surface to its lower end is less than that between the\\ncorresponding points of the opposite limb in a similar position by\\nreplacing the limb in the position it occupied when the dislocation took\\nplace the first step in reduction, that of bringing the head of the bone\\nopposite the rent in the capsule through which it has escaped and relax-\\ning the soft parts, is taken.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0506.jp2"}, "499": {"fulltext": "SYMPTOMS AND DIAGNOSIS. 433\\nCrepitus. A sound or sensation somewhat resembling the crepitus of\\na fracture is occasionally perceived while a dislocated limb is being\\nhandled. It may be the real crepitus of a fracture accompanying\\nthe dislocation, or merely the grating of the head of the bone against\\nthe edge of the periosteum of the other, or against a fibrous band, or\\neven (it is said) against a blood-clot.\\nSubjective Symptoms.\\nPain. The occurrence of the dislocation is immediately followed by\\nsharp pain in the region of the joint, which may gradually diminish or\\nmay continue for some time with unabated severity. In the former case\\nit is presumably due in great part to the laceration and bruising of the\\ntissues in the latter to the tension of those parts that have not yielded\\nto the strain. In the former case the pain is not materially relieved\\nby reduction in the latter it immediately disappears when the bone is\\nrestored to its place. In addition to this pain about the joint, there\\nmay also be tingling or numbness through the limb in consequence of\\npressure upon the large nerve trunks.\\nLoss of Function. Inability to use the limb is ordinarily complete,\\nand is due partly to the fixation created by the changed relations of the\\nbones and partly by the pain which movement causes. There is noth-\\ning characteristic in this symptom, since it is present also after fracture\\nand even after a severe contusion. Furthermore, it is sometimes absent,\\nor present in so slight a degree that the patient continues to use the\\nlimb, conscious only of some slight pain and of a certain inconve-\\nnience or lack of freedom in its use.\\nHistory. The history of the case includes the character of the vio-\\nlence, the position of the limb at the moment of the accident, possibly\\nthe perception by the patient at that moment of a sound, of the sensa-\\ntion of displacement, and the history of any previous injury to or dis-\\nease of the part or of the opposite limb so far as it may affect its use\\nfor the purpose of comparison. It is well to obtain this history before\\nproceeding to the direct examination of the limb.\\nThere can be no uncertainty as to the main fact if the relations to\\neach other of the articular ends can be made out, and the surgeon\\nshould not rest content with less than this when it can possibly be\\nattained. In every doubtful case an anaesthetic should be employed,\\nand among the doubtful cases are those in which there is the possible\\ncoexistence of a fracture either of a portion of the articular surface or\\nof the entire breadth of the bone near the joint. The latter form of\\nfracture is itself the one with which a dislocation is most frequently\\nconfounded either may be mistaken for the other and in any such\\ncase, every effort should be made to determine the exact positions occu-\\npied by the ends of the bones.\\nIn dislocations complicated by fracture of portions of the articular\\nsurface or of tuberosities to which muscles are attached, the coexistence\\nof the fracture is often incapable of demonstration and can only be\\nsuspected because of the facility with which the dislocation recurs after\\nreduction.\\n28", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0507.jp2"}, "500": {"fulltext": "434 DISLOCATIONS.\\nSuch complications as injury of a main bloodvessel or nerve will be\\nreadily recognized by attention to the characteristic symptoms to which\\nthey give rise.\\nFinally, it should be remembered that the most experienced and care-\\nful surgeons have sometimes remained in doubt, or have denied the\\nexistence of a dislocation which the subsequent course of the case has\\nshown to have been present, and the charity which the critic may him-\\nself so soon need should be cordially extended to others.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0508.jp2"}, "501": {"fulltext": "CHAPTER XXXII.\\nCOUESE AND PEOGNOSIS.\\nIf the dislocation is promptly reduced and no complications are\\npresent, the course is simple and the prognosis favorable. The swell-\\ning and pain subside, and the patient is soon able again to use the limb,\\nalthough usually with some limitation of the range of motion and with\\npain when these limits are reached. This slight disability may persist\\nfor weeks, or even months, especially in those who are constitutionally\\nprone to arthritic complications. I have known a robust, thoroughly\\nhealthy man to dislocate his shoulder, the dislocation being so slight\\nthat it was immediately reduced by accidental traction on the arm and\\nhe was able to use the limb without a day s intermission and yet,\\nthree months after the accident he was unable to lift the elbow in\\nabduction to the level of the shoulder, and could not carry his hand to\\nhis hip-pocket without causing considerable pain.\\nIf the inflammatory reaction is more severe, the pain and swelling\\nare greater and more prolonged, and the limitation of movement may\\nbecome permanent through the formation of adhesions or the conden-\\nsation and thickening of the peri-articular soft parts. It is very excep-\\ntional for this process to go on to suppuration.\\nIf the disarticulation is compound, it may follow either one of two\\ncourses either it is transformed into a simple one by the prompt union\\nof the wound, or suppuration ensues and the patient is exposed to all\\nthe accidents of a deep suppurating wound, rendered all the more exten-\\nsive by its continuity with the interior of the joint. In the latter case\\nthe result is certain to be marked by much functional disability, per-\\nhaps by total loss of mobility in the joint.\\nOther complications add to the otherwise uneventful course of a\\nsimple dislocation the features peculiar to themselves thus, injury to\\na nerve may be followed by temporary or permanent paralysis of the\\nmuscles or loss of sensation in the region supplied by it, or by a long\\ntrain of symptoms indicating an ascending neuritis. And injury to a\\nmain artery may be followed by gangrene of the limb, or by the forma-\\ntion of a traumatic or encysted aneurism. The coexistence of a fracture\\nof the neck of the bone creates a condition which for a time predomi-\\nnates over the dislocation if the latter is promptly reduced the case\\nfollows essentially the course of a fracture if it cannot be at once\\nreduced the course at first is still in the main that of a fracture, and\\nsubsequently that of an old dislocation.\\nThe fracture of a portion of the articular edge, or of an apophysis,\\nis habitually followed by no symptoms peculiar to itself, except in some\\ncases a marked tendency to recurrence of the dislocation after its reduc-\\ntion, and this tendency may persist throughout life.\\nExcluding these complications, the prognosis is a simple dislocation\\n435", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0509.jp2"}, "502": {"fulltext": "436 DISLOCATIONS.\\nof a limb, quoad vitam, is eminently favorable the prognosis with\\nregard to the restoration of form and functions depends upon the\\nreducibleness of the dislocation, and this is affected by the character\\nof the joint and of the injury, by complications, and by the time that\\nhas elapsed since the injury was received.\\nThe principal obstacle to the reduction of a dislocation commonly\\nlies in the tension of the untorn portion of the capsule and ligaments,\\nbut special difficulties may arise from the relations of the displaced\\nbone to the capsule and to various muscles and tendons. The capsule\\nmay slip in between the head of the bone and the cavity it has left,\\nand create an obstacle (by its interposition) that cannot be removed by\\nmanipulation or traction of the limb, or its torn edge may be drawn\\ntightly about the neck of the bone, as is common at the metacarpo-\\nphalangeal joint. The cases in which the former happens are those\\nin which the capsule is freely torn at or near its attachment to the\\nhumerus or femur, and in which the head of the bone is displaced\\nentirely to the outside of the capsule.\\nThe greater the length of time since the occurrence of the disloca-\\ntion, the greater will be the difficulty of reduction and after the lapse\\nof a certain length of time, which is different in different cases, reduc-\\ntion becomes impossible. The cause of this difficulty has been\\ndescribed in Chapter XXX.\\nThe period at which a dislocation is to be deemed unfit for reduc-\\ntion cannot be positively stated it varies with different joints and\\ndifferent cases. Speaking generally, it is about two months for the\\nlarger joints, but it is not prudent to assume that any dislocation which\\nhas remained unreduced for a shorter period than two months is re-\\nducible, or that every one that is older is, therefore, irreducible for in\\nthe former case we may be led to apply an amount of force that will\\nprove disastrous and in the latter disabilities that are amenable to\\ntreatment may be left unrelieved. A better guide is to be found in\\nan examination directed to ascertaining the changes produced in the\\nparts by the original injury or the disuse, and in careful, judicious\\nattempts to make reduction. The object of these attempts should not\\nbe to reduce the dislocation at any cost, but to reduce it only if the\\nreduction can be accomplished by moderate force and without grave\\nlacerations. And, indeed, I am convinced that in a doubtful case it is\\nbetter to expose the bone by incision, and divide the obstructing tissues\\nwith the knife, rather than blindly to rupture them by the application\\nof a force whose action cannot be intelligently directed, and whose\\neffects cannot be certainly foreseen and controlled. That the warning\\nis still needed is shown by the recent (1897) death of a patient in the\\nXew York Hospital after an attempt to reduce a dislocation of the\\nshoulder of six weeks standing by traction and manipulation which\\nruptured the axillary vein and broke the third, fourth, and fifth ribs.\\nEncouragement to attempt reduction even when the dislocation has\\nremained unreduced for a period much longer than that of two months\\nabove mentioned is furnished by not a few recorded cases in which it\\nhas been completely successful instances will be given in the follow-\\ning chapter.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0510.jp2"}, "503": {"fulltext": "CHAPTER XXXIII.\\nTREATMENT.\\nSpontaneous Reduction Obstacles to Reduction Anaesthesia Methods of\\nReduction Old Dislocations After-treatment Habitual Dislocation.\\nAs a rule, to which there can be very few exceptions, reduction of\\na dislocation should be attempted at the earliest opportunity. The\\npossible exceptions are cases in which the inflammatory reaction is\\nalready very great, and in which it may be anticipated that the addi-\\ntional violence inflicted during reduction would dangerously increase\\nit. But even in such cases it would be well to make gentle efforts to\\nreduce under ether, and to postpone the reduction only if these efforts\\nproved unavailing.\\nSpontaneous reduction is the term applied to that which takes place\\nwithout the intentional intervention of any external force. It may\\ntake place while the patient is asleep, through the action of the\\nattached muscles or through some chance violence, or by a fall or a\\nsudden movement.\\nSpontaneous reduction, without the aid of external force, has fol-\\nlowed shortly after attempts to reduce which have been unsuccessful\\nbut which may be thought to have made spontaneous reduction pos-\\nsible by rupture of adhesions, or laceration of the tissues, or fatigue\\nof the muscles. This variety was termed consecutive reduction by\\nLeveille, and the term was adopted by Malgaigne, who applies it both\\nto cases in which spontaneous reduction takes place after complete\\nfailure of the efforts to reduce and also to those in which an incom-\\nplete reduction spontaneously becomes complete or is gradually made\\ncomplete by prolonged action of some force applied by the surgeon\\nsuch as pressure.\\nThe obstacles to the reduction of recent uncomplicated dislocations\\narise from inflammatory swelling of the soft parts, muscular contrac-\\ntion excited by pain or the fear of pain, the in extensibility of untorn\\nportions of the capsule or ligaments of the joints, the interposition of\\nportions of the capsule between the head of the bone and its cavity,\\nand the size and position of the rent in the capsule. Not all of these\\nare present in every case, and they vary in importance. For a long\\ntime the muscles were deemed the most important, but observations\\nand experiments upon the cadaver carried on at about the same time\\nby several different persons Gunn 1 in 1851, Gelle 2 and Bigelow 3 in\\n1861, StreubeP in 1862, and Busch 5 in 1863\u00e2\u0080\u0094 fixed the attention of\\n1 Gunn Peninsular Journal of Medicine, July, 1855, p. 27.\\n2 Gelle Archives generales de Med., April and Mav, 1861.\\n3 Bigelow The Hip.\\n4 Streubel Vierteljahreschrift fur prakt. Heilkunde, 1862, vol. ii. p. 59.\\n5 Busch Arch, far klin. Chirurgie, 1863, p. 1.\\n437", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0511.jp2"}, "504": {"fulltext": "438 DISLOCATIONS.\\nsurgeons upon the relations between the bone and the capsule, showed\\nthe nature and importance of the opposition commonly offered by the lat-\\nter, and established the basis of treatment by systematic manipulation.\\nAn account has already been given of the part played by the untorn\\nportion of the capsule in determining the position assumed by the limb,\\na part so important that in regular dislocations (the term given by\\nBigelow to those in which the rent in the capsule is only partial and\\noccupies a certain definite place in it) the muscles surrounding the\\njoint may all be divided without thereby modifying the position of\\nthe limb or increasing its range of motion. At the hip the portion\\nwhich remains untorn in all the typical forms is the anterior portion\\nor Y-ligament at the shoulder it is the thicker anterior portion form-\\ning the so-called coraco-humeral ligament. It is more correct to speak\\nof the obstacle offered to reduction by this untorn portion of the cap-\\nsule as an obstacle not to reduction in general, but only to reduction\\nby certain methods, for when properly managed it offers no opposition,\\nand may possibly even be of assistance. It\\nFig. 240. may be compared to the link of a sleeve-\\nbutton, which in some positions absolutely\\nprevents the button from passing back\\nthrough the button-hole, while in other\\npositions the passage is easy. Thus, if the\\nhead of the bone is lodged behind a pro-\\njecting portion of the rim of the articula-\\ntion, the ligament (Fig. 240) is tense, and\\ntraction in any direction which tends to\\nseparate its points of attachment is effectu-\\nally opposed by it but if these points are\\nbrought nearer together by moving the\\nDiagram to illustrate tne action ghaft of bone j n the direction indicated\\nof an untorn ligament or portion it i 1\\nof capsule in opposing reduction. by the arrow, the ligament is thereby re-\\nlaxed and its opposition to the movement\\nof the head of the bone toward its cavity annulled. The position of\\nthe untorn portion of the capsule or ligament must be inferred from\\nthe posture of the limb and the directions in which motion is strongly\\nopposed.\\nIn irregular dislocations, those in which a characteristic attitude\\nis not taken by the limb and in which the mobility is marked, these\\ndifferences are due to extensive rupture of the capsule and this, by\\nremoving the restraint imposed in other cases by the untorn portion\\nof the capsule, makes reduction remarkably easy without much atten-\\ntion to the position in which the limb is held during the attempt.\\nIn addition to this opposition to movement or traction in certain\\ndirections, the capsule may offer other obstacles arising from the form\\nand position of its rent and from its own interposition between the head\\nof the bone and the cavity in which the latter is to be replaced. The\\ntearing of the capsule is caused by the pressure of the head upon it,\\nconsequently the rent is on the side toward which the head is displaced,\\nand it may be longitudinal or transverse at either attachment, or present\\na combination of the two forms. In order that either of these obstacles", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0512.jp2"}, "505": {"fulltext": "TREATMENT. 439\\nshould be present, it is necessaiy that the head of the bone should have\\npassed entirely through the rent that, in other words, its displacement\\nshould be marked. As the rent, under these circumstances, is large\\nenough to allow the head to pass out through it, it is large enough\\nto allow it to be brought back through it if it is not made too\\nnarrow and its sides too tense by traction upon them. The effect of\\ntraction to narrow the opening can be demonstrated on the cadaver\\n(Streubel l by producing a subcoracoid dislocation of the humerus or\\nan obturator or ischiatic dislocation of the femur, exposing the region\\nby removal of the muscles, and then making traction in the extended\\nposition. As the capsule is made tense the sides of the longitudinal\\npart of the rent are drawn together, and their lateral separation, which\\nalone would allow the globular head of the bone to pass back, is pre-\\nvented. The narrowness of the gap is at once relieved by changing\\nthe position of the limb in such a manner as to bring the points of\\nattachment of the capsule nearer together, and the transverse portion\\nof the rent can be lengthened by rotating the limb.\\nInterposition of the capsule between the head and its cavity may\\nexist whenever a secondary displacement has succeeded the primary\\none and the head has moved from the point at which it escaped along\\nthe outside of the capsule, but unless the capsule has been so torn as\\nto form a flap adherent by its base to the edge of the articular cavity,\\nthis interposition can be readily avoided by moving the head of the\\nbone back to the position of primary displacement. If, on the other\\nhand, such a flap has formed and has fallen between the articular sur-\\nfaces, there is no means, short of an operation that directly exposes it,\\nof certainly getting it out of the way it is attached to only one bone,\\nand consequently cannot be acted upon by moving the other or changing\\nthe relations to each other of the two.\\nSwelling of the soft parts interferes with reduction by increasing the\\nbulk of the limb within the fascia and thereby mechanically opposing\\nchanges in position. If it is very great it may be proper to defer\\nreduction and combat the swelling by rest, cooling lotions, and press-\\nure it will usually subside so promptly that the loss of time thus\\nincurred will not add appreciably to the difficulty of reduction when\\nit is undertaken.\\nContraction of the muscles, provoked by the traumatism or the fear\\nof pain, opposes reduction by preventing the preliminary changes of\\nposition and neutralizing to a greater or less extent the traction that is\\nmade upon the limb. It may be overcome by gentle and long-continued\\ntraction, or forcibly, or by anaesthesia, or it may be avoided by taking\\nthe patient unawares or distracting his attention at the critical moment.\\nAnaesthesia is far from being needed in all cases, and as there are\\ncertain discomforts and even dangers in its use an attempt to reduce\\nwithout its aid should usually be made. In New York, and, I think,\\nin most of the large cities of the United States, ether is habitually used\\nin preference to chloroform, and although chloroform is still used in\\nEurope, the greater safety of ether is almost universally admitted.\\nThe collected cases of death under chloroform apparently proved the\\n1 Streubel Loc. cit., p. 70.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0513.jp2"}, "506": {"fulltext": "440 DISLOCATIONS.\\ncorrectness of an opinion quite generally held that its use in disloca-\\ntions is especially dangerous, although no satisfactory explanation of\\nthe fact has yet been given. Of 101 fatal cases collected by Kappeler 1\\nbetween 1865 and 1876, 11 were dislocations, 20 amputations, and 11\\noperations upon the eyes of 134 cases collected by Marchand, 2 17 were\\ndislocations, and 15 extractions of teeth. It is not always necessary\\nto push the use of ether to complete anesthetization, for the relaxation\\nis sometimes sufficient during the stage of primary anaesthesia if care\\nis taken not to excite the patient unduly. Gentle traction may be made\\nupon the limb as the anesthetization is begun, and its direction gradu-\\nally changed or emerged into the desired manoeuvres as the muscles are\\nfelt to yield.\\nMethods of Reduction.\\nSince the nature of the obstacles to reduction has been more correctly\\nunderstood the methods by forcible traction have been so far superseded\\nby the methods of manipulation that they now possess only an histor-\\nical interest. They consisted essentially in extension (traction), usually\\nin the line of the dislocated limb, and counter-extension to bring the\\nhead of the bone down to the level of its cavity, followed then by\\nmeasures of coaptation to force it into place. The traction was\\nmade through bands attached to the lower segment of the limb, and\\nthe force was exerted either directly by the hands of several assistants\\nor indirectly through pulleys or screws. The amount of force some-\\ntimes exerted by these means can be inferred from the disastrous and\\neven fatal consequences that occasionally ensued, including rupture not\\nonly of muscles and ligaments but also of the principal nerves and\\nbloodvessels, and even complete avulsion of the limb. Suppuration\\nof the joint, followed by the death of the patient, an accident which is\\nnow very rare, was formerly quite common, and in very many of the\\ncases which recovered the record plainly shows the violence of the\\nreaction and how narrowly the patients escaped with their lives. The\\noccasion for the exertion of so much force arose from the faulty direc-\\ntion in which it was frequently applied, one in which the head of the\\nbone could not be brought down to the level of the cavity without\\npreliminary rupture of the opposing soft parts. The laceration caused\\nby the dislocation was increased by the treatment, in order to enable\\nthe bone to follow a course which the ligaments, if untorn, would\\neffectually bar. The method was directed against an obstacle, the\\nresistance of the muscles, which was only one, and that not the chief, of\\nthose which opposed reduction, and was pursued in ignorance of the\\nprincipal one violence was used to overcome, an obstacle which correct\\nanatomical knowledge would have enabled the surgeon to avoid.\\nIt must not be understood that this extreme violence was exerted in\\nevery case. In many the traction was made in a proper direction, or\\nat least in one in which the already existing laceration of the capsule\\nallowed the bone to be moved hence, many dislocations were reduced\\n1 Kronlein: Loc. cit., p. 66.\\n2 Marchand Des Accideuts qui peuvent cornpliquer la Seduction des Luxations trau-\\nniatiques, 1875, p. 134.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0514.jp2"}, "507": {"fulltext": "TREATMENT. 441\\nwith comparative facility, especially those of the shoulder and those of\\nthe hip in which consecutive displacement had not materially changed\\nthe posture of the limb, and in such cases traction was a proper means\\nto overcome the opposition of the muscles. It was in such cases, too,\\nthat the methods of continuous moderate traction by India-rubber,\\nweight and pulley, and suspension by the limb pendel-methode\\nwere successfully employed, and will still be when it is desired to avoid\\nrecourse to the aid of anaesthesia.\\nAs long ago as in the time of Hippocrates (fifth century B. c.) it\\nhad been known that some dislocations of the hip could be readily\\nreduced by manipulation without the aid of violent traction, and Galen\\n(second century A. D.) had pointed out that the head of the bone\\nshould be returned to its cavity along the route by which it had escaped,\\nyet these suggestions remained unknown or unheeded and the practice\\nof surgery, as regards dislocations, appears to have been not only inef-\\nfectual to relieve in a large proportion of cases, but also characterized\\nby dense ignorance of their pathology and by the crudest notions of\\nthe mechanical effects of the means by which their reduction was\\nattempted. Thus, among the methods in vogue, according to Petit,\\nfor the reduction of dislocations of the shoulder, at the beginning of\\nthe eighteenth century, were those of the door or ladder, the bar, and\\nthe ambi. In the former the patient was made to stand upon a\\nstool, and the dislocated arm was brought over the top of a door\\nor a rung of a ladder so that the latter occupied the axilla then,.\\nwhile an assistant grasped the wrist and drew it directly downward*\\nthe stool was taken away and the patient left suspended until the sur-\\ngeon pronounced the dislocation reduced or abandoned the attempt. In\\nother cases the patient was lifted from the ground upon a bar supported\\non the shoulders of two men and passing under his axilla or a large,\\nstrong man seized the patient s wrist, placed his ow 7 n shoulder under\\nthe axilla, and then suddenly straightening himself raised the patient\\nfrom the ground, at the same time drawing the arm down forcibly in\\nfront of himself. The method of the heel, so strongly recommended by\\nSir Astley Cooper, was also employed by them, and sometimes with\\nsuccess.\\nThe ambi, an instrument invented by Hippocrates, was also in favor\\nit consisted of tw T o oblong pieces of wood joined together at the end by\\na hinge, of which one was placed vertically against the side of the\\npatient, the hinge pressed well into the axilla, the other under the\\narm in the position of horizontal abduction. The arm was then firmly\\nsecured to the latter piece and forcibly depressed.\\nAs the defective mode of action of these methods became more gen-\\nerally recognized, traction by the hands of assistants or by pulleys\\nor by other apparatus was substituted, but although this was an im-\\nprovement upon its barbarous predecessors it was still employed\\nblindly, and evidently was often ineffectual. There are indications in\\nthe older writings that the practice was not so wholly bad as the teach-\\ning, that here and there men were found who not only appreciated the\\nimportance of the direction in which traction should be made, but even\\noccasionally reduced dislocations by manipulation alone, but the writer", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0515.jp2"}, "508": {"fulltext": "442 DISLOCATIONS\\nwho seems to have been the first to recognize the importance of the\\nprinciple enunciated so long before by Galen of bringing back the head of\\nthe bone by the route along which it had escaped, and of the position to be\\ngiven to the limb during the attempt, was Jean Louis Petit. His Traite\\ndes Maladies des Os was published in 1705 a second edition followed\\nin 1723, and a third in 1741. He clearly pointed out the mechanical\\n\u00e2\u0096\u00a0defects of the methods then in use, and the necessity of first bringing\\nthe head of the bone back to the opening in the capsule through which\\nit had escaped before attempting to replace it in its cavity and he drew\\nfrom observation of the different degrees of tension of the different\\nmuscles inferences as to the position in which the limb should be placed\\nand the direction in which traction should be made, which were of\\ngreat practical value, although based upon notions concerning the\\nobstacles that opposed reduction which were incomplete in that they\\ntook no account of the untorn ligaments and capsule. Thus, in dislo-\\ncation forward or downward of the shoulder he abducted the elbow\\nwidely, and in those of the thigh backward he flexed the limb and\\nthen changed its position when the head of the bone had been brought\\ndown to the proper level.\\nPetit, in thus departing from the practice of his predecessors and\\ncontemporaries, had entered upon the right path he erred in not fol-\\nlowing it far enough, and his error arose from a too limited notion of\\nthe obstacles to be overcome. He noticed that some muscles were tense\\nand others were relaxed, and he sought to place the limb in a posture\\nthat would remove these differences, while at the same time traction\\nmade in the direction of its long axis would bring the head of the bone\\nto the point at which it had escaped from its cavity. His improve-\\nments were appreciated, and his practice was essentially followed by\\nmost surgeons until within the last few years. Yet one of his early\\nsuccessors, Pouteau, 1 in a paper embodying ideas conceived in 1749\\n(see loc. cit., vol. ii. p. 237), pointed out the defects of the method as\\napplied to dislocations of the hip, and supported his own arguments\\nand modifications by the record of several successes. He says (p. 222)\\nthat in the first case of dislocation of the hip upward and outward (on\\nthe dorsum of the ilium) which he was called upon to treat he em-\\nployed Petit s method and failed. That is, he made traction with\\nthe limb somewhat flexed, counter-extension being furnished by the\\ncanvas band of Petit s machine, the centre of which pressed against\\nthe tuberosity of the ischium, while its ends lay, one in front of the\\nabdomen, the other behind the buttock. The reflections excited by\\nthis failure led him, when the next case presented itself, a few months\\nlater, to make traction with the thigh flexed at a right angle, and the\\neffort was promptly successful. He placed the patient on his back on\\nthe floor, laid the canvas band along the groin, with one end between\\nthe thighs and the other on the outer side of the injured hip, flexed the\\nthigh to a right angle, engaged the ends of the bars in the pockets of\\nthe counter-extending band, and made traction when he deemed the\\ntraction sufficient, he gently rotated the thigh outward, and reduction\\nat once took place. Furthermore, he showed that the resistance of the\\n1 Pouteau CEuvres posthuuies, Paris. 17S3. Pouteau died in 1775.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0516.jp2"}, "509": {"fulltext": "TREATMENT. 443\\nmuscles was due to their involuntary contraction and was to be more\\nreadily and safely overcome by prolonged moderate traction than by\\nmore violent but briefer efforts. He says (loc. cit,, p 226) I have\\nseveral times observed that it is easier to temporize than immediately\\nto overcome the resistance of these muscles so, when the extension\\nseems to be sufficient I maintain it at the same point for some time and\\nwait for the relaxation which fatigue must bring about. It is then only\\nnecessarv to profit by this moment of inaction to effect the reduction.\\nPouteau s practice closely resembled that which represents the appli-\\ncation of the principles of the modern method by manipulation, and is\\nidentical with that of moderate traction upon the flexed limb which is\\nnow in common use and is, I think, generally preferred to that of pure\\nmanipulation. He flexed the limb to bring the head of the bone nearer\\nthe opening in the capsule, made traction to lift it to the level of the\\ncotyloid cavity, and then turned it in by outward rotation or abduction,\\nor both. He knew even that the traction could sometimes be dispensed\\nwith and the reduction effected by manipulation alone, and, in quoting\\nsuccesses thus obtained by Maisonneuve, he predicts that a simpler\\nmethod than his own will be found. The failure of his practice to\\nbecome generalized is probably due to the influence of tradition and of\\nthe authority of Petit, reinforced as the latter was by the great advance\\nhe had made over the practice of his predecessors, and perhaps to the\\ninsufficient publication of Pouteau s views. The paper from which\\nthe above quotations are made appears to have been written in 1749,\\nbut there is no evidence that it was published elsewhere than in the\\nposthumous collection of 1783, which, consisting of disconnected essays\\nupon various subjects, probably had only a limited circulation. What-\\never the cause may have been, the result is beyond question surgeons\\ncontinued to reduce dislocations of the hip by traction with the pulleys,\\nthe limb being only slightly flexed, and by pressure applied at the\\nupper part of the thigh to move the head laterally into the cavity. Sir\\nAstley Cooper habitually used only traction, followed by rotation of\\nthe thigh inward.\\nProf. Nathan Smith, of New Haven, taught and practised a method\\nof reduction by manipulation which was published in 1831 after his\\ndeath, in his Medical and Surgical Memoirs, edited by his son, Nathan\\nP. Smith, and this, Prof. Bigelow says, covers the ground of priority\\n-of invention. (See Chapter LI., Treatment.)\\nThe next published recognition of the possibility of reducing a dis-\\nlocation of the hip by manipulation alone was by Despres, who, in 1835,\\ncommunicated to the Soci6te Anatomique of Paris 1 a new method of\\nreducing dislocations of the femur by flexion and rotation outward.\\nThe only comment it excited at the time, according to the records of\\nthe society, was the mention a few months later by Pigne of the fact\\nthat the same method was described by Beach in a Treatise on Iledi-\\n-cine, published in New York in 1833, and was there said, on the\\nauthority of Sweet, the natural bone-setter, to have been practised\\nby the savages of North America. 2 The Despres incident is mainly\\n1 Despres: Bull, de la Soc. Anatomique, September, 1835, p. 4.\\n2 Beach, like Sweet, appears to have been an irregular practitioner, and it is likely that\\nhis assertions, even when known, were not deemed worthv of serious consideration.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0517.jp2"}, "510": {"fulltext": "444 BISL CA TIOXS.\\nnoteworthy as showing how completely the previous suggestions had\\nbeen forgotten or overlooked, even by Pouteau s own countrymen. It\\nis now used by the French as a justification for speaking of the method\\nby manipulation (at the hip) as the Jlethode de Despres.\\nIn like manner, other surgeons sought to modify the practice as\\nregarded the shoulder-joint, by advising that the traction should be\\nmade in different directions and combined with rotation of the limb.\\nOf these the most noteworthy are Mothe and Lacour, since it is with\\ntheir practice that the manipulative methods are generally thought to\\nhave begun.\\nThe earlier manipulative methods were either empirical or based\\nupon more or less incorrect notions of the nature of the obstacles to be\\novercome and of the mechanism by which the result was to be obtained,\\nand it is only since the pathology of the different dislocations has been\\nbetter understood, with reference especially to the position of the rent\\nin the capsule and the influence of the portions which remain untorn,\\nthat the different procedures embraced under this method have been\\nintelligently devised and executed. They differ so widely in their\\ndetails that only the most general description can be given here they\\nconsist in giving to the limb successive positions, by which the head of\\nthe bone is first brought opposite the opening in the capsule and then\\ninto its cavity, and by which the opening in the capsule is made to\\ngape widely, or is actually enlarged if necessary. For the accomplish-\\nment of these ends the limb is used as a means of acting upon the cap-\\nsule so far as it remains attached to the bone, and the head of the bone\\nis made to take its successive positions by rotation of its shaft, or by\\nusing it as a lever which finds its fixed point either upon some adjoin-\\ning prominence of bone or in the capsule, or by moving the entire limb\\nin the direction of its long axis. Combined with these manipulations\\nit is commonly necessary to employ a certain amount of traction to over-\\ncome gravity or such resistance as is offered by the muscles.\\nIt rests essentially upon an anatomical and pathological basis con-\\nsisting of two parts, the position of the rent in the capsule and the\\nresistance of the untorn portion, and depends for its knowledge of these\\ntwo factors, in any given case, mainly upon the position occupied by\\nthe limb and the limitations of the movements. Resistance of the\\nmuscles, when present, is overcome by anaesthesia or by traction.\\nSuch traction as is required is made by the hands of the surgeon or\\nof an assistant, or by the weight of the dependent limb, or by the pro-\\nlonged action of an elastic band or of a weight suspended over a pulley.\\nContinuous traction by India-rubber bands was introduced by Legros\\nand Onimus while internes in the Paris hospitals, 1863 to 1866, and\\nadvocated by them in a paper published in 1868. 1 They recognized\\nthat their object, the fatigue of the opposing muscles, could be equally\\nwell accomplished by weight and pulley or a steel spring, but they gave\\nthe preference to India-rubber because of the ease with which it could be\\nused. Their reported cases are dislocations of the shoulder and elbow.\\nThe method of application in dislocations forward of the shoulder,\\n1 Legros and Onimus: Des Tractions continues, et de leur Application en Chirurgie..\\nArch. Generales de Med., January, 1868.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0518.jp2"}, "511": {"fulltext": "TREATMENT. 445\\nfor example, is as follows A loop is made fast to the lower part of the\\narm by turns of a roller-bandage or by strips of adhesive plaster as in\\nBuck s extension then the patient is seated in a chair, counter-exten-\\nsion provided by a band passing around the chest under the axilla and\\nover the opposite shoulder and made fast to some neighboring fixed\\npoint, the elbow gently raised to or nearly to the position of horizontal\\nabduction, and traction made in the direction of its long axis by a\\nrubber cord passed through the loop attached to the arm and around a\\nfixed point established in an appropriate position. The traction should\\nbe about twenty or twenty-five pounds, and needs to be continued for\\nfrom fifteen to thirty minutes under its influence the muscles become\\nrelaxed and the patient experiences the sensation of great fatigue, the\\nhead of the bone gradually approaches the glenoid cavity, and either\\nenters it spontaneously or is replaced by the pressure of the surgeon s\\nfingers, or by a sudden pull upon the arm.\\nContinuous traction by the weight of the limb is used at the hip and\\nshoulder. The limb is placed in such a position that its weight tends\\nto move it in the desired direction thus the thigh is allowed to hang\\ndown (the knee flexed and the leg horizontal) at the end of a table\\nupon which the body of the patient lies prone. For the shoulder, the\\npatient is placed upon his side on a cot through a hole in which the\\ninjured arm hangs directly down. To the weight of the limb in\\neither case that of a sand bag may advantageously be added. (See\\nChapters XLII. and LI.)\\nAthrotomy. Occasionally a fresh dislocation is irreducible because\\nof an exceptional position of the bones or of interposition of the soft\\nparts. I have seen this once each at the shoulder, elbow, and temporo-\\nmaxillary joints, and a number of times at the metacarpophalangeal\\njoints and in dislocations with fracture. At the shoulder the head of\\nthe humerus had passed below and then so far to the inner side of the\\nsubscapularis that its tendon was closely wrapped about the outer side\\nof the neck of the bone and had to be divided at the elbow, apparently\\nin consequence of repeated attempts to reduce, the denuded end of the\\nhumerus had been forced through the fascia in the flexure of the joint,\\nand the tendon of the biceps was lodged behind the external condyle\\nat the jaw, the meniscus had been torn away from the condyle and was\\nlodged behind it.\\nIf such an operation is done within a day or two after the accident\\nthe risk is no more than that of a similar opening of the unlacerated\\njoint; but while inflammatory reaction is active and cedema is marked\\nthe chance of suppuration is greater, and it is then well, I think, to\\nawait their subsidence before operating.\\nOld Unreduced Dislocations.\\nThe changes, above described, which take place about a dislocated\\nbone gradually increase the difficulty of reduction by meaus that are\\nsufficient while the dislocation is fresh, and ultimately make it impos-\\nsible. The conditions vary so greatly with individual cases and with\\nthe different joints, and their extent and detail are so unrecognizable", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0519.jp2"}, "512": {"fulltext": "446 DISLOCATIONS.\\nclinically and so largely a matter of inference that the difficulty cannot\\nbe measured simply by the length of time that has elapsed, and too\\noften not even by anything short of an actual trial.\\nThe common practice, until within quite recent times, was simply to\\nemploy the usual forcible means more forcibly, to rupture adhesions by\\nforcing the limb in various directions, and then to drag it into place by\\npulleys or specially devised apparatus. *AYhile this succeeded in many\\ncases, and even occasionally in some at the shoulder and hip which had\\nexisted for months, yet the record is full of accidents and disasters,\\nand many a grave warning has been uttered against the dangers of the\\nattempt even in apparently suitable cases and against the temptation to\\nsubordinate the patient s welfare to a desire to obtain an unusual success.\\nThe dangers of forcible reduction in cases of long standing, and the\\nsuperiority of operative methods to meet the special indications that\\nmay exist in them, are now so well understood that the warning is not\\nmuch needed in such cases it is in the more recent cases, those of a\\nfew weeks, that it is now specially necessary to be on guard against\\nbeing unwittingly led to strive too long, to make a stronger and still a\\nstronger pull after less force has failed. The danger is specially great\\nin the old, whose diseased arteries may so easily be bruised or torn,\\nand whose thinned bones may so easily be broken. The following\\ntwo cases which recently occurred in the service of a surgeon in a\\nprominent New York hospital, within a year of each other (1896-97),\\nillustrate the temptation and the risk.\\nA woman sixty-seven years old subcoracoid dislocation two weeks\\nold. Ether traction by pulleys, estimated at 300 pounds reduction\\non second attempt. The following day the radial pulse could not be\\nfelt, and gangrene seemed imminent seven weeks later amputation of\\nthe arm death. The autopsy showed a thrombus in the brachial\\nartery.\\nMan sixty-eight years old subcoracoid dislocation six weeks old.\\nEther manipulation to rupture adhesions Kocher\\\\s method tried\\ntwice, then heel in the axilla. Then arm carried forcibly across the\\nbody, the head slipping to the outer side of the glenoid fossa finally\\ntraction in abduction succeeded. Died five hours later. Autopsy\\nshowed rupture of the axillary vein and of the short head of the\\nbiceps capsule entirely torn from the humerus third, fourth, and\\nfifth ribs fractured in the axillary line.\\nThe alternative measures reduction by operation, excision, and\\nosteotomy have been made so much safer than formerly by improved\\nsurgical technique that they are now resorted to with increasing fre-\\nquency, and the resulting experience has been such that rules of treat-\\nment can be formulated for some of the joints. In backward dislocation\\nof the elbow formal exposure by two lateral incisions and removal of\\nthe cicatricial tissue permit complete reduction and usually a notable\\nimprovement of function. At the shoulder the range of motion after\\nreduction by operation has generally been small, and the operative\\ndifficulties are often great excision of the head gives greater mobility\\nand meets the frequent special indication of relief of pain due to press-\\nure, but the result is marred by the diminution of active control. At", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0520.jp2"}, "513": {"fulltext": "TREATMENT. 447\\nthe hip reduction by operation has proved dangerous and has failed in\\nmore than half the trials even when it has succeeded the functional\\ngain has not often been notable. (See Chapter LIII.)\\nThe facts and general principles to be considered in determining upon\\nresort to operative interference and in making a choice of methods are\\nas follows\\n1. At the present time wound infection is of more frequent occur-\\nrence after operative reduction of old dislocations of the large joints\\nthan in other primarily clean operations, and an almost inevitable\\nresult of such infection is anchylosis of the joint and even in cases\\nwhich escape infection the restoration of function is usually quite\\nincomplete. Consequently the usefulness of the limb in the existing\\nconditions and the probable gain by interference should be carefully\\nconsidered, and in doing this it is to be remembered that a limitation\\nof motion already such as greatly to restrict the use of a limb is likely\\nto increase merely by that lack of use.\\n2. A faulty fixed position may be so improved by an operation that\\nthe usefulness will be increased even if anchylosis follows.\\n3. On the other hand, and this is specially true of the hip, the im-\\nprovement to be got by a change of position may be far too slight to*\\njustify the risks of an operation so extensive as would be required for\\nreduction, and an almost equal improvement might be had by an oste-\\notomy.\\n4. Pain and trophic changes in the limb due to pressure upon nerves\\nare good reasons for interference the relief would probably be more\\nsurely and easily obtained by an excision of the head of the bone.\\n5. Excision, when undertaken only to improve function, is suitable\\nat the shoulder and elbow, but must be sparingly employed at the hip\\nwhere solidity of support is more important than mobility.\\nAfter-treatment.\\nAfter a dislocation has been reduced, there is needed, in most cases,\\nonly a simple retention bandage to confine the limb in an easy position,\\nbut in some cases dislocation of either end of the clavicle, of the\\nhead of the radius, and sometimes of the shoulder backward under\\nthe spine of the scapula (Busch and Kronlein) the tendency to recur-\\nrence is so great that special dressings are required. The joint should\\nbe kept quiet, certainly any movement that causes pain should be\\navoided, and if the inflammatory reaction threatens to be severe it\\nmust be opposed by the application of cold, or uniform gentle press-\\nure if it can be borne. After a week or two the use of the limb may\\nbe gradually resumed. In making passive motion or this use of the\\nlimb, those positions must be avoided in which the head of the bone\\nwould press upon the torn part of the capsule, or in which the sides\\nof the rent would be again separated from each other.\\nIf, as sometimes happens, the joint remains stiff, weak, and sensitive,\\nbut is cold rather than warm, and aches and perhaps becomes puffy\\nafter use, it needs massage and rubbing, and to be actively moved\\n1 For manv cases of various forms of operation see Engel, in Arch, fiir klin. Chir., 1897,\\nvol. lv. p. 603.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0521.jp2"}, "514": {"fulltext": "448 DISLOCA TIONS.\\neither by the patient or by the physician. Its sensitiveness and immo-\\nbility under such circumstances are due to the prolonged disuse, to\\nretraction and loss of pliability in the peri-articular tissues, and possibly\\nto the presence of adhesions within the cavity itself.\\nHabitual Dislocation.\\nA marked tendency to recurrence may be combated by prolonged\\nimmobilization of the joint if the injury is comparatively recent, or\\nby special treatment designed to thicken and shorten the capsular and\\nperi-articular tissues. Genzmer 1 successfully employed in two cases of\\nrecurrent dislocation of the shoulder repeated injections into the joint\\nof the pure tincture of iodine. The needle was introduced a finger-\\nbreadth below the coracoid process, and seven to ten minims were in-\\njected. The arm was then immobilized, and the injections repeated\\nfrom five to seven times at intervals of three or four days. He\\nrecommended the same treatment for habitual dislocation of the\\nlower jaw.\\nDubreuil 2 reports a cure at the shoulder by six injections, during a\\nfortnight, of two drops each of a 10 per cent, solution of chloride of\\nzinc into the peri-articular tissues. At the sternal end of the clavicle\\nI have twice obtained a good result by injecting a few drops of alcohol\\ninto the peri-articular tissues and immobilizing for a fortnight.\\nThe operative method which seems safest and most efficient at the\\nshoulder is one introduced by BAcard, 3 the formation of a permanent\\nfold in the anterior portion of the capsule by three vertical silk sutures.\\nA similar method has been used in habitual outward dislocation of the\\npatella.\\n1 Genzmer Centralblatt fur Chirurgie, 1883, p. 563.\\n2 Dubreuil: La Semaine Med., February 27, 1892.\\na Bicard Acad, de Med., October 31, 1892.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0522.jp2"}, "515": {"fulltext": "CHAPTEK XXXIV.\\nACCIDENTS THAT MAY BE CAUSED BY ATTEMPTS TO EEDUCE\\nA DISLOCATION.\\nThe complications or accidents that may be caused by the attempt\\nto reduce a dislocation may appear during the attempt, as the imme-\\ndiate consequence of the manoeuvres employed, or subsequently as a\\nmore or less remote consequence of the changed conditions, the local\\ninjuries, or the inflammation produced by those manoeuvres and they\\nmay be localized at or near the dislocated joint, or may be the result of\\na local distant change or of a more diffused impression upon the organ-\\nism. They may, therefore, be grouped as 1st, primary local accidents\\n2d, consecutive local accidents 3d, cases of hemiplegia, syncope, and\\nsudden death. The first group comprises injuries of the skin, cellular\\ntissues, muscles, vessels, nerves, and bones the second group includes\\nsuppuration in or about the joint, and oedema, gangrene, and paralysis\\nconsequent to injury to vessels or nerves. The third group includes\\nthose cases of shock or exhaustion, sometimes proving fatal, which\\nhave become exceedingly rare since the introduction of ansestbetics,\\nand those others, that have come in their place, of death due to the\\nanaesthetic itself.\\nIt is noticeable, on comparison of the cases that have occurred at\\ndifferent periods, that while some varieties of the lesions are common\\nto all times, with their varying methods of treatment, others are in a\\nmanner dependent upon the means by which the reduction has been\\nattempted. Thus, violent traction is the sole cause of some manoeu-\\nvres, such as abduction and rotation of the arm, the principal cause of\\nothers violent pressure at or near the head of the bone, prolongation\\nof the effort, and anaesthetics, each of its own peculiar varieties. Not-\\nwithstanding these differences, certain points may be recognized as\\ncommon to the greater number, such as the age of the patient and the\\nlength of time during which the dislocation has remained unreduced.\\nInjuries of the vessels have been most frequent in the old and in dis-\\nlocations of long standing, and all the other accidents have, in recent\\ntimes at least, been rarely seen except in connection with dislocations\\nthat have long remained unreduced or that have been complicated by\\nmuch inflammatory reaction. The reasons for the greater liability to\\nrupture of the arteries under these conditions are not obscure; the loss\\nof elasticity because of atheromatous change in the vessels in the old,\\nand the adhesion of the vessels to adjoining parts as a sequence of\\ninflammation are a sufficient explanation, and the mechanical difficul-\\nties created by the contraction and readjustment of the torn tissues in\\nold dislocations explain the others by the force that is required to over-\\ncome them.\\n29 449", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0523.jp2"}, "516": {"fulltext": "450 DISL OCA TIONS.\\nIntegument. The skin may be bruised or lacerated at a distance from\\nthe joint by the pressure of the cords through which traction is made,\\nor near the joint by the pressure of the hands or instruments acting\\nupon the dislocated end of the bone, or it may be torn across if the\\ntraction is exerted upon it rather than upon the bone. These lesions\\nare seldom serious, and the former may usually be avoided by protect-\\ning the surface with thick layers of cotton or flannel. Transverse\\nrupture of the skin between the points of extension and counter-exten-\\nsion is due to a faulty application of the force, by which it is exerted\\nupon the skin alone and not upon the underlying bone. The skin is\\nelastic and tough, and when unaltered by disease will support a very\\nconsiderable strain, one far in excess of that commonly needed to over-\\ncome the contraction of a muscle, but the traction may be so applied\\nthat it will act only upon the skin. Thus, if a broad band is strapped\\nsnugly about the middle of the arm and traction is made by a cord\\nattached to it, it will draw the skin downward toward the elbow and\\nif at the same time the skin of the axilla and chest-wall is prevented\\nby counter-extension from sharing in the movement, the intermediate\\nportion is put upon the stretch and may tear.\\nTo guard against the occurrence of this accident the limb should be\\nfirmly grasped, if traction by the hands is used, at the enlarged distal\\nend of the bone, so that the skin should not be drawn downward by\\nthe slipping of the hands, and the additional precaution may be taken\\nto press the skin of the forearm (in the case of a shoulder dislocation)\\nupward before the limb is grasped, and similar precautions suitable to\\nthe region should be taken at the point of counter-extension. If trac-\\ntion is made by a cord or band, it should be attached to the limb just\\nabove a bony prominence or enlargement which will prevent its slip-\\nping it should not be made fast simply by enclosing its loop in\\ncircular turns of a bandage which maintain their hold upon the skin\\nby friction.\\nSloughing of the skin, due to its compression against an underlying\\nbone by direct pressure exerted to force the latter back into place, has\\nbeen occasionally observed, in a dislocation of the astragalus, 1 and over\\nthe olecranon in an attempt made by a bonesetter to reduce a backward\\ndislocation of the elbow.\\nEmphysema of the Cellular Tissue. This has been noted in one\\ncase. Flaubert 2 reduced a dislocation of the shoulder of five weeks\\nstanding in a woman seventy years old the first attempt was unsuc-\\ncessful in the second traction was made by eight students, and the\\npatient, who at first uttered vehement cries, seemed afterward to be\\nupon the point of suffocating, and her face became purple and injected.\\nAn emphysema immediately appeared above the clavicle and spread\\nover the shoulder to the middle of the back. She died on the\\neighteenth day, apparently in consequence of the tearing away of the\\nlower four trunks of the brachial plexus at their attachment to the\\nspinal cord.\\n1 Dauve Rec. de Mem. de Med. et Chir. Milit., 1867, vol. xix. p. 143.\\n2 Flaubert: Eepertoire d Auat. et de Phys., 1827, quoted by Malgaigne.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0524.jp2"}, "517": {"fulltext": "ACCIDENTS BY ATTEMPTS TO REDUCE A DISLOCATION. 451\\nRupture of the Muscles. Under this head only those lacerations\\nof the muscles will be mentioned which are occasioned, especially in old\\ndislocations, by violent traction or by forcible, exaggerated, and long-\\ncontinued manipulation of the limb. The cases in which the injury\\nhas been confirmed by autopsy are few, only those in which death has\\npromptly followed in consequence of associated lesions or of the inflam-\\nmation to which the violence has given rise. Yet, in another of Flau-\\nbert s cases, 1 there seems to be no doubt that not only the muscles but\\nalso the ligaments and other soft parts were extensively torn. The\\ncase was one of dislocation of the elbow backward, twenty-seven days\\nold, in which traction was made upon the forearm by seven assistants\\nsuddenly the parts seemed to yield and change their positions with a\\nsound of tearing, and at the same moment a zone of narrowing or\\ndepression appeared at the level of the joint with a bony prominence\\nabove and below. It seemed to all present that the muscles and soft\\nparts covering the joint had been ruptured, leaving a gap two inches\\nlong. An enormous fluctuating swelling promptly appeared, the radial\\npulse returned the next day, and the patient recovered.\\nIn the cases confirmed by autopsy the dislocation has always been\\nof the shoulder, and the muscles most frequently torn have been the\\npectoralis major and the subscapularis.\\nAvulsion of a portion of a limb is fortunately a very rare accident,\\nExcept for one or two cases of avulsion of the thumb, known only by\\ntradition, the only instance of complete avulsion is that in which\\nAlphonse Guerin tore away the forearm at the elbow in an attempt to\\nreduce a subcoracoid dislocation of the shoulder of six weeks standing. 2\\nThe rupture took place mainly through the joint, a small portion of\\neach condyle remaining attached to the muscles of the forearm, and a\\nportion of the olecranon to the triceps. The muscles were softened\\nand brown the nerves were injected, with nodes at intervals the veins\\nwere dilated. The ends of the long bones were profoundly disorgan-\\nized, with thinning of the compact shell and rarefaction of the spongy\\npart they broke under slight pressure and could be easily perforated\\nwith the scalpel. Microscopical examination showed degeneration of\\nthe nerves, muscles, and bones.\\nThe patient died on the thirteenth day, and the autopsy showed no\\nchange in the tissues of the other limbs the muscles of the shoulder\\nwere normal, except the deltoid, the fibres of which were pale and\\ndegenerated. The nerves were matted together in the axilla and firmly\\npressed against the head of the humerus above the point of compres-\\nsion they were normal, contrasting strongly with the parts below.\\nIt is evident that the accident was favored by great trophic changes\\nin the limb, probably due to pressure upon the nerves in the axilla,\\nInjuries of the Main Bloodvessels. Although the earliest recorded\\ncases of accidents of this class occurred at about the beginning of the\\neighteenth century, the subject did not receive the attention of sys-\\n1 Malgaigne Loc. cit., p. 149.\\n2 Guerin Bull, de la Soc. de Chir., 1864, pp. 121 and 131.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0525.jp2"}, "518": {"fulltext": "452 DISLOCATIONS.\\ntematic writers on surgery until after the publication, in 1827, of an\\narticle by Flaubert. 1 Malgaigne, in 1855, discussed the subject at\\nlength in his work on dislocations, mentioning sixteen cases of all\\nkinds, certain and uncertain. Callender, 2 taking as a text his own\\nfatal case, again collected and collated the known cases and similar\\nuse was made of the material and other cases added to the list by Le\\nFort, 3 Willard, 4 and Marchand. 5 In 1882 Korte 6 reported three per-\\nsonal cases, and wrote a very full and valuable paper on the subject,\\ncontaining forty-four supposed (actually thirty eight see first edition,\\np. 79) cases of dislocation of the shoulder in which the vessels had been\\nseriously injured during the act of dislocation or of reduction and in\\n1884 Cras 7 reported a personal case of injury of the axillary artery,\\nand added a few others to Korte s list. Strictly speaking, several of\\nthese cases should not be here considered, since in them the vessel was\\ninjured at the moment of dislocation and not during reduction, and in\\nmany others it remains uncertain whether the same objection might not\\nbe made to them. They are retained because they serve equally well\\nwith the others to further the study of most features of the subject.\\nI have met with only two recorded cases in which a large bloodvessel\\nhas been injured in the reduction of any dislocation except of the\\nshoulder. These were both of the elbow, the cases of Flaubert and\\nMichaux, quoted by Marchand and Malgaigne. The former has been\\nalready quoted under rupture of the muscles in the latter the patient\\nwas ten years old, and the dislocation was of the elbow backward and\\noutward, the swelling was considerable, the radial pulse was present.\\nReduction was attempted on the day after the accident, and on the\\nnext following day, but without success. The last attempt was imme-\\ndiately followed by swelling of the elbow and by arrest of pulsation in\\nthe radial and ulnar arteries gangrene set in, and six days after the\\nattempt the limb was amputated. The tendons of the biceps and\\nbrachialis anticus were found to have been forced by the manipulation\\naround the external condyle to the posterior aspect of the humerus,\\naccompanied by the ruptured brachial artery and median nerve.\\nIn 1885 I 8 found forty-seven trustworthy accounts of injury to the\\nlarger vessels of the axilla in dislocation or reduction of dislocation of\\nthe shoulder. Since then Caldwell 9 has reported a case thought to be\\nrupture of the anterior circumflex artery, and I have learned of one of\\nrupture of the axillary vein (Weir). The latter has been quoted above\\n(p. 446). Caldwell s patient was fifty-eight years old, and the disloca-\\ntion had been promptly reduced. Six weeks later there w r as a large\\nfluctuating swelling in the outer aspect of the shoulder, over the area\\ncovered by the deltoid pulsation at wrist and in axillary artery no\\n1 Flaubert Meni. sur plusieurs cas de luxations daus lesquels les efforts pour la reduc-\\ntion ont ete suivis d accidents graves, Kepertoire d anat. et de phys., 1827.\\n2 Callender: St. Bartholomew s Hospital Eeports, 1866, vol. ii. p. 96.\\n3 Le Fort: Diet, encvclopedique des sci. med., article Axillaires.\\n4 Willard Philadelphia Medical Times, 1873, vol. iii. p. 721.\\n5 Marchand Des accidents qui peuvent compliquer la reduction des luxations traumat-\\niques, These de concours, Paris, 1875.\\n6 Korte Arch, fur klinische Chirurgie, vol. xxvii. p. 631.\\n7 Cras Bull, de la Societe de Chirurgie, 1884, p. 739.\\n8 Stimson New York Medical Journal, June 13, 1884, and first edition of this work.\\n9 Caldwell Cincinnati Lancet-Clinic, May 3, 1890.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0526.jp2"}, "519": {"fulltext": "ACCIDENTS BY ATTEMPTS TO REDUCE A DISLOCATION. 453\\nswelling in axilla. Under the impression that the swelling was due to\\nan abscess an incision was made and about a pint of clotted blood evacu-\\nated this was followed by arterial hemorrhage, arrested by pressure of\\nthe thumbs in the wound. The wound was enlarged, but the source of\\nthe bleeding was not found. The wound was packed with gauze, and\\nthe patient recovered. Of these, the axillary vein alone was ruptured\\nin four (Froriep, Price, Weir, Hailey), although I think the last one\\ndoubtful, and the artery and vein together in two (Platner, Baum). 1\\nIn most of the others the axillary artery or one of its branches was\\ninjured, but in some the source of the hemorrhage remains uncertain.\\nIn thirty-three cases death or amputation of the arm furnished the\\nopportunity to examine the region and determine the character of the\\nlesion this, in some cases, was a complete or partial rupture of all the\\ncoats of the artery or of the inner and middle coats alone, with subse-\\nquent formation of a circumscribed aneurism. In other cases the\\nvitality of the wall appears to have been diminished or destroyed by\\ndirect pressure, and this to have been followed, after the lapse of a\\nfew days, by rupture, or, still later, by the formation of an aneurism.\\nIn Gibson s second case an aneurism appears to have formed in conse-\\nquence of the earlier attempts to reduce, and then itself to have been\\nruptured when Gibson effected reduction. Bupture always appears to\\nhave taken place quite high up, and usually at the point pressed upon\\nby the head of the humerus. Callender found it necessary to divide\\nthe pectoralis minor to reach it. In the fatal cases of injury of the\\nvein alone the vessel was torn completely, or almost completely, across.\\nIn five cases only a small (one-sixth of an inch) oval opening was\\nfound on the anterior wall of the artery, and was thought to have been\\nproduced by the tearing off of a branch, the subscapular or circumflex.\\nIn other cases the subscapular or the circumflex artery was torn\\nacross at or near its origin. The cases of this kind form a consider-\\nable proportion of the whole number, and are of great importance\\nbecause they explain the persistence of the radial pulse noted in several\\nof the histories. In Parker s the swelling was at the axillary border\\nof the scapula behind, near the situation of the dorsal scapular artery\\nor the subscapular at the junction of the two in Caldwell s under the\\ndeltoid.\\nOf thirty-one cases in which the age of the patients is given, in\\ntwenty they were more than forty years old. The youngest was twenty,\\nthe oldest eighty-six. In very few of the cases it is noted that the\\narteries were atheromatous, although the advanced age of many of the\\npatients makes it probable that the elasticity of the vessels was dimin-\\nished.\\nIn more than half the cases the dislocation was recent less than\\nthree weeks. In not more than one-third of them is it reasonably\\ncertain that the lesion was caused during reduction in three cases it\\nwas certainly caused by the dislocation in the remainder the cause is\\nobscure. To these latter belong those cases in which the reduction\\n1 Possibly to these may be added Volkinann s case of wound of the axillary vein,\\nthought to have been caused by a splinter of bone. The wound was discovered during\\nan operation to excise the head.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0527.jp2"}, "520": {"fulltext": "451 DISLOCA TIOXS.\\nwas promptly effected, and without the use of much force or of exag-\\ngerated positions of the arm.\\nIn many of the others the attempt to make reduction was greatly\\nprolonged or several times repeated, and the force used was very great\\nor improperly applied. This last criticism is probably applicable to\\nthe earliest four cases (Verduc, Petit, Plainer, and Bell), about which\\nnothing is known except that death was caused by hemorrhage. In\\none of them (Bell) the use of the ambi is mentioned, and it is probable\\nthat it or the method of the door or ladder was employed in all.\\nIn some the injury was evidently caused by excessive traction in\\nothers by faulty manoeuvres, such as extreme abduction or elevation of\\nthe arm, rotation, and circumduction in others again apparently by\\ndirect compression of the vessel against the underlying bone, as by the\\nbooted heel in the axilla, or possibly by the thumbs.\\nLeaving aside the earlier cases in which faulty methods no longer in\\nuse were employed, and those old dislocations in which the relations\\nand connections had been permanently changed by fibrous or bony\\ntissue of new formation, it becomes evident that in dislocation of the\\nshoulder the accident is most to be apprehended when the elbow is\\nraised in abduction to the height of the shoulder, or is carried, as in Cal-\\nender s and AVeir s cases, across the chest and face in a wide movement\\nof circumduction and for this reason, that in these movements the dis-\\nlocated head of the bone is turned downward into the axilla, and the\\nvessels which lie upon its inner side are pressed down before it and\\nforcibly put upon the stretch, while those branches which run almost\\ndirectly outward, the subscapular and circumflex, and are fixed to the\\ntissues amid which they branch, are directly and forcibly elongated.\\nAlthough in dislocation inward the limb is shortened by being ab-\\nducted, yet the artery is not thereby relaxed, but, on the contrary is\\nstill further stretched around the head of the bone. Jossel, 1 in a recent\\ncase in which death was caused by associated injuries, found the nerves\\nof the brachial plexus, especially the circumflex nerve and the sub-\\nscapular artery, greatly stretched by the head of the humerus and,\\naccording to Korte, 2 he found in another case of recent dislocation the\\nsubscapular artery torn.\\nIn some of the cases in which it is certain or probable that the injury\\nto the vessels was inflicted at the moment of dislocation, it is noted that\\nthe latter was produced while the arm was widely abducted that is,\\nunder circumstances in which the head of the humerus would be driven\\ndownward and inward.\\nIf the dislocation is an old one, and especially if there has been\\nmuch inflammatory reaction, and the vessels have become firmly adher-\\nent to the bone or embedded in unyielding cicatricial tissue, the lia-\\nbility to rupture is increased, because of the loss of elasticity occasioned\\nby the latter condition, and because of the limitation of the strain to\\na shorter segment of the vessel in the former. If, in addition, the\\ndistensibility of the vessel has been further reduced by atheroma, the\\ndanger is still greater and this last predisposing cause may properly\\n1 Jossel Deutsche Zeitschrift, I860, vol. xiii. p. 177.\\n2 Korte Loc. cit.. p. 640.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0528.jp2"}, "521": {"fulltext": "ACCIDENTS BY ATTEMPTS TO REDUCE A DISLOCATION. 455\\nbe deemed sufficient to lead to the rupture, even when the traction is\\nslight and the manoeuvres are confined within a narrow range.\\nThe symptoms at the beginning present two widely different forms\\nin one, the less common, a tumor presenting many of the signs of an\\nencysted aneurism appears in the axilla a few days or weeks after\\nthe reduction, and increases in size rather rapidly if not successfully\\ntreated, it soon involves the skin and ruptures externally.\\nIn the other form, the more common, a diffused fluctuating swelling,\\nwithout bruit or pulsation, appears immediately, or within a few hours,\\nin the axilla, raising the pectoral and deltoid muscles, or is perhaps\\nmost prominent posteriorly, and in most cases promptly reaches a large\\nsize, even that of the adult head (Lister) the radial pulse sometimes\\npersists. The only exception to rapid growth among the recorded fatal\\ncases is Korte s third case, 1 in which the extravasated blood disap-\\npeared slowly, leaving a firm, non-pulsating lump, as large as a wal-\\nnut, in the course of the axillary artery, which a surgeon supposed to\\nbe a lymphatic gland, and undertook to extirpate nearly five months\\nafter the accident. It proved to be an aneurism containing much strati-\\nfied clot the axillary artery was tied above and below, and the patient\\ndied.\\nIn several cases the patients died promptly after the accident, some-\\ntimes after profound syncope, sometimes after a short period of appar-\\nent well-being, with symptoms of shock or acute anaemia. In two,\\nwhich finally ended in recovery, the patients were at first greatly pros-\\ntrated, and death by syncope threatened. In another gangrenous\\nemphysema developed in the arm, and the patient died forty hours\\nafter the reduction. In this case the inner and middle coats of the\\nartery were torn across just beyond the point of origin of the dorsal\\nscapular branch. The radial pulse was at first perceptible, but had\\nceased the next morning.\\nIn most of the others the swelling increased, and, in a longer or\\nshorter time, ruptured spontaneously, or was threatening to rupture\\nwhen operative interference (puncture, incision, or ligature of the sub-\\nclavian) was resorted to. The longest period was in Bellamy s case,\\nsix months after reduction, and even in this case the first hemorrhage\\noccurred five weeks after reduction.\\nIn eight cases that recovered without operation, the swelling subsided,\\nand the ecchymosis was slowly absorbed. Probably in some of them\\nthe vessel injured was one of the branches of the axillary artery, but\\nin at least one (Sands) the injury was certainly of the artery itself.\\nIn the three cases in which rupture of the vein alone was demon-\\nstrated post mortem (Froriep, Weir, Price), the patients died promptly,\\nin an hour and a half, five hours, and on the following day respectively.\\nThe histories show that, although the diagnosis, so far as the general\\nnature of the accident, rupture of a bloodvessel, is concerned, does not\\nlong remain obscure, the identity of the injured vessel cannot always\\nbe determined. If the tumor pulsates, the diagnosis of rupture of an\\nartery may be made and if, in addition, the radial pulse is present, it\\nis extremely probable that the injured vessel is not the main artery\\n1 Korte Loc. cit., p. 636.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0529.jp2"}, "522": {"fulltext": "456 DISLOCATIONS.\\nbut that one of its branches, probably the subscapular or circumflex,\\nhas been ruptured or torn off at its origin. Beyond this it does not\\nseem at present possible to go with much certainty, although the great\\npreponderance of arterial lesions in the known cases 26 out of 29\\nmakes it highly probable in any given case that an artery and not the\\naxillary vein has been torn.\\nThe terminations were as follows 16 recoveries, 32 deaths, and in 1\\n(Green s) the result is unknown 21 received no operative treatment\\nof these 6 recovered and 15 died. 1 In 16 the subclavian was tied,\\nwith 6 recoveries, 8 deaths, and 2 unknown result. In 1 a cure was\\neffected by digital pressure on the subclavian, and in 1 by stuffing the\\ncavity with gauze (ant. circumflex). In 6 an incision was made in the\\naxilla, and the artery tied above and below the point of rupture all\\ndied. In 4 the limb was disarticulated; 1 recovery, 3 deaths. The\\ntreatment in the cases that recovered without operation was simply\\ncompression of the swelling and immobilization of the arm, with the\\napplication of ice in Malgaigne s, and compression of the subclavian\\nartery in Agnew s.\\nIn drawing inferences from these results, it must be borne in mind\\nthat in many of the cases in which operations were undertaken non-\\noperative treatment had previously been employed, and had resulted\\nin a condition that made an operation necessary. Thus, using only\\nthose cases in which the record is sufficiently detailed, of the 17 cases\\nof ligature or compression of the subclavian, in 10 the operation was\\ndone after the lapse of several weeks or even months, in 1 on the\\nthird day, in 1 on the tenth day, and in 5 the length of the interval is\\nnot known. Of the 4 disarticulations, in 1 the operation was at a\\nlate date, in 1 five days after the accident, and in 2 unknown. Of\\nthe 6 treated by incision and double ligature of the axillary artery,\\nthe operation was done promptly in 2, and after a long interval in 4.\\nConsequently, the results of non-operative treatment may be tabulated\\nas follows: Of 37 patients, 6 recovered, 15 died, and 16 (with 10\\ndeaths) subsequently underwent operation, either because death by\\nhemorrhage threatened or because of the existence of a growing aneu-\\nrism. 2 A fair inference from the reported cases is that conservative\\ntreatment may properly be tried at first, but should not be prolonged\\nif the symptoms do not promptly yield and, secondly, that, in case\\nof resort to operation, ligature of the subclavian artery or disarticula-\\ntion at the shoulder is to be preferred to incision of the sac and double\\nligature of the artery. It is not easy to understand why ligature of\\nthe artery above and below has been so uniformly fatal, and notwith-\\nstanding the record I should prefer it to disarticulation, and perhaps\\neven to ligature of the subclavian.\\nExperience with arteries wounded under other conditions has shown\\nthat they will sometimes quite readily heal, or the opening made into\\nthem will close, under pressure accurately made at the point of injury,\\n1 Possibly Korte s second case should be included among the recoveries.\\n2 Korte s second case is an exception an error in diagnosis led to an operation after\\nthe aneurism had apparently undergone spontaneous cure. In Caldwell s the swelling\\nwas thought to be an abscess.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0530.jp2"}, "523": {"fulltext": "ACCIDENTS BY ATTEMPTS TO REDUCE A DISLOCATION. 45T\\nand it would, therefore, be proper to attempt to treat this injury by\\ndirect, limited pressure. Whether or not it would be possible to\\nrecognize the wounded point and make efficient pressure directly upon\\nit cannot be said, since the attempt does not appear to have been\\nmade. In default of such limited pressure, general compression of\\nthe swelling in the axilla seems to be the only resource short of opera-\\ntion. The common treatment of ruptured artery, incision and double\\nligature of the vessel, was immediately resorted to in only two of these\\ncases both were promptly fatal.\\nIn the reduction of recent dislocations, these accidents show that\\nabduction of the arm especially should be avoided, as also circumduc-\\ntion, violent traction, and rough pressure in the axilla. Kocher s\\nmethod by manipulation and mine by the unsupported weight of the\\ndependent limb appear well adapted to avoid the danger. It is also to\\nbe remembered that the injury to the vessel may be caused by the\\ndislocation itself, and its symptoms may be masked by the swelling\\ncommonly present during the first few days.\\nIn old dislocations the probability of the occurrence of the accident\\nis increased by the more forcible measures usually necessary to break\\nup the adhesions that bind the bones in their new relations and r\\nwhile it may be proper in many cases to make the attempt to restore\\nthe limb to usefulness, the possibility creates another reason for\\nabstention when the patient is old, the duration of the dislocation long,,\\nand the adhesions firm. Even a dislocated arm may be very useful,.\\nand the fatality of this accident, more than 70 per cent, of deaths,,\\nmay well cause the surgeon to hesitate to incur the risk merely for the\\nsake of ameliorating a condition which does not endanger life and is\\nquite compatible with activity and usefulness.\\nInjuries to Nerves. These also have been far more frequently\\nobserved at the shoulder than elsewhere, and there is the same diffi-\\nculty in many of the recorded cases in determining whether the injury\\nwas caused by the dislocation or by the manoeuvres employed to\\neffect a reduction.\\nThe injury may consist in direct compression of the nerve against\\nthe bone, as in attempted reduction by the method of the door or\\nladder or by the heel in the axilla, or in forcible elongation or com-\\nplete rupture of the nerve by traction upon the limb, or such change\\nin its position that the nerve is stretched around the head of the bone r\\nor in avulsion of the nerve from the spinal cord. As the autopsies\\nare few in number our knowledge of the lesions is mainly clinicaL\\nIn a case quoted in the preceding section, one of rupture of the brachial\\nartery near the elbow, the median nerve was also ruptured and this\\ndouble injury has been several times encountered in compound dislo-\\ncation of the elbow.\\nIn a case reported by Flaubert, 1 and mentioned above in the section\\non Emphysema, a dislocation of the left shoulder five weeks old in a\\nvery stout woman aged seventy years, reduction was accomplished\\nwith difficulty after prolonged traction upon the arm by eight assist-\\n1 Marchand Loc. cit., pp. 25, 67.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0531.jp2"}, "524": {"fulltext": "458 DISLOCATIONS.\\nants. Beside the emphysema extending over the neck and back, there\\nwere syncope lasting an hour, cloudiness of vision, paralysis of the\\nright arm, and left hemiplegia with loss of sensibility in the left arm\\nbut with pain referred to it. Thirty-six hours later there was sharp\\npain in the back of the head and neck and in the ears pain also in\\nthe left thigh, in which sensation was better than in the right the\\nleft arm was insensitive, without pain, and motionless the right arm\\nnumb and somewhat weakened pulse rapid, skin warm. The next\\nday the pupils were dilated and did not respond to light. On the sev-\\nenteenth day the respiration was embarrassed, the skin hot, pulse\\nrapid, prostration great and on the nineteenth day death. The\\nautopsy showed the lower four pairs of the brachial plexus on the left\\nside to have been torn away from the spinal cord the torn ends\\nplainly showed the delicate filaments by which they took their origin,\\nand the ganglions on the posterior roots could be distinguished. The\\nfirst pair had suffered no injury. The spinal dura mater was of a dark\\nbrown-red color, and the cord, at the point where the nerves had been\\ntorn away, was changed into a reddish-brown pulp in which the gray\\nand white substances seemed mingled.\\nThe two following cases recorded by Flaubert bear a close resem-\\nblance clinically to this one.\\nIn a man, fifty years old, with a dislocation of the shoulder dating\\nfrom a fortnight before, traction by three assistants caused numbness\\nand pain in the hand and wrist a second attempt, with six assistants,\\ninstantly caused numbness in the corresponding leg, and the reduction\\nwas abandoned. The following night there was sharp pain in the\\nlower cervical vertebrae, subsequently extending to the dorsal region.\\nThe arm remained almost completely paralyzed.\\nA dislocation of the shoulder seven weeks old in a woman sixty-four\\nyears of age was reduced by traction made by five assistants. At the\\nmoment of reduction the patient felt a sort of rupture at the wrist,\\nfollowed by a quivering that extended to the lower third of the arm\\nand by complete hemiplegia and great diminution of sensation on the\\nsame side, especially in the arm. The lower limb regained its power,\\nbut the arm remained paralyzed and atrophied.\\nIn other cases the effects, as indicated by the symptoms, have been\\nlimited to the limb, arm or leg, or to portions of it.\\nErichsen 2 quotes from Billroth a case of dislocation of the shoulder\\nof nine months standing which had been accompanied by partial\\nparalysis of the arm and some atrophy. The reduction was followed\\nby total paralysis. Le Bret 3 reported one which occupies a position\\nintermediate between this class and the preceding a soldier dislocated\\nhis right shoulder reduction was immediately made by traction, and\\nwas followed by paralysis of motion in the entire arm, loss of sensa-\\ntion below the elbow and on the right side of the neck, and by ptosis\\nand dimness of vision on the same side. In most of the more recent\\nrecorded cases the history leaves it in doubt whether the paralysis was\\n1 Quoted by Malgaigne: Loc. cit., pp. 158, 159.\\n2 Erichsen Surgery, Aru.ed., vol. i. p. 415.\\n3 Le Bret Soc de Biologie, 1854, p. 119. Quoted by Weir Mitchell.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0532.jp2"}, "525": {"fulltext": "ACCIDENTS BY ATTEMPTS TO REDUCE A DISLOCATION, 459\\ncaused by the dislocation or by the reduction. In the older cases,\\nin which the rough method of the door, ladder, or ambi was employed\\nfor reduction, there can be but little doubt that the paralysis was com-\\nmonly caused by the reduction. At the shoulder the nerve most\\nfrequently affected is the circumflex Marchand thinks this nerve is\\ncommonly injured by the dislocation; the others by the reduction.\\nInstances of injury in other dislocations than those of the shoulder are\\nrare. Hutchinson l describes a case of ischiatic dislocation of the\\nfemur reduced by manipulation under ether, followed by complete\\nanaesthesia of the limb below the knee except on the inner side of it\\nand of the foot.\\nMaclise 2 gives a plate of dislocation of the femur backward in which\\nthe sciatic nerve is stretched over the neck of the bone and he says\\nIn general (in dislocations into the sciatic notch) the great sciatic\\nnerve is bent over the femur and put on the stretch. I\\nhave seen it so situated in regard to the head of the femur that the\\nreduction could not possibly have been effected with safety to that\\nnerve. The plate apparently represents a dislocation produced upon\\nthe cadaver, and it seems probable that the text refers to dislocations\\nsimilarly produced. I have known of only one clinical case in which\\nsuch relations of the parts have been observed (Quain s).\\nFracture. Fracture of the dislocated bone during reduction has\\n\u00e2\u0080\u00a2occurred in dislocations of the shoulder, elbow, and hip, and not only\\nwhen great force has been employed, but also during comparatively\\ngentle manipulations to flex, abduct, or rotate the limb.\\nAt the shoulder the recorded cases appear all to have been disloca-\\ntions of long standing in elderly people, and in most the accident was\\ncaused by forcible rotation during traction. Of late years I have\\nheard of several cases of fracture in comparatively recent dislocations\\ncaused by attempts to reduce by Kocher s method. The fracture is\\nusually at or just below the surgical neck.\\nSeveral authors assert that the ribs have been broken during reduc-\\ntion by the pressure of a firm axillary pad used as a fulcrum, and also\\nsay that the lip of the glenoid cavity maybe broken during reduction.\\nIn Weir s case, quoted on page 446, the third, fourth, and fifth ribs\\nwere broken in the axillary line, apparently by pressure of the heel.\\nAt the elbow fracture of the olecranon has been frequently caused,\\neither intentionally or by accident, in the reduction of old dislocations.\\nThere is but one recorded case of its fracture in a recent dislocation,\\n\u00e2\u0080\u00a2and even in this there is some doubt whether the fracture had not taken\\nplace before the reduction was attempted. 3\\nMarkoe 4 mentions a case, apparently unique, of fracture of the\\nhumerus in an attempt to reduce an old dislocation of the elbow.\\nWhile making extension, and at the same time trying to flex the\\nforearm on the arm, the humerus gave way, and a very oblique frac-\\n1 Hutchinson Medical Times and Gazette, 1866, i. p. 194.\\n2 Maclise Dislocations and Fractures, Plate xxv. Fig. 2.\\n3 Daugier, in Malgaigne Loc. cit., p. 146.\\n4 Markoe Diseases of the Bones, p. 18.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0533.jp2"}, "526": {"fulltext": "460 DISLOCATIONS.\\nture was found to have occurred about a hand s breadth above the\\njoint.\\nIn dislocations of the hip the femur has been broken, usually at the\\nneck, but once at least at the lower end of the shaft and it is asserted\\nby some that the rim of the acetabulum also has been broken. The\\naccident appears to have been due not to traction, but to efforts made\\nby the hands of the surgeon to change the position of the limb, rota-\\ntion or abduction. Although the force thus applied is slight compared\\nwith that developed by the use of pulleys, it must be remembered that\\nits effect is greatly increased by the leverage of the limb.\\nInflammation, Suppuration, Gangrene. The inflammatory reaction\\ninduced by a dislocation is usually moderate, and rarely terminates in\\nsuppuration and when excessive reaction does follow the reduction of\\na recent dislocation, it is not always possible to determine whether the\\noriginal traumatism or the reduction is responsible for it. In disloca-\\ntions of long standing this difficulty does not exist, for the primary\\nreaction has completely subsided, or, if persistent, has become moderate\\nand chronic before the reduction is attempted, and its renewal or exacer-\\nbation is plainly due to the interference.\\nThe inflammation may be due to the direct pressure of the apparatus\\nused for making traction, or to laceration of the parts about the affected\\njoint the latter is the more dangerous because of the probability that\\nthe inflammation and suppuration may extend to the cavity of the\\njoint, but the former also has proved fatal.\\nOf the other form, laceration of the parts about the affected joint,\\nthe following case is an example. It was under the care of Malgaigne,\\nis briefly referred to by him, 1 and is reported in full by Parmentier: 2\\nA man, thirty-four years old, with an intracoracoid dislocation of six\\nmonths standing. Three attempts to reduce were made, the traction\\nin the last amounting to more than four hundred pounds, and the head\\nof the bone being brought almost back to its place, but an attempt to\\nforce it into place by lateral traction with a bandage failed and even\\nlacerated the skin on the posterior margin of the axilla. On the fifth\\nday after the last attempt the patient complained of pain in the axilla,\\nand the following day became delirious, and a large quantity of pus\\nescaped through the laceration of the skin trismus and tetanus fol-\\nlowed, and death two days later.\\nThe autopsy showed abscesses under and behind both pectoral mus-\\ncles, in the substance of the coraco-brachialis and along its under sur-\\nface, and communicating with the new articular cavity through a rent\\nin its capsule.\\nThe following case, reported by Mr. Jonathan Hutchinson, 3 is even\\nmore striking. An elderly woman, drunk, was admitted with a dislo-\\ncation into the axilla an attempt to reduce failed. The next day she\\nsaid the shoulder had been dislocated for several years, but she was not\\nbelieved, and reduction was again attempted with the aid of chloro-\\nform by moderate manual traction directly outward and the knee in\\n1 Malsaigne Loc. cit., p. 168. 2 Parmentier Bull, de la Soc. Anatomique, 1S52, p. 302.\\nJ Hutchinson Medical Times and Gazette, 1866, vol. i. p. 304.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0534.jp2"}, "527": {"fulltext": "ACCIDENTS BY ATTEMPTS TO REDUCE A DISLOCATION. 461\\nthe axilla as a fulcrum the attempt was continued for ten minutes.\\nGreat inflammation followed, the joint suppurated, and the patient\\ndied. The autopsy showed a new articular cavity formed below and\\nin front of the glenoid cavity. The soft tissues of the joint were\\nwholly destroyed by suppuration, and every trace of cartilage removed.\\nAn experience of Broca s shows that an unfortunate, even fatal,\\nresult may follow an apparently judicious and moderate attempt at\\nreduction.\\nThe patient, 1 a coachman, thirty-nine years old, entered the hospital\\nfor treatment six months after he had dislocated his left hip. Trac-\\ntion to the amount of more than five hundred pounds was made with\\nMathieu s apparatus without success, and the attempt was not repeated.\\nXo ill result appearing, the patient was discharged at the end of a week.\\nA fortnight later he was admitted to another hospital with considerable\\nswelling of the hip and peritonitis, and died on the following day.\\nThe autopsy showed a collection of pus occupying the old and new\\narticular cavities, filling the external iliac fossa, infiltrating the gluteus\\nmedius, and in contact with the entire surface of the internal and exter-\\nnal obturators and with the obturator foramen also a generalized peri-\\ntonitis, much more marked in the true pelvis than elsewhere. The\\ncourse of the lesion was thought to have been inflammation of the\\nnew joint, extension to the old one, then to the obturator internus, and\\nAnally to the peritoneum. It was thought probable that the patient\\nhad resumed work immediately after leaving the hospital, and that this\\nuntimely use of the limb had provoked the suppuration.\\nIn a few recorded cases the inflammatory reaction was so severe that\\nthe limb, or the affected segment thereof, became gangrenous. Dupuy-\\ntren 2 reported a case in which, after reduction of a dislocation of the\\nthumb by long and violent efforts, the thumb became gangrenous and\\nseparated at the metacarpophalangeal joint.\\nThese cases are to be distinguished from those in which gangrene\\nhas been caused by injury to the vessels or nerves, as in La Motte s\\ncase, 3 Weir s first case quoted in Chapter XXXIII., page 446, and\\nprobably in Delagarde s, 4 in which, after reduction of an old dislocation\\nof the shoulder, abscesses and points of gangrene formed in the limb\\nand rendered amputation at the shoulder necessary.\\nPersistent oedema of the limb, a condition resembling elephantiasis,\\nhas been observed in a few cases in which unsuccessful attempts had\\nbeen made to reduce old dislocations, apparently the result of inter-\\nference with the venous flow. In a case of Malgaigne s, quoted by\\nVelpeau, 5 the oedema of the arm disappeared simultaneously with the\\ndevelopment of numerous varicose veins in the arm and shoulder.\\nSyncope and Sudden or Early Death Fat Embolism. Beside\\nthe numerous cases already quoted in this chapter which show the\\n1 Keported by Tillaux in Bull, de la Soc. de Chir., 1868, vol. ix. p. 266.\\n2 Dupuytren Quoted by Marchand, loc. cit., p. 129.\\n3 La Motte Traite de Chirurgie, vol. iv. p. 343.\\n4 Delagarde St. Bartholomew s Hospital Reports, vol. iv. p. 89.\\n5 Marchand Loc. cit., p. 131.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0535.jp2"}, "528": {"fulltext": "462 DISLOCATIONS.\\ndangers to the life of the patient that may arise in the course of an\\nattempt to reduce a recent or an old dislocation, there are still others\\nwhich indicate that life may be seriously threatened, or even destroyed,\\nby other accidents or complications than the rupture of important\\nvessels or nerves or excessive reaction and suppuration. In some of\\nthe fatal cases the failure to make an autopsy leaves the cause of death\\nobscure, but the symptoms point to rupture of a vessel as a possible\\ncause.\\nE. Boeckel l has reported a case the autopsy of which suggests another\\nexplanation, not only of some of the deaths by syncope, but also of\\nsome attributed to the anaesthetic.\\nThe patient was a man fifty years of age, with a recent ilio-pubic\\ndislocation, who was brought to the hospital after an unsuccessful\\nattempt to reduce. Chloroform was given and reduction made in seven\\nminutes the patient grew pale, his respiration weakened and promptly\\nstopped. The autopsy showed the heart to be atrophied, both pulmon-\\nary arteries plugged by non-adherent clots, rounded like emboli, in the\\nmedium-sized branches and those of the third and fourth order, and\\nalso fat embolism of the lungs very Avidespread and intense. The iliac\\nand femoral veins were free, but there was a thrombus in the popliteal\\nvein from which it was thought those in the pulmonary arteries had\\nbeen broken off.\\nBefore the use of anesthetics, in the times when muscular resolution\\nwas sought to be obtained by measures which depressed and weakened\\nthe patient, and when the efforts to reduce were made with great vio-\\nlence and sometimes prolonged for hours, exhaustion of the patient\\nhabitually followed, and death was sometimes the consequence.\\nDeath by the action of an anaesthetic, especially chloroform, is\\nthought to occur in a larger proportion of cases of reduction of dislo-\\ncation than of other operations, but no satisfactory explanation of the\\ngreater risk, if it actually exists, has been given. Of 134 cases of\\ndeath by an anaesthetic collected by Marchand, in 17 the operation was\\nthe reduction of a dislocation; of these 11 were of the shoulder, 3 of\\nthe hip, and 1 each of the knee, elbow, and thumb.\\n1 E. Boeckel: Mort subite par enibolies pulmonaires, simulant la mortpar le chloroform\\napres reduction d une luxation de la cuisse. Eev. des Sciences Med., Oct. 15, 1881, p. 637.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0536.jp2"}, "529": {"fulltext": "CHAPTER XXXV.\\nCONGENITAL 1 DISLOCATIONS.\\nUnder the term non-traumatic may be included all dislocations\\nwhich exist at birth (congenital), although it is claimed that some of\\nthem are due to violence inflicted upon the foetus in utero, or even\\nduring delivery, and those which appear subsequent to birth as the\\nresult of non-traumatic changes in one or more of the constituent parts\\nof the joint spontaneous/ symptomatic/ inflammatory,\\nparalytic/ myopathic, chronic, tardy, dislocation by\\ndistention, by relaxation, by destruction, by deformity\\nand those which may be reproduced at will by the individual, vol-\\nuntary.\\nThe existence of dislocations (at least of the hip) in the new-born\\nchild, and their non-traumatic character, have been recognized since\\nthe earliest times, but the accurate study of the subject may be said to\\nhave begun in 1818, with Schreger, who examined post mortem two\\nspecimens in a girl two and a half years old and a woman of forty-\\neight. A few years later, 1826, Dupuytren brought the subject before\\nthe Academie des Sciences, and called attention especially to the facts\\nthat the affection was often inherited, and often bilateral. Since then\\nthe subject of congenital dislocation of the hip has been actively studied\\nby many, and the similar but much rarer affections of other joints have\\nreceived due attention.\\nStatistics. Dislocations have been observed at birth in many joints,\\nbut not only do those of the hip far exceed all others in number, but\\nthe latter are actually, as well as relatively, so rare that their statistics\\nhave not much value. Next to that of the hip the most common dis-\\nlocation is apparently of the shoulder, and then that of the head of the\\nradius. Kronlein says that the records of Von Langenbeck s Poly-\\nclinic show 90 congenital dislocations of the hip, 5 of the shoulder, 2\\nof the head of the radius, and 1 of the knee. It is not exceptional to\\nfind several dislocations present in an individual, or one or more dislo-\\ncations associated with such congenital defects as spina bifida, club-\\nfoot, ventral hernia, encephalocele, and exstrophy of the bladder.\\nAs will appear in studying the etiology of this affection, the statistics\\nof congenital dislocation of the hip include cases widely different in\\ntheir origin, and even some which are acquired and not congenital,\\nthat is, some which have been produced during the first few months of\\nlife, perhaps before the patient began to walk, by the unopposed action\\nof certain groups of muscles after paralysis of others. It seems prob-\\n1 The use of the term congenital to classify certain dislocations is objectionable for\\nseveral reasons, which will appear in the course of the discussion of the subject. It in-\\ncludes forms that radically differ in their etiology and pathology, but as these forms can-\\nnot well be distinguished from one another during life, a classification based upon other\\npoiuts cannot be realized in practice, but must be confined to the dead-house and museum.\\n463", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0537.jp2"}, "530": {"fulltext": "464\\nDISLOCATIONS.\\nable, however, that the error thus arising is not a large one, but still,\\nfor this and for other reasons, I shall here quote only the more recent\\nstatistics, believing them to be the most nearly correct. These are\\nDrachrnann s, 1 Pravaz s (quoted by Kronlein), and Kronlein s. 2\\nCongenital Dislocations.\\n1\\nPeriod.\\nCases.\\nMale.\\nFemale.\\nSingle.\\nLeft.\\nRight.\\nDrachmann\\nPravaz\\nJCronlein\\n1865-1880\\n1863-1878\\n1875-1880\\n77\\n107\\n90\\n10\\n11\\n14\\n67\\n96\\n76\\n24\\n27\\n32\\n24\\n29\\n22\\n5\\n29\\n51\\n31\\nTotal\\n274\\n35\\n239\\n83\\n75\\n5\\n111\\nPrahFs 3 are not given in sufficient detail to be included in the table\\nthey comprise 18 cases; 3 were males, 15 females, making with those\\nin the table a total of 292, of which 38 were males, 13 per cent., and\\n254 females, 87 per cent. Angot 4 says that of about 20 cases observed\\nby him at the Hopital des Enfants malades in 1882, all were girls.\\nOf 11 cases of congenital dislocation of the knee collected by Hibon, 5\\n7 were girls, 3 boys, and in 1 the sex was not recorded of these, 3,\\n1 \u00c2\u00a3irl and 2 boys, were stillborn, and presented other very marked\\ndeformities.\\nEtiology.\\nThe discussion of this branch of the subject, which was taken up\\nwith much interest after the publication of Dupuytren s memoir, was\\nnot fruitful of positive results because of the lack of anatomical mate-\\nrial and minute examination, and of failure distinctly to discriminate\\nbetween different forms and between the original bony defects and the\\nchanges produced by the long use of the deformed limb. Since the\\naffection is one which often escapes recognition until the child begins to\\nwalk, it was sometimes confounded with dislocations resulting from\\ninfantile paralysis, and as it is one which does not destroy life the op-\\nportunities for direct anatomical investigation were almost entirely re-\\nstricted to two classes of cases, the stillborn and those that died shortly\\nafter birth in consequence of other important congenital defects, and\\nthose in which the original changes had been masked or supplemented\\nby subsequent ones produced by the further displacement of the head\\nof the femur and its abnormal relations to the adjoining parts. In the\\nformer, incorrect inferences were drawn from the associated defects,\\nas when the irritation of an over-full urinary bladder or the separa-\\ntion of the symphysis pubis was deemed the immediate cause of\\n1 Drachmann Schmidt s Jahrbiich., 1881, vol. clxi. p. 170.\\n2 Kronlein Deutsche Chirurgie, Lief. 26, p. 82.\\n3 Prahl Inaug. Dis. Breslau, 1880. Abst. in Centralblatt fur Chir., 1881, p. 57.\\n4 Angot Luxations congenitales de la hauche. These de Paris, 1883, p. 11.\\n5 Hibon Luxations congenitales du tibia en avant. These de Paris, 1881, p. 7.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0538.jp2"}, "531": {"fulltext": "CONGENITAL DISLOCATIONS. 465\\nthe arrest of development of the acetabulum and in the latter the\\nattention was led far astray by prominent changes in the bones. The\\nhistory of the theories advanced has not only an historical value, but it\\nserves also to indicate certain varieties and prominent features of the\\naffection, and therefore I append the following resume made by Kron-\\nlein. It must be remembered that most of the theories deal exclus-\\nively with dislocations of the hip.\\n1. The so-called congenital dislocation is traumatic, and arises\\na, through external violence acting upon the foetus in utero, or through\\nthe action of the muscles of the foetus itself. Hippocrates and\\nthe early writers held that mechanical injuries of the belly of\\nthe mother could produce dislocation in the foetus. Cruveilhier\\ndid not entirely reject this theory in some cases. Chatelain,\\nKleeberg, Zielewicz, even specify in their three cases the injury,\\na fall in the seventh month, which, in their opinion, had caused\\nthe dislocation. Chaussier claims even that a dislocation can\\nbe caused by the contraction of the muscles of the foetus, and\\nnarrates in support the case of a young woman who, during the\\nninth month of pregnancy, felt on three occasions such violent\\nmovements of the child that she almost became unconscious.\\nWhen delivery took place at term, the child had a complete\\ndislocation of the left forearm.\\nb, during delivery.\\nCapuron (1834) held that some congenital dislocations of the\\nhip had been produced during delivery, by traction with the\\nfinger on the groin in breech-presentations.\\n2. Congenital dislocation (of the hip) is a spontaneous dislocation, and\\nis occasioned\\na, by softening and laxity of the ligamentous portion of the joint (Sedil-\\nlot, 1836). This opinion was held in part by Stromeyer (1840).\\nb, by fcetal hydrarthrosis (Parise, 1842) or other joint affections, such\\nas fungous synovitis with effusion (Verneuil and Broca), or\\ncaries and destruction of the capsule (Morel Lavallee, Albers,\\nVon Amnion).\\n3. Congenitcd dislocation (of the hip) is due to the peculiar position of\\nthe lower limbs of the fcetus in utero.\\na, it is possible that in the strongly flexed position of the hip the press-\\nure of the head of the femur upon the posterior or lower por-\\ntions of the capsule may, when the latter is abnormally iceak\\ncause dislocation (Dupuytren, 1826).\\nb, congenital dislocation of the hip is due to abnormcd adduction of\\nthe thigh in idero, to a compressed position of the fcetus due to\\ndeficiency in the amount of the amniotic liquid (Roser, 1864).\\n4. Congenital disloccdion of the hip, like most congenital deformities\\nof the joints, such as club-foot, wry neck, and spinal curvature, is the\\nresult of primary muscular contraction, which is itself to be regarded as\\nthe result of an affection of the central nervous system (J. Guerin,\\n1840, and, following him, Chaussier, Melicher, Mercer-Adam, Carno-\\nchan, Erichsen, and others).\\n5. Congenital dislocation of the hip is often only the last stage of a\\n30", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0539.jp2"}, "532": {"fulltext": "466 DISLOCATIONS.\\nparalysis and consequent atrophy of the pelvic-trochanteric muscles. This\\nfoetal paralysis leads gradually to relaxation of the ligaments, and this,\\noften only after the lapse of time, and especially after the children have\\nbegun to walk, and by the action of the weight of the body, to dislo-\\ncation (Verneuil, 1866). This theory has recently (1878) been brought\\nforward again by some of VerneuiFs pupils (Reclus, Dalby), and\\nextended to congenital dislocations of the humerus (Kirmisson).\\n(Kronlein in this fails accurately to define the position of the sup-\\nporters of this theory. Their contention is not so much that congenital\\ndislocations are thus produced, but rather that some so-called congen-\\nital dislocations originate after birth in a paralysis, and are mistakenly\\nthought to have been congenital. Reclus 1 formulates his conclusions\\nas follows\\na. From the group of so-called congenital dislocations paralytic dis-\\nlocations must henceforth be withdrawn.\\nb. These dislocations follow amyotrophies, and may appear at\\nany age, although they have rarely been seen except in infancy.\\nc. For their production two conditions are necessary atrophy of a\\nmuscular group integrity of its antagonists.\\nd. At the hip the iliac dislocation is the most common. It is due\\nto the contraction of the adductors, which is unopposed because of the\\natrophy of the gluteal and pelvi-trochanteric muscles.)\\n6. Congenital dislocation of the hip is due in most cases and these\\nshould be regarded as typical to a defect of formation or development,\\nwhich prevents the joint from assuming the normal shape. This very\\ngenerally held theory was presented by Palletta, and then taken up\\nand specially developed by Schreger, Dupuytren, Breschet, Von Am-\\nnion, and others.\\nSchreger emphasizes the fact that so-called congenital defects are not\\nproduced by an abnormal change in pre-existing, normally formed parts,\\nbut are due to defective formation or arrest of development, and that\\nis especially true of congenital dislocations of the hip. Dupuytren and\\nBreschet suggest a delayed development of the three pelvic bones form-\\ning the acetabulum. Von Amnion, 2 in his remarkable work, expresses\\nhimself very clearly concerning congenital dislocations, which he terms\\ndysarthroses congenita^. Even if their external appearance, he\\nsays, corresponds somewhat with that of dislocations acquired after\\nbirth, yet in their method of formation they differ essentially from\\nthem, and they also have only the slightest resemblance to those sec-\\nondary dislocations that follow joint disease. In many cases\\nthere is in part the greatest certainty, and in part the greatest proba-\\nbility, that the affection depends upon an arrest of the constituent parts\\nof the joint at an earlier foetal stage of development. And further, 3\\nIf the term luxatio is in general understood to mean the slipping\\nof a movable bone out of its natural joint connections, it is applicable\\nonly with the greatest restrictions to the congenital dislocations in ques-\\ntion. There are cases of so-called congenital dislocation in\\n1 Reclus Eevue Mensuelle de Med. et Chir., 1878, p. 88.\\n2 Von Amnion Die angeborenen chirurgischen Krankheiten des Menschen, 1842, p. 9.\\n3 Von Ammon Loc. cit., p. 3.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0540.jp2"}, "533": {"fulltext": "CONGENITAL DISLOCATIONS. 467\\nwhich the head of the bone has never left its corresponding joint sur-\\nface that is, has never been dislocated, but rather, on the contrary,\\nhas never been in normal and proper relations with it. According\\nto Von Amnion, then, a congenital dislocation is an arrest of develop-\\nment. The acetabulum does not develop into the usual, symmetrically\\nrounded, deep socket, but retains its earlier saucer-shape while the\\nhead of the femur, continuing to grow, becomes too large for the small\\nacetabulum, and no longer suitable to lodge in it.\\nVon Amnion recognized not only this typical form of congenital\\ndislocation but also the other varieties that had been described by other\\nauthors, and quoted cases and reproduced drawings in illustration of\\nthem. So far as the typical form is concerned, but little has been\\nadded since his time to our knowledge of its pathogeny, and that little\\nis contained in a paper published by Grawitz 1 in 1878, who, by micro-\\nscopical examination of twelve specimens of congenital dislocation in\\nseven new-born children, showed that the arrest of development con-\\nsisted in a failure of the Y-cartilage of the acetabulum to carry on the\\ngrowth of one or all of the three segments of the os innominatum.\\nHe found, in his first case, for example, the acetabulum only as large\\nas that of a foetus of about the fifth month, and the Y-cartilage broader\\nthan usual because of diminished ossification of the three adjoining\\nbones, the pubis, ischium, and ilium. The cartilage was hyaline arnd\\nvascularized, and with normal, elongated cells containing one, two, or\\nthree nuclei. On comparison with sections of a normal pelvis of the\\nsame size, a striking difference appeared at the junction of the bone\\nand cartilage. The formative zone in all three epiphyses was very\\nimperfect, its cells scanty and widely separated, and the zone of cells\\narranged above one another in rows adjoining the line of ossification\\nwas not one-third as wide as it normally is, and the arrangement of its\\ncells was irregular and broken. In some of the cases the Y-cartilage\\nwas centrally interrupted by an interposed wedge of embryonal adipose\\ntissue. On the other hand, the appearances in the femur were those of\\nnormal growth, except in one case. In no case was there premature\\nossification of the Y-cartilage, such as had been alleged shortly before\\nby Dollinger 2 in explanation of the same affection.\\nThe conclusion, I think, cannot be avoided that while in a limited\\nnumber of cases dislocations existing at birth, especially in joints other\\nthan the hip, may have been caused by traumatism, abnormal position\\nof the limb, or paralysis in the manner alleged by various writers, yet\\nin the great majority of congenital dislocations of the hip the cause is\\nto be found exclusively in arrest of development of the acetabulum by\\ndeficient action or vitality of the cells of the Y-cartilage. And to the\\ntestimony in support of this opinion furnished by anatomical examina-\\ntion of specimens may be added that drawn from clinical observation,\\nsuch as the coexistence of other deformities due to arrest of develop-\\nment, the frequency of double and multiple dislocations, the inherited\\ntendency to the affection, and its great predominance in females.\\nMany of the congenital dislocations of other joints than the hip must\\n1 Grawitz: Virchow s Archiv, 1878, vol. lxxiv. p. 1.\\n2 Dollinger: Arch, fur klin. Chirurgie, 1877, vol. xx. p. 622.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0541.jp2"}, "534": {"fulltext": "468 DISLOCATIONS.\\nalso be regarded as due to defective formation of the corresponding\\nbones, but the defect apparently is rather a malformation than the\\nresult of an arrest of the development of one of the bones constituting\\nthe joint. At the elbow, in dislocation of the head of the radius, this\\nbone is sometimes found relatively, and even actually, longer than the\\nulna. In a specimen taken from an adult, pictured by Humphry 1\\n(Fig. 241), of dislocation of the head of the radius forward and\\nupward, there was anchylosis of the joint between the ulna and\\nhumerus, and the lower third of the ulna of the other arm was lacking.\\nFig. 241.\\nCongenital dislocation of the head of the radius upward and forward, with exaggerated\\ngrowth in length.\\nIn some dislocations of the knee characterized by hyper-extension of\\nthe leg upon the thigh the cause appears to have been muscular con-\\ntraction.\\nOf the other etiological varieties that have been asserted to exist,\\none at least seems to have been proved by direct examination to exist,\\nthat in which the dislocation follows distention of the capsule and\\nligaments by dropsy of the joint during intra-uterine life.\\nPathology.\\nThe opportunities for studying the pathology of congenital disloca-\\ntions other than those of the hip have been so very rare, and the study\\nof those that exist has been made so uncertain by the doubtfulness of\\nthe diagnosis in some and the difficulty in distinguishing between\\nprimary and later changes in others, that but little can be positivelv\\nsaid concerning them. In studying specimens of dislocation of the\\nhip it is necessary, as Gurlt pointed out, to distinguish between those\\nobtained from very young children who have never walked, those\\nfrom older children whose growth was not completed, and those from\\nadults.\\nHip. The common form is dislocation upon the dorsum of the ilium\\nthe only exceptions, and they are extremely rare, are upon the pubis\\nand into the obturator foramen.\\nIn the new-born child with a dislocation the acetabulum is smaller\\nand flatter than normal, and is continuous by its flattened posterior\\nborder with another articular surface or new acetabulum lying above\\nand behind the original one. Usually, too, the head of the femur is\\nsmaller than normal, although still too large for the acetabulum, and\\nthe neck short or almost absent sometimes the head and neck together\\n1 Humphry Medico-Chirurgical Transactions, vol. xlv. p. 296.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0542.jp2"}, "535": {"fulltext": "PATHOLOGY OF CONGENITAL DISLOCATIONS.\\n469\\nhave a conical pointed form. The ligamentum teres is long and flat-\\ntened, the capsule is complete, and embraces both the old and the new\\nacetabulum. The microscopical changes have been described above.\\nFig. 242.\\nInnominate bone and femur from a case of congenital dislocation of the hip, after operation\\nfor formation of a new acetabulum. (Bradford.)\\nThe mechanism of the alteration seems plain as the femur and its\\nsocket originally are developed out of one continuous strip of tissue, they\\nare at first in normal relations to each other, but when the development\\nof the acetabulum goes on more slowly and imperfectly than that of\\nthe head of the femur the latter becomes relatively too large, and being\\nno longer firmly held in place it is gradually drawn backward and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0543.jp2"}, "536": {"fulltext": "470 DISLOCATIONS.\\nupward by the continuous action of the attached muscles, the corre-\\nsponding edge of the capsule is pressed away from the cotyloid border,\\nand a new articular surface is formed at the point where the head of\\nthe femur comes to rest. Meanwhile, the defective development of the\\noriginal acetabulum persists, and its variation from the normal is prob-\\nably still further increased by the absence from it of the femur. The\\nremaining bones and the muscles, not being put to sufficient use to feel\\nthe effect of the changed relations in the joint, suffer no change unless\\ninvolved in some associated defect of development.\\nBut as soon as the child begins to walk this change in the relations\\nof the bones and muscles to each other makes itself felt, and, as the\\nlocal developmental weakness persists, two factors are now at work to\\nremove the condition of the parts still further from the normal. The\\nacetabulum by its continued failure to share equally in the growth of\\nthe pelvis, becomes relatively smaller and more deformed, the head of\\nthe femur is removed still further from it, and becomes deformed in\\nconsequence of its irregular bearings upon the surface of the ilium\\nthe ligamentum teres becomes longer, flatter, and thinner, and the cap-\\nsule thick and strong, and its cavity commonly larger than usual. As\\nthe individual advances in life, and after puberty has been reached, the\\nascent of the femur is finally arrested, partly by the formation of a\\nsocket, and partly by the resistance of the capsule and the muscles.\\nThe elements of support then resemble in a measure those sometimes\\nfound with ununited fracture of the neck of the femur, and the pelvis,\\ninstead of resting directly upon the femur, is suspended from it by the\\ncapsule, ligaments, some of the pelvi-trochanteric muscles, and even\\nby the psoas-iliacus, the tendon of which, instead of passing down-\\nward, curves around the brim of the pelvis, and passes upward, out-\\nward, and backward to the lesser trochanter, which is now at a higher\\nlevel than the acetabulum.\\nThe head of the femur may be separated from the ilium by the inter-\\nposed capsule, so that the support is entirely by suspension, and there\\nis no real joint, one in which bony surfaces covered with cartilage play\\nupon each other or the upper and posterior attachment of the capsule\\nmay still be found above the head of the femur, upon an overgrowth\\nof bone springing from the ilium and forming the upper part of a new\\nsocket, the remainder of which is constituted by the body of the ilium.\\nThe latter bone sometimes shows at this point an overgrowth of bone,\\nand sometimes a depression with a corresponding thickening on the\\nopposite, inner surface. In the former of these two last-named con-\\nditions, it seems probable that the capsule has been for a time inter-\\nposed between the femur and the ilium, and has finally disappeared at\\nthis point under pressure, the irritation of which has caused the out-\\ngrowth of bone before its periosteum has in turn disappeared in the\\nlatter, it is probable that the attachment of the capsule has been pushed\\nback step by step, leaving a bare surface of bone which has Avorn\\naway under the pressure of the femur, or by absorption while the asso-\\nciated irritation has led to a conservative thickening on its other side.\\nThe old acetabulum is narrow and elongated, running upward and\\nbackward the ligamentum teres perhaps destroyed by over-stretching.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0544.jp2"}, "537": {"fulltext": "PLATE XXVII.\\nFig. 1. Congenital Dislocation of the Hip; Girl, 3 years old.\\nFig. 2.\u00e2\u0080\u0094 Dislocation of Semilunar Bone.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0545.jp2"}, "538": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0546.jp2"}, "539": {"fulltext": "SYMPTOMS AND DIAGNOSIS OF CONGENITAL DISLOCATIONS. 471\\nThe entire pelvis is also changed in shape by the abnormal direction\\nof the pressure to which it is subjected in walking. If the dislocation\\nis unilateral, the crest of the ilium on the corresponding side is carried\\ninward, and the tuberosity of the ischium outward, the horizontal\\nbranch of the pubis is elongated, and its direction from the symphysis\\nis more upward and backward the anterior superior spine of the ilium\\nis displaced inward and backward, and, in short, the entire bone under-\\ngoes a change in shape which carries its centre upward and backward,\\nand makes its lateral surface more vertical.\\nIf the dislocation is double, the same changes are found on both\\nsides, and the sacrum is more sharply curved.\\nCongenital dislocation of the shoulder may be either subcoracoid, sub-\\nacromial, or subspinous. R. W. Smith, 1 who was the first to describe\\nthem, gives examples and plates of the first two forms. He found the\\noriginal glenoid cavity lacking or rudimentary, and the new one well\\ndeveloped either immediately under the coracoid process or on the outer\\nside of the scapula below the acromion. Most of the cases described\\nas such appear to be traumatic (during delivery) or paralytic. (See\\nChapter XLIY.)\\nAt the elbow the head of the radius may be displaced upward along\\nthe anterior surface of the humerus, or backward, or inward so as\\npartly to overlap the coronoid process of the ulna.\\nSymptoms and Diagnosis.\\nThe symptoms of congenital dislocations differ very widely from\\nthose of the traumatic variety, and not only by the absence of symp-\\ntoms peculiar to a traumatism, but also in the signs recognizable by\\npalpation, and in the posture and mobility of the limb. In general\\nterms, the dislocation is to be recognized by an examination which\\ndetermines the abnormal position and altered shape of the correspond-\\ning ends of the bones and the range of motion, and by consideration of\\nthe history of the case.\\nIn dislocations of the hip the changes are very likely to pass unno-\\nticed until after the child has begun to walk, because during this first\\nperiod they are usually too slight to attract attention, and because an\\nexamination for their detection is not likely to be made unless it is\\nsuggested by some special reason, such as coexisting malformations,\\nor the history of similar defects in other members of the family. Even\\nafter the child has begun to walk, the defect may long remain unrecog-\\nnized if both hips are affected, because, the deformity of the regions\\nand the shortening of the limbs being symmetrical, they do not attract\\nmuch attention. Nevertheless, the changes are so characteristic that\\nwhen an examination is made the diagnosis cannot well remain in doubt.\\nWhen the dislocation is unilateral and of the common dorsal variety,\\nthe patient limps because of the shortening of the affected limb and\\nfor the same reason the spine shows a lateral- curvature, which can be\\nremoved by supporting the foot at the proper height. Because of the\\npassage of the head of the femur backward and upward upon the\\n1 R. W. Smith Dublin Medical Journal, 1839, vol. xv. p. 261.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0547.jp2"}, "540": {"fulltext": "472\\nDISLOCATIONS.\\nilium, the pelvis is tilted so that its upper portion is directed forward,\\nand a marked anterior curvature of the lower portion of the spinal\\ncolumn is produced, which disappears when the patient is recumbent.\\nInspection and manipulation reveal the ascent of the trochanter, and\\nthe head of the femur may sometimes be distinctly recognized. The\\nshortening may be slight, moderate, or very great, and can sometimes\\n243.\\nFig. 244.\\nDouble congenital dislocation of the hip.\\nbe notably increased by pressing the limb upward. Usually the glu-\\nteal muscles and those of the thigh are less developed than those of\\nthe opposite limb. The movements of the joint are even more free\\nthan normal, except perhaps in abduction, but when voluntarily per-\\nformed they are more or less lacking in precision and firmness.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0548.jp2"}, "541": {"fulltext": "TREATMENT OF CONGENITAL DISLOCATIONS. 473\\nWhen the dislocation is bilateral, the patient walks, not with a limp,\\nbut with a peculiar characteristic waddle, which sometimes amounts to\\na double limp and makes progression difficult and uncertain. The\\nupper part of the pelvis is sharply inclined forward, producing the\\nsame lordosis that is found in unilateral dislocation, but without the\\nlateral curvature unless there is a difference in the amount of the defect\\non the two sides. The arms appear unusually long, and are sometimes\\nexceptionally muscular. Often the deformity increases with time, and\\nthe patient has repeated attacks of pain in some the flexion and adduc-\\ntion are such that the disability is great.\\nAt other joints, such as the shoulder, elbow, and knee, the position\\nof the bones and the changes in their shape can usually be easily made\\nout.\\nPrognosis.\\nThe prognosis in all dislocations, except that of forward dislocation\\n(hyper-extension) at the knee, is unfavorable, so far as reduction is\\nconcerned.\\nTreatment.\\nUntil within a few years treatment of congenital dislocations of the\\nhip was practically limited to palliative measures, such as a thick sole\\nin unilateral cases and girdles and corsets which mechanically opposed\\nthe tilting of the pelvis and the ascent of the trochanter under pressure,\\nand to continuous traction maintained for months and followed by the\\nuse of traction-splints in both unilateral and bilateral cases. By these\\nmeans the functional condition in many cases appears to have been\\ngreatly improved, and much of the improvement to have been main-\\ntained.\\nOf late years much attention has been given to operative reduction,\\nor fixation, with the formation of a new acetabulum or enlargement of\\nthe existing one. Although much experience has been gained, espe-\\ncially by Lorenz and Hoffa, opinion is not yet settled as to the limita-\\ntions of the field and the choice of a method. The literature of the\\nsubject is abundant; the reader may advantageously consult articles by\\nDr. E. H. Bradford and Dr. T. H. Myers in the Annals of Surgery,\\nAugust, 1894, and by Warbasse in the same, June, 1895.\\nLannelongue has sought by periosteal irritation to create a buttress\\nof bone upon the ilium which would prevent the ascent of the femur\\nafter it had been brought down by traction. He produced this by\\ninjection through a hypodermic needle of twenty drops of a 10 per\\ncent, solution of chloride of zinc at several points in the periosteum\\nclose above the head of the femur.\\nPaci seeks to bring the head of the femur into the acetabulum after\\nextensive rupture of the capsule by manipulation flexion, abduction,\\noutward rotation, extension, in this order and keeps it there by con-\\ntinuous traction for some months. He reports many successes, and it\\nseems to be beyond question that he does bring the head to a lower\\nlevel, and keep it there even if it is not in the acetabulum. At the\\n1 Lannelongue: La Semaine Med., December 30, 1S91.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0549.jp2"}, "542": {"fulltext": "474 DISLOCATIONS.\\nleast, the method takes less time and gives a better result than pro-\\nlonged traction, but it probably is suitable to only a limited number\\nof cases.\\nThe earlier operative methods exposed the capsule by a lateral\\n(Hoffa) or anterior (Lorenz) incision then the muscles were separated\\nfrom the great trochanter, the flexors of the leg divided subcutaneously\\nnear the tuber ischii, the abductors near the pubis, the tensor vagina?\\nfemoris by open incision, and the rectus femoris through the first\\nincision. The capsule was opened, and generally detached freely from\\nthe femur, the head turned out, and the acetabulum enlarged, or a new\\none made, by chiselling.\\nThe mortality of the operation was quite serious, and Lorenz 1 has\\nsought to do away with the division of the muscles. In children not\\nover five years old, when the femur can be drawn well down, he makes\\na three-inch incision downward and outward from the spine of the\\nilium, divides the fascia lata along it and also backward, divides\\nthe capsule in front, deepens the acetabulum, and puts the head of the\\nfemur in place. In children between six and eight years, when the\\nfemur cannot be brought fully down, he exposes the capsule in the\\nsame manner while strong traction is made in slight abduction against\\ncounter- traction by a perineal band, and after division of the capsule\\ncontinuous traction until the head is brought down. In cases over\\nnine years of age, with marked shortening and slight mobility down-\\nward, preliminary traction by about thirty pounds is made for a fort-\\nnight then continuous forcible traction is made during the operation,\\nand the capsule is divided along the long axis of the neck and trans-\\nversely near the ilium. It is important to make a deep excavation\\nwith a sharp upper margin for the new acetabulum. The limb is fixed\\nin slight abduction for a month, and then massage and passive motion\\nare begun.\\nMyers recommends for old, deformed, or painful cases Kirmisson s\\nsubtrochanteric osteotomy, or HohVs new operation of removal of the\\nhead and neck and of the posterior portion of the capsule, the limb\\nbeing then dressed in abduction to insure close contact between the\\ntrochanter and ilium.\\nCongenital dislocations of other joints, except the knee, have rarely\\nreceived any treatment. A few backward dislocations of the shoulder\\nhave been reduced by open operation, not a difficult task in a case of\\nmy own, for the glenoid fossa was well formed and contained within\\nthe capsule of the existing joint. (See Chapter XLIY.)\\nIn dislocations of the tibia forward, with extreme hyper-extension\\nof the knee, a complete cure can usually be effected by forcible straight-\\nening of the limb and retention for a short time by splints.\\n1 Lorenz Volkmann s klin. Vortrage, 1895, No. 117, and Warbasse, in Annals of Sur-\\ngery, June, 1895.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0550.jp2"}, "543": {"fulltext": "CHAPTEE XXXVI.\\nSPONTANEOUS DISLOCATIONS.\\nThese are dislocations which have occurred without the intervention\\nof a recognizable traumatism. It is generally held that some of the\\nconstituent parts of the joint must have previously been so altered by\\ndisease as to facilitate the occurrence but while this preliminary change\\ndoes doubtless occur in the great majority of cases, yet there is reason\\nto think that spontaneous dislocation may take place without it, through\\nthe continuous action of the muscles, when the limb has been long kept\\nin a favorable position. Roser 1 says he has seen, in three cases, spon-\\ntaneous dislocation of the hip produced by the reflex muscular contrac-\\ntions excited by pressure on the anterior portion of the spinal cord in\\npatients affected with kyphosis and consequent paralysis. The dislo^\\ncations occurred slowly, without pain or swelling of the region, and\\nwithout a sign of coxitis.\\nThe term spontaneous, although not entirely free from objection,\\nis in general use, and is usually preferred to others that have been\\nproposed, such as pathological, symptomatic, inflammatory, and consecu-\\ntive or secondary. Volkmann 2 has classified them according to the\\nprimary changes which precede and facilitate their occurrence, as dis-\\nlocations, 1st, by distention; 2d, by destruction; 3d, by deformity;\\nincluding in the first those cases in which the joint has become loose\\nthrough distention of its capsule and ligaments by an effusion within\\nit, as in the eruptive fevers, rheumatic fever, pyaemia, and the puer-\\nperal state in the second those in which the shape of the articular end\\nof the bone has been changed by caries, as in hip-joint disease and in\\nthe third those in which the shape has been changed by non-suppura-\\ntive disease, as in arthritis deformans. To these may be added a 4th\\nclass, seen mainly in adolescents, in which the shape or growth of the\\nbone has been so modified by the effects of pressure, muscular effort,\\nor gravity that a permanent displacement takes place and a 5th,\\nparalytic or myopathic, in which the dislocation is made pos-\\nsible by paralysis of some or all of the articular muscles, and is some-\\ntimes effected by the contraction of those which have not been paralyzed.\\nAlthough the propriety of applying the term dislocation to a change\\nin the relations of two bones whose corresponding articular portions\\nhave already been destroyed has been questioned, and although the\\nchange of place does not come within the definition of dislocation pre-\\nviously given, and although the condition has but little in common\\nwith traumatic dislocations, either in symptoms or in treatment, yet\\nthe term has been almost universally accepted and retained in prefer-\\nence to the proposed substitutes.\\n1 Eoser Centralblatt f. Chirurgie, 1885, p. 569.\\n2 Volkmann: Pitha and Billroth s Chirurgie, vol. ii. part ii. p. 658.\\n475", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0551.jp2"}, "544": {"fulltext": "476 DISLOCATIONS.\\nIn all these varieties the immediate cause of the dislocation is the\\naction of gravity or muscular contraction.\\nDislocations by Distention (Volkmann). Concerning the pathology\\nof this class but little is known by direct examination, because of the\\nlack of autopsies, but the clinical history is well established. The\\njoint by far the most frequently involved is the hip a few cases have\\nbeen observed at the shoulder and knee. In the most common form\\nthe course of the symptoms is a follows: 1 A patient is attacked by\\nfebrile articular rheumatism or acute mono-articular arthritis the pain\\nis great, the limb assumes a faulty position after a few days the pain\\nsuddenly ceases, and on examination the region of the affected joint is\\nfound to present a deformity similar to that which characterizes a trau-\\nmatic dislocation. If the condition is left without treatment, the\\ninflammation comes to an end without leaving either osteitis or suppu-\\nration, but with persisting deformity if, on the other hand, the dislo-\\ncation is reduced, the deformity is thereby entirely removed, and in\\ntime complete recovery is obtained.\\nIn other cases the dislocation takes place in the course of some of\\nthe eruptive fevers or other febrile condition, sometimes without pre-\\nvious notable pain in the joint and without the knowledge, at the time,\\nof the patient. William Keen 2 collected forty-three cases of arthritis\\noccurring as a complication of typhoid fever, in thirty of which dislo-\\ncation took place, twenty-seven times at the hip, twice at the shoulder,\\nand once at the knee.\\nIt thus appears that these dislocations resemble those that are trau-\\nmatic in their sudden occurrence, the absence of any lesion of the\\nbones, and the possibility of immediate and permanent reduction with\\ncomplete restoration of function.\\nThe presence of a large effusion in the joint and the elongation of\\nthe ligaments have been assumed by all observers, and the actual pres-\\nence of an effusion of some amount has been demonstrated in some of\\nthe exceptional cases, knee and shoulder, where such demonstration\\nwas possible. On the supposition of this effusion and of the relaxa-\\ntion of the ligaments produced by it, the production of the dislocation\\nhas been explained. Yerneuil has further called attention especially\\nto the unopposed contraction of certain muscles as the immediate\\ncause.\\nIf it is remembered that at the hip these dislocations are always\\nbackward upon the dorsum of the ilium, and are preceded by the long\\nmaintenance of the limb in the position of flexion, adduction, and\\ninward rotation which so greatly favor the occurrence of this disloca-\\ntion, and that the muscles are stimulated to contraction by the pain of\\nthe arthritis, it does not appear improbable that this contraction is not\\nonly the immediate but also the preponderant cause of the accident,\\nand that the arthritis favors it not by overstretching the ligaments but\\nonly by supplying an amount of liquid that removes the obstacle created\\nby atmospheric pressure. These two conditions, pain and effusion,\\nwould explain why the dislocation does not also occur in the course\\n1 Verneuil Bull, de la Soc. de Chirurgie, 1883, p. 781.\\n2 Keen Toner Lectures, Smithsonian Institution, April, 1875.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0552.jp2"}, "545": {"fulltext": "SPONTANEOUS DISLOCATIONS. 477\\nof adynamic diseases in which the limb often remains for a long time\\nin the flexed position.\\nCertainly the theory of the production of the dislocation by simple\\noverdistention is incompatible with the easy reduction and mainte-\\nnance of the reduction noted in several cases. It was unfortunate for\\nsome of the patients that their surgeons held to this theory, and were\\nlogical enough to refrain from attempting reduction and to leave the\\npatients permanently crippled.\\nA few cases have been observed in which an acute purulent arthritis\\nhas been followed by dislocation but in such cases it is always pos-\\nsible that the capsule has been in part destroyed by the suppuration.\\nParalytic or myopathic dislocations are observed especially\\nat the shoulder. The humerus is held up and kept in contact with\\nthe glenoid cavity by the tonicity of the attached muscles, and when\\nthis tonicity fails the weight of the limb causes separation of the bones\\nand subluxation or complete dislocation. The cavity of the joint,\\nthus enlarged, is filled by an effusion, but this effusion is the conse-\\nquence of the separation rather than a favoring, precedent, and causa-\\ntive condition, for it is presumably drawn from the surrounding tissues\\nby suction, just as oedema appears under a dry cup.\\nAt the hip they are produced by the unopposed contraction of those\\nmuscles which have not been paralyzed. In Roser s three cases of\\nspinal caries, mentioned above, the dislocation was dorsal, and the\\nimmediate cause was the contraction of the adductors no longer\\nopposed by the pelvic-trochanteric muscles. The opposite form, dis-\\nlocation upon the pubis, due to paralysis of the adductors and the\\nconsequently unopposed contraction of the muscles on the outer side\\nand back of the hip, has been reported by Bradford l and Reclus. 2\\nAnother variety may be mentioned, in which by the unequal growth\\nof parallel bones, the tibia and fibula or the radius and ulna, one of\\nthem is slowly dislocated.\\nVoluntary dislocations is the name given to those which the indi-\\nvidual can produce and reduce at will. Those in which the pecu-\\nliarity has originated in a previous traumatic dislocation are due to\\nrupture of some of the ligaments or attached muscles and have been\\ndescribed among the consequences of traumatic dislocations but a\\nnumber of cases have been recorded in which this cause could not be\\ninvoked in explanation. The only case I have seen was a man about\\nthirty years of age who, a few years ago, frequented the medical\\nschools of New York and added to his income by exhibiting his pecu-\\nliar power before the classes.\\nDislocations by destruction and dislocations by deformity are\\nof less practical interest to the surgeon because less amenable to treat-\\nment, and are to be regarded rather as incidents in, or symptoms of,\\nother diseases than as morbid entities.\\nIn the former, dislocations by destruction, Volkmann included those\\ndislocations which occur in the course of chronic tubercular disease\\n1 Bradford Boston Medical and Surgical Journal, 1883, vol. cviii. p. 73.\\n2 Beclus Bevue de Med. et de Chir., 1878, p. 176.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0553.jp2"}, "546": {"fulltext": "478 DISLOCATIONS.\\nof joints or as a consequence of acute traumatic suppurative arthritis.\\nFrequent examples are seen at the hip and knee.\\nIn consequence of the destruction of the articular ligaments or of\\nthe bones themselves an abnormal mobility is created which allows\\nthe bones readily to be displaced by the action of gravity or by mus-\\ncular contraction. At the hip this displacement is usually upward\\nand backward; at the knee the well-known subluxation of the tibia\\nbackward or upward is produced by the contraction of the hamstring\\nmuscles, or, if the patient lies long upon one side and the destruction\\nis well advanced, the displacement may be lateral to the distance of an\\ninch or even more.\\nIn the latter, dislocations by deformity, Volkmann included the dis-\\nlocations which occur in the course of such affections as the morbus\\ncoxce senilis and in the arthropathies of nervous origin, Charcot s dis-\\nease/ in which the articular ends of the bones disappear by absorption\\nwithout suppuration.\\nThe remaining form has been specially studied, so far as I know,\\nonly by Madelung, 1 and only at the wrist the dislocation was always\\nof the carpus forward, and was accompanied by marked changes in\\nthe shape of the radius and of the bones of the first row of the carpus.\\nThe cause appeared to be overexertion, or, rather, prolonged and fre-\\nquently repeated exertion in patients who, presumably, were predis-\\nposed to the change by defective vitality of the bones. Volkmann\\nincludes such cases under the general head of disturbances of growth\\nof joints. 2\\n1 Madelung Deutsche Gessellschaft fur Ckirurgie, 1878, p. 259, and Arch. f. klin.\\nChir., vol. xxiii.\\n2 Volkmann Loc. cit., p. 692.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0554.jp2"}, "547": {"fulltext": "CHAPTER XXXVII.\\nDISLOCATIONS OF THE LOWEE JAW.\\nDislocations of the lower jaw constitute from 3 to 6 per cent, of\\nall dislocations according to the tables in Chapter XXVII. They\\nmay be bilateral or unilateral, the former being the more common, in\\nthe proportion of about 5 to 2 according to Malgaigne, who found 54\\nbilateral in a total of 76 cases which he collected. Of these 54, 31\\nwere in women, and this greater frequency in the female sex is univer-\\nsally recognized. The injury is rare in infancy and old age it has\\nbeen observed in patients eighteen and seventy-two years old, and has\\nbeen caused in the new-born child by obstetric manipulations.\\nIn the great majority of cases the dislocation is forward, the condyle\\nof the jaw passing in front of the articular eminence at the root of the\\nzygoma. A few instances have been reported of double or single dis-\\nlocation backward w T ith fracture of the wall separating the articular\\ncavity from the external auditory canal, of dislocation upward into\\nthe cavity of the cranium, and of unilateral dislocation outward with\\nor perhaps without, fracture of the body of the jaw. These are, how-\\never, entirely exceptional and may be briefly described before proceed-\\ning to the consideration of the common form.\\nDislocation Backward with Fracture.\\nDislocation backward with fracture of the posterior wall of the\\narticular cavity is caused by great violence received upon the chin and\\nacting from before backward. One or both condyles may be driven\\nthrough the wall into the external auditory canal, breaking the bone\\nand lacerating or pushing backward the outer cartilaginous portion.\\nThe production of the lesion is probably easier when the molar teeth\\nare lacking from the upper or lower jaw, or if the mouth is partly open\\nwhen the blow is received. The symptoms are pain in, and bleeding\\nfrom, the ear, immobility of the jaw T the mouth being held partly open,\\nand displacement backward, as shown by the relations of the front\\nteeth to each other. The absence of the condyle from its normal posi-\\ntion can be recognized by the touch, and the auditory canal is seen or\\nfelt to be obstructed by the displacement of its anterior wall.\\nDislocation Upward.\\nLe Fevre 1 reported an interesting and very exceptional case in\\nw T hich the injury was caused by a fall from the second story of a\\nbuilding, the blow being received upon the chin. The jaw was\\ndisplaced slightly backward and to the left, the teeth were close\\ntogether, and the mouth could not be opened. Slight bleeding from\\nthe left ear. The diagnosis of fracture of the condyle was made.\\n1 Le Fevre Journal Hebdornadaire, 1834, vol. iii. p. 333.\\n479", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0555.jp2"}, "548": {"fulltext": "480 DISLOCATIONS.\\nThe patient was dismissed in the fourth week still experiencing diffi-\\nculty in mastication and deglutition. Subsequently he suffered from\\nviolent headache, had several attacks of convulsions, and died about\\nsix months after the receipt of the injury. The autopsy showed that\\nthe roof of the glenoid cavity had been fractured, the condyle had\\npassed into the cranium between the fragments, the neck of the con-\\ndyle was in part destroyed, the dura mater was extensively inflamed and\\nthickened, and there was a large abscess in the middle lobe of the brain.\\nDislocation Outward.\\nRobert 1 received at the Hopital Beaujon a patient who had been in-\\njured by the passage of the wheel of a cart across the right side of his\\nface. The chin was deviated to the right, and the mouth was held open.\\nThe left condyle of the lower jaw could be distinctly felt under the skin\\nabove the root of the zygoma. Greatly surprised at this displacement\\nRobert sought for and found a vertical fracture of the body of the bone\\non the right side just in front of the ramus. The left coronoid process\\nremained under the temporal fossa, the sigmoid notch crossing and em-\\nbracing the zygoma. Reduction was made by pressing the left ramus out-\\nward until the condyle was freed from its contact with the upper surface\\nof the zygoma, and then drawing it downward and inward to its place.\\nNeis 2 reported a similar case and collected others.\\nDislocation of the Jaw Forward.\\nThis, the common form, is usually caused by muscular action, as in\\nlaughing, scolding, yawning, or vomiting, or exceptionally by violence\\nin widely opening the mouth to introduce some large object, such as an\\napple or the fist, or in drawing a tooth, or by a blow upon the jaw.\\nIn order to understand this mechanism it is necessary to recall the\\nconstruction and normal action of the joint. The lower jaw is attached\\nto the skull by a synovial capsule which is strong on its outer side (the\\nexternal lateral ligament), by an internal lateral ligament not in imme-\\ndiate relations with the joint but extending from the spinous process of\\nthe sphenoid bone to the margin of the inferior dental foramen, and by\\nthe stylo-maxillary ligament, a strong band extending from the styloid\\nprocess of the temporal bone to the posterior border of the ramus of\\nthe jaw. The joint is occupied by an intra-articular cartilage or menis-\\ncus which overlies the upper surface of the condyle and accompanies\\nit in its normal movement forward from the glenoid cavity to the emi-\\nnentia articularis when the mouth is opened. In front of the point to\\nwhich the condyle thus moves forward the surface of the eminentia\\narticularis is inclined slightly upward to become continuous with the\\nmuch narrower lower surface of the zygoma. The fibres of the mus-\\ncles attached to the ramus which close the mouth run upward and for-\\nward, and only those belonging to the deep posterior portion if the\\nmasseter are vertical or inclined backward.\\n1 Robert: Archives generates de Med., 1845, vol., vii. p. 44.\\n2 Neis Luxation du Maxillaire inf. en haut ou dans la fosse ternporale. These de Paris,\\n1879, No. 252.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0556.jp2"}, "549": {"fulltext": "DISLOCATIONS OF THE LOWER JAW. 481\\nSince the condyle moves forward when the chin descends, the centre\\nof motion of the jaw is not in the condyle, but at a point below it at\\nor near the dental foramen, and as the angle of the jaw is at the same\\ntime moved backward the axis of the ramus notably changes its\\nrelations to the direction of the fibres of the masseter, bringing the line\\nof the posterior ones behind the centre of motion where their contrac-\\ntion tends still further to open the mouth or to keep it open. Still,\\nthe cause, when muscular, is rather to be found in the excessive action\\nof the external pterygoid, aided by relaxation of the external lateral\\nligament, which latter condition is produced by the wide opening of\\nthe mouth, as will be explained more fully in the following section.\\nPathology. The opportunities directly to examine cases of disloca-\\ntion of the jaw have been very few, and experiments upon the cadaver\\ncannot entirely take their place, but it appears to be established that\\nMalgaigne s opinion that the condyle did not advance more than one\\nor two millimetres beyond the point on the articular eminence which\\nit normally reaches is not correct, but that the advance is considerably\\ngreater. In an autopsy made by Demarquay in a case of recurrent dis-\\nlocation the condyle was in front of the transverse part of the zygoma\\nthe interarticular disk was behind it. It also appears that the rupture\\nof the capsule, wdien it occurs, takes place in front between the menis-\\ncus and the condyle, but sometimes the meniscus accompanies the con-\\ndyle without rupture of the capsule. This makes the persistence of\\nthe dislocation, and especially the fixation of the jaw, difficult to\\nexplain. The earliest theory, that of Petit, the contraction of the\\nposterior fibres of the masseter, is generally rejected as inadequate.\\nAnother, also advanced by the earlier writers and recently brought\\nforward again by INelaton and accepted by Malgaigne, and supported\\nby at least one specimen which is figured in Malgaigne s Atlas, Plate\\nXVII., fig. 1, is that the coronoid process becomes engaged under\\nthe malar bone. That this may be an occasional adjuvant cause must\\nbe admitted on the facts presented, but that it is not the sole cause,\\nand probably not even a frequent one, is proved by experiments upon\\nthe cadaver which have shown the fixation to persist after removal of\\nthe coronoid process, and by the fact that in JNelaton s specimen the\\nprocess is unusually long.\\nThe slightly upward inclination of the anterior surface of the emi-\\nnentia articularis against which the displaced condyle rests is not of\\nitself sufficient, and the most recent theory, suggested by Demarquay l\\nand thoroughly studied by Mathieu, 2 that the return of the condyle is\\nopposed by the meniscus beyond which it has passed, seems to be open\\nto the objections that the meniscus is so freely movable backward that\\nit would be readily pushed back into the glenoid cavity by the return-\\ning condyle, and that in some cases it accompanies the condyle in its\\nexcursion. In a case in which I was unable to reduce 1 3 found on\\nexposing the joint that the meniscus had been torn from the condyle\\nand was so lodged in the glenoid cavity that the condyle could not\\n1 Demarquay Bull, de la Soc, de Chirurgie, 1863, vol. iv. p. 119.\\n2 Mathieu: Arch. gen. de Med., 1868, vol. ii. p. 129.\\n3 Stimson: Traus. N. Y. Surg. Soc., Aunals of Surgery, March, 1898.\\n31", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0557.jp2"}, "550": {"fulltext": "48 2 DISLOCA TIONS.\\nenter it. After removal of the meniscus the dislocation was easily\\nreduced. An autopsy reported by Perier x of a case of recurrent dislo-\\ncation showed absence of the anterior portion of the meniscus and\\nlodgement of the remainder behind the condyle after reduction. These\\nprove not that the meniscus is the cause of the fixation, but that it may\\nprevent complete reduction.\\nThe cause must be found, I think, in the ligaments, the external\\nlateral and perhaps the posterior portion of the capsule, and this opin-\\nion is supported by the tenseness of the lateral ligament observed by\\nWeber 2 and Maisonneuve 3 upon the cadaver, and by the anatomical\\nrelations of the parts. The mechanism of its action I conceive to be\\nas follows The external lateral ligament, forming the anterior part of\\nthe outer portion of the capsule, extends from the articular eminence\\ndownward and backward to the neck of the condyle, its attachment to\\nthe eminence being posterior to the point at which the lower surface of\\nthe latter begins to incline upward. This ligament (Fig. 245) is too\\nPig. 245.\\nDiagrammatic of the external lateral ligament of the lower jaw. A, when the mouth is open\\nB, when thexondyle is dislocated forward.\\nshort to allow the jaw to take such a position when the condyle is\\ndislocated forward that the long axis of the neck shall coincide with\\nthat of the ligament. When the mouth is widely opened the liga-\\nment is relaxed by the approximation of its points of attachment, and\\nthe condyle passes forward then, as the mouth is partly closed, the\\nligament becomes tense before the condyle has moved back past it, and\\nthus its further movement backward is prevented, and while it remains\\nthus displaced any force that tends to close the mouth increases the\\nobstacle to replacement by making the ligament more tense and press-\\ning the bones more firmly together. Such a force is naturally and con-\\nstantly exerted by the powerful muscles of mastication, stimulated to\\ncontraction as they are by their forcible elongation and the pain and\\nanxiety of the patient. The practical inference to be drawn from this\\nexplanation, if it is correct, is that reduction should be sought, not by\\ncrowding the body of the jaw doAvnward and backward by pressure\\nupon the molar teeth, but by first depressing the chin if possible,\\nopening the mouth Avider, so as to relax the ligament, and then press-\\ning the condyle backward and closing the mouth as it passes the artic-\\nular eminence on its way back.\\n1 Perier Bull, de la Soc. de Chirurgie, 1878, p. 222.\\n2 Weber Handbuch der allg. und spec. Chir., vol. iii. Abt. 1, p. 288.\\n9 Maisonneuve: Comptes-rendus, Acad. des. Sciences, 1862, p. 654.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0558.jp2"}, "551": {"fulltext": "DISLOCATIONS OF TEE LOWER JAW. 483\\nSymptoms. The symptoms of bilateral dislocation forward are that\\nthe mouth is held open, the lower jaw immovable and projected some-\\nwhat forward exceptionally, only the projection is present, and the\\nmouth can be closed. Speech is indistinct, swallowing difficult, and\\nchewing impossible. The condyle can be felt in advance of its usual\\nposition, and a depression marking the empty glenoid cavity can be\\nfelt in front of the ear. The checks are flattened, and the saliva\\nescapes from the mouth. The masseter and temporal muscles are\\nusually tense, and the upper anterior portion of the former is raised\\nby the coronoid process.\\nFig. 246.\\nBilateral dislocation of the lower jaw. (R. W. Smith.)\\nIf the dislocation is unilateral the physical signs are found upon\\nonly one side, the chin is turned to the opposite side, and the func-\\ntional disability is less.\\nPrognosis. The prognosis is favorable both as regards the reduction\\nof the dislocation and the degree of disability if it remains unreduced,\\nbut somewhat unfavorable in that recurrence is quite probable. If it\\nremains unreduced the parts appears slowly to adjust themselves to their\\nnew relations and finally to permit more or less satisfactory approxi-\\nmation of the jaws and restoration of the functions.\\nTreatment. The dislocation is one which, as a rule, can be easily\\nreduced, one indeed in which, as has been already said, reduction has\\noften occurred spontaneously. The methods employed have, perhaps\\nin consequence of this fact, been numerous, and have varied greatly in\\nthe objects aimed at, if not in the actual mechanism by which they\\nhave accomplished the reduction. It can be shown, I think, that many\\nof the methods and procedures have been successful not because they", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0559.jp2"}, "552": {"fulltext": "484 DISLOCATIONS.\\nmet the ideas of their originators concerning the obstacle to be over-\\ncome, but because they overcame or avoided another obstacle which\\nhad not been recognized. With few exceptions the aim of the different\\nmethods has been directly to depress the condyle and then to press it\\nbackward, and this aim has been accomplished by direct pressure down-\\nward upon the molars, or indirectly by raising the chin after having\\nplaced a wedge between the back teeth. Those who found the obstacle\\nin the hooking of the coronoid process under the malar bone sought to\\ndisengage the process by opening the mouth more widely, and then\\npressed the jaw T backward while others, again, pressed the bone directly\\nbackward by placing the thumb and forefinger of one hand against the\\ncoronoid processes and then elevated the chin by a slight blow upon it\\nfrom beneath. It is noteworthy that some of the gentlest methods,\\nsome which approach most closely to that which I conceive to be the\\nrational method, were employed by the earliest surgeons, even by Hip-\\npocrates, and were again and again resumed only to be as often neglected\\nand forgotten. Hippocrates s method, as quoted by Malgaigne, was to\\nlower the chin a little in order, according to Galen, to free the coronoid\\nprocess from the malar bone, and then to press the jaw backward, the\\npatient being meanwhile encouraged to relax his muscles and yield\\nhimself as completely as possible to the effort made in his behalf.\\nAlthough the intention and the supposed effect was to free the coro-\\nnoid process, yet the wider opening of the mouth relaxed the lateral\\nligaments and facilitated the backward propulsion.\\nIn 1862 Maisonneuve again revived the plan, after having observed\\nin many experiments upon the cadaver that the external lateral, spheno-\\nmaxillary, and stylo-maxillary ligaments were tense and that after their\\ndivision the dislocation could be reduced with great ease. He ascribed\\nthe fixation to the pressure of the condyle against the zygoma, a press-\\nure maintained by the combination of the passive resistance of the\\nligaments and the energetic contraction of the elevator muscles/ and\\nproposed to reduce by direct backward propulsion after diminishing\\nthe pressure by opening the mouth more widely.\\nIt is unquestionable that in this, as in most other dislocations, the\\nobstacles to reduction are multiple, and that contraction of the muscles\\nis one of them, and that it especially opposes reduction because it\\ndirectly resists the attempt to place the bones in the most favorable\\nposition. It is also true that methods of reduction are habitually\\nsuccessful which are not based upon correct anatomical principles, but\\nnevertheless those principles exist and are the same as in other dislo-\\ncations the opposing ligaments must be relaxed, and the bone should\\nfollow in returning to its socket the route by which it escaped from it.\\nIn the great majority of cases, as has been said, dislocation takes place\\nwhile the mouth is widely open and the ramus is inclined upward and\\nforward. Theoretically, then, the same position should be given to it\\nas a preliminary to reduction, and although the opposition of the mus-\\ncles may create practical difficulties in the way of accomplishing this\\nwhich will prevent its universal use and cause other methods to be\\npreferred in the simple cases, yet in all difficult cases and whenever\\nthis opposition has been annulled by anaestheisa this method should be", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0560.jp2"}, "553": {"fulltext": "DISLOCA TIOXS OF THE L WEB J A W. 48 5\\nemployed the mouth should be widely opened and the jaw should be\\npressed backward, or backward and slightly downward. This press-\\nure may be conveniently made by the thumbs placed inside or outside\\nthe mouth against the anterior edges of the ascending rami, the head\\nof the patient being solidly supported behind, or by pressing with the\\nforefingers against the front of the ramus, outside the mouth, and the\\nmiddle ringers against the side near the angle, while the thumbs and\\nother lingers grasp the body near the symphysis.\\nIn the method by forcible depression of the posterior portion of the\\njaw the thumbs may be used alone by placing them upon the lower\\nmolar teeth and pressing downward and backward. It is well to\\nguard them against bruising by covering them with cloths or leather,\\nand when the reduction is accomplished they should be rapidly with-\\ndrawn or slipped to the other side of the teeth to escape being bitten,\\nan accident that has happened to several surgeons and has indeed been\\nthe cause which led to the invention of other procedures.\\nInstead of direct pressure with the thumbs, hinged instruments\\nhave been used, taking their bearings upon both sets of molars.\\nIn cases of long standing in which adhesions have formed and must\\nbe ruptured before reduction can be made, these forcible measures are\\nnecessary, for the jaw cannot otherwise be moved through a range suf-\\nficient to accomplish the object. Reduction has been obtained as late as\\nthe ninety-eighth day after the occurrence of the dislocation. Reference\\nhas been above made to the personal case in which reduction was pos-\\nsible only after the detached meniscus had been removed by operation.\\nMazzoni treated an irreducible bilateral dislocation of eight months\\nstanding in a woman twenty-seven years old by excision of both con-\\ndyles, with an excellent functional result.\\nAfter reduction the mouth should be kept closed by a bandage and\\nthe patient fed on soft food for two or three weeks. It is not unlikely\\nthat the marked tendency to recurrence so commonly observed is the\\nresult of inopportune use of the jaw, perhaps also, in part, of the\\nfavorite method of reduction which tends to elongate or rupture the\\nlateral ligaments.\\nAnnandale 1 successfully treated two cases of recurrent dislocation\\nby opening the joint and suturing the meniscus to the periosteum.\\nAn incision, slightly curved, about three-quarters of an inch in\\nlength, is made over the posterior margin of the external lateral liga-\\nments of the joint, and is carried down to its capsule. Any small\\nbleeding vessels having been secured, the capsule is divided, and the\\ninterarticular cartilage is seized, drawn into position, and secured to\\nthe periosteum and other tissues at the outer margin of the articula-\\ntion by a catgut suture. Irritating injections into the peri-articular\\ntissues have also been employed.\\nPathological or Consecutive Dislocations.\\nPathological or consecutive dislocations are uncommon, and only in\\na few cases 2 has the condyle, eroded and deformed by antecedent\\n1 Annandale Lancet, 1887, i. p. 411.\\n2 Gurlt Path. Anat. der Gelenkrankheiten, p. 109, Cases 5, 11, 15.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0561.jp2"}, "554": {"fulltext": "486 DISLOCATIONS.\\ninflammation, been found outside its cavity and sometimes united by\\nbony union to the skull.\\nCongenital Dislocations.\\nThe only example of this condition of which I have found mention,\\nif a foetal monster reported by Guerin be excepted, is one described\\nby R. W. Smith. 1 The patient was a congenital idiot who died at the\\nage of thirty-eight years. The dislocation existed upon the right side\\nand was the result of defective development of the constituent parts\\nof the joint.\\n1 E. W. Smith Fractures and Dislocations, p. 273.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0562.jp2"}, "555": {"fulltext": "CHAPTEE XXXVIII.\\nDISLOCATIONS OF THE VERTEBE^ AND OF THE OCCIPUT\\nFROM THE ATLAS.\\nClassification and pathology, secondary changes, etiology, symptoms and diag-\\nnosis, prognosis, treatment Dislocations of the occiput, atlas, lower six\\ncervical vertebrae, dorsal vertebras, lumbar vertebrae.\\nThe study of dislocations of the vertebra? is closely associated with\\nthat of fractures of the same bones, because in many cases the differ-\\nential diagnosis between a fracture and a dislocation cannot be made\\nwith certainty, and because the associated lesions and consequences are\\nthe same. For some of the latter, therefore, the reader is referred to\\nthe chapter on Fractures of the Vertebrae.\\nConcerning the frequency of dislocations of the vertebra? widely\\ndifferent opinions have been held some (Delpech) denying even the\\npossibility of dislocation without fracture, others thinking them ex-\\ntremely rare, and others, again, claiming that they are quite common.\\nThe most notable member of the last group is Porta, who, according\\nto Blasius, observed no less than twenty-seven cases in thirty years.\\nBy far the most valuable contribution to the settlement of this question,\\nand indeed to the whole subject, is the monograph of Blasius, 1 who\\ncollected 294 reported cases, of which 185 were dislocations, 37 dias-\\ntases, and in 72 it remained undetermined to which of these two classes\\nthe lesion belonged. Although an autopsical examination was made\\nin 174, yet in 38 of these the account is so defective that the variety\\nand seat of the injury cannot be determined; and in only 172 of the\\n294 cases can these details be said to have been established. By far\\nthe most common seat is the cervical region, then the dorsal, and last\\nthe lumbar region, in which only a very few cases have been observed.\\nThe certain cases were divided among the decades of life as follows\\nfirst, 7; second, 17; third, 25; fourth, 15; fifth, 14; sixth, 6.\\nOf 40 cases collected by Richet, 2 the age in only 1 1 was more than\\nforty years, and in only 3 more than fifty years. This greater fre-\\nquency in those of middle life must be referred to the greater exposure\\nto the accidents that are apt to produce the lesion incident to their\\noccupation, an explanation which is corroborated by the much greater\\nfrequency of the injury in males than in females according to Blasius,\\n4 to 1 in the cervical region, and 12 to 1 in the dorsal.\\nThe difference of opinion above mentioned regarding the frequency\\nof the occurrence of the injury in general, doubtless depends in part\\nupon the definitions which the different authors have adopted, since\\n1 Blasius: Die traumatische Wirbelverrenkimgen, in Vierteljahrschrift fur prakt. Heil-\\nkunde, 1869, vol. cii. ciii.\\n2 Richet Anatomie Medico-Chirurg., p. 247.\\n487", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0563.jp2"}, "556": {"fulltext": "488 DISLOCATIONS.\\nsome accept as dislocations only those cases which are not complicated\\nby fracture, while others accept also those in which an associated frac-\\nture can be rightly deemed unessential to the production of the dislo-\\ncation. The latter view is in harmony with the classification of other\\ndislocations, and will be adopted here a dislocation of a vertebra being\\ndefined as an injury in which the adjoining articular processes on one\\nor both sides have been partly or completely separated from each other,\\nwith or without avulsion of portions of the body of either vertebra or\\nfracture of one or more processes. The term disatasis is applied to\\nthose dislocations in which, the intervertebral disks and other ligaments\\nhaving been torn,. the vertebrae are longitudinally separated from each\\nother in front or behind, but have not also been so horizontally dis-\\nplaced that the articular surfaces on either side have been put out of\\nline with each other.\\nThe terminology employed to indicate the seat and variety of the\\ndisplacement has also varied with the different writers, some speaking\\nof the upper, others of the lower, vertebra as the one that is dislocated,\\nwhile others have sought to avoid misunderstanding by using such a\\nphrase as dislocation of the fifth upon the sixth. The latter form\\ncan be advantageously employed in the report of cases, or whenever\\nany doubt might arise as to the meaning, but it will be convenient\\nhere to follow the more general practice, and speak of the upper ver-\\ntebra as the one that is dislocated, and of the direction and character\\nof its displacement as those of the dislocation.\\nClassification and Pathology. The relations of the vertebrae to each\\nother are so complex, and the combinations of different directions\\nwhich the displacements may present are so variable and numerous,\\nthat a classification of the varieties based upon these directions is not\\nonly very complicated, but it also fails to offer comparative advantages\\nsufficient to compensate for its complexity. The classification made\\nby Hueter, according to the character of the movement or the direction\\nof the force which produces the dislocation, is simple, and at the same\\ntime indicates the main features of the displacement and suggests the\\nproper method of reduction. It fails, however, to distinguish between\\nthe varieties and, therefore, while adopting it, it has appeared desir-\\nable also to use in connection with it other terms indicative of special\\nfeatures.\\nThe provisions for normal motion between adjoining vertebras consist\\nin the elasticity and compressibility of the intervertebral disks between\\nthe bodies and in the articulations placed just behind them upon the\\narches.. The normal range of motion, though varying in the different\\nportions of the column, is at best slight, and can be referred in the\\nmain to two axes for each pair, one of which lies in the median plane\\nand passes through the centre of the disk from behind forward, with\\nan inclination downward of its anterior end which is slight in the\\nlumbar and lower dorsal regions, more marked in the upper dorsal,\\nand greatest in the cervical regions (Fig. 240). The other axis is a\\nhorizontal transverse one, passing through the posterior part of the\\ndisk. Motion about the first axis produces a lateral bending of the\\ncolumn, and, in the cases in which the axis is inclined downward and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0564.jp2"}, "557": {"fulltext": "DISLOCATIONS OF THE VERTEBRA.\\n489\\nFig. 247.\\nforward, with this motion must be associated a rotation of the upper\\nvertebra by which the anterior surface of its body is turned to the side\\ntoward which the column is inclined; and the greater the inclination\\nof the axis, the more marked is this associated rotation. The move-\\nment is arrested by the contact of the margins of the adjoining articular\\nsurfaces with their bases on the concave side, and if it persists beyond\\nthis point dislocation is produced, the opposite inferior articular surface\\nof the upper vertebra being raised above the one\\nwith which it articulates by the lateral bending,\\nand being carried forward by the rotation. To\\nthese dislocations Hueter gives the name disloca-\\ntions by abduction or rotation.\\nMotion about the other, transverse, axis pro-\\nduces a bending forward (or, to a less degree,\\nbackward) of the column, during which the ante-\\nrior portion of the disk is compressed, the pos-\\nterior portion stretched, and both inferior articular\\nsurfaces of the upper vertebra are moved upward\\nand forward along the superior articular surfaces\\nof the underlying vertebra, The movement is\\nchecked, when its normal limit is reached, by the\\nligaments of the joints and arches, and, if these\\nyield, a dislocation is produced, in which the\\ninferior articular processes of the upper vertebra\\npass forward and in front of those with which they\\narticulate dislocation by flexion.\\nUnder the first head, dislocations by abduction,\\nare to be included the complete or incomplete uni-\\nlateral dislocations forward or backward, and the\\nbilateral dislocations in opposite directions, de-\\nscribed as distinct forms under these names by\\nBlasius, all of which, with one exception (the\\nunilateral dislocation backward) represent only\\ndifferent degrees of the same displacement. In-\\nstead of being entirely separated from each other,\\nthe articular surfaces may remain in contact at\\ntheir edges. If the displacement is somewhat\\ngreater, the inferior process of the upper vertebra\\npasses further forward, and sinks into the notch between the body and\\nthe superior articular process of the lower vertebra (complete unilat-\\neral dislocation, Fig. 248), and at the same time the inferior process on\\nthe opposite side may be carried backward by the movement of rotation\\n(bilateral dislocation in opposite directions). Blasius quotes four cases\\nin which the latter variety was observed and verified by post-mortem\\nexamination the dislocated vertebrae were the second, fourth, and fifth\\ncervical, and the eleventh dorsal, and the dislocation was forward on\\nthe left side in the first three, and forward on the right side in the last\\none. The unilateral dislocation backward, of which Blasius refers to a\\nfew examples exclusive of those of the occiput upon the atlas, may, I\\nthink, be attributed to the same mechanism, the displacement being\\nDirection of the median\\naxis in the different sec-\\ntions of the spinal col-\\numn. (Henke.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0565.jp2"}, "558": {"fulltext": "490 DISLOCATIONS.\\neffected in consequence of the yielding of the ligaments of the joint on\\nthe side toward which the body is bent, instead of on the opposite side-\\nas in the other cases. In a case observed by Cloquet, and briefly men-\\ntioned by Blasius, the second lumbar vertebra was dislocated in this\\nmanner, the dislocation being complicated, but unessentially, by fracture\\nof the body and arch of the vetrebra all the processes were uninjured.\\nThe patient survived several years, and the condition of the parts was\\ndetermined by autopsical examination. Under the second head, disloca-\\ntions by flexion, are included bilateral dislocations forward or backward.\\nThe force continuing to act after the normal limit of forward flexion of\\nthe column has been reached, the ligamenta subflava are ruptured, and\\nthe posterior portion of the intervertebral disk is torn or separated from\\nFig. 248.\\nComplete unilateral dislocation by rotation or abduction cervical vertebra. (Konig.)\\nthe vertebra with or without avulsion of a portion of the bone; the\\narticular processes of the upper vertebra lodge in front of those of the\\nlower in the notches. Sometimes the processes do not pass entirely\\nbeyond each other, but remain in contact at their extremities and\\nsometimes, the movement being accompanied by slight rotation of the\\nvertebrae upon each other, one articular process is displaced further\\nforward than the other. The lumen of the vertebral canal may be\\nseriously encroached upon in this dislocation, and its contents injured\\nby compression against the upper edge of the body of the lower ver-\\ntebra.\\nThe mechanism of the double dislocation backward, of which a few\\ncases have been accurately observed, has not been demonstrated, but\\nthe possibility of its production by extreme dorsal flexion of the column\\nis such that it may, provisionally at least, be placed in this class. The\\nmotion is arrested by bony contact at the arches, and by the interver-\\ntebral disks, the efficiency of whose resistance is increased by their\\ngreater distance from the fulcrum about which the rupturing move-\\nment must turn. It is interesting to note that in a case reported by\\nStanley, 1 dislocation backward of the fifth cervical vertebra, the upper\\nfive vertebrae were firmly united together by bony fusion. The dis-\\nplacement was so great that the body of the fifth rested upon the\\nlaminae and spinous process of the sixth. The additional leverage\\ncreated by this anchylosis may be invoked as an argument in favor of\\nthe theory of production by dorsal flexion.\\n1 Stanley Edinburgh Medical and Surgical Journal, October, 1841, p. 404.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0566.jp2"}, "559": {"fulltext": "DISLOCATIONS OF THE VEBTEBRJE. 491\\nTransverse dislocation has been diagnosticated in several cases, but\\nthe only one in which sufficient anatomical proof has been obtained is the\\nfollowing mentioned by Charles Bell. 1 A child was run over by a stage-\\ncoach and died of croup thirteen months later. The last dorsal ver-\\ntebra was found completely displaced to the left side of the first lum-\\nbar with slight chipping of the bone. The articulation between these\\nvertebrae is of such a character that this form of dislocation would\\nseem impossible without a fracture of the articular processes, and prob-\\nably it may still probably be deemed so except in a child. The same\\nanatomical conditions exist in the lumbar vetebrae, but in the dorsal\\nand cervical regions the articular surfaces look backward and forward\\nor are only slightly inclined to one side, consequently this form of dis-\\nlocation must there be regarded as possible.\\nIn the greater part of the dorsal region it would necessarily be asso-\\nciated with dislocation of the vertebral end of the corresponding rib.\\nIn all the clinical cases quoted by Blasius, with one exception, the\\ncervical vertebrae were concerned, and he says that the correctness of\\nthe diagnosis is very doubtful in all.\\nThe main groups and varieties, then, are as follows\\nDislocations by flexion, ventral or dorsal.\\nBilateral forward.\\nBilateral backward.\\nDislocations by abduction or rotation.\\nUnilateral forward\\nTT T iii i complete or incomplete.\\nUnilateral backward J r r\\nBilateral in opposite directions.\\nTransverse.(?)\\nThe associated lesions comprise rupture of the various ligaments,\\nmuscles, bloodvessels, and nerves, fracture of the bones, and injuries\\nof the spinal cord and its membranes, and those later changes which\\nmay be induced by the primary ones.\\nThe intervertebral disk is always ruptured or torn away from one or\\nthe other vertebra, and this rupture or separation is almost invariably\\ncomplete, and is accompanied by the avulsion of larger or smaller\\nfragments of the bone. In one or two cases the disk appears to have\\nbeen crushed.\\nThe capsular ligament, on one or both sides according to the char-\\nacter of the displacement, is always torn. The anterior and posterior\\nligaments are either torn, wholly or in part, or stripped from their\\nattachments to the bodies of the vertebrae, sometimes bringing with\\nthem in the latter case portions of the bone. The ligaments between\\nthe lamince and the spinous processes are either torn or put upon the\\nstretch, and those between the transverse processes were torn in the\\nonly reported case found by Blasius in which their condition was men-\\ntioned. Instead of rupture of the ligaments fracture of the processes\\nto which they are attached may occur, and various other fractures of\\nthe adjoining processes or of more distant parts are frequently\\nobserved.\\nThe surrounding and the attached muscles may be torn by the dis-\\n1 Bell Injuries to the Spine and Thigh-bone, 1824, p. 25.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0567.jp2"}, "560": {"fulltext": "492 DISLOCA TIONS.\\nplacement or by the direct action upon them of the dislocating vio-\\nlence.\\nThe veins coming from the bodies of the vertebrae and those of the\\nmeninges of the cord are so large and their relations with the bones\\nand ligaments are so close that hemorrhage is always free and some-\\ntimes very profuse.\\nIn dislocations of the cervical vertebrae the vertebral arteries so\\ncommonly escape injury that the possibility of their rupture has been\\ndenied, but in a case received into St. Thomas s Hospital l the verte-\\nbral artery was found to have been torn and a large amount of blood\\nto have escaped into the vertebral canal and among the muscles.\\nBlasius admits this case into his list, although all the processes of the\\nfourth vertebra were broken.\\nThe nerve trunks at their point of emergence through the interver-\\ntebral foramina may be compressed or torn on one or both sides\\nbetween the articular process of one vertebra and the body or pedicle\\nof the other and in the lumbar or lower dorsal regions the nerves\\nconstituting the cauda equina have repeatedly been found torn across\\nor compressed between the body and laminae of the adjoining vertebrae.\\nThe spinal cord and its membranes may entirely escape injury, and\\nif injured, the lesion may present any grade between simple compres-\\nsion and complete rupture. The injury may be caused by pressure of\\nthe bone against the cord or by the direct elongation of the latter.\\nAll the lining membranes may be torn, entirely across or only in part,\\nor one of them alone may be ruptured. Their rupture is necessarily\\naccompanied by the extravasation of blood, usually profuse, between\\nthe dura and the bone and amid the meninges. Occasionally an extra-\\nvasation of blood has been found within the cord itself; thus, in a\\ncase reported by Martini, 2 one of diastasis between the fourth and\\nfifth cervical vertebrae, in which there was complete rupture of all the\\nligaments and separation to such an extent that the finger could be\\npassed between the bones, the meninges were not torn, and the only\\nlesion found in the cord was a clot three centimetres long in its centre\\nand involving also the cortical substance. A similar case has recently\\nbeen reported by Quenu. 3 It is worthy of note that in three reported\\ncases 4 in which extensive paralysis was present the autopsy failed to\\nshow any lesion of the cord, and that in others there has appeared to\\nbe no fixed relation between the extent of the paralysis and the ana-\\ntomical lesions found in the cord. Probably these three, and the two\\npreceding, were cases of haematomyelia. In other cases the cord has\\nbeen found torn while the ligaments have been only slightly injured.\\nThe analysis made by Blasius to determine the relative frequency\\nand severity of injury to the cord in the different forms and at differ-\\nent seats of dislocation shows that the danger is greatest in disloca-\\ntion of the lower cervical vertebrae, the fifth and especially the sixth,\\n1 Medico-Ckirurgical Eeview. 1831, vol. xiv. (18 of analyt. series), p. 227.\\n2 Martini: Schmidt s Jahrbiicher, 1861, vol. ex. p. 195.\\n3 Quenu Le Progres Medical, February 27. 1887.\\n4 Colbome: Provincial Medical and Surgical Journal, vol. ii. p. 50; Hafner Zeit-\\nscbriftfiir Wundarzte und Geburtsbelfer. 1856, vol. ix. p. 249; and Porta: Delia lussa-\\nzioni delle vertebre, 1864, quoted by Blasius.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0568.jp2"}, "561": {"fulltext": "DISLOCATIONS OF THE VERTEBRAE. 493\\nalthough even there the cord may entirely escape injury. In the\\nvariety which he terms unilateral forward (dislocation by abduction\\nor rotation) the danger is less than in the bilateral forward or\\nbackward (dislocation by flexion) in 7 autopsies the cord was\\nfound injured in 6, and of 45 cases observed clinically, all of the neck,\\nin 9 there was evidence of injury or compression of the cord, which\\ndisappeared in 5 and was followed in 4 by inflammatory and softening\\nprocesses in the cord. The variety which he terms bilateral in oppo-\\nsite directions appears particularly free from this danger in the\\nfew cases he collected paralysis was exceptional and temporary. Of 8\\ncases of bilateral dislocation backward examined post mortem, the\\ncord was uninjured in 2, and more or less severely injured in 6 of 6\\nclinical cases, in 3 there was no paralysis, and in 3 the paralysis was\\ntemporary. Of 52 cases of bilateral dislocation forward, the cord was\\nuninjured in 17, and was injured seriously and irreparably in 11 in\\nthe remaining 24, either recovery followed or a distinction cannot be\\nmade between the effects of the mechanical violence inflicted upon the\\ncord by the dislocation and those of the later inflammatory and nutri-\\ntive changes. It must be remembered that in most of the clinical\\ncases our knowledge of the exact character of the lesion of the skel-\\neton is defective. It has recently been shown that hemorrhage within\\nthe gray matter of the cord, hcematomyelia, may be produced by a\\ntemporary diastasis of the lower cervical and upper dorsal region, and\\neven without recognizable injury of the column or its ligaments. And\\nyet there is, at first, a motor paralysis which may be as complete as\\nafter transverse rupture or crush of the cord. (See Chapter XL,\\nFractures of the Vertebrae, pp. 143-145.)\\nBlasius 1 summarizes the analysis as follows in no form of disloca-\\ntion is injury of the spinal cord a necessary consequence such injury\\nis less to be expected in unilateral dislocation, and in unilateral dislo-\\ncation forward of the cervical vertebrae it is always, or almost always,\\nonly a simple compression without crushing in bilateral dislocation\\nbackward or forward, either of the dorsal or cervical vertebrae, the\\ncord is exposed to more serious lesions and seldom escapes entirely\\nuninjured, and when the displacement is forward the cord is mechan-\\nically affected in most cases, but the cases of severe injury are fewer\\nthan those in which all injury is escaped finally, the danger is least\\nin bilateral dislocation in opposite directions.\\nSecondary Changes. When the patients survive for a sufficient\\nlength of time the signs of a more or less acute inflammatory reaction\\nappear. There is reason to believe that this reaction in the meninges\\nand cord is not so frequent or severe as that which follows injury to the\\nskull, but yet in a number of cases pus has been found in the meninges\\nand even in the centre of the cord itself. The cord may be slightly\\nsoftened and changed in color, or it may be reduced to pulp, and this\\nchange may involve only the portion corresponding to the dislocated\\nvertebra or it may extend to a greater or less distance above and below.\\nIt is probable also that other changes observed after fracture of the\\nvertebrae, such as extensive suppuration within the pia and the substi-\\n1 Blasius: Loc. cit., p. 130.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0569.jp2"}, "562": {"fulltext": "4U4 DISLOCATIONS.\\ntution of fibrous tissue for the nervous elements of the cord, may take\\nplace, for the conditions are practically the same.\\nThe intervertebral disk seems habitually to disappear by softening\\nand absorption and the ligaments undergo changes similar to those\\nobserved in other ligaments that is, their torn portions reunite by\\ncicatricial tissue or they contract new attachments in the evolution\\nof the process of repair, and they may even become ossified. The\\ntendency of the reparative process to end in suppuration, which has\\nbeen observed to be exceptionally marked after fracture of the verte-\\nbrae, has been manifested also after dislocation, although possibly only\\nin cases complicated by fracture.\\nEtiology. The causes have been habitually described as direct and\\nindirect violence and muscular action. The distinction between direct\\nand indirect violence is made by classifying under the latter those cases\\nin which the force has acted upon the column at some distance from\\nthe point of dislocation to bend it in one or another direction, and\\nunder the former those in which the force has acted directly upon the\\ndislocated vertebra. But the mechanism in most, if not in all cases\\nis certainly the same the column is forcibly bent, and the dislocation\\nis produced by this forcible bending, just as a rod may be bent or broken\\nby grasping and approximating its two ends with or without the aid of\\ndirect pressure against its centre. In the cases of dislocation by mus-\\ncular action the cervical vertebrae alone have been involved, and the\\nmovement has been that of exaggerated rotation or dorsal flexion.\\nSymptoms and Diagnosis. Most of the symptoms of dislocation\\nare the same as those of fracture of the vertebrae. There is usually the\\nsame history of violence acting upon the spinal column, either directly\\nor indirectly, to bend it beyond the limit of its normal range of motion,\\nlocalized pain increased by movement or manipulation, inability to\\nstand, partial or complete paralysis below the point of injury, diminu-\\ntion or exaggeration of the normal mobility of the affected part, with\\nor without reflex muscular rigidity of the upper segment of the column,\\nand deformity recognizable by sight or touch. The symptoms which\\nare thought to be of most service in establishing the differential diag-\\nnosis between these two injuries are crepitus and abnormal mobility\\nat the point of injury in fracture, and their absence in dislocation.\\nUnfortunately, crepitus is not always obtainable in fracture by such\\nmanipulations as are permissible, and it may be present in dislocation\\naccompanied by fracture that is, in a condition in which the disloca-\\ntion is the important injury, and the fracture a comparatively unim-\\nportant addition. Rigidity of the column at the injured point is\\ncommon but not constant in dislocation, and it may be caused in frac-\\nture, or even in contusion or sprain, by muscular contraction. But\\nwhile a positive differential diagnosis may not often be possible, a prob-\\nable diagnosis may frequently be made, at least when the injury is in\\nthe cervical region, by attention to the attitude and rigidity of the\\nneck, by recognition of the change in the relations of the transverse\\nprocesses, or of the bodies of the vertebrae so far as they are accessible\\nto examination in the pharynx, or of the lower spinous processes, and\\nby the impossibility of correcting the displacement by pressure.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0570.jp2"}, "563": {"fulltext": "DISLOCATIONS OF THE VERTEBRA, 495\\nOn the other hand, muscular contraction and pain due simply to\\nbruising of muscles or nerves or to inflammation of the vertebral joints\\nmay produce an attitude and rigidity closely resembling those of dis-\\nlocation.\\nFor the recognition of hsematomyelia motor paralysis, thermo-\\nanesthesia, and analgesia with preservation of tactile sensibility see\\nChapter XI.\\nDeformity. The deformity consists in displacement of the spinous\\nor transverse processes forward or backward or to one side, and is to be\\nrecognized by palpation. The displacement of the transverse processes\\ncan be recognized by touch only in the neck, that of the spinous pro-\\ncesses everywhere except in the upper cervical region unless the patient\\nis very fat. The body of the displaced vertebra is accessible to exami-\\nnation only in the pharynx and occasionally, as in a case reported by\\nDupuytren, by deep pressure through the anterior abdominal wall.\\nPain, although sometimes absent, is commonly present, and is pro-\\nvoked or increased by movements of the body or by direct pressure\\nupon the injured region. It has its origin in the bruising or laceration\\nof the adjoining soft parts and in pressure upon the nerves within the\\ncanal or at their points of exit through the intervertebral foramina. In\\nsome cases it is referred only to the point of injury, in others it is radi-\\nated along the course and over the region of distribution of the affected\\nnerves.\\nParalysis, entirely absent in some cases, may be partial or com-\\nplete within the affected region usually the two sides of the body are\\nsimilarly affected (paraplegia), and limitation to a lateral half of the\\nbody (hemiplegia) is unknown except where the paralysis has been only\\npartial. Motor paralysis is, as a rule, more marked and extensive than\\nsensory paralysis.\\nParalysis has been observed in the muscles of the column adjoining\\nthe point of injury, in some or all of the parts of the body below the\\npoint of injury, and occasionally in those lying above it. The last-\\nmentioned extension is to be explained by mechanical injury to the\\ncord at a higher point than the dislocation, as by overstretching in\\ndiastasis, or by extravasation of blood, or by the extension of inflam-\\nmatory processes set up by the injury.\\nInstead of paralysis, or in association with it, may be observed mus-\\ncular contractions, neuralgic pains, and hyperesthesia, presumably de-\\npendent upon inflammatory changes in the cord and meninges. In a\\nfew cases there have been general convulsions, promptly followed by\\ndeath.\\nIn addition to these symptoms of injury of the cerebro-spinal nerves\\nand centres are others of widely different character and involving many\\ndifferent tissues and organs, which, as Hutchinson l has pointed out in\\na valuable and very interesting paper, may be referred to changes in\\nthe sympathetic, especially the vasomotor system. Thus, sudden rises\\nof temperature, general or local and of longer or shorter duration, may\\nbe observed, sometimes associated with pallor of the surface or with\\nmarked pulsation in the arteries. If the injury is in the cervical region\\n1 Hutchinson London Hospital Keport, 1866, vol. iii. p. 357.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0571.jp2"}, "564": {"fulltext": "496 DISLOCATIONS.\\nthe heart-beat becomes slow but does not also show the intermissions\\nthat commonly accompany the slow pulse of injury to the brain.\\nImmobility of one or both pupils, with a slight degree of contrac-\\ntion, has been noted in other cases immobility with dilatation.\\nPriapism may accompany injury of the lower cervical and upper\\nand middle dorsal regions when it is sufficient to cause paraplegia.\\nIts frequency, compared with all cases in males, was found by Blasius\\nto be 1 to 5 at the fourth cervical, 1 to 3.6 at the fifth, 1 to 2.7 at the\\nsixth, and 1 to 2.5 at the seventh. He adds that it was present in\\nfourteen out of twenty-five cases of fracture of the sixth cervical ver-\\ntebra. The condition of the member appears, however, not always to\\nbe that of normal physiological erection, but rather of simple engorge-\\nment, the member remaining comparatively flaccid although swollen.\\nIn a few cases the priapism has been provoked only by the additional\\napplication of a local irritant, as the passage of a catheter.\\nThe rapid formation of bed-sores has also been attributed to vaso-\\nmotor or trophic changes, but while it is possible that such changes\\nmay act as a predisposing cause, yet the immediate, determining cause\\nappears to be rather the prolonged, unrelieved pressure to which the\\nparts are subjected in consequence of the paralysis.\\nThe occurrence of cystitis and ammoniacal decomposition of the\\nurine within the bladder has also been explained in the same manner,\\nbut seems rather to be the consequence of over-distention of the bladder\\nand of the use of the catheter. The later consequences of this cystitis\\nare extremely serious and may hasten or be the immediate cause of\\ndeath.\\nInjury to or change in the vasomotor nerves has been thought to be\\nthe cause also of changes sometimes observed in the lungs. In two\\ncases elsewhere mentioned I have known fracture of the cervical ver-\\ntebra? to be followed by expectoration of blood coming from the lungs,\\nand Blasius (following Moritz) describes a pulmonary congestion ap-\\npearing promptly, marked at first by increased secretion, and rapidly\\ncausing death by oedema of the lungs, usually on the second or third day.\\nPrognosis. The injury is commonly deemed, and with good reason,\\none that places the life of the patient in great danger. Of the 278\\ncases he collected Blasius collated 159 in which the diagnosis was cer-\\ntain of these 36 recovered and 123 died, a proportion of 22.6 per\\ncent, of recoveries, or 1 in 4.4. It is well worthy of note, also, that\\nof these 36 recoveries the dislocation was completely reduced in 27\\nand partly reduced in 2, and that all these 29 and 5 of the remaining\\n7 were dislocations of the cervical vertebra?.\\nIn the fatal cases death usually followed promptly upon the receipt\\nof the injury. Of 113 authentic cases more than half died within the\\nfirst week, the others at varying periods up to five months. Death,\\nespecially in the cases in which it occurs promptly, is usually the con-\\nsequence of the injury to the cord or of the inflammatory processes\\nset up in it by the injury but even when such injury exists, especially\\nif situated in the lower portion of the cord, life may be indefinitely pro-\\nlonged. Simple compression of the cord involves less danger to life\\nthan its complete or partial division or crushing, and relief of the com-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0572.jp2"}, "565": {"fulltext": "DISLOCATIONS OF THE VERTEBRA. 497\\npression may be followed by restoration of function. If the compres-\\nsion takes place gradually, even to a very marked degree and at the\\nupper end of the cord, as in several reported cases of cervical spinal\\ncaries, prolongation of life is still possible, and even marked and per-\\nmanent compression at the level of the atlas and axis has in two reported\\ncases not proved immediately fatal. In one 1 of these, dislocation of\\nthe atlas forward from both the occiput and the axis with fracture of\\nthe odontoid process, the canal was reduced to a triangular slit two\\nmillimetres wide on one side and five on the other the patient survived\\nfive months, being completely paralyzed during most of the time. In\\nthe other case, 2 incomplete dislocation of the occiput from the atlas\\ndue to caries, the patient survived three months and died of tubercle\\nof the brain.\\nIf the dislocation is reduced the symptoms may disappear promptly,\\nor the paralysis may persist in whole or in part, and the case may even\\nterminate fatally in consequence of the injury done to the cord or its\\nenvelopes.\\nTreatment. This must be directed to the reduction of the disloca-\\ntion, the prevention of its recurrence, and, if reduction is impossible, to\\nthe relief of the consequences of the displacement. If reduction is\\nto be attempted it should be done promptly, and yet it must be added\\nthat it has been successfully made in several cases as late as the eighth\\nor ninth day after the accident, and in one after the lapse of two\\nmonths, and was followed by the prompt or gradual disappearance of\\nthe paralysis.\\nThe attempt to discriminate, with reference to the question of attempt-\\ning reduction, between cases in which the paralysis is due to simple\\ncompression of the cord and those in which it is due to its laceration\\nor the effusion of blood within the canal is impracticable, because of\\nthe impossibility of making a positive differential diagnosis between\\nthose conditions. For the diagnosis of hsematomyelia see Chapter XL\\nThe possibility that the attempt may cause the instant death of the\\npatient, especially when the dislocation is in the upper part of the cer-\\nvical spine, is a weighty factor in the problem, but should not, in my\\njudgment, deter the surgeon if the patient or his friends accept the risk.\\nIt should only stimulate him to make the most accurate possible diag-\\nnosis as regards the seat, direction, and mode of production of the\\ndislocation, and most cautiously to select and execute the necessary\\nmanoeuvres. The urgency of the symptoms may leave him but scant\\ntime for observation and reflection, and the history of the case may\\nthrow no light upon the mode of production, so that the general rule\\nto return the dislocated part along the path by which it escaped from\\nits position cannot be knowingly and deliberately followed. Under\\nsuch circumstances the surgeon must trust to traction aided by such\\nflexion and rotation of the column as his best scrutiny of the displace-\\nment and knowledge of the relations of the articular processes may\\nsuggest. Anaesthesia should usually be employed.\\nThe return of the bone to its place is usually indicated by a distinct\\n1 Costes: Schmidt s Jahrbiich., vol. lxxix. p. 208.\\n2 Darriste Bull, de la Soc. Auatomique, 1838, vol. xiii. p. 144.\\n32", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0573.jp2"}, "566": {"fulltext": "498 DISLOCATIONS.\\nsound, and the rigidity which is usually present gives place to normal\\nmobility.\\nIf the dislocation is comparatively slight, moderate lateral pressure\\nmay effect reduction, as in a remarkable case reported to Blasius 1 by\\nRichter. A lad, eleven or twelve years old, consulted Eichter because\\nof deformity and stiffness of the neck caused by a fall. He found the\\nspinous process of the third cervical vertebra slightly displaced to one\\nside, and that pressure upon it caused pain. Xo paralysis. An attempt\\nto reduce the dislocation by traction on the head failed, and the child\\nwas sent home to await another attempt. On the way, the child, who\\nhad heard and comprehended the diagnosis, stopped by a wall, leaned\\nhis head and shoulder against it, and pressed forcibly with the thumb\\nagainst the opposite, convex side of the neck, and instantly reduced\\nthe dislocation. The story was confirmed by the child s companions,\\nand the surgeon at his visit found the neck straight, normally movable,\\nand free from pain.\\nAfter reduction has been made no other retentive measures than rest\\nin bed are ordinarily required, but if there is reason to fear recurrence\\nthe parts may be immobilized by gypsum bandages or padded wire\\nsplints that embrace the entire trunk if the injury is situated below\\nthe shoulders, and the head and chest if it is in the cervical region.\\nIf reduction cannot be made immobilization is still necessary to\\nfavor the formation of firm adhesions and the solidification of the\\nbones in their new relations and in addition measures may be needed\\nto meet the indications of other symptoms. Of the latter the most\\nurgent is the acute hyperemia of the lungs that has occasionally been\\nobserved, and this is most promptly and satisfactorily met by free\\nvenesection. The need of regular catheterization in the paralytic cases\\nmust not be overlooked. Permanent drainage of the bladder through\\na perineal incision has been employed, apparently with advantage, in\\nsome cases. Suprapubic drainage would probably be preferable on the\\nscore of cleanliness and easy attention.\\nDISLOCATIONS OF THE OCCIPUT AND CERVICAL VERTEBRA.\\nDislocations are far more frequent in this region than in the others.\\nThe fifth cervical vertebra is the one most frequently dislocated. The\\nanatomical differences between the articulations of the atlas with the\\nocciput and axis and those of the other vertebrae are such that a sepa-\\nrate description of the injury at the upper end of this region is necessary.\\n1. Dislocations of the Occiput (from the Atlas).\\nThe articulations between the atlas and the condyles of the occip-\\nital bone are formed on each side by a long, oval articular surface on\\nthe atlas, which is concave both from before backward and from side\\nto side the long axis of each runs from in front outward and back-\\nward and the outer margin of each is higher than the inner margin, so\\nthat each articular surface looks upward, inward, and backward, and\\n1 Blasius Loc. oit., vol. civ. p. 114.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0574.jp2"}, "567": {"fulltext": "DISLOCATIONS OF THE ATLAS. 499\\ntogether they constitute a cup-shaped socket into which the rounded\\ncondyles of the occipital bone fit, and upon which they have a motion\\nonly of flexion and extension. In addition to the ligaments uniting\\nthe two bones there are other and strong ones within the canal which\\ndirectly unite the posterior surface and apex of the odontoid process\\nwith the occipital bone and thus aid in opposing the separation of the\\natlas from the latter.\\nThe dislocation was formerly deemed quite a common one, and to\\nthis opinion succeeded another more in harmony with the anatomical\\nconditions of the joint but still erroneous, namely, that it had never\\noccurred. There are, however, three observations which positively\\ndemonstrate the occurrence of the injury, those of Costes, 1 Bouisson, 2\\nand Milner. 3 In the former a lad fifteen years old was thrown down\\nand beaten upon the back of the neck, by which the atlas was displaced\\nforward from its articulations with both the occipital bone and the\\naxis, and the odontoid process of the latter was broken off. The\\npatient s head remained inclined forward, and movements of the neck\\nwere difficult. A few days later hyperesthesia and paralysis of motion\\nappeared, and persisted, without treatment, for four months then the\\nright arm and leg became painful, and he was taken to the hospital.\\nThe pulse was feeble and slightly quickened at the posterior part of\\nthe neck was a firm swelling projecting a little on the right side which\\nsubsequently proved to be the posterior part of the axis, and the chin\\nwas turned to the left and so depressed as almost to touch the chest.\\nHe died thirty-six days after admission to the hospital.\\nAt the autopsy the skull was found dislocated backward from the\\natlas, the articular surfaces being completely separated on the right\\nside, while on the left the anterior and inner part of the articular sur-\\nface of the condyle was still in contact with the posterior part of that\\nof the atlas. At the same time the atlas was tilted forward, rotated\\nto the left in front and to the right behind, and displaced forward upon\\nthe axis the odontoid process was broken off at the base and reunited\\nby fibrous tissue in an almost horizontal position with the body of the\\naxis. The posterior arch of the atlas was so closely approximated to\\nthe body of the axis that the interval between them was reduced to a\\ntriangular slit five mm. wide on the left side and two mm. on the right.\\nIn the second and third cases the patients were instantly killed.\\nThe rarity of the occurrence is readily explained by the extent of\\nthe articular surfaces, the strength of the ligaments, and the extra-\\narticular checks to the movement of the skull upon the atlas, the effect\\nof which is to cause exaggerated movements of lateral or antero-\\nposterior flexion of the head to be transmitted to the lower vertebrae.\\nTreatment. If treatment is called for, the attempt to reduce should\\n1 Costes Schmidt s Jahrbuch., vol. lxxix. p. 208, and Malgaigne Des Luxations, p. 329.\\nBoth these accounts are abstracts of the original report in the Journal de Bordeaux,\\nAugust, 1852, and they differ materially from each other in some points. In the account\\nhere given I have in the main followed the former, since Malgaigne s appears to have\\nbeen taken from an abstract, not from the original paper.\\n2 Bouisson Schmidt s Jahrbuch. vol. lxxxii. p. 216, from Eevue Med. Chirurg. de\\nParis, vol. ii. p. 355.\\n3 Milner: St. Bartholomew s Hospital Reports, vol. x. p. 314.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0575.jp2"}, "568": {"fulltext": "500 DISLOCATIONS.\\nbe made by steady traction on the head combined with such coaptative\\npressure upon it and the vertebrae as would be suggested by the char-\\nacter of the displacement.\\n2. Dislocations of the Atlas (from the Axis).\\nThe articulation between the atlas and axis is composed not only of\\nthe two lateral articulations as in the other vertebrae, but also of that\\nbetween the odontoid process and the anterior arch of the atlas. This\\nprocess, which, genetically, is the separated body of the atlas that has\\nunited with the axis, is placed vertically behind the anterior arch of\\nthe atlas, and is firmly held in place by the strong transverse ligament\\nof the atlas, by the two alar or check ligaments which pass from the\\nbase of the process to the occipital bone at the margin of the foramen\\nmagnum, and by the vertical band of the transverse ligament, the\\nsuspensory ligament, and the posterior occipito-axial ligament which\\noverlies the others.\\nDislocation forward or backward is possible only after fracture of the\\nodontoid process or rupture of the transverse ligament, or by the slip-\\nping of the process beneath the ligament. The number of cases of the\\ninjury demonstrated by autopsy is fairly large and contains examples\\nof all three forms. In most of the reported cases the injury was a\\ndiastasis or incomplete separation of the articular surfaces, the atlas\\nbeing displaced forward, and usually so inclined that its anterior arch\\nlay in front of the body of the axis. If, in this change of place, the\\nodontoid process is broken off and accompanies the atlas, the proba-\\nbility of dangerous compression of the cord is somewhat lessened.\\nThe other forms that have been demonstrated are dislocations forward\\nand backward of both articular surfaces dislocation forward on one\\nside only (unilateral dislocation forward) has been observed only clin-\\nically except in one case l in which there was also a similar dislocation\\nof the sixth cervical. There is some reason to think that some of the\\nobscure reported cases that ended in recovery may have been of the\\nkind designated as bilateral dislocation in opposite directions, that\\nin which one articular surface is displaced forward and the opposite\\none backward, for experiment shows that this displacement can exist\\nwithout causing compression of the medulla. A case observed by\\nSedillot probably was of this kind. (Vide infra.)\\nThe following are examples of the rarer forms\\nDislocation Forward without Rupture of the Transverse\\nLigament. A man 2 sixty years old fell from a height of four or five\\nmetres, striking upon his head, and survived ten hours. The head\\nwas held in moderate dorsal flexion, but was freely movable. The\\nodontoid process had passed under the transverse ligament, and com-\\npressed the medulla. The right alar ligament was torn, the left\\nuntorn. The articular surfaces of the atlas had moved forward upon,\\nbut had not entirely left, those of the axis. There was no fracture.\\nA similar case is reported by Orton, 3 in which all the ligaments\\n1 Franchomme Journ. des Sci. Med. de Lille, May 29, 1891.\\n2 Journal de Chirurgie de Malgraigne, 1844, p. 370.\\n3 Ortou Lancet, 1876, i. p. 853.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0576.jp2"}, "569": {"fulltext": "DISLOCATIONS OF THE ATLAS. 501\\nuniting the axis to the atlas and occipital bone were torn, but the\\ntransverse ligament was uninjured, and the odontoid process lay behind\\nit compressing the cord. The injury was caused by a blow of the fist\\nreceived obliquely from behind, on the angle of the jaw. Death was\\ninstantaneous. These two are the only positive examples of this\\ninjury.\\nDislocation Backward. A woman 1 sixty-eight years of age fell\\nwhile descending a ladder, struck upon her forehead, and died instantly.\\nThe atlas was dislocated backward on both sides, the anterior ligament\\ndetached, the capsular ligaments in front torn, the odontoid process\\nbroken at its base, and the posterior arch of the atlas broken on each\\nside near the transverse process. The fracture of the atlas was thought\\nto have been caused by its impact against the spinous process of the\\naxis.\\nThere is no other reported case in which this variety has been\\ndemonstrated post mortem, but Malgaigne quotes from Ehrlich a sup-\\nposed case which ended in recovery.\\nBilateral Dislocation in Opposite Directions. Sedillot 2 re-\\nported the case of a girl who had suffered for some time with stiffness\\nof the neck and deviation of the head to the left, although it could be\\nturned to the right. The injury had been caused by a man who seized\\nher by the head from behind and forcibly twisted it to the side toward\\nwhich it remained deviated. She died seven weeks later, with increas-\\ning paralysis. The autopsy revealed a dislocation of the atlas, the\\ndetails of which are not given. The front of the odontoid process was\\nrough, and the odontoid ligaments were torn and partly destroyed, but\\nthere was no pus. Only the anterior portion of the cord was softened.\\nBlasius describes this case as one of bilateral dislocation in opposite\\ndirections although it was probably such, the description does not\\nprove it.\\nIn the commoner forms of diastasis with inclination and displace-\\nment of the atlas forward, and in complete forward dislocation the\\ntransverse ligament is ruptured, or the odontoid process is broken off\\nand accompanies the atlas. In diastasis all the ligaments uniting the\\natlas to the axis are ruptured in dislocation forward the ligaments of\\nthe posterior arch are sometimes untorn. In a case reported by Philips, 3\\nthe posterior arch of the atlas was broken off on each side and remained\\nin place, while the anterior portion, including the articular surfaces and\\ncarrying with it the fractured odontoid process, was displaced so far\\nforward and downward that it lay entirely in front of, and became\\nunited to, the body of the axis. The patient survived forty-seven\\nweeks and died of hydrothorax. The injury gave rise to no marked\\nsymptoms except persistent stiffness and pain in the neck, which were\\nattributed during life to a strumous arthritis set up by the injury.\\nI have met with no mention of injury to the vertebral arteries or\\nveins.\\nThe spinal cord may be torn across in part or entirely, or crushed,\\n1 Melchiori, quoted by Malgaigne, loc. cit., p. 333.\\n2 Sedillot Gazette Medicale, 1S42, p. 776.\\n3 Philips Med.-Chirurg. Trans, vol. xx. p. 78.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0577.jp2"}, "570": {"fulltext": "502 DISLOCATIOXS.\\nor simply compressed. In double dislocation forward, it is most likely\\nto escape injury if the odontoid process is broken off. On theoretical\\ngrounds, it is also thought not to be greatly endangered in bilateral\\ndislocation in opposite directions.\\nCause. The cause has usually been a fall or blow upon the head.\\nIn forward dislocation, and in complete diastasis, the force has prob-\\nably always been so exerted as to bend the head toward the breast in\\npartial diastasis, with rupture of the ligaments of only one side, the\\ninclination must have been toward the opposite side.\\nUnilateral dislocation or bilateral dislocation in opposite directions may\\nbe produced by exaggerated rotation of the head, as in Sedillot s case.\\nSymptoms. In simple diastasis without displacement, and without\\ninjury of the cord, there may be no symptoms except pain and exag-\\ngerated mobility of the head, and even the latter may be lacking because\\nof spasmodic contraction of the muscles. In the common form, dislo-\\ncation forward, the chin is depressed upon the chest, and a prominence\\nmay be felt at the back of the neck, below the occiput, formed by the\\nspinous process of the axis. In the pharynx may be felt the project-\\ning anterior arch of the atlas. Pain is always present, and usually\\nsevere. Philips s case, above quoted, is a marked exception in respect\\nof pain, disability, and deformity. The nervous symptoms vary with\\nthe degree of injury to the cord.\\nPrognosis. The prognosis, even accepting the cases of doubtful diag-\\nnosis followed by recovery, is very bad. Death may be caused imme-\\ndiately, or suddenly at a later period by the shifting of the loosened\\nbones and the consequent compression of the cord, or by the progress\\nof the changes induced by the primary traumatism.\\nTreatment. Immediate reduction of the displacement and the pre-\\nvention of its recurrence are imperative, if the former can be accom-\\nplished without such violence as would in itself endanger the life of\\nthe patient. Although Philips s case furnishes proof that the persist-\\nence of the displacement is not necessarily incompatible with the pro-\\nlongation of life and activity, and although this proof is supported by\\nthe survival in fair condition of several other patients who have\\nreceived injuries at the upper part of the cervical spine, the exact\\nnature of which was in doubt, but which were followed by permanent\\nrigidity and deformity of the part, yet there can be no question, I\\nthink, of the propriety of making or even of the obligation to make,\\ncautious, well-considered attempts to correct the displacement. Even\\nif dangerous pressure upon the cord has not at the time taken place,\\nyet it is certain that the condition is full of the gravest risk. The\\ndisplacement may gradually increase, as in Dubreuil s case, in which\\nthe chin did not touch the chest until the tenth or eleventh day, and\\ndeath occurred suddenly on the seventeenth, or the fatal increment of\\ndisplacement may be suddenly added by the relaxation of the spas-\\nmodically contracted muscles, or by an incautious movement of the\\npatient, or even of his attendants. This latter has occurred even after\\ncomplete reduction, as in the following case, which I quote in some\\ndetail because it will illustrate many of the prominent features of the\\ninjury.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0578.jp2"}, "571": {"fulltext": "DISLOCATIONS OF THE ATLAS. 503\\nA man l fifty-eight years of age fell down a hill-side and remained\\nall night upon the ground unconscious. In the morning he tried to\\nwalk and found himself unsteady. Help came, and he was taken\\nhome. When seen by the reporter he was seated in a chair, his chin\\nresting on his sternum, his head and neck rigidly fixed. He was con-\\nscious, not paralyzed, and complained of great pain in the neck. There\\nwas a marked prominence at the back of the neck below the occiput.\\nBy steady traction upon the sides of the head the displacement was\\ncompletely reduced with a distinct snap and crepitus, and the pain was\\nrelieved. A week later he sat up in bed, and immediately fell back\\ndead, with reproduction of the original deformity.\\nThe autopsy showed that the odontoid process had been broken off\\nwith a portion of the body of the axis, and displaced forward with the\\natlas (the transverse ligament remaining intact) so far that the lateral\\narticular surfaces were almost entirely separated.\\nAs it seems probable from the shape of the bones that dislocation\\nforward, except in cases that are immediately fatal, is very rarely\\ncomplete, the traction upon the head should be directed somewhat\\nbackward, as well as upward, so as to avoid increase of the displace-\\nment, and may be combined with counter-pressure against the back of\\nthe neck.\\nAfter reduction has been effected, and in cases of diastasis without\\ndisplacement, the head and neck must be made immovable by suitable\\ndressings.\\n3. Dislocations of the Lower Six Cervical Vertebrae.\\nThese are by far the most common of the dislocations of the spine,\\nand the articulations between the fourth and fifth and between the fifth\\nand sixth are those most frequently affected. The varieties that have\\nbeen observed and verified are diastasis, bilateral dislocation forward,\\nbackward, and in opposite directions, and unilateral forward. Of these\\nthe bilateral forward and backward may be classed as dislocations by\\nflexion, and the bilateral in opposite directions and the unilateral for-\\nward as dislocations by abduction and rotation. The bilateral forward\\nand the unilateral fonvard are the most common. The statistics of\\nBlasius show that of 108 cases in which the exact nature of the injury\\nwas ascertained 23 were diastases, 41 bilateral dislocations forward, 37\\nunilateral forward, 4 bilateral in opposite directions, and 3 bilateral\\nbackward to the latter may perhaps be added 8 others in which the\\ndiagnosis was not entirely beyond question.\\nThe positively demonstrated cases of bilateral dislocation\\nbackward are two reported by Porta and one by Stanley. The latter\\nof the fifth cervical, in which the upper five vertebra? were firmly united\\nto one another by bony fusion, has been quoted above, p. 490. The\\ndislocation was complete, the body of the fifth vertebra resting upon\\nthe lamina? and spinous process of the sixth. The injury was caused\\nby a fall backward upon the head and back. Theoretically, it may be\\nassumed that hyperflexion forward of a vertebra, combined with direct\\n1 Gibson Lancet, 1885, ii. p. 429.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0579.jp2"}, "572": {"fulltext": "504 DISLOCA TIONS.\\npressure backward upon it, would produce this form of dislocation, for\\nby the flexion a diastasis would be effected in which the posterior and\\ncapsular ligaments would be torn, and then the direct pressure back-\\nward would rupture the intervertebral disk and produce the displace-\\nment. That the injury is rare notwithstanding the frequency of the\\noccasions in which the head is bent forcibly forward is to be explained\\nby the normal freedom of motion in this direction which allows the\\nchin to be depressed upon the breast.\\nOf the four cases of bilateral dislocation in opposite direc-\\ntions I have been able to examine the original reports in none. Possibly\\nthe one attributed to Malgaigne 1 is the same as the case described in\\nhis Luxations, p. 371, as unilateral forward if so, and if it is retained\\nin the list, it would seem proper also to add Martelliere s case mentioned\\nby Malgaigne upon the following page, 372, as resembling his own in\\nthe associated slight displacement backward of the opposite inferior\\narticular process with rupture of the capsule. In Malgaigne s case\\nthere was also chipping of the lower border of the articular surface of\\nthe dislocated vertebra on the side of the principal dislocation with the\\nproduction of a notch in which the upper edge of the underlying pro-\\ncess was engaged. Similar chipping of the same border was found in\\nMartelliere s case, but the articular process had passed completely\\nbeyond the underlying one and had descended in front of it to a dis-\\ntance of nearly one-quarter of an inch. This form is an exaggeration\\nof the unilateral dislocation forward, and their causes and mode of\\nproduction will, therefore, be considered together.\\nIn bilateral dislocation forward both inferior articular sur-\\nfaces of the dislocated vertebra are carried forward beyond the anterior\\nborders of the underlying ones, and the fixation is effected either by\\nthe dropping of the processes into the notches in front of the latter, or,\\nif the movement forward is combined with anterior flexion, by the\\ninterlocking of the body of the upper vertebra with the projecting\\nlateral borders of the upper surface of the one beneath. Blasius claims\\nthat this is effected almost as frequently by posterior as by anterior\\nflexion, an opinion which it is not easy to accept.\\nIn hyperflexion forward the fulcrum is found at the anterior border\\nof the body of the vertebra, and the first effect is to produce diastasis\\nwith rupture of the posterior and capsular ligaments, and then as the\\nprojecting lip on the inferior anterior border of the body of the upper\\nvertebra engages in front of the upper border of the lower one, and\\nthe force continues to act, not simply to flex but also to crowd the head\\ndirectly down toward the chest, the body of the upper vertebra slips\\ndownward and forward, by which movement the articular surfaces are\\nseparated antero-posteriorly. Then if the neck is straightened the\\nbody .of the vertebra may be raised to its original level, and yet the\\ndislocation will be maintained by interlocking of the articular pro-\\ncesses. Under such circumstances there would be no angle in the\\ndirection of the neck, but only a depression in the nape and a projec-\\ntion in the pharynx corresponding to the body of the dislocated vertebra.\\nOccasionally the spinous process with more or less of the adjoining\\n1 Malgaigne Revue Med. Chirurg., 1S53.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0580.jp2"}, "573": {"fulltext": "DISLOCATIONS OF THE CERVICAL VERTEBRAE.\\n505\\nlaminre is broken off. The intervertebral disk is always torn, and so\\nare usually the ligamenta flava and the interspinous ligament the\\nlongitudinal (anterior and posterior) ligaments are less frequently torn,\\noften only stripped off. The spinal cord may be compressed or crushed\\nor stretched, or may escape injury.\\nAs the articular surfaces are in some cases almost horizontal, it is\\nconceivable that the dislocation may be produced by direct violence\\nacting upon the bone from behind forward, without the aid of either\\nventral or dorsal flexion of the column.\\nIn unilateral dislocation forward l (dislocation by abduction\\nand rotation) the articular surface on one side of the upper vertebra is\\ncarried upward and forward until its posterior edge has passed the\\nanterior edge of the one with which it articulates. At the same time\\nthe spinous process moves from the median line toward the side of the\\ndislocation, and the anterior surface of the body projects slightly in\\nFig. 249.\\nFig. 250.\\nDislocation of the neck by flexion\\nmedian section.\\nBilateral dislocation by flexion fourth cervical\\nvertebra; from behind. (Malgaigne.)\\nfront of that of the underlying one. In short, the movement is one of\\nrotation and abduction about the opposite articular surface as a centre,\\nand by it the vertebral canal is but slightly narrowed, and but little or\\nno violence is done to the cord. The segment of the column above the\\ndislocation is abducted, and forms with the lower part an angle or curve,\\nthe convexity of which is on the dislocated side.\\nThe normal motion in the articulations of this region is one of rota-\\ntion and abduction. The dislocation is produced by carrying the move-\\n1 Blasius (loc. cit., vol. civ. p. 82) found only one case of unilateral dislocation bad-ward\\nof the sixth cervical and even in it there was also fracture of the lamina and body\\nof the seventh vertebra on the side of the dislocation.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0581.jp2"}, "574": {"fulltext": "506 DISLOCATION S.\\nment beyond its normal limits, by any force which over-abducts or\\nover-rotates the upper part of the column. This force may be an\\nexternal one, or one developed by the muscles attached to the head.\\nOf these dislocations by muscular action Volker 1 collected fourteen\\nmore or less certain cases, and made them the basis of a careful study\\nof the subject. Additional cases have since been reported. The move-\\nment which produces the lesions is a sudden turn of the head to one\\nside if it is violent, ill regulated, if its momentum is unchecked by\\nthe antagonistic muscles, it carries the head beyond its normal limit,\\nand produces the dislocation in exactly the same manner as if an ex-\\nternal force had been applied to the head to turn it in the same direc-\\ntion.\\nFig. 251.\\nComplete unilateral dislocation by rotation or abduction.\\nIn diastasis the lesion consists essentially of more or less extensive\\nrupture of the ligaments. It is the same in its forms, nature, and\\netiology as the other varieties, with the exception of the persistent dis-\\nplacement of the bones and of the change in the relations of the artic-\\nular surfaces to each other the displacement is either entirely absent\\nor is slight. A singular instance of the production of a diastasis by\\nmuscular action is reported by Lasalle 2 a crazy man, confined in a\\nstrait-jacket in a chair, jerked his head violently backward and for-\\nward, became at once paralyzed, and died a few hours later. The\\nautopsy disclosed a separation between the fifth and sixth cervical ver-\\ntebrae, with rupture of the posterior ligament, the interspinous muscles,\\nthe ligamenta flava, and the intervertebral disk. The possible produc-\\ntion of hsernatomyelia is to be borne in mind.\\nSymptoms. Unilateral dislocation forward. The posture of the head\\nhas varied so greatly in the reported cases that it is of no value as a\\nsymptom. Xot only may the abduction of the upper segment of the\\ncolumn, which is necessary to the production of the dislocation, be\\nalmost entirely corrected by the sinking back of the articular process\\nof the upper vertebra into the notch of the lower one, but even if it\\npersists it may be so far compensated for or obscured by flexion in the\\noccipito-atloid and rolation in the atlo-axoid articulation, that it will\\nnot be recognized. The face is, however, usually turned away from\\nthe side on which the dislocation has taken place. A painful promi-\\nnence, swelling, or rounding can be recognized on the dislocated side\\n1 Volker Deutsche Zeitschrift fur Chir., 1876, vol. vi. p. 424.\\n2 Lasalle Gaz. Medicale, 1841, p. 763.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0582.jp2"}, "575": {"fulltext": "DISLOCATIONS OF THE CERVICAL VERTEBRJE.\\n507\\nit is due, according to Volker, to the angle created in the column, the\\nslight projection of the transverse process, and the contracted condition\\nof the muscles. Observers differ as to the condition of the muscles on\\nthe opposite side, some reporting them relaxed, others contracted. The\\ndeviation of the spinous process of the dislocated vertebra to the side\\nof the dislocation is a valuable sign when it can be recognized, but the\\ndepth at which the third, fourth, and fifth spinous processes are placed\\nis such that their position cannot usually be determined, and while that\\nof the second can always be felt, its deviation may be unrecognizable,\\nbecause the position of the underlying ones with which it must be com-\\npared remains unknown. The projection of the body of the vertebra\\nin the pharynx is sometimes recognizable by the finger introduced\\nthrough the mouth.\\nThe last named three signs are diagnostic if fracture can be excluded,\\nbut as the last two are unrecognizable in many cases, the first, the\\nexistence of a painful prominence on the side of the neck, is the one\\nupon which the surgeon will usually have to depend.\\nCases may occur, as they have occurred, in which the symptoms are\\nso obscure that a diagnosis be-\\ntween dislocation by muscular Fig. 252.\\naction and muscular rheumatism\\ncannot be positively made. Un-\\nder such circumstances the manip-\\nulations that would reduce a dis-\\nlocation if it were present should\\nbe carefully made. If they re-\\nduce the deformity and relieve\\nthe symptoms they both establish\\nthe diagnosis and cure the patient.\\nIn bilateral dislocation forward\\nthe symptoms vary greatly. The\\nhead may be bent far forward\\ntoward the chest with marked\\nprominence in the nape of the\\nneck of the spinous process of\\nthe vertebra next below the dis-\\nlocated one, or it may be bent\\nbackward or backward and to one\\nside, with marked projection of\\nthe trachea and perhaps larynx,\\nand irregularity in the outline of\\nthe front of the column recogniz-\\nable by palpation through the soft\\nparts. The head may be rigidly\\nfixed, or, more rarely, freely mov-\\nable. These differences depend\\npartly on the position of the dis-\\nlocated bone, the presence or\\nabsence of associated fracture, and the extent of the injury to the con-\\nnecting ligaments, partly on the direction and character of the dislocat-\\nBilateral dislocation forward of the fifth cer-\\nvical vertebra. (From a photograph.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0583.jp2"}, "576": {"fulltext": "508 DISLOCATIONS.\\ning force, and partly on the contraction or relaxation of the muscles\\nwhich control the position taken by the unaffected joints above the seat\\nof injury. In the majority of cases the head is bent forward, and an\\nangle with its apex directed backward is formed by the two segments\\nabove and below the dislocation. Attempts to move the head and\\npressure at the seat of injury are very painful. In these patients the\\nirregularity in the line of the transverse processes may sometimes be\\nrecognized by the touch and if the dislocation is not too low the pro-\\njection of the body of the vertebra may be felt in the pharynx.\\nOf the symptoms of bilateral dislocation backward nothing positive\\ncan be said. In most of the supposed cases the head has been bent\\nbackward, the face directed somewhat upward, the tissues of the front\\nof the neck tense, and respiration and deglutition somewhat interfered\\nwith.\\nIn bilateral dislocation in opposite directions it seems probable that\\nthe head would be fixed in rotation, but possibly not abducted.\\nParalysis, partial or complete, is frequently observed. Its immediate\\nimportance, its urgency, as a symptom varies accordingly as the dislo-\\ncated joint is above or below the point of exit of the phrenic nerve.\\nThe fourth cervical nerve, from which the phrenic mainly arises,\\nthough it receives a branch also from the third or fifth, leaves the ver-\\ntebral canal through the foramen between the third and fourth verte-\\nbra?, but leaves the side of the cord at a somewhat higher point. A\\ndislocation below the third cervical vertebra may cause paralysis of all\\nthe accessory muscles of respiration that act by raising the ribs, but,\\nthe diaphragm continuing to act, prolongation of life is possible. If,\\non the other hand, the dislocation is at a higher point, and the trunks\\ngoing to form the phrenic nerve are injured or the cord is so compressed\\nor torn that the integrity of the corresponding fibres within it is de-\\nstroyed, or they are all cut off from the respiratory centre, then the\\ndiaphragm also, being no longer innervated by these nerves, immedi-\\nately ceases to act, and the individual dies asphyxiated. In a few cases\\nthe threatening symptoms have been instantly relieved by changing\\nthe position of the patient or by systematic reduction of the disloca-\\ntion. In all such threatening cases and in those that are immediately\\nfatal the injury is, as a rule, at one of the upper joints. In the ex-\\nceptions there have been associated injuries to which the death is to be\\nattributed.\\nIf the paralysis is due to compression or laceration of the cord it\\nmay be complete of both motion and sensation below the point of\\ninjury, or it may involve only the motor nerves. It seems probable\\nthat the partial paralyses are due to pressure not upon the cord but\\nupon a nerve trunk in the intervertebral foramen. (See also Haema-\\ntomyelia, in Chapter XI.)\\nLoss of control over the sphincters, incontinence of urine, and the\\nother secondary symptoms of injury to the cord have been already\\nconsidered.\\nPrognosis. The mortality of dislocations of the lower six cervical\\nvertebrae, excluding cases of diastasis, cannot be positively determined\\nbecause of the uncertainty of the diagnosis in cases that recover it is", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0584.jp2"}, "577": {"fulltext": "DISLOCATIONS OF THE DORSAL VERTEBRAE. 509\\nhighest, probably 75 per cent., in bilateral dislocation forward, and\\nmuch less in the unilateral. In the fatal cases death, as a rule, comes\\npromptly, within the first week. Suppuration has been observed about\\nthe seat of injury in cases that remained unreduced. In a number of\\ncases gradual improvement has taken place in the attitude and mobility\\nof the neck. In one reported by Walton l of supposed dislocation of\\nthe third cervical forward the symptoms did not become marked until\\ntwo months after the accident and then increased to complete helpless-\\nness fifteen months after the accident they suddenly improved, and a\\nmonth later recovery was complete.\\nTreatment. In unilateral dislocation forward, at least in those pro-\\nduced by muscular action, Volker says reduction is usually easy and\\nfree from danger. Mention has been made above of the case in which\\na boy reduced his own dislocation by resting his head and shoulder\\nagainst a wall and pressing upon the prominence in the neck with his\\nthumb.\\nSimple traction upon the head, the counter-extension being made by\\nthe weight of the body, followed by rotation of the face toward the\\ndislocated side has proved successful, but it seems better and is gener-\\nally recommended that the articular process should be freed by still\\nfurther abducting the head and upper segment of the column (away\\nfrom the side of the dislocation), and then, when freed, should be\\nrotated backward into place. If traction is used it should be made in\\nthe direction of the long axis of the upper segment, not in that of the\\nlower one, for in the latter case the strain would come wholly or mainly\\nupon the untorn connections on the non-dislocated side and rather tend\\nto depress the dislocated articular process still further in front of the\\ncorresponding lower one than to raise it above it.\\nBilateral dislocations in opposite directions are to be classed with the\\npreceding as dislocations by abduction and rotation, and treated in the\\nsame manner. Probably the differential diagnosis could not be made\\nclinically.\\nIn bilateral dislocations forward the methods that have been employed\\nwith success have combined traction upon the head, either in the sitting\\nor recumbent posture, with pressure upon the front and back of the\\nneck at suitable points.\\nAfter reduction the patient should be kept quiet for some time, and\\nif reproduction of the dislocation is feared a retentive dressing should\\nbe applied. It must be rigid enough to prevent any flexion of the\\nneck forward or backward, and, after unilateral dislocation, should\\ninclude the head so as to prevent rotation. Such a dressing can be\\nconveniently made with plaster of Paris.\\nDISLOCATIONS OF THE DORSAL VERTEBRA.\\nThe cartilaginous surfaces of the articular processes in the dorsal\\nregion are placed more nearly in a vertical plane than those of the\\ncervical vertebra? the superior ones look backward and slightly up-\\nward and outward, the inferior ones, with the exception of those of\\n1 Walton Boston Medical and Surgical Journal, March 21, 1889.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0585.jp2"}, "578": {"fulltext": "510 DISLOCATIONS.\\nthe twelfth, look forward and slightly downward and inward the infe-\\nrior ones of the twelfth are placed like those of the lumbar vertebrae\\nand look outward and somewhat forward. This disposition does not\\nin itself make dislocation to either side by rotation or direct disloca-\\ntion backward with fracture difficult dislocation forward is made pos-\\nsible by flexion sufficient to raise the inferior articular processes of the\\nupper vertebrae above the superior ones of the lower. Dislocation\\nbetween the twelfth dorsal and first lumbar vertebrae seems to be much\\nless favored by the relations of the processes, and yet this is the point\\nin the combined dorsal and lumbar regions where dislocation is by far\\nmost common. Blasius 1 collected twenty-two cases in which the char-\\nacter of the dislocation was demonstrated by autopsy of these one was\\nof the third dorsal vertebra, three of the fifth, one of the sixth, one of\\nthe ninth, three of the tenth, two of the eleventh, and eleven of the\\ntwelfth of the doubtful cases ten were thought to be of the twelfth,\\nfour of the eleventh, and one each of the fifth, eighth, and tenth.\\nThe observed varieties are the bilateral forward and backward with\\nabout equal frequency, the bilateral in opposite directions, and the\\nlateral. Of the latter there are only two demonstrated cases, Bell and\\nMohren stein, twelfth dorsal, and even in these Blasius thinks the injury\\nwas primarily a unilateral dislocation forward or backward, which was\\nfollowed by bodily lateral displacement. In the few cases in which\\nthe condition of the adjoining ribs is noted, these have been found\\nsometimes dislocated and sometimes fractured not far from the column.\\nThe degree of injury to the cord varies with the character and extent\\nof the displacement. Other pathological conditions have been consid-\\nered above.\\nCauses. The causes have been forcible flexion of the trunk forward\\nand the direct action of great violence upon the back or side of the\\nspinal column, as in the fall of a heavy object, or the passage of the\\nwheel of a wagon across the body.\\nSymptoms. The symptoms of the dislocation are found in recog-\\nnizable changes in the position and relations of the dislocated vertebrae,\\nespecially in the prominence of its .spinous processor of the underlying\\none, or in its lateral displacement, and in a deviation of the column\\nwhich creates an angle at the seat of the dislocation, the apex of which\\nis usually directed backward. In some cases it is noted that the artic-\\nular processes of one or the other of the two adjoining vertebrae form\\nprominences under the skin.\\nExcessive mobility at the seat of dislocation has also been observed\\nin most cases.\\nParalysis appears to be more common and more complete in the for-\\nward than in the backward dislocations, and in a few cases has disap-\\npeared after reduction.\\nThe symptoms resemble so closely those of fracture that the differ-\\nential diagnosis, in the absence of post-mortem examination, can rarely\\nbe made with certainty. The failure to obtain crepitus is no proof of\\nthe absence of fracture, and when present it may be due to the presence\\nof an associated unimportant fracture. Reduction and the absence of\\n1 Blasius Loc. cit., vol. ciii. p. 46.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0586.jp2"}, "579": {"fulltext": "DISLOCATIONS OF THE LUMBAR VERTEBRAE. 511\\na tendency to reproduction of the deformity are the best obtainable\\nevidence that the injury was a dislocation.\\nPrognosis. The prognosis, as regards either the preservation of life\\nor the full restoration of function, is not favorable. The uncertainty\\nof the diagnosis in most cases of survival and the comparative few-\\nness of the cases depri\\\\ T e the percentages of value, and it can only\\nbe said that the injury seems more likely to prove fatal when it is\\nsituated in the upper part of the region than when in the lower, and\\nthat in quite a number of cases more or less complete recovery has\\nfollowed.\\nTreatment. Reduction, by extension and counter-extension at the\\nhip and shoulders, has been tried, and sometimes with success. If it\\nis obtained the patient must be kept absolutely recumbent for several\\nweeks, and preferably with the trunk enveloped in a plaster-of-Paris\\ndressing, and the same measures should be employed even when reduc-\\ntion has not been effected, in order to favor the consolidation of the\\nbones in their new positions.\\nDISLOCATIONS OF THE LUMBAR VERTEBRAE.\\nThe possibility of the occurrence of pure dislocation of the lumbar\\nvertebra?, which has been long in doubt because of the close interlock-\\ning of the processes and the strength of the ligaments, is proved by\\ntwo cases collected by Blasius and also, it may be said, by two others\\nin which there was present associated but unimportant fracture of\\nsome of the processes. The first two cases are those of Curling 1 and\\nPorta. 3\\nCurling presented a specimen preserved in the London Hospital\\nMuseum the intervertebral disk between the third and fourth lum-\\nbar vertebra? was destroyed, with slight splintering of the edge of the\\nbone at one or two places the body of the third projected nearly\\nhalf an inch in front of that of the fourth, and the articular processes\\nof the two bones were separated to the same distance the ligaments\\nconnecting the lamina? and the spinous processes were stretched but\\nnot materially torn.\\nThe other two cases are those of Keig 3 and Cloquet. 4 In the\\nformer a sailor twenty-three years old was crushed under a heavy iron\\ncylinder which fell across his back. The second lumbar vertebra was\\ndisplaced backward seven lines, the upper articular process of the third\\nbecoming lodged in the notch of the second the tip of the right lower\\narticular process of the second was broken off but not separated from\\nthe rest the left transverse processes of the first and second vertebra?\\nwere broken off (by muscular action, it was thought), and the spinous\\nprocesses of the ninth, tenth, and eleventh dorsal vertebra? and the\\nleft eleventh and twelfth ribs were broken. The right sacro-lumbalis\\nmuscle was completely divided transversely, and the liver and spleen\\nwere ruptured.\\n1 Curling London Hospital Eeports, vol. iii. p. 355.\\n2 Quoted by Blasius Loc. cit., vol. ciii. p. 55.\\n3 Keig Schmidt s Jahrbiich., vol. cvii. p. 69. (Blasius writes the name KeliJ\\n4 Blasius: Loc. cit., from Journal des Difibrmites, vol. i. p. 453.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0587.jp2"}, "580": {"fulltext": "512 DISLOCATIONS.\\nIn another ca.se Porta found at the autopsy a pure diastasis between\\nthe third and fourth lumbar vertebrae, the bones being separated a few\\nlines without lateral or antero-posterior displacement, and all the liga-\\nments being torn the spinous process of the third was broken at its\\nbase.\\nThe conditions which so effectually oppose dislocation with or with-\\nout fracture are the great breadth, thickness, and elasticity of the\\nintervertebral disks, the large masses of muscle that lie on each side\\nof the spinous processes, and the arrangement of the articular pro-\\ncesses by which those of each upper vertebra are received between\\nthose of the next lower and are thus absolutely prevented from mov-\\ning laterally or from being separated by lateral flexion without fracture\\nof one or the other.\\nSymptoms. The symptoms are irregularity in the line of the spinous\\nprocesses, local pain, disability, and more or less complete paralysis of\\nthe parts below. As the spinal cord is replaced throughout the greater\\npart of this section by nerve trunks, the cauda equina, which less\\ncompletely fill the canal, the paralysis is less likely to be complete than\\nwhen the injury is at a higher point, and it is also more easily recov-\\nered from if the displacement is corrected.\\nPrognosis. The prognosis is more favorable than in dislocations of\\nthe dorsal and cervical regions, presumably because of the usual\\nabsence of injury to the cord, and the less extent of the paralysis and,\\nwhile many of the cases have promptly proved fatal, death has usually\\nbeen due to associated injuries.\\nTreatment. In backward dislocation reduction appears not to have\\nbeen difficult it has been obtained by pressure upon the projecting\\nspinous process, with or without forcible extension of the column. In\\na case reported by Harrison, 1 dislocation backward of the third\\nlumbar vertebra, reduction was obtained with the aid of anaesthesia by\\nextension and counter-extension, combined with moderate pressure\\nupon the spinous process, while the patient was lying upon his back.\\nThe paralysis began to diminish on the following day, and complete\\nrecovery followed, although a slight projection in the line of the column\\npersisted. A plaster-of-Paris jacket was worn for four and a half\\nmonths.\\nPossibly the plan recommended by some of the older surgeons, of\\ncombining flexion forward with traction, would be necessary or useful\\nin some cases. It could be effected by placing the patient on his belly\\nacross the side of a barrel, or by raising him on a cloth passed under\\nhis belly.\\n1 Harrison Lancet, 1885, ii. p. 11-4=", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0588.jp2"}, "581": {"fulltext": "CHAPTER XXXIX.\\nDISLOCATIONS OF THE STEENUM.\\n(See also Fractures of the Sternum.)\\nUnder this title are included only dislocations of the normal\\ndivisions of the sternum from one another, not those of the sternum\\nfrom the clavicles or from the cartilages of the ribs they are those of\\nthe body from the manubrium, and of the ensiform process from the\\nbody.\\nDislocations of the Body from the Manubrium.\\nThe manubrium, constituting nearly the upper third of the sternum,\\nis united to the second piece, the body, by a layer of interposed carti-\\nlage, sometimes hyaline, sometimes more or less distinctly fibrous,\\nand sometimes containing a central synovial sac of variable size. Henle\\nspeaks of this central sac as of rare occurrence Maisonneuve and Brin-\\nton found it in about two-thirds of the cases examined. Ossification\\nof the band occasionally takes place in advanced life the earliest age\\nat which it has been observed is thirty-four years.\\nThe second costal cartilage articulates with both these segments of the\\nsternum at their junction. Although this division of the sternum into\\nsegments was described by the anatomists, no account thereof appears to\\nhave been taken by surgeons until, in 1842, Maisonneuve 1 read before\\nthe Acad6mie de Medecine in Paris a paper in which he called attention\\nto the anatomical divisions of this bone, and reported two cases of dislo-\\ncation of the body from the manubrium Avhich had come under his\\nobservation, and in which he had made the autopsies. Earlier records\\nshow several cases which were doubtless dislocations, but Maisonneuve\\nw T as the first to separate them from the class of fractures and apply this\\nname to them.\\nThe injury is not a common one, even if allowance is made for the\\nprobable description of some as fractures. Malgaigne, in 1855, could\\ncollect only ten examples, although he included in the list several of\\nthe older cases reported as fractures Ancelet 2 collected sixteen cases\\nof all kinds, Brinton 3 thirteen of dislocation forward, and added one\\nof his own. Gurlt, 4 in his table of fractures and disastases of the ster-\\nnum, has twenty-nine cases classified as diastasis between the first and\\nsecond pieces, and three between the second and third. Adding to\\nthese those quoted by Ancelet, Brinton, and Servier, 5 the list is increased\\nto more than forty. Only one of the patients was a woman, and the\\nages ranged from thirteen to more than sixty-five years.\\n1 Maisonneuve Arch. gen. de Med., 1843, vol. xiv. p. 249.\\n2 Ancelet Gazette des Hopitaux, 1863, p. 257.\\n3 Brinton American Journal of the Medical Sciences, July, 1867, p. 39.\\n4 Gurlt: Die Knochenbruche, 1862, vol. ii. p. 31.\\n5 Servier; Diet. Encyclopedique, 1884, art. Sternum.\\n33 513", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0589.jp2"}, "582": {"fulltext": "514 DISLOCATIONS.\\nIn sixteen the body was completely dislocated forward and upward\\nupon the manubrium, in three or four backward in two the dislocation\\nwas incomplete forward, and in one the two segments were separated\\nlongitudinally.\\nCauses. The injury has been produced by direct and indirect vio-\\nlence, and, possibly, in one or two cases, by muscular action. Guines, 1\\nin the report of a case of tetanus in a boy thirteen years old, states\\nthat on the seventh day he found the breast elevated, all the false ribs\\ndisplaced and carried upward, the sternum bent at the junction of the\\nfirst and second pieces, and forming with the ensiform process an\\neminence three inches high. The pectoral muscles were forcibly con-\\ntracted, while those of the abdomen were, if not in their natural condi-\\ntion, at least much relaxed (compared with their previous condition).\\nOn the eighteenth day, the tetanus having ceased, it is noted that the\\ndeformity of the breast persisted. I understand this to mean that\\nthere was an angular displacement at the junction of the first and\\nsecond pieces, the apex being directed backward, and the ensiform\\nprocess distant three inches further than usual from the spine.\\nIn two other cases muscular action may possibly have been the\\ndetermining cause, but the mode of production is obscure in one of\\nthem (Drache, quoted by Malgaigne), a young man fell into a cellar\\nwith some falling timber, which rested upon his chest while striving\\nto free himself he felt a snap in the region of the sternum, and the\\ndislocation was thought to have been then produced. In the other\\n(Ancelet), a boy thirteen years old was exercising on parallel bars with\\nhis chest bent forward his feet unexpectedly touched the ground, and\\na forward dislocation, complete on only the left side, was produced.\\nIn the case of longitudinal separation (Aurran and David), the\\npatient fell from a height of fifty feet, striking on his back across a\\nlow wall so that his head was on one side and his legs on the other.\\nHe received at the same time a fracture of the spinous processes of the\\nlast two dorsal vertebras, and the dislocation (a diastasis) seems, there-\\nfore, to have been produced by hyper-dorsal flexion of the spinal col-\\numn, by which the two segments of the sternum were pulled apart.\\nThe case seems, to some extent, to confirm the theory of the possibility\\nof dislocation by muscular action. The patient recovered.\\nIn three cases a forward dislocation was caused by violence received\\ndirectly upon the front of the chest, presumably upon the manubrium.\\nOne patient (Aurran) fell with a ladder, striking his chest against one\\nof the rungs another (Malgaigne) fell against the gunwale of a boat\\nthe third (Fremey 2 was struck and killed by the pole of a wagon.\\nDrache s case also is sometimes quoted as an example of direct vio-\\nlence, and so perhaps may be Richet s, 3 in which some boxes of soap\\nfell upon a man, and caused a dislocation backward of the body upon\\nthe manubrium. Reid s patient was kicked by a mule the direction\\nof the displacement is not mentioned.\\nIn Duverney s 4 patient the injury was compound, and was caused\\n1 Grumes: Arch. gen. de Med., 1829, vol. six. p. 396.\\n2 Frerney Bull, de la Soc. Anatoinique, 1S68, vol. xiii. p. 419.\\n3 Eichet, reported by Siredy in Bull, de la Soc. Anat., 1857, vol. ii. p. 305.\\n1 Duverney Maladies des Os, 1751, vol. i. p. 235.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0590.jp2"}, "583": {"fulltext": "DISLOCATIONS OF THE STERNUM. 515\\nby the forcible compression of the sides of the chest by a falling stone,\\nthe second piece being thrust forward (see Fractures, p. 175) and in\\nPitha s it was caused by similar lateral compression between the buffers\\nof two railway cars,\\nIn most of the others the injury was caused by a fall from a height,\\nby which the trunk was probably bent forcibly forward, as shown in\\nseveral of them by associated fracture of the cervical or dorsal verte-\\nbrae. The mode of production in these cases appears to be similar to\\nthat by lateral compression of the ribs the first and second ribs being\\nshorter and more rigid than the others, the manubrium remains fixed,\\nwhile the second piece is pushed forward and upward by the other ribs\\nthat articulate with it and which are themselves pressed forward by\\nthe flexion of the spine. Servier demonstrated this action upon the\\ncadaver by exposing the sternum and costal cartilages, dividing the\\nthird, fourth, and fifth of the latter, and then throwing the body back-\\nward from a sitting position so as to strike upon its shoulders on the\\nfloor the ends of the ribs could be seen to spring forward and inward.\\nPathology. In the common form, dislocations of the second piece\\nforward and upward, the bones override, sometimes as much as an\\ninch the anterior fibrous layer lining the bone is torn, the posterior\\none stripped from the second piece. The second costal cartilages almost\\ninvariably remain in contact with the manubrium. Sometimes the\\nthird and fourth have been broken.\\nIn two cases, Nelaton s and Ancelet s, the dislocation was incom-\\nplete in the latter the body was turned about its longitudinal axis\\nso that its left upper corner was elevated above the manubrium and\\nthe second costal cartilage to a distance fully equal to the thickness of\\nthe bone, while its right upper corner remained in place.\\nThe dislocations of the body backward furnish two autopsies. Saba-\\ntier s 2 patient was an elderly man who, after having been beaten with\\nthe fists, was thrown into a ditch thirty feet deep he survived for a\\nweek. The body of the sternum was displaced 2.8 cm. upward behind\\nthe manubrium there was a large extravasation of blood under the\\nskin and in the substance of the right lung, which was extensively\\nbound down by old adhesions.\\nRichet s patient, twenty-seven years old, was thrown down upon his\\nback by some heavy boxes that fell from a wagon upon his chest and\\ncaused many associated injuries he died of pyaemia on the twenty-\\nsecond day. The body of the sternum was displaced backward and\\nslightlv upward behind the manubrium the second costal cartilage on\\nthe left side remained attached to the body, that of the right side was\\nseparated from both body and manubrium, and its end was free in an\\nabscess that bathed the dislocation. There was a complete transverse\\nfracture of the manubrium half an inch above its lower end, and a\\nfracture of the body without displacement at the level of the articula-\\ntion of the fourth costal cartilages. There was a compound fracture\\nof the left leg, and simple fractures of the left third and fourth ribs\\nand of the right radius.\\nThe complications have been numerous and varied fractures of the\\n1 Gurlt Loc. cit., p. 225. Guilt Loc. cit., p. 275.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0591.jp2"}, "584": {"fulltext": "516 DISLOCATIONS.\\ncervical and dorsal vertebra?, of the ribs and costal cartilages, rupture\\nof the adherent lung, rupture of the lungs and heart (Duverney).\\nSymptoms. In the severe cases those complicated by other injuries,\\nespecially of the spinal column and thoracic viscera the general symp-\\ntoms due to the dislocation may be masked or increased by those of\\nthe other lesions in general terms, the rational symptoms in forward\\ndislocation are more or less transient oppression of breathing and sharp\\npain at the seat of injury, increased by pressure or by movements of the\\nbody or head.\\nThe neck and trunk are bent forward, the lower ribs appear promi-\\nnent, and the upper ones depressed. The anterior surface of the ster-\\nnum presents a well-marked elevation at the level of or just below the\\nfirst intercostal space, which has a sharp, well-defined upper margin\\nrising directly from the manubrium and is continuous below with the\\nbody of the sternum. The absence of the second costal cartilages\\nfrom the upper corners of the body makes it possible to recognize with\\nthe finger the shallow, saucer-like depression at these points with which\\nthey articulate. The recognition of these depressions, or the distance\\nof the upper edge of the projection from the line of the third ribs,\\nwill enable the surgeon to distinguish a dislocation from a fracture of\\nthe body and the presence of the second costal cartilages below the\\nupper edge of the projection will indicate a fracture of the manubrium.\\nPrognosis. The prognosis is grave more than half the patients have\\ndied of their injuries, though doubtless the fatal result is to be attrib-\\nuted in most of the cases to the associated lesions. In the cases that\\nhave survived a failure to effect reduction has not led to any disability\\none of the patients in the list had borne his unreduced dislocation for\\nfifteen years without inconvenience. Stetter l mentions, without giving\\nthe reference, a case observed by Audic of habitual dislocation back-\\nward (or of the manubrium forward) which recurred every time the\\npatient rose from the recumbent posture without supporting his head.\\nTreatment. Reduction is to be made by bending the trunk backward\\nand making pressure upon the projecting piece of the sternum. The\\npatient should be placed upon his back on a firm cushion or on a table\\nwith his head and shoulders projecting beyond its end, and then the\\nhead and neck should be drawn backward, and counter-extension made\\non the pelvis. It is recommended also that in dislocation backward\\nthe patient should be encouraged to make full inspirations.\\nAfter reduction is made a body bandage, or, better, a broad strip of\\nadhesive plaster, should be placed around the chest.\\nIn case of failure to reduce by these or other simple means, resort\\nshould not be had to cutting operations unless grave indications due to\\npressure upon the thoracic organs should exist.\\nPathological Dislocations. To the three examples of this kind quoted\\nby Malgaigne, Bourneville 2 has added a fourth. In two, as a result of\\nfrequent pressure against the sternum, displacement took place between\\nthe first two pieces, one angular with projection of the upper edge of\\nthe second piece, the other of the second behind the first. In the third\\n1 Stetter: Compend von den Luxationen, 1886, p. 19.\\n2 Bourneville Bull, de la Soc. Anatomique, 1869, vol. xiv. p. 56.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0592.jp2"}, "585": {"fulltext": "DISLOCATIONS OF THE STERNUM. 517\\ncase the body of the sternum and the connected costal cartilages could\\nbe pressed back to a depth of two inches. In Bourneville s there was\\ntubercular suppuration at the junction of the first two pieces, with\\nslight displacement of the second forward.\\nDislocation of the Ensiform Process.\\nOf this injury, referred to by many of the earlier writers as a pos-\\nsibility, only five or six more or less well-authenticated cases are on\\nrecord. They are those of Martin and Billard quoted by Malgaigne,\\nPolaillon, 1 Gallez quoted by Servier, and Hamilton. 2 In addition may\\nbe mentioned the reference made by Malgaigne to an example observed\\nin a new-born child by Seger, and that to one similar to Polaillon s\\nquoted by Mauriceau in the discussion on his case.\\nPolaillon s patient was a woman thirty-five years old, and her injury\\nwas caused apparently by tight lacing to conceal the enlargement of\\npregnancy all the others were males, and their injuries were caused\\nby blows received upon the epigastrium their ages were eighteen,\\nnineteen, twenty-eight, and fifty-three years.\\nXo autopsy was had in any case, and in Polaillon s alone is the con-\\ndition described with sufficient detail to make it reasonably certain that\\nthe separation took place at the line of union between the process and\\nthe body of the sternum the others may have been fractures of the\\nprocess itself. In Polaillon s the base of the process was displaced\\nbackward, and the point looked directly forward. In Hamilton s, first\\nseen by him twelve years after the accident, the cartilage was bent\\nat right angles with the sternum, pointing directly toward the spine.\\nIn the other cases the character of the displacement is not fully de-\\nscribed, but apparently the apex of the process was directed backward\\nin most.\\nIn three cases the most prominent symptom was persistent vomiting,\\nwhich in one (Hamilton s) recurred every five or six days for two\\nyears and then ceased spontaneously, in another (Martin) it was relieved\\nby grasping the process with the fingers and drawing it forward into\\nplace, and in a third (Billard), after it had lasted a month and threat-\\nened to prove fatal, it was relieved by drawing the process forward by\\nmeans of a blunt hook introduced below it through an incision. Polail-\\nlon s patient suffered sharp pain, which was excited by the pressure of\\nthe clothing and the ingestion of food, and was extremely severe during\\ndelivery reduction was impossible, and after a time the inconvenience\\ncaused by it ceased. In Gallez s case the prominence could be reduced\\nand reproduced with a click by manipulation the patient suffered only\\nlocal pain and was promptly cured by reduction maintained by the\\naid of a small compress fixed over the process by means of adhesive\\nplaster.\\n1 Polaillon Bull, de la Soc. de Chirurgie, 1877, p. 9.\\n2 Hamilton Fractures and Dislocations, 6th ed., p. 182. The account leaves it uncer-\\ntain whether this was deemed a fracture or a dislocation.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0593.jp2"}, "586": {"fulltext": "CHAPTEEXL.\\nDISLOCATIONS OF THE EIBS AND THE COSTAL CARTILAGES.\\nUxder this title are included dislocation of the ribs at their junction\\nwith the vertebra?, of the ribs from the costal cartilages, of the carti-\\nlages from the sternum, and of the cartilages of some of the lower ribs\\nfrom one another.\\nThe. head of each rib articulates with the bodies of one or two ver-\\ntebra? by a true joint containing one or two synovial sacs and strength-\\nened by firm ligaments the tubercle and neck of each rib, except the\\neleventh and twelfth, are united to the transverse process of the corre-\\nsponding vertebra by a synovial joint and ligaments and to the trans-\\nverse process of the vertebra next above by a longer ligament. The\\nunion between each rib and its costal cartilage is direct, without a\\nsynovial sac, and is strengthened on the anterior surface by the perios-\\nteum. The articulations between the costal cartilages and the sternum\\nare, with the exception of the first, true synovial joints, sometimes\\ndouble, surrounded by a capsule which is strengthened in front and\\nbehind to form the anterior and posterior ligaments. The seventh rib\\nis the lowest that articulates with the sternum. The fifth, sixth,\\nseventh, eighth, and ninth costal cartilages are united with one another\\nfor a short distance on their contiguous margins by true synovial joints\\nformed by slight projections on their margins and surrounded by\\ncapsules which are strengthened by fibres derived from the anterior\\nintercostal aponeuroses.\\nDislocation of the Head of the Rib. (Luxatio Costo-vertebralis.)\\nThe first recorded case, and that a doubtful one, was reported in\\n1753 to the Academie de Chirurgie by Buttet. His patient was a\\nman fifty-five years old who had been run over by a wagon he was so\\nfat and the swelling Avas so great that the outlines of the ribs could\\nnot be traced, and the diagnosis was based on the fact that when press-\\nure was made upon the front of the chest the sixth rib on the right side\\ncould be felt to move with a very distinct, audible click which, moreover,\\nwas reproduced whenever the patient made a movement of his trunk.\\nThe next case was HankeFs 1 in 1834 a young man fell into a clay-\\npit and received an injury in the lower dorsal region he died on the\\nfifteenth day, and the autopsy showed fractures of the eleventh dorsal\\nvertebra and of the twelfth rib on each side and a dislocation of the\\neleventh left rib.\\nDuring the next following six years six additional cases were re-\\nported, and the list has not since been added to except by Webster s\\n1 Hankel Gazette Medicale, 1834, p. 187.\\n518", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0594.jp2"}, "587": {"fulltext": "DISLOCATIONS OF BIBS AND COSTAL CABTILAGES. 519\\ncase, the date of occurrence of which is not known but is probably\\nearlier than that of the others, and by Quint. 1\\nIn all but one of the nine (Kennedy) the condition was shown by\\nautopsy. The causes were extreme violence, falls or blows, and in\\none a gunshot wound. The ribs dislocated were the first, fourth,\\nsixth or eighth, and tenth once each seventh, eleventh, and twelfth\\ntwice each in one case the right eleventh and twelfth and the left\\neleventh. In two cases the corresponding vertebra was broken, and in\\nfour one or more adjoining ribs were broken. With one exception the\\npatients died promptly or within a few days in consequence of asso-\\nciated injuries. The exception was Webster s in his the head of the\\nseventh rib was found united with the front part of the vertebra, hav-\\ning been displaced, it was thought, in a fall from a horse several years\\nbefore the injury was thought at the time to be a fracture of a rib.\\nSeparation of the Ribs from the Costal Cartilages.\\n(Luxatio Chondro-costalis.)\\nOf this injury there are only eight, possibly nine, examples on\\nrecord, and in only one of these was the condition demonstrated by\\nautopsy. Of the latter our only knowledge is through the description\\nof the specimen presented without history to the Societe Anatomique\\nby Carbonell. 2 It showed a separation of the second, third, and fourth\\ncartilages from the ribs, with fracture of the ossified union between\\nthe first rib and the sternum and of the fifth costal cartilage one centi-\\nmetre from its outer end all five ribs were also broken at their angles,\\nand the right bronchus was torn away from the trachea.\\nThe other cases are those of Chaussier, 3 Bell, 4 Bouisson, 5 De Kimpe, 6\\nBradley, 7 Stimson, 8 and B. F. Curtis. 9\\nIn four of the cases the patient had been crushed between a moving\\nbody and a wall in two the cause was a blow upon the front of the\\nchest in one the patient had long suffered with a cough and had\\nthereby produced a hernia of the lung between the eighth and ninth\\nribs on the left side and another between the seventh and eighth ribs\\non the right side at the level of their junction with the cartilages,\\naccompanied by a separation between the seventh rib and its cartilage\\non the right, and between the eighth and its cartilage on the left at\\neach of these points the rib was movable with crepitus.\\nIn Bell s case the ends of all the ribs on both sides projected dis-\\ntinctly at their junction with the cartilages in the others the displace-\\nment of the end of the rib was in some forward, in some backward.\\nIn Bradley s all the ribs from the first to the sixth were depressed in\\n1 Webster, Cooper on Dislocations and Fractures, Am. ed., 1844, p. 450 Boudet, Bull,\\nde la Soc. Anatomique, 1839, vol. xiv. p. 104 Alcock, 2 cases, London Medical Gazette,\\n1838-39, vol. ii. pp. 586 and 587; Kennedy, Dunne, and Finnecane, Dublin Medical Press.\\nFebruary and March, 1841, abstracts in Gazette Med., 1841, p. 410 and Quint, Bull.\\nMed. du Nord., June, 1888.\\n2 Carbonell Bull, de la Soc. Anatomique, 1865, p. 17.\\n3 Chaussier Bull, de la Facuite, 1814. p. 50.\\n4 Bell Surgical Observations, 1817, p. 171.\\n5 Bouisson Gurlt, loc. cit., vol. ii. p. 251. 6 De Kimpe: Gaz. des Hop.. 1852. p. 18.\\n7 Bradley Medical Eecord, August 24, 1890.\\n8 Stimson New York Medical Journal, March 1, 1890. 9 B. F. Curtis Ibid.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0595.jp2"}, "588": {"fulltext": "520 DISLOCATIONS.\\nmine the second rib was dislocated backward from its cartilage, and\\nthe cartilages of the third to the sixth forward from the sternum. In\\nBouisson s and De Kimpe s the fourth and fifth ribs respectively were\\ndisplaced forward.\\nThe possible ninth case is Monteggia s, 1 a separation of the second\\nand third costal cartilages in a very emaciated man seventy years old,\\nin consequence of a violent attack of coughing. Gurlt says Mon-\\nteggia declares expressly that it was not a fracture of the cartilage but\\na separation of the epiphysis/ by which, of course, is meant a separa-\\ntion at the costo-chondral junction.\\nThe injury is so closely allied to fracture of the cartilages that the\\nreader is referred for other details to Chapter XVI.\\nDislocation of the Costal Cartilages from the Sternum.\\n(Luxatio Chondro-sternalis.)\\nOf this injury there are fourteen recorded examples Ravaton,\\nManzotti, Monteggia, and Bell, quoted by Malgaigne Cooper, 2\\nFlagg, 3 Wol fen stein, 4 Gross, 5 Bennett, 6 Mulvany, 7 Blodgett, two cases, 8\\nStoner, 9 and mine quoted in the preceding section. There are, in addi-\\ntion, one or two cases, elsewhere referred to (see Chapter XXXIX.),\\nin which separation of the first and second pieces of the sternum has\\nbeen accompanied by complete separation of the second costal cartilage\\nfrom the sternum on one or both sides.\\nIn three of the cases (Bell, Cooper, and Blodgett s second) the cause\\nappears to have been traction exerted through the pectoralis major, in\\nswinging dumb-bells, kneading bread, and exercising on parallel bars\\nand possibly the cause was the same in Blodgett s first case, in which\\na man while carrying a piano made a violent effort to prevent its fall.\\nIn four others the cause was a fall or compression of the chest in the\\nremainder it is unrecorded or obscure.\\nThe fourth cartilage was displaced singly forward in three cases,\\nforward in combination with the fifth and sixth in two, and backward\\nwith the second and third in one the third singly, the fifth and sixth\\ntogether, and the fifth, sixth, and seventh together were displaced for-\\nward in two cases, the third to the sixth forward in one, and the first\\nand second w T ere together displaced forward and outward once (Blod-\\ngett s first). In two cases it is not stated which cartilage was dis-\\nplaced, nor in what direction.\\nThe only autopsy was in Bennett s case. The patient was a woman\\nabout fifty-six years old who had been run over by a cart and died a\\nfew days later of pleurisy and pneumonia. The third cartilage on\\nthe left side was displaced forward, and there was also fracture of the\\n1 Gurlt: Loc. cit., vol. ii. p. 250. 2 Cooper: Loc. cit.. p. 451.\\n3 Flagg Northwestern Medical and Surgical Journal, August, 1871, quoted by Ham-\\nilton.\\n4 Wolfenstein Allg. Wiener nied. Ztg., 1873, No. 44, quoted by Poinsot.\\n5 Gross Surgery, 6th ed., vol. i. p. 1132.\\n6 Bennett Dublin Journal of the Medical Sciences, 1879, i. p. 441.\\n7 Mulvany Lancet. 1882, i. p. 432.\\n8 Blodgett New York Medical Journal. 1883. vol. xxxviii. p. 34.\\n9 Stoner: The Physc. and Surg., October, 1869", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0596.jp2"}, "589": {"fulltext": "DISLOCATIONS OF RIBS AND COSTAL CARTILAGES.\\n521\\nsecond, third, fourth, and fifth ribs on the same side, and of the second\\nto the ninth ribs on the right side. The perichondrium with the\\nattached ligaments was stripped clean off. The dislocation was reduced\\nby direct pressure and did not recur it must be remembered, however,\\nin connection with this, that the corresponding rib was broken.\\nIn the single case of backward dislocation (Mulvany) the patient\\nwas a boy fifteen years old, who while steering a ship in a heavy storm\\nwas thrown violently across the deck by a w r ave and struck upon the\\nback of his left shoulder against the deck-house. The second, third,\\nFig. 253.\\nDislocation forward of the third to the sixth costal cartilages from the sternum, and of the first\\nrib backward.\\nand fourth left cartilages were displaced backward behind the sternum,\\nand the sternal end of the right clavicle was dislocated forward.\\nReduction could be effected by drawing the shoulders backward, but\\nthe displacement immediately recurred when the traction ceased. The\\npatient was kept upon his back for eighteen days, and the deformity\\nwas then found to have been much diminished. In two months he\\nwas again at work.\\nUsually there has been sharp local pain at the moment of the acci-\\ndent, subsequently excited by movements of the thorax and by local\\npressure. In one case (Mulvany) there was slight recurrent haemoptysis.\\nThe recognition of the injury appears always to have been easy, by", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0597.jp2"}, "590": {"fulltext": "522 DISLOCATIONS.\\nattention to the difference in level between the cartilage and the\\nsternum. In only one case (Wolfenstein) was it mistaken for a local\\ninflammation.\\nReduction of the forward dislocations was in every case easily effected\\nby direct pressure, but the tendency to recurrence was marked.\\nThe best treatment would appear to be the application over the dis-\\nplaced cartilage and around the chest of a broad strip of adhesive\\nplaster, as in fracture of a rib, making special local pressure, if neces-\\nsary, with a compress. Possibly a truss could be used with advantage.\\nDislocation of One Cartilage upon Another.\\n(Luxatio Chondro-chondralis.)\\nMalgaigne collected three supposed cases, one of which came under\\nhis own observation. I think they should rather be classed as dislo-\\ncations of the ribs from the cartilages, or of the cartilages from the\\nsternum, although there was also displacement above or below the level\\nof the adjoining ribs.\\nIn the following two the character of the lesion is more apparent\\nHochenzegg presented to the Gesellschaft der Aertze in Vienna a\\npatient thirty years old, who in a fall broke the bond between the\\nseventh and eighth ribs. A year later after a fit of coughing he felt\\nsomething give away in his side and found a wide space between those\\nribs.\\nAunis 2 found in a man fifty years old a dislocation forward of the\\nseventh cartilage from the eighth it could be reduced by pressure, but\\nimmediately recurred. The injury was caused by a fall backward.\\n1 Hochenzegg: Medical Press and Circular, Dec. 17, 1890.\\n2 Aunis: Gaz. Hebdom., March 13, 1892.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0598.jp2"}, "591": {"fulltext": "CHAPTEE XLL\\nDISLOCATIONS OF THE CLAVICLE.\\nOf the Sternal End Forward, backward, upward Of the Acromial End\\nSupra-acrornial, subacromial, subcoracoid Simultaneous of Both Ends.\\nOf 1103 dislocations of all kinds (Chapter XXVII.) 53 were of the\\nclavicle, nearly 5 per cent. 39 of the acromial, 14 of the sternal end.\\nThe period of greatest frequency appears to be between the thirtieth\\nand fiftieth years, and during it the injury is almost wholly confined\\nto males.\\nThe dislocation may be of either end or of both, and occasionally\\nboth clavicles have been simultaneously dislocated.\\n1. DISLOCATIONS OF THE STERNAL END OF THE CLAVICLE.\\nAnatomy. The sternal end of the clavicle is so much larger than\\nthe clavicular notch of the sternum with which it articulates that it\\nprojects above it and in front and behind. The articular surfaces are\\nseparated from each other by an interposed fibro-cartilaginous disk, or\\nmeniscus, of varying thickness, which\\nis most strongly attached above to\\nthe upper edge of the end of the clav-\\nicle, and below to the cartilage of the\\nfirst rib. On each side of it is a syn-\\novial cavity. The ligaments of the\\njoint are the interclavicular, costo-\\nclavicular, and the anterior and pos-\\nterior sterno-clavicular. The inter-\\nclavicular ligament extends across\\nfrom the upper edge of the end of\\none clavicle to that of the other above\\nthe interclavicular notch of the ster-\\nnum, sending bundles of fibres into\\nthe meniscus and to the top of the\\nsternum. The costo-clavicular liga-\\nment extends from the sternal end of\\nthe first rib upward and outward to the under surface of the clavicle\\nas far as to the subclavian vein, partly surrounding the inner end of\\nthe subclavius muscle but lying mainly behind it. It sometimes\\ncontains within itself a bursa of considerable size. The anterior and\\nposterior sterno-clavicular ligaments cover in the joint in front and\\nbehind respectively, mainly constituting its capsule. They are short\\nand quite tense.\\n523\\nFrontal section through the sterno-clav-\\nicular joint. A, rhomboid or costo-clav-\\nicular ligament B, meniscus C, inter-\\nclavicular ligament. (Henle.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0599.jp2"}, "592": {"fulltext": "524 DISLOCATIONS.\\nMotion is possible about all the axes to this extent, that the acromial\\nend of the bone can be made to describe a circle which is the base of\\na cone having an angle of 60 degrees at its apex in the joint. Move-\\nment of the shoulder downward and backward is arrested by contact\\nof the clavicle with the first rib, and if then continued this point of\\ncontact becomes the centre of motion, or the fulcrum, and the sternal\\nend of the clavicle is forced upward or forward out of its place, and\\na dislocation is produced.\\nVarieties. The dislocation may be complete or incomplete, upward,\\nforward, or backward and when complete it is usually also inward,\\ntoward the median line, and when complete forward or backward it is\\nusually also downward. Possibly a separate class of dislocations,\\nupward and outward, should be made of such cases as those of Stokes\\n(vide infra), in which the cause is the prolonged action of the stern o-\\ncleido-mastoid muscle in forced inspiration.\\nDislocation Forward. (Luxatio Claviculae Praesternalis.)\\nThis is the most common form, and is usually caused by the shoulder\\nbeing forced backward, or backward and downward. The means by\\nwhich this movement has been produced are various in some cases it\\nhas been a fall upon the point of the shoulder or upon the extended\\nhand in others, the pressure of some heavy object upon the front of\\nthe shoulder when the body was supine, as the wheel of a wagon or the\\nfoot of a horse in others, again, by the sudden slipping of a heavy\\nburden carried upon the back by straps passing around the shoulders.\\nRicherand 1 reported a case in which it was caused in a girl twenty\\nyears old by the forcible approximation of her elbows behind her back,\\nand Boyer another in which the shoulders were drawn back to give the\\npatient, a young girl, a more erect and graceful carriage. In like man-\\nner, it has been caused by the voluntary throwing back of the shoulders,\\nas in soldiers at drill, and in one case, Bardenheuer, 2 by the involun-\\ntary effort made to prevent the fall of a burden carried upon the head.\\nIn all of these the mechanism is the same the outer end of the\\nclavicle is carried back to the limit of the normal range of motion, and\\nthen it either finds a new centre of motion at the joint at which it\\ncomes into contact with the first rib, in consequence of which the\\ninner end is carried forward if the movement is prolonged, or the ante-\\nrior sterno-clavicular ligament is put upon the stretch and ruptured,\\nand then dislocation takes place.\\nIn a few cases it has been gradually produced, apparently by the\\nrelaxation of the ligaments, the dislocation then occurring whenever\\nthe arm was raised and being spontaneously reduced when it was low-\\nered. In one of my cases both clavicles were thus affected. The same\\ncondition of easy recurrence and reduction may follow a primary trau-\\nmatic dislocation.\\nIn a few cases the dislocation has been caused by the pressure of an\\naneurism at the root of the neck, and in others 3 by prolonged, forced,\\n1 Eicherand: Quoted by Polaillon, loc. cit., p. 729.\\n2 Bardenheuer: Deutsche Chirurgie, Lief. 63, a. p. 57.\\n3 Stokes Dublin Medical Journal, 1852, vol. xiii. p. 459.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0600.jp2"}, "593": {"fulltext": "DISLOCATIONS OF THE CLAVICLE. 525\\ninspiratory efforts. In the latter (two cases) the dislocations appear to\\nhave been primarily upward, and the displacement forward to have\\nbeen the consequence of the elongation of the ligaments. In one of\\nthem both clavicles were dislocated.\\nCazin l reported a case in which the dislocation was gradually pro-\\nduced in a boy eleven years old who was suffering from Pott s disease\\nof the dorsal spine with angular deformity and retraction of the corre-\\nsponding side of the chest, and who had the habit of resting on his\\nelbows in bed. Cazin thought the displacement was due to the dimi-\\nnution of the size of the upper part of the chest, not to the force\\nexerted through the arm.\\nAge. According to Bardenheuer, Fergusson met with a case in which\\nthe dislocation was produced in a child during delivery. The next\\nearliest age at which the injury has been reported is ten months it\\nwas caused by a fall from bed. 2\\nPathology. The dislocation may be complete or incomplete in the\\nlatter form the posterior portion of the articular surface of the clavicle\\nremains in contact with that of the sternum, and the anterior sterno-\\nclavicular ligament alone is ruptured. In the former the articular\\nsurfaces are completely separated, and the posterior edge of that of the\\nclavicle rests upon the front of the sternum ordinarily it lies nearer\\nthe median line and at a lower level than that of its normal position, the\\ngreatest recorded displacements being one mentioned by Richerand,\\nthree inches downward, and one reported by Jousset 3 in which the end\\nof the clavicle lay upon the second rib. This displacement inward or\\ndownward or in both directions must be secondary and due to the\\naction of the weight of the corresponding limb and to the contraction\\nof the muscles which draw the shoulder inward, downward, and for-\\nward when it is deprived of its normal support, in the same manner\\nand for the same reasons as after fracture of the clavicle. The oppor-\\ntunities for post-mortem examination have been so few that a positive\\naccount of the condition of the ligaments cannot be given. That the\\nanterior one is ruptured cannot be doubted, and it is probable that the\\nposterior one also is torn, although in some cases it may only be torn\\nfrom its attachment and left continuous with the stripped-up perios-\\nteum of the posterior surface of the clavicle. In one case 4 all the liga-\\nments except the anterior sterno-clavicular are described as intact the\\nmeniscus accompanied the clavicle and was partly torn. In a case\\nreported by Cloquet 5 there was found at the autopsy instead of rupture\\nof the posterior ligament a fracture that split the end of the clavicle\\ninto two parts, the posterior one of which remained in place, while the\\nanterior one, continuous with the shaft of the bone and capped by the\\nmeniscus, was dislocated forward. Whether or not the meniscus habit-\\nually accompanies the end of the clavicle in its displacement is not\\nknown.\\nIn the cases in which the dislocation has been slowly produced,\\nStokes s and probably Heusinger s, the ligaments were found greatly\\n1 Cazin Gaz. des Hopitaux, 1874, vol. xlvii. p. 507.\\n2 T. E. Wright: Boston Medical and Surgical Journal, 1SS0, vol. cii. p. 333.\\n3 Jousset Gaz. Medicale, 1833, p. 217. i Bull, de la Soc. Anatomique, 1879, p. 809.\\n5 Cloquet Nouveau Journ. de Med., 1820, vol. vii. p. 248, quoted by Polaillon.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0601.jp2"}, "594": {"fulltext": "526 DISLOCATIONS.\\nelongated but not torn. Stokes does not mention the position of the\\nmeniscus in Heusinger s case it accompanied the clavicle.\\nOccasionally a portion of the edge of the articular surface of the ster-\\nnum or of the clavicle has been broken off. The sternal portion of the\\nsterno-cleido-mastoid may be pushed aside or even torn away from the\\nsternum, perhaps bringing with it a scale of bone.\\nSimultaneous dislocation of the acromial end (vide infra) and frac-\\nture of the shaft have been observed as complications also a similar\\ndislocation of the other clavicle.\\nSymptoms. The principal physical sign is the projection of the end of\\nthe clavicle and, if the dislocation is complete, its displacement toward\\nthe median line or downward. If the dislocation is incomplete the\\nprojection can be made to disappear by pressing it backward, but it is\\nlikely to reappear when the pressure is removed. In the complete dis-\\nlocations the weight if the limb, if unsupported, tends to bring the\\nshoulder nearer the thorax and thus forces the end of the clavicle\\ninward or downward.\\nThe other symptoms are sharp local pain, which is greatly abated in\\na day or two, depression of the shoulder, inclination of the head toward\\nthe injured side, and inability to raise the arm.\\nThe local swelling may be so great as to mask the position of the\\nbone, and if crepitus should be present the injury may be, as it has\\nbeen, mistaken for fracture. Another error of diagnosis has been\\nto mistake the dislocated end for an exostosis and, conversely, hyper-\\ntrophy of the bone has been mistaken for a dislocation.\\nPrognosis. The prognosis is unfavorable as regards the complete\\ncorrection of the deformity, but favorable in respect of the restoration\\nof function. In almost all the reported cases projection of the end of\\nthe bone, to a greater or less extent, has persisted, but the patients have\\nbeen able to use the arm freely and with no sense of loss of power,\\neven when the dislocation has remained complete. In some the con-\\ndition of habitual or recurrent dislocation ensues, the bone\\nslipping out of place whenever certain movements of the arm are\\nmade. The discomfort caused thereby may be very great.\\nTreatment. Reduction is effected by drawing the shoulder outward\\nand slightly backward and making pressure backward on the dislocated\\nend after it has been thus brought opposite the joint. Hamilton failed\\nin two cases to effect reduction, but I have met with no other reported\\nfailures. The reduction is, however, the least part of the treatment\\nthe difficulty is to keep the bone in its place. The anatomical rela-\\ntions and the mode of production suggest that this would best be\\neffected by keeping the shoulder well forward until after repair of the\\ntorn ligaments shall have taken place, and I can account for the fail-\\nures under this plan, which was recommended by Velpeau and Mal-\\ngaigne, only by supposing that it was not properly carried out. I have\\nfound it easy to maintain the position by a figure-of-eight bandage about\\nboth shoulders, the turns crossing in front of the chest, and also by a\\nplaster-of-Paris dressing about the shoulder and chest. In the simpler\\ncases it is sufficient to immobilize the shoulder without drawing it for-\\nward, and to prevent the elevation of the arm.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0602.jp2"}, "595": {"fulltext": "DISLOCATIONS OF THE CLAVICLE. 527\\nMoulded pads of leather, gutta-percha, or plaster of Paris covering\\nthe end of the bone and the adjoining part and held in place by band-\\nages about the chest have given good results.\\nDirect pressure, usually in conjunction with fixation of the shoulder,\\nhas been applied in a great variety of ways, of which the simplest,\\nwhich may serve also as the type, was that employed by Nelaton. He\\nused an ordinary spring-truss, placing one of its pads upon the sternal\\nend of the clavicle and the other between the shoulder-blades, and\\ncarrying the spring under the axilla of the uninjured side. The objec-\\ntion to the use of pressure arises from the probability of irritating the\\nskin or even causing a slough at the point at which it is applied.\\nCombined with rest in bed upon the back and a good position of the\\nshoulder, the maintenance of the pressure for a week has proved suffi-\\ncient to prevent recurrence, although not entirely to overcome the pro-\\njection.\\nIn a case in which the total correction of the displacement would\\nbe important, the patient should be kept in bed upon the back, in order\\nto diminish the tendency to reproduction of the deformity created by\\nthe weight of the shoulder when the body is erect, and frequent inspec-\\ntion should be made to determine the efficiency of the measures.\\nShould all other means fail, digital pressure might be maintained\\nfor a week or ten days. The dressings should be worn for at least a\\nmonth.\\nHabitual or recurrent dislocation has been successfully treated by\\nprolonged retention, and in two cases by myself 1 by peri-articular injec-\\ntions of alcohol a few drops of alcohol are injected with a hypodermic\\nsyringe into the tissues in front of and below the joint, and the arm\\nimmobilized, or, at least, elevation of the elbow is avoided. In one\\ncase I made four injections at intervals of about a week in the other\\none injection was sufficient.\\nDislocation Backward. (Luxatio Claviculae Retrosternalis.)\\nThis dislocation, the second in order of frequency of those of the\\nsternal end, may be produced directly, by a force acting from before\\nbackward upon the end of the bone, or indirectly, by a force that presses\\nthe shoulder forward and inward. The latter is the more frequent.\\nIn the few recorded cases of dislocation by direct violence the cause has\\nbeen such as a fall of the patient forward, striking upon the clavicle,\\nor the fall upon him of a stone, or the passage across his chest of the\\nwheel of a w r agon. In the dislocations by indirect violence the patient\\nhas commonly been caught between two bodies, as the pole of a wagon\\nand a wall, or the side of a railway car and a wall, or between two\\nboats, in such a way that the shoulder has been pressed forward and\\ninward.\\nThe dislocation may be complete or incomplete.\\nPathology. The only recorded cases in which direct inspection of\\nthe parts has been made are those of Tyrrell 2 and Bennett. 3 In the\\n1 Stimson New York Medical Journal, November 23, 1SS9.\\n2 Tyrrell St. Thomas s Hospital Eeports, 1836, vol. i. p. 261.\\n3 Bennett Dublin Journ. Med. Sciences, 1881, vol. lxxi. p. 444.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0603.jp2"}, "596": {"fulltext": "528 DISLOCATIOXS.\\nformer a compound dislocation was caused by the point of a pickaxe\\nentering below the end of the bone the pectoralis major was freely torn\\nfrom its attachment to the clavicle, but in all probability this was\\nmainly, if not entirely, the result of a direct action upon it of the\\npoint of the pickaxe, and is not a common feature of the dislocation.\\nThe meniscus remained attached to the sternum, and the end of the\\nclavicle could be easily felt by the finger in the wound.\\nIn the second case the patient was caught between a wall and a rail-\\nway car and rolled along for some distance. The sternal end of the\\nright clavicle, accompanied by the meniscus, was dislocated backward,\\nand the cartilages of the first, second, third, and fourth ribs of the same\\nside were broken.\\nThe end of the bone is displaced inward or inward and downward,\\nand it is generally stated that it lies between the trachea and the sterno-\\nhyoid and sterno-thyroid muscles, but, in the absence of direct proof\\nof this, I am disposed to believe rather that it may lie between the\\nlatter muscle and the sternum, and below the former, for, it will be\\nremembered, the sterno-hyoid arises in part from the posterior ligament\\nof the joint and frequently from the clavicle itself, and the sterno-thyroid\\nlies behind the other and has its origin as low even as the cartilage of\\nthe second rib. Possibly the difference noted in the direction of the\\ndisplacement, inward in some, inward and downward in others, may\\ndepend upon varying relations between the bone and these muscles.\\nWhatever the relations between these parts may be, the end of the\\nbone frequently presses upon the trachea and thereby causes more or\\nless dyspnoea, or upon the oesophagus and causes dysphagia. Of six-\\nteen cases analyzed by Polaillon 1 dyspnoea was present in six and dys-\\nphagia in three. The venous congestion of the face and neck coexisting\\nwith the dyspnoea has been sometimes attributed to pressure upon the\\nbrachio-cephalic vein, but although the region into which the end of\\nthe bone is displaced is occupied by most important vessels and nerves,\\nthe recorded histories do not show that they have ever been seriously\\npressed upon.\\nBeside the complication of fracture of the cartilage of the first four\\nribs in Bennett s case mentioned above, fracture of the first rib has been\\nnoted in a case reported by Dr. N. C. Morse 2 the patient was a girl\\neight years old who had been run over by a wagon and had received a\\ndislocation backward of the sternal end of the left clavicle, with frac-\\nture of the first rib, and a dislocation outward (forward?) of the\\nsternal end of the right clavicle. Apparently the wheel had crossed\\nthe left clavicle and chest. There was great dyspnoea and marked\\nvenous congestion of the face and neck which disappeared on reduction\\nof the dislocation. The child recovered.\\nSymptoms. The absence of the end of the clavicle from its articu-\\nlation, and its position behind the sternum are recognizable by inspec-\\ntion and palpation, the course of the bone can be seen and felt to pass\\ninward behind its normal position, and the cavity and border of the\\narticular surface of the sternum can be traced with the finger.\\n1 Polaillon Diet. Eucyclopedique des Sciences Med., art. Clavicule.\\n2 Morse Cincinnati Medical News, 1377, vol. vi. p. S19.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0604.jp2"}, "597": {"fulltext": "DISLOCATIOXS OF THE CLAVICLE. 529\\nThe shoulder hangs a little forward and nearer the chest sharp pain,\\nincreased by movements of the arm or head, is felt at the seat of injury,\\nbut usually is prompt to disappear. These voluntary movements are\\nrestricted or abolished by the pain.\\nDisturbance of respiration by compression of the trachea has been\\nnoted in only about one-third of the cases, and may be slight or so\\nsevere as to threaten suffocation. Ordinarily it lasts for only a short\\ntime, even if the dislocation remains unreduced.\\nDifficulty in swallowing has been less frequently noted than dysp-\\nnoea (three times in sixteen cases).\\nPrognosis. The prognosis is favorable as regards the re-establish-\\nment of function even if the dislocation is not reduced, and reduction\\nis, as a rule, easy, and retention more complete than after dislocation\\nforward.\\nTreatment. Reduction can commonly be effected by drawing the\\nshoulder outward and backward, and this seldom requires more force\\nthan the surgeon himself can exert without assistance. In one case\\nLenoir was obliged to provide counter-extension by a bandage carried\\naround the chest and made fast to the wall, and extension by another\\nbandage passed around the upper part of the arm and drawn upon by\\ntwo assistants while a third held the elbow near the side. In another\\nof his cases one assistant placed his knee against the patient s back and\\ndrew his shoulder backward while a second assistant held up the chin,\\nand Lenoir passed his finger clown behind the end of the clavicle and\\npressed it forward. Reduction took place promptly and with a distinct\\nsnap.\\nRecurrence of the displacement should be opposed by dressings that\\nhold the shoulder back and down. The necessity exists as in disloca-\\ntion forward to examine the joint frequently with the object of promptly\\ndetecting and correcting any faulty position, and to wear the dressings\\nfor several weeks.\\nDislocation Upward. (Luxatio Claviculae Suprasternalis.)\\nThe first recorded case of this form of dislocation was published by\\nDuverney 1 in 1751, the next was observed by Sedillot 2 in 1835, and\\nMalgaigne in 1855 could collect only five cases. The number is now\\nincreased to about twenty, 3 with two autopsies, Duverney s and R. W.\\nSmith s. 4 It differs from the forward dislocation in that the bone lies\\nbehind the sternal portion of the sterno-cleido-mastoid muscle instead\\nof in front of and below it.\\nThe cause in the sudden, traumatic cases, is the forcible depression\\nof the shoulder and the acromial end of the clavicle, by which the\\nupper portion of the capsule is torn and the end of the bone lifted out\\nof the joint then, the force continuing to act and pressing the shoulder\\ninward toward the chest, the bone is forced inward to or beyond the\\n1 Duverney Traite des Maladies des Os, vol. i. p. 201.\\n2 Sedillot Contributions a la Chia-urgie, 1868, vol. i. p. 261.\\n3 For the bibliography see Malgaigne, Hamilton, and Polaillon, and cases here men-\\ntioned passim, and Evans, Gaillard s Medical Journal, March, 1888.\\n*E. W. Smith: Dublin Journal Medical Sciences, 1872, vol. ii. p. 450.\\n31", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0605.jp2"}, "598": {"fulltext": "530\\nDISLOCATIONS.\\nmedian line and sometimes upward so far even as to rest upon the ante-\\nrior surface of the larynx. A unique mode of production was reported\\nby Dr. A. N. Blodgett. 1 The patient was carrying one end of a piano\\nwhen the two men who were carrying the other end allowed it to fall.\\nThe patient felt a sharp pain at the root of the neck and front of the\\nchest, and it was found that the sternal end of the right clavicle had\\nbeen dislocated upward and inward and that the first and second costal\\ncartilages of the same side had been dislocated from the sternum for-\\nward and outward.\\nIn Duverney\\\\s case all the ligaments were torn and the periosteum\\nwas stripped from the end of the clavicle probably, therefore, the\\nmeniscus remained attached to the sternum. In R. W. Smith s case\\n(Fig. 255), the end of the left clavicle rested on the upper border of\\nthe sternum in contact with the right sterno-cleido-mastoid, having\\npassed behind the sternal portion of the left sterno-cleido-mastoid and\\nin front of the sterno-hyoids. The anterior and posterior sterno-\\nclavicular ligaments and the costo-clavicular were torn the meniscus\\naccompanied the clavicle. The subclavius muscle was relaxed but\\nnot torn. There were dyspnoea and dysphagia death was the result of\\nassociated injuries.\\nFig. 255.\\nDislocation upward of the sternal end of the clavicle. (R. W. Smith.)\\nIn a case reported by Stokes, 2 and mentioned above, the dislocation\\nis described as forward and upward, and the joints as being so loose\\nthat the sternal end of each clavicle could be easily moved in any\\ndirection this condition had been produced by the powerful action\\nof the sterno-cleido-mastoid muscles in forced inspiratory efforts pro-\\nvoked by great dyspnoea clue to ascites. At the autopsy the ligaments\\nwere found to be greatly stretched, the sterno-clavicular being half as\\nlong again as natural and the rhomboids (costo-clavicular) also elon-\\n1 Blodgett New York Medical Journal, 1883, vol. xxxviii.\\n2 Stokes Dublin Medical Journal, 1852, vol. xiii. p. 459.\\np. 34.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0606.jp2"}, "599": {"fulltext": "DISLOCATIONS OF THE CLAVICLE. 531\\ngated. The relations of the end of the clavicle to the sternal portion\\nof the sterno-cleido-mastoid are not stated, and it remains uncertain,\\ntherefore, whether the case properly belongs in the class of dislocations\\nii|) ward.\\nSymptoms. If the dislocation is incomplete the only symptoms are\\nthe projection of the end of the clavicle above its normal position, and\\nthe local pain increased by movements of the head and arms.\\nThe symptoms of the complete form are the recognizable displace-\\nment of the end of the bone inward and upward to a variable distance,\\nits position behind the sternal portion of the sterno-cleido-mastoid of\\nthe same side, the depression of the shoulder, and its approximation to\\nthe chest local pain, sometimes dyspnoea and dysphagia, inhibition of\\nvoluntary movements of the shoulder and head because of pain, and\\nsometimes the impossibility of passively raising the shoulder. The\\nemptiness of the clavicular notch of the sternum may perhaps be\\nrecognized by palpation.\\nTreatment. Reduction is effected by drawing the shoulder outward\\nand making direct pressure downward and outward upon the sternal\\nend of the clavicle, but here again the chief difficulty is to prevent\\nrecurrence. Fixation of the shoulder by various dressings and the\\nrecumbent position to avoid the depression of the shoulder by the\\naction of gravity have been employed with a fair measure of success,\\nthe resulting deformity being slight and the re-establishment of the\\nusefulness of the arm complete.\\n2. DISLOCATIONS OF THE ACROMIAL END OF THE CLAVICLE.\\nAnatomy. The outer portion of the clavicle is attached to the scap-\\nula at two points, namely at its extreme end to the inner margin of the\\nacromion by the acromio-clavicular joint, and further inward to the\\ncoracoid process by the coraco-clavicular ligaments. The articular\\nFig. 256.\\nTrapezoid\\nLigaments uniting the clavicle to the scapula. (Henle.)\\nsurfaces forming the acromio-clavicular joint are flat and oval in shape,\\nthe long axis being antero-posterior, and the upper edge of the end of\\nthe clavicle rises to a variable distance above the upper surface of the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0607.jp2"}, "600": {"fulltext": "532 DISLOCATIONS.\\nacromion. The articular surfaces are separated in part, sometimes com-\\npletely, by an interposed meniscus of fibrous tissue, wedge-shaped, with\\nits base directed upward and attached to the broad, strong superior\\nligament; the inferior ligament, usually much thinner than the superior,\\ncloses the joint below. The coraco-clavicular ligament is composed of\\ntwo portions, the postero-internal, or conoid y and the antero-external,\\nor trapezoid, as shown in Fig. 256.\\nComplete dislocation involves not only the rupture of the ligaments\\nof the joint proper, but also of the conoid and trapezoid ligaments to\\na greater or less extent. The joint allows motion in all directions, the\\nextreme ranges being, according to Albert, 20 to 30 degrees in the\\nhorizontal plane, and 60 to 70 degrees in the vertical plane and its\\ndislocation appears to be commonly effected, not by extending the\\nmovement of the joint beyond its normal limit, but by direct displace-\\nment of one bone upon the other.\\nThe clavicle may be displaced upward, supra-acromial dislocation,\\nor downward and backward, subacromial dislocation, or downward and\\nforward under the coracoid process, subcoracoid dislocation. The first\\nis by far the most common the last has been observed by only two\\nsurgeons, one of whom reported five cases.\\nSome authors, following the system of nomenclature used in the dis-\\nlocation of other joints, term them dislocations of the scapula, but the\\ninnovation has not made its way.\\nSupra-acromial Dislocation. (Luxatio Claviculse Supra-\\nacromialis.)\\nThe dislocation may be complete or incomplete in the latter the\\nclavicle is displaced upward to a distance equal or nearly equal to the\\nvertical diameter of its articular surface in the former the separation\\nof the articular surface is complete, and there is an additional displace-\\nment outward over the acromion, or outward and backward, or to a\\ngreater distance upward.\\nThe cause is usually a blow received upon the point of the shoulder\\nand directed downward with an inclination inward, forward, or back-\\nward. The vigorous contraction of the trapezius by which the clavicle\\nis prevented from accompanying the acromion in its descent seems to\\nbe an important, perhaps an essential, factor in the production of the\\nlesion, the alternative factor that has been suggested, arrest of the\\ndescent of the clavicle by contact with the first rib, seems more likely\\nto produce dislocation of the sternal end of the bone. Malgaigne\\nfound in one case marked tenderness of the trapezius and sterno-cleido-\\nmastoid muscles, and cites the fact as proof of the correctness of this\\ntheory in some cases. The absence of such tenderness in other cases\\nshould not, I think, be deemed opposing evidence, for an efficient con-\\ntraction not followed by injury of the muscle is easily conceivable. A\\ncase reported by Cloquet, 1 and sometimes quoted as an example of dis-\\nlocation by direct violence, seems clearly to indicate the important part\\nplayed by muscular action A man who was carrying a beam upon his\\n1 Cloquet Journal Hebdornadaire, 1830, vol. vii. p. 400, quoted by Malgaigne.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0608.jp2"}, "601": {"fulltext": "DISLOCATIONS OF THE CLAVICLE. 533\\nshoulder made a violent effort to keep it from falling, and found he had\\nthereby produced a dislocation. Polaillon l mentions a case communi-\\ncated to him by Dolbeau in which the dislocation was caused in a\\nwoman by an attempt to strike a child. In such a case the momen-\\ntum of the arm presumably takes the place of the more common exter-\\nnal violence received upon the shoulder. In one of my cases the dis-\\nlocation was caused by a blow from a falling brick, which also broke\\nthe acromion at its base and dislocated the humerus. (See Chapter\\nXLII.)\\nA unique case in which the dislocation was caused by a blow\\nreceived upon the clavicle from below upward is reported by Hamil-\\nton 2 a bolt three-quarters of an inch in diameter was driven through\\nthe skin on the anterior margin of the left axilla, breaking the first\\nrib, severing the coraco-clavicular ligaments, and forcing the clavicle\\nupward from its place.\\nMalgaigne reports a case in which the injury w^as apparently caused\\nby a fall upon the elbow.\\nPathology. Our knowledge of the character and extent of the\\nlaceration of the ligaments is derived almost exclusively from clinical\\nobservation and experiments upon the cadaver, for there is only one\\nreported autopsy and one museum specimen. The autopsy, reported\\nby Malgaigne, 3 was in a case of incomplete dislocation and showed\\nthat the articular facet of the clavicle had not entirely left that of the\\nacromion the superior acromio-clavicular ligament was only stretched\\nor perhaps slightly torn away from the acromion, and the inferior one\\nwas in great part ruptured on the other hand, the strong coraco-\\nclavicular ligaments were torn entirely across. There were other and\\nmore serious associated lesions, among them a comminuted fracture of\\nthe body of the scapula on the same side.\\nThe museum specimen is one preserved in St. Thomas s Hospital\\nand mentioned by Sir Astley Cooper. 4 The patient was a man sixty\\nyears old who died of pulmonary disease seven weeks after the receipt\\nof the injury. The account from which I quote states only that the\\nclavicle was found dislocated at its capsular extremity, and projected\\nconsiderably over the spine of that bone. The acromion process, just\\nwhere the clavicle is united with it, was broken off. Malgaigne,\\nquoting apparently from some other account, says that Cooper supposed\\nthat all the acromial and coracoid ligaments must have been torn. He\\nadds that this is w T hat experiments upon the cadaver indicate, but that\\nit is melancholy to limit one s self to conjectures when the specimen\\nitself can be examined. Cooper 5 gives also a drawing of a specimen\\nof an old dislocation in which the conoid ligament had become ossi-\\nfied.\\nExperiments upon the cadaver have yielded results that are not\\nentirely in accord with one another. Malgaigne found that even in\\nincomplete dislocation the capsular ligaments were completely, and the\\n1 Polaillon Diet, Ency eloped ique des Sciences Medicales, art. Clavicule, p. 719.\\n2 Hamilton Fractures and Dislocations, 1880, p. 62G.\\n3 Malgaigne Loc. cit., p. 432.\\n4 Cooper Dislocations and Fractures, Am. ed., p. 313.\\n5 Cooper Loc. cit., p. 312.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0609.jp2"}, "602": {"fulltext": "534 DISLOCATIOXS.\\ncoraco-clavicular partly, ruptured. Bouisson and Ader found that\\nincomplete dislocation could be easily produced after division of the\\nacromial ligaments and without injury to the coracoidal, and even to\\nsuch a degree that the articular surfaces were completely separated\\nvertically from each other. Ader further showed that after division\\nof the coracoidal ligaments a complete dislocation could be readily\\nproduced and the end of the clavicle removed to a distance of two\\ncentimetres from the acromion.\\nInstead of rupture of the upper acromial ligament avulsion of the\\nedge of bone on either side to which it is attached has frequently been\\nobserved clinically.\\nAmong the recorded complications are simultaneous dislocation of\\nthe sternal end of the same or of the other clavicle, fracture of the\\nclavicle, of a rib, of the acromion process, of the coracoid process, of\\nthe body of the scapula, and subcoracoid dislocation of the shoulder\\nof the same side.\\nSymptoms. In incomplete dislocation the deformity consists in the\\nelevation of the end of the clavicle to a variable distance, not equal,\\nhowever, to the thickness of the bone, above the level of the acro-\\nmion, and this elevation can be readily recognized by palpation, and\\ncan generally be reduced by moderate pressure.\\nIn complete dislocation the elevation is greater, more than an inch\\nin some cases, or is combined with displacement outward, backward,\\nor forward. The displacement outward is, of course, due to the\\napproximation of the acromion to the chest, and it is greater when the\\ndisplacement upward is also greater. The explanation of this latter\\nfact is to be found in the presumably more extensive laceration of the\\nligaments uniting the two bones. The greatest recorded overriding is\\none inch (Malgaigne). It has been observed also in some cases that\\nthe scapula has undergone a movement of rotation by which its infe-\\nrior angle is carried backward toward the spine, and the anterior,\\nupper angle is lowered, a movement that is attributed to the action of\\nthe weight of the arm; it has been observed only when the displace-\\nment inward of the scapula toward the chest has not been very\\nmarked.\\nThere is local pain, more or less severe, persisting for a variable\\nlength of time, and increased by pressure or by voluntary movements\\nof the shoulder or arm. The interference with voluntary movements\\nof the limb varies greatly, and corresponds measurably with the pain\\nand the extent of the displacement some patients are completely dis-\\nabled, others can use the limb quite freely.\\nDiagnosis. The diagnosis is to be made by recognition of the\\nchanged relations of the bones, which is easy in the cases of complete\\ndislocation, and seldom difficult in the incomplete. In the latter case\\nthe local pain and the possibility of reducing the bony prominence by\\npressure, together with its immediate reappearance on the removal of\\nthe pressure, will give the clew. The question will then lie between\\ndislocation and fracture of the clavicle near its end, and this may be\\nanswered by tracing the outline of the acromion, comparative meas-\\nurements of the two clavicles, and consideration of the presence or", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0610.jp2"}, "603": {"fulltext": "DISLOCATIONS OF THE CLAVICLE.\\n535\\nabsence of signs peculiar to fracture. The error of mistaking the\\ninjury for a dislocation of the shoulder appears to have been quite\\nfrequently made, although it is difficult to understand how it could\\noccur if the examination were thorough.\\nA contusion or sprain of a joint in which the end of the clavicle\\nstood abnormally high might easily be mistaken for a recent disloca-\\ntion, since it would present all the signs of one, but the error would\\nbe of slight importance and would cause no harm to the patient\\nbeyond perhaps a needlessly prolonged confinement of the limb.\\nPrognosis. The prognosis in the incomplete form is good, for\\nalthough the displacement has commonly persisted in some measure,\\nFig. 257.\\nComplete supra-acromial dislocation of the clavicle.\\nthe resulting deformity is slight. In the complete form, with marked\\ndisplacement, there is, in addition to the common imperfect mainten-\\nance of the reduction, an occasional inability even to make reduction.\\nIn such cases the functions of the limb may or may not be seriously\\ninterfered with by the persistence of the displacement. In the unique\\ncase quoted above from Hamilton, of dislocation by direct violence\\nacting upon the clavicle from below upward, the bone remained dis-\\nplaced two inches upward, yet the patient could use the arm as freely\\nand strongly as the other. On the other hand, in one of Bardenheuer s\\ncases, in which the displacement persisted, the diminution of function", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0611.jp2"}, "604": {"fulltext": "536 DISLOCATIONS.\\nwas considerable, and the power of abduction of the arm was almost\\nentirely lost.\\nTreatment. In most cases the reduction of even the complete dislo-\\ncation can be readily effected by drawing the shoulder either directly\\nupward, or upward and outward, or backward, and at the same time\\npressing the clavicle directly toward its place. The only opposition\\nFig. 258.\\nOld dislocation of the outer end of the clavicle\\nthat ordinarily needs to be overcome is the weight of the arm, which\\ndraws the shoulder downward and inward away from the clavicle with\\nthis is sometimes associated reflex contraction of the trapezius which\\ndraws the clavicle upward, and in a few cases the end of the clavicle\\nhas passed through the trapezius in such a way that the interposed\\nfibres of the muscle have constituted a serious obstacle to reduction.\\nTo overcome this latter obstacle Moutet l subcutaneously divided the\\nclavicular portion of the trapezius close to its insertion and was\\nthen able easily to restore the bone to its place and keep it there by\\na bandage.\\nIn making reduction the arm should be kept near the side and\\npressed directly upward. If the shoulder needs to be drawn directly\\noutward, this should be done by the hand introduced into the axilla,\\nor by grasping the upper part of the arm with both hands, the fingers\\nresting in the axilla, and the thumbs against the projecting articular\\nsurface of the clavicle, and thus drawing the shoulder outward while\\n1 Moutet: Moutpellier Medical, 1861, vol. vi. p. 219. rioted by Polaillon.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0612.jp2"}, "605": {"fulltext": "DISLOCATIONS OF THE CLAVICLE.\\n537\\nFig. 259.\\npressing the clavicle inward. In short, reduction is to be effected by\\nforcing the acromion upward, and outward, forward, or backward, as\\nmay be indicated by the direction of the displacement, by pressure\\nexerted upon it through the humerus, and by pressing the end of the\\nclavicle in the opposite direction.\\nThe maintenance of the reduction was long deemed difficult. The\\nweight of the arm constantly tends to reproduce the deformity, to carry\\nthe shoulder downward away from the clavicle, and the dressings era-\\nployed did not satisfactorily oppose it. The following simple dressing\\nwhich I devised about 1883\\nlias proved perfectly satisfac-\\ntory A strip of stout adhesive\\nplaster, about four feet long and\\ntwo or three inches wide, is\\nplaced with its centre under the\\nelbow, the forearm being flexed\\nat or within a right angle, and its\\ntwo ends are carried upward,\\none behind, the other in front,\\nof the arm, and crossed over the\\nshoulder at a point correspond-\\ning to the end of the clavicle,\\nand then fastened to the front\\nand back of the chest respec-\\ntively. While applying it, the\\nsurgeon must press the elbow\\nfirmly upward and the clavicle\\ndownward. The eye or finger\\ncan readily detect through the\\nplaster any recurrence of the dis-\\nplacement. The dressing should\\nbe worn for three or four weeks.\\nWiring of the clavicle to the\\nacromion has been practised a\\nfew times in recent and in old\\ndislocations, but is not generally\\napproved if anything of the\\nkind should need to be done\\nperiosteal catgut sutures would\\nprobably be sufficient.\\nDressing for supra-acromial dislocation of the\\nclavicle.\\nSubacromial Dislocation. (Luxatio Claviculae Subacromialis.)\\nThis dislocation, of which Petit was the first to make mention, is so\\nrare that Polaillon, in 1875, could collect only six recorded cases; the\\nlist has now been increased to eleven, or, adding Newman s, to twelve.\\nThe first four, quoted bv Malgaigne, are those of Melle, 1765, Fleurv,\\n1816, Tournel, 1837, and Baraduc, 1842. The others are two observed\\n1 Malgaigne: Loc. cit., pp. 448 and 452. Malgaigne thinks Baraduc s case was probably\\npathological, not traumatic. The reference be gives for Tournel is incorrect it should\\nbe 1837, not 1847.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0613.jp2"}, "606": {"fulltext": "538 DISLOCATIONS.\\nand reported by Morel-Lavallee, 1 one by Dr. W. B. Chase, 2 one by\\nDr. J. X. Allen 3 and one by Dr. Eaton. 4 Konig 5 refers to one that\\nwas observed in Bruns s clinic, and Bardenhener 6 makes several quo-\\ntations from the report of a case by Uhde, but does not give the refer-\\nence. He speaks also of a case reported by Gosselin in 1881, but I\\nhave been able to find only a clinical lecture by Gosselin on a case of\\nsupra-acromial dislocation. To these may be added Newman s case of\\nsimultaneous dislocation of both ends of the clavicle [vide infra), in\\nwhich the outer end was displaced under the acromion.\\nThe cause in these cases was direct violence exerted upon the upper\\nsurface of the outer end of the clavicle (Melle, Tournel, Chase), a fall\\nupon the shoulder in three (Fleury, Morel-Lavallee s two), and mus-\\ncular effort in one (Allen).\\nAllen s patient, a stout muscular girl sixteen or seventeen years old,\\nwas chopping wood, and at the moment she had the axe raised and\\nwas about to deliver the blow she felt a sharp pain in the shoulder, and\\nthe arm fell powerless by her side. When seen six weeks later there\\nwas a marked depression on the top of the shoulder, much discoloration\\nin the axilla, and the inferior angle of the scapula was thrown promi-\\nnently outward. There was complete loss of voluntary motion of the\\narm and hand, and numbness of the entire limb. Reduction was easily\\neffected by drawing the shoulder outward and backward.\\nChase s case may be taken as a type of direct violence. A boy\\neight years old fell head foremost from a height of twelve or fifteen\\nfeet and struck with the top of his shoulder against the rung of a\\nladder. An ecchymosis over the outer end of the clavicle showed where\\nthe blow had been received. The acromial end of the clavicle was dis-\\nlocated downward and somewhat backward, the shoulder was flattened\\nin front, and the acromion very prominent. Reduction, under anaes-\\nthesia, was easily effected by drawing the shoulder outward and\\nbackward and pressing the clavicle in the opposite direction.\\nThere was no tendency to recurrence and recovery was complete in\\nfive weeks.\\nOf the other two cases of direct violence, in one, Tournel s, the\\ninjury was caused by a horse stepping upon the front of the patient s\\nshoulder as he lay on the ground in the other, Melle s, the patient,\\nwho was a Russian soldier, attributed the injury to an effort he made\\nwhen six years old to lift, with the aid of another child, a keg of water\\nby means of a stick resting on his shoulder. He had also a dislocation\\nof the corresponding humerus, which apparently had been received at\\nthe same time.\\nThe autopsy in Melle s case and experiments upon the cadaver show\\nthat the ligaments uniting the acromion and coracoid to the clavicle are\\ncompletely ruptured the clinical facts show that the displacement of\\nthe clavicle is not only downward and outward under the acromion but\\n1 Morel-Lavallee Bull, de la Soc. de Chir., 1863, vol. iv. pp. 51 and 240.\\n2 Chase Transactions of the Medical Society of the State of New York, 1879, p. 170.\\n3 Allen New York Medical Kecord. 1881, vol. xix. p. 206.\\n4 Eaton: New York Medical Record, 1881, vol. xx. p. 734.\\n5 Konig: Speciel. Chirurgie, 3d ed., vol. iii. p. 16.\\n6 Bardeuheuer Deutsche Chir., Lief. 63 a, p. S9.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0614.jp2"}, "607": {"fulltext": "DISLOCATIONS OF THE CLAVICLE. 539\\nalso backward to an extent that leaves the acromial facet entirely in\\nfront of the clavicle. This is perhaps to be accounted for by the pres-\\nence of the head of the humerus, which opposes a displacement directly\\ndownward and the same anatomical fact may explain the coincident\\ndislocation of the humerus in Melle s case. The only other compli-\\ncations observed clinically are fracture of the surgical neck of the\\nhumerus, in one of Morel-Lavallee s cases, and simultaneous disloca-\\ntion of the other end of the clavicle, in Newman s but in experiments\\nupon the cadaver fractures of the acromion and of the clavicle have\\nbeen met with. In Melle s case the meniscus accompanied the\\nclavicle.\\nSymptoms. The pain at the moment of the accident may be severe\\nor slight voluntary movements of the arm are interfered w r ith, and\\nsometimes entirely prevented and in one case (Allen) there was per-\\nsistent numbness and tingling in the arm and hand, indicative of press-\\nure upon the brachial plexus. The appearance of the shoulder is\\naffected by the sinking of the acromion and rising of the inferior angle\\nof the scapula so that it appears to be inclined forward. The shoulder\\nis usually approximated to the side of the head, but may be on a lower\\nlevel than the opposite one because of the inclination of the trunk.\\nThe central portion of the clavicle may be depressed below the level\\nof the soft parts in front and behind its sternal end projects sharply\\nforward, and its acromial end can be traced with the finger to the point\\nwhere it engages under the acromion a little behind the articular facet\\non the latter. An obscure part of the description of TournePs case,\\nwhich Malgaigne found unintelligible, may possibly mean that the end\\nof the clavicle passed entirely under the acromion and projected beyond\\nits outer border. The outline of the acromion and its empty articular\\nfacet can usually be traced with the finger, although in one case the\\nswelling of the soft parts was very great.\\nPrognosis. The prognosis is favorable in Tournel s case, in which\\nthe reduction was not attempted, the patient had good use of the limb\\nin Melle s a new joint had formed between the under surface of the\\nacromion and the upper surface of the clavicle, but the effect upon the\\nfunctions of the limb cannot be known, for a dislocation of the humerus\\ncoexisted. In all the other cases in which the record is sufficiently\\ncomplete reduction was easily effected with or without the aid of anaes-\\nthesia, and there appears to have been no tendency to recurrence except\\nin one case.\\nTreatment. Reduction is made by drawing the shoulder outward\\nand backward, the arm being kept parallel to the trunk, and counter-\\nextension being made by a bandage passed around the chest. Tournel\\nreduced by placing his knee between the shoulders and drawing them\\nforcibly backward and Uhde did likewise, at the same time pressing\\nthe clavicle forward. The arm should be fixed against the trunk, and\\nthe forearm supported by a body bandage and sling.\\n1 The phrase is L epaule presentait en outre deux saillies une interne et superieure\\nformee par l acroruion, l autre externe et inferieure forniee par 1 extreinite externe de la\\nclavicule.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0615.jp2"}, "608": {"fulltext": "540 DISL CA TIONS.\\nSubcoracoid Dislocation. (Luxatio Claviculse Subcoracoidea.)\\nAuthority for the belief that this singular displacement has ever been\\nclinically observed rests upon the statements of two surgeons, Godemer\\nand Pinjon. Godemer met with his first case in 1833 and with four\\nothers in the following five years Pinjon reported a sixth example in\\n1842. Godemer s cases were reported to the Societe meclicale d Inclre\\net Loire, and published in 1843 his paper was republished by Mal-\\ngaigne in the Revue medico-chirurgicale de Paris, 1847, vol. ii. p. 155\\nPinjon s case was reported in the Journal de Medecine de Lyon, 1842,\\nvol. iii. p. 58. All systematic writers upon the subject are agreed in\\nviewing these reports with much suspicion because of their remarkable\\nsimilarity in detail and the great anatomical obstacles to the production\\nand maintenance of the displacement.\\nThe features, as described by Malgaigne, are as follows Four of the\\nsix patients were between the ages of sixty-seven and seventy-one\\nyears the remaining two are described as adults. In every case the\\ninjury was caused by a fall upon the shoulder.\\nThe symptoms were 1st. More or less pain and a large ecchymosis\\nin the coraco-acromial region.\\n2d. A depression at the normal position of the clavicle this bone\\nwas found to be inclined downward and outward, and its acromial end\\nlodged in the axilla.\\n3d. The coracoid and acromion processes were prominent under the\\nskin.\\n4th. The shoulder was inclined downward and forward the inferior\\nangle and posterior border of the scapula formed posteriorly a projec-\\ntion which disappeared when the shoulder was carried upward and\\nbackward.\\n5th. The arm was dependent, but could be easily moved in any\\ndirection except upward and inward.\\nGodemer made reduction in three cases by grasping the clavicle and\\ndisengaging it from under the coracoid process, while an assistant\\nforced the shoulder backward and outward. In his other two cases\\nthe swelling prevented reduction before the third day. Pinjon failed\\nto reduce because of the fainting of his assistant the next day reduc-\\ntion was made by a bone-setter.\\n3. SIMULTANEOUS DISLOCATION OF BOTH ENDS OF THE CLAV-\\nICLE. (TOTAL DISLOCATION.)\\nThe recorded cases of this injury are now ten in number Riche-\\nrand, 1 Morel-Lavallee, 2 North, 3 Hutchinson, 4 Haynes, 5 Col, 6 Lund, 7\\nRombeau, 8 Hulke, 9 and Newman. 10 Seven of the patients were\\n1 Richerand Arch. gen. de Med., 1831, vol. xxv. p. 108 reported by Porral, his interne.\\n2 Morel-Lavallee Bull, de la Soc. de Chir., 1859, vol. ix. p. 361.\\n3 North New York Medical Record, 1866, vol. i. p. 79.\\n4 Hutchinson: Lancet, 1871, vol. ii. p. 711.\\n5 Havnes British Medical Journal, 1872. vol. i. p. 99.\\nCol Gaz. des Hopitaux, 1872, p. 893.\\n7 Lund British Medical Journal. 1874. vol. i. p. 106.\\n8 Rombeau Bull. Gen. de Therapeutique. 1874, vol. Ixxxvi. p. 537. reported by Gros.\\n9 Hulke Lancet. 1855. vol. ii. p. 245. 10 Newman Ibid., p. 524.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0616.jp2"}, "609": {"fulltext": "DISLOCATIONS OF THE CLAVICLE. 541\\nmales, three females their ages ranged between thirteen .and forty\\nyears.\\nHaynes s patient, a weakly girl, thirteen years old, produced the\\ndislocation while washing the back of her neck with the hand of the\\naffected side there was a complete dislocation forward of the sternal\\nend, and an incomplete dislocation upward of the acromial end of the\\nclavicle.\\nIn all the other cases the cause was external violence, usually very\\ngreat. The mode of production is varied, the most common form\\nappearing to be force exerted along the transverse axis of the shoul-\\nders, and pressing forward the one that suffers the injury.\\nThe sternal end has always been displaced forward, and the only\\nadditional change in position that is mentioned is, in Morel-Lavallee s\\ncase, that it had moved rather upward than downward. The acromial\\nend was displaced backward in four cases (once to a distance of three\\nfinger-breadths), upward and outward twice, and once each forward\\nand outward, downward, and incompletely upward. In Hutchinson s\\ncase the displacement is not described further than by saying that\\nwhen pressure was made on either end of the dislocated bone the\\nother extremity rose perceptibly and protruded the skin.\\nIn six of the cases reduction of both dislocations was effected and\\nmaintained, and the patients recovered with good use of the limb and\\nbut little deformity in some of them mention is made of more or less\\npersistent projection of the sternal end. Morel-Lavallee was unable\\nto reduce the dislocation of the outer end, although he made direct\\ntraction upon it with a hook introduced through the skin. Lund, with\\nthe aid of chloroform, could only bring the bone into fair position\\nat the end of ten days the ends were found fixed in their new posi-\\ntion. In Newman s case, dislocation of the outer end under the\\nacromion, reduction was impossible the patient withdrew from the\\nhospital on the tenth day, and remained disabled. The result in\\nHutchinson s case is not recorded.\\nTreatment. Reduction has usually been effected by drawing the\\nshoulder outward and backward, and recurrence prevented by immo-\\nbilizing it in a suitable position by means similar to those employed\\nwhen the dislocation involves either end alone. Hulke used a gutta-\\npercha splint moulded over the clavicle and bound down by a bandage\\nthat crossed the shoulders and was made fast in front and behind to\\nanother about the waist.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0617.jp2"}, "610": {"fulltext": "CHAPTER XLIL\\nDISLOCATIONS OF THE SHOULDER.\\nFig. 260.\\nAnatomy Statistics Classification Anterior Dislocations Subcoracoid, in-\\ntracoracoid, treatment.\\nAnatomy.\\nThe bony surfaces which enter directly into the composition of the\\nshoulder-joint are the glenoid cavity of the scapula and the postero-\\ninternal half of the globular head of the humerus. The former is of\\nirregularly oval shape, the more pointed end above and the broader\\none below, and is slightly concave, being deepened by a low fibro-car-\\ntilaginous rim, which is continuous throughout with the capsule, and\\nabove also with the tendon of the long head of the biceps. The cavity\\nlooks outward and forward in a direction nearly midway between the\\nsagittal and frontal planes of the body when the scapula occupies its\\nusual position.\\nAgainst this shallow surface the head of the humerus rests, being\\nheld in place by atmospheric pressure, the tonicity of the muscles, and\\nthe tension of thickened portions of the\\ncapsule in different positions of the limb.\\nOn the outer and anterior portion of the\\nupper end of the humerus is the greater\\ntuberosity, bounded internally in front by\\nthe bicipital groove which lodges the long\\ntendon of the biceps and has upon its inner\\nside the lesser tuberosity. Between the\\nupper margins of these tuberosities and the\\nglobular articular head is a shallow groove,\\nthe anatomical neck.\\nThe acromion and coracoid processes lie\\nabove, the one on the outer, the other on\\nthe inner side, and the strong coraco-acro-\\nmial ligament uniting them closes in the\\nupper part of the joint, but is separated\\nfrom its cavity, as are also the two pro-\\ncesses, by the interposed capsule and the\\ntendon of the supraspinatus.\\nThe surface of the head of the humerus\\nthat is covered by articular cartilage is\\nabout one-third of that of a sphere, and the\\naxis passing through its centre meets the long axis of the shaft at an\\nangle of about 130 degrees. The linear extent of the glenoid fossa,\\n542\\nAct,\\nTo show the relations of the hu-\\nmerus and scapula. X, the lesser\\ntuberosity. F and S indicate the\\nfrontal and sagittal planes.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0618.jp2"}, "611": {"fulltext": "DISLOCATIONS OF THE SHOULDER. 543\\nincluding its fibrocartilaginous rim, on a horizontal section is less than\\nhalf as great as that of the head of the humerus on a vertical section\\nit is about two-thirds as great. The head of the humerus, therefore,\\nsimply rests against the fossa, and its displacement is but slightly\\nopposed by the conditions of contact between them. The muscles\\nwhich are most closely associated with the joint are the supraspinatus,\\ninfraspinatus, and teres minor, attached to the greater tuberosity in\\nthe order named from above downward, and the subscapularis, which,\\narising from almost the whole of the costal surface of the scapula,\\npasses forward, broadly covering the inner side of the joint with its\\nfibres and tendon, to be attached to the lesser tuberosity. The tendon\\nof the long head of the biceps, starting from the upper margin of the\\nglenoid cavity, passes upward and forward over the head of the\\nhumerus and then down the bicipital groove, carrying with it a pro-\\nlongation of the synovial membrane of the joint. The deltoid, from\\nits broad origin on the spine of the scapula, the acromion, and the\\nclavicle, covers the joint superficially on its posterior, external, and\\nanterior aspects and the coraco-brachialis, the short head of the\\nbiceps, and the great vessels and nerves lie upon its inner side.\\nFig. 261.\\nHorizontal section through the shoulder-joint A, in inward, B, in outward rotation. (Henle.)\\nThe capsule extends from the free margin of the fibro-cartilaginous\\nrim of the glenoid fossa, or from the surface of bone immediately out-\\nside of it, to the anatomical neck of the humerus. At the upper part\\nits scapular insertion is at the base of the coracoid process and sepa-\\nrated from the glenoid fossa by the tendon of the biceps on the pos-\\nterior and inner portion of the humerus it extends somewhat beyond\\nthe cartilaginous surface along the projection upon which the head rests.\\nBetween the two tuberosities the synovial membrane by which it is\\nlined is prolonged down the bicipital groove, and is reflected over the\\nlong tendon of the biceps. The capsule is reinforced at some points\\nby thickenings of itself which are known as ligaments and by tendons\\nof the scapular muscles on the inner side it is perforated by the tendon\\nof the subscapularis, and there shows a gap through which the cavity\\nof the joint communicates with the subscapular bursa, a large pouch\\nlying against the inner side of the neck of the scapula and the root of\\nthe coracoid process, between them and the upper part of the subscap-\\nularis. This opening lies just in front of the upper part of the ante-\\nrior (inner) margin of the glenoid fossa, has the form of a slit or", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0619.jp2"}, "612": {"fulltext": "544\\nDISLOCATIONS.\\ncrescent, and is usually large enough to admit the end of the finger.\\nWhen the synovial membrane has been dissected away the gap has the\\nform shown in Figs. 262 and 263, and is partly occupied by the tendon\\nof the subscapular is. The portion of the capsule which forms its\\nFig. 262.\\nSupragleno-suprahumeral\\nligament\\nSabscapularis\\nThe shoulder-joint from in front. (Farabeuf.)\\nupper margin is called the gleno-humeral ligament, or, to adopt the\\nsubdivisions described by Farabeuf, 1 the supragleno-suprahumeral, the\\nportion forming the lower margin is the supragleno-pramumeral, and\\nFig. 263.\\nThe interior of the shoulder-joint from behind: 1, coraco-humeral ligament; 2, supragleno-\\nsuprahumeral ligament 3 supragleno-prsehumeral ligament 4, prsegleno-subhumeral liga-\\nment 5, upper edge of the tendon of the subscapularis 5 its lower part; B, biceps tendon\\nC, coracoid; E, spine of scapula G, glenoid fossa. (Farabeuf.)\\nthe portion immediately below the latter is the prsegleno-subhumeral.\\nThese different portions are shown in Figs. 262 and 263, which are\\ncopied from Farabeuf \\\\s paper. Of them the one that forms the lower\\n1 Farabeuf: Bull, de la Soc. de Chirurgie, 1S85, p. 391.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0620.jp2"}, "613": {"fulltext": "DISLOCATIONS OF THE SHOULDER. 545\\nmargin of the gap, the supragleno-praehumeral, is often of slight\\nstrength and underlies and is intimately adherent to the tendon of the\\nsubscapulars.\\nThe coraeo-humeral ligament is a strong wide band extending from\\nthe root and outer border of the coracoid process over the top of the joint\\nto the neck of the humerus above the greater tuberosity, and is inti-\\nmately connected with the capsule and the tendon of the supraspinatus.\\nIt is thought to play an important part in determining the position\\ntaken by the limb when dislocated, and the manoeuvres by which the\\ndislocation can be reduced.\\nThe tendon of the supraspinatus passes between the acromion and\\nthe head of the humerus and is attached to the upper part of the\\ngreater tuberosity it is blended with the capsule and is separated from\\nthe acromion by a bursa. Below it come the tendons of the infraspi-\\nnatus and teres minor, passing to the lower and middle facets respec-\\ntively and also blended with the capsule.\\nOutside the capsule is a loose layer of connective tissue which sepa-\\nrates it and the tendons of the outer muscles from the inner surface of\\nthe deltoid within this layer is the subdeltoid bursa, extending under\\nthe acromion, which deserves special mention because of the fact that\\nwhen the tendon of the supraspinatus is torn away from its attach-\\nment in a dislocation and retracts under the acromion with the adherent\\ncapsule, this bursa is thereby opened and placed in communication with\\nthe cavity of the joint, and the upper portion of the capsule is thus\\ngreatly lengthened. The influence of these new conditions in favoring\\nrecurrence of dislocation has been discussed in Chapter XXIX.\\nWith respect to the nerves and arteries it is only necessary to speak\\nof the circumflex nerve and of the arterial branches which pass out-\\nward, the two circumflex and the subscapular. The circumflex nerve\\nwinds around behind the neck of the humerus to its outer side, to be\\ndistributed to the deltoid muscle and to the integument covering it.\\nIt may be so injured in a dislocation that the deltoid will be paralyzed,\\nperhaps permanently.\\nThe circumflex and subscapular arteries pass outward to be distrib-\\nuted among the muscles of the scapula and upper part of the arm\\nwhen in a dislocation the head of the humerus presses the axillary\\nartery inward, those branches are put upon the stretch because they are\\nprevented by the attachment of their branches to the tissues from\\nmoving inward as freely as the main trunk does, and consequently they\\nmay be ruptured or torn away from the side of the main artery. This\\naccident may be the consequence of the dislocation itself, or of the\\nefforts to reduce it.\\nThe movements which are most frequently concerned in the produc-\\ntion of a dislocation are outward rotation and abduction. In the latter\\nthe elbow is raised directly outward and forward from the side of the\\nbody by the action of the deltoid, the plane in which it moves being\\nmore or less exactly that which would be represented by the prolonga-\\ntion of the broad surface of the shoulder-blade. As the movement is\\nmade, the head slides downward on the glenoid fossa, the long head of\\nthe triceps, the lower part of the subscapularis, and the lower and inner\\n35", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0621.jp2"}, "614": {"fulltext": "546 DISLOCATIONS.\\nportion of the capsule are made tense, and the movement is arrested\\nwhen the top of the greater tuberosity comes into contact with the\\nupper margin of the glenoid fossa, and the side of the shaft close below\\nthe tuberosity touches the acromion. If the movement is now con-\\ntinued, and the arm raised to the side of the head, it is eifected by the\\nrotation of the scapula and the elevation of its outer portion. If, on\\nthe other hand, the movement is continued while the scapula is kept\\nstationary, the centre of motion is transferred to the point of contact\\nbetween the humerus and the edge of the acromion, and the head of\\nthe bone is forced downward against the already tense capsule and\\nruptures it at its lower and inner portion, where it presses directly\\nagainst it.\\nIn outward rotation when the arm is hanging by the side or is but\\nslightly abducted the movement is arrested by the tension of the cap-\\nsule on the inner side, and at the same time the lower and outer part\\nof the greater tuberosity comes into contact with the outer lip of the\\nglenoid fossa if the movement is then continued the capsule yields,\\nbut the head does not become dislocated unless some other force\\nintervenes to press it inward through the rent that has thus been\\nmade.\\nIn all the other movements similar conditions are found, and dislo-\\ncations following them are less frequent only because the movements\\nare themselves less frequently carried beyond the limits set by the\\nstructure of the joint. Thus, abduction and rotation inward are\\nchecked by contact of the arm with the body before the capsule is put\\nupon the stretch, and extension of the arm behind the axillary line\\nmust be carried very far before a new fulcrum is found, and is also a\\nmovement that is rarely produced or exaggerated by external violence.\\nStatistics.\\nThe great frequency of dislocation of the shoulder is fully explained\\nby the structure of the joint and by its exposure to the dislocating\\naction of direct and indirect violence. This frequency is so great\\nthat dislocations of the shoulder are about as numerous as all the other\\ndislocations of the body combined. The tables of statistics given in\\nChapter XXVII. show percentages varying from 40 to 51 of all\\ndislocations. Malgaigne\\\\s statistics of 489 cases contain 321 of the\\nhumerus, more than 65 per cent. Gurlt s collection of 907 cases in\\nthe hospitals of Berlin, Paris, and Philadelphia contain 563 of the\\nshoulder, 58 percent.; Bardenheuer 1 saw 20 in a total of 37 cases\\ntreated in one year, 54 per cent. Kronlein s statistics, which are espe-\\ncially valuable because they are made up from both hospital and poly-\\nclinic records, give a total of 207 dislocations of the shoulder, of\\nwhich 184 were in males and only 23 in females of Malgaigne s 370\\ncases 97 were in women classified according to age and sex they both\\nshow that the injury is rare in youth, infrequent in old age, and most\\nfrequent in middle life. The youngest recorded case, excluding obstet-\\nrical cases, is Villar s, 2 fifteen days old. The relative frequency at\\n1 Bardenheuer Deutsche Chirurgie, Lief. 63 a, p. 279.\\n2 Villar Provincial Medical Journal, August 26, 1892.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0622.jp2"}, "615": {"fulltext": "DISLOCATIONS OF THE SHOULDER. 547\\nthe different ages, established by taking into account the percentages\\nof total population belonging to those ages, differs somewhat fro,m the\\nactual frequency, the maximum being found above the age of fifty\\nyears. The proportions calculated from Kronlein s statistics with the\\naid of the relative numbers of the population at the different ages, as\\ngiven in Chapter XXVII., are rive, nine, eleven, and twelve respec-\\ntively for the decades from thirty-one to seventy. This relatively\\ngreater frequency in advanced years is much more marked in women\\nthan in men, a fact which is to be explained by the greater exposure\\nto violence incident to the occupations and habits of men in middle\\nlife. It indicates, I think, that a much larger proportion of the dislo-\\ncations in advanced life are due to falls while walking than in middle\\nlife, since that is an accident to which both sexes are more equally\\nexposed than they are to others.\\nThe relations pointed out by Kronlein as existing between disloca-\\ntions of the shoulder and those of the elbow and fractures of the\\nclavicle are interesting. His statistics show that during the first two\\ndecades of life, a period in which dislocations of the shoulder are rare,\\ndislocations of the elbow and fractures of the clavicle are most fre-\\nquent. Thus, of 109 dislocations of the elbow contained in his table,\\n80 of the patients were under twenty years of age, and of 100 cases of\\nfractures of the clavicle collected by him 70 of the patients were under\\nten years of age while of 207 dislocations of the shoulder none of the\\npatients was less than ten, and only 2 less than twenty years old. He\\nthinks fractures of the clavicle are in childhood the equivalent injury\\nof dislocations of the shoulder by direct violence in middle life, and\\ndislocations of the elbow the equivalent injury of dislocations of the\\nshoulder by indirect violence.\\nClassification.\\nThe head of the humerus in leaving the joint may pass at first up-\\nward or downward, backward or forward, and may come to rest in\\nany one of a great number of positions. The classification of the\\nvarieties is beset with much difficulty, because of their number,\\nbecause of the frequency and importance of the secondary displace-\\nments, and last, though not least, because of the number of classifica-\\ntions that have already been made and are more or less current. The\\nconfusion has been further increased by the application of the same or\\nvery similar terms to different varieties by different authors. With\\nthe rare dislocations backward, and the still rarer ones upward, there\\nis no difficulty the uncertainty arises in connection with those in which\\nthe head of the humerus has passed across the anterior lip of the gle-\\nnoid fossa. A brief account of some of the classifications and terms\\nheretofore and still in use will show their differences and resemblances,\\nand may serve as a convenient introduction and preparation for the\\nclassification that must follow.\\nSir Astley Cooper s classification, upon which those now in use in\\nEngland and America have been in the main constructed, recognized\\nfour kinds of dislocations 1. Downward and inward into the axilla", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0623.jp2"}, "616": {"fulltext": "548 DISLOCATIONS.\\n2. Forward, the head of the humerus lying under the clavicle on the\\nsternaj side of the coracoid process 3. Backward 4. Partial inward,\\nthe head resting against the outer side of the coracoid process. It is\\napparent, from his description, that the first and fourth included the\\ncommon, frequent cases, those which are now generally termed sub-\\nglenoid, or into the axilla/ and subcoracoid, respectively.\\nA few years later Malgaigne followed, also with four principal forms,\\nbut only one of them the same as Cooper s. His grouping is as follows\\nDislocations inward\\n1 3.\\nU\\nSubcoracoid, complete quite common.\\nDislocations into the axilla 2. Subcoracoid, incomplete rare.\\n3. Subglenoid rare.\\nIntracoracoid most common of all.\\nSubclavicular rare.\\nt t i j f 6. Subacromial rare.\\nDislocations backward j Subspinous very rare.\\nDislocations upward 8. Supracoracoid only two cases known.\\nAll these titles are now in general use but while the last four, and\\nperhaps the second also, are still used to designate the forms which he\\ndesignated by them, the others have been used with different, some-\\ntimes with widely different, meanings. The first form, the complete\\nsubcoracoid, was characterized by the projection of the head of the\\nhumerus in the axilla, and its position exactly below the coracoid pro-\\ncess it would be included in Cooper s first group, dislocation down-\\nward into the axilla. His second subdivision, incomplete subcoracoid,\\nwas the same as Cooper s fourth, partial dislocation inward. His\\nthird, subglenoid, was one concerning which he seems to have been far\\nfrom having very precise notions he had seen only one case, and had\\nbeen able to collect only eleven others, and of these the symptoms\\ndiffered widely, the head of the humerus being described as raising the\\nanterior wall of the axilla in one case and the posterior in another, as\\nresting against the second intercostal space in one and against the third\\nin another, and even as having perforated the wall of the chest and\\nlodged within it. The one feature which they had in common, and\\nwhich he gives as pathognomonic, was that the head of the humerus\\nwas not immediately below and in contact with the beak of the coracoid\\nprocess, but was separated from it by a greater or less interval. Appar-\\nently the class was created simply to collect together the odds and ends,\\nthe irregular cases that were not subcoracoid and the idea which sug-\\ngested the name given to it was that the primary displacement took\\nplace more directly downward than in the preceding varieties. It will\\nbe seen that the name has since been applied to a very much larger\\nproportion of cases.\\nHis second main division embraced two varieties, the intracoracoid\\nand the subclavicular. Concerning the latter there is no misconcep-\\ntion the term has remained in use, and with the same meaning. The\\ngroup is made up of those cases in which the head of the humerus has\\npassed entirely to the inner side of the coracoid process, and lies below\\nthe clavicle. But the other term, intracoracoid, is generally employed\\nin a much more restricted sense than by Malgaigne. By it he desig-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0624.jp2"}, "617": {"fulltext": "DISLOCATIONS OF THE SHOULDER. 549\\nnated the greatest number of dislocations, more than two-thirds of\\nthose he saw at the Hopital St. Louis he applied it to those in which\\nthe head of the humerus, while still remaining under the coracoid pro-\\ncess, overlapped it on the inner side by more than half its own diam-\\neter. Most of such cases are now termed subcoracoid, and only those\\nin which the head has passed almost, if not entirely, to the inner side\\nof the process are called intracoracoid.\\nThe tendency of the more recent French and German writers is to\\nmake a single group of all the dislocations in which the humerus passes\\nto the anterior side of the scapula, containing four or more subdivisions\\nor varieties, two of which, the subclavicular and intracoracoid, in the\\nnarrower sense, are accepted by all. Of the remaining two principal\\nones, the subcoracoid and the subglenoid, the former is made to include\\nthe great majority, and the subglenoid is either closely and distinctly\\nrestricted to the very rare cases in which the head of the humerus is\\ndisplaced directly downward upon the tendon of the long head of the\\ntriceps, or Malgaigne s grouping is accepted with all its diversities and\\nvagueness. In the former case the group is removed from the prin-\\ncipal division of anterior or prseglenoidal dislocations, and\\nmade to form by itself another principal division, termed disloca-\\ntions downward.\\nThe English and American writers, as a rule, divide the same\\ncases into subglenoid and subcoracoid, basing the distinction between\\nthem upon the clinical feature of the greater or less facility with\\nwhich the head of the humerus can be felt in the axilla those in which\\nit is more prominent in the axilla are subglenoid, those in which\\nit is more prominent behind the anterior wall of the axilla, close\\nbeneath the coracoid process, are subcoracoid. The objections to\\nthis grouping are that it does not sufficiently distinguish between pri-\\nmary and secondary displacements, and that the clinical features upon\\nwhich it rests present a complete series of intermediate forms, most of\\nwhich might be as properly placed in one group as in the other. The\\narbitrariness and uncertainty of the decision are well shown by a com-\\nparison of clinical and pathological statistics. Thus, Hamilton and\\nBryant say that the subglenoid is of more frequent occurrence than the\\nsubcoracoid, and Erichsen says that this is the opinion of most English\\nsurgeons while, on the other hand, Flower, 1 who made an examina-\\ntion of all the specimens contained in the London museums, 41 in\\nnumber, found that in 32 the dislocation was subcoracoid, and he adds,\\nthat of 50 cases recently observed by him in living patients the same\\nwas true of a large majority 2 he calls attention to the fact that\\nthe great frequency of subcoracoid dislocation observed in this series\\n[of specimens] does not accord with the descriptions of this injury gen-\\nerally given in the standard surgical works of the country. A few\\nyears later, in the article on the Injuries of the Upper Extremity which\\nhe prepared in connection with Mr. Hulke for Holmes s System of\\nSurgery, Mr. Flower made a classification in which the influence of\\nthis important investigation is apparent. It is as follows\\n1 Flower: Transactions London Pathological Society, 1861, vol. xii. p. 179.\\n2 The number is given as 44 in his article on Injuries of the Upper Extremity in\\nHolmes s System of Surgery.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0625.jp2"}, "618": {"fulltext": "550\\nDISLOCATIONS.\\n1. Subcoracoid. Forward and slightly downward. On to the\\nneck of the scapula, in front of the glenoid fossa, and immediately\\nbelow the coracoid process. Common.\\n2. Subglenoid. Downward and forward. Head of the humerus\\nin front of the inferior costa [border] of the scapula, below the glenoid\\nfossa. Rare.\\nHis remaining three divisions are Subclavicular, Supracoracoid, and\\nSubspinous, the latter including Malgaigne s sixth and seventh.\\nTurning now to the pathological data, to the recorded results of\\npost-mortem examinations and experiments upon the cadaver, and con-\\nfining our attention for the moment to the forms mainly in dispute,\\nthe dislocations forward (or inward) and downward, and to the points\\nthat affect the position of the head of the humerus, the following facts\\nappear\\nThe head of the humerus, when it passes across the anterior edge of\\nthe glenoid cavity, must, as a glance at Fig. 260 shows, move somewhat\\ndownward so as to get below the beak of the coracoid process the posi-\\nTendon\\nof triceps\\nTo show the range of positions that may be taken by the head of the humerus after primary dis-\\nplacement forward or downward in any of the directions between the arrows.\\ntion of the limb that most favors the production of dislocation is\\nabduction with or without external rotation. The inner and lower\\nportion of the capsule, being pressed upon by the head of the humerus,\\ntears between the tendon of the subscapulars and the triceps, the rent\\nbeing small or large and varying greatly in extent and direction in the\\ndifferent cases, but it is always on the anterior and inner side, and the\\nhead passes more or less completely through it. If the movement is\\nmore directly forward and inward and to a less degree downward, as\\nin dislocations by direct violence received on the outer side of the\\nshoulder, the head of the bone pushes the subscapularis muscle before\\nit and lodges close under the coracoid process and between that muscle\\nand the edge of the glenoid cavity. In this case no secondary dis-\\nplacement ensues, and the form would be classed as subcoracoid by all.\\nIf the movement is forcible and prolonged the subscapularis may be", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0626.jp2"}, "619": {"fulltext": "DISLOCATIONS OF THE SHOULDER. 551\\ntorn entirely across and the head may pass through it and come to rest\\non the side of the thorax under the clavicle or, as in a case quoted by\\nMalgaigne, it may pass over the upper border of the subscapularis and\\ncome to rest at the same point. If, on the other hand, the primary\\nmovement downward has been more marked, as in dislocations effected\\nby hyper-abduction of the arm, the head either passes below the sub-\\nscapularis or tears its lower portion, and then, as the elbow is lowered\\nthe head rises, pressing the subscapularis or its untorn portion upward\\nand remaining separated by it from the coracoid process. The extent\\nand direction of this movement of the head are determined largely by\\nthe resistance of the untorn portions of the capsule, notably the outer\\nand anterior part, which, by preventing the further descent of that\\npart of the humerus to which they are attached, compel the head to\\nmove upward as the elbow descends. Other factors are found in the\\nmuscles if the head lies under an untorn subscapularis its distance\\nbelow the coracoid process will be greater than when it lies under only\\nthe upper portion of the muscle, and if in addition it has passed under\\nthe teres major or downward as far as the lower border of the pectora-\\nlis major the arm will remain widely abducted or even with the elbow\\nabove the head (luxatio erecta). Or, departing still further from\\nwhat is usual, it may perhaps even turn backward after it has left its\\nsocket and pass under the long head of the triceps to lodge behind the\\nglenoid cavity, the alleged subtricipital dislocation.\\nThe head of the humerus rests against the inner side of the head or\\nneck of the scapula at any point between its junction with the broad\\naxillary border, or inferior costa, and the middle of the anterior lip\\nof the glenoid fossa, and it may lie either directly against the edge of\\nthis lip or further back on the side, as is clearly shown by the speci-\\nmens of old, unreduced dislocations preserved in the museums. And\\naccording as it occupies one or the other position it will be more or\\nless prominent in the axilla or more or less clearly seen and felt behind\\nthe pectoralis major beneath the coracoid process.\\nIt is evident, then, that the position in which the head of the bone\\nis found bears only a limited relation to the point at which it left the\\njoint, and that a classification which is sharply made upon this posi-\\ntion is not only arbitrary and uncertain for a large number of cases,\\nbut also favors inattention to points that have an important bearing\\nupon a safe and easy reduction.\\nIt is desirable that a classification should not deal minutely with\\nunimportant variations, and that instead of multiplying divisions it\\nshould rather gather into a few groups those varieties that have char-\\nacteristic and important features in common and yet, as some forms\\ndiffer widely in their symptoms from others with which they are on\\nother grounds closely related, it is equally desirable to recognize and\\nnote such differences. The distinction between regular and irreg-\\nular dislocations made by Bigelow at the hip can also be made at\\nthe shoulder, taking for the dislocations downward and forward the\\nintegrity or the rupture of the antero-external portions of the capsule\\nas the determining feature. The following classification is, in the\\nmain, the same as that of Mr. Flower, above given, and the later", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0627.jp2"}, "620": {"fulltext": "552 DISLOCATIONS.\\nFrench and German writers. It differs from that of the majority of\\nthe English and American writers in restricting the group of the\\nsubglenoid and correspondingly enlarging that of the subcoracoid\\ndislocations.\\n{Subcoracoid very common.\\nIntracoracoid exceptional,\\nsubclavicular.\\n(Subglenoid uncommon,\\nerecta very rare,\\nsubtricipital\\nt f Subacromial rare.\\nPosterior Sou-\\nSubspinous very rare.\\nUpward Supraglenoid very rare.\\nThe names of the four principal divisions indicate the direction of\\nthe primary displacement those of the subdivisions the position in\\nwhich the head of the bone lodges, with the exception of the erecta,\\nwhich takes its name from the attitude of the limb, and the subtricip-\\nital, which rather indicates the route traversed by the head than the\\nposition finally taken by it. Between the anterior and the downward\\nthe divison cannot be sharply made, and in many of the cases included\\namong the first the primary displacement has more of the downward\\nthan of the anterior feature, but it is believed that by enlarging the\\nsubcoracoid class so that it will include all but the lowest of the lower\\nforms, by extending its range so that it will distinctly include the\\nlower as well as the higher primary displacements, the necessity of\\nabducting the arm to effect reduction in those cases in which the sec-\\nondary displacement upward is marked and might otherwise lead into\\nerror will be less liable to be overlooked. The difficulty of distin-\\nguishing between the subglenoid and the lowest of the subcoracoid\\nwill arise in only a very limited number of cases and will be without\\npractical importance; at the most it will be merely a question of\\nnomenclature.\\nThere would be some advantage in further dividing the subcoracoid\\ngroup into high and low.\\nANTERIOR (AND DOWNWARD) DISLOCATIONS.\\n1. Subcoracoid.\\n2. Intracoracoid, subclavicular.\\nIn these dislocations the head of the humerus passes across the\\nanterior lip of the glenoid fossa, taking at first a direction that is for-\\nward and inward and more or less downward it may subsequently\\nmove upward or further inward. The class includes two subdivisions,\\nthe subcoracoid and the intracoracoid, of which the latter is here made\\nto include also the more marked dislocation inward known as the sub-\\nclavicular.\\nThe class embraces the subcoracoid, partial and complete, of all\\nauthors, most of the subglenoid of most English and American\\nauthors, and the intracoracoid and subclavicular of all. The terms\\naxillary dislocations and dislocations into the axilla are applied", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0628.jp2"}, "621": {"fulltext": "ANTERIOR DISLOCATIONS OF THE SHOULDER. 553\\nby some to cases that are here called subcoracoid, and the term pec-\\ntoral to the intracoracoid.\\n1. Subcoracoid Dislocations.\\nIn this form, which includes a large majority of all cases, the head\\nof the humerus lies under and in close proximity to the beak of the\\ncoracoid process, or at a distance below it that may equal or even\\nexceed a tinge r-breadth. The centre of the head may be either directly\\nbelow the beak of the coracoid process or on its outer or inner side.\\nIf more than three-fourths of the transverse diameter has passed to\\nthe inner side of the coracoid the dislocation is termed intracoracoid.\\nThe class, therefore, is continuous with the subglenoid below and with\\nthe intracoracoid on the inner side, and the separation from them is\\narbitrary and artificial, but is justified by custom and convenience in\\ndescription.\\nMalgaigne showed, as early as 1835, that in some cases the articular\\nsurface of the head of the humerus rested on the anterior edge of the\\nglenoid fossa, and such he termed incomplete. The formation of\\na separate class composed of such cases seems unnecessary and even\\nundesirable, for they diifer from the complete ones only in degree, and\\nthe difference is slight and without practical importance the symptoms\\nare like those of complete dislocation, the bone is fixed in its new posi-\\ntion, and aid is required to replace it in the joint. Moreover, in some\\nthe diagnosis (differential, between complete and incomplete) can only\\nbe made at the autopsy.\\nThe injury may be produced by direct or indirect violence, a blow\\nupon the outer and upper part of the shoulder or hyperabduction of\\nthe arm, or by muscular action. When produced by direct violence\\nthe displacement is usually in a direction that is only sufficiently\\ninclined downward to enable the head to pass below the coracoid pro-\\ncess in a case reported by Kronlein l and in one of mine 2 the blow\\nwas received from above upon the acromion and only dislocated the\\nhumerus after it had broken that process. The extent of the displace-\\nment inward is affected partly by the force of the blow and the extent\\nof the laceration of the capsule, and partly by the contraction of the\\nmuscles that adduct the limb.\\nDislocations by indirect violence are the most common, the force\\nacting to produce hyperabduction of the joint. 3\\n1 Kronlein: Deutsche Chirurgie, Lief. 26, p. 14.\\n2 My patieut was a man about 40 years old, who was admitted to the New York Hospital\\nDec. 17, 1898, after having been struck upon the outer part of the left shoulder by a fall-\\ning brick, as shown by an abrasion just beyond the outer edge of the acromion. The\\nhead of the humerus lay close beneath the coracoid, the acromion was broken at its base\\nand displaced downward and inward, with dislocation of the acromio-clavicular joint,\\nand could be moved with slight crepitus the joint surface of the clavicle could be dis-\\ntinctly felt through the skin. Reduction was easy by traction and direct pressure upon\\nthe head of the humerus. The acromion returned to its place, and there was no tend-\\nency to recurrence of the acromio-clavicular dislocation.\\n3 Hyperabduction of the joint must be distinguished from that of the limb. The former\\ncan take place even while the elbow is below the level of the shoulder, for it is deter-\\nmined by the relations between the humerus and the scapula and as the scapula is freely\\nmovable the position of the limb (with reference to the body), when the limit of motion\\nin the joint is reached, varies with that of the scapula.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0629.jp2"}, "622": {"fulltext": "554\\nDISLOCATIONS.\\nHyperabduction acts by bringing the outer side of the upper end of\\nthe humerus into contact with the edge of the acromion and thus cre-\\nating a new centre of motion for the continued movement, the effect of\\nwhich is to cause the head of the humerus to descend and rupture the\\ncapsule in its inner and lower portion. After this rupture has taken\\nplace and the upward movement of the elbow has ceased, the contrac-\\ntion of the muscles, the deltoid, pectoralis major, and latissimus dorsi,\\ndraws the head of the humerus inward past the anterior lip of the gle-\\nnoid fossa, and then when the elbow is lowered the head rises along the\\ninner side of the joint, for the untorn outer and anterior portion of the\\ncapsule is made tense and, by thus preventing the descent of the portion\\nof the bone to which it is attached, compels the movement to take place\\nFig. 265.\\nSubcoracoid dislocation on a cadaver showing rupture of lower part of the subscapular^.\\n(B. Anger.)\\nabout this portion as a centre. As the first new centre of motion at\\nthe edge of the acromion determines, in connection with the muscles,\\nthe primary displacement, so the second new centre on the humerus\\nat the outer and anterior attachment of the capsule determines the\\nsecondary displacement and the final position of the head of the bone\\nand the attitude of the limb.\\nMuscular action, the contraction of the muscles of the individual\\nhimself, can produce a dislocation either by drawing the head of the\\nbone directly out of its socket, or, much more commonly, by creating\\nconditions of leverage and momentum similar to those existing in the\\nproduction of dislocations by indirect violence. In many of the re-\\nported cases it is difficult to recognize the mechanism of the injury.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0630.jp2"}, "623": {"fulltext": "ANTERIOR DISLOCATIONS OF THE SHOULDER. 555\\nThe least questionable examples of dislocation effected by the direct\\ntraction of the muscles are those in which the injury has occurred\\nduring a convulsion. A considerable number of such have been\\nreported in one quoted below (Pollosson, page 558) the limb seems\\nto have been in the position of inward rotation at the moment of dis-\\nlocation. The examples of the other kind are numerous and varied,\\nand the explanation is usually simple. A painter raises his arm\\nto work upon a ceiling, an artilleryman to throw a shot, a patient\\nlying in bed to free its curtain caught under the pillow, a woman to\\ngrasp an object hanging on the wall in such cases hyperabduction of\\nthe joint seems to be the probable cause. In others hyperabduction\\ncan only be invoked on the supposition that the contraction of the del-\\ntoid has lowered the acromion, the arm being fixed in a position below\\nthe shoulder, as in Bichat s case of the notary who dislocated his\\nshoulder in an attempt to raise a heavy book from the floor, or in Volk-\\nmann s of a woman who tried to lift a heavy pot from a shelf at the\\nheight of her shoulder, or Malgaigne s athlete who tried suddenly to\\nlift a man kneeling in front of him, or Duplay s very muscular patient\\nwho stumbled while descending a staircase and threw out his arm to\\nsave himself from falling but touched no object with it.\\nIn other cases the influence of muscular action is entirely indirect.\\nThus, Rickert 1 tells of a very muscular man twenty-five years old who\\nreceived a subclavicular dislocation by resting his hand against a wall\\nover his head and sneezing. Bardenheuer mentions a similar case\\nobserved by Saponi. In such a case the mechanism is essentially the\\nsame as in that, for example, in which a man supported himself with\\nhis arms outstretched against a wagon to receive a sack of grain which\\nanother threw down upon his back and thereby dislocated both shoul-\\nders.\\nIt is impossible in most cases to determine the exact position and\\nattitude of the limb at the moment the dislocation occurs, and the rela-\\ntive parts taken by abduction, rotation, muscular action, and direct\\nimpulsion in its production. At present it can only be said that every\\none of the four has proved sufficient by itself, and that they have been\\nfound to co-operate in varying degrees.\\nPathology. The capsule is torn at its inner and lower portion between\\nthe tendon of the subscapulars and the triceps, and the rent extends\\nusually along the inner and lower border of the glenoid fossa for half,\\nsometimes even two-thirds, of the entire periphery. In other cases\\nthe rent extends outward and backward, rather than upward, and near\\nthe insertion of the capsule upon the humerus. Exceptionally, the\\nrent is very small, or may even be entirely lacking, its place being\\nsometimes taken by the stripping up of the continuous periosteum\\nfrom the inner side of the neck of the scapula. Eve 2 reported a case\\nof subcoracoid dislocation in which the capsule was untorn, but was\\nseparated from the anterior border of the glenoid fossa, remaining con-\\ntinuous with the periosteum which was stripped up from the costal\\nsurface of the scapula. On the posterior surface of the head of the\\n1 Rickert Maryland Medical Journal, 1883-84, vol. x. p. 339.\\n2 Eve Transactions Pathological Society of London, 1880, vol. lxiii. p. 317.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0631.jp2"}, "624": {"fulltext": "556 DISLOCATIONS.\\nhumerus was a deep vertical indentation made by impact against the\\nanterior margin of the glenoid fossa. An almost identical case was\\nshown to the London Pathological Society by D Arcy Power. 1 In\\n1880 I presented to the New York Surgical Society the shoulder-\\njoint of an old man who had died of pneumonia a week after he had\\ndislocated his shoulder. The dislocation was well marked, and reduction\\nwas effected with the aid of ether. The joint was opened from behind,\\nand the capsule was found untorn the tendon of the subscapulars was\\npartly detached at its insertion, but at no point throughout its entire\\nthickness, and the upper facet of the greater tuberosity was broken off\\nin several pieces, but not widely separated. Such cases of slight or no\\ninjury to the capsule have been classed by some writers, following\\nMalgaigne, as incomplete dislocations.\\nThe subscapulars muscle is sometimes simply pressed inward and\\nseparated from the scapula by the interposed head of the humerus, but\\nin many cases it is torn more or less widely from its lower border\\nupward, and its upper portion may lie upon the head of the humerus\\nand separate it from the coracoid process. Occasionally, instead of\\nbeing ruptured, the muscle is torn away from its attachment to the\\nhumerus, perhaps bringing with it the lesser tuberosity. I have seen\\none case in which the head passed beneath the tendon and then to its\\ninner surface, so that division of the tendon was required to effect\\nreduction.\\nThe supraspinatus is sometimes, probably often, torn from its attach-\\nment to the humerus, and the same is true in a less degree of the infra-\\nspinatus, and occasionally even of the teres minor.\\nThe teres major is sometimes slightly\\nFig. 266. torn, apparently by the partial passage of\\nthe head of the humerus between it and\\nthe subscapularis.\\nThe anterior edge of the glenoid fossa is\\noccasionally broken off, and detachment of a\\nportion of its fibro-cartilaginous rim seems\\nnot infrequent it is sometimes pushed\\nsubcoracoid dislocation to show away to some distance, bringing with it\\nthe different degrees of rotation of the periosteum Q f the scapma The aCTO-\\nthe humerus indifferent positions. r 1\\nmion and coracoid process nave both been\\nfound broken, but such injury appears to have been purely incidental\\nand should be classed as a complication.\\nThe head of the humerus lies against the edge of the glenoid fossa,\\nor further back against the side of the neck of the scapula, and either\\nclose up against the beak of the coracoid process behind the coraco-\\nbrachial and the short head of the biceps, or lower down at a distance\\ndetermined by its relations to the subscapularis and by the tension of\\nthe untorn portion of the capsule. It may lie largely on the outer side\\nof the coracoid process, or immediately below it, or it may pass entirely\\nto its inner side (intracoracoid dislocation), and it may be in outward\\nor inward rotation (Fig. 266) or in any intermediate attitude.\\nAs has been already said, avulsion of the tuberosities may take the\\n1 D Arcy Power Lancet, November 24, 1888.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0632.jp2"}, "625": {"fulltext": "ANTERIOR DISLOCATIONS OF THE SHOULDER.\\n557\\nplace of laceration of the muscles attached to them this has been\\nrarely noted of the lesser tuberosity, but frequently of the greater,\\nand especially of its upper and middle facets. Yon Thaden, 1 who\\nmade a study of this feature, found that the upper and middle facets\\nwere each sometimes torn off separately, but the lower one only in\\nconnection with the other two. The complication is of importance\\nbecause of the consequent loss of the control of the attached muscles\\noyer the humerus and the consequent exposure to recurrence of the\\ndislocation (see Chapter XXIX.), and because it opens the way for\\nthe escape of the long tendon of the biceps from its groove and its\\ninterposition between the humerus and its socket in such a way as to con-\\nstitute a serious obstacle to reduction. In the specimens Yon Thaden\\nexamined he found the tendon thus interposed three times. Kb rte 2\\nreported a similar case in which the tendon had slipped entirely out\\nof its groove and was wound around the outer and posterior side of\\nthe head.\\nFig. 267.\\nOld unreduced dislocation of the right humerus, with interposition of the capsule. At the\\ninner side of the head of the humerus is the rent in the capsule through which it passed, and\\nabove the rent is the greater tuberosity which had been torn off. At the outer side of the cora-\\ncoid process is an opening in the capsule which had been produced by the pressure of the\\nhumerus through it the glenoid fossa is seen. (Hilton.)\\nWhen the tuberosity or a portion of it is thus broken off, the frag-\\nment lies over or in the glenoid fossa, and the broken surface of the\\nhumerus rests against the inner surface of the neck of the scapula or\\nengages the edge of the fossa. The upper and outer portion of the\\ncapsule thus separated from the humerus may remain interposed be-\\ntween the head of the humerus and its socket and prevent reduction.\\nAfter reduction of the dislocation the tuberosity unites with the\\nhumerus with more or less irregularity and deformity.\\nExcept in connection with fracture of one or the other tuberosity\\n1 Von Thaden Arch, fur klin. Chir., vol. vi. p. G7.\\n2 Korte Ibid., vol. xxvii. p. 747.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0633.jp2"}, "626": {"fulltext": "558\\nDISLOCATIONS.\\nthe long tendon of the biceps is rarely dislocated, but it is sometimes\\ntorn away from its insertion or ruptured.\\nIn some specimens of old unreduced dislocation a vertical groove has\\nbeen found on the articular surface of the head of the humerus which\\nwas thought to have been caused by prolonged contact with the edge\\nof the glenoid fossa. Malgaigne, who took a special interest in the\\nspecimens as supposed examples of incomplete dislocation, suggested\\nthat the groove might have been caused at the time the injury was\\nreceived by the forcible impact of one bone against the other. It is\\ninteresting to find that this suggestion has been confirmed by autopsy in\\nEve s and Power s cases mentioned above and by two specimens of\\nrecent dislocation preserved in the Museum of the University of Edin-\\nburgh and reported in an interesting and valuable paper by Caird, 1 and\\nFig. 268.\\nSubcoracoid dislocation of the left shoulder.\\nby one reported by Broca and Hartmann 2 the indentation lay wholly\\nor in part along the junction of the head and shaft above and behind the\\ngreater tuberosity, was from one to one and a half inches long, and\\nfrom one-quarter to one-half an inch deep, and accurately fitted the\\ninner lip of the glenoid fossa. The suggestion that the causation of\\nfracture of the anatomical neck may be referred to the same mechanism\\nseems very plausible. A similar indentation adjoining the lesser tuber-\\nosity is reported by Pollosson 3 in a double dislocation by muscular\\naction convulsions of eclampsia. The position indicates that the\\nlimbs were in inward rotation at the moment of dislocation.\\n1 Caird: Edinburgh Medical Journal, February, 1887.\\n2 Broca and Hartmann Bull, de la Soc. Anat.,* 1890, No. 14.\\n3 Pollosson Eev. de Chir., November, 1888, p. 927.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0634.jp2"}, "627": {"fulltext": "ANTEBIOR DISLOCATIONS OF THE SHOULDER, 559\\nThe axillary vessels and nerves are pressed inward and are some-\\ntimes injured.\\nSymptoms and Diagnosis. The description of the symptoms will be\\nmade simpler by limiting it at first to those commonly found in the\\nmedium displacements, and subsequently indicating the differences or\\nmodifications peculiar to the exceptional grades and conditions.\\nThe patient sits with his trunk inclined toward the injured side, and\\nsupports the forearm with the other hand. The shoulder is flattened\\non the outer side so that the Hue of the deltoid runs straight down\\nfrom the acromion and makes a more marked angle with the arm at\\nits insertion than is usual. The anterior fold of the axilla lies lower,\\nfurther from the clavicle than its fellow of the opposite side, and its\\ncreases appear deeper, as if the arm were applied more closely against\\nthe chest, and the outer part of the subclavicular fossa appears more\\nfull.\\nThe elbow stands a little away from the side and can be easily\\nabducted, but any attempt to bring it nearer the side causes pain and\\nis resisted it may be in the axillary line, or in front of or behind it.\\nWhen the elbow is flexed at a right angle the forearm is directed for-\\nward and inward its direction can be passively changed to either side,\\nbut not freely. The hand cannot be brought to the opposite shoulder.\\nVoluntary movements of the dislocated joint are declared by the\\npatient to be impossible, and pain is complained of in the shoulder,\\nsometimes extending down the arm.\\nIf the axis of the arm, viewed from in front, is prolonged upward\\nby the eye it will be seen to pass to the inner side of the glenoid\\ncavity, and if the fingers are firmly pressed\\nagainst the anterior wall of the axilla in the Fig. 269.\\nline of this prolongation and a little below the a\\ncoracoid process they will encounter the firm .fi^ -^f\\nresistance of a solid body palpation shows\\nthis body to be globular, and if it can be\\ngrasped between the thumb and finger, or if\\nthe finger can find some projection on its sur-\\nface, it will be found to share in slight move-\\nments of rotation communicated to the arm by\\nthe other hand of the surgeon.\\nIf now the head of the humerus is sought\\nfor by palpation in its normal position it will Diagram t0 showthe effect\\nnot be found there; the fingers can be pressed of position upon the apparent\\nin deeply under the acromion from the outer len s th of the arm in aisioca-\\n\u00e2\u0080\u00a2i Vi n ,i tion of the shoulder. A, aero-\\nside the outer margin of the acromion is mion B lower end of bu _\\nprominent and can be easily traced. This is merus.\\nmarked when the limb is abducted.\\nIf the elbow be further abducted and the surgeon pass his fingers\\nwell up into the axilla he can there feel the head of the humerus more\\nor less distinctly according as the displacement is low or high.\\nIf the distance be measured from the outer margin of the acromion\\nto the external epicondyle of the humerus or the olecranon, it will\\nusually be found somewhat greater, perhaps half an inch, on the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0635.jp2"}, "628": {"fulltext": "560 DISLOCATIONS.\\ninjured than on the uninjured side, but if successive measurements\\nare taken as the arms are abducted the difference will disappear, and\\nin complete abduction the distance will be greater on the opposite side.\\nThe reason for this is seen by a glance at Fig. 269.\\nAs in most other dislocations, the capital point in the diagnosis is\\nthe recognition of the head of the bone and the determination of its\\nrelations to the socket from which it has escaped. Ordinarily, both\\nof these can be accomplished at the shoulder with ease and certainty,\\nand the examination is difficult only when the patient is very fat or\\nthe parts much swollen.\\nAs the attitude and range of motion of the limb depend mainly\\nupon the tension of the untorn portion of the capsule, they will be\\nmodified when the capsule is freely torn. It is in such cases that the\\ndiagnostic sign so freely trusted, the inability to bring the elbow against\\nthe side and to place the hand on the opposite shoulder, is lacking or\\nonly slightly marked.\\nWhen the displacement of the humerus is less than usual, when its\\nhead rests upon the edge of the fossa, the incomplete dislocation\\nof some writers, the symptoms are modified to this extent, that the\\nflattening of the shoulder and the abduction of the elbow are less\\nthe elbow may even lie close to the body but the limb is equally\\nfixed and incapable of being voluntarily moved. The pain also is\\ngreater. It has occasionally happened that the dislocation has been\\nreduced by the manipulations used to make the diagnosis.\\nTreatment. The treatment will be described in connection with that\\nof the following variety.\\n2. Intracoracoid Dislocations (Subclavicular Dislocations).\\nTo avoid misapprehension I repeat that the term intracoracoid\\nwas applied by Malgaigne to the class of cases which he deemed of\\nmost frequent occurrence, comprising two-thirds of the forty-nine\\ncases of shoulder dislocation observed by him at the Hopital St. Louis,\\nthose in which the head of the humerus is so placed that from one-\\nthird to two-thirds or three-fourths of its transverse diameter lies to\\nthe inner side of the coracoid process. Most of such cases are now\\nhabitually spoken of as subcoracoid, and the terms intracoracoid\\nand subclavicular are restricted to those cases in which the bone is\\ndisplaced still further inward. As between intracoracoid and\\nsubclavicular thus employed, I prefer the former name because it\\ncontains that of the anatomical landmark the relations to which form\\nthe basis of the classification.\\nThe injury may be produced by direct violence received upon the\\nouter aspect of the shoulder or by hyperabduction of the arm. The\\nessential causative feature of the variety, as compared with the sub-\\ncoracoid, is that the action of the original violence is prolonged, or\\nthat the secondary cause exaggerates the secondary displacement\\nupward and inward. After a primary displacement forward and down-\\nward by abduction of the limb, anything that forcibly presses or\\ndraws the arm inward, such as pressure inward against the elbow, or", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0636.jp2"}, "629": {"fulltext": "ANTERIOR DISLOCATIONS OF THE SHOULDER. 561\\nthe contraction of the deltoid and pectoralis major, may effect this dis-\\nplacement if the head of the bone has passed under the subscapular is,\\nor if this muscle has been sufficiently torn. The head of the humerus\\nlies against the wall of the chest, or rather against the serratus mag-\\nnus, on one side, and against the costal surface of the neck of the\\nscapula on the other. The subscapularis usually is widely torn in\\nMcXamara\\\\s case, quoted by Malgaigne, 1 it was untorn, and the head\\nof the humerus had stripped it away from the scapula and had risen\\nabove its upper border, lying against the root of the coracoid pro-\\ncess. Xo muscle or tendon was torn. In one of my own the head\\nFig. 270.\\nIntracoracoid dislocation.\\nof the bone had passed beneath and entirely to the inner side of the\\nsubscapularis.\\nThe capsule is extensively torn, and the greater tuberosity usually\\nbroken off in whole or in part and lying in the glenoid fossa.\\nThe head of the humerus passes behind the muscles arising from\\nthe coracoid process (in one recorded case, Roser s, 2 in front of the\\ncoraco-brachialis and biceps and behind the pectoralis minor) and\\noccasionally is partly interposed between the contiguous borders of the\\ndeltoid and pectoralis major, being then subcutaneous. It may lie\\n1 Malgaigne Loc. cit., p. 525.\\n2 Roser: Arch, fur phys. Heilkunde, 1844, p. 582. The dislocation had lasted for\\nseven years, and many attempts had been made to reduce it.\\n36", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0637.jp2"}, "630": {"fulltext": "562\\nDISLOCATIONS.\\nimmediately under or a little behind the clavicle, in one case (Meyer)\\nit even projected above and behind it, and it has usually been found\\nrotated inward.\\nThe long tendon of the biceps is broken, or displaced across and\\nbeyond the fractured surface left by the avulsion of the greater\\ntuberosity.\\nThe main vessels and nerves lie rather behind the head than between\\nit and the wall of the chest.\\nSymptoms. The attitude of the patient and the general appearance\\nof the shoulder are the same as in the subcoracoid variety the details\\ndiffer mainly in degree, some being less, others more, marked. The\\nflattening of the shoulder is greater, as is also, in some cases, the ful-\\nness of the subclavicular fossa, but this fulness is nearer the median\\nline. The elbow may lie near the side, even in contact with it; the\\naxis of the arm prolonged upward in front passes well to the inner\\nside of the coracoid process. The fingers cannot be passed between\\nthe head of the humerus and the chest-wall, consequently only the\\nFig. 271.\\n^rf^ m\\nIntracoracoid dislocation, with arm fixed in horizontal abduction. (Bardenheuer.)\\nshaft and lower portion of the head can be felt through the axilla but,\\non the other hand, the lower anterior edge of the glenoid fossa and the\\nneck of the scapula can sometimes be felt behind the shaft.\\nAbduction of the limb is not always easy, and is effected by eleva-\\ntion of the scapula rather than by movement of the humerus upon it.\\nDifferences in length, when the arm is dependent, are less constant\\nand marked than in the preceding variety, but if the arm can be\\nabducted upon the scapula the shortening is then greater.\\nThe dislocation can be transformed into a subcoracoid by traction\\ndownward and outward.\\nOccasionally the dislocated arm is fixed in the position of complete\\nhorizontal abduction (Fig. 271). Such are doubtless cases in which\\nthe head has left the socket at a low point while the arm was widely\\nabducted. (See Subglenoid Dislocations and Luxatio erecta, Chapter\\nXLIII.)\\n1 Bardenheuer Deutsche Chirurgie, Lief. 63 a, p. 317.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0638.jp2"}, "631": {"fulltext": "ANTERIOR DISLOCATIONS OF THE SHOULDER. 563\\nTreatment of Anterior Dislocations.\\n(See, also, Chapter XXXIII.)\\nObstacles to the return of the head of the humerus to its socket may\\nbe created by the tension of portions of the capsule which oppose its\\nmovement toward the socket, except in certain attitudes of the limb,\\nby the approximation of the sides of the rent in the capsule through\\nwhich it has passed, by the interposition of portions of the capsule or\\nof the tendon of the biceps, by its engagement behind the edge of the\\nglenoid cavity or the coracoid process, by the contraction or rigidity of\\nthe muscles and the swelling of the soft parts, and exceptionally by\\nthe interposition of the tendon of the subscapulars (see above). Those\\nwhich are most frequently concerned are the opposition of the anterior\\nportion of the capsule and the contraction of the muscles.\\nIf the portion of the capsule which extends from the base of the\\ncoracoid process and the outer, or posterior, edge of the glenoid fossa\\nto the greater tuberosity and posterior portion of the humerus, includ-\\ning the coraco-humeral ligament, remains untorn, it is stretched down-\\nward and forward across the glenoid fossa, and, being drawn tight by\\nthe weight of the elbow, it holds the head of the humerus against the\\nscapula. If now the elbow is raised, the capsule is thereby relaxed,\\nand the abducted limb can be easily drawn outward.\\nIf the capsule is so freely torn away from the humerus on the outer\\nside that it falls down between it and the glenoid fossa, it cannot be\\nlifted out of the way by manipulation of the arm, because its separation\\nis so complete that it is no longer affected by the position given to the\\nlatter. It may, perhaps, be pushed out of the way by the returning\\nbone, but that is a matter of chance rather than of skill. Probably,\\nfull abduction of the arm followed by traction would be most likely to\\naccomplish the object under such circumstances.\\nDislocation and interposition of the tendon of the long head of the\\nbiceps occurs only with avulsion of the greater tuberosity, and not\\nalways then, for it may, instead, be ruptured. Even Avhen interposed,\\nthe tendon may be fairly expected to have preserved its relations with\\nthe lower part of the bicipital groove and sheath, and consequently to\\nbe still somewhat under control by the humerus. By elevating the\\narm and flexing the elbow it will be relaxed and raised toward the\\nupper part of the joint, leaving space below for the head of the bone\\nto pass back under it.\\nAbduction of the arm and external rotation are, then, the means by\\nw T hich the most common obstacles created by the capsule are to be\\navoided.\\nThe muscles oppose reduction by their contraction excited by pain\\nor the fear of pain this can sometimes be avoided by taking the patient\\nunawares, or by fatiguing the muscles, and always by anaesthesia. A\\ncertain anxiety connected with resort to the aid of anaesthesia has arisen\\nfrom the fact that a disproportionate number of deaths caused by chloro-\\nform have occurred in the reduction of dislocations (see p. 439), but I am\\nnot aware that death has ever followed the use of ether under such cir-\\ncumstances. There are many reasons why reduction should be made,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0639.jp2"}, "632": {"fulltext": "564 DISLOCATIONS.\\nwhen conveniently practicable, without its aid, but I never hesitate to\\navail myself of the aid of ether in preference to the employment of\\nlong-continued, forcible, or painful traction, even in recent cases. In\\nthose of long standing, in which adhesions must be broken, the capsule\\nretorn, and the shortened muscles elongated, it is indispensable.\\nReduction in recent cases is usually easy, and it has been safely\\naccomplished after the lapse of many weeks and even months. It is\\nimpossible to fix a period after which reduction by traction should no\\nlonger be attempted each case must be judged by itself. Serious, even\\nfatal, accidents have followed the attempt so often that the surgeon is\\nfully justified in advising abstention on the ground that the risk is too\\ngreat to be taken. Personally, I prefer in a doubtful case to expose\\nthe joint by incision and liberate the head of the humerus by rotation\\nand traction. (See Chapter XXXIII.)\\nIn all the methods in which forcible traction is made upon the arm\\nsuccess depends largely upon efficient fixation of the scapula. When\\nthe traction is made by specially constructed apparatus the counter-\\nextension is effected by a ring or cratch arranged to bear against the\\nscapula, but when it is made by the hands of assistants the scapula\\nmay be fixed by a split band through which the arm is passed. In\\nsome cases in which only moderate traction is made a simple band\\nabout the chest is sufficient, or the pressure of the surgeon s foot or\\nhand against the side of the chest or the acromion.\\nDirect Reposition. This method, the use of which can be traced\\nback to the time of Avicenna, has been of late especially recommended\\nby Richet and Von Pitha. It is often successful in recent cases in\\nwhich the displacement and muscular contraction are not great, and\\nespecially when aided by anaesthesia. The arm, somewhat abducted,\\nis supported by the side, and the surgeon, placing his fingers in the\\naxilla on the under and inner side of the head of the humerus, and\\nhis thumbs upon the acromion, seeks to press the bone directly into\\nplace. Or the position of the hands may be reversed, the thumbs\\nbeing placed in the axilla and the fingers upon the acromion. Or, the\\npatient being seated, the surgeon supports the flexed elbow upon his own\\nforearm, gets his fingers around the head of the humerus in the axilla,\\nand presses it toward the glenoid cavity while he steadies the scapula\\nwith the other hand.\\nTraction Downward and Outward with Coaptation. In its simplest\\nform, one that is successful in a large proportion of cases, especially\\nAvith the aid of anaesthesia, the method is practised as follows The\\npatient is placed upon a bed and counter-extension is provided by a\\nband passed around his chest and made fast to a support on the\\nsound side. If anaesthesia is used the weight of the body is usually\\nsufficient for counter-extension, and this band can be dispensed with.\\nThe surgeon grasps the arm above the elbow and pulls steadily down-\\nward and outward at first, and then slowly changes the direction by\\nincreasing the abduction until the arm is nearly or quite at right angles\\nwith the body, while, at the same time, he rotates the arm outward.\\nOr the traction is made by an assistant, and the surgeon, standing\\nbeside the patient, watches the movement of the head of the humerus,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0640.jp2"}, "633": {"fulltext": "AXTEEIOE DISLOCATIONS OF THE SHOULDER.\\n565\\nand when it has approached the joint he presses it upward into place\\nwith his lingers or thumb, making counter-pressure on the acromion.\\nIf anaesthesia is not used, or if more force is used, the scapula may\\nbe fixed by bands passing over and under the shoulder or by pressure\\nagainst the edge of the acromion. Or the patient can be laid on his\\nback on the floor, and the surgeon seated beside him places his foot\\nagainst the side of the chest or the edge of the acromion and draws the\\narm directly outward.\\nIt is desirable that the elbow shall be kept partly flexed to relax the\\nbiceps, and also, if the surgeon himself is making traction, to enable\\nhim to rotate the limb inward when the head has been brought close\\nto its socket, since this manoeuvre is sometimes an efficient substitute\\nfor direct pressure upon the head.\\nFig. 272.\\nReduction of anterior dislocation of the shoulder.\\nI l have of late (1899) employed with uniform success in about a\\ndozen cases a method of making this traction wdiich is easy, expedi-\\ntious, and apparently safe. A round hole six inches in diameter is\\nmade in the middle line of a canvas cot about eighteen inches from one\\nend, and through this hole the injured limb is passed so as to hang\\nvertically downward, the patient lying on his side on the cot (Fig.\\n272). To the limb, at the wrist or elbow, is attached a weight of\\nabout ten. pounds, and the cot is raised upon blocks so that the arm will\\nhang free of the floor. In a few minutes, never more than six in my\\n1 Stimson Med. Eecord, March 3, 1900.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0641.jp2"}, "634": {"fulltext": "566 DISLOCATIONS.\\nexperience, reduction of the dislocation takes place quietly and without\\npain during the waiting. Instead of a cot, the patient might perhaps\\nbe put upon two tables placed end to end so that the body would rest\\non one and the head on the other, the arm hanging down between, but\\npossibly the lack of snug support of the shoulder, and the consequent\\nmuscular effort to maintain the position, would interfere with success\\nor at least delay it. Continuous traction by India-rubber or a weight\\nand pulley, as described on page 445, acts in the same gentle manner.\\nAnother modification is the so-called pendel-methode which occu-\\npies a position intermediate between the above and the following\\nmethod, hyper-elevation of the arm, and in which the weight of the\\npatient s body is used to make the traction. The patient is laid upon\\nthe floor on the sound side, and an assistant, standing upon a stool,\\ngrasps the dislocated arm and lifts the shoulders from the floor while\\nthe surgeon presses the head of the bone toward its socket. If a greater\\nweight is needed another assistant raises the feet so that the body is\\nwholly off the floor, or presses downward against the side of the chest.\\nIf a sufficiently robust assistant is not at hand, or if the effort is to be\\nprolonged, the suspension may be made by means of a rope attached to\\nthe arm above the elbow. Bardenheuer says that Simon reduced by\\nthis means a dislocation that had existed for a year and three-quarters.\\nTraction Upward. In this method the arm is raised beside the head\\nand drawn upon while counter-extension is made by the hand or\\nfoot upon the top of the shoulder. Diiplay, following Malgaigne,\\nspeaks of it in rather exaggerated terms as the only rational method,\\nbecause it relaxes all the muscles. The difference between it and trac-\\ntion at right angles to the body is more apparent than real, because the\\nfurther elevation of the arm is effected by a change in the position of\\nthe scapula upon the chest, without change in its relations to the\\nhumerus. The method which was known to Celsus and practised by\\nBrunus in the thirteenth century, was extensively used in England in\\nthe last century, but is more particularly connected with the name of\\nMothe in France, and of Kluge in Germany. Malgaigne says that\\nhe himself reinvented it for the fourth or fifth time in 1828 as the\\nresult of experiments upon the cadaver. It has commonly been com-\\nbined in practice with some form of the method next to be described,\\nthe bascule of the French and German authors, that in which the head\\nof the bone is pressed outward by placing a fulcrum high up in the\\naxilla and then swinging the elbow in toward the body, and has also\\nbeen frequently supplemented with external, followed by internal,\\nrotation.\\nIn its simplest form, as described by Bransby Cooper, the patient is\\nplaced upon his back on the bed or table, and the surgeon sitting beside\\nhis head draws the dislocated arm upward with one hand and fixes the\\nscapula with the other the counter-extension may be aided by a long\\nbandage or towel passing over the shoulder and fixed by both ends to\\nthe foot of the bed. After reduction has taken place, and while the\\narm is being lowered, the head of the humerus should be held in place\\nby direct pressure upon it.\\nMalgaigne s plan, when more force was needed, was to rest the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0642.jp2"}, "635": {"fulltext": "ANTERIOR DISLOCATIONS OF THE SHOULDER. 567\\npatient on the floor, and lift the arm directly upward with both hands,\\ncounter-extension being made by the weight of the body and aided, if\\nnecessary, by pressure made upon the acromion by an assistant. If\\nthis failed and he wished to try more force before resorting to the\\nbascule, he made the patient stand beside a door and raised the arm to\\na vertical position by means of a strong band made fast at the wrist or\\nelbow and carried over the top of the door then the patient was\\ndirected to bend his knees until the weight of his body should be\\nentirely supported by the dislocated arm, and, in addition, the surgeon\\ncontributed his own weight by clasping his hands over the patient s\\nacromion and kneeling beside him. The addition, as proposed by\\nLacour x in 1847, of external and internal rotation to the vertical trac-\\ntion, has added to its efficiency.\\nThe chief objection to this method is that mentioned in connection\\nwith the preceeding one, that of the risk of injuring the main vessels\\nin the axilla by unduly stretching them around the head of the\\nhumerus, and it is even greater here because the elevation, or abduc-\\ntion, is made without preliminary traction to bring the head nearer the\\nsocket.\\nAnother objection is that it is likely to increase the laceration of the\\ncapsule and of the subscapularis and thereby promote recurrence of the\\ndislocation.\\nTraction with Leverage. This method differs from that of traction\\ndownward and outward in the addition, or the substitution for direct\\ncoaptative pressure by the hands, of a leverage movement in which\\nthe head of the bone is forced outward by the adduction of the limb\\nover a fulcrum placed in the axilla. The fulcrum is usually the\\nclosed fist or the heel.\\nWhen the hand is used traction is made outward and downward by\\nan assistant, and when the head of the bone has been moved sufficiently\\nfar the surgeon places his closed fist well up in the axilla, and the\\nassistant, still maintaining the traction, swings the arm toward the side\\n(adduction), sometimes combining with it moderate rotation.\\nThe Heel in the Axilla. This method, generally known as Sir Astley\\nCooper s, but really dating back to the time of Hippocrates, was in\\nvery general use in England and America until quite recently. It is\\nunfortunately responsible for not a few more or less serious injuries to\\nthe bloodvessels and nerves of the axilla.\\nThe patient is placed upon his back on a bed or sofa and a towel or\\nstout bandage made fast to the arm above the elbow. The surgeon,\\nfacing him, seats himself upon the side of the bed and places the heel\\nof one foot, from which the shoe has been removed, well up in the\\naxilla against the head of the humerus and then makes traction down-\\nward upon the towel and maintains it until the bone is felt to slip into\\nplace. Remembering that under these conditions traction upon the\\nhumerus is directly transmitted to the scapula through the already\\ntense capsule, it seems probable that the method ow T es its efficiency to\\nthe action of the heel as a wedge, which by being forced in between\\nthe thorax and the humerus presses the latter directly outward. If\\n1 Lacour Mem. de Chirurgie, 1847, vol. i. p. 387.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0643.jp2"}, "636": {"fulltext": "568\\nDISLOCATIONS.\\nthe traction is made at first in a direction inclined away from the body,\\nand then brought more nearly parallel to it, the mechanical effect is\\nthe same as when the fist is used as above described.\\nIt may be proper to employ this method if no more force is used\\nthat can be exerted by the surgeon himself, although accidents have\\nhappened even under such circumstances, but it is certainly dangerous\\nand improper to employ it with the pulleys or assistants, and still more\\nso to substitute an iron plug for the heel as recommended and prac-\\ntised by Skey. The large vessels and nerves lie upon the inner side\\nof the head of the humerus and are exposed to be compressed between\\nit and the heel and thus directly bruised or so held fast that they may\\nbe overstretched and torn as their distal portions are drawn downward\\nin the sliding of the soft parts of the arm toward the elbow.\\nForcible Traction. If more forcible traction is needed than can be\\nmade in the methods already described, resort should be had to the\\npulleys or especially constructed apparatus. The pulleys are made fast\\nto the arm above the elbow by a broad leather band buckled tightly\\naround it or by a strap or band made fast by several turns of a wet\\nbandage it is necessary to secure it tightly to the arm, for this does\\nFig. 273.\\nReduction with the pulleys 4, dynamometer 6, liberation forceps. (Duplay.)\\nnot increase the bruising caused by the traction, and if it should slip\\nthe soft parts might be seriously torn. As a further precaution\\nagainst slipping the forearm should be bandaged and the elbow fixed\\nat a right angle. It is also advisable to interpose a dynamometer\\nbetween the pulleys and the limb to indicate the amount of force that\\nis being employed, and a pair of liberation forceps to allow the\\ntraction to be suddenly relaxed and the position of the arm changed\\n(Fig. 273).\\nThe special instruments, of which the most elaborate and ingenious\\nare made in France, are, in the main, modifications of the adjuster\\ninvented by Dr. Jarvis, of Portland, Connecticut. They consist of\\ntwo bars movable upon each other by a rack and pinion, one of which\\nis made fast by a leather bracelet to the lower part of the arm, and the\\nother to a ring or crutch that fits against the scapula. A dynamom-\\neter indicates the force exerted, and a catch sets it instantly free at\\nwill. The instruments are expensive, the occasions for their use are\\nrare, and the method is dangerous.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0644.jp2"}, "637": {"fulltext": "ANTERIOR DISLOCATIONS OF TEE SHOULDER.\\n569\\nReduction by Manipulation. (Rotation.) It has been already men-\\ntioned that rotation of the arm has long been used in connection\\nwith the various methods of extension to effect reduction, and it also\\nappears that from time to time men have sought to reduce, and some-\\ntimes with success, by moving the limb in various directions without\\nthe aid of much traction, but it is only within the present century that\\nmethods of manipulation founded upon a correct appreciation of the\\nobstacles and of the means by which they may be overcome have been\\ndevised and practised with intelligence and success. Rotation inward\\nwas long employed as the final manoeuvre to turn the head of the bone\\ninto the socket after it had been brought opposite it by traction, and it\\nstill constitutes the final step in the pure manipulative method. Exter-\\nnal rotation during traction was first employed under the influence of\\nvarious ideas concerning the part taken by the muscles in opposing the\\nreturn of the bone, or to dislodge the head from its position behind the\\nlip of the glenoid fossa then, in the light of more accurate knowledge\\nof the influence of the untorn portion of the capsule, it became the first\\nstep in the methods of reduction without traction.\\nFig. 274.\\nKocher s method of reduction by manipulation 1st movement, outward rotation. (Ceppi.)\\nOf these methods the one that is most highly esteemed and generally\\npractised is that recommended by Prof. Kocher, 1 of Bern. The fol-\\nlowing description is taken from one given at the Surgical Congress in\\nLondon, and published by his pupil Ceppi in the Revue de Chirurgie,\\n1882, p. 831 In the subcoracoid dislocation the posterior portion\\nof the capsule and the tendons of the posterior scapular muscles which\\ncover and strengthen it are untorn and are stretched over the glenoid\\nfossa. The inferior portion of the capsule which forms the lower border\\nof the rent is also very tense. But the tension is greatest at the\\nupper part of the capsule, and especially between the long tendon of\\nthe biceps and the upper border of the subscapulars, where it is\\nreinforced by the fibres of the coraco-humeral ligament. This portion\\n1 Kocher: Berlin, klin. Wochenschrift, 1870, No. 9, and Volkmann s Sammlung klin.\\nVortrage, No. 83, p. 611.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0645.jp2"}, "638": {"fulltext": "570\\nDISLOCATIONS.\\nof the capsule is twisted in the dislocation, and stretched in the form\\nof a solid cord. If now the humerus is rotated externally until the\\nflexed forearm is turned directly outward, this cord will be at the same\\ntime rotated outward, the posterior part of the capsule will be widely\\nremoved from the fossa, and the rent in the capsule will gape but the\\nhead of the humerus will still remain solidly fixed against the anterior\\nedge of the glenoid fossa because the upper and lower portions of the\\ncapsule have not been relaxed by this movement. It is only when\\nthe elbow is carried forward and raised in the sagittal plane, while the\\narm is still held in external rotation, that the upper part of the capsule\\nis seen to relax, and the head of the humerus, thanks to the tension of\\nthe lower portion which keeps it from moving forward, to enter its\\nsocket. Rotation inward then completes the reduction.\\nThe method may be formulated in detail as follows (Figs. 274, 275,\\nand 276). Dislocation of the left shoulder. The patient is seated,\\nFig. 275.\\nKocher s method of reduction 2d movement, elevation of elbow. (Ceppi.)\\nand the surgeon, kneeling beside him, flexes his elbow at a right angle\\nand presses it with his right hand against his side then, holding the\\nelbow firmly in place, he slowly and steadily moves the wrist outward\\nwith his left hand (external rotation of the humerus) until the forearm\\nstands directly outward from the side of the body if this is strongly\\nresisted the pressure must be steadily maintained until the resistance\\nyields. The evidence that the movement has accomplished what was\\nexpected of it is the appearance of greater fulness of the outer deltoid\\nregion if this does not appear the attempt will fail. Then, still main-\\ntaining the external rotation of the arm and the flexion of the elbow,\\nthe surgeon moves the elbow forward, or forward and slightly inward,\\nuntil the arm is horizontal during this movement the fulness of the\\nouter deltoid region becomes more marked, and at its termination the\\nmanoeuvre is completed by rotating the arm inward and bringing the\\nhand to the opposite shoulder. The bone may slip into place during\\nthe second movement, elevation of the elbow. Direct traction out-\\nward of the upper end of the bone by a bandage in the axilla is some-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0646.jp2"}, "639": {"fulltext": "ANTERIOR DISLOCATIONS OF THE SHOULDER. 571\\ntimes helpful, and I have sometimes found it advantageous to make\\nfirm pressure downward at the elbow (traction in the long axis of the\\narm) during the movement of outward rotation.\\nThe method as thus described is applicable to those cases in which\\nthe displacement is neither very far inward nor low down, in short,\\nto the higher forms of the subcoracoid variety and as it depends for\\nits success upon the resistance of the untorn portion of the capsule it\\nwill fail whenever the capsule is very extensively torn. When the\\ndisplacement is far inward or low, traction upon the abducted limb\\nis more likely to succeed.\\nKonig 1 modifies it for the lower anterior and subglenoid dislocations\\nby making traction in abduction, rotating outward, and then adduct-\\ning. This is practically the same as the method described as traction\\ndownward and outward and generally known as Lacour s method by\\nmanipulation.\\nFig. 276.\\nKocher s method of reduction 3d movement, inward rotation and lowering of elbow. (Ceppi.)\\nFarabeuf 2 studied Kocher s method experimentally with a view to\\ndetermine the mechanism by which its result was accomplished, and\\nreached the conclusion that the efficient agent was the untorn posterior\\nportion of the capsule, and that the upper portion, the coraco-humeral\\nligament, had little or nothing to do with it. He showed, experi-\\nmentally, that when this latter had been divided and the posterior por-\\ntion left intact the manoeuvre would still effect reduction, but that when\\nthe posterior portion was divided and the upper portion left whole it\\nfailed, and that then the head of the humerus instead of being moved\\noutward by the external rotation simply revolved about the longitu-\\ndinal axis of the shaft. His explanation is clear and intelligible.\\nAccording to it the approximation of the elbow to the side tightens the\\n1 Konis;: Speciel. Chirurejie, 3d ed., vol. iii. p. 40.\\n2 Farabeuf: Bull, de la Soc. de Chir., 1885, p. 395.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0647.jp2"}, "640": {"fulltext": "572 DISLOCATIONS.\\nposterior portion of the capsule where it extends between the posterior\\nlip of the glenoid fossa and the under and back part of the neck of\\nthe humerus this prevents the posterior surface of the humerus from\\nmoving inward when the arm is rotated outward, and consequently its\\nattachment to the humerus serves as the fixed point or centre about\\nwhich the bone rolls outward, winding itself, as it were, upon the cap-\\nsule. The elevation and adduction of the elbow, turning upon the\\nsame fixed point, then throws the head backward and further outward,\\nand finally the internal rotation unwinds the capsule and leaves every-\\nthing in place.\\nThe method is applicable to old as well as to recent cases, but the\\ndanger of breaking the humerus during the second step outward rota-\\ntion must be borne in mind, especially in elderly patients.\\nSckinzinger s method, the introduction of which appears to have ante-\\ndated Kocher s, was in like manner based upon the persistence of the\\nposterior portion of the capsule, but differed from Kocher s in the\\nsecond and third steps of the manoeuvre. He rotated the arm outward\\nuntil the hand was as far back as the elbow, and then either pressed\\nthe bone upward and outward into place by direct pressure, or turned\\nit in by slow internal rotation while an assistant made pressure on the\\ninner side of its head to prevent it from slipping back into the position\\nfrom which it had been removed by the outward rotation. The method\\nis favorably spoken of by several of the later German writers, and is\\nthought to be especially useful in rupturing the adhesions of old dislo-\\ncations without the risk of injury to the vessels or nerves.\\nCircumduction, sometimes known as Heine s method, in which, after\\nfixation of the scapula as for traction, the arm is slowly abducted, raised\\nto the side of the head, inclined slightly backward, and then brought\\nforward and downward across the face and chest, has been recom-\\nmended and used in old dislocations it is undoubtedly efficient in\\nbreaking up the adhesions, but it is a rough, uncertain, and dangerous\\nplan, and should be condemned.\\nTo recapitulate, the treatment of a recent anterior dislocation of\\naverage displacement may be thus summed up Kocher s method may\\nfirst be tried if that fails, traction downward and outward by one of\\nthe various methods should be tried, the elbow not being raised higher\\nthan the shoulder, combined with direct pressure upon the head, or\\nfollowed by adduction over the fist in the axilla. If these also fail,\\nthe patient should be etherized, and the attempt repeated. When\\nthose rare conditions are present Avhich make reduction otherwise\\nimpossible interposition of capsule or tendon of biceps or subscapu-\\nlars an open arthrotomy is justifiable if it can be done with proper\\nprecautions against infection.\\nIn older dislocations the same plan should be followed, and resort\\nshould be had to forcible traction only after other measures have failed.\\nThe signs of a successful reduction are the sound that is usually\\nheard when the bone slips into place, the restoration of form and func-\\ntion, and the diminution or cessation of pain. The sound, is not always\\nheard, and, on the other hand, a similar sound may be caused by the\\nrupture of adhesions or by the slipping of the bones upon each other.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0648.jp2"}, "641": {"fulltext": "ANTERIOR DISLOCATIONS OF THE SHOULDER. 573\\nComplete restoration of form is the best evidence this is to be deter-\\nmined by an examination similar to that employed in making the\\ndiagnosis of a dislocation and by attention to the same signs. The\\nreduction may be incomplete because of the interposition of a portion\\nof the capsule, or because of the presence of tissues of new formation\\nin the glenoid cavity. This incompleteness is shown by the abnormal\\nprojection forward of the head of the humerus under the acromion.\\nAfter-treatment.\\nAfter reduction has been obtained it is highly desirable that the\\narm should be immobilized for two or three weeks in a position\\nthat will favor the speedy repair of the lacerations of the capsule,\\ntendons, and muscles otherwise the joint may remain in a con-\\ndition that favors recurrence, and the patient may suffer much in-\\nconvenience or even disability in consequence. As the rent in the\\ncapsule is on the inner side, and as its edges are separated by external\\nrotation of the limb, the head of the humerus should be directed\\ntoward the outer side (adduction of the elbow) and the arm should be\\nkept rotated inward. These two indications are met by binding the\\nlimb to the body with the hand resting just below the opposite clavicle.\\nFixation may be made by a silicate-of-socla or plaster-of-Paris dressing\\nor even by simple bandages, but the most convenient and effective\\ndressing is a strip of adhesive plaster arranged as follows beginning\\nin front at the clavicle it is carried over the shoulder and down the\\nback of the arm, then under the elbow to the back of the forearm, and\\nalong the latter and the back of the hand to and over the top of the\\nopposite shoulder. A small pad of absorbent cotton or lint should be\\nplaced in the axilla and between surfaces of skin that are in contact.\\nIf the patient is unruly a second band may be placed circularly about\\nthe body and lower part of the arm. This dressing should be retained\\nfor two or three weeks, and the arm carried in a sling for a fortnight\\nlonger. If passive motion is made, abduction and external rotation\\nshould be avoided.\\nFor complications, accidents, prognosis, and the treatment of old\\ndislocations, see Chapter XLIV.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0649.jp2"}, "642": {"fulltext": "CHAPTER XLIII.\\nDISLOCATIONS OF THE SHOULDER.\u00e2\u0080\u0094 (Continued.)\\nDownward Dislocations Subglenoid, erecta, subtricipital Posterior Disloca-\\ntions: Subacromial, subspinous, upward dislocations.\\nDOWNWARD DISLOCATIONS.\\n1. Subglenoid.\\nUnder this title are here included those rare cases in which the\\nhead of the humerus is displaced directly downward upon the tendon\\nof the long head of the triceps, and those more frequent ones in which\\nit is engaged under the lower and inner edge of the glenoid cavity,\\nand rests against the flattened upper portion of the axillary border of\\nthe scapula on the inner side of\\nFig. 277. the tendon of the triceps. As\\nexplained in connection with\\nthe classification given in the\\npreceding chapter, the name is\\nhere restricted to a portion of\\nthose cases which are termed\\nsubglenoid by most English\\nand American authors, to those,\\nnamely, in which the head of\\nthe bone is low in the axilla.\\nBy some the term is still further\\nrestricted in use, and is applied\\nonly to the first of the two\\nforms above mentioned, those\\nin which the head is displaced\\ndirectly downward upon the\\ntendon of the triceps. Although\\nit is denied by some on theo-\\nretical grounds that this form\\ncan exist, yet it must be ad-\\nmitted not only as possible, but as having been actually observed, on\\nthe evidence of several observers who fully understood the point in\\ndispute. Von Pitha (quoted by Bardenheuer) says that he had seen\\nit only in cases in which he had the opportunity to examine the patient\\nimmediately after the accident, and before any movements had been\\ncommunicated to the limb or attempts made to reduce. He believes\\nthat the head can be easily displaced from its new position, and moved\\nupward and forward, the dislocation being thus transformed into a sub-\\ncoracoid, by involuntary or communicated movements of the arm, or\\n574\\nSubglenoid dislocation.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0650.jp2"}, "643": {"fulltext": "DOWNWARD DISLOCATIONS OF THE SHOULDER. 575\\neven by muscular action. Tillaux observed this transformation in a\\ncase while he was preparing to make a cast of the limb.\\nTwo varieties, representing extreme displacements, and characterized\\nby exceptional symptoms, the luxatio erecta and the subtricipital\\nwill be separately described.\\nThis form of dislocation was studied experimentally by Malle, 2\\nGoyrand, 3 and Panas. 4 They found that if the scapula was fixed and\\nthe arm was firmly elevated, the head of the humerus presented\\nthrough a large rent in the capsule between the subscapularis and the\\nlong head of the triceps, and that if the arm was then lowered the\\nhead would often return to its socket, but that if it was twisted out-\\nward while being lowered the dislocation would persist. The lower\\nborder of the subscapularis was always found torn and its untorn por-\\ntion rested upon the upper surface of the head and Malle claimed that\\nin order to produce the dislocation upon the cadaver it was necessary\\nto divide the portion of the capsule between the acromion and the\\nlesser tuberosity.\\nThe cause, with the single exception of Desault s doubtful case, in\\nwhich the injury was said to have been produced by a fall upon the\\nshoulder, has always been the forcible elevation of the arm, as in a fall\\nthrough a narrow opening or upon the extended elbow, by a horse\\nthrowing up his head while being led by the bridle, or as in Goyrand s\\ncase of a woman who, having fallen to the ground, had her arm dislo-\\ncated by a passer-by who sought to raise her. In one of Tillaux s\\ncases a young girl dislocated her shoulder by suddenly raising her arm\\nwhile playing at raquettes.\\nThe rent in the capsule in the specimens produced experimentally\\nhas always been comparatively small, and situated in the lower and\\ninner portion between the triceps and the subscapularis, and differs\\nfrom that of the subcoracoid form in not extending so far upward\\nalong the anterior edge of the glenoid cavity. In a specimen presented\\nby Leroy 5 to the Societe Anatomique the lesions were identical with\\nthose produced experimentally. The upper part of the capsule, includ-\\ning the insertion of the supraspinatus and infraspinatus muscles, was\\ntorn away from the humerus, from the anterior border of the bicipital\\ngroove to the tendon of the teres minor, a distance of four centimetres\\nin the lower portion was the usual rent, two and three-quarters inches\\nlong, extending from the tendon of the teres minor inward and then\\nupward along the anterior border of the glenoid cavity. The head of\\nthe humerus lay upon the axillary border of the scapula one inch below\\nthe anterior border of the coracoid process, the limb being so far rotated\\noutward that the internal epicondyle was directed forward, and the\\ngreater tuberosity rested against the anterior lip of the axillary border\\nand the adjoining portion of the neck of the scapula. The subscapu-\\nlaris was pushed upward and overlapped the head. In another reported\\nto the same society by Bouygues, 6 the head of the humerus lay below\\n1 Tillaux Anat. topographique, p. 536.\\n2 Malle: Bull, de l Acad. de Med., Paris, 1838, vol. ii. p. 941.\\n3 Goyrand Mem. de la Soc. de Chir., 1847, vol. i. p. 21.\\n4 Panas: Diet, de Med. et Ckir. pratiques, art. Epaule, p. 462.\\n5 Leroy Bull, de la Soc. Anatomique, 1844, p. 102. 5 Bouygues Ibid., 18SS, p. 5S1.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0651.jp2"}, "644": {"fulltext": "576\\nDISLOCATIONS.\\nand in front of the glenoid fossa and beneath the nntorn snbscapularis,\\nthe anatomical neck resting on the axillary border of the scapula and\\nthe lower part of the fibrocartilaginous rim the upper portion of the\\ngreater tuberosity was broken off.\\nIn a case reported by Jossel l of subglenoid dislocation caused by a\\nfall from the second story of a house, in which death followed on the\\nsecond day in consequence of an associated fracture of the skull, the\\nfollowing conditions were found The subscapular artery was entirely\\ntorn across. The head of the humerus lay between the partly torn sub-\\nscapularis muscle and the triceps upon the triangular surface of the\\nlower border of the scapula directly below the glenoid fossa. The\\ncapsule was entirely torn from the humerus, the subscapularis was\\nFig. 278.\\nSubglenoid dislocation. (From a photograph.)\\npushed upward, the edge of the glenoid fossa was a little broken at its\\nwidest part, and the upper and middle facets of the greater tuberosity\\nwere broken off, the line of fracture running into and opening the\\nbicipital groove.\\nIn Sedillot s case, quoted by Malgaigne as of this kind, the condi-\\ntions were quite exceptional abduction was so marked that the arm\\nwas held almost horizontal, the head of the humerus was situated half\\nan inch below the glenoid fossa, resting against the scapula, but also\\nengaged between the latissimus dorsi and teres major in front and the\\ntriceps behind.\\nApparently the failure of the head to rise as usual to the level which\\n1 Jossel Deutsche Zeitschrift fur Chirurgie, 1874, vol. iv. p. 124.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0652.jp2"}, "645": {"fulltext": "DOWNWARD DISLOCATIONS OF THE SHOULDER. 577\\nwould make the dislocation subcoracoid is due to the resistance of the\\nuntorn portion of the capsule on the inner side and the greater abduc-\\ntion of the limb is due to this retention of the head at a lower level,\\nfor the untorn outer portion prevents the shaft from sinking unless the\\nhead correspondingly rises.\\nSymptoms. The flattening of the outer portion of the shoulder, the\\nprominence of the acromion, and the abduction of the elbow are all\\nmore marked than in the subcoracoid dislocation and the axis of the\\narm prolonged by the eye in front passes below and to the inner side\\nof the glenoid cavity. Measured in partial abduction from the acro-\\nmion to the elbow, the arm appears longer than its fellow, and this\\nelongation may not give place in complete horizontal abduction to as\\nmuch shortening as is found in the subcoracoid form. The head of\\nthe humerus can be plainly felt in the axilla, and is separated from the\\ncoracoid process by an interval of from half an inch to an inch.\\nThe differential diagnosis from subcoracoid dislocation is made by\\nrecognition of the position of the head below the glenoid fossa the\\ncorroborative symptoms are the more marked flattening of the deltoid\\nand its angle with the arm and the wider abduction of the elbow.\\nTreatment. Theoretically, the position of the head below the glenoid\\nfossa suggests that traction should be made upward and outward, the\\nelbow being raised above the shoulder, and this plan is generally recom-\\nmended and usually successful. The objection to it is the added risk\\nof doing injury to the bloodvessels in the axilla by overstretching them\\naround the head of the humerus, as explained in the preceding chapter.\\nIt is prudent, therefore, that a trial should first be made of the\\nmethod of direct reposition (p. 564), and, that failing, of traction in\\nthe direction of the arm as found, or with a little more abduction, fol-\\nlowed by adduction while pressure outward and upward is made upon\\nthe head of the bone, or with the fist in the axilla. The reader is\\nreferred to the preceding chapter for the details.\\n2. Luxatio Erecta.\\nThis striking dislocation, first described by Middeldorpf, and his\\npupil Scharm l who reported the former s two cases, is characterized\\nby the marked elevation of the arm, the forearm usually resting on\\nthe top of the head, a position from which it cannot be lowered with-\\nout causing great pain, and by the prominence of the head low in the\\naxilla. Besides Middeldorpf \\\\s two cases I have met with the descrip-\\ntion or mention of six others by Busch, 2 Panas, 3 Lange, 4 Alberti, 5\\nHannson, 6 and Judd, 7 and a reference by Bardenheuer, 8 without\\ndetails, to a case reported by Bertin and two cases reported by Meyer.\\nThe only opportunity for direct examination of the parts was fur-\\n1 Middeldorpf: Clinique Europeenne, 1859, vol. ii., and Scharm, De nova humeri luxa-\\ntionis specie. Dissert. Inaug. Breslau, 1859 quoted by Alberti, vide infra,\\n2 Busch Archiv fur klin. Chir., 1863, vol. iv. p. 30.\\n3 Panas Diet, de Med. et Chir. pratiques, art. Epaule, p. 405.\\n4 Lange New York Medical Record, 1879, vol. xvi. p. 400.\\n5 Alberti Deutsche Zeitschrift far Chir., 1884, vol. xx. p. 475.\\n6 Hannson Centrabl. fur Chir., 1892, p. 18.\\n7 Judd New York Medical Journal, October 19, 1895. 8 Bardenheuer Loc. cit, p. 303.\\n37", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0653.jp2"}, "646": {"fulltext": "578 DISLOCATIONS.\\nnished in one of Middeldorpf s cases the patient s right arm was\\ncaught in some machinery and he was whirled around, receiving in\\naddition to the dislocation a wound of the deltoid lie died of pyaemia.\\nThe greater tuberosity had been torn off, remaining attached to its\\nthree muscles, and the acromion was broken. Scharm produced the\\ndislocation five times upon the cadaver in every case the supraspina-\\ntus and infraspinatus muscles were torn away, and in two there was\\npartial rupture of the subscapulars and pectoralis major. The main\\nbloodvessels and nerves were uninjured. My only knowledge of Mid-\\ndeldorpf s cases and Scharm s experiments comes from the brief men-\\ntion made of them by Alberti.\\nDr. Lange s case, in which the dislocation was intracoracoid rather\\nthan subglenoid) differs also from the others in the less complete eleva-\\ntion of the arm. Bardenheuer 1 says that in his experience, covering\\nabout four hundred cases of dislocation of the shoulder, he had never\\nencountered a pure luxatio erecta, but he had met with two cases in\\nwhich the arm was abducted beyond a right angle with the body. Dr.\\nLange s case might properly be regarded as an exceptional form of\\nintracoracoid dislocation intermediate between the usual form and the\\nluxatio erecta.\\nThe mechanism appears to have been forcible and extreme elevation\\nof the arm, combined in one case (Alberti s) with a blow upon the\\narm from above downward, and the elevated position after dislocation\\nwas plainly due to the tension of the anterior soft parts created by the\\nshifting of the centre of motion to a point so far below the glenoid\\ncavity. In one of Meyer s cases mentioned by Bardenheuer, a woman\\nsixty-two years old, it is said that the dislocation occurred during an\\nepileptic fit. It is stated also that in one of the cases paralysis of\\nthe brachial plexus persisted after reduction.\\nThe method of reduction adopted in all the cases was clearly the\\nproper one, not only because it succeeded but also because it corre-\\nsponded to the anatomical indications. Traction in the direction\\nassumed by the arm drew the head directly back toward its socket by\\nthe route along which it had escaped.\\n3. Subtricipital Dislocation\\nOur knowledge of this very rare, and even questionable, form is\\nlimited to a single doubtful case observed clinically by Farabeuf, 2 and\\nto subsequent experiments made by him upon the cadaver. As the\\nluxatio erecta is produced from a subglenoid by exaggerating the\\ndescent of the head of the humerus, so the subtricipital is said to be\\nproduced from the erecta by a consecutive displacement of the head\\nupward and backward, at first underneath and then behind and above\\nthe long tendon of the triceps, a displacement effected by the descent\\nof the elbow in front.\\nThe case was that of a sailor who injured his shoulder while at sea\\nfive weeks later he landed at Bordeaux, and, attempts made there to\\n1 Bardenheuer Loc. cit., p. 303.\\n2 Farabeuf: Bull, de la Soc. de Chirurgie, 1879, p. 778, and 1885, p. 396.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0654.jp2"}, "647": {"fulltext": "POSTEEIOB DISLOCATIONS OF THE SHOULDEE. 579\\nreduce having failed, he went to Paris. The arm was abducted and\\ncarried forward, and the head of the humerus rested on the back of\\nthe scapula two finger-breadths below the angle of the acromion.\\nReduction was not obtained.\\nIn his experiments upon the cadaver Farabeuf found that after rais-\\ning the arm forcibly and thus tearing the capsule at its lower part he\\ncould, by a vigorous push or a blow upon the elbow with a mallet,\\nmake the head of the humerus descend several centimetres below the\\nglenoid cavity if then the arm was lowered in front the head of the\\nbone moved backward and became engaged under the tendon, which\\ntheu held the arm abducted and directed forward and more or less\\nrotated inward.\\nFarabeuf 7 s case is apparently the one mentioned by Poinsot 1 as\\nSebilleau s and as having been examined by himself in 1881. The\\nlimb was then in slight abduction and inward rotation, the elbow and\\nfingers flexed movements at the shoulder were almost completely\\nlost. The case is described by Poinsot as one of dislocation backward\\n(subacromial or subspinous), and no reference is made by him to\\nFarabeuf s opinion concerning it, although he is named among the\\nsurgeons who had examined it.\\nFarabeuf maintains that two very similar cases observed by Richet\\nand Bottey and named by the former retro-axillary (see Posterior Dis-\\nlocations) were really examples of this variety described by him. It\\nseems more probable that Farabeuf was misled by his experiments\\nand that the three cases were merely low posterior dislocations.\\nSupposing such a case to exist, reduction should be made by first\\ntransforming the dislocation into a luxatio erecta by raising the elbow\\nwith traction to the side of the head, so as to bring the bone from\\nbeneath the triceps, and then reducing by direct traction upward.\\nPOSTERIOR DISLOCATIONS.\\nSubacromial and Subspinous.\\nDislocations backward are divided into two classes, the subacromial\\nand the subspinous, according as the head lies under the projecting\\nouter border of the acromion or further back below the spine of the\\nscapula, respectively. A variety of the subacromial, to which the\\nname retro-axillary has been given, has been recently observed and\\ndescribed by Richet and Bottey.\\nAlthough I think this division into two groups is quite generally\\naccepted by the profession, yet English and American systematic\\nwriters upon the subject have, as a rule, refused to adopt it, giving as\\na reason therefor the fact that the two differ only in an unimportant\\nfeature, the degree of the displacement, and they apply the term sub-\\nspinous to all. Flower 2 justifies the choice of this name in preference\\nto subacromial on the ground that the latter does not express any\\nchange from the normal situation of the head of the humerus under\\n1 Poinsot: Translation of Hamilton s Fractures and Dislocations, p. 867.\\n2 Flower: Holmes s System of Surgery, Am. ed., vol. i. p. 875.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0655.jp2"}, "648": {"fulltext": "580 DISLOCATIONS.\\nthe acromion. On the other hand, it may be fairly urged that, as in\\nthe great majority of cases the head is not displaced so far as to the\\nspine of the scapula, the term subspinous is misleading and improper.\\nI have preferred, in accordance with what I believe to be the general\\npractice of the profession, to retain both terms with the distinction\\nbetween them established by Malgaigne. Of the two groups the\\nsubacromial is much the more frequent, the subspinous being very\\nrare.\\nAccording to Malgaigne, the earliest recorded mention of this dislo-\\ncation was in 1834, and when he wrote, in 1855, he could collect only\\n34 cases, of which he himself observed 3. A very considerable num-\\nber of cases have been recorded since that time (I found 7 in the Index\\nMedicus for the years 1878 to 1882), and Panas s opinion that many\\nescape recognition, by being mistaken for a sprain or an articular frac-\\nture, seems fairly justified, for not only are the diagnostic symptoms\\nsometimes very obscure, but Nelaton said that he had within a short\\nperiod of time seen three cases that had passed unrecognized by sur-\\ngeons of merit. In Malgaigne s statistics 26 were men and 5 women\\nand in rather more than a quarter of them the cause was muscular\\naction. Bardenheuer saw one in which both shoulders had been dis-\\nlocated by a fall forward upon the elbows. (See, also, Chapter XLI V.,\\nCongenital Dislocations.)\\nExperiment upon the cadaver shows that the dislocation can be\\nreadily produced by forcible internal rotation of the arm, by which\\nthe posterior portion of the capsule is torn and the passage backward\\nand outward of the head is made easy. In some of the cases clinically\\nobserved it is plain that this has been the mechanism, and in others\\nit has undoubtedly aided. Thus, Piel, who wrote a thesis on the sub-\\nject in 1851, saw a woman in whom it had been caused by her husband\\ntwisting her arm in a quarrel. In seven of Malgaigne s cases and in\\nseveral that have since been reported the dislocation occurred during\\nan epileptic fit, presumably by internal rotation of the limb. In other\\ncases the cause has been a blow upon the front of the shoulder (twice\\na blow with the fist), pressure upon the back of the shoulder while the\\nelbow rested against the ground, an attempt to control the patient in\\nconvulsions, once the throwing of a stone by a boy ten years old, and\\nfrequently a fall. The anatomical features of the joint, the results of\\ncadaveric experiment, and such histories of cases as are sufficiently\\ncomplete indicate that the common mode of production is pressure\\nbackward and outward upon the head of the humerus, either directly\\nor through the elbow, combined with adduction of the limb across the\\nfront of the chest and internal rotation. Such a combination is most\\nfrequently found in falls forward in which the weight is received upon\\nthe adducted elbow. One of Malgaigne s cases is especially interesting\\nfrom this point of view, as showing the conditions of the production\\nalmost as clearly as an experiment. A woman was trying to take\\ndown a box placed high above her head, it slipped suddenly into her\\nextended hand, and the dislocation occurred. In other words, the force\\nwas exerted in a suitable direction upon an arm that was elevated,\\nadducted, and rotated inward.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0656.jp2"}, "649": {"fulltext": "POSTERIOR DISLOCATIONS OF THE SHOULDER. 581\\nIn a case observed by Tillaux the patient, a man twenty-four years\\nold, had his right arm caught in some machinery and was drawn sev-\\neral times about a revolving shaft, receiving a subspinous dislocation,\\nand in addition having the arm almost completely torn away at its\\nmiddle by being twisted several times upon itself.\\nAutopsies have been made in six recent cases in which death was\\ncaused by associated injuries. In Maisonneuve s case (the specimen\\nis pictured in Malgaigne s Atlas, Plate XXII., figs. 5 and 6) the\\npatient fell from a height of thirty feet. The capsule was torn above,\\nbelow, and on its outer side the greater tuberosity was torn off, broken\\ninto two pieces, and drawn back below the acromio-clavicular arch by\\nthe supraspinatus and infraspinatus muscles to which it remained\\nattached. The teres minor and subscapularis were still attached to the\\nhumerus the long tendon of the biceps had been torn out of its groove.\\nThe circumflex nerve was uninjured. The head of the humerus lay\\njust below the posterior angle of the acromion and was not in contact\\nwith either the spine or the neck of the scapula, but rested against the\\nposterior edge of the glenoid cavity.\\nIn Laugier s 2 case the subscapularis and supraspinatus were torn\\nfrom their insertions, and the head of the humerus had passed, as in\\nMaisonneuve s case also, between the infraspinatus and teres minor\\nand was covered only by the deltoid.\\nTwo cases were reported by Jossel, 3 one a subacromial, the other a\\nsubspinous dislocation. In the first the injury, together with a frac-\\nture of the skull, was caused by a fall into a cellar. The head of the\\nhumerus had torn through the teres minor and lay under the acromion\\nthe limb was so far rotated inward that the articular surface looked\\ndirectly outward. The supraspinatus and infraspinatus were unin-\\njured. The capsule showed a triangular rent on the outer side just\\nlarge enough to let the head through. The tendon of the subscapu-\\nlaris was still attached to the humerus, but under it and close by the\\ntendon of the biceps an irregular, movable piece of bone could be felt,\\nthe lesser tuberosity, the fracture by which it was separated extending\\ninto the bicipital groove the tubercle was split into two pieces, both\\nadherent to the tendon.\\nIn the second case the patient fell from a height of two stories,\\ndislocated the left shoulder, and sustained a compound fracture of\\nthe thigh he died on the fifth day. The head of the humerus had\\ntorn through the teres minor and lay under the spine of the scap-\\nula, separated from it by the interposed infraspinatus it was directed\\nbackward. The long head of the triceps was almost entirely torn\\nthrough, and a piece was broken from the axillary border of the scap-\\nula just below the glenoid fossa. The subscapularis and the adjoining\\npart of the capsule were torn away from the humerus, bringing with\\nthem the lesser tuberosity, the fracture of which w r as broader than in\\nthe preceding case.\\nIn the remaining two cases the dislocations were subspinous in one\\n1 Tillaux Anatoraie topographique, p. 536.\\n2 Laugier Gaz. des Hopitaux, 1846, p. 60.\\n3 Jossel Deutsche Zeitschrift fur Chir., 1874, vol. iv. p. 125.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0657.jp2"}, "650": {"fulltext": "582 DISLOCATIONS.\\nof them, quoted by Malgaigne, 1 the patient, a man sixty-two years old,\\nfell backward, and the wheel of his wagon, which carried a load of\\nthree and a half tons, passed obliquely across the right side of his\\nchest, causing injuries which resulted in his death thirty hours later.\\nSeveral ribs were fractured, as were also the body of the scapula and\\nthe inner portion of its spine. The deltoid, pectoralis major, teres\\nmajor, and teres minor were torn or crushed, and the capsule was\\nalmost entirely detached. When the arm was lowered the head of the\\nhumerus lay below the spine of the scapula in the outermost part of\\nthe subspinous fossa, the lesser tuberosity corresponding to the edge\\nof the glenoid fossa.\\nIn the other, reported by Collins, 2 a man sixty years old was knocked\\ndown and run over, sustaining, in addition to the dislocation of his\\nright shoulder, fracture of several ribs he died in a few days of pneu-\\nmonia. The capsule was torn on all sides the supraspinatus and\\nsubscapulars were torn away at their insertions, and the long tendon\\nof the biceps was detached from the bicipital groove. The head of\\nthe humerus lay between the teres minor and the infraspinatus,\\nimmediately beneath the scapular spine.\\nThe important complication of fracture of the anatomical neck has\\nbeen reported in two cases, one by Delpech, the other by Malgaigne 3\\nin each the cause was a fall upon the shoulder. In Delpech s case the\\nfall was due to an apoplexy which soon proved fatal the head had\\npassed entirely through a large rent in the postero-external part of the\\ncapsule, its fractured surface lay against the subspinous fossa, and its\\narticular surface was directed backward and covered by the infraspi-\\nnatus muscle. The muscular attachments to the humerus were all\\npreserved, and the long tendon of the biceps was intact.\\nMalgaigne s case was not seen by him until eleven months after the\\nreceipt of the injury the head of the humerus could be felt as an\\nimmovable, hemispherical body, two inches in diameter, and half an\\ninch below the posterior angle of the acromion. The arm was short-\\nened half an inch, the elbow slightly abducted and not rotated. The\\nupper end of the shaft corresponded to the glenoid cavity. The arm\\nwas slightly movable the head did not share in its movements.\\nThe results obtained by experiments upon the cadaver are in har-\\nmony with these post-mortem records. In the subacromial variety the\\nhead of the humerus is found under the acromion looking backward\\nand inward, with its anatomical neck engaged against the posterior\\nedge of the glenoid fossa, and the lesser tuberosity lying on the latter.\\nThe tendon of the subscapulars covers the anterior and inner part of the\\nfossa, and is usually more or less detached from its insertion upon the\\nhumerus. The dislocation can be transformed into a subspinous one\\nby diminishing the internal rotation sufficiently to free the lesser tuber-\\nosity, and then forcing the humerus backward toward the dorsum of\\n1 Malgaigne Loc. cit., p. 541. According to Soyez (These de Paris, 1880, No. 179) the\\ncase was treated by Denonvilliers, who deposited the specimen in the Musee Dupuytren.\\nIt is reported by Malgaigne as if he had himself observed it. Hence has arisen the error\\nof supposing that ther were different cases.\\n2 Collins Dublin Journal Med. Sci., 1879, vol. ii. p. 166.\\n3 Soyez These de Paris, 1880, No. 179, p. 28.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0658.jp2"}, "651": {"fulltext": "POSTERIOR DISLOCATIOXS OF THE SHOULDER. 583\\nthe scapula, tearing the capsule more extensively, lacerating the infra-\\nspinatus, increasing the separation of the subscapulars, and tearing\\noff also the supraspinatus from its insertion. The dividing line\\nbetween the two varieties is necessarily an arbitrary one, and in some\\ncases it must be. difficult to determine to which variety the case belongs.\\nMalgaigne s definitions are as follows The subacromial is one in which\\nthe head of the humerus lies under the posterior angle of the acromion\\nthe subspinous, one in which it has been displaced behind the angle of\\nthe acromion and lies under the spine of the scapula.\\nSymptoms. The symptoms in recent cases are not very marked, and\\nthe characteristic ones may be masked by the swelling. In the sub-\\nacromial variety the shoulder seems full behind and flattened in front.\\nThe arm hangs by the side, the elbow usually directed somewhat for-\\nward, and is rotated inward. The coracoid process can be plainly felt,\\nand perhaps seen the acromion is prominent in front. The absence\\nof the head of the humerus from its socket is recognized by pressure\\nmade in front, and its presence behind and to the outer side is deter-\\nmined by palpation combined with gentle movements of the limb. In\\nthe older cases the subsidence of the inflammatory swelling and the\\natrophy of the deltoid consequent upon disuse make the deformity\\nmore marked. Voluntary movements are abolished, and communicated\\nmovements restricted and painful. Comparative measurements have\\nnot shown constant or notable differences in length. In a case of my\\nown, a man forty-five years old, the arm was rigidly held close to the\\nside, and communicated movements were extremely painful. Reduc-\\ntion by traction, under ether, was easy, and full use of the limb was\\npromptly regained.\\nThe anteversion and adduction are probably due to the persistence\\nof the anterior portion of the capsule, which is noted in most of the\\nautopsies and all the experiments upon the cadaver.\\nIn the subspinous variety the attitude of the arm in the few reported\\ncases has not been always the same sometimes the elbow has been\\nheld close to the trunk and projected forward in Malgaigne s it was\\nrotated inward, but otherwise freely movable, and remained in such\\nposition as was given to it. In Desclaux s it was held horizontally in\\nfront of the upper part of the chest, and, as any attempt to lower it\\ncaused great pain, the patient sought to keep it immovable by placing\\nthe hand on the top of his head. The local symptoms at the shoulder\\nare much the same as those in the subacromial variety there is the\\nsame prominence of the coracoid process and acromion, the flattening\\nof the front and the fulness of the back of the shoulder, the absence\\nof the head of the humerus from its socket and its presence behind,\\nin this case, of course, further back behind the angle of the acromion\\nand below the spine of the scapula.\\nRichet, in 1882, treated a case which differed widely in one respect\\nfrom both the subacromial and subspinous forms, namely, in that the\\nhead of the humerus, instead of being in contact with the acromion, lay\\nat a distance of two finger-breadths below it, close behind the glenoid\\nfossa. He considered it a new variety, representing the first stage in\\nthe production of the subacromial, and gave it the name of retro-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0659.jp2"}, "652": {"fulltext": "584 DISLOCATIONS.\\naxillary. The case was published by Bottey, his interne, in the Pro-\\ngress Medical, August 5, 1882, and subsequently republished with\\nanother also observed by Bottey in his graduating thesis. 1 The two\\ncases resembled each other very closely the patients were women, aged\\nseventy-eight and seventy-two years, respectively, and the injury was\\ncaused in each case by a fall upon the shoulder in one, while walking\\nin the street in the other, from her bed, against a chair. The elbow\\nwas directed forward and held near the body, and in the second case\\nthe patient supported the limb with the other hand because of the pain\\nits weight caused. As both patients were thin and there was no swell-\\ning, the head of the humerus could be very distinctly felt behind the\\nposterior edge of the glenoid fossa and slightly separated from it, and\\ndistant from the acromion by two good finger-breadths. External\\nrotation of the limb was marked. Reduction was easily effected by\\ndirect impulsion, and both patients recovered promptly.\\nThe position of the head may be explained by assuming that the\\nrent in the capsule was exceptionally low, and did not extend upward\\nalong the posterior border of the glenoid fossa.\\nPrognosis. The prognosis is favorable as regards the probability of\\neffecting reduction (in two or three cases the head has been unexpect-\\nedly returned to its place by the manipulations employed to make the\\ndiagnosis), but it is very unfavorable if the dislocation is left unre-\\nduced, for then the range of motion is usually very slight. In a case\\nreported by Sir Astley Cooper, in which the dislocation immediately\\nrecurred after every reduction and was finally abandoned, the patient\\nsurvived seven years, but remained unable to use or even move the\\narm to any extent. The tendency to recurrence was attributed to the\\nseparation of the tendon of the subscapulars from the humerus, and\\nto the consequent lack of support on that side. The same tendency\\nhas been noted in other cases. Bardenheuer says it existed in three of\\nhis four, and that in two of them movements of the joint gave rise to\\ncrepitus. In some of the cases the full use of the limb has been\\nregained in a very short time after reduction, a week or ten days.\\nDiagnosis. The diagnosis, as has been already said, may be difficult,\\nespecially if there is much swelling. The injury appears to have been\\nnot infrequently mistaken for a sprain or a contusion. The attitude\\nand the direction of the axis of the arm, except in the rare subspinous\\ncases, are not sufficiently characteristic even to suggest the existence of\\nthe injury, and unless the examination is systematically made with a\\nview to determine the position of the head of the humerus, as should\\nbe done in all cases of injury in this region, the dislocation may be\\noverlooked. If the head of the bone can be felt and its relations to\\nthe acromion determined, no doubt should remain.\\nTreatment. Reduction has been easily effected in both recent and\\nold cases by a variety of methods. The one that has furnished the\\nlargest number of successes is direct pressure from behind forward\\nupon the head of the humerus with counter-pressure upon the front of\\nthe acromion, usually associated with traction upon the arm, forward\\n1 Bottey Deux cas de luxation de l epaule en arriere et en bas (luxation retro- axillaire).\\nThese de aris, 1884, No. 13.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0660.jp2"}, "653": {"fulltext": "UPWARD DISLOCATIONS OF THE SHOULDER. 585\\nor backward, or with gentle movements of the limb in various direc-\\ntions. Sedillot successfully reduced a dislocation that had existed for\\na year and fifteen days.\\nThe position and relations of the untorn portion of the capsule indi-\\ncate that the best manipulations would be elevation of the elbow in\\nfront and toward the median line, combined with inward rotation to\\nrelax the anterior portion of the capsule, and followed by direct pro-\\npulsion of the head from behind toward its socket, or by traction in\\nthe direction of the long axis of the arm. Simple external rotation\\nmight succeed when the articular surface of the head rests against the\\nedge of the glenoid cavity, as it sometimes does, for by making the\\nfront of the capsule tense it would rotate the posterior surface of the\\nbone inward and forward, but the success of this manipulation might\\neasily be prevented by the increased friction between the two bones.\\nIn a case of subspinous dislocation reported by Dr. J. E. Michael 1\\nreduction made on the fifty-ninth day remained incomplete. The\\npatient was a boy sixteen years old, who had received the injury by a\\nfall from a horse the head of the humerus lay at the junction of the\\nmiddle and outer thirds of the spine of the scapula, the arm was slightly\\nrotated inward, and the hand could be raised only to the nipple. After\\ntrying elevation and rotation without success, the head was brought by\\ntraction so nearly into place that the hand could be placed upon the\\nopposite shoulder, but the form of the shoulder remained imperfect\\nbecause of the undue prominence of the head of the humerus behind\\nand on the outer side. Six months later the deformity persisted and\\nthere was considerable emaciation of the region there was slight\\nmobility, rotation was entirely lost, and the hand could be brought to\\nthe head only with an effort.\\nUPWARD DISLOCATIONS.\\nSupraglenoid, Supracoracoid.\\nThe possibility of the occurrence of this rare form of dislocation,\\nwhich has often been denied, has at last been established by the clin-\\nical observation of several cases and the post-mortem examination of\\ntwo.\\nThe first alleged case was reported by Laugier 2 in 1834 as an incom-\\nplete dislocation upward; the second was by Malgaigne. 3 In 1858\\nBourget submitted to the Societe de Chirurgie a paper upon the subject\\ncontaining the accounts of three cases observed by himself, two of\\nw 7 hich he diagnosticated as complete dislocations, and one as incomplete,,\\nand reproducing the cases of Laugier, Malgaigne, and Avrard. Upon\\nthis paper Morel-Lavall6e 4 made an elaborate report, denying the cor-\\nrectness of the diagnosis in all the reported cases and attributing the\\nobserved deformity to a prolonged arthritis, and he supported this\\n1 Michael The Medical News, 1884, p. 621.\\n2 Laugier: Arch. gen. de Med., 1834, vol. x. p. 65; also in Dictionnaire en 30 vols., vol.\\nxiii. p. 81.\\n3 Malgaigne: Rev. medico-chirurg., 1849, vol. v. p. 30, and Luxations, p. 530.\\n4 Morel-Lavallee Bull, de la Soc. de Chir., 1858, vol. viii. p. 490.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0661.jp2"}, "654": {"fulltext": "586 DISLOCATIONS.\\nopinion by quoting the case of Soden, 1 in which the symptoms were\\nthe same as in Laugier s case, but the autopsy, five months later,\\nshowed the changes of a dry arthritis. He seems to have attached no\\nimportance to the dislocation inward of the long tendon of the biceps.\\nThe alleged cases on record are Malgaigne s, two of Bourget s, and\\nthose of Chassaignac, 2 Holmes, 3 Prescott Hewett (quoted by Holmes),\\nDenonvilliers/ Albert, 5 Busch, 6 Verneuil/ Le Dentu, Tuffier, 8 Rob-\\nson, 9 and Streeter, 10 fourteen in all, in one of which (Albert) both\\nshoulders were dislocated in the same manner and at the same time.\\nThe cases that furnished autopsies are Holmes s, Albert s, and Tuf-\\nfier s. Holmes s patient was a man fifty years old, who had fallen\\nfrom a height of about thirty feet, striking upon his head, the left side\\nof his chest, and left elbow, and receiving in addition to the dislocation\\nin question a compound dislocation of the radius and a comminuted\\nfracture of the upper portion of the ulna of the same side. The head\\nof the humerus formed a large prominence in front of the outer part\\nof the clavicle movements of the arm gave rise to crepitus. No\\nattempt to reduce was made, and the patient died on the fifteenth day.\\nAt the autopsy the head of the humerus was found immediately\\nunder the skin, having passed through the deltoid near its inner ante-\\nrior margin its articular surface was entirely above the glenoid fossa\\nand rested upon the stump left by fracture of the coracoid process\\nnear its base. The coracoid process lay on its inner, the acromion on\\nits outer side and somewhat posteriorly the coraco-acromial ligament\\nappears to have been in part torn. The subscapularis was intact, but\\nthe muscles attached to the greater tuberosity were torn through,\\nexcept a part of the teres minor. The long tendon of the biceps lay\\nbelow the head on its outer side it was still attached to the upper\\nmargin of the glenoid fossa, but some of its inner fibres had been\\nbroken away from the muscle. The capsule w r as torn at its upper and\\ninner part.\\nAlbert s case Avas first seen by him several years after the injury was\\nreceived. The patient had dislocated both shoulders by holding on to\\nthe reins of a pair of runaway horses and being drawn along the\\nground. The deformity was more marked on the left than on the\\nright side, and there consisted of a marked rounded prominence on\\nthe front and upper part of the shoulder. Both arms hung close by\\nthe side, the axis being directed obliquely from below upward and for-\\nward in front of the glenoid fossa. The prominence formed by the\\nhead of the humerus was situated in front of the acromion, rising\\nabout two centimetres above its upper surface, and this elevation could\\nbe increased by pressing the elbow upward the arms were so far rotated\\n1 Sodeu: Medico-Chirurgical Transactions, vol. xxiv. p. 212.\\n2 Chassaignac Bull, de la Soc. de Chir., 1858, vol. viii. p. 472.\\n3 Holmes Medico-Chirurgical Transactions, 1858, vol. xli. p. 447.\\n4 Denonvilliers, in Pan as Diet, de Med. et Chir. pratiques, art. Epaule, D. 469.\\n5 Albert Chirurgie, 2d ed., 1881, vol. ii. p. 287; also in Wiener med. Blatter, 1879,\\np. 453.\\n6 Busch: Arch, fur klin. Chir., 1S76, vol. xix. p. 400.\\n7 Verneuil in Pellier These de Paris, 1878.\\n8 Tuffier Bull, de la Soc. Anat., 1886, p. 292.\\n9 Eohson Annals of Surgery. 1888, p. 175.\\n10 Streeter Medical Eecord, February 26, 1887.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0662.jp2"}, "655": {"fulltext": "UPWARD DISLOCATIONS OF THE SHOULDER.\\n587\\nFtg. 2:\\nSupraglenoid dislo-\\ncation. (Albert.)\\noutward that the transverse diameter of the lower end of the humerus\\ncoincided with the transverse axis of the trunk. The outer deltoid\\nregion was not noticeably flattened, but posteriorly the fibres of that\\nmuscle were greatly relaxed and the posterior edge of the glenoid fossa\\ncould be distinctly felt through them. The point\\nof the linger could be pressed in between the head\\nand the coracoid process. Slight voluntary rotation\\nand movement of the elbow forward and backward\\nwere possible very slight passive abduction. The left\\nelbow could be flexed only to a right angle, further\\nflexion being arrested by the triceps. On the right\\nside the deformity was the same in character, but\\nless in degree, and there was the same limitation of\\nmotion. If pressure was made upon the elbow di-\\nrectly upward the movement could be distinctly felt\\nto be arrested by bony contact, and this demonstrably\\noccurred between the head of the humerus and the\\nclavicle, but if the elbow was first carried back-\\nward the head could then be pushed up higher.\\nAt the autopsy the capsule was found attached\\nthroughout to the anatomical neck of the humerus\\nand adherent also to the upper part of its articular\\nsurface thence it extended without interruption to the margin of\\nthe glenoid fossa, but its cavity was considerably enlarged. The\\ncoraco-acromial and coraco-clavicular ligaments were uninjured. The\\nupper third of the head of the humerus lay above the level of the\\ncoraco-acromial ligament, and this overlapping could easily be in-\\ncreased to half the head. The glenoid fossa was filled with a thick\\nlayer of fibrous tissue.\\nIn the fuller account given in the Wiener medicinische Blatter, 1879,\\np. 453, quoted by Poinsot, it is said that the long tendon of the biceps\\non the left side was ruptured and its end adherent to the bone in the\\nbicipital groove, and that an osteophyte an inch long had grown from\\nthe base of the coracoid process.\\nTuffier s specimen was found in the dissecting-room. The acromion\\nwas broken off near its base and turned up and out the head of the\\nhumerus was in direct contact with the acromion and coracoid, and\\nthe joint showed old changes of dry arthritis, including ossification of\\nthe long head of the triceps.\\nTo these may be added Robson s observations made during an arth-\\nrotomy. His patient was a boy sixteen years old who had received\\nhis injury six weeks earlier by the forcible dragging of his right arm\\nupward and backward. The description of the symptoms is not very\\nclear, but the head of the humerus lay about a finger-breadth in\\nfront of the right acromion and immediately to the outer side of the\\ncoracoid process. Motion of the arm was limited in every direction\\nexcept backward. The bone was exposed by a curved incision on the\\nouter side of the shoulder, and it was then discovered that in addi-\\ntion to the dislocation of the head of the humerus there was a longi-\\ntudinal fracture separating the greater tuberosity from the head and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0663.jp2"}, "656": {"fulltext": "588\\nDISLOCATIONS.\\nextending down the shaft for some distance beyond the line of incision.\\nReduction could not be effected in consequence of the glenoid\\nfossa being filled with callus and plastic material thrown out around\\nthe fracture.\\nThe other cases are as follows\\nMalgaigne. A man sixty years old was thrown from a wagon,\\nstriking upon his shoulder while his arm was held close to his side.\\nThere was much pain and he was unable to move the limb. A bone-\\nsetter handled him roughly and sent him away with his arm in a\\nsling. Two and a half months later he consulted Malgaigne. The\\nhead of the humerus was dislocated upward and forward above the\\ncoracoid process, reaching the under surface of the clavicle, and stretch-\\ning the overlying deltoid so that on perforation with a pin the latter\\nproved to be only eight millimetres in thickness shortening one-fifth\\nof an inch. Traction to the extent of more than four hundred pounds,\\ncombined with pressure upon the head downward, outward, and back-\\nward and counter-pressure on the acromion, failed to effect reduction,\\nalthough it made the head so movable that it could be drawn down a\\nfinger-breadth below the clavicle. Malgaigne meditated division of\\nthe coraco-acromial ligament, which seemed to be the obstacle, but\\nrefrained.\\nBourget s cases resembled Malgaigne s closely.\\nBusch. (Fig. 280.) A horse reared and struck the patient, who\\nwas holding him by the bridle, upon the inner and anterior part of\\nthe shoulder with his hoof. The head of the humerus was displaced\\nupward and forward, the deformity closely\\nresembling that in Malgaigne s case the\\ninfraclavicular fossa was deepened, the arm\\nhung close by the side, the posterior deltoid\\nregion was hollowed, the coracoid process\\ncould not be felt in its place. Reduction\\nfailed.\\nDenonvilliers. A man fell upon his arm,\\nbut was unable to give the details of the\\nfall. The limb hung by the side and was\\nstrongly rotated outward. Ecchymosis, pain,\\nloss of function. The head of the humerus\\nprojected forward and upward between the\\ncoracoid and the acromion and in front of\\nthe clavicle. Oblique traction, combined\\nwith a slight movement of leverage, effected\\nreduction.\\nChassaignac. A man fell from the third\\nstory of a building. The head of the hu-\\nmerus projected directly outward and ex-\\ntended above the coraco-acromial ligament.\\nMovements of the elbow forward were impossible, backward they were\\nmore free than normal. The dislocation was easily reduced by exag-\\ngerated elevation of the arm, but recurred when the arm was lowered.\\nHewett. The patient was a middle-aged woman the head of the\\nFig. 280.\\nSupraglenoid dislocation Busch s\\ncase. (Bardenheuer.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0664.jp2"}, "657": {"fulltext": "UPWARD DISLOCATIONS OF THE SHOULDER. 589\\nhumerus lay on the upper and inner side of the glenoid cavity there\\nwas distinct crepitus which ceased after reduction had been made by\\ntraction with the heel in the axilla. Apparently the patient made a\\ncomplete recovery.\\nStreeter. A man of middle age fell down stairs, striking on his\\nelbow. The coracoid process was evidently fractured, and the articular\\nhead of the humerus was plainly felt above the clavicle, the patient\\nbeing very thin. At the present time he is making good progress\\ntoward recovery.\\nFracture of the coracoid progress existed in Holmes s and Streeter s\\ncases, and possibly also in Hewett s and Busch s.\\nRupture or displacement of the long tendon of the biceps must\\noccur, and rupture of the muscles attached to the greater tuberosity\\nis noted by Holmes it seems not unlikely that the impossibility of\\nreduction in several of the cases was due to the interposition of the\\ntendon of the biceps or the stump of the supraspinatus.\\nThe mode of production cannot be determined with an approach to\\nprecision except in the cases of Holmes and Streeter, in both of which\\nthe arm was driven upward by a blow upon the elbow. Tuffier s frac-\\nture of the acromion suggests a similar cause.\\nPanas s experiments upon the cadaver show that if the arm is strongly\\nrotated outward while held close to the body, and then pressed bodily\\nupward and forward, the capsule will tear at its upper part and the\\ndislocation will be produced without fracture of the coracoid process,\\nthe head of the humerus rising not more than one centimetre above its\\nnormal position.\\nThe symptoms consist in the presence of the head of the humerus\\nin the interval between the coracoid process and the acromion above\\nits proper level. The coracoid process can be felt with difficulty,\\nif at all. Usually voluntary movements are almost or quite impos-\\nsible, and passive movements greatly restricted, and this restriction\\nexists in old as well as in recent cases.\\nIn three cases seen while the injury was recent, Denonvilliers, Chas-\\nsaignac, and Hewett, reduction was easily effected by traction in two\\nand by elevation of the elbow in one, but the dislocation recurred in\\nthe latter Verneuil reduced on the thirty-sixth day by traction aided\\nby anaesthesia. In Holmes s case the associated injuries were so severe\\nthat reduction, for which the aid of chloroform was thought to be\\nnecessary, was not attempted. Malgaigne, Bourget, and Busch failed,\\nthe duration of the dislocation at the time of the attempt being two\\nand a half, six, and five months respectively. The details of Bourget s\\nsecond case are not given, and the result in Le Dentu s I do not know.\\nIn Albert s the dislocation had existed for many years, and no mention\\nis made of any attempt to reduce. In Streeter s reduction seems to\\nhave been made. The persistent displacement in Tuffier s cannot be\\naccounted for except by supposing that the arm was too well supported\\nin a sling while the injury was recent.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0665.jp2"}, "658": {"fulltext": "CHAPTER XLIV.\\nDISLOCATIONS OF THE SHOULDEE.\u00e2\u0080\u0094 (Continued.)\\nAssociated Injuries and Complications Prognosis Habitual Dislocations Old\\nDislocations Congenital and Pathological Dislocations.\\nAssociated Injuries and Complications.\\nThe complications which may coexist with a dislocation have been\\ndescribed in Chapter XXIX. and will therefore be treated but briefly\\nhere, and mainly with the view of adding some details to the account\\nalready given. In like manner the accidents which may be caused by\\nattempts to reduce a dislocation have been described in Chapter\\nXXXIV.\\nThe injuries which are more or less frequently associated with dis-\\nlocations of the shoulder, but which are without such special bearing\\nupon the prognosis or treatment as would make them actual complica-\\ntions, have been mentioned in connection with the different forms of\\ndislocation in the preceding chapters. The most important are the\\nlacerations of the different muscles and tendons or their equivalent\\navulsion from the humerus with more or less of the tuberosities to\\nwhich they are attached.\\nLaceration of the subscapularis is frequent, and avulsion of the\\nlesser tuberosity to which it is attached is very rarely substituted for\\nit, apparently only in some of the backward dislocations. The extent\\nof the laceration of the muscle can only be inferred from the extent\\nand direction of the displacement, and it is believed to be without\\nimportant influence upon the completeness of the repair and the subse-\\nquent security of the joint. The position of adduction and inward\\nrotation in which the limb is habitually kept during, the period of con-\\nvalescence favors the repair of the muscle, and since the rupture is\\nusually incomplete the torn portions do not widely retract.\\nWith the muscles attached to the greater tuberosity it is somewhat\\ndifferent. The muscles themselves are rarely torn, but the upper and\\nmiddle facets of the greater tuberosity to which the supraspinatus and\\ninfraspinatus muscles are attached are frequently broken off and more\\nor less retracted under the acromion, or the tendons are torn away from\\nthem and retracted. The importance of this associated injury, through\\nits effect upon the subsequent usefulness and security of the joint, may\\nbe great not only may the power of voluntary external rotation be\\ndiminished thereby, but the consequent loss of support on the outer\\nside of the joint favors recurrence of anterior dislocation, and the great\\nlengthening of the upper portion of the capsule and the enlargement\\nof its cavity which are effected by the retraction of the supraspinatus\\nand the establishment of free communication between the joint and the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0666.jp2"}, "659": {"fulltext": "DISLOCATIONS OF THE SHOULDER. 591\\nsubacromial bursa make the joint much less secure, and this condition\\nis thought to be the cause of the marked tendency to recurrence\\nobserved after some anterior dislocations (see Chapter XXIX.). Sim-\\nilarly the avulsion or rupture of the subscapulars in backward dislo-\\ncations is responsible for the tendency to recurrence that has been so\\nfrequently noted in them.\\nThe tendon of the long head of the biceps appears habitually to escape\\nrupture its sheath may be opened by the avulsion of either tuberosity,\\nand then it may slip over the corresponding portion of the head, and,\\nbecoming engaged between the latter and the glenoid cavity, thus con-\\nstitute a serious obstacle to reduction. When ruptured, its end is\\nretracted into its sheath in the bicipital groove and there becomes\\nunited with the bone.\\nFracture of the greater tuberosity appears to be not often capable\\nof demonstration at least it has often been found post mortem when\\nit had not been recognized during life, although the proper explanation\\nof the failure to recognize it may be that it was not sought for. If\\nthe fragment is retained in contact with the humerus by the untorn\\nperiosteum, crepitus may perhaps be obtained by manipulation and\\nwhen the fragment is widely withdrawn it may perhaps be felt under\\nthe acromion, or its absence may be recognized by the change in the\\nshape of the corresponding part of the humerus, or the fracture may\\nbe indicated by exceptional symptoms accompanying the dislocation,\\nsuch as greater mobility of the limb or the absence of fixed abduction\\nof the elbow, or local pain on pressure.\\nFracture of the lesser tuberosity is much less frequent. To the five\\ncases mentioned in the chapter on fractures of the tuberosities of the\\nhumerus (p. 222) may be added the two reported by Jossel and quoted\\nin the preceding chapter in the section on posterior dislocations\\n(p. 581).\\nFracture of the Anatomical or Surgical Neck. This serious complica-\\ntion of the humerus is fortunately rare McBurney was able to collect\\nonly 117 reported cases, although his search was aided by those of\\nOger 2 and Porrier and Mauclaire. 3\\nThe fracture may occupy the anatomical or the surgical neck, or may\\nextend through the tuberosities, or may be extensively comminuted.\\nOf 68 cases collected by Thamhayn 4 the fracture in 14 was of the\\nanatomical neck in 2 of these reduction was effected. The displace-\\nment in the great majority of cases is forward and inward, the head\\nlying under or on the inner side of the coracoid process in a few cases\\nit has been backward under the acromion. The upper fragment may,\\nin addition, undergo rotation that will widely separate its broken sur-\\nface from that of the shaft. Cases of the rare form in which the head,\\nafter fracture of the anatomical neck, has undergone complete reversal\\nwhile remaining within the cavity of the joint have been quoted in\\nChapters XIX. and XXIX. The upper end of the lower fragment\\n1 McBurney Annals of Surgery, April, 1894, and May, 1896.\\n2 Oger- Luxations scapulo-humerales compliquees de fracture. These de Paris, 1884,\\nNo. 361.\\n3 Porrier and Mauclaire Eev. de Chir., October, 1892.\\n4 Thamhayn Schmidt s Jahrbucher, 1861, vol. cxl. p. 194.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0667.jp2"}, "660": {"fulltext": "592 DISLOCATIONS.\\nis usually drawn upward toward the glenoid fossa, overlapping the\\nupper fragment on the outer side, and it may unite in this position by\\nfibrous or bony union with the other fragment, or with the scapula.\\nThe upper fragment usually preserves its vitality and establishes new\\nvascular connections in rare instances it has become necrotic and has\\nbeen eliminated after prolonged suppuration.\\nThe diagnosis appears, in some cases, to have presented serious\\ndifficulties, because the fracture removed some of the most character-\\nistic symptoms of the dislocation, such as the fixation and attitude\\nof the limb, and the indication of the position of the head of the\\nbone that is furnished by the direction of its long axis. In general\\nterms, it may be said that when the dislocation of the head has been\\nrecognized the coexistence of a fracture may be suggested by the\\nmobility of the limb, its shortening, and the greater extent of the\\necchymosis, and proved by the independent mobility of the shaft and\\nhead with crepitus. When the signs of fracture are apparent the coex-\\nistence of a dislocation can only be recognized by determining the\\nabsence of the head from its socket, and this may be made very diffi-\\ncult by the swelling of the soft parts. It must be remembered that\\nthe same exceptional mobility may be given to the limb by extensive\\nlaceration of the capsule without fracture. The two positive signs,\\nwhich the surgeon should spare, no pains to recognize, are the absence\\nof the head of the humerus from its socket, which proves the disloca-\\ntion, and its failure to share in movements communicated to the shaft,\\nwhich proves the fracture.\\nThe treatment presents grave difficulties because the existence of\\nthe fracture deprives the surgeon of that control over the move-\\nments of the head of the bone which, in a simple dislocation, can be\\nexerted through its shaft. Reduction in a recent case may some-\\ntimes (36 out of 80 cases, Oger) be effected by direct impulsion of the\\nhead back into place. This should always be attempted, with the aid\\nof anaesthesia and gentle traction upon the abducted shaft in order to\\nutilize such periosteal connection between the fragments as may remain.\\nIn two cases of fracture of the anatomical neck I made reduction in\\nthis manner very easily, holding the limb in full abduction and press-\\ning directly upon the head with the fingers deeply placed in the axilla.\\nThis failing, the alternative plans were to seek consolidation of the\\nfracture and then to reduce the dislocation, or to prevent union of the\\nfracture and thus obtain a false joint at its seat (Riberi), or to excise\\nthe fragment. Nine reported cases of the first plan gave seven failures\\nand two successes, and even in one of the latter reduction was made in\\nthe third week. Seven cases of the second plan have been reported,\\nbut it is not easy to determine from the reports the measure of the\\nfunctional success. In cases in which the displacement was unrelieved\\nthe usefulness of the arm was even more impaired than when an\\nuncomplicated dislocation was left unreduced, because of the additional\\nadhesions created by the fracture, and a large proportion of the patients\\nappear to have suffered from the pressure effects of the dislocated head.\\nThe complication, therefore, remained a serious reproach to surgery,\\nthe only means of relief being excision of the head.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0668.jp2"}, "661": {"fulltext": "DISLOCATIONS OF THE SHOULDER. 593\\nIn this juncture Dr. McBurney devised and successfully used a\\nmethod of reduction which seems perfect in its efficiency and which,\\nat least when the fracture is through the surgical neck, involves less\\nrisk than primary excision of the fragment. He makes an incision on\\nthe outer anterior aspect down to the upper fragment, drills a hole in\\nthe latter, inserts the end of a stout hook bent at a right angle (Fig.\\n281), and with its aid makes the needed traction and rotation. After\\nreduction has been thus made, he sutures the fragments together with\\ncatgut, and then treats the limb as for fracture. He has used the method\\nin four cases, two each of the surgical and anatomical necks, all the\\nwounds healing primarily, and with a functional result as good as that\\nfollowing an uncomplicated dislocation or fracture.\\nFig. 281.\\nMcBurney s hook for making traction upon the dislocated upper fragment.\\nFor statistics of various methods of treatment after failure to reduce,\\nsee Souchon, Transactions of the American Surgical Association, 1897,\\np. 322.\\nFracture of the shaft associated with dislocation of the shoulder has\\nalso been observed several times. It is a less serious complication than\\nfracture of either the anatomical or the surgical neck, because the\\ngreater length of the upper fragment makes it easier to effect reduction.\\nFracture of the coracoid process has been observed in connection\\nwith dislocation of the humerus, not only in the cases of supracoracoid\\ndislocation mentioned above, but also in dislocation forward.\\nFracture of the acromion has also been occasionally observed.\\nKronlein s and my cases in which a blow received upon the top of the\\nshoulder first broke the acromion and then dislocated the humerus into\\nthe axilla have already been mentioned (p. 553) also Tuffier s, in an\\nupward dislocation.\\nFracture of the Glenoid Fossa. Probably the chipping of the edge\\nof the glenoid fossa is not infrequent in dislocation, and passes un-\\nrecognized because of the lack of symptoms. Fracture of a large por-\\ntion has been occasionally observed, both clinically and after death,\\nand is of great importance in favoring recurrence of the dislocation.\\nMalgaigne represents in his Atlas (Plate XXII., fig. 4) a case in which\\nthe anterior third of the fossa was broken off and had been displaced\\nbackward and become united with the neck of the scapula the symp-\\ntoms in the case were that the shoulder was less full and rounded\\n33", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0669.jp2"}, "662": {"fulltext": "594 DISLOCATIONS.\\nthan normal, and that the head of the humerus, while still in relation\\nwith the anterior part of the acromion, projected a few lines in front\\nof the inner border of the coracoid process.\\nThe special indication for treatment is to prevent recurrence of the\\ndislocation by fixation of the limb and pressure upon the head from\\nthe side on which the fracture has taken place.\\nNerves. Injury to the nerves, except of a slight and transitory\\ncharacter, is rare, and in most of the cases reported as such the injury\\nhas been inflicted during reduction. In two cases in which the injury\\nwas demonstrated by post-mortem examination, Hilton s 1 and Parise s, 2\\nthere was only a partial laceration of the circumflex nerve in the\\nformer, and in the latter rupture at different levels of the fibres com-\\nposing it, only recognizable on minute dissection the nerve trunk\\nwas extensively infiltrated with blood the dislocation was subglenoid,\\nand the nerve was tightly stretched around the head of the humerus.\\nIn Bourgues s 3 (subglenoid) the main nerves were so compressed\\nbetween the surgical neck and the fascia that they showed multiple\\ngrooves and punctate hemorrhages. In Muller s (p. 419) the nerves\\nand artery were compressed by a cicatricial band.\\nIt is occasionally found in unreduced dislocations that the sensibility\\nof the skin over most of the deltoid region, which is supplied by the\\ncircumflex nerve, is diminished or lost, and that in others after reduc-\\ntion the deltoid is paralyzed. This paralysis of the deltoid is thought\\nfrequently to be the result of direct bruising of the muscle by the\\nviolence that caused the dislocation, but that explanation does not sat-\\nisfactorily account also for the loss of sensibility in the skin, and we\\nmust, in such cases, assume that the trunk of the circumflex has been\\nstretched in the dislocation.\\nIn many of the reported cases it cannot be determined whether the\\ninjury to the nerve was caused by the dislocation or by the manoeuvres\\nmade to effect reduction in others it is clearly due to the dislocation.\\nIllustrative examples have been quoted in Chapter XXIX.\\nThe cause of the paralysis, when it involves more than the circum-\\nflex nerve, is very obscure. It has been attributed to compression of\\nthe main trunks in the axilla, but this explanation is not satisfactorily\\nsupported by post-mortem examination or experiment, and the fact\\nthat similar symptoms may follow blows that neither produce a dislo-\\ncation nor directly involve the nerves adds to the difficulty. Xelaton\\nsought to explain it by supposing a compression of the nerves between\\nthe clavicle and the first rib, and some cases have been reported which\\nindicate that this explanation may, sometimes at least, be the correct\\none. On the other hand, the prompt disappearance of the symptoms\\nin some cases after reduction clearly points to pressure by the head or\\nneck of the humerus upon the nerves as the cause.\\nThe paralysis may appear immediately or may develop gradually\\nduring the first two or three days, and it may be complete or partial.\\nIn some cases (see Chapter XXIX.) it has been followed by serious\\n1 Hilton Guy s Hospital Eeports, 1847, vol. v. p. 93.\\n2 Parise Gaz. Medicale de Paris, 1863, p. 210.\\n3 Bourgues Bull, de la Soc. Anat,, 1888, p. 581.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0670.jp2"}, "663": {"fulltext": "DISLOCATIONS OF THE SHOULDER. 595\\nchanges in the appearance and nutrition of the limb, presumably the\\neffect of an ascending neuritis. In one case Bardenheuer 1 demon-\\nstrated the existence of neuritis and perineuritis by exposing the\\nnerves, and worked a gradual cure by stretching their trunks.\\nWhatever doubt may exist as to the direct cause of the paralysis,\\nthe first step in the treatment is to reduce the dislocation after that\\nhas been accomplished, or even if it should fail, electricity should be\\npersistently employed. Some cases respond promptly to treatment, the\\ncontractility of the muscle sometimes reappearing after even the single\\napplication of a blister, while others, after weeks or months of treat-\\nment, will show no improvement. So long as the muscle reacts to\\nelectrical stimulation the prognosis is good.\\nBloodvessels. The complication of serious injury to the bloodves-\\nsels in the neighborhood of the joint is not frequent, and in the\\nrecorded cases there is often a doubt whether the injury was caused by\\nthe dislocation or by the attempt to reduce it. The subject has been\\ndiscussed in detail in Chapters XXIX. and XXXI V.\\nChest. A unique case reported by Prochaska, in which the head of\\nthe humerus was forced into the chest between the second and third\\nribs, is quoted in Chapter XXIX., p. 421.\\nCompound dislocations are rare the wound in the skin is commonly\\nin the axilla, sometimes further inward through the pectoralis major,\\nsometimes behind the joint. It is a very serious complication, although\\nthere is reason to hope that a larger proportion of successes will be\\nobtained in the future under the improved methods of treating wounds\\nthan was possible in the past. The essentials of such treatment are\\nimmobilization of the joint, drainage, and surgical cleanliness excis-\\nion of the head of the humerus may also be required under certain\\ncircumstances, such as difficulty of reduction or retention, coincident\\nfracture, uncleanliness of the wound, and imperfect drainage of the\\njoint. The prudent course is to provide abundantly for drainage, by\\nnot closing the skin wound except, perhaps, in part, and by packing\\nwith iodoform gauze for at least twenty-four hours. The last-named\\nprecaution provides a prompt and ready means of escape for the blood\\nand exudations, and at the same time does not prevent the wound from\\nbeing closed a day or tw T o later with sutures and then healing as rapidly\\nand kindly as if it were entirely fresh.\\nSimultaneous dislocation of both shoulders is deemed a rare occur-\\nrence possibly it is more frequent than is generally supposed, for I\\nfound five cases mentioned in the Index Medicus for the years 1880 to\\n1885. It is of interest only as a curiosity, for the combination does\\nnot seriously affect the prognosis or treatment. The causes in the five\\ncases referred to were as follows In one 2 the patient was seized in\\nthe street by two thieves who drew his arms upward, outward, and\\nbackward, producing subcoracoid dislocations both joints had pre-\\nviously been repeatedly dislocated. In the second 3 the patient, while\\nstanding on a platform, was caught under one arm by a chain and\\n1 Bardenheuer Loc. cit., p. 335.\\n2 G. E. Moore New York Medical Eecord, 1880, vol. xviii. p. 96.\\n3 Caskie British Medical Journal, 1881, ii. p. 854.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0671.jp2"}, "664": {"fulltext": "596 DISLOCATIONS.\\nthrown to the ground. In the third x a woman, eighty-six years old,\\nfell out of bed, receiving an intracoracoid and a subcoracoid disloca-\\ntion. In the fourth 2 a girl, twenty-one years old, was knocked down\\nby a falling wall and in the fifth, 3 a girl, the injuries occurred during\\nan epileptic convulsion. In a personal case both shoulders were dislo-\\ncated by lifting the patient by his hands out of the water into a boat.\\nAll of them were anterior dislocations. Mention has been made in\\nthe preceding chapter (p. 580) of Bardenheuer s case in which both\\nshoulders were dislocated backward by a fall forward upon the elbows.\\nAssociated dislocation of the elbow has been twice reported. Morel-\\nLavalleVs 4 patient was injured in a railway accident the head of the\\nhumerus was driven out through the skin of the outer part of the\\nshoulder and projected so far that the elbow was in contact with the\\naxilla the elbow also was dislocated.\\nMoxhay s 5 patient was a man, fifty-six years old, who was struck on the\\nback of the arm by the handle of a wrench and sustained a backward\\ndislocation of both bones of the forearm and a subcoracoid dislocation of\\nthe shoulder; the latter injury was not discovered by the surgeon until\\nthe seventh week after the accident it was then successfully reduced.\\nInjuries caused by attempts made to reduce dislocations have been\\ndescribed in Chapter XXXIV.\\nPROGNOSIS AND AFTER-TREATMENT.\\nSince our knowledge of the pathology of dislocations and of the\\ncommon obstacles to reduction has become so much more accurate\\nand complete, and especially since the introduction of the use of ether\\nand chloroform, failure to reduce a recent dislocation of the shoulder\\nhas become very exceptional. Bardenheuer says that of 400 such\\ncases treated by him within ten years he has not failed in any, and\\nonly once has he had any difficulty. I have been obliged to resort\\nto the knife in only one. The prognosis, therefore, so far as the\\nreduction of recent dislocations is concerned, is eminently favorable.\\nIt is also more favorable for the older dislocations than it formerly\\nwas, for the same reasons and because of the greater safety of opera-\\ntive interference and at the same time such cases have become more\\nuncommon, for, as a rule, they are now only those in which the dislo-\\ncation has been overlooked or not treated.\\nThe prognosis is also favorable as regards the complete restoration\\nof the functions and security of the joint, but this restoration may be\\ndelayed or prevented by inflammation or partial anchylosis of the\\njoint or by paralysis of some of the muscles, and the security may be\\nseriously diminished by partial failure of repair or by permanent\\nchanges in the joint surfaces.\\nThe after-treatment is directed to the retention of the head of the\\nbone in its place until such time as the repair of the injuries to the\\n1 Giiterbock Berlin, klin. Wochenschrift, 1885, vol. xii. p. 346.\\n2 Zinker: Idem. p. 418.\\n3 Frankel Verliandl. Berlin, raed. Gesellschaft, 1885. xiii. p. 150.\\nMorel-Lavallee Bull, de la Soc. de Chir., 1858, vol, viii. p. 490.\\n5 Moxhay Lancet, 1882, ii. p. 938.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0672.jp2"}, "665": {"fulltext": "DISLOCATIONS OF THE SHOULDER. 597\\ncapsule and peri-articular tissues is sufficiently advanced, and to the\\nprevention or cure of inflammation and anchylosis.\\nIt occasionally, though very rarely, happens that the dislocation is\\nreproduced within a few minutes of the reduction, without such move-\\nment of the arm (abduction or elevation of the elbow) as would explain\\nit, and it is then presumably due to muscular contraction, perhaps aided\\nby the interposition of a portion of the capsule. It suggests the de-\\nsirability of immediately and securely fixing the arm to the side of the\\nbody before the patient is allowed to move after reduction has been\\nmade, and of inspecting the limb shortly afterward.\\nThe traumatism is always followed by some inflammatory reaction\\nand the evidences of a more or less prolonged arthritis, but it seldom\\nhappens that this is sufficiently violent to cause apprehension or require\\nother treatment than immobilization of the limb. The severer cases\\nare those in which the limb has been too early or too freely used.\\nThe fear that prolonged immobilization of a joint would lead to its\\npermanent stiffness is, or has been, too prevalent and has led to much\\nuntimely passive or active motion of joints that have been injured, and\\nthis in turn, by keeping up the irritation, has increased the stiffness\\nwhich it was designed to diminish. After the soreness has ceased,\\nabout the third week, the patient should be encouraged to try gently\\nto increase the range of motion and freely to use the limb within the\\nlimits of pain. The retraction of the capsule, the loss of its pliability,\\nis, except in the case of prolonged inflammation and in some highly\\narthritic individuals, only temporary and will ordinarily yield to the\\nnatural daily use of the limb.\\nIf the inflammation is more severe or if it has been prolonged by\\nimprudent use of the limb the immobilization should be supplemented\\nby traction downward. Bardenheuer l highly recommends in addition\\nthat the upper end of the humerus should be kept pressed outward\\nand backward by a pad in the axilla attached to a weight above and\\nbehind the shoulder. This necessitates the recumbent posture.\\nFor late changes in the bone see the following section Habitual\\nDislocation.\\nParalysis of the deltoid causes the loss of voluntary abduction of\\nthe arm, and if prolonged leads to permanent shortening of the lower\\nand inner portion of the capsule with consequent limitation of even\\npassive abduction. It may also be followed by the sinking of the\\nhumerus downward through lack of the support normally given by\\nthe deltoid, and by consequent loss of security in the joint. Usually\\nthese paralyses get well spontaneously or under treatment by blisters\\nor electricity, but sometimes they are permanent.\\nIf the dislocation remains permanently unreduced the peri-articular\\nmuscles become wasted and the deformity of the region is thereby\\nincreased. The head forms a new socket for itself, but its availability\\nfor motion is slight, and the use of the limb is confined, as a rule, to\\nthe underhand movements. In some cases the compensatory mo-\\nbility of the scapula is such that the hand can be raised to the head,\\nand in some a degree of usefulness has been exceptionally obtained\\n1 Bardenheuer Loc. cit., p. 412.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0673.jp2"}, "666": {"fulltext": "598 DISLOCATIONS.\\nthat is far in excess of what is usual. Thus, Prochaska s patient, the\\nhead of whose humerus was lodged in the chest after having passed\\nbetween the second and third ribs, earned his living for many years\\nas a woodchopper.\\nHABITUAL DISLOCATION.\\nHabitual dislocation, by which is meant a marked tendency to the\\nreproduction of the dislocation by slight causes, such as the abduction\\nof the arm, is not infrequent and may constitute a serious disability\\nit is most frequently observed after anterior dislocations, but appears\\nto be relatively more common after the posterior ones.\\nThis tendency has generally been attributed, though without anatom-\\nical proof, to laxity of the capsule, itself the consequence of imper-\\nfect repair of the rent made in it at the time of the dislocation, but\\nthe recent researches of Jossel l show, for the forward dislocation, that\\nthe enlargement of the capsule observed in such cases sometimes takes\\nplace at its upper portion in consequence of the rupture or avulsion of\\nthe tendons of the supraspinatus and infraspinatus muscles, which\\ninvolves the rupture of the capsule at the same level and the creation\\nof a free communication between its cavity and that of the subcoracoid\\nbursa (see Chapter XXIX., p. 423). He found this condition at the\\nautopsies of five joints which had been subject to habitual dislocation\\nduring life and in four other specimens found in the course of an\\nexamination made with this object of all bodies received in the dis-\\nsecting-room during two successive winters.\\nOther specimens have shown important changes in the head of the\\nhumerus and the glenoid fossa. Lobker 2 presented at the Fifteenth\\nCongress of German Surgeons a specimen obtained, post mortem, from\\na case of habitual dislocation, which showed changes in the head and\\nglenoid fossa which were thought to be the effect of the frequent recur-\\nrence, and another specimen obtained by Vogt by excision in a similar\\ncase and showing the same changes in the head of the humerus. The\\nhead in each case was normal only on its inner anterior half the other\\nhalf had lost its roundness, and showed a depression one centimetre\\ndeep and two centimetres wide, extending from top to bottom, and\\nseparated from the normal inner half by a sharp prominent border.\\nThe surface was covered throughout by cartilage, and the depression\\nwas evidently not the result of a fracture with loss of substance. The\\ntuberosities and bicipital groove were intact the long tendon of the\\nbiceps was torn from its insertion, and had become adherent in its\\ngroove. There were evidences of the avulsion of the muscles from\\nthe greater tuberosity. The outer portion of the glenoid fossa was\\nnormal, and separated by a sharp vertical border from the large inner\\nportion which was angularly deflected backward. Both portions were\\ncovered with cartilage, and showed no sign of fracture. The head\\nand fossa fitted together in such a way that the inner half of the head\\narticulated with the inner half of the fossa, and the sharp edge of the\\nlatter occupied the depression in the former.\\n1 Jossel Deutsche Zeitschrift fur Chir., 1880, vol. xiii. p. 167.\\n2 Lobker Beilage zum Centralblatt fur Chir., 1886, p. 90.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0674.jp2"}, "667": {"fulltext": "HABITUAL DISLOCATIONS OF THE SHOULDER. 599\\nHe refers to the fact that specimens obtained by excision by Cramer,\\nIviister, and von Volkmann showed similar losses of substance in the\\nhead of the humerus, and attributes them to the frequent recurrence\\nor to a persistent subluxation by which the head is made to rest against\\nthe inner border of the fossa, instead of squarely against its face.\\nThe symptoms presented by Lobker s case during life are not given,\\nbut it does not seem possible that they could have been, at least at the\\nlast, such as are found in habitual dislocation, for that is characterized\\nby complete restoration of form in the intervals between the recur-\\nrences, while in this case the subluxation must have been persistent.\\nThree cases of habitual dislocation in which the head of the humerus\\nwas excised are referred to by Lobker as showing similar losses of sub-\\nstance in the humerus, but a reference to the original reports l shows\\nthat in all three the loss was thought to be the result of a fracture,\\nalthough in the discussion on one of them (Krister s), Riedinger\\nexpressed the opinion that it was due to absorption. As the cases\\nillustrate also the method of treatment by excision, I quote two of\\nthem briefly.\\nCramer s patient was a woman thirty years old, who dislocated her\\nshoulder forward and inward during an epi-\\nleptic fit, and again in another two months Fig. 282.\\nlater; the arm was then immobilized for\\nseveral months, and a special dressing was\\nworn most of the time afterward, especially\\nat the menstrual periods, when the attacks\\nof epilepsy were most likely to occur, but\\nnevertheless the dislocation recurred nineteen\\ntimes within five years, each time during a\\nfit reduction was sometimes easy, sometimes\\nquite difficult, and the patient was eager to\\nbe relieved of the annoyance and the dread.\\nThe head was excised through an anterior Horizontal section of the head\\nincision, and the patient made a good reCOV- ofthe humerus in Cramer s case\\nery. The functional result was fairly satis- of habitual dislocation a loss\\nfactory and was still improving two years osity; c lesser tuberosity.\\nafter the operation.\\nThe articular surface ofthe head ofthe humerus showed a shallow loss\\nof substance on its outer side four centimetres long, two broad, and about\\nthree-fourths of a centimetre in depth at the centre (Fig. 282), and there\\nwas found a small body of irregular shape, one centimetre in its greatest\\ndiameter, with a smooth surface, and attached by a long, thin pedicle to\\nthe posterior margin ofthe glenoid fossa. It was composed of bone cov-\\nered by fibrous tissue with bits of cartilage between them in places, and\\nwas thought to be a fragment broken from the head.\\nIn Volkmann s the posterior third of the head showed a smooth\\nsurface not covered by cartilage, which had been undoubtedly pro-\\n1 Cramer Berlin, klin. Wochenschrift, 1882, p. 21. Volkmann, reported by Popke\\nZur Kasuistik und Therapie der inveterirten und habituellen Schulterluxationen, Halle,\\n1882. Abstract in Centralblatt fur Chir., 1883, p. 28. Kiister Beilage zuni Centralblatt\\nfur Chir., 1882, p. 73.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0675.jp2"}, "668": {"fulltext": "600 DISLOCATIONS.\\nduced by the breaking off of a wedge-shaped piece. No such fragment\\ncould be found in the cavity, and it was thought to have been absorbed.\\nThe glenoid articular fossa was altered in shape, having become nar-\\nrower below than above. The capsule was torn away from the inner\\nand lower margin of the glenoid fossa, thus creating an opening which\\ncommunicated with the subscapular bursa. On the thickened edge of\\nthis opening was attached, by a sort of pedicle, a piece of cartilage-\\ncovered bone which was evidently the remains of a fragment broken\\nfrom the edge of the glenoid fossa. (This, if so, would be a suffi-\\ncient explanation of the recurrence.) The patient recovered from the\\noperation, and subsequently reported by letter that the condition of his\\narm was much more satisfactory than before the operation.\\nThese changes in the bones are essentially the same as those described\\nin cases of chronic, non-suppurative inflammation, in some of which it\\nis evident that the process originated in a dislocation. (See Gurlt,\\nPath. Anat. der Gelenkkrankheiten, pp. 250-267, and especially Curl-\\ning s case, p. 280, also described in the Medico- Chirurgical Transactions,\\n1837, vol. xx. p. 336, as a partial dislocation forward.) It seems not\\nimprobable that the series of observed changes may be started by an\\nordinary dislocation, that is, by one that is not distinguished by any\\nexceptional lesion such as partial fracture of the head or of the edge\\nof the glenoid cavity this is followed by a non-suppurative arthritis\\nwhich so modifies the capsule and the shape of the surfaces that a\\nrecurrence of the dislocation is made easy. The pedunculated bodies\\ncomposed of bone and cartilage, sometimes found in the joint and\\nthought to have been broken from the head of the humerus or the\\nedge of the glenoid fossa, may be of new formation. In three of four\\ncases reported by Burrell and Lovett, 1 some of the muscles of the\\nshoulder were notably atrophied.\\nThe frequency of recurrence varies greatly in the different cases in\\nsome the intervals are long, in others the dislocation is produced every\\ntime the elbow is raised, and in some the bone can be voluntarily thrown\\nout of place by the contraction of the muscles.\\nOrdinarily reduction is very easy, and the patient learns to effect it\\nhimself; in others it is at times difficult.\\nThe treatment by injections of iodine and by narrowing the capsule\\non the inner side has been mentioned in Chapter XXX III., p. 448.\\nThe latter has been employed successfully by its introducer, Ricard,\\nin two cases and by myself 2 in one. The incision occupies the interval\\nbetween the deltoid and pectoralis with an extension from its upper\\nend outward close to the acromion the corresponding portion of the\\ndeltoid is detached and turned outward. In the anterior portion of\\nthe capsule thus exposed two or three sutures of stout silk are passed\\nso as to take up a fold about three-quarters of an inch wide and run-\\nning downward and outward.\\nBurrell 3 obtained an excellent result in two cases by excising from\\nthe anterior inner portion of the capsule a piece four centimetres long\\nand one wide, and closing the gap with catgut sutures. For better\\n1 Burrell and Lovett Transactions of the American Surgical Association, 1897, p. 296.\\n2 Stimson Annals of Surgery, March, 1898, p. 364. 3 Burrell Loc. cit.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0676.jp2"}, "669": {"fulltext": "OLD DISLOCATIONS OF THE SHOULDER. 601\\nexposure of the field of operation he divided the upper three-quarters\\nof the tendon of the pectoralis major close to its insertion, and part of\\nthe tendon of the subscapularis.\\nExcision of the head of the humerus has been resorted to in at least\\nsix cases, and the reported results in some of them were good. I\\nshould think the disability would have to be great to justify so radical\\na measure, one which may in itself be so disabling.\\nYeates l describes an apparatus which he had worn with comfort and\\nadvantage to limit the range of motion and thus prevent recurrence.\\nAnother class of cases in which the tendency to recurrence is the\\nresult not of a primary traumatic dislocation but of pathological\\nchanges in the joint or of paralysis of the muscles will be considered\\nin a subsequent section.\\nTREATMENT OF OLD DISLOCATIONS THAT CANNOT BE RE-\\nDUCED BY MANIPULATION AND FORCIBLE TRACTION. 2\\nThe urgent desire of patients to be relieved of their disability or of\\nthe pain caused by the persistence of the displacement has led surgeons\\nto resort with increasing frequency to cutting operations in the hope of\\nrestoring the bone to its place or improving its position, or to excise\\nthe head. Others sought to improve the position of the limb or to\\ncreate a false joint by subcutaneous fracture or division with the saw.\\nIt is not always easy to determine from the histories of the cases the\\nmeasure of success or improvement, for in some the report ends with\\nthe operation, and in others although the result is called a success the\\ndescription leaves the reader in doubt as to the completeness of the\\nreduction or as to the improvement in function. With our more accu-\\nrate knowledge of the changes in the condition of the glenoid fossa\\nand in its relations with the capsule that follow the prolonged absence\\nof the head of the humerus from it, we may well doubt the complete-\\nness of any reputed reduction in old cases obtained by subcutaneous\\nmeasures or feel justified in believing that the benefit attributed to the\\nuse of the tenotome was a delusion, and that the really efficient agents\\nwere the manipulation and the traction. In this criticism I do not\\ninclude those tenotomies or divisions of muscles which in the earlier\\ndays took the place now filled so much more easily and safely by anaes-\\nthetics. It is addressed mainly to a method employed by Polaillon 3\\nin 1882, and subsequently used by some and highly recommended by\\nothers on his authority.\\nSubcutaneous Section. Polaillon s patient had an intracoracoid dis-\\nlocation, produced during an epileptic fit, that had existed for four\\nmonths. An attempt to reduce with the pulleys, aided by chloroform,\\nfailed, but brought the head of the humerus near its socket and directly\\n1 Yeates Lancet, June 30, 1888.\\n2 For bibliography see: Knapp, Beitarge zur klin. Chir., 1888, vol. iv. Smital, Wiener\\nmed. Wochen., 1890, No. 52; Gwyer, New York Medical Journal, March 28, 1891 Delbet,\\nArch. gen. de Med., 1893 Souchon, Transactions of the American Surgical Association,\\n1897.\\n3 Polaillon Bull, dela Soc. de Chir., 1882, p. 129.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0677.jp2"}, "670": {"fulltext": "602 DISLOCATIONS.\\nunder the coracoid process. Eleven days later the patient was again\\nchloroformed, a blunt-pointed tenotome introduced through a small cut\\nmade through the skin and muscle a finger-breadth below the tip of\\nthe acromion, and carried horizontally inward between the deltoid and\\nthe point of the humerus, its edge turned backward, and then with-\\ndrawn so as to divide the tissues lying upon the bone the point of the\\nknife was then carried through the same incision to the back of the\\nhumerus, and a similar cut made along the outer aspect of the head.\\nTwo days later the traction was renewed under chloroform, and the\\ndislocation reduced. A week later, the bone having meanwhile shown\\na constant tendency to become displaced forward and inward, a tourni-\\nquet was applied about the shoulder to keep it in place. A month\\nlater the patient was able to raise his hand to his mouth and to put it\\nbehind his head, and the movements were daily gaining in extent.\\nIt is not so uncommon for a second or third attempt to reduce by\\ntraction to succeed after the first has failed that the success in this\\ncase can be unhesitatingly attributed to the subcutaneous division, and,\\nfurthermore, it seems doubtful whether an incision made from the\\nouter side in this manner could divide anything that offered any seri-\\nous obstacle to the return of the bone. The additional cases, in which\\nthis method was successfully employed by Polaillon, are briefly men-\\ntioned in a thesis by Bardon-Lacroze. 1\\nAn open arthrotomy, by which the surgeon is enabled to see and\\nremove the obstacles to reduction, is not only more likely to be suc-\\ncessful than subcutaneous division, but, if carefully done when the\\ntissues have not been lacerated and inflamed by recent forcible attempts\\nto reduce by traction and manipulation, is also, in my opinion, not more\\ndangerous. If the conditions prove during the operation to be unfa-\\nvorable, excision of the head can be easily substituted. Souchon s\\nstatistics show 69 per cent, of the results classed as fair, good,\\nand very good after reduction by arthrotomy. Among unfavorable\\nconditions are to be counted fracture of the glenoid cavity or its occu-\\npation by a mass of fibrous tissue, fracture and marked displacement\\nof the greater tuberosity, and the need of extensive dissection to return\\nthe head to its place. The effect of the latter is shown in the com-\\nparatively frequent (16 per cent., Souchon) necrosis of the head after\\nreduction. Possibly this could be avoided by keeping the liberating\\nincisions well away from the bone. Knapp, reviewing twelve cases of\\nreduction by arthrotomy and twenty of excision of the head, advises\\nreduction only in comparatively recent cases, excision in the old ones.\\nIn a number of cases the surgeon has resorted to excision after having\\nfailed to reduce by arthrotomy.\\nIn anterior dislocations reduction by arthrotomy is best done by an\\nanterior incision along the border of the deltoid, aided if necessary by\\na horizontal extension outward and detachment of the corresponding\\npart of the deltoid from the acromion. This gives free access to the\\nouter part of the head and capsule and permits the removal of the\\nlatter from the glenoid fossa if it has become adherent to it, an abso-\\n1 Bardon-Lacroze Des sections sous-cutanees corome moyen de reduction des luxations\\nanciennes du coude et de l epaule. These de Paris, 1882, No. 209.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0678.jp2"}, "671": {"fulltext": "CONGENITAL DISLOCATIONS OF THE SHOULDER. 603\\nlutely necessary step in many cases. The liberation of the head on the\\ninner side and behind is much more difficult, and the inability prop-\\nerly to accomplish it appears to have been the cause of the rather fre-\\nquent abandonment of the attempt and the substitution of excision.\\nThe after-treatment requires maintenance of a position that effectu-\\nally opposes recurrence and a rather early resort to very limited passive\\nmotion.\\nExcision of the head is almost always to be preferred when the dislo-\\ncation has been complicated by fracture of either the anatomical or the\\nsurgical neck, because the resultant conditions faulty position, increase\\nof adhesions greatly increase the difficulty of reduction and render\\nthe functional result poor if reduction is effected. It has been done\\nby an axillary incision, especially in cases complicated by fracture of\\nthe anatomical neck. This method is of comparatively easy execution\\nand may properly be used when there is no thought of attempting\\nreduction otherwise the anterior incision should be used.\\nFractures of the surgical neck of the humerus, which has not infre-\\nquently been caused by the attempts made to reduce, has sometimes\\nbeen taken advantage of to place the limb in a better position, and\\nDespres 1 recommends that it should be intentionally produced. Others\\nhave done it with the object of subsequently preventing its reunion and\\nestablishing a false joint between the upper end of the shaft and the\\nglenoid fossa. Despres s first operation 2 was done with the object of\\nobtaining a pseudarthrosis at the seat of fracture, but bony union took\\nplace. The usefulness of the limb was, however, so much increased\\nby the change in its position that he repeated the operation upon\\nanother patient merely to effect this change, and was in this case also\\nwell satisfied w T ith the result. The proposal to generalize the practice\\ndoes not appear to have been received with much favor by his col-\\nleagues in the Surgical Society.\\nOther features of this subject have been considered in the first part\\nof this chapter.\\nDr. J. Ewing Mears 3 divided the surgical neck subcutaneously with\\nan Adams s saw and obtained an excellent result by pseudarthrosis.\\nHis patient was a man, thirty-nine years of age, and the dislocation\\nwas of two years standing. The saw w T as entered on the outer side,\\nand the division was easily effected in about five minutes. The case\\ndeserves to be remembered, and the method is to be preferred to frac-\\nturing as less dangerous and more precise. The establishment of a\\nfalse joint would be more certainly effected by the removal of a piece\\nof the shaft.\\nCONGENITAL DISLOCATIONS.\\nThis term as commonly employed embraces all dislocations which\\nare recognized at birth or which probably existed then, and which\\nhave no recognizable traumatic cause. They present three distinct\\nforms 1, one due apparently to irregular development of the joint 2,\\n1 Despres Bull, de la Soc. de Chir., 1879, p. 742.\\n2 Despres Loc. cit., p. 22.\\n3 Mears Philadelphia Medical and Surgical Reporter, 1877, vol. xxxvii. p. 287.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0679.jp2"}, "672": {"fulltext": "604 DISLOCATIONS.\\none in which the bones are normally formed and in which the displace-\\nment may have occurred during delivery 3, a third, also with normal\\nbones, in which the displacement is the late result of a paralysis\\nantedating birth or caused during delivery. While this supposed\\netiology is not completely established, yet the condition of the parts,\\nthe displacements, and the symptoms of each group are so distinct that\\nthe grouping is justified even if the etiology should prove to be differ-\\nent. There are, in addition, cases of traumatic dislocation during\\ndelivery in which the nature of the traumatism is evident and the con-\\ndition is immediately recognized and corrected. Some of the paralytic\\nforms have been described as obstetrical paralyses (vide infra).\\nThe forms that have been observed are the subcoracoid and, much\\nmore frequently, the subacromial or subspinous.\\nThe condition is a rare one its relative frequency is shown by Kron-\\nlein s collection of 98 congenital dislocations treated in Yon Langen-\\nbeck s clinic, of which 90 were of the hip, 5 of the shoulder, 2 of the\\nhead of the radius, and 1 of the knee. I have seen five cases, all\\nbackward dislocations four of them, possibly all, belonged in the\\nsecond group above named.\\nIn support of the theory of a pre-natal origin are the facts that the\\nlesion is sometimes double or associated with other congenital defects,\\nand that in one case l two children of the same family were similarly\\naffected and yet it is not impossible that both shoulders or two suc-\\ncessive children could receive the same traumatism.\\n1st Group. Irregular development. For our knowledge of the\\npathological changes we are indebted to R. W. Smith. 2 In his case of\\ndouble subcoracoid dislocation, a lunatic woman twenty-nine years old,\\nthere existed on the left side scarcely any trace of an articulating\\nsurface in the situation which the glenoid cavity occupies in the normal\\nstate but there had been formed upon the costal surface of the scapula\\na socket of a glenoid shape, measuring about an inch and a half in its\\nvertical direction and an inch and a quarter transversely (Fig. 283).\\nIt reached upward to the under surface of the coracoid process, from\\nwhich the head of the humerus was merely separated by the capsular\\nligament. The glenoid ligament, perfect in every respect, extended\\nall around it. The capsule was perfect.\\nThe head of the humerus (Fig. 284) was of an oval shape, its long\\naxis corresponding with the shaft of the bone. The oval shape Avas\\nprincipally due to the deficiency of its posterior part, and there existed\\nbetween the greater tubercle and the margin of the head of the bone,\\nwhere the investing cartilage terminated, a broad, shallow depression\\ncorresponding to the edge which separated the normal from the abnor-\\nmal portion of the glenoid cavity. The shaft of the humerus was\\nsmall and seemingly atrophied.\\nUpon the right side, although the condition of the bone was some-\\nwhat different, the characteristic features of the deformity were\\nsimilar.\\nIn his double subacromial case, a lunatic woman forty-two years\\n1 Scudder Archives of Pediatrics, April, 1890.\\n2 E. W. Smith Fractures and Dislocations, 1847.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0680.jp2"}, "673": {"fulltext": "COXGEXITAL DISLOCATIONS OF THE SHOULDER.\\n605\\nold, there was no trace of a glenoid cavity in the natural situation\\nbut upon the external surface of the neck of the scapula there was a\\nFig. 283.\\nFig. 284.\\nR. W. Smith s case of double congenital subcor-\\nacoid dislocation of the shoulder. Scapula of left\\nside.\\nThe same left humerus.\\nwell-formed socket which re-\\nceived the head of the humerus.\\nIt was an inch and three-quar-\\nters in length, and an inch in\\nbreadth it was a little broader\\nabove than below, and its sum-\\nmit was less than a quarter of\\nan inch from the under surface\\nof the acromion process. It\\nwas directed outward and for-\\nward, was covered with cartilage, and surrounded by a perfect glenoid\\nligament. The tendon of the biceps muscle arose from the most\\ninternal part of its superior extremity, whence it passed downward and\\noutward very obliquely, in order to reach the bicipital groove of the\\nhumerus. The axillary margin of the scapula, if prolonged upward,\\nwould have passed nearly altogether internal to the abnormal socket.\\nThe capsular ligament was perfect. The scapula was smaller\\nthan natural, and its muscles badly developed.\\nThe head of the humerus, upon the right side, was of an oval or\\noblong form, somewhat broader above than below its anterior half\\nalone was in contact with the glenoid cavity. This portion was cov-\\nered with cartilage, the remaining half being rough and scabrous, and\\ntotally destitute of articular cartilage. The inner edge of the humerus,\\nif prolonged upward, would have passed between these two portions of\\nthe head of the bone.\\nThe greater tubercle was natural, but the lesser was elongated and\\ncurved, forming a most remarkable process it was an inch in length,\\nand bore some resemblance to the coracoid process of the scapula. At\\nits root it presented a smooth, convex, pulley-shaped surface, round\\nwhich passed the tendon of the biceps muscle. The left humerus\\ndiffered from the right only in the smaller size of the lesser tuberosity.\\nBoth these cases were first seen by Smith upon the autopsy-table, and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0681.jp2"}, "674": {"fulltext": "606 DISLOCATIONS.\\nhe gives no history as to the length of time the deformity had lasted.\\nBoth individuals had been for many years inmates of the lunatic asy-\\nlum, and the second one was subject to epileptic convulsions, in one of\\nwhich she died. It must be admitted that the appearances are not\\nincompatible with the theory of a post-natal origin, perhaps by mus-\\ncular action in an epileptic convulsion, as in Frankel s case of double\\nsimultaneous dislocation quoted above, p. 596.\\nThe three cases of single subcoracoid dislocation observed during\\nlife by Smith seem to have been paralytic dislocations.\\n2d Group. Subacromial or subspinous, probably caused during\\ndelivery. These appear to be much the most frequent; Gaillard,\\nquoted by Malgaigne, 1 reported one, Kiister 2 one of both shoulders,\\nScudder 3 two, I have seen four, possibly five, and A. M. Phelps 4\\nreported one case, and tells me he has seen six others. My reasons\\nfor thinking this group probably traumatic are that the limitations of\\nmotion closely resemble those of the similar traumatic dislocation in\\nadults, and that the bones as shown in a few operations and in the\\nradiographs of three of my cases (Plate XXVIII.) differ from the\\nnormal only in being smaller. In my four cases and Scudder s two\\nthe right arm was affected, in Gaillard s the left and it seemed pos-\\nsible that as the right shoulder is in front in the great majority of\\nbirths, the cause might be its pressure against the arch of the pubis.\\nAgainst this, or at least limiting it, is the double dislocation in Krister s\\nand the breech presentation in one of mine. Of four cases of head pres-\\nentation delivery. was instrumental in one, easy in one, difficult in two.\\nKiister, operating upon one, found the glenoid fossa normally placed\\nbut small, and the humerus rested on its posterior border. In a case\\nI operated upon the conditions were the same. Dr. Phelps tells me\\nhe has found the fossa defective at its posterior margin, as if a piece\\nhad been broken off. Radiographs of three of my cases show an\\napparently normal glenoid fossa and humerus, but all the bones of the\\nlimb, in all four cases, were smaller than those of the other. My\\npatients when examined were six, nine, nine, and eleven years old\\nScudder s were seven and nine, Gaillard s sixteen five of the seven\\nwere girls.\\nThe head of the humerus can be seen and felt beneath and behind\\nthe acromion (Fig. 285), sometimes quite close to its normal position,\\nsometimes much further back in Gaillard s at about an equal dis-\\ntance from the two ends of the spine of the scapula. The elbow is\\ndirected forward and a little outward and is markedly rotated inward.\\nThis position is noted in all and is evidently characteristic. Motion,\\nactive and passive, is limited in all directions, especially outward rota-\\ntion and adduction. Scudder s electrical examination of the muscles\\nshowed little difference between the two sides; in one of mine the\\nmuscles supplied by the musculo-spiral and musculo-cutaneous nerves\\nwere markedly paretic, in two all were normal, and in one rotation\\nof the forearm was weak, but its range was complete. In all my\\n1 Malgaigne Loc. cit., p. 569.\\n2 Kiister Ein Chirurg. Triennium, 1882, p. 256.\\n3 Scudder Archives of Pediatrics, April, 1890.\\n4 Phelps Transactions American Pediatric Association, 1895.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0682.jp2"}, "675": {"fulltext": "X\\nX\\nw\\ni\\n2\\nCD\\nu", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0683.jp2"}, "676": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0684.jp2"}, "677": {"fulltext": "CONGENITAL DISLOCATIONS OF THE SHOULDER.\\n607\\ncases the condition was noticed at birth in one the child cried when-\\never the limb was handled, but after two months moved it voluntarily.\\nIn my fifth (doubtful) case, seen in 1886, the delivery was instru-\\nmental and very difficult the child, now dead, was four years old\\nwhen I saw him the attitude of the limb was similar to that above\\ndescribed, and all voluntary motion at the shoulder was lost I classed\\nit at the time as an obstetrical paralysis.\\nFig. 285.\\nCongenital subspinous dislocation of the shoulder.\\nThe treatment in Gaillard s case is interesting Four times in the\\ncourse of a week he made horizontal traction on the arm by means of\\na weight of sixteen pounds, continued for fifteen or twenty minutes,\\nand reinforced occasionally by traction with his hands. On the last\\noccasion the head moved an inch and a half along the scapula to the\\nedge of the glenoid fossa and was then thrown into it by a movement\\nof leverage. It almost immediately came out again. The next day\\nit was again reduced and kept in place for an hour. Ten days later\\nit was again reduced, and the arm fixed by a bandage this time the\\nreduction persisted. Two years later the limb was found to have\\ngained half an inch in length the patient could move it inward, out-\\nward, forward, and backward, could lace her clothes behind her back,\\ncarry a chair, feed herself, and play on a guitar.\\nKrister operated (excision) upon one shoulder in his double case,\\nbut the patient, who was fourteen months old, died. I operated upon", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0685.jp2"}, "678": {"fulltext": "608 DISLOCATIONS.\\none by an incision along the anterior border of the deltoid with a hori-\\nzontal outward extension from its upper end and detachment of the\\nanterior half of the deltoid from the acromion. The tendon of the\\nsubscapulars, which was tightly stretched across the glenoid fossa,\\nwas divided, and the head brought into place. The change in posi-\\ntion made the divided deltoid too short, and it was left un sutured.\\nThe wound healed primarily, and reduction was maintained. The\\npatient, who had been brought from a distance, passed from observa-\\ntion at the end of a month. In the other three cases the usefulness of\\nthe limb was such, although the attitude was awkward, that I advised\\nagainst operation. ^Nothing was done in Scudder s cases.\\nFor 3d Group, see next page.\\nPATHOLOGICAL DISLOCATIONS AND SUBLUXATIONS.\\nSubluxation or complete dislocation may be made easy by changes\\neffected in the articular surfaces or the capsule by disease, or by paral-\\nysis of the deltoid or rotator muscles which normally aid in maintain-\\ning the close contact between the bones. The reported instances are not\\nvery numerous, and even in some of these the evidence, clinical or post\\nmortem, has left not only the character and extent of the displacement\\nin doubt, but also its essential cause. Such cases do duty with the\\ndifferent writers as supposed examples of widely different lesions, such\\nas partial traumatic dislocations, new forms of dislocations, and chronic\\narthritis. Gurlt l gives to Adams (Todd s Clyclopoedia, article Shoulder-\\njoint) and Canton (London Medical Gazette, 1848, vol. vi. p. 410, and\\nvol. viii. p. Ill) the credit of having first shown that cases described\\nas partial dislocation by Sir Astley Cooper, Hargrave, and others were\\nactually examples of chronic non-suppurative arthritis. In his own\\ndescription of the changes effected by this disease in the quoted cases\\nhe does not always discriminate between those which were the effect of\\nthe prolonged inflammation and those which should probably be attrib-\\nuted to an antecedent traumatic dislocation which originated the pro-\\ncess such as rupture of the tendons of the supraspinatus and infra-\\nspinatus and subscapulars muscles, and the establishment of a large\\nopening between the cavity of the joint and the subacromial bursa. A\\ndislocation recurring after such injuries should be classed with the\\nhabitual dislocations.\\nOf the three classes made by Volkmann dislocations by distention,\\nby destruction, and by deformity (see Chapter XXXVI.) the sec-\\nond is by far the most rare, and the third apparently the most common,\\nalthough the distinction between the latter and the first cannot always\\nbe determined clinically. Indeed, I know of only one recorded case\\nin which the history clearly shows an acute non-traumatic effusion in\\nthe joint promptly followed by an abrupt appearance of the deformity\\nwith instant relief of the pain, such as has been observed at the hip\\nand knee in the course of acute rheumatism or the eruptive fevers.\\nThe case was reported by Hannon and is quoted by Malgaigne. 2 A\\n1 Gurlt Patholog. Anat. der Gelenkkrankheiten, 1853, p. 250.\\n2 Malgaigne Loc. cit., p. 562.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0686.jp2"}, "679": {"fulltext": "DISLOCATIONS OF THE SHOULDER. 609\\nman forty-five years old who had previously suffered with acute rheu-\\nmatism in the knee and hip, became feverish, and on the following day\\nhad an acute inflammation of the shoulder-joint. The pain increased,\\nand on the night between the fifth and sixth days became suddenly\\nvery severe the next morning a subcoracoid dislocation was found,\\nand was reduced with some relief of the pain. The next day the dis-\\nlocation was found to have partially recurred it was again reduced,\\nand the limb fixed with a bandage. Recovery followed.\\nMalgaigne thinks the over-distended capsule is ruptured on the inner\\nside, and thus the dislocation made possible the view seems insuffi-\\ncient to explain the easy partial recurrence. When the effusion is\\nmore slowly produced and is large the head of the humerus is sepa-\\nrated from direct contact with the glenoid cavity by a layer of liquid,\\nthe depth of which may amount to one centimetre, 1 under which cir-\\ncumstances it is evident that a slight force would be sufficient to dis-\\nplace the humerus to either side and without rupture of the capsule,\\njust as one easily produces a dislocation in a freshly dissected shoulder\\nafter making a small opening in the capsule to admit the air. This\\nrequires relaxation of the scapular muscles which normally hold the\\nbones close together, and such relaxation would not be found when the\\narthritis is acute and painful.\\nA class of cases, of which quite a number have been reported, are\\nsometimes described as traumatic dislocations upward, but Malgaigne s\\nopinion that they are the result of arthritis is noAV generally accepted\\nfor most of them. They are characterized by the projection of the\\nhead upward and forward and rigidity of the limb. Malgaigne quotes\\na case to show that the displacement may be caused by carrying the\\narm in a sling that is too short and tight.\\nMost of the specimens of dislocation by deformity are open to the\\ndoubt whether they may not actually be nearthroses following trau-\\nmatic dislocations, and this is especially true of those in which the dis-\\nlocation is forward. Gurlt 2 describes seventeen specimens concerning\\nwhich this doubt exists, and I think he might well have added to them\\nseveral of those which he describes as examples of chronic inflammation.\\nDISLOCATIONS DUE TO PARALYSIS.\\nThis variety, rare in the adult, has been shown by the investigations\\nof Duchenne de Boulogne 3 to be much more common in new-born chil-\\ndren, the paralysis being due to the pressure of the forceps or to trac-\\ntion in delivery. In consequence of the lack of support which ensues\\nupon the paralysis of the muscles of the shoulder, the weight of the\\nlimb causes it to sink downward, the only remaining support, that of\\natmospheric pressure, being presumably overcome gradually by the\\naccumulation of liquid within the capsule. The condition of the joint\\nthen resembles that of hydrarthrosis, plus the relaxation of the mus-\\ncles, and, as has been above described, any slight force is then sufficient\\n1 Albert Chirurg. und Operat., vol. ii. p. 320.\\n2 Gurlt: Loc. cit., p. 274.\\n3 Duchenne de Boulogne De l Electrisation localisee, 1871, 2d ed. and Panas Diet,\\nde Med. et Chir. pratiques, art. Epaule, p. 514.\\n39", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0687.jp2"}, "680": {"fulltext": "610 DISLOCATIONS.\\nto displace the head of the humerus to one side. Malgaigne says that\\nwhen all the muscles of the shoulder are paralyzed the displacement is\\nalways downward and forward, and usually incomplete and that when\\nthe paralysis is partial the displacement is always effected by the action\\nof the unparalyzed muscles and is reduced by the weight of the limb in\\nthe only cases of the latter kind of which he had knowledge, two in\\nnumber, the displacement was backward. He saw in a man, thirty-\\nfour years old, a double paralytic dislocation.\\nIn new-born children the dislocation is said to be always backward,\\nsubacromial. Duchenne saw in ten years eight cases of this kind.\\nIn all the cases of obstetrical paralysis which he had seen the same\\ngroup of muscles was affected, namely, the deltoid, infraspinatus,\\nbiceps, and brachialis anticus in some there was also paralysis of the\\nmuscles in the forearm and hand supplied by the musculo-spiral or\\nulnar nerve. I have seen paralysis of the same muscles (the deltoid,\\nbiceps, and brachialis anticus) appear spontaneously at the age of one\\nyear, with consequent laxity of the joint that permitted dislocation\\nforward and backward. When the paralysis is caused by the applica-\\ntion of the forceps the mechanism appears to be the pressure of the\\nedge of the instrument upon the brachial plexus on the side of the\\nneck in other cases it is the pressure of the finger used as a hook in\\nthe axilla or to bring down the arm when raised beside the head.\\nIn one of Duchenne s cases, treated by Chassaignac, a permanent\\ncure was obtained by a fixation dressing, worn for five or six weeks.\\nOccasionally the disability of the muscles is due to a traumatism\\n(myopathic dislocation). In a case reported by Wolff, 1 in which the\\nhead of the humerus had sunk almost three centimetres below the acro-\\nmion, and the disability was very great, the functions of the limb were\\nmuch improved by an operation the joint was opened posteriorly along\\nthe margin of the glenoid fossa, the articular cartilage removed, and\\nthe bones fastened together with strong silver wire. The control over\\nthe limb thus obtained through the scapula was such that it could be\\nraised and lowered and even a little adducted and abducted.\\n1 Wolff: Berl. klin. Wochenschrift, 1886, No. 52. Abstract in Centralblatt fur Chir.,\\n1887, p. 637.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0688.jp2"}, "681": {"fulltext": "CHAPTEE XLV.\\nDISLOCATIONS OF THE ELBOW.\\nAnatomy Classification Dislocations of Both Bones Backward, lateral, for-\\nward, divergent.\\nAnatomy.\\nOx either side of the lower end of the humerus is a prominence,\\nthe epicondyle, which can be easily felt, and is of great importance\\nin the recognition of any change in the relations of the bones that\\nconstitute the elbow-joint. The inner one, commonly called the\\nepitrochlea, is more prominent and well-defined than the outer one,\\nand its upper margin joins the shaft of the humerus by a sharp curve,\\nwhile on the outer side of the shaft the supinator ridge connects the\\nside of the shaft with the epicondyle by a gradual slope. Below the\\nepitrochlea is the flattened circular side of the trochlea, projecting\\ndownward and forward about half an inch, with a sharp, well-defined\\nmargin, which is masked by the olecranon and ulna when the bones\\nare in place. From this edge the articular surface of the trochlea\\npasses outward like a cone, its diameter becoming rapidly smaller for\\nabout half an inch, and then enlarges again, but less abruptly, for\\nnearly an equal distance. Above it, posteriorly, is a deep depression,\\nthe olecranon fossa, into which the tip of the olecranon is received in\\nfull extension of the joint, and above it, anteriorly, is a corresponding,\\nsmaller one, to receive the tip of the coronoid process in full flexion.\\nOn the outer side of the anterior and lower part of the trochlea, and\\nseparated from it by a shallow vertical groove, is the capitellum, or\\nradial head, of the humerus with which the head of the radius articu-\\nlates, a rounded prominence looking directly forward.\\nThe ulna articulates with the trochlea by its greater sigmoid cavity,\\nwhich has a central longitudinal ridge fitting into the central depression\\nof the trochlea, and opposing displacement to either side.\\nThe radius articulates with the capitellum by the slightly concave,\\ncircular upper surface of its cylindrical head and with the lesser sig-\\nmoid cavity on the outer side of the ulna and coracoid process by the\\nside of its head. This articular surface on the side of the head is about\\nthree-eighths of an inch long (from above downward) on the inner and\\nposterior side of the bone, the part that is in contact with the ulna in\\nsupination, but is shorter on the outer side at the part which comes in\\ncontact with the ulna in pronation.\\nThe long axis of the trochlear cones and the ovoid capitellum coin-\\ncide with one another and represent the axis of the joint for flexion\\nand extension this line crosses the lower end of the humerus from a\\npoint just below and in front of the external epicondyle to one that is\\n611", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0689.jp2"}, "682": {"fulltext": "612 DISLOCATIONS.\\njust covered by the lower part of the epitrochlea, and is inclined down-\\nward and inward from the transverse axis of the lower end of the\\nhumerus, so that the long axis of the forearm does not coincide with\\nthat of the arm, but deviates to the outer side as it passes downward.\\nWhen the bones are in place and the forearm fully extended the\\nuppermost part of the olecranon, the point of the elbow, lies on\\nor close below a transverse line drawn behind the limb from the epi-\\ntrochlea to the epicondyle; and when the elbow is flexed at a right\\nangle the same point lies a little more than an inch directly below and\\nnearly midway between these two prominences in the prolongation of\\nthe long axis of the shaft of the humerus. Ordinarily the relations\\nof these three points to one another can be readily determined, even\\nwhen the region is swollen, and they are the most convenient and\\np 28fi trustworthy aid in the recognition\\nof the existence of a dislocation of\\nthe ulna.\\nJ| The outer border of the head of\\nthe radius can be felt about three-\\nquarters of an inch below the epi-\\ncondyle in a line drawn from the\\nlatter to the wrist, and it can be\\nfelt to move when the hand is\\ngently rotated. This is the only\\npoint where the interarticular line\\nis distinctly accessible to palpa-\\ntion at all other points it is too\\nthickly covered by soft parts or\\nmasked by the parallelism and\\nclose contact of adjoining surfaces.\\nThe internal lateral ligament\\narises above from the anterior,\\nlower, and posterior portion of the\\nepitrochlea and is broadly inserted\\nbelow along the inner margin of\\nthe greater sigmoid cavity.\\nThe external lateral ligament,\\nshorter and narrower than the in-\\nThe bones of the elbow: b, the axis of motion, ternal, arises above just below the\\nepicondyle and becomes blended\\nbelow with the orbicular ligament that surrounds the head of the\\nradius, some of its posterior fibres being continued to the ulna.\\nThe anterior and posterior ligaments are thin and loose, and close in\\nthe joint between the lateral ligaments in front and behind, respectively.\\nThe orbicular, or annular, ligament, placed like a ring about the\\nhead of the radius and the adjoining portion of its neck, occupies\\nthree-fourths of a circle of which the remaining fourth is formed by\\nthe lesser sigmoid cavity of the ulna it is thus attached by its two\\nends to the ulna and encircles the head of the radius. It is reinforced\\nexternally and posteriorly by the fibres of the external lateral ligament.\\nThe synovial sac extends beyond its lower border for a short distance", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0690.jp2"}, "683": {"fulltext": "DISLOCATIONS OF THE ELBOW.\\n613\\nalong the neck of the radius, and is then reflected upward and attached\\nto this bone.\\nThe ulnar nerve passes close behind the joint on the inner side\\nbetween the olecranon and epitrochlea in close relations with the cap-\\nsule and lateral ligament.\\nFrequency.\\nIn order of frequency the dislocations of the elbow come next after\\nthose of the shoulder and fingers (Chapter XXVII.).\\nKronlein s 109 cases arranged according to age, sex, and variety are\\nas follows\\nTable of 109 Dislocations of the Elbow (Kkonleix).\\nSex.\\nAge.\\nVariety.\\nM.\\nF.\\n1-10\\n11-20\\n21-30\\n31-40\\n41-50\\n51-60\\n61-70\\n71-80\\nForearm, backward\\nRadius, alone\\n77\\n9\\n17\\n6\\n22\\n9\\n41\\n5\\n14\\n1\\n5\\n4\\n3\\n1\\n1\\nThis shows the same preponderance in males over females, 4 to 1,\\nthat is shown by dislocations in general, and that the great majority,\\n80 out of 109, occur during the first twenty-four years of life. Atten-\\ntion was called in Chapter XLII. to the difference in respect of age\\nbetween dislocations of the elbow and those of the shoulder, the latter\\nbeing rare at the age when the former are common, and most frequent\\nin middle life and Kronlein s opinion was there quoted that fractures\\nof the clavicle are in childhood the equivalent injury that is, are pro-\\nduced by the same cause of dislocations of the shoulder by direct\\nviolence in middle life, and that dislocations of the elbow are the\\nequivalent injury of dislocations of the shoulder by indirect violence.\\nAnother possible explanation of the frequency in childhood is, I think,\\nthe hyperextension of the joint which is marked at that age and is\\nusually wholly lost in adult life, at least in males.\\nClassification.\\nThe different forms of dislocation of the elbow are numerous, for\\nthe two bones of the forearm may be displaced together in any one of\\nthe four principal directions, or each may take a different direction, or\\neither may be dislocated while the other remains in place. The num-\\nber of named forms has been still further increased by making in some\\na distinction between complete and incomplete which not only\\nis not justified by any corresponding important pathological or clinical\\ndifference, but which also does not even correspond with the definition\\nof incomplete given by those who make most use of the term.\\nMany of the varieties are closely allied to one another, and produced\\nby causes that differ very slightly. Thus, if the joint is hyperextended,\\nthe ligaments torn, and a backward dislocation of both bones begun,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0691.jp2"}, "684": {"fulltext": "Dislocations of the\\nforearm on the\\narm,\\n614 DISLOCATIONS.\\nthe final position taken will vary with the direction in which the force\\ncontinues to act, and with the addition to it of lateral flexion of the\\njoint or rotation of the forearm, so that forms as widely different in\\nappearance as direct backward dislocation, lateral dislocation, and diver-\\ngent dislocation may be produced. It will be proper, therefore, as\\nwell as convenient, to describe under the more common type, backward\\ndislocation of both bones, much that concerns many of the other forms,\\nand to limit the descriptions of the latter mainly to the points of differ-\\nence.\\nThe classification which will be here followed is the same in its prin-\\ncipal features as those adopted by most recent writers. The differences\\nare in the grouping and recognition of the varieties.\\n1. Dislocations backward,\\nbackward and outward.\\nbackward and inward.\\nLateral dislocations,\\ni f inward,\\nincomplete\\ncomplete outward.\\nForward dislocations,\\nincomplete, or 1st degree.\\ncomplete, or 2d degree.\\nwith fracture of the olecranon.\\nDivergent dislocations,\\nantero-posterior.\\ntransverse.\\nf 1, 2. Backward and J 1. Incomplete, or 1st degree.\\nDislocations of the J upward, 2. Complete, or 2d degree,\\nulna alone, 3. Backward and outward, behind radius.\\n4. Forward.\\nf 1. Backward.\\nDislocations of the Q j\\ni- 1 6. .Forward,\\nradius alone. j 4 \u00c2\u00a3y el(?ngation) or the subluxation of children.\\n5. Associated with fracture of the ulna.\\nCongenital and pathological dislocations.\\nDISLOCATION OF THE FOREARM BACKWARD.\\nThis is the most common of all dislocations of the elbow. It is\\nhabitually produced by a fall, but although the examples are so numer-\\nous the mechanism or mode of production has been the subject of much\\ncontroversy, largely due to the resort to hypotheses which was stimu-\\nlated by the lack of definite knowledge. Few who fall are able to\\ndescribe the circumstances of the fall, to say whether the arm was fully\\nextended or partly flexed, whether the violence was received upon the\\nhand or upon the elbow, and a preconceived theory in the mind of the\\nsurgeon is a great help to the discovery of facts that favor it.\\nThe theory of production by forced flexion is supported, so far as I\\nknow, by only one case, and that a case that has only recently been\\nreported. Stetter 1 had a patient who, while working in a mine, was\\ncaught under a falling stone in such a way that his left elbow was\\n1 Stetter Compendium der Lehre von den Luxationen, 1886, p. 43.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0692.jp2"}, "685": {"fulltext": "BACKWARD DISLOCATIONS OF THE ELBOW. 615\\nforcibly flexed between the stone and the wall and was dislocated back-\\nward. When seen, about an hour afterward, the joint was in the posi-\\ntion of extension. Reduction was easily effected by traction, and\\nrecovery took place without incident. Fracture of the coronoid process\\ncould not be recognized.\\nThe theory of direct displacement backward glissement formu-\\nlated by Boyer, and at one time widely held, has not withstood the\\ncriticism of later writers and is no longer accepted in explanation of\\ndislocations caused by falls. A case reported by Weber nearly fifty\\nyears ago, and much quoted since, is an example of production in this\\nmanner, but not in a fall a young man, wishing to show his strength,\\nheld his arm extended while another tried to bend it the latter not\\nsucceeding, struck the front of the upper part of the forearm violently\\nwith his fist, at the same time pressing the wrist forward, and caused a\\ndislocation which could not be reduced. In like manner, the disloca-\\ntion can be produced by a blow upon the back of the arm just above the\\nelbow, as in a case quoted by Malgaigne from Flaubert, in which the\\npatient s arm was caught under an overturned wagon, and in another\\nseen by Hamilton. A similar mechanism has also been observed in\\noutward dislocation.\\nThe theory of torsion presented by Malgaigne, according to which\\nthe patient in his fall strikes upon the inner side of the slightly flexed\\nforearm and the elbow, the limb being somewhat abducted, is perhaps\\ntrue of some cases. Malgaigne s explanation is very brief; he simply\\nsays the dislocation is effected by a movement of torsion which brings\\nthe coronoid process successively inward, downward, and backward.\\nHowever obscure the explanation may be, and it suggests an origin in\\nspeculation rather than in observation, the fact remains that in a few\\nw T ell-authenticated cases the violence has certainly been received upon\\nthe upper and inner part of the forearm and not upon the palm of the\\nhand. Pingaud l quotes three such a rider falling with his horse and\\ndislocating his elbow while the hand still held the bridle a man falling\\nin the gymnasium with his forearm bent behind his back another fall-\\ning backward and rolling upon his side while his hand held his cloak\\ntogether in front of his chest.\\nHyper extension and Abduction. It is now generally believed that the\\ninjury is habitually caused by a fall upon the palm of the outstretched\\nhand, the elbow being in complete extension, and that the primary\\nrupture of the ligaments which makes the dislocation possible is\\neffected by hyperextension of the joint. That this was a possible cause\\nwas known to Petit, who had seen a compound dislocation thus pro-\\nduced; and Desault and Bichat, anticipating in this, as in so many\\nother things, the slower judgment of the profession, declared it to be\\nthe common mechanism, but the investigations which first satisfactorily\\ndemonstrated it were made by a young German surgeon in 1844,\\nRoser. 2 His results were quoted and his experiments repeated and\\nextended to other than backward dislocations by Streubel, 3 and to these\\n1 Pingaud Diet. Encyclop. des Sc. Med., art. Coude, p. 496.\\n2 Eoser Arch, fur physic-log. Heilkunde, 1844, Heft 2, p. 185.\\n3 Streubel Prager Vierteljahrschrift, 1850, vol. i. p. 1.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0693.jp2"}, "686": {"fulltext": "616 DISLOCATIONS.\\ntwo papers and the articles by Denuce l and Pingaud, above mentioned,\\nthe reader is referred for details to which the needed space cannot here\\nbe given.\\nExperiment upon the cadaver shows that when this action, of a fall\\nupon the outstretched hand, is imitated, the hand being supinated, the\\nanterior portion of the internal lateral ligament becomes tense and then\\nyields, usually at its upper insertion then, as the movement is con-\\ntinued, the rupture extends along the anterior ligament, perhaps\\ninvolving part of the brachialis anticus, the elbow bends inward, and\\nif pressure is made downward upon the head of the humerus this bone\\npasses down in front of the coronoid process and radius, and a back-\\nward dislocation is produced.\\nIn whatever direction the force may act it is evident that its first\\neffect must be to rupture one or both of the lateral ligaments, for they\\nare the ones which hold the bones together and they oppose not only\\nlateral motion but also hyperextension. According as one or the other\\nof these is first, or alone, torn, and according to the direction of the\\nforce, the details of the position in which the bones come to rest will\\nvary and the displacement will be directly backward or to either side\\nor with more or less abduction or adduction of the forearm.\\nThe frequency with which the tip, or more, of the internal epicon-\\ndyle is broken off and the flexors of the hand detached from it and the\\nadjoining bone, and with which the external lateral ligament remains\\ncontinons with the periosteum stripped up from the back of the\\nexternal condyle, convinces me that forcible abduction of the forearm,\\nduring either extension or partial flexion of the elbow, is the first step\\nin the production of the injury in a large number of cases this breaks\\nthe internal lateral ligament and frees the ulna, and then the bones slip\\npast each other, the external lateral ligament being torn or detached in\\nthe movement, and the head of the radius tearing off the corresponding\\nportion of the capsule and adjoining periosteum as it slips up behind\\nthe condyle.\\nThe cases in which the coronoid process and the portion of the head\\nof the radius which is anterior at the moment are broken off show that\\nin them the direct impulsion of the bones past each other was effected\\nby great violence acting along the axis of the forearm before these two\\nparts had entirely cleared the lower surface of the humerus.\\nIn one case that came under my observation the dislocation was\\neffected by hyperextension and torsion without the aid of the weight\\nof the body to press the humerus downward. The patient, in jumping\\ndown from his Avagon, steadied himself by grasping the rail of the\\nseat, and, the height being considerable, the wrench was sufficient to\\ndislocate the elbow.\\nPathology. The internal lateral ligament is always torn, usually at\\nits insertion upon the humerus, and the rent extends along the anterior\\nligament. The external lateral ligament is usually torn or detached\\nfrom the humerus its partial preservation in some cases notably affects\\nthe attitude of the limb and may create considerable difficulty in reduc-\\ntion. The orbicular ligament is rarely injured.\\n1 Denuce: Diet, de Med. et Ckir. prat., art. Coude.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0694.jp2"}, "687": {"fulltext": "BACKWARD DISLOCATIONS OF THE ELBOW. 617\\nThe tip of the internal epicondyle is frequently torn off, apparently\\nby avulsion through the attached flexor muscles when the fragment\\nis large it remains attached to the internal lateral ligament and is dis-\\nplaced upward and backward.\\nThe flexor muscles of the hand are sometimes quite freely torn from\\nthe humerus, the brachialis anticus is sometimes lacerated and in ex-\\ntreme displacements torn across the tendon of the biceps occasionally\\nslips around the outer side of the external condyle. In the only case\\nin which I have seen all these extensive lesions the end of the humerus\\nwas stripped of all its muscles and had passed through the fascia and\\nlay under the skin in the fold of the elbow, but the patient had been\\nsubjected to three attempts by different surgeons to reduce under ether,\\nand it is probable that the lacerations were in part due to those attempts.\\nThe capsule at the back of the external condyle is torn off by the\\nedge of the head of the radius and seems frequently to maintain its\\ncontinuity with the adjoining periosteum, which latter is stripped up\\nfor some distance and caps the head of the radius in its new position.\\nThis stripping up of the periosteum and its effect in producing new\\nbone if the dislocation remains unreduced, Avhich I pointed out in\\nthe first edition, I have repeatedly observed since. (See Chapter\\nXLVII.)\\nThe displacement of the bone varies greatly, both in extent and in\\ndirection. The top of the coronoid process may rest against the lower\\nand posterior surface of the trochlea, and the radius still remain in\\ncontact with the under surface of the capitellum by the anterior por-\\ntion of its disk, or the latter may be entirely dislocated and rest against\\nthe posterior face of the external condyle.\\nWhen the ulna is more and the radius less displaced the deviation of\\nthe wrist is to the inner side and when both bones are completely dis-\\nplaced backward deviation of the wrist to either side will incline their\\nupper ends to the opposite side, and thus bring them nearer to the\\ninternal or the external epicondyle respectively.\\nIf, in the production of the dislocation, the lateral outward flexion\\nis more marked than the hyperextension, the capitellum slips along\\nthe head of the radius to its inner side, and the latter lodges on the\\nouter surface of the former just below the epicondyle, while the coro-\\nnoid process rests against the posterior surface of the external condyle,\\nhaving been carried outward by pronation of the forearm. The long\\naxis of the forearm is deviated to the inner or the outer side the\\ninternal lateral ligament is freely torn. This is the dislocation back-\\nivard and outward, classed by some with the outward, by others with\\nthe backward dislocations, and sometimes misleadingly reported as a\\npure outward dislocation.\\nComplications. Fractures of the olecranon, the coronoid process, the\\nhead, shaft, and lower extremity of the radius, and the epitrochlea have\\nbeen observed in connection with dislocation backward. Fracture of\\nthe olecranon is effected, presumably, by the pressure of its tip against\\nthe back of the humerus when the posterior part of the lateral liga-\\nment proves stronger than the bone, and a fracture is produced with\\nangular deformity and crushing of the posterior portion of the bone", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0695.jp2"}, "688": {"fulltext": "618 DISLOCATIONS.\\nat the seat of fracture. In a case reported by W. H. Daly x of frac-\\nture of the olecranon, and probably of the coronoid process also, the\\ncoexistence of a Colles s fracture at the wrist showed plainly that the\\ninjury was produced by a fall upon the extended hand.\\nFracture of the coronoid process is probably produced when the\\nmomentum of the fall forces the humerus downward before the hyper-\\nextension has quite carried the tip of the process past the trochlea and\\nLotzbeck s experiments indicate that it can also be caused, when the\\nelbow is slightly flexed, by the direct impulsion of the lower end of\\nthe humerus in a direction parallel to that of the long axis of the\\nforearm. As the brachialis anticus is attached, not to the tip of the\\nprocess, but to its anterior face and the adjoining surface of the ulna,\\nthe displacement of the fragment is usually slight.\\nPartial fracture of the head of the radius has been observed in a\\nnumber of cases, often associated with fracture of the coronoid process.\\nIt has been described in Chapter XX. The portion broken off is the\\nanterior or inner third, and the fracture is effected by the direct press-\\nure of the condyle brought to bear upon the periphery of the disk by\\nthe displacement backward of the latter.\\nOne case of fracture of the shaft of the radius and three of fracture\\nof its lower end, Colles s fracture, complicating backward dislocation\\nof the elbow, are reported in a thesis by Dupuy. 2\\nThe dislocation may be made compound by the projection of the trochlea\\nthrough the skin in the fold of the elbow, and the brachial artery, and\\nperhaps even the median nerve, may be ruptured. In a case reported\\nby Ledderhose, 3 in which the dislocation was made compound by a trans-\\nverse wound in the fold of the elbow, the musculo-spiral nerve was torn.\\nFive months later the nerve was successfully reunited by suture.\\nIn another, reported by Ferret, 4 the median nerve, exposed for more\\nthan three inches in the wound and tightly stretched, sloughed away.\\nSymptoms. The elbow is usually flexed at an angle about midway\\nbetween complete extension and flexion at a right angle, but it may be\\ncompletely extended, or even hyperextended, as in a case reported by\\nMorel-Lavallee. 5 The limb is shortened, and if viewed from behind\\nthe shortening appears to be in the arm, because of the elevation of\\nthe olecranon, but if viewed from in front in the forearm. If a few\\nhours have passed since the injury was received, the region of the\\nelbow is occupied by a swelling which may be so great as completely\\nto mask the bony points and the characteristic changes in outline but\\nif this swelling is slight or absent the antero-posterior diameter of the\\njoint appears increased, and the transverse diameter unchanged. The\\nlower part of the triceps curves backward in the median line to the\\nend of the olecranon, creating a hollow on either side, in the outer one\\nof which may be seen a slight elevation marking the position of the\\nhead of the radius.\\n1 Daly Philadelphia Medical and Surgical Reporter, 1880, vol. xliii. p. 71.\\n2 Dupuy These de Paris, 1882, No. 151.\\n3 Ledderhose: Deutsche Zeitschrift fur Chirurgie, vol. xxv. p. 238, abstract in Cen-\\ntralblatt fur Chirurgie, 1887, p. 732.\\ni Ferret Progres Medical, May 7, 1887.\\n5 Morel-Lavallee Bull, de la Soc. de Chir., 1856, vol. vii. p. 9.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0696.jp2"}, "689": {"fulltext": "BACKWARD DISLOCATIONS OF THE ELBOW.\\n619\\nThe front of the joint appears full, and the forearm just below it is\\nbroadened by the shortening of the muscles that arise from either\\ncondyle. Sometimes the outline of the trochlea can be distinctly felt\\nor even seen, but ordinarily it is masked by the overlying muscles.\\nThe forearm may take any attitude between pronation and supina-\\ntion, for, as voluntary rotation is possible, the patient places it in the\\nmost convenient attitude. The axis of the forearm may be deviated\\nto either side (Fig. 287).\\nFlexion and extension are possible within variable, but always nar-\\nrow, limits and painful and when flexion is made the prominence of\\nthe olecranon behind the joint is increased. Abnormal lateral mobility\\nof the joint exists.\\nIf now the positions of the two epicondyles and the tuberosity of\\nthe olecranon can be recognized, it will be seen that the latter is dis-\\nplaced backward and upward, rising, if the\\nlimb is extended, above the horizontal line\\njoining the epicondyles, or projecting far\\nbehind a frontal plane passing through\\nthese two points if the limb is partly\\nflexed. This backward projection of the\\nolecranon will be increased by flexion of\\nthe elbow, and at the same time it will\\ndescend while by extension it will be\\nmoved to a higher level and brought nearer\\nthe back of the humerus.\\nThe head of the radius can be felt, per-\\nhaps even seen, under the skin below and\\nto the outer side of the olecranon close\\nbehind the external condyle, and can be\\nrecognized by the concavity of its upper\\nsurface and felt to move under the finger\\nwhen the wrist is gently rotated.\\nOn the inner side, if the swelling is not\\ntoo great, the finger passing forward and\\ndownward from the tip of the olecranon\\nsuccessively recognizes the curved inner\\nmargin of the great sigmoid cavity, possi-\\nbly also the coronoid process and the back\\nof the trochlea, and then moving around the inner side below the\\nepitrochlea to the front may trace the sharp circular margin of the\\ntrochlea and recognize its rounded surface and groove in front.\\nDiagnosis. The diagnosis should be made upon actual recognition\\nby palpation of the position of the two epicondyles, the olecranon, and\\nthe head of the radius. The surgeon should never be satisfied with\\nless than that, and if it cannot be obtained he should refuse to make\\na positive diagnosis. No attitude of the limb, no measurements, no\\napparent changes in its diameter, no considerations of abnormal\\nmobility or fixation are sufficient, and the surgeon who trusts to them\\nwill be only too likely to add to the already too long series of limbs\\ncrippled in consequence of errors in diagnosis.\\nDislocation of the elbow backward.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0697.jp2"}, "690": {"fulltext": "620 DISLOCATIONS.\\nOf the different fractures that have been mentioned as complica-\\ntions, those of the olecranon and epitrochlea are easily recognized by\\nmanipulation that of the coronoid process is indicated by easy recur-\\nrence of the dislocation after its reduction, but if the patient is ether-\\nized at the time this symptom is by no means characteristic, and, fur-\\nthermore, it is also present in those fractures of the internal condyle\\nwhich are complicated by displacement of the fragment and disloca-\\ntion of the radius backward. Fracture of the head of the radius can\\nhardly be recognized unless the fragment should be so displaced that\\nit can be felt on the outer side of the condyle.\\nThe records of discussions over cases presented to the various learned\\nsocieties show very clearly the great difficulty of making a diagnosis in\\ncases that have remained unreduced for any length of time, especially in\\nchildren in whom the injured or stripped-up periosteum rapidly forms\\nnew bone which obscures the original outlines. Much of the uncertainty\\nconcerning the character and results of reported cases is due to this fact.\\nPrognosis. The prognosis is favorable; reduction in recent cases may\\nbe confidently expected, with complete or almost complete restoration\\nof function. In old cases, of more than six weeks standing, the prob-\\nability of reduction is greatly diminished, although successes have been\\nreported after three, five, and even seven months. The greater the\\ndisplacement upward, the arm being only slightly flexed, the less is the\\nprobability of reduction after the lapse of some time, for the lacerated\\nlateral ligaments have then formed new attachments at points so high\\non the humerus that they must be again ruptured before the ulna and\\nradius can be brought below the end of the humerus, and in attempting\\nto rupture them by flexing the elbow the olecranon is liable to be\\nbroken. In addition, the sigmoid cavity fills up with fibrous tissue\\nwhich obliterates its articular surface and binds it to the back of the\\nhumerus. Furthermore, as the injury is most frequent in the young,\\nwhose periosteum is active to produce bone when irritated or stripped\\nup, obstacles may thus be created which cannot be overcome except by\\narthrotomy. In some cases of unreduced dislocation the patients have\\nin time obtained a free range of motion and a useful limb, but usually\\nthe mobility is very slight. In a discussion upon the subject in the\\nSociete de Chirurgie (Bulletins, 1861, p. 103), it was stated as the\\nexperience of several of the members that, in the older cases at least,\\nit was not uncommon to fail to make a complete reduction of the\\nradius, but that nevertheless the patients recovered full use of the\\njoint. Recurrence of the dislocation of the radius alone has also been\\nobserved. Mason l reported such a case in which the recurrence was\\nthought to have taken place during the agitation accompanying the\\nrecovery from the effects of the ether.\\nEven after an early reduction the mobility may be diminished by\\nthe results of the arthritis, especially in the old and rheumatic, or by\\nnew formations of bone about the joint which mechanically limit its\\nrange of motion, or, very exceptionally, by an ossifying myositis of the\\n1 Mason New York Medical Record. 1S80, vol. xix. p. 398.\\n2 Mysch Deutsche Zeitschrift fur Ckir., 1S99, vol. liv. p. 207.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0698.jp2"}, "691": {"fulltext": "BACKWARD DISLOCATIONS OF THE ELBOW. 621\\nCompound dislocations usually do well if kept surgically clean and\\nwell drained primary resection, in the absence of special indications,\\nshould not be done.\\nTreatment. Much less attention has been paid in the treatment of\\ndislocations backward of the elbow to the obstacles created by the\\nuntorn ligaments than in those of the shoulder or hip, and methods\\nare in general and successful use that are directly opposed in character\\nto those based upon a consideration of such obstacles and upon the\\nprinciple that a dislocated bone should be returned along the route by\\nwhich it has been displaced. The explanation of this success of faulty\\nmethods is to be found either in an extensive primary laceration of\\nboth lateral ligaments or in the possible overcoming of the obstacles\\nby increasing the laceration. The easy reduction of most dislocations\\nunder ether by direct pressure in suitable directions upon the projecting\\nends of the bones is an indication that ligamentous obstacles of impor-\\ntance do not exist and that the chief opposition is furnished by the\\nmuscles spasmodically contracted on all sides of the joint, and the\\ninference is too often drawn that, provided this opposition is overcome\\nby force or by anaesthesia, the surgeon need not particularly concern\\nhimself with the attitude of the limb during his efforts to reduce.\\nBut the success of a faulty method should not make us unmindful of\\nits defects our work should be done skilfully, as well as successfully,\\nand even if our errors will pass undetected and their consequences be\\npromptly repaired, we should not lightly commit them.\\nSuch a generally successful but faulty method is that in which the\\nforearm is flexed as nearly as possible to a right angle, drawn directly\\naway from the humerus in the direction of the long axis of the latter\\nuntil the tip of the coronoid process is brought below the trochlea, and\\nthen, the traction being relaxed, is moved forward and upward into\\nplace. Many different methods of effecting this manoeuvre have been\\nemployed, the one commonly known as Sir Astley Cooper s, although\\npractised in exactly the same manner long before his time, in which the\\nsurgeon s knee is placed in the bend of the elbow, being the most com-\\nmon. Cooper s description of it is as follows l The patient is made to\\nsit down upon a chair, and the surgeon, placing his knee on the inner side\\nof the elbow-joint, in the bend of the arm, takes hold of the patient s\\nwrist, and bends the arm. At the same time he presses on the radius\\nand ulna with his knee, so as to separate them from the os humeri, and\\nthus the coronoid process is thrown from the posterior fossa of the\\nhumerus and whilst this pressure is supported by the knee the arm\\nis to be forcibly but slowly bent, and the reduction is soon effected.\\nIt may also be accomplished by placing the arm around the post of a\\nbed, and by forcibly bending it while it is thus confined.\\nThe knee is thus used as the fulcrum of a lever of which the wrist\\nis at the end of the long arm, and the olecranon at that of the short\\none. The resistance to be overcome is that of the muscles and of the\\nsoft parts which bind the ulna and radius to the humerus, and it must\\nbe overcome to an extent that will allow the ulna to be directly sepa-\\nrated from the lower border of the humerus to a distance equal to the\\n1 Cooper Loc. cit., p. 382.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0699.jp2"}, "692": {"fulltext": "622 DISLOCATIONS.\\nheight of the coronoid process, more than half an inch the lateral\\nligaments, the upper fibres of the anconeus, and the stout fascia on the\\nouter side of the elbow must all yield to this extent. That they com-\\nmonly do so is a proof of the amount of the laceration and of the\\nforce employed. The method is faulty because it requires for its\\naccomplishment a maximum of laceration on both sides of the joint\\nwhich may have, and probably has, been escaped in the original injury,\\nand because it requires the simultaneous elongation of the muscles of\\nthe front and back of the arm. Possibly forcible pronation of the\\nupper part of the forearm, facilitated by the rupture of the internal\\nlateral ligament, would make it easier thus to disengage the coronoid\\nprocess and avoid additional laceration on the outer side.\\nThe specific objection made to this method applies equally to all in\\nwhich reduction is made while the elbow is flexed at a right angle, and\\nin a less degree to those in which the joint is partly flexed. In the\\nlatter the modes of application of the force are numerous and varied\\ntraction by pulleys, by the hand, or by a loop placed above the olecra-\\nnon, and pressure by the thumbs upon the olecranon and head of the\\nradius while the fingers are interlocked in front of the lower end of\\nthe humerus. The more extended the limb the more easily will\\nmethods of this kind succeed, but they need to be supplemented by\\nflexion or direct coaptation after the coronoid process has been brought\\nsufficiently low.\\nA possible obstacle in the way of traction in the extended or slightly\\nflexed position is the engagement of the tip of the coronoid process in\\nthe olecranon fossa of the humerus in such a way that its under sur-\\nface rests directly against the upper posterior portion of the trochlea\\nand prevents the ulna from moving bodily in the direction of its long\\naxis. It can be disengaged either by pronating the upper part of the\\nforearm, hyperextending the elbow, or by pressing the upper part of\\nthe forearm backward and the lower part of the arm forward. Except\\nfor this possible obstacle traction in complete extension meets the indi-\\ncations sufficiently and without needless increase of the laceration, and\\nthe obstacle can be readily overcome, as has just been said, by slight\\nhyperextension as suggested by Roser in 1844.\\nTraction may be made by the hands of the surgeon himself, or by\\nassistants while the surgeon watches the descent of the ulna, frees the\\ncoronoid process if necessary, and presses the radius and ulna forward\\ninto place at the proper time or it may be made by an India-rubber cord\\nor by fastening a weight to the wrist and allowing the arm to hang down.\\nThis method, traction upon the fully extended or even hyperextended\\nforearm, followed by direct pressure forward on the upper ends of the\\nulna and radius and counter-pressure backward on the lower end of\\nthe humerus, or simply by flexion, corresponds as nearly to the funda-\\nmental principle of reduction as is practicable in the usual uncertainty\\nas to the exact attitude taken by the limb at the moment of dislocation.\\nIn all cases of doubt or difficulty anaesthesia should be used and, as\\na general rule, whenever a lateral displacement is associated with the\\nbackward one the bones should be pressed sideways into line before\\nthey are drawn downward.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0700.jp2"}, "693": {"fulltext": "BACKWARD DISLOCATIONS OF THE ELBOW. 623\\nWhen the lateral element of the displacement is very marked and it\\nis probable that the primary dislocation was directly outward and has\\nbeen followed by a consecutive displacement backward, anaesthesia\\nshould not be omitted, and after full relaxation has been obtained the\\nfirst attempt should be to move the olecranon and head of the radius to\\nthe radial side of the humerus and transform the dislocation into a pure\\noutward one. By so doing the principle of replacing the bones by the\\nroute along which they have been displaced is followed, and the risk\\nof engaging the tendon of the biceps behind the external condyle is\\navoided. (See also the following section.) If the attempt, cautiously\\nmade, does not succeed, the surgeon should next seek to change the\\ndisplacement into a pure backward one and reduce as before described.\\nIf some time has elapsed since the accident, more than ten or fifteen\\ndays, it may be desirable to break up such adhesions as have formed\\nby flexion, extension, and lateral flexion, but it must be borne in mind\\nthat forced flexion always carries the risk of fracturing the olecranon.\\nThis is sometimes intentionally done to facilitate reduction in old cases\\nit is of course followed by more or less loss of the power of active\\nextension.\\nFracture of the coronoid process requires no special treatment appar-\\nently the fragment is seldom, if ever, much displaced, for it retains its\\nconnection with the capsule and, after reduction, is steadied between\\nthe lower end of the humerus and the tendon of the brachialis anticus.\\nThe special indication arising from it is to guard against a recurrence\\nof the dislocation, which is best done by keeping the elbow flexed at\\nor even within a right angle. A posterior moulded splint is an addi-\\ntional safeguard.\\nFracture of the olecranon requires the special treatment proper to\\nthat injury, but as the extended position of the joint, which is most\\nfavorable for the prompt and close repair of the fracture, exposes to a\\npartial or even complete recurrence of the dislocation, it must be avoided\\nuntil after the rupture of the lateral ligaments has been in great part\\nrepaired. If, in the flexed position, the olecranon is separated from\\nthe ulna it should be drawn down and held in contact by adhesive\\nplaster, or the fracture should be exposed and the fragments sutured.\\nFracture of the head of the radius requires prolonged rest of the\\njoint, with a view to reunion if the fragment remains in place if\\ndisplaced and readily accessible the fragment should be removed. If\\nthe fragment should remain on the inner side of the joint, between the\\nradius and ulna, it would be most easily reached through an anterior\\nincision, in making which, however, special care would have to be\\ntaken to avoid injury to the musculo-spiral nerve and its two branches,\\nthe radial and posterior interosseous.\\nFracture of the epitrochlea requires that the elbow should be kept\\nwell flexed, to relax the muscles of the forearm that arise from this\\nprominence.\\nIf the dislocation is compound, but without laceration of the soft\\nparts so extensive as to make amputation unavoidable, the parts must\\nbe thoroughly cleansed and replaced, efficient drainage provided through\\nthe wound or through counter-openings, and the limb immobilized in", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0701.jp2"}, "694": {"fulltext": "624 DISLOCATIONS.\\na plaster splint. Some, perhaps extensive, suppuration is probable in\\nthe soft parts, but the joint is likely to escape so far as to preserve a\\nfair amount of motion. Even if the brachial artery is torn the limb\\nmay still be saved and although the additional complication of rup-\\nture of the median nerve has been thought to make amputation neces-\\nsary, I think a different view would now be taken and the attempt\\nwould be made to reunite its ends. Fortunately both complications,\\nespecially the latter, are very rare.\\nAfter-treatment. In uncomplicated cases it is necessary only to\\nretain the limb in a sling for two or three weeks, or until such time as\\nthe dependent position does not cause pain. Passive motion, to prevent\\nanchylosis, is not necessary, and is actually harmful during the first\\nfortnight if it causes pain. The limb may safely be immobilized until\\nthe injury to the capsule and ligaments has been repaired. It will be\\nmore or less stiff when first taken out of the dressings, but complete\\nrestoration of its functions may be confidently expected under daily\\nuse. Exceptions to this complete recovery are sometimes found in the\\nold and rheumatic, in complicated cases, and in the young if the peri-\\nosteum has been extensively stripped up. In the first class, the old\\nand rheumatic, gentle passive motion strictly confined within the limits\\nbeyond which persistent pain and tenderness are caused, may be of\\nservice to diminish the subsequent stiffness and hasten its disappear-\\nance, and in all it may be useful to change every day or two the angle\\nat which the limb is immobilized.\\nLATERAL DISLOCATIONS OF THE FOREARM.\\nBoth bones of the forearm may be together dislocated to the inner\\nor to the outer side, and the dislocation may be complete or incom-\\nplete. In the incomplete form, in the sense in which the term has\\nbeen generally, and will here be, used, one of the two bones still\\nremains below or in front of the lower end of the humerus, although\\nit may have entirely left its own corresponding articular surface thus,\\nin the incomplete outward dislocation the sigmoid cavity of the ulna\\nlies below and embraces the external condyle, and its inner slope may\\nstill correspond to the outer part of the trochlea or may have passed\\nentirely to its outer side. In the complete outward dislocation, on the\\nother hand, the sigmoid cavity of the ulna is turned toward (pronation)\\nand embraces the outer side of the external condyle or the supinator\\nridge, and the head of the radius lies nearer the median line in front\\nof the humerus. Much confusion has arisen from the use of the terms\\noutward and inward dislocation to include also the outward and back-\\nward and the inward and backward respectively, both in text-books\\nand in the reports of cases in the journals. The terms will be here\\nrestricted to those cases in which the primary dislocation is directly\\noutward or inward, the coronoid process remaining in front of, and the\\nolecranon behind, the transverse longitudinal (frontal) plane of the\\nhumerus. In some cases of outward and backward dislocation the\\nquestion may arise whether the position in which the bones are found\\nis not the result of a consecutive displacement following a primary", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0702.jp2"}, "695": {"fulltext": "LATERAL DISLOCATIONS OF THE ELBOW. 625\\noutward displacement. I believe such consecutive displacements to be\\nvery rare, and that the great majority of backward and outward dis-\\nlocations belong, by their essential features, among the backward ones\\nwith which I have above described them.\\nIn a dislocation backward and inward this question does not arise,\\nfor a complete inward dislocation has never yet been reported but the\\nconfusion is, nevertheless, equally great, for the epithet backward\\nand inward has been indiscriminately applied to all displacements\\ntoward the inner side, including, as Trelat pointed out, three distinct\\nvarieties 1st, dislocations of both bones inward 2d, dislocations of\\nboth bones backward and inward, and 3d, dislocations backward of the\\nulna alone.\\nIncomplete Lateral Dislocations.\\nDoubtless it must be attributed to this confusion in the use of terms\\nthat the frequency of incomplete dislocations to the outer or the inner\\nside passed unnoticed until 1863, when a German surgeon, Hahn, who\\nhad practised for more than forty years at Stuttgart, published a paper 1\\nupon the subject in which he stated that he had treated 21 cases of this\\ninjury in thirty years, nearly as many as those of dislocation back-\\nward observed during the same period of these 18 were in children,\\n3 in adults 12 of the former and 2 of the latter were in males, and\\nin all but one dislocation was inward. The statement, which was\\nsupported in many points by the observations of the reviewer of the\\npaper, Streubel, at once attracted attention and has been confirmed and\\naccepted by subsequent writers the principal contributions to the sub-\\nject have been made by Hueter, 2 Nicoladoni, 3 and Sprengel. 4 Hueter\\ndescribed 6 specimens of outward dislocation obtained by resection and\\n3 cases observed clinically Nicoladoni found 4 incomplete outward\\ndislocations in 16 dislocations of the elbow observed in four and a half\\nyears and Sprengel reported that the records of the Halle clinic for\\nthe years 1873-1879 contained 32 cases, of which 20 were inward and\\n12 outward. An important feature of the last communication is that\\n15 of the 32 (11 inward, 4 outward) were old cases, and in only 1 of\\nthem could reduction be obtained. Although it is not so stated, it is\\nprobable that in many of them an error in diagnosis had been com-\\nmitted Hahn says the injury is frequently mistaken for fracture of\\nthe lower end of the humerus. In a case seven months old reported\\nby Sprengel the injury had been pronounced by a well-known London\\nsurgeon, who gave the patient a written opinion, an intercondyloid\\nfracture of the humerus, and he added that there was no trace of the\\ndislocation said to have existed Sprengel excised the joint and demon-\\nstrated the dislocation. On the other hand, KronlenVs 94 cases (p.\\n408) contain no examples, and in my experience they are relatively\\nvery few.\\nThe cause is usually a fall upon the outstretched hand exceptional\\ncauses are falls upon the inner side of the elbow and blows received\\n1 Hahn Schmidt s Jahrbiicher, vol. cxix. p. 74, and vol. cxx. p. 88.\\n2 Hueter: Arch, fur klin. Chirurgie, 1867, vol. viii. p. 153, and vol. ix. p. 935.\\n3 Nicoladoni Wiener med. Wochenschrift, 1876, pp. 570, 599, 640, and 670.\\n4 Sprengel Centralblatt fur Chirurgie, 1880, p. 129.\\n40", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0703.jp2"}, "696": {"fulltext": "626 DISLOCATIONS.\\nupon the forearm. The interlocking of the central riclge of the sig-\\nmoid cavity in the groove of the trochlea is such that direct lateral\\ndisplacement without preliminary separation of the articular surfaces,\\nor without their fracture, is impossible, and it is highly probable\\nthat the dislocation is produced by abduction of the completely ex-\\ntended forearm, or possibly by its equivalent pronation when partly\\nflexed that is, the ulna is moved downward (in the prolongation of\\nthe frontal plane of the humerus) and outward, turning upon the\\nhumero-radial articulation as a centre, and thus the internal lateral\\nligament is ruptured. The joint is thus opened upon its inner side,\\nthe sigmoid cavity and trochlea separated from each other, and only\\nthe radius and capitellum remain in contact at their outer borders. If\\nnow the capitellum slips inward along the upper surface of the radius\\nan incomplete outward dislocation is produced if, on the contrary, the\\nradius slips inward along the capitellum an incomplete inward disloca-\\ntion is the result. This mechanism can be reproduced upon the cadaver,\\nbut it must be admitted that the explanation is theoretical accurate\\nclinical observations, for reasons often above referred to, are not obtain-\\nable, and it is impossible to reproduce all the factors upon the cadaver.\\nA. Incomplete Inward Dislocations.\\nPathology. The autopsies and direct examinations that have been\\nreported and are available to show the new relations of the bones are\\nfew in number. There are two autopsies reported by Broca 1 and\\nJolivet, 2 and the case above referred to in which Sprengel excised the\\njoint seven months after the injury was received. In the latter the\\nhead of the radius rested against the lateral part of the trochlea, and\\nthe ulna was displaced so far inward that nearly half of the sigmoid\\ncavity projected free beyond the trochlea upon this free part, and\\nunited with it, lay the fractured tip of the epitrochlea. There was\\nclose fibrous union between the opposing surfaces.\\nBroca s case was a much older one the specimen and a plaster cast\\nof the limb are preserved in the Musee Dupuytren. It differs from\\nthe usual clinical form in the very marked displacement downward\\nand backward of the head of the radius. The new joint permitted full\\nflexion and almost complete extension, and the axis of the forearm was\\ninclined downward and outward 30 degrees from the prolongation of\\nthat of the humerus. The distance between the prominences formed\\nby the tip of the olecranon and the head of the radius was six centi-\\nmetres. There remained no trace of the lateral and annular ligaments a\\nfibrous capsule of new formation connected the bones with one another.\\nBroca says there was no sign of former fracture, but Denuc\u00c2\u00a3, 3 who ap-\\npears to have examined the specimen, says the external condyle appears\\nto have been broken off and displaced forward. The sigmoid cavity\\nembraces the epitrochlea, and forms a new articulation with it the\\nradius lies below the inner part of the trochlea and projects notably be-\\nhind it.\\n1 Broca Bull, de la Soc. Anatomique, 1849, p. 272.\\n2 Jolivet Bull, de la Soc. Anatomique, 1S65, p. 184.\\n3 Denuce Diet, de Med. et Chir. pratiques, art. Coude, p. 765.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0704.jp2"}, "697": {"fulltext": "LATERAL DISLOCATIONS OF THE ELBOW. 627\\nJolivet s specimen was obtained by amputation eighteen months after\\nthe injury. The elbow was flexed, the forearm semipronated, and\\nthere was very slight mobility. The olecranon, displaced inward,\\nembraced the epitrochlea by its sigmoid cavity and projected beyond\\nits inner side. The olecranon fossa was empty the anterior and inner\\npart of the head of the radius rested upon the outer articular half of\\nthe trochlea, the sharp inner border of the latter lying like a wedge\\nbetween the radius and ulna. The coronoid process lay in a new\\ngroove formed at the expense of the epitrochlea and the adjoining side\\nof the trochlea. The posterior edge of the head of the radius could\\nbe felt as a prominence at the back of the joint.\\nBoth lateral ligaments are necessarily torn the annular ligament\\nmay perhaps resist, though it must at least be put upon the stretch by\\nthe interposition of the inner anterior edge of the trochlea between\\nthe head of the radius and the coronoid process. The clinical features\\nindicate that the head of the radius lies rather below than directly in\\nfront of the trochlea, even in flexion of the elbow at a right angle.\\nSymptoms. The axis of the forearm is parallel with that of the\\narm and a little to its inner side. The prominence of the epitrochlea\\nis lost, that of the outer epicondyle increased. Flexion and extension\\nare quite free, and painless within certain limits.\\nOn palpation, the olecranon can be recognized immediately behind\\nthe position of the epitrochlea and extending so far to the inner side\\nas to mask this prominence completely the triceps shows as a rather\\nprominent elevation running downward and inward. The external\\ncondyle can be plainly felt, and the absence of the head of the radius\\nfrom its normal position recognized the latter can sometimes be felt\\nbelow the empty olecranon fossa.\\nTreatment. Reduction in recent cases appears to be easy by traction\\nin the extended position and direct pressure upon the side of the ulna.\\nTheoretically, outward lateral flexion combined with moderate traction\\nand followed by direct pressure ought to effect reduction readily and\\nwithout risk of fracture, especially if anaesthesia is employed.\\nSprengel s statistics, quoted above, indicate that reduction is very\\ndifficult in old cases out of eleven only one was reduced, but the\\nlength of time that had elapsed is not given except in the one case that\\nwas reduced, eight weeks.\\nBroca s specimen and two of SprengePs cases show that the joint,\\neven if reduction is not made, may have a free range of motion and\\nthe limb may be useful in his other cases Sprengel s attempts to\\nincrease the range of motion failed more or less completely.\\nB. Incomplete Outward Dislocations.\\nThis form, although apparently somewhat less frequent than the pre-\\nceding, has been more fully studied. Its causes and mechanism have\\nbeen described above.\\nPathology. Fig. 288 represents a specimen from an old case pre-\\nsented to the Societe Anatomique by Poumet it is described by Mal-\\ngaigne, Denuce, and Pingaud as one of the only two cases known,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0705.jp2"}, "698": {"fulltext": "628\\nDISLOCATIONS.\\nFig. 288.\\nOld incomplete outward dis-\\nlocation. (Poumet.)\\nthe other, Pinel s, being very similar. The list has since been increased\\nby the five specimens obtained by Hueter by resection, by Hutch-\\ninson s autopsy, and by Sprengel s case in which the dislocation be-\\ncame compound. A case which I reduced by\\narthrotomy three weeks after the accident\\nbelongs, I think, in this class, although the\\ncoronoid process lay behind the external\\ncondyle the epitrochlea lay in the groove of\\nthe trochlea, and a mass of new bone had\\nformed on the back of the external condyle.\\nThe last three are the only examples of the\\ncondition in the recent state of which I have\\nknowledge, and the information furnished by\\nSprengel s relates only to the position of the\\nbones.\\nSprengel s 1 patient was a girl seven years\\nold the injury was caused by a fall, was sup-\\nposed to be a fracture, and was treated by\\nimmobilization in a gypsum dressing. Five\\nweeks later she came under Sprengel s obser-\\nvation. On removal of the dressing a slough\\nan inch in diameter was found to have formed,\\nand through the opening created by it the in-\\nternal condyle presented. The head of the\\nradius could be distinctly felt below the external condyle, the ulna\\nwas displaced outward so that the outer half of the sigmoid cavity\\nembraced the capitellum the forearm was pronated and fixed in a\\nposition midway between flexion and extension. Forcible abduction\\nwas made as a preliminary to reduction, and the opening of the slough\\nwas thereby so enlarged that the position of the bones as described\\nwas verified by direct inspection. The child made a good recovery.\\nHutchinson s 2 specimen was of a recent case, the patient having\\ndied of associated injuries. The dislocation had been reduced during\\nlife on the table it could be easily reproduced, and the bones could\\nbe dislocated to either the outer or the inner side. The sigmoid notch\\nrested against the external condyle and the head of the radius pro-\\njected beyond the latter. The lateral ligaments were completely torn,\\nand there were several rents in the anterior one the orbicular liga-\\nment was entire, but much stretched. Small portions of cartilage had\\nbeen broken from the articular surfaces of all three bones.\\nPoumet s specimen (Fig. 288) is thus described by Pingaud. 3 The\\nulna, carried directly outward, has completely left the trochlea, which\\nprojects on the inner side and contains in its groove a large sesamoid\\nbone [evidently the broken-off epitrochlea, vide infra The external\\narticular slope of the sigmoid cavity is in relation with the capitellum,\\nwhich is notably hypertrophied, as is also the epicondyle, while the\\ntrochlea and epitrochlea are atrophied. The radius, displaced outward\\n1 Sprengel Loc. cit.\\n2 Hutchinson Medical Times and Gazette, 1866, vol. i. p. 410.\\n3 Pingaud Loc. cit., p. 526.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0706.jp2"}, "699": {"fulltext": "OUTWARD DISLOCATIONS OF THE ELBOW. 629\\nand especially forward, is in indirect relations with the epicondyle and\\nthe remainder of the condyle, outside of which is a small sesamoid\\nbone which completes the surface of articulation on this side. It\\nresults from these anatomical relations that the forearm is in slight\\nflexion with rotation inward; the ligaments, especially the lateral ones,\\nare in great part ruptured.\\nHueter s six specimens all showed the same displacement, and the\\nepitrochlea torn off and lodged in the groove of the trochlea. The\\nsame avulsion of the epitrochlea was found in my case and clinically\\nin five others, Albert and von Dumreicher 1 each one, and Hueter 2\\nthree, in two of which it prevented reduction, and in the others made\\nreduction very difficult. In two other cases, also observed clinically\\nby Nicoladoni, in which reduction was not attempted because of the\\nlength of time that had passed since the injury was received, fourteen\\nand five months respectively, the epitrochlea was broken off; in one\\nit could not be found, in the other it lay below and near the sharp\\ninner edge of the trochlea.\\nThe complication appears to be much more common in children\\nthan in adults of the 13 cases here quoted 7 were young, in 4 the age\\nis not given, and 2 were adults when the joints were excised.\\nNicoladoni, after experimenting upon the cadaver, reached the opin-\\nion, which seems to be correct, that this avulsion of the epitrochlea is\\neffected through the attached flexor muscles and not through the inter-\\nnal lateral ligament which is inserted only upon its base.\\nHis experiments show T that the internal lateral ligament is always\\nruptured, usually close to its insertion at the base of the epitrochlea,\\nbut sometimes nearer to or at its attachment to the ulna. The rupture\\nextends backward along the margin of the sigmoid cavity to the tip\\nof the olecranon, and in front through the anterior ligament to the\\nouter side of the coronoid process. The external lateral and the\\nannular ligaments are untorn. The clinical cases indicate, however,\\nthat the annular ligament also is sometimes ruptured.\\nSymptoms. The elbow is somewhat flexed, the angle varying in the\\ndifferent cases, the forearm pronated. The axis of the forearm is\\nsometimes parallel with and external to that of the arm, sometimes\\nadducted. The prominence of the internal condyle is increased, and\\nthe skin is tightly stretched over it. The transverse diameter of the\\nelbow is increased by the projection of the muscles and the head of\\nthe radius on the outer side. Flexion and extension are painful and\\nrestricted. In the reported cases no mention is made of lateral\\nmobility.\\nOn palpation the epitrochlea, unless broken off, is very readily felt\\nif it is broken off, the inner side and edge of the trochlea can be\\nplainly traced, and the epitrochlea may perhaps be recognized as a\\nmovable body below it, or it may have been drawn past the edge of\\nthe trochlea into its groove where it cannot be felt.\\nOn the outer side the head of the radius projects in a line with the\\nanterior or under surface of the condyle, according as the elbow is\\nmore or less flexed. The olecranon is more prominent than normal,\\n1 Nicoladoni: Loc. cit., p. 571. 2 Hueter Arch, fiir klin. Chir., vol. ix. p. 935.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0707.jp2"}, "700": {"fulltext": "630 DISLOCATIONS.\\nbecause it is lifted out of its fossa and lies against the back of the\\nmore prominent external condyle it is distant from the epitrochlea about\\ntwo inches. The triceps appears as a prominent cord directed down-\\nward and outward to the olecranon. The external epicondyle may be\\nfelt by pressing the finger firmly in above the head of the radius and\\nbehind the prominence formed by the extensor muscles of the hand.\\nAccording to Pingaud, the forearm is so pronated that the posterior\\nsurface of the ulna looks outward, and the head of the radius lies in\\nfront of the capitellum instead of being displaced outwardly. Such\\ncases belong, I think, to the class of dislocations of the ulna alone.\\nTreatment. The first indication of treatment is to lift the central\\nridge of the sigmoid cavity and the coronoid process out of the groove\\nbetween the capitellum and the trochlea, or, in other words, to separate\\nthis portion of the ulna sufficiently from the under surface of the\\nhumerus to allow it to be pushed inward past the projecting outer\\nborder of the trochlea. This may be effected by hyperextension, or\\nby outward lateral flexion if the head of the radius still rests against\\nthe under surface of the humerus so as to form a fulcrum or centre for\\nthe movement.\\nIf hyperextension is made, the movement takes place about the tip\\nof the olecranon as a centre, where it rests against the back of the\\nhumerus, and the coronoid process is carried downward away from the\\nhumerus as well as backward, and when the separation is sufficient\\ndirect pressure with the thumbs upon the head of the radius will force\\nthe bones into place, or rotation of the ulna inward (supination) will\\ncarry the tip of the coronoid process past the margin of the trochlea\\ninto the groove. Nicoladoni suggests that in the latter manoeuvre an\\nassistant should press with his thumb upon the back of the olecranon\\nto prevent the production of a backward dislocation.\\nOutward lateral flexion should be aided by traction upon the extended\\nor slightly flexed forearm, by which the articular surfaces will be sepa-\\nrated as far as the untorn ligaments will permit, then pressure by the\\nthumb upon the head of the radius will force the inner ends of the\\nbones back into line, and the straightening of the limb completes the\\nreduction.\\nIf the annular ligament is torn, its outer portion and the adjoining\\npart of the external lateral ligament may be interposed between the\\nradius and the humerus and oppose the return of the former under\\nsuch circumstances the ulna can still be reduced, but the lateral press-\\nure to effect this must be made upon the olecranon instead of the\\nradius, and then by pronating and adducting the forearm the radius is\\ndrawn past the obstacle into place. The suggestion of the existence\\nof this obstacle and of the means by which it may be avoided rests\\nentirely upon experiments on the cadaver. I do not know that it has\\never been encountered and thus overcome in practice.\\nThe complication of avulsion of the epitrochlea and its lodgement\\nin the groove of the trochlea seriously increases the difficulty of reduc-\\ntion. As above stated, in two of the five recent cases in which it was\\nrecognized reduction failed. The reason of the failure is that the dis-\\nplacement of the fragment from the groove by the returning ulna is", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0708.jp2"}, "701": {"fulltext": "OUTWARD DISLOCATIONS OF THE ELBOW. 631\\nprevented by the sharply inclined inner slope of the trochlea and by\\nthe pressure of the overlying muscles and fascia. The fragment needs\\nto be drawn downward as well as pushed inward. Albert succeeded\\nby flexing the forearm at a right angle, and then drawing it forcibly\\naway from the humerus in the direction of the long axis of the latter\\nby means of a cord passed across its anterior surface close to the\\neibow. The same method, when employed by von Dumreicher, failed,\\nas did also forcible outward lateral flexion and traction, although car-\\nried so far as to threaten rupture of the skin on the inner side of the\\nJ oint\\nPossibly the transformation of the dislocation into the direct back-\\nward form, or backward and inward, would remove the fragment from\\nthe groove and make reduction possible, or it might be practicable to\\ndraw the fragment downward out of the way by a sharp hook passed\\nthrough the skin. Other means failing, the obstacle could be easily\\nreached and removed through an incision on the inner side.\\nComplete Dislocations Outward.\\nThese dislocations, of which the first observation was reported by\\nDupuytren in 1807, although the form had been described by Petit\\nnearly one hundred years before, were apparently so rare that Mal-\\ngaigne could collect only ten reported cases. Of late, reports have so\\nmultiplied that, excluding irregular cases, and those of which the\\ndescription is not sufficiently detailed, and those which seem more\\nproperly to belong among the dislocations backward and outward, the\\nnumber of those available for study and generalization is about twenty-\\nfive. 1\\nIn most of the cases the mechanism of production cannot be deter-\\nmined, but the histories of a few are sufficiently complete to show that\\nthe cause may be a fall upon the outstretched palm or upon the elbow,\\nor a blow received upon the inner side of the forearm. Ha try s case\\nis a clear example of the first, the patient stumbled and fell forward\\nupon his hand von Pitha s patient, who fell while her hands were in\\nher muff, is an example of the second and Mears s patient, who was\\nstruck upon the inner and upper part of the forearm by a revolving\\npiece of wood while the elbow was partly flexed in an effort to draw\\n1 The bibliography, excluding doubtful cases, is as follows Dupuytren, Lecons orales,\\nvol. i. p. 131 Bouley, Bull, de la Soc. Anatomique, 1837, p. 101 Nelaton, Pathol, chirur-\\ngicale, vol. ii. p. 391 Neilson, Lancet, 1844, ii. p. 559 Robert, Gaz. des Hopitaux. 1849,\\np. 180 Soule, Gaz. Medicale, 1849, p. 717 Verneuil and Triquet, Gaz. Medicale, 1S51\\nPiogey and Dubrueil, Gaz. des Hopitaux, 1851, p. 30 Denuce, These de Paris, 1853; Flau-\\nbert, idem Puech, Gaz. des Hopitaux, 1859, p. 434 Sistach, Bull, de la Soc. deChirurgie,\\n1866, p. 520 Varick, New York Medical Record, 1867, vol. ii. p. 3S7 Andrews, idem,\\n1875, p. 720 Von Pitha. Pitha and Billroth s Chirurgie, vol. iv., abt. 2, B. p. 71, 4 cases\\nHatry, Lyon Medical, 1876, vol. xviii. p. 13; Wylie, in Hamilton s Fractures and Dislo-\\ncations, p. 698 Bertin, Union Med., 1876, p. 609 Osborne, New York Hospital Gazette,\\n1879, p. 613 Mason, New York Medical Record, 1880, vol. xvii. p. 397, 2 cases Towne,\\nidem, p. 525 Ekwurzel, Philadelphia Medical and Surgical Reporter, 1881, vol. xlv. p.\\n38: Mears, Philadelphia Medical Times, 1880-1, vol. xi. p. 89; Johnson, Transactions of\\nthe Missouri State Medical Association, 1880. p. 33; Battiscombe, Lancet, 1886, ii. p. 397;\\nHeinlein, Centbl. fur Chir., February 1, 1890 Stimson, here given; Winslow, Annals of\\nSurgery, May, 1900, p. 595. I have not been able to verify the reference for Dupuytren s\\nand Verneuil s cases. The Gazette Medicale for 1851 does not contain the latter in the\\nGazette des Hopitaux, 1851, pp. 93 and 201, is an article by Verneuil and Triquet which\\ncontains a case of incomplete outward dislocation.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0709.jp2"}, "702": {"fulltext": "632 DISLOCATIONS.\\nclown some object from above his head, is an example of the third. The\\nmechanism in a fall upon the hand is doubtless the same as that in\\nincomplete dislocation outward produced in the same manner that is,\\noutward lateral flexion is produced the internal lateral ligament is\\nruptured, and then the bones are displaced laterally past one another\\nby the continued action of the weight of the body. In one of von\\nPitha s cases this lateral flexion was observed by the mother of the\\npatient, a boy, six years old, who saw the elbow bend as he fell from\\na tree upon his outstretched hand.\\nPathology. The only recorded autopsies are those of Bouley and\\nHeinlein in the former, a compound dislocation with fracture of the\\nexternal condyle produced by a fall upon the elbow from a height of\\ntwenty-eight feet, amputation was refused, and the patient died on the\\ntwenty-fifth day. The lateral ligaments of the elbow were entirely\\nruptured both bones of the forearm were placed externally to the\\nlower extremity of the humerus, and the ulnar nerve was lacerated at\\nthe level of the trochlea. In the latter both lateral and the anterior\\nligaments were torn, the radial nerve bruised a fragment was broken\\nfrom the head of the radius, and the coronoid process was broken.\\nThe radius and ulna were also broken near the middle.\\nDisregarding one or two exceptional forms, the cases may be grouped\\nin three classes according to the character of the displacement, but in\\nsome the account is not sufficiently complete to determine to which\\nclass the case should belong. In one, apparently the least frequent,\\nthe displacement is directly outward and a little upward, so that the\\ninner edge of the sigmoid cavity rests against the outer surface of the\\nexternal condyle, the elbow being partly flexed, with the olecranon\\nbehind and the coronoid process in front of the epicondyle. The\\nradius preserves its relations with the ulna and is situated still further\\nto the outer side, or is carried to a somewhat higher level by pronation\\nof the forearm. This involves complete rupture of the lateral and an-\\nterior ligaments. In Neilson s case it was thought the external condyle\\nwas broken the olecranon was three inches above its usual position.\\nIn the second class the forearm is pronated as well as flexed, and\\nthis pronation is effected by rotation about the long axis of the ulna,\\nso that the head of the radius lies above, or even further inward than,\\nthe ulna. The great sigmoid cavity embraces the outer surface of the\\nexternal condyle, the tip of the olecranon lying behind the condyle\\nand that of the coronoid process in front of it. The anterior surface\\nof the ulna looks inward. The head of the radius lies above its nor-\\nmal position, in front of the humerus, and possibly still in contact with\\nthe upper part of the articular surface of the capitellum. Study of\\nthe skeleton indicates that this form can be easily produced from an\\nincomplete outward dislocation by pronation of the limb it is, I think,\\nthe most common of the three classes, and it seems possible that the\\nexternal lateral ligament may be preserved untorn. Denuce has given\\nit the name of sub-epicondylar, in distinction from the following, third\\nclass, which he terms supra-epicondyhr. He thinks the distinction is\\nan important one and that the difference depends upon the rupture or\\nthe integrity of the attachment of the muscles upon the epicondyle.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0710.jp2"}, "703": {"fulltext": "OUTWARD DISLOCATIONS OF THE ELBOW.\\n633\\nIn the third class the ulna and radius, pronated and flexed, are car-\\nried higher up along the outer border of the humerus, two inches in\\nOsborne s case. The sigmoid cavity may embrace the supinator ridge,\\nand the radius still lies in front of the humerus, or both bones may be\\ndisplaced also backward so that the coronoid process and the articular\\nsurface of the radius are posterior to the ridge.\\nIt is noteworthy that in none of the cases is fracture of the epi-\\ntrochlea mentioned in one or two it is said that the epitrochlear\\nmuscles were torn away at their insertion.\\nTwo cases, in which an additional consecutive displacement had fol-\\nlowed by which both bones were brought around in front of the\\nhumerus and pronated so far that their posterior surfaces were directed\\nforward, were reported by Cloquet 1 and Maisonneuve. 2 The latter s\\npatient Avas a woman who had fallen out of bed upon her elbow, and\\nwho was so thin that the position of the bones could be accurately\\ndetermined the lower end of the humerus projected prominently\\nbehind and was there covered only by the skin, while the triceps\\nran forward and outward over the epicondyle. The ulna was com-\\nFig. 289.\\nFig. 290.\\nComplete outward dislocation of the elbow. Supra-\\nepicondylar. (Stimson.)\\npletely turned around so that its pos-\\nterior surface looked forward and the\\nsigmoid cavity lay against the front of\\nthe trochlea. The head of the radius\\ncould not be felt. The limb was\\nslightly flexed and greatly pronated.\\nReduction was effected by moving the\\nolecranon outward and backward\\naround the external condyle to the\\nback of the humerus, and then reducing in the usual manner the\\nbackward dislocation thus produced.\\n1 Cloquet: Quoted by Malgaigne, loc. cit., p. 616.\\n2 Maisonneuve Gaz. des Hopitaux, 1867, p. 145.\\n^x\\\\\\nComplete outward dislocation.\\n(Denuce.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0711.jp2"}, "704": {"fulltext": "634 DISLOCATIONS.\\nSymptoms. Of the first variety, dislocation directly outward with-\\nout rotation of the forearm (Fig. 289), Puech s case may be taken as\\na type. The patient was a man forty-one years old, and the injury\\nwas caused by a fall from a height of about two feet, the elbow striking\\nagainst some stones. The forearm was extended and supinated it\\ncould be passively flexed nearly to a right angle, but could not be pro-\\nnated its axis lay entirely to the outside of the humerus, and the\\ntransverse diameter of the elbow was nearly doubled. Tracing the\\nbones with the finger behind, from the epitrochlea outward, the sur-\\ngeon recognized all the points of the lower end of the humerus, then\\nthe olecranon well above and to the outer side of the condyle, and then\\nthe head of the radius lower than the olecranon but still above the\\nlower line of the humerus. In other similar cases extreme mobility\\nof the joint is mentioned as if the two segments of the limb were\\nvery loosely attached to each other.\\nIn the second variety, sub-epicondylar the axis of the forearm\\nappears generally to be inclined downward and inward (adduction)\\nflexion at, or even within (Pitha), a right angle is common semi-pro-\\nnation or full pronation. The transverse diameter of the elbow is\\nincreased, but not so much as in the preceding variety. The supinator\\nand radial extensor muscles form a well-defined prominence above and\\nin front of the joint the tendon of the triceps shows as a prominence\\ndirected downward and outward, and the tendon of the biceps can\\nsometimes be felt running in the same direction in front.\\nThe outlines of the lower end of the humerus can be distinctly\\ntraced from the epitrochlea outward to the capitellum the external\\nepicondyle is masked by the ulna, but sometimes can be felt by press-\\ning the finger deeply in above the latter. The cup-shaped surface of\\nthe head of the radius can be felt unless it lias been carried so far\\ninward by the pronation of the limb that it rests against the front of\\nthe humerus.\\nIn the third variety, supra-epicondylar (Fig. 290), the forearm\\nis flexed at, or nearly at, a right angle and pronated the transverse\\ndiameter at the lower part of the arm is increased. The greater the\\ndisplacement upward, the greater is the passive mobility of the limb\\nin the plane of flexion and extension. The lower end of the humerus\\nis accessible to the touch even more completely than in the two preced-\\ning varieties, for it projects completely below, and even its external\\ncondyle can be traced. The deformity on the outer side varies with\\nthe extent and character of the final displacement, for the bones of the\\nforearm are sometimes carried backward, crossing the humerus, or, as\\nin Maisonneuve s and Cloquet s cases, carried forward to the front of\\nthe humerus.\\nIt is noteworthy that in three of the four cases in which reduction\\nwas not made the patients had good control of the limb and a free\\nrange of motion was established. Wylie s patient thought his arm\\nwas as serviceable as ever. Robert s patient was seventy years old\\nand his injury dated from infancy he had an extensive range of\\nflexion and extension. In Denuce s case (Fig. 289) the olecranon\\nprojected nearly an inch behind the humerus, the arm could be fully", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0712.jp2"}, "705": {"fulltext": "FOBWABD DISLOCATIONS OF THE ELBOW. 635\\nextended and flexed nearly to a right angle. In ISelaton s case there\\nwas flexion nearly at a right angle.\\nIt is also noteworthy that in no case were there symptoms of inter-\\nference with the circulation, and in only one case (Mears) were there\\nsymptoms of injury to the nerves. In his there were pain in the fingers\\nand numbness in the distribution of the median nerve.\\nTreatment. Reduction has been effected without difficulty in all the\\nrecent cases, except TTinslow s, by extension and direct manipulation of\\nthe upper ends of the radius and ulna. The laceration of the ligaments\\nand muscles is so great that the bones are freely movable, and special\\nmanoeuvres intended to relax opposing bands are seldom necessary. Ex-\\nceptions to this may be found sometimes in the first and second varieties\\nin the first the head of the radius may pass through and be caught, as\\napparently happened in Puech s case, between two muscular bundles,\\nwhich may then need to be relaxed by flexing and abducting the fore-\\narm in the second, which appears sometimes, as has been said, to\\ndiffer from the incomplete outward dislocations only in the addition of\\npronation of the forearm, the external lateral ligament remaining\\nuntorn, the first movement must be to supinate the limb and thus turn\\nthe sigmoid cavity under the capitellum and bring the head of the\\nradius to the outer side the dislocation is then an incomplete outward\\none, and is reduced accordingly.\\nDISLOCATIONS OF THE FOREARM FORWARD.\\nAlthough mentioned by Hippocrates and characterized by him as the\\nmost painful of all and fatal in a few days, and admitted by all sub-\\nsequent writers, the first recorded case (and that a questionable one) of\\nthis dislocation was published only a hundred years ago, and the num-\\nber has not yet reached twenty-five, even including seven cases in\\nwhich the olecranon was broken off and remained in place. 1\\nOf the 13 cases in which the age is mentioned, 1 was six years old,\\nH were eight, 2 fourteen, 2 fifteen, and 1 each eighteen, twenty, thirty-\\nfour, thirty-eight, and forty years old, 1 was an adult, and 1\\nmiddle aged. The cause in the greater number of cases appears to\\nhave been a fall upon the flexed elbow in one (Pryor) it was a blow\\n1 The bibliography is as follows Evers, Monin, Guyot, Wittlinger, quoted by Streubel\\nin Prager Vierteljahrschrift, 1850, ii. p. 37, and by Malgaigne, loc. cit., p. 626 Guerre,\\nquoted by Pingaud in Diet. Encyclopedique, 1st ser., vol. xxi. p. 708 Chapel, quoted by\\nMalgaigne, loc. cit., p. 617, as a dislocation outward Colson, Leva, quoted by Debruyn\\nin Annales de la Chirurgie Francaise et Etrangere, 1843, vol. ix. pp. 44 and 45, and by\\nStreubel; Richet, Archives generales, 1839, vol. vi. p. 472; Prior, Lancet, 1844, ii. p. 366\\nAncelon, L Union Medicale, 1859, vol. iii. p. 394; Canton, Dublin Medical Journal, 1860,\\nii. p. 24 Secrestan, Gazette des Hopitaux, 1860, p. 598; Caussin, L Union Medicale, 1861,\\nvol. xi. p. 475, and Bulletins de la Societe de Chirurgie, 1861, vol. ii. p. 451 Richet, Bull,\\nde la Soc. de Chirurgie, 1859, vol. ix. p. 110 Morel-Lavallee, idem, p. 107 Greenaway.\\nquoted by Hutchinson. Medical Times and Gazette, 1866, i. p. 409 Langmore, Lancet,\\nabstract in New York Medical Record, 1867, vol. ii. p. 10 Rigaud, Bulletins de la Societe\\nAnatomique, 1870, p. 15; Date, Lancet, 1872, ii. p. 597; Mons, Deutsche Mil. Zeitschrift.\\n1877, p. 401 quoted by Poinsot, loc. cit., p. 951 Kronlein, Deutsche Chirurgie, Lief. 26.\\np. 30; Stimson, see Plate IX. Ray, quoted by Piatt, Fractures and Dislocations of Upper\\nExtremity, 1899, p. 200 Fulton, Med. Record, 1S97, vol. Iii. p. 738. References have also\\nbeen made to a case by Ferguson, Surgery, 3d ed., p. 241, one by Roser, Chirurg. Anat.,\\n1844, p. 477, and one by Flaubert.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0713.jp2"}, "706": {"fulltext": "636 DISLOCATIONS.\\nby the handle of a crane upon the back of the elbow in two certainly\\n(Date, Ray), and probably in others, it was a fall upon the palm of the\\nhand in Fulton s it was traction on the extended arm, without frac-\\nture of the olecranon in one (Caussin) the patient s hand was caught\\nbetween two cogwheels and both bones of the forearm were broken at\\nthe middle as well as dislocated and in one (Morel-Lavallee) the\\npatient fell from a wagon and was run over, the wheel passing across\\nthe elbow and breaking the olecranon and coronoid process.\\nIn seven of the cases the olecranon was broken, and in these the\\nmechanism of the dislocation is easily understood, for, the resistance\\nof the olecranon being removed, the two bones can be easily displaced\\nforward and upward along the front of the humerus by a force acting\\nupon the back of the forearm. Such cases, I think, should hardly be\\nput in this class the dislocation is secondary to, and made possible by,\\nthe fracture of the olecranon. A personal case of this kind is shown\\nin Plate IX. I have recently (1899) seen another. In the case of a\\nfall or of a blow 7 upon the flexed elbow the direction of the force is\\nprobably inclined somewhat away from the axis of the forearm and is\\nmore nearly parallel with the posterior portion of the articular surface\\nof the olecranon, and it must be great enough to rupture the lateral\\nligaments without the aid of leverage. All attempts to reproduce the\\ndislocation upon the cadaver by this mechanism, forced flexion and\\ndirect impulsion, have failed, except after preliminary division of the\\nlateral ligaments.\\nIn the case of a fall upon the hand there is clinical evidence to show\\nthat this form is closely allied to the lateral dislocations, and that it is\\nproduced by lateral outward flexion supplemented by sufficient torsion\\n(supination) of the limb to bring the olecranon forward under the\\ntrochlea in several cases the displacement was outward as well as for-\\nward in Chapel s, so far outward that the case has been classed with\\nthe lateral dislocations.\\nPathology. One autopsy (Richet), three amputations (Canton, Morel-\\nLavallee, Rigaud), tw T o compound fractures of the olecranon without\\namputation (Richet, Guerre), one compound dislocation without frac-\\nture (Prior), and experiments upon the cadaver show how great the\\nlaceration sometimes is. In Prior s case, in which the patient was\\nstruck upon the under side of the left arm at the elbow-joint by\\nthe rapidly-revolving handle of a crane, there was a large wound at the\\npoint where the blow was received, occasioning a general disconnec-\\ntion of its parts, muscular and otherwise, excepting immediately in\\nfront. The radius and ulna were driven upward and forward on the\\nhumerus the condyles of the latter and its shaft for two and a half\\nor three inches projected through the wound nearly at right angles\\nwith the forearm, as completely stripped as if cleaned with a knife.\\nThere was no fracture. Reduction was made the patient recovered\\nafter much suppuration in and around the joint, and the final result\\nwas good, the limb gaining in freedom and power.\\nIn Canton s case, the patient, a man forty years old, was thrown\\nfrom a wagon apparently he struck upon the extended hand, but the\\nforearm was immediately flexed and twisted under his chest. The", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0714.jp2"}, "707": {"fulltext": "FORWARD DISLOCATIONS OF THE ELBOW. 637\\nforearm was flexed, the hand supinated, the swelling very great, and\\nthe skin tense and threatening to slough over the internal condyle. The\\nanteroposterior and lateral diameters of the joint were increased, and\\nthe head of the radius could be indistinctly felt externally and ante-\\nriorly. The diagnosis was not made, and attempts to correct the\\nmaladjustment failed after a delay of forty-eight hours, during\\nwhich the swelling increased and sloughing was established, amputa-\\ntion well above the condyles was resorted to.\\nExamination of the limb showed (Fig. 291) that the upper surface\\nof the olecranon rested against the front of the capitellum the annular\\nand interosseous ligaments were whole, the anterior ligament was rup-\\ntured except in its centre, the posterior and both lateral ligaments\\nruptured. The triceps was completely detached from the olecranon.\\nThe two radial extensor muscles and all the muscles arising from the\\nepicondyle except the supinator brevis and the anconeus were detached,\\nas was also the epitrochlear head of the flexor carpi ulnaris. The ulnar\\nnerve was torn behind the condyle. The\\nother large nerves and the main vessels\\nwere uninjured.\\nRichet s first patient was eighteen years\\nold and had fallen from a height of forty-\\nfive feet. The forearm was slightly flexed\\nand in supination, and was immovable\\nit was shortened an inch, measuring from\\nthe epicondyles to the lower ends of the\\nradius and ulna. The olecranon was in\\nplace and movable; two inches below it\\nwas a large wound through which the lower\\nend of this fragment projected. The head\\nOf the radius and the broken end of the Forward dislocation of the elbow;\\nn 1 n Canton s case.\\nulna were recognizable m the told ot the\\nelbow a fingerbreadth above the condyles. Reduction was easy by\\ntraction, but recurrence at once followed. The patient died three hours\\nlater. The autopsy showed the annular ligament to be intact.\\nIn addition to these two varieties, dislocation with and without frac-\\nture of the olecranon, the difference between which is so important,\\nthere is another, based upon clinical and experimental evidence, to\\nwhich the name incomplete is given in it the upper end of the olecra-\\nnon rests against the under and anterior surface of the humerus instead\\nof passing upward in front of it. So far as can be inferred from the\\nreported cases it is the most common form. The use of the terms first\\nand second degree, to distinguish between the two forms, is, I think,\\nto be preferred to that of incomplete and complete.\\nIn ChapePs case the additional outward dislocation, which is noted\\nin several of the others, was so great that Malgaigne classes it with the\\noutward dislocations. The patient was a boy fourteen years old. The\\nradius formed a marked prominence under the skin on the outer side\\non its inner side could be felt the olecranon and its sigmoid cavity.\\nThe two bones overrode the humerus in front about two centimetres\\nthe epicondyle lay behind the ulna. Mons s case seems to me to be of", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0715.jp2"}, "708": {"fulltext": "6 38 DISLOCA TIONS.\\nthe same kind. It is quoted by Poinsot as a unique example of diver-\\ngent dislocation, ulna forward and radius outward. The description\\nis limited to this statement and does not definitely exclude the possi-\\nbility that the ulna may have been displaced outward as well as forward.\\nFracture of the epitrochlea has been observed in one case (Date s), a\\nboy fourteen years old, and this is the one in which the evidence that\\nthe dislocation was produced by external lateral flexion in a fall upon\\nthe hand is most complete. The head of the radius was prominent\\noutside of and below the outer condyle above it was a deep depression\\nin which the condyle could be obscurely felt the olecranon was below\\nits usual position, resting with its extreme end against the trochlea\\n(first degree, or incomplete). The limb was semi-flexed. Reduction\\nwas easy under chloroform the radius first, and then the ulna, going\\nback into place with a distinct snap. If this account of the positions\\nof the two bones is accurate the annular ligament was probably torn.\\nSymptoms. In five of the cases uncomplicated by fracture it is stated\\nthat the forearm was lengthened, more than an inch in one of thern,\\nand with this coincided a position of the limb which is mentioned in\\nseveral others, namely, slight or partial flexion, which could generally\\nbe changed somewhat in either direction. In one in which the range\\nof motion is specified (Langmore), the limb was held at an angle of 130\\ndegrees, could be flexed to a right angle and extended to 160 degrees\\nin another (Colson), hyperextension could be made without causing pain,\\nand during the movement the olecranon passed forward between the\\nbiceps and pronator teres.\\nIn correspondence with this lengthening there is flattening of each\\nside and of the back of the elbow, unless the swelling is sufficient to\\nmask it, with prominence of the inner and sometimes of the outer con-\\ndyle, and the formation of a transverse sulcus appreciable by the touch\\nbehind between the humerus and the olecranon. In one case the fore-\\narm was also abducted. In Canton s case the forearm was flexed\\nbeyond a right angle the olecranon rested against the capitellum, and\\nthe triceps was torn completely from it. It seems probable that detach-\\nment or rupture of the triceps is a necessary condition of the passage\\nof the olecranon to any distance along the front of the humerus, and\\nthat the existence or absence of the detachment may constitute the\\nessential difference between the complete and incomplete forms, or the\\nfirst and second degrees. The clinical features which differentiate the\\ntwo forms are that in the lesser form the olecranon is prominent below\\nthe humerus when the elbow is flexed, and the forearm is lengthened\\nwhen it is extended or but slightly flexed. In the second, complete\\nform, the forearm is more or less shortened when extended, but is\\nlengthened when flexed at or near a right angle, and its antero-poste-\\nrior diameter is increased because of the projection of the coronoid\\nprocess in the fold of the elbow. The biceps tendon can be recognized\\non the outer side of the latter, and beyond it the head of the radius.\\nPosteriorly, in both forms, the olecranon fossa is empty the direction\\nof the ulna also plainly indicates the change in the position of its\\nupper end unless the swelling is great.\\nCourse and Prognosis. In only one case (Canton) did the dislocation", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0716.jp2"}, "709": {"fulltext": "DIVERGENT DISLOCATIONS OF THE ELBOW. 639\\nremain unreduced, and, as in this the diagnosis was not made because\\nof the swelling, there is no reason to suppose that a suitable attempt\\nto reduce would have been less successful than it proved in the others.\\nIt was also the only case, of those uncomplicated by a compound frac-\\nture of the olecranon, that did badly and in which amputation was\\nthought to be necessary. The history of the case, moreover, suggests\\nthat the decision was reached rather hastily and on grounds that might\\nbe deemed insufficient.\\nOf the 7 compound dislocations, of which 6 were complicated by\\nfracture of the olecranon, 3 recovered, 2 underwent amputation after\\nthe joint had suppurated, 1 died three hours after the accident, which\\nwas a fall from a height of forty-eight feet, and in 1 (Kronlein) the\\nresult is unknown, Of the 3 recoveries, the joint suppurated in 2\\n(Prior, Richet s second), the process ending in anchylosis in one of them\\nin the remaining 1 the patient recovered apparently without suppura-\\ntion, the fracture of the olecranon united by a fibrous band one centi-\\nmetre long, and two and a half months after the accident the hand\\ncould be brought to the mouth and the elbow extended to an angle of\\n150 degrees. Whether antiseptic methods will improve this poor\\nrecord remains to be seen.\\nTreatment. In all the cases in which the olecranon rests against the\\nlower part of the end of the humerus, the so-called incomplete dislo-\\ncations, reduction has been easily effected by pressing or pulling the\\nupper end of the forearm downward and backward, or by flexing the\\nlimb against the knee or the arm of an assistant placed in the fold of\\nthe elbow. In Greenaway s case the bones slipped into place almost\\nspontaneously when the elbow was flexed.\\nIn the cases in which the bones are displaced further upward it is\\ndesirable to flex the limb within a right angle and then to pull the\\nupper ends of the bones back into place by a strap passed around the\\nfront of the forearm close to the elbow.\\nDislocations complicated by compound fracture of the olecranon must\\nbe treated in accordance with the general principles of treatment of\\ncompound articular fractures, of which they are a severe form, severe\\nbecause of the greater extent of the laceration of the soft parts. In\\nmy own case, simple fracture of the olecranon, seen about two months\\nafter the accident, I made reduction by an incision along the ulna\\nwhich exposed the joint and the fracture.\\nDIVERGENT DISLOCATIONS OF THE RADIUS AND ULNA.\\nThe characteristic feature of this form is that the radius and ulna\\ndo not accompany each other, but are displaced in divergent directions.\\nTwo varieties have been observed the antero-posterior, in which the\\nulna passes up behind the humerus, and the radius passes up in front,\\nand of which there are fourteen recorded cases l and the transverse, of\\n1 Bulley, Provincial Medical and Surgical Journal, 1841, quoted in the Gazette Medi-\\ncale, 1841, p. 666 Michaux, quoted by Debruyn in Annales de Chir. Francaise et\\nEtrangere, 1843, vol. ix. p. 52 Mayer, Gazette des Hopitaux, 1848, p. 232 Von Pitha,\\nPitha and Billroth s Chirurgie, 4th vol. 2d Abt. B. p. 78; Chevalier, Arch. Med. Beiges,\\nOctober, 1870, quoted by Bardeleben, Chirurgie, vol. ii. p. 759; Gripat, Bull, de laSociete", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0717.jp2"}, "710": {"fulltext": "640 DISLOCATIONS.\\nwhich there are two cases, in which the divergence was mainly lateral,\\nthe olecranon passing to the inner side behind the epitrochlea, and the\\nradius to the outer side. 1 Several authors make an additional variety,\\nulna backward, radius outward, on the basis of the case of Samuel\\nWhite quoted by Cooper, 2 which seems to me to be a dislocation of\\nboth bones backward and outward and Poinsot makes a fourth variety\\nof the case of Mons which I have placed among dislocations of both\\nbones forward.\\nA. Antero-posterior.\\nExcluding Chevalier s case, of which I have no details, the thirteen\\npatients were, with one exception (Tillaux), males, and with three\\nexceptions, adults two were nine years old, one thirteen. The cause\\nwas usually a fall from a considerable height, or with violence, as from\\na moving railway car, a horse, or a wagon in one it was a fall while\\ncarrying a heavy timber, in another while wrestling and in Tillaux s\\nthe patient, while lighting a match, struck her elbow against a piece\\nof furniture behind her the pain was so great that she fainted and\\nfell to the floor, where she was found with her elbow abducted and\\nflexed. Scott s patient was thrown from a horse, striking upon his\\nhead and hands he found his elbow dislocated and the forearm partly\\nflexed a bystander pulled it straight, and he felt something give way\\nin the joint, and a bone appeared to slip forward possibly a disloca-\\ntion of the ulna alone backward was thereby transformed into the\\ndivergent one which was afterward recognized. Von Pitha s patient\\nfell head foremost from the second story of a building upon a pile of\\nplanks between which the extended forearm was caught and held while\\nthe body was violently precipitated backward.\\nPingaud, 3 experimenting upon the cadaver, found it easy to produce\\nthe dislocation by forced pronation of the forearm after division of\\nthe internal lateral ligament this fact, taken in connection with the\\nfall upon the hand noted in several of the cases, indicates that the\\nmechanism, in these cases at least, is a lateral outward flexion, by\\nwhich the internal lateral ligament is ruptured, followed or accom-\\npanied by forcible pronation, and then by the direct movement down-\\nward of the humerus between the two bones. Fracture of the epi-\\ntrochlea observed in one case (Arnozan) supports the theory of outward\\nlateral flexion. In two cases (von Pitha, Gripat) the coronoid process\\nwas broken in both the fall was from a considerable height.\\nThe explanation of the mechanism in the two cases in which the\\ninjury was attributed to a fall upon the abducted and flexed elbow\\nAnatomique, 1872, p. 176 Arnozan, Bordeaux Med., 1873, p. 402, quoted by Poinsot, loc.\\ncit., p. 945 Tillaux, Gazette des Hopitaux, 1877, p. 786 Minich, Lo Sperimentale, 1880,\\nquoted by Poinsot Mason, New York Medical Kecord, 1880, vol. xvii. p. 397 Scott,\\nBristol Medico-Cbirurgical Journal, March, 1886, p. 36 Duret, reported by Vanheu-\\nverswyn, Journal des Sc. Med. de Lille, Sept. 9, 1892 Petzholdt, Arch, fur klin. Chir.,\\n1894, vol. xlix, p. 243 Ferguson, British Medical Journal, April 6, 1895, p. 753.\\n1 Guersant, reported by Warmont in Eevue Medico-Chirurgicale, vol. xvi. p. 303,\\nquoted by Pingaud in Diet. Encyclopedique, art. Coude, p. 600, and by Poinsot Wight,\\nPhysic, and Surgeon, Ann Arbor, February, 1893.\\n2 Cooper Dislocations and Fractures, American edition, p. 384.\\n3 Pingaud: Loc. cit., p. 598.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0718.jp2"}, "711": {"fulltext": "DIVERGENT DISLOCATIONS OF THE ELBOW. 641\\n(Michaux and Tillaux) shares in the difficulty which attaches to the\\nexplanation of dislocation of both bones backward by the same cause.\\nIf the alleged rotation of the ulna backward and outward around the\\nradius, by which the internal lateral ligament is torn, is accepted, it\\nwill not be difficult to conceive that the radius may remain in front\\nbut even this leaves unexplained the forcible descent of the humerus\\nbetween the two bones which requires the rupture of the annular and\\ninterosseous ligaments.\\nIn Duret s case the sigmoid cavity looked outward (supination), and\\nVanheuverswyn found he could reproduce this form upon the cadaver\\nby forced supination of the partly flexed forearm after division of the\\nupper part of the interosseous ligament.\\nPathology. Two of the patients (von Pitha, Gripat) died of the\\nassociated injuries, but the displacement at the elbow was much greater\\nthan that observed in the other cases.\\nIn von Pitha s the autopsy showed a wide separation of the radius\\nand ulna from each other, complete rupture of the capsule, and of the\\nannular, interosseous, and both lateral ligaments, fracture of the coro-\\nnoid process, and avulsion of the biceps and brachialis anticus.\\nIn Gripat s case, a boy thirteen years old, the coronoid process had\\nbeen broken off and the olecranon had passed almost directly upward,\\nremaining close to the posterior surface of the humerus the radius\\nwas displaced forward and outward. The internal lateral ligament\\nhad been torn away at both its insertions; the external one remained\\nattached at its upper insertion, and to the broken coronoid process and\\npart of the anterior ligament. The annular ligament was torn away\\nat its posterior attachment to the ulna.\\nSymptoms. The attitude of the limb is noted in nine cases in six\\nit was slightly flexed, in three nearly straight in one case supinated,\\nin the others midway between pronation and supination, or slightly\\npronated. The general appearance of the region probably resembles\\nthat of dislocation of both bones backward, for in three of the cases\\nthe anterior position of the radius was not noticed until after the ulna\\nhad been reduced. Excluding the two fatal cases, the displacement\\nof the ulna upward is still very marked four centimetres in Tillaux s\\ncase, two or three finger-breadths in Michaux s, and one and a half\\ninches above the condyles in Scott s and Ferguson s in Tillaux s it\\nwas also displaced somewhat to the inner side. In four cases the\\nposition of the radius is exactly noted in two (Bulley, Tillaux) it\\nwas in the coronoid fossa in Mason s it rested on the outer portion\\nof the humerus in Petzholdt s it overlapped the inner edge of the\\ntrochlea.\\nActive movements, both flexion and rotation, are impossible, and\\npassive movements restricted and painful.\\nIn two cases (Mayer, Tillaux) reduction failed, the attempt being\\nmade on the fourteenth and eighth days respectively. In both the\\njoint remained quite stiff. In Mason s the attempt was made on the\\nnineteenth day prolonged efforts under ether brought the ulna into\\nplace, but the radius slipped toward the outer side and could not be\\nentirely reduced. The final result is not known. In the others\\n41", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0719.jp2"}, "712": {"fulltext": "642 DISLOCATIONS.\\nreduction was effected without much difficulty, usually the ulna first,\\nthen the radius, but in Bulley s the radius remained a little forward,\\nand was finally reduced by continuous pressure upon it.\\nTreatment. Traction should be made in the direction of the axis\\nof the forearm to bring the ulna into place, and in case of need it\\nmight be well to combine it with some outward lateral flexion to avoid\\nthe opposition of the external lateral ligament; after the ulna is\\nreduced the radius should be pressed back into place with the thumbs\\naided by pronation and adduction of the forearm. It is quite likely\\nthat the return of the radius to its place may be impeded by the inter-\\nposition of the annular ligament.\\nB. Transverse.\\nOf this variety there are only two recorded cases. Guersant s is as\\nfollows The patient was a boy fifteen years old, who fell from a tree,\\nthree or four metres, on his left side, striking on the palm of his\\nhand. The elbow was enormously swollen the transverse diameter\\nwas greatly increased, and the antero-posterior one seemed lessened.\\nThe head of the radius formed a considerable prominence entirely to\\nthe outer side of the epiphysis of the humerus and a little upward\\nalong its outer border. It was so far displaced outward that there\\nseemed to be an interval between it and the epicondyle the skin was\\nvery tightly stretched over it.\\nThe olecranon was displaced inward behind the epitrochlea, which\\nit embraced in its sigmoid cavity. In the great space between the\\nolecranon and radius lay almost the entire articular surface of the\\nhumerus.\\nThe forearm was semi-flexed, and in a position midway between pro-\\nnation and supination voluntary movements were impossible, passive\\nmovements very restricted. There was also a fracture of the forearm\\nthree centimetres from the wrist.\\nWight s patient was a woman thirty years old, who had fallen while\\nwalking, the pronated right arm being caught under the body. Sup-\\nposing the injury to be a backward dislocation he attempted to reduce\\nunder ether, and after failing made a closer examination. He then\\nfound that the radius was on the outer and the ulna on the inner side\\nof the humerus. No other details. He reduced the radius by press-\\ning on its head while making traction and adduction, and then the\\nulna by traction and adduction (abduction using the external con-\\ndyle as a fulcrum, and at the same time firmly flexing the elbow.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0720.jp2"}, "713": {"fulltext": "CHAPTER XLVI.\\nDISLOCATIONS OF THE ELBOW.\u00e2\u0080\u0094 (Continued.)\\nIsolated Dislocations of the Ulna and Radius.\\nDISLOCATIONS OF THE ULNA ALONE.\\nSedillot, in a paper presented to the Academic des Sciences in 1837,\\nwas the first of modern writers to call attention to this class of dislo-\\ncations, although Sir Astley Cooper had previously described as of\\nthis kind a specimen preserved at St. Thomas s Hospital. Malgaigne\\nand other surgeons and writers strenuously opposed the interpretation\\nof cases cited in support of the claim that the occurrence of this form\\nis possible, and denied the possibility on anatomical grounds, claiming\\nthat the ulna cannot be displaced backward and upward unaccompanied\\nby the radius, except after rupture of the interosseous ligament and\\nthose uniting the lower ends of the bones, of which there is no clinical\\nevidence. The specimen figured and described by Cooper is claimed\\nby them to be one of dislocation backward of both bones, and one\\npresented by Robert to the Societe de Chirurgie, in 1847, was declared\\nby Malgaigne to be of the same character. I have examined Cooper s\\nspecimen, which is still preserved at St. Thomas s Hospital, and have\\nno doubt that it is simply an old unreduced backward dislocation\\nof both bones, the error in interpretation having been due to a failure\\nto appreciate the new formation of bone behind the external condyle.\\nMalgaigne admits, however, on the authority of a case observed by\\nhimself, the possible dislocation of the ulna alone backward and to the\\nouter side behind the radius. The dispute is in part one of terms it\\nmust be admitted, I think, that the head of the radius in some of\\nthe reported cases has changed its relations with the capitellum, but\\nthe change is a very slight one, a simple slipping backward or forward\\nfor a distance of a few millimetres, without a change in its level corre-\\nsponding to that of the ulna. The erroneous belief in the impossibility\\nof the occurrence without the extensive lacerations mentioned arose\\napparently from a failure to consider the effect of a change in the rela-\\ntion of the axes of the arm and forearm, for while the occurrence of\\nan isolated dislocation of the ulna backward and upward might be\\nimpossible while those relations remained unchanged, yet if, the joint\\nbeing extended, the forearm is adducted, turning upon the head of\\nthe radius as a centre, the olecranon must necessarily move upward\\nbehind the humerus or, the joint being flexed at a right angle, the\\nsame movement of adduction will displace the olecranon backward\\nin like manner abduction of the forearm can bring the olecranon for-\\nward or downward.\\n643", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0721.jp2"}, "714": {"fulltext": "644\\nDISLOCATIONS.\\nThe following recorded cases serve as a basis of the description to\\nbe given. Some in which the correctness of the diagnosis is in doubt,\\nor of which I have not been able to consult the detailed reports, have\\nbeen omitted.\\nFig. 292.\\n1. Backward Dislocation.\\nBackward dislocation presents itself under three forms. In the\\nfirst, that in which the displacement is slightest, the ulna is carried\\nbackward, either directly or by inward rotation of the forearm about\\nthe radius as a centre, until the coronoid process has cleared the\\ntrochlea, and then is moved slightly upward behind it by adduction\\nof the forearm (Fig. 292) in the second form, the movement upward\\nis prolonged until the coronoid process lodges in the\\nolecranon fossa in the third, the primary movement\\nof rotation is prolonged until the olecranon lies behind\\nthe radius. The first form is the most common, and\\nis sometimes termed incomplete/ in accordance\\nwith a similar use of the term in the backward dis-\\nlocation of both bones of the second form there are\\nonly two recorded examples (Malgaigne, Wilson).\\nSome writers make an additional variety, dislocation\\nbackward and inward, a distinction which it does\\nnot seem necessary to preserve.\\nCause. The cause in the larger number of cases\\nhas clearly been a fall upon the outstretched hand\\nin one, Brun, a blow received upon the elbow from\\nbehind while the weight of the body rested upon the\\nextended arm.\\nIn von Pitha s case the injury was received in such\\na way that the mode of production is clearer than in\\nmost accidents, and, as the case is typical in other\\nrespects, I reproduce the account.\\nA girl six years old and her little brother were\\nengaged in a trial of strength, in which each sought\\nto move an open door against the other s opposition,\\nthe girl standing with her back against the wall and her out-\\nstretched hands against the door, the hinges being at her left side.\\nTwo other brothers came to the help of the first, and under their com-\\nbined efforts the girl s left arm suddenly doubled up with an audible\\nsnap, and when von Pitha examined it half an hour later, he found\\nthe most distinct picture of a dislocation of the ulna backward.\\nThe thin arm was in almost complete extension, the forearm being\\n1 Boudant, Revue Medicate, 1830, vol. i. p. 85, quoted in full by Sedillot Sedillot,Gazette\\nMedicale, 1839, vol. vii. p. 369 Diday, idem, p. 393 Brun (three cases I, idem, 1844, p. 580\\nRobert, Gazette des Hopitaux, 1847, p. 272 von Pitha, Pitha and Billroth s Chirurgie,\\nvol. iv. part ii. B, p. 87 Malgaigne, Luxations, p. 631 Duguet, Bulletins de la Societe\\nAnatoniique, 1863, p. 278; Mathieu, Gazette des Hopitaux, 1866, p. 330; Waterman, Bos-\\nton Medical and Surgical Journal, 1869, vol. Ixxxi. p. 1S7; Wilson, Canada Journal of\\nthe Medical Sciences, 1880, vol. v. p. 346; Waters, Maryland Medical Journal, 1883, vol.\\nx. p. 402 Loison, Arch, de Med. et Pharm. Mil., September, 1890, inward Weight, Brook-\\nlyn Medical Journal, September, 1S89; and Stimson, case here given, both forward.\\nDislocation of ulna\\nalone backward, first\\nform. (Sedillot.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0722.jp2"}, "715": {"fulltext": "DISLOCATIONS OF THE ULNA ALONE. 645\\nslightly inclined toward the ulnar side the fold of the elbow was some-\\nwhat raised by the projecting trochlea the olecranon was very promi-\\nnent behind, but barely raised above its normal level the elbow was\\nnotably thicker, but not broader the head of the radius was in its\\nplace pronation and supination were but slightly restricted, but the\\nleast movement of flexion was very painful. Reduction was easily\\naccomplished by grasping with the left hand the humerus above the\\ncondyles, and with the right the forearm in such a way that the thumb\\nand lingers specially compressed the ulna, and then supinating, abduct-\\ning, and extending until there was slight dorsal flexion at this moment\\nhe distinctly felt the lifting of the coronoid process, and on increasing\\nthe traction it suddenly slipped back over the trochlea with a snap.\\nPain at once ceased, and the patient could flex the joint.\\nExperiments upon the cadaver by Sedillot and Streubel l indicate\\nthat the mode of production is similar to that of backward dislocations\\nof both bones together that is, the forearm is abducted (Streubel) or\\nhyperextended (Sedillot) until the internal lateral ligament yields, and\\nthen rotated inward and adducted to carry the coronoid process past\\nthe trochlea and engage its point against the posterior surface of the\\nlatter. If the adduction is increased, and especially if at the same\\ntime the orbicular ligament is torn, the olecranon rises to a higher point\\nand may pass to the inner side. If, on the other hand, adduction is\\nabsent and the rotation is prolonged, the olecranon is carried around\\nbehind the radius, and the form is produced.\\nPathology. Two specimens (Robert, Duguet) and one compound\\ndislocation (Boudant) furnish but scanty information of the patholog-\\nical details, for which we must mainly depend upon experiment. Of\\nthe two specimens, Robert s alone was of a recent case.\\nDuguet s specimen was taken from a man, fifty years old, who had\\nreceived the injury twenty years previously. There was anchylosis in\\nthe extended position, but pronation and supination were preserved.\\nThe ulna was displaced backward and upward so that its upper end\\nwas two centimetres above the line uniting the two epicondyles, and a\\nnearthrosis had formed between the tip of the olecranon and the back\\nof the humerus above and a little to the inner side of the olecranon\\nfossa. It is probable, therefore, that the coronoid process was lodged\\nin the olecranon fossa. Concerning the radius two statements are made\\nthe first is that it had preserved its relations with the external condyle\\nthe second, that it was appreciably (sensiblement) displaced forward,\\nand nreserved its movements of rotation. I understand these to mean\\nthat the head was directly below the condyle and a very little in front\\nof the position it would normally occupy in that attitude (extension\\nof the limb).\\nIn Robert s case the injury was caused by a fall on the palm of the\\nhand the limb was partly flexed, the olecranon prominent posteriorly\\nand elevated the head of the radius could not be felt because of the\\nswelling, but it could be moved backward and forward with cartilagi-\\nnous crepitus. At the autopsy the coronoid process was found in the\\nolecranon fossa, and the radius in place; the humerus appeared to have\\n1 Streubel: Prager Vierteljahrschrift, 1850, ii. p. 54.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0723.jp2"}, "716": {"fulltext": "646 DISLOCATIONS.\\nbeen twisted so that its anterior aspect looked outward (in other words,\\nthe forearm was addncted) the annular ligament and some of the fibres\\nof the external lateral ligament were torn. The condition of the inter-\\nnal lateral ligament is not mentioned. The brachialis anticus and\\nbrachial artery were ruptured.\\nBoudant s patient w T as a man forty-nine years old, who had fallen\\nfrom the first story of a building and received a compound dislocation\\nthe wound was eighteen or twenty lines in length on the inner and\\nanterior part of the elbow, and was thought to have been caused by\\ncontact with a large, rough stone. It seems, however, not unlikely\\nthat it was caused from within outward by the pressure of the trochlea\\nin hyperextension of the joint. The olecranon, which was prominent\\nposteriorly, could be seen through the wound, and the finger introduced\\ninto the latter recognized the radius in place. Reduction was easy, and\\nthe patient made a good recovery.\\nThe experiments made upon the cadaver show that the internal\\nlateral ligament is always ruptured, and that the orbicular ligament\\nescapes injury if the displacement is not great.\\nSymptoms. In the first and second forms, dislocation backward and\\nupward, the limb is usually in almost complete extension (in Duguet s\\nand Waterman s cases it was flexed at a right angle), and cannot be\\nflexed without causing much pain, but pronation and supination are\\nfree and painless. The normal deflection of the forearm toward the\\nouter side is lost, and in its place may be a deflection toward the ulnar\\nside. This deflection is easily recognized by the eye when the limb is\\nextended, but when the joint is flexed at or near a right angle it may\\nbe overlooked unless comparative measurements are made in Diday s\\ncase the length of the ulnar border, from the epitrochlea to the lower\\nend of the ulna, was an inch shorter than that of the other arm, while\\nthe radial borders were of equal length. The antero-posterior diameter\\nof the joint is increased, and the fold of the elbow is filled out by the\\ntrochlea.\\nThe olecranon is prominent behind the humerus, and may rise well\\nabove the line of the epicondyles it may be nearer the epitrochlea\\nthan usual. The head of the radius can be felt in its place, and it is\\nby the determination of this fact, together with the displacement of the\\nolecranon, that the diagnosis of the variety of the dislocation is made.\\nIn the two recorded cases of the third form, dislocation of the ulna\\nbackward and outward behind the radius (Malgaigne, Wilson), the\\nelbow was flexed nearly at a right angle. In Malgaigne s the forearm\\nwas pronated and deviated outward; the greater sigmoid cavity was\\ndirected outward (sic), the coronoid process outward and forward.\\nThis attitude of the ulna suggests that the dislocation was not effected\\nby rotation of the forearm.\\nTreatment. In Dnguet s case reduction was not made in the others\\nit was easily obtained. Waterman tried Cooper s method of the knee\\nin the elbow, and Skey s of traction upon the upper part of the flexed\\nforearm in the line of the humerus, without success, and. then easily\\nreduced by hyperextension. The readiest method in the first and\\nsecond forms appears to be that employed by von Pitha, and described", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0724.jp2"}, "717": {"fulltext": "DISLOCATIONS OF THE RADIUS ALONE. 647\\nabove supination, abduction, and hyperextension of the forearm.\\nMalgaigne and Wilson reduced (third form) by direct pressure upon\\nthe olecranon, first backward to free it from the radius, and then\\ninward.\\n(A case described by Bichet, 1 as a new kind of dislocation by rota-\\ntion, seems, from its title and from some of its features, to belong to\\nthis class, but the account is so incomplete that it is not available.)\\n2. Dislocation Inward.\\nOf this there is only one reported case, Loison s. The patient, a\\nman twenty-four years old, fell backward upon the left elbow, bruising\\nthe skin on the inner side an inch below the epitrochlea; the wounds\\nsuppurated the diagnosis was not made until the forty-second day.\\nThen the radius was found in place, and the olecranon displaced inward\\nso that the sigmoid cavity embraced the epitrochlea. Four months\\nafter the accident, reduction not having been made, the limb could be\\nactively flexed to 80 degrees and extended to 135 degrees rotation\\napparently well preserved.\\n3. Dislocation Forward.\\nMarch 13, 1895, I saw at the Hudson Street Hospital a man thirty-\\nfive years old, who had injured his right elbow in falling backward,\\nthe arm being caught under him. As he complained of handling I\\ngave ether, Dr. Carmalt assisting. The following notes were made at\\nthe time The elbow is held at a right angle, but can be somewhat\\nflexed and extended is movable laterally. The epitrochlea can be\\nplainly felt, also the inner face and edge of the trochlea, the overlying\\nflexor muscles of the hand having been torn away from the humerus.\\nThe tip of the olecranon is below and even a little in front of the\\ntrochlea, the inner anterior portion of the articular surface of which\\ncan also be felt on depressing the skin. The head of the radius is in\\nplace in front of the capitellum. The forearm is markedly abducted.\\nReduction was easily made by slight rotation backward (pronation)\\nof the ulna and adduction of the forearm. Then by pronation and\\nabduction the dislocation could be easily reproduced. When the bones\\nwere in place abduction of the forearm was possible, but not adduction.\\nApparently the lesions were avulsion of the flexor muscles from the\\nhumerus and rupture of the internal lateral ligament. The ulnar\\nnerve was uninjured.\\nThe only other reported case is Wight s the symptoms were similar,\\nand reduction was easily made.\\nDISLOCATIONS OF THE RADIUS ALONE.\\nAlthough statistics show that these dislocations are not very rare (1.4\\nto 4 per cent, in the tables in Chapter XXVII.)? an d although the\\n1 Richet Nouveau genre de luxation incomplete du coude par pivotement. Gazette\\ndes Hopitaux, 1879, p. 737.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0725.jp2"}, "718": {"fulltext": "648 DISLOCATIONS.\\nearliest writers mentioned them, yet they were almost completely lost\\nsight of until about one hundred and fifty years ago, and even now\\nare far from being clearly understood. Duverney, in 1751, gave a\\ndetailed account of two forms. Since that time observations have\\naccumulated, and four varieties are now well established the dislo-\\ncations forward, backward, and outward, and one seen exclusively in\\nchildren, and caused by traction upon the wrist, the nature of which,\\nthough not entirely undisputed, is generally believed to be a diastasis\\nor direct separation it is usually termed dislocation by elongation.\\nThe mode of production of all the forms is still obscure, and the\\nnumerous experiments that have been made upon the cadaver by vari-\\nous investigators, Roser, Malgaigne, Streubel, Denuce, Pingaud, Barros,\\nwhile they have shown how the dislocations may be produced upon the\\ncadaver, have not made it clear how they actually are produced in the\\npatients who come under observation in some cases the clinical facts\\ndirectly contradict the conclusions drawn from experiment.\\n1. Dislocation Backward.\\nThis was one of the forms described by Duverney, and one of the\\nearliest to be accepted as proved by later surgeons. Its apparent fre-\\nquency is in part due to the inclusion in the list of reported cases of\\nthose in which the dislocation is associated with fracture of the internal\\ncondyle, and probably also of others which belong in the group of dis-\\nlocations by elongation. Two varieties are described, the complete and\\nthe incomplete, the latter resting upon a few questionable and one\\nwell-observed case, that of Denuce l a lad nineteen years old fell from\\na swing, his pronated arm being caught under his body in such a way\\nthat the blow, as shown by an ecchymosis, was received upon the\\nmiddle of the anterior aspect of the forearm. Pain limitation of\\nmotion the elbow semiflexed, the forearm fixed in complete prona-\\ntion. A bone-setter tried in vain to reduce it, and a fortnight later\\nthe patient consulted Denuce, who found behind the elbow, on a level\\nwith the condyle, and to the inner side of the epicondyle, a small promi-\\nnent tumor, which rolled under the finger in pronation, and was evi-\\ndently the head of the radius, a little overlapping its ordinary position\\nposteriorly.\\nOf the complete cases the instances are much more numerous, but\\nin some of them the question arises whether the upper surface of the\\nradius had entirely left the articular surface of the capitellum, or was\\nstill in contact with it by its anterior portion if such contact did exist,\\nthe term complete can be properly applied only to the separation\\nof the radius from the lesser sigmoid cavity of the ulna.\\nThe cause, in the majority of cases, appears to have been a fall upon\\nthe outstretched hand that the cause was a fall in most cases is certain,\\nbut whether it was upon the hand or the elbow is often far from clear,\\nor whether it acted by direct impulsion or by exaggerated rotation.\\nIn a case reported by Cameron 2 the character and mode of action of\\nthe violence are more clearly shown than usual, but they are entirely\\n1 Denuce Diet, de Med. et Chir. pratiques, art. Coude, p. 777.\\n2 Cameron Lancet, 1884, vol. i. p. S85.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0726.jp2"}, "719": {"fulltext": "DISLOCATIONS OF THE RADIUS ALONE. 649\\nexceptional, and the ease does not aid to clear up the obscurity in which\\nthe question is enveloped. The patient was a man fifty-two years old,\\nwho was caught between a wall and a cart backing against it in such a\\nway that his forearm was compressed lengthwise between them, the\\npalm of the hand being pressed against the cart, and the back of the\\nelbow against the wall probably the hand was completely pronated.\\nWhen seen, immediately after the accident, the head of the radius lay\\njust under the skin behind the external condyle, where it formed a\\ndistinct projection, revealing to the eye its characteristic shape with the\\ncavity on its extremity. The hand and forearm were prone all move-\\nments were painful, and gave the impression of considerable fixity of\\nthe joint. Pain at the wrist led to an examination, which showed\\nthat the styloid extremity was also dislocated downward, exactly as\\nin cases in which the radius is shortened by the common fracture of\\nits lower extremity.\\nWhile the character of the force and the direction of its action in\\nthis case are clear, pressure exerted against the lower end of the radius\\nin the line of its long axis, yet it is far from being clear how such a\\nforce, so applied, could produce such a displacement, for the head of the\\nradius is squarely placed against the anterior face of the capitellum,\\nnot upon an inclined surface along which it could be displaced. And\\nyet, that there is something in the anatomical structure of the joint\\nwhich permits the occurrence and forbids the rejection of the case on\\nthe supposition of abnormal conditions, is indicated by the fact that\\ntwo similar cases have been reported by Wagner, 1 in which the mode\\nof production was the same as in Cameron s, but the head of the radius\\nwas displaced to the outer side of the condyle instead of behind it,\\nand a flat, wedge-shaped piece was broken off its inner side.\\nStreubel, 2 in his experiments upon the cadaver, found that he could\\nproduce the dislocation in only one way, by hyperextending the supi-\\nnated forearm until the head of the radius had been carried completely\\nbehind the line of the condyle, then forcing it upward, and at the same\\ntime bending the forearm to the radial side, and finally flexing it again\\nwhile holding the radius pressed firmly back with the thumb of the hand\\nthat grasped the forearm. It is by no means probable that this rather\\ncomplicated manoeuvre, which, moreover, has entirely failed in my\\nhands, is a reproduction of what has taken place in the falls that have\\nproduced the dislocation. The radius is dislocated not only from the\\nhumerus, but also from the ulna, and this requires the rupture of the\\norbicular ligament. To effect that, something more is required than\\nhyperextension of the elbow, even with the addition of direct propul-\\nsion upward of the radius. Supination of the forearm will not effect\\nit, aud while direct propulsion backward of the bone would undoubt-\\nedly produce the dislocation, the clinical facts do not indicate this as\\nthe cause. Possibly in hyperextension and outward lateral flexion, as\\nin StreubePs experiments, the head of the radius may become engaged\\nbehind the slight projection of the articular surface of the capitellum\\nat the bottom of the condyle, and be thereby prevented from accom-\\n1 Wagner Beilage zum Centralblatt fur Chirurgie, 1886, No. 24, p. 93\\n2 Streubel Prager Vierteljahrschrift, 1S50, vol. ii. p. 68.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0727.jp2"}, "720": {"fulltext": "650\\nDISLOCATIONS.\\npanying the ulna in its return forward when the elbow is again flexed this\\nwould supply the strain necessary to separate the radius from the ulna,\\nbut I must add that all the attempts I have made thus to produce the dis-\\nlocation were fruitless the result was always a dislocation of both bones.\\nThere are no post-mortem records of recent cases, and the dissection\\nof those of long standing is not an entirely trustworthy indication of\\nthe condition and the relations of the parts when the injury is fresh.\\nA case observed by Mr. Rivington L is of particular importance, because\\nthe position of the head is more exactly noted than is usual in the\\ndescriptions. The patient was a lad fourteen years old, and the injury\\nhad been received five months previously in a scuffle, during which he\\nwas violently shaken by the forearm, and thrown down, striking his\\nelbow against the leg of a table. There was a marked prominence\\nat the back of the joint below the external condyle, and by the side\\nof the olecranon process. The head of the radius was displaced\\nmore directly backward than is usual, according to the descriptions of\\nthe books, not lying in any wise behind the external condyle, but a\\nlittle overlapping the articular end of the humerus. Flexion and\\nextension were almost unimpaired, pronation was good, and supination\\nto more than half the usual extent. Reduction failed.\\nIn a specimen of an old dislocation, which had been received in child-\\nhood and had existed for many years, presented by Petit 2 to the Society\\nAnatomique, the head of the radius was directly below the summit of\\nthe epicondyle when the elbow was flexed at a right\\nangle. In another specimen found in the dissect-\\ning-room and described and figured by Sir Astley\\nCooper, the head of the radius could be seen, as\\nwell as felt, behind the external condyle of the os\\nhumeri. The coronary ligament was torn through\\nat its forepart, and the oblique had given way.\\nThe capsular ligament was partially torn, and the\\nhead of the radius would have receded still more,\\nhad it not been supported by the fascia which\\nextends over the muscles of the forearm. The\\naccompanying figure (Fig. 293) indicates that the\\nhead of the radius had risen very slightly above\\nthe lowest part of the articular portion of the con-\\ndyle, and that its position was probably the same\\nas in Mr. Rivington s case.\\nIn another specimen of old dislocation presented\\nto the Soci6te de Chirurgie by Bernadet, 3 the head\\nof the radius had been displaced a little backward,\\ndownward, and outward the external lateral liga-\\nment entirely covered the cup-shaped surface of\\nthe head the annular ligament no longer existed\\nexcept upon the inner side, and there it was notably thickened and\\nobliquely deviated.\\n1 Eivington Lancet, 1879, vol. ii. p. 942.\\n2 Petit: Bull, de la Societe Anatomique, 1874, p. 904.\\n3 Bernadet Bull, de la Soc. de Chir., 1861, p. 462.\\nFig. 293.\\nJ JW*\\nDislocation of the\\nhead of the radius\\nbackward. (Cooper.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0728.jp2"}, "721": {"fulltext": "DISLOCATIONS OF THE RADIUS ALONE. 651\\nIn the specimens which Streubel obtained by experiment he always\\nfound the anterior portion of the capsule torn and the capitellum\\nprojecting through the rent the external lateral ligament was more or\\nless torn at its anterior border, the internal lateral ligament uninjured\\nthe annular ligament was always torn in front, either at its insertion\\nby the lower sigmoid cavity, or further outward the oblique ligament\\nwas torn, doubtless in consequence of the exaggerated supination.\\nThese facts, though not numerous or entirely free from objection,\\nindicate that the position of the dislocated head of the radius, even in\\nfull extension, is lower than that commonly assigned to it in systematic\\ndescriptions and shown in the plates accompanying them that it does\\nnot rise above the shallow groove which marks the posterior and lower\\nmargin of the articular surface of the capitellum. At this point the\\nupper margin of the head would be but very little below the axis of the\\njoint, and consequently would have to move over only a short distance\\nin full flexion and extension of the limb.\\nIn recent cases the elbow is slightly flexed, the forearm pronated\\nvoluntary and communicated movements are painful and limited in\\nrange, but in old cases the freedom of motion is almost completely\\nrestored, supination remaining the most imperfect. The diagnosis is\\nmade by recognition of the head of the radius behind its normal place\\nin extension, behind and below it in flexion at a right angle. It may\\nlie close beside the olecranon or further to the outer side. Its projec-\\ntion, unless the swelling is considerable, is such that the entire extent\\nof its concave upper surface can be felt. Measurement of the radial\\nborder of the forearm from the epicondyle to the styloid process of the\\nradius may show some shortening, half an inch according to Streubel.\\nTreatment. The dislocation in recent cases has usually been reduced\\npromptly by pressure on the head of the radius, aided or not by trac-\\ntion upon the wrist, and this method has succeeded even when several\\nweeks had passed since the receipt of the injury. But in some cases\\nreduction has been impossible or the displacement has shown a marked\\ntendency to recur, both circumstances probably due in the recent cases\\nto the interposition of a portion of the capsule, but in the older ones\\nalso to permanent change in the relations of the shafts of the radius\\nand ulna and to adhesions between them. This interposition of the\\ncapsule has been demonstrated in one or two cases in which arthrotoniy\\nhas been done (see Chapter XLVIL). Probably the best position to\\ngive the limb during the attempt is that of supination and full exten-\\nsion, and if direct pressure does not then restore the bone to its place\\ntraction should be made at the wrist, and the forearm gradually bent\\nto the inner side, and then the direct pressure renewed.\\nIn some old cases excision of the head has improved function;\\n2. Dislocation of the Radius Outward. 1\\nExcluding the cases in which the dislocation is accompanied by frac-\\nture of the ulna in its upper portion and those in which the displace-\\n1 For bibliography see Nelaton, Path. Chir., vol. ii. p. 400 Gerdy, Arch. gen. de Med.,\\n1835, vol. vii. p. 161 Parker, New York Journal of Medicine, 1852, p. 189 Pitha and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0729.jp2"}, "722": {"fulltext": "652\\nDISLOCATIONS.\\nFig. 294.\\nment outward is comparatively slight and is associated with a more\\nimportant displacement backward or forward, the recorded instances\\nof this injury are very few, and in some of these, even, the description\\njustifies a doubt whether they should not rather be placed in one of\\nthe two other classes.\\nIn Nelaton s case the dislocation occurred in childhood and had\\nexisted for twenty years the position of the radius is shown in Fig.\\n294. Flexion and extension were preserved supination was impos-\\nsible.\\nWagner reported to the German Surgical Congress, in 1886, three\\noases of dislocation outward complicated by fracture of the inner por-\\ntion of the head of the radius. In the\\nfirst two cases the injury was caused\\nby pressure against the back of the\\nflexed elboAV while the palm of the\\nhand was resting against a firm object\\nin front. Thus, a lad, eighteen years\\nold, pushing a coal-wagon on a tram-\\nway with his forearm pronated and\\nflexed, was struck on the elbow by\\nanother wagon coming up from behind.\\nA year had elapsed since the accident\\nwhen the first case was seen, during\\nwhich the joint had been steadily grow-\\ning stiffer. The elbow was flexed at a\\nright angle; flexion, extension, and\\nrotation were almost entirely lost. On\\nthe outer side of the external condyle\\nwas a large bony prominence, the\\nthickened and immovable head of the\\nradius there were no abnormalities in\\nthe other parts of the joint, and no\\nsign of a fracture of the ulna. The\\nhead of the radius was excised it was\\nfound thickly enveloped in fibrous tis-\\nsue, to which the appearance of thick-\\nening was due, and had lost from its\\ninner side a flat, w 7 edge-shaped piece\\nconstituting about one-sixth of its di-\\nameter. The fragment w T as found ad-\\nherent to the capsule and was also removed. Recovery took place\\nwithout accident, and the mobility of the joint steadily increased for\\nsome time. At the time of the report, nine years later, flexion could\\nbe made to an angle of 80 degrees, extension to 150 degrees, pronation\\nw r as almost normal, supination somewhat restricted.\\nIn the second case, a man, twenty-six years old, was injured in the\\nBillroth, Chirurgie, vol. iv. Part II. B. p. 92; Pingaud, Diet. Encyclop. des Sc. Med., art.\\nCoude Wagner, Beilage zum Centbl. fur Chir., 1886, No. 24, p. 93; Lobker, ibid., p. 92;\\nBartels, Arch, fur klin. Chir., 1874, vol. xvi. p. 643; Schroter, ibid., vol. xlvi. p. 4.\\nThomassin s and Chedieu s cases, quoted by Malgaigne, seem to belong among the\\nanterior dislocations.\\nDislocation of the head of the radius\\noutward the trochlea is much broadened.\\n(Xf.laton.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0730.jp2"}, "723": {"fulltext": "DISLOCATIONS OF THE RADIUS ALONE. 653\\nsame manner, and was seen while the injury was fresh. Reduction\\nwas effected, after several unsuccessful attempts, by, first, adduction of\\nthe flexed limb, then by the utmost possible abduction, with supina-\\ntion, of the completely extended limb, combined with pressure upon\\nthe head of the radius. When the dressings were removed, a month\\nlater, passive movements were very painful and limited, and, as no\\nimprovement followed, excision was done five months after the accident.\\nThe head of the radius was found thickened and absolutely fixed, and\\nthe fragment reunited to it by a loose fibrous union the failure of\\nunion was attributed to the interposition of a small piece of the artic-\\nular cartilage. Recovery followed without accident, but the mobility\\nof the joint was not increased.\\nIn the third case the patient had received his injury twenty-two\\nyears before, when six years old, by a fall from a horse. The head\\nof the radius stood outside upon the external condyle, and was flat-\\ntened on its inner side; there was no sign of any injury to the ulna.\\nThe movements of the joints were completely normal.\\nLobker, in a paper read before the same congress, reported two cases\\nof the same combination of dislocation outward with fracture of the\\ninner portion of the head of the radius treated by excision. In each\\ncase the fragment had become united to the adjoining parts by a pedicle.\\nOf the 26 cases collected by Schrotter 3 were complicated with frac-\\nture of the head of the radius and 13 with that of the ulna.\\nBartels reported a unique case in which the heads of both radii had\\ngradually become displaced outward. The patient was a man forty-\\nthree years old, who, while lying in hospital with a broken leg, called\\nthe surgeon s attention to his elbows. He said that the deformity\\ndated from his eleventh year his father had at that time put him at\\nhard work, usually pushing a loaded cart pain was soon felt in the\\nelbows, and increased steadily, but he was kept at work. The head of\\nthe radius rested on the outer side of the external condyle when the\\nlimb was fully extended and supinated when extended and pronated,\\nthe head was less prominent, and rested partly on the outer part of the\\narticular surface of the capitellum, and when flexed and pronated the\\nhead returned to its place.\\nBarros could produce the dislocation experimentally in only one way,\\nby pressure against the ball of the hand, and simultaneous forcible\\nadduction of the forearm, by which the external lateral ligament was\\ntorn.\\nThe general symptoms in the recent cases showed no specialor char-\\nacteristic features the limb appears to have been partly flexed and\\npronated, and the movements of the joint restricted. In the older\\ncases, the normal movements were more or less completely re-estab-\\nlished\\nThe diagnosis is made by recognition of the presence of the head of\\nthe radius on the outer side of the condyle. Reduction, except when\\nthere is fracture of the head or interposition of the torn orbicular liga-\\nment, should be easy by adduction of the forearm and direct pressure\\non the head of the radius.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0731.jp2"}, "724": {"fulltext": "654 DISLOCATIONS.\\n3. Dislocations Forward.\\nThese are the most common of the three varieties, even excluding\\nfrom them the not unusual subluxation which occurs in children, and\\nwill be described in the next section, and those cases which are com-\\nplicated by fracture of the ulna (vide infra). The dislocation is char-\\nacterized by the position of the head of the radius in front of its\\nnormal position when the forearm is extended, and above it when the\\nforearm is flexed at a right angle. Several authors describe two forms,\\nthe complete and the incomplete, including in the latter those cases in\\nwhich in flexion at a right angle the head of the radius has not entirely\\nleft the articular surface of the capitellum, but remains in contact with\\nits upper portion. The distinction between complete and incomplete is\\nan arbitrary one and does not seem to deserve to be retained, for even\\nin the former the head of the radius sometimes descends upon the\\narticular surface of the capitellum when the limb is extended.\\nThe causes mentioned in the reported cases include falls upon the\\nhand or upon the elbow, and traction upon the forearm. In experi-\\nments upon the cadaver the dislocation has been produced by forced\\npronation, in which, according to Filugelli, quoted by Streubel, a ful-\\ncrum is established by contact between the radius and ulna in their\\nupper third at the point at which they cross, the effect of which is to\\ncause the head of the radius to move forward and inward, with rupture\\nof the anterior portion of the annular ligament when the pronation is\\nexaggerated.\\nAs in the two preceding varieties, the mode of production is far from\\nclear. That the head should be displaced by direct violence is not\\ndifficult to comprehend, but the cases in which this mode of production\\ncan be invoked are few. Traction upon the forearm, combined prob-\\nably with exaggerated pronation, must also, I think, be admitted as an\\noccasional cause, especially in children, both because of its efficiency\\nto produce the dislocation upon the cadaver, and because the histories\\nof one or two cases in adults are not open to any other explanation,\\nas in Boyer s case of the footman who slipped while getting up behind\\na carriage, and remained suspended by his hands. It seems probable\\nthat some of the cases in which the injury was received in childhood,\\nand remained unreduced, may have been dislocations by elongation, and\\nthat the head remained fixed in its new position, or perhaps was still\\nfurther displaced by use. In a fall upon the hand, it seems probable\\nthat the dislocation could be produced only by hyperextension and\\npressure upon the lower end of the radius, aided by supination or pro-\\nnation, and this opinion is confirmed by experiment. A case of Mal-\\ngaigne s l seems to support this theory? for at the patient s death, seven\\nweeks after the accident, the posterior fourth of the head of the radius\\nwas found to have been broken off. In two of Lbbker s 2 cases a\\npiece was broken from the outer portion of the head, which suggests,\\nwhat is probable also on other grounds, that abduction of the forearm\\nmay also be a factor.\\n1 Malgaigne Loc. cit.. p. 651.\\n2 Lobker Beilage zum Centralblatt fur Chir., 1886, No. 24, p. 92.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0732.jp2"}, "725": {"fulltext": "DISLOCATIONS OF THE BADIUS ALONE. 655\\nIn a case reported by Ross 1 the dislocation occurred during an epi-\\nleptic convulsion and was attributed to muscular action, the unopposed\\ncontraction of the biceps and pronator radii teres.\\nPathology. No autopsies have been reported in recent cases. In\\nexperiments upon the cadaver (Streubel, Pingaud) the capsule has been\\nfound torn transversely in front close to its attachment to the humerus\\n(Fig. 295), and the annular ligament untorn and encircling only the\\nneck of the radius while the head projected forward through the rent\\nin the capsule and rested, by its posterior edge only, against the artic-\\nular surface of the capitellum.\\nFig. 295.\\nHilton s case of dislocation of the head of the radius forward.\\nIn a number of cases, ten or twelve, the opportunity has arisen to\\nexamine old dislocations. Malgaigne has described his own, quoted\\nabove, in which the posterior fourth of the head of the radius was\\nbroken off and the capsule was intact, and two specimens in the Musee\\nDupuytren (cases of Desault and Prestat). Cooper 2 describes and\\nfigures a specimen preserved at St. Thomas s Hospital the others are\\nthose of Danyau, 3 Debruyn, 4 two cases, Hilton, 5 Trelat, 6 Kronlein, 7 a\\nspecimen in the Museum at Zurich, and Lobker, the two cases above\\nreferred to see, also, Schrotter. 8\\nIn Malgaigne s, Danyau s, one of Debruyn s, Trelat s, and the two\\nspecimens of the Musee Dupuytren the annular ligament was stretched\\nbut not torn in Hilton s its upper portion was torn, but the more\\nexternal and superficial fibres remained intact and were closely wrapped\\nabout the neck of the radius in Cooper s the annular, oblique, fore-\\npart of the capsular, and a portion of the interosseous ligament were\\ntorn through. With reference to some of these cases the question has\\nbeen raised whether the annular ligament found at the autopsy was\\nnot one of new formation.\\nThe head of the radius rests, in partial flexion, upon the anterior\\nsurface of the external condyle above and usually somewhat to the\\ninner side of its normal position, and either in contact with the coro-\\nnoid process or (Hilton) separated from it by the interposed tendon of\\nthe brachialis anticus. In some cases a piece has been broken from\\nits posterior or outer border. In several of the cases a hollow had\\n1 Streubel Loc. cit., p. 75. 2 Cooper Loc. cit., p. 392.\\n3 Danyau Annales de la Chir. Francaise et Etrangere, 1841, vol. ii. p. 72.\\nDebruyn Annales de la Chir. Francaise et Etrangere. 1843. vol. ix. p. 88.\\n5 Hilton Guy s Hospital Reports, 1847, vol. v. p. 93.\\n6 Trelat Bull, de la Societe Anatoniique, 1858, p. 487.\\n7 Kronlein Deutsche Chirurgie, Lief. 26, p. 44.\\n8 Schrotter Arch, fur klin. Chir., vol. xlvi.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0733.jp2"}, "726": {"fulltext": "656 DISLOCATIONS.\\nformed for its reception on the anterior surface of the humerus the\\nnew articulation was either entirely above the old one, or included the\\nupper part of the capitellum, or (Trelat) extended over the outer por-\\ntion of the front of the trochlea. The head of the radius was deformed\\nand had suffered the loss of more or less of its cartilage of incrustation\\nin some cases it was enlarged, in others diminished in size. In Kron-\\nlein s specimen an extensive outgrowth of bone had formed upon the\\ninner side, giving the upper end of the bone an appearance similar to\\nthat of the upper end of the femur, and articulating with a new cavity\\nupon the humerus it is stated that the movements of rotation had been\\ncompletely restored.\\nAn interesting feature in Hilton s case was that the radius had been\\ndisplaced bodily upward along the ulna, and this displacement had pro-\\nduced changes at the wrist.\\nMalgaigne observed and called especial attention to abduction of the\\nforearm, which does not appear to have been observed by others. It\\nfurnishes a satisfactory explanation of the displacement of the radius\\nupward as well as forward, which could not otherwise be accounted for\\nexcept by such a change in the level of the bones at the wrist as was\\nnoted in Hilton s case. Abduction of the forearm might easily be\\noverlooked while the joint is partly flexed unless comparative measure-\\nments are made.\\nSymptoms. The elbow is slightly flexed and the forearm almost\\nalways more or less pronated in a few cases supination has been pres-\\nent. Voluntary and communicated movements are painful, and of the\\nlatter flexion nearly to a right angle and almost complete extension are\\npossible, pronation is usually complete, but supination much restricted.\\nAbduction of the forearm has been noted, possibly it is quite common,\\nand when present it can be demonstrated by comparative measurements\\nof the radial borders of the two forearms, the injured one being short-\\nened. The region of the elbow is swollen in front and on the outer\\nside the absence of the head of the radius from its normal position is\\nshown by the depressibility of the soft parts on the outer side of the\\njoint below the condyle, and its presence in the fold of the elbow can\\ngenerally be recognized by the finger sometimes it is so prominent\\nthere that it appears to be subcutaneous, and the saucer-like depression\\nof its upper surface can be traced when the joint is extended. Flexion\\nof the forearm is abruptly arrested at or near a right angle by the\\nimpact of the head of the radius upon the front of the humerus.\\nIn the older cases the restoration of function may be almost com-\\nplete, the range of motion being limited only in extreme flexion and\\nsupination.\\nIn Hilton s case the associated changes at the wrist caused a corre-\\nsponding deformity there, abduction of the hand and it seems not\\nunlikely that even in some recent cases the wrist may be painful or\\ndistorted.\\nTreatment. Reduction has been easy in some recent cases, and diffi-\\ncult or impossible in others. The measures which have been most\\nsuccessful are traction upon the radius at the wrist, the forearm being\\nsupinated and extended, combined with pressure upon the head of the", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0734.jp2"}, "727": {"fulltext": "DISLOCATIONS OF THE RADIUS ALONE. 657\\nradius. Malgaigne suggests, very properly, that adduction of the fore-\\narm would be more likely than traction to overcome the overriding of\\nthe radius. Hilton reduced the displacement in his specimen, which\\nhad existed for many years, by placing a small wedge between the\\nupper surface of the radius and the humerus, and then flexing the fore-\\narm by pressing upon the lower end of the ulna when flexion was\\nnearly complete direct pressure upon the head of the radius forced it\\nbackward into place. The effect of this device was to displace the\\nradius downward along the ulna to a distance equal to the thickness of\\nthe wedge, and to rupture the ligaments which bound the two bones\\ntogether. A marked tendency to recurrence has been frequently\\nnoticed, and has generally been attributed to interposition of a portion\\nof the capsule. I am inclined to think it due, in some cases at least,\\nto the persistence of this bodily displacement of the radius upward.\\nIf so, the condition would be shown, after reduction, by loss of the\\noutward inclination of the forearm in full extension, and the effort\\nshould be made to overcome it by restoring this angle by forcible\\nabduction.\\nThe position of the rent in the anterior portion of the capsule sug-\\ngests that after reduction the joint should be kept flexed, and although\\nrecurrence of the dislocation has taken place with the limb in this\\nposition, it does not seem so likely to favor such recurrence as the\\nextended position.\\n4. Dislocation by Elongation, or the Subluxation of Young\\nChildren. 1\\nUnder these names is described an injury w T hich is very frequently\\nobserved, but the nature of which, after nearly two centuries of dis-\\ncussion, is still in dispute. Its features are well marked a young\\nchild, generally less than three years old, is lifted or pulled by the\\nhand it cries out with pain, and refuses to use the limb, which hangs\\nmotionless by the side, somewhat flexed at the elbow, and more or less\\npronated. A careful examination fails to discover marked changes in\\nthe anatomical relations of the bones at the elbow or wrist passive\\nmotion at both joints is free, but painful, except supination, which is\\nresisted often during the manipulations made in the examination, or\\non forced supination, a slight click is heard, and the child at once is\\nable to use the limb freely without pain.\\nAs early as 1671 Fournier described the injury as an incomplete\\ndislocation characterized by relaxation of the ligaments and elongation\\nof the radius, meaning by the latter direct separation downward or\\ndiastasis. Nearly a hundred years later, Duverney gave a clear and\\n1 The papers upon this subject are numerous the following bibliography contains the\\nmore important Gardner, London Medical Gazette, 1837, vol. xx. p. 87S Hodges, Boston\\nMedical and Surgical Journal. 1862, vol. lxvii. p. 129 Goyrand, Gazette medicale de\\nParis, 1837, p. 115, and Bull.de la Societe de Chirurgie, 1861, p. 605; Pingaud, Diet.\\nEncyclopedique, art. Coude, p. 580; Hamilton, New York Medical Journal, Jan. 3, 1885,\\np. 8; Duverney, Maladies des Os, 1751 Bouley, De radii superioris extremitatisdimotione,\\nin infantibus frequeutiori, 1787; Rendu, Gazette medicale, 1841, p. 301 Perriu. Journal\\nde Chirurgie de Malgaigne, vol. v. p. 145; Streubel, Prager Vierteljahrschrift, 1850, vol.\\nii. p. 90 Van Arsdale, Annals of Surgery, June, 1889.\\n42", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0735.jp2"}, "728": {"fulltext": "658 DISLOCATIONS.\\nexact description of it as an injury occurring frequently in children\\nhe attributed it to forcible traction at the wrist, and gave as its chief\\nsymptom the opposition to supination of the forearm, and as the treat-\\nment forcible supination with pressure from before backward upon the\\nhead of the radius followed by flexion of the elbow. He thought the\\ninjury was not merely an elongation of the radius, but also the escape\\nof its head below the edge of the orbicular ligament. Nearly a cen-\\ntury and a half has passed since the publication of his views, and but\\nlittle has been added to his description of the etiology, symptoms, or\\ntreatment, and while the years have brought many other theories con-\\ncerning the pathology his is the one that is now most widely held.\\nIn 1787 Bottentuit presided at the presentation, and, according to\\nMalgaigne, was probably the real author, of a thesis by Bouley before\\nthe Ecoles de Chirurgie, in which the theory of the agency of forced\\npronation in the production of the injury was advanced; it was argued\\nthat in this movement the radius and ulna came into contact at the\\npoint where they crossed each other near the elbow, and that, the\\nmovement being continued, the head of the radius was displaced for-\\nward or outward.\\nAt the beginning of the present century Martin, in France, 1809,\\nand Monteggia, in Italy, 1814, described the injury and reported cases,\\nbut the former, unfortunately, appears to have encountered also some\\ndislocations backward, and he not only included them in the same\\ngroup, but he also thought that the radius was dislocated backward in\\nall, and this opinion has survived in a measure until the present time,\\nand has led systematic writers to describe a dislocation backward as\\none of the forms, although it does not appear that there is any other\\nauthority for the statement than Martin.\\nAs the injury is one that seems but rarely to fall under the observa-\\ntion of the general surgeon, probably because of the facility with\\nwhich it is reduced, the authors of the surgical text-books either made\\nno mention of it or followed in their brief descriptions the account\\ngiven by Martin, or by those who had copied from him. But between\\n1836 and 1850 several cases were published in England and in France,\\nand new theories concerning its nature were advanced. Gardner in\\n1837 and Rendu in 1841 attributed the fixation to the locking of the\\nbicipital tuberosity behind the ulna, but the latter, who in two cases\\nhad made the important observation that the wrist also was swollen\\nand tender, added to this supposed locking of the tuberosity, which he\\nregarded as probably exceptional, a rupture of the ligaments of the\\nwrist. Perrin, in 1849, thought the head of the radius was caught\\nbelow the lower edge of the lesser sigmoid cavity, and Goyrand, who\\nsaw a large number of cases, thought the lesion was an incomplete\\ndislocation, in which the displacement was so slight as to cause no\\nrecognizable deformity at the elbow. Malgaigne, 1854, included it\\namong the incomplete dislocations forward, and others did likewise.\\nIn 1850 Streubel made the theory of incomplete luxation more\\ndefinite, by showing that if the forearm of the cadaver of a young\\nchild was forcibly pronated, the head of the radius moved forward,\\nand the posterior portion of the capsule was forced in by atmospheric", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0736.jp2"}, "729": {"fulltext": "DISLOCATIONS OF THE RADIUS ALONE. 659\\npressure between the radius and the capitellum, and that if then the\\npronation was diminished, the slight displacement of the radius and\\nthe interposition of the capsule would persist even while gentle move-\\nments of the joint were made but that under sudden extension and\\nsupination the normal relations would be established. In like manner,\\nforced supination would displace the radius backward, and lead to\\ninterposition of the anterior portion of the capsule. In the bodies of\\nadults neither manipulation would produce this result.\\nIn 1856 Chassaignac 1 described, under the title paralysie doulou-\\nreusc desjeunes enfants a number of cases of the injury under dis-\\ncussion, together with others of a different nature, and attributed the\\nsymptoms in all to injury of the nerves of the limb. Finally, in\\n1861, Goyrand 2 returned to the subject in a lengthy paper, in which\\nhe abandoned his previous view and advanced the last new theory,\\nthat the lesion was situated not at the elbow, but exclusively at the\\nwrist, and consisted in a dislocation of the triangular fibro-cartilage in\\nfront of the lower end of the ulna. His experiments showed that in\\ncomplete pronation the fibro-cartilage was carried so far forward as\\nalmost entirely to uncover the end of the ulna, and that in forced pro-\\nnation the uncovering became complete. In reply to a question asked\\nby Velpeau, he admitted that the displacement did not persist upon\\nthe cadaver unless the hand was held upward and supinated, but he\\nthought that the tonic contraction of the muscles in the living would\\nmaintain it. He did not explain w T hy such a lesion should be more\\neasily produced in a child than in an adult.\\nIt may be worth while to add that the editor of the Medico- Chirur-\\ngieal Review, in 1839, thought the injury was a separation of the\\nupper epiphysis of the radius, and Fougeu, in 1861, a separation of\\nthe lower one.\\nPingaud, 3 in his experiments upon the cadaver, found, as Goyrand\\nhad similarly done in 1837, that the head of the radius could be\\ndrawn out through the orbicular ligament by forcible adduction of the\\nforearm, so far that its anterior edge would engage below the lower\\nborder of the ligament (Fig. 296), and the bones would remain sepa-\\nrated by a distance of about a quarter of an inch, but without dis-\\nplacement of the radius forward, backward, or outw r ard, unless forced\\npronation was added to the adduction, in which case the head moved\\nforward and as this condition of the parts coincided with a limitation\\nof the freedom of rotation of the forearm similar to that observed\\nclinically in the cases in question, and as the normal relations of the\\nparts w T ere restored by the same manoeuvres which relieved the little\\npatients, he reached the conclusion that the nature of the lesion\\nobserved clinically was the same as that which he had produced\\nexperimentally, and that the clinical injury was, therefore, a disloca-\\ntion of the radius downward below the annular ligament, or, in other\\nwords, that Duverney s theory was the correct one. He showed fur-\\nther, that the younger the child the more easily could this displace-\\n1 Chassaignac Archives generates de Med., 1856, vol. i. p. 653.\\n2 Goyrand Bull, de la Societe de Chir., 1861, p. 596.\\n8 Pingaud Loc. cit., 1878.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0737.jp2"}, "730": {"fulltext": "660 DISLOCATIONS.\\nrnent be effected, and the more complete, circularly, would it be. He\\nwould not assert that this was the only cause of the clinical condition,\\nbut contented himself with proving that it was at least one his reserve\\nbeing apparently due to the inapplicability of the explanation to the\\nreported cases in which the radius was said to have been displaced\\nbackward, cases which we have seen to rest only upon Martin s asser-\\ntion. His experiments have been repeated, and his results verified by\\nothers Poinsot accepts his explanation fully for the usual cases, and\\nStreubePs for those of displacement backward.\\nFig. 296.\\nSubluxation of the head of the radius. (PiXGArD.j\\nTurning now to the clinical evidence, for there have been no post-\\nmortem examinations, it appears that the injury is common in young\\nchildren between the ages of one and three years, and is rarely seen\\nafter the age of six years, and not infrequently recurs. Goyrand (loc.\\ncit.. 1861) had seen at least two hundred cases in thirty vears, and\\nquotes Chabrely [Journal de Mededne de Bordeaux, October, I860,\\np. 481 as saying that hardly a month passed, he might say hardly a\\nweek, in which he was not called to a case, and Fougeu as having seen\\nthirty-five cases in the discussion that followed the reading of Gov-\\nrand s paper, Marjolin stated that he had seen about sixty cases.\\nSnedden 1 saw ten cases in ten years in private practice and Linde-\\nman 2 saw twenty-four cases and Van Arsdale one hundred in two years\\nin dispensary practice. The cause is traction upon the arm at the hand\\nor wrist, as in lifting a child, or in holding it when it stumbles, and in\\ntwo cases in drawing the arm through the sleeve of the dress. It\\nseems to me that exaggerated pronation does not enter into the mechan-\\nism by which the lesion is produced, but that the violence is simply\\ntraction exerted upon the extended elbow, possibly combined with\\nadduction, for traction would tend to make the limb exactly straight,\\nand thus overcome the normal inclination of the forearm outward or\\nthe grasp upon the forearm may be so firm that an actual inward incli-\\nnation would be produced in case the effort was not a simple traction,\\nbut was combined with a movement that tended to swing the child\\n1 Snedden British Medical Journal. 1882, vol. i. p. 499.\\n2 Lindernan British Medical Journal, 1SS5, vol. ii. p. 105S.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0738.jp2"}, "731": {"fulltext": "DISLOCATIONS OF THE RADIUS ALONE. 661\\nupward along a curve whose centre was its wrist and whose radius\\nwas its extended arm. At least, in lifting a living child by the\\narm I have not been able to make exaggerated pronation, for rota-\\ntion at the shoulder is so free that the limit of pronation is not easily\\nreached, and this is unquestionably true when the child is lifted by\\nboth hands.\\nThe child at once cries out in pain and refuses to use the limb, which\\nhangs motionless by its side, or is supported, with the elbow slightly\\nflexed, across the front of the abdomen the wrist is completely or\\npartly pronated. Examination shows sensitiveness at the outer por-\\ntion of the elbow, in some cases also at the back of the wrist, and in\\nothers exclusively at the wrist, with swelling after the lapse of from\\nthirty to thirty-six hours. The head of the radius is sometimes\\nslightly but distinctly displaced forward, but in most cases no other\\nchange than a slight longitudinal separation between the radius and\\nthe capitellum is recognizable. There is pain on pressure over the\\nhead of the radius.\\nAlthough the child does not voluntarily move the joint, it can be\\nfreely moved by the surgeon in every direction except supination, and\\nwill sometimes be held by the child in such a position as may be given\\nto it. In only one recorded case, Duges, 1 was the limb in supination\\nwith that exception the constant and pathognomonic symptom is the\\ninterference with supination.\\nThese facts, taken in connection with the results of experiment, indi-\\ncate that Duverney s opinion was correct and that the injury consists\\nin the escape of the front portion of the head of the radius below the\\norbicular ligament, and that it is produced by traction and adduction\\nof the extended forearm. Goyrand s last explanation dislocation of\\nthe triangular fibro-cartilage at the wrist cannot maintain itself against\\nthe overwhelming clinical evidence of the existence of a lesion at the\\nelbow, supported, as it is, by experiment, especially since it has no\\nbetter foundation than the impression that the click which was heard\\nduring reduction was produced at the wrist and not at the elbow.\\nAgainst its correctness are the facts that although exaggerated prona-\\ntion will effect such a dislocation, yet there is nothing to prove that\\nthe displacement will not immediately correct itself when the limb is\\nreleased, and that there is not only no proof of the intervention of\\nexaggerated pronation in clinical cases, but it was, furthermore, cer-\\ntainly absent in some, and probably in all. The only difficulty is to\\nexplain the well-established symptoms of injury at the back of the\\nwrist in some of the cases. Possibly such cases may be of a different\\ncharacter from the others, actual dislocation backward of the lower\\nend of the ulna (vide infixt), and Goyrand s explanation may be true\\nof them or the symptoms may be due to an associated sprain of the\\nwrist.\\nThe experience of Chassaignac, who treated his cases as paralytic\\nand saw them gradually recover, indicates that the lesion may be spon-\\ntaneously corrected but, on the other hand, there is reason to think\\nthat some of the cases of forward dislocation of the head of the radius\\n1 Duges Journal liebdoniadaire, 1831, vol. iv. p. 196.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0739.jp2"}, "732": {"fulltext": "662 DISLOCATIONS.\\nfound in adults, which had existed from childhood, were originally of\\nthis kind, and that the head had gradually become displaced further\\nforward. All who have treated cases agree that reduction is easily\\neffected, usually by supination some add flexion of the elbow.\\nDISLOCATION OF THE HEAD OF THE RADIUS WITH FRACTURE\\nOF THE ULNA.\\nThe coincidence of a fracture of the shaft of the ulna with disloca-\\ntion of the head of the radius is not infrequent, and, since the discovery\\nof either of the two injuries may lead the surgeon to overlook the\\nother, the possibility of the coexistence should always be borne in mind.\\nMalgaigne attached so much importance to this warning that he formu-\\nlated and italicized the following two recommendatious\\n1. In any fracture of the ulna alone look for a dislocation of the\\nradius.\\n2. In every fracture of the forearm in which the swelling extends\\nabove the elbow, remember that simple fracture is rarely accompanied\\nby so much swelling, and carefully explore the articulation.\\nTo complete the warning a third precaution should be added, namely,\\nthat in every dislocation of the head of the radius alone, fracture of\\nthe ulna should be sought for.\\nThe complication has received the attention of most systematic\\nwriters upon dislocations, and has been made the subject of mono-\\ngraphs by Malgaigne, 1 Greiner, 2 and Dorfler. 3 The latter collected\\nnineteen cases, but the injury appears to be of more frequent occur-\\nrence than this fact would indicate, for Malgaigne saw four cases, von\\nPitha two or three, and Dorfler reports four cases from the practice of\\nthe surgeon under whom he was serving. I have seen at least ten.\\n(Plate IX., fig. 1.)\\nThe cause in a certain number of cases five of Dorfler s nineteen\\nhas been direct violence, as the kick of a horse, received upon the inner\\nor inner and posterior aspect of the upper part of the ulna, first break-\\ning that bone and then driving the head of the radius forward and\\noutward from its place in others it has been a fall upon the arm, and\\nit is uncertain w T hether the ulna was broken by direct or indirect vio-\\nlence. In Gerdy s case the patient declared that he fell upon his\\nextended hand and in one that came under my care in August, 1885,\\nthe patient, a boy seven years old, had fallen from a wagon and sus-\\ntained a compound fracture of the ulna at its middle, the wound in the\\nskin being in the centre of the anterior aspect of the limb and having\\nbeen produced from within outward by the sharp end of one of the\\nfragments the radius was displaced forward, upward, and inward so\\nfar that its concave upper surface could be distinctly felt. There was\\nno bruise on the back of the forearm, and I thought the fracture had\\nbeen produced by indirect violence, a fall on the hand.\\n1 Malgaigne Revue medico-chirurgicale, vol. xiii. pp. 82 and 90.\\n2 Grenier Recherches sur la luxation du radius que complique la fracture du tiers\\nsuperieur du cubitus. These de Paris, 1878.\\n3 Dorfler Fractur der ulna in ihrem oberen Drittel combinirt mit Luxation des Radius\\nDeutsche Zeitschrift fur Chir., 1886, vol. xxiii. p. 338.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0740.jp2"}, "733": {"fulltext": "DISLOCATIONS OF RADIUS WITH FRACTURE OF ULNA. 663\\nThe only autopsical record I have found is one by Marchand/ and,\\nunfortunately, it is not entirely clear. It is stated that the external\\nlateral ligament was torn, the ulna was broken in its upper third, and\\nthe head of the radius was displaced to the outer side of the epicon-\\ndyle the annular ligament was untorn, but no longer surrounded\\nthe neck of the radius it seemed rather to embrace the radial capsule\\n(cupule, head and the radius seemed to have escaped below it.\\nDorfler s experiments showed that the parallelism of the radius and\\nthe lower fragment of the ulna was preserved, with production of an\\nangle in the ulna at the point of the fracture the annular and anterior\\nligaments were torn. The limb w T as shortened, and crepitus was per-\\nceived on handling it. Clinically, a prominent feature is the marked\\nswelling at the elbow, due in part to the displacement of the radius\\nand in part to inflammatory reaction. The displacement of the radius\\nis usually forward, sometimes forward and inward, forward and out-\\nward, or directly outward.\\nAmong the complications were observed subluxation of the lower\\nend of the ulna, wound of the integument either by the direct action\\nof the causative violence or from within outward by the end of the\\nfragment, making the fracture compound, fracture of the epicondyle\\nor external condyle, and more or less paralysis of the extensor muscles\\nof the wrist and fingers due to stretching or rupture of the musculo-\\nspiral or posterior interosseous nerve.\\nThe prognosis is good if the displacements are promptly corrected\\nand even if the dislocation of the radius persists the restoration of\\nfunction may be nearly complete.\\nOn the other hand, failure of union of the fracture has been noted\\n(Norris 2 and persistent extensor paralysis (Dorfler).\\nReduction in recent cases has been easy the most suitable method\\nappears to be traction upon the extended limb, followed by direct press-\\nure upon the radius and then by flexion of the elbow. The extended\\nposition during traction is desirable in order to avoid the interposition\\nof the torn anterior ligament. After reduction the limb should be\\nkept flexed within a right angle, and midway between supination and\\npronation.\\nIn an old case where the fracture was at the upper end of the ulna\\n(Plate IX.) I made reduction by open arthrotomy from behind.\\n1 Marchand Bull, de la Societe Anatomique, 1874, p 680.\\n2 Norris American Journal of the Medical Sciences, vol. xxxi. p. 20.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0741.jp2"}, "734": {"fulltext": "CHAPTEK XLVII.\\nDISLOCATIONS OF THE ELBOW.\u00e2\u0080\u0094 (Continued.)\\nTreatment of Old Dislocations Congenital and Pathological Dislocations.\\nTREATMENT OF OLD DISLOCATIONS.\\nThe loss of mobility in old dislocations of the elbow, especially of\\nthe backward ones, is often so great that the disability is serious the\\npatient is unable to bring the hand to the head or chest, and is able to\\nuse it only in the arc of a circle whose radius is nearly equal to the\\nlength of the extended limb, and he may, in addition, possess only such\\nrotation as can be effected by movements at the shoulder. Although\\nsuccessful attempts to reduce dislocations of several months 5 standing\\nwere occasionally reported, yet failure was the rule, and the only means\\nof alleviating the conditions were fracture of the olecranon and excision\\nof the joint, operations which, while they increased the range of mo-\\ntion, brought with them disadvantages of their own, such as loss of\\nactive extension and lack of solidity, which disinclined the surgeon to\\noffer, and the patient to accept them.\\nConsideration of the anatomo-pathological conditions of an old unre-\\nduced backward dislocation not only fully explains the difficulty of\\neffecting reduction, but even makes it appear surprising that reduction\\nshould ever have been satisfactorily accomplished. The overriding of\\nthe bones along the back of the humerus leads to the formation of\\nnew cicatricial bonds between the olecranon and the humerus and to\\nthe establishment of new attachments by the torn lateral ligaments so\\nfar above and behind the centre of motion of the old joint that almost\\nno flexion is possible without their rupture or elongation, and the\\nreturn of the bones to their place can be effected only after a far more\\nextensive rupture of these soft parts than that which accompanied the\\ndislocation. In attempting to rupture these bonds by forced flexion\\nthe forearm is used as a lever the fulcrum of which is situated on the\\nulna below the coronoid process, and the rupturing strain is exerted\\nthrough the olecranon upon the ligaments and adhesions connected\\nwith it, and it is not to be wondered at that this process should so fre-\\nquently have been broken in the manipulation. In addition, the greater\\nsigmoid cavity very promptly fills with cicatricial tissue, partly of new\\nformation and partly furnished by the upper part of the posterior por-\\ntion of the capsule which slips in between it and the back of the\\nhumerus and permanently occupies the concavity which should, after\\nreduction, embrace the trochlea this pad of tissue is found so firmly\\nunited to the cartilage of the olecranon that its removal in the reported\\narthrotomies has required the use of the knife. The adhesion of the\\n664", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0742.jp2"}, "735": {"fulltext": "OLD DISLOCATIONS OF THE ELBOW. 665\\ncapsule to the articular surface of the front of the trochlea and the\\ncapitellum has not been found to be so close, and the cartilage of their\\nsurfaces has been found, even after the lapse of several months, almost\\nentirely unaltered in appearance.\\nFurthermore, the injury is common in the young, in whom the osteo-\\ngenic power of the periosteum is great and in whom the epiphyses are\\nstill growing. The effect of the injury, especially if the periosteum is\\nstripped up, is, therefore, to produce new formations of bone around\\nthe joint which contract adhesions with the other bones or mechanically\\ninterfere by interposition to prevent the reduction of the dislocation\\nand, further, the epiphysis of the humerus, relieved of the pressure\\nnormally exerted upon it by the radius and ulna, grows more rapidly\\nand irregularly, and its articular surface may thus lose its shape and\\nbecome unfit to receive the others again. This deformity by exagger-\\nated growth has been especially noticed in the capitellum (see Patholog-\\nical and Congenital Dislocations), the extension being downward and\\nforward.\\nThese changes are clearly incompatible with successful reduction by\\nthe means employed in fresh cases, even if the force employed be suffi-\\ncient to rupture the adhesions and bring the bones down to the proper\\nlevel. It is true that successes have been occasionally reported, but the\\nreports rarely go beyond the statement that reduction was accomplished,\\nand they leave the subsequent history of the case and degree of re-\\nestablishment of the functions unrecorded. Until quite recently the\\nonly methods employed have been forcible attempts to reduce by trac-\\ntion and the breaking of adhesions, sometimes aided by subcutaneous\\ndivision of the tendon of the triceps, or of adhesions on the sides and\\nback of the joint, increase of the range of motion by the same means\\nwithout reduction, reduction after fracture of the olecranon by forcible\\nflexion, and excision of the joint.\\nAlbert says that Liston, more than forty years ago, successfully\\nreduced an old dislocation after subcutaneous division of all tense\\nbands, and that in 1847 Blumhart successfully practised arthrotomy\\nin a similar case, making two lateral incisions, and dividing through\\nthem all the adhesions that opposed reduction. This case appears to\\nhave been entirely lost sight of, and it was not until thirty years later,\\nin 1879, that Trendelenburg, 1 in a paper recommending temporary\\ndivision of the olecranon to facilitate operations upon the elbow-joint,\\nreported a case of incomplete outward, or outward and backward, dis-\\nlocation of both bones with avulsion of the epitrochlea which he had\\ntreated by making an incision along the tendon of the biceps, and chis-\\nelling away enough bone from the lower end of the humerus in front\\nof the coronoid process to allow flexion to a right angle the result was\\ngood to that extent. A little later Volker 2 reported a case of incom-\\nplete outward dislocation of the left elbow of six months standing in\\na boy thirteen years old, in which, after division of the olecranon, he\\nhad divided the adhesions, dissected away the new tissues in the sig-\\nmoid fossa, and had then been able to reduce as the change in the\\n1 Trendelenburg Archiv fur klin. Chir., 1879, vol. xxiv. p. 790.\\n2 Volker: Deutsche Zeitschrift fur Chir., 18S0, vol. xii. p. 541.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0743.jp2"}, "736": {"fulltext": "666 DISLOCATIONS.\\nshape of the bones favored recurrence he removed the head of the\\nradius. His incision was U-shaped, the sides extending along the\\nborders of the triceps, and the bottom of the U crossing the olecranon\\nat the point where it was to be divided. The position of the limb\\n(anchylosis in almost complete extension) and the evidences of serious\\npressure upon the ulnar nerve were important factors in the determi-\\nnation to operate. He was so pleased with the result that he looked\\nforward with confidence to the adoption of the method in all old dis-\\nlocations with much disability.\\nTrendelenburg l promptly claimed priority in the suggestions of pre-\\nliminary division of the olecranon, and reported a case of backward\\ndislocation of both bones of eight weeks standing successfully treated\\nin the same manner. His incision was a curved transverse one, the\\nconvexity directed upward, crossing the median line well above the\\nolecranon, and the flap was then dissected and reflected downward to\\nthe point at which the olecranon was to be divided this division of\\nthe olecranen was done with a chisel. Because of difficulty in bringing\\nthe olecranon down the limb was dressed in extension, but after the\\nnineteenth day, when the wound was healed, the position was gradu-\\nally changed, and four weeks later the joint could be flexed to a right\\nangle. The olecranon reunited solidly in this case and in Volker s.\\nIn 1885 Nicoladoni 2 published a short paper on the application of\\narthrotomy to old dislocations of various joints, and included in it the\\nreport of two cases in which he had practised it at the elbow. The\\nfirst case was an almost complete outward dislocation of the left elbow\\nin a lad sixteen years old, which had existed for eight months the\\nepitrochlea was broken off and drawn under the trochlea the limb\\nwas in extension, flexion was entirely lost, but rotation was preserved.\\nAn incision eight centimetres long was made in front along the inner\\nborder of the trochlea, and through this the fractured epitrochlea was\\nremoved a second incision of the same length was made on the outer\\nside of the joint through which, after removal of a small piece of bone\\nthat had been broken from the condyles, the soft parts were separated\\nfrom the radius and the humerus then, through a longitudinal cut\\nmade in the tendon of the triceps, the adhesions between the olecranon\\nand the back of the humerus were separated, and the bones were then\\neasily restored to place. The wound healed after slight suppuration,\\npassive motion was begun after the third week, and the patient, was\\ndismissed after seven and a half weeks with the elbow flexed and\\nmovable through an arc of 35 or 40 degrees. Nme months later he\\nwrote that he could flex and extend the joint freely, but that rotation\\nwas not quite so free.\\nThe second patient was a large, powerful man, forty-one years old,\\nwith a backward dislocation that had existed for six months. The\\nlimb was almost completely extended and immovable there was some\\npassive rotation. The olecranon was situated unusually high. Two\\nlateral incisions, each sixteen centimetres long, were made through\\nthe first, over the outer condyle in front of the head of the radius, the\\n1 Trendelenburg Centralblatt far Chir., 1880, p. 833.\\n2 Xicoladoni Wiener med. Wochenschrift, 1885, p. 728.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0744.jp2"}, "737": {"fulltext": "OLD DISLOCATIONS OF THE ELBOW.\\n667\\nsoft parts were separated from the bone, leaving the periosteum undis-\\nturbed, into the trochlea and above the fossa trochlearis in front and\\nbehind through the second incision, on the inner side of the elbow,\\nthe flexor muscles were cut away close in front of the epitrochlea, and\\nthe separation of the soft parts from the bones completed. The greater\\nsigmoid cavity was found filled with hard cicatricial tissue, which was\\ncut and scraped away after separation of the posterior attachment of\\nthe orbicular ligament. Reduction was then easily made. Recovery\\ntook place without incident, and the patient was dismissed at the end\\nof four weeks, the wounds being almost healed. There was good active\\nrotation, but very little flexion passively, there was complete extension\\nand flexion to a right angle.\\nIn 1886 I operated upon a five-months backward dislocation in a\\ngirl eleven years old by an incision on the outer side and division of\\nthe olecranon. My attention had been attracted by a mass of bone\\nattached to the back of the humerus and capping the head of the\\nradius, which I believed to be of new formation and to require removal.\\nThe conditions found on exposure (Fig. 297) confirmed this opinion\\nFig. 297.\\nFig. 298.\\nNew formation of bone on an old\\nunreduced dislocation.\\nResult of operative reduction of old dislocation.\\nthe mass was cut away and the dislocation was reduced. The case is\\ngiven in detail in the New York Medical Journal, April 2, 1887. The\\nresult was not satisfactory, recurrence having taken place under the\\ndressing. The information thus gained fixed my attention upon the\\nimportance of the mass of new bone, the formation of which I attrib-\\nuted to the stripping up of the periosteum from the back of the con-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0745.jp2"}, "738": {"fulltext": "668 DISLOCATIONS.\\ndyle by the displaced head of the radius, enabled me properly to\\nestimate the difficulties, and encouraged me to operate in other cases.\\nIn 1891 l I reported seven additional cases, in five of which I had\\noperated with good results. I have since operated upon several other\\ncases the results have all been flexion within a right angle and exten-\\nsion varying from 120 to 170 degrees, and preservation of rotation\\n(Figs. 298, 299).\\nThe operation 2 is done by a long incision on the outer side exposing\\nthe head of the radius and the mass of new bone the latter is freely\\nchiselled away, and the capitellnm exposed by free division of the soft\\nparts, keeping the knife at a little distance from the bone so as not to\\ndamage the periosteum. Through the incision the sigmoid fossa is\\ncleared of fibrous tissue. A second incision, about four inches long,\\nis then made on the inner side, curving close behind the epitrochlea or\\nits site, the ulnar nerve is drawn forward and the olecranon freed if\\nthe epitrochlea has been broken off and displaced upward and back-\\nward it must be detached from the humerus, preserving its relations\\nwith the lateral ligament. The cleaning of the sigmoid cavity is then\\ncompleted. If the attachments of the olecranon to the back of the\\nFig. 299.\\nResult of operative reduction of old dislocation.\\nhumerus have been thoroughly divided reduction can now be easily\\nmade and maintained, unless the dislocation has existed so long that\\nthe flexor muscles of the hand have become permanently shortened, in\\nwhich case they must be partly divided close to the humerus.\\nVamossy 3 reported Nicoladoni s experience nine cases successfully\\ntreated by arthrotomy between 1886 and 1890. Kunn 4 reports MaydPs\\nexperience of five cases treated by resection and one by arthrotomy\\nand Helferich 5 reports two cases successfully reduced by the aid of two\\nlateral incisions.\\nIn old incomplete outward lateral dislocations little is to be hoped for\\nfrom forcible subcutaneous rupture of the adhesions, for the common\\ninterposition of the fractured epitrochlea cannot thus be overcome, and\\nthe probabilities are decidedly against the success of an attempt to\\nremove by this means the cicatricial obstacles on the inner side. The\\nchoice lies between improving the attitude by forcible flexion, if the\\n1 Stirnson On the Treatment of Old Dislocations of the Elbow, New York Medical\\nJournal, October 24, 1891.\\n2 Stimson Operative Surgery, third edition, 1895, p. 139.\\n3 Vamossy Wiener klin. Wochenschrift, December 11, 1890.\\n4 Kunn Internat. klin. Eundschau, September 6, 1891.\\n5 Helferich Deutsche med. Wochenschrift, August 10, 1893.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0746.jp2"}, "739": {"fulltext": "DISLOCATIONS OF THE ELBOW. 669\\nlimb is extended, and arthrotomy, the internal incision being made in\\nfront of the trochlea rather than upon its side.\\nIn old dislocations of the radius alone, in which partial or complete\\nanchylosis renders an operation desirable, the examples quoted in the\\npreceding chapter may serve as guides. In those cases in which the\\ndislocation has occurred in childhood and has been followed by exag-\\ngerated growth in length of the radius excision of its head is the only\\nsuitable operation, and in other cases it is probably the means most\\nlikely to improve function.\\nSprengel l reports a case of dislocation backward and outward of the\\nhead of the radius of five weeks standing in a boy six years old in\\nwhich he effected reduction and obtained a perfect functional result by\\narthrotomy and removal of a portion of the back of the capsule that\\nwas interposed between the head of the radius and the ulna. He made\\nan anterior incision along the edge of the supinator longus, exposed\\nthe musculo-spiral nerve and its two branches and drew them outward\\nwith the outer flap by this means the capsule was freely exposed to\\nview, and he was enabled to see that the rent was on its outer side, and\\nthen by drawing the head of the radius outward with a sharp hook the\\nobstacle to reduction was found to be a fold of the posterior portion of\\nthe capsule (probably part of the annular ligament) interposed between\\nthe radius and ulna, and firmly adherent to the lesser sigmoid cavity.\\nAfter having liberated this fold he was able to replace the head of the\\nradius and to close with catgut sutures the rent in the capsule except\\nover a small space on the outer side.\\nHe refers to a case of backward dislocation of the head of the radius\\nin which he obtained a similar success by arthrotomy and separation of\\nthe capsule from the upper surface of the radius.\\nCONGENITAL AND PATHOLOGICAL DISLOCATIONS.\\nAlthough a considerable number of cases have been reported as con-\\ngenital dislocations of the upper end of the radius, yet in all of them\\nthe proof that the deformity existed at birth is defective in a few\\nit was noticed at so early a period that the probability of its con-\\ngenital existence is great in others, and even in those in which both\\nradii were affected, the displacement can be referred with equal plausi-\\nbility to causes operating after birth, and the alterations in the shape\\nof the bones to the effect of the displacement and the changed func-\\ntional conditions.\\nTo the 13 alleged cases briefly quoted and analyzed by Malgaigne,\\n9 of which are quoted in detail by Gurlt, 2 may be added several that\\nhave been since reported, those of Humphrv, 3 Hayem, 4 Mitscherlich, 5\\nAllen, 6 Hamilton, 7 Phillips, 8 Pye-Smith, 9 Heele, 10 and Herskovits. 11\\n1 Sprengel Centralblatt far Chirurgie, 1886, p. 153.\\n2 Gurlt Beitrage zur Vergleich. path. Anat. der Gelenkkrankheiten, 1853, p. 317.\\n3 Humphry Medico-Chirurgical Transactions, vol. xlv. p. 296.\\n4 Hayem Bull, de la Societe Anatomique, 1864, p. 56.\\n5 Mitscherlich Arch, fur klin. Chir., 1865, vol. vi. p. 218.\\n6 Allen: Glasgow Medical Journal, 1880, vol. xiv. p. 44. 7 Hamilton Loc. cit., p. 888.\\n8 Phillips British Medical Journal, 1883, vol. i. p. 773.\\n9 Pye-Smith Lancet, 1883, vol. ii. p. 993. 10 Heele Lancet, 1886, vol. ii. p. 249.\\n11 Herskovits: Wiener med. Presse, Februarv 12, 1888.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0747.jp2"}, "740": {"fulltext": "670 DISLOCATIONS.\\nIn addition is a case, a dislocation forward, observed and briefly men-\\ntioned by Kronlein. 1\\nThe first 4 were examined post mortem, the others only clinically.\\nIn 5 of them the dislocation was backward, in 3 forward in all both\\nradii were dislocated. Humphry s, Hayem s, Allen s, and Hersko-\\nvit s were in adults, of whom no previous history was obtained. In\\nHumphry s the lower part of the left ulna was lacking, evidently\\nbecause of defective development the right ulna w x as firmly anchy-\\nlosed to the humerus nearly at a right angle, and was eight inches long,\\nits lower end was Avell formed and was on the usual level with the\\nradius the radius was also eight inches long, and its head was dis-\\nplaced upward and rested against a the forepart of the ridge that\\nascends from the outer condyle to the shaft, it was somewhat irregu-\\nlar in shape, and its extra length was developed in its shaft and not in\\nits neck as in several of the other reported cases. The trochlea of the\\nhumerus was imperfect. The displacement upward was clearly the\\nresult of the elongation of the radius, whatever the cause of the orig-\\ninal displacement from contact with the capitellum may have been.\\nMitscherlich s patient was a girl six years old who had been born\\nwith clubfoot both elbows were deformed, and this defect was thought\\nalso to have existed from birth. The head of the radius could be felt\\nin front of the outer half of the coronoid process; extension was per-\\nfect, but flexion was limited on the right side to an angle of 70 degrees\\nand on the left to one of 110 degrees; both hands were supinated.\\nExcision of the left elbow was done by von Langenbeck with the\\nobject of increasing its range of motion, and the child died in conse-\\nquence of the operation. The specimen showed that the trochlear\\nsurface of the humerus was narrowed in front by extension upon it of\\nthe exceptionally large circular surface for the head of the radius. The\\narticular surface of the ulna was normal, but the radius was not in\\ncontact with it.\\nAllen s specimen was taken from the body of an elderly man with-\\nout history. Both elbows were affected flexion was normal, extension\\npossible only to a right angle rotation was entirely lost, the limbs\\nbeing fixed in pronation. Both radii were displaced backward, but\\nonly the left elbow is described in detail. The specimen was not pre-\\nsented as an example of congenital dislocation, but only to show the\\nchanges effected in the bones in consequence of unreduced dislocation\\nin early life. These changes modified the shape of the lower end of\\nthe humerus and of the radius. The radius crossed the front of the\\nulna and was united with it by bony union for a distance of about three\\ninches at their upper part below this part the shaft of the radius was\\nmuch thickened. The neck of the radius was one and a half inches\\nlong, so that the head was carried well upward behind the humerus on\\nthe inner side of the olecranon, and this overriding was further increased\\nby the abnormal growth of the external condyle downward and out-\\nward, the extent downward of the growth being estimated at half an\\ninch. The trochlear surface was deformed, mainly by the loss of much\\nof its inner lip. The olecranon fossa was so far filled up that the sep-\\n1 Kronlein Deutsche Chirurgie, Lief. 26, p. 97.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0748.jp2"}, "741": {"fulltext": "DISLOCATIONS OF THE ELBOW. 671\\nturn between it and the coronoid fossa was one-third of an inch thick.\\nThe shaft of the ulna was small its lower end was normal and pre-\\nserved the usual relations with the radius. The specimen appears\\nclosely to resemble those of the earlier cases reported by Sandifort,\\nDubois, and Verneuil, and has as much, or as little, reason to be\\nthought congenital as most of the others. It is of value in the inter-\\npretation of the changes observed in other specimens.\\nHerskovits s patient was a man twenty-one years old the head of\\neach radius was displaced backward and outward, the capitellum small.\\nFlexion was nearly complete, extension to 135 degrees, pronation com-\\nplete, supination lost. So history of injury.\\nFor details of other cases, see first edition.\\nThe arguments upon which the attribution of a congenital character\\nwas based in most of the older cases and in those of Humphry and\\nHayem, and which apply equally well to Allen s, are the existence of\\nthe deformity on both sides and the changes in the shape of the artic-\\nular ends of the bones in Humphry s and in Deville s there is in\\naddition the lack of the lower part of the ulna.\\nThe irregularities in the bones may, in part at least, be fairly attrib-\\nuted to the change in their relations, especially the very notable one of\\nelongation of the neck of the radius reported in several cases. This\\nis in keeping w T ith similar instances of overgrowth at other points\\nwhere the normal conditions of pressure have been lost, and with the\\ncoincident elongation downward of the external condyle of the humerus\\nnoted in Allen s case and in one of R. W. Smith quoted by Gurlt. 1\\nIt requires only that the displacement should occur before the growth\\nof the skeleton is complete.\\nThe only recorded case of dislocation of both bones of the forearm\\nat birth is one reported by Chaussier and quoted by Pingaud. 2 A\\nyoung woman during the ninth month of pregnancy felt her child\\nmove so vigorously that she almost lost consciousness. The move-\\nments were repeated three times in the course of ten minutes delivery\\ntook place normally at term. The child was weak and presented a\\ncomplete dislocation of the forearm backward. Malgaigne thought it\\nprobable that the lesion was produced, not by the convulsive action of\\nthe muscles, but by the striking of the limb against the wall of the\\nuterus.\\nA few instances of dislocation due to pathological changes within\\nthe joint, such as fungous arthritis or relaxation of the ligaments in\\nthe course of an acute illness, have been reported.\\n1 Gurlt Loc. cit., p. 320.\\n2 Pingaud: Diet. Encyclopedique des Sc. Med., art. Coude, p. 606.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0749.jp2"}, "742": {"fulltext": "CHAPTER XLVIII.\\nDISLOCATIONS AT THE WRIST.\\nDislocations of the Lower Eadio-ulnar Joint of the Radio-carpal Joint of\\nthe Carpal Bones Carpo-metacarpal Dislocations.\\nDISLOCATIONS OF THE LOWER RADIOULNAR JOINT.\\nThese dislocations, obscurely mentioned by the earlier writers, were\\nfirst described, according to Malgaigne, in 1771, by Desault, who\\nreported five cases and said he had observed a great number of others.\\nHe spoke of the injury as a dislocation of the radius, but Boyer and\\nDupuytren preferred to call it a dislocation of the ulna, and their choice\\nhas been generally accepted and followed. Both traumatic and patho-\\nlogical forms have been described. The reported cases are com-\\nparatively few if those cases are excluded in which the injury is a\\ncomplication of a fracture of the lower end of the radius, and those\\ninjuries observed in young children which are generally thought to be\\na subluxation of the head of the radius, but which some consider dis-\\nlocations of the lower end of the ulna few surgeons who have reported\\ntheir experience have seen more than a single case. Tillmanns 1 col-\\nlected 48 cases in addition to one observed by himself, of which the\\ndislocation of the ulna was forward in 16, backward in 18, and inward\\nin 9, and in 5 the direction was not stated but in 3 of the first group,\\n8 of the second, all of the third, and 1 of the fourth, there was also\\nfracture of the radius, and in 4 others the ulna perforated the skin and\\nthere is reason to think the radius also was fractured. Excluding the\\ncases complicated by fracture and including only 3 of Desault s 5,\\nthere remain 12 dislocations forward and 10 backward to these may\\nbe added 2 backward and 3 forward seen or collected by Hamilton, 3\\nforward collected by Poinsot, 1 fonvard of my own, 2 1 forward by\\nHoist, 3 and 3 backward by Ridlon, 4 Horrocks, 5 and Berger, 6 making\\na total of these two varieties of 20 forward and 15 backward. The\\nreported dislocations inward or, more strictly speaking, downward and\\ninward, are really dislocations of the broken end of the radius and the\\nattached carpus upward to these may be added also the few cases of\\ndislocation of the head of the radius (q. v.) in which the entire bone\\nhas been displaced upward along the ulna.\\nDislocations Backward.\\nThe cause in most of the cases tabulated above was exaggerated\\npronation of the wrist in some the mechanism is not indicated, and\\n1 Tillmanns Arch, der Heilkunde, 1S74, vol. xv. p. 249.\\n2 Stimson New York Medical Journal, Mav 25, 1889.\\n3 Hoist Centralbl. fur Chir., Juue 20, 1891.\\n1 Ridlon New York Medical Journal, April 25, 1891.\\n5 Horrocks Lancet, June 27, 1891. 6 Berger L Union Med., April 13, 1895.\\n672", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0750.jp2"}, "743": {"fulltext": "DISLOCATIONS AT THE WRIST. 673\\nin others it is not clear. A few of them, Desault, Duges, Rendu, have\\nbeen included either by the surgeon himself (Rendu) or by other writers\\namong dislocations of the upper end of the radius by elongation, and\\nin these the injury was produced in very young children by traction\\nupon, or forced pronation of, the hand. Sometimes the exaggerated pro-\\nnation has been effected by external violence, as in Boyer s case, in which\\na lad engaged his hand between the spokes of a moving wheel sometimes\\nby muscular action, as in one of Desault s, a washerwoman who was\\nwringing clothes, or in one of Rognetta s, a carpenter who was drilling\\na hole in a plank Dalechamp s patient was bitten at the wrist by a horse.\\nThe pathology has not been shown by direct examination of either\\nrecent or old cases, and the only experiments bearing upon it are those\\nof Goyrand, quoted in Chapter XLVL, and they show only that by\\nexaggerated pronation the triangular fibro-cartilage uniting the radius\\nand ulna could be carried so far forward as to clear the end of the ulna\\nentirely he did not succeed in producing by this means a dislocation\\nthat would maintain itself without the aid of pressure upon the hand.\\nIt seems probable that in the clinical cases there was also rupture of\\nthe posterior radio-ulnar ligament.\\nSymptoms. The hand is slightly or markedly pronated its adduc-\\ntion has been noted by some, and diminution of the transverse diameter\\nof the wrist by others. Flexion and extension of the wrist are free\\nsupination difficult.\\nThe deformity consists in a marked projection of the lower end of\\nthe ulna on the back of the wrist, and a corresponding depression in\\nfront the ulna may, in addition, slightly overlap the end of the radius,\\nso that its axis if prolonged downward would pass to the middle finger.\\nIn connection with these may be mentioned a unique case reported\\nby Schmid l of dislocation of the radius forward from the ulna and\\ncarpus, caused by a fall upon the hand.\\nThe diagnosis appears to be easy. Malgaigne calls attention to the\\ndanger of mistaking the cause for the effect in old cases in which the\\ndislocation follows a chronic arthritis, and also of overlooking an asso-\\nciated fracture of the radius.\\nSeduction. Reduction has always been readily effected by direct\\npressure on the radius, aided sometimes by abduction or supination of\\nthe hand occasionally supination alone has been sufficient. Even in\\nold cases sixty days reduction has been easily made.\\nRecurrence has been noted in three cases. In one of Hamilton s the\\ndislocation had existed twenty years, but the movements of the limb\\nwere perfect.\\nDislocations Forward.\\nDislocation of the lower end of the ulna forward appears commonly\\nto have been caused by direct violence acting in opposite directions upon\\nthe lower ends of the radius and ulna while the hand was more or less\\nsupinated. It does not clearly appear that the cause has ever acted by\\ncarrying the movement of supination beyond its normal limit, although\\nit is not improbable that this was the case in one or two instances.\\n1 Schmid Correspondenz-Blatt d. Wurttemberg arztl. Landvereins, November 16, 1892.\\n43", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0751.jp2"}, "744": {"fulltext": "674 DISLOCA TIONS.\\nNo post-mortem examination has been reported, and the pathology\\nof the injury can, therefore, only be inferred. Desault, however, met\\nwith a specimen of an old dislocation in the cadaver of a man sixty\\nyears old the hand could not be extended, and rotation was very\\nlimited. The sigmoid cavity of the radius was filled with cellular\\ntissue the head of the ulna, situated in front of this cavity, rested on\\na sesamoid bone to which it was attached by a capsular ligament.\\nOther injuries had contributed to the loss of motion.\\nIn an entirely unique case reported by Valleteau l the dislocation\\nwas compound. The patient s forearm had been caught between the\\nspokes of a moving wheel the ulna projected twenty-eight lines\\nthrough the skin, crossing the front of the radius, which appears not\\nto have been broken.\\nSymptoms. The forearm is partly pronated or in varying degrees\\nof supination, the wrist flexed or extended, rotation difficult and pain-\\nful. The lower end of the ulna is prominent in front, with a corre-\\nsponding depression behind, and sometimes displaced toward the outer\\nside so that it overlaps the front of the radius and its axis is directed\\ntoward the middle of the hand. The radius maintains its relations\\nwith the carpus. In my case I could not determine the position of\\nthe triangular fibro-cartilage.\\nThe diagnosis is easy, but search should be made, as in the preced-\\ning variety, for the possible coexistence of a fracture of the radius.\\nThe best method of reduction appears to be by direct pressure upon\\nthe ulna and counter-pressure on the radius.\\nDislocations Inward and Downward.\\nDislocations inward and downward have been observed in connec-\\ntion with fracture of the radius or, very rarely, with dislocation of its\\nupper end, and are to be deemed complications or incidents of the\\nother and more important injury.\\nIn like manner, the serious complication of perforation of the skin\\nby the ulna has occurred only once except in connection with fracture\\nof the radius.\\nPathological dislocations have been reported as the consequence of\\nchronic suppurative arthritis and also of non-suppurative arthritis\\nprovoked by a sprain or by a fracture of the radius. Possibly the\\ncase reported by Rognetta, 2 of a negro who suffered from an habitual\\ndislocation of the ulna backward gradually produced by the effects of\\nhis occupation as a woodsawyer, belongs in this category, the ligaments\\nhaving become relaxed in consequence of an arthritis set up by the\\nconstantly repeated mechanical violence of the movement.\\nDISLOCATIONS OF THE RADIO-CARPAL JOINT.\\nThese dislocations, long thought to be common because fracture of\\nthe lower end of the radius was habitually supposed to be a disloca-\\n1 Valleteau Gazette Medicale. 1836, p. 250.\\n2 Eognetta: Archives gen. de Med., 1834, vol. v. p. 396.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0752.jp2"}, "745": {"fulltext": "DISLOCATIONS AT THE WRIST. 675\\ntion until Dupuytren forced a recognition of the error, are now known\\nto be of infrequent occurrence. Dupuytren, in the vigor of his cor-\\nrection of the error, went to the other extreme and pronounced them\\nunknown or of very great rarity, and this assertion has colored the\\ngeneral opinion concerning their frequency even to the present time.\\nThe statistics that have since been collected are not entirely trust-\\nworthy, perhaps, for the error in diagnosis appears still to be made\\nand not all reported cases can be unhesitatingly accepted, but there is\\nreason to think that the rarity is not very great, and there are enough\\nwell-authenticated cases to make it possible to trace a general descrip-\\ntion of the injury. Malgaigne collected 14 cases, 8 of backward, 6 of\\nforward dislocation. Parker 1 collected 33 cases, 23 backward and 10\\nforward. Tillmanns, 2 1874, collected 24, 13 backward and 10 for-\\nward and Servier 3 in 1880 collected 26 besides 1 observed by him-\\nself, 13 backward, 13 forward, and 1 outward, of which 19 were not\\ncontained in Tillmann s paper. I saw 1 and collected 13 cases pub-\\nlished between 1880 and 1887, 12 backward and 2 forward, and it is\\nworthy of note that 5 of these were reported in the Britisli Medical\\nJournal within six weeks of one another, March and April, 1880, the\\nreports of the last 4 having been called out by that of the first.\\nAlbert speaks of 5 within his knowledge or observation. Even sup-\\nposing Parker s 33 to include all of Malgaigne s and Tillmann s, and\\ncounting 19 of Servier s, this would still give a total of about 70 cases\\nmore or less well authenticated, the correctness of the diagnosis in a\\nnumber of them being entirely beyond question.\\nThe necessity of receiving with some caution those cases that have\\nbeen observed clinically and reported with scanty detail is shown by\\nthe errors in diagnosis that have been made by experienced surgeons\\nfully aware of the difficulty. Malgaigne 4 narrates three striking cases.\\nAt the time when Dupuytren was first questioning the correctness of\\nthe diagnosis in which fracture of the lower end of the radius was\\nhabitually taken to be a backward dislocation of the wrist, a patient\\npresenting all the usual signs of this injury died at the Hotel Dieu.\\nPelletan declared it to be a dislocation, Dupuytren a fracture, and the\\nformer did not vary from his opinion until after the last stroke of the\\nscalpel had exposed the bone and showed the injury to be a fracture\\nwith crushing of the lower end of the radius. In 1834 Roux made\\nthe diagnosis of dislocation backward in the case of a child that had\\nfallen from a tree again dissection proved it to be a fracture, with\\nseparation of the epiphysis. Still more remarkable was a case reported\\nby Chassaignac 5 in which he excised the projecting ends of the radius\\nand ulna, thinking the case was dislocation on careful examination it\\nproved to be a separation of the epiphysis of the radius. The diffi-\\nculty is probably not so great in dislocations of the carpus forward.\\nThe dislocation may be complete or incomplete backward or for-\\nward, and in one case was incomplete outward it may be simple or\\n1 Parker Transactions of the South Carolina Medical Association. Abstract in the\\nNew York Medical Eecord, 1876, vol. vi. p. 396.\\n2 Tillmanns Loc. cit. 3 Servier Gazette Hebdom., 1S80, p. 211.\\n4 Malgaigne Loc. cit., p. 703.\\n5 Chassaignac Bull, de la Societe de Chir., 1868, p. 225.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0753.jp2"}, "746": {"fulltext": "676 DISLOCATIONS.\\ncompound, or associated with fracture of the radius or ulna. Appar-\\nently fracture of the edge of the articular surface of the radius on the\\nside toward which the carpus is dislocated is not infrequent; such\\nfracture of the posterior lip of the radius is known in this country as\\nBarton s fracture/ 7 but it appears to me properly to belong among\\nthe dislocations, the fracture being only an incident or complication.\\nThe incomplete dislocations are mainly those in which only the outer\\nportion of the carpus, the scaphoid and semilunaris, is dislocated from\\nthe radius, while the inner portion maintains its relations with the\\ntriangular fibro-cartilage and ulna this variety appears to be produced\\nby a movement of rotation (pronation or supination) in which either\\nthe radius or the carpus is kept stationary while the other moves away\\nfrom it it appears to be sometimes associated with disturbance of the\\nrelations of the lower radio-ulnar joint.\\nIn addition to the traumatic, a few pathological and congenital dis-\\nlocations have been reported.\\nDislocations Backward.\\nCauses. The causes of this dislocation are characterized by great\\nviolence, as a fall from a height upon the palm of the hand in some\\ncases the wrist appears to have been flexed forward, doubled under\\nthe patient, in a fall while walking, or from a slight elevation.\\nIn two almost identical cases, Billroth l and Rydygier, 2 the mode of\\nproduction is clearly shown in the former, the patient, while pressing\\nwith the palm of his hand against a railway car in an effort to\\narrest its motion, was struck upon the back of the elbow by another\\ncar moving in the opposite direction, and a compound dislocation of\\nthe wrist was produced, the articular surfaces of the radius and ulna\\nprojecting through the skin on the palmar surface. Rydygier s patient\\nwas caught in the same way between a wagon and a wall alongside of\\nwhich it was moving.\\nPathology. The pathology is illustrated by a number of post-mortem\\nexaminations, and by some cases complicated by wounds which per-\\nmitted direct examination of the joint. The autopsy that has been\\nreported with most detail is that of a case observed by Voillemier. 3\\nThe patient was a man twenty-seven years old, who had fallen from the\\nthird story of a building, and received injuries which caused his death\\nin four hours. The violence that caused the dislocation of the wrist\\nwas apparently received upon the palm of the hand while in dorsal\\nflexion. The external and posterior ligaments were ruptured, the\\nanterior was torn away from the radius, and the internal was intact\\nbut was separated from the ulna by avulsion of its styloid process.\\nThe tendons and muscles of the back of the forearm were not torn,\\nbut had been stripped off the radius, bringing with them the perios-\\nteum and small pieces of attached bone. The superficial flexor muscle\\nwas widely perforated and torn by the styloid process of the radius at\\nits inner portion, that corresponding to the tendons of the ring and\\n1 Billroth Arch, fur klin. Chir., vol. x. p. 601, quoted by Tillmauns.\\n2 Kydygier: Deutsche Zeitschrift, fur Chir., 1881, vol. xv. p. 289.\\n2 Voillemier: Arch. gen. de Med., 1839, vol. vi. p. 401.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0754.jp2"}, "747": {"fulltext": "DISLOCATIONS AT THE WRIST. 677\\nlittle fingers, the remainder being pushed to the outer side together\\nwith the median nerve and radial vessels.\\nIn Lenoir s case a narrow fragment of the posterior articular border\\nof the radius had been broken off; it remained attached to the capsule\\nand was displaced backward with the carpus. This is the so-called\\nBarton s fracture of the radius (p. 289). In no other autopsy\\nof a backward dislocation has this fracture been reported, but it has\\nbeen suspected to exist in some of the cases observed clinically, and a\\nfeAv specimens of the reunited fracture without history are in existence.\\nIn a case quoted in the Centralblatt fur Ghirurgie, 1884, p. 279, both\\nstyloid processes were broken.\\nIn one of my own the semilunar bone remained attached to the\\nradius, and the scaphoid was broken.\\nOf the incomplete form, that in which only the outer portion of the\\ncarpus is dislocated, the only case given in sufficient detail is that of\\nDupuy 1 the patient, a young and muscular porter, while trying to\\nlift a cask had his hand forcibly supinated while the radius remained\\npronated. On examination two hours later the hand was found flexed\\nand half supinated, while the radius was pronated. Both styloid pro-\\ncesses could be distinctly felt, that of the ulna in its normal relations\\nwith the carpus, but that of the radius and the articular surface of the\\nlatter projecting as a ridge on the posterior aspect of the wrist. No\\ncrepitus no shortening of the limb. Reduction was effected by trac-\\ntion and direct pressure.\\nIn short, the dislocation is habitually accompanied by an extensive\\nlaceration of the ligaments, especially the anterior and external avul-\\nsion of the posterior lip of the articular surface of the radius may take\\nthe place of rupture of the posterior ligament. The extensor tendons\\nare lifted from their grooves but not torn the flexors may be torn or\\npushed to the outer side by the projecting radius the median nerve\\nand radial artery have always escaped injury, even when the radius\\nhas been driven through the skin. The carpus may be displaced\\ndirectly backward so as to rest upon the posterior surface of the radius,\\nwithout change in the relations of the several bones that constitute it,\\nor with more or less separation of them from one another, the semi-\\nlunar bone in two cases being completely detached from the others and\\nremaining attached to the radius or the displacement may be complete\\nonly on the radial side, the movement being one of rotation (supina-\\ntion) of the carpus turning on its inner side as a centre. A superficial\\ntransverse rent in the skin on the palmar surface of the wrist observed\\nin one case was probably caused by overstretching of the skin across\\nthe projecting end of the radius.\\nSymptoms. The deformity bears a close resemblance to that of Colles s\\nfracture, but yet the differences are such that Albert 2 says he was able\\nto make the differential diagnosis at sight. These differences are that\\nthe swelling on the anterior aspect of the wrist and lower part of the\\nforearm extends further down, nearer to the hand, in dislocation than\\nin fracture, reaching even to the ball of the thumb, and ends more\\n1 Dupuy: Journ. de Bordeaux, July, 1850, quoted by Tilluiauus.\\n2 Albert: Cbirurg., vol. ii. p. 440.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0755.jp2"}, "748": {"fulltext": "6 78 DISLOCA TIOXS.\\nabruptly that on the back of the wrist is more sharply outlined at its\\nupper border. In addition, the hand and wrist are commonly more\\nflexed upon the forearm and less movable in dislocation, and may be\\nadducted.\\nOn palpation the styloid processes should be recognized, and their rela-\\ntions to each other and to the bones of the hand and wrist determined\\nin fracture the styloid process of the radius is displaced upward to or\\nabove the level of that of the ulna, its distance from the head of the\\nsecond metacarpal bone, for instance, is unaltered while in dislocation\\nthe styloid process of the radius remains on a lower level than that of\\nthe ulna, and its distance from the head of the second metacarpal bone is\\nlessened it is also further removed anteriorly from the back of the wrist.\\nIn some of the cases the upper margin of the dorsal swelling could\\nbe distinctly felt to be hard and rounded, the convexity directed upward\\nand the bony thickness of the wrist to be notably increased antero-\\nposteriorly, and movable upon the shaft of the radius. The anterior\\nswelling is hard and irregular.\\nReduction has usually been easily effected by traction upon the hand\\nand direct pressure on the carpus, and as a tendency to recurrence is\\nnot to be anticipated, no other dressings are needed than such as will\\nsecure immobility.\\nIn compound cases the treatment should be rigorously antiseptic,\\nwith ample provision for drainage. Many surgeons think that a par-\\ntial excision in such cases favors recovery without accident, but I believe\\nthat opinion to be a survival from the pre-antiseptic days, and that\\ncleanliness, drainage, and rest will make excision unnecessary.\\nThe prognosis is favorable in the uncomplicated cases, and even\\nwhen the dislocation has remained unreduced the re-establishment of\\nthe functions of the joint has been satisfactory.\\nDislocations Forward.\\nThe causes of the forward dislocations have commonly been a forci-\\nble bending of the hand forward or backward. In two cases it was\\ndirect violence in one of them, Moore, 1 the fall of a heavy weight\\nupon the wrist while the latter was resting on the ground (the account\\ndoes not state whether the forearm w T as resting on its anterior or pos-\\nterior surface) in the other, Dieu, 2 the patient was kicked on the back\\nof the hand by a horse.\\nPathology. Seven autopsies have been reported, Malle, 3 Letenneur, 4\\nCollin, 5 Jarjavay, 6 Boinet, 7 Goodall, 8 and Dubar. 9 In addition, there\\nis a compound dislocation, for which Bransby Cooper 10 amputated the\\nposition and extent of the wound are not stated, the only detail that is\\n1 Moore: New York Medical Record, 1880, vol. xviii. p. 96.\\n2 Dieu Bull, de la Societe de Chirurgie, 1884, p. 296.\\n3 Malle Quoted by Malgaigue, Tillinanns, and Servier.\\n4 Letenneur: Bull, de la Societe Anatomique, 1839, vol. xiv. p. 162.\\n5 Collin Ibid., 1844, p. 335. 6 Jarjavay Ibid., 1861, p. 312.\\n7 Boinet Bull, de la Societe de Chirurgie, 1868, p. 211. This specimen was taken from\\nthe body of an old woman in the dissecting-room possibly the case was one of spon-\\ntaneous dislocation.\\n8 Goodall Lancet, 1878, vol. i. p. 937.\\n9 Dubar Gaz. des Hopitaux, July 23, 1892. 10 Cooper Loc cit., p. 422.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0756.jp2"}, "749": {"fulltext": "DISLOCATIONS AT THE WRIST. 679\\ngiven being that the flexor tendon of the thumb was torn through.\\nThese autopsies show rupture of the anterior and external lateral\\nligaments, and sometimes of all, the carpus being displaced well\\nupward along the anterior aspect of the radius and ulna in one case,\\nGoodall, the connection between the semilunar and cuneiform was\\ndestroyed, the latter bone retaining its normal relations with the trian-\\ngular fibro-cartilage, while the scaphoid and semilunar with the rest\\nof the carpus were displaced forward and upward, so that these two\\nbones passed over the free torn border of the ligament stretching from\\nthe styloid process of the radius to the cuneiform, which was thus left\\ninterposed between them and the articular surface of the radius, and\\nprevented complete reduction. Apparent reduction was easily effected\\nduring life, but the displacement at once recurred there were other\\nwounds, and the patient died of tetanus on the eighth day. The ante-\\nrior lip of the articular surface was broken off in two cases, and in\\none of these and another the styloid process of the radius was broken\\noff. Fracture of the styloid process was observed clinically by Mal-\\ngaigne, and fracture of the anterior lip was suspected in a case treated\\nby me in 1882, because of crepitus perceived during reduction, and\\nbecause of the facility with which the dislocation could be reduced and\\nreproduced. Boinet says that in producing the dislocation upon the\\ncadaver he always fractured the anterior lip of the radius.\\nSymptoms. The hand may occupy any position between moderate\\ndorsal and palmar flexion, the latter being the more common, and the\\nfingers slightly flexed. Voluntary and passive movements of the wrist\\nare restricted and painful. In a case reported by Roland, 1 a boy twelve\\nyears old, who had fallen five or six feet and struck upon the back of\\nhis flexed right hand, the wrist was immovable in right-angled flexion\\nand the fingers were flexed into the palm and could not be straightened.\\nDuring the struggles of etherization the bones snapped back into place;\\nthere was no tendency to recurrence, and the boy made a prompt recov-\\nery, using the hand freely in a few days. The deformity consists in a\\nmarked depression on the back of the wrist, the upper border of which\\nis marked by the sharply projecting outline of the radius and the end\\nof the ulna, and in a corresponding rounded prominence on the front\\nof the wrist, formed by the displaced carpus. The hand appears to be\\nshortened at the expense of the wrist, and an actual shortening can be\\ndemonstrated by measurement from the styloid process ,of the radius\\nto the finger. The antero- posterior diameter of the wrist is increased.\\nIn the old cases (Collin, Jarjavay, Boinet) a new articular surface\\nhad formed on the anterior surface of the radius and ulna, in two of\\nthe cases a full inch above their lower ends. In Collin s the limb was\\nequal in strength and freedom of use to the other, and all the move-\\nments were complete except those of abduction and adduction of the\\nwrist, in which there was slight and greater loss respectively.\\nReduction has been easily effected, with or without anaesthesia, by\\ntraction upon the hand or by direct pressure on the displaced bones or\\nby a combination of the two. In my case slight displacement forward\\npersisted.\\n1 Roland Philadelphia Medical Times, 1S79, vol. ix. p. 430.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0757.jp2"}, "750": {"fulltext": "680 DISLOCATIONS.\\nDislocations Outward.\\nOf this form of dislocation only one case has been reported, by\\nChapplain, 1 of Marseilles. The patient was a man, forty-seven years\\nold, who had fallen from a height of four metres, the weight of his\\nbody being received upon his left hand. The hand was widely dis-\\nplaced to the outer side, and through a wound situated upon the inner\\nside of the wrist the bones of the forearm projected and exposed their\\nentire articular surface. The wound of the skin extended from the\\njunction of the posterior and internal surfaces of the wrist, around\\nthe latter, and half-way across the anterior surface. The styloid pro-\\ncess of the radius had been broken off, and it accompanied the carpus\\nin its displacement. The pisiform was almost completely detached\\nand crushed the connections of the semilunar with the carpal bones\\nhad been ruptured, and it preserved its relations with the radius. There\\nwas, in addition, a dislocation of the elbow backward.\\nThe fragments of the pisiform, the styloid process of the radius, and\\nthe semilunar were removed, and the dislocation easily reduced. A\\nsingle suture was placed at the centre of the wound, and the hand and\\nforearm were thickly enveloped in cotton firmly bound on (Guerin s\\ndressing). A second dressing was applied on the eleventh day and\\nremoved on the twenty-second, when a large abscess was found on the\\nback of the hand and forearm, and the wound made at the time of\\nthe accident nearly healed. A subsequent note, five and a half months\\nafter the injury was received, states that the wounds were all healed,\\nthe phalangeal and metacarpophalangeal joints had almost entirely\\nregained their mobility, the wrist was completely anchylosed, and the\\nelbow only slightly movable.\\nPathological Dislocations of the Radio-carpal Joint.\\nThese dislocations, so far as they are due to destructive disease of\\nthe joint, are of secondary interest, and do not readily lend themselves\\nto a general description. Malgaigne quotes a few cases, generally\\nreported briefly, of dislocations forward that have been slowly pro-\\nduced in consequence of hydrarthrosis, arthritis, permanent contraction\\nof the flexor muscles, and the retraction of cicatricial bands he refers\\nalso to two cases briefly mentioned by Guerin among his congenital\\ndislocations, One in a child of six years, and the other in a girl of\\nfourteen years with incomplete paralysis of the muscles of the fore-\\narm, in which the dislocation was backward and upward and backward\\nand outward respectively. A more common form, one that has been\\nseen with sufficient frequency to have received special study, is the\\nfollowing\\nSpontaneous Subluxation Forward.\\nThis affection was first described by Dnpuytren 2 as a condition of\\nthe joint which might be mistaken for a dislocation, and of which he\\n1 Chapplain Bull, de la Societe de Chirursie, 1874, p. 479.\\n2 Dupuytren Clinique Chirurgicale. vol. iv. p. 209.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0758.jp2"}, "751": {"fulltext": "DISLOCATIONS AT THE WRIST. 681\\nhad seen a considerable number of cases, especially in men whose\\noccupations compelled them to make repeated, sudden, and violent\\ntraction with their hands, as in working a press or dressing cloth. He\\nsaid that under the influence of these efforts the ligaments of the joint\\nbecame stretched so that the bones were capable of more extensive\\nchange of place than was normal the carpus, being no longer held\\nfirmly against the bones of the forearm, yielded to the traction of the\\nflexor muscles and shifted to a position in front of their lower ends.\\nAll the signs of a dislocation were present except pain and inflamma-\\ntion. The more or less considerable deformity and weakness were the\\nonly inconveniences of the condition, and were not sufficient to cause\\nthe patients to intermit their work or seek medical help. Ordinarily\\nthe deformity could be reduced by traction, but it recurred as soon as\\nthe parts were left at rest.\\nMalgaigne, referring to this description, says that he had for twenty\\nyears vainly sought an example of the condition in the largest press-\\nrooms of Paris, and had met with only one, in a patient thirty-six\\nT ears old, in whom the condition developed at about the age of twelve\\nyears apparently as the result of carrying heavy burdens in this case\\nthe carpus was displaced forward and upward, three centimetres above\\nthe lower end of the ulna, and one centimetre above that of the radius,\\nthe antero-posterior diameter of the wrist was five and a half centi-\\nmetres on the ulnar side, but could be reduced to four and a half cen-\\ntimetres by pressure, on the radial side it was only four centimetres,\\nbut the articular edge of the radius [posterior?] was much depressed\\nand apparently inclined forward. Above the carpus, on the anterior\\nsurface of the radius, and apparently adherent to it, was a bony promi-\\nnence. All movements were free, except dorsal flexion, which was\\nnotably diminished.\\nIn 1878 Madelung 1 read before the Seventh Congress of German\\nSurgeons a paper upon the subject based upon the observation of\\ntwelve cases and the post-mortem examination of one. Of his twelve\\npatients the dislocation was unilateral in ten (four on the right side,\\nfive on the left, and in one the side was not noted), and bilateral in\\ntwo; eight patients were females, four males. The earliest age at\\nwhich the condition originated was the thirteenth year; in only two\\ncases did it begin after the twenty-third year. All but one of the\\npatients belonged to the working class, but their occupations were not\\nmarked by great muscular efforts. The specimen was obtained from\\nthe body of a woman about twenty years old, who had died apparently\\na short time after confinement. The appearance of the limb was so\\ntypical that he was convinced of the correctness of the diagnosis of\\nspontaneous subluxation, even in the absence of any history of the\\ncase. There was no sign of chronic inflammation of the bones of the\\narm or of any part of the skeleton. The limb was frozen and then\\nsawn longitudinally in two places. The first section was made through\\nthe centre of the os magnum and its articulation with the semilunar,\\nand divided the end of the radius so near its ulnar border that a por-\\n1 Madelung: Deutsche Gesellschaft fur Chirurgie, 1S78, p. 259, and Archiv fiir klin-\\nische Chirurgie, 1879, vol. xxiii. p. 395.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0759.jp2"}, "752": {"fulltext": "682\\nDISLOCATIONS.\\ntion of the incisura semilunaris shows in the section. The second sec-\\ntion divides the lower part of the ulna into two equal parts and passes\\nthrough the cuneiform, pisiform, and unciform bones. The sections\\nshow that the radial side of the carpus is displaced about half an inch\\nforward and an equal distance upward by the absorption of the anterior\\nhalf of the lower end of the radius, the posterior half persisting like\\na malleolus extended over the dorsum of the wrist, and the displace-\\nment forward of the ulnar side of the carpus is much more marked.\\nFig. 300.\\nMadelung s case of spontaneous dislocation of the carpus forward longitudinal section\\nthrough (C) the os magnum and (L) the semilunar.\\nFig. 301.\\nThe same: longitudinal section through the ulna, (H) the unciform, and (T) the cuneiform.\\nIt seems probable that a case reported by Jean T as a double congen-\\nital dislocation forward was of this character. On the right side the\\ncuneiform was placed well in front of the ulna the semilunar and\\nscaphoid not so far in front of the radius, which had formed a new\\narticular surface by loss of its anterior lip. In the left w T rist the dis-\\nplacement was of the same character but less marked. Possibly, also,\\nBoinet s case, quoted above, page 678, and R. W. Smith s case 2 of sup-\\nposed congenital dislocation belong to this class, and also one observed\\nclinically and reported by Pooley 3 as a double congenital dislocation\\nforward.\\n1 Jean Bull, de la Societe Anatomique, 1875, p. 398.\\n2 K. W. Smith Loc. cit., p. 251.\\n3 Pooley American Practitioner, 1880, vol. xxi. p. 216.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0760.jp2"}, "753": {"fulltext": "DISLOCATIONS AT THE WRIST. 683\\nThe production of the deformity in the cases observed clinically was\\nalways gradual, requiring from six months to two years for its full\\ndevelopment, and in no case could it be attributed to a traumatism,\\neither slight or severe, and in no case were there any signs of acute or\\nchronic inflammation of any part of the joint. In most cases the\\npatients attributed it to continuous hard labor with the hands, but it did\\nnot appear that this labor was more than usually prolonged or hard.\\nThe women usually attributed it to washing clothes two of the men\\nwere farmers, one a tanner, and one a shoemaker. In the discussion\\nthat followed the reading of the paper Hirschberg said he had seen\\ntwo clearly marked cases, the result of practice at the piano. The\\ndeformity in all the cases was accompanied by pain in the joint and\\nwas marked especially by the increasing prominence of the end of the\\nulna. After a time the pain ceased, the deformity remained stationary,\\nand the freedom of use of the limb was unimpaired except by diminu-\\ntion or total loss of dorsal flexion.\\nAfter Madelung s attention had been called to the subject by obser-\\nvation of his earlier cases, he took pains critically to examine the wrists\\nof people in all classes of society, and was astonished to find how fre-\\nquently he encountered slight deviations from the normal shape, all of\\nwhich were of the type of spontaneous dislocation forward and were\\ncharacterized not only by the abnormal projection of the end of the\\nulna but also by change in the articular surface of the radius and\\nthe position of the carpus. He attributed the more notable changes\\nin the end of the radius found in the fully developed cases to the\\narrest of the growth of its anterior portion and to the overgrowth of\\nits posterior portion stimulated by the loss of the opposing pressure\\nnormally exerted by the carpus, and he sees an analogy between this\\nchange and those observed in pes valgus and genu valgum. I have\\nseen one case, a young lady who spent much time at the piano.\\nSymptoms. The most marked deformity is seen when the limb is\\nviewed in profile from the ulnar side the end of the ulna projects\\nmarkedly at the back of the wrist; the hand is displaced toward the\\npalmar side, and the antero-posterior diameter of the wrist is greatly\\nincreased. Seen from the radial side the displacement forward does\\nnot appear so great, and the depression below the end of the radius is\\nbridged over by the extensor tendons if these tendons are relaxed by\\ndorsal flexion of the hand the posterior part of the articular surface of\\nthe radius can be traced with the finger, and its edge can be felt to be\\nrounder than usual. In addition, the entire epiphysis appears to be\\nbent forward.\\nBy traction and pressure the carpus can be brought nearer to the\\nulna, but it returns at once to its former place when the pressure is\\nremoved. No change can be effected in the relations of the carpus\\nand radius.\\nSometimes the region is very painful points that are tender on\\npressure are seldom found, and usually only at the upper margin of\\nthe joint. Every movement of the joint, especially dorsal flexion, is\\nvery painful.\\nActive and passive dorsal flexion is limited to an extent that corre-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0761.jp2"}, "754": {"fulltext": "684 DISLOCATIONS.\\nsponds to the degree of the subluxation, and in the most marked cases\\nthe hand cannot be carried backward beyond straight extension. The\\nrange of palmar flexion is more often increased than diminished, unless\\npain is present.\\nTreatment. The alteration in the shape of the bones fully explains\\nthe failure of the few attempts that have been made forcibly to reduce\\nthe displacement, and the fact that the limb recovers nearly its full\\nusefulness after the growth of the skeleton ceases and the progress of\\nthe displacement is arrested, furnishes a sound reason against operative\\ninterference. Prolonged attempts made by Madelung to improve the\\nposition by fixation in gypsum dressings and methodical manipulations\\ndid no good beyond relief of pain, and after he had learned the pathol-\\nogy and nature of the affection he limited his treatment to efforts to\\nincrease the strength of the arm in all its parts by methodical use and,\\nin some cases, to the wearing of a moulded leather bracelet which could\\nbe tightened or loosened and was kept in place by a loop passing\\nbetween the thumb and index-finger this prevented movements of\\nthe wrist and left the fingers free.\\nCongenital Dislocations of the Radio-carpal Joint.\\nThe question of congenital dislocation of the wrist is extremely diffi-\\ncult and obscure, for in the great majority of the reported cases the\\nhistory is so defective that the period at which the displacement took\\nplace must remain uncertain, although in most of them it was certainly\\nduring infancy or early childhood. In some the congenital origin of\\nthe malformation can hardly be called in question, because it is marked\\nby great irregularities of shape and development extending over sev-\\neral bones and joints, but the propriety of classifying such cases as\\ndislocations may well be questioned, for not only do the joint surfaces\\npresent hardly a trace of their normal form, but also one or more of\\nthe constituent bones may be entirely lacking. Such cases seem much\\nmore properly to belong among the congenital malformations and\\nto require classification as club-hands rather than as dislocations.\\nIn most of the reported cases in which the deformity has involved only\\nthe wrist the theory of congenital origin has been based upon the\\nabsence of the history of any traumatism that could account for the\\ndeformity, upon the statements of the patient or his friends that it had\\nexisted as long as they could remember, and upon its symmetrical\\noccurrence in both wrists. The history of spontaneous dislocations\\nforward shows how defective this argument is.\\nThe only alleged example of congenital dislocation which is accepted\\nas such by Bouvier l and Malgaigne is one reported by Marigues in\\n1755 it was observed in a stillborn child. The radius was widely\\nseparated from the ulna at its lower end, and in the interval between\\nthem were lodged the bones of the first row of the carpus which were\\nheld in place by strong ligaments the hand was hooked inward, and\\nit was held in this position especially by a strong ligament which\\nextended from the second row of the carpus to the end of the radius.\\n1 Bouvier: Diet. Encyclopedique des Sc. Med., art. Main Bote, p. 166.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0762.jp2"}, "755": {"fulltext": "DISLOCATIONS AT THE WHIST. 685\\nK. W. Smith l describes in detail several specimens of displacement\\nand deformity which he deemed of congenital origin, and quotes a\\nwell-known case reported by Cruveilhier in the ninth livraison of his\\nAnatomie Pathologique. One of these cases and two or three others\\nwhich have also been reported as congenital have been mentioned in\\nthe preceding section.\\nDISLOCATIONS OF THE CARPAL BONES.\\nThese present themselves as isolated dislocations of the individual\\nbones or as partial or incomplete dislocations of the medio-carpal joint.\\nOf the eight bones which form the carpus only the pisiform on the\\nulnar side and the trapezium on the radial side can be distinctly pal-\\npated. The former is felt as a small, hard lump at the junction of the\\npalm and wrist close below the inner end of the lowest of the transverse\\ncreases that cross the Avrist it rests upon the anterior face of the cunei-\\nform bone. The trapezium can be readily grasped between the thumb\\nand finger just above the base of the first metacarpal bone. A line\\ndrawn straight across the back of the wrist from one end to the other\\nof the lowest transverse crease on the palmar surface crosses the neck\\nof the os magnum directly above the base of the third metacarpal when\\nthe hand is extended in line with the forearm, and the finger can feel\\na distinct depression at this point, the upper margin of which is formed\\nby the lower face of the semilunar if now the wrist is flexed forward\\nthe hollow becomes filled by a projecting piece of bone, the head of the\\nos magnum. The medio-carpal joint is that between the three bones\\nof the first row above and the four bones of the second row below.\\nMedio-carpal Dislocations.\\nOf these, one dislocation backward, verified by autopsy, and two\\nforward, observed clinically, have been reported. Possibly some of\\nthe cases reported as dislocations of the os magnum were of this kind.\\nA backward dislocation was reported by Maisonneuve 2 in a patient\\nwho had fallen from a height of forty feet. The hand, displaced bodily\\nto a plane posterior to that of the forearm, was shortened several lines\\nbehind, a few lines below the styloid processes, was a transverse bony\\nprominence more than a centimetre high, with a depression below,\\nopposite the transverse fold of the wrist. The fingers were flexed, and\\na considerable effort was required to extend them. The bones of the\\nsecond row were completely separated from those of the first, and over-\\nrode them posteriorly more than a centimetre. A small piece of the\\nscaphoid remained attached to the trapezium, and a portion of the\\ncuneiform, with the pisiform, accompanied the unciform. The internal\\nand external lateral ligaments of the radio-carpal joint were completely\\nruptured, as were also the anterior and posterior ligaments uniting the\\ntwo rows of the carpus.\\nAn incomplete dislocation forward was reported by Despres. 3 The\\n1 E. W. Smith Fractures and Dislocations, 1847, p. 238.\\n2 Maisonneuve Mem. de la Soc. de Chir., quoted by Malgaigne.\\n3 Despres Bull, de la Soc. de Chirurgie, 1875, vol. i. p. 412.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0763.jp2"}, "756": {"fulltext": "686 DISLOCATIONS.\\npatient was presented with his deformity to the Societe de Chirurgie,\\nand as there was a difference of opinion concerning the nature of the\\nlesion a committee was appointed to examine and report upon it they\\nunanimously confirmed the diagnosis. The patient was a man twenty\\nyears old the injury was caused by a fall from a swing, probably upon\\nthe back, the hand being caught between the body and the ground.\\nWhen he came to the hospital, a week later, there was no swelling or\\nredness of the region on the back of the Avrist, a finger-breadth below\\nthe edge of the radius, was a depression below which the wrist and\\nhand had their normal appearance, and above which, between it and\\nthe radius, the finger recognized a distinct bony resistance. The axis\\nof the hand was deviated outward. On the palmar surface the tendon\\nof the palmaris longus and the thenar and hypothenar eminences were\\nprominent. All the movements of the wrist were preserved, and only\\nforced flexion was painful. Forced extension increased the displacement\\nwithout notably changing the form of the palmar surface of the wrist.\\nDuring flexion the prominence of the head of the os magnum was less\\napparent than in the other wrist the movement reduced the dislocation.\\nThe treatment consisted in maintaining the hand in the flexed posi-\\ntion in which the bone returned to its place by means of a spica ban-\\ndage it was begun eleven days after the accident, and by the fourth\\nday the pain had disappeared and the wrist had regained its form and\\nfunctions. The bandage was worn a week longer.\\nA complete dislocation forward has been reported by Richmond 1 the\\npatient was a man, forty-seven years old, who fell upon his hand from\\na height of about nine feet. The hand, from the wrist to the knuckles,\\nwas very noticeably shortened there was a prominent transverse ridge\\non the back of the wrist below the ends of the radius and ulna, and\\nbelow this ridge was a marked depression. On the palmar aspect the\\nbase of the hand was unduly prominent, the general direction of the\\nmetacarpal bones being quite altered by their bases being pushed for-\\nward toward the palm. Voluntary flexion and extension were lost.\\nThe ends of the radius and ulna seemed separated somewhat from each\\nother the transverse dorsal ridge could be demonstrated to be the first\\nrow of carpal bones with the semilunar unduly prominent between it\\nand the radius and ulna flexion and extension, although restricted,\\ncould be obtained with considerable ease and without crepitus. None\\nof the carpo-metacarpal joints had sustained any injury. On the pal-\\nmar prominence the trapezoid could be felt placed more anteriorly than,\\nand considerably above, the level of the trapezium and nearer the\\nulnar side the head of the os magnum could be felt slightly overlapping\\nthe ends of the radius and ulna, which on the palmar surface were\\nquite obscured and on flexion and extension of the hand the os mag-\\nnum could be felt to ride on their anterior surface. The displacement\\nof the unciform, although distinct, was much less marked.\\nIsolated Dislocation of the Different Bones of the Carpus.\\nThis is a rare injury, yet instances have been reported of the dislo-\\ncation of almost every one of them.\\n1 Kichniond Lancet, 1879, vol. i. p. 844.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0764.jp2"}, "757": {"fulltext": "DISLOCATIONS OF CARPAL BONES. 687\\nScaphoid. The only reported instances of dislocation of the scaphoid\\nalone are two quoted by Cooper, 1 one simple, the other compound, and\\none by King. 2 The first was reported by a medical student who was\\nserving as dresser in the hospital, and as the symptoms are not\\ndescribed in detail some doubt must remain as to the accuracy of the\\ndiagnosis it was complicated by fracture through the lower articular\\nsurface of the radius. It is as follows: A woman, sixty years old, fell\\nupon the back of her hand and fractured the radius obliquely out-\\nward, through the lower articulating surface. The fractured portion,\\nwith the os scaphoides, was thrown backward upon the carpus. The\\nwrist was slightly bent, and there was an evident projection at the back\\nof the carpus. Crepitus was felt in moving the hand or the styloid\\nprocess of the radius backward or forward.\\nIn the second the dislocation was compound, and the wound, which\\nwas caused by machinery, was so extensive as to make it the most\\nprominent feature of the injury it extended through two-thirds of the\\ncircumference of the wrist the scaphoid projected at the back part,\\nbeing attached only on the side toward the joint the radial artery and\\nthe extensor tendons of the thumb, middle, and forefingers were torn\\nthrough. The scaphoid was removed. The patient recovered.\\nIn King s, the dislocation was caused by a fall upon the palm, and\\nwas forward with rotation, the radial articular surface being directed\\nforward. Two months after the accident it was reduced by open\\narthrotomy.\\nA supposed case of backward dislocation was observed at the Hudson\\nStreet Hospital in 1899. The injury was an old one, the patient\\napplying for some other affection. The lesion was carefully examined\\nby two members of the house-staff, who concurred in the diagnosis.\\nA case of dislocation forward of the scaphoid complicating fracture\\nof the lower end of the radius, in which the bone was removed through\\nan incision, was reported by Cameron. 3 Six years later he 4 again\\nreported the case, this time as one of dislocation of the semilunar bone,\\nbut made no mention or explanation of the previous statement con-\\ncerning it, although he described the case in the same terms as before.\\nA case (Forgue) in which the scaphoid and semilunar were together\\ndislocated forward is described in the Gazette hebdomadaire de Mont-\\npettier, 1887, vol. ix. No. 1. The semilunar had undergone complete\\nrotation and presented in a contused wound on the front of the wrist.\\nSemilunar. Thirteen cases of dislocation of the semilunar bone, one\\nof them double (Flower), have been reported, including Cameron s\\ncase above mentioned. 5 In seven of them, Mougeot, Flower, Gross,\\nBuchanan, Stimson, and Albertin, the dislocation was compound, and in\\n1 Cooper: Loc. cit., pp. 432 and 436. 2 King Annals of Surg., August, 1899.\\n3 Cameron Glasgow Medical Journal, 1878, p. 102.\\nCameron, Lancet, 1884, vol. i. p. 885.\\n5 The references are Mougeot, quoted by Malgaigne Flower and Hulke, Holmes s Sys-\\ntem of Surgery, Am. ed., vol. i. p. 881 Erichsen, Science and Art of Surgerv, Am. e*d.,\\n1873, vol. i. p. 421 Taaffe, British Medical Journal, 1869, vol. i. p. 335 Chisolin, Phila-\\ndelphia Medical Times, 1870-71, vol. i. p. 335 Gross, Philadelphia Medical Times, 18S0-\\n81, vol. xii. p. 220; Buchanan, Medical Times and Gazette, 1885, vol. i. p. 113 Albertin,\\nLa Province Medicale, 1887, p. 420, and a second case in Lyon Medical, December 9,\\n1894 Gamgee, Lancet, July 6, 1895 Stimson, New York Medical Journal, January 3,\\n1891, p. 20, and a second case in Annals of Surgery, March, 1898, p. 365.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0765.jp2"}, "758": {"fulltext": "688 DISLOCATIONS.\\nsix of these the bone was removed. In four others the bone was removed\\nthrough an incision made for the purpose. In all the cases the cause\\nseemed to be forced flexion of the wrist. In one case, Erichsen, the\\ndislocation was backward, and in eight forward in the others the\\ndirection is not stated. In the forward cases the bone could be felt or\\nseen on the palmar aspect of the wrist, in mine distinctly above the\\nlevel of the edge of the radius the fingers were flexed and their exten-\\nsion was resisted and painful. Plate XXVII. shows the position of the\\nbone in my simple case.\\nIn the single case of backward dislocation, Erichsen, the patient had\\nfallen from a height, doubling his right hand under him a small\\nhard tumor was felt projecting on the dorsal aspect of the wrist it\\nreadily disappeared on extending the hand and employing firm press-\\nure, but started up again so soon as the wrist was forcibly flexed. It\\nwas evident that the bone belonged to the first row of the carpus and\\nfrom its size, its position toward the radial side of the carpus, and its\\nshape, which could be very distinctly made out, there could be little\\ndoubt that it was the semilunar bone.\\nThe frequent association of a wound on the anterior aspect of the\\nwrist and the nature of the cause make it probable that the dislocation\\nforward is effected while the hand is in dorsal flexion, yet in Taaffe s\\ncase it was thought the blow was received upon the back of the hand.\\nThe prognosis is unfavorable in four of the five simple forward cases\\nit was deemed necessary to remove the bone in order to relieve the dis-\\nability in the third the result is not stated. Of the seven compound\\ncases there was profuse suppuration in two, leading to amputation in\\none and partial anchylosis in the other three got well with a useful\\njoint, one died of tetanus, and the seventh appears to have died, prob-\\nably of associated injuries, as the fall was from a great height.\\nUnciform. The only recorded case of dislocation of the unciform\\nbone is one very briefly reported by Buchanan v a man fell from a rail-\\nway car he was found to have a simple luxation of the unciform\\nbone anteriorly. It lay just beneath the skin, and its process could be\\ndistinctly outlined. Reduction was effected by direct pressure on the\\nbone while the borders of the hand were approximated. Considering\\nthat the case, if correctly diagnosticated, is unique, the brevity of the\\nreport is to be regretted.\\nPisiform. The pisiform has been reported dislocated in three cases\\nin two (Erichsen, Fergusson) by muscular effort in one (Gras 2 by the\\npressure of the hand upon a flat-iron while ironing clothes. In Erich-\\nsen s case the bone was drawn up the arm for a distance of nearly an\\ninch. Doubtless the displacement was the result of rupture of the\\ntendon below the bone.\\nOs Magnum. Many authors speak of partial dislocation of the head\\nof the os magnum backward as a not infrequent accident produced by\\nprolonged, perhaps not violent, use of the hand, or by a sudden effort,\\nor a fall. Malgaigne classifies the former as pathological dislocations\\nthey are characterized by the appearance on the back of the wrist just\\n1 Buchanan Philadelphia Medical and Surgical Reporter, 1881-82, vol. xlvi. p. 418.\\n2 Gras Gazette Medicale, 1835, p. 542.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0766.jp2"}, "759": {"fulltext": "PLATE XXIX.\\nFig. 1\u00e2\u0080\u0094 Old Dislocation backward of the Os Magnum.\\nFig. 2. Same as Fig. 1,", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0767.jp2"}, "760": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0768.jp2"}, "761": {"fulltext": "DISLOCATIONS OF CARPAL BONES. 689\\nabove the base of the third metacarpal bone of a small, hard, round\\nlump, especially during palmar flexion, which disappears more or less\\ncompletely during dorsal flexion, and can sometimes be temporarily\\nreduced by pressure. It ordinarily causes little or no disability.\\nThe more distinctly traumatic cases are those of Richerand (quoted\\nby Cooper 1 and Seeger (quoted by Tillmanns). Richerand s patient\\nwas a woman who grasped the side of her bed during parturition, turn-\\ning her wrist forward, and felt a sharp pain in the wrist. A fortnight\\nlater, a hard, circumscribed tumor was found at the back of the carpus,\\nformed by the head of the os magnum, which was readily replaced by\\nmaking gentle pressure on it, and extending the hand. Richerand\\nhad seen another similar case, as had also Chopart and Boyer.\\nCooper s patient was a young, muscular man, who had fallen upon\\nhis hand in such a way as to bring the palmar aspect of the fingers\\ninto contact with the forearm. At the point of most pain was a round,\\nhard tumor, rather larger than a marble, which produced a most evi-\\ndent deformity on the back of the wrist opposite to and above the base\\nof the third metacarpal. The hand was slightly bent, and extension\\ncaused considerable pain the tendon of the extensor carpi radialis\\nbrevior was displaced slightly to the radial side the forefinger was\\nabducted from the middle one, and any attempt to approximate them\\ngave great pain at the base of their metacarpal bones and opposite\\nthe base of the middle one was a depression, quite evident to both sight\\nand touch. Reduction was effected by making traction on the fore and\\nmiddle fingers, while pressure was made upon the os magnum. On\\nflexing the hand the deformity w T as reproduced it was again corrected,\\nand the hand placed in splints.\\nSeeger 2 saw in 1829 and 1830 two cases of dislocation of the head\\nof the os magnum backward caused in young men by falls upon the\\nclosed fist. Reduction was effected by traction and forcible flexion of\\nthe hand, in one case easily, in the other only after several attempts.\\nThe hand was kept in splints in the extended position from six to eight\\nweeks, with compresses in front and behind. Recovery was complete.\\nThe only case of total dislocation of the bone of w r hich I know was\\nin a patient who applied at the Hudson Street Hospital in 1899\\nbecause of another injury. A lump was noticed at the back of his\\nwrist, which he said dated from an injury received nine years before.\\nTwo skiagrams taken at the time (Plate XXIX.) clearly show the\\nthree bones of the first row in place and the projection of the dislocated\\nbone over the site of the os magnum. There w T as no loss of function.\\nTrapezoid. The diagnosis of dislocation of the trapezoid backward\\nwas made in a case reported by Gay; 3 the patient was a man, thirty-\\ntwo years old, and the injury was caused by striking with the fist in\\nplay. At the base of the metacarpal bone of the index-finger was a\\nsharp, hard, slightly movable bunch, raised one-quarter of an inch,\\nand tender on pressure. There was no crepitus the metacarpal\\nbones were of the same length. It could not be reduced. Two\\n1 Cooper Loc. cit., p. 434.\\n2 Seeger: Mittheilungen der Wiirtt. arztl. Vereins, vol. i., quoted by Tillmanns.\\n3 Gay Boston Medical and Surgical Journal, 1869, vol. lxxxi. p. 1SS.\\n44", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0769.jp2"}, "762": {"fulltext": "690 DISLOCATIONS.\\nmonths later the deformity was unchanged, but the hand had become\\nnearly as good as the other.\\nTrapezium. Two cases of dislocation backward of the trapezium\\nalone have been reported byUhde 1 and von Mosengeil. 2\\nUhde s patient was a man, thirty-three years old, who had been\\nknocked down by a wagon. The right thumb and the region of its\\nmetacarpal bone was bruised, swollen, and painful, and at the\\njunction of the first metacarpal and trapezium an unusual mobility\\nof the latter bone was recognizable, and instead of the normal depres-\\nsion between the tendons of the extensor secundi and extensor primi\\ninternodii on extension of the hand there was to be seen a small\\nangular tumor corresponding to the trapezium, which projected on\\nflexion of the first and second metacarpals about three and a half lines\\nabove the level of the back of the hand, and disappeared on straight\\nextension of these bones with a creaking sound. Six months later the\\ntrapezium was found to project one and a half lines on the radial side.\\nVon MosengeiPs patient had a deformed hand, the thumb and its\\nmetacarpal bone having the shape and position of a finger the dis-\\nplacement, half a centimetre, was produced by a blow received upon\\nthe palm of the hand it was reduced by flexion and pressure.\\nThere is one case in the records of the out-patient department of the\\nHudson Street Hospital. It did not come under my observation, and\\nthe details are lacking in the report.\\nOs Magnum and Trapezoid. Uhde 3 briefly describes, under the title\\nluxatio ossis multanguli minoris et ossis capitati, a case of injury to\\nthe wrist marked by a projection on the back of the hand, which he\\nattributed to the displacement of the trapezoid and os magnum. The\\ninjury was caused by a fall upon the anterior ends of the metacarpal\\nbones. It does not appear from the description whether the bones\\nwere thought to be dislocated from the metacarpals as well as from the\\nfirst row of the carpus. The prominence could be reduced by pressure,\\nand reappeared on flexion of the wrist.\\nA case reported by Alquie, of Montpellier, has been frequently\\nquoted there was much displacement of the carpal bones on the radial\\nside, but not only was its character uncertain, but in addition the region\\nhad suffered from two different accidents, one of which was accompa-\\nnied by great laceration of the soft parts.\\nCARPOMETACARPAL DISLOCATIONS.\\nCases have been reported of the isolated dislocation of every one of\\nthe metacarpal bones except the fifth, and of the combined dislocation\\nof two or more.\\nFirst Metacarpal. Dislocations of the metacarpal bone of the thumb\\nare the most frequent and important almost all have been back-\\nward.\\nVery little is known of dislocations forward. Sir Astley Cooper 4\\nsays, In the cases which I have seen of this accident the metacarpal\\n1 Uhde Deutsche Kliuik, 1850, vol. ii. p. 539.\\n2 Von Mosengeil Arch, fur klin. Chirurgie, 1871, vol. xii. p. 723.\\n3 Uhde Loc. cit. Cooper Loc. cit., p. 443.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0770.jp2"}, "763": {"fulltext": "CARPO-METACARPAL DISLOCATIONS. 691\\nbone has been thrown inward, between the trapezium and the root of\\nthe metacarpal bone supporting the index-finger it forms a protuber-\\nance toward the palm of the hand the thumb is bent backward and\\ncannot be brought toward the little finger. Poinsot quotes a reference\\nby Vidal de Cassis to a case of incomplete dislocation forward which\\nhe had easily reduced.\\nAlbert l saw two cases of incomplete dislocation outward; one was\\nold, the other recent. In the latter the injury was produced in a trial\\nof strength by grasping hands. The displacement was easily reduced,\\nbut immediately recurred. After reduction the thumb was fixed in\\nabduction by a silicate dressing and so maintained for six weeks.\\nComplete recovery.\\nDislocations backward may be complete or incomplete the former\\nare infrequent, the latter quite common. Of the 43 cases of metacarpal\\ndislocation in my statistics (Chapter XXVII.) almost all were of this\\nbone and of this kind. The cause may be a forced flexion of the\\nthumb into the palm of the hand, or its forced movement in the oppo-\\nsite direction, or direct violence received upon the thenar eminence,\\nas in striking upon the handle of a chisel, or in striking a blow with\\na hammer, or in the bursting of a gun.\\nSpecimens of old dislocation have been dissected by Foucher 2 and\\nGerin-Roze 3 in the former the upper end of the metacarpal bone was\\ndisplaced backward and a little inward, and was flexed at a right angle\\nto and fused with the trapezium in addition, the second metacarpal\\nwas displaced upward about two centimetres on the back of the wrist,\\nretaining the insertion of the extensor carpi radialis, and the third\\nmetacarpal had been broken at its middle. The injury was caused by\\nthe bursting of a gun. In Gerin-Roze s case the displacement was\\ndirectly backward, the anterior edge of the base of the metacarpal rest-\\ning upon the posterior edge of the inferior articular surface of the\\ntrapezium incomplete reduction could be made.\\nIn the incomplete form the posterior edge of the base of the meta-\\ncarpal bone can be seen and felt in the interval between the tendons of\\nthe extensor primi and extensor secundi internodii as a hard lump\\ncontinuous with the shaft of the bone and reducible by pressure. The\\nthumb is generally somewhat flexed toward the palm, but may be\\nextended or straight. Movement is limited and painful, and flex-\\nion increases the apparent displacement.\\nIn the complete form the dorsal prominence is more distinct, and\\nrests upon the trapezium which forms a recognizable lump in the ball\\nof the thumb. The thumb is shortened by the ascent of the meta-\\ncarpal bone, its first phalanx appearing in consequence to have passed\\nupward into the thenar muscles, and it is usually flexed at the carpo-\\nmetacarpal joint.\\nIn some, even recent, cases reduction has been impossible, but usually\\nit has been effected without difficulty by traction on the thumb and\\ndirect pressure forward and downward upon the projecting end of the\\n1 Albert: Chirurgie. vol. ii. p. 445.\\n2 Foucher: Bull, de laSoc. Anatomique, 1856, p. 6.\\n3 Gerin-Koze: Bull, de la Soc. Anatomique, 1858, p. 266.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0771.jp2"}, "764": {"fulltext": "692 DISLOCATIONS.\\nbone. Early recurrence has been noted in some cases, and in a few\\nprevention of recurrence has been difficult or incomplete. Moulded\\nsplints of leather, plaster, or gutta-percha, and pasteboard or wooden\\nsplints with compresses at the back of the joint are ordinarily used, and\\nhave given satisfactory results. In one case the only dressing con-\\nsisted of strips of adhesive plaster, running from the back of the forearm\\naround the ball of the thumb, and back between it and the index-finger\\nto the forearm, so as to maintain the member abducted and extended.\\nThe restoration of function after reduction is complete, and even\\nwhen the dislocation has remained unreduced some patients have been\\nable to make good use of the thumb in others the movement of\\nadduction and opposition has been much restricted.\\nThe second metacarpal has been reported dislocated forward in two\\ncases and backward in five cases in one of the latter together with\\ndislocation of the first, and in another with dislocation of the third.\\nAn additional case, observed by himself, is mentioned by Demarquay, 1\\nin which the first and second were together dislocated, but the direction\\nis not stated, and no details are given.\\nThe forward cases are those of Bourget (quoted by Malgaigne) and\\nMarsh (quoted by Hamilton). In Bourget s, the cause was excessive\\npressure on the upper posterior part of the bone in Marsh s, it was\\nan oblique blow with a hammer on the back of the clenched hand. In\\nboth cases the proximal end of the bone could be felt in the palm, and\\na corresponding depression on the back in the former case the lower\\nend of the bone was inclined forward, and the finger appeared short-\\nened nearly one-fourth of an inch. Both were easily reduced by trac-\\ntion on the finger and pressure on the end of the bone.\\nThe uncomplicated backward cases are those of Hamilton 2 and Hum-\\nbert; 3 the former was caused in a woman, twenty-eight years old, by a\\nfall upon the closed hand. Reduction was easily effected. Humbert s\\npatient was a man thirty years old, who was kicked by a horse upon\\nthe hand that held the reins, the blow falling on the back of the lower\\nend of the second metacarpal bone and the adjoining phalanx the\\nupper end of the bone could be felt as a hard, circumscribed promi-\\nnence on the back of the hand, and the finger, measured by the adjoin-\\ning one, appeared five millimetres short. Reduction was made by\\ntraction and direct pressure downward and forward. Apparently the\\ndislocation had been caused by forced palmar flexion of the bone.\\nThe case in which the dislocation was associated with that of the\\nfirst metacarpal is that of Foucher, mentioned above.\\nIn two cases seen by Hamilton there was incomplete dislocation back-\\nward of the upper end of the second and third metacarpals, caused by\\nstriking a blow 7 with the fist in both cases the dislocation was old, and\\nhad persisted in spite of attempts to maintain reduction.\\nThird Metacarpal. In addition to these two cases, in which the injury\\nwas associated with dislocation of the second metacarpal, dislocation\\nbackward of the third metacarpal has been reported by Blandin 4 and\\n1 Demarquay Bull, de la Societe de Chirurgie, 1851, vol. ii. p. 171.\\n2 Hamilton: Loc. cit., p. 724. 3 Humbert: Union Medicale, 1868, vol. v. p. 527.\\nBlandin Gazette des Hopitaux, 1844, p. 552.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0772.jp2"}, "765": {"fulltext": "CARPO-METACARPAL DISLOCATIONS. 693\\nRoux. 1 Blandin s patient fell, while holding a roll of paper, and\\nstruck his hand against a post; the blow was slight, and caused no\\npain at the time, but the middle finger promptly became powerless,\\nand the hand numb and swollen. There was a linear transverse ecchy-\\nmosis at the back of the first phalanx of the middle finger, close by\\nthe metacarpal joint, and, on movement, a crackling that resembled\\ncrepitus. Xo other symptoms are mentioned. Blandin made the diag-\\nnosis of diastasis or incomplete dislocation of the third metacarpal\\nbone, but others who saw the case thought the bone was broken. The\\ntitle of the report of the case is incomplete dislocation upward.\\nRoux s patient had been injured in a mine explosion a hard, cir-\\ncumscribed, subcutaneous tumor could be seen and felt on the back of\\nthe wrist, continuous and moving with the third metacarpal the middle\\nfinger was shortened. The dislocation was reduced by direct pressure,\\nbut appears to have recurred, for at the autopsy the base of the bone\\nwas found resting on the back of the os magnum the second meta-\\ncarpal was broken.\\nFourth Metacarpal. An incomplete backward dislocation of the\\nfourth metacarpal was reported by Maurice. 2 It was caused by the\\npremature explosion of a cartridge which the patient was putting\\ninto a Chassepot gun the plunger was driven backward against the\\npalm of the hand. There w T as a prominence half a centimetre high\\non the back of the hand, corresponding to the upper end of the fourth\\nmetacarpal. Reduction was easy, and recovery prompt.\\nThe four inner metacarpal bones (II., III., IV., V.) have been simul-\\ntaneously displaced in four cases, Vigouroux, 3 Hamilton, 4 Tillaux, 5 and\\none of my own in the first and second the dislocation was backward,\\nin the others forward.\\nVigouroux s patient was injured, when eighteen years old, by the\\nexplosion of a pistol which he held in his left hand. At his death, at\\nthe age of sixty-two years, there was found a complete dislocation\\nbackward of the last four metacarpal bones these bones were flexed\\nforward and the proximal phalanx of each of the last three fingers was\\nincompletely dislocated backward. The index-finger and the lower\\npart of its metacarpal bone were lacking. All the joints of the carpus,\\nincluding that of the trapezium and first metacarpal, were normal.\\nHamilton s patient was struck at the battle of Fredericksburg by a\\nball which entered at the ulnar side of the hand and crossed the back\\nof the wrist between the last row of carpal bones and the skin. When\\nseen by Hamilton five years later the displacement (backward) was\\nvery conspicuous no fragments of bone had ever escaped. The move-\\nments of all the fingers, except the index- and little fingers, were\\nunimpaired.\\nTillaux s patient, whom I had the good fortune to see when he was\\nadmitted to the Lariboisiere Hospital, was twenty years old twelve\\ndays before admission to the hospital he had fallen backward from a\\n1 Roux Union Medicale, 1848, p. 224. 2 Maurice: Gazette Medicale, 1868, p. 5S7.\\n3 Vigouroux Bull, de la Societe Anatoruique, 1856, p. 15.\\n4 Hamilton Loc. cit., p. 724.\\n5 Tillaux Bull, de la Societe de Chirurgie, 1875, p. 415.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0773.jp2"}, "766": {"fulltext": "694 DISLOCATIONS.\\nwindow, about ten feet, striking upon the back of his flexed hand.\\nThe hand was flexed on the wrist and could not be actively extended.\\nThere was a dorsal depression corresponding to the line of junction of\\nthe carpal and metacarpal bones, sharply limited above by a transverse\\nprominence which was evidently formed by the second row of the car-\\npus, and on the palmar surface at the same level the ball of the hand\\nwas more prominent than usual. The relations of the first metacarpal\\nwith the trapezium were unchanged. Moderate traction with direct\\npressure forward reduced the displacement with a click, and by making\\npressure in the opposite direction it was again produced. After a\\nsecond reduction the limb was immobilized for a fortnight. Complete\\nrecovery.\\nMy patient was a lad fifteen years old who was admitted to the Pres-\\nbyterian Hospital in January, 1887, after having fallen down an eleva-\\ntor shaft, a distance of about forty feet, and received a compound\\nfracture of the right forearm, a severe injury of the right hip, the\\nnature of which could not be satisfactorily made out, and a dislocation\\nof the left carpo-metacarpal joints. When I first saw the patient, three\\nweeks later, the last-named injury had not been recognized. The hand\\nwas then in almost complete extension on the wrist and occupying a\\nplane somewhat anterior to that of the wrist and forearm. The back\\nof the wrist formed a rounded resistant prominence, continuous above\\nwith the back of the radius and ulna and terminating below in a sharp,\\nwell-defined, transverse ridge, which extended completely across from\\nthe fifth to the second metacarpal and curved upward on the outer side\\ntoward the styloid process of the radius. The finger, passed upward\\nalong the back of the metacarpus, was arrested by this ridge, which\\nappeared to be about one-quarter of an inch high and corresponded to\\nthe line of the carpo-metacarpal joints. The first row of carpal bones\\nwas in normal relations with the forearm and with most of the second\\nrow, but the relations of the trapezium could not be clearly made out.\\nI was under the impression that it was displaced somewhat forward\\nfrom the scaphoid it had preserved its relations with the first meta-\\ncarpal bone. The ball of the hand was abnormally prominent, and\\nthe antero-posterior diameter of the wrist appeared thereby increased\\nthe transverse diameter was unchanged.\\nThe deformity was easily reduced by traction and direct pressure,\\nbut immediately recurred when the pressure was removed. Reduction\\nwas maintained for ten days by keeping the limb in a plaster-of-Paris\\ndressing; on removal of the dressing the deformity did not recur, but\\na few hours later the patient reproduced it while experimenting to\\nascertain if the reduction was permanent. It was again reduced, and\\nthe limb dressed as before. Three weeks later the reduction was com-\\nplete and permanent except for some projection forward of the first\\nmetacarpal and trapezium, and the wrist and fingers had regained\\ntheir mobility.\\nDislocation of All Five Metacarpals. Poulet 1 reported a case of incom-\\nplete dislocation forward of all five metacarpal bones; the injury was\\ncaused by a fall from a horse and was associated with a wound of the\\n1 Poulet Bull, de la Soc. de Chir., 1884, p. 902.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0774.jp2"}, "767": {"fulltext": "CABPO-METACARPAL DISLOCATIONS. 695\\nskin on the ball of the hand and slight chipping of the anterior edges\\nof the carpal bones. The swelling and the inflammatory reaction were\\nso great that an examination was not made until after the lapse of a\\nmonth. There was then found on the back of the hand a projection\\nformed mainly by the os magnum, and below it a depression extending\\nfrom the trapezium to the unciform. On the palmar surface the ball\\nof the hand projected forward, the palmar fold was effaced, and a deep,\\nill-defined bony prominence could be felt. The interdigital spaces were\\ntwo centimetres nearer the styloid processes than on the other hand.\\nPartial reduction and restoration of mobility were obtained.\\nErichsen gives a woodcut and description of a plaster cast in the\\nUniversity College Museum, London, taken from a patient in whom\\nhe thinks this dislocation must have existed and Rivington l reported\\nthe case of a patient who had been run over by a wagon and had sus-\\ntained a compound dislocation forward of all the metacarpal bones,\\nthe base of the third projecting through a transverse wound near the\\ncentre of the palm the first phalanx of the thumb was also dislocated,\\nand the index-finger so injured that its amputation was necessary.\\nThe base of the third metacarpal was excised and the dislocation\\nreduced. After dangerous suppuration and high fever the patient\\nrecovered with a fairly useful hand.\\n1 Bivington Lancet, 1873, vol. i. p. 270.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0775.jp2"}, "768": {"fulltext": "CHAPTEK XLIX.\\nDISLOCATIONS OF THE THUMB AND FINGERS.\\nProximal Phalanx of Thumb of the Fingers Middle Phalanges Distal\\nPhalanges.\\nThe tables in Chapter XXVII. show that metacarpo- phalangeal\\ndislocations of the thumb and fingers and dislocations of the phalanges\\nin combined hospital and polyclinic services amount to nearly 25 per\\ncent, of all dislocations. Of the metacarpophalangeal dislocations\\nthose of the thumb are much the most numerous.\\nDISLOCATIONS OF THE PROXIMAL PHALANX OF THE THUMB.\\nThese dislocations are not only the most frequent of those involving\\nthe phalanges, but they also derive a special interest from the fre-\\nquency with which the reduction has been found to be very difficult\\nor has entirely failed. The cause of this difficulty has been the sub-\\nject of much study and experiment upon the cadaver during the last\\nhundred years, which may be said to have culminated in an elabo-\\nrate paper read by Farabeuf l before the Societe de Chirurgie of Paris\\nin 1875, in which the anatomy of the joint was described with much\\ndetail. This description and his explanation of the cause of the diffi-\\nculty have been generally copied and accepted by writers in Germany\\nand France. The experience I have gained in arthrotomies indicates\\nthat he has somewhat overestimated the importance of the sesamoid\\nbones in opposing reduction.\\nAnatomy. The head of the metacarpal bone projects on its palmar\\naspect in the form of a well-rounded tubercle or condyle covered with\\ncartilage, and more prominent on its outer than on its inner side.\\nThe ligaments of the joint here concerned are the two lateral and the\\nstrong anterior or glenoid the latter is continuous on either side with\\nthe others and is stiffened by the development within it of the two sesa-\\nmoid bones belonging to the short muscles attached to the base of the\\nphalanx. The tendon of the flexor longus pollicis lies nearer the inner\\nthan the outer side it is lodged at its lower end in a firm sheath, which\\nextends upward to, and is connected with, the glenoid ligament.\\nThe short muscles and their attachments are made tense by abduct-\\ning the thumb, and are relaxed by pressing the metacarpal bone into\\nthe palm of the hand. The long flexor and the extensors are relaxed\\nby inclination of the hand toward the radial side. Consequently, to\\nrelax as much as possible the various muscles attached to the thumb,\\nthe hand should be held in straight extension and slight abduction,\\nand the thumb should be pressed into the palm, adduction.\\n1 Farabeuf: Bull, de la Societe de Chirurgie, 1S76, p. 21.\\n696", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0776.jp2"}, "769": {"fulltext": "PLATE XXX.\\nFresh Dorsal Dislocation of the Thumb.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0777.jp2"}, "770": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0778.jp2"}, "771": {"fulltext": "DISLOCATIONS OF THE THUMB AND FINGERS.\\n697\\nThe dislocation may be backward, forward, or to the inner side\\ncomplete or incomplete.\\nBackward Dislocations.\\nThis is the most frequent form, and the one in which reduction of\\nthe dislocation is often difficult.\\nThe common cause is exaggerated dorsal flexion of the first phalanx.\\nWhen the normal limit of the movement is reached the anterior liga-\\nment is put upon the stretch and, the movement being continued, yields\\nat its attachment to the metacarpal bone, so that the anterior ligament\\naccompanies the phalanx in its movement.\\nFig. 302.\\nFig. 303.\\nIncomplete dislocation of the thumb.\\nIncomplete dislocation. (Farabeuf.)\\na. Incomplete Form. If this movement is not carried further than\\nto the position shown in Fig. 302 the articular end of the phalanx rests\\nagainst the posterior margin of the head of the metacarpal bone, and\\nis maintained in this position by the tension of the portions of the\\nadductor and abductor muscles which are attached directly to the\\nphalanx, for their line of traction is now posterior to and above the\\nnew centre of motion. The attitude of the member is represented in\\nFig. 303.\\nThis incomplete form is the one which many people, especially the\\nyoung, can voluntarily produce by contracting the extensor muscles.\\nThe anterior ligament and the sesamoid bones rest like an apron\\nagainst the anteroinferior articular surface of the metacarpal bone,\\nand the dislocation can be readily reduced by moderate traction upon\\nthe phalanx and flexion.\\nb. Complete Form. If, however, the movement is carried further,\\nthe phalanx entirely leaves the articular surface of the metacarpal\\nbone, and moves upward on its dorsum, being followed by the anterior\\nligament and the sesamoid bones (Figs. 304 and 305). The external lat-\\neral ligament is torn, and usually the internal one also the tendon of the\\nflexor longus pollicis may remain in position, and be tightly stretched\\nacross the articular face of the metacarpal bone, as has been seen in\\nsome compound dislocations (e. g., Esmarch x or, and much more com-\\nmonly, it accompanies the inner sesamoid bone to the inner side of the\\n1 Esmarch Berlin, klin. Wochenschrift, 1876, p. 629, first case.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0779.jp2"}, "772": {"fulltext": "698\\nDISLOCATIONS.\\nmetacarpal occasionally it passes to the outer side of the metacarpal\\nbone, accompanying the external sesamoid, but probably it does so only\\nwhen, in the production of the dislocation, the thumb is bent to the\\nouter side as well as backward. The head of the metacarpal bone\\nFig. 304.\\nSimple complete dislocation outer side. (Farabeuf.J\\nprojects through the rent in the capsule, and the tendons of the adduc-\\ntor, abductor, and the two portions of the flexor brevis rest against its\\nsides. The phalanx stands erect upon the dorsum of the metacarpal\\nbone, being held there by the tension of the abductor and adductor.\\nFig. 305.\\nFig. 306.\\nSimple complete dislocation right\\nthumb. The long flexor tendon is dis-\\nplaced to the inner side. (Farabel t f.)\\nSimple complete dislocation. (Farabeuf.)\\nThe dislocation is sometimes made compound by the rupture of the\\nsoft parts on the palmar aspect of the joint.\\nThe appearance of the member is characteristic (Fig. 306 and Plate\\nXXX.) The phalanx is thrown back vertically upon the metacarpal\\nbone, and the latter is adducted, the thenar eminence being consequently", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0780.jp2"}, "773": {"fulltext": "DISLOCATIONS OF THE THUMB AND FINGERS. 699\\nincreased in thickness and diminished in breadth. The head of the meta-\\ncarpal bone projects in front as a round, smooth prominence close under\\nthe skin, over which the tendon of the long flexor may perhaps be felt.\\nThe phalanx is quite movable from side to side, and can be rotated it\\ncan also be turned down so as to be parallel with the metacarpal bone, but\\nthis movement should be avoided lest it produce the condition to which\\nFarabeuf gave the name of complex form, the essential feature of which\\nhe thought to be the interposition of the sesamoid bones between the\\nphalanx and metacarpal, and which presents great difficulty of reduc-\\ntion. The cause of this difficulty, in all the cases in which I have\\nexposed the joint, has been the torn edge of the anterior ligament\\nclosely drawn across the back of the metacarpal behind its head, and\\na slight nicking of that edge made reduction easy. It is believed that\\nflexion of the dislocated phalanx tends to produce this engagement of\\nthe capsule, but I know that it can take place without that aid.\\nFig. 307.\\nComplex dislocation of the thumb outer side. The hook raises the periosteal continuation of\\nthe lateral ligament, exposing the reflected and interposed capsule. (Farabeuf.)\\nTreatment. The attitude of the thumb is maintained by the tension\\nof the short muscles attached to it, and all that is necessary to over-\\ncome that opposition is to relax the muscles by pressing the metacar-\\npal bone toward the palm then reduction is made, w T hile maintaining\\nthe phalanx in rectangular dorsal flexion, by pressing its base down-\\nward toward the end of the metacarpal and flexing when the proper\\nlevel is reached. If the torn anterior ligament has not caught behind\\nthe head, as just described, it will be pushed before the base of the\\nphalanx and the latter will turn past the head of the metacarpal in\\nflexion as soon as it descends far enough.\\nIf, on the other hand, the ligament has caught above the head it\\nbecomes a serious obstacle; it may sometimes be freed by rotating the\\nphalanx while pressing it downward as just described, and the bone\\nhas sometimes been got into place by forcible traction in straight\\nextension. The latter is probably only accomplished when the trac-\\ntion has torn the attachments sufficiently to permit the phalanx to be\\ndrawn quite away from the metacarpal, and I think the plan is dis-\\ntinctly inferior to an open arthrotomy.\\nIn reduction by arthrotomy the incision is made longitudinally\\nalong the projection of the head of the metacarpal as soon as this is\\nexposed the sides of the incision are drawn apart and the torn edge of", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0781.jp2"}, "774": {"fulltext": "700\\nDISLOCATIONS.\\nthe ligament, which can be distinctly seen above it somewhat as in\\nFig. 305, is nicked at its centre the dislocation is then easily reduced. 1\\nI presume the nicking might be done without a long incision, by pass-\\ning in a sharp-pointed tenotome. In some cases it has been sufficient\\nto lift the long flexor tendon around to the front from the side of the\\nhead, which, I presume, is efficient because the tendon is attached to\\nthe capsule and brings it with it in the movement.\\nThe prognosis in the past has not been favorable. Polaillon, 2 ana-\\nlyzing 58 cases, found that reduction had failed in 11 and had been\\neffected only after numerous and prolonged attempts in 16 in 8 the\\ndislocation was compound, and in 3 of these the head of the metacar-\\nFig. 308.\\nComplex dislocation. (Fakabeuf.\\npal bone was excised. In one case (Bromfield), nearly a hundred\\nyears ago, such violent traction was made that the terminal phalanx\\nwas torn off; the case has been persistently quoted as a warning ever\\nsince, but if it is remembered that traction is especially ill-adapted to\\neffect reduction in difficult cases the warning will not be longer needed.\\nIn other cases the thumb has become gangrenous in consequence of\\nthe violence inflicted upon it by the traction.\\nIn the cases in which the dislocation has been left unreduced and\\nthe phalanx has been lowered to a position in which it is parallel with\\nthe metacarpal bone, the usefulness of the member has been in great\\npart restored, although, of course, the deformity persisted and the joint\\nwas immovable.\\nForward Dislocations.\\nThese dislocations, much rarer than the preceding and less difficult\\nto reduce, result usually from a fall or blow upon the back of the\\nflexed phalanx that is, by exaggerated palmar flexion, but in at least\\none case (Lombard) from exaggerated dorsal flexion presumably com-\\nbined with direct impulsion of the phalanx toward the palm accord-\\ning to Foucart s 3 experiments dorsal flexion needed to be combined\\nwith forced abduction in order to rupture the internal lateral ligament.\\n1 Stinison New York Medical Journal, March, 30, 1889.\\n2 Polaillon Diet. Encyclopedique des Sc. Med., art. Doigt.\\n3 Foucart These de Paris, 1876, No. 199, quoted by Poinsot.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0782.jp2"}, "775": {"fulltext": "DISLOCATIONS OF THE THUMB AND FINGEBS. 701\\nPathology. The pathology has been shown by six autopsies, Wood/\\nMeschede, 2 Foucart, two cases, Eve, 3 and one of my own not before\\nreported. In two of these (Foucart, Eve) the injury was recent in\\nMeschede s it had lasted forty-eight days and in Foucart s second\\ncase, in Eve s, and in mine it was of long standing. The recent cases\\nshow, as is also found in experiments upon the cadaver, that the pos-\\nterior and lateral parts of the capsule are torn, including the lateral\\nligaments, but that the connection between one or both sesamoid bones\\nand the metacarpal bone may persist. The extensor tendons may be\\nstretched directly over the projecting head of the metacarpal bone or\\nthey may be deviated to either side in my case the tendon of the\\nextensor primi internodii appeared to have been detached and retracted.\\nThe base of the phalanx lies against the anterior surface of the meta-\\ncarpal bone, and, in recent cases at least, does not appear to be notably\\ndisplaced upward it may lie directly in front, or be somewhat dis-\\nplaced to either side, and the phalanx may be in straight extension or\\npartly flexed.\\nIn the older cases a more or less complete nearthrosis forms between\\nthe bones, and fibrous bands and bony outgrowths give the joint suffi-\\ncient solidity to make it useful.\\nSymptoms. The deformity is characterized by the position of the\\nphalanx in front of the metacarpal bone, the projection of the head of\\nthe latter on the dorsum of the member, and the rather deeply placed\\nprominence formed by the base of the phalanx at the lower part of the\\nthenar eminence. The thumb appears in some cases to have undergone\\nslight rotation about its long axis, and the attempt has been made to\\nshow a connection between the direction of this rotation and that of\\nthe lateral displacement of the extensor tendons that is, it has been\\nclaimed that when the rotation is such that the nail looks outward the\\ntendons have been displaced toward the outer side, and vice versa.\\nIn one reported case the dislocation was made compound by rupture\\nof the soft parts covering the back of the joint recovery was delayed\\nby a phlegmon of the ball of the thumb.\\nTreatment. Reduction is generally easy, and is effected either by\\ntraction and coaptation, or, better, by forced flexion of the thumb\\naided, if necessary, by impulsion downward of its base. This latter\\nmethod is analogous to that recommended in the treatment of the\\ndorsal variety, but there is not the same urgent reason for it that arises\\nin the latter from the relations of the capsule. If any difficulty should\\narise from the tension of the displaced extensor tendons the phalanx\\nshould be inclined toward the side on which they lie before making\\nthe usual manoeuvre.\\nLateral Dislocations.\\nBessel-Hagen 4 reports a unique case of dislocation to the ulnar side.\\nThe patient was twenty-eight years old the injury was caused appar-\\n1 Wood: Transactions Pathological Society of London, 1853, vol. iv. p. 250.\\n2 Meschede Virchow s Archiv, 1866, vol. xxxvii. p. 510.\\n3 Eve Lancet, 1880, vol. i. p. 133.\\n4 Bessel-Hagen Arch, fur klin. Chir., 1888, p. 386.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0783.jp2"}, "776": {"fulltext": "702 DISLOCATIONS.\\nently by forcible bending of the thumb toward the opposite side.\\nReduction by traction and pressure.\\nMETACARPOPHALANGEAL DISLOCATIONS OF THE FINGERS.\\nThe shallow cavity formed by the articular surface of the base of the\\nproximal phalanx is deepened by the thick anterior portion of the cap-\\nsule, which forms, as in the thumb, a stout transverse band or apron\\nwhich accompanies the phalanx in its displacement, and may in like\\nmanner become interposed between the bones in a backward disloca-\\ntion. The resemblance is still further increased by the occasional devel-\\nopment of a sesamoid bone in this ligament, especially at the index-\\nfinger its next most frequent appearance is at the little finger.\\nDislocations of the proximal phalanges of the fingers are much less\\nfrequent, even when taken together, than those of the thumb and\\nthose of the index-finger are more frequent than those of the other\\nthree fingers. Of 28 cases collected by Polaillon, the dislocation in\\n17 was backward, in 10 forward, in 1 not given 15 were of the index-\\nfinger, 4 of the middle, and 3 each of the ring and little fingers in\\n2 adjoining fingers were dislocated, and in 1 all four.\\nBackward Dislocations.\\nThe common cause is hyperextension (dorsal flexion) of the finger.\\nExperiment upon the cadaver and direct observation in compound dis-\\nlocations or after arthrotomy in irreducible ones, show that the rupture\\nof the capsule takes place in front along its attachment to the meta-\\ncarpal bone. In a case reported by Willemer l the dislocation was\\nirreducible by manipulation, and Konig resorted to arthrotomy,\\nmaking an incision on the ulnar side of the palmar surface of the joint\\n(index-finger) he found the anterior portion of the capsule had been\\ndrawn back past the articular surface of the phalanx so that it was\\ncompletely interposed between the two bones, and that a sesamoid bone\\nwas developed on it. This makes the case strictly analogous to the\\ncomplete form of backward dislocation of the thumb, and corroborates\\nthe opinion that the cause of the irreducibility in the latter is to be\\nfound in the position of the torn anterior ligament rather than in the\\ntension of the tendons of the short muscles.\\nLange 2 says of his case The smallest possible cord of the capsule,\\nwhich was torn from its attachment to the metacarpus, had interposed\\nitself like an apron between the dorsum of the metacarpus and the\\nborder of the articular plane of the phalanx. He was obliged\\nto incise and draw outward the light lateral parts of the capsule,\\nwhen reduction was effected without difficulty. A fair result was\\nobtained.\\nA similar condition was observed in a case upon which Volkmann 3\\noperated in like manner with a good result, and in one of my own.\\n1 Willemer: Centralblatt fur Chirurgie, 1883, p. 566.\\n2 Lange: New York Medical Record. 1879, p. 100.\\n3 Volkmann Eeported by Eanke, Berlin, klin. Wocliensckrift, 1877, p. 524.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0784.jp2"}, "777": {"fulltext": "DISLOCATIONS OF THE THUMB AND FINGERS. 703\\nThe symptoms are the prominence of the base of the phalanx on the\\ndorsum of the hand, and that of the head of the metacarpal bone in\\nthe palm, more or less shortening of the finger, and loss or diminution\\nof function. The finger may be extended or slightly flexed upon the\\nmetacarpus in one case the first phalanx was in rectangular dorsal\\nflexion. The middle and distal phalanges are straight or slightly\\nflexed.\\nIn 5 of Polaillon s 17 cases the dislocation was complicated by a\\nwound on the palmar aspect of the joint through which the head of\\nthe metacarpal bone projected, and in another the skin was so tightly\\nstretched over the end of the bone that it threatened to slough. In 2\\ncases reduction failed (without operation), and in 5 it was difficult, and\\nwas at last effected by rectangular dorsal flexion of the phalanx and\\ndirect impulsion downward as in backward dislocation of the thumb.\\nTreatment. If the dislocation is incomplete reduction may be easily\\neffected by moderate traction followed by flexion, but in the complete\\ncases it is certainly more prudent to act as in the similar dislocations\\nof the thumb in order more surely to avoid the interposition of the\\nanterior portion of the capsule.\\nForward Dislocations.\\nThe cause, except in an incomplete case observed by Malgaigne,\\nhas always been notable violence received upon the finger, usually in a\\nfall, but the mode of production is not clear. Malgaigne s patient was\\na shoemaker and caused the dislocation by turning in his hand the\\nshoe upon which he was at work.\\nThe symptoms are the presence of the base of the phalanx in the\\npalm and the projection of the head of the metacarpal bone at the\\nback of the hand. The finger is extended or slightly flexed, and\\nappears usually to be deviated to one or the other side, sometimes very\\nmarkedly, with displacement of the extensor tendons toward the same\\nside. Reduction has been effected by traction and coaptative pressure.\\nPossibly flexion would be efficient in the more difficult cases, as in the\\nsimilar dislocations of the thumb.\\nDISLOCATIONS OF THE MIDDLE PHALANGES.\\nThese dislocations may be backward, forward, or lateral.\\nBackward.\\nThe usual cause is a fall upon the palmar surface of the extended\\nfinger, which produces the dislocation by hyperextension of the phalanx\\nand sometimes ruptures the skin over the front of the joint. The\\nphalanx may remain hyperextended upon the proximal one, even to a\\nright angle, or may be lowered so that its axis is parallel to that of the\\nother. The diagnosis is readily made by examination of the relations\\nof the bones, and ordinarily reduction is easily made by direct impul-\\nsion of the hyperextended phalanx or by traction and flexion. The", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0785.jp2"}, "778": {"fulltext": "704 DISLOCATIONS.\\nanterior portion of the capsule resembles that of the metacarpopha-\\nlangeal joints in being thick and rigid, and it is quite possible, there-\\nfore, that it may become interposed as above described and make\\nreduction difficult or impossible, as in a case treated by Polaillon 1 in\\nwhich all measures failed. It seems advisable, therefore, that the first\\ntrial should be of direct impulsion upon the hyperextended phalanx,\\nand, this failing, the phalanx, still extended, should be pressed bodily\\ntoward the side on which the flexor tendons may be displaced and then\\nrotated so as to carry the tendons forward past the head of the other\\nphalanx.\\nForward.\\nThese may be complete or incomplete, according to the extent to\\nwhich the base of the middle phalanx is displaced upward along the\\npalmar aspect of the proximal one. The symptoms are the w T ell-\\nmarked prominence of the head of the first phalanx on the back, and\\nthe less marked projection of the base of the second phalanx on the\\npalmar surface when it is extended. With the displacement upward\\nmay be associated some lateral displacement or a lateral deviation of\\nthe axis of the second phalanx.\\nReduction is easily made by traction and coaptative pressure, but in\\nan old case treated by Hamilton the effort had failed, and in one treated\\nby Thorens the aid of anaesthesia w r as necessary.\\nLateral.\\nOf these but few cases have been reported Polaillon could collect\\nonly eight, of which the dislocation was to the inner side in seven, and\\nto the outer side in one. In a case quoted by him from Chedan the\\nmiddle phalanges of the last three fingers were simultaneously dislo-\\ncated toward the inner side, forming almost a right angle with the side\\nof the first phalanx. Duplay, 2 who saw a case, says the dislocated\\nphalanx is markedly deviated inward so as to form almost a right angle\\nand to cross the course of the adjoining finger. At the apex of the\\nangle the lower end of the first phalanx can be felt the dislocated\\nphalanx projects on its inner side.\\nIn Rollet s case of dislocation to the outer side the base of the second\\nphalanx of the ring finger projected upon the outer side of the first\\nphalanx the second phalanx was somewhat inclined inward, and the\\ndistal phalanx was slightly flexed. The shortening was about two-\\nthirds of a centimetre.\\nIn two of the eight cases the dislocation was compound, but the\\npatients recovered without anchylosis.\\nReduction was easily effected in every case by traction and coaptation.\\nDISLOCATIONS OF THE DISTAL PHALANGES.\\nThese dislocations may be backward, forward, or lateral, the former\\nbeing by far the most frequent forward dislocations have, I believe,\\nbeen encountered only in the thumb.\\n1 Polaillon Loc. cit., p. 184. 2 Duplay Pathologie Externe, vol. iii. p. 332.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0786.jp2"}, "779": {"fulltext": "DISLOCATIONS OF THE THUMB AND FINGERS. 705\\nBackward.\\nBackward dislocation of the distal phalanx is commonly caused by\\na fall or blow upon the end of the outstretched finger. The disloca-\\ntion may be complete or incomplete, simple or compound, and it may\\nbe directly backward or backward and to one side.\\nThe anterior ligament is torn away from one or the other bone, in\\nthe thumb usually from the proximal phalanx, in the lingers from the\\ndistal one. The lateral ligaments remain intact, unless the dislocation\\nis to one side as well as backward. The flexor tendon may be torn\\naway from its attachment, or it may be displaced to one side.\\nReduction is usually easy, but may be made difficult by interposition\\nof the anterior portion of the capsule when this accompanies the distal\\nphalanx or by the tension of the displaced tendon. In several com-\\npound cases of the thumb the obstacle created by the tendon was clearly\\ndemonstrated and was overcome by drawing the tendon aside with a\\nblunt hook or dividing it.\\nThe phalanx may be hyperextended, or straight, or flexed across the\\nend of the proximal one. The coexistence of a wound on the palmar\\nsurface of the joint is frequent, thirty-two times in fifty-five cases col-\\nlected by Polaillon, and has led to very serious consequences, anchy-\\nlosis, gangrene, suppuration extending to the forearm, tetanus.\\nAlthough ordinarily of easy reduction, yet in one-quarter of Polail-\\nlon s cases reduction failed. As his list is made up largely of reported\\ncases it undoubtedly contains an exceptionally large proportion of diffi-\\ncult and complicated ones, but still the number of failures, thirteen, is\\nlarge enough to indicate that reduction may often require much care\\nand skill. The principles controlling it are the same as in the back-\\nward dislocations of the other joints, and although simple traction\\nhas often sufficed it is prudent to refrain from it and to reduce by\\ndirect impulsion of the hyperextended phalanx, especially at the\\nthumb. In one case Hamilton divided the lateral ligaments subcuta-\\nneously.\\nForward.\\nThese dislocations have been observed only at the thumb, and in a\\nlarge proportion of the reported cases they have been made compound\\nby a wound on the palmar surface. The cause, in the few reported\\ncases, has been a blow upon the end of the phalanx by which it was\\nforcibly hyperextended. In some cases the phalanx remained in this\\nposition, its dorsal surface resting against the articular face of the\\nproximal phalanx, and its base projecting on the palmar surface; in\\nother cases the phalanx was slightly flexed, and its base displaced\\nupward along the anterior surface of the proximal one.\\nReduction has usually been easy by traction or direct pressure.\\nLateral.\\nThese dislocations, of which only four or five have been reported,\\nhave been caused by falls, by a kick, and by violently shaking the\\n45", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0787.jp2"}, "780": {"fulltext": "706 DISLOCATIONS.\\nhand while grasping it by the end of the finger. The phalanx may\\npreserve its parallelism with the other, being simply displaced upward\\nalong its side, or it may form a lateral angle with it, its base resting\\nagainst the side of the other. In Gogue s case, quoted by Malgaigne,\\nthere was a transverse wound fifteen millimetres long through which\\nthe head of the middle phalanx protruded. In Duges s case reduction\\nwas not attempted in the others it was easy.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0788.jp2"}, "781": {"fulltext": "CHAPTER L.\\nDISLOCATIONS OF THE PELVIS. DISLOCATIONS OF THE\\nCOCCYX.\\nThe union of the two innominate bones at the symphysis pubis is\\nby a solid fibro-cartilaginous band, and without an articular cavity,\\nand the rupture of this band, or its separation from one or the other\\nbone, belongs more properly among fractures than among dislocations.\\nBetween the articular surfaces of the ilium and sacrum there is usually\\nan articular cavity, but it is often more or less obliterated by fibrous\\nunion between the opposed cartilaginous surfaces. Pure separations\\nat these points without fracture are rare, and, except at the pubic sym-\\nphysis, hardly to be diagnosticated with certainty during life. The\\nreader is, therefore, referred for most that pertains to the subject to the\\nchapter upon fractures of the pelvis.\\nMalgaigne described the lesions as dislocations, and most writers have\\nfollowed his example. His classification is as follows\\nDislocations of the pubic symphysis.\\nDislocations of the sacro-iliac symphysis.\\nDislocations of these two symphyses, or of the ilium.\\nDislocations of the two sacro-iliac symphyses, or of the sacrum.\\nDislocations of the three symphyses, or of the three bones simulta-\\nneously.\\nDislocations of the coccyx.\\nOf these, only the last is, strictly speaking, to be deemed a disloca-\\ntion.\\nDISLOCATIONS OF THE COCCYX.\\nThe systematic descriptions of dislocations of the coccyx which are\\ngiven by the earlier writers were called in question by those of the first\\nhalf of the present century, some of whom, especially Boyer, went so\\nfar as to deny that the lesion had ever occurred. Malgaigne, however,\\ncollected six cases of dislocation forward, and described a backward\\nform on the authority of Lauverjat. To these six may be added four\\nthat have been since reported, Roeser, 1 Bonnefont, 2 two cases, and\\nMouret, 3 the first of which is an example of a variety, lateral disloca-\\ntion, that has not heretofore been described. It must further be said\\nthat many cases have been encountered and reported in which a group\\nof symptoms identical with those observed in cases reported as dislo-\\ncations, and following similar accidents, falls, blows upon the anal\\nregion, has been presented, and the conclusion seems to be unavoid-\\nable, either that dislocations or fractures of the coccyx are much more\\n1 Roeser: Froriep s Notizen, 1857, vol. ii. No. 10. Abstract in Brit, and For. Med. Chir.\\nEev., 1857, vol. xx. p. 414.\\n2 Bonnefont Union Medicale, 1859, vol. i. p. 136.\\n3 Mouret Eec. de Mem. de Med. Chir. et Pharm. militaires, 1859, vol. i. p. 350.\\n707", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0789.jp2"}, "782": {"fulltext": "708 DISLOCATIONS.\\nfrequent than the number of reported cases indicates, or that the prom-\\ninent symptoms which accompany the recognized cases, the excessive\\npain, disability, and general nervous disturbance, are due to something\\nelse than the displacement of the bone. Against the latter alternative\\nmay be urged the immediate relief and prompt recovery which have\\nfollowed the reduction of the displacement. Six cases in which the\\ngeneral symptoms were similar to those of dislocation, but in which no\\ndisplacement was recognizable, are reported by Warren, 1 and Mouret s\\ncase may perhaps be classed with them.\\nOf eight of the above cases in which the sex is noted, six were\\nwomen, and two men all were adults and the obscure injury just\\nreferred to, in which the symptoms are the same, except that no dis-\\nplacement is recognizable, is also much more frequent in women than\\nin men.\\nDislocations Forward.\\nThe usual cause is violence received upon the region of the coccyx\\nin a fall upon the buttocks or astride a bar, or by the breaking of a\\nchamber upon which the patient was sitting. The two men, Ravaton,\\nMouret, were injured while on horseback, one of them suddenly in\\njumping a ditch, the other without special cause or incident, the pain\\ncoming on gradually, and increasing for tw T enty-four hours, and then\\nsuddenly becoming very severe after a slight change of position, with\\na sensation of something slipping in the rectum.\\nThe pain at the moment of the accident is so severe as sometimes to\\ncause the patient to faint there is pain in defecation, and frequent calls\\nto urinate. The pain radiates down the thighs, and sometimes over\\nthe trunk, head, and arms the patient is unable to sit up, and the\\nslightest movement may greatly increase the suffering. Coughing and\\nsneezing and sometimes even every act of inspiration increase the local\\npain. If the condition remains unrelieved (Turner, a week Ravaton,\\nseventeen days Bonnefont, a month) the general health suffers seri-\\nously, the patient becomes feverish, and the mind dulled.\\nExternal examination may show an ecchymosis and swelling over the\\nsituation of the coccyx and a displacement of this bone forward the\\nfinger introduced into the rectum recognizes an angular displacement of\\nthe coccyx, in which its point is directed forward, and which is some-\\ntimes so great that the bone stands almost at right angles to its normal\\nposition, and presses the posterior wall of the rectum sharply forward.\\nIf now the finger is hooked over the projecting end of the coccyx\\nit can be readily drawn back into place, and the reduction is followed\\nby immediate, instantaneous relief of all the symptoms. A marked\\ntendency to recurrence usually exists and may make it necessary to\\nrepeat the reduction several times. In one of Bonnefont s cases a gum\\ncatheter with a stylet was bent into the shape of a hook and so placed in\\nthe anus that by traction upon the projecting portion the bone could be\\nkept in place. In Turner s case the cure was less complete the coccyx\\npreserved an abnormal mobility for many years, and the patient was\\nobliged to facilitate defecation by introducing her finger into the anus.\\n1 Warren Surgical Observations, Boston, 1867, p. 593.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0790.jp2"}, "783": {"fulltext": "DISLOCATIONS OF THE COCCYX. 709\\nDislocation Backward.\\nDislocation backward is lightly mentioned by some writers as a not\\ninfrequent accident during parturition. Malgaigne quoted Lauverjat\\nas follows The considerable deviation backward of this bone some-\\ntimes causes its dislocation. I have seen one case. The patient suf-\\nfered astonishingly, and could not sit I reduced the coccyx and she\\nwas immediately cured.\\nLateral Dislocation.\\nOf this only one case, Roeser, has been reported. The patient, a\\nlarge, corpulent woman, thirty-six years old, fell astride the back of a\\nchair. She at once suffered severe pain in the coccygeal region, much\\naggravated by attempts to sit, but she was able to go about for some\\nhours. At last the pain became so severe that she took to her bed,\\nwhen she found she could neither move nor turn. When seen the next\\nday there was so much immobility and stiffness of the body as to sug-\\ngest tetanus. Besides the severe pain in the coccygeal region she com-\\nplained of a painful, tense, dragging sensation, extending up toward\\nthe nape, and along the arms to the fingers, which felt numb. She\\ncould not bear to make the slightest movement. The head was con-\\nfused, and the intellect somewhat clouded. No unnatural sensation in\\nthe lower limbs urine and feces were passed naturally.\\nA small swelling was felt on the left side of the fissure of the but-\\ntocks, which proved to be the coccyx torn away from the sacrum, and\\ncarried toward the left ischium. The end of the sacrum from which\\nit had been displaced could be plainly felt. The finger in the rectum\\nshowed the exact nature of the displacement still better, and when firm\\npressure was made downward and to the right against the displaced\\nbone, it suddenly resumed its normal position. The patient declared\\nshe immediately felt quite another being, the confusion of the head and\\npainful sensation along the spine and arms disappearing. At the end\\nof the fifth day no inconvenience beyond a slight burning pain near\\nthe sacrum remained.\\nThe severity of the symptoms in all these forms appears to be due\\nto a special sensitiveness of the region which, as has been said, is mani-\\nfested by similar symptoms associated with no traumatism or local\\nchange, or, as in a case of my own, only with a dry arthritis of the\\njoint. The removal of the coccyx in the non-traumatic cases (coccy-\\ngodynia) gives great relief.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0791.jp2"}, "784": {"fulltext": "CHAPTER LI.\\nDISLOCATIONS OF THE HIP.\\nAnatomy Statistics Cases of Compound Dislocations Classification Back-\\nward Dislocations Dorsal, everted dorsal, anterior oblique.\\nAnatomy.\\nThe bony constituents of the hip-joint are the acetabulum, or cot-\\nyloid cavity of the os innominatum, and the globular head of the femur.\\nThe former is an almost hemispherical cavity, situated at the junction\\nof the ilium, ischium, and pubis, and formed by the projection from\\ntheir outer surface of a strong bony rim, which is especially thick and\\nprominent behind and above, and is lacking below for nearly an inch\\nat the point where the cavity adjoins the foramen ovale, the cotyloid\\nnotch. The depth of the cavity is increased by a fibro-cartilaginous\\nrim set upon its edge, the labrum cartilagineum, or cotyloid ligament,\\nwhich crosses the cotyloid notch, and is there termed the transverse\\nligament. The centre of the cavity lies in a line drawn from the\\nanterior superior spine of the ilium to the lowest or most anterior part\\nof the tuberosity of the ischium. The wall of the cavity is thin at its\\ncentre and lower part, and is elsewhere very thick and strong. Its\\ngrowth takes place at the junction of the three bones which combine\\nto form it, this junction being marked during the period of growth by\\na thin layer of conjugal cartilage having the shape of an inverted Y.\\nThe head of the femur is rather more than half of a sphere, having\\na radius of about an inch, and is so placed upon the neck that rather\\nmore than half of its cartilage-covered surface is in front and above\\n(in the upright position) and rather less than half is behind and\\nbelow. At a point a little below that at which a prolongation of the\\nlong axis of the neck would touch its surface is a depression, within\\nwhich the upper end of the ligamentum teres is attached.\\nThe neck is directed inward, upward, and slightly backward from\\nits junction with the shaft, the angle which it makes with the long\\naxis of the latter being about 130 degrees. The great trochanter, con-\\ntinuous with the outer surface of the shaft, overlaps the neck above\\nand behind, its highest part being situated posteriorly and curved\\ninward the portion which is most external and most nearly subcuta-\\nneous is about an inch below the upper margin.\\nThe capsule is attached above along the entire periphery of the\\ncotyloid cavity, just outside the free margin of the labrum cartilagi-\\nneum, and below to the femur at or near the junction of the neck and\\nshaft, extending in front to the inter-trochanteric line, above nearly\\nto the root of the great trochanter in the digital fossa, behind to the\\nneck itself a little short of its outer limit, and below to the upper part\\n710", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0792.jp2"}, "785": {"fulltext": "DISLOCATIONS OF THE HIP.\\nIll\\nof the lesser trochanter. It is composed of fibres arranged longitudi-\\nnally and circularly, and varies greatly in strength and thickness at\\ndifferent points. Those portions which are especially thickened by\\nmultiplication of the longitudinal fibres are known as accessory liga-\\nments of these the strongest and most important is the one situated\\nin the anterior part of the capsule, and known as the ilio-femoral liga-\\nment, or the ligament of Bertin, or Bigelow s Y-ligament (Fig. 309).\\nThis arises from the anterior\\ninferior spine of the ilium, and Fig. 309.\\nfrom the surface of the bone\\nimmediately behind it and above\\nthe edge of the acetabulum, and\\nits fibres passing downward\\ndiverge to form two strong\\nbands, of which the inner passes\\nalmost vertically to the lower\\npart of the anterior intertrochan-\\nteric line, and the outer to the\\nupper part of the same line.\\nThe ligament is about one-fourth\\nof an inch thick at its thickest\\npart, and is very strong, perhaps\\nthe strongest in the body, and\\nwill sustain without rupture a\\nstrain of from 250 to 750 pounds\\n(Bigelow). Its inner portion is\\nespecially concerned in limiting\\nextension of the limb; its outer\\nportion in limiting eversion.\\nThe other thickened portions\\nof the capsule are those known\\nas the pubo-femoral and ischio-\\nfemoral ligaments the former\\narises from the anterior and\\ninferior portion of the acetabular\\nmargin and the pubis as far\\ninward as the pectineal eminence, and extends in the anterior and\\nlower part of the capsule to its insertion above the small trochanter.\\nThe ischio-femoral ligament is a strong band of fibres on the outer\\nand posterior portion of the capsule, arising from the groove on the\\nischium below the acetabulum. The pubo-femoral ligament limits\\nabduction the ischio-femoral limits inversion. On each side of the\\npubo-femoral band the capsule is very thin outside and behind the\\nY-ligament the capsule is very strong, limiting adduction and inward\\nrotation (Bigelow).\\nThe joint is thickly covered in by muscles, of wdiich it is desirable\\nhere to mention only one, the obturator internus, which plays an\\nimportant part in the backward dilocations. This muscle, arising\\nfrom the inner surface of the obturator foramen and the surface of\\nbone between it and the great sacro-sciatic notch, passes outward\\nThe ilio-femoral, or Y-ligament. (Bigelow.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0793.jp2"}, "786": {"fulltext": "712 DISLOCATIONS.\\nthrough the small sacro-sciatic notch, turns sharply forward, and is\\ninserted upon the front part of the inner surface of the great trochanter\\nin conjunction with the two geinelli which arise respectively from the\\nspine and tuberosity of the ischium. Above it is the pyriformis, below\\nit the quadrat us femoris.\\nThe centre of the head of the femur lies about two inches directly\\nbelow the anterior inferior spine of the ilium, and at about the same\\ndistance downward and outward from the centre of, and in a direction\\nat right angles to, a line drawn from the anterior superior spine of the\\nilium to the spine of the pubis. When the bones are normal and in\\nplace, and the limb is partly flexed, a line drawn across the outer aspect\\nof the thigh from the anterior superior spine of the ilium to the lowest\\npart of the tuberosity of the ischium will cross the upper part of the\\ngreat trochanter. This is known as Nelaton\\\\s, or the ischio-iliac line\\nits relations to the trochanter have great diagnostic importance. In\\nthe child, according to Hueter, the trochanter is brought somewhat\\nhigher by the relative shortness of the neck of the femur.\\nExtension and abduction are checked in the living by the ligaments\\nof the joint, flexion and adduction by the muscles or by the contact of\\nthe limb with the abdomen in flexion. The range of abduction and\\nadduction is further modified by the position of the limb as regards its\\nflexion and its rotation about the long axis.\\nThe position of the limb in which dislocation of the hip most fre-\\nquently occurs is that of flexion, adduction, and inward rotation, and\\nthe dislocation which then occurs is usually one of the backward forms,\\nalthough after the head of the bone has left the socket abduction and\\noutward rotation of the limb may lodge it in the obturator foramen.\\nIn this position the posterior and inferior portion of the capsule is put\\nupon the stretch and ruptured. By outward rotation and abduction the\\nhead may be forced out at the lower and inner part of the capsule below\\nthe pubo-femoral ligament, toward the obturator foramen in each case\\na new centre is found for the exaggerated movement in the more or\\nless direct contact between the neck of the femur and the margin of\\nthe acetabulum or in the tension of part of the Y-ligament. The force\\nwhich produces the dislocation, therefore, almost always acts indirectly,\\neither by moving the limb upon the fixed trunk or by moving the\\ntrunk upon the fixed limb. In the great majority of cases the\\nY-ligament remains untorn, and by the restraint which it exerts upon,\\nthe movements of the displaced femur it determines in a large measure\\nthe character of the secondary displacement, the attitude in which the\\nlimb comes to rest, and the manipulations by which the dislocation can\\nbe reduced. This influence is so great that Bigelow based upon it the\\ndistinction which he made between regular and irregular dis-\\nlocations, the former including those cases in which the ligament\\nremained untorn and the attitude of the limb was in consequence char-\\nacteristic the latter those in which the ligament was more or less torn\\nand the attitude and displacement variable. The distinction has some-\\ntimes an important bearing upon the treatment and deserves to be\\npreserved.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0794.jp2"}, "787": {"fulltext": "DISLOCATIONS OF THE HIP. 713\\nStatistics.\\nThe tables in Chapter XX VII. show that the percentages of dislo-\\ncation of the hip, compared with all dislocations, vary from 1.25 to 2\\nper cent. Agnew 1 says that of 912 dislocations admitted to the\\nPennsylvania Hospital 89 (9.75 per cent.) were of the hip. Of\\nKronlein s 8 cases 4 were in patients not more than ten years old, and\\nof PrahPs 2 41 cases 12 were of the same age, 8 were between eleven\\nand twenty, and 11 were between twenty-one and thirty years old.\\nThis preponderance in youth is, however, not found in Agnew s list or\\nin the 41 cases collected by T Malgaigne or the 84 cases collected by\\nHamilton. The latter were divided as follows\\nUnder 15 years .15\\n15 to 30 32\\n30 45 29\\n45 60 7\\n60 85 1\\nAgnew s 89 cases are thus divided\\n15 to 25 years 39\\n25 35 26\\n35 45 12\\n45 55 6\\n55 65 5\\n65 75 1\\nAlthough the numbers are larger in Hamilton s collection than in\\nPrahPs, yet, as the latter are the integral statistics of a single hospital\\nand dispensary, I think its percentages are more likely to represent the\\nactual proportions than those of a collection of published cases are.\\nI do not know how to account for the absence from Agnew s list of\\npatients under fifteen years of age.\\nThe earliest age at which a dislocation has been reported is six\\nmonths; 3 it was a dislocation upon the obturator foramen, and was\\ncaused by the fall of a chair in which the child was tied. In the\\nreport by W. A. Johnson, 4 of a clinical lecture by Prof. Gross, it is\\nsaid, upward of six years ago this child, M. S., aged seven years, had\\na fall, and received a dorsal dislocation of the hip. The note is\\nentitled, Dislocation of the hip-joint in a child six months of age.\\nBartels 5 reported a dorsal dislocation at eleven months caused by the\\neffort made to put on a shoe. Several others have been reported\\nbetween the ages of eighteen months and five years.\\nThe oldest patient is one reported by Kennedy, 6 a woman, aged\\nninety-one years and five months, who received a dorsal dislocation of\\nthe right hip by a fall, while walking across a smooth floor it was\\nreduced on the twelfth day by manipulation, and two days later the\\npatient died. The autopsy verified the diagnosis. The next oldest\\n1 Agnew: Surgery, vol. ii. p. 89.\\n2 Prahl Inaug. Dis., Centralbl. far Chir., 1881, p. 57.\\n3 Powdrell: Lancet, 1868, vol. i. p. 617.\\n4 Johnson: Philadelphia Medical Times, 1876-7, vol. vii. p. 5.\\n5 Bartels: Arch, fur klin. Chir., 1874, vol. xvi. p. 650.\\n6 Kennedy: Cincinnati Lancet and Clinic, 1878, vol. i. p. 256.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0795.jp2"}, "788": {"fulltext": "714 DISLOCATIONS.\\npatient, eighty-six years, was also a woman/ and the next a man\\neighty-one years old, whose dislocation w 7 as suprapubic and was veri-\\nfied by autopsy four years later the neck of the bone was broken by\\nan attempt to reduce while the injury w r as recent the case was reported\\nby Verneuil. 2\\nThe injury is much more common in males than in females of\\nAgnew s 89 cases, 11 were women of 115 cases collected by Hamilton,\\n104 were males.\\nConcerning the relative frequency of the different varieties it can be\\nsaid that those in w T hich the head of the femur is found resting upon\\nthe lower part of the ilium behind the outer posterior half of the ace-\\ntabulum, the so-called iliac dislocation, to preserve for the moment\\nthe old classification, or still lower down on the upper part of the\\nischium, ischiatic dislocations, are much more frequent than those\\nin which it rests in front or on the inner side of the acetabulum, the\\nsuprapubic and obturator dislocations. The dislocations upon the dor-\\nsum of the ilium are generally thought, on clinical evidence, to be\\nmore frequent than the ischiatic, but a comparison of the cases exam-\\nined after death does not corroborate this view Malgaigne collected\\n10 autopsies of ischiatic dislocations, and only 6 of the iliac, one of\\nthese being primarily ischiatic, and Lossen, 3 taking only cases reported\\nsince 1855, found 19 ischiatic and only 5 iliac. Probably Malgaigne s\\nsupposition is correct that many ischiatic cases observed clinically are\\nthought to be iliac indeed, it will further appear that in many iliac\\ndislocations the head of the femur has primarily passed downward and\\nbackward, and that its presence upon the dorsum of the ilium is due\\nto a secondary displacement upward. Roser goes so far as to claim\\nthat the iliac dislocations, in which the head of the femur has left the\\ncotyloid cavity by its upper posterior portion, are the rarest of all the\\nprincipal forms. Of the two anterior forms the obturator seems to be\\nmore frequent than the suprapubic, but the reported cases are too few\\nto justify a positive assertion.\\nSimultaneous dislocation of both hips has been reported in about thirty\\ncases (see Chapter LIIL).\\nCompound dislocations are very rare, as might be expected from the\\nthickness of the soft parts which everywhere cover in the joint. The\\nrecorded cases are those of Walker, 4 Bransby Cooper, 5 Macouchy, 6\\nMoxon, 7 a German military surgeon, 8 Taylor, 9 Woodward, 10 Langmaid\\nand Cabot, reported by Perkins, 11 and Cheever. 12 In the first case the\\npatient fell under a wagon, the wheel passing over the back of his\\npelvis and right thigh the head of the femur was forced forward\\n1 Gauthier Quoted by Malgaigne, loc. cit., p. 805.\\n2 Verneuil: Bull, de la Soc. de Chir., 1865, vol. vi. p. 495.\\n3 Lossen Deutsche Chirurgie, Lief. 65, p. 30.\\n4 Walker Quoted by Cooper, loc. cit., p. 80.\\n5 Cooper Loc. cit., p. 76.\\n6 Macouchy Dublin Hospital Gazette, 1872, vol. i. p. 21.\\n7 Moxon Medical Times and Gazette. 1872, vol. i. p. 96.\\n8 Centralblatt fur Chirurgie, 1880, p. 504.\\n9 Taylor Lancet, 1881, vol. i. p. 732.\\n10 Woodward Boston Medical and Surgical Journal, 1883. vol. cviii. p. 129.\\n11 Perkins Ibid., October 16, 1890. p. 362.\\n12 Cheever Ibid., May 28, 1891, p. 523.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0796.jp2"}, "789": {"fulltext": "DISLOCATIONS OF THE HIP. 715\\nupon the groin and through the skin. Reduction suppuration\\ndeath in three weeks. The second is not spoken of by Cooper as a\\ncompound dislocation, but the history indicates that it probably was\\none the patient, a lad seventeen years old, was run over by a wagon,\\nthe wheel passing across the back of his thigh and producing a dislo-\\ncation forward and inward, the head of the femur lying to the inner side\\nof the great vessels. A rather large lacerated wound was situated just\\nbelow Poupart s ligament, a little to the inner side of its centre. Pro-\\nfuse suppuration followed, and the patient died on the twentieth day.\\nMacouchy s patient was a boy fourteen years old, who fell from a\\nmast to the deck, a distance of sixty feet, and received, in addition to\\nthe dislocation, a fracture of the base of the skull. When seen, he\\nwas sitting on the deck with the head of the femur appearing between\\nhis legs, through his pilot-cloth trousers, as if protruded from his anus.\\nThe head, neck, and great trochanter protruded through the integu-\\nments covering the posterior third of the ischium, the head of the bone\\nresting on the posterior part of the tuberosity of the ischium of the\\nopposite side. The head was sawn off, and the shaft replaced. The\\npatient died two days later.\\nMoxon s patient, a railway porter, was injured by a moving train\\nand died shortly afterward in Guy s Hospital. The position of the\\nlimb was that of dislocation on the dorsum ilii. There was a large\\nirregular rent in the skin corresponding to the junction of the left\\nsacro-sciatic ligament with the tuber ischii. On passing three or four\\nfingers into the hole a way was found through a pulp of torn muscles\\nand bloodclot, till the fingers rested on the naked head of the thigh\\nbone. The gluteal muscles were much torn up and infiltrated with\\nblood. The head of the thigh bone lay half an inch outside the great\\nsciatic nerve, free under the remains of the glutei. It had escaped\\nthrough the muscles immediately around the joint by passing between\\nthe quadratus femoris and obturator internus. A portion of the head\\nof the bone remained in the socket, attached by the round ligament.\\nThe fifth case was that of an artilleryman who fell in front of the\\ngun his left leg was bent back so that the heel lay against the back\\nof the shoulder, and the head of the femur projected through the fold\\nof the groin. There was profuse bleeding from the femoral vein.\\nDeath in twenty-four hours.\\nTaylor s patient was a lad seventeen years old, who was overthrown\\nby a falling tree and received a dislocation into the obturator foramen\\ntogether with an irregular wound nearly two inches long in the\\nperineum through which the head of the femur could be distinctly\\nfelt. Most of the muscles had been separated from the descending\\nramus of the pubis and the ascending ramus of the ischium. Reduc-\\ntion was made with some difficulty, and the limb immobilized on a long\\nside splint. The wound healed promptly, and at the end of nine weeks\\nthe splint was removed, but on the next day inflammatory symptoms ap-\\npeared on the side of the hip, and an abscess formed and was opened.\\nEight months later Taylor met the patient riding on horseback.\\nWoodward s patient, a boy twelve years old, was caught under a\\nfreight car and rolled over and over, receiving several fractures in", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0797.jp2"}, "790": {"fulltext": "716 DISLOCATIONS.\\naddition to the dislocation. The wound was a slit about two inches\\nlong on the inner side of the thigh two and a half inches below the\\nangle of the pubes. The head of the femur, together with the great\\ntrochanter entirely stripped of its muscles, projected completely through\\nthe opening for about four inches and lay across the scrotum. Its point\\nof exit was just anterior to the adductor longus. Xo fracture of the\\nfemur or pelvis was detected, and the great vessels were uninjured.\\nThe patient died in five hours, and after death reduction could not be\\nmade.\\nLangmaid s patient was a girl eight years old who had been run\\nover by a heavy wagon. The wound extended from a point one inch\\nabove and within the anterior superior spine across the groin to the\\ninner side of the thigh, the head of the femur presenting in it near its\\ncentre. The muscles directly under the wound were severed, the\\nadductor longus completely, the pectineus, psoas, and gracilis partially.\\nConsiderable hemorrhage the femoral vessels were outside and\\nbeneath the neck of the femur. Reduction. The wound suppu-\\nrated, but the child recovered with complete anchylosis.\\nCheever s patient, a man fifty years old, was thrown down by the\\nfall of a heavy case the head of the femur protruded through a wound\\nin the groin below the outer part of Poupart s ligament. The head\\nwas excised patient died on the third day. The autopsy showed the\\nfemoral vessels to be intact. Death was apparently due to associated\\ninjuries, shock, and extensive fat embolism of the lungs.\\nThe gravity of the condition, 7 deaths in 9 cases, is largely due to\\nassociated injuries and shock, 5 deaths in the remaining 4 the wound\\nsuppurated after reduction, and 2 of them died. The urgent question\\nis whether or not to excise the head of the femur in order to diminish\\nthe danger if suppuration should follow. In fresh, uninfected cases\\nI should think it unnecessary if ample drainage was provided.\\nClassification.\\nThe classifications adopted by the earlier writers were necessarily\\nfaulty and deficient because of the lack of recorded experience and\\npost-mortem examinations. That of Hippocrates, containing four\\nprincipal forms, outward, inward, forward, and backward, was em-\\nployed, according to Malgaigne, until the seventeenth or eighteenth\\ncentury, although the terms do not seem always to have been applied\\nin the same sense. Petit, in the eighteenth century, made two main\\ngroups, inward and outward, each with two subdivisions, the four\\nbeing upward and inward, downward and inward, upward and out-\\nward, and downward and outward, but he thought it impossible that\\nthe latter form could occur. Verduc, about the same time or a little\\nearlier, sought to establish a classification based upon the place at which\\nthe head of the femur came to rest, and in this he was supported by\\nDuverney and Bertrandi, and thus arose the terms dislocation upon the\\nilium, upon the ischium, upon the pubes, into the foramen ovale. Sir\\nAstley Cooper gave us dislocations upward, or on the dorsum ilii, down-\\nward, or into the foramen ovale, backward, or into the ischiatic notch, and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0798.jp2"}, "791": {"fulltext": "DISLOCATIONS OF THE HIP. 717\\ndislocation on the pubes; and Gerdy followed with suprapubic, sub-\\npubie, iliac, sacro-sciatic, and ischiadic, the latter being directly down-\\nward.\\nMalgaigne was the first to bring to the subject the results of careful\\nstudy of many pathological specimens he showed that in the back-\\nward dislocations the head of the femur did not go so far as the ana-\\ntomical terms used in Cooper s classification, for example, would\\nindicate, but that, on the contrary, it usually remained so near the\\ncotyloid cavity that it partly overlapped it, incomplete disloca-\\ntions, as he called them, and he proposed a classification in four groups,\\nof which the first two were the same as Petit s, though the names are\\ndifferent, as follows\\nDislocations backward lia complete incomplete.\\ni. ischiatic, complete, incomplete.\\nDislocations forward ^\u00c2\u00b0-P ubic\\nI ischio-pubic.\\nDislocations upward supracotyloid.\\nDislocations downward ^^^1\\nThe names ilio-pubic and ischio-pubic were taken from those of cor-\\nresponding depressions on the margin of the cotyloid cavity along\\nwhich the head of the femur was thought to pass, and, acting on the\\nsame plan, Nelaton gave the name ilio-ischiatic to all the backward\\ndislocations, which Malgaigne preferred to divide into two groups.\\nIn Germany Roser and Busch adhered to the method of classifica-\\ntion according to the direction taken by the head of the femur later,\\nAlbert made three groups backward, forward and upward, and for-\\nward and downward, and Konig and Lossenfour backward (iliac and\\nischiatic), forward (suprapubic and infrapubic), supracotyloid, infra-\\ncotyloid.\\nIn England Sir Astley Cooper s classification has been quite closely ad-\\nhered to, although some surgeons (Erichsen) place the backward dislo-\\ncations, those upon the dorsum ilii and into the sciatic notch,\\nin one group and call them dislocations backward and upward.\\nIn America Hamilton used Cooper s classification and Agnew does\\nthe same, although he groups the iliac and ischiatic together as vari-\\neties of a single form upward and backward.\\nBigelow, 1 to whose researches and writings so much of the recent\\nadvance in the knowledge of the subject and in the treatment of the\\ninjury is due, made a classification of seven regular and principal\\nforms, which he based not merely upon the direction in which the bone\\nhad been dislocated or the point at which it came to rest, but also upon\\nthe integrity of the Y-ligament or the rupture of its outer branch, and\\nthe changes in the attitude of the limb which arise from such rupture.\\nSuch a classification was open to the objection that it gave equal rank\\nto forms Avhich were only variations of others, and a few years later he\\nmodified it 2 by grouping all under four heads and by suppressing the\\ndistinction between the dorsal and the dorsal below the tendon,\\n1 Bigelow: The Hip. 2 Bigelow: Lancet, 1878, vol. i. p. 894.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0799.jp2"}, "792": {"fulltext": "718 DISLOCATIONS.\\nwhich latter name he had previously given to the lower of the two\\ndorsal varieties, the dislocations into the sciatic notch of Cooper.\\nHis new classification, then, was the following\\nExternal to the socket comprising the dorsal and the dorsal with\\ne version.\\nInternal to the socket on the perineum, the thyroid foramen, and\\nthe pubes.\\nBelow the socket dislocation toward the tuberosity of the ischium.\\nAbove the socket the subspinous, the supraspinous, and the anterior\\noblique.\\nThis also was open to the serious objection that varieties which were\\nalike in their mode of production, in the point at which the head of\\nthe femur left the socket, in the direction it afterward took, and in\\ntreatment were placed in different main divisions, and he, therefore,\\nwent further and presented in the same paper the following classifica-\\ntion which he recommended as a sufficient practical grouping.\\nDorsal, comprising the dislocation on the tuberosity of the ischium, the\\ndorsal, the everted dorsal, the anterior oblique, and the supraspinous.\\nThyroid, comprising that in the perineum and that on the thyroid\\nforamen.\\nPubic, comprising the pubic and the subspinous.\\nTurning now to the results of the examination of specimens and of\\nexperiments upon the cadaver, it appears that in the more frequent\\nforms the head of the femur passes over the outer, posterior, margin\\nof the cotyloid cavity, usually at or below its horizontal diameter,\\nwhile the limb is flexed, adducted, and rotated inward then by\\nthe sinking of the knee the femur turns upon its attachment to the\\nY-ligament as a centre, and the head rises to a higher level along the\\nouter surface of the acetabulum or further backward on the flat surface\\nof the ilium in front of, and seldom higher than the apex of, the great\\nsciatic notch. It is to be borne in mind that this apex is not very\\nmuch above the level of the highest part of the cotyloid margin. In\\nthis movement the head of the femur frequently passes behind the\\nuntorn tendon of the obturator internus, leaving that tendon between\\nitself and the acetabulum. Or, if it crosses the margin of the coty-\\nloid cavity at or above its horizontal diameter, it may tear the obturator\\ninternus and pyriformis or pass between these muscles and come to\\nrest at the same point as before. The former is the dislocation\\nbelow the tendon, the latter the dorsal or the dislocation\\nupon the dorsum ilii, as these terms were originally used, but the\\ndistinction is one which cannot often be made clinically- The impor-\\ntant difference between them is in the situation of the rent in the cap-\\nsule, which is higher in the latter than in the former, and will probably\\npermit reduction by traction downward.\\nExceptionally, if, after the dislocation has occurred, the knee is still\\nfurther lowered and the limb abducted and rotated outward, the outer\\nbranch of the Y-ligament ruptures and the head of the femur passes\\nforward along the ilium toward its anterior inferior spine or the\\ninterval between the two spines, the everted dorsal of Bigelow,\\nthe supraspinous or part of the supracotyloid of others. The", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0800.jp2"}, "793": {"fulltext": "DISLOCATIONS OF THE HIP. 719\\nattitude of the limb in this is very different from that of the com-\\nmon backward dislocation of which this is a variety by secondary\\ndisplacement.\\nBut the head of the femur may not only come to rest directly above\\nthe cotyloid cavity by a secondary displacement forward and inward\\nit may also reach nearly the same point by a secondary displacement\\noutward and backward from a primary dislocation forward upon the\\npubis. The distinction between the two is radical, for in the former\\nthe root of the Y-ligament lies on the inner side of the head, which\\nmust be returned to its socket by passing backward behind the ace-\\ntabulum and in the latter the Y-ligament lies to its outer side and\\nthe head must be returned along the front or inner side of the acetab-\\nulum. There is still a third way in which the head may be placed\\nabove the acetabulum, although at a somewhat lower level, and that is\\nby direct displacement upward, with rupture of the upper part of the\\ncapsule and of the Y-ligament, but this is extremely rare.\\nThe dislocations forward (or inward) and upward and inward and\\ndownward offer no difficulties in classification each has its character-\\nistic symptoms, although the perineal variety of the latter is somewhat\\nsharply distinguished from the obturator or thyroid variety by the\\ngreater flexion and abduction of the limb. Bigelow thinks the supra-\\npubic can be produced by a secondary displacement upward after the\\nhead has escaped at the lower part of the capsule during flexion of the\\nlimb, in a similar manner and by the same mechanism (lowering of the\\nknee) as a secondary iliac dislocation is produced from a primary\\nischiatic one. In short, he thinks {Lancet, 1878) that in most cases\\nthe head of the femur escapes over the lower margin of the acetabulum\\nand then passes upward as the limb is lowered, and either behind or\\nin front of the acetabulum according as the limb is adducted or\\nabducted, and upon this theory he bases a simple rule of treatment\\napplicable to both anterior and posterior dislocations, namely, flex the\\nlimb at a right angle to bring the head below the socket, and then lift\\nit into place.\\nFinally, the head may be displaced downward upon the adjoining\\nbranch of the ischium, and rest there (subcotyloid) the position is one\\nfrom which the head can be easily displaced, either backward or for-\\nward, and the dislocation thereby transformed into a dorsal or obtura-\\ntor one.\\nThe distinction between the two backward forms, upon the dorsum\\nilii and toward the sciatic notch, wdiich has already been abandoned by\\neminent surgeons (Bigelow, Erichsen, Albert), does not appear to de-\\nserve to be retained, except, perhaps, to establish corresponding vari-\\neties in the group; and the anterior oblique, everted dorsal, and supra-\\nspinous clearly belong in the same class by their mode of production\\nand treatment. The class of supracotyloid dislocations, made by some\\nwriters to contain the two last mentioned, the rare dislocations directly\\nupward, and some of the suprapubic, will be limited to those in which\\nthe head appears to have moved directly upward. The corresponding\\nclass and term of subcotyloid must be retained for the rare dislo-\\ncations dowmward upon the tuberosity of the ischium.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0801.jp2"}, "794": {"fulltext": "720 DISLOCATIONS.\\nThe terms upward and downward must not be taken too literally.\\nThey appear to have been rather carelessly used at first without strict\\nregard to the normal position of the pelvis. When the body is upright,\\nthe upper border of the symphysis pubis lies a little below the level\\nof the centre of the cotyloid cavity, and the tuberosity of the ischium\\nlies not directly below this cavity, but below and behind. The classi-\\nfication, then, which will here be used is as follows\\nf dorsal, comprising the iliac and ischiatic, or\\nthose upon the dorsum ilii and into the\\n-p.. ischiatic notch of the writers.\\nDislocation backward -j eyerted comprising the anterior oblique,\\nsupraspinous, and some of the supracoty-\\nloid.\\nDislocations downward obturator.\\nand inward perineal.\\ntv i v f ilio-pectineal.\\nDislocations torward i u-\\nand upward\\nsuprapubic 1 pubic.\\n1 intrapelvic.\\nDislocations directly upward (supracotyloid or subspinous).\\nDislocations downward on the tuberosity of the ischium.\\nAs in the classification of dislocations of the shoulder, the names of\\nthe principal groups indicate the direction of the primary displacement\\nand, consequently, the position of the rent in the capsule, and the\\nnames of the varieties show either the place at which the head of the\\nfemur comes to rest or the special symptomatic feature which marks\\nthe variety.\\nBACKWARD DISLOCATIONS.\\n1. Dorsal.\\n2. Everted dorsal.\\nIn this class of dislocations the head of the femur in leaving the\\ncotyloid cavity passes over its posterior margin at a higher or lower\\npoint while the limb is flexed, adducted, and rotated inward. In the\\ngreat majority of cases the limb preserves this attitude, and the head\\nrests not far from and behind, or behind and above, the margin of the\\nacetabulum, between it and the great sciatic notch, or it may lie a\\nlittle higher upon the concave surface of the ilium these constitute\\nthe dorsal variety, and include the iliac and ischiatic of other\\nwriters. In other cases external rotation of the limb takes place with\\nor without abduction and extension in the latter case the limb crosses\\nthe opposite thigh and the toes are everted, the head of the femur lies\\nabove the socket, and the lower part of the neck corresponds to the\\nupper and posterior margin of the acetabulum, the anterior oblique\\nvariety; in the former case (with abduction and extension) the outer\\nbranch of the Y-ligament is ruptured, the head of the femur lies\\nabove the socket, and the everted limb lies parallel to its fellow, or\\nslightly abducted the everted dorsal variety. The class includes all\\nthe backward dislocations of other authors, and most of those that\\nhave sometimes been grouped under the term supracotyloid.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0802.jp2"}, "795": {"fulltext": "BACKWARD DISLOCATIONS OF THE HIP. 721\\n1. Dorsal Dislocations.\\nIn these dislocations, which are by far the most common of all dis-\\nlocations of the hip, the head of the femur lies behind and above the\\ncotyloid cavity, either close to and overlapping its edge (Malgaigne s\\nincomplete form) or further away upon the ilium. It may pass\\nbelow the obturator internus and rise behind it, or between it and the\\npiriformis, or above the latter, or both muscles may be completely\\ntorn across. The group, therefore, includes the dislocations upon\\nthe dorsum ilii and those into the ischiatic notch of Cooper, or\\nthe dorsal and the dorsal below the tendon of Bigelow s first\\nclassification, or the iliac and ischiatic of others.\\nCauses. Dorsal dislocations are commonly caused by violence that\\napproximates the knee and the pelvis while the thigh is flexed,\\nadducted, and rotated inward, as in a fall from a height, or in the fall\\nof a heavy body upon the back of the patient while he is stooping for-\\nward. Less frequently the dislocation is produced mainly or solely\\nby flexion, adduction, and inward rotation, one of the three move-\\nments being exaggerated. Thus, in a case reported by Moffat, 1 the\\npatient was drawing a railway carriage along the track he fell for-\\nward and rolled upon his back outside the rail to escape the car, but,\\nas it passed, the end of the footboard caught his leg and bent it upon\\nand across his belly (flexion and adduction). The car had to be raised\\nwith a jack-screw to free him, and when released he was lying upon\\nhis back with the limb in the position described. When examined at\\nthe hospital, the thigh was slightly flexed and rotated inward, the toes\\noverlapping those of the other foot.\\nIn a case reported by Dupuytren, exaggerated adduction appears to\\nhave been the chief factor. A delicate man, twenty-one years old,\\nwas thrown, while wrestling, upon his left side, and in the fall the left\\nthigh was forcibly carried across the front of the other by contact of\\nthe side of the knee with the ground. In a case observed by Mal-\\ngaigne, and in another quoted by him from Mercier, exaggerated\\ninward rotation appeared to be the principal cause; both patients were\\nwomen who slipped and twisted the foot inward while walking.\\nA case, exceptional not only by its mode of production but also by\\nthe age of the patient, was reported by Bartels and has been referred\\nto above. The patient was a child eleven months old, and the dislo-\\ncation was caused by the effort of a shoemaker to put on its shoe while\\nit was sitting on its nurse s knee.\\nIn two cases in which the head was split into two pieces, one of\\nwhich remained in the socket attached to the ligamentum teres, it is\\nevident that the flexion, adduction, and rotation were not carried far\\nenough to turn the head out of the socket, and the dislocation, strictly\\nspeaking, was a complication of a fracture of the head produced by\\nviolent pressure of the inner segment against the outer and upper\\nmargin of the cavity; in like manner the dislocation may be facili-\\ntated by the breaking off of a considerable portion of the acetabular\\nring. There is reason to think that some dislocations are produced in\\n1 Moffat Lancet, 1878, vol. ii. p. 251.\\n46", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0803.jp2"}, "796": {"fulltext": "722 DISLOCATIONS.\\nthis manner by violence acting directly upon the upper part of the\\nthigh, as in the passage across it of the wheel of a heavy wagon.\\nIt is by no means uncommon for a dorsal dislocation to be produced\\nby the transformation of one downward and inward (obturator) during\\nmanipulations made to effect reduction, the head passing below and be-\\nhind the acetabulum during flexion and adduction of the limb, and, in\\nlike manner, a dorsal may be transformed into an obturator dislocation.\\nOccasionally dorsal dislocation takes place gradually while the\\npatient is confined to bed by illness, especially by acute articular rheu-\\nmatism and the infectious or eruptive fevers. These spontaneous\\ndislocations are considered in Chapter LIU.\\nPathology. The condition of the capsule and of the muscles about\\nthe joint and the position of the head of the femur have been clearly\\nshown by direct examination of a considerable number of specimens\\nof recent dislocation, and by old ones, and by experiment upon the\\ncadaver. Among the autopsies of fresh dislocations recently reported\\nmay be mentioned those by Moxon, 1 MacCormac, 2 Adams, 3 Morris, 4\\nLee, 5 Humphry 6 three cases, Rutherford, 7 and Stimson. 8\\nThe capsule is torn always in its lower posterior part, and usually\\nalso in its under part, but the rent varies greatly in extent and shape.\\nFrequently it lies about midway between the upper and lower posterior\\ninsertions of the capsule; sometimes the capsule is torn away from the\\nfemur, and, rarely, away from the acetabulum.\\nIn Morris s and Lee s cases the conditions were exceptional in the\\nformer (Fig. 310) the capsule was ruptured on its lower and inner\\nside, and w T as clearly peeled up from off the back of the neck of the\\nfemur as far as the digital fossa. The rent\\nFig. 310. commenced below the pectineo-femoral band,\\nmidway between the acetabulum and the femur\\nand ran (1) outward and backward to the neck\\nof the latter, which it reached just above and\\nbehind the small trochanter, and (2) inward\\nand backward across the thin portion of the\\ncapsule toward the acetabulum, which it nearly\\nreached a little behind the ischial border of the\\ncotyloid notch. It thus formed two sides of\\nMorris s case of dorsal disio- a la openino which was made qua drilateral\\ncation femur flexed and ab- p -F i r n r 1\\nducted to show the rent in the m form by the detachment ot the nap Irom the\\ncapsule. back of the femoral neck. Evidently the\\nhead had escaped downward.\\nIn Lee s case the capsule w r as freely lacerated all around, a small\\nportion remaining attached to the femur in front and behind. This\\nwas, therefore, an irregular dislocation, and to the extensive lacera-\\ntion of the capsule corresponded a variation in the symptoms which\\n1 Moxon Medical Times and Gazette. 1872, vol. i. p. 96.\\n2 MacCormac: St. Thomas s Hospital Eeports, 1871, vol. ii. p. 143.\\n3 Adams: Transactions of the Pathological Society of London, 1870, vol. xxi. p. 305.\\n4 Morris Medico-Chirurgical Transactions, 1877, vol. lx. p. 161.\\n5 Lee: St. George s Hospital Eeports, 1872-74, vol. vii. p. 169.\\n6 Humphry Lancet, 1886, vol. ii. p. 1011.\\n7 Rutherford Glasgow Medical Journal, May, 1889.\\n8 Stimson New York Medical Journal, August 10, 1889, p. 163.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0804.jp2"}, "797": {"fulltext": "BACKWARD DISLOCATIONS OF THE HIP. 723\\nfully corroborates Bigelow s views the report says Two of the\\nmain signs of dislocation were absent, namely, the advanced position\\nof the knee with the foot resting upon the opposite one, and marked\\nshortening. The head of the femur was below the pyriformis muscle\\nand immediately behind the acetabulum.\\nThe preservation of the anterior portion of the capsule, the ilio-\\nfemoral ligament, is constant, as has been said, in the cases which\\nBigelow terms regular, those which are marked by the common\\nand characteristic symptoms of the dislocation, and, as he also pointed\\nout, the strong portion of the capsule at its upper and posterior part is\\nalso usually untorn and opposes the ascent of the head upon the ilium.\\nThe ligamentum teres is usually torn from its attachment to the\\nfemur, but sometimes is ruptured.\\nOf the muscles, the quadratus femoris is usually completely torn\\nacross, but sometimes (Humphry s third case) is intact the gemelli\\ncommonly are torn, but the obturator internus which is so closely asso-\\nciated with them frequently escapes or is only partly lacerated, prob-\\nably because of its greater length. The pyriformis and obturator\\nexternus are sometimes torn partly or entirely across the glutei\\nusually escape injury entirely or are only slightly lacerated.\\nThe head of the femur may lie close to the margin of the acetabu-\\nlum, even overlapping the cavity, or it may be displaced to a variable\\ndistance backward or backward and up-\\nward. The lowest point at which its Fig. 311.\\ncentre rests is the base of the spine\\nof the ischium (Adams 1 and Quain 2\\noverlapping both sciatic notches and\\nthe highest, except perhaps in excep-\\ntional cases, appears to be opposite the\\napex of the great sciatic notch, which,\\nin the recumbent position, is directly\\nbelow the anterior superior spine of the\\nilium, the line uniting the two passing\\nabout an inch above the margin of the\\ncotyloid cavity. Fifty years ago Quain\\n,ii ii Dislocation below and then behind and\\ndemonstrated by autopsy the error above the obturator internus.\\ncontained in the name given by Sir\\nAstley Cooper to the lower form of dislocation into the sciatic notch,\\nand formally called attention to it and a few years later Malgaigne\\nshowed that the head of the bone was much less upon the ilium in the\\nhigher form than was supposed, and further that in many, perhaps a\\nmajority, of the dislocations upon the dorsum ilii the femur left\\nthe socket at its lower posterior part and subsequently passed upward,\\nso that in such cases the primary dislocation was ischiatic, and the\\niliac was secondary. This view has been amply confirmed. In 11\\nspecimens of old dislocations which Malgaigne examined, the head of\\nthe femur rose in 5 only to the level of a line drawn from the anterior\\nsuperior spine of the ilium to the apex of the great sciatic notch, in 2\\n1 Adams Loc cit.\\n2 Quain: Medico-Chirurgical Transactions, 1848, vol. xxxi. p. 337.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0805.jp2"}, "798": {"fulltext": "724\\nDISLOCATIONS.\\nit rose half a centimetre above this line, in 2 one centimetre, in 1 one\\nand a half centimetres, and in 1 two centimetres. There is no reason\\nto suppose that in old dislocations the head is at a lower level than in\\nrecent ones, indeed it is probably somewhat higher.\\nWhen the head of the femur leaves the socket at its lower part it\\npasses usually below the obturator interims and then rises behind it,\\nso that this muscle is interposed between it and the acetabulum (Fig.\\n811). Or it may lie immediately beneath the obturator interims and\\npress it forcibly upward, as in Adams s case (Fig. 312), which remained\\nunreduced until the patient s death on the fourteenth day, and in which\\nthe muscle was so tightly stretched over the upper part of the head\\nthat a deep groove had formed in the articular cartilage of the latter\\nexactly corresponding in size and direction to the tendon the head\\nrested on the spine of the ischium, and the obturator externus and\\nquadratus femoris were ruptured. Or the head may pass above the\\nobturator internus, between it and the pyriformis, as in MacCormac s\\ncase (Fig. 313), in which it rested behind the acetabular ridge opposite\\nFig. 312.\\nFig. 313.\\nAdams s case a, head of femur b, obturator\\nexternus ruptured c, quadratus femoris rup-\\ntured; d, sciatic nerve.\\nMacCormac s specimen of recent dorsal dis-\\nlocation. The head of the femur lies just be-\\nhind the acetabulum, below the pyriformis,\\nand above the obturator internus and the torn\\ngemellus muscles.\\nthe middle and upper part of the great ischiatic foramen, behind the pos-\\nterior border of the gluteus medius, and only covered by the gluteus\\nmaximus and the integument. This is an example of a real primary\\niliac dislocation, and the rent in the capsule was merely on the\\nback part, and the neck was as it were locked over the acetabular ridge,\\nand the strong anterior part of the capsule was tightly stretched.\\nThe edge of the acetabulum is sometimes chipped, and in two of\\nthe cases above quoted (Quain, Morris) there was a fracture through\\nthe ilium into the cotyloid cavity, and in the latter there was also a\\nfracture of the ramus of the ischium. In both cases the injury was\\ncaused by great violence.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0806.jp2"}, "799": {"fulltext": "BACKWARD DISLOCATIONS OF THE HIP. 725\\nIn a case reported by Birkett l the head of the femur was split ver-\\ntically, the inner half remaining in the acetabulum and still attached\\nto the ligamentum teres, and the other, continuous with the neck,\\nbeing displaced backward above the obturator interims. A similar\\ncase, quoted above among compound dislocations, p. 715, was reported\\nby Moxon and in another reported by Kiedel 2 the head and neck were\\nsplit longitudinally, both fragments being displaced from the socket.\\nCrile 3 reported a case of fracture of the posterior third of the head\\nand of the posterior half of the rim of the acetabulum. In my case\\nthe head of the femur was deeply indented, apparently by contact with\\nan osteophyte close behind the rim of the acetabulum, and a portion\\nof the labrum cartilagineum had been broken off. In a case seen by\\nLossen i the neck of the femur had been broken at the moment of dis-\\nlocation, but doubtless after the head of the bone had left the socket.\\nIn several reported cases the neck has been broken during an attempt\\nto reduce, and in a few in which fracture has been recognized it has\\nremained uncertain whether it occurred simultaneously with the dislo-\\ncation or was caused by the surgeon. (See Chapter LIII.)\\nThe sciatic nerve commonly lies behind the head of the femur and\\nat the most is only slightly pressed upon, but in Quain s case it was\\nstretched over the neck of the femur.\\nSymptoms. The patient is unable to bear his weight upon or volun-\\ntarily to move his injured limb if he stands upright it shows moder-\\nate flexion and adduction, marked inversion, and more or less shorten-\\ning, the toes resting on those of the other foot. When he is placed\\nupon his back the apparent adduction and flexion are increased, the\\nknee resting just above the other patella or crossing the thigh at a\\nhigher point. The contours of the outer and posterior regions of the\\nhip are changed by loss of the normal depression behind the trochanter,\\nelevation of the gluteal fold, and abnormal fulness due to the approxi-\\nmation of the insertions of the gluteal muscles. The trochanter rises\\nto a variable distance above the line drawn from .the anterior superior\\nspine of the ilium to the tuberosity of the ischium, and its distance\\nfrom the first-named prominence is increased. The head of the femur\\ncan be obscurely felt through the gluteus maximus and recognized by\\nits movements when the limb is flexed or rotated. The empty socket\\ncannot be felt from in front, because it is covered by the anterior por-\\ntion of the capsule and the psoas and iliacus, but the depressibility\\nof the soft parts in Scarpa s space is as great as, or greater than, that\\non the opposite side, whereas in fracture of the neck of the femur this\\ndepressibility is diminished.\\nThe limb can be still further adducted and flexed, but it cannot be\\nabducted or rotated outward. The apparent shortening varies greatly\\nin degree in different cases, and the actual shortening cannot always be\\ndetermined with accuracy because of the difficulty in placing the limbs\\nsymmetrically. Concerning this shortening the most contradictory\\nstatements have been made some surgeons, relying solely upon the\\n1 Birkett Medico-Chirurgical Transactions, 1869, vol. lii. p. 133.\\n2 Kiedel Beilage zum Centralbl. fur Chir., 1885, p. 92.\\n3 Crile Annals of Surgeiy, May, 1891. i Lossen: Deutsche Chir., Lief. Co, p. 55.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0807.jp2"}, "800": {"fulltext": "726\\nDISLOCATIONS.\\nFig. 314.\\nappearance of the limb and seeing that the knee lay well above the\\nopposite one, have described the shortening as great others, looking\\nonly to the new relations of the bones as shown upon the skeleton,\\nha ye described the shortening as moderate or even as absent in the\\nlower forms. The error in the first arises from not taking into account\\nthe eifect of adduction to create an apparent shortening of the adducted\\nlimb when compared with its non-adducted, still more with its abducted,\\nfellow that in the second arises from considering the question only\\nwith reference to the position of extension. If the head of the femur\\nis displaced backward toward the spine of the ischium, the length of\\nthe limb measured in extension (if that is possible) from the anterior\\nsuperior spine of the ilium to the\\nknee or ankle will not be diminished,\\nfor the moyement backward of the\\nhead has beeii at right angles to the\\nline of measurement and has not\\nbrought the knee any nearer to the\\npelvis but if the measurement is\\nmade while the thigh is flexed at\\nabout a right angle the measured\\nlength will be less by about two\\ninches than that of the other limb in\\nthe same position, for now the\\nmeasured line is nearly parallel to\\nthe direction of displacement. When\\nthe head is displaced upward as well\\nas backward the difference in the\\namount of shortening in these two\\npositions of the limb is much less,\\nfor the direction of the displacement\\ndeviates at about the same angle\\nfrom the measured line in each atti-\\ntude. Of course, in each limb the\\nmeasured length is less when the\\nthigh is flexed, but the difference in\\nthe comparatiye measurements of\\nthe two limbs is not affected in the\\nhigh dislocations and is greatly\\naffected in the low ones. In mak-\\ning measurements the two limbs\\nmust be symmetrically placed as\\nregards flexion and adduction, and\\nthe fixed adduction of the injured\\nlimb sometimes interferes seriously with the accomplishment of this\\ncondition, for its knee occupies the position to which the other one\\nshould be brought, and, therefore, an equal adduction cannot be given\\nto the sound limb without carrying its knee across at a higher or lower\\nlevel, and thus giving it an unsym metrical flexion. It must also be\\nremembered that apparent symmetry of position is not sufficient, the\\nsymmetry must be real in that the angles of flexion and adduction on\\nDorsal dislocation of the hip, showing\\nflexion, adduction, and internal rotation.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0808.jp2"}, "801": {"fulltext": "BACKWARD DISLOCATIONS OF THE HIP. 727\\nthe pelvis are the same. Fortunately the exact determination of the\\nshortening is not necessary to the diagnosis of the dislocation.\\nWhen the head passes below the tendon of the obturator interims\\nand does not secondarily rise upon the ilium, the inversion and flexion\\nof the limb are greater than when the head comes to rest at a higher\\npoint, and may be so great that the limb crosses the opposite thigh as\\nhigh as its middle. The flexion may be so masked by the tilting of the\\npelvis that the thigh will lie nearly along-side the other, parallel to\\nthe long axis of the body, but the condition can be recognized by\\nattention to the compensatory curve (lordosis) of the lumbar vertebrae\\nindeed, Syme l said he made the diagnosis of ischiatic dislocation with-\\nout other handling of the patient than that necessary to recognize the\\nlordosis.\\nThe cause of the comparative fixation of the limb, of its attitude,\\nand of the loss of even passive abduction and external rotation was\\nfirst clearly shown by Bigelow, in his classical monograph upon the\\nHip. Others had recognized, in a measure, the part taken by the\\nstrong anterior portion of the capsule in determining the attitude of\\nthe limb, but he was the first to study the subject in all its bearings\\nand to present a complete account of the relations and influences of the\\nY-ligament in all forms of dislocation, one which was at once and every-\\nwhere accepted and has been made the basis of the present methods of\\nreduction. He says, 2 The inversion is chiefly due to the outer branch\\nof the Y-ligament, as is shown by the fact that the characteristic sign\\ndisappears when this branch is divided/\\nDiagnosis. The recognition of the character of the injury is rarely\\ndifficult. The group of prominent symptoms loss of function adduc-\\ntion, inversion, and flexion of the limb; resistance to abduction, exten-\\nsion, and outward rotation elevation of the trochanter above Nelatoir s\\nline are not found in any other affections except perhaps hip-joint dis-\\nease of long standing. The mistake most frequently made is that of\\nconfounding it with a fracture of the neck of the femur, or, to speak\\nmore definitely, is that of supposing a fracture of the neck to be a\\ndislocation. I have met with several instances of this, some of which\\nled to litigation. The differences between the symptoms of the two\\ninjuries are striking and usually sufficient to make the mistake impos-\\nsible if ordinary attention is paid to them the fixity of the limb in dis-\\nlocation, with the knee thrown forward and inward against or upon the\\nopposite thigh, the prominence of the trochanter, and, usually, its\\nincreased distance from the anterior superior spine of the ilium, con-\\ntrast strongly with the straight, everted, powerless limb and flattened\\nhip of fracture of the neck. Fractures with inversion and dislocations\\nwith eversion are entirely exceptional. When the two injuries have\\ncoexisted the diagnosis has sometimes been made by recognizing that\\nthe head, which could be felt out of its place, did not share in the\\nmovements communicated to the shaft, 3 and sometimes by the splitting\\nand enlargement of the great trochanter.\\n1 Syme London and Edinburgh Monthly Journal, 1843, vol. iii. p. 498.\\n2 Bigelow The Hip, p. 38.\\n3 Koch Berlin, klin. Wochenschrift, 1882. p. 492.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0809.jp2"}, "802": {"fulltext": "728 DISLOCATIONS.\\n2. Everted Dorsal Dislocations.\\nIn this class, of which there are but few recorded cases, are here\\nincluded Bigelow s anterior oblique, everted dorsal, and some of the\\nsupraspinous. It is characterized, as the name indicates, by eversion\\nof the limb in place of the inward rotation which is so prominent a\\nfeature of the common dorsal dislocation, and this symptom is due in\\nall cases, except perhaps the very rare anterior oblique, to rupture of\\nthe outer branch of the Y-ligament. In the supraspinous variety the\\nhead of the bone lies above the anterior inferior spinous process of the\\nilium in the notch between it and the superior spine.\\nAlthough occasional cases had been previously reported, the variety\\nwas not described by systematic writers before Bigelow, and was not\\neven mentioned by Malgaigne, although possibly one or two of the\\ncases classed by him as supracotyloid may have been of this kind.\\nIn a paper by Blasius l on supracotyloid dislocations several cases of\\nthis variety (everted dorsal) are included, together with others in which\\nthe head had reached nearly the same position by passing outward after\\nprimary dislocation forward and upward upon the pubis, and a few\\nin which the dislocation was primarily directed upward. The same\\ngrouping has been followed by other writers, and in no reported case\\nprevious to 1850 does it appear to have been recognized that the head\\nhad reached this position by a secondary displacement after dislocation\\nbackward and upward. Blasius s paper although published in 1874,\\nmust be classed with those of an earlier period, for it is really the\\nrepublication by his son in a graduating thesis of researches made\\nsome time earlier, and it makes no mention of Bigelow s work. It\\nis, in one respect, a publication to be regretted, for the authority of\\nits writer and its date combine to further the acceptance without exami-\\nnation of the grouping, or classification, which cannot properly be\\naccepted in view of the important pathological differences between the\\nindividual cases of which it is made up.\\nCases reported before 1850 and quoted as of this kind by Bigelow\\nand as possibly such in my first edition, appear to me to be more prob-\\nably dislocations directly upward by hyperextension of the limb I\\nhave recently seen such a one the symptoms of which closely resem-\\nbled those quoted. (See Upward Dislocations,)\\nIn 1850 the possibility of the production of this form by trans-\\nformation of a dorsal dislocation was shown in an attempt made\\nin the New York Hospital to reduce a dislocation into the sciatic\\nnotch. The case is reported by Lente; 2 after traction had been\\nmade and suddenly relaxed the thigh was abducted and rotated\\noutward, and this brought the head of the femur above the acetab-\\nulum, and below the anterior superior spinous process the shorten-\\ning was then about two inches the limb very much rotated out-\\nward, the rotundity of the hip greater than that of the other, and\\nthe trochanter major one inch further from the anterior superior\\nspinous process.\\n1 Blasius Arch, fur klin. Chir., 1874, vol. xvi. p. 207.\\n2 Lente New York Journal of Medicine, 1850, p. 314.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0810.jp2"}, "803": {"fulltext": "BACKWARD DISLOCATIONS OF TEE HIP. 729\\nFive years later Van Buren 1 observed in the same hospital a case\\nwhich, so far as I know, is the first in which the absence of inversion\\nand marked adduction was noted in a case recognized as a dorsal dis-\\nlocation. The limb was shortened about an inch the foot and leg\\nwere slightly everted. This eversion, it was afterward ascertained,\\ncould be readily increased by manipulation but there was an evident\\nobstacle at the hip to inversion of the foot. The knee was slightly\\nflexed, so that the width of the hand could be readily passed between\\nits popliteal aspect and the surface of the bed. The obliquity of the\\nfemur toward its fellow was very slightly increased. Upon the front\\nof the thigh at its upper third a very manifest concavity or sinking in\\nwas noticeable, the usual anterior convexity of the limb being lost.\\nThe trochanter was about an inch and a half behind and above its usual\\nposition, and, during etherization, it was quite movable on attempting\\nrotation of the limb. Finally, the head of the femur could be felt\\nobscurely but pretty certainly rotating in the ischiatic notch, low down,\\nand in contact with its posterior margin. The anterior convexity of\\nthe spine at the loins was also much increased, so that under ether\\nmore than the width of the hand could be passed between it and the\\nsurface of the bed. Thus the case presented all the classical features\\nof luxation into the ischiatic notch, and more than usually well marked,\\nwith the exception of adduction of the lower end of the femur and\\ninversion of the foot. After several failures to reduce by manipula-\\ntion and traction doAvnward, reduction w T as effected by traction while\\nthe limb was flexed at right angles to the pelvis, followed by abduction\\nand extension.\\nIn 1864 Symes 2 reported a case, and suggested for the variety the\\nname of dorsal with eversion. This was subsequent to Bigelow s\\nresearches but previous to his publication of them except in his lec-\\ntures. The limb was shortened two inches, the foot extremely everted,\\nthe buttock flattened, and the head of the femur two inches below the\\nanterior superior spine of the ilium. By flexion of the limb the dislo-\\ncation was made dorsal, and a feature of special interest is that then,\\nas the limb lay untouched upon the table, eversion gradually took place\\nunder the influence of gravity, and the head returned to its former\\nplace.\\nIn 1874 Kocher 3 observed a similar case in a woman, forty-nine\\nyears old the limb was fully extended, markedly everted, and short-\\nened three centimetres the head could be felt below and to the outer\\nside of the anterior superior spine of the ilium. By flexion and inward\\nrotation the dislocation became dorsal with the characteristic symp-\\ntoms, and then by extension and outward rotation the original symp-\\ntoms were reproduced.\\nPathology. In a case which I reported to the New York Surgical\\nSociety, December, 1887, and January, 1888, 4 the head could be dis-\\ntinctly felt below and rather to the outer side of the anterior superior\\n1 Van Buren New York Medical Times, 1856, vol. v. p. 126, and reprinted in his Con-\\ntributions to Practical Surgery, p. 157.\\n2 Symes Dublin Quarterly Journal of the Medical Sciences, 1864, vol. xxsviii. p. 272.\\n3 Kocher Volkmann s Sanimlung klin. Vortrtige, No. 83, p. 631.\\n4 Stimson New York Medical Journal, January and February, 1888.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0811.jp2"}, "804": {"fulltext": "730 DISLOCATIONS.\\nspinous process the outer branch of the Y-ligament was ruptured and\\nthe muscles behind the trochanter extensively lacerated. Complete\\nreduction was prevented by interposition of the anteroinferior part of\\nthe capsule.\\nVan Buren s case, and a very similar one reported by Annandale, 1\\nshow that the head may lie much further to the outer side and lower.\\nBigelow s experiments show that this eversion depends upon the\\nrupture of the outer branch of the Y-ligament. The head of the\\nfemur escapes at the back of the joint while the limb is flexed,\\nadducted, and rotated inward, and then by external rotation the outer\\nbranch is torn if, then, the head remains in its position opposite or\\nbelow the sciatic notch, the position and symptoms are such as are\\nnoted in Van Buren s and Annandale s cases, the flexion and slight\\nadduction being due to the remaining untorn branch of the ligament.\\nThe change in the position of the head noted in the other cases Bige-\\nlow was able to reproduce experimentally from a common dorsal dis-\\nlocation by carrying the limb across the symphysis, so that the outer\\nand convex surface of the socket shall correspond to the hollow beneath\\nthe neck of the femur. With some force the thigh can now be everted,\\nand afterward brought down across the upper part of its fellow.\\n(This is the form to which he gave the name anterior oblique.\\nIf, in this position, it is desired to bring the limb toward a perpen-\\ndicular, the outer branch of the Y-ligament must be ruptured. Thus\\nliberated, it hangs suspended by the inner ligament, and becomes capa-\\nble of lateral motion and of rotation and this is probably the con-\\ndition under which supraspinous luxation, although rare, usually\\noccurs.\\nFig. 315 shows in the dotted lines the head of the femur thus hooked\\nover the remaining part of the ligament.\\nThe anterior oblique is a variety which I feel some hesitation in pre-\\nserving, because Bigelow appears to have observed it only in experi-\\nments upon the cadaver, and to have known of only one recorded\\ncase 2 in which the attitude resembled that found in his experiments.\\nThe specimen in that case is represented in Fig. 316. The mode of\\nproduction has been quoted in the preceding paragraph. The Y-Kga-\\nment is untorn.\\nSymptoms. The symptoms of the everted dorsal may be the same\\nas those of the common dorsal dislocation, with the exception that\\nthere is marked or slight eversion of the limb instead of inversion or,\\nif the head of the femur has moved forward above the anterior inferior\\nspinous process, they may differ widely, for the limb is then shortened\\nabout two inches, slightly abducted, more or less everted, and fully\\nextended. In my case, a woman fifty-five years of age, the limb was\\nparallel with the other and so far everted that the foot rested on its\\nouter border; it could be adducted and flexed but not abducted or\\nrotated inward. Shortening one and three-quarter inches. By flex-\\ning and adducting the limb and then rotating inward the attitude and\\nappearance became that of the common dorsal variety. Reduction\\n1 Annandale Lancet. 1876, vol. i. p. 208.\\n2 Oldnow: Guy s Hospital Eeports, 1836, vol. j. p. 97.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0812.jp2"}, "805": {"fulltext": "BACKWARD DISLOCATIONS OF THE HIP.\\n731\\nwas made by flexing to a right angle, rotating inward, and then lift-\\ning. The dislocation recurred several times. The patient died about\\na month after the accident (associated injuries and phthisis). The\\neversion of the limb is liable to lead to the mistake of supposing the\\ninjury to be a fracture of the neck of the femur, especially in the cases\\nin which the limb is also extended. The greater fixation of the limb\\n.and the recognition of the position of the head and of the continuity\\nFig. 315.\\nFig. 316.\\nSupraspinous dislocation. When the femur takes the\\nposition indicated by the dotted line, only the inner\\nbranch of the Y-ligament remains untorn. (Bigelow.)\\nAnterior oblique dislocation.\\nOldnow s case.\\nwith the shaft, as shown by its sharing in the movements communicated\\nto the latter, will establish the diagnosis.\\nThe rupture of the outer branch of the Y-ligament is the explana-\\ntion of the inability noted in some of the cases to reduce by manipu-\\nlation alone; traction in the flexed position is needed to bring the head\\nforward into the socket; abduction fails to do it because of the loss\\nof the support of the outer branch of the ligament.\\nTreatment of Backward Dislocations.\\nThe method of reduction so long in use, and which left so many\\ndislocated hips unreduced, that in which it was sought to draw the\\nbone into place by traction upon it with compound pulleys while the\\nlimb was almost fully extended, has at last been abandoned in favor\\nof the methods of simple manipulation or of moderate traction in the\\nflexed position, or of a combination of the two. The advantages of\\nthe flexed position, the possibility of reducing by the aid of moderate\\ntraction when the thigh is flexed at a right angle with the trunk, wove\\nrepeatedly pointed out by different writers during the last century and", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0813.jp2"}, "806": {"fulltext": "732 DISLOCATIONS.\\nthe first half of the present one (see Chapter XXXIII.), and the pos-\\nsibility of reducing by manipulation alone (flexion, outward rotation,\\nand abduction) was also demonstrated, but neither seems to have had\\nany influence in modifying the general practice, although some sur-\\ngeons, notably Prof. Nathan Smith of Xew Haven, taught and habit-\\nually practised traction with the limb flexed at a right angle, and he\\nalso, in 1831, formulated a method by manipulation alone.\\nDespres, 1 in 1835, independently formulated the method by flexion\\nand outward rotation; and Reid, 2 in 1851, did the same, preceding the\\nflexion with marked adduction but they assumed that the principal\\nobstacle to reduction lay in the resistance of the muscles, and their\\nmanipulations were designed to overcome or avoid this.\\nBigelow 3 quotes Smith s description of this method by manipulation\\nfrom his Jledical and Surgical Memoirs, edited in 1831 by his son,\\nXathan R. Smith, as follows The first effort which the operator\\nmakes is to flex the leg upon the thigh, in order to make the leg a lever\\nwith which he may operate on the thigh bone. The next movement\\nis a gentle rotation of the thigh outward, by inclining the foot toward\\nthe ground and rotating the knee outward. Xext, the thigh is to be\\nslightly abducted by pressing the knee directly outward. Lastly, the\\nsurgeon freely flexes the thigh upon the pelvis by thrusting the knee\\nupward toward the face of the patient, and at the same moment the\\nabduction is to be increased. Bigelow adds, this covers the ground\\nof priority of invention. It belongs to Xathan Smith. In\\n1835, Despres, and in 1851, Reid, of Rochester, enunicated the same\\nviews the practice was good, but both Prof. Smith and Dr. Reid based\\nthe method upon and sought its mechanism in its erroneous theory of\\nmuscular resistance.\\nAfter 1850 the attention of surgeons and anatomists began to be\\ndirected more specifically to the opposition offered by the untorn por-\\ntions of the capsule and to the position of the rent in it, and many\\nexperiments were made upon the cadaver to obtain a more accurate\\nknowledge of the matter. Among these mav be mentioned those of\\nMeyer, 4 Gunn, 5 Roser, 6 Bigelow, 7 Gelle, 8 Busch, 9 and Tillaux. 10 Of\\nthese Bigelow s researches were by far the most complete and accurate,\\nand to his classical work must be referred the popularization and gen-\\neral acceptance of the views now held and the methods of treatment\\nbased upon them. The importance of the anterior portion of the cap-\\nsule, the Y-ligament, had indeed been specifically pointed out by one or\\ntwo earlier writers it is mentioned in Hyrtl s Topographische Anato-\\nmie, in Meyer s paper in 1 850, and by von Pitha u in 1863 but Bigelow\\n1 Despres Bull, de la Soc. Anatomique, September, 1835, p. 4.\\n2 Reid Buffalo Medical Journal, August, 1851.\\n3 Bigelow: Lancet, 1878, vol. i. p. 861.\\n4 H. Meyer: Zeitschrift fur rat. Med., 1850, vol. ix. p. 250.\\n5 Gunn Penins. Journal of Medicine. 1853-4, vol. i. p. 97.\\n6 Eoser Archiv fur phvs. Heilkunde. 1857, vol. i. p. 42.\\n7 Bigelow The Hip. 1S69. Experiments made in 1860.\\n8 Gelle Arch. gen. de Med., 1861.\\n9 Busch Arch, fur klin. Chir., 1863, vol. iv. p. 11.\\n10 Tillaux Bull, de la Soc. de Chir.. 1868, p. 274.\\n11 Von Pitha Pitha and Billroth s Chirurgie, vol. iv. part 2, B, p. 161.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0814.jp2"}, "807": {"fulltext": "BACKWARD DISLOCATIONS OF THE HIP. 733\\nwas the first to study its influence in detail, to show its constant action\\nin all typical forms, and to base upon it methods of reduction for the\\ndifferent forms, and to him belongs the credit not only of independent\\ndiscovery but also of the still more important benefit conferred by\\nimpressing the facts upon the profession by his careful, thorough in-\\nvestigations and his clear exposition of the facts and principles. l\\nIt is now generally recognized that the chief obstacle to reduction\\nis created by the tension of the Y-ligament in the partly extended posi-\\ntion of the limb, and that this is to be removed by flexion of the limb\\nupon the trunk. At the same time the movement of flexion brings\\nthe head of the femur down along the back of the acetabulum so that\\nit lies opposite the opening in the capsule if, as is usually the case, it\\nhas left the socket at its lower posterior part and has risen to a higher\\nlevel by the subsequent extension of the limb, enlarging the rent\\nupward in the movement if, more rarely, the head has left the socket\\nat a higher level while the limb was only slightly flexed, this move-\\nment of flexion in reduction, unless carried beyond a right angle, does\\nnot place the head below the opening, or at least, if it does so, the\\nmovement enlarges the rent downward so that the way is still open\\nfor the return of the head to its place. Another reason for making\\nthis movement is found in some cases in the interposition of the obtu-\\nrator interims between the head and the socket, the cases, so-called, of\\ndislocation below the tendon in which the head has secondarily\\nrisen toward the dorsum ilii. During the movement the adduction and\\ninternal rotation of the limb are preserved or even somewhat increased\\nin order to lift the head of the femur away from contact with the pelvis\\nand from behind the projecting rim of the acetabulum.\\nThe directions given by Bigelow in his first publication 2 are as fol-\\nlows\\nBy Traction. Lay the patient, when etherized, on his back upon\\nthe floor, bend the limb at the knee, flex the thigh upon the abdomen,\\nadduct and rotate it a little inward, to disengage the head of the bone\\nfrom behind the socket. The Y-ligament is then relaxed.\\nIf the bone can now be abducted beyond the perpendicular, the\\ncapsule and other tissues are probably so torn or relaxed that reduction\\nmay be accomplished without much difficulty the thigh need only be\\nforcibly lifted or jerked toward the ceiling, with a little simultaneous\\ncircumduction or rotation outward, to direct the head of the bone\\ntoward the socket.\\nIn his later paper in the Lancet, 1878, he gives them more briefly\\nin the following terms\\n1. Flex and forcibly lift. If this fails,\\n2. Flex and lift while abducting. If this fails, it will be found\\nthat the rent in the capsule has been so enlarged that the first method\\nmay now prove successful.\\nBigelow adds to his first description three other methods of making\\n1 The claim of priority in the discovery of the part played by the anterior portion of\\nthe capsule made for Prof. Gunn, of Chicago, is, I think, sufficiently answered by Prof.\\nBigelow in a letter published in the Chicago Medical Examiner, January, 1870, p. 25.\\n2 Bigelow Loc. cit., p. 46.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0815.jp2"}, "808": {"fulltext": "734 DISLOCATIONS.\\nthe manipulation and applying the force, and, although the mechanism\\nis the same in all, the multiplicity of the directions has been criticised\\nby recent German writers, who seem to regard the four as essentially\\ndifferent from one another.\\nKocher, 1 after making this criticism, describes what he calls his own\\nmethod, and this is quoted approvingly by Albert and Konig. Its\\nidentity with Bigelow s appears to me to be complete, although it com-\\nbines his two methods by traction and by manipulation. It is as follows\\n1. Inward rotation to relax the capsule and lift the head from the\\nposterior surface of the pelvis.\\n2. Flexion, to a right angle and gently, preserving the existing\\nadduction and inward rotation.\\n3. Traction, to make the capsule tense, so that it can be utilized in\\nthe following movement, and to raise the head to the level of the\\nacetabular margin, thus overcoming the action of gravity.\\n4. Outward rotation this makes the posterior part of the capsule\\nand outer band of the Y-ligament tense, and turns the head forward\\ninto the socket.\\nThere are a number of practical points connected with the carrying\\nout of these directions which require attention. The pelvis may need\\nto be steadied or immobilized during traction, in order that the limb\\nmay not be too soon or unwittingly abducted, and this may be done\\neither by the hands of assistants or by the pressure of the surgeon s\\nfoot upon the anterior superior spinous process of the ilium of the\\ninjured side while he is lifting the thigh.\\nThe traction upon the thigh may be made by the hands of the sur-\\ngeon, but if the patient is a muscular adult the force that can be thus\\nexerted may be insufficient, and it can then be conveniently supple-\\nmented by passing a bandage tied in a long loop under the patient s\\nflexed knee and over the surgeon s shoulders this leaves his hands\\nfree to rotate the thigh by means of the leg. It is important to remem-\\nber that reduction is to be made by traction, not by manipulation, for\\nif the thigh falls backward by its own weight or is pressed back by\\nthe surgeon while he is manipulating it may seriously change its\\nrelations with the tissues about it.\\nA much more convenient plan, one which I have habitually em-\\nployed for many years, 2 is to place the patient face downward upon a\\ntable with his legs projecting so far beyond the edge that the injured\\nthigh hangs directly downward while the surgeon grasps the ankle,\\nthe knee being flexed at a right angle (Fig. 317). The other limb is\\nheld horizontal by an assistant. The weight of the limb now makes\\nthe needed traction in the desired direction, and the surgeon has only\\nto wait for the muscles to relax and the bone to resume its place with-\\nout further effort on his part than a slight rocking or rotation of the\\nlimb. Occasionally I have added the weight of a small sand-bag at\\nthe knee or have made sudden slight pressure at the same point. It\\nwill often succeed without anaesthesia and sometimes so quietly that\\nthere is no jar or sound indicating the return to place. In only two\\n1 Kocher: Volkniann s klinische Vortrage, No. 83.\\n2 Stimson New York Medical Journal, August 3, 1889.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0816.jp2"}, "809": {"fulltext": "BACKWARD DISLOCATIONS OF THE HIP.\\n735\\ncases has it failed in my hands both were then reduced by traction in\\nthe axis of the partly flexed limb. I presume that in both the bone\\nhad left the socket at its upper posterior segment iliac dislocation.\\nIf manipulation alone is used external rotation must be carefully\\navoided during the first steps, lest it should convert the dislocation into\\nan everted dorsal by throwing the head forward above the socket and\\nextreme flexion and abduction without simultaneous traction are also to\\nbe avoided, in order to escape the conversion of the dislocation into one\\nupon the obturator foramen by the passage of the head below the socket.\\nFig. 317.\\nReduction of dorsal dislocation of the hip by the weight of the limb.\\nThe everted dorsal dislocations are reduced after first converting them\\ninto the dorsal form. This conversion is effected by flexion and inward\\nrotation, with adduction, if necessary, to make room for the head of\\nthe bone to slide upon the ilium the rupture of the outer branch of\\nthe Y-ligament deprives the operator of much of the advantage of rota-\\ntion, and the dislocation must, therefore, be reduced by direct traction\\ntoward the socket, with local guidance of the head. In my own case,\\nin which, after conversion into the dorsal form the tendency of the\\nhead again to pass forward above the acetabulum was very marked,\\noutward rotation had to be carefully avoided.\\nThe possibility of fracturing the neck of the femur during manipu-\\nlation must be borne in mind (see Chapter LI 1 1.).", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0817.jp2"}, "810": {"fulltext": "CHAPTER LIL\\nDISLOCATIONS OF THE HIP.\u00e2\u0080\u0094 (Continued.)\\nDislocations Downward and Inward Obturator, perineal Forward and Up-\\nward Suprapubic, iliopectineal Upward Subspinous, supracotyloid\\nDownward on the Tuberosity of the Ischium.\\nDISLOCATIONS DOWNWARD AND INWARD.\\n1. Obturator or thyroid dislocations, or dislocations upon the\\nthyroid foramen and 2, perineal dislocations.\\nIn this class of dislocations the head of the femur leaves the socket\\nat its lower, or lower and inner, part, and passes forward and inward\\nto rest upon the obturator foramen (obturator dislocation), or passes\\nstill further, and, crossing the ischio-pubic ramus, projects in the per-\\nineum (perineal dislocation). The limb is flexed, abducted, and usually\\nrotated outward.\\nObturator or Thyroid Dislocations.\\nThese dislocations, although infrequent, are apparently the second in\\norder of frequency of those of the hip, and it seems not improbable\\nthat this form, in part at least, is the first stage in the production of\\nsome of the suprapubic, and even some of the dorsal dislocations that is,\\nthe head of the bone, having left the socket at its lowest part in forced\\nflexion of the limb, may either be turned backward behind the acetab-\\nulum by adduction, internal rotation, and diminution of the flexion, or\\nforward and upward upon the pubis by external rotation and exten-\\nsion the obturator form is produced by its passage more directly for-\\nward and inward upon the obturator foramen by abduction and\\nexternal rotation.\\nCause. The commonest cause appears to be great violence acting\\nupon the back of the pelvis while the limb is flexed and abducted, as\\nin the fall of a heavy object upon the back of a man who is stooping\\nforward with his legs separated. Simple abduction of the extended\\nlimb is apparently sufficient to produce the injury, as is shown by a\\ncase reported by Corne, 1 in which the thigh of a drunken soldier was\\nforcibly abducted by his comrades. In a case reported by Keate, 2 and\\nanother by Barker, 3 the mechanism was apparently the same in the\\nformer the patient, while riding, fell into a ditch, his horse falling upon\\nhim and widely separating his legs the head of the femur lay close\\nto the tuber ischii. In the latter the patient fell from a height of\\n1 Corne: Recueil de Mem. de Med. Mil., February, 1867, quoted by Losseu.\\n2 Keate London Medical Gazette, vol. x. p. 19, quoted by Bigeiow.\\n3 Barker American Journal of the Medical Sciences, 1854, vol. xxvii. p. 412.\\n736", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0818.jp2"}, "811": {"fulltext": "THYROID DISLOCATIONS OF THE HIP.\\n737\\nFig. 318.\\nabout thirty feet, striking upon a sandbank and having his legs widely\\nseparated both thighs were dislocated.\\nIn another set of cases it is difficult to determine whether the cause\\nhas been direct impulsion of the head of the femur downward and\\ninward by a force acting on the outer side of the great trochanter, or\\nwhether it has been exaggerated abduction by pressure forward of the\\nouter part of the pelvis, as in a case reported by Treub, 1 in which a\\nman while lying on his face was run over by a wagon, the wheels pass-\\ning obliquely across his left hip at the level of the trochanter and the\\npelvis from left to right, and received a dislocation of the left hip.\\nPathology. The reported autopsies in recent cases are very few. 1\\nThey show rupture of the capsule on the inner and lower side, usually\\nnear the acetabulum and sometimes extending along the neck, and\\nlaceration of the obturator externus and pectineus. Sometimes the\\nobturator is pushed before the head of the bone. In one case (Duboue)\\nthe femoral vein was torn. The head of the femur rests on the obtu-\\nrator foramen or on the ramus beyond it. In a recent one of my own\\nthe ligamentum teres was untorn.\\nSeveral specimens of old dislocation have been examined those of\\nMoreau and Stanski, quoted by Malgaigne, Cooper, 3 and Sedillot. 4\\nIn these the head occupied the\\nforamen ovale more or less com-\\npletely, and a new socket had\\nbeen formed by the growth of\\nbone around it in Cooper s case\\nthe head was so completely en-\\nclosed by this new socket that\\nit could not be removed from it\\nwithout breaking its edge, and\\nyet it w T as freely movable and\\nwas covered with articular carti-\\nlage. In Stanski s the Y-liga-\\nment had been completely trans-\\nformed into bone, and the head\\nof the femur lay near the tuber-\\nosity of the ischium, the limb\\nbeing much flexed and abducted.\\nIn Sedillot s the head of the\\nfemur was atrophied and ir-\\nregular, but the limb was so\\nserviceable that the patient was\\na professional soldier, and shared\\nin all the campaigns of the army.\\nExperiments upon the cadaver corroborate the clinical and post-\\nmortem data concerning both the pathology and the mode of produc-\\nObturator dislocation. (Bigelow.)\\n1 Treub Centralblatt fur Chirurgie, 1882, p. 729.\\n2 Verhaeghe, Gazette des Hopitaux, 1851, p. 283; Schinziiiger, Wiener med. Presse.\\n1880, No. 3, quoted by Poinsot Curling, Medical Times and Gazette, 1853, vol. ii. p.\\n423; Duboue\\\\ Bull, de la Societe Anatomique, 1858, p. 496; Annandale, British Medical\\nJournal, 1870, vol. i. p. 101.\\n3 Cooper Loc. cit., p. 50. 4 Sedillot Gazette des Hopitaux, 1S61, p. 94.\\n47", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0819.jp2"}, "812": {"fulltext": "738 DISLOCATIONS.\\ntion. If the dislocation is produced by abduction of the extended\\nlimb the rent in the capsule is found to lie on the inner side of the\\njoint, while, when it is produced by abduction and outward rotation\\nfollowing flexion, or by transformation of a primary dorsal dislocation,\\nthe rent is mainly on the under side, and its extension in front and\\nupward is effected by secondary displacement of the head. The\\nY-ligament, remaining untorn, keeps the limb partly flexed, abducted,\\nand everted (Fig. 318), the head of the femur rests against the inner\\nand under side of the acetabulum, and is prevented from rising by its\\npressure against this part of the bone and by the untorn portion of the\\ncapsule above.\\nA case of compound dislocation has been quoted in Chapter LI.\\nIn a case reported by Cooke the shaft of the femur was also broken\\njust below the trochanters the patient was a boy nine years old, and\\nthe injury was caused by a fall. Probably the dislocation was first\\nproduced, and then the bone was broken by a continuation of the force,\\nor by a second blow. Reduction was easily effected by direct pressure\\non the head, and the patient made a good recovery.\\nSymptoms. The limb is flexed, abducted, and usually rotated out-\\nward, and it appears to be elongated because the foot is projected and\\nbrought to the ground by a compensatory tilting of the pelvis forward\\nand downward on the same side (Figs. 319, 320). The trochanteric\\nregion is flattened, and the trochanter lowered and displaced inward\\nthe adductors are usually tense. The outward rotation of the limb is\\nnot marked and may be absent, or there may even be some inward\\nrotation.\\nThe statements concerning the comparative length of the limbs on\\nmeasurement are contradictory, presumably because of the failure of\\nsome observers to place the two limbs in symmetrical positions, or\\nbecause of the greater or less abduction and flexion of the limb when\\nmeasured. Thus, in marked flexion and abduction measurement from\\nthe anterior superior spine of the ilium to the knee or ankle will show\\nshortening of the injured limb; while, if the limb is extended and but\\nslightly abducted the measurement may show an actual elongation.\\nThe head of the femur may be more or less distinctly felt on deep\\npressure toward the obturator foramen from the inner side. The\\nstatement occasionally made that the head can be felt to move by the\\nfinger in the rectum pressed against the inside of the foramen when\\nthe limb is rotated is an error of observation. The same sensation can\\nbe obtained when the joint is not dislocated, and is due to the alter-\\nnate stretching and relaxation of the obturator interims during the\\nmovement.\\nSometimes the patients have been able to walk quite well immedi-\\nately after the accident, and some of them have not sought advice\\nuntil after the lapse of several days, even a fortnight. Sedillot states\\nthat this was so in three of the five cases which he had seen, and one\\nof the patients came to him only because he noticed that he could not\\ncompletely adduct the limb.\\nThe diagnosis of the dislocation and of the variety is made by\\n1 Cooke: Lancet, 1864, vol. i. p. 37.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0820.jp2"}, "813": {"fulltext": "THYROID DISLOCATIONS OF THE HIP.\\n739\\nattention to the attitude and fixation of the limb, the impossibility of\\ncompletely extending and adducting it, the elongation in the extended\\nposition, the depression of the trochanter, and the presence of the head\\nof the femur in its new position.\\nFig. 319.\\nFig. 320.\\nObturator dislocation. (Stimson.)\\nObturator dislocation. (Johnson.)\\nTreatment. Bigelow, in his original paper, gives ten procedures for\\nreducing thyroid and downward dislocations, which may be grouped\\nas four different methods 1, manipulation 2, traction in the axis of\\nthe flexed and abducted limb 3, traction outward against the upper\\npart of the thigh 4, transformation into a dorsal dislocation, and\\nreduction as such. In his last paper 1 he seems to prefer the last\\n1 Bigelow Lancet, 1878, vol. i. p. 861.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0821.jp2"}, "814": {"fulltext": "740\\nDISLOCATIONS.\\nFig. 321.\\nmethod, adducting the thigh in order to carry the head to the dorsum\\nand enlarge the opening in the capsule, and then reducing by flexion\\nand forcible lifting of the head toward the socket.\\nHis directions 1 for reducing by manipulation are: Flex the limb\\ntoward a perpendicular, and abduct it a little to disengage the head\\nof the bone then rotate the shaft strongly inward, adducting it, and\\ncarrying the knee to the floor. The trochanter is then fixed by the\\nY-ligament and the obturator muscle, which serve as a fulcrum.\\nWhile these are wound up and shortened by rotation (Fig. 321), the\\ndescending knee pries the head upward\\nand outward to the socket. In\\nthis manoeuvre the action of the liga-\\nment may be aided, if necessary, by a\\ntowel passed round the head of the\\nfemur to draw it upward and outward.\\nRotation outward may be substituted\\nfor inward rotation.\\nThe clinical histories show that in-\\nward and outward rotation have suc-\\nceeded, each after the other has failed,\\nand that the former is quite likely to\\ntransform the dislocation into a posterior\\none as outward rotation most surely\\nprevents this change, surgeons appear\\nnow to prefer it. The directions given\\nby Kocher, 2 and approvingly quoted by\\nthe German surgeons, are as follows\\n1. Flexion of the thigh to a right angle with the pelvis, while\\npreserving the abduction and outward rotation in which the limb is\\nfound. This leaves all parts of the capsule relaxed.\\n2. Traction, to make the posterior part of the capsule tense, and to\\nbring the head nearer the socket.\\n3. Outward rotation, which, acting through the tense posterior por-\\ntion of the capsule and outer branch of the Y-ligament, brings the\\nhead upward and backward into place.\\nDirect pressure or traction outward upon the upper part of the thigh\\nhas often proved a valuable aid, either by directly moving the head of\\nthe femur toward the socket or by furnishing a fulcrum by means of\\nwhich the head could be moved in this direction by adducting the\\nknee. One of Bigelow s procedures, for example, is to place the\\npatient in a sitting posture with a log, or post, or bedpost between\\nhis thighs, and pry the head outward over this fulcrum by means of\\nthe long shaft of the femur.\\nMy own cases have been easily reduced, under ether, by increasing\\nthe flexion and rotation, making traction in the long axis of the limb,\\nand then lowering and rotating inward.\\nKocher 3 reduced a dislocation of four weeks standing, which had\\nresisted all other methods, by making continuous traction in the axis\\nReduction of obturator dislocation by\\nrotation showing the mechanism of the\\nmanoeuvre. (Bigelow.)\\n1 Bigelow The Hip, p. 79.\\n3 Kocher Loc. cit., p. 620.\\nKocher Volkniann s klin. Vortrage, No. 83.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0822.jp2"}, "815": {"fulltext": "PERINEAL DISLOCATIONS OF THE HIP. 741\\nof the limb and combining with it elastic traction laterally on the\\nupper part of the thigh. On the morning of the fourth day reduction\\nwas found quietly to have taken place.\\nIn a case in which the dislocation had existed for twenty months\\nand the disability was great, MacCormac excised the head and tro-\\nchanter with a good result. The patient was a sailor nineteen years\\nold. For details of the case (see Chapter LIIL).\\nPerineal Dislocations.\\nThe recorded cases of this form are not numerous. 1 It is character-\\nized by the presence of the head more superficially placed than in the\\nobturator variety and displaced to a greater distance from the socket,\\nso as even in one case to press upon the urethra and interfere with the\\nFig. 322.\\nPerineal dislocation of hip. (Stimson.)\\nvoiding of the urine. In Taylor s case, quoted above among compound\\ndislocations of the hip, page 715, the dislocation was made compound\\nby a rent in the integument of the perineum nearly two inches long;\\nand, possibly, Woodward s case, quoted in the same section, may be\\nlooked upon as an extreme form of this variety.\\nThe cause appears to be extreme abduction of the limb, caused in\\nmy three cases by the fall of a heavy body upon the patient s back as\\nhe stood or knelt with the thigh flexed and abducted. Probably the\\n1 See also a paper by Riedenger in Munch, nied. Wochenschrift, August 16, 1S92.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0823.jp2"}, "816": {"fulltext": "742 DISLOCATIONS.\\ncapsule is widely torn, and thus may be explained the varying attitude\\nof the limb in respect of inversion or eversion. In an autopsy reported\\nby Shaw 1 not only was the capsule extensively detached at its inner\\nand posterior insertion upon the acetabulum, but also the iliofemoral\\nligament was partly separated from the neck of the femur, and a small\\nrent extended from that point into the capsule.\\nIn my three cases 2 the thigh was flexed and abducted so that it stood\\nfar out from the side of the body, making an angle of between 60 and\\n70 degrees with the sagittal and frontal planes (Fig. 322). When the\\nother limb was placed as nearly as possible in the corresponding posi-\\ntion (the same degree of abduction could not be obtained) the distance\\nbetween the knees was thirty inches, and measurement from the ante-\\nrior superior spine to the knee showed from one and a half to four\\ncentimetres shortening. A rounded mass, the head of the femur,\\ncould be felt beginning one inch from the mid-line of the perineum\\nand extending forward to the adductor longus and backward nearly to\\nthe level of the anus. Adduction and extension painful and opposed\\nslight additional flexion and rotation possible. All were easily reduced\\nby the method given above, flexion and traction.\\nTheoretically reduction should be most readily effected by traction\\nin the axis of the abducted limb and by direct pressure upon the head\\nof the bone or upon the upper part of the shaft, anesthesia being used\\nto prevent opposition by the muscles. The extensive laceration of\\nthe capsule and ligaments would probably make purely manipulative\\nmethods ineffective.\\nDISLOCATIONS UPWARD AND FORWARD, AND INWARD AND\\nFORWARD. SUPRAPUBIC.\\nIliopectineal. Pubic. Intrapelvic.\\nIn these dislocations the head of the femur comes to rest upon the\\nsuperior ramus of the pubis, either at the iliopectineal eminence above\\nand a little to the inner side of its normal position (iliopectineal), or,\\nmore rarely, nearer the symphysis pubis (pubic). On the one side the\\nposition merges into that of the supracotyloid, and on the other into\\nthat of the obturator. Some of the iliopectineal, in which the head has\\nremained very close to the anterior inferior spine of the ilium, have been\\ndescribed by their reporters and others under the name supracotyloid,\\nand some writers describe the pubic variety as a variety of the obtu-\\nrator, or, rather, of a class to which they give the name prceglenoid or\\ndislocations forward and inward. Exceptionally the head may pass\\nunder or through Poupart s ligament and rest in the iliac fossa, the\\nintrapelvic or swprapectineal dislocations.\\nThe head of the bone may leave the socket at its upper and inner\\npart, and in this case it appears probable that the head rests on the\\niliopectineal eminence, or it may leave it at a somewhat lower point\\n1 Shaw: Transactions of the Pathological Society of London, 1859, vol. x. p. 211.\\n2 For full details of two see New York Medical Journal, August 3, 1889; the third is\\nshown in Fig. 322.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0824.jp2"}, "817": {"fulltext": "SUPRAPUBIC DISLOCATIONS OF THE HIP. 743\\nand pass inward and forward to the symphysis, or it may pass at first\\ninward and downward across the obturator foramen while the limb is\\nHexed, and then move upward to rest upon the upper and front surface\\nof the superior ramus of the pubis as the limb is subsequently low-\\nered. It is to be remembered that the upper border of the symphysis\\npubis is a little below the level of the centre of the cotyloid cavity in\\nthe upright position.\\nIn correspondence with these differences in the position taken by the\\nhead are found differences in the mode of production, according as the\\nhead is moved more directly upward, upon the iliopectineal eminence,\\nby hyperextension of the limb, or is first turned more directly forward\\nby outward rotation and abduction and then, after rupture of the ante-\\nrior and inner part of the capsule, is pressed upward or inward. Of\\nthe former there are a number of clinical examples in which the limb\\nitself has been hyperextended, or, more commonly, the trunk has been\\nviolently pressed backward while the limb was fixed thus, a man steps\\ninto a hole and falls backward another, wrestling, is forcibly bent\\nbackward by his antagonist. Of the latter, outward rotation and\\nabduction, the clinical instances are not so clear, but the possibility of\\nthe production in this manner has been fully proved by experiment\\nupon the cadaver a muscular woman, 1 carrying a keg of potatoes on\\nher back, stumbled and, to avoid a fall forward, threw her body with\\na twisting movement backward a man 2 while swimming made a vigor-\\nous thrust with his legs and felt a sharp pain in the groin he was still\\nable to walk, though with much difficulty, and on examination a dislo-\\ncation upon the pubis was found.\\nPathology. The pathology has been shown by several autopsies in\\nrecent and old cases. Aubry 3 found the capsule torn along its anterior\\nhalf near its insertion upon the acetabulum the psoas and the crural\\nnerve crossed the front of the neck the head of the femur lay between\\nthe psoas and pectineus, raising the latter and the vessels there was\\nan interval of two centimetres between it and the anterior inferior\\nspinous process of the ilium. Roser 4 found the rent in the front of the\\ncapsule extending from the anterior inferior spinous process down to\\nthe notch the psoas and iliacus were pushed outward, and the vessels\\ncrossed the head the small external rotators were drawn inward and\\npressed into the acetabulum by the great trochanter. Albert 5 found\\nthe head resting against the outer side of the iliopectineal eminence\\nand covered on its inner half by the psoas and iliacus when it was\\npressed further upward the muscle lay across its neck. The iliopec-\\ntineal fascia (the deeper part of the sheath of the vessels) was untorn,\\nbut nevertheless the artery was displaced outward by the head so that\\nit rested across its centre and curved outward immediately below Pou-\\npart s ligament the capsule was torn above and in front for about\\none-third of its circumference, the greater part of the iliofemoral\\nligament being uninjured the ligamentum teres was torn away at its\\n1 Albert Chirurgie, vol. iv. p. 274. 2 Ure: Lancet, 1S57, vol. ii. p. 470.\\n3 Aubry: Bull, de la Societe de Chirurgie, 1853, vol. iii. p. 377.\\n4 Eoser Arch, fur phys. Heilkunde, 1857, vol. i. p. 58.\\n5 Albert Loc. cit., p. 276.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0825.jp2"}, "818": {"fulltext": "744 DISLOCATIONS.\\ninsertion upon the head, and the cartilaginous rim of the acetabulum\\nwas entirely uninjured; the posterior rotators were relaxed. Kocher 1\\nfound the capsule torn along its anterior half close to its insertion upon\\nthe femur, the portion which remained attached to the acetabulum\\nhanging as a flap between the head and the socket the psoas and\\niliacus were stretched across the neck of the bone, and the vessels lay\\nto the inner side of the head the ligamentum teres was torn away\\nnear its attachment to the acetabulum, and the cartilaginous rim of the\\nsocket was uninjured.\\nIn a case reported by Stokes 2 in which the head had passed over the\\nbrim into the pelvis, the superior ramus of the pubis had been frac-\\ntured and much comminuted. The patient died on the table immedi-\\nately after reduction, by pulmonary embolus, it was thought.\\nCases in which the dislocation was compound have been quoted in\\nChapter LI., p. 715 in one of them the femoral vein was ruptured.\\nIn a case reported by Goldsmith and quoted on p. 418, in which\\nthe dislocation had remained unreduced for two months when the\\npatient came under observation, there was found a diffused pulsating\\nswelling occupying the iliac fossa and extending down to the middle\\nof the thigh, which had appeared a few days after the accident the\\nexternal iliac artery was tied, and at the patient s death, five days\\nlater, the femoral and external iliac arteries were found to be perforated\\nfor the distance of an inch on their postero-external aspect, and the\\nhead of the femur lying in the cavity of the aneurism.\\nFig. 323.\\nOld unreduced suprapubic dislocation of the hip. (Cooper.)\\nIn one or two cases pressure upon the anterior crural nerve has been\\nmanifested by numbness in its area of distribution.\\nA case treated by Bransby Cooper 3 and examined after death at the\\n1 Kocher: Loc. cit., p. 616. 2 Stokes: British Medical Journal, 1880, vol. ii. p. 916.\\n3 Cooper Loc. cit., p. 78, and Guy s Hospital Eeports, 1836, vol. i. p. 82.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0826.jp2"}, "819": {"fulltext": "DISLOCATIONS OF THE HIP.\\n745\\nFig. 324.\\nend of three weeks is reported in detail, but it is not clear how much\\nof the laceration of the muscles was due to the dislocation and how\\nmuch to the repeated attempts to reduce it. The anterior part [of\\nthe capsule], where crossed by the tendons of the psoas and iliacus\\nmuscles/ was the only part untorn the head of the femur lay in the\\ngroin on the inner side of the great vessels and above the internal\\ncircumflex artery.\\nIn an old case examined by Sir Astley Cooper the head of the\\nthigh bone had torn up Poupart s ligament, so as to penetrate be-\\ntween it and the pubes. Upon the pubes a new acetabulum is\\nformed for the neck of the thigh bone, the\\nhead of the bone bein^ above the level of the\\nthe pubes (Fig. 323). The femoral artery\\nand vein were placed on its inner side,\\nso that the head of the bone rested between the\\ncrural sheath and the anterior inferior spinous\\nprocess of the ilium.\\nVerneuil, 2 in attempting to make reduction\\nthirty-six hours after the accident in a patient\\neighty-one years old, fractured the neck of\\nthe femur. Four years later the patient died\\nthe head was found lying in the notch between\\nthe anterior inferior spinous process and the\\niliopectineal eminence, between the psoas and\\nthe rectus. In another old case reported by\\nDouglas 3 in which there was also a fracture of\\nthe neck of the femur the head was on the\\ninner side of the vessels; the history of the case\\ndid not show when the fracture had been pro-\\nduced.\\nSymptoms. The cases in which the head of\\nthe femur lies upon the iliopectineal eminence\\nappear to be the more common, and this may,\\ntherefore, be taken as the typical form in it\\nthe limb is but slightly, if at all, abducted,\\nmarkedly everted, and somewhat shortened\\n(Fig. 324), and the head of the femur can be eoV (Bigelow.)\\nfelt more or less distinctly in the groin, with\\nthe artery pulsating directly in front of it or to its inner side. When\\nthe head is displaced further toward the median line the limb is\\nabducted and flexed as well as everted, and its position is more like\\nthat of an obturator dislocation the capital difference is the position\\nof the head on the pubis where it can be distinctly felt and perhaps\\neven seen. The vessels lie on its outer side. In both forms the outer\\nand posterior portions of the hip are flattened, and the trochanter can\\nbe felt covering the cavity of the acetabulum.\\nIliopectineal dislocation..\\nThe limb is usually a little\\nmore advanced and abduct-\\n1 Cooper Loc. cit., p. 71.\\n2 Verneuil Bull, de la Societe de Chirurgie, 1870, vol. xi. p. 245.\\n3 Douglas London and Edinburgh Monthly Journal of Medical Sciences, 1843, vol. iii.\\np. 1064.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0827.jp2"}, "820": {"fulltext": "746 DISLOCATIONS.\\nAdduction is difficult or impossible abduction and flexion usually\\nare easy. Some patients have been able to walk immediately after\\nthe accident, but none appear to have done so as freely as some with\\nobturator or supposed supracotyloid dislocations.\\nThe attitude of the limb is like that found after fracture of the\\nneck of the femur, and the differential diagnosis is made by attention\\nto the presence of the head in the groin, the flattening of the outer\\naspect of the hip, and the depression of the trochanter.\\nIn a case reported by Rothe l the patient, a girl fifteen years old,\\nwas unable to extend the leg upon the thigh three weeks after the acci-\\ndent, and the disability was attributed to overflexion of the knee at the\\ntime the dislocation was received. While pushing a swing forward\\nshe tripped, fell on her knee, and was then pressed backward to the\\nground by the returning swing. Reduction was made under chloro-\\nform by flexion, rotation inward, and adduction.\\nOf the intrapelvic (Scriba) or suprapectineal (Bartels) dislocation\\ncases have been reported in detail by Scriba, 2 Bartels, 8 and Stokes\\n(above quoted). Scriba s patient, a boy thirteen years old, while stand-\\ning with his legs wide apart and the left one thrown back, Avas struck\\nupon the breast and overthrown. The limb was flexed at the knee and\\nhip, adducted and rotated inward. The head of the femur lay above\\nthe torn Poupart s ligament deep in the iliac fossa, and the neck rested\\non the superior ramus of the pubis. The artery, vein, and nerve\\ncrossed the head and were fully compressed. Slight inward rotation\\nand adduction were the only movements possible. During manipula-\\ntion outward rotation suddenly took place and persisted. Reduction\\nwas made by lifting the head with the fingers until it rested on the\\nramus, and then following with acute flexion, adduction, inward rota-\\ntion, and finally extension.\\nBartels s patient was a man forty-seven years old who had been\\nthrown down by a heavy weight. The limb was shortened about three\\ninches, fully extended, parallel to the median line of the body, and\\nwidely rotated outward. The fold of the groin was obliterated by a\\ndiffuse swelling extending to the upper limit of the left hypogastrium\\nthe head could be distinctly palpated through the abdominal wall,\\nwhich it slightly raised the greater trochanter was directed backward\\nand could not be felt. Flexion was impossible inward rotation very\\nlimited.\\nTreatment. The rule, of which the application is so general, that in\\nattempting reduction the limb should first be placed in the position\\nwhich it occupied when the dislocation occurred, is not suitable to\\nthose suprapubic dislocations in which the dislocation takes place\\nwhile the limb is extended. Traction upon the fully extended,\\nabducted, and everted limb has indeed been sometimes successful, but\\nit has oftener failed and has led to various accidents. The method\\nwas early abandoned because of the risk of injury to the vessels by\\noverstretching across the projecting head of the femur, and flexion was\\n1 Eothe Deutsche Klinik, 1868. p. 343.\\n2 Scriba Centralblatt fur Chirurgie, 1879, p. 703.\\n3 Bartels: Arch, fur kliu. Chir., vol. xvi. p. 651.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0828.jp2"}, "821": {"fulltext": "DISLOCATIONS OF THE HIP. 747\\nresorted to to diminish this risk and to remove what was thought to be\\nthe principal obstacle, tension of the psoas and iliacus. Of the six\\nprocedures given by Bigelow almost all include traction upon the\\nflexed thigh and rotation inward in some, direct pressure downward\\nand outward upon the head of the bone or the upper part of the thigh\\nis recommended, and outward rotation is mentioned in one as an equally\\ngood substitute for inward rotation.\\nKocher s method is the same as one of those given by Bigelow, and\\nI reproduce it here because of its more detailed account of the obstacles\\nto be overcome and the means by which the manipulation accom-\\nplishes it.\\nFlexion relaxes the Y-ligament, but nevertheless by tightening the\\nposterior part of the capsule it presses the head more firmly against\\nthe brim of the pelvis or even pushes it further upward under Pou-\\npart s ligament it is therefore necessary that the movement should\\nnot be allowed to take place upon the head as a centre, but that the\\nhead should be enabled or forced to descend along the anterior surface\\nof the pelvis as the knee is raised before the tightening of the posterior\\nportion of the capsule has made this descent impossible. This can be\\neffected by traction in the axis of the limb or by direct pressure down-\\nward and backward upon the head. The steps of the method, then,\\n-are\\n1. Traction in the axis of the limb as it lies, in order to bring the\\nhead over the brim of the pelvis it is rarely necessary to aid this by\\nincreasing the extension, abduction, and outward rotation of the limb.\\nBy this means the posterior portion of the capsule is made tense, and\\nits point of attachment to the back of the neck of the femur is thereby\\nmade the centre for the following movements\\n2. Pressure with the hand upon the head of the femur to prevent its\\nreturn upward during flexion. Sometimes this is sufficient to make\\nreduction.\\n3. Flexion, in order to relax the Y-ligament it should not be car-\\nried to a right angle, otherwise too much strain will be made upon the\\nposterior portion of the capsule.\\n4. Rotation inward, by which the head is returned to the socket.\\nIn cases in which the head lies nearer the symphysis abduction of\\nthe limb during traction is necessary to relax the Y-ligament and the\\nuntorn portion of the capsule and thus allow the head to approach the\\nacetabulum and in those, possibly rare, cases in which this position is\\nsecondary to a primary displacement downward and inward (obturator)\\nthe flexion will be seen to bring the head back to the obturator fora-\\nmen, and then the final steps should be those suitable to that form of\\n\u00e2\u0080\u00a2dislocation.\\nDISLOCATIONS DIRECTLY UPWARD.\\nSubspinous (Bigelow). Supracotyloidea. Sus-cotyloidienne\\n(Malgaigne).\\nConcerning no other class of reported cases of dislocations of the hip\\nis the uncertainty as to the nature and extent of the lesion, the point", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0829.jp2"}, "822": {"fulltext": "748 DISLOCATIONS.\\nat which the head has left the socket, and the mode of production so\\ngreat as in those in which the head is found more or less directly above\\nthe socket. As has been above said, Blasius grouped under one head\\nsupmcotyloidea cases in which the head of the femur comes to rest\\nabove the socket either by secondary displacement forward and upward\\nfrom a primary dorsal (the everted dorsal of the present classification),\\nor by secondary displacement backward from a primary suprapubic, or\\nby direct dislocation upward, and this grouping, which, while very\\nproper in a monograph, seems to me objectionable in a systematic\\ndescription of all the forms, has been accepted and followed by several\\nof the later German writers, Albert, Konig, Lossen. Bigelow groups\\nMalgaigne s variety with those cases in which the head lies further to\\nthe inner side (suprapubic), and makes them all a subvariety under\\nthe name subspinous. Hamilton makes no formal classification of\\nthem, but contents himself with citing a few cases, mainly as anom-\\nalous dislocations, some as subspinous, others as supraspinous.\\nThe essential feature of the class, as I view it, is the rupture or\\navulsion of the upper part of the Y-ligament; this differentiates it\\nradically in its probable mode of production and treatment from those\\nin which the head of the bone comes to rest at or near the same place\\nafter having left the socket at a lower point in front or behind and\\npassed upward on either side of the untorn ligament.\\nThe incompleteness of many of the descriptions is such that the\\nmaterial for a positive opinion upon the character of the displacement\\nis lacking, and such cases must, therefore, be passed by without defi-\\nnite classification, but there remain a few which sufficiently establish\\nthe existence of this variety in which the head is displaced directly\\nupward toward or a little behind the anterior inferior spinous process\\nof the ilium.\\nThe cases in which the position of the head of the femur has been\\nverified by autopsy are those of Wormald, 1 Gerdy, 2 Travers, 3 and St.\\nGeorge s Hospital, 4 and the doubtful ones of Cruveilhier, 5 Gely, 6 and\\nDeville. 7 Wormald s patient was a man forty years old, Avho had\\nreceived his injury at the age of fourteen, by a fall from a ladder, and\\nhad since had good use of the limb. The head of the femur lay\\nbetween the edge of the acetabulum and the anterior inferior spinous\\nprocess, and was surrounded by the capsule. The ligamentum teres\\nwas not ruptured. The cotyloid cavity formed part of the new socket.\\nThe limb was somewhat everted and abducted, and shortened half an\\ninch. Gerdy s patient was caught in a revolving shaft and whirled\\naround by it many times the injury was supposed to be a fracture of\\nthe neck of the femur, and its true character was only recognized\\nwhen reduction took place during flexion of the limb. He died on the\\nfollowing day. The head of the femur lay on the outer third of\\n1 Wormald: London Medical Gazette, 1837, vol. xix. p. 658.\\n2 Gerdy Reported by Baron, Gaz. Medical e de Paris, 1838, p. 630.\\n3 Travers Medico-Chirurgical Transactions, 1837, vol. xx. p. 112. Autopsy by Cadge\\nIbid., 1855, vol. xxxviii. p. 88.\\n4 St. George s Hospital Lancet, 1840-41, vol. ii. p. 281.\\n5 Cruveilhier: Bull, de la Soc. Anatomique, 1837, p. 164.\\n6 Gely Ibid., 1840, p. 303. 7 Deville Ibid., 1843, p. 264.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0830.jp2"}, "823": {"fulltext": "DISLOCATIONS OF THE HIP.\\n749\\nFig. 325.\\nthe upper border of the acetabulum, below and just outside of the\\nanterior inferior spinous process the capsule was torn along the\\nupper edge of the cavity, and the centre of the head was eight lines\\nabove that of the latter. Fig. 236 represents an apparently similar\\nspecimen.\\nIn Travers s and Cadge s case\\nthe head lay between the superior\\nand inferior spinous processes of\\nthe ilium (Fig. 325) and was cov-\\nered by a complete bony cap lined\\nwith a dense pearly-white tissue\\nresembling fibro cartilage. The\\nedge of the new cavity was con-\\nnected with the neck of the femur\\nby a thick capsular ligament.\\nThe rectus muscle, which had\\nbeen torn from its origin, was in-\\nserted upon the edge of the new\\ncavity.\\nThe St. George s Hospital case\\nwas a recent one the head of the\\nfemur lay about an inch below and\\nto the outer side of the anterior\\nspinous process, and the trochanter\\nOld supracotyloid dislocation.\\nand Cadge s case.\\nTravers s\\nwas still further to the outer side and\\nbehind the trochanter minor rested\\non the outer edge of the acetabulum.\\nThe capsular ligament was exten-\\nsively lacerated at its upper part. The gluteus medius and minimus\\nwere nearly torn through about two inches from their attachment to the\\ntrochanter the gemelli and quadratus femoris were slightly lacerated.\\nThe following case, which I reported in the Annals of Surgery, De-\\ncember, 1892, shows the symptoms (Fig. 326). A man forty years old\\nwas thrown down by a heavy case which slipped while he was unload-\\ning it from a wagon and forced him backward against another box and\\nthen sidewise to the ground. When I saw him, three hours later, he\\nwas lying on his back with the right thigh extended, slightly abducted,\\nand so far everted that the foot rested along the entire length of its\\nouter border on the bed. The upper anterior portion of the thigh close\\nbelow the groin was rounded and swollen, and showed two incomplete\\ntransverse rents in the skin about two inches long and about two inches\\nbelow the anterior superior spine of the ilium, which evidently had\\nbeen caused by overstretching of the skin (hyperextension of the\\njoint). The outward rotation gave the thigh a very peculiar appear-\\nance the bulk of the quadriceps extensor formed a longitudinal mass\\non the outer side between the anterior (inner) aspect and a deep longi-\\ntudinal depression extending from the trochanter to the side of the\\nknee. Every attempt to move the limb caused pain and sharp con-\\ntraction of the muscles.\\nEther was administered. The limb could then be easily placed", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0831.jp2"}, "824": {"fulltext": "750\\nDISLOCATIONS.\\nalongside of and parallel with the other the shortening was two cen-\\ntimetres. The head of the femur lay directly beneath the skin and\\ncould be distinctly outlined. It lay just external to a line drawn\\ndownward from the anterior superior spinous process, and its upper\\nborder was about one inch below that prominence. Internal rotation\\nwas impossible moderate flexion was easy.\\nReduction was easily effected by flexing the hip about twenty\\ndegrees, and then making moderate traction along its axis with one\\nhand at the knee, and direct pressure downward and backward upon\\nthe head of the femur with the other. By fully extending the thigh\\nand making slight pressure forward against the upper part of its pos-\\nterior aspect the dislocation was easily reproduced, and was then again\\nreduced as before.\\nFig. 326.\\nUpward dislocation of the hip. (From a photograph.)\\nThrough what was apparently an extensive gap in the soft parts\\nbeneath the skin at the point occupied by the head of the femur before\\nreduction I could distinctly feel the surface of the ilium and, a little\\nin front, the anterior inferior spinous process.\\nA long side splint was applied, and the patient placed in bed.\\nConvalescence was uneventful, and the patient was discharged, April\\n15th, thirty-six days after the accident. May 24th he called on me;\\nhe walked without a cane, and complained only of a slight feeling of\\nweakness in the limb. Hyperextension of the hip caused no pain\\nactive flexion of the hip was restricted one-half.\\nI know of no case exactly like it. One reported by Morgan resem-\\n1 Morgan Guy s Hospital Eeports, 1836, p. 79.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0832.jp2"}, "825": {"fulltext": "DISLOCATIONS OF THE HIP. 751\\nbles it in the apparent mode of production and the attitude of the\\nlimb, but the head of the bone lay below and to the inner side of the\\nanterior superior spine. Possibly Cheever s case, quoted in Chapter\\nLI. among compound dislocations, may have been of the same kind\\nthe description is not sufficiently detailed to make it certain, It was\\nevident that my case just escaped being made compound by rupture\\nof the tense skin. In Mason s and Allin s 1 and in Tiffany s, 2 the\\nattitude was similar and the head of the bone could be felt below or\\nbelow and to the inner side of the anterior superior spine. Allin\\nreported his case as a suprapubic dislocation his patient received the\\ninjury by stumbling and falling forward while ascending a flight of\\nsteps. In each case reduction was effected with some difficulty by\\ntraction and, in Allin s and Tiffany s, rotation inward. Possibly some\\nof the intrapelvic dislocations have been produced in the same\\nmanner, and differ only in the higher position of the head given by\\nsecondary displacement.\\nThere is another small group of cases in which the displacement is\\nthought to be of the same kind but of less extent, and the opinion\\nfinds some support in the autopsy of Wormald s case, above quoted.\\nThere are e version, slight shortening, and some flexion of the limb,\\nand the patients have usually been able to walk. The head of the\\nfemur cannot be felt the trochanter is prominent, slightly elevated, and\\nmore distant from the symphysis pubis than its fellow is. Milner s 3\\ncase is the least doubtful example. It may be remembered that cases\\nwith quite similar symptoms have been reported as thyroid disloca-\\ntions.\\nIn others, with the same attitude of the limb, the head of the femur\\ncould be felt directly above the socket or a little to the inner side.\\nIn the first group it is evident that in some the Y-ligament and\\nattachment of the rectus are freely ruptured, and that in others the\\nhead is displaced slightly upward and the upper part of the. capsule\\nonly partly torn, and the neck of the femur probably crossed by the\\nuntorn rectus, a condition differing only slightly from the suprapubic.\\nIn the second group it is possible that the head is displaced upward\\nto the outer side of the inferior spinous process where it would, be\\nhidden by the overlying muscles, but in that case the marked eversion\\nnoted in all is inexplicable without rupture of the Y-ligament. I am\\ndisposed to think the cases were all thyroid dislocations, an opinion\\nsupported by the slight fulness of the groin and elevation of the fem-\\noral artery noted in Milner s.\\nDISLOCATION DOWNWARD UPON THE TUBEROSITY OF THE\\nISCHIUM. INFRACOTYLOID.\\nIn this form of dislocation the head escapes over the lower edge of\\nthe socket and rests just below it upon the outer surface of the body\\nof the ischium. The reported cases are very few, but it seems prob-\\n1 Allin: Reported by Hamilton, loc. cit., p. 785.\\n2 Tiffany Maryland Medical Journal, 1883, vol. x. p. 525.\\n3 Milner St. Bartholomew s Hospital Reports, 1874, vol. x. p. 316.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0833.jp2"}, "826": {"fulltext": "752 DISLOCATIONS.\\nable that the dislocation is much more frequent as a primary, transi-\\ntory one, leading to either a dorsal or an obturator dislocation, being\\nconverted into the former by inward rotation and adduction, or into\\nthe latter by outward rotation and abduction and, furthermore, some\\nof the cases have probably been reported as obturator dislocations, for\\nthe dividing line between them is somewhat arbitrary thus, Keate s\\ncase, referred to above in the paragraph on the causes of obturator\\ndislocations, is quoted by Malgaigne as a subcotyloid dislocation. The\\nform was first described by Bonn 1 in 1800, and again by Ollivier. 2\\nThe cause is the same as that of many dorsal and obturator disloca-\\ntions, namely, forcible flexion of the thigh, but exaggerated abduction\\nfollowed by slighter flexion appears also to be capable of producing it.\\nThus, in a case reported by Roux 3 the patient fell with his right leg in\\na hole the left one remained stretched out on the ground in abduction\\nand was dislocated and Ollivier s patient, a man, seventy-two years\\nold, was knocked down by a branch of a falling tree which struck\\nagainst the lower inner part of his right thigh and forcibly abducted it.\\nPitha 4 speaks of a case in which the dislocation was caused by the\\nforcible bending of the body backward, but, as Albert points out, not\\nonly is his description of the symptoms unintelligible, but it also does\\nnot appear how a rent in the lower part of the capsule could be pro-\\nduced in this way. He describes the supracotyloid and infracotyloid\\ntogether as vertical dislocations, and possibly has placed this case\\nin the wrong paragraph.\\nThe only autopsy is one reported by Luke, 5 the patient, a man, fifty\\nyears old, died in consequence of associated injuries the dislocation,\\nwhich had been easily reduced, was reproduced at the autopsy, and as\\nthe bone could be made to take no other position it was thought that\\nthe reproduction was exact. The head of the femur was situated\\nmidway between the ischial notch and the thyroid hole, immediately\\nbeneath the lower border of the acetabulum; the gemellus inferior\\nand quadratus femoris had been torn, and the ligamentum teres com-\\npletely detached the capsule was torn in its lower part.\\nExperiment upon the cadaver shows that the Y-ligament remains\\nuntorn and compels flexion of the thigh upon the pelvis, which, how-\\never, may be masked, as in other forms, by inclination of the pelvis.\\nThe retention of the head upon the tuberosity is due to the narrowness\\nof the rent in the capsule and to the support given by the untorn por-\\ntions and as the laceration can be easily extended on either side the\\neasy transformation into a dorsal or obturator dislocation is intelligible.\\nThe flexion may be even to a right angle Ollivier s patient was\\nbrought to the hospital seated in a chair the limb is more or less\\nabducted, and may be slightly inverted or everted. Measurement in\\nOllivier s case, when the other thigh was brought into a similar posi-\\ntion, showed no difference in length, and by the lengthening which has\\nbeen noted in other cases was probably meant only an apparent elon-\\n1 Bonu Quoted by Lossen.\\n2 Ollivier: Arch. gen. de Med., 1823, vol. iii. p. 505.\\n3 Eoux Revue Medico-chirurgicale, 1849. vol. v. p. 364.\\nPitha Pitha and Billroth, p. 163.\\n5 Luke: Medical Times and Gazette, 1858, vol. i. p. 12.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0834.jp2"}, "827": {"fulltext": "DISLOCATIONS OF THE HIP. 753\\ngation due to the abduction and the consequent inclination of the pelvis.\\nThe buttock appears rounded and more prominent, especially when\\nlooked at from below when the patient is lying on his back with both\\nthighs flexed, and the adductors of the thigh and the flexors of the\\nleg are very prominent at the upper part. The great trochanter is\\nfurther from the crest of the ilium, and the head of the femur can\\nsometimes, but rarely, be felt in its new position.\\nMovements of the limb are restricted and more or less painful\\nflexion to a right angle is usually possible, abduction comparatively\\nfree, adduction limited but in Roux s case the thigh could be carried\\nacross the other one. Both of Gurney s l patients could walk fairly\\nwell immediately after the accident, and Roux s could walk a little at\\nfirst, but was soon completely disabled by the pain.\\nReduction has been easy (Roux was unsuccessful on the thirty-fifth\\nday with the aid of chloroform) and has usually been effected by trac-\\ntion in the axis of the limb, with or without direct pressure upon the\\nhead of the bone sometimes the dislocation has been first transformed\\ninto a dorsal or obturator and then reduced.\\nA suitable method would be Flexion, if not already present trac-\\ntion correction of the existing rotation, if any to be aided by direct\\npressure on the head of the femur from behind. 2\\nDislocation into the pelvis through the fractured floor of the acetab-\\nulum has been described in Chapter XXII. A brief reference is\\nmade by Kronlein 3 to a unique case observed by him in which, by a\\nfall upon the feet, the head of each femur was driven through the floor\\nof the acetabulum.\\n1 Gurney Lancet, 1845, vol. iii. p. 412.\\n2 A paper by Chapplain in the Bulletins de la Societe de Chirurgie, 1874, p. 461, contain-\\ning a detailed report of a case observed by himself and an analysis of several others, may\\nbe advantageously consulted by those especially interested in the subject.\\n3 Kronlein Deutsche Chirurgie, Lief. 26, p. 25.\\n48", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0835.jp2"}, "828": {"fulltext": "CHAPTER LIIL\\nDISLOCATIONS OF THE HIP.\u00e2\u0080\u0094 (Continued.)\\nComplications Simultaneous Dislocation of Both Hips Accidents in Attempts\\nto Reduce Prognosis Habitual Dislocations Treatment of Old Disloca-\\ntions Congenital and Pathological Dislocations.\\nCOMPLICATIONS OF DISLOCATIONS OF THE HIP.\\nAmong the complications of dislocations of the hip are unusually\\nextensive injuries to the soft parts, rupture of or dangerous pressure\\nupon large nerves and blood-vessels, and fracture of bones. Mention\\nhas been made of all in connection with the different varieties of\\ndislocation, and it is necessary only to group and briefly summarize\\nthem.\\nRupture or laceration of the muscles about the joint is doubtless\\npresent in some degree in all cases, and is rarely so extensive as to\\ndeserve to be looked upon as a complication. In the dorsal disloca-\\ntions the head of the femur may be so far displaced that the gluteus\\nmedius, and even the gluteus maximus may be in part ruptured, and\\nin the thyroid dislocations the adductors may be extensively torn from\\nthe inferior ramus of the pubis and the adjoining part of the ischium,\\nas observed in Taylor s compound case above quoted. In the supra-\\npubic form the pectineus may be torn, and in the extreme variety\\nknown as intrapelvic, in which Poupart s ligament is ruptured, the\\nattached muscles forming the anterior wall of the abdomen must also\\nsuffer some injury. The extension of the bruising and laceration of\\ncourse increases the shock and inflammatory reaction, but calls for no\\nspecial treatment beyond a more rigid and prolonged confinement to\\nbed and avoidance of movement.\\nFor compound dislocations see Chapter LI.\\nRupture or injury of the femoral vessels has been observed only in\\nsuprapubic and obturator dislocations. The suprapubic ones are those\\nof a German military surgeon 1 and Goldsmith, 2 quoted in Chapters\\nXXIX. and LI. the obturator case is that of Duboue. 3 In the first\\nmentioned the femoral vein was torn and the patient died promptly\\nin Goldsmith s an aneurism involving the external iliac and femoral\\narteries formed, and was treated two months after the accident by liga-\\nture of the external iliac the patient died. In Duboue s case there\\nwas also fracture of the pelvis at the junction of the ilium and pubis,\\nbut without displacement the head of the femur rested upon the\\nischio-pubic branch of the pelvis rather below than upon the obturator\\nexternus the femoral vein was torn. The patient died.\\n1 Centralblatt fur Chirurgie, 1880, p. 504.\\n2 Goldsmith American Journal Of the Medical Sciences, July, 1860, p. 30.\\n3 Duboue Bull, de la Soc. Anatomique, 1858, p. 496.\\n754", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0836.jp2"}, "829": {"fulltext": "DISLOCATIONS OF THE HIP. 755\\nThe sciatic nerve in the autopsy of one dorsal dislocation 1 has been\\nfound stretched across the front of the neck of the femur, and in sev-\\neral dislocations produced experimentally upon the cadaver it has been\\nfound in the same position, but the only recorded instances within my\\nknowledge in which symptoms of injury to it have been present are a\\ncase reported by Jonathan Hutchinson 2 in which the muscles supplied\\nby it were paralyzed and remained so at the time of the report several\\nmonths after the accident, and one by Allis {The Hip) in which the\\nattempts to reduce were thought to have wound the nerve about the\\nneck of the femur.\\nAssociated fractures of the head, neck, and shaft of the femur, of\\nthe rim and floor of the acetabulum, and of different parts of the\\npelvis have been reported.\\nFracture of the head of the femur has been reported in four cases of\\ndorsal dislocation. 3\\nFracture of the neck of the femur occurring coincidently with the\\ndislocation or subsequently during an attempt to reduce has been\\nobserved a number of times. Wippermann 4 reported one case and\\ncollected thirteen others of which he gives abstracts, but his list\\nincludes one case (Hervez de Chegoire) which was probably a simple\\nfracture without dislocation, and Birkett s, in which the fracture was\\nof the head, and does not include a number of other reported cases;\\nthus, Hamilton quotes no less than twelve cases in which fracture was\\ncaused during an attempt to reduce, and of these YVippermann s paper\\ncontains only one. The only cases of which I have knowledge 5 in\\nwhich the neck appears certainly to have been broken at the moment\\nof dislocation are one reported by Tunnecliff, 6 one by Post 7 in which\\nboth hips were dislocated, and one by Lossen, 8 and even in the latter\\nthe patient was not seen by the reporter until six weeks after the acci-\\ndent the patient, an old man, was standing on a ladder when it fell,\\nhe struck upon his feet and then, with the injured side, against the\\nunderlying ladder, and Lossen supposed the dislocation to have been\\nproduced by the second blow. The head lay on the ilium the limb,\\nalmost consolidated, still showed signs of extracapsular fracture/\\nWhen Dr. Tunnecliff saw his patient a month after the accident he\\nwas inclined to doubt the existence of a fracture, but he felt forced to\\naccept the evidence as conclusive. He found the same shortening\\nand oblique position of the limb as described above. 7 On the thirty-\\neighth day after the accident reduction was effected by free manipula-\\ntion to break up the adhesions, followed by flexion and abduction with\\ndirect pressure on the head; the bone returned to the socket with an\\naudible snap, but as crepitus was felt it was thought that the union of\\n1 Quain: Medico-Chirurgical Transactions, 1848, vol. xxxi. p. 337.\\n2 Hutchinson Medical Times and Gazette, 1866, vol. i. p. 194.\\n3 Birkett, Medico-Chirurgical Transactions, 1869, p. 133; Moxon, Medical Times and\\nGazette, 1872, vol. i. p. 96 Riedel, Beilage zum Centralbl. far Chir., 1885, p. 92 Crile,\\nAnnals of Surgery, May, 1891.\\n4 Wippermann Arch, fur klin. Chirurgie, vol. xxxii. p. 440.\\n5 In Harcourt s and Chitwood s cases, quoted by Kammerer {vide infra), the diagnosis\\nis wholly untrustworthy De Morgan gives no details.\\n6 Tunnecliff: American Journal of the Medical Sciences, 1868, vol. lvi. p. 123.\\n7 Post New York Medical Record. 1878, vol. xiii. p. 366.\\n8 Lossen Deutsche Chirurgie, Lief. 65, p. 55.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0837.jp2"}, "830": {"fulltext": "756 DISLOCATIONS.\\nthe fracture had been destroyed. Five weeks later the patient could\\nwalk with one crutch, and measurement showed but half an inch short-\\nening of the limb. He has progressed favorably since that time.\\nPost s patient was a girl thirteen years old who, six months before\\nadmission, had received a blow upon the back with a twisting of the\\nbody to the right and the lower extremities to the left. Both hips\\nwere dislocated, and there was also fracture of the neck of the left\\nfemur, the head of which had become necrosed a sinus communicated\\nwith it as it lay on the dorsum ilii. The head was removed through\\nan incision, and the limb straightened. The right dislocation was\\nreduced by manipulation, and the patient became able to walk with\\ncrutches, the function of the right limb being fully restored, the left\\nbeing shortened four and one-half inches.\\nPossibly reduction might be effected by direct pressure upon the\\nhead under anaesthesia, but it seems unlikely. Possibly, also, reduc-\\ntion could be made by pressure through a posterior incision exposing\\nthe head, but as the usefulness of the limb, after reduction, would\\ndepend largely upon the preservation of the vitality of the head and\\nits union with the shaft, and as this depends upon the preservation of\\nthe continuity of a sufficient amount of the periosteum, it is by no\\nmeans certain that all cases are fit for reduction or that they would\\nremain so after the cutting necessary to effect it. The fact that in\\nthree cases the head became necrotic shows that the laceration of the\\nperiosteum when the fracture is through the narrow part of the neck\\nis probably greater than in similar fracture without dislocation. The\\nalternatives would be to await consolidation and then seek to reduce,\\nas in TunneclifFs case, or to seek a pseudarthrosis at the seat of frac-\\nture, or to correct the attitude of the limb and seek union with a view\\nto the formation of a new socket for the head on the ilium, or to excise\\nthe head if the fracture is near it. Possibly McBurney s hook could\\nbe advantageously used in fracture at the base of the neck, or even\\nin fracture through the neck, making the incision in front.\\nFracture of the shaft of the femur, occurring coincidently with its\\ndislocation, has been observed a few times. Hamilton collected four\\ncases, those of Bloxham, 1833, Thornhill, 1836, Eteve, 1838, and\\nMarkoe, 1853, in all of which it is claimed that reduction was effected.\\nHe rejects Thornhill s claim as altogether incredible, and doubts\\nif a dislocation existed in Markoe s. In Bloxham s and Eteve s the\\nfracture was near the middle of the shaft, in Thornhill s in its upper\\nthird, and in Markoe s the site is not mentioned. In Bloxham s the\\ndislocation was on the pubis, and was reduced on the seventh or eighth\\nday by traction with pulleys, the limb having been secured with splints,\\nand by direct pressure on the head of the bone. In Eteve s the dis-\\nlocation was backward, and reduction was effected by making slight\\ntraction upon the upper part of the flexed thigh, and by direct pressure\\non the head of the bone.\\nTo these may be added Cooke s case of obturator dislocation with\\nfracture just below the trochanter, quoted in Chapter LIL, Cooper s\\nof dorsal dislocation with fracture at the middle of the shaft, and\\nDelagarde s of backward dislocation with double fracture of the shaft..", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0838.jp2"}, "831": {"fulltext": "DISLOCATIONS OF THE HIP. 757\\nCooke s patient was nine years old, and reduction was easily effected\\nby direct pressure on the head. Cooper s 1 patient was a lad sixteen or\\neighteen years old as the reduction of the hip was, of course, im-\\npracticable, union of the fracture was alone sought at first, and after\\nrive weeks, the bone appearing tolerably firm, careful extension by\\npulleys was made for half an hour, and was successful. He also\\nquotes 2 another case in which reduction was not made.\\nIn Delagarde s 3 case the dislocation was backward, and the shaft was\\nbroken in two places. The dislocation remained unreduced, and the\\nhead was subsequently excised.\\nKammerer 4 reported a suprapubic case with fracture between the\\nupper and middle thirds in which reduction was not made, and col-\\nlected twelve other cases of fracture of the shaft with various disloca-\\ntions.\\nPossibly reduction might be effected in dorsal cases by using the\\nweight of the limb to make traction in the prone position, as described\\nin Chapter LI., and in other forms traction, with pressure on the head,\\nshould be tried; this failing, McBurney s hook (Fig. 281) should cer-\\ntainly be tried, as it involves less laceration and gives better control\\nthan forceps applied through an incision.\\nAssociated fracture of the pelvis, usually of the rami of the pubis\\nand ischium, and sometimes extending into the acetabulum, has been\\nreported. It has always been caused by great violence acting directly\\nupon the patient, and has usually been combined with other injuries\\nwhich have proved fatal.\\nDetachment of the Labrum Cartilagineum. Zinner 5 reports a case of\\ndorsal dislocation complicated by a double vertical fracture of the\\npelvis extending from the pectineal eminence through the margin of\\nthe acetabulum to the tuber ischii and through the inner border of the\\ninferior ramus of the pubis, and by detachment of the labrum carti-\\nlagineum the latter was entirely torn away, with the exception of a\\nsmall piece at its upper outer part, and, with its ends twisted about\\neach other, was wedged between the outer margin of the acetabulum\\nand the neck of the femur and prevented reduction. The ligamentnm\\nteres was torn from the acetabulum and remained attached to the head\\nof the femur and to the labrum. Detachment of a portion is prob-\\nably not rare.\\nSIMULTANEOUS DISLOCATION OF BOTH HIPS.\\nSimultaneous dislocation of both hips has been reported in about\\nthirty cases. 6 Usually the dislocation is not the same on both sides,\\nbut if backward upon the ilium in one it is forward upon the obtura-\\n1 Cooper Dislocations and Fractures, American edition, 1844, p. 40.\\n2 Cooper Loc. cit., p. 41.\\n3 Delagarde St. Bartholomew s Hospital Eeports, 1866, vol. ii. p. 183.\\n4 Kammerer New York Medical Journal, February 16, 1889.\\n5 Zinner: Zeitschrift fiir Heilkunde, vol. viii. p. 121; abstract in Centralblatt furChir.,\\n1888. p. 55.\\n6 For bibliography of 26 cases see Niehans, Deutsche Zeitschrift fiir Chirurgie, 18S8.\\nvol. xxvii. p. 467 also a double dorsal dislocation, Pfeiffer, in Boston Medical and Surgi-\\ncal Journal, August 4, 1887.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0839.jp2"}, "832": {"fulltext": "758 DISLOCATIONS.\\ntor foramen or upon the pubis in the other. The common cause is a\\nheavy blow received upon the back or side while the patient is bending\\nforward, by which he is twisted to one side, so that one thigh is abducted\\nand the other adducted. Of this mode of production Boisnot s l case\\nis a good example a bale of goods fell upon a powerful man, forty\\nyears old, striking him upon the left side of the head and neck, and\\nbending him to the right, and caused a dorsal dislocation on the left\\nside, and a suprapubic one on the right. In Barker s case, quoted in\\nChapter LI I., both dislocations were obturator, and were caused by a\\nfall from a height of about thirty feet upon a sand bank, the patient\\nstriking upon his feet and having them widely separated. In Schin-\\nzinger s 2 case, dorsal on one side and suprapubic on the other, it was\\nthought the latter might have been caused by the efforts of the by-\\nstanders to drag the patient from under the bank of earth that had\\nfallen upon him.\\nSimultaneous dislocations of the left hip backward and of the right\\nknee forward and upward were reported by Brittain, 3 and of the knee\\nand hip of the same side by Hulke. 4\\nACCIDENTS CAUSED BY ATTEMPTS TO REDUCE.\\nBefore the use of ether and chloroform to obtain anaesthesia, and\\nthe general substitution of milder methods in the place of forcible\\ntraction by pulleys, it w T as not rare for severe inflammatory reaction,\\nand even suppuration, to follow reduction or the attempt to reduce, or\\nfor the patient to die in consequence of the shock and exhaustion pro-\\nduced by the efforts of the surgeon. Cooper 5 says there are plenty\\nof cases on record of fatal abscesses from violent attempts at the\\nreduction of dislocated hips. Such consequences are now extremely\\nrare, but, even when forcible traction or other violent manipulations\\nhave not been employed, they must still be expected occasionally to\\noccur as the result in part at least of the original traumatism.\\nFracture of the neck or even of the shaft of the femur has been\\ncaused in a number of cases by the surgeon in his efforts to reduce,\\neither by forcible traction or by manipulation. Although in modern\\nmethods but little force, comparatively, is applied by the surgeon, yet\\nit must be remembered that the force is habitually applied on the long\\narm of a lever of which the neck of the femur is the short arm, and\\nthe fracturing strain upon the latter is thereby greatly augmented.\\nThe fracture, apparently, takes place more frequently during rotation\\nor abduction than during the flexion of the limb. In most of the\\nreported cases the account is limited to the circumstances attending\\nthe fracture, and no mention is made of the subsequent course of the\\ncase. Of the 14 cases collected by Wippermann (vide supra), includ-\\ning also the one in which the fracture occurred simutaneously with\\nthe dislocation and another in which it probably did, the final result is\\n1 Boisnot: American Journal of the Medical Sciences, October, 1867, p. 396.\\n2 Schinzinger Wiener med. Presse, 1880, quoted by Kronlein.\\n3 Brittain London Medical Gazette, 1836, vol. xviii. p. 257.\\n4 Hulke British Medical Journal, 1883, vol. ii. p. 1.\\n5 Cooper Loc. cit., p. 33.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0840.jp2"}, "833": {"fulltext": "DISLOCATIONS OF THE HIP. 759\\nindicated in 9 of these consolidation of the fracture took place in 3\\nand failed in 6, and in two of the latter (Czerny, Bryck), in both of\\nwhich the fracture was secondary and through the narrow part of the\\nneck, an abscess formed, from which the necrotic head of the femur\\nwas subsequently removed. See also Kammerer, supra.\\nFractures produced during moderate manipulation in recent cases\\nshould be treated in accordance with the considerations affecting the\\ntreatment of simultaneous fracture and dislocation.\\nIn Stokes s fatal case of suprapubic dislocation, in which death was\\nattributed to pulmonary embolus, it is impossible to say whether the\\nfatal result was due to the traumatism or to the reduction. If it was\\ndue to pulmonary embolus the clot must have formed before reduction\\nwas attempted, and the latter could only have caused its detachment.\\nIn a case of fresh dorsal dislocation that came under my care in\\nBellevue Hospital in 1886, death occurred an hour and a half after\\nthe accident and half an hour after easy reduction by the weight of\\nthe limb in the prone position, without anaesthesia. The patient was a\\nmuscular young man, a worker in a brewery, and the dislocation was\\ncaused by a fall from a wagon. He was brought to the hospital within\\nan hour after the accident, and presented marked symptoms of shock\\nrestlessness, sighing, cool surface, small pulse. No autopsy.\\nPROGNOSIS AND AFTER-TREATMENT.\\nThe prognosis after reduction in uncomplicated cases is favorable,\\nthe patients usually regaining good use of the limb. The inflamma-\\ntory reaction is usually slight, and other treatment than rest in bed\\nfor two or three weeks is rarely required. Occasionally there is a\\ntendency to recurrence which needs to be combated either by slight\\npermanent traction upon the limb or by keeping it in an attitude that\\nis unfavorable to recurrence, extension, abduction, and outward rota-\\ntion after a dorsal dislocation.\\nIf reduction is not made the patient will be permanently crippled\\nto a greater or less degree. Usually a new articular socket is formed\\nby bony outgrowths about the head which permits some motion, and\\nthe principal disability is due to the attitude of the limb, to its lack\\nof parallelism with the other, and to the necessity of tilting and curv-\\ning the spine in order to bring the foot to the ground but in a few\\ncases patients have also suffered from persistent pain aggravated by\\nuse, and even from numbness or paralysis due to pressure on a nerve.\\nIn the dorsal dislocations the attitude of the limb, flexion and abduc-\\ntion, adds considerably to the actual shortening, and the patient may\\nbe unable to walk without crutches or a support attached to the sole\\nof the shoe. In unreduced suprapubic, supracotyloid, and obturator\\ndislocations the attitude is often less faulty and in a number of cases\\nthe limb has been very serviceable.\\nHABITUAL DISLOCATIONS.\\nA considerable number of cases have been reported in which the\\nhip could be voluntarily dislocated by muscular contraction or by", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0841.jp2"}, "834": {"fulltext": "760 DISLOCATIONS.\\nslight pressure upon the foot when the limb was placed in a certain\\nattitude, or in which the dislocation recurred involuntarily during use\\nof the limb. Perier 1 collected fifteen cases, more or less authentic,\\nincluding one observed by himself and exhibited to the Societe de\\nChirurgie, and Hamilton nine additional ones. In some the peculi-\\narity clearly followed a traumatic dislocation, in others it was the con-\\nsequence of congenital or acquired alterations in the constituent parts\\nof the joint. Only the former will be here considered, the latter\\nbelonging more strictly in the classes of spontaneous or pathological\\ndislocations.\\nThe two most satisfactory examples are one observed by Bigelow 2\\nand another quoted by him from a report furnished by Dr. E. M.\\nMoore both were dorsal. In Bigelow s case the hip was dislocated\\nwhile the legs were crossed, a wagon in which the man was riding\\nhaving pitched into a hole. In a few hours the hip was reduced by\\nflexion. Eight days after the accident, in attempting to walk upon\\nthe limb, it was again partially luxated, when the patient himself\\nreplaced it by pushing against it with one hand and pressing with the\\nother against his knee. Since that time both luxation and reduction\\nhave been comparatively easy, and the patient now displaces the head\\nof the bone backward upon the edge of the socket by muscular action,\\nand reduces it by throwing the leg out sidewise. The luxation is\\nsometimes attended with pain, and the prominence caused by the head\\nof the luxated bone is sensitive to the touch. The displacement is\\nrather a subluxation, and the limb exhibits slight flexion, shortening,\\nand inversion.\\nDr. Moore s patient was a soldier, who, while skirmishing up a\\nhill, sprang back suddenly to avoid the gun of a comrade in advance.\\nHis left foot became entangled, and his weight dislocated his hip. He\\nfelt the injury, and supposed it out of joint. Some comrades pulled\\nit in. He immediately resumed skirmishing, and marched seven miles,\\nfrom 10 A.M. until 6 p.m. He lay down at night, and went on duty\\nthe next day, sharp-shooting, crawling all day. He continued this\\nkind of duty five days, and returned to camp, when he was imme-\\ndiately put in intrenchments, and worked two days and two nights.\\nAfterward he went on picket, and entered the hospital on the sixteenth\\nday after the accident. At present he can luxate the hip-joint at any\\ntime, and does it by pressing the foot on the floor to fix it firmly, con-\\ntracting the adductors, and throwing out the pelvis. The head sud-\\ndenly leaves the acetabulum and goes on the dorsum ilii.\\nAs no autopsy has been reported in any such case, the explanation\\nof the peculiarity can only be inferred. It is probable that the rent in\\nthe capsule is insufficiently repaired, and the edge of the acetabulum\\nlowered at the point where the head of the femur escapes.\\nTREATMENT OF OLD, UNREDUCED DISLOCATIONS.\\nThere is the same uncertainty in old dislocations of the hip as in\\nthose of other joints, as to the length of time after which reduction\\n1 Perier Bull, de la Soc. de Chir., 1859, vol. x. p. 12. 2 Bigelow: The Hip, p. 112.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0842.jp2"}, "835": {"fulltext": "DISLOCATIONS OF THE HIP. 761\\nshould not be attempted. Cases have been reported in which reduc-\\ntion has been effected after the lapse of many weeks, or even months\\nSir Astley Cooper 1 reports a case in which reduction was said to have\\nbeen produced by a fall after the lapse of five years the only evidence\\nof reduction is that a loud crack was heard at the time of the fall, and\\nthat the patient when met in the street a few weeks later, walked with-\\nout limping.\\nHamilton collected fifteen cases in which it was claimed that reduc-\\ntion had been successfully accomplished after the lapse of long periods,\\nand shows that but few, if any, of them can be deemed trustworthy\\nin a number of them the dislocation was clearly not traumatic, and in\\nthe others the reports are brief and unsatisfactory. Sir Astley Cooper s\\nstatement that eight weeks was the period after which it would be\\nimprudent to attempt reduction has been taken rather too literally,\\nand the sounder judgment is that the question is to be determined by\\nother facts than the simple length of time that has elapsed, such as\\nthe distance of the head from the acetabulum, its mobility, the degree of\\nthe inflammatory reaction, the usefulness of the limb, and the health or\\nconstitution of the patient. The reasons which have been elsewhere\\ngiven when considering the same question with reference to other joints\\nare equally applicable to the hip, and forbid, in my judgment, forcible\\nattempts by traction and manipulation.\\nThe special measures that have been employed either to effect reduc-\\ntion or to improve the functional condition of the limb are open\\narthrotomy, osteotomy or fracture of the neck or shaft, and excision\\nof the head or of the head, neck, and trochanter.\\nThe first is applicable to relatively recent cases which are thought to\\nbe not absolutely irreducible, to be supplemented in case of failure by\\nexcision. The others are applicable to older cases, as palliative measures\\ndesigned to improve the position of the limb and make it movable.\\nOpen arthrotomy has been tried in 30 cases, 2 in 11 reduction was\\neffected, in 19 it failed and resort was had to excision in 18 and to\\nosteotomy in 1. Of the 11 cases in which reduction was made, a good\\nor fair functional result followed in 8, 1 died of sepsis, in 1 the head\\nof the bone became necrotic and was removed, and in 1 recurrence\\ntook place. Almost all the cases belong to the antiseptic period they\\nshow, unless the operative methods have been faulty, that reduction is\\nimpracticable in about two-thirds of all cases and must then end in\\nexcision, osteotomy, or abandonment. The danger to life in the\\nattempt is probably not fully shown by the statistics, for the fatal cases\\nare more likely than others to go unpublished. I know of one fatal\\ncase, about 1896, that is not included in the list; the operation was\\nlong and difficult, and the patient died in a few hours. Almost all\\nthe operations in the dorsal cases, which are the great majority, were\\ndone by a posterior or external incision which does not give easy\\naccess to the joint and to the parts which presumably most oppose\\n1 Cooper Loc. cit., p. 81.\\n2 For bibliography see 1st edition Kirn, Beitrage zur klin. Chir., 18S9, vol. iv. p. 537\\nHarris, Annals of Surgery, September, 1894 En gel, Arch, fiir klin. Chir., 1897, p. 629\\nand Sajous Annual, passim.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0843.jp2"}, "836": {"fulltext": "762 DISLOCA TIONS.\\nreduction I am, therefore, disposed to believe that the anterior\\napproach recommended by Fiorani and employed by Vecelli (Kirn)\\nwith division of the Y-ligament close to the femur would make reduc-\\ntion easier, but it might favor recurrence.\\nExcision of the head, or of the head, neck, and trochanter, has been\\nreported in the 18 cases above mentioned, after an attempt to reduce,\\nand in 9 others. 1 In Paci s the division was made below the trochan-\\nter. Two died in the others the functional result is generally reported\\nas good or fair.\\nOsteotomy, through or below the neck, has been done by Van Wahl\\nand Kock 2 and by Yilleneuve 3 after failure to reduce by arthrotomy\\nin two the reported result was good, in the third (Kock) the bone\\nhealed in a faulty position.\\nIn deciding w T hether or not to interfere in an old case, and in choos-\\ning a method if interference is determined upon, several things beside\\nthe mere fact of the existence of the dislocation must be considered. If\\nthe limb is useful, if the patient is not suffering from pressure effects,\\nand if he is no longer young, prudence will often dictate abstention.\\nQuieta non movere Or, at the most, an osteotomy may be done to\\nbring the limb into a more convenient and serviceable position. If the\\npatient is younger, if the disability is greater, if the position of the\\nhead causes serious pressure effects, reduction by arthrotomy may be\\nattempted, preferably, I think, by an anterior incision, with the deter-\\nmination to abandon the attempt if it proves difficult and to substitute\\nexcision. But the surgeon must carefully consider the present useful-\\nness of the limb, the probability of the usefulness that will follow the\\ninterference, and the risk to life incurred in the attempt to improve.\\nSubcutaneous fracture of the neck has never, so far as I know, been\\nintentionally done to correct a vicious position of the limb, but in a\\nnumber of cases in which it has occurred during an attempt to reduce\\nit lias been utilized for this purpose and w 7 ith good results, although,\\nas above mentioned, necrosis of the head of the femur has twice ensued.\\nCONGENITAL DISLOCATIONS.\\n(See Chapter XXXV.)\\nSPONTANEOUS OR PATHOLOGICAL DISLOCATIONS.\\nAlmost all the different kinds of spontaneous dislocation have been\\nobserved at the hip, and many of them with a frequency that has not\\nbeen observed at other joints. The weight of the body in w r alking is\\na factor of much importance and constantly at work, the effect of\\nwhich is well shown in three cases reported by Liicke, 4 in which the\\n1 Delagarde, St. Bartholomew s Hospital Keports, 1866, vol. ii. p. 183; Sydney Jones r\\nLancet, 1884, vol. ii. p. 870 Ratirnow, St. Petersburg Med. Woehen., Julv 30, 1888; Graziana,\\nCentralblatt fur Chir., 1890, p. 244 Karumerer, Medical Record, March 4, 1893 Flower,\\nBritish Medical Journal, Nov. 2, 1895; Browne, Ibid., February 15, 1896; Ostermayer,\\nCentralblatt fur Chir., Mav 11, 1895: Paci, Arch. Italian de Pediat., vol. vii.\\n2 Van Wahl and Kock Berlin, klin. Woch., 1882, p. 492.\\n3 Villeneuve Eev. d Orthopedie, 1892, p. 161.\\nLiicke Quoted by Forgue and Maubrac, Luxations pathologiques, Paris, 1886, p. 15.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0844.jp2"}, "837": {"fulltext": "DISLOCATIONS OF THE HIP. 763\\ndislocation followed rhachitic changes in the shape of the femurs and\\nthe spinal column. The patients were children who, at birth and\\nduring infancy, showed no sign of dislocation after a time rhachitic\\nchanges occurred, the displacement appeared and walking became\\ndifficult. Lucke found a marked lumbar lordosis and anterior curva-\\nture of the femurs the trochanters were displaced far backward, and\\nthe dislocation was evident. He thought the curvature of the femurs\\nwas the primary change, and the lordosis compensatory of it, and that\\nthe dislocation was due to changes in the acetabulum following the con-\\nsequent pressure at an unusual point.\\nOf similar character are those cases in which the dislocation has\\ntaken place in a healthy joint in consequence of the prolonged main-\\ntenance of some exceptional attitude, as in a case reported by Franks 1\\nof a child five years old, who had been confined to the bed for many\\nmonths by an arthritis of the left hip, and had lain upon its left side\\nwith the knees and hips flexed, and the right hip adducted a dorsal\\ndislocation took place without pain on the right side. Here the con-\\ntraction of the muscles takes the place of the weight of the body in\\nproducing the dislocation when the limb is long held in a favorable\\nattitude, and many examples of this effect have been reported in cases\\nin which the joint was the seat of an arthritis, as in acute articular\\nrheumatism, or in continued fevers, typhoid, scarlatina, in which usu-\\nally there are indications of inflammation of the joint, although in\\nsome cases attention was first called to the joint by the appearance of\\nthe deformity. As the individual usually lies with the thigh flexed\\nand adducted, the dislocation almost always takes place backward and\\nupward but in a case observed by Stromeyer, 2 a man eighteen years\\nold, affected with acute articular rheumatism, especially of the hip,\\nduring the entire course of which he had lain on his side, the disloca-\\ntion was into the obturator foramen.\\nParalytic or myopathic dislocations of the hip, those in\\nwhich the displacement is effected by the unopposed contraction of cer-\\ntain muscles or groups of muscles, whose antagonists are paralyzed,\\nhave been most frequently seen as a consequence of infantile paralysis.\\nAs has been shown in Chapter XXXVI. they were formerly con-\\nfounded with congenital dislocations, and were first clearly separated\\nfrom them by Verneuil, 3 and afterward studied in detail by some of\\nhis pupils, especially Reel us. 4 When the paralysis involves all the\\nmuscles of the hip the joint becomes loose, and the femur may be dis-\\nplaced and replaced at will, but when only a part of the muscles are\\nparalyzed the contraction of the others leads to a permanent displace-\\nment. If the posterior muscles are paralyzed, and the adductors\\nremain in good condition, the dislocation is dorsal if the adductors\\nare paralyzed and the glutei remain sound, the dislocation is forward\\nupon the pubis. One of the cases observed by Reclus may be taken\\nas a good example of one form a child, which had previously been\\n1 Franks: Lancet, 1883, vol. ii. p. 15.\\n2 Stromeyer Handbuch der Chir., 1844, vol. i., quoted by Forgue and Maubrac.\\n3 Verneuil Bull, de la Societe de Chirurgie, 1866.\\n4 Eeclus Eevue de Med. et Chir., 1878, p. 176.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0845.jp2"}, "838": {"fulltext": "764 DISLOCATIONS.\\nhealthy and well formed, was attacked at the age of seven years with\\nhigh fever and a paralysis which, at first general, became localized in\\nthe glutei and the other pelvi-trochanteric muscles the other groups,\\nespecially the adductors of the thigh, recovered their activity a well-\\nmarked dorsal dislocation followed. 1\\nIn a case reported by Bradford, 2 a girl, eighteen months old, the\\nright thigh Avas flexed and abducted at a right angle, the adductors\\nwere paralyzed, the glutei and tensor vaginse femoris sound. The head\\nof the femur could be felt in the groin upon the superior ramus of the\\npubis midway between the symphysis and the anterior superior spine\\nof the ilium. Reduction was effected, but the limb remained almost\\npowerless.\\nThe cases should be treated by prompt reduction, if possible, and\\nthe maintenance of the limb in an attitude that opposes recurrence.\\nIn three cases reported by Roser 3 in 1885, at the Congress held at\\nStrasburg, the paralysis was due to spinal disease in one of them the\\npatient produced the dislocation by swinging his legs forward while\\nwalking with crutches in the other two the dislocation took place in\\nbed without appreciable cause.\\nThe limitation of the paralysis to one group of muscles is to be\\nexplained by the fact that the adductors are supplied by the obturator\\nnerve, a branch of the lumbar plexus, and the posterior muscles by\\nbranches of the sacral plexus, and that the medullary centres of these\\nnerves are at different points in the cord, that of the former being at\\na higher point than the other, probably at the upper part of the lumbar\\nenlargement.\\nDislocations due to destruction of the bony parts of the joint by\\ntubercular disease are comparatively common their consideration\\nbelongs rather to the subject of disease of the hip-joint.\\nIn like manner the consideration of those dislocations which follow\\nchanges in the bones produced by chronic rheumatism or dry arthritis\\nor in ataxia belongs to works upon those subjects. The alterations in\\nthe shape of the bones, either by atrophy or by hypertrophy, are\\nso marked that reduction or maintenance of reduction is impossible.\\nIn dry, or deforming, arthritis not only are all the constituent parts of\\nthe joints involved in the changes, but the muscles also become degen-\\nerated the bones are usually hypertrophied by outgrowths at the bor-\\nders of the articular surfaces, they lose their articular cartilage, and\\nbecome eroded at points of contact. The changes in locomotor ataxia\\nare characterized by early and rapid atrophy of the head and neck of\\nthe femur with destruction to a greater or less extent of the rim of the\\nacetabulum. Sometimes dislocation takes place abruptly with well-\\nmarked and characteristic symptoms in other cases the symptoms are\\nmore like those of fracture of the neck of the femur, the foot is everted\\nand the trochanter raised, but the movements are exceptionally free\\nand may be painless.\\n1 See paper by Karewski, Arch, far kliu. Chir., 1888. vol. xxxvii. p. 346.\\n2 Bradford Boston Medical and Surgical Journal, 1883, vol. cviii. p. 73.\\n3 Eoser Quoted by Forgue and Maubrac, loc cit., p. 43.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0846.jp2"}, "839": {"fulltext": "CHAPTER LIV.\\nDISLOCATIONS OF THE KNEE.\\nForward Backward Lateral Antero-lateral By Rotation Dislocation of\\nthe Semilunar Cartilages Congenital Spontaneous or Pathological Dis-\\nlocations.\\nAnatomy.\\nThe knee-joint may be regarded as composed of two joints, of\\nwhich one is formed by the patella and femur, the other by the femur\\nand tibia and the latter is composed of two parts, differing somewhat\\nfrom each other, each of which is formed by one of the condyles of the\\nfemur and the corresponding portion of the upper surface of the tibia.\\nThe condyles of the femur are separated from each other by the inter-\\ncondylar notch, and between the condylar surfaces of the tibia is a\\ndepression which is interrupted in the centre by the spine.\\nThe ligaments which bind the femur to the tibia and fibula are the\\nexternal and internal lateral, the posterior, and the crucial. The\\ninternal lateral ligament, long and flat, extends from the internal\\ntuberosity of the femur to the inner side of the shaft of the tibia the\\nexternal lateral, more rounded and cord-like, extends from the exter-\\nnal tuberosity of the femur to the head of the fibula, overlying the\\ntendon of the popliteus above and being embraced by the tendon of the\\nbiceps below. The short external lateral ligament, lying somewhat\\nmore deeply and posterior to the other, is attached above to the\\nside of the condyle and below to the styloid process of the fibula. The\\nposterior ligament is attached above to the upper part of the intercon-\\ndylar fossa of the femur and below to the posterior margin of the\\nhead of the tibia. The crucial ligaments extend from either side of\\nthe intercondylar notch to the depression in front of and behind the\\nspine of the tibia. In full extension of the knee these ligaments are\\nmade tense, but in flexion at a right angle the lateral ones, especially\\nthe external lateral, are relaxed.\\nThe semilunar fibro-cartilages are intra-articular structures attached\\nto the head of the tibia at their outer margins and ends and having\\nfree smooth surfaces above and below they are triangular on vertical\\nsection, the peripheral border being thick, the central thin as they are\\nrings, not disks, each leaves the corresponding condylar surface of the\\ntibia uncovered at the centre. The internal one is semicircular, and\\nits ends are attached in front of and behind the spine of the tibia\\nrespectively the external one is nearly a complete circle, and its- ends\\nare attached to the spine of the tibia between those of the internal one,\\nits posterior end is also attached to the inner condyle of the femur in\\nconnection with the posterior crucial ligament. The external cartilage\\n765", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0847.jp2"}, "840": {"fulltext": "766 DISLOCATIONS.\\nis movable upon the tibia, this freedom of motion being utilized in the\\noutward rotation of the leg which occurs at the end of extension, while\\nthe internal one is more fixed and serves mainly to make a more con-\\ncave surface for articulation with the internal condyle of the femur.\\nThe anterior borders of the two cartilages are connected together by\\na slight transverse band, the transverse ligament; it is sometimes\\nlacking.\\nThe capsular membrane fills the gaps between the ligaments and\\nthose portions which extend from either side of the patella to the\\nfemur and tibia in connection with the vasti muscles and the fascia lata\\nare called the lateral ligaments.\\nThe synovial membrane extends well up on the front of the thigh,\\nfrequently communicating with a bursa under the quadriceps, and\\ninvests the crucial ligaments by a reflection from the posterior wall.\\nBetween the tibia and patella it rests upon a mass of fat, forming two\\nlateral folds, the alar ligaments, and sending backward from its middle\\nanother fold, the ligamentum mucosum, which is attached to the front\\nof the intercondylar notch. By these folds and the crucial ligaments\\nthe joint is divided into three more or less freely communicating com-\\npartments.\\nFunctionally, the femoro-tibial joint is a ginglymo-arthrodial, its\\nmovements being effected by a combination of gliding, rolling, and\\nrotation of the bones upon each other. In complete extension no rota-\\ntion is possible, but as the knee is flexed outward rotation appears and\\nincreases, reaching 21 degrees at rectangular flexion and 31 degrees at\\nflexion 30 degrees within a right angle. (Mayer.)\\nIn complete extension the patella rests upon the upper part of the\\ntrochlear surface of the femur, and as flexion is made it moves down-\\nward and is gradually turned outward by the increasing prominence of\\nthe internal condyle, so that at the last it rests by its upper and outer\\nfacet on the front of the external condyle and by its inner facet against\\nthe narrow surface of the outer margin of the internal condyle. As\\nthe movement of extension approaches its limit the tibia undergoes\\nslight outward rotation in which the external semilunar cartilage does\\nnot participate, that is, the outer condylar surface of the tibia moves\\nbackward under the fibro-cartilage correspondingly, when flexion is\\nbegun from the position of complete extension it is accompanied by\\ninward rotation of the tibia. The limitation of extension is affected\\nby the posterior and lateral ligaments, that of flexion by the contact of\\nthe soft parts of the calf and thigh and of the posterior margin of\\nthe semilunar cartilages with the back of the condyles of the femur.\\nDisplacement of the tibia forward, backward, or to either side is op-\\nposed by the lateral and crucial ligaments.\\nStatistics.\\nDislocations of the knee, of the femoro-tibial joint, are rare, con-\\nstituting about 1 per cent, of all cases. They are divided according\\nto the direction in which the tibia is displaced into for ward, backward,\\noutward, and inward dislocations, and dislocations by rotation. Mai-", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0848.jp2"}, "841": {"fulltext": "DISLOCATIONS OF THE KNEE. 767\\ngaigne made additional groups of intermediate forms. The disloca-\\ntion may be complete or incomplete, simple or compound. A tabula-\\ntion which I made by the aid of the references to periodical literature\\nin the Index- Catalogue of the Surgeon- General s Library showed that\\nof 114 traumatic cases the dislocation was forward in 52, backward\\nin 34, outward in 21, inward in 4, lateral in 1, and by rotation\\nin 3. In 21 of them the dislocation was compound; 11 forward, 4\\nbackward, 6 outward.\\nThe injury is very rare in childhood, the two youngest patients in\\nmy list being aged ten and eleven respectively it is of exceptional\\ngravity because of the size of the joint, because it is usually caused by\\ngreat violence, and because of the frequency with which it is compound\\nand with which the popliteal vessels are injured. Amputation has been\\nresorted to in a large proportion of cases. Simultaneous dislocation\\nof both knees has been observed in a few cases.\\nDISLOCATIONS FORWARD.\\nThese may be complete or incomplete, simple or compound. The\\ncomplete seem to be very much rarer than the incomplete the com-\\npound occur in an exceptionally large proportion, over 21 per cent.\\nin the tabulation just given, and the wound is habitually made by\\nrupture of the soft parts posteriorly w T here they are stretched\\nacross the projecting condyles of the femur in hyperextension of\\nthe leg.\\nThe cause may be either hyperextension of the leg, or violence\\nreceived upon the front of the thigh or the back of the leg near the\\nknee. The former appears to be much the more common in it the-\\ntibia turns upon its anterior margin as a centre, putting the posterior,\\nlateral, and crucial ligaments upon the stretch, and after their rupture\\nit glides forward along the condyles, or the condyles slide backward\\nalong it. The hyperextension may be produced by a force applied to\\nthe back of the leg or foot, or, more commonly, by the propulsion of\\nthe trunk and thigh while the leg is held stationary and upright\\nthus, a man running down a hill steps into a hole, the leg entering to\\nits upper third, and falls forward. In a case of my own the patient,\\na large heavy man, was standing in an elevator which was sud-\\ndenly stopped while descending rapidly; he received the dislocation\\nwithout falling or being struck, apparently by hyperextension of the\\nknee. The tibia overrode the femur one and a half inches. The\\nother cause, direct violence, may act upon the front of the knee while\\nthe leg is either extended or partly flexed. In another set of cases,\\nof which I have met with the records of four examples, the mode of\\nproduction is not clear the patients were caught in rapidly revolving\\nwheels or shafts and whirled around many times, the body passing at\\nsome part of its course through a narrow space in three of these cases\\nboth knees were dislocated, in two of them one dislocation being for-\\nward, the other backward, and in the third one dislocation was forward\\nand the other inward.\\nIn a case of my own in which the patient was similarly caught by", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0849.jp2"}, "842": {"fulltext": "768 DISLOCATIONS.\\na shaft he was wedged against the ceiling, but not carried through,\\nreceiving forward dislocations of both knees, one compound on the\\ninner side with rupture of all the internal hamstring muscles through\\ntheir fleshy parts well above the joint. He made a good recovery, but\\neight months later paralysis of the external popliteal group persisted\\non one side, and control of the knee was defective on the side on which\\nthe muscles had been torn. With the aid of a brace for that knee and\\na rubber muscle for the paralyzed anterior tibial group he was able to\\nwalk and work.\\nIn a case reported by Cotton l the ligaments of the joint had gradu-\\nally grown so weak that the knees bent backward as the patient got\\nout of bed one morning a compound dislocation, with rupture of the\\npopliteal artery, was produced.\\nPathology. In the incomplete form, that in which the upper articu-\\nlar surface of the tibia is still in contact by its posterior portion with\\nthe inferior surface of the condyles, the injury to the ligaments and\\nother soft parts appears to be slight in the only autopsy, one reported\\nby Desormeaux, 2 the anterior crucial ligament alone was torn, and that\\nonly in part. In the complete form, on the other hand, the injuries\\nare very extensive one or both lateral ligaments, one or both crucial,\\nthe posterior, and the lateral ligaments of the patella are completely\\nruptured or widely torn. The posterior muscles, the biceps, gastrocne-\\nmius, popliteus, even the soleus and vastus internus are lacerated or\\ndivided the internal and external popliteal nerves may be torn or\\nbruised, the popliteal artery and vein ruptured, the skin of the poplit-\\neal space torn through. Sometimes the ligaments are ruptured, some-\\ntimes they are torn from the femur, perhaps bringing with them\\nportions of the bone the protruding condyles appear sometimes as if\\nthey had been cleaned with a knife. The overriding of the tibia and\\nfemur may amount to two or even three inches in Mayo s 3 it was said\\nto be fully four inches.\\nThe injuries to the popliteal artery are of exceptional interest and\\nimportance. Its inner and middle coats may be torn completely across\\n(Annandale, Cotton, Knichynicki, 4 Lowe, 5 two cases, Vevers, 6 and\\nStewart and Turner, quoted by Spillmann in most of them the dislo-\\ncation was compound); or, as in a case examined by Malgaigne, there\\nmay be several small rents at atheromatous, calcareous points. The\\nartery may be simply compressed and remain competent to perform its\\nfunctions when the pressure is removed (Davis, 7 Hixon 8 or it may\\nbe so bruised that a thrombus will subsequently form (Brittain). The\\npopliteal vein appears from the reports to have been less frequently\\ntorn, but when bruised it also may become occupied by a thrombus.\\nIt seems probable that in the cases in which gangrene followed the\\nvein as well as the artery was injured. The opportunities for direct\\n1 Cotton Proceedings of the Connecticut Medical Society, 1S80, vol. ii. p. 54.\\n2 Desormeaux Bull, de la Soc. de Chirurgie, 1853, vol. iii. p. 367.\\n3 Cooper Loc. cit., p. 187.\\n4 Knichynicki Allg. Wiener med. Zeitung, 1873, vol. xviii. p. 255.\\n5 Lowe St. Bartholomew s Hospital Reports, 1869, vol. v. p. 80.\\n6 Vevers Lancet, 1869, vol. ii. p. 542.\\n7 Davis: Philadelphia Medical Times, 1876-77, vol. vii. p. 270.\\n8 Hixon: North American Medico-Chirurgical Review, 1858, vol. ii. p. 76.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0850.jp2"}, "843": {"fulltext": "PLATE XXXI.\\nFig. 1. Anterior dislocation of the Knee.\\nFig. 2.\u00e2\u0080\u0094 Posterior dislocation of the Knee.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0851.jp2"}, "844": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0852.jp2"}, "845": {"fulltext": "DISLOCATIONS OF THE KNEE.\\n769\\nFig. 327.\\nPatella\\nexamination after death or amputation have been numerous among\\nthe reports may be mentioned those by Malgaigne, Volkmann, 1 Albert, 2\\nBirkett, 3 Annandale, 4 Brittain, 5 Madelung, 6 Spillmann, 7 and Lowe,\\nabove quoted.\\nSymptoms. The leg is usually in almost complete extension, and\\nwhen viewed from the side it is seen to lie in a plane more or less ante-\\nrior to that of the thigh, according as the dislocation is complete or\\nincomplete it may be hyperextended or partly flexed, and may be\\nrotated in either direction. The outlines of the projecting condyles\\ncan be seen and felt in the popliteal space, and above the tibia in front\\nlies the patella, more or less horizontal and freely movable, and the\\nskin above it shows marked transverse folds the flat articular surface\\nof the tibia can be felt on each side of the ligamentum patella. In\\nthe incomplete form the deformity is less marked, and the diagnosis\\nmay be difficult if the region is swollen.\\nThe limb may be fixed in its position, or it may be movable in any\\ndirection, hyperextension, flexion to a right angle, or laterally.\\nIf the skin is broken the rent is transverse and posterior, and\\nthrough it one or both condyles may project, or the finger can be\\nreadily passed into the joint. The\\nmain vessels and the internal pop-\\nliteal nerve commonly lie in the\\nintercondylar notch, and may\\nsometimes be plainly visible.\\nInjury to, or compression of,\\nthe artery is shown by the loss of\\npulsation in the arteries of the\\nfoot and ankle injury to the\\nnerve by loss of sensation or\\nnumbness, and, later, by changes\\ndue to defective nutrition of the limb and by pain, sometimes severe.\\nThe course after injury to the artery is well shown in the report of\\nAnnandale s case, that after injury to the nerve in Le Dentu s. 8\\nAnnandale s patient complained that the foot felt cold, but sensation\\nin the toes was normal the dislocation was easily reduced, and the\\npatient did well for a week then it was noticed that the foot was livid\\nand cold. Two days later blebs had appeared upon it, and the discol-\\noration had advanced upon the leg three days later the signs of gan-\\ngrene were marked, and the limb was then amputated above the knee.\\nThe inner and middle coats of the popliteal artery, which were ather-\\nomatous, were torn about an inch above its bifurcation, and curled\\ninward the vessel was plugged by a firm clot.\\nLe Dentu s patient, a man twenty-seven years old, was caught in\\nthe belt of machinery and whirled around rapidly, his legs striking\\nExternal condyle of femur\\nAnterior dislocation of the knee.\\n1 Volkmann Beitrage, zur Chir., p. 119.\\n2 Albert: Wiener med. Presse, 1872. 3 Birkett Lancet, 1850, vol. ii. p. 703.\\n4 Annandale Lancet, 1881, vol. ii. p. 903.\\n5 Brittain London Medical Gazette, 1836, vol. xviii. p. 257.\\n6 Madelung Berlin, klin. Wochensehrift, 1873.\\n7 Spillmann: Diet, encyclop. des Sc. Med., art. Genou, p. 600.\\n8 Le Dentu Bull, de la Soc. de Chirurgie, 1880, p. 591.\\n49", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0853.jp2"}, "846": {"fulltext": "770 DISLOCATIONS.\\neach time against the ceiling he received a complete dislocation for-\\nward of the right knee, and a complete backward dislocation of the\\nleft one the latter was reduced immediately, the former on the next\\nday. On the nineteenth day the patient complained of sharp pain in\\nboth legs, and on examination an eschar as large as a fifty-cent piece\\nwas found on the left calf, and another over the right tendo Achillis\\nthe former healed promptly, the latter increased, and part of the tendon\\nsloughed. The pain became very severe in the right leg, it was neu-\\nralgic in character, a sensation of numbness with darting pain in the\\nfoot and sometimes in the leg, recurring especially at night. It per-\\nsisted until the thirty-fifth day, and returned a week later. On the\\nforty-fifth day another eschar appeared on the sole of the right foot\\nopposite to the head of the first metatarsal bone. Sensation, which\\nhad previously been dulled in front, was now entirely lost throughout\\nthe right leg, except in the region supplied by the long saphenous\\nnerve. Four days later the pain ceased, and the eschars began to heal.\\nSeven months after the accident the patient returned to the hospital\\nthere was considerable atrophy of the right leg, loss of power in the\\nmuscles that move the foot and toes, and some stiffness at the ankle.\\nThe movements of both knees were normal, and the ligaments appeared\\nto have reunited solidly. The patient limped in walking, but the limp\\nwas due solely to the atrophy of the muscles and to the persistence on\\nthe outer side of the sole of the right foot of one of the three ulcera-\\ntions that had appeared upon the foot and heel. The trophic troubles\\nwere attributed to a neuritis of the popliteal nerves occasioned by their\\nlaceration or bruising at the time of the accident.\\nParalysis of the muscles of the outer side of the leg has been ob-\\nserved in three other cases, Brand, Unruh, and Poinsot, 1 in one of\\nwhich, however (Brand), the fibula had been broken at its upper end.\\nOf the compound cases, several recovered with good use of the\\nlimb in others, amputation or excision of the joint was done.\\nThe prognosis is grave in the compound cases and in those in which\\nthe artery has been injured, and it is not very favorable even in the\\nsimpler ones. It must be remembered that gangrene may delay its\\nappearance until the second or even the third week, and that even in\\nsome simple cases which have done w T ell for a week or two suppuration\\nof the joint has ultimately occurred. Even after simple dislocations\\nthat have done well there is ordinarily some limitation of the move-\\nments of the joint.\\nTreatment. Reduction is easy by traction and coaptation of the ends\\nof the bones ordinarily, no more force is required in the traction than\\nan assistant can make with his hands. Flexion of the knee to an\\nacute angle has proved successful. The suggestion that the leg should\\nbe hyperextended, and the head of the tibia then pressed directly down-\\nward, is a dangerous one, because of the chance of injury to the pop-\\nliteal vessels.\\nThe rule of conduct in the presence of compound dislocations, and\\nof those in which there is evidence of injury to the popliteal artery,\\nhas been the subject of recent discussion. Several compound disloca-\\n1 Poinsot Translation of Hamilton, p. 1142.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0854.jp2"}, "847": {"fulltext": "DISLOCATIONS OF THE KNEE. 771\\ntions in which the artery was intact have recovered, and even with full\\nsubsequent use of the joint, and I believe that the conservation of the\\nlimb under such circumstances should be attempted.\\nThe same rule should be followed in case of arrest of pulsation in\\nthe distal arteries that is, the surgeon should wait until it has become\\nevident that the vitality of the limb is lost. If the gangrene is dry\\nlittle is to be feared from delay, but if the limb becomes swollen and\\ndiscolored, with loss of sensation, indicating arterial supply and venous\\nobstruction, delay is more dangerous and the formation of a line of\\ndemarcation cannot be safely awaited.\\nDISLOCATIONS BACKWARD.\\nThese may be complete or incomplete in the former the head of\\nthe tibia is displaced backward and upward behind the condyles in\\nthe latter it still remains partly in contact by its upper surface with\\nthe condyles.\\nThe common cause is direct violence received upon the upper end of\\nthe tibia in front, or upon the lower end of the femur behind, but in\\nsome cases the application of the force is more indirect, as when the\\nbody and thigh are forced forward while the leg is held. In four cases\\nthe patients were caught in machinery and whirled around and in\\none case a boy, eleven years old, suffered a compound dislocation by\\nhaving his leg caught between the spokes of a wagon-wheel.\\nPathology. The posterior ligament is torn, and usually one or both\\nof the lateral ligaments in a case of complete dislocation with rupture\\nof the popliteal artery (quoted by Malgaigne x in which Robert resorted\\nto amputation, all the ligaments were intact except for two rents, each\\nthree centimetres long, in the posterior portion of the capsule through\\nwhich the tibia protruded. It seems likely that the crucial ligaments,\\nor at least the posterior one, must also be ruptured. The muscles\\nwhich bound the popliteal space have been reported untorn, but widely\\ninfiltrated with blood and in other cases one or both heads of the\\ngastrocnemius and the popliteus have been torn. The semilunar\\ncartilages may be in part detached or otherwise injured. In a case\\nreported by Vast 2 a portion of the tubercle of the tibia had been\\ntorn off by the strain upon the ligamentum patella?. The popliteal\\nvessels, both artery and vein, are sometimes completely torn across,\\nand sometimes only the inner and middle coats of the artery are torn,\\nan injury the consequences of w T hich may easily be as serious as those\\nof complete rupture. This injury is. produced by the forcible stretch-\\ning of the vessels across the sharp posterior margin of the head of\\nthe tibia.\\nThe patella may be drawn directly downward so as to lie below its\\nnormal position, or it may be displaced outward to the side of the con-\\ndyle. In a case reported by Fitzgerald 3 the patella was broken into\\nseveral pieces, and the joint was opened at the end of a fortnight by\\nthe sloughing of the overlying skin. The injury was caused by the\\n1 Malgaigne: Loc. cit., p. 945. 2 Vast Bull, de la Soc. de Chirurgie, 1877, p. 68S.\\n3 Fitzgerald: Australian Medical Journal, 1882, p. 554.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0855.jp2"}, "848": {"fulltext": "772 DISLOCATIONS.\\nfall of a heavy case upon the front of the knee. The joint suppurated,\\nbut the patient recovered without entire loss of mobility.\\nAs complications, fracture of the femur above the condyles, Testut, 1\\nand fracture of the tibia just below the knee, Adams, 2 have been re-\\nported also rupture of the tendon of the quadriceps femoris, Walsh-\\nman, 3 Lossen. 4\\nSymptoms. The leg is usually hyperextended upon the thigh, the\\nantero-posterior diameter of the knee notably increased, the head of\\nthe tibia placed behind its usual position, and, in the complete disloca-\\ntions, also above the level of the lower surface of the condyles of the\\nfemur. The leg may also be deviated somewhat to either side, and\\nexceptionally it may be flexed. The head of the tibia can be felt in\\nthe popliteal space, and a marked depression exists below the condyles\\nof the femur in front. The patella may lie against the front part of\\nthe under surface of the condyles, or may be displaced to the outer\\nside, or rotated upon its axis. The amount of shortening is slight in\\nthe incomplete form in the complete form it may be one or two inches.\\nPressure upon or rupture of the popliteal artery is manifested by\\nabsence of pulsation in the posterior tibial and dorsalis pedis arteries,\\nand may result in gangrene of the limb.\\nThe diagnosis is not difficult and as reduction is usually easy the\\nprognosis in simple, uncomplicated cases is good; but attention should\\nalways be paid to the presence or absence of pulsation in the distal\\nbranches of the artery, both before and after reduction.\\nIn some reported cases in which the dislocation has remained unre-\\nduced, the patient has had good use of the limb. Two such are the\\ncases of Bagnall-Oakeley 5 and Karewski. 6 The former s patient was\\na man, seventy-years old, who had dislocated his left knee at the age\\nof nine months he had always made full use of the limb, and had\\nearned his living as a brickmaker. A false joint had formed between\\nthe femur and tibia, which permitted 15 degrees of flexion. The foot\\nand leg were normally developed the thigh had an abnormal anterior\\ncurvature. The patella could not be recognized, and was thought to\\nhave become united with the femur. The different prominences of\\nthe lower end of the femur were absolutely subcutaneous and seemed\\nready to perforate the skin, but there was no trace of previous ulcera-\\ntion.\\nKarewski s patient was a servant girl, thirty-two years old, whose\\ndislocation had existed for more than sixteen years. The right limb\\npresented a typical dislocation backward, and when viewed from\\nbehind looked like a genu recurvatum, while when seen from in front\\nand the side the thigh overhung the leg to a certain extent. The\\nmuscles of the calf were somewhat atrophied the nerves and vessels\\nstretched above the tibia like tense cords. The growth of the bones had\\nbeen materially affected, the tibia being three centimetres shorter than\\nthe other, and also thinner while the femur was lengthened by three\\n1 Testut: Bordeaux Medical, 1S74. 2 Adams Lancet, 1881, vol. ii. p. 1108.\\n3 Walshman Quoted by Cooper, loc. cit. 5 p. 190.\\nLossen Deutsche Chirurgie, Lief. 65, p. 131.\\n5 Bagnall-Oakeley Lancet, 1882, vol. i. p. 53.\\n6 Karewski Arch, fur klin. Chir., 1886, voL xxxiii. p. 525.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0856.jp2"}, "849": {"fulltext": "DISLOCATIONS OF THE KNEE. 773\\nor four centimetres. The overriding of the tibia and femur was four\\ncentimetres. Flexion and extension were normal, both actively and\\npassively, and although there was much lateral mobility the functions\\nof the limb were admirably performed. Pain was felt only after excep-\\ntional use.\\nIn Lossen s case, in which reduction was attempted at the end of\\nsix weeks and failed, the patient finally walked well extension was\\ncomplete flexion to a right angle. The rupture of the external lat-\\neral ligament resulted in the production of a genu varum.\\nTreatment. Reduction, which is usually easy, has been effected by\\ntraction with coaptative pressure upon the adjoining ends of the femur\\nand tibia and flexion of the knee and hip. In some cases flexion\\nalone has been sufficient.\\nSpence l successfully treated an irreducible dislocation by open\\narthrotomy. The patient was a man, sixty years old, who had received\\nthe dislocation March 15, 1876, two days before admission to the hos-\\npital. After a failure to reduce under anaesthesia, continuous traction\\nwith a weight of sixteen pounds was made for three days, and then a\\nsecond unsuccessful attempt was made. March 22d, traction with\\npulleys having also failed, the joint was opened by a curved incision\\nbelow the patella it was found filled with clots, the internal lateral\\nligament broken, and the posterior part of the internal semilunar car-\\ntilage displaced. After division of the external lateral ligament and\\nthe tendons of the hamstring muscles, the dislocation was easily\\nreduced. The wound was drained and dressed antiseptically, the limb\\nplaced on a long posterior splint, and continuous traction made with a\\nweight of eight pounds. As the lower end of the femur tended to\\nproject anteriorly, pressure was made upon it in front. The traction\\nwas maintained until June 15th, and when the patient was last seen,\\nSeptember 13th, the limb promised to be very useful.\\nIn compound dislocations, and in those complicated by injury to the\\nmain vessels and nerves, the principles of treatment are the same as in\\ndislocations forward.\\nLATERAL DISLOCATIONS.\\nLateral dislocation, more rare than either of the preceding varieties,\\nmay be outward or inward, complete or incomplete, simple or com-\\npound. The outward form is more common than the inward. The\\nterm subluxation has been applied to those cases in which the displace-\\nment is slight.\\n1. Outward Dislocations.\\nOf the complete form of this dislocation Malgaigne could find only\\none recorded case, and that a doubtful one but, since the publication\\nof his work, von Pitha 2 has reported two cases in which the disloca-\\ntion was nearly, perhaps quite, complete; Hughes 3 has since published\\na third, and McKenzie 4 a fourth. Von Pitha s first patient was a\\n1 Spence Lancet, 1876, vol. ii. p. 534.\\n2 Pitha and Billroth Chirurgie, vol. iv., part 2, B., p. 258.\\n3 Hughes: Lancet, 1880, vol. ii. p. 974.\\n4 McKenzie Canadian Practitioner, January, 1893.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0857.jp2"}, "850": {"fulltext": "774 DISLOCATIONS.\\nyoung woman who, while carrying a heavy basket on her back, sud-\\ndenly doubled up under it. The right tibia was so completely dislo-\\ncated outward that its entire upper articular surface stood out free, so\\nthat von Pitha could easily lay four fingers upon it. The skin was\\ntightly and smoothly stretched over the articular surface, and was con-\\ntinuous at a sharp angle with that of the side of the thigh the edge\\nof the tibia threatened to cut through the tense, thin skin, and in like\\nmanner the internal condyle of the femur projected abruptly over the\\nleg. The patella was displaced outward, and was placed obliquely,\\nalmost transversely. Reduction was extraordinarily easy. The reac-\\ntion was so slight that the patient left the hospital on the next day.\\nHis second patient was a robust young man who received his injury\\nby springing to the sidewalk from an overturning wagon the symp-\\ntoms were similar, reduction easy. Hughes s and McKenzie s cases\\nwere also similar in appearance and ease of reduction. Hughes s\\npatient died promptly McKenzie s recovered.\\nIn the incomplete form only a part of the head of the tibia, usually\\nall the outer half, projects beyond the side of the external condyle of\\nthe femur.\\nThe commonest cause is outward flexion of the knee, abduction, pro-\\nduced by a fall upon the foot or by the pressure of a heavy weight upon\\nthe posterior, or by a blow upon the outer, side of the knee in the lat-\\nter case the blow is probably received upon the lower end of the femur\\nand not upon the tibia. A rarer cause is direct violence acting trans-\\nversely upon the outer side of the lower end of the femur or the inner\\nside of the head of the tibia without causing lateral inflection (Annan-\\ndale). The mode of production appears to be rupture of the internal\\nlateral and perhaps of the crucial ligaments by abduction of the leg,\\nfollowed by the lateral gliding of the articular surfaces.\\nThe only reports of direct examination of the injured joint are fur-\\nnished by Hargrave 1 and Bonn, quoted by Malgaigne, and by Wells. 2\\nHargrave s patient died on the fifty -third day, after suppuration of the\\njoint the internal lateral ligament was completely ruptured, the exter-\\nnal partly torn the anterior crucial torn across, the posterior crucial\\nand the ligaments of the patella intact. Bonn s was an old unreduced\\ndislocation; he says all the ligaments were intact and that the external\\ncondyle of the femur rested upon the crest of the tibia. In Wells s\\ncase a large scale of bone was torn from the inner side of the internal\\ncondyle the patient died on the fourth day in consequence of gangrene\\nof the limb.\\nInstead of being directly outward the displacement may also be\\nsomewhat backward or forward. When compound, the wound has\\nalways been on the inside. In one compound case, Notta, 3 the pop-\\nliteal artery was ruptured and the patient died after amputation.\\nSymptoms. The symptoms are more or less marked in accordance\\nwith the degree of the displacement the internal condyle of the femur\\nprojects more or less markedly on the inner side, and the outer part of\\n1 Hargrave: Dublin Quarterly Journal Med. Sci., 1850, vol. ix. p. 473.\\n2 Wells: American Journal of the Medical Sciences. 1832, vol. x. p. 25.\\n3 Notta: Annales Med. du Calvados, 1876, quoted by Poinsot.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0858.jp2"}, "851": {"fulltext": "DISLOCATIONS OF THE KNEE.\\n775\\nthe head of the tibia on the outer side and the greater the displace-\\nment the more likely, according to Malgaigne, is it that the outer part\\nof the tibia will be rotated backward. The displacement outward of\\nthe patella shows corresponding variations in degree it may be simply\\ninclined, so that its vertical axis is directed downward and outward,\\nor it may be carried to the outer side of the external condyle.\\nThe leg may be flexed or extended, and is usually adducted, but\\nmay be widely abducted (Fig. 328) voluntary movements are gener-\\nally impossible.\\nPrognosis. The prognosis does not differ materially from that in the\\ntwo preceding forms but it is worthy of note that in a case seen six\\nyears after the accident by Desormeaux (quoted by Spillman) the leg\\nwas permanently abducted 45 degrees, presumably the consequence of\\nfailure of repair of the internal lateral ligament. In another, reported\\nby Morgan, 1 in which the dislocation had remained unreduced for three\\nFig. 328.\\nOTl 3\\nRobert s case of dislocation of the knee outward, with abduction.\\nand a half years, the limb could be flexed to a right angle but could\\nnot be voluntarily extended, so that the patient fell whenever the leg\\nbecame at all bent while he was standing upon it.\\nTreatment. Reduction, generally very easy, is effected by traction\\nand direct coaptative pressure upon the ends of the bones. It is very\\nimportant that the limb should be immobilized for a long time after\\nreduction in order that the torn ligaments may solidly reunite. Prob-\\nably it would be well to keep the limb for three or four months in a\\nfirm dressing which would keep it extended and prevent lateral bend-\\ning. Massage and passive motion might be systematically employed\\nduring much of this time if loss of normal mobility were feared.\\nIn a case reported by Braun 2 of incomplete outward dislocation\\nwhich proved irreducible arthrotomy was done. The patient was a\\nman forty -four years old the leg was rotated inward and abducted at\\nan angle of 145 degrees the internal condyle of the femur was promi-\\n1 Morgan Lancet, 1825-26, vol. ix. p. 843.\\n2 Braun Deutsche med. Wochenschrift, 1882, p. 291.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0859.jp2"}, "852": {"fulltext": "776 DISLOCATIONS.\\nnent, and a small movable piece of bone could be felt below its inner\\nside. A curved incision eight centimetres long was made parallel to\\nthe internal condyle. The small piece of bone proved to be the\\ndetached internal tuberosity. The rent in the capsule was closely\\nfilled by the internal condyle it was slightly enlarged with the knife,\\nand then reduction was easily made. The patient made a slow recov-\\nery the joint remained stiff.\\nThe treatment of compound dislocations and of those in which the\\nartery has been torn is the same as in forward dislocations (q. v.).\\n2. Inward Dislocations.\\nThese also may be complete or incomplete, simple or .compound.\\nOf the complete form there are only two cases on record, Miller and\\nHoffman, 1 and Galli, both quoted by Malgaigne. The first was a\\nman twenty-eight years old who while getting into a carriage caught\\nhis leg between the spokes of the wheel and could not free it before\\nthe horses started. The femur was completely separated from the tibia\\nand projected outward and downward, the external condyle presenting\\nthrough a wound in the skin three inches long. Through this wound\\nthe joint and the uninjured popliteal artery could be seen. Reduction\\nwas made at once without difficulty recovery.\\nGalli s patient, a very muscular young man, was thrown from a\\nhorse, striking upon the right foot with the limb abducted. The lower\\nend of the femur had almost entirely passed through the soft parts on\\nthe outer side; the ligamentum patellae was ruptured. Reduction was\\nmade and the patient recovered.\\nThe causes of the incomplete form are similar to those of the out-\\nward dislocations lateral flexion of the knee or a blow upon the outer\\nside of the tibia or on the inner side of the condyle of the femur.\\nIn a case quoted from Cooper by Malgaigne 2 in which there was also\\nrotation inward of the tibia, the soft parts covering the external con-\\ndyle of the femur behind and externally had been ruptured. The\\nlimb was amputated, and dissection showed a large rent in the vastus\\nexternus immediately above its insertion upon the patella posteriorly\\nthe capsule and gastrocnemius were torn the lateral and crucial liga-\\nments were intact.\\nThe symptoms of the incomplete form are the projection of the head\\nof the tibia on the inner side and of the external condyle of the femur\\non the outer side. The leg may be inclined outward or inward, rotated\\ninward, and more or less flexed.\\nReduction appears always to have been effected without much diffi-\\nculty by traction and coaptative pressure and the only special feature\\nin the prognosis arises from the rupture of the internal lateral ligament,\\nfor if its repair is not thorough, or if the limb is prematurely used,\\nthe leg tends to deviate outward (knock-knee) under the weight of the\\nbody. It would, therefore, be advisable to support the joint for a long\\ntime by means of a brace.\\n1 Miller and Hoffman London Medical Eepository, 1825, p. 346.\\n2 Cooper Quoted by Malgaigne, loc. cit., p. 960.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0860.jp2"}, "853": {"fulltext": "DISLOCATIONS OF THE KNEE. Ill\\nANTEROLATERAL DISLOCATIONS.\\nAnterolateral dislocations constituted in Malgaigne s classification\\na separate class of very rare occurrence, the tibia being displaced for-\\nward and outward. Of the latter form he found only one recorded\\nexample and that a doubtful one. In the very rare examples of dis-\\nlocation forward and inward no special features appear and the same\\nmay be said of the equally rare dislocations backward and outward.\\nThey may, therefore, be treated as belonging to the forward and back-\\nward dislocations respectively.\\nDISLOCATIONS BY ROTATION.\\nIn this form the dislocation is characterized by a rotation of the leg\\nabout its longitudinal axis or about a parallel axis passing through the\\ncentre of one of the condylar surfaces of the tibia in the former case\\nboth condylar surfaces are displaced from their corresponding con-\\ndyles, and the dislocation is said to be complete in the latter only one\\nof them is thus displaced, and the dislocation is said to be incomplete.\\nThe descriptive terms outward and inward are used, as in normal rota-\\ntion of the leg, according to the direction in which the toes are turned.\\nOutward Rotation.\\nThe first recorded case is one reported by Dubreuil and Martelliere, 1\\nat the time internes in Malgaigne s service. The patient was a woman,\\nwho while walking in the street was struck upon the back of the leg\\nby the end of a ladder carried upon a cart. She was knocked down\\nby the blow, her foot caught between the rounds of the ladder, and she\\nwas dragged a few feet. When brought to the hospital, the leg was com-\\npletely extended and rotated outward, so that the internal tuberosity\\nwas in front, below the trochlea of the femur, the external tuberosity\\nand the head of the fibula behind in the intercondylar notch. The\\npatella lay upon the outer side of the external condyle. There was\\nalso a compound fracture of both bones of the leg in the middle\\nthird. Reduction was easily made two hours after the accident by\\nslight traction upon the upper portion of the leg followed by inward\\nrotation. Recovery took place, but the joint was not firm, and nine-\\nteen months after the accident the patient could not take a step with-\\nout crutches.\\nBy experiment upon the cadaver the reporters found they could\\nproduce the dislocation by forcible outward rotation of the leg con-\\ntinued until the ligaments were felt to* yield. The lateral ligaments\\nwere then found to be ruptured or torn from one or the other insertion\\nthe capsule, the fascia on the outer side, and some muscular bundles\\nwere torn, the semilunar cartilages loosened or displaced. The crucial\\nligaments were not torn but lay parallel with each other in the trans-\\nverse vertical plane passing through their upper insertions. In one\\nexperiment the tendon of the biceps was torn away from the head of\\nthe fibula. The tendon of the semi-membranosus was wrapped under\\nthe internal condyle and prevented full extension of the leg.\\n1 Dubreuil and Martelliere: Arch. gen. de Med., 1852, vol. xxx. pp. 150 and 288.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0861.jp2"}, "854": {"fulltext": "778 DISLOCATIONS.\\nSulzenbacher l reported another case and repeated and confirmed\\nthese experiments. His patient was a young Italian laborer, and the\\ndislocation was caused by forcible outward rotation of the leg followed\\nby hyperextension of the knee. The leg was extended, neither\\nabducted nor adducted, and so far rotated outward that as the patient\\nlay on his back the outer border of the foot rested on the bed. Beside\\nthe rotation there was displacement backward and outward of the\\nupper end of the tibia. Notwithstanding the swelling there was a\\ndistinct projection of the condyles, and the soft parts below them were\\ndeeply depressible. Below the internal condyle was a movable piece\\nof bone as large as a bean. The upper end of the tibia could be felt\\nin the hollow of the knee projecting backward and outward and so\\nrotated that the outer surface and the head of the fibula lay furthest\\nback and the outer articular surface could be felt through the soft\\nparts. The inner articular surface lay in the depths of the popliteal\\nfossa, the patella laterally, so that it rested snugly on the outer sur-\\nface of the external condyle, its anterior surface being directed outward.\\nThere was one inch shortening, and the antero-posterior diameter of\\nthe joint was notably increased.\\nReduction was easily effected by flexing the leg a little, then rotating\\nit inward and pressing the head forward, and finally extending.\\nThere was a tendency during the first fortnight to subluxation back-\\nward and outward a gypsum dressing was worn during the second\\nfortnight, and on its removal the tendency had ceased. At the end of\\nsix weeks the patient could walk with a cane.\\nThe case differs from the preceding one in the additional backward\\nand outward displacement of the rotated leg.\\nExperimenting on the cadaver, Sulzenbacher found that by rotating\\nthe leg outward 45 degrees he got an incomplete dislocation, accompa-\\nnied by the appearance of a small fragment of bone under the internal\\ncondyle similar to that observed in his case, and that then by hyper-\\nextension he could make the dislocation complete and exactly like that\\nof his patient. The lesions found on dissection differed from those\\nnoted by Dubreuil and Martelliere in this, that the crucial ligaments\\nwere ruptured and the external lateral ligament untorn. The small\\nmovable piece of bone proved to be the part of the internal condyle\\nto which the internal lateral ligament was attached.\\nIn a case reported by Boursier 2 still another variety is shown, the\\nrotation taking place about the internal condyle as a centre. The\\npatient, while standing with the outer side of his right leg resting\\nagainst the cross-bar of a pair of skids by which he was unloading a\\nlarge cask, was overthrown by the rapid descent of the cask which\\nstruck against the inner side of the right knee. The pain was very\\nsevere, and when raised by his companions he was unable to stand.\\nThe knee appeared a little enlarged transversely the external condyle\\noverlapped the corresponding articular surface of the tibia, forming a\\nrather large, hard, rounded prominence. The patella, firmly fixed upon\\nthis condyle, w T as placed obliquely, its external border tending to turn\\n1 Sulzenbacher: Wiener med. Presse, 1880, vol. xxi. p. 272.\\n2 Boursier Journ. de Med. de Bordeaux, 1882-83, vol. xii. p. 225, quoted by Poinsot.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0862.jp2"}, "855": {"fulltext": "DISLOCATIONS OF THE KNEE. 779\\nforward. The relations of the internal condyle and inner surface of\\nthe tibia were normal. Palpation was painful along the interarticular\\nline, especially at the outer side. Voluntary movement was impossible.\\nPassively, flexion could be made nearly to a right angle, but was very\\npainful the limb could not be completely extended, and there was no\\nrotation. No sign of fracture. Reduction was easily made under\\nanaesthesia by slight traction and inward rotation of the leg. The\\npatient recovered completely.\\nAnother case has been reported by Mazel, 1 and Malgaigne quotes the\\naccounts of two specimens of old unreduced dislocations given by God-\\nman and Petrequin. Of the former it is only said that the leg has un-\\ndergone complete outward rotation, so that the foot points directly out-\\nward, the heel corresponding to the hollow of the other foot, and the\\narticulation of the knee crossing its natural position at right angles.\\nStill another variety, displacement forward of the inner side of the\\nhead, the outer remaining in place, has been recently reported by\\nHenaff. 2 A sailor, thirty-three years old, while squatting with his\\nheels together, thighs abducted, and knees flexed, was struck upon the\\ninner side of the head of the left tibia by an iron ring through which\\na hawser had begun to run rapidly. When brought to the hospital\\nthe leg was partly flexed and not deviated to either side flexion and\\nextension were limited, abnormal lateral movements very free. The\\nrelations of the external condyle and tibia were unchanged the inner\\nside of the head of the tibia was displaced forward, and the internal\\ncondyle was prominent posteriorly. The patella was inclined so that\\nits anterior face looked forward and inward, its inner border rested on\\nthe inner condylar surface of the tibia, and its outer border and point\\nraised the skin, the point being nearly in the median line. Reduction\\nwas easily effected by traction and internal rotation, and the patient\\nmade a complete recovery.\\nInward Rotation.\\nOf this the only recorded instance is one reported by Paris, and\\nquoted by Malgaigne. The internal condyle of the tibia had slipped\\nbehind the corresponding condyle of the femur. The limb was short-\\nened five or six centimetres, and the leg and thigh formed an arc of a\\ncircle. Malgaigne supposes this to have been an incomplete disloca-\\ntion by rotation inward, and explains the alleged shortening as an\\nerror of observation. He mentions in connection with it a singular\\ndisplacement which he had himself seen, and which he thought\\nbelonged to this class more than to any other. When seen by him it\\nhad existed five years. Although the patient limped, he flexed and\\nextended the leg quite freely. In extension the internal condyle pro-\\njected very slightly forward and inward, and the relations of the exter-\\nnal condyle were normal. In marked flexion the internal condyle\\nprojected considerably forward and inward, the inward projection\\nbeing more than two centimetres, and the external condyle projected\\nslightly forward.\\n1 Mazel Montpellier Medical, 1863, vol. x. p. 76. 2 Heuaff These de Paris, 18S3, No. 277.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0863.jp2"}, "856": {"fulltext": "780 DISLOCATIONS.\\nDISLOCATION OF THE SEMILUNAR CARTILAGES.\\nSubluxation of the Knee. Hey s Internal Derangement\\nof the Knee.\\nA certain group of symptoms at the knee, occasioned usually by\\nslight violence, such as the twisting of the leg, or marked flexion of\\nthe joint, and having a decided tendency to recur, to which attention\\nAvas first permanently called by Hey l nearly one hundred years ago,\\nhave only of late been clearly connected with displacement of a semi-\\nlunar cartilage as the cause. In many cases the symptoms are identical\\nwith those caused by a floating cartilage in the joint, and many of the\\nreported cases, especially the earlier ones, were probably of this char-\\nacter. Hey reported five cases, and said he had seen many others\\nthe difficulty always occurred suddenly, sometimes without recognizable\\ncause during ordinary use of the limb, the joint becoming locked\\nin the position of slight flexion, with more or less pain, the patient\\nbeing unable to bring his heel to the ground and walking on the toes,\\nbut the joint could always be freely moved passively. It was always\\nrelieved by gradual passive extension of the limb followed by sudden\\nfull flexion.\\nIn 1731 Bassius (quoted by Malgaigne) reported the first case, but\\nit differs notably from all that have since been reported, for the exter-\\nnal semilunar cartilage had become much hypertrophied in conse-\\nquence of an arthritis, and formed a projection on the outer side as\\nlarge as the thumb it could be pressed into place with crepitus, and\\nbecame displaced when the pressure was removed.\\nIn some cases a distinct projection had been noticed in front, formed\\nby one or the other cartilage, which could be made to disappear by\\npressure or by flexing and extending the joint, and with the disappear-\\nance of the projection the symptoms ceased. It was upon these few\\ncases of recognizable projection and upon the sensation sometimes felt\\nof a distinct slipping or jar in the joint while it is moved, that the\\ntheory of displacement of the cartilage rested, it being supposed that it\\nslipped forward upon the head of the tibia so that its thicker posterior\\nmargin lay between the condyle and tibia at or in front of the point\\nwhere they come most nearly into contact or actually touch.\\nThe only pathological data came from chance examination of a few\\nknees without history thus in two specimens described by Reid 2 and\\nGodlee, 3 the rupture of the attachments had taken place along the\\nperiphery of the cartilage, and it had lodged vertically in the inter-\\ncondylar notch alongside the spine of the tibia and the posterior crucial\\nligament. In each the opposing articular cartilage on the condyle and\\ntibia showed some roughening. Reid s patient died in the hospital,\\nand during his stay there had made no complaint of the knee, and had\\nnot been observed to limp.\\nIn another, Fergusson (quoted by Marsh) found in a dissecting-\\n1 Hey Observations in Surgery, Am. ed., 1805, p. 208.\\n2 Eeid Edinburgh Medical and Surgical Jourual, 1834, vol. xlii. p. 377.\\n3 Godlee Transactions of the Pathological Society of London, 1879-80, vol. xxxi. p. 240.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0864.jp2"}, "857": {"fulltext": "DISLOCATIONS OF THE KNEE. 781\\nroom subject that one of the semilunar cartilages had been torn from\\nthe tibia throughout its whole length, except at its ends, so that in\\nflexion and extension it sometimes slipped behind the articular sur-\\nfaces. The cartilage was flattened in its outer margin, and when it\\npassed behind the condyle of the femur, seemed to fit to the articular\\nsurfaces as accurately as the internal cavity does in the natural condi-\\ntion of the parts.\\nMarsh l gives a fourth case In a subject lately in the dissecting-\\nroom of St. Bartholomew s Hospital, a considerable piece had become\\npartially detached from the rim of the internal cartilage, and was found\\nstanding up like a tongue, so that it would have had the effect, when\\nit was nipped between the bones (as it was in certain positions of the\\njoint), of locking the knee. A deep groove on the cartilaginous edge\\nof the femur had been formed by long pressure, for its accommodation.\\nSince 1881, when Nicoladoni 2 exposing what he thought to be a\\nfloating cartilage found it was the displaced meniscus, and 1885, when\\nAnnandale 3 reported four cases diagnosticated as displacement and\\nformally treated by arthrotomy, the pathology of the condition has\\nbeen made clear by a number of direct examinations through incisions.\\nThe meniscus most frequently displaced is the internal. The detach-\\nment may be of the anterior end or of a variable length of the periphery,\\nor of a piece from the free border of the cartilage. The meniscus\\nmay be displaced into the intercondyloid notch, or backward into the\\njoint, or slightly forward in front, or the detached end may escape for-\\nward or backward and to the side. Partial detachment of a piece from\\nthe upper border seems to be not infrequent one such case is quoted\\nabove; Croft 4 reports another I have seen one.\\nShaffer 5 thinks the ligamentum patella? is elongated in most cases\\nI have not been able to verify the observation.\\nSymptoms. In most of the cases the symptoms are like those occa-\\nsioned by a floating cartilage the patient feels that the knee has\\nsuddenly become locked, with more or less pain and loss of power\\nover the limb, which he can neither flex nor extend. Then, after a\\ntime, and as the result of manipulation of the joint or of the limb,\\nhe feels that all is right again, and walks as well as before. In\\nothers the joint has remained stiff and slightly flexed for weeks,\\nor even years (Smith s 6 and has then been cured by pressure with\\nthe thumb upon the projecting semilunar cartilage, while the joint\\nwas repeatedly flexed and extended. In some cases the cartilage,\\nusually the internal, can be distinctly felt to project in front in others\\nit appears to be absent, and in others again there is no recognizable\\nchange.\\nLe Fort, 7 himself the subject of the affection, felt that something\\nbecame displaced forward in the knee whenever the joint was mark-\\n1 Marsh Diseases of Joints, p. 199.\\n2 Nicoladoni Arch, fur klin. Chir., 1881-2, vol. xxvii. p. 667.\\n3 Annandale British Medical Journal, 1885, vol. i. p. 779, and 1887, vol. i. p. 319.\\n4 Croft British Medical Journal, March 19, 1888.\\n5 Shaffer Annals of Surgery, October. 1898.\\n6 Smith Transactions of the Clinical Society of London, 1884, vol. xvii. p. 123.\\n7 Le Fort Bull, de la Soc. de Chirurgie, 1879, p. 578.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0865.jp2"}, "858": {"fulltext": "782 DISLOCATIONS.\\nedly flexed, and returned to its place with a distinct snap and with pain\\nwhen the limb was straightened. On one occasion the displacement\\nappeared to be backward the pain in straightening the limb was very\\nsevere and lasted for a week.\\nIn a case seen by Agnew, 1 a lady, while playing with a kitten on the\\nfloor, suddenly found both knees had become locked, so that she was\\nunable to rise.\\nAs in these last instances, flexion of the knee beyond a certain point\\nis, in some cases, sure to produce the condition, and this is then\\nrelieved by extension but in most the occurrence is not so uniform in\\nits mode of production, and the commonest cause appears to be out-\\nward rotation of the leg with slight flexion.\\nTreatment. Treatment has almost always yielded good results, both\\nin relieving the condition and in preventing recurrence. The manipu-\\nlations which have proved most efficient in the common form, those\\ndue to a twist or turn of the leg, have been the ones recommended by\\nHey, extension as far as is possible without much pain, and then sud-\\nden forcible flexion. When the cartilage can be felt to project pressure\\nupon it should be conjointly employed. Smith 2 insists upon the neces-\\nsity of repeating the reduction daily for several weeks.\\nThe after-treatment may require permanent pressure by a pad at the\\npoint at which the cartilage tends to protrude, or the wearing of a\\nbrace that will limit the movements of the joint. Marsh, who has\\ntreated many cases, recommends a clamp (Fig. 329) which consists\\nof a steel band passing across the back of the joint, and ending later-\\nally in two plates, which clasp the joint and skirt the edges of the\\npatella, a pad. being placed beneath\\nthe plate, should either of the semi-\\nlunar cartilages be felt to project.\\nProlonged immobilization of the\\nlimb in a fixed dressing has been\\nused in a number of cases and\\nseemed to diminish the tendency\\nto recurrence.\\nOperative measures to effect a\\nradical cure have been resorted to\\nin a considerable number of cases\\nthe object has been either to remove\\nthe displaced cartilage or to restore\\nit to place and secure it there bv\\nClamp to prevent displacement of a semi- sutures The rep0 rted results have\\nlunar cartilage. n i t i\\nbeen uniformly good, the removal\\nof the meniscus appearing to create no functional difficulty. A longi-\\ntudinal incision on the antero-lateral aspect, or a transverse one at the\\narticular line has been employed. Barker 2 in four of six cases found\\nthe meniscus hidden in the intercondyloid notch, drew it out with a\\nhook, sutured it in place, and got a good result, as he did also in the\\nother two by fixation.\\n1 Agnew Surgery, vol. ii. p. 114.\\n2 Smith Lancet, June 13, 1891. 3 Barker Lancet, September 18, 1897.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0866.jp2"}, "859": {"fulltext": "DISLOCATIONS OF THE KNEE. 783\\nCONGENITAL DISLOCATIONS.\\nExcluding a few cases in which various malformations of the knee\\nhave been found in foetal monstrosities showing many other abnormali-\\nties, and one or two doubtful cases, the reported cases of congenital dis-\\nlocation are now nearly forty in number/ in 22 the dislocation was\\nunilateral, backward in 2, forward in 20 with hyperextension of the\\nleg upon the thigh, frequently so extreme that the foot lay at the groin.\\nOf the 15 bilateral dislocations 11 were forward, 2 backward, 2 inward\\n6 of the cases were stillborn, and many showed other defects of devel-\\nopment.\\nIn a few cases there is mention of a blow or fall received by the\\nmother while carrying the child, but it cannot be maintained that such\\na cause is in any case clear. The facility with which the displacement\\nFig. 330.\\nCongenital dislocation of the knee.\\nin the unilateral cases could always be reduced, the normal shape of\\nthe bones, and the prompt establishment of the functions of the limb\\npoint toward an accidental mechanical cause probably, in the move-\\nments of the foetus the leg is extended and becomes engaged in such a\\nposition that it cannot be flexed, and then by the pressure of the wall\\nof the uterus hyperextension is effected. Hyperextension in conse-\\nquence of unopposed contraction of the quadriceps can hardly be\\nsupposed, for the flexors have not been found paralyzed. In Hamil-\\nton s case of double backward dislocation the flexors were con-\\ntracted, and their tendons had to be divided before the legs could be\\nstraightened.\\n1 In addition to the bibliography given in the 1st edition see Joachimsthal, in Berlin,\\nklin. Woch., October 21, 1889, p. 923, 4 cases, and New York Medical Journal, March 2,\\n1889, 6 cases.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0867.jp2"}, "860": {"fulltext": "784 DISLOCATIONS.\\nIn Friedleben s (bilateral) the articular surface of the tibia rested\\nagainst the front of the lower end of the femur the condyles of the\\nfemur and the head of the tibia were normally developed, the patella\\nnormally attached, the capsule loose and large.\\nIn Albert s, a new-born child, both legs were in dorsal flexion at a\\nright angle. The articular surface of the femur varied from the nor-\\nmal. The upper part of the synovial sac and the ligamentum alare\\nwere lacking. The inner semilunar cartilage was only a narrow strip,\\nthe outer one was well developed the crucial ligaments were very\\nbroad and long, the inner one being inserted further inward on the\\ntibia than normal on slight outward rotation of the leg the two crucial\\nligaments became parallel to each other. The popliteal vessels and\\nnerves lay behind the external condyle.\\nThe attitude of the limb at birth, in the forward dislocations, was\\nhyperextension to or beyond a right angle, sometimes so extreme that\\nthe front of the leg was actually in contact with the front of the thigh\\nusually there was no deviation of the leg to either side. It was always\\nfreely movable, could be brought down to the position of straight exten-\\nsion by moderate force, and in most cases could even be flexed nearly\\nor quite as far as usual on removal of the pressure the limb resumed\\nthe position of hyperextension. While the joint was dislocated the\\ncondyles of the femur projected at the back of the popliteal space, the\\nhead of the tibia lying against their anterior surface, and the patella\\nsituated well up on the thigh. In several cases the skin on the front\\nof the knee was thrown into transverse folds, in the grooves between\\nwhich sebaceous matter had sometimes collected. Nothing in any case\\nindicated that the dislocation was recent and traumatic, and the experi-\\nments made by Hibon upon the bodies of newborn and stillborn chil-\\ndren show that in a similar forcible dislocation, even by a force acting\\ncontinuously for several hours, detachment of one or both epiphyses\\nalways occurred, with, however, but slight separation and not always\\nwith rupture of the periosteum. In the forcible straightening of the\\nleg the quadriceps became tense, and in a few cases this tension pre-\\nvented further flexion of the straightened limb.\\nThe results of treatment Ave re almost always very good, the limb\\nshowing a complete restoration of form and function after a few weeks;\\nbut in two cases the result was not entirely satisfactory. Six weeks\\nafter birth the leg in Perier s case showed exaggerated extension and\\noutward rotation the quadriceps was manifestly retracted, and showed\\nas a tense cord whenever the attempt was made even slightly to flex\\nthe leg. In the hope of an ultimate return to the normal condition,\\nGueniot, who then had charge of the case, limited treatment to the\\nmaintenance of the extended position and to slight passive flexion and\\ntraction repeated two or three times daily. In the other case, Maas,\\nthe limb when first seen was in anterior flexion at a right angle\\nreduction was easily made, and the limb could then be normally flexed.\\nIt was placed in a plaster-of-Paris dressing for six weeks, and as the\\ntendency to recurrence had not then entirely disappeared the dressing\\nwas renewed for a time, and afterward a leather knee-cap was worn.\\nIn its second year the child walked for a time without support, but at", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0868.jp2"}, "861": {"fulltext": "DISLOCATIONS OF THE KNEE. 785\\nthe time of the report, when it was two and a half years old, there\\nwas -till a tendency to anterior flexion and abduction, and a brace was\\nconstantly worn.\\nSPONTANEOUS OR PATHOLOGICAL DISLOCATIONS.\\nThese are very frequent at the knee, mainly as the result of chronic\\ndisease involving the ligaments and the bones of the joint, and of pro-\\nlonged maintenance of the partly flexed position. There are also\\ninstances on record of sudden dislocation due to muscular contraction\\nduring an acute arthritis, and quite a number of the class to which\\nVolkmann gave the name deformations-luxationen, or dislocations by\\ndeformity, those in which the shape of the articular ends of the bones\\nhas been greatly changed without suppuration, as in arthritis defor-\\nmans and Charcot s disease.\\nThe principal displacements are backward and backward and out-\\nward, usually combined with outward rotation of the leg. As a great\\nexception dislocation forward has occasionally been observed.\\nUllman reports two cases of bilateral subluxation inward gradually\\nproduced by swinging the body from side to side while at work.\\nExamples of dislocation due to the prolonged action of the flexor\\nmuscles, the knee being long held partly flexed because of disease at\\nsome point in the thigh, are not very uncommon, and in young people\\nits effect is intensified by the exaggerated growth of the femoral con-\\ndyles downward by which the lateral ligaments become too short to\\npermit the tibia to return to its place. This last-mentioned change\\nwas first pointed out by Volkmann, in 1874, and deserves to be con-\\nstantly borne in mind, for if the attempt is made forcibly to straighten\\nsuch a limb the tibia may turn upon its anterior edge as a centre, so\\nthat when straightened it is found to lie well behind its proper posi-\\ntion, dislocation by leverage, as it has been termed.\\nThe dislocations that occur in the course of chronic tubercular or\\nother destructive disease must here be passed with simple mention.\\n1 Ullman Centralbl. fur Chir., August 11, 1894.\\n50", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0869.jp2"}, "862": {"fulltext": "CHAPTEE LV.\\nDISLOCATIONS OF THE PATELLA.\\nGeneral Considerations Cause Outward Complete, incomplete, vertical\\nInward Complete Reversal Congenital Habitual or Pathological.\\nDislocations of the patella are rare, less than 1 per cent, of all\\ndislocations, according to the tables in Chapter XXVII., and the infre-\\nquency with which they have come under the observation of individual\\nsurgeons and the incompleteness or the obscurity of the reports of\\nmany cases have combined to make the systematic descriptions rather\\nartificial and unsatisfactory. The physical conditions and relations of\\nthe patella, which is really a sesamoid bone developed in the tendon of\\nthe quadriceps extensor and not an integral part of the joint, are entirely\\ndifferent from those of other bones, and the changes in position and\\nrelations which it undergoes in displacement are very varied. The\\nanterior articular surface, or trochlea, of the femur extends higher\\nupon the outer than the inner side and presents a central groove\\nbounded laterally by a sharp margin from which the internal and\\nexternal surfaces of the inner and outer condyles, respectively, run\\nabruptly backward, and the outer condyle projects more sharply for-\\nward than the inner one does. The articular or posterior surface of\\nthe patella presents a longitudinal ridge nearer its inner than its outer\\nmargin from which the surface slopes forward to the edge. From each\\nlateral border of the bone passes a strong aponeurotic expansion, the\\nso-called lateral ligaments of the patella, portions of the fascia lata\\nwhich receive expansions from the vasti muscles and are attached to\\nthe tibia; of the outer one, the ilio-tibial ligament is the strongest\\npart and tends to displace the patella outward when the knee is flexed.\\nA superficial layer, given off from the fascia lata on the sides, crosses\\nthe front of the patella and is separated from it by a bursa. In full\\nextension of the knee the patella lies upon the upper part of the\\ntrochlea of the femur, but it can be drawn almost completely above it\\nby the forcible contraction of the quadriceps. This muscle is inserted\\nupon the upper border and somewhat on each side of the patella, and\\nthe long axis of the muscle is inclined to that of the patella and its\\nligament as the shaft of the femur is to that of the tibia that is, they\\nmeet at an obtuse angle whose apex is directed inward. As a conse-\\nquence of this inclination the traction of the muscle tends to displace\\nthe bone toward the outer side, and this tendency is resisted by the\\nprojection of the anterior surface of the outer condyle and by the inter-\\nnal lateral ligament of the patella.\\nThe first collation of recorded cases was made by Malgaigne 1 in\\n1 Malgaigne Gazette Medicale, 1836, p. 433.\\n786", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0870.jp2"}, "863": {"fulltext": "DISLOCATIONS OF THE PATELLA. 787\\n1836 the 25 cases which he then collected were increased to 46 in\\n1855, when he published his work on dislocations. Streubel 1 in 1866\\ncollected 120 cases and made a number of experiments upon the\\ncadaver. Elaborate articles were furnished by Panas 2 in 1872 and\\nBerger 3 in 1877, but the most original and at the same time the most\\nrecent one is the paper by von Meyer, 4 Professor of Anatomy at\\nZurich.\\nThe patella may be displaced to different distances on the outer or\\nthe inner side while the knee is extended or partly flexed, and with\\nsuch displacement may be combined varying degrees of rotation about\\nits own longitudinal axis. These combinations are so numerous and\\nvaried that if a classification should be made according to them it\\nwould confuse rather than simplify their study and description. Mal-\\ngaigne in his first paper, based on only twenty-five cases, described\\nnine forms of dislocations, including one upward and after rupture of\\nthe ligamentum patella?, but in his later work he made only two prin-\\ncipal forms, dislocation outward and inward, with subvarieties corre-\\nsponding to the degree of displacement and the addition to it of more\\nor less rotation of the patella upon its axis. As some of the most\\nstriking differences depend upon this last element, it will perhaps sim-\\nplify the subject first to consider the conditions which determine the\\nfixation of the displaced bone, and in doing this I shall speak only of\\ndisplacements to the outer side, which are much more common.\\nThe bone may be displaced to the outer side by muscular action or\\nby a force acting upon its inner lateral border as it passes sideways\\nalong the projecting surface of the condyle its outer border is raised\\nand its inner border depressed into the bottom of the trochlear groove\\nif the force continues to act the patella is carried past the edge of the\\ntrochlea to the outer side of the external condyle, and when its longi-\\ntudinal ridge passes this edge the outer border of the patella may be\\nturned backward by the traction of its outer lateral attachments and\\nthe bone comes to rest with its articular surface against the outer side\\nof the condyle, and its anterior surface looking outward or it may\\nundergo no rotation, and may come to rest with its inner border against\\nthe outer surface of the condyle, its anterior surface looking more or\\nless directly forward, and its outer border projecting markedly out-\\nward or, again, it may undergo rotation in the opposite direction and\\ncome to rest with its inner border directed backward, its anterior sur-\\nface looking inward against the outer surface of the condyle, and its\\nouter border directed forward. These three forms constitute the\\ncomplete outward dislocations.\\nIf the force is not sufficient to carry the patella entirely past the\\nouter edge of the trochlea, the bone may come to rest with its inner\\nborder in the bottom of the trochlear groove, its posterior surface rest-\\ning partly against the outer surface of the trochlea and partly project-\\ning beyond it, its outer border directed forward and outward, and its\\nanterior surface looking forward and inward the incomplete out-\\n1 Streubel Schmidt s Jahrbiicher, 1866, vol. cxxix. p. 311, and vol. cxxx. p. 54.\\n2 Panas: Diet, de Med. et Chir. pratiques, vol. xvi. p. 40, art. Genou.\\n3 Berger: Diet. Encyclop. des Sc. Med., 3d series, vol. v. p. 334, art. Eotule.\\n4 Von Meyer: Arch. fur klin. Chirurgie, 1882-3, vol. xxviii. p. 256.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0871.jp2"}, "864": {"fulltext": "788 DISLOCATIONS.\\nward or the rotation may be somewhat greater, and Avhile the inner\\nborder still rests in the groove of the trochlea the outer border looks\\ndirectly forward, and the anterior surface directly inward vertical\\nor edgewise dislocation or the rotation may be still greater, the\\nanterior surface being turned so as to look directly backward and lie\\nupon the front of the trochlea, and the posterior surface looking\\ndirectly forward under the skin complete reversal.\\nIt appears, then, that the bone frequently becomes fixed, and firmly\\nfixed, in positions of apparently great instability that is, resting upon\\nthe front or side of the femur only by its narrow lateral edge, and the\\nfixation which is given to it in these positions is given by the tension\\nof the soft parts attached to it and by the\\noverlying fascia. It may be compared to\\na stick on end under a tightly stretched\\nsheet, which will stand not only upright,\\nbut also when inclined, so long as its\\nlower end does not slip along the ground,\\nor its upper along the sheet.\\nIt also appears, in consequence, that the\\nbone may take many intermediate posi-\\ntions between the extremes, and that con-\\nsequently the grouping of the different\\npositions must be somewhat arbitrary.\\nThe terms in general use are complete and\\nincomplete outward and inward disloca-\\ndisiocations of the patella. tions, edgewise or vertical (outw T ard and\\ninward) dislocations, and complete reversal\\nin either of the two directions. Dislocations upward and downward\\nshould not, I think, have a place in the classification, since they are\\nthe secondary results of other lesions, rupture of the ligamentum\\npatella?, or of the tendon of the quadriceps, which are to be deemed\\nthe principal and controlling ones. Among the incomplete outward\\nand inward dislocations those in which one edge of the patella is\\nturned sharply forward differ from the corresponding edgewise ones\\nonly in the degree of rotation, and the distinction between them is not\\nonly difficult to make in practice, but also does not seem worth pre-\\nserving. I shall, therefore, group them all as edgewise dislocations,\\nand limit the term incomplete to others in which the rotation is absent\\nor slight.\\nThe outward dislocations are much the more common it is doubtful\\nif any really complete inward dislocation has been recorded, and of\\nMalgaigne s 46 cases only 6 w r ere incomplete inward. Of the vertical\\nor edgewise dislocations the outward appear to be somewhat more\\nfrequent than the inward.\\nCause. The cause and mode of production of the different forms\\nare, in many respects, the same. The dislocation may be produced\\neither by muscular action, contraction of the quadriceps, or by external\\nviolence acting directly upon the patella. Of the former there are\\nmany unquestionable examples a man dislocates the patella while\\nfencing, a woman by jumping backward and to one side, a boy by", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0872.jp2"}, "865": {"fulltext": "DISLOCATIONS OF THE PATELLA.\\n789\\njumping upward and turning partly around to strike a ball. Of the\\nlatter, external violence acting directly upon the patella, the com-\\nmon examples are falls and blows upon the knee in several instances\\na man riding a horse has struck his knee violently against another\\nmoving in the opposite direction. In a number of cases it has been\\nnoted that the knee was previously affected with hydrarthrosis, and in\\na few genu valgum existed. In the cases of frequent, or habitual, dis-\\nlocation some such predisposing cause is supposed always to exist.\\nOUTWARD DISLOCATIONS.\\n1. Complete.\\nIn complete outward dislocations the patella is displaced entirely to\\nthe outer side of the external condyle, against which it rests either by\\nits posterior, cartilaginous surface, or, more rarely, by its inner border,\\nits anterior surface being still directed forward, or by the inner part\\nof its anterior surface, the outer border projecting forward and the\\nanterior surface looking inward.\\nAccording to von Meyer, and his opinion is based upon clinical\\nobservations, as well as upon anatomical and experimental data, the\\npatella can reach this position either by passing outward at or above\\nthe upper part of the trochlea in complete extension or hyperextension\\nof the knee, or by passing outward and upward over the lower border\\nof the condyle while the knee is flexed\\nnearly to a right angle. In the former case\\nthe dislocation may be produced by muscular\\naction, the contraction of the quadriceps ex-\\ntensor, by w T hich the patella is raised so high\\nthat its passage is no longer resisted by the\\nouter border of the trochlea. Hyperextension\\nof the knee favors the displacement by carry-\\ning the patella still higher above the trochlea.\\nOther conditions that favor the displace-\\nment are exaggerated outward rotation of\\nthe leg and bending inward of the knee.\\nAs illustrative examples Meyer quotes cases\\nreported by Foucart and Robert. A mus-\\ncular young man jumping down from a\\nstool (apparently backward) felt a sharp\\npain, and found he could no longer stand\\non the right foot examination showed an\\noutward dislocation of the patella. A\\nwoman, carrying a heavy burden upstairs,\\nfelt a sharp pain and a cracking in the right\\nknee, and was unable to walk the patella was dislocated outward.\\nExternal violence can produce the dislocation at the same, upper,\\npoint.\\nIn either case the further displacement of the patella downward\\nupon the outer surface of the condyle and its fixation there are aided\\nComplete dislocation of the\\npatella outward. (Anger.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0873.jp2"}, "866": {"fulltext": "790\\nDISLOCATIONS.\\nby the subsequent flexion of the knee which involuntarily follows upon\\nthe sensation of an injury received there.\\nIn studying the manner in which displacement took place, by exter-\\nnal violence, while the knee was partly flexed, von Meyer found that\\nthe resistance of the ligamentum patella? compelled the bone to move\\nin a curve downward and outward, so that it lodged over the lower\\npart of the condyle, or even in the groove between it and the tibia, and\\nthe tendon of the quadriceps slipped sidewise over the edge of the\\ntrochlea, and lay upon the outer surface of the condyle.\\nPathology. The pathology of the commoner form has been studied\\nonly in experiments upon the cadaver and in specimens of old unre-\\nduced dislocations, of which seven cases have been reported. In four\\nof these seven cases the internal lateral ligament of the patella was\\ntorn, and in one the rent extended upward in the vastus internus more\\nthan three inches above the patella. Experiments upon the cadaver\\nconfirm these facts. Fig. 332 represents a specimen obtained experi-\\nmentally. It may be added that in three cases of long standing the\\nbones had undergone various changes in some the patella was hyper-\\ntrophied, in others atrophied in some it had lost part or all of its\\narticular cartilage in some the leg was distinctly rotated outward,\\npresumably the result of the traction exerted upon it through the\\nligamentum patellar.\\nThe only examination of an uncomplicated recent case of which I\\nhave knowledge is one reported by Andrews; 1 the specimen was\\nobtained by amputation, which was rendered necessary by a compound\\nfracture of the leg. The displacement was of the rare form in which\\nthe patella has undergone no deviation about its longitudinal axis and\\nrests against the external condyle only by its inner border (Fig. 333).\\nThe patient had been run over by a freight car.\\nThe patella w T as found shoved nearly straight out-\\nward with its inner edge resting firmly against the\\nouter condyle, and with its front and back surfaces\\npresenting in a nearly normal direction. At the\\nplace where the inner border of the patella rested\\nagainst the femur the shell and spongy tissue of the\\ncondyle were crushed in, making an oval or spoon-\\nshaped hollow about one inch long and five-eighths\\ninch wide. The sharp inner edge of the patella rested\\nfirmly in this hollow and was thus effectually pre-\\nvented from slipping. The rest of the patella was\\nstoutly held in position, like a tent-pole or derrick,\\nby tight bands drawing in three different directions,\\nas follows 1. By a portion of the vastus externus\\nmuscle drawing the outer angle upward, inward, and\\nbackward. 2. By a part of the rectus femoris, not\\nrepresented in the figure, but drawing upward, inward,\\n3. By the ligamentum patellae, drawing downward and\\nFig. 333.\\nAndrews s case\\nof dislocation of\\nthe patella out-\\nward.\\nand forward,\\ninward.\\nThe vastus internus was torn off.\\nThe inner half of the rectus\\n1 Andrews Annals of Anatomy and Surgery, 1883, vol. vii. p. 199.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0874.jp2"}, "867": {"fulltext": "DISLOCATIONS OF THE PATELLA.\\n791\\nwas torn off with the vastus interims, and the lateral attachments of\\nthe capsular ligament to the sides of the patella were effectually ripped\\naway, but the outer part of the rectus was still attached.\\nSymptoms. The symptoms are loss of power to stand upon the limb\\nor actively to move the knee, pain, and deformity. The knee is usually\\npartly flexed, but occasionally has been found fully extended. Passive\\nmotion is painful, complete extension usually possible, further flexion\\nrarely possible.\\nThe knee appears broadened and flattened anteriorly the normal\\nprominence of the patella is lost, and in its place is a depression through\\nwhich the anterior articular surface of the condyles can be distinctly\\ntraced unless the swelling is too great. The patella can be readily felt\\nupon the outer side of the condyle, and the tendon of the quadriceps\\nand the ligamentum patella? show as tense\\nbands under the skin. Usually the patella Fig. 334.\\nrests with its articular surface against the\\nouter surface of the condyle and its inner\\nborder directed forward, but, as has been\\nalready said, it may stand directly out from\\nthe condyle, resting against it by its inner\\nborder only, or it may be rotated in the op-\\nposite direction so that its outer border is\\ndirectly in front.\\nTreatment. The method of treatment that\\nhas proved the most successful is one pro-\\nposed more than a hundred years ago by\\nValentin, which consists in full extension\\nof the knee and flexion of the hip to relax\\nthe quadriceps, followed by direct pressure\\nwith the hands upon the patella it may be\\nnecessary to increase the laxity of the ten-\\ndon of the quadriceps by pressing the lower\\npart of the muscle downward toward the\\nknee. Possibly a device which Duplay em-\\nployed successfully in a vertical dislocation\\nmight be used, if pressure with the hands\\nfailed he inserted the points of a strong\\ndouble hook through the skin, engaged them under the edge or in the\\nanterior surface of the patella, and drew the bone forward. Moreau\\ndid an arthrotomy, but the joint suppurated and the patient barely\\nescaped with his life. Albert and Konig speak rather lightly of the\\nrisk involved in such an operation, and the latter employed it in a\\ncase of three months standing.\\nIn cases that have remained unreduced the usefulness of the limb\\nhas sometimes been well restored, the patients being able to walk freely\\nand troubled only in making complete extension. In other cases, again,\\nthe disability has been great, the knee being stiff and the patient able\\nto walk only with crutches. Occasionally the accident is followed by\\na marked tendency to recurrence on flexion of the knee.\\nDislocation of the patella out-\\nward. (Duplay.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0875.jp2"}, "868": {"fulltext": "792 DISLOCATIONS.\\n2. Incomplete.\\nThe cases to which I limit this group are those in which the dislo-\\ncation takes place while the knee is extended, and in which the patella\\nrests above and partly to the outside of the outer part of the femoral\\ntrochlea, its apex being probably still on the median side of the crest.\\nIt is to be remembered that in most systematic descriptions the group\\nis made also to include cases of moderate edgewise or vertical displace-\\nment, those in which the inner border of the patella rests in the hollow\\nof the trochlea and the outer border projects outward and forward\\nbut still the majority of the reported cases are of the kind to which I\\nhave restricted the use of the term. There are, however, cases of\\nhabitual dislocation in which the patella moves outward during flexion\\nof the knee and the outer border turns backward, which might properly\\nbe termed incomplete. Malgaigne l reports one such in which the con-\\ndition followed a primary traumatic dislocation, and a number have\\nbeen reported in which the condition developed gradually or was\\nthought to have existed at birth.\\nThe causes are essentially the same as those which produce the com-\\nplete outward dislocations in which the patella escapes at or above the\\nupper part of the trochlea, that is, muscular action and external vio-\\nlence received while the knee is fully extended or even hyperextended.\\nVon Meyer finds the explanation of the incompleteness of the dis-\\nlocation in the supposition that the lateral movement of the patella\\ntakes place while it is .still at a lower point upon the femur than it is\\nwhen it undergoes displacement outward the outer margin of the\\ntrochlea engages in the sulcus at the junction of the patella and liga-\\nmentum patellae, and thus the bone is prevented from being drawn\\nfurther outward by the traction of the ilio-tibial band.\\nDirect examination has been reported in only one case, and that an\\nold one, Diday 2 the specimen came from a man thirty-four years old\\nthe deformed patella rested on the external condyle and was prevented\\nfrom moving inward by a bony ridge which occupied the trochlea the\\narticular surface extended an inch higher upon the outer than upon\\nthe inner condyle. The patient walked without difficulty.\\nThe limb is in extension, and any attempt to flex is painful. The\\ninner half of the trochlea can be distinctly traced with the finger, and\\nthe patella can be recognized above and to the outer side of its* normal\\nposition, with its anterior surface looking almost directly forward, and\\nif inclined at all it appears to be usually inclined outward.\\nThe treatment is the same as that of the complete form flexion of\\nthe hip and extension of the knee to relax the quadriceps, followed by\\ndirect pressure inward upon the patella. Reduction is easy and some-\\ntimes spontaneous in a case reported by Cooper the reduction followed\\nimmediately and spontaneously upon the displacement, the only proof\\nof the dislocation being a demonstrable rupture of the inner anterior\\npart of the capsule and swelling of the joint.\\n1 Malgaigne Loc. cit., p. 912.\\n2 Diday: Bull, de la Societe Anatomique, 1836. p. 297.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0876.jp2"}, "869": {"fulltext": "DISLOCATIONS OF THE PATELLA. 793\\n3. Outward Edgewise or Vertical Dislocations.\\nAccording to Malgaigne this form of dislocation was first reported\\nin 1777 by Xannoni, an Italian surgeon, who communicated two cases\\nto the Academic royale de Chirnrgie. His account appears not to\\nhave been credited, and the subject was not again mentioned until\\nMalgaigne, in 1836, gave a description of it. Since that time a con-\\nsiderable number of cases have been reported without making a very\\nthorough search I found about thirty, five of which were reported in\\nthe New York Medical Record between the years 1873 and 1879, and\\nin cliis enumeration I have not included cases reported as incomplete\\noutward dislocations, although I include such in the classification.\\nThe dislocation is characterized by a displacement outward of the\\npatella and its rotation upon its longitudinal axis, by which its inner\\nborder is brought to rest at or near the bottom of the groove of the\\ntrochlea, while the outer border projects more or less directly forward\\nand its anterior surface looks inward it is said by Panas that its apex\\nis also directed slightly backward.\\nMuscular action is the most frequent cause, and in some cases the\\ncontraction of the muscle appears not to have been forcible, as in\\nMartin s 1 patient, a young girl, who caused the dislocation by moving\\nin bed in others more force has been exerted, as a boy in throwing a\\nsnowball, a man in wrestling, another in stumbling, another in jump-\\ning. External violence is a less frequent cause a blow upon the inner\\nedge of the patella by which the bone is pushed outward, its inner\\nborder depressed into the hollow of the trochlea, and its outer border\\nraised by the passage of the bone along the slope of the external con-\\ndyle. The mode of production by muscular action has not been made\\nclear.\\nThe patella may rest partly against the projecting outer portion of\\nthe trochlea, or it may touch the femur only by its inner edge even\\nwhen its outer border still lies somewhat to the outer side of a sagittal\\nplane passing through the inner one, and in one case, Payen, quoted\\nby Malgaigne, the patella had turned more than 90 degrees, so that its\\nouter border lay a little to the inner side of the inner border. Its\\nfixation in this position without lateral support must be attributed to\\nthe tension of the overlying soft parts and the untorn parts of the\\ncapsule, for in one case in which both the tendon of the quadriceps\\nand the ligamentum patella? were cut subcutaneously by the surgeon\\nin the effort to reduce, the bone remained as firmly fixed as before.\\nThe knee is generally extended, but in some cases it was flexed half\\nway to a right angle, and is usually immovable because of pain. The\\ndeformity is characterized by the sharp projection of the outer border\\nof- the patella in front, on each side of which the skin is depressed so\\nthat the anterior and articular surfaces of the patella can be felt, but\\nsometimes the skin is stretched tightly toward each side.\\nThe most successful treatment has been that recommended for the\\npreceding forms flexion of the hip, extension of the knee, and pressure\\nupon the patella, the latter being so directed as to force the projecting\\n1 Martin Arch. gen. de Med., 1831, vol. xxvi. p. 259.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0877.jp2"}, "870": {"fulltext": "794 DISLOCATIONS.\\nouter border outward and backward, but this has failed in several cases\\nin which reduction was afterward obtained by forced flexion of the leg\\nor, in one case, by getting the patient forcibly to contract the quadriceps\\nand then pressing upon the patella after it had been thus drawn upward.\\nPossibly Duplay s device, above mentioned, of drawing the patella for-\\nward with a strong sharp hook, would be of use by diminishing the\\nfriction between it and the femur. Eben Watson, and others following\\nhis example, succeeded by slightly flexing the leg upon the thigh during\\nanaesthesia, pressing the patella moderately outward, and then suddenly\\nextending the leg. Three surgeons have resorted to section of the liga-\\nmentum patellae, and one of them also to that of the tendon of the\\nquadriceps, but without success, and in the last one the joint suppu-\\nrated and the patient died.\\nINWARD DISLOCATIONS.\\nThese are so similar to the outward dislocations in their nature,\\ncauses, symptoms, and treatment that a detailed description is unnec-\\nessary.\\nComplete Inward.\\nThis dislocation is denied by several authors, the only alleged cases\\nbeing those of Putegnat and Walther, both quoted by Malgaigne. The\\nformer was traumatic in origin, but when the patient came under\\nobservation the condition was that of habitual dislocation the patient,\\na girl thirteen and a half years old, had fallen upon her knees five\\nyears before, and since that time both patella? had been so freely mov-\\nable that she sometimes amused herself by dislocating and reducing\\nthem more than a hundred times in an hour. The right patella could\\nbe more easily dislocated outward, the left one inward but both could\\nbe dislocated so completely inward that their anterior surfaces were\\nexactly in contact when the knees were brought together. The liga-\\nments were so relaxed that the legs could not be completely extended\\nby the contraction of the quadriceps.\\nOf Walther s case, nothing is known but a brief description in\\nLatin of a specimen in a museum at Berlin. Malgaigne thought it\\nmight be a complete inward dislocation, but admits that its character\\nis uncertain.\\nIncomplete Inward.\\nOf complete inward dislocation only one case has been reported, by\\nKey; 1 it also was quoted by Malgaigne. The patient, a girl twenty\\nyears old, slipped and fell she felt great pain in the left knee, and\\nwas unable to walk. The patella was found resting on the inner\\ncondyle, the outer part of its articulating surface being supported\\nobliquely by the projecting edge of the trochlea of the femur. Gentle\\npressure on the inner edge of the patella, as the limb lay on the bed,\\nreduced it to its natural position. The joint suppurated, and appar-\\nently the patient died or the limb Avas amputated. The tendon of the\\nvastus externus was partly torn through.\\n1 Key Guy s Hospital Keports, 1836, vol. i. p. 260.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0878.jp2"}, "871": {"fulltext": "DISLOCATIONS OF THE PATELLA. 795\\nInward Edgewise or Vertical Dislocation.\\nThis seems to be nearly as frequent as the corresponding outward\\nform. Possibly its relative frequency and the rarity or absence of the\\ncomplete and incomplete inward forms are to be explained by the\\ngreater projection inward of the internal condyle, and the relative\\nshortness of the ligamentum patellar, which prevents the patella from\\nreaching that side of the condyle.\\nCOMPLETE REVERSAL.\\nComplete reversal, the outer border passing in front to the inner side,\\nso that the anterior surface rests against the trochlea and the articular\\nsurface is directed forward, has been reported in only two cases, which\\nare briefly quoted by Malgaigne as follows: In 1752 J. Sue saw a\\ndislocation produced by muscular action in which he clearly recog-\\nnized a two-thirds reversal of the patella from without inward without\\nany evidence of rupture of the ligaments. Subsequently Hevin said\\nthat he had heard Bruyeres read before the Academie royal de Chir-\\nurgie the details of a total reversal of the patella upside down, also\\nwithout rupture of the ligaments; in the latter case the cause was a\\nblow received upon the inner part of the knee.\\nComplete reversal, the inner border passing in front to the outer\\nside, has been reported in three cases, Castara, quoted by Malgaigne,\\nWragg, 1 and Gaulke. 2\\nCastara s patient, a girl seventeen years old, bent forward to lift a\\nbook from a table, resting her weight upon the extended right leg, and\\npressing the outer border of the patella against the edge of a chair\\nshe suddenly cried out, and Castara, summoned immediately, found\\nthe leg partly flexed, and could extend it but very little. The patella\\nrested by its outer border upon the outer and upper part of the trochlea\\nof the femur, which it covered only over a breadth of a quarter of an\\ninch its inner border inclined outward and projected in this direction\\ntwo and a half centimetres, its articular surface looking forward and\\ninward. The tendon of the quadriceps and the ligamentum patella?\\neach formed a quite thick and hard rounded cord above and below.\\nThe surgeon grasped the bone with his thumbs and forefingers, and by\\na simple movement of rotation from behind forward, and from without\\ninward, restored it easily to its place.\\nWragg s patient was a negro, who had been struck upon the outer\\nside of the right patella. The limb was extended and immovable.\\nThe inner border of the patella had turned forward and outward, and\\nlay about half an inch to the outside of the normal position of the\\nouter border; the outer border could be felt deep in the trochlea about\\nhalf an inch from its inner edge. The tendon of the quadriceps and\\nthe ligamentum patellae showed under the skin as hard twisted cords\\nvery little passive motion at the knee. The dislocation was reduced\\n1 Wragg: Charleston Medical Journal, May, 1856, abstract in Schmidt s Jahrbiicber,\\n1856, vol. xci. p. 362.\\n2 Gaulke Deutsche Klinik, 1863, p. 108.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0879.jp2"}, "872": {"fulltext": "796 DISLOCATIONS.\\neasily by pressing with the thumbs against the projecting border, and\\nwith the index- and middle fingers against the outer border in the\\nopposite direction. The reaction was slight, and the patient made a\\ngood recovery.\\nGaulke s patient, a girl seventeen years old, injured her knee in a\\nfall from a horse, and was not seen by him until ten days after the\\naccident. The patella lay entirely upon the outer condyle of the\\nfemur, and had been so turned about its longitudinal axis that its pos-\\nterior surface looked forward and inward, and the anterior surface\\nbackward and outward. After several failures he reduced by making\\npressure against the projecting inner border with one jaw of a vise,\\nsuch as is used by carpenters to hold pieces of wood that have been\\nfreshly glued together, the counter-pressure being made with the other\\njaw against the internal condyle. The force of the screw was so\\napplied as to press the inner border of the patella forward and inward,\\nwhile its outer border was expected to move along the outer slope of\\nthe trochlea. After many efforts, the patella suddenly moved with a\\nsnap, turned about its long axis, and fell back into place. The patient\\nrecovered in a fortnight.\\nCONGENITAL DISLOCATIONS.\\nIn a number of reported cases the term congenital has been used\\nalthough the writers knew that the dislocation had first appeared long\\nafter birth in most of the others it has not been possible to ascertain\\nwith certainty the date of the appearance of the condition, and in many\\nthe probability is very great that it had been gradually developed long\\nafter birth. The reported cases in which it is reasonably certain that\\nthe condition existed at birth are not numerous, perhaps fifteen or\\ntwenty, but if to these are added the other cases which several of the\\npatients have said existed in other members of their families, the num-\\nber becomes considerably increased. The principal paper upon the\\nsubject is one by Zielewicz x Bessel-Hagen 2 recently read one before\\nthe Berlin Medical Society, and presented two cases, but the published\\nabstract is very short. Zielewicz s paper gives the details of 13 cases,\\nin 3 of which the patella was dislocated upward with elongation of its\\nligament in the remaining 10 the dislocation was outward. The con-\\ngenital character of the first 3 is uncertain. Of the outward ones in\\nwhich the sex is noted, 6 were males, 3 females in 5 both patellae were\\ndislocated, and in all the patients were able to make good use of the\\nlimb.\\nBessel-Hagen points out that the cases may be grouped in three\\nclasses: 1. The incomplete, in which the patella lies upon the outer\\ncondyle when the knee is extended, and returns to its normal place\\nwhen the knee is flexed 2, complete intermittent, in which the displace-\\nment occurs during flexion 3, complete permanent, in which the dis-\\nplacement is increased during flexion, and is not overcome during\\nextension.\\n1 Zielewicz Berlin, klin. Wochenschrift, 1869, vol. vi. p. 25.\\n2 Bessel-Hagen Deutsche med. Wochenschrift, 1881, p. 45.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0880.jp2"}, "873": {"fulltext": "DISLOCATIONS OF THE PATELLA. 797\\nCaswell 1 reported a case of congenital dislocation of both patellae in\\na man, forty-three years old, who said that five members of his family,\\nin three generations, had the same deformity his father, sister, son,\\nand nephew. Dr. Caswell examined the son and confirmed the state-\\nment to that extent.\\nShapleigh 2 saw a man, thirty-nine years old, both of whose patellae\\nwere dislocated outward, resting on the upper and outer surface of\\nthe external condyle of the femur. They were of normal size. The\\npatient said the condition had existed from birth, and that his grand-\\nfather, father, and one of his own children, four generations, had the\\nsame deformity. The man walked without difficulty and had served\\nas a soldier during the war.\\nAn anonymous writer 3 reported a case of congenital dislocation of\\nboth patellae in a girl whose father, aunt, and aunt s daughter were in\\nthe same condition.\\nHABITUAL OR PATHOLOGICAL DISLOCATIONS.\\nA number of varying conditions in the bones or ligaments of the\\nknee may have for consequence the frequent, even habitual, dislocation\\nof the patella in certain positions or movements. Almost without\\nexception, these dislocations are to the outer side and complete. Many\\ncases reported as congenital are probably of this character Isemeyer, 4\\nindeed, published an elaborate paper on the subject in which he claimed\\nthat all reported cases of congenital dislocation were really pathological\\nones.\\nAmong the alleged causes are relaxation of the ligaments, chronic\\narthritis of different kinds, malformations of the knee, especially genu\\nvalgum, and injury of the lower part of the vastus internus.\\nIn genu valgum the increased abduction of the leg upon the thigh\\nproduces a corresponding exaggeration of the angle between the quad-\\nriceps and the ligamentum patella? in consequence of which the con-\\ntraction of the muscle constantly tends to draw the patella outward,\\nand if the patella passes to the outer side of the outer condyle the\\nmuscle then aids still further to abduct the leg and increase its devia-\\ntion. Indeed, in some of the reported cases it has remained in doubt\\nwhether the abduction of the leg preceded or was itself the conse-\\nquence of the dislocation of the patella.\\nCondamin 5 reported a case in which persistent outward displacement\\ntook place gradually in consequence of operative division of the lower\\nportion of the vastus internus in the treatment of an osteomyelitic\\nabscess.\\nThe patella is habitually very movable, and the dislocation takes\\nplace or is increased during flexion of the knee and is reduced or\\ndiminished during extension. The functions of the limb are more or\\nless interfered with, complete voluntary extension being difficult or\\n1 Caswell American Journal of the Medical Sciences, July, 1865.\\n2 Shapleigh Boston Medical and Surgical Journal, 1881, vol. cv. p. 252.\\n3 New York Medical Journal, 1885, vol. xlii. p. 27.\\n4 Isemeyer: Arch, fur klin. Chirurgie, 1866, vol. viii. p. 1.\\n5 Condamin Lyon Med., September 30, 1888.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0881.jp2"}, "874": {"fulltext": "798 DISLOCATIONS.\\nimpossible. The femur tends to rotate inward, and the leg outward\\nand to become abducted.\\nA case which resembles Putegnat s of complete inward dislocation\\nin the facility with which the patient could rapidly produce and reduce\\nthe dislocation by muscular action is reported by Albert; 1 the patient\\nwas a boy, sixteen years old, with genu yalgum on the affected side.\\nWhen the knee was held at an angle of 160 degrees he could repeat\\nthe production and reduction with great rapidity and ease. Flexion\\nat 150 degrees was the limit at which voluntary reduction could be\\nmade voluntary dislocation was possible even when flexion was carried\\nto 90 degrees.\\nThe treatment consists in the wearing of a knee-cap designed to\\noppose the displacement during flexion or to restrict the flexion to the\\nrange beyond which the displacement took place.\\nRoux 2 relieved a case of habitual dislocation outward following\\nrupture of the aponeurosis on the inner side by dividing the vastus\\nexternus, suturing the rent on the inner side, and displacing the inser-\\ntion of the ligamentum patellae upon the tibia half an inch inward.\\nBradford 3 did the same with success.\\nAnother French surgeon (I have mislaid the reference) relieved the\\ncondition by narrowing the internal lateral expansion by means of\\nthree silk sutures so placed as to make a longitudinal tuck in it others\\nhave excised a piece and closed the opening with sutures.\\n1 Albert Chirurgie, vol. iv. p. 396. 2 Eoux Eev. de Chir., August, 1888.\\n3 Bradford Boston Medical aud Surgical Journal, February 20, 1896.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0882.jp2"}, "875": {"fulltext": "CHAPTER LVI.\\nDISLOCATIONS OF THE FIBULA.\\nOf the Upper End Of the Lower End Spontaneous or Pathological.\\nThe fibula may be dislocated at its upper or at its lower end, and\\nas the result of external violence, or of muscular action, or of unequal\\ngrowth of the tibia and fibula.\\nDISLOCATIONS OF THE UPPER END.\\nOf these there are now about twenty-five reported cases. 1 In the\\nmajority the displacement was outward and forward, in others back-\\nward, and in a few upward. It is to be remembered that, as the head\\nof the fibula is situated behind the most external part of the tibia, a\\ndislocation forward must also be outward.\\nOf cases complicated by fracture of either the tibia or fibula, or of\\nboth bones, quite a number have been reported. Of those in which\\nthe dislocation is produced by the overriding of the fragments by\\nwhich the head of the fibula is forced upward, it is only necessary to\\nsay that, although the reported displacement has been very great in\\nsome cases, it does not appear seriously to have affected the treatment\\nof the fracture, and in most cases reduction was easy. In some, in\\nwhich the fracture united with shortening, there remained a permanent\\ndisplacement of the head of the fibula upward. The dislocation is\\nnot always upward, but is sometimes forward, and sometimes the head\\nhas been freely movable backward and forward.\\n1. Forward.\\nThe cause has been a fall with the leg bent under the body or a mus-\\ncular effort without a fall, and there is reason to think that the forcible\\ndepression and inversion of the front of the foot may be a factor in\\nthe production thus, Savournin s patient caught her heel while\\ndescending a staircase and the foot was sharply depressed and turned\\ninward, and in my two patients, one of whom had not fallen, move-\\nment of the foot in the direction mentioned caused pain at the site of\\nthe dislocation after reduction. Tillaux, also, observed a case of dias-\\ntasis associated with fracture of the lower end of the tibia (p. 383).\\nThe head of the fibula can be seen and felt in front and outside of\\nits normal position, and the tendon of the biceps shows plainly in an\\nunusual curve. The patient is usually unable to walk because of pain,\\nbut can move the knee quite freely.\\n1 In addition to the bibliography given in the first edition, see Hirschberg, Arch, fur\\nklin. Chir., 1888, vol. xxxvii. p. 199; Leggett. Lancet, March 31, 1888; and Stimson, New\\nYork Medical Journal, May 25, 1889, and February 6, 1892\\n799", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0883.jp2"}, "876": {"fulltext": "800 DISLOCATIONS.\\nReduction has usually been easy by direct pressure while the knee\\nwas partly flexed in Savournin s Case while the knee was extended\\nand the foot in dorsal flexion. I was obliged to resort to arthrotomy\\nin one case. Leggett refers to an unreported case in which reduction\\nfailed, two attempts having been made under anaesthesia. The obstacle\\nin my case appeared to be a strong fibrous band extending from the\\nhead of the fibula to the front of the tibia after its division reduction\\nwas easy.\\n2. Backward.\\nIn at least one of these, Dubreuil, the cause clearly seems to have\\nbeen forcible contraction of the biceps in the others the patients fell,\\nand the cause may have been a twist of the leg which ruptured the\\ntibio-fibular attachments by the pull of the external lateral ligament\\nof the knee, the biceps then acting to displace the bone backward.\\nIn two cases the foot was slightly everted, and in one of them there\\nwas a sensation of cold and numbness along the peroneal region of the\\nleg in one the tendon of the biceps was tense. The displacement is\\ndescribed as backward in all, and its extent as one inch in DubreuiPs.\\nReduction was effected without much difficulty in three by direct\\npressure upon the head of the fibula while the knee was flexed. In\\nDubreuiPs the displacement recurred on the following day, and was\\nthen less easily reduced a knee-cap of leather was then worn for\\ntwelve days, and the patient was then able to walk with a cane, but\\nfor some time the leg had a tendency to bend outward ultimately\\nrecovery was complete, as it was also in the other two cases.\\nErichsen and Oldright did not see their patients until some time\\nafter the accident in the former s the displacement was permanent\\nand the a limb was somewhat weakened, so that the patient could not\\njump, but otherwise he suffered no inconvenience. In Oldright s\\nthe displacement could be easily reduced, but it immediately recurred;\\nlocal pressure and immobilization of the knee failed to cure. Possibly\\nretention by a strip of adhesive plaster placed round the upper part of\\nthe le^ would be effective.\\n3. Upward. 1\\nOf this form there are only three reported cases, Boyer, St oil, and\\nSorbets, and the account of the latter is too incomplete to be of any\\nuse or even to establish the accuracy of the diagnosis.\\nBoyer s patient appears to have received a dislocation outward of\\nthe foot or a Pott s fracture of the ankle in which the fibula, instead\\nof breaking, had been pushed bodily upward the extent of the dis-\\nplacement is not stated the restoration of the foot to its place cor-\\nrected the upper dislocation also, and the patient recovered.\\nIn StolPs case the head of the fibula is described as standing\\nnotably higher than normal on the outer surface of the tibia, and\\nforming there an immovable, firm, sharply projecting tumor, very\\npainful on pressure. He quotes DubreuiPs case as identical, and\\nattributes the displacement to the forcible contraction of the biceps,\\nand, therefore, it seems possible that the dislocation may belong among\\n1 This is sometimes called total dislocation, because the lower end also is displaced.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0884.jp2"}, "877": {"fulltext": "DISLOCATIONS OF THE FIBULA. 801\\nthe backward ones. The patient was a circus-rider and received the\\ninjury in jumping from his horse, alighting upon his toes. The sole\\nwas everted, the toes abducted the inner side of the ankle swollen\\nand tender passive motion of the knee and ankle very painful numb-\\nness of the outer side of the leg. No fracture could be found. Re-\\nduction was made by forcible traction on the foot, the knee being\\nHexed at a right angle, and was accompanied by a snapping sound.\\nDISLOCATIONS OF THE LOWER END.\\nOf this the only two recorded cases, excluding, of course, the numer-\\nous ones in which diastasis of this joint has formed one of the lesions\\nof Pott s fracture at the ankle and the few cases in which the same\\ndiastasis has been part of inward or outward dislocation of the foot,\\nare one observed by Nelaton in the service of Gerdy and one in the\\nservice of Tillaux reported by Dunand. 1 Gerdy s patient came to the\\nhospital thirty-nine days after the accident. The wheel of a wagon\\nhad passed across the lower end of his leg and had forced the external\\nmalleolus so far backward that it was almost in contact with the outer\\nborder of the tendo Achillis the outer surface of the astragalus could\\nbe felt through almost its entire extent. The patient walked fairly\\nwell, and Gerdy thought no attempt to reduce should be made.\\nIn Tillaux s case the patient in stepping from an omnibus caught\\nhis foot and fell forward. The foot was everted, there was a large\\necchymosis on the inner side of the leg and foot, and another on the\\nouter side the ankle was swollen and tender, especially on the inner\\nside no fracture could be found. The low T er end of the fibula was\\nfreely movable forward and backward with cartilaginous crepitus,\\nand could be drawn outward so far that the end of the finger could be\\ninserted between it and the astragalus. The patient made a good\\nrecovery.\\nI have seen one case of dislocation backward from the tibia, possibly\\nwith preservation of the relations with the calcaneum. The patient,\\na lad of seventeen, was admitted to the House of Relief, July 17,\\n1889, having been injured in the left ankle while wrestling. The\\nfoot was abducted, its inner side normal and painless the lower part\\nof the fibula was prominent, the region swollen and tender. A care-\\nful examination was made under ether, and the above diagnosis reached.\\nOn adduction of the front of the foot the bone returned to its place\\nwith an audible snap. The dislocation was then reproduced by abduc-\\ntion of the foot, and again reduced by adduction.\\nSPONTANEOUS OR PATHOLOGICAL DISLOCATIONS.\\nThese have been reported as occurring at the upper end in conse-\\nquence of inflammation of the joint, of rhachitic changes in the bones,\\nand of exaggerated growth of the tibia following necrosis. In the\\nsame group may be classed a dislocation outward reported by Bryant,\\nwhich was due to arrest of the growth of the tibia.\\n1 Dunand These de Paris, 1878, No. 217.\\n51", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0885.jp2"}, "878": {"fulltext": "802 DISLOCATIONS.\\nMalgaigne, after quoting a general description given by Cooper,\\naccording to which chronic hydrarthrosis leads to the easy displace-\\nment of the head of the fibula and to much weakness and fatigue in\\nwalking, describes a case under his own care in which this laxity of\\nthe joint existed in certain movements of the knee the fibula was dis-\\nplaced backward, returning almost at once to its place with a cracking\\nsound the condition followed an arthritis which had produced a sim-\\nilar relaxation of the knee. In a case of rhachitic curvature of the\\nleg in an infant Malgaigne thought he could recognize the head of the\\nfibula displaced upward almost to the level of the articular surface of\\nthe tibia, and on examining the rhachitic skeletons preserved in the\\nMusee Dupuytren he found several examples the displacement was\\nupward and outward at the upper end, the lower end preserving its\\nnormal relations.\\nDislocation downward of the upper end due to elongation of the\\ntibia following necrosis was described by Parise (quoted by Malgaigne),\\nwho reported three cases. In one of them the elongation was three\\ncentimetres on the inner side of the tibia, one and a half centimetres\\non the outer. Malgaigne subsequently saw and reported a fourth\\ncase. The conditions did not affect the functions of the limb.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0886.jp2"}, "879": {"fulltext": "CHAPTER LVII.\\nDISLOCATIONS AT OR NEAR THE ANKLE.\\nDislocations of the Foot (Tibio-tarsal) Subastragaloid Total Dislocation of\\nthe Astragalus Medio-tarsal Congenital.\\nAnatomy.\\nThe principal movements of the foot are that of flexion and\\nextension, or dorsal and plantar flexion, which takes place in the\\njoint formed by the astragalus and the tibia and fibula, and that of\\nadduction and abduction combined, respectively, with inversion and\\neversion of the sole, which takes place in the joints between the astrag-\\nalus on one side, and the calcaneum and scaphoid on the other, and is\\naided by slight motion between the calcaneum and cuboid. The axis\\nof the first joint, the ankle, is horizontal and nearly transverse, its\\ninner end inclining forward that of the other runs obliquely from a\\npoint near the inner tuberosity of the calcaneum upward and forward\\nto a point on the upper surface of the neck of the astragalus.\\nThe astragalus articulates above with the under surface of the tibia,\\nand on the sides with the malleoli, between which it is so snugly placed\\nthat no lateral motion is possible. On each side the lateral ligament\\npasses to the astragalus and calcaneum from the malleolus, and the\\nlower ends of the tibia and fibula are bound together by ligaments in\\nfront and behind. The range of dorsal and plantar flexion is nearly 90\\ndegrees, and as the articular surface of the astragalus is somewhat nar-\\nrower behind than in front some lateral motion of the joint is possible\\nin full plantar flexion.\\nThe rounded head of the astragalus articulates with the posterior\\nconcave surface of the scaphoid, the inferior calcaneo-scaphoid liga-\\nment, and slightly with the anterior end of the calcaneum. On the\\nunder surface of the astragalus are two articular facets corresponding\\nto two on the upper surface of the calcaneum, and between them is the\\nstrong interosseous ligament which fills the canal formed by a groove\\non each bone separating its two articular surfaces, and binds the bones\\nfirmly together. The maximum range of motion in these joints is\\nabout 40 degrees, and is limited partly by bony contact and partly by\\nthe ligaments.\\nIn this chapter I shall describe four different dislocations those of\\nthe foot, those of the astragalus, the subastragaloid, and the medio-\\ntarsal dislocations under the first term are included those in which\\nthe astragalus, while maintaining its relations with the other bones of\\nthe foot, is displaced from the bones of the leg; under the second,\\nthose in which it is also displaced from the calcaneum and scaphoid\\nunder the third, those in which the astragalus remains in the tibio-\\n803", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0887.jp2"}, "880": {"fulltext": "804 DISLOCATIONS.\\nfibular mortise and is separated from the calcaneum and scaphoid and\\nunder the fourth, those in which the scaphoid and cuboid are together\\ndislocated from the astragalus and calcaneum.\\nDISLOCATIONS OF THE FOOT. TIBIO-TARSAL DISLOCATIONS.\\nThe displacements of the astragalus and the foot are so complex\\nthat the nomenclature of the various dislocations presents serious diffi-\\nculties, and the confusion has been increased by the varying practices\\nof different writers, some of whom treat the tibia as the dislocated bone\\nand apply the terms indicative of direction to it, while others consider\\nthe foot as the dislocated portion. I shall here follow the latter prac-\\ntice, and shall use in the classification only four main terms, disloca-\\ntions forward, backward, outward, and inward, disregarding for the\\nmoment the many deviations in the direction of the toes and of the\\nsole which are seen in conjunction with the principal dislocations. Of\\nthese four the first two are pure dislocations in the latter two are fre-\\nquently placed cases in which the displacement is associated with frac-\\nture of one or both bones of the leg, and of which the more common\\nforms have been elsewhere described among fractures at the ankle.\\nIt must be freely conceded that the classification, especially in respect\\nof the last two groups, is arbitrary and open to serious criticism, but\\nso are all others that have been proposed, and it is believed that this\\none has a sound clinical basis in so far that the terms outward and\\ninward correspond to displacement outward, or eversion, or to displace-\\nment inward, or inversion of the foot, the symptoms which would at\\nonce attract the attention of the surgeon, and that its divisions coincide\\nalso with those of the modes of production.\\nTwo striking varieties, in which the toes are turned directly inward\\nor outward, will be mentioned under inward and outward dislocations\\nrespectively. The latter has been classified by some as a separate\\nform, under the title of dislocation of the foot by rotation outward.\\nThe mechanism of the joint and the mode of production of the dis-\\nlocations have been experimentally studied by many surgeons and\\nanatomists, of whom I shall here name only one of the more recent,\\nHonigschmied, 1 whose experiments were exceptionally numerous, and\\nwhose article is very full.\\n1. Dislocations Backward.\\n(Syn. Dislocations of the lower end of the tibia forward see also\\nFractures at the Ankle.)\\nIn these dislocations the astragalus, and with it the foot, is displaced\\nbackward to a variable distance, with rupture of the lateral ligaments\\nand sometimes of other parts of the capsule, and sometimes with frac-\\nture of one or both malleoli or of the posterior edge of the lower\\narticular surface of the tibia.\\nThe cause is usually extreme plantar flexion of the foot, in which\\nthe posterior border of the end of the tibia comes into contact with the\\n1 Honigschmied Deutsche Zeitschrift fur Chir., 1877, vol. viii. p. 239.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0888.jp2"}, "881": {"fulltext": "DISLOCATIONS AT OR NEAE THE ANKLE. 805\\nposterior lip of the astragalus (Henke 1 by which a new centre of\\nmotion is established behind the line of the malleoli the continuation\\nof the movement ruptures the lateral and the anterior ligaments, and\\nthe bones being thus freed the tibia is pushed forward over the astrag-\\nalus, or the foot is pushed backward under the tibia, according as the\\ncausative violence acts upon the leg or upon the foot. The rupture of\\nthe ligaments is the first step, and the fixation of the astragalus behind\\nthe tibia takes place by correction of the plantar flexion. Commonly\\nthe injury is produced by a fall backward while the foot is fixed. In\\nan incomplete dislocation reported by Sanson (quoted by Albert) the\\npatient s leg was bent under him in a fall in such a way that the dor-\\nsum of the foot and the front of the leg rested on the ground, and the\\nbuttocks rested on the heel in this case the mechanism appears to have\\nbeen pure exaggerated plantar flexion. Examples of pure primary dis-\\nlocation are rare, Malgaigne could find only eighteen reported cases\\nbut partial, and perhaps complete, dislocations occurring as a second-\\nary result of rupture of the lateral ligaments or fracture of the fibula\\nand internal malleolus, as in fracture by eversion at the ankle, are fre-\\nquent, and always need to be guarded against in the treatment of this\\nlast-named injury; they are produced either by the falling backward\\nof the insufficiently supported foot, as the patient lies upon his back,\\nor by contraction of the flexor muscles, and occasionally subcutaneous\\ndivision of the tendo Achillis has been resorted to to overcome or\\nprevent it.\\nHonigschmied produced the dislocation twenty times and found the\\nresults quite constant in 14 the internal lateral and the anterior branch\\nof the external lateral ligament were the first to yield, being torn away\\nfrom their insertions, then the middle and posterior branches of the\\nexternal lateral ligament yielded, and the foot was thus completely\\nfreed. The ligaments were torn away, and occasionally small scales\\nof bone came away with them. In 5 experiments on the bodies of\\nelderly people, both malleoli were broken off in 3, and the external\\nmalleolus in 2. The internal malleolus broke at its base, and the line\\nof fracture ran dowmvard and backward that of the external mal-\\nleolus ran upward and backward, beginning just above the insertion\\nof the anterior branch of the lateral ligament.\\nClinically and post mortem the same lesions have been found frac-\\nture of the external malleolus is common, that of the internal malleolus\\nand of the posterior articular border of the tibia is occasionally seen.\\nThe foot appears shortened in front, and the heel lengthened, to an\\nextent that varies with the degree of the displacement, the maximum\\nbeing about an inch the lower end of the tibia projects more or less\\nmarkedly in front and sometimes is exposed by rupture of the skin\\nthe extensor tendons may be felt as tense cords crossing to the dorsum\\nof the foot, and the tendo Achillis curves backward to the heel leaving\\non each side a well-marked depression between itself and the malleolus.\\nThe toes may be a little depressed, and perhaps abducted or adducted.\\nIf the fibula is broken its malleolus accompanies the foot in its dis-\\nplacement backward.\\n1 Henke Zeitschrift fur rat. Med., 1858, 3d ser., vol. ii. p. 177.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0889.jp2"}, "882": {"fulltext": "806 DISLOCATIONS.\\nReduction, with the exception of Cooper s first case, in which he\\nappears not to have made the diagnosis at the time, has always been\\neasily obtained by pressing the foot forward and the lower end of the\\nleg backward, and the limb should then be immobilized, preferably in\\na posterior moulded splint so as more surely to prevent recurrence.\\n2. Dislocations Forward.\\n(Syn. Dislocations of the lower end of the tibia backward.)\\nIn this dislocation, which is much rarer than the preceding, the\\nastragalus, and with it the foot, is displaced forward from beneath the\\ntibia. Malgaigne collected only five cases, Delamotte, Colles, Xela-\\nton, Pierre, and R. W. Smith, and I am able to add only five more,\\nHuguier, 1 Sarazin, 2 Augarde, 3 Willemin, 4 and Hornby, 5 making ten\\nin all.\\nThe mode of production may be by dorsal flexion of the foot fol-\\nlowed by impulsion of the tibia downward and backward by a force\\nacting in the direction of its long axis, or by direct pressure of the\\nfoot forward and of the leg backward while they are at right angles to\\neach other. Among the recorded cases are clear examples of each,\\nsuch as R. W. Smith s and Xelaton s of the former, and Huguier s\\nof the latter. R. W. Smith s 6 patient, while standing with the hip\\nand knee flexed and with the foot resting on a stone in such a manner\\nthat the toes were higher than the heel, was struck upon the knee by\\na falling cask which forced it downward and increased the flexion at the\\nknee and ankle. In Xelaton s case, 7 a woman, who fell from the\\nfourth floor, the anterior lip of the articular surface of the tibia was\\nbroken off, and the upper surface of the astragalus was scratched\\nautero-posteriorly, showing that the tibia had been inclined forward so\\nthat the edge of the fracture was in contact with the astragalus and\\nhad been pressed firmly against it as the tibia slipped backward.\\nThe second method of production differs, therefore, from the first\\nonly in the direction in which the force and counter-force are applied,\\nboth acting, in the second, at right angles to the long axis of the limb,\\nthe one upon the front of the lower end of the tibia, the other in the\\nopposite direction upon the back of the heel. Huguier s case is an\\nexample a man, while engaged in turning a railway turntable, fell\\nand caught his foot in such a manner that the heel was fixed and a\\nprojecting rail on the moving turntable pressed against the front of\\nthe tibia six inches above the ankle and produced a well-marked dis-\\nlocation of the foot forward.\\nThe symptoms are lengthening of the front of the foot and shorten-\\ning of the heel, with effacement of the depressions on each side of the\\ntendo Achillis. The foot is in the position of more or less plantar\\n1 Huguier Gaz. des Hopitaux, 1855, p. 469, and Arch. gen. de Med., 1868, vol. i. p. 513.\\n2 Sarazin llecueil de mem. de med. chir. et pharm. mil., 1860, vol. iv. p. 66.\\n3 Augarde Idem, 1880, vol. xxxvi. p. 168.\\n4 Willemin L Union med., 1866, vol. xxix. pp. 50 and 73.\\n5 Hornby Medical Times and Gazette, 1871, vol. ii. p. 10.\\n6 R. W. Smith Dublin Quarterly Journal of Medicine, 1852, vol. i. p. 465.\\n7 Xelaton Pathol, externe, vol. ii. p. 477.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0890.jp2"}, "883": {"fulltext": "DISLOCATIONS AT OB NEAR THE ANKLE. 807\\nflexion, and in one or two cases the hollow of the instep was exagger-\\nated. The upper articular surface of the astragalus can be felt in front\\nof the end of the tibia, and the malleoli are nearer to the heel and to\\nthe sole than normal.\\nIn four cases reduction was easily made by traction and direct press-\\nure in Smith s it could not be made, but there is reason to think the\\nefforts were not guided by a correct appreciation of the nature of the\\ninjurv Xelaton s patient was killed by the fall j in the remaining cases\\nthe details of treatment are lacking.\\n3. Dislocations Inward.\\nIn this division are placed those cases in which, usually by adduction\\nand inversion (supination), the foot is moved downward and to the\\ninner side, so that the astragalus leaves the tibio-fibular mortise more\\nor less completely. Two distinct forms are observed in one the foot\\nis markedly inverted and the upper surface of the astragalus can be\\nseen and felt raising the skin under the external malleolus in the\\nother the inversion of the foot is less or is absent and there is marked\\nadduction, so that sometimes the ends of the toes point directly inward\\nin the latter form it is thought that the displacement is secondary to a\\nbackward dislocation.\\nMalgaigne includes in the group (which he terms tibio-tarsal dislo-\\ncations outward) many cases complicated by fracture of the astragalus\\nor of one or both bones of the leg but of his total of 22 cases, 8 were\\nnot thus complicated, and to these I can add 5, Busch, 1 Nunnely, 2\\nEames, 3 Carmichael, 4 and Spaeth. 5 I have described under frac-\\ntures by inversion and adduction of the foot the lesions and symp-\\ntoms in cases in which fracture is present and the displacement is slight.\\nExcluding for the moment those cases in which the displacement is\\nsecondary to a backward dislocation, it seems probable that the cause\\nis violent supination, or inversion, of the foot, but the histories of the\\ncases do not positively establish this opinion. In most the cause has\\nbeen a fall, usually from a height.\\nThe astragalus fits so snugly and squarely into the tibio-fibular mor-\\ntise that in a considerable proportion of cases it cannot be turned in it\\nabout its own antero-posterior axis without breaking the external mal-\\nleolus or forcing it away from the tibia by the pressure of the upper\\nouter edge of the astragalus. In the experiments which Honig-\\nschmied made by fixing the foot in a vise and bending the leg directly\\ntoward the inner side tibial flexion the external malleolus was\\nbroken 5 times, the external lateral ligament torn from its insertion\\n12 times, and in 3 cases the joint remained unopened and separation\\ntook place between the astragalus and the calcaneum. These results\\ncoincide in the main with those obtained in a similar manner by Bon-\\nnet, and Honigschmied accepts the latter s opinion that the fracture of\\nthe malleolus is effected by the direct pressure upon it of the outer\\n1 Busch Lehrbuch der Chir., vol. ii., part 3, p; 327; quoted by Lossen.\\n2 Nunnely British Medical Journal, 1868, vol. ii. p. 362.\\n8 Earues Idem, 1871, vol. i. p. 503. 4 Carmichael Idem, 1871, vol. ii. p. 35.\\n5 Spaeth Miinchen. med. Wochen., January 17, 1888.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0891.jp2"}, "884": {"fulltext": "808 DISLOCATIONS.\\nupper border of the astragalus and not by traction exerted through the\\nexternal lateral ligament. Bonnet frequently found the internal mal-\\nleolus also broken, Honigschmied never.\\nIn one case, Busch, in which there was no fracture, the dislocation\\nwas compound and the bones of the leg protruded through the wound\\nin front, the astragalus lay entirely to the inner side of the internal\\nmalleolus, and the foot was greatly adducted Busch thought the dis-\\nlocation had been primarily backward. In Bardy s case fracture of\\nthe fibula was noted, and in Ravaton s (both quoted by Malgaigne)\\nthere was diastasis of the lower tibio-fibular joint, which gave him\\nmuch trouble in the treatment.\\nIn some cases, in which the displacement inward may be assumed to\\nhave been secondary to a backward dislocation, the adduction of the\\nfoot has been very great, 90 degrees, so that the toes pointed directly\\ntoward the other ankle in the others the adduction is less, but the\\ninversion is great in Carmichael s the plantar aspect pointed to the\\nmiddle line of the body, in Earnest the plantar aspect of the foot\\nwas completely inverted, in Spaeth s the inner border lay directly\\nbeneath the tibia. In some the external malleolus was very promi-\\nnent in Nunnely s there was a large and well marked projection\\nbelow the outer malleolus over which the skin was very tense, and\\nthere was a deep, narrow depression at the inner malleolus where the\\nskin was also very tight.\\nReduction has always been easily effected by traction and eversion\\nof the foot, and in the uncomplicated cases the recovery has been\\ncomplete.\\n4. Dislocations Outward.\\nThe injuries which have been described under this head are, almost\\nwithout exception, those which are now commonly known as Pott s\\nfracture at the ankle, and which have been described in Chapter XXV.\\nas fractures by eversion and abduction of the foot. A few more or\\nless doubtful cases have been reported which differ more or less from\\nthose of Pott s fracture in their mode of production and lesions, and\\nwhich might be termed partial dislocations of the foot outward. One\\nsuch, Boyer, has been quoted in Chapter LVI. as an example of\\nupward dislocation of the head of the fibula.\\nIn four cases, Huguier, 1 Thomas, 2 Soubie, 3 and Knust, 4 the foot has\\nbeen so far abducted that the toes pointed directly outward. This form\\nwas first observed by Huguier and described by him as dislocation of\\nthe foot by rotation outward. His patient was overthrown by a cask,\\nwhich rolled upon his legs Thomas s by a falling mass of straw\\nSoubie s fell from a height of six feet, alighting upon his left foot,\\nwhich was then engaged between a large stone and the trunk of a vine\\nwhile the body was twisted to the right, and the patient fell on his\\nright side and Knust s twisted his right foot in like manner, the body\\nturning to the left. In Huguier s case the external malleolus was\\nseparated from the tibia, pressed backward, and rotated outward, and\\n1 Huguier L Union Medicale, 1848, p. 128. 2 Thomas Eevue de Chirurgie, 1887, p. 821.\\n3 Soubie Quoted by Thomas. 4 Knust Ceutralbl. fur Chir., 1898, p. 320.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0892.jp2"}, "885": {"fulltext": "DISLOCATIONS AT OR NEAR THE ANKLE. 809\\nthe shaft of the fibula was broken in the upper third. In the other\\ntwo cases no fracture was found. Eeduction was easily effected under\\nanaesthesia in the first three cases not mentioned in the fourth.\\n5. Compound and Complicated Dislocations of the Foot.\\nDislocations of the foot may be compound, primarily or secondarily,\\nwith protusion of the bones of the leg or of the astragalus through\\nthe wound, and they may be complicated by rupture of bloodvessels\\nand by other fractures than those of the malleoli already referred to.\\nIn dislocations that are primarily compound the wound of the skin\\nmay be made from within outward by the projecting bone or by contact\\nwith the ground. In those that become secondarily compound the\\nsloughing of the soft parts may be due to the pressure of the unre-\\nduced bones or to bruising of the soft parts inflicted at the time of\\ndislocation.\\nStatistics that have been collected from the period anterior to the\\nintroduction of antiseptic methods cannot be trusted to show the neces-\\nsity or desirability of amputation or excision. Later ones (Scudder 1\\nshow that conservative treatment may be safely tried in many cases.\\nAmputation or excision is indicated when infection is certain, the\\npatient feeble, or the functional result otherwise likely to be bad.\\nNeither the loss of the astragalus nor anchylosis of the ankle-joint\\nusually causes much disability. Particular attention must be given\\nto drainage, and as the astragalus completely fills the space between\\nthe malleoli separate drainage must be provided for the back and front\\nof the joint.\\nThe limb must be carefully immobilized with the foot at a right\\nangle to the leg and without inversion or eversion, in order that if the\\njoint should become stiff the disability will not be increased by a\\nfaulty position of the foot.\\nSUBASTRAGALOID DISLOCATIONS. DISLOCATON OF THE AS-\\nTRAGALO-CALCANEOID AND THE ASTRAGALO-SCAPHOID\\nJOINTS.\\nFor the establishment of this group in the classification of disloca-\\ntions of the tarsal bones we are indebted to Broca, 2 who, in a remark-\\nable paper read before the Society de Chirurgie in 1852, carefully\\nanalyzed the scattered cases that had been reported under various titles\\nand gave a detailed and systematic description of the various forms of\\nthe injury, to which little has since been added except in amplification\\nof the statistics. His plan of subdivision recognized dislocations back-\\nward, inward, and outward of the calcenum and scaphoid from the\\nastragalus. Malgaigne added a fourth variety, dislocations forward,\\nand changed the nomenclature by treating the astragalus as the dislo-\\ncated bone and applying the terms indicative of the direction of the\\ndisplacement according to its position with relation to the others. I\\n1 Scudder Boston Medical and Surgical Journal, April 7, 1892.\\n2 Broca Mem. de la Soc. de Chirurgie, 1852, vol. iii. p. 566, and abstract in Bull, de la\\nSoc. de Chirurgie, 1853, vol. iii. p. 241.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0893.jp2"}, "886": {"fulltext": "810\\nDISLOCATIONS.\\nshall here follow Broca s use of the terms, which is in harmony with\\nthat used in the other dislocations.\\nThe dislocation, then, presents four varieties that in which the cal-\\ncaneum and scaphoid are displaced inward (and somewhat backward),\\nthe head of the astragalus projecting on the outer part of the dorsum\\nof the foot that in which they are displaced outward and those in\\nwhich they are displaced directly forward or backward and downward.\\nThe first two are about equal in frequency and together comprise most\\nof the reported cases of each of the last two only one or two exam-\\nples have been reported. The most notable addition to the collected\\nstatistics has been made by Poinsot. 1\\n1. Dislocations Inward, or Inward and Backward.\\nThe cause is forcible inversion and adduction of the foot, usually\\ncombined with violence acting in the direction of the long axis of the\\nleg, as in a fall from a height. The displacement is rarely, if ever,\\ndirectly inward, but is also somewhat backward, so that the head of\\nthe astragalus rests partly upon the cuboid. The only autopsy is one\\nmade in an old case by Quenu 2 there was shortening of the dorsum\\nof the foot and elongation of the heel, and the\\nfoot was in the position of varus. The head\\nof the astragalus lay upon the interarticular\\nlines between the calcaneum and cuboid and\\nthe cuboid and scaphoid, overlapping the\\nformer half an inch and thus resting on the\\ncuboid. The posterior border of the astragalus\\nlay in the groove between the anterior and pos-\\nterior superior articular surfaces of the calca-\\nneum, and its posterior lip had been broken off\\nand remained in its normal relations with the\\ncalcaneum. There was no fracture of either\\nmalleolus. The dorsal is pedis artery and the\\nextensor tendons lay to the inner side of the\\nhead of the astragalus the peroneal tendons\\nhad been displaced from their groove and sepa-\\nrated half an inch from the fibula. In other\\ncases the displacement has been greater and the\\nskin has been broken on the outer side of the\\nfoot in one of Malgaigne s the head of the\\nastragalus Avas almost in contact with the fifth\\nmetatarsal bone in one of Letenneur s it cor-\\nresponded to the outer border of the foot and\\nprojected entirely through a wound in the skin, and the calcaneum\\nhad been completely displaced from its inferior articular surface. In\\none of my own the external malleolus protruded through and was\\ntightly grasped by a rent in the skin evidently perforation had\\n1 Poinsot L intervention chirurgicale dans les luxations compliquees du cou-de-pied,\\nParis, 1877, and his translation of Hamilton s Fractures and Dislocations, p. 1196.\\n2 Quenu Progres Med., 1883, p. 187.\\nSubastragaloid dislocation\\ninward 5, sustentaculum\\ntali 4, inner malleolus.\\n(Du Bourg.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0894.jp2"}, "887": {"fulltext": "DISLOCATIONS AT OB NEAR THE ANKLE.\\n811\\noccurred while the foot was in extreme inversion, and I was obliged\\nto lengthen the opening downward for an inch in order to reduce.\\nThe patient made a good recovery, with some limitation of inversion\\n(supination) of the foot. The form and degree of the displacement\\nvary with the different combinations of displacement inward, back-\\nward, and by adduction of the front of the foot, the latter sometimes\\nleaving the posterior part of the calcaneum less displaced inward than\\nits front part. With the dislocation there are sometimes associated\\ninjury to the calcaneo-cuboid joint, rupture of its ligaments, and par-\\ntial dislocation of the bones.\\nThe symptoms are more or less shortening of the dorsum of the foot\\nand lengthening of the heel, adduction of the toes, and elevation of\\nthe inner border of the foot prominence of the tip of the external\\nmalleolus and of the head of the astragalus on the outer side of the\\ndorsum, with marked depressibility of the soft parts below each the\\ninternal malleolus is deeply placed under the skin, and below and\\nbehind it can be felt the projecting sustentaculum tali, and in front of\\nit the inner surface of the scaphoid.\\nFig. 336.\\n2. Dislocations Outward.\\nOf these Malgaigne makes two varieties, distinguished clinically by\\nthe existence of marked abduction of the toes\\nin one, and its absence in the other. In the\\nformer (his luxation oblique en dedans, or obliquely\\noutward, according to the nomenclature here\\nused) the posterior articular surface of the\\nastragalus is not separated from the calcaneum,\\nbut the foot has turned upon the posterior cal-\\ncaneo-astragaloid joint, or upon the outer part\\nof the interosseous ligament as a centre, and\\nthe scaphoid has been carried to the outer side\\nof the head of the astragalus, and also some-\\ntimes either upward or downward. In the sec-\\nond form, that without abduction of the toes,\\nthe foot is displaced bodily outward from be-\\nneath and in front of the astragalus. The\\ncause in the former is forcible abduction of the\\nfoot in the latter it appears to be either abduc-\\ntion and eversion of the foot, or great violence\\nexerted directly against the inner side of the\\nfoot, or the outer side of the lower part of the\\nleg. The dislocation may be primarily or sec-\\nondarily compound, the wound in the skin cor-\\nresponding to the head of the astragalus which\\nmay project entirely through it. The tendon\\nof the tibialis anticus sometimes lies along the\\ninner and upper part of the neck of the astrag-\\nalus, which is thus tightly held between it and\\nthe calcaneo-scaphoid ligament. In a case of the oblique form quoted\\nSubastragaloid dislocation\\noutward. (Malgaigne.)", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0895.jp2"}, "888": {"fulltext": "812 DISLOCATIONS.\\nby Malgaigne, in which the patient died four days after the acci-\\ndent, the outer part of the interosseous ligament in the sinus tarsi was\\nentire the inner part was ruptured. In one of the complete outward\\nform, of which the specimen was dissected, and reported by Xelaton\\n(Fig. 336), the head of the astragalus rested against the inner side of\\nthe scaphoid, and its posterior lip was engaged in the groove in the\\nupper surface of the calcaneum the lower part of the internal lateral\\nligament, the interosseous ligament, and the astragalo-scaphoid liga-\\nment were ruptured, and the posterior and outer part of the external\\nmalleolus was broken.\\nThe calcaneo-cuboid joint may also be injured, and the bones partly\\ndisplaced from each other.\\nThe symptoms in the oblique variety are the marked abduction of\\nthe foot, more or less eversion, and marked prominence of the head of\\nthe astragalus on the inner side. In a case reported by Boyer the dis-\\nplacement was slight, and was at first overlooked when recognized, it\\nwas irreducible, but the patient regained good use of the limb.\\nThe symptoms in the variety in which the displacement is directly\\noutward are the marked displacement of the foot, with but little, if\\nany, eversion or abduction, the axis of the leg falling to the inner side,\\nand somewhat in front of the part of the foot to which it normally\\ncorresponds. Above the outer surface of the calcaneum and cuboid\\nis a notable depression in the place of the usual prominences formed\\nby the external malleolus and the head of the astragalus. The inter-\\nnal malleolus is very prominent and nearer to the level of the sole,\\nand below and in front of it is the projecting head of the astragalus.\\nOn the dorsum of the foot the scaphoid is recognizable with a depression\\nbehind it.\\n3. Dislocation Backward.\\nIn this the calcaneum and scaphoid are displaced directly backward,\\nthe scaphoid descending to a lower level so as to lie under the head or\\nneck of the astragalus. Deviation of the foot to either side would\\ncreate forms intermediate between this and the two preceding ones. A\\nnumber of reported cases, which were claimed to be subluxations of\\nthis kind, the relations between the scaphoid and astragalus being\\nchanged while those between the calcaneum and astragalus remained\\nunchanged, were rejected by Broca as errors of diagnosis, but are\\naccepted by Malgaigne as probably correct. In some of them reduc-\\ntion was easy in others it failed, but the persistence of the displace-\\nment did not permanently impair the functions of the limb.\\nOf the complete form there are only two recorded examples the\\nfirst is the much quoted case of Prof. Carmichael, reported by Mac-\\ndonald. 2 Carmichael, in his eifort to avoid a fall when his horse\\nstumbled and came upon his knees, leaned back in the saddle and\\nthrust his feet forward his weight was received upon the inner side\\nof the ball of the right foot, and the dislocation was thereby produced,\\nthe deformity being so great that it was recognizable through his boot.\\n1 Nelaton Bull, de la Soc. Anatomique. 1S35, p. 38.\\n2 Macdonald Dublin Quarterly Journal Med. Sci., 1838, vol. xiv. p. 235.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0896.jp2"}, "889": {"fulltext": "DISLOCATIONS AT OR NEAR THE ANKLE. 813\\nThe toes were abducted about 30 degrees, the foot slightly everted\\nthe concavity of the tendo Achillis was manifestly increased and the\\nheel lengthened the astragalus could not be felt behind the tibia.\\nBelow and in front of the inner malleolus was a hard prominence, over\\nwhich the skin was tense, formed by the inner surface of the astragalus.\\nThe most striking deformity was a prominence on the dorsum of the\\nfoot immediately in front of the tibia it presented a fiat surface\\nbroad enough to receive the finger, from which there was an abrupt\\ndescent upon the anterior part of the tarsus. Over the projection\\ncaused by the head of the astragalus thrown on the upper surface of\\nthe scaphoid and cuneiform bones, the integuments were so tense that\\nit was very evident a small additional force would have driven it\\nthrough the skin. The distance from the internal malleolus to the\\nend of the great toe was one inch less than on the other foot No\\nfracture could be found. Flexion and extension were very painful.\\nThe dislocation was reduced by traction with the pulleys and direct\\npressure on the heel and leg.\\nThe second case was observed by Thierry, and communicated to\\nMalgaigne by Broca; the dislocation was caused by a fall upon the\\ntoes; the head of the astragalus was prominent under the skin, the\\nfront of the foot appeared shortened, the heel lengthened the foot was\\nextended, and not deviated to either side. Good recovery.\\nAn irregular case of subastragaloid dislocation backward and out-\\nward in which the scaphoid preserved its relations with the astragalus\\nand the anterior portion of the line of dislocation ran between the\\nscaphoid and cuneiform bones was reported by Kaufmann. 1 The dis-\\nplacement had existed nine months and was then treated by excision\\nof the scaphoid and head of the astragalus with a good result.\\n4. Dislocation Forward.\\nOf this only two examples have been reported, one by Parise,\\nquoted by Malgaigne, the other by Broca. 2 Parise s patient was\\ninjured by being crushed under a heavy weight, the thigh being flexed\\non the trunk, the leg on the thigh, and the foot on the leg (dorsal\\nflexion). Nine months afterward the condition was as follows the\\nfoot was at a right angle with the leg, a little adducted, and very\\nslightly everted it was displaced forward, so that it appeared length-\\nened in front, and the external malleolus almost touched the tendo\\nAchillis. The extensor tendons on the instep were tense, and no\\nprominence could be felt beneath them, but on the outer side a bony\\nprominence could be felt, which was thought to be the head of the\\nastragalus, and immediately in front was a depression which admitted\\nthe finger. The hollow between the astragalus and calcaneum seemed\\nto be filled. Behind, the prominence of the heel was completely lost,\\nthe leg flattened, and its surface interrupted at the level of and a little\\nbelow the malleoli by a bony prominence which raised the tendo\\nAchillis and overlapped the heel nearly half an inch above it was\\n1 Kaufmann Centralblatt fur Chir., 18S8, p. 369.\\n2 Broca Eeport by Petit of a cliuical lecture, Gaz. Hebdorn., 1874, p. 316.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0897.jp2"}, "890": {"fulltext": "814 DISLOCATIONS.\\nanother, less prominent, formed by the posterior articular edge of the\\ntibia. There was no trace of fracture, no separation of the malleoli.\\nThere was slight motion in the tibio-tarsal joint motion in the joints\\nof the tarsus was entirely lost. The patient could hardly walk without\\ncrutches.\\nIn Broca s case the displacement was much less marked, and the\\nonly symptoms were an increase of one centimetre in the distance from\\nthe internal malleolus to the great toe, and a corresponding shortening\\nof the heel, and the absence of abnormal prominence of the astragalus\\nin front of the tibia. By traction and pressure under chloroform the in-\\nequality in the measurements was overcome and the patient, at the time\\nof the report, was in a fair way to recover. So far as can be judged\\nfrom the report, Broca did not consider the diagnosis entirely clear, and\\nthe symptoms as given are identical with those of Sarazin s case of\\nincomplete tibio-tarsal dislocation forward. The differential diagnosis\\nbetween these two injuries would have to be made on the existence of\\na gap between the astragalus and scaphoid in the subastragaloid dislo-\\ncation, and the absence of such a gap and possibly the abnormal promi-\\nnence of the upper articular surface of the astragalus in front of the\\ntibia in the incomplete tibio-tarsal dislocation forward. The recogni-\\ntion of either symptom might be made difficult or impossible by\\nswelling.\\nDiagnosis of Subastragaloid Dislocations.\\nIf the date of the injury is so recent that swelling has not yet super-\\nvened, or so remote that it has disappeared, the diagnosis may usually\\nbe made with considerable ease and certainty, but if swelling is pres-\\nent it may be very difficult. The important functional features are\\nthe preservation of the normal movements in the tibio-tarsal joint,\\nand the loss or the exaggeration in one or the other direction of the\\nlateral and rotatory movements of the foot which take place in the\\nsubastragaloid and medio-tarsal joints. As no lateral motion takes\\nplace in the tibio-tarsal joint, except in the position of full plantar\\nflexion, the exaggeration of the normal movement to either side must\\nbe due, when the ankle is sound, to injury of the two last-named joints.\\nThe physical signs are the preservation of the relations between the\\nastragalus and the bones of the leg, as shown by the normal relations\\nof the malleoli to the head of the astragalus and by the absence of\\nabnormal projection of the body of the astragalus in front or behind\\nthe tibia, the changes in length of the front part of the foot and heel,\\nand the change in the relations of the calcaneum and scaphoid with\\nthe astragalus and malleoli.\\nTreatment of Subastragaloid Dislocations.\\nThe statistics collected by Broca and Poinsot give 23 simple cases\\nin which reduction was attempted; to these may be added Pick s l case.\\nOf these 24 reduction was successfully made in 14 and the ultimate\\n1 Pick Lancet, 1S80, vol. i. p. 170.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0898.jp2"}, "891": {"fulltext": "DISLOCATIONS AT OB NEAR THE ANKLE. 815\\nresult was good in 2 the reduction was incomplete, and 1 of these\\ndied of septicaemia. The 8 failures (excluding the 2 incomplete reduc-\\ntions) gave 4 secondary amputations with 3 deaths, 3 secondary re-\\nmovals of the astragalus with 1 death, and 1 good functional result\\nnotwithstanding the persistence of the deformity.\\nIn 7 additional cases in which reduction was not attempted, 4 of\\nthe patients (Du Bourg, Dubreuil, See, quoted by Poinsot, and Quenu)\\nhad apparently good use of the limb, although in 1 of them sloughing\\nand a violent arthritis followed the accident; in 1, Brown, 1 reduction\\nwas made after six months in 2 (Sinnigen, quoted by Poinsot, Raffa 2\\nthe disability was such that the patient sought relief Sinnigen removed\\nthe astragalus and external malleolus, and at the time of the report\\ndeath by septicaemia was expected Raffa chiselled away the head and\\nthe neck of the astragalus and was then able to straighten the foot\\nrecovery without suppuration good result.\\nIn 2 cases (~Verneu.il, 3 Ore, quoted by Poinsot) primary excision of\\nthe astragalus was done, in each with a good result. In VerneniPs\\nthere was fracture of the astragalus and rupture of the peroneal artery\\nin Ore s an attempt to reduce had failed and gangrene of the tense\\nskin was imminent.\\nOf compound dislocations 17 cases were collected by Broca and 6\\nadditional by Poinsot in 1884, and to these 1 reported by Jackson 4 and\\nmine are to be added of these reduction was made in 11, with 2 deaths,\\nwith persistent suppuration apparently maintained by necrosis in 2, and\\nwith secondary removal of the astragalus in 1. In 14 reduction was\\nnot made in 3 of these primary amputation was done, in 10 removal\\nof the astragalus, with 2 deaths, and in 1 the head of the astragalus\\nbecame necrosed and was spontaneously cast out, the patient recover-\\ning. The results of primary removal of the astragalus according to\\nthese statistics are rather better than those of reduction, but, as has\\nbeen said before, the value of these statistics as a basis for the choice\\nof a method of treatment has been greatly diminished by the improve-\\nment in the methods of treatment of open wounds that has taken place\\nin the last few years, and there is good reason to hope that suppuration\\nand its attendant dangers will be less frequent in future.\\nReduction, which has sometimes been made by traction with the\\nhands alone, more frequently has needed the aid of pulleys, even when\\nanaesthesia has been employed. The knee should be flexed to relax\\nthe muscles of the calf, and the traction in the lateral cases should be\\ndownward and usually also forward, and coaptative pressure should be\\nmade upon the foot and leg. The cause of the irreducibility in some\\ncases is not entirely clear it has been attributed to the engagement of\\nthe posterior lip of the astragalus in the groove on the upper surface\\nof the calcaneum, and in the outward cases to the constriction of the\\nastragalus under the tendon of the tibialis anticus.\\n1 Brown Lancet, 1876, vol. i. p. 314.\\n2 Eaffa: Centralblatt fur Chir., 1885, p. 211.\\n3 Verneuil Bull, de la Soc. Anatomique, 1872, p. 493.\\n4 Jackson Lancet, 1881, ii. p. 590.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0899.jp2"}, "892": {"fulltext": "816 DISLOCATIONS.\\nTOTAL DISLOCATION OF THE ASTRAGALUS.\\nDouble Dislocation of the Astragalus\\nThis dislocation is a combination of the two preceding ones, the\\ntibio-tarsal and the subastragaloid, the astragalus being simultaneously\\ndisplaced from its normal relations with the bones of the leg, the cal-\\ncaneus, and the scaphoid. It is much more frequent than either of\\nthe other two and is often compound. The astragalus may be displaced\\nforward, backward, or to either side, or to any intermediate position,\\nand may at the same time be rotated about any of its axes, or it may\\nbe rotated while remaining in the tibio-fibular mortise. The varieties\\nof dislocation are, consequently, very numerous, but they may be\\ngrouped as dislocations forward, backward, outward and forward, and\\ninward and forward, these terms indicating the direction in which the\\nastragalus is displaced, and dislocations by rotation, including in the\\nlatter only those in which the bone remains more or less completely\\nwithin the mortise.\\nThe causes are varied, the most common being falls from a height\\nupon the feet and violent twisting of the foot, as when it has been\\ncaught between the spokes of a wheel. It is seldom possible to deter-\\nmine the exact mode of production in any given case, and experiment\\nupon the cadaver has not done much to elucidate the subject but it\\nseems probable that dorsal or plantar flexion and abduction or adduc-\\ntion are requisite to rupture the ligaments that bind the astragalus to\\nthe other bones, and that then it is forced from its place by pressure\\nexerted through the bones of the leg.\\n1. Dislocation Forward.\\nIn this form, which is very rare, the astragalus is displaced directly\\nforward. To the briefly described and somewhat doubtful cases col-\\nlected by Malgaigne, Delorme 1 added only two, in one of which (Morel-\\nLa vallee) the astragalus had been rotated 180 degrees about its vertical\\naxis and both malleoli were broken the foot was very movable on the\\nastragalus, and the astragalus on the tibia. The sides of the bone\\ncould be distinctly felt, and its posterior surface, which looked directly\\nforward. Reduction was easily made. In the other case, Barrall, the\\ndislocation was compound, the head of the astragalus projecting\\nthrough the wound and resting on the dorsal surface of the scaphoid.\\nBoth it and the foot were freely movable. The extensor tendons and\\nthat of the tibialis anticus were ruptured, the malleoli and calcaneum\\nwere broken.\\n2. Dislocation Outward and Forward.\\nIn this, the most common form, the head of the astragalus rests on\\nthe outer cuneiform and the cuboid bones or even on the fifth meta-\\ntarsal, its posterior part lying just within the mortise, and is freely\\nmovable the foot is adducted and inverted and usually displaced\\n1 Delorme Diet, de Med. et Chir. pratiques, 1879, vol. xxvii. p. 640.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0900.jp2"}, "893": {"fulltext": "DISLOCATIONS AT OB NEAR THE ANKLE. 817\\nbodily inward, so that the external malleolus is prominent and the\\ninternal hidden, and sometimes the adduction of the front of the foot\\nis very marked and combined with abduction of the heel. If the dis-\\nlocation is compound the astragalus presents in the wound, which com-\\nmonly extends backward to or beyond the external malleolus. The\\nlower end of the fibula may be torn away from the tibia, and either\\nor both malleoli broken. With the displacement may be combined\\nvarious kinds and degrees of rotation of the astragalus, and sometimes\\nthe astragalus is broken.\\n3. Dislocation Inward and Forward.\\nIn this, the second in order of frequency, the foot is everted and\\nabducted, but sometimes is bodily displaced to the outer side without\\ndeviation. The astragalus projects in front of or below the internal\\nmalleolus, and its head appears always to be depressed, sometimes so\\nfar that the bone must have undergone rotation of 90 degrees about its\\ntransverse axis. In a case reported by Hunt l it was so far rotated\\nabout its vertical axis that the head was directed toward the middle of\\nthe other foot. If the injury is compound the wound lies on the inner\\nside and extends backward below the malleolus. It may be accom-\\npanied by fracture of the malleolus.\\n4. Dislocation Inward.\\nA unique case is reported by Seiler. 2 The astragalus lay directly\\nbeneath the internal malleolus and had been so rotated that its lower\\nsurface looked inward. A free incision was made and the bone\\nrestored to its place. The internal malleolus and sustentaculum tali\\nhad been broken. Eecovery with good function.\\n5. Dislocation Backward.\\nIn this form, which also is rare, the astragalus may be displaced\\nbackward or backward and to either side, and in some of the reported\\ncases the bone has been broken at the neck and only the posterior frag-\\nment has been displaced. Malgaigne 3 collected 8 cases, including one\\nreported by Denonvilliers, which he places 4 among dislocations by\\nrotation in place, but which, I think, belongs here the cases are\\nPhillips 2, Lizars, Liston, Turner, Nelaton, Denonvilliers, and one\\nanonymously reported in the Lancet, 1838-39, vol. ii. p. 559. To\\nthese Delorme adds 5 Blatin, Lejeune, MacCormac, Pichorel, and\\nCheever he also quotes Foucher as having reported two cases, but, I\\nthink, erroneously, one of them being Denonvilliers s case, the other\\nThierry s, a dislocation by rotation. Another case was reported by\\nMunro, 5 and one by -myself, 6 and another, Legros Clark, is reported in\\nMacCormac s paper, making 16 in all. In the seven printed in italics\\n1 Hunt: Philadelphia Medical Times, 1872, vol. iii. p. 50.\\n2 Seiler Correspblt. fur Schweiz. Aerzte, August 15, 1893.\\n3 Malgaigne: Loc. cit., p. 1058. 4 Malgaigne Loc. cit., p. 1060.\\n5 Munro: Lancet, 1859, vol. ii. p. 364.\\n6 Stimson New York Medical Journal, May 28, 1887, p. 594.\\n52", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0901.jp2"}, "894": {"fulltext": "818 DISLOCATIONS.\\nthe bone was broken at the neck, and only the posterior fragment was\\ndislocated. 1\\nOf the 9 not complicated by fracture of the astragalus, the disloca-\\ntion was backward in 6, backward and outward in 1, Turner, and back-\\nward and inward in 2, Lancet, Munro. Reduction was made in 3\\n(Lancet, Blatin, Munro), and failed in 4, the functional result being\\ngood in 3 of the latter Turner, and apparently Nelaton, removed the\\nastragalus.\\nOf the 7 complicated by fracture, the displacement in Lejeune s is\\ndescribed as backward, in the others as backward and inward the\\ndifference is slight, for in the latter the most prominent part of the\\nastragalus projects but little beyond the level of the side of the internal\\nmalleolus. The tendons of the flexor longus digitorum and tibialis\\nposticus are displaced upon the inner side of the malleolus, and that\\nof the flexor longus pollicis sometimes lies to the outer side of the\\nastragalus and sometimes is pushed directly backward by it. The\\nfragment is also rotated, so that its trochlear surface looks inward,\\nand its fractured surface is directed forward and downward. The line\\nof fracture runs from the anterior border of the trochlea into the groove\\noccupied by the interosseous ligament. In 3, Lejeuue, MacCormac,\\nDenonvilliers, the injury was compound; in Cheever s the skin over\\nthe astragalus sloughed, but the ulcer soon healed without having\\nexposed the bone.\\nReduction was made in none, although Pichorel divided the tendo\\nAchillis, and Cheever successively divided the tendo Achillis, the tibi-\\nalis anticus and posticus, the flexor longus digitorum, and the flexor\\nlongus pollicis at the toe. In three, MacCormac, Clark, Cheever, the\\npatients recovered with good use of the limb in 1, Pichorel, suppura-\\ntion followed and the limb was amputated in 2, Denonvilliers, Stim-\\nson, the posterior fragment was removed and both patients died, mine\\nof pneumonia on the ninth day. The result in Lejeune s is not stated.\\nThe astragalus can be felt behind the ankle, either pressing the tendo\\nAchillis backward or lying on one side of it. If the entire bone is\\ndisplaced the absence of the head from its normal position is shown\\nby the depressibility of the soft parts behind the scaphoid. Marked,\\nincorrigible flexion of the terminal phalanx of the great toe is noted\\nin three of the cases. In mine the tendons of the peroneus longus and\\nbrevis were displaced upon the outer side of the external malleolus.\\nIn the three cases in which reduction was made the means employed\\nwere traction followed by extension of the foot, traction, direct pressure,\\nand inversion of the foot, and traction and direct pressure in Munro s\\ncase several months elapsed before the patient regained good use of\\nthe limb.\\n6. Dislocation by Rotation.\\nIn this class are not included those numerous cases in which the bone\\nhas undergone rotation in connection with displacement from the tibia\\n1 The following are two of the references MacCormac (and Clark s case), Transactions\\nof the Pathological Society of London, 1875, vol. xxvi. p. 174, with plate of specimen ob-\\ntained two years later Cheever, Boston Medical and Surgical Journal, 1S75, vol. xciii.\\np. 237.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0902.jp2"}, "895": {"fulltext": "DISLOCATIONS AT OR NEAR THE ANKLE. 819\\nand fibula, but only those in which it still lies mainly within the\\nmortise.\\nTwo distinct varieties of this class may be made those in which the\\nbone has been rotated upon its vertical or transverse axis, and also,\\nperhaps, upon the antero-posterior axis, but still remains in great part\\nwithin the mortise and those in which the bone still lies almost exactly\\nin its normal position between the malleoli and has undergone only\\nrotation about its antero-posterior axis.\\nThe division between the first variety and that of dislocations for-\\nward and inward is rather arbitrary and is perhaps not always to be\\nmade clinically, and the three cases collected by Malgaigne differ\\nnotably from one another. Barwell, 1 in a val Liable paper containing\\na well-observed and well-reported case of his own and abstracts of all\\nthe other alleged cases except Chevallez s, proposes to term the injury\\ndislocation of the foot with version, or with torsion, of the astragalus,\\napplying the term version to the cases of rotation about the vertical\\naxis, and torsion to those of rotation about the antero-posterior axis.\\nI see no sufficient reason for using the term dislocation of the foot,\\nwhich has already been employed for another form of injury; and\\nversion and torsion do not in themselves indicate the sense in which\\nthey are used, but must be accompanied by a definition.\\nMalgaigne gives four cases of rotation about the vertical axis, but\\nI have placed one of them, Denonvilliers, among the dislocations\\nbackward. To the remaining three Barwell adds two reported by\\nYerebely 2 in three of them the head of the astragalus lay below the\\ninternal malleolus, in one just behind it, and in one just in front of\\nthe external malleolus. As they cannot w T ell be grouped I give a sum-\\nmary of each.\\nLaumonier The head of the astragalus protruded under the internal\\nmalleolus between the tendons of the tibialis posticus and flexor longus\\ndigitorum, the trochlea lying transversely in the mortise and forcing\\napart the tibia and fibula.\\nFoucher: 3 The specimen was taken from a subject found in the\\ndissecting-room. The astragalus had been rotated 90 degrees about its\\nvertical axis, the trochlea being still upright in the mortise, and the\\nhead below the internal malleolus. The tendon of the tibialis posticus\\nand the posterior tibial artery lay in front of the internal malleolus.\\nThe posterior half of the astragalus lay on the calcaneum, the latter\\nbone lying under the external malleolus and displaced forward and\\noutward, and its axis directed forward and inward. The cuboid was\\npartly dislocated downward from the calcaneum. There was no cica-\\ntrix the foot was flattened, the heel shortened.\\nThierry The head of the astragalus projected midway between the\\ninternal malleolus and the tendo Achillis, the outer border of the foot\\nwas much raised, and it w r as then seen that the bone was also so turned\\nthat its upper surface looked forward and inward, the tibia resting on\\nthe internal lateral face of the body of the bone, and the internal border\\n1 Barwell: Medico-Chirurgical Transactions, 1883, vol. lxvi. p. 39.\\n2 Verebely: Wiener med.Wochenschrift, 1S69, vol. xix. pp. 279 and 296.\\n3 Foucher Bull, de la Societe Anatomique, 1S54, vol. xxix. p. 3S8.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0903.jp2"}, "896": {"fulltext": "820 DISLOCATIONS.\\nof the trochlea exactly occupied the angle between the internal mal-\\nleolus and the under surface of the tibia. Amputation recovery.\\nVerebely Male, twenty-nine. Fibula fractured above the malle-\\nolus. Under the internal malleolus the skin was very tense about\\nan inch lower there was a hard bony prominence about half an inch\\nin diameter. Reduction failed. At the end of the third week an\\nabscess was opened, and it was seen that the prominence under the\\nmalleolus was the head of the astragalus. After four months treat-\\nment the man could with difficulty put the foot to the ground.\\nVerebely, second case Male, forty-five. The foot was at right\\nangles with the leg, the sole looking somewhat inward and upward.\\nUnder the easily distinguishable outer malleolus and in front of it a\\nlong projection half an inch in diameter may be plainly felt this can\\nbe moved without much pain backward and forward independently of\\nthe other bones. Behind the scaphoid is a considerable hollow.\\nReduction failed.\\nOf the second variety, rotation about the antero-posterior axis, Mal-\\ngaigne gives seven cases, most of which Barwell rejects because of the\\nincompleteness of the description or because the astragalus was more\\nor less displaced from the mortise. Rejecting Boyer s, Smith s, Lis-\\nton s, and two of Dupuvtren s, there still remain Malgaigne s own and\\none of Dupuvtren s to these are to be added Barwell s and Cheval-\\nlez s. 1 In all four cases the condition was shown by direct examina-\\ntion Malgaigne describes a specimen from an old case, Chevallez s\\npatient was killed by the fall that caused the dislocation, and Dupuy-\\ntren and Barwell excised the astragalus. In Malgaigne s, Chevallez s,\\nand Barwell s the rotation was outward, that is, the upper surface of\\nthe trochlea had become external and rested against the inner face of\\nthe external malleolus, although in Malgaigne s the rotation was some-\\nwhat less than 90 degrees in Dupuvtren s the bone was turned com-\\npletely upside down, rotation of 180 degrees.\\nOf Malgaigne s specimen, which is represented in his Atlas, Plate\\nXXX., Fig. 5, it is said that the head of the astragalus rested on the\\nscaphoid and cuboid its trochlea, turned outward, corresponded almost\\nentirely to the inner facet of the fibula, and its inner side lay under\\nthe tibia. The rotation, however, was not a complete quarter of a\\ncircle, for a portion of the outer side of the body of the astragalus\\ncould still be seen partly in contact with the point of the external\\nmalleolus and looking downward and outward. There was bony\\nanchylosis between the astragalus and calcaneum, and it was evident\\nthat the man had walked only on the outer border of his foot.\\nIn Chevallez s specimen there was subluxation of the head of the\\nastragalus on the scaphoid, the upper surface of the trochlea was\\nturned outward, the calcaneum was broken transversely and its pos-\\nterior fragment driven up behind the astragalus the lateral ligaments\\nof the ankle were detached, and the anterior border of the lower end\\nof the tibia was broken.\\nDupuvtren s patient was a man fifty years old, who had jumped\\nfrom a ladder, alighting on his heel. There was a large, hard, irreg-\\n1 Chevallez Bull. de. la Soc. Anatoruique, 1870, vol. xlv. p. 406.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0904.jp2"}, "897": {"fulltext": "DISLOCATIONS AT OR NEAR THE ANKLE. 821\\nalar, and irreducible prominence in front of the tibia and extending\\nto the instep. An incision was made parallel to the axis of the foot,\\nand the head and neck of the astragalus were immediately brought\\ninto view. Efforts to remove the bone failed, for the posterior part\\nwas grasped and held fast between the tibia and calcaneum. On seek-\\ning for the cause of this fixation it, was found that the astragalus was\\nturned around in such a way that its upper surface was directed down-\\nward, its lower upward, and that the hook-like process at its inferior\\nand posterior part was fixed beneath the tibia so as completely to\\nfrustrate our efforts to extract it. The patient did well.\\nBarwell s patient, a man twenty-eight years old, was injured by the\\noverturning of his wagon. When seen an hour and a half after the\\naccident the foot was greatly inverted, its front somewhat turned in,\\nthe heel raised. The inner malleolus was much hidden beneath it the\\nskin was thrown into two ridges by three deep folds drawn in segments\\nof concentric circles from a centre a little above the malleolus. The\\nouter malleolus projected abnormally, the skin over it was rather\\ntightly drawn. About an inch in front of it and a little below its\\nlevel Avas a rounded projection, which also somewhat stretched the skin.\\nAn inch and a half up the leg and in front of the fibula was a small\\nbut deep wound. The foot was immovable and painful. Below and\\nin front of the inner malleolus deep pressure revealed absence of the\\nusual bony substratum, the finger sank into a hollow bounded in front\\nby the tuberosity of the scaphoid, which lay abnormally near the mal-\\nleolus. The rounded projection in front of the malleolus could readily\\nbe recognized as the head of the astragalus. A little way behind this\\nwas a ridge of bone, also evidently a part of the astragalus it led from\\nthe head backward and a little upward, disappearing under the upper\\npart of the malleolus, at the angle between it and the anterior edge of\\nthe tibia. This ridge was markedly convex outward. The extensor\\ntendons, pressed together, ran in a bundle a little distance inside the\\nrounded projection. The wound communicated with the injury. No\\nfracture could be detected.\\nIt was seen that the relations of the astragalus to the other bones\\nwere altered, although it was still within the mortise, but the exact\\nnature of the injury was not recognized. Various attempts were made\\nto reduce, and even the tendo A chillis was divided, but in vain a\\nmoulded splint was applied, and the wound dressed with carbolic acid.\\nTwo days later a semilunar incision was made from the middle of\\nthe lower end of the tibia across the head of the astragalus to the tip\\nof the outer malleolus, the flap turned up, and the bone fully exposed.\\nIt was a little turned on its vertical axis, the head having moved out-\\nward, and 90 degrees on its antero-posterior axis, the trochlea being in\\ncontact with the cartilaginous surface of the external malleolus. The\\ninner upper angle of the trochlea fitted closely into the reentrant angle\\nformed by the external malleolus and the tibia. The bone was not at\\nall displaced forward that is, it did not protrude abnormally from its\\nsocket. The interosseous ligament had been ruptured the few remain-\\ning fibres were divided, and the bone removed. Examination of the\\ncavity failed to show any fracture or detachment of cartilage. The", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0905.jp2"}, "898": {"fulltext": "822 DISLOCATIONS.\\npatient made a good recovery, and was discharged nine and a half\\nweeks after the operation.\\nTreatment of Total Dislocations of the Astragalus.\\nThe statistics, collected by Broca, Dubreuil, and Poinsot, show that\\nof 121 cases of dislocations not compound, 43 were successfully\\nreduced, and it is worthy of note that Poinsot s list, composed of\\ncases reported between 1864 and 1883, shows 19 reductions in 31\\ncases, about 60 per cent., and as many of Broca s cases were treated\\nwithout the aid of anaesthesia it may reasonably be hoped that Poin-\\nsot s percentage is an indication of the success that will be obtained in\\nthe future. Primary extirpation of the astragalus was done in 9 of the\\n121 cases, with 6 successes, 1 death, and 2 deaths after secondary am-\\nputation. Consecutive extirpation was done in 41 cases, with 39 suc-\\ncesses and 2 deaths. Of 15 cases in which the dislocation remained\\nunreduced and in which the result is known (excluding those of sec-\\nondary extirpation) the functional result in 8 was good.\\nOf 63 compound dislocations, collected by Broca, reduction was\\nmade in 9, and of these 9 cases 6 recovered, secondary removal of the\\nastragalus was done in 2, and 1 died. Poinsot adds 2 cases in which\\nreduction was made 1 was successful, in the other extirpation became\\nnecessary.\\nIn 58 compound cases primary removal of the astragalus was done,\\nwith 42 successes, 14 deaths, and 2 consecutive amputations followed\\nby death.\\nFor reasons that have been already given, we have the right to\\nexpect better results in the future in compound cases, and may feel\\nencouraged to make reduction whenever it is possible. Expectation\\nin irreducible compound dislocations has almost always ended in\\nremoval of the astragalus, or amputation, or death, and the cases will\\nprobably be very few in which primary removal of the astragalus will\\nnot give the patient the most speedy recovery, the least risk, and the\\nmost useful limb.\\nOf 56 simple irreducible dislocations contained in these statistics,\\nsuppuration of the joint and sloughing of the skin followed in at least\\n41, and there is not much reason to suppose that the frequency of this\\nresult will be much, if at all, diminished in the future, for the excit-\\ning cause bruising, pressure, and destruction of the blood-supply of\\nthe astragalus will be repeated. It is important, therefore, to deter-\\nmine the proper course to be pursued under such circumstances. In\\n1884 Dr. McBurney, of Xew York, successfully reduced a dislocation\\nforward and inward by exposing the head of the astragalus through\\nan incision, and lifting the tendon of the tibialis anticus which tightly\\nembraced the neck of the bone and had prevented reduction other\\nequally good results have since been obtained by the same means.\\nPrimary removal of the astragalus is recommended by Barwell in all\\ncases in which certain and sufficient but not too persevering, attempts\\nat reduction have failed, and the facts that four-fifths of the cases\\nleft to themselves have ended in suppuration and secondary removal", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0906.jp2"}, "899": {"fulltext": "DISLOCATIONS AT OF NEAR THE ANKLE. 823\\nof the astragalus, and that the functional result after removal is good,\\nwill he generally accepted as a justification of the advice, but it needs,\\nI think, to be conditioned upon the failure of reduction by arthrotomy.\\nIn short, the plan to be pursued in simple cases is to attempt reduc-\\ntion by traction upon the foot with the hands or pulleys, under anaes-\\nthesia, and with the knee flexed, and by direct pressure so applied as\\nlirst to correct such rotation of the bone as may exist, and then to\\nforce it back into place. This failing, expose the bone by incision, and\\nseek to remove the obstacle to reduction and then to reduce this also\\nfailing, remove the astragalus. In cases in which the astragalus is not\\nonly dislocated but also broken, I think primary removal is the safest\\nplan, even in cases of backward dislocation of the posterior fragment,\\nalthough in three such treated without removal the patients recovered\\nwith useful limbs:\\nIn compound dislocations reduction is to be sought unless the\\nastragalus is entirely detached or the lacerations are so extensive that\\nsuppuration is unavoidable otherwise, primary removal of the astrag-\\nalus, or amputation if clearly indicated.\\nMEDIO-TARSAL DISLOCATION.\\nIn this the dislocation takes place in the medio-tarsal joint, the\\nscaphoid and cuboid being together displaced from the astragalus and\\ncalcaneum which preserve their relations to each other and to the\\nbones of the leg. Broca, in the paper above quoted, pointed out that\\nmost dislocations previously reported under this title were actually\\nsubastragaloid. Partial dislocation of the cuboid from the calcaneum\\nappears to be frequently associated with subastragaloid dislocations,\\nbut the cases in w T hich the medio-tarsal joint alone is involved are few.\\nCases too briefly described to be positively accepted were reported by\\nJ. L. Petit, Liston, and Cooper, but more recently four cases have\\nbeen placed on record in two of which the diagnosis was confirmed at\\nthe autopsy. Thomas 1 reported a case in the service of Denonvilliers;\\nthe patient s foot had been crushed by the wheel of a cart. The plan-\\ntar surface was convex, the dorsum so swollen that the bones could\\nnot be felt the foot was shortened, and its anterior portion could be\\nmoved laterally, but the movements were painful and accompanied by\\ncrepitus. The diagnosis of fracture of the head or neck of the astrag-\\nalus and rupture of the calcaneo-cuboid ligaments was made. The\\npatient died of erysipelas, and at the autopsy the tibio-tarsal and cal-\\ncaneo-astragaloid joints were found intact the head of the astragalus\\nand the cuboid surface of the calcaneum formed a very marked abnor-\\nmal prominence above the second row of the tarsus the scaphoid was\\nfractured antero-posteriorly, and its outer fragment projected on the\\nplantar surface the cuboid was still in contact with the inferior half\\nof the anterior end of the calcaneum the superior medio-tarsal liga-\\nments were ruptured, and the inferior calcaneo-scaphoid partly\\ndetached the inferior calcaneo-cuboid was unbroken.\\nAnger s 2 patient was injured by a fall from a height. There was\\n1 Thomas Mem. de la Soc. Med. d Indre et Loire, 1887, quoted by Duplay and Delorme.\\n2 B. Anger Traite iconographique, p. 334.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0907.jp2"}, "900": {"fulltext": "824 DISLOCATIONS.\\nslight flattening of the arch of the foot, without deviation, and with\\nconsiderable ecchymotic and inflammatory swelling. He died of ery-\\nsipelas. At the autopsy the head of the astragalus was found above\\nand in front of the scaphoid, and the cuboid facet of the calcaneum\\nupon the upper surface of the cuboid. The superior calcaneo-scaphoid\\nand internal calcaneo-cuboid ligaments were ruptured and torn from\\ntheir anterior insertions. It was difficult to reduce the dislocation even\\nafter dissection. The only fracture was of the anterior part of the\\nscaphoid, the tubercle of which was almost entirely torn away.\\nIn the third case, Ward, 1 the dislocation was old. The foot pre-\\nsented a remarkably twisted appearance, the anterior part being directed\\nconsiderably inward, and the inner edge somewhat elevated. The\\ndorsum was shortened one inch. The anterior ends of the calcaneum\\nand astragalus projected distinctly on the dorsum. The external mal-\\nleolus had been fractured.\\nIn the fourth, Fuhr, 2 the dislocation was outward. The patient was\\nsixty-six years old and had fallen six feet the foot was slightly pro-\\nnated and the projection of the posterior surfaces of the scaphoid and\\ncuboid could be distinctly felt in front of the external malleolus.\\nCONGENITAL DISLOCATIONS OF THE ANKLE-JOINT.\\nKraske 3 exhibited at the Ninth Congress of the German Surgical\\nSociety two patients, father and son, with congenital dislocation of\\nboth ankles, and also the two legs of another child of the same father\\nwdiich had died in infancy and had been similarity affected. The\\nabnormality was a subluxation outward accompanied by, and probably\\ndue to, defective development of the fibula. In all three cases the\\nmiddle and upper part of the fibula w T as lacking, but in the specimen\\na small upper epiphysis existed. In the father the lower end of the\\nfibula was only four centimetres long and was obliquely placed, the\\napex directed outward. The articular surface of the tibia was also\\noblique, looking downward and outward the foot was flattened, mark-\\nedly abducted, and moderately pronated. The legs, compared with\\nthe thighs, were abnormally short and slight.\\nResection of both ankles had been done upon the son to correct the\\nfaulty position of the foot on the right side the internal malleolus\\nand a comparatively large part of the astragalus had been removed\\non the left, the entire lower end of the tibia and a small piece of the\\nastragalus.\\nOther forms of congenital subluxation belong to the subject of\\nclubfoot.\\n1 Ward Transactions of the Pathological Society of London, 1849-50, p. 254.\\n2 Fuhr: Munch, med. Woch., March 8, 1892.\\n3 Kraske Beilage zuni Centralblatt fur Chir., 1882, No. 29, p. 85.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0908.jp2"}, "901": {"fulltext": "CHAPTEE LVIII.\\nDISLOCATIONS OF THE TAESAL AND METATARSAL BONES\\nAND OF THE TOES.\\nIn addition to the dislocations described in the preceding chapter,\\nthe bones of the tarsus may be dislocated separately and in various\\ncombinations. None of the different kinds has occurred with suffi-\\ncient frequency to permit systematic grouping and description, and in\\nmost of them the exact nature of the injury cannot be said to have\\nbeen positively established, for the difficulties of the diagnosis upon\\nthe living are usually very great and the surgeon is limited to the\\nrecognition of the more prominent features. I shall confine the\\naccount of them mainly to the enumeration of the different varieties\\nthat have been observed, with bibliographical references for the con-\\nvenience of those who may desire to examine the reports in detail.\\nCalcaneum. Malgaigne quotes a case in which the calcaneum was\\nbodily displaced to the outer side, but apparently was not entirely sep-\\narated from the astragalus and scaphoid. Reduction was easy. Also\\na second, Canton, 1 found upon the cadaver, in which the calcaneum\\nwas displaced to the outer side together with the external malleolus\\nits anterior end lay between the cuboid and scaphoid, almost in con-\\ntact with the third cuneiform and the astragalus was rotated inward\\nabout 45 degrees.\\nScaphoid. The scaphoid has been dislocated forward and outward\\nin connection with the astragalus, the dislocation being compound\\n(Burnett), forward and inward (Rizzoli, quoted by Poinsot), upward\\nand backward in conjunction with the first and second cuneiforms and\\nthe first two metatarsals and with dislocation of the third metatarsal\\nand fracture of the cuboid (Chassaignac 2 upward and inward in con-\\njunction with the first cuneiform (Lonsdale 3 or with the middle cunei-\\nform (Clarke 4 or outward, upward, or inward alone (Piedagnel,\\nWalker, R. W. Smith, quoted by Malgaigne, Bryant 5 or from the\\ncuneiforms only, as seen by Garland 6 in a case that was compound.\\nIn a case reported by Enos 7 the cuneiform bones and the cuboid were\\ndisplaced outward from the scaphoid and calcaneum.\\nCuboid. The only case of dislocation of the cuboid of which I have\\nknowledge, except in connection with other dislocations as above\\ndescribed, is one reported by Bell, 8 in which it was displaced upward\\n1 Canton Lancet, 1847, vol. i. p. 505.\\n2 Chassaignac Bull, de la Soc. de Chir., 1861, vol. i. p. 307.\\n3 Lonsdale: Lancet, 1857, vol. ii. p. 192.\\n4 Clarke London Medical Times, 1851, vol. iii. p. 233.\\n5 Bryant: Surgery, 3d American edition, 1881, p. 813.\\n6 Garland Lancet, 1857, vol. ii. p. 270.\\n7 Enos New York Journal of Medicine, 1857, vol. yii. p. 98.\\n8 Bell New York Journal of Medicine, 1859, vol. vii. p. 329.\\n825", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0909.jp2"}, "902": {"fulltext": "826 DISLOCATIONS.\\nin connection with the fifth metatarsal by inversion and adduction of\\nthe foot. Reduction was made.\\nCuneiform Bones. All three cuneiform bones and the second and\\nthird have been displaced together, and the first and second have been\\ndisplaced separately. Isolated dislocations of the first are the most\\nfrequent, Lemoine l collected eleven such cases, to which may be added\\ntwo observed by Bryant 2 the displacement is usually upward and\\ninward, in only one case downward and inward (Fitzgibbon 3 some-\\ntimes the bone is displaced from all the three with which it is normally\\nin contact, sometimes the first metatarsal is displaced with it. The\\nsymptoms are flattening of the arch of the foot, prominence of the\\ndisplaced bone, and a depression at its normal site. In some cases\\nreduction has been easily made in others the attempt has failed.\\nThe second cuneiform has been separately dislocated upon the\\ndorsum in three cases, Foulker, 4 Laugier, and Lagarde (quoted by\\nDelorme 5 the displacement being slight in one and nearly complete\\nin the others, and accompanied in one by other serious injuries of the\\nfoot, and followed in another (Foulker) by sloughing of the skin,\\ngrave symptoms, and ultimate recovery. In a case of multiple injuries\\nof the foot reported by Lagrange 6 the second cuneiform was displaced\\nupward from all its connections except that with the scaphoid.\\nThe second and third cuneiforms were displaced together upon the\\ndorsum in a case reported by Key (quoted by Malgaigne) the dislo-\\ncation, which was incomplete, was caused by direct violence and accom-\\npanied by extensive laceration of the skin. The patient died.\\nAll three cuneiforms have been reported displaced together upon the\\ndorsum in several cases, but it does not appear in the histories whether\\nor not they were separated only from the scaphoid or also from the\\ncuboid and metatarsals in one of them, Bertherand, 7 they were accom-\\npanied by the metatarsals and the dislocation could not be reduced.\\nDISLOCATIONS OF THE METATARSAL BONES FROM THE TARSUS\\nAND FROM ONE ANOTHER.\\nMalgaigne collected twenty-one cases of the various dislocations, and\\nHitzig 8 collected twenty-nine.\\nThe first metatarsal is much more frequently dislocated than the\\nothers, and the displacement appears always to have been upward\\nexcept in one case, Demarquay, 9 in which the base lay under that of\\nthe second metatarsal in this latter the first metatarsophalangeal joint\\nwas also dislocated, compound, and Demarquay removed the bone.\\nA frequent cause has been a fall while on a horse, the pressure of the\\nstirrup against the inner and under surface of the bone apparently\\n1 Lemoine Eevue de Chirurgie, 1883, vol. iii. p. 118.\\n2 Bryant Loc. cit., p. 813.\\n3 Fitzgibbon Dublin Journal of the Medical Sciences, 1877, vol. ii. p. 271.\\n4 Foulker: Lancet, 1856, vol. ii. p. 283.\\n5 Delorme Diet, de Med. et Chir. prat., vol. xxvii. art. Pied.\\n6 Lagrange Bull, de la Soc. Anatomique. 1871, p. 180.\\n7 Bertherand Bull, de la Soc. de Chir., 1856-57, vol. vii. p. 361.\\n8 Hitzig Berl. klin. Wochenschrift, 1865, p. 393.\\n9 Demarquay Bull, de la Soc. de Chir., 1870, vol. x. p. 35.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0910.jp2"}, "903": {"fulltext": "DISLOCATIONS OF THE METATARSAL BONES. 827\\ncausing the injury. The symptoms frequently indicate the coexistence\\nof a sprain of neighboring joints. Reduction has always been easy\\nby traction and direct pressure.\\nIsolated dislocation of the second metatarsal upon the dorsum has\\nbeen reported in one case, Brault and Belin, quoted by Hitzig that of\\nthe third downward and backward in one, Tufnell l that of the fourth\\nupon the dorsum in three, Malgaigne, Surmay, 2 and Gosselin. 3\\nThe fourth and fifth metatarsals have been together dislocated upward\\nand inward, Monteggia, and upward and backward, South both quoted\\nby Malgaigne. The third and fourth, Hartmann, and the first and\\nsecond, Marit, have been together displaced both quoted by Delorme. 4\\nThe first, second, and third were dislocated together upon the dorsum\\nin two cases, Laugier, quoted by Malgaigne, and Wilms, quoted by\\nHitzig, and downward into the sole in a case reported by Tufnell 5 in\\nthe latter case the injury was caused by the fall of a horse and was\\nirreducible, but the patient recovered good use of the limb the later\\nhistory is recorded in the same journal, 1855, vol. xx. p. 302.\\nDislocation of the second, third, and fourth together upon the dor-\\nsum was seen by Malgaigne once the same diagnosis was made by\\nhim in another case, but at the autopsy it was found that the fifth was\\nalso partly dislocated from the cuboid and that the first together with\\nthe internal cuneiform was displaced inward. A case is reported by\\nFavier. 6\\nDislocation of the first four metatarsals has been reported in three\\ncases, Malgaigne, Hitzig, Demarquay; 7 in Malgaigne s the first three\\nwere displaced downward, the fourth upward in the other two the\\ndisplacement was upward. Malgaigne was able to reduce the fourth,\\nDemarquay the first and Hitzig all notwithstanding the persistence\\nof part of the dislocation the two patients had good use of the limb.\\nAll the metatarsal bones may be displaced together upward, inward,\\ndownward, or outward of the latter two forms only one example\\nof each has been reported. Smyly 8 saw all five bones dislocated\\ndownward by the fall of a wagon which pressed the heel forward\\nw r hile the toes were fixed reduction was made. The case of disloca-\\ntion inward is Kirk s, quoted by Malgaigne, who distrusts the diag-\\nnosis.\\nOf dislocation outward five cases have been reported, Laugier and\\nLacombe, quoted by Malgaigne, Tutschek, quoted by Hitzig, Mignot-\\nDanton, 9 and Despres. 10 The interlocking of the base of the second\\nmetatarsal between the first and third cuneiform bones must make a\\nlateral dislocation impossible except as secondary to one upward or\\ndownward or unless accompanied by fracture in Laugier s and Des-\\n1 Tufnell Dublin Quarterly Journal of the Medical Sciences, 1855, p. 302.\\n2 Surmay Bull, de la Soc. de Chir,, 1876, vol. ii. p. 579.\\n3 Gosselin Gaz. des Hopitaux, 1876, p. 755.\\n4 Delorme: Diet, de Med. et Chir., prat., vol. xxvii. art. Pied.\\n5 Tufnell Dublin Quarterly Journal of the Medical Sciences, 1854, vol. xvii. p. 65.\\n6 Favier Arch, de Med. et Pharm. mil., November, 1888.\\n7 Demarquay Gaz. des Hopitaux, 1865, p. 534.\\n8 Smyly: Dublin Quarterly Journal of the Medical Sciences, 1854, vol. xvii. p. 317.\\n9 Mignot-Danton Arch. gen. de Med., 1866, vol. ii. p. 405.\\n10 Despres: Bull, de la Soc. Anatomique, 1878.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0911.jp2"}, "904": {"fulltext": "828 DISLOCATIONS.\\npres s the second metatarsal was broken at its upper end, and in\\nMignot-Danton s and Laeombe s the third was broken. In four cases\\nreduction was made.\\nDislocation upward may be complete or incomplete, and sometimes\\nthe whole or part of the first cuneiform remains attached to the first\\nmetatarsal and is displaced with it. Hitzig collected eleven cases.\\nThe most frequent cause is direct violence, but in two cases it was mus-\\ncular action, the efforts of the patients to avoid falling after having\\nslipped while carrying heavy bundles. The autopsies and the com-\\npound cases have shown rupture of the dorsal and of some of the\\npalmar ligaments, rupture and laceration of some of the interosseous\\nligaments and muscles, fracture of some of the metatarsal bones and\\noccasionally of the cuboid and first cuneiform, and sometimes separa-\\ntion of the first or fifth metatarsal laterally from the others. The\\nmetatarsus may remain in line with the rest of the foot or be deviated\\nto either side, and the bases of its bones form a transverse ridge either\\ncorresponding exactly to the line of the joints or at a somewhat higher\\npoint upon the tarsus. Reduction was made more or less completely\\nin some of the cases in others it failed, but the patients gradually\\nrecovered the use of the limb in one compound case, Mazot, primary\\namputation was done.\\nSUBLUXATION OF THE HEAD OF A METATARSAL BONE.\\nIn the severest form of this affection, first described by Dr. T. G.\\nMorton, 1 the head of the fourth metatarsal less frequently the third\\nappears to be displaced from its normal relations with the adjoining\\none on each side, and also with its toes. The most recent paper on the\\nsubject, one which contains a full bibliography, is by Jones and\\nTubby; 2 the reader is referred to it for the pathology, symptoms, and\\ntreatment. It seems appropriate here to refer only to the severe form\\nin which excision of the head of the metatarsal bone or of the entire\\njoint is occasionally necessary for relief.\\nDISLOCATIONS OF THE TOES.\\n1. Metatarso -phalangeal Dislocations.\\nDislocations of the Great Toe. The most common cause is a fall\\nupon the toe among the less frequent are the act of kicking, receiv-\\ning the weight of the body upon the toe alone in going upstairs, and\\nviolence received upon the metatarsus. The injury is frequently com-\\npound. The dislocation has been upward, backward, and to one side,\\nthe most frequent appearing to be those to the outer side and back-\\nward, and secondly those directly backward the former of these two\\nis almost always compound, with projection of the head of the meta-\\ntarsal bone through the wound on the inner and lower aspect of the\\njoint. Coexistent sprain or subluxation of the first tarso-metatarsal\\njoint has been occasionally noted.\\n1 Morton Amer. Journ. Med. Sci., January, 1876.\\n2 Jones and Tubby Metatarsalgia or Morton s Disease, Annals of Surgery, September,\\n1898.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0912.jp2"}, "905": {"fulltext": "DISLOCATIONS OF THE TOES. 829\\nOf 14 simple cases collated by Delorme reduction was easily made\\nin 8 and failed in 4 of the compound cases the head of the metatarsal\\nbone was excised in 5, and the entire bone removed in 3 of 14 com-\\npound cases in which the attempt to reduce was made it was successful\\nin 9. The means employed to reduce have been traction and direct\\npressure upon the base of the phalanx. Probably in the difficult cases\\nthe special procedures employed in the corresponding dislocations of\\nthe thumb would be advantageous.\\nDislocations of the Other Toes. Dislocation of the four outer, the\\nfour inner, or of all five toes together has been reported in several\\ncases, the direction of the displacement being upward and backward\\nor directly outward in the latter the head of the metatarsal projected\\nthrough a wound and had to be excised before reduction could be made.\\n2. Dislocations of the Phalanges.\\nAYith one exception, the second phalanx of the third toe, in all the\\ncases that have been reported the dislocation was of the terminal pha-\\nlanx of the great toe. In one case reduction could not be made in\\nanother, which was compound, a portion of the bone was subsequently\\ncast off.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0913.jp2"}, "906": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0914.jp2"}, "907": {"fulltext": "INDEX TO FRACTURES.\\nA BSOBPTION of bone after fracture,\\nJ\\\\. 59, 110\\nAcetabulum, 302\\nrim, 308\\nAcromion, 209\\nAge, influence of, on frequency, 20\\nAllis, relaxation of fascia lata, 328\\nAmbulatory treatment, 100\\nAmputation, 106\\nAnderson, suture of patella, 368\\nAneurism after fracture of clavicle, 193\\nAngle, splint for jaw, 170\\nAnkle, 382\\nApophyses, separation of, 24\\nArrest of growth, 29, 225, 287, 354,\\n383\\nArteries, injuries of, 67\\nAstragalus, 396\\nAsymmetry, normal, of limbs, 49\\nAtlas, 146\\nAtrophy of limb, 76\\ninterstitial, 38\\nAxillary vein, torn, 229\\nAxis, 146\\nBAILEY, hsematomyelia, 143\\nBarker, suture of patella, 370\\nBarton s fracture of the radius, 289\\nBigelow, neck of femur, 311, 319\\nBloodvessels, injury of, 67\\nBolton, hsematomyelia, 143\\nneck of femur, 316\\nBraun, head of femur, 310\\nBuck s extension, 95, 346\\nBurrell, fracture of spine, 155\\nCALCANEUM, 396\\nCallus, exuberant, 60, 71\\nformation of, 55\\npainful, 71\\nretarding influences upon, 109\\nsoftening of, 75\\nweak, 75\\nCalender, edge of radius, 290, 291\\nforearm, 271\\nCancer, a cause of fracture, 46\\nCarpal bones, 293\\nCartilages, fracture of costal, 185\\nCauses of fracture, 38\\ndetermining, 39\\nmuscular action, 40\\npredisposing, 38\\nacquired tendency, 39\\ncancer, 46\\ncongenital tendency, 38\\ndisease of nerve centres, 45\\ninherited tendency, 39\\nosteomyelitis, 47\\nrachitis, 45\\nsyphilis, 45\\nCeci, suture of patella, 371\\nChaput, patellar disability, 372\\nChest, discoloration of skin by compres-\\nsion of, 183\\nClavicle, 189\\ncomplications, 193, 197\\netiology, 195\\npathology, 189\\nrelations to dislocation of shoulder,\\n547\\nsimultaneous fracture of both, 198\\nsymptoms and course, 196\\ntreatment, 199\\nClinical course, 62\\nCoccyx, 305\\nColles s fracture, 279\\nComminuted fractures, 27\\nComplications of fracture, 66\\nearly local, 66\\ngeneral, 69\\nlate local, 71\\nCompound fractures, 30\\ntreatment, 103\\nCondyloid process of inferior maxilla,\\n165, 166, 170\\nCoracoid, 211\\nCoronoid process of inferior maxilla,\\n165\\nof ulna, 266\\nCrepitus, 51\\nCubitus valgus, 250\\nvarus, 235, 241, 247\\n831", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0915.jp2"}, "908": {"fulltext": "832\\nINDEX TO FRACTURES.\\nDANDRIDGE, fracture of spine,\\n155\\nDeformity, a symptom, 49\\nDelirium, 71\\nDepressions, 24\\nDiagnosis, 49\\nDisplacements, 34\\nDressings, permanent, 92\\ntemporary, 86\\nEMBOLISM, 76\\nfat, 70\\nEnsiform appendix, 177\\nEpiphysis, separation of, 28\\nrepair, 61\\nEpitrochlea, 244\\nEtiology, 38\\nExtracapsular, of femur, 312, 318, 330\\nFAILUKE of union, 62, 109\\netiology, 110\\ntreatment, 113\\nFemoral artery, torn, 343\\nvein, torn, 343\\nFemur, 309\\nabsorption of neck, 324\\nangle of neck, 310\\nfractures at the lower end, 350\\nintercondyloid, 350\\nof either condyle, 355\\nseparation of epiphysis, 353\\nat the upper end, 309\\nof great trochanter, 340\\nof small trochanter, 340\\nof the head, 310\\nof the neck, 310\\nbony union after, 320\\ncauses, 313\\nclassification, 312\\ndiagnosis, 330\\nexcision of head, 338\\nfixation of head, 337\\nimpaction, 319\\ninversion in, 320, 326\\npathology, 314\\nthrough the neck, 314\\nat base of neck, 318\\nseparation of epiphyses,\\n316\\nprognosis, 331\\nrepair, 320\\nsymptoms, 325\\ntreatment, 334\\nthrough great trochanter and\\nneck, 339\\nof the shaft, 341\\nprognosis, 345\\nsymptoms, 344\\ntreatment, 346\\nin children, 349\\nFemur, fractures of the shaft, failure of\\nunion, 350\\nFenestrated splints, 93\\nFibula, 394\\nFingers, 295\\nFissures, 23\\nFixation, direct, 98\\nFoot, 396\\nForearm, 259\\nat the elbow, 259\\ncoronoid process, 266\\nhead and neck of radius, 268\\nolecranon, 259\\nof the shaft, 271\\nboth bones, 271\\nradius, 278\\nulna, 276\\nat the wrist, 279\\nColles s, 279\\nother than Colles s, 289\\nFractura diacondylica, 255\\nGANGKENE, 68\\nGreen-stick fractures, 23\\nGrowth, arrest of, 29, 225, 287, 354, 383\\nexaggeration of, 75\\nGunshot fractures, 32, 106\\nGunstock deformity of elbow, 235, 241,\\n247\\nGurlt, statistics, age, 20\\ncompound fractures, 31\\ncostal cartilages, 185\\nfemur, 309\\nhyoid, 171\\ninferior maxilla, 164\\nlarynx and trachea, 173\\nmuscular action, 41, 42\\nsternum, 176\\nsyphilitic, 46\\ntumor, 47\\nvertebra, 139, 145, 149-151\\nGutters, wire, 88\\nH^MATOMYELIA, 143, 145\\nHeart, wound in injury of chest,\\n177, 181\\nHemorrhage, 67\\nHennequin s splint for arm, 231\\nColles s fracture, 284\\nfemur, 313, 329, 337, 344\\nHodgen s splint, 96, 335\\nHudson Street Hospital statistics, com-\\npound fractures, 31\\ngeneral, 19\\nhumerus, 238, 244\\nseason, 21\\nHumerus, 215\\nlower end, 237\\nabove the condyles, 239\\narticular process, 255", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0916.jp2"}, "909": {"fulltext": "I2WEX TO FRACTURES.\\n833\\nHumerus, lower end, capitellum, 256\\ndevelopment of epiphysis, 238,\\n253\\ndiagnosis, 257\\nepitrochlea, 244\\nexternal condyle, 248\\nepicondyle, 246\\nintercondyloid fracture, 251\\ninternal condyle, 246\\nseparation of epiphysis, 253\\ntrochlea, 257\\ntreatment. 258\\nshaft, 233\\nupper end, 215\\nanatomical neck and tuberosities,\\n216\\nhead, 216\\nseparation of epiphysis, 223\\nsurgical neck, 22Q\\nsymptoms, 229\\ntreatment, 230\\ntuberosities, 221\\nHutchinson, arrest of growth of leg,\\n383\\nepiphysis of humerus, 223\\ntrochanter minor, 341\\nHyde, statistics of femur, 309\\nHyoid bone, 171\\nILIUM, 306\\nImmobilization of joints, 102\\nIncomplete fractures, 23\\nInherited tendency to fracture, 39\\nInterdental splint, 169\\nIntra-articular fracture, 29\\nrepair of, 60\\nIntracapsular, of femur, 312, 314, 330\\nIntra-uterine, 47\\nIschsemic contraction, 68\\nIschium, 307\\nIterative fracture, 75\\nJOINTS, management of, 102\\nstiffness of, 75\\nJugular vein, torn in fracture of clavicle,\\n194\\nKING, neck of femur, 311\\nKingsley, interdental splint, 169\\nKocher, anatomical neck of humerus,\\n217\\nepiphysis of humerus, 226\\nexternal condyle, 251\\nfemoral neck, 312, 339\\nupper epiphysis, 316\\nLANE, fracture of first rib, 180\\ns acromion, 206\\n53\\nLane, fracture of coracoid, 211\\nLarynx, 172\\nLeg, fractures of, 374\\nfibula, 394\\nlower end, 381\\nby eversion, 383\\nby inversion, 391\\ncomminuted, 382\\nposterior portion of tibia, 392\\nseparation of epiphysis of fibula,\\n395\\nof tibia, 383\\nsupramalleolar, 382\\nshaft, 377\\nupper end, 374\\nepiphysis of fibula, 394\\nof tibia, 376\\nspine of tibia, 376\\ntubercle of tibia, 376\\nLiability, inherited, 39\\nLigamentum patellae, retraction, 360\\ndetachment, 372\\nLoew, statistics of prognosis, 118\\nLongitudinal fractures, 26\\nLotzbeck, fracture of coronoid, 267\\nLucas-Championniere, massage, 100\\nLung, hernia of, 183, 186, 519\\ninjured, in fracture of clavicle, 195\\nin fracture of ribs, 181\\nMALAR bone, 160\\nMaigaigne s hooks, 367\\nMalgaigne, statistics, age, 20\\nfemur, 293\\nhyoid, 171\\nmetacarpus, 309\\nMarsh, fracture of first rib, 180\\nMassage, 99\\nMayor s scarf for clavicle, 201\\nMaxilla, inferior, 164\\ncondyloid process, 165, 166, 170\\ncoronoid process, 165\\ntreatment, 167\\nsuperior, 161\\nMcBurney, epiphysis of femur, 355\\nMetacarpal bones, 293\\nMetatarsal bones, 400\\nMiddeldorpf s triangle, 232\\nMobility, abnormal, 50\\nreturn of, 112\\nMoore, dressing for clavicle, 204\\nepiphysis of humerus, 226\\nMoulded splints, 90\\nMultiple fractures, 30\\nMumford, compound fractures, 32\\nMuscles, atrophy of, 76\\ndegeneration of, 68\\nMuscular action, a cause of fracture,\\n40\\nMusculo-spiral nerve, 74, 229, 234", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0917.jp2"}, "910": {"fulltext": "834\\nIXDEX TO FRACTURES.\\nNECROSIS, 59\\nNerve disease a cause of fracture,\\n45\\ninclusion in callus, 74\\ninjury of, 73, 245\\nNose, 157\\nOBLIQUE fractures, 25\\nOlecranon, 259\\nOsteomyelitis, a cause, 47\\nPAIN, a symptom, 52\\nParalysis, a result of fracture, 73\\nits effect on repair, 111\\nPatella, 358\\ncauses, 358\\ncourse and terminations, 361\\ndisability after fracture, 362, 372\\npathology, 359\\nrefracture, 363, 373\\nsymptoms, 361\\ntreatment, 364\\nnon-operative, 365\\noperative, 368\\nPathological fractures, 43\\nPathologv of fracture, 22\\nPelvis, 297\\nacetabulum, 302, 308\\ncoccvx, 305\\ncourse, 303\\ndiagnosis, 303\\ndouble vertical fracture, 300\\nilium, 306\\nischium, 307\\nlateral portion of ring, 300\\npubic portion of ring, 300\\npubis, 307\\nseparation in front and behind, 299\\nof all three joints, 299\\nof pubic symphysis, 298\\nof sacro-iliac symphysis, 299\\nPeriosteal bridge, 36, 5Q\\nfringe, 360\\nPeriosteum, extent of injury, 55\\nshare in repair, 56\\nPlane, double inclined, 97\\nPlaster of Paris, 90, 92\\nPneumonia, 71\\nPolaillon, metacarpus, 293\\nPoland, epiphvsis of femur, 317, 354\\nfibula, 395\\nhumerus, 254\\ntibia, 376\\nseparation of epiphysis, 38\\ntrochanter, 340\\nPott s fracture at ankle, 383\\nPouteau, fracture of radius, 279\\nPrognosis, general, 117\\nPseudarthrosis, 109\\ncauses, 110\\nPseudarthrosis, symptoms, 112\\ntreatment, 113\\nPubis, 307\\nRACHITIS, a cause, 45\\nRadius, Colles s fracture, 279\\nfractures at wrist other than\\nColles s, 289\\nof head and neck, 268\\nof shaft, 278\\nstyloid process, 291\\nRamsperger, statistics, 118\\nReduction, 79\\nRepair, 55\\nof cartilage, 60, 187\\nopposing influences, 110\\nRetention, 84\\nRheumatism, a cause, 45\\nRibs, 180\\nby muscular action, 181\\nRieael, head of femur, 310\\nRoberts, fracture of radius. 291\\nRobson, suture of patella, 368\\nSACRUM, transverse fracture, 304\\nvertical fracture, 300\\nSarcoma after fracture, 73\\nSavre, dressing for clavicle, 202\\nScaphoid, 293\\nScapula, 206\\nacromion, 209\\nbody, 206\\ncoracoid process, 211\\nglenoid cavity, 213\\ninferior angle, 208\\nneck, 212\\nspine, 209\\nupper angle, 209\\nSeason, influence of, 21\\nSecondary fracture, 75\\nSenn, fracture of neck of femur, 334\\nSeparation of epiphysis, 28\\nSepticaemia, 69\\nShaffer, fracture of neck of femur, 336\\nSkin, injury of, 66\\nstained by compression of chest, 183\\nSkull, 120\\nmechanism and pathology, 121\\npathological and reparative processes,\\n129\\nsymptoms and treatment, 130\\ncircumscribed, of vault, 130\\nfissured, with brain injury, 133\\ninternal table, 127, 135\\nperforation of base, 137\\nrupture of middle meningeal, 135\\nSmith s anterior splint, 89\\nSmith, R. W., neck of femur. 320. 322,\\n326, 331\\nhumerus. 219", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0918.jp2"}, "911": {"fulltext": "INDEX TO FRACTURES.\\n835\\nSmith, R. W., radius, 280\\nSpine, 189. (See Vertebra?.)\\nSpiral fractures, 26\\nSplinters, vitality of, 58\\nSplints. 86\\nlong side, 96\\nplaster-of-Paris, 90\\nsuspended, 89\\nSpontaneous fractures, 43\\nStatistics, compound fractures, 31\\ndelayed union, 109\\nepiphyses, 28\\ngeneral, 19\\ninfluence of age, 20\\nseason, 21\\nsyphilis, 46\\ntumor, 47\\nmuscular action, 41, 42\\nprognosis, 118\\nSternum, 175\\nStiffness of joints, 75\\nStocking splint, 91\\nStromeyer s cushion, 236\\nSubclavian vein, torn in fracture of\\nclavicle, 194\\nSubjective symptoms, 52\\nhistory, 53\\nloss of function, 52\\npain, 52\\nSuppuration after fracture, 69\\nSupracondyloid of humerus, 239\\nSupramalleolar fracture, 382\\nSusDended splints. 89\\nSustentaculum tali, 398, 817\\nSuture of bones, 98\\nSymptoms, 49\\nobjective signs, 49\\nabnormal mobility, 50\\ncrepitus, 51\\ndeformity, 49\\nSyphilis, a cause, 45\\nTETANUS, 71\\nThorburn, fracture of spine, 155\\nThrombosis, 67, 76\\nThyroid extract in delayed union, 113\\nTibia, 374. (See Leg.)\\nTibial artery, torn, 378\\nToes, 401\\nTrachea, 174\\nTraction by suspension, 96, 349\\nby weight and pulley, 94\\ncontinuous, 94\\nTransverse fractures, 25\\nTreatment, 78\\nambulatory, 100\\nTreatment by amputation, 106\\nof compound fractures, 103\\nof compound articular fractures, 101\\nof gunshot fractures, 106\\nof pseudarthrosis, 111\\nof vicious union, 115\\nTrochanter major, 339, 340\\nminor, 340\\nULNA, coronoid process, 266\\nolecranon, 259\\nshaft, 276\\nstyloid process, 291\\nUlnar nerve, injury of, 245\\nUnion, deformed or faulty, 114\\ndelaved, or failure of, 62, 109\\nfibrous, 62, 109\\nY-SHAPED fractures, 26\\nVarieties, 22\\nof direction, 25\\nof seat, 28\\nVelpeau, dressing for clavicle, 202\\nVertebrae, 139\\ncourse and terminations, 150\\netiology, 144\\npathology, 140\\narches, 141\\nbodies, 140\\ncord, 143\\nprocesses, 142\\nsymptoms, 144\\natlas and axis, 146\\nlower cervical and upper dorsal,\\n147\\nlower dorsal and upper lumbar,\\n149\\nlower lumbar, 150\\ntreatment, 153\\nVertical suspension, 97, 349\\nVolkmann s foot-rest, 95\\nischaemic contraction, 68\\nsplint, 88\\nsuture of patella, 372\\nVon Bergmann, of orbital plate, 127\\nold fracture of patella, 372\\nw\\nEED S splint, 97\\nWhitman, femoral neck, 310\\nupper epiphysis, 317\\nJTYGOMA, 160", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0919.jp2"}, "912": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0920.jp2"}, "913": {"fulltext": "INDEX TO DISLOCATIONS.\\nACCIDENTS during reduction, 446,\\n449\\nAcetabulum, fracture of edge, 725\\nof floor, 753\\nAcromion, fracture of, 553, 593\\nAfter-treatment, 447\\nAge, influence of, 409\\nAmbi, 441\\nAnaesthesia, dangers of, 439\\nAneurism, after dislocation, 417\\nAngot, congenital, 464\\nAnkle, congenital dislocations of, 824\\ndislocations at or near, 803\\nAnnandale, recurrent, of jaw, 485\\nmeniscus, of knee, 781\\nAnterior oblique dislocation of hip, 730\\nArteries, injured in dislocation, 416\\nin reduction, 446, 451\\nArthrotomy to reduce, 445\\nAstragalus, dislocation of, 804\\ntotal dislocation of, 816\\nAtlas, dislocation of, 500\\nAxillary artery, injured in dislocation,\\n417\\nin reduction, 446, 453\\nBARWELL, astragalus, 819\\nBissel-Hascen, congenital, of pa-\\ntella, 796\\nBigelow, hip, classification, 717\\nreduction, 437, 733, 739\\nBlasius, vertebra?, 487, 492, 496, 510\\nBloodvessels injured during reduction,\\n446, 451\\nin dislocation, 416\\nBone, overgrowth after dislocation, 426\\nBrachial artery, injured in dislocation,\\n418\\nin reduction, 452\\nplexus, torn in reduction, 458\\ninjured, 578\\nBrachialis anticus, ossified, 620\\nBradford, congenital, of hip, 473\\nBroca, subastragaloid, 809\\nsuppuration, 461\\nBurrell, recurrent, of shoulder, 600\\nBusch, obstacles to reduction, 437\\nCALCANEUM, dislocation of, 828\\nCaldwell, rupture of circumflex,\\n452\\nCapsule, an obstacle, 438\\nlesions of, 414\\nCarpal bones, dislocation of, 685\\nCarpo-metacarpal dislocations, 690\\nCauses, determining, 411\\npredisposing, 410\\nCircumflex artery, injured in disloca-\\ntion, 417, 453\\nnerve, injured in dislocation, 419,\\n591\\nClavicle, dislocations of, 523\\nacromial end, 531\\nsubacromial, 537\\nsubcoracoid, 540\\nsupra-acromial, 532\\nboth ends, 540\\nsternal end, 523\\nbackward, 527\\nforward, 524\\nhabitual, 526, 527\\nupward, 529\\nCoccyx, dislocations of, 707\\nComplications {see also Special Disloca-\\ntions), 415\\nof bloodvessels, 416\\nof bones, 415\\nof nerves, 418\\nof soft parts and skin, 421\\nof viscera, 421\\nCompound dislocations, 421\\nCongenital dislocations {see also Special\\nDislocations), 463\\netiology, 464\\npathology at hip, 468\\nat shoulder, 471\\nstatistics, 463\\nsymptoms, 471\\ntreatment, 473\\nConsecutive reduction, 437\\nCoracoid process, fracture of, 593\\nCoronoid process of ulna, fracture of,\\n618, 632, 641\\nCostal cartilages, dislocations of, 519\\nCourse, 435\\nCras, injuries of vessels, 452\\n837", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0921.jp2"}, "914": {"fulltext": "838\\nINDEX TO DISLOCATIONS.\\nCrural nerve, pressed on in dislocation,\\n421\\nCuboid, dislocation of, 825\\nCuneiform bones, dislocation of, 826\\nDEATH by anaesthetic, 439, 462\\nsudden, after reduction, 461\\nDefinitions, 405\\nDegeneration after dislocation, 421, 428\\nDespres, method of, 443\\nold, of shoulder, 603\\nDiagnosis, 430\\nDistention, dislocation by, 476\\nDivergent dislocation of radius and\\nulna, 639\\nDorfler, radius, with fracture of ulna, 662\\nDollinger, congenital of hip, 467\\nDorsal dislocations of the hip, 721\\nDubreuil, habitual dislocation, 448\\nDuchenne, paralytic, of shoulder, 609\\nDuverney, radius, by elongation, 657\\nELASTIC traction, 444\\nElbow, anatomy of, 611\\ndislocations of (see also Radius\\nand Ulna), 611\\nbackward dislocations, 614\\nafter-treatment, 624\\ncomplications, 418, 419, 617\\ndiagnosis, 619\\npathology, 616\\nprognosis, 620\\nsymptoms, 618\\ntheories of production, 614\\ntreatment, 621\\nclassification, 613\\ncongenital and pathological,\\n669\\ndivergent dislocation of radius\\nand ulna, 639\\nforward dislocations, 635\\nfracture during reduction, 459\\nfrequency, 613\\ninjury of nerves in, 419, 618,\\n632\\nof vessels in, 418\\nisolated, of radius, 647\\nof ulna, 643\\nlateral dislocations, 624\\ncomplete outward, 631\\nsubepicondylar, 634\\nsupra-epicondylar, 634\\nincomplete, 625\\ninward, 626\\noutward, 627\\nold unreduced, treatment, 664\\nrelations to dislocations of\\nshoulder and fracture of\\nclavicle, 547\\nEmbolism, fat, 461\\nEmbolism, fatal, 462\\nEmphysema during reduction of shoul-\\nder, 450, 457\\nEngel, operation in old, 761\\nEnsiform process, dislocation of, 517\\nEpitrochlea, fracture of, 616, 629, 638\\n640, 666\\nErecta, luxatio, 577, 603\\nEtiology, 410\\nEverted dorsal dislocation of hip, 728\\nFARABEUF, anatomy of shoulder,\\n544\\nreduction of shoulder, 571\\nsubtricipital, 578\\nthumb, 696\\nFat embolism, 461\\nFemoral artery, injured, 418, 754\\nvein, injured, 754\\nFemur, fracture of head, 725, 755\\nof neck, 725, 745, 755\\nof shaft, 738, 756\\nFibula, dislocations of, 799\\nlower end, 801\\nspontaneous and pathological, 801\\nupper end, 799\\nFingers, dislocations of, 696\\ndistal phalanges, 704\\nmetacarpophalangeal, 702\\nof middle phalanges, 703\\nFlaubert, rupture of brachial plexus,\\n450, 457\\nFlower, classification, shoulder, 549\\nFoot, dislocations of, 804\\ncongenital, 808\\nForearm, avulsion of, 451\\nFracture as a complication, 415\\nduring reduction, 459\\nGANGRENE, 424, 460\\nGelle, obstacles to reduction, 437,\\n732\\nGlenoid fossa, fracture of, 593\\nGrawitz, congenital, of hip, 467\\nGreiner, radius, with fracture of ulna,\\nm 662\\nGuerin, avulsion of forearm, 451\\nGunn, obstacles to reduction, 437, 732\\nHABITUAL dislocations, 412. 448\\nof hip, 759\\nof shoulder, 413, 423, 598\\ntreatment, 448\\nHaematomyelia, 143, 145, 493\\nHahn, lateral, of elbow, 625\\nHarris, operation in old, 761\\nHibon, congenital, of knee, 464\\nHip, anatomy of, 710\\ndislocations of, 710-764", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0922.jp2"}, "915": {"fulltext": "INDEX TO DISLOCATIONS.\\n839\\nHip, dislocations of, accidents in reduc-\\ntion. 75$\\nafter-treatment, 759\\nbackward dislocations, 721\\nanterior oblique, 730\\ndorsal, 721\\npathology, 722\\nsymptoms, 725\\neverted dorsal. 728\\ntreatment, 731\\nclassification, 716\\ncomplications, 754\\ncompound, 714\\ncongenital, 468\\ndirectly upward, 747\\ndownward and inward, 736\\nobturator, 736\\nperineal, 741\\non tuberosity of ischium, 751\\nfracture during reduction, 758\\nof acetabulum, 753\\nof femur, 725, 738, 755, 756\\nhabitual dislocations, 759\\nileo-pectineal, 742\\ninfracotyloid, 751\\ninjury of nerves in, 459, 744, 755\\nof vessels in, 418, 754\\nintrapelvic, 742\\nlabrum cartilagineum, detachment\\nof, 757\\nold dislocations, treatment of 760\\narthrotomy, 761\\nexcision, 762\\nosteotomy, 762\\nparalytic dislocations, 763\\npathological dislocations, 762\\nprognosis, 759\\nsimultaneous, of both hips, 757\\nspontaneous dislocations, 762\\nstatistics, 713\\nsubspinous, 747\\nsupracotyloidea, 747\\nsuprapubic, 742\\nthrough acetabulum, 753\\nupward and forward (suprapubic),\\n742\\nHitzig, metatarsus, 826\\nHonigschmied, tibio-tarsal, 804\\nHudson Street Hospital statistics, 407\\nHueter, outward, elbow, 629\\nHumphry, congenital, of radius, 468, 670\\nHutchinson, suppuration, 460\\nvertebrae, 495\\nTLEO-PECTINEAL dislocation of\\n1 hip, 742\\nIndia-rubber, traction by, 444\\nInfracotyloid dislocation of hip, 751\\nInternal derangement of knee, 780\\nIntracoracoid dislocation of shoulder,\\n560\\nIntrapelvic dislocation of hip, 742\\nIrregular dislocations, 438, 712\\nIsemeyer, pathological, of patella, 797\\nJAW, dislocation of lower, 479\\nbackward, with fracture, 479\\ncongenital, 486\\nforward, 480\\noutward, 480\\npathological, 485\\nupward, 479\\nJb ssel, recurrent, of shoulder, 423\\nsubglenoid, 576\\nKAMMERER, fracture of femur, 757\\nKirn, operation in old, 761\\nKnee, dislocations of, 765\\nantero-lateral, 777\\nbackward, 771\\nby rotation, 777\\ncongenital, 464, 783\\nforward, 767\\ninjuries of nerves in, 769\\nof vessels in, 417, 768\\nlateral, 773\\ninward, 776\\noutward, 773\\nspontaneous and pathological, 785\\nstatistics, 766\\ninternal derangement, 780\\nsemilunar cartilages, 780\\nKocher on reduction of hip, 734, 740,\\n747\\nof shoulder, 569\\nKbrte, injuries of vessels, 452\\nKrbnlein, congenital, 463, 464\\nstatistics, congenital, 464\\nelbow, 613\\ngeneral, 408\\nLABHUM cartilagineum, detachment\\nof, 757\\nLbbker, habitual, of shoulder, 598\\nradius, 653\\nLorenz, congenital, of hip, 474\\nLung, hernia of, 183, 186, 519\\nMADELUNG, spontaneous, of wrist,\\n681\\nMalgaigne, classification, hip, 717\\nshoulder, 548\\nradius, with fracture of ulna, 662\\nManipulation, reduction bv, 443\\nat hip, 732\\nat shoulder, 569\\nMarchand, accidents in reduction, 440,\\n452\\nMarkoe, fracture of humerus, 459", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0923.jp2"}, "916": {"fulltext": "840\\nINDEX TO DISLOCATIONS.\\nMcBurney s hook, 593\\nMears, old, of shoulder, 603\\nMedian nerve, injury of, 419, 618\\nMedio-carpal dislocations, 685\\n-tarsal dislocations, 823\\nMetacarpal bones, 690\\nMetacarpophalangeal dislocations of\\nfingers, 702\\nof thumb, 696\\nMetatarsal bones, dislocations of, 826\\nsubluxation of head, 828\\nMetatarso-phalangeal dislocations, 828\\nMeyer, patella, 787\\nMorton, metatarsalgia, 828\\nMuscles torn during reduction, 451\\nMuscular action, a cause of dislocation,\\n411\\nMusculo-spiral nerve torn, 618, 662\\nMyers, congenital, of hip, 473\\nMyopathic dislocations, 477\\nMyositis ossificans, 620\\nMysch, ossifying myositis, 620\\nNERVES, injured, 418, 454, 457, 578,\\n594, 618, 769\\nNicoladoni, old, of elbow, 6QQ\\nOBSTETRICAL paralysis, 609\\nObturator dislocation, 736\\nOcciput, dislocation of, 498\\n(Edema, persistent, 429, 461\\nOld dislocations, pathology, 425\\ntreatment, 445\\nOlecranon, fracture of, 617, 636\\nOs magnum, dislocation of, 688, 690\\nPACI, congenital, of hip, 473\\nParalysis after dislocation of shoul-\\nder, 419, 458, 597\\nParalytic dislocations, 477\\nof hip, 763\\nof shoulder, 609\\nParker, radio-carpal, 675\\nPatella, dislocations of, 786\\ncomplete reversal, 795\\ncongenital, 796\\nedgewise or vertical, 793, 795\\nhabitual or pathological, 797\\ninward, 794\\noutward, 789\\nPathological dislocations, 475\\nPathology of old dislocations, 425\\nof recent dislocations, 414\\nPelvis, dislocations of, 707\\nPendel-methode, at shoulder, 566\\nPerineal dislocations, 741\\nPetit, principle of reduction, 442\\nPhalanges of foot, dislocations of, 829\\nof hand, dislocations of, 696\\nPhalanges of hand, distal, 704\\nmiddle, 703\\nproximal, 696, 702\\nPingaud, radius, by elongation, 659\\nPisiform, dislocations of, 688\\nPoinsot, subastragaloid, 810\\nPopliteal artery torn, 417\\nPouteau on reduction of hip, 442\\nPrahl, statistics of hip, 713\\nPriapism in spinal injury, 496\\nPrognosis, 435\\nRADIO-CARPAL dislocations, 674\\nbackward, 676\\ncongenital, 684\\nforward, 678\\noutward, 680\\npathological, 680\\nspontaneous, 680\\n-ulnar joint, lower, 672\\nbackward, 672\\nforward, 673\\nRadius, head broken, 618\\nisolated dislocations of, 647\\nbackward, 648\\nby elongation, 657\\nforward, 654\\noutward, 651\\npathological and congenital, 468,\\n471, 669\\nwith fracture of ulna, 662\\nRecurrent dislocations, 412\\nReduction, 437\\naccidents during, 446, 449\\nby manipulation, 443\\nconsecutive, 437\\nmethods of, 440\\nobstacles to, 437\\nspontaneous, 437\\nRepair, 422\\nRetro-axillary dislocation, 583\\nRheumatism, dislocation in, 476\\nRibs, broken, 421\\ndislocations of, 518\\nRicard, habitual, of shoulder, 600\\nSCAPHOID, dislocations of carpal,\\n687\\ntarsal, 825\\nSchinzinger, reduction of shoulder, 572\\nSchrotter, radius alone, 653\\nSciatic nerve, pressure upon, 725, 755\\nScudder, compound, of foot, 809\\ncongenital, of shoulder, 604\\nSemilunar bone, dislocation of, 687\\ncartilages, dislocation of, 780\\nServier, radio-carpal, 675\\nShoulder, anatomv of, 542\\ndislocations of, 542-610\\nanterior, 552", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0924.jp2"}, "917": {"fulltext": "INDEX TO DISLOCATIONS.\\n841\\nShoulder, dislocations of, anterior, after-\\ntreatment, 573, 596\\nby muscular action, 412\\niutra-coracoid, 560\\nsubcoracoid, 553\\npathology, 555\\nsymptoms, 559\\ntreatment, 563\\naccidents during, 446, 449\\nbv manipulation, 569\\nKocher, 569\\nSchinzinger, 572\\ndirect reposition, 564\\nheel in axilla, 567\\ntraction downward, 564\\nupward, 566\\nwith leverage, 567\\nclassification, 547\\ncomplications, 590\\nfracture of acromion, 553\\nof coracoid, 589, 593\\nof glenoid fossa, 593\\nof neck, 582, 591\\nof shaft, 593\\nof tuberosity, 581, 591\\ninjury of nerves, 419, 457, 594\\nof vessels, 418, 451\\ncompound dislocations, 595\\ncongenital dislocations, 471, 603\\ndownward dislocations, 574\\nluxatio erecta, 577, 603\\nsubglenoid, 574\\nsubtricipital, 578\\nhabitual dislocations, 413, 423, 598\\ninjury of nerves in, 419, 457, 594\\nof vessels in, 416, 451\\nold dislocations, treatment, 601\\narthrotomy, 602\\nexcision, 603\\nfracture, 603\\nosteotomy, 603\\nsubcutaneous section, 601\\nparalytic dislocations, 609\\npathological, 608\\nposterior dislocations, 579\\nsymptoms, 583\\ntreatment, 584\\nprognosis, 596\\nrecurrent, 413, 423, 598\\nrelation to other injuries, 547\\nretro-axillary, 583\\nsimultaneous, of both shoulders,\\n580, 586, 595\\nstatistics, 546\\nsubacromial, 579\\nsubspinous, 579\\nupward (supracoracoid), 585\\nSkin torn during reduction, 450\\nSmith, Nathan, on manipulation, 443,\\n732\\nSmith, R. W., congenital, of shoulder,\\n604\\nSouchon, old dislocations of shoulder,\\n593\\nSpinal column (see Vertebrse), 487\\nSprengel, lateral, elbow, 625\\nSpontaneous dislocations, 475\\nreduction, 437\\nStatistics, congenital, 463, 464\\ndeath by anaesthetic, 440\\ngeneral* 407, 408, 546\\ninfluence of age, 409\\nof paralysis, 419\\ninjury of vessels, 451, 456\\nSternum, dislocations of body, 513\\nof ensiform process, 517\\nStreubel, lateral, elbow, 625\\nobstacles to reduction, 437\\npatella, 789\\nradius alone, 649\\nby elongation, 658\\nSubacromial dislocation of clavicle, 537\\nof shoulder, 579\\nSubastragaloid dislocations, 809\\nSubclavicular dislocation, 560\\nSubcoracoid dislocation of clavicle, 540\\nof shoulder, 553\\nSubepicondylar dislocation, 634\\nSubglenoid dislocation, 574\\nSubscapular artery torn, 453, 454, 576\\nSubspinous dislocation of hip, 747\\nof shoulder, 579\\nSubtricipital dislocation, 578\\nSuppuration, 421, 440, 460, 493, 758\\nSupra-acromial dislocation of clavicle,\\n532\\nSupracoracoid dislocation of shoulder,\\n585\\nSupracotyloid dislocation of hip, 747\\nSupra-epicondylar dislocation, 634\\nSuprapubic dislocation, 742\\nSus-cotyloidienne dislocation, 747\\nSymptoms, 430\\nSyncope, 461\\nTARSAL bones, dislocation of, 825\\nThumb, dislocations of, 696\\nbackward, 697\\nforward, 700\\nlateral, 701\\ndistal phalanx, 704\\nproximal phalanx, 696\\nThyroid dislocation, 736\\nTibio-tarsal dislocation, 804\\nTillmanns, lower radio-ulnar, 672\\nradio-carpal, 675\\nToes, dislocation of, 828\\nTraction by gravity, 445\\nelastic, 444\\nTrapezium, dislocation of, 690\\nTrapezoid, dislocation of, 689, 690\\nTreatment, 437\\nTrendelenberg, old, of elbow, Q65", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0925.jp2"}, "918": {"fulltext": "842\\nINDEX TO DISLOCATIONS.\\nULNA, fracture with dislocation of\\nradius, 662\\nisolated dislocation of, 643\\nUlnar artery torn, 419\\nnerve, injured, 419, 632, 637\\nUnciform, dislocation of, 688\\nYAN ARSDALE, radius by elonga-\\ntion, 660\\nYerneuil, congenital, 466\\nVertebrae, dislocations of, 487\\natlas, 500\\ncervical vertebra?, 503\\nclassification, 488\\ndorsal vertebrae, 509\\netiology, 494\\nlumbar vertebrae, 511\\nocciput, 498\\npathology, 488\\nprognosis, 496\\nsecondary changes, 493\\nsymptoms, 494\\ntreatment, 497\\nViscera, injury to, 421\\nVolker, old, of elbow, 665\\nVolkmann, pathological, 475\\nVoluntary dislocations, 477\\nVon Ammon, congenital, 466\\nWARBASSE, congenital, of hip, 473\\nWielard, injuries of vessels, 452\\nWier, fracture of ribs, 446\\nrupture of axillary vein, 446, 453\\nWippermann, fracture of neck of femur,\\n755\\nWrist, dislocations at, 672\\npathological, 680\\nY\\nLIGAMENT, 711\\nossified, 737\\nZIELEWICZ, congenital, of patella.\\n796", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0926.jp2"}, "919": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0927.jp2"}, "920": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0928.jp2"}, "921": {"fulltext": "Catalogue of Books\\nPUBLISHED BY\\nLea Brothers Company,\\n706, 708 710 Sansom St., Philadelphia.\\nIll Fifth Avenue, New York.\\nThe books in the annexed list will be sent by mail, post-paid, to any Post-Office in the\\nUnited States, on receipt of the printed prices. No risks of the mail, however, are assumed\\neither on money or books. Intending purchasers will therefore in most cases find it more\\nconvenient to deal with the nearest bookseller.\\nSTANDARD MEDICAL PERIODICALS.\\nProgressive Medicine.\\nA Quarterly Digest of New Methods, Discoveries and Improvements in the Medical and\\nSurgical Sciences by Eminent Authorities. Edited by Dr. Hobart Amory Hare. In\\nfour abundantly illustrated, cloth bound, octavo volumes of 400-500 pages each, issued\\nquarterly, commencing March 1, 1899. Per annum (4 volumes), $10.00, delivered.\\nThe Medical News.\\nWEEKLY, $4.00 PER ANNUM.\\nEach number contains 32 quarto pages, abundantly illustrated. A crisp, fresh weekly\\nprofessional newspaper.\\nThe American Journal of the Medical Sciences.\\nMONTHLY, $4.00 PER ANNUM.\\nEach issue contains 128 octavo pages, fully illustrated. The most advanced and enter-\\nprising American exponent of scientific medicine.\\nThe Medical News Visiting List for 1900.\\nFour styles, Weekly (dated for 30 patients); Monthly (undated, for 120 patients per\\nmonth) Perpetual (undated, for 30 patients weekly per year; and Perpetual (undated, for\\n60 patients weekly per year). Each style in one wallet-shaped book, leather bound, with\\npocket, pencil and rubber. Price, each, $1.25. Thumb-letter index, 25 cents extra.\\nThe Medical News Pocket Formulary for 1900.\\nContaining 1700 prescriptions representing the latest and most approved methods of\\nadministering remedial agents. Strongly bound in leather, with pocket and pencil. Price,\\n$1.50, net.\\nCOMBINATION RATES.\\nALONE. IN COMBINATION\\nS American Journal of the Medical Sciences $4.00 4\\na Medical News 4.ooj^ 7 5 l$i5.oo\\nProgressive Medicine 10.00 j\\ng Medical News Visiting List 1.25\\nft. Medical News Formulary 1.50, net.\\nIn all $20.75 for $16.00\\nFirst four above publications in combination $15.75\\nAll above publications in combination 16.00\\nOther Combinations will be quoted on request. Full Circulars and Specimens free.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0929.jp2"}, "922": {"fulltext": "LEA BROTHERS CO. S PUBLICATIONS.\\nABBOTT (A. C). PRINCIPLES OF BACTERIOLOGY: a Practical Manual for\\nStudents and Physicians. New (5th) edition enlarged and thoroughly revised. In one\\nhandsome 12mo. volume of 5^5 pages, with 109 engravings, of which 26 are colored.\\nJust ready. Cloth, $2.75, net.\\nALLEN (HARRISON). A SYSTEM OF HUMAN ANATOMY; WITH AN\\nINTRODUCTORY SECTION ON HISTOLOGJY, by E. O. Shakespeare, M.D.\\nComprising 813 double-columned quarto pages, with 380 engravings on stone on 109 full-\\npage plates, and 241 woodcuts. One volume, cloth, $23. Sold by subscription only.\\nA TREATISE ON SURGERY BY AMERICAN AUTHORS. FOR STUDENTS\\nAND PRACTITIONERS OF SURGERY AND MEDICINE. Edited by Ros-\\nwell Park, M.D. New condensed edition. In one large octavo volume of 1261 pages,\\nwith 625 engravings and 38 plates. Just ready. Cloth, net, $6.00 leather, net, $7.00.\\nJI^^This work is published also in a large edition, comprising two octavo volumes.\\nVol. I., General Surgery, 799 pages, with 356 engravings and 21 full-page plates in colors\\nand monochrome. Vol. II. Special Surgery, 796 pages, with 451 engravings and 17\\nfull-page plates in colors and monochrome. Price per volume, cloth, $4.50; leather,\\n$5.50, net.\\nAMERICAN SYSTEM OF PRACTICAL MEDICINE. A SYSTEM OF PRAC-\\nTICAL MEDICINE. In Contributions by Eminent American Authors. Edited by\\nAlfred L. Looms. M.D., LL.D., and W. Gilman Thompson, M.D. In four very hand-\\nsome octavo volumes of about 900 pages each, fully illustrated. Complete work now ready.\\nPer volume, cloth, $5 leather, $6 half Morocco, $7. For sale by subscription only.\\nProspectus free on application.\\nAMERICAN SYSTEM OF DENTISTRY. IN TREATISES BY VARIOUS\\nA UTHORS. Edited by Wilbur F. Litch, M.D., D.D.S. In four very handsome super-\\nroyal octavo volumes, containing about 4000 pages, with about 2200 illustrations and many\\nfull-page plates. Volume IV., preparing. Per volume, cloth, $6 leather, $7 half\\nMorocco, $8. For sale by subscription only. Prospectus free on application to the Publishers.\\nAMERICAN TEXT-BOOK OF ANATOMY. See Gerrish, page 7.\\nAMERICAN TEXT-BOOKS OF DENTISTRY. IN CONTRIBUTIONS BY\\nEMINENT AMERICAN A UTHORITIES. In two octavo volumes of 600-800 pages\\neach, richly illustrated\\nPROSTHETIC DENTISTRY. Edited by Charles J. Essig, M.D., D.D.S.,\\nProfessor of Mechanical Dentistry and Metallurgy, Department of Dentistry, University\\nof Pennsylvania, Philadelphia. 760 pages, 983 engravings. Cloth, $6 leather, $7, net.\\nOPERATIVE DENTISTRY. Edited by Edward C. Kirk, D.D.S., Professor\\nof Clinical Dentistry, Department of Dentistry, University of Pennsylvania. 700 pages,\\n751 engravings. Cloth, $5.50; leather, $6.50, net.\\nAMERICAN SYSTEMS OF GYNECOLOGY AND OBSTETRICS. In treatises\\nby the most eminent American specialists. Gynecology edited by Matthew D. Mann,\\nA.M., M.D., and Obstetrics edited by Barton C. Hirst, M.D. In four large octavo\\nvolumes comprising 3612 pages, with 1092 engravings, and 8 colored plates. Per volume,\\ncloth, $5 leather, $6 half Russia, $7. For sale by subscription only. Prospectus free.\\nASHHURST (JOHN, JR.). THE PRINCIPLES AND PRACTICE OF SUR-\\nGER Y. For the use of Students and Practitioners. Sixth and revised edition. In one\\nlarge and handsome 8vo. volume of 1161 pages, with 656 engravings. Cloth, $6 leather, $7.\\nA SYSTEM OF PRACTICAL MEDICINE BY AMERICAN AUTHORS. Edited\\nby William Pepper, M.D., LL.D. In five large octavo volumes, containing 5573 pages\\nand 198 illustrations. Price per volume, cloth, $5 leather, $6 half Russia, $7. Sold\\nby subscription only. Prospectus free on application to the Publishers.\\nA PRACTICE OF OBSTETRICS BY AMERICAN AUTHORS. See Jewett t\\npage 9.\\nATTFIELD (JOHN). CHEMISTRY GENERAL, MEDICAL AND PHAR-\\nMACEUTICAL. New (16th) edition, specially revised by the Author for America.\\nIn one handsome 12mo. volume of 784 pages, with 88 illustrations. Cloth, $2.50, net\\nPhiladelphia, 706 708 ana 710 Sansom St.\u00e2\u0080\u0094 New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0930.jp2"}, "923": {"fulltext": "LEA BROTHERS CO. S PUBLICATIONS.\\nBACON iGORHAM). ON THE EAR. One 12mo. volume, 398 pages, with 109\\nengravings and one colored plate. Cloth, $2, net.\\nBARNES (ROBERT AND FANCOURT). A SYSTEM OF OBSTETRIC MED-\\nICINE AND SURGERY, THEORETICAL AND CLINICAL. The Section on\\nEmbrvologv bv Prof. Milnes Marshall. In one large octavo volume of 872 pages,\\nwith 231 illustrations. Cloth, $5 leather, $6.\\nBARTHOLOW (ROBERTS). CHOLERA; ITS CAUSATION, PREVENTION\\nAND TREATMENT. In one 12mo. volume of 127 pages, with 9 illustrations.\\nCloth, $1.25.\\nBILLINGS (JOHN S.). THE NATIONAL MEDICAL DICTIONARY. Includ-\\ning in one alphabet English, French, German, Italian and Latin Technical Terms used in\\nMedicine and the Collateral Sciences. In two very handsome imperial octavo volumes,\\ncontaining 1574 pages and two colored plates. Per volume, cloth, $6 leather, $7 half\\nMorocco, $8.50. For sale by subscription only. Specimen pages on application.\\nBLACK (D. CAMPBELL). THE URINE IN HEALTH AND DISEASE,\\nAND URINARY ANALYSIS, PHYSIOLOGICALLY AND PATHOLOGI-\\nCALLY CONSIDERED. In one 12mo. volume of 256 pages, with 73 engravings\\nCloth, $2.75.\\nBLOXAM (C. L.). CHEMISTRY, INORGANIC AND ORGANIC. With\\nExperiments. New American from the fifth London edition. In one handsome octavo\\nvolume of 727 pages, with 292 illustrations. Cloth, $2 leather, $3.\\nBROCKWAY (FRED. J.). A POCKET TEXT-BOOK OF ANATOMY. 12mo.\\nof about 400 pages, richly illustrated. Shortly.\\nBRUCE (J. MITCHELL). MATERIA MEDICA AND THERAPEUTICS.\\nNew (6th) edtion. In one 12mo. volume of 600 pages. Just ready. Cloth, $1.50, net.\\nSee Students Series oj Manuals, page 14.\\nPRINCIPLES OF TREATMENT. In one octavo volume of 625 pages. Just\\nReady. Cloth, $3.75, net\\nBRYANT (THOMAS). THE PRACTICE OF SURGERY. Fourth American\\nfrom the fourth English edition. In one imperial octavo volume of 1040 pages, with 727\\nillustrations. Cloth, $6.50 leather, $7.50.\\nBUMSTEAD (F. J.) AND TAYLOR (R. W.). THE PATHOLOGY AND\\nTREATMENT OF VENEREAL DISEASES. See Taylor on Venereal Diseases,\\npage 15.\\nBURCHARD (HENRY H.). DENTAL PATHOLOGY AND THERAPEUTICS,\\nINCLUDING PHARMACOLOGY. Handsome octavo, 575 pages, with 400 illus-\\ntrations. Cloth, $5 leather, $6, net.\\nBURNETT (CHARLES H.). THE EAR: ITS ANATOMY, PHYSIOLOGY\\nAND DISEASES. A Practical Treatise for the Use of Students and Practitioners.\\nSecond edition. In one 8vo. volume of 580 pages, with 107 illustrations. Cloth, $4\\nleather, $5.\\nCARTER (R. BRUDENELL) AND FROST (W. ADAMS). OPHTHALMIC\\nSURGERY. In one pocket-size 12mo. volume of 559 pages, with 91 engravings and\\none plate. Cloth, $2.25. See Series of Clinical Manuals, page 13.\\nCASPARI (CHARLES, JR.). A TREATISE ON PHARMACY. For Students\\nand Pharmacists. In one handsome octavo volume of 680 pages, with 288 illustrations.\\nCloth, $4.50.\\nCHAPMAN (HENRY C). A TREATISE ON HUMAN PHYSIOLOGY. New\\n(2d) edition. In one octavo volume of 921 pages, with 595 illustrations. Just ready.\\nCloth, $4.25; leather, $5.25, net.\\nPhiladelphia, 706, 708 and 710 Sansom St.\u00e2\u0080\u0094 New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0931.jp2"}, "924": {"fulltext": "LEA BROTHERS CO. S PUBLICATIONS.\\nCHARLES (T. CRANSTOUN). THE ELEMENTS OF PHYSIOLOGICAL\\nAND PATHOLOGICAL CHEMISTRY. In one handsome octavo volume of 451\\npages, with 38 engravings and 1 colored plate. Cloth, $3.50.\\nCHEYNE (W. WATSON). THE TREATMENT OF WOUNDS, ULCERS\\nAND ABSCESSES. In one 12mo. volume of 207 pages. Cloth, $1.25.\\nCHEYNE (W.WATSON) AND BURGHARD (F. P.). SURGICAL TREAT-\\nMENT. In seven octavo volumes, illustrated. Volume I, just ready. 299 pages and\\n66 engravings. Cloth, $3.00, net. Volume II, just ready. 382 pages, 141 engravings.\\nCloth, $4.00, net. Volume III. Just Ready. 300 pages, 100 engravings. Cloth, $3.50, net.\\nVol. IV. In Press.\\nCLARKE (W. B.) AND LOCKWOOD (C. B.). THE DISSECTOR S MANUAL.\\nIn one 12mo. volume of 396 pages, with 49 engravings. Cloth, $1.50. See Students Series\\nof Manuals, page 14.\\nCLELAND (JOHN). A DIRECTORY FOR THE DISSECTION OF THE\\nHUMAN BODY. In one 12mo. volume of 178 pages. Cloth, $1.25.\\nCLINICAL MANUALS. See Series of Clinical Manuals, page 13.\\nCLOUSTON (THOMAS S.). CLINICAL LECTURES ON MENTAL DIS-\\nEASES. New (5th) edition. Crown 8vo., of 736 pages with 19 colored plates. Cloth,\\n$4.25, net.\\nJSggr 1 Folsom s Abstract of Laws of U. S. on Custody of Insane, octavo, $1.50, is sold in\\nconjunction with ClovMon on Mental Diseases for $5.00, net, for the two works.\\nCLOWES (FRANK). AN ELEMENTARY TREATISE ON PRACTICAL\\nCHEMISTRY AND QUALITATIVE INORGANIC ANALYSIS. From the\\nfourth English edition. In one handsome 12mo. volume of 387 pages, with 55 engrav-\\nings. Cloth, $2.50.\\nCOAKLEY (CORNELIUS G.). THE DIAGNOSIS AND TREATMENT OF\\nDISEASES OF THE NOSE, THROAT, NASO-PHARYNX AND TRACHEA.\\nIn one 12mo. volume of 526 pages, with 92 engravings, and 2 colored plates. Cloth,\\n$2.75, net.\\nCOATES (W. E., Jr.). A POCKET TEXT-BOOK OF BACTERIOLOGY\\nAND HYGIENE. 12mo., of about 350 pages with many illustrations. Shortly.\\nCOATS (JOSEPH). A TREATISE ON PATHOLOGY. In one volume of 829\\npages, with 339 engravings. Cloth, $5.50 leather, $6.50.\\nCOLEMAN (ALFRED). A MANUAL OF DENTAL SURGERY AND PATH-\\nOLOGY. With Notes and Additions to adapt it to American Practice. By Thos. C.\\nStellwagen, M.A., M.D., D.D.S. In one handsome octavo volume of 412 pages, with\\n331 engravings. Cloth, $3.25.\\nCOLLINS (C. P.). A POCKET TEXT-BOOK OF MEDICAL DIAGNOSIS.\\n12mo. of about 350 pages. Shortly.\\nCOLLINS (H. D.) AND ROCKWELL (W. H., JR.). A POCKET TEXT-\\nBOOK OF PHYSIOLOGY. 12mo., of 316 pages, with 153 illustrations. Just\\nReady. Cloth, $1.50, net; flexible red leather, $2.00, net.\\nCONDIE (D. FRANCIS). A PRACTICAL TREATISE ON THE DISEASES\\nOF CHILDREN. Sixth edition. 8vo. 719 pages. Cloth, $5.25 leather, $6.25.\\nCORNIL (V.). SYPHILIS: ITS MORBID ANATOMY, DIAGNOSIS AND\\nTREATMENT. Translated, with Notes and Additions, by J. Henry C. Simes, M.D.,\\nand J. William White, M.D. In one 8vo. volume of 461 pages, with 84 illustrations.\\nCloth, $3.75.\\nPhiladelphia, 706, 708 and 710 Sansom St\u00e2\u0080\u0094 New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0932.jp2"}, "925": {"fulltext": "LEA BROTHERS CO. S PUBLICATIONS.\\nCROCKETT iM. A.). A POCKET TEXT-BOOK OF DISEASES OF\\nWO HEX. 12mo. of 368 pages, with 107 illustrations. Just Ready. Cloth, $1.50, net.\\nFlexible Eed Leather, $2.00, net.\\nCROOK (JAMES K.). MINERAL WATERS OF UNITED STATES. Octavo\\n574 pages. Just ready. Cloth, $3.50, net.\\nCULBRETH DAVID M. R. MA TERIA MEDIC A AND PHARMA COLOGY.\\nIn one handsome octavo volume of 812 pages, with 445 engravings. Cloth, $4.75.\\nCUSHNY (ARTHUR R.) A TEXT-BOOK OF PHARMACOLOGY AND\\nTHERAPEUTICS. Octavo of 728 pages, with 47 illustrations. Just ready. Cloth,\\n$3.75, net.\\nDALTON (JOHN C). A TREATISE ON HUMAN PHYSIOLOGY. Seventh\\nedition, thoroughly revised. Octavo of 722 pages, with 252 engravings. Cloth, $5; leather,$6.\\nDOCTRINES OF THE CIRCULATION OF THE BLOOD. In one hand-\\nsome 12mo. volume of 293 pages. Cloth, $2.\\nDAVENPORT (F. H.). DISEASES OF WOMEN. A Manual of Gynecology.\\nFor the use of Students and General Practitioners. New (3d) edition. In one hand-\\nsome 12mo. volume, 387 pages and 150 engravings. Cloth, $1.75, net.\\nDAVIS (F.H.). LECTURES ON CLINICAL MEDICINE. Second edition. In\\none 12mo. volume of 287 pages. Cloth, $1.75.\\nDAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. For Students and\\nPractitioners. In one very handsome octavo volume of 546 pages, with 217 engravings,\\nand 30 full-page plates in colors and monochrome. Cloth, $5 leather, $6.\\nDE LA BECHE S GEOLOGICAL OBSER VER. In one large octavo volume of 700\\npages, with 300 engravings. Cloth, $4.\\nDENNIS (FREDERIC S.) AND BILLINGS (JOHN S.). A SYSTEM OF\\nS UR GER Y. In Contributions by American Authors. In four very handsome octavo\\nvolumes, containing 3652 pages, with 1585 engravings, and 45 full-page plates in colors\\nand monochrome. Per volume, cloth, $6 leather, $7 half Morocco, gilt back and\\ntop, $8.50. For sale by subscription only. Full prospectus free.\\nDERCUM (FRANCIS X.), Editor. A TEXT-BOOK ON NERVOUS DIS-\\nEASES. By American Authors. In one handsome octavo volume of 1054 pages, with\\n341 engravings and 7 colored plates. Cloth, $6 leather, $7, net.\\nDE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS; THEIR\\nCLASSIFICATION, HISTORY, SYMPTOMS, PATHOLOGY AND TREAT-\\nMENT. Very handsome octavo, 240 pages, 46 engravings, and 9 full-page plates in\\ncolors. Limited edition, de luxe binding, $4, net.\\nDRAPER (JOHN C). MEDICAL PHYSICS. A Text-book for Students and Prac-\\ntitioners of Medicine. Octavo of 734 pages, with 376 engravings. Cloth, $4.\\nDRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF MODERN\\nSURGERY. A new American, from the twelfth London edition, edited by Stanley\\nBoyd, F.R.C.S. Large octavo, 965 pages, with 373 engravings. Cloth, $4; leather, $5.\\nDUANE (ALEXANDER). A DICTIONARY OF MEDICINE AND THE\\nALLIED SCIENCES. Comprising the Pronunciation, Derivation and Full Explan-\\nation of Medical, Dental, Pharmaceutical and Veterinary Terms. Together with much\\nCollateral Descriptive Matter, Numerous Tables, etc. New (3d) edition. Square octavo\\nvolume of 652 pages with 8 colored plates. Just Ready. Cloth, $3.00, net; limp\\nleather, $4.00, net.\\nDUDLEY (E. C). A TREATISE ON THE PRINCIPLES AND PRACTICE\\nOF GYNECOLOGY. For Students and Practitioners. New (2d) edition. In one\\nvery handsome octavo volume of 717 pages, with 453 engravings, of which 47 are\\ncolored, and 8 full page plates in colors and monochrome. Just Ready. Cloth, $5.00, net;\\nleather, $6.00, net; half morocco, $6.50, net.\\nDUNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE DISEASES\\nOF WOMEN. Delivered in St. Bartholomew s Hospital. In one octavo volume of\\n175 pages. Cloth, $1.50.\\nPhiladelphia, 706, 708 and 710 Sansom St\u00e2\u0080\u0094 New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0933.jp2"}, "926": {"fulltext": "LEA BROTHERS CO. S PUBLICATIONS.\\nDUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCIENCE. Con-\\ntaining a full Explanation of the Various Subjects and Terms of Anatomy, Physiology,\\nMedical Chemistry, Pharmacy, Pharmacology, Therapeutics, Medicine, Hygiene, Dietetics.\\nPathology, Surgery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecology,\\nObstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc. By Robley Dungli-\\nson, M.D., LL.D., late Professor of Institutes of Medicine in the Jefferson Medical Col-\\nlege of Philadelphia. Edited by Richard J. Dttnglison, A.M., M.D. Twenty-second\\nedition, thoroughly revised and greatly enlarged and improved, with the Pronunciation,\\nAccentuation and Derivation of the Terms. With Appendix. Imperial octavo of about\\n1400 pages. Shortly.\\nDUNHAM (EDWARD K.). MORBID AND NORMAL HISTOLOGY. Octavo,\\n450 pages, with 360 illustrations. Cloth, $3.25, net.\\nNORMAL HISTOLOGY. New (2d) edition. Octavo, 319 pages, with 244\\nillustrations. Just Ready. Cloth, $2.50, net.\\nEDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND MATERIA\\nMEDIC A. In one 8vo. volume of 544 pages. Cloth, $3.50 leather, $4.50.\\nEDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for Students and\\nPractitioners. In one handsome 8vo. volume of 576 pages, with 148 engravings.\\nCloth, $3 leather, $4.\\nEGBERT (SENECA). HYGIENE AND SANITATION In one 12mo. volume of\\n359 pages, with 63 illustrations. Cloth, $2.25, net.\\nELLIS (GEORGE VINER). DEMONSTRATIONS IN ANATOMY. Being a\\nGuide to the Knowledge of the Human Body by Dissection. From the eighth and revised\\nEnglish edition. Octavo, 716 pages, with 249 engravings. Cloth, $4.25 leather, $5.25.\\nEMMET (THOMAS ADDIS). THE PRINCIPLES AND PRACTICE OF\\nG YNMCOL OGY. For the use of Students and Practitioners. Third edition, enlarged\\nand revised. 8vo. of 880 pages, with 150 original engravings. Cloth, $5 leather, $6.\\nERICHSEN (JOHN E.). THE SCIENCE AND ART OF SURGERY. A new\\nAmerican from the eighth enlarged and revised London edition. In two large octavo\\nvolumes containing 2316 pages, with 984 engravings. Cloth, $9 leather, $11.\\nESSIG (CHARLES J.). PROSTHETIC DENTISTRY. See American Text-books\\nof Dentistry, page 2.\\nEVANS (DAVID J.). A POCKET TEXT-BOOK OF OBSTETRICS. 12mo.\\nof about 300 pages, amply illustrated. Shortly.\\nFARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS. Fourth\\nAmerican from fourth English edition, revised by Frank Woodbury, M.D. In one\\n12mo. volume of 581 pages. Cloth, $2.50.\\nFIELD (GEORGE P.). A MANUAL OF DISEASES OF THE EAR. Fourth\\nedition. Octavo, 391 pages, with 73 engravings and 21 colored plates. Cloth, $3.75.\\nFLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND PRACTICE\\nOF MEDICINE. New (7th) edition, thoroughly revised by Frederick P. Henry,\\nM.D. In one large 8vo. volume of 1143 pages, with engravings. Cloth, $5; leather, $6.\\nA MANUAL OF AUSCULTATION AND PERCUSSION; of the Physi-\\ncal Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fifth\\nedition, revised by James C. Wilson, M.D. In one handsome 12mo. volume of 274\\npages, with 12 engravings.\\nA PRACTICAL TREATISE ON THE DIAGNOSIS AND TREAT-\\nMENT OF DISEASES OF THE HEART. Second edition, enlarged. In one\\noctavo volume of 550 pages. Cloth, $4.\\nA PRACTICAL TREATISE ON THE PHYSICAL EXPLORATION\\nOF THE CHEST, AND THE DIAGNOSIS OF DISEASES AFFECTING\\nTHE RESPIRATORY ORGANS. Second and revised edition. In one octavo vol-\\nume of 591 pages. Cloth, $4.50.\\nMEDICAL ESSA YS. In one 12mo. volume of 210 pages. Cloth, $1.38.\\nON PHTHISIS ITS MORBID ANA TO MY, ETIOL OGY, ETC. A Series\\nof Clinical Lectures. In one 8vo. volume of 442 pages. Cloth, $3.50.\\nPhiladelphia, 706, 708 and 710 Sansom St New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0934.jp2"}, "927": {"fulltext": "LEA BROTHERS CO. S PUBLICATIONS.\\nFOLSOM (C. F.). AN ABSTRACT OF STATUTES OF U S. ON CUSTODY\\nOF THE INSANE. In one 8vo. volume of 108 pages. Cloth, $1.50. With Clouston\\non Mental Diseases (see page 4), at $5.00, net, for the two works.\\nFORMULARY, THE NATIONAL. See Stitte, Maisch Caspari s National Dispensa-\\ntory, page 14.\\nFORMULARY, POCKET. See page 1.\\nFOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New (6th) and\\nrevised American from the sixth English edition. In one large octavo volume of 923\\npages, with 257 illustrations. Cloth, $4.50 leather, $5.50.\\nFOTHERGILL (J. MILNER). THE PRACTITIONER S HAND-BOOK OF\\nTREATMENT. Third edition. In one handsome octavo volume of 664 pages.\\nCloth, $3.75 leather, $4.75.\\nFOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEMISTRY (IN-\\nORGANIC AND ORGANIC). Twelfth edition. Embodying Watts Physical and\\nInorganic Chemistry. In one royal 12mo. volume of 1061 pages, with 168 engravings, and\\n1 colored plate. Cloth, $2.75 leather, $3.25.\\nFRANKLAND (E.) AND JAPP (F. R.). INORGANIC CHEMISTRY. In one\\nhandsome octavo volume of 677 pages, with 51 engravings and 2 plates. Cloth, $3.75\\nleather, $4.75.\\nFULLER (EUGENE). DISORDERS OF THE SEXUAL ORGANS IN THE\\nMALE. In one very handsome octavo volume of 238 pages, with 25 engravings and\\n8 full-page plates. Cloth, $2.\\nFULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR-PASSAGES.\\nTheir Pathology, Physical Diagnosis, Symptoms and Treatment. From second English\\nedition. In one 8vo. volume of 475 pages. Cloth, $3.50.\\nGALLAUDET (BERN B.). A POCKET TEXT-BOOK ON SURGERY.\\n12mo. of about 400 pages, with many illustrations. Shortly.\\nGANT (FREDERICK JAMES). THE STUDENT S SURGERY. A Multum in\\nParvo. In one square octavo volume of 845 pages, with 159 engravings. Cloth, $3.75.\\nGERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. By American\\nAuthors. Edited by Frederic H. Gerrish, M.D. In one imp. octavo volume of 915\\npages, with 950 illustrations in black and colors. Cloth, $6.50; flexible water-proof,\\n$7 sheep, $7.50, net.\\nGIBBES (HENEAGE). PRACTICAL PATHOLOGY AND MORBID HIS-\\nTOLOG Y. Octavo of 314 pages, with 60 illustrations, mostly photographic. Cloth, $2.75.\\nGOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. volume of 589\\npages. Cloth, $2. See Students Series of Manuals, page 14.\\nGRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. New\\nAmerican edition thoroughly revised. In one imperial octavo volume of 1239 pages,\\nwith 772 large and elaborate engravings. Price with illustrations in colors, cloth, $7\\nleather, $8. Price, with illustrations in black, cloth, $6 leather, $7.\\nGREEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY AND MOR-\\nBID ANATOMY. New (8th) American from eighth and revised English edition.\\nOct. 595 pages, with 215 engravings and a colored plate. Cloth, $2.50, net.\\nGREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEMISTRY. For\\nthe Use of Students. Based upon Bowman s Medical Chemistry. In one 12mo. volume\\nof 310 pages, with 74 illustrations. Cloth, $1.75.\\nGRINDON (JOSEPH). A POCKET TEXT-BOOK OF SKIN DISEASES.\\n12mo. of 350 pages, with many illustrations. Shortly.\\nGROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DISEASES,\\nINJURIES AND MALFORMATIONS OF THE URINARY BLADDER,\\nTHE PROSTATE GLAND AND THE URETHRA. Third edition, revised by\\nSamuel W. Gross, M.D. Octavo of 574 pages, with 170 illustrations. Cloth, $4.50.\\nHABERSHON (S. 0.). ON THE DISEASES OF THE ABDOMEN, comprising\\nthose of the Stomach, (Esophagus, Caecum, Intestines and Peritoneum. Second Amer-\\nican from the third English edition. In one octavo volume of 554 pages, with 11 engrav-\\nings. Cloth, $3.50.\\nPhiladelphia, 706, 708 and 710 Sansom St New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0935.jp2"}, "928": {"fulltext": "LEA BROTHERS CO. S PUBLICATIONS.\\nHALL (WINFIELDS.). TEXT-BOOK OF PHYSIOLOGY. Octavo, 672 pages,\\nwith 343 engravings and 6 colored plates. Just Beady. Cloth, $4.00, net; leather,\\n$5.00, net.\\nHAMILTON ALLAN McL ANE NEB VO US DISEASES, THEIB DESCBIP-\\nTION AND TBEATMENT. Second and revised edition. In one octavo volume of\\n598 pages, with 72 engravings. Cloth, $4.\\nHARDAWAY (W. A.). MANUAL OF SKIN DISEASES. New (2d) edition.\\nIn one 12mo. volume, 560 pages with 40 illustrations and 2 colored plates. Cloth,\\n$2.25, net.\\nHARE (HOB ART AMORY). A TEXT-BOOK OF PBACTICAL THEBA-\\nPE UTICS, with Special Keference to the Application of Kemedial Measures to Disease\\nand their Employment upon a Rational Basis. With articles on various subjects by well-\\nknown specialists. New (8th) and revised edition. In one octavo volume of 796 pages,\\nwith 37 engravings and 3 colored plates. Just Beady. Cloth, $4.00, net; leather, $5.00, net\\nPBACTICAL DIAGNOSIS. The Use of Symptoms in the Diagnosis of Dis-\\nease. New (4th) edition, revised and enlarged. In one octavo volume of 623 pages,\\nwith 205 engravings, and 14 fu]J-page plates. Cloth, $5, net.\\nEditor. A SYSTEM OF PBACTICAL THEBAPEUTICS. By American\\nand Foreign Authors. In a series of contributions by eminent practitioners. In four\\nlarge octavo volumes comprising 4600 pages, with 476 engravings. Vol. IV., now ready.\\nRegular price, Vol. IV., cloth, $6; leather, $7; half Russia, $8. Price Vol. IV. to\\nformer or new subscribers to complete work, cloth, $5 leather, $6 half Russia, $7.\\nComplete work, cloth, $20 leather, $24 half Russia, $28. For sale by subscription only.\\nFull prospectus free on application to the publishers.\\nON THE MEDICAL COMPLICATIONS AND SEQUELS OF TYPHOID\\nFEVEB. Octavo, 276 pages, 21 engravings, and2 full-page plates. Cloth, $2.40, net.\\nHARTSHORNE (HENRY ESSENTIALS OF THE PBINCIPLES AND\\nPBACTICE OF MEDICINE. Fifth edition. In one 12mo. volume, 669 pages,\\nwith 144 engravings. Cloth, $2.75 half bound, $3.\\nA HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 12mo.\\nvolume of 310 pages, with 220 engravings. Cloth, $1.75.\\nA CONSPECTUS OF THE MEDICAL SCIENCES. Comprising Manuals\\nof Anatomy, Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and\\nObstetrics. Second edition. In one royal 12mo. volume of 1028 pages, with 477 illus-\\ntrations. Cloth, $4. 25 leather, $5.\\nHAYDEN (JAMES R.). A MANUAL OF VENEBEAL DISEASES. New (2d)\\nedition. In one 12mo. volume of 304 pages, with 54 engravings. Cloth, $1.50, net.\\nHAYEM (GEORGES) AND HARE (H. A.). PHYSICAL AND NATUBAL\\nTHEBAPEUTICS. The Remedial Use of Heat, Electricity, Modifications of Atmos-\\npheric Pressure, Climates and Mineral Waters. Edited by Prof. H. A. Hare, M.D.\\nIn one octavo volume of 414 pages, with 113 engravings. Cloth, $3.\\nHERMAN (G. ERNEST). FIBST LINES IN MID WIFEB Y. 12mo., 198 pages\\nwith 80 engravings. Cloth, $1. 25. See Students Series of Manuals, page 14.\\nHERMANN L. EXPEBIMENTAL PHABMA COL OGY. A Handbook of the\\nMethods for Determining the Physiological Actions of Drugs. Translated by Robert\\nMeade Smith, M.D. In one 12mo. vol. of 199 pages, with 32 engravings. Cloth, $1.50.\\nHERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In one handsome\\n12mo. volume of 429 pages, with 80 engravings and 2 colored plates. Cloth, $2.50.\\nHILL (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS DISOBDEBS.\\nIn one 8vo. volume of 479 pages. Cloth, $3.25.\\nHILLIER (THOMAS). A HANDBOOK OF SKIN DISEASES. Second edition.\\nIn one royal 12mo. volume of 353 pages, with two plates. Cloth, $2.25.\\nHIRST (BARTON C.) AND PIERSOL (GEORGE A.). HUMAN MONSTBOS-\\nITIES. Magnificent folio, containing 220 pages of text and illustrated with 123 engrav-\\nings and 39 large photographic plates from nature. In four parts, price each, $5. Limited\\nedition. For sale by subscription only.\\nPhiladelphia, 706, 708 and 710 Sansom St. New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0936.jp2"}, "929": {"fulltext": "LEA BROTHERS CO. S PUBLICATIONS.\\nHOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS USED IN\\nMEDICINE AND THE COLLATERAL SCIENCES. New (13th) edition. In\\none 12mo. volume of 845 pages. Just Ready. Cloth, $3.00, net.\\nHODGE (HUGH L.). ON DISEASES PECULIAR TO WOMEN, INCLUDING\\nDISPLACEMENTS OF THE UTERUS. Second and revised edition. In one\\n8vo. volume of 519 pages, with illustrations. Cloth, $4.50.\\nHOFFMANN (FREDERICK) AND POWER (FREDERICK B.). A MANUAL\\nOF CHEMICAL ANAL YSIS, as Applied to the Examination of Medicinal Chemicals\\nand their Preparations. Third edition, entirely rewritten and much enlarged. In one\\nhandsome octavo volume of 621 pages, with 179 engravings. Cloth, $4.25.\\nHOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Principles and\\nPractice. A new American from the fifth English edition. Edited by T. Pickering\\nPick, F.RC.S. In one handsome octavo volume of 1008 pages, with 428 engravings.\\nCloth, $6 leather, $7.\\nA SYSTEM OF SURGERY. With notes and additions by various American\\nauthors. Edited by John H. Packard, M.D. In three very handsome 8vo. volumes\\ncontaining 3137 double-columned pages, with 979 engravings and 13 lithographic plates.\\nPer volume, cloth, $6 leather, $7 half Russia. $7.50. For sale by subscription only.\\nHORNER (WILLIAM E.). SPECIAL ANATOMY AND HISTOLOGY. Eighth\\nedition, revised and modified. In two large 8vo. volumes of 1007 pages, containing 320\\nengravings. Cloth, $6.\\nHUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one octavo\\nvolume of 308 pages. Cloth, $2.50.\\nHUTCHISON (ROBERT) AND RAINY (HARRY). CLINICAL METHODS.\\nAn Introduction to the Practical Study of Medicine. In one 12mo. volume of 562 pages,\\nwith 137 engravings and 8 colored plates, Cloth, $3.00.\\nHYDE (JAMES NEVINS). A PRACTICAL TREATISE ON DISEASES OF\\nTHE SKIN. New (5th) edition, thoroughly revised. Octavo, 866 pages, with 111\\nengravings and 24 full-page plates, 8 of which are colored. Just Ready. Cloth, $4.50,\\nnet; leather, $5.50, net; half morocco, $6.00, net.\\nJACKSON GEORGE THOMAS THE READ Y-REFERENCE HANDB OK\\nOF DISEASES OF THE SKIN. New (3d) edition. 12mo. volume of 637 pages,\\nwith 75 engravings, and one colored plate. Cloth, $2.50, net.\\nJAMIESON (W. ALLAN). DISEASES OF THE SKIN. Third edition. Octavo,\\n656 pages, with 1 engraving and 9 double-page chromo-lithographic plates. Clothe $6.\\nJEWETT (CHARLES). ESSENTIALS OF OBSTETRICS. In one 12mo. volume\\nof 356 pages, with 80 engravings and 3 colored plates. Cloth, $2.25.\\nTHE PRACTICE OF OBSTETRICS. By American Authors. One large octavo\\nvolume of 763 pages, with 441 engravings in black and colors, and 22 full-page colored\\nplates. Cloth, $5.00, net leather, $6.00, net half morocco, $6.50, net.\\nJONES (C. HANDFIELD). CLINICAL OBSERVATIONS ON FUNCTIONAL\\nNEii VO US DISORDERS. Second American edition. In one octavo volume of 340\\npages. Cloth, $3.25.\\nJULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE AND\\nPRACTICE. Second edition. In one octavo volume of 549 pages, with 201 engrav-\\nings, 17 chromo-lithographic plates, test-types of Jaeger and Snellen, and Holmgren s\\nColor-Blindness Test. Cloth, $5.50; leather, $6.50.\\nKIRK (EDWARD C). OPERATIVE DENTISTRY. See American Text-books of\\nDentistry, page 2.\\nKING (A. F. A.). A MANUAL OF OBSTETRICS. New (8th) edition. In one\\n12mo. volume of 612 pages, with 264 illustrations. Just Ready. Cloth v $2.50, net.\\nKLEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In one pocket-\\nsize 12mo. volume of 506 pages, with 296 engravings. Cloth, $2.00, net.\\nSee Students Series of Manuals, page 14.\\nPhiladelphia, 706, 708 and 710 Sansom St.\u00e2\u0080\u0094 New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0937.jp2"}, "930": {"fulltext": "10 LEA BROTHERS CO: S PUBLICATIONS.\\nLANDIS (HENRY G.). THE MANAGEMENT OF LAB OB. In one handsome\\n12mo. volume of 329 pages, with 28 illustrations. Cloth, $1.75.\\nLA ROCHE (R.). YELLOW FEVEB. In two 8vo. volumes of 1468 pages.\\nCloth, $7,\\nLAURENCE (J. Z.) AND MOON (ROBERT C). A HANDY-BOOK OF\\nOPHTHALMIC SUBOEBY. Second edition. In one octavo volume of 227 pages,\\nwith 66 engravings. Cloth, $2.75.\\nLEA (HENRY C). CHAPTEBS FBOM THE BELIGIOUS HISTOBY OF\\nSPAIN; CENSOBSHIP OF THE PBESS MYSTICS AND ILLUMINATI;\\nTHE ENDEMONIADAS EL SANTO NINO DE LA GUABDIA; BBI-\\nANDA DE BABDAXI. In one 12mo. volume of 522 pages. Cloth, $2.50.\\nA HISTOBY OF AUBICULAB CONFESSION AND INDULGENCES\\nIN THE LATIN CHUBCH In three octavo volumes of about 500 pages each.\\nPer volume, cloth, $3. Complete work just ready.\\nFOBMULABY OF THE PAPAL PENITENTIABY. In one octavo\\nvolume of 221 pages, with frontispiece. Cloth, $2.50.\\nSTUDIES IN CHUBCH HISTOBY. The Kise of the Temporal Power-\\nBenefit of Clergy Excommunication. New edition. In one handsome 12mo. volume\\nof 605 pages. Cloth, $2.50.\\nSUPEBSTITION AND FOBCE ESSAYS ON THE WAGEB OF LAW,\\nTHE WAGEB OF BATTLE, THE OBDEAL AND TOBTUBE. Fourth\\nedition, thoroughly revised. In one royal 12mo. volume of 629 pages. Cloth, $2.75.\\nAN HISTOBICAL SKETCH OF SACEBDOTAL CELIBACY IN THE\\nCHBISTIAN CHUBCH. Second edition. In one handsome octavo volume of 685\\npages. Cloth, $4.50.\\nLOOMIS (ALFRED L.) AND THOMPSON (W. GILMAN), Editors. A SYS-\\nTEM OF PBA CTICAL MEDICINE. In Contributions by Various American Authors.\\nIn four very handsome octavo volumes of about 900 pages each, fully illustrated in black\\nand colors. Complete work now ready. Per volume, cloth, $5 leather, $6 half\\nMorocco, $7. Foi- sale by subscription only. Full prospectus free on application to the\\nPublishers.\\nLUFF (ARTHUR P.). MANUAL OF CHEMISTBY, for the use of Students of\\nMedicine. In one 12mo. volume of 522 pages, with 36 engravings. Cloth, $2. See\\nStudents Series of Manuals, page 14.\\nLYMAN (HENRY M.). THE PBACTICE OF MEDICINE. In one very^hand-\\nsome octavo volume of 925 pages with 170 engravings. Cloth, $4.75; leather, $5.75.\\nLYONS (ROBERT D.). A TBEATISE ON FEVEB. In one octavo volume of 362\\npages. Cloth, $2.25.\\nMACKENZIE (JOHN NOLAND). THE DISEASES OF THE NOSE AND\\nTHBOAT. Octavo, of about 600 pages, richly illustrated. Preparing,\\nMAISCH (JOHN M.). A MANUAL OF OBGANIC MATEBIA MEDICA.\\nNew (7th) edition, thoroughly revised by H. C. C. Maisch, Ph.G., Ph.D. In one very\\nhandsome 12mo. of 512 pages, with 285 engravings. Cloth, $2.50, net.\\nMALSBARY (GEO. E.). A POCKET TEXT-BOOK OF THEOBY AND\\nPBACTICE OF MEDICINE. 12mo. 405 pages, with 45 illustrations. Just Beady.\\nCloth, $1.75, net; flexible red leather, $2.25, net.\\nMANUALS. See Students Quiz Series, page 14, Students Series of Manuals, page 14, and\\nSeries of Clinical Manuals, page 13.\\nMARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. volume of\\n468 pages, with 64 engravings and a colored plate. Cloth, $2. See Series of Clinical\\nManuals, page 13.\\nPhiladelphia, 706, 708 and 710 Sansom St.\u00e2\u0080\u0094 New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0938.jp2"}, "931": {"fulltext": "LEA BROTHERS C0. y S PUBLICATIONS. 11\\nMARTIN (EDWARD.) SURGICAL DIAGNOSIS. One 12mo. volume of 400\\npages, richly illustrated. Preparing.\\nMARTIN (WALTON) AND ROCKWELL (W. H., JR.). A POCKET TEXT-\\nBOOK OF CHEMISTRY AND PHYSICS. 12mo. 366 pages, with 137 illus-\\ntrations. Just ready. Cloih, $1.50, net; flexible red leather, $2.00, net.\\nMAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For the use of\\nStudents and Practitioners. Second edition, revised by L. S. Rau, M.D. In one 12mo.\\nvolume of 360 pages, with 3] engravings. Cloth, $1.75.\\nMEDICAL NEWS POCKET FORMULARY. See page 1.\\nMITCHELL (JOHN K.). REMOTE CONSEQUENCES OF INJURIES OF\\nNERVES AND THEIR TREATMENT. In one handsome 12mo. volume of 239\\npages, with 12 illustrations. Cloth $1.75.\\nMITCHELL (S. WEIR). CLINICAL LESSONS ON NERVOUS DISEASES.\\nIn one very handsome 12mo. volume of 299 pages, with 17 engravings and 2 colored plates.\\nCloth, $2.50.\\nMORRIS (MALCOLM). DISEASES OF THE SKIN. New (2d) edition. In one\\n12mo. volume of 601 pages, with 10 chromo-lithographic plates and 26 engravings.\\nCloth, $3.25, net\\nMULLER (J.). PRINCIPLES OF PHYSICS AND METEOROLOGY. In one\\nlarge 8vo. volume of 623 pages, with 538 engravings. Cloth, $4.50.\\nMUSSER (JOHN H.). A PRACTICAL TREATISE ON MEDICAL DIAG-\\nNOSIS, for Students and Physicians. New (3d) edition. In one octavo volume of\\n1082 pages, with 253 engravings and 48 full-page colored plates. Just Ready. Cloth,\\n$6.00, net; leather, $7.00, net.\\nNATIONAL DISPENSATORY. See Stille, Maisch Caspari, page 14.\\nNATIONAL FORMULARY. See National Dispensatory, page 14.\\nNATIONAL MEDICAL DICTIONARY. See Billings, page 3.\\nNETTLESHIP (E.). DISEASES OF THE EYE. New (6th) American from sixth\\nEnglish edition. Thoroughly revised. In one 12mo. volume of 562 pages, with 192\\nengravings, 5 colored plates, test-types, formulae and color-blindness test. Just Ready.\\nCloth, $2.25, net.\\nNICHOLS (JOHN B.) AND VALE (F. P.). A POCKET TEXT-BOOK OF\\nHISTOLOGY AND PATHOLOGY. 12mo. of 459 pages, with 213 illustrations.\\nJust ready. Cloth, $1.75, net; flexible red leather, $2.25, net.\\nNORRIS (WM. F.) AND OLIVER (CHAS. A.). TEXT-BOOK OF OPHTHAL-\\nMOLOGY. In one octavo volume of 641 pages, with 357 engravings and 5 colored\\nplates. Cloth, $5 leather, $6.\\nOWEN (EDMUND). SURGICAL DISEASES OF CHILDREN. In one 12mo.\\nvolume of 525 pages, with 85 engravings and 4 colored plates. Cloth, $2. See Series of\\nClinical Manuals, page 13.\\nPARK (WILLIAM H.). BACTERIOLOGY IN MEDICINE AND SURGERY.\\n12mo. 688 pages, with 87 engravings in black and colors and 2 colored plates. Just\\nReady. Cloth, $3.00, net.\\nPARK (ROSWELL), Editor. A TREATISE ON SURGERY, by American Authors.\\nFor Students and Practitioners of Surgery and Medicine. New condensed edition.\\nIn one large octavo volume of 1261 pages, with 625 engravings and 38 plates. Just\\nReady. Cloth, net, $6.00; leather, net, $7.00. K^This work is published also in a\\nlarge edition, comprising two octavo volumes. Vol. I., General Surgery, 799 pages, with\\n356 engravings and 21 full-page plates in colors and monochrome. Vol. LL, Special\\nSurgery, 796 pages, with 451 engravings and 17 full-page plates in colors and mono-\\nchrome. Price per volume, cloth, $4.50; leather, $5.50, net.\\nPARVIN (THEOPHILUS). THE SCIENCE AND ART OF OBSTETRICS.\\nThird edition In one handsome octavo volume of 677 pages, with 267 engravings and\\n2 colored plates. Cloth, $4.25 leather, $5 25.\\nPhiladelphia, 706, 708 and 710 Sansom St\u00e2\u0080\u0094 New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0939.jp2"}, "932": {"fulltext": "12 LEA BROTHERS CO. S PUBLICATIONS\\nPEPPER S SYSTEM OF MEDICINE. See page 2.\\nPEPPER (A. J.). SURGICAL PATHOLOGY. In one 12mo volume of 511 pages,\\nwith 81 engravings. Cloth, $2. See Students 1 Series of Manuals, page 14.\\nPICK (T. PICKERING). FRACTURES AND DISLOCATIONS. In one 12mo.\\nvolume of 530 pages, with 93 engravings. Cloth, $2. See Series of Clinical Manuals, p. 13.\\nPLAYFAIR (W. S.). A TREATISE ON THE SCIENCE AND PRACTICE\\nOF MID WIFER Y. New 7th American from the Ninth English edition. In one\\noctavo volume of 700 pages, with 207 engravings and 7 full page plates. Cloth, \u00c2\u00a73.75,\\nnet leather, $4.75, net.\\nTHE SYSTEMATIC TREATMENT OF NERVE PROSTRATION 4.ND\\nHYSTERIA. In one 12mo. volume of 97 pages. Cloth, $1.\\nOLITZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE EAR\\nAND ADJACENT ORGANS. Second American from the third German edition.\\nIn one octavo volume of 748 pages, with 330 original engravings.\\nPOCKET FORMULARY. See/page 1.\\nPOCKET TEXT-BOOKS Cover the entire domain of medicine in sixteen volumes of\\n350 to 450 pages each, written by teachers in leading American medical colleges.\\nIssued under the editorial supervision of Beiot B. Gallaudet, M.D. of the College of\\nPhysicians and Surgeons, New York. Thoroughly modern and authoritative, concise\\nand clear, amply illustrated with engravings and plates, handsomely printed and\\nbound. The series is constituted as follows Anatomy (preparing), Physiology (ready),\\nChemistry and Physics (ready), Histology and Pathology (ready), Materia Medica,\\nTherapeutics, Medical Pharmacy, Prescription Writing and Medical Latin (ready),\\nPractice (ready), Diagnosis (shortly), Nervous and Mental Diseases (ready), Surgery\\n(prepariny), Genito- Urinary and Venereal Diseases [preparing), Skin Diseases\\n(preparing), Eye, Ear, Nose and Throat (shortly), Obstetrics (shortly), Gynecology\\n(ready), Diseases of Children (ready), Bacteriology and Hvgiene (shortly). For further\\ndetails see under respective authors in this catalogue. Special circular free on appli-\\ncation.\\nPOTTS (CHAS. S.). A POCKET TEXT-ROOK OF NERVOUS AND\\nMENTAL DISEASES. 12mo. of 455 pages, with 88 illustrations. Just ready.\\nCloth, $1.75, net; flexible red leather, $2.25, net.\\nPROGRESSIVE MEDICINE. See page 1.\\nPURDY (CHARLES W.). BRIGHT S DISEASE AND ALLIED AFFEC-\\nTIONS OF THE KIDNEY. In one octavo volume of 288 pages, with 18 engrav-\\nings. Cloth, $2.\\nPYE-SMITH (PHILIP H.). DISEASES OF THE SKIN. In one 12mo. volume\\nof 407 pages, with 28 illustrations, 18 of which are colored. Cloth, $2.\\nQUIZ SERIES. See Students Quiz Series, page 14.\\nRALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 12mo. volume of\\n314 pages, with 16 engravings. Cloth, $1.50. See Students Series of Manuals, page 14.\\nRAMSBOTHAM (FRANCIS H.). THE PRINCIPLES AND PRACTICE OF\\nOBSTETRIC MEDICINE AND SURGERY. Imperial octavo, of 640 pages,\\nwith 64 plates and numerous engravings in the text. Leather, $7.\\nREMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEMISTRY.\\nNew (5th) edition, thoroughly revised. In one 12mo. volume of 326 pages. Cloth, $2.\\nRICHARDSON (BENJAMIN WARD). PREVENTIVE MEDICINE. In one\\noctavo volume of 729 pages. Cloth, $4 leather, $5.\\nROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF MODERN\\nSURGERY. New (2d) edition. In one octavo volume of 838 pages, with 474\\nengravings and 8 plates. Just Ready. Cloth, $4.25, net; leather, $5.25, net.\\nTHE COMPEND OF ANATOMY. For use in the Dissecting Roorn and in\\npreparing for Examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents.\\nPhiladelphia, 706, 708 and 710 Sansom St.\u00e2\u0080\u0094 New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0940.jp2"}, "933": {"fulltext": "LEA BROTHERS CO.S PUBLICATIONS. 13\\nROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE NERVOUS\\nSYSTEM. In one handsome octavo volume of 726 pages, with 184 engravings. Cloth,\\n$4.50; leather, $5.50.\\nSCHAFER (EDWARD A.). THE ESSENTIALS OF HISTOLOGY, DESCRIP-\\nTIVE AND PRACTICAL. For the use of Students. New (5th) edition. In one\\nhandsome octavo volume of 350 pages, with 325 illustrations. Cloth, $3, net.\\nA COURSE OF PRACTICAL HISTOLOGY. Second edition. In one\\n12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25.\\nSCHLEIF (WM.). A POCKET TEXT-BOOK OF MATERIA MEDICA,\\nTHERAPEUTICS, PRESCRIPTION WRITING. MEDICAL LATIN AND\\nMEDICAL PHARMACY. 12mo. 352 pages. Just Ready. Cloth, $1.50, net;\\nflexible red leather, $2.00, net.\\nSCHMITZ AND ZUMPT S CLASSICAL SERIES.\\nADVANCED LATIN EXERCISES Cloth, 60 cents; half bound, 70 cents.\\nSCHMITZ S ELEMENTARY LATIN EXERCISES. Cloth, 50 cents.\\nSALLUST. Cloth, 60 cents half bound, 70 cents.\\nNEPOS. Cloth, 60 cents half bound, 70 cents.\\nVIRGIL. Cloth, 85 cents; half bound, $1.\\nCURTIUS. Cloth, 80 cents half bound, 90 cents.\\nSCHOFIELD (ALFRED T.). ELEMENTARY PHYSIOLOGY FOR STU-\\nDENTS. In one 12mo. volume of 380 pages, with 227 engravings and 2 colored plates.\\nCloth, $2.\\nSCHREIBER (JOSEPH). A MANUAL OF TREATMENT BY MASSAGE\\nAND METHODICAL MUSCLE EXERCISE. Translated by Walter Mendel-\\nson, M.D., of New York. In one handsome octavo volume of 274 pages, with 117 fine\\nengravings.\\nSENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edition. In one\\noctavo volume of 268 pages, with 13 plates, 10 of which are colored, and 9 engravings.\\nCloth, $2.\\nSERIES OF CLINICAL MANUALS. A Series of Authoritative Monographs on\\nImportant Clinical Subjects, in 12mo. volumes of about 550 pages, well illustrated. The\\nfollowing volumes are now ready Yeo on Food in Health and Disease, new (2d)\\nedition, $2.50; Carter and Frost s Ophthalmic Surgery, $2.25; Marsh on Diseases\\nof the Joints, $2 Owen on Surgical Diseases of Children, $2 Pick on Fractures and\\nDislocations, $2.\\nFor separate notices, see under various authors names.\\nSERIES OF POCKET TEXT-BOOKS. See page 12.\\nSERIES OF STUDENTS MANUALS. See next page.\\nSIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICROSCOPICAL\\nAND CHEMICAL METHODS. New (3d) and revised edition. In one handsome\\noctavo volume of 563 pages, with 138 engravings and 18 full-page plates in colors.\\nJust Ready. Cloth, $3. 50, net.\\nSIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures and Laboratory\\nWork for Beginners in Chemistry. A Text-book specially adapted for Students of Phar-\\nmacy and Medicine. New (6th) edition. In one 8vo. volume of 536 pages, with 46\\nengravings and 8 plates showing colors of 64 tests. Cloth, $3. 00, net.\\nSLADE (D. D.). DIPHTHERIA ITS NATURE AND TREATMENT. Second\\nedition. In one royal 12mo. volume, 158 pages. Cloth, $1.25.\\nSMITH (EDWARD). CONSUMPTION; ITS EARLY AND REMEDIABLE\\nSTAGES. In one 8vo. volume of 253 pages. Cloth, $2.25.\\nSMITH (J. LEWIS). A TREATISE ON THE DISEASES OF INFANCY\\nAND CHILDHOOD. Eighth edition, thoroughly revised and rewritten and greatly\\nenlarged. In one large 8vo. volume of 983 pages, with 273 illustrations and 4 full-\\npage plates. Cloth, $4.50 leather, $5.50.\\nPhiladelphia, 706, 708 and 710 Sansom St.\u00e2\u0080\u0094 New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0941.jp2"}, "934": {"fulltext": "14 LEA BROTHERS CO. S PUBLICATIONS.\\nSMITH (STEPHEN). OPERATIVE SURGERY. Second and thoroughly revised\\nedition. In one octavo vol. of 892 pages, with 1005 engravings. Cloth, $4 leather, $5\\nSOLLY (S. EDWIN). A HANDBOOK OF MEDICAL CLIMATOLOGY.\\nIn one handsome octavo volume of 462 pages, with engravings and 11 full-page plates,\\n5 of which are in colors. Cloth, $4.00.\\nSTILLE (ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUSATION,\\nSYMPTOMS, LESIONS, PREVENTION AND TREATMENT. In one 12mo.\\nvolume of 163 pages, with a chart showing routes of previous epidemics. Cloth, $1.25.\\nTHERAPEUTICS AND MATERIA MEDIC A. Fourth and revised edition.\\nIn two octavo volumes, containing 1936 pages. Cloth, $10; leather, $12.\\nSTILLE (ALFRED), MAISCH (JOHN M.) AND CASPARI (CHAS. JR.).\\nTHE NATIONAL DISPENSATORY: Containing the Natural History, Chemistry,\\nPharmacy, Actions and Uses of Medicines, including those recognized in the latest Phar-\\nmacopoeias of the United States, Great Britian and Germany, with numerous references\\nto the French Codex. Fifth edition, revised and enlarged in accordance with and em-\\nbracing the new U. S. Pharmacopoeia, Seventh Decennial Bevision. With Supplement\\ncontaining the new edition of the National Formulary. In one magnificent imperial\\noctavo volume of 2025 pages, with 320 engravings Cloth, $7. 25 leather, $8. With\\nready reference Thumb-letter Index. Cloth, $7. 75 leather, $8. 50.\\nSTIMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. New\\n(4th) edition. In one royal 12mo. volume of 581 pages, with 293 engravings. Cloth, $3.00,\\nnet. Just Ready.\\nA TREATISE ON FRACTURES AND DISLOCATIONS. In one hand-\\nsome octavo volume of 831 pages, with 326 engravings and 20 full-page plates. Cloth,\\n$5 leather, $6, net.\\nSTUDENTS QUIZ SERIES. A New Series of Manuals in question and answer for\\nStudents and Practitioners, covering the essentials of medical science. Thirteen volumes,\\npocket size, convenient, authoritative, well illustrated, handsomely bound in limp cloth,\\nand issued at a low price. 1. Anatomy (double number); 2. Physiology; 3. Chemistry\\nand Physics 4. Histology, Pathology and Bacteriology 5. Materia Medica and Thera-\\npeutics 6. Practice of Medicine 7. Surgery (double number) 8. Genito-Urinary and\\nVenereal Diseases 9. Diseases of the Skin 10. Diseases of the Eye, Ear. Throat and\\nNose; 11. Obstetrics; 12. Gynecology; 13. Diseases of Children. Price, $1 each, except\\nNos. 1 and 7, Anatomy and Surgery, which being double numbers are priced at $1.75 each.\\nFull specimen circular on application to publishers.\\nSTUDENTS SERIES OF MANUALS. A Series of Fifteen Manuals by Eminent\\nTeachers or Examiners. The volumes are pocket-size 12mos. of from 300-540 pages, pro-\\nfusely illustrated, and bound in red limp cloth. The following volumes may now be\\nannounced: Herman s First Lines in Midwifery, $1.25; Luff s Manual of Chemistry,\\n$2; Bruce s Materia Medica and Therapeutics (sixth edition), $1.50, net; Gould s Sur-\\ngical Diagnosis, $2; Klein s Elements of Histology (5th edition), S2.00, net; Pepper s\\nSurgical Pathology, $2; Treves Surgical Applied Anatomy, $2; Ralfe s Clinical\\nChemistry, $1.50; and Clarke and Lockwood s Dissector s Manual, $1.50\\nFor separate notices, see under various authors names.\\nSTURGES (OCTAVIUS). AN INTRODUCTION TO THE STUDY OF CLIN-\\nICAL MEDICINE. In one 12mo. volume. Cloth, $1.25.\\nSUTTON (JOHN BLAND). SURGICAL DISEASES OF THE OVARIES\\nAND FALLOPIAN TUBES. _ Including Abdominal Pregnancy. In one 12mo. vol-\\nume of 513 pages, with 119 engravings and 5 colored plates. Cloth, $3.\\nTAIT (LAWSON DISEASES OF WOMEN AND ABDOMINAL SURGERY\\nVol. 1. contains 554 pages, 62 engravings, and 3 plates. Cloth, $3.\\nTANNER (THOMAS HAWKES). ON THE SIGNS AND DISEASES OF\\nPREGNANCY. From the second English edition. In one octavo volume of 490 pages,\\nwith 4 colored plates and 16 engravings. Cloth, $4.25.\\nPhiladelphia, 706, 708 and 710 Sansom St.\u00e2\u0080\u0094 New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0942.jp2"}, "935": {"fulltext": "LEA BROTHERS CO. S PUBLICATIONS. 15\\nTAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New American\\nfrom the twelfth English edition, specially revised by Clark Bell,, Esq., of the N. Y.\\nBar. In one octavo volume of 831 pages, with 54 engravings and 8 full-page plates.\\nCloth, $4.50; leather, $5.50.\\nON POISONS IN RELATION TO MEDICINE AND MEDICAL\\nJURISPRUDENCE. Third American from the third London edition. In one 8vo.\\nvolume of 788 pages, with 104 illustrations. Cloth, $5.50 leather, $6.50.\\nTAYLOR (ROBERT W.). THE PATHOLOGY AND TREATMENT OF\\nVENEREAL DISEASES. Few (2d) edition. In one very handsome octavo volume\\nof about 800 pages, with about 230 engravings and many colored plates. Shortly.\\nA PRACTICAL TREATISE ON SEXUAL DISORDERS IN THE MALE\\nAND FEMALE. New (2d) edition. In one octavo volume of 434 pages, with 91\\nengravings and 13 plates. Just Ready. Cloth, $3.00, net.\\nA CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES.\\nIncluding Diagnosis, Prognosis and Treatment. In eight large folio parts, measuring\\n14 x 18 inches, and comprising 213 beautiful figures on 58 full-page chromo-lithographic\\nplates, 85 fine engravings, and 425 pages of text. Complete work now ready. Price per\\npart, sewed in heavy embossed paper, $2.50. Bound in one volume, half Russia, $27\\nhalf Turkey Morocco, $28. For sale by subscription only. Address the publishers. Spec-\\nimen plates by mail on receipt of 10 cents.\\nTAYLOR (SEYMOUR) INDEX OF MEDICINE. A Manual for the use of Senior\\nStudents and others. In one large 12mo. volume of 802 pages. Cloth, $3-75.\\nTHOMAS (T. GAILLARD) AND MUNDE (PAUL P.). A PRACTICAL\\nTREATISE ON THE DISEASES OF WOMEN. Sixth edition, thoroughly\\nrevised by Paul F. Munde, M.D. In one handsome octavo volume of 824 pages, with\\n347 engravings. Cloth, $5 leather, $6.\\nTHOMPSON (W. GILMAN). A TEXT-BOOK OF PRACTICAL MEDICINE.\\nFor Students and Practitioners. In one handsome octavo volume of 1012 pages, with\\n79 illustrations. Just Ready. Cloth, $5.00, net; leather, $6.00, net.\\nTHOMPSON (SIR HENRY). CLINICAL LECTURES ON DISEASES OF\\nTHE URINARY ORGANS. Second and revised edition. In one octavo volume of\\n203 pages, with 25 engravings. Cloth, $2.25.\\nTHE PATHOLOGY AND TREATMENT OF STRICTURE OF THE\\nURETHRA AND URINARY FISTULA. From the third English edition. In\\none octavo volume of 359 pages, with 47 engravings and 3 lithographic plates. Cloth,\\n$3.50.\\nTHOMSON (JOHN). A GUIDE TO THE CLINICAL EXAMINATION AND\\nTREATMENT OF SICK CHILDREN. In one crown octavo volume of 350 pages\\nwith 52 illustrations. Cloth, $1.75, net.\\nTIRARD (NESTOR). MEDICAL TREATMENT OF DISEASES AND SYMP-\\nTOMS. Handsome octavo volume of 627 pages. Just Ready. Cloth, $4.00, net.\\nTODD (ROBERT BENTLEY). CLINICAL LECTURES ON CERTAIN\\nACUTE DISEASES. In one 8vo. volume of 320 pages. Cloth, $2.50.\\nTREVES (FREDERICK). OPERATIVE SURGERY. In two 8vo. volumes con-\\ntaining 1550 pages, with 422 illustrations. Cloth, $9 leather, $11.\\nA SYSTEM OF SURGERY. In Contributions by Twenty-five English Sur-\\ngeons. In two large octavo volumes, containing 2298 pages, with 950 engravings and\\n4 full-page plates. Per volume, cloth, $8.\\nSURGICAL APPLIED ANATOMY. In one 12mo. volume of 583 pages,\\nwith 61 engravings. Cloth, $2. See Students Series of Manuals, page 14,\\nTUTTLE (GEO. M.). A POCKET TEXT-ROOK OF DISEASES OF\\nCHILDREN. 12mo. 374 pages, with 5 plates. Just Ready. Cloth, $1.50, net\\nflexible red leather, $2.00, net.\\nPhiladelphia, 706, 708 and 710 Sansom St.\u00e2\u0080\u0094 New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0943.jp2"}, "936": {"fulltext": "16 LEA BROTHERS CO. S PUBLICATIONS.\\nVAUGHAN (VICTOR C.) AND NOVY (FREDERICK G.). PTOMAINS,\\nLEUCOMAINS, TOXINS AND ANTITOXINS, or the Chemical Factors in the\\nCausation of Disease. Third edition. In one 12mo. volume of 603 pages.\\nVISITING LIST. THE MEDICAL NEWS VISITING LIST for 1900. Four\\nstyles Weekly (dated for 30 patients) Monthly (undated for 120 patients per month)\\nPerpetual (undated for 30 patients each week) and Perpetual (undated for 60 patients\\neach week). The 60-patient book consists of 256 pages of assorted blanks. The first\\nthree styles contain 32 pages of important data, thoroughly revised, and 160 pages of\\nassorted blanks. Each in one volume, price, $1.25. With thumb-letter index for quick\\nuse, 25 cents extra. Special rates to advance-paying subscribers to The Medical News\\nor The American Journal or the Medical Sciences, or both. See page 1.\\nWATSON (THOMAS). LECTURES ON THE PRINCIPLES AND PRAC-\\nTICE OF PHYSIC. A new American from the fifth and enlarged English edition,\\nwith additions by H. Hartshorne, M.D. In two large 8vo. volumes of 1840 pages, with\\n190 engravings. Cloth, $9 leather, $11.\\nWEST (CHARLES). LECTURES ON THE DISEASES PECULIAR TO\\nWOMEN Third American from the third English edition. In one octavo volume of\\n543 pages. Cloth, $3.75; leather, $4.75.\\nON SOME DISORDERS OF THE NERVOUS SYSTE3I IN CHILD-\\nHOOD. In one small 12mo. volume of 127 pages. Cloth, $1.\\nWHARTON (HENRY R.). MINOR SURGERY AND BANDAGING. New\\n(4th) edition. In one 12mo. volume of 596 pages, with 502 engravings, many of which\\nare photographic. Just Ready. Cloth, $3.00, net.\\nWHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR THERA-\\nPEUTIC INDEX. Including Medical and Surgical Therapeutics. In one square\\noctavo volume of 917 pages. Cloth, $4.\\nWILLIAMS (DAWSON). MEDICAL DISEASES OF INFANCY AND\\nCHILDHOOD. In one 12mo. volume of 629 pages, with 18 illustrations. Cloth,\\n$2.50, net.\\nWILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. A new and\\nrevised American from the last English edition. Illustrated with 397 engravings. In\\none octavo volume of 616 pages. Cloth, $4 leather, $5.\\nWINCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED In one\\noctavo volume of 484 pages. Cloth, $4.\\nWIPPERN (A. G.) AND BALLENGER (W. L.). A POCKET TEXT-BOOK\\nOF DISEASES OF THE EYE, EAR, NOSE AND THROAT. 12mo. of\\nabout 400 pages with many illustrations. Shortly.\\nWOHLER S OUTLINES OF ORGANIC CHEMISTRY Translated from the\\neighth German edition, by Ira Remsen, M.D. In one 12mo. volume of 550 pages.\\nCloth $3.\\nYEARBOOK OF TREATMENT FOR 1898. A Critical Review for Practitioners of\\nMedicine and Surgerv- In contributions by 24 well-known medical writers. 12mo., 488\\npages. Cloth, $150/\\nYEAR-BOOKS OF TREATMENT for 1892, 1893, 1896, and 1897, similar to above.\\nEach, cloth, $1.50\\nYEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New (2d) edition.\\nIn one 12mo. volume of 592 pages, with 4 engravings. Cloth, $2.50. See Series oj\\nClinical Manuals, page 13.\\nYOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo. volume of 475\\npages, with 286 illustrations. Cloth, $4 leather, $5.\\nPhiladelphia, 706, 708 and 710 Sansom St.\u00e2\u0080\u0094 New York, 111 Fifth Avenue.", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0944.jp2"}, "937": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0945.jp2"}, "938": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0946.jp2"}, "939": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0947.jp2"}, "940": {"fulltext": "AUG 23 1900", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0948.jp2"}, "941": {"fulltext": "", "height": "4257", "width": "2491", "jp2-path": "practicaltreati00stim_0949.jp2"}, "942": {"fulltext": "", "height": "4501", "width": "2806", "jp2-path": "practicaltreati00stim_0950.jp2"}}