in old age, it is because the exciting causes are less operative, since
the fragility of the bones, as a general rule, increases with age. It
will be noticed, also, that somewhat in proportion as the bone is more
brittle, its fracture will be more nearly transverse, so that very old
persons have frequently what has been not inaptly termed the " pipe-
stem fracture ;" but we must except from this rule fractures occurring
in children, which are also not unfrequently transverse, often denticu-
lated or splintered, and but rarely oblique. In all of the intermediate
periods of life, oblique fractures are by far the most common.
Females are less liable to fractures than males, except in old age,
when the law seems, in general, to be reversed. As to the season of
the year, it has been generally observed by surgical writers that
fractures were more frequent in winter than in summer, and an
explanation has been sought for in the greater rigidity of the muscles
during the cold weather, and the greater liability to falls upon the ice
and frozen ground. Some have affirmed that the bones themselves
were more brittle; but, aside from the improbability of this last
explanation, it is a matter of question whether fractures are actually
more frequent in the winter than in the summer. If, on the one
hand, the rigidity of the muscles and falls upon slippery walks are
active causes in the production of fractures in the one season, on the
other hand, falls from buildings and accidents from a great variety of
similar causes are equally active agents in the other. ^
Mollities ossium, rickets, cancer, tertiary lues, scrofula, gout, scurvy,
merciirialization, and, in short, all diseases dependent upon cachexias, '
more or less predispose to the occurrence of fractures. Inflammation
of the periosteum, also, or of the bone itself, may predispose to frac-
ture. It is said, moreover, that the bones of persons who have lain a
long time in bed break easily.
Exciting Causes, — The exciting, determining, or immediate causes of
fractures are of two kinds : mechanical violence and muscular action.
Of these two, mechanical or external violence is much the most
frequent cause ; and this violence may operate in two ways: by acting
directly upon the bone at the point at which it separates, and then we
say the fracture is " direct," or from " direct violence ;" or by acting
upon some point remote from the seat of fracture, and then we say the
Digitized by
Google
80 GENERAL ETIOLOGY OF FRACTURES.
fracture is " indirect," or from a "counter-stroke." When a persoa
falls from a height, alighting upon his feet, and the leg or thigh is
broken, the fracture is indirect ; so also if the bone is broken by flexioa
or torsion. Even direct pressure upon one side of a lon^ bone in a
child may produce a partial fracture upon the opposite side, which is
properly an indirect fracture; or a direct blow upon the trochanter
major may occasion a counter- fracture through the neck of the femur.
Fractures from muscular action occur most often in the patella,
calcaneum, humerus, femur, tibia, and olecranon process of the ulna.
These accidents imply generally some conditions of the bones them-
selves which predispose them to fracture ; but I have seen one example
of a fracture of the shaft of the femur in a large and perfectly healthy
man, occasioned by a twist of the leg in rolling tenpins. I have also
known the tibia and patella to break from natural muscular action in
persons of uncommon vigor. Fractures sometimes occur in the violent
contractions of the muscles during convulsions, and where no abnormal
condition of the bones could be assumed to exist. Parker, of New
York, relates a case of fracture of the humerus in a negro preacher,
which occurred in the act of gesticulation ; also, a fracture of the
clavicle occasioned by striking a dog with a whip; in another case
the humerus was broken in attempting to throw a peach ; but the most
singular case of all was a fracture of the humerus caused by an eflfort
to extract a tooth.'
Lente, of New York, has seen both femurs broken in epileptic
convulsions, in a child twelve years of age. The left femur was broken
April 10th, 1859, at the junction of the upper with the middle third,
and the right femur was broken at the same point eight months after,
and about six weeks later he died. The first fracture united with
Qonsiderable bowing and shortening. The second did not unite at all.
He had been subject to epilepsy since he was fifteen months old.'
Eemarkable examples of fragility of the bones have been from time
to time recorded. Gibson relates the case of a young man who at
the age of nineteen had suffered twenty-four fractures. Arnott speaks
of a girl who at the age of fourteen had suffered thirty-one fractures ;
Esquirol had in his possession the skeleton of a woman in which
were found traces of more than two hundred fractures; and we have
had, at the Charity Hospital, a man eet. 53, who had suffered eleven
fractures and two dislocations, in whose case both the susceptibility
to fractures and to dislocations appeared to be hereditary.* In most
of these cases, so far as is known, union occurred rapidly.
Nearly all of the cases of fractures occasioned by muscular contrac-
tion seen by me were transverse, or nearly so, indicating, perhaps,
also the existence of some unusual fragility ; and most of these have
been unattended with shortening, the ends of the bones not becoming
completely displaced from each other. The example of fracture of
» Parker, New York Journ. Med., July, 1852, p. 95.
« Am. Med. Times and Advertiser, July 21, 1860, p. 41.
s The Physician and Pharmaceutist, Feb. 1870. Report by Armenag Assadoorian,
House Surgeon.
Digitized by
Google
GENERAL ETIOLOGY OF FRACTURES. 81
the shaft of the femar just mentioned, as having been broken in rolling
tenpins, was, however, an exception. The bone shortened to the ex-
tent of an inch or more, in consequence of overlapping, and in this
position it has finally united.
Intra-uterine fractures are not yet fully explained, but it is probable
that they, like extra-uterine fractures, may be ascribed sometimes to
external violence, and at other times to simple muscular contraction,
both perhaps acting upon bones already somewhat predisposed by a
peculiar constitutional cachexy.
Lawrence Proudfoot, of New York, has related a case of compound
fracture in utero occurring in the practice of Dr. Freeman, which was
apparently caused by e^xternal violence. Mrs. F., aet. 88, always
having enjoyed good health, during the sixth month of gestation,
while attempting to pass through a very narrow passage, was severely
pressed upon the abdomen, and immediately experience a severe pain
in that region, accompanied with nausea and faintness. The following
day, uterine hemorrhage, with pain, commenced j and these svmptoms
continued at intervals, in a form more or less severe, up to the period
of her delivery, which'occurred at full time, and was perfectly natural.
At birth, the right foot of the child, a female, was found to be much
distorted, and in a condition of valgus with equinus, the outer side of
the foot being laid against the side of the leg above the external mal-
leolus. The tibia, also, of the same limb, near its middle, seemed to
have been the seat of a compound fracture ; the two ends of the bone
having united at an angle slightly salient anteriorly, and the skin
presenting over the point of fracture an old cicatrix. The soft tissues .
adjacent were considerably thickened. Seventeen months after birth,
when the child was seen by Drs. Proudfoot, Van Buren, and Isaacs,
the footy although much improved by the means employed by Dr.
Freeman, was still considerably deformed, in consequence of the con-
traction of the tendo-Achillis ; on cutting which, the limb was found
to be of the same length with the other.^
Dr. Aristide Sodrigue, of Hollidaysburg, Pa., has communicated a
case of fracture with dislocation, which he ascribes to a similar cause.
The woman, when about four months with child, fell on her left side,
striking upon a board, and hurting herself severely. At the full period
she was delivered of a well-grown male child., its left humerus was
found to be dislocated into the axilla, and both the radius and ulna oH
the same limb had been broken through their lower thirds> but were
now united by bony callus at an angle of about 45^, and slightly
overlapped. In all other respects the child was perfect. It does not
appear that anything was done to the fracture, and the attempt to
reduce the humerus was unsuccessful. Four years later Dr. S. saw
the lad, and found him strong and hearty, the dislocated humerus
having grown nearly at the same rate with the opposite, but the
forearm remained '' short and deformed as at birth.*' The hand was
of the same size as the hand of the sound limb.*
> Proudfoot, New York Journ. Med., Sept. 1846, p. 199.
' Rodii^e, Amer. Journ. Med. Sci., Jan. 1854, p. 272.
Digitized by
Google
82 GENERAL ETIOLOGY OF FRACTURES.
Devergie has given an account of a woman, who, when seven
months with child, struck her abdomen against the corner of a table.
Intense pain followed, lasting some time. She went her full period,
however, and the child was then found to have a fracture of the left
clavicle, the fragments being overlapped somewhat, and united in
this position by a firm and large callus.' A woman also six months
gone met with a similar accident, and at the full time she gave birth
to a feeble child, having in one leg a separation of the shaft of the
tibia from its lower epiphysis. The end of the shaft was necrosed,
and projected through a wound in the integument. This child died
on the thirteenth day.*
Schubert reports the case of a female delivered before her term, of
twins, one of whom was born with a fracture of the left thigh, which
had occurred in utero; the fractured bone had pierced the flesh,
through which it projected more than an inch, and it was carious.
The mother stated that about six weeks before the accouchement,
during a movement of the foetus, she had heard a noise like that
produced by breaking a stick, and from that moment she had felt
pricking pains in her belly.* It is probable that in this instance the
fracture was the result of a muscular action, although it is possible
that it was occasioned by the thigh having become entangled between
the legs of the twin. Similar cases have been recorded by Ploucquet,
Kopp, Devergie, Cams, Schubert, Sachse, Moffat, and Brodhurst.*
In many other examples upon record* the explanation is plainly
enough to be sought for in the abnormal or rachitic condition of the
bones. Monteggia saw, in a newly born infant, twelve ununited frac-
tures. Chaussier, who has published a memoir upon this subject,
mentions two very extraordinary cases, in one of which the child pre-
sented forty-three fractures, and in the other, one hundred and twelve.*
I myself was permitted to see, on the 29th of June, 1853, with Drs.
Hawley and White, of Buffalo, an infant only four days old, who was
born at the full time, of a healthy mother, in whom nearly all of the
long bones were separated and movable at their epiphyses, the motion
being generally accompanied with a distinct crepitus. The bones
were also much enlarged in their circumference; the bones of the
forearm and the femur were greatly curved ; the fontanelles unusually
open, and the clavicles were entirely wanting. The child was of full
size, but looked feeble. It died in a condition of marasmus six months
after birth ; at which time some degree of union had taken place at
several of the points of separation, the limbs having been supported
constantly with pasteboard splints and rollers.
I have also seen one example of complete separation of the tibia
and fibula near the middle of the leg, which I was disposed to regard
as defective development, rather than as an instance of intra-uterine
> Devergie, Rev. M^d., 1825.
« Malgaigne, from Archiv. G^n. de M6d., t. xvi. p. 288.
* Amer. Journ. Med. Sci., May, 1828, p. 228 ; from Zeitsch. fur Staatsarz. von
Henke, 7e Erg. Heft., p. 811. Holmes' Surgery, vol. iv. p. 826.
* Holmes' Surgery, vol. iv. 827, from Med.-Chir. Trans., vol. xliU., 1860, art. 8.
* Lond. Med. Times and Qaz., April 7, 1860. New Orleans Med Journ. , Nov. 186a
6 Chaussier, Bullet, de la Faculte de Med. de Paris, 1813, p. 301.
Digitized by
Google
GENERAL SEMEIOLOGY AND DIAGNOSIS. 88
fracture ; and a gentleman in Michigan has sent me an account of
another, which I am inclined to think belongs to the same class of
deformities, although he thought it might be a case of intra-uterine
fracture.
Fractures occurring from violence inflicted upon the child by the
accoucheur, or from contractions of the neck of the womb while the
child is in transitu, are more common occurrences, and do not require
a separate consideration. I shall mention several in connection with
the various bones in which they have taken place ; among which, one
of the most interesting is that published by Jacob H. Vanderveer,
of Long Branch, N. J. The mother came to bed on the 18th of
January, 1847, after a labor of more than twelve hours. It was a foot
presentation ; the child weighed fourteen pounds, and was perfectly
healthy, but one of the thighs had suflFered a complete fracture, occa-
sioned probably by the strong contractions of the cervix uteri. With
careful splinting and bandaging, the bone was finally, but not without
some difficulty, kept in position and made to unite, so that at the date
of the report one would not discover that the bone had been broken,
except by close inspection.*
CHAPTEE III.
GENERAL SEMEIOLOGY AND DIAGNOSIS.
Fbactures are liable to be confounded with contusions, and with
various other local injuries, but most often with dislocations; and
especially when the fracture has taken place near one of the articu-
lations, is the differential diagnosis sometimes rendered exceedingly
difficult. It is with particular reference, therefore, to the general
points of distinction between fractures and dislocations, that I now
propose to speak. The special signs or points of difference which
belong to each individual case will be considered in their proper
places.
The most important general or common signs of a fracture — and by
"common" signs I mean those which are common to most fractures —
are crepitus, mobility, and an inability on the part of the fragments
to maintain their positions when reduced ; indeed, in many cases, this
constantly recurring displacement is due to the fact that the surgeon
is unable to accomplish a complete reduction. While, on the other
hand, dislocations are almost as uniformly characterized by the absence
of crepitus, by preternatural immobihty, and by the fact that, when
reduced, the bones do not usually require support to retain them in
place, or indeed, we may say, by the fact that they are generally
reducible.
* Vanderveer, Amer. Journ. Med. Sci., May, 1847, p. 878.
Digitized by
Google
84 GENERAL SEMEIOLOGY AND DIAGNOSIS.
Let US study these phenomena a little more in detail.
Crepitus, occasioned by the chafing of the broken surfaces upon
each other, when actually present, is almost positive evidence of the
existence of a fracture. It is possible, however, to confound the chaf-
ing of engorged tendinous sheaths, or of inflamed joints upon which
fibrinous effusions have occurred, or of emphysema even, for the true
crepitus of a fracture ; but to the experienced ear and well-practised
touch these sensations are seldom a source of error. The one is rough,
crackling, or even clicking sometimes, while the other is more sub- .
dued, and imparts a more uniform sensation to the hand, and but
rarely conveys an actual sound, unless the ear is directly applied or
the stethoscope is employed. It is only when the crepitus is trans-
mitted obscurely through a great mass of soft tissues, or sufficient
time has elapsed for the ends of the fragments to become softened by
inflammation and partially covered with a plastic material, or when,
indeed, a dislocation is actually coincident with the fracture, that the
surgeon is left in doubt. Occasionally, also, the existence of caries or
of necrosis, in connection with a dislocation, might lead to the sup-
position of a fracture ; but the history of the case, aside from the
remaining common signs, and the special symptoms hereafter to be
enumerated, would prevent any possibility of error. In a few cases
the diagnosis may be facilitated by the application of the ear or of the
stethoscope as first recommended by Lisfranc'
It must not be forgotten, moreover, that a fracture at one point
may transmit the sensation of crepitus distinctly enough, but in such
a direction, owing to the relations of other bones to the one broken,
as to mislead the surgeon, and induce him to locate the fracture in the
wrong bone. Several examples of this species of deception I shall
hereafter have occasion to mention.
Valuable and important as is crepitus in its relations to differential
diagnosis, unfortunately it is not always present, and for reasons
which must be plainly stated. First : we cannot, in a pretty large
proportion of cases, bring tYe broken ends again into apposition.
Whatever mere theorists may say to the contrary, and notwithstand-
ing surgeons up to this time have rarely ventured to allude to this
subject, the fact is that we do not usually "set" broken bones. We
do not, even at the first, bring them into complete apposition, unless it
is as the exception. I speak of bones once completely displaced by
overlapping, and these constitute the majority of examples which
come under the surgeon's observation. Second : in transverse frac-
tures of the patella, and in fractures of the olecranon process of the
ulna, of the coracoid and acromion processes of the scapula, and in all
similar detachments of processes and apophyses, the action of the
muscles, by displacing the fragments, may prevent crepitus from
being readily produced. Third : in a few cases, such as certain frac-
tures of the neck of the femur, of the neck and head of the humerus,
&c., the broken ends are impacted, or so driven into each other as to
forbid the production of motion and crepitus ; or they may be simply
> New England Med. Joorn., 1S24, p. 220.
Digitized by
Google
GENERAL SEMEIOLOGY AND DIAGNOSIS. 85
denticulated, and the consequences; so far as crepitus is concerned,
will be the same.
Finally, in very many incomplete fractures, crepitus does not exist;
and even when it is present, the sensation is feeble, or very much
modified, sometimes resembling the chafing of lymph, and at other
times giving only a faint and single click. Under the head of crepitus
we may properly include the sharp crack sometimes felt, or even
heard, by the patient at the moment of fracture.
Preternatural mobility, less valuable as a means of diagnosis than
crepitus, is, nevertheless, more constantly present, being never absent,
in some degree, in all complete, non-impacted, and non-denticulated
fractures ; but its presence does not, like crepitus, render the existence
of a fracture quite certain. Whenever the bony lesion takes place in
the vicinity of a joint, it may be difficult or impossible to determine
whether the mobility of the limb is due to motion in the joint or to
motion at the supposed seat of fracture. While, on the other hand,
the preternataral immobility so generally observed in dislocations
may give place to preternatural mobility, as when the ligaments and
tendons surrounding the joint are extensively torn, or the system itself
is laboring under the shock of the accident, or when from any other
cause there exists great general prostration.
As to the third common sign mentioned, namely, that in the case
of fractures the bones do not generally support tnemselves, but de-
mand for this purpose the interposition of splints, bandages, and even
of extending and counter-extending forces, its authority rests upon
the same evidence as does the assertion already made that bones once
separated entirely, cannot generally be " set," that is, placed again end
to end in such a manner as to be made effectually to support each
other. It rests upon the evidence of my own personal experience ; to
which I am permitted to add, also, the personal experience of Mai-
gaigne, who, with a frankness which does him great credit, and which,
I am sorry to say, has hitherto found few imitators, remarks : " Second,
That overlapping is the most stubborn of all. Here I will add a dis-
agreeable truth, which classical authors have kept too much out of
sight, namely, that it is so stubborn that in an immense majority of
cases the efforts of art are unable to overcome it."^ And it must be
observed further, that if we shall often find it possible to bring the
broken surfaces sufficiently into contact to develop crepitus, they may
still be unable to maintain themselves in this position, owing to the
obliquity of the line of fracture.
The other common signs of fracture may be briefly stated. Pain
at the seat of fracture ; swelling ; ecchym9sis ; deformity, produced
by either an angular, transverse, or rotatory displacement of the frag-
ments, and which is quite as often due to the direction and force of
the impulse which occasioned the fracture as to the action of the mus-
cles ; separation of the fragments, as in fractures of the patella and
olecranon process ; and inability to move the limb, a phenomenon due
in part to the breaking of the bony lever upon which the muscles
1 Malgaigne, Traitd des Fractures et des Luxations, Paris ed., t. i. p. 102.
Digitized by
Google
86 GENERAL SEMEIOLOGY AND DIAGNOSIS.
acted, and in part to the intense pain caused by any such attempts.
This latter symptom is, however, oftem entirely absent. It is not
generally present in impacted fractures, in serrated and partial frac-
tures, or in many other fractures in which the periosteum has not yet
completely given way.
Velpeau was the first, I think, to call attention to the fact that
patients with broken clavicles could very generally raise the arm
above the shoulder and even to the head, and I have repeatedly veri-
fied the observation, notwithstanding the separation of the fragments
has been complete, and the overlapping considerable. In fractures of
the neck of the femur and of the tibia it is no uncommon thing for the
patient to walk some distance after the receipt of the injury.
As has been previously stated, fractures of long bones, caused by
muscular action, generally occur near the middle of the shaft, and
they are usually transverse. Direct fractures are also more nearly
transverse than indirect fractures, but less so than those caused by
muscular action ; while those indirect fractures which are caused by
a force applied in the direction of the axis of the bone are, in general,
very oblique. But what is of more importance in connection with
diagnosis is, that in this latter class of cases the fracture usually takes
place near the point upon which the force of the blow is received
Thus, for example, a fall upon the hand generally causes a fracture of
the lower end of the radius — a CoUes fracture — or if both bones break,
it is generally below the middle, and very seldom indeed in the
upper third. A fracture of the shaft of the humerus near the con-
dyles is a frequent result of a fall upon the elbow. The classical
fracture of the clavicle, at the junction of the middle and outer thirds,
is usually caused by a fall upon the shoulder. A fall upon the foot
causes a fracture, in most cases, near the lower end of the tibia, and
the same is true, quite often, of the lower end of the femur. Exceptions
to the rule above stated are most commonly met with in advanced
life, when falls upon the elbow occasion fractures at the surgical neck
of the humerus, and falls upon the shoulder sometimes cause frac-
tures near the sternal end of the clavicle. Similar accidents also break
the tibia near its upper extremity, and the femur within its capsule.
I cannot dismiss this subject without calling attention to the neces-
sity of exercising care and gentleness as well as skill in the examina-
tion of broken limbs. Nothing, in my opinion, betrays a lack of
judgment as well as of common humanity, on the part of the surgeon,
so much as a rude and reckless handling of a limb already pricked
and goaded into spasms by the sharp points of a broken bone. It is