The Project Gutenberg EBook of A Treatise on Fractures, Luxations, and
other Affections of the Bones, by Pierre-Joseph Desault

This eBook is for the use of anyone anywhere in the United States and most
other parts of the world at no cost and with almost no restrictions
whatsoever.  You may copy it, give it away or re-use it under the terms of
the Project Gutenberg License included with this eBook or online at
www.gutenberg.org.  If you are not located in the United States, you'll have
to check the laws of the country where you are located before using this ebook.

Title: A Treatise on Fractures, Luxations, and other Affections of the Bones

Author: Pierre-Joseph Desault

Editor: Xavier Bichat

Translator: Charles Caldwell

Release Date: January 3, 2019 [EBook #58602]

Language: English

Character set encoding: UTF-8

*** START OF THIS PROJECT GUTENBERG EBOOK A TREATISE ON FRACTURES ***




Produced by Thiers Halliwell, Sonya Schermann and the
Online Distributed Proofreading Team at http://www.pgdp.net
(This file was produced from images generously made
available by The Internet Archive)






Transcriber's notes:

The text of this e-book has been preserved as in the original,
including inconsistent capitalisation and hyphenation. Archaic and
inconsistent spellings have also been preserved except where obviously
misspelled in the original. A list of corrections and inconsistencies
is appended at the end of the book.

In this transcription, italic text is denoted by _underscores_ and bold
text by *asterisks*.

Footnotes have been renumbered and positioned below the relevant
paragraphs.




                              A TREATISE

                                  ON

                         FRACTURES, LUXATIONS,

                               AND OTHER

                       AFFECTIONS OF THE BONES,

                           BY P. J. DESAULT,

             SURGEON IN CHIEF TO THE HOTEL-DIEU OF PARIS,

           WHEREIN HIS OPINIONS AND PRACTICE, IN SUCH CASES,
                      ARE STATED AND EXEMPLIFIED.

                        EDITED BY XAV. BICHAT;

                             WITH PLATES.

                      TRANSLATED FROM THE FRENCH,
                      BY CHARLES CALDWELL, M. D.

            WITH NOTES, AND AN APPENDIX CONTAINING SEVERAL
                     LATE IMPROVEMENTS IN SURGERY.

                             PHILADELPHIA:

              PRINTED BY FRY AND KAMMERER, LÆTITIA COURT.

                                 1805.




_District of Pennsylvania, to wit_:

[Illustration: {SEAL}]

BE IT REMEMBERED, That on the twentieth day of February, in the
twenty-ninth year of the independence of the United States of America,
A. D. 1805, Charles Caldwell, M. D. of the said district, hath
deposited in this Office, the Title of a Book, the Right whereof he
claims as proprietor, in the words following to wit:

“A Treatise on Fractures, Luxations, and other Affections of the Bones,
by P. J. Desault, surgeon in chief to the Hotel-Dieu of Paris, wherein
his Opinions and Practice, in such cases, are stated and exemplified.
Edited by Xav. Bichat; with Plates. Translated from the French, by
Charles Caldwell, M. D. With Notes, and an Appendix containing several
late improvements in surgery.”

In conformity to the act of the Congress of the United States,
intituled, “An act for the encouragement of learning, by securing the
copies of maps, charts, and books, to the authors and proprietors of
such copies during the times therein mentioned:” And also to the act,
entitled, “An act supplementary to an act, entitled, “An act for the
encouragement of learning, by securing the copies of maps, charts, and
books, to the authors and proprietors of such copies during the times
therein mentioned,” and extending the benefits thereof to the arts of
designing, engraving and etching historical and other prints.”

    D. CALDWELL,
    Clerk of the District of Pennsylvania.




CONTENTS.


    MEMOIR I.                                                       PAGE
    On the Fracture of the Condyls of the lower Jaw,                   1

    MEMOIR II.
    On the Fracture of the Clavicle,                                   8
    Explanation of the first Plate,                                   39

    MEMOIR III.
    On the Luxation of the Clavicle,                                  41
           Luxation of the Sternal extremity,                         42
                    of the Humeral extremity,                         54

    MEMOIR IV.
    On Fractures of the Acromion, and of the lower angle of
          the Scapula,                                                57
       Fracture of the Acromion,                                   _ib._
                of the lower angle of the Scapula,                    63

    MEMOIR V.
    On the Fractures of the upper end or neck of the Humerus,         67

    MEMOIR VI.
    On the Fracture of the lower extremity of the Humerus,
          with a separation of the Condyls,                           90

    MEMOIR VII.
    On the Luxation of the Humerus,                                  102

    MEMOIR VIII.
    On the Fracture of the bones of the Fore-arm,                    146
           Fracture of the Radius,                                   160
                    of the Ulna,                                     167
                    of the Olecranon,                                168

    MEMOIR IX.
    On the Luxation of the Fore-arm,                                 184

    MEMOIR X.
    On the Luxations of the Radius over the Ulna,                    199
           Luxation of the lower extremity of the Radius,            204

    MEMOIR XI.
    On the Fractures of the Thigh,                                   214
           Fractures of the body of the Os Femoris,                  215
                     of the upper end of the Os Femoris,             258
                     of the great Trochanter,                      _ib._
                     of the neck of the Os Femoris,                  260
                     of the lower extremity of the Os Femoris,       280
    Explanation of the second Plate,                                 291
    Thoughts on Luxations of the Os Femoris upward and forward,      292

    MEMOIR XII.
    On spontaneous Luxations of the Os Femoris,                      299

    MEMOIR XIII.
    On the Fracture of the Rotula,                                   304

    MEMOIR XIV.
    On the formation of foreign bodies in the joint of the knee,     325
    Observations and Reflections on forms of Apparatus[1] for
          fractures of the leg,                                      342

      [1] (_Appareil._) I am fully sensible that the word Apparatus,
      does not, according to the common acceptation of the term,
      convey, in English, precisely the same ideas, that the word
      “_appareil_” does, in French; but it certainly approaches
      much nearer to it than any other term found in English works
      on surgery. It signifies a collection or assemblage of means,
      used for the attainment of a particular end; and this is,
      in substance, what Desault meant by the term “_appareil_.”
      His “appareil” (apparel) for a broken bone included splints,
      bandages, bolsters, and every thing else necessary for retaining
      the fractured ends in apposition. The English reader will
      naturally enough annex the same ideas to the word Apparatus, as
      used throughout the present work. I have, therefore, thought
      proper to adopt it, rather than to introduce a new or uncommon
      term, and am sure, that, for all practical purposes, it will be
      found sufficiently expressive of the meaning of the original.
      And I am much more solicitous to become instrumental in giving
      some aid to the surgeon in the practice of his profession, than
      to escape the censure of the fastidious critic.

    TRANS.

    MEMOIR XV. On the Division of the Tendo Achillis,               355

    MEMOIR XVI. On the Fracture of the Os Calcis,                   374

    MEMOIR XVII. On complicated Luxations of the Foot,              379


    APPENDIX.

    ARTICLE I.
    Dr. Physick’s new and successful method of treating an old
          and obstinate fracture of the os humeri,                  403

    ARTICLE II.
    An account of Dr. Physick’s improvement of
          Desault’s apparatus for making permanent extension in
          oblique fractures of the os femoris,                      407

    ARTICLE III. Explanation of the third Plate,                    409




PREFACE

BY THE TRANSLATOR.


The business of a translator, though very limited as to its range, may
be extensive and important in its consequences, and, though humble in
its end, is oftentimes extremely difficult in its nature. Prohibited
from adding any thing to, or in any measure transgressing the bounds
of, the meaning of his original, he is obligated to interpret that
meaning with faithfulness and accuracy. In this latter point consists
the difficulty of his task. If several different readers oftentimes
attach as many different meanings to parts and sentences of works
written in their own language, how much more likely will this be to
occur with respect to such as are written in a foreign language?
For readers to differ in the former case is common, in the latter
unavoidable.

The translator of the following work is far from affirming, that he has
in no instance deviated from the meaning of his original. To hazard
an assertion like this, would be assuming to himself more than is
consistent with modesty or, perhaps, with truth. He trusts, however,
that such deviations are very rare, that if they do occur they are but
slight in themselves, and never connected with facts or principles of
practical importance. He can, at least, very confidently declare, that
they have never been the offspring of carelessness or design.

Should any one open this volume in quest of the flowers of fancy, or
the embellishments of style, he will close it again without being
gratified. Ambitious only of communicating new and useful matter,
and too intent on things to be in any measure choice of his words,
the celebrated original was regardless, perhaps to a fault, of the
ornaments of diction. Rich in the resources of a capacious and exalted
intellect, he poured forth his knowledge like precious ore from the
mine, leaving to others of inferior capacities the humbler task of
refining and polishing it.

With such an example before him, the translator thought it best to
follow in some measure the footsteps of his illustrious guide, without
venturing to chalk out a new and different track for himself. As his
principal object, throughout the work, has been to make himself
clearly understood, and that in as few words as practicable, he has
never hesitated, when they came in competition, to sacrifice elegance
to precision and ornament to perspicuity. He has even in some instances
been guilty of intentional tautology, for the purpose of rendering
his meaning the more clear and definite. For this he flatters himself
he need offer no apology to those, who prefer utility to pleasure and
sense to sound. And, as to readers of an opposite cast of mind, should
any such choose to sit in judgment on him, he neither deprecates their
censure nor courts their approbation.

A circumstantial analysis of the following memoirs would constitute a
paper too extensive to be introduced here in the form of a preface,
and a mere outline or general character of them would be altogether
useless. The translation is now before the public, and every reader
must judge of its merit for himself. On this point the translator will
only observe, that the attention which he has been necessarily led
to bestow on the work, has been to him the best school of surgery he
ever attended, as far as relates to affections of the bones. Should
other practitioners throughout the United States derive equal benefit
from perusing his translation, he will rejoice in a consciousness of
having, at least in one instance, been of service to his country.

Such are the extent and importance of Desault’s improvements in
some branches of practical surgery, as to constitute a new epoch
in the history of the profession. His different forms of apparatus
for fractures and luxations are certainly more rational in their
construction, and more efficacious in their action, than those of
any other writer. But their excellence does not arise from these
circumstances alone. Their cheapness and simplicity, taken in
conjunction with the ease and quickness with which they may be every
where made and applied, greatly enhance their value, particularly to
practitioners in the country. If they be not already at hand, they
can be easily prepared by the surgeon or his assistants, without any
material loss of time. The sufferings of the patient, therefore,
whatever may be the form of fracture or luxation under which he
labours, need never be prolonged, by any delay in obtaining the
necessary apparatus. It is thus that the means and processes of every
art become simple and easy, in proportion as the art itself approaches
perfection: and thus that the truly great artist is known, not by the
multiplicity and the complex nature of his forms of apparatus, but by
the numerous ends which he accomplishes by means the most simple and
easy of construction.

Several French practitioners, in projecting improvements on the forms
of apparatus of Desault, have evidently rendered them more complex,
more expensive, and therefore more difficult to be constructed or
procured, without adding in the smallest degree to the efficacy of
their action. This is particularly the case with respect to Boyer, in
his attempt to substitute a new apparatus for a fractured clavicle, in
place of that invented by Desault. The latter can be constructed in a
very few minutes by the surgeon or one of his assistants, without any
expense, whereas the former must be made by a workman employed for
the purpose, and is necessarily attended with both cost and delay.
Nor is it always practicable, particularly in the country, to procure
a workman capable of making this apparatus. But this is not all. On
Desault’s plan, the same apparatus for a fractured clavicle will fit,
and may be applied to, persons of different sizes and figures; whereas,
on the plan of Boyer, each patient must have an apparatus constructed
particularly for himself. No practitioner, therefore, can hesitate
a moment in deciding to which of these two forms of apparatus the
preference is due.

Similar remarks may be made respecting Boyer’s apparatus for making
permanent extension in oblique fractures of the os femoris. It is much
more complex and difficult to be constructed than that of Desault. Nor
does it possess a single advantage over it as improved by Drs. Physick
and Hutchinson. In a word, the forms of apparatus of Boyer may answer
well enough in hospitals and in cities, where the expence of such
articles is not much regarded, and where workmen to make them can be
readily procured. But, as the practitioner in the country is generally
obliged to be himself the constructor of the forms of apparatus which
he uses, and as he is not at all times prepared to meet heavy expenses,
it is to those recommended and employed by Desault that he must
necessarily have recourse.

With these remarks the translator submits to the good sense and candour
of his countrymen the following sheets, as the offspring of some of
his hours of leisure throughout the winter. He hopes that the appendix
subjoined by himself will not be regarded as either an useless or an
unpleasing addition. Every native of the United States, whose bosom
glows as it ought, with that noblest of passions, the _amor patriæ_,
will witness with pride and exultation the improvements that are daily
making in the arts and sciences, by the industry and enterprize of his
enlightened countrymen. Such a mind will enjoy in anticipation the
glory of his country, at that period, when she will be able to reflect
back, with increased splendour, the light which she has so long been
borrowing from the countries of Europe.

The translator does not plead the want of time as an apology for any
imperfections or errors which his translation may exhibit. Yet he
believes it to be true, that had he had more time to bestow on it, he
could probably have rendered it more worthy of public patronage.




A TREATISE

ON

FRACTURES, DISLOCATIONS, &c.




MEMOIR I.

ON THE FRACTURE OF THE CONDYLES OF THE LOWER JAW.


§I.

1. The lower jaw, a kind of moveable hammer, destined, to use the
words of a certain physiologist, to triturate the aliments against the
almost immoveable anvil of the upper jaw, is more exposed to the action
of external bodies, and consequently to fractures, than most of the
other bones of the face. But all parts of it are not alike subject to
such accidents. Common in its body, but less frequent in its branches
or sides, fractures sometimes occur in the two processes in which its
branches terminate. One of these processes, concealed by the zygoma,
embosomed in the temporal muscle, and covered by the masseter, is less
liable to fractures than the other, which serves as the centre of the
motions performed by the bone, and is protected externally only by the
parotid gland.


§II.

2. A fracture of the condyle may sometimes arise from a
_counter-stroke_, as when, in consequence of some external force being
applied from before backwards, and from below upwards against the
chin, this process is driven against the projecting rim of the glenoid
cavity; at other times it may be the effect of an immediate or direct
stroke, as when a body in motion strikes with force against the region
of the joint, and does violence to that portion of the bone.

3. But in whatever manner the fracture may be produced, it generally
occurs in the slender part of the bone which supports the condyle,
below the insertion of the pterygoideus externus. It is characterized
by a pain more or less acute, necessarily accompanying the motions of
the jaw; by a difficulty more or less considerable, in the performance
of these motions; by a crepitation, oftentimes distinct, when, in
consequence of the angle of the jaw being pushed forward, or the jaw
itself alternately depressed and elevated, the separated surfaces rub
against each other; by an inequality of surface sometimes perceptible
directly over the fractured condyle; by the ease with which, on being
pushed forward, it may be forced into the depression beneath the
zygoma; and by its remaining stationary, during the movements of the
lower jaw, from which it is separated. These signs, though generally
characteristic, are subject to an uncertainty proportioned to the
swelling that occurs in the part.

4. In this accident a displacement is almost always produced by
muscular action. The pterygoideus externus, being attached to the
condyle, draws it forward and upward, towards the external wing of
the pterygoid apophysis, its fixed point of insertion. On the other
hand, the body of the bone is left behind, being held by the masseter
and external pterygoid muscles, the course of which is opposed to a
displacement in the same direction; so that there always exists a
separation, more or less perceptible, between the two fragments of bone.

5. Hence, if proper means be not used to restore the contact between
the broken ends of the bone, the following consequences will be likely
to occur: 1st. Their reunion will be tedious, because in every bone
this process is, in point of rapidity, inversely proportioned to
the separation of the divided surfaces: 2dly, This reunion may even
entirely fail to take place, if the bone be subject to the slightest
movements, as I have witnessed in a particular case, where the
condyle, not being reunited to the other part, exfoliated, and was in
part discharged through the external integuments: 3dly, Under such
circumstances, the callus produced in the process of healing, being
situated near to the joint, and rendered irregular and deformed by the
separation of the parts, is apt to impede muscular action, and do a
permanent injury to the functions of the jaw.


§ III.

6. As the whole apparatus in this case consists in a passive resistance
to the active powers employed in producing a displacement, it follows
from what has been said (4), that the bandage intended to prevent
this displacement, and by that means to guard against the accidents
specified above (5), ought, either effectually to bring back to its
natural situation, the condyle which is drawn forward, or pull in this
last direction (that is, forward) the body of the bone which is still
retained in its usual position, in order that it may thus be brought
into contact with the condyle.

The first of these measures is impracticable, in consequence of the
situation of the condyles, which are too deeply enveloped by the
surrounding parts, and offer a hold too small to be acted on. The
second, therefore, remains to be adopted, and is the more easily
executed, in as much as the angle of the jaw, from its projecting and
being but slightly covered by the integuments, may without difficulty
be directed from behind forward by a proper force.

7. The fingers of the surgeon temporarily supply this force, at the
time of reduction; but it is necessary that it should be permanently
kept up by means of the apparatus. This end is attained, in the
following manner:

Place behind the angle of the jaw, which must be first pushed forward,
thick compresses, to fill up the hollow under the ear, and form an
eminence higher than the surface of the surrounding parts; pass over
these compresses, in an oblique manner, the bandage commonly used in
lateral fractures of the bone, the application of which must in this
case commence on the sound side.

These compresses, being more projecting than the surrounding surface,
will necessarily sustain a greater pressure, because the compression
made by a bandage is in proportion to the projection of the part on
which it is applied. Hence, being firmly supported, they will retain
the body of the bone in a line with the displaced condyle (4).

8. In addition to this mode of applying the bandage, it is necessary
that the fractured bone should be kept in a state of perfect rest. The
internal pterygoid and masseter muscles, tending by their contractile
efforts to draw the angle of the jaw backwards, sometimes overcome the
resistance of the apparatus, and, by producing a second displacement,
give rise to the accidents formerly mentioned (5).

Let the lower jaw be now brought into perfect contact with the upper
one, and not separated from it during the first few days after the
injury, except so far as may be necessary for the admission of
nourishing broths. Should a tooth have been lost, the space which it
occupied will furnish, without disturbing the bone, an opening for the
conveyance of nourishment to the patient. Let talking, laughing, and
every thing that might produce a separation between the body of the
bone and the condyle, be carefully avoided. The further treatment of
the accident should be such as is generally applicable to all fractures
of bones, and need not be at present particularly detailed.

The following cases, reported by citizen Giraud, second surgeon to the
Hotel-Dieu, will confirm the advantages of this mode of treatment.

CASE I. Margaret Bessonet, aged thirty-four, was admitted into the
hospital on the 10th of May, 1791. On the preceding day she had
received a violent fall on her chin: a severe pain, and a preternatural
mobility in the left side of the jaw, had been the immediate
consequences of the accident: from these symptoms, taken in conjunction
with those formerly mentioned (3), Desault discovered that a fracture
of the condyle existed, which he reduced and supported in the usual
manner (7).

After being somewhat uneasy during the first few days, the patient
became reconciled to the action of the bandage, which, by inattention,
had been two or three times disturbed and put out of order, but which,
by being carefully reapplied, and aided by the necessary precautions
(8), restored to the bone its natural form and solidity, by the
thirtieth day, and on the thirty-sixth the patient was discharged
perfectly cured. The only inconvenience she experienced, was a slight
difficulty in the motions of the jaw, an effect naturally resulting
from the long continued inactivity of the muscles, but which was soon
removed by means of exercise.

CASE II. Claudius Laurat, aged twenty-seven, fell as he was carrying
a heavy burden. In his fall his chin struck with violence against a
beam that lay in his way. In an instant he experienced a sharp pain
in his right temple, and found it almost impossible to move his jaw.
Two hours afterwards a considerable swelling appeared in the part,
extending from the angle of the jaw above the ear. The patient was
admitted into the Hotel-Dieu, where the circumstances of the fall and
the symptoms that followed, gave satisfactory evidence of a fracture of
the condyle. It was reduced and supported as in the preceding case. On
the day following, the swelling was removed, doubtless by means of the
compression which had been made on it; the other symptoms (3), hitherto
scarcely perceptible, became more obvious; the bandage was reapplied,
and the disease terminated, in about twenty-nine days, in the same
manner with that of case 1.




MEMOIR II.

ON THE FRACTURE OF THE CLAVICLE.


§ I.

1. Man enjoys an advantage which nature has bestowed on but few of the
quadrupeds, namely, a power of moving his upper extremities in every
direction. The clavicle being a kind of arch placed between the breast
and shoulder, forms a centre, moveable indeed but solid, for these
motions, a part of which can no longer be performed, when this arch, in
consequence of being broken, ceases to afford them a point of support.
Hence it follows, that the fracture of this bone may be said to reduce
the individual who sustains it, when considered in relation to its
functions, to a level with that numerous division of animals that are
destitute of clavicles.

2. Few diseases of the kind are more frequently met with than this.
The natural curve of the clavicle, its situation immediately under the
skin, the want of a support to its middle part, the great proportion of
spongy substance which enters into its composition, the projection of
the shoulder exposing it to the action of external bodies; all these
circumstances concur in rendering the accident frequent, particularly
among that class of men subject, from their occupations, to violent
exertions of the upper extremities.

Here then, more than in the generality of fractures, we should feel
an interest in the advancement of the art of surgery; and yet,
having hitherto employed in it but feeble means, our efforts have
been attended with imperfect success. Hippocrates has observed, that
some degree of deformity almost always accompanies the reunion of a
fractured clavicle; all writers since his time have made the same
remark; experience has confirmed the truth of it, and as much time has
been spent in hypothetical speculations to explain the accident, as in
serious inquiries how to prevent it. At length Desault proved that a
feeble and unskilful mode of treatment was the sole cause of a want of
success, and that, by being more correct and judicious, art might be as
successful here, as in other fractures. In order to give a correct view
of his practice in this disease, I will examine the causes, varieties,
and signs of a fracture of the clavicle; the accidents of which it is
susceptible; the mode and the causes of the displacement of the broken
ends of the bone; the indications that arise out of those causes, and
the manner of answering these indications as well during, as after, the
reduction.


§ II.

OF THE CAUSES AND VARIETIES.

3. The action of external bodies is almost the only known cause of this
fracture, whether these bodies strike the shoulder with violence, or
the shoulder be forcibly driven against them. But this action is not
in every case the same; its application is most frequently mediate or
indirect, but is sometimes immediate or direct.

In the first case there is a true _counter-stroke_, the ordinary
effect, either of a severe blow on the point of the shoulder, which
is the most common occurrence; or, as happens less frequently, of a
fall on the arm when it is extended for the purpose of guarding the
body from the force of the accident. Under these circumstances, being
pressed between the sternum, which makes resistance, and the body which
acts on its extremity, the clavicle is bent in that direction which is
most natural to it; but, not being sufficiently flexible, it gives way
generally in the place where its curvature is the greatest. Thus the
ribs are broken, when the sternum, by being violently driven backward,
forces them to bend in the centre beyond their natural flexibility.

In the second case, the fracture occurs at the spot where the stroke
is given. Here the momentum or quantity of force applied on the bone,
surpassing the solidity which the bone possesses, its continuity is
necessarily destroyed.

4. But in whatever way the fracture is produced, it is either oblique
or transverse, single or double, in the middle or towards the
extremities of the bone, simple or compound.

An oblique fracture is most frequently the effect of a
_counter-stroke_; a transverse fracture is the more common result
of the immediate action of external bodies; a counter-stroke seldom
produces any thing but a simple fracture; while compound fractures are
generally owing to a direct stroke. The one produces a solution of
continuity in the middle of the bone, or thereabout; because in that
part the curvature is most considerable. The other is almost always
the cause of this solution, when it occurs at the extremities. To the
latter alone, is a double division to be attributed. The reason of
these differences is already so plain, that it would be a waste of time
to dwell on an explanation of them.


§ III.

OF THE SIGNS.

5. The several phenomena that attend a fracture of the clavicle, taken
together, leave in general but little doubt as to its existence,
particularly when the fracture is oblique. As is the case in most other
instances of the kind, so here, an acute pain is felt at the instant of
the stroke; sometimes a cracking of the bone is distinctly heard by the
person injured; on every occasion, it becomes suddenly impracticable to
perform circular or rotatory motions with the arm; motions from before
backwards can still be executed, but are difficult and painful, and, as
I have already observed (1), the individual injured is reduced to the
class of animals destitute of clavicles.

Oftentimes the shoulder of the injured side, being more or less
depressed, loses its level with the other. It is also evidently drawn
forward and inward. The distance between the acromion and sternum, on
the affected side, is found on comparison, to be evidently less than on
the opposite side. In almost every case, that portion of the fractured
bone, which adheres to the sternum, forms a visible protuberance above
and on the inside of the shoulder.

6. In the mean time the pain continues. The painful drawing or dragging
occasioned by the weight of the arm forces the patient, for the purpose
of relieving it, to bend his body towards the side affected, and
incline his head in the same direction. This forms a peculiar attitude,
which of itself was frequently sufficient to disclose to Desault the
nature of the disease. We have oftentimes witnessed him establishing
the truth of this diagnostic, by merely looking at patients entering
the amphitheatre, who had been brought thither for the reduction of
such fractures.

By this position, the pains are generally relieved, because the arm
finds some degree of support; but should the patient wish to change his
position, or perform any particular motions, the pains return almost as
acutely as at first.

7. If to these signs, which are almost all of them founded in reason,
we add those that are still more palpable to the senses, such as the
mobility of the two broken ends of the bone; the crepitation produced
by their friction against each other; the depression felt at the point
of fracture, by passing the fingers over the upper surface of the bone;
and the facility of restoring to it its natural form and direction,
by moving the shoulder upwards, outwards, and backwards; it will be
difficult to be mistaken respecting the nature of this fracture. This
is perhaps more particularly the case, when the fracture is oblique, as
this kind offers the most striking diagnosis, and cannot be involved
in uncertainty, unless when a considerable swelling occurs in the
parts around the fracture. But, even then, as the circumspection
of the practitioner will necessarily direct his attention to this
circumstance, the obscurity of the signs will have no unfavourable
influence on the cure.

8. When the fracture is transverse, there is sometimes more difficulty
attending the diagnosis. The corresponding inequalities of the divided
surfaces may mutually penetrate each other and interlock, and thus
prevent a displacement. Does any uncertainty on this score exist?
Placing your fingers on the two extremities of the bone, order an
assistant to move the arm in every direction, and the motions will
be communicated to the clavicle; but, if a fracture exist, they will
be most perceptible in the fragment adjoining the shoulder, and will
separate it from that attached to the sternum. This method will seldom
deceive us, is easily employed, and subjects the patient to but a
momentary pain.


§ IV.

OF ACCIDENTS.

9. We do not generally find fractures of the clavicle accompanied by
such accidents as the anatomical relations of the parts might lead us
to apprehend. The external force being all expended in fracturing the
bone, extends but feebly to the brachial plexus, which would be much
injured by the shock, were the bone to yield, without breaking, to the
action of external bodies striking against it. Hence, without doubt,
would arise serious affections, as may be fairly inferred from the
analogy of blows on the head and vertebral column, and as is indeed
confirmed by certain cases reported by Desault.

CASE I. Two bricklayers were brought to the Hotel-Dieu, who had met
with similar accidents. A piece of timber, thrown from a building,
in which they were engaged, had struck them, the one on the external
part of the left clavicle, the other about the middle of the right. A
considerable wound pointed out in each the place on which the blow had
been received. But the former, having escaped a fracture, experienced
nothing but an acute pain, while the second had the bone broken in two
places.

The customary apparatus was applied to the latter, and the treatment
which we shall presently describe, being pursued, the result was that
complete success which never failed to crown the attentions of Desault.
In the other patient a considerable swelling made its appearance the
day after the accident. On the third day a numbness and partial loss
of the power of motion occurred in the arm of the affected side. Soon
afterwards an insensibility came on, and by the seventh day, the
paralysis of the arm was complete. It was not till after a tedious
treatment, an account of which would be foreign from my present
subject, that the limb recovered in part its original strength.

From whatever cause the fracture of the clavicle in this latter patient
was prevented, it is evident, that the whole of the force employed to
produce the fracture in the other, acted here on the brachial plexus,
and gave rise, by means of concussion, to the accidents which followed.

10. The axillary artery, though running near to the clavicle, in common
with the brachial nerves, experiences, notwithstanding, less frequently
than they do, injurious effects from the fracture of this bone. I
know not of any instance where a puncture from the broken ends of the
clavicle has produced in this artery a false aneurism. To conclude,
like all other fractures, that of which we are now treating, may be
connected with wounds, splinters, &c. But in general, as Hippocrates
remarks, the fracture of the clavicle assumes in common cases a mild
aspect.


§ V.

OF DISPLACEMENT.

11. Most of the symptoms formerly mentioned (5 and 6) as accompanying a
fracture of the clavicle, are evidently the result of a displacement of
its broken ends. Yet this phenomenon, taken notice of by all authors,
and considered by them as a necessary effect of the disease, does not
occur in every case (8). There are instances, in cases of transverse
fractures, where the extremity attached to the shoulder, has retained
its natural position. Three examples of this kind occurred in the
Hotel-Dieu in the course of the year 1787.

12. Instances have also been known, in which the sternal fragment, when
fractured obliquely upwards, has supported the end of the humeral in
such a manner as to prevent any derangement. Desault was accustomed
to relate several cases, where similar occurrences took place; but,
in general, this state of things is rare, in comparison with that in
which the fragments lose their natural level.

Almost always, then, there is more or less of a perceptible overlapping
(_chevauchement_) produced, either, by the elevation (a circumstance
which is very rare) of the external fragment over the internal; or, (as
commonly occurs) by the depression of the former beneath the latter.

13. Of the first of these modes of displacement (a mode but rarely
mentioned by authors) a few examples are to be found among the
observations of Desault, one of which he has recorded in his journal.
Hippocrates speaks of the phenomenon as a thing that was familiar to
him.

14. The second kind of displacement, that which we constantly find
in practice, and which the laws of muscular action render almost
inevitable, takes place in such a manner that the shoulder appears
to obey the impulse of two powers, one of which draws it downwards,
and along with it the external fragment of the clavicle, which is
displaced by this power in the direction of its transverse diameter, or
thickness. The other power approximates the shoulder to the breast, and
draws it forward, carrying along with it the same fragment, which is by
this means displaced in a longitudinal direction.

That we may the better understand them and their effects, let us, in
our minds, separate these two powers, although they are perfectly
simultaneous in their action. A knowledge of them will lead us to a
knowledge of the resistances which ought to be opposed to them. But let
us first remark, that the humeral fragment, being drawn downward and
inward, takes sometimes such a direction, that its internal extremity
passes backward under the sternal fragment, its external end continuing
to point forward: this disposition can be understood from its natural
direction.

15. The first of these powers, namely, that which depresses the point
of the shoulder, appears to have escaped the notice of the ancient
physicians of Greece, who attributed the apparent depression of this
part, to the elevation of the sternal fragment, and, accordingly,
endeavoured by making compression on the latter, to restore it to
a level with the other. Hippocrates, more judicious than those who
had preceded him, demonstrated that their doctrine, false in its
principles, was still more dangerous in its consequences, and that
the sternal fragment being immoveable, lost its relative position
with respect to the humeral, only because the latter was depressed
by the weight of the arm. This doctrine of the father of physic is
satisfactorily proved, by a comparison of the sound shoulder with
the diseased one, and has since been admitted by all practitioners.
Indeed, the mere recollection that one of the uses of the clavicle is
to support the shoulder at that level necessary for the performance of
its functions, is alone sufficient to convince us, that, in case of its
ceasing to fulfil that office, the shoulder must obey the laws of its
own gravity, increased by that of the hand and arm.

16. The illustrious Petit, and with him Duverney, in acknowledging this
cause of displacement, have added to it as another the action of the
deltoid muscle on the external end of the bone; in this action, the
end of the clavicle is the moveable point, while the humerus affords
the fixed point. But how can we admit this cause, when the humeral
fragment, in passing under the sternal, moves in a backward direction?
So far is the deltoid muscle from drawing the bone downward, that here
the bone rather draws the muscle in part backward, and yet, in such a
case, the displacement is as perceptible as in any other. Besides, when
the sternal fragment, broken obliquely upwards, supports the humeral
and prevents a displacement, why does not the deltoid produce this
displacement?

It is then in the weight of the arm and shoulder alone, that we must
look for the passive power, which depresses them, and which produces a
displacement in the direction of the transverse diameter or thickness
of the clavicle.

17. A second power, highly active, co-operates with this. I allude to
the permanent contraction of the muscles, that extend from the breast
to the clavicle and shoulder: from this cause arises the displacement
in the longitudinal direction of the bone.

The pectoralis major, the pectoralis minor, the subclavius, the
serratus major, and the trapezius, unite their efforts in producing
this displacement. These muscles are, in certain respects, antagonists
to each other, but they all unite in drawing the shoulder forward
and inward. None of them appears to act with more effect than the
pectoralis major. To this, in particular, is to be attributed the
displacement in a forward direction.

Except in the instances stated above, the action of the muscles is not
immediate. They act only secondarily on the external fragment, which,
being stedfastly attached to the scapula and humerus, is obedient to
the motions impressed by the muscles on these two bones; motions which,
in a sound state, the clavicle has a power of controlling.

18. To the weight of the lower extremity (15 and 16), and the
spontaneous action of the muscles (17) must be added, as another cause
of displacement, the motions which are communicated to the arm by
external bodies, and which, being imparted ultimately to the clavicle,
derange the fragments, by separating them, approximating them, or
making them overlap each other, according to the direction in which
they act.

19. When a fracture occurs at the extremity next the shoulder, no
displacement of the fragments in general takes place. This circumstance
is attributed to the action of the trapezius, which draws each fragment
upwards with equal force. However this may be, it is doubtless to such
cases that we must refer the complete cures, obtained without any
retentive apparatus, by Gasparetti, Brown, and other writers. Hence
also, without doubt, arise the difficulties experienced by certain
practitioners, such as Duverney, with respect to the diagnosis of this
disease. These fractures may be mistaken for fractures of the acromion,
being situated so immediately in its vicinity.


§ VI.

OF THE REDUCTION.

20. On looking into the causes of that displacement (15 ... 18), so
common in fractures of the clavicle, it appears that in almost every
case, the external extremity of the humeral fragment is drawn, by a
double power, downward, inward, and forward. Hence it follows, 1st.
That the resistance opposed to this power, by the means used for
the purpose of reduction, and the retentive apparatus subsequently
employed, ought to be directed upward, backward, and outward,
these directions being the reverse of those in which the powers of
displacement act: 2dly. That, in as much as these powers, viz. the
weight of the parts and the action of the muscles, are in constant
operation, and, besides, as the motions of the arm are continually
disturbing the fragments of the bone, the apparatus ought to be equally
constant in its action, and should keep up, without any remission, the
effect produced, at first, by the means of reduction. This principle is
applicable to every case, and ought to be the standard of comparison,
for determining the advantages or disadvantages of different bandages,
and processes for the reduction of fractures of the clavicle.

21. But we are not to suppose, that these processes have heretofore
manifested an exact application of this rule. Hippocrates directed
to press the arm close to the ribs, and at the same time to push it
upwards, in such a manner, as to make the shoulder appear as sharp
and pointed as possible. Hence his precept, to lay the patient down
on his back, the back being supported by some projecting body, and
then to press the shoulders backward; hence again, when the humeral
fragment is drawn inward, his advice to press the elbow close to the
breast. This twofold expedient was attended with great difficulties,
even under the direction of the father of medicine. Celsus only copied
Hippocrates, adding nothing whatever to his mode of practice. Paul of
Egina, more judicious in this case, conceived, that for the purpose
of forcing the shoulder outward, and rendering it, agreeably to the
idea of Hippocrates, very projecting and sharp, it would be advisable
to place the fulcrum or point of support, not in the middle of the
back, but under the arm-pit. A woollen ball was employed by him for
this purpose, a practice which would, at once, have carried the art
near to perfection, if, after being employed to reduce the fragments,
this process had been continued for the purpose of retaining them in
apposition.

22. No new method distinguished the surgery of the Arabians. It is
necessary to come down to the time of Guy of Chauliac, before we
meet with the method which is almost universally adopted at present,
and which consists in placing between the shoulders, the knee of an
assistant, whose hands are to be employed in drawing them forcibly
backwards. But it is evident that this is only doing, while the patient
is in an erect position, what Hippocrates did, after having laid him
with his back on a projecting body. Here, then, the art seems to
have degenerated, after the time of Paul of Egina: and, indeed, on
comparing this process with the general principles already established
(20), it will be immediately perceived, that the powers of replacement
do not here act in an opposite direction to those of displacement.

Hence the difficulties of reduction, the time spent in the operation,
and the sufferings by which it was sure to be accompanied. The
fragments were brought together, it is true; but it was only by varying
the movements, and changing their direction, that the point of contact
was ultimately found.

23. Desault conceived, in the year 1768, that to reduce, in the most
effectual manner, a fracture of the clavicle, it was necessary not only
to push the shoulder backward and upward, as was commonly done, but,
above all, to force it outward, and that the power destined to draw it
in this latter direction, ought to act horizontally, according to the
course of the clavicle, in the same way, as, in an oblique fracture of
the thigh or leg, the extension for replacing the fragments is made in
the direction of the bone.

24. As the union of the humerus to the clavicle, by means of the
scapula, communicates to the one the movements of the other, it is
easy, by placing the ball used by Paul of Egina, under the arm-pit, to
convert the arm into a lever of the first kind.[2]

    [2] That form of lever, where the weight to be raised or the
    resistance to be overcome, is at one end, the force at the other,
    and the fulcrum or prop between them. This form is well represented
    by the handle of a pump, where the piston is the weight or
    resistance, the hand of the drawer of water the force, and the iron
    pin, on which the handle works, the fulcrum or prop.

    TRANS.

The lower extremity of the arm being then pressed towards the body,
the upper end is separated from it, and becomes, with regard to the
clavicle, what the efforts of an assistant who makes the extension, in
a fracture of the leg, are to the foot of the patient.

The mode of reduction being established, it was necessary, in the next
place, to invent a bandage, calculated to retain the broken ends of
the bone in contact. Desault thought it practicable to unite these two
points of treatment, in the same process, that is to say, to reduce,
and at the same time to retain the fracture. Here the art is indebted
to him for an improvement, which, I will venture to say, carries it
near to perfection. To judge of this, it will be necessary only to
take a hasty survey of the different kinds of apparatus proposed by
different writers.


§ VII.

OF THE MEANS OF RETAINING A REDUCTION.

25. Here all authors seem to have been directed by the same principle.
This is to keep the shoulder of the affected side, 1st, drawn forcibly
backwards, 2dly, approximated towards the shoulder of the sound side.
Such was the practice of the Greek physicians, whom we have seen in
common with Hippocrates, Celsus, and Paul of Egina, employing a kind
of bandage, varied in its form, according to the displacement it was
intended to remedy.

Above all others, we find an application of this principle, in the
figure of 8 bandage, a particular form, which was employed in practice
by Albulasis, an Arabian, and afterwards by his countrymen, as well as
by Lanfranc, Guy of Chauliac, and their contemporaries. The use of this
bandage was continued by Pare and his successors, and has been lately
modified by several authors, such as Heister, Petit, Brunninghausen, &c.

26. But under whatever form it shows itself, its action is always
the same, and always insufficient. On comparing its effect with the
general principle, on which every apparatus for the clavicle should
be constructed (20), we perceive, that it by no means answers the
threefold indication, of retaining the shoulder backward, outward, and
upward.

27. In relation to carrying the shoulder backward it loses half of
its effect, because, its force being decomposed (so to speak) by the
obliquity of its direction, is divided into two channels. One of these
runs parallel to the shoulder and acts to no purpose, while the other,
being perpendicular to it, is alone effective; hence it must act with a
force equal to 10, in order to produce an effect equal to 5.

28. The indication, to draw the humeral fragment outward, far from
being fulfilled, is here diametrically counteracted. The scapula, being
approximated to that of the opposite side, draws the humeral fragment
towards the trunk, making it underlap the internal one, and, in this
respect, the figure of 8 bandage acts posteriorly in precisely the same
manner, during the treatment, that the contractions of the muscles did
anteriorly before the reduction.

29. Should the shoulder be supported, at such an elevation, as might
have a constant tendency to destroy the influence of its own gravity?
this is evidently prevented by the very oblique direction of the turns
of the bandage. Suspending the arm in a sling, is the only way, in
which that end can be attained. But does this mode always possess
sufficient firmness and stability? The arm, not being here sufficiently
fixed, may be constantly in motion, which, by deranging its situation,
must communicate very troublesome and injurious movements to the
fragments of the clavicle. One of the principal faults of all bandages
consists, in not preventing these movements, by restraining the
movements of the arm.

To the other disadvantages of this mode, need I add that of its making,
by the turns of the bandage, an undue compression on the projecting
edges of the arm-pit, and producing thereon troublesome and painful
excoriations?

30. From the want of a mutual correspondence and fitness between the
indications already enumerated (20), and the manner in which the
figure of 8 bandage acts, it is evident that the former can never
be satisfactorily fulfilled by the latter. Hence we may judge, what
improvement the art has received from the iron cross of Heister,
the compress of Petit, drawn transversely over the oblique turns of
the bandage, the waistcoat which Brasdor fastened round the thorax
of his patients, and the leathern apparatus, lately proposed by a
German practitioner. These means, though diversified in their form,
are similar in their effect, and, being nothing but modifications of
the figure of 8 bandage, possess, like it, the radical fault of not
offering a resistance directly opposed to the two-fold power, arising
from the muscular action and the gravitation of the shoulder.

As to what remains, it will be sufficient to show the insufficiency
of the process of reduction (22), by means of the knee placed between
the shoulders, in order to demonstrate the existence of a like
insufficiency in all those forms of apparatus, which, as Brasdor
remarks, have for their object a continuance, during the treatment, of
the effect produced by that process.

31. On the other hand, those indications will be fulfilled with
exactness, by such a form of apparatus as will render permanent the
action of the means of reduction which were employed by Paul of Egina,
by certain Arabian physicians, and by Pare; which have been renewed by
Desault, and tend to draw the shoulder upward, backward, and outward
(23 and 24).

Pecceti appears, in the last century, to have had a faint view of
the proper indication on this subject, when, under the article of
fractures, he advises the ball to be suffered to remain under the
arm during the treatment of the injury. But the figure of 8 bandage,
united to this expedient, counterbalances its effect, rendering it of
no avail, and Pecceti was therefore no more successful than others, in
obtaining a cure of the fracture, unaccompanied by deformity.

32. An overlapping more or less perceptible never failed to accompany
the consolidation or knitting of the bone, and here, as in many other
cases, practitioners laboured to explain what they knew not how to
prevent. The impracticability of surrounding the part, as in other
fractures, with a circular bandage, appeared to Heister, Petit, and
Duverney, to be the cause of this deformity. They supposed that to be
a superabundant callus, which was nothing but a displacement of the
fragments. These visionary hypotheses ceased to exist, as soon as this
displacement was prevented by a proper apparatus.

Desault sought for this form of apparatus, as well as for his other
bandages, in the multiplied application of means already known, without
inventing new ones. Bandages and compresses, easy to be procured, and
already rendered familiar to surgeons by daily use, served him for the
construction of his apparatus, for which several machines had been
already proposed.

33. The pieces of which this apparatus is composed, are,

1st. Three rollers, three inches broad; the two first, six, and the
other eight, ells long, each one rolled up separately.

2dly. A bolster or pad (a, b, Fig. 1), made in the form of a wedge,
out of pieces of old linen. Its length should be equal to that of the
humerus, its breadth four or five inches, and its thickness at the base
(a), about three inches.

3dly. Two or three long compresses.

4thly. A small sling for the arm, (Fig. 5).

5thly. A piece of linen large enough to cover the whole bandage.

Every thing being properly arranged, the following is the mode of
applying the apparatus, which of itself reduces the fracture.

34. The patient being placed in a standing position, or, if his case
render that impracticable, on a seat without a back, an assistant
elevates the arm of the affected side, and supports it at nearly a
right angle with the body (Fig. 2), while the surgeon places under the
arm-pit the head of the bolster, which descends along the side of the
thorax, and which another assistant, situated at the patient’s sound
side, holds by the two upper corners.

35. The surgeon now takes one of the first rollers, applies the end
of it on the middle of the bolster, fixes it there by two circular
turns round the body, and passes a turn obliquely (a a) along the fore
part of the thorax, ascending to the sound shoulder: the roller then
descends behind, passes under the arm, and returning in front of the
thorax, makes a circular turn and a half, horizontally. Having reached
the hind part of the thorax, it reascends obliquely by the cast (b),
as it had done before, and passes over, before, and under, the sound
shoulder; having thus crossed the turn (a a), the roller again passes
across the hind part of the thorax, and finishes by circular turns,
which completely cover the bolster. A pin is now to be fixed in the
place of crossing of the roller on the sound shoulder, to prevent the
turn (a) from slipping downward.

The application of this first roller is intended for no other
purpose, than firmly to fix the bolster which is held up by the two
oblique turns before and behind, and secured against the body, by the
subsequent circular turns.

36. The bolster being fixed, the surgeon applying one hand to its
external surface, pushes it upwards, and, with the other, taking hold
of the elbow, after having half-bent the fore arm, lowers the arm,
till it is laid along the bolster. He then presses its lower extremity
forcibly against the side of the thorax, pushing it upwards at the same
time, and directing its upper extremity a little backwards.

The application of the bandage constitutes a part of the process of
reduction. The humerus, now converted into a lever of the first kind,
is drawn at its upper end from the shoulder, in proportion as its lower
end, is approximated to the thorax. The scapulary fragment being drawn
along with it, and directed at the same time upward and backward, comes
into contact with the sternal fragment, and in an instant the deformity
of the part disappears.

37. The arm being thus situated, is given in charge to an assistant,
who retains it in the same position in which he received it from the
surgeon, by pressing on it with one hand, and with the other supporting
the fore arm half bent, and placed horizontally across the breast.

The second roller is next to be applied. The end of this is carried
under the arm-pit of the sound side. It is then brought across the
breast, over the superior part of the diseased arm, and extends across
the thorax behind till it passes under the arm-pit. Two circular turns
cover the first. The roller must then ascend to the lower part of
the shoulder, by oblique turns (c. c. Fig. 3), each of which must be
overlapped by the succeeding one, to the extent of about the third part
of its breadth. It is necessary that these turns be applied in such a
way, as to bind but very gently above, and to increase in tightness,
as they descend nearer to the lower extremity of the humerus.

The use of this second roller is, to supply the place of the hand of
the assistant, in pressing the arm against the side of the thorax;
its effect evidently is to draw the upper extremity of the arm
outwards, and, as it is already directed backwards, to retain it in
that position. The compression of the circular turns on the arm, being
thus gradually augmented, becomes, on the one hand, more efficacious,
because it acts on a greater surface, and on the other, less
troublesome, because, being more divided, it is less felt at the lower
extremity of the arm, where it bears with most force.

38. A third indication remains still to be fulfilled, namely, to retain
the shoulder in its elevated position, and, by that means, to assist
in the extension of the fragments, which already has some effect in
preventing a depression.

To fulfil this indication, an assistant sustains the elbow in its
elevated position, with one hand, and, with the other, supports the
patient’s hand before his breast, while the surgeon fills with lint the
hollow spaces around the clavicle. He then applies on the clavicle,
at the place where it is fractured, the two long compresses, wet with
vegeto-mineral water, or some other cooling liquid. Taking now the last
roller, he fixes the end of it under the sound shoulder; from thence
he brings it obliquely across the breast, over the long compresses,
and carries it down behind the shoulder along the posterior part of
the arm, till it passes under the elbow. From this point, he again
carries it obliquely upwards across the breast to the arm-pit, then
across the back, over the compresses, and brings it down again before
the shoulder, along the front of the humerus till it again reaches
the elbow. From thence the roller again ascends obliquely behind the
thorax, passing under the arm-pit, where the first cast of the roller
is covered, and from whence it again starts, to run the same course we
have just described. This constitutes a second round, which covers in
part the first, and forms a kind of double triangle (e, f, d), situated
before the breast, and over the circular turns of the other rollers
(c. c. Fig. 4). The remaining part of the roller, brought from behind
forward, is employed in circular turns over the arm, and round the
thorax, for the purpose of preventing the displacement of the first
part. To make it the more secure, it is fastened with pins at its
different places of crossing.

The sling (Fig. 4) is next passed under the hand, and fastened above
to the ascending turns (d), and not to the circular (c c), which the
weight of the hand would be likely to draw downward.

39. It is only necessary to examine the course of this third roller,
to see, that, united to the sling, it is well calculated to support
the external fragment, which the weight of the shoulder has a tendency
to depress, on a level with the internal one. It supplies the place
of the assistant, who raises the elbow and supports the hand of the
patient, in like manner as the second roller performs the office of the
assistant, who presses the lower part of the humerus against the side
of the thorax.

On the other hand, the circular turns, by which the application of the
third roller is finished, being directed from before backward, push
in the same direction the arm and shoulder, which have been already
carried that way, by the process of reduction, and thus retain them in
their proper places.

Hence may be inferred the truth of the proposition, which we have been
endeavouring to demonstrate; namely, that the bandage of Desault,
constructed according to the general principle formerly established
(20), for fractures of the body of the clavicle, is calculated to
retain the external extremity of the humeral fragment upward, outward,
and backward.

40. The casts of the rollers, thus surrounding the thorax, however
well they may be secured, are yet liable to be displaced, particularly
when the patient is in bed. This inconvenience may be avoided, by
surrounding the whole with a piece of linen, leaving nothing uncovered,
but the sound arm, which is at liberty to perform its usual motions.

The arm of the diseased side, being thus fixed in such a manner, as
to constitute a whole or entire body with the thorax, follows its
movements, without producing any displacement. It is thus, that by the
apparatus for a continued extension of the thigh, the fragments of
the _os femoris_, forming an immoveable whole with the pelvis, cannot
change their situation, even in following the motions of the trunk.

Hence arises, in fractures of the clavicle, this advantage, that the
patient is not obliged to keep his bed, but is able even to attend to
his business, during the progress of the cure.

41. I will not dwell on the numerous objections urged by different
authors against the bandage which has just been described. What answer,
indeed, can be given to those writers, who fancy that they behold the
patient in the greatest danger of immediate suffocation; who dread an
approaching mortification of the arm of the diseased side; who allege,
contrary to the rules of the art, that there is no impression made
immediately on the clavicle, but on a neighbouring bone; who, &c. &c.?
Twenty times in a year, has experience answered those objections, in
the Hotel-Dieu; and there is not a pupil of Desault, who has not, as
well in this, as in many other cases, seen that objections, plausible,
indeed, when considered in the closet, or at a distance from a sick
room, dwindle to nothing at the bed-side of the patient.

42. In those cases (which, as Hippocrates remarks, very rarely occur)
where the external fragment projects over the internal one (12),
the bandage must be somewhat varied, although the two principal
indications, of drawing the shoulder backward and outward, must still,
as in other cases, be fulfilled. The only additional circumstance,
therefore, necessary to be attended to here, is, not to elevate the
shoulder, by pushing it upwards. This may be easily avoided, 1st,
by omitting to raise the elbow, when applying the bandage; 2dly, by
drawing the third roller a little tighter than usual.[3]

    [3] This paragraph is so obscure in the original, that a
    translation of it would be scarcely intelligible. Instead of a mere
    translation, therefore, I have given rather a comment on what I
    believe to be its true meaning.                          TRANS.

The fragments, being reduced to the same level, and brought into
apposition, by this two-fold attention, will unite as in ordinary cases.

If the fracture exist at the end of the clavicle next to the humerus,
the difficulty of their being displaced renders the application of
the bandage less necessary. Prudence, however, demands that it be not
altogether neglected.


§ VIII.

OF THE TREATMENT DURING THE FORMATION OF THE CALLUS.

The regimen to be pursued during the reunion of the clavicle, varies
according to circumstances. It is impracticable to lay down general
rules, applicable to all affections of this kind. Here, however, much
more than in other cases, if the division of the bone be simple, and
no unfortunate accident occur, it is always unnecessary to restrain
the patient from his usual course of life, beyond the second or third
day. But, though internal means are for the most part omitted in the
treatment, the apparatus is a subject on which too much attention
cannot be bestowed. With whatever degree of exactness it may be at
first applied, it will soon become loose, and oppose a diminished
resistance to the weight of the shoulder, and the action of the
muscles. Hence, unless it be frequently examined, the fragments will
be displaced. The following case furnishes a detail of the treatment
subsequent to the reduction, to which, in ordinary cases, Desault had
recourse.

CASE III. Mary Adel, aged thirty, as she was crossing a path covered
with ice, in the severe winter of 1788, fell on the point of her left
shoulder, and fractured the clavicle about the middle. Being brought to
the Hotel-Dieu a few hours after the accident, she was dressed in the
manner just described, and, as the fracture was simple, it was judged
sufficient to make a slight diminution in the quantity of her aliment,
during the two or three first days. The dressing was moistened every
morning, with vegeto-mineral water, at the place corresponding to the
fracture.

On the fourth day the piece of linen that surrounded the bandage was
removed, for the purpose of examining the state of the parts. Every
thing was found in its proper situation, and the covering was replaced
till the seventh day, when the rollers appeared to be somewhat relaxed.
The apparatus was taken off, and reapplied as at first, the compresses
being carefully moistened with vegeto-mineral water, at the part lying
over the fracture. After the third day the patient was permitted to
return to her usual regimen. The third roller being a little deranged
on the tenth day, it was taken off, and reapplied as at first, together
with the sling. The fragments were examined and found in perfect
contact. The patient was up during the whole day, walked about the
house, and experienced no other inconvenience than that of not being
able to use the left arm.

On the thirteenth day, the bandage was again reapplied, and allowed to
remain till the sixteenth, when the patient having disturbed it, it
was once more changed. At this period, the fragments, already firmly
united, exhibited scarcely a vestige of the division they had sustained.

The reunion was complete by the twentieth day, when all the pieces
of apparatus were dispensed with, except the bolster and the second
roller, which were also removed two days afterwards, as they were found
to be no longer necessary.

The continued inactivity of the limb, during the treatment, had
occasioned a stiffness in the shoulder. This was gradually done away by
making the patient move her arm in all directions, twice a day, each
time, for the space of an hour.

On the twenty-ninth day she left the hospital, carrying with her
nothing to remind her of the injury she had sustained. She was free
from that uneasiness which is the consequence of a tedious and
ill-managed treatment, during which the exercise of the limb has been
neglected.


§ IX.

OF COMPLICATIONS.

44. We are in possession of but few observations particularly relative
to the different complications, that may accompany fractures of
the clavicle. The treatment, in such cases, varied according to
circumstances, must be accommodated to the indications common to all
fractures of this kind.

When splinters, displaced in different directions, whether adhering to
the bone or not, irritate the soft parts, and, having passed through
the integuments, appear without, most practitioners advise to remove
them and cut off such parts as project beyond the fractured end of the
bone, previously to reduction. This direction is founded on the severe
pains which, in such cases, accompany the common treatment of the
injury, and which the figure of 8 bandage always augments, by drawing
the shoulder inward, and consequently pressing the soft parts against
the projecting parts of the fragment, or the points of the splinters.
But if the splinters, adhering as yet to each other and to the bone, by
means of the periosteum, have not assumed the nature of foreign bodies,
(that is, if they be not actually dead) it is always proper to replace
them. It is here only that we meet with an occasion for that part of
the process, of reduction denominated conformation,[4] which is never
requisite in other cases.

    [4] That process or operation in which the surgeon uses his hands
    to effect the reduction and apposition of parts, which cannot
    be accomplished by extension and counter-extension alone. If
    a bone be broken into two or three pieces, mere extension and
    counter-extension will not bring all the fragments into their
    proper places, so as to restore the natural form of the part.
    In such cases, the surgeon uses his hands to aid the action of
    the extended muscles, and this is the process which our author
    denominates _conformation_. The term occurs in many places in the
    course of the work.                                        TRANS.

A fragment which has penetrated the soft parts, but has not been long
exposed to the air, disappears, and is replaced by extension, provided
it be properly directed. Being retained afterwards in a state of
constant extension, it can neither be displaced, nor cause pain by
irritating the parts, which is the inevitable result of the figure of 8
bandage.

In cases of this kind, it is useful to protect the shoulder with a
small splint, which may support the turns of the bandage, and prevent
their pressure on the splinters, or the broken ends, which they might
otherwise disturb. These precautions are alike indispensable when the
fracture is double.

CASE IV. Francis Ricord, twenty-five years of age, was received in the
month of July, 1790, into the Hotel-Dieu of Paris. On the preceding
day, a piece of timber having fallen from a considerable height on
his right shoulder, had broken the clavicle of that side into several
pieces. Severe pains, which occurred at the moment of the accident,
had continued throughout the night, and were still sensibly felt. The
slightest motion of the part augmented them to such a degree, as to
extort from the patient piercing cries.

The point of the shoulder being very much depressed, was also drawn
perceptibly forward and inward; and a large echymosis, without any
external wound, occupied its whole extent.

Desault being satisfied that the several fragments were all connected
together, and that none of them was separated from the periosteum,
placed, as in ordinary cases, the bolster under the arm, completed the
reduction, and applied a splint along the course of the clavicle, after
having, with his hands, brought the fractured pieces into contact.
Confident, then, that the form of the part was perfectly restored, he
applied the bandage, which was moistened with vegeto-mineral water,
twice or thrice a day.

At the moment of reduction the pains ceased, and were felt no more till
the fifth day, when the bandage being a little relaxed, admitted of a
slight displacement of the fragments. This displacement was removed,
and the pains along with it, by the reapplication of the apparatus.

During the six first days a very strict diet was enjoined. This,
however, was dispensed with by degrees, till, on the thirteenth day,
the patient returned to his usual regimen. On the seventeenth day,
there remained nothing of the echymosis, but a yellow tinge, the
customary consequence, of such an accident. The precautions inculcated
in the preceding case, were employed also in this, and the patient
was discharged perfectly cured, on the forty-second day from the time
of his admission. Nor had he experienced, during his treatment, those
severe and long continued pains, which, under a different management,
so frequently accompany this kind of fracture.


EXPLANATION OF THE FIRST PLATE.

  Fig. 1. A bolster made in the form of a wedge, intended to be placed
       between the arm and the side of the thorax.

  _a._ Its base, which should fit the hollow of the arm-pit.

  _b._ Its summit reversed, against which the elbow is to be applied.

  Fig. 2. The first roller applied for the purpose of fixing the
       bolster against the side of the thorax.

  _a a._ Oblique casts before, passing over the opposite shoulder, in
       order to hold it up.

  _b._ Oblique casts from behind, crossing the first ones on the
       shoulder.

  _d d._ Circular casts round the trunk, covering the bolster, which
       they fix laterally.

  Fig. 3. The second roller, applied to fix the arm against the bolster.

  _a & b._ Portions of the oblique casts of the first roller, left
       uncovered by this one.

  _c c._ Turns of the second roller, covering those of the first,
       loose above, and tighter below, for the purpose of drawing the
       superior extremity of the humerus outwards.

  _d._ Their passage over the side opposite to the bolster.

  Fig. 4. The third roller intended to keep the point of the shoulder
       raised.

  _a a & b._ Oblique casts of the first roller, remaining uncovered.

  _c c._ Turns of the second, seen through the opening of those of
       the third.

  _d._ Oblique casts of the third, ascending from the arm-pit over the
       shoulder of the diseased side, to descend again behind, along
       the arm, and pass under the elbow.

  _f k._ A continuation of the preceding casts, reascending under the
       sound arm-pit, and from thence behind the thorax, over the
       diseased shoulder.

  _e._ A continuation of the same casts, descending on the fore side of
       the arm, passing under the elbow, and ascending again under the
       arm-pit of the sound side.

  _g._ The remainder of the roller, intended to be employed in circular
       turns, in order to secure the casts _e_, and prevent them from
       slipping outward.

  Fig. 5. A sling which should be fastened to the oblique cast _d_
       (Fig. 4), to support the hand.

[Illustration: _Pl. 1_

_Fig. 1._

_Fig. 2._

_Fig. 3._

_Fig. 5._

_Fig. 4._

    _Engrav'd by W. Kneafs._]




MEMOIR III.

ON THE LUXATION OF THE CLAVICLE.


§ I.

1. The clavicle, which forms a moveable abutment for the shoulder, and
receives and sets bounds to most of the movements of that part, and of
the arm, exhibits at its extremities, two articulations, essentially
different from each other in their form, dispositions, and uses. These
differences give rise to differences equally essential with regard to
the dislocations to which they are subject.

2. On the sternal extremity, a small surface, convex from above
downwards, and concave from before backwards, is fitted, by means of
an intervening cartilage, to a much smaller surface of the sternum,
concave and convex in opposite directions.

One capsule, two ligaments, viz. the interclavicular and
costo-clavicular ligaments,[5] and the anterior portion of the
sterno-cleido-mastoideus muscle, strengthen the connexion of these two
surfaces, and tend, on one hand, to prevent their luxation, while, on
the other, this luxation is favoured and facilitated by the following
circumstances: 1st, the disproportion between the dimensions of the two
articulating surfaces; 2dly, the mobility of the joint; and 3dly, by
this joint’s constituting a kind of centre for the motions of the arm.

    [5] I find in English books of anatomy no appropriate names for
    these two ligaments. I am therefore obliged to translate the French
    terms for them literally. The anatomist will have no difficulty in
    recollecting their situation.                          TRANS.

3. On the humeral side, an elliptical surface, slightly convex, and
inclined downwards, is immediately joined to a corresponding surface of
the acromion, elliptical also, a little concave and directed upwards.
Hence two kinds of inclined plains, which would be very liable to
dislocations, by sliding easily over each other, were they not firmly
secured by a capsule, by accessory fibres, by the intersection of those
of the deltoid and trapezius muscles, and, above all, by two ligaments,
the rhomboid and the conoid.[6]

    [6] I do not recollect any terms in English works of anatomy
    equivalent to these.                                   TRANS.

Having laid down these preliminary considerations, let us proceed to
examine, in particular, each kind of luxation to which the clavicle is
subject.


LUXATION OF THE STERNAL EXTREMITY.


§ II.

OF THE CAUSES AND DIFFERENT KINDS OF DISPLACEMENT.

4. The sternal articulation of the clavicle experiences different
changes, according to the different movements of this bone. If
these movements be in a backward direction, the articulating
surface is turned forward, straining the anterior part of the
capsule, the corresponding ligament, and the extremity of the
sterno-cleido-mastoideus muscle. If, on the other hand, they be in a
forward direction, the posterior ligament, and the adjacent portion
of the capsule are overstretched. In motions directed upwards, the
costo-clavicular ligament, and the external and inferior part of
the capsule, and in those directed downwards, the inter-clavicular
ligament, and the internal portion of the capsule, experience a similar
degree of tension.

5. Hence it follows, 1st. That the natural movements of the shoulder
may be regarded as predisposing causes of luxation, because at the part
where tension is excessive, the ligaments are disposed to give way,
and suffer the sternal extremity to escape: 2dly. That the efficient
causes will be, all external forces acting on the clavicle in such a
way as to increase its motions beyond their natural degree, and beyond
the resistance which the ligaments are capable of making. Thus a fall
on the point of the shoulder, forcing it suddenly backward and inward,
produces a luxation forward. But, in general, as the strength of the
articular ligaments is superior to the resistance of the clavicle
itself, a fracture takes place more frequently than a luxation, in the
proportion of nearly six to one.

Though falls on the point of the shoulder are oftentimes productive of
luxation of the clavicle, they are not the exclusive causes of that
accident. Desault has seen the sternal extremity forced from its cavity
by the knee being pushed violently against the middle of the back,
while the shoulders were drawn at the same time backwards.

CASE I. A porter dislocated his clavicle in the following manner. He
was carrying a very heavy burden, suspended from his shoulders by cords
that passed under each arm-pit. Being desirous of resting himself by
the way, he placed on a block the burden he carried, which slipping
backward, drew his shoulders in the same direction, and at the instant
of his attempting to retain it and prevent it from falling, produced a
luxation of the clavicle.

7. It follows from what has been said respecting the different states
of the articulation, during its various motions (4), that the clavicle
is not equally liable to be luxated in every direction. Inclining
naturally backward, but a very slight degree of motion in that
direction is necessary, to effect a luxation forward. To produce a
luxation backward or inward, it is necessary, on the other hand, that
the humeral extremity of the bone should make a sweep at least three
times the extent of that required in the preceding case. Besides,
motions in this direction are accompanied with pain, particularly if
they be made by force. Luxation downward is prevented, on the one
hand, by the cartilage of the first rib, which presents to the bone
an insurmountable barrier. On the other hand, to produce this kind
of luxation, it would be necessary for the external extremity of the
clavicle to be forced upwards, an occurrence very seldom occasioned
by falls. Luxation upward, or over the superior edge of the sternum,
must be the effect of a stroke, which, by depressing the point of the
shoulder, and forcing it at the same time forward, presses the sternal
extremity against the internal and superior part of the capsule, which,
being thus lacerated, suffers a luxation to take place. But such a
derangement of the articulating surfaces is very rarely produced by
falls. Whence it follows, that of the different kinds of luxation of
the clavicle, that in a downward direction is altogether impracticable.
Those backward and upward, though possible, occur but rarely in
practice; while that in a forward direction, on the contrary, is not
an unfrequent accident. This tends to confirm the observations of
practitioners, and particularly of Desault, whose immense collection on
the subject furnishes examples of the last kind of luxation only.

8. In these luxations, there is for the most part, a rupture of the
capsular ligament, and an escape of the bone through the opening. But
sometimes the ligament is only preternaturally distended, and then the
luxation is incomplete.


§ III.

OF THE SIGNS.

9. But whatever may be the causes or kind of the luxation, its
diagnosis is always easy. If it be forward, the direction of the stroke
which the shoulder has received, furnishes, at first, some ground of
suspicion. The accident is certainly known by the appearance of a hard
and unnatural protuberance in front of the sternum, and behind the
extremity of the sterno-cleido-mastoideus muscle, by the existence of
a sensible depression or hollow at the joint, and by the situation of
the shoulder, which is pushed further backward, and is less projecting
and more approximated to the trunk, than in its natural state. Add
to these, a difficulty in performing motions in a forward direction,
which, when somewhat forced, reduce, in proportion as they are
accomplished, the size of the protuberance formed by the displaced end.
The head is always inclined towards the side where the luxation exists;
an attitude which relieves the painful drawing or tension produced
in the sterno-mastoideus muscle, by the humeral extremity pushing it
forward.

10. A protuberance over the superior edge of the sternum, a difficulty
in raising the shoulder, the pain which results from attempting such
a motion, the diminution of the protuberance which it occasions,
the absence of the sternal extremity from its natural cavity, the
approximation of the shoulder to the thorax, and its depression and
diminished projection, compared to its usual state, afford evidence of
a luxation upwards.

11. A luxation inward or backward, would be characterized by a
projection of the shoulder exteriorly, by a difficulty in performing
motions in a backward direction, by the alarming effects, which, as
Petit remarks, the compression of the trachea would doubtless produce,
and by a depression or hollow at the joint, more perceptible here than
in the two preceding cases.

12. These appearances will be more or less striking, accordingly as
the membranes, lacerated or only distended, offer a greater or less
resistance.


§ IV.

OF THE REDUCTION.

13. To reduce a luxation, is, in general, to make the bone re-enter
its cavity, by retracing, or returning along, the same route which
it followed in escaping from it. Now, in a forward luxation, the
displacement is from behind forward, in an upward one from below
upward, in an inward or backward one from before backward, but, in each
of the three, it is more particularly from without inward. In the first
case, therefore it is backward, in the second, forward, in the third
downward, but, in each of the three, more particularly outward, that
the powers for producing extension must be directed.

14. Hence the method generally employed by most practitioners,
recommended by almost every author who has written on the subject,
adopted by Petit, Duverney, Heister, &c. and which consists in
placing the knee between the shoulders of the patient, as a point of
resistance, by the aid of which the shoulders may be drawn backward,
fulfils only half of the indication of cure; because at the time
that the humeral extremity is drawn backward, it is not directed
sufficiently outward.

Hence a difficulty of replacing the bone sometimes occurs, a difficulty
always removed, when, pursuant to the method employed by Desault in
fractures of the clavicle (see Desault’s method), the arm is made to
serve as a lever of the first kind, to carry backward and outward, the
head of the bone, which is displaced in the opposite directions, when
the luxation is forward. This method possesses the advantage, not
only of giving the powers of extension a proper direction, but also of
increasing them to a degree even beyond what is necessary for effecting
a reduction, by removing them further from the resisting force. Hence
it is unnecessary to adopt any particular measures for restoring and
preserving the form of the part, as the extension is alone sufficient
for that purpose.

These principles, evidently applicable in effecting a reduction, are
still more strikingly so in the means destined for retaining it. Let
us apply what I have just said, to a case of dislocation in a forward
direction. It will be easy to transfer it afterwards to the other kinds
of luxation.


§ V.

OF THE MEANS OF RETAINING A REDUCTION.

15. Few luxations are so speedily reduced, but few are more easily
displaced again, than that of the clavicle. This disposition is the
reverse of that of most other luxations, which are reduced indeed
with difficulty, but seldom afterwards suffer a displacement. The
cause of this we find, 1st, in the extreme mobility of the clavicle,
to which all the motions of the arm are communicated; 2dly, in this
further consideration, that most of the muscles, which have their
insertion towards the shoulder, tend to draw this bone inward, when
the ligaments, in consequence of being either broken or distended, as
happens in this accident, do not offer a sufficient resistance.

16. From this two-fold cause of displacement, arises a two-fold
indication in the arrangement and application of the apparatus. These
are, 1st, to render the clavicle immoveable, by restraining every kind
of motion in the shoulder and arm; 2dly, to retain the extremity of
the clavicle outward, a direction opposed to that in which it has a
tendency to be displaced. But if to those indications we compare the
forms of apparatus hitherto used, we will readily perceive that they
are insufficient to fulfil them.

17. The figure of 8 bandage, so generally in use, and all the various
modifications, under which it has been revived, without being
improved, fix the clavicle in the very direction most favourable to a
displacement, and even do it in the very manner in which that accident
is sometimes brought about; as maybe seen in the history of the case of
the porter (6). This bandage does not, under any of its modifications,
prevent the motions of the shoulder, because it does not restrain those
of the arm, which remains free and unencumbered. Far from constituting
an antagonist power to, it even co-operates with, that which has
produced the displacement. (For further light on this subject, see what
has been already said on the fracture of the clavicle, pages 22 and 25.)

Bell, in condemning the figure of 8 bandage, not so much because of its
action being insufficient, as because of its obstructing respiration,
proposes, as a substitute for it, a kind of machine analogous to the
iron cross of Heister, which, being fixed by straps passing under
the arm-pit, and round the neck and body, is intended to retain the
parts firm and immoveable. But the motions of the arm not being
restrained, nor the action of the muscles of the shoulder opposed by an
antagonizing power, places this piece of apparatus in the same class
with those, which, from not being devised and constructed on a proper
view and conception of the causes of displacement, have no affinity to
rational practice.

18. The apparatus for a continued extension, invented by Desault, for
fractures of the clavicle, fulfil here all those indications in which
the others fail.

By this, 1st. The aim, being firmly fixed against the side, by means
of the roller (_c c_ Fig. 3), can communicate no motion either to the
shoulder, or the clavicle. 2dly. The shoulder itself, being forcibly
drawn outward, with the upper extremity of the humerus, by the action
of the kind of lever into which this bone is converted, and to which
the bolster (_a b_ Fig. 1) serves as a fulcrum, cannot, by its
movements, derange the luxated bone. 3dly. The sternal extremity, being
drawn both by the muscles which tend to displace it inwardly, and by
the bandage which acts on it in an opposite direction, remains fixed
between those two antagonizing forces, which thus destroy each other.
Hence the apparatus of Desault, when accurately applied, offers to both
of these powers of displacement, a resistance perfectly calculated to
combat them.

20. We must, however, admit that this apparatus partakes of one
inconvenience, common indeed to all bandages, but which is perhaps more
particularly applicable to this in consequence of the numerous casts
of the rollers that form it, namely, the great facility with which it
becomes relaxed. Hence one cause of displacement, which the most exact
and scrupulous attention cannot at all times prevent.

CASE. Desault had, for a long time, the care of a patient, whose
luxation, having been neglected for four days, was reduced on the
fifth, by a surgeon, who, for the purpose of retaining it, employed
a bandage of a particular kind. An hour afterwards, a motion of the
shoulder backward, displaced the luxated extremity: a new reduction was
the consequence; on the day following, another displacement, and so on
in succession, for ten days, at the expiration of which, Desault being
consulted, applied to the part the bandage formerly described.

On being examined the next day, the apparatus was found in a favourable
state. On the day following, a slight displacement rendered necessary a
new application of the bandage, which, this time, continued longer than
before. But, about the expiration of the third day, the projection of
the bone was again considerable. Finally, the patient recovered, with a
very perceptible protuberance in front of the sternum, and a difficulty
of motion, great at first, but less afterwards, and which exercise
succeeded ultimately in removing.

21. The application of the apparatus differs from that intended for a
fracture of the clavicle, only in this, that it is of service to place
on the luxated extremity, graduated compresses,[7] calculated to make
pressure backward and outward, and which are to be secured by the turns
of the roller (b Fig. 4).

    [7] Compresses laid one upon another, of which the upper one is
    still the smallest, not in relation to thickness, but as far as
    regards length and breadth.                              TRANS.

A second precaution, not less essential, is, to push the humeral
extremity of the clavicle, a little forward, and fix it in that
direction, in order that the sternal being directed backward, may be
removed from the place[8] through which it has a tendency to escape.

    [8] The rupture in the capsule that surrounds the joint.     T.

22. Desault almost always obtained complete success by this process,
and by the most accurate attention to prevent the relaxation of the
bandage. In the mean time, a stiffness, more or less considerable,
always remains in the joint for a long time after the reduction, and it
is not unfrequently a month or two before the part recovers its usual
facility of motion.

The following cases, collected by Brochier, confirm the doctrine for
which I have been contending.

CASE II. A man luxated the clavicle by falling on the point of his
shoulder, and forcing it backward. He was immediately brought to the
Hotel-Dieu, where Desault demonstrated to his pupils, that the head of
the bone, carried in front of the sternum, was removed nearly an inch
from its natural cavity, the ligaments of which were no doubt lacerated.

Here, as in the fracture of the clavicle, the application of the
bandage answered the purpose of reduction, and removed the protuberance
formed by the extremity of the bone.

The patient, being strong and vigorous, and having received besides a
violent contusion, was bled twice, and confined to a low diet. On the
following day, no derangement; on the fourth day, a slight displacement
of the bone, the rollers a little relaxed, bandage applied anew. Eighth
day, no sensible displacement. Eleventh day, some swelling around
the joint; compresses, wet with vegeto-mineral water, ordered to be
frequently renewed. Twentieth day, the swelling almost gone, and no
disposition to a displacement; the apparatus was removed; motions at
first difficult, and contracted. Twenty-ninth day, more free and easy.
Thirty-fourth day, returned to their natural state.

CASE III. Mary Rivert luxated her clavicle, on the seventh day of
January 1789. Being brought some time afterwards, to the Hotel-Dieu,
she was treated in the same manner as the foregoing patient, and with
the same result, except that a very slight protuberance remained at the
extremity of the bone, and the confined state of the motions continued
a little longer. Desault related, in his lectures, other instances of
cures being performed without the least remaining deformity.

After all, even supposing the method just proposed, to possess no other
advantage, than that of diminishing the protuberance of the bone,
which, under other modes of treatment, is almost inevitable, and by
that means preventing the motions of the part from being confined, it
would still, without doubt, be a great step towards the perfection of
the art.

23. Should a luxation backwards occur, the same process of reduction
should be adopted, with this difference, that the extension ought to
be made forward and outward; and the same apparatus should be applied
for retaining the parts, except that the humeral extremity ought to be
directed a little backward, in order that the sternal extremity, being
carried forward, may be removed from the place of laceration in the
capsule.

In like manner, should the bone be luxated upwards, it would be
necessary to draw the arm outwards, and elevate slightly the point of
the shoulder, for the purpose of depressing the sternal extremity.


LUXATION OF THE HUMERAL EXTREMITY.


§ V.

OF THE KINDS OF LUXATION.

24. Luxations of the humeral extremity of the clavicle, take place,
according to Petit, in two ways, 1st, under, and 2dly, over the
acromion. If we attend to the disposition of the articulating surfaces,
the superior of which rests obliquely on the inferior; if we examine,
in particular, the relative position of the corocoid apophysis with
respect to the clavicle, it will be difficult to conceive how the first
kind of luxation can occur, without being accompanied by a fracture.
Yet some facts added by Desault to the doctrine of Petit, on this
point, seem to demonstrate the possibility of the clavicle sliding
under the acromion. As to luxations forward and backward, the mobility
of the shoulder, the facility with which it yields to motions impressed
on it in these two directions, and the want of a resisting power, make
the two bones that compose it, move together, still preserving their
relative position.

The luxation upward, then, is that which ought chiefly to occupy the
attention of the practitioner. Yet even this is less frequent than
the luxation of the sternal extremity, on account of the very great
strength of the retaining ligaments, which, when this luxation occurs,
must be, if not lacerated, at least very much distended.


§ VI.

OF THE MECHANISM AND THE APPEARANCES.

25. A fall on the point of the shoulder is the most frequent cause of
this luxation. The two articulating surfaces, representing an inclined
plain, slide along each other, in such a manner, that that which
belongs to the acromion is pushed inward, while that of the clavicle
is directed outward. The capsule being stretched, gives way, and then
the displacement is manifested by a preternatural protuberance over
the acromion; by a stiffness in the motion of the shoulder; by the
direction of this part, which is evidently drawn inward and downward;
by the inclination of the head of the patient to the side affected;
by a bending of the body; and by severe pains in the luxated part.
These characters are essentially distinct, and ought to have prevented
the error of Galen, who mistook a case of this kind for a luxation
of the os humeri downward. Hippocrates and Ambrose Pare have foreseen
the possibility of this mistake and even warned young practitioners to
be on their guard against it. But, as citizen Sabattier judiciously
observes, the position of the head of the humerus, under the arm, in
a luxation of that bone, will remove all uncertainty respecting the
nature of the injury.


§ VII.

OF THE REDUCTION AND THE MEANS OF RETAINING IT.

26. The reduction, in this case, is generally attended with but little
difficulty. The acromion being drawn outward, by the upper end of the
os humeri, which, by means of a fulcrum placed under the armpit, is
made to act as a lever of the first kind, is restored, without much
trouble, to its natural contact with the corresponding surface of the
clavicle. But, it soon becomes deranged again, unless it be retained
in its place by a proper apparatus. Now, on what principle ought
this apparatus to be constructed? To prevent the displacement, which
generally occurs from without inwards, it ought evidently to act from
within outwards. Whence it follows, that the rollers in the figure
of 8 bandage, recommended in this case by all writers, instead of
preventing, actually favour the displacement (17), because they act in
the same direction with, and therefore assist, the powers that produce
it.

27. Here, in like manner as in the preceding case, the bandage of
Desault fulfils with precision the indications of cure, because, by
it, the point of the shoulder is, particularly, drawn outward; and if,
in certain cases, a slight projection of the humeral extremity still
remains, it is to be attributed to the inefficacy of the means of
execution, and not to the principles on which they are founded.




MEMOIR IV.

ON FRACTURES OF THE ACROMION, AND OF THE LOWER ANGLE OF THE SCAPULA.


§ I.

FRACTURE OF THE ACROMION.

1. There is no part of the scapula more liable to fractures than the
acromion. Being but slightly covered by the soft parts, this insulated
kind of appendix has not, in all positions of the humerus, a solid
point of support. A strong muscular force oftentimes acts on it with
great energy. Being large in front, it presents in that direction
a considerable surface to receive the action of external bodies.
Whence it follows, that if it is not oftentimes broken, this is to be
attributed, not so much to its natural disposition, as to the position
which it generally assumes in falls.

2. The fracture, which is almost always transverse, is sometimes at the
summit, and sometimes at the base of this apophysis, and is usually
produced by a violent shock from a body falling on the shoulder, by a
blow received on that part, &c.

3. But in whatever place it occurs, it greatly resembles a fracture of
the humeral extremity of the clavicle, of which the acromion appears
like a continuation. There is accordingly a strong analogy between the
phenomena, the consequences, and the modes of treating these two kinds
of fractures.

4. This accident is characterized, 1st, By a severe pain experienced
by the patient, at the place of the fracture. This pain is increased
by the elevation of the arm, which, generally hangs motionless down
along the side. 2dly, If the humerus be removed from the trunk, the
hand being at the same time placed on the acromion, the extremity of
this apophysis is felt sinking downward, creating thereby an evident
depression in the part. 3dly, Generally, the two fragments lose, of
their own accord, their relative position; and unless the precaution
about to be mentioned be used, their displacement becomes manifest,
being produced by the weight of the arm, and the contractions of the
deltoid muscle. 4thly, The head is inclined to the affected side.


§ II.

OF THE REDUCTION.

5. Two different processes have been long in use for the reduction of
fractures of the acromion. One consists in elevating the arm almost to
a right angle with the body, in order, as Heister remarks, to throw
the deltoid muscle into a state of relaxation, and then to be able,
with the fingers, to place the fragments in their natural situation.
In the other mode, the humerus is suffered to retain the position it
has assumed, that is, to hang down the side; the surgeon then taking
hold of the elbow, pushes it vertically from below upwards, in such
a manner, that the head of the bone, pressing against the acromion,
elevates and replaces it.

6. Petit seems to have adopted indiscriminately these two methods, one
of which, however, is greatly superior to the other. Indeed, it is
evident, that if the humerus be removed from the trunk, its head will
necessarily sink down in the glenoid cavity. Being thus separated from
the fractured apophysis, it leaves beneath it a hollow or vacancy,
into which the fragment will be pushed, should it be in any measure,
compressed by the casts of the roller, during the application of the
bandage.

7. On the other hand, if the arm still fixed against the side, be
pushed upwards, it will afford to the acromion a solid point of
support, which, during the application of the apparatus, will prevent
its displacement downwards. This consideration is unquestionably of
moment, during the process of reduction; but ought more particularly,
to command the attention of the practitioner, in the choice of means
destined to maintain the reduction.


§ III.

OF THE MEANS FOR MAINTAINING THE REDUCTION.

8. As the displacement is most likely to occur downwards, particularly
in motions of the arm, it is necessary that a continued resistance
be opposed to this tendency. But this resistance should be made by
the head of the humerus, which, if properly directed, will represent,
during the treatment, a kind of splint, which art ought to render fixt
and immoveable lest, being contiguous to the divided surfaces, it might
derange, by its motions, the work of nature in effecting their reunion.
Hence it follows, that the precise and immediate intention of the whole
apparatus destined to support fractures of the acromion apophysis, is,
1st, to keep the head of the humerus constantly elevated or pushed
upwards: 2dly, carefully to prevent all motions of the arm and shoulder.

9. If the means, heretofore employed in this fracture, be examined, it
will be perceived that they by no means fulfil this twofold indication.

A compress placed immediately over the fracture; a roller passed round
this to secure it; a ball or bolster[9] put into the hand; the fore-arm
supported in a sling; such is the apparatus recommended by Petit.
In addition to this, Duverney judiciously advises to keep the sling
elevated, for the purpose of keeping the head of the humerus applied
under the fractured pieces. He employed also the spica-bandage which
has been equally recommended by Heister.

    [9] Une pelotte.

10. But, in the employment of these means, the arm, not being confined
against the trunk, can move with ease, and derange the fragments, and,
therefore, the second indication is not fulfilled. Will even the first
be fulfilled? By no means. The sling, being soon deranged, by the
movements of the arm, which are oftentimes involuntary, suffers it to
sink down again, and then the fragments, being no longer supported, are
displaced. Hence the difficulties attending the treatment, difficulties
which have not escaped the notice of authors, and which Heister thus
expresses: “_Nemo ita curari solet_, _ut brachium postea, liberi sursum
attollere queat_,” an observation, which the celebrated Cheselden made
before him, in describing the scapula.

11. These inconveniences will be avoided, by fixing the arm, as
recommended by Desault, firmly against the trunk, by converting, so
to speak, the arm and the trunk into one single and solid piece, in
such a manner, that the humerus having no other motions but those in
common to it and the thorax, may not be able to communicate any others
to the fragments, which are supported by its head. This advantage can
be easily obtained, by means of the bandage, already described, for
fractures of the clavicle, modified agreeably to the circumstances of
the case, in which it is to act.

12. A bolster or pad of an equal thickness in all its parts, is placed
under the arm. The arm is then to be pressed down on this, in like
manner as in the bandage for the clavicle. The fractured apophysis is
now to be covered by two compresses; one extending from the clavicle
to the spinous processes of the vertebræ, while the other, lying over
this, and running in a contrary direction, crosses it at the place
of the fracture. The whole is then to be secured by a roller, which,
starting from the arm-pit of the sound side, pursues nearly the same
course with that destined, in fractures of the clavicle, to retain
the shoulder upwards. (See what has been said on this subject, when
treating of the structure of the bandage.)

13. By this mean, the two-fold indication of keeping the humerus
immoveable, and directed upwards (8), is evidently fulfilled, as I
have already proven at full length, when treating of fractures of the
clavicle; and a reunion, without deformity, may be looked for, of which
we have an instance in the following case, recorded by Derrecagaix.

CASE I. Nicholas Gay, aged twenty-nine, was struck, in passing under
a decayed building, by a stone, which, having become loosened, fell
on the point of his shoulder. In an instant he experienced severe
pain, and a difficulty of moving his arm, particularly upwards. Soon
afterwards there occurred a swelling of the shoulder, and a large
echymosis at the place where the blow was received. The pain, not so
acute during a state of rest, was increased by the motions of the arm,
and even by leaning the head towards the opposite side, which latter
circumstance was, no doubt, owing to the contraction of the trapezius
muscle.

A surgeon being called, judged it sufficient to make use of discutient
applications, to which the swelling and the echymosis appeared to
yield in the course of a few days. On a more accurate examination, a
fracture was discovered, supposed to be in the external part of the
clavicle, and for which the patient was sent to the Hotel-Dieu.

The fracture was discovered to be in the middle of the acromion,
which it divided transversely. The bandage already mentioned (12)
was applied, and, from the first day, the patient was left to his
usual regimen. Fifth day, a renewal of the apparatus which had become
relaxed: seventh day, a fresh displacement, in consequence of an
unguarded motion: a fresh application of the bandage, which continued
in its place till the sixteenth day, when it was replaced anew:
thirty-second day, reunion complete; a stiffness in the motions of the
part, which exercise removed by degrees, and of which the patient felt
no remains after the forty-eighth day.


FRACTURE OF THE LOWER ANGLE OF THE SCAPULA.


§ IV.

OF THE SIGNS OR APPEARANCES AND DISPLACEMENT.

14. Next to the acromion, the lower angle of the scapula is that
portion of the bone most liable to be fractured. The usual causes
of it are, falls on the side, or blows received on the part. It is
characterized by a displacement which is always perceptible. On the
one hand, the fleshy portion of the serratus-major, which is attached
to the inferior fragment, draws it directly forward, while it is drawn
upward by the teres-major, and some of the fibres of the latissimus
dorsi. On the other hand, the body of the bone itself remains behind,
being held by the rhomboid muscles. Hence arises a separation, which
renders it difficult to mistake the fracture. Should any doubts still
remain, let the shoulder be drawn backwards and the scapula along with
it: let the fingers be, at the same time, placed on the lower angle,
to ascertain whether or not it follows the motions of the bone; if
it does, there is no division: but if, on the contrary, it remains
stationary, the existence of the fracture is evident.


§ V.

OF THE REDUCTION, AND THE MEANS OF RETAINING IT.

15. Here, as in all other fractures, the means of reduction must be
founded on the causes of displacement. To effect the replacement,
therefore, it is necessary, either to push backward and downward, the
angle which is displaced in a contrary direction, in order that it may
be brought into contact with the body of the bone, or else to draw the
body of the bone forward and upward, that it may meet the displaced
angle. It is thus, that in a fracture of the condyle, the body of the
jaw, is drawn into contact with the fragment.

16. But the first mode of reduction is difficult, and the means of
maintaining it impracticable. It is necessary, therefore to have
recourse to the second, which is the more easily executed, as the
scapula follows the movements of the arm, and as, by drawing this limb
forward, and the elbow of it outward, that bone is removed from the
spinous processes of the vertebræ, and directed in such a manner, as
to be brought into contact with its inferior fragment. This situation
possesses another advantage, as it throws into a state of relaxation
the muscles which tend to displace the lower fragment.

Hence it follows, 1st, That here, in like manner as in fractures of the
clavicle, it is not on the fractured bone, that the force must act, but
on the humerus. 2dly, That the humerus ought to be, during the whole
treatment, immoveably fixed, because its motions, being communicated to
the scapula, must soon derange the contact necessary to a reunion.

18. On these principles were founded the apparatus of Desault, and his
process of reduction, which consisted, 1st, in drawing the arm forward,
and separating the elbow a little from the thorax; 2dly, in fixing the
fore-arm at an angle sufficiently acute, to direct the hand to the
point of the opposite shoulder; and 3dly, to bring afterwards into
proper apposition and form, the fragments already approximated to each
other by the first movements.

19. To retain this reduction, the arm and fore-arm must be permanently
fixed in the above position. This object is attained in the following
manner, 1st, A bolster in form of a wedge, being placed between the
arm and the side, its apex situated in the arm-pit, affords the double
advantage of keeping the elbow at a distance from the thorax, and of
rendering the position of the arm less fatiguing by serving as a point
of support to it. 2dly, Compresses wet with some discutient liquid,
are applied on the part corresponding to the fracture. 3dly, The whole
is now to be secured by a roller, seven or eight yards long. The first
turns of this roller, must secure the hand of the affected side on the
sound shoulder to which it had been applied, during the reduction,
and running afterwards from before backwards, pass over the place
of the fracture, for the purpose of retaining the compresses on it.
The wedge-formed bolster is to be secured on the thorax, by circular
turns around it. Then, passing under the sound arm-pit, after having
made these circular turns, the roller must be brought behind again,
conducted obliquely over the shoulder of the diseased side, along the
anterior part of the arm, under the elbow, and behind the thorax,
where it is carried obliquely, in order to pass again under the sound
arm-pit. From this place it ascends again anteriorly over the affected
shoulder, redescends along the posterior part of the arm, repasses
under the elbow, returns under the arm-pit, and terminates finally
in circular turns round the trunk, and arm together. Hence it may be
observed, that, in the first turns of the roller, this bandage greatly
resembles the third roller applied in the fracture of the clavicle, to
retain the point of the shoulder upward and backward (Fig. 4. plate I.)

20. By this, 1st, The movements of the arm being entirely impeded,
they cannot have any influence on those of the shoulder; hence, in
this respect, the fragments are suffered to remain in contact. 2dly,
The serratus-major and teres-major muscles, being kept in a state of
habitual relaxation, can no longer draw the inferior fragment forward,
which cannot, therefore, be separated from the body of the bone.
3dly, Nor can the body of the bone, being permanently held in this
situation, be removed from the fragment; whence, in both respects, a
displacement will be effectually prevented. This threefold advantage
is not possessed by any of the different kinds of apparatus hitherto
proposed, such as the sling and cross-bandage, employed by Petit, which
have the fault of suffering the arm to move backward, of allowing the
scapula to be easily separated from its insulated angle, of retarding
by that means the cure, and even of preventing it entirely, while, by
the process just described, it is usually completed by the thirtieth
day.




MEMOIR V.

ON THE FRACTURES OF THE UPPER END OR NECK OF THE HUMERUS.[10]


    [10] For a very important improvement made by Dr. Physic in the
    treatment of an old fracture of the os humeri, and which may be
    applied also to similar fractures of other bones, see Article I. of
    the Appendix.                                           TRANS.

1. The language of the surgeon differs, in this case, from that of
the anatomist, and by the expression, “fracture of the neck of the
humerus,” is here meant not that of the slight circular depression,
which separates the head from the tuberosities of the bone, but rather
that of the contracted or diminished portion of the bone, which
commences at the tuberosities above, and being continued down the body
of the bone, receives at its lower end the insertion of the tendons of
the pectoralis major, the latissimus dorsi, and the teres major. Many
practitioners consider this neck or contracted portion as extending
even to the insertion of the deltoid muscle.

2. Several facts, the truth of which it is difficult to call in
question, attest the possibility of a fracture of the neck of the bone,
so called in anatomical language. I have myself seen, in the humerus
of a young man, aged seventeen years, the head of the bone exactly
separated from its body, by a division which had but slightly affected
the upper extremity of the tuberosities. But the examples of this
nature which occur in the annals of surgery are too few, to enable us
to lay down any general principles for the treatment of such fractures.


§ II.

OF THE VARIETIES AND THE CAUSES.

3. The operation of external bodies, active, when they are thrown
against the shoulder, passive, when the shoulder, or the arm, is
forcibly driven against them, is always the cause of a fracture of the
neck of the humerus. From the mechanism of the part, the division is
sometimes direct, and sometimes the effect of a counter-stroke.

The first of these arises very generally from a fall on the point of
the shoulder, and as in such a case, the commotion or shock must be
very great, to extend with sufficient force through the thick mass
which forms the deltoid muscle, that muscle sometimes suffers both
contusion and an echymosis. Blood may even escape from a rupture of
some of the arteries or veins of the joint, and form, as Desault has
observed, a collection or tumour which it would be imprudent to open.

The other is the effect of a fall on the elbow, separated, at the time,
some distance from the trunk, or on the hand, which, by a natural
instinct, is thrown out, together with the arm and fore-arm, in order
to break the violence of the fall.

4. The varieties of this kind of fracture originate, 1st, from the
spot which it occupies, being either the middle or the lower part,
rarely the upper part, of the neck of the humerus: 2dly, from the state
of the surrounding soft parts, which sometimes remain quite natural,
and at other times become distended and tumefied. This circumstance
always involves the diagnosis in more or less uncertainty; 3dly, from
the direction of the fracture, which is sometimes transverse, but
usually oblique, particularly when produced in the second mode, that
is, by a counter-stroke (3); 4thly, from the relative situation of
the fragments, which may remain in contact, an occurrence however but
very rare, or may separate from one another in a direction inwardly or
upward; and, 5thly, from different complications, with which it may be
attended.


§ III.

OF THE SIGNS AND THE DISPLACEMENT.

The whole of the signs of a fracture of the neck of the humerus, taken
together, characterize its existence in a manner sufficiently evident.
But it is not always an easy matter to take a view of them all at once,
and in such a case, there are more difficulties attending the diagnosis
here, than in any other fracture of the humerus.

An acute pain is felt at the instant of the fall; and sometimes a crack
or report is plainly heard. There is always a sudden inability to move
the limb, which, being left to itself, hangs motionless. But if any
external force act on it, it yields to it without resistance, and may
be moved by it with great ease in every direction.

These motions are accompanied with severe pain, and, if carried too
far, may give rise to very troublesome affections, as has been observed
in patients, where the fracture was mistaken for a luxation.

Beneath the acromion, is discovered a depression, always situated lower
down, than that which accompanies the fracture of that apophysis. If
one hand be placed on the head of the bone, while the other is employed
in moving the lower fragment in different directions, or, while an
assistant, engaged in making the necessary extension, communicates to
this fragment a rotatory motion, 1st, the head will be perceived to
remain motionless; 2dly, the friction of the two divided ends will
produce a crepitation more or less perceptible. This twofold sign is
always decisive as to the existence of a fracture; but the swelling
of the joint may occasionally prevent the practitioner from availing
himself of it.

The fragments remain sometimes in contact, without experiencing
any displacement, in which case, most of the signs not manifesting
themselves, the diagnosis is rendered more difficult. But most
frequently a displacement occurs, and then it is the inferior fragment
that is deranged, and not the superior one which is so short that it
can be but little effected by the action of the muscles.

7. The displacement is in general but slightly perceptible in the
longitudinal direction of the bone, unless when, in a very oblique
fracture, the fragments present points which irritate the muscles,
excite them to contraction, and augment their force; or, when a blow
of great violence, continuing to act after the bone is broken, causes
the fragments to overlap each other. Thus has the body of the bone been
forcibly drawn upwards, or driven in the same direction, till having
passed through the deltoid muscle, and the external integuments, it has
even risen considerably above the level of its head.

But in general, as Petit observes, the weight of the limb hanging down
the side, opposes to the action of the muscles a sufficient degree
of resistance; and it is in the direction of the cross-diameter or
thickness of the bone, that the displacement most frequently occurs. It
is to be observed, that the lower fragment is driven either inward or
outward, rarely in any other direction. In the first case, which is by
far the most common, the elbow is somewhat removed from the body, and
cannot be brought near to it without pain; in the second, which is more
rarely met with, it is moved in an opposite direction.

In the one, the contractions of the deltoid muscle and the natural
curve of the humerus, in the other, the united action of the pectoralis
major, the latissimus dorsi, and the teres-major, appear to have an
essential influence on the displacement.

In each case, the displacement is facilitated by the mobility of the
lower fragment, and of the shoulder, when an apparatus from being
improperly constructed, fails to prevent the movements of the whole
extremity.

8. The signs which have just been detailed, do not always furnish such
luminous evidence, particularly to an inexperienced practitioner, as
to prevent the occurrence of very serious mistakes. Of this Desault
related many examples in his lectures.

CASE. J. M*** Est*** falling on his elbow, fractured the neck of the
humerus. A surgeon was immediately called, who, finding a depression
beneath the acromion, a protuberance in the hollow of the arm-pit,
and the humerus directed outwards, pronounced, without further
examination, that there existed a luxation in a downward direction.
Wishing to reduce it immediately, he employed, to no purpose, the
common processes. Acute pains were the consequence. The opening in the
capsule being too narrow was irritated, and the member subjected to
great violence of motion. At length the pains became insupportable; the
operators gave over their fruitless efforts, and Desault was called.

He discovered the mistake from the immobility of the head; from the
depression beneath the acromion being lower down than in a luxation;
and from the existence of a crepitation. A reduction was effected
without loss of time; the apparatus was applied, but in the evening
a considerable swelling occurred around the arm-pit; soon afterwards
inflammation was superadded; a vast collection of matter succeeded,
and, notwithstanding the utmost attention, it was five months before
the patient was restored to health.

9. To this example, I could add others, where the most serious
accidents have resulted from a similar mistake. It must be
acknowledged, however, that, if, in a fracture, the displacement be
inward and a little forward, the greater part of the signs herein
detailed (5) apply equally to a fracture and a luxation: but then, as
we have just seen in the preceding case, the immobility of the head,
the place of the depression beneath the acromion, and the crepitation,
will remove any doubts that may be excited in the mind of the surgeon,
by the protuberance in the arm-pit, the direction of the arm, &c. &c.


§ IV.

OF THE PROGNOSIS.

10. A fracture of the neck of the humerus assumes, in general, a
character not very troublesome; and if, as Heister says, “a fracture
near the head is worse, and more difficult to be cured,” this is less
owing to the nature and seat of the disease, than to the difficulty of
keeping the fragments in contact.

Seldom have the reunion of the bone, and the removal of all the
disagreeable effects accompanying the accident, required a longer
time than is necessary for the cure of other fractures. The numerous
examples, which occurred in the Hotel-Dieu, during Desault’s direction
of the surgical department, confirm the truth of this assertion,
notwithstanding some doubts that may have been raised respecting it,
by prejudices formerly entertained, on the subject of fractures in the
vicinity of joints.

From twenty-six to thirty days are sufficient for the reunion: this was
the term commonly required in the Hotel-Dieu.

11. If judiciously managed, art readily removes all the accidents
attendant on this fracture; but, if otherwise, the consequences are apt
to prove troublesome. It is here, much more particularly than in other
places, that all deformity of the part ought to be prevented; because,
the neck of the humerus being near to the centre of the motions of the
arm, will very essentially impede those motions if it be not properly
reunited. A deformed callus has been known to produce, in the hollow of
the arm-pit, a protuberance, which has, in part, prevented abduction,
and appeared to keep up an habitual swelling in the limb.

It is, then, from the perfection of the apparatus, and not from the
vicinity of the injury to a joint, that the prognosis is to be formed,
both as to the consequences, and as to the duration of the fracture.
Keep the fragments in exact and regular contact, and there will be no
obstacle to that success which seldom forsook Desault.


§ V.

OF THE REDUCTION.

12. The reduction in this case is usually attended with but little
difficulty, and the great multiplicity of means hitherto used for that
purpose, demonstrate only the barrenness of the art.

Most of the machines destined to reduce the luxation of the humerus,
have been applied to this fracture. Thus the ladder,[11]* the door,†
and the club,‡ placed under the arm-pit, served at once the
purposes of counter-extension, and conformation, while the powers for
producing extension were applied to the elbow, and more rarely to the
wrist. Thus Hippocrates recommended a wooden cross, the effect and
mode of action of which are nearly the same. These means, in general,
besides being insufficient, are liable to a further objection, in
consequence of their acting on the edges of the pectoralis major,
latissimus dorsi, and teres major, which being thus forced upwards,
draw the fragment to which they adhere in the same direction, and
thereby constitute an obstacle to the reduction. (See what will be
advanced on the subject of luxations of the humerus.)

    [11] (* L’echelle, † la porte, ‡ le baton.) These pieces of
    machinery, though formerly in use, are now, I believe, in all parts
    of the world, laid aside. It would be superfluous, therefore, to
    consume time in describing either them, or their mode of operation.
                                                             TRANS.

13. To machines succeeded the use of straps, weights suspended to the
limb, &c. These processes were entirely useless, in as much as they
were intended only to increase the natural powers of the operator,
which are already more than sufficient of themselves. They will,
therefore, in a short time, exist only in the history of surgery.

Petit proposed to reduce this fracture, by first raising the arm to a
right angle with the body, and then directing one assistant to make
the requisite extension, by taking hold of the elbow with his hands,
while another grasped the point of the shoulder, for the purpose
of counter-extension. This method was attended with the threefold
inconvenience, of subjecting the patient to great fatigue and pain,
of weakening the extending powers, by bringing them too near to the
point required to be moved, and of irritating the muscles that draw the
lower fragment upwards, and thus exciting them to contract. Hence the
difficulties sometimes attendant on reduction, which is always simple
in itself, when, after the trunk is properly fixed, gentle extensions
are made by taking hold of the fore-arm in a half-bent state. The
following is the mode of reduction practised by Desault.

14. The patient is seated either on a chair or on the side of a bed.
The arm is slightly separated from the body, and carried a little
forward.

One assistant is directed to fix and secure the trunk in a proper
manner. This he does by pulling at the arm of the sound side,
taking hold of it near to the hand, and extending it in a direction
perpendicular to the axis of the body. This mode of counter-extension
is preferable to that commonly employed, which consists in applying
the hands to the upper part of the patient’s shoulder. Indeed, on the
one hand, the power being farther removed from the resisting force,
need not be so great. And, on the other, the body being entirely
unencumbered, renders it easy for the surgeon to apply the roller
without discontinuing, or in any way disturbing, the extension.

Another assistant makes extension on the fore-arm, which serves him
as a lever, where, one hand being placed behind or on the back of
the wrist, forms the point of support, (or fulcrum), while the other
applied to the anterior and middle part of the fore arm, on which it
makes pressure from above downward, represents the power; the fragments
to be brought into contact constitute the resistance.

The relaxation of the muscles produced by this semi-flexion of the
fore-arm, and the slight separation of the arm from the trunk, greatly
favour this mode of extension; a mode recommended by the ancients,
adhered to by the English, and which possesses the advantage of leaving
uncovered all that portion of the limb on which the apparatus is to be
applied, and by that means of allowing the hands of the assistant to
keep the same position during the whole time of the application.

A small degree of force, judiciously directed according as the
displacement is inward or outward, is sufficient to effect the
reduction, which even takes place of its own accord, under this
process. If the surgeon lays his hands on the place of fracture, it
is rather to examine the state of the fragments, than to assist in
bringing them into apposition.


§ VI.

OF THE MEANS OF MAINTAINING THE REDUCTION.

16. All kinds of apparatus for fractures, being nothing but resistances
opposed by art, to the powers which produce displacement, it follows,
that they should all act in directions precisely opposed to the
directions of those powers. But, we have seen (7), that, in the present
case, these powers are, 1st, the action of external bodies, favoured
by the extreme mobility of the arm and shoulder; 2dly, the action
of the latissimus dorsi, the pectoralis major, and the teres major,
which carry the inferior fragment inward, or, what is more common, of
the deltoid muscle, which draws it outward; 3dly, the contractions of
the muscles of the arm, which have a slight tendency to draw the same
fragment upwards.

17. Therefore, 1st, to render the arm and shoulder immoveable; 2dly, to
carry the upper end of the lower fragment outward or inward, according
to the direction in which it is displaced; and, 3dly, to draw this
fragment downward, are the three indications that ought to be fulfilled
by every bandage intended for a fracture of the neck of the humerus.
The last merits less attention than the other two, because, as already
observed, the weight of the limb alone is nearly sufficient to answer
it.

18. Let us inquire, whether or not the kinds of apparatus, hitherto
employed, have been adequate to the fulfilment of these indications.

The ancients, in obedience to the precept of Hippocrates, fixed the
arm against the breast, and confined it there by a bandage recommended
by Celsus, and constantly employed by Paul of Egina. “_Præstat antem_,
says he, _brachium, ad thoracem moderate deligare, ut ne, si id
commoveatur, figuram avertat_.” Pare still preserved this process,
which the moderns have now entirely abandoned, and which, taken alone,
could properly fulfil only the first indication. The second indication
was less happily fulfilled, by a kind of bandage added to the first,
by Celsus, Paul of Egina, and the Arabians, the necessary effect of
which was, to force the lower fragment outwards. It is surprising that
Heister and Lamotte should have confined themselves to the use of this
for the retention of the fragments.

What shall we say of the eighteen-tailed bandage exclusively adopted
by Petit and Duverney? The arm, not being fixed by it, was liable to
be moved, and the fragments to be displaced by the least shock. There
was nothing to prevent the lower fragment from obeying the powers
tending to carry it either inward or outward. Indeed the bandage was of
no avail whatever in giving support to a fracture, as was observed by
Louis, in his “Dissertation on Petit’s Diseases of the Bones.”

Suppose the arm, as some have advised, to be supported only by a sling.
Not one of the indications just established (17) could by such means be
fulfilled.

Perhaps the bolster of tow proposed by Moscatti, would have surpassed
all these means, in the advantages it offered, had it not, by leaving
the arm moveable below, and the shoulder above, still favoured a
displacement.

Le Dran has also advised the use of a bolster composed of that of
Moscatti, and bole Armenian. It fixed the arm more firmly against
the trunk and in this respect, certainly approached nearer to the
attainment of the object in view.

19. It is obvious, from this comparison between the indications of
cure (17), and the means hitherto employed for the fulfilment of them
(18), that nothing satisfactory had yet been done, and that a proper
apparatus was still a desideratum. The success experienced by Desault,
in the use of that which we are about to describe, has perhaps proven,
that this desideratum exists no longer.

20. The pieces which compose it, are, 1st, Two rollers, the one from
five to six, and the other from eight to ten yards long, each one about
three inches wide: 2dly, Three strong splints, of different lengths,
each about two inches broad: 3dly, A small bolster made of linen,
from three to four inches thick, at one end, tapering like a wedge to
the other, and of a sufficient length to reach from the arm-pit to
the elbow; 4thly, A sling for the purpose of supporting the fore-arm;
5thly, A piece of linen to surround the whole apparatus.

Every thing being properly arranged, the reduction, effected in the
manner already stated (14), and the assistants still continuing the
extension:

1st, The surgeon takes the first roller, wet with vegeto-mineral water,
fixes one end of it by two circular turns on the upper part of the
fore-arm, and carries it up along the arm by oblique turns, moderately
tight, and overlapping each other about two-thirds of their breadth.
Having reached the upper part of the limb, he makes some reversed turns
to prevent the wrinkles that would be caused by the unevenness that
occurs in this place. He then passes two casts of the roller under the
opposite arm-pit, and bringing the ball to the top of the shoulder
again, gives it into the hand of an assistant.

2dly, The first splint is then placed before, and reaches from the fold
of the arm, to a level with the acromion. The second on the outside,
reaching from the external condyle to the same level. The third behind,
reaching from the olecranon to the fold of the arm-pit. The bolster
placed between the arm and the thorax is a substitute for a fourth
splint, which is by that rendered unnecessary. An assistant now secures
them, by grasping them with his hand towards the curvature of the
elbow, so as not to hinder the application of the remaining part of the
bandage.

3dly, The surgeon takes hold of the roller again, descends by oblique
and reversed turns along the splints, which he fixes by binding them
moderately tight, and terminates the bandage at the upper part of the
fore-arm, where he had commenced.

4. The assistants still continuing the extension, the surgeon places
the bolster between the arm and the trunk, taking care that the thick
end be uppermost, if the displacement be in an inward direction, but
lowermost, if it be in an outward one, as is most commonly the case
(7). The bolster is to be fastened at top by two pins to a cast of the
roller.

5. The arm is now pressed towards the trunk, and fixed against the
bolster, by means of the second roller. This roller is applied like
that which, in fractures of the clavicle, fastens down the arm to the
bolster, by the oblique turns _c. c._ (Fig. 3. plate I.), with this
difference, that in the present case, the turns ought to be very tight
below, and looser above, if the displacement be in an inward direction.
But, on the other hand, if it be outwardly, they must be loose below,
and tight above.

6. The fore-arm is now to be suspended in a sling, and the whole
apparatus afterwards surrounded by a piece of linen, which, by
protecting the casts of the roller from friction, prevents them from
being disturbed.

21. If we now compare the action of this apparatus with the indications
of cure formerly laid down (17), it will be easy to perceive, that, by
it, they are extremely well fulfilled. Indeed, the arm, being firmly
fixed against the trunk, cannot move, otherwise than by motions common
to it and the trunk, and nothing can derange the lower fragment, which
is equally immoveable. Nor can the shoulder communicate any motion
to the superior fragment. The bolster being differently disposed,
according to the direction in which the lower fragment is displaced,
will serve to move it in an opposite direction.

Should this fragment be forced inwards, the thick head of the bolster
will separate it to a distance from the thorax. It will be maintained
in this state of separation, by the casts of the roller, which, being
very tight below, will act on it as on a lever of the first kind,
of which the bolster, forms the fulcrum, while the resistance to be
overcome is the action of the latissimus dorsi, the pectoralis major
and the teres major. The casts of the roller, by pressing the elbow
to the body, will draw the fractured end of the bone in a contrary
direction; and, in this respect, the bandage may be considered as an
artificial muscle, forming a perfect antagonist to the natural ones.

22. If the displacement be in an external direction, as most commonly
occurs (7), a contrary effect must be produced, as well by the
pressure made by the bandage, on the upper extremity of the displaced
fragment, as by the situation of the elbow which is directed outwards
by means of the thick end of the bolster being placed lowermost. The
external splint will also prevent the displacement outwards, as well
by opposing to the bone a mechanical resistance, as in compressing
the deltoid muscle, which is the principal cause of the displacement.
The derangement of the lower fragment forward and backward, will be
prevented by the two splints before and behind.

The displacement longitudinally, already checked by the weight of the
limb, will be still further prevented, by the compression made on the
muscles of the arm, which are the instruments of displacement, by the
splints and the bandage.

23. To the advantage of keeping the fragments exactly in place, this
apparatus unites that of not confining the patient, who is not obliged
to keep his bed, and to whom a lying position is even, in general, more
troublesome and injurious than an erect one. This observation applies
to the treatment of fractures of the clavicle, of the scapula, and even
of the fore-arm, when no accident has rendered them complicated.

Desault has cured several patients, but more particularly two, who,
being obliged to travel daily, did not, except on the day of the
accident, deviate in any measure from their usual mode of life.

An inexperienced surgeon sometimes applies the rollers too tight, in
which case, a swelling of the fore-arm is the consequence. This is
remedied by relaxing the bandage; but if, notwithstanding this, the
swelling still continues, it will be necessary to extend the bandage
from the hand to the shoulder.


§ VII.

OF THE SUBSEQUENT TREATMENT.

24. The pain ceases as soon as the apparatus is applied, because the
fragments, now brought into perfect contact, cease to irritate the
surrounding parts. Nor does it return during the treatment, as they are
firmly retained, and not suffered again to separate.

It is rare that any serious accident follows this fracture, and, among
the numerous examples met with by Desault, he has scarcely ever had
one such to encounter: yet he generally paid but little attention to
those internal means which are usually combined with external ones. In
most cases, the patients pursued the regimen to which they had been
accustomed.

In cases, where a considerable swelling attacked the upper part of
the joint, a circumstance which occasionally occurs in practice, one
or two bleedings, a diet more or less strict, and the use of diluent
drinks, constituted the internal treatment. Of this the following case,
related by Brochier, furnishes a detail.

CASE II. Maria Catharine Bardelle, aged forty-five, of a high
complexion, fell, as she was carrying a heavy load, on the elbow of the
right side, the arm being extended a little from the body. The neck of
the humerus was fractured, and all the usual signs combined in pointing
out the nature of the accident.

A surgeon was immediately called, who mistaking it for a luxation, made
useless attempts to reduce it, tormented the patient for half an hour,
and then left her to be sent to the Hotel-Dieu.

Desault discovered it at first sight to be a fracture, and foreseeing
the consequences of the improper steps that had been taken, ordered
blood-letting, and a low diet, after having effected the reduction, and
applied the apparatus already described (20).

In the evening, a considerable swelling appeared around the
articulation; the pains continued; a diluting drink composed of
dog-grass and oxymel was prescribed. Second day, the swelling is
gaining ground; pains increased; blood drawn again; diet and drink
continued; apparatus is frequently wet with vegeto-mineral water,
particularly at the upper part. Third day, a little better; pains
diminished, swelling checked; weak soup is allowed. Fourth day, a
diminution of the swelling; pains almost gone. Sixth day, the swelling
has almost disappeared; light food; bandage, having become loosened, is
reapplied.

Tenth day, tongue foul; nausea; want of appetite; symptoms of a bilious
diathesis. Bitter drink is prescribed; the day following, a grain of
tartar emetic is given in solution.

Thirteenth day, the patient is in her ordinary state; the apparatus
is renewed. Twenty-fourth day, the reunion is evidently advancing.
Thirty-second day, the consolidation is complete.

The patient now began to perform gentle motions with the limb, which
she gradually increased, till about the fortieth day, when she was
perfectly well, and free in all her motions.

25. I will here repeat an observation, already made, on the subject
of the bandage for the clavicle, of which this is nothing else than a
modification. In a short time the bolster sinking downward, the bandage
becoming relaxed, and the splints less tight, do not effectually oppose
a displacement, unless the bandage be daily examined, and reapplied,
when it seems to act too feebly. There are many surgeons, who have not
been fortunate in retaining the fragments with exactness, because,
trusting too far to the action of the bandage, they have for a long
time neglected to examine it; this remark is applicable to every
apparatus composed of rollers.

26. Here, much more than in other cases, it is all-important that the
limb be accustomed to motion, after the process of consolidation.
Situated near to the joint, the fracture always leaves some stiffness
in it, which time no doubt wears away, but which will sooner disappear
under the above treatment.


§ VIII.

REMARKS ON COMPLICATED FRACTURES.

27. Complicated fractures of the neck of the humerus are to be classed
with all other accidents of a similar nature, and it would be difficult
here to lay down such general rules as would be applicable to every
case. The practitioner must be always governed by circumstances. The
necessity of the case sometimes urges him to the adoption of daring
measures, which, in developing the resources of the art, do honour to
the talents of him who exercises it. Of this the following case is a
proof.

CASE III. Pierre Lena, aged fifteen, as he was at work on a scaffold,
forty feet from the ground, fell from that height on the corner of a
stone. He experienced instantly such severe pains, that he was unable
to rise. He was carried to the house of a surgeon, who, believing that
he had suffered a luxation, made fruitless attempts to reduce it,
produced in the part an enormous swelling, augmented his pains, and all
to no purpose.

The patient was carried to the Hospital of Charity, where Desault at
the time was surgeon in chief. A fracture of the neck of the humerus
was discovered, through the tumefaction and echymosis, which had
overspread the whole shoulder. A suitable bandage was applied.

A few days afterwards, a manifest fluctuation, an evidence of an
effusion of blood, disclosed the necessity of making an opening.
This was accordingly done, and the fingers being introduced into the
part, several large splinters were discovered, and a sharp-pointed
bone, the end of the lower fragment, pricking the deltoid muscle, and
occasioning, no doubt, the pains which had hitherto continued without
intermission.

The indication was evident. To give vent to all the splinters, and
cut off the point of the bone, or to amputate the limb, was the
only alternative that was left. Most of the practitioners that were
consulted were in favour of the last measure. But Desault ventured to
repose a hope in the first, the successful issue of which would be the
certain preservation of the limb. He performed the operation as follows.

A large incision made in the posterior, and one still larger in the
anterior part of the arm, enabled him to remove with ease all the
splinters. Then taking hold of the pointed extremity of the inferior
fragment, he drew it through the anterior opening, and cut it off
with a saw and a pair of cutting forceps. He then replaced it with
his fingers, and fixing the head of the bone in its proper position,
applied an apparatus somewhat similar to that intended for the
retention of fractures.

A suppuration taking place, the patient was dressed every day. Several
abscesses were formed during the course of the treatment; each time the
pus was discharged by means of an incision.

At the end of four months, the bone was perceived to be in a state of
necrosis. The dressings were regularly continued; but the patient,
becoming tired of his residence in the hospital, left it, being able
to move without difficulty, and having, in the upper part of his arm,
a deep fistula, from whence there was a constant escape of ichorous
matter, and through which several splinters were discharged, in the
space of six months which he passed at his own house.

About the expiration of this period he returned to the Hospital of
Charity. Desault had, in the mean time, left this institution to take
charge of the Hotel-Dieu. Amputation was proposed to the patient
as his only resource. He refused to comply, and went to Desault,
who, examining the state of the parts, found an irregular callus
formed, which he removed, together with a portion of the soft parts
corresponding to the fracture. At the end of two months and a half, the
patient was discharged perfectly cured, except a weakness in the limb,
which disqualified him for hard labour.

28. This case may throw considerable light on the difficult question
relative to amputations at the joint. But this is not the place to
state the ideas of Desault on that point of practice.

I will only observe, that in many cases of gun-shot wounds, a similar
treatment would probably save life, without exposing the wounded to
the dangers of an operation, in which so considerable a portion of
the system cannot be removed with impunity, and would secure to them
a limb, for the preservation of which they ought not to shrink from
the pains and hazards of a tedious treatment. To sacrifice a part for
the preservation of the whole, is the last resource of the art. It is
necessary, before resolving on this, to exhaust those previous ones
that might restore the whole of our organs to life and their proper
functions.




MEMOIR VI.

ON THE FRACTURE OF THE LOWER EXTREMITY OF THE HUMERUS, WITH A
SEPARATION OF THE CONDYLS.


1. Fractures of the humerus, accompanied with a separation of the
condyls, appear to have escaped the notice of most authors who have
written on diseases of the bones. The ancients have transmitted nothing
to us on this point. Petit, Duverney, and Bell, among the moderns,
have made no mention of it. Heister adverts to this fracture of the
bone, only to express an unfavourable prognostic respecting it,
without determining the mode in which it is to be remedied. Yet it is
by no means rare to meet with examples of it in practice. Desault, in
particular, has had frequent occasions to observe it.


§ I.

OF ITS VARIETIES AND SIGNS.

2. These fractures, like those of the condyls of the os femoris, are
rarely the effect of a counter-stroke. They are almost always produced
by the immediate action of external bodies; such, for instance, as a
fall on the joint of the arm; the wheel of a carriage passing over this
part, &c. &c.

3. Whatever may be their cause, they generally occur in such a manner,
that a longitudinal division separates the condyls from each other,
and, extending upwards to a greater or less distance, is terminated by
another transverse or oblique division, which passes through the whole
thickness of the body of the bone, so that there are three fragments,
and two fractures.

4. Sometimes the division is simple; in which case, being directed
outwards or inwards, it crosses the lower end of the humerus, obliquely
from above downwards, and terminating at the joint, separates but one
of the condyls from the body of the bone, leaving the other adhering to
it.

5. In the first case (3), there is more deformity at the broken
extremity of the humerus; and the mobility is also greater. If the
fingers, placed before or behind, press on the limb in the direction
of the longitudinal fracture, the two condyls will be separated from
each other, the one yielding in an outward, and the other in an inward
direction, leaving a fissure or opening between them. The part at the
same time expands in breadth. Thus, the two condyls of the os femoris,
are seen to separate from each other when in a similar fracture,
pressure is made on the rotula. The fore-arm is almost constantly in
a state of pronation. When we take hold of one of the condyls in each
hand, and endeavour to make them move in opposite directions, they can
be brought alternately forward or backward: and, if their surfaces
touch, a manifest crepitation is heard.

6. In the second case (4), the condyls cannot be so easily separated
from each other; but it is always practicable by taking hold of that
one which is divided from the body of the bone, and moving it from
before backward, to produce a crepitation, which is a sufficient proof
that a fracture exists. In a case where the external condyl was alone
separated, Desault found the limb in a constant state of supination, a
position to be attributed, without doubt, to the muscles attached to
this condyl.

7. An acute pain, the almost inevitable effect of the flexion or
extension of the fore-arm, the habitual semi-flexion of the limb, a
tumefaction of it sometimes supervening, and a swelling more or less
considerable, around the joint, are symptoms which accompany both modes
of division (3 and 4). The fracture may further be rendered complicated
by means of wounds, splinters, &c. when the blow has been very severe,
or when a pointed fragment has made its way through the surrounding
soft parts, &c.


§ II.

OF THE PROGNOSIS.

8. The preceding assemblage of signs, leaves in general but little
doubt on the subject of the diagnosis; but is the establishment of a
solid prognosis attended with the same facility?

If authors be consulted, they will be all found to agree, in
considering the communication of fractures with a joint as a
complication of a very serious nature. A swelling of the adjacent
parts, their inflammation, a continuance of the pains after the
reduction, extensive abscesses, a gangrene even of the soft parts,
and a caries of the bones; such, according to these authors, are
the almost inevitable consequences of these kinds of fractures, of
which an anchylosis is the most favourable termination that can be
expected. Petit, Heister, and Duverney, do not describe the evils that
accompany these accidents. Pare, in speaking of them, says, “In such
cases, the violence done to the tendons generally gives rise to great
inflammation.”

9. From whence can arise these exaggerated fears? Can it be, as is
pretended, the mere communication of the fracture with a joint, that is
productive of such serious affections? What relation, then, can reason
discover between the cause and the effect? Does not experience answer
in other cases, in a manner that admits of no reply, when it furnishes
us with the analogy of fractures of the rotula, the olecranon, &c.?

Modern researches have entirely abolished the ancient theory of an
effusion of callus into the joint, and with it one of the principal
causes assigned by writers for the accidents and evils which they so
much dreaded.

The admission of air into an articular cavity, would be, without doubt,
in such cases, a consideration of more weight; but this does not occur
except in fractures accompanied with wounds, and yet all those in the
vicinity of joints, whether compound of not, are regarded as extremely
dangerous. Besides, observation has oftentimes proven to Desault, that
even the contact of air is not so dangerous as it has been commonly
supposed, and many instances occurred to him in his practice, where,
notwithstanding such a complication, a perfect cure was obtained.

10. It is, then, to the want of a skilful mode of treatment, and
to the irritation experienced in the parts, in consequence of an
ill-constructed apparatus being applied to them, that the accidents
formerly mentioned (8) ought to be attributed. Such accidents never
occurred to Desault, in any of the numerous cases that fell under
his care. It is thus that in the fracture of the neck of the os
femoris, the insufficiency of the means, is oftentimes productive of
unfavourable results.


§ III.

OF THE REDUCTION, AND THE MEANS OF MAINTAINING IT.

11. The displacement here is, in general, inconsiderable, because,
being drawn in contrary directions, by the muscles of the arm and
fore-arm, the condyls separated from the bone remain stationary between
these two forces. A fall, a percussion, or some other external cause,
can alone produce a displacement, by communicating some degree of
motion to the fragments. Now, from what was formerly said (5 & 6), the
condyls may, under such an impulse, move either forward or backward, or
else may separate from each other, leaving between them an intermediate
void. Hence the apparatus ought to oppose to them a resistance in these
four directions, namely, inward, outward, forward, and backward; a
resistance which it will be easy to make, by means of four splints,
placed in these directions, and properly retained by a roller. The two
lateral splints, are particularly necessary, when the condyls are both
separated from the body of the bone, and divided from each other (3).
If one of them be still attached to the humerus (4), a splint on that
side becomes less useful.

12. It is needless for the apparatus to extend as high up as in a
fracture of the arm. What effect, in sustaining the fragments, would
casts of a roller have, when applied to the body of the bone, above the
place of division? Their only advantage would consist in compressing
the brachial and triceps muscles, and in that way preventing their
action.

On the other hand, the roller must be continued along the fore-arm, in
order that the elbow joint may correspond, according to the judicious
precept of Paul of Egina, to the middle of the bandage, which is in
general more compact and solid, in the middle than in any other part,
and also, that a slight compression may be thus made on the muscles
attached to the condyls.

13. The pieces which compose the apparatus, are 1st, A roller five or
six yards long, and three inches broad, made of soft linen or muslin,
and rolled up in a ball. 2dly, Four splints (11), two of them flexible
in the middle, in order that they may bend to fit the fold of the arm,
and the elbow, and the other two very strong and inflexible, intended
to be applied at the two sides.

14. Every thing being arranged, the reduction is effected in the
following manner. One assistant is directed to make extension at the
upper part of the arm, which he grasps with both his hands; another
makes extension on the fore-arm half-bent, which he uses as a lever
of the second kind,[12] where one of his hands, being placed under the
wrist, forms a fulcrum, while the other applied towards the fold of
the arm, represents the power. The surgeon, in the mean time brings
the condyls together, adjusts their level and apposition, both between
themselves, and with the body of the bone, and then proceeds to the
application of the apparatus, the limb being still kept in a half-bent
position, as was long since recommended in such cases by Paul of
Egina. “_Si in vicinia cubiti brachium fractum est, etiam ipse cubitus
deligandus, angulari figura servata._”

    [12] In this form of lever, the power is applied between the
    fulcrum and the weight to be moved, or the resistance to be
    overcome.                                             TRANS.

15. The roller (13), wet with vegeto-mineral water, which facilitates
its application, and prevents the swelling of the part, is fastened
by one of its ends, about two-thirds down the fore-arm, and continued
upwards by oblique and reverse casts, to the joint. The surgeon then
passes a cast of the roller from the anterior and superior part of the
fore-arm, to the posterior and inferior part of the arm (humerus),
redescends by an oblique cast from the other side, over the fore-arm,
and returning along the first track, makes a number of casts in the
form of the figure of 8, round the joint, which he next covers by
circular casts, applied so close to each other, as to leave no opening
between them; he then proceeds upwards by oblique casts, as at the
first, to the middle part of the arm (humerus), when the roller is
given into the hand of an assistant.

The first of the splints (13) is now placed anteriorly on the fore-arm
and arm, and, if it does not bend, in such a manner, as to accommodate
itself to the fold of the arm, the vacant space beneath it is filled
up with compresses, laid on top of each other, so as to make its
compression uniform throughout. The second, being applied on the
posterior side part of the arm, moulds itself to the projection of the
elbow, while the other two occupy the sides. These are secured below by
an assistant, while the surgeon resuming the roller, which he had just
given out of his hand, fixes them firmly by circular casts descending
along the arm and fore-arm.

The limb is then laid on a pillow, so disposed that the hand may be
raised higher than the elbow, in order to prevent the subsequent
swelling, which is oftentimes produced by the fracture, as has been
already mentioned (7).

16. The effect of this bandage is simple, and has a particular relation
to those directions and causes, in and by which, displacements might
occur. The two lateral splints prevent the separation of the condyls
from each other; the anterior and posterior ones prevent them from
moving backward or forward; the muscles are compressed; the motion of
the joint is prevented; and, in common, no great length of time is
necessary for the reunion of the bone.

As soon as this is accomplished, it is of importance to move the limb
in every direction, to prevent that stiffness, which is so commonly
the consequence of fractures situated in the neighbourhood of joints.
The following case, drawn up by Le-geulle, will furnish the reader
with a detailed account of the treatment pursued, in such accidents, by
Desault.

CASE I. Joseph Kisler, an ostler, aged forty-one, fell from a height of
thirty feet, on the left side, his arm being undermost, and fractured
the lower end of the humerus. A surgeon gave him immediate assistance,
and, at the expiration of two days, he was carried to the Hotel-Dieu.

From the signs formerly mentioned (5 and 7), Desault discovered a
fracture, consisting in a separation of the condyls from each other, by
a longitudinal division, and from the body of the bone, by a transverse
one. The usual apparatus (16) was applied, and, from a state of extreme
anguish, which he had till now suffered, the patient experienced
immediate relief.

In the mean time, a considerable swelling around the joint, pointed out
the necessity of blood-letting, a low diet, and other antiphlogistic
remedies. These were immediately had recourse to, and the limb was
placed in the proper position (16).

Notwithstanding these precautions, the tumefaction and redness were
increased on the following day. The bandage was applied anew, and wet
from time to time with vegeto-mineral water.

On the following days, pain less severe, the bandage kept constantly
wet with the same fluid.

Eighth day, the swelling almost gone; the apparatus, being loosened,
was again reapplied.

Fifteenth day, the fragments, being examined, were found in regular
contact, and already united by a substance of considerable firmness;
the strictness of regimen gradually relaxed; solid food taken in small
quantity.

Nothing new till the twenty-second day, when the splints were laid
aside, having become useless, in consequence of the rapid progress of
reunion: from this time till the completion of the cure, nothing was
used but the simple roller.

On the twenty-fourth day, gentle flexion and extension of the arm and
fore-arm were for a short time performed; these movements were attended
with acute pain, notwithstanding which, the fortitude of the patient
enabled him to persevere in them.

Thirtieth day, no pain accompanies the movements of the arm: the range
of these movements visibly increased; the roller laid aside; from this
time the range of motion increases rapidly.

On the thirty-seventh day, the patient was discharged perfectly
cured, and free from every vestige of his disease, except a trifling
stiffness, which was doubtless soon removed by the motions of the joint.

17. When wounds, splinters, or severe contusions, render these kinds
of fractures more complicated, an inflammation occurring on the
articular surfaces, may cause them to unite together, and by that
means give rise to an anchylosis. But this accident, inevitable in
such a case, according to writers, does not always occur, provided
nature be assisted, by a judicious mode of treatment, in her attempt
to reunite the broken bone. Desault has established this truth, in
many instances. Here, as in other joints, he has oftentimes obtained
a complete cure, without the loss of motion, although the part had
sustained the greatest violence. Incisions, easily made, the extraction
of splinters, a frequent renewal of dressings, a most vigilant care to
prevent all jarring of the limb, and consequently all derangement of
the contact of the fragments, an assemblage or combination of those
minute attentions, which art cannot teach, which genius suggests, and
which characterize the true surgeon; a precaution (not to be dispensed
with) to make the limb perform motions, gentle at first, but gradually
increased afterwards, when the adhesion of the parts has acquired
sufficient solidity to admit of it; such are, in general, the steps and
circumstances constituting the bases of that treatment, requisite in
these complicated fractures, which, like all others, appear, in each
case, to assume a new aspect, and to present different indications.

CASE II. A person, carrying a heavy burden, fell with his elbow on
a sharp corner of a bar of iron. The external condyl was broken,
being separated from the body of the bone, by an oblique division
running into the joint. Anteriorly, a large contusion; posteriorly,
a transverse wound; on the outside, the end of the condyl projecting
through the soft parts, which it had lacerated: such were the
complications of a fracture, for which the patient was admitted into
the Hotel-Dieu, on the seventh day of January, 1794.

On examining the state of the parts, Desault discovered, in the
transverse wound, two splinters which when extracted, gave vent to an
effusion of blood. He reduced, instead of cutting it off, as authors
have advised, the end of the separated condyl, applied a bandage of
strips,[13] and, to prevent accidents, ordered a strict diet, copious
blood-letting, and diluting drinks.

    [13] (_Bandage a bandalettes._) This is a most convenient form
    of bandage, in fractures of the upper or lower extremities. It
    is composed of strips of soft linen or muslin, from two to three
    inches wide, and of a length accommodated to the size of the
    limb, on which they are to be applied. These strips are not sewed
    together, but merely laid along side of each other, or rather
    spread in such a way that their adjoining edges may overlap a
    little. Being thus arranged, on the bed or mattress, where the
    patient is to lie, the broken limb is placed on them, when the
    surgeon, taking them, one by one, folds them round it, so as to
    form a very perfect and neat covering. The number of these strips
    must be regulated by the extent of the limb, or, at least, of that
    portion of the limb, which they are intended to cover.     TRANS.

Compresses wet with vegeto-mineral water, kept the apparatus constantly
moist.

On the day following, the dressing was renewed superficially; severe
pains in the part; abated towards evening; almost gone next day; low
diet continued.

Fourth day, pains returned; an incipient swelling around the joint;
more blood drawn.

Sixth day, considerably better; all the apparatus renewed; suppuration
beginning to appear.

Tenth day, a small abscess on the external condyl opened, and a
splinter extracted posteriorly.

Fifteenth day, the parts assume a flattering aspect; suppuration
favourable; fragments in contact; from this time the dressings are less
frequent.

Twentieth day, a bilious diathesis; edges of the wounds livid; loss of
appetite; nausea; vomiting; an emetic is administered.

Thirtieth day, unfavourable appearances gone; reunion commencing;
wounds visibly healing. Fortieth day, all external injuries healed,
except the one situated anteriorly; callus already very firm; gentle
motions performed with the limb, which is still surrounded by the
apparatus.

Forty-seventh day, the apparatus become useless; motions gradually
increased; articulation already tolerably free. Fifty-seventh day,
bilious diathesis returned; low diet and evacuants. Sixty-fifth day,
the patient discharged from the hospital; consolidation perfect; wounds
entirely healed; motions of extension still difficult to be performed
in their full extent, but are recovered in a great measure, and will
doubtless, in a short time, be completely re-established, provided the
same mode of treatment be continued.




MEMOIR VII.

ON THE LUXATION OF THE HUMERUS.


§ I.

GENERAL REMARKS ON THE JOINTS, AND ON THAT OF THE HUMERUS IN PARTICULAR.

1. Nature, who, according to the wants of different species of animals,
has varied the number of their articulations, knows also how to vary
their structure, according to the uses of the different parts of their
bodies. With great mobility, she has sometimes connected great solidity
and strength, as is the case in the vertebral column; in other
instances, parts very solid and compact, are capable of performing
but feeble motions, as the carpus, the tarsus, &c. And, lastly, other
parts, again, capable of great motion, possess so little solidity and
firmness as to be easily deranged by the action of external bodies.
Such, in man, is the articulation of the humerus with the scapula, of
the sternum with the clavicle, &c.

2. Hence there exist three classes of articulations, very different
from each other. To the last, as enumerated above, belongs, in a
particular manner, the history of luxations, and, in this, as the
solidity varies, the frequency of dislocations is equally various; no
luxation occurs more frequently than that of the humerus; indeed, in a
comparative catalogue of accidents of this kind, it alone has, during
certain years, occurred oftener, in the Hotel-Dieu, than that of all
the other bones, taken collectively.

3. Every thing seems to favour the escape of this bone from its natural
cavity. 1st, On the part of the articulating surfaces, a cavity
somewhat oval and very shallow, aided by a slight cartilaginous ring,
receives a half-spherical head, twice its own diameter from above
downwards, and three times as large from before backwards. 2dly, On
the part of the ligaments, this articulation is strengthened by only
a simple capsule. This capsule is thin and weak on its lower side, a
direction in which there is nothing to prevent a luxation, while it is
thicker on its upper side, where the acromion and coracoid apophyses,
and a strong ligament, present an obstacle almost insurmountable. 3dly,
As far as respects the muscles and the motions of the joint, strong
and numerous bundles of fibres surrounding the articulating surfaces,
communicate to them motions easily performed in every direction, and
which, by pushing the head of the humerus against the different parts
of the capsule, distend it, predispose it to laceration, and indeed
even rupture it, when the quantum of their force is superior to its
resistance. 4thly, As far as relates to external bodies, what bone is
more exposed to their action than this, particularly among that class
of persons, engaged, for a livelihood, in hard labour?

4. Subject to the influence of these different predisposing causes, the
humerus would be constantly liable to luxations, did not the scapula,
moveable like itself, furnish it, by accompanying its motions, with
a point of support, differently disposed, according to the different
position of its superior extremity; so that, to this two-fold mobility
of the articulating surfaces, is to be attributed, in a great measure,
the stability of their connexion.


§ II.

OF THE KINDS OF THIS LUXATION.

5. The upper articulation of the humerus, though predisposed, in
general, to luxations, is not equally so in every direction. There
is a point at which luxation cannot take place. There are others,
where, though possible, this accident has never been observed. It is
necessary, therefore, before examining the mechanism of this luxation,
to mention with precision, the directions in which it may occur.
On this point, writers have differed in a very singular manner.
Sometimes, to express the same thing, they have used a different
language; and, at other times, have, by the same words, expressed
things widely different. Always agreeing as to certain modes of
dislocation, they have been divided as to others; while, in the midst
of those contrarieties, the surgeon being embarrassed, is at a loss on
what ground to found his practice.

6. The ancients, knowing but little of the natural relation of
the parts surrounding the joint, were ignorant of the accidental
ones, which these several parts assume, in the case now under our
consideration. Hence, without doubt, arises the confusion, of their
opinions on the subject.

Many admitted of four kinds of luxations; a great number acknowledged
only three; some subscribed to but two; while others believed in the
possibility of none but one.

7. The first divided differently the directions in which the bone might
be luxated. Some contended for luxations upward, downward, forward,
and backward; and such was the opinion of the first Greek physicians,
predecessors to the father of medicine, who has transmitted the opinion
to us accompanied with a demonstration of its fallacy. Others have
divided them into those that take place downward, upward, outward, and
forward. This division is adopted by Galen, who yet produces only an
example of a forward luxation, and does not give us to understand what
he means by a luxation upward and inward.

8. The second distinguished the modes of this luxation, sometimes
into downward, forward, and backward; as was the case with Oribazes;
at other times, into downward, outward, and inward, according to the
opinion of Paul of Egina, who, no doubt, adopted exactly the preceding
division, expressing it only in different words; sometimes into
downward, forward, and upward; such was the sentiment of Albucasis,
who, notwithstanding, considered a luxation upward, as a very
difficult, and very rare occurrence.

9. The third were of opinion, that, in undergoing a displacement, the
head of the humerus could be carried only downward, under the arm-pit,
which is the most common direction, or forward, a course which it takes
more rarely. Celsus is almost the only writer who has contended for
this division. “_Humerus_, says he, _modo in alam excidit, modo in
partem priorem_.”

10. Lastly, The fourth believe, with Hippocrates, in none but a
displacement downwards, the only one which that physician has met with
in his practice. “_At vero humerus, inferiorem in partem excidit; aliam
in partem excidere non audivi._”

11. The moderns, in borrowing from the ancients their divisions of
luxations, did not, like them, determine a priori and in a vague
manner, the precise spot and direction of displacement; but ascertained
these points by subsequent observation, with more precision, in
proportion as a knowledge of anatomy shed light on them. They also paid
particular attention to the essential difference between primitive and
consecutive luxations.

12. Petit admitted of four kinds of luxations, 1st, downward, on
the edge of the scapula: this is a very rare occurrence: 2dly,
outward, under the spine of that bone, a kind very difficult to be
primitively produced. 3dly, inwards, under the hollow of the armpit.
4thly, forward, between the corocoid apophysis and the clavicle. With
this illustrious practitioner, Heister acknowledged four kinds of
displacements; but, here again, was a new variety, both in expression,
and in meaning. The one says, downward, under the arm-pit, the other
forward, under the pectoralis major; the one, backward, under the
scapula, the other outward, under its spine. According to Duverney,
luxations are never primitively in any other direction than downward;
the others being only the subsequent effect of muscular action.

13. In the midst of these very complicated modes of treating a very
simple subject, it is necessary, first, in order to acquire definite
ideas, to divide luxations of the humerus into primitive, which are the
immediate effect of external violence, and consecutive, which succeed
the primitive, through the influence of causes which I am about to
consider.

Let us suppose four lines to inscribe, in form of a parallelogram, the
oval surface of the glenoid cavity, one representing the superior edge,
another the inferior, a third the internal, and the fourth the external.

14. It is evident that the head of the humerus cannot be displaced
towards the superior edge. In that direction, must be encountered, the
acromion and corocoid apophyses, the strong ligament passing between
them, the tendons of the triceps and supra-spinatus muscles, and the
fleshy mass of the deltoid; all which, taken together, constitute an
insurmountable obstacle to the escape of the head of the bone upwards.
Besides, what power could carry it upwards? In order that this kind of
luxation might take place, it would be necessary, that the head of the
bone should be carried outwards at the same time, as well as upwards,
a circumstance which is impossible, because the trunk prevents the
lower extremity (the elbow) from being directed sufficiently inward to
produce such an effect.

15. On the contrary, in other directions, but very little resistance
is to be met with. Towards the inferior edge of the cavity, the long
portion of the triceps; the tendon of the subscapularis, towards the
internal edge; and towards the external edge, the tendons of the
infra-spinatus, and teres minor, yield with ease to a force directed
against them, and permit the occurrence of primitive luxations,
downward, inward, and outward. Downward, between the tendon of the
long portion of the triceps, and that of the subscapularis; inward,
between the subscapulary muscle and fossa;[14] and outward, between the
fossa infra-spinatus and the muscle of the same name. These modes of
displacement are not alike frequent, as will be mentioned presently.

    [14] (_La fosse sous-scapulaire_). I know of no English anatomical
    term for this. I therefore translate it literally. The same is true
    with respect to “_fossa sous-epineuse_,” translated here, fossa
    infra-spinata.                                            TRANS.

16. Having escaped from its cavity, and being primitively placed in
one of these three situations, the head of the humerus oftentimes
changes its position. Then, to a primitive luxation downward or inward,
succeeds a consecutive or secondary one; but never to a luxation in an
outward direction, if such ever occur, because the spine of the scapula
forms an obstacle to it.

A secondary luxation inward, may succeed a primitive one downward;
there is nothing to oppose the head of the humerus in the course it
takes, to enter between the subscapulary muscle and fossa. If, on the
other hand, it be disposed to pass to the external side, the tendon of
the triceps opposes it; and, notwithstanding what Petit has advanced,
there is no secondary luxation in that direction.

17. It sometimes happens, that, having escaped either from the internal
part, or from the inferior part of the capsule, the head passes behind
the clavicle, and forms there a secondary luxation upwards, as has
been observed by Ambrose Pare, and by Gallien, and of which an example
or specimen was preserved in the cabinet of Desault. But, here, the
secondary displacement must take place in a slow manner, and when it
has taken place, art can seldom remove it, on account of the strong
adhesions formed by the bony surfaces. Thus, in the example mentioned,
there was a new cavity formed behind the clavicle, and the humerus
adhered to the surrounding parts by a kind of new ligaments.

18. It appears from what has been said, that the humerus is subject to
four different kinds of displacement. 1st, _Downward_: 2dly, _outward_,
in both of which directions the luxation is always primitive; 3dly,
_inwards_, where it is sometimes primitive, and sometimes consecutive;
4thly, _upwards_, where it can never be otherwise than consecutive.

The second and fourth are very rare occurrences, and bear so small a
proportion to the others, that the latter alone ought to command the
attention of the practitioner.


§ III.

OF THE CAUSES AND THE MECHANISM.

19. The causes and the mechanism of luxations of the humerus, vary
according as the displacement is primitive or consecutive.

The action of external bodies, directed against the arm, but more
particularly falls, where this part strikes forcibly against a
resisting body, give rise in general to primitive luxations, and,
according as it is differently situated at the time of the fall, the
humerus determines, by its position, the different kinds.

20. If it be separated from the trunk, without being carried either
before or behind it, if the elbow be elevated, and the fall be on the
side, the weight of the body, being almost entirely supported by this
bone, pushes its upper extremity downward, distends the inferior part
of the capsule, lacerates it, and produces a luxation downward, in
which it may even be favoured by the action of the pectoralis major,
the latissimus dorsi, and the teres major, as has been judiciously
observed by Fabre. In such a case, these muscles, involuntarily
contracting to support the trunk, act like the power or force in a
lever of the second kind, the resistance to which is formed by the
head of the bone, which they draw downward, while the lower extremity
of the humerus, resting on the ground, constitutes the fulcrum. Some
authors even regard, as an immediate cause of luxation, the powerful
contraction of the deltoid muscle, which depresses the head of the
bone, and forces it through the lower side of the capsule, a mode
of displacement, the existence of which observation incontestibly
establishes. The case of a scrivener, so often cited, is well known,
who in lifting a book of records luxated his humerus in a downward
direction.

21. The mechanism of a primitive luxation inwards, differs a little
from the preceding. The elbow, being at once separated from the trunk,
and carried backward, the person falls: the weight of the body rests
on the humerus; the capsule is lacerated in its fore-part; and a
displacement in the same direction supervenes.

22. In a luxation outwards, the elbow is carried forward, towards the
opposite shoulder; the capsule being stretched outwardly, gives way
in that part, provided the humerus be acted on by a sufficient power.
But what can this power be? In a fall, the arm being pushed against
the trunk, and stopped by it, cannot carry its motion to a sufficient
extent to produce a laceration of the capsule. Hence a luxation
outwards must be extremely rare. Indeed no instance of it is to be
found in books of surgery. Desault, in particular, never witnessed it.
Besides, when in a fall, the arm, separated from the body, is carried
backward or forward, the weight of the body acts obliquely on it, and
it is but partially subjected to the action of the latissimus dorsi,
the pectoralis major, and the teres major. So that no kind of luxation
ought from these considerations, to be very frequent, except that in
a downward direction, where the influence of both causes is direct.
Yet luxation inwards is common enough, and in many instances Desault
has observed this primitive mode of displacement, though many modern
authors doubt the fact, believing, with Hippocrates, that, primitively,
all luxations are downwards.

23. It may so happen that in a primitive luxation, the capsule is
only greatly stretched, in which case, the articulating surfaces are
but partially displaced; but this membrane more frequently suffers a
rupture, through which the head of the bone escapes. To this phenomenon
writers, in general, have paid too little attention, notwithstanding
the opening of dead bodies has oftentimes demonstrated its existence to
practitioners, particularly to Desault, who has given two examples of
it modelled in wax; one, of a luxation inward, and the other downward,
both found in subjects that died in the Hotel-Dieu. Bell relates some
analogous facts, and another English surgeon has also had occasion to
meet with them.

24. Oftentimes, in compound fractures, one of the fragments passes
through the integuments. In the dislocation of the humerus something
similar to this occurs. The capsule is sufficiently lacerated to allow
the head to escape; but the opening, being then too narrow, forms
around the neck of the bone a noose or kind of collar, which prevents
it from re-entering the place which it originally occupied. Thus, in
the fractures of which I have just spoken, the aperture in the skin
does not, at times, admit of the reduction of the fragment, without a
previous dilatation.

In this case, an attempt is made to reduce the luxation: the capsule is
pressed in folds against the glenoid cavity, and, interposing itself
between it and the head of the humerus, renders fruitless the efforts
of the surgeon who would replace the bone. Desault was the first who
observed this practical fact, two instances of which are recorded in
his journal, and which has frequently since occurred in the Hotel-Dieu.
In such a case, the head is in general extremely moveable, because,
being entirely without the capsule, there is nothing to impede its
motion.

25. When, to a primitive luxation a consecutive one succeeds, several
causes may concur in its production. If a second fall happen, the arm,
being separated from the body, the head of the humerus having nothing
to retain and secure it, obeys, with great facility, the power tending
to displace it in that direction, and suffers a fresh removal from the
bed which it accidentally occupies.

CASE I. A man fell in descending a ladder, and luxated his humerus in
a downward direction. Desault being immediately called, discovered the
nature of the disease, but deferred the reduction till evening. In the
interval, the patient went to get into a chaise: his foot slipped, and
he fell a second time. The pains became more severe than at the time
of the first accident; and Desault, on his return, instead of finding,
as in the morning, the head of the humerus under the hollow of the
arm-pit, discovered it to be behind the pectoralis major.

26. Muscular action is one permanent cause of a new displacement.
Suppose the humerus luxated downward, the pectoralis major, and the
deltoid muscles draw its superior extremity upward and inward, which,
offering to their action but a feeble resistance, changes its position
and that in a two-fold direction.

27. The different motions of the arm may also, according to their
direction, produce the same effect. Thus we have often witnessed a
luxation inwards succeeding to a luxation downwards, in consequence of
unskilful attempts to reduce it.


§ IV.

OF THE SIGNS.

28. The diagnosis of luxations of the humerus, presents in general, but
few difficulties.

Whatever may be the mode or seat of the displacement, there always
exists, as Hippocrates has observed, a manifest depression under the
acromion, which exhibits a prominence more perceptible than in its
natural state. The motions of the part are almost all accompanied with
pain; the greater part of them are impracticable; all of them very much
confined. The arm cannot move, without a synchronous motion of the
shoulder, because, the articulation being no longer able to exercise
its functions, these two parts constitute, so to speak, but one body.

29. Besides these signs, which characterize generally every species
of luxation of the humerus, each species is marked by certain others
peculiar to itself. If the displacement be downward, the arm is a
little longer than in its natural state; it can be moved gently
outwards; but an acute pain is the inevitable consequence of moving
it forward or backward. The elbow is more or less removed from the
axis of the body, by the action of the deltoid, the long portion of
the biceps, and the supra-spinatus muscles, which, being unnaturally
stretched, contract themselves and tend to carry the bone outward. The
pains which result from this position, force the patient, in order to
relieve them, to lean towards the affected side, to keep the fore-arm
half-bent, the elbow resting on the hip, so that the arm, finding a
place of support, may be freed from the painful movements, and from
the disagreeable sensation produced by its own weight. From this
attitude alone, was Desault in the habit of discovering luxations in
a downward direction, and was rarely mistaken in his diagnosis. It is
thus, that, in a fracture of the clavicle, the inclined position of the
patient is oftentimes, at first sight, characteristic of the nature of
his complaint. Beneath the hollow of the arm-pit there always exists
a protuberance more or less perceptible, formed by the head of the
humerus.

30. To the general signs of luxations of the humerus (28), that in an
inward direction adds the following: the elbow, being separated from
the trunk of the body, is carried a little backward; the humerus seems
to direct itself towards the middle of the clavicle; motions backward
are not very painful, while those in a forward direction are extremely
so; under the pectoralis major a manifest protuberance exists; the arm
is but little longer than in a natural state; the attitude is the same
as in the preceding case.

31. Should a luxation in an outward direction occur, it would be
particularly characterized by a hard tumour under the spine of the
scapula, by the direction of the elbow forward, by its separation from
the trunk, and by a little increase in the length of the arm.

A protuberance behind the clavicle, an obvious shortening of the arm,
together with its direction, would plainly disclose a luxation upwards.

32. The signs discriminative of the nature of luxations of the humerus,
are not always accompanied by the same degree of certainty as those
that announce merely its existence. Thus, nothing is more difficult
than to determine when a luxation inward is primitive, and when it is
consecutive, the same phenomena being common to both. Nothing but an
exact history of the disease, stating the order in which the phenomena
have succeeded each other, can throw light on this point, which is the
more interesting and important, as, according to the one or the other
state of things, the processes of reduction ought to vary. In the first
case, the head re-enters its natural cavity by a short route; whereas,
in the second, it arrives there by a much longer one.

If, as Petit pretended, there exist luxations backward, sometimes
primitive, and sometimes consecutive, the same remark may be applied to
them with equal propriety.

33. Certain signs, common to luxations of the humerus, fractures of its
neck, and dislocations of the scapulary extremity of the clavicle,
might here create some uncertainty, if in the one, the absence of a
tumour under the arm-pit, and of a depression under the acromion,
did not prevent a mistake, which Hippocrates declared to be easily
committed, into which, according to Galen, the masters of the art of
wrestling fell, and which Pare cautions us to avoid; and if, in the
other, the appearances proper to a fracture, did not prevent a mistake
which would be serious in its consequences, and which sometimes results
from the direction of the humerus, and the kind of protuberance formed
in the arm-pit, by the end of the inferior fragment. (_See Fracture of
the neck of the humerus_).


§ V.

OF ACCIDENTS PRODUCED BY THE LUXATION.

34. Luxations of the humerus are but rarely followed by any serious
accidents. Sometimes a swelling more or less considerable appears,
immediately after the fall, in and around the arm-pit. This is the
effect of an increased irritability of the part, and is seldom of long
duration. Desault’s remedy for it was the application of compresses wet
with vegeto-mineral water, or of cataplasms moistened with the same
liquid.

35. Several authors, particularly Bell, speak (as if it were a familiar
accident) of an œdematous swelling of the whole upper extremity,
caused, in inward luxations, by a compression of the axillary glands.
This phenomenon has not often occurred in the Hotel-Dieu, except in
luxations of long standing: and when it has been met with in certain
cases, very happy effects have been produced, by the action, continued
for several days, of a roller applied with considerable tightness after
the reduction, and reaching from the fingers to the arm-pit.

CASE II. Maria ***, falling from some height, her elbow being separated
from her body and directed backwards, luxated her shoulder inwardly.
Several days elapsed before she received any surgical aid. She was
afterwards admitted into the Hotel-Dieu, where the displacement was
discovered through a very considerable swelling, which occupied the
parts around the articulation of the humerus. The reduction was
accomplished, and the swelling left to itself, which, far however from
disappearing, with the cause that produced it, seemed to gain ground.
A roller was then applied, and on the day following the tumefaction
was reduced to half its former size. The same means are continued. The
compression is gradually increased, and by the ninth day, the limb
restored to its natural form, performs, as before, all its functions.

36. There is another accident, on which authors have dwelt a little,
which was known to Avicenna, and which oftentimes fell under the notice
of Desault. I allude to a paralysis of the upper extremity, the effect
of compression made by the head of the bone, in inward luxations, on
the nerves of the brachial plexus. This accident sometimes resists
every expedient of art, as appears from the following case, collected
by myself, in the Hotel-Dieu.

CASE III. Maria Dougour, fell on her right side, and experienced
immediately all the signs of a downward luxation. A surgeon was called,
who moved the bone violently in every direction; he made no extension;
he kept the patient in torture for an hour; and at the expiration of
that time pronounced the luxation irreducible, because the head of the
bone, instead of returning into its natural cavity, had moved inwardly.
Indeed, in the midst of his unskilful efforts, a consecutive luxation
inwards had succeeded to a primitive one downwards.

On the same evening, an evident insensibility occurred in the part. A
swelling, joined to a sense of coldness, accompanied it. On the fourth
day, the paralysis was complete.

On the tenth day the patient was brought to the Hotel-Dieu, where the
processes of art which we shall presently describe, replaced the bone,
without removing the effects of its luxation.

To remedy this, irritating means were employed, simple at first, but
multiplied and combined afterwards, and pushed so far as to occasion
redness accompanied by small blisters. These were continued for three
weeks; blistering plasters were applied; all in vain; the paralysis
continued, and as long as a year afterwards the patient was still
affected with it.

37. This accident is, in general, extremely obstinate, when, as in
the preceding case, the nerves have experienced a long continued
pressure. Under such circumstances, the most powerful means are
often ineffectual. Moxa has been oftentimes used by Desault, which
he applied over the clavicle, at the very origin of the brachial
plexus. The success, with which he at first applied this remedy, did
not always accompany his use of it, so that notwithstanding several
cures performed by it, yet, to the majority of patients to whom it was
applied, it was wholly useless.

39. But, if the head of the humerus make on the nerves but a momentary
pressure, and the reduction be accomplished shortly after the paralytic
symptoms occur, oftentimes then the insensibility disappears of itself,
and the cure may be always greatly assisted by the application of
powerful stimulants; such, for instance, as volatile liniment, composed
of oil of almonds and ammonia, which Desault frequently employed, and
of which he increased the strength, so as to render it rubefacient.

CASE IV. Joanna Saq luxated her arm, by falling on her right side,
in the month of July, 1788. In the evening of the same day, all the
precursory symptoms of paralysis made their appearance. The affection
was complete on the day following.

The patient was brought to the Hotel-Dieu, where the reduction, being
accomplished, afforded no relief. On the third day, the paralysis still
continuing, the volatile liniment was directed, in the proportion at
first of two drachms of ammonia to an ounce of the oil of almonds.
This produced no effect. Being increased in strength on the fifth day,
it still appeared to be useless. On the eighth it was made of such a
degree of strength, as to occasion slight pustules over the whole of
the diseased extremity. On this, motion began to return, feeble at
first, but increasing by degrees, till by the sixteenth day, it was
as free and perfect as in a natural state. During all the time, the
liniment was applied twice a day over the arm and fore-arm, which were
at the same time subjected to strong friction during the space of half
an hour.

39. The pains which accompany luxations of the humerus, claim in
general some attention from the practitioner. These have sometimes
arisen to such a height, as to produce real disorder in the animal
economy, particularly in luxations inwardly, where, resulting, no
doubt, from the compression of the axillary nerves, they render
immediate reduction more necessary, and are generally removed by it.


§ VII.

OF THE REDUCTION.

40. We may throw into two classes the numerous means, under all their
variety of modifications, proposed for the reduction of luxations of
the humerus. The one consists in forcing, by some mechanical power,
the head of the bone into the cavity from which it had escaped,
whether extension has been previously employed or not. The other is
confined to disengaging it from the situation, into which it has been
accidentally driven, leaving to the action of the muscles the care of
its replacement.

In the first of these, art does every thing; in the second, it only
gives the proper direction to the powers of nature. These latter
give but one course or direction to the action of powers externally
applied: in the former, the head of the bone always moves in the
diagonal of two powers opposed to each other at an angle more or less
acute.

41. A history of the means destined to act in the first mode, would be
too tedious to be introduced in this place, would throw no light on
the processes about to be proposed, and are detailed at full length in
many authors, to which the reader is referred. It will be sufficient
to observe, that they all act somewhat in the following manner. Some
body, placed under the arm-pit, serves as a fulcrum, on which the arm
is made to move like a lever of the first kind, the resistance to which
is constituted by the displaced head of the humerus, while the power
is applied either at the lower part of this bone, or at the wrist. The
extremity of the humerus being directed upwards and inwards, moves its
head in the opposite directions, towards the glenoid cavity, where it
replaces it with more or less facility.

In this manner acted that machine so celebrated among the ancients
and moderns, under the name of “_Ambi Hippocratis_,” whether it was
employed in the precise form described by that prince of physicians,
or with the additions and corrections, infinitely varied, which it has
received from Paul of Egina, Ambrose Pare, Duverney, Freke, &c. By
this, a double motion is communicated to the head of the humerus, which
is, at the same time, directed, 1st, in the course above mentioned;
and, 2dly, in such a manner, as to disengage it from the unnatural
situation which it occupies.

42. Extension by the arm produces, in common, the second effect, and
this is made in different modes. Sometimes the weight of the body
on one side, and pulling by the luxated limb on the other, serve to
produce it; and such was the mode of action of the ladder, the door,
and the club, described in the treatise on fractures by Hippocrates,
and revived in many modern works. At other times, the body was
immoveably fixed, and a powerful extension made by the arm. This was
the mode in which the machines of Oribasus operated, and also one of
the methods formerly consecrated in the public places where the athletæ
held their combats.

43. On some occasions, no extension is perceptibly made, but at the
same time in which the extremity of the humerus is forced outwards by a
body placed under the arm-pit, the surgeon pushes it upwards into the
glenoid cavity: and such were the other modes of reduction practised
by the masters in the athletic art. Hence it appears, that the first
class of the numerous means, employed for the reduction of luxations,
may be divided into those which consist in impulsion, those where mere
extension is practised, and those where recourse is not had to either.
My object here is not to examine into the inconveniences attending each
of these means: a sufficient number of authors have already done this;
particularly Petit and Bell. I shall only point out the disadvantages,
which, being common to all, ought to induce them all to be excluded
from a rational mode of practice.

44. The escape of the head of the bone through the ruptured and
lacerated capsule, constitutes essentially the displacement under
consideration. But, it is never possible to ascertain with precision
the place of this rupture: how, then, can the head of the humerus be
directed towards it by an artificial force?

45. However well prepared for the purpose the body may be, which is
placed under the arm-pit, to serve as a fulcrum, always a chafing more
or less troublesome, and oftentimes distensions and serious lacerations
are the consequences of its application, when the body is suspended
on it, as in the mode by the door, the club, &c. where Petit has seen
a fracture of the neck of the humerus occur, and even a laceration,
followed by an aneurism of the axillary artery.

46. Every one has not at his command the different means above
mentioned (41 and 42), whence the difficulty of procuring them, or of
constructing them, and the loss of time, precious in relation to the
reduction, which is almost always easily accomplished in proportion to
the expedition used; these charges apply, among many other means, to
that machine so complicated, and so well known, under the name of the
mitten[15] of Petit.

    [15] (_De mouffle de Petit._)

47. Supposing the luxation to be consecutive, how can mechanical means
make the head of the bone retrace the route it has pursued in becoming
displaced? For example, if to a displacement downwards has succeeded
a displacement inwards, it will be necessary for the head to return
downwards before it can re-enter its cavity. But, can the direction
of the movements be thus varied? This whole apparatus of artificial
means, for ever contradictory, oftentimes acts in an inverse direction
to that of the muscular action, which is the essential and chief agent
in the process of reduction.

Should the luxation take place upwards, the insufficiency of these
means must be evident.

48. Perhaps, however, they may be employed with some advantage, when a
primitive luxation downwards is quite recent, and the head of the bone
is near to its cavity. In such a case the lower edge of the scapula
presents to it an inclined plane, along which it can easily glide, when
pushed by some external force. It is doubtless to this disposition
of the bone to replace itself, that we must attribute the successes,
greatly exaggerated, but in part real, on which the inventor of every
machine endeavours to found the superior merit of his mode of operating.

But, in this case, it is useless to accumulate artificial forces,
where natural ones are sufficient, and where the operator may, with
his hands, effect the reduction the more easily, as he can with more
accuracy vary the direction of his movements.

49. Thus Desault oftentimes employed a process which was attended
with great success, and which, like some of the preceding, ought to
be referred to impulsion. The patient being seated on a chair of a
moderate height, he took hold of the hand of the affected side, placed
it between his knees, and carried it downward and backward, for the
purpose of making extension, and disengaging the head of the bone;
while an assistant held the trunk with a view to counter-extension,
which was sometimes effected to a sufficient degree, by the weight of
the body and the efforts of the patient. At the same time the hands of
the surgeon, applied to the arm, in such a manner that the fingers of
each were in contact with the hollow of the arm-pit, and the thumbs
with the external part of the arm, drew upwards and a little outwards
the head of the humerus, which in common returned with ease into its
natural cavity.

50. Petit mentions this process, not such as it is here described, but
complicated with the use of a napkin passed under the arm-pit of the
patient, and round the neck of the surgeon, who, by raising his head,
drew the displaced extremity upwards. This additional mean, always
unnecessary, and not judiciously constructed, is generally ineffectual,
because, with it, the operator cannot at pleasure vary his movements.
The hands alone are always sufficient, and a vast number of examples
attest the efficacy of this method, when employed after the manner of
Desault.

CASE VI. Nicholas Juan fell on his side, his arm being separated from
his body, as he was crossing, in January 1790, the place Notre-Dame,
opposite to the Hotel-Dieu. An acute pain was immediately experienced;
a protuberance appeared suddenly under the arm-pit; and under the
acromion a depression equally sudden. He was lifted up, and carried
straight to the Hospital, where Desault was just beginning a clinical
lecture. The luxation being manifested by these appearances, was
immediately reduced by the foregoing means. A few days rest were
enjoined on the patient, but, on the same evening, he proceeded on his
way, blaming himself, for having lost half of his day’s journey.

51. In analogous cases of very recent luxations downwards, Desault
twice or three times effected the reduction by means still more simple,
as the following case, reported by Heraut, testifies.

CASE VII. Maria Louisa Favert fell, as she was descending a ladder, and
having luxated her arm, was carried at her request, immediately after
the accident, to the Hotel-Dieu. Desault perceiving the nature of the
disease, placed, under the hollow of the arm-pit, his left hand, to
serve as a fulcrum while with his right, applied on the inferior and
external part of the arm, he approximated the humerus to the trunk,
pushing it at the same time upwards. By this double movement, directed
upwards and outwards, the head of the humerus re-entered its cavity
without the least resistance. The arm was suspended in a sling for two
days, and on the fourth the patient returned to her usual labour.

52. There exists some analogy between this method and one of those
mentioned, by Hippocrates, to have been practised in ancient times, in
the public games, where the exertions of body exposed those engaged to
frequent luxations.

It is not only in luxations downwards, that the first of the simple
processes which I have mentioned (49), may be applied. Primitive
luxations inwardly, yield sometimes to its use, and the Journal of
Surgery furnishes two instances of success in similar cases; one in a
female sixty-three years of age, and the other in one of fifty-one, of
a strong constitution, and in whom the reduction was effected without
resistance.

53. But, in general, these means are ineffectual and it becomes
necessary to have recourse to extension, which, when employed alone,
forms the second class of means intended for reducing luxations of
the humerus. Many writers have adopted this exclusively, though some
practitioners, indulging their imagination in the vast field of
invention, deserted the common track, and had recourse to various
kinds of machinery. Celsus depended on extension alone, in common
cases of luxation downward and forward. Albucasis employed no other
means, Douey, Douglass, and Heister, among the moderns, reject
unconditionally the use of machines, as always useless, and often
dangerous. Finally, Dupoui and Fabre, examined and analysed with great
exactness the process of extension, and pointed out, in every case, the
means of rendering it advantageous, by managing in the best manner the
extending forces, and in the luxation of the humerus, in particular,
to prevent the inconvenience of straps placed under the arm-pit of the
patient, demonstrated the inutility of the movement commonly called
conformation. In these respects, surgery stands indebted to them for
real advancement, and their doctrine, at this day, very generally known
and received, was principally reduced to practice by Desault, who made
it the basis of his method of reduction in all fractures and luxations.

54. To proceed to the reduction of a luxation of the humerus, it is
necessary to have such a number of assistants as to be able, according
to the resistance of the parts, to increase the force intended to
overcome it. But two are commonly sufficient. They should furnish
themselves with a linen ball, thick enough to project beyond the level
of the pectoralis major and the latissimus dorsi, when placed in the
axilla, and two straps, one formed of flannel doubled several times,
four inches broad, and eight or nine feet long, the other of a napkin
regularly folded. This latter is not often absolutely necessary.

Every thing being properly arranged, the patient is seated on a
chair of a moderate height, or else laid on a table firmly fixed and
covered with a simple mattress, in order that the trunk, by being in a
horizontal position, may not prevent the motions communicated to the
arm from being directed downwards.

55. Desault continued, for a long time, to place the patient in the
first of these positions, which, though employed by practitioners
generally, is by no means the most favourable. By adopting it indeed
the arm may be very well drawn in a transverse direction; but if, as
oftentimes happens, it becomes necessary to direct extension upwards or
downwards, the assistant, then, being obliged to elevate himself, or
to stoop, cannot, in either of these attitudes, exert his strength to
advantage, but is confined and embarrassed, and cannot with ease vary,
at the pleasure of the surgeon, the direction in which the arm is drawn.

As far as relates to the patient, that situation in which the body is
only in part supported, is much more fatiguing than one where the whole
of it reposes equally on a horizontal plain. Perhaps, in relation
to the surgeon, it would be more advantageous, in enabling him to
accomplish the process of conformation[16]; but, as will be presently
observed, this process is always useless. These considerations induced
Desault, in the last years of his practice, to renounce the first
position, and have recourse only to the second.

    [16] That is, to draw, or otherwise force the head of the os
    humeri, with his hands, towards the glenoid cavity, while the
    assistants are making extension and counter-extension. In doing
    this, he must pull the head upwards, if it be lodged in the axilla,
    backward if it be under the upper part of the pectoralis major, &c.
    Desault, however, contends that this assistance from the surgeon
    is unnecessary, and that extension and counter-extension are alone
    sufficient to effect the reduction.                         TRANS.

56. The patient being properly situated, under the arm-pit of the
affected side is placed the linen ball, on which the middle of the
first strap is then applied. The two ends of this strap being now
brought obliquely upwards, before and behind the thorax, so as to meet
on the top of the sound shoulder, and being held by an assistant, serve
to fix the body, and to make counter-extension, nor does the action
of the strap bear on the edges of the pectoralis major and latissimus
dorsi, in consequence of the ball which projects beyond their edges.
Were it not for this, these muscles, being pulled upwards, would draw
in the same direction the humerus, to which they are attached, and
would thus destroy the effect of the extension, which is made in the
following manner.

57. Two assistants take hold of the fore-arm above the wrist, or else a
folded napkin is fixed on that part, having its two ends twisted around
each other. These ends, thus folded together, are given to one or two
assistants, who begin to pull in the direction of the humerus. To this
first movement, intended to disengage the head of the bone from the bed
which it occupies, another succeeds, which must vary according to the
kind of luxation. If the luxation be downwards, the surgeon gradually
approximates the arm to the trunk, at the same time that he pushes it
gently upwards. By this process, the head of the bone, being drawn from
the trunk, and brought towards the glenoid cavity, usually re-enters it
with but little resistance.

If the luxation be inwards, the extremity of the humerus, after
extension according to the direction of the bone, should be carried
upward and forward, in order that its head may be directed backwards.
Steps the very reverse of these must be pursued, if a luxation in an
outward direction is to be reduced.

58. In general, when, by the first extension, the head of the bone
is disengaged, the motion communicated to it by the subsequent ones,
ought to be in a direction precisely opposite to that which it pursued
in escaping from its cavity. But what are the variations of this
direction? Extensive experience alone can clearly determine this point.
Without experience the practitioner works in darkness. The minutiæ or
particulars of the process of reduction, being different in different
cases and according to different circumstances, can be neither
foreseen, nor taught by precept.

59. If the head of the bone experience any difficulty in re-entering
its cavity, it is necessary, when the extensions have been made, to
communicate to the bone different movements, varied according to the
different directions of displacement, and regulated by the principle
just established. Oftentimes this method effects what extensions alone
cannot; and the head of the bone, carried by these movements towards
its cavity, enters it while they are performing.

60. If the luxation be consecutive, then the first extension made in
the direction of the displaced bone, is intended to bring its head into
the place where it was primitively lodged, in order that it may be
afterwards acted on as if it were a case of primitive luxation. It is
oftentimes only at the moment of reduction, that it is practicable to
ascertain to which kind of luxation the accident belongs. Indeed, as
in most cases, the reduction takes place of itself when the extensions
are well executed, if the head be consecutively drawn inward, it is
seen to descend along the internal part of the scapula, till it arrives
near to the inferior part of that bone, and then to reascend towards
the rupture in the capsule through which it passes into its natural
situation.

61. I have said that when the extension is properly made, the reduction
takes place almost spontaneously. Indeed whatever may be the kind of
primitive luxation, it is evident, that the muscles surrounding the
articulation must be stretched on one side, while they are relaxed on
the other; whence there will necessarily arise a change both in their
contractions, and in the direction of these contractions, and such is
the nature of this change, that, in case the muscles act, instead of
bringing the head towards the rupture in the capsule, they will draw it
in another direction, and by that means produce a consecutive luxation.

62. But, if the extensions render the muscles straight, and restore
to them their primitive direction, then, obeying their natural
irritability, which is still further increased, by means of the
extension, they will draw the head to the rupture in the capsule, and
force it to re-enter it, with much more certainty than this can be done
by the efforts of the surgeon, who is always ignorant of the precise
situation of this rupture. On the other hand, if the extension be
not judiciously made how can it restore to the muscles their natural
direction? In such a case, the head of the bone will be drawn towards
some other part of the capsule than that where the rupture exists, and
hence, the difficulties that so frequently occur, in reducing luxations
of the humerus.

63. From these circumstances it follows; 1st, that the whole art in the
treatment of luxations, consists in giving to the extending powers a
proper direction; 2dly, that, in general, the process of conformation
is unnecessary and useless; 3dly, that to reduce a luxation is not to
replace the head of the bone in its cavity, by force, but to restore
the muscles to such a state, as to enable them to replace it. Here,
therefore, as in every other case, art is only the minister and
handmaid of nature.

There are instances, however, where the muscles cannot act properly
in consequence of the long standing or age of the luxation, and in
consequence of adhesions, more or less strong, having taken place
between the surrounding parts. In such cases it is necessary to employ
proper measures to force the head of the bone into its cavity, as it
cannot be carried thither by the muscles.

64. Reason concurs with experience, which is on all subjects the best
authority, in establishing the truth of this doctrine, respecting the
reduction of luxations of the humerus. In this operation, Desault
employed, in general, nothing but extensions, varied according to
circumstances, until the muscles thrown into a favourable state, were
themselves enabled to accomplish the reduction. The most immediate
success constantly crowned his practice on this point. This success
was, no doubt, owing to his judiciously remaining inactive himself, and
suffering the muscles to do the work, after the necessary extensions
had been made.

65. When the reduction is accomplished, if the arm, in consequence
of being very moveable, appears likely to be displaced again, it is
necessary, for a few days, to fix it in such a manner as to prevent
all motion; an object which may be effectually attained by Desault’s
bandage for fractures of the clavicle.

All writers recommend, for this purpose, the use of the _Spica_
bandage.[17] But what service can this render? It does not restrain
the motions of the humerus, which, hanging down the side, may move
forward, backward, &c. and produce a new displacement; an accident that
may be always prevented by the bandage proposed.

    [17] With the particular mechanism and mode of action of this
    bandage, I am unacquainted. Nor are these matters of much moment,
    as the bandage is, I believe, entirely out of use.        TRANS.


§ VIII.

OF CIRCUMSTANCES RENDERING REDUCTION DIFFICULT.

66. I will close this memoir by an examination into some circumstances,
which may either prevent reduction or render it difficult, and into
certain accidents that sometimes accompany it.

I have said that, on some occasions, the rupture of the capsule, being
too narrow to admit the head of the humerus to repass it, and return to
its cavity, constitutes one of the principal obstacles to a reduction
(24). To enlarge this passage, by further lacerating its edges, is
evidently the indication that here presents itself. This is fulfilled
by communicating to the bone great motion, either by circumduction, or
rotation on its own axis, forcing it suddenly in different directions,
particularly in that direction in which the luxation has been produced.
Its superior extremity must be, at the same time, pushed forcibly
against the ruptured capsule, which, by being thus pressed between two
resisting bodies, will suffer a more extensive rupture. Reduction,
oftentimes impracticable previously to these violent and varied
motions, takes place of itself as soon as they have been properly made.
Of this the practice of Desault furnishes many examples.

CASE VIII. In the Journal of Surgery are recorded two cases, one by
Anthaume, the other by Faucheron, which establish this doctrine.

John Seligni, a robust man, forty-four years of age, fell on the
point of his shoulder, on the 19th of July 1791; the pain, which was
increased by moving his arm, and the swelling which supervened almost
immediately, induced him to enter the Hotel-Dieu. The efforts of
assistants were at first insufficient, and it was not till after a
uniform extension continued for several minutes, that the head of the
humerus was drawn by the muscles against the glenoid cavity. The bone
appeared to enter the cavity, although the persons present did not hear
the collision or clashing of the articulating surfaces, which is almost
always perceived in cases of recent luxation: but immediately the
humerus was again displaced, without its being practicable to retain
it. On the occurrence of this phenomenon, Desault conceived that the
head of the bone had pushed before it the capsular ligament, through
which it could not pass, in consequence of the narrowness of the
opening which had been made at the time of the luxation. He proceeded
to move the arm forcibly in every direction, in order to enlarge the
opening, and immediately felt a kind of laceration, which satisfied
him that his views were accomplished. He then re-commenced extension,
which it was again necessary to continue, as at first, for some time,
in order to overcome the resistance of the muscles. The reduction was
attended with no further difficulty. The humerus continued still to
have a great tendency to be displaced, and it was necessary to employ,
for several days, a bandage similar to that for a fractured clavicle.

CASE IX. Maria Laurencier, aged sixty, fell on her right elbow, and
luxated the humerus of the same side. Eight hours afterwards she
came to the Hotel-Dieu, on the eighth of March, 1789. The reduction
was attempted in the usual manner; but, although the extensions were
properly directed, and the head of the humerus brought against the
glenoid cavity, it was still displaced again as soon as the limb was
let go, a circumstance which created a suspicion, that the opening of
the capsule was too narrow to allow the head of the bone to pass. The
assistants ceased making extension, and Desault, taking hold of the
lower extremity of the arm, impressed on it great motion, particularly
in the direction of the luxation, for the purpose of enlarging the
laceration of the capsule. The extensions were now renewed, and the
reduction succeeded with great ease.

67. A second obstacle, more difficult to be surmounted in the process
of reduction, is that arising from the long continuance of the
luxation. The head of the bone, having continued for a long time in the
bed into which it has been accidentally thrown, forms adhesions to it;
the surrounding cellular membrane becomes thickened, and makes, so to
speak, a new capsule for the head, which opposes its replacement, and,
when the reduction cannot be accomplished, supplies in some measure
the office of the old joint, by the movements which it allows to take
place.

Most writers, and Bell in particular, advise, in such a case, never to
attempt a reduction, which, being of no avail as to the luxation, might
prove dangerous to the patient, in consequence of the violence it would
do to the parts. This doctrine was for a time, the doctrine of Desault:
but experience, in his latter years, led him to a bolder practice.

68. The complete success which he experienced in luxations of fifteen
or twenty day’s standing, encouraged him to make the attempt, at
the end of thirty and thirty-five days, and we have, three or four
times, during the two last years of his life, seen him successful in
replacing, after the expiration of two and a half, and even three
months, the head of the bone which had escaped, both through the
inferior, and the internal side of the capsule.

However powerful, and however long continued the extensions were, none
of those terrible accidents occurred, with which we are threatened by
authors. Twice only did a phenomenon occur, which it was difficult to
foresee, and of which I will presently speak.

69. In cases of this kind, it is necessary, previously to making
extension, to move the bone very forcibly in every direction, in order
first to break the adhesions, to tear the condensed cellular membrane,
which serves as an accidental capsule, and to produce, so to speak, a
second luxation, with a view to make way for a perfect reduction of the
first. The straps being then applied, as in ordinary cases, serve the
purpose of extension, for the accomplishment of which the number of
assistants must be increased.

70. Oftentimes the first efforts are fruitless, and the luxated head
remains stationary, amidst the most violent efforts. Let the extensions
then be discontinued: renew the forcible motions of the limb: carry
the humerus upwards, downwards, forward, and backward: force the
resistances to give way; make the arm describe a large arch of a circle
round the place which it occupies; let the rotatory motions on its
own axis be impressed on it anew; and then recommence the extensions,
and let them be made in every direction. By these, the head, already
disengaged by means of preceding violent motions, will be brought to a
level with the glenoid cavity, and ultimately replaced.

It may not be improper to confirm by experience the truth of these
precepts, which might to some appear rash, in consequence of the
changes that seem likely to occur in the glenoid cavity, during the
absence of the head of the humerus. I will relate, among others, a case
reported by Giraud, second surgeon to the Hotel-Dieu.

CASE X. Maria Gauthier, thirty-four years of age, entered the
Hotel-Dieu, on the twentieth of June, 1790, to be cured of a luxation
of three months standing, produced originally by a fall on the arm,
which was separated, at the time, from the body and carried backward.
Different surgeons had, at different times, attempted the reduction,
but always without effect, and when every hope of a cure appeared to
have expired, Desault, imboldened by reiterated success, tried whether
or not he would be equally fortunate in this case.

The patient being placed in a horizontal position, as already directed
(55), great motions were first impressed on the limb: extensions were
then commenced, first in the direction of the luxation, and afterwards
forward and backward. Vain efforts; the head remains immoveable;
new motions are again made in every direction, and afterwards, the
extensions are renewed: the same want of success. The patient being
fatigued, the reduction was deferred till the day following, when the
same trials were, after a short time, attended with complete success.
The head being at first disengaged, and afterwards drawn slowly along
the track through which it had passed in becoming displaced, at
length re-entered the capsule. The arm, being supported by the usual
apparatus, soon became œdematous, and, notwithstanding the remedies
common in such cases, the swelling continued for two months. The
motions performed by the limb in the mean time, restored to it, by
degrees, its usual suppleness; and, on the sixty-eighth day after her
entrance, the patient was discharged cured.

To this case, I might subjoin many others, and, in particular, that
of John Putot, also reported by Giraud, and in which the means just
described (69 and 70), succeeded in the reduction of a luxation at the
expiration of the fourth month. But too great an accumulation of facts
distract the attention, and add nothing to conviction, especially when
they are already so plain as those just related.

71. But further, in cases of this kind, where a very old luxation
presents great obstacles to reduction, although the attempts made
to reduce it, do not actually force the head of the bone into the
capsule, still they may not prove entirely useless. By bringing the
head nearer to the glenoid cavity, or placing it even on that cavity,
and making it form new adhesions there, after having destroyed its old
ones, the motions of the limb will be facilitated. For, in cases, where
the luxation is not fairly reduced, these motions will be always less
impeded, in proportion as the head of the bone occupies a place less
remote from its natural situation.

72. A third obstacle, common to the reduction, of every kind of
luxation, is the muscular force, increased by the irritation of the
displaced bone, beyond its natural degree. So great, at times, is
this force, that the head of the bone cannot be moved, even by the
strongest efforts. What means should then be employed? 1st, Those
which diminish general irritability, such as blood-letting, bathing,
a relaxing regimen, &c. 2dly, Those which act locally, in diminishing
the irritability of the muscles of the shoulder. For example: the
application of emollient cataplasms or fomentations to the part; or,
what is still better, a powerful extension, continued for some time. In
consequence of such extension, the muscles of the part become fatigued,
whence their contractions are succeeded by a state of atony, of which
advantage may be taken to replace the bone. Frequently this extension
ought to be continued for a very long time; and we have known Desault
not to complete the reduction in less than half a day, or even a whole
day, the limb being suffered to remain all that time in the apparatus
for fractures of the clavicle, which draws the shoulder and muscles
outwards. Thus, in fractures of the thigh, where muscular contraction
prevents the contact of the fragments, permanent extension previously
employed, assists in producing this contact.


§ IX.

OF ACCIDENTS CONSEQUENT TO REDUCTION.

73. It is rare that any serious accident follows the reduction of a
luxation of the humerus. A swelling, more or less extensive, sometimes
shows itself around the joint, particularly when extension has been
forcible and long continued; but this, being, in general, easily
removed, by means of discutients, does not demand particular attention.

74. Another accident which rarely occurs in practice, respecting which
but little is to be found in surgical writings, and with which Desault
occasionally met, is, a considerable emphysema, suddenly appearing
at the time of reduction. In the midst of those powerful extensions,
rendered necessary by the ancient state of the luxation, a tumour
suddenly appears under the pectoralis major. By a rapid increase it
extends itself towards the hollow of the arm-pit, the whole of which it
soon occupies. It then propagates itself in a backward direction, and,
in the space of a few minutes, its bulk is sometimes equal to that of
the head of an infant. A practitioner, if unacquainted with the nature
of this accident, might take it for an aneurism, produced by a sudden
rupture of the axillary artery, in consequence of the violence done to
that vessel by the extensions of the limb. But, if attention be paid to
the resistance of the tumour, to its want of pulsation, to the place of
its first appearance, (which is usually under the pectoralis major, and
not under the hollow of the arm-pit, to which it only propagates itself
afterwards, as Desault has observed in similar cases that fell under
his notice), to the action of the pulse still continuing, unless the
patient should faint from debility, as happened to the subject of the
following case, which we had occasion to witness at the amphitheatre,
sometime previous to the death of Desault, and to the colour of the
skin which suffers no change; if these circumstances be attended to,
it will be difficult not to distinguish one of these accidents from
the other. In that now under consideration, discutients applied to the
tumour, such, for example, as vegeto-mineral water, and a gentle and
regular compression made by the bandage intended to support the arm
after reduction, are the most efficacious means that art can employ.

CASE XI. Simon Cerisiat, sixty years of age, presented himself on the
nineteenth of December, 1794, as the subject of a public consultation,
which, every day preceded the clinical lecture of Desault, to receive
advice for a luxation inwards, which he had suffered a month and a half
before, and for the reduction of which no attempt had been yet made.

Convinced, by the example of luxations more ancient, of the
practicability of reducing this, Desault undertook it immediately in
the presence of his pupils.

The patient being laid on a table, firmly fixed and covered with a
mattress, great motions were impressed on the luxated limb upward,
forward, and outward, with a view to destroy the adhesions contracted
with the surrounding parts. Extensions were then made in the manner
already mentioned (66 and 67).

Nothing was gained by the first attempt, the head remaining immoveable,
in the midst of the efforts to displace it. Further motions were made
in every direction, to break if possible, the attachments which held
it; and these were followed by further extensions.

While these were making in a forcible manner, the head was perceived
to approach by degrees towards the glenoid cavity, near to the edge
of which it reached in two minutes, and was at length replaced, by a
sudden movement of the limb from behind forward.

Scarcely was the reduction accomplished, when a tumour rose suddenly
under the pectoralis major, propagated itself towards the arm-pit, and
occupied immediately its whole extent.

All the assistants, astonished at the phenomenon, knew not to what
circumstance to attribute it. Desault himself, a little embarrassed,
thought first of an aneurism suddenly produced by the violence of the
extension. The pulse of the patient, being scarcely perceptible in the
side affected, and a syncope which supervened, appeared at first to
favour this suspicion: but immediately the absence of a fluctuation, of
a pulsation, and of a change in the colour of the skin, the return of
the pulse, the circumscription of the tumour, its resistance, and the
sound caused by striking on it, produced a belief that it was owing,
not to an effusion of blood, but to a disengagement of air that had
been confined in the now lacerated cells of the cellular membrane.

Over the whole of the swelling were applied compresses wet with
vegeto-mineral water, while a regular compression was made on it by
means of a bandage, which, at the same time, kept the arm fixed against
the trunk.

In the night there occurred severe pains around the articulation
and the tumour, accompanied with high fever, both which symptoms
disappeared on the following day. Third day, a diminution of the
emphysematous swelling; and an entire cessation of fever and pain.
Eighth day, tumour reduced to half its original size; the arm made to
perform gentle motions, and disengaged from the apparatus; discutients
continued. Thirteenth day, tumour entirely gone. In the place which
it had occupied a large echymosis appeared, produced no doubt, by a
rupture of the small vessels at the time of reduction, but which,
till now, had not been perceptible externally, in consequence of the
emphysematous swelling of the parts, and which was treated by the same
means as the emphysema. Seventeenth day, a yellow tinge, mixed with
the colour of the echymosis, an evidence of its resolution, which was
complete by the twenty-seventh day.

During all this time, the patient had accustomed his limb to constant
motion; a facility in the movement of it had thereby returned; and he
was perfectly well when he left the Hotel-Dieu, on the thirtieth day
from the time of his admission, and the sixty-fifth from the occurrence
of the accident.




MEMOIR VIII.

ON THE FRACTURE OF THE BONES OF THE FORE-ARM.


§ I.

1. The fore-arm, composed of two bones, neither of them very strong,
and covered below by a small quantity of soft parts, is exposed
still more than the humerus, to the action of external bodies, and
is articulated at the upper end in such a manner, as not to yield,
like it, in every direction to the impulses which it receives. From
these considerations, it is one of those parts where fractures most
frequently occur, and, in a comparative view of affections of this kind
in the Hotel-Dieu, it has oftentimes held the first place.

2. It would be useless to mention here the disposition of the bones
which compose the fore-arm, their irregularly prismatical form, their
thickness unequally distributed, their direction obviously different,
and their motions differently combined. It is sufficient to observe,
that, for the perfection of one part of these motions, a space, wide in
the middle, and narrow at the ends, must separate the two bones, that,
without this space the radius, impeded in its movements on the cubitus,
would compress the muscles, restrain their action, and would be
unable to perform the motions of pronation and supination; whence the
fore-arm, being confined, as it were, to mere flexion and extension,
would not, in its uses, correspond to our wants.

These things being premised, we will observe, that fractures of the
fore-arm may have their seat, 1st, in both bones at the same time;
2dly, they may occupy but one of them: hence three kinds of fractures
more or less different in their phenomena, their consequences, and
their treatment.


FRACTURE OF THE FORE-ARM.


§ II.

OF THE VARIETIES AND THE CAUSES.

3. Fractures of both bones of the fore-arm, may occur either at the
ends, or in the middle of the limb. Frequent in the middle, and
somewhat common below, they seldom occur in its upper part, where the
fleshy portions of numerous muscles, combined with a considerable
thickness of the ulna, resist the motions which tend to produce
them. The two bones, though most commonly broken on the same line,
are, however, sometimes broken on different ones. The fracture is
almost always single: at times, however, it is double, and Desault,
in particular, was once called to a patient, over whose fore-arm the
wheels of a carriage had passed, and had broken it both in the middle
and at the lower end, so that it evidently exhibited six fragments
distinct from each other. The two middle ones, though completely
insulated, united again to the others with but very little deformity.
Like all other similar affections, these may be rendered compound by
wounds, splinters, &c. circumstances which, as they fall within the
general class of such injuries, will not be treated of at present.

14. They occur, in general, in two ways, being the result, sometimes
of the action of external bodies, immediately applied, and at other
times of the same action, operating by way of a counter-stroke. The
occasional percussion of a body on the fore-arm, furnishes an example
of the first mode of fracture. This is much more frequent, in general,
than the other, which usually arises from a fall on the wrist; but, in
such a case, as it is the large lower end of the radius that forms the
principal point of articulation with the hand, that bone alone sustains
almost all the force of the stroke, and is very generally the exclusive
seat of the fracture.


§ III.

OF THE SIGNS OR APPEARANCES.

It is in general difficult to be mistaken with respect to the signs
which characterize fractures of the fore-arm. A mobility of the limb
where it was before inflexible; a crepitation almost always easily
perceived; a depression, sometimes evident, at the place of division;
a protuberance sometimes formed under the skin by the fragments; pain
produced by the motion of the part; a crack sometimes heard by the
patient, at the moment of the accident; an inability to perform the
motions of pronation and supination; the almost constant semi-flexion
of the fore-arm; such, together with the phenomena common to all
fractures, are those which essentially characterize this, and which
must generally remove all doubts which the swelling of the limb may
temporarily create respecting its existence.

6. There is a circumstance, however, where a fracture near to the
joint of the wrist, may give rise to appearances similar to a
luxation of that part. In both cases, indeed, a convexity behind,
and a depression before, or the reverse, are perceived, and are the
effect of a displacement of the fragments. But the styloid apophysis
being carefully examined, will always determine, according as it is
found above or below the deformity, from which of the two causes the
deformity arises. Besides, a greater mobility in one than in the other
affection, and a crepitation, will guard the practitioner from an
error, into which I saw a surgeon fall in the presence of Desault, whom
he called on to consult, in the case of a child six years old, which
laboured under a supposed luxation.


§ IV.

OF DISPLACEMENT.

7. Most of the phenomena which accompany fractures of the fore-arm
(5), are evidently the result of a displacement of the fragments; a
displacement, not, in general, very perceptible in the longitudinal
direction of the bones, because the muscular action, tending to produce
it in that direction, is not very powerful. When it does occur in this
way, it is most frequently the immediate effect of the stroke that
produced the fracture.

8. But it is different with respect to a displacement in the cross
direction of the bone. Here the cause of the separation of the broken
ends, may be the same with the cause of their fracture, as happens in
the passage of a carriage wheel over the limb, or in the falling of
some body against it; and then, 1st, the fragments are separated from
before backward, or contrarywise, and hence, a protuberance on the one
side of the limb, and a depression on the other; 2dly, or else they
are pressed against each other laterally from without inwards. From
this latter cause arises that inequality which the limb exhibits at the
place of the fracture; the slight depression which it manifests on its
sides; and the protrusion or bulging out of its anterior and posterior
surfaces, by means of the mass of muscles which are pushed in these
directions, by the approximation of the fragments to each other.

9. A proper reduction removes the first kind of displacement, namely,
that which occurs in the cross direction of the bone backward or
forward (8); and unless an external force be applied anew, it does
not again return. On the contrary, how exact soever the reduction may
be, in the second kind, namely, that which takes place laterally from
without inwards, the fragments are soon found to have approached each
other again. Above, the pronator teres presses the superior fragment
of the radius against that of the ulna; below, the two fractured
extremities are pressed against each other, by the contractions of the
pronator quadratus. From this double cause arises, unless something
prevent it, the contact of the four fractured ends, which have been
sometimes found united together by a common callus, as is proven by
several cases sent to Desault, and by the cases of different patients
admitted into the Hotel-Dieu, after having undergone an improper
treatment. In such cases, the movements of pronation and supination
being entirely destroyed, are but imperfectly supplied, as Duverney
remarks, by those of a rotation of the arm.

But if the four broken ends should not even be joined together by
a common callus, still the space between the bones being evidently
diminished, impedes muscular action and the motions of the limb
depending thereon.


§ V.

OF THE REDUCTION.

10. It follows from what has been said on the displacement of the
fragments (8), and on the causes which have a constant tendency to
re-produce this displacement (9), that the extending forces, intended
to remove it, should be, in general, less powerful than in most other
fractures, because their principal object is, to restore to the limb
its natural length, which is here but very little affected.

11. Previously to the application of these, it is necessary, according
to the precept of Hippocrates, to place the fore-arm in a middle state
between pronation and supination, flexion and extension. This position
is highly favourable to the relaxation of the muscles, and is that,
above all others, as the father of medicine observes, which those who
have sustained a fracture naturally assume, and which alone they can,
for a long time, retain, without experiencing any inconvenience.

12. The fore-arm being thus placed, an assistant makes extension, by
taking hold of the four fingers; a mode to be adopted in preference
to that of Petit, who directs us to make extension at the wrist; for
the real momentum or force of a power is in the inverse ratio of its
distance from the place of resistance. At the same time, another
assistant makes counter-extension on the humerus, which he grasps with
both his hands, in such a manner, that his thumbs correspond to the
back part of it, while his fingers cross each other anteriorly.

13. It further follows, from what was said (8 and 9), that the process
of conformation, so often useless and even injurious, in other
fractures of bones, is necessary here, to restore to the fragments that
exact contact which they have lost, in a transverse direction. If the
displacement be forward, the surgeon pushes both fragments backward,
while the assistants maintain the extension. If the bones project
backwards, they must be pushed in the contrary direction. As to a
lateral displacement (8) in which the broken ends approach each other,
it is not altogether useless, as Petit observes, to endeavour to remove
it, by forcing the muscles into the space between the bones. This
is done by making a moderate pressure on the anterior and posterior
surfaces of the fore-arm, in order that the bones, being thus removed
from each other, may come in contact with their broken ends. If this be
done, when the apparatus is first applied, the reduction is attended
with but little difficulty, and the ends of the fragments are easily
retained in apposition.


§ VI.

OF THE MEANS OF MAINTAINING THE REDUCTION.

14. Our forms of apparatus are nothing but means of continuing, for
a long time, that state of things, which extension and the process
of conformation temporarily produce at the time of reduction. This
principle, though generally acknowledged, was particularly neglected
in such fractures, as that now under consideration, till the time of
Petit, who made it the basis of his practice. Before him, there was
a common inconvenience attached to every kind of bandage. The two
bones being pressed against each other, by circular rollers applied
externally, were thus drawn in that very direction, in which the action
of the pronator muscles already tended to displace them; because, the
form of the fore-arm being irregular, made these rollers act more
powerfully on its lateral parts, where it is very convex, than either
behind or before, where it is very flat. It is well known that bandages
will make the greatest pressure on the most projecting parts of the
limbs round which they are applied; so that, if the fore-arm be bound
or pressed on behind and before with a force equal to one, it will
sustain laterally, that is, on its sides or edges, a pressure equal to
two. Hence results, not only a tendency in the radius to approach the
ulna, but also, a want of resistance in the muscles situated on the
posterior and anterior sides of the fore-arm. For these muscles being,
from their flatness, less compressed than the bones, give way, and do
not, by forcing themselves between them, oppose the approach of the
bones to each other.

15. Such was the disadvantage of the apparatus of Hippocrates,
consisting of one roller applied immediately on the skin, of a
many-tailed bandage intended to retain this, and of four splints,
applied on the seventh day, and secured by another roller. Such
was also the inconvenience of several bandages, proposed after the
time of Hippocrates, by different authors, who modified his without
improving it, and who, in attempting to alter it, even added to its
imperfections. Thus, the compresses with which the limb was first
covered, previously to the application of the rollers, served only,
by becoming wrinkled, to render the compression unequal, fatiguing,
and even painful to the patient. In like manner the pasteboard, which
many authors, particularly Duverney, have substituted for splints,
and which a majority of practitioners employ, even at the present
day, soon becoming softened by moisture, bends without resistance,
becomes incapable of preventing a displacement, and has at least the
inconvenience of being useless.[18]

    [18] On this point Desault is certainly mistaken. Paste-board, when
    of a proper thickness and well applied, makes an excellent splint
    for fractures of the fore-arm. It moulds itself to the form of the
    arm, sits easy, and retains the fracture extremely well.    TRANS.

16. Is it to be wondered at then that a perfect cure of fractures of
the fore-arm has been regarded as a thing of so much difficulty, and
that most authors should have advised practitioners, as a thing of
prudence, to warn the patient of its being impracticable to cure him,
without the loss of the motions of pronation and supination? Thus, in
like manner, it was formerly declared, that a constant deformity was
the necessary consequence of fractures of the clavicle.

17. Petit first conceived, that he discovered, in the very means
destined to prevent the displacement, the cause of its being continued,
and that, in order to be effective, the bandage ought to do constantly
what the hands of the surgeon do at the time of reduction (13); that
is, it ought to oppose to the unremitting action of the pronators,
a resistance equally unremitting, by pressing the muscles into the
interstice between the bones. But, after having discovered the end to
be attained, he accomplished it only in an imperfect manner. For by
first applying a roller immediately round the fore-arm, he reproduced,
in part, the very inconveniences and disadvantages he wished to
prevent, by placing anteriorly and posteriorly two long and thick
graduated compresses, intended to keep the bones asunder, by forcing
the muscles between them.

18. Duverney, more judicious, proposed to place the graduated
compresses of Petit on two circular compresses, previously applied
round the fore-arm. But what availed these circular compresses? If
they be drawn tight, will they not produce that approximation of the
bones which the surgeon wishes to avoid? And if they be not tight, they
will, in consequence of their loose and pliable state, form troublesome
and inconvenient wrinkles, without being productive of any good to
counterbalance this inconvenience.

19. It was from these different considerations, that Desault modified,
as I am about to mention, the apparatus for fractures of the fore-arm.
To a great degree of simplicity, this apparatus unites, when thus
improved, great ease to the patient, and its advantages are proven by
the freedom in the different movements of the arm always experienced
by the numerous patients, whom he was called to attend. The pieces of
the apparatus are, 1st, Two graduated compresses, one of them of such
a length as to extend from the elbow to the wrist, and the other from
the wrist to the fold of the arm on the inside. They are to be formed
each of a single piece of linen, folded seven or eight times on itself,
in such a manner, that the lower fold may be an inch wide, while the
others, laid on top of each other, gradually diminish in width to the
last. The thickness of these compresses ought to be less in very fat
persons, where the anterior and posterior surfaces of the arm are more
convex. 2dly, A roller about four yards and a half long, and four
inches wide. 3dly, Four thin but stiff wooden splints, long enough to
reach, one, from the fold of the arm to the wrist, the second, from the
interval or hollow space between the olecranon and the condyl to the
same part, the third from the internal condyl of the humerus to the
styloid process of the ulna, and the fourth from the eternal condyl to
the styloid apophysis of the radius. The breadth of the two first ought
to be double that of the other two, as the latter occupy a space of but
half the width of that occupied by the former.

20. Every thing being arranged, the reduction is to be executed as
already directed (11–13); and while the extensions are still continued,
the surgeon wets with vegeto-mineral water, or some other discutient
liquid, the graduated compresses, and places them on the anterior and
posterior part of the fore-arm, (which must be firmly supported in a
state between that of pronation and supination, 11), in such a manner,
that their broadest part or base may be in immediate contact with the
limb. He then secures them with a roller wet with the same liquid,
the casts of which, being first fixed at the place of the fracture,
descend obliquely to the wrist, and are secured at the hand by being
passed between the thumb and the fore-finger. Running across the back
of the hand, the roller then reascends, either by oblique or reverse
turns, according to the inequalities of the fore-arm, till it reaches
the elbow. Here the surgeon relinquishes the roller, giving it into the
hand of an assistant, and places the four splints on the parts already
mentioned (19), while the hands of a second assistant secures them, by
grasping them all at their lower end, next to the wrist. The surgeon
then resumes the roller, and, in order to fix the splints immoveably,
descends with it along the fore-arm by circular casts, till he reaches
the hand, where he finishes.

There is, in the application of this bandage, an essential precaution
to be observed; which is, that as each turn of the roller passes
over the graduated compresses, the surgeon ought to press on these
compresses with the thumb and fore-finger of his left hand, in order
that the muscles, by being forced into the interstice between the
radius and ulna may prevent their approximation, which would produce an
inequality in the compression made by the apparatus.

21. After the application of the apparatus, if the patient be obliged
to keep his bed, the fore-arm is to be extended on a pillow, taking
care to keep it always half-bent, and guarded by hoops from the weight
of the bed-clothes. But if the fracture be not a compound one, and if
the fall has done no injury to the system in general, it is unnecessary
to confine the patient to a position wearisome, and oftentimes
insupportable to many persons. Then the limb is to be suspended in
a sling, which is always sufficient to support it, without having
recourse to the kind of hollow case recommended by Bell, which is
seldom at hand, and the use of which must be extremely inconvenient.

22. The subsequent treatment to be adopted in such fractures is
simple and easy: to wet the apparatus daily, for a few days, with
vegeto-mineral water, to obviate, by proper means, the accidents that
may occur; to renew the application of the roller at the end of eight
days, or perhaps later, according to the degree of its relaxation; to
repeat this application two or three times during the course of the
treatment; to allow, at first, but light diet, which may be afterwards
more solid, and given in larger quantity, and to admit finally of a
return to the patient’s usual mode of living: such was, in cases of
fracture, the practice of Desault, which was always attended with happy
effects.

23. Sometimes a considerable swelling occurs, after the application of
the bandage, on the back and face of the hand; small blisters appear
between the fingers; the patient experiences sharp pains along the
fore-arm; and other small blisters rise on its surface. It is then
necessary to remove the apparatus, to open the blisters by pricking the
cuticle, and dress the part with cerate spread on linen rags; replace
the apparatus, making it less tight than before, taking care to renew
it every day, till the excoriation be entirely gone. This accident, of
no great consequence in itself, has frequently occurred to Desault,
although the rollers were applied at first with but a moderate degree
of tightness.

24. The consolidation being completed generally in twenty-four or
twenty-five days, leaves, at this time, a little stiffness in the
joints, in consequence of their having remained so long without
motion: the movements of pronation and supination are performed but
imperfectly. Their return is facilitated and hastened by frequent
exercise of the limb, as well at its junction with the os humeri, as in
its own proper joints; and, in general, by the fifteenth or twentieth
day from the removal of the apparatus, things are in the same state in
which they stood before the fracture.


FRACTURE OF THE RADIUS.


§ VII.

OF THE CAUSES AND THE DISPLACEMENT.

25. The radius, which is the moveable and almost the only support or
abutment of the hand, receives, in falls on that part, a much greater
share of the shock than the ulna, which is joined to the hand by only
a small surface. Hence, without doubt, arises the greater frequency of
the fractures of the radius; fractures which, when produced by falls on
the hand, are evidently the result of a counter-stroke. Oftentimes also
this bone is broken by the immediate action of external bodies, because
it is defended below with but a thin covering of muscles.

In whatever way the fracture may be produced, it occurs in the middle
or at the extremities of the bone; very rare near its articulation
with the os humeri, it is more common in its middle; but more frequent
still at its lower end. The difference arises probably from this
circumstance, that, in falls on the wrist or hand, the shock is
weakened and lost in proportion as it is propagated upwards.

26. In such fractures, displacement is almost constantly observable
in the thickness or cross direction of the bone and fore-arm, and is
produced by the action of the pronator muscles, which, by forcing
the fragments of the radius towards the ulna, tend to diminish the
interval between the bones. The ulna remaining unbroken, always
prevents any displacement in a longitudinal direction. The first
kind of displacement is the more perceptible, in proportion as the
fracture is nearer to the middle part of the radius, where the bones
are at the greatest distance from each other. This displacement is
seldom outwards, because the interosseous ligament prevents that: yet
experience furnishes some exceptions to this rule.

CASE I. Desault was called, in the month of July, 1781, to visit a
mason, who, sleeping at the foot of a wall, with his fore-arm stretched
out, received on the anterior part of it, a round stone, of the size
of a bowl, which, falling from a scaffold, fractured the radius in its
middle, and produced a large contusion, accompanied by an enormous
swelling, to which the usual discutient remedies were applied. On
the fifth day the swelling had in part disappeared; but then there
was discovered a very evident protuberance of the inferior fragment,
which, by pointing outwards, separated itself from the superior one,
which remained nearly in its place. The interval between the bones was
evidently increased below.

The fracture was reduced by pressing the lower fragment inwards, and,
instead of employing graduated compresses the whole length of the limb,
they reached only to its middle, along the part corresponding to the
superior fragment. The roller was drawn a little tighter below than
above, in order to keep the inferior part of the radius near to the
ulna.

By being treated afterwards in the usual mode, the fracture was cured.
But, in consequence of being over-stretched by the separation of
the bones, the ligaments of the wrist became the seat of a tedious
lymphatic swelling, which left behind it some degree of stiffness.

27. Examples of this kind occur too rarely to affect the general law
relative to the direction of the displacement of a fractured radius, a
displacement which, if not properly treated, makes the fragments unite
in such a manner as to form an angle pointing inwardly towards the
ulna, as is evinced by a perceptible depression under the cuticle. In
such a case, from this contraction or narrowing of the interval between
the bones, arise the inconveniencies already mentioned (9).


§ VIII.

OF THE SIGNS.

28. The diagnosis of fractures of the radius is in general easy, when
they occur at the lower end, or in the middle (25). In these two
cases, a depression more or less perceptible, on the external side
of the fore-arm; an inability to perform pronation or supination,
by the action of the muscles alone; and a severe pain, necessarily
resulting from moving the bone in this two-fold direction. Such are the
particular signs or appearances which first disclose the existence and
the place of the fracture. The reality of the accident is afterwards
more fully confirmed by the signs common to all fractures, namely, the
flexibility of the bone, the crepitation perceived by moving it in
different directions, &c.

29. Desault cautioned his pupils not to confound this last sign or
symptom with a kind of noise, sometimes heard in the sheaths of the
tendons of the extensor longus, extensor brevis, and abductor longus; a
noise resulting from a filtration of synovial fluid into the sheaths,
or produced by some other cause. But, besides this crepitus in the
sheaths being a very rare occurrence, it is always easy to distinguish
it from a crepitation of the bone, by this circumstance, that the first
is heard on merely pressing the parts, but the latter only by making
the bony surfaces rub against each other. Besides, by an experienced
ear there is no danger of any mistake being committed.

30. If the fracture exist at the upper end, the thick muscular covering
which there surrounds the radius, renders the diagnosis more difficult.
Petit has, however, thrown some light on the subject, by judiciously
advising to place one hand on the upper extremity of the radius, and
with the other to make the fore-arm rotate on this bone. The solution
of continuity or fracture will be rendered evident, if, in the midst
of these motions, the head remain stationary. But if, on the other
hand, it rotate, it has sustained no injury. These two circumstances
can be easily explained; but, it is not so easy for the practitioner to
avail himself of them in every case. This precept may also be applied
in cases where a considerable swelling, occupying the whole fore-arm,
conceals from the touch of the surgeon the fragments of the bone, even
when broken in the middle.


§ IX.

OF THE REDUCTION, AND THE MEANS OF MAINTAINING IT.

31. The reduction of a fracture of the radius is effected in nearly
the manner already described for that of the two bones of the fore-arm
(10–13), except that, here, the extension must be less, because there
exists no displacement in a longitudinal direction (26).

To remove that which exists in a cross direction, an assistant whose
business it is to make extension, places the hand in a state of
adduction, for the purpose of removing the inferior fragment outwards.
This precept cannot be applied to much advantage, if the division exist
towards the upper end, on account of the interosseous ligament.

At the same time the surgeon endeavours to bring the ends of the bone
into perfect contact, by pushing them in a direction opposite to that
of their displacement; and when he has attained this end, he begins
the application of a bandage or apparatus the same as that already
described (19 and 20), with this difference, that as the ulna is here
sound, and performs, in relation to the fractured radius, the office of
a natural splint, it is unnecessary to place an artificial one between
the internal condyl of the humerus, and the styloid apophysis of the
ulna.

32. The consolidation or cure is here always more speedy than in the
preceding cases, where nature, with the same amount of means and
resources, has twice the quantum of labour to perform, and where she
supplies her deficiency of power, by the greater length of the time
which she employs. In general the bone is united by the twentieth or
twenty-fourth day.

33. When the fracture exists at the superior part of the radius, it is
essential, after the removal of the apparatus, to make the limb very
frequently perform all its natural motions. In such a case, indeed, the
parts sometimes swell, become stiff, and an anchylosis of the fore-arm
may be the consequence, as Ambrose Pare observes, in his book on
fractures, where he says he has seen many accidents of this kind. Galen
has remarked the same thing before him. The following case reported by
Jeo. Dol**, confirms the truth of it.

CASE II. Jane Rene was received into the Hotel-Dieu, in consequence of
a fracture of the upper extremity of the radius, produced by a fall
on that part, for which she was subjected to the treatment already
described (31). The apparatus being removed at the expiration of
twenty-five days, the consolidation was perceived to be complete.
The motions of pronation and supination were impracticable; those of
flexion and extension very much impeded. The patient was now ordered
to have the fore-arm moved daily, in these several directions, for
the space of an hour, and this space was even increased morning and
evening, notwithstanding the pains which, at first, accompanied the
exercise. On the eighth day pronation and supination could already
be performed in a small degree; they became more and more free, in
proportion as the exercise of the limb was longer continued; finally,
on the twenty-second day from the removal of the apparatus, the
patient was conducted, according to custom, to the amphitheatre, where
all the pupils witnessed the perfect freedom of the motions.

CASE III. A few days after this, a man, who had left the Hotel-Dieu
about eight months before, while under treatment for a similar
fracture, returned, to be the subject of a public consultation in
consequence of a different disease.

Desault, on interrogating him, learnt from him that the treatment for
the fracture had been continued at his own house (31), but that, when
the apparatus was removed, no motion had been impressed on the limb,
and that the surgeon had even kept it in a sling. The fore-arm was then
examined; it was half bent, constantly in a state of pronation, and
could not, by any force, be brought into a state of supination. The
motions of flexion and extension, were so limited as to be scarcely
sufficient for the common wants of the patient, who, under proper
treatment, might have been cured like the preceding one, as Desault
remarked to his pupils at the time.

34. The patient who was the subject of this second case, was sent
to the mineral springs, but derived no benefit from the use of the
waters. If this were a proper occasion, I could mention many instances
where this remedy, so highly spoken of by many physicians of the
present time, has had no effect, except to deprive the patient of more
efficacious means, by making him lose that time, during which exercise
frequently repeated, would have effected a cure, but which, coming too
late, could be of no avail.


FRACTURE OF THE ULNA.


§ X.

OF THE CAUSES AND THE SIGNS.

35. The ulna, less frequently broken, in general, than the radius,
scarcely ever suffers alone from falls on the wrist or hand. Most
commonly its fracture is direct, and occurs, in particular, in cases
where a person in falling, extends the fore-arm for the purpose
of supporting himself, and strikes its internal part against some
resisting body.

The division, though it does take place occasionally in all parts of
the bone, occurs most frequently near to the lower end, where its
slender size, compared to that of its upper end, its more projecting
situation, and its thinner covering of soft parts, act as predisposing
causes.

36. In whatever part it may exist, the touch must readily detect it,
when the fingers are drawn along the internal surface of the ulna,
which lies almost immediately under the skin. If moved in contrary
directions, the fragments will also, by their mobility and crepitation,
disclose the nature of the injury. A depression more or less
perceptible is observed on the internal part of the fore-arm, produced
by a displacement of the fragments, which are carried towards the
radius, more particularly of the inferior fragment, as Petit has well
observed, the superior one remaining almost immoveable.


§ XI.

OF THE REDUCTION, AND THE MEANS OF MAINTAINING IT.

37. The reduction does not differ from that of the radius (31), except
in this, that the assistant who makes the extension, must place the
hand in the opposite state, namely, that of abduction, in order that
the fragments may be brought into contact, while the surgeon assists
in this process, by pushing the broken ends of the bone in a direction
opposite to that of their displacement.

As in the foregoing case, three splints are sufficient for the
apparatus, where the radius, being unbroken, performs the office of a
fourth.

The exercise of the limb, after the consolidation of the bone, is in
general less necessary here, than in fractures of the radius (34),
because the ulna, being an immoveable point of support for the motions
of rotation, concurs in them only in a passive manner.


FRACTURE OF THE OLECRANON.


§ XII.

REMARKS ON THE OLECRANON.

38. The ulna is surmounted, at its upper end, by a considerable
appendix, curved before, where it corresponds to the articulation of
the fore-arm, and is covered with cartilage; convex behind, where
there is nothing to separate it from the external integuments, and is
attached at its upper end to the strong tendon of the triceps muscle,
which appears to be incorporated with it. This appendix resembles
greatly, in its structure, form, and uses, the rotula, from which it
would differ in nothing, if the inferior ligament of the latter were
ossified, so as to form a bony continuity between it and the tibia. It
is exposed to fractures, perfectly similar to those of the rotula, but
which differs so essentially from the other fractures of the ulna, as
to call for a separate examination.

39. The ancients appear to have had but little knowledge of fractures
of the olecranon, respecting which they have transmitted nothing to us,
unless with Dalechamps, we find cause to recognize a reference to this
affection in the following passage of Paul of Egina: _Cubitus frangitur
... circa partem ad cubiti gilbum_.

Most of the moderns have spoken of it only in a vague manner; no one
has described with accuracy the signs which characterize it; and few
have given satisfactory ideas on its treatment. Petit has not spoken
of it separately, and Duverney, who concludes with it his article
respecting fractures of the fore-arm, has but imperfectly described for
it a bandage which is in itself equally imperfect. Bell does not give
us, on this point, an exposition of either his opinions or his practice.

Yet this fracture is by no means so rare as to justify the silence of
authors, and its treatment merits a degree of attention beyond that
which is requisite in most other fractures.


§ XIII.

OF THE VARIETIES AND CAUSES.

40. The olecranon suffers fractures at its base and at its summit,
but more frequently in the first, than in the second situation. The
division, though very generally transverse, is sometimes oblique.
Desault met with an instance of an oblique fracture of the olecranon in
a man, who had sustained a violent blow on his fore-arm from a club.

41. The causes which produce it are, either muscular action, a
circumstance that very rarely occurs, or the direct action of external
bodies, which is by far the most common case. The reverse of this is
true with regard to fractures of the rotula, which are almost always
produced by the contraction of the muscles attached to that bone.

42. The olecranon has been at times separated from the ulna, by the act
of throwing a stone with great force. In such cases, the fracture has
been produced by the immediate action of the triceps muscle. This is
the first mode of division.

The second occurs when a violent blow is received on the elbow, or,
more particularly, from falls on that part: for example, if, when
descending a flight of stairs, our heel slip and we fall backwards, the
arm is suddenly thrown behind to save the body. In such a case, the
olecranon striking forcibly against one of the steps, and being pressed
between it and the weight of the body, is broken. In this way was the
disease produced in a majority of the patients attended by Desault for
fractures of the olecranon.


§ XIV.

OF THE SIGNS.

43. We meet here with the same appearances and state of things, which
constantly occur in fractures of the rotula. The triceps extensor,
finding no longer in the continuity or sound state of the ulna, a
resistance to its contractions, draws upwards the short fragment to
which it adheres, produces between it and the lower one an interval
more or less perceptible, and gives rise to the greater part of the
other characteristic signs of the affection: these are, 1st, An
interval or space between the fragments, corresponding to the posterior
part of the articulation. This interval may be increased at pleasure,
by increasing the flexion of the fore-arm, or by making the patient
contract the triceps muscle, and may be again diminished, by bringing
the arm into a state of extension: 2dly, An inability in the patient to
extend the fore-arm spontaneously, which is the necessary result of the
separation of the triceps from the ulna: 3dly, A constant semiflexion
or half-bent state of the fore-arm, produced by the contractions of
the biceps and brachialis internus muscles, to which no antagonists
are now opposed: 4thly, An elevation, more or less perceptible, of
the olecranon above the condyls, which, on the contrary, rise above
it, when, in a natural state of the parts, the fore-arm is half-bent:
5thly, A facility of moving the upper fragment in every direction,
without communicating any motion to the ulna; 6thly, A peculiar
sensation experienced by the patient, to whom it seems, when he makes
an effort to extend the fore-arm, as if some body or substance were
detached or broken off from his elbow, and carried upwards. The patient
may realize the justness of this sign, by comparing it with what he
feels on attempting to extend the opposite fore-arm, placed in the same
position.

44. If to these signs be added the circumstances which accompany
the accident, the severe pain that is always felt, the crack which
is sometimes heard by the patient, and the possibility of producing
a perceptible crepitation, by rubbing the fragments in contrary
directions, after having first brought them together, it will be
difficult to be mistaken respecting the existence of the fracture,
which indeed the swelling of the part alone can conceal from the
practitioner, if, as sometimes happens, it be considerable. But then,
being soon dispersed, either spontaneously, or by the action of
discutients, it leaves the accident unmasked, accompanied by the signs
just enumerated.

45. To the swelling is oftentimes added, an echymosis more or less
considerable, when the accident has been produced by a fall on the
elbow. But by this, no change is effected in the essential characters,
which are always sufficient to distinguish a fracture from a luxation
backwards, with which it has been sometimes confounded, as appears from
many examples recorded in different works.


§ XV.

OF THE PROGNOSIS.

46. I will not dwell on the question, so much agitated of late, namely,
whether or not the olecranon be susceptible of consolidation or
reunion. Already has it been hundreds of times answered by experience.
What could theory add to the conviction already impressed on us from
that quarter? It was by exhibiting to the crowd of pupils who attended
his clinical lectures, fractures of this kind perfectly reunited, that
Desault refuted the weak arguments, of the periosteum not being able,
in consequence of not covering the anterior surface of the olecranon,
to produce a union between its fragments, of the synovia mixing with
the matter of callus, diluting it, weakening it, preventing it from
becoming sufficiently hard for the purpose of reunion, &c. We will
only observe, that these ideas are borrowed from a theory which modern
experiments have proven to be unfounded, and which, were it true, would
be applied in the present case quite unphilosophically, since it would
deny to certain parts of man the power or property of restoration or
being healed, a property common to all the component parts of beings
endowed with life, and which even constitutes one of their essential
and discriminative characters.

47. Is the consolidation of the olecranon effected in the same mode
as in other bones? The observations of many practitioners, Camper in
particular, seem to prove that a ligamento-cartilaginous substance is
always the medium of the union of fragments. Desault once found this
substance in a corpse, but it was in a case where the fracture had been
improperly treated, and where, of course, no inference could be drawn
with regard to ordinary cases.

48. But of what import to us are the means which nature employs?
The indication is still the same. The fragments must be always kept
in contact, that the reunion may be immediate, and that, as David
observes, in his memoir on motion and rest in surgical diseases, the
apophysis may not, by becoming too long in consequence of the space
occupied by the callus, impede the extension of the forearm on the os
humeri.


§ XVI.

OF THE MEANS OF CONTACT BETWEEN THE FRAGMENTS.

49. There are no fractures, the treatment of which demands more
attention, or is surrounded with more difficulties, than that of the
olecranon. Here art cannot, as in the thigh, and the clavicle, oppose
to the ever active power of the natural muscles, a constant resistance
produced by the action of a kind of artificial muscle, consisting in
permanent extension. The superior fragment, being too small to give
any purchase to extending forces, can be only pushed downwards, and
kept in that position with a greater or less degree of stability and
firmness, while the ulna, so to speak, is drawn to meet it. Whence it
follows, that extension here is of little use, and that it is chiefly
by position or attitude, aided by a judicious conformation, that the
reduction is effected.

50. The position has varied in the hands of different practitioners.
Some have proposed that, in which the fore-arm is half-bent, so as
to form a right angle with the os humeri. The example mentioned by
David, is not the only one where recourse has been had to this. But,
by rejecting the general principle respecting the reunion of parts,
which requires them to be kept in perfect contact, this mode is exposed
to a double inconvenience. The reunion is extremely slow in being
accomplished, and, when ultimately obtained, is accompanied by the
loss of one part of the movements of the limb, in consequence of the
length of the callus. This callus must necessarily fill up the whole
space that intervened between the fragments during the treatment, and
being thus added to the natural extent of the olecranon, lengthens this
appendix to such a degree, that, in extending the fore-arm, its summit
or upper end comes too soon into contact with the cavity in the os
humeri destined to receive it.

51. This practice appears to have been chiefly owing to an opinion then
in existence, that an anchylosis being the necessary consequence of the
fracture, it was proper to place the arm in that position in which it
would be most likely to be still of some service.

52. We must not, however, by throwing the fore-arm into the greatest
possible degree of extension, allow it to be drawn into the opposite
extreme. From this error the same inconveniencies would result. In
such a case, should the fragments touch each other, and press too hard
at their posterior edges, they must inevitably leave an intervening
vacuity or space between their anterior edges. Hence a greater
thickness of callus on the one side than on the other, and consequently
an impediment more or less troublesome in the motions of the joint. If
the inferior fragment do not touch the superior one, it sinks into the
olecranon cavity, leaves the other behind it, and hence another source
of irregularity in the consolidation.

53. Between these two extremes (50 and 51), it remains to choose a
middle course, and that position will be best, in which the fore-arm
shall be, so to speak, in a state between semi-flexion and extension.
By this the fragments, being brought into perfect contact, will
experience no obstacle to a reunion, which will be therefore both
speedy and uniform.

54. But it would be useless to place the limb in a proper position,
if no means were made use of to retain it there. Being immediately
submitted to the action and influence of a multitude of causes, it
will lose its position, and the work of nature being interrupted, the
consolidation will be retarded.

Hence appears, both the necessity of placing a solid body, as Desault
did, before the whole of the limb, to prevent its flexion, and the
insufficiency of the apparatus proposed by Duverney and others, who
directed to lay a thick compress on the fracture, to surround the elbow
then by a circular one, to secure the whole by a kind of figure of 8
bandage, similar to that used in blood-letting, and, finally, to place
the limb on a pillow, without further precaution.

55. Position alone evidently acts only on the lower fragment, which
it directs towards the upper one. But it is also necessary to draw
the upper fragment towards the lower one, and fix it there, and this
is certainly the most difficult point; because, the triceps muscle
having a constant tendency to contract, opposes its action to the
approximation of the fragments, and indeed prevents it, if, as in the
means usually proposed and adopted, the pieces of the bandage glide
easily over each other.

56. These considerations determined Desault to search for some means
which, being more efficacious than those already in use, might better
fulfil the indications of the fracture. He accordingly invented the
apparatus which we are about to describe; some ideas of this apparatus
are indeed borrowed from other bandages. The success which attended
the use of it at the Hotel-Dieu, will, without doubt, introduce it
generally into rational practice, where the insufficiency of the old
forms of apparatus is acknowledged.

1st, The fore-arm being placed in the position already directed (53),
two assistants retain it in that situation, while the surgeon applies
on its lower part the end of a roller five or six yards long, and about
four inches wide, wet with some discutient liquid, making with it, at
first, one or two circular turns to fasten it. Then ascending from
below upwards, he covers the whole of the fore-arm with oblique and
reverse turns moderately tight.

2dly, Having arrived at the joint, he stops, and makes an assistant
draw the skin of the elbow upwards, lest, being loosened and wrinkled
by means of the extension, it might get between the fragments, and
create an impediment to their reunion. Then, taking hold of the
olecranon, he draws it down towards the ulna, and passes behind it, as
a substitute for his fingers which have hitherto kept it firmly fixed,
a cast of the roller, which he brings from the anterior part of the
fore-arm above the elbow. Descending again with the roller along the
external side of the arm, and returning across the anterior part, he
pursues again the same course, so as to make the casts of the roller
lie on each other, and surround the elbow like a kind of figure of 8.

3dly, The surgeon proceeds now by oblique turns, to the upper part
of the arm, where he fixes the roller, by a circular turn, and gives
it into the hand of an assistant. He next applies along the arm and
fore-arm, a splint very strong, but a little bent at the place which
corresponds to the joint, in order to prevent too great an extension
of the limb: then, resuming the roller, he employs it, in a descending
direction, to secure the splint.

4thly, The apparatus being applied, the limb is placed on a pillow, so
as to be equally supported throughout its length, and is protected by
hoops from the weight of the bed-clothes.

57. To the bandage which we have just described, Desault added formerly
a strip of linen, to be placed all along the posterior part of the arm,
secured first at its upper end by circular casts, which began above;
this strip was secured afterwards by oblique casts, as far as to the
place where it met the olecranon, separated from the ulna. Here, the
surgeon quitting the roller, took hold of the bit of linen, and drew
it downwards, and along with it the circular casts of the roller,
together with the muscles on which these casts were applied, and also
the fragment which the muscles drew upwards. An assistant then secured
it here, while the surgeon, after having made some casts in form of the
figure of 8, descended to the inferior part of the fore-arm, where the
end of the strip was made fast by tight circular turns. (See fracture
of the rotula.)

58. The intention of this additional piece of apparatus, was to draw
down the superior fragment, to prevent the circular casts of the roller
from separating by their relaxation, and, by that means, to retain the
fragments in apposition. But, on the one hand, may not the superior
fragment be drawn by the hand, as well as by a roller employed for
the purpose? And, on the other, if the circular casts of the roller
be liable to become relaxed, why not the strip of linen also? These
considerations induced Desault to lay it aside, and use the bandage in
the form just described.

59. The advantages it offers are far from being equivocal. 1st, The
limb is kept in a state of invariable extension by the anterior splint,
and, on this account, there can be no displacement on the part of the
inferior fragment. 2dly, The bandage, which accurately envelopes the
whole limb, restrains the action of the muscles by compressing them,
and prevents in part the contractions of the triceps; while the casts
in the form of the figure of 8, applied with skill and precision,
hold down the superior fragment, and render it difficult for it to be
displaced. 3dly, Without the application of a roller over the whole
limb, a swelling, more or less considerable, would probably be the
effect of the constriction at the elbow, which must necessarily be
somewhat tight, because, as the turns of the roller, in form of the
figure of 8, act on the olecranon obliquely, if they be too loose, they
will slip and not perform the office of retention.

60. Like all kinds of apparatus composed of rollers, this ought to be
frequently examined, lest, by becoming relaxed, it should not make
sufficient resistance to the triceps, which is always disposed to draw
itself upwards. There can be no period fixed on for the reapplication
of the apparatus; the moment it begins to become slack, it ought to be
renewed: three or four times during the course of the treatment are
generally sufficient. Should a considerable swelling give reason to
suspect that the constriction is too great, it will be necessary to
remove the bandage in order to apply it anew.

61. The period necessary for the reunion of fractures of the olecranon
varies, according as the bandage is more or less exactly kept in its
place. Among ten cases of this kind, collected in the Hotel-Dieu,
four united in twenty-four days, three in twenty-eight, and three in
thirty-two. Hence, taking the mean term, all other circumstances being
alike, the process of cure requires about twenty-six days.

62. When this is completed, it is necessary to impress on the limb
motions of flexion and extension, gradually increased every day. This
is, as David properly observes, the most certain method of avoiding a
stiffness, and even an anchylosis, too often the consequence of this
fracture.

63. But that illustrious practitioner, in recommending this salutary
remedy, has erred with regard to the mode in which it operates. To
consume, by degrees, a superabundant callus in the interior of the
articulation, and thus reduce it to a level with the articulating
surfaces, is not, as he conceives, the effect which these motions
produce. This opinion, founded on the ancient doctrine of an osseous
juice, is refuted by the dissection of many bodies of patients that
died during the treatment, and in which Desault discovered no trace,
either of an effusion of osseous juice, during the reunion, or of its
superabundance after this reunion had been completed.

The exercise communicated to the limb, appears to act principally by
removing the congestion of the tendons and membranes surrounding the
joint, which, being at first irritated by the fracture, are thrown into
a state of _engorgement_; and further by dissipating a kind of numbness
which affects the muscles after they have remained too long in a state
of rest.

64. But whatever may be its mode of action, it ought to be gradually
increased, according to the state of the parts, and continued for at
least twenty days, a period sufficiently long to restore to the limb,
in general, its natural motions.

65. It is seldom that after this methodical treatment, the patient is
exposed to an anchylosis, a thing inevitable in such cases, according
to most authors, A celebrated surgeon, believing the long continued
extension of the fore-arm to be the cause of this accident, has advised
here to abandon every kind of bandage, and to commit the cure entirely
to nature. But this doctrine, contrary to the general principles of
the reunion of divided parts, has not in its favour the result of
experience, which proves that, under such neglect, the stiffness in
the parts near to the joint is always as great as in other cases, that
the reunion is more tedious and more deformed, and that sometimes it
cannot be accomplished at all. The analogy of the inconveniences and
disadvantages attributed to the method of Foubert, in fractures of
the neck of the os femoris, constitutes another argument against this
method, which is now almost entirely abandoned.

66. To the cases already published, proving the success of that which
we have proposed, let us add one more, reported by Maublanc.

CASE IV. Silvan de la Noue, aged thirty, fell on his elbow, having
his fore-arm bent, while the shoulder of the same side supported a
heavy load. Acute pains at the instant of the fall; a sudden inability
to extend the fore-arm; a considerable swelling appears almost
immediately, around the joint; and a superficial echymosis at the hind
part.

During the night the pains were augmented, the swelling increased, and,
on the day following, February 9th, 1791, the patient was received into
the Hotel-Dieu.

From the presence of the signs formerly mentioned (43), Desault
recognized the fracture, and applied the apparatus (56),
notwithstanding the swelling and echymosis, persuaded that the
compression made by this apparatus on the tumefied parts, was the most
effectual mode to remove the enlargement.

Next day, pains almost gone; swelling diminished; on the fifth day,
the bandage become loose, by the almost entire disappearance of the
swelling; a new application of it; the joint wet frequently with
vegeto-mineral water.

Seventh day, usual regimen allowed; ninth day, a slightly bilious
disposition; evacuants somewhat active administered, to remove it.

Thirteenth day, a third application of the apparatus; echymosis
entirely gone.

Thirtieth day, the consolidation complete; the apparatus laid aside;
from this time motions gradually impressed on the limb.

Fifty-eighth day, the patient discharged, free in all his motions,
except a little stiffness, which exercise will soon remove. Since that
time, it has been understood that the limb had completely recovered its
natural functions.




MEMOIR IX.

ON THE LUXATION OF THE FORE-ARM.


§ I.

1. The solidity and security of joints are increased in proportion as
the extent of their motions is diminished. This inverse proportion
of these two properties to each other, is in a particular manner
remarkable in the upper extremities, where the connexion of the
humerus with the scapula, of the fore-arm with the humerus, and of the
bones of the wrist among themselves, appear, in regular gradation, to
acquire the one as they lose the other: hence, their predisposition to
luxations is extremely different. We will examine those to which the
fore-arm is subject.

2. An angular ginglymus unites to the humerus the bones of the
fore-arm, which are again connected with each other by a double lateral
ginglymus. Eminences and depressions, reciprocally receiving and
received, constitute the first kind of articulation, where, proceeding
from without inwardly, we find, 1st, the small head of the humerus,
entering or rather joining the upper articular cavity of the radius,
which moves on it: 2dly, the external groove of the humerus, receiving
the rim of the same cavity of the radius: 3dly, a projection which,
rising from the external edge of the coronoide[19] cavity, extends to
the corresponding edge of that of the olecranon, and is received into
the external depression of the sigmoid cavity:[20] 4thly, the large
groove of the humerus, receiving the middle eminence of this same
cavity: 5thly, a considerable projection, obliquely applied to the
internal depression which receives it.

    [19] Not generally named in English works of anatomy.

    [20] _Echancrure sigmoide._

3. These numerous connexions secure the solidity of the joint, which
is still farther strengthened before by the coronoid apophysis,
together with the fleshy and tendinous extremities of the biceps,
and brachialis muscles, and by the olecranon behind; at the inferior
part, by the anconeus; on the sides by two ligaments which descend
from the two tuberosities, and strong muscular fasciæ running from
the same parts. The whole articulation is also surrounded by a thick
capsule, strengthened by numerous accessory fibres. With such powers of
resistance, how can this joint suffer a luxation? Yet next to that of
the os humeri, it is perhaps most frequently subject to this accident.


§ II.

OF THE KINDS AND CAUSES OF DISPLACEMENT.

4. Writers have admitted in general four kinds of displacement;
backward, forward, outward, and inward. But all these are not alike
frequent, as is proved by experience, and demonstrated by the relative
situation of the parts.

5. In a backward direction the olecranon and the radius may pass up
behind the humerus, as the coronoid apophysis offers but little
resistance in consequence of its slight curvature. On the other hand,
the kind of hook formed by the olecranon, prevents it and the radius
from passing before the lower articulating extremity of the humerus,
and therefore, without a fracture of the olecranon, a luxation in that
direction is impracticable: at the sides, the two lateral ligaments,
but more particularly the reciprocal joining or interlocking of the
uneven articulating surfaces, present almost insurmountable obstacles
to luxations laterally. Whence it follows, that luxation backward is
much more frequent than the others; compared to lateral luxations, it
is, at least, in the proportion of ten to one: with luxations forward,
no comparison can be made; neither Petit nor Desault having ever met
with such.

6. An external force produces the whole of these luxations, but
according to each, this force must vary. In a fall sideways, suppose
the hand be applied to the ground, with the arm extended, to save the
body. It is evident that the resistance of the ground will tend to make
the bones of the fore-arm pass upwards over the humerus, while the
weight of the body pushing that bone downward and forward, will make it
glide over the coronoid apophysis. Thus, the capsule, being distended
before by the humerus, and behind by the bones of the fore-arm, will
give way in one or the other place, or in both, as Desault observed
in a man, who fell on his side, as he was carrying a heavy load: the
weight of the body increased by the load, had such an effect, that the
bones overlapped each other nearly two inches.

7. It appears from this, that a state of extension is the position
most favourable to a displacement backwards; a doctrine by no means
conformable to that of most practitioners, who consider a state of
flexion as necessary to the accident. But, then, in what direction
should the fall take place, in order that the olecranon may pass
upwards? Applied as it is against the side of the cavity that receives
it when the arm is extended, would not this apophysis prevent such
passage? Whatever may be the mode of displacement, the olecranon, in
passing upward and backward, may incline a little to the one or the
other side.

8. I have already said, that without a fracture of the olecranon, no
luxation forward can occur (5). But what cause can act with sufficient
power on the parts to produce both accidents at the same time? It
would be necessary that a fall which had produced a fracture should
be succeeded by another fall; but in such a case, the fore-arm would
be half-bent, and it is in a state of extension alone (7) that the
luxation can take place.

9. Lateral luxations, that is, luxations at the sides have been divided
into complete, when the two articular ranges of the arm and fore-arm,
have lost their connexion entirely, and incomplete, when only one bone
or one part of a bone has been separated from its natural connexion
with the humerus. But what cause can act with sufficient force to
produce the first kind of luxation, namely, that which is complete? In
such an accident so great would be the extent of the wreck and ruin of
the part, that without doubt amputation would be the only resource.

10. The second kind of lateral displacement is the result of a stroke
which forces violently the extremity of the fore-arm outward or
inward. A footman, says Petit, in falling from a carriage, had his arm
entangled between the spokes of the wheel, and suffered in consequence
a luxation outwards. Another produced one inwardly, by being thrown
from his horse, and falling with his arm under him, on rough ground.
Strokes of this kind may, as that author remarks, vary in a singular
manner. But, in general, in all of them, the fore-arm must represent a
lever of the first kind, where the power acts on the end next the hand;
the resistance being in the joint, and the fulcrum in the middle.


§ III.

OF THE SIGNS.

11. To form an idea of the signs or appearances of a luxation
backwards, let us examine, for a moment, the natural situation of the
olecranon, and the condyls of the humerus. As these eminences are
easily felt under the skin, a knowledge and recollection of their
situation will serve as a standard of comparison, to judge of the
changes they experience in a luxation. When the fore-arm is extended,
the olecranon is on a level with the internal condyl, and a little
above the external one. In a state of flexion, it descends below this
level, and is then farther below the internal than the external condyl.
In either situation, it is nearer to the first than to the second, the
radius separating it from the latter.

12. But, when a luxation has taken place, this apophysis, still
remaining on a level with the two condyls, even although the fore-arm
be half-bent, is oftentimes separated from the internal one, and driven
towards the other: a preternatural protuberance announces this change
of position of the olecranon. The coronoid apophysis, whose posterior
surface glides in the large groove of the humerus, corresponds to this
groove now only with its anterior surface: sometimes the olecranon
cavity[21] receives its extremity. The radius passes backward over
the small head of the humerus. At the fold of the arm, a transverse
protuberance, more perceptible on the internal side, announces the
presence of the displaced articular extremity of the os humeri. Over
this extremity are reflected the biceps and the brachialis muscles
in a state of violent distension. These muscles, greatly irritated
by such distension, continue in a state of habitual contraction, in
consequence of which, they keep the fore-arm half-bent. Nor can the
anconeus muscle, which is necessarily relaxed, act so as to prevent
this semiflection. Severe pains would be the consequence of attempts to
extend the fore-arm; the limb is in a state of pronation; yet I find
among the cases collected by Desault, several examples where supination
existed; this state is explained by the relaxed condition of the
pronator muscles. At the level of or opposite to the coronoid cavity
is a depression or hollow manifesting the absence of the apophysis of
that name.

    [21] That deep depression in the os humeri, which, in a natural
    state of the parts, receives the upper end of the olecranon process.
                                                                TRANS.

13. Should chance give rise to a luxation forward, an anterior
projection of the two bones of the forearm, and above all, of the
coronoid eminence, a depression corresponding to the olecranon
cavity, the extremity of the humerus carried backward and downward,
the rigid extension of the fore-arm, a protuberance behind formed by
the fractured olecranon (5), and severe pains, necessarily resulting
from attempts to bend the limb, &c. would constitute the principal
characteristic signs of the displacement.

14. In lateral luxations, a protuberance at the internal or external
side of the articulation, always shows of what kind it is. If the
displacement be to the internal side, the olecranon is then situated
behind the small tuberosity: the middle protuberance of the os humeri
bears on the radius, which is sometimes placed even behind the internal
articular eminence of that bone, which then rests on the external
depression of the great sigmoid cavity. Hence, as Petit judiciously
observes, arises the direction of the fore-arm outward, the above
eminence presenting a manifest obliquity in that direction. In this
luxation, the ulna has been known to lose entirely its connexion
with the humerus, and the radius to be brought into contact with the
internal condyl of that bone. This is what some authors call a complete
luxation. Others reserve that name for cases where, the two articular
ranges have lost their correspondence or apposition entirely.

15. In a luxation outwards, the olecranon corresponds to the external
condyl; the middle projection of the humerus, to the internal
depression of the great sigmoid cavity; the small head of this bone, to
the external depression; the radius projects outwards; and the humerus
makes a protuberance inwardly.

16. After all, these changes of situation vary remarkably, and it
belongs to theory rather than practice, to trace their history, with
precision. In general, luxations outwardly happen more frequently
than those inwardly, a circumstance which is fully explained by the
structure of the joint. In both, the lateral ligaments are almost
always lacerated.

A swelling more or less considerable accompanies all the different
kinds of luxation, and is sometimes carried so far as to involve the
diagnosis in great uncertainty, particularly when the displacement is
not very great. This phenomenon (the swelling), seems, in general, to
correspond, in a direct ratio, to the force with which the articulation
resists. Indeed the violence, and consequently the irritation, are
always in proportion to the resistance of the parts.


§ IV.

OF THE REDUCTION.

17. The means of reduction vary according to the different kinds
of displacement. They are all, however, founded on nearly the same
principles, and it will be easy to form proper ideas of them, when we
shall have given an account of the means necessary to be employed in
luxations backward, of which the others are only modifications.

Here genius seems to have been as prodigal of resources, as nature has
been of obstacles. Indeed, to accomplish the reduction, we sometimes
see the surgeon placing his elbow in the fold of the affected arm,
interlocking his fingers with those of the same limb, and, then,
bending with his whole force, both his own fore-arm, and that of the
patient, to effect at the same time extension, counter-extension, and
reduction or conformation: at another time we see him fixing the fold
of the injured arm against some resisting body, such as a bed-post;
and while an assistant, then, pushes the displaced olecranon against
this body, he himself, pressing on the shoulder with one hand, and
grasping the fore-arm with the other, bends it forcibly, in order,
by that means, to produce a replacement: again, a body of some size,
being placed in the fold of the arm, serves as a fulcrum, on which the
fore-arm, being suddenly flexed, moves and acts like a lever of the
first kind, of which the power, being applied at the extremity next
the hand, draws it backward and upward, and by that means pushes in
a contrary direction its luxated end, where the resistance is made.
On some occasions, the fore-arm of the diseased side, bent at a right
angle, is placed on a horizontal table, and, while the lower extremity
of the humerus is thus resting on the table, the surgeon pushes
it backward with one hand, and with the other, taking hold of the
extremity of the fore-arm, draws it in a contrary direction.

18. The ancients employed the three first modes. Pare has had
engravings of them made: Scultel has also given figures of them as
practised by Hippocrates. The Arabians knew of no other modes, nor did
their descendants, who were only compilers from them. The practitioners
of our own day still continue their use. But, in general, they are
chargeable with the numerous inconveniences and faults of producing
intense pain, of not being completely under the direction of the
surgeon, of bringing the point of luxation too near to the place on
which counter-extension is made, and of bruising and doing violence to
the parts: nor do they disengage, by means of previous extension, the
luxated ends of the bones, to facilitate their replacement in their
natural situations.

This last charge is not applicable to the last of the processes
proposed by Petit. But, here, the extending forces are most commonly
insufficient; the surgeon, having both his hands engaged, is not
able to act on the joint to assist in the replacement: and the
counter-extension made is too near to the point of luxation.

19. In common cases, Desault employed a method as simple and more
efficacious, which few writers have recommended, and none have
described with accuracy.

The patient is, indifferently, either seated or standing. The fore-arm
being half-bent, an assistant takes hold of the extremity next the
hand, to make extension; another, to make counter-extension, takes
hold of the humerus a little below its middle, with both hands, the
fingers crossing before, and the thumbs behind. The extension is
made gradually, and when it begins to move the olecranon, and draw
it from the place it accidentally occupies, the surgeon, to aid in
the reduction, grasps the lower end of the humerus with both hands,
crosses his fingers in the fold of the arm, applies his thumbs to the
olecranon, and drawing the first backward, pushes at the same time the
latter forward; thus, he favours, on the one hand extension, and on the
other counter-extension, and in that way finishes the reduction.

20. This method is most commonly practised with success, in recent
luxations, where we have oftentimes seen the reduction effected at
the Hotel-Dieu, by the simple process of pushing, as just mentioned,
the olecranon forward, the humerus being held backward, without any
previous extension, while the fore-arm was merely supported by the
assistants.

21. But the luxation being oftentimes of long standing, presents
very great difficulties. What means must then be employed? It is an
established principle, that the force with which a power acts, is
in direct proportion to its distance from the point of resistance.
Augment this distance, and the extending forces, being doubled and
even trebled, will more easily dislodge the luxated extremity. But
this indication is fulfilled, by two long straps, formed each of a
towel folded several times, one of which is fixed above the wrist,
and the other round the humerus a little below its middle. Extension
is then made at their extremities, and is almost always sufficient,
when aided by skilful efforts of the surgeon (19), to accomplish the
reduction. The application of a strap round the humerus is never
necessary, unless when the resistance is very great; because, in
counter-extension, it is requisite only to withstand or bear against
the efforts of extension, but not to act in a contrary direction.

22. But in cases of this kind, the strap, placed, as we have directed,
round the lower part of the humerus, has sometimes the disadvantage of
compressing too much the brachialis and the biceps muscles, and thus
preventing them from acting; this inconvenience is particularly felt in
old luxations, where great force is employed; for, the more active then
the contraction of these muscles is, the more it will aid the surgeon
in his efforts to draw the bones into their natural situation, when
once disengaged by extension, from that which they had accidentally
occupied. If, in such a case, we impede the contraction of these
muscles, how can they fulfil this office?

23. It was this which, in certain cases, induced Desault to place his
counter-extension under the armpit, by means of a strap passing, as
in the luxation of the humerus, over a ball previously fixed in this
hollow, and crossing, not on the top of the opposite shoulder, but
behind that of the diseased side. By this contrivance the humerus was
drawn or rather held back, by a force acting perfectly in the line of
its direction. But is not this force situated too near to the centre of
motion? The strap for making extension, fastened at the wrist, answers
very well, as has been already mentioned (21).

24. Should the luxation be forward, the extension must be directed
according to the state and position in which the fore-arm is found,
which is always extended. The hands of assistants alone (19), or straps
(21), may then serve to make the extension, which the surgeon must aid,
by grasping, in a direction the reverse of that in the preceding case,
the lower extremity of the humerus, that is, by crossing his fingers
behind, and placing his thumbs on the coronoid apophysis, to push it
downward and backward.

25. The strap for counter-extension, would in such a case, always
afford the greatest advantage, by being placed exactly as in luxations
of the humerus, that is, by running to, and crossing on, the opposite
shoulder; the direction or course of the fore-arm, which is necessarily
in a state of extension, sufficiently explains this; finally, the
reduction of the luxation must be succeeded by the reduction of the
olecranon (5), and by the application of a proper apparatus to retain
the whole.

26. The reduction of lateral luxations, differs but little from that of
luxations backwards. The displaced extremities must be first dislodged
by previous extension (19). The surgeon, then, taking hold of the
lower part of the arm, places his fingers before, and with his thumbs,
crossed on the olecranon, pushes that apophysis forward and inward,
if the displacement be outwardly, but forward and outward if it be
inwardly. Does the case prove very difficult, recourse must be had
to the other means (21 and 23). The hands of the surgeon must still,
according to the direction of the displacement, assist the extension
made by the straps.


§ V.

OF THE MEANS OF MAINTAINING THE REDUCTION.

27. Luxations of the fore-arm have, oftentimes, a great disposition
to occur anew, after having been reduced, whether they be recent, or
of long standing. Extension readily dislodges the olecranon and the
radius, and replaces them perfectly in their natural situation; but if
any thing interrupt them, the displacement is sometimes immediately
renewed: suppose the parts even remaining in contact, the slightest
motion may derange this contact, and give rise to a necessity for a
new reduction, more difficult, oftentimes, than the first. Hence it is
always prudent to employ a retentive apparatus for some time.

28. But, on what principle and for what purpose ought it to be applied?
The motions communicated to the fore-arm by external bodies, but, more
particularly, the action of the muscles inserted in the bones that have
been reduced, are here the causes of their displacement. Hence, 1st,
to render the limb immoveable; 2dly, to push the articular ends of
the bones in a direction opposite to that in which they are drawn by
the muscles, and have a tendency to be displaced: such is the twofold
indication of the bandage; an indication not fulfilled by the kind of
bandage and the sling which Petit proposed, and which leave the arm
free to move, and the muscles free to act.

29. Desault employed the following apparatus: 1st, The arm and fore-arm
are first covered by oblique turns of a roller, intended both to
protect them from the impression of splints, and to diminish the power
and action of the muscles, by the pressure made on them: 2dly, Behind
the olecranon is to be placed a thick compress, designed to retain
it downwards, and which must be secured by a strong splint, situated
behind, and curved at the elbow, to accommodate it to the flexion of
the fore-arm: 3dly, On the sides are placed two other splints, chiefly
necessary in lateral luxations: 4thly, The whole is to be secured by
the remaining part of the roller, by which the arm and fore-arm are
already covered.

In this bandage, the immobility of the arm is secured by the splints,
while the olecranon is pushed by the compress, in a direction the
reverse of that of its displacement. But these circumstances constitute
the double indication that was to be fulfilled (28).

30. The period at which these means may be dispensed with, is
undetermined. It belongs to the surgeon to examine and ascertain,
when the natural connexions of the joint are sufficiently confirmed.
Then motions, at first gentle, are to be impressed on the limb;
being afterwards gradually increased, they remove by degrees that
stiffness, which usually follows a dislocation, particularly an old
one. But if it has existed too long, to give the limb motion, is then
the only resource: the new attachments or adhesions, contracted by
the articulating surfaces in their displaced state, render reduction
impracticable. We must then confine ourselves merely to increasing the
extent of the motions, which the displaced fore-arm is yet capable of
performing.

31. There is, in general, all other things being favourable, a hope of
accomplishing the reduction, till the end of the second month after the
accident. Desault succeeded in it, at even a later period. What trouble
or hardship is it, at last, to try extension? Should no other end be
gained, but merely to bring the bones nearer to their natural cavities
or situations, even without actually replacing them, this will aid
their movements, the extent of which is inversely proportioned to their
distance from these cavities.




MEMOIR X.

ON THE LUXATIONS OF THE RADIUS OVER THE ULNA.


1st, Most authors who have written on the luxations of the fore-arm,
have omitted considering separately those confined to the radius
alone. Some detached observations may be found here and there, on the
luxations of the upper extremity of this bone, which Duverney alone
has treated at some length. Those of its lower extremity, though more
frequent, and more easily produced, appear to have almost entirely
escaped the attention of the French practitioners, who have transmitted
nothing to us on that point, owing, no doubt, to their having had no
knowledge of it from experience. But since, at the present day, a
sufficient number of facts are collected on the subject, some account
of these displacements cannot be a matter of indifference to the art,
and it may be traced with as much precision as the accounts of other
similar accidents.


§ I.

OF THE DIFFERENCES IN POINT OF STRUCTURE BETWEEN THE TWO ARTICULATIONS
OF THE RADIUS WITH THE ULNA.

2. The radius, the moveable agent in pronation and supination, rolls
on the ulna its fixed basis or abutment, by means of two small
articulating surfaces, the one at its upper end, slightly convex,
broad within, and narrow without, corresponding to the small sigmoid
cavity, in which it is lodged; and the other at its lower end, concave,
semicircular, and fitted to the convex edge of the ulna, which it
receives. Hence two kinds of articulation different from each other,
with respect to their motions, the connexion of their surfaces, and the
ligaments which strengthen them. Let us specify these differences; they
will serve to shed light on those that exist between the displacements
of the two extremities of the radius.

3. At its upper end, the radius, in performing pronation and
supination, moves only on its own axis; at its lower end, it rolls
round the axis of the ulna: therefore, being farther removed from
their centre, its motions must have both a greater range and greater
force, in the latter case than in the former. The head of the radius,
turning on itself within the annular ligament, cannot distend it in
any direction or part. The cellular membrane attached to this ligament
is alone slightly stretched, but being loose and elastic, it yields
without resistance. At its lower end, on the contrary, the radius,
turning from without inwards during pronation, keeps the capsule
posteriorly in a state of tension, and draws it against the immoveable
head of the ulna, which tends to pass through it, if the motion be
forcible. The same phenomenon occurs in a contrary direction, during
supination; the radius is directed backward, and the ulna inward. Being
in this case distended before, and relaxed behind, the capsule is
disposed to laceration anteriorly.

4. In addition to this disposition, the ligaments of the two
articulations are disproportioned in their strength. Thin and weak at
the lower articulation, thick and firm at the upper one, they are in
this respect strikingly different. The head of the radius, resting
against the small but firmly fixed head of the humerus, finds there, in
most of its movements, an obstacle to displacement. On the contrary,
its lower end, drawing along with it in its movements, the bones of the
carpus which are connected with it, derives from them no solid support.


§ II.

DIFFERENCES IN THE LUXATIONS OF THE RADIUS; DIFFICULTIES OF THAT AT ITS
UPPER END.

5. It follows from what has been said (3 and 4), 1st, that the lower
articulation of the radius is not only exposed to the action of more
causes of displacement, but possesses fewer means of resisting those
causes, and that, from the threefold consideration of its motions, the
ligaments which connect its articulating surfaces, and their relation
to each other, it must be frequently subject to luxations: 2dly, that
for reasons the very reverse of these, its upper articulation must be
very seldom subject to luxation.

6. Indeed, what cause is there to produce luxation in this latter
joint. Is it from a forcible exertion of pronation or supination that
this accident can occur? Surely not: for, on the one hand, as the
lower articulation offers less resistance than the upper one, it is
evident that, in either state of motion, it being the weakest, will
be displaced first, and the motion being thus checked, can no longer
operate to the displacement of the other. On the other hand, however
forcible the motion may be, there will be in the upper articulation,
nothing but a rotation of the bone on its own axis (3). How, then,
without being carried forward, backward, &c. can the head be displaced?
Indeed, it would be necessary that all the fastenings or bonds of
attachment muscular and ligamentous, should be first broken. But these
are too strong, and the motion is too weak. Can the displacement be
produced by a blow impressed on the radius from below upwards? By no
means: because the head of the humerus making, in this case, a solid
resistance will not permit it to escape from the capsule (4). Can it
arise from a violent extension or flexion of the fore-arm? No. This
effort being altogether confined to the ulna, affects the radius in but
a very faint degree.

7. It appears from hence, that the accidental luxation of the upper end
of the radius, suddenly produced by external causes, must, if it ever
occur, be extremely rare. But it is not so with respect to luxations
which take place slowly in this joint, particularly in children, where,
in consequence of repeated efforts, the ligaments become relaxed.
But this kind of displacement, being almost always complicated with
a swelling of the joint, and sometimes not to be reduced by the
expedients of art, cannot be comprised in my present plan.

9. But experience would seem to have at times exposed the fallacy of
these considerations and reasonings, founded merely on the structure
of the parts. Duverney relates some instances of luxations of the
head of the radius, produced suddenly by external causes. Two other
practitioners are also of opinion that they have witnessed similar
displacements. But did they examine the subject with all that attention
which it required? A similar case was reported to the Academy of
Surgery, by one of its associates; but doubts were entertained with
regard to its reality: and, ultimately, there were so few facts in its
favour, and such strong presumptions against it, that Desault was
induced to deny the luxation altogether, till its reality should, by
new proofs, be more certainly established.

After all, if it should occur, the same signs which announce the
luxation, when the ligaments, in consequence of being gradually
relaxed or in some way distended, permit the head of the radius to
be insensibly displaced, would then appear as the sudden effect of
external violence.


LUXATION OF THE LOWER EXTREMITY OF THE RADIUS.


§ III.

OF THE KINDS OF DISPLACEMENT.

9. The causes which produce the displacement of the lower end of
the radius, are the same with those that give rise to other similar
affections. 1st, The convulsive action of the pronator and supinator
muscles, is doubtless a rare cause of the accident, since Desault never
met with an instance of it. 2dly, The action of external bodies, which,
by forcibly and suddenly producing the motions of pronation, rupture
the posterior portion of the capsule, or, by those of supination,
lacerate its anterior portion.

10. Hence two kinds of displacement, the one forward, the other
backward. The first is somewhat frequent; the second is much less so.
The latter was never seen by Desault but once, and that was in the
corpse of a man who had had both his arms luxated, but respecting the
circumstances of which he could receive no information. The other
kind occurred frequently in his practice, of which five examples
have been already published. The difference no doubt arises from
this circumstance, that the greater part of our powerful motions are
performed only in the direction of pronation. This appears to be proven
by the following circumstances.

11. If, in several dead bodies, we lay bare the bones of the fore-arm,
still united by their ligaments, and push the extremity of the radius
forcibly backwards, that is, in the direction of supination, a
laceration will as readily occur in the anterior part of the capsule,
as it will in its posterior part, when, by forcibly pushing the same
extremity forward, the motion of pronation is performed. Hence the
difference does not arise from the structure, but from the direction of
the motions impressed on the limb.


§ IV.

OF THE SIGNS.

12. The signs which characterize a luxation of the radius forward,
are, 1st, The constant pronation of the limb: 2dly, An inability in it
to assume the state of supination, and even severe pains arising from
attempting it: 3dly, A protuberance larger than common, formed behind,
by the small head of the ulna passing through the capsule: 4thly, The
end of the radius being situated more anteriorly than natural: 5thly,
The constant adduction, and almost constant extension of the wrist:
6thly, The semiflexion of the fore-arm, and very often of the fingers:
this position is generally assumed by the fore-arm, in affections of
the bones that form it, and, in the present case, cannot be changed
without considerable pain: 7thly, A swelling more or less extensive,
which sometimes appears around the articulation, at the moment of
the accident, and which never fails to occur afterwards, unless the
reduction be immediately effected. This occurrence may conceal the
state of the articulation, and make the accident be considered, at
first sight, as a sprain, as Desault witnessed in certain cases, where
the disease had been mistaken by the surgeons who were first called to
the persons injured. It is easy to conceive of the sad consequences of
this mistake, which, by preventing any effort at reduction, gives the
articular surfaces time to form adhesions, and thus oftentimes renders
the mischief irreparable.

13. If to these signs be added, the severe pains experienced by the
patient, the circumstances of the fall, in which the fore-arm is
violently drawn into a state of pronation, we will have a view of every
thing that can here aid the practitioner in his diagnosis.

14. Most of the foregoing signs, taken in the opposite sense, would
characterize a luxation of the radius backward, should it occur: such,
for example, as a forced supination of the limb, an inability as to
pronation, the pains that would result from this movement if performed
by force, the tumour formed anteriorly by the extremity of the ulna,
the posterior situation of the large head of the radius, and the
abduction of the wrist.

15. The dead body, in which Desault observed this kind of displacement
(9), being dissected with care, exhibited in the articular parts, the
following diseased state. The tendons of the flexor muscles, pushed
outwards, adhered to one another and to the skin; a substance of a
cellular texture filled up the sigmoid cavity of the radius, and
occupied the place of the cartilage which naturally invests it: the
inter-articular ligament, which passes between the ulna and the os
pyramidalis, scarcely touched the head of the ulna, having followed the
radius backwards; and the head of the ulna, situated before the sigmoid
cavity of the radius, rested on one of the ossa sesamoidea, to which it
was attached by a capsular ligament.


§ V.

OF THE REDUCTION.

16. Extension so important in the reduction of other luxations, renders
scarcely any service in this: impulsion alone answers the purpose. If
the displacement be forward, it is reduced in the following manner: The
patient sits or stands indifferently; the latter position, however, has
sometimes this advantage over the former, that by placing the part to
be operated on more on a level with the hands of the surgeon, it gives
him both more readiness and more force in his motions: one assistant
supporting the elbow, separates the arm a little from the body; while
another taking hold of the hand and fingers, gives them also an equable
support.

17. The surgeon grasps the extremity of the fore-arm, with both hands,
one placed on its internal, and the other on its external side, so
that his two thumbs may meet before, between the ulna and the radius,
and the fingers behind. He then exerts himself to separate the two
bones from each other, by pushing the radius backward and outward,
and retaining the ulna in its place; in the mean time the assistant
who supports the hand, endeavours to move it in the direction of
supination, and consequently to draw the radius, with which it is
connected, into the same state. Being thus pushed in a direction
opposite to that of its displacement, by two forces, the one exerted
directly on it, and the other acting indirectly, the radius is forced
outwards, and the ulna, returning through the opening in the capsule,
is replaced in the sigmoid cavity.

18. Should a luxation of the radius backwards ever occur, the same
process executed in an inverse direction, would serve the purposes
of reduction. The surgeon with his fingers would have to press the
extremity of the radius forward and inward, while a forcible pronatory
movement impressed by the assistant on the hand intrusted to him, would
favour the effort and finish the reduction.

19. The disappearance of the signs (12 ... 14) of the luxation bespeak
its reduction. In general the pain is entirely removed; sometimes a
perceptible sound, or report, caused by the passage of the bone through
the opening in the capsule, announces the replacement.

20. When the luxation is of long standing, it is always attended with
more or less difficulty, occasioned by the adhesions of the surrounding
soft parts to the articulating surfaces, by the thickening of the
capsule, which diminishes the size of its opening, by the rigidity
contracted by the whole part, &c. It is, in such cases, useful to
employ emollient applications for some time previously to attempting
the reduction, in order to produce such a relaxation, and diminution of
the congestion, as may favour the efforts of the surgeon.

21. The first patient whom Desault visited at the Hotel-Dieu in quality
of surgeon in chief, had a luxation forward, of more than two months
standing, in which the use of these means facilitated the reduction:
but they are sometimes insufficient, and then the radius remains
immoveable, and the forearm performs its motions but partially.

22. It would seem as if nature, always industrious to provide, amid
the disorders of our organs, some resources for the exercise of their
functions, has been desirous of preventing here, the inconvenience
attendant on a failure of reduction, by rendering luxations backward
much more difficult than those forward. Indeed if the fore-arm be kept
constantly in a state of supination, it will be much less useful, than
if it were always in a state of pronation, the situation in which most
of the motions necessary to our existence are performed.


§ VI.

OF THE SUBSEQUENT TREATMENT.

23. When the reduction is finished, the articulating surfaces have
sometimes a great tendency to be displaced, by the different movements
of the fore-arm, a tendency of which we may easily form an idea, if we
observe, that in a state of pronation, the head of the ulna presses
against the back part of the strained capsule, and consequently against
its opening, when the luxation has been forward: a contrary state of
things occurs in a luxation backward. Whence it is always prudent
to avoid, for some time, the motions of pronation and supination,
according to the direction of the displacement.

24. Should the tendency to displacement be very great, it will be
necessary to adopt the simple method pointed out in a case already
published by Desault.

CASE I. The case was a luxation forward, which was easily reduced.
But the easier the reduction, the more difficult was it to retain the
replaced parts. This was at length accomplished, by fixing the fore-arm
in a state of supination, and applying one thick compress behind the
ulna, while the radius was pushed backward by another compress, placed
on its anterior part, both secured by a common roller. This apparatus
was continued for the space of a month, after which the reduced bones
remained in their natural situation. The patient began, at first, to
perform gentle motions of the wrist, avoiding those of pronation, on
which he afterwards ventured by degrees, and with great caution.

25. These gentle motions frequently repeated, when a displacement is
no longer to be apprehended, remove that unavoidable rigidity which,
for some time, occupies the parts around the joint. It is advisable,
for some time, to apply on the hand and extremity of the fore-arm,
compresses wet with some discutient liquor, to prevent the swelling
resulting perhaps from the inactivity and sprain of the parts. This was
the practice of Desault.

I will close this memoir by two cases, extracted from the Journal of
Surgery, in order to confirm, by experience, what has been already
settled in theory.

CASE I. Desault was called to visit a child five years old, supposed to
be labouring under a fracture of the arm. He learnt from the parents
of the child, that, as it was lying in a very low bed, a young man
who was playing with it, had taken hold of its fore-arm, and drawn it
towards him, twisting it forcibly at the same time in the direction of
pronation; that the effort had been accompanied by a report, and the
child had immediately experienced an acute pain throughout the whole
limb, but more particularly along the posterior part of the fore-arm.

When Desault saw the patient, no swelling had as yet supervened; the
arm was removed from the body, and carried a little forward, while
the fore-arm, half-bent, was kept in a state between pronation and
supination. There existed, at its lower and back part, a preternatural
tumour, formed by the head of the ulna carried behind the sigmoid
cavity of the radius. The hand was a little extended, and in a state
of adduction. The patient carefully preserved that position, and, as
soon as it was changed, or the part affected touched, manifested signs
of the most acute pain.

From these appearances, Desault discovered immediately a luxation of
the radius forward, which was reduced in the manner already mentioned
(16 and 17). By this process, the bones, being a little separated from
each other, were replaced with facility. The suffering of the patient
was immediately at an end; the limb resumed its natural state, and
performed its functions as freely as before; lest some congestion might
be the consequence, the injured parts were covered by compresses wet
with camphorated spirits; these were secured by a bandage moderately
tight, and no accident whatever supervened.

CASE II. On the 29th of January, 1789, Madeleine Fuser, a washer-woman,
thirty-four years of age, had the lower extremity of the radius luxated
forward.

Just as she had finished wringing a sheet, another washer-woman, who
was assisting her to wring it, giving it a forcible jerk, did violence
to her left arm, which was at the time in a state of strong pronation.

The woman experienced immediately a severe pain, accompanied by a
sensation as if something had been torn. The sheet dropt from her
hand, and she fell on the ground. Believing that she had received
only a sprain, she neglected to apply for aid, and did not enter the
Hotel-Dieu till the sixth day after the accident.

There was then a little swelling at the lower part of the fore-arm and
at the wrist: the latter was extended and in a state of adduction;
the fingers were bent. This woman suffered but little, when her hand
was supported and kept still; but the pains became severe, when she
attempted to move it. It was plainly perceived that the radius was
placed before the ulna, and that the bones overlapped each other.

Process of reduction the same as in the preceding case. It was
accompanied by a kind of report, and its completion was clearly
announced by the restoration of the natural shape of the limb, and by
the freedom of its motions. Compresses wet with vegeto-mineral water
were applied to the wrist.

This patient remained fifteen days in the hospital, at the end of
which, she performed with ease the motions of the wrist and hand.




MEMOIR XI.

ON THE FRACTURES OF THE THIGH.


§ I.

1. The os femoris, being in man, a moveable support for the weight of
the whole body, appears to be better secured than the other bones, from
accidents that might affect its continuity. The numerous masses of
muscle that immediately surround it; the thick and compact layers or
fasciæ that form its more exterior covering; and an articulation loose,
and ready to yield, in every direction, to the motions impressed on it,
all seem, on the one hand, calculated for its preservation.

2. But, on the other hand, being visibly curved in its middle, bent at
its upper end almost at a right angle, longer in proportion in man than
in quadrupeds, placed, in most falls, between the ground which resists,
and the weight of the body which presses on it; it would seem, from
these latter circumstances, to be less calculated to resist external
force. And, if to these considerations be added those of the causes
which have an immediate action on it, it will be easy to perceive,
that, in a comparative scale of the bones most exposed to fractures,
it holds, next to the bones of the leg, one of the highest grades. The
proportion which its fractures bear to those of the leg, is, according
to the observations of Desault, as one to three; but to that of most
other bones it is equal if not superior.

3. The os femoris, being in its body irregularly cylindrical and curved
behind, becomes larger towards its lower end, where it terminates in
two articulating masses, which rest immediately on two corresponding
surfaces of the os tibiæ; changing its direction above, it inclines
towards the acetabulum, and inserts into that cavity a round head,
supported by a neck which is entirely enclosed in the capsule of the
joint.

4. From this different conformation of its different parts, arises
such a variety in the fractures which occur in it, that they cannot be
treated of under the same head. Hence the division into fractures of
the body and of the extremities, which is borrowed from anatomists, and
will be followed in the present memoir, where we will consider in order,

    1st, The fractures of its body,
    2dly, Those of its upper extremity,
    3dly, Those of its lower extremity.


FRACTURES OF THE BODY OF THE OS FEMORIS.


§ II.

OF THE VARIETIES AND CAUSES.

5. The os femoris may be fractured indifferently at any point between
its condyls and its neck. But the part where this accident most
frequently occurs, is about the centre of the curve of the bone, where
most of the motions and shocks impressed on it by external violence
expend their force.

6. Whatever may be the seat of the fracture, its direction is sometimes
transverse, but most frequently oblique, a variety which does not
affect the real nature of the disease, but which possesses, as to its
consequences, a very important influence. As in other affections of
the kind, so here, the bone is sometimes affected alone, and, at other
times, to a fracture simple or complicated by means of splinters,
is added an injury done to the surrounding soft parts. Hence result
compound fractures, differently varied, according to the nature of the
parts affected, and to the extent and other circumstances of these
affections. But, as Petit observes, this bone is less frequently
shattered or crushed into several pieces, than those that are more
superficially situated.

7. Extraneous causes are known to render falls more frequent in man
than in other animals, and to multiply in him the fractures of the
lower extremities, by multiplying the action of external bodies on
these extremities. This action may be exerted on the os femoris in two
modes. Sometimes only passive, it merely offers a resistance to the
power which puts the bone in motion; thus, in a fall, the os femoris,
being pressed between the ground which resists, and the weight of the
body that bears on it, bends beyond the extent of its flexibility
or pliancy, and finally gives way. At other times the influence of
external bodies is actively and directly exerted in this accident: thus
a stone, or a piece of timber, falling on the thigh, fractures the
bone, in consequence of communicating to it a degree of motion greater
than its power of resistance.

8. In common, the first mode of division is by a true counter-stroke,
similar to that which fractures the clavicle, the ribs, &c. In the
second mode, the fracture is always direct. The middle part of the bone
is generally broken in a counter-stroke: wherever the direct stroke
is received, that is the place of the fracture which it produces; the
division, most frequently oblique in the first case, is sometimes
perpendicular or transverse in the second. From a counter-stroke result
most commonly simple fractures, while compound ones are usually owing
to a direct stroke.


§ III.

OF THE SIGNS AND THE DISPLACEMENT.

9. In whatever manner a fracture of the os femoris may have occurred
(7), its existence is characterized by the following signs: severe
local pain at the instant of the accident; a sudden inability to move
the limb; a preternatural mobility occurring in some particular part;
a crepitation sometimes distinct, when the two fragments are rubbed
against each other; and a deformity, which may be considered under the
threefold relation, of length, thickness, and direction.[22] These
signs, being common to most fractures, exhibit but few circumstances
peculiar to those of the os femoris, except that of the deformity.
Respecting this circumstance, in particular, it is essentially
necessary to possess accurate ideas, because, having an incessant
tendency to recur, especially in oblique fractures, it must constitute
a primary object of attention during the treatment.

    [22] (_La longueur, l’epaisseur, et la direction._) That is, the
    thigh may be shorter than natural, owing to the ends of the broken
    bone overlapping each other; it may have a protuberance on one
    side, in consequence of these ends being separated or displaced
    laterally; or the direction of the limb may be changed, by a bend
    or angle being produced in the bone at the place of the fracture.
                                                              TRANS.

10. It may be laid down as a general principle, that all fractures of
the os femoris are accompanied with some deformity; the exceptions to
this rule are too few to be worthy of notice. If this deformity be
considered in relation to length, it will be found that, in oblique
fractures, the limb is always shorter than that of the opposite side, a
circumstance which plainly points out an overlapping of the fragments.
But, on examining the place of fracture, it is easy to discover, that
this overlapping arises from the inferior fragment mounting upwards on
the superior one, which itself remains immoveable. Now, what power,
but the contraction of the surrounding muscles, can communicate to the
inferior fragment a motion from below upwards? Attached, on the one
hand, to the pelvis, and on the other to this fragment, to the rotula,
the tibiæ, and the fibula, these muscles have on the former their
fixed, and on the latter their moveable points, and, drawing the leg,
the knee, and the inferior portion of the thigh upward, they produce
the displacement and shortening either mediately or immediately.
In this displacement, the adductores, the semi-tendinosus, the
semi-membranosus, the rectus anterior, the rectus internus, &c. are the
principal agents.

11. The following case communicated to Desault by a surgeon, who
had been formerly his pupil, proves how great the influence of
this cause is; a cause which is indeed generally acknowledged, but
not sufficiently attended to by practitioners, with a reference to
permanent extension. It is this that induces me to relate the case.

CASE I. A carpenter falling under the ruins of his scaffold, was
immediately taken up and carried home, where a surgeon discovered an
oblique fracture of the os femoris, but without any displacement. The
thigh, which appeared even a little longer than the other, was fixed in
an apparatus too slack to prevent muscular action. Next day, the length
of the thigh was the same, but the whole extremity was in a paralytic
state, accompanied by an entire inability to discharge urine.

The moxa was proposed. The patient being placed in the position
directed by Pott, for fractures of the os femoris, the fire was
applied; some movements were the consequence; the application being
repeated on the sixth day, the muscles instantly recovered their power
of action, and then the shortening of the limb became evident, and
still returning immediately after being removed by extension, rendered
it necessary to have recourse to an apparatus calculated for permanent
extension.

12. In this case, the muscular influence is evident. Indeed the shock
having produced a temporary suspension of the excitability of the part,
the fragments remained in place and in proper contact with each other:
but the moxa having awakened the excitability again in the muscles
of the thigh, they resumed their action and caused, as usual, the
inferior fragment to mount on the superior.

13. Hence it follows, 1st, that it is principally to the action of the
muscles that we must attribute the displacement, in the longitudinal
direction of the bone; 2dly, that, as that action, being the effect of
an inherent power, is constantly exerted, the limb must have a constant
tendency to this displacement, particularly in oblique fractures, where
the two extremities of the bone represent two inclined plains, which
readily glide along each other.

14. To this must be still added another cause, which operates
injuriously in the course of the treatment. However solid the bed
may be on which the patient lies, the nates or buttocks, being the
most projecting part of the body, soon form a depression in it; hence
arises an inclination or descent of the plain or surface on which
the body lies. The body therefore sliding downwards, pushes before
it the superior fragment, and makes it overlap the inferior one. In
consequence of this, the muscles, being irritated by the points of
the bones, increase the force of their contractions, and, as we have
already observed (10), draw the inferior fragment upwards. This double
movement of the two ends of the bone in contrary directions, produces
only a single effect, namely, the overlapping of these ends, but
carries this overlapping to a higher degree.

15. Transverse fractures are less exposed to displacement, in the
longitudinal direction of the bone, because the fragments when in
contact, support each other. In such a case, the inferior fragment,
drawn by the muscles, finds a point of resistance against the superior
one, while the latter, when pressed downward by the weight of the body,
pushes the former before it, and thus both preserve their relative
position.

16. A deformity of the fractured os femoris, in the direction of
its cross-diameter or thickness (9), always accompanies that in its
longitudinal direction, and sometimes exists alone. This takes place
when, in a transverse fracture the two ends of the bone, losing their
contact, are carried, the one outward, and the other inward, or when
the one remains in its place, while the other is separated from it. In
such a case, the superior fragment is not, as in the preceding one,
immoveable by means of muscular action; because the action of the
pectineus, the psoas, the illiacus, and the first adductores, derange
its natural direction, and contribute to its displacement.

17. The deformity of the limb, in relation to its direction, in other
words, the crookedness of the limb (9) is either the result of the
stroke which fractured it, or, what is more common, of the ill directed
efforts of those who lift and carry the patient, and, by an improper
position, bend the two fragments, so as to make them form an angle with
each other. Desault was once called to a patient, whom he found seated
on a bed, in such a manner, that the upper part of the thigh was in a
horizontal position, and the lower, hanging with the leg in almost a
perpendicular one. Doubtless the triceps femoralis, equally attached to
both fragments, bends them by its contraction, and produces a change in
the direction of the limb.

18. Whatever may be the kind of the deformity, whether in a
longitudinal or lateral direction, the inferior fragment may either
preserve the natural position in which it is placed, or experience a
rotatory motion on its axis outwards, which is a common occurrence,
or inwards, a circumstance which is more rare. This rotation always
renders the displacement more serious, and ought to have an influence,
as I shall presently observe, on the means of reduction.


§ IV.

OF THE PROGNOSIS.

19. Fractures of the os femoris, though seldom very distressing, in
common cases, from any accidents that immediately accompany them, are
sometimes rendered so, by inconveniences which are the consequences
of them, when they are oblique. Celsus declared, that a shortening of
the limb, more or less considerable, was always the result of such
fractures. Most authors have copied and repeated this assertion, and,
even at the present day, the opinion is advocated by a great number of
practitioners. It must be acknowledged, that, if we compare the natural
powers that are engaged in producing displacement (10 ... 15), with the
artificial resistance made by most of our forms of apparatus, we will
perceive that there is between the two forces so great a disproportion
in point of strength, that the former can never yield to the latter.
But, is it in the nature of all forms of apparatus to be unable to
overcome the force of the displacing powers? Cannot an equilibrium be
established, so as to retain the fragments in contact? The remainder
of the present memoir will throw some light on this problem, which will
become less difficult of solution, if we call to mind, that the action
of muscles, though very powerful at first, diminishes afterwards by
degrees, in consequence of their being kept in a state of permanent
extension; that even a weaker power may, by acting constantly,
accomplish ultimately, what could not have been effected at once, by
another power much stronger, if only momentarily applied; and that
compression made by circular bandages, tends also to diminish the force
and prevent the action of muscles.

Desault has cured, at the Hotel-Dieu, a vast number of fractures of the
os femoris, without the least remaining deformity, and there are but
few of his pupils who have not witnessed his success, some instances of
which will be cited in this memoir.

20. It is, above all, from the well combined use of these two means,
the extension and compression of the muscles, that that success was
derived. The advantage of extension, in diminishing muscular force, is
evident, particularly in the reduction of certain luxations, those of
the humerus, for example, where we are frequently unable to succeed,
till after having extended the muscles for a longer or shorter time.

Fractures of the rotula and of the olecranon, prove equally the utility
of compression in effecting the same purpose; for, when the muscles
are not compressed by a bandage, they draw the fragment upwards with a
double and even treble force.

21. Accidents relating to complications of the fracture, such as
splinters, wounds, &c. are to be classed with compound fractures in
general, and cannot be treated of in this place.


§ V.

OF THE REDUCTION.

22. Two great indications enter into the treatment of fractures in
general, and of that of the os femoris in particular; namely, to bring
the fragments into proper contact, and to maintain them so. Let us
examine each of these in all their details.

Hippocrates, and every practitioner since his time, have replaced
the fragments by what they call extension, counter-extension, and
coaptation.[23] This threefold method, though sanctioned by long usage,
and rendered almost venerable by age, is by no means necessary at all
times in practice, as will presently be observed. Previously to having
recourse to it, it is necessary to place the patient in a suitable
position. But this position varies: most of the moderns adopt, after
the example of the ancients, a horizontal position: so that the thigh
may be extended on the body, and the leg on the thigh. This is the
common practice at present in France.

    [23] A term of nearly the same import with “conformation.”
                                                          TRANS.

23. Pott imagined, on the contrary, that if the lower extremity were
kept in a half-bent position, the muscles, being more relaxed, would
offer less resistance to the efforts of the extension: he, therefore,
proposed to bend the leg on the thigh, and the thigh on the pelvis, and
to lay the patient on his side, a position, which, when first employed
in reduction, was to be continued throughout the treatment, during
which it would render the causes of displacement less active (10 ...
15). Bell adopted this method, which indeed appears to be generally in
use in England.

24. But the difficulty of making extension and counter-extension,
with the limb thus situated, the necessity of making them on the
fractured bone itself, and not on a part distant from the fracture,
such as the lower part of the leg; the impossibility of comparing
the diseased thigh with the sound one, to judge of the regularity
of the conformation; the uneasiness occasioned by this position, if
long continued, though it may at first appear the most natural; the
troublesome and painful pressure of the body on the great trochanter of
the affected side; the derangements to which the fragments are exposed
when the patient goes to stool; the difficulty of fixing the leg with
sufficient steadiness, to prevent it from affecting the os femoris by
its motions; the evident impracticability of this method, when both
thighs are broken; and, finally, experience, which, in France, has
been by no means favourable to the position recommended by Pott: such
were the considerations, which determined Desault to have recourse to
it no more, after having tried it on two patients, in one of whom the
limb was considerably shortened, notwithstanding the most scrupulous
attentions.

25. Besides, all that is gained by the relaxation of some muscles, is
lost, by the tension of several others. The knee cannot be bent without
the triceps flexor being brought into action; an inconvenience the more
serious, as this muscle acts immediately on both fragments. The rectus
anterior, though relaxed by the flexion of the thigh, will be thrown
into a state of tension by the flexion of the leg. The muscles attached
posteriorly to the upper fragment, and even to the superior part of the
lower one, will also in certain positions of the limb be rendered tense.

26. Hence it follows, that there can be no just comparison instituted
as to the position proper for the limb, between fractures of the upper
and those of the lower extremities; that, in the latter, the method
pursued by the English surgeons presents an aggregate or general amount
of inconveniences so great as to overbalance that of its advantages;
and, that the position directed by Hippocrates and the other Greek
physicians (22) ought to be adopted.

27. Having determined on the position, the operator proceeds to
extension and counter-extension, which are to be made first in the
direction of the limb as deformed or altered by the fracture, but must
be changed afterwards according to the natural direction of the thigh.
I need not here repeat the directions for this double operation: common
to all fractures, they contain nothing particular, in relation to
that of the thigh. But, on what part should extension be made? Petit,
Heister, Duverney, and all their predecessors, recommend to apply the
means or powers for making extension above the knee; a precept which
is still to be found in the surgical department of the Encyclopedia. A
strap surrounding the lower part of the thigh, aided by another placed
at the ancle, serves, in this respect, to draw the inferior fragment
downward.

28. Dupouy was the first to remark, that this practice rendered it
necessary to employ great force, and that it would be better to make
extension only on the foot. To this consideration Fabre added that
of the inconvenience of the pressure made on the muscles, a pressure
which, by irritating them and making them contract, multiplies the
obstacles to the reduction.

Desault adopted their doctrine, from nearly the same views of the
subject, introduced it into the Hotel-Dieu, and the success which
attended it, in his practice, contributed not a little to bring it into
general use.

29. For the purpose of making extension, he used the foot as a lever
of the first kind. The two hands of an assistant, grasping it in such
a manner, as to make the fingers cross on the back of it, while the
thumbs, also crossing each other, corresponded to the sole, represented
the power; the articulation represented the centre of motion, or
fulcrum, and the leg together with the lower fragment, the resistance.
The requisite motion was then communicated to the foot, and in that way
was the extension effected. This mode is more advantageous than that
usually employed, where the hands are applied to the lower extremity
of the leg; for the force of the extending power is generally in the
inverse ratio of its distance from the resistance intended to be
overcome.

30. What I have said of extension (28), applies also to
counter-extension. The strap, which was formerly placed for this
purpose in the groin of the affected side, by compressing the
adductores, and the rectus internus, produced in them a contraction,
which, by drawing the lower fragment towards the pelvis, opposed
obstacles to the reduction, which are seldom experienced, when, like
Desault, the surgeon contents himself with having the trunk held by
assistants, either exclusively at the hips, or both at the hips and
under the arm-pits. The resistance being always easily overcome in this
affection, renders it unnecessary to have recourse to more powerful
means.

31. Hippocrates advises, in fractures of the os femoris, to aid
extension by coaptation, performed with the hand. All practitioners,
since his time, have added this third manœuvre or process to the two
first, namely, extension and counter-extension. But, what effect
can the hands produce, in most cases, on the bone through the thick
covering of the soft parts? Are we able to communicate to it through
such a mass whatever lateral movement we please? Being quite lost in
the intervening soft parts, will our efforts reach the bone, in the
direction which we give them? The muscles bring the fragments into
contact, much better than we can, as soon as extension has removed
their overlapping. Indeed, if well executed extension makes the lower
fragment return along the same track which it pursued in becoming
displaced, it will then be inevitably brought into contact with the
upper one by the contraction of the muscles. Besides, in most oblique
fractures, is it not evident, that the lower fragment must be made
to slide from above downward, on the inclined plain presented by the
upper one, and on which it has slided from below upward, in becoming
displaced? Is it while extension is making that coaptation ought
to be performed? Certainly not: because, if the extension be well
directed, an attempt at coaptation will derange it; and if it be not
well directed, its course ought to be changed. Is it after extension
is finished that recourse ought to be had to coaptation? By no means:
because if there be then any remains of deformity, it must be owing to
extension having been improperly directed. The remedy, therefore, is,
to renew the extension, and direct it properly.

32. Hence, it follows, in general, that coaptation is here a feeble
assistant towards reduction; that if it renders any service, it is
only in cases of displacement laterally, or in the direction of the
cross-diameter of the bone; and that it is by giving the proper
direction to extension, by managing it according to the disposition of
the muscles, and by knowing when to augment and when to slacken it,
that the fragments are brought into regular contact.

33. If the inferior fragment has experienced a rotatory motion on its
own axis outwards or inwards (18), the assistant ought, in making
extension, to turn the limb very gradually in the opposite direction.

34. Extension was formerly attended with difficulties, which are
rarely met with at the present day. Oftentimes, if we give credit to
authors, it was altogether useless to endeavour, in the first instance,
to reduce the fracture, and restore the limb to its natural length,
as the contraction of the muscles rendered the operation absolutely
impracticable. Hence, applications of a soothing and sedative nature
were employed, previously to an attempt at reduction. The following
circumstances have been assigned as the cause of these difficulties.
The upper strap, irritating and drawing upwards the adductores and
the rectus internus, drew the lower fragment in the same direction,
while the semi-tendinosus, semi-membranosus, biceps, &c. being drawn
downwards by the lower strap applied over them, drew the pelvis also
downwards, and, consequently, the superior fragment connected with it.
From this double action arose a double motion directly opposed to that
which ought to be produced by extension.

35. There are still cases, where the muscles, in consequence of
being irritated by projections or points of bone, by the efforts of
the assistants, and by a morbid state of the nerves, increase their
contraction to such a pitch that no practicable force can bring the
fragments into apposition. What means are then to be employed? All
those, in general, that diminish irritability, varied according to
circumstances, such as diet, venesection, &c. In such cases, Desault
obtained the most happy effects, by placing the limb in a state of
continued extension; fatigued by the permanent tension in which they
are thus kept, the muscles relax by degrees; their force diminishes; at
length they yield, and the reduction is accomplished.


§ VI.

OF THE MEANS OF MAINTAINING THE REDUCTION.

36. The mere reduction of a fracture of the os femoris, is but one step
towards the cure. In this, more than in the fracture of any other bone,
causes which act incessantly (13) tend to subvert the momentary work of
art; it is here, then, in particular, that means ought to be devised
for maintaining this work. But, the first of these means is a suitable
position of the limb. I have already mentioned the inconveniences
that result, both as to the reduction and subsequent treatment, from
that proposed by Pott (24 ... 26). The patient must, then, be laid
horizontally on a plain exactly even, and not capable of being affected
or rendered uneven by the weight of the body. Instead of feather beds
generally used in other cases at the Hotel-Dieu, Desault, in cases of
fractures, substituted firm and hard mattresses, which, not sinking
in the least, by the pressure of the body, give no cause to apprehend
those continual displacements, to which a soft bed exposes the patient.
These mattresses supersede the advice of certain authors who direct a
plank to be placed under the patient.

37. The second means, not less efficacious than the first, consist
in the forms of apparatus, in which the limb is placed, and which,
being differently modified according to the fancies of their different
authors, present us with an assemblage of various splints, compresses,
&c. To appreciate, with accuracy and correctness, the advantage and
disadvantage of these, let us first unfold the curative indications
which they ought to fulfil; we will then compare their mode of
action with these indications, from whence will result, as necessary
inferences, the object of our research.

38. The intention of every form of apparatus being, to prevent the
displacement of the fragments, the causes of this displacement ought to
be the basis or foundation of its mechanism and construction. But these
causes in the present case are, 1st, the muscular action drawing the
inferior fragment upwards (10); 2dly, the weight of the body pushing
the superior fragment downwards (14); whence every form of apparatus
intended to keep the os femoris in place when fractured obliquely,
ought, 1st, to draw the lower fragment downward and retain it there;
2dly, to draw and retain upwards the superior fragment, and the trunk
which bears on its upper end. This principle is applicable generally,
and subject only to a few exceptions which I shall notice when treating
of transverse fractures, where the displacement is lateral, or in the
direction of the cross-diameter of the bone, or where no displacement
at all exists. 3dly, The apparatus must also be so constructed as to
prevent the rotatory motions of the lower fragment (18), and secure the
immobility of the limb, lest by means of some motion being communicated
to it, the fragments might be deranged.


§ VII.

OF THE MANNER IN WHICH THE DIFFERENT PIECES OF THE APPARATUS ACT.

39. If to these indications we compare the mode of action of the
different pieces that unite in composing our common forms of apparatus
which do not make permanent extension, such as common bandages,
splints, compresses, bolsters, &c. we will perceive that they are
but ill calculated to fulfil them: and first of bandages. Whether
the common roller, or the eighteen-tailed bandage be employed,
their mode of operation is the same: their only action is, to add a
second exterior and artificial covering to the natural cutaneous and
aponeurotic covering of the thigh; to press against the fragments
the muscles which form for them a kind of natural case intended
to keep them in apposition; and to augment, by this pressure, the
lateral resistance of the soft parts. By this contrivance, lateral
displacements will, in part, be well guarded against, and, in this
respect, these bandages are useful in transverse fractures. But what
is there in them to prevent the two inclined plains of an oblique
fracture from sliding on each other? What provision is there in them
to secure the limb from the effects of motions and shocks which may
be accidentally impressed on it from without? Will the pelvis be kept
steady by them? or will muscular action be sufficiently checked and
kept under by them? The force of the muscles will indeed be slightly
diminished by means of compression; and to make this compression is
the principal use of these bandages in oblique fractures. But will mere
compression be sufficient to prevent a displacement in the longitudinal
direction of the bone, particularly if the rollers be slack, as certain
practitioners recommend, on the ground of the fallacious theory of
Duhamel, who conceived, that a constriction too tight, would injure the
action of the periosteum, which, according to him, is the sole agent
in the formation of callus? So much, then, for bandages, whose only
use is to prevent, by compression, the swelling of the limb, and to
diminish, in some degree, the contraction of the muscles, which they
press against the fractured bone.

40. These remarks apply equally well to the use of compresses; which
make but a very feeble resistance against a powerful cause, and cannot
be considered as any obstacle whatever to displacement. What can be
said of those surgeons who, from servile attachment to a particular
form of apparatus, do not consider a fracture as reduced, unless a
certain quantity of compress secured by a given quantity of roller, be
applied on the limb. Servile imitators in an art which calls for genius
in its votaries, they are only capable of following, without reflection
or judgment, the steps of their predecessors.

41. Bandages will do nearly as much harm as good in fractures of the
os femoris, if, as was practised by the ancients, they be formed
by a single roller surrounding the limb: in such a case, the limb
being necessarily raised up at each time of their reapplication,
will be exposed to continual displacements. Hence the ingenious
idea of applying to simple fractures of the lower extremities the
eighteen-tailed bandage, invented for compound fractures, and by means
of which the thigh may be suffered to remain at rest. But to this
bandage belongs also an inconvenience. The pieces which compose it,
being stitched together, cannot be separated, and if one of them be
soiled they must all be changed. Hence the superiority of the bandage
of slips, known in former times, and engraved by Scultel, but long
since forgotten, till Desault revived the use of it, and adopted it
exclusively, both in simple and in compound fractures.

42. Splints of different kinds, which form the second division of the
pieces of apparatus, used for fractures of the os femoris, have the
advantage of fixing the limb in a solid and firm manner, and securing
it from any displacement that might result from jolts, or muscular
contraction, arising from the inattention of patients: these prevent,
more effectually than bandages, any displacement laterally, and, on
this account, their use is sufficient, even without extension, in
transverse fractures: they also prevent, particularly if they be made
of wood, the rotatory motion of the thigh either outwards or inwards
(18). But if the division be oblique, will they prevent the gliding of
the fragments over one another, and the consequent shortening of the
limb? They can evidently produce this effect in no other way, than by
the forcible pressure made by the pieces of apparatus, particularly
by the straps or bandages that secure the splints, and then, to
make effectual resistance, it would be necessary to apply them with
such a degree of tightness as would endanger the life of the limb.
Will splints prevent the trunk from sinking downwards, and pushing
the superior fragment before it? Will they prevent the muscles from
acting on the lower fragment? Can they, in a word, fulfil all the
indications formerly pointed out (28)? Certainly they cannot. Splints,
then, are calculated only to prevent displacement in the lateral or
cross direction of the bone, and to secure, better than bandages, the
immobility of the limb. Whence it follows, that they ought not, in
this case, to be confined to the thigh alone, but should extend to the
leg, whose movements, if communicated to the os femoris, may derange
the contact of the ends of the bone. The neglect of this precaution,
contributed formerly not a little to displacement and deformity.

43. In former times a kind of splints was in use, which were made by
securing bundles of straw round sticks proportioned in length to the
length of the limb to which they were to be applied. But as these,
from being of a round or cylindrical form, touched the limb with but
a narrow surface, they did not retain the fracture with sufficient
firmness. They were, therefore, very properly exchanged for flat and
strong wooden splints, (such as Desault used) which retain the fracture
much better, in consequence of presenting to the limb a broad surface,
and thereby rendering it in some measure immoveable.

44. The bolsters for filling up interstices, being less intended to
prevent displacement, (in which respect they are, notwithstanding
useful) than to guard the limb from the immediate pressure of the
splints, usually consist of several folds of old linen; this is the
form adopted at the Hotel-Dieu; but to these Desault preferred small
pallets or bags filled with chaff, which, fashioned according to the
form and disposition of the limb, may, at the pleasure of the surgeon,
be made thicker or thinner, to suit the inequalities of the surface, in
consequence of the ease with which the chaff may be moved from one part
of the bag to another.

45. From the foregoing examination of the action of bandages and
splints, it appears, that the common apparatus, formed by their union,
but not calculated to effect a permanent extension, may perhaps answer
in cases of transverse fractures, which indeed but rarely occur, but
are always insufficient when the division is oblique, because they
cannot fulfil the double indication of drawing the inferior fragment
down, and retaining the superior one up (38).


§ VIII.

OF PERMANENT EXTENSION, AND THE MEANS OF EFFECTING IT.

46. By what means then can this indication be effectually fulfilled? By
that which will perpetuate, throughout the whole treatment, the action
of those means by which reduction was effected; by that which, to the
ever active power of the muscles, will oppose a resistance constant in
its action; by that which, forming on the exterior of the thigh a kind
of artificial muscle, may become an antagonist to the natural muscles
of the part, and neutralize their efforts, by acting in a contrary
direction, and which, by pushing up the pelvis and retaining it there,
may prevent it from being pushed downward by the weight of the trunk
(14). But what other mean than that of permanent extension, unites
these advantages? Whatever form of apparatus may be employed to obtain
it, it is permanent extension alone that can prevent the displacement,
because it alone is founded on principles calculated to meet and
obviate the causes by which displacement is produced.

47. The ancients, though less informed than we are respecting the
nature of these causes, knew better how to appreciate their effects.
All their forms of apparatus made a permanent extension, a measure
which has been abandoned by most of the moderns, and regarded, even
at present, in France, by a great number of practitioners, as always
dangerous, and seldom useful. Let us set in opposition to the vain
fears which it inspires, a few thoughts, and much experience.

48. It is from the very object which is proposed to be attained, that
the first difficulties arise. What must we think of a limb in a state
of preternatural tension, where all the parts being overstretched must
experience an uneasiness not to be supported? I answer, that it is not
a preternatural elongation that extension produces; on the contrary,
being intended to prevent a preternatural shortening, it has for its
object to restore the parts to their ordinary state, and to give to the
muscles their habitual degree of tension, by opposing such contractions
in them as are not habitual: under this point of view, it performs,
in relation to the muscles, those very functions which are discharged
by the bone itself, when sound and unbroken, as is fully experienced
by all patients, when the apparatus is applied. Its use not only does
not increase pain, but is alone calculated to diminish it, because, by
bringing the fragments into apposition, it prevents the soft parts from
being irritated by the points of the bones.

49. Is the swelling of the limb to be dreaded, as some pretend? But
whence can this swelling arise? From the over-stretching of the parts?
I have already proved that they are not over-stretched. From the
pressure of the straps? Perhaps this cause might produce a swelling,
if, as formerly, it were applied above the knee; but, by placing it, as
Desault did, near to the ancle, by surrounding, with a thick compress,
the lower part of the leg, where the straps pass, and by securing the
foot with a tight bandage under the straps, if their action be dreaded,
this fear must be done away; and, besides, experience, which is the
only true test of the dangers of a process, by no means justifies the
apprehension. The venæ saphenæ and the absorbents that accompany them,
are free from the compression, which bears principally on the tendo
Achillis, and the malleoli.

50. What shall we say in reply to the censure thrown on the process of
permanent extension, in the memoirs of the academy, where it is charged
with having been oftentimes productive of ulceration and even gangrene,
in consequence of the pressure of the upper strap? What method can
escape censure, if it be unskilfully pursued? What process will not
be injurious, if mutilated and ill managed by ignorance or a want of
discretion? To represent the thing properly, let us suppose the worst:
a circular bandage, in consequence of being drawn too tight, produces
mortification in the subjacent parts; must circular bandages be on
this account entirely rejected? An unskilful hand, in an operation for
cancer, opens the axillary artery; must we therefore cease to search
under the arm-pit for schirrous glands?

51. Permanent extension is, say some, insufficient to overcome muscular
action; it is opposing to a power equal to 1000, a resistance equal to
only 100. But this force of the muscles, which is oftentimes so great
at the time of reduction, diminishes gradually, by the pressure of
the bandages, by the immobility of the limb, and, above all, by long
continued extension; for a continued effort equal to 10, will soon
perform what could not be effected by a temporary exertion of a force
equal to 100. Let us pass over the more minute objections made against
permanent extension, and search among the different modes of performing
it, that to which practitioners ought to give a preference.

52. We may throw into two classes the general modes proposed by
different authors for effecting permanent extension. Under the one are
included those modes requiring simple means, such as straps, splints,
&c. while the other embraces such as, from being complex, necessarily
call for the use of different machines.

53. In the first class are comprehended:

1st, The method employed in the first instance by the Arabians, adopted
afterwards by their successors in medicine, and proposed, at a still
later period, by Petit, Heister, and Duverney, and which consists in
fixing, at the head and foot of the bed, during the whole treatment,
straps intended for the purpose of extension.

2dly, The mode of extension, adopted by many practitioners, which
consisted in suspending to a strap fixed at the knee, and reflected
over some suitable body, a weight proportioned to the power of the
cause which it was intended to combat.

3dly, The ingenious idea of Bruninghausen, who, confining by a kind of
stirrup, the diseased leg against the sound one, made the latter serve
as a splint to retain the fractured limb on its proper line, and thus
preserve its natural length.

4thly, Under this class also must we arrange the means employed by
Desault, and which we will presently describe.

54. The second class of means invented for the purpose of making
permanent extension, in fractures of the thigh, comprehends:

1st, The Glossocome, the bed of Hippocrates,[24] and other machines,
used by the ancients, to effect a reduction, in fractures of the os
femoris, and, at the same time, to maintain the reduction, by being
left on the limb.

    [24] (_Le lit d’Hippocrate._) As many of the machines mentioned
    here have probably never been seen in this country, and as there
    is, perhaps, scarcely one of them used, at present, in any country,
    I shall not consume the time of the reader by troubling him with
    descriptions of them.                                     TRANS.

2dly, Numerous machines, invented for the purpose of suspending a
weight intended to make extension. These have been differently varied
and modified, more by the imagination than the judgment. Engravings of
some of them are to be found in Scultet, Fabricius of Hilden, Pare, &c.

3dly, The machine of Bellocq, proposed to the Academy of Surgery, a
description of which is contained in their memoirs, and which possesses
an advantage not found in the others, namely, that of taking its point
of extension at the lower part of the leg.

4thly, The machine of Nook, surgeon at Norwich, improved by Aitkin, an
engraving of which is given by Bell.

5thly, A new Glossocome, published in the works of Manne, and a great
number of other machines, the ephemeral offspring of the genius of
their authors, the utility of which experience has seldom confirmed,
and which were even dead-born in the opinion of practitioners. I barely
mention these, because a circumstantial description of them would lead
me from my subject.

55. We may discover at a single glance the comparative merits of
these two classes of apparatus. Extension produced by simple means,
such as straps, splints, &c. (50), may at all times, and under all
circumstances, be had recourse to; because the means necessary for
making it may always and every where be found. Are we desirous, on
the other hand, of having recourse to machines (54)? These are seldom
at hand, and oftentimes not to be obtained: the expense attending the
purchase of them, prevents most surgeons from procuring them. They no
doubt possess the advantage of multiplying forces, and rendering them
more powerful: but, I have already said (51), that a gentle resistance,
if long continued, is sufficient to overcome at length the contraction
of the muscles, though at first extremely active and energetic.

56. In the first point of view, the first class of means is doubtless
preferable to the second. But they both partake generally of the
inconvenience of placing the point of extension above the knee. I have
already mentioned the effects which this produces with respect to
muscular action, at the time of the reduction (28). To the injurious
effects there stated may be added the swelling of the limb, arising
from the compression made by the straps, the disadvantage of the
mobility of the leg, which is not fixed, and the motions of which,
being communicated to the thigh, may separate the fragments after they
have been brought into apposition. Further, the straps may readily
slip down over the knee, and thus leave the fragments subject to the
mischievous influence of muscular contraction.

57. To these general disadvantages, add those peculiar to each form of
apparatus, which are too tedious to be detailed at present, and you
will perceive, that the little success hitherto obtained from continued
extension, is owing, not to the nature of the measure itself, but to
the manner of employing it, and that, in the present case, as in cases
of fractured clavicles, another step towards perfection remained to be
made.

58. Desault, in the first instance, attempted only to improve the
ancient process, which consisted in fixing the straps for extension to
the foot and head of the bed. He remedied the inconvenience of fixing
the straps at the knee, by doing, throughout the whole treatment,
what Fabre and Dupouy did only at the time of reduction (29); that
is, he placed the seat of extension at the foot. The hold for
counter-extension was also changed. This he made by a bandage for the
body, fastened round the breast, and drawn only moderately tight, lest
it might impede the patient’s respiration. The rest of the apparatus
was nearly as I shall presently describe.

59. This was, for a long time, the only apparatus which Desault used.
He introduced it into the Hotel-Dieu, after having employed it at the
hospital of Charity, with great success. In the mean time, the utmost
care and attention were here indispensable: every day it was necessary
to examine the rollers several times, as they readily became relaxed.
The pelvis, not being well secured, could communicate motion to the
fracture: it was difficult to raise the patients to the close-stool.
Besides, the slightest disease of the chest, rendered the pressure
of the body-bandage insupportable. It was this very inconvenience
which, having, in a certain case, rendered the preceding apparatus
inadmissible, suggested to Desault the following one.

60. This consists, to speak in general terms, in taking the points of
extension, above, on the tuberosity of the os ischium of the diseased
side, and below, on the malleoli; in securing the straps or rollers,
destined for making extension, on the two ends of a strong splint,
placed along the outside of the limb; and in converting, so to speak,
the pelvis, the thigh, the leg, and the foot into one entire and solid
piece.

The pieces which compose it are, 1st, A common junk-cloth[25] (FFF
plate II.), accommodated to the size of the limb and the splints:
2dly, a bandage for the body (BB) and one passing under the thigh (H)
to secure the first on the side opposite to the fracture: 3dly, three
stiff splints, an inch and a half wide, the external one of which (AA)
being very strong, must be long enough to extend from the spine of
the ileum, to the distance of four inches below the sole of the foot.
This splint is hollowed out or notched at its lower end, and has a
mortise in it a little higher up. The upper splint (CC) occupies the
space included between the fold of the groin and the upper part of the
knee: and the internal one, which reaches from the upper and internal
fold of the thigh, to the sole of the foot: 4thly, three bolsters, an
external, an internal, and an upper one (d d d d) consisting of small
bags of chaff: 5thly, a bandage of strips (E) accommodated as to number
to the circumstances of the case, separate from one another, each three
inches broad, and long enough to go twice round the limb, arranged from
below upwards, and overlapping each other, about one third of their
breadth: 6thly, one long and two circular compresses, intended to be
applied immediately on the limb next to the skin: 7thly, two strong
rollers (g g and L) intended for extension and counter-extension, at
least an ell and a half long: 8thly, one long and thick compress, and a
sufficient number of bits of tape.

    [25] (_Drap-fanon._) This is a piece of linen or muslin (Desault
    appears to have used flannel, which is not however so good) spread
    under the broken limb, reaching in length from one end of it to
    the other, and wide enough to go about twice round it. It is to
    be folded at its edges several times round the internal and the
    long external splints, in order to retain them the better, and
    make them bear with more steadiness and advantage on the limb. The
    junk-cloth and these two splints, when properly applied, form a
    kind of soft elastic case, in which the limb rests. This case is of
    service in securing the bolsters in their places. The junk-cloth is
    the outside piece of the apparatus, except the bits of tape which
    go round and secure the whole. In arranging the different pieces,
    therefore, on the bed or mattress, where the patient is to lie, the
    surgeon places the tapes first, the junk-cloth next, the bandage of
    strips next, and so on, in an order the reverse of that in which he
    afterwards applies them on the limb.                        TRANS.

61. Every thing being ready, previously to putting the patient to bed,
the pieces of apparatus are to be arranged on that part of the bed
corresponding to the fractured thigh, in the order in which they are
to be successively applied. If the patient has been already laid in
the place where he is to remain, the limb must be raised with great
caution, and, during the extension, each piece gently slipped under it,
or the whole must be passed under at once, being first rolled round the
several splints, in such a manner, that the apparatus requires only to
be opened.

62. Extension is now made in the mode already pointed out (29 and 30),
and then the application of the apparatus is begun, for which the
surgeon must be situated on the external side of the fractured thigh,
while an aid, placed on the other side, gives him assistance.

1st, On the thigh, next to the skin, are first applied the long and
circular compresses, accurately spread out so as to have no wrinkles
in them, and previously wet with vegeto-mineral water. Around it are
then applied, in succession and from below upwards, each strip of the
bandage (EE) moderately tight.

2dly, The lower end of the leg is now covered with a thick compress,
intended to prevent the impression of the roller (L), which is fixed
in such a manner, that its middle is first laid on the tendo Achillis,
a little above the heel, while its two ends, crossing each other on
the upper part of the foot, are carried on each side to its sole,
where crossing again, they are then laid down till the close of the
application of the apparatus.

3dly, Along the thigh are placed laterally two bolsters, which, from
their thickness being easily increased or diminished in consequence of
the moveable nature of the chaff, mould themselves to the inequalities
of the limb.

4thly, Around the two lateral splints, the surgeon and his assistant
roll, each on his respective side, the two edges of the junk-cloth, so
that both splints, by being accurately applied on the bolsters, may
make a uniform compression on the whole part.

5thly, The third bolster (d d d d) is then applied on the anterior part
of the limb, and over it the splint (CC).

6. The bits of tape passed under the apparatus to the number of four
for the thigh, and three for the leg, are tied in succession on the
external splint, lest the knots, should they correspond to the thigh,
might, by their contact, prove troublesome. That one next to the
fracture is tied first, and they are all drawn as tight as the patient
can bear them without uneasiness.

7. The body-bandage is now fixed on the pelvis, in such a manner, as
to secure laterally the external splint, and is itself retained by the
sub-femoral bandage (H), that is, the bandage passing under the thigh.

8. A thick compress placed beneath the tuberosity of the ischium,
serves as a cushion or bolster to protect the part from the pressure
of the roller (g g) which, being passed first under the apparatus,
and drawn afterwards obliquely from within outwards, and from above
downwards, takes its points of bearing or action, in one part, on the
tuberosity of the ischium, and in the other, on the upper end of the
external splint, and is tied in the fold or hollow of the groin.

9. The two ends of the bandage (L) previously made to cross each other
on the sole of the foot, are passed the one through the mortise, and
the other through the hollow or notch in the lower end of the same
splint, and then, being drawn forcibly, are tied in a firm knot, so as
to act as a substitute for the hands of the assistant, who now lets go
the patient’s foot.

10. If the roller (g g) become relaxed, it is tightened again, and the
patient being laid in a suitable position, the limb is protected from
the pressure of the bed clothes, by a kind of basket placed over it.

11. A roller (K k) laid first on the sole of the foot, and then brought
across over its upper side, and fastened laterally to each splint,
serves to secure that part from turning outward or inward, and thus
prevents the rotation of the limb.

63. If the mode of operation of this bandage be compared with the
general indications formerly established (38) for all oblique fractures
of the os femoris, it will be easy to perceive that, conformably
to those indications, it tends, 1st, to draw the inferior fragment
downward; 2dly, to retain the superior one up; 3dly, and to prevent the
rotation of the lower fragment, and secure the immobility of the limb.

64. It is evident that the bandage or roller (g g) so unites the
pelvis to the external splint (AA), that the latter cannot be pushed
upwards, without drawing the former in the same direction, as well as
the superior fragment which adheres to it. But if, after this roller
is fixed, the lower one (L) be tightened, the first effect produced
is, to push the external splint forcibly upwards; the second, to draw
the leg, and with it the inferior fragment downwards; so that, by
fixing the roller (L) in the notch and mortise of the splint with the
necessary degree of tightness, extension and counter-extension are made
permanent. By this means the muscles, being kept on a stretch, lose by
degrees their power of contraction, which is still further diminished,
by the immoveable state in which they are kept, and by the compression
made on them by the bandage of strips. So that, on the one hand, the
inferior fragment will have no tendency to rise upwards, and even if it
had, it will meet with a sufficient resistance to prevent it; while, on
the other hand, the superior fragment will not be pushed downwards by
the pelvis.

65. To this advantage is added that of a state of perfect immobility.
The pelvis, the leg, the thigh, and the foot being firmly fixed on the
external splint, constitute one entire whole, all the parts of which
must retain, with respect to each other, the same relative position.
Should even a stroke be accidentally given to this assemblage of parts
now converted into a solid whole, each portion of it will move at the
same time, there will be no partial motion, and the relative position
of the parts will not be changed. Hence the advantage of being able to
raise the patient without apprehension; a most desirable circumstance
indeed, in a position so painful and so long continued (26). The
external splint, being extended beyond the sole of the foot, prevents
the lower fragment from obeying a tendency, which it sometimes has,
to displace itself by a rotation on its axis. Should this tendency
be towards the internal side, an occurrence much more rare, the
lengthening of the internal splint will effectually prevent it.

66. These considerations induced Desault to renounce his ancient
mode of making permanent extension, and employ this exclusively, in
the latter years of his practice. Like all other kinds of apparatus,
formed principally of rollers, this is very subject to become relaxed;
and requires, therefore, great attention on the part of the surgeon.
It ought to be examined attentively every day, particularly the two
extending bandages (L and g g). As soon as they become relaxed, they
must be immediately tightened again: without this precaution, the
effect of the apparatus will be lost. Be vigilant also, with respect to
the compress placed between the roller (g g) and the tuberosity of the
ischium. Should this slip, the roller being frequently tightened, and
pressing immediately on the skin, may produce excoriations and ulcers
difficult to be healed, particularly in females. The roller itself may
slip, and then, having no longer a solid point of support and action on
the tuberosity of the ischium, it makes extension in but an imperfect
manner.

67. One of the charges brought against this apparatus is, the facility
with which the upper roller becomes displaced, a facility that imposes
a degree of care and attention, of which few surgeons are capable, and
which, when bestowed even by Desault himself, did not always prevent
the shortening of the limb.

68. Further, the extension made on the fold of the thigh, partakes,
a little, of the inconvenience that accompanied the ancient mode of
reduction, namely, that of compressing and irritating the muscles of
the upper and internal part of the thigh (30). This inconvenience would
be still more sensible, if, for want of extending to a sufficient
distance up the pelvis, the upper splint should allow the roller to
cross the muscles at an angle somewhat acute, as it would then enclose
and press on the greater part of them.

69. If some unfavourable cases, resulting without doubt from these
inconveniences, did occur in the practice of Desault, a multitude
of successful ones still attest the advantages of this method; and
there is not a pupil who attended any time at the Hotel-Dieu, without
witnessing them. I will relate but one case, collected by Chorin, to
furnish a detail of the treatment subsequent to reduction, referring
the reader for further information to the Journal of Surgery.

CASE II. Theresa Little-John, aged 45 years, fell, drawn by the weight
of her own body, through a window in a balcony, from which she was
leaning. She was instantly taken up, carried to her own house, and from
thence to the Hotel-Dieu, which she entered on the 28th of October,
1790. From the signs mentioned (9), a fracture was discovered towards
the lower part of the thigh; its oblique disposition required an
apparatus to make permanent extension. This was applied in the usual
manner, and, in an instant, the patient, who had experienced, since her
fall, severe pain, became calm, and was completely relieved.

In the night, pains returned; agitation; some spasmodic motions; an
anodyne draught administered in the morning. In the course of the
day, these troublesome symptoms disappear; a slight swelling at the
ancle. Third day, no pain; swelling gone; aliment increased. Sixth
day, patient permitted to return to her usual regimen; extending
rollers relaxed; lower one tightened: eleventh day, apparatus renewed;
fragments in perfect contact: thirteenth day, limb moved incautiously;
a slight shortening; apparatus reapplied; extending bandages drawn
tight: sixteenth day, a disposition slightly bilious; evacuants
administered with success: twenty-fourth day, a third application of
the bandage: thirtieth day, progress in consolidation already very
evident; the limb straight: fortieth day, extending rollers laid aside:
fifty-second day, consolidation complete without the least deformity.

70. The muscular force, in children, being weak, and the weight
of the body inconsiderable, have, in general, much less influence
in producing a displacement in them than they do in adults. When,
therefore, fractures occur in subjects under six or seven years old,
the resistance, on the part of the apparatus, need not be so great. In
general the lateral pressure which it makes, and the bearing of its
different pieces against the limb, are sufficient to prevent the return
of deformity, when this has been perfectly removed by reduction.

71. In such cases Desault covered the thigh with a circular bandage,
made of a roller seven ells long, and three inches broad. Beginning
with this below, near to the condyls, he carried it upwards, by oblique
and reversed turns, to the pelvis, round which he threw a cast; then,
giving the ball into the hand of an assistant, he applied four splints,
one before, another behind, and one on each side: directing these to
be held at their lower part near to the knee, he resumed the roller,
and secured them firmly by a second series of circular and reversed
turns, descending to the lower extremity of the thigh. The limb was
then placed in a proper position, and, in general, of whatever kind
the fracture was, whether oblique or transverse, this simple bandage,
without the aid of permanent extension, was sufficient to retain it.

72. It would be difficult to determine the period necessary for the
consolidation of fractures of the os femoris. Numerous circumstances
concur to influence this work of nature, which is, in general, extended
beyond the term of forty days, vulgarly assigned to it by the people
at large. Besides, a stiffness of the limb, the inevitable effect of
its long state of rest, still adds to the length of the patient’s
confinement, by retarding the necessary motions, the return of which,
as in other similar cases, can be accelerated only by exercise.

73. Complicated fractures of the os femoris, being included in the
general class of solutions of continuity of that description, cannot
be at present particularly considered. We will only remark, that here,
in like manner, as in fractures of the clavicle, permanent extension
constitutes the most effectual method of preventing the pains,
oftentimes insupportable, occasioned by splinters or points of bone
irritating the soft parts, from being pressed against them by muscular
action in its tendency to shorten the limb.


§ IX.

OF PERMANENT EXTENSION IN OLD FRACTURES.

74. I will close this article by a few remarks on the advantages
of permanent extension in old fractures. Nature reunites fractures
differently, according to the relation of the divided surfaces to each
other. Are those surfaces in perfect contact? If so, they are chiefly
instrumental in the formation of callus, which then probably acts in
a manner similar to the reunion of wounds. On the other hand, does an
overlapping of the fragments separate the divided surfaces from each
other; the reunion takes place then principally on the sides, by a kind
of enlargement of the bones, produced no doubt by the periosteum. Such
is the mode of consolidation, which, on opening dead bodies, is found
in most oblique fractures of the os femoris, succeeded by a shortening
of the limb.

75. Hence it follows, that this shortening, which would readily yield
to extension, at the time of the fracture, becomes obstinate in its
resistance, in proportion to the age of the accident. In such a case,
indeed, the substances destined to reunite the overlapping fragments,
acquiring daily more and more solidity, oppose to the reduction
obstacles constantly increasing. Hence, most practitioners regard
this reduction as beyond the resources of art, after the expiration
of the twelfth or fifteenth day. Nor is this opinion entertained
without some foundation, for at a later period, almost all efforts at
reduction, however powerful, have proved unavailing. But that which
cannot be performed by a very powerful effort, acting momentarily, is,
notwithstanding, oftentimes easily attainable by a much weaker one,
provided it be long continued. The following cases are in proof of this.

CASE III. Ann Gallot, of Melun, aged sixty-nine, having fractured her
right thigh, by falling down the steps of a cellar, remained twenty-two
days without assistance, and without even knowing the nature of the
accident, when, on consulting a surgeon, she was sent to the hospital
at Versailles. From the long standing of the disease, a reduction
being despaired of, and no one being willing even to undertake it, the
patient was sent to the Hotel-Dieu, on the 27th of February, 1791.

A shortening of four inches distinguished the diseased thigh from the
sound one. The overlapping was sensible to the touch: in the mean
time, a slight mobility at the place of fracture, inspired a hope of
being able, if not to restore to the limb its natural form, at least
to diminish the contraction. Several efforts were made at first, but
without success, as Desault foresaw. The apparatus for permanent
extension was applied: on the day following, the extending rollers
being a little relaxed, were again tightened. Fourth day, a sensible
increase in the length of the limb; apparatus renewed. Ninth day, the
left thigh but an inch longer than the other: eleventh day, equality
in length almost re-established. After this, the apparatus was kept
constantly applied and renewed from time to time.

Fortieth day, consolidation already perceptible: forty-sixth day,
symptoms of a putrid fever have made their appearance: fiftieth day,
symptoms worse; fifty-second, something better: fifty-fifth, worse
again: fifty-seventh, dead. On opening the body, an oblique fracture
was found, its surfaces very nearly in apposition, and already united
by a very solid callus.

CASE IV. Joseph Maugrin, a saddler, broke his thigh in the month of
July, 1793. A surgeon being called to him, placed his limb in an old
form of apparatus, which did not prevent a shortening, to the extent
of an inch and a half, from showing itself on the following day: hence
a new reduction, and a new application of the apparatus: but soon
afterwards, another shortening; the same means to remove it; the same
failure of means. Weary of such trials, the surgeon abandoned the limb
to its fate, contenting himself with merely keeping it in the apparatus.

On the twenty-ninth day, Desault being called in consultation, and
finding the thigh shorter by three inches than that on the opposite
side, proposed permanent extension, persuaded that this expedient alone
would soon be sufficient to re-establish the contact of the fragments.
The proposal was acceded to. On the day following, the effects were
already perceptible; the thigh was lengthened by almost an inch. By the
sixth day, it was equal in length to the other: during this period, the
extending rollers were tightened twice a day.

At the end of two months the consolidation was complete, and the
patient walked perfectly well, except that there was a little
shortening of the limb, trifling though indeed, compared to what would
have been the consequence, had the original treatment been continued.

76. The lengthening of the limb, in these cases, was evidently owing to
the continued action of the apparatus, which effected, in a length of
time, what the momentary efforts of the surgeon could not accomplish.
This it did, by destroying or gradually lengthening the medium of
union, which already connected the overlapping fragments, by that means
bringing their separated surfaces or ends into contact, and almost
restoring to the bone its primitive form.

Art cannot always, with certainty, command such success, and perhaps,
even at a less advanced period, a more rapid progress of reunion might
leave but little ground for hope. But, could only an inch in length be
gained by permanent extension, would it not be proper to have recourse
to it, particularly as no inconvenience can result from the trial? To
prevent deformity altogether, is the first object of art; but when that
cannot be attained, to lessen it is the second.


FRACTURES OF THE UPPER END OF THE OS FEMORIS.

The history of fractures of the upper end of the os femoris, includes,
1st, Those of the great trochanter: 2dly, Those of the neck. These
fractures, sometimes existing together, and at other times separately,
are very different with regard to the frequency of their occurrence:
the one taking place very rarely, has but slightly engaged the
attention of practitioners, who have multiplied their researches with
regard to the other, particularly in late years.


FRACTURES OF THE GREAT TROCHANTER.


§ X.

OF THE VARIETIES AND CAUSES.

77. Fractures of the great trochanter are the effect either of falls
on that protuberance, or of the action of bodies striking against it.
Oblique or transverse, situated sometimes at its summit, and sometimes
at its base, these fractures may be either simple or complicated.
They are rendered complicated sometimes by splinters and a swelling,
as happens when a ball produces the division, and at other times by a
fracture of the neck of the bone, an example of which we find in the
Journal of Surgery, in the case of a man seventy years of age, who had
been long subject to the itch.

78. Whatever the varieties may be, the fracture will be characterized,
1st, By a facility of moving the great trochanter in every direction,
while the pelvis and the thigh remain without motion: 2dly, By a
crepitation, arising from the friction of the divided surfaces against
each other: 3dly, By there being no shortening of the limb, when the
fracture exists alone: 4thly, By the fragments being brought together
in abduction, and separated in adduction: 5thly, By the position of
the great trochanter being higher and more anterior than natural. The
presence of these signs is the more readily perceived, because, being
superficially situated, this protuberance can be easily felt, and
yields to the motions impressed on it.


§ XI.

OF THE REDUCTION, AND THE MEANS OF RETAINING IT.

79. The reduction is effected, by pushing the separated fragment in
the direction opposite to that of its displacement, by bringing it
to its natural level, and, in certain cases, by moving the thigh a
little outwards; it is retained by means of some compresses placed by
its sides, and secured by a roller directed obliquely from the sound
hip towards that part of the thigh corresponding to the fracture, and
representing a true spica bandage.

80. A fracture produced by a gun-shot wound, always renders large
incisions necessary, for the purpose of extracting foreign bodies, and
relaxing the aponeurosis of the fascia lata, which suffers too great a
degree of tension in this place, and might, if not dilated, produce a
very troublesome stricture. A fracture complicated by splinters, but
without an external wound, and produced by a body striking against the
part, seldom requires any particular apparatus, because, adhering as
yet to the periosteum, the separated portions of the os femoris may
unite again, either among themselves, or with the fragments.


FRACTURES OF THE NECK OF THE OS FEMORIS.


§ XII.

OF THE CAUSES.

81. The neck of the os femoris, being surrounded by a large mass of
soft parts, and protected by the great trochanter, which forms its
external boundary, is almost completely secured from the immediate
action of external bodies, and consequently from direct fractures.
Whenever it sustains a fracture, it is always by a true counter-stroke,
resulting from a fall, sometimes on the great trochanter, and at other
times on the sole of the foot or the knee. But fractures produced
in the first mode, are much more frequently met with in practice,
than those produced in the second, doubtless because, in the latter,
the motion is weakened by the extent of parts through which it is
distributed, previously to its arrival at the neck of the os femoris.
Out of thirty observations made by Desault, on fractures of this
description, twenty-four of them were produced by falls on the side.
All those recorded by Sabatier, in his interesting memoir, appear to
have been produced by similar falls.


§ XIII.

OF THE VARIETIES.

82. Fractures of the neck of the os femoris may occur, 1st, in the
middle part of it, where it is smallest, and where nature has not
thrown together, as she does in the middle of the long bones so often
exposed to fractures, a great quantity of compact substance: 2dly, at
its upper end, where it is united to the head of the bone: 3dly, at its
junction with the great trochanter, where the solution of continuity
may be outside of the joint, a circumstance which doubtless happens
much more frequently than has been hitherto suspected.

83. The division, rarely oblique, is almost always transverse:
sometimes, in the latter case, the neck remains enclosed or imbedded,
as it were, in the body of the bone, being fractured in such a way, as
to present a hollow or notch of greater or less depth. Several cases
of this kind occurred to Desault; one of them, modelled in wax, is
deposited in the collection of the School of Health, and the original
preparation is in my possession. The fracture, though frequently
simple, is sometimes complicated with that of the great trochanter.

CASE V. A man having received a kick from a horse, on the external
and upper part of the left thigh, fell down, and, not being able to
move, was carried home. Desault being called to him, discovered, 1st,
that the great trochanter, separated from the bone, yielded readily
to every impression it received: 2dly, that the limb was perceptibly
shortened; that the least effort was sufficient to restore to it its
natural length; and, that the foot was turned outwards, all which are
characteristic signs of a fracture of the neck.


§ XIV.

OF THE SIGNS.

84. Whatever may be the mode and place of the fracture, its diagnosis
presents difficulties which experience and habit may doubtless
overcome, but which too frequently puzzle and embarrass the most
enlightened practitioner. Let us endeavour to diminish them somewhat,
by tracing, in their order of succession, the symptoms which
characterize the accident.

85. At the time of the fall, a sharp pain is felt; sometimes a report
is plainly heard; a sudden inability to move the limb occurs; the
patient cannot rise, a circumstance, however, which does not always
take place. A case is recorded in the fourth volume of the Memoirs of
the Academy of Surgery, where the patient walked home after the fall,
and even rose up on the following day. Some examples of a similar
nature fell under the notice of Desault, one of which he has recorded.
The interlocking of the two fragments formerly mentioned (83), may
serve to explain this fact, which is, however, in general, very rare.

86. A shortening almost always occurs in the broken limb, but this is
more or less perceptible, according as the extremity of the fragments
is retained by the capsule, or as, the division being without the
cavity, no resistance is made to their displacement. The muscular
action, drawing the lower fragment upwards, and the weight of the
trunk, pushing the pelvis and the superior fragment downwards, furnish
here, as in fractures of the body of the bone, the two-fold cause of
this shortening. I will not repeat what has been already said on this
subject (10 ... 14); I will only observe, that, in the present case,
the influence of the muscles is even more considerable, because, the
lower fragment being much longer, is of course attached to a greater
mass of muscular fibres. A slight effort is sufficient, in general,
to remove this shortening, which, however, soon returns, when the
effort ceases. This circumstance Goursault and Sabatier have observed,
not to occur in certain cases, till some time after the accident. A
tumefaction appears in the anterior and upper part of the thigh, almost
always proportioned to its shortening, of which it appears to be the
effect.

87. The projection of the great trochanter is almost entirely removed.
That protuberance, being directed upward and backward, is approximated
to the spine of the ilium. But if it be pushed in the opposite
direction, it readily yields, and then, returning to its proper level,
allows the patient to move the thigh.

88. The knee is a little bent. A severe pain always accompanies the
motions of abduction, when they are communicated to the limb. If, while
the hand is applied to the great trochanter, the limb be made to rotate
on its axis, this bony protuberance is perceived to turn on itself as
on a pivot, instead of describing, as it does in its natural state, the
arch of a circle, of which the neck of the os femoris is the radius.
This sign, which was first observed by Desault, is very perceptible,
when the fracture is at the root of the neck, less, when it is in
the middle, and very little, when it exists towards the head of the
bone; these are circumstances, the cause of which it is unnecessary to
unfold. In rotatory motions, the lower fragment, rubbing against the
upper one, produces a distinct crepitation, a phenomenon which does not
however always occur.

89. The point of the foot is usually turned outwards; a position
which Sabatier, Bruninghausen, and most other practitioners regard as
a necessary effect of the fracture, although Ambrose Pare and Petit
have borne witness that it does not always exist. Two cases, reported
on this subject by celebrated surgeons, have been thought unfounded
by Louis, who has attributed them either to an error in language, or
a mistake of the transcriber. But the practice of Desault has fully
confirmed their possibility. The first patient whom he had under his
care, at the hospital of Charity, after he was appointed surgeon in
chief, laboured under a fracture which presented this phenomenon. Many
other examples occurred to him afterwards, and he believed it might
be laid down as an established principle, that, in fractures of the
neck of the os femoris, the direction of the foot outwards is to that
inwards as 8 to 2.

90. The common opinion is, that this direction outwards is to be
attributed to the muscles that perform rotation. But, were that
the case, 1st, it is evident that it would always exist: 2dly, all
the muscles running from the pelvis towards the trochanter, except
the quadratus, are in a state of relaxation, in consequence of the
approximation of the os femoris to their points of insertion: 3dly,
muscles in a state of contraction would not allow the point of the foot
to be drawn so easily inwards. Is it not more probable, that the weight
of the part draws it in the direction in which it is usually found.

91. From the foregoing considerations, it follows, that none of the
signs of a fracture of the neck of the os femoris, is exclusively
characteristic, that the whole of them, taken separately, would be
insufficient, and that it is their assemblage alone which can throw on
the diagnosis that light which is oftentimes wanting to it, even in
the view of able practitioners. But after all, in the present case, as
in every other one, should any doubt exist, it is right to take the
safe side, and apply the apparatus, which is indeed useless but not
dangerous if the disease does not exist, but indispensably necessary if
it does.


§ XV.

OF THE PROGNOSIS.

92. The existence of a fracture being ascertained, what prognosis is to
be formed respecting it? In answer to this general question, it will
be sufficient, I think, to resolve the following particular ones. What
accidents accompany the fracture in the first instance? What phenomena
make their appearance during its reunion? In what manner does it affect
the patient, as to his power of walking, after reunion has taken place.

93. If we attend to the opinion of authors, on this fracture, we will
find that they represent it in very dismal colours, as if it were
necessarily productive of the most serious effects. Inflammation of the
parts adjacent to the neck of the os femoris, numerous and repeated
abscesses arising from this inflammation, propagating themselves
externally and communicating with the interior of the joint, gangrene
itself, as Morgagni remarks in a particular case, convulsions of
the limb, an œdema occurring in it, and a slow fever destroying the
patient by degrees; such is the dismal catalogue of misfortunes,
generally considered as necessarily attendant on the kind of fracture
under consideration. Bruninghausen remonstrated against this fatal
prognosis of authors, and Siebold, one of the most celebrated German
practitioners, among a great number of cases that fell under his care,
had no such accidents to encounter. Desault never experienced them.
Doubtless they are prevented by our more exact and more skilful
modes of treatment. It is thus that under a more judicious treatment,
fractures of the olecranon and of the rotula, are no longer marked with
those terrible consequences formerly attributed to them.

94. In as much as the organization of the os femoris, is nearly the
same in its neck and in its body, it is difficult to conceive how the
progress of nature can be different in fractures of these two parts;
why the first, in being denied the power of healing or reunion should
be, in this respect, distinguished from all other living parts of
animals, which are particularly characterized by that power, when they
have sustained a solution of continuity. Many practitioners, even at
the present day, advocate this doctrine, which is built, one while,
on the circumstance of the periosteum not being continued along the
neck of the os femoris; another while, on a belief that the head of
this bone cannot receive a sufficiency of nourishment for the work of
consolidation, in consequence of being attached to the rest of the
system, only by the round ligament, and again, on an opinion, that the
synovial fluid, by wetting the divided surfaces, prevents their reunion.

95. But is the periosteum the only agent in the formation of callus?
Modern experience has refuted this opinion, which, like many others,
will therefore in a short time exist only in the history of our errors.
Were it even true that the periosteum is here indispensably necessary,
is not its place supplied by the fold of the capsule, which surrounds
both the head and neck of the os femoris? Besides, why cannot callus
be formed by that part which has had sufficient power to accomplish
ossification, since it is universally acknowledged, that, in these two
processes, the labour of nature is nearly the same.

96. The head of the bone, separated from the soft parts, and attached
to the acetabulum by the round ligament, always receives through that
ligament a sufficiency of nutriment to enable it to live in that
cavity; for, there is no instance of its having suffered mortification
in consequence of a fracture. Why, then, should it not partake of the
properties of life, and particularly of the faculty of reunion when
placed in regular apposition with the body of the bone?

97. What shall we say respecting the idea of the synovia wetting the
divided surfaces, and by that means preventing their reunion? The
history of fractures communicating with joints, better known at the
present day, answers this objection, which is indeed nothing but the
offspring of mere hypothesis. To these considerations, which are
dictated by reason, and to which many more might be added, let us unite
the proofs derived from experience, and we will find numerous examples
of cures actually performed, particularly in latter times; the truth
of this is attested by many cases collected by Desault, both at the
hospital of Charity and the Hotel-Dieu. Bruninghausen and Siebold,
have had equal success. Many analogous facts have been presented to
the Academy of Surgery. In the cabinet of the School of Health, are
deposited some preparations obtained from the cabinet of Desault,
calculated to remove all difficulties and doubts from this subject.

98. We must acknowledge, however, that in persons advanced in years,
the cure is always difficult, often very tedious, and sometimes
impracticable, however carefully the treatment may be conducted. But
this is only a necessary consequence of the laws of ossification,
which, constantly accumulating in the bones too great a quantity of
calcareous matter, seems to deprive them by degrees both of life and
all its properties. Yet Lesne laid before the academy a case of reunion
obtained in a subject at the advanced age of eighty-four.

99. The observations of some modern practitioners seem to prove, that
the reunion here is not produced by a substance similar to common
callus, but by a kind of ligamento-cartilaginous tissue, in like manner
as in the rotula, and the olecranon. But why need we inquire after the
means employed by nature? those of art must be the same. It will be
always necessary to favour the reunion, by bringing the fragments into
contact, and maintaining them so. Without this contact, either a cure
will never be obtained, or the substance destined to effect a reunion,
becoming deformed and too bulky, will impede motion.

100. Lameness has been long considered as the inevitable consequence
of fractures of the neck of the os femoris. Ludwig, professor of
surgery at Leipsick, has particularly advocated this opinion, which is
supported by Sabatier, and Louis, who considered the total destruction
of the neck of the bone, as the cause of the lameness. But few such
examples are to be found on record. Ruisk has given an engraving of
one. Lameness when it does take place, depends, as it does in oblique
fractures of the body of the bone, on the overlapping of the fragments,
to which no opposition has been made; so that the insufficiency of our
means, and not the nature of the disease, gives rise to this accident,
which Desault seldom experienced in his practice.

101. From what has been said, it appears, that, in all respects,
authors have given a much more unfavourable prognosis in fractures of
the neck of the os femoris than facts and the nature of the affection
will justify, that the progress of these fractures is the same with
that of all others, and that, when treated with equal skill, there is
no reason why their termination should not be equally favourable.


§ XVI.

OF THE REDUCTION AND THE MEANS OF MAINTAINING IT.

102. Reduction, in this case, is attended in general with but little
difficulty. The patient, lying on his back, is held under the
arm-pits, and by the upper part of the pelvis, by assistants who
make counter-extension in this way, without being obliged to pass,
as recommended by the Academy of Surgery, a strap under the affected
thigh (30). Another assistant makes extension, according to the
method formerly described (29), drawing the point of the fragment
very gradually in the direction opposite to that which it has taken
in becoming displaced, and making the thigh at the same time rotate
a little on its own axis. This gentle rotation renders success more
certain.

103. If things be properly arranged, a slight effort is sufficient to
bring the separated fragments into contact and to restore to the limb
its natural form; for, as I have already observed (86), a facility of
reduction is even one of the characters of this fracture. But it is
very difficult for art to maintain permanently what she easily effects
at the time of reduction, and on this account, our curative processes
are oftentimes insufficient.

104. These processes may be considered under three classes, according
as they relate 1st, to position; 2dly, to bandages; 3dly, to the forms
of apparatus for making permanent extension.

In the first class must be included the method of Foubert, employed
in ancient times, according to Louis, and which consists in placing
the patient on a horizontal plain, while the limb is secured by
simple splints, and the foot by a kind of shoe. But in a short time
the muscular action, to which no resistance whatever is made, draws
the lower fragment upwards, while the weight of the body pushes the
pelvis downwards, and along with it the superior fragment. Hence a
new reduction, the effect of which is again immediately destroyed as
at first. Thus are new displacements succeeded by new replacements
throughout the whole course of the treatment.

105. This method, almost universally adopted in latter times, and
approved of by Louis, was in vogue at the hospital of Charity, when
Desault entered it. Ought we then to be surprised, that the fracture
was considered as incurable? Here indeed the plainest and most
important indication is evidently disregarded. Nothing to retain the
fragments in apposition, nothing to prevent them from being constantly
moved. Does not the method of Foubert very closely resemble those
experiments, in which, the bone of an animal is broken intentionally,
and then to prevent a reunion and form an artificial joint, the
fragments are kept in constant motion?

106. Will any better success attend the method of securing the leg, as
Dalechamp recommends, to the foot of the bed? In such a case the trunk
and the pelvis glide down along the inclined plain made by the pressure
of the nates (14), and hence a constant cause of the shortening of the
limb.

107. The second class of curative means, includes different forms of
apparatus simply retentive. Pare, Petit, and Heister, recommend, as
most useful, the _Spica_ of the groin.[26] But what effect can this
produce? What force applied in that part can keep the lower fragment
down, and the pelvis up, secure the immobility of the limb, and prevent
its rotation outwards? If the bandage be tight, it will compress the
muscles unequally, make them contract, and thus become the cause of
a contraction or shortening of the limb. In some respects, there is
more advantage to be derived from the tin case lined with cloth on its
inside, which Fabricius of Hilden applied to the external part of the
thigh; a method which has been renewed since his time, by certain
celebrated practitioners of Germany; from the pasteboard case proposed
by Duverney as a substitute for that of tin; from the retentive
plaster[27] of Buffle employed likewise by Arnaud; and from the splints
adopted by most practitioners. But can these means, (so differently
varied in form, yet still the same in their action), while they prevent
displacement laterally or in the cross-direction of the bone, prevent
it also in the longitudinal direction, which latter ought to be the
principal object in view? Will they make any resistance to the muscular
action? See what has been already said on splints, bandages, &c.
(89 ... 95).

    [26] _Le Spica de l’aine._                                TRANS.

    [27] (_L’ecusson._) The literal meaning of this word is an
    escutcheon, or a coat of arms. But when used in surgical language,
    it signifies a retentive or strengthening plaster. Such I conceive
    its meaning to be in the present instance.                TRANS.

108. The insufficiency of these forms of apparatus, arises from their
not being constructed with a proper view or reference to the general
principle that ought to be observed in the treatment of every fracture;
namely, that the means intended to prevent displacement, ought to be
founded on the causes that produce it. But, these causes here, are,
1st, The action of the muscles which draw the lower fragment upwards:
2dly, The weight of the body which pushes the pelvis downwards: 3dly,
The weight and direction of the foot and leg, which tend to carry the
toes outwards by a rotatory motion. Hence, the threefold indication or
end of every apparatus, is, 1st, To keep the body of the bone down:
2dly, To retain the pelvis up: and 3dly, To secure the foot nearly in
a right line with the leg.

109. The first consideration leads us naturally to the second. The
means destined to fulfil this three-fold indication, must be constant
in their action, since the causes which they have to combat act without
remission. Hence the necessity of an apparatus for permanent extension.
See what has been said on the nature of this expedient (46 ... 51), on
the different modes of effecting it (52 ... 57), and particularly on
the mode pursued by Desault (58 ... 70).

110. The mechanism of his apparatus for permanent extension is the
same here as in fractures of the body of the bone. The limb is secured
against a strong splint, to the two ends of which two rollers, running
one from the pelvis, and the other from the foot, are firmly tied. The
first of these rollers holds the pelvis up, and the second draws the
foot down: hence the two first indications are fulfilled. The third
is also fulfilled by the extension of the limb, which prevents its
rotation outwards, by means of the outside splint, which passing beyond
the sole of the foot keeps it immoveable.

111. The bandage of strips and compresses, which in fractures of the
body of the bone, are previously applied round the limb, and oppose in
some measure its motions laterally, are here entirely useless. Being
all indeed applied on the lower fragment, what purpose could they
answer towards fixing it against the upper one? They could do nothing
but compress the muscles, and by that means diminish their power
of contraction: but extension alone produces this effect. Desault
rejected the bandage altogether, and contented himself with the use of
splints and bolsters, as appears from the following case reported by
Couteau.

CASE VI. Maria Nof, as she was running on the ice, in the severe winter
of 1788, slipped, and falling on the great trochanter, fractured the
neck of the os femoris. She was immediately carried to the Hotel-Dieu,
where the signs formerly mentioned (60 ... 66) disclosed at once the
nature of her disease. The shortening of the limb was less than in
ordinary cases.

The apparatus was applied in the following manner. The junk-cloth, the
body-bandage, and the bits of tape, were laid on the bed, in the order
already mentioned (60): the patient was then placed in such a manner
that the affected thigh corresponded exactly to the middle of them.
The reduction being effected, the two splints were applied, one on the
external and the other on the internal side of the limb; on each side,
and along the anterior part of the thigh, the bolsters were laid: three
bits of tape for the leg, four for the thigh, and the body-bandage
for the pelvis, served to secure the splints. One end of a roller,
which had been previously fixed on the upper side of the foot, passing
through the mortise on the external splint, and being tied to the other
end which passed through the hollow or notch, produced extension,
while counter-extension was made by means of another roller directed
obliquely from the tuberosity of the ischium over the superior part of
the same splint, which it drew downwards. This was the same apparatus
formerly described (60 ... 66), except as to the bandage of strips, the
compresses, and the anterior splint, which running only from the fold
of the groin, had no effect in retaining the fragments.

The treatment was simple. No general disease of the system existing,
the patient returned, in a few days, to her usual regimen. Being
visited every day, the apparatus was frequently tightened; and was
renewed six times at different intervals.

A bilious disposition shewed itself on the seventeenth day. This
was removed by an emetic given in solution, and after this nothing
remarkable occurred. On the fifty-second day the state of the parts
was examined. The consolidation was almost accomplished; by the
sixtieth day it was complete, and the patient was discharged a few days
afterwards, experiencing only a slight degree of lameness.


§ XVII.

OF THE SUBSEQUENT TREATMENT.

112. It is more essential here than in fractures of the body of the os
femoris, to keep up extension with the utmost exactness, because, in
the present case, a much greater number of muscles being attached to
the lower fragment, very greatly augment the powers tending to displace
it. Hence the necessity of examining the apparatus every day, to see
whether or not any shortening of the limb has occurred, to tighten,
if they be relaxed, the rollers that make extension, and to renew the
application of the whole, if it be in any measure deranged.

113. The proper treatment here, as well as in most other fractures,
consists more in these attentions, taken collectively, than in the use
of internal means. It is to the want or neglect of such attentions,
that we ought to attribute the little success obtained by many surgeons
from the bandage of Desault.

CASE VII. A man, having fractured his thigh by a fall, called in a
surgeon, who, reducing the fracture, and retaining it by this bandage,
examined the state of the parts every day, and finding no derangement
of the splints, neglected attending to the rollers destined for making
extension. Seventh day, a shortening of two inches; a new reduction,
and a new application of the bandage; the same want of attention as
before; the same shortening at the expiration of a few days; the means
were then rejected, and declared, in a publication, to be insufficient.
How often do processes and modes of practice of great utility, by
being transmitted from person to person, or from book to book, lose at
length, that credit they are entitled to, and that approbation which
they ought to command!

114. Serious accidents so seldom accompany fractures of the neck of
the os femoris, that there is no necessity of employing numerous
means to remove them. A diet somewhat strict for a few days, diluting
drinks, and then a return to the patient’s usual mode of living, unless
something besides the fracture should forbid it, constituted the simple
treatment pursued by Desault in common cases. Any varieties resulting
from accidental circumstances, must fall under the general treatment of
fractures.

115. The period necessary for the healing of fractures of the neck
of the os femoris, is represented by most authors as being longer
than the term required in other similar affections. We read, in the
Memoirs of the Academy of Surgery, that oftentimes the cure is not
complete in less than three or four months. The reason of this will be
evident, if we consider, on the one hand, that the reunion is always
more tedious, in proportion as the contact of the fragments is more
frequently interrupted: and, on the other, that, in the means formerly
employed, there was nothing opposed to the powers of displacement.
Hence it follows, that, if skilfully treated, this fracture ought to
follow nearly the same course with others. It is this that confirmed
the superior excellence of the practice of Desault, who almost always
obtained a cure, all other things being equal, such as age, strength of
constitution, &c. in the space of forty-five or fifty-five days.

116. We discover, in general, that the cure is complete, from a
disappearance of the signs of the fracture, more particularly from the
motions of the great trochanter, in which circumduction[28] succeeds to
rotation on its own axis, when the limb is made to move on itself, that
is, to rotate outwards or inwards. The power of standing and walking
is an infallible evidence of this reunion; nor are these exertions
practicable, till the expiration of some time after it is completed;
this circumstance is owing to a stiffness remaining in the parts
around the joint, occasioned by long extension and a want of motion,
and which exercise alone can effectually remove. (See what has been
already said on this subject, in several parts of this work.)

    [28] A motion or sweep describing the arch of a circle.    TRANS.

117. Numerous cases may be adduced in favour of the doctrine laid down
in this memoir. But a sufficient number have been already published in
the Journal of Surgery. I shall subjoin only two, drawn up by Manoury
and Seveille.

CASE VIII. Maria ***, aged forty, falling on the great trochanter,
experienced a sudden pain, and heard a considerable report: she rose,
however, and with difficulty made her way home. On the day following, a
shortening of an inch was perceived in her thigh: the great trochanter
was drawn backward and upward: walking was now impracticable, the foot
remained turned inwards. Notwithstanding this latter circumstance,
Desault, being called to the patient, declared that a fracture existed,
which was evidenced in particular by a rotatory motion of the great
trochanter on its own axis. The necessary apparatus being applied,
was carefully examined every day by Manoury, to whom the patient was
intrusted. No shortening of the limb occurred, nor did any unfavourable
accident supervene, and, by the thirty-ninth day, the fracture was
exactly and firmly united; on the forty-third, the splints were
removed; and on the fiftieth, the patient could walk without assistance.

CASE IX. John Rignal fractured the neck of the os femoris by falling,
not as in the preceding case, on the great trochanter, but on the knee,
which was bent at the time of the fall, while the shoulder of the same
side supported a heavy load. He was brought to the Hotel-Dieu, where
the same signs, as in the preceding case, (except that here the foot
was turned inwards) furnishing ground for the same diagnosis, gave rise
to the same treatment, which, in fifty days, was followed by a result
equally favourable.


FRACTURES OF THE LOWER EXTREMITY OF THE OS FEMORIS.

118. The lower extremity of the os femoris, being thicker than the
rest of the bone, and protected from the action of external bodies
by a thinner covering of soft parts, is yet better secured from
fractures than the other parts, for the following reasons: 1st, because
counter-strokes, so frequently the cause of fractures of the body
and neck of the bone, can affect this part but rarely: 2dly, because
the os femoris, being more moveable at a distance from the centre of
its motions, yields more easily to whatever strokes and impressions
it there receives: 3dly, because motion, when distributed through a
greater bulk of matter, has less power to destroy its continuity.


§ XVIII.

OF THE VARIETIES AND THE CAUSES.

119. The fractures which occur in the lower extremity of the os
femoris, are of two kinds very different from each other. Sometimes
situated above the condyls, they only separate these from the body
of the bone: at other times, affecting the condyls themselves,
they extend into the very joint. My attention shall at present be
confined exclusively to the latter kind, as the other may, in almost
every respect, be classed with the fractures which have been already
considered. Most authors have neglected to treat of fractures of
this kind, under a distinct head, from a persuasion, that, owing to
their communication with the joint, they ought to be ranked among
complicated fractures, which are known to require a mode of treatment
very different from that employed in such as are simple. But I shall
presently show what regard ought to be paid to this ancient opinion.

120. The division presents itself, in general, under two different
forms: 1st, running obliquely from above downwards, and from within
outwards or from without inwards, it may separate a greater or smaller
portion of one of the condyls from the rest of the bone: 2dly, these
two bony protuberances may be divided from each other by a longitudinal
fracture, meeting another transverse or oblique fracture, which by
either passing through the whole thickness of the bone, separates both
condyls from it, or extending only half way through it, separates but
one of them. The fracture is single in the first case, but double in
the second. The latter occurs in practice more frequently than the
former. Both are usually produced directly, that is, by the immediate
action of external bodies. Yet the following fact seems to evince that
the accident may, possibly at least, arise from a counter stroke.

CASE X. The corpse of a man of forty, was brought into the amphitheatre
of Desault, soon after he became a public teacher. One of the pupils,
on preparing to dissect the body, discovered a preternatural mobility
in one of the condyls. The knee was examined. A double fracture was
found, accompanied by a separation of the two condyls. On inquiry
it was ascertained that the corpse came from the Hotel-Dieu. It
was further discovered, with certainty, that the injured subject,
in jumping through a window, had alighted on his feet, and that he
experienced instantly a severe pain in his knee, and fell on the
ground, unable to support himself.

Here, no doubt but the condyls, by being violently pressed between the
weight of the body and the articulating surfaces of the tibia, had been
fractured by a counter-stroke.


§ XIX.

OF THE SIGNS.

121. But whatever may be the precise form and figure of the fracture,
its signs are easily comprehended: a very perceptible separation
oftentimes exists between the two condyls, increasing the transverse
diameter of the knee. The rotula, sinking into this chasm between the
condyls, renders the part more flat from before backwards, than it is
in its natural state. If the rotula be pressed in a backward direction,
the condyls are separated still further from each other. If, on the
other hand, pressure be made on each side of the lower part of the
os femoris, the condyls are brought together, and the knee resumes
its usual shape. If we take hold of a condyl in each hand, it will be
easy, by moving them alternately backward and forward, to make them rub
against each other, and produce a crepitation which characterizes the
fracture beyond a doubt.

122. If the upper fracture be oblique, a shortening of the limb more
or less perceptible is always the effect of it: this appears to be
principally owing to the weight of the body which pushes the upper
fragment down, and to the action of the muscles which draws the lower
ones up (10 ... 14). In this case, the superior fragment, being
forcibly pushed against the integuments, has sometimes lacerated, and
even passed through them, giving rise to consequences of a serious
nature. Desault has published a case of this kind. A similar effect has
been produced, though more rarely, by the inferior fragment, in which
case much mischief has arisen from the admission of air into the joint.

123. Sometimes when the upper fracture extends through the whole
thickness of the os femoris, the extremity of the bone is turned round,
so that the external condyl lies behind, the internal before, and the
rotula on the outside, while the foot points in the same direction.
A case of this kind is recorded in the Journal of Surgery. The body
of the bone, being pressed into the chasm or interval between the two
condyls, may prevent their reunion, by pushing them asunder, and thus
give rise to various accidents.

124. Most of these phenomena will fail to occur, if the upper division,
passing only half way through the bone, break off but one of the
condyls, or if, passing through even the whole of the bone, it be
perfectly transverse; but cases of this description are seldom met with.


§ XX.

OF THE PROGNOSIS.

125. I have little to add to the observations already made on the
prognosis in fractures of the condyls of the os humeri. All that I have
there said is applicable to the os femoris. As is the case with regard
to the former fractures, so also here, the apprehensions of authors
have been greatly exaggerated by their visionary doctrine respecting
injuries of the joints: both reason and experience unite in showing
such apprehensions to be unfounded.

I shall only observe, that in the present case, even more particularly
than in fractures of the condyls of the os humeri, most of the
unfortunate events that take place, are owing to the insufficiency of
the means employed for effecting a cure. Indeed, as I have already
observed (45), all those means can have no effect in opposing the
continual tendency of the fragments to become displaced, if the upper
fracture[29] of the os femoris be oblique. And in most cases, this
fracture is oblique: hence it follows, 1st, that the bony points of
the fragments being constantly pushed, during their displacement,
against the ligaments that surround the joint, will perpetuate in them
the irritation first produced by the fracture, and thus give rise to
swelling, inflammation, and all the other morbid affections of the
part, so much dreaded by authors, and attributed by them to the mere
communication of the fracture with the joint: 2dly, that the best
expedient to prevent such affections, is an apparatus that shall retain
the divided surfaces in perfect contact with each other by means of
permanent extension.

    [29] That which forms the superior boundary of the longitudinal
    fracture by which the condyls are separated from each other.
                                                             TRANS.

126. It is obvious that this extension will be less necessary, if the
upper division of the os femoris be transverse, because, then, the
condyls and the body of the bone will find a mutual point of support
against each other.


§ XXI.

OF THE MEANS OF CONTACT BETWEEN THE FRAGMENTS.

127. Since the same causes, as in the preceding cases, tend here to
destroy this contact, when the superior fracture is oblique (122), the
apparatus ought, therefore, to be so constructed as to counteract these
causes, that is, it ought, 1st, to draw the two condyls down; 2dly, to
retain the pelvis up, and with it the superior fragment. This twofold
indication relates only to the upper division of the bone, without any
reference to that which separates the condyls; 3dly, it is necessary
to counteract the tendency which the condyls may have to separate from
each other.

128. Permanent extension, made in the manner already mentioned (60 ...
63), fulfils the two first indications; while two lateral splints, and
the bandage of strips fulfils the third. Desault, therefore, applied to
this particular case his apparatus for permanent extension, modified
only in such a way, that, instead of terminating at the knee, the
bandage of strips was continued to a distance down the leg, in order
that its action might be the more efficacious. For, it is well known,
that it is at its middle part that the firmness and retentive power of
a bandage are greatest, because the casts of the roller at the upper
and lower ends, serve to secure those in the middle. The upper splint
being altogether useless, was not employed.

129. If the superior fracture be transverse, the condyls, as I have
already said, meet with resistance against the body of the bone, while
they, on the other hand, support it in such a manner, as to prevent
it from descending, though pushed by the weight of the body along the
inclined plain made by the pressure of the nates. Here, then, permanent
extension is generally useless, and all that is necessary is, to retain
the condyls and prevent their separation by means of lateral pressure.
The same apparatus may still be employed, provided the two rollers for
extension be laid aside.

130. If a wound in the soft parts accompany the fracture, whether it
be produced by the same cause, or by the subsequent passage of the
fragments through the integuments, and whether it communicate with
the articulation or not, it is necessary, as soon as suppuration has
taken place, to renew the dressings every day or every other day,
taking care, in the mean time, to supply, by the hands of an assistant,
the want of extension by means of the apparatus. The following case,
extracted from the Journal, exhibits a specimen of the treatment that
ought to be adopted in similar cases.

CASE XI. Claudius Legrange, aged thirty-one, and of a sound
constitution, was wounded by the kick of a horse, on the internal
condyl of the left os femoris. The violence of the pain obliged him to
throw himself on a heap of straw, that lay at a little distance, and
which he reached by hopping on his right foot. The pains were augmented
by this, for at each step, the thigh being alternately bent or extended
at the injured part, was moved sometimes backward and sometimes
forward. The patient was brought to the Hotel-Dieu, a few hours after
the accident.

The signs already specified (121 and 122) announced to Desault, a
longitudinal fracture separating the two condyls, and terminated above
by another fracture of the body of the bone, which descended obliquely
from about five inches above the external condyl, to within two inches
of the internal one.

The muscles of the thigh, by means of violent contraction, had drawn
that portion of the os femoris attached to the external condyl upwards,
and the superior fragment downwards. The sharp point of the latter had
passed through the skin, and produced a wound of an inch and a half in
extent, on the inside of the thigh, and a little above the condyl.

The patient being undressed, was placed on a bed nearly horizontal, on
which had been previously spread the necessary pieces of apparatus,
disposed in proper order. Desault then examined the wound, extracted a
splinter of the bone, covered the wound with lint, and then proceeded
to the application of the apparatus which he usually employed in such
cases (128).

The extension was accompanied by no pain: on the other hand, it gave
immediate relief: diluting drinks were prescribed. Next day, no pain;
pulse a little raised; no dryness, nor any alteration of the skin; diet
the same as on the preceding day; the apparatus wet with vegeto-mineral
water. Fourth day, a new application of the apparatus, which had become
relaxed; appearances of suppuration.

From this time the dressing was renewed every other day, till the
sixteenth, when the wound was cicatrized. After this the apparatus
was not touched except when deranged; it was only wet from time to
time with vegeto-mineral water, and great pains were taken to keep up
the extension. The apparatus was not laid aside till the sixty-fourth
day, although the callus appeared to have acquired a state of solidity
somewhat sooner.

The patient was soon in a situation to take exercise. The stiffness
then disappeared rapidly, and, in about three weeks, he left the
hospital, able to bend the leg to a right angle with the thigh, and
under a full confidence that he would in a short time regain all the
motions of the limb.


§ XXII.

OF THE SUBSEQUENT TREATMENT.

131. As soon as the consolidation is complete, the motions of the
limb must commence. These, at first gentle and confined, must be
afterwards, increased in extent, and more frequently repeated, till, at
length, the limb should be exercised every day for two or three hours
without intermission. The position and direction of the leg ought to
be constantly changed. One while, the thigh should be elevated by a
bolster, so as to flex the leg; at another time, the bolster should
be fixed under the leg to keep it extended. The rotula must be moved
in every direction, and, as soon as the patient can leave his bed, he
should take exercise himself. These precautions are more necessary here
than in any other fracture, because a stiffness of the parts adjacent
to the joint, is always the inevitable consequence of a long state of
rest. Certainly writers would not have considered anchylosis as the
most favourable termination of such fractures, had they been acquainted
with the effect of exercise and rest in that now under consideration.

132. Provided the mode of treatment here laid down be faithfully
pursued, the affection is seldom accompanied by those numerous
accidents, of which so much has been said. The callus is formed in the
usual manner: and, on some occasions, where the patients have died at
the Hotel-Dieu, in consequence of some affection not connected with the
fracture, the two condyls have been found perfectly united together
and to the body of the bone. An instance of this kind is recorded in
the Journal of Surgery.

133. Let us, in the mean time, not speak too favourably of that,
respecting which the ancients were accustomed to speak too
unfavourably. Even the practice of Desault would expose our error.
Sometimes the most assiduous attention, and the most careful
application of the apparatus, have not been sufficient to prevent
abscesses around the knee, and an anchylosis of the joint. Desault
related a case where even a caries of the articulating surfaces
occurred. But some extraneous circumstances appeared to have an
influence in these instances: and it may be laid down as a general
rule, that fractures of the lower extremity of the os femoris, require
the same treatment with fractures of its other parts.

[Illustration: _Plate 2._

    _Tanner, Sc._]


EXPLANATION OF THE SECOND PLATE.[30]

    [30] For an account of an improvement of the splint, represented
    in this plate, projected by Dr. Physick, and now used in the
    Pennsylvania hospital, see Article II. of the Appendix.    TRANS.

  This figure represents the apparatus for permanent extension,
       employed by Desault in oblique fractures of the os femoris.

  AA. The external splint, with a notch and a mortise in it at the
       lower end to fix the inferior extending roller.

  BB. A bandage passing round the body, intended to secure this splint
       against the pelvis.

  CC. The anterior splint, reaching only to the knee.

  d d d d. The anterior bolster, extending along the whole limb, and
       secured by pieces of strong tape.

  EE. A portion of the bandage of strips, seen between the anterior
       and the external lateral bolsters.

  FF. The junk-cloth intended to be folded round the two lateral
       splints.

  g g. The superior extending roller, passing round the end of the
       external splint, and fixed underneath on the tuberosity of the
       ischium.

  H. The sub-femoral roller or strap, intended to prevent the bandage
       BB, which passes round the body, from slipping upwards.

  K k. A roller usually passed round the foot, to prevent it from
       turning.

  L. The inferior extending roller, fixed in the mortise and the
       notch of the external splint.


THOUGHTS

ON LUXATIONS OF THE OS FEMORIS, UPWARD AND FORWARD.

1. Few kinds of luxation of the os femoris occur in practice more
rarely than this. Practitioners who have seen it, and those who,
on the authority of others, have described it, without having seen
it, have all given an unfavourable prognosis respecting it, for the
following reasons: 1st, on account of the inevitable rupture of the
round ligament: 2dly, on account of the distension, and even laceration
of the capsule, and of the compression and overstretching of the
nerves and blood-vessels: 3dly, on account of the great difficulty of
reduction. The following case will prove, that in all these respects,
the apprehensions of authors have been exaggerated, that the obstacles
to reduction arise less from the nature of the displacement, than from
the nature of the means employed to remedy it; and that, if properly
directed, art would here be as successful as in other cases.

CASE. (Collected by C***). About the close of the winter
which preceded the death of Desault, a porter was brought to the
Hotel-Dieu, in consequence of a fall which he had received about two
hours before, in the following manner. As he was carrying on his
shoulders a heavy burden, his foot slipped, while his leg and thigh
were directed backwards: he fell on his knee, his thigh maintaining
still the same direction; so that the conjoined weight of his own body
and of the burden which he carried, aided by the velocity of the fall,
forcing the head of the os femoris, which pointed at the time forward
and upward, against the distended capsule, lacerated it and drove the
articulating end through the opening. Continuing still to act, it
ruptured the ligament, which connects the extremity of the bone to the
articulating cavity, and forced the head in front of the os pubis,
where it could be easily felt.

At the moment of the fall, an acute pain was felt in the part; and the
power of moving the limb was suddenly lost; the patient was carried
home, where a surgeon who visited him, considered the accident as a
fracture of the neck of the os femoris, and sent him to the Hotel-Dieu,
to undergo the necessary treatment.

Desault having examined the parts, discovered, from the following
appearances, not a fracture, but a luxation upward and forward. The
limb was nearly an inch shorter[31] than natural; the point of the
foot was turned outwards; the thigh being in a state of painful
extension, could not be flexed on the body; adduction and abduction
were alike painful; the great trochanter, being more approximated than
usual to the anterior and superior spine of the os ilium, was also too
far forward; finally, the projecting head of the bone could be felt, as
I have already said, in the groin.

    [31] A case of luxation of the head of the os femoris in a
    forward direction, but differing in some respects from the above,
    occurred lately in the Pennsylvania hospital under the care of Dr.
    Physick. The doctor reduced this luxation in the amphitheatre, in
    the presence of his class, by a process which was also somewhat
    different from that adopted by Desault.

    In the case of Desault’s patient the luxated limb was shorter than
    the sound one: in that of Dr. Physick’s it was evidently longer.
    This was no doubt owing to the head of the os femoris having, in
    the former case, passed farther up towards the superior rim of the
    os pubis than it had in the latter. In both cases the protuberance
    formed by the head of the bone in the groin could be readily felt.

    For the purpose of making counter-extension, Desault passed a strap
    between the scrotum and the thigh of the sound side: Dr. Physick,
    for the same purpose, passed the strap between the scrotum and
    the affected thigh. He conceived that by this mode he could act
    with more effect on the pelvis, and more effectually prevent the
    acetabulum of the affected side from being drawn in any measure
    downward by the extending forces. It would seem, that by making
    counter-extension, in such a case, on the sound side, the pelvis
    is made to rotate, so to speak, on its own axis, in the direction
    in which the counter-extension is made. The necessary effect of
    this rotation must be, a slight descent of the acetabulum of the
    affected side. But to retain the acetabulum firmly up is the true
    and only end of counter-extension. Dr. Physick appears therefore to
    have availed himself of the greatest mechanical advantage of which
    the situation of the parts admitted.

    Again: Desault placed the strap on which extension was made just
    above the ancle: Dr. Physick placed the strap intended for the same
    purpose above the knee. His object in this was, to have the leg
    free and unincumbered, in order that he might be able to use the
    limb with more advantage, as a lever of the first kind, to assist
    in moving the head of the os femoris towards the acetabulum. The
    fulcrum of the lever into which the limb was thus converted, was a
    strap passed round the affected thigh a few inches below the groin,
    and drawn laterally with great force in a direction opposite to
    that in which the bone was displaced.

    In this case extension and counter-extension were made by means of
    powerful sets of pullies. Notwithstanding this, these forces were
    not alone sufficient to subdue the resistance of the muscles. The
    reduction was not completed till muscular contraction had been
    weakened, and the patient reduced almost to a state of syncope, by
    the loss of nearly two quarts of blood. This copious evacuation,
    co-operating with the fatigue which the muscles of the limb
    necessarily sustained, in consequence of the powerful extension
    to which they were for some time subjected by the action of the
    pullies, overcame all resistance and the head of the bone was
    finally replaced. To exhaust the energy of the resisting muscles by
    forcible and permanent extension, and to weaken the action of the
    system generally, by copious blood-letting, appear to be the two
    most effectual modes of ensuring success in the reduction of all
    obstinate cases of luxation.

    Another point of difference between these two cases of luxation
    remains yet to be mentioned. In Desault’s case the head of the os
    femoris was, as he tells us, displaced in a direction “upward and
    forward.” In Dr. Physick’s case, the direction of the displacement
    was downward and forward. This was proved beyond all doubt, by the
    circumstance of the affected limb being longer than the sound one.
                                                                TRANS.

The reduction was effected in the following manner. The patient being
laid on a firm table, spread with a mattress, a strap was fastened
above the ancle, for the purpose of extension; another, intended for
counter-extension was placed between the scrotum and the thigh of the
sound side, and brought up the back and front of the pelvis, along the
body, till it passed over the shoulder, where it was twisted together
and secured.

Extension was then begun, precisely in the direction in which the thigh
pointed; and, during the execution of it, a rotatory motion inwards
was given to the limb. At the expiration of a few minutes, the head of
the bone remaining almost immoveable, notwithstanding the efforts to
dislodge it, Desault directed extension to be discontinued, and, taking
hold of the thigh, moved it in every direction, with a view to enlarge
the opening in the capsule, the narrowness of which he suspected to be
the cause that prevented the reduction.

Extension was then resumed, and varied in every direction, while the
surgeon endeavoured to give assistance by pushing the head of the
bone forcibly downwards, with his thumbs, and the palms of his hands.
Useless efforts; the displaced bone remained stationary.

Desault ordering extension to be again discontinued, recommenced the
motions of the os femoris, and even increased their force, changing
them in every direction, for the purpose of lacerating the capsule.
After this, extension was again renewed, with better success than
before. Indeed, on the very first effort, the head resumed, of itself,
its natural situation, without any further assistance on the part of
the surgeon.

The sufferings of the patient ceased almost instantaneously; towards
evening a slight swelling appeared around the joint, over which
an emollient cataplasm was applied. On the day following, all the
unfavourable symptoms were gone, and in about a fortnight the patient
was able to return to his usual exercises, which, however, he was
directed to pursue, for some time, with moderation.

2. There are, in this case, two circumstances, on which the
practitioner should fix his attention, and which may throw great light
on the reduction of all luxations of the os femoris, as they will be
found applicable to most accidents of the kind. These are, 1st, The
narrowness of the opening in the capsule. 2dly, The inutility of the
motion or process of conformation, when that opening has been enlarged.

3. We formerly observed, when treating of luxations of the humerus,
that one of the obstacles to reduction was, the narrowness of the
opening in the capsule; the same circumstance occurs here. That
membrane, lacerated at the time when the head of the os femoris is
driven against it, is dilated sufficiently to let the head escape:
but, the edges of the lacerated membrane, coming together again, and
being thus drawn tight around the neck of the bone, retain it in that
position, and prevent the head from re-entering the acetabulum. Thus,
in a fracture, where one of the extremities of the bone is protruded
through the integuments, the opening in the skin, by closing tightly
round that extremity, sometimes prevents its reduction.

4. In such a case, what is the first and most obvious indication? It
is necessary to increase the extent of the opening in the capsule,
by moving the limb in every direction. Some persons have deemed it
impossible to tear this membrane anew. But, if we recollect, that the
neck of the os femoris, being placed between the edges of the opening,
must necessarily draw them asunder by the motions impressed on it, it
is easy to conceive, that the angles, where these edges unite, will
be torn, if the motions be carried to an inordinate degree: besides,
experience proves here, as well as with regard to the humerus, the
truth of the doctrine contended for. Are we to apprehend, as these same
persons will have it, that serious accidents may be produced by such
violent motions? Experience again answers in the negative. Nothing,
then, can be more certain, than that this observation, respecting the
opening in the capsule, is a great stride towards perfection in the
treatment of luxations in general, and particularly of that now under
consideration.

5. When this obstacle to reduction has been removed, it is then very
readily effected, and that without the process of conformation. Indeed
that process is almost always unnecessary. For what purpose should
it be employed? Is it to increase the effect of extension, and thus
disengage the head of the bone from the place which it accidentally
occupies? In this point of view, it is nothing but a very feeble force,
added to a very powerful one, which receives from it, therefore, but
little assistance: it is much better, if necessary, to augment the
extending forces themselves. Is it to push the head of the bone into
its cavity, after the extensions have dislodged it? It is to the
muscles, and not to the efforts of the surgeon, that the performance
of this office belongs. Indeed, the surgeon must act altogether in the
dark in this respect, as he cannot possibly ascertain the precise point
where the opening in the capsule exists: he may, therefore, even push
the head of the bone against a sound part of the capsule, and thus
himself create an obstacle to the reduction, which he is attempting to
favour.

6. The muscles, on the other hand, by their contraction, naturally draw
the head of the bone into its place, because the direction of their
fibres is such as obliges them to do it. The great art of managing
luxations, then, consists, in ascertaining clearly the obstacles that
prevent reduction, in removing them, and, then, committing the rest to
extension, and the powers of nature properly directed.




MEMOIR XII.

ON SPONTANEOUS LUXATIONS OF THE OS FEMORIS.


1. Our modern treatises on diseases are little else than fabrics
artfully constructed of materials confusedly scattered through the
writings of the ancients. Many of those materials oftentimes escape
our notice, and we find them only, after practice has disclosed them
to us, in the chambers of the sick. Thus, Hippocrates had an accurate
knowledge of spontaneous luxations of the os femoris, and has even left
an aphorism expressly on that subject. Yet this disease appeared to be
unknown to the physicians who came after him, till John Louis Petit,
having met with it in his practice, drew the attention of practitioners
to it, by a memoir respecting it, published among those of the Academy
of Sciences, in the year 1722.

2. The history of this affection, which was considered afterwards, _ex
professo_, in his course on diseases of the bones, has been sanctioned
by the assent of all practitioners, to whom it has since very
frequently occurred, and who have generally admitted as Louis observes,
the doctrine of Petit, respecting the cause on which it seems to depend.

3. Experience bears witness, that usually a fall on the great
trochanter, more rarely on the knee, or the sole of the foot, precedes
it, and has doubtless some share in producing it. But what is the
nature of the primary affection which, rising immediately from this
occasional cause, becomes the immediate cause of the luxation? Petit,
and with him the practitioners of the present day, have conceived, that
the different parts of the joint, being irritated and contused, pour
out, in consequence of the injury received, a superabundant quantity
of synovial fluid, which, not being absorbed with the same rapidity,
accumulates in the articular cavity, distends the capsule, and, by
degrees, forces the head of the os femoris from its natural cavity.
Hence astringent and tonic remedies, with alum, spirit of wine, &c. are
directed to be applied externally to the upper part of the diseased
thigh.

4. But this doctrine, and the practice which results from it, seem by
no means to accord with our knowledge of anatomy. The truth of this was
deeply impressed on the mind of Desault, who had frequent opportunities
of witnessing the disease.

CASE I. A young woman walking hastily along the street, slipped and
made a false step, in which the left thigh, being violently twisted,
supported for a moment the whole weight of the body.

A severe pain experienced at the moment, obliged her to stop at first,
but becoming easier afterwards, permitted her to proceed on her way,
and soon ceased entirely. A sensation of weight occurring in the
part about fifteen days afterwards, was at first troublesome to the
patient in walking. This sensation was afterwards succeeded by a dull,
deep-seated pain, accompanied by a swelling in the parts around the
joint.

During six or seven months the limb was observed to increase in
length gradually, but very slowly. At the expiration of that time,
a contraction took place suddenly, and, in one night, the diseased
thigh became shorter than the other by nearly two inches. The patient
was then admitted into the hospital, where, after some time, she sunk
under her disease. On opening the body the following appearances
were presented to Desault, who was then consulting surgeon to the
institution.

The cartilage of the acetabulum swollen to such a degree as to fill up
the whole extent of that cavity, was yellowish and inorganic, somewhat
resembling bacon, both in colour and consistence. A soft, spongy,
whitish substance projected in the middle of it, the remains no doubt
of the round ligament. The head of the os femoris, situated where it
is usually found in luxations outward and upward, was surrounded by a
cartilage equally tumefied.

5. Here the cause of the displacement of the os femoris was evident.
The cartilages becoming tumefied, in consequence of the contusion
and violence done to them, had by degrees, filled up the acetabulum,
forcing out in the same gradual manner the head of the bone. Hence
arose the original lengthening of the limb. But as soon as the head
had escaped from the lacerated capsule, the limb was drawn upwards and
consequently shortened, by the action of the muscles, and the weight of
the body pushing the pelvis downward.

CASE II. Some years afterwards, Desault had occasion to witness again
the same disease, in the person of a man aged thirty-seven, who put
himself under his care, but, being obliged to leave Paris, a short
time afterwards, retired into the country, where he died in about six
months, enfeebled and consumed by a hectic fever.

On opening the body, the surgeon of the place discovering the same
phenomenon as in the preceding case, made a preparation of the part,
and sent it to Desault, whose pupil he had been.

6. In this case the shortening was not so sudden as in the preceding
one. It appeared at first to be coming on, during five days, in an
imperceptible manner, when, fatigued with lying in bed, and having on
that day drank a little, the patient attempted to walk, supported only
by a cane. By evening, a shortening of two inches and a half had taken
place, an effect evidently produced by the weight of the body on the
diseased thigh. Hence the necessity of confining the patient to a state
of perfect rest, of preventing, in particular, standing and walking,
and all positions in which the diseased thigh would have to sustain the
weight of the body.

CASE III. Maria Genette was received into the Hotel-Dieu, in
consequence of a fall on the great trochanter. She had been attacked
by a pain in the joint of the thigh of the same side. Walking, which
was performed with difficulty, augmented the pain, and standing, though
more tolerable, could not be long continued. The thigh was evidently
longer than the other. To leave the disease to nature, and confine the
patient to a state of rest, constituted the practice of Desault. What
effect could the external use of astringents, recommended by Petit,
produce in such a disease? Some time after her admission, the patient
was attacked by dysentery, in consequence of which she was removed to
the medical ward, where she died.

On opening the body, the parts in the neighbourhood of the joint were
evidently tumefied, and the capsule was stretched from above downwards.
The head of the os femoris was situated on the external edge of the
acetabulum. The capsule, though greatly elongated was still in a state
of tension; and the articular cartilage was swollen to such a degree,
as nearly to fill up the cavity. The quantity of synovial fluid was
less than natural.

7. This case, taken at a period of the disease not far advanced,
fully confirms the inference deducible from the two preceding ones,
respecting the cause of spontaneous luxations. Here, indeed, the
capsule not having given way, the swelling having only just commenced,
and the synovia existing in but small quantity, the progress of nature
was evident. Here, also, occurred a sign not noticed by Petit; namely,
the elongation of the limb, which always, in such cases, precedes its
contraction.

From what we have said, it appears, 1st, that the efficient cause of
spontaneous luxations of the os femoris, is a swelling of the articular
cartilages, which alters and destroys their organization: 2dly, that
the presence of this swelling must necessarily render fruitless all
attempts that might be made to replace the head of the bone in its
cavity: 3dly, that the change in the organization of the cartilages,
renders astringents, discutients, and other external means applied
for the purpose of removing the tumefaction, entirely useless: 4thly,
that here, as in many other cases, art ought to confine itself to the
palliation of effects, and not attempt the removal of causes.




MEMOIR XIII.

ON THE FRACTURE OF THE ROTULA.


§ I.

1. The rotula, a sort of bony production of the sesamoid kind, attached
to the tendon common to the extensors of the leg, represents a moveable
pulley, intended to slide on that formed by the separation of the
condyls of the os femoris. It protects the joint which it covers,
and, in point of structure, use, and situation, greatly resembles the
olecranon, from which it differs only in this, that, instead of being a
continuation or process of the tibia as the olecranon is of the ulna,
it is only attached to that bone by a strong and thick ligament which
is inserted into its tuberosity. Hence it follows, that between the
injuries of the one and the other, there must be a great analogy: and
indeed most of the signs characteristic of fractures of the olecranon,
are characteristic also of those of the rotula, and the treatment
which, in such cases, is suitable for the former, differs but little
from that required by the latter.


§ II.

OF THE VARIETIES AND CAUSES.

2. Fractures of the rotula may, in general, assume any direction,
transverse, longitudinal, or oblique: but the first kind occurs in
practice much more frequently than the others; and so great indeed
is the disproportion, that it has almost exclusively attracted the
attention of authors, in the numerous forms of apparatus invented to
retain the fragments.

3. A shattering of the bone, the effect of a violent blow; a contusion;
an echymosis; an effusion of blood into the adjacent soft parts; one
or more wounds of the soft parts, with or without an opening into the
joint; a swelling, the degree of which varies greatly, according to the
state of the fracture, and the disposition of the subject, but which is
constantly present; a double division of the bone, one of which, being
longitudinal, forms an angle with the other, which is transverse; and a
concomitant fracture of the condyls of the os femoris, or of the tibia:
such are the varieties and complications, of which the fracture under
consideration is susceptible.

4. But this fracture may be produced in two modes. 1st, by the
action of external bodies: 2dly, by that of the extensor muscles.
The first mode of division takes place in falls on the knee, or when
a body in motion strikes against it, and, in this case, there is no
counter-stroke, the rotula being too small for such an occurrence,
and always sustaining the fracture where it receives the blow. In the
second, the fall is only subsequent to the fracture, and, as Camper
has well observed, is most frequently the effect of it. For instance,
the line of gravity of the body is, by some cause, removed behind it;
the anterior muscles contract themselves to bring it forward again;
the extensors act on the rotula; it is broken, and a fall ensues.
Again, the leg is suddenly thrown into a state of violent extension;
the extensors act with great force; a fracture is the consequence,
and the patient falls. A soldier once fractured his rotula in kicking
at his serjeant; thus the olecranon, in like manner, has been broken
by throwing a stone. A man, in the Hotel-Dieu, fractured the rotula
of each knee, in the operating room, by means of convulsive motions,
produced by the operation of lithotomy.

5. The action of external bodies, can alone produce a longitudinal
fracture, as when a person falls on a sharp projecting piece of timber:
but this may also produce a transverse fracture. On the other hand,
muscular action can never give rise to any but the latter kind, since
the direction of this fracture is at a right angle with that of the
extensors. A fracture resulting from the action of external bodies, is
oftentimes accompanied by a wound, a contusion, or a shattering of the
part (2); a fracture, arising from muscular action, is always simple,
except as to a swelling around the joint. The latter cause may, instead
of fracturing the rotula, rupture the common tendon of the muscles,
or, what is more common, the inferior ligament. Desault has seen many
examples of this: Petit has also observed several, and Sabatier has
sometimes met with them. External violence seldom produces this double
accident.


§ III.

OF THE SIGNS AND THE DISPLACEMENT.

6. In longitudinal fractures the diagnosis is always accompanied with
more or less difficulty, because the extensor muscles, drawing by
their contractions the two fragments equally upwards, and the inferior
ligament holding them equally down, tend to keep them in apposition,
and to prevent them from separating. Sometimes also the ligamentous
production which covers the rotula, remains entire and serves to keep
the fragments together. It will be necessary, therefore, should the
existence of such a fracture be suspected, to move the two sides of the
rotula in opposite directions, by pressing them to the right and to the
left, in order to arrive at certainty on the subject. Should a wound
exist, as is oftentimes the case (5) the diagnosis is less difficult.

7. If the division be transverse, the diagnosis becomes then as
plain and easy, as it is difficult and obscure in cases where it is
longitudinal. In such a case, a considerable separation or space
exists between the two fragments, sensible to the touch, when the
hand is placed on the knee. In this separation, the fragments are not
displaced by the same means. The superior fragment being attached to
the extensors, is drawn upwards with great force by these muscles, the
action of which the rotula no longer resists. The lower fragment, on
the other hand, being attached only to the inferior ligament, is not
moved by any muscle, and cannot be displaced in any other way than by
the motions of the leg with which it is still connected.

8. Hence it follows, 1st, that, in a state of extension, the separation
is the least possible, because it is then produced on the part of
the superior fragment only; 2dly, that in a state of flexion it is
greatest, because then both fragments concur alike in producing it;
3dly, that it may be increased or diminished by varying the degrees of
flexion.

9. This fracture is further characterized by the following
circumstances, namely, a practicability of moving the fragments
transversely in opposite directions, and of producing, by that means,
some degree of crepitation, provided they be first brought close
together; by the pain which accompanies these motions; by the swelling
common to every kind of fracture of the rotula, and which, if very
great, may involve the other signs in more or less uncertainty; by
a difficulty of standing; and an almost entire loss of the power
of walking, in consequence of the extensors being no longer able to
communicate motion to the leg, unless when the fracture exists very low
down, near to the inferior ligament.

10. The touch will always discover in what part of the bone the
fracture is situated, which, if it be oblique, will partake more
or less of the characters of the longitudinal or the transverse,
accordingly as it approaches to the one or the other.


§ IV.

OF THE PROGNOSIS.

11. Many authors have pretended that fractures of the rotula cannot
be cured, and it even appears that the Academy of Surgery adopted
this opinion, on receiving a memoir from a Flemish physician, which
contained several facts tending to establish that principle. But what
do these facts prove? That in some particular cases, reunion did not
take place, but they do not show that this was owing to the nature of
the fracture.

12. But, what, in such cases, could prevent a cure from taking place?
The structure of the rotula differs, say they, from that of the other
bones. Now, admitting this difference of structure to be real, it
certainly approaches to the structure of tendons to which indeed it
bears a strong affinity. But, who does not know, that, when tendons are
divided, they unite as readily as bones? Besides, is not the power of
reunion common to every part endowed with life? I have already shown,
when treating of other fractures that communicate with joints, what
credit is due to those hypotheses so often revived but never confirmed,
nay even clearly proved to be unfounded, such as, an effusion of callus
into the joint, a failure of reunion from a want of periosteum on the
posterior part of the bone, the synovia diluting the matter of callus,
and thus preventing it from being duly prepared, &c.

13. The inflammation of the articulating surfaces and of the ligaments
around the joint, ought to have more influence in constituting an
unfavourable prognosis, than any circumstance that authors have
mentioned. But experience proves, that, when judiciously treated, these
fractures are not accompanied by that accident, and even that the
swelling, which for the most part attends them, always yields more or
less speedily, when a bandage, uniformly applied, presses equally on
all parts around the joint, and thus forms a kind of discutient, while
at the same time it retains the fragments.

14. Pare, Fabricius of Hilden, and a number of other writers, have
pretended, that some degree of lameness must always be the consequence
of this fracture. But, from what causes must this lameness so certainly
arise? Is it from a want of reunion in the part? I have already shown
(11 and 12) that this apprehension is wholly unfounded. Is it from
an anchylosis? This accident cannot take place, except either in
consequence of inflammation occurring in the articulating surfaces,
(and I have already shown how that may be avoided, 13) or of a
stiffness in the ligaments, and I shall hereafter make it appear that
that may be readily prevented by motion. Is it from the fragments being
drawn asunder, and in that state united by an intermediate substance
of too great an extent? I shall prove, that a bandage properly
constructed, is always sufficient to keep these fragments in contact.

From these considerations it appears, that writers have, in general,
without sufficient cause, given an unfavourable prognosis, in relation
to fractures of the rotula, which have, indeed, a great affinity to
other affections of the same kind.


§ V.

OF THE REDUCTION AND THE MEANS OF MAINTAINING IT.

15. I have already observed (7), that the causes of the separation of
the fragments are, as far as respects the upper one, the contraction of
the extensor muscles; and, in relation to the lower one, the flexion
of the leg; whence it follows, that the means of preserving contact
between these fragments are 1st, all those that are calculated for the
prevention of muscular action; 2dly, such as may keep the limb in a
state of permanent extension. Hence two leading curative indications
must be fulfilled by the bandage constructed for fractures of the
rotula: the last of these indications presents in general but little
difficulty; but, with regard to the other, the case is different. To
fulfil the latter, it is necessary first, to weaken the contractile
force of the muscles, and by that means diminish the effort which they
make to draw the superior fragment upwards; and then, to oppose to
them a proper mechanical resistance, which, by acting in a direction
the very reverse of that in which they act, may countervail their
efforts.

16. But the force of contraction is diminished, 1st, by throwing the
muscular fibres into a state of relaxation; this end is best attained
by bending the thigh on the pelvis: 2dly, by making compression over
the whole limb, by means of a circular bandage, which, by confining the
muscles, tends to restrain and weaken their action. Thus it is known
that the advantage of the bandage employed to unite transverse wounds,
consists chiefly in that compression which, by diminishing muscular
action, prevents the retraction of their edges. Another advantage
resulting from the bandage in this case is, that it prevents the
swelling of the limb.

17. As to the mechanical resistance, which must act in a direction
opposite to that of the contraction of the muscles, and, by that means,
prevent the displacement of the superior fragment, it cannot, in the
present case, be of the same nature as in fractures of the thigh, the
clavicle, &c. where permanent extension is practised. The superior
fragment offers too small a purchase for any extending forces to act
on. This resistance must be made, then, by placing some body above this
fragment, and retaining it in that situation with a force sufficient
to hinder the fragment from rising upwards: such as a few turns of a
roller drawn tight, a bit of leather, some hollow compresses, &c.

18. It is evident from the foregoing principles, that every bandage
intended to retain a transverse fracture of the rotula, ought to
be calculated to maintain the following state of things: 1st, the
extension of the leg on the thigh; 2dly, the flexion of the thigh on
the pelvis; 3dly, a uniform compression over the whole limb; and,
4thly, some mechanical resistance properly secured above the superior
fragment: the three last expedients relate to the displacement of that
fragment alone; while the first has a relation to that of the lower
one. Let us examine whether or not the bandages, hitherto employed by
different authors, be calculated for these purposes.

19. M. Valentin, believing that position alone was sufficient to retain
the fragments in contact, neglected the application of apparatus
entirely, which he even considered as hurtful, in consequence of the
swelling it produced; but experience soon proved the insufficiency of
this method. The slightest movement, or the least effort on the part
of the patient, made the extensor muscles contract, which, drawing
the superior fragment upwards, separated it from the lower one; and,
as the time of reunion is in direct proportion to the distance of the
fragments from each other, it must, under such treatment, have been
necessarily tedious, and sometimes must have even failed altogether.

20. As to a swelling being produced by the bandage, this never occurs,
unless when some openings are left, through which the integuments
protruding become tumefied: but, when the pressure is uniform
throughout, when the fluids find throughout an equal resistance, this
accident is not to be apprehended, as is proved by the practice of
Desault, who never met with it; on the contrary, a bandage properly
constructed and applied, is calculated to prevent swelling (16).

Mere position, then, though always of service in this affection, is not
alone sufficient, because it fulfils only the first of the indications
or principles laid down with respect to every form of apparatus for
transverse fractures (18), namely, that which relates only to the lower
fragment; while those that relate to the upper one, remain still to be
fulfilled.

21. Most authors have employed, with a view to these, a kind of figure
of 8 bandage, known in art by the name of _Kiastre_,[32] and approved
of by Petit, Heister, &c. This is made of a roller formed into two
balls, which are brought across each other alternately under the ham,
passing over two hollow or forked compresses, that enclose the two
fragments of the rotula.

    [32] I know not of any English term equivalent to this.       T.

But the unequal pressure which this makes on the unequally projecting
parts of the knee, renders its application extremely painful,
particularly below, where the pasteboard covering applied by Louis,
immediately on the skin, afforded but a feeble protection to the
tendons of the flexors. Besides, it did not prevent the swelling, which
is indeed a necessary consequence both of this unequal pressure, and of
the openings left between the casts of the bandage. This swelling is
taken notice of by all writers, and is, according to them, one of the
troublesome circumstances attending the fracture. The third indication
is not all fulfilled (18).

22. The extensor muscles, not being at all compressed, will act with
their whole force on the upper fragment, and, on the slightest effort
of the patient, overcome the resistance of the bandage, the action of
which, being oblique with respect to the fragment, is inconsiderable,
unless it be drawn very tight, and thus a displacement will again
occur. This obliquity of the turns of the roller obliges the surgeon,
either to draw it very tight, in which case a swelling is inevitable,
or to make it but moderately tight, and then the apparatus will be
insufficient to resist the action of the muscles.

23. Most of the objections to the ancient apparatus for fractures of
the rotula, apply also both to that proposed by Ravaton in his surgery,
and to that which Bell employs in his practice. Both of these, while
they fail in making sufficient resistance to muscular action, as well
as in fulfilling the third condition laid down as necessary to every
bandage (18), contribute to the swelling, and can rarely produce a
perfect contact between the fragments. Thus Bell has well observed,
that the reunion is rarely perfect, and that there is always a
separation more or less perceptible.

24. The complication, the intricacy, the expense, and other more
weighty inconveniences of the machine described by Garengeot in his
treatise on instruments, and employed, for the first time, by Arnaud,
and also of that which was proposed and used by Solingen, have, long
since, entirely banished them from among the means of reduction.

25. Some practitioners have advised the uniting bandage used in cases
of transverse wounds, which is formed, as is well known, of two small
rollers or strips placed in the longitudinal direction of the limb,
one of them having holes in it, to which the divisions of the other
are fastened. Both of these are first secured by circular turns; being
then drawn in opposite directions so as to meet, they draw the parts
on which they are applied in the same directions. But the action of
this bandage is confined to the integuments, and would have of course
but a feeble influence on the fragments beneath. It is also attended
with this further inconvenience, that by wrinkling the integuments,
and throwing them into folds, it might press them down between the
fragments, and thus prevent their contact. Besides, it is liable to
most of the objections urged against the preceding one.

26. This view of the means employed by different practitioners, to
counteract the causes of displacement in this fracture, are sufficient
to convince us, that the difficulties hitherto experienced in the
treatment of it, have arisen from the feebleness of the former, and the
strength of the latter. So great indeed have been these difficulties,
that some authors, conceiving a reunion impossible, have, in conformity
to such an opinion, though contrary to all the rules and principles of
the profession, advised us to abandon the patient to himself. But I
have already exposed the fallacy of that opinion, respecting the want
of a healing power in the rotula (12), an opinion which, if generally
adopted, would give rise to consequences of the most serious nature.
In the present case, as in all other fractures, the contact of the
fragments ought to be the chief object of the surgeon’s efforts.

27. But ought this contact to be perfect and exact? Several authors,
particularly Bell, have conceived, that the motions of the limb can
be performed as well with a slight separation of the fragments. Pott
even declares that such a separation will enable the patient, after his
recovery, to walk with more ease. Flajani advances the same opinion in
a dissertation on the subject.

From this doctrine arose a new mode of treatment, which consisted in
not suffering the fragments to be at rest. They were accordingly,
during the cure, put frequently in motion, the more effectually to
prevent an anchylosis, which is sometimes the consequence of this
fracture.

28. But, on the one hand, it is difficult to conceive, on what this
opinion of these authors can be founded; while, on the other, reason
declares, in the plainest and most forcible terms, that the more the
state of a bone, after it has been broken, differs from its natural
state, the less free will be the exercise of its functions, and, that
the perfection of the treatment of fractures consists, in leaving
behind it no vestige of the accident.

29. This truth was frequently confirmed in the experience of Desault,
who had an opportunity of seeing numerous fractures of the rotula, both
in the Hotel-Dieu, and in his private practice. He always observed,
that, when the separation of the fragments was considerable, and the
ligamento-cartilaginous substance uniting them was of some extent,
standing and walking were performed with much difficulty; that the
patient was exposed to frequent falls, from the want of a proper
correspondence, in point of strength and motion, between the two limbs;
and that, on the contrary, the less extensive the separation and the
substance that filled it up were, the more free and easy were the
motions of the part, which still remained, however, somewhat defective
and imperfect, unless every vestige of the division was obliterated.

Paul of Egina long since observed, that, when no means of reduction
were employed, though the patient might walk tolerably well on a level
surface, he could not, without difficulty go up an ascent.

30. From what has been said, it follows, 1st, that in the treatment
of this fracture, the perfect contact of the fragments ought to be
the principal object of the practitioner; 2dly, that the kinds of
apparatus employed by different authors, are but ill calculated for
the attainment of this end, because they fulfil but imperfectly the
indications formerly laid down (18). Let us see whether or not the
apparatus of Desault be any better suited to this purpose.

31. The bandage, which he employed in this case, analogous to that for
fractures of the olecranon, is composed, 1st, of one splint, two inches
broad, and long enough to reach from the tuberosity of the ischium, to
a little above the heel; 2dly, of two rollers, five or six yards long,
and nearly three inches wide; 3dly, of another single roller, with two
holes about the middle of it, a little longer than the injured limb of
the patient, along the fore part of which it must be extended.

32. Every thing being arranged for the application of the apparatus,

1st, One assistant secures the pelvis, in the same manner as in
fractures of the lower extremities; while another keeps the leg in a
state of perfect extension on the thigh, and the thigh on the pelvis.

2dly, The surgeon, then, standing by the side of the fractured limb,
extends along the anterior part of the leg and thigh the roller with
holes in it, having previously wet it with vegeto-mineral water, taking
care to make the two openings correspond to the lateral parts of the
rotula, that, by being thus better adapted to its shape, it may not be
thrown into wrinkles.

3dly, He then secures it on the top of the foot, by three circular
casts of a roller placed one over the other, three or four inches above
its lower end which must next be turned up over the three first casts,
and made fast by two other ones. Then, while the compress roller[33] is
secured above by an assistant, he passes up along the leg by oblique
and reverse turns, according to the inequalities of the limb.

    [33] The roller or strip with holes in it, which is extended along
    the fore part of the limb, serving, in some measure, the purpose of
    a compress.                                                 TRANS.


4thly, Having arrived at the lower part of the knee, he pushes the
lower fragment upwards, and makes below it two or three circular turns
to secure it. He then gives the roller into the hands of an assistant,
and directing him who holds the long compress roller, to draw it
forcibly upwards, pushes the integuments of the knee in the same
direction, lest, by becoming interposed between the fragments, they
might prove an obstacle to their reunion. Passing then the fingers of
his left hand through the holes in the compress-roller he places them
behind the superior fragment and pushes it forcibly downwards.

5thly, When the reunion of the fragments is exact, without any space
intervening, he resumes the roller, and passing it obliquely under the
ham, and bringing it up again behind the superior fragment, withdraws
his fingers which held this fragment down. In place of his fingers, he
then applies two or three tight circular casts, covers the knee with
several oblique casts in form of the figure of 8, so as to leave no
opening between them, and, then, continues the bandage up along the
thigh, securing by it the compress-roller extended along the fore part
of the limb.

6thly, When he has arrived at the upper part of the limb, the assistant
who holds the compress-roller, drawing it forcibly upwards, doubles
down its end over the circular casts. The surgeon next fixing this end
by several additional casts, descends again along the thigh, covers the
knee by a few more oblique turns, and finishes with the roller on the
leg.

33. This first part of the bandage evidently fulfils the third and
fourth indications (18). The compression of the roller on the muscles
weakening their action and impeding their motions prevents their
tendency to draw the superior fragment upwards: while the circular
casts passed behind this fragment, acting in opposition to the
muscular contractions, prevents it from moving upwards in obedience to
them. The long compress-roller, stretched on the fore part of the limb,
being first secured below, and then drawn forcibly upwards, presses
the casts of the roller against each other, and prevents those that
correspond to the thigh from slipping upwards, and thus abandoning the
superior fragment, and prevents also those on the leg from slipping
down and withdrawing their support from the inferior fragment. As there
remains no vacant space between the circular turns, their pressure is
uniform throughout: no swelling can consequently supervene (20).

34. But the first and second indications remain still to be fulfilled
(18): it is necessary to prevent the separation of the lower fragment,
by the extension of the leg on the thigh, and to throw the muscles into
a state of relaxation by extending the thigh on the pelvis, and to
maintain permanently, by the apparatus, that double position, which the
assistant maintains only during the operation.

35. To obtain the first effect different means have been employed; but
none answers so well, to extend the limb and retain it immoveably in
that state, as a long and strong splint, placed, as Desault did it,
subsequently to the application of the first part of the bandage, along
the posterior part of the limb. An assistant must hold the end of this
splint, while the surgeon secures it in its place by the second roller
(31): in this way the extension of the leg is effected.

36. To obtain the extension of the thigh, it is necessary to place on
the top of each other, two or three bolsters or little bags filled
with chaff, so disposed as to form an inclined plain, considerably
elevated towards the heel above the level of the bed, but which,
gradually descending to the same level towards the tuberosity of the
ischium, forms a supporting basis on which the whole limb may rest in a
uniform manner. By this twofold extension of the leg and of the thigh,
the lower fragment is kept up immoveably, and the muscles are kept in a
state of relaxation.

Hence it follows, that this bandage fulfils extremely well the
conditions laid down (18), and that it ought to be preferred to all the
others (19 ... 25), which answered the indications only in part.

37. Whatever may be the advantages of this bandage over the others,
it must still be acknowledged to have its inconveniences. The rollers
become relaxed in a short time; their compression is less active;
the muscles, being less confined, contract more readily; hence the
necessity of frequently repeating the application of the apparatus, a
circumstance which is very troublesome, on account of the roller which
composes it, and covers the whole limb. The resistance of it even
when it is recently applied, is not always equal to the power of the
muscles, whence the most assiduous attention is necessary, to obtain
such a consolidation as to leave no trace of the fracture behind. Few
persons ever possessed, like Desault, the art of overlooking nothing
that might in any way contribute to the success of his treatment: from
this, no less than from the excellence of his processes, arose the
number of his cures. Let us confirm, by a few examples selected from
among a great many, the doctrine here laid down. The following cases
were collected by Julian and Bezard.

CASE I. Francis Leclert, of a sanguine temperament, fell on the 7th of
October, 1790, on his right knee, and produced a transverse fracture
of the rotula. He was not able to rise; he was carried home, where a
surgeon, on discovering the nature of his disease, advised him to be
taken to the Hotel-Dieu.

He was conveyed thither on the day following, and, in the interval, a
considerable swelling had occurred around the joint. The usual bandage
was employed; the pains ceased immediately after its application; a
copious blood-letting was directed, and a low diet was prescribed.

The whole apparatus was wet with vegeto-mineral water, two or three
times a day. On the next day some light food was allowed, and the
quantity increased by degrees, till in a short time the patient
returned to his usual regimen. Eighth day, the swelling being almost
gone, the bandage had become relaxed it was therefore reapplied. Every
day the inclined plain formed by the bolsters was carefully examined,
and put in order again as often as it became deranged.

Fifteenth day, a new application of the apparatus: twentieth day, an
evacuation in consequence of a bilious disposition. Nothing particular
occurred from this time till the completion of the cure, which took
place on the sixty-seventh day after the accident: no depression
existed at the place of the fracture: the motions were perfectly free;
these were aided, by daily exercising the knee joint for some time.

CASE II. Vincent Grenier, aged thirty-eight, making a false step, fell
on the rotula, and fractured it, on the 6th of June, 1791: he was
brought to the Hotel-Dieu, where Desault demonstrated to his pupils, by
the usual signs the existence of the disease: a considerable swelling
had already taken place. The bandage formerly described was applied:
the same precaution as in the preceding case; apparatus examined
every day; renewed as often as relaxed; extension maintained with
great exactness. On the forty-fifth day, the consolidation was nearly
effected; on the fifty-second it was complete, the joint was exercised
for some time, and on the seventy-seventh day the cure being in all
respects complete, the patient was discharged.




MEMOIR XIV.

ON THE FORMATION OF FOREIGN BODIES IN THE JOINT OF THE KNEE.


1. The history of foreign bodies divides itself naturally into two
great sections; the one includes those that are introduced from
without; the other such as are formed within our own systems. This
latter section may be again divided into two classes; to the first
class belong bodies altogether inorganic, such as the different
kinds of stones; to the second, those which are truly organic, and
become foreign only by being situated in places where they impede
the functions, such as cartilaginous or bony productions, existing
accidentally within the joints.

On the subject of the latter class, art is much more deficient than she
is with regard to the former. Let us endeavour to assist her a little,
by giving a sketch of the opinions and practice of Desault with respect
to these productions.

2. Before his time, the surgery of France appears to have contained
scarcely a record of this affection. Described only in some ancient
works, such as the writings of Pare, it had been forgotten by the
moderns, when numerous instances of it were suddenly met with by
English and German surgeons, and soon afterwards by Desault, who
illustrated and confirmed the practice of his predecessors in it, and
even added something of his own.

3. All the joints may become the seat of these concretions; Haller
found many of them in that of the lower jaw; Bell mentions, as a very
rare occurrence, their existence at the junction of the foot with the
leg. Some authors have met with them in the wrist; but none are more
common, or merit more particular attention, than those that exist in
the joint of the knee. To these alone shall the following observations
be confined, because these alone have fallen under the notice of
Desault.


§ II.

OF THE VARIETIES.

4. Concretions of the joints do not always assume the same aspect. They
vary greatly as to number, size, figure, structure, &c. In general,
these bodies exist singly; sometimes, however, two of them are found
in the same joint, and then they may be extracted either at the same
time, or in succession, as was once done by Desault. Some English
surgeons have also met with two concretions, and Morgagni has found
even twenty-five, in the same joint.

5. They vary also in size. The largest ever met with by Desault, was
fourteen lines in its longest, and ten in its shortest diameter. Six
lines diameter in every direction, was the measure of the smallest one
that occurred in his practice.

6. Their figure is sometimes lenticular and smooth on both sides,
sometimes unequal, rough in one part, even in another, concave on
one side, convex on the opposite, sometimes marked around the
circumference and sometimes not with reddish points, and having
occasionally a stem of a cellular texture and of some length, as may
be seen in a paper by Theden. They usually consist of a single mass,
but are in some cases divided into several lobules united by a kind of
ligaments, as in the fourth case related in the Journal of Surgery.
Though most frequently detached and floating in the interior of the
joint, they have yet been found adhering by means of small portions of
cellular substance, loose and capable of being stretched, or tight,
hard, and even of a ligamentous nature.

7. If, from the external figure, we pass to the structure of these
bodies, we will find them existing in three different states. Sometimes
purely cartilaginous, sometimes completely bony, they at other times
partake of both these states, in which case a bony nucleus is covered
with a cartilaginous crust. Out of five cases, recorded by Desault,
three are of the first, and two of the third kind. Many authors have
met with the second kind, particularly Morgagni, who has even found in
the same joint, some bodies of a bony and others of a cartilaginous
nature. Hence it appears, that this variety of structure is to be
attributed to the longer or shorter standing of the disease, that every
concretion must pass successively through these three states, and that
there is a great analogy between the formation of such bodies and
natural ossification.

8. If we examine a body of the third kind cut in two through the
middle, we will find it red and vascular in the centre, like an
epiphysis, even when it is floating in the joint perfectly loose and
free from adhesion.

9. Bell, in his treatise on surgery, speaks of a kind of tumour, at
first soft, membranous, and adhering to the internal surface of the
capsule, but which, according to him, may become afterwards hard and
solid, and be detached so as to float loose in the joint. But are
not these tumours different in their nature from those destined to
be converted into bone? Do they, in fact, ever undergo the changes
mentioned by Bell? Desault having never met with any of them, was
unable to offer an opinion on the subject. In the mean time, an
observation made by Monro, may serve to throw some light on the
question: he once saw, in one of these productions, a cellular nucleus
surrounded by a covering of bone.

10. Though usually simple and free from complication, this affection
may, according to some authors, give rise occasionally to a dropsy in
the joint. Pare is the first who has made mention of this: he found
one of these bodies in a patient’s knee, into which he had made an
incision for the purpose of drawing off a collection of water. Simson,
on extracting a similar body, gave vent to four ounces of water. But,
as on the one hand, a dropsy of a joint oftentimes exists without
these foreign bodies; so, on the other, these bodies are almost always
found disconnected from dropsy. Nor is there any affinity between the
acknowledged causes of an accumulation of synovia, and the presence of
these bodies; so that when the two diseases do exist together, it is
altogether probable, that they are independent of each other.


§ III.

OF THE CAUSES.

11. The formation of articular concretions succeeds frequently to blows
or falls received on the joint, in which case, a swelling more or
less considerable in the surrounding soft parts, showing itself from
the first, and remaining for some time, at length allows the foreign
body to be perceived, and does not, in general, disappear during the
continuance of the body in the part.

12. Sometimes no external injury contributes to the formation of the
body, and then, a spontaneous swelling precedes its detection, as
Desault observed in two patients, where nothing was known to have
concurred in the production of the disease. Constant rest increases
this swelling, while exercise and a temperate mode of life diminish it.

13. But what can be the immediate cause of these tumours? Are they,
as some allege, an aggregation or crystallization of particles of
matter conveyed into the interior of the joint by the synovia, in the
same manner as the rudiments of a stone are conveyed into the bladder
by the urine? Their organic appearance and the vessels that pervade
them, are unfavourable to such an opinion. Can they be, agreeably to
the conjecture of Theden, articular glands bruised by means of strokes
or falls? Or are they, as some authors will have it, portions of the
cartilage of the joint, detached by the same causes? How then will
their spontaneous formation be explained?

But why trouble ourselves about the cause, provided we can remedy the
effects? Nature conceals from us the means, and discloses to us nothing
but the results. Theories are fluctuating; but experience is still the
same: let us search, then, by an attention to facts, for that which we
cannot learn from first principles.


§ IV.

OF THE SIGNS.

14. The phenomena which announce the presence of foreign bodies in
the joint of the knee, are sometimes clothed in a character of such
evidence, that they cannot be mistaken; at other times, the nature of
the disease eludes the most accurate researches: the cause of this
variety may be easily perceived.

As the joint presents different depressions and eminences, and as the
bodies, being usually loose and detached, may travel through its whole
extent, they produce different effects, according to the particular
situations which they occupy. If lodged in a depression, they are
not compressed, and cannot, of course, give rise to any troublesome
affection. If they bear on an eminence, such as the condyls, or the
posterior part of the rotula, they are forcibly compressed, and must
derange, in some measure, the functions of the joint. Hence the precise
nature of the affection cannot be at all times derived from the state
of the symptoms.

15. Sometimes the patient can stand and walk with perfect freedom
and ease, while, at other times, a sudden pain seizing him, obliges
him to sit down, or even causes him to fall, if there be nothing at
hand to support him. This pain subsists for a longer or shorter time.
One motion produces it, and sometimes another, made in an opposite
direction, removes it. But in common it is of some continuance, and
then the patient is obliged to keep his bed.

16. If the state of the joint be examined, it will be found more or
less swollen, when the pain is very acute. When the pain ceases,
the swelling in part disappears. It is never sufficient to prevent
the fingers, when drawn along the external surface of the joint,
from discovering the presence of the foreign body, when it forms a
protuberance under the integuments. It is then found sometimes above
the rotula, by the side of the tendon of the extensor muscles, and that
is the place where it usually produces least pain; at other times,
it is lower down, in front of the condyls, and by the side of the
rotula. It is occasionally found immediately behind the tendon of the
extensor muscles; in this case so acute is the pain, that the patient
is generally unable to stand. But it is when it is situated behind the
rotula, near to the projecting ridge which runs across its posterior
surface, that it gives rise to the most serious affections.

17. The body passes from one place to another, on the least motion,
and sometimes, as Bell observes, the patient, on changing his position
during sleep, is awakened by severe pain, in consequence of the foreign
body being moved by this change. It happens, in certain cases, that it
disappears, and lies concealed for some time, in the back part of the
joint. During this period the joint performs all its functions with
freedom and ease. Desault made this remark, in the case of a captain of
dragoons, from whom, for the first time in his practice, he extracted
one of these bodies, and who, for six months previously, had been able
to perform all the motions of the joint freely, without pain. This
person, experiencing no uneasiness, considered himself perfectly cured,
when the body suddenly reappeared, in consequence of a hasty extension
of the leg.

18. If the body, when projecting under the integuments, be gently
compressed, it yields to the pressure, changes its situation, and,
according to the impression it has received, moves either to the
internal or the external side of the joint, or reciprocally from one
side to the other, passing also behind the rotula, behind the inferior
ligament, or sometimes behind the tendon of the extensor muscles. In
these alternate displacements, it may in some cases be turned round,
in such a manner that its anterior surface will take the place of its
posterior one, and then resume its primitive situation. Desault met
with an instance, in which the patient himself was in the habit of
turning the body round in this manner.

19. Bell, in conformity to the distinction of articular concretions
into cellular and solid, attributes to each division its peculiar
signs. In the first case, the pains, being rather obtuse than sharp,
are constant; in the second, they are extremely acute, but disappear
and return at intervals. Supposing the division to be a real one, cases
of the last description certainly occur much more frequently than those
of the first.


§ V.

OF THE TREATMENT.

20. From what has been said it follows, 1st, that these cartilages
floating through the joints, do mischief mechanically (14), by coming
into contact with the articular surfaces: 2dly, that to obviate this
mischief, it is necessary either to prevent their contact, by fixing
the bodies in a spacious part of the joint, and thus doing constantly
what nature does on certain occasions, or to extract them through an
opening made into the articular cavity.

21. Hence, art can have recourse to but two methods of cure, all hope
of discussing these tumours by external applications being, as Bell
observes, entirely extinguished.

22. The first method was proposed by Middleton and Gooch, who having
brought the foreign body into a situation where it produced no pain,
endeavoured to confine it there a length of time sufficient to make it
form adhesions with the corresponding part of the capsule. As we are
not informed of the result of the experiments of these two physicians,
we are left to our own conjectures on the subject.

23. Are these foreign bodies capable of forming adhesions? Supposing
they are, will the internal surface of the capsule attach itself to
them at the pleasure of the surgeon? Even admitting the existence of
both these conditions, by what means can the bodies be kept stationary
for a length of time sufficient for the formation of these adhesions?
Will they not be displaced by the slightest motion? Besides,
experience seems to be unfavourable to the expedient. I have already
said (17) that, in a certain case, the foreign body disappeared for six
months, remaining, no doubt, during that whole time, in the same place:
but, if it could not, on that occasion, form adhesions, if a motion was
sufficient to produce its reappearance, can we expect that art will be
more fortunate in her attempts?

24. But, even admitting that the foreign body does form these adhesions
with the capsule, if it should increase in size in the part of the
joint which it occupies, becoming in a short time disproportioned to
its extent, it will impede motion as before, and produce, by degrees,
nearly the same affections.

25. From these considerations it follows, that the only expedient which
can promise a radical cure is, the extraction of the foreign body. In
the performance of this extraction, an incision must first be made
through the integuments and the capsule.

26. This operation, simple and easy in itself, has given rise to
apprehensions as to its consequences, which have long prevented
practitioners from undertaking it.

It was in former times a maxim in surgery, that wounds of the joints
are, if not mortal, at least extremely dangerous, in consequence of
their admitting air into contact with the articulating surfaces. But
observation has demonstrated the fallacy of this doctrine, and Desault
in particular, has thrown great light on the subject, as I have
frequently had occasion to mention in the course of this work: so that,
at the present day, it is clearly ascertained, that, if judiciously
treated, these wounds are seldom productive of serious consequences.

27. Hence it follows, that the operation we are considering, when
skilfully performed, never gives rise to any dangerous or disagreeable
affections. Experience has proved the truth of this assertion in the
practice of Theden, Simson, Gooch, Broomfield, Bell, and Desault,
the latter of whom performed the operation five times with complete
success. The only case in which he was less fortunate, was that
of a man, in whom the wound of the integuments closed up at first
without any accident, but which was succeeded by two abscesses, one
in the thigh, and the other in the leg, but without any affection of
the interior of the joint. This patient was subject to a wandering
rheumatism, which oftentimes attacked the lower extremities, and
was perhaps in the present case the chief cause of the unfavourable
occurrences.

28. It is to the English that we are indebted for the first operation
performed for the extraction of these bodies. An account of this is
given in the Transactions of a society in Edinburgh. Since that, the
operation has been frequently repeated, and more than ten instances of
it were already on record, when Desault first performed it in France.
His method, somewhat different from that of others, was as follows.

1st, The patient must be laid on a bed, or seated on a high chair.
The first position, however, is to be preferred, because when it is
adopted, the patient need not be moved after the operation.

2dly, The leg is extended on the thigh, in order to relax the anterior
part of the capsule of the joint.

3dly, The surgeon then searches for the foreign body, moves it to the
internal side of the joint, against the attachment of the capsule, and
secures it between his thumb and the fore-finger of his left hand,
while an assistant draws the skin over the fore part of the rotula.

4thly, Taking then a common bistoury, he makes, on the protuberance
formed by the body, a longitudinal incision of an extent proportioned
to its size, through both the integuments and the capsule, so as to lay
the body bare at the first stroke.

5thly, Sometimes the body escapes immediately of its own accord, in
consequence of the compression made on it by the fingers. If its
passage out be not spontaneous, a small scoop or a taper-pointed
spatula passed under it, answers the purpose of extracting it. But,
in the introduction of these instruments, it is necessary to avoid
touching the articulating surfaces with their ends, lest, by being
irritated, they might swell, and give rise to troublesome accidents.

6. If any resistance be met with, enlarge the opening and the
extraction will become easy. Without this precaution, the edges of the
wound, being bruised and irritated by the passage of the body, will
swell, inflame, and unite again with difficulty.

7. When the extraction is finished, the assistant who draws the
skin towards the inside of the joint, suddenly lets it go, when it
returns to its natural situation. This causes the two incisions, which
corresponded, at the time of the operation, to change their relative
situation, the one remaining internal and the other becoming external.

8. Hence arises a twofold advantage; the entrance of air into the
interior of the joint is prevented, and the external and loose portion
of the capsule, being drawn inwards with the skin, unites with the
condyl, if it be not brought into exact apposition with the other
portion of the capsule, divided near its attachment.

9. The extraction being finished, it is then necessary to examine
carefully, in order to ascertain whether or not the joint contain any
more of these foreign bodies. On some occasions, when this is even the
case, they cannot at the time be discovered. Desault himself was once
deceived on this score, in consequence of which his patient was obliged
to submit to a second operation.

10. The incision in the integuments is now united by means of adhesive
plaster. Over this are laid compresses and a little lint, and the whole
secured by a few turns of a roller drawn moderately tight.

11. The leg being then placed on a pillow, is kept in a state of
extension, by means of a splint applied, for a few days, behind the
joint.

29. If we examine but for a moment the process in this operation, we
must perceive, that an incision made through the skin and capsule at a
single stroke, is, in no respect, less advantageous than one made at
two strokes, as recommended by all practitioners, and that, it is in
the following respects greatly preferable to it: 1st, it shortens the
operation very considerably: 2dly, it diminishes the pain: 3dly, it
exposes the joint a much shorter time to the contact of the air.

30. The object of the operator is better answered by drawing the
skin outward and towards the rotula, than by either depressing it,
as Broomfield did, or raising it, as Bell does. Being more loose and
more easily stretched in this direction, the opening in it is removed
farther from that in the capsule, which prevents more certainly the
access of air to the joint, and also favours the examination of the
capsule.

31. In the mean time, the operation may succeed, even although the
openings in the integuments and the capsule correspond to each other.
Many English and German practitioners, without previously stretching
and changing the natural situation of the skin, make a common incision,
which they dress afterwards like a simple wound, and are yet no less
successful than others in the result of their operations. This is
a further proof of the fallacy of the ancient surgical doctrine,
respecting the admission of air into the cavities of joints. Perhaps
Desault might have omitted this precaution, had any operations of the
kind occurred in his practice during the last years of his life.

32. The operation is seldom attended with much pain. Only one patient
manifested signs of this in the practice of Desault. Nor have those
operations of the kind performed in England been more painful, so that
it may be laid down as a principle, that in most cases no primitive
accident is to be dreaded.

33. With regard to hemorrhagy, as there is no large artery near the
place of the incision, there is nothing to be apprehended on that
score. Oftentimes there is scarcely any loss of blood at all, as may be
seen in the first case published in the Journal of Surgery. But, even
admitting that a small articular branch be divided, the reunion of the
edges of the wound will be sufficient to check the hemorrhagy, in the
same manner as in the operation for the hare-lip, the contact of the
divided integuments of the lip, puts an end to the hemorrhagy from the
small arteries of the part.


§ XIV.

OF THE SUBSEQUENT TREATMENT.

34. I have already said that but little is to be apprehended on the
score of accidents subsequent to the operation (26). Out of the
numerous operations of the kind performed lately in Europe, but few
cases have proved troublesome in their consequences, and even these
were influenced by some foreign circumstances. Thus, for example, one
of the patients of Simson rode out on horseback a few hours after the
operation, on a cold and stormy day, and thus produced a troublesome
affection of the part. A similar remark may be made respecting the case
formerly mentioned (27).

35. The apparatus or dressing remains untouched for the two or three
first days, during which time it is necessary to wet it frequently
with vegeto-mineral water. It is a certain truth, that the use of this
liquid retards the suppuration of wounds, and that, when continued a
due length of time, it keeps inflammation at that degree most proper
for the process of healing.

36. On the removal of the dressing, the wound is sometimes so perfectly
healed up, as not to exhibit the least discharge. At other times a
slight suppuration takes place; but, at the end of a few days, the cure
is complete. Under the care of Desault, it was always effected in eight
or ten days.

37. Let us bring the doctrine just laid down to the test of experience.
Five cases have been published on this point. I have selected two of
them, both which occurred in the same subject, where we find the same
operation twice performed with equal success.

CASE I. M. Vielle, aged nineteen, was attacked about the beginning of
the year 1790, by a spontaneous swelling in the joint of the knee.
Inconsiderable at first, but increased afterwards by a laborious
journey, it disappeared at the end of two months, discovering to the
touch, near the internal edge of the rotula, a foreign body, which was
hard and moveable, and which somewhat impeded the motions of the joint.

About a month afterwards, the swelling returned, and, having continued
for three months, disappeared again, when the body was found at the
external side of the rotula, increased in size. Sundry external
applications were tried for six months without success.

Weary of this unavailing practice, the patient came, in March, 1791, to
consult Desault, who discovered a cartilaginous substance of a flat and
circular figure. Its usual situation was at the external side of the
joint, but it could be easily moved to the internal side, and could be
turned on its own axis within the joint, nor did it occasion any pain,
when suffered to remain at rest by the side of the rotula. But, when
it passed behind the tendon of the extensor muscles, the patient was
unable to stand, and he experienced severe pains when it made its way
under the condyls or behind the rotula.

The indication was evident. Before the operation Desault prepared the
patient by a proper regimen, and then, in the method already described
(28), extracted a foreign body, whitish, and oval, fourteen lines in
length, ten in breadth, and two and a half in thickness at its middle.
It consisted of three pieces, united by a ligamentous substance,
and was smooth on the side next the joint, but rough with irregular
tubercles on the opposite side, and on its circumference. There was no
loss of blood during the operation: the usual dressing was applied,
after the most attentive examination, as to the existence of a second
body.

Neither pain nor swelling supervened, and by the fourth day, the
reunion was complete. In a short time motion was performed with as much
ease as before the occurrence of the complaint. In the mean while, a
degree of uneasiness remained in the joint; but barely perceptible at
first, this uneasiness continued to increase; in about four months,
symptoms of the existence of another foreign body made their appearance.

M. Vielle being now a distance from Desault, put himself under the care
of his brother, who extracted a second body, in the manner already
described, except that the incision was made at two strokes.

Dressing the same as in the preceding case, with this additional
precaution, that the thigh and leg were covered by a roller, for the
purpose of moderating the action of the muscles.

No fever, no pain; the reunion completed on the eighth day, except a
small point in the centre of the wound, which suppurated slightly till
the fourteenth. There was now neither difficulty in walking, nor the
least sensation of pain. Since that time, M. Vielle has enjoyed the
entire use of his limb.


OBSERVATIONS AND REFLECTIONS

ON FORMS OF APPARATUS FOR FRACTURES OF THE LEG.

§ I.

1. CASE I. (Reported by Levacher). Catharine Belet, aged fifty-five, of
a strong and vigorous constitution, fractured her leg in the middle,
by a false step in alighting from a carriage. Being carried home, in
a careless manner, she was visited by a surgeon, who merely reducing
the fracture, but applying nothing to retain the reduction, sent the
patient to the Hotel-Dieu. She was conveyed on the same day to the
amphitheatre, where Desault discovered the existence of the affection
by the following signs.

Pain in the middle of the leg, less severe when the limb was at
rest, more so when it was suddenly moved; the patient absolutely
unable to support herself on it so as either to stand or walk since
the accident; inequalities sensible to the touch on the anterior
surface of the tibia; a shortening or contraction of about half an
inch; a preternatural mobility at the place of the fracture; evident
crepitation, produced by the rubbing of the fragments against each
other, when moved in contrary directions: a change in the direction
of the lower fragment, which was bent somewhat outwards. These signs,
added to the circumstance of the fall, evidently announced a simple
fracture of both bones. The reduction was effected in the following
manner.

One assistant made counter-extension by grasping the lower part of the
thigh with both his hands, the fingers being placed behind it, and his
thumbs corresponding to its anterior surface. Another made extension,
not as writers recommend, at the lower part of the leg, but on the foot
itself, which was taken hold of in such a manner that the fingers met
on its upper side, while the thumbs crossed each other on its sole. In
this way a lever of the first kind was formed, the resistance to which
was the fragment to be replaced, while its centre of motion was in the
joint.

Extension being directed at first in the course or line of the
displacement, till the limb had attained its usual length, was then
directed in such a way as to restore to the leg its natural form. By
this, the fragments being brought into apposition, united exactly
without the process of coaptation being employed.[34] The apparatus,
usually employed by Desault in such cases, was applied to maintain the
reduction: the different pieces of it had been previously arranged on a
pillow in the following order: 1st, four strong pieces of tape placed
at equal distances from each other; 2dly, a junk-cloth,[35] long enough
to reach from the knee beyond the sole of the foot; 3dly, a bandage of
strips, similar to that described for the thigh (page 246), arranged
in the usual mode; 4thly, two long compresses, the lower one of which
being the longest was turned back on the other; three bolsters had also
been prepared; these, being formed of several pieces of linen joined
together, were about one inch and a half thick: the broadest of these
was designed to be placed on the anterior part of the leg; the two
other lateral ones, though narrower, were a little longer, in order
that, by folding back on themselves, they might be accommodated to the
inequalities of the limb; 6thly, lastly, there were also prepared two
splints, an inch broad, three lines thick, and of the same length with
the junk-cloth.

    [34] That is, without any assistance from the hands of the surgeon.
                                                               TRANS.

    [35] Analogous in its form and uses to that employed in fractures
    of the thigh. It may not be amiss, on this occasion to mention,
    that in the form of apparatus for oblique fractures of the leg,
    represented in the Appendix, plate III. no junk-cloth is necessary.
                                                               TRANS.

Every thing being ready, the assistants still keeping up extension
raised the leg a little, while a pillow was slipped under it, to
support it equally and uniformly throughout its whole length. The leg
was placed on this pillow in such a way as to correspond exactly to the
middle of the apparatus which was arranged in order on it, and was
previously wet with vegeto-mineral water.

On the anterior part of the leg was then applied a long compress,
extending from the knee to the upper part of the foot. Over this were
lapped the other two compresses, which had been previously placed in
order as part of the apparatus. These were then secured by the bandage
of strips, the application of which was begun at the lower strip next
to the foot, and continued successively upwards with the rest, making
them cross each other at the anterior part of the leg.

On the sides were placed the bolsters which were doubled at the ancle
to protect that part from the pressure it might otherwise sustain. The
splints were then applied along the external surfaces of the bolsters,
the edges of the junk-cloth having been previously folded round them,
in order to render their pressure the more close and steady. Along the
fore part of the leg was laid the largest of the bolsters, and the
whole was then secured by the four pieces of tape tied on the external
splint, with a degree of tightness sufficient to keep the fragments
immoveable.

A compress wet with vegeto-mineral water covered the foot, and was
secured by a roller, applied in such a manner, that its two ends,
crossing on the back of the foot, were fastened laterally to the two
splints.

The leg, being firmly fixed by this apparatus, and gently flexed by
means of a pillow placed under it, was protected by hoops from the
pressure of the bedcloaths. The fragments being now in complete
apposition irritated the parts no longer, in consequence of which the
pain ceased.

The patient being properly disposed in bed, remained tranquil and
easy throughout the remainder of the day. Diluting drinks and light
nourishment were prescribed.

Next day, no pain; patient composed; a slight swelling on the back of
the foot; the apparatus wet anew with vegeto-mineral water. Fourth day,
the bandages a little relaxed; the point of the foot turned somewhat
outwards; a new application of the apparatus. Seventh day, bilious
symptoms appear, loathing of food, nausea, and bitterness of the mouth.
Eighth day, tongue furred, inclination to vomit; loss of appetite; a
grain of tartar emetic given in solution; copious dejections; evidently
better: next day, appetite returned, tongue clean. Tenth day, a third
application of the apparatus, which had become too loose. Fifteenth
day, fresh bilious symptoms; further evacuations; success the same.
Twentieth day, consolidation evidently advancing; no deformity of
the limb; fourth application of the apparatus. Thirty-second day,
consolidation almost complete; the apparatus still kept on till the
forty-second day, when the patient was discharged perfectly cured.

2. This case, which is in no respect different from those that most
frequently occur in practice, presents us with a view of the mode
of reduction, the means of retention, and the subsequent treatment,
employed by Desault, in cases of the kind. The advantage of the
bandage of strips, which allows the limb to be uncovered without being
disturbed, is now generally acknowledged in fractures of the lower
extremities. In the treatment of these, practitioners reject entirely,
at present, the roller bandage, which was recommended by Petit,
Heister, and all the authors who preceded them, and which, by producing
a new displacement, at each time of reapplication, may entirely prevent
the fragments from uniting. The bandage of Scultet, brought into use
again by Desault, the form of which has been just described, is also
preferable to the eighteen-tailed bandage, which some practitioners
still employ.

3. The strips which compose the former bandage, being narrower than the
tails of the latter, can be more neatly applied to the leg, as they
more readily mould themselves to its inequalities; the compression made
by them is, therefore, more exact, more uniform, and consequently less
inconvenient. If one of the strips become soiled, it can be changed
without deranging the bandage. (Respecting this point, see what was
said on fractures of the thigh.) This bandage being less bulky than the
eighteen-tailed one, is therefore less troublesome to the patient.

4. The broad and strong splints which form a part of this apparatus,
have the following advantages over those previously used both by the
ancients and the moderns; 1st, they come in contact with and bear on
a larger extent of the surface of the limb; 2dly, they consequently
maintain the fragments in apposition with greater firmness and effect;
3dly, they prevent the rotation of the foot outwards, an accident
which very frequently occurs when the fracture is complete, that is,
when both bones are broken; 4thly, they remain constantly in their
place, without slipping either forward or backward, an inconvenience
necessarily attendant on the other splints, which, from their roundish
form, touch the limb in only one point or line.

5. To sustain the foot, Petit recommends a piece of a board to be
applied immediately to its sole, and supported by two bits of tape
fastened to the splints. This practice is adopted to some extent
even at present: but a simple roller, applied in the manner already
mentioned, is sufficient for the purpose; the tendency of the foot to
turn outwards is never so strong as not to be effectually resisted by
this expedient: besides, should the piece of board be placed ever so
little too vertically, it retains the foot in a state of inconvenient
and painful flexion.

6. The situation of the leg, gently flexed by means of a thick cushion
or pillow placed between it and the mattress, is, in all respects to
be preferred to the method of Pott, which is exclusively adopted by
Bell. What, indeed, can be the object of this latter method? To relax,
say they, the muscles, that tend to make the lower fragment overlap
the upper one. But is it not evident, that most of these muscles, not
being attached to the os femoris at all, cannot be influenced by this
position? To obtain the relaxation of the posterior muscles, it is
necessary to flex the foot; but, in such a case, the anterior muscles
are necessarily in a state of tension: this completely counter-balances
the relaxation of the others, and, therefore, there is nothing whatever
gained. It is certainly much best to allow the leg to be in a state of
moderate flexion, such as we assume when asleep, and which appears to
be the most natural.

7. The apparatus just described, produces on the fragments a twofold
action: 1st, by a kind of side walls formed by the splints, it prevents
their displacement laterally, and from this circumstance alone, is
fully sufficient for the retention of transverse fractures: 2dly, the
pressure of the rollers, splints, and bolsters, if these be applied
with sufficient tightness, prevents the lower fragment from mounting on
the upper one, and thus preserves the natural length of the limb. Hence
its advantages in oblique fractures; and, as the powers of displacement
are weaker here than in the thigh, this apparatus, is in general,
sufficient to counteract them.

8. It is true that cases do sometimes though rarely occur, where,
in consequence, of being irritated by splinters, or the points of
the fractured bone, or acted on by some other causes which make them
contract, the muscles overcome the resistance of the apparatus, and
make the fragments overlap. Under such circumstances, permanent
extension affords here the same advantages as in fractures of the thigh.

9. Most authors, to obtain the desired end in such cases, recommend
means calculated to act on the thigh. Thus, Manne proposes the use
of his glaussocome. Desault, under such circumstances, effected his
purpose by the apparatus described in the following case.


§ II.

10. CASE II. Pierre Bejol, aged thirty-seven, of a strong and vigorous
constitution, fell, as he was carrying a heavy load, over a beam which
lay in his way. His leg was fractured towards its lower part; he
was lifted up and carried home, where a surgeon, by making unskilful
efforts at reduction, gave him extreme pain.

A roller and a kind of round splint applied to each side of the
limb, forming the whole of the apparatus, and not being sufficient
to retain the fragments, soon allowed them to overlap each other
nearly two inches. The pains continue; a considerable swelling appears
around the fracture; the patient is greatly agitated; he is brought
to the Hotel-Dieu, where, from the deformity of the limb, Desault
was satisfied, at first sight, of the existence of a fracture; on a
more attentive examination, it was discovered to be complete and very
oblique.

The muscles being tense and in a state of violent contraction, drew the
inferior fragments very forcibly upwards; these were finally, however,
by means of well directed efforts, brought into perfect contact,
with the superior fragments: the difficulty now lay in maintaining
this contact. The age of the patient, his strength, and the almost
convulsive state of the muscles, gave reason to apprehend that a
displacement was about to occur. An attempt was made to prevent this in
the following manner.

The patient being laid on a bed properly prepared,

1st, The foot and the leg above the ancle, were covered by a bolster
or compress, round which was passed a strong roller intended for the
purpose of making extension. The ends of this roller, being left free,
were carried, one on the outside, and the other on the inside of the
limb.

2dly, Below the tubercle of the tibia was placed another bolster,
surrounding the leg, and on this, was secured another roller for the
purpose of counter-extension. The ends of this roller, after crossing
under the knee, were left hanging loose one on each side of the limb.

3dly, The two rollers being thus arranged, while the assistants, still
continued to make extension, the surgeon applied successively, and in
the order already mentioned, the compresses, the bandage of strips, and
the bolsters.

4thly, He then took two splints with notches in their lower ends, of
the same breadth with the splints already described, but long enough to
reach, each of them, from four inches above the knee to the distance of
four inches beyond the sole of the foot. One of these was applied on
the outside and the other on the inside of the leg.

5thly, The surgeon then taking hold of the two ends of the upper
roller, drew them over the upper ends of the corresponding splints,
while an assistant crossing the two ends of the lower roller under
the sole of the foot, drew the external end over the lower extremity
of the internal splint, and the internal end over the lower extremity
of the external splint. Carrying them, then, up along each side, he
brought them, at the middle of each splint, to meet the ends of the
upper roller, to which they were firmly secured by knots, so as to
make extension at the foot, and counter-extension at the knee. The two
fragments, being drawn by this apparatus, the one down and the other
up, could not again overlap.[36]

    [36] For a view and description of an excellent form of apparatus
    for oblique fractures of the leg, constructed on the principles of
    that here described, see article III. plate III. of the Appendix.
                                                             TRANS.

On the same day the patient was bled copiously; a low diet was
prescribed; some diluting drinks were administered; and the whole
apparatus was frequently wet with vegeto-mineral water.

Next day, fever; restlessness; blood-letting repeated; the extending
rollers, having become relaxed, were tightened. Third day, evidently
better. Fifth day, a new application of the apparatus; some swelling
of the foot; a few small blisters on the leg; these were opened and
dressed with cerate spread on linen. Eighth day, the patient easy and
tranquil; a little shortening of the limb; a third application of
the bandage. Twelfth day, bilious symptoms appear. Thirteenth day,
an emetic given in solution; symptoms decline. Twentieth day, the
fractured limb in a favourable state; the roller for extension laid
aside; that formerly described employed in its place. Thirtieth day, an
appearance of consolidation. Thirty-fourth day, bilious symptoms recur;
further evacuations. Forty-third day, consolidation perfect; scarcely a
vestige of the fracture remains. Exercise is repeated for several days.
Fiftieth day the natural strength and motion of the part completely
restored.

11. The general end to be answered by every bandage intended to retain
a very oblique fracture of the leg, is evidently, 1st, to hold the
knee up, and with it the superior fragments; 2dly, to draw the lower
fragment down: from this twofold effect arises a twofold resistance
diametrically opposed to the powers of displacement, which are; 1st,
the slipping down of the trunk, which pushes the thigh before it, and
with it the upper fragments of the leg; 2dly, the action of the muscles
of the leg, drawing the foot upwards, and the lower fragment along with
it.

12. But, if to these indications we compare the bandage described in
the foregoing case, we will perceive that they are perfectly fulfilled
by it. Indeed the splints forming a kind of pullies which change the
direction of the rollers, we must count on the action of these rollers
only from the part of the limb which they surround, to the ends of the
splints over which they are reflected: whence it follows, that the
two ends of the upper roller, reflected over the superior extremities
of the splints, cannot be drawn down along each of these splints,
without that part of the rollers, which reaches from the leg to these
extremities, being drawn up, and with it the knee and the upper
fragment. In like manner, the ends of the lower roller cannot be drawn
up towards the ends of the upper one, without those portions of them
which run from the sole of the foot, being drawn down and pulling the
foot and the inferior fragments along with them.

13. Hence it follows, that by tying on each side, one end of the upper
roller to the corresponding end of the lower one with sufficient
tightness, the two indications above laid down (12) are accurately
fulfilled.

14. But, in general, the common bandage is sufficient, as I have
already mentioned, even in cases of oblique fractures, to prevent the
ascent of the lower fragments on the upper ones. Desault never employed
any others in the last years of his practice, and it was only in cases
of extraordinary disposition to muscular contraction, that he ever
had recourse to the second kind. By means of the common apparatus, he
was able to prevent the overlapping of the fragments from forming any
protuberance on the anterior and internal part of the leg.

15. We must acknowledge, however, that this apparatus is liable to the
same objection with most others intended for permanent extension. The
roller placed below the knee, for the purpose of counter-extension,
surrounds almost all the muscles, which tend to make the inferior
fragments overlap the superior ones, by drawing the foot upwards. By
pressing on and irritating these, it favours, and even excites their
contractions, and, by that means, gives rise to a shortening of the
limb, the very accident which the apparatus is intended to prevent.
This inconvenience induced Desault, in a particular case, to substitute
to the preceding apparatus, that used for permanent extension in
fractures of the thigh.




MEMOIR XV.

ON THE DIVISION OF THE TENDO ACHILLIS.


1. It might be supposed that a work on diseases of the soft parts,
would be a more proper place for this article, than the present one,
where my express object is to treat of affections of the hard parts.
What induces me to insert it here is, the analogy which exists between
a division of the tendo Achillis and a fracture of the os calcis, the
light which the treatment of the one throws on that of the other, and
the example of the celebrated Petit, who, in his work on diseases of
the bones, speaks also of this division.


§ I.

OF THE CAUSES AND VARIETIES.

2. The division of the tendo Achillis is the result, either, 1st, of
the action of a cutting instrument; or, 2dly, of muscular action: hence
two very different modes of its production, the one by a wound, the
other by a rupture. The first is not a very rare accident, because
the projection of the tendon exposes it oftentimes to the stroke of
external bodies: the second, though but little noticed by the ancients,
has been frequently observed by the moderns, since their attention was
called to it by Petit.

3. The manner in which the division is produced by a wound, has nothing
particular in it; that by a rupture, takes place in the following
manner. A man leaps over a ditch, but his spring or exertion is too
weak; he reaches the opposite bank only with the ends of his feet:
the line of gravity not falling on the ground, the weight of the body
throws the feet into a state of violent flexion, the muscles contract
with great force, to prevent a fall backwards, and, at that instant,
the tendon is ruptured, in consequence of being drawn downwards by the
violent flexion of the foot, and upwards by the effort of the muscles:
hence it appears that Petit was deceived with regard to the mechanical
cause of the rupture, which he considered as taking place at the moment
of the patient’s alighting on his feet, when, as he said, the tendons
were surprised, so to speak, into a state of too great tension. It is
easy to apply the principles of this particular case to others that
may happen, and where the position may not be the same; such as, when
we leap on a table, &c. Sometimes slighter efforts have produced the
effect; and, as Louis observes, dancers have sometimes ruptured the
tendo Achillis by making a powerful exertion on the point of the foot,
as well as by other motions.

4. Divisions produced in the first mode, may be situated in any part
of the tendon. Those produced in the second, occur more particularly
about its middle: to that part the effort or strain is most forcibly
determined, and there the resistance is the weakest. The rupture of the
tendon may, according to Petit, be either complete or incomplete; but,
if we consider the simultaneous contraction of the gastrocnemii and
soleus muscles, and the intimate manner in which their two tendons are
united at a considerable distance above the heel, it will be difficult
to conceive how these tendons can be ruptured separately. With regard
to divisions produced by cutting instruments, the case is different:
there, the weapon may pass half way through the tendon either from
behind or laterally; and perhaps divisions of this kind are much more
frequently incomplete than otherwise, in consequence of the great
resistance of the tendinous fibres.


§ II.

OF THE SIGNS.

5. The superficial situation of the tendo Achillis, always renders
the diagnosis of its division easy. It can be rendered difficult
only by the occurrence of a considerable swelling, an accident that
rarely happens. If there be an external wound, the depth to which the
instrument has penetrated, and the possibility of sometimes feeling
the ends of the tendon between the edges of the wound, are the first
evidences of its division. If, on the other hand, the tendon be only
ruptured, then at the moment when the rupture happens, a report is
heard by the patient, not sharp, and like the crack of a whip, as is
said to take place when the plantaris muscle is ruptured, but more dull
and flat, according to the account given to Desault by a patient, whom
he interrogated on the subject.

6. In either case, there occurs suddenly, if not an entire inability,
at least, an extreme difficulty in either standing or walking: hence
the patient falls, and is unable to rise again; but, in divisions that
are only partial or incomplete (4), this sign does not occur. Between
the divided ends of the tendon there exists a depression sensible to
the touch. This depression is increased by the flexion of the foot, but
diminished and even entirely removed by its extension.

7. The patient can spontaneously flex the foot, none of the flexor
muscles being affected, and this flexion may be carried even beyond
what is natural, because the divided tendon forms no obstacle to it
behind. Spontaneous extension is also practicable, in as much as the
peroneus longus, tibialis posticus, &c. which remain uninjured, are
capable of producing that motion. Some have alleged that the calf of
the leg must be increased in size by the swelling of the gastrocnemii
and soleus muscles, in consequence of their state of contraction; but
modern experience has shown, that there is but little reliance to be
placed on that appearance.


§ III.

OF THE PROGNOSIS.

8. Divisions of the tendons are not in general dangerous. These organs,
being insensible in their nature, are not painful when ruptured,
as is proved both by experiments on living animals, and by the
observations of surgeons who have had such affections under their care,
more particularly of Monro, who experienced the accident in his own
person. No inflammation supervenes, and if a swelling be sometimes the
consequence, it is in general soon dispersed, leaving behind it nothing
serious.

9. Whence arose then the exaggerated fears of the ancients respecting
injuries of this kind? Doubtless from an opinion which was then
entertained, that tendons and nerves were of the same nature. Hence the
severe pains, the convulsions, and even death itself, which, according
to them, frequently happened, and was always to be apprehended, as
the consequence of injuries done to these organs. Lamotte, among the
moderns, still entertained these prejudices, when, in speaking of
affections of the tendo Achillis, he said, “So dangerous are they in
their consequences, that they can seldom be brought to a favourable
termination.”

10. Doubtless the unskilful treatment, employed by the ancients, in
cases of this kind, the use of the bloody suture without proper means
to retain the parts in a suitable situation, the abuse of irritating
remedies applied externally, the imprudent administration of oily
substances, and, still more, the motions of the patient, contributed
not a little to the production of those accidents, which no longer
occur in the practice of the moderns, since the nature and treatment
of the disease is better understood. It has been proved, by late
observations, that the division of the tendo Achillis is apt to
produce some diminution in the size of the affected leg. But this
soon disappears, nor does it, indeed, even occur, if, by a proper
application of the bandage, a speedy union of the divided part be
obtained. The patients of Desault never experienced it.


§ IV.

OF THE INDICATIONS OF CURE.

11. That I may present, in order, what I have to offer on the treatment
of the division of the tendo Achillis, 1st, I will lay down, with
precision, the indications of cure that arise out of this division:
2dly, with these indications I will compare the means used by different
authors, by which the insufficiency of almost all of them will be
demonstrated: 3dly, by showing the relation or correspondence that
subsists between these indications, and the apparatus employed by
Desault, I will prove that it fulfils them sufficiently, and is,
therefore, to be preferred to every other.

12. To bring the edges of the division into contact, and to retain them
so, are here, as in other simple wounds, the two general principles of
treatment. The first of the principles presents an easy indication; it
is only to extend the foot forcibly on the leg. The indications that
arise out of the other, are more difficult to be fulfilled.

13. To form a proper idea of these, let us call to mind what it is that
prevents the contact of the divided ends. As far as relates to the
lower end, it is the flexion of the foot on the leg, and with respect
to the upper one, the contractions of the gastrocnemii and soleus
muscles, which are not now opposed by the continuity of the tendon.
Therefore, 1st, to keep the foot permanently extended; and 2dly, to
oppose the action of these muscles, are the two general indications
or objects of every apparatus destined to retain the two ends of the
tendon in contact.

14. But, the action of the muscles may be opposed in different ways;
1st, by keeping the muscles themselves in a state of relaxation.
This relaxation may be easily effected, as far as relates to the
gastrocnemii, in consequence of their insertion into the posterior part
of the condyls of the os femoris: it is sufficient, for this purpose,
to keep the leg half-bent on the thigh: 2dly, by a judicious and well
directed compression made on the muscles. I say judicious and well
directed, because it ought to bear chiefly on the fleshy portion, and
not on the tendon, otherwise it will depress its divided ends, destroy
their contact, and make them unite, not with each other, but with the
adjacent parts, and thus produce considerable lameness. At the same
time that care is taken not to depress the divided ends, these ends
must not be permitted to move from side to side, a kind of displacement
which may readily occur, in consequence of the hollow or depression
situated on each side of the tendon. But, the only expedient to
attain this twofold purpose, is, to place in these hollows, some soft
substance, lint, for example, which may project sufficiently to protect
the tendon behind, and to retain it laterally.

15. This compression, that ought to be made by the bandage, appears
to have escaped all writers, as none of them have given it a place
among their means of cure. Yet, do we not plainly perceive, that,
by confining the muscles, impeding their contractions, and reducing
their irritability by its long continued use, it must tend to prevent
the superior end from being drawn upwards and thus separated from
the inferior one? Will not compression, in this case, be similar to
the effect of the uniting bandage, in transverse wounds, where the
great number of circular casts which cover the limb, are particularly
intended to weaken muscular action, analogous to what takes place in
hare-lip, where the compresses do as much good by compressing the
muscles, as by bringing together the edges of the divided lip? But
further, besides reducing the force of the muscles, does not this
compression serve to prevent the swelling of the limb, an effect almost
inevitably resulting from its state of rest and deficiency of action?
So far, then, from being, as Louis says, one of the inconveniencies of
the first bandage of Petit, it constitutes one of its principal titles
to a preference among practitioners.

16. It appears from what has been just advanced (13 ... 15), that the
following are the three ends to be attained by every bandage, intended
to retain the divided ends of the tendo Achillis in contact; 1st, the
immobility of the foot in a state of permanent extension on the leg;
2dly, the immobility of the leg, in a state of semiflexion, on the
thigh; 3dly, a judicious and well directed compression made on the
whole leg and foot, but bearing on the tendon with only sufficient
force, to keep it from moving backward or laterally. Let us compare the
methods of authors with these indications.


§ V.

OF THE DIFFERENT METHODS OF CURE.

17. The treatment recommended by authors may be reduced to three
general methods. The first consists in rejecting all artificial aid,
and leaving the cure to nature and the position of the limb. To the
second belongs the use of sutures, intended to retain the edges of the
division together. The third includes the different kinds of apparatus
employed for the same purpose.

18. _First method._ Chronological order places this method after the
others. But this order must be disregarded by him, whose object is
things rather than time. The history of the sciences calls sometimes
for the approximation of distant periods, and, at other times, for the
separation of those already approximated.

19. Several practitioners, in France and England, have lately
proscribed the use of all external means. Pibrac and Dupouy were of
opinion, that the mere precaution of the patient not to flex the foot,
assisted by constant rest, was sufficient. Hoin and Gauthier mention
many cases in confirmation of this doctrine. M. J. Rodbard, surgeon at
Ipswich, having ruptured his own tendon about three inches above the
heel in leaping over a little rivulet, instead of confining himself to
bed, continued in the exercise of his profession. He walked every day,
without any other precaution than that of not flexing the foot, and
five years afterwards, he was able, as he mentions, “to walk, run,
mount or alight from his horse, without pain, in a word, the affected
leg performed its functions as well as the other one.” We have an
account of a patient who was cured without a bandage by A. Petit.

20. Was there indeed a true rupture of the tendon, in all these
cases, particularly in those where the patients continued to walk
as before the accident? Most of the cases which we have seen prove
the impossibility of either standing or walking (6). But, admitting
that they were ruptures, are we authorized to pursue the mode of
treatment there adopted? Certainly we are not. None of the indications
formerly mentioned (16) is there fulfilled. What is there, under such
circumstances, to prevent an involuntary motion from destroying the
contact of the divided ends, by forcibly flexing the foot and extending
the leg? The limb is not subject to any compression. Should such an
accident happen, the cure must necessarily be tedious. Besides, if
the ends be separated, a reunion cannot take place, except by an
intermediate substance, which, by filling up the vacant interval
between them, must lengthen the tendon. In consequence of this, the
muscles will be impeded in their contractions, and the foot in its
motions, as Desault has oftentimes observed in animals, which he left
to themselves, after having divided the tendo Achillis. Thus, in a
fracture of the rotula, the motion of the limb is very much impaired,
when the ligamento-cartilaginous substance which unites the fragments
is too long.

21. Hence it follows, that here, in like manner as in other ruptures
of the tendons, art must assist nature, because without the former the
powers of the latter will be insufficient.

22. _Second method._ The ancients pursued a course not less uncertain,
and much more dangerous. Sutures, sanctioned by general custom, were
extended to wounds in the tendons, and were even more especially
employed in such cases, because the tendinous end being drawn forcibly
and greatly displaced by the contraction of the fleshy portion in
which it terminates, it was deemed necessary to oppose to this force a
greater resistance.

23. What useful end was attained by this practice? Muscular action
was left perfectly free; and the only thing done was an attempt
made to resist its effect. But, in a short time the tendinous ends,
in consequence of being forcibly stretched by the contractions of
the muscles, either gave way at the points where the stitches were
introduced, or, in case they did not give way, became swollen, painful,
and inflamed, in consequence of the violent distension which they
suffered: hence the serious affections produced by such treatment (9
and 10).

24. The ancients, then, were mistaken, with respect to the indications
in this disease, which are, not to resist muscular contraction left
free and unimpeded, but to check and prevent this contraction, by
the means formerly pointed out (16). It is a principle generally
acknowledged at the present day, that sutures ought not to be used as
a mean of approximating divided parts, but only to keep the edges of
parts already approximated in perfect contact. But, in the present
case, the means of approximation being sufficient for the purpose of
exact contact, sutures are altogether unnecessary. This, however,
does not hold true in every case, though certain practitioners, who
have too generally rejected the use of sutures, contend that it does.
Finally, however, these means have been excluded from the treatment of
the division of the tendo Achillis, and the doctrine of the Academy of
Surgery, though erroneous in many other cases, has established, with
regard to the present one, the true practice.

25. _Third method._ It is to the celebrated Petit that we are indebted
for that method of treating the division of the tendo Achillis, which
consists merely in position maintained by apparatus. Having ascertained
that the extension of the foot brought the fragments into contact, he
conceived the idea of continuing this extension throughout the whole
treatment, for the purpose of continuing the contact also. This was a
happy idea, the simplicity of which recommended it to practitioners,
and which, being once discovered, has formed the common basis of all
the numerous processes devised since by different authors.

26. When we consider the action of these several processes, and compare
it with the indications formerly laid down (16), we may divide the
processes themselves into three general classes. Thus, some of them
fulfil only the first and third of these indications, namely, the
permanent extension of the foot, and a regular compression made on the
leg; others fulfil only the first and second, the latter of which
consists in keeping the leg constantly flexed on the thigh; while
those of the third and last class, fulfil the first indication only.
This manner of classing the processes, will shorten the consideration
of each of them individually, since it is evident that each class
is chargeable with one general inconvenience, namely, that of being
deficient with respect to one or two of the leading indications. I
shall examine nothing, therefore, but the disadvantages peculiar to
each.

27. To the first class belongs, almost exclusively, the first
bandage invented by Petit. It is formed by a long compress, placed
longitudinally behind the leg and foot, and secured by a roller
applied regularly on these parts. The two ends of the compress, being
reflected back, are then knotted together behind the leg so as to
extend the foot. This expedient is simple and ingenious, and would be
preferable to all others, were it not that, besides the charge of not
fulfilling the second general indication (16), it is further liable
to the following objections: 1st, the compression which it makes is
injudicious and ill directed, because it bears not only on the fleshy
portion of the leg, but also on the divided tendon, which being more
projecting and therefore more exposed, has its two ends pressed down
and separated: 2dly, in some cases, it does not maintain the extension
of the foot with sufficient certainty: 3dly, it does not prevent
displacement in a lateral direction.

28. To the second class belong, 1st, the celebrated slipper of Petit,
substituted by that author for his first bandage; this machine was
composed of a slipper fixed to the foot, of a knee-piece[37] secured
on the lower part of the thigh, and of a strap running from the one
and fastened to the other, to extend at pleasure the foot on the leg,
and to flex the leg on the thigh: 2dly, the bandage of Duchanoy, made
in imitation of the preceding apparatus, and consisting of a simple
sock surmounted by a roller, which running along the back part of the
leg, was fastened to another roller applied round the lower part of the
thigh. Besides the general objection of not at all fulfilling the third
indication (16), these processes are liable also to the following ones;
1st, they fatigue the toes by the constant pressure of the slipper and
the sock, as Monro experienced in his own person, to such an extent
that he was unable to support their use; 2dly, the slipper is quite too
complicated, and is therefore seldom at hand when wanted. The apparatus
of Duchanoy, does not possess sufficient solidity and steadiness.

    [37] (_Genouilliere._) I believe this was a piece of apparatus made
    of leather, somewhat similar to the top of a boot, and secured on
    the limb just above the knee.                              TRANS.

29. In the third class are included, 1st, the first machine of Monro,
formed of a slipper similar to that of Petit, surmounted by a strap
of leather, which was to be fastened by a buckle to a kind of guetre
or spatterdash, fixed on the upper part of the leg; 2dly, the second
apparatus of the same author, subject, like the other, to several
inconveniences; 3dly, the simple apparatus of Schneider, who rested
satisfied with maintaining the extension of the foot, by a splint
placed anteriorly. Besides various other objections to them, these are
all chargeable, alike, with the radical fault, of not fulfilling the
second and third indications (16).

30. From this comparison of the indications (16) with the means
destined to fulfil them, it appears that there were material defects on
the part of the latter. Let us examine whether or not that of Desault
was better calculated for the purpose. It is, so to speak, nothing but
a modification of the apparatus of Petit (27), but such a modification
as amounts to an improvement in principle, and entitles it to be called
the apparatus of Desault.

31. The pieces which compose it are; a compress two inches broad, and
long enough to reach from the lower part of the thigh to the distance
of four inches beyond the foot; a roller five or six yards long and
two inches wide; a sufficient quantity of lint; and two long graduated
compresses.

32. Every thing being ready;

1st, An assistant supports the foot and leg, the former in a state of
great extension, and the latter half-flexed: another assistant supports
the thigh, grasping it about its middle.

2dly, If there be a wound of the integuments, a little lint wet with
vegeto-mineral water is laid directly over the division of the tendon;
if it be a simple rupture, this precaution is unnecessary. Under the
foot, up behind the leg, and the lower part of the thigh, is then
extended the long compress, which is to be secured in that situation by
the hands of the assistants.

3dly, The hollows situated at the sides of the tendo Achillis, are
then filled up with pledgets of dry lint, surmounted by the two long
graduated compresses, which retain the pledgets, and must project a
little beyond the tendon, because they are liable to be rendered flat
by pressure.

4thly, The surgeon now taking the roller, makes at first several
circular turns round the toes, fixing the long compress there, the end
of which, being reflected over these first casts, is secured by a few
additional ones which cover the whole foot, and are afterwards directed
obliquely above and below the division, round which is formed a kind of
figure of 8, that brings the edges of the wound into perfect contact.
If there be no wound of the integuments, it is necessary to take care,
lest the skin interposing between the divided ends of the tendon,
should separate them, and thus prevent their reunion. Ascending, then,
by circular casts, along the whole leg, and even to the lower part
of the thigh, the surgeon there turns down the upper end of the long
compress, and securing it by a few more circular casts, finishes the
application of the roller.

5thly, The apparatus being thus applied, and the extension of the foot
and the flexion of the leg firmly secured by it, the leg is then placed
on a pillow or bolster, one side of which corresponding to the angle
which the leg forms with the thigh, assists in keeping it half-flexed.

6thly, Should the long compress prove insufficient to keep the foot
extended, or should it, by becoming relaxed too soon, render frequent
reapplications of the apparatus necessary, (circumstances which rarely
happen when the bandage is well applied), a splint placed anteriorly,
as was the case in Schneider’s apparatus (29), completely remedies the
defect.

33. On comparing this apparatus with the indications formerly laid
down, in the present disease (16), we find it evidently calculated
to fulfil them with great exactness. 1st, The extension of the foot
is permanently secured, both by the long compress, and by the splint
when it is employed: 2dly, the same compress, aided by the bolster or
pillow placed under the leg, maintains the flexion of the leg on the
thigh: 3dly, The muscles are effectually compressed; their action is
impeded in part by the compression of the circular bandage, which does
not bear on the tendon, in consequence of the bolsters of lint placed
on each side of it: these bolsters prevent the tendon both from moving
laterally, and from being depressed: hence it follows, that the action
of the circular bandage is precisely conformable to the principles
already established (14 and 15); and that the whole of the apparatus,
taken together, fulfils perfectly all the indications (16); this is an
advantage not to be derived from any of the forms of apparatus used by
preceding authors.

34. This apparatus is in no degree complex or troublesome. Simple and
easy, it requires nothing for its construction but what the surgeon
can easily obtain, and what he can even himself prepare. There exists
a great analogy between it and the bandages which Desault used for the
reunion of transverse wounds, and for fractures of the rotula and the
olecranon. A truly great man does not estimate his merit, by the number
of processes which he invents; he well knows that the perfection of art
consists in producing numerous effects by few and simple means.

35. We will confirm, by two cases, the principles laid down in this
memoir. One of these relates to a division of the tendon, connected
with a wound, and was reported by Bezard; the other by Manouri, and
relates to a simple rupture of the tendon.

CASE I. J. B. Lavigne, aged thirty, as he was going down into a cellar
without light, struck his leg against the edge of a sharp saw, which
completely divided the tendo Achillis. The patient was immediately
carried to the Hotel-Dieu. The wound of the integuments was transverse,
two inches long, and had its edges but slightly separated from each
other. The ends of the tendon, in contact during the extension of the
foot, were separated two inches when it was flexed.

The usual apparatus was applied (32), and the limb placed on a bolster,
in a position favourable for the relaxation of the posterior muscles.

In the evening, wound painful; pulse raised; a copious blood-letting;
low diet. Next day, more blood taken away; antiphlogistic regimen,
which was continued for several days, till the symptoms were gone: no
troublesome accident occurred. Tenth day, the apparatus taken off;
the wound partly healed; the apparatus reapplied, and continued till
the twentieth day, when the perfect reunion of the parts rendered its
further use unnecessary. From this time the patient began to walk
on crutches. Thirty-sixth day, could walk well without his crutches.
At this period, a small abscess occurring in his heel, induced him
to remain in the Hotel-Dieu two weeks longer, when he was discharged
perfectly cured.

CASE II. M. Delp, leaping with some of his young companions, ruptured
the tendo Achillis, about two inches above the os calcis. Both standing
and walking became instantly impracticable: the patient falling down,
was taken up, carried home, and from thence to Paris, where he arrived
in the evening. Desault being immediately called to him, found him
affected with all the signs of a division of the tendon; such as, a
hollow between its divided ends, which was increased by the flexion
of the foot, diminished by its extension, &c. The usual apparatus was
immediately applied, and as the patient felt but little pain, only a
moderate blood-letting was prescribed. Next day, no alteration in the
treatment; antiphlogistic regimen; low diet continued for some days,
when the patient was permitted to return to his usual mode of living.
Ninth day, apparatus removed for the first time: a slight separation of
the ends of the tendon; and a wrinkle in the skin interposed between
them: a new application of the bandage, taking care to free the
integuments from wrinkles. Twelfth day, a relaxation of the rollers; a
third application of the bandage: every thing found in a good state;
but, the patient being, from sprightliness, too much inclined to exert
himself, a splint was applied anteriorly to prevent the extension of
the foot. Seventeenth day, a fourth application of the apparatus,
which was not moved again till the thirtieth. At this period, the
reunion was somewhat advanced: fortieth day, almost complete. Fiftieth
day, the patient was permitted to leave his bed, and take very gentle
exercise, which he continued to increase gradually, till the sixtieth
day, when he was discharged cured. Doubtless the tediousness of this
case was owing to the slight separation which existed for some time
between the fragments.




MEMOIR XVI.

ON THE FRACTURE OF THE OS CALCIS.


§ I.

1. The os calcis, being a short and thick bone, has such a power of
resistance, that it is but seldom fractured. Such an accident does,
however, sometimes occur, and may arise from two causes, 1st, the
action of external bodies, which is rare: 2dly, the contraction of
the gastrocnemii and soleus muscles, from which it almost always
proceeds. Thus, the rotula is more frequently broken by the action of
the extensor muscles, than by blows received on the bone from without:
there is, however, this difference between the effects of muscular
contraction in these two cases, namely, that in the former, the rupture
of the tendo Achillis is common, and the fracture of the os calcis very
rare; whereas in the latter, on the contrary, the rotula is oftentimes
broken, while the tendon of the extensors remains almost always sound.
This phenomenon is explained by the difference between the thickness of
the two bones, between the length of the two tendons, and between the
power of the causes.

2. Be the cause of the fracture what it may, it generally occurs in
that portion of the os calcis, called its great tuberosity, which
projects behind the astragulus, which corresponds above and below to a
large quantity of cellular membrane, inwardly to the great groove of
the bone, externally to some ligamentous attachments, and behind to the
insertion of the tendo Achillis.

3. It is known, 1st, by an evident inequality under the heel: 2dly, by
an elevation, sensible to the touch, of the posterior fragment above
its usual level: 3dly, by an almost entire inability either to stand or
walk: 4thly, by severe pain being the inevitable consequence of moving
the foot: 5thly, by its being practicable to increase the displacement
by flexing, and to diminish it by extending the foot: 6thly, by the
facility with which the posterior fragment may be moved in every
direction by taking hold of it with one hand, and steadying the foot
with the other: 7thly, by a swelling more or less considerable, which
frequently appears around the divided surfaces.

4. The ancients gave in general an unfavourable prognosis respecting
this kind of fracture. Hippocrates was apprehensive of some injury
being done to the surrounding parts. Pare considered the case mortal,
on account of the laceration of numerous vessels which are connected
with the bone. Most of the moderns adopt these principles, not for the
foregoing reasons, but on account of the vicinity of the accident to
the joint of the foot. The practice of Desault cannot throw much light
on this subject, as he never had more than one or two such cases of
fracture under his care; but the analogy of other fractures, situated
in the neighbourhood of joints and even extending into them, induces us
to believe, that, if properly treated, fractures of the os calcis will
terminate as favourably as those of other bones.


§ II.

5. If we attend to the signs just mentioned (3), we will perceive that
they almost all result from the displacement of the fragments. But,
whence arises this displacement? As far as the anterior fragment is
concerned in it, it arises from, and is increased by, the flexion of
the foot; and, as far as relates to the posterior one, it is to be
attributed to the contraction of the muscles attached to the tendo
Achillis, which is itself inserted in that fragment. Hence it follows,
that the apparatus intended to prevent this displacement, ought, 1st,
to keep the foot permanently extended on the leg: 2dly, to prevent
the action of the muscles, by keeping them in a state of habitual
relaxation by means of the constant flexion of the leg on the thigh,
by making on those whose contractions are dreaded, such a regular and
well directed compression as may disqualify them for contracting;
and, lastly, by placing behind the posterior fragment some resisting
substance, to prevent it from rising upwards.

6. If to these indications we compare Desault’s apparatus for a rupture
of the tendo Achillis, as described in the preceding memoir, we will
readily perceive 1st, that it perfectly fulfils that indication which
relates to the anterior fragment; 2dly, that that one which relates
to the posterior fragment will be equally well fulfilled by the half
flexed state of the leg, by the compression made on the muscles, and by
a thick compress, not very broad, laid transversely above the fragment,
secured by the long roller, and afterwards by a circular bandage, which
must form here, as in the case of a fractured rotula, a kind of figure
of 8 around the fracture. This compress is the only modification of the
apparatus requisite to accommodate it to the particular case now under
consideration.

7. In applying the figure of 8 bandage here, as well as in the case
of a fractured rotula, to prevent the ascent of the fragment, it is
necessary to use the utmost care to free the integuments from wrinkles
both above and below the fracture, lest by getting between the
fragments, they might keep them asunder, and thus impede their reunion.

8. Desault used to relate in his lectures, the case of a woman whom he
had formerly seen receiving a fracture of the os calcis, by falling
from a great height. I cannot state the case fully, because I am not in
possession of all the facts. The following one however drawn up during
the first years of Desault’s practice in the Hotel-Dieu, will furnish
an example of his mode of treatment.

CASE. A man, likely to be arrested by some one who pursued him, leapt
from a window nearly twelve feet high. In lighting, his feet struck on
a beam which lay in his way, in such a manner, that the fore part of
them only was supported. He made an effort to recover his equilibrium,
but as the line of gravity of his body had nothing to rest on, he fell
backwards, rose in order to make his escape, but fell a second time
unable to rise again.

When assistance came to him, he complained of a severe pain in his
heel, and said, that on falling, he had heard a considerable report. He
was taken up, and assisted in walking to the Hotel-Dieu, where he did
not arrive without pain, being able to bear only on the point of the
diseased foot, and suffering greatly if he attempted to put his heel to
the ground.

From the signs mentioned (3), Desault perceiving that there existed a
fracture of the os calcis, made arrangements for reducing it. This he
did by extending the foot on the leg, and drawing down the exterior
fragment from the elevation to which muscular contraction had raised
it, so as to bring it into perfect contact with the body of the bone.
He then applied the common apparatus for a rupture of the tendo
Achillis, with the modification already pointed out (6).

In the evening venesection was prescribed: the patient experienced
sharp pains at the place of the fracture; a slight swelling occurred at
the ends of the toes; an anodyne was prescribed. Next day, evidently
better: venesection again. Fourth day, the patient is allowed to return
to his usual regimen. Eighth day, apparatus removed for the first
time; fragments in contact. Fifteenth day, a second application of the
bandage. Nineteenth day, bilious symptoms. Twenty-first, an emetic
given in solution. Thirty-second day, further evacuations: apparatus
renewed. Forty-seventh day, consolidation complete. A stiffness
remained in the part for some time, but this was gradually removed by
exercise.




MEMOIR XVII.

ON COMPLICATED LUXATIONS OF THE FOOT.


§ I.

1. Complicated luxations of the foot, like complicated fractures, show
themselves under such a variety of forms, are accompanied by so many
peculiar affections, and so many different circumstances are connected
with them, that it would be difficult to lay down rules applicable
to their treatment in all cases. On this subject, indeed, art is in
possession of certain general principles, liable however to numerous
exceptions and modifications. In the treatment of such cases, who can
fix the limits between reduction, and amputation or extirpation? Who
can point out, with precision, where the one ceases to be useful and
becomes hazardous; while the others constitute the only resources of
art? Experience and talents alone are capable of deciding on these
points, and that only in the chambers of the sick. It is, therefore,
less by precept than example that practitioners ought to be instructed
here.

2. To furnish suitable examples on this head constitutes my only object
in the present memoir, which will consist of the histories of a few
cases, with such inferences and remarks as the occasion may seem most
naturally to suggest. Here the practice of a great master, varying his
means with the varying forms of disease, will serve as models to those
who may meet with similar cases. Our experience is composed of the
facts which we receive from reading, as well as of those derived from
observation. Who would have a right to call himself a surgeon, if he
had no other title to that name, but such as resulted exclusively from
his own personal observation?

3. However difficult it may be, as already observed, to speak in
general terms, on the present subject, we may yet assert with safety,
that authors have greatly exaggerated the danger of complicated
luxations of the foot. Terrified at the extent and unpromising
appearance of the accidents, these writers have lost that confidence in
the powers of nature which we never ought to abandon. They have taken
up an opinion, that luxations of the foot, differing in their symptoms
from other luxations, require also a different mode of treatment; that
reduction, by perpetuating the accidents of the case, must prove fatal,
and that amputation ought to be adopted as the only resource. Cases do
certainly at times occur, where a doctrine different from this would be
fatal in its effects: such are those terrible lacerations, where the
foot is entirely separated from the leg, except some shreds of flesh
with a few tendons among them that still retain it.

4. But, provided the blood-vessels have escaped, and any hope of
circulation and life in the part still remain, the success of reduction
should always be first tried; and the following examples will show,
what ought to be expected from this practice, when accompanied by
skilful treatment.


§ II.

LUXATION OF THE FOOT, COMPLICATED BY A FRACTURE OF THE FIBULA, TIBIA,
&C.

CASE I. (The following case was collected by Leveille.) Abraham Genty,
aged forty-three, a dealer in wine, as he was running along the street,
slipped, and made a false step on his left foot, which turned with
its external edge under him, and its internal edge upwards. He fell,
luxated his foot, and fractured the fibula.

The patient was carried home, where a surgeon who was ignorant of his
profession being called, did nothing but apply a cataplasm to the foot.
In the evening the parts began to swell, and were extremely painful;
fever supervened, accompanied with great restlessness. Third day, to a
rapid increase of all the symptoms was added a delirium; blood-letting
from the jugular vein was prescribed to no purpose; things continued
to grow worse till the sixth day, when the patient was brought to the
Hotel-Dieu, in extreme danger.

The following was then the state of the parts. A considerable swelling
around the joint; a projection of the malleolus internus, with a
depression underneath it; a preternatural direction of the tibia
before, and of the os calcis, behind; a depression near the lower
end of the fibula; a crepitation readily perceived, on moving the
fragments; a large tumour on the outside of the foot: with a depression
and mobility of the malleolus externus.

The luxation was immediately reduced. Extension made on the foot and
leg brought the parts into their proper situations, where they were
retained by means of the bandage for fractures of the leg, and four
compresses well secured by the bandage. One of these compresses, being
placed on the malleolus internus, another on the outside of the foot,
a third on the anterior and lower part of the tibia, and the fourth
under the os calcis, prevented these different parts from being again
displaced.

As soon as the apparatus was applied, the pupils remarked with
astonishment, that the restlessness of the patient ceased, that his
pains were relieved, and his delirium disappeared; he expressed his
surprise at the state from which he had just recovered, and was now
able to give an accurate account of his fall. He was scarcely put to
bed, when he fell into a tranquil sleep, which lasted three hours. For
six days previously he had not slept a moment.

In the evening, the patient was free from pain, and perfectly tranquil.
Diluting drinks were prescribed, with twenty-five drops of Hoffman’s
anodyne liquor: the apparatus was wet from time to time with
vegeto-mineral water: the patient slept well throughout the night.

Next day, the apparatus renewed: the parts perfectly in place: swelling
diminished; same means continued. Sixth day, the anodyne discontinued.
Tenth day, swelling still less; echymosis gone; a yellow colour in the
skin, an evidence that resolution is going forward. Twentieth day,
swelling gone.

Thirtieth day, the fracture of the fibula healed; that bone slightly
separated from the tibia: the circular roller drawn tighter; and a
thick compress placed on the external malleolus, to bring it to its
proper place. Forty-fifth day, the apparatus for a fractured leg
removed, and a simple roller substituted in its place: the motions of
the foot painful and contracted; a small gangrenous spot appeared on
the heel. Fifty-fifth day, the ulcer which proceeded from this spot
healed: motions of the part more free and extensive. Sixty-first day,
the patient able to walk without assistance, though not without pain.

5. It is difficult to find an instance where the advantages of
reduction have been more remarkable than in the preceding one.
The patient had passed six days in pain, extreme agitation, and
uninterrupted delirium: the foot was reduced, and these unfavourable
appearances instantly vanished, and were succeeded by a state of
tranquillity. Alarmed by such a state of things, the ancients would
doubtless have proceeded to amputation. Let us examine into the motives
which led Desault to an opposite line of practice, and then inquire
into the cause of the success with which that practice was crowned.

6. Had amputation been performed here, it must have been for one of the
two following reasons; 1st, for fear of gangrene; or 2dly, to remove
the unfavourable symptoms that existed. The first apprehension would
have been quite visionary, in as much as all the blood-vessels were
sound. Would the second consideration have been any better founded? It
was perfectly obvious, that the unfavourable symptoms which existed
arose from the tension and overstretching of the parts, in consequence
of the preternatural position of the bones of the foot. The indication
was evident. Replace these bones in their natural situations, the
strained parts will then necessarily become relaxed, and all the
troublesome and alarming symptoms cease with the cause that produced
them. Experience confirmed the justness of this reasoning.

7. But the mere replacement of the parts would be of very little avail,
if it were not permanently maintained, and followed up by a judicious
mode of treatment. Without such treatment there would doubtless be
reason to apprehend all that train of troublesome consequences, of
which authors speak in such frightful terms, and which arise, not from
the nature of the luxation, but from the manner in which the patient
is treated. A loose apparatus, incapable of preventing displacement,
would allow the bones to be deranged anew, and to produce again an
overstraining of the parts, accompanied with pain, swelling, &c.
Irritating local applications, such as camphorated spirits of wine,
&c. would increase these pains; emollients which are employed in other
cases would keep up the swelling.

8. It follows from what has just been said, that an opposite mode
of treatment ought to succeed the reduction, and this we see was
the case in the preceding instance. There, when the bones were once
reduced, all new displacement was prevented, because the apparatus
was so constructed, as to counteract the tendency of the bones to
be displaced. The external edge of the foot, which had been turned
outwards, was now pushed inwards by a thick compress; the same means
served to push outwards the internal malleolus, which had received by
the accident an inclination inwards, and to push the anterior part
of the tibia backward, and the os calcis forward, both of which were
displaced, as has been remarked, in contrary directions. Two strong
splints fixed the lateral compresses, while the anterior and posterior
ones were firmly secured by rollers. In the midst of all these
resistances, the foot being necessarily immoveable, no new displacement
could occur.

9. A suitable and judicious position, in which the foot, raised a
little higher than the leg, was placed on a pillow forming an inclined
plain, prevented swelling, while gentle compression, made by a bandage,
contributed to the same end. This end was also further attained by the
external topical applications. To relieve pain and remove congestion,
were here, as in sprains, the two indications to be fulfilled. To these
indications the spirituous and the relaxing applications formerly in
use, are alike opposed. Vegeto-mineral water, on the contrary, fulfils
them extremely well. Hence the necessity of keeping the apparatus
constantly wet with that liquid.

10. Regimen influences not a little the success of the treatment.
A strict diet is necessary during the time of the inflammatory and
unfavourable symptoms. Any excess might then prove fatal. Desault
gave, in his lectures, an account of a woman, who had her foot luxated
outward, and the astragulus forward. Her fever was considerable, her
pains excruciating, and the swelling wore an alarming aspect. The
luxations were reduced: all the threatening appearances vanished, and
every thing seemed to promise a favourable termination of the disease.
But, on the fiftieth day, the patient, having procured strong food, ate
largely of it: in the evening all the unfavourable symptoms returned;
the swelling became great, and a few days afterwards she died.

But if strong food be prejudicial during the time in which bad symptoms
are to be dreaded, a diet too strict would be equally injurious when
that time is passed. The weakened powers of the system would not be
adequate to the purposes of a cure, particularly to the consolidation
of the bone, should the case be a fracture. Desault, therefore,
permitted the patient to increase his diet by degrees, and at length to
return to his usual regimen.

11. The following case, reported by Giraud, proves still further the
advantages of this simple mode of treatment, which, should it even
fail, always allows the surgeon to avail himself of amputation, which
is indeed the last resource of art, and should never be employed till
rendered indispensable by the failure of all other means.

CASE II. Maria Constant, aged forty-six, descending a flight of stairs
in haste, fell, and luxated her right foot outwards, the tibia
inwards, and fractured the fibula near to the lower end.

Her cries brought assistance to her, and she was carried to the
Hotel-Dieu. Giraud, who then officiated as surgeon in chief, visited
her, and discovered that there existed both a luxation and a fracture,
though most of the signs were rendered obscure by a considerable
swelling: a slight echymosis occupied the back of the foot, and severe
pains were experienced.

Extension on the foot, and counter-extension on the leg, dislodged
the parts by degrees from their accidental situations, while, by the
process of conformation, the surgeon endeavoured to bring them into
their natural ones. This was soon effected without much violence: the
unfavourable appearances soon vanished; the pain ceased; an apparatus
similar to the former one was applied, and kept wet with a strong
solution of common salt, instead of the vegeto-mineral water.

In the evening, the pulse being full, and somewhat raised, a moderate
blood-letting was deemed necessary. Next day, the apparatus was kept
constantly moist, and some part of it which had become relaxed was
tightened. The pulse continuing full, a low diet was prescribed.

Fifth day, the apparatus taken off; contact between the bones perfect:
a yellowish tinge bespoke an incipient resolution of the echymosis:
a slight swelling of the leg: vesications formed on the part: these
are opened and a quantity of acrid water discharged from them. Sixth
day, light nourishment allowed; a small excoriation of the heel, which
is dressed with cerate spread on a linen rag. Seventh day, regimen
less strict; no bad symptoms supervene. Eighth day, the excoriation
enlarged; same dressing. Tenth day, the excoriation become fungous:
caustic is applied to remove it.

Twenty-eighth day, the discharge from the leg decreased; from this time
the dressings are renewed only every other day. Thirty-second day, the
ulcer is cicatrized: no pains in the leg. Thirty-ninth day, fracture of
the fibula firmly united: no deformity remaining; the apparatus is laid
aside: the joint remains stiff: motions performed by the limb difficult
at first, but become gradually more free. Forty-sixth day, symptoms of
bile; gentle evacuants. Fifty-fourth day, the patient is discharged
cured, except a slight impediment in walking, which exercise will soon
remove.

12. To this example, I might add many others, where similar
displacements, properly treated, terminated with equal success: no
pain; no swelling; no inflammation; and therefore, of course, no
mortification. Yet these are occurrences of which authors speak, as if
they were the usual consequences of such luxations, where, to a violent
injury done to the soft parts, is added a fracture near to, or even
communicating with, a joint. The erroneous opinions of the ancients and
most of the moderns, respecting the dangers arising from such vicinity
or communication, have contributed not a little to their unfavourable
prognosis in the cases under consideration. Should the patient survive
the disease, his inevitable lot, according to them, must be, a complete
anchylosis of the leg with the foot. But, the preceding cases fully
prove, that this apprehension is unfounded. A considerable time is
doubtless necessary, for the recovery of motion, on account of the
distension and rupture of the ligaments, the long continued inactivity
of the parts, and the swelling which they have undergone. But this
recovery can always be effected by means of exercise, gentle at first,
increased afterwards, and regulated according to the principles so
frequently laid down in the course of this work. Much more to be relied
on is such exercise, than the long catalogue of discutient means, such
as pumping of water on the parts, alkaline baths, mineral waters, and
all other external applications, so often extolled as efficacious, and
so often found entirely useless.


§ III.

LUXATION OF THE FOOT, COMPLICATED BY A SEPARATION OF THE BONES OF THE
LEG, AT THEIR LOWER END.

CASE III. (The following case was reported by Thevenot). I. Joseph
Schneider, an ebonist, aged thirty-six, as he was walking in haste, on
the 23d of March, 1792, fell forward, his foot being forced backward
and outward. He experienced at the instant severe pains in the joint:
he was unable to rise, and was therefore carried home, where a surgeon,
after making a slight extension, applied a roller on the limb, and
did nothing further. The patient experienced no relief. The pains
increased; a swelling supervened; convulsive motions began to occur;
and the patient was brought to the Hotel-Dieu, six days after the
accident.

From the deformity of the foot, Desault immediately discovered that it
was luxated. Its point was directed outwards, while its sole was turned
in the same direction: beneath the malleolus internus, which was too
prominent, was a tumour formed by the astragulus. The crepitation of
the bones which was easily heard, the preternatural distance between
the tibia and the fibula, the mobility of this latter bone, and the
absence of the signs of a fracture, plainly showed that a separation of
the two bones of the leg had taken place.

A reduction was immediately effected by means of extension and
counter-extension, and was announced when it took place by a report
distinctly heard. It was then retained by a bandage, calculated to
answer a twofold purpose; 1st, to approximate, and keep together, the
two bones of the leg: 2dly, to secure the contact and immobility of the
bones of the foot.

Blood-letting was prescribed: an anodyne mixture administered; low
diet; in the night severe pains were felt; next day, they were
increased; on dressing the limb, nothing amiss discovered; all the
parts in perfect contact: no vestige of separation between the tibia
and the fibula: a new apparatus applied; and kept constantly moist.
Third day, the patient better: fifth day, the fibula a little separated
from the tibia: the circular bandage drawn tighter to reduce it to its
place again. Tenth day, every thing in its natural state: no pains:
swelling gone. Fifteenth day, a simple roller substituted in place
of the bandage for a fracture of the leg. Nineteenth day, the patient
began to walk, with the assistance of a stick: twenty-third day, walks
easily: twenty-eighth day, is dismissed perfectly cured, and nearly
free in all his motions.

13. The separation of the bones of the leg, at their lower end, does
not constitute a very serious complication of luxations of the foot,
although the contrary is asserted by several authors. Desault met
with this accident several times in the course of his practice, but
never saw it terminate otherwise than favourably. But here, as in all
other cases, the most minute attention is necessary to ensure success,
the want of which is more frequently owing to the negligence of the
surgeon, than to the deficiencies of the art. The bandage employed
after reduction ought to act principally from without inwards, and in
a direction perpendicular to the axis of the lower part of the leg, in
order to approximate the two bones. It will be of some service, in this
respect, to place on each bone a compress, which, projecting more than
the rest of the circumference of the limb, will be more compressed, and
on that account, contribute to the end in view.


§ IV.

LUXATION OF THE FOOT, ACCOMPANIED BY A DISPLACEMENT OF THE ASTRAGULUS
AT ITS ARTICULATION WITH THE OS SCAPHOIDE.

14. Petit never met with more than two instances of that displacement
of the astragulus, now under consideration. His general prognosis on
the subject is more favourable than that respecting other luxations
of the foot, with which he never saw the present luxation of the
astragulus complicated, as occurred in the following cases. Had such
complex cases fallen under his notice, there can be little doubt, but
he would have declared amputation to be the only recourse of art on the
occasion.

But the experience of Desault demonstrates to us here, as well as in
the preceding cases, the great extent to which we ought to carry our
confidence in the powers of nature, when skilfully guided by the hand
of art. The following case was communicated to me by Leveille.

CASE IV. John Baptist Landrin, a postilion, aged thirty-six, was
brought to the Hotel-Dieu, on the 19th of February, 1791.

On the morning of the same day, a horse on which he was mounted having
fallen, his foot was caught under the belly of the animal. As soon as
he was disencumbered of the vast weight, he endeavoured to rise, but in
vain. The pains which he experienced in his foot were extreme. He was
carried home, where some surgeons, having ascertained that his foot
was luxated, but being unable to reduce it, sent him to the Hotel-Dieu.

Desault on examining him, found the bones of his foot to be situated as
follows. The internal part of the os calcis corresponded to the lower
extremity of the tibia: the back of the foot was directed outwards, and
its external edge downwards: under the skin and in front of the tibia
was the astragulus, resting on the scaphoide and first of the cuneiform
bones, where it formed a considerable projection: on the back of the
leg, the fibula corresponded to the tendo Achillis. The pains had been
inconceivably great from the moment of the accident.

Imboldened by numerous instances of success in similar cases, Desault,
notwithstanding the extent of the disease, attempted the reduction.
One assistant took hold of the superior part of the leg to make
counter-extension, and another, for the purpose of extension, grasped
the metatarsus with one hand, and the heel with the other. While these
were pulling in different directions, the surgeon applying his thumb
on the astragulus, endeavoured to force it into its place. His efforts
were ineffectual: the opening through the capsule of the astragulus
being too narrow, would not suffer it to pass. Desault perceiving
this, cut through the integuments which covered the bone, and having
laid bare the capsule and the ligaments which strengthen it, made
an incision into them of a sufficient extent, taking care to avoid
the tendon of the tibialis anticus, which was brought into view. The
openings being thus enlarged, admitted of an easy reduction, and all
the parts resumed, without difficulty, their natural situation.

The reduction being effected, the wound was closed, and covered with
some lint. A square compress was then placed on the back of the foot,
while a long one was applied to its sole, and the whole secured by an
apparatus similar to that described in the preceding case. The patient
was confined to a very strict diet, and ordered to use diluting drinks.

Next day, a slight bilious diathesis; an emetic in solution given;
apparatus renewed. Fourth day, an abscess on the malleolus externus
opened; a copious discharge of pus. Eighth day, the parts in perfect
contact; a favourable discharge from the wounds; dressings applied
twice a day. Fifteenth day, a general œdema; aperient ptisans ordered.
Twentieth day, the œdema gone: a bilious diathesis returned: in
consequence of this, the wounds became pale: another emetic given.
Twenty-seventh day, a very painful excoriation occurred on the heel:
care taken not to let the foot rest on that part, as the sore appeared
to be the effect of compression. Thirtieth day, the wounds in a
favourable way: all the bones in exact contact. Fortieth day, apparatus
laid aside, and a simple roller substituted in its place: wounds
already cicatrizing. Fiftieth day, the limb put in gentle motion, which
is gradually increased every day. Same dressing continued till the
eightieth day: wounds not yet cicatrized. Hundred and twenty-seventh
day, a considerable swelling around the joint: a splinter made its
way out, and was followed in a few days by several more. In the fifth
month an abscess formed on the heel, from which, when opened, another
splinter escaped. In the mean time, the patient left the Hotel-Dieu.
During his absence more splinters were discharged. Returning about a
year afterwards with a small ulcer, he was dismissed again in a short
time, perfectly cured, except a slight stiffness of the joint.

15. The reduction of this luxation of the foot presents a difficulty
worthy of the attention of practitioners, as well on account of its own
nature, as in consideration of the process which was employed on the
occasion: I allude to the narrowness of the opening in the capsule. I
mentioned, on a former occasion, the obstacles sometimes created by
this circumstance to the reduction of luxations of the os humeri and
the os femoris. It was impracticable in the present to enlarge the
opening in the capsule, as could be done in those cases, by moving the
head of the bone in all directions; because the bone was too small to
afford any purchase to the surgeon. The only resource was, the use of
the knife; and the operation was the more easily performed, on account
of the capsule being situated immediately beneath the integuments, from
which circumstance it could be the more speedily brought into view.

16. The apprehension of mischief resulting from the admission of air
to the articulating surfaces, would no doubt, in this case, have
restrained most practitioners: but, even supposing this apprehension
to be well founded, ought it to deter the surgeon from adopting the
only possible mean of effecting a reduction, and of thus putting an end
to the alarming state of things arising from the displacement of the
bones? Desault proved in numerous instances, that the apprehensions
of authors respecting such cases have been greatly exaggerated, and
that it is practicable to cure wounds that penetrate into the cavities
of joints, in the same manner as if they were simple wounds, and with
but very little more danger to the patient. Yet it would seem, that
the tediousness of the cure and the exfoliation of the bones, arose,
in the present case, from the opening made into the joint, and perhaps
also, in part, from the disposition and habit of the patient. Finally,
in those alarming injuries of the joints, unconnected with external
wounds, where practitioners have looked to no resource but that of
amputation, Desault has, in a short time, and without any dangerous
occurrence, restored to the subjects the free use of their limbs. The
following case, drawn up by Plaignault, is a proof of this.

CASE V. Pierre Phipe, aged twenty-four, fell, on the 20th of February,
1788, from an elevation of more than twenty feet: lighting on his foot,
he turned it outwards, sunk instantly to the ground, and was unable to
rise again. He was carried home, and from thence to the Hotel-Dieu.

Desault examining him on his arrival, discovered a luxation of the
foot outwards, and of the astragulus forward and upward: the patient’s
sufferings were great. Convinced that the most effectual method to
relieve these was to reduce the luxation, the surgeon undertook it
immediately, pushed the astragulus into its place without difficulty,
and with a report which was heard by every one present, while the
bones of the foot were brought into their proper situation by means of
extension. In an instant the pains vanished and the motions of the foot
became easy. The necessary apparatus was applied. The activity of the
pulse called for blood-letting, which was immediately performed. A low
diet was prescribed.

On the two following days blood-letting was repeated, both on account
of the active state of the pulse, and of a considerable swelling which
took place in the joint. The apparatus was kept constantly wet with
vegeto-mineral water. Eighth day, somewhat better: echymosis gone.
Fifteenth day, the apparatus laid aside. From this time the foot was
gently moved every day. Eighteenth day, the patient able to stand
on the affected foot without pain. Twenty-sixth day, walks with the
assistance of a staff. Thirty-ninth, walks without limping, and enjoys
all the motions of the foot. Discharged.


§ V.

LUXATION OF THE FOOT, COMPLICATED WITH AN ESCAPE OF THE ASTRAGULUS,
THROUGH THE CAPSULE AND THE LACERATED INTEGUMENTS.

17. When, in a luxation of the foot, the integuments, capsule, and
ligaments are so lacerated, as to suffer the astragulus to escape, it
would oftentimes be imprudent to attempt its reduction, as was done in
the preceding cases. The violence already done to the parts around the
joint is excessive; but this would be increased by the extension, and
other efforts necessary in reduction. Whatever care might be taken, it
would be difficult to prevent a vast swelling, long continued pains,
and perhaps even a caries of the bone exposed to the air, with all
those sufferings and dangers, to which such an accident gives origin.
In such a case all the bones of the foot have been known to become
carious, a state of things, which calls for the ultimate resources of
art, and draws after it a train of evils, which it is always of the
utmost importance to prevent.

18. What means are then to be employed? Two expedients only remain.
1st, the amputation of the foot; 2dly, the extirpation of the
astragulus. The first is a cruel resource, which should never be
adopted but in the last extremity, because it deprives the patient of
a portion of himself, necessary to the performance of his functions.
But the measure is forbidden by a reason still more powerful. Amidst
the general disorder of the system, the severe pains experienced by the
patient, the convulsions, and the delirium which oftentimes exists,
what ground has the surgeon to hope for success? Will not the operation
add to the number of these alarming appearances? Will it not aggravate
them? May it not render them fatal? Both reason and experience reply in
the affirmative.

19. In such a case, then, the extirpation of the astragulus is the
expedient to be preferred. What, indeed, are its inconveniences? 1st,
An inevitable anchylosis of the foot and leg: 2dly, a shortening of the
affected limb. But a leg even in this state, is still better than a
wooden leg, which is the necessary consequence of amputation: besides,
a leg of the former description occasions no great inconvenience in
either walking or standing, whereas one of the latter, produces extreme
lameness: in the first case, a heel on the affected side somewhat
higher than that on the other, is an easy method of removing the
deformity. What, then, are such trifling disadvantages, when compared
with the evils which they ward off? The extirpation of the astragulus
is accompanied with but little pain. The want of this intermediate
body between the leg and the foot, by producing a relaxation of the
surrounding soft parts, prevents pain and swelling in such cases:
should abscesses supervene, they will not, if properly treated, greatly
retard the cure. In a word, experience coincides with this doctrine.
Desault has seen it twice verified in the practice of other surgeons,
and three times in his own. I have known of but one case of the kind,
in which the termination was fatal, and there, a malignant fever,
induced by the contaminated air of the hospital, certainly contributed
to the death of the patient, which did not occur till two months after
the reduction.

CASE VI. Desault usually gave in his lectures, the history of a case
where the success of this practice was remarkable. A man was brought
to the Hotel-Dieu, with a luxation of the foot, complicated with
a fracture of the lower part of the leg, and a laceration of the
ligaments and capsule, through which the astragulus had escaped by a
luxation forward and upward, so as to have half of its anterior surface
exposed. The extent of the injury seemed to call for amputation.
But the youth, the vigour, and sound constitution of the patient,
gave ground to hope that a process less desperate might succeed. The
astragulus, already separated anteriorly, was extracted by dividing the
attachments which held it to the os calcis, and the bones of the leg:
the reduction was then effected without difficulty. The parts being
replaced more readily in consequence of the removal of this bone, were
retained so by means of a bandage similar to that for fractures of
the leg, but modified so as to suit the particular case. The patient
lost blood once or twice: the apparatus was kept constantly wet; a
very strict regimen was prescribed for some days; but few troublesome
symptoms occurred; a slight swelling took place, but was soon removed;
a favourable suppuration came on; the dressing was renewed twice a
day; some splinters escaped occasionally; several abscesses formed
successively were opened, and healed up again: the wounds themselves
closed, and the patient finally recovered, with an anchylosis, indeed,
between the foot and leg, and a limb a little shorter than natural, but
which still served the purposes of walking and standing.

20. To this example, I might add those of other patients treated at the
Hotel-Dieu, in the same manner and with equal success. But what purpose
would such an accumulation of facts answer? It would only fatigue the
reader without adding to his conviction.

21. If the injury accompanying the luxation be so extensive, as to
destroy the principal blood-vessels, and leave no hope of saving the
limb, amputation becomes then the only resource, and the case assumes
a resemblance to those where the limbs are shattered by cannon balls:
the success then depends very much on the strength or weakness of the
patient.

CASE VII. A man fell from a carriage: his foot becoming entangled
between the spokes of the wheel, was almost separated from the leg. It
adhered only by a small portion of skin behind, and by the tendons of
the muscles which run to the toes both above and below.

Desault was called to the patient, whom he found in a most deplorable
state: the pains which he suffered were excruciating: the parts around
the wound were greatly swollen; a general spasm affected the system:
amputation was judged necessary, but was deferred till the symptoms
should be mitigated. The limb was dressed: next day, a gangrene began
to affect the foot, which was then separated from the leg by cutting
the tendons: the ends of the tibia and fibula exfoliated; the wound
healed, and the patient now enjoys, in part, the functions and uses
of the leg, by means of an artificial foot, framed and fitted on by
an ingenious mechanic. Had the limb been too hastily amputated while
the patient was affected with general spasms, fatal consequences would
probably have ensued.




APPENDIX.


ARTICLE I.

The following interesting paper, extracted from the Medical Repository,
Hexad: ii. vol. i. p. 122 ... 124, will give the reader a better idea,
than he can receive from any other source, of Dr. Physick’s new and
successful method of treating an old and obstinate fracture of the os
humeri.

    _A Case of Fracture of the Os Humeri, in which the broken ends of
    the bone not uniting in the usual manner, a cure was effected by
    means of a seton. Communicated to Dr. Miller by Philip S. Physick,
    M. D._

“Isaac Patterson, a seaman, twenty-eight years of age, applied to me
in May, 1802, in consequence of a fracture of his left arm, above the
elbow joint, which had taken place several months before; but the ends
of the bone not having united, rendered his arm nearly useless to him.

“The history he gave me was, that on the 11th of April, 1801, after
having been at sea seven months, his arm was fractured by a heavy sea
breaking over the ship. Nothing was done for his relief until next day,
when the captain and mate bound it up, and applied splints over it.
No swelling supervened, nor did he suffer any pain, Three weeks after
this accident, he arrived at Alexandria, when the state of the arm was
examined by a physician, who told him, that the ends of the bone were
not in a proper situation. After making an extension, the splints and
bandages were again applied. He remained in Alexandria four months,
when, finding his arm no stronger, he left off all dressings, and went
on board the New-York frigate as steward: in this capacity he remained
near the Federal City six months, and by being under the necessity of
using his arm as much as possible, he found the connexion between the
ends of the bones became looser and looser, till, at length, the arm
bent as easily as if a new joint had been formed at the place of the
fracture. From the frigate he went to Baltimore, where an attempt was
made by machinery to extend the arm, and keep the ends of the bone
in apposition, by continuing the extension. Under this treatment he
remained two months, but experiencing no benefit, he was advised to
come to Philadelphia.

“On examining the arm, I found that the humerus had been fractured
about two inches and a half above the elbow joint, and that the ends
of the bone had passed each other, about an inch: the lower fragment,
or that nearest the elbow, was situated over, and on the outside of
the upper portion of the bone. The connexion that existed between the
ends of the humerus was so flexible, as to allow of motion in every
direction, and by forcible extension, the lower end might be pulled
down considerably, but never so low as to be on a line with the end of
the upper extremity. He was admitted into the Pennsylvania hospital,
the latter end of May; but the weather becoming very hot, it was
judged best to defer any operation that might be necessary, until the
fall of the year. Unfortunately he then contracted a bilious fever, of
which he was so ill, that his life was despaired of for some days. From
this fever his recovery was so slow, that it was not thought proper
to perform any operation until December. It still remained to decide,
by what means a bony union of the humerus, might most probably be
effected. In the year 1785, when a student, I had seen a case in our
hospital, similar to this in every essential circumstance, in which an
incision was made down to the extremities of the fractured bone, which
were then sawed off, thereby putting the parts into the condition of a
recent compound fracture. No benefit, however, was derived from this
painful operation, and some months afterward the arm was amputated.
This case had made a strong impression on my mind, and rendered me
unwilling to perform a similar operation. I therefore proposed to some
of the medical gentlemen of the hospital, who attended in consultation,
that a seton-needle, armed with a skein of silk, should be passed
through the arm, and between the fractured extremities of the bone,
and that the seton should be left in this situation, until by exciting
inflammation and suppuration, granulations should rise on the ends
of the bone, which uniting and afterwards ossifying, would form the
bony union that was wanting. This operation being agreed to, it was
performed on the 18th of December, 1802, twenty months after the
accident happened. Before passing the needle, I desired the assistants
to make some extension of the arm, in order that the seton might be
introduced as much as possible between the ends of the bone. Some lint
and a pledget were applied to the orifices made by the seton-needle,
and secured by a roller. The patient suffered very little pain from the
operation. After a few days the inflammation (which was not greater
than what is commonly excited by a similar operation through the flesh,
in any other part) was succeeded by a moderate suppuration. The arm was
now again extended, and splints applied. The dressings were renewed
daily for twelve weeks, during which time no amendment was perceived;
but soon afterwards the bending of the arm at the fracture was observed
to be not so easy as it had been, and the patient complained of much
more pain than usual whenever an attempt was made to bend it at that
place. From this time, the formation of the new bony union went on
rapidly, and, on the fourth of May, 1803, was so perfectly completed,
that the patient could move his arm, in all directions, as well as
before the accident happened. The seton was now removed, and the small
sores occasioned by it, healed up entirely in a few days. On the 28th
May, 1803, he was discharged from the hospital; perfectly well, and he
has since repeatedly told me that his arm is as strong as it ever was.”

To the preceding paper it is unnecessary to add, that the mode of
treatment there stated might be adopted in similar fractures of other
bones, provided a seton-needle could be passed near to the ends of the
fragments, without any risque of wounding blood-vessels, nerves, or
other parts of importance. It is thus that solitary facts minutely
detailed and well substantiated, oftentimes grow into principles of
extensive application.


ARTICLE II.

    _An account of Dr. Physick’s improvement of Desault’s apparatus for
    making permanent extension in oblique fractures of the os femoris._

Dr. Physick having observed that in the application of Desault’s
apparatus, the patient was sometimes injured by the pressure of the
strap or roller _g g_ (plate 2) which passes under the tuberosity of
the ischium for the purpose of making counter-extension, devised the
following method of remedying this inconvenience, in which he succeeded
to his wishes.

He directed the upper end of the long external splint to be formed like
the head of a crutch, and the splint itself to be lengthened so as to
reach and bear against the axilla of the affected side, which must
be well defended from pressure by a bolster of flannel or some other
soft material. By this expedient the Dr. evidently formed two points
of counter-extension, instead of one, as is the case in the apparatus
of Desault. Between these two points, namely, the axilla and the
perineum, the same quantity and force of pressure is, by Dr. Physick’s
improvement, _divided_, which, in the original apparatus of Desault, is
borne by the _perineum alone_. The risque of excoriation and injury to
the patient, then, in the former case, is to that which he runs in the
latter, only as one to two, or nearly so. As it is no less the duty of
the surgeon to prevent suffering than it is to remove deformity or to
save life, Dr. Physick has certainly in this respect made an important
step in the advancement of his profession.

But there is still another advantage derived from the lengthening of
the external splint. In the original apparatus of Desault, the strap
_gg_ intended for counter-extension, by passing no higher up than the
spine of the ilium, runs too much across, and therefore acts too much
on, the upper part of the thigh. By this it not only irritates the
muscles of the part, and induces them to contract, but also tends to
draw the upper fragment of the os femoris a little outward, and thus to
render the thigh in some measure deformed. But, in the improvement of
Dr. Physick, the strap _gg_ is secured in a mortise cut in the external
splint, about midway between the spine of the ilium and the axilla.
This strap, by being thus carried higher up on the body, does not run
across the thigh at all. It consequently presses on and irritates the
muscles much less, acts more in the direction of the os femoris, and
has no tendency to draw the superior fragment outward.

Hence this improvement not only diminishes the patient’s sufferings,
but gives him, perhaps, the best possible chance of having his limb
preserved free from deformity.

[Illustration: _Plate 3._

_Fig. 1._

_Fig. 2._

_Fig. 3._

_Hooker delt._

    _Tanner, Sc._]

Another improvement made on the lower end of the external splint by Dr.
James Hutchinson deserves also to be mentioned. It was found that in
the original apparatus of Desault, the strap or roller L (plate 2)
used for the purpose of extension, had a tendency to draw the foot too
much outward. This fault Dr. Hutchinson very ingeniously remedied, by
attaching to the lower part of the external splint, a little above the
mortise, a small block extending inwardly, at a right angle with the
splint, so far as to be on a line with the middle of the sole of the
foot. Over the end of this block, in which a notch is cut to receive
them, the ends of the strap L are carried, previously to their being
secured to the external splint. By means of this expedient extension is
made precisely in the direction of the limb, and the inconvenience of
drawing the foot outward is completely obviated.

Thus improved by Drs. Physick and Hutchinson, the apparatus of Desault
for oblique fractures of the os femoris, leaves, perhaps, scarcely a
remaining desideratum on the subject.


ARTICLE III.

EXPLANATION OF THE THIRD PLATE.

This plate gives a full view of an apparatus for making permanent
extension, in oblique fractures of the leg, when both bones are broken.
This apparatus was first devised and constructed several years ago, by
Dr. James Hutchinson, then a pupil in the Pennsylvania hospital, and is
now in general use among the practitioners of Philadelphia.

Fig. 1. Represents the leg and foot, with the apparatus applied.

A. A common roller, passed several times round the leg a little below
the knee, on which counter-extension is made.

B. A silk handkerchief folded, or a strong roller made of soft muslin,
passed once round the leg, just above the ancle, from behind forward.
C. The place where its two ends cross each other to pass down along
each side of the foot, as seen at _b_, to D, where they are secured by
a knot drawn but moderately tight. _a a._ The same ends continued to
E where they are again secured by a firm knot over the cross piece F,
which passes between the two strong splints G G, that run on each side
of the leg from a little above the knee, to the distance of four or
five inches beyond the sole of the foot. This is the bandage by which
extension is made, as will be mentioned hereafter.

H. Two bits of strong tape, each about two feet long, placed in the
longitudinal direction of the leg, and firmly secured by the roller A,
which passes over their middle. Two such bits of tape, are thus applied
on each side of the leg, and their four ends, passing through four
holes in the upper end of each of the splints G G, are secured on their
outsides by firm knots as represented at H.

Fig. 2. A view of one of the splints G G, separated from the leg.

_a._ The four holes in the upper end, through which the bits of tape H
pass.

_b._ The mortise in the lower end, which receives the cross-piece F.

Fig. 3. A view of the cross-piece F, which must be firmly fixed in one
of the splints G G, but moveable in the mortise of the other, so that
the splints may be taken asunder at pleasure.

The following is the method of applying this apparatus.

While extension and counter-extension are made by two assistants, the
surgeon placing the bits of tape H on each side of the leg, secures
them firmly by the roller A applied round the limb, with a proper
degree of tightness. He then applies the middle of the handkerchief
or roller B on the tendo Achillis, brings its ends across each
other, before the leg at C, and carrying them down along each side
of the foot, secures them by a knot at D. Letting go the ends of the
handkerchief B, he next places on each side of the leg the splints G
G, connects them at the lower end by the cross-piece F and secures
them at the upper end by the tapes H. He then resumes the ends of the
handkerchief B, carries them downward as seen at _a a_ and secures them
by a firm knot at E round the cross-piece F.

From this view and explanation of the apparatus Fig. 1, I presume its
construction, application, and mode of operation will be very easily
understood. It is unnecessary therefore to add, that the extension and
counter-extension made on the limb, will be directly proportioned to
the degree of force with which the ends _a a_ of the handkerchief B are
drawn over the cross-piece F. As action and reaction, in this case,
must, as in all others, be equal, the splints G G will be pushed upward
by the ends of the handkerchief B with precisely the same force that
is applied on these ends to draw the foot and lower fragments downward.
Hence the counter-extension made above on the roller A will be exactly
equal to the extension made below by the handkerchief B.

I ought to have observed, that it is necessary to defend the soft
parts, both above and below, from the pressure of the extending and
counter-extending straps, by means of soft compresses applied next to
the skin. This is particularly necessary on the instep C where the ends
of the handkerchief B cross each other. It requires some attention on
the part of the surgeon to prevent this spot from being excoriated,
especially if it be found necessary to make a forcible extension.

If the fracture be simple, a bandage of strips previously applied round
the limb from the ancle to the knee is highly useful. It secures the
fragments more effectually from lateral displacement, and prevents the
swelling of the leg. A simple roller applied with a moderate degree of
tightness round the foot, is also of service in preventing a swelling
in that part, as well as in removing it if it has already occurred.

This apparatus is still more strikingly useful in compound fractures,
on account of the facility with which it enables the surgeon to
apply the necessary dressings. These can be renewed as often as may
be requisite, without giving the patient the least pain, without
discontinuing extension, or in any measure whatever deranging the
fragments. The surgeon can also, in all cases, discover by a single
glance of his eye, whether or not the fragments are in proper
apposition. It is right to secure the whole apparatus by three bits
of tape passed round it, similar to those tied round the leg in the
apparatus for fractures of the thigh, as represented in plate 2.

I shall only add, that the surgeon must employ such bolsters and
compresses as he may find necessary to support the limb, and protect
it from undue pressure, and that he must be vigilant to prevent, by
frequent examinations, the extending and counter-extending straps from
becoming relaxed.

For a few further remarks on the subject of this apparatus, the reader
is referred to a paper published by Dr. Hutchinson, in the second
number of the Philadelphia Medical Museum.




    FINIS.


Inconsistencies:

  armpit/arm-pit
  condyl/condyle
  coracoid/corocoid
  coronoid/coronoide
  expence/expense
  fixt/fixed
  forearm/fore-arm/fore arm
  inconveniencies/inconveniences
  plane/plain
  Scultel/Scultet
  teres-major/teres major


Corrections:

  aingly → singly
  appplication → application
  backwaad → backward
  Bruningaushen → Bruninghausen
  cataloginous → cartilaginous
  ciscumstance → circumstance
  considerasion → consideration
  constanly → constantly
  controuling → controlling
  cotemporaries → contemporaries
  croud → crowd
  decieve → deceive
  divison → division
  Engravd → Engraved
  examing → examining
  exextremities → extremities
  faciæ → fasciæ
  follow- → following
  imitatators → imitators
  make → makes
  matrass → mattress
  nect → neck
  of of → of
  passsive → passive
  percieve → perceive
  recieves → receives
  resourse → recourse
  the the → the
  to to → to
  whould → would
  1303 → 1803 (date)
  67 → 66 (para numbering error)





End of the Project Gutenberg EBook of A Treatise on Fractures, Luxations,
and other Affections of the Bones, by Pierre-Joseph Desault

*** END OF THIS PROJECT GUTENBERG EBOOK A TREATISE ON FRACTURES ***

***** This file should be named 58602-0.txt or 58602-0.zip *****
This and all associated files of various formats will be found in:
        http://www.gutenberg.org/5/8/6/0/58602/

Produced by Thiers Halliwell, Sonya Schermann and the
Online Distributed Proofreading Team at http://www.pgdp.net
(This file was produced from images generously made
available by The Internet Archive)

Updated editions will replace the previous one--the old editions will
be renamed.

Creating the works from print editions not protected by U.S. copyright
law means that no one owns a United States copyright in these works,
so the Foundation (and you!) can copy and distribute it in the United
States without permission and without paying copyright
royalties. Special rules, set forth in the General Terms of Use part
of this license, apply to copying and distributing Project
Gutenberg-tm electronic works to protect the PROJECT GUTENBERG-tm
concept and trademark. Project Gutenberg is a registered trademark,
and may not be used if you charge for the eBooks, unless you receive
specific permission. If you do not charge anything for copies of this
eBook, complying with the rules is very easy. You may use this eBook
for nearly any purpose such as creation of derivative works, reports,
performances and research. They may be modified and printed and given
away--you may do practically ANYTHING in the United States with eBooks
not protected by U.S. copyright law. Redistribution is subject to the
trademark license, especially commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg-tm mission of promoting the free
distribution of electronic works, by using or distributing this work
(or any other work associated in any way with the phrase "Project
Gutenberg"), you agree to comply with all the terms of the Full
Project Gutenberg-tm License available with this file or online at
www.gutenberg.org/license.

Section 1. General Terms of Use and Redistributing Project
Gutenberg-tm electronic works

1.A. By reading or using any part of this Project Gutenberg-tm
electronic work, you indicate that you have read, understand, agree to
and accept all the terms of this license and intellectual property
(trademark/copyright) agreement. If you do not agree to abide by all
the terms of this agreement, you must cease using and return or
destroy all copies of Project Gutenberg-tm electronic works in your
possession. If you paid a fee for obtaining a copy of or access to a
Project Gutenberg-tm electronic work and you do not agree to be bound
by the terms of this agreement, you may obtain a refund from the
person or entity to whom you paid the fee as set forth in paragraph
1.E.8.

1.B. "Project Gutenberg" is a registered trademark. It may only be
used on or associated in any way with an electronic work by people who
agree to be bound by the terms of this agreement. There are a few
things that you can do with most Project Gutenberg-tm electronic works
even without complying with the full terms of this agreement. See
paragraph 1.C below. There are a lot of things you can do with Project
Gutenberg-tm electronic works if you follow the terms of this
agreement and help preserve free future access to Project Gutenberg-tm
electronic works. See paragraph 1.E below.

1.C. The Project Gutenberg Literary Archive Foundation ("the
Foundation" or PGLAF), owns a compilation copyright in the collection
of Project Gutenberg-tm electronic works. Nearly all the individual
works in the collection are in the public domain in the United
States. If an individual work is unprotected by copyright law in the
United States and you are located in the United States, we do not
claim a right to prevent you from copying, distributing, performing,
displaying or creating derivative works based on the work as long as
all references to Project Gutenberg are removed. Of course, we hope
that you will support the Project Gutenberg-tm mission of promoting
free access to electronic works by freely sharing Project Gutenberg-tm
works in compliance with the terms of this agreement for keeping the
Project Gutenberg-tm name associated with the work. You can easily
comply with the terms of this agreement by keeping this work in the
same format with its attached full Project Gutenberg-tm License when
you share it without charge with others.

1.D. The copyright laws of the place where you are located also govern
what you can do with this work. Copyright laws in most countries are
in a constant state of change. If you are outside the United States,
check the laws of your country in addition to the terms of this
agreement before downloading, copying, displaying, performing,
distributing or creating derivative works based on this work or any
other Project Gutenberg-tm work. The Foundation makes no
representations concerning the copyright status of any work in any
country outside the United States.

1.E. Unless you have removed all references to Project Gutenberg:

1.E.1. The following sentence, with active links to, or other
immediate access to, the full Project Gutenberg-tm License must appear
prominently whenever any copy of a Project Gutenberg-tm work (any work
on which the phrase "Project Gutenberg" appears, or with which the
phrase "Project Gutenberg" is associated) is accessed, displayed,
performed, viewed, copied or distributed:

  This eBook is for the use of anyone anywhere in the United States and
  most other parts of the world at no cost and with almost no
  restrictions whatsoever. You may copy it, give it away or re-use it
  under the terms of the Project Gutenberg License included with this
  eBook or online at www.gutenberg.org. If you are not located in the
  United States, you'll have to check the laws of the country where you
  are located before using this ebook.

1.E.2. If an individual Project Gutenberg-tm electronic work is
derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of the
copyright holder), the work can be copied and distributed to anyone in
the United States without paying any fees or charges. If you are
redistributing or providing access to a work with the phrase "Project
Gutenberg" associated with or appearing on the work, you must comply
either with the requirements of paragraphs 1.E.1 through 1.E.7 or
obtain permission for the use of the work and the Project Gutenberg-tm
trademark as set forth in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg-tm electronic work is posted
with the permission of the copyright holder, your use and distribution
must comply with both paragraphs 1.E.1 through 1.E.7 and any
additional terms imposed by the copyright holder. Additional terms
will be linked to the Project Gutenberg-tm License for all works
posted with the permission of the copyright holder found at the
beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project Gutenberg-tm
License terms from this work, or any files containing a part of this
work or any other work associated with Project Gutenberg-tm.

1.E.5. Do not copy, display, perform, distribute or redistribute this
electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1 with
active links or immediate access to the full terms of the Project
Gutenberg-tm License.

1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form, including
any word processing or hypertext form. However, if you provide access
to or distribute copies of a Project Gutenberg-tm work in a format
other than "Plain Vanilla ASCII" or other format used in the official
version posted on the official Project Gutenberg-tm web site
(www.gutenberg.org), you must, at no additional cost, fee or expense
to the user, provide a copy, a means of exporting a copy, or a means
of obtaining a copy upon request, of the work in its original "Plain
Vanilla ASCII" or other form. Any alternate format must include the
full Project Gutenberg-tm License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,
performing, copying or distributing any Project Gutenberg-tm works
unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or providing
access to or distributing Project Gutenberg-tm electronic works
provided that

* You pay a royalty fee of 20% of the gross profits you derive from
  the use of Project Gutenberg-tm works calculated using the method
  you already use to calculate your applicable taxes. The fee is owed
  to the owner of the Project Gutenberg-tm trademark, but he has
  agreed to donate royalties under this paragraph to the Project
  Gutenberg Literary Archive Foundation. Royalty payments must be paid
  within 60 days following each date on which you prepare (or are
  legally required to prepare) your periodic tax returns. Royalty
  payments should be clearly marked as such and sent to the Project
  Gutenberg Literary Archive Foundation at the address specified in
  Section 4, "Information about donations to the Project Gutenberg
  Literary Archive Foundation."

* You provide a full refund of any money paid by a user who notifies
  you in writing (or by e-mail) within 30 days of receipt that s/he
  does not agree to the terms of the full Project Gutenberg-tm
  License. You must require such a user to return or destroy all
  copies of the works possessed in a physical medium and discontinue
  all use of and all access to other copies of Project Gutenberg-tm
  works.

* You provide, in accordance with paragraph 1.F.3, a full refund of
  any money paid for a work or a replacement copy, if a defect in the
  electronic work is discovered and reported to you within 90 days of
  receipt of the work.

* You comply with all other terms of this agreement for free
  distribution of Project Gutenberg-tm works.

1.E.9. If you wish to charge a fee or distribute a Project
Gutenberg-tm electronic work or group of works on different terms than
are set forth in this agreement, you must obtain permission in writing
from both the Project Gutenberg Literary Archive Foundation and The
Project Gutenberg Trademark LLC, the owner of the Project Gutenberg-tm
trademark. Contact the Foundation as set forth in Section 3 below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend considerable
effort to identify, do copyright research on, transcribe and proofread
works not protected by U.S. copyright law in creating the Project
Gutenberg-tm collection. Despite these efforts, Project Gutenberg-tm
electronic works, and the medium on which they may be stored, may
contain "Defects," such as, but not limited to, incomplete, inaccurate
or corrupt data, transcription errors, a copyright or other
intellectual property infringement, a defective or damaged disk or
other medium, a computer virus, or computer codes that damage or
cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
of Replacement or Refund" described in paragraph 1.F.3, the Project
Gutenberg Literary Archive Foundation, the owner of the Project
Gutenberg-tm trademark, and any other party distributing a Project
Gutenberg-tm electronic work under this agreement, disclaim all
liability to you for damages, costs and expenses, including legal
fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE
TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
defect in this electronic work within 90 days of receiving it, you can
receive a refund of the money (if any) you paid for it by sending a
written explanation to the person you received the work from. If you
received the work on a physical medium, you must return the medium
with your written explanation. The person or entity that provided you
with the defective work may elect to provide a replacement copy in
lieu of a refund. If you received the work electronically, the person
or entity providing it to you may choose to give you a second
opportunity to receive the work electronically in lieu of a refund. If
the second copy is also defective, you may demand a refund in writing
without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set forth
in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO
OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT
LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied
warranties or the exclusion or limitation of certain types of
damages. If any disclaimer or limitation set forth in this agreement
violates the law of the state applicable to this agreement, the
agreement shall be interpreted to make the maximum disclaimer or
limitation permitted by the applicable state law. The invalidity or
unenforceability of any provision of this agreement shall not void the
remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the
trademark owner, any agent or employee of the Foundation, anyone
providing copies of Project Gutenberg-tm electronic works in
accordance with this agreement, and any volunteers associated with the
production, promotion and distribution of Project Gutenberg-tm
electronic works, harmless from all liability, costs and expenses,
including legal fees, that arise directly or indirectly from any of
the following which you do or cause to occur: (a) distribution of this
or any Project Gutenberg-tm work, (b) alteration, modification, or
additions or deletions to any Project Gutenberg-tm work, and (c) any
Defect you cause.

Section 2. Information about the Mission of Project Gutenberg-tm

Project Gutenberg-tm is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new computers. It
exists because of the efforts of hundreds of volunteers and donations
from people in all walks of life.

Volunteers and financial support to provide volunteers with the
assistance they need are critical to reaching Project Gutenberg-tm's
goals and ensuring that the Project Gutenberg-tm collection will
remain freely available for generations to come. In 2001, the Project
Gutenberg Literary Archive Foundation was created to provide a secure
and permanent future for Project Gutenberg-tm and future
generations. To learn more about the Project Gutenberg Literary
Archive Foundation and how your efforts and donations can help, see
Sections 3 and 4 and the Foundation information page at
www.gutenberg.org



Section 3. Information about the Project Gutenberg Literary Archive Foundation

The Project Gutenberg Literary Archive Foundation is a non profit
501(c)(3) educational corporation organized under the laws of the
state of Mississippi and granted tax exempt status by the Internal
Revenue Service. The Foundation's EIN or federal tax identification
number is 64-6221541. Contributions to the Project Gutenberg Literary
Archive Foundation are tax deductible to the full extent permitted by
U.S. federal laws and your state's laws.

The Foundation's principal office is in Fairbanks, Alaska, with the
mailing address: PO Box 750175, Fairbanks, AK 99775, but its
volunteers and employees are scattered throughout numerous
locations. Its business office is located at 809 North 1500 West, Salt
Lake City, UT 84116, (801) 596-1887. Email contact links and up to
date contact information can be found at the Foundation's web site and
official page at www.gutenberg.org/contact

For additional contact information:

    Dr. Gregory B. Newby
    Chief Executive and Director
    gbnewby@pglaf.org

Section 4. Information about Donations to the Project Gutenberg
Literary Archive Foundation

Project Gutenberg-tm depends upon and cannot survive without wide
spread public support and donations to carry out its mission of
increasing the number of public domain and licensed works that can be
freely distributed in machine readable form accessible by the widest
array of equipment including outdated equipment. Many small donations
($1 to $5,000) are particularly important to maintaining tax exempt
status with the IRS.

The Foundation is committed to complying with the laws regulating
charities and charitable donations in all 50 states of the United
States. Compliance requirements are not uniform and it takes a
considerable effort, much paperwork and many fees to meet and keep up
with these requirements. We do not solicit donations in locations
where we have not received written confirmation of compliance. To SEND
DONATIONS or determine the status of compliance for any particular
state visit www.gutenberg.org/donate

While we cannot and do not solicit contributions from states where we
have not met the solicitation requirements, we know of no prohibition
against accepting unsolicited donations from donors in such states who
approach us with offers to donate.

International donations are gratefully accepted, but we cannot make
any statements concerning tax treatment of donations received from
outside the United States. U.S. laws alone swamp our small staff.

Please check the Project Gutenberg Web pages for current donation
methods and addresses. Donations are accepted in a number of other
ways including checks, online payments and credit card donations. To
donate, please visit: www.gutenberg.org/donate

Section 5. General Information About Project Gutenberg-tm electronic works.

Professor Michael S. Hart was the originator of the Project
Gutenberg-tm concept of a library of electronic works that could be
freely shared with anyone. For forty years, he produced and
distributed Project Gutenberg-tm eBooks with only a loose network of
volunteer support.

Project Gutenberg-tm eBooks are often created from several printed
editions, all of which are confirmed as not protected by copyright in
the U.S. unless a copyright notice is included. Thus, we do not
necessarily keep eBooks in compliance with any particular paper
edition.

Most people start at our Web site which has the main PG search
facility: www.gutenberg.org

This Web site includes information about Project Gutenberg-tm,
including how to make donations to the Project Gutenberg Literary
Archive Foundation, how to help produce our new eBooks, and how to
subscribe to our email newsletter to hear about new eBooks.