this time of 17 pounds; to-day he weighs 146 pounds, showing a gain of 28 pounds in less than ten months; stands five feet ten and a half inches tall when standing on longest leg, walks a distance of four miles daily to and from school, has plowed some, and with the aid of an extension shoe will be able to do the work of any twenty-year-old boy, and I have the head of his femur in my possession, which if any member wishes to see I will gladly exhibit. It is true there is a shortening of two and a half inches in the leg, and at point of operation three inches smaller in circumference than the other. He began to walk without crutches last September, three months after operation, and has not used a crutch at all since the 30th of last December.

Now I trust that if this paper does no more it will bring out a liberal discussion, and that some member will be able to make clear to my mind how that false joint was formed as he unquestionably has one; the mobility is as good as in the one that has never been diseased.

FRACTURES OF THE CLAVICLE.

BY W. F. WESTMORELAND, M.D., ATLANTA.

In all ages these fractures have proved an interesting field for surgical investigation, and nearly every prominent surgical name is associated with their pathology or treatment. No fracture has so taxed the ingenuity of the surgeon in providing a suitable splint to hold the broken bone in proper position, with comfort to the patient, that it may unite without deformity.

To mention the numerous devices, splints and appliances in medical literature would only fatigue without compensation. Gurlt records about seventy of varying utility. Their scope extends from the postural position of Hippocrates, the dressings of Velpeau and Devault, the splint of Sayre, to the more complicated apparatus of Hensner. All of them have objectionable features, and amongst them can be found appliances guaranteed to inflict more pain than the most refined instrument of torture of the Spanish Inquisition.

A glance at the surgical anatomy of the bone is necessary before entering into a discussion of the treatment.

The shoulder girdle, composed of the clavicle and scapula, is imperfect both in front and behind; in front it is completed by the sternum with which the clavicle articulates. Thus the framework of the shoulder is pivoted upon the trunk at the sterno-clavicular articulation, its only point of osseous connection. "This articulation is

the center of all movements of the shoulder, and admits of a limited amount of motion in every direction, circumduction included. These full movements are due to the interposition of an interarticular fibro-cartilage between the joint surfaces."

While the scapula is somewhat movable upon the clavicle in the principal movements of the shoulder, those of the clavico-acromial joint can be practically ignored and the skeleton of the shoulder can be regarded as practically a single bone in dealing with this question.

The interarticular fibro-cartilage seems to act as an elastic buffer to break shocks and resist pressure from the shoulder, as well as to connect the bones and prevent inward displacement. The strength of the joint mainly depends upon its ligaments, and it is to this and the fact that the force of the blow (indirect) is generally transmitted along the long axis of the clavicle, that dislocation rarely occurs and the bone is usually broken. The acromioclavicular articulation reinforced by the strong coracoclavicular ligament is even more securely fastened.

It should be remembered that depression of this bone is principally affected by gravity, slightly assisted by the sub-clavius, the only muscle which acts directly upon the clavicle. The function of the sub-clavius is rather to limit the mobility of the clavicle than to impress motion upon it.

The muscles which raise the shoulder as in shrugging are the upper fibers of the trapezius, the levator anguli scapulæ, the clavicular head of the sterno-mastoid, assisted to a certain extent by the two rhomboids which pull the interior angle of the scapular backward and upward and so raise the clavicle. It is drawn backward by the rhomboids and by the lower and middle fibers of the trapezius; forward, by the serratus magnus and the pectoralis minor.

Nature seems to have recognized the exposed position and violence this bone is subjected to, and has tried to provide for the inevitable strain by great elasticity, freedom of motion, and curves to present a greater surface to decompose the force it has frequently to undergo. But with all its protection it is the most frequently fractured bone in the body, the radius being a close second.

Of 2,705 fractures treated at Middlesex Hospital in sixteen years, ending June 30, 1867, 1,540 or 57% per cent. were of the clavicle and radius; 772, or 281⁄2 per cent. of the clavicle, and 768 of the radius.

There are several points of analogy in the fracture of these bones which are interesting. Where elasticity and curves have been given the clavicle great bulk has been given the radius at the point most frequently fractured; both in those portions most usually fractured are, as regards muscular attachments, intermediate bones; that is, they have no muscles acting directly on them. The radius is the only osseous point of connection between the bones of the wrist and the forearm; the clavicle is the connecting osseous link between the shoulder and the trunk, this anatomical condition subjecting them more frequently to the strain of indirect violence. Nearly all the fractures of these bones occur at one particular point, are usually oblique and are the result of indirect violence. The only dissimilar point between them is the age; of greatest frequency, over half the fractures of the clavicle occurring in the infant under five years of age, when the bone is soft, while fractures of the radius occur with increasing frequency after middle age as the bone becomes more calcified and particularly in the female. Kronlein has suggested that falls on the shoulder break the clavicle of a child but dislocate the shoulder of an adult.

Special fractures of the clavicle are those of the sternal

end, very rare; those of the acromial extremity, of which there are two-one between the coraco-clavicular ligament, and one external to it-rare, and those of the shaft, which are frequent, most of them occurring at one point-the junction of the outer with the inner two-thirds of the shaft, which is also the junction of the two curves and the weakest part of the bone.

Fractures from direct violence may occur in any portion of the bone and are usually transverse in direction. Those of the two extremities are practically always the result of this character of force. But indirect violence is responsible for the very large majority of the fractures of the clavicle and these fractures are usually of the shaft at the point mentioned, and are oblique in direction.

About thirty fractures from muscular action have been reported. Hamilton thinks incomplete fractures occur frequently, but that they are overlooked.

Considering the exposed position of this bone compound fractures are exceedingly rare, only five cases other than the result of gunshot wounds being reported. I have had two from gunshot wounds.

A few multiple and comminuted fractures and quite a number of simultaneous fractures of both bones have been reported.

Considering the proximity of the vessels, nerves and lungs to the clavicle, their injury is exceedingly rare, the sub-clavius muscle probably affording decided protection to the sub-clavian vessels and the brachial plexus. Complications involving the sub-clavian artery have occurred in about twelve, the internal jugular vein in one, the brachial plexus in fifteen, and the lungs in five, cases.

The usual classical symptoms by which fractures are diagnosed are present in those of the clavicle; and it is only in the incomplete fractures of this bone, and those of