IL I 
 
 ^*'*****'*'»'»«'*'«'**'»'V«A<VWM/WVVV^^ 
 
,p^y ' - T'<rWm ^^W^ 
 
 
 Sil.- 
 
 
 
Wm^ 
 
 \ 
 
-jLAU^^ ^^ 
 
 ^y^^'r-zTr 
 
THE LECTURES OF BOTER 
 
 UPON 
 
 DISEASES OF THE BONES, 
 
 ARRANGED INTO A SYSTEMATIC TREATISE, 
 
 BY A. RICHERAND, 
 
 PROFESSOR OK ANATOMY AND PHILOSOPHY, AND PRINCIPAL SURGEON 
 TO THE NORTHERN HOSPITAL AT PARIS. 
 
 ILLUSTRATED WITH PLATES. 
 
 ^■»e>«^ 
 
 TRANSLATED FROM THE FRENCH 
 
 By M, FARRELL, M. D. 
 two volumes in one. 
 
 m^^^m. 
 
 THE FIRST JMERICJN EDITION, 
 
 WITH 
 
 NOTES AND ADDITIONAL PLATES, 
 By JOSEPH HARTSHORNE, M. D. 
 
 -~^ PRINTED AND SOLD BY JAMES HUMPHREYS, 
 
 Ctrner of Second and ITa/nut-jtreets, 
 
 1805. 
 
D'tstriSl of Pennsyl'vanla, to nvii : 
 
 BE IT REMEMBERED that on the fifth day of August, 
 in the thirtieth year of the Independence of the United States of Ante' 
 rica. A.D. 1805, Joseph Hartshorne, of the said distri£l, hath de- 
 posited in this ojffice the Title of a Book, the right 'whereof he claims as 
 Proprietor, in the lucrds follonuing, to «wit : 
 
 " The Lectures of B oyer upon Diseases of the Bones, arranged 
 " into a Systematic Treatise, by A. Richerand, Professor of Ana- 
 " tomy and Philosophy, and Principal Surgeon to the Northern Hos- 
 *' pital at Paris — Illustrated ixjith Plates^Translated from the 
 *' French hy M. Parrel, M.D. — Tt^-o Volumes in one.-— The first 
 *' American Edition, ivith Notes and Additional Plates, by Joseph 
 " Hartshorne, M. D^ 
 
 In conformity to the aSl of the Congress of the United States, intituled, 
 " an Ad for the encouragement of learning, by securing the copies of 
 maps, charts, and book;, to the authors and proprietors of such copies 
 during the times therein mentioned'^— and also to the ad entitled, "an 
 ad supplementary to an ad, entitled, ' ' an ad 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 Distrid of Pennsylvania, 
 
3 71 iL 
 
 TRANSLATOR'S PREFACE. 
 
 THE celebrity of the Authors of this Treatise 
 entitles it to a considerable share of attention. 
 Boyer, a distinguished professor of surgical pathology, 
 and an eminent practitioner of surgery, who is the 
 principal author, would have contented himself with 
 delivering the substance of it in his public Lectures, 
 had not some of his pupils attempted to publish from 
 their notes a spurious edition of the work. These 
 copyists presented Boyer's doctrine in so mutilated 
 a form, that it was found necessary to give a genuine 
 edition of the Lectures to the public. Richerand, 
 professor of anatomy and physiology, and practitioner 
 of surgery, in which department he has distinguished 
 himself by his writings,* at the request of his friend 
 Boyer, and immediately, under his inspection, under- 
 took this task: but he has not confined himself to the 
 duty of a compiler; he has enriched the work by- 
 many of his own observations. 
 
 The want of a complete treatise in English, on 
 the Diseases of the Bones, must have been felt by- 
 students in surgery. The present work, it is pre- 
 
 • See Professor Richerand's Elements of Physiology, tramlated 
 from the French by R. Kerrison, 8vo. printed for J, Murray, 32, 
 Fleet-street. 
 
IV TRANSLATOR S PREFACE. 
 
 sumed, will not only fill up this deficiency, but faci- 
 litate the study of surgery, and expedite the progress 
 of those who devote themselves to that branch of 
 medical knowledge. 
 
 A scrupulous attention has been paid to preserve 
 the precise meaning of the authors. Their ideas 
 have been rendered in plain and intelligible language • 
 and it is hoped that the work, as it is now presented 
 to the public, will answer the same purposes to the 
 English reader, that the original does to the French, 
 
 ERRATA. 
 
 Page II, line lo from the bottom, for astragolos read astragalus, 
 34, line 17, for though read through. 
 40, line 2, for Fabrice de H'dden read Fabricius H'lldanus.* 
 
 44, line 20, for analogously read analogous,* 
 
 45, line 1 1 from the bottom, and page 82, line 10 from the bottom, 
 
 for Ledran read Le Dran.* 
 109, line 7, for tear read hear. 
 116, line 2 from the bottom, (or greatb read great. 
 121, line 22, dele the.* 
 
 121, line 4 from the bottom, for Hook read Gooch.f 
 J56, line 5 from the bottom, for parietal rtad parietal.* 
 343, line 2 from the bottom, for ad-vantage read disadvantage, 
 251, line 3 from the bottom, for latterly read laterally. 
 305, line 4, for bare read bear. 
 
 * These are errors of the London copy. 
 
 f This also is an error, (and probably a typographical error), of the London 
 edition. See Benjamin Bell's System of Surgery, or Gooch's Medical and Chirur- 
 gical Observations. 
 
CONTENTS. 
 
 VOLUME I. 
 
 PACE 
 
 Introduction 9 
 
 CHAPTER I. 
 
 Or Fractures in general. . ii 
 
 § I. Of the different Species of FraSure . . . . ib. 
 
 § 2. Of the Causes of Fra£lures l8 
 
 § 3. Of the Signs of Fraclures , . 19 
 
 § 4. The Prognosis of Fractures 7.\ 
 
 § 5. Of the Treatment of Fradures ....;. 23 
 
 § 6. Of the Formation of Callus 36 
 
 CHAP. II. 
 Of the Fractures of the Bones of the Nose 46 
 
 CHAP. III. 
 Of the Fractures of the Lower Jaw . , . 218 
 
 CHAP. IV. 
 Of the Fractures of the Vertebra ... 54 
 
 CHAP. V. 
 
 Of the Fractures of the Sternum .... 57 
 
 CHAP. VI. 
 Of Fractures of the Ribs 59 
 
 CHAP. VIL 
 
 Of Fractures of the Bones of the Pelvis . 64 
 
 § I . Of FraSliires of the Sacrum ....... ib. 
 
 § 2. Of FraSiures of the Os Coccygis 65 
 
 § 3. OfFrailuresoftheOssainnominata .... 66 
 
 CHAP. VIII. 
 Of Fractures of the Scapula 68 
 
 CHAP. IX. 
 Of Fractures of the Clavicle 72 
 
 CHAP, X. 
 Of Fractures of the Humerus 78 
 
VI CONTENTS. 
 
 CHAP. Xr. PAGE 
 
 Of Fractures of the Fore-arm 83 
 
 § I. Of FraSlurei of both the Bones 84 
 
 § 2. Of Fraaures of the Radius 87 
 
 § 3. Of Fraaures of the Cubitus 88 
 
 § 4. Of Fradures of the Olecranon 89 
 
 CHAP. XII. 
 
 Of Fractures of the Bones of the Hand . . 93 
 
 § I. Of FraSures of the Bones of the Carpus .... ib. 
 
 § 2. Of Fradures of the BoJies of the Metacarpus . . . ib. 
 
 § 3 . Of Frailures of the Phalanges of the Fingers , , 94 
 
 CHAP. Xllf. 
 Of Fractures of the Thigh 96 
 
 CHAP. XIV. 
 Of Fractures of the Neck of the Femur . . 102 
 
 CHAP. XV. 
 Of Fractures of the Patella 129 
 
 CHAP. XVI. 
 
 Of Fractures of the Bones of the Leg . . . 143 
 
 § 1 . Of Fraaures of both the Bones ib. 
 
 § 2. Of FraSiures of the Tibia 147 
 
 § 3. Of FraSiures of the Fibula 148 
 
 CHAP. XVII. 
 Of Fractures of the Bones of the Foot . . 152 
 
 CHAP. XVIII. 
 Of Wounds, and Denudation, of Bones . . . 154 
 CHAP. XIX. 
 
 Of Necrosis 157 
 
 CHAP. XX. 
 Of Caries 164 
 
 CHAP. XX r. 
 Of Exostosis 17^ 
 
 CHAP. XXII. 
 Of Osteo-sarcoma . 182 
 
CONTENTS. VI! 
 
 VOLUME II. 
 
 CHAP. I. PACE 
 
 Of Rickets 189 
 
 CHAP. II. 
 Of the Fragility of Bones 197 
 
 CHAP. III. 
 
 Of Sprains 199 
 
 CHAP. IV. 
 
 Of Luxations in general 204 
 
 § I. Of the Differences of Luxations 205 
 
 § 2. Of the Causes of Luxations 207 
 
 § 3. Of the Symptoms of Luxation 209 
 
 § 4. Of the Prognosis in Luxations 21 1 
 
 § 5. General Treatment of Luxations 212 
 
 CHAP. V. 
 Of Luxations of the Lower Jaw ...... 220 
 
 CHAP. VL 
 
 Of Luxations of the Vertebra 225 
 
 § I. Of Luxations of the Head from the first Vertebra . 226 
 § 2. Of Luxations of the first cervical Vertebra from the 
 
 second ib. 
 
 CHAP. VII. 
 Of Luxations of the Bones of the Pelvis . . 230 
 
 CHAP. VIII. 
 
 Of Luxations of the Clavicle 234 
 
 § I. Of Luxations of the Extremity next the Sternum . . ib. 
 § 2. Of Luxations of the Extremity next the Humerus . •237 
 
 CHAP. IX. 
 Of Luxations of the Os Humeri 239 
 
 CHAP. X. 
 
 Of Luxations of the Fore-arm 251 
 
 § I. Of Luxations of the Fore-arm from the Humerus . • ib. 
 § 2, Of Luxations of the superior Extremity of the Radius 
 
 from the Ulna 255 
 
 ^ 3. Of Luxations of the inferior Extremity of the Ulna . 257 
 
VIU CONTENTS. 
 
 CHAP. XL PAGE 
 
 Of Luxations of the Hand 259 
 
 § 1. Of Luxations of the Wrist « . ib. 
 
 § 2. Of Luxations of the Bones of the Carpus and Meta- 
 carpus '. » 261 
 
 § 3. Of Luxations of ihe Fingers 262 
 
 CHAP. XIL 
 Of Luxations of the Femur ....... 264 
 
 CHAP. XIIL 
 Of Spontaneous Luxations of the Femur . . 271 
 
 CHAP. XIV. 
 Of Luxations of the Patella . t 278 
 
 CHAP. XV. 
 Of Luxations of the Bones of the Leg . « . 282 
 
 CHAP. XVL 
 Of Luxations of the Foot 284 
 
 CHAP. xvn. 
 
 Of Dropsy of the Articulations 288 
 
 CHAP. xvin. 
 
 Of Foreign Bodies formed in the Articu- 
 lations 293 
 
 CHAP. XIX. 
 Of Wounds of the Articulations 297 
 
 CHAP. XX. 
 Of White Swellings of the Joints 301 
 
 CHAP. XXL 
 Of Anchylosis . ; . 310 
 
 CHAP. XXIL 
 
 Of the Deviations of Bones, and the Means 
 used for Preventing and Correcting the 
 Deformity arising from them 314 
 
 ANALYTICAL INDEX ; 321 
 
 NOTES . . . • 357 
 
A TREATISE, 
 
 INTRODUCTION. 
 
 BONES are subjeft to the same diseases as the soft parts. This 
 assertion may at first appear to be made at random, but its 
 truth will be proved by the explanation into which we are about to 
 enter. Hardness, which is their distinctive quality, does not belong 
 to them in every stage of their existence; their soft and gelatinous 
 state in the embryo is changed in a more advanced stage of life to 
 that of cartilage, which finally hardens by the deposition of a 
 neutralized combination of lime and phosphoric acid, in its pa- 
 renchymatous structure. To this saline inorganized substance is to 
 be ascribed whatever difference is found between the bones and 
 soft parts. When deprived of this substance, whether artificially, 
 by immersion in an acid, or by the operation of the disease call- 
 ed rachitis, they become soft and flexible, and are reducible, by 
 long maceration, to a cellular strudlure, in which vessels of every 
 species are seen to ramify. 
 
 The existence, however, of the phosphate, and of a small 
 quantity of carbonate of lime in bones, has a great influence on 
 their diseases; the circulation is in some degree obstru<5led by the 
 presence of this inorganized matter, and all the vital properties 
 are thereby rendered more obscure. Thus all the diseases of the 
 bones, which depend on a greater or less excitement of these 
 properties, are slow in their progress, and of the chronic kind, 
 although similar affections of the soft parts would produce acute 
 diseases. A solution of continuity, for instance, or a simple 
 -wound of the soft parts, heals and reunites in two or three days, 
 if the parts be brought into immediate contadti but a wound or 
 
lO INTRODUCTION. 
 
 fra£hire of a bone requires twenty days at least, not unfrequently 
 
 forty or fifty, and even several months in some cases; and in ge- 
 neral it may be said, that the cure will be slow in proportion to 
 the person's age; because, as years increase, the proportion of 
 the saline part of the bones increases also. 
 
 How much greater is the duration of exostosis than of phleg- 
 mon or any other swelling of the soft parts? Is not necrosis, 
 which is the true gangrene of the bony substance, equally slow? 
 Is not the separation of the living from the mortified part slower 
 than in the gangrene of soft parts? This long duration of these 
 diseases, and the tardy succession of their symptoms, will be 
 greater or less in proportion to the greater or less relative quanti- 
 ty of saline matter in the bones; whence it follows, that their 
 progress will be quicker in the infant than in the adult, and, ceteris 
 paribus, that they will be slower in old age than at any other pe- 
 riod. 
 
 The best and most ancient division of the diseases of the bones 
 is that which distributes them into two orders; the first of which 
 comprehends whatever afFefts each bone singly, in its substance 
 or continuity; the second comprehends their diseases in the 
 joints, and in their points of contact one with another. But it is 
 to be oberved, that the diseases of this second order may afFe<n: 
 also the substance of the bones, as, frequently, in cases of white 
 or lymphatic swellings of th€ joints, caries of the extremities of 
 the bones accompanies the morbid affedlion of the surrounding 
 soft parts. 
 
 The first order of the diseases of the bones comprehends their 
 fractures, wounds, exostosis, necrosis, and caries, the ricketty 
 softening of the bones, their friability, and that morbid state 
 known by the name of spina ventosa, or osteosarcoma. 
 
 The second order embraces sprains, luxations, dropsy of the 
 articulations, the diseases arising from preternatural substances 
 generated in the articulations, white or lymphatic swellings, and 
 anchylosis. 
 
 It shall be shewn in the sequel, that the assistance of art is 
 indispensable, and efficacious in the greater number of these dis- 
 eases. Whatever relates to fraclures shall first be considered: Of 
 all the diseases of the bones they are the most frequent; to none 
 is a stridl attention more necessary; in the treatment of none i& 
 the utility of the surgical art more evident. 
 
II 
 
 CHAPTER I. 
 
 OF FRACTURES IN GENERAL. 
 
 FRACTURE is defined a solution of continuity of one or of 
 several bones, resulting from a force of extension dispropor- 
 tionate to, and exceeding their natural extensibility. We shall not, 
 in imitation of the greater part of authors, add, " produced by 
 some external cause*," for though the most usual cause of fractures 
 be some external force, yet muscular force is sometimes the sole 
 cause. It is this alone that always occasions the frafture of the 
 patella, olecranon, and cakaneum. This definition might be ap- 
 plied to a solution of continuity produced by a cutting instrument, 
 and therefore very different from frafture properly so called; but 
 a rigorous precision of language is not to be expecleci, particular- 
 ly in medical subjedts. 
 
 SECTION I. 
 
 Of the different Species of FrhSture. 
 
 Fractures differ from one another in five respects; 1st, as to 
 the bone affedled; 2d, as to the part of the bone; 3d, as to the 
 direction of the fraclure; 4th, as to the relative position of the 
 fractured portions; 5thly, and finally, as to the attending circum- 
 stances by which the fra(Sl;ure may be either simple, or variously 
 complicated. We proceed to consider them successively in these 
 respects. The fraftured bone may be broad, such as the scapula, 
 or bones of the pelvis; ur short, as the calcaneum and astragolos; 
 or belong to the class of long bones, as is most frequemly the 
 case. The situation and use of the broad bones do nor expose 
 them much to be fraclured, with the exception, however, of 
 those of the cranium; in which case, the fracture is less to be at- 
 tended to than the affedtion of the brain, v/hich it almost neces- 
 sarily occasions. 
 
 The fradture of short bones is still less frequent, on account of 
 the equality of the three dimensions; and if not produced by an 
 external force or weight, which crushes, or rather grinds the part, 
 
12 , OF FRACTURES IN GENERAL. 
 
 is almost always produced by muscular contraction, which is by 
 much the most frequent cause of the fracture of the patella, of 
 the olecranon, and calcaneum. The long bones, whether they 
 serve as pillars, as levers, or as arch-ending points of support 
 and resistance, are much exposed to fradlure, and are more fre- 
 quently fra(n:ured than any other class of bones; therefore, all 
 that is to be said of fraflures in general, is principally applicable 
 to theiTi. 
 
 These bones may be fractured in different points of their 
 length, and that happens most frequently in the point of bisec- 
 tion; in which case, the fracture is produced, like that of a stick 
 bent beyond its natural extensibility, by a force applied at each 
 extremity. These bones may, however, be fractured more or 
 less near their extremities; sometimes even it happens in their ex- 
 treme points, as shall be explained in treating of the fractures of 
 the neck of the femur and humerus. Sometimes, too, the same 
 bone is fractured in different points, whether it be caused by a 
 weight falling on a fragment of a single fra£ture, or whether a 
 cause of that nature alone, and exclusively of any pre-existing 
 fraClure, break the bone into several distinct splinters. This last 
 species of fradlure, which the ancients termed " nut-like," in 
 allusion to the breaking of a nut by a hammer, is distinguished 
 by the descriptive name of comminutive fradture. 
 
 The differences relative to the part of the bone fractured, esta- 
 blish a distinction of great importance, and not purely scholastic, 
 as is imagined by some; for these differences influence the treat- 
 ment and prognosis, as shall be proved. Thus, in a fradture of 
 the middle part of a bone, though, on account of the bone being 
 less thick in that part, and the contiguous surfaces therefore less 
 extensive, the fradlured portions are more easily and more widely 
 separable one from the other, yet this kind of fracture is the 
 least dangerous; because, in such cases, the cause is seldom ap- 
 pUed to the part fradtured, and for that reason the surrounding 
 soft parts are injured equally seldom. Another reason of this 
 difference is, that a less force suffices to break the bone in the 
 middle than in any other part; besides, the means usually em- 
 ployed to keep the fradtured portions in just contadl are more ef- 
 fedtual, because they are longer. Add to all this, that inflamma- 
 tion, stiffness, and anchylosis of the joint, are less likely to hap- 
 pen than when the bone is fradtured near the articulation. 
 
 With respedl to the diredtion of the fracture, there are several 
 distindtions to be made. It is called transverse when its diredtion 
 is perpendicular to the axis of the bone; oblique, when it devi- 
 ates from the perpendicular. In this respedl also, the comminu- 
 
OF FRACTURFiS IN GENERAL. IJ 
 
 tlve fracture is to be considered as of a particular species. This 
 frafture of the bone into several pieces of different diretftions, is 
 always attended with contusion of the surrounding soft parts. 
 Another species of frafSture of a longitudinal direftion has been 
 admitted by Duveniey^ of which he quotes two cases, and com- 
 pares it to the cracks which sudden drying causes in a board that 
 had been impregnated with humidity. J. L. Petit has, with 
 reason, denied the possibility of this species of fradlure; arguing, 
 that the cause which could fradlure a bone longitudinally would, 
 fradlure it more easily transversely, and must necessarily have 
 done so. The cases of these pretended fractures related by Du- 
 verney are by no means satisfaflory; for it is very difficult to as- 
 certain the existence of such a fradlure through the skin, perios- 
 teum, and intermediate parts. Heister admits its possibility how- 
 ever, and even asserts, that the panaris is for the most part ow- 
 ing to the longitudinal fradture of the finger-bones j but this er- 
 roneous opinion has been amply refuted by Louis at the conclu- 
 sion of his discourse on Petit's Treatise on the Diseases of the 
 Bones. We adopt the opinion of this latter author, and rejedl as 
 impossible, the longitudinal frafture, unless that name be applied 
 to longitudinal splinters of comminutive fra61ure, as is most like- 
 ly to happen when the fracture is occasioned by a gun-shot. 
 
 The most important distinction of fraftures is that resulting 
 from the different situations of the fra<5tured portions; the know- 
 ledge of their derangements is of the greatest importance, be- 
 cause the principal obje^ in the treatment of fraftures is to pre- 
 vent or remedy these derangements. The separation of the frac- 
 tured parts is not, however, essential to the disease, for it oftea 
 happens that the leg is fractured without any change in the form 
 of the limb; and this is particularly t]ie case when the tibia alone 
 is fractured at its superior extremity, because its diameter is con- 
 siderable in that part, and the extensive surfaces in contadt can- 
 not separate without difficulty: the fibula also contributes to re- 
 tain the fradtured portions in their natural situation. But when 
 both bones of the fore-arm or leg are fractured, it rarely happens 
 that the derangement of the parts is not the distinctive sign and 
 proof of the accident. This derangement attends, almost with- 
 out exception, the fra£ture of the thigh and arm, these members 
 being each formed of a single bone, and surrounded by very pow- 
 erful muscles. The causes of this derangement, and its varieties, 
 shall next be considered. 
 
 It may happen in the direction of the diameter of the bone, be 
 parallel to, or form an angle with the axis, or merely affe6t the 
 circumference. 
 
14 OF FRACTURES IN GENERAL. 
 
 When a bone is fraftured transversely, the contiguous surfaces 
 may remain in partial contadt, or be totally separated. In a frac- 
 ture of the tibia, for instance, the inferior portion of the bone 
 may be pushed inward, and totally separated from the superior; 
 or the external part of the former may be placed in contact with 
 the internal of the latter. This incomplete derangement in 
 the direction of the diameter of the bone, does not produce any 
 shortening of the limb; but when this derangement is complete^ 
 then follows that parallel to the axis of the bone. The derange- 
 ment in the diredtion of the diameter happens when jhe fradtu- 
 red bone is of a considerable size, as the tibia, for instance, 
 and the fradlure transverse; and when the proper means of keep- 
 ing the parts in their natural situation have been too long neg- 
 lected. But if the fracture be oblique, the surfaces not extensive, 
 and the accident negledled, the derangement in the diredlion of 
 the axis takes place, and the limb is shortened. In this last-men- 
 tioned might be included the fradlure of the patella, olecranon, 
 and calcancum; with this difference, however, that in the latter 
 cases the fracTtured ends recede one from the other, and are al- 
 ways found separated by a greater or less distance, instead of 
 passing one by the other, as in the former case. 
 
 The third species, viz. that in which two fragments form an 
 angle one with the other, has not been mentioned by authors, 
 and takes place principally in cases of comminutive frafture. It 
 might happen, however, in a simple fradture of the leg, as may 
 easily be conceived by supposing the foot placed on an inclined 
 plane; in which case the angle formed would be salient anterior- 
 ly, if the heel were lower than the fore part of the foot, posteri.. 
 orly if the contrary. 
 
 The fourth species, or that affedl:lng the circumference, is pro- 
 duced by the rotation of the inferior fradtured portion on the 
 superior, in such a manner as that the part which was anterior 
 becomes internal or external. We have an instance of this spe- 
 cies of derangement in the fradture of the neck of the femur; 
 when the foot being ill supported by the apparatus, and obeying 
 its weight, aided by that of the leg and by the contraction of the 
 muscles, turns outward, and carries the inferior fragment in the 
 same direction; in which case, the anterior part of the body of 
 the bone corresponds no longer to the anterior part of the neck. 
 
 The bones being but passive instruments of loco-motion, pos- 
 sess not, in their own organization, any cause of the change of 
 situation which takes place, but yield to exterior causes, to the 
 weight of the member, and to muscular contraction; whence it 
 appears, that the causes of this change of situation may be v-ery. 
 
 ,8' 
 
OF FRACTURES IN GlfNERAL. I5 
 
 various. The cause of the fradlure may also be the cause of the 
 derangement of the fra(^tured portions; as when the thigh, for 
 instance, is fraftured by a fall from some height: if the weight 
 of the body, pressing on the inferior extremity which bears on 
 the ground, bends the femur forward, the force will not be en- 
 tirely spent in producing the fracture, but will, in addition, pro- 
 duce a greater or less derangement of the fractured portions. 
 
 The celebrated Ambrose Pare has offered, in his own case, a 
 fracture and separation of the bones produced by the same cause. 
 This eminent surgeon reeeived a kick from a horse on the leg, 
 with such force, that the lower fracftured portion abandoned en- 
 tirely the upper, which, impelled by the weight of the body, 
 pierced the flesh, integuments, stocking, and gaitre, and drove 
 its pointed extremity even into the earth. 
 
 The -yveight of the limb suffices alone to produce the angular 
 derangement, or that affecting the circumference, as has been 
 already explained, when treating particularly on that subje£l. 
 Another cause is, the impulse frequently communicated to the 
 limb, by the assistants, during the dressing: but of all these cau- 
 ses, the most powerful is the contraction of the muscles. 
 
 Of the muscles which surround a fraftured bone, some are at- 
 tached to that bone in a great part of its lengih, and therefore in 
 many cases to both portions of the fradtured bone. Others ex- 
 tend from the bone which is superior to that fradlured, to that 
 which articulates with the lower portion, or to the lower frag- 
 ment itself; there are still others which terminate in the upper 
 fragment, the other extremity of which may be more or less dis- 
 tant. The muscles of the thigh offer examples of these three 
 different dispositions. The triceps is attached to the whole length 
 of the femur; the biceps, semi tendinosus, and semi-membrano- 
 sus, descend from the pelvis to the leg, to which the lower part 
 of the femur is articulated, and all the movements of which it 
 obeys; the great adductor muscle has its insertion in the lower 
 part of the femur itself: finally, the psoas, iliacus, pedlineus, &c. 
 &c. descend from the loins and the pelvis, and have their inser- 
 tion near the superior extremity of the femur. 
 
 The muscles which are attached to both portions of the frac- 
 tured bone, contribute very little to their change of situation; 
 but may, however, draw them both to the side on which they 
 are inserted, and thus change the direftion of the limb. The 
 triceps, and more particularly its middle part, adls thus on the 
 fradlured femur, and renders the thigh convex anteriorly. The 
 brachialis anterior tends to produce the same effeft, when the hu- 
 merus is fradtured below its middle part. Eut the change from 
 
l6 OF FRACTURES IN GENERAL. 
 
 the natural situation is principally owing to the muscles which are 
 inserted into the lower portion of the fradlured bone, or the limb 
 with which it articulates. Let us suppose the frafture of the hu- 
 merus between its superior extremity and the insertion of the 
 great pecloral muscle; this muscle, aided by the latissimus dorsi 
 and teres major, draws the inferior portion inward and upward, 
 and causes it to ascend on the interior side of the superior, which 
 rests motionless on account of its shortness, and because the mus- 
 cles, which are inserted into it, are not a£led on by any cause 
 that excites them to a6Vion, In the frafture of the neck of the 
 femur, the superior portion of the fractured bone has no muscle 
 inserted into it, and remains motionless in the articulating cavity. 
 Those muscles which, on the contrary, are attached to the lower 
 portion, draw it upward and backward, and render its being dis- 
 placed in that direction inevitable. 
 
 The lower portion being adled on by the limb to which it is ar- 
 ticulated, follows all its motions, and is liable to be displaced by 
 the acftion of the muscles which are inserted into it. Thus, in 
 fractures of the body of the femur, the biceps, semitendinosus, 
 and other muscles, draw the leg, and with it the inferior portion, 
 upward, inward, and back-ward, and cause it to ascend on the 
 internal, and a little on the posterior side of the superior portion, 
 the inferior extremity of which projects, in that case, on the an- 
 terior and external side. 
 
 In the fra£lures of the leg, the gastrocnemii muscles, &c. draw 
 the inferior portion upward and backward, with the foot-, for in 
 this, as in every similar case, the stronger muscles displace the 
 lower portion of the fractured bone, and draw it in their direc- 
 tion: hence it is, that in this case the portion is drawn backward as 
 well as upward, because the muscles are more numerous and 
 larger on the back part of the leg than on any other. Therefore, 
 when a fracfture takes place in any part of a bone, it is easy to de- 
 termine, from a knowledge of the muscles, what species of de- 
 rangement will follow, if there be no counterafting cause. Fi- 
 nally, the muscles which have their insertion in a superior frag- 
 ment, may produce its separation from the inferior. When the 
 femur is fra<Stured immediately below the small trochanter, the 
 iliac and psoas muscles draw forward the inferior extremity of the 
 superior fragment, which raises the skin and projects more or 
 less. It is to be observed, however, that the displacing of this 
 fragment is very rare, whilst the inferior fragment is displaced in 
 almost every case. 
 
 Hitherto we have considered the derangements of fratftures as 
 simple, but they may be complicated; as for example, when in a 
 
OF FRACTURES IN GENERAL. If 
 
 simple fra^lure of the femur, the lower fragment has ascended 
 upward and inward, and the foot being ill supported inclines ex- 
 ternally at the same time. The derangement in this case will be 
 composed of the four species already described. 
 
 There are other differences still which depend on the fracHrures 
 being simple or compound. A simple fracture is that in which 
 the soft parts have received no other injury than that necessarily- 
 produced by the frafture; for it is easy to conceive, that a frac- 
 ture cannot take place without lacerating more or less the perios- 
 teum, the small blood-vessels, and the muscular fibres contiguous 
 to the fracture; some degree of Contusion and of swelling follows 
 necessarily, and the skin of the part becomes livid and yellow in 
 two or three daj-s. A frafture is compound when it is accompa- 
 nied by circumstances which require particular modes of treat- 
 ment i such are a much greater degree of contusion than ordi- 
 nary; a solution of continuity of the surrounding soft parts, whe- 
 ther that be immediately produced by the fradluring cause, or by 
 the fragments penetrating through the skin, after having lacerated 
 the intermediate soft parts: this happens when the fradlure is very 
 oblique and the fragments pointed. This compound fracture may 
 be rendered still more complex, by the rupture of a large blood- 
 vessel, whether an artery or vein, and by the effusion of blood in 
 the cellular texture, which would be its necessary consequence. 
 
 Fra£tures are but rarely accompanied with luxation-, in which 
 case the luxation must necessarily precede the fracture; for the 
 fra<Sture once effected, the fragments are not susceptible of luxa- 
 tion: any motion which may be communicated to them can only 
 impel them into the surrounding soft parts producing more or less 
 laceration. 
 
 Finally, fractures may be accompanied with other morbid af- 
 fedlions, whether pre-existing to the fracture, succeding that ac- 
 cident, or operating as its predisposing cause. Thus persons af- 
 fe£led with a fradlure, are also often affected at the same time 
 with a vitiated state of the solids and humours; such are, for in- 
 stance, the scurvy," scrofula, the venereal disease, or cancer. Add 
 to all this, that the irritation caused by a fracture may be the occa- 
 sion of an acute fever, which generally changes to the reigning 
 epidemic. 
 
 We shall not treat here of the distinftion of fra£bjres into com- 
 plete and incomplete; because these denominations appear to us 
 unfounded, and fit only to lead into error. By complete fradhires, 
 authors mean those in which both bones of a limb are at the same 
 time fradlurcd; as those of the leg or fore-arm: incomplete, those 
 in which only one of these bones is fractured, the other not being 
 3 
 
iS OF THE CAUSES OF FRACTURES. 
 
 injured; but it is evident that in this case the frafture is complete; 
 for to the term incomplete, we can only attach the idea of a bone 
 partially fradlured, an occurrence utterly impossible. 
 
 SECTION ii. 
 
 ' Of the Causes of Fra£lures. 
 
 The causes of fraftures are as various as the means by virhiclt 
 that efFedt may be produced; and, like the causes of other dis- 
 eases, may be divided into predisposing, and remote. In the 
 first class of causes are ranged the situation and functions of the 
 bones, the age of the individuals, and their diseases, if affefted by 
 any. Superficial bones arc more easily fradVured than those which 
 are covered by a considerable depth of soft parts. The functions 
 of some bones render them more liable to be fractured than others; 
 thus the radius, which supports the hand, and serves in some 
 respect as a handle to it, is more liable to be fraftnred than the 
 cubitus. The clavicula, which preserves the shoulder and ster- 
 num in their proper position, and supports on its arched extre- 
 mity all the motions of the superior extremity, is on that account 
 frequently fracStured. The gradual accumulation of phosphate of 
 lime in the cellular structure of the bones, renders them brittle 
 in proportion as we advance in life. In old age the proportion of 
 the inorganized to the organized part is so great, that the bones 
 are then fradlured by the slightest cause. In childhood, on the 
 contrary, the fibrous and organized part prevails, and communi- 
 cates its properties to the bone, which is then flexible and elastic. 
 An advanced period of life is theri, to be reckoned as one of the 
 predisposing causes of fradlures. Certain acrimonies, a0e<n: the os- 
 seous system, by attacking its organized part, and reducing it to 
 the same state as in old age, and render i-t even still more brittle. 
 Thus, women affedced with old and ulcerated cancers, have been 
 known to fraftui^e their bones, in performing the natural and or- 
 dinary motions of the body, or merely in changing their position 
 in bed; instances of which are recorded by Louis and Saviard. In 
 cases of this nature, all the bones of the body being equally af- 
 fedled, several fractures happen at the same time, and reduce the 
 sufferer to the lowest state of wretchedness. The principal indi- 
 cation in such cases is not that of the fracture, as it is only a symp- 
 tom of a more dangerous disease, the cure of which ought prin- 
 cipally to be attended to. A certain degree of cold has been num- 
 
OF THE CAUSES OF FRACTURES. 1 9 
 
 bered among the predisposing causes of frafture; but if this acci- 
 dent be more frequent in winter than in summer, it is because 
 persons are then more hable to accidents from faUing. 
 
 Every efficient cause adls in overcoming the natural cohesion of 
 the osseous particles, by separating these particles, and lengthen- 
 ing the bone beyond its natural extensibility; the force thus a<5ling, 
 may have been applied on the part fradlured immediately, or on 
 some distant part. When the cause of the fracture is applied to 
 both ends of a bone, the bone is curved by the approximation of 
 its extremities; thus it is, that, by falling on the shoulder, the 
 clavicle, forcibly pressed against the sternum, is curved and frac- 
 tured, as if by wh^t the French term contrecoup. In falling on the 
 knees, the femur, pressed between the weight of the body and 
 the ground, bends about its middle part, and the fra^ure takes 
 place there. In these and similar cases, the natural curvature of 
 the bones contributes, with the force applied, to determine the 
 frafture in a certain part; and in such cases the contusion is less 
 considerable than if the fradlure had been produced by a force 
 immediately applied to the fradlured part ; for the aftion of the 
 fraftured extremities on the surrounding soft parts is then the only 
 cause of laceration or irritation. But a force which fraftures a 
 bone exadlly on the part which it strikes, bends it to the opposite 
 side, and wounds or lacerates the soft parts. Thus a blow of a 
 stick on the middle part of the clavicle, where the fleshy parts give 
 it but a trifling support, bends it downward and backward, and 
 fradlures it, but never without producing a greater or less contu- 
 sion, and sometimes a contused wound. If the frafluring force 
 s/:rike a bone equally supported in all its parts, the frafture will be 
 of the comminutive species, that is, in several fragments: the 
 contusion is always great in such cases. 
 
 SECTION in. 
 
 Of the Signs of FraBures. 
 
 The signs or symptoms of fradlures drawn from circumstances, 
 ^nd established by reasoning, are never conclusive. The pain, 
 for instance, however intense, and the impossibility of moving 
 the limb, may be occasioned by a simple contusion, a luxation, and 
 a variety of other causes. The immediate signs (the natural evi- 
 dence of which precludes reasoning), generally called sensible 
 ijjjnsj s^ch, for instance, as an alteration in the form of tlie limb. 
 
20 OF THE SIGNS OF FRACTURES. 
 
 its being shortened, and the crepitation produced by the fra£lu- 
 red surfaces in rubbing one against the other^ can alone give any 
 certainty of the existence of a fracture. 
 
 When the Hmb affe£led is found shorter than the other, it is 
 necessary, before pronouncing on the existence of a frafture, to 
 be certain that no luxation has taken place, that it is not natural- 
 ly so, nor in consequence of a former fradlure ill set. In com- 
 paring the length of the lower extremities, the body should be 
 placed, so as that the anterior and superior processes of the ossa 
 ilia may be in a line parallel to the horizon; for if one of them 
 be lower than the other, the member of that side will appear 
 longer than the other. 
 
 Whoever has acquired a precise knowledge of the natural cast 
 and conformation of our members, he more especially who has 
 accurately studied the relative situation of the processes on the 
 extremities of the bones, will quickly perceive any change indu- 
 ced by- a fradlure. Whenever, in consequence of a blow or a 
 fall, a member becomes concave in a part where it is naturally 
 convex or straight, and vice ■versa; this change of form and di- 
 rection must be attributed tq a fracture, ^yith derangement of the 
 fragments. The internal side of the great toe, when the foot 
 bears on an horizontal plane, ought to be in the same perpendi- 
 cular line with the inside of the patella: nothing but a fradlure 
 of both bones of the leg can change this relative position of these 
 parts. The relative position of the condyles of the humerus, and 
 of the apophyses of the olecrarlon, indicate in like manner the 
 luxation or fradlure of the humerus. The derangement of the 
 fragments may sometimes be perceiyed by moving the fingers on 
 the parts of the bone which are least covered by the integuments. 
 This sign is easily .detected in the fradtures of bones which are 
 not surrounded by much flesh, but which lie almost immediately 
 under the skin: such, for example, are those of the lower jaw 
 and the clavicles. 
 
 But of all the symptoms, crepitation is the most general and 
 distindtive; and can never be confounded by an experienced 
 pradtitioner with the noise produced by emphysema, by an aque- 
 ous effusion, or the defedl of synovia. In order to know if this 
 symptom exists, the operator, in some cases, seizes the member 
 between both his hands, and presses it in different points of its 
 length; it is thus that the fradlures of the radius are ascertained, 
 by pressing that bone from the external side to the internal. In 
 other cases the operator takes a fragment in each hand, and by 
 turning their extremities in opposite diredlions, produces the 
 crepitation, if the fradlure really exists: if the volume of the 
 
OF THE SIGNS OF FRACTURES. It 
 
 member requires it, the operator causes the superior fragment to 
 be held by an assistant, whilst he moves the inferioron it, if the 
 fradlure really exists, as is supposed by the trial, for which reason 
 we have used the term fragments, as if it really did exist. 
 
 Although in the greater number of cases it be easy to ascertain 
 the existence, or non-existence of a fradlure, by the foregoing 
 signs; yet there are cases in which certainty is very difficult to be 
 obtained. This difficulty may depend on several causes. 
 
 In some cases the bone afFe<Si:ed is surrounded by such a depth 
 of fleshy parts, that the solution of continuity is almost impossi- 
 ble to be ascertained, and the crepitation is very indistinft. If in 
 a case of this nature, such, for instance, as in some fraftures of the 
 neck of the femur, the separation of the fragments one from the 
 other be inconsiderable, the fradture may easily remain undisco- 
 vered. The fradture of one of the bones of the fore-arm or leg 
 is often difficult to be perceived, because the other bone remain- 
 ing whole, preserves the form of the member, by preventing 
 any considerable separation of the fragments. 
 
 Finally, if the surgeon be not called in, until a compound frac- 
 ture has been still further complicated by an inflammatory swell- 
 ing, it will be extremely difficult to ascertain with certainty the 
 existence of the frafture; and thongh that knowledge should be 
 obtained, yet it will be prudent to await the abatement of the 
 symptoms before any attempt be made to set the frafture. 
 
 When every possible trial has failed, and doubts still remain on 
 the existence of a fra<5ture, it will be prudent to apply the ordi- 
 nary apparatus imbibed with some resolvent liquid; after the 
 lapse of a few days, the apparatus should be taken off, and dis- 
 continued if it be found that no frafture exists, or re-applied, in 
 the contrary event; at all events, no inconvenience can arise from 
 [ts first application. 
 
 SECTION IV. 
 The Prognosis of FraBures 
 
 Is different according to the bone fradlured, the part of the 
 bone where the frafture has happened, the dired:ion of it, and 
 the circumstances which attend it. 
 
 The frafture of bones which are superficial, and but thinly co- 
 vered, is, cateris paribusy less dangerous than the fracture of 
 bones surrounded by many and strong muscles. Fra<5lures of the 
 
12 THE PROCr^OSIS OF FRACTURES. 
 
 superior extremities are always less dangerous than those of the 
 inferior extremities. The fra£lure of the middle part of a bone 
 is less dangerous than that of its extremities; because in the 
 former case it happens frequently, that the cause has not a6l- 
 ed immediately; that the soft parts are not much contused, and 
 the inflammatory swelling is less to be apprehended. Fraftures 
 of the extremities of bones may produce a false anchylosis of the 
 neighbouring articulation. It is thus that in the frafture of the 
 femur, a little above the condyles, the congestion extends to the 
 knee, and occasions a stiffness, which it is difficult to remove : 
 if the inflammation extend to the articulation, the consequence 
 is still worse. Finally, the splints a£ling only on one of the 
 fragments, render their disjundlion very easy. Therefore, the 
 frafture of the neck of the femur is more dangerous than that of 
 the body of the same bone. With respe^l to the dire£lion of the 
 fradhire, those which are transverse are less dangerous than the 
 oblique; and the greater the obliquity, the greater the danger, 
 as the disjunction is on that account more easy; for which reason, 
 a very oblique frafture of the body of the femur is esteemed fully 
 as dangerous as that of its neck. 
 
 The accidents which attend a fra£kure add more or less to its 
 danger. In a case of extreme contusion, attendant on a commi- 
 nutive fraflure, and in which some of the splinters have lacerated 
 the part to an excessive degree, the inflammation may be so vio- 
 lent, as that mortification will ensue, and extend from the mem- 
 ber to the trunk, and kill the patient in a very few days. In ge- 
 neral, fradlures complicated with contusion and wound, are more 
 dangerous in the inferior than in the superior extremities. 
 
 Finally, the prognosis v/ill be more or less unfavourable, ac- 
 cording to the health and age of the individual. In a debilitated 
 old man, a fradlure is more dangerous, than in a person in the 
 flower of youth and health. There are certain dispositions of 
 the body, which influence very much the prognosis. Scurvy, 
 for instance, retards to such a degree the formation of the callus, 
 that, joined with old age, it may prevent it entirely. The state 
 of pregnancy, notwithstanding what authors have said of it, does 
 rot retard the consolidation of a fra<^ure, at least not to any sen- 
 sible degree. 
 
OF THE TREATMENT OF FRACTURES. 23 
 
 SECTION V. 
 
 Of the Treatment of FraElures. 
 
 The first and principal indication in a fradlure, without de- 
 rangement of the fragments, is to retain the fragments in their 
 natural situation, to prevent the bad symptoms which generally 
 follow, or combat them if they have already taken place; but if 
 there be derangement, as most generally happens, it will be ne- 
 cessary, in the first place, to set the bone, that is, to restore the 
 fragments to their natural situation. 
 
 The manner of setting a fractured bone varies, according to 
 the nature and species of the fracture; and the precept is not 
 perfe6tly correft, which says, that in every fradlure, extension, 
 counter-extension, and coaptation are necessary; because in seve- 
 ral cases the extension and counter- extension are perfedlly useless^ 
 as, for instance, in the fractures of the patella and olecranon, in 
 which the fragments separate in opposite diredlions. It is mere- 
 ly necessary for their redudlion to push the fragments one tcv- 
 wards the other, having first extended the leg or fore-arm, in 
 order to relax the muscles which have their insertion in the part 
 affefted. In the derangement in the dire<f!:ion of the diameter of 
 the bone, only a very slight degree of extension will be necessa- 
 ry, in order to diminish the friction of the fractured surfaces, 
 which move in contrary directions. Extension and counter-ex- 
 tension are still useless, when the displaced fragments form an 
 angle one with the other; for it will suffice to place the member 
 on an horizontal plane, in order to reduce the member to its na- 
 tural dire£tion. The derangement of the circumference is alike 
 easily reduced by a rotatory motion given to the lower fragment, 
 in the direction contrary to that which it took in quitting its na- 
 tural situation. 
 
 Extension and counter-extension are not therefore of any very 
 evident utility, except in the derangement in the diredtion of the 
 axis of the bone, in which both fragments mutually pass one 
 another. 
 
 Extension is the force exerted on the lower fragment, in order 
 to bring its superior extremity lower than the inferior extremity 
 of the superior fratftured portion: counter-extension is a resisting 
 force, which prevents the whole limb, or even the bodv, from 
 obeying the force of extension. The hands of intelligent assist- 
 ants are always best for both these purposes; it is but very sel- 
 dom that anv advantage can be derived from the use cf more 
 
24 OF THE TREATMENT OF FRACTURES. 
 
 powerful means, which by their excessive force extend too vio- 
 lently the muscles and soft parts, occasion much pain, and pro- 
 duce spasmodic contraction of the muscles, which resist always 
 in proportion to the force of extension, and on that account ren- 
 der it most frequently of no efFecl. 
 
 The pra<5lice was formerly to apply the force of extension on 
 the inferior fragment, and that of the counter-extension on the 
 superior; but exclusive of the difliculty of seizing the two frag- 
 ments, which difficulty is in some cases insurmountable, as in the 
 fracture of the neck of the femur; there is, besides, a great dis- 
 advantage attending it when practicable, namely, the spasmodic 
 contraction of the muscles which snrround the fracture, caused 
 by the irritation and violence which they suffer. 
 
 It is therefore better to make the extension on the lower part of 
 the limb, or on the bone which articulates with the inferior frag- 
 ment, and the counter-extension or that which articulates with the 
 superior. In a fracture of the leg, for instance, the extending force 
 should act on the foot, and the counter-extending on the thigh; 
 whilst in that of the thigh, these opposing forces should be applied 
 to the leg and pelvis. There Is nothing to be said as to the degree 
 of forc€ to be employed, because that must vary according to the 
 extent of the derangement, and the number and strength of the 
 muscles which have produced it. The direClion in which these 
 forces ought to aCt, is that which the inferior fragment pursued 
 in taking its unnatural position; but this applies alone to the force 
 of extension, because the opposing force is a mere resistance. 
 Thus, if, in a fracture of the thigh, the lower fragment has 
 ascended on the internal side of the superior, the foot and knee 
 will be turned a little externally; and the extension ought there- 
 fore to be directed at first downward, and outwards; afterwards, 
 in proportion as the limb recovers its proper direction, the frag- 
 ment ought to be drawn into its natural position. The assistants 
 employed in this operation should be very intelligent, because, 
 when extension is well made, coaptation becomes very easy. It 
 is much easier to set a fraCture, than to keep the bones in their 
 place; in which it ditters from luxation, which is difBcuk to be 
 reduced, but easily prevented from relapsing. The means com- 
 monly in use to maintain the portions of a fractured bone in exaCt 
 contact, and the member perfeCtly motionless during the time 
 necessary fv)r the formation of the callus, are reducible to a pro- 
 per position, repose, bandages, and other kinds of apparatus, 
 such zs famns^ faux-f a f ions, compresses, stuffing, splints, machines 
 of various constructions, and the means of efFeCting perpetual 
 extension. We shall consider each of these in detail, successively. 
 
OF THE TREATMENT OF FRACTURES. "^■•"'^ 25 
 
 In the first place, a situation is to be given to the limb, in which 
 it riiay continue as long as the afFe(fliort lasts; for that purpoise it 
 ought to be placed on a horizontal plane, so disposed, that the 
 intervals between it and certain parts of the limb shall be filled 
 up, in order that every part of it may be equally supported. 
 This horizontal support ought to be capible of making a conside- 
 rable resistance; without, however, being hard enough to give 
 any uneasiness Or pain. For this purpose a mattress of hair seems 
 preferable to any other; biecause one of wool oi: feathers yields 
 too much to the weight of the limb and apparatus. . 
 
 Surgeons were for some time divided in their opinions oh the 
 best position. Pott has advised the limb to be kept half bent; 
 which position, he says, has the advantage of giving to the mus- 
 cles which surround an articulation, an equal and moderate de- 
 gree of tension ; whereas, if the member be placed straight, some 
 of thiese muscles will be much extended, whilst others are as much 
 relaxed. The latter position, however, is that ^vhich it general- 
 ly preferred. 
 
 Demi-flexion is th6 most natural position} it is that which our 
 limbs spontaneously assumie during sleep, and has for that reason 
 been recommended both by Galen and Hippocraties: but a limb 
 half bent, is not solidly fixed, and changes frequently its situati- 
 on, by numerous involuntary motions, which may be occasioned 
 by dreams or pain. This position has, besides, this great incon- 
 venience, that during the treatment, the length of the fra^red 
 limb cannot be compared with that of the opposite side, nor can 
 it therefore be known if the frafture be well set, and the appara- 
 tus well applied; and in truth, demi-flexion becomes at length as 
 painful as the extension at full length. The advantages of the 
 former have therefore been a Httle exaggerated by Pott, as well 
 as the disadvantages of the latter, which alone is now used in 
 France, and generally adopted in foreign coiintries. 
 
 In whatever position the limb is placed, most perfe£l repose is 
 absolutely necessary, particularly in the commencement; for if 
 the fraftured pieces be moved one upon the other, nature cannot 
 efFe£t their reunion, which would therefore be retarded or total- 
 ly prevented, if the frifWon of the surfaces were frequent, and 
 suffered to continue long; in which case an articulation would be 
 formed in the situation of the frafture, and consequently the pa- 
 tient remain disabled for ever after. 
 
 It is necessary to apply proper bandages and other apparatus, 
 
 without which the position given to the member, however good, 
 
 would be insufficient; because, without these, the involuntary 
 
 motions which are inevitable, those which are produced by pain, 
 
 4 
 
26 OF THE TREATMENT OF FRACTURLS. 
 
 and those again which are rendered necessary by our natural v/aftts^ 
 would certainly, without that precaution, disturb more or less thi 
 just relative position of the fraflured pieces, which even the de- 
 pressions and inequality of the bed would affect, if not guarded 
 against. 
 
 Bandages had been for a long time considered as the most ef- 
 fedtual means of retaining the fragments in just contact; but it is 
 easy to prove, that bandages, however contrived, can have but 
 little, or absolutely no effedt for this purpose. We shall examine 
 successively, those which have been in use, viz. the roller, eight- 
 een tailed bandage, and that of Scultet, composed of separate 
 pieces. 
 
 The first ought to be long enough to cover the whole limb, 
 three inches broad, and rolled Up in one. It is applied, by draw- 
 ing first three folds of it over the fractured parts; it is then mad^ 
 to descend to the extremity of the limb, in such a manner, as 
 that each roll shall cover a part of the preceding; it is made to 
 ascend again in like manner to the situation of the fracture, when 
 three folds more of it are applied; after which the superior part 
 of the limb is covered, in the same manner as the inferior; and 
 if the bandage be long enough, it may be again rolled on down- 
 wards. Let us suppose this bandage applied to a fra(Sture of the 
 middle part of the femur, or humerus: it is plain that those parts 
 of it which are applied on one of the fragments alone, are abso* 
 lutely of no effe6l, and that that part of it only which comprehends 
 both fragments, can contribute to keep them in contact. But in 
 order to understand how extremely trifling its effedl must be, it 
 is sufficient to remark, that, as it is but three inches broad, it can 
 include only an inch and a half of each fractured portion; and 
 that this very trifling power is stiil farther diminished, by the 
 greater or less quantity of soft parts which intercept its action. 
 
 In this respect, the eighteen-tailed bandage is preferable to the 
 former. It is composed of three pieces of linen, equal in length to 
 the member, and broad enough to pass once and a half round the 
 limb. These pieces are sewed together by a seam, which runs from 
 one extremity to the other; and afterv/ards, cut each into three; 
 so that the whole is composed of eighteen pieces, nine at each 
 end. The bandage thus composed, being moistened, is extend- 
 ed under the limb, and the middle piece on each side is first ap- 
 plied on the situation of the fracture, then the superior ones, 
 and afterwards the inferior, and so successively with the middle 
 and inferior pieces. The six middle pieces of this bandage act 
 with more efficacy on the frafcure, than the folds of the former 
 bandage; because being much broader, they encompass a greater 
 
OF THE TREATMENT OF FRACTURES. 27 
 
 part of it. It has this other advantage over the former bandage, 
 that its appHcation is easier, and does not require that the Umb 
 should be kept raised, nor exposed to many motions, which are 
 always hurtful. 
 
 Scultet's bandage is composed of as many pieces of three in- 
 ches broad each, as are necessary to cover the whole length of 
 the member, in lapping two thirds over one another. It is com- 
 posed of a piece of linen, of three times the length of the 
 limb, and broad enough to pass once and a half round the limbj 
 it is to be cut according to its breadth, in pieces of three inches 
 broad each: this done, the pieces are extended under the mem- 
 ber, one covering three? parts of the other in proceeding from 
 the inferior part. This bandage like the two former,, acts only 
 by the pieces which encompass at once the contiguous parts of 
 the two fragments; it is preferable however in ih^ following re- 
 spefts. 
 
 It contributes as much as the others to rnaint^in thje fragments 
 in their just position; it compresses sufEciently the member, and 
 prevents any oedema j it is in this respect preferable to the 
 eighteen-tailed bandage, the parts of which not passing one on 
 the other, do not compress all the parts equally; whence it hap- 
 pens, that those parts whiclj .correspond to the edges of the 
 pieces become oedematous. 
 
 This bandage can be taken off, and re-applied, without mo- 
 ving the limb, in which it is far preferable to the first mentioned 
 bandage, the disadyan.tage of which in that respeft has been al- 
 ready pointed out. The eighteen-tailed bandage cannot be so 
 conveniently renewed as that of Scultet, because, when any part 
 of it is soiled by purulent matter, or any other cause, it is neces.- 
 sary to remove it entirely, and apply another; whereas any par- 
 ticular piece of that of Scultet may be changed, and a new one 
 applied in its place, which may be done without moving the 
 jmember, by fastening the new one to the extremity of the old, and 
 drawing it into its proper situation at the same time that this latter 
 is taken away. It ought, therefore, to be preferred to the two 
 former, except in cases of simple fra^lure of the superior ex- 
 Iremities. 
 
 Although bandages may be of no great use for keeping the 
 broken pieces in their proper position, yet they are useful for 
 supporting topical applications, and preventing oedema of the 
 iimb; they are still further useful in benumbing the muscles, and 
 in preventing their contraftlon. 
 
 The faux-famu is a cloth rolled on itself, and differs from the 
 fanon in this, that in the latter there is enclosed a piece of wood. 
 
l8 OP THE TREATMENT OF FRACTURES 
 
 They are applied on the internal and external sides of the limbj 
 but our limbs, like the fansns^ being nearly round, these latter 
 come in contaft with the limb but by a very narrow surface, so 
 that in tightening the strings by which they are secured, they are 
 liable to slide forwa^"d or backward; in which cases their aftion is 
 frustrated, i^o effeft produced, and the fradtured portions sepa- 
 rate without any difficulty. 
 
 Splints are much surer means; they may be formed of different 
 substances, and their shape and length accommodated to those of 
 the limb in which the fradhire has taken place. 
 
 Splints made of pasteboard were formerly in use, which being 
 W€|t \yere easily adapted to the form of the member, and in dry- 
 ing were pioulded to it. They have been also made of the bark 
 of trees, but the brittleness of these caused them to be laid aside. 
 At present, \food or tin are the only materials of which splints 
 are made: they are usually thin and narrow, and rounded at 
 tKeir extremities: their length must be deteripined by circun>- 
 stances. Those of tin are extremely proper for simple frji£hires 
 of the superior extremities; their flexibility admitting them to be 
 adapted exactly to the form of the member. In case of not ha- 
 ving them, their want may be supplied by thin laths of flexible 
 wood, susceptible of being moulded into the shape of a trough. 
 In general, splints for the superior extremities ought to equal the 
 fra£hjred bone in length. In fra£tures of the arm, the splint 
 which is placed on the for^ part, ought to be a little shortened, 
 and not to descend to the bend of the arm, in order that its de- 
 mi-flexion may not be prevented. 
 
 The splints designed for the inferior extremities ought to be 
 strong, thick and flexible, and longer than the member. For a 
 fracture of the thigh, the external splint ought to extend from 
 the superior part of the os ilium, to a little lower than the sole of 
 the foot; the internal should equally descend from the upper and 
 internal part of the thigh to a little below the foot, and the an- 
 terior from the groin to the superior part of the leg. In frac- 
 tures of the leg, the internal and external splints ought to ascend 
 above the knee, and descend below tlie foot. 
 
 In order to understand how the splints a£t, it is necessary to 
 recoUedt what has already been said of the derangement of frag- 
 ments; it is clear they prevent that in the direction of the diar 
 meter of the bone, by being in opposition one to the other, 
 on every side of the bone, and by resisting therefore any force 
 which might tend to move either fragment internally or exter- 
 nally, forward or backward. In fractures of the inferior extre- 
 
OF THE TREATMENT OF FRACTURES. 29 
 
 fahy, no posterior splint is necessary, because its place is supplied 
 by the plane on which the member rests. 
 
 Splints prevent also the angular derangement of the fragments, 
 by supporting each of them in the whole length of the member. 
 They prevent also the derangement in the circumference; but in 
 prder to do so, they must aft on that part of the limb which is 
 articulated with the lower fragment. For in a fradlure of the 
 femur, for instance, if the splints do not descend below the thigh 
 there is nothing to prevent the weight of the foot or leg, or that 
 of the bed-cloaths, from turning them either inward or outward, 
 and with them the lower fragment. 
 
 The derangement in these three last mentioned direflions is 
 more easily prevented by splints, than that in the direftion of the 
 axis, or by chevauchement. If the frafture be transverse, the 
 splints prevent even this latter kind of derangement, because 
 they obviate that in the direction of the diameter of the bone, 
 which must i^ecessarily precede it. But, if the fracture be ob- 
 lique, that is, with sloped surfaces, the fragments do not then 
 oppose a sufficient mutual resistance, but slide on one another 
 with a facility proportional to the obliquity of the fracture. 
 
 In such a case, the splints can oppose the derangement only by 
 the degree of compression which they make on the whole length 
 of each fractured portion; but if the fracture be very oblique, the 
 surfaces smooth, and the part surrounded by strong muscles, this 
 derangement will probably take place. Thus it is found by expe- 
 rience to be almost impossible to maintain properly adjusted, an 
 qblique fracture of the body of the femur, by the aid of splints 
 alone. It is equally difficult to remedy by their means oblique 
 fractures of the clavicle; because they cannot be applied on every 
 side of that bone. 
 
 The impossibility qf obtaining, in certain cases, a cure exempt 
 from all deformity, by ordinary means, has made surgeons recur 
 to another apparatus, which, by drawing continually the two pie- 
 ces in opposite directions, prevents them from repassing one on 
 the other, and keeps the fractured surfaces in just contact all the 
 time necessary for their consolidation ; this method has been 
 termed perpetual extension. 
 
 This apparatus should not be applied before the irritation and 
 spasm of the muscles are completely removed. It prevents the 
 muscular fibres from being too forcibly stretched or elongated be- 
 yond their natural extensibility ; it supplies the place of the bone, 
 which, before the frafture, regulated the contraftion of the 
 
3© OF THE TREATMENT OF FRACTURES, 
 
 muscles. Its application may be submitted to some general rules, 
 which I shall copy here from a work on that subjeft.* 
 
 RULE I. 
 
 To apply the extending Force on the Parts of the Members inferior 
 and superior to the fraBured Bone. 
 
 The extending and counter-extending forces ought not to be 
 applied immediately on the fractured bone, but on that which 
 articulates with the inferior fragment, for the extension; and 
 for counter-extension, on that which articulates with the superior. 
 Continued extension not differing from simple extension and 
 .counter-extension, except in its being continue^, the same rea- 
 soning applies to both cases. 
 
 RULE II. 
 
 To aEi on as great a Superficies as possible. 
 
 In order to fulfil this condition, the bandages and other pieces 
 of the apparatus, ought to be as broad as possible. The etfe£t 
 which external causes have on our bodies, is small in proportion 
 to the extent of the surfaces on which they a£l; because the ac- 
 tion is then supported by a greater number of parts. A thin and 
 narrow bandage of linen folds on itself quickly, and becomes a 
 hard cord, which causes a distension of the vessels of the inferior 
 part of the member, by obstructing the return of the lymph and 
 venous blood. 
 
 RULE in. 
 
 To give to the extending Power a Direction parallel to the Axis of 
 
 the Bone. 
 
 The science of mechanics teaches us that the aclion of a force 
 on a lever is decomposed, if its direction be oblique to the lever, 
 
 * Anatomio-surgical Dissertation on Fia€lures of the Neck of t\tz FeiTiur, br 
 A. Richerand, oftivo, Paris, year 7. 
 
OF THE TREATMENT CF FRACTURES. Jl 
 
 one part of it a£ling in that diredlion, and the other in that of the 
 lever; that is, in geometrical terms, the force acling on the lever 
 will be to the vrhole force as the angle, formed by its direction 
 with the lever, is to a right angle. It is easy to perceive that the 
 part of this force which is not employed to effect the desired pur- 
 pose, must counteract the proposed end, by causing pain, and 
 uselessly compressing the parts. 
 
 RULE IV. 
 
 The Extension ought to he as gradual as poss'ibUy operating sloivlyt 
 and by Degrees. 
 
 Animal parts which yield to long continued and insensible ac- 
 tion of exterior causes, resist any violent and sudden effort, and 
 revolt against it, as it were, with all their force: thus the slower 
 and the less rapid the extension, the more easily do the parts of 
 our body yield. 
 
 Continued extension does not exclude the ordinary apparatus, 
 but is additional to it. 
 
 As every part of the surface of our limbs does not lie in the 
 same plane, that is, as our limbs are prominent in some parts, and 
 depressed in others, and therefore liable to be hurt and bruised 
 by hard, straight, and inflexible splints, even to the degree of 
 producing gangrene, some means of remedying these disadvan- 
 tages, and preventing these bad e£Fe£ts, were naturally recurred 
 to. For this purpose the different depressions of the limb are 
 filled with lint, rags of eld linen, compresses, or, what is still 
 better, with little bags of the chaff of oats 5 the facility, which 
 these latter offer, of moving the chaff from one part to another, 
 as well as their soft and equable pressure, give them an evident 
 advantage: by these means the pressure becomes equal on every 
 part of the length of the member. Finally it is not superfluous 
 to remark, that tape ought to be preferred to strips of linen, 
 which knot with difficulty, particularly when wet, for the pur- 
 pose of binding externally the whole apparatus. The number 
 of these tape strings must be proportioned to the length of the 
 member; as must the length of the bags of chaff to that of the 
 splints, the action of which they are intended to moderate. 
 
 We shall in the next place examine what is required by the 
 third indication of frafture.'' that is, to prevent the complications 
 which may succeed to it, and to remedy them when they have 
 Teally taken place. 
 
32 OF THE TREATMENT OF FRACTURES. 
 
 In every frafture, with the exception of those of the sUperiof 
 extremities, which are simple, the patient ought to be confined 
 to a low regimen for the first four or five days : more or less blood 
 should be drawn, if it be not contra-indicated by extreme old age, 
 or great debility. No greasy irritating plasters, of which quacks 
 make so much use, such for instance, as the plaster of Cyroane, 
 are to be employed; but in their stead, it will be sufficient mere- 
 ly to cover the limb with several folds of compresses soaked in 
 camphorated spirit, or a solution of the acetate of lead, or any 
 other repellent liquid, with which also the other parts of the 
 bandage should be moistened. A solution of common salt is to 
 be avoided, because that salt would quickly crystallize, hardening 
 thereby the dilfferent pieces of the bandage, and giving them a 
 stiffiiess unpleasant to the patient. The bowels should be kept 
 open by gentle laxatives; such as veal broth, whey acidulated 
 with tamarinds, &c. When the lapse of a few days renders this 
 regimen no longer necessary, the patient should be allowed a mo- 
 derate quantity of very nutritive and easily digestible food; for it 
 would be not only useless, but dangerous to prolong the low regi- 
 men, in the case of a simple fra£lure, which does not sensibly 
 disturb the functions, and which requires for its consolidation, a 
 degree of vital energy in the solids, which a too sparing diet would 
 enfeeble. 
 
 We shall not here amuse our readers with the different means 
 recommended to increase the viscidity of the blood, in. order 
 thereby to accelerate the consolidation of the frafture; but pro- 
 ceed to consider the treatment adapted to compound fraftures: 
 this treatment must vary according to the nature of the compli- 
 cation. 
 
 Under this head, we have to consider, in the first place, the 
 very difficult, but also very rare case of fra^ure accompanied 
 by luxation. When this takes place, the Itixation must have pre- 
 ceded the frafture; for a bone once fra«^bired, is no longer capa- 
 ble of luxation. The principal question is, to which of the acci- 
 dents shall we in the first place direifl our attention ? Some are of 
 opinion, that the dislocated fragment should be first replaced in 
 its natural articulation ; others, on the contrary, recommend to 
 await the consolidation of the fra£ture, before any attempt be 
 made to remedy the luxation: but we adopt, most decidedly, the 
 first opinion; for during the treatment of the fradlure, the soft 
 parts acquire a stiffness, and become so habituated, if the expres- 
 sion may be allowed, to their new situation, that the dislocation 
 cannot, without great difficulty, be remedied ; but if in order to 
 effedt it, violent eflbrts and straining are unavoidable, it will in 
 
OF THE TREAtMENT OF FRACTURES. 33 
 
 that case be better to set the fra£bire first ; and as soon as the con- 
 solidation is a little advanced, habituate the member to certain 
 gentle motions, in order to preserve the suppleness of the liga- 
 ments, which will facilitate the cure of the dislocation, when the 
 complete consolidation of the frafture allows it to be attempted. 
 
 When the soft parts of a fractured limb are violently contused, 
 but without external wound, the apparatus should not be too 
 touch braced; and Scultet's bandage should in such cases be al- 
 ways used, even though the frafture be in the superior extremity. 
 A large portion of blood should be immediately drawn, and the 
 blood-letting repeated, except the patient has the stomach full, 
 as is generally the case in hospitals; for the common people are 
 usually brought there in a state of intoxication. The bandages 
 must be taken off on the following day; this rule is without ex- 
 ception; the negleft of it has caused a mortification of the limb, 
 which takes place by the bandages becoming too tight, in conse- 
 quence of the swelling which ensues, and by the consequent 
 stoppage of the circulation. On this first removal of the banda- 
 ges, the member is generally found hard, tumefied, tense, and 
 the patient complains of great pain. In which case the fra£lured 
 part is to be covered with emollient poultices, over which the 
 proper bandage may be applied, and the splints moderately braced. 
 In cases of extreme contusion, without a wound of the integu- 
 ments, the tension and inflammatory swelling may become so in- 
 tense, as to cause the cuticle to rise in little blister-like vesicles 
 filled with a limpid serum, very different from that blackish serum 
 which fills the vesicles attendant on mortification. These vesi- 
 cles should be opened without detaching the cuticle, and the 
 small openings covered with linen on which some cerate has been 
 spread. By these simple means the surgeon has the satisfacSVion 
 of seeing the inflammation, and all its menacing consequences, 
 subside in a few days, leaving merely a slight degree of ecchymo- 
 sis, which disappears in a short time. The poultices are then 
 discontinued, the patient is allowed a nourishing diet, the splints 
 are braced to the ordinary degree, and the treatment is after- 
 wards the same as that of a simple fradture. 
 
 If a vessel of a certain magnitude is opened by a frafture, and 
 the cellular texture of the limb becomes distended by the effused 
 blood, which may be perceived by the tumefaction, and black or 
 livid colour of the Aember, the surgeon ought, without hesita- 
 tion, to make an incision in the part over the artery, and apply on 
 it t\vo ligatures, one above the other, below the wounded part. 
 J. L. Petit relates a case of a false primative aneurism, produced 
 by the laceration of the anterior tibial artery in a fratture of th» 
 5 
 
34 OF THE TREATMENT OF FRACTURES'. 
 
 leg. It is possible too, that the laceration of a vein may occasfoti! 
 an effusion of blood, easy to be mistaken for a false primitive' 
 aneurism. Such, probably, was the case of the female of Gros^ 
 Caillou, who fradtured her leg with a wound by falling from her 
 cart. In three or four days after entering the hospital De la 
 Charitey the leg swelled enormously, the skin' became of a vio- 
 lent colour, and of. a marbled appearance; and there issued from 
 the wound but a small quantity of blood. The lesion of the an- 
 terior tibial artery was suspefted ; the taking of it up was not, 
 however, attempted : the patient was bled, emollient poultices 
 were applied, and by these simple means the tension quickly di- 
 minished, and the effusion and distension vanished; a considera- 
 ble degree of ecchymosis, however, remained, which gradually 
 disappeared. 
 
 The wounds which render a fracture compound may be owing 
 to the cause of the fracture, or may be occasioned by the penetra- 
 tion of the point of one of the fragments though the integuments. 
 In the latter case, the wound should be enlarged by a bold laci^ 
 sion, and the projedting fragment pushed into its proper situation. 
 But if the projefting part be of a considerable length; if the mus- 
 cles contract spasmodically, and much exertion and straining be 
 necessary to reduce it, it would be better, in such a case, to cut 
 off a portion of the projefiing bone, Avhich would facilitate its 
 reduction, and prevent an excessive laceration of the parts. A 
 young man having the thigh fradtured,. with a p-oje£Uon of two 
 inches of the superior fragjnent stripped of its periosteum, was 
 well for two days after the forced reduction of this portion, with- 
 out having any part of it cut off; but orx the third day the limb 
 became violently inflamed, the tension and tumefadtion extreme, 
 mortification quickly followed, gained rapidly on the trunk, and 
 put an end to the patient's existence. When the fradture has 
 been reduced, as has been diredted, without too violent exer- 
 tions, the Avound is generally treated as tv simple division of the 
 integuments. Copious and repeated blood-letting obviates the 
 inflammatory symptoms so much to be apprehended. 
 
 When the wound is produced by tlie same cause as the fradture,- 
 such, for instance as the wheel of a very heavy carriage, which 
 causes much contusion, the nature and method of the treatment 
 must vary according to th« circumstances of the case. If the 
 lesion be excessive, the soft parts torn, enormously contused,, 
 and almost totally disorganized, the able and experienced prac- 
 titioner sees at the first glance if the member be inevitably lost, 
 or if mortification be certain: in which case he resolves instantly 
 on amputating, and prevents by this conduct, the mischief whicb 
 
OF THE TREATMENT OF FRACTURES. 35 
 
 Triight ensue from the gangrene, the extent of which might prove 
 fatal. It is true, that in many cases in which the loss of the 
 member was deemed inevitable, patients have preserved it by 
 their own obstinacy. We ought not however, on that account, 
 to follow the example of Van Swieten, who drawing a general 
 rule from a single fa£l, establishes it as a maxim, that amputation 
 should never be immediately performed after a fracture. In sup- 
 port of this doftrine, he cites a case of comminutive fra<5ture, in 
 which amputation was decided on, but the patient was deterred, 
 or would not submit to it. La Motte treated the patient as in less 
 extraordinary cases: he extracted several splinters, opened some 
 abscesses, and succeeded finally in efFefting a recovery, withorit 
 the loss of the limb; but Dot, however, without having experi- 
 enced a great number of disagreeable occurrences, of which this 
 surgeon has given the particulars. It is impossible to establish 
 any general rule for cases of this kind. The surgeon must be 
 directed by his own talents and sagacity in each particular case. 
 
 In most cases, if the injury be not very great, the fra6lur« 
 may be set, and the splinters, which are entirely separated from 
 Xhe bone and from the soft parts, may be extra^d; the wound 
 is then gently dressed, th« bandage of Scultet is applied, and the 
 splints are but very slightly braced. The patient is restricted to 
 the severest regimen, and copiously bled: a degree of inflamma- 
 tion equal to the extent of the evil is to be eKpe(n:ed. If, on the 
 third or fourth day, the tension become extreme, the part cold 
 and livid, with vesicles arising on it, gangrene is certain. It is 
 then necessary to wait until the progress of the gangrene is ar- 
 rested, which, however, may be anticipated by the antiphlogistic 
 regimen, and by making incisions to favour the separation. As 
 soon as the mortification is stopped, and a red inflamed circle 
 marks the boundary between the sound parts and those mortified, 
 it is necessary to ampmat^; for if the putrid sanies be absorbed 
 into the system, it vyill produce slow fever and death. 
 
 If the inflammatory swelling terminate by suppuration, as 
 most generally happens, it is apt to be very abundant. When 
 suppuration has commenced, the emollient poultices are discon- 
 tinued. The dressings are repeated as often as may be necessary, 
 to prevent the pus from retarding the consolidation by stagnating 
 on the surfaces of the broken portions. The strength of the pa- 
 tient should be supported by the most nourishing diet, and by 
 tonic medicines, such as the extra£t of bark, &c. 
 
 By this treatment it generally happens that in about a month 
 the suppuration diminishes, the lips of the wound begin to close, 
 ^nd the consolidation of the fracture advances; but a greater or 
 
^6 OF THE FORMATION OF CALLUS, 
 
 less deformity is inevitable, from the impossibility of bracing suf<» 
 ficiently the apparatus. In some cases, the suppuration conti- 
 nues, and the fragments, always immersed in pus, cannot reunite*, 
 the pus is absorbed, and the patient dies of the marasmus, to 
 which diarrhoea and colliquative sweats reduce him. In order 
 to prevent this fatal termination, it is necessary to amputate as 
 soon as it is perceived that the suppuration cannot be stopped. 
 Delay in this case would be very dangerous. 
 
 It appears, therefore frpm the principles which we have esta- 
 blished, that comminutive fra(fture, always attended with much 
 disorder of the parts, offers three distinft cases in which ampu- 
 tation is necessary; 
 
 First, When the disorder and disorganization is such as to ren- 
 der gangrene inevitable. 
 
 Secondly, When gangrene takes place in opposition to the weU 
 directed use of antiphlogistic remedies. 
 
 Thirdly, When the too abundant suppuration prevents the con- 
 solidation of the fradlure, and induces debility and hectic fever. 
 
 SECTION VI. 
 
 Of the Formation of Callus. 
 
 All that art can do in any fracture, is to maintain the frag- 
 ments in contact; their reunion and identification is the work of 
 nature alone: The different opinions on the mode in which this 
 is effected, are as follow: 
 
 The ancients attributed it to the effusion of what they called the 
 osseous juice, a fluid capable of growing hard, and contrafting strong 
 adhesions with each of the fragments, by which means it was suppo- 
 sed to join them together, as two pieces of wood are united by glue. 
 The moderns who have adopted this opinion of the ancients, 
 have said that this ossifiable humour was furnished by the vessels 
 of the bone and surrounding parts, these vessels being developed 
 by the inflammatory state.* An English surgeonf has compared 
 this secretion to that of pus in the inflammation of soft parts. 
 But in allowing the existence of this osseous juice or humour, 
 ■which, by the bye, is mere supposition (for the ancients did not 
 understand by it either the gluten extradied from bones by mean? 
 
 * See the Memoirs of Haller and Rordenave, coUedled by Faiijeroux. 
 ■)• Essays on Fraftures and Luxations, by John Aitlcin. London, 1790. 
 
OF THE FORMATION OF CALLUS. 37 
 
 of ebullition in Papin's digester, nor the phosphate of lime, which 
 fills the cells formed by this gelatinous matter;) yet would it re- 
 main to be proved how the thickening or concretion of this fluid 
 could constitute solid organized matter. By being effused be- 
 tween the fragments, this inorganized fluid should naturally in- 
 tercept or dam up the medullary canal; but that does not take 
 place, as any one may be convinced, by splitting a bone which 
 had been fra£lured and re-consolidated. Finally, this osseous hu- 
 mour should naturally, by its effusion, create tumours of greater 
 or less magnitude in the neighbourhood of the fradlure. 
 
 And, in fadt, the deformity which attends a great number of 
 fra<flures treated without method, has been attributed to the de- 
 fedlive or superabundant efiiision of this matter. Thus, say the 
 advocates of this opinion, the fraflure of the clavicle is always 
 attended with more or less deformity, because the particular po- 
 sition of that bone does not admit the application of a bandage, 
 which, as in other cases, might prevent a redundant effusion of 
 the osseous juice. The opinion of Duverney vvas different; he 
 thought that the irregular formation of the callus was owing not 
 t'j any want or defeat of bandage, but to the bone's being strip- 
 ped of its .periosteum, and wanting, therefore, the means of gi- 
 ving to the callus its just conformation. But at present it is known 
 beyond all doubt, that this irregularity of form is to be ascribed 
 to the ill setting of the fradlurc. 
 
 When the phenomena of the production of callus were ob- 
 served with more care, a more natural explanation of this opera- 
 tion was attempted. 
 
 Duhamd attributed it to the periosteum, which he considered 
 also as the organ of ossification. When a bone is fractured (says 
 that great naturalist), the periosteum of the two fragments unites 
 first; afterwards this membrane swells, and forms a kind of 
 hoop around the frafture. The periosteum thus tumefied, im- 
 bibes the humours, softens, and becomes a kind of jelly, which 
 passes quickly to the state of cartilage. Vessels are formed in 
 this cartilaginous substance; and nuclei of bone originate in se- 
 veral points, and gradually unite; and when the part of the pe- 
 riosteum adjoining the fracture is thus united, it has the appear- 
 ance of a ring, which comprehends each of the fragments, and 
 keeps them united. It was immediately objc<n:ed to Duhamel, 
 that in splitting a bone lengthwise, both fragments were found 
 united, and not in simple contact, like two pieces of wood held 
 together by a ring, agreeably to his theory. In order to answer 
 this objedlion, he supposes that the periosteum extends itself 
 from the circumference to the centre of the bone, and that this 
 
3? OF THE FORMATION OT CALLUS. 
 
 elongated part of it underwent a process similar to that of the 
 parts contiguous to the fraclure, and thus identified the two 
 pieces. 
 
 The intimate adhesion of the periosteum to the bone, and its 
 inextensibility, caused some doubts on this elongation} besides, 
 did it really take place, the medullary canal would in consequence 
 be obstructed. This theory has, for these reasons, been almost 
 universally abandoned, and has at present but few partizans. 
 
 When there happens a solution of continuity of the soft parts 
 of our bodies, if the lips of the wound be not brought into im- 
 mediate contadt, the vessels became turgi<l, the vascular tissue 
 extends forwards, and gives rise to those small red conical tu- 
 mours known by the name of granulations. This augmentation 
 in the calibre of the vessels, and a certain degree of inflamma- 
 tion in the granulations which arise from them, are means which 
 nature employs to effect the reunion of divided parts. But it is 
 not knoAvn, whether or not, in this case, the fibres of one side 
 become continuations of those of the other; if the vessels iden- 
 tify in like manner by anastomosing; or if an humour of a cer- 
 tain nature be efl:'used between the divided parts, which it agglu- 
 tinates together. The only thing certainly known on this subject 
 is, that the cicatrix is organized, as has been proved by incontest- 
 able experiments. 
 
 There is a stri£l: analogy between what takes place in the soluf 
 tion of contiuuity of soft and osseous parts. The irritation cau- 
 sed by the fradlure produces the extension and turgescence of 
 the vessels of the periosteum, of those of the bone itself, and of 
 those of the medullary membrane ; and then the only condition 
 necessary to consolidation is that the fradlured surfaces be pla- 
 ced in just contact. But this operation of nature, by which an 
 organized substance is produced, is slower in bones than in soft 
 parts, which are furnished with numerous vessels, and in which 
 the vital properties are not impeded, as in the bones, by the de- 
 position of a saline inorganized matter. In examining a hone ha- 
 ving a consolidated fraiSture, the place of the consolidation is 
 marked merely by a line; and if the bone be split, the medulla- 
 ry canal is found narrowed at that part, and in some cases totally 
 obstructed. 
 
 The production of granulations on the membrane which lines 
 the bone, accounts for this narrowing or obstruction of the me- 
 dullary canal, one or other of which takes place, according to 
 the greater or less activity of the vessels of that part. This the- 
 ory, suggested by the striking analogy between the fleshy and 
 <j.ss<ious parts, supported by observation of the phenomena of the 
 
OT THE FORMATION OF CALLUJ. J9 
 
 generation of callus in aniaials, has this further advantage over 
 all the others, that it stands uncontroverted by any h€t: on the 
 contrary, it is confirmed by all the fadts hitherto observed. Thus 
 it offers a very natural and easy explanation of the difference of 
 time required for the formation of callus in youth and old age, 
 by the different proportions of the phosphate of lime which the 
 bones contain at these periods. 
 
 The generation of callus is then an operation perfectly analo- 
 gous to the cicatrization of wounded soft parts: its being more 
 tardy is owing to the difference in the activity of the vital prin- 
 ciple in these, and in bony parts. During a few days immedi- 
 ately subsequent to a fracture, the inflammation exists only in the 
 neighbouring soft parts, and the bone seems perfedtly inert; but 
 its texture is soon after perceived to soften in that part, and the 
 fractured surfaces become covered with granulations produced by 
 the enlargement of the blood-vessels. This growth takes place 
 without any secretion of pus, and the consolidation is effedled by 
 a process as little understood as that of cicatrization. Instead of 
 pus, the enlarged vessels secrete and deposit a calcareous phos- 
 phate, which gives a solidity equal to that of the rest of the bone. 
 
 But leaving to physiologists the task of explaining the forma- 
 tion of callus, let us consider what more particularly interests us, 
 that is, the means of accelerating, retarding, or totally prevent- 
 ing it. These means or causes are either general or local: we 
 shall proceed to consider both the one and the other in detail. 
 
 The callus is formed, cateris paribus, with more promptitude 
 and facility in infancy and youth than in the adult or irr old age. 
 The younger the individual, the greater the proportion of the 
 gelatinous to the calcareous part of the bones, and the more ra- 
 pid on that account is the organization. 
 
 When the individual is extremely old, the vital principle be- 
 comes extin<ft, as it were, by the accumulation of calcareous phos- 
 phate, the enlargement of the vessels cannot take place, and con- 
 sequently the consolidation, particularly if to old age be joined a 
 vitiated state of the fluids, such as the scurvy, cancer, Sec. can- 
 not be effe<Sted : these diseases alone suflice in many cases to pro- 
 duce the same effe<St. A strong robust man of the sanguine tem- 
 perament, recovers much more rapidly from a fr-i<^ure than a 
 weak person, or one aftefted with a cachexy. The difference of 
 sex causes no difference in the generation of callus. At the pe- 
 riod, however, of the cessation of the menses in our climate, 
 that is, from the forty-fifth to the fiftieth year, its generation is 
 slower, and the cure of fractures of women of that age is subject 
 to the same irregulairities as their other diseases. 
 
40 OF THE FORMA'^IO^f OF CALLUS. 
 
 The state of pregnancy does not perceptibly retard the generd- 
 tion of callus, though Fabrice de Hilden wishes to form a conclu- 
 sion to the contrary from the observation of a few fa6ls. 
 
 However favourable the general disposition may be to the quick 
 consolidation of a frafture, different local circumstances may re- 
 tard it. If one of the fractured portions does not receive a suf- 
 ficient quantity of blood to nourish it, and to maintain in it the 
 necessary vital force, the vessels will not be enlarged, nor, of con- 
 sequence, the fracture consolidated. An instance of this is seen 
 in fraftures of the neck of the femur, in which the head of that 
 bone is completely separated from its body, and the ligament 
 which performed the funftions of periosteum, and which envelo- 
 ped the neck, is torn; so that the only vessels that enter the part 
 of the bone thus detached, are those that pass to it by the round 
 ligament; which cannot in old age, when these vessels are nearly 
 obliterated, furnish a sufficient quantity of blood for the genera- 
 tion of callus. It is necessary, then, that both fractured portions 
 be endued with a certain vital energy, without which it would be 
 as useless to attempt their union, as that of a gun-shot wound be- 
 fore the parts disorganized by the violent contusion, be separated 
 from the sound parts by suppuration. 
 
 Another local condition favourable to the formation of callus 
 is, that the surfaces of the fractured portions be brought precise- 
 ly into contact. Let us suppose, for example, a transverse frac- 
 ture of the femur, and that the fragments, after sliding one upon 
 the other, have fallen into the derangement in the length of the 
 bone, the fraflured portions cannot, in this case, touch one ano- 
 ther without the periosteum intervening. Inflammation will be 
 extremely slow; and even at the end of two months the progress 
 in the formation of callus will be scarcely perceptible. To effeft, 
 in this case, a complete cure, even with a shortening of the mem- 
 ber, will be extremely difficult. It is therefore absolutely neces- 
 sary to maintain the fradlured portions in the position in which 
 they have been set, as already prescribed. 
 
 The perfeft immobility of the fradlured portions is not less es- 
 sential to their union, than their proper contact and vitality. Ir 
 the fragments were moved every day, no progress towards a union 
 could be made; or were there fleshy granulations already formed, 
 they would be quickly obliterated by the friction, and the surfa- 
 ces would become smooth and polished. The periosteum and 
 cellular texture, distended and thickened, would form a kind of 
 -orbicular ligament round the ends of the fractured portions, and 
 an unnatural articulation would be formed, which would render 
 the member absolutely useless. 
 
OF THE FORMATION OF CALLUS. 41 
 
 When the usual period of consolidation Is past, the apparatus 
 ought to be taken o£F, and the limb examined, to see if the frac- 
 tured portions have continued in the situation in which they were 
 placed, and if the whole limb constitute but one piece. The 
 time necessary for reunion depends on several circumstances, of 
 which the principal are, the age of the patient, and the kind of 
 bone fractured. In general, fractures of the bones of the supe- 
 rior extremities are consolidated in a shorter time than those of 
 the inferior. Thus we frequently see a fra£ture of the clavicle 
 in adults consolidated in thirty days, and that of the radius and 
 cubitus In nearly the same interval; that of the humerus in from 
 about thirty-five to forty days; whereas those of the leg and thigh 
 require generally from forty to fifty days. A vulgar prejudice 
 exists on this subjedl: among the lower order of persons, who are 
 those usually brought into hospitals: they think that every frac- 
 ture ought to be consolidated in forty days exactly. But it is im- 
 possible to predldt what time may be necessary for this purpose. 
 In an infant, consolidation will take place six or eight days soon- 
 er than in an adult; and in an old man eight or ten days later. 
 
 If, on raising the apparatus, the limb be swelled, or a tumour 
 be observed In the situation of the fradlure, in consequence of 
 the ends of the fractured portions having passed one another; 
 and if, at the same time, the member, more or less shortened, 
 be moveable in that part, it will be evident that the fradlure Is 
 not consolidated, and that the apparatus has nut had its due ef- 
 fect, whether from being badly applied, or not sufiiciently exa- 
 mined from time to time. 
 
 If, instead of this sweUing, the pieces be found moveable one 
 on the other, and separated by a small interval, and the member 
 has not diminished In length, the want of consolidation proceeds, 
 in this case, either from the patient's advanced age, a vicious 
 state of the fluids and solids, or from some imprudent motions 
 of the limb during the treatment. In this latter case, if the 
 fracture has already been of some months standing, the contigu- 
 ous extremities of the fragments are worn into a rounded form 
 by the fridion, and surrounded by a species of ligament formed 
 of condensed cellular membrane, so that an unnatural articula- 
 tion Is formed at this place. 
 
 Finally, It is possible, that on taking off the apparatus, the 
 frafture may be found not to have consolidated, but with a 
 shortening and deformity of the limb. In this case it will be re- 
 quisite to adopt the following proceedings. 
 
 If the ends of the fractured portions pass one another, or if 
 the fractured surfaces are partially in contadt, or totally separated, 
 6 
 
42 OF THE FaKMATiON Of CALLUS, 
 
 it will be necessary to reset the fra£ture, and to employ continii*-' 
 ed extension, if the ordinary means be insufficient for maintain- 
 ing the fragments in their just relative situation. The duration 
 of this second treatment is at least as long as that of the first; 
 for if the natural period of consolidation b6 once past, the frac- 
 tured surfaces are no longer equally disposed to unite. 
 
 If the fractured portions continue very moveable one on the* 
 other, notwithstanding the just position has been preserved, and; 
 if the cause of this be the advanced age of the patient, the same 
 apparatus should be reapplied, and the vigour of the patient in- 
 creased by the v;ell directed use of wine and nourishing diet. 
 By persevering in these means a cure is at length effefted in the 
 space of five or six months. But if some constitutional disease, 
 such as cancer, scurvy, &c. be suspe£led of being the cause of 
 non-consolidation, these diseases must be combatted by appro- 
 priate remedies, the mechanical means persevered in, and every 
 kind of motion of the limb abstained from. 
 
 But whether the fradlured portions have passed one another, 
 or whether an articulation has been formed between the fra<ftured 
 surfaces, if the fra<fture has been already of several months du- 
 ration, the aftion of the fradlured surfaces ought to be revived 
 by rubbing them forcibly one against the other, in order to ex- 
 cite the degree of inflammation necessary for the generation of 
 callus. The fractured ends of the bones having by these means 
 acquired a disposition favourable to their agglutination, the ap- 
 paratus should be reapplied, the extension continued, if neces- 
 sary, and the treatment prolonged until the cure be complete. 
 
 If, notwithstanding these means, the pieces do not unite, 
 there remains another and last resource, the cutting off of their 
 extremities. This operation is painful, terrifying, and of dubious 
 event; its success has, however, been frequent enough to war- 
 rant the trial. It would be impracticable in fradlures of the leg 
 and fore-arm, on account of the difficulty of separating from the' 
 integuments the two bones of which each of these parts is form- 
 ed, and on account of the numerous nerves and arteries which 
 would be in danger of being wounded by the large incisions ne- 
 cessary for this operation. It is therefore pra61;ioable only in the 
 femur and humerus, especially the latter. 
 
 This operation is performed by making a longitudinal incision 
 ever the fradture, on that side of the limb where the bone is 
 most prominent and least covered; the nerves and vessels are ta 
 be avoided with the utmost care; each end of the fractured por- 
 tions is nicely laid bare, and made to project beyond the soft 
 parts, which may be protected by compresses, or by a thin plate 
 
OF THE FORMATION OF CALLUS. 43 
 
 of lead or pasteboard, from the aftion of the saw with which a 
 sufficient quantity of each fragment is to be taken ofF. This part 
 «f the operation being performed, the extremities of the fradlured 
 .portions are restored to the position which they ought to have, 
 and tlie woand dressed with soft hnt, in short, the subsequent 
 treatment is the same as tliat already prescribed in the case of 
 compound frafture; that is, Scultet's bandage is to be appUed 
 moderately tight, as well as the splints and other parts of the 
 apparatus; for beyond all doubt a violent inflanunation and copi- 
 ous suppuration will succeed. An abundant formation of puru- 
 Jent matter is disadvantageous, on account of the pus stagnating 
 in the bottom of the wound, lubricating the fra<ftured surfaces, 
 and preventing their agglutination. 
 
 Citizen Boyer has performed this operation but once; and al- 
 though he was not successful, I think it my duty to mention the 
 case. 
 
 A man, aged thirty-six, had his right arm fra£lured, and no- 
 thing was done to adjust the fraftured bone. The solution of con- 
 tinuity took place above the middle part of the humerus: this arm 
 had been for so long a time useless to the patient, that he was 
 determined to undergo any tri^l for efFefting a cure, but would 
 not listen to any proposal of amputation. This operation was 
 then resolved on: an i:icision was made over the fracture on the 
 external sidte of the arm, a little above the place where the radial 
 nerve winds on the humerus, for the purpose of saving this 
 nerve, and thus preserving from paralysis the posterior muscles 
 of the fore arm: this incision being made, he exposed the end of 
 the inferior fragment, and caused it to project by raising the el- 
 bow and pushing it inward. 
 
 The soft parts were prote£ted by means of a plate of wood, 
 and the conical or rounded part of the ends of the bone was then 
 sawed oflF. The part of the operation for the superior portions 
 was more difficult; for the conical part was longer and the point 
 sharper: one of the collateral arteries was opened, on which a 
 ligature was applied. The end being sawed off, as in the former 
 case, and with the same precautions, and both fractured portions 
 being restored to their natural direction, it was found that they 
 were separated one from the other by an interval of two inches 
 and an half. In brder to bring them into contact, the elbow was 
 raised by means of two casts of a bandage, drawn from the fore- 
 arm bent to the shoulder of the opposite side. For the two first 
 days immediately after the operation, no bad symptom took 
 place. The inflammatory swelling and tension, as well as the 
 fever, were such as might be expected from the extent of the 
 
44 OF THE FORMATION OF CALLUS. 
 
 wound. But on the third day the fever became more violent 5 
 a redness, and quickly after an erysipelas, appeared on the arm 
 of the opposite side; the inflammation extended to the shoulder, 
 and afterwards to the fractured arm. The tension was extreme; 
 instead of pus there flowed from the wound a bloody sanies^ 
 gangrene came on, and the patient died on the sixth day. 
 
 The cure obtained by this operation is necessarily attended 
 with a shortening of the member; but this inconvenience is but 
 slight with respe6l to the arm: in the thigh it is evident that 
 more or less lameness is necessarily the consequence of it. 
 
 It cannot be denied but that this operation is one of the most 
 difiicult in surgery, but it ought not to be renounced for that 
 reason, when any hope may be had of recovering by it the usie 
 of a disabled member, and when the patient wishes at all risks 
 to make the experiment. But should the patient prefer ampu- 
 tation to this cruel and uncertain chance, that operation ought t6. 
 be recurred to, when all the other resources of our art have been 
 tried in vain. 
 
 The progress of the callus to perfect consolidation is, analo- 
 gously to that of the osseous system in general, slow and gradual. 
 The patient is not, therefore, to be allowed the free use of a 
 fra^lured limb immediately after the reunion of the fracture. In 
 fraflures of the inferior extremities, crutches ought to be used 
 for some time, and the limb which had been fractured charged 
 with its share of the weight of the body, but by little and little. 
 From not paying sufficient attention to this circumstance, the 
 callus has been sometimes so much pressed, as that the limb was 
 shortened, and consequently lameness induced. Besides, the 
 slightest false step might cause a relapse of the fracture; for, not- 
 withstanding what certain authors have said to the contrary, the 
 consolidated part of a fractured bone is never stronger than the 
 other parts, nor even equally strong, until after a considerable 
 lapse of time. 
 
 To procure the reunion of the fragments without any shortening 
 of the limb, is not the sole objedt to be attended to in the treat- 
 ment of a fradture. During the time that the member is neces- 
 sarily motionless, the muscles lose the habit of motion, and grow 
 rigid, and a false anchylosis frequently follows-. This conse- 
 quence is particularly to be apprehended in fradtures which take 
 place near the articulations (as has been already mentioned), in 
 those, for instance, of the patella, of the inferior extremity of 
 the femur, of the olecranon, or of the condyles of the humerus. 
 It most frequently takes place in the articulations of the knee, el- 
 bow and instep. It may be prevented by gently moving the limb 
 
OF THE FORMATION OF CALLUS." 45 
 
 from time to time, as soon as the consolidation is so far advanced 
 as that its progress cannot be retarded by these motions. Finally, a 
 false anchylosis may be removed by general bathing, by the use 
 of the shower-bath, by resolvent plasters, and by continued and 
 gentle efforts, as shall be more fully detailed in treating of that 
 iaffeftion. 
 
 As fraiftures of the skull are more important by the necessarily 
 attendant affection of the brain than by the simple consideration 
 of the fracture, we think it most methodical to refer them to 
 wounds of the head. The same may be said of the greater part 
 of the fraftures of the bones of the upper jaw, the parts of which 
 being strongly united together, and to the bones of the skull, 
 render them susceptible only of comminutive fracture, when the 
 fra^lured part is that on which the cause has immediately afted. 
 
 Let us suppose that the wheel of a carriage rolls over a per- 
 son's head (of which the examples are but too frequent), and that 
 the zygomatic arch is thereby fractured ; in such a case the sur- 
 geon's duty would be merely to bleed the patient, and use other 
 means to combat the inflammatory symptoms. It would not be 
 prudent to make an incision into the depression of the temple, in 
 order to raise the zygomatic arch, at the risk of opening the tem- 
 poral superficial artery, and of causing much pain by the lacera- 
 tion of the nerves, except in the case that the fradtured bone 
 crushed into the crotaphyte muscle, should excite great pain and 
 other bad consequences. 
 
 If in a fra(Slure of the superior maxillary bones, there should 
 be detached from the body of one of these bones, a part of the 
 alveolar process with one or more teeth, as in the third case of Le- 
 dran's Surgical Observations, it would be necessary to follow the 
 example of this surgeon; viz. to fasten silk threads to the teeth 
 of the broken portion, which adheres still by the gum, and by 
 the internal membrane of the mouth; and then to attach these 
 threads to the teeth of the adjacent sound part, the fragment be- 
 ing first placed in its natural situation. Dentists frequently em- 
 ploy this mean for the purpose of fastening artificial teeth; and 
 its use has been advised in cases of fradlure of the lower jaw. 
 We shall give the details of the fractures of this last-mentioned 
 bone, after having first treated of those of the bones of the nose; 
 these being in this respeft the only bones of the face which me- 
 rit particular consideration. 
 
4^ 
 
 CHAPTER 11. 
 
 OF THE FRACTURES OF THE BONES OF THE NOSE. 
 
 THESE symmetrical bones, with the ascending processes of 
 the maxillary bones by which they are supported, form a 
 kind of arch. As they projeft in the middle of the face, and are 
 but slightly covered by soft parts, they are much exposed to dif- 
 ferent kinds of frafture from different causes. 
 
 In all these cases the cause of the fradlure is always applied to 
 that part immediately where the solution of continuity takes place, 
 and the fradlure may be oblique, longitudinal, or transverse, 
 without derangement of the fragments; but it more frequently 
 happens that the bones are splintered and crushed into the cavity 
 of the nostril; that the nose loses its natural form, and that the 
 neighbouring soft parts are much bruised by being crushed be- 
 tween the bones and the cause of the fradture, whether a body 
 against which the nose has been forcibly struck, or one which 
 may have been strongly impelled against it. 
 
 ■ If the soft parts have suffered no solution of continuity, an4 
 if the fragments have not been displaced, the fracture may not be 
 discovered, because the form of the nose does not change. An 
 oversight in this case is not dangerous, as the use of emollients and 
 resolvents is all that is required. If the fra£lure be comminutive, 
 not only the inflammatory symptoms ought to be combatted by 
 blood-letting and other antiphlogistic aaieans, but further, the 
 fragments ought to be replaced, as they strain and irritate the 
 soft parts, already contused, by their unnatural situation. For 
 that purpose the operator takes a grooved sound, a female cathe- 
 ter, a ringhandled forceps, or any such instrument, introduces h 
 into the nostrils, and by using it as a lever, pushes the fragments 
 outward; at the same time with the index of the left hand applied 
 to the ridge of the nose, he prevents them from being pushed out 
 too far, and from lacerating the integuments. Sometimes the 
 bones continue in the situation in which they have been thus 
 placed; but it may happen, that, from being much fraftured, and 
 badly supported by the soft parts, they fall again inwards; in 
 which case a canula of elastic gum should be directed along th^ 
 
OF THE FRACTURES OF THE BONES OF THE NOSE. 47 
 
 inferior surface of each nostril, which ought then to be stuffed 
 with lint, and gently thrust in, lest the pituitary membrane should 
 be hurt. 
 
 In cases of comminutlve frafture, with depression of the splin- 
 ters, it would be imprudent to wait the disappearance of the in- 
 flammatory symptoms, before making an attempt to raise and ad- 
 just the fragments; because, during the interval, the portions of 
 bone might reunite in an unnatural situation, and produce de- 
 formity of the nose. 
 
 Frafture of the nasal bones is sometimes attended w^ith very 
 dangerous symptoms, whether produced by a violent commotion 
 given to the head by the cause of the fradlure, or by a co- exist- 
 ing frafture of the bones of the skull; or, as some authors think, 
 by the concussion communicated to the perpendicular part of the 
 ethmoidal bone, and thence to its cribriform part, which would, 
 in that case, be fractured, on account of its great tenuity. The 
 laceration of the dura mater and its vessels, caused by the fradlure 
 of the cribriform lamella of the ethmoidal bone, would produce 
 effusion, and thus give rise to all the symptoms. It is certain 
 that cases have occurred where blows on the root of the hose have 
 produced coma, convulsions, and death; particularly when the 
 nasal bones were not fradlured. How such an injury may take 
 place may be easily conceived by the consideration of the effedl of 
 contre-coup, commotion, and other consequences which may en- 
 sue, if a great part of the percussive force be not consumed m 
 producing the fradlure. 
 
 This etiology is, however, applicable but to persons advanced in 
 age, because in youth the perpendicular part of the ethmoidal 
 bone articulates with only a very small part of the nasal bones; 
 the rest of these bones being then supported by the cartilage 
 which separates the nostrils, and with which that part of the eth- 
 moidal bone is connefted. At this last mentioned period, the 
 nasal processes of the os frontis are their principal support, and 
 ought therefore to receive the principal part of the concussion. 
 
4i 
 
 CHAPTER III. 
 
 OF THE FRACTURES OF THE LOWER JAW. 
 
 THE great mobility of this bone is the reason of its being 
 seldom fradhired. A violent blow may however fra6ture it, 
 and wound at the same time, more or less, the neighbouring soft 
 parts. It may also be fradlured by the passage of the wheel of 
 a carriage across it. An impelled force which fradtures this bone 
 tends first to increase the elliptic curve which is its natural form, 
 and that in proportion as it a£ls nearer to, or farther from the 
 angle of that bone •, so that if a succession can be admitted in the 
 rupture of the fibres, the rupture ought to commence in those 
 which are external. When on the contrary, the solution of con- 
 tinuity is the effect of a force immediately and direftly applied 
 on the part that breaks, there is no tendency to increase the na- 
 tural curve, but that part is pushed inward, and the solution of 
 continuity commences on the inside. 
 
 These fra^ures vary, first, as to the part of the bone fractured. 
 That sometimes takes place near the chin, but seldom so as to pro- 
 duce the division of the symphysis of that part, though it be not 
 impossible. At other times the fracture takes place more or less 
 near the angle of the bone. Two fra£lures may occur in it at the 
 same time, by which it would be divided into three pieces, of 
 which, that corresponding to the chin is extremely difficult to 
 manage; because many of the muscles which draw the lower jaw 
 downwards, are attached to that part. 
 
 The lower jaw is subjedt to be fra£tured, not only near the 
 symphysis, but also near the processes which terminate its branch- 
 es; that is, near the condyles and the coronoid processes. Of 
 these two parts, the condyle is that which is the more frequently 
 fra£lured, it being covered merely by the parotid gland; the co- 
 ronoid process being, on the contrary, protedled by the temporal 
 muscle, by the masseter and by the zygomatic process. 
 
 The fra£lures of the lower jaw may vary infinitely in their di- 
 reflions; be perpendicular to its basis, oblique, or longitudinal: 
 of this latter, examples have been seen, in which a portion of the 
 
OF THE FRACTURES OF THE LOWER JAW. 49 
 
 alveolar part, with the teeth implanted in it, was detached from 
 the rest of the bone. 
 
 These fraclures are seldorh simple, particularly if the frafturing 
 cause has been dire(n:ly applied. The soft parts' are always more 
 or less contused or wounded. J. L. Petit mentions an instance of 
 the complete denudation of the coronold process, in a case of 
 fradlure by a kick from a horse. 
 
 In order to form a clear idea of the different ways in which the 
 fra<5lured portions of the lower jaw may be deranged, it is neces- 
 sary to take a brief view of the muscles by which that bone is 
 moved. The temporal muscle having its convergent fibres col- 
 ledled into one parcel, descends from the temporal to the zygo- 
 matic fossa, and embraces with its inferior angle the coronoid 
 process of the lower jaw, of which it is the principal elevator. 
 The masseter descends from the zygomatic arch to the external 
 side of the branch of the lower jaw. The pterygoideus intcrnus 
 descends obliquely backward to the internal side of the same an- 
 gle: this muscle serves not dnly to raise the lower jaw', but also 
 to move it a little forward. This last motion is however, especi- 
 ally performed by the pterygoideus externus, which, passing ob- 
 liquely outward and backward, embraces the neck, ot* narrowed 
 part which supports the condyle. 
 
 The muscles which draw down the lower jaw, ire attached to 
 the body of that bone, and especially to the process at the chin. 
 The greater part of these muscles come from the os hyoides. • 
 Those attached to it are the platysma myoides, the digastrici, the 
 niylo-hyoidei, the genio-hyoidei, and the genio glossi. 
 
 Let us see in the next place, how these different muscles con- 
 tribute to produce the derangement of the fractured portions. If 
 the frafture be near the symphysis, on Which is the processus in- 
 nominatus, that side to which this process belongs, is drawn 
 downward and backward by the submaxillary muscles, and even 
 by those which extend from the clavicle and sternum, to the os 
 hyoides, while the other fragment is supported by the levator 
 muscles-, if the fradture be more backward toward the branches, 
 the derangement takes place in the same manner, but with a lit- 
 tle more difficulty. In the double fraiSlures, the middle portion is 
 perpetually drawn downward and backward by the muscles which 
 are attached to the process at the chin, whilst the two lateral are 
 supported by the levator-muscles. 
 
 If the branch be the part fradtured, any considerable degree 
 of derangement is prevented by the masseter which is attached 
 to each of the fractured portions. If the neck of the condyle be 
 7 
 
^O OF THE FRACTURES OF THE LOWER JAW. 
 
 the part fra(Stured, the condyle will be drawn forward by the 
 adlion of the pterygoideus externus. 
 
 All these different derangements, except the last, take place 
 in the same line as that which passes from the teeth to the basis 
 of the bone. The fradlured portions are never deranged so as 
 that one passes on the other, or in the direction of their length; 
 for the action of none of the muscles of the lower jaw is parallel 
 to the axis of that bone: besides, its extremities are retained in 
 the glenoidal cavities of the temporal bones. 
 
 When a blow is received on the lower jaw, or the bone is in- . 
 jured by a fall on that part, or by the pressure of some heavy bo- 
 dy, and at the same time an acute pain is felt in the part; and 
 when, with these circumstances, an inequality is found at the ba- 
 sis of that bone by moving the fingers along it; when some of 
 the teeth, corresponding to that inequality, are found to have 
 lost their level, one being lower than the other; and when, be- 
 sides, by seizing these apparently deranged parts, one in each 
 hand, and impelling them in opposite directions, a mobility and 
 crepitation are perceived, there can be no doubt as to the exist- 
 ence of a frafture; although there be no denudation of the bone 
 by wound, nor any laceration of the gums; circumstances, how- 
 ever, which would render the fradture still more evident. 
 
 The fradlures of the branches and condyles are not so easily 
 distinguished as those of the body of the bone. Yet t}xe acute 
 {lain which the patient feels in the region of the ear, especially 
 when he moves the jaw, the crepitation produced by these mo- 
 tions, or by pressure on the condyle, are sufficient evidence of 
 its existence; if an inflammatory swelling has not taken place be- 
 fore the surgeon has been called in. In that case, the diagnosis 
 cannot be established, until, by the lapse of a few days, by bleed- 
 ing, poultices, and regimen, the tumour has been dissipated. 
 
 Fra6ture of the lower jaw is in general not very dangerous. 
 When simple, it would get well spontaneously; but there would 
 be, it is true, some deformity, which it is the surgeon's duty to 
 prevent. 
 
 Compound fractures of the lower jaw are more dangerous; and 
 if the nerve which goes to the teeth, be torn, which rarely hap- 
 pens, because the greater part of these fradtures take place between 
 the symphysis and the foramen by which this nerve comes out 
 from the conduit through which it runs in the substance of the 
 bone, the square and triangular muscles of the chin are paralysed. 
 The skin of that part and the internal membrane of the under 
 lip preserve their sensibiUty, which it appears they owe to some 
 
I 
 
 OF THE FRACTURES OF THE LOWER JAW. ^l 
 
 threads of the portio dura of the seventh pair; but the paralysis 
 of these muscles does not prove of itself that the jaw is fradtured 
 
 In order to set afra^ure simple or double of the lovv^er jaw, it 
 suffices to push the deranged part upward and a little forward, and 
 afterwards, by pressing on the basis of the bone, to bring it ex- 
 actly on a level with the portion which has preserved its natural 
 position; which may be done by bringing all the teeth of the 
 lower jaw into close contact with those of the upper. But the 
 facility of setting this fradlure is more than counterbalanced by 
 the difficulty of maintaining it set. Different means of accom- 
 plishing this purpose have been proposed; but those alone a£t ef- 
 ficaciously which keep both jaws together, by supporting the lovrcr 
 jaw, and keeping it applied to the superior or upper jaw. 
 
 All other means would be useless, if the jaw were not kept per- 
 feftly motionless. And this immobility is extremely difficult to 
 be obtained, on account of the motions induced by mastication, 
 deglutition, and speech; but which ought to be suspended for a 
 time. For the two or three first days the patient should be re- 
 strained to a very small quantity of food and nourished afterwards 
 with broths, which may be given by introducing a small spoon 
 between the teeth a little separated. If he should happen to 
 want a tooth, that will be a fortunate circumstance on this occa- 
 sion, because broths may be given through the opening by 
 means of a canula, without causing the least motion to the frac- 
 tured bone. If the patient be unmanageable, and insist on eat- 
 ing or speaking, in opposition to the surgeon's advice, the forma- 
 tion of the callus will be slow, and the cure difficult, and inevi- 
 tably attended with deformity. An opening might also be pre- 
 served by introducing two pieces of cork, one on each side be- 
 tween the teeth. 
 
 It has been proposed to tie the two pieces together by means of 
 a gold or silver wire, passed from some of the teeth on one side 
 of the fracture, to those adjacent on the other side. But exclu- 
 sively of this being very difficult, and even impossible in persons 
 who have the teeth very close set, the wire could only prevent the 
 longitudinal derangement. But we have already shewn that the 
 fractured portions have no tendency to derangement in that direc- 
 tion, and consequently, that this expedient could be of use only 
 in case of a part of the alveolar process being detached from the 
 rest of the bone. 
 
 Some pradlitioners have made use of a pasteboard mould, com- 
 posed of a semicircular piece, excavated for the purpose of recei- 
 ving the neck: This piece is placed horizontally, with its convex 
 edge projedting a little beyond the basis of the lower jaw. Ano- 
 
52 OF THE FRACTURES OF THE LOWER JAW, 
 
 ther piece, of about an inch in breadth, is placed so as to extend 
 from one angle of the jaw bone to the other, having its under 
 edge corresponding to the outer edge of the other, and its upper 
 edge on a level ^yith the under lip. Both these pieces are moi- 
 stened with a resolvent liquid, which renders them flexible and 
 more easily adapted to the form of the jaw. On these pieces are 
 placed compresses, also moistened with a resolvent liquid, and a 
 chin bandage is applied over all. Although the pasteboard, on 
 being dry, constitutes a kind of mould, in which the lower jaw 
 is contained, yet as it a6ls on the fra<fture only as it is afted on by 
 the bandages, and as it injures by its hardness the soft parts 
 on which it presses, it has been abandoned. 
 
 If the fradlure be simple, the operator will commence by apr 
 plying two bands externally, of three fingers breadth each: one 
 of these is to be passed under the chin, and fastened on the top 
 of the head to the patient's cap-, the other is to be applied imme- 
 diately to the chin and jaw, and fastened at the occiput; after 
 which the chin bandage is applied; this bandage must be so long 
 as that the two ends of it may cross on the top of the head, and 
 broad enough to extend from the lip to the middle point between 
 the chin and the neck. The extremities of this bandage are split 
 to near the middle part, in which a hole is made to receive the 
 chin, and two ends are knotted on the top of the head, and the 
 other two on the occiput. For greater security, two bandages of 
 this construction might be applied; but if the patient be perverse, 
 and the fracture double, it will be necessary to apply the double 
 chevestrcy which is more easily done than described. 
 
 Fra£lure of the condyles requires the following modification of 
 the apparatus. As that process is incessantly drawn forward by 
 the ptcrygoideus externus, it would be necessary to push it back; 
 but being so short, and situated so deeply it cannot be adted on 
 but with great difHculty; for which reason the lower portion must, 
 if possible, be pushed into contact with the condyle, which may 
 be done by making the chevestre aft on the angle, and aiding its 
 adlion by means of a thick and graduated compress placed on that 
 angle. It is almost needless to remark, that if both condyles be 
 fractured, the double chevestre ought to be employed ; in this 
 case the parts are with difHculty kept in their situation; the ap- 
 paratus ought therefore to be often examined, and reapplied fre- 
 quently. 
 
 It is particularly important in fractures of the condyles to ob- 
 tain a cure without deformity, because the motion of the bone 
 would be afTefted by any deformity that would remain. If the 
 
OF THE FRACTURES OF THE LOWER JAW, 5^ 
 
 patient insists on eating or speaking during the treatment, it is 
 probable that there will be no reunion, that the condyle will ex- 
 joliate, and be cast out through a fistulous opening. Thus a cart- 
 er, who quitted the hospital De la Charite, after being three 
 months a patient in it, but without being perfectly cured of a 
 double fracture of thelower jaw, one near the middle part, the 
 Other near the right condyle, returned after an absence of seven 
 or eight months to Citizen Boyer, who extrafted from a fistula, 
 in the external conduit of the ear, a bony mass, which had evi- 
 dently the form of the condyle. 
 
 When at the end of fifteen or twenty days, the pieces begin 
 to unite, soft food maybe given to the patient, instead of broths; 
 and according as the solidity augments, the consistence of the 
 food may be increased. The cure will be complete between the 
 thirtieth and thirty-fifth day, if nothing interrupts its natural 
 progress. 
 
 After what we have already said on compound fi*a£tures, in 
 treating of fractures in general, it is unnecessary to repeat here 
 particularly what is there related, and which may be so easily 
 applied to the fi-a£lure of the lower jaw, attended with vio- 
 lent contusion, or a division of the soft parts covering it. It 
 may be remembered, however, that this bone frequently exfoli- 
 ates, when the frafture is accompanied with a wound, and that 
 the cure is on that account much more tedious. 
 
54 
 
 CHAPTER IV. 
 
 OF THE FRACTURES OF THE VERTEBRA. 
 
 THE bones which compose the spine are seldom fradlured, 
 because, hke otlier short bones, they resist any violence 
 that might be appUed to them, by the equahty of their three di- 
 mensions. If any great force be appUed to the vertebral column, 
 it is apter to lacerate the intervertebral cartilages, or to separate 
 them from the vertebrae, than to fradture these bones: they may 
 however, be fradtured in the very part against which the force 
 has been immediately applied. The spinal processes which pro-, 
 je6t from the body of the bones is the part most liable to be frac- 
 tured, because it is that which is weakest and the most superfici- 
 ally situated. But it seldom happens that the fracture is limited 
 to a single vertebra-, several of them are generally fractured at 
 once, and the spinal marrow suffers at the same time a commo- 
 tion or contusion to a greater or less degree: and much less dan- 
 ger is to be apprehended from the fracture, than from the lesion 
 of that substance. In fadt, every cause that will fradtuire the ver- 
 tebrae, must give a commotion to the spinal marrow. 
 
 It is thus that this substance suffers from a fall on the back 
 from an elevated situation, or from the aclion of a bullet, which 
 strikes against the vertebrae after having penetrated through the 
 soft parts: the displaced pieces of the fractured bones might in 
 such cases press on that substance, or the fractured splinters might 
 penetrate into it after having pierced the dura mater and its other 
 tunics. The laceration of its vessels might also produce an effu- 
 sion, which by its pressure would, as effectually as any other 
 cause, produce a paralysis of the organs whose nerves proceed 
 from the parts of the spinal marrow below the fracSture. 
 
 The variety of causes which may give rise to symptoms analo- 
 gous to those of frafture of the vertebrje, render it difficult to 
 establish a diagnosis. Yet, when a person has fallen on his back 
 from an elevated situation, or when a body very forcibly impel- 
 led, as a bullet discharged from a musket, has struck that part, 
 if a fradture has taken place, some derangement of the spinal 
 process of the fractured vertebra may be observed, by an atten- 
 \ 
 
OF THE FRACTURES OF THE VERTEBRA. ^^ 
 
 tive examination of the part affefted. Much pain is caused by 
 pressing on that process-, the inferior extremities are paralysed, 
 as also the redlum and bladder; the patient is afflided with a re- 
 tention of urine and faces, or with an involuntary discharge of 
 the latter. 
 
 A sack of flour, weighing 300 tbs. fell on the back of the neck 
 of a porter of the corn-hall, in a, moment that he was off his 
 guard, and laid him prostrate. He complained of a very acute 
 pain in the neck; and on being conveyed to La Charite, it was 
 found that the spinal process of the seventh vertebra of the neck 
 was more prominent than it naturally is. The superior and infe- 
 rior extremities were paralytic, respiration became difficult, the 
 bladder and reftum ceased to perform their fun<Slions, and the 
 patient was suddenly cut off. On opening the body, a fratSture 
 of the seventh vertebra was found, with derangement of a frag- 
 ment which compressed the spinal marrow. 
 
 The three following cases, of which the two first, like the 
 foregoing, have been observed at Ln Charke, prove that the 
 commotion or violent distention of the spine can produce the same 
 symptoms as a fracture' of the vertebrse. 
 
 A hosier fell into a shallow ditch on his loins; the commotion 
 was sulScient to produce a paralysis of the inferior extremities. 
 After his death, which followed from the fall, no disorganization 
 could be perceived, nor any effusion either in the cranium or 
 vertebral canal. 
 
 A builder fell from a height of fourteen feet, and remained 
 for sometime senseless; and, on recovering from that situation, 
 found that he had lost the use of his inferior extremities. He had 
 at the same time a retention of urine, an involuntary discharge 
 of the fieces, and some disorder in the function of respiration. 
 Death followed on the twelfth day after the accident; the body 
 was opened, and the vertebral canal was found to contain a san- 
 guineous serum, the quantity of which was sufficient to fill a lit- 
 tle more than its lower half. 
 
 A man excerclsing himself at feats of activity, distended so 
 much the intervertebral ligaments, that he was instantly seized 
 with an acute pain in the part so distended, by the strained pos- 
 ture which he had assumed: the next day, the inferior extremi- 
 ties, the bladder, and reilum, were paralytic, and the patient 
 died in a few weeks. 
 
 This paralysis of the inferior extremities, the necessary con- 
 comitant of fradlure of the vertebrae, and of any lesion of the 
 medulla spinalis, is not, in itself, a mortal affeftion; but the pa- 
 tient, losing the power of loco-motion, and being obliged to 1^ 
 
56 OF THE FRACTURES OF THE VEiLTE^AM* 
 
 perpetually on his back, soon feels a troublesome itching in the 
 region of the sacrum, on which the pressure of the body is prin- 
 cipally concentrated; the skin of this part becomes inflamed, and 
 gangrene ensues to a greater or less degree, because the pressure 
 on that part intercepts the course of the humours. The bone is 
 quickly denuded, the ulcer extends rapidly, and consumes the 
 patient's strength; the dissolution is accelerated by the retention 
 of the excrements from the paralysis of the redlum and bladder. 
 The catheter, which must be introduced into this latter organ for 
 the purpose of evacuating the urine, gives admission to the airj 
 its mucous secretion becomes more abundant, and its substance 
 thickened ; a slimy matter flows out with the urine, and the pe- 
 nis and scrotum become oedematous, &c. A slow fever succeeds 
 these symptoms; and the patient, however robust he maybe, falls 
 in a few weeks. We have known, however, a man of a very vi 
 gorous constitution, to have survived for six months an accident 
 of this nature. Examples of recovery are recorded, but they are 
 extremely rare, and to be ascribed to the secret operations of 
 nature, rather than to the efforts of art; and we repeat, that 
 scarcely one in thirty recovers. Almost all die from the ex- 
 haustion of their strengh, by slow fever, colliquative diarrhoea, &c. 
 
 Any attempt at setting these fraiStures, would be not only use- 
 less, but dangerous, by the straining which it would occasion. 
 General treatment alone can be had recourse to; the inflamma- 
 tion and obstruction of the part affedled may be moderated by 
 cupping and scarification. 
 
 If the patient be afl^e£led with a flatulent distension of the abi^ 
 domen, vomiting, hiccup, .and other symptoms of that nature, 
 the abdomen may be rubbed with a solution of two drachms of 
 camphire, in a sufficient quantity of oil; purgative clysters may 
 be also given, and antispasmodic medicines. A catheter should 
 be allowed to remain in the bladder, with its external orifice 
 corked, in order that the patient's bed may not be wet: the ul- 
 cerations of the sacrum are to be dressed simply with pieces c( 
 linen covered with cerate. If the gangrenous eschar comes ofi^, 
 styrax ointment ought to be applied; and if the patient be fortu- 
 nate enough to recover the use of the bladder, rectum, and in- 
 ferior extremities, this return of the natural forces may be aided 
 by friiftions with tinilure of cintharldes, on the course of the 
 nerves of the paralytic organs; and as soon as the patient is able 
 to ride, or even walk with the aid of crutches, he will find it 
 beneficial to drink the sulphureous waters of Bourbon or Bare- 
 ges. 
 
OF THE FRACTURES OF THE STERNUM. 57 
 
 Such is the treatment in cases of fradlure of the spine. 
 Some authors recommend trepanning or cutting out a portion 
 of the fra(ftured bone, when the compression of the spinal 
 marrow by effused fluid, or its disorganization by the a(ftion of 
 a spUnter, is suspected ; but exclusively of the difficulty of that 
 operation, on account of the great depth of the intermediate 
 soft parts, the indication is never sufficiently evident to autho- 
 rise it. 
 
 If a fracture of the vertebrae, or an afFedlion of the spinal 
 marrow, take place in the neck, death follows rapidly. This 
 effeft is instantaneous, if the lesion be as high as the origin of 
 the cervical nerves, which convey nervous energy to the dia- 
 phragm; for that organ being for the most part supplied by 
 these nerves, is deprived of the power of motion, by any 
 considerable lesion ~of them. 
 
 The lesion of the fourth and fifth cervical pair of nerves by 
 fra£ture, supposes that accident to have taken place in the 
 third vertebra; because the vertebral nerves originate a little 
 higher than the hole by which they pass out of the vertebral 
 canal. 
 
 CHAPTER V. 
 
 OF THE FRACTURES OF THE STERNUM. 
 
 THE position of this bone, supported laterally by the flex- 
 ible cartilages of the ribs, the great number of pieces of 
 which it consists, unless in old age, its thickness, and spongy 
 texture, co-operate in securing it against fractures. It may, 
 however, be fra<Slured, and in two different ways. The frac- 
 ture takes place generally on the part where the force is imme- 
 diately applied; but it may be occasioned by an extention, ope- 
 rating on both extremities of the bone. 
 
 David has cited (from a memoir on contrecoupSy published 
 under the name of Basile, among the prize essays of the aca- 
 demy) the case of a mason, who, in falling from a great height, 
 struck against a cross-bar which intercepted his fall; and on 
 8 
 
58 OF THE FRACTURES OF THE STERNUM. 
 
 v^hich the trunk was so extended, that the sternum was rup- 
 tured transversely by the violent adtion of the abdominal and 
 the sterno-cleido-mastoidei muscles. In cases of this nature, 
 very rare it is true, the fradture must be simple, and without 
 derangement of the fragments, or affedlion of the soft parts. 
 But in those produced by the immediate aftion of an external 
 cause, the soft parts are necessarily affecHied, and the fractured 
 portions may be impelled into the mediastinum, and cellular 
 texture, so as to wound the pericardium, heart, or lungs. 
 
 Solutions of continuity of the sternum, like those of the 
 cranium, are attended with a greater or less effusion of blood, 
 mingled with a medullary substance, which is very abundant 
 in the sternum j but the consequences of this effusion are very 
 different in the two cases. The slightest effusion within the 
 cranium, gives rise to the most alarming symptoms, and causes 
 sometimes the death of the patientj but in this case, on the 
 contrary, however abundant that effusion may be, it seldom 
 occasions dangerous symptoms. The heart and lungs being 
 composed of a substance less delicate and less compressible than 
 the brain, suffer little or no inconvenience from this effusion: 
 besides, the capacity of the thorax is variable, and may on 
 that account accommodate itself to an unusual quantity of 
 fluid. 
 
 A simple fradhire is ascertained by the mobility of the 
 "pieces: that which is compounded with contusion, wound, ef- 
 fusion of blood, or by the splinters being thrust inward, is 
 easily known by simple inspeftion of the part. 
 
 A simple fra£lure of the sternum requires no other treat- 
 ment than the application of compresses, repose, and a proper 
 position, that is, on the back, with the head and pelvis raised; 
 so that the muscles already mentioned, which are attached to 
 its extremities, may be in a relaxed state. But in cases (which 
 are much more frequent) of frafture, with contusion, wound, 
 or penetration of splinters into the mediastinum, the patient 
 should be bled, and confined to a low regimen; poultices 
 should be applied; and the necessary incisions made for ex- 
 tradVing th6 splinters from the mediastinum, or for giving issue 
 to the effused fluids. It is but very seldom necessary to tre- 
 pan the sternum for either of these purposes ; and that opera- 
 tion becomes necessary only when that part of the sternum 
 which has been denuded, becomes affefled with caries, the fis- 
 tula proceeding from which would be incurable by any other 
 means. Then a transverse or crucial incision should be 
 
OF THE FRACTURES OF THE RIBS. 59 
 
 made on the part where the probe points out the course of the 
 fistula. The part affected ought to be laid entirely bare, and 
 completely removed, by a single or repeated application of the 
 instrument, according as it happens to be more or less exten- 
 sive. The instrument ought to be precisely the same as that 
 used for the head, and applied with all possible care, lest, by 
 pressing on it too much, it should be driven into the thorax, 
 particularly as the sternum, naturally capable of making no 
 great resistance, is then less so in consequence of the caries. 
 
 The appendix xyphoides is not susceptible of derangement 
 backward 5 for, though violently struck and driven backward 
 by a blow on what is vulgarly termed " the pit of the stomach," 
 yet it restores itself by its own elasticity. It may be fractured 
 in aged persons, as it is then ossified; but even in that case the 
 remedies are resolvents and emollients, according to the degree 
 of contusion. However, as the organs contained in the epi- 
 gastric region may have suffered from the same cause that pro- 
 duces the fracture, it might be prudent to draw blood in pro- 
 portion to the patients strength, and to confine him for a few 
 days to the antiphlogistic regimen. 
 
 CHAPTER VI. 
 
 OF FRACTURES OF THE RIBS. 
 
 THE ribs are placed obliquely on each side of the thorax, 
 and terminate in a cartilaginous substance, by means of 
 which they articulate with the sternum. This oblique direc- 
 tion, and the cartilaginous termination, render them but little 
 liable to fractures. Some, however, are more exposed to frac- 
 tures than others; thus the first, or superior, being protected 
 by the bones of the shoulder, and by the arm itself, when it 
 hangs by the side, and the lower on account of their great 
 flexibility, are less liable to be fraflured than the middle ones. 
 Fractures of the ribs differ from one another by the part of 
 the bone in which the frafture takes place, by the direction of 
 the fra<rture, and by the cause, or its way of adting. 
 
60 OF THE FRACTURES OF THE RIBS. 
 
 Fra<^ures of the ribs happen generally near the middle of 
 the bone; and this is the case, whether one or more of them 
 be fradtured at the same time. The fradture is sometimes 
 transverse, at other times oblique; in which case the fracStu- 
 red portions may penetrate the skin or pleura, according to the 
 diredlion they take. 
 
 As the cause of fradkures of the ribs may a£l either on their 
 opposite extremities, or on their middle part, a distinction of 
 them has been made into fraiStures inwards or outwards. In 
 the latter, both extremities of the rib are at the same time 
 bent towards one another, so that the convexity of the rib is 
 increased, and the fraflure is efFe£led when its natural extensi- 
 bility is exceeded. This frafture is not without some reason 
 termed outward; for it may be easily conceived that the exter- 
 nal fibres are the first ruptured, and that there is a succession 
 from the external to the internal side, although the fradlure be 
 efFe(fted almost instantaneously. This species of fracture is 
 sometimes observed from the body being violently pressed be- 
 tween a wall against which the back is supported, and a wheel 
 of a carriage which presses on the anterior part of the breast. 
 
 The fradlure inwards is caused by a body strongly impelleci 
 against the middle and convex part of the nb; or when, in 
 falling, that part strikes against a hard unyielding body; in 
 which case the frafturing cause tends to straighten the rib, and 
 consequently the fracture commences internally. 
 
 In whatever manner the fracture is produced, it may be 
 complicated with contusion or external wound. The sloped 
 and pointed pieces of broken bone directed internally, may, 
 by lacerating the pleura and substance of the lungs, give rise 
 to emphysema. 
 
 Fractures of the ribs are indicated by an acute pain felt in 
 breathing. However, the part should be carefully exami- 
 ned, by pressing the posterior part of the rib inward, and 
 the anterior backward, and by thus ascertaining if there ex- 
 ists in that part anjr unnatural motion, or if any crepitation 
 can be produced. In fractures of the ribs the derangement 
 cannot take place either in the dire<5tion of the diameter of 
 the bone, nor in that of its axis or length. The ribs being 
 fixed posteriorly to the spine, and anteriorly to the sternum, 
 cannot shorten, as the interval between these fixed extremi- 
 ties is invariable. Neither can the derangement take place by 
 one of the broken pieces becoming higher or lower than the 
 other, because the same muscles are attached to both frag- 
 
OF THE FRACTURES OF THE RIBS. 6l 
 
 ments, and keep them at the same distance from the neigh- 
 bouring ribs. The only derangement possible is the angular, 
 which may be salient internally or externally, according as the 
 fradture is in one or other of these diredlions. Experiments 
 made on the dead subjedl, confirmed the reasoning used in 
 this case. 
 
 Having taken off the muscles which cover the thorax, I 
 fractured the true ribs by placing a great weight on the ster- 
 num, the body being laid on its back. This fradlure was not 
 attended with any derangement. If the weight on the ster- 
 num was increased, or the sides of the thorax pushed forci- 
 bly downward, the moveable pieces were not thereby displa- 
 ced, but merely compelled to form with their contiguous ex- 
 tremities a salient angle externally. This angle was salient 
 internally, in a subjeft the ribs of which were broken by a 
 violent blow of a hammer on the middle part. Whether the 
 projection was internal or external, it might be effaced by 
 merely distending the cavity of the thorax as in inspiration.* 
 
 The derangement cannot then take place, unless the mus- 
 cles be torn by the violence of the blow which caused the frac- 
 ture, and a portion of the rib completely detached. 
 
 When one or more ribs are affefted with simple fracture, it 
 will be necessary merely to apply on the fracStured part com- 
 presses moistened with a resolvent fluid; vvhich compresses 
 may be kept on by means of a bandage placed round the body, 
 and drawn tight enough to impede the motion of the ribs, and 
 to compel the patient to perform respiration chiefly by the 
 descent and elevation of the diaphragm.. When the fra^lure 
 is outward, the compresses should be pretty thick, in order to 
 i-epress the salient angle. When it is inward, they should be 
 applied on the extremities of the rib or ribs, in order to force 
 outward the fraftured ends which have a tendency to point in- 
 wards towards the lungs. The bandage round the body is pre- 
 vented from falling downwards by means of a seapulary band- 
 age. 
 
 When the apparatus does not confine the ribs sufficiently, 
 and in consequence the fradlured parts move and give pain in 
 the a6l of respiration, the quadriga ought to be applied in its 
 stead. This bandage commences by a stellated cross on the 
 shoulder, and it is then made to descend on the thorax in folds; 
 that is, each succeeding roll covering a part of the preceding. 
 
 * Memoirs of the Society of Medical EmuLtlon, vol. iii. page 159. 
 
62 OF FRACTURES OF THE RIBS. 
 
 In order to render it more secure, it may be fastened with pins 
 in different places. It is seldom necessary to raise the apparatus 
 in order to view the state of the parts underneath, as the ec- 
 chymosis disappears of itself in a very few days. 
 
 When the violence has been considerable, and the lungs have 
 been contused or lacerated by the pieces of bone, the patient 
 suffers much pain, has acute fever, thirst, and difficulty of 
 breathing; in short, all the symptoms of an inflammation of 
 the lungs. In this case the treatment ought to be the same as 
 in pneumonia; among the remedies for which, copious and re- 
 peated bleedings hold the first rank. 
 
 With respe£t to the emphysema, which is the name given 
 to a tumour formed by the admission of air into the cellular 
 texture, it may be produced by a fracflure of the ribs in the 
 following manner. Let us suppose that a pointed piece of bone, 
 impelled into the thorax, lacerates the pleura, and vesicular 
 texture of the lungs, and that the air which escapes through 
 the lungs in the aft of inspiration is received between them and 
 the pleura in the cavity of the thorax. In the succeeding ex- 
 piration, the cavity of the thorax becomes diminished ; the air 
 contained in it being compressed, endeavours to escape by the 
 part where it finds least resistance, that is, by the wound of 
 the pleura; but as there may exist no external wound in the 
 thorax, or even, though there did, should it be narrow and 
 sinuous, the air could not escape externally; it must therefore, 
 make its way into the neighbouring cellular texture, which it 
 distends and tumefies. This effect of a single inspiration and 
 expiration, is increased by a second, a third, &c. to the degree 
 that the air may pervade the cellular texture of the whole body, 
 except the palms of the hands and soles of the feet ; because 
 in these parts certain ligamentous processes unite the integu- 
 ments so closely to the subjacent aponeurosis, that the in- 
 terjacent cellular texture cannot admit the air. A case of 
 emphysema has been observed, in which the whole body 
 had acquired a most enormous volume: the anterior side of 
 the thorax was eleven inches deep. If something be not 
 done to stop the progress of the emphysema, the air, after 
 having filled the cellular texture under the skin, makes its 
 way along the vessels into the substance of the viscera, the 
 forms and funftions of which it deranges, and in a short time 
 destroys life. Happily this accident rarely succeeds to a frac- 
 ture of the ribs. Citizen Boyer has seen only one example of 
 it, which was that of a labourer, who received his death from 
 the explosion of the powder-mills of Crenelle in 1793. Le-r 
 
OF THE FRACTURES OF THE RIBS. 6^ 
 
 dran, in his 24th Surgical Observation, makes mention of the 
 case of a coachman, in whom a fra^lure of the fifth true rib, in 
 consequence of a kick from a horse, was followed by an em- 
 physema, in which the integuments were inflated to the depth 
 of four inches. 
 
 In cases of this nature, it is necessary to follow the example 
 of that able pra<fi:itionerj that is, to apply pyramidal compresses 
 on the part where the emphysema commences ; the compresses 
 should be impregnated with some resolvent liquid, and braced 
 according as the tumour collapses. 
 
 If the emphysema, already far advanced, be still making 
 progress, it will be necessary to make an incision into that side 
 of the thorax where the fracSture of the ribs, with lesion of 
 the pleura and lungs, was suspe(n;ed: the air, finding free egress 
 though this wound, will no longer pass into the cellular texture. 
 The validity of this precept will be rendered evident, by con- 
 sidering that emphysema never follows large incised wounds of 
 the thorax; and that, on the contrary, it is frequently compli- 
 cated with narrow and oblique wounds made by a pointed in- 
 strument, such as a small sword. 
 
 Whatever means be adopted for arresting the progress of the 
 emphysema, the air which has already passed into the cellular 
 texture, loses its elasticity; its component parts combine with 
 the fat and lymph contained in the cellular substance, and the 
 tumefied parts return gradually to their former size. This ter- 
 mination of the disease may be accelerated a little by making 
 incisions in different parts of the body, and applying resolvents 
 over them. 
 
 The cartilages of the ribs cannot be broken before they are 
 ossified. As long as they retain their cartilaginous stru(Sture, 
 and remain supple and flexible, though they may be bent in 
 towards the lungs, yet, being eminently elastic, they return 
 to their natural shape as soon the external force is removed. 
 Nothing, then, can be more ridiculous, nothing more dange- 
 rous than the absurd pradlice of bone-setters for raising what 
 they call " depressed ribs." Their greasy and irritating plasters 
 ought also to be proscribed; for such topical applications can 
 only irritate the skin, excite an erysipelatous inflammation, 
 augment the pain which the contusion produces; and, by inspi- 
 ring a false security, cause the consequences of the affection to 
 be neglefted. When the ossified cartilages are fractured in an 
 old person, the treatment is the same as that for a fra^re of 
 any other part of the rib. 
 
64 
 
 CHAPTER VII. 
 OF FRACTURES OF THE BONES OF THE PELVIS. 
 
 SECTION I. 
 
 Of Fractures of the Sacrum, 
 
 THIS bone is not much exposed to be fra£lured: it is thick 
 and of a spongy texture, deeply situated, and covered by 
 a great depth of soft parts, which deaden any force that tends 
 to fracture it by afting on its great diameter, or transmit that 
 force to the ossa innominata, between which it is fixed as a 
 wedge. Some powerful cause, such as the fall of a very heavy 
 body, or the passage of a carriage-wheel on the convex side of 
 that bone, can alone fradlure it: it may be also fradtured by a 
 fall on the same part from a great height. Thus we find that 
 these fradlures of it, which may have different directions, and 
 exist in difi^erent parts, are always produced by a force which 
 has crushed the bone. No muscle tends to derange by its con- 
 tractions the position of the broken portions; and the fradtures 
 are, therefore, dangerous only by the contusion which the 
 parts contained in the pelvis may suffer; and which, by produ- 
 cing effusion of blood, inflammation, and abscesses, may de- 
 stroy the patient. 
 
 The treatment of these fra£bures consist simply in tying a 
 napkin round the pelvis, an emollient poultice being previously 
 applied on the fradtured part. Inflammation, and its concomi- 
 tants, are prevented by bleeding, low diet, and other means, 
 of which mention shall be made in treating of fradlures of the 
 ossa innominata. 
 
OF FRACTURES OF THE OS COCCyOIS, 65 
 
 SECTION II. 
 
 » Of FraElures of the Os Coccygis. 
 
 This little bone, though much slighter than the sacrum, is, 
 however, not so often fradlured, because it offers no point on 
 which an external force can a6t with advantage -, and because, 
 by its mobility, it can yield to any impelled force, and return 
 again to its natural position. 
 
 When it is fradlured, as by a fall on. the buttocks, the pain 
 which ensues, and which augments by walking, indicates the 
 existence of the fracture. Some fibres of the glutsei are attach- 
 ed to this bone, and by moving the fragments one on the other, 
 in the a£t of walking, produce the painful sensation; this sen- 
 sation may however, depend on the contusion, and cannot, 
 therefore, be considered a proof of the existence of the fradhire. 
 
 This kind of fra6hire does not require any apparatus for keep- 
 ing the broken pieces in a just position; although the levatores 
 ani may draw the anterior fragment a little forward. Resolvents, 
 or emollient poultices, as the circumstances may require, ought 
 to be applied; it may be also necessary to take away some blood; 
 and the most perfedt repose should be enjoined, in order that 
 the action of the glutsei muscles may not interrupt the conso- 
 Hdation. 
 
 It is not amiss to remark here, that falls on the buttocks are 
 frequently attended with bad consequences, when, from a fool- 
 ish bashfulness, the patient conceals his sufferings, or refuses 
 to submit to examination by a surgeon. 
 
 Thus, the sister of a celebrated aftor, who refused to submit 
 to examination, although she suffered much pain in the region 
 of the coccyx, allowed an abscess to form in that part, on 
 opening which, the os coccygis was found fraftured, and af- 
 fefted with caries, as was also the inferior extremity of the 
 sacrum. 
 
66 OF FRACTURES OF THE OSSA INNOMINATAo 
 
 SECTION III. 
 
 Of FraBures of the Ossa Innominata. 
 
 Fractures of these bones are not frequent, but never take 
 place without an attendant contusion of the external soft parts, 
 and sometimes of the parts contained in the pelvis. Different 
 parts of these bones may be fra<ftured, and the fracture may run 
 in different dire£lions. The anterior and superior spinal process 
 of the OS ilium may be fradtured, and with it the adjacent part of 
 the ridge of that bone; of which we have seen an example in 
 the case of a farrier, who received a kick from a horse on that 
 part. The ossa pubis and ossa ischia, being protected by the 
 inferior extremities, are less frequently fradlured than the ilia. 
 No derangement takes place In the fradlured portions, whatever 
 may be the dire(ftion of the fradlure; not even in fradlures of 
 the ossa ilia, which is the more to be wondered at, as these 
 bones are very thin: this immobility of the broken parts is to be 
 ascribed to the thick and strong muscles which are attached in- 
 ternally and externally to the broken portions. 
 
 But these fractures are rendered very dangerous by the ex- 
 travasation of blood and medullary substance into the cellular 
 texture of the pelvis, and by the contusion of the parts which 
 are contained in it. When the pelvis has been fradhired by 
 the passage of a wheel, by the fall of a heavy body on it, by a 
 fall on the breech, the patient is entirely disabled from walking. 
 If the pelvis be pressed in opposite directions, the motion of 
 the broken pieces on one another will be perceived, a crepita- 
 tion will be heard, and some inequalities arising from the de- 
 rangement of the bones may be clearly distinguished. The 
 existence of the frafture being ascertained, the surgeon's first 
 care will be to obviate the consequences of inflammation by co- 
 pious and repeated blood-letting. If inflammation has already 
 taken place, it must be combatted by the same means; at the 
 same time topical remedies are to be applied. The pelvis ought 
 to be surrounded with a napkin folded in the shape of a band- 
 age for the trunk; and in cases where the contusion is exces- 
 sive, the bones splintered and loose, and the neighbouring 
 parts disorganized, as it would be impossible for the patient to 
 move or go to stool without suffering the most excruciating 
 
OF FRACTURES OF THE OSSA INNOMINATA. 67 
 
 pain, it will be necessary to pass a piece of strong girth web 
 under the pelvis, the corners of which, coUedled into one, are 
 to be fastened to a pully suspended from the top of the bed: 
 by means of this pully, the patient may raise himself with very 
 little effort. Citizen Boyer invented this apparatus for a pa- 
 tient affected in the manner we have just described: he was 
 able to raise himself with the greatest ease, and to such a de- 
 gree as that a flat vessel might be placed under him. It is ap- 
 plicable to all cases of compound fradture of the inferior ex- 
 tremities, in which it may be necessary to raise the patient fre- 
 quently. 
 
 However judicious the treatment, and well-dire£led the an- 
 tiphlogistic remedies, the inflammatory symptoms will generally 
 be so intense, that an excessive suppuration will be the conse- 
 quence; and large abscesses will form, in which the pus will 
 stagnate, in consequence of the great quantity of cellular tex- 
 ture in that part of the body. 
 
 Sometimes, however, the patient recovers, the effused blood 
 is absorbed, and the inflammation ends in resolution. It may 
 happen too, that detached splinters shall give rise to subsequent 
 abscesses, as in a case related by Marety in the Memoirs of the 
 Academy of Dijon, of a woman who had had a fradlure of the 
 pubis, and from whom he extra<Sl:ed a large portion of that 
 bone through an abscess formed hi the labia pudendi. 
 
 Desault in giving an exit to a coHe£lion of urine which had 
 taken place from a frafture of the pelvis, found a splinter which 
 he extracted from the bottoin of the wound. 
 
 If the bladder be perforated by a splinter, this should be ex- 
 tracted, and a catheter introduced into the bladder, in order to 
 prevent the accumulation of urine, and its consequent effusion 
 into the abdominal cavity. Chopart gives an example in Vol. II. 
 of his Treatise on the Diseases of the Urinary Passages, which 
 justifies this pradlice. 
 
 It may be said, that artificial means are but of small effect 
 in fractures of the pelvis, that the treatment must be general, 
 and that even this is not always efficacious, when (as most ge- 
 nerally happens) the fracture is complicated with lesion of the 
 external soft parts and contents of the pelvis. 
 
CHAPTER VIII. 
 
 OF FRACTURES OF THE SCAPULA. 
 
 THIS bone is seldom fraftured, because, being suspended 
 on the superior lateral and posterior part of the trunk, 
 and moveable in that situation, it yields easily to any force im- 
 pelled against it. All its parts are not, however, equally se- 
 cure from fra£ture. The acromion, vsrhich terminates exter- 
 nally its spinal process, and advances, like an arch, over the 
 head of the humerus, forming thus a part of the shoulder, is 
 easily fradlured, because, being but thin, and lightly covered 
 ■wieh soft parts, it yields easily to a force pressing it downward, 
 where it is supported only by cellular texture. The inferior 
 angle of the scapula is, after the acromion, that part of it 
 which is most easily fractured. The coracoid process is too 
 deeply seated to be frad^tured, except in the case of gun-shot 
 ■wound: that is the only one in which J. L. Petit met an exam- 
 ple of it. It has also been fraftured by the fall of a heavy 
 body on it; in this case, the soft parts were excessively contu- 
 sed, and the patient died. 
 
 Fra<Slures of the scapula, whether passing from its superior 
 to its inferior edge, across the spinal process, or from its ex- 
 ternal to its internal edge, are always accompanied with con- 
 siderable contusion, because the fracturing cause must have 
 afted immediately on the part. The first mentioned, or lon- 
 gitudinal fraftures, are less frequent than the transverse. The 
 vertical diameter being the greater, a greater force would of 
 course be necessary to fracture the bone in that direction than 
 in the other. Longitudinal fradtures cause but very little de- 
 rangement, because the muscles which are attached to the surface 
 of the scapula, prevent the separation of the fractured portions. 
 In transverse fradtures, the derangement is not quite so trifling. 
 The serratus anticus major draws forward the lower portion, 
 to which it is principally attached. The rhomboides may also 
 concur in producing this derangement, which is always great 
 enough to be perceived by the fingers drawn along the base. 
 
OF FRACTURES OF THE SCAPULA. 69 
 
 or internal side, where the inequality will be produced. In 
 fra<Stures of the acromion and inferior angle, the derange- 
 ment is much more considerable. The weight of the arm, and 
 the contradlion of the deltoid muscle, draw downward the 
 acromion, at the same time that the trapezius and levator sca- 
 pulae draw the rest of the bone upward and backward. The 
 serratus anticus major draws forward the lower angle, the rest of 
 the scapula remaining in its natural situation ; or if the angular 
 portion be considerable, the teres major and some fibres of the 
 latissimus dorsi contribute to its derangement forward and up- 
 ward. 
 
 If the coracoid process is fra£hired, the peftoralis minor, 
 the coraco-brachialis, and short portion of the biceps, concur 
 in drawing it forward and downward. 
 
 These different fraiftures may be ascertained by the following 
 signs: the longitudinal ones are, however, not easily distin- 
 guished. If much pain be felt in consequence of a blow or 
 fall on the shoulder, the part should be examined; for by feel- 
 ing the scapula, and pressing it in different direcStions, the mo- 
 tion of the broken pieces, and crepitation, may be perceived, 
 particularly if the patient be not fat, and an inflammatory 
 swelling has not as yet supervened. Transverse fractures are 
 more easily distinguished by the inequality which they cause in 
 the basis of the scapula, by the mobility of the pieces, which 
 may be moved in opposite diretStions, by seizing in one hand 
 the inferior angle, and in the other the acromion and spinal 
 process. 
 
 The derangement is so considerable in a frafture of the in- 
 ferior angle, that it is impossible to be mistaken, or to overlook 
 it; this part being quite detached, remains motionless, although 
 the rest of the scapula should be moved. 
 
 The pain which always attends the frafhire of the acromi- 
 on, and which is increased by the motions of the arm, the al- 
 teration in the form of the shoulder, and the mobihty of the 
 acromion, v/hich has descended, and which ascends when the 
 elbow is raised close to the trunk, are the distindive marks of 
 this frafture. The small quantity of soft parts covering the 
 acromion renders the discovery of it very easy. 
 
 The contusion which constantly attends fractures of the sca- 
 pula, whatever may be the part fra(ftured, is the most dan- 
 gerous symptom. Abscesses have sometimes formed in the 
 fossa subscapularis in consequence of fractures of the scaoula, 
 and effusions have taken place in the thorax, when the frac- 
 
70 or FRACTURES OF THE SCAPULA. 
 
 taring cause has a^led with such violence as to extend the con- • 
 tusion to the parietes of that cavity. 
 
 When the scapula is fractured longitudinally, or transverse- 
 ly, near its spinal process, k is merely necessary to fix the arm 
 to the side of the trunk by means of a bandage, vphich in- 
 cludes the arm and trunk, and which descends from the shoul- 
 der to the elbow. The steadiness of this bandage is still fur- 
 ther increased by applying a roller which embraces the shoul- 
 der and the elbow. Bv binding the arm in this manner, the 
 motions of the shoulder are prevented, because its motions are 
 only concomitant to those of the arm. This apparatus, or 
 that of Desault for the fracture of the scapula, with the omis- 
 sion of the cushion for the arm-pit, is by much preferable to 
 that by which the hand of the side affefted is placed on the 
 shoulder of the opposite side — a situation which is unnatural 
 and fatiguing, and which cannot be long persevered in. 
 
 As the inferior angle, when separated by firaclure from the 
 rest of the bone, is, like the condyloid process of the jaw, 
 little susceptible of being acted on by any means in our power, 
 it will be necessary to aft o> the scapula itself, to push it 
 downward and forward toward the inferior fragment, which 
 the serratus anticus major has drawn in that diredlion. 
 
 In this case too, it is on the arm that it will be necessary to 
 act, in order to move the scapula. The arm is to be pushed 
 inward, downward, and forward, the fore-arm being half 
 bent: it must be kept in this position by a circular bandage se- 
 ven yards long. It will be proper at the same time to aft on 
 the angular detached portion by means of compresses, which 
 may be pressed backward by some rounds of a bandage, and 
 thus brought in contaft with the rest of the bone. The arm 
 may be supported by a sling knotted on the opposite shoulder. 
 
 The acromion, when fraftured, is drawn downward and 
 outward by the aftion of the deltoides, at the same time that 
 the rest of the bone is drawn upward and backward by the 
 trapezius and levator scapulae. This frafture is set by raising 
 the arm in such a manner as that the head of the humerus 
 may push upward the acromion, which has descended, and 
 which naturally covers it like an arched roof; at the same time 
 an assistant pushes the scapula forward and downward in a di- 
 reftion opposed to that which is given the arm. In order that 
 the parts may remain in this situation, it will be necessary that 
 the aftion by which they have been placed in it be perpetuated 
 by bandages; that is, that the arm be supported parallel to the 
 
OF FRACTURES OF THE SCAPULA. 7 1 
 
 trunk, and that the shoulder be pressed downward at the same 
 time. 
 
 To effe£l this, a circular bandage is applied round the trunk 
 and arm, and afterwards made to ascend from the elbow 
 to the shoulder, and mce versa. In this last direiSlion, the 
 bandage has the advantage of securing on the shoulder the 
 compresses, moistened with a repellent liquid, of raising the 
 humerus against the acromion, of which it ought to be the 
 support while nature efFe£ls the consolidation, and pressing 
 down the scapula to the level of the acromion. This bandage, 
 like all those of the thorax, is very liable to be displaced, on 
 account of the motion of the thorax; it ought, therefore, to 
 be frequently reapplied, never forgetting on these occasions to 
 have the elbow raised, and the shoulder pressed down. 
 
 Although fractures of the scapula consolidate in the ordinary 
 time of from thirty-five to forty days, yet in those of the acro- 
 mion it will be necessary to continue the bandage a little longer: 
 not that the generation of callus is slower in that part of the 
 bone than in any other, but because that process is acted on by 
 two strong muscles, which might rupture the callus, if expo- 
 sed to their action before it had acquired a great degree of so- 
 lidity. 
 
 To these mechanical means general remedies may be ad- 
 ded, such as blood-letting, &c. The consequence of these frac- 
 tures are seldom dangerous. A case has been given, however, 
 in which the cellular texture which unites the subscapularis 
 muscle to the depression of that name, became inflamed, sup- 
 purated, and a deep-seated abscess was formed, for which it 
 was found necessary to trepan the scapula. A person received 
 a thrust of a sword in the shoulder; the weapon, after having 
 penetrated the integuments and infraspinatus muscle, pierced 
 also the scapula, and wounded the subscapularis muscle. The 
 inflammatory symptoms were intense, and an abundant sup- 
 puration took place. In order to stop the suppuration, Mare- 
 chal enlarged the fistulous orifice by trepanning the scapula. 
 The operation was attended with success, as we learn from the 
 author of its eulogium, which is found at the commencement 
 of the second volume of the Memoirs of the Academy of Sur- 
 gery. 
 
72 OF FRACTURES OF THE CLAVICLE. 
 
 CHAPTER IX. 
 
 OF FRACTURES OF THE 'CLAVICLE. 
 
 MANY causes conspire to render the clavicle liable to 
 fradture: it is long and slender, supported in Its mid- 
 dle part only by cellular texture; and protected externally but 
 by a very thin covering of soft parts. But Its fundtions con- 
 tribute much more than these circumstances to render the frac- 
 ture of it frequent. It serves to keep the scapula at a proper 
 distance from the sternum, and adls as a point d'appui to the 
 humerus, every impulse of which it receives and transmits to 
 the sternum. 
 
 A frafture of this bone may take place in any part of its 
 length, but it most frequently happens near its middle, because 
 its curvature is greatest at that part. Sometimes, but rarely, it 
 takes place near the extremity, articulated with the scapula. — 
 Fractures of it may be transverse or oblique ; simple, or com- 
 plicated with contusion, wound, or detached splinters — differ- 
 ences which depend on the action of the fra(Sluring cause. A 
 blow on the shoulder, and of sufficient momentum^ will, as it 
 a£ls directly, fradlure the bone in that part on which it is in- 
 £li(5led, and will at the same time lacerate or eontund the soft 
 parts. A comminutive fracture may be produced by this 
 means; and if the violence be sufficiently great, the subclavian 
 vessels, and nerves which lie between the clavicle and first rib 
 may be torn; and a paralysis of the arm produced: this affec- 
 tion frequently follows the fall of a heavy body on the shoul- 
 der. 
 
 If the frasSlure be caused by contre-coup, in which case the 
 fradluring force is immediately applied to the ends of the bone, 
 it is not necessarily complicated with contusion. A fracture 
 may be occasioned in this way by a fall on the point of the 
 shoulder, or on the hands, the arms being extended. It may 
 happen, however, in this case, that the clavicle, pressed very 
 forcibly against the sternum, may be bent much "beyond its 
 natural curve, and fradlured so obliquely, that the broken por- 
 tions shall pierce through the integuments. 
 
OF FRACTURES OF THE CLAVICLE, 73 
 
 Frailures of the clavicle are generally attended with de- 
 rangement of the broken portions, those, however, excepted, 
 which take place near the extremity articulated with the sca- 
 pula, and within the coraco-clavicular ligaments. Although 
 the bone be very slender in this part, yet it is so strongly at- 
 tached to the scapula by these fibrous productions, that the 
 derangement is scarcely sufficient to indicate the existence of 
 the fraiSlure. 
 
 The mechanism of the derangement of the pieces is easily 
 understood: the external portion is that which is always de- 
 ranged, because the internal, retained in its articulation by the 
 costoclavicular ligaments, and drawn in opposite diredlions by 
 the sterno-cleido-mastoideus, and peCloralis major, is immova- 
 bly fixed. The external fragment, on the contrary, being 
 weighed down by the arm, and drawn in the same direction 
 by the a6lion of the deltoides, and being at the same time 
 drawn forward and inward by the pedloralis major, is carried 
 under the internal portion, which forms an eminence over 
 it. ^ 
 
 From the moment that the fradlure of the clavicle allows the 
 shoulder to approach the sternum, the arm falls on the fore 
 part of the breast; and the patient resembles in that particular, 
 an animal without a clavicle. 
 
 One of the principal signs of fradlure of the clavicle, is the 
 impossibility which the patient finds of applying the hand of 
 the side afFedted to his forehead, because that a6l requires a 
 semicircular motion of the humerus, which cannot be perform- 
 ed if that bone has not a firm point d^apptii. If the patient 
 attempts this motion of the arm, it may be remarked that he 
 merely bends the fore-arm and inclines his head, in order to 
 bring the hand and forehead into contadl. In addition to this 
 sign, it will be observed, that the shoulder and superior extre- 
 mity are placed more anteriorly on the breast and nearer the 
 sternum, than in their natural state, or than those of the op- 
 posite side. The patient leans to the fra£lured side; and if 
 the part be examined before a swelling and inflammation has 
 come on, the motion of the pieces on one another may be 
 perceived, and the proje6lion formed by the end, generally of 
 the internal portion, will be evident. A crepitation may be 
 produced by the motion of the shoulder, but not without 
 causing great pain. These signs, independently of preceding 
 circumstances, establish clearly the diagnosis of fradlures of 
 the clavicle. 
 
 10 
 
74 OF FRACTURES OF THE CLAVICLE. 
 
 If Ihe soft parts have suffered no extraordinary contusion, a 
 fracture of the clavicle is not dangerous; but if the fracture be 
 comminutive, the soft parts lacerated, and the nerves of the 
 brachial plexus injured, much danger may result from it. 
 
 For no fracture have so many bandages and so much appa^ 
 ratus been invented, as for that of the clavicle. We shall ex- 
 amine them successively, and point out their defeats and per- 
 fections. The ancients and many of the moderns have ima- 
 gined, that in order to set a fra<Slure of this bone, it was ne- 
 cessary to have the shoulder drawn back, and fixed in that 
 position: to effect this, it was ordered that the patient should 
 be placed on a low stool, so that an assistant might place his 
 knee between his shoulders, which he drew back at the same 
 time with both his hands, whilst the surgeon applied the band- 
 age, which was to keep the parts in this position. It is easy to 
 perceive that in thus drawing the shoulders toward one ano- 
 ther, the scapula is pushed toward the sternum, and with it 
 the external portion of the clavicle, which passes under the in- 
 ternal. If this portion be sharp pointed, and the shoulders 
 drawn back with great force, it may lacerate and pierce the 
 integuments. The bandage in form of the figure 8, with 
 which it is attempted to keep the parts in this position, does 
 not corre£t the defedl in any degree. The manner of its ap- 
 plication is as follows: While the assistant adts as above men- 
 tioned, the operator applies one end of a seven yard bandage, 
 rolled up in one, to the arm-pit of the side affected, and 
 draws it obliquely to the opposite shoulder, round which it is 
 made to pass, and from this to the other shoulder, about 
 which it is to be rolled in the same manner, and crossed after- 
 wards repeatedly before and behind. As this bandage a£ts ob- 
 liquely, its force is decomposed; it is therefore necessary to 
 draw it very tight, in order to keep the shoulders back. But 
 this extreme constri(ftion of the bandage excoriates the parts 
 about the arm-pits, particularly in cases of women, and causes 
 much distress, without producing any good; besides, the 
 drawing back of the scapulae forces the fractured portions to 
 overlap, which is the very reverse of the desired effedl; but 
 luckily the obliquity of its action prevents it from afting so 
 forcibly as to confine the shoulders; even though, as prescri- 
 bed by J. L. Petit, they should be braced behind by a com-' 
 press. The iron cross proposed by Heister, the corselet de- 
 scribed by Brasdor in the Memoirs of the Academy, and the 
 leather strap proposed by Brunninghaussen, are only modifica- 
 
OF FRACTURES OF THE CLAVICLE. 75 
 
 tions of the figure of 8 bandage,, and have no advantage over 
 it. All a£t obliquely on the shoulders, tend to efFeft a de- 
 rangement of the fraftured portions, by drawing the scapulae 
 toward one another, excoriate the parts about the arm-pits, 
 and do not prevent the descent of the arm. 
 
 The general rules which we have given for setting fra^res, 
 are to be attended to in those of the clavicle. Extension is to 
 be performed by means of the limb, which articulates with the 
 fraftured bone, and in the direction of this latter. This dou- 
 ble purpose is answered by using the humerus as a lever of the 
 first species, that is, by bringing its inferior extremity forward, 
 inward, and upward, and pushing the shoulder backward, up- 
 ward, and outward: the humerus may be converted into a le- 
 ver of the first species, by placing a cushion in the arm-pit, 
 which cushion will a£l as a fulcrum to the lever. 
 
 The Arabians, and Ambrose Pare, saw, though indistinftly, 
 the necessity of this pra£lice, and now and then had recourse 
 to it; but it remained for Desault fully to d^velope it, and in-? 
 vent an appropriate apparatus. 
 
 The practice of this celebrated surgeon consisted in applying 
 in the arm-pit a cushion, made of hair or flocks, five or six inches 
 long, and three inches and a quarter thick at its base. To the 
 corners of its base, placed upward, are fastened two strings, 
 which being passed across the back and breast, are to be tied 
 on the opposite shoulder. The cushion being thus placed, the 
 surgeon seizes the patient's elbow, the fore-arm being bent, 
 and brings it forward, upward, and inward, pressing it with 
 force against the breast. By this mancEuvre the humerus car- 
 ries the shoulder outward; the ends of the fractured portions 
 are placed opposite one another, and the deformity disappears. 
 All that is then necessary, is to fix the arm in that situation, 
 and prevent it from moving all the time that nature requires 
 for the consolidation of the fracture. For this purpose an as- 
 sistant supports the arm in the position given to it by the sur- 
 geon; while he takes a bandage nine yards long, rolled up in 
 one, and places one end of it in the arm-pit of the opposite 
 side, and draws it from thence over the superior part of the 
 arm, and across the back to the same part. This first cast of 
 the bandage is exactly covered by another, which secures it, 
 and the succeeding casts are made to overlap one another one 
 third, until the arm is covered down to the elbow; taking care 
 at the same time to draw the bandage tighter in proportion as 
 it descends; because the bandage must be considered as the 
 

 76 OF FRACTURES OF THE CLAVICLE. 
 
 force which aiEh on the lever ; for which reason it shoiuld ope^ 
 rat* particularly on its extremity. 
 
 This first bandage being applied, compresses impregnated 
 with camphorated spirit, or any other resolvent fluid, are pla- 
 ted along the fradlured bone. Then, another bandage as long 
 as the former, is taken by the operator, and one end of it 
 placed under the arm-pit of the opposite side, from whence it 
 is drawn across the breast over the compresses and the fractur- 
 ed part, down behind the shoulder and arm, and upward on 
 the breast, after having passed under the elbow; it is then 
 brought across to the sound shoulder, under and round which 
 it is passed, in order to secure the first cast; it is then drawn 
 across the back, brought over the compresses, carried down 
 before the shoulder and arm, under the elbow, and obliquely 
 behind the back to the arm-pit, where the application com- 
 menced. The same process is repeated until the bandage is 
 entirely applied. The principal use of this bandage is to sup- 
 port the arm 5 it admits therefore of some variety in its appli- 
 cation. By means of these two bandages, the external broken 
 portion is raised upward, and pushed outward, and therefore 
 tlie two principal obje£ls are attained. The whole apparatus 
 may be still further fixed and secured, by pinning the bandage 
 where it appears to have any effect. Finally, the hand is to 
 be supported by means of a sling. 
 
 It has been recommended to make the cushion for the arm- 
 pit of old linen, but hair or flocks are preferable for that pur- 
 pose. A cushion made of them is soft, and will not benumb 
 the arm by compressing the brachial plexus, or occasion an in- 
 flammation or gangrene of the parts. 
 
 It must be allowed that this bandage of Desault fulfils every 
 indication of cure; but it has a disadvantage necessarily attend- 
 ant en every such bandage, passed by a great number of casts 
 round a part so bulky as the trunk, it is easily deranged. The 
 dilatation of the thorax contributes much to this efi^eft, parti- 
 cularly in women. It has a further disadvantage with respedl 
 to females, namely, its pressure on the mammse, which must 
 make it at least very troublesome. In both man and woman it 
 renders respiration difficult. To these disadvantages may be 
 added that arising from the difliculty of applying it, on ac- 
 count of the number of pieces of which it consists, and the 
 length of time required for its application. Every time that it 
 becomes deranged, it will be necessary, in order to re-apply it. 
 
OF FRACTURES OF THE CLAVICLE. 77 
 
 to raise the arm and move the shoulder more or less, which 
 motion counteracts the consolidation of the fracture. 
 
 Convinced by his own experience, of these disadvantages of 
 Desault's apparatus. Citizen Boyer has invented the following 
 one, more simple and less troublesome; by means of which he 
 has efFefted a complete cure of a fracture of the clavicle, 
 without deformity. 
 
 It consists of a girdle of linen cloth, quilted, and six inches 
 broad, which passes round the trunk on a level with the elbow: 
 it is fixed on by means of three straps, and as many buckles 
 fastened to its extremities. At an equal distance from its ex- 
 tremities are placed externally on each side two buckles: that is, 
 two anterior and two posterior to the arm. A bracelet of 
 quilted linen cloth, five or six fingers broad, is placed on the 
 lower part of the arm of the side affected, and laced on the 
 outside of the arm; four straps fixed to this bracelet, that is, 
 two before and two behind, correspond to the buckles on the 
 outside of the girdle, already described, and answer the pur- 
 pose of drawing the lower part of the arm close to the trunk; 
 the more so as the straps, by being two before and two behind, 
 prevent the arm from moving either backward or forward. 
 With this apparatus, as well as with the preceding, the cushion 
 must be applied under the arm. 
 
 Nothing can be easier than the treatment of a simple frac- 
 ture by means of this apparatus, the use and application of 
 which may be more easily conceived by the assistance of the 
 engraving at the end of this volume. The patient himself may 
 tighten the straps and press the elbow to the trunk, whenever 
 it is found necessary. He may quit his bed in a few days and 
 walk about, having the hand and fore-arm supported in a sling. 
 A fracture of the clavicle is frequently consolidated in thirty 
 days, during which time the patient need not be confined to 
 any very strict regimen. 
 
 These fraiSlures, when compound, are treated as directed 
 in Chapter I. In some cases it may be necessary to rub an irri- 
 tating substance on tlie arm, when a paralytic affection of it re- 
 mains. If the fracture be double or comminutive, it will be 
 well to apply a flexible splint over the compresses moistened 
 with a resolvent liquid, as already directed. 
 
 If Desault's bandage be employed, it will be necessary to re- 
 new it as often as it becomes slack; and we believe that its hal- 
 ving been found unsuccessful by several practitioners, is to be 
 ^scribed to the negleCt of this particular circumstance. 
 
7» 
 
 CHAPTER X. 
 
 OF FRACTURES OF THE HUMERUS. 
 
 THIS bone may be fra£tured in any point of its length: in 
 the middle, at either extremity, or above the insertion of 
 the pe(Storalis major, latissimus dorsi, and teres nnjor. The af- 
 fection in this last-mentioned case is termed fradture of the neck 
 of the humerus J but that denomination has not the merit of 
 being stridlly anatomical. It is possible, however, that what 
 is striflly called the neck of the humerus may be fradlured, par- 
 ticularly by a gun-shot wound. By neck of the humerus, we 
 understand that circular narrowing which separates the tube- 
 rosities from the head. 
 
 The fractures of this bone may be transverse or oblique, sim- 
 ple or compound. In short, whatever has been said of the 
 differences of fra£lures in general, is applicable to those in par- 
 ticular. The same may be said of the causes, whether acting 
 on the extremities of the bone, or immediately on the part 
 fractured. 
 
 The transverse fractures of the middle part under the inser- 
 tion of the deltoid muscle, are attended with but a trifling de- 
 rangement. The anterior bracliialis and triceps brachialis, at- 
 tached posterioi'ly and anteriorly to both fractured portions, 
 counteracfl one another, and admit only a slight angular de- 
 rangement. When the fracture takes place above the insertion 
 of the deltoid muscle, the inferior portion is first drawn out- 
 ward, and then upward on the external side of the superior. 
 Fractures of the humerus, near its lower end, such particularly 
 as are transverse, are not subject to much derangement : an cf- 
 fe£t which is to be attributed to the breadth of the fractured sur- 
 faces; to their being covered posteriorly by the triceps brachi- 
 alis, and anteriorly by the brachialis anterior, which admit only 
 a slight angular derangement by the inferior portion being 
 drawn a little forward. 
 
 The oblique fractures are always attended with derangement, 
 whatever be the part fractured. The inferior portion being 
 
OF FRACTURES OF THE HUMERUS. 79 
 
 drawn upward by the action of the deltoldes, biceps, coraco- 
 brachialis, and long portion of the triceps, glides easily on the 
 superior, and passes above its lower extremity. Finally, frac- 
 tures of the neck of the humerus are always attended with de- 
 rangement, which is produced by the action of the pe£loralis 
 major, latissimus dorsi, and teres major, which being attached 
 to the lower portion near its superior extremity, draw it first 
 inward and then upward, in which last direcliion it is ix)werful- 
 ly aided by the biceps, coraco-brachialis, and long portion of 
 the triceps. The superior portion itself is, in this case direfVed 
 a little outward by the action of the Infraspinatus, supraspinatus, 
 and teres minor, which make the head of the humerus perform 
 a rotatory motion in the glenoidal cavity. 
 
 We proceed to examine the different marks by which these 
 fractures may be ascertained. 
 
 The shortening and change in the direction of the limb, the 
 crepitation, which may be very distinctly perceived by moving 
 the broken pieces in opposite directions, the pain, and impos- 
 sibility of moving the arm, &c. joined to the history of the 
 preceding circumstances, render it easy to establish a diagnosis. 
 It may happen however, from ignorance or inattention, that a 
 luxation of the cubitus may be mistaken for a fracture of the 
 lower extremity of the humerus. In treating of luxation, we 
 shall state how this mistake, which might be of the most dan- 
 gerous consequence, may be avoided. 
 
 Fraftures of the neck of the humerus are not so easily ascer- 
 tained, and have been frequently, for want of attention, con- 
 founded with luxations of that bone. The diagnostic symp^ 
 toms of theses two affeftions are however very different. 
 
 When the neck of the humerus is fractured, a depression is 
 observed at the superior extremity and external side of the arm, 
 which is very different from that accompanying the luxation 
 downward and inward of that bone, in the latter case, under 
 the projeiStion of the acromion, a deep depression is found ia 
 the part which the head of the humerus naturally occupies; 
 whereas, in the fracture of the neck of that bone, the shoulder 
 retains its natural form, the acromion does p.ot project, and 
 the depression is found below the point of the shoulder. Be- 
 sides, in examining the arm-pit, instead of finding there a round 
 tumour formed by the head of the humerus, the fra<n:ured and 
 unequal extremity of that bone will be easily distinguished. 
 The motion of the broken portions, and the crepitation which 
 
86 OF tRACTURES OF THE HUMERUS. 
 
 may be produced by moving them, serve still further to esta- 
 blish the diagnosis. 
 
 A simple frafture of the^ body of the humerus is not a very 
 dangerous afFedtion: in that near the extremities, the danger 
 is greater, because, as has already been mentioned, inflamma- 
 tion and false anchylosis are more to be apprehended, and the 
 management of the frafture is more difficult. 
 
 Transverse or oblique fradlures of the humerus are easily 
 set. An assistant placed on the side not afFe<5led, and having 
 his hands passed before and behind the thorax, fixes the shoul- 
 der, while another draws down the humerus, by seizing the 
 fore-arm, or even the condyloid processes of the humerus: the 
 operator then places the fradtured surfaces in proper contadl. 
 The criterion of the frafture being well set, is the arm having 
 its proper length, form and diredlion, so that the external con- 
 dyloid process or tuberosity of the humerus may correspond 
 with the most salient part of the shoulder. When the frac- 
 ture is thus set, the surgeon takes a bandage eight yards long 
 rolled up in one, and having placed some lint in the palm of 
 the hand, commences the application of the bandage on that 
 part, drawing by its means the fingers close together, after 
 which it is rolled upward on the rest of the arm, each cast 
 covering a part of the preceding. When it is brought as far 
 as the elbow, the fore-arm is to be bent; and when carried 
 as high as the depression under the insertion of the deltoides, 
 some lint is to be placed under it, in order that the com- 
 pression may be as equal as possible; the whole arm is to be 
 covered alike; but three folds one over the other, are to be 
 made on the situation of the fradlure. When the bandage has 
 reached the shoulder, four thin splints of wood, or, still 
 better, of tin, slightly convex, are to be applied one oppo- 
 site the other on the arm; or, if the arm be very slender, 
 three splints may suffice. While an assistant holds these splints, 
 they are fixed by turns of the bandage carried downwards, 
 which cover one another partially as before. The bandage is 
 brought up again in the same manner; and, if long enough, 
 down again on the arm and fore-arm. The turns of the band- 
 age which serve to fix the splints, ought not to be drawn so 
 tight as to cause pain. 
 
 It is indispensably necessary to apply the bandage on the 
 hand and fore-arm, as otherwise these parts would tumefy, on 
 account of the circulation in the veins and lymphatics being 
 ©bstruded. This obstruftion, though not very painful, is at 
 
OF FRACTlTRES OF THE HUMERUS. 8l 
 
 least troublesome. Besides, the articulation is rendered stiff 
 by the swelling, and the stagnant fluid becoming thick, con- 
 duces very much to produce a false anchylosis. Should this 
 precaution have been omitted at first, the bandage should be 
 applied even after the swelling has taken place. It is scarcely 
 necessary to say, that every part of the bandage ought to be 
 impregnated with some resolvent liquid: independently of the 
 repellent effefts of the liquid, the bandage can be better appli- 
 ed when wet than when dry. 
 
 If the patient keep his bed, a pillow should be placed un- 
 der the arm; on the contrary, if he remain up, it will suffice 
 to support the hand half prone in a sling. If the patient be 
 very vigorous, it will be prudent to draw some blood, and to 
 put him on a very low diet for some time. If no bad symp- 
 tom come on after the application of the apparatus, it need 
 not be taken ofl' before the fifth day, and afterwards every 
 eighth or tenth day, so that the consolidation will be found 
 perfe(Sl at the fourth or fifth removal. It should be more fre- 
 quently re-applied for a fracture of the lower extremity of 
 the humerus. The articulations of the elbow and shoulder 
 should be frequently moved, in order to prevent a false anchy- 
 losis ; but the motion should not be attempted before the callus 
 has acquired a certain degree of solidity. 
 
 If the fradlure be complicated with violent contusion, and 
 great inflammation be inevitable, or already established', the 
 limb should be placed on a pillow, the fore-arm half bent, the 
 hand prone, and a little raised, in order to facilitate the circu- 
 lation in the veins and lymphatics. Scultet's bandage is first 
 applied, its separate pieces being previously extended on a 
 linen cloth as long as the humerus; the splints are rolled in 
 this cloth, and applied over the bandage, care being taken to 
 place little chaff bags where they may be necessary, as before 
 dire£led. The strings or tapes with which the whole is to be 
 bound externally, should not be drawn too tight. It will be 
 necessary to apply emollient poultices on the arm, when the 
 resolvent applications do not discuss the swelling. By accom- 
 panying these means with the general treatment in similar ca- 
 ses, such as bleedings, rigorous abstinence, diluent and cool- 
 ing drinks, the inflammatory symptoms disappear in seven or 
 eight days, and the rolled bandage, as last described, may be 
 substituted for that of Scultet. If the fra£ture be comminu- 
 tive, or complicated with wound, the treatment will vary as 
 directed in Chapter I. on the General Treatment of Fra(ftures. 
 U 
 
S2 OF FRACTURES OF THE HUMERUS. 
 
 It has been advised in fractures of the lower extremity of 
 the humerus, to place the four splints in such a manner as that 
 they should extend equally on the arm and fore-arm, care be- 
 ing taken to equallize the anterior and posterior sides, particu- 
 larly the bend of the arm and olecranon, with the rest of the 
 limb, by means of graduated compresses properly disposed. — 
 But this extension of the whole member would be painful, and 
 might produce a false anchylosis of the elbmv. 
 
 If the case require it, four splints may be so hinged in their 
 middle part, as that the anterior and posterior ones should 
 open or close up on their breadth, and the two lateral ones on 
 their edges. Instead of these hinged splints, Citizen Boyer 
 has successfully employed four simple splints for the humerus, 
 and four more for the fore-arm. 
 
 The fra£lure of the neck of the humerus requires a mode of 
 treatment which it is necessary to particularize. It has been 
 proposed in this ease to apply the spica, or the eighteen tailed 
 bandage, and other means equally insufficient. Moscati, a 
 surgeon of Milan, sensible of the difficulty of ailing in these 
 cases, on the superior portion, invented a means by which this 
 inconvenience was overcome. This consisted in filling the 
 arm-pit, previously covered with a cloth fastened on the out- 
 side of the shoulder with tow soaked in a mixture of alum and 
 the white of an egg beat up together. He covered the shoul- 
 der with a similar preparation, and over that applied the spica 
 bandage. This mixture dried up rapidly, and formed a hard 
 crust x-ound the part. Thi^s mode of treatment (described by 
 the author in the Memoirs of the Academy of Surgery) has a 
 great disadvantage; it forces the patient to keep his arm at a 
 distance from the trunk; and this strained and unnatural po- 
 sition is incompatible with the exact juxta-position of the bro- 
 ken portions, the situation of which cannot be known while 
 covered bv this substance. 
 
 Ledran thought of combining this invention of Moscati's 
 with the means used by the ancients, which consisted in ma- 
 king the trunk serve as an internal splint, and binding the arna 
 to the trunk by a circular bandage. This correction by I.e- 
 dran led to the invention of the bandage for the clavicle, the 
 application of which Desault extended to fractures of the neck 
 of the humerus. According to this method, the arm is en- 
 veloped by a bandage, and the elbow pressed toward the 
 breast, a cushion being first placed in the arm-pit: another 
 ciixuJar bandage is then passed round the arm and trunks 
 
OF FRACTURES OF THE FORE-ARM.' 8j 
 
 splints are applied to the anterior, posterior, and lateral parts 
 of the arm, and some compresses wet with a resolvent liquid 
 are applied on the shoulder. 
 
 By means of this apparatus, fradhires of the neck of the 
 humerus consolidate as easily, and sometimes in less time than 
 those of its middle part. 
 
 It sometimes happens, that in young subjects the head of 
 the humerus, being yet but an epiphysis, separates from the 
 rest of the bone in consequence of a blow or fall; which af- 
 fedlion, both as to the diagnostic symptoms and treatment, is 
 analogous to a frafture of the same part in a more advanced 
 age. It is, however, particularly necessary in this case, to fill 
 the arm-pit so as to throw outward the lower portion of bone ; 
 because, if the parts be not exadily and fairly united, the mo- 
 tions of the arm will be impeded to a certain degree for ever 
 after. 
 
 In compound fractures of the n^ck of the humerus, as well 
 as in those of the body of that bone, no attempt is to be made 
 to set the fracture till the inflammatory symptoms have subsi- 
 ded. 
 
 CHAPTER XL 
 
 OF FRACTURES OF THE FORE-ARM. 
 
 SOME authors have denominated complete, those fraftures 
 of the fore-arm in which both bones are fractured : and 
 incomplete, those in which one only is frailured. We have 
 already given it as our opinion that these denominations are 
 fallacious, and we will substitute for them that of frafture of 
 the fore-arm, when both the bones of which it is composed 
 are fractured; and that of the radius or cubitus, where only 
 cne of these bones is fractured. 
 
84 or FRACTURES OF THE FORE-ARM. 
 
 SECTION I. 
 
 Of FraElures of the Fore-arm. 
 
 They are almost always the consequence of a fall, or blow 
 on the fore-arm, and take place in the part on which the cause 
 has immediately adied. It is difficult to imagine, that, by a 
 fall on the palm of the hand, both bones could be fractured at 
 once, because the radius alone receives the impulse communi- 
 cated by the hand: the cubitus having no immediate connexi- 
 on with the hand, cannot be often fra£l:ured by this cause. 
 
 These bones may be fra(Slured on the same level, as most 
 frequently happens, or the fracture of one may be higher than 
 that of the other. Fradlures of these bones, whether trans- 
 verse or oblique, are generally complicated with greater or less 
 contusion, wound, detached splinters, and other concomitants 
 of affections of this kind. 
 
 The connexion of the two bones of the fore-arm, by the inr 
 terosseous ligament which occupies the interval by which they 
 are separated, and the manner in which the muscles which are 
 attached to both, are inserted into them, render the derange- 
 ment of the broken pieces in the longitudinal dire£iion very 
 difficulty and, in reality, a derangement in this dire(rtion has 
 been seldom observed, and never to any considerable degree: 
 when it does take place, it is to be ascribed to the cause of the 
 frafture rather than to muscular contraction. The derange- 
 ment in the dire<ftion of the diameter, on the contrary, always 
 takes place in such a manner as that the four pieces approach 
 one another, and the interosseous interval diminishes, or is en- 
 tirely obliterated at that part near the seat of the fracture; 
 which approximation of the ends of the bones causes an evi- 
 dent deformity of the part. 
 
 To this derangement must be added the angular, which the 
 fracturing cause always produces, either forward or backward, 
 according to its direCiion. 
 
 The existence of these fraClures is easily ascertained from, 
 the history of the circumstance, from the pain, which is ren- 
 dered more acute by moving the hand, from the impossibility 
 of performing pronation or supination of the hand, and from 
 the noise produced by the fridlion of the fractured surfaces 
 
OF FRACTURES OF THE FORE-ARM. 85 
 
 whenever these motions are attempted; finally, from the 
 change in the form of the arm, the anterior and posterior sides 
 of which appear tumefied by the protusion of the muscles 
 which the broken bones have displaced from the interosseous 
 interval, the other sides being depressed, and from the mobi- 
 lity of the broken portions, and change in the dire(5lion of the 
 arm. 
 
 When these bones are fraftured near their inferior extremi- 
 ties, the inflammatory swelling might render a diagnosis less 
 clear, and cause the fratSlure to be mistaken for a luxation of 
 the hand. But the two cases may be distinguished by simply 
 moving the hand; by which motion, if there be luxation with- 
 out fraclure, the styloid processes of the radius and cubitus 
 will not change their situation; but if a fradlure do exist, 
 these processes will follow the motion of the hand. 
 
 In order to adjust a fracture of these bones, the fore-arm is 
 bent to a right angle with the arm, and the hand placed in a po- 
 sition between pronation and supination. The fore-arm and 
 hand being thus placed, an assistant seizes the four fingers of 
 the patient, and, by pulling, extends the fractured parts, while 
 another assistant makes counter extension by fixing the hume- 
 rus with both his hands. By these means the operator is ena- 
 bled to restore the bones to their natural situation, and to push 
 the soft parts into the interosseous space, by a gentle and gra- 
 duated pressure on the anterior and posterior sides of the arm. 
 Coaptation is very easy in fra£lures of these bones, as are in- 
 deed all the other parts of the operation, in which effort and 
 violence are net at all required. 
 
 The fradture being thus set, the bones are kept in their 
 place by applying first on the anterior and posterior sides of 
 the fore-arm two longitudinal and graduated compresses, the 
 base of which is to be in contact with the arm. The depth 
 of these compresses should be proportioned to the thickness 
 of the arm, increasing as the diameter of the arm diminishes. 
 In the next place, the surgeon takes a bandage about six yards 
 long, rolled up in one, and makes three turns of it on the 
 fradtured part, descends then to the hand by casts partially su- 
 perposed on one another, and envelopes the hand in passing 
 the bandage between the thumb and index: the bandage is 
 then carried upward in the same manner, and reverted where- 
 ver the inequality of the arm may render it necessary. The 
 compresses and bandage being thus far applied, the surgeon 
 lays on two splints, one anteriorly, the other posteriorly, and 
 
S6 OF FRACTURES OF THE FORE-ARM. 
 
 passes the part of the bandage that yet remains over them, In 
 such a manner as entirely to cover them. It may not be unne- 
 cessary to remark, that the compresses and splints should be 
 of the same length as the arm. It would be useless to employ 
 lateral splints in this case, unless (what is scarcely ever to be 
 expe«n:ed or met with) a derangement should have taken place 
 in that direction. It is evident, that lateral splints would coun- 
 teract the compresses and two other splints, by increasing the 
 radio-cubital diameter of the arm, and by concurring with the 
 a<flion of the pronatores to move the pieces into the interosse- 
 ous space. The surgeon's attention should be most particular- 
 ly dire^ed to preserve the interosseous space; for, if this be 
 obliterated, the radius cannot rotate on the cubitus, nor the 
 motion of pronation or supination be executed; and this ob- 
 je6l may be obtained with certainty by applying the compresses 
 and splints in such a manner as that the fleshy parts may be 
 forced into, and confined in, the interosseous space, and by 
 renewing the bandage every seven or eight days. 
 
 Such is the treatment of a simple fraclure of the fore-arm; 
 If the contusion be excessive, with wound or comminutive 
 frafture, the splinters should be extracted, the arm placed on 
 a pillow, and dressed with the usual topical applications adapt- 
 ed to the degree of inflammation, the patient bled, and Scul- 
 tet's bandage applied. If the inflammatory symptoms conthiue 
 a certain length of time, the bones consolidate in a manner 
 that deforms the arm, and renders it impossible to perform the 
 movements of pronation and supination: this may be prevent- 
 ed, if the inflammatory symptoms disappear so much on the 
 fifteenth or twentieth day as to admit the application of the 
 apparatus for simple fractures. 
 
 If the fraclure be simple, and the contusion inconsiderable, 
 it will not be necessary to confine the patient to bed: he may 
 be allowed to walk about and attend to his business, having 
 the arm supported in a sling. The consolidation is generally 
 perfect in thirty or forty days, no difference being perceivable 
 in the time necessary for the generation of the callus in the 
 case in which the two bones are fra<Slured, and that in which 
 onlv one is broken. 
 
OF FRACTURES OF THE RADIUS. 87 
 
 SECTION II. 
 
 Of Fracf lives of the Radius. 
 
 Of all fractures of the fore-arm, this is the most frequent; 
 the radius being almost the sole support of the hand, of which 
 it has been called the manubrium, and being in the same line 
 with the humerus, is for both these reasons more exposed to 
 frailure than the cubitus, which corresponds with the hand 
 only by a very small surface, and which does not form ^^ 
 strait line with the humerus. 
 
 Fradlures of this bone, v/hethcr transverse or oblique, rear 
 its middle part or extremities, may be caused by a fall or blow- 
 on the fore-arm, or, as happens in most cases, by a fall on the 
 palm of the hand. When the body is thrown off its centre of 
 gravity, and falling appears inevitable, we are apt from habit to 
 extend our arms, and let the hands come first to the ground; 
 in which case the radius, pressed between the hand which is 
 supported on the ground, and the humerus, from which it re- 
 ceives the whole momentum of the body, is bent, and if the 
 fall be sufficiently violent, broken more or less near its middle 
 part. When after an accident of this kind, pain and a diffi- 
 culty of performing the motions of pronation and supination 
 supervene, the probability of a fradlure of the radius is very 
 strong. The truth is fully ascertained by drawing the hand 
 along that* bone on the external side of the fore- arm, with as 
 great a degree of pressure as the pain excited will admit : be- 
 sides, in endeavouring to perform supination or pronation of 
 the hand, a crepitation will be heard, and the moving of the 
 broken portions perceived, if the bone be in reality fradlured ; 
 but it is not amiss to warn against mistaking the noise made by 
 the tendons of the muscles of the thumb which wind on the 
 inferior and exterior part of the radius, for a crepitation pro- 
 duced by the rubbing of the fradlured surfaces. These tendons 
 are thick and dry in labouring people, and cause a certain noise 
 on being moved in their sheaths, in which there is a scarcity 
 of synovia. This noise is easily distinguished from crepitation 
 by an experienced ear. When the fra<Si:ure takes place near 
 the head of the radius, the diagnosis is more difficult on ac- 
 count of the depth of soft parts over the bone in that part. In 
 
8B OF FRACTURES OF* THE RADIUS. 
 
 this case the thumb is to be placed under the external condyle 
 of the OS humeri, and on the superior extremity of the radius, 
 and at the same time the hand is to be brought to the prone 
 and supine positions. If in these trials, always painful, the 
 head of the bone rests motionless, there can be no doubt of its 
 being fractured. The causes of derangement are here the same 
 as in fradtures of the fore-arm, and it can never take place but 
 in the direftion of the diameter of the bone, and is effected 
 principally by the action of the pronating muscles. The cubi- 
 tus serves as a splint in fradtures of the radius-, and the more 
 effectually so, as these two bones are conneiSled with one ano- 
 ther in their whole length. Notwithstanding the evidence of 
 the mechanism which prevents the longitudinal derangement, 
 J. L. Petit has thought that derangement possible. 
 
 Extension and counter-extension are made in the same way 
 as in fractures of both, bones of the fore arm, wltii this slight 
 difference, that the assistant who makes the extension should 
 incline the hand to the cubital side of the fore- arm. Great 
 care is to be taken, that, by means of graduated compresses 
 placed on the anterior and posterior sides of the fore-arm, the 
 natural shape be restored, the convexity produced by the frai?- 
 ture removed, and that the bandage may act principally on the 
 extremities of the dorso palmaris diameters, by which adtlon 
 the fleshy parts will be pressed in between the two bones, and 
 therefore these bones kept separate, and the Interosseous space 
 preserved to the extent which is natural, and Avhich is necessa- 
 ry for the pronation and supination of the hand. 
 
 It would be superfluous to repeat here what has been said in 
 the preceding section on the mode of perfecStlng the cure, and 
 combatting the symptoms which might complicate the fracture: 
 the treatment in this respedt being absolutely the same in both 
 cases. 
 
 SECTION 11.1. 
 
 Of FraHures of the Cubitus. 
 
 Fractures of this bone, less frequent than those of the radius 
 for the reasons already mentioned, take place generally at its 
 lower extremity, because it is smaller and less covered at that part 
 
 i 
 
OF FRACTURES OF THE CUBITUS. 89 
 
 than at any other; consequently we find, that a frafVure of 
 this bone is almost always the result of a force a<Sting immedi- 
 ately on the part fraclured; as, for instance, when one falls 
 and strikes the internal side of the fore-arm against a hard re- 
 sisting body. On applying the hand judiciously on the inside 
 of the fore-arm, this fradlure is easily ascertained by the de- 
 pression in that part, from the inferior portion being drawn 
 towards the radius by the aclion of the pronator radii quadratus. 
 This derangement is in general less than that which takes place 
 in fractures of the radius. The superior portion of the cubitus 
 remains unmoved, as has been well observed by J. L. Petit. 
 
 In this case the assistant who extends the parts, inclines the 
 hand to the radial side of the fore-arm, the surgeon pushes the 
 flesh between the two bones, and applies the apparatus last de- 
 scribed. In all fradlures ' of the bones of the fore-arm, and 
 particularly in those which are near the head of the radius, a 
 false anchylosis is to be apprehended, and should be guarded 
 against by moving the elbow gently and frequently, when the 
 consolidation is advanced to a certain degree. This precaution 
 is more especially necessary in fractures of the olecranon. 
 
 SECTION IV. 
 
 Of FraEiiires of the Olecranon. 
 
 This curved process, by which the cubitus is terminated su- 
 periorly, its anterior surface being covered with cartilage, and 
 its posterior having the tendon of the triceps brachialis inserted 
 into it, is very analogous to the patella*, and the resemblance 
 would be perfect, if the latter, instead of being attached to 
 the tibia by a strong ligament, were a continuation of its sub- 
 Stance, as the olecranon is of that of the cubitus. This simili- 
 tude is still stronger in the fradlures of these two bones; so that 
 what will be said on fraftures of the patella, to which a long 
 chapter shall be consigned, may be applied to those of the ole- 
 cranon. 
 
 These last-mentioned, which almost always take place at the 
 base, and seldom at the summit of the olecranon may be ob- 
 lique, but are more frequently transverse. They are occa- 
 sioned sometimes by the contraction of the triceps brachialis, 
 
90 OF FRACTURES OF THE OLECRANON. 
 
 but more frequently by some external force, as by a fall back- 
 ward on the elbow. The fracture of the patella is, on the con- 
 trary, more frequently produced by muscular contraction than 
 by an external cause. 
 
 When the olecranon is detached from the cubitus by any 
 cause, it is always drawn upward by the contradliun of the tri- 
 ceps brachialis, and the interval between it and the cubitus is 
 perceptible to the touch or sight, and increases or diminishes by 
 the fl( Tcion or extension of the fore-arm. The ascent of the sepa- 
 rated olecranon along the lower extremity of the humerus, may 
 be more or less considerable: in all cases however, it ascends 
 abo^-'i the condyles, or lower tuberosities of the humerus. Fi- 
 nall}, the olecranon may be pushed by the fingers to one side 
 or other, without any motion being communicated to the cu- 
 bitus. 
 
 Nothing can be easier than to distinguish by these marks a. 
 fradlure of the olecranon, from a luxation of the cubitus back- 
 ward, with which, however, it has been confounded. It is true, 
 that v;hen the fraClure has been occasioned by an extremely 
 violent cause, the contusion and inflammatory swelling may 
 be so great as to render the diagnosis difficult, if not impossi- 
 ble. But this uncertainty should not influence the treatment, 
 which must be diredled first against the inflammation, whether 
 the fracture exist or not. When the inflammation and its con- 
 comitant symptoms have been allayed by blood-letting, the use 
 of emollients and other such means, the discovery of the frac- 
 ture will be easyj and if it be found to exist, it is to be treated 
 in the following manner. 
 
 The divided parts are brought into contadl, by extending the 
 fore-arm, and pushing down the olecranon from the place to 
 which it had been drawn by the contradlion of the triceps. 
 The principal objecl is to counteract the action of this muscle, 
 which tends incessantly to separate the detached olecranon from 
 the cubitus. To efFeCl this purpose, a circular bandage, mode- 
 rately broad, is passed on the fore arm, fully extended; this 
 being done the olecranon is pushed down into contact with the 
 cubitus, and the middle part of a long compress placed behind 
 it, the extremities of which are brought downward and cros- 
 sed on the anterior part of the fore-arm; after which several 
 turns of the bandage made so as to cross one another, are car- 
 ried round the articulation of the elbow. The bandage should 
 then be rolled up on the humerus, in order to diminish, by 
 pressure, the irritability of the triceps brachialis, which is re- 
 
OF FRACTURES OF THE OLECRANONT. 9! 
 
 laxed by the extension of the fore-arm. This bandage being 
 applied, the bend of the fore-arm is filled with lint, and a long 
 splint applied on it anteriorly, by which the flexion of the arm 
 is prevented. This splint is fixed by the same bandage, rolled 
 on downward from the shoulder to the wrist, and upward 
 again if the bandage be long enough. The oblique casts of 
 the bandage, which cross one another on the articulation, form- 
 ing a kind of a figure of 8, ought to be nicely applied, and 
 drawn very tight j because if but slightly braced, their aflion, 
 which is oblique, will not be sufficient to confine the olecranon 
 to its situation. Previous to the application of these oblique 
 casts, the skin of the olecranon should be drawn up by an as- 
 sistant; for, if this precaution be not taken, it may sink be- 
 tween the divided portions and prevent their conta£l. 
 
 Though the contact be exaft immediately after the applica- 
 tion of the bandage, yet if, as is apt to happen, the bandage 
 become relaxed, or if the patient inadvertently contract the 
 triceps, the olecranon ascends, because the bandage, adting per- 
 pendicularly to its direction, can but feebly oppose the ascent 
 of this process. An interval will therefore exist between the 
 cubitus and olecranon, which will be filled up by granulations, 
 and by the thickening of the periosteum, or tendinous expan- 
 sion of the triceps which covers that bone; and the reunion of 
 the parts will be effected by means of an intermediate ligamen- 
 tous substance, the length of which will depend on the careful 
 application and frequent renewal of the bandage. 
 
 To this cause as Camper supposed, is to be attributed the 
 Impossibility of obtaining an immediate reunion of the olecra- 
 non to the cubitus, and not to a defect of periosteum, or hu- 
 meftation of the parts by synovia, as some authors have 
 thought. 
 
 We state the grounds of our opinion on this subje(5t in treat- 
 ing of fra<Stures of the neck of the humerus, and of the parella. 
 In forty or forty-five days the ligamentous substance acquires 
 its greatest consistence, but the articulation should not be kept 
 motionless so long; gentle motion may be commenced on the 
 twenty-fifty or. thirtieth day. The object of these motions is to 
 prevent a false anchylosis of the articulation, not, as David 
 thought by preventing the growth of inequalities or asperities 
 on the callus but by facilitating the absorption of the inspissa- 
 ted fluids accumulated about the part ; by stimulating the secre- 
 tion of synovia, and exciting the irritability of the muscles, 
 benumbed by long ina(Sl:ivity. 
 
92 OF FRACTURKS OF THE OLECRANON. 
 
 In cases of recovery obtained by these means, the olecranon 
 adheres to the cubitus firmly enough to transmit to it the ac- 
 tion of the triceps muscle, and to moderate the extension of 
 the fore-arm. 
 
 Compound fra(rture of the olecranon is an accident of the 
 most grievous nature on account of the great number of nerves 
 which pass in the neighbourhood of that part ; it should there- 
 fore be treated with the greatest care : the inflammatory symp- 
 toms are to be combated by copious and repeated bleedings i 
 the arm is to be placed half bent on a pillow, and dressed with 
 Scultet's bandage. In these cases the intermediate ligamentous 
 substance is always longer than in simple fracture, and, conse- 
 quently, the force of the arm is much diminished. If a false 
 anchylosis be prevented by judiciously exercising the articula- 
 tion as soon as the state of the parts will permit, the patient 
 may think himself fortunate. 
 
 If the inflammatory swelling, &c. be not dissipated before 
 the twenty-fifth or twenty-sixth day, the application of the ap- 
 paratus we have described will be useless, because it will be ne- 
 cessary, at that time, to begin to exercise the articulation, the 
 formation of the ligamentous substance being then considerably 
 advanced. 
 
n 
 
 CHAPTER XII. 
 
 OF FRACTURES OF THE BONES OF THE HAND. 
 
 SECTION I. 
 
 Of FraBm'es of the Bones of the Carpus. 
 
 THE eight small bones which, placed in two rows, com- 
 pose this part of the hand, are susceptible only of com- 
 miautive fracture. Their smallness, and spongy texture, do 
 not admit of their being fractured but by a cause which a£ts 
 on them immediately; and, in fadt, fractures of them are al- 
 ways occasioned either by a gun-shot wound, or some very 
 heavy body falling on the hand. It is obvious that in cases of 
 this nature, more attention is to be paid to the state of the 
 soft parts than to the fra(Sture. It often happens, that fractures 
 of these bones render amputation at the articulation of the 
 wrist necessary, or even that of the fore-arm. 
 
 SECTION II. 
 
 Of Fraclures of the Bones of the Aletacarpus. 
 
 Fractures of these bones are rare, because any impulse re- 
 ceived by the hand is divided between all these bones. That 
 which supports the thumb, and which is imconnected with the 
 others, Avould be frequently fractured, if its mobility did not 
 secure it against that accident. 
 
 These fractures are always the result of a force immediately 
 applied i for the length of the metacarpal bones, though ranged 
 
94- FRACTURES OF THE METACARPUS. 
 
 in the class of long bones, so little exceeds their other dimen- 
 sions, that It can never happen that a force acling on their ex- 
 tremities can break them about their middle part. If the hand 
 be very forcibly pressed between two bodies, or if a heavy bo- 
 dy fall on it, commlnutlve fracture will be the result; and al- 
 most always several of these bones are fractured at once. The 
 following case, however, furnishes an example of a fraflure of 
 one of them. An armourer proving some muskets, made use 
 of an iron ram-rod for setting fire to the priming: the musket 
 was forced back by the explosion, and the iron rod thrust into 
 his hand, so as to projcft on the other side, and raise up the 
 integuments. The rod was drawn out, and the wound dressed 
 with lint and emollient poultices; and on the fourth day the 
 patient complained of excessive pain, when he attempted to 
 bend the fourth or ring finger. On examining the part with 
 care, and pressing the fourth bone of the metacarpus, it was 
 found by the crepitation and motion, that that bone was frac- 
 tured. Two long compresses were applied, one to the palmi 
 and the other to the back of the hand, both corresponding- 
 to the fractured bone: over these were placed splinis, which 
 extended to the extremity of the finger. A bandage was then 
 rolled round the hand and three last fingers. The suffering of 
 the patient ceased immediately on the application of this band- 
 age, and his recovery was complete in six weeks. Comminu- 
 tive fradture of these bones, as well as that of the carpus, fre-» 
 quently renders amputation necessary. 
 
 SECTION III. 
 
 Of F-raclurcs of the Phalanges of the Fingers. 
 
 Fractures of these bones being uniformly the effedl of the 
 immediate action of the cause, are always attended with more 
 or less contusion. The alteration in the form of the finger, 
 the motion of the broken pieces, and the crepitation occasion- 
 ed by it, leave no doubt as to the existence of the frafturc. 
 
 The longitudinal derangement of a fractured phalanx is ve- 
 ry difficult; and, in fa£l, that in the horizontal direction is 
 almost the only one observed : it is cfl'e(rted by the lloxor 
 tendons, which draw the inferior portion to their side. The 
 
FRACTURES 07 THE FINGERS, 95 
 
 broken pieces may be brought into their proper situation, by 
 pulling by the extremity of the finger, whilst the hand is fixed 
 by an assistant. A circular bandage, moistened with a solu- 
 tion of acetate of lead, is then rolled round the finger, and 
 over that are placed four splints of thin wood or pasteboard, 
 which are fixed on by the same bandage: tlie whole dressing 
 is completed by including the two adjacent fingers in the last 
 turns of the bandage. 
 
 Fra<flures of these bones are generally united in twenty-five 
 or thirty days, but the finger continues a little stiff for about 
 two months, at the end of which time the stiffness entirely 
 Tanishes. 
 
 When a very heavy body has crushed the extremities of the 
 fingers, or when they have been bruised by a folding door, the 
 soft parts are generally lacerated, the nail torn off, and the last 
 phalanx fra«Slured and denudated. If in such cases the parts 
 hold together bya shred of a- certain thickness, 'and which con- 
 tains vessels enough for the nourishment of the phalanx, the 
 reunion of the parts should be attempted. The prospect of 
 success, it is true, is not great in most cases; but if our en- 
 deavours to save the finger fail, amputation is still as much in 
 our power as in the commencement. 
 
 If the last phalanx alone is crushed, it will be better to am- 
 putate at once, than attempt to save the joint. The cure would 
 be tedious and difficult, on account of the exfoliation that 
 would take place. Besides, the part being deformed, instead 
 of being useful would be troublesome. By amputating at the 
 articulation with the second phalanx, a simple wound is substi- 
 tuted to the lacerated and ragged wound produced by the cause 
 of the fracture. This will heal in a very short time, if care 
 be taken to preserve a siifiiciency of skin to cover the sru-face 
 of the articulation. 
 
96 
 
 CHAPTER XIII. 
 
 OF FRACTURES OF THE THIGH. 
 
 WHAT has been said of the treatment of fraclures in 
 general, in the first chapter of this work, is more 
 especially applicable to those of this bone than to any other. 
 The femur is much exposed to fradlure from the nature of its 
 functions, its length and dire£lionj and notwithstanding the 
 great depth of soft parts by which it is covered, yet it is fre- 
 quently fractured. 
 
 It may be fra(Sl:ured in any point of its length, near the mid- 
 dle or either extremity. We shall devote a particular chapter 
 to fraftures of its superior extremity, or neck; but, besides 
 these last mentioned, there is another species of fracSlure, 
 which consists in the separation of the great trochanter from 
 the body of the femur. In the fraftures of the lower extre- 
 mity of the femur, not only one of the condyles may be sepa- 
 rated longitudinally from the rest of the bone, but both con- 
 dyles may, at the same time, be separated one from the other, 
 and from the rest of the bone. All varieties of simple or 
 compound fradbure may be observed in those of the femur. — 
 They may be produced in any part of it by a cause adting im- 
 mediately on that part, or by a force ailing on its extremities, 
 which will probably produce a fracture of the middle part, 
 where the bone is naturally bent: a fradlure produced by any 
 of these causes, may be transverse or oblique. 
 
 Derangement of the fraftured portions is a uniform conco- 
 mitant of fradlures of the thigh; it may take place in any of 
 the four direi^ions already repeatedly mentioned, but that 
 most frequently observed is the longitudinal derangement by 
 which the limb is shortened. The numerous muscles of the 
 thigh, by means of which derangement may be efFc6ted, are 
 divisible into three classes, relative to the manner in which 
 they tend or contribute to effedt it. The three portions of the 
 triceps femoris are attached to both pieces, and tend to produce 
 the angular derangement by drawing the two fractured nor- 
 
OF FRACTURES OF THE THIGH. 57 
 
 tions to a salient angle on the outside, where their fibres are 
 the strongest and most numerous. The biceps femoris, semi- 
 tendinosus, semimembranosus, sartorius, redlus internus, and 
 third addudlor, all those, in short, which extend from the pel- 
 vis to the inferior portion, or to the leg with which it articu- 
 lates, tend to draw the inferior portion upward, on the internal 
 side of the superior, the extremity of which forms a tumour 
 on the external side of the thigh. The inferior portion is that 
 which is always displaced, except when the fradture takes place 
 immediately under the small trochanter, to which pioce'i'^ are 
 attached, by a common insertion, the psoas and illiacus muscles; 
 which muscles would, in such a case, draw the superior portion 
 upward and forward, producing by that means a tumour in 
 the groin. 
 
 When the femur is fractured immediately above the con- 
 dyles, the inferior piece is drawn backv/ard, and its superior 
 surface turned downward by the atftion of the gastrocnemius 
 externus, plantaris, and popliteus muscles. When the great 
 trochanter is detached from the rest of the bone, it is drawn 
 upward by the muscles which are inserted into it, but without 
 producing any change in the diredtion or form of the thigh. 
 
 The angular derangement in which the foot inclines either 
 inward or outward, is the effedt of the weight of the foot, or 
 of the bed clothes, rather than of muscular contra(5lion. It 
 shall be mentioned more particularly in treating of fractures of 
 the neck of the femur. 
 
 Deformity and diminution of the length of the limb, a 
 change in its dire6lion, the tumour occasioned by the deranged 
 portions of the broken bone, the impossibility of performing the 
 ordinary motions, the acute pain and crepitation produced by 
 the motion of the broken pieces one on the other, indicate a 
 fracture of the femur in such a marked manner, that it is im- 
 possible to mistake it. Fractures of the thigh are, caterls pari- 
 busy more dangerous than those of any other of our limbs, on 
 account of the difficulty of keeping the pieces in a proper si- 
 tuation. The ancients considered a fracture of the femur dif- 
 ficult to be cured without a shorteniiag of the limb; but at 
 present the possibility of cure without any change or deformi- 
 ty is attested by numerous instances. It is to be remarked, 
 however, that nlore unremitting care and attention is necessa- 
 ry in fraiHiures of this bone, than in those of any other. 
 13 
 
9? OF FRACTURES OF THE THIGH, 
 
 We shall point out, at some length, the objecls to which 
 the attention is to be particularly directed in the treatment of 
 these fraftures. 
 
 The bed in which the patient is to lie should not exceed 
 three feet in breadth; a broader bed would render the raising 
 and re-application of the apparatus very troublesome. It should 
 have no foot-board, otherwise the assistant, whose duty it is 
 to make the extension, could not conveniently draw the leg in 
 the proper diredlion. Instead of a bed of down or feathers, a 
 hair mattress should be used, which will not allow the limb, the 
 ■weight of which is augmented bv the apparatus, to sink. If 
 mattresses of wool are the only bedding to be found, their so- 
 lidity should be increased by placing between them thin elastic 
 boards. The head of the patient should repose on a simple 
 pillow, the horizontal position being one of the desiderata. 
 When the head is too much raised by pillows, &c. the body 
 tends to descend, and deformity of the limb will be the conse- 
 quence, whatever attention may be paid in other respefts. 
 
 These particulars relative to the bed being punftually attend- 
 ed to, an apparatus, as follows, is in the next place to be pre- 
 pared: First, as many bandages, of three fingers breadth each, 
 as will be sufficient to cover the leg and thigh, and which will 
 form what has been already described under the name of Scul- 
 tet's bandage: secondly, a number of long compresses, wet 
 with some resolvent liquid, which are placed on such parts of 
 the limb as appear most inflamed: thirdly, a splint-cloth, or 
 fanon^ in which the two lateral splints are rolled: the splints 
 should be long enough to extend externally, from the ridge of 
 the OS ilium, and internally, from the articulation of the fe- 
 mur to a few inches beyond the sole of the foot ; and anteri- 
 orly from the groin, or anterior side of the articulation of the 
 femur with the bones of the pelvis, to the instep: fourthly, three 
 bags of chaff, by means of which the sides of the thigh may be 
 rendered parallel with the splints: fifthly, and finally, five strings 
 or ribbands, by which the rest of the apparatus arc to be secured 
 externally: two are to be placed on the thigh, two on the leg, 
 and one is to be crossed on the instep and sole of the foot, and 
 its ends made fast to the internal and external splints, in order 
 to prevent the vacillation of the foot. 
 
 Some pra(Stiti oners apply Scultet's bandage on the thigh only, 
 and do not extend it to the leg, nor envelope the foot in long 
 compresses, drawn moderately tight j in consequence of which 
 negledl, the leg and foot are apt to swell, from the return of 
 
©F FRACTURES OF THE THIGH. ^A 
 
 the fluids being impeded by the compression of the bandage on 
 the thigh. 
 
 This apparatus should be extended on the bed on which the 
 patient is to be laid, in the order of their application ; that is, 
 first the strings or ribbands; next the fauofi or splint-cloth; and 
 over that Scultet's bandage, of which the different parts should 
 partially cover one another; and last of all, the compresses. 
 The patient, if dressed, is to be undressed very gently, and 
 the fractured limb is to be moved as little as possible. In con- 
 veying the patient to the bed on which he is to lie during the 
 treatment, the surgeon himself ought to support the fractured 
 limb, and place it exactly on the middle of the apparatus. The 
 setting is in the next place to be proceeded to; to effect which, 
 the strongest of the assistants renders the pelvis immoveable, by 
 pressing on the anterior and superior processes of the ossa ilia, 
 whilst another assistant seizes the foot with both hands, the 
 thumbs applied to the sole, and the fingers crossed on the up- 
 per part, and draws it with a gradual effort, first obliquely 
 outward, and then quickly in its natural- direction : the surgeon 
 placed on the external side, performs the coaptation; but the 
 great depth of integuments renders this part of the operation 
 almost entirely useless. 
 
 The natural form and length of the limb being restored, the 
 assistants continue the extension and counter extension, while 
 the surgeon applies the different parts of the apparatus in the 
 order already described, rolling compresses on the thigh and leg, 
 and commencing the application of Scultet's bandage from the 
 lower extremity of the leg, and proceeding upward. The splints 
 rolled up in the cloth, are placed perpendicularly on their edges, 
 at a small distance from the leg, in which interval bags of chaff 
 are to be placed, and, on the chaff being pushed into the dif- 
 ferent depressions, so as to equalize the surface of the limb, and 
 provide for the equable pressure of the splints, these latter are 
 pressed against the limb by the hands of an assistant, while the 
 surgeon ties on the strings, by commencing with the one at the 
 middle part of the thigh. The fillet crossed on the foot, and 
 tied to the extremities of the lateral splints, is the last apphed. 
 
 It may be necessary to bleed the patient once or twice, and to 
 confine him to the antiphlogistic regimen for four or five days, 
 at the end of which time no disagreeable consequences are to be 
 apprehended. If the pain and suffering of the patient be not 
 excessive, the apparatus need not be raised for the first three 
 or four days, but this measure should not be deferred beyond 
 
lOO OF FRACTURES OF THE THIGH. 
 
 that time; fof, however well the fracture may have been set, 
 and however well and permanently the apparatus may appear to 
 have been applied, yet it is possible that the pieces of bone may 
 have been displaced by the aftion of the muscles. By neglect- 
 ing this precaution, and raising the apparatus only every eight 
 days, the fractured portions have passed one another, and con- 
 solidated in that situation, and a lameness has been produced, 
 which could never be remedied. At the end of about forty-five 
 days, when, after having reapplied the apparatus eight or nine 
 times, the callus is found so far formed as to bear the motion 
 of the whole member, Scultet's bandage is to be taken off^ 
 and a simple roller substituted in its stead, capable of compres- 
 sing the soft parts, and of preventing the oedematous swelling 
 likely to take place. 
 
 The foregoing mode of treating fraftures of the femur, and 
 which is efFecStual when they are transverse, is of little or no 
 efFeft in cases of oblique fraclure, which was supposed by the 
 ancients to produce necessarily a shortening of the limb. In 
 order to prevent this continued extension, the mechanism of 
 which shall be explained in the chapter on fra£lures of the neck 
 of the femur, has been employed by the moderns. 
 
 If a very young child, as for instance, one of two or three 
 years, is to be treated for a fracture of the thigh, a roller of 
 one piece may be employed instead of Scultet's bandage. Four 
 elastic wooden splints should be applied on the opposite sides of 
 the limb, and secured by the circular bandage, a part of which 
 has been already applied. It is not necessary, in this case that 
 the splints should be longer than the limb, because the foot, at 
 that age, bears a less proportion to the rest of the member, than 
 at a more advanced period, and is not weighty enough to draw 
 the limb to either side with it. The principal reason for pre- 
 ferring the circular bandage in the case of children, is the dif- 
 ficulty of re-applying the other apparatus every day, or as often 
 as it maybe soiled by the urine and faces : it will be necessary, 
 for the same reason to roll up the whole limb, after the appara- 
 tus has been applied, in several folds of a strong linen cloth, 
 which should be renewed every day. This is the only case in 
 which Scultet's bandage is not to be preferred to any other. 
 
 When the femur is fradlured near the condyles, it will be 
 necessary to stuff the hollow of the ham with lint, in order to 
 prevent the lower fractured portion from being drawn back by 
 the action of the muscles attached to It: if this derangement be 
 not guarded against, the popliteal nerves and vessels may be 
 
OF FRACTURES OF THE THIGH, lOI 
 
 wounded by the protrusion of the fraftured end of the bone, 
 and the worst consequences may ensue. 
 
 If the great trochanter be separated from the rest of the 
 bone, the middle part of a long compress is to be applied on 
 that process, and its extremities drawn downward and inward ; 
 over which compress a spica bandage for the groin is to be ap- 
 plied. 
 
 More time is necessary for the consolidation of fradlures of 
 the femur, than for those of any other long bone, on account 
 of the great compadbiess of its texture, particularly near its 
 middle part. For this reason it is in general necessary to con- 
 tinue the apparatus applied for fifty days, and sometimes for 
 even a longer time. 
 
 If the consolidation be very tedious, a stiffness in the articu- 
 lation of the knee will be a necessary consequence; and, if the 
 fracture be so near the condyles as that the swelling and ob- 
 strudlion may extend to the articulation, this consequence vi'ill 
 be inevitable, and very difficult to remove. 
 
 It would be superfluous to repeat here, respecting compound 
 fradtures of the femur, what has been already said on this sub- 
 ject in the first chapter, and frequently repeated by particular 
 applications. We shall therefore without further delay, pro- 
 ceed to consider the fradlures of the neck of the femur. 
 
102 
 
 CHAPTER XIV. 
 
 OF FRACTURES OF THE NECK OF THE FEMUR. 
 
 THE neck of the femur may be fractured in any point of 
 its extent. The fracture, however, most frequently takes 
 place in its middle part, and more generally towards or at its 
 base, than at its union Math the head of the femur, although 
 its base is its thickest part. These fractures exist stricStly speak- 
 ing, within the articulation; the orbicular ligament of which 
 adheres to the lower portion of the bone, the superior having 
 no connexion with the rest of the body, but by the round liga- 
 ment; except, however, the case in which the ligament re- 
 flected round the neck is not entirely ruptured. These fractures 
 are almost always transverse; the reason of which is found in 
 the spongy texture of the bone. In many cases the surfaces of 
 the divided bone are very unequal, the one being marked with 
 asperities or eminences, and the other with corresponding de- 
 pressions. 
 
 There is another species of variety of this fracture which takes 
 place outside the articulation, near the union of the bone with 
 its trochanters, and sometimes between these two eminences, 
 the greater of which adheres then to the superior portion. 
 There have been so many instances of fractures of this nature, 
 that all are now agreed as to the possibility of their taking 
 place. 
 
 A member of the ci-devant Academy of Surgery fell on the 
 great trochanter; the extremity of this side became shorter 
 than that of the opposite, the foot and the knee inclined out- 
 ward, and in short, all the symptoms of frac^ture of the neck of 
 the femur were manifest, and the existence of such a fracture 
 was agreed on by a number of his brother surgeons. The frac- 
 ture was treated in the ordinary way, and a cure was obtained, 
 but not without a shortness of the limb. This person died short- 
 ly after from another disease; his body was opened, and the 
 
 \ 
 
OF FRACTURES OF THE FEMUR. lOJ 
 
 articulation of the thigh examined, when it was found that the 
 fracture had taken place below the insertion of the orbicular li- 
 gament. I am indebted for this case to Citizen Lesne, a dis- 
 tinguished member of the Academy, and editor of the Posthu- 
 mous Works of J. L. Petit. Citizen Boyer has met several cases 
 of a similar kind. 
 
 I have seen a remarkable case of a shortened inferior extre- 
 mity, in an old man, who died in the hospital of La Charitffy 
 in the year seven. A double fradlure was found, one inside and 
 one outside the orbicular ligament; the latter between the two 
 trochanters, the larger of which was separated from the rest of 
 the bone. Although the patient was eighty three years of age, 
 yet the consolidation had commenced. 
 
 Fradlure of the neck of the femur, generally simple, is some- 
 times complicated with that of the great trochanter, very rarely 
 with contusion, because the force which produces it does not 
 aft immediately on the part. Protefted by a great depth of 
 soft parts, and by the great trochanter, the neck of the femur 
 is seldom fradlured comminutively. That might however take 
 place from a gun-shot wound; but as in that case the bones of 
 the pelvis must also be fractured, and the parts contained in it 
 injured : the fradlure of the neck of the femur is but the slight- 
 est part of the affedlion. 
 
 Amongst the various fradlures of the neck of the femur ought 
 to be enumerated the decollation of the epiphysis, which, 
 though rare, has yet been observed. Pare* mentions the pos- 
 sibility of this decollation, allows that its diagnosis is extremely 
 obscure, and assures us at the same time, that it has been often 
 mistaken by very expert surgeons for a luxation. Young per- 
 sons only are subjedl to this accident, because it cannot take 
 place when the cartilage which unites the neck to the bone is 
 ossified. 
 
 The superior extremity of the femur is entirely cartilaginous 
 in the new-born infant; but soon after birth three points of ossi- 
 fication maybe observed in it, one corresponding to the head of 
 that bone, and the two others to the trochanters. These osse- 
 ous points gradually spread, the cartilage diminishes, and at 
 length entirely disappears; but the ossification of the head and 
 neck is much slower than that of the trochanters ; nor does the 
 cartilage of these parts totally disappear before the eighteenth 
 or twentieth year. 
 
 * Works of Ambrose Pare, lib. 15. chap. ai. 
 
104 OF FRACTURES OF THE FEMUR. 
 
 It is easy to conceive that an accident, which at a more ad- 
 vanced period of life would produce fratfture of the neck of 
 the femur, will with more facility separate the head before the 
 age of eighteen or twenty. It may even happen that a force 
 "which does not produce this decollation, shall however, disjr- 
 ganize the cotyloid cavity, by impelling inward towards the 
 pelvis the parts of the three bones of which that cavity is com- 
 posed. Ludwig* has given a case of this kind. When the 
 head and neck of the femur are completely united, their point 
 of union is seldom the situation of a fra^hire; and, as Duver- 
 ney remarks, decollation is then impossible! . '^^^ symptoms of 
 decollation differ little from those of fra6lure: the dull crepita- 
 tion which has been given as a sign by J. L. Petit:]:, is by his own 
 acknowledgement very equivocal. But this difficulty in form- 
 ing a diagnosis is of no great consequence, as the treatment 
 does not differ from that of fracture of the neck of the femur; 
 nor is the prognosis more unfavourable, notwithstanding what 
 Columbus^, arguing from the difficulty of setting the divided 
 portions with acuracy, says to the contrary. 
 
 Predisposing Causes. — Brittleness of the bones, as well as the 
 vices of the constitution on which it depends, has been already 
 given a« a predisposing cause of fra(fture. Caries may be look- 
 ed on as a predisposing cause of fra6lure of the neck of the fe- 
 mur, by its destroying a part of the substance of the femur j 
 but as in this case artificial means can have no effect in produ- 
 cing a consolidation of the fraflure, and as the caries will pro- 
 bably occasion the patient's death, unless nature effedt the union 
 of the carious bone with some part of the pelvis, it seems use- 
 less to give any further consideration to fractures, or division of 
 the neck of the femur from this cause. Rickets, which some 
 authors have mentioned as a predisposing cause of fradlure, ra- 
 ther prevents it by rendering the bones flexible. 
 
 Duverney has given a case of a fraclure of the neck of the 
 femur, in which the vcYiereal disease was evidently the predis- 
 posing cause. But in cases arising from an internal cause, the 
 removal of that cause is the principal objedl. 
 
 Exciting Causes. — A fall on the great trochanter is the most 
 frequent exciting cause j and fracture of the neck of the femur 
 
 * De Co'ilo Femoiii ejusqiie Frnflura Progranima. Lipsiae. 
 •f- Traite des Maladies des Os, vol. i. chap. 2, art. j,, 
 X Ibid. \: I. ii. 
 \ De Re Anatomica. 
 
OF FRACTURES OF THE FEMUR, I0<; 
 
 is SO frequently a consequence of that accident, that when the 
 one h.is taken place, the other is generally presumed. This ob- 
 servation made by Citizen Sabatier* has been confirmed by ma- 
 ny particular cases treated in the principal hospitals in Paris. A 
 fall on the feet or knees sometimes occasions a fradVure of the 
 neck of the femur, in which case the weight of the body must 
 be thrown more on one side than on the other. 
 
 Let us examine the manner in which this fradlure maybe pro- 
 duced. 
 
 When a person falls on the great trochanter, the neck of the 
 femur is a£led on by that eminence which has ^ point d'nppition 
 the ground, and by the body which a(Sts immediately on the 
 head of the femur. By this action and re-a6lion, a force is ex- 
 erted on the neck of the femur, which tends to make it paral- 
 lel with the rest of the bone. By this tendency, that part of 
 the bone is curved beyond its natural extensibility, and from 
 the nature of the curve into which it is forced, its lower fibres 
 break first, and so on successively to the superior, which break 
 last; on the supposition that the rupture of these fibres was suc- 
 cessive. In falling on the feet or knees, on the contrary, the 
 tendency of the fracluring cause is to force the neck of the fe- 
 mur to forma right angle with the bone; and the rupture of 
 the fibres must of course commence in the superior. 
 
 From this view of the mechanism of these fractures, it is evi- 
 dent that they are never direct, that is, produced by a cause 
 acting immediately on the part; but that they are, on the con- 
 trary, always the effevSl of a force communicated to that part 
 hy contre-cotip or transmitted re-aclionj as has been observed by 
 Davidf. The contusion which in general is but ti-lfling in in- 
 dlredl fratTtures, or those ^^^r contre-cotip^ may however be con- 
 siderable in this case, when produced by a fall on the trochan- 
 ter; for this reason, that, though the force be transmitted, yet, 
 on account of the shortness of the neck of the femur, the frac- 
 ture must take place near the part immediately afi:e<5led; so 
 that, with respeit to contusion, fradtures of this part may be 
 considered as direct. 
 
 Fractures of the neck of the femur are always attended with 
 derangement: it is po-sible, however, that this derangement 
 may not take place for a few days after the fra(fture. There 
 arc in the Memoirs of the Academy of Surgery, the particulars 
 
 * Msm. At V Acad, de Chiiiirj^ie 
 
 -}- Frize-qticstioiis of tlie Academy of Surgery, vol. iv. 
 
 14. 
 
Io6 OF FRACTURES OF THE FEMUR. 
 
 of a case in which a man after having fractured the neck of 
 the femur by a fall, was able to rise without any assistance, and 
 walk home to his lodging. A similar case is found in Desault's 
 Journal. Finally, a great number of cases collected by Louis, 
 Duverney, Sabatier, and other authors of no less authority, 
 and those observed by Citizen Boyer, leave no doubt on the 
 possibility of a derangement ensuing several days after the 
 fraclure. And it is easy to conceive that in a fra^lure of what 
 is properly called the neck of the femur, the orbicular ligament 
 may oppose the derangement, and counteract the aftion of the 
 powerful muscles, which pass from the pelvis to the lower frac- 
 tured portion, into which, also, the orbicular ligament is in- 
 serted. 
 
 Another cause which must contribute to prevent derange- 
 ment, is the proje(5lions and depressions of the surfaces of the 
 pieces, which inequalities render lateral motion difEcult. We 
 have already remarked this circumstance, in treating of the di- 
 rection of the fracture, which, accurately speaking, is neither 
 oblique nor transverse. 
 
 The fraifirures within the articulation are never attended with 
 a very considerable derangement. The orbicular ligament yields 
 a little without being torn; the body and neck of the bone, in- 
 stead of their oblique or angular position becomes redlilinear; 
 from which change of diredlion, as well as from a slight de- 
 rangement in the dirC(Slion of the diameter, arises the shorten- 
 ing of the limb. Louis has asserted that the derangement may 
 be considerable, but has not supported this assertion either 
 by facts or reasoning. In fractures outside the articulation, or 
 between the trochanters, the muscles which tend to produce 
 the derangement act without any opposition and draw the in- 
 ferior fractured portion outward, upward, and a little back- 
 ward toward the iliac depression. The great trochanter ap- 
 proaches the brim or ridge of the iliac bone, but never passes 
 under the glutei muscles, which cover the surface of that 
 bone. 
 
 The action of the muscles which are inserted into the infe- 
 rior portion, and particularly that of the glutei, is not the sole 
 cause of the derangement; that effect being in part produced 
 by the weight of the body, which forces the pelvis downward, 
 and with it the superior portion of the femur: muscular a<Stion' 
 is however the principal cause. 
 
 Besides the longitudinal derangement, that in the circum- 
 ference also takes place in consequence of the rotation of tlie 
 
OF FRACTURiES OF THE FEMUR. 107 
 
 whole inferior extremity outward. This is effedted by the 
 weight of the part, rather than by the allien of the rotatory 
 muscles. If the rotation of the Uinb were produced by the con- 
 tra£lion of these muscles, there would be more difficulty in 
 bringing the foot to its natural position, or in inclining it in- 
 ward, than in reality is found in bringing it in any of these di- 
 retStions. But in order to be fully convinced of the cause of 
 this rotation, it is only necessary to observe the position which 
 the inferior extremiry assumes, when a person laid horizontally 
 on his back abandons it to its own weight: in such a case the 
 foot and knee incUne constantly outward. 
 
 The derangement may take place internally, either by a par- 
 ticular disposition of the extremity, by the pressure of the 
 bej-clothes, or some such cause. Pare and Petit describe the 
 derangement as having taken place internally, in all the cases 
 of this kind that occurred to them. Louis has endeavoured to 
 give a favourable turn to the report of Pare. He says that Pare 
 meant merely to state that the foot was separated from the op- 
 posite leg by a less interval than the knee of the same side; 
 which observation is true in a certain sense, even when both 
 are turned outward. As to Petit we must either suppose that 
 a deference for the opinion of Pare led him into an error of fact 
 or expression, or that the mistake originated with the copyist 
 or printer. But since the publication of Louis's explanation in 
 the Memoirs of the Academy, the possibility of derangement 
 inwards has been ascertained by observation. Desault conclu- 
 ded from his experience that the rotatory derangement inward 
 "was to that outward as 1 : 4. 
 
 Diagnosis. — The resemblance between the symptoms of this 
 fracture and luxation, has frequently occasioned these two af- 
 fedlions to be confounded witli one another. Thus we find 
 that luxation of the femur was known to the ancients, and that 
 fradture of the neck of that bone was unknown until described 
 by Pare. He is, at least the first author who has given any 
 clear and positive information on that subjedl. Since his time, 
 observations on the nature of this afFeftion have been multipli- 
 ed; but as yet authors are not agreed as to the symptoms by 
 which it is distinguished. 
 
 Fradture of the neck of the femur is so frequent a conse- 
 quence of a fall on the great trochanter, that the former ha- 
 ving taken place, renders the other highly probable: an acute 
 pain felt in the articulation augments that probability. But the 
 fell or pain which may not exist even when the fracture has 
 
I08 OF FRACTURES OF THE FEMUR. 
 
 taken place, as in a case related by Duvcrney, are equivocal, 
 or at best but corroborating circumstances. The sensible signs 
 are those alone on which the diagnosis is to be founded : they 
 are as follows: 
 
 It sometimes happens, that in the moment of falling the pa- 
 tient hears a crack in the articulation, and remains without the 
 power of raising himself. Shortening of the limb is a conse- 
 quence of this fra6lure; but as that does not always take place 
 immediately, it cannot assist in forming the diagnosis in every 
 case; but the uncertainty arising from tlie want of that sign is 
 quickly removed, for the shortness supervenes in a few days. It 
 may not be superfluous to remark, that in ascertaining the 
 shortness of the limb, the patient should be laid supine on an 
 horizontal plane, and the pelvis so placed as that its anterior 
 and superior spinous processes may be in the same horizontal 
 line. 
 
 The point of the foot is turned outward, as is the knee, and 
 the l-jg bent so as that the heel is turned inward, and placed be- 
 hind the ankle of the other foot, in the depression between the 
 annie and tendo Achiliis. 
 
 It very rarely happens that the heel is placed above the an- 
 kle, except, however, when the fracture is outside the articu- 
 Lation, and the longitudinal derangement very consiJerable. 
 In fractures of the part strictly called the neck, it would be 
 necessary, in order that the ankle should be so placed, that the 
 fravSture had been produced by a fall on the feet or knees from 
 a great height, and that the orbicular ligament had been en- 
 tire! 7 torn, of which no example has as yet been observed. 
 
 The limb may be brought to its natural length by means of 
 extension and counter-extension, but it shortens again instant- 
 ly if left to itself. The foot may, with great facility, be placed 
 in its natural position, without causing in any degree the pain 
 and suffering which Citizen Sabatier seems to have apprej end- 
 ed •, he says, that the attempt is imprudent, and the motion 
 difficult. The asperities of the broken pieces can seldom irritate 
 or lacerate the soft partSj because the orbicular ligament is sel- 
 dom entirely torn: to that cause, however. Citizen Sabatier 
 attributes the pain and difficulty, which he considers as being 
 so formidable 
 
 In bringing the limb into its natural diretStion, the fractured 
 surfaces are rubbed one against the other j and this friction, 
 more or less considerable according to the asperity of the sur- 
 faces, produces a crepitation, which is one of the surest signs 
 
OF FRACTURES OF THE FEMUR. 
 
 109 
 
 of fra^ure. It has been asserted by some writers, that the 
 great depth of soft parts prevents the crepitation from being 
 heard, whieh for that reason, say they, can be no sign of this 
 fraiSlure. But the clear and distin(St perception of the noise is 
 a better proof of its existence than any reasoning can be of its 
 impossibihty; and we assert, that it is possible in most cases to 
 tear it. I have myself frequently heard it, by applying, it is 
 true, a very attentive ear. 
 
 In turning the limb, in order to place the foot straight, or 
 to incline it inward, the gfeat trochanter will be found, by 
 placing the hand on it, to move in a very small space, or, as it 
 were, on itself pivot-like. But in the rotation of the thigh 
 in its natural state, that eminence describes an arch ol a circle, 
 the radius of whieh is composed of the length of the neck and 
 head of the femur ; but after the fradlure, the diameter of this 
 circle is composed of the diameter of the bone and of that part 
 of the neck which remains below the fracture. Whence we 
 may conclude, that arches described by the great trochanter in 
 cases of fraiSture of the neck of the femur, will be so much the 
 greater, as the fracture takes place nearer the head, and that this 
 arch will be at its maximum in the case of decollation of tJie 
 epiphysis. In order to appreciate this sign it will be necessary 
 to compare the arches described by the trochanter of the 
 fra£lured member with those described by that of the opposite 
 side. 
 
 When the fracture is outside the articulation, the trochanter 
 appears less, and is nearer the ridge of the ossa ilia than in the 
 natural state. The buttock is also rounder than natural, 011 
 account of the relaxation of the muscles. 
 
 Another sign of which authors have made no mention, but 
 which is constant, is the impossibility of raising the member 
 all at once; that is, of bending the thigh on the pelvis, the 
 leg being extended on the thigh. It is necessary for the exe- 
 cution of this motion, that the limb have a point d'appui in the 
 acetabuluni: it may be compared to the circular motion with 
 which the hand is raised to the forehead, and which is imprac- 
 ticable when the humerus has lost its point d" appui by a fracture 
 of the clavicle. In attempting to raise the thigh, the patient 
 first bends the leg analogously to the effort made to bring the 
 hand to the forehead, by bending the fore- arm.* 
 
 * It will always be easy to d stinguish the imposs b lity of this motion 
 resulting fiom puin, tVoni that resulting horn the want ct' a point d^cppui 
 
IIO OF FRACTURES OF THE FEMUR. 
 
 According to Louis, much pain is produced by moving the 
 fraftured limb from that of the opposite, and none at all by 
 the contrary motion: this difference he attributes to the action 
 of the lower fractured portion on the soft parts of the external 
 side, and considers the pain caused thereby as a distindlive sign 
 of the fracture. We have already said, that a derangement as 
 considerable as that supposed by Louis never takes place. If it 
 really did, adduilion and abdudtion ought to be equally painful; 
 and, in fadl, every motion given the limb, no matter m what 
 diredlion, causes more or less pain; but pain, however produ- 
 ced, is a very equivocal sign, as it belongs equally to all dis- 
 eases of the articulation. 
 
 Of all affeftions, there is none so easily confounded with 
 the fradture of which we are treating as the different species 
 of luxation of which the thigh is susceptible. The luxation 
 upward and outward is the most easily mistaken for fracSture, 
 notwithstanding the two affections have in common only the 
 shortening of the member. The impossibility of restoring the 
 limb to its natural length by a gentle effort, its permanence in 
 the natural situation when once restored, and, before that is 
 done, the impossibility of turning the foot outward, which has 
 been carried inward, are signs by which that species of luxa- 
 tion can be easily distinguished from fradture of the neck of 
 the femur. 
 
 In the luxation inward and upward, In which the head of 
 the femur is propelled toward the pubis, the extremity is 
 shortened, and the foot turned outward ; neither of which cir- 
 cumstances can be corrected without antecedently restoring the 
 femur to its natural situation. 
 
 Luxations downward, whether inward or outward, can ne- 
 ver be mistaken for this fracture, because in these the member 
 is always lengthened. 
 
 The secondary, or spontaneous luxation of the femur, is al- 
 ways preceded by dull pains felt in the superior and inferior ar- 
 ticulations of that bone; it is further characterized by a gradu- 
 al elongation of the member, and then by a sudden shortening 
 and a diminution in the interval which separates the great tro- 
 chanter from the ridge of the iliac bone; by the inclination in- 
 ward of the foot and knee; finally, by all the symptoms of lux- 
 ation upward and outward, joined to the induration of the soft 
 
 for the ferhiir. This impossibility remaining after the inflammntory symp- 
 toms have ceased, will always be a pathognomonic sign. 
 
OF FRACTURES OF THE FEMUR." Ill 
 
 parts, the abscesses which form in these parts, and which ter- 
 minate in fistulse. All these signs leave no possibility of its 
 being mistaken for a fradlure of the neck of the femur, an 
 affe(Stion with which it has nothing in common, except indeed 
 that the spontaneous luxation is sometimes produced by the 
 same cause as the fradl:ure, namely, a fall on the foot, knee, 
 or great trochanter, by which the cartilages of the articulation 
 are contused. The irritation caused by this contusion produces 
 a turgescence and swelling of the cartilages and cellular tex- 
 ture that accompanies the round ligament. This tumefadlion 
 augments until the acetabulum is entirely filled, and the head 
 of the femur expelled from that cavity. 
 
 It appears, then, that a striiSt comparison of the symptoms 
 will enable the surjreoJi to distinguish a fracture of the neck of 
 the femur from any affection of the hip joint. But we must 
 acknowledge, en the other hand that fractures of this part of 
 the femur, which are without any, or with very little derange- 
 ment, are not always very easy to be ascertained or distinguish- 
 ed. An old man fell on the great trochanter, and the length 
 of the extremity of that side was found to have diminished 
 half an inch in consequence of this fall; but there was no other 
 symptom of frafture. ' Citizen Boyer pronounced the existence 
 of a fra(5lure of the neck of the femur, and a second surgeon 
 confirmed this decision. A third pra^lltioner was not clearly 
 of the same opinion; but remarked that the shortening might 
 be owing to the contra(Slion of the muscles; but as there was 
 no symptom of that contraction which could not produce the 
 shortening of the limb without nearly obliterating at the same 
 time the interarticular cartilages, the apparatus for fracture was 
 applied, because, whichever opinion was the true one, no in- 
 convenience or evil could result from its application. The pa- 
 tient died of an ascites in five days. On dissefting the articu- 
 lation of the thigh, a fra<Sture of the neck of the femur was 
 found, and consolidation had commenced, though it had ad- 
 vanced but very little. 
 
 We shall recapitulate in a few words what distinguishes this 
 fracture: a fall on the great trochanter followed by pain in 
 the articulation, with the impossibility of bending the thigh 
 on the pelvis, the leg being extended on the thigh; shortness 
 of the extremity, which is easily removed, but returns as soon 
 as the extending force is discontinued; an inclination of the 
 foot and knee outward, with great facility of moving these parts 
 to their natural situation; crepitation produced in eiiccting dif- 
 
112 OF FRACTURES OF THE FEMUR. 
 
 ferent movements; and the smallness of the circle in which the 
 great trochanter moves in a rotatory motion. We can seldom 
 be mistaken as to the existence of this fracture, if we attend 
 to all these circumstances. 
 
 When the want of any important symptom renders the 
 case doubtful, the apparatus should however be applied, as no 
 danger can result from its application, provided the inflamma- 
 tory symptoms have disappeared. It generally happens that in 
 a few days the shortening of the extremity removes any doubt 
 that might have been entertained; and this shortening, as we 
 have already mentioned, may be retarded by the mutual inser- 
 tion of the fradlured surfaces, or by the resistance of the orbi- 
 cular ligament. 
 
 The prognosis of fra^lures of the neck of the -femur is very 
 difficult to establish. Some authors consider them as highly 
 dangerous, always occasioning inflammation of the cartilages 
 and surrounding soft pai*ts. Morgagni* has made some obser- 
 vations, which tend to give weight to thi* unfavourable prog- 
 nosis. Others, on the contrary, consider these disagreeable 
 consequences as extremely rare, so much so as never to have 
 met them in their praflice. This we can say, that these frac- 
 tures are never followed by secondary or spontaneous luxation 
 of the femur, which proves that the contusion of the cartila- 
 ges has not been excessive, and that probably the whole force 
 was spent in efFefling the frafture. 
 
 The difference of opinion on the prognosis of this affection 
 does not regard merely the inflammation and abscesses which 
 it may occasion, and the fistulx w^hich result from these ab- 
 scesses. Some authors are of opinion, that the shortening of the 
 limb can by no means be guarded against; and others, that the 
 consolidation of the fraflure cannot be at all efFefted. There 
 are some, however, who aflirm that the consolidation is ob- 
 tained in this case as in any other. As the treatment must be 
 accommodated to whichever of these opinions is adopted, it is 
 necessary to consider carefully the greater or less probability 
 of each, how far any of them may be true, and the restrifli- 
 ons which they may require; and to consider, in short, in what 
 particulars they may serve to dire^ the treatment. By recur- 
 ring to what we have already advanced on the formation of 
 callus, and on the different theories on that subje<Sl, we shall 
 acquire at once a solution of the problem. 
 
 * hlorg3gr[\ Je Causis et Sedibus Morb. EjM>t. 56. 
 
OF FRACTURES OF THE FEMUR. n^ 
 
 Thus those who have admitted the existence of an osseous 
 humour from which the callus is 'formed, have argued, that 
 fractures of the neck of the femur cannot be cured, because 
 this osseous humour is perpetually diluted by the synovia, with 
 which the broken ends must always be moistened. The par- 
 tisans of Duhamel's opinion have given as a reason for the sup- 
 posed non-consolidation of this fraiSture, the want of the pe- 
 riosteum on that part. But, in fa<St, it is furnished with a pe- 
 riosteum by the fibrous duplicature of the orbicular ligament 
 which is refledled round it, and which, provided itself with a 
 very vascular texture, transmits to the bone the vessels that 
 nourish it. But fatSts, which attest the possibility of consoli- 
 dation, render it unnecessary to enter into any verbal refuta- 
 tion of assertions and theories. Numerous instances of reco- 
 very are related, and preparations which prove that consolida- 
 tion had taken place, are to be met in many anatomical col- 
 leftions. The consolidation is, doubtless, slower and more 
 difficult in this than in other parts, but the difference in the 
 time necessary for cure may be easily accounted for by our 
 theory of the formation of callus. 
 
 The possibility of the consolidation of a fra6lure supposes 
 that each of the broken portions is endued with a certain de- 
 gree of vitality: the splinters of bone which, in comminutive 
 fracture, are totally detached, never reunite. In fraifture of 
 the neck of the femur, the inferior portion is endued with all 
 the conditions necessary to a prompt reunion; but the superior, 
 on the contrary, enclosed entirely in the acetabulum, and in 
 contadl: only with the cartilaginous surface of that cavity and 
 with the orbicular ligament, has no connexion with the rest 
 of the body, but by means of the round ligament which con- 
 veys to it a few blood vessels, but which are not sufficient for 
 giving its vascular texture the degree of turgescence necessary 
 for the generation of callus. In most cases, the duplicature of 
 the orbicular ligament, which we have already described, is 
 but partially torn, and a communication between the vessels of 
 the head of the femur, and those of the other parts, is pre- 
 served, by means of which the consolidation is principally ef- 
 fected. To the complete rupture of the orbicular ligament* 
 ought probably to be attributed the non-consolidation of some 
 
 * The motion communicated to tlie limb, in order to produce crepita- 
 tion, alv/ays obscure, may aid in completing the lupture ; for which rea- 
 son the trial ought not to be made without the greatest cuution. 
 
 15 
 
114. OF FRACTURES OF THE FEMUR. 
 
 cases of fra^lure. Old age is, however, the most frequehf 
 cause of non-consolidation: and those who are of opinion that 
 the fradlure of the neck of the femur is incurable, endeavour 
 to support that opinion by instances of this kind in old persons. 
 Ruisch cites many cases communicated to him by Gerard 
 Borst, who was physician to an hospital of old women at Am- 
 sterdam, in Avhich a recovery could not be cffecled. In these 
 persons great age v/aa an invincible obstacle to the formation 
 of the callus, and was the sole reason why, after death, the 
 head of the bone was found diminished, decayed, and con- 
 verted into a kind' of ligamentous cap. 
 
 I dare say too, that the great hospitals of Paris destined for 
 the recepiiqn of aged persons, as La Salpetriere and the Hos- 
 pital of Invalids, could furnish instances of the same kind suf- 
 ficient to warrant the induction that this fracture is incurable 
 ,beyond a certain age, if not sufficient to lead into error by too 
 general an application of particular fa£ts. 
 
 It is not in our power, however, to mark precisely the pe- 
 riod beyond which a cure is not to be hoped for. To be able 
 to settle this, it would be necessary that the cfFecfcs of old age 
 were uniform in every individual, and that the degree of se- 
 nility were always commensurate with the number of years. — - 
 Lesne shewed, at the Academy of Surgery, the femur of a 
 woman aged eighty-nine, with marks of a consolidated fracture 
 of its neck. I have pubUshed the case of a man aged eighty- 
 three, in whom the consolidation of a double fracture Avas con- 
 siderably advanced. Numerous fa6ts of this nature authorize 
 and require the application of the apparatus in all cases, except 
 where the patient, reduced to the last stage of decrepitude and 
 debility, cannot support its v/eight, or is attacked by some 
 mortal disease. But at the same time, the surgeon should, for 
 his own sake, accjuaint the patient and his friends with the un- 
 certainty of the cure, in order to ward off" any imputation 
 that might be made in case of failure. 
 
 Authors who have considered the consolidation as impossi- 
 ble, have ascribed to that cause the shortening of the limbj 
 whilst others, partisans of the opposite opinion, have however, 
 considered the shortening and lameness as uniformly arising 
 from the improper position of the fradturcd pieces; the lower 
 of which, say they, slides on the superior, obeying the con- 
 traction of the muscles v/hich draw it upward, so that tlve 
 fractured surfaces can no longer correspond cxaftly, and the 
 niciiiber becomes necessarily shortened in proportion to the 
 
OF FRACTURES OF THE FEMUR, I 15 
 
 ascent of the inferior fraftured portion, and diminution of the 
 obtuse angle formed by the neck of the femur with the body 
 of that bone. Or it may happen that the fractured surfaces 
 shall have no point of mutual contaclj that the angle, from 
 oblique, shall become right, or nearly so; and that the union 
 shall be eftecled by means of a ligamento-cartilaginous substance: 
 a case of this kind has probably given rise to the opinion that 
 the reunion of these fracftures was analogous to that of the 
 patella and olecranon. 
 
 Fabricius Hildanus, Platner, Ludvvig, S:c. have positively 
 asserted, that a recovery without shortening and lameness was 
 impossible. Louis and Citizen Sabatier appear to have adopted 
 the same opinion, which, however, is now known to be erro- 
 neous from the success obtained in various cases. Of this suc- 
 cess, Desault's practice furnishes many instances; from that of 
 Citizen Boyer, which has been equally extensive and success- 
 ful, I shall content myself with citing one example. 
 
 A strong robust hackney-coachman fell from the box, and 
 fractured the neck of the femur; the great trochanter having 
 borne the rea<fi:ion of the fall. The contusion was such as 
 might be expedled from the height of the fall and the person's 
 weight. Four hours after the accident, when he was convey- 
 ed to La Charitey on the 20th Prairial, 5th year, the swelling 
 and tension were extrem.e. Emollient poultices were applied, 
 bleeding and an antiphlogistic regimen were prescribed. The 
 limb being but little shortened, afforded a ground of presuming 
 that the fracture was within the articulation. On the subsiding: 
 
 o 
 
 of the inflammatory symptoms, the apparatus for making conti- 
 nued extension was applied, and reapplied, as often as its relax- 
 ation rendered it necessary. Gangrenous eschars were formed 
 on the instep and tendo Achillis, although thick compresses 
 were placed between these parts and the pieces of the appara- 
 tus: it is possible, however, that they might have been pre- 
 sented, had the patient, a man of nncomrnon firmness and 
 courage, complained of the pressure being too great. The re- 
 union was complete on the fiftieth day, as was proved by the 
 motion of the whole limb: on the sixtieth day the patient 
 quitted his bed, and walked about with crutches; and, at the 
 end of three months, left the hospital perfectly recovered, 
 there being then no perceptible difference in the length of his 
 two inferior extremities. 
 
 It is then established by what prec-edes, that a cure without 
 lameness may be obtained^ as well as a perfect consolidation. 
 
Il6 OF FRACTURES OF THE FEMUR. 
 
 but by means, It is true, unknown till lately. It is not surpri- 
 sing that surgeons, unacquainted with this means, supposed 
 lameness an inevitable consequence of fractures of the neck of 
 the femur. 
 
 The general causes which retard or prevent the formation of 
 callus will affedl fractures of the neck of the femur more than 
 any other, because the formation of the callus is slower there 
 than in any other part; for which reason every motion should 
 be particularly avoided, as well as every other circumstance 
 that might disturb the generation of callus. In this case more 
 than in any other, a disposition to cancer, scurvy, &c. is un- 
 favourable, and a state of general debility is also injurious; it 
 should, therefore, be combated with extraordinary vigilance. 
 Pregnancy, which we suppose to be in general of little or no 
 effect, might, however, diminish the probability of a perfe^ 
 consolidation of a fracSture of the neck of the femur. 
 
 The particular objefts to which, in treating these fractures, 
 we are to dire6t our attention, are no other than those already 
 mentioned in general, namely, to set the bone, keep the 
 pieces in their place, and combat any unfiivourable symptom 
 that may arise. The means of effetfting extension and coun- 
 ter-extension are the same as in other fractures of the femur, 
 and for the same general reasons as mentioned in treating of 
 the fracture of the body of that bone. If it be necessary to 
 employ a great number of assistants, a cloth, on which each 
 may pull, should be rolled on the inferior part of the leg, and 
 tw^o others round the pelvis; the extremities of one of which 
 should be joined and held above the hip of the side affefted, 
 for the purpose of making counter-extension; whilst another 
 should be brought in the opposite dire(Stion, and held by a suf- 
 ficient number of assistants, in order to prevent the pelvis 
 from being drawn to the fraftured side. The joint adtion of 
 these two last mentioned means of counter-extension is neces- 
 sary to render the pelvis immovable. In most cases, however, 
 this purpose is answered by simpler means. 
 
 Previous to any attempt to remedy the longitudinal derange- 
 ment by means of extension and counter-extension, it will 
 be necessary to corredt that of the circumference, by gi- 
 ving tlie foot its natural direction. Coaptation is a part of the 
 operation totally useless in setting a fradturc of the neck of the, 
 femur, on account of the greath depth of soft parts, and the 
 total impossibility of a^ing on the superior piece of bon^. 
 
OF FRACTURES OF THE FEMUR, II7 
 
 If on the first attempt to extend the limb, the muscles are 
 found to contract powerfully, it will be useless to continue ef- 
 forts painful and fruitless for the patient. The best practice to 
 be adopted then, is to apply the apparatus for fra^ures of the 
 body of the bone, draw some blood from the patient, put him 
 on an antiphlogistic regimen, and wait the removal of the spas- 
 modic state. This state is much less frequent in the fradlures 
 of the neck of the femur than in those of the body of that 
 bonej because in the former the fractured ends are within the 
 orbicular ligament, and cannot therefore irritate the soft parts. 
 When it was customary to apply the extendmg force above the 
 knee, and the counter-extending to the groin, the spasmodic 
 state was much more frequent than since the present improved 
 practice has been adopted. 
 
 The difficulty of keeping the pieces in their place in a frac- 
 ture of the neck of the femur is inversely proportional to the 
 facility with which the setting is effefted; for which reason the 
 jnefficacy of the ordinary means has been long ago acknow- 
 ledged in oblique fractures of the body of that bone, as well as 
 in fractures of its neck. Different expedients have been devi- 
 sed at different periods, to remedy this disadvantage. We shall 
 compare their merits, after first considering the position in 
 which the limb should be placed. 
 
 The half-bent state recommended by Pott for the inferior as 
 well as superior extremity, is attended with a great number of 
 inconveniences, the mention of some of which will suliice for 
 its rejedtion; the facility with which the limb changes from 
 that position, the difficulty of applying the apparatus, the im- 
 possibility of comparing the length of the limb with that of the 
 opposite side; finally, the pain produced by the continual 
 pressure on the great trochanter, and the gangrene which en- 
 sues. 
 
 In fracture of the neck of the femur, as in all those of the 
 inferior extremity, the leg should be extended on the thigh, 
 and the thigh on the pelvis. This position must be secured by 
 means of an apparatus, on the invention of which the imagi- 
 nation of practitioners and theorists has been very a6tive. The 
 expedients for effedling this are so numerous, that a descrip- 
 tion of them would lead us too far from our objecl:. Studious to 
 avoid any superfluous details, and equally so any important omis- 
 sion, we shall range, in two classes, the different apparatus: in 
 the first, those which do not effect any extension; in the se- 
 cond, those which do. 
 
Il8 OF FRACTURES OF THE FEMUR. 
 
 Several authors have recommended the spica bandage of the 
 groin, composed of a piece of linen cloth, of a considerable 
 breadth, and long enough to be rolled round the pelvis several 
 times. This bandage being rolled up in one, is drawn three or 
 four times round the pelvis, and then several times obliquely 
 on the superior part of the thigh, by directing it towards the 
 great trochanter, thence round the body, and so successively j 
 but instead of fixing the fra<5lured portions, it contributes to 
 derange them. As much of it as is applied on the pelvis, is ab- 
 solutely useless-, and the oblique casts, upward and outward, 
 can have no other effedl than that of deranging the lower por- 
 tion of bone-, that Is, of causing its ascent to the external iliac 
 depression. Finally, the application of the spica requires that 
 the limb be supported and raised up from the bed, which can- 
 not be done without disturbing the generation of the callus. 
 This objeiflion is of the greatest importance, because the spica 
 requires to be frequently renewed, as It relaxes quickly, and is 
 soon soiled with'the patient's urine and fasces. 
 
 The eighteen-tailed bandage, and the fanons or faux-famny. 
 ■with which it is assisted, aift only on the inferior portion of bone, 
 yield like it to the causes of derangement, andean therefore be 
 of no utility. And even though this bandage should adt on 
 both the fractured portions, it is now well ascertained, that 
 bandat^es, whatever may be their constru<5l:ion, can contribute 
 but very little to the confining of pieces of a broken bone ; and 
 that, relatively to that obje(fh, the effect of this as well as of the 
 others, is absolutely null. As to \X\q. fanons ovfaiix-fanons, their 
 circular shape admits them to act only by single points, or a 
 single line of contact; for which reason their effedt can be but 
 very trifling. Besides, if the bands by which they are secured 
 be drawn tight, they "will necessarily be displaced by sliding 
 backward or forward. 
 
 Others have employed long splints, of which the external 
 ascended on the ribs, and the anterior on the abdomen; buth 
 of which, and the Internal splint, extended beyond the foot. 
 Tlie depressions were filled with some kind of stufHng, in or- 
 der to procure an equable pressure; and the splints were kept 
 applied to the limb by ribbands or tape, and secured at their su- 
 perior extremities by a roller passed round the trunk, the im- 
 mobility of which, with respe6t to the limb, was one of the 
 obje<5ts proposed. But this immobility of the body could not 
 prevent the glutei muscles, as well as all the others, v/hich ex- 
 tend from the pelvis to the femur or leg, from drawing the ia- 
 
or FRACTURES OF THE FEMUR. 11^ 
 
 flerior portion of the femur upward and outward ; for which 
 reason this means has been abandoned, though it has, over the 
 two preceding, the advantage of correcting the derangement 
 in the circumference. Dalechamp hit on the expedient of 
 fastening the leg to the foot of the bed ; but as the body was 
 not fixed, it slipped down and rendered this precaution useless. 
 To these may still be added, the tin trough, lined with fustian, 
 invented by Fabricius Hildanus, and in which the outside of 
 the thigh was placed, the oblique bandages, and all that as- 
 semblage of petty contrivances heaped on the limb by Duver- 
 ney. All these expedients act only on the inferior portion of 
 the femur, yield to all the causes that move it, and can in no 
 manner oppose the shortening of the extremity. 
 
 There remains another method which demands a more par- 
 ticular notice. It was proposed by Foubert, adopted by Louis 
 and Citizen Sabaticr, and approved of by the Academy of Sur- 
 gery. This method was for some time looked on as the m.ost 
 efFeftual for the treatment of fractures of the neck of the 
 femur. 
 
 The frafture being set according to the rules prescribed, and 
 compresses, impregnated with a resolvent liquid, applied to the 
 articulation ; the thigh and leg are fixed by means of fanonsy 
 and the foot by means of a slipper or sole. The inferior por- 
 tion of the femur is in a very short time drawn outward and up- 
 ward by the contraction of the muscles. This derangement, 
 foreseen by the inventor of the method, is remedied by reset- 
 ting the fraClure every day, and reapplying the apparatus. From 
 the fifteenth to the twentieth day, the derangement becomes 
 less frequent, and the part less irritable; for which reason there 
 is less muscular contratStion. After the twenty-fifth, the re- 
 setting is no more necessary, the limb is allowed to rest, and the 
 fations are kept employed, tightening them as often as they re- 
 lax, for three months and a half, at which time the apparatus 
 may be totally removed. This invention, originally suggested 
 by Ambrose Pare, does not merit all the encomiums whiqh 
 have been bestowed upon it. Nothing can more effectually re- 
 tard, or even prevent the formation of the callus, than the 
 motions communicated to the limb, at the very time that na- 
 .ture is most actively employed in generating it. 
 
 In order to keep, in fractures of the neck of the femur, the 
 pieces in their proper situation, it is necessary that some cause 
 counteracts that which tends to produce their derangement. 
 This latter aCts by drawing upv.^.rd -i^TA outward the inferior 
 
I20 OF FRACTURES OF THE FEMUR. 
 
 portion, making it ascend on the external side of the superior, 
 which is itself pushed downward by the weight of the pelvis 
 and body. A further derangement is produced by the falling 
 outward of the foot and knee: in order to prevent which, it 
 has been proposed to tie the toes to those of the other foot. 
 Brunninghausen used to fix the leg of the fradlured side to that 
 of the opposite, by means of a sort of stirrup, making, by this 
 contrivance, the sound leg aft as a splint; but these means 
 serve merely to prevent the falling outward of the foot, but 
 not at all the shortening of the limb. Besides, the position 
 cannot be long persevered in, because fastening both legs to- 
 gether, incommodes the patient very much. 
 
 A continued extension is the only means of keeping down 
 the lower portion of the femur, of opposing the descent of the 
 superior, of counteracting the irritability of the muscles, and of 
 producing a cure without lameness or deformity. We do not 
 propose, as already remarked in the first chapter of this work, 
 to overcome, by this means the strong and involuntary con- 
 tractions of the muscles which immediately succeed the frac- 
 ture, and which should be opposed by a moderate and gradual 
 extending force. Tiie application of the apparatus for making 
 continued extension is not prudent, until the spasmodic state 
 be completely removed. It is not intended that this apparatus 
 shall preternaturally extend the muscular fibre, by drawing its 
 extremities in opposite direcSlions, but merely that it shall sup- 
 ply the place of the bone, by opposing the contraclile power 
 naturally inherent in the fibre, and always tending to act. 
 
 Almost all those who have acknowledged the indispensable 
 necessity of continued extension, have invented different means 
 for putting it into execution. Their respective merits can be 
 appreciated by comparing their different ways of acting with 
 the general rules already laid down for effefting this purpose. 
 
 The bed of Hippocrates, and the Glossocomon used by the 
 ancients, engraved in the Works of Pare, have been abandon- 
 ed on account of their complication: they had no other advan- 
 tage than that of adting in the direction of the fractured bone. 
 By acting immediately on the fractured thigh, in effecting ex- 
 tension and counter-extension, their acStion was limited to a 
 small surface, and the limb lengthened abruptly. 
 
 The method used by Avicenna, adopted by Petit, Heister, 
 and Duverncy*, who have somewhat modified it, consisted in 
 
 * The greater part of authors recommend the use of the spica, in addi- 
 tion to the extension and counter-excension produced by ih:^ means. 
 
I 
 
 OF FRACTURES OF THE FEMUR. 121 
 
 fastening to the head and foot of the bed, the bands with 
 which the extension and counter-extension were to be efFedted. 
 The superior were applied on the upper part of the thigh, and 
 the inferior above the knee. 
 
 Petit advises to place two bands at the same time, one above 
 the knee and another above the ankle, to aft alternately, so 
 that when one becomes troublesome it may be relaxed and the 
 other used. 
 
 Besides the unsteadiness of the band placed above the knee, 
 and the irritation of the muscles occasioned by it; this method 
 has still further the disadvantage of the thigh and pelvis not 
 being so fixed by it as to constitute one piece; without which 
 essential condition, the superior portion of the femur yields to 
 all the motions of the pelvis, with which it is connefted. The 
 loosening of the bands, which is frequent in proportion to their 
 length, is another objection which decides the absolute insuffi- 
 ciency of this method. In confirmation of this opinion, we 
 may quote the testimony of the Arabians themselves, invent- 
 ors of this method, who used it in every case of fra£ture of 
 the femur, whatever might be its direftion, but who acknow- 
 ledge that the cure was seldom effe£led without a lameness. 
 
 Others have endeavoured to the efFeft extension, by means 
 of a band applied above the ankle, and which, passed over a 
 pully, had a weight suspended from the other extremity. The 
 puUy was so disposed, as that the weight adled in the direftion 
 of the fraftured bone, which joined to the advantage of afting 
 on the leg, produced a well diredled extension: this, however, 
 was rendered useless on account of there being no counter-ex- 
 tension, to prevent the body from being drawn downwards. 
 
 The machine of Bellocq, described and engraved in the 
 third volume of the Memoirs of the Academy of Surgery, is 
 at present generally abandoned. By it, extension is made in 
 the direiSlion of the limb, on the lower part of the leg, and 
 gradually; but the counter-extension adls immediately on the 
 superior part of the thigh: besides, the great difficulty of ap- 
 plying this machine, justifies the oblivion into which it has 
 fallen. Many other apparatus successively proposed after that 
 of Bellocq, and of which they were but modifications, have, 
 like their model, fallen into dis-use. 
 
 The machine of Hook, perfedted by Aitken, and described 
 by Bell, afts in the direction of the limb, and produces a slow 
 and gradual extension, by means of screws, but it has the dis- 
 advantage of adling immediately on the inferior part of the 
 16 
 
122 OF FRACTURES OF THE FEMUR. 
 
 thigh, und on a small surface. Thus, while two precepts are 
 observed, two others not less important are neglefted: besides, 
 nothing opposes the falling outward of the foot and knee, nor 
 the inclination of the hip to the same side. 
 
 Desault perceived all these imperfections and defedts, and 
 invented an apparatus by which the obje<5l proposed is more 
 perfedtly fittained, and by means much simpler. It might be 
 added perhaps, that with a few modifications, it would com- 
 prise every advantage that can be expected from such an appa- 
 ratus. His first attempts were directed only to corredl the an- 
 cient methods. He attached the trunk to the head-board of 
 the bed, by means of long bands fastened to a bandage passed 
 under the arm pits: he applied, in the next place, the middle 
 of a band on some thick compresses placed on the back part 
 of the leg, a little above the ankles; the extremities of this 
 band crossed on the superior part of the foot, and knotted on 
 the sole, were then fastened to the foot of the bed. To this 
 disposition was joined the ordinary means or apparatus. This 
 method had a disadvantage of which we have already taken 
 notice, namely, the facility with which the bands relax; be- 
 sides which, the immobihty of the body was very fatiguing, 
 and the difficulty of breathing, on account of the bandage 
 round the trunk, was still more distressing. This last menti- 
 oned disadvantage induced Desault, in a particular case,* to 
 apply the bandage on the pelvis, to which it was fixed by 
 bands passed under the thighs. 
 
 Desault ascertained by different experiments, that the ob- 
 jedt particularly to be aimed at, and which was essential, was 
 such a disposition as that the foot, leg, thigh, and pelvis, 
 should constitute but one whole; so that, though the different 
 parts thereof should be drawn in different directions, yet they 
 should still, with respedt to one another, preserve the same 
 mutual relation. Convinced of the justness of this conclusion, 
 he invented the following apparatus to answer these purposes. 
 
 A strong splint, long enough to extend from the ridge of 
 the OS ilium to a certain length beyond the sole of the foot, 
 is a principal part of this apparatus: this splint should be two 
 inches and a quarter broad, and have each of its extremities 
 pierced in shape of a mortice, and terminated by a semicircu- 
 lar niche. It is applied on the exterior side of the thigh, by 
 means of two strong linen bands, each being more than a yard 
 long. 
 
 * Surgical Journal, vol. i. 
 
OF FRACTURES OF THE FEMUR, 1 23 
 
 The middle part of one of these bands is to be applied to 
 the inside of the thigh, at its upper part; its ends are brought 
 to the exterior side of the thigh, passed through the mortice, 
 and knotted on the semicircular niche. Compresses are to be 
 previously placed under the middle part of the band, in order 
 to prevent any disagreeable pressure; as well as on the tubero- 
 sity of the ischium, which Desault considered as the principal 
 point of adlion of this band. The inferior part of the leg is, 
 in the next place, covered with compresses, on which the mid- 
 dle part of the second band is placed: the extremities of this 
 band are crossed on the instep and upper part of the foot, then 
 on the sole, after which they are conveyed outward, and one 
 end passed through the mortice and knotted with the other on 
 the niche, with such a degree of force as to pull the inferior 
 portion of the femur downward, and to push the splint up- 
 ward, and by this means the pelvis and superior fractured por- 
 tion. On the internal side of the limb is placed a second 
 splint, which extends from the superior part of the thigh, to 
 a certain distance beyond the foot. A third is placed on the 
 anterior part, and extends from the abdomen to the knee. 
 The superior extremities of the anterior and exterior splints 
 are fixed by means of a bandage passed round the pelvis. A 
 band, the middle part of which is placed under the sole of 
 the foot, and the extremities crossed on its superior surface 
 and fastened to the splints, prevents the motion of the foot, 
 as does also to a considerable degree the action of the splints. 
 
 It may not be superfluous, perhaps, to remark, that previ- 
 ous to the application of this apparatus, the whole limb should 
 be covered with compresses, moistened with a solution of the 
 acetate of lead, and that Scultet's bandage is to be applied on 
 the thigh and leg over these compresses, and a roller to be 
 passed round the foot : these parts of the apparatus should be 
 moistened with a resolvent liquid. These have the double ad- 
 vantage of diminishing the irritability of the muscles, and pre- 
 venting any stagnation of the fluids. 
 
 This apparatus of Desault's has, in the hands of that cele- 
 brated surgeon produced a great number of cures; but it must 
 at the same time be acknowledged that it has frequently failed: 
 the causes of failure may be found in defeats which it is easy 
 to point out. 
 
 The superior band has a triple disadvantage; first, that of 
 forcing the inferior portion of the femur outward; secondly, of 
 pushing the superior upward; thirdly, of rolling itself into a 
 
124 OF FRACTURES OF THE FEMUR. 
 
 cord, compressing thereby painfully the adduftor and re£lus in- 
 ternus, the spasmodic contradlion, of which, in consequence of 
 the pressure, tends still further to produce the ascent of the 
 inferior portion of the femur. These disadvantages would be 
 all removed, by giving the band a point d'appui on the tuberosi- 
 ty of the ischium. 
 
 The difficulty, however, of afling on a globular eminence 
 of a small surface, and covered by a great depth of soft parts, 
 is easily seen: the extension of the thigh on the pelvis increases 
 this difficulty, by increasing the depth of the soft parts. This 
 tuberosity would be more prominent for the inverse reason, 
 if, according to Pott's method, the limb were placed in the 
 half-bent position. The difficulty of adling on this tuberosity 
 is much greater in women than in men, on account of the 
 greater quantity of cellular substance about this part in females. 
 Not only is it difficult to make the band a6l on that tuberosity, 
 but other disadvantages result from it; for the great pressure 
 of the band on these delicate parts, causes much pain, ulcera- 
 tion, and sometimes gangrene. To these circumstances De- 
 sault attributed the ill success which he sometimes met with. 
 
 The inferior band has nearly the same disadvantages as the 
 superior; its dire<flion is oblique downward and outward, and 
 its action tends therefore to produce a derangement of the 
 pieces of bones. This tendency is counteradted, it is true, by 
 the band diredled to be applied to the back part of the leg 
 above the ankle, crossed on the superior and inferior surfaces 
 of the foot, and fastened to the lower extremities of the in- 
 ternal and external splints. The compresses with which the 
 inferior part of the leg is covered, do not always proteft it 
 from the extreme constriftion of the lower band^ which being 
 narrow, forms itself quickly into an hard cord, and causes 
 pain by adling on a narrow surface. The gangrenous eschars, 
 which are sometimes produced by the constriction of this band- 
 age, are so considerable, as to denude in many cases the ten- 
 do Achillis, and the tendons of the extensor muscles of the 
 toes. These tendons, exposed to the contact of the air, arc 
 apt to exfoliate, and consequently the bones which they are 
 destined to move will remain motionless. The oblique adlion 
 of this band renders a great constriction necessary. 
 
 If, in order to appreciate exadlly the merit of this method, 
 we compare its manner of acting with the general rules alrea- 
 dy laid down for effecting perpetual extension, we shall find 
 that some of these rules are transgressed, and others not com- 
 
OF FRACTURES OF THE FEMUR. 1^5 
 
 pletely observed. Thus the extending force a£ts on that part 
 of the limb which articulates with the inferior fra(^ured por- 
 tion; but the superior band adts on the superior fractured por- 
 tion; and the bands being narrow and liable to roll up like a 
 cord, do not aft on large surfaces. Both the inferior and su- 
 perior bands being oblique, they cannot a£t in the direction of 
 the bone. Finally, their a6tion cannot be gradually increased. 
 The method of Citizen Boyer, which remains to be described, 
 is striiSlly conformable to all these rules. By his apparatus and 
 method, the extension is gradual and in the dire<Stion of the 
 bone; and none of the muscles which surround the fractured 
 bone are compressed. 
 
 The apparatus consists of a splint, a sole, or slipper, and a 
 sous-cuisse. The splint should be four feet long, three fingers 
 breadth wide, and about four or five lines in thickness, and 
 made of hard and inflexible wood. A groove about half an 
 inch wide, the extremity of which is covered with iron, runs 
 along this splint for about half its length. In this groove is 
 placed a screw which occupies its whole length, one end of it 
 being supported against the plate of iron with which the ex- 
 tremity of the groove is covered, the other being adapted to a 
 key by which it is turned. To this screw is fastened, in the 
 manner shewn in the plate, an apparatus to which the sole is 
 fixed. The superior part of the splint is received into a pocket 
 formed in the sous-cuisse. The sole is made of iron, and co- 
 vered vyith shammy leather; towards the heel a large piece of 
 soft leather is attached to it, which piece is divided into two, 
 and serves to fix the sole to the foot. It is fixed to the part 
 of the apparatus connefted with the screw. 
 
 The sous-cuisse is composed of two parts, which meet at an 
 acute angle. It is made of strong leather, covered with sham- 
 my and well stuffed with wool, like the girdle of a truss; one 
 of the parts should be long enough to pass obliquely round 
 the upper part of the thigh, its extremity terminating in a 
 strap pierced with holes: the other should be only three inch- 
 es long, and terminated by a buckle. At the place where both 
 parts meet, a piece of leather is sewed in form of a pocket, 
 into which the superior part of the splint is received. 
 
 It is difficult to give a satisfaftory explanation of all the par- 
 ticular parts of which this apparatus is composed; but a suffi- 
 ciently correal idea of it may be formed by taking a view of 
 the plate No. 2. 
 
126 OF FRACTURES OF THE FEMUR. 
 
 The apparatus is applied in the following manner: after ha- 
 ving surrounded the upper part of the thigh with a soft gir- 
 dle of cotton three inches broad, the sous-cuisse is applied over 
 it. Then the foot and lower part of the leg is surrounded 
 with some soft matter, in order to secure against the effefts of 
 pressure, and the sole is applied to the foot. Next the superi- 
 or part of the splint is introduced into the pocket of the sous~ 
 cuisse^ and the sole is attached at the proper place to the re- 
 mainder of the apparatus. 
 
 The application being thus far advanced, the necessary stuff- 
 ing and two splints, one anteriorly, the other internally, are 
 applied and secured in the ordinary manner. Every thing be- 
 ing thus disposed, the screw in the groove is turned by the 
 key, and the sole descends and brings the foot with it, whilst 
 the superior part of the splint is pushed upwards. In this 
 way the limb may be extended gradually, and the extension 
 increased as may be necessary. 
 
 Which ever apparatus is adopted, it will be necessary to exa- 
 mine it frequently, to tighten the bands, which are quickly 
 relaxed in Desault's apparatus, and to give a few turns to the 
 screw in that of Boyer; but for the latter, not near so much 
 attention is necessary: the straps of skin by which the exten- 
 sion and counter-extension are made, though over extended 
 by any accidental cause, return again t^ the proper degree of 
 constriction, on account of their elasticity; and though they 
 should become relaxed, the means of bracing them are easy. 
 When Desault's apparatus is used, it will be necessary to in- 
 crease the thickness of the compresses on the back part of the 
 leg, the tuberosity of the ischium, and inside of the thigh, as 
 soon as these parts begin to excoriate. 
 
 Topical applications, except those necessary for combating 
 the inflammatory symptoms, are absolutely useless. If there 
 be contusion and violent inflammation, the removal of these 
 must precede the application of any apparatus. The bed on 
 which the patient is laid, should not, as already mentioned, be 
 too soft, but ought to be, on the contrary, firm enough to 
 prevent his sinking into it. By adopting Desault's method, or 
 that of Boyer, the patient may satisfy his natural wants with- 
 out inconvenience. 
 
 The general rule of confining the patient to a low regimen 
 should be modified in the present case; because in this, more 
 than in any other, it is necessary to support and increase the 
 vital action of the parts. A rigourous abstinence, which would 
 
OF FRACTURES OF THE FEMUR. 127 
 
 in other cases only retard the formation of callus, might to- 
 tally prevent it in this. Therefore, though the quantity 
 of nourishment should be less than that used in a state of 
 perfedt health, because the exercise taken in that state ren- 
 ders reparation more necessary, yet any abstinence that might 
 induce debility should be avoided. 
 
 Does the difficulty with which fractures of the neck of the 
 femur consolidate, authorize the use of internal remedies, which 
 might accelerate the consolidation? 
 
 The ancients wei*e of opinion that in a few days after a frac- 
 ture the patient should be nourished with rich gelatinous food. 
 Andre de la Croix,* and Fabricius ab Aquapendente, pre- 
 scribe formally, in imitation of Galen,f the use of farinaceous 
 and young animal food, and that of inspissating medicines. 
 Ambrose Pare:}; has given the same directions, and observed 
 them himself in the treatment of the fradhire of his leg. Fa- 
 bricius Hildanus§ remarks with reason, that aliments of this 
 kind are diflicult of digestion, and m.ust therefore be very un- 
 fit for a patient in a state of inaClivity. But the same objection 
 lies against the use of csteocolla, recommended by the same 
 praiftitioner, and condemned by Van Swieten,|| on the same 
 principle as the inspissating or viscid aliments of Galen, Osteo- 
 colla, so highly recommended by Fabricius, has been used by 
 the greater number of sui'geons. Some cases are found in the 
 Philosophical Transactions,** in which the production of a part 
 of the femur is attributed to the use of it ; but Citizen Pinel, 
 translator of this work, judiciously remarks, that it is difficult to 
 conceive how a stone of a calcareous nature, and of the melac- 
 tite species, could aid the generation of callus. The use of 
 gelatinous food which came into use on the supposition of its 
 being of a nature analogous to the supposed osseous fluid, has 
 been discontinued; and the theory on v/hich it was founded, 
 has been abandoned. Spirituous liquors, recommended to- 
 
 • Dum substantia cartilaginea, compafta ac densa, quam Latini callum 
 vocant, gigniiurj eo tempore viscosum alimer.tuin commeiidatur. An- 
 tlieasa Cruce, vol. ii. lib. i, cap. 6, de Cibo. 
 
 f De Methodo, lib. 6, cap. 5. 
 
 X Lib. 15, cap. 28. 
 
 § Surgical Observations, Cent. 1. Obs. 92. 
 
 II Comment, on Hermann Boeih, Aph. 
 
 •* Abridgment of th« Phil. Trans.— Med. and Surg. 
 
128 OF FRACTURES OF THE FEMUR. 
 
 ward the end of the treatment, for the purpose of hardening 
 the caUus, have, in like manner, fallen into disuse. 
 
 Nourishment easy to digest, and the moderate use of spirit- 
 uaus drinks, particularly for old people, aid that expansion of 
 the vascular texture, necessarv for the generation of callus. A 
 scrupulous attention should be paid to the manner of living, 
 when the vital forces are found to languish from any cause 
 whatever. 
 
 The time which nature employs for the consolidation of a 
 fradlure of the neck of the femur,* has already been men- 
 tioned. We repeat however, that the apparatus should not be 
 finally removed before the sixteenth or seventeenth day; and 
 that three months must elapse from the day of the fracture to 
 that on which the patient may be safely allowed to quit his bed, 
 and walk even with the aid of crutches. The premature use of 
 the limb has been more than once the occasion of its being 
 shortened, after the formation of the callus had been conside- 
 rably advanced, and a cure without blemish on the point of 
 being efFecled. A shortening of the limb is particularly to be 
 apprehended, if the pieces are united by meany-of a ligamento- 
 cartilaginous substance. That the premature use of the limb 
 may occasion this unfortunate accident may be easily conceived, 
 by refledling that the callus does not attain its ultimate degree 
 of consistence until after the lapse of several months. 
 
 A stiffness in the articulation is not much to be apprehended, 
 though some instances of it are related by authors; these exam- 
 ples would be more numerous, if the stiffness were produced by 
 an effusion of osseous juice into the articulation, as some au- 
 thors have thought. It is well known at present that this 
 stiffness or false anchylosis is owing to the impeded circulation 
 in the part, and to the muscles having lost the habit of motion 
 by a long inactivity. Fractures of the patella and olecranon are 
 more frequently than any others attended with this conse- 
 quence. 
 
 To this description of the treatment of fradlures of the neck 
 of the femur, we have only to add, that cases occur in which 
 the approved method cannot be adopted. I have often seen 
 patients who could not support the pain produced by it. In 
 which case, or in that of the patient's being old, the continued 
 extension ought not to be persisted in : the apparatus for frac- 
 
 * The consolidation was always effected from the foity-fifth to the fif- 
 tieth day, according to the cases related in the Surgical Journal. 
 
OF FRACTURES OF THE PATELLA. l<ig 
 
 tures of the body of the bone must be had recourse to, with 
 the additional precaution of guarding against the rotatory de- 
 rangement, by making the internal and external splints extend 
 beyond the foot. A cure thus obtained, will be attended with 
 a shortening of the limb. 
 
 If the patient were abandoned to nature, the continual mo- 
 tion which would take place, and the friftion, would destroy 
 the head of the bone, and often too what remains of the neck, 
 as has been observed by Morgagni. The shortening is so great 
 in that case, that the limb is nearly useless. Boehmer has ju- 
 diciously remarked, in his Osteologic Institutions, that the de- 
 ficiency alone of a point d'appui would cause lameness, though 
 the member should have lost no part of its length. 
 
 CHAPTER XV. 
 
 OF FRACTURES OF THE PATELLA. 
 
 THESE fractures may be transverse, or of different de- 
 grees of obliquity; but are seldom found longitudinal. 
 The transverse fra£lure is frequently occasioned by a sudden 
 and violent contraction of the extensor muscles of the leg, 
 which a£t on the patella: this cause remained a long time un- 
 noticed, and the fractures produced by it were ascribed to the 
 fall which was the consequence of the fradlure. It is at pre- 
 sent generally acknowledged to be the immediate cause of the 
 fracture, and by that means the cause of the fall. 
 
 It will be asked, perhaps, why the tendon of the extensors 
 of the leg, and the inferior ligament of the patella, are not 
 ruptured rather than the patella itself.'' To which it may be 
 answered, that the extensibility of the tendinous and ligamen- 
 tous parts renders them less liable to be ruptured than the pa- 
 17 
 
130 OF FRACTURES OF THE PATELLA. 
 
 tella, the hardness of which is more than compensated by itar 
 brittleness as an osseous substance. 
 
 Though fracSture of the patella is the most frequent conse- 
 quence of a violent contracStion of the extensors, yet a rupture 
 of their tendon and the inferior ligament is sometimes pro- 
 duced by the same cause. In both cases the symptoms, prog- 
 nosis, and indications, are the same j and the treatment is per- 
 fe<^ly identical. 
 
 To form a correal idea of the manner in which fraftures of 
 the patella take place, it is necessary to recollect, that the ere£t 
 posture is the firmest possible, when the centre of gravity is in 
 a line perpendicular to the basis on which the body is support- 
 ed; that though the line passing through the centre of gravity 
 may cease to be perpendicular, yet the body does not fall, but 
 is kept ere6l by the action of muscles, which counterajfls the 
 deviation from the perpendicular dire<^ion: finally, that if this 
 line fall on no part of the base, the body must necessarily fall 
 towards that side to which the line inclin-es. 
 
 If the centre of gravity fall behind the base, so that the 
 body tends backwards, the extensor muscles of the leg contrail 
 with great violence, in order to prevent the flexion of the 
 thighs, at the same time that the superior part of the body i& 
 also drawn forward by the contraiStion of muscles, and the cen- 
 tre of gravity replaced on its natural support. If this contrac- 
 tion of the muscles be not sufficient to bring the body forward, 
 the obliquity of the axis of the centre of gravity still increa- 
 sing, the adtfon of the muscles will increase in consequence; so 
 that the patella pushed forward by the inferior extremity of 
 the femur, drawn with great force by the tendon of the triceps 
 and re6lus anterior, and retained in the opposite direction by 
 the inferior ligament, is fradlured transversely. 
 
 The effort made to resist falling is not the only occasion on 
 which the patella is violently acted on by an instantaneous con- 
 traction of the muscles inserted into it. It is exposed to the 
 effects of a violent contraction of the muscles in leaping, which 
 as performed by the human species, consists principally in the 
 sudden extension of the low*^r extremities, which are always 
 bent to the leap: for which reason a fraCture of the patella of- 
 ten occurs in dancers, and always takes place the instant of their 
 quitting the ground. Another circumstance in which a trans- 
 verse fra<Sture of the patella may take place, is that in which, 
 the point of the foot is forcibly impelled forward; an instance, 
 of which is found in the case of a soldier, who made an atf 
 
OF FRACTURES OF THE PATELLA. I3I 
 
 tempt to kick his sergeant. In this case, the manner in which 
 the fracture takes place is analogous to that of the olecranon, 
 produced by the a£lion of throwing a stone. Another case of 
 this fracture is that of a man brought to La CbaritCy in the 
 month of Pluvio'se, 8th year. This person was a coachman; 
 his horses took fright while he sat negligently on the box; on 
 which occasion he extended suddenly the right leg, at the same 
 moment that the point of the right foot slipped off the board 
 on which it rested. He felt instantly a very acute pain in the 
 knee, and heard very distinctly, at the same time, a loud crack; 
 and, on applying his hand to the part, he found the patella 
 fractured transversely, and divided into two pieces, which were 
 separated an inch one from the other. These instances remove 
 every doubt on the possibihty of this fracture being effected by 
 muscular action alone ; and if any further evidence were neces- 
 sary, it would be found in a case of a fracture of this nature, 
 which took place by the violent contractions of the mucles of 
 the thigh of a man in convulsions. 
 
 Falling on the knees is a no less frequent cause of transverse 
 fracture of the patella: in this case it takes place easily when 
 this bon€, made to project by the flexion of the leg, strikes 
 against some very hard, resisting body. When the leg is bent, 
 the patella is supported only by its extremities on the superior 
 end of the tibia, and the articular part of the femur, so that its 
 middle part is without any support, and corresponds with the 
 interval between the two last-mentioned bones : this space is 
 occupied by the adipose cellular texture found behind the infe- 
 rior ligament of the patella. In this situation of the parts, the 
 patella is easily fractured, because the middle part of it, which 
 is unsupported, is the thinnest, and because it is steadily fixed by 
 the action of the tendon and ligament which are inserted into it. 
 The direction of the fradture depends generally on the shape of 
 the body against which the knee strikes. Should, for instance, 
 its projecting part be transverse to the patella, the fraClure will 
 have the same direftion ; if longitudinal the fracture will be 
 longitudinal, &c. The same may be said of the violent impul- 
 sion of a body against the patella. In all cases this bone may 
 be broken into several pieces, and the soft parts lacerated ; or 
 the fradlure may be complicated with a rupture of the capsular 
 ligament, and an effusion of blood into the articulation. 
 
 Transverse fractures of the patella are always attended with 
 a separation of the fraftured portions. When the cause of 
 fraaure has been just sufficient to produce the solution of con- 
 tinuity of the bone, without disorganizing its fibrous covering. 
 
1^2 OF FRACTURES OF THE PATELLA. 
 
 the derangement is at first scarcely perceptible ; but this mem- 
 brane stretches in a Uttle time. The shghtest motions of the 
 leg are sufEcient for elongating, or even totally rupturing this 
 substance : in which case the separation becomes instantly 
 considerable, and the articulation, from being no longer sup- 
 ported, bends under the weight of the body. The following 
 case is a remarkable instance of a fradlure, in which the sepa- 
 ration of the pieces, and the fall which is the inevitable conse- 
 quence of it, did not immediately follow the solution of con- 
 tinuity. The person while dancing, heard a dull noise in the 
 right knee, and felt a slight pain in the same part. Some mi- 
 nutes after in walking about the room, he heard another crack 
 in the same knee, and fell without the power of raising himself. 
 On being brought to La Charlie the portions of the patella were 
 found separated an inch and three fourths, which with the other 
 signs, left no doubt on the existence of fradlure. An uniting 
 bandage, such as is generally made use of for simple incised 
 wounds, was applied, and renewed as often as its relaxation 
 rendered it necessary. On the thirtieth day of the treatment^ 
 the knee was gently moved, in order to prevent a false anchy- 
 losis, and the motion was afterwards continued every day until 
 the patient quitted the hospital. An interval of about one line 
 in breadth separated the two pieces, which was entirely filled 
 up by a ligamentous substance, of a very inextensible nature. 
 
 Two causes concur to produce the separation of the frac- 
 tured portions; one of which is, the contraction of the exten- 
 sor muscles, which always takes place when their natural ten- 
 dency to contradt is not opposed, and by which the superior 
 portion is drawn upward on the superior part of the thigh: the 
 second cause is the flexion of the leg, the principal bone of 
 which draws downward the inferior piece which is attached to 
 it. The separation will be, then, great in proportion to the 
 force of muscular contraftion, the degree of flexion of the leg 
 on the thigh, and the extension or laceration, more or less of the 
 tendinous expansion which covers the anterior surface of the pa- 
 tella, and which is attached to the lateral parts of that bone, and 
 adheres strongly at the same time, to the capsular ligament. 
 
 Nothing can be easier than the diagnosis of fractures of the 
 patella. If this bone be fractured transversely, by a forced ex- 
 tension of the leg, the patient falls, and remains without the 
 power of rising. The fall may instantly -succeed the fraflure, 
 or there may be some interval. The impossibility of rising ex- 
 ists also when the fradure is efiedted by a fall on the knee. If 
 
OF FRACTURES OF THE PATELLA. I33 
 
 raised by the aid of others, the patient falls again If he attempts 
 to advance; he can, however, move backward, by drawing the 
 soles of his feet along on the ground, and by taking care not 
 to bend the knee. 
 
 A boy fell on the ice the 1 1th Nivose, year 8, and fra£lured 
 transversely the patella of the right side: his efforts to rise were 
 to no purpose; he was therefore obliged to make his way on his 
 back to a neighbouring house, sixty paces distant. He was 
 there put on his feet, and, by leaning on another person, was 
 able to walk backward three hundred paces to the place of his 
 destination, from which he was conveyed to La Charite. On 
 the 12th a slight degree of swelling manifested itself about the 
 articulation; to reduce which, and to calm the pain which was 
 very acute, emollient poultices were applied. The Inflammatory 
 symptoms entirely disappeared on the eighth day after the acci- 
 dent, at which time the usual apparatus was applied. Toward 
 the conclusion of the treatment, the articulation was exercised 
 gradually every day: the patient quitted the hospital In the be- 
 ginning of Ventose, having the portions of the patella united 
 by a ligamentous substance, half an inch broad. The great 
 strength of this ligamentous substance rendered the joint of the 
 knee sufficiently strong, though it was a little stiff on the pa- 
 tient's quitting the hospital. 
 
 Besides the signs resulting from the cause and circumstances 
 of a fracture of the patella, there are others still equally easy 
 to be ascertained, and not less conclusive. A depression is 
 found on the anterior part of the knee. Instead of the promi- 
 nence naturally formed by the patella at that part : the two 
 fractured portions, which are more or less separated one from 
 the other, may be made to approach by extending the leg on 
 the thigh, and bending the thigh on the pelvis; and they may 
 be moved laterally in opposite clire6tions: a crepitation may be 
 very easily produced, on account of the slight covering of soft 
 parts. A case may occur however, in which the separation of 
 the fractured portions cannot be distinguished, as when there Is 
 a great Inflammatory swelling about the knee; but this uncer- 
 tainty is of no importance; because, even were the frafture 
 ascertained, nothing could be done to bring the divided por- 
 tions together, until the Inflammation had abated. 
 
 Is the consolidation of a frafture of the patella analogous 
 to that of other bones? or is the process of nature different In 
 this case from what It Is In all others? Some authors have 
 been of opinion that the fraiSlured portions of this bone are 
 
 \ 
 
134 OF FRACTURES OF THE PATELLA. 
 
 susceptible of an immediate reunion, by being placed in con- 
 ta£^; but the greater number question the possibility of such 
 a reunion; and assert, on the contrary, that the pieces are al- 
 ways united by means of a ligamentous substance, which is 
 long, thin, and very extensible, when the fradture has not been 
 well treated; but which is, on the contrary, short, thick, and 
 unyielding, when the treatment has been well diredled. 
 
 Camper is the principal author of the latter theory, which 
 he supports by a great number of cases. The Academy of 
 Surgery adopted it on the evidence of similar fafts; and it is 
 now brought forward in a Treatise on Surgery,* lately publish- 
 ed in the north : we do not hesitate to subscribe to it. 
 
 Those who maintain that the consolidation of a fradlure of 
 the patella is analagous to that of fractures of other bones, ap- 
 peal to experience, and cite numerous instances of an immedi- 
 ate reunion, which they attribute to a more perfect mode of 
 treatment. But as this pretended immediate reunion has not 
 been attested by disse£tion of the part after death, it is possi- 
 ble that a very close connexion, by means of a ligamentous 
 substance, scarcely perceptible to the touch through the inte- 
 guments, may have been taken for an immediate union. A 
 postillion received a kick from a horse the 8th Messidor, year 
 6, which fractured the patella of the left knee, near its infe- 
 rior angle: the fibrous expansion prevented the separation of 
 the pieces for some time. The inflammatory symptoms not 
 being intense, yielded quickly to the usual antiphlogistic treat- 
 ment: the uniting bandage was applied, and the knee gradu- 
 ally moved as soon as the progress of the cure allowed it to be 
 done with safety. The patient quitted the hospital on the 18th 
 Thermidor, perfectly recovered: and so small was the interval 
 between the two pieces, that, without a very attentive exami- 
 nation, it might be supposed that there was none. But had 
 they who supported the theory of the union by a ligamentous 
 substance, contented themselves with opposing their adversa- 
 ries by fa£ts, the question could not have remained long unde- 
 cided. They attempted to explain the faft; and their adver- 
 saries, by being able easily to overthrow their reasoning, 
 
 * " Patella frafla, baud uti alia corporis humani ossa, verb callo concres- 
 cit, sed fragmenta, solum mcdiaiite substantia finnioie, cellulosa, cartilagi- 
 nosa, cum ligamento mucoso concurrente, conglutinantur, er fiirtijori cica- 
 trisatione ligamentorum continentur, quod oonstans experient'a, in vivis 
 et cadavarihus, nos edocuit." — Callisen, Pnncipia Systemacis Chir, 
 Hod. § ?288. 
 
OF FRACTURES OF THE PATELLA^ I3J 
 
 thought that they had thereby proved that the fa<fi: never oc- 
 curred, as if a bad explanation could invalidate a well attested 
 faa. 
 
 We have already shewn that the explanation of the non- 
 consolidation of fractures, founded on the want of a perioste- 
 um and lubrification of the fraclured surfaces by the synovia, 
 is vague. 
 
 Some authors, supposing that the patella was differently or- 
 ganized from other bones, have endeavoured to explain, from 
 this difference of stru6lure, the peculiarities of the consolida- 
 tion of its fradlures. But it does not differ in its organization 
 from the other small bones of the body, among which it is 
 classed by the greater number of anatomists. Like them, it is 
 composed principally of a spongy texture, covered by a very 
 thin layer of compacft substance. The fibres of the patella, 
 when perfeftly ossified, are visibly the continuation of those of 
 the tendon, in the midst of which it is formed. This diredtion or 
 continuation of fibres is easily demonstrated by the action of ni- 
 tric acid on the patella, the calcareous part of which it dissolves. 
 The consolidation of fracflured bones is effeiSled by the same 
 process as the cicatrization of wounds of soft parts; that is, by a 
 turgescence and expansion of the vascular texture of the part: 
 hence, the less dense, and the more specifically light any bone 
 is, the greater is the number of vessels which pass through it, 
 and the less is the proportion of its saline parts to its volume; 
 and further, the more intimate and multiplied are its points of 
 contact with the neighbouring soft parts, so much the more ener- 
 getic is its vital aftion, and the more rapid its consolidation 
 when fradhared. The fractured surfaces of the patella, on 
 which a great number of vessels are distributed, are, for the 
 foregoing reasons, much disposed to the inflammatory turges- 
 cence, so necessary for the union of divided parts; and the 
 consolidation would be very prompt if the granulations could 
 be brought into immediate contact, and if mechanical causes 
 did not countera^l: the consolidating process. 
 
 According to Callisen, the adipose cellular texture placed 
 behind the inferior ligament of the patella, presses itself be- 
 tween the divided portions of that bone, and prevents their 
 immediate reunion. When the leg is fully extended, the in- 
 ferior ligament of the patella is also in a state of tension, and 
 the cartilaginous trochlea of the condyles of the femur leaves 
 no vacuum behind the patella: in which disposition of the 
 parts, says Callisen, this cellular substance is forced upv/axd 
 
13^ OF FRACTURES OF THE PATELLA. 
 
 and forward, and thrust between the pieces of bone, so as to 
 prevent their conta6l and immediate reunion: but in no case is 
 this cellular substance placed between the patella and anterior 
 part of the condyles of the femur; and even though it should 
 be placed there, and should insinuate itself between the frac- 
 tured portions, yet it could not prevent their immediate reuni- 
 on, if it ^'ere possible to keep them in contact by a proper 
 apparatus. 
 
 The impossibility of doing so is the sole obstacle to the im- 
 mediate reunion of the fradtured portions; and the cause of 
 this impossibility is found in the contractility of the extensor 
 muscles, which cannot be directly opposed by any bandage. 
 For were it attempted to press down the superior portion, and 
 confine it in its place by a bandage, it is plain that this means 
 could only adt perpendicularly to the muscles which tend to 
 draw it upward, and cannot therefore be completely efFedtual ; 
 there remains, consequently, a greater or less interval between 
 the two portions of bone, the fibrous covering of which be- 
 comes turgid and inflamed from the tension and irritation, and 
 insinuates itself into the interval, so as to fill it up entirely. 
 Such, in our opinion, is the cause and mode of formation of 
 this ligamentous substance. 
 
 The strength, thickness, and inextensibility of this sub- 
 stance, is in an inverse proportion with its length. When 
 long, it is thin, -weak, and extensible, and transmits but im- 
 perfe<Stly the adlion of the extensor muscles to the leg. When 
 short, on the contrary, it is thick, strong, and unyielding, and 
 does not perceptibly diminish the aftion of the muscles, nof 
 impede the motion of the articulation. 
 
 The diminution of muscular adlion is not the sole disadvan- 
 tage resulting from the length of this ligamentous substance; 
 the strength of the knee, the flexion of which is naturally 
 graduated by the patella, is also diminished by it; for the low- 
 er extremity of the femur having no longer its natural support 
 and resistance, the flexion is sudden and abrupt: hence per- 
 sons so a£fe6led fall from the slightest cause. Galen* relates 
 the case of a wrestler, whose patella ascended on the anterior 
 part of the thigh, in consequence of the rupture of its inferior 
 ligament. Every flexion of the knee put this person in the 
 most imminent danger of falling. Descending a declivity was 
 painful to him, and he wife always obliged to use a stick on 
 
 * De Usu Partiiim, lib. iii. cap. 15. 
 
OF FRACTURES OF THE PATELLA. IJ7 
 
 Such occasions. Ambrose Pare* informs us, that those who 
 have had the patella fraiHured have much difficulty in ascend- 
 ing a rising ground, but that they can walk with ease in 
 an horizontal direflion. Duverneyf mentions the case of 
 a young man, whose patella was raised above the condyles 
 of the femur, and fixed there, in consequence of the rupture 
 of its inferior ligament. This person could not walk up stairs, 
 but could readily come down. Morgagni| mentions a great 
 number of similar fafts. I might add several others, all con- 
 curring to prove, that, when the knee has lost the support of 
 the patella, walking on rugged uneven ground is very difficult, 
 and ascending a steep place almost impossible. 
 
 From what has preceded, it appears that the great objecl to 
 be attended to in the treatment of fra(Stures of the patella, is 
 the diminution of the interval between the pieces, in order 
 that the ligamentous substance, which is necessarily generated, 
 may be as short and strong as possible. Previous to the appli- 
 cation of the apparatus, means are to be used to prevent the 
 accession of inflammation*, or, if it has taken place, every ef- 
 fort is to be made to remove it. As inflammation does not in- 
 stantly succeed the fradlure, its approach may be sometmies en- 
 tirely prevented. The most efficacious remedies in such case 
 are fomentations with a solution of acetate of lead, and parti- 
 cularly cold applications, such as pounded ice, or very cold 
 water. These remedies are particularly applicable before the 
 accession of the inflammatory symptoms. When the inflam- 
 mation supervenes, the afflux of humours to the part, which 
 the irritation tends to produce, is to be opposed, and the return 
 of these humours into the circulation favoured. Do we not 
 find, that in plunging into a bath at the freezing point, any 
 part which has been exposed to the action of an irritating 
 cause, as, for instance, the immediate adlion of fire, or any 
 injury which excites inflammation, is rendered in some degree 
 torpid, or has its sensibility diminished.'' Which diminution of 
 sensibility is a mark of a partial suspension of the vital proper- 
 ty of th6 part, and is accompanied with a great diminution of 
 the pain. The principle of irritability resides in the nerves, 
 they being the sole organs of sensibility. By a momentary 
 extindlion of that property, or by a considerable diminution of 
 
 * OEuvres d'Ambroise Pare, b. xv-cap. zi. 
 
 ■j- Treatise on the Diseases of the Bones, vol i. 
 
 X De Scdibus & Causis Morboruin, Epiit. 56, No. 27, 
 
 IS 
 
IjS OF FRACTURES OF THE PATELLA. 
 
 it, do we not i\^£l aj^?inst the cause of the evil, rather than 
 against its effects? Whatever may be the value of this reason- 
 ing, experience teaches us, tliat in the case in question, and in 
 all similar cases, the immersion of the part in cold water is 
 useful, and should be continued for several hours, the water 
 being frequently reviewed, in order to keep up the cold. If 
 the s\n-geon has not arrived in time to have recourse to this 
 means, or if the contusion be so violent as to render inflamma- 
 tion inevitable, the general antiphlogistic treatment is to be 
 pursued, and adapted to the age, strength, temperament, &c. 
 of the patient. The pain is alleviated, and the tension dimi- 
 nished, by extending the leg. Bell recommends the applica- 
 tion of a great number of leeches to the part; but it appears to 
 us that this cannot be done with safety in the greater number 
 of .cases; for the irritation produced by their bites, added to 
 that already existing, might bring on gangrene of the part, 
 and the patient's death. In most cases, as when the fradlure 
 is a consequence of a fall on the knee, the inflammation is in- 
 considerable, and disappears in a few days; then compresses, 
 wet with a solution of acetate of lead, may be placed on the 
 part, and the apparatus may be applied over them. 
 
 If the contusion be excessive, and blood be effused into the 
 articulation through its lacerated capsule, as well as into the 
 cellular texture, the inflammatory symptoms will be violent, 
 then an antiphlogistic regimen and copious blood-letting must 
 be had recourse to; and should a suppuration take place, not- 
 withstanding our endeavours, incisions should be made, in or- 
 der to give a free issue to the purulent matter. This treat- 
 ment is sometimes successful, but at other times, notwithstand- 
 ing every precaution, the patient is cut off". Such was the fate 
 of a mason, brought to La Char'ite^ whose patella had been 
 crushed rather than fraiStured by the fall of a large stone. If 
 the contusion be not confined to the anterior part of the knee, 
 the leg should not be fully extended, but placed rather half 
 bent, that being the position in which all the soft parts are 
 equally relaxed. This position produces, it is true, a separa- 
 tion of the divided portions of bone; but the treatment must 
 be in the first instance directed against the inflammatory symp- 
 toms rather than against the fracture. If the inflammation be 
 not subdued before the twentieth or twenty-fifth day, it will 
 be useless to apply the apparatus ; because the ligamentous sub- 
 stance is already formed, and has acquired a tolerable consist- 
 ence: its length is much greater than it would be, were it pos- 
 
OF FRACTURES OF THE PATELLA. ,13^ 
 
 sible to apply the apparatus, and the strength of the knee is 
 considerably diminished. The patient is doomed to the disad- 
 vantage already mentioned, of not being able to walk on an 
 uneven surface but with great difficult)'', nor to ascend a rising- 
 place without some artificial support. When the Inflamniato- 
 ry symptoms are subdued in this case, all that remains to be 
 done is to guard against a false anchylosis, by gradually moving 
 the leg from the moment that it can be done with safety, un- 
 til the motion is free, and not attended with pain. 
 
 The condudl to be pursued when the inflammation has been 
 overcome in time to admit of the application of the apparatus, 
 or when it was originally trifling, has been already pointed outj 
 we shall, however, recapitulate the particulars: the leg is to be 
 extended on the thigh, and the thigh is to be bent on the pel- 
 vis. The limb is to be supported in this position by means of 
 pillows, or some such bodies, placed under it from the buttock 
 to the heel, and means are to be used to keep the fractured 
 portions in contact. 
 
 Some authors have been of opinion that this position was 
 alone suflicient, and that all apparatus for confining the pieces 
 are useless. This is the opinion of Valentin and Citizen Saba- 
 tier, who relates in the Memoirs of the Academy of Surgery, 
 1783, several cases of fractures of the patella cured by this 
 position alone. But it must be observed, with all due de- 
 ference to the opinion of these practitioners, that as no mea- 
 sure is taken to secure against the motion of the limb 
 or the irritability of the muscles, which tend incessantly to 
 draw the superior fradtured portion upwards, there is every 
 probability that the interval between the pieces of bone will be 
 considerable. Besides the ligament which fills up this interval 
 will be still further lengthened, and therefore weakened, by 
 the incautious motions of the limb; or it may be broken be- 
 fore it has acquired its full consistence. This will inevitably 
 be the case if the patient, frcyTi any cause, bend the knee for- 
 cibly: such an accident would necessarily retard the cure, or 
 totally prevent it, if frequently repeated. 
 
 The bandage in the form of the figure 8, and composed of 
 a band rolled up from both ends, the two globes of which are 
 made to cross one another alternately in the ham, and to em- 
 brace both sides of the patella, causes a congestion of the foot 
 and leg, by not compressing the whole limb. Besides, the ac- 
 tion of this bandage is oblique, and much of it is spent in 
 merely compressing the neighbouring soft parts, which it irri- 
 
J40 OF FRACTURES OF THE PATELLA. 
 
 |:ates, and sometimes excoriates; neither is this inconvenlenc*; 
 remedied by the pasteboard trough, and compresses propose4 
 by Louis as an addition to this bandage. The part of its action 
 which is employed on the fradlured parts is always insufficient 
 to keep them in contaft, if the constriction be not greater than 
 the patient can bear for any length of time. If, in order to 
 avoid this disadvantage, the bandage be not drawn sufficiently 
 tight, its objedt will be entirely frustrated, and its application 
 useless. These defedts, occasioned this bandage to be re- 
 jected, and led to the invention of another much less objec- 
 tionable. 
 
 A bandage, which, instead of occasioning an oedematous 
 swelling of the limb, obviates it by making an equable pressure 
 on all its parts, which adts in diredt opposition to the muscles, 
 which tend to separate the portions of bone, and which, by 
 acting on these muscles, diminishes their irritability and en- 
 feebles their action, must concur powerfully with a good posi- 
 tion to efFeCt a favourable union of the divided portions of the 
 patella. The uniting bandage used for transverse wounds pos- 
 sesses all these advantages, when modified as we shall present- 
 ly mention. The relaxed state into which the parts are put 
 by the extension of the leg on the thigh, and the flexion of 
 the thigh on the pelvis, favours its a6tion. 
 
 In applying this bandage, one assistant fixes the pelvis, 
 while another raises and supports the whole inferior extremity. 
 The surgeon takes a strip of linen longer than the whole limb, 
 and broader than the patella, extends it on the inferior part of 
 the leg, and fixes it by several turns of a roller; he then turns up 
 the inferior extremity of the piece of linen, over which he again 
 winds the roller, which he continues to apply as far as the articu- 
 lation of the knee. He then commits the roller to an assistant, 
 while he himself extends the skin over the patella, lest it should 
 sink or be thrust in between the pieces of bone, which he brings 
 into as close contact as possible, and includes them in two long 
 compresses passed obliquely round them, and crossed in the 
 ham. In the next place he extends the longitudinal piece of 
 linen first mentioned on the knee and thigh, as before on the 
 leg, and again takes the roller, which he carries obliquely over 
 the compresses, observing at the same time to let the folds 
 cross one another in the ham. The application of this roller 
 is continued upward on the thigh, and by its means the longi- 
 tudinal piece of linen is fixed nearly as far up as the groin, 
 from which its superior extremity is turned downward, having 
 
OF FRACTURES OF THE PATELLA; I4I 
 
 been previously drawn upward with much force. The roller 
 is again carried downward over this double strip, and continu- 
 ed over the knee and leg until it is entirely applied. Another 
 roller is passed several times on the foot, and the whole com- 
 pleted by applying a long splint on the back part of the limb 
 from the buttock to the heel. This splint is kept applied by 
 means of several turns of a bandage passed round it, and the 
 pressure made by it may be prevented from being inconvenient 
 by placing a long cushion of chafF between it and the limb. By 
 this means the patient is prevented from bending his leg, which, 
 without this precaution, he would probably do, and thus frus- 
 trate all our efforts. The pain arising from the constriction 
 and continued extension renders it impossible for the patient to 
 keep the limb extended without the assistance of a splint. 
 
 This apparatus preserves the pieces of bone exactly in their 
 place in the comrhencement; but as the circumference of the 
 limb quickly diminishes, the rollers become relaxed ; the mus- 
 cles which were adted on perpendicularly, are no longer suffi- 
 ciently compressed j they therefore draw upwards the superior 
 jjortion. But this separation will be very inconsiderable, if the 
 patient be frequently visited, and the rollers tightened as often 
 as they are found loose. 
 
 This chapter might be much extended, by drawing from the 
 profound oblivion in which they are buried the numerous ap- 
 paratus invented at different and distant times for the treatment 
 of fraftures of the patella. Some advantage might, however, 
 be derived from the use of some of them, such as the pieces 
 of metal, leather, or pasteboard, with an opening in the mid- 
 dle for the reception of the patella. Or for these apparatus 
 might be substituted two pieces of metal, covered so as to em- 
 brace the patella. The concave sides of these metallic pieces 
 might be covered with hair, in order to diminish the pressure 
 on the soft parts. This apparatus does not exclude the appli- 
 cation of the splint and rollers, &c. 
 
 These general principles of treatment being once established, 
 nothing can be easier than to apply them to particular cases. 
 
 We shall describe another apparatus, which appears to us 
 very capable of keeping the leg extended, and the portions of 
 bone in the greatest possible state of approximation. This 
 consists of a trough, long enough to extend from the superior 
 part of the thigh to the s.uall of the leg, and wide enough to 
 receive the thigh and leg. Small buttons are fixed to the edges 
 of this trough, to which may be attached two straps, that cross 
 
142 OF FRACTURES OF THE PATELLA. 
 
 one another, and are fastened in the following manner. The 
 trough being lined with carded cotton or soft linen rags, the 
 limb is placed in it in such a manner as that the calf of the leg 
 shall correspond to its middle part: it is then fixed in that situ- 
 ation by means of a circular bandage. One of the leather 
 straps is then fixed to one of the inferior buttons, which rises 
 vertically from the external edge or border of the trough, and 
 conveyed upward and inward, and fastened to one of the supe- 
 rior buttons of the internal side. The other strap is fixed .in 
 the same way from the inside outward, so that they cross one 
 another at their middle part, and embrace the superior frac- 
 tured portion in their ■ inferior angle. It will be necessary to 
 extend the skin over the patella before the straps are tightened. 
 Compresses soaked in a resolvent liquid are then applied, and 
 a few turns of the remaining part of the roller are passed round 
 the whole. The extremities of the straps should be made of 
 leather, but the middle parts of buffalo-skin stuffed with hair 
 like a bandage for a herni<«, in order to guard against any ex- 
 coriation of the parts on which they press. The simple me- 
 chanism of this apparatus may be more perfe^ly comprehended 
 by means of the engraving, Plate 3, fig. 1 and 2. 
 
 Some authors have been of opinion that the separation of 
 the fractured portions, so far from injuring the motions of the 
 knee, was, on the contrary, favourable to these motions; and 
 have in consequence, proscribed every species of bandage which 
 could prevent that separation. These authors content them- 
 selves with simply moving the limb after the disappearance of 
 the inflammatory symptoms, in order to guard against a false 
 anchylosis. They allow the limb to remain in the half-bent posi- 
 tion. But a stiffness in the articulation of the knee is a conse- 
 quence much less to be dreaded than the weakness and disabi- 
 lity which necessarily result from the length of the intermedi- 
 ate ligamentous substance : for which reason this method has 
 but very few partisans. It is applicable only in cases of a longi- 
 tudinal fradlure of the patella, which very seldom happens, 
 and in which the pieces remain naturally in conta<n:. An anchy- 
 losis may be always guarded against with certainty, by begin- 
 ning to move the articulation about the twenty-fifth day. If the 
 treatment has been judicious and regular, no danger can re- 
 sult from gentle motion of the joint at that period; and the 
 extent to which the motion is carried may be increased every 
 day until flexion and extension can be performed freely and 
 without pain. 
 
f\ 
 
143 
 
 CHAPTER XVI. 
 
 OF FRACTURES OF THE BONES OF THE LEG. 
 
 SECTION I. 
 
 Of FraBures of the Leg, 
 
 THIS name is given to frad\ures of the leg when both the 
 bones composing it are broken; and such fractures are 
 much more frequent than those of the tibia or fibula singly. 
 The middle part of these bones is that which is generally frac- 
 tured; for the great thickness and strength of the superior part 
 of the tibia render fractures at that part very rare; but the in- 
 ferior, not being equally strong, is sometimes fra^lured, and 
 with it the fibula. Both bones are generally fra^lured at the 
 same height : this is a necessary consequence of the simultane- 
 ous a£lion of the fracturing cause. 
 
 These fraClures may be transverse or oblique, and are subjecSt 
 to every species of derangement. The longitudinal derange- 
 ment is, however, much less common than the horizontal or 
 angular. In the former case, the inferior pieces are almost al- 
 ways drawn outward and backward, whilst the superior proje<n: 
 internally and forward. The angular derangement may be pro- 
 duced either by the action of the posterior muscles of the leg or 
 the weight of the bodj'-, and in either case the angle will be 
 salient anteriorly. The salient angle may take place posteriorly, 
 if the heel be too much raised. The derangement in the cir- 
 ''umference arises from the inclination of the foot inward or 
 outward, but it most commonly fails in the latter direction. 
 The longitudinal derangement is extrei^ely rare, and cannot 
 
144 OF FRACTURES OF THE LEG. 
 
 easily take place in transverse fractures, on account of the con-^ 
 siderable extent of the fractured surfaces; but in oblique frac- 
 tures the inferior pieces are almost always drawn upward by the 
 adlion of the posterior muscles of the leg, in which position of 
 the parts the lower ends of the superior portions project anteri- 
 orly, and may be felt by the hand. Sometimes, however, 
 when the solution of continuity is obliquely downward and out- 
 ward, the anterior projection will be produced by the lower 
 pieces. In some cases the pointed ends of the bones tear and 
 penetrate the integuments in both kinds of derangement. 
 
 Fradlure of the leg is accompanied by all the signs or symp- 
 toms mentioned in treating of fraflures in general in the first 
 chapter. Change of direction and shape of the limb, pain, and 
 incapability of motion, mobility of the fractured pieces, and 
 crepitation always distinct, &c. — all these circumtances render 
 this fraiSture so evident, that it is impossible to be mistaken re- 
 specting its existence. 
 
 The prognosis, less unfavourable than in fradtures of the 
 thigh, varies according to the part of the bone fra£tured, the 
 direction of the fraCture, and many other circumstances. The 
 fraCtures which take place near the knee are not much subjeCt 
 to derangement, on account of the thickness of the bone in 
 that part ; but are however, more dangerous than those of the 
 middle part, as being subjeCtto be followed by a stiffness of the 
 knee joint. FraCtures of the inferior part are still more dan- 
 gerous. Oblique fraCtures are very difficult to be managed; 
 and when their derangement is upward and outward, the in- 
 teguments are very apt to be torn by the projecting points of 
 the superior portions of bone. 
 
 As to the treatment of a simple fraCture of the leg, the pa- 
 tient is to be carefully undressed in the first place, and then 
 laid on a hard and narrow bed, perfectly horizontal, and with- 
 out any board at the end. Afterwards the apparatus are ar- 
 ranged in the following manner: 1, three pieces of tape, or 
 linen; 2, a square piece of linen cloth longer than broad; 3, a 
 sufficient number of short pieces of linen to cover the whole 
 leg, or Scultet's bandage; 4, two quadrilateral compresses; 5, 
 three cushions of oaten chaff, and three splints, two lateral^ 
 long enough to extend from the knee to a small distance be- 
 yond the sole of the foot, and a third anterior shorter than th^ 
 leg. All the pieces of the apparatus being thus disposed, and 
 the compresses and short bandages being wet with a resolvent 
 liquid, an assistant takes hold of the knee with both his hands. 
 
OF FRACTURES OF THE LEO, I45 
 
 and another seizes the foot, having both his thumbs applied to 
 its sole: while both pull in opposite direiSlions, the surgeon per- 
 forms coaptation. The moment that the bones come into their 
 right situation is easily known, on account of the thin covering 
 of the tibia anteriorly. The square compresses are then laid 
 over the leg, and on them Scultet's bandage, commencing al- , 
 ways with the lowest pieces. The lateral splints, in the next 
 place, rolled up in the square linen cloth, are applied in such 
 a manner as that they may rest perpendicularly on their edges, 
 nearly in contact with the leg, between which and them a bag 
 of chaff is placed on each side, by means of which the depres- 
 sions of the leg are filled up. The remaining chaff-bag is placed 
 on the anterior part of the leg for a similar purpose, and over 
 it the third splint. An assistant holds fast with both his hands 
 the different pieces thus placed, while the surgeon secures them 
 more permanently by means of the three linen bands, which he 
 knots over the external splint, commencing always with the 
 middle one. The apparatus is completed by securing the foot 
 by means of a small band to the lateral splints, in order to pre- 
 vent it from falling to either side. But as the foot might be 
 forced to either side by the weight of the bed-clothes, this in- 
 convenience is guarded against by means of a hojop placed per- 
 pendicularly on its ends over the leg. If the patient's stomach 
 be not full he should be bled, and afterwards confined to a low 
 regimen. 
 
 Not only is it useless to place compresses under the heel, as 
 was practised by the ancients, but it is attended with manifest 
 disadvantages. The heel being raised by these compresses, 
 supports the whole weight of the limb; and the pressure some- 
 times occasions gangrene, to such a degree, that the os calcis 
 is laid bare. Besides, by the elevation of the heel, the frac- 
 tured part of the leg loses its support, and a salient angle is 
 produced backward by the weight of the limb. 
 
 A roller cannot be substituted for Scultet's bandage, but in 
 cases of children under two years of age. 
 
 If on the day after the application of the apparatus, the foot 
 be neither painful nor swelled, and a slight degree of oedema 
 be alone perceptible in that part, the apparatus need not be 
 removed. It will be necessary to tighten the external bands 
 every day, and to wet the whole with a repellent liquid; and 
 at the end of eight days the apparatus should be re-applied. 
 Some pra^itioners do not change the first dressing for eighteen 
 or twenty days: but it frequently happens, that during this 
 19 
 
146 OF FRACtURpS OF THE LEG. 
 
 time the fra^red portions become deranged in the direction of^ 
 the diameter or axis of the bone, and that their consolidation^ 
 has already advanced considerably in this vicious position. This 
 derangement may be occasioned by some accidental or involun- 
 tary motions; some defeft in the first application of the appara- 
 tus, or (what is of the greatest importance) by the bed not be- 
 ing perfectly horizontal. The pradlice of deferring for such a 
 length of time the re-applrcation of the apparatus, has probably 
 originated from the use of the circular bandage or roller. The 
 motion which should necessarily be given to the limb in re-ap- 
 plying that bandage, was certainly a sufiicient justification of 
 the practice. In adopting the improved method which we have 
 described, the whole apparatus should be re-applied ever}' seven 
 days, and the external bands tightened whenever the relaxation 
 may render it necessary. 
 
 On the fortieth or forty-fifth day, the progress of consolida- 
 tion may be examined ; and if the callus be found solid, the 
 circular bandage or roller may be safely substituted for that 
 which we have described, and the patient may be. allowed to 
 sit up and take any convenient posture, and in a very short 
 time to walk about with the aid of crutches. The stiflhess of 
 the knee and instep arising from the long ina6livity, will render 
 walking diflficult for some time. 
 
 For the three or four first days the patient should be allowed 
 only broths, which may be gradually changed for more sub* 
 stantial food. If he be costive during his confinement, clysters 
 may be administered; and should other incidental symptoms 
 occur, they are to be combated by appropriate remedies. 
 
 We shall not trouble our readers by treating particularly of 
 compound frafture of the leg, because we could only repeat 
 what we have already very minutely detailed. 
 
 When the leg is fradlured very obliquely, continued exten- 
 sion ought to be employed, particularly when the points of the 
 fraftured portions penetrate though the integuments. In cases 
 of this nature, in which there is some hope of preserving ths 
 limb, if the patient be strong and healthy, some blood should 
 be taken from the arm, and the- extending apparatus applied.. 
 
OF FRACTURES OF THE LEG. I47 
 
 SECTION U. 
 
 K)f FraElures of the Tibia. 
 
 This bone bears the whole weight of the body transmitted to 
 it from the femur, and is fradlured on that account more fre- 
 jqucntly than the fibula, though it is much thicker and stronger 
 than the latter. But as fractures of it are almost always trans- 
 verse, they are not very dangerous. 
 
 If the fracture take place near the inferior extremity, the 
 great extent of the fractured surfaces prevents any considerable 
 derangement of the fraftured portions; and the fibula acting as 
 ^ support on the external sides, contributes also to this efl^efl:. 
 Besides there is no tendency to derangement from muscular 
 ,a6tion. 
 
 This circumstance renders a diagnosis of fra^res of the tibia 
 .often very difficult, and the difficulty is further increased by 
 the little pain and inconvenience produced by such a fra^ure; 
 for persons have been known to walk, although the tibia wjws 
 at the same time fraftured. 
 
 Whenever there is reason to suspect this affection, in conse- 
 quence of a blow or a fall on the leg, the part should be minute- 
 ly examined. The fingers are to be moved along the anterior 
 side of the tibia, the slightest inequality in which may be ea- 
 sily perceived, on account of its being covered only by the 
 skin; and the motion of the pieces may be perceived, by sei- 
 zing the opposite ends of the bone and pushing them in contra- 
 ry directions. This motion, however, and the crepitation 
 which should accompany it, are very indistinct, on account of 
 the fibula not allowing the fractured portions to be sufficiently 
 moved on one another. 
 
 The patient conplains of a constant pain in his leg, and par-, 
 ricularly near the seat of the fracture. This pain continues for 
 a much longer time than that which is the effect oif a mere 
 contusion, and it is increased by walking. 
 
 By means of these signs, the existence of this fracture may 
 be ascertained; but little is to be done in the treatment of it. 
 The slight derangement which has taken place, is to be correct- 
 ed by moving the pieces in the direction opposite to that in 
 whicli the derangement has taken place; but before giving 
 
148^ OF FRACTURES OF THE LEG. 
 
 them this motion, they should be drawn in opposite direflions, 
 hi order to diminish the friclion of the fraflured surfaces. A 
 long compress is then placed on the anterior part of the leg, 
 and over that a roller or circular bandage; with which the leg 
 being covered, three splints of pasteboard, or thin wood, are 
 applied and bound on by the part of the roller which remained 
 unappUed. 
 
 The patient is to be confined to his bed, and not allowed to 
 use the affedled limb until the fracture is consolidated. In 
 cases of aged or adult persons, it would perhaps be more pru- 
 dent to use the ordinary apparatus for fraclures of the leg, than 
 the roller. "Whichever mode is adopted, the bandage may be 
 taken off on the fortieth or forty-fifth day, at which time the 
 consoHdation is complete. The articulations of the knee and 
 ■ foot are but little affefted by this fradlure, and the slight stiff- 
 ness of them, arising from inaftivity, is soon removed, and the 
 patient is able to walk about in a few days. 
 
 SECTION III. 
 
 Of Fi'a^ures of the Fibula. 
 
 The fibula, though slenderer than the tibia, is less frequent- 
 ly fraftured. It is not charged with the weight of the body, 
 and its principal use seems to be that of preventing the disloca- 
 tion of the foot outwards, in a forced abdu6tion. . Thus we see 
 that it is placed externally, descends below the articulation of 
 the tibia with the foot, and forms the external ankle. It is be- 
 sides more flexible than the tibia, and can execute in its double 
 articulation with this latter bone some obscure motions, which 
 consume a greater or less share of any force that might tend to 
 fra<Slure it. 
 
 Yet, from the very nature of its fun(fl:ions, the fibula is ex- 
 posed to certain fracflures, of which no author has taken par- 
 ticular notice. In every step that is made on an uneven ground, 
 the foot presses against the inferior extremity of this bone. By 
 this action of the foot on the external ankle, the fibula is pres- 
 sed upward, and as the nature of its articulation with the tibia 
 does not allow it to ascend in any perceptible degree, it is for- 
 ced to bend more or less in proportion to the force applied. 
 
OF FRACTURES OF THE LEO. I49 
 
 Tlie elasticity of this bone enables it for some time to resume its 
 natural direction, when the force is removed. But as the same 
 force adls frequently, and is never intermitted but for very short 
 intervals, the bone acquires insensibly a permanent bend, in- 
 stead of being perfectly straight, as it is in the infant. This bend 
 becomes more evident in proportion as age advances, and as the 
 limb has been used. 
 
 Climbing anjmals, such as the squirrel, and others, whose 
 feet are always in a forced abduftion, have the fibula stronger 
 in proportion, and more convex externally, than it is in the 
 human species. It has been observed by Citizen Cuvier and 
 Dumeril, that in the animal called the three-toed sloth, the 
 inferior extremity of the fibula is inserted into a socket on the 
 superior surface of the astragalus, in such a manner as that the 
 foot must be considerably strengthened by it, and secured 
 against dislocation by the extreme abdu(5lion which this animal 
 is obliged to make, in grasping the trunks of the trees oa 
 which he climbs. 
 
 The motions of adduction and abduction, in which the 
 sole of the foot is turned inwards or outwards, are very limit- 
 ed in the human species, and much less extensive than those 
 of flexion and extension. It sometimes happens, however, 
 that the foot, from missing its support, or being entangled by 
 something, is turned forcibly invsrards or outwards; in which, 
 case the ligaments of the articulation are always strained, and 
 very frequently lacerated. It is in a case of this kind, when 
 the foot is forcibly turned outwards, that the fibula is fractured 
 by the pressure of the astragalus, the dislocation of which, out- 
 wards, it prevents, when the foot is forcibly turned in the same 
 direction. 
 
 The action of the foot is always the immediate cause of 
 fracture produced in this way. If the convexity of the fibula 
 outwards were uniform, so that the whole length of the bone 
 should form an arch of a circle; if it were of an equal thick- 
 ness and strength in all its parts, and if its muscular and liga- 
 mentous connexions with the tibia were also of an equal 
 strength in every part, the fra£lure would always take place in 
 its centre: but none of these conditions exist, and the fra<fhire 
 takes place generally below its middle half. If the abduftion 
 of the foot has been very violent and sudden, the fibula may 
 be fradtured at about an inch above its lower extremity, by 
 which the external ankle is separated from the body of the 
 bone. 
 
150 or FRACTURES OF THE LEO, 
 
 To the fraftures produced by this cause are to be added 
 those resulting from a fall, or a blow on the external side of 
 the leg, in which the bone always yields in the part to which 
 the force is immediately applied, and in a diredlion opposite to 
 its natural curve. 
 
 Whatever be the manner in which a frafture of the fibula 
 is produced, the pieces are not susceptible of the longitudinal 
 derangement; but are in all cases drawn a little towards the ti- 
 bia, by the muscles placed in the interval between themv 
 Hence a fradlure of this bone will be best ascertained by press- 
 ing the fra£lured portions inward, as it is in that diredlion that 
 their motion can be best perceived. This symptom, and cre- 
 pitation, which is a consequence of it, may be also observed 
 in the abdudlion and addudiion of the foot. These signs are 
 more evident when the fradture takes place near the inferior 
 extremity, than when it happens near the superior, which is 
 covered with thick muscles. But a fraclure of the lower part 
 may be very difficult to be ascertained, when the articulation 
 of the foot has been at the same time violently strained, and 
 the inflammation and swelling have arrived at a great height. 
 In cases of this nature, some pr addition ers turn all their atten- 
 tion to the afFe£lion of the articulation, that is to reduce the 
 luxation of the astragalus, and combat the inflammatory sympr 
 toms, without doing any thing for the fradlure. 
 
 But so imperfedt a mode of treatment must be attended with 
 the worst consequences. The peronei muscles, which extend 
 the foot by raising its external edge, and turning its sole out- 
 ward, aft incessantly, and draw the foot gradually into that 
 position. The fraftured portions are deranged longitudinally, 
 the inferior being drawn upward along the internal side of th^ 
 superior. The astragalus is carried under the internal ankle, 
 and forms a considerable tense tumour there; the skin becomes 
 inflamed and ulcerated at this part, and a fistula is formed, 
 which communicates with the articulation of the foot. The 
 patient cannot support himself on the afFefted limb, and ir^ 
 time the symptoms become more and more alarming, and may 
 lead to the necessity of amputating the part. Fabre quotes twQ 
 examples of the Vad consequences resulting from negledling 
 a fracture of the fibula; they are to be found in his Researches 
 on certain Points of Physiology and Pathology. I have my- 
 self seen the foot distorted, and the fracture not consolidated, 
 in the case of an old man who died of a malignant fever, in 
 one of the medical wards of La Charite. 
 
OF FRACTURES OF THE LEG. I5I 
 
 It will therefore be prudent, in every case of a strained foot, 
 to examine carefully the lower extremity of the fibula, and to 
 apply an appropriate apparatus, if there be the slightest sus- 
 picion of a frafture. The first step of the treatment should be 
 to cover the affedled part with emollient poultices, and to take 
 some blood from the arm ; and if it be found that the bone is 
 fractured, so soon as the swelling and inflammation are abated, 
 Scultet's bandage should be applied, and the distortion of the 
 foot prevented by means of two splints, which descend fi"onx 
 above the knee, to a short distance beyond the foot externally, 
 and internally as low as the ankle. It is perhaps superfluous to 
 repeat that the splints should be rolled in a splint-cloth, and 
 tied on with bands, and that bags of chaff should be placed 
 between them and the leg, in the depressed parts. 
 
 This apparatus should be continued for a month, and fre- 
 quently removed, in order to renew the emollient applications. 
 In this lapse of time, the frafture generally consolidates, but a 
 stiffness remains in the joint, of which it will be prudent to 
 Warn the patient. This, however, will be removed in a few 
 months by bathing and fridtion, but above all by exercise, the 
 suspension of which was its principal cause. 
 
 If the fradhire take place towards the middle part of the 
 bone, the ordinary apparatus for frafture of the leg should 
 be applied, and thick compresses placed on the anterior and 
 posterior sides of the leg, by means of which the antero-pos- 
 terior diameter being increased, the bandage can adt in that di- 
 redlion, and press the fleshy parts into the interosseous inter- 
 val, and thus prevent the fradiured portions from obeying their 
 tendency to approach the tibia. But preserving the interos- 
 seous interval is not so important here as in the fore-arm, be- 
 cause in the former it merely serves to lodge some muscles^ 
 the foot not having to execute any motions which require the 
 rotation of the fibula on the tibia. 
 
1^1 
 
 CHAPTER XVII. 
 
 OF FRACTURES OF THE BONES OF THE FOOT. 
 
 SECTION I. 
 
 Of the FraBures of the Os Calcis. 
 
 THE solidity of this bone, the three dimensions of which 
 are nearly equal, renders it but little liable to be fracElu- 
 red. The causes by which it may be fraftured are muscular ac- 
 tion and external violence, and' in this respeft it resembles the 
 olecranon and patella. The violent and instantaneous contrac- 
 tion of the gastrocnemii muscles is sufficient to detach from the 
 remainder of the bone that part of it called the tuberosity, into 
 which the tendo Achillis is inserted, and which extends back- 
 ward beyond the astragalus. Though the gastrocnemii muscles 
 are at least as strong as the extensors of the arm or leg, yet 
 fra£lures of the os calcis are, on account of its thickness, much 
 less frequent than those of the patella or olecranon. Fradlures 
 of it are also less frequent than the rupture of the tendo Achil- 
 lis, the contrary to which takes place with respe<Sl to the ten- 
 dons of the extensors of the arm and leg, which are stronger 
 than the osseous parts to which they are attached. 
 
 Some rare examples of fracSlure of the os calcis from muscu- 
 lar a6lion maybe cited: that, for instance, of a woman detain- 
 ed against her will at La Salpetriere. She converted her sheets 
 into a rope, and by means of them descended from her win- 
 dow; but the sheets not reaching to the ground, she let her- 
 self drop on her feet. On touching the ground, she heard a 
 crack in one of her heels, and fell without the power of rai- 
 
OF FRACTURES OF THE OS CALCIS. I Jj 
 
 sing herself. On examination the os calcis was found to be 
 fraihired. 
 
 The existence of this fracture is discovered by the circum- 
 stances of the case: a fall on the sole of the foof, a crack 
 heard in the moment of the fall; pain, which is increased by 
 the motion of the part; the almost absolute impossibility of 
 standing or walking; a greater or less sweUing of the heel; 
 the mobility and elevation of that part of the os calcis into 
 which the tendo AtJhillis is inserted; finally, the crepitation 
 and interval between the fractured portions — are all marks 
 which separately or conjointly lead to the discovery of the 
 fradture, it may be observed, however, that the separation of 
 the fra6lured portions is not easily ascertained, on account of 
 the thickness of the integuments. 
 
 In setting this frafture, it is necessary to extend the foot on 
 the leg, and to bend the leg on the thigh. In this position the 
 two portions of the os calcis can be very easily brought into 
 contain:, the superior of which is drawn upward by the gastroc- 
 nemii muscles. 
 
 The foot and leg are kept in this position all the time neces- 
 sary for the consolidation, by means of the slipper invented by 
 J. L. Petit for a rupture of the tendo Achillis. 
 
 The uniting bandage used for transverse wounds may be 
 substituted for the slipper, when from local circumstances, the 
 latter cannot be had; but it must be modified as follows: the 
 end of a bandage is placed on the superior surface of the foot, 
 whence the bandage is reverted on the sole, and the end is 
 made fast by circular casts round the foot: this bandage is then 
 drawn along the posterior side of the leg to the ham (the foot 
 being previously extended), on which part it is fixed by other 
 circular casts: it is thence brought downward forcibly, and the 
 application of it terminated by rolling along the leg what re- 
 mains. To this bandage might be added a long compress, the 
 middle part of which should be applied above the posterior 
 portion of the os calcis, and the exti* mities crossed on the su- 
 perior surface of the foot, and turned under the sole. This 
 compress may be fixed by a bandage rolled on the foot in the 
 shape of the figure 8. 
 
 The union of this frafture is effedted in thirty or forty days, 
 at the end of which time the patient may be allowed to bend 
 his foot. He must, however for some days, avoid any forced 
 flexion of the foot, as also an excessive extension by rising nn 
 his toes. 
 
 20 
 
1^4 OF WOUNDS, ANft 
 
 The other bones of the tarsus, as the astragalus, cuboide?, 
 scaphoides, and the three ossa cuneiformia, are susceptible on- 
 ly of comminutive fradlure. The same may be said of the 
 bones of the metatarsus, and the phalanges of the toes. On 
 the treatment of fradhires of these bones we have nothing to 
 add to what has been already said in general on compound 
 fractures, op in particular on fradures of the bones of the hand*. 
 
 CHAPTER XVIlt. 
 
 OF WOUNDS, AND DENUDATION OF BONES. 
 
 THE bones may be stripped, not only of the integuments/ 
 muscles, &c. by which they are naturally covered, but- 
 also of the periosteum, which- is their intimate and appropri- 
 ate covering. 
 
 Cutting or eontundlng instruments may produce this denu- 
 dation of the bone without injuring its substance, or they may 
 cut or contuse its external fibres. Th^se two cases must be 
 carefully distinguished, as the contusion of th€ bone is attend- 
 ed with consequences much more serious thaft those of a simple 
 denudation; 
 
 If the bone has been merely stripped of its periosteum ancb 
 integuments, and these parts are immediately replaced, so a» 
 to exclude the contact of the air and bandages, the reunion of 
 the periosteum is found to take place in a very short time. 
 But if the external lamin>, of the bone have been contused, or 
 if its surface has been left a long time exposed to the adtion of 
 the air, or to the fridlion of bandages,- exfoliation becomes a- 
 necessary consequence. All the external laminae must separate*, 
 and before this separation is effected, the cicatrization. of the 
 external wound would be rather injurious. Should the wound in' 
 the integuments be prematurely closed, purulent matter will 
 continue to form underneath, the contused laminse will exfo- 
 liate, an abscess will point externally and burst spontaneously,. 
 
DENU,pATION Of BONES. i^^ 
 
 and tfee matter that escapes from them wiU contain small splint- 
 ers of bone. Old age is unfavourable to the healing of 
 wounds and contusion of the bones; because, as ihe cure can 
 be effected only by means of the vascular texture of the bone 
 and periosteum, the turgescence and expansion of this must 
 be slow and difficult in proportion to the person's age. The 
 treatment adapted to the different cases is as follows: 
 
 If the bone be simply laid bare, the integuments, if not 
 completely separated, should be instantly replaced. This pre- 
 cept holds good in all cases, whatever may be the patient's age, 
 if the bone has not been already a long time exposed to the 
 contact of the air. At the same time it must be allowed that 
 it is very difficult to know by mere inspe<Stion whether the 
 bone be contused or not; but should that be the case, and even 
 should suppuration and exfoliation be inevitable, no bad con - 
 Gequence can result from the attempt to produce an immediate 
 cicatrization; whereas, in the contrary event, the duration of 
 the treatment will be much abridged. If it be impossible to 
 unite the wound by the first intention, its lips are to be kept 
 separate by lint interposed, and the whole is to be lightly co- 
 vered. In a short time granulations appear, and the external 
 laminse of the bone exfoliate. Sometimes, however, and par- 
 ticularly in young persons, the bone becomes soft and red, and 
 granulations arise from it, which bleed from the slightest x;ause. 
 It has been said, that the bone exfoliates insensibly in this 
 case; but this observation is not found tp be true: the laminse 
 of the bone are not broken down, dissolved, and carried off 
 by suppuration. The change consists of a softening of the 
 bone, and conversion of it into a fleshy substance, which unites 
 with the soft parts. 
 
 In this last mentioned case the cure is much mor-e prompt 
 than when a real exfoliation takes place. The process of ex- 
 foliation resembles that of the separation of gangrenous es- 
 chars: the mode in which the separation is fffefted is equally 
 unknown in both cases. In exfoliation, it is merely known 
 that the subjacent vessels grow turgid, expand, and pullulate, 
 and that a line of separation is observed between the contused 
 "iaminoe and the sound part of the bone. The former are u-n- 
 dermined, as it were, and their connexion shaken by the pu- 
 rulent matter formed under them, and at length are entirely 
 detached, and may be easily removed by the fingers or a for- 
 *;eps. When the bottom of the wound is entirely freed, the 
 
156 OF WOUNDS, &C. OF BONES. 
 
 granulations that arise from it unite with the soft parts, and in 
 a short time the wound is cicatrized. 
 
 Various processes have been employed for expediting the 
 exfoliation. Thus the ancients covered the bone with pledgits 
 of lint impregnated with spirits, or with a tin(n:ure of myrrh 
 and aloes; but it is found that these applications retard the ex- 
 foliation by opposing the expansion of the vessels ; for which 
 reason they have been laid aside, and oily relaxing applications 
 have been substituted for them. 
 
 • It has been proposed to perforate in different parts the lami- 
 nse which are to exfoliate, on the supposition that this pradlice 
 facilitates the growth of the granulations. The perforations 
 have certainly this effedl, but the granulations, by shooting up 
 throuch them, retain the lamina: rather than aid their exfolia- 
 tion: each vessel spreadmg as it rises, and assummg in some 
 respeft the shape of a broad-headed nail. It will then be more 
 prudent to limit the treatment to the use of unctuous or emol- 
 lient applications. By means of these remedies, the texture of 
 the part will be sufficiently relaxed, and the developement of 
 the vessels facilitated. But if the portion of bone to be exfo- 
 liated be very considerable and deep seated, these applications 
 are nearly useless, at least their effect must be very trifling; 
 then we must content ourselves with covering the part with 
 lint, and trusting to time and nature for effedling the separa- 
 tion. 
 
 Though the exfoliation be complete, as may be known by 
 the motion of the piece, it may still happen that the circumfe- 
 rence of the detached portion may be encroached on by the 
 growth of the soft parts, and thus prevented from separating. 
 In this case it will be necessary to disengage it by making an 
 incision in some point of the circumference of the wound, af- 
 ter which it may be drawn out by the fingers or a forceps. In 
 general, there is but very little difficulty in removing it. 
 
 The action of cutting instruments is not always limited to the 
 mere denudation of the bone; they sometimes completely divide 
 it: this, however, is but a rare occurrence. It sometimes hap- 
 pens that a part of the bone is cut off", of which there are nu- 
 merous instances in wounds of the head, where a part of the 
 pariotal bone, with its pericranium, a portion of the occipito- 
 frontalis muscle and hairy scalp, have been entirely separated 
 by a blow of a sword. 
 
 When a wound of the soft parts is accompanied by a similar 
 affedlion of the subjacent bone, an immediate reunion of the 
 
OF NECROSIS. 157 
 
 soft parts must not be attempted. Lint is to be gently intro- 
 duced into the fissure, and the wound healed from the bottom; 
 for a solid cicatrix of the soft parts cannot be expected until 
 the wound in the bone is first cicatrized. 
 
 If the bone of one of our limbs be cut quite through, as in the 
 cases mentioned by La Peyronie, Warner, and others j and if a 
 piece of flesh remain undivided, which contains the principal 
 vessels of the limb, it will be prudent to reunite the parts, and 
 place the limb in the apparatus used in cases of frafture of the 
 part. 
 
 The time necessary for the remiion of the parts in cases of 
 this nature is full as long as that in those of frafture, and the 
 consolidation is effedled in the same manner as in the former 
 case. 
 
 CHAPTER XIX. 
 
 OF NECROSIS. 
 
 THAT affection of bones by which a part of their sub- 
 stance is deprived of the vital principle, has been termed 
 necrosis: the affected part of the bone, in this case, bears a 
 stricl analogy to that of soft parts in which a gangrene has taken 
 place. This disease was not distinguished from caries by the 
 ancients, and it has been termed " dry caries" by some of the 
 moderns. Necrosis and caries are, however, essentially dif- 
 ferent. 
 
 Osseous parts attacked by necrosis are absolutely deprived of 
 the vital principle: but this is not the case when they are simply 
 carious; for caries is an affeiTlion exactly analogous to foul and 
 corroding ulcers of the soft parts. 
 
 All the bones of the body are subject to necrosis, but some 
 are more frequently attacked by it than others j the broad 
 
158 or NECROSIS. 
 
 boiies, for instance, and those which are but lightly covered 
 with soft parts, such as the bones oi the skull, the lower jaw, 
 the clavicle, the scapulae, the humerus, femur, and tibia. The 
 short bones are seldom attacked by it, but are much more sub- 
 jeft to caries. The afFe£lion may be either partial, or it may 
 extend to the entire bone. Thus we find a long bone afFedled 
 in some part of its length, or entirely diseased from one end 
 to the other, and broad hones affefted only in their external 
 iaminx, or in their entire substance. 
 
 The middle portion of long bones, or that part of them 
 which is most compaft, least porous, and consequently least 
 endued with the vital principle, is that which necrosis most ge- 
 nerally attacks : the extremities of these bones, and in general 
 all spongy bones, are much less liable to it. This disease never 
 extends to the articulations, even when the whole diameter of 
 the middle part of the bone is affected by it: the extremities 
 covered with cartilage separate from the dead part of the bone, 
 and if this be removed by nature or art, they unite with the 
 ossified periosteum, which occupies the place of the separated 
 portion. 
 
 When the necrosis is superficial, the superior lamellse are 
 separated from the rest of the bone; but this separation is al- 
 ways preceded by a suppuration produced by the irritation given 
 to the surrounding soft parts by the dead portion of bone. It 
 is to be observed, that no part of the substance of the dead 
 portion of bone goes to the formation of this purulent matter; 
 for it seems to be not only incapable of furnishing matter for 
 the formation of pus, but is entirely without the sphere of vi- 
 tal action. 
 
 if a broad bone, as the os frontis, for instance, be attackpd, 
 the skin over the aftedled part tumefies, becomes inflamed, and 
 assumes a brown or violet colour-, it grows gradually thinner, 
 bursts at length, and gives issue to the purulent matter contain- 
 ed under it. The necrosis of the bone is then ascertained by 
 introducing a probe, which is found to pass on a rough and 
 naked surface, if the afieclion of the bone really exist. 
 
 In a case of complete necrosis of a long bone, the limb swells 
 at the part affefled, and a hard and painful tumour is formed 
 on it. Abscesses form at various points, they burst, and thei> 
 openings degenerate into fistula*. The discharge from these in 
 the commencement is white and inodorous, but becomes se- 
 rous and fetid in a short time. This matter is sometimes ab- 
 £orbed in such quantity as to produce marasmus, hedlic fevet. 
 
or NECROSIS. 159 
 
 &c. In cases of necrosis, in which the whole bone Is afFeftcd, 
 the periosteum separates from the portion of diseased bone, 
 its vessels seem to take on a new aftion, a calcareous phosphr.te 
 is deposited in its texture, it acquires hardness, and in time 
 forms a cylinder, in which the dead part of the bone is in- 
 cluded. This new bone, which is in fa£l the periosteum os- 
 sified, is rough on its surface, and has but a distant resemblance 
 to that which it replaces. Various holes are observed in it, 
 through which the purulent matter and mouldering portions of 
 bone escape, the fistulous openings in the soft parts being con- 
 tinuations of these holes, and the muscles of tlie limbs are in- 
 serted into it. 
 
 The dead part, completely separated from the sound, and 
 enclosed by the indurated periosteum, is called sequestra: this 
 separation is perfedlly analogous to that of nrjortified soft parts. 
 
 The promptitude with which gangrened soft parts are sepa- 
 rated, is much greater than that with which a dead portion of 
 bone is detached ; but this difference is to be entirely attributed 
 to the state of the vital energy of the parts, which is much more 
 considerable in one case than in the other. 
 
 The causes of necrosis may be divided into internal and ex- 
 ternal; the latter are blows, excessive pressure, imprudent ap- 
 plications of caustics ; as happened in the case of a woman who 
 had caustic potash applied to an exostosis on the internal side 
 of the tibia. But necrosis is most frequently produced by an 
 internal cause, such as scrofula, or syphilis. In persons thus 
 constitutionally affe£led, a blow or other external accident, may 
 prove an exciting cause of the disease. 
 
 By whatever cause produced, the following symptoms cha- 
 rafterize it: excruciating pains in the part affecSbed, which no 
 emollient nor sedative application can assuage. As there is no 
 visible swelling in the commencement of the disease, these 
 pains are frequently attributed to rheumatism. The pain 
 which was felt at first but about the middle of the bone, extends 
 towards its extremities, if the bone affe<Sted be a long one : tha 
 part swells, the skin becomes inflamed, and the tumour, which 
 was hard at first, grows soft in different parts, or abscesses 
 form in it, which burst, and whose openings degenerate into 
 fistulas. The surface of the bone, if not deep seated, as the 
 tibia for instance, may be seen through this opening; in which 
 case the nature of the disease may be ascertained beyond all 
 doubt ; but an equal certainty may be had. when the bene U 
 
i6o OF NECROSrS. 
 
 covered by a great depth of soft parts, by the insertion of a 
 probe. 
 
 There is at first a copious discharge of purulent matter, but 
 the quantity gradually diminishes, and splinters of dry bone, 
 coloured, as if they had been buried a long time in the earth, 
 come out with the pus. The disease may be said to be at its 
 height at this period, for now the dead part is separated by the 
 vital energy of the sound. By introducing a probe at this time, 
 pieces of the bone are felt detached and loose. These symp- 
 toms of necrosis, evident enough in affeftions of the long bones 
 covered with thick muscles, are still more so in cases of flat su- 
 perficial bones, as those of the skull for instance: in affections 
 of the latter, the skin becomes first thick, hard, and reddish; 
 but it soon bursts, and an ulcer is formed in it. 
 
 The prognosis varies in this disease according to the bone af- 
 fedted, and the circumstances with which it may be oompli- 
 cated. 
 
 If the disease be confined to the surface of a flat bone, or 
 though it should aftcCl it quite through, it is not very dange- 
 rous, and nature alone effects the cure. If the assistance of art 
 be necessary, it is only in combating the disease of the system. 
 However, if there be a large surface affected, and if the intro- 
 duction of instruments for the purpose of extracting the splint- 
 ers be difficult, the prognosis becomes more unfavourable. Ne- 
 crosis, when confined to the surface of the middle part of long 
 bones, is equally free from danger as in the former case, and 
 nature alone effeCts a cure. But the prognosis is far different 
 when a large portion of the bone is affeCted, and when this 
 portion is contained in the cavity of the cylinder formed by 
 the ossified periosteum; for though nature has been able to se- 
 parate it, yet the assistance of art is necessary to remove it 
 from its osseous covering. 
 
 In cases of necrosis, in which the dead bone is entirely in- 
 cluded in that newly formed, the prognosis may vary according 
 to the state of the soft parts of the limb, the age and strength of 
 the patient, and the form of the new osseous substance. The 
 tumefaction of the limb may be excessive, the fistulx numerous, 
 the suppuration abundant, and the strength may be reduced by 
 colliquative diarrhoea and heCtic fever. In such circumstances 
 the danger is much greater than if the suppuration were trifling, 
 the patient young ami healthy: and the danger will be still less 
 if the new bone be naturally perforated, so as that the old one 
 may be drawn out. 
 
OF NECROSIS. l6l 
 
 The surgeon, whose art is so useful in most diseases of the 
 bones, can, in cases of necrosis, be but a simple speiflator of 
 the operations of nature, which are frequently successful: it 
 may be said with truth, that necrosis proves the efficacy of na- 
 ture, and the insufficiency of art. Art can assist nature only 
 in removing that part of the bone which the vital principle has 
 abandoned ; as has been amply shewn in the Memoirs of the 
 Academy of Surgery, in David's Treatise on Necrosis, and 
 more particularly in a Latin work on that disease, by M. Weid- 
 man. If the necrosis be superficial, or not very extensive, na- 
 ture alone is sufficient to remove effedlually the diseased part; 
 but art assists in cases of deep-seated necrosis, in which the 
 dead bone, after its complete separation, is enclosed in the 
 new. 
 
 The treatment adapted to the necrosis of broad or flat bones, 
 or that of long bones when the disease is confined to the sur- 
 face of their middle part, is very different from that which 
 should be followed when the necrosis has seized the entire body 
 of the latter. We shall therefore explain these different modes 
 of treatment successively. 
 
 When one of the large bones of the skull is attacked by necro- 
 sis in any part of its surface, nothing is to be done until exfolia- 
 tion takes place. The progress of this process is marked by an 
 inflammatory circle round the part to be separated, by a fissure 
 which succeeds, and marks the same circumference, and which 
 grows wider and wider every day. If at this time the diseased 
 portion be struck with a probe, a noise is heard which indi- 
 cates an empty space under it : it becomes loose soon after, and 
 may be very easily removed. The separation of it may be ac- 
 celerated by stirring it every day, but it is useless to apply any 
 instrument for the purpose of thinning it; for the exfoliating 
 of a thick lamella is just as easy as that of a thin. The use of 
 the trepan is equally inapplicable for this purpose, as it is im- 
 possible to know beforehand to what depth the exfoliation will 
 take place, and if that depth be not entirely taken off, the 
 slightest lamella which remains will be just as troublesome as if 
 the whole remained: nature will require as much time to se- 
 parate it, as if it had been much thicker. We have already 
 pointed out the inutility of perforating the affedled part of the 
 bone, with the intention of facilitating the exfoliatioiV We 
 have also remarked, that un£tuous and emollient bodies are 
 better topical applications than spirituous irritating substances, 
 such as tinflures of aloes and myrrh; or than caustic, which. 
 
•l62 OF NECR0SJ3. 
 
 br irritating the subjacent parts, often causes the disease tO'ex'- 
 tend. 
 
 It is plain that the topical afFeftion will continue to extend 
 incessantly, when it depends on a constitutional disease; there- 
 fore, while nature tends to remove the former, it will be neces- 
 sary to oppose appropriate remedies to the general disease, 
 whether venereal, cancerous, scrofulous, or scorbutic. 
 
 If one of the bones of the cranium be affected with necro- 
 sis, and the brain be compressed by pus, it will be necessary to 
 use the trepan, as advised by Quesnai, in order to remove the 
 pus accumulated on the dura mater. The trepan is not applied 
 in this case against the disease itself, but against a very dange- 
 rous consequence of it. In stirring the piece, in order to ac- 
 celerate its separation, care must be taken not to break it, as 
 the extraction of the remaining portion, generally covered with 
 soft parts, might be difficult. It is found necessary in. many 
 cases to make use of a spatula, or some such instrument, to 
 disengage the splinter from the granulations which encroach on 
 its surface, and take root as it were in its inequalities: this may 
 take place to such a degree, that it may be sometimes necessa- 
 ry to make an incision into the soft parts, in order to extract 
 more readily th€ portion of dead bone. 
 
 When the piece is extracted, the disease is reduced to the 
 state of a simple wound. The granulations which arise from 
 the diploe, or dura mater, wh«n any of the bones of the skull 
 has exfoliated, become the foundation of a solid cicatrix. The 
 bone always remains thin in that part; and it has been found 
 necessary to proteft the part of the cranium, from which an ex- 
 foliation of this kind took place, with a piece of leather or 
 pasteboard. 
 
 When the exterior lamellae of a long bone are afFefted with 
 necrosis, the treatment is precisely the same. If it be ascer- 
 tained by the introduction of a probe through a fistulous open- 
 ing, that an exfoliation of the bone has taken place, an incision 
 must be made for the purpose of extracting the exfoliated piece. 
 But when this disease affeCts the whole of a cylindrical bone, 
 and when the periosteum is ossified around the diseased bone, 
 it will be necessary to acquire the greatest certainty of the com- 
 plete separation of the decayed portion from the new one. "In 
 order to ascertain this, we attend to the duration of the disease, 
 but principally to the motion that maybe communicated to the 
 decayed portion, by introducing a probe through one of the 
 fistulous openings. It happens sometimes that, in moving the 
 
OF NECRosrs. i6;^ 
 
 limb, aJioise may be heard from the colliiion of the decayed 
 bone against the parietes of the new one. 
 
 When nature has done her duty, the assistance of art must 
 be called in to complete the cure; but the extraclion of the 
 dead bone is an operation of a painful and hazardous nature, 
 and should not be undertaken without refle6ting very seriously 
 on its probable consequences, and on those of the disease if left 
 to itself. The operation is extremely difficult when the diseased 
 bone is covered with a great number of very thick muscles, as 
 the femur for instance. In that case saving the patient's life 
 alone, endangered by the excessive suppuration and absorption 
 of the pus, is the only thing that can induce the surgeon to 
 perform the operation ; the patient being at the same time firmly 
 resolved to suffer any thing for the chance of saving Jiis life. 
 It will be necessary to try if the disease has exteuded as far as 
 the articulations, in which case it would be better to ampu- 
 tate, than attempt to save the limb. 
 
 The operation being decided on, the following is the method 
 •to be followed. It is commenced by laying bare the affedled 
 bone on the side least covered with soft parts, and on which 
 there will be the least danger of meeting principal nerves and 
 ■blood-vessels. Thus the inferior and external part of the hu- 
 merus is that in v/hich the incision should be made when this 
 bone is affe£ted; when the disease is seated in the cubitus, the 
 ^internal side of the fore arm; and when in the radius, its ex- 
 ternal side; the lower part and external side of the tliigh, when 
 the femur is affected; and the anterior and internal side of the 
 leg, which is covered by the skin only, when the tibia is the 
 part diseased. This part of the operation does not consist of a 
 simple incision, but of two semi-elliptic incisions, the parts be- 
 tween which are to be completely removed. This prat^tice is by 
 much preferable to the use of caustic, the action of which is 
 tedious, and might extend to the regenerated bone, and de- 
 stroy its texture. If the patient be timid, caustic may be used, 
 but the greatest care must be taken to confine its action to the 
 soft parts. If the hemorrhage be great, and the patient's suf- 
 fering intense, the wound may be washed, and filled with lint; 
 and the rest of the operation deferred to the following day. 
 After having laid the bone bare, two or three pieces are to be 
 cut out from its inferior part by means of a trepan; the inter- 
 vals which separate the holes are then forced out with a chisel 
 and mallet; and a passage being thus opened, nothing remaius 
 put to extract through it the decayed boncj which is found to 
 
l6'4 OF CARIES. 
 
 lie without any connexion in the inside. The deep wound pror 
 duced by this operation is then filled with lint, and dressed in 
 future like a simple wound, which is to be healed by suppura- 
 tion -, but the recovery is always slow. If the length of the de- 
 cayed bone be inconsiderable, the perforation may be made in 
 the middle part of the new one. But when that is not the 
 case it will be advisable to trepan the inferior part of the bone, 
 as a less opening will suffice there than in the middle part, and 
 as the situation is more favourable for the evacuation of the 
 pus. 
 
 Notwithstanding the prodigious disorganization and suppu- 
 ration necessarily attendant on this operation, it has however 
 been followed with success in some instances related by David. 
 
 We are of opinion that few cases occur in which it is neces- 
 sary to perform this operation; that the reasons for undertaking 
 it are seldom conclusive; and that it should not be had recourse 
 to without the maturest deliberation. 
 
 CHAPTER XX. 
 
 OF CARIES. 
 
 THE more we advance in the study of diseases of the 
 bones, the greater is the obscurity in which we find them 
 involved; and if there be any of them, the nature of which 
 may be said to be totally unknown, it is certainly that which is 
 our present subject of consideration. 
 
 The clearest way in which we can convey an idea of caries, 
 is, by comparing it to those ill conditioned ulcers of soft parts, 
 which are symptoms of a diseased state of the system. But 
 the idea given by this comparison is not sufficiently comprehen- 
 sive; we shall therefore endeavour to supply its deficiency by 
 an exadl detail of the appearances of bones affected with this 
 disease. 
 
OF CARIES. 165 
 
 Every part of the osseous system is liable to carles •, but it has 
 been observed, that spongy bones are oftener attacked by it 
 than those that are compa£l; thus the vertebra, astragalus, 
 and other bones of the tarsus, those of the carpus, the sternum, 
 and the extremities of long bones, are the most frequent seat 
 of this disease. For a similar reason the bones of young per- 
 sons are more subjedl to it than those of persons advanced in 
 life. 
 
 Very little information is to be acquired by reading the works 
 of the authors who have treated of this disease. Almost all of 
 them have confounded it wjiia necrosis, which they termed dry 
 caries -, others have considered it to be the same as exostosis. For 
 our part we are of opinion that there is only one species of this 
 disease, but that this is susceptible of several modifications. 
 The substance of a bone afFe£ted by it becomes so soft, that the 
 end of a blunt probe may be easily forced into it. The open- 
 ings with which the bone is perforated, are filled with fungous 
 flesh, which bleeds from the slightest cause: there is a dis- 
 charge of a blackish serum from these perforations, which has 
 at all times a disagreeable smell, but which is particularly fetid 
 when exposed to the conta£l of the air. Necrosis and caries 
 differ in this particular respedl: in the former, the bone affect- 
 ed is entirely deprived of the vital principle j but in the latter 
 ^his principle exists, and the disease consists of a morbid aiSlion, 
 by which the osseous texture is destroyed. 
 
 The causes of caries are distinguished into internal and ex- 
 ternal j the internal are the most frequent, because a contusion 
 or external violence is apter to produce necrosis than caries. It 
 may happen, however, that a blow on a spongy bone shall oc- 
 casion a caries of it, by producing an extravasation of blood or 
 medullary juice, which cannot be afterwards taken into the 
 system by absorption. 
 
 Abscesses are said to occasion sometimes a caries of the 
 bones, over which they take place; and we are toid, that the 
 existence of the morbid state of the bone may be ascertained 
 by introducing a probe to the bottom of the abscess. 
 
 Conformably to this theory, it has been laid down as a rule, 
 that abscesses situated over bones should be opened at an 
 early period, in order to prevent any disorder of the bone or 
 periosteum from the stagnation of the purulent matter. But if 
 abscesses formed over certain bones, as, for instance, over the 
 anterior face of the tibia, or mastoid process of the temporal 
 bone, be frequently accompanied with caries, the latter is the 
 
l66 OF CARIES. 
 
 cause, and not a consequence, of the abscess. Pus, which is a 
 bland, un(5tuous, and inodorous fluid, never attacks the soft 
 parts with which it is in conta<5l, until its qualities are changed 
 by exposure to the air. When an abscess forms in the anteri- 
 or part of the parietes of the abdomen, the peritoneum of that 
 part, naturally a thin membrane, instead of being corroded, 
 beconies thick and strong enough to resist the effusion of the 
 pus into the cavity of the abdomen. The periosteum becomes 
 thickened in similar circumstances, when the abscess is a con- 
 sequence of an external injury. 
 
 We may conclude, then, that caries is seldom produced by 
 an external cause; and that most frequently a blow or external 
 injury, wh-en followed by that disease, has adled only as an 
 exciting cause, z disposition to it having pre-existed. There 
 is every reason to believe that it may be ascribed in almost all 
 cases to a disease of the system, such as scrofula, lues, scurvy, 
 or even cancer. 
 
 Scurvy diminishes the energy of the contra^ile fibre, and 
 diffuses a principle of dissolution in the solids and fluids. Tfie 
 blood rendered more fluid by it than natural, oozes through 
 the pores of its small vessels: spots or ecchymoses manifest 
 themselves, first in the parts in which the circulation is most 
 languid, as on the hands and feet: the muscles become soft and 
 painful; the gums swell, and separate from the alveolar pro- 
 cess: the periosteum may become tumefied in like manner, 
 and lose its connexion with the bone affe£ted with caries. 
 
 Scrofula attacks the spongy part of bones and the lymphatic 
 system. A caries from this cause is very frequent in the tarsus, 
 carpiis, elbow, and knee; but k is ahvays preceded by a white 
 swelling. 
 
 The venereal disease is sometimes a cause of caries, though 
 its adtion on the osseous system more generally produces ne- 
 crosis or exostosis. However, when it attacks the bones of the 
 nose, it produces a caries of them, by which they are consu*- 
 med, and the face sadly disfigured. The bones of the palate 
 are sometimes destroyed in the same manner, and by the same 
 cause. 
 
 In cancers of the mammae, the sides of the sternum are of- 
 ten found carious; which proves that cancerous ulcers may, 
 as well as the preceding diseases, occasion a cai-ies of the bones 
 in their neighbourhood. 
 
 Nothing can be easier than to ascertain the existence of a 
 superficial caries; and when the affedled bone is deep-seated. 
 
OF CARIES. 167 
 
 it may be discovered by introducing a probe; for if the bone 
 be cariour,.the probe may be easily forced into its substance. 
 But bones which we cannot readily come at may be carious, in 
 which case the diagnosis is somewhat more difficult*, however, 
 if a fistula, from which a fetid blackish matter flows, be dire£l- 
 ed towards a bone, and if the surrounding soft parts be at the 
 same time turgid and indurated, there is every reason to appre- 
 hend a caries. The black colour of the discharge is, however, 
 equivocal j because, as remarked by Ambrose Pare, it may be 
 occasioned by a bit of agaric or other foreign body introduced 
 into the wound. It will be prudent, therefore, in dubious cases, 
 to trust chiefly to the history of the disease. 
 
 If a person aiFeO:ed with a certain constitutional disease, feel 
 deep-seated and acute pains in any of his bones ; and if the 
 pained part swell, and become the seat of an abscess, from 
 which a purulent matter of a bad quality flows, there is every 
 reason to believe that the bone afl'ecSted with pain is carious. 
 Inert abscesses are attended with nearly the same symptoms, 
 with this difi^erence, that they are not preceded by pain. Ca- 
 ries occasioned by syphilis affecSVs most commonly the tibia, os 
 frontis, ossa nasi, ossa palati, and sternum. Whenever, there- 
 fore, any of these bones become carious, whilst the person la- 
 bours under syphiHs, there is just ground for concluding that 
 the caries is a symptom of the venereal affe<Slion. 
 
 A caries of the vertebrae is known by peculiar symptoms, 
 among which a paralysis of the inferior extremities, and the 
 formation of abscesses in the groin, verge of the anus, or lum- 
 bar region, are the most remarkable. 
 
 The prognosis is more unfavourable in cases of caries of spon- 
 gy bones, than in those of a similar affection of compadt ones, 
 thus there is not so muc"h to be apprehended when the bones 
 of the cranium or the scapulce are atTefted, as when the extre- 
 mities of long bones are similarly diseased. Caries of the 
 bones of the carpus and tarsus is also very dangerous. The evil, 
 en account of these bones being in such close contact, extends 
 from one to the other; and when one of them becomes carious, 
 it is very difficult to stop the progress of the disease without am- 
 putating the limb. 
 
 This operation is often the only resource in our power 
 against caries of short bones, or of the extremities of long 
 ones; and we are even deprived of this when the bone afFeiSted 
 with it is. deep-seated: thus caries of the head of the femur, 
 or of the cotyloid cavity, cannot be remedied by thi« operati- 
 
l68 Oi* CARIES. 
 
 on. The same may be said of caries of the spine, also named 
 gibbosity, in which, as well as in the preceding case, our 
 treatment must be merely palliative. 
 
 Caries from an external cause is less dangerous as well as less 
 frequent than that from an internal; and that resulting from 
 an internal disposition is much more dangerous when it pro- 
 ceeds from a scrofulous or cancerous diathesis, than from a ve- 
 nereal or scorbutic; for some efficacious remedies against the 
 latter are known; but cancer and scrofula resist all the reme- 
 dies with which we are as yet acquainted. It is also more dan- 
 gerous to old than to young persons, not that its progress is 
 not more rapid in the latter, as already mentioned, but because 
 nature is more capable of limiting its ravages in youth than in 
 old age. Finally, the prognosis is further influenced by the 
 extent of the disease, the patient's strength, and state of the 
 neighbouring soft parts. 
 
 There is, perhaps, no disease in which the indications of 
 cure are more vague than in caries, and none in which the 
 treatment is less regular. The ancients prescribed unftuous or 
 relaxing applications, but they preferred acrid irritating sub- 
 stances, such as the powder of euphorbium, tindlure of aloes 
 and myrrh, oil of turpentine, mineral acids, caustic alkali, or 
 even the aclual cautery. Monro, Tenon, and, in imitation of 
 them, some modern practitioners, have preferred the use of 
 unftuous and emollient applications; but, in order to discover 
 the preferable mode of treatment, it is necessary to take a 
 close view of the evil against which it is to be directed. We 
 must then consider, that a bone a£Fe6led with caries is a prey 
 to a morbid action of its own parts, and that this acStion creeps 
 from one part to another, and pervades the whole with great- 
 er or less rapidity, if art does not come to the assistance of na- 
 ture to arrest its progress. 
 
 If the caries be produced by some affection of the system, 
 this should be ascertained and combated with appropriate re- 
 medies. Thus the use of mercurial and sudorific medicines ar- 
 rests the progress of caries proceeding from the venereal dis- 
 ease, and aids nature in separating the unsound from the sound 
 part. The use of spirituous drinks, vegetable diet, and aeids, 
 removes at once scurvy and the caries, to which it had given 
 rise, &c. &c. But if it has been occasioned by an external 
 cause, or if it has remained after the internal one has been re- 
 moved, so as to be reduced to the state of a mere topical af- 
 fection, its progress may be arrested, and the separation of the 
 
OF CARIES. 169 
 
 diseased parts facilitated by the use of such substances as stimu- 
 late the parts, or such as absorb and neutralize the fluids which 
 tend to propagate the morbid adlion. Thus the desiccation of 
 a carious ulcer has been effected by the use of an absorbing 
 powder and pledgets of lint that had been dipped in tindlure of 
 aloes and myrrh. 
 
 If these remedies be found ineffectual, recourse must be had 
 to more active ones; a pledget of lint dipped in a solution of ni- 
 trate of silver, may be applied on the carious part, and renewed 
 every day. This portion of the bone is by this means, quickly 
 dried up, and reduced to the state of a simple necrosis; the pro- 
 pagation of the morbid a£lion is arrested, and nature effefts a 
 separation of the diseased parts. It will not be amiss, however, 
 to move frequently the dried piece, and it may be necessary to 
 prevent the fungous flesh from spreading so as to impede the 
 exfoliation. The ulcer heals after the exfoliation has taken 
 place, and the cicatrix is more or less deep, and of a red co- 
 lour, not blackish and livid, as a cicatrix formed over a dis- 
 eased bone. 
 
 If the caries be very humid, that is, if a great quantity of 
 sanies flow from it, these remedies even the murcurial nitrate, 
 will be of no effedt. The sanies washes the pledget, and di- 
 lutes the caustic so much, that its aftion.is considerably en- 
 feebled. Caustic pot-ash would be subject to the same incon- 
 venience. In these cases, the a£lual cautery is a remedy to be 
 preferred to all others: by its action the carious part is in an 
 instant reduced to the state of an inorganic dry substance, and 
 the caries thus converted into necrosis. This remedy is appli- 
 cable to every case of humid caries where the surrounding soft 
 parts have not a manifest tendency to cancer. Sometimes, 
 however, the soft parts surrounding a carious bone have that 
 tendency in so advanced a degree, that the acStual cautery 
 would necessarily occasion the developement of that morbid 
 state. The general rules to which the use of the aftual caute- 
 ry may be reduced are as follow: 
 
 In the first place, all the carious part of the bone must be 
 laid bare, whether by cutting away the soft parts, or destroy- 
 ing them by caustic. The" latter method being tedious, incon- 
 venient and uncertain, should not be used unless when the pa- 
 tient will not submit to the use of the knife. The bone being 
 in this manner laid bare and scraped, the surgeon provides him- 
 self with several cauterizing irotis of the same form, because 
 the application of one is seldom suflicient. It will also be ne- 
 22 
 
lyO OF CARIES. 
 
 cessary to provide a number of canulx when the cautery is t9 
 be applied on a bone from about which the soft parts cannot 
 be completely raised, as, for instance, on the os coccygis, or 
 sacrum: by means of these canulae, the hot iron can be intro- 
 duced without injuring the soft parts. In every case it will be 
 necessary to protect the surrounding parts as much as possible 
 from the a£tion of the cautery. 
 
 The iron, whatever may be its size, should be heated white, 
 as the hotter it is the more rapid and less painful is its aiStion. 
 On the instant of its application, a black thick smoke rises 
 from the surface of the burning bone, the smell of which re- 
 sembles exactly that of burning horn: the great quantity of 
 sanies quickly diminishes the heaf, for which reason a second 
 is to be immediately applied with the same precautions; and a 
 third, if the two preceding have not burned deep enough. Care 
 should be taken to extirpate the disease by burning every part 
 that is affe£ted; and if the use of the cautery has not always 
 had the success expected from it, the failure of it is to be attri- 
 buted to the timidity of the operator. A carious bone becomes 
 worse by the application of the a£lual cautery, if the evil be 
 not entirely rooted out; just as a cancerous tumour becomes 
 irritated, and makes a more rapid progress, if imperfectly cau- 
 terized. 
 
 The a£lual cautery a£ls by evaporating the noxious fluids in 
 which the carious bone was immersed; by changing the caries 
 into necrosis, and by irritating the subjacent sound parts, and 
 exciting that a£Vion of the vessels by which the dead part of 
 the bone must be thrown off". 
 
 It is almost superfluous to remark here, that this operation 
 cannot be undertaken with any hopes of success, if the inter- 
 nal cause of the caries still exist. 
 
 Let us examine, in the next place, the modifications of this 
 general treatment, which may be required for any particular 
 bone. 
 
 The bones of the cranium are often afl"e^ed with the vene- 
 real caries, of which pain and tumefa6lion of the part are the 
 first symptoms. The tumour augments and becomes soft, and 
 on bursting spontaneously, or being opened by an instrument, 
 a thin, serous, purulent matter flows from it. If a probe be 
 now introduced into the wound, the bone will be found to be 
 carious. The first remedies must, in this case, be diredled 
 against the disease of the system. The use of caustics is en- 
 tirely inadmissible; for should their action extend too far, the 
 
or CARIES. 171 
 
 worst consequences might result from it, such as inflammation 
 of the brain or its meaibranes. It is better to remove the dis- 
 eased part of the bone by means of a trepan. In laying the 
 bone bare, as much of the integuments should be preserved as 
 will be sufficient to cover the wound, which precaution will 
 accelerate the cure. 
 
 It is particularly in caries of the mastoid portion of the tem- 
 poral bone that the use of the cautery is admissible. Abscesses 
 are frequently formed in consequence of caries in that part of 
 the bone; these burst, and their openings degenerate into fis- 
 tulae. If a carious state of the bone be discovered by the in- 
 troduiflion of a probe, the bone is to be laid bare, and the 
 cautery applied, and repeated until the caries is completely de- 
 stroyed. The mastoid portion of the temporal bone is spongy 
 in its texture, and sufficiently thick to prote£l the brain and 
 its membranes from the action of the cautery. Tenon and 
 Chopart pradlised this operation with success. 
 
 The bones of the face, and those of the nose and palate, 
 are very subject to the venereal caries; but this affi.^(n:ion of 
 them disappears by removing the general disease of the sys- 
 tem. The parts, however, remain deformed in consequence 
 of the loss of substance; 
 
 The colledlion of matter which frequently takes place in the 
 antra maxiliaria sometimes occasions a caries of the bones 
 v/hich form these cavities. In these cases, all that is necessa- 
 ry is to perforate into the cavjty through the alveolar process; 
 for as soon as the collected matter gets a free passage, the fistu- 
 las, if any have been formed externally, dry up, the carious 
 part of the bone separates and comes away, and the wound in 
 the soft parts heals at the same time. 
 
 The caries of the os unguis, which^is sometimes complica- 
 ted with fistula lachrymalis, is remedied by the different ope- 
 rations performed for giving a free passage to the tears. The 
 scorbutic caries of the alveolar process is removed by the same 
 remedies as the general disease. 
 
 As soon as the system is perfe6lly clear of the scorbutic dia- 
 thesis, the bone exfoliates, and the gums acquire their natural 
 firmness. Detersive gargles may be used to accelerate this ter- 
 mination. 
 
 Caries of the spine is attended with much worse consequen- 
 ces; the gibbosity and secondary abscesses of which it is the 
 cause, generally prove fatal. When the anterior part of any 
 of the vertebroe becomes afFe^Sled with caries in consequence of 
 
172 OF CARIES. 
 
 a diseased state of the system,* the purulent matter that is 
 formed makes its way into the cellular texture which lines the 
 anterior part of the spine, and descends by its own weight 
 along the vessels to the superior part of the pelvis; whence it 
 sometimes flows along the external iliac arterv into the groin, 
 where it forms a tumour. At other times it descends into the 
 pelvis along the hypogastric vessels, and forms tumours about 
 the anus; finally, it may penetrate through the fibres of the 
 lumbar paries of the abdom.en, and manifest itself at the 
 posterior part of the pelvis. These accumulations of pus, or 
 symptomatic abscesses, are always preceded for a longer or 
 shorter time, by pain in some part of the spine; and the tu- 
 mour forms without any antecedent or co-existing inflamma- 
 tion of the part. The abscess acquires insensibly an enormous 
 volume, and the pus makes its way into the cellular texture of 
 the limb of the afi'edled size: its side may, however, be dimi- 
 nished by compression, and its contents seem to retreat into 
 the abdomen. Tiie integuments inflame at length, and burst 
 in the most proje<5ting point; a thin purulent matter flows from 
 the opening; it is, at first perfectly inodorous, hat soon ac- 
 quires a fetid smell, and changes colour. This alteration in 
 the qualities of the pus seems to be owing to the contact of the 
 air; but so great is its fetidness, that the patient's existence is 
 loathsome to himself, and insupportable to others: the absorp- 
 tion of this matter brings on slow fever, diarrhoea, colliquative 
 sweats, and marasmus, and the patient is at length cut off. As 
 the fatal event is distant in proportion to the retardation of the 
 opening of the abscess, and to its prote£lion, when opened, 
 from the contact of the air, it is evident that it should not be 
 opened as long as it can be avoided; and that when it becomes 
 absolutely necessary, the opening should be as small as possi- 
 ble, and the air carefully excluded. Both these purposes are 
 answered by making the opening with a seton needle, and 
 leaving the seton in the abscess; but as this is not the pro- 
 per place to give a full account of the treatment of these ab- 
 scesses, we shall proceed to the consideration of that affe<Slion 
 of the spine which has been termed gibbosity. 
 
 This affection does not always depend on a caries of the ver- 
 tebrae; and when it arises from that cause, the caries is then of 
 a peculiar nature, being almost dry, and unattended with the 
 
 • Masturba^Ion is frequently a cause of tliis caries, Citizen Boyei's 
 pra£lice has furnished him wjih many examples ot it. 
 
OF CARIES. 173 
 
 formation of abscesses. The affected vertebra, filled with holes, 
 and as if moth-eaten, yields to the incumbent weight; the body 
 of that which is superior to it descends, while its spinous pro- 
 cess ascends and projects under the integuments. A never-fail- 
 ing symptom of this disease is a paralysis of the inferior extremi- 
 ties, rectum, and bladder. If the derangement take place in the 
 vertebrae of the neck ^^ which is very rare), the patient is soon 
 destroyed in consequence of the paralysis of the muscles by 
 which respiration is performed. When the derangement of the 
 vertebra is gradual, the progress of the caries being slow, a 
 numbness is first felt in the lower extremities, which is the pre- 
 cursor of paralysis: but the bladder, redlum, and inferior ex- 
 tremities, soon become paralytic, and the patient is confined to 
 his bed until relieved by death. Gibbosity from this cause is 
 fatal to adult persons. That observed in young children is dif- 
 ferent in its consequences, and seems to proceed from a diffe- 
 rent cause-, that is, from a collapse of the vertebrae before they 
 have acquired their full consistence, rather than from a carious 
 affe6lion. In cases of this kind, a perfeft recovery has been ef- 
 fedled by applying caustic to the sides of the tumour, by burning 
 moxa, or rubbing irritating substances on the spine, and by 
 joining to these means the use of the cold bath and a tonic re- 
 gimen. 
 
 When the same person is at once affeifled with gibbosity and 
 secondary abscesses, there is no chance of his recovery. 
 
 Enough has been said to shew the extreme danger of caries 
 of the spine, and the insufficiency of art in the treatment of it. 
 The spongy texture of the sternum renders it very liable to 
 be effe<Sted with caries, the progress of which is, for the same 
 reason, more rapid in it than in any other bone. The soft parts 
 which cover the carious portion of bone, become inflamed, and 
 abscesses form, which burst in a little time. The state of the 
 bone may now be discovered by introducing a probe through 
 one of these openings; and very often, besides the caries, it is 
 found that an effusion of pus has taken place into the anterior 
 part of the mediastinum. In which cases .he probe penetrates 
 more or less into the cavity of the thorax, and the pus con- 
 stantly flows in greater or less quantity through the fistula : it 
 most frequently happens that the stagnation of the pus, the mor- 
 bid changes which it undergoes, and the effects of its absorption 
 in this state into the system, render it necessary to apply the 
 trepan to the sternum. Among the bad consequences of caries 
 of the sternum, may be reckoned the destruction of a part of 
 
174 OF CARIES. 
 
 the pleura, or even of the pericardium: although in the great- 
 er number of cases the former of these membranes becomes 
 thicker in the part corresponding to the abcess, and sometimes 
 cartilaginous, or even bony. The pulsation of the heart be- 
 comes very manifest by the destruction of the pericardium. 
 Harvey profited of a case of this nature to shew this phenome- 
 non to the King of England, and several other persons. But 
 whether the thickening of a part of the pleura, or the destruc- 
 tion of a portion of the pericardium, be the consequence of the 
 abscess, the cavity of the thorax, properly so called, is not 
 opened in either case. 
 
 The treatment of caries of the sternum varies according to 
 the circumstances of the case ; it may be remarked however, 
 that the particular structure of the bone renders a caries of it 
 extremely dangerous. A spontaneous recovery is scarcely to be 
 expected, although the following case furnishes an instance of 
 it. A person convalescent from another disease, was suddenly 
 seized with an acute pain behind the sternum; respiration be- 
 came difficult, and a fever supervened. At length a tumour, 
 ■with fludluation, manifested itself a little lower than the middle 
 part of the bone. A small portion of caustic pot ash was applied 
 to this tumour; and on dividing the crust formed by it, a great 
 quantity of the pus flowed out and the patient felt much re- 
 lieved. After opening the abscess, the suppuration gradually 
 diminished, and the fistulous orifice was closed up in th^ space 
 cf a few months; during which time however, the patient re- 
 sided in the country, and used a nourishing diet and tonic me- 
 dicines. It ought to be remarked, that it is possible that the 
 abscess may not, in this case, have proceeded from a caries of 
 the sternum; and that the pus collected in the anterior medias- 
 tinum may have made its way outward through the opening 
 which is often found in this part of the sternum. 
 
 The treatment of caries of the sternum does not differ from 
 that which has been already generally described. Particular 
 care must be taken however, that in applying caustics, their 
 influence may not extend to the organs of respiration. But 
 when instead of caustics, cutting instruments ai-e used, the part 
 affected, however extensive, should be' totally removed. This 
 operation is not attended with great danger, because the inter- 
 nal mammary artery, if opened, can be easily taken up. After 
 the bone has been removed, the pleura, corresponding to the 
 empty space, will be found to thicken in that part, and to ac- 
 quire a cartilaginous hardness, so as to replace, in some degree^ 
 
OF CARIES. 175 
 
 the bone which has been destroyed. However, after the 
 wound is completely healed, it will be prudent to cover the 
 part with a piece of pasteboard or leather. If the carious part 
 cannot be totally removed, it will be necessary to make two 
 perforations in the lower part of the sternum, in order to give 
 a free passage to the purulent matter. Though the disease will 
 not be radically removed by this means, yet the sufferings of 
 the patient will be considerably alleviated. 
 
 Caries of the ribs, or that of the bones of the pelvis, offers 
 nothing particular, it is to be remarked, however, that when 
 the posterior ends of the ribs, or the anterior face of the sa- 
 crum, are affefted, secondary abscesses may take place as in si- 
 milar affeftions of the vertebrae. Caries of the sacrum often 
 succeed a gangrene of the soft parts which cover its convex 
 side: in which case it will be necessary to wait a spontaneous 
 exfoliation; or if nature does not appear adequate to that ope- 
 ration, and if a great quantity of fungous flesh be found to 
 grow up through the carious bone, it will be necessary to apply 
 the adtual cautery, according to the rules already laid down. 
 Liquid caustics are improper in this case, because by passing 
 the large cancelli, they might penetrate to the sound parts of 
 the bone, and occasion a necrosis of it. 
 
 Caries of the different parts of the iliac bone, and particu- 
 larly of the cotyloid ctivity, shall be treated of in the article 
 on secondary or spontaneous luxation of the femur. 
 
 Caries of the extremities of long bones, as it usually accom- 
 panies white swellings of the articulations, will be considered 
 in treating of the latter affeilions. 
 
176 
 
 CHAPTER XXI. 
 
 OF EXOSTOSIS. 
 
 A SWELLING may take place in bones as well as in 
 other parts, from a determination and accumulation of 
 fluids; but there is a particular kind of tumour which forms 
 on their surface, and which is denominated exostosis. This 
 name, however, comprehends different species, which should 
 be considered as distincflj thus that affedlion which has been 
 described under the name of spina ventomy or osteosarcoma^ is a 
 distinct disease: there is also another species of exostosis diffe- 
 rent from all others, and which consists principally in a thick- 
 ening and tumefaction of the periosteum; it may very proper- 
 ly be termed /j^nW/oj-zV. Exostosis, properly so called, is rare, 
 the reason of which is easily perceived from the consideration 
 of the hardness and consistence of the texture of the bones, 
 the small number of their vessels, and consequently the diffi- 
 culty of a copious influx of humours into them. 
 
 The tumefied portion of bone acquires in some cases such a 
 hardness, that no remains of a fibrous strudlure can be distin- 
 guished in it, and it absolutely resembles ivory; in other cases 
 it is spongy; and finally it may be composed of osseous and 
 fleshy parts; this latter variety resembles very much spina ven- 
 tosa. 
 
 The bones most frequently affefled with exostisis are the 
 broad bones of the head, the lower jaw, sternum, humerus, 
 radius, cubitus, the bones of the carpus, the femur, and tibia. 
 There is, however, no bone of the body which may not be- 
 come the seat of this disease, and the affeftion may extend to 
 a greater or less portion of it. It is not uncommon to find the 
 broad bones of the cranium affected with exostosis in their 
 whole extent; the ossa parietalia, for instance, sometimes ac- 
 quire an inch in thickness from this morbid affedlion. 
 
 In most cases, however, tKe exostosis rises from the surface 
 of the bone, and manifests itself as a hard round tumour. It 
 sometimes appears towards the extremities of long bones, and 
 
OF EXOSTOSIS. 177 
 
 at other times, more or less, near their middle part; and it is 
 reiiarked that exostosis originating from a venereal cause arc 
 found principally on compadt bones, and such of these as are 
 but lightly covered with soft parts, as those of the cranium 
 and face, and the tibia at its internal side; whilst, on the con- 
 trary, those arising from a scrofulous diathesis appear on the 
 spongy extremities of long bones, and on short ones of a simi- 
 lar texture. These two diseases are almost the sole causes of 
 this topical affedlion of the bones. A cancerous or scorbutic 
 diathesis seldom occasions it. They more commonly produce 
 caries, by effedting a separation of the periosteum from the 
 bone. It must be remarked, however, that exostosis and ca- 
 ries have the greatest aiSnity with one another; as is evident 
 from the greater part of exostoses terminating in caries. J. L. 
 Petit pointed out this analogy by a detailed comparison of the 
 two diseases. The conversion of exostosis into caries takes 
 place particularly in spongy bones, and in persons affefted with 
 scrofula. The ivory exostosis never terminates in caries. 
 
 Exostosis proceeds very rarely from an external cause, such 
 as a contusion, though such a consequence is not imposdble. 
 In most cases it is produced by an internal disease, and princi- 
 pally by lues venerea, or scrofula, as already mentioned. 
 
 An enlargement of the extremities of long bones, that of 
 the whole substance of short ones, joined to a swelling of the 
 glands of the neck, a delicacy and whiteness of the skin, a 
 fulness of the face, and tumefadlion of the point of the nose 
 and upper lip, are marks of a scrofulous diathesis. 
 
 The osseous system is attacked by the venereal disease only 
 in the advanced stages of that disorder. The formation of ex- 
 ostoses from this cause is generally preceded by dull pains, 
 which appear to be deep-seated, and which are generally most 
 severe during the night. 
 
 An exostosis is always hard, but varies in size, and may be 
 indolent or painful. By these marks, and by its firm adhesion 
 to the bone, it may be always distinguished from every other 
 kind of tumour. But if, on the contrary, the enlargement 
 takes place in a short bone, and if its hardness, though consi- 
 derable, be somewhat less than that just described, on which 
 the finger can make no impression, it is probably a periostosis; 
 which is by no means an uncommon symptom of the venereal 
 disease. It is sometimes impossible to ascertain the existence 
 of an exostoses before the patient's death • such was the case of 
 an individual whose parietal bone had been found, after death, 
 23 
 
178 OF EXOSTOSIS. 
 
 to be three times thicker than natural. A similar case is rela- 
 ted in the Memoirs of the Academy of Dijon. In this instance 
 the person died from an exostosis on the internal side of the 
 OS pubis, whieh by pressing on the neck of the bladder pre- 
 vented the passage of the urine, or the introduflion of a ca- 
 theter. 
 
 It is possible that the head of a luxated bone may be mista- 
 ken for an exostosis: this was the case with a young man 
 whose clavicle was dislocated at that end of it attached to the 
 sternum. The tumour formed by the end of the displaced 
 bone, was mistaken for an exostosis, and was treated as such; 
 but the incfficacy of the treatment induced the patient to ap- 
 ply to Desault, then head surgeon of La Charite. This prac- 
 titioner recognized instantly the luxation outward of the clavi- 
 cle. ^ It is also possible, that the enlargement of the ends of 
 bones of rickety persons may be mistaken for exostosis; but 
 though this kind of enlargement does not constitute a real ex- 
 ostosis, yet it cannot be denied but that some analogy does ex- 
 ist between them. Another species of tumour which might be 
 mistaken for an exostosis, is that formed by fungous excrescen- 
 ces growing from the dura mater, which, after having destroyed 
 a part of the bones of the cranium, protrude externally; but 
 the real nature of these may be discovered by an attentive ex- 
 amination of their consistence and progress, and by attending 
 to the pulsation of them, which is evident and synchronous 
 with those of the heart. 
 
 The efFe(Sts of exostosis may be divided into general and 
 particular: thus the swelling is accompanied by a sense of 
 weight; pain is produced by the morbid adtion, and the affect- 
 ed part is necessarily deformed. 
 
 Its particular effects arise from its situation: thus, should an 
 exostosis take place in the orbit, the eye would necessarily be 
 expelled from that cavity; and an expulsion of the eye from 
 that cause has in faft been observed. Should a tumour of this 
 nature arise from the clavicle or sternum internally, it might 
 occasion death, by compressing the principal blood vessels, ar- 
 terial or venous. An exostosis of the pubis might, as already 
 mentioned, occasion a retention of urine; or a similar tumour 
 on any of the bones of the pelvis, internally, might render 
 parturition in the natural way impossible. 
 ' The prognosis differs according to the nature of the primary 
 disease from which t;ie exostosis originates, and according to 
 the particular change in the texture of the bone. Exostoses 
 
OF EXOSTOSIS. 179 
 
 from an external cause are much more difficult to cure than 
 those arising from an internal one; because the latter may be 
 combated by appropriate medicines; but in the former, no in- 
 ternal remedy can have any effect, and the extirpation of the 
 tumour is the only expedient. An exostosis produced by a scro- 
 fulous diathesis is much more difficult to cure than that arising 
 from any other constitutional disease. Unfortunately, medicines 
 have been as yet found ineffectual in scrofula, and the pradli- 
 tioner has generally the mortification of seeing exostosis from 
 this cause mock his general remedies, and pass on to a caries, 
 to which it has a particular tendency. 
 
 The ivory exostosis, if situated so as not to impede the adlion 
 of any organ, is the least dangerous of all ; for although it be 
 impossible to procure the absorption of this tumour, in which 
 no vessel, nor fibre, nor pore, can be discovered, and which 
 appears a compadl and homogeneous mass, yet after it has 
 gradually acquired a certain volume, which is never very great, 
 it becomes stationary, and causes no inconvenience, but that 
 arising from Its weight. 
 
 Our complete ignorance of the pathology of exostosis, or of 
 the manner in which it is formed, accounts for the Imperfection 
 of our treatment of It. The opinion of J. L. Petit, relative to 
 it, is at present totally abandoned: that author attributed the 
 greater part of the diseases of the bones to a defect of elasticity 
 in the periosteum. We find nothing more probable in the 
 opinion of a more modern author, who attributes exostosis to a 
 diminution of the natural quantity of phosphoric acid. 
 
 We shall however endeavour to lay down some principles for 
 the treatment of it. The first step to be taken. Is to discover 
 the primary disease, which when once ascertained, must be the 
 principal object of treatment. 
 
 If the patient has formerly laboured under a venereal affec- 
 tion, which he has reason to think has not been totally eradi- 
 cated, or if there are venereal symptoms present, the exostosis 
 may be safely attributed to that disease. It may be observed 
 here, that a venereal taint which has been but partially com- 
 bated, is more difficult to remove than that for which no remedy 
 has been used. At all events, mercurial preparations are to be 
 judiciously administered, and the use of them persevered in 
 until all the venereal symptoms disappear. 
 
 This mode of treatment is certainly the most efficacious; but 
 should the evil resist the use of the milder preparations of mer- 
 cury, it must be given in small doses, in the state of corrosive 
 
loo OF EXOSTOSIS. 
 
 sublimate, which may be advantageously dissolved in a decoc- 
 tion of sarsaparilla, or other sudorific article. If mercury in 
 any form does not agree with the patient, sudorifics alone must 
 be used: three glasses of a strong decoction of sarsaparilla and 
 guaiacum, in which a few grains of alcali may be dissolved, are 
 to be given daily; and the tumour is to be covered with a 
 mercurial plaster. If the pain be very great, and prevent sleep, 
 some opium may be added to the plaster. This latter appli- 
 cation som.etimes aiTords very considerable relief. 
 
 When the anti-venereal treatment has been continued for two 
 months or more, if the venereal symptoms disappear, and the 
 exostoses diminish in size and become indolent, it would be 
 useless or even pernicious to persevere in the use of the general 
 remedies. It is not unfrequcnt to find nn exostosis which was 
 only a symptom of syphilis continue after the removal of the 
 general disease, particularly when the infection has existed for 
 a length of time in the system. The topical affection should 
 in this case be left to nature, if its situation do not impede the 
 action of some organ essential to life; under which circum- 
 stances, its removal by an operation becomes necessary. 
 
 In treating a venereal exostosis by mercurial reinedies, it is 
 of tb£ utmost importance to regulate their use in such a man- 
 ner as that the mouth may be but slightly affedted, and a sali- 
 vation avoided. Little reliance can be had on the topical ap- 
 plications, with which the tumour is generally covered ; nor can 
 it be reasonably expected that they should adl efFedlually on the 
 osseous system, through the integuments and soft parts. Hem- 
 lock plasters, and similar applications, only irritate the skin, and 
 occasion erysipelas and excoriations, which add to the suffer- 
 ings of the patient. 
 
 The sci'ofulous exostosis is opposed by the internal use of 
 tonic medicines, by the application of discutients to the part, 
 by sea-bathing, or by pumping on the part water in which 
 some alcali has been dissolved. But often all our endeavours 
 are fruitless ; the exostosis degenerates into caries ; the soft 
 parts which cover the diseased bone become inflamed, and ab- 
 scesses are formed, the openings of v'/hlch become fistulous. 
 The slow fever which ensues from the absorption of the pus 
 and the copious discharge, exhaust the patient's strength, and 
 the only resource that now remains is amputation; but this 
 even is sometimes impracticable, from the situation or extent 
 of the diseased part. 
 
OF EXOSTOSIS. l8l 
 
 When, as is generally the case, the scrofulous exostosis ter- 
 minates in caries, the treatment will be the same as if caries had 
 supervened without being preceded by exostosis. 
 
 The scorbutic exostosis requires the same treatment as the 
 disease of which it is a symptom. As to the cancerous exos- 
 tosis, which is as rare as the scorbutic, its cure is as difhcult as 
 that of cancer itself. When the part cannot be extirpated, 
 opiates and other palliative means are to be had recourse to. 
 
 If the disease has originated from an external cause, or if it 
 be merely local, the primary disease of which it was a symptom 
 being removed, it is best to leave it to nature. The use of 
 caustics, or the actual cautery, occasions much pain, and, in- 
 stead of doing good, adds to the evil. This is the case with 
 an unfortunate woman, who had caustic applied to an exostosis 
 of the internal side of the tibia-, but which, instead of remo- 
 ving the exostosis, produced a necrosis, of which she is not 
 yet well, though two years have elapsed since the application 
 of the caustic. How ever, should the tumour, from its situa- 
 tion or size, press on, and derange some important organ, as 
 the eye for instance, which it may turn to one side or the 
 other, or totally expel from the orbit, it will be necessary to 
 proceed to the follov.'ing operation. 
 
 If the tumour rise from one of the broad bones of the skull, 
 to which it is connedled by a narrow neck, the integuments 
 over it are divided by a crucial incision, and dissefled from the 
 bone. The periosteum is then to be cut round the neck of the 
 tumour, which is finally removed by a thin sharp saw. This 
 mode of operating is much to be preferred, even when the 
 neck of the tumour is not very narrow, to that in which a 
 chisel, and mallet of lead, are used; for the concussion given 
 to the brain by the latter mode may bring about the worst 
 consequences. If the base of the tumour be so thick, that it 
 cannot be sawed through by a small fine saw, it will be neces- 
 sary to divide it into several parts by vertical sections, which 
 parts may be easily sawed through in succession. 
 
 When the chisel and mallet are used, it will be necessary to 
 fix immovably the part to be acted on, and to direct the chisel 
 obliquely, so that its aftion by cutting maybe increased. If 
 after having removed in this manner the greater part of the 
 tumour, its base be found carious, it will be necessary to re- 
 move by the chisel, or even a scraper, as much as possible of 
 the diseased part, and to destroy what remains by the atSlual 
 cautery. 
 
l82 OF OSTEO-SARCOMA. 
 
 If the tumour to be removed by the chisel be very thick, it 
 will be necessary to make holes in it in different points by a 
 perfornniLj instrument, by which means its basis will be dimi- 
 nished, and its removal facilitated. After the tumour has 
 been removed, granulations sprout from the surface of the 
 bone, and in a little time the wound is cicatrized. But I must 
 remark, that cases rarely occur, in which it would be justifia- 
 ble to perform this operation, and that in by far the greater 
 number of instances the local affection is much less to be 
 dreaded than the means used for removing it. 
 
 We have designedly omitted mentioning the lamellated ex- 
 ostosis, in which the internal part of the diseased bone is con- 
 verted into flesh. This species of disease has been improperly 
 confounded with exostosis, but it more properly belongs to 
 those classed under the general name of osteo-sarcoma. 
 
 CHAPTER XXII. 
 
 OF OSTEO-SARCOMA. 
 
 WE comprehend under this denomination all the osseous 
 tumours to which authors have given the different 
 names of spina ventosa, poedarthroeace, and osteo-sarcoma ; 
 but in colledling them thus under one general name, we do not 
 mean to say that these different denominations refer to a single 
 disease, but merely that they have, notwithstanding their dif- 
 ferences, certain points of resemblance which justify this clas- 
 sification. It is extremely difficult, says Marcus Aurelius 
 Severin, to ascertain to what kind of organic lesion this affec- 
 tion is to be ascribed.* The bone affedled is sometimes totally 
 converted into a soft, lardy, homogeneous substance, resem- 
 
 * Non est sane facile decerni quo sit genere ccnsendus hie affeflus. Mar. 
 Aur. Sev. de Poedarthroeace. 
 
OF OSTEO-SARCOMA. 183 
 
 bling a concerous gland. At other times it is filled with fun- 
 gous flesh, which is covered exteriorly by a thin plate of com- 
 padl substance, perforated by a great number of holes; finally, 
 there are cases in which the bone becomes reduced into a soft 
 gelatinous substance. We shall give a remarkable example of 
 this species at the end of this chapter. 
 
 The first species or variety which we have mentioned is that 
 which merits particularly the name of osteo-sarcoma, which 
 signifies, in itself, the conversion of an osseous substance into 
 flesh: it may be doubted, however, if the name of flesh be 
 properly applied to this substance, which resembles rather a 
 scirrhus of soft parts than flesh, and which presents no mark 
 of organization. The soft parts which surround a bone thus 
 afl'ected participate in the disease, which is always announced 
 by very acute pains, and which originates sometimes from an 
 internal disease, and particularly from the cancerous virus; at 
 other times, from an external cause, as a violent contusion: in 
 many cases it can be traced to no cause. 
 
 The second species, named spina ventosa, or pcedarthrocace, 
 consists in a swelHng of the head or body of a long bone, in 
 such a manner as that its cancelli become very much enlarged. 
 The medullary membrane which lines these cancelli becomes 
 thick, and granulations sprout from it, which destroy by their 
 growth the substance of the bone, so that there only remains 
 an external shell filled with small holes. To this species must 
 be referred the swellings of the articulations of the phalanges, 
 arising from scrofula, and which often lead to the necessity of 
 amputating. This operation should not, however, be hastily 
 recurred to, as nature sometimes effe£ls a cure in which she 
 may be aided by bathing the parts in a diluted solution of pot- 
 ash or soap- water. When a bone that has been thus diseased 
 is macerated, the internal fleshy substance separates, and the 
 dilated bone remains a mere empty and brittle shell. 
 
 In every species of this disease, the pains are at first dull 
 and deep-seated, but in a short time they become more in- 
 tense, and the volume of the bone increases, though the soft 
 parts appear yet in their natural state. The latter, however, 
 soon become red and inflamed, and abscesses form in them, 
 which burst, and their openings degenerate into fistulx. 
 
 The osteo-sarcoma, of whatever species, is in general a dan- 
 gerous disease, and often requires the amputation of the part 
 afFedted. When a tendency to this disease from a venereal 
 cause is discovered early, its progress may be prevented; but 
 
184 OF OGTEO-SARCOMA. 
 
 if the disorganization of the bone has once taken place, its 
 structure can never be restored. The swellings of the extre- 
 mities of the phalanges of the fingers and toes are the least 
 alarming of all affections of this kind. They seldom render 
 amputation necessary; in general, the wound in the integu- 
 ments puts on a more healthy appearance, the fistulse dry up 
 and heal, and the patient recovers, but with the loss it is true, 
 of , the motion of the joint. 
 
 When the structure of 3 large portion of bone is disorgan- 
 ized by osteo-sareoma or spina ventosa, and the patient har- 
 rassed by acute pain, and exhausted by slow fever, diarrhoea, 
 and colliquative sweats, it will be necessary to amputate the 
 part, if the operation be practicable. But should the extent 
 or situation of the evil render amputation useless or impracti- 
 cable, all that can then be done is to support the patient's 
 strength by an invigorating diet and tonic medicines, and pal- 
 liate his sufferings by means of opium. 
 
 Amputation is generally successful, except in cases of real 
 osteo-sarcoma, which, absolutely analogous to a carcinomatous 
 affection of the soft parts, takes deep root, and may, like it, 
 attack the bone again after this operation has been performed. 
 This return is particularly to be apprehended when the lym- 
 phatic glands in the neighbourhood of the diseased part are 
 swelled and indurated. 
 
 We have spoken of a particular disorganization of the bones, 
 in which their substance, and that of the surrounding soft 
 parts, become soft, and are converted into a gelatinous mass. 
 The following case presents a remai-kable instance of this spe- 
 cies of osteo-sarcoma. 
 
 A priest, aged forty-seven, fell as he was running in the Rue 
 de Barres, the 1 3th Vendemaire, year 7, and received a con- 
 tusion on the right shoulder, v/hich was not, however, so con- 
 siderable as to prevent him from attending to his usual occu- 
 pations; both pain ind contusion vanislied in a short time. 
 Four months after he felt intermittent pains in the right arm, 
 which were relieved by extending the arm forcibly. A tu- 
 mour as large as an egg manifested itself near the shoulder, the 
 pain arising from which was assuaged by volatile liniment ; but 
 it soon became very acute, and the arm lost the power of mo- 
 tion. He was received in this state into the Hotel-Dieu, where 
 he remained two months, during which time the shoulder was 
 kept covered with emollient poultices. The pain diminished, 
 but the tumour, which had been stationary, increased rapidly 
 
OF OSTEO-SARCOMA. 1 85 
 
 in size, and extended over the shoulder and into the armpit. 
 After leaving the Hotel Dieu, he remained with his friends 
 until the 2d Ventose, year 9, when he entered the hospital of 
 St. Louis. The tumour, or rather the shoulder (for that part, 
 though much increased in size, had not lost its natural shape), 
 was moveable, though it appeared to be connedled by some 
 points to the side of the thorax: it was equally hard and elastic 
 in every part, but little eminences were formed on its surface. 
 The skin, though very much distended, had preserved its na- 
 tural colour, and a considerable degree of pressure might be 
 made on the tumour without increasing the pain. The right 
 trapezius muscle, which supported principally the weight of the 
 tumour, was much extended, and drawn into the shape of a 
 cord visible through the skin. The pain appeared to be pro- 
 duced by the extension of the skin and compression of the aux- 
 iliary plexus of nerves: its violence was considerably diminished 
 by emollient applications and by the use of opiates, the dose of 
 which it was found necessary to augment when the atmosphere 
 seemed overcharged with elesflricity ; as the pain was then much 
 increased, and seemed to dart in different directions tlirough 
 the tumour with the rapidity of lightning. The great extent 
 of the swelling of the lateral and superior parts of the thorax, 
 our ignorance of its nature, and of the real state of the articula- 
 tion, prevented us from amputating at the shoulder joint. 
 
 The tumour continued to augment, and the pains to become 
 more intense; the emaciation and debility increased; opium 
 could no more procure sleep or diminish pain; diarrhcEa came 
 on, and the patient died on the 2d Fru6lidor, five months after 
 his entrance into the hospital of St. Louis. The tension of the 
 skin of the tumour seemed to diminish, and the tumour itself 
 to collapse, on the moment of the patient's death. Its circum- 
 ference was still thirty-six inches, and its diameter sixteen: its 
 weight, with that of the arm, was about thirty-three pounds, 
 while that of the other arm was only about six, which left a 
 difference of twenty-nine pounds. When the skin was thus 
 relaxed, a fluftuation was perceptible, which could not be felt 
 before, unless in the little eminences on the surface, which 
 were liable to disappear and change their situation. A trocar 
 was twice plunged into the tumour in different parts, yet no 
 fluid escaped. I then opened it in presence of Citizen Lassus, 
 Thouret, and many other practitioners. 
 
 The skin was thinner than natural, and its texture decom- 
 posed : that is, the fibres and lamellae of which it is composed 
 24. 
 
l86 OF OSTEO-SARCOMA. 
 
 were separated and distin£l. The muscles, and particularly the 
 deltoides, were extremely emaciated, and seemed to form a 
 second fleshy covering not more than one line thick. A yellow 
 gelatinous mass was found in the centre, and which resembled, 
 in many respe^ls, jelly in which some blood had been mixed. 
 The humerus was nearly destroyed to its inferior extremity. 
 The nerves and arteries, pressed against the integuments, did 
 not seem to have been injured. The surface of the glenoid 
 cavity was destroyed, and converted into a gelatinous substance. 
 A chemical analysis of this substance proved it to be composed 
 of a great proportion of gluten, a small quantity of albumen, 
 and some salts. The clavicle was found in a healthy state, and 
 no part of the scapula was affected but that which forms the 
 glenoid cavity. 
 
 The diseased part has been preserved, and deposited in the 
 Anatomical Gallery of the School of Medicine of Paris; where 
 also may be seen a drawing of the tumour in the last stages of 
 the disease. An idea of it may be formed from an attentive ex- 
 amination of a drawing given by Marc. Aur. Severin* of a 
 Spaniard who died of a similar tumour. 
 
 There are other examples of similar tumours. Citizen Las- 
 sus has colledled the particulars of a great number of cases of 
 this kind, and has made them the subject of an Essay presented 
 to the School of Medicine. 
 
 * De recondita Abscessinm Natura, edit, de Leyd. 
 
VOLUME II, 
 
A TREATISE, 
 
 CHAPTER 1. 
 
 OF RICKETS. 
 
 THIS disease Is most generally met with in young chil- 
 dren, and but very seldom in adults; however, persons 
 that have suffered from it in their youth, may be attacked with 
 it after puberty. The memorable case given by Morand in the 
 Memoirs of the Academy of Sciences, 1753, furnishes a re- 
 markable instance of its attack after this period of life. 
 
 The bones of the foetus whilst in the womb may be affedled 
 by it: Pinel has given, in Fourcroy's Journal, a description of 
 the skeleton of a ricketty foetus. But it most generally mani- 
 fests itself from the sixth or seventh month, to the fourteenth 
 or fifteenth, or much about the period of the first dentition. 
 J. L. Petit, and many others, have considered difiicult cutting 
 of the teeth as a principal cause of it. 
 
 It is not as yet decided whether this disease, the charafteris- 
 tic mark of which is a softening of the bones from a deficiency 
 of phosphate of lime, be a primary affe£lion, or a symptom of 
 scrofula, lues, or scurvy: Do<fl:or Portal maintains the latter 
 opinion. 
 
190 OF RICKETS. 
 
 "We will observe, however, that there seems to be a great 
 connexion between rickets and scrofula: the swelling of the 
 mesenteric glands, the colour of the skin, the flaccidity of the 
 muscles, and other symptoms observed in rickets, are marks 
 of a scrofulous diathesis. 
 
 Whatever may be its cause, its progress is as follows: the 
 child generally suffers from cutting his teeth, and is tormented 
 for some time by a continual diarrhoea; at length the belly 
 swells, and becomes hard and tense; the skin is now dry and 
 scaly: the limbs diminish in thickness, and the whole body 
 becomes emaciated; the ends of the bones swell, and the joints 
 of the extremities appear like so many knots; the bones lose 
 their consistence, or become flexible, and the muscular sub- 
 stance decays. The patient, reduced to this miserable state, is 
 incapable of moving, and every effort he makes, or even the 
 weight of his body, bends the bones. The head preserves, 
 however, its natural size, and in most cases becomes even 
 larger than natural. The brain, which does not seem to share 
 in the general dissolution, becomes evolved, its extension not 
 being opposed by the softened bones in which it is included, 
 and the understanding is prematurely developed. The eyes 
 have an uncommon brilliancy, and all the senses are extremely 
 acute: however, cases have been met In which great marks of 
 stupidity or dulness accompanied the disease. 
 
 The affection does not always stop here; sometimes the 
 bones become carious, or a white svv^eliing appears in some of 
 the joints; either of which in general proves fatal. 
 
 The vertebral column is particularly liable to be affefted by 
 rickets, and the disease is sometimes confined to it alone. 
 When the cervical vertebrx are attacked, the anterior part of 
 the neck projects, and the head falls backwards, and appears 
 sunk between the shoulders. When the affedlion is general, 
 the vertebral column becomes shorter, and is curved in various 
 directions; the breast beomes deformed, not only in conse- 
 quence of the curvature of the spine, but by the depression of' 
 the ribs and projection of the sternum; the bones of the pelvis 
 fall inwards,' and generally the pubis approaches, the sacrum; 
 and the diameters of the pelvis are so much diminished, that, 
 parturition must be rendered difficult or impossible. Howe- 
 ver, some women deformed by rickets, bring forth full-grown 
 children, without any difficulty; but I believe that in such 
 cases the rickets come on after puberty, at which time there is 
 much less danger of the pelvis being aftedted than in infancy. 
 
OF RICKETS. 191 
 
 The curvature of the clavicles increases, and becomes more 
 prominent anteriorly; the scapulae grow shorter; the humeri 
 become curved outward towards their superior part, wliilst 
 their inferior is carried forwards; the bones of the fore-arms 
 are curved in the same manner; but the superior extremities, 
 as they do not support any part of the weight of the body, are 
 always much less deformed than the inferior, and they are 
 always bent towards that side into. which the most powerful 
 muscles are inserted. 
 
 The bones of the thighs are curved forwards or outwards, the 
 anterior and external parts of the thigh becoming more promi- 
 nent; the neck of the femur, from being oblique, becomes 
 perpendicular with the body of the bone; the knees fall in- 
 wards; the internal and anterior sides of the tibia become con- 
 vex, and the external side of the legs concave; the feet are 
 thrown outwards, not only on account of the knees falling in, 
 but also, because the inferior end of the fibula cannot suffici- 
 ently oppose the abduction of the foot. 
 
 Nothing certain has been ascertained as to the proximate 
 cause of rickets; conjedlures however have not been wanting 
 on this subject. Some have supposed that the bones are de- 
 prived of their phosphate by an acid; but what acid is this? 
 How is it generated ? Does the acid smell of the breath of the 
 ricketty patient indicate any thing respecting it,'' 
 
 Is the softening of the bones owing to a defeat of reparation, 
 while their ordinary loss is going on? or is there a disease in 
 the bones by which they are decomposed and consumed, whilst 
 the digestive organs do not furnish a sufficient supply of calca- 
 rious phosphate ? or is the passage of this salt from the chylo- 
 poetic viscera prevented by the obstruftion of the mesenteric 
 glands? We must acknowledge that ricketty patients, notwith- 
 standing their voracious appetite, appear to digest their food 
 but badly, and that the passage of the chyle must be impeded 
 by the obstruftion of the mesenteric glands, in which calcareous 
 concretions have been found; lastly, does the chyle contain a 
 less quantity of phosphate of lime than natural? or does this 
 salt, instead of being deposited in the bones, pass to other 
 parts? and what is the cause of this deviation? 
 
 If the body be anatomically inspected after death, the parts 
 will be found in the following state: 
 
 The muscles are pale and emaciated; the cellular substance 
 is quite destitute of fat; the brain is in general found larger 
 than natural, soft, and containing a preternatural portion of 
 
192 OF RICKETS. 
 
 humidity; the spleen and liver are flaccid and enlarged; the 
 intestines are pale, or rather whitish; all the lymphatic glands, 
 especially those of the mesentery and bronchiac, are enlarged, 
 and the latter sometimes suppurated; the bones, reduced to 
 their fibrous state, are flexible, bent in several diredtions, and 
 easily cut. 
 
 There have been various opinions as to the cause of the cur- 
 vature of the bones. Glisson, who wrote towards the middle 
 of the seventeenth century, is the first who expressly treated 
 of rickets: his explanation of the curvature is as follows: 
 
 The humours, says he, that go to nourish the bones, are 
 accumulated more on one side than on the other, and thus curve 
 the bone, or make it incline to the opposite side, in the same 
 manner as a column might be curved by introducing in the 
 same line, and on the same side, wedges between its different 
 parts. But how is it proved that the humours are deposited 
 on one side in preference to another? and how comes it that 
 the curvature takes place in most persons in the same direc- 
 tion ? 
 
 Mayow, an English author, gives the following hypothesis: 
 the tendons being dry and shortened, oppose the elongation 
 of the bones, and bend them in the same way as a young tree 
 is bent, by bringing both its ends towards one another by 
 means of a cord. But, without having recourse to this far- 
 fetched comparison, we find an easy and natural explanation 
 of the fadl in the effects of the weight of the body, and mus- 
 cular contradlion. The deviations are in general an excess of 
 the natural curvature; and it is easy to conceive that the weight 
 of the body, and muscular a6lion, which produce this natural 
 curvature, may occasion an excess of it, when the bones are 
 incapable of resisting the forces that adl on them. It is also 
 found that the natural as well as the diseased curvature is al- 
 ways in the diredlion in which the most powerful muscles a6l; 
 thus the tibia and fibula are curved outwards and backwards; 
 and the femur is curved inwards and backwards, the muscles 
 of the internal and posterior part of the thigh being more 
 powerful than those of the external and anterior. 
 
 Rickets is an hereditary disease in some families, though 
 parents that have been affected with it, have sometimes a 
 healthy and robust offspring. I think it can be traced, in 
 some instances, to a venereal taint, which, though not the 
 immediate cause, is very often an exciting cause of it and scro- 
 fula. At least, it is certain that syphilis transmitted from pa- 
 
OF RICKETS. 193 
 
 rents to their children, appears in the latter in a manner very 
 different from that in which the former are affefted. Thus 
 we find, that the children of the indigent and profligate are 
 those most generally affected with rickets; but at the same 
 time it must be allowed, that there are many circumstances 
 which conduce to this disease; such as a damp and cold resi- 
 dence, impure air, inattention to cleanliness, and a deficiency 
 of food. 
 
 Though, we do not fully adopt the opinion of Petit as to the 
 influence of dentition, still we must allow that the aftion then 
 going on in the osseous system, must be intimately connected 
 with the cutting of the teeth; and that difficult dentition, tlue 
 pain and bowel complaints arising from it, may favour, in a 
 powerful manner, the action of the exciting causes of rickets. 
 
 It is singular enough that the teeth preserve their hardness, 
 though they become loose from the softening of the alveolar 
 processes: the softening of the jaw bones is sometimes attended 
 with excessive pain, but at other times it takes place without 
 any pain at all. 
 
 The prognosis is always unfavourable in rickets; there is no 
 medicine which afts directly against it : and even in the most 
 favourable cases it is impossible to guard against deformity. 
 However, the danger to life is great in proportion to the num- 
 ber of bones affedled, the more or less speedy progress of the 
 disease, and the age of the patient. Children at the breast are 
 in greater danger than those that have rieached three or four 
 years. If the bones about the thorax be considerably affected, 
 the cavity is diminished, the lungs are compressed, the func- 
 tion of respiration goes on imperfectly, and hence a number of 
 diseases which are fatal of themselves. 
 
 Sometimes the disease advances but slowly, and the patient 
 arrives at puberty before he is quite well; but the great revo- 
 lution that takes place in his system at this time, arrests the 
 progress of the complaint. Measles, small-pox, and other 
 diseases to which children are subjeft, have sometimes brought 
 about this happy termination: the limbs recovered their size, 
 the enlargement of the joints disappeared, and no mark of 
 rickets remained but the deformity. 
 
 We know of no medicine which can be said to possess any 
 efiicacy in this disease : tonics are indicated, and they should 
 be used. But the principal advantage is to be derived from 
 general treatment: the patient, if resident in a city, is to be 
 removed to the country, where an elevated and dry situation 
 
194 <5F RICKETS. 
 
 should be chosen; he is to be supplied with a nourishing diet, 
 and a moderate quantity of wine. But as the poor, amonsj 
 whom the disease is most frequently observed, cannot change 
 their residence, they should be placed in the highest apartment 
 of the house, which should be kept well ventilated; and in the 
 warm season the patient covered with a shirt, should be exposed 
 for a considerable time every day to the sun; care, however, 
 should be taken that his head be protected against the influence 
 of the rays. 
 
 The bed on which ricketty patients lie, should consist of no- 
 thing more than a hair mattress, or oaten chaff; or it might 
 be made of dried fern-leaves, among which some aromatic 
 herbs were mixed. Such beds are much better than those 
 made of feathers; for they do not yield to the weight of the 
 body, and they are much drier. If the patient be very young, 
 he should be placed on his back, so that the weight of his 
 body may have as little influence as possible on the bones; but 
 as it is painful to remain constantly in this position, he may be 
 allowed to sit up now and then, but not on a soft chair: he is 
 to be placed on a seat capable of making a uniform resistance, 
 %vith a high straight back, and without arms. If the seat were 
 soft, the patient, to find 7i point d'appui, would incline forwards; 
 and if it had arms, were he to lean on them, his shoulders 
 would be raised, and the cervical vertebra; curved forwards. 
 He should not be allowed to walk for a considerable time; for 
 at first he will be incapable of doing so without assistance, and 
 the strings and ribbands necessary for supporting him, contri- 
 bute, by pressing on the parietes of the thorax, to deform that 
 cavity. 
 
 EriiStions are useful. They may be made either with dry 
 flannel, impregnated with aromatic vapours, or with flannel wet 
 with mint, rosemary, lavender, or other aromatic waters. A 
 hair brush, much used by the English, is an excellent instru- 
 ment for this purpose. Frictions determine the fluids to the 
 surface of the body," promote perspiration, and increase the 
 circulation. 
 
 The clothing should be wide, and composed of materials 
 which are light, and which do not transmit freely the heat of 
 the body. If the patient be a child at the breast, the nurse's 
 qualities should be inquired into; if she is feeble, unhealthy)^ 
 or pregnant, . the child should be committed to another nurse, 
 possessing the very opposite qualities. If the child be --^'caned, 
 he is to be nourished with well-fermented bread, and animal 
 
OF RICKETS. 195 
 
 food simply roasted; and wine is to be allowed him in small 
 quantities, often repeated. As to exercise, if it do not in- 
 crease the curvature of the bones, as much of it should be taken 
 as will not fatigue the patient; and when the softness of the 
 bones is such that any exercise which would require conside- 
 rable muscular a6lion cannot be used, riding in a carriage, 
 or sailing, should be had recourse to. 
 
 Independently of the general means just pointed out, there 
 are particular remedies which may be used in cases to which 
 they are adapted. 
 
 If the patient suffer from dentition, that is, if he be tor- 
 mented with griping pains and diarrhoea, or if he shriek se- 
 verely now and then, and have convulsive twitches, opium 
 should be given. If he be troubled with worms, rhubarb and 
 other supposed vermifuge medicines may be administered. 
 
 It is very common to find ricketty patients troubled with 
 worms: the weakness of the alimentary canal, and the quan- 
 tity of mucus collected in it, favour the generation of worms, 
 the existence of which in the intestines is indicated by colic 
 pains, itching of the nose, acidity of the breath and perspira- 
 tion, dilation of the pupil, &c. &c. 
 
 We may endeavour to discuss the swelling of the mesenteric 
 glands, by small doses of infusion of rhubarb, and by repeated 
 friftions on the abdomen. I am conjfident that much benefit 
 might be derived in these cases from making the patient laugh 
 heartily every day, by tickling him; in this convulsive motion, 
 the organs contained in the cavities of the thorax and abdomen 
 are agitated and pressed in every dire(5lion, and the motion of 
 the fluids in their small vessels is accelerated. 
 
 If it appear that syphilis or scrofula has had any share in 
 producing the rickets, the treatment applicable to each of these 
 diseases should be had recourse to. In case of a venereal taint 
 being the cause, tonics should be combined with the use of 
 mercurials; for the latter, by itnducing debility, accelerate the 
 progress, of th? rickets. 
 
 The knowledge of the cause of the softening of the bones, 
 necessarily leads to endeavours to obviate it, or repair the in- 
 juries it occasions. But how are we to introduce a sufliciency 
 of phosphate of hme.^ How are we to stimulate the absorbents, 
 and make them take up a greater portion of this salt ? And, 
 supposing that this could be effected, how can we cause it to be 
 deposited in the bones? Madder, from its known property of 
 tinging the bones red, was supposed to have a particular action 
 
 
196 OF RICKETS. 
 
 on the osseous system, but it is now well ascertained that It 
 has no greater effeft in rickets than any other bitter plant. 
 
 Thus it appears that our chief objedt in treating this disease, 
 is to restore general health and strength as much as in our 
 power: the general treatment already pointed out, is what is 
 most to be depended on for this purpose, but it maybe assisted 
 by the use of bark and other tonic medicines. 
 
 Mechanical means have been proposed for obviating the ef- 
 fects of this disease. It is nearly useless to attempt using any 
 machines with very young children, and it is also impossible 
 to confine them on their back in bed; besides, it would be 
 extremely injurious to keep them confined in this posture: the 
 continued extension of the limbs, and the inadlivity of the 
 muscles, would add to the general debility, and consequently 
 increase the disease. Splints, then, applied to the limbs, strong 
 leather boots, and the apparatus for the spine, are really useful 
 only in cases in.which the patient is of a certain age, and when 
 the progress of the disease is gradual, and the strengtfi not too 
 much exhausted; and even in most of these cases, the inac- 
 tivity necessarily occasioned by these machines, is produdlive 
 of disadvantages which are not compensated by their good 
 effecls. Apparatus of this kind are fitter for correcting vicious 
 attitudes contracted by healthy children, than deformity arising 
 from ricketSo 
 
197 
 
 CHAPTER II. 
 
 OF THE FRAGILITY OF BONES. 
 
 WE have seen that a softening of the bones may be pro- 
 duced by a deficiency of phosphate of lime: we shall 
 now consider a disease of an opposite charafter, which con- 
 sists in a deficiency of the gelatinous part. This substance, to 
 which bones owe their flexibility, and in which their vitality 
 resides, may be so deficient in them, that they will break on 
 the application of yery slight causes. This disease has been 
 called friability, or fragility, from the tendency of the bo'-e to 
 crumble or fall in pieces. The state of the bone, in this case, 
 may be well conceived from that of a calcined bone. 
 
 This afi^edtion is a natural consequence of old age. The pro- 
 portion of phosphate of lime deposited in the osseous tissue, 
 increases as we advance in life, and that of the organized part 
 diminishes in.a similar proportion; so that a period arrives at 
 which the quantity of the former so much predominates, that 
 the bones, dead as it were before life abandons the other parts, 
 break on the slightest occasions. 
 
 The disease at this period of life is necessarily incurable. If 
 the fractures be reduced, and an apparatus kept applied on the 
 limb for several months, no progress towards consolidation is 
 observed. Tonics and stimulants are of no use. There are so 
 few vessels in the bones capable of conveying fluids, that no 
 granulation form. 
 
 A similar fragility of the bones is observed in adults; but in 
 them it arises from a venereal, scrofulous, or cancerous taint. 
 
 When the whole mass of fluids is infedled with the matter 
 of cancer, it sometimes happens that this virus attacks the 
 bones, destroys their vital parts, and renders them as brittle 
 as if they had been calcined. Saviard and Louis mention cases 
 of this kind. The latter relates the case of a nun who attended 
 La Salpetrierey who broke her arm by simply leaning on a ser- 
 vant as she was entering a carriage. A very singular case of 
 this kind is related in the London Medical Journal; this un- 
 
198 OF THE FRAGILITY OF BONES. 
 
 fortunate person could not turn in bed without fracturing some 
 bone. 
 
 This alarming symptom is completely irremediable when it 
 arrives at this stage. 
 
 The bones are sometimes remarkably brittle in the latter 
 stages of syphilis. In such cases the primary disease claims 
 our chief attention. 
 
 The bones in the latter stages of scurvy become so brittle, 
 that they break on slight occasions, and do not consolidate af- 
 terwards. Mead observed, that scurvy was verv unfavourable 
 to the consolidation of fradlures, and that in some cases of 
 sailors which he observed, the callus was destroyed by scur\'y 
 after it had been formed. 
 
 If the bones of a scorbutic person be boiled, the periosteum 
 separates very soon, lamellae scale off, and, in some cases, the 
 bone dissolves entirely. They also fall into powder if kept for 
 some time, but particularly if exposed alternately to heat and 
 moisture. 
 
 We may conclude from the preceding observations, that 
 fragility is rather a symptom of senility, or of some disease that 
 affefts the bones, by destroying their organic parts, than a pri- 
 mary disease. We should not have consigned a chapter to it, 
 did we not hope, that the etiology of rickets may in time be 
 elucidated by a comparison of these two affedtions. 
 
199 
 
 CHAPTER III. 
 
 OF SPRAINS. 
 
 SPRAIN may be defined, a more or less violent tension of 
 the ligaments and other soft parts surrounding an articu- 
 lation; the tension may be carried so fap as to burst and lacerate 
 many of the ligaments. All the articulations are not equally 
 liable to this accident; those which admit of an extensive and 
 free motion, all the round or loose articulations, in which the 
 bone moves in a variety of diredlions, as the articulation of the 
 OS humeri with the scapula, and that of the femur with the 
 ossa innominata, are very little subject to it. The latitude of 
 motion they admit of, the small number, laxity, and parti- 
 cular stru<n:ure of their ligaments, render them more liable to 
 luxations from inconsiderable efforts, than to sprains. In the 
 articulations by ginglymus, on the contrary, in which the mo- 
 tion is confined to two ways by the reciprocal conformation of 
 the surfaces of the joint, and by strong and numerous liga- 
 ments, sprains take place often er than luxations. Of this 
 kind of articulation is that of the foot with the leg, in which 
 the astragalus, received like a tenon into a quadrangular cavity, 
 is surrounded on all sides by very strong Hgaments. Next to 
 the articulation of the foot comes that of the wrist, then those 
 of the knee and elbow, in which a sprain rarely occurs. 
 
 The nature of the affection may be thus explained: suppose 
 the foot or hand to be fixed, and the leg or fore-arm pushed 
 forwards in any direction, the ligaments placed on the side 
 against which these parts are forcibly propelled, will be put in 
 a considerable state of tension, and strained; the tension may 
 be carried so far as to lacerate the ligaments, of which there 
 have been many instances. The tendons, and other soft parts, 
 such as the nerves, vessels, and even the skin, are overstretched 
 and pained. Those parts placed on the side towards which 
 the displaced bone tends, are more or less injured in the angle 
 which intercepts the luxated bones: they experience a contusion, 
 
209 
 
 OF SPRAINS. 
 
 by which the small vessels are bruised and lacerated, and a con- 
 siderable ecchymosis produced. The tension to which the 
 parts of the joints are subjc<Sted in sprains, is not then confined 
 to the ligaments alone, it extends to all the parts in the neigh- 
 bourhood; this gives an explanation of the sharp pains that 
 accompany them, and of the inflammatory swelling which 
 succeeds. In fa£t, although ligaments are endowed with a 
 peculiar kind of sensibility, which renders the extension of 
 them painful, nevertheless, they do not possess a sensibility so 
 exquisite as that the irritation of them alone could cause so 
 much pain, and such a considerable inflammatory determina- 
 tion, as that frequently occasioned by a sprain. 
 
 A sprain, then, in the moment of its produflion or taking 
 place, consists only of the tension, and sometimes laceration 
 of the soft parts surrounding an articulation; but the pain 
 which arises from it, quickly determines the fluids to the irri- 
 tated part; a swelling more or less considerable supervenes; 
 the skin often appears black, livid, and spotted, from the in- 
 filtration of the blood which escapes from the ruptured vessels 
 into the cellular texture. 
 
 When both parts of the affe(5led articulation are formed of 
 many bones, it may happen that the ligaments which unite 
 them may be torn, and the extremities of the articulations 
 disjointed and separated from one another. This diastasis haS 
 been observed in the inferior extremities of the tibia and fibula, 
 in those of the radius and ulna. 
 
 When the sprain is slight, the pain produced by it gradually 
 diminishes, the sv^'elling is resolved, the ecchymosis extends 
 and disappears, the motion of the parts becomes easy, and at 
 the end of some days the articulation is restored to its natural 
 state. Nevertheless, if the sprain has been considerable, and 
 especially if very strong ligaments, such as the internal liga- 
 ments of the articulation of the foot with the leg, have been 
 partially or entirely torn, nature requires a considerable time 
 to unite the divided part; the joint with difficulty acquires 
 strength, and a feebleness remains in it, which disposes it to 
 the same accident. 
 
 A sprain is easily distinguished by attending to the history 
 of the circumstances relating to it, such as a fall or false step, 
 in which the foot or wrist, as the vulgar say, has been more 
 or less wrenched. The state of the articulation that has suf- 
 fered, ought however to be attentively examined, in order to 
 discover if the ligaments have been lacerated, or If a disloca- 
 
OF SPRAINS. 201 
 
 tion of the extremities of the joint be combined with the sprain. 
 When the parts admit of motion in every direction, however 
 difficult and painful it may be, we conclude that a simple 
 sprain, and not luxation, has taken place. 
 
 The prog:nosis is unfavourable, in proportion as the extension 
 and laceration have been considerable. In scrofulous persons 
 sprains are very dangerous, because they often give rise to 
 white swellings. 
 
 The treatment of sprains varies according to the continuance 
 of the affecHiion. Should the surgeon be called in on the mo- 
 ment that the sprain has taken place, he should endeavour to 
 prevent the effefts of the irritation caused in the strained joint. 
 For this purpose the diseased part is to be plunged into cold 
 water, or still better into powdered ice. The brisk impression 
 occasioned by the cold, constriiSts all the parts, and diminishes 
 the diameter of all the small vessels, so much, as to prevent 
 the admission of the blood determined to them by tlie irrita- 
 tion. Besides, the extreme cold, by diminishing sensibility, 
 abates the irritation itself, and thus in two ways prevents the 
 influx of fluids. But to derive from refrigerants all the advan- 
 tages that may be expected, it is not enough to leave the dis- 
 eased part exposed to them for half an hour, or even an hour; 
 it must remain immersed in them during several hours, and 
 they must be renewed as they acquire heat, so that their adllon, 
 at once repellant and sedative^ may preserve the same energy. 
 These means, if not continued for a certain length of time, far 
 from being useful, do an injury, by exciting a reaclion which 
 determines the humours to the part where the irritation had 
 already too powerfully invited them. Should a woman have 
 her menses when this accident happens, these means could not 
 be had recourse toj the immersion in cold water would almost 
 infallibly suppress the menstrual discharge, and induce a disease 
 more grievous than the sprain itself. The same would be the 
 case should we have to treat a person with delicate lungs. 
 "When the part is reipoved from the ice, it must be covered 
 with cloths soaked in cold liquids, such as vegeto-minoral 
 water, spirit in which camphor or sal ammoniac has been dis- 
 solved, a mixture of vinegar and water. Sec. with which the 
 part is to be continually moistened. By a treatment of this 
 kind, a violent sprain often produces only a very moderate 
 swelling, and the disagreeable consequences are never com- 
 pletely developed. 
 
'202 OF SPRAINS. 
 
 It is scarcely necessary to condemn here the absurd praftice 
 of ignorant bone-setters, Avho agitate, twist, and press the 
 affe^ed joint in every direftion, or advise the patient to roll a 
 cylinder of wood under the sole of the diseased foot. The 
 repellent mode of treatment can be successful only shortly after 
 the accident has taken place; at the end of twelve hours, the 
 irritation which has not been subdued, and the efFefts of which 
 have not been prevented, has already produced an influx of 
 humours, with swelling, pain, and inflammatory tension of the 
 adjacent parts. It then becomes necessary to take a quantity 
 of blood proportioned to the age and temperament of the pa- 
 tient, the degree of the sprain, and severity of the symptoms. 
 
 Emollient cataplasms are applied, with the view of relaxing 
 the Solids, and of abating irritation; the use of them is to be 
 continued as long as the inflammatory teasion and pain are pre- 
 sent; but when the swelling begins to be resolved, which 
 change is announced by the subsiding of the tumour, the 
 wrinkling of the skin, the extension of the ecchymosis over 
 the limb, which becomes yellow, resolvents are to be combined 
 with the emollients: for this purpose a poultice composed of 
 crumbs of bread and linseed meal boiled in wine, or in a strong 
 decodlion of elder-flowers, is applied; the cataplasms are to be 
 rendered more and more resolvent, and towards the end of 
 the complaint, resolvents only are to be used: lastl)', solvents, 
 such as styr ax-plaster, sprinkled over with the flower cf sulphur^ 
 &c. Sec. are to be substituted for them, and pumpings with 
 "water in which some sulphuret of potash has been dissolved, 
 ov with natural or artificial warm waters, are to be prescribed. 
 
 The diseased part must be kept in a total state of inaction 
 for as long time as possible, and the limb preserved in the ho- 
 rizontal posture, which favours the subsiding of the tumour, 
 by facilitating the return of the fluids. The patient should not 
 be allowed to walk, or make use of his wrist, until the pain 
 has entirely vanished; he should even be informed that the 
 pains will return, and be felt at intervals for six months or a 
 year, and also advised not to fatigue too much the weak joint. 
 A roller is to be firmly passed round the foot and leg: by this 
 precaution the cedematous swelling of the limb will be pre- 
 vented, which, without it, would inevitably take place. This 
 treatment is indispensably necessary, when the sprain is accom- 
 panied with a complete or incomplete rupture of some liga- 
 ment, and with the separation or diastasis of the ends of the 
 
OF SPRAINS. 203 
 
 joint, a coiTipHcation which renders the cases more serious, and 
 the cure more tedious and difficult. 
 
 If the sprain be badly treated, or if the patient use the af- 
 fedled joint before all the symptoms entirely disappear, some 
 swelling still remains in the part; soon, in consequence of 
 some stress, the pains that were only lulled, re-appear, the 
 swelling increases, but in a slow manner, and assumes the ap- 
 pearance rather of an indolent than inflammatory tumour, 
 being very hard and without any change of colour in the skin; 
 and in rime it extends to all the ligaments and soft parts in the 
 neighbourhood of the joint. The healthiest and most robust 
 persons may have tumours of this kind supervene, as the conse- 
 quence of ill-treated sprains. Nevertheless it is certain, that 
 the existence of a scrofulous diathesis gives a strong predisposi- 
 tion to them: in this latter case, the sprain may be considered 
 the exciting cause of the disease, which attacks an enfeebled 
 and pained part predisposed to it. However, sprains that have 
 been negledled, often render amputation necessary, on account 
 of the enlargement and caries of the bones that succeed to 
 them. 
 
 It may suffice for us to say, without giving the particulars 
 of numerous instances of this melancholy termination, that 
 sprain, an afFeftion so trifling in the eyes of the vulgar, is one 
 of the most frequent causes of diseases of the joints, which, in 
 civil hospitals, render amputation necessary. 
 
 The rules to be followed in the treatment of the bad symp- 
 toms succeeding to sprains, will be given in the chapter on 
 white swellings. To give them here, would put us under the 
 Necessity of making useless repetitions. 
 
204 
 
 CHAPTER IV. 
 
 0|!' LUXATIONS IN GENERAL. 
 
 LUXATION takes place every time that the articular ex- 
 tremities of bones abandon their natural relations, whe- 
 ther it be that the head of a bone escapes from a cavity destined 
 to receive it, or that the surfaces of the joint cease to corres- 
 pond one to the other. The dislocation may be either total or 
 partial: hence luxations are divided into complete and incom- 
 plete. 
 
 In order to consider the nature of luxations, a previous know- 
 ledge of the anatomy of the articulations, and of the different 
 modes of the junftion of bones, is necessary. Thus, to form a 
 just idea of the different kinds of luxation of which the bone is 
 susceptible, of the manner in which it takes place, to under- 
 stand perfe«^ly its symptoms, easily seize the indications of 
 cure, and make choice of the proper means of fulfilling them, 
 the particular conformation, and mutual or reciprocal relation 
 of the surfaces by which the bones conie in contacl, and are 
 articulated, must be previously known. These relations should 
 be learnt on fresh bones covered with their cartilages, and 
 having their cavities furnished with the cartilaginous borders 
 which increase their depth, and with the synovial glands which 
 furnish the liquor by which they are moistened. 
 
 It is equally necessary to have correal: notions of the muscles 
 surrounding the articulation; of the vessels and nerves in its 
 vicinity; of the motions of which the joint is capable, and the 
 changes which the soft parts and bony prominences undergo 
 when these movements are executed. 
 
 After having acquired this information, it is necessary to 
 know that luxations, as well as fraftures, present characters 
 which are general and common to all luxations, and objects 
 which are peculiar and confined to each species. 
 
OF THE DIFFERENCES OF LUXATIONS. iO^ 
 
 SfeCTION I. 
 
 Of the Differ etices of Luxations. 
 
 Luxation^, taken in a general point of view, differ from 
 one another i Ij with respect to the articulation in which they 
 take place 5 2, the extent of the dislocation j 3, the direction in 
 which the bone is displaced; 4, the length of time they have 
 continued ; 5, the circumstances which accompany them, and 
 which mark them out as simple or compound; 6, and lastly, 
 with respe£t to the cause that has produced them. 
 
 The extent and variety of motion a joint admits of, give the 
 measure of the tendency of the bones composing it to be lux- 
 ated. Thus, the round or loose articulations, such as that of 
 the humerus with the scapula, are those in which luxations are 
 most frequent; in the gingl3'moidal articulations, on the con- 
 trary, which admit only of motion in two opposite dire£lionSi 
 they are very rare. The frequency of luxations in the orbicular 
 articulations, and the unfrequency of them in the ginglymoidal, 
 may be explained from many circumstances independent of 
 the greater or less motion they admit of. In the ginglymoidal, 
 the surfaces of the extremities of the bones which come in 
 contact, and are adapted to one another, are of considerable 
 extent; and when a foreign power a£ls on them, and forces 
 them in contrary direftions, they have to describe a great space 
 before dislocation takes place; the ligaments which surround 
 them are very numerous and strong, and the muscles placed 
 on their sides are disposed in a manner to prevent their de- 
 rangement. 
 
 With respeft to the extent of the dislocation, luxations are 
 distinguished into complete and inooniplete: the latter denomi- 
 nation is given them v/hefi the surfaces of the joint are yet iu 
 contaft by some points of its cartilages, without being entirely 
 displaced, but at the same time not exa<Stly corresponding. In-* 
 complete luxations take place only in the articulations by gin- 
 glymus, as in those of the foot, the knee and the elbov/. When 
 complete dislocation takes place in these parts, the fci-ce that 
 has effected it must have been very great; thus luxation in 
 them is almost always incomplete. The same is not the case 
 
206 OF THE DIFFERENCES OF LUXATIONS. 
 
 with the orbicular articulations, the greater number of which 
 are susceptible of no other luxation than the complete. 
 
 If the head of the humerus or femur is forced on the cartila- 
 ginous brim that surrounds and deepens the cavity destined to 
 receive it, the osseous ball, covered with cartilage, and having 
 its surface smooth and lubricated, comes in contadl with the 
 parts on which it rests by only a very few points, and thus 
 either re-enters the cavity it has abandoned, or escapes entirely 
 out of it: in the latter case the luxation is complete. 
 
 There are some articulations, which, though truly orbicular, 
 may nevertheless admit of incomplete luxations. For instance, 
 the head of the astragalus may be so displaced as only to aban- 
 don in a partial manner the cavity in the posterior face of the 
 OS navicularej but in this case the orbicular ligament is tight, 
 very strong, and the motion inconsiderable. In considering 
 fraclures in general, we have seen that they could not, like 
 luxations, be distinguished into complete and incomplete, the 
 latter denomination not being adapted to a solution of conti- 
 nuity in one of the bones of the leg and fore-arm. We shall 
 see, in treating of luxations of the lower jaw, that some, on a 
 principal somewhat similar, but equally erroneous, have wished 
 to call incomplete that in which only one of the processes of 
 the maxilla is displaced from the glenoid cavity of the os tem- 
 poris. Lastly, to conclude what relates- to the extent of the 
 dislocation, when the head of the bone has entirely escaped 
 from its cavity, it may still be forced to a greater or less dis- 
 tance between the interstices of the muscles. 
 
 As to the different directions in which a bone may be dis- 
 placed: in the round articulations it may be luxated in the di- 
 rection of all the radii that pass from the centre of the circle 
 formed by the circumference of the articular cavity. There is 
 not, in faCt, a point of the edge of the glenoid cavity, by which 
 the humerus may not escape. Nevertheless, as shall be ex- 
 plained when wc treat of particular luxations, various circum- 
 stances depending en conformation cause the luxation to take 
 place in certain dire<5tions ascertained by observation, so that 
 the varieties of luxations distinguished by the course of the 
 displaced bone are much less numerous than might at first be 
 supposed. Luxations are named, superior, inferior, anterior, 
 posterior, S:c. according to the approximation of the bone to 
 these directions. With respect to the ginglymoidal articula- 
 tions, which, as we have seen, constitute a class entirely diffe- 
 rent from the orbicular, considered in v/h?.: rdatrs to their 
 
OF THE CAUSES OF LUXATIONS. IQ-J 
 
 luxations as well as their motions, the bones which form them 
 describe two lines, during their luxation, which cross one 
 another at right angles-, the first by passing from one side to 
 the other, the second from the anterior to the posterior part. 
 
 The continuance of luxations constitutes a difference of the 
 highest importance, and influences considerably the manner of 
 treating them. In faft, the reduction of a luxated bone which 
 has remained so for several days, is much more difficult than 
 that of one more recently displaced. 
 
 The soft parts, and the bone itself, have acquired a certain 
 position, and the ligaments and muscles surrounding the dis- 
 eased joint become stiff, and difficultly yield to the efforts made 
 to reduce the bone. If a certain number of days have elapsed, 
 the laceration in the ligaments may be so far cicatrized as to 
 render the redu<5l:ion impossible. Lastly, the extremities of 
 the joint may be grown to the bones against which they have 
 been forced. 
 
 A luxation may be simple, that is to say, consist only of 
 the reciprocal abandoning of the surfaces of the joint, and the 
 laceration of the ligaments which is inseparable from it ; it may 
 be complicated with greater or less contusion, with a wound, 
 fracture, or rupture of a blood-vessel, and consequently an ef- 
 fusion of blood into the cellular substance, with contvfsion of a 
 considerable nerve, and a paralysis of the organs to which It is 
 distributed, &c. &o. 
 
 SECTION II. 
 
 Of the Causes of Luxations. 
 
 The causes may be divided into external and Internal: both 
 are predisposing or occasional. 
 
 The predisposition to luxation may depend on circumstances 
 natural or accidental. The natural are, the joint admitting of 
 great latitude of motion, the small extent of surfaces by which 
 the bones come in conta£l, the laxity and small number of the 
 ligaments uniting them, the weakness of one side of an articu- 
 lation, arising, for Instance, from a great notch on one side, 
 as Is observed In the interior and inferior part of the acetabulum. 
 Disease, such as a paralysis of the muscles v»'hich surround an 
 
208 OF THE CAUSES OF LUXATIONS. 
 
 articulation, a debility and relaxation of its liganDents, give zhih 
 a predisposition In a paralysis of the deltoid muscle, tiie 
 weight of the arm alone has been known to occasion an "lon- 
 gation and gradual relaxation of the round ligament of the ar- 
 ticulation of the humerus with the scapula, and remove the 
 head of the former bone to the distance of two or three inches 
 from the glenoid cavity. I have observed in a child, who la- 
 boured under an atrophia of the muscles of the arm an empty 
 space of nearly an inch between the head of the bone and the 
 surface of the cavity, which could be distin£lly felt through the 
 emaciated deltoid muscle. 
 
 Sometimes the relaxation of the ligaments appears without 
 any evident cause, and gives such a disposition to luxations, 
 that they take place fron.i the slightest causes: such was the 
 case of a woman, who could not yawn even moderately with- 
 out luxating the lower jaw. It rxiay not be amiss to observe, 
 that these luxations, depending on the excessive relaxation of 
 the ligaments, are, on accoimt of the relaxation itself, very 
 easily reduced, 
 
 A swelling or distension of the cartilages of the joints and 
 caries of the bones, may also dispose to luxations; but in these 
 cases, the affection of the cartilages and the caries constitute a 
 particulaV and primary disease. Luxation is to be considered 
 then only as an additional symptom; and it is perhaps without 
 foundation, as shall be mentioned in the db^pteron spontane- 
 ous luxations of the femur, that authors have ran.ked this dis- 
 ease of the hip among these afFeftions. 
 
 In order that external violence, a blow, a fail, or even the 
 a£lion of the muscles, produce luxation in a round articulation, 
 the axis of the bone must be placed in a direcStion more or less 
 oblique with respe<ft to the surface with which it is articulated. 
 If, for example, the os humeri hang exaclly along the sides of 
 the body, or perpendicularly with respe(fi: to the glenoid cavity 
 of the scapula, no force is capable of luxating it. If a person 
 fall on the elbow while the fore-arm is in this position, the 
 head of the humerus will be forced against the cavity formed 
 to receive it; but if the arm be removed from the body, the 
 axis of the os humeri will fall obliquely on the surface of the 
 glenoid cavity, which will favour Its passing out of the socket; 
 and this disposition to luxate will be increased in proportion as 
 the angle formed by the axis of the bone with the surface of the 
 cavity deviates from a right angle. 
 
OF THE SYMPTOMS OF LUXATION. 20CJ 
 
 A fall, or any other kind of external violence, may cause a 
 luxation almost always incomplete in the ginglymoidal articula- 
 tions; but in the round articulations, the action of the nauscles 
 has constantly a share. Thus, for instance, if a person fall on 
 the elbow whilst the arm is raised from the body and carried 
 directly outwards, the shock which this part receives will cer- 
 tainly tend very much to force the head of the humerus out of 
 its cavity on the lower and internal side; but the action of the 
 pectoralis major, latissimus dorsi, and teres major, contributes 
 very much to it. In faft, the elbow, resting on the ground, 
 becomes the fulcrum, or centre of motion of the humerus; in 
 this state we obey a mechanical instindt, which leads us sud- 
 denly to bring the arm close to the body; and as the resistance 
 made by the ground prevents this, the violent and instantane- 
 ous contraction of the pectoralis major, latissimus dorsi, and 
 teres major, draws downwards and inwards the head of the 
 humerus, the luxation of which is, as we have demonstrated, 
 the efFe(St of two causes. 
 
 In this instance, we have seen how muscular a£tion conduces 
 to luxations in the round articulations; in some cases, this ac- 
 tion alone is sufficient to effedt them. It is in this way that 
 ■violent convulsions produce luxations as well as fractures. 
 
 Whatever may be the manner in which the causes a<ft, lux- 
 ations are always accompanied with more or less laceration of 
 the ligaments surrounding the joint; and in the round articu- 
 lations, as those of the shoulder and hip, the fibrous capsules 
 are always torn. 
 
 SECTION III. 
 
 Of tie Symptoms of Luxaito:i. 
 
 We will not mention pain and inability of moving the limb, 
 as they are equivocal symptoms, and common to luxations, 
 fractures, and simple contusion. They are not, however, to 
 be entirely overlooked; but when we make a diagnosis, we 
 should endeavour to found it on the existence of symptoms 
 manifest to the senses, such as an elongation or shortening of 
 the limb, a change in its shape and direction, and lastly, the 
 absolute impossibility of performing certain motions. We will 
 '07 
 
2IO OF THE SYMPTOMS OF LUXATION. 
 
 say little on the manner of ascertaining the existence of these 
 different symptoms, as we have already spoken of it in giving 
 the general history of fractures. 
 
 A luxation cannot possibly exist without the afFe£led limb 
 being either lengthened, as happens in the inferior extremity, 
 ■when the head of the femur passes out downwards and inwards, 
 and rests in the foramen ovale, or shortened, as takes place 
 when the same bone is luxated upwards and backwards, and 
 has its superior extremity directed towards the external depres- 
 sion in the ilium. In truth, the shortening or elongation is 
 rarely observed but in the oi'bicular articulations; however, the 
 absence of these symptoms in the ginglymoidal is amply com- 
 pensated by the superficial situation of the bones, which ren- 
 ders it easy to ascertain their relative positions. 
 
 The dire£lion of the bone is changed: for the luxated end 
 cannot leave its natural place without having the other carried 
 in a direction contrary to it. Thus, in the luxation of the hu- 
 merus downwards and inwards, the arm is placed obliquely 
 downwards and outwards, instead of falling straight along the 
 side. This symptom, taken from the diredlion of the member, 
 is, like many others, much easier to be distinguished in recent 
 luxations than in those that have continued for a considerable 
 time. From the change of situation and direction of the bone, 
 there must necessarily result a relaxation of some muscles, 
 whilst others are considerably overstretched and strained, as 
 may be seen with respecl to the deltoid muscle in cases of lux- 
 ations of the humerus, which are the most frequent. This 
 unequal and unnatural tension and relaxation of the muscles may 
 C9ntribute also in aiding us to form a diagnosis in cases of lux- 
 ation. 
 
 The change in the shape of the limb is also removed by time. 
 In fadl, one would presume, from the manner in which the 
 shape of the point of the shoulder is restored after a luxation of 
 the humerus by a projection of bone arising from the convex 
 edge of the acramion, that the head of the cs humeri was not 
 forced Into the axilla. In these alterations of the natural shape 
 of the limbs, we are to comprehend the changed relations of 
 the eminences of a joint to one another, the existence of pro- 
 jeftions in places where the limb should present depressions, 
 and depressions where it should present eminences. In the 
 luxation of the arm inwards and downwards, a hard tumour is 
 felt in the axilla, which, on account of its roundness, is easily 
 ascertained to be this part of the bone. 
 
OF THE PROGNOSIS IN LUXATIONS. 211 
 
 Our limbs, even when fradtured, may be made to perform 
 several motions, and be put in various attitudes. In a fracture 
 of the femur, the surgeon, not in truth without causing more 
 or less pain to the patient, may, by taking hold of the leg, 
 move it round in a circular diredtion, and may point the foot 
 inwards and outwards — motions altogether impossible in luxa- 
 tions, before the reduction of the displaced bone. 
 
 By combining all these symptoms, it is impossible to form a 
 wrong diagnosis in cases of luxation. A mistake would be ex- 
 tremely dangerous; for if the luxation be not discovered, the 
 patient attributes his not being able to use his limb to the con- 
 tusion and pain; but if the continuance of the symptoms in- 
 duce him to have recourse to other persons better instruifted or 
 more attentive, they ascertain the nature of the affe6lion, to 
 the no small shame of the surgeon who has mistaken it. In- 
 stances of errors of this kind are more frequent than one would 
 imagine, especially in the country, where the branch of surgery 
 which we treat of in this work is often in the hands of ignorant 
 persons. 
 
 SECTION IV. 
 
 Of the Prognosis in Luxations. 
 
 The luxations which take place in the ginglymoidal articu- 
 lations, differ much from those in round articulations, in what 
 relates to prognosis, as well as in many other points of view: 
 the latter are much less dangerous than the former. As the 
 adlion of muscles has a great share in producing them, the vio- 
 lence done to the external parts is less, and the laceration of 
 the soft parts is not so considerable: even in articulations of the 
 same kind, the extent of the evil is measured by the largeness 
 of the surfaces of the joint, the number and strength of the 
 muscles surrounding it, and the thickness and number of its 
 ligaments. It is for these reasons that luxations of the foot 
 and knee are more dangerous than those of the elbow and 
 wrist: the former require a much greater degree of external 
 violence to produce them, in consequence of which the injury 
 done to the soft parts is much greater. 
 
212 GENERAL TREATMENT OF LUXATIONS. 
 
 A difficulty in reducing the luxated bone renders the luxa- 
 tion more or less troublesome. With respeft to this point, 
 luxations of the round articulations are more unfavourable than 
 those of the ginglymoidal; those of the femur more than those 
 of the humerus, because the efforts to reduce the former are 
 often counteracted by the action of very powerful muscles. 
 
 Luxations arising from a swelling of the cartilages of the 
 joints, from a caries of the bones, or from a relaxation of the 
 ligaments, are always attended by more grievous consequences 
 than those occasioned by external violence. Lastly, a contusion 
 more or less considerable, laceration of vessels, or destruftion 
 of the substance of nerves, render the prognosis more or less 
 unfavourable. The latter circumstance occasions a paralysis of 
 the muscles to which the disorganized nerve furnished branches. 
 We have seen, in a luxation of the humerus downwards and 
 inwards, a paralysis of the deltoid muscle produced by the vio- 
 lent contusion of the circumflex nerve, which is chiefly be- 
 stowed on that muscle. 
 
 SECTION V- 
 
 General Treatment of Luxations. 
 
 To reduce the luxated bone, keep it in its place, and prer, 
 vent or remove the symptoms with which the luxation may 
 be complicated, form the three indications which are to be 
 fulfilled in the treatment of luxations. The reduction is ac- 
 complished, as in cases of frafture, by three means opposite in 
 their aftion, but tending to the same end, viz. extension, coun- 
 ter-extension, and co-aptation. It is useless to repeat the de- 
 -finition of each of these terms, and in what each of these mo- 
 tions consisits. 
 
 The reduction of a luxation is the most difficult and import- 
 ant part of the treatment of it. Contrary to Avhat takes place 
 in fra6tures, which are easily reduced, but difficultly kept so, 
 luxations are hard to reduce; but when the bone is once ad- 
 justed, it is easily kept in its place. It will not then be useless 
 to examine minutely all the particulars of this operation: and 
 first, with respe^ to extension, we will examine in order on 
 wliat part the apparatus for making it should be applied, the 
 
GENERAI, TREATMENT OF LUXATIONS. 21^ 
 
 means employed for this purpose, the degree of force to be 
 used, and the direction in which it is to be made. 
 
 The extending force should be applied, not on the luxated 
 bone, but on that with which it is articulated, and as far as 
 possible from it. The observance of this precept is still more 
 necessary in luxations than in fradtures. 
 
 All the ancient authors advised applying the extending force 
 on the luxated bone; for instance, to apply it above the knee 
 in luxations of the femur, and above the elbow in those of the 
 humerus. Many of the moderns have followed their instruc- 
 tions; and this mode is found recommended by J L. Petit and 
 Duverney, in their Treatises on the Diseases of the Bones. 
 Two members of the Academy of Surgery, Fabre and Dupouy, 
 saw the inconvenience of this practice, and substituted for it a 
 mode of treatment now generally adopted. Their practice, 
 which consists in applying the extending force on the bone that 
 articulates with the luxated one, has two most important ad- 
 vantages: first, the muscles that surround the luxated bone are 
 not compressed, nor stimulated to spasmodic contradlions, which 
 would prevent the reduction, not only by opposing a force su- 
 perior to that employed for the purpose of reduftion, but also 
 by retaining the head of the bone engaged in the interstices of 
 the contradled muscles. Secondly, the extending force is much 
 more considerable than can be obtained by the other mode; for, 
 as Dupouy has observed, by elongating thus the arm of the 
 lever, we acquire a degree of power, which the difficulties 
 presented in a great number of cases often force us to have re- 
 course to. 
 
 It has been apprehended, it is true, that the extending force 
 applied at a distance from the luxated bone, would lose in the 
 articulations of the limb a part of its cfFeft: thus, it has been 
 said, that a part of the extending force applied at the wrist in a 
 luxation of the humerus, is employed in elongating the liga- 
 ments of the elbow joint. But this objection is ill founded: all 
 the muscles which go from the humerus to the fore-arm, by 
 strengthening the articulation of these bones, make it answer 
 as a continued lever, along whicli the force is communicated 
 without any loss. 
 
 Force applied by the hands of intelligent and strong a'ssist- 
 ants, is preferable to any mechanical means in the redu£Vion of 
 luxations: the number of assistants may be increased at will, 
 and the force proportioned to the resistance that is experienced : 
 should there not be room for a sufficient number to grasp the 
 
214 GENERAL TREATMENT OF LUXATIONS. 
 
 limb, they may pull by a napkin folded longimdinally, and 
 tied on the limb. The quantity of force employed, though it 
 is impossible to ascertain it exailly, is better known when we 
 make use of a certain number of assistants, than when we use 
 a pulley, which may a£t with such force without our perceiving 
 it, as to lacerate the muscles, ligaments, and even the skin 
 which covers the articulation, and thus occasion the most dire- 
 ful sufferings. 
 
 It is impossible to assign the precise degree of force to be 
 employed: it is to be varied and proportioned according to the 
 strength of the patient and the number and force of the mus- 
 cles surrounding the articulation. It has been said, that in 
 reducing a luxation there is occasion for more address than 
 force: it would be true to say that the union of both is neces- 
 sary. Often, six assistants accomplish that which three cannot 
 do, and nine or ten perform that which cannot be done by six. 
 But when the redudlion cannot be effedled by the number of 
 assistants which in reason we suppose capable of overcoming 
 the resistance, all further attempts must be suspended. The 
 action of pullies, or any other machine analogous to them, 
 would sooner tear the integuments than produce an elongation 
 of the muscles. 
 
 As to the direftionin which the extending force is to be ap- 
 plied: at first it should be the same as that which the disloca- 
 tion has given to the luxated bone. In order to prove how 
 indispensably necessary this rule is, let us suppose that the 
 head of the humerus, luxated inwards, is forced into the fossa 
 subscapularis, between the subscapiilaris muscle and the scapula: 
 in this case, the elbow is not only moved out from the trunk, 
 but even carried backwards. Now, should we commence the 
 reduction by pulling in the natural direction of the humerus, that 
 is, direffcly outwards, the head of the bone would be pressed, 
 against the fossa subscapularis, it would not slide along easily, 
 the force would be spent in pushing the scapula backwards, an4 
 the irritation would excite the contraction of the muscles in the 
 part where the head of the bone has been carried. 
 
 Extension is then to be made at first in the dire£lion which 
 the luxated bone has taken; but in proportion as the muscles 
 elongate and yield to the force acting on them, the hone is to 
 be gradually brought back to its natural position; in this way 
 the head of the bone is disengaged from the parts in which 
 it has been placed, and is brought hack to the cavity it has 
 
GENERAL TREATMENT OF LUXATIONS. 215 
 
 left, by making it describe the same course it took in escaping 
 from it. 
 
 The best-di reeled extension will be useless, if the bone 
 with which the luxated one has been articulated is not kept 
 motionless by counter-extension, a force equal to the other, 
 but made in a contrary direction. The counter-extending 
 power applied to the luxated bone itself, would be attended, in 
 almost every case, with the double inconvenience of producing 
 a spasmodic contraction of the muscles, and preventing the 
 elongation of them necessary for the reduclion. Let us sup- 
 pose that in a luxation of the thigh, the counter-extending 
 fillet be applied in the fold of the groin of the diseased side, 
 the consequence will be, that the redlus internus and addu61:ores 
 muscles, in a state of tension between the pelvis and thigh, 
 will be curved inwards, and consequently shortened when 
 their elongation is absolutely necessary; besides, the compression 
 they experience will also increase their contracTtion. It must 
 be, then, as in cases of fracture, on the part placed immediately 
 above the luxated bone that we are to apply the counter-extend- 
 ing force: It is made by means of fillets, pulled by a number of 
 assistants, equ?il to that of those who make the extension. As 
 to the direction in which this force is to be made, it should be 
 always perpendicular to the surface of ths luxated joint. In a 
 luxation of the elbow, for instance, the counter-extension should 
 be made in a line parallel to the os humeri; and in a similar 
 aSeelion of the femur, this force applied to the pelyis should 
 be made perpendicularly to the surface of the acetabulum. The 
 same rule is to be observed with respe£l: to the shoulder in lux- 
 ations of the humerus, as will be mentioned in treating of par- 
 ticular luxations. Counter-extension is in some sort a vis iner- 
 ticc; for this reason the most intelligent assistants should be 
 placed to make extension, the degree of which should be 
 diredled by the surgeon. Coaptation is easily performed, when 
 the extension is sufficient: in a luxation of the humerus, when 
 the head of the bone is disengaged, and the assistants bring it 
 hastily to its natural direction, the surgeon seizes the moment, 
 and with one hand presses on the superior and internal part of 
 the arm, whilst, at the same time, with the other he supports 
 the elbow, and thus conducts the head of the bone into the 
 glenoid cavity. If a luxation take place in a ginglymoidal arti- 
 culation, as it is rarely complete, in such cases we use exten- 
 sion and counter-extension only with the view of diminishmp" 
 the fridlion of the surfaces of the joint, necessarily oceasioned 
 
2l6 GENERAL TREATMENT OF LUXATIONS. 
 
 by the opposite motions given them in order to place theni in 
 their natural situation. 
 
 By an exa£l observance of the general rules just laid down, 
 we shall be able, in almost all cases, to reduce luxations. How- 
 ever, when the operation fails, notwithstanding the most judi»- 
 oious attempts to accomplish it, the cause of failure must be 
 looked for. Sometimes it is owing to the insufficiency of the 
 means employed; then we succeed by increasing the number 
 of assistants, or by diminishing the muscular force of the pa- 
 tient, which is done in various ways. 
 
 Change of posture often produces this effeft; we have seen 
 patients, who, while seated on a chair, and supporting them- 
 selves with the feet against the ground, could not have had 
 their luxations reduced by the greatest efforts. By extending 
 them on a long and settled table, their muscles, deprived of a 
 centre of motion, yielded with an unexpefted facility. 
 
 If this means proves insufficient, the patient is to be repeat- 
 edly bled, after short intervals; he is to use the warm bath, 
 and be confined to a very low diet. At the end of twenty- four 
 hours, when he is brought down by this treatment, the luxa- 
 tion, before irreducible in appearance, may now be reduced with 
 facility. The state of intoxication, induced by spirituous li- 
 quors or opium, is favourable; the muscles attached to the 
 luxated bone participate in the general debility, and elongate 
 by the slightest effort. It is thus that Citizen Boyer alone, and 
 at the first attempt, while the assistants were preparing the 
 apparatus, reduced a luxation of the arm of an intoxicated |J&s- 
 tillion. Some authors have even advised to intoxicate the pa- 
 tients, when the luxations could not be reduced by the ordinary 
 means; and cases have been met with, in which even this 
 pra£lice has failed. 
 
 Lastly, one more resource remains, v/hich has sometimes 
 succeeded; it was first employed by Le Cat, in a luxation of the 
 jaw, and consists in fatiguing, by continual action, the muscles 
 which surround the luxated bone. It is well known that the 
 contra6lile faculty of our organs is exhausted by exercising 
 them too long, and that the frequent repetition of their con- 
 tractions necessarily brings about a collapse: the surgeon just 
 cited, availed himself of this fadt. The levatores muscles 
 of the lower jaw were spasmodically contracted, in a case of 
 luxation of that bone, and would not admit of having it brought 
 down : Le Cat introduced a small stick between the teeth, and 
 
GENERAL TREATMENT OF LUXATIONS. 2I7 
 
 making use of it as a lever, combated the a£lion of the muscles, 
 until they fell into a state of atony, and allowed him to accom- 
 plish the reduflion. David has derived similar advantages from 
 the same praftice, in luxations of the thigh and arm. This 
 circumstance enables us to explain why a luxation that has re- 
 sisted the fruitless efforts of an intelligent surgeon, aided by a 
 sufficient number of assistants, afterwards yields to a much less 
 considerable force, used by a less dexterous practitioner. 
 
 With respeft to luxations that have been mistaken, and not 
 reduced for several days after the accident; the swelling of the 
 ligaments, and other soft parts, the contradlion of the hole in 
 the capsule, through which the head of the bone passed, ren- 
 der the redu<5lion of them difficult, if not altogether impossible. 
 The use of warm baths arid pumping is then recommended, 
 with a view of emptying, as it were, and rendering pliable, the 
 parts about the joint: exercise should be combined with these, 
 and the luxated bone should be kept in motion for some time 
 6very day, in order to disengage Its head, relax the soft parts, 
 and enlarge the opening by which it is to pass. 
 
 All these endeavours are very often fruitless, In cases where 
 more than a month has elapsed since the luxation. The term 
 beyond which we cannot hope to reduce luxations of the gln- 
 glymoidal articulations, is ir.uch shorter; after twenty or twen- 
 ty-four days, they are in general irreducible, from ari anchylosis 
 having taken place. 
 
 We know that a luxation Is reduced from the limb having re- 
 covered its natural length, shape, and diredtion, and from the 
 capability of performing certain motions impossible in luxations. 
 The limb should not be moved but with the greatest caution : a 
 relapse of a luxation of the humerus has taken place, and a 
 second operation has been rendered necessary, by incautiously 
 carrying the hand to the forehead by a semi-circular motion. 
 
 The cessation of pain has been considered a sign of the bone 
 having entered its natural situation: by cessation, we are to 
 understand a remarkable diminution, rather than a total disap- 
 pearance of pain. Lastly, the noise made by the head of the 
 bone on entering its cavity, is an unequivocal sign of the luxa- 
 tion being reduced. It is necessary to observe all these symp- 
 toms. In order to be convinced that the reduftlon has taken 
 place; by doing so we shall be seldom mistaken, though in- 
 stances to the contrary have been sometimes met with. 
 
 We very rarely fail to reduce a recent luxation, and perhaps 
 there are none absolutely irreducible: thus we ought not to be 
 28 
 
2l8 GENERAL TREATMENT OF LUXATIONS. 
 
 discouraged, and desist, when we cannot easily obtain the re- 
 du£lion, but multiply our means, and endeavour to surmount 
 the obstacles. 
 
 To preserve the luxated bone in its place, we have only to 
 keep the limb without motion. Thus, as the humerus cannot 
 be luxated but when it is at some distance from the body, a 
 return of its dislocation will be prevented by tying the elbow to 
 the lateral parts of the trunk. The bandage employed for 
 keeping the limb motionless, should be applied on the oppo^ 
 site extremity of the bone. Thus, after a luxation of the arm, 
 when we apply on the elbow the means for keeping the bone 
 in its place, we aft on that point of the humerus the most dis- 
 tant from its articulation with the scapula, and the force thus 
 applied to the extremity of the lever is much increased. The 
 same rule should be observed in the application of a bandage 
 to the chin, after a luxation of the jaw. This pradlice is pre- 
 ferable to the use of the chevestre\ consequently all authors re- 
 commend it in this particular case; but they have overlooked, 
 in other cases, the principle established above, and from which 
 they derived such happy efFefts in the treatment of luxations 
 of the jaw. Thus, the spica bandage for the scapula, and that 
 for the groin, are very defeftive in cases of luxation of the arm 
 and thigh; for, by afting on the centre of motion of these 
 bones, they are incapable of keeping them fixed. 
 
 When the luxation arises from any internal cause, such as 
 paralysi- of the muscles, relaxation of the ligaments, or general 
 debility, we endeavour to remove the cause by appropriate re- 
 medies, and, at the same time, restore the luxated bone to its 
 proper place, and keep it fixed. 
 
 Amongst the accidents with which luxations are complicated, 
 contusion is certainly the most frequent. They may also be 
 accompanied with inflammation, wounds, rupture of vessels, 
 contusion of nerves, and even frafture. In treating in general 
 of the latter, we have said, that in such case luxation always 
 preceded the fra£lure; and that it was impossible to conceive, 
 that a bone, in which a solution of continuity took place, could 
 be luxated. The treatment to be adopted in this troublesome 
 complication has been also pointed out. The other symptoms 
 supervening to luxations, are treated as if they were compli- 
 cated with fraftures; we have nothing then to add to what has 
 been said on that subjeft. It is proper, however, to observe, 
 that paralysis, arising from a contusion of the nerves, is a fre- 
 quent consequence of luxations of the arm; and when we con- 
 
■4- 
 
 GENERAL TREATMENT eF LUXATIONS. 219 
 
 sider the relation between the head of the humerus, and the 
 brachial plexus, we are astonished that it does not happen of- 
 tener than it really does. 
 
 When a luxated bone is not reduced, sometimes it remains 
 in the place into which it has been forced 5 but much of- 
 tener it changes its situation: it is carried along by the a£lion 
 of the muscles, and is removed farther and farther from the 
 cavity of the joint. It is in this way that in luxations of the 
 thigh upwards and outwards, the glutei muscles, by making 
 the convex surface of the head of the femur slide along the ex- 
 ternal depression of the ilium, which it touches only by a small 
 point, force up the bone, until the shortening of the limb is 
 as considerable as the natural extensibility of the parts will 
 admit. 
 
 But whether the head of the luxated bone preserve its first 
 position, or take another, the pressure it makes on the bone 
 on which it rests produces two efFefts: the head of the one is 
 flattened, while a depression is made in the other. The ca- 
 vity of the joint sometimes preserves its natural state, and some- 
 times its depth diminishes; the latter takes place when the 
 head of the bone remains near its cavity, and compresses the 
 circumference of it. The ligaments grow thick, their lacera-r 
 tions consolidate, and they acquire a greater consistence than 
 natural. The muscles, impeded in their action, lose their 
 consistence, become of the nature of ligaments, and sometimes 
 even are attached to the ligaments by a deposition of osseous 
 matter, and thus form a kind of bony case, which constitutes 
 with the displaced bone a new articulation. 
 
 If the bone is not reduced, the limb remains deformed, and 
 scarcely any use can be made of it for some months; but in time 
 it gradually comes to its natural direction; and when the head 
 of the bone has acquired a certain mobility in its new articula- 
 tion, it is capable of considerable latitude of motion. Never- 
 theless, the muscles, from being compressed and obstrudled in 
 their adtion, decay, and the size of the limb diminishes: this 
 diminution is much more remarkable in children than in adults. 
 
 This difference is so great, that it may be distinguished at 
 first sight whether the accident happened during infancy or 
 maturity. 
 
M 
 
 220 
 
 CHAPTER V. 
 
 OF LUXATIONS OF THE LOWER JAW. 
 
 THIS bone can only be luxated anteriorly, whether one or 
 both condyles escape from the glenoid cavities of the 
 ossa temf)orum, with which it is articulate-d. Luxations of it 
 are denominated complete or incomplete; but these denomina- 
 tions are erroneous, as they would lead us to believe, that the 
 bone may be luxated without its condyles being'removed en- 
 tirely from the glenoid cavities of the temporal bones. Every 
 luxation, but that anteriorly, is rendered impossible by the 
 natural conformation of the parts. In reality, before a luxa- 
 tion backwards could take place, the maxilla inferior must be 
 elevated above the point of contact of the arch formed by the 
 teeth, and meet no opposition to its dislocation in this direc- 
 tion from the osseous portion of the auditory canal; and further, 
 it must be efFefted without the aid of any muscle. Luxations 
 laterally, to the right or left, are equally impossible, on account 
 of the resistance made by the spinous processes of the sphenoid 
 bone, and the internal ligaments of the articulation. These 
 ligaments, like all the others of the same part, would in truth 
 afford a feeble resistance; for the muscles are here very evi- 
 dently the principal means of strengthening the articulation: 
 but, independently of these considerations, it is evident, from 
 the form of the bone, that a blow given to it ojn its sides, tends 
 rather, by increasing its curvature, to fradture it, than to lux- 
 ate it. 
 
 In very young infants, any luxation of the jaw is impossible : 
 in thern the body and branches of the bone meet at an obtuse 
 angle. Now, from this conformation, it follows, that the con- 
 dyles, the necks of which have nearly the same dire(5tion as 
 the body of the bone, cannot, by any motion of the jaw, be 
 moved out of th^ir cavities; and, in order to produce a luxa- 
 tion, the jaw should be pulled down, and the mouth opened 
 to a degree which it could not admit of. Were it not for this 
 
OF LUXATIONS OF THE LOWER JAW. Ill 
 
 truly admirable disposition, how frequent would not luxations 
 be at this period of life, either from the cries of the child, or 
 from attempts to put too large bodies into its mouth! 
 
 The causes of luxations of the lower jaw are very often in- 
 ternal: rarely has it been seen, that a blow given from above 
 downwards, or from before backwards, or a fall on the chin, 
 has produced luxation of it; it almost always arises from ex- 
 cessive yawning. In every great depression of the jaw, the 
 condyles slide from behind forwards, under the transverse root 
 of the zygomatic processes. The cartilaginous cap which en- 
 velops the condyles, and follows them in all their motions, fur- 
 nishes to them still an articular cavity: but the depression of 
 the bone continuing, the ligaments give way, the condyles pass 
 before the transverse apophyses, and thus fall into the zygo- 
 matic depressions. In this motion, the angles of the jaw are 
 raised and carried backwards, whilst the condyles are depressed 
 and carried forwards*, and the bone, as is well known, by turn- 
 ing on an axis which may be supposed to pass through its 
 branches nearly about the middle of their height, performs an 
 imperfedl revolution. 
 
 The mode in which luxations of the jaw take place has been 
 differently explained. Some have imagined, that the bone 
 being forcibly carried down by the submaxillary muscles, and 
 carried forwards bv the pterygoidei externi, its coronoid apo- 
 physes perched on the eminences of the cheek-bone and be- 
 came a fixed point for the adlion of the levatores muscles, 
 which dragged the condyles into the zygomatic depressions. 
 But to prove how ill-founded this theory is, it is sufficient to 
 observe, that in no case is the coronoid apophysis carried on 
 the eminence of the cheek bone, and that even when the lux- 
 ation has taken place, an interval can be still felt between these 
 two bony parts. 
 
 When the mouth is shut, the axis of the maxilla inferior forms 
 with a Une drawn in the dire£lion of the middle of the masseter 
 muscle, an obtuse angle anteriorly, and a salient angle poste- 
 riorly, consequently when this muscle contrafts, in order to 
 move the lower jaw, its aftion is decomposed, one part tends to 
 elevate it perpendicularly, and the other to carry it forwards. 
 In proportion as the jaw is depressed, and its angles, to the ex- 
 ternal sides of which the masseters are attached, are carried 
 upwards and backwards, the medium line of the dire(flion of 
 the bone tends to become parallel with that of the masseters; 
 and if these m.usclcs contrail when the bone is in this position. 
 
222 OF LUXATIONS OF THE LOWER JAW. 
 
 the greater part of their force is employed to bring the condyle* | 
 into the zygomatic depressions. 
 
 This explanation, very little different from that given by '^ 
 Citizen Pinel,* in a Memoir in which he applies geometry to 
 explain the theory of luxations, appears to us much better than 
 the preceding, which is found in a Treatise on Diseases of th« 
 Bones, and Surgical Operations, by Chopart and Desault. But, 
 whatever may be the manner in which tne levatores of the jaw 
 produce a luxation of this bone in its depressed state, the parts 
 which surround the articulation are affedled in the following 
 manner: The condyles carried before the transverse root of the 
 zygomatic processes into the zygomatic depressions, compress 
 in a greater or less degree the deep-seated temporal nerves and 
 those going to the masseters, which nerves, in their way to 
 their destination, pass before the neck of these processes. This a 
 compression of the nerves by the condyles, explains the pain 
 accompanying luxation of the jaw much more satisfadlorily, than 
 does the elongation of the masseters and other muscles to which 
 they have been attributed. The tension of the masseter, tem- 
 poral and internal pterygoid muscles, is not so considerable as to 
 produce them. The pterygoideus externus is relaxed j the fee- 
 ble ligaments which surround the articulation are in a state of 
 tension, the interarticular cartilages accompany the condyles, 
 and furnish them, even in the zygomatic depressions with a 
 kind of cavity. The mouth is more or less open. It is more 
 so in recent luxations, than in those that have continued for 
 some time. An empty space is felt before the ear, where the 
 condyles were placed. The coronoid process forms under the 
 cheek-bone an eminence which is felt through the cheek, or by 
 introducing the finger into the mouth. The cheeks and tem- 
 ples are flattened by the lengthening of the temporal, masseter, 
 and buccinator muscles; the saliva flows in large quantities 
 from the mouth, irritated by constant exposure to the air, 
 which increases its secretions. The compression made on the 
 salivary glands, and the irritation and friftion they experience, 
 contribute to render the secretion of the saliva still more abun- 
 dant. The arch formed by the teeth of the lower jaw is placed 
 anterior to that formed by those of the upper, and the direftion 
 
 * The Physical Journal'of the Abbe Rozier cortains many Memoirs of 
 Ci'izen Pincl's en the same suhje6t ; we should have most willingly trans- 
 ferred the results of them to this work, did it not require a greater share 
 of the knowledge (f geometry to understand them, tlvan is jpossessed by 
 the generality of readers. 
 
OF LUXATIONS OF tHE LOWER JAW. 223 
 
 of their edges shews that this disposition is unnatural. Lastly, 
 the patient can neither speak nor swallow during the first days 
 of the luxation. 
 
 The symptoms just pointed out, and which are sufficient to 
 enable us to establish a clear diagnosis when the luxation is 
 recent, are far from being so well marked when the disease has 
 continued several days or weeks. In these cases the jaw is ele- 
 vated insensibly, and approaches the maxilla superior; the pa- 
 tient recovers by degrees the faculty of speech and deglutition, 
 but he still stammers, and the saliva drivels from his mouth. 
 A luxation of the jaw is far then from presenting circum- 
 stances from which we are to form so unfavourable a prog- 
 nosis as that made by Hippocrates, who says that it is fatal, 
 unless reduced before the tenth day. Perhaps trismus, or lock- 
 jaw, "which is much more dangerous than luxation, has been 
 confounded with it. The extreme facility with which these 
 luxations take place in some persons, does not render the prog- 
 nosis more unfavourable; in such the redu£lion is easily effedted, 
 and often there is no necessity for having recourse to profes- 
 sional men to accomplish it. Lastly, the operation of reduct- 
 ion is in all cases simple, and certainly successful when it is 
 done after the following manner: 
 
 The patient is to be seated on a low stool, with his head 
 supported against the breast of an assistant, who, by placing 
 his hands across the forehead, is to fix the head. In this po- 
 sition of the patient, the surgeon's hands are on a level with 
 the mouth; which is advantageous, because he is not obliged 
 to elevate them, and consequently can act with greater force 
 on the jaw. The surgeon, after securing his thumbs with 
 linen, to prevent being pained by the compression he makes on 
 the teeth, introduces them into the mouth, and places them as 
 far back as possible on the great molares, at the same time 
 bending under the chin the four fingers of each hand. If there 
 is not room for all the fingers he uses, at least, the index and 
 middle finger. Having thus seized the jaw, he presses with 
 his thumbs on the grieat molares, brings the jaw downwards 
 &nd backwards, and disengages the condyles from the zygo- 
 matic foss* into which they were carried. When the muscles 
 obey this effort, and it is found that the condyles yield to it 
 and descend, the chin is to be elevated by the fingers; thus 
 converting the bone into a lever of the first kind. In elevating 
 the jaw, it is to be pushed backwards. 
 
 When the extension has been effei^ual, that is to say, when 
 the muscles are elongated by the effort to depress the bone, 
 
224 Of LUXATIONS 0# THE LOWER JAW. 
 
 they contract spasmodically the moment that the condyles are 
 disengaged from the zygomatic fossx, and bring these processes 
 into the glenoid cavities so rapidly and forcibly, that there 
 would be danger of having the thumbs much bruised by the sud- 
 den approximation of the teeth, if the precaution were not 
 used of quickly dire£ling them outwards, and placing them be- 
 tween the cheek and the jaws. 
 
 When the luxation is reduced, which is known by its cha- 
 ra£leristic symptoms disappearing, and especially by the jaws 
 coming together in their natural manner, a relapse is prevented 
 in this way: the chin-bandage is to be applied, to prevent the 
 motion of the bone, which it does in a most effectual manner, 
 as it resists the muscular adlion that tends to produce it at the 
 point the fa:rthest removed from the centre of motion. This 
 bandage is not to be removed but when the patient takes food. 
 During the first days, the aliments should be liquid, or such as 
 require no mastication. When solid food can be used, the pa- 
 tient should be careful to support the chin with his hand each 
 time that he v.-ishes to depress it. 
 
 We have m.entioned in the preceding chapter the manner in 
 which Le Cat succeeded in reducing a luxation of the jaw, viz. 
 by fatiguing the muscles. This means would be proper in a 
 similar case, and should be had recourse to. 
 
 Let us mention here, in order to censure it, the praflice of 
 reducing luxations of the jaw, by giving a blow of the fist to 
 the Under part of the chin. Some, however, say, that this 
 defeclive mode has sometimes succeeded; but it is easily per- 
 ceived that the blow given from below upwards, tends to force 
 the condyles deeper and deeper into the zygomatic fossae, and 
 that, given from before backwards, it may fradlure thes6 pro- 
 cesses. 
 
 The ancients placed two pieces of stick between the great 
 molares, and a£ling with them as levers to depress the lower 
 jaw, they elevated the chin by means of a bandage, the ends of 
 which met on the top of the head. This process, described 
 with much perspicuity by Devigo, is extremely methodical; it 
 is not, however, preferable to that of the moderns, which, 
 more simple than it, has still the advantage of not exposing the 
 teeth to be broken by the sticks, at the moment when the con- 
 dyles re-enter their cavities. 
 
 In luxations which have been called incomplete, that is to 
 sav, when only one condyle has escaped from its cavity, the 
 treatment requires so little modification, that I do not think It 
 necessary to enter Into further details on this subje(5l. 
 
?25 
 
 CHAPTER VI. 
 
 OF LUXATIONS OF THE VERTEBRA. 
 
 THE large surfaces by which these bones correspond, th© 
 number and thickness of their ligaments, the strength 
 of the muscles lying on the column formed by them, the small 
 motion of which each vertebra is capable, and lastly, the ver- 
 tical direction of their articulating apophyses, render a luxation 
 of them in the dorsal and lumbar part of the column, entirely 
 impossible. A violence, though ever so considerable, cannot 
 displace them without first fracturing them. The same is not 
 the case with the cervical vertebrae; the extent of their articu- 
 lating surfaces is less, the ligamento-cartilaginous substance 
 which unites their bodies has more pliability, the motion of their 
 articulations is greater, and their articulating surfaces have an 
 oblique direction, which allows them to have an obscure rota- 
 tory motion; consequently luxations of them are sometimes 
 met with. I have seen a case in which the neck was luxated 
 by a violent rotatory motion of the cervical vertebrae, and the 
 luxation resisted all means that were employed to reduce it. 
 The cause of impediment was felt towards the middle of the 
 column formed by the cervical vertebrae; from which circum- 
 stance we may conclude that the dislocation did not consist of 
 a separation of the first vertebrae from the second, which is 
 admitted to be possible by all authors, but that it took place 
 lower down in the cervical part of the column. 
 
 It appears from well-attested fa£ls, that luxations may take 
 place in the vertebral column; such as those of the head from 
 the first vertebra, and of the first vertebra from the second. 
 These, and especially the latter, are the most frequent; but 
 others, though much rarer and more diflicult, may however 
 take place. 
 
 29 
 
226 OF LUXATIONS OF THE FIRST 
 
 SECTION I. 
 
 Of Luxations of the Head from the first Vertebra. 
 
 The articulation of the occipital bone with the first vertebra 
 of the neck is strengthened by means of many ligaments, and 
 admits of only very limited motions. It is well known, that 
 the motions of inclination of the head to the right and left, and 
 of flexion and extension, take place along the whole length of 
 the cervical vertebrae. We have no instance of luxation of the 
 head from the first vertebra by an external cause; such a dislo- 
 cation, if possible, would instantly destroy the individual to 
 whom it happened, by the compression and disorganization of 
 the spinal marrow. But nature, which cannot bear so sudden 
 a change, is habituated to it when it takes place gradually and 
 insensibly; and the spinal marrow, which a sudden though in- 
 considerable derangement of the spine would totally disorganize, 
 is not sensibly injured when it takes place by degrees; cases of 
 rachitis furnish us many proofs, of this. It is only in this way 
 that we can explain how the individual from whom the prepa- 
 ration in the Museum of Natural History was taken, could ex- 
 ist until such very great deformity took place in his spine. 
 
 SECTION II. 
 
 Of Luxations of the first cervical Vertebra from the second. 
 
 It is principally in the triple articulation of these two verte-p 
 brae, that the motion of rotation of the head to the right or left 
 takes place; for the union of the first vertebra to the occipital 
 bone is so close, that the motion of both is the same. This 
 rotation of the first vertebra on the second, which the laxity 
 and weakness of the ligaments that go from one to the other, 
 and the direftion of their articulating apophyses, render easy, 
 would be frequently carried beyond its natural bounds; and 
 luxation would take place every time we turn our head with 
 force, if the motion were not confined by two very thick liga- 
 
CERVICAL VERTEBRA FROM THE SECOND. 227 
 
 ments, which go from the sides and summit of the toothlike 
 process of the second vertebra to the edges of the great occipital 
 hole. When this motion is forced beyond its proper limits, 
 the ligaments are torn, and the lateral parts of the body of the 
 first vertebra glide along on the articulating horizontal pro- 
 cesses of the second If the head is turned from the left to the 
 right, the left side of the body of the vertebra is carried before 
 its corresponding articulating surface, whilst the right side falls 
 behind its corresponding surface. In this luxation, sometimes 
 the toothlike process, the ligaments of which are broken, leaves 
 the ring formed for it by the transverse ligament and the an- 
 terior arch of the first vertebra, and presses on the spinal mar- 
 row, the substance of which it destroys; at other times it re- 
 mains on its ring, but the diameter of the vertebral canal is 
 always diminished at this place, and the spinal marrow expe- 
 riences a compression, and at the same time a contortion, by 
 which it is lacerated It is easily conceived that the patient 
 cannot survive a derangement of this nature; every lesion of 
 the spinal marrow at this height is quickly fatal. Louis, in 
 making researches on the manner of dying of hanged persons, 
 found that those despatched by the executioner of Lyons, pe- 
 rished by the luxation of the first vertebra from the second j 
 whilst those hanged at Paris were suffocated by strangulation. 
 He discovered the cause of this difference in a rotatory motion 
 given to the body of the culprit by the executioner of Lyons, at 
 the moment that the ladder was taken from under his feet. 
 We ought to attend to this observation, when we examine in 
 a judicial capacity the body of a person found hanged. We 
 should carefully examine the second vertebra, and see if it be 
 luxated. If so, the individual has not been guilty of suicide, 
 for the luxation must have resulted from a violent motion com- 
 municated to the body by the assassins. 
 
 The following case given by J. L. Petit, furnishes an instance 
 of luxation produced by the motion occasioned by the person 
 himself; the circumstances of it are so extraordinary, that we 
 shall relate them at full length. 
 
 " The only son of a tradesman, aged between six and seven 
 «< years, went into a neighbouring shop, the proprietor of which 
 « was a friend of his father's. This person playing with the 
 « child, put one hand under his chin and the other on the back 
 " of his head, and then raised him up in the air, telling him 
 <' that he was gomg to shew him his grandfather, a common 
 « expression among the vulgar. ^ Scarcely was the child raised 
 
228 OF LUXATIONS OF THE FIRST 
 
 « from the ground, when he began to struggle, and by his 
 «* efforts dislocated his neck, and died on the spojt. The father, 
 " on hearing of the death of his child, ran in a fit of passion 
 " after his neighbour, who fled before him, but not being able 
 « to catch him, he threw at him a sadler's hammer which he 
 « had in his hand, and buried the cutting part of it in the de- 
 " pression of his neck. The weapon cut all the muscles, pe- 
 " netrated into the space between the first and second cervical 
 <t vertebra, divided the spinal marrow, and occasioned almost 
 ** instantaneous death. Thus both perished nearly in a similar 
 *' manner." J. L. Petit, who quotes no authority to support 
 this fact, avails himself of the opportunity of censuring this 
 dangerous sort of play, and observes with justice, that the mo- 
 tion which the child gave himself was the cause of his death. 
 
 The relaxation of the ligaments of the toothlike process may 
 favour this luxation. Such probably was the case of a young 
 man, who found a difiiculty to bring his head back to its natural 
 posture, each time that he turned it to the right or left. There 
 are many cases of luxation of the neck, in which death does 
 not succeed the accident; but in these, the dislocation takes 
 place in the third, fourth, fifth, or sixth vertebrae, and only 
 one articulating process is luxated: in these cases, the diameter 
 of the vertebral canal is not so much diminished as to compress 
 the spinal marrow, and destroy life; but a wry-neck remains, 
 which becomes incurable, unless the real cause of it be found 
 out. 
 
 A child, whilst playing on his mother's bed, suddenly felt 
 pain in his neck, accompanied with a distortion, which he could 
 not remove. Desault, to whom the child was brought, disco- 
 vered a luxation of the vertebrx of the neck; but before trying 
 to reduce it, he informed the mother that the child might die 
 in the attempt. This information terrified the mother so much, 
 that she took away her child without having any thing done to 
 relieve it. 
 
 A lawyer writing at his desk, heard the door behind him 
 open; he quickly turned round his head to see who was co- 
 ming in, but could not bring it back again to its natural direft- 
 ion. Many surgeons of Paris have seen this patient: his head 
 was turned to the right, and slightly inclined to the shoulder 
 of the same side This inclination was much less than it would 
 have been in a spasmodic contradlion of the sterno-cleido-mas- 
 toideus muscle. 
 
-Cervical vertebra from the second. 229 
 
 Thus, when, in consequence of a sudden and violent effort, 
 the head is found turned to one side, either right or left, with 
 inability to bring it back, the ear a little inclined to one side, 
 and the sterno-cleido-mastoideus in a state of relaxation, there 
 can be no doubt but that a luxation of one of the cervical ver- 
 tebrae has taken place. 
 
 If the luxation produce no symptom which indicates a com- 
 pression of the spinal marrow, it is prudent to abstain from all 
 attempts to reduce it. However, if the patient absolutely insist 
 on our interfering, we are to proceed in this way: we begin by 
 inclining the head to the side towards which it is dire£led, in 
 order to disengage the articulating process of the upper verte- 
 brje: this part of the operation is extremely dangerous, as it 
 may kill the patient by causing a compression on the spinal mar- 
 row. When the process is disengaged, the head and neck are 
 brought to their right direction, by making them perform a ro- 
 tatory motion the contrary of that which had taken place in the 
 luxation. A relapse is prevented by keeping the head free from 
 motion. This is done by means of bandages, which are at- 
 tached to the head and shoulders. 
 
23C 
 
 CHAPTER VII. 
 
 OF LUXATIONS OF THE BONES OF THE PELyiS. 
 
 NONE of the assemblage of bones which form the pelvis, 
 are susceptible of a true luxation. It is impossible that 
 the OS sacrum, inclosed between the two ossa innominata, can 
 abandon the position in which it is confined by such powerful 
 means. The os coccygis, which has more motion, is easier 
 fractured than luxated. Citizen Boyer has however observed a 
 derangement of it, in a man greatly emaciated in consequence 
 of long disease: he had considerable ulcerations in the neigh- 
 bourhood of the coccyx, and the bone itself was laid bare by 
 the separation of a large gangrenous eschar. There was an 
 interval of nearly two inches between the summit of the sacrum 
 and the base of the os coccygis. But in proportion as he re- 
 covered strength, the bone was drawn backwards, and was at 
 last united to the sacrum, notwithstanding the aflion of the 
 levatores ani which are attached to it. The ossa innominata 
 are too firmly articulated with one another, and with the sa- 
 crum, to admit of luxation; however, the symphysis pubis and 
 sacro-iliac synchondrosis, which in the natural state admit of 
 no motion, may be so relaxed, or the ligamento-cartilaginous 
 substance which unites them may be so far destroyed, and the 
 bones thereby rendered so moveable, that progression, which 
 requires the firm union of these bones, becomes difiicult. Is 
 this relaxation of the articulations, and the consequent seceding 
 of the bones, a means employed by nature to increase the dia- 
 meters of the pelvis, and facilitate parturition ? Louis has shewn, 
 in a dissertation, which is found in the first part of the fourth 
 volume of the Memoirs of the Academy of Surgery, how many 
 different opinions authors have on this subjeft. Some, in re- 
 ality, suppose that the relaxation of the articulations is the na- 
 tural state towards the end of pregnancy; others consider it as 
 being always morbid. Were we permitted to give an opinion 
 
OF LUXATIONS OF THE PELVIS. 23 1 
 
 on this subjeft, which comes chiefly under the cognizance of 
 accoucheurs, we would say, that the symphysis pubis and the 
 sacro-iHac synchondrosis abound with juices, and are swelled 
 and relaxed in a remarkable manner, in most women during 
 pregnancy, that this relaxation seldom goes so far as to allow 
 the bones to move and be separated; and lastly, that the mo- 
 tion or separation of the bones is to be considered rather as a 
 morbid than natural state. 
 
 A lady was suddenly delivered of a child, without almost any 
 pain: but the ovum came away entire, and with such rapidity, 
 that the women in the chamber could scarcely reach her in 
 time to receive it. No bad symptom supervened until the 
 fourth day: at this time a fever appeared, and the patient died 
 on the seventh day. Citizen Boyer, on opening the body, per- 
 ceived that the ossa pubis were moveable, and remarked this 
 circumstance to Citizen Baudelocque. Curious to discover the 
 cause of it, they divided the symphysis pubis, and found a great 
 vacuum in the centre of it, round which the relaxed ligamento- 
 cartilaginous substance formed a raised margin, which was made 
 to puff up by the approximation of the ossa pubis. In every 
 other particular the pelvis was well formed, and the woman 
 had had many easy deliveries. 
 
 When a woman, towards the end of pregnancy, after partu- 
 rition, or during any other time, feels pain in the articulations 
 of the pelvis, and the mobility of the bones renders progression 
 difficult and tottering, she should be confined to her bed, the 
 pelvis should be surrounded with bandages drawn very tight, 
 and the region of the pubis should be covered with astringent 
 applications J but as these latter aft only on the external surface, 
 we are to expedt much less from them than from corroborants 
 administered internally, and the use of bandages. 
 
 The treatment suited to a relaxation of the symphysis pubis 
 is also adapted to that of the sacro-iliac synchondrosis. We do 
 not beheve that a sudden and violent separation of the thighs 
 can produce a disjointing of the latter, though a case of this 
 kind is given in the Anatomico-surgical Observations of Blasius. 
 It is probable that the motion of the bones in this case took 
 place from the laxity of the ligaments; and thiff seems to be 
 proved by the history of the patient, who was a young student 
 in law, and, as Blasius expresses it, of an effeminate constitu- 
 tion and a relaxed and delicate habit. 
 
 But that which a sudden and violent separation of the thighs 
 cannot produce may be occasioned by external violence. Louis's 
 Dissertation, cited above, is terminated by the following case: 
 
232 OF LUXATIONS OF THE 
 
 A sack of wheat, of three hundred and fifty pounds weight,^ 
 fell on the back of a labourer who was unloading a waggon. 
 The posterior part of the pelvis, on which the weight fell, was 
 very much shaken; however, the pain was so inconsiderable, 
 that it was only after some days that the patient sought relief. 
 The bad symptoms now increased rapidly, and he died on the 
 twentieth day. On opening the body, the os ilium of the right 
 side was found separated from the sacrum, passing nearly three 
 inches behind it; the parts contained in the pelvis were in- 
 flamed, there was an effusion of purulent matter into the lower 
 region of the abdomen, and the luxated bones moved freely on 
 one another. 
 
 The possibility of a luxation of the sacro-iliae synchondrosis 
 by external violence is then proved beyond all doubt ^ but it 
 must be very rare; and in the particular case just related, no- 
 thing less than a very great weight favoured by the position of 
 the pelvis could have caused it. An antiphlogistic treatment is 
 particularly adapted to such cases; for the danger depends on 
 the inflammation which must necessarily follow such considera- 
 ble external violence, and which, if it extend to the organs 
 contained in the cavity of the pelvis, may produce the worst 
 Gonsequences. The accession of inflammation should, if pos- 
 sible, be prevented; if not, it becomes quickly fatal, unless it 
 is arrested in its progress by copious and repeated bleedings, the 
 use of warm baths, emollient fomentations, and the most rigid 
 abstinence. 
 
 As to the supposed luxations of the ribs admitted by some 
 authors, we should have observed, respedling them, the same 
 silence as J. L. Petit, did not a case inserted in the Memoirs of 
 the Academy of Surgery, after the death of that celebrated prac- 
 titioner, seem to establish the possibility of their taking place. It 
 is not, however, difficult to perceive, in reading this case, that the 
 surgeon who has given it has committed a strange mistake, by 
 taking a simple fradture of the posterior extremity of these bones 
 for a luxation of them. If we attend to the nymber and force of 
 the ligaments which attach the ribs to the vertebrae and ster- 
 num, and also to the manner in which the intercostal and other 
 muscles confine them, we shall not easily conceive how external 
 violence, whether it acts on their middle or extremities, can 
 luxate them. They are so firmly attached to the surrounding 
 parts, that it is very difficult to separate them from the body 
 in the dead subjeft; and in preparing skeletons, we often break 
 them if we are not careful to cut all their bonds of union be- 
 
Cones of the pelvis. 233 
 
 fore we attempt to detach them from the parts with which they 
 are articulated. All the symptoms presented by the case of the 
 patient of Buttet, surgeon of Etampes, indicate a fracture of 
 the neck or posterior extremity of the rib; the pain, crepita- 
 tion, and motion of the bone, are characteristic marks of it. 
 The author proves nothing by saying, that the noise arising 
 from the motion of the rib was very distinft, and heard by him- 
 self and his assistants, whilst that which charadterizes fraftures 
 is only sensible to the hands, and that the rib could be moved 
 in its whole length. First, it cannot be conceived how the 
 noise which accompanies the motion of fra<Slured bones can be 
 sensible to the organ of touch. Next, the fra(Slure having taken 
 place very near the posterior extremity of the rib, rendered it 
 impossible to draw any conclusion from its motion, as in this 
 case it would have the appearance of moving entirely along its 
 length; besides, it is very difficult to feel this motion through 
 the muscles of the spine. Thus we regard luxations of the 
 ribs as totally impossible, though Ambrose Pare, and after him 
 Barbette, Junker, Platner, and Heister, admit them, and give 
 different species of them. 
 
 We must not, with Lieutaud, give this name to afFe6tIons 
 in which the body of the dorsal vertebrae and the head of the 
 rib are separated from one another by a caries of these parts. 
 
 It might happen, that by a violent and sudden contraction 
 of the pedtoralis major, the cartilage of the sixth true rib, to 
 the whole extent of which this muscle is attached, might be 
 separated from that of the seventh; and that the very thin cap- 
 sule which keeps them together might be torn. The pain 
 alone would point out this affection. With respedt to the 
 depression of the other cartilages, and of the appendix xypho- 
 ides, we refer to what we have said on that subje£t in treating 
 of fractures of these parts* 
 
 50 
 
^34 
 
 CHAPTER VIII. 
 
 OF LUXATIONS OF THE CLAVICLE. 
 
 LUXATIONS are in general much less frequently met 
 with than fractures. How numerous are fractures of the 
 body and neck of the femur compared to luxations of this bone ! 
 A surgeon, who has seen hundreds of the former, generally 
 meets in the course of a long and extensive praftice only a very 
 few cases of primary luxations ©f the thigh. These general 
 considerations apply, in a certain degree, to the bone, the lux- 
 ations of which form the subject of this chapter. We find, in 
 fact, that fractures of the clavicle are much more frequent than 
 luxations of it, and it has been supposed that they bear a pro- 
 portion to one another of 6 to 1 . These luxations are distin- 
 guished into that of the extremity next the sternum, and that 
 of the extremity next the humerus. 
 
 SECTION I. 
 
 Of Ltmations of the Extremity next the Sternum. 
 
 This extremity presents a large surface, which is articulated 
 with another much smaller in the lateral and superior part of 
 the sternum. This disproportion in the 'articulating surfaces 
 disposes to dislocations, which are also favoured by the weak- 
 ness of the ligaments, and the motions and funftions of the 
 Joint. It is, in faft, in this articulation, furnished internally 
 with an inter-articular cartilaginous lamina, that all the efforts 
 made by the superior extremity terminate. 
 
 The clavicle may be luxated at this extremity forwards, back- 
 wards, and upwards, but never downwards: the cartilage of 
 the first rib borders its extremity on this side, and renders a 
 
OF LUXATIONS OF THE CLAVICLE. 235 
 
 luxation of it in this direction impossible. Of the three possi- 
 ble kinds of luxation, that anteriorly is the most frequent, and 
 indeed almost the only one met with. To eff&6\ it, it is only 
 necessary that the clavicle, naturally directed backwards, be 
 carried still more in that dire6Vion: this motion of the shoul- 
 der backwards is the easiest and most extensive of any of which 
 this part is capable. Accordingly, nature has diminished, as. 
 much as in her power, the tendency to dislocation which results 
 from it, by giving great force to the anterior ligament, which 
 is still strengthened by the portion of the sterno-cleido-mastoi- 
 deus attached to the sternum. Luxations backwards and up- 
 wards are very rare: to effeCt the former, the shoulder must have 
 been pushed forwards violently and to a considerable distance, 
 and at the same time suddenly depressed by a great force: a 
 combination of these circumstances sometimes takes place in 
 falls. Lastly, of the two luxations upwards and backwards, 
 the latter is that most rarely met with. 
 
 If the shoulder be pushed violently backwards, the extremity 
 of the clavicle next the sternum is carried forwards, lacerates 
 the capsule of the articulation, the anterior ligament, and the 
 tendon of the sterno-cleido-mastoideus muscle, abandons the 
 surface it was articulated with, and passes before the superior 
 part of the sternum-, forming under the skin, the only covering 
 at this place, a hard, projecting, circumscribed tumour, which 
 follows the motions of the shoulder. The force which causes 
 the luxation will a£l with the greatest advantage, if applied to 
 the point of the shoulder, which is the part the most distant 
 from the articulation in which the dislocation takes place. A 
 baker's boy, in order to repose himself, rested his basket full of 
 bread on the parapet of a bridge: the basket lost its equilibrium, 
 and vv^as falling backwards; the boy endeavoured to oppose it, 
 and in the effort, the straps which passed under each arm-pit 
 afted so powerfully on the point of his shoulders, that one of 
 his clavicles was luxated forwards. 
 
 When the shoulder is suddenly depressed, the extremity of 
 the clavicle next the sternum is luxated^asily upwards, as there 
 is nothing to limit its motion in this dire<51;ion, except the inter- 
 clavicular ligament •, which, however, being relaxed by the 
 greater contiguity of the two bones, makes only a very feeble 
 resistance. 
 
 In the luxation backwards, the extremity of the clavicle is 
 carried behind the superior part of the sternum; but in this, as 
 in the two preceding, all the ligaments that surround the arti- 
 
S.^^ OF LUXATIONS OF THE CLAVICLE." 
 
 culatlon are torn: this is the case, even with the costo-clavicular 
 ligament, which does not immediately belong to it. This la- 
 ceration, with the pecuHarity of strudlure, renders the treat- 
 ment of this luxation difficult. 
 
 The superficial situation of the clavicle renders a diagnosis 
 very easy. If the luxation be forwards, a hard circumscribed 
 tumour is felt, or even seen, on the anterior and superior part 
 of the sternum, which is made to disappear by carrying the 
 shoulder forwards and outwards; and an empty space is found 
 where the head of the clavicle should be placed, &c. &c. In 
 luxation upwards, the space between the sternal ends of the 
 clavicles is diminished. If the luxation be backwards, there is 
 a depression at the place where the extremity of the clavicle 
 should be placed, and a tumour is formed by it at the anterior 
 and inferior part of the neck, which, as J. L. Petit observes, 
 may compress the trachea arteria, oesophagus, jugular vein, ca- 
 rotid artery, and nerves; lastly, the head is inclined towards 
 the affe^ed side. By attending to these appearances, and to 
 the history of the circumstances, we shall be able to ascertain 
 the existence of the dislocation, and find out in what dire«Stion 
 it has taken place. 
 
 A luxation of this extremity of the clavicle is reduced In the 
 same way as a fra6lure of this bone; that is, by making a lever 
 of the arm, by means of which the shoulder is brought out- 
 wards;' and when the shoulder is brought outwards in this 
 manner it is pushed forwards, if the luxation has taken place 
 in that diredlion; backwards, if it be posteriorly; and we elevate 
 it if the bone Is dislocated upwards. By these means we make 
 extension, disengage the extremity of the bone, and bring it 
 towards Its corresponding articulating surface: when in this 
 state, by pressing on it with the thumb, it Is restored to its 
 natural situation; but it Is as difficult to keep It In its place, as 
 it is easy to reduce It. All the ligaments being more or less 
 lacerated, the articulating surfaces, which are smooth and dis- 
 posed obliquely, slide easily on one another from the least mo- 
 tion of the shoulder. 
 
 The apparatus used In fractures of the clavicle is to be applied 
 in cases of luxations of the extremity next the sternum. But 
 it must be observed, that this apparatus, which makes a conti- 
 nued extension by means of the cushion placed in the axilla, 
 though ever so well applied, will not keep the clavicle exactly 
 in its place; and notwithstanding the greatest assiduity of the 
 surgeon, the luxated extremity will remain more prominent 
 
OF LUXATIONS OF THE CLAVICLE. 237 
 
 than that of the opposite side. This slight and inevitable de- 
 formity would not be prevented, even though the tourniquet 
 proposed by Brasdor to make pressure on the extremity, and 
 thus keep it reduced, were used. It will be necessary to con- 
 tinue the use of the bandage for a considerable time, in order 
 to favour the union of the lacerated ligaments. 
 
 SECTION ir. 
 
 Of Luxations of the Extremity next the Humerus. 
 
 These luxations, less frequent than the former, take place 
 by a mutual sliding of two oblique and small surfaces on one 
 another, which form the articulation of the humeral extremity 
 of the clavicle with the acromion of the scapula. As these ar- 
 ticulating surfaces are turned upwards, luxation seldom takes 
 place but in this diredtionj it is proved, however, that it may 
 take place downwards, and that the extremity of the clavicle 
 may sHde and pass under the acromion. The very great force 
 of the conoid and trapezoid ligaments which unite the clavicle 
 to the scapula, renders luxations of the humeral extremity very 
 rare. The dislocation upwards, the only one that merits par- 
 ticular consideration, may be occasioned by a fall on the summit 
 of the shoulderj in which case, the humeral extremity of the 
 clavicle slides upwards on the facet of the acromion, and mounts 
 on this process, which is itself caried a little under the displaced 
 bene, when the shoulder is drawn inwards by the aftion of 
 the muscles which bring the arm near the body. In this lux- 
 ation, the capsule, the superior ligament of the articulation, as 
 also the aponeurotic expansion of the trapezius and deltoid 
 muscles, and the conoid and trapezoid ligiments, are ruptured. 
 
 This luxation, which is always occasioned by 'falling on the 
 shoulder, may be said so be produced by the violence of the fall 
 and the a6tion of the trapezius muscle. This muscle, the fi- 
 bres of v/hich arc attached to the external half of the clavicle, 
 contrafts, and tends to elevate the shoulder, and bring it back- 
 wards; but as the shoulder is forced against the ground, and 
 cannot obey this a6lion, the conoid and trapezoid ligaments are 
 torn, and the humeral extremity of the clavicle displaced. This 
 explanation will not appear improbable to those who know 
 
SjS OF LUXATIONS OF THE CLAVICLE. 
 
 what prodigious force muscles, in appearance the weakest, ex- 
 ert, and what enormous resistance they sometimes surmount. 
 
 The existence of this luxation is easily assertained. If there 
 be pain in the top of the shoulder succeeding to a fall on that 
 part; and if, on examination, the extremity of the clavicle be 
 found projefting under the skin covering the acromion, we 
 may be sure it has taken place. Besides, the patient inclines 
 his head to the affedled side, and moves as little as possible ei- 
 ther the arm or shoulder, because he cannot move these parts 
 without calling into adlion the deltoid or some other muscle, 
 which would consequently extend the motion to the diseased 
 part, and cause pain. This luxation is not attended with such 
 dangerous consequences as those related by Ambrose Pare. He 
 says,* the bone cannot be reduced, the patient will remain dis- 
 abled, and will never be able to carry his hand to his mouth or 
 head. In fadl, the clavicle has been often but imperfeftly re- 
 duced, and the patients were not disabled; and this is what is 
 observed even in the greater number of cases: the ligaments 
 heal without uniting, and the luxation relapses as soon as the 
 bandage is removed. I have seen a person who had a luxation 
 of this kind, and who, after five months regular treatment, 
 could not move his arm without dislocating the clavicle; when- 
 ever he used his arm, the scapula was carried backwards, and 
 its base raised up the skin. 
 
 We reduce this luxation by carrying the arm outwards, by 
 putting a cushion in the axilla, and applying Desault's bandage 
 for fractures of the clavicle, in such a manner as that all the 
 turns of it which ascend from the elbow to the shoulder may 
 bear on the luxated extremity, compress it, and keep it in its 
 place. 
 
 * Works of AmbroEe Pare, chap. il. of Luxations of the Clavicle. 
 
239 
 
 CHAPTER IX. 
 
 OF LUXATIONS OF THE OS HUMERI. 
 
 THERE is no articulation which admits of such extensive 
 motion, as that of the humerus with the scapula: conse- 
 quently, luxations of the former are extremely frequent: their 
 number equals, if not exceeds, that of the luxations of all the 
 other bones. The head of the humerus, a large hemispherical 
 body, is not, properly speaking, entirely received in the gle- 
 noid cavity of the scapula, which, notwithstanding the fibrous 
 margin with which it is surrounded, is not deep enough for 
 this purpose. It touches this cavity by only a very few pointsj 
 the greater part of its surface is in contact with the orbicular 
 ligament. The articulation itself, though admitting of great lati- 
 tude of motion, is by no means provided with very strong liga- 
 ments; it derives its principal strength from the orbicular liga- 
 ment, and an accessary one which comes from the coronoid 
 process of the scapula. These circumstances render dislocations 
 of the arm so easy, that, were it not for the great mobility of 
 the scapula, which follows the humerus in ail its motions, the 
 latter would be dislocated by every trifling effort. The mobility, 
 then, of the articulating surfaces diminishes the frequ-oncy of 
 luxations, which are favoured by so many circumstances. 
 
 The humerus can be luxated only in three directions, down- 
 wards, inwards or forwards, and outwards or backwards. Lux- 
 ation upwards, admitted by some authors, is rendered impossible 
 by many causes: first, the acromion and coracoid process form, 
 with the triangular ligament which goes from the one to the 
 other, a kind of vault over the articulation; therefore, the first 
 effedt of every effort to push the humerus upwards, would tend 
 to frafture these two processes, and tear their ligament; and as 
 the head of the humerus should be carried at once upwards and 
 outwards, before it could be luxated in this direClion, the trunk 
 prevents this disposition of the parts by not allowing the elbow 
 to be brought sujSiciently inwards. Lastly, the tendons of the 
 
240 OF LUXATIONS OF THE OS HUMERI. 
 
 biceps and supraspinatus, and the fleshy mass of the deltoid 
 muscle, efficaciously prevent this luxation. There is even one 
 of the three species of luxation of the humerus, of which, 
 though it has been described, and the possibility made evident, 
 we are not acquainted with a single instance: it is the luxation 
 outwards or backwards. The other two then are those that 
 merit the attention of pra(fi:itioners : the first is oftener met 
 with than the second; it is even so frequent, that many authors, 
 conformably to the opinion of Hippocrates, think that every 
 primary luxation of the humerus takes place downwards: we 
 say primary luxation ; for the possibility of a subsequent change 
 of place, by which the head of the luxated humerus is carried 
 fortvards, is generally admitted. In order to explain this sub- 
 sequent change of place, let us suppose the head of the hume- 
 rus, in a luxation downwards, to be placed between the tendon 
 of the long portion of the triceps, and that of the subscapularis; 
 but by a fall or muscular adlion, to be pushed forwards and 
 inwards, and obliged to lodge between the fossa subscapularis 
 and the muscle of that name. Luxation downwards can never 
 be converted into that backwards; though the contrary opinion 
 is supported by J. L. Petit; but, respectable as his authority 
 may be, we easily conceive that the resistance made by the 
 tendon of the long portion of the triceps must prevent it. 
 
 Luxation of the humerus downwards is the most frequent, 
 not only on account of the great extent of motion of the bone 
 necessary to produce it, but also because the lower part of the 
 orbicular ligament is the thinnest and weakest, and the least 
 supported. The tendons of the supraspinatus, teres minor, 
 and subscapularis, are in some sort confounded with the orbi- 
 cular ligament before they are inserted into the tuberosities of 
 the humerus, and thus increase, in a remarkable manner, its 
 strength and thickness on the superior side; the tendons of the 
 teres minor and infraspinatus support the head of the bone on 
 the outside; above, the same purpose is answered by the ten- 
 don of the supraspinatus, and that of the long portion of the 
 biceps; and anteriorly and interiorly it is protedled by the ten- 
 don of the subscapularis. The inferior part of the articulation 
 is deprived of a similar support, and corresponds to the cellular 
 substance, the glands, nerves, and blood-vessels that fill the 
 axilla. Now, when the elbow is carried upwards and outwards, 
 the head of the humerus, by pressing on the inferior side of 
 the obicular ligament, may easily lacerate it; but in the mean 
 time, the tendon of the long portion of the triceps opposes its 
 
OP^ LUXATIONS OF THE OS HUMERI. 24I 
 
 )?sfcape precisely at the inferior part of the cavity, and forces it 
 ^o pass out at its inferior and internal part. In this luxation the 
 head of the humerus is found placed on the superior and inter- 
 nal part of the external costa of the scapula, having before it 
 the anterior edge of the subscapularis, and the tendon of the 
 long portion of the triceps behind it. The laceration of the cap- 
 sular ligament is inseparable from this luxation j it could not 
 take place without this happening. 
 
 In order that this dislocation may take place, the elbow must 
 be moved outwards from the body,* and even a little elevated : 
 in this motion of the arm, the head of the humerus slides from 
 above downwards, and presses on the internal and inferior part 
 of the orbicular ligament. The difficulty we experience in 
 luxating the arm downwards in the dead body, is so great, that 
 we may conclude, that the weight of the body alone would sel- 
 dom luxate it in falls on the elbow, were it not for the co-ope- 
 tation of muscular action. In order to elucidate the manner iri 
 which this luxation is efFedled, let us suppose a case : A person 
 falls from a place somewhat elevated, on his elbow moved otit 
 from the body ; but, on the very moment that the elbow reach- 
 es the ground, the pectoralis major, teres major and latissimus 
 dorsi, contract, and draw the arm near the body : now, the con- 
 sequence must . be, as the elbow is fixed against the ground, 
 that the muscles will bring downwards and inwards the head 
 of the humerus. This force, co-operating with that of the fall, 
 forces the head of the humerus through the ligament, and 
 produces, a luxation downwards. The humerus represents 
 here, as in all its motions, a lever of the third kind ; but its re- 
 lations are changed, the force remaining alwaj^s at the middle, 
 the pomt d'appuiy which was in the articulation of the hume- 
 rus, is now transferred to the elbow. 
 
 Some authors think, that when the arm is moved out from 
 the body, the adlion of the deltoid muscle alone can produce a 
 dislocation of it ; and in support of this opinion they refer to 
 the case of a person who luxated his arm in attempting to 
 raise a registry-book. 
 
 When the luxation has taken place, the head of the hume- 
 rus, placed, as already observed, between the subscapularis 
 jauscle and this tendon of the long portion of the triceps, fills 
 
 * I have £,iven in the Journal de MeJecirie, the liisfoiy of a luxatiuu 
 produced by a fall on the topcf tlic bhoulder ; but we inaye.isily conceive 
 ihat such ca.'^es nuist be ex'remely rare, and that fracture of the r.eck cf 
 the hume;\!5 is tj be expected from iucli u cauoc, rather than luxauuu. 
 
242 or LUXATIONS OF THE OS HUMERI. 
 
 the hollow of the arm-pit ; the orbicular ligament, torn on its 
 internal side, is stretched over, and covers the glenoid cavity •, 
 fhe deltoides and infraspinatus muscles are elongated on account 
 of the separation of their points of insertion ; the teres minor 
 and subscapularis areneither stretched nor elongated, for if their 
 superior fibres experience attention, the inferior are relaxed ; 
 the coracobrachialis, the biceps and triceps, are elongated, and 
 the fore-arm is more or less bent •, the brachial plexus and ax- 
 illary vessels are not injured ; the circumflex nerve, which 
 furns under the head of the humerus in its course to the deltoid 
 niuscle, is overstretched, and the injury to which it is exposed 
 may destroy its fun^Hon : a paralysis of the deltoides results j 
 and, consequently, an inability to elevate the arm outwards, is 
 sometimes a consequence of an injury done to this nerve in a 
 luxation of the humerus. 
 
 The symptoms which mark a luxation of the arm are nu- 
 merus, and easy to be distinguished- The affedted arm is long- 
 er than the other : we convince ourselves of this fadl, by un-- 
 dressing the patient, and examining the height of his elbows. 
 The arm loses its vertical position, and Inclines obliquely down- 
 wards and outwards, and the elbow is very much separated, 
 from the body if the luxation be recent. When, in the heal- 
 thy state, the fingers are moved along the external part of the 
 OS humeri, an equal resistance is felt along its whole length ; 
 but, in a case of luxation, it is only at the middle part that this 
 resistance is felt ; on the upper part, the integuments, no long- 
 er supported by the superior extremity of the bone, yield to 
 the pressure of the fingers. The acromion projects ; an empty 
 space is felt under it, in which the head of the humerus should 
 be placed ; the summit of the shoulder has lost its roundness ; 
 and a hard tumor, formed by the head of the humerus, is 
 found in the axilla. The patient cannot perform the motion 
 of circumdudlion, in which the arm describes a cone, the base 
 of which is at the ends of the fingers, and the summit at the 
 articulation of the humerus with the scapula ; neither can 
 he bring his hand to his head by describing a semicircular 
 line from without inwards. If we diredl him to perform 
 this motion, he bends the fore-arm, and stoops his head to- 
 wards his hand. It is often unnecessary to attend to all 
 these circumstances, as the existence of the luxation may 
 be ascertained by a simple inspection of the arm, but especially 
 by the change in its diredlion. However, we have given an 
 ample detail of all its charadleristic marks, as it is well attested 
 that uninformed or inattentive surgeons have sometimes been. 
 
OF XUXATIONS OF THE OS HUMERI. 24J 
 
 misfaken in their diagnosis. We have mentioned, in treating 
 of fraftures of the humerus, the marks by which luxations of 
 this bone downwards are distinguished from fractures of its 
 neck. 
 
 The prognosis is uncertain ; for though very often no seri- 
 ous symptom accompanies afFeftions of this kind, still there may 
 be great difficulty in reducing the bone, and a paralysis of the 
 deltoid muscle may ensue. Professor Boyer has seen three ca- 
 ses of this kind. 
 
 The means proposed to efFe£l the reduction are extremely nu- 
 merous ; and, defeftive as a great number of them are, it may 
 be useful to take a view of them, in order to point out what 
 led to their disuse. The most ancient is the ambc of Hippo- 
 crates, a machine not used in these times, and scarcely to be 
 met with in the richest cabinets of surgical apparatus. It is 
 composed of a piece of wood, rising vertically from a pedestal, 
 which is fixed ; with the vertical piece is articulated, after the 
 manner of a hinge, an horizontal piece, with a gutter formed 
 in it, in which the luxated limb is laid, and secured with lea- 
 ther strings. The patient places himself on one side of the 
 machine ; his arm is extended in the gutter, and secured ; the 
 angle formed by the union of the ascending piece and the ho- 
 rizontal branch is lodged in his arm-pit, and then the horizon- 
 tal branch is depressed. In this way extension is made, whilst 
 the vertical part makes counter-extension, and its superior part 
 tends to force the head of the humerus into its cavity. But 
 there is nothing to fix the scapula, and the compression made 
 by the superior part of the vertical .portion of the machine 
 tends to force the head of the humerus into its cavity before it 
 is disengaged by the extension-, besides, it compresses the mus- 
 -cles, stimulates them to contradlion, and thus re^ndcrs the elon- 
 gation of them impossible. 
 
 The ladder is attended with the same inconveniences. In 
 this process, a ladder, six or seven feet high, is placed vertically, 
 and fixed in this situation : the upper step is surrounded by a 
 linen cloth; the patient is elevated by means of a stool, so as to 
 be able to pass the diseased arm over this step ; a number of 
 assistants take hold of the arm hanging on the opposite side of 
 the ladder, and extend it, whilst the weight of the patient, 
 from under whom the stool has been taken, makes counter-ex- 
 tension, and the step tends, by pushing upwards the head of 
 the humerus, to force it into its cavity. This process has this 
 additional advantage, that the force canftot be proportioned 
 to the resistance, since it is alv/ays in proportion to the weight 
 
244 OF LUXATIONS OF THE OS HUMERI. 
 
 of the patient. If he is very tall and corpulent, the neck o£ 
 the humerus may be fraftured. 
 
 The process by the door has the same disadvantages as the for- 
 mer, and differs from it only by placing the upper edge of a 
 door, instead of the upper step of a ladder, under the axilla. 
 The same objeftions may be made to the process in which two 
 strong men, by placing a stick in the axilla, and putting the 
 ends of it on their shoulders, raise the patient from the ground, 
 and keep him suspended, whilst a number of assistants draw 
 the arm downwards. 
 
 Similar defedls are found in many other machines recommend- 
 ed for this purpose; that proposed by J. L. Petit is not exempt 
 ifrom them •, and, notwithstanding the engraving and long de- 
 scription which this surgeon has given of it, it is impossible to 
 •understand its mechanism. Independently of the great pres- 
 sure which it makes on the muscles, the force with which it a^Tls 
 is difficultly appreciated. 
 
 It has been also proposed to extend the patient on a carpet 
 spread on the floor, while the surgeon, extended also, but with 
 his feet towards the head of the patient, places his left heel in 
 the axilla, and presses with it on the head of the humerus, 
 and, at the same time, draws the arm with all his force. But 
 the arm being parallel to the trunk, it becomes difficult to dis- 
 engage the head of the humerus ; the heel compresses the mus- 
 cles, and there is nothing to fix the scapula. 
 
 Lastly, it has been recommended to place the patient and sur- 
 geon seated opposite one another, with the hand of the former 
 secured between the knees of the latter ; this being done, the 
 surgeon inclines backwards, and brings with him the hand 
 squeezed between the knees, whilst with his hands he endea- 
 vours to restore the head of the humerus. It is easily perceived 
 that the operator can, in this situation, exert but very little 
 force: and, if this process has succeeded in some cases, it is 
 because the reduction was very easy, and would have been ac- 
 complished by any means, even the least rational. 
 
 The method we are now to describe is by much the least ex- 
 ceptionable : its effe^ls are not contrary to any of all the rules 
 laid down in treating of the general therapeutics of luxations. 
 
 A large piece of old linen, rolled up in a bundle, or, still bet- 
 ter, a broad cushion of oaten chaff, folded on itself, is to be 
 placed as high as possible in the hollow of the arm-pit ; the 
 bundle ought to be big enough to fill the entire hollow, and to 
 reach beyond the borders of it in such a m«nner as to diminish 
 the pressure made on the tendons of the pe<Storalis major, latis . 
 
OF LUXATIONS OF THE OS HUMERI. 245 
 
 simus dorsi, and teres major, by counter extension. A sheet 
 or table-cloth, folded longitudinally to about four fingers breadth, 
 is used for making counter-extension ; the middle of this is ap- 
 plied on the cushion, and the ends of it, carried obliquely be- 
 fore and behind the breast to the opposite shoulder, are com- 
 mitted to assistants. This part of the apparatus fixes the trunk, 
 and even the scapula, to a certain degree ; but this bone, un- 
 compressed towards the middle of its external border, would 
 yield to the extending force, and the redudtion would be im- 
 practicable, if it were not fixed in the following manner : a 
 napkin, folded longitudinally, to about three fingers breadth, 
 is applied across the top of the shoulder, and one or two assist- 
 ants take the ends of it, which are brought horizontally before 
 and behind the breast to the other side of the trunk; and lastly, 
 another assistant presses the acromion from above downwards, 
 and prevents the folded napkin from moving out of its place. 
 
 Extension is made by assistants, who pull by a napkin, folded 
 diagonally, and tied round the wrist of the patient. Every 
 thing being thus arranged, and the patient seated, the surge- 
 on places himself on the external side of the arm, dire(Sls the 
 proceedings, attends to the elongation of the muscles, and, 
 when he sees them yield to the extending efi^orts, conducSts the 
 head of the bone into its cavity. The two hands placed on the 
 internal and superior part of the arm are sufiicicnt for this pur- 
 pose j a napkin passed under the patient's arm and round the 
 neck of the surgeon would be both embarrassing and useless. 
 The assistants employed for making extension draw first in an 
 oblique direcSlion downwards and outwards ; but, apprised by 
 the surgeon, they bring the arm at the proper time in its natu- 
 ral direction, whilst he forces upwards and outwards the head 
 of the humerus. That the coaptation may be made with the 
 greatest advantage possible, the operator should convert the hu- 
 merus into a lever of the third species, the inferior part of which 
 is supported against his breast. The effort of the assistants who 
 extend the arm is to co-operate with that of the operator, who 
 dire£ls all the proceedings. When the muscles are sufficiently 
 elongated, and the head of the bone disengaged, the elbow is 
 brought inwards and forwards, in order to give the humerus its 
 natural direction. This is to be done without suspending the 
 extension, tlie cessation of which would allow the muscles to 
 reassume their power, and bring back the head of the humerus 
 to the place from which it had been disengaged. 
 
 When the first attempts at reduction fail, bleedings and warm 
 Jjaths are to be had recourse to j and, after these have had their 
 
■246 OF LUXATIONS OF THE OS HUMERI. 
 
 ■effe^l, the patient Is to be placed on a strong and firmly fixed 
 table, anJ the operation is to be recommenced. By repeating 
 the attempts, the muscles are fatigued, their force is exliausted, 
 and the reduction is rendered more easy. If, at the end of 
 some days, after repeated endeavours, and inducing debility by 
 the usual means, even by the excessive use of spirits and opi- 
 um, we are not successful, we advise the patient to call in o- 
 ther pradlitioners ; but in no case or under no circumstances 
 are pullies or other extending machines of this kind to be used. 
 I have seen in a department distant from the capital, a patient, 
 absolutely tortured by the violent means that were employed to 
 reduce a luxation of his arm, and yet the reduction was not ac- 
 complished. The patient, an adult, strong and robust, was 
 stretched on a bench, and held down by a number of men ; 
 a band passed round the inferior part of the luxated arm, was 
 tied to a vine- press, which was turned by twelve men ; but 
 scarcely had they put the machine in motion, when the skin 
 of the shoulder and arm-pit cracked in many places ; the la- 
 ceration would have been more considerable, or indeed the 
 arm would have been torn from the body, if the assistants who 
 were employed to hold down the patient had remained deaf 
 to his cries. 
 
 Citizen Boyer has seen the same consequences from similar 
 attempts to reduce an old luxation of the humerus. The bands 
 for making counter-extension were fixed to a post, and exten- 
 sion was made by a pulley. The pedtoralis major, latissimus 
 dorsi, and teres major, were not elongated in the smallest de- 
 gree, and the attempt was given up, without accomplishing the 
 reduction, though the force employed was so considerable as to 
 lacerate the skin, and produce the most exquisite torture. It 
 has been supposed that the narrowness of the opening through 
 ^vhich the head of the humerus has escaped, might resist its re- 
 duction ; and in cases where this obstacle is susped^ed, surgeons 
 have direcied to move the luxated arm in a. variety of diredlions, 
 in order to make the opening wider by increasing the laceration. 
 But, independently of the difficulty of ascertaining the rea- 
 lity of this cause, how can the opening through which the 
 head of the bone has escaped, be too little at the end of a few- 
 hours to re-ndmit it ? Is not the effect of this practice, in cases 
 T\'here this obstacle has been supposed, to be attributed to the 
 lassitude of the muscles that it produces, rather than to an en- 
 largement of the laceration in the orbicular ligament ? 
 
 We have said, in treating of luxations in general, that at 
 the end of a month or six v/eeks, reduction is, if not impossi- 
 
OF LUXATIONS OF THE OS HUMERI. 247 
 
 ble, at least very difficult -, and we have pointed out tlie me- 
 thod to be pursued when this operation is attempted in these ca- 
 ses. 
 
 Luxation of the humerus inwards may be primary or secon- 
 dary. If a person fall from a height on his elbow placed out- 
 wards and backwards, the a6lion of the muscles co-operates 
 with the effe£ls of the fall, and both force out the head of the " 
 humerus at the anterior and internal part of its cavity, and pro- 
 pel it into the fossa subscapularis between the scapula and 
 subscapularis muscle. In this luxation, the external edge of 
 the subscapularis is moved from tlie fossa by the head of the 
 humerus, which lacerates even the texture of this muscle, 
 when the violence has been great, and the luxation elfeiSled 
 with rapidity. As to secondary luxations in this direiStion, 
 they take place when the head of the humerus deserts the 
 part of the scapula on which it was placed in a luxation down- 
 wards, and is drawn by the adlion of the muscles, parti- 
 cularly by that of the pedioralis major, along the fossa subsca- 
 pularis, and under the subscapularis muscle to the inferior side 
 of the clavicle. 
 
 Some have believed that the head of the humerus might be 
 carried upwards towards the clavicle, and be placed between the 
 great pectoral muscle and the subscapularis ; but the relations 
 of the latter muscle with the internal side of the articulation 
 are such, that it should be turned under the head of the hu- 
 merus before a secondary luxation could take place in this di- 
 rection. The subscapularis, carried inwards, remains always 
 at the internal side of the head of the humerus ; and if this 
 latter part ascends near to the coracoid process, it can only do 
 so by sliding between the subscapularis muscle and the fossa of 
 the same name : in that case, the hard and round tumor which 
 is felt below the clavicle and before the point of the shoulder, 
 is formed by the head of the humerus, covered not only by the 
 peifloralis major and minor, but also by the subscapularis. 
 
 In the luxation of the humerus inwards, the arm preserves 
 nearly its natural length, unless the head of the bone be brought 
 secondarily towards the clavicle, in which case it is shortened. 
 The elbow is placed outwards frcun the body, and carried 
 backwards ; a bony eminence is felt at the superior and external 
 part of the breast, before the point of the shoulder, and below 
 the clavicle ; there is no tumour in the axilla; the point of the 
 shoulder is more round, and the acromion is L"„s prominent 
 than in luxations downwards j l^tly, the motion of circiunduc- 
 Uon is impossible. 
 
•248 OF LUXATIONS 01- THE OS HUMERI. 
 
 The prognosis is more unfavourable in this luxation than irf 
 that downwards j the straining of the parts has been greater, 
 the laceration more considerable, and the reduction is more dif- 
 ficult ; it is particularly difficult when the luxation is of a long 
 standing, and of the secondary kind. The head of the bone, 
 in these circumstances, often grows to the superior part of the 
 fossa subscapularis. The process for reducing it is the same as 
 that used in the luxation downwards, with this slight difference : 
 the assistants who extend the arm are to pull at first in the di- 
 rection of the elbow which was carried backwards, and not 
 bring it forwards but at the moment when the head of the bone 
 is disengaged from the muscle and the fossa subscapularis. If 
 the luxation be secondary, we are first to endeavour to bring 
 the head of the humerus downwards into the hollow of the 
 arm-pit, and then replace it as in cases of luxation downwards. 
 
 There is no well-attested instance of luxation of the hume- 
 rus outwards or backwards, though many authors appear to have 
 admitted the possibility of it. It cannot take place secondarily, 
 and succeed to a luxation downwards, because the tendon of 
 the long portion of the triceps opposes it. Should a fall on 
 the elbow placed inwards and forwards produce it primarily, 
 the head of the humerus would be carried into the fossa infras- 
 pinalis between the external part of this fossa and the infraspi- 
 pinatus and teres minor muscles. The resistance of the spine 
 of the scapula would prevent the humerus from ascending so 
 high as to occasion a shortness of the arm ; but the elbow 
 would be placed inwards and forwards. The acromion would 
 projeft, especially anteriorly ; an eminence would be felt be- 
 hind the shoulder below the. spine of the scapula ; the motion 
 of the humerus would be painful, and that of circumducHrion 
 impossible. It is to be reduced according to the rules already 
 laid down ; but the arm is to be drawn at first inwards and for- 
 wards, in order to disengage the head of the bone before bring- 
 ing it to its natural diredlion. 
 
 Whatever may be the kind of luxation, the reduced bone is 
 easily kept in its place, by preventing the motion of the arm ; 
 and as luxation can take place only when the arm is at some 
 distance from the trunk, a return of it will be certainly pre- 
 vented by tying the elbow to the side. A bandage carried se- 
 veral times round the trunk, and including the elbow, answers 
 this purpose. The spica bandage applied to the point of the 
 shoulder would not answer so well the proposed end 5 its action, 
 from being confined to the superior extremity of the humerus. 
 
OF LUXATIONS OF THE OS HUMERI. 249 
 
 would not prevent the motion of the elbow; consequently we 
 find, that it is now only used to retain emollient and resolvent 
 topical applications, which it is sometimes necessary to app'y to 
 the shoulder. Different symptoms which may accompany or 
 succeed luxations of the humerus, such as pain, paralysis of the 
 deltoid muscle, or oedema of the arm, may render such topical 
 applications necessary. 
 
 If the shoulder be much contused, and the pain considerable, 
 emollient cataplasms are to be applied to the pained part j and 
 if the patient be young and strong, some blood is to be taken 
 away. When, by this treatment, the pain is diminished, the 
 emollients are to be replaced by resolvents, with a view of dis- 
 cussing the ecchymosis. In the generality of cases, the pain 
 has entirely vanished, and the patient has recovered the entire 
 use of his arm at the end of a month. 
 
 The cedema may arise from the compression made by the 
 head of the humerus in the axilla on the veins and lymphatic 
 vessels, which bring back the fluids of the superior extremity. 
 The round figure of the head of the humerus and its polished 
 •surface render it unfit for making great pressure, so that it slides 
 easily over the soft parts, and seldom produces this symptom. 
 Paralysis is much more frequently met with, and it would be a 
 much more frequent consequence if the brachial plexus and ax- 
 illary vessels did not easily escape from the round and slippery 
 surface of the head of the humerus. If these nerves are slightly 
 compressed by this bony eminence, a numbness and pain are 
 felt in the arm, but these symptoms diappear on the reduction 
 being accomplished. This is not the case with the paralysis 
 produced by the contusion and disorganization of the plexus ; 
 it often resists the application of the most powerful remedies j 
 however, the effe£ls of blisters and fri(ftions with irritating sub- 
 stances, such as the tindliure of cantharides, may be tried. I 
 have seen much benefit arise in these cases from burning moxa 
 behind the clavicle, and immediately above the brachial plexus. 
 
 The paralysis, as we have mentioned, is sometimes confined 
 to the deltoid muscle. It depends then on the contusion and in- 
 jury done to the circumflex nerve by the head of the humerus 
 which bends it under it. This afleftion is sometimes very ob- 
 stinate, resists the usual remedies, and is followed by a diminu- 
 tion of volume in the muscle. 
 
 Lastly, there is an accident which may arise from the efforts 
 to reduce a luxation, with which the praflitloner ought to be 
 made acquainted, in order that he may not be alarmed at its 
 32 
 
afO OF LUXATIONS OF THE OS HUMERI. 
 
 taking place. It is generally produced by the violent efforts 
 nece(^ary to reduce an old luxation, and it was in a case of this 
 kind that it presented itself to Desault. This surgeon, after 
 reducing with great difficnlty a luxation inwards, which had 
 continued for six weeks, perceived a tumour forming rapidly un- 
 der the great pedtoral muscle, which soon extended to the ax- 
 illa, and filled its entire cavity. Desault and his assistants 
 thought that an aneurism was produced by the rupture of an 
 artery: but their apprehensions were soon removed. It after- 
 wards appeared that the tumour was formed, according to the 
 opinion of some, by an effusion of venous blood ; according to 
 that of others, by air escaping from the lungs ; but the former 
 appears by much the most probable, as the tumour disappeared on 
 the thirteenth day, and left a large ecchymosis, which was not 
 discussed before the twenty-seventh day. 
 
 Anchylosis is never a consequence of luxations of the hume- 
 rus, when they are reduced. The motion of the arm, first 
 impeded by the pain, becomes daily more free, and is soon 
 performed with as much facility as before the luxation had ta- 
 ken place. The recovery of the patient is accelerated by mo- ' 
 ving the arm every day as much as the state of the soft parts sur- 
 rounding the articulation will admit. It is even rare to find an 
 anchylosis in luxations of the arm which have not been reduced. 
 The head of the humerus makes a depression in the part of the 
 scapula with which it is in contaft, and forms a new articulation, 
 which allows more or less extensive motion j but it will be Tor 
 ever impossible to carry the hand semicircularly to the head» 
 
251 
 
 CHAPTER X. 
 
 OF LUXATIONS O^ THE FORE-ARM. 
 
 THIS chapter will be divided into three sections : in the 
 first we will treat of luxations of both bones of the fore- 
 arm from the humerus ; in the second we will describe luxation 
 of the superior extremity of the radius from the ulna, and in 
 the third we will treat of luxations of the inferior extremity of 
 the ulna from the radius. 
 
 SECTION I. 
 
 t)f Luxations of the Tore-arm from the Humerus % 
 
 Notwithstanding the extent of the surfaces of the articu- 
 lation of the radius and ulna with the os humeri, the strength 
 of the muscles and ligaments surrounding it, and the mutual 
 reception of the eminences which makes it a perfedl angular 
 ginglymus, a dislocation of these two bones from the extremity 
 of the humerus may take place at the same time. They are 
 luxated for the most part backwards, sometimes laterally, but 
 very rarely anteriorly : the latter luxation cannot take place 
 tfithout a fradlure of the olecranon. Luxation backwards is 
 the most frequent : it is facilitated by the small size of the co- 
 tonoid process, which, when the extremity of the humerus is 
 forcibly pushed downwards and forwards, may slide behind it, 
 and mount up even to the cavity which receives the olecranon 
 during the extension of the fore-arm. 
 
 Luxations latterly are much less frequent, and are always in- 
 complete. The great extent of the articulating surfaces in their 
 transverse direilion, the reciprocal union of their inequalities. 
 
252 OF LUXATION OF THE FORE-ARM 
 
 and especially the strength of the ligaments and muscles, which 
 arising from the internal and external condyles of the inferior 
 extremity of the humerus, go to the fore-arm and hand, give 
 great strength to the articulation, and render it impossible to 
 effeOi by any violence a complete luxation laterally. 
 
 In the luxation backwards, the radius and ulna may ascend 
 niore or less behind the humerus 5 but the coronoid process of 
 the ulna is always carried above the articular pulley, and is 
 found lodged in the cavity destined to receive the olecranon. 
 The head of the radius is placed behind and above the external 
 condyle of the humerus. The annular ligament, "which con- 
 lines the superior extremity of the radius to the ulna, may be 
 lacerated : in which case, even when the bones are reduced, it 
 is difficult to keep them in their proper places, as the radius 
 tends constantly to separate from the ulna. 
 
 This luxation always takes place from a fall on the hand ; for, 
 when we are falling, we are led by a mechanical instinct to bring 
 our hands forrvards to prote£l the body. If, in this case, the su- 
 perior extremity, instead of resting vertically on the ground, 
 be placed obliquely with the hand nearly in a state of supination* 
 the repulsion which it receives from the ground will cause the 
 two bones of the fore-arm to ascend behind the humerus, 
 vfhilst the weight of the body pressing on the humerus 
 dire£led obliquely downwards, forces its extremity to pass down 
 before the coronoid process of the cubitus. 
 
 The fore-arm in this luxation is in a state of demi-flexion, 
 and every attempt to extend it occasions smart pains. The si- 
 tuation of the olecranon, with respe<ft to the condyles of the 
 humerus, is changed. The olecranon, which in the natural 
 state is placed on a level with the external condyle, which is 
 itself situated lower than the internal, is higher than it. 
 
 This luxation may be mistaken for a fra(^ure of the olecra- 
 non, of the head of the radius, or even of the inferior extremity 
 of the humerus : such a mistake is attended with very bad con- 
 sequences -, for if the reduction be not effedled before the end 
 of fifteen or twenty days, it is impossible to accomplish it after- 
 wards. Sifch was the case of a student of law, who fell down 
 stairs and luxated his fore-arm backwards. The surgeon to 
 whom he applied, thought he discovered a fradlure of the 
 head of the radius, and treated him as if a fra£Vure had really 
 taken place ; but at the end of twenty days the error was de- 
 tefted, without a possibility of reducing the luxation. The 
 swelling, more or less considerable, which supervenes in twenty- 
 four hours after the accident, renders a diagnosis difficult i the 
 
FROM THE HUMERUS. 253 
 
 the bony prominences are so covered by it, that it is impossi- 
 ble to examine their respedlive situations. Besides, the rubbing 
 of the coronoid process and olecranon against the humerus, 
 causes a grating noise similar to that in fradlure. From these 
 circumstances it must appear, that much attention is requisite 
 to establish a diagnosis between fra<5lure of the head of the ra- 
 dius, and dislocation of the fore-arm backwards. 
 
 Different methods have been proposed to reduce this luxa- 
 tion of the fore-arm : some diredt to place the elbow of the 
 patient on a table covered with many folds of cloth ; while the 
 surgeon places his elbow in the bend of the arm, insinuates 
 his fingers between those of the patient, and bending his fore- 
 arm draws up the hand, and presses at the same time with his 
 elbow on the inferior part of the humerus. But the force that 
 can be applied in this way is inconsiderable ; besides, the pres- 
 sure forces the inferior extremity of the humerus against the 
 luxated bones, increasing the fri<ftion and the difficulty of reduc- 
 tion. The same inconvenience attends the method which con- 
 sists in placing the fold of the luxated arm against a bed-post, 
 and bending the arm by means of an assistant, while the surgeon 
 pushes the olecranon downwards and forwards. 
 
 The following method is by much preferable. The patient 
 being firmly seated, an assistant seizes the middle part of the 
 humerus, and makes counter-extension, while another assistant 
 makes extension by drawing by the inferior part of the fore-arm; 
 the surgeon, seated on the outside, grasps the elbow with his 
 two hands, by applying the four fingers of each hand to the 
 anterior part of the humerus, and the thumbs to the posterior, 
 Avith which he presses on the olecranon, in a direction down- 
 wards and forwards. This method will be in general successful. 
 If the strength of the patient, or the long continuance of the 
 luxation, render it necessary to employ a greater force, a fillet 
 is to be applied on the wrist to make extension, and a cushion 
 is to be placed in the axilla, and the arm and trunk fixed as is 
 done in cases of luxation of the humerus. 
 
 When the luxation is reduced, which is known by the noise 
 the bones make in reassuming their situation, by the relative 
 position of the processes, by the form of the part, and the fa- 
 cility of flexion and extension, long compresses moistened with 
 a resolvent Uquid, are to be applied to the elbow. They should 
 be arranged obliquely, so as that their extremities may cross 
 one another, and the whole form a figure of 8, which arrange- 
 ment will prevent them from falling off. The fore-arm is to 
 
254 OF LUXATIONS OF THE FORE-ARM 
 
 be neither much bent nor extended. A roller is to be passed 
 tightly round the hand and fore-arm, in order to prevent an ef- 
 fusion of lymph. The laceration which always takes place, is 
 accompanied with more or less inflammatory swelling, which is 
 to be combated by blood-lettings, emollient cataplasms, ano- 
 dynes, resolvents, &c. 
 
 At the end of seven or eight days, when the inflammatory 
 symptoms are nearly gone, the articulation Is to be^ gently mo- 
 ved, and the motion is to be increased every day, in order to 
 prevent anchylosis, to which it is remarkably disposed. 
 
 In a luxation of the fore-arm backwards, the annular liga- 
 ment which confines the head of the radius to the extremity of 
 the ulna is sometimes torn, and the radius passes before the cu- 
 bitus. In such cases the motions of pronation and supinatioii 
 are difficult and painful, though the principal luxation has been 
 reduced. The head of the radius may be easily replaced, by 
 pressing It from before backwards, and it is kept in its place by 
 adding to the apparatus above described, a compress, which is 
 to be applied to the superior and external part of the fore-arm. 
 The bandage and compresses are to be taken off every two or 
 three days, and re-applied : this precaution is very necessary, 
 on account of the relaxation of the bandages, and the necessity 
 of moving the articulation to prevent an anchylosis. 
 
 If the luxation be not soon reduced, it becomes irreducible ; 
 the superior extremities of the bones of the fore-arm grow to 
 the humerus at its posterior part, and the patient can neither 
 bend nor extend his arm. However, in some cnses, especially 
 in young persons, some motion is acquired in time, the heads 
 of the radius and ulna make depressions in the humerus, and 
 form for themselves cavities, in which they perform some mo- 
 tions, but always imperfedlly. 
 
 The luxation forwards should be treated as a fradlure of the 
 olecranon, with which it would be inevitably accompanied. It 
 may be necessary, on account of the great injury done to the 
 soft parts, to bleed the patient copiously, and put him on an 
 antiphlogistic regimen. 
 
 As to the lateral luxations, either inwards or outwards, they 
 are always incomplete, and easily discovered. They are redu- 
 ced by drawing the humerus and fore-arm in contrary direftions, 
 and at the same time pushing the extremity of the humerus 
 and the two bones of the fore-arm in opposite direftions. The 
 extension and counter-extension diminish the fri<ftion of the 
 surfaces of the articulation, and facilitate their sliding over one 
 another. 
 
FROM THE HUMERUS. 255 
 
 These luxations cannot be produced without considerable vi- 
 olence ; but when the bones are reduced, they are easily kept 
 in their place. It will be sufficient to pass a roller round the 
 part, to put the fore-arm in a middle state, neither much bent 
 nor extended, and to support it in a sling. But much inflam- 
 mation is to be expected, from the injury done to the soft parts. 
 In order to prevent it, or at least mitigate it, the patient is to 
 be bled two or three times, and put on a low diet, and the ar- 
 ticulation is to be covered with emollient cataplasms. It is 
 scarcely necessary to repeat that the arm is to be moved as soon 
 is the state of the soft parts will admit of it. 
 
 SECTION H. 
 
 Of Luxations of the superior Extremity of the Radius from the Ulna. 
 
 The two bones of the fore-arm, articulated laterally by a 
 double ginglymus, may be luxated from one another. But of 
 these dislocations, of which the ancients make no mention, 
 there is none more frequent than that of the head of the ra- 
 dius from the ulna. The superior extremity of the former may 
 be forced before or behind the little sigmoid cavity of the ulna, 
 destined to lodge a part of its circumference. They may take 
 place instantaneously, from a violent and sudden effort, or gra- 
 dually j and on account of this difference, they are divided in- 
 to primary and secondary. We will treat first of the primary. 
 
 Though the superior extremity of the radius, in its different 
 motions round the ulna, turns on its own axis, yet different ob- 
 servations prove that this extremity of the bone may be dislo- 
 cated. The possibility of its luxation forwards, which ought 
 to be rarer than that backwards, is easily conceived. The cause 
 of the one being more frequent than the other may be this ; 
 the motion of supination, which must take place to produce lux- 
 ation forwards, is less free and less extensive than that of pro- 
 nation, in which the luxation backwards is effe^ed ; besides, 
 the little sigmoid cavity in the ulna presents anteriorly on its 
 margin a bony prominence, which prevents in some degree the 
 head of the radius from passing on that side. 
 
 Many cases of primary luxation of the radius backwards are 
 found in the work of Duverney. Citizen Boyer has met 
 
256 OF LUXATIONS OF THE RADIUS. 
 
 with it twice in a child of ten or twelve years of age. I have 
 seen a similar afFeftion, in a child of the same age, in conse- 
 quence of a fall. In this luxation, the hand is irj the state of 
 pronation, and cannot be brought to its natural state, which is 
 the medium between pronation and supination. The eminence 
 formed by the head of the radius, instead of being felt under the 
 external condyle of the humerus, is placed behind at the external 
 side of the olecranon. A depression is felt at the superior and ex- 
 ternal part of the fore-arm. In order to reduce it, the left hand is 
 to be placed on the elbow, so as to be able to push with it the 
 head of the radius from behind forwards, and the patient's 
 hand is to be taken by the other and brought towards supina- 
 tion, while the displaced extremity is pushed forwards. The 
 noise heard at the moment that the extremity of the radius 
 enters the sigmoid cavity, the remission of the pain, the change 
 in the shape, and the facility of performing pronation and su- 
 pination, indicate that the luxation has been reduced. The 
 after-treatment consists in surrounding the part with compresses, 
 wet with resolvent liquids, and in covering the entire limb 
 with a roller The articulation should be frequently moved, 
 but always very gently, as the annular ligament unites with, 
 difficulty, and only after a long time. 
 
 The secondary luxation of the superior extremity of the 
 radius, arises from small efforts often repeated, which, without 
 immediately displacing the bone, disposes it to relinquish gra- 
 dually the sigmoid cavity. It takes place in young children. 
 Nurses generally take children by the hand when they walk, 
 to prevent them from falling; and when they are in danger of 
 falling, support them by drawing up the arm with the hand in 
 an overstretched state of pronation. The same is done some- 
 times to put them over a little stream, or even to carry them 
 to a certain distance. The straining occasioned in this way, 
 produces a dull pain, which each repetition of the pra<fl:ice in- 
 creases. The child complains of this pain when the articula- 
 tion of the elbow is pressed on. He makes less uie of this 
 arm than of the other, and if he receives a sweetmeat in the 
 hand of this side, he passes it to the other to convey it to his 
 naouth. In this state of the disease, it will be only necessary 
 to avoid a repetition of the cause, and to apply embrocations 
 to the part. If these precautions are negle<fted, and if the 
 pra(5tice of raising the child by the arnj be persisted in, the 
 pain continues and increases; a swelling appears in the pained 
 joint; the superior extremity of the radius is carried backwards; 
 the motions of the fore-arm are obstructed, and usually, in 
 
X)F LUXATIONS OF THE ULNA. 257 
 
 scrofulous children, the tumefaftion of the joint increases; the 
 extremities of the bones become carious ; abscesses form, 
 which either on breaking spontaneously, or being artificially 
 opened, cause fistulous openings into the joint. Then the dis- 
 location of the extremity of the radius is no more the principal 
 disease; this consists of a painful swelling of the soft parts, and 
 enlargement and caries cf the ends of the bones. In the chap- 
 ter on white swellings we will give the treatment of it. 
 
 SECTION III; 
 
 ^ Of Luxations of the inferior Extremity of the Ulna. 
 
 We give this denomination to the dislocations of the Infe- 
 rior extremities of the bones of the fore-arm, which other au- 
 thors describe under the name of luxations of the inferior ex- 
 tremity of the radius. Although this extremity moves on the 
 ulna, yet, as the head of the latter evidently escapes from the 
 sigmoid cavity of the radius, and as, in considering the afFe<flion 
 as arising from this dislocation, it is easier to explain the phe- 
 nomena of it, we have adopted this name in preference. 
 
 The inferior extremity of the ulna may be luxated anteri- 
 orly, or posteriorly, from the inferior extremity of the radius. 
 
 The first of these luxations, of which we have but few exam- 
 ples, must be much less frequent than the second, because the 
 excessive supination of the hand necessary to produce it is more 
 difloicult than its pronation. It is well known that it is in the 
 state of pronation that the hand performs almost all its motions, 
 and fulfils the greater part of the purposes to which it is adapted. 
 In this luxation, the head of the radius rolls from before back- 
 wards, or from within outwards on the head of the ulna, and 
 pushes it forwards; if the luxation take place rapidly, the liga- 
 ments between the bones will be torn, and the little heati of the 
 ulna will be forced before the inferior extremity of the radius. 
 In this state, the hand is in a continual state of supination, and 
 cannot be brought to that of pronation; a tumour is felt before 
 the radius; there is an empty space where the inferior extremity 
 of the cubitus should be; and this bone, instead of being pa- 
 rallel with the radius, crosses it obliquely at its inferior part. 
 Redu(Sl;ion is easily efi^e£led. It is done by pulling the arm, 
 33 
 
258 OF LUXATIONS OF THE ULNA. 
 
 and at the same time turning it a little inwards, whilst the 
 bead of the ulna is pushed backwards, and the extremity of 
 the radius carried forwards, the person who extends the arm 
 bringing the hand at the same time to the state of pronation. 
 The noise made by the replacing of the bones, the disappear- 
 ance of the deformity, and the facility of putting the hand in 
 the supine or prone state, shew that the luxation is reduced. 
 Compresses wet with resolvent liquids, and a roller passed 
 tightly round the fore-arm, are all the apparatus that are ne- 
 cessary after the reduction; the hand is to be kept at rest and 
 supported in a sling. This luxation, if negledled, would lead 
 in a very short time to the loss of motion in the joint from an 
 anchylosis. 
 
 Citizen Boyer has met a remarkable case of luxation of the 
 cubitus anteriorly, which is extremely rare. A woman engaged 
 in a riot, that took place in a coffee-house near the market- 
 place of Saint Germain, was pushed out of the house by a man 
 who twisted her hand violently in the supine diredllon; she 
 felt horrible pain, and cried out that her wrist was breaking, 
 and In the moment saw that a deformity supervened. Profes- 
 sor Boyer was called in; he found the hand fixed in the supine 
 state, the fore-arm bent, and the hand supported before the 
 breast. The oblique diredtion of the inferior extremity of the 
 ulna which crossed the radius, was very remarkable. The 
 redudtlon was accomplished only by the fourth attempt. 
 
 The luxation backwards of the inferior extremity of the ul- 
 na, described by authors under the name of luxation forwards 
 of the Inferior extremity of the radius, has been frequently ob- 
 served. It is more frequent than the former, because the mo- 
 tion of pronation, by which It is occasioned, is more habitual 
 than that of supination; and as luxation forwards is produced 
 by a violent supination, so that backwards Is the result of a 
 violent and sudden pronation. Such was the case of the female 
 mentioned In Desault's Surgical Journal, who luxated the cubi- 
 tus backwards in wringing wet cloths; in doing which, the 
 hands are put In the greatest state of pronation possible. The 
 hand In this luxation Is fixed In the prone state, is incapable of 
 supination, and Is a little Inclined inwards. The ulna crosses 
 the radius obliquely, but its little head forms a tumour behind 
 the inferior extremity of this bone. It is reduced in the same 
 manner as the luxation forwards, with this difference, that the 
 hand is to be moved in a contrary diredllon. If the luxation 
 has been ncgledled, and a swelling of the articulation has su- 
 
OF LUXATIONS OF THE WRIST. 259 
 
 pervened, no attempt is to be made to effect a redu£lion until 
 the swelling is discussed by means of emollient cataplasms; we 
 should not however defer the reduftion too long, as it often 
 becomes impossible after a very short time. In the latter case, 
 the person is not so much disabled in the luxation backwards, 
 as in that forwards; the state of pronation being much more 
 convenient for the purposes of the hand, than that of supina- 
 tion. 
 
 CHAPTER XI. 
 
 OF LUXATIONS OF THE HAND. 
 
 SECTION I. 
 
 Of Luxations of the Wrist. 
 
 FOUR kinds of luxations may take place in the articulation 
 of the bones of the carpus with the inferior extremities 
 of those of the fore-arm, viz. luxation forwards, backwards, 
 inwards, and that outwards. But the two first, especially that 
 backwards, are the most frequent, because the motions of flex- 
 ion and extension are much more extensive than those of ad- 
 duction and abdudlion, and because the extent of the articula- 
 ting surfaces is greater from within to the outside, than from 
 before backwards ; besides, the styloid apophyses of the radius 
 and ulna strengthen the external and internal sides of the arti- 
 culation, and render dislocation in the transverse direiStion still 
 more difficult. 
 
l6o OF LUXATIONS OF THE WRIST. 
 
 The articulation of the hand with the fore-arm is remarkable 
 in this, that it admits of flexion and extension nearly to the 
 same extent; whilst these two motions, in all the other articu- 
 lations, have parely the same latitude, that of flexion being 
 always the most considerable. 
 
 Luxation backwards is facilitated by the direftion of the con- 
 vex articulating surfaces of the scaphoides, semilunaris, and 
 pyramidalis, which, inclined more backwards than anteriorly, 
 must be more disposed to slide in this direction than in ^ny 
 Other. It is caused by a fall on the back of the hand while 
 much bent; in which case the first range of bones of the wrist 
 slides backwards into the oblong cavity of the two bones of the 
 fore-arm, extends and lacerates the posterior ligament, and 
 forms an eminence behind the ends of the radius and ulna. 
 This tumour, the depression at the anterior part of the wrist, 
 and the extraordinary flexion of the hand which cannot be ex- 
 tended, are the distinguishing marks of this luxation. It is re- 
 duced by fixing the fore-arm, and drawing the hand, whilst 
 pressure is made on the eminence formed by the displaced car- 
 pus to force it back into its cavity. An assistant fixes the arm, 
 and jjie surgeon makes extension and adjusts the bones. Lux- 
 ation forwards is occasioned by a fall on the palm of the hands, 
 the fingers being extended, and more force being applied to 
 the inferior part of the palm than to the superior. It is rarely 
 complete; the hand remains painfully extended, and cannot 
 be restored to its natural direction without some difliculty. 
 The numerous tendons which pass before the wrist, and the 
 annular ligament which confines them, being pushed forwards, 
 render it so difficult to discover the eminence formed by the 
 bones of the wrist before the ends of those of the fore-arm, 
 that this affe<5lion may be easily mistaken for a sprain. Conse- 
 quently, in all doubtful cases, we should proceed as if the lux- 
 ation had really taken place, and bring the hand into its proper 
 direction. 
 
 Luxations backwards, but especially those forwards, are al- 
 ways accompanied with a more or less considerable laceration 
 of the ligauients, and are followed by an inflammatory swelling 
 di^cult to subdue; hence the full use of the wrist is not re- 
 covered for a considerable time. When the bones are reduced, 
 the remainder of the treatment is the same as in cases of sprains 
 refrigt rents and repellents are to be first used, amd then emol- 
 lients and resolvents. The patient must not fatigue the hand 
 
OF THE BONES OF THE CARPUS, &C. 26 1 
 
 much, even for some time after complete recovery, lest he ex- 
 cite inflammation, and lay the foundation of a white swelling. 
 Luxations inwards, and those outwards, are never complete. 
 The laceration of the ligaments, a tumour at the internal or ex- 
 ternal side of the joint, and distortion of the hand, are the 
 concomitant symptoms of these luxations, and mark them out 
 sufficiently. They are reduced by making gentle extension, 
 and causing the two surfaces of the joint to slide on one ano- 
 ther in a dire£l:ion contrary to what they took in luxating, and 
 by bringing the hand into its natural situation. The danger of 
 these luxations depends less on the dislocation than on the 
 Straining and laceration of the soft parts, which are always fol- 
 lowed by more or less tumefa<^ion, a symptom difficult to sub- 
 due, and often the cause of anchylosis, or even of caries. 
 
 SECTION II. 
 
 Of Luxations of the Bones of the Carpus and Metacarpus 
 
 The motions of the bones of the carpus in their articulations 
 with one another are so limited, and their connexion is so 
 strong, that a dislocation of them appears entirely impossible. 
 However, the head of the os magnum, which is received in a 
 deep cavity formed for it by the scaphoides and semilunaris, 
 jcnay escape from this cavity, be luxated backwards by too great 
 a flexion of the bones of the first range on those of the second, 
 and form a tumour on the superior part of the back of the 
 hand. I have lately seen a remarkable case of this luxation. 
 Mrs. B. in a labour pain, seized violently the edge of her mat- 
 tress, and squeezed it forcibly, turning her wrist forwards; 
 she instantly heard a slight crack, and felt some pain, to which 
 her other sufferings did not allow her to attend. Fifteen days 
 afterwards, happily delivered, and recovered by the care of 
 Professor Baudelocque, she shewed her left hand to this cele- 
 brated accoucheur, and expressed her disquietude about the 
 tumour which appeared on it, especially when much bent. I 
 was called to visit this lady. I found that this hard circum- 
 scribed tumour, which disappeared almost totally by extending 
 the hand, was formed by the head of the os magnum luxated 
 backwards; I replaced it entirely by extending the hand, and 
 
262 OF LUXATIONS OF TH^ FINGERS. 
 
 making gentle pressure on it. As the afFe£tion did not impede 
 the motion of the part, as the tumour disappeared on extend- 
 ing the hand, and as it would have been even little apparent 
 in any state of the hand, had Mrs. B. been more in flesh, I 
 advised her not to be uneasy about it, and to apply no re- 
 medy to it. Chopart observed a similar dislocation in a butcher. 
 Professor Boyer's practice has presented him also a case of it. 
 
 As to the bones of the metacarpus, they are connected so 
 closely and strongly, and support one another so firmly in ef- 
 forts made against the palm of the hand, that they are never 
 luxated. The ligaments of their articulations may, however, 
 be overstretched and torn, and a painful diastasis produced, 
 which will require the use of emollients and resolvents, with 
 immobility of the hand as long as the affe£lion continues. 
 
 Notwithstanding the mobility of the articulation of the tra- 
 pezium with the first bone of the metacarpus, the latter is lux- 
 ated but very rarely. Efforts made on the thumb, which is 
 supported by this bone, would produce rather a luxation of the 
 first phalanx, than that of the metacarpal bone. The second 
 and third bones are so firmly articulated with one another, and 
 with the bones of the second row of the carpus, that they are 
 not susceptible of any luxation whatever. As to the fourth and 
 fifth, a little more moveable, and supported by the os unci- 
 forme, their articulations are more susceptible of sprains than 
 true luxations. 
 
 SECTION III. 
 
 Of Luxations of the Fingers. 
 
 The first phalanges may be luxated backwards at their aiw 
 ticulations with the bones of the metacarpus. A luxation of 
 them forwards would be very difiicult, if not altogether impos- 
 sible> on account of the disposition of the articulating surfaces 
 of the metacarpal bones, which are much elongated forwards, 
 and allow a great extent of motion to the phalanges in this 
 dire<ftion, without losing contact with them; and on account 
 of the resistance made by the palm of the hand, which would 
 restrain the flexion carried beyond what the inclination of the 
 articulating surfaces would admit of. Luxations inwards can 
 
OF LUXATIONS OF THE SINGERS. iS^ 
 
 take place only In the first phalanges of the thumb and little 
 finger J as to that outwards, the first phalanx of the thumb alone 
 is susceptible of it. This phalanx is also the most exposed to 
 luxations backwards. When a violent effort is made on the 
 thumb from before backwards, its first phalanx slips behind 
 the head of the first metacarpal bone, and remains extended, 
 while the second is bent, its flexor-muscle being thrown into 
 aftion by the irritation. The distortion of the thumb, the im- 
 possibility of bending the first phalanx, and the pain, render 
 this luxation sufiiciently evident. 
 
 The more violent the effort necessary to produce these lux- 
 ations, the more grievous are their consequences. In some per- 
 sons in whom the ligaments are excessively relaxed, they pro- 
 duce nojnconvenience. In such, the first phalanx of the thumb 
 may be luxated at will j but then it is as easily reduced as dis- 
 placed. 
 
 These luxations should be quickly reduced, for, at the end 
 of eight or ten days, they are irreducible. Desault, in a case of 
 this kind, proposed making an incision behind the superior 
 extremity of the phalanx, and by means of it to introduce a 
 spatula, in order to push the phalanx into its place ; but the 
 patient, frightened at the operation, would not submit to it. 
 Citizen Boyer has also observed in a hair-dresser, a luxation 
 backwards irreducible from having continued too long. 
 
 The redudtion is not as easy as one might imagine. The num- 
 ber and force of the muscles which are inserted into the first 
 phalanx of the thumb, and the little hold we can take of this 
 part in order to make extension, render the reduction difficult. 
 Luxations of the first phalanges of the thumb and little finger 
 inwards, that of the thumb outwards, and luxations of the first 
 phalanges of the other fingers backwards, are all reduced by 
 making extension on the inferior extremity of the affedled fin- 
 ger, round which a fillet is to be passed if there be occasion for 
 much force. The wrist is fixed by an assistant, who makes 
 counter-extension, and the surgeon replaces the bone. The 
 first and second phalanges are also susceptible of luxation back- 
 wards, which only difiers from the former by being more easily 
 reduced. After the reduftion is accomplished, a roller is put 
 round the finger to prevent a return of the luxation. 
 
l64 
 
 CHAPTER XII. 
 
 OF LUXATIONS OF THE FEMUR. 
 
 THE articulation of the femur with the bones of the pelvis 
 is so strong and well secured, that luxations of it are not 
 frequent; thus they are much rarer than those of the humerus, 
 yet they are described by all authors, ancient and modern* 
 But I am disposed to think that pradlitioners have often con- 
 founded primary luxations of the femur with fradtures of the 
 neck of this bone, which are much more common. 
 
 These luxations may take place upwards and outwards on the 
 external face of the os ilium, upwards and forwards on the 
 body of the os pubis, downwards and inwards on the foramen 
 ovale, and downwards and outwards on the os ischium. Hence 
 their division, generally admitted, into four well-marked spe* 
 cies. 
 
 Luxation upwards and outwards, and that downwards and 
 inwards, are the most frequent ; and it is not easy to ascertain 
 which of these two takes place oftenest. No anatomical reason 
 can be given for the frequency of the first* ; the edge of the 
 acetabulum projects more at the superior and exterior parts 
 than at any other; the orbicular ligament, which is very thick 
 at this place, nnd the interior ligament of the articulation, 
 which must be previously ruptured, oppose the dislocation in 
 this diredlion. There is little, on the contrary, to oppose the 
 luxation downwards on the foramen ovale. The inferior and 
 internal part of the circumference of the cavity, the place by 
 which the bone escapes in this species of luxation, presents a 
 deep notch formed into a hole by a ligament, under which the 
 vessels of the articulation enter. The orbicular ligament is thin- 
 ner here than at any other place; the motion of abduftion, in 
 which this luxation takes place, is more extensive than that of 
 
 * Except the disposition of the head of the femur, the articulating part 
 of which, covered with cartilage, is cgjitinued farther upwards and out- 
 wards, than downwards and inwards. 
 
OP LUXATIONS OF THE FEMUR. 265 
 
 addu£l'ion; and lastly, the round ligament within the articular 
 tion does not oppose if, as it may take place without its being 
 ruptured. 
 
 Luxation upwards and forwards is very rare ; that down- 
 wards and backwards is still more so; and, perhaps as shall be 
 observed farther on, never occurs but secondarily. 
 
 When, by a fail from a place more or less elevated, on the 
 soles of the feet, or on the knees, the thigh is pushed for- 
 wards and inwards, the head of the femur, forced towards the 
 superior and external part of the acetabulum, breaks the inter- 
 nal and orbicular ligaments, escapes through the laceration in 
 the latter, and ascends on the external face of the os ilium ; 
 but as the part of the os ilium immediately above and at the 
 external side of the cavity, is very convex, the head of the 
 femur soon abandons its first position, and slides backwards 
 and upwards into the external fossa of the os ilium, following 
 the inclination of the plane towards this fossa, and obeying 
 the action of the glutJei muscles which draws it in this direc- 
 tion. The head of the femur, in ascending thus on the exter- 
 nal face of the os ilium, pushes upwards the glutseus minimus, 
 which forms a sort of cap for it ; and the glutseus maximus 
 and medius are relaxed by the approximation of the points 
 into which they are inserted. The pyriformis is nearly in its 
 natural state, the gemini, obturatores, and quadratus femoris, 
 are a little elongated. The psoas magnus and iliacus internus 
 are relaxed, as are also the other muscles inserted into the tro- 
 chanter minor. If to this description it be added, that the or- 
 bicular ligament, torn at its superior part, is stretched over 
 the acetabulum and covers it, an exact idea may be formed of 
 the change occasioned in the surrounding parts by this luxation 
 of the femur. 
 
 The affected thigh is shorter than the sound one : it is a lit- 
 tle bent, and carried inwards. The knee inclines more for- 
 wards and inwards than the opposite one ; the leg and thigh 
 are turned inwards, and the foot points in this direction. The 
 trochanter major is brought nearer the anterior and superior 
 spinous process of the os ilium, and is at the same time ele- 
 vated and carried a little forwards ; the latter circumstance 
 may be considered as the necessary consequence of the rotation 
 inwards of the thigh. The natural length of the Umb cannot 
 be restored without reducing the luxation ; the foot cannot be 
 turned outwards, and any attempt to do so causes pain ; but 
 the inclination of the foot Inwards may be increased. If the pa- 
 34 
 
0.66 OF LUXATIONS OF THE FEMUR. 
 
 tient endeavours to walk, he extends the foot to put the top of 
 of it on the ground ; and though the heel is raised, he is still 
 lame ; for the diseased limb remains always shorter than the 
 other, and the pain occasioned by the attempt to walk ren- 
 ders progression still more difficult. 
 
 Luxation of the femur upwards and outwards has nothing 
 in common with the fracture of the neck of this bone but the 
 shortness of the limb. The easy rotation of the member 
 outwards and inwards, &c. &c. preclude all possibility of con- 
 founding them, unless the surgeon be remarkably inattentive. 
 
 It is difficult to assign the cause of the foot and remainder of 
 the limb being turned inwards in this luxation. It may be esta- 
 blished as a general rule, that luxated members always take a 
 direftion determined by the elongation of the muscles of the 
 side opposite that to which the luxated bone is carried : thus in 
 luxation of the arm downwards and inwards, the deltoides and 
 infraspinatus muscles, lengthened by the separation of their 
 points of insertion, move the elbow out from the body, and 
 give the arm an oblique direction. In this case, the obtura- 
 tores, gemini, and quadratus femoris, being elongated, the 
 point of the foot ought to be turned outwards. This pheno- 
 menon depends perhaps on the external portion of the orbicu- 
 lar ligament which comes from the anterior and inferior spine 
 of the OS ilium ; this portion, which is very thick, being 
 elongated in the luxation outwards, draws the great trochanter, 
 forwards, and consequently turns inwards the entire limb. 
 
 The difficulty of reducing luxations of the thigh, from the 
 strength and number of its muscles, renders every dislocation 
 of which it is susceptible very distressing. The laceration and 
 injury done to the soft parts are nearly as considerable as io 
 dislocations of the ginglymoidal articulations. 
 
 To effect the reduction, the patient is extended on a table 
 firmly fixed, and covered with a mattress which is to be tied 
 to it j a sheet folded longitudinally is applied to the groin of the 
 sound side, in order to make counter-extension. The middle 
 part is applied against the superior and internal part of the 
 thigh, and the two ends passed before and behind the pelvis, 
 cross on the hip, and are held by a sufficient number of assist- 
 ants. By this means the trunk is fixed, but there is nothing 
 to prevent the pelvis from yielding to the extending force. To 
 answer this purpose, another sheet folded in a similar mannftr 
 is placed transversely on the spine of the os iliui'O, and its ends 
 are brought horizontally before and behind the abdomen to- 
 wards the hip of the opposite side, where they are held by as- 
 
OF LtrXATtONS OF THE FEMUR. 267 
 
 sistants. This apparatus, similar to that placed on the point 
 of the shoulder in a luxation of the arm, answers the same 
 purposes, as it presses only on the superior part of the glutaeus 
 maximus and medius, and does not stimulate them to contraifl. 
 The extending force is to be applied to the inferior part of the 
 leg, in order to have it as far as possible from the parts which 
 resist the return of the head of the femur. The number of 
 assistants for making extension and counter extension is to be 
 proportioned to the exigencies of the circumstances and the 
 power of the muscles. The surgeon, placed at the external 
 side of the limb, presses on the great trochanter, and when 
 the head of the bone has been brought on a level with the 
 acetabulum, he endeavours to force it into it. 
 
 The disappearance of all the symptoms, and especially the 
 noise made by the head of the femur on re-entering its cavity, 
 indicate the success of the operation. This success is seldom 
 obtained without having previously made several fruitless en- 
 deavours, whether from not employing sufficient force to make 
 extension and counter-extension, or from a spasmodic contrac- 
 tion of the muscles obstinately resisting the redudlion. 
 
 When the bone is reduced, it is prevented from leaving its 
 place by bringing the thighs together by means of a bandage 
 placed above the knees. In the generality of cases it will be 
 adviseable to take some blood from the patient, and confine 
 him for a few days after the accident to a very low diet ; and 
 in all cases the hip is to be covered with emollient and resol- 
 vent applications, which may be kept on by means of the spica 
 bandage for the groin. This bandage is well adapted to this 
 use, but is not at all fit for keeping the luxated bone in its pro- 
 per place, as its a£lion is made too near the centre of motion. 
 The patient should be particularly diredled not to walk too 
 soon, nor at any time to fatigue too much the afFefted joint. 
 It remains always weaker than the other ; the round ligament 
 never unites completely, if even its reunion be possible. When 
 the limb has not been left at rest for a sufficient length of time, 
 (twenty days at least), the pain can never be said to have en- 
 tirely disappeared ; it is revived by the slightest effi^rt, and at 
 length becomes permanent. The patient, however, does not 
 complain much of the pain, but it is more than probable that 
 it is occasioned by a swelling of the cartilages and synovial 
 glands of the articulation, the direful forerunner of spontane- 
 ous luxation of the femur, and of caries of the bones forming 
 the acetabulum; 
 
268 OF LUXATIONS OF THE FEMUR. 
 
 Luxation of the thigh downwards and inwards, or into ikt 
 foramen ovale, is nearly as frequent as that just described; it is 
 favoured, as we have said, by the great extent of the motion 
 of abduftion of the thigh; by the notch at the inferior and in- 
 ternal part of the acetabulum; by the weakness of the orbicu- 
 lar ligament at this side ; and lastly by the situation of the round 
 ligament, the rupture of which is not a necessary consequence 
 of it. It is occasioned by a fall on the feet or knees conside- 
 rably separated from one another. The head of the femur 
 slides from without inwards on the bottom of the acetabulum, 
 and comes against the inferior and internal portion of the or- 
 bicular ligament, which it lacerates, and passes on to the fora- 
 men ovale between the ligament and the obturator externus. 
 
 In this species of the luxations of the femur, the state of the 
 soft parts surrounding the articulation is as follows : the glutaei, 
 gemini, obturatores, quadratus femoris, psoas magnus, and 
 iliacus internus, are elongated by the separation of their points 
 of insertion. The rotation of the limb outwards is produced 
 by the elongation of these muscles. The adducSlors, elongated, 
 form at the interior part of the thigh a tense cord, which is 
 felt from the pubis to below the middle of the thigh. 
 
 The afFedted thigh is longer than the sound one ; the head 
 of the femur being placed lower than the acetabulum, the 
 great trochanter is removed to a greater distance from the an- 
 terior and superior spinous process of the os ilium, and the 
 thigh is flattened in consequence of the elongation of the mus- 
 cles. The adductors, extended obliquely from the pubis to 
 the femur, form a cord which elevates the skin of the inter- 
 nal part of the thigh. A hard round tumour is felt at the in- 
 ner and superior part of the thigh, formed by the head of the 
 femur, which elevates the soft parts situated before the foramen 
 ovale. The leg is slightly bent ; the knee and foot turned 
 outwards, cannot be brought back to their proper direction. If 
 the patient attempt to walk a few steps, he makes a semicircu- 
 lar motion with the foot, and places at once the entire sole on 
 the ground; and though he keep the knee bent, still the limb 
 is too long, and occasions lameness. The mode of progression 
 of persons whose thigh is luxated in this direction may be com- 
 pared to that of a mower : the elongated extremity, like the 
 leg which the mower keeps forwards, describes a semicircular 
 motion outwards. 
 
 All these symptoms taken together form a combination too 
 striking to admit of error in our diagnosis, or to allow us to 
 
OF LUXATIONS OF THE FEMUR. 269 
 
 confound this luxation with any other, or even with fracture 
 of the neck of the femur. 
 
 The prognosis is somewhat less unfavourable in this than in 
 luxation upwards and outwards. The muscles, which might 
 oppose the reduction, being all elongated by the very circum- 
 stance of the luxation itself, render the reducStion easier; besides, 
 the contusion of the soft parts is less considerable, and the 
 round ligament is stretched, but not broken. It is reduced in 
 the same manner as the other, except that the extension is to 
 be made at first downwards and outwards, before bringing the 
 limb to its natural direction. 
 
 Luxation upwards and forwards is much rarer than the pre- 
 ceding, and more than one pra6lioner has described it rather 
 as possible than as having absolutely taken place. It has been 
 also called luxation on the pubis, though it may be reasonably 
 presumed that the head of the femur is removed so f?.r from 
 the acetabulum but in very few cases, and that it only advances 
 near the ilio-pe£tinseal eminence. Desault met a luxation of 
 thii kind in a porter of the flour-market: his foot slipped, and 
 the leg and thigh were carried backwards, whilst a heavy bur- 
 den was placed on his shoulders. His body was bent back- 
 wards, and the head of the femur, directed forwards and up- 
 wards, burst its capsule and triangular ligament, and passed 
 under the crural arch into the fold of the groin, where it was 
 easily felt through the integuments. 
 
 The whole extremity is turned outwards in this luxation: it 
 is also shortened. The great trochanter, brought nearer the 
 anterior and superior spinous process of the os ilium, is placed 
 before that eminence; that part into which the psoas and ilia-' 
 cus muscles are inserted is raised up, and a tumour is formed 
 by the head of the femur in the fold of the groin, which com- 
 presses more or less the crural nerves placed at the external side 
 of the vessels of this name, and occasions dull pains, with 
 numbfless and even paralysis, when the contusion has been very 
 great; the knee, turned outwards, is also carried backwards^ 
 This symptom is particularly remarkable shortly after the acci- 
 dent has taken place; for if the dislocation has continued some 
 days, the thigh may reassume its natural dlrecTtion, and per- 
 form even gentle rotatory motions inwards, the direction out- 
 wards still continuing. It is proper to remark, with respedt to 
 the tumour formed by the head of the femur in the groin, that 
 the psoas and iliaeus muscles may, in fraiftures of the femur 
 immediately under the little trochanter, bring forwards the su- 
 
ayo or luxations of the femur. 
 
 perior portion of this bone, cause it to project in the groin, an^ 
 form an eminence there which might impose on us, if we were 
 not apprized of the possibiUty of such an event taking place. 
 
 This luxation is particularly dangerous, as it requires a com- 
 bination of violent efforts to produce it, and as it necessarily 
 must be accompanied with great contusion and lacerations. 
 Nevertheless, in the case treated by Desault, the reduftion^ 
 though difficult, was not followed by any serious accident; and 
 the patient, at the end of fifteen days, had almost entirely re- 
 covered the strength and use of his limb. 
 
 The process for reducing it does not differ from that pointed 
 out for the others. 
 
 Luxation of the femur downwards and backwards may, like 
 that of the humerus inwards and forwards, be either primary 
 or secondary. It is primary, when, in consequence of some 
 effort, the head of the femur is forced from the acetabulum at 
 its inferior and posterior part, and is placed at the jun£\ion of 
 the OS ilium and ischium; it is secondary, when it succeeds to 
 the luxation upwards and outwards, the head of the fenuir, 
 which was placed at first in the external iliac fossa sliding down- 
 tvards and backwards, its passage in this direcStion being fa- 
 voured by the bending of the thigh on the pelvis. 
 
 In these two cases, the head of the femur rests against that 
 part of the ossa innominata where the os ilium and ischium 
 join. The muscles which cover the posterior part of the arti- 
 culation, such as the pyriformis, gemini, obturatores, and qua- 
 dratus femoris, are raised up and stretched; the psoas magnus 
 and illiacus internus are in a great state of tension, and this 
 explains the turning of the limb outwards. When this luxa- 
 tion is primary, the extremity is lengthened; a hard tumour is 
 felt at the posterior and inferior part of the thigh; the great 
 trochanter, by' descending, is removed farther from the spine 
 of the OS ilium, and the knee and sole of the foot are turned 
 outwards; but if it be secondary, the thigh is much bent Against 
 the pelvis; the knee and sole of the foot are turned inwards, 
 because the primary luxation has been upwards and outwards. 
 Secondary luxation in this dire(5lion is much more frequent 
 than the primary: in reducing it, the same rules are to be ob- 
 served as in other species of luxations. 
 
 Whatever may be the species of luxation, we should always 
 be certain that it is perfectly i-educcd before leaving the patient. 
 To ascertain thi:;, v/e ought to move the thigh in various di- 
 
OF SPONTANEOUS LUXATIONS OF THE FEMUR. 27 I 
 
 reftlons, taking care at the same time to omit that motion 
 which might reproduce the luxation. 
 
 When a luxation of the femur upwards and outwards has 
 not been reduced, the thigh remains short, and becomes shorter 
 every day, until the head of the femur has made for itself a 
 kind of articular cavity in the surface of the external iliac fossa. 
 The acetabulum lessens in size, or is entirely obliterated. The 
 glutaeus minimus is emaciated, and serves as an orbicular liga- 
 ment to the new articulation. The head of the femur loses its 
 spherical figure, is forced backwards, and its neck becomes 
 shorter; the person is lame, and walks on the point of the 
 foot. If the luxation is downwards and inwards, the foramen 
 ovale becomes the new articulating cavity; the obturator ex- 
 ternus, raised and pushed inwards by the head of the femur, 
 becomes emaciated and ligamentous, and it and the glutseus 
 minimus even sometimes ossify. The lameness arises in this 
 case from the excess of length of the diseased limb, which al- 
 ways dimmishes in size, in consequence of the muscles not 
 being sufficiently exercised, or their adtion being impeded. 
 
 CHAPTER XIII. 
 
 OF SPONTANEOUS LUXATIONS OF THE FEMUR. 
 
 IT is not, perhaps, without transgressing the rules of noso- 
 logy, that these afFe6lions, which arise from a swelling or 
 caries of the ends of the bones, have been ranked among the 
 luxations of the femur. The dislocation, by some called spon- 
 taneous, by others secondary, is in fa6l but the symptom of a 
 more grievous affedlion which always precedes it, and against 
 which our treatment should be principally direfted. The 
 names spontaneous and secondary are well applied to it; the 
 first, because it often appears to come of itself without any 
 
272 or SPONTANEOUS LUXATIONS OF THE FEMUR. 
 
 apparent cause; the second, because it is the consequence of 
 another disease. This luxation, though much more common 
 than the primary, has been unknown from the time of Hippo- 
 crates, who describes it by the name of disease of the hips 
 [morbus coxarum) in two of his Aphorisms, to that of J. L. 
 Petit; who, though he mistook its etiology, has nevertheless 
 given a very exatl description of it in the Memoirs of the Aca- 
 demy of Sciences for the year 1 722. 
 
 Two principal varieties of secondary luxations are pointed 
 out. In the one, the dislocation is occasioned by the swelling 
 of the cartilages which line the acetabulum and cover the head 
 of the femur, and by the enlargement of the cluster of glands 
 in the interior of the articulation, and which have been a long 
 time considered as destined for the secretion of synovia. In 
 the other, it arises from caries of the circumference of the 
 acetabulum or head of the femur. The same causes may occa- 
 sion both varieties; they are either external or internal. 
 
 It is only lately that surgeons have admitted the possibility of 
 secondary luxation of the femur from an external cause. It 
 ■Was generally believed that it could be produced only by internal 
 causes, which, in fa6t, are the most frequent. But it is now 
 clearly ascertained, that contusion of the cartilages and seba- 
 ceous cluster of glands of the joint from a fall on the feet, 
 knees, or great trochanter, may occasion an inflammation and 
 swelling of these parts, by which the head of the femur will 
 be expelled from its cavity. 
 
 From whatever cause it arises, its most ordinary course is 
 this: the cartilages and sebaceous glands, irritated by the ex- 
 ternal violence, or by a scrofulous, venereal, or scorbutic taint, 
 become swelled; the cartilages grow soft, and degenerate into 
 a greyish substance like lard; their sensibility increases, and 
 pains, at fli-st dull and slight, but soon acute and deep-seated, 
 are felt in the diseased joint. The head of the femur, pushed 
 outwards by the tumefaftion, is gradually expelled from its 
 cavity; and when it is on a level with the margin of the ace- 
 tabulum, it is drawn upwards and outwards on the external 
 iliac fossa, by the gluta.'i muscles, and but very rarely down- 
 wards and inwards on the foramen magnum. 
 
 If, on the commencement of the pains, the patient be ex- 
 tended on a plane, and the two superior and anterior spines 
 of the ossa iha put in a horizontal hne, it will be found, on ex- 
 amining the affected limb, and comparing its length with the 
 sound one, that it is somewhat longer than the other. Thi<: 
 
OF SPONTANEOUS LUXATIONS OF THE FEMUR. ayj 
 
 elongation increases as the disease advances, and is never so 
 considerable as just at the period when tlie head of the femur, 
 on a level with the edge of the acetabulum, is about to pass 
 over it. At this moment, the luxation being complete, the 
 head of the femur is carried away by the adlion of the mus- 
 cles, and the limb is on a sudden shortened by several inches, 
 except in the very rare cases in which the bone is carried down- 
 wards and inwards on the foramen ovale. Sharp pains are felt 
 during the whole course of the disease; they may arise from 
 the affeftion of the cartilages, or from the straining of the or- 
 bicular ligament. They have this very striking peculiarity, that 
 the patient complains of them more in his knee than in his hip, 
 which in the beginning of the disease might lead into error. 
 
 When the luxation has taken place, the extremity is much 
 shortened; the knee and point of the foot are turned inwards; 
 the great trochanter is brought nearer the spine of the os ilium; 
 the leg is bent; in fa^l, all the symptoms of primary luxation 
 upwards and outwards are evident. The part over the articu- 
 lation swells and grows round; the skin is soon put on the 
 stretch; the cellular substance swells and becomes thick, and 
 the tumour puts on the appearance of a white swelling; in some 
 time, a softness is felt at different points, which correspond to 
 so many abscesses; these burst, and their openings degenerate 
 into fistulge. A matter, at first serous, and without smell, flows 
 from them; but its qualities are soon changed by the conta£t 
 of the air, it becomes acrid, irritating, and so fetid, that the 
 patient and those near him can scarcely bear the smell of it : 
 this matter, taken into the system by absorption, produces 
 hedlic fever, marasmus, colliquative diarrhoea, and death. 
 
 On opening the body, the acetabulum is found filled by its 
 cartilage, which is converted into a soft greyish substance; the 
 sebaceous glands of the joint are also swelled; the substance of 
 the head of the femur is altered, and its shape is more or less 
 changed according to the continuance of the disease; collections 
 of fetid pus are found in the interstices of the muscles, which 
 are discoloured and diminished in size; and the os innomina- 
 tum and the head of tiie femur are frequently carious. 
 
 Such is the exadl history of the first variety of the disease. 
 The progress of its symptoms is somewhat different from what 
 is observed in that occasioned by caries; different appearances 
 are also found by examination after death. 
 
 In the second variety, the pains are at first acute, and ac- 
 companied with swelling of the hip: considerable abscesses form 
 ^5 
 
274 OF SPONTANEOUS LUXATIONS OF THE FEMUR. 
 
 in this part, which soon burst; a matter, at first inodorous, 
 flows abundantly from them, but in a little time it is vitiated 
 by the contact of the air, and the openings through which it 
 passes degenerate into fistulse. 
 
 The extremity, which was not sensibly elongated, becomes 
 suddenly shortened;* the head of the femur mounts up to the 
 external iliac fossa; and the patient, exhausted by the copious 
 suppurations and heclic fever, is generally carried off. On 
 opening the joint, it is found that the edge of the acetabulum 
 has been destroyed to a greater or less degree by caries, that 
 the cavity has t3een nearly effaced, and that the head of the 
 femur has participated in the disease. 
 
 Both the varieties which we have just described may be in- 
 duced even in a person enjoying good health and of a robust 
 constitution, by a quick commotion of the hip, as happens 
 from making a false step, by a fall on the sole of the feet, on 
 the knees, or even on the great trochanter. A much less de- 
 gree of the cause will produce them, if the patient labour un- 
 der a scrofulous, venereal, or scorbutic taint. Scrofula has 
 been so frequently the cause of them, that it has been supposed 
 that they never originated from any other; but though it may 
 be the most frequent cause, still cases are met in which its ex- 
 istence could not be suspected. 
 
 It may be objedled by those who believe that an internal 
 cause is absolutely necessary to produce the disease, that the 
 contusion of the parts about the joint a6ls only as an occasional 
 cause; that in luxations supposed to be produced by a fall on 
 the great trochanter, the injury, by determining to the articu- 
 lation, the principle which vitiates the humours, only developes 
 a disease, the germ of which was contained in the constitu- 
 tion. 
 
 J. L. Petit, to whom we are indebted for the first accurate 
 description of spontaneous luxations of the femur, gives the 
 following explanation of the manner in which they take place. 
 
 " By a fall on the great trochanter, the head of the femur 
 «' is violently forced against the sides of the acetabulum; and 
 « as it fills exactly the cavity, the cartilages, synoval glands, 
 " and round ligaments, must receive a violent commotion, 
 
 * Sometimes a caries of the acetabulum is not followed by luxation of 
 the thigh, Cifzen Boyer met a case of this kind, in which the bottom of 
 the cavity onlv was afFtfted ; tlie ed^es were sound. The pus made its 
 way into the pelvis, and formed an abscess in the gioin, which burst, and 
 left a fistulous opening. 
 
OF SPONTANEOUS LUXATIONS OF THE FEMUR. 275 
 
 « which will occasion obstruiStion, inflammation, and a depo- 
 " sition of matter: the synovia, especially, will be accumulated 
 " in the cavity of the articulation; the capsule will be distended 
 ** by it, and the head of the femur gradually expelled until it 
 *' is entirely luxated." A little refledtion will shew the futility 
 of this explanation: admitting even that the secretion of syno- 
 via was increased by the contusion, without any increase of the 
 absorption of it, which is always proportionate to its secretion, 
 and that this fluid, accumulated between the neck of the femur 
 and orbicular ligament, distended this latter, still a dislocation 
 would not take place-, a dropsy of the joint would be the con- 
 sequence; for the liquid could not expel a hard resisting body 
 such as the head of the femur; and if the synovia accumulated 
 between the neck of the femur and the ligament should become 
 thick, it would tend more to confine the bone to its cavity than 
 to displace it. Petit knew very well that there was a dispro- 
 portion between the cavity and the head of the femur; but he 
 was mistaken as to the cause of this disproportion, and as to 
 the nature of the substance which filled the cavity, and ex- 
 pelled the head of the femur. 
 
 The prognosis in these luxations is always' unfavourable; it 
 is, however, more or less so, according to the age and consti- 
 tution of the patient, the species of luxation, its continuance, 
 and the cause which has produced it. If the patient be young 
 and strong, the affedlion recent, and accompanied only by dull 
 pains and inconsiderable elongation of the extremity, if there 
 be no internal taint, and if the cause has been external, the 
 danger is much less than if the patient were weak and exhaust- 
 ed, the disease of a long standing, and complicated with fistulx, 
 &c. &c. The prognosis is still more unfavourable when the 
 luxation takes place downwards and inwards, the head of the 
 femur being placed in the foramen ovale, and the extremity 
 elongated. This species of luxation is fortunately very rare; 
 the lameness in it, arising from the elongation of the limb, is 
 much more troublesome than that arising from the shortness 
 of it. 
 
 The principal object in the treatment of this disease, is to 
 prevent the spontaneous luxation. If this once takes place, 
 the danger increases, and the patient may consider himself 
 happy if the head of the femur attaches itself to the portion of 
 the OS innominatum against which it bears, or, making a de- 
 pression, forms a new articulation. Whenever, in consequence 
 of a fall on the feet, knees, or great trochanter, a person feels, 
 
2^6 OF SPONTANEOUS LUXATIONS OF T^E FEMUR. 
 
 in walking, dull pains in the hip, or knee, he should be di- 
 re(Sled to keep the limb in the most perfeft repose, until they 
 entirely disappear. Unfortunately, there are few patients who 
 will confine themselves to bed for a complaint apparently so 
 trifling, or submit to the bleedings and strict regimen neeessary 
 in such a case. At the same time that means such as these are 
 used, emollients and resolvents may be applied to the hip. 
 
 If a constitutional taint be suspe<Sted, our attention must be 
 diredted to it, and remedies given to combat it; thus we exa- 
 mine carefully if the patient labours under scrofula, which is 
 characterized by the softness of the flesh, discolouration of the 
 skin, swelling of the upper lip and sides of the nostrils, and 
 enlargement of the lymphatic glands in some parts of the body, 
 Sec. Sec. If it is discovered that scrofula has produced the dis- 
 ease without the co-operation of any external cause, or if it has 
 given the predisposition, and a fall has been the occasional 
 cause, tonics must be administered, such as good wine, bitter 
 vegetable infusions, extra6l of bark, &c. an issue is at the same 
 time to be established at some distant part, to prevent the de- 
 termination of the humours to the diseased joint. 
 
 A large blistei , applied to the hip, and renewed every twen- 
 ty-four hours, produces very good effects. It seems to deter- 
 mine to the skin the irritation that has taken place in the cavity 
 of the joint, and the abundant serous discharge that it occa- 
 sions, reduces the swelling of the aftecSted parts; this discharge 
 should be kept up by dressing the blistered surface with an 
 irritating ointment. I have seen the best efFefts from a blister 
 applied at the commencement of the disease; the limb, though 
 somewhat elongated, was restored to its natural length by 
 means of it. 
 
 When all the means we have recommended, with perfedl 
 rest, the use of blisters, or any other stimulant, such as moxa, 
 have been used in vain, and the constitutional taint has not 
 been subdued, then all our endeavours should tend to arrest 
 the progress of the disease, by favouring the astachment of the 
 head of the femur to the bones of the pelvis. For this purpose, 
 perfedt rest of the limb is absolutely necessary. The leg and 
 thigh should be kept extended; without this precaution, the 
 patient, from his natural tendency to bend the limb, in order 
 to diminish pam, may give it such a diredlion that it will be 
 entirely useless to him after his recovery. Le Cat cites an in- 
 stance of this kind: the patient having escaped the dangers of 
 a tedius suppuration, recovered, but the femur was grown to 
 
OF SPONTANEOUS LUXATIONS OF THE FEMUR. 277 
 
 the OS Innominatum, so as to form a right angle with it: thus, 
 from having neglected the precaution of keeping the thigh ex- 
 tended, the Hmb was rendered not only useless but inconve- 
 nient, and the person enjoyed but very imperfectly the advan- 
 tages of his recovery. 
 
 If, notwithstanding this treatment, abscesses form in differ- 
 ent points of the tumour, they should be allowed to burst of 
 themselves, in order that the admission of air into them may 
 be retarded as much as possible; and if it be deemed neces- 
 sary to open them, the incision should be very small, and 
 the operation deferred as long as possible. 
 
 When fistulous openings are established, they should be 
 dressed so as to prevent as much as possible the admission of 
 air: and detergent injedlions, composed of barley-v/ater, wine, 
 and honey, a solution of alcali, or any other liquid more or 
 less suited to the sensibility of the parts, should be thrown into 
 the fistulous passages. The strength is to be supported, and 
 every means used to resist the exhaustion occasioned by a long 
 and copious suppuration. Mineral waters, extract of bark, or 
 syrup of bark for very young children, and a nourishing and 
 invigorating diet, are to be used with this view. If the sup- 
 puration diminishes, and a tendency to anchylosis is suspected, 
 the thigh is to be extended as much as the pains will allow, 
 and kept in that position by means of splints; these are neces- 
 sary on account of the patient's constantly endeavouring to bend 
 his thigh, in order to diminish pain. If the patient is young, 
 the epoch of puberty is often favourable to him; the great re- 
 volution which the solids and fluids undergo at this period, 
 proves serviceable; the diseased parts exfoliate, the fistulae dry 
 up, and the head of the femur attaches itself to some point of 
 the OS innominatum. We must not endeavour, by moving the 
 limb, to establish a new articulation; for, by disturbing the 
 head of the femur, the irritation might be renewed, the in- 
 flammation increased, and the anchylosis, a very happy termi- 
 nation of a disease in which the life of the patient is in so great 
 danger, prevented. 
 
 Secondary luxation of the femur downwards and inwards on 
 the foramen ovale, is less frequent than that upwards and out- 
 wards; however, many cases of it have been observed. A 
 young man felt acute pains in his hip, which swelled conside- 
 rably in a very short time; the limb became elongated, and 
 was turned outwards; the knee and point of the foot were in- 
 clined in the same direclion ; the leg was half bent, and a tu- 
 
278 Ot LUXATIONS Of THE PATELLA. 
 
 mour appeared at the superior and internal part of the thigh 
 in the perineum: a fluftuation being discovered in the tumour, 
 it was opened, a great quantity of pus escaped, and the patient 
 found himself relieved. The operator was applauded for his 
 success, but the pus, at first benign, soon became fetid: the 
 patient was exhausted in a short time, and died. On opening 
 the articulation. Citizen Boyer found the acetabulum destroyed 
 by caries, which had committed some ravages also in the head 
 of the femur. 
 
 This luxation presents the same symptoms as the primary 
 one in the same diredlion, and requires the same treatment as 
 the secondary luxation upwards and outwards. When the 
 patients recover by an anchylosis of the head of the femur with 
 the bones of the pelvis, the lameness arisuig from the excess of 
 length in the limb, is much more inconvenient than that re- 
 sulting from its shortness. 
 
 CHAPTER XIV. 
 
 OF LUXATIONS OF THE PATELLA. 
 
 THIS bone, placed on the anterior part of the knee, may 
 be luxated upwards, downwards, outwards, and inwards, 
 but the two last only, properly speals;ing, merit the name of 
 luxation. The patella in fadl cannot be luxated downwards, 
 and descend below the knee, but when the tendon of the ex- 
 tensor muscles of the leg is broken transversely: in which case, 
 the tibia, in the flexion of the leg, will bring down the patella, 
 and displace it in the same manner as it does the inferior frac- 
 tured portion in a transverse fracture of this bone. 
 
 Luxation upwards may depend on a rupture of the inferior 
 ligament of the patella. This substance, though very thick 
 and strong, and the tendon of the redtus anterior and triceps 
 
OF LUXATIONS OF THE PATELLA. 279 
 
 muscles, of which it is only a continuation, are sometime bro- 
 ken transversely; in which case, the muscles carry the bone 
 above the condyles of the femur, as they draw up the superior 
 piece in transverse fraftures of it. It is easily seen, that the 
 dislocations of the patella, in these two cases, is only the effedl 
 of the rupture of the tendon of the extensors of the leg, or of 
 the ligament which unites it to the tibia. 
 
 Luxations inwards or outwards take place when the patella 
 is violently pushed in one or other of these directions. Great 
 relaxation of the inferior ligament of the patella may give a 
 predisposition to them. Such was the case of the young man, 
 the particulars of which are given by Citizen Itard, in the 
 Medical Journal*, the relaxation of the inferior ligaments was 
 such, that the patellae were luxated outwards by the slightest 
 motion of the knees. 
 
 Of the lateral luxations, that outwards is the most frequent. 
 This may arise from the internal edge of the patella proje<fting 
 more than the external, which disposition is favourable to the 
 a<n:ion of the means by which it is pushed outwards, and from 
 the extent of the articulating surface of the external condyles 
 of the femur, which allows the patella to slide easily on it. 
 
 The external condyle of the femur naturally more eminent 
 anteriorly than the internal one, may be depressed; and this 
 depression, whatever may be the cause of it, favours luxation 
 in this diredlion. I have seen among the military conscripts, 
 three cases of luxation of the left patella outwards, which ap- 
 peared to depend on this cause. In these three individuals, 
 from twenty to twenty-two years of age, the patella was placed 
 at the external side of the condyle, without having, however, 
 entirely deserted it; its anterior face was turned outwards, its 
 posterior Inwards; and Its Internal edge was placed anteriorly, 
 and projected under the skin, and the external edge was di- 
 rected backwards. The luxation had taken place in all during 
 infancy. Nothing was easier than to replace the patella; it 
 was done by relaxing the extensors of the leg and bending the 
 thigh; but, unless confined to its place. It was soon again dis- 
 located; pulled by the tendon of the extensors, and Its Inferior 
 ligament, which had contracted an oblique direction, It sllded 
 along to the outer side of the knee. 
 
 A patient, at this moment In the hospital Saint Louis, la-' 
 hours under a luxation of the patella outv/ards, occasioned by 
 a gun-shot wound in the neighbourhood of the knee; the bone 
 is easily reduced, but quickly abandons its situation. In all 
 
2So OF LUXATIONS OF THE PATELLA. 
 
 siich cases, the strength of the articulation of the knee is cott* 
 siderably diminished, and the whole extremity is reduced in 
 size. 
 
 The patella is easily replaced, but difficultly kept in its situ- • 
 ation. The latter purpose might be accomplished, by applying 
 a bandage about the joint, the pieces of which, embracing the 
 sides of the patella, would fix it on the anterior part of the 
 knee. But how is the derangement of this bandage to b6 
 guarded against in the motions of the knee, and what is to 
 prevent the patella from passing outwards? None of the per- 
 sons just mentioned found it necessary to apply for surgical aid; 
 they suffered no great inconvenience from the luxation, and, 
 as it exempted them from military service, they were little 
 anxious to have it remedied. Indeed, it is very probable that 
 no treatment would have been successful in such cases. 
 
 Luxations outwards, produced by external violence, may be 
 either complete or incomplete •, it is seldom complete, as it re- 
 quires a very considerable violence to force the patella entirely 
 from the external condyle of the femur. A gentle flexion of 
 the knee favours it very much; in this posture, the muscles, the 
 tendon of which is attached to the patella, are relaxed, and 
 the internal edge of the patella projects, and is favourably 
 situated for the a£lion of an external force impelled against it. 
 
 Valentin, in his Criticisms on Surgery, gives a case of lux* 
 ation of this kind. The Duke de Coigni, in galloping in the 
 streets, struck his knee 'against the wheel of a carriage, and 
 luxated the patella outwards. He was carried to the house of 
 Botentuit, an ignorant, but very celebrated bone-setter, who 
 made many endeavours to reduce the luxation, but which were 
 fruitless on account of the position in which he had placed the 
 limb; he kept the patient on his feet, and made him extend 
 his leg forcibly. Valentin, family surgeon to the Duke, ar- 
 rived, and reduced the bone "with the greatest facility, by 
 placing the patient on a bed, extending his leg, and bending 
 the thigh towards the pelvis. 
 
 A young man, in running in a room, knocked his knee against 
 the corner of a trunk ; the blow was so violent as to luxate the 
 patella outwards. Citizen Sabatier was consulted; he endea- 
 voured to reduce it, but met very great resistance. Citizen 
 Boyer was called in: by using much force he efFe£led the re- 
 duftion, but not without a great many attempts. 
 
 In luxations of the patella outwards, the patient feels very 
 acute pain, and cannot bend his leg; the knee is deformed. 
 
OF LUXATIONS OF THE PATELLA. 281 
 
 the pulley (fflhe condyles of the femur is felt through the skin, 
 and the patella forms a tumour before the external condyle i 
 instead of the faces of the patella being anteriorly and poste- 
 riorly, the anterior is become the external and the posterior 
 the internal; the internal edge is turned more forwards than 
 inwards, and the external is become nearly the posterior. This 
 position of the patella has made $om6 believe that it might be 
 luxated by turning half over, that is, by placing itself per- 
 pendicularly before the pulley of the femur, with one of its 
 edges, now become posterior, lodged in the groove of the pul- 
 ley. Others have even admitted the possibility of a complete 
 inversion, in which the posterior face of the patella becomes 
 the anterior. But it cannot be conceived, that the extensors 
 of the leg, and the inferior ligament of the patella, could allow 
 such an inversion to take place j and if the patella was only 
 half inverted, and one of its edges rested on the pulley of the 
 femur, the points of contact would be so few, that it would 
 slip into its natural position. 
 
 The symptoms of luxation inwards are nearly the same as 
 those just described: there is this difference, however, that the 
 tumour formed by the patella is placed internally. In both 
 species, if called in before the swelling takes place, we can feel 
 through the skin the two faces of the patella; the posterior, 
 excavated, turned towards the femur, and the anterior pro- 
 jefting under the skin. 
 
 A complete luxation cannot take place without great relaxa- 
 tion oi the inferior ligament, and tendon of the extensor mus- 
 cles, or without very considerable external violence; in which 
 case the luxation, easy to reduce, would not be the most dan- 
 gerous symptom. 
 
 In every species of luxation of the patella, redu<Stioa is to be 
 eSe£ted as soon as possible. It is done by placing the patient 
 on a bed with the leg extended and the thigh bent. In this 
 position the extensor muscles and their tendon, as well as the 
 inferior ligament of the patella are relaxed; and this bone may 
 be moved and pushed with ease in the direction which the spe- 
 cies of luxation requires. We think it is always possible to re- 
 duce the patella, without making an incision Ln the integu- 
 ments, and introducing a spatula under the bone. This ope- 
 ration, though recommended, has never been performed, and 
 never could, without bringing the patient into great danger. 
 
 The noise made by the bone in reassuming its place, and the 
 disappearance of the symptoms, announce the reduction; the 
 36 
 
282 OF LUXATIONS OF THE 
 
 patient can now bend and extend the leg. The mflammatory 
 swelling, which generally supervenes, is to be subdued by bleed- 
 ings and topical applications. This treatment, with a few days 
 rest, will be sufficient; after some time the knee is to be moved 
 gently, to prevent a stiffness of the joint, which, without this 
 precaution, is very likely to take place. 
 
 CHAPTER XV. 
 
 OF LUXATIONS OF THE BONES OF THE LEG. 
 
 THE tibia, at its articulation with the condyles of the 
 femur, may be luAated in four different diredlions; viz. 
 anteriorly, posteriorly, and laterally to either side of the knee. 
 The luxation backwards is always incomplete*, it could not be 
 otherwise without a very great laceration of the soft parts. It 
 is as often secondary as primary, and in such cases it is a con- 
 comitant of white swelling, a disease much more grievous than 
 the dislocation, and almost always requiring amputation. 
 
 Luxation forwards is still more rare than that backwards; 
 the ligaments of the knee and the greater part of the tendons 
 surrounding it, being placed nearer its posterior than anterior 
 part, prevent the too great extension of the leg. Luxations 
 inwards and outwards are the most frequent. They are always 
 incomplete, on account of the extent of the articulating sur- 
 faces, and the strength of the part surrounding the articula- 
 tion. They take place from the femur being drawn either in- 
 wards or outwards, while the leg is fixed. 
 
 The luxation backwards is distinguished by attending to the 
 following circumstances: it is impossible to extend the leg; the 
 patella, closely applied to the pulley of the femur, forms an 
 eminence, under which there is an empty space, and the in- 
 ferior ligament is extended obliquely downwards and back- 
 
BONES OF THE LEG. 283 
 
 wards; and a proje£lion formed by the extremity of the tibia, 
 is felt in the ham, &c. &c. 
 
 Symptoms of an opposite kind accompany the luxation for- 
 wards. Those inwards and outwards are easily known from 
 the deformity of the joint. In the first, the external condyle 
 of the femur is lodged in the internal cavity of the tibia, and 
 the internal condyle proje<^s and forms a tumour at the in- 
 ternal side of the knee: the contrary takes place in the se- 
 cond. When they are complete, which is extremely rare, 
 the tibia is carried entirely to the internal or external side of 
 the femur. In every case of luxation the laceration of the 
 ligamentous parts is so great, that the ends of the tibia and 
 femur may be easily placed in their natural situations; there is 
 ^^scarcely occasion for even gentle extension and counter-exten- 
 sion. It happens sometimes, notwithstanding the extent of the 
 articulating surfaces, that a return of the luxation takes place 
 from the great laceration of the parts which should confine the 
 bones. To prevent this, an apparatus similar to that used in 
 fradlures of the thigh is to be applied. Disagreeable symptoms, 
 occasioned by the laceration of the soft parts, are always to be 
 expedledj our attention should be particularly diredled to mo- 
 derate and subdue them. The antiphlogistic regimen must be 
 stridlly observed, and the other means of preventing and sub- 
 duing inflammation had recourse to. If the inflammation ter- 
 minates in suppuration, the abscesses are to be opened by 
 making a large incision. In general, large openings are to be 
 made in abscesses seated in the neighbourhood of joints, to allow 
 a free evacuation of the pus, which by stagnating might become 
 acrid, and attack the cartilages of the joint; but, if the abscesses 
 be formed in consequence of a caries of the ends of the bones, a 
 very small opening is to be made, in order to prevent as much 
 as possible the admission of air. If the inflammation terminates 
 in gangrene, we must wait until nature has arrested the progress 
 of the mortification, and then amputate. The separation of 
 the living from the dead part, is marked by an inflamed circle. 
 The progress of the mortification is very often so rapid that it is 
 impossible to save the patient; and perhaps a complete luxation 
 of the tibia from the femur may be considered as a case re- 
 quiring immediate amputation. However, before a general 
 precept of this kind can be established, it must be founded on 
 observations well made and judiciously compared. 
 
 The fibula is difficultly displaced from the tibia, with which 
 it forms two articulation* ; nevertheless we may conceive, that, 
 
lS4 OF LUXATIONS OF THE FOOT. 
 
 in a violent and sudd&n turn outwrards of the foot, if its liga- 
 ments are naturally relaxed, it may slide from below upwards, 
 so as to touch the external condyle of the femur. Citizen 
 Boyer has seen a luxation of this kind in consequence of a dis- 
 location of the foot outwards. By putting the foot in its na- 
 tural direftioh, the fibula descended into its proper place. 
 Compresses soaked in resolvent liquids were placed over the 
 parts, and a roller was passed round the foot and leg, to pre- 
 vent a return of the luxations. The patient had a tardy reco- 
 very, and some stiffness of the foot remained, though the pre- 
 caution of moving it, when the state of the parts would admit 
 it, was not hegledled. 
 
 CHAPTER XVL 
 
 OF LUXATIONS OF THE FOOT. 
 
 THESE luxations are but seldom met with; the great vio- 
 lence necessary to produce them, and the difficulty of 
 effecting them, account for their unfrequency. Before they 
 can take place, the astragalus must be partially or totally forced 
 from the quadrangular cavity formed for it by the two bones 
 of the leg, and in which it is received like a tenon in a mor- 
 tice. The sides of the articulation are strengthened by very 
 strong ligaments, which go from the tibia and fibula to the os 
 calcis and astragalus, and by the two malleoli. An external 
 violence, it is true, may distend or even br^ieak these ligaments; 
 but its force being almost entirely spent in producing this effe£t, 
 will not be sufficient to force the astragalus from the cavity in 
 which it is enclosed. 
 
 The foot may be luxated inwards or outwards, forwards or 
 backwards, and the luxation in any of these direftions may be 
 complete or incomplete. Luxations inwards and outwards are 
 
OF LUXATIONS OF THE FOOT. 2S5 
 
 the most frequent; the former however occurs more frequently 
 than the latter: the internal malleolus not descending so low as 
 the external, the astragalus has a less space to describe from 
 without inwards, than in the contrary direction. It is occa- 
 sioned by a violent abdu£tion of the foot, and is easily known 
 from the derangement of this part, the sole of which is turned 
 outwards, and the back inwards; from the pain, and inability 
 of moving the foot; and lastly, from the eminence formed be>- 
 low the internal malleolus by the astragalus. 
 
 In the luxation outwards, it is equally impossible to move 
 the foot; the sole is turned inwards and the back outwards, 
 and the astragalus forms an eminence below the external mal- 
 leolus. 
 
 Luxations of the foot are always dangerous; their conse- 
 quences may be so dreadful as to occasion death, and in very 
 many cases they render amputation necessary. However, the 
 prognosis is not always so unfavourable; for it is clearly pro- 
 ved, that many patients have recovered without any thing ex- 
 traordinary having occurred during their treatment. This in- 
 validates the general rule laid down by J. L. Petit, to ampu- 
 tate before twenty-four hours after the luxation. It is also now 
 well ascertained that dislocations likely to produce the most 
 mischievous consequences, have had a happy termination, and 
 that this was the case, though the soft parts have been very 
 much injured, the ligaments nearly quite ruptured, and the 
 astragalus completely removed from the foot. 
 
 The reduction should be accomplished as soo» as possible, in 
 every luxation of the foot; if deferred, the inflammatory symp- 
 toms and swelling which supervene, will render it diiHcult and 
 painful. To effect this, one assistant makes counter-extension 
 by fixing the leg, and another draws the foot, whilst the sur- 
 geon pushes the latter part in a direftion contrary to that in 
 which it was luxated. If the luxation be inwards, the external 
 edge of the foot must be depressed by elevating the internal, 
 when it is found that the ligaments yield to the extension: the 
 contrary is done in luxations outwards. The articulation is 
 covered with compresses moistened with resolvent liquids; and 
 splints which reach below the sole of the foot, are applied on 
 the inside and outside of the leg. 
 
 Consequences more or less disagreeable are always to be es- 
 pefted, which may be moderated or even prevented by copious 
 and repeated bleedings. Sometimes, notwithstanding the enor- 
 mous derangement and laceration of the soft parts, no bad 
 
286 OF LUXATIONS OF THE FOOT. 
 
 symptom succeeds, and the patient recovers with an unexpect- 
 ed rapidity; but in very many cases, violent inflammation su- 
 pervenes and quickly terminates in gangrene. In other cases 
 the inflammation terminates in suppuration, abscesses form and 
 heal up, and the patient recovers. Sometimes, however, there 
 is a caries of the ends of the bones conjoined with them. 
 
 The experienced praftitioner is to judge, from the nature 
 and violence of the symptoms, when immediate amputation is 
 necessary. A great number of observations posterior to those 
 of J. L. Petit, prove that, by following his instru(Slions, we 
 should often amputate a limb which might be preserved. It is 
 also ascertained by experience, that the astragalus may be ex- 
 tirpated with advantage, when the laceration is such, that it is 
 only attached by a few shreds of ligament. The tibia, in con- 
 sequence of this extirpation, descends, and rests on the supe- 
 rior face of the os calcis, to which it grows, and the patient 
 recovers, it is true, with an anchylosed joint; but such a termi- 
 nation is preferable to losing the foot by amputation, or run- 
 ning the risk of the dangerous symptoms arising from preser- 
 ving the astragalus. Ferrand performed this operation on an 
 invalided soldier, who was in the habit of carrying the bone in 
 his pocket. Desault performed it three times with success. 
 One of his three patients (a female) died three months after 
 the operation; but she evidently fell a vitSlim to an hospital 
 fever, which was by no means connedted with the complaint 
 for which she was admitted into the hospital. On dissecting 
 the foot, the extremity of the tibia was found already partially 
 attached to the os calcis. There is no doubt but that the ope- 
 ration would have been crowned with success, had the person 
 survived the other disease. 
 
 Fracture of the fibula near its inferior extremity, is a fre- 
 quent complication of luxation of the foot inwards. This bone 
 is to be carefully examined in all such cases, and the foot is to 
 be supported, whether the fibula be fractured or not, by means 
 of the ordinary apparatus for fra<ftures of the leg. 
 
 Luxations forwards and backwards, less frequent than tho^e 
 described, are however sometimes met with. The first is occa- 
 sioned by a fall backwards, while the foot is fixed to the 
 ground; the second by a fall on the feet, with the body inclined 
 forwards, and the leg much bent. The luxation forwards is 
 more difficultly produced than that backwards, on account of 
 the articular pulley of the astragalus, which inclines towards 
 the posterior side, being permitted to slide much on the tibia. 
 
OF LUXATIONS OF THE FOOT. IS7 
 
 ^frlthout abandoning it in the extension of the foot. When 
 the extension is carried too far, luxation forwards is produced. 
 
 In the luxation backwards, the external and posterior liga- 
 ments, and the posterior part of the capsule, are torn; in that 
 forwards, the anterior and external ligaments, the anterior 
 fibres of the internal lateral ligament, and the anterior part of 
 the capsule, are torn. The symptoms of the first species are, 
 a diminution of length in that part of the foot between the lower 
 part of the leg and the anterior extremity of the toes, elonga- 
 tion of the heel, tension of the ten do Achillis, and relaxation 
 of the extensors of the toes. It is impossible either to bend or 
 extend the foot: this symptom distinguishes luxation from 
 sprain, in which the foot may be moved, though not without 
 pain, however high the inflammatio,n may be. 
 
 Contrary symptoms accompany the luxation forwards : the 
 foot is lengthened, the heel is shortened, and the foot, much 
 extended, cannot be bent, &c. 
 
 The redu^ion of both is easily effedted ; after which it will 
 be necessary to use efFeflual means to prevent a relapse. The 
 mode of treatment to be afterwards observed, for subduing the 
 unfavourable symptoms that supervene, is the same as that 
 pointed out for luxations inwards and outwards. "When gan- 
 grene takes place in any luxation of the foot, we must defer 
 amputation until its ravages are arrested. In cases where the 
 inflammation is moderate, and the destruftion of the soft parts 
 not considerable, the articulation may be preserved; and to 
 prevent a stiffness of the joint, the foot is to be moved as soon 
 as circumstances will admit of it. 
 
 The very thick and short ligamentous substance which unites 
 the astragalus to the os calcis, binds them so strongly together, 
 that they follow one another in their motions, and form, as it 
 were, but one bone. Hence they are never completely sepa- 
 rated, even in the most desperate cases of luxation of the foot; 
 but one or both of them may be luxated from the scaphoides 
 and cuboides. The transverse dire(Stion of the articulation 
 formed by these four bones, suggested to Chopart the inge- 
 nious idea of amputating only a part of the foot. But these 
 luxations, less dangerous thau the others, can be occasioned 
 only by a violent effort, in which the anterior part of the foot 
 is fixed, as happened in the two cases related by J. L. Petit: 
 the foot was fastened in an iron grate, whilst the body was 
 drawn backwards. The astragalus and os calcis may, under 
 these circumstances, be luxated, but particularly the former, 
 
i88 OF DROPsy OF the articulations. 
 
 the head of which slides from below upwards, in the cavity of 
 the posterior face of the scaphoides, and forms a tumour on 
 the back of the foot. The inflammatory swelling renders it 
 often difficult to ascertain this luxation. It is not easily re- 
 duced, even shortly after it has taken place. Citizen Boyer 
 failed in a case of this kind, in which the head of the astraga- 
 lus was luxated upwards and inwards, by a fall from a horse; 
 but in some time the person felt no inconvenience from the 
 affe£tion, he could walk without pain or lameness, and nothing 
 remained but the deformity occasioned by the tumour. 
 
 The other bones of the tarsus and metatarsus are too strongly 
 tied together to admit of luxation. The phalanges of the toes 
 cannot be luxated by external violence, on account of their 
 shortness. However, the possibility of luxation of the first 
 phalanx of the great toe from the first bone of the metatarsus 
 may be easily conceived. It is not necessary to give here the 
 rules to be followed in such a case. They consist in reducing 
 the luxation, and amputating the great toe, when the state of 
 the soft parts renders it impossible to preserve it. 
 
 CHAPTER XVII. 
 
 OF DROPSY OF THE ARTICULATIONS. 
 
 THE synovial fluid, which lubricates the surfaces of all 
 the joints, may be accumulated in such quantity in the 
 capsule which secretes it, as to form a disease called by authors 
 hydarthrus, or dropsy of the joint. Though the possibility of 
 this accumulation taking place in all the articulations may be 
 conceived, yet there is no well-attested instance of this happen- 
 ing in any of them but in the knee. 
 
 Dropsy of the joints seldom depends on a general affe<Slion 
 of the system, and rarely co-exists with other dropsical af- 
 
OF DROPSY OF THE ARTICULATIONS. 289 
 
 feftions, such as hydrothorax, ascites, and anasarca. It ap- 
 pears to be a partial afFeftion, and to be produced by local 
 causes, which a6l by destroying the balance between the ex- 
 halation and absorption of the synovia. The accumulation of 
 this sero-albuminous fluid seems to arise in most cases from an 
 increased exhalation, and not from a diminution of absorption. 
 In fact, affedlions of this kind come on, in general, from vio- 
 lent exercise of the articulation, from fatiguing the hgamcnts, 
 and from the repeated friction of its surfaces in too long and 
 laborious exercise. 
 
 Motion, as we have established in another work, is the prin- 
 cipal stimulus by which the secretion of the synovia is increased, 
 and the fluids determined to the joint. This determination is 
 considerable in proportion to the friction and pressure of the 
 ends of the joint against one another. When this stimulus is 
 carried to a certain degree, an acStive exhalation, or rather 
 slight phlogosis, is produced, and the serous secretion is very 
 considerably increased. It is in a similar way that dropsies of 
 the breast and abdomen are often occasioned by a slow and la- 
 tent inflammation of the pleura or peritoneum. 
 
 The nqf^ure of the remote causes of hydarthrus corroborates 
 what we have advanced concerning its formation. It is very 
 often a consequence of acute rheumatism, and sometimes forms 
 a crisis of that disease. Many observers, and particularly 
 Storck, have remarked the tendency which acute rheumatism 
 has to terminate by an effusion of a sero-lymphatic fluid into 
 the cellular substance in the neighbourhood of the joints of the 
 lower extremities, or into the interior of the joint itself. The 
 more rapid the progress of the inflammatory symptoms, the 
 more prompt is the effusion, consequently it takes place slowlj'- 
 in chronic rheumatism and in chronic gout. The swelling of 
 the joints in these complaints, and the deposition of matter 
 which takes place into the parts about the articulation, may 
 also produce an increased exhalation of synovia. The pains 
 which accompany white swellings often occasion an accumula- 
 tion of synovia in the capsule of the joint. I have seen, in 
 dissedting two of these swellings of the knee, the synovia col- 
 lected nearly to the quantity of two ounces. 
 
 But we must remember that the inflammation which pro- 
 duces dropsy of the joint is only slight-, if very considerable, it 
 would suspend the secretion of synovia, and give rise to anchy- 
 losis by the mutual adhesion of the dried surfaces of the joint. 
 AVe are decidedly of opinion, that the articulation of the knee 
 'J7 
 
igO OP DROPSY OF THE ARTICULATIONS. 
 
 only has hitherto presented a colleftion of synovia sufficient to 
 merit the name of dropsy: such an accumulation never takes 
 place in the hip joint, though J. L. Petit attempts to explain 
 spontaneous luxations of the femur from this cause. 
 
 We must not confound this disease with encysted tumours, 
 which are sometimes formed on the sides of the knee near the 
 patella. The latter are circumscribed, and a fluctuation is felt 
 in them; they are not accompanied with pain or discolouration 
 of the skin; on opening them, an albuminous fluid escapes, 
 and the sides of the cyst are niade to adhere to one another by 
 pressure ; or when this does not succeed, by means of an irri- 
 tating injedlion, which excites an inflammation on its surface. 
 This practice is free from danger, because the cyst is shut on 
 all sides, and has no communication with the interior of the 
 joint. We must also take care not to confound with dropsy 
 of the joint certain white swellings, in which the cellular sub- 
 stance, distended with fluid, presents a kind of fluctuation. 
 This symptom is particularly apt to lead into error in swellings 
 of the cluster of lymphatic and sebaceous glands situated above 
 the patella, between the tendon of the extensor muscles of the 
 leg and the anterior and inferior part of the femiif. In the 
 commencement of some white swellings, this tissue, distended 
 with lymph, elevates and pushes forwards the tendon of the 
 extensors of the leg, displaces the patella, and raises it up 
 from the condyles of the femur. In these cases, the patella is 
 replaced by pressure, and the swelled mass being displaced, 
 forms two tumours at the sides of the tendon, which are tense 
 and elastic, and have an internal motion; but the sensation 
 communicated by this motion is very diflerent from that occa- 
 sioned by the undulation of a fluid: it is like that of something 
 Slipping from under the finger. However, there is such simi- 
 larity in these symptoms, that an inattentive surgeon may be 
 easily led into error. 
 
 Arthritic, cedematous, and white swellings of the knee, and 
 foreign bodies formed in it, are accompanied with symptoms 
 so different from those of dropsy of this joint, that there is no 
 occasion to point them out here. The marks by which the 
 existence of the latter affection is ascertained are these: a dull 
 pain is felt in the articulation, the knee loses its oval form, and 
 presents an irregular colourless tumour, in which a fluctuation 
 is felt at those places where the capsule is slack, and forms little 
 round eminences which project about the joint. The most con- 
 siderable of these arc placed at the sides of the patella, which 
 
# OF DROPSy OF THE ARTICULATIONS. 2gi 
 
 is itself pushed upwards by the fluid, but it may be replaced by 
 bending the leg. The form of the tumour is varied by the mo- 
 tions of the knee; but it always proje<^ts more at the anterior 
 part of the articulation than in the ham, at which place the 
 synovial membrane presents only a small surface, and is sup- 
 ported by the cross ligaments which pass behind it. A flu<Slur 
 ation is felt by striking the tumour; the thinness of the soft 
 parts renders it very easy to ascertain the undulation of the 
 fluid. The nature of the disease is sufficiently manifest when 
 all these symptoms are present. 
 
 The prognosis is unfavourable, on account of the difficulty 
 of discussing the tumour, and the danger of a caries of the car- 
 tilages and ends of the bones, or an anchylosis, supervening. 
 
 As dropsy of the knee-joint never depends on the causes 
 which produce general dropsy; and as, instead of appearing in 
 persons labouring under general debility, it is always met with 
 in the strong and robust, a particular mode of treatment is re- 
 quired in it. Stimulants, purgatives, diuretics, or sudorifics, 
 are either useless, or at least can give but a very feeble assist- 
 ance. It is from topical applications that benefit is to be ej^- 
 peifted. The mildest of these are to be commenced with, and 
 they in general succeed in recent cases, in which the efllision 
 has not been considerable, and has been suddenly formed in a 
 crisis of acute rheumatism, or any other acute disease. Resol- 
 vent liquids, such as camphorated spirit of wine, frictions with 
 a brush, or warm flannel impregnated with some aromatic va- 
 pour, with volatile camphorated liniment, alcohol, ether, or 
 even with mercurial ointment as advised by Bell, determine the 
 fluids to the skin, increase the insensible perspiration of which it 
 is the organ, and promote the absorption of the effused fluid. 
 Fumigations with the vapour of vinegar, from which Monro 
 witnessed good effects, with the vapour of benzoin and other 
 balsams, and pumping with warm water in which neutral salts 
 have been dissolved, a£t in the same manner. But of all topical 
 stimulants, the most ac^live and most effecHiual is a blistering 
 plaster, in which the proportion of cantharides is not so consi- 
 derable as to cause great vesications. Tralles used synapisms, 
 and Storek applied cataplasms of the ranunculus. We must, 
 however, take care not to carry the use of these remedies so 
 far as to disorganize the structure of the cellular tissue, which 
 often occasions ulcers difficult to cure, and extremely painful. 
 For the same reasons we are not to use cupping and scarifying 
 but with great circumspe£lion. 
 
292 OF DROPSY OF THE ARTICULATIONS. W 
 
 When all these means have been used for a sufficient time 
 ■without any benefit, and when the turnour impedes the mo- 
 tion, and causes a contraction and atrophia of the limb, we 
 must have recourse to a surgical operation. It consists in ma- 
 king a puncture with a trocar into the cavity of the tumour, 
 and allowing the water to escape through the canula. This 
 operation, though easily performed, is a delicate and danger- 
 ous one, on account of the admission of air into the joint. 
 The conta£t of air has not, as we shall see in treating of wounds 
 of the articulations, all the bad effefts attributed to it by au- 
 thors. However, the morbid state of the synovial membrane, 
 and the irritation already existing in it, may render it more 
 sensible to the impression of this fluid than it would be were 
 there no disease in the joint; and, in faft, cases have occurred 
 in which the qualities of the synovia were considerably changed 
 by the contact of air: this fluid, instead of being inodorous, ac- 
 quired a disagreeable odour, lost its transparency by the mix- 
 ture of a purulent matter, produced an inflammation which 
 extended to the capsule and cartilages, and at last occasioned a 
 caries of the ends of the bones. 
 
 To prevent these direful consequences, and the introduftion 
 of air which occasions them, a superficial incision is to be made 
 in the skin at the most projecting part of the tumour; after 
 which, the lips of the wound are to be much separated, and 
 the trocar used in the operation for the hydrocele, pushed cau- 
 tiously in an oblique direction from the bottom of the incision 
 into the cavity of the tumour. The skin collapses after the 
 evacuation of the water, and covers the pundture made by the 
 trocar, the canula of which is to be drawn away when all the 
 water has drained ofi\ 
 
 "When the operation is finished, the patient is to be put to 
 bed with his knee half bent ; the joint is to be covered with 
 cloths wet with spirituous liquors, or other astringent fluids, 
 with the view of preventing the return of the efixision. We 
 will m.ention, in the chapters on white swellings and anchylo- 
 sis, the treatment to be adopted in cases in which the synovia 
 has its qualities changed, and produces caries or anchylosis. 
 
293 
 
 CHAPTER XVIII. 
 
 OF FOREIGN BODIES FORMED IN. THE 
 ARTICULATIONS. 
 
 THE foreign bodies which are formed and developed in the 
 interior of the articulations, are to be carefully distin- 
 guished from arthritic concretions deposited in their neighbour- 
 hood. These foreign bodies, which alone will be considered 
 in this chapter, may take their origin in the inside of every ar- 
 ticulation in which there is motion. They have been found in 
 the articulation of the lower jaw with the temporal bones, in 
 that of the wrist with the bones of the fore-arm, and that of 
 the foot with the leg ; but no joint is more subjecl to them than 
 the knee. Ambrose Pare has made mention of these substan- 
 ces ; latterly, praftitioners have directed their attention to them, 
 and have proposed methods of removing them. 
 
 These foreign bodies have various appearances, and are found 
 in greater or less quantity : sometimes they resemble a frag- 
 ment of cartilage, which moves about in the joint, but which 
 is attached to the capsular membrane-, at other times they are 
 detached, hard, and, as it were, inorganic, and can be moved 
 to any part of the joint. A concretion of this kind, the size 
 of a large hazel-nut, was found in the knee of a woman who 
 died in the hospital Saint Louis. Citizen Fourcroy, who has it 
 in his possession, compares it to tubercles found in certain fishes, 
 for instance, to those on which the prickles of the ray-fish are 
 elevated. As to their number, it varies, from one, which is 
 the most common, to twenty-five, a number at first sight very 
 considerable, but for which we have the incontestable evidence 
 of the illustrious Morgagni. Their size is very variable ; some 
 have been found of an inch and a half in their greatest diameter, 
 whilst others have scarcely equalled the size of a lentil. They 
 have generally the form of this seed, but they have been met 
 with of various forms, as long, oval, rough, or broken on 
 their surface, concave, or convex. The chemical analysis of 
 them shews that the cartilaginous ones are chiefly composed of 
 
294 OF FOREIGN BODIES 
 
 albumen, and the hard solid ones principally of phosphate of 
 lime. 
 
 It is difacuU, without doubt, to give an explanation of the ori- 
 gin and growth of these substances, but it is certain that they al- 
 ways impede more or less the motion of the joint in which they 
 grow. Sometimes they succeed to the swelling and contusion 
 occasioned by a fall or blow on the knee ; at other times they 
 arc formed spontaneously without any apparent cause ; and in 
 both cases their presence is indicated by tumefaction of the 
 knee, which is increased by rest, and diminished by moderate 
 exercise. Are they formed by the crystallization of the salts 
 held in solution by the synovia, in the same way as the crystal- 
 lizable parts of the urine form calculi in the bladder ? How, in 
 this case, do they become organized ? for many of them have 
 vessels, and evident marks of organization. Theden supposed 
 that they were formed by a portion of the synovial cluster 
 of glands on the outside of the capsule, which was bruised 
 and nearly detached by the shock occasioned by a false step. 
 Some authors have imagined that they were portions of car- 
 tilage detached from those covering the ends of the bones, 
 or placed between them. Morgagni ascertained that they 
 could not originate in this manner, for the articulation and car- 
 tilages were perfetStly sound and whole in the subjefts in whom 
 they were found in the greatest number. Nothing then is 
 more obscure than the etiology of this affection. Happily, 
 though its causes are involved in obscurity, it is easily distin- 
 guished, and can be treated with great hopes of success. 
 
 If these substances are free and detached, they can pass ea- 
 sily from one part to another of the articulation, and enter in- 
 to all its corners •, in this case, it is difficult to establish the ex- 
 istence of them, but it is particularly difficult to extract them ; 
 the moveable body, whilst we are making the incision to ex- 
 tract it, may slide from the place where it projedled under the 
 skin, and fall into the cavity in the posterior part of the knee. 
 Sometimes it occasions no pain : this arises from the body be- 
 ing fixed in some place in which it does not impede the motion 
 of the knee ; as, for example, at the sides of the patella, or 
 of the tendon of the extensors of the leg. At other times it 
 occasions much distress: this is caused by its being placed be- 
 tween the posterior face of the patella and the articular pulley 
 of the femur. As it can occupy alternately these different 
 places, it is easy to explain, as Bell observes, why patients af- 
 fected with this complaint are often roused from their sleep by 
 
Formed in the articulations. 295 
 
 sharp pains arising from the change of situaticn of the body 
 during sleep. 
 
 A more or less considerable enlargement takes place round 
 the knee during the continuance of the pains, but it is still easy 
 to feel the body through the skin and capsule. It forms an emi- 
 nence under the integuments, and may be pushed in any di- 
 retftion, and made to projevSt at the internal or external sides of 
 the inferior ligament of the patella, at the internal cr external 
 sides of this bone itself, or of the tendon of the extensors of 
 the leg. Sometimes the laxity of the integuments and capsule 
 is so great, that we can seize the body and twist it. Desault 
 has seen a case of this kind. 
 
 It is impossible to obtain a resolution of these substahces. 
 This desirable termination cannot take place but by means of 
 vital adtion ; now, this aftion is so little to be expeOed in the 
 greatest number of them, they being in some degree inorganic, 
 and topical stimulants and resolvents can aft with so little efFedt 
 through the integuments, that the removal of them by these 
 means is scarcely to be looked for. Some English surgeons 
 have proposed to fix and confine the body in a part of the ar- 
 ticulation where it could not impede motion, and where it 
 might form an adhesion with the capsule ; but how are we to 
 confine a body which tends incessantly to change its situation ? 
 Besides, the adhesion cannot be formed without a certain de- 
 gree of inflammation in both surfaces, of which the foreign 
 substance is very rarely susceptible. Lastly, should the adhe- 
 sion, which requires a certain degree of organization in the body, 
 take place, the concretion would be susceptible of growth, 
 and in time would impede, by its size, the motion of the knee. 
 
 The most simple, prompt, and certain method of cure, is 
 the extraction of the foreign body, an operation always easily 
 performed, and free from danger, if the following rules are 
 observed. The patient being stretched on his back, with the 
 leg extended, in order to relax the soft parts at the anterior of 
 the articulation, the surgeon looks for the foreign body, and 
 bringing it to the internal side of the patella, at which place 
 the capsule is very lax, fixes it with his thumb and fore-finger. 
 An assistant draws outwards the skin over the patella, and the 
 surgeon makes a longitudinal incision, through the integuments, 
 on the body. The incision should be made deep enough by 
 one stroke of the knife, and proportioned to the size of the 
 body to be extrafted. Sometimes it is forced through the in- 
 cision by compressing it between the fingers. If it be attached 
 
1^6 OF FOREIGN BODIES 
 
 by a fold of the capsule, which serves it as a ligament, this 
 is to be divided with' a history or scissarsj if there be occa- 
 sion to enlarge the incision, it is to be done with the knife ; 
 and pincers, or other instrun:ients which may lacerate, bruise, 
 or occasion inflammation of the surfaces of the joint, are never 
 to be intrqduced. The substance being extracted, the assistant 
 removes his hand, and leaves the skin to its own elasticity, 
 which brings over the wound in the capsule the portion of the 
 integuments which had been drawn to one side. 
 
 By making the incision in this way, the admission of air into 
 the joint is prevented, and all the bad consequences, such as 
 inflammation, suppuration, and caries, are obviated. 
 
 After having extracted one, or as many bodies as may be 
 found in the articulation, the lips of the wound are imme- 
 diately brought together by means of adhesive plaster ; some 
 compresses, wet with resolvent liquids, are applied over the 
 joint, and the whole dressing is supported by some turns of a 
 roller drawn pretty tight. The leg is to be placed on a pillow, 
 and kept extended, in order to relax the soft parts about the 
 incision, and thus prevent pain and the approach of inflamma- 
 tion. 
 
 Though the precaution of making the incision in the skin, 
 in a line difierent from that in which it is made in the capsule, 
 is rational, yet it is not absolutely necessary to the success of 
 the operation. Many surgeons have omitted it, and afterwards 
 obtained the immediate union of the divided parts; which 
 proves, as will be mentioned in treating of wounds of the 
 joints, that wounds of the articulations are attended with less 
 danger than the ancients and a great number of the moderns 
 have imagined. The pain occasioned by the extradlion is in- 
 considerable, but it may be acute, if the patient be extremely 
 sensible to impressions, or if a considerable branch of the in- 
 ternal saphena nerve, which is very variable in its diredlion, 
 come under the edge of the history. The loss of blood, when 
 even one of the articular arteries is divided, is very inconside- 
 rable; it scarcely merits the name of hsemorrhage, and is easily 
 stopped by bringing together the sides of the wound. For 
 some days after the operation, the compresses should be fre- 
 cjuently moistened with resolvent liquids, and the knee kept 
 perfedlly at rest; the patient should not be permitted to rise 
 before the fifteenth or twentieth day, though the wound may 
 have cicatrized in the first week; for it is much better, in these 
 cases to carry precaution too far, than to be deficient in it. 
 
FORMED IN THE ARTICULATIONS. 297 
 
 When, on account of the admission of air into the articula- 
 tion, or the improper use of instruments in extracting the body, 
 inflammation takes place, it is combated by emollient applica- 
 tions and copious and repeated bleedings. If abscesses form, 
 they are to be opened; and when the symptoms have abated, 
 the limb is to be gently moved, and the motion increased every 
 day, in order to prevent a stiffness of the joint. All the ob- 
 servations that we have made here respedling these bodies are 
 applicable to those only found in the knee; and this is the only 
 joint on which it has been necessary to perform an operation in 
 order to remove them. Their presence in other articulations 
 would not be so easily discovered, neither would it cause the 
 same inconveniences. Should extraftion, in these cases, be 
 necessary, the operation would be so much the more danger- 
 ous, as the joint is deep-seated, and surrounded with import- 
 ant parts. 
 
 CHAPTER XIX. 
 
 OF WOUNDS OF THE ARTICULATIONS. 
 
 ALIj the ancient writers on surgery speak in the same 
 terms of the danger of wounds of the articulations; and 
 almost all modern authors are of their opinion. We will prove, 
 in this chapter, that wounds of the articulations, sometimes 
 followed by serious consequences, often heal with the greatest 
 facility, and that the apprehensions of authors respefting them 
 are imfounded. 
 
 A man was wounded in the elbow by a piece of glass, which 
 penetrated into the cavity of the joint. The glass was extra«rt- 
 ed, and the lips of the wound were brought together, and 
 supported by adhesive plaster; his recovery was quick, and 
 not interrupted by any unfavourable circumstance. 
 38 
 
293 OF WOUNDS OF THE ARTICULATIONS. 
 
 Another man was wounded by a small sword in the same 
 joint; he was carried to the hospital de la Charite. On examin- 
 ing the wound, it was /bund that the capsule of the joint was 
 opened. This wound healed like the most simple puncture. 
 
 As the practitioners of all ages have agreed in referring the 
 danger of wounds of the joints to the admission of air, the fa- 
 cility with which pundlured wounds of the articulations heal, 
 may be accounted for from the narrowness of the wound, and 
 the difficulty opposed to the insinuation of air. But experience 
 also proves, that wounds of the joints, by cutting instruments, 
 are not very dangerous, though the admission of air into them 
 is manifest. 
 
 A Alassacreur of the second of September, who seized by the 
 hair a prisoner of the Abbaye Saint Germain^ received on his wrist 
 the blow levelled at the head of the victim. The posterior part 
 of the articulation was entirely opened, and the convexity for- 
 med by the scaphoides, semilunaris, and pyramidalis, aban- 
 doned the ends of the bones of the fore-arm. He was admit- 
 ted into the hospital cle la Charite ; the lips of the wound were 
 immediately brought together j the hand wr.s kept much ex- 
 tended by means of a splint •<, the skin, tendons of the extensor 
 muscles, and the capsules, all healed by the first intention, and, 
 at the end of twelve days, he was discharged, quite cured. 
 
 A boy employed in the kitchen of the hospital de la Charitey 
 had the articulation of his wrist opened by a piece of a vessel 
 of delph ware ; the lips of the wound were brought together, 
 and the patient recovered in a very few days. 
 
 A shoemaker's v/ife opened with a sharp cutting instrument 
 the articulation of her wrist on the external side, for about one 
 third of its circumference ; the tendons of the radiales externi, 
 extensores, and long abduclor of the thumb, were divided. 
 Citizen Boyer was called in ; he closed the wound, which 
 healed by the first intention, and was cicatrized on the third 
 day. 
 
 The facility with Avhich tlie incisions made in the joints for 
 the purpose of extracting foreign bodies, heal, proves also, that 
 wounds of the articulations are not attended with so much dan- 
 ger as has been generally supposed. But though the fa£ts 
 just related, fully invalidate the opinions of the ancients, yet it 
 must be allowed that such a happy termination does not always 
 take place. Cases sometimes occur, in which the wound is 
 followed by a violent inflammation that terminates in gangrene, 
 or lays the foundation of a caries of the ends of the bones. 
 
OF WOUNDS OF THE ARTICULATIONS. 2^9 
 
 These melancholy consequences, as tlie ancients have well ob- 
 served, seem to be brought about by the contaft of air, which 
 excites an inflammation of the synovial membrane. But tliat 
 this cause can produce these effefts, it must be continued for 
 some time, and must make a considerable impression on the 
 capsule and cartilages. The imprudent application of charpie, 
 or any other dressing, to the surfaces of the joint, produces still 
 more dangerous consequences. A man received a sabre-wound 
 on the external side of the wrist, which opened the articula- 
 tion; he was brought to the hospital de la Charlie; one of the 
 monks, who then dire£led that institution, filled the wound 
 with charpie ; an enormous swelling took place, gangrene su- 
 pervened, and the patient died. 
 
 The danger is equally great when the wound suppurates ; the 
 purulent matter, formed in the joint, irritates the parts^ and 
 causes an exfoliation of the cartilages, or caries of the ends of 
 the bones. These consequences are also to be apprehend when 
 the wounding instrument has not only penetrated into the joint, ' 
 but wounded the cartilages, or ends of the bones. A young 
 man received a sabre-wound in the anterior and external part 
 of the knee, which entirely divided the patella; the lips of the 
 wound were brought exadtly together ; but a great swelling came 
 on, and excluded every hope of union by the first intention. The 
 dressings were taken off, the parts were covered with a cata- 
 plasm, and the patient was bled ; but the swelling continued to 
 increase, an abscess formed above the patella, between the 
 femur and the triceps cruralis, and the entire limb became 
 much swelled. Death soon ensued, and, on disscftion, the 
 patella was found divided, and the cartilages partly disorgan- 
 ized. 
 
 Another young man received in a duel a sabre-v/ound on 
 the anterior part of the point of the shoulder, which opened 
 the articulation of the humerus with the scapula, and divided 
 the end of the clavicle next the scapula, the deltoid muscle, 
 and a portion of the great perioral muscle. The wound was 
 immediately dressed by bringing its sides together, but a hae- 
 morrhage came on the third day, which made it necessary to 
 remove the dressing. The vessel was too deep-seated to be 
 discovered and taken up ; an attempt was made to stop the he- 
 morrhage by stuffing the wound, after which a violent inflam- 
 mation supervened, which terminated in the formation of 
 enormous abscesses. The patient died, and the articulation 
 was found full of pus. 
 
300 OF WOUNDS OF THE ARTICULATIONS. 
 
 A young man, aged eighteen years, received a sabre-wound 
 in the inferior part of the left arm -, the weapon came obUquely 
 from above downwards, and cut off entirely the external con- 
 dyle of the OS humeri. The wound was not dressed for two 
 days after the accident, at which time he was brought to the 
 hospital de la Charite ; the divided parts were now brought to- 
 gether, but the swelling soon obliged us to relax the.strips of ad- 
 hesive plaster; emollients were applied; pus and synovia flowed 
 abundantly from the wound, especially when pressure was made 
 on the sides of the articulation ; abscesses formed j the fever 
 assumed a bad aspect; the swelling extended to the whole of 
 the limb, and the patient was on the point of dying; amputa- 
 tion of the arm was now had recourse to, by which the pa- 
 tient's life was saved. On opening the articulation, the soft 
 parts surrounding it were distended with pus, the joint itself 
 was filled with a fetid purulent matter, the cartilages were 
 nearly destroyed, and the head of the radius was somewhat 
 carious. 
 
 What inferences are we to deduce from all these fadts ap- 
 parently contradi6lory ^. What prognosis are we to form in 
 wounds of the articulations .■' What treatment is adapted to 
 them .'' The prognosis must be necessarily doubtful ; it is fa- 
 vourable, when the wounded joint is superficial, the wound in 
 the integument and capsule not extensive, and consisting of a 
 simple incision without contusion ; when no vessel is opened, 
 or principal nerve wounded ; and, lastly, when with these fa- 
 vourable circumstances the admission of air has been prevented 
 by quickly closing the wound. 
 
 The principal indications of cure are, to bring the divided 
 parts into contact, to exclude the air, remove foreign sub- 
 stances, and keep the limb free from every thing that might ex- 
 cite inflammation. When this practice is not successful, we must 
 combat the inflammation, open the abscesses, prevent the stag- 
 )iation of the pus by making counter-openings ; and, lastly, 
 amputate the limb, when preserving it brings the patient's life 
 in danger. 
 
-JO I 
 
 CHz\PTFR XX. 
 
 OF WHITE SWELLINGS OF THE JOINTS. 
 
 THE name of lymphatic tumour, or white swelling, has 
 been given to swellings of the joints, unaccompanied 
 with symptoms of inflammation. Such is the definiiion of 
 them given by Bell in a Dissertation on White Swellings, at 
 the end of his Treatise on Ulcers. In fa^V, an increased heat 
 and discoloration of the skin are never observed, at least in the 
 beginning of these swellings ; there is simply a tum.efaclion of 
 the part, with pain more or less deep seated. The English 
 author just mentioned has very justly marked out two principal 
 varieties of this disease. 
 
 In the first, called rheumatic, the patient feels dull pains in 
 the whole of the limb, before the appearance of the tumour, 
 which h often a critical termination of rheumatism. The pain 
 now becomes fixed in the joint, and diminishes in violence ; 
 the soft parts surrounding the articulation swell more or less ; 
 but there is no change in the colour of the skin, nor is there 
 an increase of heat. If the disease be seated in the knee, the 
 patient keeps the leg more or less bent, in order to relieve pain ; 
 the muscles, tendons, and even soft parts, from remaining in 
 this contracted state, become stiff, and hence results contrac- 
 tion or rigidity of the limb, or even a complete anchylosis. 
 The pains increase by degrees, the swelling augments and dis- 
 tends the skin ; inflammation takes place, which terminates in 
 suppuration, and the formation of abcesses in the cellular sub- 
 stance ; these burst spontaneously, and leave fistulous openings. 
 Through these fistulx flows a whitish or serous matter, at first 
 inodorous, but it is soon vitiated by the contact of air, and be- 
 comes fetid. The disease extends its ravages from the soft 
 parts to the cartilages and ends of the bones. The leg is con- 
 siderably diminished in si^e ; this may depend on the impedi- 
 ment to the distribution of the fluids, bv the pressure made on 
 the vessels by the enlarged and indurated parts, or rather on 
 
302 OF WHITE SWELLINGS OF THE JOINTS. 
 
 the swelled joint drawing to itself most part of the fluids, and 
 thus diminishing the quantity which should go to nourish the 
 leg. The immobility of the limb tends also to diminish the 
 nutrition of the leg, since it is found that the emaciation ex- 
 tends to the inferior part of the thigh. The skin, excessively 
 distended, becomes inflamed and ulcerated ; the veins become 
 varicose, and burst ; and the patient, exhausted by the conti- 
 nuation of pain, and the absorption of purulent matter, drags 
 on a miserable existence for some time, and dies. 
 
 The course of the disease is described here as it takes place 
 in the knee, which is its most usual seat ; but the articulations 
 of the elbow, hip, wrist, and foot, are by no means exempt 
 from it. 
 
 On dissciStlng the diseased joint, the soft parts are found in- 
 durated, decomposed, and in a confused, greyish mass, some- 
 what resembling lard. The swelled ligaments form one body 
 with the cellular substance j the cartilages preserve, in some 
 cases, their natural colour •, in others, especially when the af- 
 fe£lion has continued long, they and the ends of the bones are 
 affected with caries. The cellular tissue placed behind the infe- 
 rior ligament of the patella, between the femur and the tendon 
 of the extensors of the leg, in the ham, and behind the cross 
 ligaments of the knee in the interval between the condyles of 
 the femur, has also the colour, appearance, and consist- 
 ence of lard. In some cases, collefiions of a bad purulent 
 matter are found in different parts of the cellular substance. 
 
 The white swelling produced by a scrofulous taint, which 
 establishes itself in the great articulations, has sometimes an 
 appearance, and pursues a course similar to that just described ; 
 at other times dull, deep-seated, and circumscribed pains pre- 
 cede it, and announce its formation. The swelling is at first 
 scarcely perceptible, and when it becomes more considerable, 
 it is perceived, that it arises almost entirely from an augmenta- 
 tion of volume in the ends of the bones, and that the integu- 
 ments scarcely participate in the morbid state. The limb be- 
 comes emaciated and contrafled, the pain appears confined to 
 the centre of the joint, and to the extremities of the bones ; 
 emollient and anodyne applications neither appease the pain, 
 nor produce a resolution of the swelling ; lastly, the patient, 
 exhausted by his suS^erings, perishes. On opening the knee, 
 every part is found in a natural state, except the cartilages, and 
 ends of the bones, which are ailedled with caries. 
 
OF WHITE SWELLINGS OF THE JOINTS. 303 
 
 It would be too tedious to describe the different forms under 
 which this disease may present itself ; after pointing ont its two 
 principal varieties, it will be sufficient to remark, tlv.it it dif- 
 fers so much in different individuals, that it is scarcely accom- 
 panied by the same symptoms in two patients. 
 
 White swellings are sometimes produced by rheumatic affec- 
 tions ; but most generally they originate from a scrofulous taint. 
 They seldom appear to be produced by an external cause, 
 hough they s ometimes follow strains that have been neglected, 
 or badly treated, and fradlures in the neighbourhood of the 
 joints. Sometimes the swelling comes on rapidly without any 
 apparent cause. Such was the case of a young man, whose 
 arm I have lately amputated for a white swelling, and caries of 
 the elbow joint. Lastly, a blow, fall, or any external violx?nce, 
 may produce the swelling in a scrofulous person, in whom the 
 cause of the disease seems to be easily called forth. 
 
 The enlargement of the ends of the phalanges, considered 
 by some authors as a species of spina ventosa, belongs to the 
 class uf white swellings. This disease, as has been already ob- 
 served, affefts both the substance of the bones and their arti- 
 culations. 
 
 The prognosis is always unfavourable, whatever may be the 
 age or constitution of the patient, the cause or duration of the 
 disease. The tumours are very seldom discussed ; they almost 
 uniformly resist the numerus remedies with v/hich they are 
 combated. In some fortunate cases, the disease, arrived at a 
 certain pitch, makes no further progress ; the pains diminish, 
 and in time disappear ; the limb remains contracted ; the ends 
 of the bones grow to one another, and the patient escapes 
 death, but has an anchylozed joint. 
 
 In the greater number of cases, the patient, harassed by vi- 
 olent pains, is exhausted by the copious suppuration, he6tic fe- 
 ver, and colliquative diarrhoea, and no resource is left but the 
 amputation of the afie<rted parts. The prognosis is somevv^hat 
 less unfavourable in cases of children who have not yet attained 
 the age of puberty. This period, so favourable for the cure 
 of scrofula, brings about also that of white swellings, by de- 
 stroying the evil which is its most frequent cause. 
 
 The diseases the most difncult to cure, are those in which 
 the greatest number of remedies have been u;ed ; we must not 
 then bc-astonished at the multiplicity of means proposed for the 
 cure of white swellings. These, v/hether adopted on rational 
 
304 OF WHITE SWELLINGS OF THE JOINTS. 
 
 principles, or recommended empirically, must be adapted to 
 the variety of the disease, and the stage in which it exists. 
 
 The limb must be kept perfectly at rest : without this pre- 
 caution, the remedies cannot produce any good effect ; for the 
 motion of the affe<fted parts augments the primary cause of the 
 disease. Thus, in white swellings of the knee, the patient 
 should remain in bed, with his leg as much extended as the 
 pains, and tendency which he has to bend it, will permit. If 
 he be young and vigorous, and if an external cause has produ- 
 ced the disease, or contributed to its developement, or if it 
 has been occasioned by a rheumatic affection, some blood may 
 be taken away in the beginning of the disease. The aliments 
 should be mild, and taken in small quantities at a timej the 
 drinks should be refrigerant and copious ; and the diseased 
 joint should be covered with an emollient cataplasm, which is 
 to be renewed twice a day. Such are the means for subduing 
 the inflammation which is in some degree latent in the joint ; to 
 these may be joined the application of leeches, or even scarifi- 
 cations, v/hich Bell prefers, and by which he says we may draw- 
 away at once eight or ten ounces of blood. When the pains 
 diminish, and the tumour tends to a resolution, the emollients 
 are rendered somewhat repellent ; a cataplasm made of the 
 root of briony boiled in milk may then be applied with advan- 
 tage. Black soap, brought to the consistence of a liniment 
 by means of camphorated spirit of wine, has been also em- 
 ployed with some benefit. Fri;Slions about the knee, with a 
 volatile liniment, composed of an ounce of oil and half an ounce 
 of ammonia, have been found useful. The joint is to be rubbed 
 tv.'ice a day with this liniment, and afterwards covered with a 
 piece of fine linen that has been soaked in the same substance. 
 
 Mild laxatives, such as tamarinds, cream of tartar, dissolved 
 in whey, or different laxative salts dissolved in veal broth, 
 are to be administered at the same time. They cause a 
 determination of the fluids to the intestines, and thus divert 
 them ffom the diseased articulation. Lastly, when the ir- 
 ritation and inflammation are abated, the most active resol- 
 vents are to be used. Blisters are then applied to the articula- 
 tion, and sometimes the blistered surface is made to suppurate, 
 and the dischartje is kept up by a stimulating ointment. Bell 
 recommends, strongly, friftions, with mercurial ointment, which 
 have, he says, the double advantage of introducing into the 
 system a powerful solvent, and increasing the adlion of the skin. 
 They are to be frequently repeated every day, and continued 
 until the m.outh is gently afFecled. 
 
OF WHITE SWELLINGS OF THE JOINTS. 305 
 
 Le Dran, and many other pratflitioners, have advised to 
 pump warm water on the affe(Sled joint. To derive from this 
 praftice its full efi'eft, the water must fall from an elevated place, 
 be used as warm as the patient can bare it, and be rendered 
 stimulant by a neutral salt, or an alcali, dissolved in it. It is in 
 this way that pumping is used in the hospital Saint Louis, 
 which contains a greater number of patients labouring under 
 white swellings than any other hospital in Paris. The mineral 
 waters of Bareges and fiourbonne, &c. may be used in a similar 
 maimer. Warm baths, of a diluted alcaline solution, anjj va- 
 pour barhs of the same solution, have been recommended. 
 Much benefit is said to be derived from a kind of animal bath 
 used in the following manner, the patient introduces the af- 
 fected joint into an opening made in the belly of an animal re- 
 cently killed, and keeps it for some time among the warm in- 
 testines. The mild temperature and un^luosity of this bath, 
 produces an effedl similar to that obtained by folding the omen- 
 tum of a sheep round the joint, as recommended by Bell. 
 
 Very violent means, such as the adtual cautery, and burn- 
 ing with moxa, often produce a diminution of the swelling ; 
 but some enlargement still remains, and the pain becomes in- 
 tense. By such powerful stimulants, the state of the patient 
 is rendered more distressing, his disease is aggravated, and its 
 progress is accelerated. 
 
 When the treatment is successful, the joint remains for a 
 length of time incapable of motion, and very often anchylo- 
 zed. But the incapability of motion must not be always consi- 
 dered as a certain mark of anchylosis ; it often depends only on 
 the stiffness of the soft parts, and particularly of the tendons. 
 This may be remedied in time, by moving the limb every day, 
 and gradually increasing the motion ; and by the use of warm 
 baths, pumpings, and fomentations. However, all interference 
 whatever should be abstained from, when there is a suspicion 
 that the ends of the bones are unsound, or anchylozed ; endea- 
 vours to move the limb, in such cases, would cause so much ir- 
 ritation as to reproduce the primary affeftion. 
 
 In cases where the white swelling is evidently scrofulous, the 
 antiphlogistic plan cannot be pursued 5 tonics and corroborants 
 are then to be administered, with which may be combined the 
 application of solvent and stimulant plasters, such as the soap 
 plaster, that of cicuta, &c. &c. Often in these cases, as ia 
 the preceding, however assiduous and rational the treatment, 
 the swelling continues to increase \ at first, hard and elastic in 
 39 
 
3C6 OF WHITE SWELLINGS OF THE JOINTS. 
 
 Some places, It soon points, and a fludluation is felt in It ; ab- 
 scesses burst spontaneously, and their openings degenerate into 
 fistulse. 
 
 Some empirics have been daring enough to Irritate the tu- 
 mour with acrid and stimulating applications, in order to con- 
 vert the languid swelling into a phlegmon, and afterwards ob- 
 tain a termination of it either by resolution or suppuration. 
 Fabricius ab Aquapendente mentions a case of this kind, in 
 which a charlatan enveloped the knee with a synapism of a very 
 acrid vegetable. An a£live Inflammation took place, which, 
 combated in the ordinary way, terminated by resolution ; and 
 the patient recovered the entire use of his knee. But this 
 case cannot serve as a rule ; In the greater number of Instances 
 in which a similar treatment would be followed, It would infal- 
 libly accelerate the progress of the swelling, and caries of the 
 ends of the bones, increase the sufFerjngs, and hasten the 
 death of the patients. 
 
 When there are many abscesses about the joint, and the col- 
 ledllons of pus are considerable. It is necessary to prevent the 
 stagnation of this fluid, and the absorption of it, by enlarging 
 the fistulous openings, and renewing the dressings repeatedly. 
 It is sometimes useful in these cases to pass a seton in the fistu- 
 • lous passage. This favours the escape of the purulent matter, 
 and Impedes the introduclion of the air. If the pains be pe- 
 netrating and excessive, their intensity may be diminished by 
 the external and internal use of sedatives and opiates ; but 
 when they are not appeased by these remedies, but become 
 more intolerable, and take away the patient's rest ; and when 
 hecHiic fever, a constant diarrhoea, and colliquative sweats, 
 bring on marasmus, and endanger the patient's life, the am- 
 putation of the limb, the last resource in such an invincible 
 disease, must be had recourse to. We must not, however, 
 be In too great a hurry to perform this operation, le^f the pa- 
 tient accuse us of precipitance in taking away a limb which 
 might be preserved. Besides, a state of debility is extremely 
 favourable for most surgical operations, and for amputations In 
 particular. It obviates violent Inflamnratlon, the troublesome 
 consequence of every operation in which a great number of sen- 
 sible organs are concerned. However, we do not understand, 
 by a state of debility, that state in which the patient Is exhaust- 
 ' ed and harassed by the continuance of the disease, diarrhoea, 
 and colliquative sweats. Bell appears to recommend deferring 
 the operation until this state of exhaustion has taken place. A 
 
OF WHITE SWELLINGS OF THE JOINTS. 307 
 
 dangerous precept. If observed, the patient, consumed by 
 marasmus, will be no more able to furnish organic aftiou suf- 
 ficient for the healing of such a wound as results from amputa- 
 tion. 
 
 In order to determine on the necessity or Impropriety of this 
 operation, the state of the patient must be attentively examined, 
 the resources of nature considered, and what is to be fear- 
 ed, and what may be hoped for, maturely weighed. If the 
 disease is recent ; if no suppuration has yet taken place •, 
 if the pains are supportable j and if the patient preserves his 
 plumpness and vigour, the use of the means likely to produce 
 a resolution of the swelling is to be persisted in. It would be 
 contrary to all rule to amputate In this case ; for, on the one 
 hand, the violence of the Inflammatory symptoms Is to be 
 dreaded j and, on the other, the cause of the disease Inherent 
 In the solids, and diffused in the fluids, has not yet fixed itself 
 entirely in the joint. We must therefore defer operating until 
 it is firmly established in the articulation ; and until, consumed, 
 as it were, by the produ£lion of the disease. It Is rendered In- 
 capable of changing Its situation, or taking a new residence In 
 another joint.* 
 
 Lastly, the operation Is not to be performed but In cases 
 where one joint only Is affefted ; If many articulations, the 
 knee and elbow for instance, are attacked, we must not think 
 of operating. " In reality. It Is doubtful If death be not prefer- 
 able to the mutilation that would result from such operations -, 
 besides, the danger attending them would diminish very much 
 the probability of their success. It Is, then, only in affedlions 
 of the small joints, such as the phalanges, that the different 
 parts can be extirpated. When many of the principal articu- 
 lations are affeiSted at the same time, and the disease is advanced, 
 death is Inevitable. 
 
 A pradlice less terrifying than amputation. Inasmuch as it 
 does not deprive the patient of his limb, has been proposed in 
 cases of white swelling. It consists in cutting off, or extirpa- 
 ting, the carious extremities of the bones, when the state of 
 the soft parts admits It. 
 
 • How will the physiologists of this country receire this reasoning ? It Is 
 evidently founded on the doftrine of the humoral pathologists. It may be 
 asked, what evidence is there, that the cause (in the opinion of tlie author) 
 so firmly fixed in the solid?, and widely diffused in the fluids, abandons 
 its spacious residence to confine itself in a single joiAt ? and why the solids 
 and fluids do not manifest some appearance of its having deserted them ? 
 ^ Translator. 
 
308 OF WHITE SWELLINGS OF THE JOINTS. 
 
 This operation is practicable only in cases where the affec- 
 tion is confined to the ends of the bones, and extends but vtry 
 little to the soft parts. If, for instance, the cellular tissue and 
 ligaments about the knee are swelled, and coll^fted into a ho- 
 mogeneous lardy mass, no person would think of performing 
 it. It is, then, confined to cases in "which the bones only are 
 affefted. In an affeftion thus limited, which isjjy no means 
 frequent, the ends of the bones are cut off in this wav. 
 
 If the head of the humerus be diseased, which is ascertained 
 by an attentive examination of the tumour, and particularly by 
 the introduction of a probe through the fistulae which commu- 
 nicJite with the articulation, the operation is commenced by ma- 
 king on the external and upper part of the arm two longitudi- 
 nal incisions^ directed obliquely downwards, and distant frotn 
 one another about two iuches at their superior part, but ap- 
 proaching as they descend^ and uniting in the form of a large 
 V, A triangular flap formed of the skin and deltoid muscle, 
 is preserved in this way. It is disse^ed and raised upwards by 
 detaching the muscle from the superior and external part of the 
 humerus ; it is then committed to an assistant, and the surgeon 
 bringing the elbow forwards and inwards with his left hand, 
 cuts the orbicular ligament of the articulation with his right : 
 the ligament is made tense by the direction given to the arm 
 by this motion of the elbow. The tendons of the subscapula- 
 ris, infraspinatus, supraspinatus, and teres minor, are to be 
 cut at the same tinje : this being done, the head of the hume- 
 rus is easily luxated upwards and outwards, without cutting 
 the tendons of the peftoralis major, latissimus dorsi, and teres 
 major, which has been recommended, but which could not be 
 done without danger, of wounding the brachial vessels and 
 nerves. The head of the humerus being thus luxated, the ex- 
 tent of the caries is ascertained ; next, the glenoid cavity of the 
 scapula is examined, in order to discover if it be afFe6ted ; a 
 plate of lead or piece of pasteboard is then placed under the 
 head of the humerus to protect the soft parts, and the carious 
 portion of the latter bone is sawed off. During the adt of saw- 
 ing, an assistant prevents the humerus from descending, and 
 at the same time keeps it fixed and motionless. 
 
 The circumflex artery is the only vessel to be taken up in this 
 operation; it is found at the posterior and superior part of the 
 triangular flap. 
 
 The extirpation of the head of the humerus was first prac- 
 tised by Wlxite; the patient recovered in four months, and 
 
OF WHITE SWELLINGS OF THE JOINTS. 3C9 
 
 his arm, shorter by nearly two inches, preserved its shape and 
 strength. Bent, of Newcastle, as he relates in the sixty-fourth 
 volume of the Philosophical Trafisaflionsy performed soon after- 
 wards the same operation. Since this period, many English 
 surgeons say they have performed it. Vigarous, of Montpellier, 
 has also given a case of it in a Memoir presented to the Acade- 
 my of Surgery in 1774-. 
 
 Park, a surgeon of Liverpool, conceived and executed the 
 bald project of extending to the articulations of the knee and 
 elbow, the operation performed on the humerus by White. 
 But in these cases, the circumstances are much more unfavour- 
 able, and the cutting off" the ends of the bones much more 
 difficult. Nevertheless, Park has performed the operation with 
 success, on the knee of a man thirty-three years of age, and of 
 a robust constitution. This surgeon made two parallel inci- 
 sions along the sides of the patella, which extended to two 
 inches above, and two below this bone •, one of the articular 
 arteries was divided and taken up; a transverse incision was 
 made at two inches above the joint, and another at two inches 
 below it ; one comprised the half of the thickness of the thigh, 
 the other, half of that of the leg ; all the anterior ligaments 
 were cut, and the patella was removed, after which a knife was 
 insinuated behind the femur, to separate the flesh from the 
 bones, to the extent of about four inches. The edge of the 
 knife was kept close to the posterior part of the bones, in order 
 to avoid wounding the popliteal vessels and nerves. The inci- 
 sion behind the bones being thus made, a plate of lead, or a 
 large spatula, was introduced into it, in order to prote£l the 
 vessels and nerves of the ham from the saw. In this case two 
 inches were cut from the femur, and one inch from the tibia; 
 the bones were then replaced, their ends brought into contaft, 
 and the angles of the wound were closed by a few stitches. 
 The disagreeable symptoms that succeeded were numerous and 
 distressing, notwithstanding the relaxed state of the soft parts; 
 however, in about four months the patient was able to walk. 
 The ends of the bones grew together ; the knee was turned 
 outwards; the limb, shortened by three inches, supported the 
 weight of the body very well ; and the patient could walk with- 
 out the assistance of crutches. 
 
 There are few surgeons intrepid enough to undertake a si- 
 milar operation. The lesion of the popliteal vessels and nerves, 
 the violence of inflammation, and an abundant suppuration. 
 
JIO OF ANCHYLOSIS. 
 
 are the perils to which a patient is exposed, to preserve a limb 
 always deformed, and not more useful than a wooden leg. 
 
 When the elbow is to be operated on, the incisions must be 
 made on the posterior side of the joint, as the principal vessels 
 and nerves are placed on the anterior side. As to the rest, the 
 same rules are to be observed as in the preceding case. 
 
 CHAPTER XXI. 
 
 OF ANCHYLOSIS. 
 
 ALL affections of the articulations, which consist of a total 
 or partial immobility of the joint, are comprised under 
 the general denomination of anchylosis. It is said to be in- 
 complete, when there is only a stiffiiess of the joint ; and com- 
 plete, when all motion is impossible, from the ends of the 
 bones growing together. It is further distinguished into dry 
 and suppurating ; but the last is a symptom of white swelling. 
 Anchylosis is seldom a primary disease, it almost jlways suc- 
 ceeds to another complaint. Thus it is seen to take place after 
 fra£lures, particularly when in the neighbourhood of joints; 
 after sprains, luxations complicated with contusion, or badly 
 reduced, and white swellings, &c. &c. Diseases foreign to 
 the bones, such as an aneurism of the popliteal artery, or 
 abscesses formed in the neighbourhood of a joint, may occa- 
 sion it. In a word, every thing that keeps a joint motionless, 
 tends to produce an anchylosis, and one so much the more 
 complete, as the limb remained long without motion. Anchy- 
 losis from ina£lion appears to arise from the gradual diminution, 
 or even total cessation, of the secretion of the synovia. It is 
 well known that the friftion of the ends of the joints excites 
 the secretion of this fluid. 
 
OF ANCHYLOSIS. JM 
 
 One may conceive the possibility of a complete anchylosis 
 taking place in all the joints of the body, from being confined 
 to bed for a length of time, without motion.* The secretion of 
 the synovia diminishes gradually, and at length ceases entirely; 
 then the surfaces of the joint, deprived of this fluid, and de- 
 siccated, are attacked by an adiaesive inflammation, similar to that 
 which takes place in the pleura, and which in a vast number of 
 cases occasions an adhesion of the costal portion of the pleura 
 to that covering the lungs. The ligaments, tendons, and soft 
 parts surrounding the articulation, acquire during the inadlion, 
 a rigidity which is difficultly removed ; this may arise from the 
 vital power of the parts being rendered torpid by the inadlivity; 
 or from the growing together of the different parts of the cel- 
 lular substance ; or from its becoming more dense from the in- 
 spissation of the lymph and fat deposited in it. 
 
 Haiving said so much on the formation of anchylosis, let lis 
 see what is the influence of the various causes which produce it. 
 When a bone is fra^lured in the neighbourhood of a joint, the 
 limb is kept motionless by the apparatus, during the whole pe- 
 riod of ossification or union of the ends of the bonej besides, 
 the inflammatory swelling which coi^stantly supervenes, extends 
 to the articulation, and attacks the ligaments, capsule, and in 
 general all the surrounding parts. Sometimes it only increases 
 the consistence, thickness, and rigidity of these parts ; at other 
 times it produces a mutual adhesion of the surfaces of the joint, 
 by impeding the secretion of the synovia. This is one of the 
 principal reasons for reputing fra^lures of bones near their ex- 
 tremities, more dangerous than those of their centre. How- 
 ever, the latter are always followed by more or less stiffness in 
 the articulations of the fraflured bone ; but this arises from the 
 state of inacftivity, in which the limb has remained, and it may 
 be removed by exercising the limb gently, and increasing the 
 motion gradually. 
 
 The stiffness succeeding to fractures has been for a long time 
 attributed to an effusion of bony matter into the interior, or 
 cellular substance in the vicinity of the joint. This mattei*, 
 say the ancients and moderns, is a kind of glue which unites 
 more or less completely the ends of the bones, and at the same 
 time indurates the soft parts. This theory, which is found in 
 the treatises of J. L. Petit and Duverney, is abandoned, since 
 the existence of an osseous juice is rejected, and the formation 
 
 * Noiiveaux Elemens de Physiologie, tome il. chap. Des Mcuvemens. 
 
312 Cf ANCHYLOSIS. 
 
 of callus in fradlures better understood. Besides, disse<flions 
 of anchylozed joints have never discovered the osseous concre* 
 tions, which should result from such supposed effusions. The 
 opinion, that a change, or inspissation, of the synovia, was 
 the most frequent cause of anchylosis, is not better founded. 
 On dissecting a joint in which a complete anchylosis has taken 
 place, the ends of the bones are found united at one point j and 
 in this part the surfaces have lost their natural polish ; but the 
 parts which have not formed an adhesion, preserve their polish, 
 and their surfaces are lubricated by a small quantity of synovia, 
 not different from that found in the healthy state. 
 
 However various the causes of anchylosis, the mode in which 
 it takes place is always the same : when desiccated, inflamed, 
 and sometimes even suppurating, as happens in some white 
 swellings with caries of the ends of the bones, grow together ; 
 when it is incomplete, that is to say, when it consists of a diffi- 
 culty of motion in the part, and the impossibility of perform- 
 ing the same motions as in the healthy state, the surfaces of 
 the joint are still contiguous, and the disease exists only in the 
 soft parts surrounding the articulation. 
 
 It is essential to distinguish these tv/o species, since the first 
 or true anchylosis is altogether incurable, and is to be consi- 
 dered, in most cases, a happy termination of a grievous disease. 
 The false or incomplete anchylosis is rather a consequence of 
 disease, than a primary affection. When a considerable abscess 
 takes place in the vicinity of a joint, for instance near the wrist 
 or joints of the fingers, the destruction of the cellular substance 
 occasions a stiffness which it is impossible to prevent j but when 
 the tendons exfoliate, the bones to which they are attached re- 
 main motionless, and a complete anchylosis inevitably ensues. 
 Therefore, when abscesses form near the joints of the fingers, 
 and when they are followed by exfoliation of the tendons, the 
 fingers should be bent, in order that they may anchyloze in 
 that direction, which is much less inconvenient and much more 
 favourable for the various uses of the hand, than permanent 
 extension. On the contrary, when there is a suspicion that 
 the knee will remain stiff, after the operation for a popliteal 
 aneurism, the leg must be kept as much extended as the pains 
 will permit. The same conduCt is to be observed, when, after 
 a spontaneous luxation of the femur, it is perceived that th« 
 head of this bone will attach itself to the pelvis, and that the 
 disease will terminate by anchylosis. In these cases, as well 
 as in every other, when the bones are grown together, even 
 
OF ANCHYLOSIS. 31^ 
 
 though the limb may have a bad and inconvenient dlreftion, it 
 would be imprudent, or even dangerous, to endeavour to de- 
 stroy the adhesions. In faft, it could not be done without 
 using considerable violence and causing great pain, and would 
 be followed by inflammatory symptoms that would renew the 
 adhesion, or by caries of the bones, which might occasion the 
 death of the patient. 
 
 When the false or incomplete anchylosis is apprehended, 
 measures should be taken to prevent it. These consist in mo- 
 ving the afFefted limb as much as the state of the soft parts will 
 permit. This precaution is much more necessary in afFeftions 
 of the ginglymoidal articulations, than in those of the orbi- 
 cular, on account of the tendency of the former, from the 
 great extent of their surfaces, the multiplicity of their ligaments, 
 and small extent of motion, to become anchylozed. The ex- 
 ercise of the joint, by extending the contracted soft parts, calls 
 forth their vital properties, and promotes the secretion of the 
 synovia, by causing a fridlion of the articulating surfaces. A 
 crepitation, arising from the synovia being deticient, is first 
 heard ; but as soon as this fluid is secreted in greater quantity, 
 and lubricates the surfaces of the joint, this cracking noise 
 ceases. A certain share of precaution is to be used in moving 
 the limb j the motion, if rudely performed, might cause pain, 
 and induce a swelling and even caries of the ends of the bones. 
 It is by proportioning it to the state of the limb, and increasing 
 daily its extent, as the soft parts yield and grow supple, that 
 good effedts can be derived from it. The exercise of the joint 
 is not to be left to the patient himself, neither is it to be con- 
 fided to ignorant persons, who might think that they moved 
 the anchylozed joint, while the motion took place in the one 
 above it. It is thus that a patient labouring under a stiffriess of 
 the elbow, if dire«Sted to put that joint frequently in motion, 
 moves the entire upper part of the arm, by making the hume- 
 rus turn in its articulation with the scapula. If inflammation 
 be excited by these attempts, they must be suspended until the 
 inflammation is subdued, and not recommenced until the pain 
 (eases. We are often obliged to use considerable force in elon- 
 gating contradled muscles, and it is to the great violence em- 
 ployed in such cases that ignorant bone-setters are often in- 
 debted for their success. 
 
 The efficacy of the exercise of the joint is increased, and its 
 effe<Sls seconded, by warm baths, emollient applications, by 
 frictions with the grease of fowls and other animals, nnd espe- 
 40 
 
J 14 OF THE DIVIATIONS OF BONES, &C. 
 
 cially by pouring warm water on the part, from a very elevated 
 situation. Animal baths, and the other means mentioned in 
 the chapter on white swellings, may be also used. When all 
 these means fail, the warm waters of Bourbonne, Bareges, Spa, 
 Bath, and Aix in Savoy, or other warm mineral waters, may 
 be had recourse to. The inconvenience arising from the dis- 
 tance of these mineral waters is now happily removed, as those 
 that are prepared artificially, are found to be fully as effeflual 
 as those obtained from the mineral spring itself. Citizen Paul 
 and Company have instituted an establishment for this purpose; 
 and already the waters of Bareges and Loueche, &c. are pre- 
 pared artificially, and used at this place in the form of baths or 
 pumpings w^ith much success. For this we have the testimony 
 of Dr. Lafisse, inspeiSlor of the establishment. 
 
 CHAPTER XXII. 
 
 OF THE DEVIATIONS OF BONES, 
 
 AND THE MEANS USED FOR PREVENTING AND CORRECTING 
 THE DEFORMITY ARISING FROM THEM. 
 
 THE bones, which give proportions to our different parts, 
 and by which we are maintained in the eredl posture, 
 may grow in an unnatural direftion •, and like the branches of a 
 tree, whose growth is impeded by any cause, may bend under 
 the weight of the body and the a6lion of the muscles, so as to 
 render motion extremely inconvenient. But it is only in in- 
 fancy, when the tissue of the bones is flexible, and the ossifi- 
 cation incomplete, that this vitiated conformation can take 
 place. Affections of this kind are very easily prevented, but 
 are very difficult to remove, and are entirely incurable unless 
 encountered before they have attained a certain degree. 
 
OF THE DEVIATIONS OF BONES, &C. 315 
 
 They are sometimes occasioned by negle^ in the clothing 
 nnd exercise of children ; in other cases, they arise from a want 
 of equilibrium in the aftion of certain antagonist muscles. Thus 
 confining children in swaddling-clothes, the use of stays, pre- 
 hiature exercise, and the habit of remaining in bad attitudes, 
 as frequently occasion them as the difference arising primarily 
 in the aftion and disposition of the muscles. 
 
 Physicians had, for a long time, raised their voice against 
 the barbarous use of swaddling-clothes, in which the limbs of 
 the infant were so clogged, and kept in such a state of inac- 
 tivity, that they could neither grow nor acquire strength ; but 
 it remained for the persuasive eloquence of Jean -Jacques to ef- 
 fedl a revolution in this part of physical education, which rea- 
 soning could not produce.* 
 
 Children are, now-a-days, scarcely ever wrapped up in swad- 
 dling-clothes : they are generally covered with wide and warm 
 vestments, which protect them from the cold, and at the same 
 time do not prevent the developement of their organs. 
 
 The use of stays is no less obje<Stionable. The breast and 
 superior part of the abdomen is surrounded with these cuirassesy 
 with the view of diminishing their capacity, and giving to the 
 waist a delicacy altogether unnatural, and consequently remote 
 from beauty. But they are not only injurious to beauty alone, 
 their effects are pernicious to health -, wide above, and growing 
 narrow downwards, they resemble a cone placed inversely to 
 that formed by the thorax, which is naturally wider at its in- 
 ferior part than at its summit. The breast, subjected to con- 
 tinual compression, must become deformed, and have its form 
 
 * '• All our wisdom consists in servile prejudices ; all our customs are 
 ** subjugating, painful, and re tri6live. Civilised man draw- hi-; first 
 •• breath, and expires — in slavery ; at birth, he is laid in swaddling-clothes, 
 ** when dead, he is nailed down in a coffin. At* long as he preserves the 
 *• human figure, he is enchained hy our institutions 
 
 " The new-born child has need of ptietching himself and moving his 
 " limbs, to shake off that torpor, in which, rulled up like a ball, he has 
 *' remained for so long a time. His limbs are extended, it is true, but 
 ** confined in such a manner that iie cannot move them ; his head is tied 
 «* down by stay bands ; it would seem to be feared that he should have 
 " the appearance of being alive. 
 
 *• Thvs the impulsion from within, or the tendency of the internal 
 " parts to grow and be developed, meets an insurmountable opposition, 
 *' The infant makes continual, but useless efforts, which exhaust his 
 " force, and retard the accession of strength. He was more at his case, 
 " less cramped, and less compressed in the amnios, than in his new si- 
 ** tuation } I do not see what he has gained by coming into the world." 
 
3l6 OF THE DEVIATIONS OF BONES, &C. 
 
 changed from conical to oval, or both its extremities made nar- 
 rower than natural ; hence, in consequence of the lateral de- 
 pression of the ribs, the adtion of the lungs is impeded, diffi- 
 culty of respiration brought on, and a remarkable disposition 
 to phthisis pulmonalis induced. However, though the habitual 
 wearing of stays may be attended with these disadvantages, 
 still they are not to be altogether proscribed, as there are cer- 
 tain cases in which they may be used with some advantage. 
 
 Let us suppose, for instance, the shoulders of a child to be 
 of a different height, which inequality may be the result of a 
 bad habit, or may be occasioned by the muscles on each side 
 not possessing the same degree of force. If the right shoulder 
 be lower than the left, the child should wear stays in which the 
 notches under the arms are not on a level ; that in the right 
 side should not be so deep as that in the left, in order to raise 
 up the right shoulder. By the continued use of this apparatus, 
 the muscles of the left side recover strength enough to balance 
 those of the right, the habit of remaining in a bad attitude is 
 interrupted, and the child is restored to his natural shape. It 
 would be in vain to recommend the child to incline to the op- 
 posite side, as a force which he could not subdue, causes, un- 
 known to him, the deformity. It is necessary, that the pressure 
 made by the corset against the arm-pit keep him constantly in 
 mind of making resistance to the depression of the shoulder, by 
 throwing into action the muscles of the opposite side. 
 
 The vertebral column, naturally curved by the weight of 
 the body, is liable to many deviations. We have treated of 
 those arising from rickets : we will mention here those only 
 that arise from another cause. Children, from their sight be- 
 ing naturally very weak, or from contra<Sling a habit of stooping 
 their head to inspect substances closely, bend the neck beyond 
 its natural limits ; if this habit be neglefted, and nothing done 
 to correct it, the bones become indurated in this curved situ- 
 ation, and the head remains always inclined forwards. The 
 same thing happens in the back or loins of young persons of a 
 delicate constitution. The extensor muscles of the trunk, too 
 weak to support the spine, allow it to be preternaturally bent 
 by the weight of the head, thoracic and abdominal viscera. 
 The nature of the person's occupation influences very much 
 the diredlion in which the curvature takes place. The breast 
 and shoulders are consequr^ntly deformed ; the former becomes 
 prominent on the side towards which the curvature tends, and 
 is depressed on the opposite side. The use of stays stuffed at 
 
OF THE DEVIATIONS OF BONES, &C. 317 
 
 the side, opposed to the curvature or prominence of the spine, 
 is then to be recommended ; or the machine of Levacher, de- 
 scribed in the fourth volume of the Memoirs of the Academy 
 of Surgery, may be used. A vertical piece of iron ascending 
 along the spine, and embracing the back part of the head by 
 two wings reaching to the forehead, and a circular bandage to 
 keep the head extended, are the principal parts of this inge- 
 nious machine, repeatedly applied with success by the inventor 
 of it. If the head only is bent forwards, a pasteboard stock 
 very high anteriorly may be worn. Whatever mechanical 
 means are used, they should be applied in such a manner as 
 not to impede in the smallest degree the motion of the affefted 
 parts. In faft, it is an essential point to combine exercise with 
 them, which it is known is the best means of re-establishing 
 the strength of the enfeebled muscles. Tonics, cold bathing, 
 friftion, a nourishing diet, and, in short, every thing recom- 
 mended in the treatment of rickets, are to be combined with 
 the use of machines. 
 
 If the child be very young, and cannot walk without the 
 assistance of leading-strings, the precaution must be taken of 
 sewing these to a broad girdle, so attached to the child's clothes 
 that it may support the entire body without ascending up under 
 the arm-pits, and thus compressing the axillary nerves and 
 vessels. In general, the use of girdles and leading-strings is 
 injurious; children should be left to themselves, and not forced 
 to walk before their strength admits of it. Premature walk- 
 ing, by making the legs bend under the weight of the body, 
 render them sometimes bowed ; at ether times the knees are 
 turned inwards, that is to say, the child is in-kneed, and the 
 feet are turned outwards *, for the position of the feet is always 
 influenced by that of the knees ; thus, when the knees are 
 turned inwards, the feet are turned outwards, and vice versa. 
 
 It is important to know this relation necessarily resulting 
 from the disposition of these parts, when we attempt remedy- 
 ing their mal-conformation. It is on the knowledge of it that 
 is founded the simple but efficacious pradlice of raising the in- 
 ternal edge of the foot, when the knee inclines too much in- 
 wards ; and of raising, on the contrary, the external edqe, 
 when the knee is turned outwards, and the leg bowed. ' 
 
 When a child, from having been put to \valk too soon, or 
 from any other cause, shall be in-kneed or bow-legged, nothing 
 is to be done in the first case but to have the internal edj^e of 
 the sole of the shoe made somewhat thicker ; and in the se- 
 
31 8 OF THE DEVIATIONS OF BONES, &C, 
 
 cond, to have the same done to the external side. The con- 
 stant addudlion and abdu6lion of the foot, if this simple pre- 
 taution be attended to, influences in time the knee, and insen- 
 sibly makes it straight. This treatment will be certainly suc- 
 cessful if the child be young : his bones, flexible at this time> 
 will yield easily to the force used to straighten them. 
 
 There is another species of malconformation, in which the 
 feet are turned entirely either inwards or outwards. Persons 
 labouring under this distortion, to whatever side the sole of the 
 foot is turned, are said to be club-footed. The Romans dis- 
 tinguished two species of this deformity : they call those vari 
 whose feet were turned inwards, and va/gi those whose feet were 
 turned outwards. 
 
 In the first species, the sole of the foot is turned inwards^ 
 its internal edge becomes the superior, and its external the in- 
 ferior : the toes are bent ; and the back of the foot, turned 
 outwards, is usually more arched than natural. The contrary 
 circumstances are observed in the second species. In bothj 
 the deviation of the foot, when carried to a certain degree^ 
 renders progression extremely difficult. 
 
 This deformity is occasioned by an inequality in the respec- 
 tive force of the adductors and abdudlors of the foot ; which 
 inequality may depend on the position in which the foetus was 
 placed in the womb, or on the manner in which it has been 
 treated after birth. 
 
 Nothing is easier than to discover the affeftion, even though 
 very inconsiderable ; the leg itself is deformed and curved out- 
 wards if the sole of the foot is turned inwards, and vice versa. 
 It is of the greatest importance to oppose the deviation of the 
 foot at the moment that it begins to take place. The bones are 
 then soft, cartilaginous, and flexible, and take any form giveti 
 to them -, but as the person advances in age, they become hard) 
 preserve the false position in which they have been drawn, and 
 the part remains forever deformed. 
 
 As the foot is oftener turned inwards than outwards, the 
 most useful apparatus in the greatest number of these casesj 
 consists of a boot or buskin, to the sole of which is attached a 
 spring bent into a semicircle. This boot is to be worn by the 
 patient in such a manner as that the convexity of the same cir-* 
 cle may bear against the external part of the leg. The spring 
 thus curved, attached below to the sole of the foot, and above 
 to the external and superior part of the leg by means of a broad 
 knee-band, tends constantly to become straight, presses on the 
 
OF THE DEVIATIONS OF BONES, &C. 3I9 
 
 external side of the leg, and at the same time serves to bring, 
 the foot outwards. If its use be persisted in from a very early 
 period until the process of ossification is finished, the limb may 
 be brought to its natural direction. But it is impossible to ef- 
 fe6l this when the treatment has not been commenced early, 
 and before the parts have acquired their entire consistence. In 
 such cases, the patients should wear the boot and spring during 
 his life. 
 
 The internal use of tonics should be combined with the ap- 
 plication of this apparatus, for frequently these distortions are 
 accompanied with symptoms which indicate a state of cachexy 
 or general debility. 
 
 When, in consequence of a burn, a limb remains contracted, 
 the cicatrices must be destroyed, and the limb brought to its 
 proper direftion, and kept so by means of a proper apparatus 
 until the wound is healed. If, after an extensive burn of the 
 palm of the hand, the fingers are contradted and kept con- 
 stantly bent, an incision must be made into the cicatrix, but 
 not deeper than the skin, lest the vessels, nerves, and tendons, 
 so numerous in this part, might be wounded, and the fingers, 
 after being extended, must be attached to a broad piece of 
 board placed on the back of the hand. By this means the 
 wound will heal, while the fingers are kept parallel to the bones 
 of the metacarpus. 
 
 A little girl was admitted into the hospital de la Charite, 
 with her fingers reverted on the back of her hand in conse- 
 quence of a burn : the froena, which confined them, were di- 
 vided transversely behind the articulation of the first phalanges, 
 with the bones of the metacarpus : the fingers were brought to 
 their natural direction, and fixed so by means of a board pla- 
 ced on the palm of the hand, and some lint was put between 
 the lips of the wound. Each finger was tied by a little band 
 which passed through the clefts of the board, so that the wounds 
 on the back of the hand might be dressed without deranging 
 the apparatus. A larger cicatrix was formed, and the girl re- 
 covered without any deformity. 
 
 When cicatrices, in consequence of a burn, gangrenous carbun- 
 cle, or any other loss of substance, take place at tlie anterior- 
 part of the neck, the skin is often overstretched, and fisena are 
 formed, which keep the head bent and turned more or less lO 
 one side. In such cases, as in every other, the frsena must be 
 cut, the lips of the wound separated and dressed with lint, 
 and the head kept extended during the formaticn of the new 
 
320 OF THE DEVIATIONS OF BONES, &C. 
 
 cicatrix. The iron cross of Heister, and in general all the ma- 
 chines proposed for remedying curvatures of the spine, may 
 be employed for preserving the head in its proper direction. 
 
 In contractions arising from the continual contracted state of 
 the flexor muscles, it is often useful to contend against the 
 force of these muscles, and bring the limb straight. This di- 
 rection is the most favourable for the functions of the limbs, 
 even when they are anchylozed. 
 
 A young man, in consequence of an abscess which formed in 
 the posterior and inferior part of the thigh, and which was fol- 
 lowed by a great loss of the cellular substance of the ham, and 
 of that about the popliteal vessels and nerves, had the biceps 
 cruris, semitendinosus and semimembranosus muscles, so con- 
 tracted, that the leg formed a right angle with the thigh. The 
 leg could be extended by a force that overcame the contraction, 
 but quickly reassumed the bent state on the removal of the 
 force. Professor Boyer, convinced that in this case it was ne- 
 cessary to contend unceasingly against a power that was always 
 aCting, had a machine constructed by Citizen Oudet,* which, 
 by keeping the limb in a constant state of extension, both du- 
 ring rest and exercise, at length overcame the contraction. 
 
 * This ingenious artist, honoured by the approbation of the Academy 
 of Surgery, and esteemed worthy of national rewards, live in the street 
 des Fosses Saint-Germain-des-Pres, Hotel de la Fautriere, Paris. The 
 different apparatus for fra6lures of the clavicle, neck of the femur, and 
 patella, an engraving and description of which are given in this work, 
 hive been construfted by him. 
 
ANALYTICAL INDEX. 
 
 ABSCESSES ; the dimension of the opening made in them to be 
 regulated according to th'.ir situation and cause, page 283. 
 'Al'veolar process, partly (with one or more teeth) detached in a frac* 
 
 ture of the superior maxillary bones ; treatment, 45. 
 Anchylosis : distinguished into complete and incomplete, 3 Id. 
 seldom a primary diseasej ibid. 
 anchylosis from inadion arises from the dimindtidn or cessation of 
 
 the secretion of the synovia, 311. 
 a case of complete anchylosis ot all the joints might happen froth 
 
 long confinement motionless in bed, ibid. 
 influence of the causes which produce this disease ; as, from a bone 
 
 fradlured in the neighbourhood of a joint, ibid. 
 thestifFness succeeding to fradures has been erroneously attributed 
 to an effusion of osseous matter (36 and 37) into the interior of 
 the joint, 312. 
 mode in Which anchylosis takes place, always thfc same, it. 
 the distindion of complete and incomplete essential to be observed 
 irt regulating the treatment ; when the former will ensue, such a 
 previous disposition should be made of the parts as will be most 
 convenient after its determination, ibid. 
 •^measures for prevention or removal of the latter, 45, 313 and 
 314. 
 Aneurism : the laceration of a vein may be easily mistaken for H false 
 
 primitive aneurism, 34. 
 Apparatus by which a patient may raise himself in bed, 67. 
 Articulations. See the articles Dropsy; Foreign Bodies; 
 
 White Swellings; and Wounds. 
 Astragulus, may in some cases of lu:(ation of the foot, be extirpated 
 with advantage ; instances, 286. 
 fraSures o\ this bone : See the article Tarsus. 
 its luxations : See the article Foot. 
 
 Bandages : their importan<», in cases of fraftare, to maintaining the 
 fragments iii the relative position, 2^. 
 their inefHcacy, however, to preserve the fraftured portions in just 
 
 contadt, 26. 
 — examination of the different sorts of bandages, in this latter 
 
 view ; 1 , the roller, ib. 
 • — 2, the eighteen-tailed bandage ; its construdion, and applica- 
 tion : preferable to the former, ib. 
 —3, Scultet's bandage ; its construdion, and application, 27. 
 
 this, in most cases, superior to the other two, ib. 
 the great use of bandages, ib. 
 Bladder", treatment of, when perforated by a splinter from a fraflure 
 
 of the pelvis, 6j. 
 Bones : cause of their hardness ; and operation of this cause in the 
 several wounds and disorders of the bones, 9 and 10. 
 41 
 
322 ANALYTICAL INDEX. 
 
 (Bones. Continued.) 
 
 division of the diseases of the bones into two classes, lo. 
 Buttocks : dangerous consequences of concealing violent falls on this 
 part ; instance, 65. 
 
 Cakis as: causes by which it may he/ra^ureJ; muscular aftion, or 
 external violence, 152. 
 
 — instance of the former case, i^. 
 
 signs of this fra£lure, 153. 
 
 method of setting, ii. 
 
 — of keeping the foot and leg in the proper position, iiiif. 
 
 time of consolidation, ih. 
 
 luxations of this bone : See the article Foot. 
 Callus: formation of; different opinions of the mode in which the 
 consolidation of the fraftured portions of bones is efFefted, 36. 
 
 — opinion of the ancients ; ascribing it to the effusion of the osseous 
 juice, 36 and 37. 
 
 —a modern opinion ; attributing it to the periosteum, 37. 
 
 —a true principle on this subject; analogy between what takes 
 place in the cases of a solution of continuity in the soft and in the 
 osseous parts, 38. 
 
 progress of the generation of callus, 39. 
 
 — it is formed with more promptitude and facility in youth than 
 in more advanced age, ii. 
 
 —its formation how affeded by extreme old age, or by difference 
 of sex, ii. 
 
 ——by the state of pregnancy, 40. 
 
 local circumstances by which its produdion may be retarded ; by 
 the want of a due quantity of blood to one of the fraftured por- 
 tions, ib. 
 
 —by the surfaces of the fragments being not preserved in just con- 
 taft and in pcrfeft immobility, Of, 
 
 usual period in which consolidation is effefted ; vulgar prejudice 
 on this subjeft, 41. 
 
 —examine the state of the limb at the expiration of that period : 
 treatment to be adopted in different circumstances of its appear- 
 ance then; i. If it is swelled, or exhibits a tumour and is 
 shortened and moveable, 41. 
 
 2, if the pieces are moveable and separated, but no contraction, 
 
 a. 
 
 — 3, if the fraflure has not consolidated, but with a shortening and 
 deformity of the limb : — when the ends pass each other, or the 
 surfaces are partially in contaft or totally separated, i5. 
 
 when the portions continue very moveable on one another, 
 thoHgh the just position has been preserved, 42. 
 
 —In casis of nut proper consolidation, after a term of several 
 months, iB. 
 
 —When, after using all other means, the pieces do not unite, last 
 resource, of cutting off their extremities (see the article Extre- 
 mities), 42 to 44. 
 
 the patient is not to be at once allowed the free use of the limb after 
 the reunion of the fradure, 44. 
 
ANALYTICAL INDEX. J23 
 
 {Callus. Continued.) 
 methods of removing a false anchylosis occasioned by the motion- 
 less state of the member during cure, ib. 
 The formation of callus greatly retarded by the scurvy, 22. 
 — it has even been observed to be destroyed by that cause, after 
 it had been formed, 198. 
 Caries. The nature of this disease much involved in obscurity, 
 164. 
 somewhat analogous to certain ulcers of the soft parts, ib. 
 spongy bones, and those of young persons, most liable to it, ib. 
 has been confounded with necrosis, and with exostosis ; its p^cu> 
 liar symptoms, and difference in this respeft from necrosis, 
 157, 165. 
 its causes : distinguished into internal and external ; the former 
 
 most frequent, 165. 
 abscesses said to occasion sometimes caries; they are, however, 
 
 in the cases alleged, its consequence and not its cause, ib. 
 is seldom produced by an external cause, and may almost always 
 
 be ascribed to a disease of the system, 166. 
 — the operation of scurvy, as a cause of caries, ib. 
 ——of scrofula ; bones which it most frequently alFeds in this 
 manner, ib. 
 
 3f the venereal disease, iB. 
 of cancers of the mamma:, ib. 
 diagnosis, in different cases : as, in superficial, deep-seated, or in- 
 accessible bones ; in constitutional diseases ; and in syphilii, 
 — in caries of the vertebra?, ib. 
 prognosis ; most favourable in spongy bones, and in those of the 
 
 \6-j. 
 carpus and tarsus, ib. 
 
 —•in affeftions of these latter, and in short bones in general, and 
 in the extremities of long ones, amputation is frequently the only 
 resource, ib. 
 caries from an external cause, less dangerous also than from an 
 internal ; and of the latter, that from scrofula or cancer more 
 dangerous than from lues and scurvy ; more dangerous likewise 
 to old than to young persons, 16S, 
 Treatment, very irregular : praftice of the ancients, and of some 
 moderns ; must be determined by a close view of the evil against 
 which it is to be direfted, ib. 
 —if produced by an affeftion of the system, this to be ascertained 
 
 and combated with appropriate remedies, ib. 
 — if by an external cause, or remaining after the removal of the in- 
 ternal one, apply stimulating, or absorbent and neutralizing, sub- 
 stances, 169. 
 
 but if these are ineffeflual, use more aflive one?, which will 
 reduce the part to the state of a simple necrosis, 169. 
 
 should the caries be very humid, the actual cautery must be 
 resorted to, (except in certain cases) ; rules fcr its application ; 
 its manner of attion, 169 and 170, 
 Modifications of this general treattnent, in particular bones ; in the 
 bones of the cranium, 171. 
 
324 ANALYTICAL INDEX. 
 
 (Caries. Continaed.) 
 
 —{In the mastoid portion of the temporal bone the cautery is p^jr- 
 ticularly applicable, ib. 
 
 —In the bones of the face, nose, and palate, ib. 
 
 —-In those of the antra maxillaria, 171. 
 
 —In the OS unguis; and scorbutic caries of the alveolar procesf;, 
 ib. 
 
 —In caries of the spine: its dangerous prognosis, 171 and 172, 
 Its symptoms, J73. 
 insufficiency of art in the treatment of this afFe^ion, ib. 
 
 —In carjej of the sternum : rapid progress of the afFe6lion in this 
 "'bone, and its dangerous conseq^iiences, 174,. 
 
 -I— remarkable instance of a spontaneous recovery, ib. 
 
 —— treatment ; in the application of caustics, or of cutting instra- 
 ments, ib. 
 
 —In caries of the ribs, or of the bones of the pelvis, 175. 
 
 —In caries of the different parts of the iliac bone, ib. 
 
 In caries of the extremities of long bone, ib. 
 
 Its affinity with exotosis, which frequently terminates in caries, 177. 
 Carpus i nature and treatment of yra^ar^5 of, 93. 
 
 luxations oi its bones vyiih those of its fore-arm, 259. 
 
 these luxations may take place forwards, backwards, inwards, or 
 outwards 5 the first two sorts the rao5t frequent, 260. 
 
 peculiarity of the articulation of the hand with the fore-arip, in 
 admitting of flexion and extension near/y to the same extent, ib. 
 
 cause, and process, of luxation backwards ; its signs and method 
 of reduftion, ib. 
 
 luxation forwards ; Its cause ; it Is rarely complete ; is difficultly 
 distinguished from a sprain, all doubtful cases to be treated as 
 luxations, ib. 
 
 luxation either backwards, or (particularly) forwards, accompa- 
 nied wiih laceration of the ligaments, and followed by trouble- 
 some inflammatory swelling ; treatment after redu£lion, ib. 
 
 luxation inwards, or outyyards : never complete ; its diagnosis ; 
 method of reduction ; the danger depends chiefly on the strain- 
 ing and laceration of the soft parts, 261. 
 
 Luxations of the bones of the Carpus and Metacarpus, ib. 
 
 luxation of the heaci pf the os magnum backwards ; inflance, and 
 treatment, z6i and 26Z. 
 C^r«J^J of FRACTURES ; divided into predisposing, and remote, 18. 
 
 the predisposing causes ; the situation of the functions of the bones ; 
 instances, ib. 
 
 — ^he age, and the diseases, of individuals ; instances, ib. 
 
 —a certaii degree of cold improperly reckoned among these cau- 
 ses, 19. 
 
 the rem le causes, and their different operation, ib. 
 
 —I, when the frafture is produced at a distance from the parts on 
 which the force is applied ; instances, ib. 
 
 —2, when produced exaftly on the part struck; instance, ib. 
 case of comminutive fradure, ib. 
 
 Causes of Luxation; are divided into external and internal j 
 and both are predisposing or occasional, 207. 
 
ANALYTICAL INDEX. J25 
 
 (Causes o/ivx AT ION. Continued.) 
 
 1, the predisposing: are either nataral or accidental : the natu- 
 ral ; as, confirmation of the joint, ligaments, articulations. 
 &c. il>. 
 
 —the accidental ; zs, disease, in various cases, 2g8. 
 
 2, the occasional causes ; the efFeftof these depends upon the dl- 
 reftion of the axis of the bone at the moment, 209. 
 
 —in the round articulations, the adtion of the muscle has always a 
 
 share in producing the luxation, 208. 
 — in some cases, muscular adlion alone will efFeft a luxation, 209. 
 luxations, from whatever causes, always accompanied with lacera- 
 tion of the ligaments surrounding the joint, 209. 
 Children : caution against a dangerous manner of playing with (hem ; 
 in an instance of a iatal luxation of the vertebrs thus occasi- 
 oned, 227. 
 See also the article Deviations of the Bones, 
 Clavicle: On the Fracture of this bone; it is very liable to this 
 accident, from various circumftances, 72. 
 the fradture may be at any part of the length of the bone; and ei- 
 ther transverse or oblique, simpleor differently complicated, :i. 
 — -frafture caused by contre-coup, is not necessarily complicated 
 
 with contusion, ih. 
 derangements of the broken portions, 73. 
 
 —mechanism of these derangements , the external portion is al- 
 ways that which is deranged, ii. 
 falling of the arm in a fradlure, ii. 
 signs of frafture, :i. 
 
 by what complications these fradlures are rendered dangerous, 74. 
 examination of the various bandages invented for this frafture ; that 
 
 of the ancients, ii. 
 — that in the form of the figure 8. ii. 
 ——different modifications of this latter, li. 
 the proper treatment, 75. 
 
 — account of Desault's appropriate apparatus, 75 and 76, 
 — improved invention of Boyer, 77. 
 
 treatment of a simple fradlure by means of this latter con- 
 trivance, ill. 
 treatment of compound fraftures, ii. 
 caution in using Desault's bandage, /^. 
 
 On Luxations of this bone ; these are much less frequent than frac- 
 
 tures, 235. 
 I, of Luxations of the Extremity near the Sternum, iL 
 these dislocations are favoured by the conformation of the parts, ii, 
 may take place forwards, backwards, or upwards ; but never 
 
 downwards, 235. 
 — the anterior most frequent ; the others very rare, particularly 
 
 the backward, 236. 
 manner in which the anterior luxation is effefted ; instance, ii. 
 —the upward, ii. 
 
 — the backward, the treatment of this is difficult, 236. 
 —Diagnosis of each, 238, 
 
J26 ANALYTICAL INDEX. 
 
 (Clavicle: luxations oi. Continued.) 
 
 the redudlion to be efFefted in the same manner as in cases of frac- 
 ture, 75, 238. 
 
 —and the apparatus also the same, 77 and 238. 
 
 2, of Luxations of the Extremity next the humerus, 239. 
 
 these luxations very rare, and scarcely occur in any other direflion 
 than upwards, ib. 
 
 — cause, and process, of dislocation in that diredlion, ib* 
 
 •*—— manner in which it is efFedted. ib. 
 
 —diagnosis, 240. 
 
 — prognosis, less dangerous than affirmed by Pare, ib. 
 
 — the luxation often imperfcdly reduced, ib. 
 
 — method of redudlion ; bandage, 77 and 240. 
 
 Instance in which a dislocation of this bone was mistaken for ex- 
 ostosis, 178. 
 Coccygis os; ttidomfraiiured, 65. 
 
 signs of such an accident, ib. 
 
 treatment, ib. 
 
 dangerous consequences of concealing violent falls on the buttocks, 
 ib. 
 
 — instance, ib. 
 
 IjCss easily luxated ; instance, however, of this accident, 228. 
 CoU improperly accounted a predisposing cause of frafture, 18. 
 Comminuti've fra£iure described, 12. 
 
 treatment, in various circumstances ; and cases in which amputa- 
 tion is necessary, 34, 35, and 36. 
 Complete and incomplete fradures ; this distinftionis unfounded, 17. 
 Compound fraBure defined, 17. 
 
 treatment in the different cases of complication (See the article 
 Treatment'), 32 to 36. 
 Consolidation offraclures. See the article Callus, 
 Contrat5ions occisioned by burns ; treatment for, 319. 
 
 — by the continual contraded state of the flexor muscles ; instance, 
 
 320- 
 Counter-extension, See the article Extension. 
 Crepitation the most general and distinftive symptom of frafture, z©. 
 
 methods of discovering the existence of this criterion, 20. 
 Crutches ; vast importance of a proper and sufficient use of them in 
 
 recovery from a fradure of the lower extreniities, 44. 
 
 Demi-Jlexion ; comparative advantages and disadvantages of this po- 
 sition, and of straightness, for a fradlured limb during cure, 35. 
 
 Denudation of the Bones. See the article Wounds. 
 
 Derangement of the fraftured portions of a bone ; its causes and va- 
 rieties, 13. 
 these latter considered : 1, In the direftionof the diameter ; and, 
 2, parallel to the axis : instances of each, 14. 
 
 3, the fragments forming an angle with each other ; instances, ib, 
 
 4, derangement afTedting the circumference ; instance, ib. 
 Causes of derangement ; always exterior: as, i, the cause of the 
 
 fradure; instances, (case of the celebrated Ambrose Pare), 15. 
 
ANALYTICAL INDEX. ^1'] 
 
 z, the weight of the limb, or the impuUc communicated to it 
 
 during the dressing, 15. 
 — 3, the most powerful, the contraftion of the muscles (See the 
 
 article Muscles), ib. 
 Complicated derangements ; instance, ib. 
 Deviations of the bones, and the deformity arising from 
 
 them ; can take place only in infancy, 314. 
 their causes ; among which are the use of swaddling-clothes, and 
 
 of stays, 315. 
 —cases, however, in which stays of a certain construftion may 
 
 serve to correal disproportions, 316, 317. 
 caution in the use of leading-strings ; in general they are injurious, 
 
 by inducing the too early practice of walking, and thus ocasion- 
 
 ing the knees to become turned inwards or outwards, 317. 
 — simple and efficacious method of remedy for this deformity, 318. 
 deformity of the feet, {club-footed: its different species: cause; 
 
 necessity of early attention to; and treatment, ib, 
 treatment of contraftions occasioned by burns, 319. 
 — by the continual contracted state of the flexor muscles; instances, 
 
 ib. 
 Differences oi ■Lvx AT \Qii St 23. 
 
 1, witli resped to the articulation in which they take place ; much 
 more frequent in the round or loose articulation than in the gin- 
 glymoidal, 201;. 
 
 2, as to the extent of the dislocation ; distinflion into complete and 
 incomplete, ib. 
 
 — the complete instanced in luxation of the humerus or femur, 204. 
 
 — the incomphte, in dislocation of the head of the astragalus, ib. 
 
 an erroneous distindlion of incomplete has been attempted to 
 
 be established, 206. 
 
 — the dislocation, when complete, may be to a greater or less dis- 
 tance, ib, 
 
 3, as to the direction in which the bone is displaced ; in the round 
 articulations it may be in the direftions of all the radii of the 
 circle, ib. 
 
 limitations on this point, from circumstances of conforma- 
 tion, ib. 
 —— distindlion of inferior, superior, &c. tb, 
 — direftion, in the ginglymoidal articulations, ib. 
 
 4, as to the length of time they have continued ; a difference of 
 the highest importance, 207. 
 
 — a sufficient interval, may even have rendered the reduftion im- 
 possible, ib. 
 
 5, as to the accompanying circumstances; which occasion the 
 distindlion into simple and compound, ib. 
 
 6, as to the cause which has produced them : See the article Cau- 
 ses of LUXATION. 
 
 Differences of fractures. See the article Species. 
 Dropsy of the articulations (or Hydarthrus) ; occurs 
 only in the knee, 288. 
 rarely co-exists with any other dropsical affedlion, but is produced 
 by local causes; their operation, 289. 
 
328 ANALYTICAL INDEX. 
 
 (Dropsy of the articulations. Continued.) 
 —may be occasioned also by acute or chronic fheumatisin, and 
 
 chronic gout, ib, 
 coUeftions of synovia sufficient to merit this name erroneously said 
 
 to have occurred in the hip-joint, ib. 
 this disease not to be confounded with encysted tumours on the side 
 of THE KNEE near the patella; (distinguished symptoms of 
 these latter ;) nor with certain white swellings ; (this last mis- 
 take may be easily made,) 290. 
 distinguishing symptoms from arthritic, cedamatous, and white 
 
 swellings of the knee, and foreign bodies formed in it, 290. 
 prognosis unfavourable, 291. 
 
 peculiar mode of treatment in this disease ; by topical applica- 
 tions, 291. 
 —if these means fail, a surgical operation to be resorted to ; this 
 described, 292. 
 after treatment, ib. 
 Dura mater : tumour formed by fungous excrescences from this bone; 
 
 may be mistaken for exostosis ; diciinftive signs, 178. 
 Eighteentailed bandage -y its construdion, application, and compara- 
 tive advantage, 26. 
 Emphysema ; its produdion, and ^treatment in different stages, dz 
 
 and 63. 
 Exostosis ; distlnft species of, 176. 
 
 different cases ; the ivory exostosis, the Spungy, and that compo- 
 sed of osseous and fleshy parts, ib. 
 bones which are mo*t frequently affefled with this disease, ib. 
 its different appearances ; almost always caused by lues or scro- 
 fula ; its affinity with caries, and frequent termination in that 
 affet^ion, 176 and 177. 
 very rarely proceeds froni an external cause, r77. 
 signs of a scrofulus diathesis, ib. 
 —of a venereal, ib. 
 
 diagnosis ; peculiarity from" that of a pcriostosis, ib: 
 the existence of exostosis, sometimes cannot be ascertained before 
 
 the patient's death ; instances, ib. 
 the head of a luxated boncj the enlargement of the ends of ricketty 
 bones, or the tumour formed by fungous excrescences from the 
 dura mater, may all be mistaken for exostosis, 178. 
 general effefts of exostosis ; a sense of weight; pain ; and defor- 
 mity, ib. 
 ' — particular effedls : as, in ejiostosis in the orbit of theeye; on 
 
 the pubis ; or on any of the bones of the pelvis, ib. 
 Prognosis, different according to different circumstances ; exos- 
 toses from an external cause more difficult than from an internal 
 one ; of the latter, that produced by a scrofulus diathesis most 
 so, ib. 
 Erroneous opinions in the general pathology of this affeftion, 179. 
 Principles of treatment ; the primary disease must be afcertained, 
 
 and made the chief objeft in this view, 179 and 180.. 
 if a venereal affedtion has existed, oris present, in the constitution, 
 mild or strong applications of mercury, Scq. i8c. 
 
ANALYTICAL INDEX. 329 
 
 (Exostosis. Continued.) 
 
 — after a certain time and efFeft, the general remedies to be dis- 
 continued, ib. 
 
 —caution in the use of mercury ; little reliance in these cases on 
 topical applications, ib, 
 
 treatment in scrofulous cases ; often inefFedlual, ib.^ 
 
 — if the exostosis terminates in caries, the method of cure the 
 same as if this latter had been the original afFeftion, }8i. 
 
 the scorbiKic and the cancerous, exostoses, ib. 
 
 exostosis from an external cause, or merely local, should (after re- 
 moving the primary disease) be left to nature ; the use of caus- 
 tics, or the aftual cautery, dangerous, ib. 
 
 —treatment however, when the tumour presses on and deranges 
 some important organ ; removal by the saw ; much preferable 
 to the chisel and mallet, ib. 
 
 direction for the use of these latter, when adopted, ib, 
 this dreadful remedy seldom justifiable, i8z. 
 
 Lamellated exostosis, ib. 
 Extension and counter-extension : not always necessary in setting a 
 fractured hone, 'i instances, 23. 
 
 the hands of intelligent assistants always best for both these pur- 
 poses ; more powerful means injurious, ib. 
 
 should be applied not on the fragments themseJve?, but on the 
 bones which articulate with them ; instances, 24. 
 
 degree of force to be employed ; and its direftion ; instances, ih. 
 
 Apparatus for effefting perpetual extension, 29. 
 
 its application and a£lion, ib. 
 
 — various rules on the former point, 30 and 31. 
 
 sundry contrivances for eiFefting perpetual extension and counter- 
 extension in fractures of the neck of the femur, 120 to 126. 
 
 Some remarks respefting the method of making extension and 
 counter-extension in a case of Luxation, 245 and 246. 
 See also in the article Treatment (general) ot luxations. 
 Extremities of \.\ie fractured ^oxuor.s of the bones may be cut off, as 
 a last resource when all other means fail of making them unite, 
 
 .42- 
 this pradlicable only in the femur and humerus, ib. 
 
 method of performing the operation, ih, 
 
 — unsuccessful instance, 43 and 44. 
 
 this operation very difficult, but not to be renounced for that rea- 
 son, 44. 
 
 May be piaftised also on iV,e carious extremities incases of white 
 swellings of the joints, 307. 
 
 — as, of the knee ; method, 308. 
 
 — of the humerus, ib. 
 
 instances, ib, 
 
 — instance, of the knee, 309. 
 
 ——great danger of this case, il. 
 
 — method, in the elbow, 310. 
 Femur. Luxations oi x.\\q ii:mnr ; not frequent, and have been per- 
 haps often confounded with fradures of the neck of this bone^ 
 264. 
 
 42 
 
« 
 
 ■.*>A' 
 
 330 ANALYTICAL INDEX. 
 
 (Femur, Continued.) 
 divided into four species : i , luxation upwards and outwards ; and 
 2, downwards and inwards; these two the most frequent, 26/^. 
 —3 luxation upwards and forwards ; and 4, downwards and back- 
 
 w.'.rdb : very rare, 265. 
 the First species considered : its process, ih. 
 — its symptoms, and distinflive diagnosis from frafturc of the 
 neck of this bone, ih 
 
 ause of the limb being turned inwards in this loxation, 266. 
 
 — tn'Jch laceration and irjury done to tne soft parts, ih. 
 —method of effecting re ^uflion, ih. 
 
 signs of success in this operation, 267. 
 
 alter treatment, ih 
 
 the Second species, downwards and inwards; its causes, and pro- 
 cess, 268. 
 
 — ubsequent state of the soft parts surroundjng the articulations, 
 th 
 
 — diagnosis ; too striking to admit of any mistake, ih. 
 
 —prognosis, less unfavourable than in the First species ; method 
 of renufti 'n, 269. 
 
 the Third species, upwards and forwards ; very rare ; instance, 
 however, ih. 
 
 — --yroptnms, ih. 
 
 — prognosis dangerous, 270. 
 
 — reludlion, same as in the preceding species, ih. 
 
 the Founh species, dow .wards and backwards ; may be either pri- 
 mary or secondary, ih. 
 
 — general symptoms in both cases and peculiar ones in each, ih. 
 
 — he secondary class muci more frequent than the primary, zyq* 
 — ieJnftion, same as in the preceding species, ih. 
 
 GL.ieral camion in the reduction of these luxations, ih, 
 
 cons -quences of luxations of the First and Second species, if not 
 duced, 270 and 271. 
 
 Spontaneous Luxations or the Femur. SfC that article. 
 
 Instance of the carious extremity of this bone and of the tibia cut 
 cfF in the ca«s of white swelling, 309. 
 
 For i^rflf/arw of this bone. See the articles Neck of the Fe- 
 mur; and Th igh. 
 Fihula; less frequently _/V<zr/Kr<?// than the tibia, 148. 
 
 causes by which it is exposed to this accident ; adion exerted on 
 the fibula in walking on uneven ground, ih. 
 
 formation and disposition of this bone in climbing animals, 149. 
 
 manner in which it is fradtured in the human subjed^, by the foot 
 being forcibly turned inwards or outwards, ih, 
 
 fraftures from a fall, or a biow, 150. 
 
 kin'l of derangernent, in all cases, ih. 
 
 diagnosis, ib. 
 
 in trafturt- wit'i intense straining of the articulation of the foot^ 
 and inflammation, some praftisers confine their attention to 
 these accompanying circumstances; dangerous consequences of 
 this treatment, ib. 
 
 —-proper method in such cases, 151. 
 
Analytical iSDEx. ^31 
 
 \Fihula. Continued.) 
 
 time of consolidation, 151. 
 
 treatment of fradlures towards the middle part of the bone, ih. 
 
 fradlure near the inferior extremity a frequent complication of in- 
 ward luxation of the foot ; treatment, 286. 
 
 For fradlure ot both bones of the leg, see the article Leg. 
 
 The Luxation of this bone from the tibia is diiHculr, but may oc- 
 cur : instance ; treatment 283. • 
 Fingers. See the article Phalanges. 
 
 Foot : O 1 Fractures of the Boa-rs of; See the articles M<..'i;.'.3;v«i ; 
 Phalanges (of the toes) ; and Tarsus, 
 
 luxations of the foot ; seldom occu.-, 0:1 account of the confirma- 
 tion of the parts, 284. 
 
 may be either inwards, outwards, forwards or backwards ; and 
 in each case complete or incompiete; the two former diredions 
 most frequent, particularly the first ; its cause and symptoms, 
 284, 285. 
 
 — symptoms of the outward luxation, 285. 
 
 Luxations o( the foot always dangerous, and sometimes fatal ; 
 the prognosis, however, not always so unfavourable, ib. 
 
 the reduftion should be effefted as soon as possible : method ; and 
 after-treatment, ib. 
 
 the nature and violence of the symptoms decide with respefl to 
 amputation ; the astragalus may in some cases be extirpated 
 with advantage ; instances. 286. 
 
 frafture of the fibula near its inferior extremity a frequent compli- 
 cation of the ir.ward luxation ; treatment, ib. 
 
 causes of forward and backward luxations ; the fcrrricr more dif- 
 ficultly produced, ib. 
 
 — process of each ; symptoms of the backward luxation; hovv 
 distinguished from sprain, ib, 
 
 '■ symptoms of the forward luxation, ib, 
 
 — redudion of both species ; and treatment, 287. 
 
 The astragalus and os calcis never ccmpleiely separated by luxa- 
 tion, lb. 
 
 —may, however, be disjoined (one or both) from the scaphcidss 
 and cuboides, ib. 
 
 (— — ingeiiious idea of Chopart, of amputating only a part of 
 the foot, ib, 
 
 i—- causes of this luxation: it is often with difficulty ascertained ; 
 and not easily reduced, instance, ih. 
 
 the other bones of the tarsus and metatarsus cannot be luxated, 
 288. 
 
 See also the article Phalanges (of the toes). 
 
 Deformity of the feet, {club -foot e'd :) its different species; cause; 
 necessity of early application ; and treatment, 318, 319. 
 Fore-arm ; On Fra6lures of, 83. 
 
 distinction ; into fraclures of both, or of only one, of the bones, 
 
 84- 
 I, Fradtures of both the bores ; generally take place ia the part 
 on which the cause has immediately afled, ih. 
 
7»>fV4 
 
 332 ANALYTICAL INDEX-. 
 
 (Fore-arm; fraftares of. Continued.) 
 
 the two bones may be fraftured on the same, or on a different level ; 
 the fraftures are generally complicated, 84. 
 
 species of derangement : that in the longitudinal direftion, ex- 
 tremely rare ; that in the diredlion of the diameter, i6. 
 
 —the angular derangement, ;^. 
 
 signs of frafture, ii, ^ 
 
 — fradlure near the inferior extrernity, how distinguished from lux- 
 ation, 85. 
 
 jetting the fradlure, ii. 
 
 application of compresses, bandages, and splints : the compresses 
 and splints should be of the same length as the arm; lateral 
 splints useless and injurious, 85. 
 
 treatment of cases of excessive contusion, with wound or commi- 
 nuiive fradture, 86. 
 
 time of consolidation, z^. 
 
 2, and 3, Fradlure of the Radius or Cubitus only: See those ar- 
 ticles. 
 
 Of Luxations of the fore- arm, 251. 
 
 I, of Luxations of the fore-arm from the Humerus ; they may be 
 
 either backwards, laterally, or anteriorly : the first the most 
 
 frequent ; the lateral much less so, and always incomplete; the 
 
 anterior very rare, 251. 
 process of the Backward luxation, 252. 
 — this always takes place from a fall on the hand, ii. 
 —situation of the parts after the dislocation, ii. 
 — this luxation may be mistaken for fradlure ; instance : the diag- 
 nosis is difficult, ii. 
 — different means of redudlion ; attended wiih inconvenience, 253, 
 
 a preferable method, ii. 
 
 after treatment, 253, 254. 
 
 — case of rupture of the ligament confining the head of the radius 
 
 to the extremity of the ulna; treatment, 254. 
 — necessity of speedy redudlion of these luxations, 2^. 
 luxation Forwards ; to be treated as a fradlure of the olecranon 
 
 (See that article). il>. 
 luxation Laterally; method cf redudlion, ii. 
 — keeping the bones in their place, preventing, or mitigating, 
 
 the inflammation, 255. 
 2, of Luxation of the Superior Extremity of the Radius from the 
 
 Ulna, ii>. 
 this the most frequent of the relative dislocations of the bones of 
 
 the fore-arm, il>. 
 divided into primary and secondary luxations; the former class 
 
 considered, ii, 
 — cause of the backward being (in this case) more frequent than 
 
 the anterior luxation, ii>. 
 — state of the parts in the backward luxation, 256. 
 
 method of redudlion ; and after-treatment, iL 
 
 —Secondary luxation ; its causes, il>. 
 

 ANAL'VTICAL INDEX. 233 
 
 (Fore-arm; luxaiionsof. Continued. 
 
 — takes place frequently in young children, fiom ihe mischievous 
 praftices of nurses : treatment ; and consequences ot r.eglcd>, 256, 
 
 257- . , ' . 
 
 3, ot Luxations of the inferior Extremity of the Ulna ; this name 
 adopted in preference to that (u'.ed by other authors) of Luxa- 
 tions of the inferior extremity ot the radius, 257. 
 
 these luxations may take place anteriorly or posteriorly ; the latter 
 by much the most frequent, ib. 
 
 — process of the former, ib. 
 
 remarkable instance of this case, 258. 
 
 — instance of luxation backwards, ib, 
 
 its process, ib. 
 
 method of reduftion ; and treatment, ib. 
 
 :his luxation less inconvenient in its consequences thtn thai 
 in the forward direiflion, ib. 
 Foreign bodies formed in the artigulations ; to be 
 carefully distinguished from arthritic concretions depcs'ted in 
 their neighbcurliocJ, 293. 
 
 may occur in the inside ot every articulation in which there is mo- 
 tion, but none more subjeft to them than THE knee, ib, 
 
 [The subsequent detail of circunriStances and treatment, applica- 
 ble only to those found in this joint.] 
 
 their different appearances, number, size, form, and substance, ib. 
 
 their origin and growth, difficult to explain; various suppcsitions 
 on this point, 294. 
 
 their different symptoms, and circumstances, ib. 
 
 these substances cannot be resolved, ncr (with advantage, if at all) 
 fixed and confined, 295. 
 
 extradion the best method of cure ; process of this operation, and 
 after-treatment, ib. 
 
 Case of these bodies in othes. joints, 297. 
 Fractures; natural cause of iheir superior tardiness In reu. . 
 
 beyond that of wounds of the flesh, 9. 
 definition of fra£ture, 1 1 . 
 See the articles Causes, Prcgmsis, Species, SigKS, and Trec/fraii, 
 
 of Fractures ; Callus ; and the names of the principal lones. 
 Fragility ; state in which this disease appears in the bones, 107. 
 it is a natural consequence of eld age, 9. lo, 197. " 
 — at that period of life the disease is incurable, 198. 
 sometimes occurs in adults, from a venereal, scrciulcus, cr cr.r. 
 
 cerous taint, ib. 
 — operation of the last cause ; remaik?ble instances, ib. 
 — ot the venereal taint ; in this case tie primary disease claims the 
 
 chief attention, ib. 
 —of scorbutic afFedions, ib. 
 
 ■appearance of the bones of a scorbutic perron, when boiiec, 
 
 ib. 
 conclusion; fragility rather a symptom of senility cr seme disease, 
 
 than itself a disease; the etiohgyof Rickets may perhsps in 
 
 •lime be elucidated by a ccmpariscn of these two aJItiSiicr*, .-1. 
 
;.fv''>^ 
 
 
 334 ANALYTICAL INDEX. 
 
 Hand ; On the Frailuies and Luxations of the bones of. See tlie 
 different arciclcs Capus, Metacarpus ; and Phalanges of the fin- 
 gers. 
 Hanging: different manner of dying, of the criminals hanged at Ly- 
 003 and those at Paris ; occasioned by a trivial custom of the 
 executioner of the former place, 227. 
 Hardness: cause of this peculiar quality of the bones ; and its pro- 
 gress from infancy to mature age, 9. 
 Humerus ; On the FraSIures of, 78. 
 
 may be fraftured in any point of its length, ih. 
 
 the fradtures may be either transverse or oblique, simple or com- 
 pound, ih. 
 
 — transverse fraftures, 78. 
 
 — oblique fra&ures, il. 
 
 gei\fral diagnosis, 79. 
 
 — fradlures in the neck of the humerus not so easily ascertained ; 
 direftions on this point, iB. 
 
 different degrees of danger, in fraftures at different lengths of the 
 bone, 80. 
 
 operation of setting transverse or oblique fraftures; bandage, 
 &c. ih. 
 
 — the bandage must be applied on the hand and fore- arm, ih. 
 
 positions of the arm ; and general treatment, 81. 
 
 — in cases complicated with violent contus'on, or comminutive, ih. 
 
 position of the splints, in fraftur^-s of the lower extremity of the 
 humerus; Boyei's praftice, 82. 
 
 particular treatment; in fraflures of the neck of the humerus, ih. 
 
 — M'jscati's method ; its great disadvantage, ih. 
 
 — corredled by Le Dran, ih. 
 
 — further improved by Desaulr, ih. 
 
 ———eminent merit of this Improvement, 83. 
 
 treatment of a case sometimes happfning in young subjects, of the 
 head of the humerus (while yet but an epiphysis) separating 
 from the rest of the bone by a blow or fall, ih, 
 
 compound fradlures not to be sec till the inflammation has sub- 
 sided, ih. 
 
 Of Luxations of the Os Humeri, 239. 
 
 equal in ftequency the luxations or all the other bones, ih. 
 
 may take place in three direftions ; downwards, inwards or for- 
 wards, and outwards or backwards : luxation upwards is impos- 
 sible, ih. 
 
 — the luxation even outwards or backwards'^scarcely occurs ; the 
 other two species therefore merit chief attention, 239. ' 
 
 the downward direftion more frequent than the inward or forward ; 
 and in that case a subsequent change of place m?y carry the 
 head of the humerus in this latter diredlion, but cannot carry it 
 backward, 240. 
 
 I, Consideration of the downward luxation: causes which render 
 this the most frequent diredion, ih, 
 
 manner in which this luxation is performed, elucidated, 241. 
 
 it has been thought that when the arm is moved out from the body, 
 
ANALYTICAL INDEX. ^3$ 
 
 (Humerus; luxations of. Continued.) 
 
 the aflion of the deltoid muscle alone can produce a dislocation ; 
 
 case cited, iB* 
 state of the parts when the luxation has taken place, 242. 
 diagnosis ; marks by which the downv.ard luxations are distin- 
 guished from fraclares of its neck, 79, 242, 243. , 
 prognosis, uncertain, 243. 
 means toefFedl redudlion ; enumeration and description of various 
 
 which have fallen into disuse: the amBe of Hippocrates, i5. 
 — the ladder, ih, 
 —the prucess by the door, 244. 
 — Petit's machine, ih. 
 — the patient and the surgeon both extended on the floor, &c. il. 
 
 ^ or seated opposite one anoiher, &c. ih. 
 
 a more umxceptionable method, 244, 2/^.5. 
 
 -—if the first attempts fail, bleeding and warm bathiRg and repeat 
 
 the operation ; in no circumstances pullies or other extending 
 
 machines to be employed, 245, 246. 
 useless and exquisite torture produced by the adoption of such 
 
 mechanical contrivances, 246. 
 erroneous supposition that the narrowness of the opening through 
 
 which the head of the humerus has escaped resists its redudlion, 
 
 ih, 
 method of reduction after a certain interval has elapsed, 217, 246. 
 
 2, Luxation inwards ; may be primary or secondary, 247. 
 erroneous opinion, that the head of the humerus may be carried 
 
 upwards towards the clavicle, and be placed between the great 
 
 peftoral muscle and the subscapularis, ih. 
 diagnosis, ii, 
 
 prognosis; more unfavourable than in downward luxation, 248. 
 — means of reduftion, nearly the same as in this latter, ib. 
 
 3, Luxation outwards or backwards; no well-attested instance of 
 this exists, though it appears to have been admitted possible, ih. 
 
 cannot take place secondarily, and succeed to a luxation down- 
 wards, ih. 
 
 diagnosis, in the event of its occurrence, ih, 
 
 •^means of reduftion, ib. 
 
 General treaiment of each species : means of keeping the reduced 
 bone in its place, ib. 
 
 topical applications if necessary, in contusions of the shoulder; 
 emoliients, bleeding (in certain cases), and resolvents, 249. 
 
 :— in oedema of the arm ; its causes ; seldom occurs, ib. 
 
 ' — in paralysis; different treatment according to its different causes, 
 ib. 
 
 • sometimes confined to the deltoid muscle, il. 
 
 Tumour sometimes produced by the violent tfFurts necessary to re- 
 duce an old luxation ; its nature, 250. 
 
 Anchylosis never a consequence of luxations of the humerus when 
 reduced, and even rarely when they are not reduced, 2:;o. 
 
 Method of cutting ofFthe carious extremity of this bone (wiien the 
 state of the soft parts will admit of it) in the case of white 
 swelling, 308. 
 
 instance; 309. 
 
^2^ ANALYTICAL INDEX. 
 
 I/ia (ossa), fra£lurcs of. Sec the following article. 
 Innominata ossa ; ihese bones seldom fra6iured, 66. 
 
 the fradlure may occur in different parts of them, and take diffe- 
 rent directions, ib. ' 
 
 no derangement of the portions ever takes place, ii, 
 
 these fraftures rendered very dangerous by extravasation and con- 
 tusion, ib. 
 
 their signs, ib, 
 
 treatment, ib. 
 
 — apparatus by which the patient may raise himself in bed, 6j. 
 
 the inflammation gen rally produces suppuration and abscesses, ib. 
 
 detached splinters sometimes give rise to subsequent abscesses, ib. 
 
 treatment if the bladder is perforated by a splinier, :b. 
 
 These bones are too firmly articulated to admit of 'Luxation ; the 
 articulations, however, may be rehxed to a certain degree, 230. 
 
 question whether this relaxation is a means fmployed by nature to 
 facilitate parturition, ib. 
 
 — when the relaxation goes so far as to allow the bones to be moved 
 and separated, it is rather a morbid than a natural state, ib. 
 
 —instance of fatal sudden and easy delivery ; appearance of the 
 ossa pubis and symphysis on dissection, 231. 
 
 treatment in relaxation of the symphysis pubis, or of the sacro-iliac 
 synchondrosis, 231. 
 
 —a sudden and violent separation of the thighs not capable alone 
 of producing a disjointing of the latter, ib. 
 
 this may, however, be occasioned by external violence, in- 
 stance, 232. 
 
 these cases must be very rare: proper treatment; the anti- 
 phlogistic, ib. 
 Ischia (cisa). See the preceding article. 
 Jav/. See Lev/ er jaw, 
 
 Kne E. See the article Dropsy of the articulations; Fo- 
 reign BODIES FORMED IN THE ARTICULATIONS; and 
 
 White SWELLINGS. . •.- 
 
 Deformity of this part (of being turned inwards or outwards) fre- 
 quently induce in children by the practice of too early walking; 
 
 simple and efficacious method of remedy, 317. 
 
 Leg; Cii the i"/-^c7«;rj of, 143. 
 
 this name comprises those traflures only in which both bones are 
 
 broken ; the middle of each is the part generally fradured, ib. 
 in;'.y he either transverse or oblique; and arc liable to every sort 
 
 ci" derangement, ib. 
 diagnosis, 144. 
 prognosis, varies according to many circumstances ; fraflures near 
 
 the kaec, or the inferior part, more dangerous than of the aiid- 
 
 dlf; oblique fraClures very difficult to be managed, ib. 
 treatment of simple fradtures : disposition of the patient; appara- 
 
 tus, and its application ; bleeding, and low regimen, 144, 145. 
 — -coaipresfcs under the lieel, not to be prnflised, 145. 
 
ANALYTICAL INDEX. J37 
 
 (Leg ; fra£lures of. Con t i nued . ) 
 
 — roller, for very young children only, 145. 
 
 —the apparatus should be re-applied at the end of eight days, and 
 afterwards every seven days ; dangerous praftice of not changing 
 the first dressing for eighteen or twenty days, ib. 
 
 — time of consolidation, 146. 
 
 — regimen, &c. ih. 
 
 in verv oblique fradtures, continued extension should be employed, 
 ib, ' 
 
 For frafiures of either bone singly, see the articles Fibula', and 
 Tibia ; And for luxations of the Bones of the Leg, see also those 
 two articles. 
 Longitudinal fraBures, an inadmissible distin£lion, 13. 
 Lower jaw; kinds of /'ra^SFwrs to which it is liable j and their me- 
 thod of producing the effeft, 48. 
 
 variations as to the part of the bone fraftured, ib. 
 
 -^as to thedireftion of the frafture, ib. 
 
 these fradtures seldom simple, 49. 
 
 -^causes producing the derangement of the fraftured portions; the 
 complicated disposition and adlion of the muscles, ib* 
 
 symptoms of frafture, 50. 
 
 :■ — in the branches and condyles, ib. 
 
 these fraftures in general not dangerous, il. 
 
 — compound fraftures, however, are so, ib. 
 
 operation of setting a simple or double frafture, 51. 
 
 great difficulty of maintaining the fragments in the just position ; 
 particularly of keeping the jaw motionless, on account of its na- 
 tural funftions, ib, 
 
 ^—methods of feeding the patient, in this latter view, ib. 
 
 —ligatures of gold or silver wire, unnecfessaryi and not of general 
 utility, ib, 
 
 '' — pasteboard moulds injurious, 51, 
 
 — the use of bandages preferable ; method of applying them, 52. 
 
 • -modiiicatioii of this apparatus required ih fracture of the con- 
 dyles, 52. 
 
 particular inrtportance in frafturcs of the condyles ro obtain a cure 
 without deformity : ieffefts of perverseness in the patient during 
 the treatment ; instance, 52. 
 
 period of cure, 53. 
 
 fradture with violent contusion, or it division bf the soft parts, 53. 
 
 On Luxations of the Lower Jaw; the distinftion into complete and 
 incomplete is erroneous, 220. 
 
 these luxations can take place only anteriorly, ib. 
 
 • — in very young infants, they are impossible in any direftion, ib. 
 
 the causes are almost always internal ; as, from excessive yawn- 
 ing, 221. 
 
 processof the luxation, ib. 
 
 —theory of the mode in which it is effedled ; ill-founded, j3. 
 
 •——a much better theory on this subjedl, iB. 
 
 43 
 
<*'i-^:. . •'T'^s 
 
 33^ ANALYTICAL INDEX. 
 
 (Lower jaw; luxations of. Continued.) 
 
 macnjr in which the parts surrounding the articulation are affcft- 
 
 ed, 222. 
 
 diagnosis, z^. 
 
 — these appearances much less distinfl when a certain interval has 
 elapsed, 223. 
 
 prognosis : much less unfavourable than that established by Hip- 
 pocrates ; and not the more so in persons in whom the luxation 
 is made with facility, ih. 
 
 mode of le 'u^ion, ih. 
 
 — after-treatment, 224. 
 
 method of reducing the luxation by fatiguing the muscles, 224. 
 
 censurable pradice of reducing these luxations by a bluw o) the 
 fist, i6. 
 
 pradticc of ihe ancients, of u<;ing pieces of stick as levers between 
 the great mnlarr s, to depress the lower jaw ; the modern pro- 
 cess preferable, il>. 
 
 In dislocations of one condyle only, little modification of the treat- 
 ment is required, i6. 
 Luxation: rarely accompanies Fradures, 17, 32. 
 
 —question of the treatment of such cases when they occur ; whe- 
 ther the dislocated fragment should be Jirst replaced, or not, till 
 the consolidation of the frafture is efFeitei, 32. 
 
 the head of a luxated btine may be mistaken for exostosis; instance, 
 in dislocation of the clavicle, 178. 
 
 Luxation described : divided ^nto complete and incomplete, 204. 
 the previous anatomical knowledge necessary to consider the na- 
 ture of tbis afi^edlion, iB. 
 luxations afford both general and specific characters, il>. ^ 
 
 See the articles Diffcrenca ; Sympioms ; Prognosis ; and Treatment. 
 
 Metacarpus : fractures of these b? nes rarely occur, 93. 
 
 the^e Iradures always caused by a force immediately applied ; al- 
 most in all cases several of the bones are fraftured at once, ib, 
 
 — case, h.vvever, of a f^adure of a single o'e, 94. 
 
 comiTiinutive fra£lure frequently renders amputation necessary, ih. 
 
 These bones are never luxated : the ligaments of their articulations 
 may, h vvever, be torn; treatment, 261. 
 
 different liability of each bone to Inxation, 262. 
 Metatarsus \ the bones of, susceptible only of comminutive_/r«<!7«rf, 
 154. 
 
 treatment, the same as those of the Hand, 93, 154. 
 
 These bones cannot be luxated^ 288. 
 Muscles : their powerful effodls in the derangement of the fradured 
 portions 0^ a bone, 15. 
 
 three d iff- rent cases of this; all instanced in the muscles of the 
 thigh, ib. 
 
 I, c^se of muscles attached to both the portions; instances, ib, 
 
 2, muscles inserted into the lower portion, or the limb with 
 
 which it articulates ; instances, 16. 
 
 —3, muscles inserted into the superior fragment; instance, ib. 
 
ANALYTICAL INPEX. 339 
 
 Negk of the femur ; On the Fra£luresol^ ic2. 
 
 these tradturet> most frequently take place in its middle part ; ex- 
 ist within the articulation ; and are almost always transverse, 
 
 ib. 
 —another species, which takes place outside the articulation, near 
 
 the union of the bone with its trochanters, and sometimes be- 
 tween these two eminences, ib, 
 — instance, of fra£lure below the orbicular ligament, ib. 
 
 remarkable instance, of a double fradure, one inside and 
 
 one outside that ligament, 103. 
 frafture of the neck of the femur sometimes complicated with that 
 
 of the great trochanter, very rarely with contusion ; may be 
 
 comminutive, from a gun-shot wound, ib. 
 case or decollation of the epiphysis, ib. 
 — progress of os5ification in the superior extremity of the femur, 
 
 from infancy, ib. 
 — possibiliiy of this species of dlsjunclion in the early part of life; 
 
 its diagnoois, treaiment, and prognosis, X03, 104, 
 predisposing causes of these fradures ; briitieness of the bones, 
 
 vices ot the constitution, caries, rickets, 104. 
 - — ven-real d.s-ase, ib. 
 exciting causes: a fall on the great trochanter; or a fall on the 
 
 feet or kr.ees, 104, j©5. 
 —manner in vvhicii the tradure is produced in each of these two 
 
 cases, 105. 
 these fractures are never direft, but the contusion may nevertheless 
 
 be considerable, ih. 
 always attended with derangement, though this may not ensue for 
 
 several days after the fradture, ib. 
 —the delay in this circumstance may be produced by the resistance 
 
 of the orbicular ligament, or of the roughness of the surfaces of 
 
 the pieces, 102, 106. 
 — Jerangemcnt in fractures within the articulation, and in those 
 
 outside it, 106. 
 —causes of drrangement ; the weight of the body, but principally 
 
 muscular aftipn, ib. 
 — derangement in the circumference; that in an outward diredlion, 
 
 caused by the weight of the part, 107. 
 
 that in an inward diret^tlon : its cause ; its possibility ascer- 
 tained by observations; its proportion to the outward direftion, 
 
 ib. 
 Diagnosis; resemblance ofjhe symptoms to those of luxation, has 
 
 occasioned frequent mistakes, ib. 
 the sensible signs alone t' be depended upon, ic8. 
 — the shortening of ths limb; cautions in ascertaining this sign, 
 
 ib, 
 — position of the foot, the knee, and the leg, ib. 
 ——of the heel ; seldom placed so high as above the ankle of the 
 
 o:her foot, ih. 
 —restoring the limb to its natural length and dlreftion, and the 
 
 foot to its position ; sensible signs observed in those operations, 
 
 (crepitation, which is audible in the former ; and diminution of 
 
w- 
 
 ,'J40 ANALYTICAL INDEX. 
 
 (NecK OF THE femur: its fffk^lures. Coniinued.) 
 
 the arch described by the great trochanter, in the latter), io3, 
 109. 
 
 — alierattons in the appearance of the trochanter and of the but- 
 tock, in fradure outside the articulation, 109. 
 
 —impossibility ot raising the member all at once, a constant sen* 
 sible sig), log. 
 
 —a distinctive si^n proposed by Louis; unfounded, and otherwise 
 inadmissible, no. 
 
 the signs by which the different species of luxation may be distin- 
 guished iroax fracture ; ;, luxation upward and outward, ii>. 
 
 ——2, luxaiiun n.ward and upward, il>. 
 
 —3, luxations downward, 16. 
 
 •^4, the secondary or spontaneous luxation, ii. 
 
 »— tradures, however, with very little cr-no derangement some- 
 times diflicuit tu be abcertained or distinguished ; instance, in. 
 
 recapitulation of the distindive sensible signs oi fradure, i6. 
 
 when doubt is entertained, the apparatus should be applied, 112. 
 
 l*rognosis, verv difficult to e»tabiish, li. 
 
 differences of opinion on that subjed ; importance of a right deci- 
 sion on these, as it will dired the w'aole treatment, ii, 
 
 1, opinion of those who affirm that the consolidation of the fradure 
 cannot be at all effeded ; arguments 01 the assertors of an os- 
 seous juice (see p. 36), and of ttie favourers of Duhamei's the- 
 ry (see p. 37) : both ttiese parties answered, by fads and expe- 
 rience, 112, 113. 
 
 —argument founded on a want of a sufficient degree of vitality in 
 the superior fragment ; atiswered, by the insiaices relied on for 
 its support having bef n drawn from cases of the complete rup- 
 ture of the orbicular ligament, or of old age, 39, 113, 114. 
 
 2, opinion of those who affirm that the shortening of the limb can 
 by no means be preven:ed ; their different theories on the cause 
 of this supposed inevitable consequence. 114. 
 
 — writers by whom this opinion has been adopted : cojitradided by 
 many instances; one adduced, 115. 
 
 conclusion, ii. 
 
 Motion of the parts to be particularly avoided during the treat- 
 ment of these fradures, as tending to retard the naturally slov^ 
 formation of the callus there, 1 16. 
 
 Principal objeds to which the attention should be di reded in treat- 
 ing these fradures: i, setting the bone; application of the 
 united force of several assistants iitfeffeding extension, ii. 
 
 —previously to extension, the derangement in the circumference 
 should becorreded, i6. 
 
 —coaptation totally useless, ii>. 
 
 —treatment, if on the f^rst attempt at extension the muscles con- 
 trad powerfully, 117. 
 
 3, keeping the pieces in their place ; difficulty of this point, i6. 
 — (question of the position considered; the half- bent state to be 
 
 t'>tally rejeded ; proper position, 16. 
 — numerous contrivances for this purpose; examination of these : 
 (Srit) of those which do not effcd any extension, iL 
 
ANALYTICAL INDEX. 34I 
 
 (Neok OF THE femur; its fraftures. Continue-'.) 
 
 —— —ihe spica bandage of the groin, iiS. 
 
 .. -the eighteen-taiicd bandage, as&i&Ced by the fanons or faux- 
 fanons, ib. 
 
 • long splints ; and some other expedients : all inefFedlual, 
 
 118, 119. 
 
 ——method of Foubert ; by continual resetting, 119. 
 
 method of Brunninghausen, iS. 
 
 — (secondly) contrivances for efFecli.ig perpetual extension ; their 
 application, and purpose, 120 
 
 —the bed of Hippocrates j and the Glosscomcn used by the an- 
 cients, ii. 
 
 method of Avicenna and others, of fastening the bands for 
 extension to the head and foot of the bed, 120, 121. 
 
 —use of a pulley and weight, 121. 
 
 machine of BeUocq, ii. 
 
 machine of Hook, perfefted by Aitken, ii. 
 
 ——particular account of Desauh's apparatus; and its applica- 
 tion, 122, 123. Its disadvantages, 124, 125. 
 
 — —improved and perfect apparatus of Boyer described ; and its 
 application, 125, 126. 
 
 —— -cautions in the use of the two last, 1 26. 
 
 3, removin;! any unfavourable symptoms: topical applications: 
 contusion and violent inflammation ; regimen, ii. 
 
 Question whether in these fradlures internal remedies ought to be 
 resorted to for accelerating the consolidation ; as, rich gelatinous 
 food, osteoci'lla, or spirituous liquors, 126 to 128. 
 
 —nourishment easy to digest, and spirits in moderate quantities, 
 useful, 128. 
 
 time of consolidation, ii. 
 
 a stiffness in the articulation not much to be apprehended,,. /5. 
 
 in some cases the improved method cannot be adopted, i5. 
 
 consequences which would follow if the patient were abandoned to 
 nature, 129. 
 
 For its Luxations, see the article Femur. 
 NscROSis : striilly analogous to gangrene of the soft parts; essen- 
 tially different from caries, 157 to 164. 
 
 bones which it most frequently attacks ; it may be either partial, 
 or extend to the whole substance, 157. 
 
 of long bones, the middle part is most subjeA to it ; and never the 
 articulations, 158. ' 
 
 when the necrosis is superficial, the superior lamellae are separated 
 after a suppuration, ih. 
 
 progress of the afiadlionin a broad bone, ib. 
 
 — in complete necrosis of a long bone, ib. 
 
 separation of the periosteum from the diseased portion ; this 
 is analogous to the process of mortification in the soft parts, but 
 is performed much more slowly, 159. 
 
 causes of necrosis ; internal, and external, ib. 
 
 general diagnosis, 160. 
 
z^- 
 
 w 
 
 J42 ANALYTICAL INDEX. 
 
 (Necrosis. Continued.) 
 
 prognosis ; varies, according to the bone affedled and to circum- 
 stances of coinplicaiion, 160. 
 
 —in partial, and in large, affeftions of flat or long bonf^s, ib. 
 
 —in cases where the dead bone is entirely included in thac newly 
 tormel, ib. 
 
 in this affedioa nature must be left to her own operations ; the as- 
 sistance of art is confined toexiratting the dead portions, 161. 
 
 treatment in necrosis oi broad or flat bones; as, one of the large 
 bones of the skull, ih. 
 
 ——jne of the c;snes of the cranium, 162. 
 
 — of tile exterior lamellae of a long bone, the same, ib. 
 
 — in necrosis of the eatire body of a long bone, 163. 
 
 ■he ex'traflion of the dead bone from within the ossified peri- 
 osteum in ihis case, is a painful and h^izurdous process, 163. 
 
 method of performing this operation, when determined on, 
 
 ib. 
 
 should not be had recourse to without the most mature delibe- 
 ration, 164. • 
 Nose; the bones of, much exposed to Fradlure, 46. 
 
 most frequent kinds of fradures, ib. 
 
 case where the soft parts are not divided, nor the fragments dis- 
 place!.^, ib. 
 
 comminutive fradure ; treatment, and operation, for its re-estab- 
 lishment, 47. ' 
 
 —in this fradlure with depression of the splinters, the fragments 
 should be adjusted without waiting the disappearance of the in- 
 flammation, ib. 
 
 fraftuie of these bones sometimes attended with very da-^gerous 
 symptoms, ib. 
 
 — tnis etiology, however, applicable only to persons advanced in 
 age, ib. 
 
 Oblique fraSiure defined , 12. 
 
 more dangerous than the transverse ; the greater the obliquity, the 
 
 greater the danger, 22. 
 Olecranon : analogy between the fraftures of this bone and those of 
 
 the patella, 89. 
 — the former almost always occur at its base, and most frequently 
 
 from some external force, ib. 
 signs of these fraftures, 90. 
 —may be thus easily distinguished from a luxation of the cubitus 
 
 backward, ib. 
 treatment ; application of compresses, bandages, &c. 90 to 91. 
 time of re-establishment; gentle motion to be commenced earlier, 
 
 91- 
 grievous nature of compound fraftures; treatment, ib. 
 
 protracted inflammation, 92. 
 
 Osseous juice ; an effusion of, supposed by the ancients to be the efH- 
 cieat cause of the consolidation of fractures, 36, 37. 
 
 OsTEO-SARCOMA : different specics into which this disease Is some- 
 times divided, 182. 
 

 ANALYTICAL INDEX. 343 
 
 (OsTEO-SARCOMA. Continued.) 
 
 1, the osteo-sarcoma, peculiarly so called, 183. 
 
 2, the spina ventosa, or poedarthrocace, ii. 
 general diagnosis, iB. 
 
 each species is usually dangerous ; effect of venereal affections in 
 producing it; swellings of" the phalanges of the fingers and toes 
 are the least dangerous, ii. 
 
 the treatment in aggravated cases; amputation, if practicable, 
 
 in the real osteo-sarcoma, even ampution may be ineffectual to 
 
 prevent a return of the affection, i5. 
 f«m trkable instance of the second species ; in the conversion of the 
 
 bones and surrounding parts into a gelatinous mass, 18410 187. 
 
 Pare, Ambrose; his case, of a complicated fracture cf the leg, 15. 
 Patella; the FraElures of, may be either transverse or obliqae, 
 129. 
 
 the transverse frequently occasioned by contraction of the extensor 
 muscles of the leg, il, 
 
 — expla^tion why that cause does not rather rupture the tendon 
 of the extensors of the leg, and the inferior ligament of the pa- 
 tella, ih, 
 
 ——this effect, in reality, is sometimes produced; but the symp- 
 toms, prognosis, indications, and treatment, are the same in 
 both cases, 130. 
 
 •i— illustration of the manner in which the fracture of the patella is 
 caused by these contractions ; as, ip the effort to resist falling, 
 ih. 
 
 — the same violent contraction may be produced, and accompanied 
 by the same effects, in leaping, and other exertions, 130, 131. 
 
 fracture occa?ioned by falling on the knees, or by the violent im- 
 pulsion of a body against the patella, 131. 
 
 transverse fractures always attended with a separation of the frac- 
 tured portions, though tl'is may not immediately lake place 5 
 remarkable instance, ih. 
 
 — this separation is produced by the concurrence of two causes ; 
 the contraction of the extensor muscles, and the flexion of the 
 .leg, 132. 
 
 Diagnosis, very easy : as, falling without the power of rising, or 
 of moving (when raised by others) except backward by draw- 
 ing the feet along the ground ; instance, and treatment, ih. 
 
 further signs: depression (instead of prominence) on the anterior 
 part of the knee ; alterations producible in the relative position 
 of the fractured portions, 133. 
 
 Consolidation of these fractures: question whether this is effected 
 by immediate reunion, or by means of a ligamentous substance, 
 ih, 
 
 authorities by which the latter theory is sanctioned, ih. 
 
 the arguments for the former, 134. 
 
 an instance : the theory of the intervention of a ligamentous sub- 
 stance is well founded, ib. 
 
viiJ.? 
 
 344 ANALYTICAL IKDEX. 
 
 (Patella. Continued.) 
 
 the organization of the patella is in no nanner different from that 
 of other bones, and the peculiarities in the consolidation of its 
 fractures arise from merely mechanical causes 135. 
 
 erroneous supposition of Cillisen as to the 'mpediment to reunion 
 of the fragments ; its sole occasion is in fact the impossibility of 
 keeping them in contact by a proper apparatus, ib. 
 
 nnture of this ligamentous substance, I 36. 
 
 —when it is long, it diminishes the muscular aflion, and the 
 strength of the knee ; instance?, ib. 
 
 Objefts of attention in the treatment; the principal is, the dimi- 
 nution of the interval between the pieces, 137. 
 
 previous means to prevent, or remove, inflammation: i, the pre- 
 ventatives, ib. 
 
 •~2, the remedies : immersion in cold water, useful ; leeches, in- 
 jurious; wet compresses, 137. 
 
 in cas'-s of excessive contusion, 138. 
 
 application of the apparatus when prafticable : 1, position of the 
 limb, 139. 
 
 -——position alone, without confining the pieces, is insufficient, it-. 
 
 —2, bandages ; that in the form of a figure 8 is inconv'Jnicnt anii 
 injurious, ib. 
 
 • • principles of a proper bandage, 140. 
 
 ' its application, 140, 141. 
 
 •—some advantage might be drawn from a knowledge of the nume- 
 rous exploded apparatus, 141. 
 
 —•another apparatus described, consistin£^ of a trough. Sec. ib. 
 
 — method of some authors, to use no sort of bandage, but permit 
 the ligamentous substance to be lengthened ; mischievous efTefts 
 of this treatment, 142. 
 
 0[ Luxations of this bone ; may take place in four dire£llons, 278. 
 
 i , downwards ; this can exist only with a transverse rupture of the 
 tendon of the extensor muscles of the leg, ib. 
 
 2, upwards; this may depend on a rupture of thft inferior liga- 
 ment of the patella, 278. 
 
 3, inwards; and 4, outwards: a predisposition to these may be, 
 a great relaxation of the inferior ligament ; instance, 279. 
 
 —of these two, the Outward is the most frequent ; its cause, //>. 
 
 it may be favoured by a depression of the external condyle 
 
 of the femur; instances, ib.ri 
 
 instance of luxation in this direftion occasioned by a gun-shot 
 
 H'ound, ib. 
 
 ——in this luxation the bone is easily replaced, but difficultly 
 kept in its situation, 280, 
 
 the outward luxation may be either complete or incomplete: 
 
 it is seldom complete : instances, however, ib. 
 
 symptoms, an! process, of outward luxation, ib. 
 
 — Inward luxation ; its symptoms, 281. 
 
 Complete luxations cnn occur only in certain circumstances, ib. 
 
 In every species, reduction to be eiTeifled as soon as possible ; me- 
 thod, ib. 
 
 — symptoms of redu£\ion ; and afrer-treatmefit. ib. 
 
.:■■ %^ •. 
 ANALYTICAL INDEX. 345 
 
 Pelvis: On t\it Fraciures of the bones of, 64. 
 
 See the articles Coccygis ; Innom'tnata ossa ; a;.d Sacrum. 
 
 artificial m^ans are ot small effefl in thrse fraduresj and even ge- 
 neral treatment not always efficacious, 6j. 
 
 None of the assemblage of bones which form the Pelvis are suscep- 
 tible of a true Luxation : S e however, on this subjed, the above- 
 mentioned three articles, and also the a-ticle Ribs. 
 Periosteum : theory which attributes to this membrane the consolida- 
 tion of fradlures, 37. 
 Periostosis ; a species of exostosis, 176. 
 
 its distinguishing marks, from those of that disease stri£lly so call- 
 ed, ib. 
 Phalanges of the Fingers : t\it fracture of these bones always attended 
 with contusion ; signs ot fradure, 94. 
 
 longitudinal derangement very rare ; the horizontal is almost the 
 only one observed; operations of setting, and dressing, 95. 
 
 time of re-establishment, ib. 
 
 treatment in cases of the extremities being crashed, or braised by 
 a folding door, ib. 
 
 — if the last phalanx alone is crushed^ much better to amputate at 
 once, ib. -. . , 
 
 oi luxations : the first phalanges may be luxated backwards, but not 
 forwards, 262. 
 
 luxations inwards can occur only in the first phalanges of the thumb 
 and little finger ; outwards, in the first phalanx of the thumb 
 alone, 263. 
 
 this last-mentioned phalanx the most exposed to luxations back- 
 wards ; their process, and signs, ib, 
 
 their prognosis, ib. 
 
 these luxations should be quickly reduced ; method of opera- 
 tion proposed by Desault in a case of this kind, ib. 
 
 ■ the reduftion not so easy as might be imagined, ib. 
 
 method of rcdudion in various of these luxations ; and after-treat- 
 ment, ib. 
 
 See also 184, 303. 
 
 phalanges of the Toes ; susceptible only of comminutive fraSlurc, 
 
 154. ■- 
 
 treatment, the same as those of the fingers, ib, 
 cannot be luxated hy external violence, 288. 
 —but the first phalai^x of the great toe may be luxated from the 
 first bone of the metatarsus ; treatment, ib. 
 Paedarthrocace See the article Osteosarcoma. 
 Position of a fradlurcd limb during cure, 25. 
 
 Pregnancy ; does not perceptibly retard the consolidation of a fradure, 
 23, 40. 
 relaxation of the articulations of the ossa innominata during preg- 
 nancy : See the article Innominata ossa (luxations ) . 
 Pyognosis : of fraSures ; different according to various circumstances; 
 as, the bone tradured, the part of the bone, and the diredion of 
 the fradure ; instances of each, 21, 22. 
 - — according to the points ot complication, 22. 
 41 
 
34^ ANALYTICAL INDEX. 
 
 {Prognosis. Continued.) 
 
 — accordlngjto the health and age of the individual ; instances, zz. 
 
 In Luxation: dislocations in the round articulations much less dan- 
 gerous than in the ginglymoidai, 211. 
 
 the difficulty of reducing the luxated bone renders the luxation 
 more or less troublesome, ib. 
 
 luxations arising from certain distempered occasions have worse 
 consequences than those trom external violence ; and if accom- 
 panied with particular circumstances of complication, render 
 the prognosis proportionately more unfavourable, 212. 
 Pubis ossa : See the article Innominata ossa. 
 
 Radius : fraSures of this bone more frequent than those of the cubi- 
 tus, 87. 
 
 usual causes of these fraftures, ib. 
 
 signs of fradture, ib. 
 
 derangement, can only be in the direftion of the diameter ; the 
 longitudinal, however, thought possible by Petit, 88. 
 
 extension and counter-extension, ib. 
 
 caution in the application of compresses and bandages, ih. 
 
 method of cure, &c 86 and 83. 
 
 For luxations of this bone, see the article Fore-arm. 
 Ribs ; On the Fractures of: the middle ribs most liable to this ac- 
 cident, 59. 
 
 the part fradfured is generally, near the middle of the bone, 60. 
 
 distinftion of fradlures into inwards and outwards, ib. 
 
 possible complications, ib. 
 
 signs of these fractures, ib, 
 
 derangement of the fraftured portions: cannot take place in the 
 direction of the diameter of the bone, nor in that of its axis ; 
 but only angularly, ih, 
 
 —experiments on this subjeft, 61. 
 
 treatment of simple fraftures, either inwards or outwards ; band- 
 ages, ib. 
 
 •—of cases where the violence has been considerable,^and the Iung« 
 contused or lacerated, 62. 
 
 —of the case of emphysema, in its different stages, 62, 63. 
 
 the cartilages of the ribs ; the absurd praftice for raising " de- 
 pressed ribs" exposed, 63. 
 
 luxations of the Ribs : cannot occur ; an instance which has been 
 produced to the contrary, has been mistaken, and was in reality 
 a simple frafture of the posterior extremity, 232. 
 
 this name has been confounded with separations of the dorsal ver- 
 tebrae from the head of the rib by caries, 233. 
 
 possible separation of the cartilage of the sixth true rib from that of 
 the seventh by contraftion of the peftoralis major ; depression 
 of the other cartilages, and of the appendix xyphoides, 59, 6j, 
 
 233- 
 Rickets : the enlargement of the ends of bones of ricketty persons 
 may be mistaken for exostosis, 178. 
 persons who have suffered by rickets in their infancy, may be at- 
 tacked again with this disease after puberty, 189. 
 
ANALYTICAL INDEX. ^47 
 
 (Rickets. Continued.) 
 it sometimes aiFeds the bones of the foetus, bat most generally 
 
 appears from the sixth or seventh to the fourteenth or fifteenth 
 
 month after birth ; difficult cutting of the teeth haj been consi- 
 dered as a cause, 189. 
 uncertain whether it is a primary affeflion, or a symptom of either 
 
 scrofula, lues, or scurvy ; a great connexion appears between 
 
 it and scrofula, ib. 
 progress of the disease, 90. 
 —sometimes extends to produce caries in the bones, or white 
 
 swelling in the joints, ih. 
 the vertebral column particularly liable to this afFe6lion, ib. 
 its efFeiils, when general, on the different bones of the body, 191. 
 conjeftures, and queries, as to the proximate cause of rickets, ib% 
 appearance of the different parts, an anatomical inspeflion after 
 
 death, ib. 
 opinions as to the cause of the curvature of the bones ; opinion of 
 
 Glisson ; attributes it to the irregular accumulation of the hu- 
 mours, 192. 
 —of Mayow ; to the tendons being dry and shortened, ib. 
 —may be more probably deduced from the effeft of the weight of 
 
 the boJy, and muscular contraction, ib. 
 hereditary in some families ; may in some such instances be traced 
 
 to a venereal taint, ib. 
 influence ot dentition on the produftion or progress of this disease, 
 
 considered, 193. 
 — it is singular that the teeth preserve their hardness, ib. 
 prognosis always unfavourable, ib. 
 the crisis of puberty, or sometimes the diseases to which children 
 
 are subjetl, arrest the progress of the complaint, ib. 
 treatment : no medicine of efficacy known ; general treatment 
 
 principally advantageous, ib. 
 — air, and diet ; exposure to the sun; materials of the bed, and 
 
 position of the patient if very young; chairs; walking to be 
 
 avoided, 194. 
 — friftions useful, ib. 
 — clothing, ib. 
 — qualities of nurses (of children at tke breast) j food for weaned 
 
 children ; exercise, ib. 
 particular remedies ; in complaints from dentition ; or in worms, 
 
 —this last complaint very common in ricketty patients ; its signs, 
 ib. 
 
 means of discussing the swelling of the njiesenteric glands ; tick- 
 ling every day, to produce hearty laughter, very useful, ib. 
 
 if proceeding in any degree from syphilis or scrofula, the treat- 
 ment for those diseases to be recurred to, ib. 
 
 it would be a principal object, if practicable, to restore the hard- 
 ness of the bones, (see 9) ; madder has no efFedt in this purpose, 
 196. 
 
 the great end thus, is to restore general health and strength, ih. 
 
 mechanical means are ill adapted for this disease, ib. 
 
348 ANALYTICAL INDEX. 
 
 Roller ; its inefficacy for the purposes to which it is applied in the 
 treatment of Iradlures, 26. 
 
 Sacrum ; this bone not much exposed to fra^ures, 64. 
 
 treatment, in those accidents, i6» 
 
 Not capabit of luxation, 230. 
 
 case of relaxation of the .;acro-iIiac synchondrosis : See the article 
 hmominata oaa (luxation J. 
 Scapula : this boae not much exposed to fraftare, from its posi- 
 tion, 68. 
 
 — its different parts, however, vary in this respeft, ib. 
 
 these fradures always accompanied with considerable contusion, ib. 
 
 the longitudinal hai^lore less frequent than the transverse, and 
 causes very little derangement, ib. 
 
 derangement in transverse iradures, or of the acromion and infe- 
 rior angle, ih. 
 
 — in fradluresof the coracoid process, ib. 
 
 signs of these different fraftures ; the longitudinal, difficultly dis- 
 tinguished, 69. 
 
 — the transverse, more easily, ib. 
 
 — the fradureof the inferior angle, manifested by the considerable 
 derangement, ib. 
 
 —that of the acromion, very easily, by a combination of circum- 
 stances, ib. 
 
 the contusion attending these fraflures, the most dangerous symp- 
 tom ; abscesses, ib. 
 
 apparatus for fixing the arm steady during the cure, 70. 
 
 treatme t in fraftures of the inferior angle, ib. 
 
 — uf the acromion, ih. 
 
 time of cons.lidaiioa, 71. 
 
 — in fradures of the acromion continue the bandage a little long- 
 er, ib. 
 
 general remedies ; as, blood-letting, &c. ib. 
 
 these fraftures seldom dangi rous ; instance, however, in which it 
 was found necessary to trepan, ib. 
 Scultet's bandage ; iis construction, application, and superior advan- 
 tages, 27. 
 Scurvy ; its powerful influence in retarding the consolidation of frac- 
 tures, 22. 
 
 appi:arance of the bones of a scorbutic person, when boiled, 198. 
 Signs oi fra&ures : the sensible signs can alone give certainty of a 
 frafture, 19. 
 
 cautions in judging from the relative shortness of the limb, 20. 
 
 judgments from the change of form and diredion of the members, 
 ib. 
 
 derangement of the fragments sometimes perceptible by the fin- 
 gers, ib. ■: 
 
 crepitation the most general distindlve symptom, ih. 
 
 cases whicii preclude any certainty of decision : as, depth of fleshy 
 parts; doabie"bones ; or inflammatory swelling, 21. 
 
 — treatment on such occasions, ih. 
 
 Signs oi luxation : Seethe article Symptoms. 
 
ANALYTICAL INDEX. 349 
 
 Simple /ra^ure defined, 17. 
 
 its general treatment, 32. 
 Species oi frailures I distindion of five different, 10. 
 
 1, as to the bone affefled, 11. 
 
 —the broad bones not much exposed to this accident, ih. 
 — the short ones still less so, and almost always by muscular con- 
 traction alone; ib, 
 — the long bones very liable, iB. 
 
 2, as to the part of the bones, \z. 
 
 —in the point of biseftion, generally ; more or less near, or even 
 
 at, the extremities ; or in different points at once, ih. 
 — this distinction is of real anri great importance, iB. 
 
 3, as to the direftion of the fradure, ih. 
 
 — the transverse, the oblique, and the comminolive frafture, ih. 
 — the furth'er distindion, of longitudinal fradlure, is inadmissible, 
 
 4, as to the relative situation of the fra£tured portions, ih. 
 
 — causes and varieties of their derangement (See the article De- 
 rangement), iB. 
 
 5, distinction between simple and compound fra£tures ; descrip- 
 tion of each, 17. 
 
 Fraftures are rarely accompanied with luxation, ih. 
 
 they may be accompanied wuh, or may produce, other morbid af- 
 fections ; instances. iB. 
 
 the distinction of fraCtures into complete- and incomplete is un- 
 founded, ih. 
 
 Species of luxations : See the article Differences. 
 Spina 'ventosa. See the article Osteo sarcoma. 
 Spinal processes, marrow, &c. See the article Vertebrje. 
 Splints; their comparative utility in the treatment of fractures, 28. 
 
 materials ; and length and construction for different parts, ih. 
 
 their method of aCtion ; they prevent derangements in the direc- 
 tion of the diameter, angularly, and (if properly applied) in 
 the circumference, ih. 
 
 • — derangement in the direction of the axis in oblique fraCtures, 
 and derangement in oblique fraCtures of the clavicle, almost im- 
 possible to be prevented by splints alone, 29. 
 
 importance of attention to filling the different inequalities and de- 
 pressions of the limb with proper soft substances ; tape, as an 
 external binding for the whole apparatus, preferable to strips of 
 linen, 31. 
 Spontaneous luxations of the femur; called also Secondary, 
 271. 
 
 two principal varieties : First variety ; from the swelling of the 
 cartilages, and the enlargement of the glands in the interior of 
 the articulation, 272. 
 
 — this variety may be produced by an external cause, iL. 
 
 — its ordinary process, ih. 
 
 — symptoms, and consequences, ih. 
 
 appearance on opening the body after death, 273. 
 
 Second variety, from caries of the circumference of the acetabu- 
 lumi or head of the femur: its symptoms, progress, and ap- 
 pearance on opening the joint, 274. 
 
3S^ ANALYTICAL INDEX. 
 
 (Spontaneous luxations. Continued.) 
 
 Other causes of both varieties; icrolula especially, 274. 
 
 —objections 0/ those who think an internal cause absolutely neces- 
 sary, ;^. 
 
 Petit's explanation of the manner in which these luxations- take 
 place, ilf. 
 
 —futility of this explanation, 275. 
 
 Prognosis; diiFerent according to the age and constitution of the 
 patient, the species of luxation, its continuance, and cause, iB, 
 
 Treatment: the principal objeft is to prevent the spontaneous lux- 
 ation ; method, i6. 
 
 — if a constitutional taint is sospefted, the remedies must be di- 
 refted to this, 276. . 
 
 — good cfFefts of a large blister on the hip, iB. 
 
 when these means fail, the progress of the disease shoifld be arrest- 
 " ed by favouring the attachment of the head of the femur to the 
 bones of the pelvis ; treatment, ii, 
 
 —if, nevertheless, abscesses are formed, their opening should be 
 retarded, 277. 
 
 The luxation downwards and inwards less frequent than that up- 
 wards and outwards ; instance, however, of the former, i6. 
 
 its treatment, and consequences, 278. 
 Sprains; definition of this term, 199. 
 
 different sorts of articulations more or less liable to this accident, 
 
 a. 
 
 nature of the affeflion explained, ti>. 
 
 —appearances which immediately follow it, 200. 
 
 time of re-establishment in cases of slight, or of more considerable, 
 injury, ii. 
 
 diagnosis, ii. 
 
 prognosis, unfavourable according to circumstances, 201. 
 
 treatment, varies according to the continuance of the afFeftion ; if 
 adopted immediately, apply cold water or powdered ice for a 
 considerable length of time, except in certain cases, ii. 
 
 absurd pradlice of ignorant bone-setters, 202. 
 
 the repellent mode cannot succeed if an interval of twflve hours 
 has elapsed : treatment in ^this case ; bleeding, emollient cata* 
 plasms, resolvents, solvents, ii. 
 
 — long inadlivity, and posture, of the limb ; application of a rol- 
 ler, ii. 
 
 serious ultimate consequences of bad treatment in any respeft, 203. 
 
 dangerous nature of this afFeftion, £0 trifling in the eyes of the vul- 
 gar, a. 
 
 treatment of the bad symptoms succeeding to sprains, i^. 
 
 Sprain of the foot, how distinguished from luxation backwards., 
 287. 
 Stays, a frequent cause of deformity in children, or of dangerous 
 disease, 315. 
 
 cases, however, in which stays of a certain construdlion may serve 
 to corretll disproportions, 316, 317. 
 Sternum : this bone not much liable to fraftures ; different ways, 
 however, in which they may happen, 57. 
 
ANALYTICAL INDEX. 35 1 
 
 (Sternum. Continued.) 
 
 1, by extension operating on both cjttremi tics of the bone; in- 
 stance (produced by the violent adlion of muscles), 57. 
 
 2, by the immediate aftion of an external cause; its attendant 
 circumstances, 58. 
 
 effusions of blood attending solutions of continuity, however abun- 
 dant, seldom dangerous, ib. 
 
 simple fradlure ; its signs, and treatment, ib. 
 
 complicated fiadure ; treatment, ib. 
 
 — trepanning seldom necessary j very great care in performing 
 this operation, 59. 
 
 affcftions of the appendix xyphoides, ib. 
 Sv;addli7ig.clothes, a very produdive cause of deformity, 315. 
 Symptoms of luxation : pain, and inability of moving the limb, equi- 
 vocal symptoms, but not to be disregarded, 209. 
 
 others, more decisive: i, an elongation, or shortening, of the 
 limb ; both instanced in dislocations of the head of the femur, 
 210. 
 
 — 2, change in the diredlion of the bone; most easily distingaisb- 
 ed in recent cases, ib. 
 ■ change in the shape of the limb, ib. 
 
 — 3, the imposbibility of performing certain motions, 211. 
 
 by these different circumstances a clear diagnosis is established; 
 frequency, and disgrace, of an error in this point, ib. 
 
 Sytaptoms of fracture: See the article iS/g^«j. 
 Synovia : its qualities have, in some cases, been considerably changed 
 by the contaft of air, so as to produce inflammation which ter- 
 minated in a caries of the ends of the bones, 292. 
 
 See also the Chapter on Dropsy of the Articulations, 288. 
 
 Tarsus; On fracture of the bones of: of the os Calcis. See that 
 
 article, 
 the other bones susceptible only of comminutive frafture, 154. 
 treatment, the same as tho^e of the Hand, 93. 154. 
 For luxations of these bones, see the article Foot. 
 Thigh. This member exposed to a great variety oi fra^ures, 96. 
 all the species of derangement may occur ; the longitudinal the 
 
 most frequent; a£tioa of the numerous muscles in producing 
 
 these, 96. 
 —the muscular aSion in fraftures above the condyles ; and, when 
 
 the great trochanter is detached from the rest of the bone, ib. 
 -~<4he angular derangement occasioned by the inclination of the 
 
 foot, 97. 
 signs of fraflures ; these accidents more dangerous in this than in 
 
 any other limb, and require more unremitting care and atten- 
 tion, ib. 
 •ome diredions in this last point : dimensions and construftion of 
 
 the bed ; and disposition of the body of the patient, 98. 
 —apparatus: bandages; compresses; splints, and their different 
 
 lengths ; bags of chaff, to fill the intervals of the limb ; strings, 
 
 or ribbands, 98, 99. 
 —error of some praftitioners in th« application of bandages, 98. 
 
35'^ ANALYTICAL INDEX* 
 
 {Tkich: fraaures oi. Continued.) 
 — earliest trentment : arrangement of the apparatus, on the bed ; 
 
 disposition and removal of the patient; setting, 99. 
 ■ application of the apparatus, ib. 
 — subsequent treatment: bleeding, and regimen; periodical re- 
 moval of the apparatus ; time lor final removal of the bandage, 
 
 ^g, 100. 
 in cases of oblique frafture, continued extension to be employed, 
 
 100. 
 treatment of very young children, ib. 
 in frafturcs near the condyles, the hollow of the ham must be 
 
 stuffed with lint, ib. 
 compress and bandage in separation of the great trochanter from 
 
 the rest of the bone, loi. 
 time of consolidation, ib. 
 —in very tedious cases, a stiffness in the articulation of the knee 
 
 to be apprehended, ib. 
 compound fraftures, ib. 
 See also the article Neck of the femur. 
 
 For luxations of the Thigh, See the article Femur. 
 Tibia : the fra£iures of this bone are almost always transverse, and 
 therefore not very dangerous, 147. 
 if near the inferior extremity, no considerable derangement takes 
 
 place, ih. 
 this last circumstance occasions the diagnosis to be often very dif- 
 ficult, ih. 
 usual means of ascertaining it, ii. 
 treatment; setting, 148. 
 
 time of consolidation ; the articulations are not injured, ib. 
 For fractures o^ both bones of the leg, see the article Leg. 
 luxations of the Tibia at its articulations with the condyles of the 
 
 femur; may occur in four different diredtions, 282. 
 — I, backwards; this always incomplete, and as often secondary 
 
 as primary, ib. 
 —2, forwards ; more rare than the preceding, ib. 
 3 1 and 4, laterally; inwards or outwards: these the most fre- 
 quent, and always incomplete, ib. 
 symptoms of the backward, and of the opposite, luxation, ib. 
 ~of the lateral luxations, 283. 
 
 in every case of luxation the redudlion is easy ; method of prevent- 
 ing a return, from the too great laceration of the parts, ib. 
 the principal objeft of Treatment is the laceration of the soft parts : 
 inflammation ; abscesses ; gangrere : perhaps a complete luxa- 
 tion of the tibia from the femur may be considered as a case re- 
 quiring immediate amputation, 283 
 Instance of the carious extremity of this bone and of the femur cut 
 off in the case of white swelling, 3Q9. 
 Toes. See the article Phalanges. 
 Vransverse fraSita-e dthnedi, 12. 
 
 less dangerous than oblique, 21. 
 'rreat?ne?u (general) ui fratiures : first indication is to confine. Or 
 restore the fragments to their natural situation, 22. 
 
ANALYTICAL INDEX. 353 
 
 iXreatment of fra3ures. Continued.) 
 
 — methods of setting a fraftuied bone: extension and counter-. 
 extension, not always necessary (See the article Extetujon) 
 
 ^3' 24. 
 
 second indication: to maintain the portions in exa£l conta£l, and 
 
 _, motionless, during the consolidation of the frafture, 24. 
 ° — situation^of the limb: a horizontal plane; its adaptation, and 
 materials, 25. 
 
 •^rpositicn o( the limb; demi-flexion, or straightness: advantages 
 and disadvantages of each ; thft.-Jatter preferable, ib. 
 
 — necessity of peitedt repose to the limb, ib. 
 
 —bandages (See that article), ib. 
 
 — faux-fanons, splints (See that article), and apparatus for efFeil- 
 ing perpetual extension (See the article Extension), 27 to 31. 
 
 third indication ; to prevent any succeeding complication, 3 1. 
 ■ ■ solutions proper to be applied to the parts, 32. 
 regimen, ib. 
 
 •^or, to remedy the different cases of COTiplication when they have 
 taken place, ib. 
 
 ——as, I, the case of fradture accompanied with luxation, ih. 
 
 question whether the dislocated fragment should be first re- 
 placed, or not, till the consolidation of the fradure is efFedled, 
 
 33- 
 2, when the soft parts are violently contused, without external 
 
 wound, ib. 
 
 3, when a vessel of a certain magnitude is opened by a frac- 
 ture ; instance, ib. 
 
 4, wounds occasioned by the penetration of the point of on« 
 
 of the fragments through the integuments ; instance, 34. 
 
 I ■ wounds occasioned by the same causes as the frafturc, as in 
 jcomminutive fradtures : treatment ; the various circumstances 
 and cases in which amputation is necessary, 34 to 36. 
 
 Treatment of luxations : principal indications to be fulfilled in this 
 view; i. To reduce the luxated bone, 212. 
 
 this is efFefted by means of extension, counter-extension, and co- 
 aptation, ib. 
 
 — Extension: part on which the extending force should be ap- 
 plied ; advantage oi th« modern pradice over the ancient in 
 this respeft, 213. 
 
 — — objeftion to the former, ill-founded, ib. 
 
 — means of effefting extension ; the hands of intelligent and strong 
 assistants preferable to any mechanical means, ib. 
 
 —degree of force to be used ; to be varied according to circum- 
 stances ; mechanical means never to be resorted to, 214. 
 
 — diredtion in which it is to be applied : should be at first that 
 which the luxated bone has taken ; illustration of the necessity 
 of this pradtice, ib. 
 
 the bone to be gradually brought back to Its natural position 
 ib. 
 
 — Counter-extension: part on which the force- for this pprpoic 
 should be applied, 215. 
 
 4S 
 
* 
 
 354 ' ANALYTICAL INDEX. 
 
 {^Treatment of luxaliom. Continued.) 
 
 —means of efFeiting counter-extension ; the hands of the assistants, 
 by the use of fillets, ih. 
 
 — diredion in which this force is to be made; always perpendicu- 
 lar tp the surface of the luxated joint, zB. .*s,^- 
 
 •—the most intelligent of the assistants should be employed in ma- 
 king extension, ih. ^ 
 
 —Coaptation ; easily performed when the extensiotf^s sufficient, 
 
 '^ . . . . ^ 
 
 when the operations fail throjngh insufliciency of the means em- 
 ployed, these may be aided either by increasing (he number of 
 assistants, or diminishing the muscular force of the patient, 216. 
 
 —different ways of effcdling the latter purpose ; by change of 
 posture, ib. 
 
 hy repeated bleeding, the warm feath, and very low diet, ih. 
 ■ a state of intoxication favourable to this end ; it has ever 
 been advised tu intoxicate the patient in that view, ib. 
 
 by fatiguing with c6ntinual aftion the musclts surrounding 
 the luxated bone; instances of this praftice, ih. 
 
 luxations that have, through mistake, continued several days be- 
 fore application, difficult or impossible to be reduced : treat- 
 ment ; warm baths and pumping, exercise, and regular mo- 
 tion of the luxated bone, 217. ^ 
 
 —if a certain period has elapsed, and anchylosis has geni^ally 
 taken place, ib. 
 
 signs of the luxation being reduced, ib. 
 
 the praftitioner should never be discouraged and despair in cases 
 (if recent luxation; perhaps none such are absolutely irreduci- 
 ble, 218. 
 
 2, Tu preserve the reduced bone in its place: perfeft rest is the 
 only requisite ;^mployiiient of bandages for this purpose, 218. 
 
 luxation arising from any internal cause, ib. 
 
 3, To^prevent or remove the symptoms with which the luxations 
 may be complicated ; enumeration of these causes of complica- 
 tion, including lra£lure (See 17, 32); treatment in each case, 
 218 . • f 
 
 Consequences of luxations not reduce^, 219. 
 
 Vertebrje: these bones not much liable to yra-ffKr^; when it dqgs 
 
 occur, the mere fradure is less dangerous than the consequent 
 
 lesion of the spinal marrow, 54. 
 — manner in which (in such a case) the efieft on that substance is 
 
 produced, ih. 
 the diagnosis of these fraftures is difficult to establish : some rules j 
 
 instance, 54, 55. 
 the common, n or violent distension of the spine may produce the 
 
 same cff^dts as a fracture of this sort ; instance, 55. 
 process of the fatal termination of these accidents, 55, 56. 
 attempts at setting this fradure are useless ; general treatment the 
 
 only resource, 54. 
 —treatment in flatulent distension of the abdomen, &c. ib. 
 trepanning has been injudiciously recommended, 57. 
 
♦ ^ ANALYTICAL INDEX. ^SS 
 
 (Vertsbr^. XJonlinued.) 
 
 fradure of the vertebra;, or afFeflion of the spinal marrow, In. the 
 
 neck, produces speedy or instantaneous death, i^. 
 —lesion ot the fourth and Hith cervical pairot nerves, ii>. 
 
 Of luxations of the Vertebrae; these dislocations in the dorsal and 
 lumbar part of the column are impossible; but in the cervical 
 vertebjs they may occur, 225. 
 
 —instance, ot a luxation lower down than the second vertebra, ii. 
 
 Luxations of the Head from the first Vertebra, 226. 
 
 cannot be occasioned by an external cause ; such an occurrence 
 would destroy the individual, i5. 
 
 may take place gradually and insensibly, iS. 
 
 Luxations of the First Cervical Vertebra from the Second; ren- 
 dered easy by the conformation of ttie parts, ii. 
 
 process of the luxation, /^. 
 
 circumstances wliich sometimes render it fatal, by a compression 
 of the spinal marrow, 227. 
 
 different manner of dying, of the criminals hanged at Lyons and 
 those at Paris ; occasioned by a trivial custom of the executioner 
 of the former place, i5. 
 
 remarkable case of fatal lux^ition, from the motion occasioned by 
 the person himself; a caution against a dangeruus manner of 
 playing with children, i3, 
 
 the relaxation of the ligaments of the tooth-like process may fa- 
 vour this luxation ; in luxations of the neck which are not fatal, 
 the dislocation takes piace lower down than the second vertebra, 
 228. 
 
 —instances, ii. 
 
 — symptoms of these cases, 229. 
 
 in luxations not indicating a compression of the spinal marrow, 
 their reduflicn should not be attempted ; method of proceeding, 
 however, when the patient insists upon it, il>. 
 
 White sv/ellings of the joints ; defined, 301. 
 
 varieties: i, the rheumatic ; its symptoms, progress, and conse- 
 quences, 301, 302. 
 
 occurs in various articulations, but principally in i&e knee, 302. 
 
 —appearance on dissedion, ii?. 
 
 — 2, from a scrofulous taint: the various symptoms, progress, 
 consequences, and appearance on dissedtion, i6. 
 
 numerous farms of this disease in different patients, 236. 
 
 seldom produced by an external cause ; sometimes occurs without 
 any apparent cause ; in scrofulous persons it may follow external 
 violence, 303. 
 
 theenlargementof the ends of the phalanges, (183, 184,) belongs 
 to this class of diseases, 303. 
 
 the prognosis always unfavourable; less so in children under the 
 age ot puberty. iB. ' 
 
 a multiplicity ot remedies have been proposed for this disease, ii. 
 
 treatment, 304. 
 
 —warm or mineral water, &c. kind of animal bath, 305. 
 
35^ ANALYTICAL INDEX. * § 
 
 (White swellings of the joints. Continued.) 
 
 —very violent means, as the adlual cautery and burning with 
 nioxa, dangerous, 305. 
 
 —after-treatment, ib. 
 
 treatment in scrofulous cases, 305. 
 
 daring pradice of some empirics, in employing acrid and stimu- 
 lating applications J instance ot entire rectory in this treat- 
 ment, 305. 
 
 treatment in cases of numerous abscesses, and considerable col- 
 ledions of pus, 306, 
 
 amputation, when necessary ; not to be too hastily resorted t0) ii. 
 
 — considerations determining on the propriety of this operaltion/ 
 
 —not to be performed but in cases where only one joint is afFeft- 
 ed, ib. 
 
 pra«5lice proposed instead of amputation; of cutting ofF or extir- 
 pating the carious extremities of the bones, when the state of ihe 
 soft parts admits of it, 307. 
 
 — cases in which alone this operation is practicable, 308. 
 
 — method of performing it ; on the head of the humerus, ib, 
 
 ——instances, 309. 
 
 —proposed by Paric to be extended to the articulations of the knee 
 and elbow: but this is more hazardous : instance of his accom- 
 plishing it on the former, ib. 
 
 —its danger, and small comparative recommendations, 310. 
 
 — mei!iod in performing it on the elbow, ib. 
 Wounds, and Denudation, of the Bones; these two cases 
 must be carefully distinguished, 154. 
 
 if the bone is merely stript, replace the parts immediately and the 
 periosteum will speedily reunite, ib. 
 
 if the external lamina; are contused, or its surface is long exposed 
 to the air or to the fridlion of bandages, exfoliation takes place, 
 and the integuments must not be prematurely closed, ib. 
 
 treatment in each case : i, in simple denudation, 155. 
 
 — 2, in cases of exfoliation : nature of this process, ib. 
 
 — method employed to expedite the exfuliation ; oily relaxing ap- 
 plications, 156. 
 ■perforation for this purpose, injurious, ib. 
 
 —incision sometimes necessary, to separate the detached portion, 
 ib. 
 
 3, in cases of complete division of the bone, ib: 
 —the wound must be healed from the bottom, 157. 
 
 — if the bone is cut quite through, treatment and apparatus to be 
 applied as in a case of fraflurr, ib. 
 
 and the time of reunion, and manner of consolidation, the 
 
 • same, 157. 
 
 Wounds of the Articulations ; held to be dangerous, by all 
 the ancient and almost all the modern writers, 297. 
 
 instances, on the contrary, of their healing with the greatest fa- 
 cility ; I, a wound in the elbow by a piece of glass which pe- 
 r.etrated into the cavity of the joint, ib. 
 
ANALYTICAL INDEX. 357 
 
 (Wounds, and Denudation, of the Bones. Continued.) 
 
 — 2, a wound in the same joint by a small sword, in which the 
 capsule of the joint was opened, 298. 
 
 instances that wounds by cutting instruments are not very danger- 
 ous, even notwithstanding the admission of air ; 1, the poste- 
 rior part of the articulation of the wrist entirely opened, ih. 
 
 —2, the same articulation opened, by a piece of a vessel of delf 
 ware, ib. 
 
 —3, the same articulation opened for about one third of Its cir- 
 cumference, ib. 
 ji —The facility with which Incisions are made to extraft foreigti 
 bodies, also a proof of this, ib. 
 
 the occurrence of inflammation in cases of the latter description, 
 terminating in gangrene or ultimately in caries, must arise 
 from long-continued and powerful adion of the air, 299. 
 
 •^the imprudent application of dressings to the surfaces of the 
 joint still more dangerous: instance, a sabre-wound on the ex- 
 ternal side of the wrist filled with charpie, ib, 
 
 —the danger equally great when the wound suppurates: instances; 
 — 1, a sabre-wound dividing the patella, ib. 
 
 2, a sabre-wound on the anterior part of the point of the 
 
 shoulder, 299. 
 
 ——.3, a sabre-wound in the inferior part of the arm, 300. 
 
 conclusion; the prognosis of wounds in the articulations, in what 
 circumstances favourable, ib. 
 
 indications of cure, ib. 
 Wrist. See the article Carpus. 
 
 Zygomatic arch: case of its frafture (as, by the wheel of a carriage) ; 
 treatmerit, 45. 
 
4 # 
 
NOTES. 
 
 NOTE I. 
 
 «< THE apparatus for perpetual extension should not be applied 
 before the irritation and spasm of the muscles are completely 
 removed i" Page 29. 
 
 There are certainly many cases in which this rule will hold 
 good. But the spasmodic adlion of the muscles has frequently 
 been removed by applying the apparatus for permanent exten- 
 sion. In a case of oblique compound fra^lure of both bones of 
 the leg, which occurred last winter in the Pennsylvania Hos- 
 pital, under the care of Dr. Physick these disagreeable symp- 
 toms were entirely done away by the application of the exten- 
 ding splints invented by Dr. Hutchinson. A few hours after 
 being applied, the splints by accident became displaced, in con- 
 sequence of which the pain and spasmodic action returned. 
 The patient was immediately relieved by again adjusting the 
 splints. 
 
 , NOTE II. 
 
 "A man aged 36 had his arm fra£lured, and nothing was done 
 to adjust the fractured bone. This arm had been so long use- 
 less to the patient, that he was determined to undergo any trial 
 for effecting the cure, &c." Page 43. 
 
 In a case very similar to this. Dr. Physick pursued a different 
 and more successful mode of treatment. Instead of sawing off 
 
,360 NOTES. 
 
 the ends of the frafVured portions of bone, a seton was passed 
 between them. The wound went through all the different 
 stages which arc necessary to effe£t re-union in compound frac- 
 tures. Inflammation and suppuration were succeeded by gra- 
 nulations, which, by ossifying, produced a complete bony union 
 at the end of thirteen weeks from the day on which the ope- 
 ration was performed. The seton was removed at the end of 
 the twelfth week. 
 
 See a Paper by Dr. Physick, in the New-York Medical Re- 
 pository, Hex. 2. vol. 1. p. 122. 
 
 NOTE III. 
 "If in a fra£lure of the superior maxillafy bone, &c." Page 4^5. 
 
 In the third volume of the London Medical Fa£ts and Ob- 
 servations a case is related, in which the ligatures as recom- 
 mended by Le Dran were of very little use in retaining the 
 fra£lured portions in their natural situation. This indication, 
 however, was completely fulfilled, by placing a piece of sponge 
 between the teeth of the upper and lower jaw. The gradual 
 expansion of the sponge reduced the frafture in about thirty- 
 six hours. The sponge was changed daily for about a month. 
 Its use was then discontinued entirely, and the patient reco- 
 vered soon after without any deformity, except the loss of the 
 fore teeth. 
 
 NOTE IV. 
 
 " Paralysis induced by fradlures of the cervical vertebrx.** 
 Pages 55y oSj 57. 
 
 Persons labouring under paralytic afFeftions are very liable 
 to gangrene, from long continued pressure. In other lingering 
 diseases, the pain which the compression of any part occasions, 
 generally compels the patient to change his position. In palsy 
 however, this salutary warning is never given. But, how easily 
 may we guard against the evils that would result from this sus- 
 pension of some of the operations of nature, by substituting 
 those of art. All that is necessary is to change frequently the 
 position of the patient. 
 
NOTES. 361 
 
 l"'he etfeft of pressure from the weight of the body, is not 
 the only evil that we have to contend with in fra£lures of the 
 cervical vertebrae. 
 
 Muscular aftion is frequently the cause of the greater part 
 of the dreadful consequences which almost invariably succeed 
 fra^lures of these bones. The circumstance of their being so 
 very moveable upon each other, will perhaps, in some measure, 
 explain the facSi:, that injuries done to them are so frequently 
 fatal. If the whole spinal canal were a complete and immove- 
 able bony tube, fradlures might sometimes take place in the 
 spine, as they do in the cranium, without depression. 
 
 But as this canal is composed of a number of distin£l bones, 
 each of which has strong muscles inserted into different parts 
 of it, we cannot easily conceive, that a fraclure of any of the 
 true vertebra can ever occur, without being accompanied with 
 a compression of the spinal marrow. In what manner shall we 
 endeavour to remove this compression ? Perhaps the best an- 
 swer that we can give to this question will be to relate the fol- 
 lowing case: 
 
 Peter Colberry was admitted into the Pennsylvania Hospital 
 on the 15th November, ISOi. About half an hour previously 
 to his admission, he fell from a height of ten feet, upon his 
 head and back. 
 
 The upper and lower extremities were paralytic, the head 
 was turned a little to the left side, and the neck was somewhat 
 contrafted. The patient was unable to rotate the head upon 
 the second vertebra, but could easily turn it in every direftion 
 by moving the whole neck. Upon making some extension a 
 crepitation was felt in the cervical vertebrx. His pulse at this 
 time was so much depressed as to be scarcely perceptible. On 
 the morning of the 16th it became somewhat fuller, and the 
 pain in the neck increased considerably. This symptom how- 
 ever, was by no means so distressing, as a difficulty of breathing 
 which came on about this time. The man was unable to cough, 
 and was apparently almost suffocated by a collection of mucus 
 in the trachea. Upon turning him so as to have the face 
 downward, with a view of examining the vertebrcc, so great a 
 compressioa v/as made upon the abdominal viscera, and dia- 
 phragm, as almost to put a stop to respiration. 
 
 Dr. Physick ordered an apparatus to be applied, by which the 
 neek was kept extended. The feet of the patient were secured 
 to the lower, and his head to the upper part of the bedstead. See 
 Plate 1. fig. 1. 
 
 46 
 
302 NOTES. 
 
 Two hours after this dressing had been appUed, the man reco- 
 vered in some measure, the use of his arms. The difficuhy of 
 respiration however, continued, and at 5 o'clock on the morning 
 of the 17th he died. 
 
 The muscles were not contrafted, and the blood had not co- 
 agulated. The spinous process of the fifth, and the body of the 
 sixth cervical vertebra, were fractured, and pressed upon the 
 spinal marrow. A considerable quantity of dark coloured coa- 
 gulated blood was found between the spinal marrow and the 
 membrane, which lines the cavity of the spine. 
 
 The immediate cause of this man's death was, in all probabi- 
 lity, a coUedtion of mucus in the trachea, which a paralysis of 
 the abdominal mtiscles, rendered him unable to discharge. 
 
 Notwithstanding the fatal termination of this case, the cir- 
 cumstrmce of the patient's being able to move his arms soon 
 after the application of the apparatus, affords some ground for 
 the belief, that in fraftures of the cervical vertebrae, permanent 
 extension of thfe neck may sometimes retain the fragments in 
 their natural situation, and prevent them from pressing upon the 
 spinal marrow. 
 
 A delineation of this apparatus is given in Plate 1. fig. 1. 
 
 A. A. Bandages passed round the ancles. 
 
 B. Another bandage tied to the former, and secured to the 
 upright piece C. at the foot of the bed. This servos to make 
 the counter extension. 
 
 For the extension a leather strap D. is passed round the head, 
 and buckled on the vertex. E. another strap sewed to the 
 former, and carried under the occiput. 
 
 F. F. A bandage which ties the strap to the nut G. of the 
 screw 2. 
 
 Fig. 2. A m.ale and female screw, invented and first used by 
 Dr. James Stuart, in fraiStures of the feg and thigh. 
 
 The use of this dressing is attended with several inconveni- 
 encies. It is frequently necessary to move the body of the pa- 
 tient — whenever this is done the extension will be rendered 
 more or less oblique. It requires too much force, as almost all 
 the ligaments and muscles of the whole body must be elongated. 
 
 I have proposed an apparatus, Plate 1. fig. 3, 4, 5, which may 
 perhaps obviate some of these objections. 
 
 Fig. 3. Two pieces of board about two feet in length, half 
 an inch thick, and eight inches wide. The lower end should 
 be excavated and covered with bolsters to receive the shoulders. 
 Two mortises in the upper ends receive the cross pieces fig. 4. 
 
s 
 
NOTES. 2^2 
 
 Fig. 5. is a representation of the apparatus, when applied- 
 Bandages, or leather straps, are passed round the head as in fig. 
 1. carried through a hole in the first cross piece, and tied to 
 the screw. 
 
 If the screw should not be at hand, a common tourniquet 
 will answer the same purpose. 
 
 In fractures of the dorsal vertebrae, this dressing would be of 
 no avail. For if a fradlure occur in any part of the spine below 
 the last cervical vertebra, it is evident, that the counter exten- 
 sion must be made against some point below the first rib. If, 
 instead of making the counter extension, as proposed by Dr. 
 Physick, the ossa ilia should be chosen for that purpose, nothing 
 is gained •, as it is frequently necessary to raise the pelvis, and irj 
 doing this, an angle v/ould be formed at the fradlured part. 
 
 NOTE V. 
 
 "Apparatus forfraftures of the clavicle." Page 77. 
 
 This apparatus is simple in its construftion, and can be very 
 easily applied. It fulfils every indication which should be at»- 
 tended to in the treatment of these fradlures, except that of 
 raising the arm. With a view of supplying this desideratum, 
 and of rendering the dressing for a fradtured clavicle still more 
 simple, I have proposed a modification of Boyer's apparatus- 
 
 As the construdtion and manner of applying it will be readily 
 understood by taking a view of Plate 2. we need not enter into 
 a lengthy description of it. 
 
 Fig. 1. a cushion, to be placed under the arra. Fig. 2. a 
 roller, about twelve inches in width, and four feet long, confines 
 the cushion to the body. This part of the dressing has holes 
 at each extremity, through which tapes are passed, and three 
 loops L. L. L. Before the tapes are tied, the fore arm is to be 
 carried through the middle loop, as at L. fig. 5. 
 
 Thus the first bandage serves the double purpose of confining 
 the cushion to the body, and of supporting the fore arm. To 
 prevent the cushion from slipping downward, it may either be 
 sewed to the roller 2, or supported by straps passed over the 
 opposite shoulder. 
 
 Fig. 3. another piece of linen, six inches wide, and about 
 ^ye feet in length. It is passed over the arm, and through the 
 
364 NOTES. 
 
 loops L. L. L. and tied behind with tapes. The straps A. B. 
 fig. 5. which support the whole dressing, may be either passed 
 through loops, or sewed to the first bandage, before and behind. 
 
 Fig. 4, a bandage four inches wide, and a yard long, sypports 
 the elbow, and counteracts the tendency of the external frag- 
 ment to be carried downward by the weight of the arm. 
 
 The strap C. D. prevents this bandage from slipping off the 
 shoulder. 
 
 NOTE VI. 
 « Fra<5hires of the Femur." Page 125. 
 
 To the obje£lions made by Boyer to Desault's splint, we may 
 ^dd the difficulty of preventing the foot from turning outward, 
 and carrying with it the inferior fragment. 
 
 A bandage passed round the foot, and tied to the internal and 
 external splints, offers very little resistance. The internal splint 
 being connedled only by bandages to the rest of the apparatus 
 is drawn outward by the weight of the foot. 
 
 Another very great inconvenience in the use of Desault's 
 splint is, that the bandages by which extension and counter ex- 
 tension are made, aft obliquely. This objeftion has been in 
 some measure obviated by improvements made in the construc- 
 tion of this splint by Dr. Physick, and Dr. Hutchinson. In 
 iPlate 3. we have endeavoured to give a view of these improve- 
 ments. 
 
 a. a. a. Represents the axis of the os femoris. 
 
 D. The splint first used by Desault. 
 
 d. d. d. The bandage which makes the counter extension 
 
 against the tuberosity of the ischium. 
 
 e. e. e. The bandage passed round the ancle, for the purpose. 
 
 of making extension. 
 
 The dotted lines P. shew the addition made to the upper ex- 
 tremity of this splint by Dr. Physick — p. p. p. the bandage 
 which makes the counter extension. 
 
 H. The block added by Dr. Hutchinson to the lower end of 
 the sphnt, and h. h. h. the extending bandage passed round the 
 ancle, and over the middle of the block. 
 
 The upper end of this splint is excavated, so as to resemble 
 the head of a crutch, and covered with a cushion. The coun- 
 ter extension is made against the axilla and the tuberosity of 
 
 
i 
 
 e 
 s 
 
 L. 
 11 
 I. 
 
 le 
 s- 
 
 ey 
 
 IS, 
 
 ec- 
 
 or 
 
 red 
 
 Ma> 
 
 in- 
 
 )es 
 lal 
 ral 
 
 ya 
 
 the 
 
 bv 
 by 
 oot 
 
NOTES. 365 
 
 the ischium. It is sometimes necessary to remove the bandage, 
 in order to examine the perineum. Whenever this is done, 
 the extension may still be continued, by making the whole of 
 the counter extension against the axilla. 
 
 The obliquity in the a£tion of the extending and counter- 
 extending bandages, is thus considerably diminished; but it is by 
 no means entirely removed, nor is any provision made against 
 the tendency of the foot to fall outward. 
 
 Should the alterations which I am about to propose in the 
 construftion of Desault's splint be deemed worthy of a fair trial, 
 future experience will determine whether they merit the name 
 of improvements. Instead of the bandage which Desault di- 
 re£ls to be passed between the scrotum of the affected limb, and 
 tied to the external splint, for the purpose of making the 
 counter extension, a piece of wood of an elliptical form, is 
 made to surround the anterior and lateral parts of the thigh. 
 This part of the apparatus, which for the sake of brevity shall 
 be called the semi-circle, is to be placed on the thigh as in fig. 1. 
 Plate if. The external extremity presses against the spine of the 
 ilium, while the internal compresses the tuberosity of the is- 
 chium. 
 
 R. R. shew two lateral proje£lions pierced with holes. They 
 should be about six inches in length, and parallel with the axis, 
 of the OS femoris. 
 
 E. F. a handkerchief passed through a hole in each projec- 
 tion, carried under the thigh, and tied at F. By tightening or 
 relaxing this band, the circle may be in some measure enlarged 
 or diminished. 
 
 Fig. 2, is a view of the apparatus applied to the left thigh. 
 
 A. B. the splints of the usual length, and about seven in- 
 ches in width. 
 
 C. the semi-circle. 
 
 c. c, c. c. four holes in the external splint, with the tapes 
 which tie it to the external lateral projedlion. The internal 
 splint is connected in the same manner, to the internal lateral 
 projection. 
 
 p. the cross piece upon which the extension is made by a 
 bandage passed round the ancle. 
 
 a. a. a. b. b. b. bags of chaff, scmev.'hat wider than the 
 splints. 
 
 E. F. two cross pieces passed through mortises and secured by 
 pegs. They serve to keep steady the whole apparatus, and by 
 pressing the bags of chaff against the Hmb, they prevent the foot 
 from turning inward or outward. 
 
J 
 
 66 NOTtS. 
 
 G. a bandage passed round the pelvis and external splint^ 
 The effects of pressure should be guarded against by ap- 
 plying strips of adhesive plaister to the perineum, over the spine 
 of the ilium, and round the ancle. A bolster should also be 
 made to fit the upper edge of the semicircle. 
 
 Tlie bandage which passes round the ancle and is tied to 
 the last cross piece, draws downward the inferior fragment, and 
 at the same time, prevents the pelvis and superior fragment 
 from descending, by pushing upwards the internal and external 
 splints. By the former, the semi-circle is pressed against the 
 tuberosity of the ischium, and by the latter against the spine of 
 the ilium. In this manner, the extension, and counter exten- 
 sion, are made ia a direction parallel with the axis of the os 
 femoris. 
 
 NOTE VII. 
 
 " "When the leg is fradlured very obliquely, continued ex- 
 tension ought to be employed." Page 146. 
 
 The splints invented by Dr. Hutchinson are well calculated 
 to fulfil this indication. They are so simple in their construc- 
 tion, that a satisfactory description oi: them may be given with- 
 out the aid of a plate. 
 
 The splints are about four inches wide, and long enough to 
 reach from the knee to some distance beyond the foot. The 
 upper end of each has four holes. At the lower end they are 
 connected by a cross piece passed through mortises. 
 
 This apparatus is very easily applied. For the purpose of 
 making the counter extension, two pieces of tape are bound to 
 the inside, and two more to the outside of the leg, by a band- 
 age passed round the limb, just below the knee. With these 
 tapes, the upper ends of the splints are tied to the bandage. 
 Another bandage passed round the ancle, and tied to the cross 
 piece, makes th^ extension. 
 
 NOTE VIII. 
 
 " The extending force is to be applied to the inferior part of 
 the leg, in order to have it as far as possible from the part? 
 
NOTES. 367 
 
 which resist the return of the head of , the femur. Luxations 
 of the femur." Page 267. 
 
 • When we apply the extending force to the inferior part of 
 the hmb, as directed by Boyer, we must extend the leg. When 
 this is done, the flexor muscles which originate from the pel- 
 vis, and are inserted into the leg, have the same effect as if they 
 were inserted into the os femoris — viz. they draw the head of 
 the bone upwards, and offer a considerable resistance to the 
 reduction. This resistance may be very much diminished by 
 bending the leg. 
 
 Two cases of luxated os femoris, came under the care of 
 Dr. Physick last winter, in the Pennsylvania Hospital. In the 
 first attempts which were made to reduce these dislocations, 
 the extending bandage was placed above the knee. 
 
 Whenever any considerable degree of extension was made, 
 the bandage slipped. It was necessary then, either to pass the 
 bandage round the ancle, and extend the leg; or to flex the 
 leg, and apply the bandage just below the knee. Dr. Physick 
 preferred the latter, and soon after accomplished the redudlion. 
 
 POSTCRIPT. 
 
 On the second of August, several days after the foregoing 
 notes had been handed to the printer, the editor was called to 
 a case of oblique fradlure of the os femoris. The patient was 
 a child aged two years and five months. Desault's splint was 
 applied and had a very happy effecl in lessening pain, by re- 
 straining the convulsive adtion of the muscles. On the next 
 day however, the patient became extremely restless. The 
 counterextending bandage had so much excoriated the perine- 
 um, that every attempt to increase the extension gave great 
 pain. 
 
 In the afternoon, thirty-three hours after the accident, this 
 dressing was removed, and the apparatus delineated in Plate 4 
 was applied. 
 
 Dr. James Hutchinson very obligingly offered to witness the 
 effefts of this method of dressing fractures of the thigh. 
 
 It was the opinion of this gentleman, that the necessary de- 
 gree of extension in this case was made with little force, an<i 
 consequently with little pain, in a dire£lion parallel with the 
 
368 NOTES. 
 
 > 
 axis of the os femoris : that the foot with the inferior fragment 
 
 were efFedhially prevented from turning either inward or out- 
 ward. 
 
 The child is now (8th August) entirely free fi"om pain, and 
 no difference can be perceived in the length of the lower ex- 
 tremities. 
 
 THE END. 
 
 PRACTICAL OBSERVATIONS IN SURGERY, 
 
 ILtUSTRATED WITH 
 
 CASES AND PLATES: 
 Br WILLIAM HEY, Esq, F. R. S. 
 
 Member of the Roya^ College of Surgeons in London: Honorary Member of the Royal 
 
 Medical Society of Edinburgh ; and of the "Literary and Philosophical Society 
 
 of Manchester : And Senior Surgeon of the General Infirmary at Leeds. 
 
 THE FOREGOING WORK 
 
 Is in the Press of James Humphreys, printing on Subscription, 
 
 On the follonving Terms : 
 
 To make one volume, large o£lavo, on a handsome type and good paper. 
 
 The price to Subscribevs will be three dollars for it in boards, and three dollars and 
 
 a quarter bound; to be paid for on delivery. 
 To non-subscribers the price will be ;n:teased as soon as published. 
 
 Thtjinr.ual Review, published under the direction of Doctor Aiken, speaking of the 
 aio've Work, says, 
 
 " The abilities and experience of th-e ingenious Author of this 
 work have already gained him considerable celebrity, and the 
 publication now before us will be found to possess those claims 
 to attentive consideration, which are derived from accurate ob- 
 servation, sound judgment, and a perspicuous detail of interest- 
 ing fac^s." 
 
 SrsscRiPTior s are received by said Humphreys, at his Book-store on the Ex- 
 change, the Co n2r of Second and Walnut-streets. 
 
:";>>: 
 
?■ 
 
 mm 
 
 ■':■:■ ' 
 
?*.; 
 
 Date Due 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 L. B. Cat. No. 1 137 
 
 1 
 
Richerand 
 
 4;i4wb 
 
 Diseaaea of the Bones 
 
 316.71 R359 
 
 43498