a pair of very thick oblong pads on the ischial tuberosities, so that in sitting the point of the coccyx was in a deep pit.-J. F. S.]

620. The Hip-bone (die Darmbeine, Germ.; l'Os des Iles, Fr.) is more exposed to fracture than the other bones of the pelvis. The direction of the fracture varies; sometimes only one, sometimes both hip-bones are broken, or even the share (das Scham-) and haunch bones (das Sitzbein, Germ.) Only much violence, as a fall from a great height, or being run over by a heavy waggon, and the like, can produce these fractures; there fore they are always accompanied with severe bruising and tearing of the soft parts, and with symptoms of concussion of the spinal marrow and of the sacral nerves.

[I have seen several cases of fracture of one or other portion of these bones, but I do not recollect any one in which symptoms of concussion of the spinal cord existed. The most obvious circumstance is the great collapse which generally accompanies the accident, and which depends rather on the tearing or bursting of the bladder usually occurring in these accidents, than on the injury of the bone itself. From the same cause these fractures are almost invariably fatal; the least serious are fractures of the expanded part of the hip-bone. I have known one instance of recovery from compound fracture of the hip-bone.

621. The diagnosis of fractures of the hip, share, or haunch-bone is often very difficult, because the broken ends are generally not at all displaced. The slightest motion of the body and of the lower limbs causes severe pain at the seat of fracture. The fracture may often be discovered by pressure upon the hip-bone and other pelvic bones; or by its mobility, and by its crepitation when the thigh is moved. If fracture of the hipbone extend through the hip-socket and the broken ends be separated, the thigh may be shortened, the foot and knee turned inwards, and the case may be mistaken for a dislocation of the head of the thigh-bone (1). The shortened leg may easily be brought down, by pulling, to its natural length, but retracts immediately the pulling is left off; the foot has no disposition to fall aside; in pressing on the trochanter or iliac crest of the injured side, deep crepitation is felt; both trochanters stand out equally distant from the upper anterior spine of the ilium (a). When the hip-bone is separated from the rump-bone and the share and haunch bones are broken, the foot is shortened, but retains its proper position. These cases are distinguished from dislocation by the crepitation, which is easily discovered on moving the thigh, and by its more free motions of the latter. If there be displacement of the ends of the fracture, elevations and depressions are felt; and also examination of the pelvic cavity through the rectum or the vagina often declares fracture of the pelvic bones. By the separation of the ends of the fracture inwards, especially if they be split, the parts in the cavity of the pelvis are injured, extravasation of the urine and the like are produced (2).

[(1) The discovery of fracture of the hip-bone is generally easy, by fixing the true pelvis with one hand, and with the other, having thrust in the fingers over the crest of the hip-bone as far into the iliac pit as the abdominal muscles will permit, attempting to move it in and out, which may be done if it be broken. In the same way, but less readily fracture of the haunch-bone may be ascertained, by grasping its tuberosity and endeavouring to move it.

Displacement in these fractures, so far as I have observed, is rarely of any great extent, and the bones are so covered by soft parts, that they would generally be overlooked, were it not that the circumstances of the accident being told, leads to an exami nation of the injury to determine its extent. I do not see any great advantage derived from making an examination by the rectum or by the vagina.-J. F. S.]

(a) COOPER, ASTLEY, above cited, p. 105.-FRICKE, Annalen der Chirurg. Abtheil. des allgem. Krankheit.; in Hamburg, vol. ii. p. 131.-EARLE, HENRY, above cited, p. 250,

(2) A very remarkable case of fracture of the haunch-bone, which was followed by abscess in the perineum and extensive urinary fistulæ, but which recovered after eighteen months, is related by HOUSTON (a).

622. If fracture of the pelvic bones be accompanied with displacement, nothing can be done except putting the patient in such position that the muscles inserted into the pelvis should be at rest; a broad band must be applied around the pelvis, and the patient recommended to keep quiet. The accompanying symptoms of inflammation or injury of the spinal marrow require the same treatment as in fracture of the vertebra. If the broken pelvic bones be displaced, it must be attempted to return them to their proper place, as in fracture of the share and haunch-bone, by the introduction of the finger into the vagina or into the rectum. If by splintering of the bones the bladder be injured, and the urine extravasated, its further extension must be prevented by incision and by the introduction of the catheter.

[As I have already mentioned, displacement in fracture of either of the pelvic bones rarely occurs, and, therefore, introducing the finger into the rectum or vagina is not generally requisite.-J. F. S.]

VIII. OF FRACTURE OF THE BREAST-BONE.

(Fractura Sterni, Lat.; Bruch des Brustbeines, Germ.; Fracture du Sternum, Fr.) 623. Fracture of the Breast-bone is rare, on account of its elastic connexion with the ribs, and on account of its sponginess. It is either consequent to severe violence which immediately strikes the breast-bone, or on violent bending backwards of the body (b). Its direction is generally transverse, more or less oblique, or the bone is broken into different pieces. The broken ends may be driven inwards by the violence which has caused the fracture, or the lower end, which is more raised in the motions of the chest than the upper, lies over it. From this displacement, as well as from the effect of the violence, the organs of the cavity of the chest may be variously wounded, inflammation of the lungs and of the pleura, spitting of blood, collections of blood in the mediastina, and subsequently suppuration in the breast-bone itself, or beneath it, may be produced.

624. The diagnosis is never difficult, on account of the superficial position of the breast-bone. If accompanied with displacement of the fractured pieces, it is easily discovered by examination; in fractures without displacement an unusual movement of the breast-bone is always observed in breathing, and crepitation, which the patient himself also perceives. A fixed pain is at the same time felt in the breast-bone, which increases on breathing; and there is much accompanying oppression, cough, spitting of blood, palpitation, and so on.

625. If the fractured ends be not displaced, a compress dipped in a dispersing lotion is to be applied on the seat of the fracture, and the motions of the chest prevented by a tightly applied breast-bandage. The patient must be kept quiet, with his chest a little raised and his head bent forwards. If the ends of the fracture be separated, they must be put right

(a) Case of Fracture of the Pelvis attended with sloughing of the urethra and singularly extensive urinary fistula, cured by operation after the lapse of one year and a half; in Dublin Journal of

VOL. I.

Medical and Chemical Science, vol. viii. p. 11. 1836.

(b) CHAUSSIER; in Révue Médicale, Nov. 1827. 2 N

as soon as possible; for which purpose the patient must be much bent backwards, and a pillow laid beneath his back. If the setting cannot be in this way effected, and the symptoms are pressing, the seat of fracture must be laid bare, and the replacement of the displaced ends of the bone effected with an elevator; and if this be insufficient, the edge of the fracture must be first removed by means of the lenticular, or perforation of the breastbone must be made. This, however, has been objected to by CHARLES BELL and others as useless, inasmuch as to the existing injury a new one is added, without advantage, which my own experience has also confirmed. If, after complete replacement, the one end of the fracture have a disposition to become displaced, it must be kept in its proper position by means of a graduated compress and breast-band, which DUPUYTREN endeavours to effect by a splint upon the breast-bone, and GÜNTHER by a splint fastened upon the chest with starch bandage. If such fracture be cured without the broken ends of the bone being brought into place, constant cough, oppression, and distressing palpitation of the heart are produced. The general treatment must be directed according to the injuries accompanying the fracture and the inflammatory condition of the organs in the chest. Collections of blood and pus behind the breast-bone render the application of the trepan necessary.

[I do not know any instance in which the severe symptoms here enumerated have occurred in fracture of the breast-bone; and I should not be disposed to perform any operation for raising the depressed end of the bone, for the reasons assigned by CHARLES BELL, and also because I should fear that the violence which would drive the breastbone in so as to produce such severe symptoms, would have caused such other serious mischief as to render the operation useless, and therefore not permissible.-J. F. S.]

IX.-OF FRACTURE OF THE RIBS.

(Fractura Costarum, Lat.; Bruch der Rippen, Germ.; Fracture des Côtes, Fr.) 626. Fracture of the Ribs most commonly happens to the lower true ribs, as the false ribs by their mobility yield to the external violence, and the upper true ones are protected by the collar-bones. The ribs usually break at their most convex part. The cause of fracture is either violence which thrusts the ribs from before backwards, or which squeezes them inwards at their middle; in the former case the ends of the fracture project out, and in the latter inwards, by which the pleura or the lungs (1) are wounded, and inflammation of them, extravasation into the cavity of the chest and emphysema are produced. The broken surfaces are mostly oblique, and more or less uneven.

That severe cough can produce a broken rib, which has been wrongly denied, is shown by a case in the Dublin Journal of Medical and Chemical Science, 1833, July, p. 355, in which the fracture of a rib happened to a woman of forty-seven years old, during a severe fit of coughing. A pain, however, connected with displacement or tearing of some muscular fibres caused by severe cough, is not to be confounded with that just mentioned.

[(1) The heart is sometimes penetrated by the end of a broken rib, of which, in St. Thomas's Museum, there is an example in the following

CASE.-A. B. was admitted into George's Ward,

June 3, 1839, 9 A M., having been a short time previously run over by his own cart. He was able to walk from the gate to the surgery, a distance of about a hundred yards, but complained of difficulty in breathing. The fourth and fifth ribs of the left side were found to be fractured, and a bruise of the soft parts at the same spot. He lived only nine hours, and seemed to die of suffocation. On examination much blood was found poured out beneath the skin covering the chest, principally on the left side; but there were also some clots on the right side. The first piece of the breast-bone was broken.

The upper two ribs on the right side were broken near their cartilages; and the upper five on the left side through their middle. The cavity of the left pleura contained two pints of bloody serum, and the left lung was collapsed, and torn at its apex. The sharp splintered end of one of the ribs, which had penetrated the pleura, had passed also through the pericardium, which contained a small clot of blood, and wounded the heart near its apex. There was a large tear through the right side of the diaphragm, but no blood in the cavity of the belly.-J. F. S.]

627. The diagnosis of this fracture is often very difficult, as the broken ends can project only inwards and outwards (indeed, in many cases the broken ends resume their natural position); and this displacement, especially in fat persons, often cannot be well distinguished, particularly if swelling have already commenced. The patient feels a fixed and more or less severe pain, which increases on breathing; crepitation is felt if the hand be placed on the seat of fracture and the patient bidden to cough; crepitation, and frequently unevenness of the ribs, if they be closely examined through their whole length and a moving pressure made on them. An air swelling (emphysema) appearing on the seat of injury is an undoubted proof of fracture of a rib.

628. The local treatment of fracture of the ribs consists merely in preventing their motions, by means of a broad breast-band applied sufficiently tight. If the broken ends have fallen inwards, or have an inclination so to do, a compress is to be placed on the fore and hind ends of the broken bone, and over them the chest-bandage. The especial object of this bandaging is always the restriction of the violent motions of the chest; the patient no longer hears so frequently the striking together of the fractured ends, and the pain is always much diminished. It is, therefore, improper not to apply a bandage, as recommended by many persons. The treatment of the patient must, in other respects, be in reference to the inflammatory condition produced by the violence itself or by the fracture. The patient should observe the strictest quiet, and must be frequently bled, and so on. A severe cough, which causes much pain, and produces displacement of the ends of the fracture, requires, with the proper antiphlogistic treatment, antispasmodic remedies, an emulsion with nitre, opium, or extract of hyoscyamus. If extravasation of blood occur in the cavity of the chest, or emphysema, they must be treated according to the rules laid down in wounds of the chest.

For the purpose intended a properly applied chest-band is sufficient. GRAEFE employs an elastic chest-girdle with spiral springs; LARREY, his immovable apparatus; and SEUTIN applies pasteboard splints; MALGAIGNE will prevent respiration on the sound side but not on the injured side, by sticking plaster, which passes from the seventh rib of the affected side back to the spine, and above the healthy shoulder, and terminates at the hip of the injured side. A padded pasteboard splint, according to BAILLIE, applied, with an aperture for the seat of fracture, would afford great ease.

[Although in fracture of the ribs of one side, bandaging the chest (without, however, the compresses which CHELIUS recommends in some cases to be applied) is the most proper and efficient treatment, yet, if the ribs on both sides be broken, and especially if many of them, no bandage must be employed, as the breast-bone being partially unsupported, the broken ribs slip behind each other, and being thrust into the pleura, render the patient's condition worse. The only thing to be done, therefore, is to keep the chest raised, and so supported by pillows as to keep it as much at rest as possible, and encourage breathing by the diaphragm.

When there is much and inconvenient emphysema, a few punctures through the skin should be made for the escape of the air.-J. F. S.]

629. The cartilages connecting the ribs with the breast-bone may break without being ossified. If the fracture of the cartilage be near the breast

bone, the inner portion sticks out and crosses the outer part. The contrary happens if the fracture be far from the breast-bone, which depends on the finger-like attachment of the m. triangularis sterni. The diagnosis is easy, on account of the separation of the ends of the fracture. The setting is not difficult, and succeeds best if at the moment of inspiration an attempt be made to press the ends of the fracture into their place. A broad breast-band (according to MALGAIGNE, an English truss) should be put on sufficiently tight, which cannot, however, always completely prevent the displacement of the ends of the fracture, though it fixes them in place; in consequence the pain, which depends on the movements of the fractured ends, is diminished; and in this way the union is favoured, which is always perfected by a bony ring more or less surrounding the ends of the fracture.

X.-OF FRACTURES OF THE SHOULDER-BLADE.

(Fractura Scapula, Lat.; Bruch des Schulterblattes, Germ.; Fracture de l' Omoplate, Fr.)

630. The Fractures of the Shoulder-blade are those of the acromion, of the neck, of the coracoid process, of the body, and of the lower angle. These are always consequent on very severe violence to which the bone is subjected; the accompanying accidental bruising therewith connected is generally more dangerous than the fracture itself.

[CHELIUS Overrates the violence necessary for the production of these fractures, which, excepting that of the lower angle, is rarely produced by a direct blow, and usually by a fall on the elbow, which drives the head of the arm-bone upwards. Nor have I ever seen any very serious bruising of the soft parts attending these accidents.—J. F. S.]

631. The acromion is most frequently broken, and generally at its base and horizontally. The outer portion is dragged down by the weight of the arm, and the shoulder inclined downwards and somewhat inwards: a depression is felt at the seat of fracture, which subsides if the arm be somewhat separated from the trunk, and raised parallel to its long axis; and when in this position the arm is moved, there is distinct crepitation (1). At the moment of the accident the patient feels a dropping down of the arm, and has but little power to raise it.

For the purpose of bringing the broken ends into proper place, and there retaining them, a conical pad should be placed between the arm and the trunk, with its thick base below the elbow, the arm pressed upwards and confined in that position with a bandage, which should be carried in shape of a figure of around both shoulders and the elbow of the injured side. The fore-arm is to be supported in a sling. Should this apparatus not serve the purpose, as for example, in women with large bosoms, the arm must be supported on a pillow with a strap, or the patient should be kept in bed, and the arm put at a right angle with the trunk. [(1) To these signs of a broken acromion may be added the jutting of the fractured end of the spine of the bone, and the flattened form which the shoulder assumes instead of its natural rounded shape, by which the appearance of dislocation into the arm-pit is produced, and with which it is often confounded, but is easily distinguished from, by raising the elbow, when the roundness of the shoulder is restored and the appearance of dislocation ceases.-J. F. S.]

632. Fracture of the neck of the Shoulder-blade is rare, and only consequent on very great violence; it is therefore always accompanied with considerable bruising. The lower end of the fracture is so much drawn down that the shoulder has an appearance similar to that of dislocation,