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A TREATISE 
 
 on 
 
 FRACTURES, LUXATIONS, 
 
 AND OTHER 
 
 AFFECTIONS OF THE BONES, 
 BY P. J. DESAULT, 
 
 SURGEON IN CHIEF TO THE HOTEL-DIEU OF PARIS, 
 
 WHEREIN HIS OPINIONS AND PRACTICE, IN SUCH CASES, 
 ARE STATED AND EXEMPLIFIED. 
 
 EDITED BY XAV. BICHAT; 
 
 WITH PLATES. 
 
 TRANSLATED FROM THE FRENCH, 
 
 BY CHARLES CALDWELL, M. D. 
 
 WITH NOTES, AND AN APPENDIX CONTAINING SEVERAL 
 LATE IMPROVEMENTS IN SURGERY. 
 
 PHILADELPHIA: 
 
 PRINTED BY FRY AND KAMMERER, L^TITIA COURT,. 
 1805. 
 
 V^' 
 
District of Pennsylvania, to ivit: 
 
 ^>-^ BE IT REMEMBERED, That on the twentieth 
 s SEAL ^ day of February, in the twenty-ninth year of the inde- 
 
 '^-'v^ pendence of the United States of America, A. D. 1 805, 
 Charles Caldwell, M. D. of the said district, hath deposited in 
 this Office, the Title of a Book, the Right whereof he claims 
 as proprietor, in the words following to wit: 
 
 " A Treatise on Fractures, Luxations, and other Affections 
 " of the Bones, by P. J. Desault, surgeon in chief to tlie Hotel- 
 " Dieu of Paris, wherein his Opinions and Practice, in such 
 *' cases, are stated and exemplified. Edited by Xav. Bichat; 
 " with Plates. Translated from the French, by Charles Cald- 
 " well, M. D. With Notes, and an Appendix containing several 
 " late improvements in surgery." 
 
 In conforaaity to the act of the Congress of the United States, 
 intituled, " An act for the encouragement of learning, by secur- 
 ing the copies of maps, charts, and books, to the authors and pro- 
 prietors of such copies during the times therein mentioned:" 
 And also to the act, entitled, " An act supplementary to an act, 
 entitled, "An act for the encouragement of learning, by securing 
 the copies of maps, charts, and books, to the authors and propri- 
 etors of such copies during the times therein mentioned," and 
 extending the benefits thereof to the arts of designing, engraving 
 and etching historical and other prints." 
 
 D. CALDWELL, 
 Clerk of the District of Pennsylvania. 
 
CONTENTS. 
 
 MEMOIR I. PAGE 
 On the Fracture of the Condyls of the lower Jaw, 1 
 
 MEMOIR II. 
 
 On the Fracture of the Clavicle, 8 
 
 Explanation of the first Plate, 39 
 
 MEMOIR III. 
 
 On the Luxation of the Clavicle, 41 
 
 Luxation of the Sternal extremity, 42 
 
 of the Humeral extremity, 54 
 
 MEMOIR IV. 
 On Fractures of the Acromion, and of the lower angle of 
 
 the Scapula, 57 
 
 Fracture of the Acromion, ib. 
 
 of the lower angle of the Scapula, 63 
 
 MEMOIR V. 
 On the Fractures of the upper end or neck of the Humerus, 67 
 
 MEMOIR VI. 
 On the Fracture of the lower extremity of the Humerus, 
 with a separation of the Condyls, 90 
 
 MEMOIR VII. 
 On the Luxation of the Humerus, 102 
 
 MEMOIR VIII. 
 
 On the Fracture of the bones of the Fore-arm, 146 
 
 Fracture of the Radius, 160 
 
 of the Ulna, 1 6f 
 
 I of the Olecranon, 168 
 
MEMOIR IX. PAGE 
 Oh the Luxation of the Fore-arm, 1 84 
 
 MEMOIR X. 
 
 On the Luxations of the Radius over the Ulna, 199 
 
 Luxation of the lower extremity of the Radius . . . 204 
 
 . MEMOIR XI. 
 
 On the Fractures of the Thigh, ' 214 
 
 Fractures of the body of the Ob Femoris, 215 
 
 of the upper end of the Os Femoris, . . . 258 
 
 of the great Trochanter, ib. 
 
 of the neck of the Os Femoris, 260 
 
 of the lower extremity of the Os Femoris, 280 
 
 E!splanation of tlie second Plate, 291 
 
 Thoughts on Luxations of the Os Femoris upward .and 
 forward, , 292 
 
 MEMOIR XII. 
 On spontaneous Luxations of the Os Femoris, . 299 
 
 MEMOIR XIH. 
 On tlie Fracture of the Rotula, 304 
 
 MEMOIR XIV. 
 
 On the foiTTiation of foreign bodies in the joint of the knee, 325 
 Observations and Reflections on forms of Apparatus* for 
 fractures of the leg, 342 
 
 * (Apfiareil.) I am fully sensible that the word Apparatus, 
 does not, according to the common acceptation of the term, 
 convey, in English, precisely the same ideas, tliat the word 
 '^' appareil" does, in French ; but it certainly approaches much 
 nearer to it than any other term found in English works on sur- 
 gery. It signifies a collection or assemblage of means, used for 
 the attainment of a particular end; and this is, in substance, 
 what Desault meant by the term " apfiareil." His " appai*eil" 
 (apparel) for a broken bone included splints, bandages, bolsters, 
 and every thing else necessary for retaining the fractured end^- 
 
MEMOIR XV. FAGE 
 On the Division of the Tendo Achillis, 355 
 
 MEMOIR XVI. 
 On the Fracture of the Os Calcis, 374 
 
 MEMOIR XVII. 
 On complicated Luxations of the Foot, 379 
 
 APPENDIX. 
 
 ARTICLE I. 
 
 Dr. Physick's. new and successful method of treating an 
 old and obstinate fracture of the os humeri, 403 
 
 ARTICLE II. 
 An account of Dr. Physick's improvement of Desault's 
 apparatus for making permanent extension in oblique 
 fractures of the os femoris, 407 
 
 ARTICLE III. 
 Explanation of the third Plate, 409 
 
 in apposition. The English reader will naturally enough annex 
 the same ideas to the word Apparatus, as used throughout the 
 present work. I have, therefore, thought proper to adopt it, ra- 
 ther than to introduce a new or uncommon term, and am sure, 
 that, for all practical purposes, it will be found sufficiently ex- 
 pressive of the meaning of the original. And I am much m^ore 
 solicitous to become instrumental in givmg some aid to the sur- 
 geon in the practice of his profession, than to escape the censure 
 of the fastidious criti<i. Te aks. 
 
PREFACE 
 
 BY THE TRANSLATOR. 
 
 The business of a translator, though very 
 limited as to its range, may be extensive and 
 important in its consequences, and, though 
 humble in its end, is oftentimes extremely diffi- 
 cultin its nature. Prohibited from adding any 
 thing to, or in any measure transgressing the 
 bounds of, the meaning of his original, he is 
 obligated to interpret that meaning with faith- 
 fulness and accuracy. In this latter point con- 
 sists the difficulty of his task. If several 
 different readers oftentimes attach as many 
 different meanings to parts and sentences of 
 works written in their own language, how 
 much more likely will this be to occur with 
 respect to such as are written in a foreign lan- 
 guage? For readers to diff'er in the former 
 case is common, in the latter unavoidable. 
 
 The translator of the following work is far 
 from affirming, that he has in no instance de- 
 viated from the meaning of his original. To 
 hazard an assertion like this, would be as sum- 
 
Vlll 
 
 ing to himself more than is consistent with 
 modesty or, perhaps, with truth. He trusts, 
 however, that such deviations are very rare, 
 that if they do occur they are but sUght in 
 themselves, and never connected with facts or 
 principles of practical importance. He can, at 
 least, very confidently declare, that they have 
 never been the offspring of carelessness or 
 design. 
 
 Should any one open this volume in quest 
 of the flowers of fancy, or the embellishments 
 of style, he will close it again without being 
 gratified. Ambitious only of communicating 
 new and useful matter, and too intent on things 
 to be in any measure choice of his words, the 
 celebrated original was regardless, perhaps to 
 a fault, of the ornaments of diction. Rich in 
 the resources of a capacious and exalted intel- 
 lect, he poured forth his knowledge like pre- 
 cious ore from the mine, leaving to others of 
 inferior capacities the humbler task of refining 
 and polishing it. 
 
 With such an example before him, the 
 translator thought it best to follow in some 
 measure the footsteps of his illustrious guide, 
 without venturing to chalk out a new and dif- 
 ferent track for himself. As his principal ob- 
 ject, throughout the work, has been to make 
 
IX 
 
 himself clearly understood, and that in as few 
 words as practicable, he has never hesitated, 
 when they came in competition, to sacrifice 
 elegance to precision and ornament to perspi- 
 cuity. He has even in some instances beeri 
 guilty of intentional tautology, for the purpose 
 of rendering his meaning the more clear and 
 definite. For this he flatters himself he need 
 offer no apology to those, who prefer utility to 
 pleasure and sense to sovind. And, as to read- 
 ers of an opposite cast of mind, should any 
 such choose to sit in judgment on him, he nei- 
 ther deprecates their censure nor courts their 
 approbation. 
 
 A circumstantial analysis of the following 
 memoirs would constitute a paper too exten- 
 sive to be introduced here in the form of a 
 preface, and a mere outline or general charac- 
 ter of them would be altogether "useless. The 
 translation is now before the public, and every 
 reader must judge of its merit for himself. 
 On this point the translator will only observe, 
 that the attention which he has been necessa- 
 rily led to bestow on the work, has been to 
 him the best school of surgery he ever attend- 
 ed, as far as relates to affections of the bones. 
 Should other practitioners throughout the 
 United States derive equal benefit from peru- 
 
 1 
 
X 
 
 sing his translation, he will rejoice in a con- 
 sciousness of having, at least in one instance, 
 been of service to his country. 
 
 Such are the extent and importance of De- 
 sault's improvements in some branches of 
 practical surgery, as to constitute a new epoch 
 in the history of the profession. His different 
 forms of apparatus for fractures and luxations 
 are certainly more rational in their construc- 
 tion, and more efficacious in their action, than 
 those of any other writer. But their excel- 
 lence does not arise from these circumstances 
 alone. Their cheapness and simplicity, taken 
 in conjunction with the ease and quickness 
 with which they may be every where made and 
 applied, greatly enhance their value, particu- 
 larly to practitioners in the country. If they 
 be not already at hand, they can be easily pre- 
 pared by the surgeon or his assistants, without 
 any material loss of time. The sufferings of 
 the patient, therefore, whatever may be the 
 form of fracture or luxation under which he 
 labours, need never be prolonged, by any delay 
 in obtaining the necessary apparatus. It is 
 thus that the means and processes of every art 
 become simple and easy, in proportion as the 
 art itself approaches perfection: and thus that 
 the truly great artist is known, not by the 
 
XI 
 
 multiplicity and the complex nature of his. 
 forms of apparatus, but by the numerous ends 
 which he accomplishes by means the most' 
 simple and easy of construction. 
 
 Several French practitioners, in projecting 
 improvements on the forms of apparatus of 
 Desault, have evidently rendered them more 
 complex, more expensive, and therefore more 
 difficult to be constructed or procured, without 
 adding in the smallest degree to the efficacy 
 of their action. This is particularly the case 
 with respect to Boyer, in his attempt to substi- 
 tute a new apparatus for a fractured clavicle, 
 in place of that invented by Desault. The 
 latter can be constructed in a very few minutes 
 by the surgeon or one of his assistants, with- 
 out any expense, whereas the former must be 
 made by a workman employed for the purpose, 
 and is necessarily attended with both cost and 
 delay. Nor is it always practicable, particular- 
 ly in the country, to procure a workman capa* 
 ble of making this apparatus. But this is not 
 all. On Desault's plan, the same apparatus 
 for a fractured clavicle wiH fit, and may be ap- 
 plied to, persons of different sizes and figures; 
 whereas, on the plan of Boyer, each patient 
 must have an apparatus constructed particu- 
 larly for himself. No practitioner, therefore,. 
 
xu 
 
 can hesitate a moment in deciding to which of 
 these two forms of apparatus, tibe prefeence -is 
 due.. .V-,..:, -•"•.-:-••■>:. '^y 
 
 Similar remarks may be made respecting 
 Boyer's apparatus for making permanent ex- 
 tension in obHque fractures of the os femoria. 
 It is much more complex and difficult to he 
 constructed than that of Desault. Nor does it 
 possess a single advantage over it as improved 
 by Drs. Physick and Hutchinson. In a word, 
 the forms of apparatus of Eoyer may answer 
 well enough in hospitals and in cities, where 
 the expence of such articles is not much regard- 
 ed, and where workmen to make them can be 
 readily procured. But, as the practitioner in 
 the country is generally obliged to be himself 
 the constructor of the forms of apparatus which 
 he uses, and as he is not at all times prepared 
 to meet heavy expenses, it is to those recom- 
 mended and employed by Desault that he must 
 necessarily have recourse. 
 
 With these remarks the translator submits 
 to the good sense and candour of his country- 
 men the following sheets, as the offspring of 
 som.e of his hours of leisure throughout the 
 winter. He hopes that the appendix subjoined 
 by himself will not be regarded as either an 
 useless or an unpleasing addition. Every na- 
 
XUl 
 
 tivd of the United States, whose bosom glov/:- 
 as it ought, with that noblest of passions, the 
 amor patria, will witness with pride and ezulta- 
 tion the improvements that are daily making in 
 the arts and sciences, by the industry and enter- 
 prize of his enlightened countrymen. Such <i 
 mind will enjoy in anticipation the glory of hh 
 country, at that period, when she will be able 
 to reflect back, with increased splendour, th( 
 light which she has so long been borrowing 
 from the countries of Europe. 
 
 The translator does not plead the want ci 
 time as an apology for any imperfections or 
 errors which his translation may exhibit. Yei 
 he believes it to be true, that had he had more 
 time to bestow on it, he could probably have 
 rendered it more worthy of public patronage. 
 
A TREATISE 
 
 FRACTURES, DISLOCATIONS, he. 
 
 MEMOIR I. 
 
 ON THE FRACTURE OF THE CONDYLES OF THE 
 LOWER JAW. 
 
 §1. 
 
 1. THE lower jaw, a kind of moveable ham- 
 mer, destined, to use the words of a certain physi- 
 ologist, to triturate the aliments against the almost 
 immoveable anvil of the upper jaw^, is more exposed 
 to the action of external bodies, and consequently 
 to fractures, than most of the other bones of the face. 
 But all parts of it are not alike subject to such acci- 
 dents. Common in its body, but less frequent in 
 its branches or sides, fractures sometimes occur in 
 the two processes in which its branches terminate. 
 One of these processes, concealed by the zygoma, 
 embosomed in the temporal muscle, and covered by 
 the raasseter, is less liable to fractures than the other, 
 which serves as the centre of the motions performed 
 by the bone, and is protected externally only by the 
 
 parotid gland, 
 
 2 
 
§ II. 
 
 2. A fracture of the condyle may sometimes 
 arise from a counter-stroke, as when, in consequence 
 of some external force being applied from before 
 backwards, and from below upwards against the 
 chin, this process is di'iven against the projectmg 
 rim of the glenoid cavity ; at other times it may be 
 the effect of an immediate or direct stroke, as when 
 a body in motion strikes with force against the regi- 
 on of the joint, and does violence to that portion of 
 the bone. 
 
 3. But in whatever manner the fracture may be 
 produced, it generally occurs in the slender part of 
 the bone which supports the condyle, below the in- 
 sertion of the pterygoideus extemus. It is charac- 
 terized by a pain more or less acute, necessarily 
 accompanying- the motions of the jaw; by a difficulty 
 more or less considerable, in the performance of 
 these motions; by a crepitation, oftentimes distinct, 
 when, in consequence of the angle of the jaw being 
 pushed forward, or the jaw itself alternately depressed 
 and elevated, the sepai'ated surfaces rub against each 
 other ; by an inequality of surface sometimes per- 
 ceptible directly over the fractured condyle ; by the 
 ease v/ith which, on being pushed forv/ard, it may 
 be forced into the depression beneath the zygoma; 
 and by its remaining stationary, during the move- 
 ments of the lower javv^, from Avhich it is sepai'ated. 
 These signs, though generally characteristic, are 
 subject to an uncertainty proportioned to the swell- 
 ing that occurs in the part. 
 
4. In this accident a displacement is almost always 
 produced by muscular action. The pterygoideus 
 extenius, being attached to the condyle, draws it 
 forward and upward, towards the external wing of 
 the pterygoid apophysis, its fixed point of insertion. 
 On the other hand, the body of the bone is left be- 
 hind, being held by tlie masseter and external ptery- 
 goid muscles, the course of which is opposed to a 
 displacement in the same direction; so that there 
 always exists a separation, more or less perceptible, 
 between the two fragments of bone, 
 
 5. Hence, if proper means be not used to restore 
 the contact between the broken ends of the bone, 
 the following consequences will be likely to occur : 
 Xst. Their reunion will be tedious, because in every 
 bone this process is, in point of rapidity, inversely 
 proportioned to the separation of the divided sur- 
 faces : 2dly, This reunion may even entirely fail to 
 take place, if the bone be subject to the slightest 
 movements, as I have witnessed in a particular case, 
 where the condyle, not being reunited to the other 
 part, exfoliated, and was in part discharged through 
 the external integuments: 3dly, Under such circum- 
 stances, the callus produced in the process of healing, 
 being situated near to the joint, and rendered irregu- 
 lar and deformed by the separation of the parts, is apt 
 to impede muscular action, and do a permanent in- 
 jury to the functions of the jaM\ 
 
§ III. 
 
 6. As the whole apparatus in this case consists 
 in a passive resistance to the active powers employed 
 in producing a displacement, it follows from what 
 has been said (4), that the bandage intended to pre- 
 vent this displacement, and by that means to guard 
 against the accidents specified above (5), ought, 
 either effectually to bring back to its natural situation, 
 the condyle which is dra^vn forward, or pull in this 
 last direction (that is, forward) the body of the bone 
 T't hich is still retained in its usual position, in order 
 that it may thus be brought into contact with the 
 condyle. 
 
 The first of these measures is impracticable, in 
 consequence of the situation of the condyles, which 
 ai^e too deeply enveloped by the sun-ounding parts, 
 and offer a hold too small to be acted on. The 
 second, therefore, remains to be adopted, and is the 
 m.ore easily executed, in as much as the angle of the 
 jaw, from its projecting and being but slightly 
 covered by the integuments, may without difficulty 
 be directed from behind forward by a proper force. 
 
 7. The fingers of the surgeon temporarily supply 
 this force, at the time of reduction; but it is neces- 
 sary that it should be permanently kept up by means 
 of the apparatus. This end is attained, in the folio w- 
 mannerr 
 
 Place behind the angle of the jaw, which must 
 be first pushed forward, thick compresses, to fill up 
 the hollow under the ear, and form an eminence 
 higher than the surface of the surrounding parts; 
 pass over these compresses, in an oblique manner, 
 
the bandage commonly used in lateral fractures of 
 the bone, the application of which must in this case 
 commence on the sound side. 
 
 These compresses, being more projecting than 
 the surrounding surface, will necessarily sustain a 
 greater pressure, because the compression made by 
 a bandage is in proportion to tlie projection of the 
 part on which it is applied. Hence, being firmly 
 supported, they will retain the body of the bone in a 
 line with the displaced condyle (4). 
 
 8. In addition to this mode of applying the ban- 
 dage, it is necessary that the fractured bone should 
 be kept in a state of perfect rest. The internal ptery- 
 goid and masseter muscles, tending by their contrac- 
 tile efforts to draw the angle of the jaw backvv^ards, 
 sometimes overcome the resistance of the apparatus, 
 and, by producing a second displacement, give rise 
 to the accidents formerly mentioned (5). 
 
 Let the lower jaw be now brought into perfect 
 contact mth the upper one, and not separated from 
 it during the first few days after the injury, except 
 so far as may be necessary for the admission of nou- 
 rishing broths. Should a tooth have been lost, the 
 space which it occupied will furnish, without dis- 
 turbing the bone, an opening for the conveyance of 
 nourishment to to the patient. Let talking, laughing, 
 and every thing that might produce a separation be- 
 tween the body of the bone and the condyle, be care- 
 fully avoided. The further treatment of the accident 
 should be such as is generally applicable to all fi'ac- 
 tures of bones, and need not be at present particularly 
 detailed. 
 
The following cases, reported by citizen Giraud, 
 second surgeon to the Hotel-Dieu, will confirm the 
 advantages of this mode of treatment. 
 
 Case I. Margaret Bessonet, aged thirty-four, 
 was admitted into the hospital on the 10th of May, 
 1791- On the preceding day she had received a vio- 
 lent fall on her chin : a severe pain, and a preterna- 
 tural mobility in the left side of the jaw, had been the 
 immediate consequences of the accident : from these 
 symptoms, taken in conjunction with those formerly 
 mentioned (3), Desault discovered that a fracture of 
 the condyle existed, which he reduced and support- 
 ed in the usual manner (7). 
 
 After being somewhat uneasy during the first few 
 days, the patient became reconciled to the action of 
 the bandage, which, by inattention, had been two or 
 three times disturbed and put out of order, but 
 which, by being cai'efully reapplied, and aided by 
 the necessary precautions (8), restored to the bone 
 its natural form and solidity, by the thirtieth day, and 
 on the thirty- sixth the patient was discharged per- 
 fectly cured. The only inconvenience she experi- 
 enced, was a slight difficulty in the motions of the 
 jaw, an effect naturally resulting from the long con- 
 tinued inactivity of the muscles, but which was soon 
 removed by means of exercise. 
 
 Case II. Claudius Laurat, aged tw^enty- seven, 
 fell as he was caiTying a heavy burden. In his fall his 
 chin struck with violence against a beam that lay in 
 his way. In an instant he experienced a sharp pain 
 in his right temple, and found it almost impossible to 
 move his javv% Two hours afterwards a considerable 
 
swelling appeared in the part, extending from the an- 
 gle of the jaw above the ear. The patient was admitted 
 into the Hotel-Dieu, where the circumstances of the 
 fall and the symptoms that followed, gave satisfactory- 
 evidence of a fracture of the condyle. It was reduced 
 and supported as in the preceding case. On the day 
 following, the swelling was removed, doubtless by 
 means of the compression which had been made on 
 it; the other symptoms (3), hitherto scarcely percep- 
 tible, became more obvious ; the bandage was re- 
 applied, and the disease terminated, in about twenty- 
 nine davs, in the same manner with that of case 1« 
 
MEMOIR II. 
 
 ON THE FRACTURE OF THE CLAVICLE. 
 
 1. Man enjoys an advantage which nature has 
 bestowed on but few of the quadrupeds, namely, a 
 power of moving his upper extremities in every 
 direction. The clavicle being a kind of arch placed 
 between the breast and shoulder, forms a centre, 
 moveable indeed but solid, for these motions, a part 
 of which can no longer be performed, w^hen this arch, 
 in consequence of being broken, ceases to afford 
 them a point of support. Hence it follows, that the 
 fracture of this bone may be said to reduce the indi- 
 vidual who sustains it, when considered in relation 
 to its functions, to a level with that numerous divi- 
 sion of animals that are destitute of clavicles. 
 
 2. Few diseases of the kind are more frequently 
 met with than this. The natural curve of the clavi- 
 cle, its situation immediately under the skin, the 
 want of a support to its middle part, the great propor- 
 tion of spongy substance which enters into its com- 
 position, the projection of the shoulder exposing it 
 to the action of external bodies ; all these circum- 
 stances concur in rendering the accident frequent, 
 pailiculaiiy among that class of men subject, from 
 their occupations, to violent exertions of the upper 
 extremities. • 
 
 Here then, more than in the generality of frac- 
 tures, we should feel an interest in the advancement 
 
of the art of surgery ; and yet, having liitherto em- 
 ployed in it but feeble means, our efforts have been 
 attended with imperfect success. Hippocrates has 
 observed, that some degree of deformity almost al- 
 ways accompanies the reunion of a fractured clavi- 
 cle; all writers since his time have made the same 
 remark; experience has confirmed the truth of it, 
 and as much time has been spent in hypothetical 
 speculations to explain the accident, as in serious in- 
 quiries how to prevent it. At length Desault proved 
 that a feeble and unskilful mode of treatment was the 
 sole cause of a want of success, and that, by being 
 more correct ai>d judicious, art might be as success- 
 ful here, as in other fractures. In order to give a 
 correct view of his practice in this disease, I will 
 examine the causes, varieties, and signs of a frac- 
 ture of the clavicle ; the accidents of which it is sus- 
 ceptible; the mode and the causes of the displacement 
 of the broken ends of the bone; the indications that 
 arise out of those causes, and the manner of answer- 
 ing these indications as well during, as after, the re- 
 duction. 
 
 OF THE CAUSES AND VARIETIES. 
 
 S. The action of external bodies is almost the 
 only known cause of this fracture, wliether these bo- 
 dies strike the shoulder with violence, or the shoul- 
 der be forcibly di'iven against them. But this action is 
 not in every case the same; its application is most 
 frequently mediate or indirect, but is sometim.es 
 immediate or direct. 
 
 3 
 
In the first case there is a true counter-stroke, thfe 
 ordinary elFect, either of a severe blow on the point 
 of the shoulder, which is the most common occur-^ 
 rence; or, as happens less frequently, of a fall on the 
 arm when it is extended for the purpose of guard- 
 ing the body from the force of the accident. Under 
 these circumstances, being pressed between the 
 sternum, which makes resistance, and the body 
 which acts on its extremity, the clavicle is bent in 
 that direction which is most natural to it; but, not 
 being sufficiently flexible, it gives way generally in 
 the place where its curvature is the greatest. Thus 
 the ribs are broken, when the sternum, by being 
 violently driven backward, forces them to bend in 
 the centre beyond their natural flexibility. 
 
 In the second case, the fracture occurs at thfe 
 spot where the stroke is given. Here the momen- 
 tum or quantity of force applied on the bone, sur- 
 passing the solidity which the bone possesses, its 
 continuity is necessarily destroyed. 
 
 4. But in whatever way the fracture is produced, 
 it is either oblique or transverse, single or double, in 
 the middle or towards the extremities of the bone, 
 simple or compound. 
 
 An oblique fracture is most frequently the effect 
 of a counter -stroke ; a transverse fracture is the more 
 common result of the immediate action of external 
 bodies j a counter-stroke seldom produces any thing 
 but a simple fracture ; while compound fractures are 
 generally owing to a direct stroke. The one produces 
 a solution of continuity in the middle of the bone, 
 or thereabout; because in that part the curvature 
 
11 
 
 is most considerable. The otlier is almost always 
 th,e cause of this solution, when it occurs at the ex- 
 extremities. To the latter alone, is a double divi* 
 sioxi to be attributed. The reason of these differ- 
 ences is already so plain, that it would be a waste 
 of time to dwell on an explanation of them. 
 
 §111. 
 
 OF THE SIGNS. 
 
 5. The several phenomena that attend a fracture 
 of the clavicle, taken together, leave in general but 
 little doubt as to its existence, particularly when the 
 fracture is oblique. As is the case in most other in, 
 stances of the kind, so here, an acute pain is felt at the 
 instant of the stroke ; sometimes a cracking of the 
 bone is distinctly heard by the person injured ; on 
 every occasion, it becomes suddenly impracticable 
 to perform circular or rotatory motions with the arm ; 
 motions from before backwards can still be execu- 
 ted, but are difficult and painful, and, as I have al- 
 ready observed (1), the individual injured is reduced 
 to the class of animals destitute of clavicles. 
 
 Oftentimes the shoulder of the injured side, be- 
 ing more or less depressed, loses its level with the 
 other. It is also evidently drawn forward and inward. 
 The distance between the acromion and sternum, on 
 the affected side, is found on comparison, to be evi- 
 dently less than on the opposite side. In almost 
 every case, that portion of the fractured bone, which 
 adheres to the sternum, forms a visible protuberance 
 above and on the inside of the i^houlder. 
 
12 
 
 6. In the mean time the pain continues. The pain- 
 ful drawing or dragging occasioned by the weight of 
 the ai'm forces the patient, for the purpose of reUeving 
 it, to bend his body towards the side affected, and in- 
 cline his head in the same direction. This forms a pe- 
 cuhar attitude , which of itself was frequently sufficient 
 to disclose to Desault the nature of the disease. We 
 have oftentimes witnessed him establishing the truth 
 of this diagnostic, by merely looking at patients en- 
 tering the amphitheatre, who had been brought thi- 
 ther for the reduction of such fractures. 
 
 By this position, the pains are generally relieved, 
 because the arm finds some degree of support; but 
 should the patient wish to change his position, or 
 perform any paiticular mxOtions, the pains return 
 almost as acutely as at first. 
 
 7. If to these signs, v/hich are almost all of them 
 founded in reason, we add those that are stiil more 
 palpable to the senses, such as the mobility of the 
 two broken ends of the bone; the crepitation pro- 
 duced by their friction against each other; the de- 
 pression felt at the point of fracture, by passing the 
 fingers over the upper surface of the bone; and the 
 facility of restoring to it its natural form and direc- 
 tion, by moving the shoulder upwards, outwards, 
 and backwards; it will be difficult to be mistaken 
 respecting the nature of this fracture. This is per- 
 haps more particularly the case, v/hen the fracture is 
 oblique, as this kind offers the most striking diagnosis, 
 and cannot be involved in uncertainty, unless when 
 a considerable swelling occurs in the parts around the 
 fracture. But, even then, as the circumspection of 
 
13 
 
 the practitioner will necessarily direct his attention to 
 this circumstance, the obscurity of the signs will have 
 no unfavourable influence on the cure. 
 
 8. When the fracture is transverse, there is some- 
 times more difficulty attending the diagnosis. The 
 corresponding inequalities of the divided surfaces 
 may mutually penetrate each other and interlock, 
 and thus prevent a displacement. Does any uncer- 
 tainty on this score exist ? Placing your fingers on the 
 two extremities of the bone, order an assistant to 
 move the arm in every direction, and the motions 
 will be communicated to the clavicle ; but, if a frac- 
 ture exist, they will be most perceptible in the frag- 
 ment adjoining the shoulder, and will separate it from 
 that attached to the sternum. This method will sel- 
 dom decieve us, is easily employed, and subjects the 
 patient to but a momentary pain. 
 
 UV. 
 
 OF ACCIDENTS. 
 
 9. We do not generally find fractures of the cla- 
 vicle accompanied by such accidents as the anatomi- 
 cal relations of the parts might lead us to apprehend. 
 The external force being all expended in fracturing 
 the bone, extends but feebly to the brachial plexus, 
 which would be much injured by the shock, were 
 the- bone to yield, without breaking, to the action of 
 external bodies striking against it. Hence, without 
 doubt, would arise serious affections, as may be fairly 
 inferred from the analogy of blows on the head and 
 
H 
 
 vertebral eolumn, and as is indeed confirmed by 
 ^itain cases reported by Desault. 
 
 Case I. Two bricklayers were brought to the 
 Hotel-Dieu, who had met with similar accidents. A 
 piece of timber, thrown from a building, in which 
 they were engaged, had struck them, the one on the 
 external part of the left clavicle, the other about the 
 middle of the right, A considerable wound pointed 
 out in each the place on which the blow had been re- 
 eeived. Bat the former, having escaped a fracture, 
 experienced nothing but an acute pain, while the 
 second had the bone broken in two places. 
 
 The customary apparatus was applied to the latter, 
 ^nd the treatment which we shall presently describe, 
 being pursued, the result was that complete success 
 which never failed to crown the attentions of Desault. 
 In the other patient a considerable swelling made its 
 appearance the day after the accident. On the third 
 day a numbness and partial loss of the power of mo- 
 tion occurred in the arm of the affected side. Soon 
 afterwards an insensibility came on, and by the se- 
 venth day, the paralysis of the arm was complete. It 
 was not till after a tedious treatment, an account of 
 which would be foreign from my present subject, 
 that the limb recovered in part its original strength. 
 
 From whatever cause the fracture of the clavicle 
 in this latter patient was prevented, it is evident, that 
 the whole of the force employed to produce the frac- 
 ture in the other, acted here on the brachial plexus, 
 and gave rise, by means of concussion, to the acci- 
 dents which followed. 
 
IB 
 
 10. The axillary artery, though innning near to 
 the clavicle, in common with the brachial nerves, 
 -experiences, notwithstanding, less frequently than 
 they do, injurious effects from the fracture of this 
 bone. I know not of any instance Where a puncturfe 
 from the broken ends of the clavicle has produced in 
 this artery a false aneurism. To conclude, like all 
 other fractures, that of which we are now treating, 
 may be connected with wounds, splinters, &c. But 
 in general, as Hippocrates remarks, the fracture of 
 the clavicle assumes in common cases a mild aspect. 
 
 OF DISPLACEMENT. 
 
 11. Most of the symptoms formerly mentioned 
 (5 and 6) as accompanying a fracture of the clavicle, 
 are evidently the result of a displacement of its bro- 
 ken ends. Yet this phenomenon, taken notice of l>y 
 all authors, and considered by them as a necessary 
 effect of the disease, does not occur in every case (8). 
 There are instances, in cases of transverse fractures, 
 where the extremity attached to the shoulder, has 
 retained its natural position. Three examples of 
 this kind occurred in the Hotel-Dieu in the course 
 ofthe year 1787. 
 
 12. Instances have also been known, in which the 
 sternal fragment, when fractured obliquely upwards, 
 has supported the end of the humeral in such a man- 
 ner as to prevent any derangement. Desault was 
 accustomed to relate several cases, where similar 
 occurrences took place ; but, in general, this state 
 
16 
 
 of things is rare, in comparison with that in which 
 the fi'aginents lose their natural level. 
 
 Almost always, then, there is more or less of a 
 perceptible overlapping fcheiiauchementj produced, 
 either, by the elevation (a circumstance which is 
 very rare) of the external fragment over the internal; 
 or, (as commonly occurs) by the depression of the 
 former beneath the latter. 
 
 13. Of the first of these modes of displacement 
 (a mode but rai'ely mentioned by authors) a few ex- 
 amples are to be found among the observations of 
 Desault, one of wliich he has recorded in his journal. 
 Hippocrates speaks of the phenomenon as a thing 
 that was familiar to him. 
 
 14. The second kind of displacement, that which 
 we constantly find in practice, and which the laws 
 of muscular action render almost inevitable, takes 
 place in such a manner that the shoulder appears to 
 obey the impulse of two powers, one of which draws 
 it downwards, and along with it the external fi-ag- 
 ment of the clavicle, which is displaced by this pow- 
 er in the direction of its transverse diameter, or 
 thickness. The other power approximates the shoul- 
 der to the breast, and draws it forward, carrying 
 along with it the same fragment, which is by this 
 means displaced in a longitudinal direction. 
 
 That we may the better understand them and 
 their effects, let us, in our minds, separate these two 
 powers, although they ai'e perfectly simultaneous in 
 their action. A knowledge of them will lead us to a 
 knowledge of the resistances which ought to be 
 ©pposed to them. But let us first remark, that the 
 
17 
 
 humeral fragment, being drawn downward and in~ 
 ward, takes sometimes such a direction, that its 
 internal extremity passes backward under the sternal 
 fragment, its external end continuing to point for- 
 ward : this disposition can be understood from its 
 natural direction. 
 
 15. The first of these powers, namely, that which 
 depresses the point of the shoulder, appears to have 
 escaped the notice of the ancient physicians of 
 Greece, who attril;)uted the apparent depression of 
 this part, to the elevation of the sternal fragment, 
 and, accordingly, endeavoured by making compres- 
 sion on the latter, to restore it to a level with the 
 other. Hippocrates, more judicious than those who 
 had preceded him, demonstrated that their doctrine, 
 false in its principles, was still more dangerous in its 
 consequences, and that the sternal fragment being 
 immoveable, lost its relative position with respect to 
 the humeral, only because the latter was depressed 
 by the weight of the arm. This doctrine of the father 
 of physic is satisfactorily proved, by a comparison of 
 the sound shoulder with the diseased one, and has 
 since been admitted by all practitioners. Indeed, the 
 mere recollection that one of the uses of the clavicle 
 is to support the shoulder at that level necessary for 
 the performance of its functions, is alone sufficient 
 to convince us, that, in case of its ceasing to fulfil 
 that office, the shoulder "must obey the laws of its 
 own gravity, increased by that of the hand and arm.. 
 
 16. The illustrious Petit, and with him Duvemey, 
 in acknowledging this cause of displacement, have ad- 
 ded to it as another the action of the deltoid muscle on 
 
 4 
 
IS 
 
 the external end of the bone ; in this action, the end 
 of the clavicle is the moveable point, while the hu- 
 merus affords the fixed point. But how can wc 
 admit this cause, when the humeral fragment, in 
 passing under the sternal, moves in a backward 
 direction ? So far is the deltoid muscle from drawing 
 the bone downward, that here the bone rather draws 
 the muscle in part backward, and yet, in such a case, 
 the displacement is as perceptible as in any other. 
 Besides, when the sternal fragment, broken obliquely 
 upwards, supports the humeral and prevents a dis- 
 placement, why does not the deltoid produce this 
 displacement? 
 
 It is then in the weight of the arm and shoulder 
 alone, that we must look for the passive power, 
 which depresses them, and which produces a dis- 
 placement in the direction of the transverse diameter 
 or thickness of the clavicle. 
 
 17. A second power, highly active, co-operates 
 with this. I allude to the permanent contraction of 
 the muscles, that extend from the breast to the cla- 
 vicle and shoulder: from this cause arises the dis- 
 placement in the longitudinal direction of the bone. 
 
 The pectoralis major, the pectoralis minor, the 
 subclavius, the serratus major, and the trapezius, 
 unite their efforts in producing this displacement. 
 These muscles are, in certain respects, antagonists 
 to each other, but they all unite in drawing the 
 shoulder forward and inward. None of them appears 
 to act with more effect than the pectoralis major. 
 To this, in particular, is to be attributed the displace- 
 ment in a forward direction. 
 
19 
 
 Except in the instances stated above, the action 
 of the muscles is not immediate. They act only 
 secondarily on the external fragment, which, being 
 stedfastly attached to the scapula and humerus, is 
 obedient to the motions impressed by the muscles 
 on these two bones; motions Avhich, in a sound state, 
 the clavicle has a power of controuling. 
 
 18. To the weight of the lower extremity (15 
 and 16), and the spontaneous action of the muscles 
 (17) must be added, as another cause of displace- 
 ment, the motions which are communicated to the 
 arm by external bodies, and which, being imparted 
 ultimately to the clavicle, derange the fragments, by 
 separating them, approximating them, or making 
 them overlap each other, according to the direction 
 in which they act. 
 
 19. When a fracture occurs at the extremity next 
 the shoulder, no displacement of the fragments in 
 general takes place. This circumstance is attributed 
 to the action of the trapezius, which draws each frag- 
 ment upwards with equal force. However this may 
 be, it is doubtless to such cases that we must refer 
 the complete cures, obtained mthout any retentive 
 apparatus, by Gasparetti, Brown, and other -writers. 
 Hence also, without doubt, arise the difficulties ex- 
 perienced by certain practitioners, such asDuvemey, 
 with respect to the diagnosis of this disease. These 
 fractures may be mistaken for fractures of the aero- 
 mion, being situated so immediately in its vicinity. 
 
20 
 
 § VI. 
 
 OF THE REDUCTION- 
 
 20. On looking into the causes of that displace- 
 ment (15... 18), so common in fractures of the cla- 
 vicle, it appears that in almost every case, the exter- 
 nal extremity of the humeral fragment is <irawn, by 
 a double power, downward, inward, and forward. 
 Hence it follows, 1st. That the resistance opposed to 
 this power, by the means used for the purpose of 
 reduction, and the retentive apparatus subsequently 
 employed, ought to be directed upward, backward, 
 and outward, these directions being the reverse of 
 those in which the powers of displacement act : 2dly. 
 That, in as much as these powers, viz. the weight 
 of the parts and the action of the muscles, are in 
 constant operation, and, besides, as the motions of 
 the arm are continually disturbing the fragments of 
 the bone, the apparatus ought to be equally constant in 
 its action, and should keep up, "\\dthout any remis- 
 sion, the effect produced, at first, by the means of 
 reduction. This principle is applicable to every 
 case, and ought to be the standard of comparison, for 
 determining the advantages or disadvantages of dif-" 
 ferent bandages, and processes for the reduction of 
 fractures of the clavicle. 
 
 21. But we ai^e not to suppose, that these pro- 
 cesses have heretofore manifested an exact applica- 
 tion of this rule. Hippocrates directed to press the 
 arm close to the ribs, and at the same time to push 
 it upwards, in such a manner, as to make the shoul- 
 der appear as sharp and pointed as possible. Hence 
 
21 
 
 his precept, to lay the patient downon his back, the 
 back being supported by some projecting body, and 
 then to press the shoulders backward; hence again, 
 when the humeral fragment is diawn inward, his 
 advice to press the elbow close to the breast. This 
 twofold expedient was attended with great diffi- 
 culties, even under the direction of the father of 
 medicine. Celsus only copied Hippocrates, adding 
 nothing whatever to his mode of practice. Paul of 
 Egina, more judicious in this case, conceived, that 
 for the purpose of forcing the shoulder outward, and 
 rendering it, agreeably to the idea of Hippocrates, 
 very projecting and sharp, it would be advisable to 
 place the fulcrum or point of support, not in the 
 middle of the back, but under the arm-pit. A wool- 
 len ball w^as employed by him for this purpose, a 
 practice which would, at once, have carried the art 
 near to perfection, if, after being employed to reduce 
 the fragments, this process had been continued for 
 the purpose of retaining them in apposition. 
 
 22. No new method distinguished the surgery of 
 the Arabians. It is necessary to com.e down to the 
 time of Guy of Chauliac, before we meet with the 
 method which is almost universally adopted at pre- 
 sent, and which consists in placing between the 
 shoulders, the knee of an assistant, whose hands are 
 to be employed in drawing them forcibly backwards. 
 But it is evident that this is only doing, while the 
 patient is in an erect position, what Hippocrates did, 
 after having laid him with his back on a projecting 
 body. Here, then, the art seems to have degenerated, 
 after the time of Paul of Egina: and, indeed, on 
 
22 
 
 comparing this process with the general principles 
 already established (20), it will be immtdiately 
 perceived, that the powers of replacement do not 
 here act in an opposite direction to those of displace- 
 ment. 
 
 Hence the diiliculties of reduction, the time spent 
 in the operation, and the sufferings by which it was 
 Sure to be accompanied. The fragments were 
 brought together, it is true ; but it was only by vary- 
 ing the movements, and changing their direction, 
 ^at the point of contact was ultimately found. 
 
 23. Desault conceived, in the year 1768, that to 
 reduce, in the most effectual manner, a fracture of 
 the clavicle, it was necessaiy not only to push the 
 shoulder backward and upward, as was commonly 
 done, but, above all, to force it outward, and that the 
 power destined to draw it in this latter direction, 
 ought to act horizontally, according to the course of 
 the clavicle, in the same way, as, in an oblique frac- 
 ture of the thigh or leg, the extension for replacing 
 the fragments is made in the direction of the bone. 
 
 24. As the union of the humerus to the clavicle, 
 by means of the scapula, communicates to the one 
 the movements of the other, it is easy, by placing 
 the ball used by Paul of Egina, under the arm-pit, 
 to convert the arai into a lever of the first kind.* 
 
 * That form of lever, where the weight to be raised or the 
 resistance to be overcorae, is at one end, the force at the other, 
 and the fulcrum or prop between them. This form is well repre- 
 sented by the handle of a pump, where the pistcai is the weight 
 or resistance, the hand of the drawer of v/ater the force, and 
 the iron pin, on which the handle works, the fulcrum or prop. 
 
 Traxs. 
 
23 
 
 The lower extremity of the arm being then pressed 
 towards the body, the upper end is separated from 
 it, and becomes, with regard to the clavicle, what 
 the efforts of an assistant who makes the extension, 
 in a fracture of the leg, are to the foot of the patient. 
 The mode of reduction being established, it was 
 necessary, in the next place, to invent a bandage, cal- 
 culated to retain the broken ends of the bone in con- 
 tact. Desault thought it practicable to unite these two 
 points of treatment, in the same process, that is to say, 
 to reduce, and at the same time to retain the frac- 
 ture. Here the art is indebted to him for an improve- 
 ment, which, I will venture to say, carries it near to 
 perfection. To judge of this, it will be necessary 
 only to take a hasty survey of the different kinds of 
 apparatus proposed by different writers. 
 
 §VII. 
 
 OF THE MEAXS OF RETAINING A REDUCTION. 
 
 25. Here all authors seem to have been directed 
 by the same principle. This is to keep the shoulder 
 of the affected side, 1st, drawn forcibly backwards, 
 2dly, approximated towards the shoulder of the sound 
 side. Such was the practice of the Greek physici- 
 ans, whom we have seen in common with Hippocra- 
 tes, Celsus, and Paul of Egina, employing a kind of 
 bandage, varied in its form, according to the dis- 
 placement it was intended to remedy. 
 
 Above all others, we find an application of this 
 principle, in the figure of 8 bandage, a particular 
 form, vy^hich was employed in practice by Aibulasis, 
 
an Arabian, and afterwards by his countrymen, as 
 well as by Lanfranc, Guy of Chauliac, and their co- 
 temporaries. The use of this bandage was continued 
 by Pare and his successors, and has been lately 
 modified by several authors, such as Heister, Petit, 
 Brunninghausen, &c. 
 
 26. But under whatever form it shows itself, its 
 action is always the same, and always insufficient. 
 On comparing its effect with the general principle, 
 on which every apparatus for the clavicle should be 
 constructed (20), we percieve, that it by no means 
 answers the threefold indication, of retaining the 
 shoulder backward, outward, and upward. 
 
 27. In relation to carrying the shoulder backward 
 it loses half of its effect, because, its force being de- 
 composed (so to speak) by the obliquity of its di- 
 rection, is divided into two channels. One of these 
 runs parallel to the shoulder and acts to no purpose, 
 while the other, being perpendicular to it, is alone 
 effective ; hence it must act with a force equal to 10, 
 in order to produce an effect equal to 5. 
 
 28. The indication, to draw the humeral frag- 
 ment outward, far fi'om being fulfilled, is here diame- 
 trically counteracted. The scapula, being approxi- 
 mated to that of the opposite side, draws the hume- 
 ral fragment towards the trunk, making it underlap 
 the internal one, and, in this respect, the figure of 8 
 bandage acts posteriorly in precisely the same man- 
 ner, during the treatment, that the contractions of 
 the muscles did anteriorly before the reduction. 
 
 29. Should the shoulder be supported, at such an 
 elevation, as might have a constant tendency to de- 
 
25 
 
 stroy the influence of its own gravity? this is evi- 
 dently prevented by the very obUque direction of 
 the turns of the bandage. Suspending the arm in a 
 sling, is the only way, in which that end can be at- 
 tained. But does this mode always possess sufficient 
 firmness and stability? The arm, not being here suf- 
 ciently fixed, maybe constantly in motion, which, by 
 deranging its situation, must communicate very trou- 
 blesome and injurious movements to the fragments 
 of the clavicle. One of the principal faults of ail ban- 
 dages consists, in not preventing these movements, 
 by restraining the movements of the arm. 
 
 To the other disadvantages of this mode, need I 
 add that of its making, by the turns of the bandage, 
 an undue compression on the projecting edges of 
 the arm-pit, and producing thereon troublesome and 
 painful excoriations? 
 
 30. From the want of a mutual correspondence 
 and fitness between the indications already enume- 
 rated (20), and the manner in which the figure of 8 
 bandage acts, it is evident that the former can never 
 be satisfactorily fulfilled by the latter. Hence we 
 may judge, what improvement the art has received 
 from the iron cross of Heister, the compress of Pe- 
 tit, drawn transversely over the oblique turns of the 
 bandage, the waistcoat which Brasdor fastened round 
 the thorax of his patients, and the leathern apparatus, 
 lately proposed by a German practitioner. These 
 means, though diversified in their form, are similar 
 in their effect, and, being nothing but modifications 
 of the figure of 8 bandage, possess, like it, the radi- 
 cal fault of not offering a resistance directly opposed 
 
 5 
 
26 
 
 to the two- fold power, arising from the muscular 
 action and the gravitation of the shoulder. 
 
 As to what remains, it will be sufficient to show 
 the insufficiency of the process of reduction (22), by 
 means of the knee placed between the shoulders, in 
 order to demonstrate the existence of a like insuffi- 
 ciency in all those forms of apparatus, which, as 
 Brasdor remarks, have for their object a continuance, 
 during the treatment, of the effect produced by that 
 process. 
 
 31. On the other hand, those indications will be 
 fulfilled v/ith exactness, by such a form of apparatus 
 as will render permanent the action of the means of 
 reduction which were employed by Paul of Egina, 
 by certain Arabian physicians, and by Pare; w^hich 
 have been renewed by Desault, and tend to draw 
 the shoulder upward, backward, and outwai^d (23 
 and 24). 
 
 Pecceti appears, in the last century, to have had 
 a faint view of the proper indication on this subject, 
 when, under the article of fractures, he advises the 
 bail to be suffered to remain under the anii during 
 the treatment of the injury. But the figure of 8 ban- 
 dage, united to this expedient, counterbalances its 
 effect, rendering it of no avail, and Pecceti was 
 therefore no more successful than others, in obtain- 
 ing a cure of the fracture, unaccompanied by de- 
 formity. 
 
 32. An overlapping m.ore or less perceptible 
 never failed to accompany the consolidation or knit- 
 ting of the bone, and here, as in many other cases, 
 practitioners laboured to explain what they knew not 
 
27 
 
 how to prevent. The impracticability of surround- 
 ing the part, as in other fractures, with a circu- 
 lar bandage, appeared to Heister, Petit, and Duver- 
 ney, to be the cause of this deformity. They sup- 
 posed that to be a superabundant callus, which was 
 nothing but a displacement of the fragments. These 
 visionary hypotheses ceased to exist, as soon as this 
 displacement was prevented by a proper apparatus. 
 
 Desault sought for this form of apparatus, as well 
 as for his other bandages, in the multiplied applica- 
 tion of means already known, without inventing 
 new ones. Bandages and compresses, easy to be 
 procured, and already rendered familiar to surgeons 
 by daily use, served him for the construction of his 
 apparatus, for which several machines had been al- 
 ready proposed* 
 
 33. The pieces of which this apparatus is com- 
 posed, are, 
 
 1st, Thi-ee rollers, three inches broad; the two 
 first, six, and the other ^ight, ells long, each one 
 rolled up separately. 
 
 2dly. A bolster or pad (a, b. Fig, 1), made in the 
 form of a wedge, out of pieces of old linen. Its " 
 length should be equal to that of the humerus, its 
 breadth four or five inches, and its thickness at the 
 base (a), about thi^ee inches, 
 
 3dly, Two or three long compresses. 
 
 4thly. A small sling for the ai^m, (Fig. 5), 
 
 5thly, A piece of linen large enough to cover the 
 whole bandage. 
 
 Every thing being properly arranged, the follow- 
 ing is the mode of applying the apparatus, which of 
 itself reduces the fracture. 
 
28 
 
 34. The patient being placed in a standing posi- 
 tion, or, if his case render that impracticable, on a 
 seat without a back, an assistant elevates the arm of 
 the affected side, and supports it at nearly a right 
 angle with the body (Fig. 2), while the surgeon 
 places under the arm-pit the head of the bolster, 
 which descends along the side of the thorax, and 
 w^hich another assistant, situated at the patient's 
 sound side, holds by the two upper corners. 
 
 35. The surgeon now takes one of the first roll- 
 ers, applies the end of it on the middle of the bolster, 
 fixes it there by two circular turns round the body, 
 and passes a turn obliquely (a a) along the fore part 
 of the thorax, ascending to the sound shoulder: the 
 roller then descends behind, passes under the arm, 
 and returning in front of the thorax, makes a circu- 
 lar turn and a half, horizontally. Having reached 
 the hind part of the thorax, it reascends obliquely by 
 the cast (b), as it had done before, and passes over, 
 before, and under, the sound shoulder ; having thus 
 crossed the turn (a a), the roller again passes across 
 the hind part of the thorax, and finishes by circular 
 turns, which completely cover the bolster. A pin is 
 now to be fixed in the place of crossing of the roller 
 on the sound shoulder, to prevent the turn (a) fi-om 
 slipping downward. 
 
 The application of this first roller is intended for 
 no other purpose, than firmly to fix the bolster which 
 is held up by the tvvo oblique turns before and be- 
 hind, and secured against the body, by the subse- 
 quent circular turns. 
 
 36. The bolster being fixed, the surgeon apply- 
 ing one hand to its external surface, pushes it up- 
 
29 
 
 wards, and, with the other, taking hold of the elbow, 
 after having half-bent the fore arm, lowers the arm, 
 till it is laid along the bolster. He then presses its 
 lower extremity forcibly against the side of the tho- 
 rax, pushing it upwards at the same time, and direct- 
 ing its upper extremity a little backwards. 
 
 The application of the bandage constitutes a part 
 of the process of reduction. The humerus, now con- 
 verted into a lever of the first kind, is di'awn at its 
 upper end from the shoulder, in proportion as its 
 lower end, is approximated to the thorax ► The 
 scapulary fi-agment being drawn along with it, and 
 directed at the same time upward and backwai'd, 
 comes into contact with the sternal fragment, and in 
 an instant the deformity of the part disappeai's. 
 
 37. The arm being thus situated, is given in 
 charge to an assistant, who retains it in the same po'- 
 sition in which he received it from the surgeon, by 
 pressing on it with one hand, and with the other 
 supporting the fore arm half bent, and placed hori- 
 zontally across the breast. 
 
 The second roller is next to be applied. The 
 end of this is carried under the arm-pit of the sound 
 side. It is then brought across the breast, over the 
 superior part of the diseased arm, and extends across 
 the thorax behind till it passes under the arm-pit„ 
 Two circular turns cover the first. The roller must 
 then ascend to the lower part of the shoulder, by 
 oblique turns (c. c. Fig. 3), each of v/hich must be^ 
 overlapped by the succeeding one, to the extent of 
 about the third part of its breadth. It is necessary 
 that these turns be applied in such a way,, as to bind 
 
30 
 
 but very gently above, and to increase in tightness, 
 as they descend neai'er to the lower extremity of the 
 humerus. 
 
 The use of this second roller is, to supply the 
 place of the hand of the assistant, in pressing the 
 ai'm against the side of the thorax ; its effect evidently 
 is to draw the upper extremity of the arm outw^ards, 
 and, as it is already directed backwards, to retain it 
 in that position. The compression of the circular 
 turns on the arm, being thus gradually augmented, 
 becomes, on the one hand, more efficacious, because 
 it acts on a greater surface, and on the other, less trou- 
 blesome, because, being more divided, it is less felt 
 at the lower exti'emity of the arm, where it bears 
 with most force. 
 
 38. A third indication remains still to be fulfilled, 
 namely, to retain the shoulder in its elevated position, 
 and, by that means, to assist in the extension of the 
 fragments, which already has some effect in prevent- 
 ing a depression. 
 
 To fulfil this indication, an assistant sustains the 
 elbow in its elevated position, with one hand, and, 
 with the other, supports the patient's hand before his 
 tareast, while the surgeon fills with lint the hollow 
 spaces around the clavicle. He then applies on the cla- 
 vicle, at the place where it is fractured, the two long 
 compresses, wet vv'ith vegeto-mineral water, or some 
 other cooling liquid. Taking novf the last roller, he 
 fixes the end of it under the sound shoulder; from 
 thence he brings it obliquely across the breast, over 
 the long compresses^ and carries it down behind the 
 shoulder along the posterior part of the arm, till it 
 
•passes under the elbow. From this point, he again 
 carries it obliquely upwards across the breast to the 
 arm-pit, then across the back, over the compresses, 
 and brings it down again before the shoulder, along 
 the front of the humerus till it again reaches the el- 
 bow. From thence the roller again ascends oblique- 
 ly behind the thorax, passing under the arm-pit, 
 where the first cast of the roller is covered, and from 
 whence it again starts, to run the same course we 
 have just described. This constitutes a second 
 round, which covers in pait the first, and forms a 
 kind of double triangle (e, f, d), situated before the 
 breast, and over the circular turns of the other rollers 
 (c. c. Fig. 4). The remaining part of the roller, 
 brought from behind forward, is employed in circular 
 turns over the arm, and round the thorax, for the 
 purpose of preventing the displacement of the first 
 part. To make it the more secure, it is fastened with 
 pins at its different places of crossing. 
 
 The sling (Fig. 4) is next passed under the hand, 
 and fastened above to the ascending turns (d), and 
 not to the circular (c c), which the weight of the 
 hand would be likely to draw downward. 
 
 39. It is only necessary to examine the course of 
 this third roller, to see, that, united to the sling, it is 
 well calculated to support the external fragment, 
 which the weight of the shoulder has a tendency to 
 depress, on a level with the internal one. It supplies 
 the place of the assistant, who raises the elbow and 
 supports the hand of the patient, in like manner as 
 the second roller performs the office of the assistant, 
 who presses the lower part of the humerus against 
 the side of the thorax. 
 
32 
 
 On the other hand, the circular turns, by which 
 the apphcation of the third roller is finished, being 
 du'ected from before backward, push in the same 
 direction the arm and shoulder, wiiich have been 
 already carried that way, by the process of reduction, 
 and thus retain them in their proper places. 
 
 Hence may be infened the truth of the proposi- 
 tion, which we have been endeavouring to demon- 
 strate; namely, that the bandage of Desault, con- 
 structed according to the general principle formerly 
 established (20), for fractures of the body of the cla- 
 vicle, is calculated to retain the external extremity 
 of the humeral fragment upw^ard, outward, and back- 
 ward, 
 
 40. The casts of the rollers, thus surrounding the 
 thorax, however v/ell they may be secured, are yet 
 liable to be displaced, particularly when the patient 
 is ini)ed. This inconvenience may be avoided, by 
 suiTounding the whole with a piece of linen, leaving 
 nothing uncovered, but the sound arm, which is at 
 liberty to perform its usual motions. 
 
 The arm of the diseased side, being thus fixed in 
 such a manner, as to constitute a whole or entire 
 body with the thorax, follows its movements, with- 
 out producing any displacement. It is thus, that by 
 the apparatus for a continued extension of the thigh, 
 the fragments of the os femoris, forming an immove- 
 able whole w^ith the pelvis, cannot change their situ- 
 ation, even in following the motions of the trunk. 
 
 Hence arises, in fractures of the clavicle, this ad- 
 vantage, that the patient is not obliged to keep his 
 bed, but is able even to attend to his business, during 
 ihQ progress of the cure. 
 \ 
 
53 
 
 41. I will not dwell on the numerous objections 
 urged by different authors against the bandage which 
 has just been described. What answer, indeed, can 
 be given to those winters, who fancy that they behold 
 the patient in the greatest danger of immediate suffo- 
 cation; who dread an approaching mortification of 
 the arm of the diseased side; who allege, contrary 
 to the rules of the art, that there is no impression 
 made immediately on the clavicle, but on a neigh- 
 bouring bone ; who, &c. &c. ? Twenty times in a 
 year, has experience ansv/ered those objections, in 
 the Hotel-Dieu ; and there is not a pupil of Desault, 
 who has not, as well in this, as in many other cases, 
 seen that objections, plausible, indeed, when consi- 
 dered in the closet, or at a distance from a sick room, 
 dwindle to nothing at the bed-side of the patient. 
 
 42. In those cases (which, as Hippocrates remarks, 
 very rarely occur) where the external fragment pro- 
 jects over the internal one (12), the bandage must 
 be somewhat varied, although the two principal indi- 
 cations, of drawing the shoulder backward and out- 
 ward, must still, as in other cases, be fulfilled. The 
 only additional circumstance, therefore, necessary to 
 be attended to here, is, not to elevate the shoulder, by 
 pushing it upwards. This may be easily avoided, 
 1st, by omitting to raise the elbow, when applying 
 the bandage ; 2dly , by drawing the third roller a little 
 tighter than usual.* 
 
 * This paragraph is so obscure in the original, that a trans- 
 lation of it would be scarcely intelligible. Instead of a mere 
 translation, therefore, I have given rather a comment on what 
 I believe to be its true meaning. Traxs. 
 
34 
 
 The fragments, being reduced to the same level, 
 and brought into apposition, by this two-fold atten^ 
 tion, will unite as in ordinary cases. 
 
 If the fracture exist at the end of the clavicle next 
 to the humems, the difficulty of their being displaced 
 renders the application of the bandage less necessary. 
 Prudence, however, demands that it be not altogether 
 neglected. 
 
 § VIII. 
 
 6f tee treatment during the formation 
 of the callus. 
 
 The regimen to be pursued during the reunion of 
 the clavicle, varies according to circumstances. It is 
 impracticable to lay down general rules, applicable to 
 all affections of this kind. Here, however, much 
 more than in other cases, if the division of the bone be 
 simple, and no imfortunate accident occur, it is al- 
 ways unnecessai-y to resti^ain the patient from his 
 usual course of life, beyond the second or third day. 
 But, though internal means are for the most part 
 omitted in the treatment, the apparatus is a subject on 
 which too much attention cannot be bestowed. With 
 whatever degree of exactness it may be at first ap- 
 plied, it will soon become loose, and oppose a dimi- 
 nished resistance to the v/eight of the shoulder, and 
 the action of the muscles. Hence, unless it be fre- 
 quently examined, the fragments will be displaced. 
 The following case furnishes a detail of the treatment 
 subsequent to the reduction, to which, in ordinary 
 cases, Desault had recourse. 
 
55 
 
 Case III. Mary Adel, aged thirty, as she was 
 crossing a path covered with ice, in the severe win- 
 ter of 1788, fell on the point of her left shoulder, and 
 fractured the clavicle about the middle. Being 
 brought to the Hotel-Dieu a few hours after the acci- 
 dent, she was dressed in the manner just described, 
 and, as the fracture was sinaple, it was judged suffi- 
 cient to make a slight diminution in the quantity of 
 her aliment, during the two or three first days. The 
 dressing was moistened every morning, with vegeto- 
 mineral water, at the place corresponding to the frac- 
 ture. 
 
 On the fourth day the piece of linen that surroun- 
 ded the bandage was removed, for the purpose of 
 examining the state of the parts. Every thing was 
 found in its proper situation, and the covering was 
 replaced till the seventh day, when the rollers appear- 
 ed to be somewhat relaxed. The apparatus was 
 taken off, and reapplied as at first, the compresses 
 being carefully moistened with vegeto-mineral water, 
 at the part lying over the fracture. After the third 
 day the patient was permitted to return to her usual 
 regimen. The third roller being a little deranged 
 on tlie tenth day, it was taken off, and reapplied as 
 at first, together with the sling. The fragments were 
 examined and found in pei'fect contact. The patient 
 was up during the whole day, walked about the 
 house, and experienced no other inconvenience than 
 that of not being able to use the left arm. 
 
 On the thirteenth day, the bandage was again re- 
 applied, and allowed to remain till the sixteenth, when 
 the patient having disturbed it, it was once more 
 
36 
 
 changed. At this period, the fi-agments, already firm- 
 ly united, exhibited scai'cely a vestige of the division 
 they had sustained. 
 
 The reunion was complete by the twentieth day, 
 when ail the pieces of apparatus were dispensed with, 
 except the bolster and the &ccuud luUer, which were 
 also removed two days afterwards, as tliey were found 
 to be no longer necessary. 
 
 The continued inactivity of the limb, during the 
 treatment, had occasioned a stiffness in the shoulder. 
 This was gradually done away by making the patient 
 move her arm in all dii'ections, twice a day, each 
 time, for the space of an hour. 
 
 On the twenty-ninth day she left the hospital, 
 carrying v/ith her nothing to remind her of the injury 
 she had sustained. She was free from that uneasiness 
 which is the consequence of a tedious and ill-mana- 
 ged treatment, during which the exercise of the limb 
 , has be^ neglected. 
 
 § IX. 
 
 OF COMPLICATIONS. 
 
 .. 44. We are in possession of but few observations 
 particularly relative to the different complications, 
 that may accompany fi^actures of the clavicle. The 
 treatment, in such cases, varied according to circum- 
 stances, must be accommodated to the mdications 
 common to all fractures of this kind. 
 
 When splinters, displaced in different directions, 
 whether adhering to the bone or not, irritate the soft 
 parts, and, having passed through the integuments, 
 
37 
 
 appear without, most practitioners advise to remove 
 them and cut ofF such parts as project beyond the 
 fractured end of the bone, previously to reduction. 
 This direction is founded on the severe pains which, 
 in such cases, accompany the common treatment of 
 the injury, and which the figure of 8 bandage always 
 augments, by drawing the shoulder inward, and con- 
 sequently pressing the soft parts against the project- 
 ing parts of the fi^agment, or the points of the splinters. 
 But if the splinters, adhering as yet to each other and to 
 the bone, by means of tlie periosteum, have not assum- 
 ed the nature of foreign bodies, (that is, if they be not 
 actually dead) it is always proper to replace them. It 
 is here only that we meet wdth an occasion for that 
 part of the process, of reduction denominated con- 
 formation,^- which is never requisite in other cases. 
 
 A fragment which has penetrated the soft parts, 
 but has not been long exposed to the air, disappears, 
 and is replaced by extension, provided it be properly 
 directed. Being retained afterwards in a state of con- 
 stant extension, it can neither be displaced, nor cause 
 pain by irritating the parts, which is the inevitable 
 result of the figure of 8 bandage. 
 
 * That process or operation in which the surgeon uses his 
 hands to effect the reduction and apposition of parts, which 
 cannot be accomplished by extension and counter-extension 
 alone. If a bone be broken into two or three pieces, mere 
 extension and counter-extension will not bring all the frag^ 
 ments into their proper places, so as to restore the natural 
 form of the part. In such cases, the surgeon uses his hands to 
 aid the action of the extended muscles, and this is the process 
 which our author denominates conformation. The term occurs 
 in many places in the course of the work. Trans., 
 
In cases of tliit^ kind, it is useful to protect the 
 shoulder with a small splint, which may support the 
 turns of the bandage, and prevent their pressure on 
 the splinters, or the broken ends, which they might 
 otherwise disturb. These precautions are alike indis- 
 pensable when the fracture is double. 
 
 Case IV. Francis Ricord, twenty ^five years of 
 age, was received in the month of July, 1790, into the 
 Hotel-Dieu of Paris. On the preceding day, a piece 
 of timber having fallen from a considerable height on 
 his right shoulder, had broken the clavicle of that 
 side into several pieces. Severe pains, which occur- 
 red at the moment of the accident, had continued 
 throughout the night, and were still sensibly felt. The 
 slightest motion of the part augmented them to such 
 a degree, as to extort from the patient piercing cries. 
 
 The point of the shoulder being very much de- 
 pressed, was also drawn perceptibly forward and in- 
 ward; and a large echymosis, without any external 
 wound, occupied its whole extent. 
 
 Desault being satisfied that the several fragments 
 were all connected together, and that none of them 
 was separated from the periosteum, placed, as in or- 
 dinary cases, the bolster under the arm, completed 
 the reduction, and applied a splint along the course 
 of the clavicle, after having, with his hands, brought 
 the fractured pieces into contact. Confident, then, 
 that the form of the part was perfectly restored, he 
 applied the bandage, which was moistened with 
 vegeto-mineral water, twice or thi'ice a day. 
 
 At the moment of reduction the pains ceased, and 
 were felt no more till the fifth day, when the bandage 
 
39 
 
 being a little relaxed, admitted of a slight displace- 
 ment of the fragments. This displacement was remo- 
 ved, and the pains along with it, by the reapplication 
 of the apparatus. 
 
 During the six first days a very strict diet was 
 enjoined. This, however, was dispensed with by 
 degrees, till, on the thirteenth day, the patient re- 
 turned to his usual regimen. On the seventeenth 
 day, there remained nothing of the echymosis, but a 
 yellow tinge, the customary consequence, of such an 
 accident. The precautions inculcated in the preced- 
 ing case, were employed also in this, and the patient 
 was discharged perfectly cured, on the forty-second 
 day from the time of his admission. Nor had he 
 experienced, during his treatment, those severe and 
 long continued pains, which, under a different ma- 
 nagement, so frequently accompany this kind of frac- 
 tui'e. 
 
 EXPLANATION OP THE FIRST PLATE. 
 
 Fig. 1. A bolster made in the form of a wedge, in- 
 tended to be placed between the arm and the side 
 of the thorax. 
 
 a. Its base, which should fif the hollow of the arm-pit. 
 
 b. Its summit reversed, against which the elbow is to 
 
 be applied. 
 Fig. 2. The first roller applied for the purpose of 
 
 fixing the bolster against the side of the thorax. 
 a a. Oblique casts before, passing over the opposite 
 
 shoulder, in order to hold it up. 
 b. Oblique casts from behind, crossing the first ones 
 
 on the shoulder. 
 
40 
 
 d d. Circular casts round the trunk, covering the bol- 
 ster, which they fix laterally. 
 Fig. 3. The second roller, applied to fix tlie arm 
 
 against the bolster. 
 a^ b. Portions of the oblique casts of the first roller, 
 
 left uncovered by this one. 
 c c. Turns of the second roller, covering those of the 
 first, loose above, and tighter beioAv, for the pur- 
 pose of dj'awing the superior extremity of the 
 humerus outwards. 
 d. Their passage over the side opposite to the bolster. 
 Fig. 4. The third roller intended to keep the point of 
 
 the shoulder raised. 
 a a^b. Oblique casts of the first roller, remaining 
 
 uncovered. 
 c c. Turns of the second, seen through the opening 
 
 of those of the third. 
 d. Oblique casts of the tliird, ascending fi-om the arm- 
 pit over the shoulder of the diseased side, to de- 
 scend again behind, along the arm, and pass under 
 the elbow. 
 f k. A continuation of the preceding casts, reascend- 
 ing under the sound ami-pit, and from thence 
 behind the thorax, over the diseased shoulder. 
 c. A continuation of the same casts, descending on 
 the fore side of the arm, passing under the elbow, 
 and ascending again under tlie aim-pit of the 
 sound side. 
 g. The remainder of the roller, intended to be em- 
 ployed in circular turns, in order to secure the 
 casts (f , and prevent them from slipping outward. 
 Fig*. 5. A sling vv^hich should be fastened to the ob- 
 lique cast d (Fig. 4), to support the hand. 
 
//. t 
 
 jSnifravi by'W.Knr.afs. 
 
41 
 MEMOIR III. 
 
 ON THE LUXATION OF THE CLAVICLE, 
 
 1. The clavicle, which forms a moveable abut- 
 ment for the shoulder, and receives and sets bounds to 
 most of the movements of that part, and of the arm, 
 exhibits at its extremities, two articulations, essen- 
 tially different from each other in their form, dispo- 
 sitions, and uses. These differences give rise to dif- 
 ferences equally essential with regard to the disloca- 
 tions to which they are subject. 
 
 2. On the sternal extremity, a small surface, con- 
 vex from above downwai'ds, and concave fi'om before 
 backwards, is fitted, by means of an intervening car- 
 tilage, to a much smaller surface of the sternum, 
 concave and convex in opposite directions. 
 
 One capsule, two ligaments, viz. the interclavi- 
 cular and costo- clavicular ligaments,* and the ante- 
 rior portion of the sterno-cleido-mastoideus muscle, 
 sti'engthen the connexion of these two surfaces, and 
 tend, on one hand, to prevent their luxation, while, 
 on the other, this luxation is favoured and facilitated 
 by the following circumstances : 1st, the dispropor- 
 tion between the dimensions of the two articulating 
 
 * I find in English books of anatomy no appi'opriate names 
 for these two ligaments. I am therefore obliged to translate 
 the French terms for them literally. The anatomist will have 
 no difficulty in, recollecting their situation. Trans. 
 
 7 
 
42 
 
 surfaces; 2dly, the mobility of the joint; and Sdly, 
 by this j oint's constituting a kind of centre for the 
 motions of the arm. 
 
 3. On the humeral side, an elliptical surface, 
 slightly convex, and inchned downwards, is imme- 
 diately joined to a corresponding surface of the acro- 
 mion, elliptical also, a little concave and directed 
 upwards. Hence two kinds of inclined plains, which 
 would be very liable to dislocations, by sliding easily 
 over each other, were they not firmly secured by a 
 capsule, by accessory fibres, by the intersection of 
 those of the deltoid and trapezius muscles, and, 
 above all, by two ligaments, the rhomboid and the 
 conoid.* 
 
 Having laid down these preliminary considera- 
 tions, let us proceed to examine, in particular, each 
 kind of luxation to which the clavicle is subject. 
 
 LUXATION OF THE STERNAL EXTRE- 
 MITY. 
 
 II. 
 
 OF THE CAUSES AND DIFFERENT KINDS OF 
 DISPLACEMENT. 
 
 4. The sternal articulation of the clavicle expe- 
 riences different changes, according to the different 
 movements of this bone. If these movements be in 
 a backward direction, the articulating surface is 
 
 * I do not recollect any terms in English works of ana- 
 tomy equivalent to these, Tran^ 
 
43 
 
 turned forward, straining the anterior part of the cap- 
 sule, the corresponding ligament, and the extremity 
 of the stemo-cleido-mastoideus muscle. If, on the 
 other hand, they be in a forward direction, the poste- 
 rior ligament, and the adjacent portion of the capsule 
 are overstretched. In motions directed upwai^ds, the 
 costo- clavicular ligament, and the external and infe- 
 rior part of the capsule, and in those directed down- 
 wards, the inter- clavicular ligament, and the internal 
 portion of the capsule, experience a similar degree of 
 tension. 
 
 5. Hence it follows, 1st. That the natural move- 
 ments of the shoulder may be regarded as predispo- 
 sing causes of luxation, because at the part where 
 tension is excessive, the ligaments are disposed to 
 give way, and suffer the sternal extremity to escape : 
 2dly. That the efficient causes will be, all external 
 forces acting on the clavicle in such a way as to in- 
 crease its motions beyond their natural degree, and 
 beyond the resistance which the ligaments are capa- 
 ble of making. Thus a fall on the point of the shoul- 
 der, forcing it suddenly backward and inward, pro- 
 duces a luxation forward. But, in general, as the 
 strength of the articular ligaments is superior to the 
 resistance of the clavicle itself, a fracture takes place 
 more frequently than a luxation, in the proportion of 
 nearly six to one. 
 
 Though falls on the point of the shoulder are of- 
 tentimes productive of luxation of the clavicle, they 
 are not the exclusive causes of that accident. De- 
 sault has seen the sternal extremity forced from 
 its cavity by the knee being pushed violently against 
 
44 
 
 the middle of the back, while the shoulders Were 
 dra^vn at the same time backwards. 
 
 Case I. A porter dislocated his clavicle in the 
 following manner. He was carrying a very heavy bur- 
 den, suspended from his shoulders by cords that, 
 passed under each arm-pit. Being desirous of resting 
 himself by the way, he placed on a block the burden 
 he carried, which slipping backward, drew his shoul- . 
 ders in the same direction, and at the instant of his 
 attempting to retain it and prevent it from falling, 
 produced a luxation of the clavicle. 
 
 7. It follows from what has been said respecting 
 the different states of the articulation, during its vari- 
 ous motions (4), that the clavicle is not equally liable 
 to be luxated in every direction. Inclining naturally 
 backward, but a very slight degree of motion in that 
 direction is necessaiy, to effect a luxation forward. 
 To produce a luxation backward or inward, it is ne- 
 cessary, on the other hand, that the humeral extre- 
 mity of the bone should make a sweep at least three 
 times the extent of that requu'ed in the preceding 
 case. Besides, motions in this direction are accompa- 
 nied with pain, particularly if they be made by force. 
 Luxation downwai^d is prevented, on the one hand, 
 by the cartilage of the first rib, which presents to the 
 bone an insurmountable barrier. On the other hand, 
 to produce this kind of luxation, it would be neces- 
 sary for the external extremity of the clavicle to be 
 forced upwards, an occurrence very seldom occa- 
 sioned by falls. Luxation upward, or over the supe- 
 rior edge of the sternum, must be the effect of a 
 stroke, which, by depressing the point of the shoul- 
 
45 
 
 der, and forcing it at the same time forward, presses 
 the sternal extremity against the internal and superior 
 part of the capsule, which, being thus lacerated, suf- 
 fers a luxation to take place. But such a derangement 
 of the articulating surfaces is very rarely produced 
 by falls. Whence it follows, that of the different kinds 
 of luxation of the clavicle, that in a downward direc- 
 tion is altogether impracticable. Those backward 
 and upward, though possible, occur but rarely in 
 practice ; while that in a forwai'd direction, on the 
 contrary, is not an unfrequent accident. This tends 
 to confirm the observations of practitioners, and par- , 
 ticularly of Desault, whose immense collection on 
 the subject furnishes examples of the last kind of 
 luxation only. 
 
 8. In these luxations, there is for the most part, a 
 rupture of the capsular ligament, and an escape of the 
 bone through the opening. But sometimes the liga- 
 ment is only preteniaturally distended, and then the 
 luxation is incomplete. 
 
 §111. 
 
 OF THE SIGNS. 
 
 9. Bu T whatever may be the causes or kind of the 
 luxation, its diagnosis is always easy. If it be forward, 
 the direction of the stroke which the shoulder has 
 received, furnishes, at first, some ground of suspicion. 
 The accident is certainly known by the appearance of 
 a hai'd and unnatural protuberance in front of the ster- 
 num, and behind the extremity of the sterno-cleido- 
 mastoideus muscle, by the existence of a sensible de- 
 
 I 
 
46 
 
 pression or hollow at the joint, and by the situation of 
 the shoulder, which is pushed further backward, and 
 is less projecting and more approximated to the trunk, 
 than ill its natural state. Add to these, a difficulty in- 
 p'erforming motions in a forward direction, which, 
 when somewhat forced, reduce, in proportion as they 
 areacGomplished, the size of the protuberance formed 
 bly the displaced end. The head is always inclined 
 towards the side where the luxation exists; an atti- 
 tude which relieves the painful drawing or tension 
 produced in the sterno-mastoideus muscle, by the 
 humeral extremity pushing it forward. 
 
 10. A protuberance over the superior edge of the 
 sternum, a difficulty in raising the shoulder, the pain 
 which results from attempting such a motion, the di- 
 minution of the protuberance which it occasions, the 
 absence of the sternal extremity from its natural cavity, 
 the approximation of the shoulder to the thorax, and 
 its depression and diminished projection, compared 
 to its usual state, affi^rd evidence of a luxation up- 
 wards. 
 
 11. A luxation inward or backward, would be 
 characterized by a projection of the shoulder exterior- 
 ly, by a difficulty in performing motions in a back- 
 ward direction, by the alarming effects, which, as Petit 
 remarks, the compression of the trachea would doubt- 
 less produce, and by a depression or hollow at the 
 joint, more perceptible here than in the two preceding 
 cases. 
 
 12. These appearances will be more or less stri- 
 king, accordingly as the membranes, lacerated or only 
 distended, offer a greater or less resistance. 
 
• ■ §rv- 
 
 OF THE REDUCTION. 
 
 13. To reduce a luxation, is, in general, to mak© 
 the bone re-enter its cavity, by retracing, or retmiiing 
 along, the same route which it followed in escaping 
 from it. Now, in a forward luxation, the displace- 
 ment is from behind forward, in an upward one from 
 below upward, in an inward or backwaad one fron?. 
 before backwai'd, but, in each of the three, it is more 
 particularly from without inward. In the first case, 
 therefore it is backward, in the second, forward, in 
 the third downward, but, in each of the three, more 
 particularly outward, that the powers for producing 
 extension must be directed. 
 
 14. Hence the method generally employed by 
 most practitioners, recommended by almost every 
 author who has written on the subject, adopted by 
 Petit, Duvemey, Heister, &c. and which consists in 
 placing the knee between the shoulders of the patient, 
 as a point of resistance, by the aid of which the shoul- 
 ders may be drawn backward, fulfils only half of the 
 indication of cure ; because at the time that the hu- 
 meral extremity is drawn backward, it is not directed 
 sufficiently outward. 
 
 Hence a difficulty of replacing the bone sometimes 
 occurs, a difficulty always removed, when, pursuant 
 to the method employed by Desault in fractures of 
 the clavicle (see Desault's method), the arm is 
 made to serve as a lever of the first kind, to carry 
 backward and outward, the head of the bone, which 
 is displaced in the opposite directions, when the lux^ 
 
48 
 
 ation is forwai'd. This method possesses the advan^ 
 tage, not only of giving the powers of extension a 
 proper direction, but also of increasing them to a 
 degree even beyond what is necessary for effecting a 
 reduction, by removing them further from the resist- 
 ing force. Hence it is unnecessary to adopt any par- 
 ticular measures for restoring and preserving the form 
 of the part, as the extension is alone sufficient for that 
 purpose. 
 
 These principles, evidently applicable in effecting 
 a reduction, are still more strikingly so in the means 
 destined for retaining it. Let us apply what I have 
 just said, to a case of dislocation in a forward direc- 
 tion. It will be easy to transfer it afterwards to the 
 other kinds of luxation. 
 
 §V. 
 
 OF THE MEANS OF RETAINING A REDUCTION. 
 
 15. Few luxations are so speedily reduced, but 
 few are more easily displaced again, than that of the 
 clavicle. This disposition is the reverse of that of 
 most other luxations, which are reduced indeed with 
 difficulty, but seldom afterwards suffer a displace- 
 ment. The cause of this we find, 1st, in the extreme 
 mobility of the clavicle, to which all the motions of 
 the arm are communicated; 2dly, in this further con- 
 sideration, that most of the muscles, which have their 
 insertion towards the shoulder, tend to di'aw this bone 
 inward, when the ligaments, in consequence of being 
 either broken or distended, as happens in this accident, 
 do not offer a sufficient rosistance. 
 
49 
 
 16. From this two-fold cause of displacement, 
 arises a two-fold indication in the arrangement and 
 application of the apparatus. These are, 1st, to ren- 
 der the clavicle immoveable, by restraining every 
 kind of motion in the shoulder and arm; 2dly, to 
 retain the extremity of the clavicle outward, a direc- 
 tion opposed to that in which it has a tendency to be 
 displaced. But if to those indications we compare 
 the forms of apparatus hitherto used, we will readily 
 perceive that they are insufficient to fulfil them. 
 
 17. The figure of 8 bandage, so generally in use, 
 and all the various modifications, under which it has 
 been revived, without being improved, fix the clavi- 
 cle in the very direction most favourable to a dis- 
 placement, and even do it in the very maimer in which 
 that accident is sometimes brought about; as maybe 
 seen in the history of the case of the porter (6). This 
 bandage does not, under any of its modifications, 
 prevent the motions of the shoulder, because it does 
 not restrain those of the arm, which remains free and 
 unencumbered. Far from constituting an antagonist 
 power to, it even co-operates with, that which has 
 produced the displacement. ( For further light on this 
 subject, see what has been already said on the fracture? 
 of the clavicle, pages 22 and 25.) 
 
 Bell, in condemning the figure of 8 bandage, not 
 so much because of its action being insufficient, as 
 because of its obstructing respiration, proposes, as a 
 substitute for it, a kind of machine analogous to the 
 iron cross of Heister, which, being fixed by straps 
 passing under the ai'm-pit, and round the neck and 
 body, is intended to retain the parts firm antl immove- 
 
50 
 
 able. But the motions of the arm not being restrain- 
 ed, nor the action of the muscles of the shoulder op- 
 posed by an antagonizing power, places this piece of 
 apparatus in the same class with those, which, from 
 not being devised and constracted on a proper view 
 and conception of the causes of displacement, have 
 no affinity to rational practice. 
 
 18. The apparatus for a continued extension, in- 
 vented by Desault, for fractures of the clavicle, fulfil 
 here all those indications in which the others fail. 
 
 By this, 1st. The arm, being firmly fixed against 
 the side, by means of the roller [c c Fig. 3), can com- 
 municate no motion either to the shoulder, or the 
 clavicle. 2dly. The shoulder itself, being forcibly 
 drawn outward, with the upper extremity of the 
 humerus, by the action of the kind of lever into which 
 this bone is converted, and to which the bolster {ab 
 Fig. 1 ) serves as a fulcrum, cannot, by its move- 
 ments, derange the luxated bone. 3dly. The sternal 
 extremity, being drawn both by the muscles which 
 tend to displace it inwardly, and by the bandage 
 which acts on it in an opposite direction, remains 
 fixed between those two antagonizing forces, which 
 thus destroy each other. Hence the apparatus of 
 Desault, when accurately applied, offers to both of 
 these powers of displacement, a resistance perfectly 
 calculated to com.bat them. 
 
 20. We must, however, admit that this apparatus 
 partakes of one inconvenience, common indeed to all 
 bandages, but which is perhaps more particularly ap- 
 plicable to this in consequence of the numerous casts 
 of the rollers that form it, namely, the great facility 
 
51 
 
 with which it becomes relaxed. Hence one cause of 
 displacement, which the most exact and sciTipulous 
 attention caimot at all times prevent. 
 
 Case. Desault had, for a long time, the care of 
 a patient, whose luxation, having been neglected for 
 four days, was reduced on the fifth, by a surgeon, 
 who, for the purpose of retaining it, employed a ban- 
 dage of a particular kind. An hour afterwards, a 
 miotion of the shoulder backward, displaced the 
 luxated extremity : a new reduction was the conse- 
 quence ; on the day following, another displacement, 
 and so on in succession, for ten days, at the expira- 
 tion of which, Desault being consulted, applied to 
 the part the bandage formerly described. 
 
 On being examined the next day, the apparatus 
 M^as found in a favourable state. On the day follow- 
 ing, a slight displacement rendered necessary a new 
 application of the bandage, which, this time, conti- 
 nued longer than before. But, about the expiration of 
 the third day, the projection of the bone was again 
 considerable. Finally, the patient recovered, with a 
 very perceptible protuberance in front of the sternum, 
 and a difficulty of motion, great at first, but less after- 
 wards, and which exercise succeeded ultimately in 
 removin.^. 
 
 21* The application of the apparatus differs fi-om 
 that intended for a fracture of the clavicle, only in 
 this, that it is of service to place on the luxated ex- 
 tremity, graduated compresses,* calculated to make 
 
 * Compresses laid one upon another, of which the upper 
 one is still the smallest, not in relation to thickness, but as far 
 as regards length and breadth, Trans. 
 
B2 
 
 pressure backward and outv/ard, and which are to be 
 secured by the turns of the roller (b Fig. 4. ) 
 
 A second precaution, not less essential, is, to 
 push the humeral extremity of the clavicle, a little 
 forward, and fix it in that direction, in order that the 
 sternal being directed backward, may be removed 
 fi-om the place* through which it has a tendency to 
 escape. 
 
 22. Desault almost always obtained complete 
 success by this process, and by the most accurate 
 attention to prevent the relaxation of the bandage. 
 In the mean time, a stiffness, more or less conside- 
 rable, alwa}^s remains in the joint for a long time af- 
 ter the reduction, and it is not unfrequently a month 
 or two before the part recovers its usual facility of 
 motion. 
 
 The following cases, collected by Brochier, con- 
 firm the doctrine for which I have been contending. 
 
 Case II. A man luxated the clavicle by falling 
 on the point of his shoulder, and forcing it back- 
 wai'd. He was immediately brought to the Hotel- 
 Dieu, where Desault demonstrated to his pupils, 
 that the head of the bone, can'ied in fi'ont of the ster- 
 num., vv^as removed nearly an inch from its natural 
 cavit}^, the ligaments of which were no doubt lace- 
 rated. 
 
 Here, as in the fracture of the clavicle, the appli- 
 cation of the bandage answered the purpose of re- 
 duction, and removed the protuberance formed by 
 the extremity of the bone. 
 
 * The rupture in the capsule that surrounds the joint. T. 
 
53 
 
 The patient, being strong and vigorous, and hav- 
 ing received besides a violent contusion, was bied 
 twice, and confined to a low diet. On the following 
 day, no derangement ; on the fourth day, a sliglit 
 displacement of the bone, the rollers a little relaxed, 
 bandage applied anevf . Eighth day, no sensible dis- 
 placement. Eleventh day, some swelling around the 
 joint ; compresses, wet with vege to- mineral water, 
 ordered to be frequently renewed. Twentieth day, 
 the swelling almost gone, and no disposition to a 
 displacement ; the apparatus was removed ; motions 
 at first difiicult, and contracted. Tv/enty-ninth day, 
 more free and easy. Thirty-fourth day, returned to 
 their natural state. 
 
 Case III. Mary Rivert luxated her clavicle, on 
 the seventh day of January 1789. Being brought 
 some time afterwards, to the Hotel-Dieu, she was 
 treated in the same manner as the foregoing patient, 
 and with the same result, except that a very slight 
 protuberance remained at the extremity of the bone, 
 and the confined state of the motions continued a 
 little longer. Desault related, in his lectures, other 
 instances of cures being performed without the least 
 remaining deformity. 
 
 After all, even supposing the method just propo- 
 sed, to possess no other advantage, than that of di- 
 minishing the protuberance of the bone, winch, un- 
 der other modes of treatment, is almost inevitable, 
 and by that means preventing the motions of the part 
 from being confined, it would still, v/ithout doubt, 
 be a great step towards the perfection of the art'. 
 
54 
 
 23. Should a luxation backwards occur, the skme 
 process of reduction should be adopted, with this dif- 
 ference, that the extension ought to be made forward 
 and outward; and the same apparatus should be ap- 
 plied for retaining the paits, except that the humeral 
 extreinity ought to be directed a little backward, in 
 order that the sternal extremity, being carried for- 
 ward, may be removed from the place of laceration 
 in the capsule. 
 
 In like manner, should the bone be luxated up- 
 wards, it would be necessary to draw the arm out- 
 wards, and elevate slightly the point of the shoulder, 
 for the purpose of depressing the sternal extremity. 
 
 LUXATION OF THE HUMERAL EXTRE- 
 MITY. 
 
 § V. 
 
 or THE KINDS OF LUXATION. 
 
 24. Luxations of the humeral extremity of the 
 clavicle, take place, according to Petit, in two ways, 
 1st, under, and 2dly, over the acromion. If we attend 
 to the disposition of the ailiculating surfaces, the 
 superior of which rests obliquely on the inferior; if 
 we examine, in paiticular, the relative position of the 
 corocoid apophysis with respect to the clavicle, it 
 will be difficult to conceive how the first kind of 
 luxation can occur, without being accompanied by a 
 fracture. Yet some facts added by Desault to the 
 doctrine of Petit, on this point, seem to demonstrate 
 the possibility of the cla%dcle sliding under the aero- 
 
55 
 
 mion. As to luxations forward and backward, the 
 mobility of the shoulder, the facility with M^iich it 
 yields to motions impressed on it in these two dii'ec- 
 tions, and the want of a resisting power, make the 
 two bones that compose it, move together, still pre- 
 serving their relative position. 
 
 The luxation upward, then, is that which ought 
 chiefly to occupy the attention of the practitioner. 
 Yet even this is less frequent than the luxation of the 
 sternal extremity, on account of the very great 
 strength of the retaining ligaments, which, when this 
 luxation occurs, must be, if not lacerated, at least 
 very much distended. 
 
 § VI. 
 
 OF THE MECHANISM AND THE APPEARANCES. 
 
 25. A fall on the point of the shoulder is the most 
 frequent cause of this luxation. The two articulating 
 surfaces, representing an inclined plain, slide along 
 each other, in such a manner, that that which belongs 
 to the acromion is pushed inward, while that of the 
 clavicle is directed outward. The capsule being 
 stretched, gives way, and then the displacement is 
 manifested by a preternatural protuberance over the 
 acromion ; by a stiffness in the motion of the shoul- 
 der ; by the direction of this part, which is evidently 
 drawn inward and downward; by the inclination of 
 the head of the patient to the side affected; by a 
 bending of the body ; and by ^severe pains in tlie 
 luxated part. These characters are essentially dis- 
 tinct, and ought to have prevented the error of 
 
56 
 
 Galen, who mistook a case of this kind for a luxa- 
 tion of the OS humeri downward. Hippocrates and 
 Ambrose Pare have foreseen the possibilit}^ of this 
 mistake and even warned young practitioners to be eai 
 their guard against it. But, as citizen Sabattier judi- 
 ciously observes, the position of the head of the hu- 
 merus, under the ai'm, in a luxation of that bone, 
 will remove all uncertamty respecting the iiature of 
 the injur}'. 
 
 y VII. 
 
 or THE EEDUCTION^ AND THE MEANS OF RE- 
 TAINING IT. 
 
 26. The reduction, in this case, is generally at- 
 tended with but little difficulty. The acromion being 
 drawn outwai'd, by the upper end of the os humeri, 
 which, by means of a fulcrum placed under the ann- 
 pit, is made to act as a lever of the first kind, is re- 
 stored, without much trouble, to its natural contact 
 with the corresponding surface of the clavicle. But, 
 it soon becomes deranged again, unless it be retained 
 in its place by a proper appai'atus. Now, on what 
 principle ought this appai'atus to be constructed? 
 To prevent the displacement, which generally 'oc- 
 curs from wdthout inwards, it ought evidently to act 
 from within outwards. Whence it follows, that the 
 rollers in the figure of 8 bandage, recommended in 
 this case by all ^.Titers, instead of preventing, actually 
 favour the displacement (17), because they act in 
 the same direction \^dth, and therefore assist, the 
 powers that produce it. 
 
57 
 
 57. Here, in like manner as in the preceding 
 case, the bandage of Desault fulfils with precision 
 the indications of cure, because, by it, the point of 
 the shoulder is, particularly, drawn outward ; and if, 
 in certain cases, a slight projection of the humeral 
 extremity still remains, it is to be attributed to the 
 inefficacy of the means of execution, and not to the 
 principles on which they are founded. 
 
 MEMOIR IV. 
 
 ON FRACTURES OF THE ACROMION, AND OF THE 
 LOWER ANGLE OF THE SCAPULA. 
 
 FRACTURE OF THE ACROMION. 
 
 1. There is no part of the scapula more liable 
 to fractures than the acromion. Being but slightly 
 covered by the soft parts, this insulated kind of ap- 
 pendix has not, in all positions of the humerus, a solid 
 point of support. A strong muscular force oftentimes 
 acts on it with great energy. Being large in front, it 
 presents in that direction a considerable surface to 
 receive the action of exteiTial bodies. Whence it fol- 
 lows, that if it is not oftentimes broken, this is to be 
 attributed, not so much to its natural disposition, as 
 to the position which it generally assumes in falls. 
 
 2. The fracture, which is almost always trans- 
 verse, is sometimes at the summit, and sometimes 
 
 9 
 
at the base of tliis apophysis, and is usually produced 
 by a violent shock from a body falling on the shoul- 
 der, by a blow received on that part, &c. 
 
 3. But in whatever place it occurs, it greatly re- 
 sembles a fracture of the humeral extremity of the 
 clavicle, of which the acromion appears like a con- 
 tinuation. There is accordingly a strong analogy be- 
 tween the phenomena, the consequences, and the 
 modes of treating these two kinds of fractures. 
 
 4. This accident is characterized, 1st, By a se- 
 vere pain experienced by the patient, at the place of 
 the fracture. This pain is increased by the elevation 
 of the arm, which, generally hangs motionless dov/n 
 along the side. 2dly, If the humerus be removed 
 from the trunk, the hand being at the same time pla- 
 ced on the acromion, the extremity of this apophysis 
 is felt sinking downward, creating thereby an evident 
 depression in the part. 3dly, Generally, the two frag- 
 mients lose, of their own accord, their relative posi- 
 tion ; and unless the precaution about to be men- 
 tioned be used, their displacement becomes manifest, 
 being produced by the weight of the arm, and the 
 contractions of the deltoid muscle. 4thly, The head 
 is inclined to the affected side. 
 
 ui. 
 
 OF THE REDUCTION. 
 
 5. Two diiferent processes have been long in 
 use for the reduction of fractures of the acromion. 
 One consists in elevating the arm almost to a right 
 angle with the body, in order, as Heister remarks, 
 
59 
 
 to throw the deltoid muscle into a state of relaxation, 
 and then to be able, with the fingers, to place the 
 fragments in their natural situation. In the other 
 mode, the humerus is sujBPered to retain the position 
 it has assumed, that is, to hang down the side ; the 
 surgeon then taking hold of the elbow, pushes it ver- 
 tically from below upwards, in such a manner, that 
 the head of the bone, pressing against the acromion, 
 elevates and replaces it. 
 
 6. Petit seems to have adopted indiscriminately- 
 these two methods, one of which, however, is greatly 
 superior to the other. Indeed, it is evident, that if the 
 humerus be removed from the trunk, its head will 
 necessarily sink down in the glenoid cavity. Being 
 thus separated from the fractured apophysis, it leaves 
 beneath it a hollow or vacancy, into which the frag- 
 ment will be pushed, should it be in any measure^ 
 compressed by the casts of the roller,, during the ap- 
 plication of the bandage. 
 
 7. On the other hand, if the arm still fixed against 
 the side, be pushed upwards, it will afford to the acro- 
 mion a sohd point of support, which,^ during the ap- 
 plication of the apparatus, will prevent its displacement 
 downwards. This consideration is unquestionably of 
 moment, during the process of reduction; but ought 
 more particularly, to command the attention of the 
 practitioner, in the choice of means, destined to main- 
 tain the reduction. 
 
60 
 
 § III. 
 
 OF THE MEANS FOR MAINTAINING THE 
 REDUCTION. 
 
 8. As the displacement is most likely to occur 
 downwards, particularly in motions of the arm, it is 
 necessary that a continued resistance be opposed to 
 this tendency. But this resistance should be made 
 by the head of the humerus, which, if properly direct- 
 ed, will represent, dming the treatment, a kind of 
 splint, which art ought to render fixt and immoveable 
 lest, being contiguous to the divided surfaces, it might 
 derange, by its motions, the work of nature in effect- 
 ing their reunion. Hence it follows, that the precise 
 and immediate intention of the whole apparatus des- 
 tined to support fractures of the acromion apophysis, 
 is, 1st, to keep the head of tlie humerus constantly 
 elevated or pushed upwards: 2dly, carefdlly to pre- 
 vent all motions of the arm and shoulder. 
 
 9. If the means, heretofore employed in this frac- 
 ture, be examined, it will be perceived that they by 
 no means fulfil this tw^ofold indication. 
 
 A compress placed immediately over the fracture; 
 a roller passed round this to secure it ; a ball or bol- 
 ster* put into the hand; the fore-arm supported in a 
 sling; such is the apparatus recommended by Petit. 
 In addition to tliis, Duvemey judiciously advises to 
 keep the sling elevated, for the purpose of keeping 
 the head of the humerus applied under the fractured 
 pieces. He employed also the spica-bandage which 
 has been equally recommended by Heister. 
 
 * Une pelotte. 
 
61 , 
 
 10. But, in the employment of these means, the 
 arm, not being confined against the trunk, can move 
 with ease, and derange the fragments, and, therefore, 
 the second indication is not fulfilled. Will even the 
 first be fulfilled? By no means. The sling, being 
 soon deranged, by the movements of the arm, which 
 are oftentimes involuntary, suffers it to sink down 
 again, and then the fi:-agments, being no longer sup- 
 ported, are displaced. Hence the difficulties attend- 
 ing the treatment, difficulties which have not escaped 
 the notice of authors, and which Heister thus ex- 
 presses: '' Nemo ita curari solely ut hrachium postea^ 
 liberi sursum attollere queat,^'' an observation, which 
 the celebrated Cheselden made before him, in de- 
 scribing the scapula. 
 
 11. These inconveniences will be avoided, by 
 fixing the arm, as recommended by Desault, firmly 
 against the trunk, by converting, so to speak, the arm 
 and the trunk into one single and solid piece, in such 
 a manner, that the humerus having no other motions 
 but those in common to it and the thorax, may not 
 be able to communicate any others to the fragments, 
 which are supported by its head. This advantage 
 can be easily obtained, by means of the bandage, 
 already described, for fi^actures of the clavicle, modi- 
 fied agreeably to the circumstances of the case, in 
 which it is to act. 
 
 12. A bolster or pad of an equal thickness in all 
 its parts, is placed under the arm. The arm is then 
 to be pressed down on this, in like manner as in the 
 bandage for the clavicle. The fractured apophysis is 
 now to be covered by two compresses; one extend- 
 
ing from the clavicle to the spinous processes of the 
 yertebrEe, while the other, lying over this, and run-, 
 ning in a contrary direction, crosses it at the place of 
 the fracture. The whole is then to be secured by a 
 roller, which, starting from the arm-pit of the sound 
 side, pursues nearly the same course with that destin-r 
 ed, in fractures of the clavicle, to retain die shoulder 
 upwards. (See what has been said on this subject,, 
 when treating of the structure of the bandage.) 
 
 13. By this mean, the two-fold indication of keep- 
 ing the humerus immoveable, and directed upwards 
 (8), is evidently fulfilled, as I have already proven at 
 full length, when treating of fractures of the clavicle; 
 and a reunion, without deformity, may be looked for, 
 of which we have an instance in the following casej. 
 recorded by Derrecagaix. 
 
 Case I. Nicholas Gay, aged twenty-nine, was 
 struck, in passing under a decayed building, by a 
 stone, which, having become loosened, fell on the 
 point of his shoulder. In an instant he experienced 
 severe pain, and a difficulty of moving his arm, parti- 
 cularly upwards. Soon afterwards there occurred a 
 swelling of the shoulder, and a large echymosis at the 
 place where the blow was received. The pain, not 
 so acute during a state of rest, was increased by the 
 motions of the arm, and even by leaning the head to- 
 wards the opposite side, which latter ciscumstance- 
 was, no doubt, owing to the contraction of the trape- 
 zius muscle. 
 
 A surgeon being called, judged it sufficient to^ 
 make use of discutient applications, to which the 
 swelling and the echymosis appeared to yield in the 
 
63 
 
 C6urs<t of a few days. On a more accurate examina* 
 tion, a fracture was discovered, supposed to be in the 
 external part of the clavicle, and for which the patient 
 was sent to the Hotel-Dieu. 
 
 The fracture was discovered to be in the middle 
 of the acromion, which it divided transversely. The 
 bandage already mentioned ( 12) was applied, and, from 
 the first day, the patient was left to his usual regimen* 
 Fifdi day, a renewal of the apparatus which had be- 
 come relaxed : seventh day, a fresh displacement, in 
 consequence of an unguarded motion : a fresh appli- 
 cation of the bandage, which continued in its place 
 till the sixteenth day, when it was replaced anew; 
 thirty-second day, reunion complete; a stiffness in 
 the motions of the part, which exercise removed by 
 degrees, and of which the patient felt no remains after 
 the forty-eighth day. 
 
 FRACTURE OF THE LOWER ANGLE OF 
 THE SCAPULA. 
 
 OF THE SIGNS OR APPEARANCES AND DIS- 
 PLACEMENT. 
 
 14. Next to the acromion, the lower angle of the 
 scapula is that portion of the bone most liable to be 
 fractured. The usual causes of it are, falls on the 
 side, or blows received on the part. It is character- 
 ized by a displacement which is always perceptible. 
 Oa the one hand, the fleshy portion of the sen'atus- 
 
64 
 
 major, which is attached to the inferior fragment, 
 draws it directly forward, while it is di^awn upward 
 by the teres-major, and some of the fibres of the 
 latissimus dorsi. On the other hand, the body of the 
 bone itself remams behind, being held by the rhom- 
 boid muscles. Hence arises a separation, which 
 renders it difficult to mistake the fracture. Should 
 any doubts still remain, let the shoulder be drawn 
 backwards and the scapula along with it: let the fin- 
 gers be, at the same time, placed on the lower angle, 
 to ascertain whether or not it follows the motions of 
 the bone ; if it does, there is no division : but if, on 
 the contrary, it remains stationary, the existence of 
 the fracture is evident. 
 
 OF THE REDUCTION, AND THE MEANS OF 
 RETAINING IT. 
 
 15. Here, as in all other fractures, the means of 
 reduction must be founded on the causes of displace- 
 ment. To effect the replacement, therefore, it is neces- 
 sary, either to push backward and downward, the an- 
 gle which is displaced in a contrary direction, in order 
 that it raay be brought into contact with the body of 
 the bone, or else to draw the body of the bone for- 
 ward and upward, that it may meet the displaced an- 
 gle. It is thus, that in a fracture of the condyle, the 
 body of the jaw, is drawn into contact with the frag- 
 ment. 
 
 16. But the first mode of reduction is difficult, and 
 the means of maintaining it impracticable. It is ne- 
 
65 
 
 cessary, therefore to have recourse to the second, 
 which is the more easily executed, as the scapula fol- 
 lows the movements of the arm, and as, by drawing 
 this hmb forward, and the elbow of it outward, that 
 bone is removed from the spinous processes of the 
 vertebrae, and directed in such a manner, as to be 
 brought into contact with its inferior fragment. This 
 situation possesses another advantage, as it throws in- 
 to a state of relaxation the muscles which tend to 
 displace the lower fragment. 
 
 Hence it follows, 1st, That here, in like manner 
 as in fractures of the clavicle, it is not on the fractured 
 bone, that the force must act, but on the humerus. 
 2dly, That the humerus ought to be, during the 
 whole treatment, immoveably fixed, because its mo- 
 tions, being communicated to the scapula, must soon 
 derange the contact necessary to a reunion. 
 
 18. On these principles were founded the appa- 
 ratus of Desault, and his process of reduction, which 
 consisted, 1st, in drawing the arm forward, and sepa- 
 rating the elbow a little from the thorax ; 2dly, in 
 fixing the fore-arm at an angle sufficiently acute, to 
 direct the hand to the point of the opposite shoulder; 
 and 3dly, to bring afterwards into proper apposition 
 and form, the fragments already approximated to each 
 other by the first movements. 
 
 19. To retain this reduction, the arm and fore-arm 
 must be permanently fixed in the above position. This 
 object is attained in the following manner, 1st, A bol- 
 ster in form of a wedge, being placed between the arm 
 anc the side, its apex situated in the ann-pit, affiDrds 
 the double advantage of keeping the elbow at a dis- 
 
 10 
 
m 
 
 tance from the thorax, and of rendering the position of 
 the arm less fatiguing by serving as a point of support 
 to it. 2dly, Compresses wet with some discutient 
 liquid, are apphed on the part corresponding to the 
 fracture* 3dly, The whole is now to be secured by a 
 roller, seven or eight yards long. The first turns of 
 this roller, must secure the hand of the affeeted side 
 on the sound shoulder to which it had been applied, 
 during the reductioUy and running afterwards from 
 before backwards, pass over the place of the fracture, 
 for the purpose of retaining the compresses on it. The 
 wedge-formed bolster is to be secured on the tliorax, 
 by circular turns around it. Then, passing under the 
 sound arm-pit, after having made these cuxular turns, 
 the roller must be brought behind again, conducted 
 obliquely over the shoulder of the diseased side, along 
 the anterior part of the arm, under the elbow, and be- 
 hind the thorax, where it is carried obliquely, in or- 
 der to pass again under the sound arm-pit. From 
 this place it ascends again anteriorly over the affected 
 shoulder, redescends along the posterior part of the 
 arm, repasses under the elbow, returns under the aim- 
 pit, and terminates finally in circular turns round the 
 trunk, and arm together. Hence it may be observed, 
 that, in the first turns of the roller, this bandage great- 
 ly resembles the third roller applied in the fracture af 
 the clavicle, to retain the point of the shoulder up- 
 ward and backward (Fig. 4. plate I.) 
 
 20. By this, 1st, The movements of the arm be- 
 ing entirely impeded, they cannot have any influence 
 on those of the shoulder ; hence, in this respect, the 
 fragments are suffered to remain in contact. 2dly, 
 
- \ 67 
 
 The serratus-major and teres-major muscles, being 
 kept in a state of habitual relaxation, can no longer 
 draw the inferior fragment forward, which cannot, 
 therefore, be sepai'ated from the body of the bone. 
 3dly, Nor can the body of the bone, being perma- 
 nently held in this situation, be removed from the 
 fragment ; whence, in both respects, a displacement 
 will be effectually prevented. This threefold advan- 
 tage is not possessed by any of the different kinds of 
 apparatus hitherto proposed, such as the sling and 
 cross-bandage, employed by Petit, which have the 
 fault of suffering the arm to move backward, of al- 
 lowing the scapula to be easily se]^)arated from its 
 insulated angle, of retarding by that means the cure, 
 and even of preventing it entirely, while, by the pro- 
 cess just described, it is usually completed by the 
 thirtieth day. 
 
 MEMOIR V. 
 
 ON THE FRACTURES OF THE UPPER END OR 
 NECK OF THE HUMERUS."* 
 
 1. The language of the surgeon differs, in this 
 case, from that of the anatomist, and by the expres- 
 sion, " fracture of the neck of the humerus," is here 
 
 * For a very important improvement made by Dr. Physic 
 ill the treatment of an old fracture of the os humeri, and which 
 may be appUed also to similar fractures of other bones, see Ar- 
 ticle I. of the Appendix. Tra*[s. 
 
68 
 
 meant not that of the slight circular depression,' 
 which separates the head from the tuberosities of the 
 bone, but rather that of the contracted or diminished 
 portion of the bone, which commences at the tube- 
 rosities above, and being continued down the body 
 of the bone, receives at its lower end the insertion of 
 the tendons of the pectoralis major, the latissimus 
 dorsi, and the teres major. Many practitioners con- 
 sider this nect or contracted portion as extending 
 even to the insertion of the deltoid muscle. 
 
 2. Several facts, the truth of which it is difficult 
 to call in question, attest the possibility of a fracture 
 of the neck of the bone, so called in anatomical lan- 
 guage. I have myself seen, in the humerus of a young 
 man, aged seventeen years, the head of the bone ex- 
 actly separated from its body, by a division which 
 had but slightly aifected the upper extremity of the 
 tuberosities. But the examples of this nature which 
 occur in the annals of surgery are too few, to enable 
 us to lay down any general principles for the treat- 
 ment of such fractures. 
 
 § II. 
 
 OF THE VARIETIES AND THE CAUSES. 
 
 3. The operation of external bodies, active, when 
 they are thrown against the shoulder, passsive, when 
 the shoulder, or the arm, is forcibly driven against 
 them, is always the cause of a fracture of the neck 
 of the humerus. From the mechanism of the part, 
 the division is sometimes direct, and sometimes the 
 effect of a counter- stroke. 
 
69 
 
 The first of these arises very generally from a 
 fall on the point of the shoulder, and as in such a case, 
 the commotion or shock must be very great, to ex- 
 tend with sufficient force through the thick mass 
 which forms the deltoid muscle, that muscle some- 
 times suffers both contusion and an echymosis. 
 Blood may even escape from a rupture of some of 
 the arteries or veins of the joint, and form, as De- 
 sault has observed, a collection or tumour which it 
 would be imprudent to open. 
 
 The other is the effect of a fall on the elbow, 
 separated, at the time, some distance from the trunk,' 
 or on the hand, which, by a natural instinct, is thrown 
 out, together with tlie arm and fore -arm, in order to 
 break the violence of the fall. 
 
 4. The varieties of this kind of fracture originate, 
 1st, from the spot which it occupies, being either the 
 middle or the lower part, rarely the upper part, of the 
 neck of the humerus : 2dly, from the state of the 
 surrounding soft parts, which sometimes remain quite 
 natural, and at other times become distended and 
 tumefied. This circumstance always involves the 
 diagnosis in more or less uncertainty ; 3dly, from the 
 direction of the fracture, which is sometimes trans- 
 verse, but usually oblique, particularly when pro- 
 duced in the second mode, that is, by a counter- 
 stroke (3); 4thly, fi-om the relative situation of the 
 fragments, which may remain in contact, an occur- 
 rence however but very rare, or may separate from 
 or.e another in a direction inwardly or upward; and, 
 5thly, from different complications, with which it may 
 be attended. 
 
70 
 ^ III. 
 
 OF THE SIGNS AND THE DISPLACEMENT. 
 
 The whole of the signs of a fracture of the neck 
 of the humerus, taken together, characterize its ex- 
 istence in a manner sufficiently evident. But it is not 
 iilways an easy matter to take a view of them all at 
 once, and in such a case, there are more difficulties 
 attending the diagnosis here, than in any other jfrac- 
 ture of the humerus. 
 
 An acute pain is felt at the instant of tlie fall ; and 
 sometimes a crack or report is plainly heard. There 
 is always a sudden inability to move the hmb, which, 
 being left to itself, hangs motionless. But if any 
 external force act on it, it yields to it without resist- 
 ance, and may be moved by it with great ease in 
 every direction. 
 
 These motions are accompanied with severe pam, 
 and, if carried too far, may give rise to very trouble- 
 some affections, as has been observed in patients, 
 where tlie fracture was mistaken for a luxation. 
 
 Beneath the acromion, is discovered a depression, 
 always situated lower down, than that which accom- 
 panies the fracture of that apophysis. If one hand be 
 placed on the head of the bone, while the other is em- 
 ployed in moving the lower fragment in different di- 
 rections, or, while an assistant, engaged in making 
 the necessary extension, communicates to this frag- 
 ment a rotatoiy motion, 1st, the head will be per- 
 ceived to remain motionless; 2dly, the friction of the 
 two divided ends will produce a crepitation more or 
 
71 
 
 kss perceptible. This twofold sign is always deci- 
 sive as to the existence of a fracture ; but the swell- 
 ing c^ the joint may occasionally prevent the prac- 
 titioner from availing himself of it. 
 
 The fragments remain sometimes in contact, with- 
 out experiencing any displacement, in which case, 
 most of the signs not manifesting themselves, the 
 diagnosis is rendered more difficult. But most fre- 
 quently a displacement occurs, and then it is the in- 
 ferior fragment that is deranged, and not the superior 
 one which is so short that it can be but little effected 
 by the action of the muscles. 
 
 7. The displacement is in general but slightly 
 perceptible in the longitudinal direction of the bon€,> 
 unless when, in a very oblique fracture, the frag- 
 ments present points which irritate the muscles, ex- 
 cite them to contraction, and augment their force ; 
 or, when a blow of great violence, continuing to act 
 after the bone is broken,causes the fragments to over- 
 lap each other. Thus has the body of the bone been 
 forcibly drawn upwards, or driven in the same direc- 
 tion, till having passed through the deltoid muscle, 
 and the external integuments, it has even risen con- 
 siderably above the level of its head. 
 
 But in general, as Petit observes, the weight of 
 the limb hanging down the side, opposes to the action 
 of the muscles a sufficient degree of resistance; and 
 it is in the direction of the cross- diameter or thick- 
 ness of the bone, that the displacement most frequent- 
 ly occurs. It is to be observed, that the lower frag- 
 ment is driven either inward or outward, rarely 
 in any other direction. In the first case, which is hy 
 
72 
 
 far the most common, the elbow is somewhat remo- 
 ved from the body, and cannot be brought near to 
 it without pain; in the second, which is more rarely- 
 met with, it is moved in an opposite direction. 
 
 In the one, the contractions of the deltoid muscle 
 and the natural curve of the humerus, in the other, 
 the united action of the pectoralis major, the latissi- 
 mus dorsi, and the teres-major, appear to have an 
 essential influence on the displacement. 
 
 In each case, the displacement is facilitated by 
 the mobility of the lower fragment, and of the shoul- 
 der, when an apparatus from being improperly con- 
 structed, fails to prevent the movements of the whole 
 extremity. 
 
 8 The signs which have just been detailed, do 
 not always furnish such luminous evidence, particu- 
 larly to an inexperienced practitioner, as to prevent 
 the occurrence of very serious mistakes. Of this De- 
 sault related many examples in his lectures. 
 
 Case. J. M*** Est*** falling on his elbow, 
 fractured the neck of the humerus. A surgeon was 
 immediately called, who, finding a depression be- 
 neath the acromion, a protuberance in the hollow of 
 the arm-pit, and the humerus directed outwards, 
 pronounced, without further examination, that there 
 existed a luxation in a downward direction. Wish- 
 ing to reduce it immediately, he employed, to no 
 purpose, the common processes. Acute pains were 
 the consequence. The opening in the capsule being 
 too narrow was irritated, and the member subjected 
 to great violence of motion. At length the pains be^ 
 came insupportable ; the operators gave over their 
 fruitless efforts, and Desault was called. 
 
73 
 
 He discovered the mistake from the immobility 
 of the head; from the depression beneath the acro- 
 mion being lower down than in a luxation; and from 
 the existence of a crepitation. A reduction was 
 effected without loss of time ; the apparatus was ap- 
 plied, but in the evening a considerable swelling oc- 
 curred around the arm-pit ; soon afterwards inflam- 
 mation was superadded ; a vast collection of matter 
 succeeded, and, notwithstanding the utmost atten- 
 tion, it was five months before the patient was resto- 
 red to health. 
 
 9. To this example, I could add others, where 
 the most serious accidents have resulted from a simi- 
 lar mistake. It must be acknowledged, however, 
 that, if, in a fracture, the displacement be inward 
 and a little forward, the greater part of the signs here- 
 in detailed (5) apply equally to a fracture and a lux- 
 ation : but then, as we have just seen in the prece- 
 ding case, the immobility of the head, the place of 
 the depression beneath the acromion, and the crepi- 
 tation, will remove any doubts that may be excited 
 in the mind of the surgeon, by the protuberance in 
 the arm-pit, the direction of the arm, &c. &c. 
 
 UV. 
 
 OF THE PROGNOSIS. 
 
 10. A fracture of the neck of the humerus as- 
 sumes, in general, a character not very troublesome ; 
 and if, as Heister says, " a fracture near the head is 
 worse, and more difficult to be cured," this is less 
 owing to the nature and seat of the disease, than ta 
 the difficulty of keeping the fragments in contact, 
 
 11 
 
74 
 
 Seldom have the reunion of the bone, and the 
 removal of all the disagreeable eifects accompanying 
 the accident, required a longer time than is necessary 
 for the cure of other fractures. The numerous ex- 
 amples, which occurred in the Hotel-Dieu, during 
 Desault's direction of the surgical department, con- 
 firm the truth of this assertion, notwithstanding some 
 doubts that may have been raised respecting it, by 
 prejudices formerly entertained, on the subject of 
 fractures in the vicinity of joints. 
 
 From twenty- six to thirty days are sufficient for 
 the reunion : this was tlie term commonly required 
 in the Hotel-Dieu. 
 
 11. If judiciously managed, art readily removes 
 all the accidents attendant on this fracture ; but, if 
 otherwise, the consequences ai-e apt to prove trou- 
 blesome. It is here, much more particularly than in 
 other places, that all deformity of the part ought to 
 be prevented; because, the neck of the humerus be- 
 ing near to the centre of the motions of the arm, will 
 very essentially impede those motions if it be not 
 properly reunited. A deformed callus has been known 
 to produce, in the hollow of the arm-pit, a protube- 
 rance, which has, in part, prevented abduction, and 
 appeared to keep up an habitual swelling in the limb. 
 
 It is, then, from the perfection of the appai'atus, 
 and not from the vicinity of the injury to a joint, 
 that the prognosis is to be formed, both as to the 
 consequences, and as to the duration of the fracture. 
 Keep the fragments in exact and regular contact, and 
 there will be no obstacle to that success which sel- 
 dom forsook Desault. 
 
75 
 
 OF THE REDUCTION. 
 
 12. The reduction in this case is usually attend- 
 ed with but little difficulty, and the great multiplicity 
 of means hitherto used for that purpose, demonstrate 
 only the barrenness of the art. 
 
 Most of the machines destined to reduce the 
 luxation of the humerus, have been applied to this 
 fracture. Thus the ladder,* the door,f and the 
 club, J placed under the arm-pit, served at once the 
 purposes of counter-extension, and conformation, 
 while the powers for producing extension were ap- 
 plied to the elbow, and more rarely to the wi'ist. 
 Thus Hippocrates recommended a wooden cross, 
 the effect and mode of action of which are nearly the 
 same. These means, in general, besides being insuf- 
 ficient, are liable to a further objection, in conse- 
 quence of their acting on the edges of the pectoralis 
 major, latissimus dorsi, and teres major, which being 
 thus forced upwards, draw the fragment to which 
 they adhere in the same direction, and thereby con- 
 stitute an obstacle to the reduction. (See what will 
 be advanced on the subject of luxations of the hu- 
 merus.) 
 
 13.. To machines succeeded the use of straps, 
 weights suspended to the limb, &c. These processes 
 
 (* L'echelle, f la porte, | le baton.) These pieces of ma- 
 chinery, though formerly in use, are now, I believe, in all parts 
 of the world, laid aside. It would be superfluous, therefore, to 
 consume time in describing either them, or their mode of 
 operation. Trans. 
 
'76 
 
 were entirely useless, in as much as they were Intend- 
 ed only to increase the natural powers of the operator, 
 which are already more than sufficient of themselves. 
 They will, therefore, in a short time, exist only in the 
 history of surgery. 
 
 Petit proposed to reduce this fracture, by first 
 raising the arm to a right angle with the body, and 
 then directing one assistant to make the requisite ex- 
 tension, by taking hold of the elbow with his hands, 
 while another grasped the point of the shoulder, for 
 the purpose of counter-extension. This method was 
 attended with the threefold inconvenience, of subject- 
 ing the patient to great fatigue and pain, of weaken- 
 ing the extending powers, by bringing them too near 
 to the point required to be moved, and of irritating 
 the muscles that draw the lower fragment upwards, 
 and thus exciting them to contract. Hence the diffi- 
 culties sometimes attendant on reduction, which is 
 always simple in itself, when, after the trunk is pro- 
 perly fixed, gentle extensions are made by taking 
 hold of the fore-arm in a half-bent state. The follow- 
 ing is the mode of reduction practised by Desault. 
 
 14. The patient is seated either on a chair or on 
 the side of a bed. The arm is slightly separated from 
 the body, and carried a little forward. 
 
 One assistant is directed to fix and secure the 
 trunk in a proper manner. This he does by pulling 
 at the arm of the sound side, taking hold of it near to 
 the hand, and extending it in a direction perpendi- 
 cular to the axis of the body. This mode of counter- 
 extension is preferable to that commonly employed, 
 which consists in applying the hands to the upper part 
 
77 
 
 of the patient's shoulder. Indeed, on the one hand, 
 the power being farther removed from the resisting 
 force, need not be so great. And, on the other, the 
 body being entirely unencumbered, renders it easy 
 for the surgeon to apply the roller without disconti- 
 nuing, or in any way disturbing, the extension. 
 
 Another assistant makes extension on the fore- 
 arm, which serves him as a lever, where, one hand 
 being placed behind or on the back of the wrist, 
 forms the point of support, (or fulcrum), while the 
 other applied to the anterior and middle part of the 
 fore arm, on which it makes pressure from above 
 downward, represents the power; the fragments to 
 be brought into contact constitute the resistance. 
 
 The relaxation of the muscles produced by this 
 semi- flexion of the fore-arm, and the slight separation 
 of the arm from the trunk, greatly favour this mode 
 of extension; a mode recommended by the ancients, 
 adhered to by the English, and which possesses the 
 advantage of leaving uncovered all that portion of the 
 limb on which the apparatus is to be applied, and by 
 that means of allowing the hands of the assistant to 
 keep the same position during the whole time of the 
 application, 
 
 A small degree of force, judiciously directed ac- 
 cording as the displacement is inward or outward, is 
 sufficient to effect the reduction, which even takes 
 place of its own accord, under this process. If the 
 surgeon lays his hands on the place of fracture, it is 
 rather to examine the state of the fragments, than to 
 assist in bringing them into apposition. 
 
78 
 
 §VI. 
 
 OF THE MEANS OF MAINTAINING THE 
 REDUCTION. 
 
 16. All kinds of apparatus for fractures, being 
 nothing but resistances opposed by art, to the powers 
 which produce displacement, it follows, that they 
 should all act in directions precisely opposed to the 
 directions of those powers. But, we have seen (7), 
 that, in the present case, these powers are, 1st, the 
 action of external bodies, favoured by the extreme 
 mobility of the arm and shoulder; 2dly, the action 
 of the latissimus dorsi, the pectoralis major, and the 
 teres major, which carry the inferior fragment inward, 
 or, what is more common, of the deltoid muscle, 
 which draws it outward ; 3dly, the contractions of 
 the muscles of the arm, which have a slight tendency 
 to draw the same fragment upwards. 
 
 17. Therefore, 1st, to render the arm and shoul- 
 der immoveable ; 2dly, to carry the upper end of the 
 lower fragment outward or inward, according to the 
 direction in which it is displaced; and, 3dly, to draw 
 this fragment downward, are the three indications 
 that ought to be fulfilled by every bandage intended 
 for a fracture of the neck of the humerus. The last 
 merits less attention than the other two, because, as 
 already observed, the weight of the limb alone is 
 nearly sufficient to answer it. 
 
 18. Let us inquire, whether or not the kinds of 
 apparatus, hitherto employed, have been adequate to 
 the fulfilment of these indications. 
 
79 , 
 
 The ancients, in obedience to the precept of Hip- 
 pocrates, fixed the arm against the breast, and con- 
 fined it there by a bandage recommended by Celsus, 
 and constantly employed by Paul of Egina. " Prees- 
 tat antem^ says he, brachium, ad thoracem moderate 
 deligare ^ ut ne ^ slid commoveatur, figurama^ertat.'''' 
 Pare still preserved this process, which the modems 
 have now entirely abandoned, and which, taken alone, 
 could properly fulfil only the first indication. The 
 second indication was less happily fulfilled, by a kind 
 of bandage added to the first, by Celsus, Paul of 
 Egina, and the Arabians, the necessary effect of which 
 was, to force the lower fragment outwards. It is 
 surprising that Heister and Lamotte should have con- 
 fined themselves to the use of this for the retention 
 of the fragments. 
 
 What shall we say of the eighteen-tailed bandage 
 exclusively adopted by Petit and Duverney ? The 
 arm, not being fixed by it, was liable to be moved, 
 and the fragments to be displaced by the least shock. 
 There was nothing to prevent the lower fragment 
 from obeying the powers tending to carry it either 
 inward or outward. Indeed the bandage was of no 
 avail whatever in giving support to a fracture, as was 
 observed by Louis, in his " Dissertation on Petit's 
 Diseases of the Bones. ' ' 
 
 Suppose the arm, as some have advised, to be 
 supported only by a sling. Not one of the indications 
 just established (17) could by such means be fulfilled. 
 
 Perhaps the bolster of tow proposed by Moscatti, 
 would have surpassed all these means, in the advan- 
 tages it offered, had it not, by leaving the arm move- 
 
able below, and the shoulder above, still favoured a 
 displacement. 
 
 Le Dran has also advised the use of a bolster 
 composed of that of Moscatti, and bole Armenian. 
 It fixed the arm more firmly against the trunk and 
 in this respect, certainly approached nearer to the 
 attainment of the object in view. 
 
 19. It is obvious, from this comparison between 
 the indications of cure (17), and the means hitherto 
 employed for the fulfilment of them (18), that nothing 
 satisfactory had yet been done, and that a proper ap- 
 paratus was still a desideratum. The success expe- 
 rienced by Desault, in the use of that which we are 
 about to describe, has perhaps proven, that this desi- 
 deratum exists no longer. 
 
 20. The pieces which compose it, are, 1st, Two 
 rollers, the one from five to six, and the other fi'om 
 eight to ten yards long, each one about three inches 
 wide : 2dly, Three strong splints, of different lengths, 
 each about two inches broad : 3dly, A small bolster 
 made of linen, from three to four inches thick, at one 
 end, tapering like a wedge to the other, and of a suffi- 
 cient length to reach from the arm-pit to the elbow; 
 4thly, A sling for the purpose of supporting the fore- 
 arm; 5thly, A piece of linen to surround the whole 
 apparatus. 
 
 Every thing being properly arranged, the reduc- 
 tion, effected in the manner already stated (14), and 
 the assistants still continuing the extension : 
 
 1st, The surgeon takes the first roller, wet with 
 vegeto-mineral water, fixes one end of it by two cir- 
 cular turns on the upper part of the fore-arm, and 
 
81 
 
 carries it up along the arm by oblique turns, mode- 
 rately tight, and overlapping each other about two- 
 thirds of their breadth. Having reached the upper part 
 of the limb, he m.akes some reversed turns to pre- 
 vent the wrinkles that would be caused by the une- 
 venness that occurs in this place. He then passes two 
 casts of the roller under the opposite arm-pit, and 
 bringing the ball to the top of the shoulder again, 
 gives it into the hand of an assistant. 
 
 2dly, The fxrst splint is then placed before, and 
 reaches from the fold of the arm, to a level with the 
 acromion. The second on the outside, reaching from 
 the external condyle to the same level. The third be- 
 hind, reaching from the olecranon to the fold of the 
 arm-pit. The bolster placed between the arm and 
 the thorax is a substitute for a fourth splint, which 
 is by that rendered unnecessary. An assistant now 
 secures them, by grasping them with his hand to- 
 wards the curvature of the elbow, so as not to hinder 
 die application of the remaining part of the bandage. 
 
 3dly, The surgeon takes hold of the roller again, 
 descends by oblique and reversed turns along the 
 splints, which he fixes by binding them moderately 
 tight, and terminates the bandage at the upper part 
 of the fore-arm, where he had commenced. 
 
 4. The assistants stiU continuing the extension, 
 the surgeon places the bolster between the arm and 
 the trunk, taking care that the thick end be upper- 
 most, if the displacement be in an inward direction, 
 but lowermost, if it be in an outward one, as is most 
 commonly the case (7). The bolster is to be fastened 
 
 at top by two pins to a cast of the roller. 
 
 12 
 
82 
 
 5. The arm is now pressed towards the trunk, 
 and fixed against the bolster, by means of the second 
 roller. This roller is applied like that which, in frac- 
 tures of the clavicle, fastens down the arm to the bol- 
 ster, by the oblique turns c. c. (Fig. 3. plate I.), with 
 this difference, that in the present case, the turns 
 ought to be very tight below, and looser above, if 
 the displacement be in an inward direction. But, on 
 the other hand, if it be outwardly, they must be loose 
 below, and tight above. 
 
 6. The fore-arm is now to be suspended in a sling, 
 and the whole apparatus afterwards surrounded by a 
 piece of linen, which, by protecting the casts of the 
 roller from friction, prevents them from being dis- 
 turbed. 
 
 21. If we now compare the action of this appara- 
 tus with tlie indications of cure formerly laid down 
 (17), it will be easy to perceive, that, by it, they are 
 extremely well frilfilled. Indeed, the arm, being 
 firmly fixed against the tnmk, cannot move, other- 
 wise than by motions common to it and the trunk, 
 and nothing can derange the lower fragment, which 
 is equally immoveable. Nor can the shoulder com- 
 municate any motion to tlie superior fragment. The 
 bolster being differently disposed, according to the 
 direction in which the lower fragment is displaced, 
 will serve to move it in an opposite direction. 
 
 Should this fragment be forced inwards, the thick 
 head of the bolster will separate it to a distance from 
 the thorax. It will be maintained in this state of se- 
 paration, by the casts of the roller, .which, being very 
 tight below, will act on it as on a lever of the first 
 
83 
 
 kind, of which the bolster, forms the fulcrum, while 
 the resistance to be overcome is the action of the 
 latissimus dorsi, the pectoralis major and the teres 
 major. The casts of the roller, by pressing the elbow 
 to the body, will draw the fractured end of the bone 
 in a contrary direction; and, in this respect, the ban- 
 dage may be considered as an artificial muscle, form- 
 ing a perfect antagonist to the natural ones. 
 
 22. If the displacement be in an external direc- 
 tion, as most commonly occurs (7), a contrary effect 
 must be produced, as well by the pressure made by 
 the bandage, on the upper extremity of the displaced 
 fragment, as by the situation of the elbow which is 
 directed outwards by means of the tliick end of the 
 bolster being placed lowermost. The external splint 
 will also prevent the displacement outwards, as well 
 by opposing to the bone a mechanical resistance, as 
 in compressing the deltoid muscle, which is the 
 principal cause of the displacement. The derange- 
 ment of the lower fragment forward and backward, 
 will be prevented by the two splints before and be- 
 hind. 
 
 The displacement longitudinally, already checked 
 by the weight of the limb, will be still further pre- 
 vented, by the compression made on the muscles of 
 the arm, which are the instruments of displacement, 
 by the splints and the bandage. 
 
 23. To the advantage of keeping the fragments 
 exactly in place, this apparatus unites that of not con- 
 fining the patient, who is not obliged to keep liis bed, 
 and to whom a lying position is even, in general, more 
 troublesome and injurious than an erect one. This 
 
84 
 
 observation applies to the treatment of fractures of the 
 oiavicle, of the scapula, and even of the fore-arm, 
 when no accident has rendered them complicated. 
 
 Desault has cured several patients, but more par- 
 ticularly two, vi^ho, being obliged to travel daily, did 
 not, except on the day of the accident, deviate in any 
 measure from their usual mode of life. 
 
 ,^ An inexperienced surgeon sometimes applies the 
 rollers too tight, in which case, a swelling of die fore- 
 arm is the consequence. This is remedied by relax- 
 ing the bandage; but if, notwithstanding this, the 
 swelling still continues, it will be necessary to extend 
 the bandage from the hand to the shoulder. 
 
 § VII. 
 
 or THE SUBSEQUENT TREATMENT. 
 
 24. The pain ceases as soon as the apparatus is 
 applied, because the fragments, now brought into 
 perfect contact, cease to irritate the sun'ounding parts. 
 Nor does it return during the treatment, as they are 
 firmly retained, and not suffered ag-ain to separate. 
 
 It is rare that any serious accident follows this 
 fracture, and, among the numerous examples met 
 with by Desault, he has scarcely ever had one such 
 to encounter : yet he generally paid but little atten- 
 tion to those internal means which are usually com- 
 bined with external ones. In most cases, the patients 
 pursued the regimen to which they had been accus- 
 tomed. 
 
 In cases, where a considerable swelling attacked 
 tiie upper part of the joint, a circumstance which 
 
85 
 
 occasionally occurs in practice, one or two bleedings, 
 a diet more or less strict, and the use of diluent 
 drinks, constituted the internal treatment. Of this 
 the following case, related by Brochier, furnishes a 
 detail. 
 
 Case II. Maria Catharine BardeHe, aged forty- 
 five, of a high complexion, fell, as she was carrying 
 a heavy load, on the elbow of the right side, the arm 
 being extended a little from the body. The neck of 
 the humerus was fractured, and all the usual signs 
 combined in pointing out the nature of the accident. 
 
 A surgeon was immediately called, who mistak-* 
 ing it for a luxation, made useless attempts to reduce 
 it, tormented the patient for half an hour, and then 
 left her to be sent to the Hotel-Dieu. 
 
 Desauit discovered it at first sight to be a fracture, 
 and foreseeing the consequences of the improper 
 steps that had been taken, ordered blood-letting, and 
 a low diet, after having effected the reduction, and 
 applied the apparatus already described (20). 
 
 In the evening, a considerable swelling appeared 
 around the articulation; the pains continued; a dilut- 
 ing di'ink composed of dog- grass and oxymel was 
 prescribed. Second day, the sv»^elling is gaining 
 ground; pains increased; blood drawn again; diet 
 and drink continued; apparatus is frequently wet 
 with vegeto-mineral water, particularly at the upper 
 part. Third day, a little better; pains diminished, 
 swelling checked; weak soup is allowed. Fourth 
 day, a diminution of the swelling; pains almost gone. 
 Sixth day, the swelling has almost disappeared; light 
 food; bandage, having become loosened, is reapplied. 
 
86 
 
 Tenth day, tongue foul ; nausea; want of appe- 
 tite; symptoms of a bilious diathesis. Bitter drink 
 is prescribed; the day following, a grain of tartar 
 emetic is given in solution. 
 
 Thirteenth day, the patient is in her ordinary 
 state; the apparatus is renewed. Twenty-fourth day, 
 the reunion is evidently advancing. Thirty- second 
 day, the consolidation is complete. 
 
 The patient now begail to perform gentle mo- 
 tions with the limb, which she gradually increased, 
 till about the fortieth day, when she was perfectly 
 well, and free in all her motions. 
 
 25. I will here repeat an observation, already 
 made, on the subject of the bandage for the clavicle, 
 of which this is nothing else than a modification. In 
 a short time the bolster sinking downward, the ban- 
 dage becoming relaxed, and the splints less tight, do 
 not eifectually oppose a displacement, unless the ban- 
 dage be daily examined, and reapplied, when it seems 
 to act too feebly. There are many surgeons, who 
 have not been fortunate in retaining the fragments 
 with exactness, because, trusting too far to the action 
 of the bandage, they have for a long time neglected 
 to examine it ; this remark is applicable to every 
 apparatus composed of rollers. 
 
 26. Here, much more than in other cases, it is 
 all- important that the limb be accustomed to motion, 
 after the process of consolidation. Situated near to 
 the joint, the fracture always leaves some stiffiiess in 
 it, which time no doubt wears away, but which will 
 sooner disappear under the above treatment. 
 
87 
 § VIII. 
 
 REMARKS ON COMPLICATED FRACTURES. 
 
 27. Complicated fractures of the neck of the hu- 
 merus are to be classed with all other accidents of a 
 similar nature, and it would be difficult here to lay 
 down such general rules as would be applicable to 
 every case. The practitioner must be always govern- 
 ed by circumstances. The necessity of the case 
 sometimes urges him to the adoption of daring mea- 
 sures, which, in developing the resources of the art, 
 do honour to the talents of him who exercises it. Of 
 this the following case is a proof. 
 
 Case III. Pierre Lena, aged fifteen, as he was 
 at work on a scaffold, forty feet from the ground, fell 
 from that height on the comer of a stone. He expe- 
 rienced instantly such severe pains ^ that he was una- 
 ble to rise. He was carried to the house of a surgeon, 
 who, believing that he had suffered a luxation, made 
 fruitless attempts to reduce it, produced in the part 
 an enormous swelling, augmented his pains, and all 
 to no purpose. 
 
 The patient was carried to the Hospital of Chari- 
 ty, where Desault at the time was surgeon in chief. 
 A fracture of the neck of the humerus was discover- 
 ed, through the tumefaction and echymosis, which 
 had overspread the whole shoulder. A suitable ban- 
 dage was applied. 
 
 A few days afterwards, a manifest fluctuation, an 
 evidence of an effusion of blood, disclosed the neces- 
 sity of making an opening. This was accordingly 
 done, and the fingers being introduced into the part. 
 
88 
 
 several large splinters were discovered, and a sharp- 
 pointed bone, the end of the lower fragment, pricking 
 the deltoid muscle, and occasioning, no doubt, the 
 pains which had hitherto continued without inter- 
 mission. 
 
 The indication was evident. To give vent to all 
 the splinters, and cut off the pomt of the bone, or to 
 amputate the limb, was the only alternative that was 
 left. Most of the practitioners that were consulted 
 were in favour of the last measure. But Desault ven- 
 tured to repose a hope in the first, the successful is-» 
 sue of which would be the certain preservation of 
 the limb. He performed the operation as follows. 
 
 A large incision made in the posterior, and one 
 stiU larger in the anterior part of the arm, enabled 
 him to remove with ease all the splinters. Then ta- 
 king hold of the pointed extremity of the inferior 
 fragment, he drew it through the anterior opening, 
 and cut it off with a saw and a pair of cutting forceps. 
 He then replaced it with his fingers, and fixing the 
 head of the bone in its proper position, applied an 
 apparatus somewhat similar to that intended for the 
 retention of fractures. 
 
 A suppuration taking place, the patient was dres- 
 sed every day. Several abscesses were formed duiing 
 the course of the treatment ; each time the pus was 
 discharged by means of an incision. 
 
 At the end of four months, the bone was perceiv- 
 ed to be in a state of necrosis. The dressings were 
 regularly continued ; but the patient, becoming tired 
 of his residence in the hospital, left it, being able to 
 move without difficulty, and having, in the upper 
 
89 
 
 part of his ami, a deep fistula, from v^Ahence there was 
 a constant escape of ichorous matter, and through 
 which several splinters were discharged, in the space 
 of six months which he passed at his own house. 
 
 About the expiration of this period he returned 
 to the Hospital of Charity. Desault had, in the mean 
 time, left this institution to take charge of the Hotel- 
 Dieu. Amputation was proposed to the patient as his 
 only resource. He refused to comply, and went to 
 Desault, who, examining the state of the parts, found 
 an irregular callus formed, which he removed, toge- 
 ther with a portion of the soft parts corresponding to 
 the jfracture. At the end of two months and a half, 
 the patient was dischai'ged perfectly cured, except a 
 weakness in the limb, which disqualified him for hard 
 labour. 
 
 28. This case may thi^ow considerable Jight on 
 the difficult question relative to amputations at the 
 joint. But this is not the place to state the ideas of 
 Desault on that point of practice. 
 
 I will only observe, that in many cases of gun- 
 shot wounds, a similar treatment would probably 
 save life, without exposing the wounded to the dan- 
 gers of an operation, in which so considerable a por- 
 tion of the system cannot be removed with impunity, 
 and would secure to them a limb, for the preservation 
 of which they ought not to shrink from the pains and 
 hazards of a tedious treatment. To sacrifice a part 
 for the preservation of the whole, is tlie last resource 
 of the art. It is necessary, before resolving on this, 
 to exhaust those previous ones that might restore the 
 whole of our organs to life and their proper functions. 
 
 13 
 
90 
 
 MEMOIR VI. 
 
 ON THE FRACTURE OF THE LOWER EXTREMITY 
 OF THE HUMERUS, WITH A SEPARATION OF 
 THE CONDYLS. 
 
 1. Fractures of the humerus, accompanied 
 with a separation of the condyls, appeal' to have 
 escaped the notice of most authors who have written 
 on diseases of the bones. The ancients have trans- 
 mitted nothing to us on this point. Petit, Duverney, 
 and Bell, among the moderns, have made no mention 
 of it. Heister adverts to this fracture of the bone, 
 only to express an unfavourable prognostic respecting 
 it, without determining the mode in which it is to be 
 remedied. Yet it is by no means rare to meet with 
 examples of it in practice. Desault, in particular, 
 has had frequent occasions to observe it. 
 
 OF ITS VARIETIES AND SIGNS. 
 
 2. These fractures, like those of the condyls of 
 the OS femoris, are rarely the effect of a counter- stroke. 
 They are almost always produced by the immediate 
 action of external bodies; such, for instance, as a fall 
 on die joint of the arm ; the wheel of a caiTiage pass- 
 ing over this part, &c. &c. 
 
 3. Whatever may be their cause, they generally 
 occur in such a manner, that a longitudinal division 
 separates the condyls from each other, and, extending 
 
91 
 
 upwards to a greater or less distance, is terminated by 
 another transverse or oblique division, w^hich passes 
 through the whole thickness of the body of the bone, 
 so that there are three fragments, and two fractures. 
 
 4. Sometimes the division is simple; in which 
 case, being directed outwards or inwards, it crosses 
 the lower end of the humerus, obliquely from above 
 downwards, and terminating at the joint, separates 
 but one of the condyls from the body of the bone, 
 leaving the other adhering to it. 
 
 5. In the first case (3), there is more deformity 
 at the broken extremity of the humerus; and the 
 mobility is also greater. If the fingers, placed before 
 or behind, press on the limb in the direction of the 
 longitudinal fracture, the two condyls will be separa- 
 ted from each other, the one yielding in an outward, 
 and the other in an inward direction, leaving a fissure 
 or opening between them. The part at the same time 
 expands in breadth. Thus, the two condyls of the 
 OS femoris, are seen to separate from each other when 
 in a similar fracture, pressure is made on the rotula. 
 The fore-arm is almost constantly in a state of pro- 
 nation. When we take hold of one of the condyls 
 in each hand, and eixleavour to make them move in 
 opposite directions, they can be brought alternately 
 forward or backward : and, if tlieir surfaces touch, 
 a manifest crepitation is heard, 
 
 6. In the second case (4), the condyls cannot be 
 so easily separated from each other; but it is alv/ays 
 practicable by taking hold of that one which is divided 
 from the body of the bone, and moving it from before 
 backward, to produce a crepitation, which is a sufii- 
 
I 92 
 
 cient proof that a fracture exists. In a case where the 
 external condyl was alone separated, Desault found 
 the limb in a constant state of supination, a position 
 to be attributed, without doubt, to the muscles attach- 
 ed to this condyl. 
 
 7. An acute pain, the almost inevitable effect of 
 the flexion or extension of the fore-arm, the habitual 
 semi-flexion of the limb, a tumefaction of it some- 
 times supervening, and a swelling more or less con- 
 siderable, around the joint, are symptoms which ac- 
 company both modes of division (3 and 4). The 
 fracture may further be rendered complicated by 
 means of wounds, splinters, &c. when the blow has 
 been very severe, or when a pointed fragment has 
 made its way through the sun'ounding soft parts, &c^ 
 
 § II. 
 
 OF THE PROGNOSIS. 
 
 8. The preceding assemblage of signs, leaves in 
 general but little doubt on the subject of the diagno- 
 sis; but is the establishment of a solid prognosis 
 attended with the same facility ? 
 
 If authors be consulted, they will be all found to 
 agree, in considering the communication of fractures 
 with a joint as a complication of a very serious na- 
 ture. A swelling of the adjacent parts, their inflam- 
 mation, a continuance of the pains after the reduction, 
 extensive abscesses, a gangrene even of the soft parts, 
 and a caries of the bones ; such, according to these 
 authors, are the almost inevitable consequences of 
 th^se kinds of fractures^ of which an anchylosis ia 
 
93 
 
 the most favourable termination that can be expected. 
 Petit, Heister, and Duverney, do not describe the 
 evils that accompany these accidents. Pai'e, in speak- 
 ing of them, says, " In such cases, the violence done 
 to the tendons generally gives rise to great inflamma- 
 tion. 
 
 9. From whence can arise these exaggerated 
 fears ? Can it be, as is pretended, the mere commu- 
 nication of the fracture with a joint, that is productive 
 of such serious affections? What relation, then, can 
 reason discover between the cause and the effect? 
 Does not experience answer in other cases, in a 
 manner that admits of no reply, when it furnishes us 
 with the analogy of fractures of the rotula, the ole- 
 cranon. Sec? 
 
 Modern researches have entirely abolished the 
 ancient theory of an effusion of callus into the joint, 
 and with it one of the principal causes assigned by 
 writers for the accidents and evils which they so 
 much dreaded. 
 
 The admission of air into an articular cavity, 
 would be, without doubt, in such cases, a considera- 
 tion of more weight ; but this does not occur except 
 in fractures accompanied with wounds, and yet all 
 those in the vicinity of joints, whether compound of 
 not, are regarded as extremely dangerous. Besides, 
 observation has oftentimes proven to Desault, that 
 even the contact of air is not so dangerous as it has 
 been commonly supposed, and many instances oc- 
 curred to him in his practice, where, notwithstanding 
 such a complication, a perfect cure was obtained. 
 
94 
 
 10. It is, then, to the want of a skilful mode of 
 treatment, and to the irritation experienced in the 
 parts, in consequence of an ill-constructed apparatus 
 being applied to them, that the accidents formerly- 
 mentioned (8) ought to be attiibuted. Such acci- 
 dents never occurred to Desault, in any of the nume- 
 rous cases that fell under his care. It is thus that in 
 the fracture of the neck of the os femoris, the insuf- 
 ficiency of the means, is oftentimes productive of 
 unfavourable results. 
 
 III. 
 
 OF THE REDUCTION, AND THE MEANS OF MAIN- 
 TAINING IT. 
 
 11. The displacement here is, in general, incon- 
 siderable, because, being drawn in contrary direc- 
 tions, by the muscles of the arm and fore-arm, the 
 condyls separated from the bone remain stationary 
 between these two forces. A fall, a percussion, or 
 some other external cause, can alone produce a dis- 
 placement, by communicating some degree of mo- 
 tion to the fragments. Nov/, from what was formerly 
 said (5 & 6), the condyls may, under such an impulse, 
 move either forward or backward, or else may sepa- 
 rate from each other, leaving between them an inter- 
 mediate void. Hence tlie apparatus ought to oppose 
 to them a resistance in diese four directions, namely, 
 inward, outward, forward, and backward ; a resist- 
 ance which it will be easy to make, by means of four 
 splints, placed in these directions, and properly re- 
 tained by a roller. The two lateral splints, are paiti- 
 
95 
 
 cularly necessaiy, when the condyls are both separated 
 from the body of the bone, and divided from each 
 other (3). If one of them be still attached to the hu- 
 merus (4), a splint on that side becomes less useful. 
 
 12. It is needless for the apparatus to extend as 
 high up as in a fracture of the arm. What effect, in 
 sustaining the fragments, would casts of a roller have, 
 when applied to the body of the bone, above the place 
 of division? Their only advantage would consist in 
 compressing the brachial and triceps muscles, and in 
 that way preventing their action. 
 
 On the other hand, the roller must be continued 
 along the fore-arm, in order that the elbow joint may 
 correspond, according to the judicious precept of 
 Paul of Egina, to the middle of the bandage, which 
 is in general more compact and solid, in the middle 
 than in any other part, and also, that a slight com- 
 pression may be thus made on the muscles attached 
 to the condyls. 
 
 13. The pieces which compose the appai'atus, are 
 1st, A roller five or six yai^ds long, and three inches 
 broad, made of soft linen or muslin, and rolled up in 
 a ball. 2dly, Four splints (11), two of them flexible 
 in the middle, in order that they may bend to fit the 
 fold of the arm, and the elbow, and the other two very 
 strong and inflexible, intended to be applied at the two 
 sides. 
 
 14. Eveiy thing being arranged, the reduction is 
 effected in the following manner. One assistant is 
 directed to make extension at the upper part of the 
 arm, which he grasps with both his hands; another 
 makes extension on the fore-arm half-bent, which he 
 
96 
 
 uses as a lever of the second kind,* where one of his 
 hands, being placed under tlie wrist, forms a fulcrum, 
 while the other applied towards the fold of the arm, 
 represents the power. The surgeon, in the mean time 
 brings the condyls together, adjusts their level and 
 apposition, both between themselves, and with the 
 body of the bone, and then proceeds to the application 
 of the apparatus, the limb being still kept in a half- 
 bent position, as was long since recommended in 
 such cases by Paul of Egina. '■'■Si in 'oicinia cubiti 
 brachium fr actum est, etiam ipse cubitus deligandus,, 
 angulari Jigura seroata.'''' 
 
 15. The roller (13), wet with vegeto- mineral 
 water, which facilitates its application, and prevents 
 the swelling of the part, is fastened by one of its 
 ends, about two-thirds down the fore-arm, and con- 
 tinued upv/ards by oblique and reverse casts, to the 
 joint. The surgeon then passes a cast of the roller 
 from the anterior and superior part of the fore -arm, 
 to the posterior and inferior part of the arm (humerus), 
 redescends by an oblique cast irom the other side, 
 over the fore-arm, and returning along the first track, 
 makes a number of casts in the form of the figure of 
 8, round the joint, which he next covers by circulai* 
 casts, applied so close to each other, as to leave no 
 opening between them ; he then proceeds upwai^ds by 
 oblique casts, as at the first, to the middle pait of 
 the arm (humerus), when the roller is given into the 
 hand of an assistant. 
 
 * In this form of lever, the power is applied between the 
 fulcrum and the weight to be moved, or the resistance to be 
 overcome. Trans. 
 
91 
 
 The first of the sphnts (13) is now placed anteri- 
 orly on the fore -arm and arm, and, if it does not bend, 
 in such a manner, as to accommodate itself to the 
 fold of the arm, the vacant space beneath it is filled 
 up with compresses, laid on top of each other, so as 
 to make its compression uniform throughout. The 
 second, being applied on the posterior side part of 
 the arm, moulds itself to the projection of the elbow, 
 while the other two occupy the sides. These are se- 
 cured below by an assistant, while the surgeon resu- 
 ming the roller, which he had just given out of his 
 hand, fixes them firmly by circular casts descending 
 along the arm and fore-arm. 
 
 The limb is then laid on a pillow, so disposed 
 that the hand may be raised higher than the elbow, 
 in order to prevent the subsequent swelling, which is 
 oftentimes produced by the firacture, as has been al- 
 ready mentioned (7). 
 
 16. The eifect of this bandage is simple, and has 
 a particular relation to those directions and causes, in 
 and by which, displacements might occur. The two 
 lateral splints prevent the separation of the condyls 
 fi'om each other; the anterior and posterior ones pre- 
 vent them from moving backward or forward ; the 
 muscles are compressed ; the motion of the joint is 
 prevented ; and, in common, no great length of time 
 is necessary for the reunion of the bone. 
 
 As soon as this is accomplished, it is of impor- 
 tance to move the limb in every direction, to pre- 
 vent that stiffiiess, which is so commonly the conse- 
 quence of fractures situated in the neighbourhood 
 of joints. The following case, drawn up by Le- 
 
 14 
 
9^ 
 
 geuUe, will furnish the reader with a detailed account 
 of the treatment pursued, in such accidents, by De^ 
 sault. 
 
 Case I. Joseph Kisler, an ostler, aged forty- 
 one, fell from a height of thirty feet, on the left side, 
 his arm being undermost, and fractured the lower 
 end of the humerus. A surgeon gave him immedi- 
 ate assistance, and, at the expiration of two days, he 
 was caiTied to the Hotel-Dieu. 
 
 From the signs formerly mentioned (5 and 7), De- 
 sault discovered a fracture, consisting in a separation 
 of the condyls from each other, by a longitudinal di- 
 vision, and from the body of the bone, by a transverse 
 one. The usual apparatus (16) was applied, and, 
 from a state of extreme anguish, which he had till 
 now suffered, the patient experienced immediate 
 relief. 
 
 In the mean time, a considerable swelling around 
 the joint, pointed out the necessity of blood-letting, 
 a low diet, and other antiphlogistic remedies. These 
 were immediately liad recourse to, and the limb was 
 placed in the proper position (16). 
 
 Not^vithstanding these precautions, the tumefac- 
 tion and redness were increased on the following day. 
 The bandage was applied anew, and wet from time 
 to time with vegeto-mineral water. 
 
 On the following days, pain less severe, the ban- 
 dage kept constantly wet with the same fluid. 
 
 Eighth day, the swelling almost gone ; the appa- 
 ratus, being loosened, was again reapplied. 
 
 Fifteenth day, the fragments, being examined, 
 were found in regulai' contact, and already united by 
 
99 
 
 a substance of considerable firmness ; the strictness 
 pf regimen gradually relaxed ; solid food taken in 
 small quantity. 
 
 Nothing new till the twenty- second day, when 
 the splints were laid aside, having become useless, 
 in consequence of the rapid progress of reunion : 
 from this time till the completion of the cure, no- 
 thing was used but the simple roller. 
 
 On the twenty-fourth day, gentle flexion and ex- 
 tension of the arm and fore -arm were for a short time 
 performed; these movements were attended with 
 acute pain, notwithstanding which, the fortitude of 
 the patient enabled him to persevere in them. 
 
 Thirtieth day, no pain accompanies the m.ove- 
 ments of the arm : the range of these movements 
 visibly increased ; the roller laid aside ; from this 
 time the range of motion increases rapidly. 
 
 On the thirty- seventh day, the patient w^as dis- 
 charged perfectly cured, and free from every vestige 
 of his disease, except a trifling stiffness, which was 
 doubtless soon removed by the motions of the joint. 
 
 17. When wounds, splinters, or severe contu- 
 sions, render these kinds of fractures more compli- 
 cated, an inflammation occurring on the articular sm'- 
 faces, may cause them to unite together, and by that 
 means give rise to an anchylosis. But this accident, 
 inevitable in such a case, according to WTiters, does 
 not always occur, provided nature be assisted, by a 
 judicious mode of treatment, in her attempt to re- 
 unite the broken bone. Desault has established this 
 truth, in many instances. Here, as in other joints, 
 he has oftentimes obtained a complete cure, without 
 
100 
 
 the loss of motion, although the part had sustained 
 the greatest violence. Incisions, easily made, the ex- 
 traction of splinters, a frequent renewal of dressings, 
 a most vigilant care to prevent all jarring of the limb, 
 and consequently all derangement of the contact of 
 the fragments, an assemblage or combination of those 
 minute attentions, which art cannot teach, which ge- 
 nius suggests, and which characterize the true sur- 
 geon ; a precaution (not to be dispensed with) to 
 make the limb perform motions, gentle at first, but 
 gradually increased afterwards, when the adhesion of 
 the parts has acquired sufficient solidity to admit of 
 it ; such are, in general, the steps and circumstances 
 constituting the bases of that treatment, requisite in 
 these complicated fractures, which, like all others, 
 appear, in each case, to assume a new aspect, and 
 to present different indications. 
 
 C A SE II. A person, carrying a heavy burden, fell 
 with his elbow on a sharp corner of a bar of iron. 
 The external condyl was broken, being separated 
 from the body of the bone, by an oblique division 
 running into the joint. Anteriorly, a large contusion; 
 posteriorly, a transverse wound; on the outside, the 
 end of the condyl projecting through the soft parts, 
 which it had lacerated : such were the complications 
 of a fracture, for which the patient was admitted into 
 the Hotel-Dieu, on the seventh day of January, 1794. 
 
 On examining the state of the parts, Desault dis- 
 covered, in the transverse wound, two splinters which 
 vv'hen extracted, gave vent to an effusion of blood. 
 He reduced, instead of cutting it off, as authors have 
 advised, the end of the separated condyl, applied a 
 
101 
 
 bandage of of strips,* and, to prevent accidents, or- 
 dered a strict diet, copious blood-letting, and dilut- 
 ing drinks. 
 
 Compresses wet with vegeto-mineral water, kept 
 the apparatus constantly moist. 
 
 On the day following, the dressing was renewed 
 superficially ; severe pains in the part ; abated towards 
 evening; almost gone next day; low diet continued. 
 
 Fourth day, pains returned ; an incipient swell- 
 ing around the joint; more blood drawn. 
 
 Sixth day, considerably better; all the apparatus 
 renewed ; suppuration beginning to appear. 
 
 Tenth day, a small abscess on the external condyl 
 opened, and a splinter extracted posteriorly. 
 
 Fifteenth day, the parts assume a flattering aspect; 
 suppuration favourable; fragments in contact; from 
 this time the dressings are less frequent. 
 
 Twentieth day, a bilious diathesis ; edges of the 
 wounds livid; loss of appetite; nausea; vomiting; 
 an emetic is administered. 
 
 * (Bandage a bandalettes.) This is a most convenient form 
 of bandage, in fractures of the upper or lower exti^emities. It 
 is composed of strips of soft linen or muslin, from two to thi'ee 
 inches wide, and of a length accommodated to the size of the 
 limb, on which they are to be applied. These strips are not 
 sewed together, but merely laid along side of each other, or ra- 
 ther spread in such a way that their adjoining edges may over- 
 lap a little. Being thus arranged, on the bed or matrass, where 
 the patient is to lie, the broken limb is placed on them, when 
 the surgeon, taking them, one by one, folds them round it, so as 
 to form a very perfect and neat covering. The number of these 
 strips must be regulated by the extent of the limb, or, at least, 
 of that portion of the limb, which they are intended to cover. 
 
 Trans. 
 
102 
 
 Thirtieth day, unfavourable appearances gonej 
 reunion commencing; wounds visibly healing. For- 
 tieth day, all external injuries healed, except the one 
 situated anteriorly ; callus already very firm ; gentle 
 motions performed with the limb, which is still sur- 
 rounded by the apparatus. 
 
 Forty- seventh day, the apparatus become useless; 
 motions gradually increased; articulation aheady 
 tolerably free. Fifty-seventh day, bilious diathesis 
 returned; low diet and evacuants. Sixty-fifth day, 
 the patient discharged from the hospital ; consolida- 
 tion perfect; wounds entirely healed; motions of 
 extension still difficult to be performed in their full 
 extent, but are recovered in a great measure, and 
 will doubtless, in a short time, be completely re-esta- 
 blished, provided the same mode of treatment be 
 continued. 
 
 MEMOIR VII. 
 
 ON THE LUXATION OF THE HUMERUS. 
 
 GENERAL REMARKS ON THE JOINTS, AND ON 
 THAT OF THE HUMERUS IN PARTICULAR. 
 
 1. Nature, who, according to the wants of dif- 
 ferent species of animals, has vai'ied the number of 
 their articulations, knows also how to vary their 
 structure, according to the uses of the different parts 
 of their bodies. With great mobility, she has some- 
 times connected great solidity and strength, as is the 
 
103 
 
 case in the vertebral column ; in other instances, parts 
 very solid and compact, are capable of performing 
 but feeble motions, as the carpus, the tarsus, Sec. 
 And, lastly, other paits, again, capable of great mo- 
 tion, possess so little solidity and firmness as to be 
 easily deranged by the action of external bodies.. 
 Such, in man, is the articulation of the humerus with 
 the scapula, of the sternum with the clavicle, &c. 
 
 2. Hence there exist three classes of articulations, 
 very different from each other. To the last, as enu- 
 merated above, belongs, in a particular manner, the 
 history of luxations, and, in this, as the solidity varies, 
 thefi^equency of dislocations is equally various ; no lux- 
 ation occurs more frequently than that of the hume- 
 rus ; indeed, m a comparative catalogue of accidents 
 of this kind, it alone has, during certain years, occur- 
 red oftener, in the Hotel-Dieu, than that of all the 
 other bones, taken collectively. 
 
 3. Every thing seems to favour the escape of this 
 bone from its natural cavity. 1st, On the part of the 
 articulating surfaces, a cavity somewhat oval and very 
 shallow, aided by a slight cartilaginous ring, receives 
 a half- spherical head, twice its own diameter fi-om 
 above downwards, and three times as large from be- 
 fore backwards. 2dly, On the part of the ligaments, 
 this articulation is strengthened by only a simple 
 capsule. This capsule is thin and weak on its lower 
 side, a direction in which there is nothing to prevent 
 a luxation, while it is thicker on its upper side, wherc 
 the acromion and coracoid apophyses, and a strong 
 ligament, present an obstacle almost insurmountable. 
 3dly, As far as respects the muscles and the motions 
 
104 
 
 of the joint, strong and numerous bundles of fibres 
 surrounding the articulating surfaces, communicate 
 to them motions easily performed in every direction, 
 and which, by pushing the head of the humerus 
 against the different parts of the capsule, distend it, 
 predispose it to laceration, and indeed even rupture 
 it, when the quantum of their force is superior to its 
 resistance. 4thly, As far as relates to external bodies, 
 what bone is more exposed to their action than this, 
 particularly among that class of persons, engaged, for 
 a livelihood, in hai'd labour? 
 
 4. Subject to the influence of these different pre- 
 disposing causes, the humerus would be constantly 
 liable to luxations, did not the scapula, moveable like 
 itself, furnish it, by accompanying its motions, with 
 a point of support, differently disposed, according to 
 the different position of its superior extremity ; so 
 that, to this two-fold mobility of the articulating sur- 
 faces, is to be attributed, in a great measure, the 
 stability of their connexion. 
 
 OF THE KINDS OF THIS LUXATION, 
 
 5, The upper articulation of the humerus, though 
 predisposed, in general, to luxations, is not equally 
 so in every direction. There is a point at which lux- 
 ation cannot take place. There are others, where, 
 though possible, this accident has never been obser- 
 ved. It is necessary, therefore, before examining 
 the mechanism of this luxation, to mention with pre- 
 cision, the directions in which it may occur. On this 
 
105 
 
 point, writers have differed in a very singular man- 
 ner. Sometimes, to express the same thing, they have 
 used a different language ; and, at other times, have, 
 by the same words, expressed things widely different. 
 Always agreeing as to certain modes of dislocation, 
 they have been divided as toothers; while, in the 
 midst of those contrarieties, the surgeon being em- 
 barrassed, is at a loss on what ground to found his 
 practice. 
 
 6. The ancients, knowing but little of the natural 
 relation of the parts surrounding the joint, were ig- 
 norant of the accidental ones, which these several 
 parts assume, in the case now under our considera- 
 sion. Hence, without doubt, arises the confusion, 
 of their opinions on the subject. 
 
 Many admitted of four kinds of luxations; a 
 great number acknowledged only three; some sub- 
 scribed to but two; while others believed in the 
 possibility of none but one. 
 
 7. The first divided differently the directions in 
 which the bone might be luxated. Some contended 
 for luxations upward, doMaiward, forward, and back- 
 ward; and such was the opinion of the first Greek 
 physicians, predecessors to the father of medicine, 
 who has transmitted the opinion to u^ accompanied 
 with a demonstration of its fallacy. Others have divided 
 them into those that take place downward, upwai'd, 
 outward, and forward. This division is adopted by 
 Galen, who yet produces only an example of a for- 
 ward luxation, and does not give us to understand 
 what he means by a luxation upward and inward. 
 
 15 
 
ma 
 
 8. The second distinguished the modes of this 
 luxation, sometimes into downwai'd, forward, and 
 backward; as was the case with Oribazes; at other 
 times, into downward, outward, and inward, accord- 
 ing to the opmion of Paul of Egina, who, no doubt, 
 adopted exactly the preceding divison, expressing it 
 only in different words; sometimes into downward, 
 forward, and up\T'ard; such was the sentiment of Al- 
 bucasis, who, notwithstanding, considered a luxation 
 upward, as a very difficult, and yevy rare occurrence. 
 
 9. The third were of opinion, that, in undergo- 
 ing a displacement, the head of the humerus could 
 be earned only downward, under the aiTQ-pit, which 
 is the most common direction, or forwai'd, a course 
 which it takes more rarely. Celsus is almost the only ^ 
 •writer who has contended for this division, " Hu- 
 7nerus, says he, modo in alam excidity modo in par- 
 tem priorem.'''' 
 
 10. Lastly, The fourth believe, with Hippocrates^, 
 in none but a displacement downwards, the only 
 one which that physician has met with in his prac- 
 tice. " At liero humerus^ inferior em in partem exci- 
 dit; aliajn in partem excidere non audivi.'''' 
 
 11. The moderns, in borrowing from the ancients 
 their divisions of luxations, did not, like them, de- 
 termine a priori and in a vague manner, the precise 
 spot and direction of displacement; but ascertained 
 these points by subsequent observation, wAih. more 
 precision, in proportion as a knowledge of anatomy 
 shed light on them. They also paid particular atten- 
 tion to the essential difference betv/een primitive and 
 consectiti-s'e luxations. 
 
107 
 
 12. Petit adttiitted of four kinds of luxations, 1st, 
 downwai'd, on the edg-e of the scapula : this is a very 
 rare occurence : 2dly, outward, under the spine of 
 tliat bone, a kind very difficult to be primitively pro- 
 duced. 3dly, inwards, under the hollow of the aim- 
 pit. 4thly, forward, between the corocoid apophysis 
 and the clavicle. With this illustrious practitioner, 
 Heister acknowledged four kinds of displacements; 
 but, here again, Vv^as a new variety, both in expres- 
 sion, and in meaning. The one says, downvi^ard, 
 under the arm-pit, the other forwai'd, under the pec- 
 toralis major; the one, backv/ard, under the sca- 
 pula, the other outward, under its spine. Accord- 
 ing to Duverney, luxations are never primitively in 
 any other direction than downwai'd ; the others being 
 only the subsequent effect of muscular action. 
 
 13. In the midst of these very complicated modes 
 of treating a very simple subject, it is necessarj^, first, 
 in order to acquire definite ideas, to divide luxations 
 of the humerus into primitive, which are the imme- 
 diate effect of external violence, and consecutive, 
 which succeed the primitive, through the influence 
 of causes which I am about to consider. 
 
 Let us suppose four lines to inscribe, in form of 
 a parallelogram, the oval surface of the glenoid cavity, 
 one representing the superior edge, another the inferi- 
 or, a thu'd the internal, and the fourth the external. 
 
 14. It is evident that the head of the humerus 
 cannot be displaced towards the superior edge. In that 
 direction, must be encountered, the acromion and 
 corocoid apophyses, the strong ligament passing be- 
 tween them, the tendons of the triceps and supra- 
 
108 
 
 spinatus muscles, and the fleshy mass of the deltoid; 
 all which, taken together, constitute an insurmount- 
 able obstacle to the escape of die head of the bone 
 upwards. Besides, wliat power could carry it up- 
 wards? In order that this kind of luxation might take 
 place, it v/ould be necessary, that the head of the 
 bone should be carried outwards at the same time, 
 as well as upwards, a circumstance which is im- 
 possible, because the trunk prevents the lower extre- 
 mity (the elbow) from being directed sufliciently 
 inward to produce such an effect. 
 
 15. On the contrary, in other directions, but veiy 
 little resistance is to be met with. Towards the infe- 
 rior edge of the cavity, the long portion of the triceps; 
 the tendon of the subscapularis, towards the internal 
 edge ; and towards the external edge, the tendons of 
 the infra-spinatus, and teres minor, yield with ease 
 to a force directed against them, and permit the occur- 
 rence of primitive luxations, downward, inward, and 
 outward. Downward, between the tendon of the long 
 portion of the triceps,and that of the subscapularis ; in- 
 ward, between the subscapulary muscle and fossa;* 
 and outward, between the fossa infra-spinatus and the 
 muscle of the same name. These modes of displace- 
 ment are not alike frequent, as will be mentioned pre- 
 sently. 
 
 16. Having escaped from its cavit}", and being 
 primitively placed in one of these tliree situations, the 
 
 * ( La fosse sous-scafiulaire ) . I know of no English anato- 
 mical term for this. I therefore translate it literally. The same 
 is true with respect to '■^Jossa sozis-ejiineuse" translated here» 
 fossa infra-spinata. Trans. 
 
109 
 
 head of the humerus oftentimes changes its position. 
 Then, to a primitive luxation downward or inward, 
 succeeds a consecutive or secondary one ; but never 
 to a luxation in an outward direction, if suxih ever 
 occur, because the spine of the scapula forms an ob- 
 stacle to it. 
 
 A secondary luxation inward, may succeed a pri- 
 mitive one downwai'd ; there is nothing to oppose the 
 head of the humerus in the course it takes, to enter 
 between the subscapulary muscle and fossa. If, on 
 the other hand, it be disposed to pass to the external 
 side, the tendon of the triceps opposes it ; and, not- 
 withstanding what Petit has advanced, there is no 
 secondary luxation in that direction. 
 
 17. It sometimes happens, that, having escaped 
 either from the internal part, or from the inferior part 
 of the capsule, the head passes behind the clavicle, 
 and forms there a secondary luxation upwards, as 
 has been observed by Ambrose Pare, and by 
 Gallien, and of which an example or specimen was 
 preserved in the cabinet of Desault. But, here, the 
 secondary displacement must take place in a slow 
 manner, and when it has taken place, art can seldom 
 remove it, on account of the strong adhesions formed 
 by the bony surfaces. Thus, in the example men- 
 tioned, there was a new cavity formed behind the 
 clavicle, and the humerus adhered to the surround- 
 ing parts by a kind of new ligaments. 
 
 18. It appears from what has been said, that the 
 humerus is subject to four different kinds of displace- 
 ment. 1st, Dovinnjoard : 2dly, outward, in both of 
 which directions the luxation is always primitive ; 
 
110 
 
 Sdiy, inwards, where it is sometimes primitive, and 
 sometimes consecutive ; 4thly, upwards, where it 
 can never be otherwise than consecutive. 
 
 The second and fourth are very rare occun*ences, 
 and bear so small a proportion to the others, that the 
 latter alone ought to command the attention of the 
 practitioner. 
 
 \ III. 
 
 OF THE CAUSES AND THE MECHANISM. 
 
 19. The causes and the mechanism of luxations 
 of the humerus, varj^ according as the displacement 
 is primitive or consecutive. 
 
 The action of external bodies, directed against 
 the ai'm, but more particulai'ly falls, where tliis part 
 strikes forcibly against a resisting body, give rise in 
 general to primitive luxations, and, according as it is 
 differently situated at the time of the fall, the hume- 
 rus determines, by its position, the different kinds. 
 
 20. If it be separated from the trunk, without be- 
 ing can'ied either before or behind it, if the elbow be 
 elevated, and the fall be on the side, the weight of 
 the body, being almost entirely supported by this 
 bone, pushes its upper extremity do^viiward, dis- 
 tends the inferior part of the capsule, lacerates it, and 
 produces a luxation do'wn^vard, in which it may even 
 be favoured by the action of the pectoralis major, the 
 latissimus dorsi, and the teres major, as has been ju- 
 diciously observed by Fabre. In such a case, these 
 muscles, involmitarily contracting to support the 
 trunk, act like the power or force in a lever of the 
 second kind, the resistance to which is formed by 
 
Ill 
 
 the head of the bone, which they di'aw downward, 
 while the lower extremity of the humerus, resting 
 on the ground, constitutes the fulcrum. Some au- 
 thors even regard, as an immediate cause of luxation^ 
 the powerful contraction of the dehoid muscle, whicb 
 depresses the head of the bone, and forces it through, 
 the lower side of the capsule, a mode of displacement, 
 the existence of which observation incontestibly esta- 
 blishes. The case of a scrivener, so often cited, is 
 well known, who in liftmg a book of records hixated 
 his humerus in a do"\niward direction. 
 
 21. The mechanism of a primitive luxation in- 
 wards, differs a little from the preceding. The elbow, 
 being at once separated from the trurik, and caiTied 
 backward, the person falls : the Vv'eiglit of the body 
 rests on the humerus ; the capsule is lacerated in its 
 fore-part ; and a displacement in the same direction 
 supervenes. 
 
 22. In a luxation outwards, the elbow is carried 
 jforward, to^vards the opposite shoulder ; the capsule 
 being sti'etched outwardly, gives way in that part, 
 fffovided the humerus be acted on by a sufficient 
 power. But what can this power be ? In a fall, the 
 arm being pushed against the tnmk, and stopped by 
 it, cannot carry its motion to a sufficient extent to 
 produce a laceration of the capsule. Hence a luxa- 
 tion outwards must be extremely rare. Indeed no 
 instance of it is to be found in books of surgery. 
 Desault, in particular, never witnessed it. Besides, 
 when in a fall, the arm, separated from the body, is 
 carried backward or forwai'd, the weight of the body 
 s^cts obliquely on it, and it is but partially subjected 
 
112 
 
 to the action of the latissimus dorsi, the pectoralis 
 major, and the teres major. So that no kind of luxa- 
 tion ought from these considerations, to be very fre- 
 quent, except that in a doi'^oiward direction, where 
 the influence of both causes is direct. Yet luxation 
 inwards is common enough, and in many instances 
 Desault has observed this primitive mode of displace- 
 ment, though many modem authors doubt the fact, 
 believing, with Hippocrates, that, primitively, all 
 luxations are downwards. 
 
 23. It may so happen that in a primitive luxation, 
 the capsule is only greatly stretched, in which case, 
 the articulating surfaces are but pailially displaced ; 
 but this membrane more frequently suffers a rupture, 
 through which the head of the bone escapes. To this 
 phenomenon v/r iters, in general, have paid too little 
 attention, notwithstanding the opening of dead bodies 
 has oftentimes demonstrated its existence to practi- 
 tioners, particularly to Desault, who has given two 
 examples of it modelled in wax ; one, of a luxation 
 inward, and the other downward, both found in sub- 
 jects that died in the Hotel-Dieu. Bell relates some 
 analogous facts, and another English surgeon has 
 also had occasion to meet with them. 
 
 24. Oftentimes, in compound fractures, one of the 
 fragments passes through the integuments. In the 
 dislocation of the humerus something similar to this 
 occurs. The capsule is sufiiciently lacerated to allow 
 the head to escape ; but the opening, being then too 
 narrow, forms around the neck of the bone a noose or 
 kind of collar, which prevents it from re-entering the 
 place which it originally occupied. Thus, in the frac- 
 
113 
 
 tures of which I have just spoken, the aperture In the 
 skin does not, at times, admit of the reduction of the 
 fragment, without a previous dilatation. 
 
 In this case, an attempt is made to reduce the lux- 
 ation : the capsule is pressed in folds against the gle- 
 noid .cavity, and, interposing itself between it and the 
 head of the humerus, renders fruitless the efforts of 
 the surgeon who would replace die bone. Desault 
 was the first who observed this practical fact, two in- 
 stances of which are recorded in his journal, and 
 which has frequently since occurred in the Hotel- 
 Dieu. In such a case, the head is in general extreme- 
 ly moveable, because, being entirely without the 
 capsule, there is nothing to impede its motion. 
 
 25. When, to a primitive luxation a consecutive 
 one succeeds, several causes may concur in its pro- 
 duction. If a second fall happen, the arm, being 
 separated from the body, the head of the humerus 
 having nothing to retain and secure it, obeys, with 
 great facility, the power tending to displace it in that 
 direction, and suffers a firesh removal from the bed 
 which it accidentally occupies. 
 
 Case L A man fell in descending a ladder, and 
 luxated his humerus in a downward direction. De- 
 sault being immediately called, discovered the nature 
 of the disease, but deferred the reduction till evening. 
 In the interval, the patient w€nt to get into a chaise : 
 his foot slipped, and he fell a second time. The pains 
 became more severe than at the time of the first acci- 
 dent; and Desault, on his return, instead of finding, 
 as in the morning, the head of the humerus under the 
 
 16 
 
114 
 
 hollow of the arm-pit, discovered it to be behitid the 
 pectoralis major. 
 
 26. Muscular action is one permanent cause of a 
 new displacement. Suppose the humerus luxated 
 downward, the pectoralis major, and the deltoid mus- 
 cles draw its superior extremity upward and inward, 
 which, offering to their action but a feeble resistance, 
 changes its position and that in a two-fold direction. 
 
 27. The different motions of the arm may also, 
 according to their direction, produce the same effect. 
 Thus we have often witnessed a luxation inwards 
 succeeding to a luxation do"viaiwards, in consequence 
 of unskilful attempts to reduce it. 
 
 § IV. 
 
 OF THE SIGNS. 
 
 28. The diagnosis of luxations of the humerus, 
 presents in general, but few difficulties. 
 
 Whatever may be the mode or seat of the dis- 
 placement, there always exists, as Hippocrates has 
 observed, a manifest depression under the acromion, 
 which exhibits a prominence more perceptible than 
 in its natural state. The motions of the part are al- 
 most all accompanied with pain ; the greater pai't of 
 them are impracticable ; all of them very much con- 
 fined. The arm cannot move, without a synchronous 
 motion of the shoulder, because, the articulation be- 
 ing no longer able to exercise its functions, these two 
 parts constitute, so to spealc, but one body. 
 
 29. Besides these signs, which characterize gene- 
 rally everj^ species of luxation of the humerus, each 
 
115 
 
 species is m^ked by certain others peculiar to itself. 
 If the displacement be downward, the arm is a little 
 longer than in its natural state; it can be moved 
 gently outwards ; but an acute pain is the inevitable 
 consequence of moving it forward or backward. 
 The elbow is more or less removed from the axis of 
 the bod}^ by the action of the deltoid, the long por- 
 tion of the biceps, and the supra- spinatus muscles, 
 which, being unnaturally stretched, contract them- 
 selves and tend to carry the bone outward. The pains 
 which result from this position, force the patient, in 
 order to relieve them, to lean towards the affected 
 side, to keep the fore-arm half-bent, the elbow resting 
 on the hip, so that the arm, finding a place of support, 
 may be freed from the painful movements, and from 
 the disagreeable sensation produced by its own 
 weight. From this attitude alone, was Desault in the 
 habit of discovering luxations in a downward direc- 
 tion, and was rarely mistaken in his diagnosis. It is 
 thus, that, in a fracture of the clavicle, the inclined 
 position of the patient is oftentimes, at first sight, 
 characteristic of the nature of his complaint. Beneath 
 the hollow of the arm-pit there always exists a protu- 
 berance niore or less perceptible, formed by the head 
 of the humerus. 
 
 30. To the general signs of luxations of the hu- 
 merus (28), that in an inward direction adds tlie fol- 
 lowing : the elbow, being separated from tlie trunk 
 of the body, is carried a little backward; the hume- 
 rus seems to direct itself towards the middle Of the 
 clavicle; motions backward are not very painful, 
 while those in a forward direction are extremely so; 
 
116 
 
 under the pectoralis major a manifest protuberance 
 exists; the arm is but Httle longer than in a natural 
 state ; the attitude is the same as in the preceding case.. 
 
 31. Should a luxation in an outward direction oc- 
 cur, it would be pai'ticularly characterized by a hard 
 tumour under the spine of the scapula, by the direc- 
 tion af the elbow forward, by its separation from the 
 trunk, and by a little increase in the length of the arm, 
 
 A protuberance behind the clavicle, an obvious 
 shortening of the arm, together with its direction^ 
 would plainly disclose a luxation upwards. 
 
 32. The signs discriminative of tte nature of 
 luxations of the humerus, are not always accompa- 
 nied by the same degree of certainty as those that 
 announce merely its existence. Thus, nothing is 
 more difficult than to determine when a luxation in- 
 ward is primitive, and when it is consecutive, the 
 same phenomena being common to both. Nothing 
 but an exact history of the disease, stating tlie order 
 in which the phenomena have succeeded each other, 
 can throw light on this point, which is the more in- 
 teresting and important, as, according to the one or 
 the other state of things, the processes of reduction 
 ought to vary. In the first case, the head re-enters 
 its natural cavity by a short route ; whereas, in the 
 second, it arrives there by a much longer one. 
 
 If, as Petit pretended, there exist luxations back- 
 ward, sometimes primitive, and sometimes consecu- 
 tive, the same remark may be applied to them wdth 
 equal propriety. 
 
 33. Certain signs, common to luxations of the 
 humerus, fi^actures of its neck, and dislocations of 
 
117 
 
 the scapulary extremity of the clavicle, might here 
 create some uncertainty, if in the one, the absence of 
 a tumour under the arm-pit, and of a depression under 
 the acromion, did not prevent a mistake, which Hip- 
 pocrates declared to be easily committed, into whichy 
 according to Galen, the masters of the art of wrestling 
 fell, and which Pare cautions us to avoid; and if, in 
 the other, the appearances proper to a fracture, did 
 not prevent a mistake which would be serious in 
 its consequences, and which sometimes results from 
 the direction of the humerus, and the kind of protu- 
 berance formed in the arm-pit, by the end of the in- 
 ferior fragment. (See Fracture of the neck of the hu- 
 merus J. 
 
 § V. 
 
 OF ACCIDENTS PRODUCED BY THE LUXATION". 
 
 34. Luxations of the humerus are but rarely fol- 
 lowed by any serious accidents. Sometimes a swell- 
 ing more or less considerable appears, immediately 
 after the fall, in and around the arm-pit. This is the 
 effect of an increased irritability of the part, and is 
 seldom of long duration. Desault's remedy for it 
 was the application of compresses wet with vegeto- 
 miner?d water, or of cataplasms moistened with the 
 same liquid. 
 
 35. Several authors, particularly Bell, speak (as 
 if it were a familiar accident) of an oedematous swell- 
 ing of the whole upper extremity, caused, in inward 
 luxations, by a compression of the axillary glands. 
 This phenomenon has not often occurred in the Hotel- 
 
118 
 
 Dkii, except in luxations of long standing: and 
 when it has been met with in certain cases, very 
 happy effects have been produced, by the action, 
 continued for several days, of a roller *ipplied widi 
 considerable tightness after the reduction, and reach- 
 ing from the fingers to the arm-pit* 
 
 Case II. Maria ***, falling from some height, 
 her elbow being separated from her body and direc- 
 ted backwards, luxated her shoulder inwardly* Seve- 
 ral days elapsed before she received any surgical aid. 
 She was afterwards admitted into the Hotel-Dieu, 
 where the displacement was disciovered through a 
 very considerable swelling, which occupied the parts 
 ai'ound the articulation of the humerus. The reduc- 
 tion was accomplished, and the swelling left to itself, 
 which, far however from disappearing, with the cause 
 that produced it, seemed to gain ground. A roller 
 was then applied, and on the day following the tu- 
 mefaction was reduced to half its former size. The 
 same means are continued. The compression is gra- 
 dually increased, and by the ninth day, the limb re- 
 stored to its natural form, performs, as before, all its 
 functions. 
 
 36. There is another accident, on which authors 
 have dwelt a little, which was known to Avicenna, 
 and which oftentimes fell under the notice of Desault. 
 I allude to a paral3^sis of the upper extremity, the 
 effect of compression made by the head of the bone, 
 in inwai'd luxations, on the nerves of the brachial plex- 
 us. This accident sometimes resists every expedient , 
 of ait, as appears from the following case, collected 
 bv mvself, in the Hotel-Dieu. 
 
119 
 
 Case IIL Maria Dougour, fell on her right side, 
 and experienced immediately all the signs of a down- 
 ward luxation. A surgeon was called, who moved the 
 bone violently in every direction ; he made no exten- 
 sion ; he kept the patient in torture for an hour ; and at 
 the expiration of that time pronounced the luxation ir- 
 reducible, because the head of the bone, instead of re- 
 turning into its natural cavity, had moved inwardly. 
 Indeed, in the midst of his unskilful efforts, a conse- 
 cutive luxation inwards had succeeded to a primitive 
 one downwards. 
 
 On the same evening, an evident insensibility 
 occurred hi the part. A swelling, joined to a sense 
 of coldness, accompanied it. On the fourth day, the 
 paralysis v/as complete. 
 
 On the tenth day the patient was brought to the 
 Hotel-Dieu, where the processes of art which we 
 shall presently describe, replaced the bone, without 
 removing the effects of its luxation. 
 
 To remedy this, irritating means were employed, 
 simple at first, but multiplied and combined after- 
 wards, and pushed so far as to occasion redness ac- 
 companied by small blisters. These were continued 
 for three weeks ; blistering plasters were applied; all 
 in vain ; the paralysis continued, and as long as a year 
 afterwards the patient was still affected with it. 
 
 37. This accident is, in general, extremely obsti- 
 nate, when, as in the preceding case, the nerves have 
 experienced a long continued pressure. Under such 
 circumstances, the most powerful means are often 
 ineffectual. Moxa has been oftentimes used by De- 
 sauit, which he applied over the clavicle, at the ^^ery 
 
120 
 
 Qrigin of the brachial plexus. The success, with 
 which he at first applied this remedy, did not alway^s 
 accompany his use of it, so that notwithstanding se- 
 veral cures performed by it, yet, to the majority of 
 patients to whom it was applied, it was wholly 
 useless. 
 
 39. But, if the head of the humerus make on the 
 nerves but a momentary pressure, and the reduction 
 be accomplished shortly after the paralytic symptoms 
 occur, oftentimes then the insensibility disappears of 
 itself, and the cure may be alw^ays greatly assisted by 
 the application of powerful stimulants; such, for in- 
 stance, as volatile liniment, composed of oil of al- 
 monds and ammonia, which Desault frequently em- 
 ployed, and of which he increased the strength, so 
 as to render it rubefacient. 
 
 Case IV. Joanna Saq luxated her arm, by falling 
 on her right side, in the month of July, 1788. In the 
 evening of the same day, all the precursory symp- 
 toms of paralysis made their appearance. The affec- 
 tion was complete on the day following. 
 
 The patient was brought to the Hotel-Dieu, 
 where the reduction, being accomplished, afforded 
 no relief. On the third day, the pai'alysis still conti- 
 nuing, the volatile liniment was directed, in the pro- 
 portion at first of two drachms of ammonia to an 
 ounce of the oil of almonds. This produced no effect. 
 Being increased in strength on the fifth day, it still 
 appeai'ed to be useless. On the eighth it was made 
 of such a degree of strength, as to occasion slight 
 pustules over the whole of the diseased extremity. 
 On this, motion began to return, feeble at first, but 
 
121 
 
 increasing by degrees, till by the sixteenth day, it 
 was as free and perfect as in a natural state. During 
 all the time, the liniment was applied twice a day over 
 the arm and fore-arm, which were at the same time 
 subjected to strong friction during the space of half 
 an hour. 
 
 39. The pains which accompany luxations of the 
 humerus, claim in general some attention from the 
 practitioner. These have sometimes arisen to such a 
 height, as to produce real disorder in the animal eco- 
 nomy, paiticularly in luxations inwardly, where, re- 
 sulting, no doubt, from the compression of the axil- 
 lary nerves, they render immediate reduction more 
 necessary, and are generally removed by it.. 
 
 § VII. 
 
 OF THE REDUCTION. 
 
 40. We may throw into two classes the numerous 
 means, under all their variety of modifications, pro- 
 posed for the reduction of luxations of the humerus. 
 The one consists in forcing, by some mechanical 
 power, the head of the bone into the cavity from 
 which it had escaped, whether extension has been 
 previously employed or not. The other is confined 
 to disengaging it from the situation, into which it 
 has been accidentally driven, leaving to the action of 
 the muscles the care of its replacement. 
 
 In the first of these, art does every thing ; in the 
 second, it only gives the proper direction to the pow- 
 ers of nature. These latter give but one course or 
 direction to the action of powers externally applied : 
 
 17 
 
122 
 
 in the former, the head of the bone always moves In 
 the diagonal of two powers opposed to each other at 
 an angle more or less acute. 
 
 41. A history of the means destined to act in the 
 first mode, would be too tedious to be introduced in 
 this place, would throw no light on the processes 
 about to be proposed, and are detailed at full length 
 in many authors, to \^'hich the reader is referred. It 
 will be sufficient to observe, that they aU act some- 
 what m the following manner. Some bod}^, placed 
 under the ai-m-pit, sers^es as a fulcrum, on which the 
 ai'm is made to move like a lever of the first kind, the 
 resistance to v\^hich is constituted by the displaced 
 head of the humerus, while the power is applied 
 either at the lower part of this bone, or at the wrist. 
 The extremity of the humerus being directed up- 
 wards and inwai'ds, moves its head in the opposite 
 directions, towards the glenoid cavity, where it re- 
 places it with more or less facility. 
 
 In this manner acted that machine so celebrated 
 among the ancients and moderns, under the name of 
 *' Atnbi Hippocratis^'''' whether it was employed in the 
 precise form described by that prince of physicians, 
 or with the additions and corrections, infinitely varied, 
 which it has received from Paul of Egina, Ambrose 
 Pare, Duvemey, Freke, &c. By this, a double mo- 
 tion is communicated to the head of the humerus, 
 which is, at the same time, directed, 1st, in the course 
 above mentioned; and, 2dly, in such a manner, as to 
 disengage it from the unnatural situation which it 
 occupies. 
 
123 
 
 42. Extension by the arm produces, in com- 
 mon, the second effect, and this is made in different 
 modes. Sometimes the weight of the body on one 
 side, and puUing by the luxated Hmb on the other, 
 serve t<j produce it; and such was the mode of ac- 
 tion of the fadder, the door, and the club, described 
 in the treatise on fractures by Hippocrates, and reviv- 
 ed in many modem works. At otlier times, the body 
 was immoveably fixed, and a powerful extension 
 made by the arm. This was the mode in which the 
 machines of Oribasus operated, and also one of the 
 methods formerly consecrated in the public places 
 where the athletas held their combats. 
 
 43. On some occasions, no extension is percepti- 
 bly made, but at the same time in which the extre- 
 miity of the humerus is forced outwards by a body 
 placed under the arm-pit, the surgeon pushes it up- 
 wards into the glenoid cavity : and such were the 
 other modes of reduction practised by the masters in 
 the athletic art. Hence it appears, that the first class 
 of the numerous means, employed for the reduction 
 of luxations, ma}^ be divided into those Vv^hich consist 
 in impulsion, those where mere extension is practis- 
 ed, and those where recourse is not had to either. My 
 object here is not to examine into the inconveniences 
 attending each of these means : a sufficient number 
 of authors have already done this; particularly Petit 
 and Bell, I shall only point out the disadvantages, 
 which, being common to all, ought to induce them 
 all to be excluded from a rational mode of practice. 
 
 44. The escape of the head of the bone tlirough 
 the ruptured and lacerated capsule, constitutes essen- 
 
124 
 
 tially the displacement under consideration. But, it 
 is never possible to ascertain with precision the place 
 of this rupture : how, then, can the head of the hume- 
 rus be directed towards it by an artificial force? 
 
 45. However well prepared for the purpose the 
 body may be^ which is placed under the arm-pit, to 
 serve as a fulcrum, always a chafing more or less 
 troublesome, and oftentimes distensions and serious 
 lacerations are the consequences of its application, 
 when the body is suspended on it, as in the mode by 
 the door, the club, &:c. where Petit has seen a fi-ac- 
 ture of the neck of the humerus occur, and even a 
 laceration, followed by an aneurism of the axillary 
 artery. 
 
 46. Every one has not at his command the differ- 
 ent means above mentioned (41 and 42), whence the 
 difficulty of procuring them, or of constructing them, 
 and the loss of time, precious in relation to the reduc- 
 tion, which is almost always easily accomplished in 
 proportion to the expedition used; these chai'ges ap- 
 ply, among many other means, to that machine so 
 complicated, and so well known, under the name of 
 the mitten* of Petit. 
 
 47. Supposing the luxation to be consecutive, 
 how can mechanical means make the head of the bone 
 retrace the route it has pursued in becoming displa- 
 ced? For example, if to a displacement downwards 
 has succeeded a displacement inwards, it will be ne- 
 cessary for the head to return downwards before it 
 can re-enter its cavity. But, can the direction of the 
 
 * (De mouffle de Petit.) 
 
125 
 
 movements be thus varied? This whole apparatus of 
 artificial means, for ever contradictory, oftentimes 
 acts in an inverse direction to that of the muscular 
 action, which is the essential and chief agent in the 
 process of reduction. 
 
 Should the luxation take plape upwards, the in- 
 sufficiency of these means must be evident. , 
 
 48. Perhaps, however, they may be employed 
 with some advantage, when a primitive luxation 
 downwards is quite recent,, and the head of die bone 
 is near to its cavity. In such a case the lower e:dgQ 
 of the scapula presents to it an inclined plane, along 
 which it can easily glide, when pushed by some ex- 
 ternal force. It is doubtless to this disposition of the 
 bone to replace itself, that we must attribute the suc- 
 cesses, greatly exaggerated, but in part real, on which 
 the inventor of every machine endeavours to found 
 the superior merit of his mode of operating. 
 
 But, in this case, it is useless to accumulate artifi- 
 cial forces, where natural ones are sufficient, and 
 where the operator may, with his hands, effect the re- 
 duction the more easily, as he can with more accuracy 
 vary the direction of his movements. 
 
 49. Thus Desault oftentimes employed a process 
 which was attended^ with great success, and which, 
 like some of the preceding, ought to be referred to 
 impulsic'ii. The patient being seated on a chair of a 
 moderate height, he took hold of the hand of the 
 affected side, placed it between his knees, and carried 
 it downward and backward, for the purpose of mak- 
 ing extension, and disengaging the head of the bone; 
 while an assistant held the trunk with a view to coun- 
 
ter-extension, which was sometimes effected to a 
 sufficient degree, by the -weight of the body and the 
 efforts of the patient. At the same time the hands of • 
 the surgeon, applied to tlie arm, in such a manner 
 that the fingers of each were in contact with the hol- 
 low of the arai-pit, and the thumbs with the external 
 part of the arm, di'ew upwards and a little outwards 
 the head of the humerus, which in common returned 
 wdth ease into its natural cavity. 
 
 50. Petit mentions this process, not such as it is 
 here described, but complicated with the use of a 
 napkin passed under the arm-pit of the patient, and 
 round the neck of the surgeon, who, by raising his 
 head, drew the displaced extremity upwards. This 
 additional mean, always unnecessaiy, and not judici- 
 ously constructed, is generally ineffectual, because, 
 with it, the operator cannot at pleasure vary his 
 movements. The heinds alone are always sufficient, 
 and a vast number of examples attest the efficacy of 
 this method, when employed after the manner of De- 
 sault. 
 
 Case VI. Nicholas Juan fell on his side, his 
 arm being separated from his body, as he was cross- 
 ing, in January 1790, the place Notre-Dame, oppo- 
 site to the Hotel-Dieu. An acute pain was immedi- 
 ately experienced; a protuberance appeai'ed sud- 
 denly under the arm-pit; and under the acromion a 
 depression equally sudden. He was lifted up, and 
 carried straight to the Hospital, where Desault was 
 just beginning a clinical lecture. The luxation being 
 manifested by these appeai'ances, was immediately 
 reduced by the foregoing means. A few days rest 
 
127 
 
 were enjoined on the patient, but, on the same even- 
 ing, he proceeded on his way, blaming himself, for 
 having lost half of his day's journey. 
 
 51. In analogous cases of very recent luxations 
 do^vnwards, Desault twice or three times effected the 
 reduction by means still more simple, as the follow- 
 ing case, reported by Heraut, testifies. 
 
 Case VII. Maria Louisa Favertfell, as she was 
 descending a ladder, and having luxated her arm, 
 was carried at her request, immediately after the 
 accident, to the Hotel-Dieu. Desault perceiving the 
 nature of the disease, placed, under the hollow of the 
 arm-pit, his left hand, to serve as a fulcrum while 
 with his right, applied on the inferior and external 
 part of the arm, he approximated the humerus to the 
 trunk, pushing it at the same time upwards. By this 
 double -movement, directed upwards and outwards, 
 the head of the humxCrus re-entered its cavity with- 
 out the least resistance. The arm was suspended in 
 a sling for two days, and on the fourth the patient re- 
 turned to her usual labour. 
 
 52. There exists some analogy between this me- 
 thod and one of those mentioned, by Hippocrates, to 
 have been practised in ancient times, in the public 
 games, where the exertions of body exposed those 
 engaged to frequent luxations. 
 
 It is not only in luxations downwards, that the 
 first of the simple processes w^hich I have mentioned 
 (49), maybe applied. Primitive luxations inw^ardlj', 
 yield sometimes to its use, and the Journal of Sur- 
 gery furnishes t-^vo instances of success in similai' 
 cases; one in a female sixty -three years of age, and 
 
128 
 
 the other in one of fifty- one, of a strong constitu- 
 tion, and in whom the reduction was effected with- 
 out resistance. 
 
 53. But, in general, these means are ineffectual 
 and it becomes necessary to have recourse to exten- 
 sion, which, when employed alone, forms the second 
 class of means intended for reducing luxations of 
 the humerus. Many writers have adopted this exclu- 
 sively, though some practitioners, indulging their 
 imagination in the vast field of invention, deserted 
 the common track, and had recourse to various kinds 
 of machinery. Celsus depended on extension alone, 
 in common cases of luxation downward and forward. 
 Albucasis employed no other means, Douey, Dou- 
 glass, and Heister, among the moderns, reject uncon- 
 ditionally the use of machines, as always useless, and 
 often dangerous. Finally, Dupoui and Fabre, exa- 
 mined and analysed with great exactness the process 
 of extension, and pointed out, in every case, the 
 means of rendering it advantageous, by managing in 
 the best manner the extending forces, and in the lux- 
 ation of the h'.imerus, in particular, to prevent the 
 inconvenience of straps placed under the arm-pit of 
 the patient, demonstrated the inutility of the move- 
 ment commonly called conformation. In these res- 
 pects, surgery stands indebted to them for real 
 advancement, and their doctrine, at this day, very 
 generally known and received, w^as principally redu- 
 ced to practice by Desault, who made it the basis of 
 his method of reduction in all fractures and luxations. 
 
 54. To proceed to the reduction of a luxation of 
 tlie humerus, it is necessary to have such a number 
 
129 
 
 of assistants as to be able, according to the resistance 
 of the parts, to increase the force intended to over- 
 come it. But two are commonly sufficient. They 
 should furnish themselves with a linen ball, thick 
 enough to project beyond the level of the pectoralis 
 major and the latissimus dorsi, when placed in the 
 axilla, and two straps, one formed of fiaimel doubled 
 several times, four inches broad, and eight or nine 
 feet long, the other of a napkin regularly folded. This 
 latter is not often absolutely necessary. 
 
 Every thing being properly arranged, the patient 
 is seated on a chair of a moderate height, or else laid 
 on a table firmly fixed and covered with a simple 
 mattress, in order that the trunk, by being in a hori- 
 zontal position, may not prevent tlie motions commu- 
 nicated to the arm from being directed downwards. 
 
 55. Desault continued, for a long time, to place 
 the patient in the first of these positions, which, 
 though employed by practitioners generally, is by 
 no means the most favourable. By adopting it indeed 
 the arm may be very well drawn in a transverse di- 
 rection ; but if, as oftentimes happens, it becomes 
 necessary to direct extension upwards or dov/n- 
 wards, the assistant, then, being obliged to elevate 
 liimself, or to stoop, cannot, in either of these atti- 
 tudes; exert his strength to advantage, but is confi- 
 ned and embarrassed, and cannot with ease vary, at 
 the pleasure of the surgeon, the direction in which 
 the arm is drawn. 
 
 As far as relates to the patient, that situation in 
 which the body is only in part supported, is much 
 more fatiguing than one where the whole of it reposes 
 
 18 
 
130 
 
 equally on a horizontal plain. Perhaps, in relation to 
 the surgeon, it would be more advantageous, in ena- 
 blinghim to accomplish the process of conformation*; 
 but, as will be presently observed, this process is al- 
 ways useless. These considerations induced Desault, 
 in the last years of his practice, to renounce the first 
 position, and have recourse only to the second. 
 
 56. The patient being properly situated, under 
 the arm-pit of the affected side is placed the linen 
 ball, on which the middle of the first sti'ap is then 
 applied. The two ends of this strap being now 
 brought obliquely up^vards, before and behind the 
 thorax, so as to meet on the top of the sound shoul- 
 der, and being held by an assistant, serve to fix the 
 body, and to make counter-extension, nor does the 
 action of the strap bear on the edges of tlie pectoralis 
 major and latissimus dorsi, in consequence of the ball 
 which projects beyond their edges. Were it not for 
 this, these muscles, being pulled upwards, would 
 draw in the same direction the humerus, to which 
 they are attached, and would thus destroy the effect 
 of the extension, which is made in the following 
 manner. 
 
 * That is, to draw, or otherwise force the head of the os hu- 
 meri, with his hands, towards the glenoid cavity, while the as- 
 sistants are making extension and counter-extension. In doing 
 this, he must pull the head upwards, if it be lodged in the ax- 
 illa, backward if it be under the upper part of the pectoralis 
 major, &:c. Desault, however, contends that this assistance 
 from the surgeon is unnecessary, and that extension and coun- 
 ter-extension are alone sufficient to effect the reduction. 
 
 Traks. 
 
131 
 
 57. Two assistants take hold of the fore-arm 
 above the wrist, or else a folded napkin is fixed on 
 that part, having its two ends twisted around each 
 other. These ends, thus folded together, are given 
 to one or two assistants, who begin to pull in the di- 
 rection of the humerus. To this first movement, in- 
 tended to disengage the head of the bone from the 
 bed wliich it occupies, another succeeds, which must 
 vary according to the kind of luxation. If the luxa- 
 tion be downwards, the surgeon gradually approxi- 
 mates the ann to tlie trunk, at the same time that he 
 pushes it gently upwards. By this process, the head 
 of the bone, being drawn from the trunk, and brought 
 towards the glenoid cavity, usually re-enters it with 
 but little resistance. 
 
 If the luxation be inwards, the extremity of the 
 humerus, after extension according to the direction 
 of the bone, should be carried upward and forward, 
 in order that its head may be directed backwards. 
 Steps the very reverse of these must be pursued, if 
 a luxation in an outward direction is to be reduced. 
 
 58. In general, when, by the first extension, the 
 head of the bone is disengaged, the motion commu- 
 nicated to it by the subsequent ones, ought to be in 
 a direction precisely opposite to that which it pursued 
 in escaping from its cavity. But what are the valua- 
 tions of this direction? Extensive experience alone 
 can clearly determine this point. Without experience 
 the practitioner works in darkness. The minutije. 
 or particulars of the process of reduction, being dif- 
 ferent in different cases and according to difierent 
 circumstances, can be neither foreseen, nor taught 
 by precept. 
 
132 
 
 59. If the head of the bone Experience any diffi- 
 culty in re-entering its cavity, it is necessary, when 
 the extensions have been made, to communicate to 
 the bone different movements, varied according to 
 the different directions of displacement, and regulated 
 by the principle just established. Oftentimes this me- 
 thod effects what extensions alone cannot; and the 
 head of the bone, carried by these movements to- 
 wai'ds its cavity, enters it while they are performing. 
 
 60. Ifthe luxation be consecutive, then the first 
 extension made in the direction of the displaced bone, 
 is intended to bring its head into the place where it 
 was primitively lodged, in order that it may be 
 afterguards acted on as if it were a case of primitive 
 luxation. It is oftentimes only at the moment of 
 reduction, that it is practicable to ascertain to which 
 kind of luxation the accident belongs. Indeed, as in 
 most cases, the reduction takes place of itself when 
 the extensions ai'e well executed, if the head be con- 
 secutively drawn inward, it is seen to descend along 
 the internal part of the scapula, till it an'ives near to 
 the inferior part of that bone, and then to reascend to- 
 Avards the rupture in the capsule through v/hich it 
 passes into its natural situation. 
 
 61. I ha^e said that when the extension is pro- 
 perly made, the reduction takes place almost spontane. 
 ously. Indeed whatever may be the kind of primitive 
 luxation, it is evident, that the m^uscles surrounding 
 the articulation must be stretched on one side, while 
 tliey are relaxed on the other; whence there will 
 necessai'ily arise a change both in their conti-actions, 
 and in the direction of these contractions, and such 
 
133 
 
 is the nature of this change, that, in case the muscles 
 act, instead of bringing the head towards the rupture 
 in the capsule, they will di'aw it in another direction, 
 and by that means produce a consecutive luxation. 
 
 62. But, if the extensions render the muscles 
 straight, and restore to them their primitive direction, 
 then, obeying their natural iiTitability, which is still 
 further increased, by means of the extension, they 
 will draw the head to the rupture in the capsule, and 
 force it to re-enter it, wath much more certainty than 
 this can be done by the efforts of the surgeon, who 
 is always ignorant of the precise situation of this rup- 
 ture. On the other hand, if the extension be not 
 judiciously made how can it restore to the muscles 
 their natural direction? In such a case, the head of 
 the bone will be drawn towards some other part of 
 the capsule than that where the rupture exists, and 
 hence, the difficulties that so frequently occur, in re- 
 ducing luxations of the humerus, 
 
 63. From these circumstances it follows; 1st, 
 that the whole art in the treatment of luxations, con- 
 sists in giving to the extending powers a proper di- 
 rection; 2dly, that, in general, the process of con- 
 formation is unnecessary and useless; 3diy, that to 
 reduce a luxation is not to replace the head of the 
 bone in its cavity, by force, but to restore the muscles 
 to such a state, as to enable them to replace it. Here, 
 therefore, as in every other case, art is only the 
 minister and handmaid of nature. 
 
 There are instances, however, where the muscles 
 cannot act properly in consequence of the long stand- 
 ing or age of the luxation, and in consequence of 
 
134 
 
 adhesions, more or less strong, having taken place 
 between the surrounding parts. In such cases it is 
 necessary to employ proper measures to force the 
 head of the bone into its cavity, as it cannot be car- 
 ried thither by the muscles. 
 
 64. Reason concurs with experience, which is on 
 all subjects the best authority, in estabhshing the 
 truth of this doctrine, respecting the reduction of 
 luxations of the humerus. In this operation, Desault 
 employed, in general, nothing but extensions, varied 
 according to circumstances, until the muscles thro"vvii 
 into a favourable state, were themselves enabled ta 
 accomplish the reduction. The most immediate suc- 
 cess constantly crov/ned his practice on this point. 
 This success was, no doubt, owing to his judiciously 
 remaining inactive himself, and suffering the muscles 
 to do the -work, after the necessary extensions had 
 been made. 
 
 65. When the reduction is accomplished, if the 
 arm, in consequence of being very moveable, ap- 
 pears likely to be displaced again, it is necessary, for 
 a few days, to fix it in such a manner as to prevent 
 all motion; an object which may be effectually at- 
 tained by Desault' 3 bandage for fractures of the 
 clavicle. 
 
 All writers recommend, for this purpose, the use 
 of the »S))ic<^ bandage.* But what service can this 
 render? It does not restrain the motions of the hume- 
 
 * With the particular mechanism and m,ode of action of 
 this bandage, I am unacquainted. Nor are these matters of 
 much moment, as the bandage is, I believe, entirely out of use. 
 
 Trans. 
 
135 
 
 rus, which, hanging down the side, may move for- 
 ward, backward, &c. and produce a new displace- 
 ment; an accident that may be always prevented by 
 the bandage proposed. 
 
 § VIII. 
 
 OF CIRCUMSTANCES RENDERING REDUCTION 
 DIFFICULT. 
 
 66. I will close this memoir by an examination 
 into some circumstances, wliich may either prevent 
 reduction or render it difficult, and into certain acci- 
 dents that sometimes accompany it. 
 
 I have said that, on some occasions, the rupture 
 of the capsule, being too narrow to admit the head of 
 the humerus to repass it, and return to its cavity, con- 
 stitutes one 6f the principal obstacles to a reduction 
 (24). To enlarge this passage, by further lacerating 
 its edges, is evidently the indication that here presents 
 itself. This is fulfilled by communicating to the bone 
 great motion, either by circumduction, or rotation on. 
 its own axis, forcing it suddenly in dilFerent direc- 
 tions, particularly in that direction in which th,e lux- 
 ation has been produced. Its superior extremity 
 muse be, at the same time, pushed forcibly against 
 the ruptured capsule, which, by being thus pressed 
 between two resisting bodies, will suifer a more ex- 
 tensive rupture. Reduction, oftentimes impracticable 
 previously to these violent and varied motions, takes 
 place of itself as soon as they have been properly 
 made. Of this the practice of Desault furnishes many 
 examples. 
 
136 
 
 Case VIII. In the Journal of Surgery are re- 
 corded two cases, one by Anthaume, the other by 
 Faucheron, which estabUsh this doctrine. 
 
 John Sehgni, a robust man, forty-four years of 
 age, fell on the point of his shoulder, on the 19th of 
 July 1791 ; the pain, which was increased by moving 
 his arm, and the swelling which supervened almost 
 immediately, induced him to enter the Hotel-Dieu. 
 The efforts of assistants were at first insufficient, and 
 it was not till after a uniform extension continued 
 for several minutes, that the head of the humerus 
 was drawn by the muscles against the glenoid cavity. 
 The bone appeared to enter the cavity, although the 
 persons present did not hear the collision or clashing 
 of the articulating surfaces, which is almost always 
 perceived in cases of recent luxation: but immedi- 
 ately the humerus was again displaced, without its 
 being practicable to retain it. On the occurrence of 
 this phenomenon, Desault conceived that the head 
 of the bone had pushed before it the capsular liga- 
 ment, through which it could not pass, in consequence 
 of the narrowness of the opening which had been 
 made at the time of the luxation. He proceeded to 
 move the arm forcibly in every direction, in order to 
 enlarge the opening, and immediately felt a kind of 
 laceration, which satisfied him that his vie^vs were 
 accomplished. He then re-commenced extension, 
 which it was again necessary to continue, as at first, 
 for some time, in order to overcome the resistance of 
 the muscles. The reduction was attended with no 
 further difficulty. The humerus continued still to 
 have a great tendency to be displaced, and it was ne- 
 
137 
 
 eessary to employ, for several days, a bandage simi- 
 lar to that for a fractured clavicle. 
 
 Case IX. Maria Laiirencier, aged sixty, fell on 
 her right elbow, and luxated the humerus of the same 
 side. Eight hours afterwards she came to the Hotel- 
 Dieu, on the eighth of March, 1789. The reduction 
 was attempted in the usual manner; but, although 
 the extensions were properly directed, and the head 
 of the humerus brought against the glenoid cavity, it 
 was still displaced again as soon as the limb was let 
 go, a circumstance which created a suspicion, that 
 the opening of the capsule was too narrow to allow 
 the head of the bone to pass. The assistants ceased' 
 making extension, and Desault, taking hold of the 
 lower extremity of the arm, impressed on it great 
 motion, particularly in the direction of the luxation, 
 for the purpose of enlarging the laceration of the cap- 
 sule. The extensions were now renewed, and the 
 reduction succeeded with great ease. 
 
 67. A second obstacle, more difficult to be sur- 
 mounted in the process of reduction, is that arising 
 from the long continuance of the luxation. The- 
 head of the bone, having continued for a long time in 
 the bed into which it has been accidentally thrown,, 
 forms adhesions to it; the surrounding cellular mem- 
 brane becomes thickened, and makes, so to speak, a- 
 new capsule for the head, which opposes its replace- 
 ment, and, when the reduction cannot be accom-- 
 plished, supplies in some measure the office of the- 
 old joint, by the movements which it allows to take- 
 place. 
 
 19 
 
138 
 
 Most writers, and Bell in particular, advise, in 
 such a case, never to attempt a reduction, which, being 
 of no avail as to the luxation, might prove dangerous 
 to the patient, in consequence of the violence it would 
 do to the parts. This doctrine was for a time, the 
 doctrine of Desault: but experience, in his latter 
 years, led him to a bolder practice. 
 
 68. The complete success which he experienced 
 in luxations of fifteen or twenty da}^s standing, encou- 
 raged him to make the attempt, at tlie end of thirty 
 and thirty-five days, and we have, three or four times, 
 during the two last years of his life, seen him success- 
 ful in replacing, after the expiration of two and a 
 half, and even three months, the head of the bone 
 •which had escaped, both through the inferior, and the 
 internal side of the capsule. 
 
 However powerful, and however long continued 
 the extensions were, none of those tenible accidents 
 occurred, v^ith which we are threatened by authors. 
 Twice only did a phenomenon occur, which it was 
 difficult to foresee, and of which I will presently 
 speak. 
 
 69. In cases of tliis kind, it is necessary, previous- 
 ly to making extension, to move the bone yery for- 
 cibly in every direction, in order first to brea^ the 
 adlieslons, to tear the condensed cellular membrane, 
 which serves as an accidental capsule, and to produce, 
 so to speak, a second luxation, with a view to make 
 way for a perfect reduction of the first. The straps 
 being then applied, as in ordinary cases, serve the 
 purpose of extension, for the accomplishment of 
 which the number of assistants must be increased. 
 
139 
 
 70. Oftentimes the first efforts are fruitless, and 
 the luxated head remains stationary, amidst the most 
 violent efforts. Let the extensions then be disconti- 
 nued : renew the forcible motions of the limb : carry 
 the humerus upwards, downwards, forward, and 
 backward: force the resistances to give way; make 
 the arm describe a large arch of a circle round the 
 place which it occupies; let the rotatory motions on 
 its own axis be impressed on it anew; and then re- 
 eommence the extensions, and let them be made in 
 eveiy direction. By these, the head, already disen- 
 gaged by means of preceding violent motions, will 
 be brought to a level with the glenoid cavity, and 
 ultimately replaced. 
 
 It'may not be improper to confirm by experience 
 the truth of these precepts, which might to some ap- 
 pear rash, in consequence of the changes tliat seem 
 likely to occur in the glenoid cavity, during the ab- 
 sence of the head of the humerus. I will relate, 
 among others, a case reported by Giraud, second 
 surgeon to the Hotel-Dieu. 
 
 Case X. Maria Gauthier, thirty- four years of 
 age, entered the Hotel-Dieu, on the twentieth of June, 
 1790, to be cured of a luxation of three months 
 standing, produced originally by a fall on the arm, 
 which was separated, at the time, from the body and 
 carried backward. Different surgeons had, at differ- 
 ent times, attempted the reduction, but always with- 
 out effect, and when every hope of a cure appeai'ed 
 to have expired, Desault, imboldened by reiterated 
 success, tried whether or not he would be equally 
 fortunate in this case. 
 
140 
 
 The patient being placed in a horizontal position, 
 as already directed {55), great motions were first im- 
 pressed on the limb: extensions were then com- 
 menced, first in the direction of the luxation, and 
 afterwards forward and backward. Vain efforts; the 
 head remains immoveable; new motions are again 
 made in every direction, and afterwai'ds, the exten- 
 sions are renewed: the same want of success. The 
 patient being fatigued, the reduction was deferred till 
 the day following, when the same trials were, after a 
 short time, attended with complete success. The 
 head being at fii'st disengaged, and afterwards drawn 
 slowly along the track through which it had passed in 
 becoming displaced, at length re-entered the capsule. 
 The arm, being supported by the usual apparatus^ 
 soon became oedematous, and, notwithstanding the 
 remedies common in such cases, the swelling conti- 
 nued for two months. The motions performed by 
 the limb in the mean time, restored to it, by degrees, 
 its usual suppleness; and, on the sixty-eighth day 
 after her entrance, the patient was discharged cured. 
 
 To this case, I might subjoin many others, and, 
 in particular, that of John Putot, also reported by 
 Giraud, and in which the means just described (69 
 and 70), succeeded in the reduction of a luxation at 
 the expiration of the fourth month. But too great 
 an accumulation of facts distract the attention, and 
 add nothing to conviction, especially when they arc 
 already so plain as those just related. 
 
 71. But further, in cases of this kind, where a 
 very old luxation presents great obstacles to reduc- 
 tion, although the attempts made to reduce it, do not 
 
141 
 
 actually force the head of the bone into the capsule, 
 still they may not prove entirely useless. By bring- 
 ing the head nearer to the glenoid cavity, or placing 
 it even on that cavity, and making it form new adhe- 
 sions there, after having destroyed its old ones, the 
 motions of the limb will be facilitated. For, in cases, 
 where the luxation is not fairly reduced, these motions 
 will be always less impeded, in proportion as the 
 hestd of the bone occupies a place less remote from 
 its natural situation. 
 
 72. A third obstacle, common to the reduction 
 of every kind of luxation, is the muscular force, in- 
 creased by the irritation of the displaced bone, beyond 
 its natural degree. So great, at times, is this force, 
 that the head of the bone cannot be moved, even by 
 the strongest eiforts. What means should then be 
 employed? 1st, Those which diminish general irri- 
 tability, such as blood-letting, bathing, a relaxing re- 
 gimen, &c. 2dly, Those which act locally, in dimi- 
 nishing the irritability of the muscles of the shoulder. 
 For example : the application of emollient cataplasms 
 or fomentations to the part ; or, what is still better, 
 a powerful extension, continued for some time. In 
 consequence of such extension, the muscles of the 
 part become fatigued, whence their contractions arc 
 succeeded by a state of atony, of which advantage 
 may be taken to replace the bouQ. Frequently this 
 extension ought to be continued for a very long time ; 
 and we have known Desault not to complete the re- 
 duction in less than half a day, or even a whole day, 
 the limb being suffered to remain all that time in the 
 apparatus for fractures of the clavicle, which draws 
 
• U4 
 
 the shoulder and muscles outwards. Thus, in frac- 
 tures of the thigh, where muscular contraction pre- 
 vents the contact of the fragments, permanent exten- 
 sion previously employed, assists in producing this 
 contact. 
 
 OF ACCIDENTS CONSEqUENT TO REDUCTION. 
 
 73. It is rare that any serious accident follows^ 
 the reduction of a luxation of the humerus. A swell- 
 ing, more or less extensive, sometimes shows itself 
 around the joint, particularly when extension has' 
 been forcible and long continued; but this, being,' 
 in general, easily removed, by means of discutients, 
 does not demand particular attention. 
 
 74. Another accident which rai'ely occurs in' 
 practice, respecting which but little is to be found in 
 surgical writings, and with which Desault occasion- 
 ally met, is, a considerable emphysema, suddenly- 
 appearing at the time of reduction. In the midst of 
 those powerful extensions, rendered necessary by the 
 ancient state of the luxation, a tumour siiddenly ap- 
 pears under the pectoralis major. By a rapid increase 
 it extends itself tovi^ards the hollow of the arm-pit, 
 the whole of which it soon occupies. It then propa- 
 gates itself in a backward direction, aiid, in the space 
 of a few minutes, its bulk is sometimes equal to that 
 of the head of an infant. A practitioner, if unac- 
 quainted with the nature of this accident, might take 
 it for an aneurism, produced by a sudden rupture 
 of the axillary artery, in consequence of the violence 
 
143 
 
 done to that vessel by the extensions of the limb. 
 But, if attention be paid to the resistance of the tu- 
 mour, to its want of pulsation, to the place of its first 
 appearance, (which is usually under the pectoralis 
 major, and not under the hollow of the aim-pit, to 
 which it only propagates itself afterwards, as Desault 
 has observed in similar cases that fell under his notice), 
 to the action of the pulse still continuing, unless the 
 patient should faint from debility, as happened to the 
 subject of the following case, which we had occasion 
 to witness at the amphitheatre, sometime previous to 
 the death of Desault, and to the colour of the skin 
 which suffers no change ; if these circumstances be 
 attended to, it will be difficult not to distinguish one 
 of these accidents from the other. In that now und^r 
 consideration, discutients applied to the tumour, 
 suehj for example, as vegeto-mineral water, and a 
 gentle and regular compression made by the ban- 
 dage intended to support the arm after reduction, 
 are the most efficacious means that art can employ. 
 
 Case XI. Simon Cerisiat, sixty yeai's of age, 
 presented himself on the nineteenth of December, 
 1794, as the subject of a public consultation, which, 
 every day preceded the clinical lecture of Desault, 
 to receive advice for a luxation inwai"ds, which he had 
 suffered a month and a half before, and for the re- 
 duction of which no attempt had been yet made. 
 
 Convinced, by the example of luxations more 
 ancient, of the practicability of reducing this, De- 
 sault undertook it immediately in the presence of Ms 
 pupils. 
 
144 
 
 The patient being laid on a table, firmly fixed and 
 covered with a mattress, great motions were impressed 
 on the luxated limb upwai'd, for\^^ard, and outward, 
 ivitli a view to destroy the adhesions contracted with 
 the surrounding parts. Extensions were then made in 
 the manner already mentioned (66 and 67). 
 
 Nothing w^as gained by the first attempt, the head 
 jemaining immoveable, in the midst of the efforts to 
 displace it. Further motions were made in every 
 direction, to break if possible, the attachments which 
 held it; and these were followed by further exten- 
 sions. 
 
 While these were making in a forcible manner, 
 the head was perceived to approach by degrees to- 
 wards the glenoid cavit}^, near to the edge of which 
 it reached in two minutes, and was at length replaced, 
 by a sudden movement of the limb from behind 
 forward. 
 
 Scarcely Vv'^as the reduction accomplished, when 
 a tumour rose suddenly under the pectoralis major, 
 propagated itself towards the arm-pit, and occupied 
 immediately its whole extent. 
 
 All tlie assistants, astonished at the phenomenon, 
 knew not to what circumstance to attribute it. De- 
 sault himself, a little embaiTassed, thought first of an 
 aneurism suddenly produced by the violence of the 
 extension. The pulse of the patient, being scarcely 
 perceptible in the side affected, and a syncope which 
 supervened, appeared at first to favour this suspicion : 
 but immediately the absence of a fluctuation, of a 
 pulsation, and of a change in the colour of the skin, 
 the return of the pulse, the circumscription of the tu- 
 
145 
 
 tiiour, its resistance, and the sound caused by strik- 
 ing on it, produced a belief that it was owing, not to 
 an effusion of blood, but to a disengagement of air 
 tliat had been confined in the now lacerated cells of 
 the cellular membrane. 
 
 Over the whole of the swelling were applied com- 
 presses wet with vegeto-mineral v/ater, while a regu- 
 lar compression was made on it by means of a ban- 
 dage, which, at the same time, kept the arm fixed 
 against the trunk. 
 
 In the night there occurred severe pains around 
 the articulation and the tumour, accompanied with 
 high fever, both which symptoms disappeared on the 
 following day. Third day, a diminution of the em- 
 physematous swelling; and an entire cessation of 
 fever and pain. Eighth day, tumour reduced to half 
 its original size; the ai^m made to perform gentle 
 motions, and disengaged from the appai^atus; discu- 
 tients continued. Thiileenth day, tumour entirely 
 gone. In the place which it had occupied a large 
 echymosis appeared, produced no doubt, by a rup- 
 ture of the small vessels at the time of reduction, but 
 which, tili now, had not been perceptible externally, 
 in consequence of the emphysematous swelling of 
 the parts, and which was treated by the same means 
 as the emphysema. Seventeenth day, a yellow tinge, 
 mixed with the colour of the echymosis, an evidence 
 of its resolution, which was complete by the twenty- 
 seventh day. 
 
 During all this time, the patient had accustomed 
 his limb to constant motion; a facility in the move- 
 ment of it had thereby returned; and he was perfectly 
 
 20 
 
i46 
 
 well when he left the Hotel-Dieu, on the thirtieth day* 
 from the time of his admission, and the sixty-fifth 
 from the occurrence of the accident. 
 
 MEMOIR VIII. 
 
 ON THE FRACTURE OF THE BONES OF THE 
 FORE-ARM. 
 
 §1. 
 
 1. The fore-arm, composed of two bones, nei- 
 ther of them very strong, and covered below by a 
 small quantity of soft parts, is exposed still more than 
 the humerus, to the action of external bodies, and is 
 articulated at the upper end in such a manner, as not 
 to yield, like it, in every direction to the impulses 
 which it receives. From these considerations, it is 
 one of those parts where fractures most frequently 
 occur, and, in a comparative view of affections of 
 this kind in the Hotel-Dieu, it has oftentimes held 
 the first place. 
 
 2. It would be useless to mention here the dis- 
 position of the bones which compose the fore-arm, 
 their irregulai'ly prismatical form, their thickness 
 unequally distributed, their direction obviously 
 different, and their motions differently combined. 
 It is sufficient to observe, that, for the perfection of 
 one part of these motions, a space, wide in the mid- 
 dle, and naiTow at the ends, must separate the two 
 
147 
 
 bones, that, without this space the radius, impeded 
 in its movements on the cubitus, would compress the 
 muscles, restrain their action, and would be unable 
 to perform the motions of pronation and supination; 
 whence the fore-arm, being confined, as it were, to 
 mei-e flexion and extension, would not, in its uses, 
 correspond to our wants. 
 
 These things being premised, we will observe, 
 that fractures of the fore-arm may have their seat, 1st, 
 in both bones at the same time ; 2dly, they may oc- 
 cupy but one of them : hence thi'ee kinds of fractures 
 more or less different in their phenomena, their con- 
 sequences, and their treatment. 
 
 FRACTURE OF THE FORE-ARM. 
 
 § II. 
 
 OF THE VARIETIES AND THE CAUSES. 
 
 3. Fractures of both bones of the fore-arm, 
 may occur either at the ends, or in the middle of the 
 limb. Frequent in the middle, and somewhat com- 
 mon below, they seldom occur in its upper part, 
 where the fleshy portions of numerous muscles, com- 
 bined with a considerable thickness of the ulna, re- 
 sist the motions which tend to produce them. The 
 two bones, though most commonly broken on the 
 same line, are, however, sometimes broken on diflTer- 
 ent ones. The fracture is almost always single : at 
 times, however, it is double, and Desault, in particu- 
 lar, was once called to a patient, over whose fore-ai-m 
 the wheels of a carriage had passed, and had broken 
 
148 
 
 it both in the middle and at the lower end, so that it 
 evidently exhibited six fragments distinct from each 
 other. The two middle ones, though completely in- 
 sulated, united again to the others with but very little 
 deformity. Like all other similar affections, these 
 may be rendered compound by wounds, splinters, 
 Sec. circumstances which, as they fall within the ge- 
 neral class of such injuries, will not be treated of at 
 present. 
 
 14. They occur, in general, in two ways, being 
 the result, sometimes of the action of external bodies, 
 immediately applied, and at other times of the same 
 action, operating by way of a counter- stroke. The 
 occasional percussion of a body on the fore-ai'm, fur- 
 nishes an example of the first mode of fracture. This 
 is much more frequent, in general, than the other, 
 which usually arises from a fall on the wrist; but, in 
 such a case, as it is the large lower end of the radius 
 that forms the principal point of articulation with 
 the hand, that bone alone sustains almost all the force 
 of the stroke, and is very generally the exclusive seat 
 of tlie fracture. 
 
 § III. 
 
 OF THE SIGNS OR APPEARANCES. 
 
 It is in general difficult to be mistaken with re- 
 spect to the signs which characterize fractures of the 
 fore-arm. A mobility of the limb where it was before 
 inflexible; a crepitation almost always easily per- 
 ceived; a depression, sometimes evident, at the place 
 of division; a protuberance sometimes formed under' 
 
149 
 
 the skin by the fragments ; pain produced by the 
 motion of the part ; a crack sometimes heard by the 
 patient, at the moment of the accident ; an inability 
 to perform the motions of pronation and supination; 
 the almost constant semi-flexion of the fore-arm; 
 such, together with the phenomena common to all 
 fractures, are those which essentially characterize 
 this, and wdiich must generally remove all doubts 
 which the swelling of the limb may temporarily cre- 
 ate respecting its existence. 
 
 6. There is a circumstance, however, where a frac- 
 ture near to the joint of the wrist, may give rise to 
 appearances similar to a luxation of that part. In both 
 cases, indeed, a convexity behind, and a depression 
 before, or the reverse, are perceived, and are the 
 effect of a displacement of the fragments. But the 
 styloid apophysis being cai'efully examined, will 
 always determine, according as it is found above or 
 below the deformity, from which of the two causes 
 the deformity arises. Besides, a greater mobility in 
 one than in the other affection, and a crepitation, w ill 
 guard the practitioner from an error, into Vv hich I 
 saw a surgeon fall in the presence of Desault, Vvhom 
 he called on to consult, in the case of a child six years 
 old, which laboured under a supposed luxation, 
 
 OF DISPLACEMENT. 
 
 7. Most of the phenomena which accompany 
 fractures of the fore-ai-m (5), are evidently the result 
 of a displacement of the fragments ; a displacement^ 
 not, in general, very perceptible in the longitudinal 
 
150 
 
 direction of the bones, because the muscular action, 
 tending to produce it in that direction, is not very 
 powerful. When it does occur in this way, it is most 
 frequently the immediate effect of the stroke that 
 produced the fracture. 
 
 8. But it is different with respect to a displace- 
 ment in the cross direction of the bone. Here the 
 cause of the separation of the broken ends, may be 
 the same with the cause of their fracture, as happens 
 in the passage of a carriage w^heel over the limb^ or 
 in the falling of some body against it; and then, 1st, 
 the fragments are separated from before backward, 
 or contrarj^wise, and hence, a protuberance on the 
 one side of the limb, and a depression on the other; 
 2dly, or else they are pressed against each other late- 
 rally from without inwards. From this latter cause 
 arises that inequality which the limb exhibits at the 
 place of the fracture ; the slight depression which it 
 manifests on its sides ; and the protrusion or bulging 
 out of its anterior and posterior surfaces, by means of 
 the mass of muscles which are pushed in these direc- 
 tions, by the approximation of tlie fragments to each, 
 other. 
 
 9. A proper reduction removes the first kind of dis- 
 placement, namely, that which occurs in the cross di- 
 rection of the bone backward or forv/ard (8) ; and un- 
 less an external force be applied anew, it does not again 
 return. On the contrary, how exact soever the reduc- 
 tion may be, in the second kind, namely, that which 
 takes place laterally from without inwards, the frag- 
 ments are soon found to have approached each other 
 again. Above, the pronator teres presses the superior 
 
151 
 
 fragment of the radius against that of the ulna ; below, 
 the two fi^actured extremities are pressed against each 
 other, by the contractions of the pronator quadratus. 
 From this double cause arises, unless something pre- 
 vent it, the contact of the four fractured ends, which 
 haye been sometimes found united together by a 
 common callus, as is proven by several cases sent ta 
 Desault, and by the cases of different patients admit- 
 ted into the Hotel-Dieu, after having undergone an 
 improper treatment. In such cases, the movements 
 of pronation and supination being entirely destroyed, 
 are but imperfectly supplied, as Duvemey remarks, 
 by those of a rotation of the arm. 
 
 But if the four broken ends should not even be 
 joined together by a common callus, still the space be- 
 tween the bones being evidently diminished, impedes 
 muscular action and the motions of the limb depend- 
 ing thereon, 
 
 OF THE REDUCTION. 
 
 10. It follows from what has been said on the dis- 
 placement of the fragments (8), and on the causes 
 which have a constant tendency to re-produce this 
 displacement (9), that the extending forces, intended 
 to remove it, should be, in general, less powerful 
 than in most other fractures, because their principal 
 object is, to restore to the limb its natural length, 
 which is here but very little affected. 
 
 11. Previously to the application of these, it is 
 necessaiy , according to the precept of Hippocrates, to 
 
152 
 
 place the fore-arm in a middle state between pronation 
 and supination, flexion and extension. This position 
 is highly favourable to the relaxation of the muscles, 
 and is that, above all others, as the father of medicine . 
 observes, which those who have sustained a fracture 
 naturally assume, and w^hich alone they can, for a 
 long time, retain, without experiencing any inconve- 
 nience. 
 
 12. The fore-arm being thus placed, an assistant 
 makes extension, by taking hold of the four fingers ;, 
 a mode to be adopted in preference to that of Petit, 
 who directs us to make extension at the wrist; for the 
 real momentum or force of a power is in the inverse 
 ratio of its distance from the place of resistance. 
 At the same time, another assistant makes counter- 
 extension on the humerus, which he grasps with both 
 his hands, in such a manner, that his thumbs corres- 
 pond to the back part of it, while his fingers cross 
 each other anteriorly. 
 
 13. It further follows, from what was said (8 and 
 9), that the process of conformation, so often useless 
 and even injurious, in other fractures of bones, is ne- 
 cessary here, to restore to the fragments that exact 
 contact M^hich they have lost, in a transverse direc- 
 tion. If the displacement be forv/ard, the surgeon 
 pushes both fragments backward, v/hile the assist- 
 ants maintain the extension. If the bones project back- 
 wards, they must be pushed in the contrary direc- 
 tion. As to a lateral displacement (8) in which the 
 broken ends approach each other, it is not altogetlier 
 useless, as Petit observes, to endeavour to remove 
 it, by forcing the muscles into tiie space between the 
 
153 
 
 bones. This is done by making a moderate presstire 
 on the anterior and posterior surfaces of the fore-arm, 
 in order that the bones, being thus removed from 
 each other, may come in contact with their broken 
 «nds. If this be done, when tiie apparatus is first ap- 
 plied, the reduction is attended widi but Uttle diffi- 
 culty, and the ends of the fragments are easily retain- 
 ed in apposition. 
 
 § VL 
 
 'OF THE MEANS OF MAINTAINING THE 
 REDUCTION. 
 
 14. Our forms of app^atus are nothing but 
 means of continuing, for a long time, that state of 
 things, which extension and the process of conform- 
 ation temporarily produce at the time of reduction. 
 This principle, though generally acknowledged, was 
 particularly neglected in such fractures, as that now 
 under consideration, till the time of Petit, wlio made 
 it the basis of his practice. Before him, there was a 
 common inconvenience attached to every kind of 
 bandage. The two bones being pressed against each 
 other, by circular rollers applied externally, were 
 thus drawn in that very direction, in which the action 
 of the pronatci' muscles already tended to displace 
 them; because, the form of the fore-arm being ir- 
 regular, made these rollers act more powerfully on 
 its lateral parts, where it is very convex, than either 
 behind or before, where it is very flat. It is well 
 known tliat bandages will make the greatest pressure 
 
 21 
 
154 
 
 on the most projecting parts of the limbs round 
 which they are applied; so that, if the fore-arm be 
 bound or pressed on behind and before with a force 
 equal to one, it will sustain laterally, that is, on its 
 sides or edges, a pressure equal to two. Hence results, 
 not only a tendency in the radius to approach the ul- 
 na, but also, a want of resistance in the muscles situ- 
 ated on the posterior and anterior sides of the fore- 
 arm. For these muscles being, from their flatness, 
 less compressed than the bones, give way, and do 
 not, by forcing themselves between them, .oppose 
 the approach of the bones to each other. 
 
 15. Such was the disadvantage of the apparatus 
 of Hippocrates, consisting of one roller applied im- 
 mediately on the skin, of a many-tailed bandage in- 
 tended to retain this, and of four splints, applied on 
 the seventh day, and secured by another roller. Such 
 was also the inconvenience of several bandages, pro- 
 posed after the time of Hippocrates, by different au- 
 thors, who modified his without improving it, and 
 who, in attempting to alter it, even added to its im- 
 perfections. Thus, the compresses with which the 
 limb was first covered, previously to the application 
 of the rollers, served only, by becoming vrrinkled, to 
 render the compression unequal, fatiguing, and even 
 painful to the patient. In like mamier the pasteboai'd, 
 which many authors, particularly Duvemey, have 
 substituted for splints, and which a majorit}^ of prac- 
 titioners employ, even at the present day, soon be- 
 coming softened by moisture, bends without resist- 
 ance, becomes incapable of preventing a displace- 
 
155 
 
 ment, and has at least the inconvenience of being 
 useless.* 
 
 16. Is it to be wondered at then that a perfect 
 cure of fractures of the fore-arm has been regarded 
 as a thing of so much difficulty, and that most authors 
 should have advised practitioners, as a thing of pru- 
 dence, to warn the patient of its being impracticable 
 to cure him, without the loss of the motions of pro- 
 nation and supination? Thus, in like manner, it was 
 formerly declared, that a constant deformity was the 
 necessary consequence of fractures of the clavicle. 
 
 17. Petit first conceived, that he discovered, in 
 the very means destined to prevent the displacement, 
 the cause of its being continued, and that, in order 
 to be effective, the bandage ought to do constantly 
 what the hands of the surgeon do at the time of re- 
 duction (13); that is, it ought to oppose to die unre- 
 mitting action of the pronators, a resistance equally 
 unremitting, by pressing the muscles into the inter- 
 stice between the bones. But, after having discover- 
 ed the end to be attained, he accomplished it only in 
 an imperfect manner. For by first applying a roller 
 immediately round the fore-arm, he reproduced, in 
 part, the very inconveniences and disadvantages he 
 wished to prevent, by placing anteriorly and posteri- 
 orly two long and thick graduated compresses, in- 
 tended to keep the bones asunder, by forcing the 
 muscles between them. 
 
 * On this point Desault is certainly mistaken. Paste-board, 
 when of a proper thickness and well applied, makes an excel- 
 lent splint for fractures of the fore-arm. It moulds itself to the 
 form of the arm, sits easy, and retains the fracture extremely 
 well. Trans, 
 
156 
 
 18. Duvemey, more judicious, proposed to place 
 the graduated compresses of Petit on two circular 
 compresses, previously applied round the fore-arm^ 
 But what availed these circular compresses? If thej^ 
 be drawn tighty will they not produce that approxi- 
 mation of the bones which the surgeon wishes to 
 avoid? And if they be not tight, they will, in conse- 
 quence of their loose and pliable state, fcam trouble- 
 some and inconvenient wrinkles, without being pro- 
 ductive of any good to counterbalance this incon- 
 venience, 
 
 19. It was from these different consideration Sy 
 that Desault modified, as I am about to mention, the 
 apparatus for fractures of the fore-arm. To a great 
 degree of simplicity, this apparatus unites, when thus 
 improved, great ease to the patient, and its advan- 
 tages ai'e proven by the freedom in the different move- 
 ments of the arm always experienced by the nume- 
 rous patients, whom he was called to attend. The 
 pieces of the apparatus are, 1st, Two graduated com- 
 presses, one of them of such a length as to extend 
 from the elbow to the wrist, and the other from the 
 wrist to the fold of the arm on the inside. They are 
 to be formed each of a single piece of linen, folded 
 seven or eight times on itself, in such a manner, that 
 the lov/er fold may be an inch wide, while the others^ 
 laid on top of each other, gradually diminish in width 
 to the last. The thickness of these compresses ought 
 to be less in very fat persons, where the anterior and 
 posterior surfaces of the arm are more convex. 2dly, 
 A roller about four yards and a half long, and four 
 inches wide. 3dly, Four thin but Ltlff wooden splints^ 
 
U7 
 
 long enough to reach, one, from the fold of the arm 
 to the wrist, the second, from the interval or TioUow 
 space between the olecranon and the condyl to the 
 same part, the third from the internal condyl of the 
 humerus to the styloid process of the ulna, and the 
 fourth from the external condyl to the styloid apo- 
 physis of the radius. The breadth of tiie two first 
 ought to be double that of the other two, as the latter 
 occupy a space of but half the width of that occupied 
 by the former. 
 
 20. Every thing being arranged, the reduction 
 is to be executed as already directed (11 — 13); and 
 while the extensions are still continued, the surgeon 
 wets with vegeto-mineral water, or some other dis- 
 cutient liquid, the graduated compresses, and places 
 them on the anterior and posterior part of the fore- 
 arm, (which must be firmly supported in' a state be- 
 tween that of pronation and supination, 11), in such 
 a manner, that their broadest part or base may be 
 in immediate contact with the limb. He then secures 
 them with a roller wet with the same liquid, the casts 
 of which, being first fixed at the place of the fracture, 
 descend obliquely to the wrist, and are secured at 
 the hand by being passed between the thumb and 
 the fore-finger. Running across the back of the 
 hand, the roller then reascends, either by oblique or 
 reverse turns, according to the inequalities of the 
 fore-arm, till it reaches the elbow. Here the surgeon 
 relinquishes the roller, giving it into the hand of an 
 assistant, and places the four splints on the parts al- 
 ready mentioned (19), while the hands of a second 
 assistant secures them, by grasping them all at their 
 lower end, next to the ^^Tist. The surgeon then re- 
 
158 
 
 sumes the roller, and, in order to fix the splints im- 
 moveably, descends with it along the fore-arm by 
 circular casts^ till he reaches the hand, where he 
 finishes. 
 
 There is, in the application of this bandage, an 
 essential precaution to be observed; which is, that as 
 each turn of the roller passes over the graduated com- 
 presses, the surgeon ought to press on these com- 
 presses with the thumb and fore-finger of his left 
 hand, in order that the muscles, by being forced into 
 the interstice between the radius ajid ulna may pre- 
 vent their approximation, which would produce an 
 inequality in the compression made by the apparatus, 
 
 21. After the application of the apparatus, if the 
 patient be obliged to keep his bed, the fore-arm is to be 
 extended on a pillow, taking care to keep it always half- 
 bent, and guarded by hoops from the w^eight of the 
 bed-clothes. But if the fi'acture be not a compound 
 one, and if the fall has done no injury to the system 
 in general, it is unnecessary to confine the patient to 
 a position wearisome, and oftentimes insupportable 
 to many persons. Then the limb is to be suspended 
 in a sling, which is always sufficient to support it, 
 without having: recourse to the kind of hollow case 
 recommended by Bell, which is seldom at hand, and 
 the use of which must be extremely inconvenient. 
 
 22. The subsequent treatment to be adopted in 
 such fractures is simple and easy : to wet the appa- 
 ratus daily, for a few days, wdth vegeto-mineraJ water, 
 to ob^date, by proper means, the accidents that may 
 occur; to renew the application of the roller at the 
 end of eight days, or perhaps later, according to the 
 degree of its relaxation ; to repeat this application two 
 
159 
 
 or tliree times during the course of the treatment ; to 
 allow, at first, but light diet, which may be after- 
 wards more solid, and given in larger quantity, and 
 to admit finally of a return to the patient's usual mode 
 of hving: such was, in cases of fi^acture, the prac- 
 tice of Desault, which was always attended with 
 happy effects. 
 
 23. Sometimes a considerable swelling occurs, 
 after the application of the bandage, on the back and 
 face of the hand; small blisters appear between the 
 fingers; the patient experiences sharp pains along 
 the fore -arm; and other small blisters rise on its sur- 
 face. It is then necessary to remove the apparatus, 
 to open the blisters by pricking the cuticle, and dress 
 the part with cerate spread on linen rags ; replace the 
 apparatus, making it less tight than before, taking care 
 to renew it every day, till the excoriation be entirely 
 gone. This accident, of no great consequence in 
 itself, has frequently occurred to Desault, although 
 the rollers w^ere applied at first with but a moderate 
 degree of tightness. 
 
 24. The consolidation being completed generally 
 in twenty-four or twenty-five days, leaves, at this 
 time, a little stiffness in the joints, in consequence of 
 their having remained so long without motion: the 
 movements of pronation and supination are perform- 
 ed but imperfectly. Their return is facilitated and 
 hastened by fi'equent exercise of the limb, as well at 
 its junction with the os humeri, as in its own proper 
 joints ; and, in general, by the fifteenth or twentieth 
 day fi"om the removal of the apparatus, things are in 
 the same state in which they stood before the fracture. 
 
160 
 
 FRACTURE OF THE RADIUS. 
 § VII. 
 
 OF THE CAUSES AND THE DISPLACEMENT. 
 
 25. The radius, which is the moveable and almost 
 the only support or abutment of the hand, receives, in 
 falls on that part, a much greater share of the shock 
 than tlie ulna, which is joined to the hand by only a 
 small surface. Hence, witliout doubt, arises the 
 greater frequency of tlie fractures of the radius ; 
 fractures ^vhich, v. hen produced by falls on the hand, 
 are evidently the result of a counter- stroke. Often- 
 tinjes also this bone is broken by the immediate ac- 
 tion of external bodies, because it is defended below 
 with but a thin covering of muscles. 
 
 In whatever way the fracture may be produced, 
 it occurs in the middle or at the extremities of the 
 bone; very rare near its articulation with the os hu- 
 meri, it is more common in its middle; but more 
 frequent still at its lower end. The difference arises 
 probably from this circumstance, that, in falls on the 
 wrist or hand, the shock is weakened and lost in pro- 
 portion as it is propagated upwards. 
 
 26. In such fractures, displacement is almost con- 
 stantly observable in the thickness or cross direction 
 of the bone and fore-arm, and is produced by the 
 action of the pronator muscles, which, by forcing die 
 fragments of the radius towards the ulna, tend to di- 
 minish the interval between the bones. The ulna re- 
 maining unbroken^ always prevents any displacement 
 
161 
 
 in a longitudinal direction. The first kind of dis- 
 placement is the more perceptible, in proportion as 
 the fi-acture is nearer to the middle part of the radius, 
 where the bones are at the greatest distance from each 
 other. This displacement is seldom outwards, be- 
 cause the interosseous ligament prevents that: yet 
 experience furnishes some exceptions to this rule. 
 
 Case I. Desault was called, in the month of 
 July, 1781, to visit a mason, who, sleeping at the 
 foot of a wall, with his fore-arm stretched out, re- 
 ceived on the anterior part of it, a round stone, of the 
 size of a bowl, which, falling from a scaffold, fractured 
 the radius in its middle, and produced a large contu- 
 sion, accompanied by an enormous swelling, to which 
 the usual discutient remedies were applied. On the 
 fifth day the swelling had in part disappeared; but 
 then there was discovered a very evident protube- 
 rance of the inferior fragment, which, by pointing 
 outwards, separated itself from the superior one, 
 which remained nearly in its place. The interval be- 
 tween the bones was evidently increased below. 
 
 The fracture was reduced by pressing the lower 
 fragment inwai'ds, and, instead of employing gradua- 
 ted compresses the whole length of the limb, they 
 reached only to its middle, along the part correspond- 
 ing to the superior fragment. The roller was drawn. 
 a little tighter below than above, in order to keep the 
 inferior part of the radius near to the ulna. 
 
 By being treated afterwards in the usual m.ode, 
 
 the fracture was cured. But, in consequence of being 
 
 over- stretched by the separation of the bones, the 
 
 ligaments of the wiist became the seat of a tedious 
 
 22 
 
162 
 
 fymphatic swelling, which left behind it some degree 
 of stiffness. 
 
 27. Examples of this kind occur too rarely to 
 affect the general law relative to the direction of the 
 displacement of a fractured radius, a displacement 
 which, if not properly treated, makes the fragments 
 unite in such a manner as to form an angle pointing 
 inwardly towards the ulna, as is evinced by a percep- 
 tible depression under the cuticle. In such a case, 
 fi'om this contraction or narrowing of the interval be- 
 tween the bones, arise the inconveniencies already 
 m,entioned (9). 
 
 ^ VIIL 
 
 OF THE SIGNS. 
 
 28. The diagnosis of fractures of the radius is in 
 general easy, when they occur at the lower end, or in 
 the middle (25). In these two cases, a depression 
 more or less perceptible, on the external side of the 
 fore-arm ; an inability to perform pronation or supi- 
 nation, by the action of the muscles alone; and a se- 
 vere pain, necessarily resulting from moving the bone 
 in this two-fold direction. Such are the particular 
 signs or appearances which first disclose the existence 
 and the place of the fracture. The reality of the acci- 
 dent is afterwards more fully confirmed by the signs 
 common to all fractures, namely, the flexibility of the 
 bone, the crepitation perceived by moving it in dif- 
 ferent directions, &c. 
 
 29. Desault cautioned his pupils not to confound 
 this last sign or symptom with a kind of noise, some* 
 
163 
 
 times heard in the sheaths of the tendons of the ex- 
 tensor longus, extensor brevis, and abductor longus; 
 a noise resulting from a filtration of synovial fluid into 
 the sheaths, or produced by some other cause. But, 
 besides this crepitus in the sheaths being a very rare 
 occurrence, it is always easy to distinguish it from a 
 crepitation of the bone, by this circumstance, that 
 the first is heard on merely pressing the parts, but 
 the latter only by making the bony surfaces rub 
 against each other. Besides, by an experienced ear 
 there is no danger of any mistake being committed. 
 
 30. If the fracture exist at the upper end, the thick 
 muscular covering which there surrounds the radius, 
 renders the diagnosis more difficult. Petit has, how- 
 ever, thrown some light on the subject, by judiciously 
 advising to place one hand on the upper extremity of 
 the radius, and with the other to make the fore-arm 
 rotate on this bone. The solution of continuity or 
 fracture will be rendered evident, if, in the midst of 
 these motions, the head remain stationar}^ But if, on 
 the other hand, it rotate, it has sustained no injuiy. 
 These two circumstances can be easily explained; 
 but, it is not so easy for the practitioner to avail him- 
 self of them in every case. This precept may also be 
 applied in cases where a considerable swelling, occu- 
 pying the whole fore- arm, conceals from the touch 
 of the surgeon the fragments of the bone, even when 
 broken in the middle. 
 
164 
 
 § IX. 
 
 or THE REDUCTION, AND THE MEANS OF MAIN- 
 TAINING IT, 
 
 31. The'reduction of a fracture of the radius is ef- 
 fected in nearly the manner already described for that 
 of the two bones of the fore-arm (10 — 13), except 
 that, here, the extension must be less, because 
 there exists no displacement in a longitudinal direc- 
 tion (26). 
 
 To remove that v^^hich exists in a cross direction, 
 an assistant whose business it is to make extension, 
 places the hand in a state of adduction, for the pur- 
 pose of removing the inferior fragment outwards. 
 This precept cannot be applied to much advantage, 
 if the division exist towards the upper end, on ac- 
 count of the interosseous ligament. 
 
 At the same time the surgeon endeavours to bring 
 the ends of the bone into perfect contact, by pushing 
 them in a direction opposite to that of their displace- 
 ment; and when he has attained this end, he begins 
 the application of a bandage or appai'atus the same as 
 that already described (19 and 20), with this differ- 
 ence, that as the ulna is here sound, and performs, in 
 relation to the fractured radius, the office of a natural 
 splint, it is unnecessary to place an artificial one be- 
 tween the internal condyl of the humerus, and the 
 styloid apophysis of the ulna. 
 
 32. The consolidation or cure is here always more 
 speedy than^ in the preceding cases, where nature, 
 with the same amount of means and resources, has 
 
165 
 
 twice the quantum of labour to perform, and where 
 she supplies her deficiency of power, by the greater 
 length of the time which she employs. In general the 
 bone is united by the twentieth or twenty-fourth day. 
 
 33. When the fracture exists at the superior part 
 of the radius, it is essential, after the removal of the 
 apparatus, to make the limb very frequently perform 
 all its natural motions. In such a case, indeed, the 
 parts sometimes swell, become stiff, and an anchy- 
 losis of the fore-arm may be the consequence, as 
 Ambrose Pare observes, in his book on fractures, 
 where he says he has seen many accidents of this 
 kind. Galen has remarked the same thing before 
 him. The following case reported by Jeo. Dol**, 
 confirms the truth of it. 
 
 Case IJ. Jane Rene was received into the Hotel- 
 Dieu, in consequence of a fracture of the upper ex- 
 tremity of the radius, produced by a fall on that part, 
 for which she was subjected to the treatment already 
 described (31). The apparatus being removed at 
 the expiration of twenty-five days, the consolidation 
 was perceived to be complete. The motions of prona- 
 tion and supination were impracticable; those of 
 flexion and extension very much impeded. The pa- 
 tient was now ordered to have the fore-aim moved 
 daily, in these several directions, for the space of an 
 hour, and this space was even increased morning and 
 evening, notwithstanding the pains which, at first, 
 accompanied the exercise. On the eighth day prona- 
 tion and supination could already be performed in a 
 small degree; they became more and more free, in 
 proportion as the exercise of the limb was longei!" 
 continued; finally, on the twenty-second day from 
 
166 
 
 tlie removal of the apparatus, the patient was con- 
 ducted, according to custom, to the amphitheatre, 
 where all the pupils witnessed die perfect freedom of 
 the motions. 
 
 Case III. A few days after this, a man, who had 
 left the Hotel- Dieu about eight months before, while 
 under treatment for a similar fracture, returned, to be 
 the subject of a public consultation in consequence 
 of a different disease. 
 
 Desault, on interrogating him, learnt from him 
 tliat the treatment for the fracture had been continued 
 at his own house (31), but that, when the apparatus 
 was removed, no motion had been impressed on the 
 limb, and that die surgeon had even kept it in a sling. 
 The fore-arm was then examined; it was half bent, 
 constantly in a state of pronation, and could not, by 
 any force, be brought into a state of supination. The 
 motions of flexion and extension, were so limited as 
 to be scarcely sufficient for the common wants of the 
 patient, who, under proper treatment, might have - 
 been cured like the preceding one, as Desault re- 
 marked to his pupils at the time. 
 
 34. The patient vi'^ho was the subject of this se- 
 cond case, was sent to the mineral springs, but de- 
 rived no benefit from tlie use of the waters. If this 
 were a proper occasion, I could mention many in- 
 stances where this remedy, so highly spoken of by 
 many physicians of the present time, has had no ef- 
 fect, except to deprive the patient of more efficacious 
 means, by making him lose that time, during which 
 exercise frequently repeated, w^ould have effected 
 a cure, but which, coming too late, could be of no 
 avail. 
 
167 
 FRACTURE OF THE ULNA. 
 
 OF THE CAUSES AND THE SIGNS. 
 
 35. The ulna, less frequently broken, in general, 
 than the radius, scarcely ever suffers alone from falls 
 on the wrist or hand. Most commonly its fracture is 
 direct, and occurs, in particular, in cases where a per- 
 son in falling, extends the fore -arm for the purpose 
 of supporting himself, and strikes its internal part 
 against some resisting body. 
 
 The division, though it does take place occasional- 
 ly in all parts of the bone, occurs most frequently near 
 to the lower end, where its slender size, compared to 
 that of its upper end, its more projecting situation, 
 and its thinner covering of soft parts, act as predis- 
 posing causes. 
 
 36. In whatever part it may exist, the touch must 
 readily detect it, when the fingers are drawn along the 
 internal surface of the ulna, which lies almost imme- 
 diately under the skin. If moved in contrary direc- 
 tions, the fragments will also, by their mobility and 
 crepitation, disclose the nature of the injury. A de- 
 pression more or less perceptible is observed on the 
 internal part of the fore-arm, produced by a displace- 
 ment of the fragments, which are carried towards the 
 radius, more particularly of the inferior fhigment, as 
 Petit has well observed, the superior one remaining 
 almost immoveable. 
 
168 
 
 XL 
 
 OF THE REDUCTION, AND THE MEANS OF MAIN- 
 TAINING IT. 
 
 37. The reduction does not differ from that of 
 the radius (31), except in this, that the assistant who 
 makes the extension, must place the hand in the op- 
 posite state, namely, that of abduction, in order that 
 the fragments may be brought into contact, while 
 the surgeon assists in this process, by pushing the 
 broken ends of the bone in a direction opposite to 
 that of their displacement. 
 
 As in the foregoing case, three splints are suffi- 
 cient for the appai'atus, where the radius, being un- 
 broken, performs the office of a fourth. 
 
 The exercise of the limb, after the consolidation 
 of the bone, is in general less necessary here, than in 
 fractures of the radius (34), because the ulna, being 
 an immoveable point of support for the motions of 
 rotation, concm's in them only in a passive manner. 
 
 FRACTURE OF THE OLECRANON. 
 ^XII. 
 
 REMARKS ON THE OLECRANON. 
 
 38. The ulna is surmounted, at its upper end, by 
 a considerable appendix, curved before, where it cor- 
 responds to the articulation of the fore-arm, and is 
 covered with cartilage; convex behind, where thercj 
 
169 
 
 is nothing to separate it from the external integu- 
 ments, and is attached at its upper end to the strong 
 tendon of the triceps muscle, which appears to be in- 
 corporated with it. This appendix resembles greatly, 
 in its structure, form, and uses, the rotula, from 
 which it would differ in nothing, if the inferior liga- 
 ment of the latter were ossified, so as to form a bony 
 continuity between it and the tibia. It is exposed to 
 fi^actures, perfectly similar to those of the rotula, but 
 ^vhich differs so essentially from the other fractures of 
 the ulna, as to call for a separate examination. 
 
 39. The ancients appear to have had but little 
 knowledge of fractures of the olecranon, respecting 
 which they have transmitted nothing to us, unless 
 with Dalechamps, we find cause to recognize a refer- 
 ence to this affection in the following passage of Paul 
 of Egina : Cubitus frangitur, . . circa partem ad cubiti 
 gilbum. 
 
 Most of the modems have spoken of it only in a 
 vague manner; no one has described with accuracy 
 the signs which characterize itj and few have given 
 satisfactory ideas on its treatment. Petit has not 
 spoken of it separately, and Duverney, who concludes 
 with it his article respecting fractures of the fore-arm, 
 has but imperfectly described for it a bandage "which 
 is in itself equally imperfect. Bell does not give us, 
 on this point, an exposition of either his opinions or 
 his practice. 
 
 Yet this fracture is by no means so rare as to jus- 
 tify the silence of authors, and its treatment merits a 
 degree of attention beyond that which is requisite in 
 most other fractures. 
 
 23 
 
170 
 § XIII. 
 
 OF THE VARIETIES AND CAUSES. 
 
 40. The olecranon suffers fractures at its base and 
 at its summit, but more frequently in the first, than in 
 the second situation. The division, though very 
 generally transverse, is sometimes oblique. Desault 
 met with an instance of an oblique fracture of the ole- 
 cranon in a man, who had sustained a violent blow 
 on his fore-arm from a club. 
 
 41. The causes which produce itai'€, either mus- 
 cular action, a circumstance that very rarely occurs, 
 or the direct action of external bodies, which is by 
 far the most common case. The reverse of this is 
 tine with regard to fractures of the rotula, which are 
 almost always produced by the contraction of the 
 muscles attached to that bone. 
 
 42. The olecranon has been at times separated 
 from the ulna, by the act of throwing a stone witli 
 great force. In such cases, the fracture has been pro- 
 duced by the immediate action of the triceps muscle. 
 This is tlie first mode of division. 
 
 The second occui's when a violent blow is receiv- 
 ed on the elbow, or, more particularly, from falls on 
 that pait r for example, if, when descending a flight 
 of stairs, our heel slip and we fall backwards, the arm 
 is suddenly tlirown behind to save the body. In such 
 a case, the olecranon striking forcibly against one of 
 the steps, and being pressed between it and the weight 
 of the body, is broken. In this way was the disease 
 produced in a majority of the patients attended by 
 Desault for fi-actures of the olecranon. 
 
171 
 § XIV. 
 
 OF THE SIGNS. 
 
 43. We meet here with the same appearances and 
 state of things, which constantly occur in fractures of 
 the rotula. The triceps extensor, finding no longer in 
 the continuity or sound state of the ulna, a resistance 
 to its contractions, draws upwards the short fragment 
 to which it adheres, produces between it and the 
 lower one an interval more or less perceptible, and 
 gives rise to the greater part of the other character- 
 istic signs of the affection : these are, 1st, An inter- 
 val or space between the fragments, corresponding to 
 the posterior part of the articulation. This interval 
 may be increased at pleasure, by increasing the flexion 
 of the fore-arm, or by making the patient contract the 
 triceps muscle, and may be again diminished, by 
 bringing the arm into a state of extension : 2dly, An 
 inability in the patient to extend the fore-arm spon- 
 taneously, which is the necessary result of the separa- 
 tion of die triceps from the ulna: 3dly, A constant 
 semiflexion or half-bent state of the fore-arm, pro- 
 duced by the contractions of the biceps and brachialis 
 intemus muscles, to which no antagonists ai'e now 
 opposed: 4thly, An elevation, more or less percepti- 
 ble, of the olecranon above the condyls, which, on the 
 contrary, rise above it, when, in a natural state of the 
 parts, the fore-arm is half-bent: 5thly, A facility of 
 moving the upper fragment in every direction, without 
 communicating any motion to the ulna; 6thly, A 
 peculiar sensation experienced by the patient, to 
 
172 
 
 ^vhom it seems, when he makes an effort to extend the 
 fore-arm, as if some body or substance were detached 
 or broken off from his elbow, and carried upwards. 
 The patient may realize the justness of this sign, by 
 comparing it with what he feels on attempting to ex- 
 tend the opposite fore-arm, placed in the same posi- 
 tion. 
 
 44. If to these signs be added the circumstances 
 which accompany the accident, the severe pain that 
 is always felt, the crack which is sometimes heard 
 by the patient, and the possibility of producing a per- 
 ceptible crepitation, by rubbing the fragments in 
 contrary directions, after having first brought them 
 together, it will be difficult to be mistaken respecting 
 the existence of the fracture, which indeed the sw^ell- 
 ing of the part alone can conceal from the practi- 
 tioner, if, as sometimes happens, it be consider- 
 able. But then, being soon dispersed, either spon- 
 taneously, or by the action of discutients, it leaves the 
 accident unmasked, accompanied by the signs just 
 enumerated. 
 
 45. To the swelling is oftentimes added, an echy- 
 mosis more or less considerable, when the accident 
 has been produced by a fall on the elbow. But by 
 this, no change is effected in the essential characters, 
 which are always sufficient to distinguish a fracture 
 from a luxation backwards, with which it has been 
 sometimes confounded, as appears from many ex- 
 amples recorded in different works. 
 
173 
 § XV. 
 
 OF THE PROGNOSIS. 
 
 46. I will not dwell on the question, so much 
 agitated of late, namely, whether or not the olecranon 
 be susceptible of consolidation or reunion. Already 
 has it been hundreds of times answered by experi- 
 ence. What could theory add to the conviction al- 
 ready impressed on us from that quarter? It was by 
 exhibiting to the croud of pupils who attended his 
 clinical lectures, fractures of this kind perfectly re- 
 united, that Desault refuted the weak arguments, of 
 the periosteum not being able, in consequence of not 
 covering the anterior surface of the olecranon, to pro- 
 duce a union between its fragments, of the synovia 
 mixing with the matter of callus, diluting it, weak- 
 ening it, preventing it from becoming sufficiently 
 hard for the purpose of reunion, &c. We will only 
 observe, that these ideas are borrowed from a theory 
 which modem experiments have proven to be un- 
 founded, and which, were it true, would be applied 
 in the present case quite unphilosophicaliy, since it 
 would deny to certain parts of man the power or 
 property of restoration or being healed, a property 
 common to all the component parts of beings endowed 
 with life, and which even constitutes one of their es- 
 sential and discriminative characters. 
 
 47. Is the consolidation of the olecranon effected 
 in the same mode as in other bones? The observations 
 of many practitioners. Camper in particular, seem to 
 prove that a ligamento-cataloginous substance is al- 
 
174 
 
 ways the medium of the union of fragments. De- 
 sault once found this substance in a corpse, but it 
 was in a case where the fracture had been improperly 
 treated, and where, of course, no inference could be 
 drawn with regard to ordinary cases. 
 
 48. But of what import to us are the means 
 which nature employs? The indication is still the 
 same. The fragments must be always kept in con- 
 tact, that the reunion may be immediate, and that, 
 as David observes, in his memoir on motion and rest 
 in surgical diseases, the apophysis may not, by be- 
 coming too long in consequence of the space occu- 
 pied by the callus, impede the extension of the fore- 
 arm on the OS humeri. 
 
 ^ XVI. 
 
 OF THE MEANS OF CONTACT BETWEEN TH£ 
 FRAGMENTS. 
 
 49. There are no fi'actures, the treatment of which 
 demands more attention, or is surrounded with more 
 difficulties, than that of the olecranon. Here art can- 
 not, as in the thigh, and the clavicle, oppose to the 
 ever active po^ver of the natural muscles, a constant 
 resistance produced by the action of a kind of artifi- 
 cial muscle, consisting in permanent extension. The 
 superior fragment, being too small to give any pur- 
 chase to extending forces, can be only pushed down^ 
 wards, and kept in that position with a greater or less 
 degree of stability and firmness, while the ulna, so to 
 spealc, is drawn to meet it. Whence it follows, that 
 extension here is of little use, and that it is chiefly by 
 
175 
 
 position or attitude, aided by a judicious conforma- 
 tion, tliat the reduction is effected. 
 
 50. The position has varied in the hands of dif- 
 ferent practitioners. Some have proposed that, in 
 wliich the fore-arm is half-bent, so as to form a right 
 angle with the os humeri. The example mentioned 
 by David, is not the only one where recourse has 
 been had to this. But, by rejecting the general 
 principle respecting the reunion of parts, which re- 
 quires them to be kept in perfect contact, this mode 
 is exposed to a double inconvenience. The reunion 
 is extremely slow in being accomplished, and, when 
 ultimately obtained, is accompanied by the loss of one 
 part of the movements of the limb, in consequence 
 of the length of the callus. This callus must neces- 
 sarily fill up the whole space that intervened between 
 the fragments during the treatment, and being thus 
 added to the natural extent of the olecranon, length, 
 ens this appendix to such a degree, that, in extend- 
 ing the fore-arm, its summit or upper end comes too 
 soon into contact with the cavity in the os humeri 
 destined to receive it. 
 
 51. This practice appears to have been chiefly 
 owing to an opinion then in existence, that an anchy- 
 losis being the necessary consequence of the fracture, 
 it was proper to place the arm in that position in 
 which it would be most likely to be still of some 
 service. 
 
 52. We must not, however, by throwing the 
 fore-arm into the greatest possible degree of exten- 
 sion, allov/ it to be drawTi into the opposite extreme. 
 From this en-or the same inconveniencies would re- 
 
176 
 
 suit. In such a case, should the fragments touch 
 each other, and press too hard at their posterior 
 edges, they must inevitably leave an intervening va- 
 cuity or space between their anterior edges. Hence 
 a greater tliickness of callus on the one side than on 
 the other, and consequently an impediment more or 
 less troublesome in the motions of the joint. If the 
 inferior fragment do not touch the superior one, it 
 sinks into the olecranon cavity, leaves the other be- 
 hind it, and hence another source of irregularity in 
 the consolidation. 
 
 53. Between these two extremes (50 and 51), it 
 remains to choose a middle course, and that position 
 will be best, in which the fore-arm shall be, so to 
 speak, in a state between semi-flexion and extension. 
 By this the fragments, being brought into perfect 
 contact, will experience no obstacle to a reunion, 
 which will be therefore both speedy and uniform. 
 
 54. But it w^ould be useless to place the limb in 
 a proper position, if no means were made use of to 
 retain it there. Being immediately submitted to the 
 action and influence of a multitude of causes, it will 
 lose its position, and the work of nature being inter- 
 rupted, the consolidation will be retarded. 
 
 Hence appears, both the necessity of placing a 
 solid body, as Desault did, before the whole of the 
 limb, to prevent its flexion, and the insufiiciency of 
 the apparatus proposed by Duverney and others, who 
 directed to lay a thick compress on the fracture, to 
 suiTOund the elbow then by a circular one, to secure 
 the v/hole by a kind of figure of 8 bandage, similar 
 to that used in blood-letting, and, finally, to place the 
 limb on a pillow, without further precaution. 
 
177 
 
 55. Position alone evidently acts only on the 
 lower fragment, which it directs towards the upper 
 one. But it is also necessary to draw the upper frag- 
 ment towards the lower one, and fix it there, and this 
 is certainly the most difficult point; because, the 
 triceps muscle having a constant tendency to con- 
 tract, opposes its action to the approximation of the 
 fragments, and indeed prevents it, if, as in the means 
 usually proposed and adopted, the pieces of the ban- 
 dage glide easily over each other. 
 
 56. These considerations determined Desault to 
 search for some means which, being more efficacious 
 than those already in use, might better fulfil the indi- 
 cations of the fracture. He accordingly invented the 
 apparatus which we are about to describe; some 
 ideas of this apparatus are indeed borrowed from 
 other bandages. The success which attended the 
 use of it at the Hotel-Dieu, will, without doubt, in- 
 troduce it generally into rational practice, where the 
 insufficiency of the old forms of apparatus is acknow- 
 ledged. 
 
 1st, The fore-arm being placed in the position alrea- 
 dy directed (53), two assistants retain it in that situa- 
 tion, while the surgeon applies on its lower part the 
 end of a roller five or six yards long, and about four 
 inches wide, wet with some discutient liquid, making 
 with it, at first, one or two circular turns to fasten it. 
 Then ascending from below upwards, he covers the 
 whole of the fore-ai^m with oblique and reverse turns 
 moderately tight. 
 
 2dly, Having arrived at the joint, he stops, and 
 makes an assistant draw the skin of the elbow up- 
 
 24 
 
178 
 
 wards, lest, being loosened and wrinkled by means 
 of the extension, it might get between the fragments, 
 and create an impediment to their remiion. Then, 
 taking hold of the olecranon, he draws it down to- 
 wards the ulna, and passes behind it, as a substitute 
 for his fingers which have hitherto kept it firmly fix- 
 ed, a cast of the roller, which he brings from the an- 
 terior part of the fore-arm above the elbow. Descend- 
 ing again with the roller along the external side of 
 the ai^m, and returning across the anterior part, he 
 pursues again the same course, so as to make the 
 casts of the roller lie on each other, and surround the 
 elbow like a kind of figure of 8. 
 
 3dly, The surgeon proceeds now by oblique 
 turns, to the upper part of the ai'm, where he fixes 
 the roller, by a circular turn, and gives it into the 
 hand of an assistant. He next applies along the arm 
 and fore-arm, a splint very strong, but a little bent at 
 the place vdiich corresponds to the joint, in order to 
 prevent too great an extension of the limb : then, 
 resuming the roller, he employs it, in a descending 
 direction, to secure the splint. 
 
 4thly, The apparatus being applied, the limb is 
 placed on a pillow, so as to be equally supported 
 throughout its length, and is protected by hoops from 
 the weight of the bed-clothes. 
 
 57. To the bandage which we have just describ- 
 ed, Desault added formerly a strip of linen, to be 
 placed all along the posterior part of the arm, se- 
 cured first at its upper end by circular casts, which 
 began above; this strip was secured afterwai'ds by 
 oblique casts, as far as to the place where it met the 
 
179 
 
 olecranon, separated from the ulna. Here, the sur= 
 geon quitting the roller, took hold of the bit of linen, 
 and drew it downwards, and along with it the circular 
 casts of the roller, together with the muscles on which 
 these casts were applied, and also the fragment which 
 the muscles drew upwards. An assistant then secur- 
 ed it here, while the surgeon, after having made some 
 casts in form of the figure of 8, descended to the in- 
 ferior part of the fore-arm, where the end of the strip 
 was made fast by tight circular turns. (See fracture 
 of the rotula.) 
 
 58. The intention of this additional piece of ap- 
 paratus, was to draw down the superior fragment, to 
 prevent the circular casts of the roller fi:om separat- 
 ing by their relaxation, and, by that means, to retaia 
 the fragments in apposition. But, on the one hand, 
 may not the superior fragment be di'awn by the hand, 
 as well as by a roller employed for the purpose ? 
 And, on the other, if the circular casts of the roller 
 be liable to become relaxed, why not the strip of linen 
 also? These considerations induced Desault to lay 
 it aside, and use the bandage in tit© form just de- 
 scribed. 
 
 59. The advantages it offers ^e far from being 
 equivocal. 1st, The limb is kept in a state of invari- 
 able extension by the anterior splint, and, on this ac- 
 count, there can be no displacement cm the part of 
 the inferior fragment. 2dly, The bandage, which ac- 
 curately envelopes the whole limb, restrains the action 
 of the muscles by compressing them, and prevents 
 in part the contractions of the triceps ; while the casts 
 in the form of the figure of 8, applied with skill and 
 
180 
 
 precision, hold down the superior fragment, and ren- 
 der it difficult for it to be displaced* 3dly, Without 
 the application of a roller over the whole limb, a swel- 
 ling, more or less considerable, would probably be 
 the effect of the constriction at the elbow, which must 
 necessarily be somewhat tight, because, as the turns 
 of the roller, in form of the figure of 8^ act on the 
 olecranon obliquely, if they be too loose, they will 
 slip and not perfonn the office of retention. 
 
 60. Like all kinds of apparatus composed of rol- 
 lers, this ought to be frequently examined, lest, by 
 becoming relaxed, it should not make sufficient re- 
 sistance to the triceps, which is always disposed to 
 dra*w itself upwai'ds. There can be no period fixed 
 on for the reapplication of the apparatus; the moment 
 it begins to become slacks it ought to be renewed: 
 three or four times during the course of the treatment 
 are generally sufficient. Should a considerable swell- 
 ing give reason to suspect that the constriction is toer 
 great, it will be necessary to remove the bandage in 
 order to apply it anew. 
 
 61. The period necessary for the reunion of frac- 
 tures of the olecranon varies, according as the bandage 
 is more or less exactly kept in its place. Among ten 
 cases of this kind, collected in the Hotel- Dieu, four 
 united in twenty-four days, three in twenty -eight, 
 and three in thirty-two. Hence, taking the mean term, 
 all other circumstances being alike, the process of 
 cure requires about twenty- six days. 
 
 62. When this is completed, it is necessary to 
 impress on the limb motions of flexion and exten- 
 sion, gradually increased every day. This is, as Da- 
 
181 
 
 vid properly observes, the most certain method of 
 avoiding a stiffness, and even an anchylosis, too often 
 the consequence of this fracture. 
 
 63. But that illustrious practitioner, in recom- 
 mending this salutary remedy, has erred with regard 
 to the mode in which it operates. To consume, by- 
 degrees, a superabundant callus in the interior of the 
 articulation, and thus reduce it to a level with the ar^ 
 ticulating surfaces, is not, as he conceives, the effect 
 which these motions produce. This opinion, founded 
 on the ancient doctrine of an osseous juice, is refuted 
 by the dissection of many bodies of patients that died 
 during the treatment, and in which Desault discover- 
 ed no trace, either of an effusion of osseous juice, 
 during the reunion, or of its superabundance after 
 this reunion had been completed. 
 
 The exercise communicated to the limb, appears 
 to act principally by removing the congestion of the 
 tendons and membranes surrounding the joint, which, 
 being at first irritated by the fracture, ai^e thrown into 
 a state of engorgement ; and further by dissipating 
 a kind of numbness which affects the muscles after 
 they have remained too long in a state of rest. 
 
 64. But whatever may be its mode of action, it 
 ought to be gradually increased, according to the 
 state of the parts, and continued for at least twenty 
 days, a period sufficiently long to restore to the limb, 
 in general, its natural motions. 
 
 65. It is seldom that after this methodical treat- 
 ment, the patient is exposed to an anchylosis, a thing 
 inevitable in such cases, according to most authors, 
 A celebrated surgeon, believing the long continued 
 
182 
 
 extension of the fore-arm to be the cause of this acci- 
 dent, has advised here to abandon every kind of ban- 
 dage, and to commit the cure entu-ely to nature^ 
 But this doctrine, contrary to the general principles 
 of the reunion of divided parts, has not in its favour 
 the result of experience, which proves that, under 
 such neglect, the stiffness in the parts near to the joint 
 is always as great as in other cases, that the reunion 
 is more tedious and more deformed, and that some- 
 times it cannot be accomplished at all. The analogy 
 of the inconveniences and disadvantages attributed to 
 the method of Foubert, in fractures of the neck of the 
 OS femoris, constitutes another argument against this 
 method, which is now almost entirely abandoned. 
 
 66. To the cases already published, proving the 
 success of that which we have proposed, let us add 
 one more, reported by Maublanc. 
 
 Case IV. Silvan de la None, aged thirty, fell on 
 his elbow, having his fore-arm bent, while the shoul- 
 der of the same side supported a heavy load. Acute 
 pains at the instant of the fall ; a sudden inability to 
 extend the fore-arm ; a considerable swelling appears 
 almost immediately, around the joint; and a superfi- 
 cial echymosis at the hind part. 
 
 During the night the pains were augmented, the 
 swelling increased, and, on the day following, Febru- 
 ary 9th, 1791, the patient was received into the Hotel- 
 Dieu. 
 
 From the presence of the signs formerly menti- 
 oned (43), Desault recognized the fracture, and ap- 
 plied the apparatus (56), notwithstanding the swelling 
 and echymosis, persuaded that the compression made 
 
183 
 
 by this apparatus on the tumefied parts, was the most 
 effectual mode to remove the enlargement. 
 
 Next day, pains almost gone ; swelling diminish- 
 ed; on the fifth day, the bandage become loose, by 
 the almost entire disappearance of the swelling; a 
 new application of it ; the joint wet frequently with 
 vegeto-mineral water. 
 
 Seventh day, usual regimen allowed; ninth day, 
 a slightly bilious disposition; evacuants somevv'hat 
 active administered, to remove it. 
 
 Thirteenth day, a third application of the appa- 
 ratus ; echymosis entirely gone. 
 
 Thirtieth day, the consolidation complete; the 
 apparatus laid aside ; from this time motions gradu- 
 ally impressed on the limb. 
 
 Fifty-eighth day, the patient discharged, free in 
 all his motions, except a little stiffness, which exer- 
 cise will soon remove. Since that time, it has been 
 understood that the limb had completely recovered its 
 natural functions. 
 
184 
 MEMOIR IX. 
 
 ON THE LUXATION OF THE FORE-ARM. 
 
 1. Th E solidity and security of joints are increased 
 in proportion as the extent of their motions is dimi- 
 nished. This inverse proportion of these two proper- 
 ties to each other, is in a particular manner remai^k- 
 able in the upper extremities, where the comiexion 
 of the humerus with the scapula, of the fore-arm with 
 the humerus, and of the bones of the wrist among 
 themselves, appear, in regular gradation, to acquire 
 the one as they lose the other: hence, their predispo- 
 sition to luxations is extremely different. We will 
 examine those to which the fore-arm is subject. 
 
 2. An angulai' ginglymus unites to the humerus 
 tiie bones of the fore-ann, wliich are again connected 
 with each other by a double lateral ginglymus. Emi- 
 nences and depressions, reciprocally receiving and 
 received, constitute the first kind of articulation, 
 where, proceeding fi^om without inwardly, we find, 
 1st, the small head of the humerus, entering or rather 
 joining the upper articulai' ca\'ity of the radius, which 
 moves on it: 2dly, the external groove of the hume- 
 rus, receiving the rim of the same cavity of the radius: 
 3dly, a projection which, rising fi'om the external 
 edge of the coronoide* cavity, extends to the corres^ 
 ponding edge of that of the olecranon, and is received 
 
 * Not generally named in English works of anatomy. 
 
185 
 
 into the external depression of the sigmoid cavity:* 
 ^-thly, the large groove of the humerus, receiving the 
 middle eminence of this same cavity: 5thly, a con- 
 siderable projection, obliquely applied to the internal 
 depression which receives it. 
 
 3. These numerous connexions secure the solidi- 
 ty of the joint, which is still farther strengthened be- 
 fore by the coronoid apophysis, together with the 
 fleshy and tendinous extremities of the biceps, and 
 brachialis muscles, and by the olecranon behind; at 
 the inferior part, by the anconeus; on the sides by 
 two ligaments which descend from the two tuberosi- 
 ties, and strong muscular facile running from the 
 same parts. The whole articulation is also surround- 
 ed by a thick capsule, strengthened by numerous 
 accessory fibres. With such powers of resistance, 
 how can this joint suffer a luxation? Yet next to that 
 of the OS humeri, it is perhaps most frequently sub- 
 ject to this accident. 
 
 § II. 
 
 OF THE KINDS AMD CAUSES OF DISPLACEMENT. 
 
 4. Writers have admitted in general four kinds of 
 displacement ; backward, forward, outward, and in- 
 ward. But all these are not alike frequent, as is prov- 
 ed by experience, and demonstrated by the relative 
 situation of the parts. 
 
 5. In a backward direction the olecranon and 
 the radius may pass up behind the humerus, as the 
 
 * JEchancrure si^moide. 
 25 
 
186 
 
 Coronoid apophysis offers but little^esistance in con- 
 sequence of its slight curvature. On the other hand, 
 the kind of hook formed by the olecranon, prevents 
 it and the radius from passing before the lower arti- 
 culating extremity of the humeiiis, and therefore, 
 without a fi-acture of the olecranon, a luxation in 
 that direction is impracticable : at the sides, the two 
 lateral ligaments, but more paiiiculai'ly the recipro- 
 cal joining or interlocking of the uneven articulating 
 surfaces, present almost insurmountable obstacles 
 to luxations laterally. Whence it follows, that luxa- 
 tion backward is much more frequent than the others; 
 compai'ed to lateral luxations, it is, at least, in the 
 proportion of ten to one: with luxations fonvard, 
 no comparison can be made ; neither Petit nor De- 
 sault having ever met with such. 
 
 6. An external force produces the Vvhole of these 
 luxations, but according to each, this force must 
 vary. In a fall sideways, suppose the hand be applied 
 to the ground, with the ai'm extended, to save the 
 body. It is evident that the resistance of the ground 
 will tend lo make the bones of the fore-arm pass up- 
 w^ards over the humerus, while the weight of the 
 bod}' pushing that bone downward and forward, will 
 make it glide over the coronoid apophysis. Thus, 
 tlie capsule, being distended before by the humerus, 
 andbeliindby the bones of the fore-arm, w^ill give 
 way in one or the other place, or in both, as Desault 
 obser^^ed in a man, v\^ho fell on his side, as he was 
 caiTying a heavy load : the weight of the body in- 
 creased by the load, had such an effect, that the 
 bones overlapped each other nearly two inches. 
 
187 
 
 7. It appears from this, that a state of extension 
 is the position most favourable to a displacement 
 backwards; a doctrine by no means conformable to 
 that of most practitioners, who consider a state of 
 flexion as necessary to the accident. But, then, in 
 what direction should the fall take place, in order 
 that the olecranon may pass upwards ? Applied as ii 
 is against the side of the cavity that receives it when 
 the arm is extended, would not this apophysis pre- 
 vent such passage ? Whatever may be the mode of 
 displacement, the olecranon, in passing upward and 
 backward, may incline a little to the one or the other 
 side. 
 
 8. I have already said, that without a fracture of 
 the olecranon, no luxation forward can occur (5). 
 But what cause can act with sufficient power on the 
 parts to produce both accidents at the same time ? 
 It would be necessary that a fall which had produced 
 a fracture should be succeeded by another fall; but 
 in such a case, the fore-arm whould behalf-bent, and 
 it is in a state of extension alone (7) that the luxation 
 can take place. 
 
 9. Lateral luxations, that is, luxations at the sides 
 have been divided into complete, when the two arti- 
 cular ranges of the arm and fore -arm, have lost 
 their connexion entirely, and incomplete, when only 
 one bone or one part of a bone has been separated 
 from its natural connexion with the humerus. But 
 what cause can act with sufficient force to pro- 
 duce the first kind of luxation, namely, that which 
 is complete ? In such an accident so great ^vould be 
 the extent of the -wTCck and ruin of the part, that 
 
188 
 
 without doubt amputation would be the ordy re- 
 source. 
 
 10. The second kind of lateral displacement is the 
 result of a stroke which forces violently the extre- 
 mity of the fore-aiTQ outward or inward. A footman, 
 says Petit, in falling from a carriage, had his arm 
 entangled between the spokes of the wheel, and suf- 
 fered in consequence a luxation outwards. Another 
 produced one inwardly, by being thrown from his 
 horse, and falling with his arm under him, on rou^ 
 ground. Strokes of this kind may, as that author re- 
 marks, vary in a singular manner. But, in general, 
 in all of them, the fore- arm must represent a lever of 
 the first kind, where the power acts on the end next 
 the hand; the resistance being in the joint, and the 
 fulcrum in the middle. 
 
 § III. 
 
 GF THE SIGNS. 
 
 11. To form an idea of the signs or appearances 
 of a luxation backwards, let us examine, for a mo- 
 ment, the natural situation of the olecranon, and 
 the condyls of the humerus. As these eminences 
 are easily felt under the skin, a knowledge and recol- 
 lection of their situation will serve as a standard of 
 comparison, to judge of the changes they experience 
 in a luxation. When the fore-arm is extended, the 
 olecranon is on a level with the internal condyl, 
 and a little above the external one. In a state of 
 flexion, it descends below this level, and is then far- 
 ther below the internal than the external condyl. In 
 
189 
 
 either situation, it is nearer to the first than to the 
 second, the radius separating it from the latter. 
 
 12. But, when a luxation has taken place, this 
 apophysis, still remaining on a level with the two 
 condyls, even although the fore-arm be half-bent, is^ 
 oftentimes separated from the internal one, and dri\^en 
 towards the other: a preternatural protuberance an- 
 nounces this change of position of the olecranon. 
 The coronoid apophysis, whose posterior surface 
 glides in the large groove of tlie humerus, coitcs- 
 ponds to this groove now only with its anterior sur- 
 face: sometimes the olecranon cavity*- receives its 
 extremity. The radius passes backward over the 
 small head of the humerus. At the fold of the arm, 
 a transverse protuberance, more perceptible on the 
 internal side, announces the presence of the displaced 
 articular extremity of the os humeri. Over this ex- 
 tremity are reflected the biceps and the brachialis 
 muscles in a state of violent distension. These mus- 
 cles, greatly irritated by such distension, continue in 
 a state of habitual contraction, in consequence of 
 which, they keep the fore-arm half-bent. Nor can 
 the anconeus muscle, which is necessarily relaxed, 
 act so as to prevent this semiflection. Severe pains 
 would be the consequence of attempts to extend the 
 fore-arm ; the limb is in a state of pronation ; yet I 
 find among the cases collected by Desault, several 
 examples where supination existed; this state is ex- 
 plained by the relaxed condition of the pronator mus- 
 
 * That deep depression in the os humeri, which, in a 
 natural state of the parts, receives the upper end of the ole- 
 cranon process. Trans. 
 
190 
 
 cles. At the level of or opposite to the coronoid cavity 
 is a depression or hollow manifesting the absence of 
 the apophysis of that name. 
 
 13. Should chance give rise to a luxation forward, 
 an anterior projection of the two bones of the fore- 
 arm, and above all, of the coronoid eminence, a de- 
 pression corresponding to the olecranon cavity, the 
 extremity of the humerus carried backward and 
 downward, the rigid extension of the fore-arm, a pro- 
 tuberance behind formed by the fractured olecranon 
 (5), and severe pains, necessarily resulting from at- 
 tempts to bend the limb, &c. would constitute the 
 principal characteristic signs of the displacement. 
 
 14. In lateral luxations, a protuberance at the in- 
 ternal or external side of the articulation, always shows 
 of what kind it is. If the displacement be to the in- 
 ternal side, the olecranon is then situated behind the 
 small tuberosity : the middle protuberance of the os 
 humeri bears on the radius, which is sometimes 
 placed even behind the Internal articular eminence of 
 that bone, which then rests on the external depression 
 of the great sigmoid cavity. Hence, as Petit judici- 
 ously observes, arises the direction of the fore-arm 
 outward, the above eminence presenting a manifest 
 obliquity in that direction. In this luxation, the ulna 
 has been known to lose entirely its connexion with the 
 humerus, and the radius to be brought into contact 
 with the internal condyl of that bone. This is what 
 some authors call a complete luxation. Others re- 
 serve that name for cases where, the two articular 
 ranges have lost their correspondence or apposition 
 entirely. 
 
191 
 
 15. In a luxation outwards, the olecranon corres- 
 ponds to the external condyl; the middle projection 
 of the humerus, to the internal depression of the 
 great sigmoid cavity; the small head of this bone, 
 to the external depression; the radius projects out- 
 wards; and the humerus makes a protuberance in- 
 wardly. 
 
 16. After all, these changes of situation vary re- 
 markably, and it belongs to theory rather than prac- 
 tice, to trace their history, with precision. In gene- 
 ral, luxations outwardly happen more frequently than 
 those inwardly, a circumstance which is fully ex- 
 plained by the structure of the joint. In both, the 
 lateral ligaments are almost always lacerated. 
 
 A swelling more or less considerable accompanies 
 all the different kinds of luxation, and is sometimes 
 carried so far as to involve the diagnosis in great un- 
 certainty, particularly when the displacement is not 
 very great. This phenomenon (the swelling), seems, 
 in general, to correspond, in a direct ratio, to the 
 force with which the articulation resists. Indeed the 
 violence, and consequently the irritation, are always 
 in proportion to the resistance of the parts. 
 
 §IV, 
 
 OF THE REDUCTION. 
 
 17. The means of reduction vary according 
 to the different kuids of displacement. They ai^e all, 
 however, founded on nearly the same principles, and 
 it will be easy to form proper ideas of them, when 
 we shall have given an account of the means neces- 
 
192 
 
 sary to be employed in luxations backward, of which 
 tlie others are only modifications. 
 
 Here genius seems to have been as prodigal of 
 resources, as nature has been of obstacles. Indeed, 
 to accomplish the reduction, we sometimes see the 
 surgeon placing his elbow in the fold of the affected 
 arm, interlocking his fingers with those of the same 
 limb, and, then, bending with his whole force, both 
 his own fore-arm, and that of the patient, to effect at 
 the same time extension, counter-extension, and 
 reduction or conformation: at another time we see 
 him fixing the fold of the injured arm against some 
 resisting body, such as a bed-post; and while an as- 
 sistant, then, pushes the displaced olecranon against 
 tliis body, he himself, pressing on the shoulder with 
 one hand, and grasping the fore-arm wdth tlie other, 
 bends it forcibly, in order, by that means, to produce 
 a replacement: again, a body of some size, being 
 placed in the fold of the arm, serves as a fulcrum, on 
 which the fore-arm, being suddenly flexed, moves 
 and acts like a lever of the first kind, of which the 
 power, being applied at the extremity next the hand, 
 draws it backward and upward, and by that means 
 pushes in a contrary direction its luxated end, where 
 the resistance is made. On some occasions, the fore- 
 arm of the diseased side, bent at a right angle, is 
 placed on a horizontal table, and, while the low^er ex- 
 tremity of the humerus is thus resting on the table, 
 the surgeon pushes it backward \\4th one hand, and 
 with the other, taking hold of the extremity of the 
 fore-arm, draws it in a contrary direction. 
 
193 
 
 18. The ancients employed the three first modes. 
 Pare has had engravings of them made : Scultel has 
 also given figures of them as practised by Hippo- 
 crates. The Arabians knew of no other modes, nor 
 did their descendants, who were only com.pilers from 
 them. The practitioners of our own day still conti- 
 nue their use. But, in general, they are chargeable 
 with the numerous inconveniences and faults of pro- 
 ducing intense pain, of not being completely under 
 the direction of the surgeon, of bringing the point of 
 luxation too near to the place on which counter-ex- 
 tension is made, and of bruising and doing violence to 
 the parts : nor do they disengage, by means of pre- 
 vious extension, the luxated ends of the bones, to 
 facilitate their replacement in their natural situations. 
 
 This last charge is not applicable to the last of 
 the processes proposed by Petit. But, here, the ex- 
 tending forces are most commonly insufiicient; the 
 surgeon, having both his hands engaged, is not able 
 to act on the joint to assist in the replacement : and 
 the counter- extension made is too near to the point 
 of luxation. 
 
 19. In common cases, Desault employed a me- 
 thod as simple and more efiicacious, which few wri- 
 ters have recommended, and none have described 
 with accuracy. 
 
 The patient is, indifferently, either seated or stand- 
 ing. The fore-arm being half-bent, an assistant takes 
 hold of the extremity next the hand, to make exten- 
 sion ; another, to make counter-extension, takes hold 
 of the humerus a little below its middle, with both 
 
 hands, the fingers crossing before, and the tliumbs 
 
 26 
 
1^4 
 
 behind. Tlie extension is made gradually, and when 
 it begins to move the olecranon, and draw it from the 
 place it accidentally occupies, the surgeon, to aid in 
 the reduction, grasps the lower end of the humerus 
 with both hands, crosses his fingers in the fold of the 
 arm, applies his thumbs to the olecranon, and draw- 
 ing the first backward, pushes at the same time the 
 iatter forwai'd; thus, he favours, on the one hand ex- 
 tension, and on the other counter-^extension, and in 
 that way finishes the reduction. 
 
 20. This method is most commonly practised 
 ■with success, in recent luxations, where we have of- 
 tentimes seen the reduction effected at the Hotel- 
 Dieu, by the simple process of pushing, as justmicn- 
 tioned, the olecranon forward, the humerus being 
 held backward, without any previous extension, while 
 the fore-arm was merely supported by the assistants. 
 
 21. But the luxation being oftentimes of long 
 standing, presents very great difficulties. What means 
 must then be employed? It is an established princi- 
 ple, that the force with which a power acts, is in di- 
 rect proportion to its distance from the point of resist- 
 ance. Augment this distance, and the extending 
 forces, being doubled and even trebled, will more 
 easily dislodge the luxated extremity. But this indi- 
 cation is fulfilled, by two long straps, formed each of 
 a towel folded several times, one of which is fixed 
 above the wrist, and the other round the humerus a 
 little below its middle. Extension is then made at 
 their extremities, and is almost always sufficient, 
 when aided by skilful efforts of the surgeon (19), to 
 accomplish the reduction. The application of a strap 
 
195 
 
 round the humerus is never necessary, unless when 
 the resistance is very great; because, in counter- 
 extension, it is requisite only to withstand or bear 
 against the efforts of extension, but not to act in a 
 contrary direction. 
 
 22. But in cases of this kind, the strap, placed, as 
 Xve have directed, round the lower part of tlie hume- 
 rus, has sometimes the disadvantage of compressing 
 too much the brachialis and the biceps muscles, and 
 thus preventing them from acting; this inconveni- 
 ence is particularly felt in old luxations, where great 
 force is employed ; for, the more active then the con- 
 traction of these muscles is, the more it will aid the 
 surgeon in his efforts to draw the bones into their na- 
 tural situation, when once disengaged by extension, 
 from that which they had accidentally occupied. If, 
 in such a case, we impede the contraction of these 
 muscles, how can they fulfil this office ? 
 
 23. It was this which, in certain cases, induced 
 Desault to place his counter- extension under the arm- 
 pit, by means of a strap passing, as in the luxation of 
 the humerus, over a ball previously fixed in this hol- 
 low, and crossing, not on the top of the opposite 
 shoulder, but behind that of the diseased side. By 
 this contrivance the humerus was drawn or rather 
 held back, by a force acting perfectly in the line of 
 its direction. But is not this force situated too near 
 to the centre of motion? The strap for making exten- 
 sion, fastened at the wrist, answers very well, as has 
 been already mentioned (21). 
 
 24. Should the luxation be forward, the extension, 
 must be directed according to the state aud position 
 
196 
 
 in which the fore-arm is found, which is always ex- 
 tended. The hands of assistants alone (19), or 
 straps (21), may then serve to mabrthe extension, 
 which the surgeon must aid, by grasping, in a direc- 
 tion the reverse of that in the preceding case, the 
 lower extremity of the humerus, that is, by crossing 
 his fingers behind, and placing liis thumbs on the 
 coronoid apophysis, to push it downward and back- 
 ward. 
 
 25. The strap for counter-extension, would in 
 such a case, always afford the greatest advantage, by 
 being placed exactly as in luxations of the humerus, 
 that is, by running to, and crossing on, the opposite 
 shoulder; the direction or course of the fore-arm, 
 which is necessarily in a state of extension, sufficient- 
 ly explains this ; finally, the reduction of the luxation 
 must be succeeded by the reduction of the olecranon 
 (5), and by the application of a proper apparatus to 
 retain the whole. 
 
 26. The reduction of lateral luxations, differs but 
 little from that of luxations backwards. The dis- 
 placed extremities must be first dislodged by previ- 
 ous extension (19). The surgeon, then, taking hold 
 of the lower part of the arm, places his fingers before, 
 and with his thumbs, crossed on the olecranon, 
 pushes that apophysis forward and inward, if the dis- 
 placement be outwardly, but forward and outward 
 if it be inwardly. Does the case prove very difficult, 
 recourse must be had to the other means (21 and 23). 
 The hands of the surgeon must still, according to 
 the direction of the displacement, assist the extension 
 made by the straps. 
 
107 
 
 OF THE MEANS OF MAINTAINING THE 
 REDUCTION. 
 
 27. Luxations of the fore-arm have, oftentimes, 
 a great disposition to occur anew, after having been 
 reduced, whether they be recent, or of long standing. 
 Extension readily dislodges the olecranon and the 
 radius, and replaces them perfectly in their natural 
 situation; but if any thing interrupt them, the dis- 
 placement is sometimes immediately renewed : sup- 
 pose the parts even remaining in contact, the slight- 
 est motion may derange this contact, and give rise to 
 a necessity for a new reduction, more difficult, often- 
 times, than the first. Hence it is alwaj^s prudent to 
 employ a retentive apparatus for some time. 
 
 28 i But, on what principle and for what purpose 
 ought it to be applied? The motions communicated 
 to the fore-arm by external bodies, but, more parti- 
 cularly, the action of the muscles inserted in the bones 
 that have been reduced, are here the causes of their 
 displacement. Hence, 1st, to render the limb im- 
 moveable; 2dly, to push the articular ends of the 
 bones in a direction opposite to that in which they 
 are drawn by the muscles, and have a tendency to be 
 displaced : such is the twofold indication of the ban- 
 dage ; an indication not fulfilled by the kind of ban- 
 dage and the sling which Petit proposed, and which 
 leave the arm free to move, and the muscles free 
 to act. 
 
198 
 
 29. Desault employed the following apparatus : 
 1st, The ai'm and fore-arm are first covered by oblique 
 turns of a roller, intended both to protect them from 
 the impression of splints, and to dirninish the power, 
 and action of the muscles, by the pressure made on 
 them : 2dly, Behind the olecranon is to be placed a 
 thick compress, designed to retain it dowiiwai'ds, and 
 which must be secured by a strong splint, situated 
 behind, and curved at the elbow, to accommodate it 
 to the flexion of the fore-arm : 3dly, On the sides are 
 placed two other splints, chiefly necessaiy in lateral 
 luxations : 4thly, The whole is to be secured by the 
 remaining part of the roller, by which the arm and 
 fore-arm are already covered. 
 
 In this bandage, the immobility of the arm is 
 secured by the splints, while the olecranon is pushed 
 by the compress, in a direction the reverse of that of 
 its displacement. But these circumstances constitute 
 the double indication tliat was to be fulfilled (28). 
 
 30. The period at which these means may be dis- 
 pensed with, is undetermined. It belongs to the 
 surgeon to examine and ascertain, when the natural 
 connexions of the joint ai-e sufl[iciently confirmed. 
 Then motions, at first gentle, are to be impressed on 
 the limb ; being afterwards gradually increased, they 
 remove by degrees that stiflhess, which usually fol- 
 lows a dislocation, particularly an old one. But if it 
 has existed too long, to give the limb motion, is then 
 the only resource : the new attachments or adhesions, 
 contracted by the articulating surfaces in their dis- 
 placed state, render reduction impracticable. We 
 must then confine ourselves merely to increasing the 
 
199 
 
 extent of the motions, which the displaced fore-arm 
 is yet capable of performing. 
 
 31. There is, in general, all other things being 
 favourable, a hope of accomplishing the reduction, 
 till the end of the second month after the accident. 
 Desault succeeded in it, at even a later period. What 
 trouble or hardship is it, at last, to try extension? 
 Should no other end be gained, but merely to bring 
 the bones nearer to their natural cavities or situations, 
 even without actually replacing them, this will aid 
 their movements, the extent of which is inversely 
 proportioned to their distance from these oavities. 
 
 MEMOIR X. 
 
 ON^THE LUXATIONS OF THE RADIUS OVER THE 
 
 ULNA. 
 
 1st, Most authors who have written on the lux- 
 ntions of the fore-arm, have omitted considering se- 
 parately those confined to the radius alone. Some 
 detached observations may be found here and there, 
 on the luxations of the upper extremity of this bone, 
 which Duvemey alone has treated at some length. 
 Those of its lower extremity, though more frequent, 
 and more easily produced, appear to have almost 
 entirely escaped the attention of the French practi- 
 tioners, who have transmitted nothing to us on that 
 point, owing, no doubt, to their having had no 
 knowledge of it from experience. But since, at the 
 
200 
 
 present day, a sufficient number of facts are collected 
 on the subject, some account of these displacements 
 cannot be a matter of indifference to the art, and it 
 may be traced with as much precision as the accounts 
 of other similar accidents. 
 
 I. 
 
 OF THE DIFFERENCES IN POINT OF STRUCTURE 
 BETWEEN THE TWO ARTICULATIONS OF THE 
 RADIUS WITH THE ULNA. ' 
 
 2. The radius, the moveable agent in pronation 
 and supination, rolls on the ulna its fixed basis or abut- 
 ment, by means of two small articulating surfaces, the 
 one at its upper end, slightly convex, broad within, 
 and narrow without, coiTCsponding to the small sig- 
 moid cavity, in which it is lodged ; and the other 
 at its lower end, concave, semicircular, and fitted to 
 the convex edge of the ulna, which it receives. Hence 
 two kinds of articulation different fi-om each other, 
 v/ith respect to their motions, the connexion of their 
 surfaces, and the ligaments which strengthen them. 
 Let us specify these differences ; they will serve to 
 shed light on those that exist between the displace- 
 ments of the two extremities of the radius. 
 
 3. At its upper end, the radius, in performing 
 pronation and supination, moves only on its o\Yn axis ; 
 at its lower end, it roils round the axis of the ulna: 
 therefore, being farther removed from their centre, 
 its motions must have both a greater range and greater 
 force, in the latter case than in the former. The 
 head of the radius, turning on itself within the annu- 
 
201 
 
 lar ligament, cannot distend it in any direction or 
 part. The cellular membrane attached to this liga- 
 ment is alone slightly stretched, but being loose and 
 elastic, it yields without resistance. At its lower 
 end, on the contrary, the radius, turning from with- 
 out inwards during pronation, keeps the capsule 
 posteriorly in a state of tension, and draws it against 
 the immoveable head of the ulna, which tends to pass 
 through it, if the motion be forcible. The same 
 phenomenon occurs in a contrary direction, during 
 supination; the radius is directed backward, and the 
 ulna inward. Being in this case distended before, 
 and relaxed behind, the capsule is disposed to lace- 
 ration anteriorly. 
 
 4. In addition to this disposition, the ligaments 
 of the two articulations are disproportioned in their 
 strength. Thin and weak at the lower articulation, 
 thick and firm at the upper one, they are in this re- 
 spect strikingly diflPerent. The head of the radius, 
 resting against the small but firmly fixed head of the 
 humerus, finds there, in most of its movements, an 
 obstacle to displacement. On the contrary, its lower 
 end, drawing along with it in its movements, the 
 bones of the carpus which are connected with it, de- 
 rives from them no solid support. 
 
 27 
 
202 
 
 II. 
 
 DIFFERENCES IN THE LUXATIONS OF THE RA- 
 DIUS; DIFFICULTIES OF THAT AT ITS UPPER 
 END. 
 
 5. It follows from what has been said (3 and 4), 
 1st, that the lower articulation of the radius is not only 
 exposed to the action of more causes of displacement, 
 but possesses fewer means of resisting those causes, 
 and that, from the threefold consideration of its 
 motions, the ligaments which connect its articulating 
 surfaces, and their relation to each other, it must be 
 frequently subject to luxations : 2dly, that for reasons 
 the very reverse of these, its upper articulation must 
 be very seldom subject to luxation. 
 
 6. Indeed, what cause is there to produce luxa- 
 tion in this latter joint. Is it from a forcible exertion 
 of pronation or supination that this accident can oc- 
 cur? Surely not: for, on the one hand, as the lower 
 articulation offers less resistance than the upper one, 
 it is evident that, in either state of motion, it being 
 the weakest, will be displaced first, and the motion 
 being thus checked, can no longer operate to the dis- 
 placement of the otlier. On the other hand, however 
 forcible the motion may be, there will be in the upper 
 articulation, nothing but a rotation of the bone on its 
 own axis (3). How, then, without being carried for- 
 ward, backward, &c. can the head be displaced? 
 Indeed, it would be necessary that all the fastenings 
 or bonds of attachment muscular and ligamentous, 
 should be first broken. But these are too strong, and 
 
203 
 
 the motion is too weak. Can the displacement be 
 produced by a blow impressed on the radius from 
 below upwards? By no means: because the head 
 of the humerus making, in this case, a solid resistance 
 will not permit it to escape from the capsule (4). 
 Can it arise from a violent extension or flexion of 
 the fore-arm? No. This effort being altogether con-r 
 fined to the ulna, affects the radius in but a very faint 
 degree. 
 
 7. It appears from hence, that the accidental lux- 
 ation of the upper end of the radius, suddenly pro- 
 duced by external causes, must, if it ever occur, be 
 extremely rare. But it is not so with respect to luxa- 
 tions which take place slowly in tliis joint, particularly 
 in children, where, in consequence of repeated efforts, 
 the ligaments become relaxed. But this kind of dis- 
 placement, being almost always complicated with a 
 swelling of the joint, and sometimes not to be redu- 
 ced by the expedients of art, cannot be comprised in 
 my present plan. 
 
 9. But experience would seem to have at times 
 exposed the fallacy of these considerations and rea- 
 sonings, founded merely on the structure of the parts. 
 Duvemey relates some instances of luxations of the 
 head of the radius, produced suddenly by external 
 causes. Two other practitioners ai'e also of opinion 
 that they have witnessed similar displacements. But 
 did they examine the subject with all that attention 
 which it required? A similar case was reported to the 
 Academy of Surgery, by one of its associates; but 
 doubts were entertained with regard to its reality i 
 and, ultimately, there were so few facts in its favour. 
 
204 
 
 and such strong presumptions against it, that Desault 
 was induced to deny the luxation altogether, till its 
 reality should, by new proofs, be more certainly 
 established. 
 
 After all, if it should occur, the same signs which 
 announce the luxation, when the ligaments, in conse- 
 quence of being gradually relaxed or in some way 
 distended, permit the head of the radius to be insen- 
 sibly displaced, would then appear as the sudden ef- 
 fect of external violence. 
 
 LUXATION OF THE LOWER EXTRE- 
 MITY OF THE RADIUS. 
 
 UIL 
 
 OF THE KINDS OP DISPLACEMENT. 
 
 9. The causes which produce the displacement 
 of the lower end of the radius, are the same with those 
 that give rise to other similar affections. 1st, The 
 convulsive action of the pronator and supinator mus- 
 cles, is doubtless a rare cause of the accident, since 
 Desault never met with an instance of it. 2dly, The 
 action of external bodies, which, by forcibly and sud- 
 denly producing the motions of pronation, rupture 
 the posterior portion of the capsule, or, by those of 
 supination, lacerate its anterior portion. 
 
 10. Hence two kinds of displacement, the one 
 forward, the other back\A^ard. The first is somewhat 
 frequent; the second is much less so. The latter was 
 never seen by Desault but once, and that was in the 
 
205 
 
 corpse of a man who had had both his arms luxated, 
 but respecting the circumstances of which he could 
 receive no information. The other kind occurred fre- 
 quently in his practice, of which five examples have 
 been already published. The difference no doubt 
 arises from this circumstance, that the greater part 
 of our powerful motions are performed only in the 
 direction of pronation. This appears to be proven by 
 the following circumstances. 
 
 11. If, in several dead bodies, we lay bare the 
 bones of the fore-arm, still united by their ligaments, 
 and push the extremity of the radius forcibly back- 
 wards, that is, in the direction of supination, a lacera- 
 tion will as readily occur in the anterior part of the 
 capsule, as it will in its posterior part, when, by for- 
 cibly pushing the same extremity forward, the motion 
 of pronation is performed. Hence the difference does 
 not arise from the structure, but from the direction 
 of the motions impressed on the limb. 
 
 •OF THE SIGNS. 
 
 12. The signs which characterize a luxation of 
 the radius forward, are, 1st, The constant pronation 
 of the limb : 2dly, An inability in it to assume the 
 state of supination, and even severe pains arising 
 from attempting it : 3dly, A protuberance larger than 
 common, formed behind, by the small head of the 
 ulna passing through the capsule : 4thly, The end of 
 the radius being situated more anteriorly than natural : 
 5thly, The constant adduction, and almost constant 
 
206 
 
 extension of the wrist: 6th]y, The semiflexion of 
 the fore-arm, and very often of the fingers : this po- 
 sition is generally assumed by the fore-arm, in affec- 
 tions of the bones that form it, and, in the present 
 case, cannot be changed without considerable pain : 
 7thly, A swelling more or less extensive, which some- 
 times appears around the articulation, at the moment 
 of the accident, and which never fails to occur after- 
 wards, unless the reduction be immediately effected. 
 This occurrence may conceal the state of the articu- 
 lation, and make the accident be considered, at first 
 sight, as a sprain, as Desault v/itnessed in certain 
 cases, where the disease had been mistaken by the 
 surgeons who were first called to the persons injured. 
 It is easy to conceive of the sad consequences of this 
 mistake, which, by preventing any effort at reduc- 
 tion, gives the articular surfaces time to form adhe- 
 sions, and thus oftentimes renders the mischief irre- 
 parable. 
 
 13. If to these signs be added, the severe pains 
 experienced by the patient, the circumstances of the 
 fall, in which the fore-arm is violently di^awn into a 
 state of pronation, we will have a view of every thing 
 that can here aid the practitioner in his diagnosis. 
 
 14. Most of the foregoing signs, taken in the op- 
 posite sense, would chaiTtcterize a luxation of the ra- 
 dius backvv^ard, should it occur : such, for example, 
 as a forced supination of the limb, an inability as to 
 pronation, the pains that would result from this move- 
 ment if performed by force, the tumour formed ante- 
 riorly by the extremity of the ulna, the posterior 
 situation of the large head of the radius, and the ab- 
 duction of the v/rist. 
 
207 
 
 15. The dead body, in which Desault observed 
 this kind of displacement (9), being dissected with 
 care, exhibited in the articular paits, the following 
 diseased state. The tendons of the flexor muscles, 
 pushed outwards, adhered to one another and to the 
 skin ; a substance of a cellular texture filled up the 
 sigmoid cavity of the radius, and occupied the place 
 of the cartilage which naturally invests it : the inter- 
 articular ligament, which passes between the ulna 
 and the os pyramidalis, scaicely touched the head of 
 the ulna, having followed the radius backwards; and 
 the head of the ulna, situated before the sigmoid 
 cavity of the radius, rested on one of the ossa sesa- 
 moidea, to which it was attached by a capsular liga- 
 ment. 
 
 ' ^ V. 
 
 OF THE REDUCTION 
 
 16. Extension so important in the reduction of 
 other luxations, renders scarcely any service in this: 
 impulsion alone ansv/ers the purpose. If the dis- 
 placement be forward, it is reduced in the foliov/ing 
 manner : The patient sits or stands indifferently ; the 
 latter position, however, has sometimes this advan- 
 tage over the former, that by placing the part to be 
 operated on more on a level with the hands of the 
 surgeon, it gives him both more readiness and more 
 force in his motions: one assistant supporting tlie 
 elbow, separates the arm a little from the body ; while 
 another taking hold of the hand and fingers, gives 
 them also an equable support. 
 
208 
 
 17. The surgeon grasps the extremity of the fore- 
 arm, with both hands, one placed on its internal, and 
 the other on its external side, so that his two thumbs 
 may meet before, between the ulna and the radius, 
 and the fingers behind. He then exerts himself to 
 separate the two bones from each other, by pushing 
 the radius backward and outward, and retaining the 
 ulna in its place ; in the mean time the assistant who 
 supports the hand, endeavours to move it in the 
 direction of supination, and consequently to draw the 
 radius, with which it is connected, into the same 
 state. Being thus pushed in a direction opposite 
 to that of its displacement, by two forces, the one 
 exerted directly on it, and the other acting indirectly, 
 the radius is forced outwards, and the ulna, return- 
 ing through the opening in the capsule, is replaced 
 in the sigmoid cavity. 
 
 18. Should a luxation of the radius backwards 
 ever occur, the same process executed in an inverse 
 direction, would serve the purposes of reduction. 
 The surgeon with his fingers would have to press 
 the extremity of the radius forward and inward, while 
 a forcible pronatory movement impressed by the as- 
 sistant on the hand intrusted to him, would favour 
 the effort and finish the reduction. 
 
 .19. The disappearance of the signs (12.... 14) of 
 the luxation bespeak its reduction. In general the 
 pain is entirely removed; sometimes a perceptible 
 sound, or report, caused by the passage of the bone 
 through the opening in the capsule, announces the 
 replacement. 
 
209 
 
 20. When the luxation is of long standing, it is 
 always attended with more or less difficulty, occa- 
 sioned by the adhesions of the surrounding soft parts 
 to the articulating surfaces, by the thickening of the 
 capsule, which diminishes the size of its opening, 
 by the rigidity contracted by the whole part, &:c. It 
 is, in such cases, useful to employ emollient applica- 
 tions for some time previously to attempting the re- 
 duction, in order to produce such a relaxation, and 
 diminution of the congestion, as may fevour the 
 efforts of the surgeon. 
 
 21. The first patient whom Desault visited at the 
 Hotel- Dieu in quality of surgeon in chief, had a 
 luxation forward, of more than two months standing, 
 in which the use of these means facilitated the re- 
 duction: but they are sometimes insufficient, and 
 then the radius remains immoveable, and the fore- 
 aiTTi performs its motions but partially. 
 
 22. It would seem as if nature, always industrious 
 to provide, amid the disorders of our organs, some 
 resources for the exercise of their functions, has been 
 desirous of preventing here, the inconvenience at- 
 tendant on a failure of reduction, by rendering lux- 
 ations backward much more difficult than those for- 
 ward. Indeed if the fore-arm be kept constantly in 
 a state of supination, it will be much less useful, 
 than if it were always in a state of pronation, the 
 situation in which most of the motions necessary to 
 our existence are performed. 
 
 28 
 
210 
 
 §VI. 
 
 OF THE SUBSEqUENT TREATMENT. 
 
 23. When the reduction is finished, the articulat- 
 ing surfaces have sometimes a great tendency to be 
 displaced, by the different movements of the fore-arm, 
 a tendency of which we may easily form an idea, if 
 we observe, that in a state of pronation, the head of 
 the ulna presses against the back part of tlie strained 
 capsule, and consequently against its opening, when 
 the luxation has been forward: a contrary state of 
 things occurs in a luxation backwai^d. Whence it is 
 always prudent to avoid, for some time, the motions 
 of pronation and supination, according to the direction 
 of the displacement. 
 
 24. Should the tendency to displacement be very 
 great, it will be necessary to adopt the simple me- 
 thod pointed out in a case already published by De- 
 sault. 
 
 Case I. The case was a luxation fonvard, which 
 was easily reduced. But the easier the reduction, the 
 miore difficult wsls it to retain the replaced parts. This 
 was at length accomplished, by fixing the fore-ai'm in 
 a state of supination, and applying one thick compress 
 behind the uhia, wliile the radius was pushed back- 
 ward by another compress, placed on its anterior part, 
 both secured by a common roller. This apparatus 
 was continued for the space of a month, after wliich 
 the reduced bones remained in their natural situation. 
 The patient began, at first, to perform gentle motions 
 of the wrist, avoiding those of pronation, on wliich 
 
211 
 
 he afterwards ventured by degrees, and with great 
 caution. 
 
 25. These gentle motions frequently repeated, 
 when a displacement is no longer to be apprehended, 
 remove that unavoidable rigidity which, for some 
 time, occupies the parts ai'ound the joint. It is ad- 
 visable, for some time, to apply on the hand and 
 extremity of the fore-arm, compresses wet with some 
 discntient liquor, to prevent the swelling resulting 
 perhaps from the inactivity and sprain of the parts. 
 This was the practice of Desault. 
 
 I will close this memoir by two cases, extracted 
 from the Journal of Surgery, in order to confirm, by 
 experience, what has been already settled in theory. 
 
 Case I. Desault was called to visit a child five 
 years old, supposed to be labouring under a fi^acture 
 of the arm. He learnt from the pai^ents of the child, 
 that, as it was lying in a very low bed, a young man 
 who was playing with it, had taken hold of its fore- 
 ann, and di'awn it towards him, twisting it forcibly 
 at the same time in the direction of pronation ; that the 
 eifort had been accompanied by a report, and the 
 child had immediately experienced an acute pain 
 throughout the whole limb, but more pailicularly 
 along the posterior part of the fore-arm. 
 
 When Desault saw the patient, no swelling had as 
 yet supervened ; the arm was rem^oved fi-om the body, 
 and canied a little forward, while the fore-arm, half- 
 bent, was kept in a state between pronation and supi- 
 nation. There existed, at its lower and back pait, a 
 preternatural tumour, formed by the head of the ulna 
 carried behind the sJ2:moid cavitv of the radius. The 
 
212 
 
 hand was a little extended, and in a state of adduction.' 
 The patient carefully preserved that position, and, as 
 soon as it was changed, or the part affected touched, 
 manifested signs of the most acute pain. 
 
 From these appearances, Desault discovered im- 
 mediately a luxation of the radius for^vard, which was 
 reduced in the manner already mentioned ( 16 and 17). 
 By this process, the bones, being a little separated 
 from each other, were replaced with facilit)^ The 
 suffering of the patient w^as immediately at an end; 
 the limb resumed its natural state, and performed its 
 functions as freely as before ; lest some congestion 
 might be the consequence, the injured parts were 
 covered by compresses wet with camphorated spirits ; 
 these were secured by a bandage moderately tight, 
 and no accident whatever supervened. 
 
 Case II. On the 29th of January, 1789, Made- 
 leine Fuser, a washer-woman, thirty-four years of 
 age, had the lower extremity of the radius luxated 
 forward. 
 
 Just as she had finished wringing a sheet, another 
 washer- woman, who was assisting her to wring it, 
 giving it a forcible jerk, did violence to her left arm, 
 which w^as at the time in a state of strong pronation. 
 
 The woman experienced immediately a severe 
 pain, accompanied by a sensation as if something had 
 been torn. The sheet dropt from her hand, and she 
 fell on the ground. Believing that she had receiv- 
 ed only a sprain, she neglected to apply for aid, and 
 did not enter the Hotel-Dieu till the sixth day after 
 the accident. 
 
213 
 
 There was then a Httle swelling at the lower part 
 of the fore-arm and at the wrist : the latter was ex- 
 tended and in a state of adduction; the fingers were 
 bent. This woman suffered but little, when her hand 
 was supported and kept still ; but the pains became 
 severe, when she attempted to move it. It was plain- 
 ly perceived that the radius was placed before the 
 ulna, and that the bones overlapped each other. 
 
 Process of reduction the same as in the preceding 
 case. It was accompanied by a kind of report, and 
 its completion was clearly announced by the restora- 
 tion of the natural shape of the limb, and by the free- 
 dom of its motions. Cojnpresses wet with vegeto- 
 mineral water were applied to the \\Tist. 
 
 This patient remamed fifteen days in the hospital, 
 at the end of which, she performed with ease the mo- 
 tions of the \mst and hand. 
 
214 
 MEMOIR XI. 
 
 ON THE FRACTURES OF THE THIGH* 
 
 1. The OS femoris, being in man, a moveable 
 support for the weight of the whole body, appears to 
 be better secured than the other bones, from accidents 
 tliat might affect its continuity. The numerous masses 
 of muscle that immediately surround it; the thick 
 and compact layers or fascics that form its more exte- 
 rior covering ; and an articulation loose, and ready to 
 yield, in every direction, to the motions impressed 
 on it, all seem, on the one hand, calculated for its 
 preservation. 
 
 2. But, on the other hand, being visibly curved 
 in its middle, bent at its upper end almost at a right 
 angle, longer in proportion in man than in quadru- 
 peds, placed, in most falls, between the ground which 
 resists, and the weight of the body which presses on 
 it; it would seem, from these latter circumstances, 
 to be less calculated to resist external force. And, if 
 to these considerations be added those of the causes 
 which have an immediate action on it, it will be easy 
 to perceive, that, in a comparative scale of the bones 
 most exposed to fractures, it holds, next to the bones 
 of the leg, one of the highest grades. The propor- 
 tion which its fractures bear to those of the leg, is, 
 according to the observations of Desault, as one to 
 three; but to that of most other bones it is equal if 
 not superior. 
 
215 
 
 S. The OS femoris, being in its body irregularly 
 cylindrical and curved behind, becomes larger to- 
 wards its lower end, where it terminates in two artic- 
 ulating masses, which rest immediately on two cor* 
 responding surfaces of the os tibiae; changing its 
 direction above, it inclines towards the acetabulum, 
 and inserts into that cavity a round head, supported 
 by a neck which is entirely enclosed in the capsule 
 of the joint. 
 
 4. From this different conformation of its different 
 parts, arises such a variety in the fractures which oc- ^ 
 cur in it, that they cannot be treated of under the ' 
 same head. Hence the division into fractures of the 
 body and of the extremities, which is borrowed from 
 anatomists, and will be followed in the present me- 
 moir, where we will consider in order, j 
 
 1st, The fractures of its body, 
 :2dly, Those of its upper extremity, 
 3dly, Those of its lower extremity. 
 
 FRACTURES OF THE BODY OF THE OS 
 FEMORIS. I 
 
 ui. 
 
 OF THE VARIETIES AND CAUSES. 
 
 5. The OS femoris may be fractured indifferently 
 at any point between its condyls and its neck. But 
 the part where tliis accident most frequently occurs, 
 is about the centre of the curve of the bone, where 
 most of the motions and shocks impressed on it by 
 e:5ternal violence expend their force. 
 
216 
 
 6. Whatever may be the seat of the fracture, its 
 direction is sometimes transverse, but most frequent- 
 ly oblique, a variety which does not affect the real 
 nature of the disease, but which possesses, as to its 
 consequences, a very impoitant influence. As in other 
 affections of the kind, so here, the bone is sometimes 
 affected alone, and, at other times, to a fracture sim- 
 ple or complicated by means of spUnters, is added 
 an injury done to the surrounding soft parts. Hence 
 result compound fractures, differently varied, accor- 
 ding to the nature of the parts affected, and to the ex- 
 tent and other circumstances of these affections. But, 
 as Petit observes, this bone is less frequently shatter- 
 ed or crushed into several pieces, than those that are 
 more superficially situated, 
 
 7. Extraneous causes are kno^'VTi to render falls 
 more frequent in man than in other animals, and to 
 multiply in him the fractures of the lower extremities, 
 by m.ultiplying the action of external bodies on these 
 extremities. This action may be exerted on the os 
 femoris in two modes. Sometim.es only passive, it 
 merely offers a resistance to the power which puts the 
 bone in motion; thus, in a fall, the os femoris, being 
 pressed between the ground which resists, and the 
 weight of the body that bears on it, bends beyond 
 the extent of its flexibility or pliancy, and finally gives 
 wav. At other times the influence of external bodies 
 is actively and directly exerted in this accident : thus 
 a stone, or a piece of timber, falling on the thigh, 
 fi'actures the bone, in consequence of communicat- 
 ing to it a degree of motion greater than its power 
 of resistance. 
 
217 
 
 5. In common, the first mode of division is by a 
 tru€ counter- stroke, similar to that which fractm'es 
 the clavicle, the ribs, &c. In the second mode, the 
 fracture is always direct. The middle part of the 
 bone is generally broken in a counter- stroke: where- 
 ever the direct stroke is received, that is the place 
 of the fracture which it produces ; the division, most 
 frequently oblique in the first case, is sometimes 
 perpendicular or transverse in the second. From a 
 counter- stroke result most commonly simple frac- 
 tures, while compound ones are usually owing to a 
 direct stroke. 
 
 § III. 
 
 OF THE SIGNS AND THE DISPLACEMENT. 
 
 9. In whatever manner a fracture of the os femo- 
 ris may have occurred (7), its existence is character- 
 ized by the following signs : severe local pain at the 
 instant of the accident; a sudden inability to move 
 the limb ; a preternatural mobility occurring in some 
 particular part; a crepitation sometimes distinct, when 
 the two fragments are rubbed against each other; 
 and a deformity, which may be considered under the 
 threefold relation, of length, thickness, and direc- 
 tion.* These signs, being common to most fractures, 
 
 * (La longueur.^ Vepaisseur^ et la direction.) That is, the 
 thigh may be shortea* than natural, owing to the ends of the 
 broken bone overlapping each other ; it may have a protube- 
 rance on one side, in consequence of these ends being separated 
 or displaced laterally ; or the dii^ection of the limb may be 
 changed, by a bend or angle being produced in the bone at the^ 
 place of the fracture. Trans, 
 
 29 
 
exhibit but few circumstances peculiar to those of 
 the OS femoris, except that of the deformity. Respect- 
 ing this circumstance, in particular, it is essentially- 
 necessary to possess accurate ideas, because, having- 
 an incessant tendency to recur, especially in oblique 
 fractures, it must constitute a primary object of at- 
 tention durmg the treatment. 
 
 10. It may be laid down as a general principle, 
 that all fractures of the os femoris ai'c accompanied 
 with some deformity ; the exceptions to this rule are 
 too few to be worthy of notice. If this deformity be 
 considered in relation to length, it will be found that, 
 in oblique fractures, the limb is always shorter than 
 that of the opposite side, a circumstance which plainly 
 points out an overlapping of the fragments. But, on 
 examining the place of fracture, it is easy to disco- 
 ver, that this overlapping aiises from the inferior 
 fragment mounting upwards on the superior one, 
 which itself remains immoveable. Now, what power, 
 but the contraction of the surrounding muscles, can 
 communicate to the inferior fragment a motion from 
 below upwards? Attached, on the one hand, to the 
 pelvis, and on the other to tliis fragment, to the rotu- 
 la, the tibiae, and the fibula, these muscles have on 
 the former their fixed, and on the latter their move- 
 able points, and, di^awing the leg, the knee, and the 
 inferior portion of the thigh upward, they produce 
 the displacement and shortening either mediately or 
 immediately. In this displacement, the adductores, 
 tlie semi-tendinosus, the semi-membranosus, the 
 rectus anterior, the rectus internus, &c. are the prin- 
 cipal agents* 
 
219 
 
 11. The following case communicated to De- 
 sault by a surgeon, who had been formerly his pu- 
 pil, proves how great the influence of this cause is; 
 a cause which is indeed generally acknowledged, but 
 not sufficiently attended to by practitioners, with a 
 reference to permanent extension. It is this that in- 
 duces me to relate the case. 
 
 Case I. A carpenter falling under the ruins of 
 his scaffold, was immediately taken up and carried 
 home, where a surgeon discovered an oblique frac- 
 ture of the OS femoris, but without any displace- 
 ment. The thigh, which appeared even a little longer 
 than the other, was fixed in an apparatus too slack 
 to prevent muscular action. Next day, the length 
 ofthe thigh was the same^ but the whole extremity 
 was in a paralytic state, accompanied by an entire 
 inability to discharge urine. 
 
 The moxa was proposed. The patient being 
 placed in the position directed by Pott, for fracture^ 
 ofthe OS femoris, the fire was applied; some move- 
 ments were the consequence; the application being 
 repeated on the sixth day, the muscles instantly re- 
 covered their power of action, and then the shorten, 
 ing of the limb became evident, and still returning 
 immediately after being removed by extension, 
 rendered it necessary to have recourse to an apparatus 
 .calculated for permanent extension. 
 
 12. In this case, the muscular influence is evif- 
 dent. Indeed the shock having produced a tempo- 
 rary suspension of the excitability of the part, the 
 fragments remained in place and in proper contact 
 with each other : but the moxa having awakened the 
 excitability again in the muscles of the thigh, they 
 
220 
 
 resumed their action and caused, as usual, the infe- 
 rior fragment to mount on the superior. 
 
 13. Hence it follows, 1st, that it is principally to 
 the action of the muscles that we must attribute the 
 displacement, in the longitudinal direction of the 
 bone; 2dlv, that, as that action, being the effect of an 
 inherent power, is constantly exerted, the limb must 
 have a constant tendency to this displacement, par- 
 ticularly in oblique fractures, where the two extre- 
 mities of the bone represent two inclined plains, 
 which readily glide along each other. 
 
 14. To this must be still added another cause^ 
 which operates injuriously in the course of the treat- 
 ment. However solid the bed may be on which the 
 patient lies, the nates or buttocks, being the most 
 projecting pait of the body, soon form a depression 
 in it; hence arises an inclination or descent of the 
 plain or surface on which the body lies. The body 
 therefore sliding doA\aiw^ai'ds, pushes before it the 
 superior fragment, and makes it overlap the inferior 
 one. In consequence of this, the muscles, being 
 instated by the points of the bones, increase the force 
 of their contractions, and, as we have already obser- 
 ved (10), di'aw the inferior fragment upwards. This 
 double movement of the two ends of the bone in 
 contiTuy directions, produces only a single effect, 
 namely, the overlapping of these ends, but carries 
 this overlapping to a higher degree. 
 
 15. Transverse fractures are less exposed to 
 displacement, in the longitudinal direction of the 
 bone, because the fragments when in contact, sup- 
 port each other. In such a case, the inferior fragment, 
 drawn by the muscles, finds a point of resistance 
 
221 
 
 against the superior one, while the latter, when pres- 
 sed downward by the weight of the body, pushes the 
 former before it, and thus both preserve their relative 
 position. 
 
 16. A deformity of the fractured os femoris, in 
 the direction of its cross-diameter or thickness (9), 
 always accompanies that in its longitudinal direction, 
 and sometimes exists alone. This takes place when, 
 in a transverse fracture the two ends of the bone, 
 losing their contact, ai*e carried, the one outward, and 
 the other inward, or when the one remains in its place, 
 while the other is separated from it. In such a case, 
 the superior fragment is not, as in the preceding one, 
 immoveable by means of muscular action; because 
 the action of the pectineus, the psoas, the illiacus, 
 and the first adductores, derange its natural direction, 
 and contribute to its displacement. 
 
 17. The deformity of the limb, in relation to its 
 direction, m other words, the crookedness of the 
 limb (9) is either the result of the stroke which 
 fractured it, or, wliat is more common, of the ill 
 directed efforts of those who lift and carry the pa- 
 tient, and, by an improper position, bend the two 
 fragments, so as to make them form an angle with 
 each other. Desault was once called to a patient, 
 whom he found seated on a bed, in such a manner, 
 that the upper part of the thigh was in a horizontal 
 position, and the lower, hanging with the leg in al- 
 most a perpendicular one. Doubtless tlie triceps fe- 
 moralis, equally attached to both fragments, bends 
 them by its contraction, and produces a change in 
 the direction of the limb. 
 
222 
 
 18. Whatever may be the kind of the deformitj^, 
 whether in a longitudinal or latei'al direction, the in- 
 ferior fi'agment may either preserve the natural posi- 
 tion in which it is placed, or experience a rotatory 
 motion on its axis outwards, which is a common 
 occurrence, or inwards, a circumstance which is more 
 rare. This rotation always renders the displacement 
 more serious, and ought to have an influence, as I 
 shall presently obser\^e, on the means of reduction. 
 
 UV. 
 
 OF THE PROGNOSIS. 
 
 19. Fractures of the os femoris, tliough seldom 
 very distressing, in common cases, from any acci- 
 dents that immediately accompany them, are some- 
 times rendered so, by inconveniences which are the 
 consequences of them, M^hen they ai'e oblique. Celsus 
 declared, that a shortening of the limb, more or less 
 considerable, v.as always the result of such fractures. 
 Most authors have copied and repeated this assertion, 
 and, even at the present day, tlie opinion is advocated 
 by a great number of practitioners. It must be ac- 
 knowledged, that, if we compare the natural powers 
 that ai'e engaged in producing displacement (10... 15), 
 with the artificial resistance made by most of our 
 forms of appai'atus, we will perceive that there is bcf 
 tween the two forces so great a disproportion in point 
 of strength, that the former can never yield to the 
 latter. But, is it in the nature of all forms of appara- 
 tus to be unable to overcome the force of the displac- 
 ing powers? Cannot an equilibrium be established, 
 
223 
 
 ^o as to retain the fragments in contact? The remain- 
 der of the present memoir will throw some light on 
 this problem, which will become less difficult of solu- 
 tion, if we call to mind, that the action of m.uscles, 
 though verj^ powerful at first, diminishes afterw^ards 
 by degrees, in consequence of their being kept in a 
 state of permanent extension ; that even a weaker 
 power may, by acting constantly, accomplish ulti- 
 mately, what could not have been eifected at once, by 
 another power much stronger, if only momentarily^ 
 applied; and that compression made by circular ban- 
 dages, tends also to diminish the force and prevent 
 the action of muscles. 
 
 Desault has cured, at the Hotel- Dieu, a vast num- 
 ber of fractures of the os femoris, without the least 
 remaining deformity, and there are but few of his 
 pupils who have not witnessed his success, some in- 
 stances of which will be cited in this memou*. 
 
 20. It is, above all, from the well combined use- 
 of these two means, the extension and compression of 
 the muscles, that that success was derived. The ad- 
 vantage of extension, in diminishing muscular force, 
 is evident, particularly in the reduction of certain 
 luxations, those of the humerus, for example, where 
 we are frequently unable to succeed, till after having- 
 extended the muscles for a longer or shorter time. 
 
 Fractures of the rotula and of the olecranon, pro'>c 
 equally the utility of compression in effecting the same 
 purpose; for, when the muscles are not compressed 
 by a bandage, they dravv* the fragment up^^ards v/ith, 
 a double and even treble force. 
 
224 
 
 21. Accidents relating to Complications of the 
 fracture, such as sphnters, wounds, &c. are to be 
 classed with compound fractures in general, and can- 
 not be treated of in this place. 
 
 §V. 
 
 OF THE REDUCTION. 
 
 22. Two great indications enter into the treatment 
 of fractures in general, and of that of the os femoris 
 in particular; namely, to bring the fragments into 
 proper contact, and to maintain them so. Let us ex- 
 amine each of these in all their details. 
 
 Hippocrates, and every practitioner since his time, 
 have replaced the fragments by what they call exten- 
 sion, counter-extension, and coaptation.* This three- 
 fold method, though sanctioned by long usage, and 
 rendered almost venerable by age, is by no means 
 jiecessary at^l times in practice, as will presently be 
 observed. Previously to having recourse to it, it is 
 necessary to place the patient in a suitable position. 
 But this position varies : most of the moderns adopt, 
 after the example of the ancients, a horizontal posi- 
 tion : so that the thigh may be extended on the body, 
 and the leg on the thigh. This is the common prac- 
 tice at present in France. 
 
 23. Pott imagined, on the contrary, that if the 
 lower extremity were kept in a half-bent position, the 
 muscles, being more relaxed, would offer less resist- 
 
 * A term of nearly the same import with ''conformation." 
 
 Trans. 
 
^1 
 
 ^fce t6 the efforts oF the extension : he, therefore, 
 proposed to bend the leg on the thigh, and the thigh' 
 On the pelvis, and to lay the patient on his side, ai'' 
 position, which/ when first employed in reduction, 
 ■\^ais to be continued throughout the treatment, during 
 "which it wouicl render the causes of displacement less' 
 active (10... 15). Bell adopted this method, which 
 indeed appears to be generally in use in England. 
 
 24. But the difficulty of making extension and 
 counter-extension, with the limb thus situated, the 
 necessity of making them on the fractured bone itself, 
 and not on a part distant from the fiticture, such as 
 the lower part of the leg; the impossibility of com- 
 paring the diseased thigh with the sound one, to judge 
 of the regularity of the conformation ; the uneasiness 
 occasioned by this position, if long continued, though' 
 it may at first appear the most natural; the trouble- 
 some and painful pressure of the body on the great 
 trochanter of the affected side ; the derangements to' 
 which the flragments are exposed when the patient 
 goes to stool; the difficulty of fixing the leg with 
 sufficient steadiness, to prevent it from affecting the 
 OS femoris by its motions ; the evident impractica- 
 bility of this method, when both thighs are broken; 
 and, finally, experience, which, in France, has been 
 by no means favourable to the position recommended 
 by Pott: such were the considerations, which deter- 
 mined Desault to have recourse to it no more, after 
 having tried it on two patients, in one of whom the 
 limb was considerably shortened, notwithstanding the 
 most scrupulous attentions. 
 
 30 
 
226^ 
 
 25. Besides, all that is gained by the relaxation of 
 some muscles, is lost, by the tension of several 
 others. The knee cannot be bent without the triceps 
 flexor being brought into action ; an inconvenience 
 the more serious, as this muscle acts immediately on 
 both fragments. The rectus anterior, though relax- 
 ed by the flexion of the thigh, will be throwTi into a 
 state of tension by the flexion of the leg. The mus- 
 cles aj;tached posteriorly to the upper fragment, and 
 even to the superior part of the lower one, will also 
 in certain positions of the limb be rendered tense. 
 
 26. Hence it follows, that there can be no just 
 comparison instituted as to the position proper for 
 the limb, between fractures of the upper and those 
 of the lower extremities; that, in the latter, the 
 method pursued by the English surgeons presents an 
 aggregate or general amount of inconveniences so 
 great as to overbalance that of its advantages ; and, 
 that the position directed by Hippocrates and the 
 other Greek physicians (22) ought to be adopted. 
 
 27. Having determined onr^e^ position, the ope- 
 rator proceeds to extension and counter- extension, 
 which are to be made first in the direction of the limb 
 as deformed or altered by the fi-acture, but must be 
 changed afterwards according to the natural direction 
 of the thigh. I need not here repeat the directions 
 for this double operation : common to all fractures, 
 they contain notliing particular, in relation to that of 
 the thigh. But, on what part should extension be 
 made? Petit, Heister, Duvemey, and all their pre- 
 decessors, recommend to apply the means or powers 
 for making extension above the knee; a precept 
 
227 
 
 which is still to be found in the surgical department of 
 the Encyclopedia. A strap surrounding the lower 
 part of the thigh, aided by another placed at the ancle, 
 serves, in this respect, to draw the inferior fragment 
 downward. 
 
 28. Dupouy was the first to remark, that this 
 practice rendered it necessaiy to employ great force, 
 and that it would be better to make extension only 
 on the foot. To this consideration Fabre added 
 that of the inconvenience of the pressure made on 
 the muscles, a pressure which, by irritating them 
 and making them contract, multiplies the obstacles 
 to the reduction. 
 
 Desault adopted their doctrine, from nearly the 
 same views of the subject, introduced it into the 
 Hotel-Dieu, and the success which attended it, in 
 his practice, contributed not a little to bring it into 
 general use. 
 
 29. For the purpose of making extension, he 
 used ^he foot as a lever of the fii'st kind. The two 
 hands of an assistant, grasping it in such a manner, 
 as to make the fingers cross on the back of it, while 
 the thumbs, also crossing each other, corresponded 
 to the sole, represented the power; the articulation 
 represented the centre of motion, or fulcrum, and 
 the leg together with the louver fragment, the resist- 
 ance. The requisite motion was then communicated 
 to the foot, and in that way was the extension effected. 
 This mode is more advantageous than that usually 
 employed, where the hands are applied to the lower 
 extremity of the leg ; for the force of the extending 
 power is generally in the inverse ratio of its distance 
 fi'om the resistance intended to be overcome. 
 
^23 
 
 30. What I have said of extension (2i8), applies 
 also to counter-extension. The strap, which was for- 
 merly placed for this purpose in the groin of the af- 
 fected side, by compressing- the adductores, and the 
 rectus intemus, produced in them a contraction, 
 which, by drawing the lower fragment towards the 
 pelvis, opposed obstacles to the reduction, which are 
 seldom experienced, when, like Desault, the surgeon 
 contents himself with having the trunk held by assisjt- 
 ants, either exclusively at the hips, or both at the 
 hips and under the arm-pits. The resistance being 
 always easily overcome in this affection, renders 
 it unnecessary to have recourse to more powerful 
 means. 
 
 31. Hippocrates advises, in fractures of the os 
 femoris, to aid extension by coaptation, performed 
 with the hand. All practitioners, since his time, have 
 added this third mancEuvre or process to the two first, 
 namely, extension and counter- extension. But, what 
 effect can the hands produce, in most cases, on the 
 ^one through the thick covering of the soft parts? 
 Are we able to communicate to it through such a 
 mass whatever lateral movement we please? Being 
 quite lost in the intervening soft parts, will our efforts 
 reach the bone, in the direction which we give them? 
 The muscles bring the fragments into contact, much 
 better than we can, as soon as extension has removed 
 their overlapping. Indeed, if well executed extension 
 make the lower fragment return along the same tracl^ 
 which it pursued in becoming displaced, it will then 
 be inevitably brought into contact with the upper 
 one by the contraction of the muscles. Besides, in 
 
229 
 
 most oblique fractures, is it not evident, that the 
 lower fragment must be made to slide from above 
 downwai'd, on the inclined plain presented by the 
 upper one, and on which it has slided from below 
 upward, in becoming displaced? Is it while exten- 
 sion is making that coaptation ought to be perform- 
 ed? Certainly not: because, if the extension be well 
 directed, an attempt at coaptation v/ill derange it; 
 and if it be not well directed, its course ought to be 
 changed. Is it after extension is finished that recourse 
 ought to be had to coaptation? By no means : because 
 if there be then any remains of deformity, it must be 
 owing to extension having been improperly directed. 
 The remedy, therefore, is, to renew the extension, 
 and direct it properly. 
 
 32. Hence, it follows, in general, that coaptation 
 is here a feeble assistant towards reduction ; that if it 
 renders any service, it is only in cases of displacement 
 lateraiiv, or in the direction of the cross-diameter of 
 the bo .e ; and that it is by giving the proper direc- 
 tion to extension, by managing it according to the 
 disposition of the muscles, and by knowing when to 
 augment and when to slacken it, that the fragments 
 are brought into regular contact. 
 
 33. If the inferior fragment has experienced a 
 rotatory motion on its own axis outwards or inwards 
 (18), the assistant ought, in making extension, to 
 turn the limb very gradually in the opposite direction. 
 
 34. Extension was formerly attended with diffi- 
 culties, which are rarely met Vvdth at the present day. 
 Oftentimes, if we give credit to authors, it \vas alto- 
 gether useless to endeavour, in the first instance, to 
 
230 
 
 reduce the fracture, and restore the limb to its natu- 
 ral length, as the contraction of the muscles rendered 
 the operation absolutely impracticable. Hence, appli- 
 cations of a soothing and sedative nature were em- 
 ployed, previously to an attempt at reduction. The 
 following circumstances have been assigned as the 
 cause of these difficulties. The upper strap, irritat- 
 ing and drawing upwards the adductores and the 
 rectus intemus, drew the lower fragment in the same 
 direction, while the semi-tendinosus, semi-membra- 
 nosus, biceps, &c. being drawn downwards by the 
 lower strap applied over them, di'ew the pelvis also 
 downwards, and, consequently, the superior fragment 
 connected with it. From this double action arose a 
 double motion directly opposed to that which ought 
 to be produced by extension. 
 
 35. There are still cases, where the muscles, in 
 consequence of being irritated by projections or 
 points of bone, by the efforts of the assistants, and 
 by a morbid state of the nerves, increase their con- 
 traction to such a pitch that no practicable force can 
 bring the fragments into apposition. What means are 
 then to be employed? All those, in general, that di- 
 minish irritability, varied according to circumstances, 
 such as diet, venesection, &c. In such cases, Desault 
 obtained the most happy effects, by placing the limb 
 in a state of continued extension ; fatigued by the 
 peiTuanent tension in which they ai'e thus kept, the 
 muscles relax by degrees ; their force diminishes ; at 
 length they yield, and the reduction is accomplished. 
 
231 
 
 §VI. 
 
 OF THE MEANS OF MAINTAINING THJE 
 REDUCTION. 
 
 36. The mere reduction of a fracture of the os 
 femoris, is but one step towards the cure. In this, 
 more than in the fracture of any other bone, causes 
 which act incessantly (13) tend to subvert the mo- 
 mentary work of art; it is here, then, in paiticular, 
 that means ought to be devised for maintaining this 
 work. But, the first of these means is a suitable po- 
 sition of the limb. I have already mentioned the 
 inconveniences that result, both as to the reduction 
 and subsequent treatment, from that proposed by Pott 
 (24... 26). The patient must, then, be laid horizon- 
 tally on a plain exactly even, and not capable of 
 being affected or rendered uneven by the weight of 
 the body. Instead of feather beds generally used in 
 other cases at the Hotel-Dieu, Desault, in cases 
 of fractures, substituted firm and hard mattresses, 
 \fhich, not sinking in the least, by the pressure of the 
 body, give no cause to apprehend those continual 
 displacements, to which a soft bed exposes the pa- 
 tient. These mattresses supersede the advice of 
 certain authors who direct a plank to be placed under 
 the patient. 
 
 37. The second means, not less efficacious than 
 the first, consist in the forms of apparatus, in which the 
 limb is placed, and which, being di^erently modified 
 according to the fancies of their different authors, pre- 
 sent us with an assemblage of various splints, corn- 
 
23^ 
 
 presses, Sec. To appreciate, with accuracy and correct- 
 ness, the advantage and disadvantage of these, let us 
 first unfold the curative indications which they ought 
 to fulfil ; we will then compare their mode of action 
 with these indications, from whence will result, as 
 necessary inferences, the object of our research. 
 
 38. The intention of every form of apparatus 
 being, to prevent the displacement of the fragments, 
 the causes of this displacement ought to be the basis 
 or foundation of its mechanism and construction. 
 But these causes in the present case are, 1st, the 
 muscular action di'awing the inferior fragment up- 
 wards (10); 2dly, the weight of the body pushing 
 the superior fragment downwards (14); whence 
 every form of apparatus intended to keep the os 
 femoris in place when fractured obliquely, ought, 
 1st, to draw the lower fragment downward and retain' 
 it there ; 2dly, to draw and retain upwards the supe- 
 rior fragment, and the trunk which bears on its up- 
 per end. This principle is applicable generally, and 
 subject only to a few exceptions which I shall notice 
 when treating of transverse fractures, where the dis- 
 placement is lateral, or in the direction of the cross- 
 diameter of the bone, or where no displacement at 
 all exists. 3dly, The apparatus must also be so con- 
 structed as to prevent the rotatory rriotions of the 
 lower fragment (18), and secure the immobility of 
 the limb, lest by means of some motion being com- 
 municated to it, the fragments might be deranged. 
 
233 
 
 § VII. 
 
 OF THE MANNER IN WHICH THE DIFFERENT 
 PIECES OF THE APPARATUS ACT. 
 
 39. If to these indications we compare the 
 mode of action of the different pieces that unite in 
 composing our common forms of apparatus which 
 do not make permanent extension, such as com- 
 mon bandages, spUnts, compresses, bolsters, &c. 
 we will perceive that they are but ill calculated to 
 fulfil them: and first of bandages. Whether the 
 common roller, or the eighteen-tailed bandage be 
 employed, their mode of operation is the same : their 
 only action is, to add a second exterior and artificial 
 covering to the natural cutaneous and aponeurotic 
 covering of the thigh ; to press against the fragments 
 the muscles which form for them a kind of natural 
 case intended to keep them in apposition; and to 
 augment, by this pressure, the lateral resistance of 
 the soft parts. By this contrivance, lateral displace- 
 ments will, in part, be well guarded against, and, in 
 this respect, these bandages are useful in transverse 
 fractures. But what is there in them to prevent the 
 two inclined plains of an oblique fracture from sliding 
 on each other? What provision is there in them to 
 secure the limb fi^om the effects of motions and 
 shocks which may be accidentally impressed on it 
 from without? Will the pelvis be kept steady by 
 tliem? or will muscular action be sufficiently checked 
 and kept under by them? The force of the muscles 
 
 will indeed be slightly diminished by means of 
 
 31 ^ 
 
234 
 
 compression; and to make this compression is tlie 
 principal use of these bandages in oblique fractures. 
 But will mere compression be sufficient to prevent 
 a displacement in the longitudinal direction of the 
 bone, particularly if the rollers be slack, as certain 
 practitioners recommend, on the ground of the fal- 
 lacious theory of Duhamel, who conceived, that a 
 constriction too tight, would injure the action of the 
 periosteum, which, according to him, is the sole 
 agent in the formation of callus? So much, then, for 
 bandages, whose only use is to prevent, by compres- 
 sion, the swelling of the limb, and to diminish, in 
 some degree, the contraction of the muscles, which 
 they press against the fractured bone, 
 
 40. These remarks apply equally well to the use 
 of compresses ; which make but a very feeble resist- 
 ance against a powerful cause, and cannot be consi- 
 dered as any obstacle whatever to displacement. 
 What can be said of those surgeons who, from 
 servile attachment to a particular form of apparatus,^ 
 do not consider a fracture as reduced, unless a cer- 
 tain quantity of compress secured by a given quan- 
 tity of roller, be applied on the limb. Servile imita- 
 tators in an ai't which calls for genius in its votaries, 
 they are only capable of following, without reflection 
 or judgment, the steps of their predecessors. 
 
 41. Bandages will do nearly as much harm as. 
 good in fractures of the os femoris, if, as was prac- 
 tised by the ancients, they be formed by a single roller 
 surromiding the limb: in such a case, the limb being 
 necessarily raised up at each time of their reapplica- 
 tiouj will be exposed to continual displacements* 
 
23B 
 
 Hence the ingenious idea of applying to simple frac- 
 tures of the lower extremities the eighteen-tailed ban- 
 dage, invented for compound fractures, and by means 
 of which the thigh may be suffered to remain at rest. 
 But to this bandage belongs also an inconvenience. 
 The pieces w^hich compose it, being stitched together, 
 cannot be separated, and if one of them be soiled they 
 must all be changed. Hence the superiority of the 
 bandage of slips, knov/n in former times, and engrav- 
 ed by Scultel, but long since forgotten, till Desault 
 revived the use of it, and adopted it exclusively, both 
 in simple and in compound fractures. 
 
 42. Splints of different kinds, which form the se- 
 cond division of the pieces of apparatus, used for 
 fractures of the os femoris, have the advantage of 
 fixing the limb in a solid and firm manner, and secur- 
 ing it from any displacement that might result from 
 jolts, or muscular contraction, arising from the inat- 
 tention of patients : these prevent, more effectually 
 than bandages, any displacement laterally, and, on this 
 account, their use is sufficient, even without exten- 
 sion, in transverse fractures : they also prevent, par- 
 ticularly if they be made of wood, the rotatory motion 
 of the thigh either outwards or inwards (18). But if 
 the division be oblique, Vv^ill they prevent the gliding 
 of the fragments over one another, and the consequent 
 shortening of the limb? They can evidently produce 
 this effect in no other way, than by the forcible pres- 
 sure made by the pieces of apparatus, paiticulai'ly by 
 the straps or bandages that secure the splints, and 
 then, to make effectual resistance, it would be neces- 
 sary to apply them with such a degree of tightness as 
 
256 
 
 would endanger the life of the limb. Will splints 
 prevent the trunk from sinking downwards, and push- 
 ing the superior fragment before it? Will they pre- 
 vent the muscles from acting on the lower fragment? 
 Can they, in a word, fulfil all the indications formerly 
 pointed out (28)? Certainly they cannot. Splints, 
 then, are calculated only to prevent displacement in 
 the lateral or cross direction of the bone, and to se- 
 cure, better than bandages, the immobility of the limb. 
 Whence it follows, that they ought not, in this case, 
 to be confined to the thigh alone, but should extend 
 to the leg, whose movements, if communicated to the 
 OS femoris, may derange the contact of the ends of the 
 bone. The neglect of this precaution, contributed 
 formerly not a little to displacement and deformity. 
 
 43. In former times a kind of splints was in use, 
 w^hich were made by securing bundles of straw round 
 sticks proportioned in length to the length of the limb 
 to which they were to be applied. But as these, from 
 being of a round or cylindrical form, touched the limb 
 with but a nan^ow surface, they did not retain the 
 fracture with sufficient firmness. They were, there- 
 fore, very properly exchanged for flat and sti'ong 
 v/ooden splints, (such as Desauit used) which retain 
 the fracture much better, in consequence of present- 
 ing to the limb a broad surface, and thereby 'render- 
 ing it in some measure immoveable. 
 
 44. The bolsters for filling up interstices, being 
 less intended to prevent displacement, (in which re- 
 spect they are, notwithstanding useful) than to guard 
 the limb from the immediate pressure of the splints, 
 usually consist of several folds of old linen ; this is the 
 
237 
 
 form adopted at the Hotel-Dieu ; but to these Desault 
 preferred small pallets or bags filled with chaff, which, 
 fashioned according to the form and disposition of the 
 limb, may, at the pleasure of the surgeon, be made 
 thicker or thinner, to suit the inequalities of the sur- 
 face, in consequence of the ease with which the chaff 
 may be moved from one part of the bag to another. 
 
 45. From the foregoing examination of the action 
 of bandages and splints, it appears, that the common 
 apparatus, formed by their union, but not calculated 
 to effect a permanent extension, may perhaps answer 
 in cases of transverse fractures, which indeed but 
 rarely occur, but ai'e always insufficient when the 
 division is oblique, because they cannot fulfil the 
 double indication of drawing the inferior fragment 
 down, and retaining the superior one up (38). 
 
 § VIII. 
 
 OF PERMANENT EXTENSION, AND THE MEANS 
 OF EFFECTING IT. 
 
 46. By what means then can this indication be 
 effectually fulfilled? By that which will perpetuate, 
 throughout the whole treatment, the action of those 
 means by which reduction was effected; by that 
 which, to the ever active power of the muscles, will 
 oppose a resistance constant in its action; by that 
 which, forming on the exterior of the thigh a kind of 
 artificial muscle, may become an antagonist to the 
 natural muscles of the part, and neutralize their ef- 
 forts, by acting in a contrary direction, and which, 
 by pushing up the pelvis and retaining it there, may 
 
238 
 
 prevent it from being pushed downward by the 
 weight of the trunk (14). But what other mean than 
 that of permanent extension, unites these advantages? 
 Whatever form of apparatus may be employed to ob- 
 tain it, it is permanent extension alone that can pre- 
 vent the displacement, because it alone is founded 
 on principles calculated to meet and obviate the causes 
 by which displacement is produced. 
 
 47. The ancients, though less informed than we 
 are respecting the nature of these causes, knew bet- 
 ter how to appreciate their effects. All their forms of 
 apparatus made a permanent extension, a measure 
 which has been abandoned by most of the moderns, 
 and regarded, even at present, in France, by a great 
 number of practitioners, as always dangerous, and 
 seldom useful. Let us set in opposition to the vain 
 fears which it inspires, a few thoughts, and much 
 experience. 
 
 48. It is from the very object which is proposed 
 to be attained, that the first difficulties arise. What 
 must we think of a limb in a state of preternatural 
 tension, where all the parts being overstretched must 
 experience an uneasiness not to be supported? I an- 
 swer, that it is not a preternatural elongation that ex- 
 tension produces ; on the contrary, being intended 
 to prevent a preternatural shortening, it has for its ob- 
 ject to restore the parts to their ordinary state, and to 
 give to the muscles their habitual degree of tension, 
 by opposing such contractions in them as are not ha- 
 bitual: under this point of view, it performs, in rela- 
 tion to the muscles, those very functions which are 
 discharged by the bone itself, when sound and un- 
 
239 
 
 broken, as is fully experienced by all patients, when 
 the apparatus is applied. Its use not only does not 
 increase pain, but is alone calculated to diminish it^ 
 because, by bringing the fragments into apposition, 
 it prevents the soft parts from being irritated by the 
 points of the bones. 
 
 49. Is the swelling of the limb to be dreaded, as 
 some pretend? But whence can this swelling arise? 
 From the over- stretching of the paits? I have already 
 proved that they are not over- stretched. From the 
 pressure of the straps? Perhaps this cause might pro- 
 duce a swelling, if, as formerly, it were applied above 
 the knee; but, by placing it, as Desault did, near to 
 the ancle, by surrounding, with a thick compress^ 
 the lower part of the leg, where the straps pass, and 
 by securing the foot with a tight bandage under the 
 straps, if their action be dreaded, this fear must be 
 done away; and, besides, experience, which is the 
 only true test of the dangers of a process, by no 
 means justifies the apprehension. The venas saphense 
 and the absorbents that accompany them, are free 
 from the compression, which bears principally on 
 the tendo Achiilis, and the malleoli. 
 
 50. What shall we say in reply to the censure 
 thrown on the process of permanent extension, in the 
 memoirs of the academy, where it is charged with 
 having been oftentimes productive of ulceration and 
 even gangrene, in consequence of the pressure of the 
 upper strap? What method can escape censure, if it 
 be unskilfully pursued? What process will not be 
 injurious, if mutilated and ill managed by ignorance 
 or a want of discretion? To represent the thing pro- 
 
240 
 
 perly, let us suppose the worst : a circular bandage, 
 in consequence of being drawn too tight, produces 
 mortification in the subjacent parts; must circular 
 bandages be on this account entirely rejected? An 
 unskilful hand, in an operation for cancer, opens the 
 axillary artery; must we therefore cease to search 
 under the arm-pit for schirrous glands? 
 
 51. Permanent extension is, say some, insuffi- 
 cient to overcome muscular action ; it is opposing to 
 a power equal to 1000, a resistance equal to only 100. 
 But this force of the muscles, which is oftentimes so 
 great at the time of reduction, diminishes gradually, 
 by the pressure of the bandages, by the immobility 
 .of the limb, and, above all, by long continued exten- 
 sion ; for a continued effort equal to 10, will soon 
 perform what could not be effected by a temporary 
 exertion of a force equal to 100. Let us pass over 
 tlie more minute objections made against permanent 
 extension, and search among the different modes of 
 performing it, that to which practitioners ought to 
 give a preference. 
 
 52. We may throw into two classes the general 
 modes proposed by different authors for effecting 
 permanent extension. Under the one are included 
 those modes requiring simple means, such as straps, 
 splints, &c. while the other embraces such as, from 
 being complex, necessarily call for the use of different 
 machines. 
 
 53. In the first class are comprehended: 
 
 1st, The method employed in the first instance 
 by the Arabians, adopted afterwards by their suc- 
 cessors in medicine, and proposed, at a still later 
 period, by Petit, Heister, and Duverney, and which 
 
241 
 
 consists in fixing, at the head and foot of the bed, 
 during the whole treatment, straps intended for the 
 purpose of extension. 
 
 2dly, The mode of extension, adopted by many 
 practitioners, which consisted in suspending to a strap 
 fixed at the knee, and reflected over some suitable 
 body, a weight proportioned to the power of the 
 cause which it was intended to combat. 
 
 3dly, The ingenious idea of Bruninghausen, who> 
 confining by a kind of stirrup, the diseased leg 
 against the sound one, made the latter serve as a 
 splint to retain the fi-actured limb on its proper line, 
 and thus preserve its natural length. 
 
 4thly, Under this class also must we an-ange the 
 Hffieans employed by Desault, and which we will 
 presently describe. 
 
 54. The second class of means invented for the 
 purpose of making permanent extension, in fi^ac- 
 tures of the thigh, comprehends: 
 
 1st, The Glossocome, the bed of Hippocrates,* 
 and other machines, used by the ancients, to effect 
 a reduction, in fractures of the os femoris, and, at the 
 same time, to maintain the reduction, by being left 
 on the limb. 
 
 2dly, Numerous machines, invented for the 
 purpose of suspending a weight intended to make 
 extension. These have been differently varied and 
 
 * (Le lit d'Hipfiocrate.) As many of the machines men- 
 tioned here have probably never been seen in this country, 
 and as there is, perhaps, scarcely one of them used, at pre-^ 
 sent, in any country, I shall not consume the time of the reader 
 by ti'oubling him with descriptions of them. Teaks. 
 
 32 
 
242 
 
 modified, more by the imagination than the judgment. 
 Engravings of some of them are to be found in 
 Scultet, FabriciusofHilden, Pare, Sec. 
 
 34ty, The machine of Bellocq^ proposed to the 
 Academy of Surgeiy, a description of wliich is con- 
 tained in their memoirs, and which possesses art 
 advantage not fcnapd, in the others, namely, that ol 
 taking its point of extension at the IctiWier part of the 
 
 leg. 
 
 4thly, The machine of Nook, surgeon at Nor- 
 wich, improved by Aitkin, an engraving of which is 
 given- by Bell. 
 
 5thly, A new Glossocome, published in the 
 works of Manne, and a great number of other ma- 
 chines, the ephemeral offspring of the genius of their 
 authors, the utility of which experience has seldom 
 confirmed, and which were even deacL-born in the 
 opinion of practitioners. I barely mention these, 
 because a circumstantial description of them would 
 lead: me from my subject. 
 
 5-5n. We may discover- at a^ single glance the com- 
 parative merits of these two classes of apparatus. 
 Extension produced by simple means, such as straps, 
 splints, &c. (50), may at all times, and under all cir- 
 eumstances,. be had recourse to ; because the means 
 necessary for making it may always and every where 
 be found. Are we desirous,, on the other hand, of 
 having recourse to machines (54)? These are seldom 
 at hand, and oftentimes not to be obtained : the ex- 
 pense attending the purchase of them, prevents most 
 surgeons fi^om procuring them. They no doubt pos- 
 sess the advantage of multiplying forces, and render- 
 
243 
 
 ing them more powerful : but, I iiave already said 
 (51), that a gentle resistance, if long continued, is 
 sufficient to overcome at length the contraction of the 
 inuscles, tliough at first extremely active and ener- 
 getic. 
 
 56. In the first point of view., the first class of 
 ttieans is doubtless preferable to the second. But 
 they both partake generally of the inconvenience of 
 placing the point of extension above the knee. I have 
 already mentioned the effects which this produces with 
 respect to muscular action, at the time of the reduc- 
 tion (28). To the injurious effects there stated may be 
 added the swelling of the limb, arising from the com- 
 pression made by the straps, the disadvantage of the 
 mobility of the leg, which is not fixed, and the mo- 
 dons of which, being communicated to the thigh, 
 naay separate the fragments after they have been, 
 brought into apposition. Further, the straps may 
 readily slip down over the knee, and thus leave the 
 fragments subject to the mischievous influence of 
 muscular contraction. 
 
 57. To these general disadvantages, add those 
 peculiar to each form of apparatus, which are too te- 
 dious to be detailed at present, and you will perceive, 
 that the little success hitherto obtained from continued 
 extension, is owing, not to the nature of the measure 
 itself, but to the manner of employing it, and that, in 
 the present case, as in cases of fractured clavicles, 
 another step towards perfection remained to be made. 
 
 58. Desault, in the first instance, attempted only 
 to improve the ancient process, which consisted in 
 fixing the straps for extension to the foot and head of 
 
244 
 
 the bed. He remedied the inconvenience of fixing 
 the straps at the knee, by doing, throughout the whole 
 treatment, what Fabre and Dupouy did only at the 
 time of reduction (29) ; that is, he placed the seat c^ 
 extension at the foot. The hold for counter-extension 
 was also changed. This he made by a bandage for 
 the body, fastened round the breast, and drawn only 
 moderately tight, lest it might impede the patient's 
 respiration. The rest of the apparatus was nearly as 
 I shall presently describe. 
 
 59. This was, for a long time, the only apparatus 
 which Desault used. He introduced it into the Hotel- 
 Dieu, after having employed it at the hospital of Cha- 
 rity, with great success. In the mean time, the ut- 
 most care and attention were here indispensable: 
 every day it was necessary to examine the rollers se- 
 veral times, as they readily became relaxed. The 
 pelvis, not being well secured, could communicate 
 motion to the fracture : it was difficult to raise the 
 patients to the close-stool. Besides, the slightest 
 disease of the chest, rendered the pressure of the body- 
 bandage insupportable. It was this very inconveni- 
 ence which, having, in a certain case, rendered the 
 preceding apparatus inadmissible, suggested to De- 
 sault the following one. 
 
 60. This consists, to speak in general terms, in 
 taking the points of extension, above, on the tubero- 
 sity of tlie OS ischium of the diseased side, and 
 below, on the malleoli; in securing the straps or 
 rollers, destined for making extension, on the two 
 ends of a strong splint, placed along the outside of 
 the limb; and in converting, so to speak, the pelvis. 
 
245 
 
 the thigh, the leg, and the foot into one entire and 
 solid piece. 
 
 The pieces which compose it are, 1st, A com- 
 mon junk-cloth* (FFF plate II.), accommodated to 
 the size of the limb and the splints : 2dly, a ban- 
 dage for the body (BB) and one passing under the 
 thigh (H) to secure the first on the side opposite to 
 the fracture : 3dly, three stiff splints, an inch and a 
 half wide, the external one of which (AA) being 
 very strong, must be long enough to extend from 
 the spine of the ileum, to the distance of four 
 inches below the sole of the foot. This splint is 
 hollowed out or notched at its lower end, and 
 has a mortise in it a little higher up. The upper 
 splint (CC) occupies the space included between 
 the fold of the groin and the upper part of the knee : 
 and the internal one, which reaches from the upper 
 
 (* Drafi-fanon.) This is a piece of linen or muslin (De- 
 sault appears to have used flannel, which is not however so 
 good) spread under the broken limb, reaching in length from 
 one end of it to the other, and wide enough to go about twice 
 round it. It is to be folded at its edges several times round the 
 internal and the long external splints, in order to retain them 
 the better, and make them bear with more steadiness and ad- 
 vantage on the limb. The junk-cloth and these two splints, 
 when properly applied, form a kind of soft elastic case, in 
 which the limb rests. This case is of service in securing the 
 bolstt-rs in their places. The junk-cloth is the outside piece of 
 the apparatus, except the bits of tape which go round and se- 
 cure the whole. In arranging the different pieces, therefore, 
 on the bed or mattress, v/here the patient is to lie, the surgeon 
 places the tapes first, the junk-cloth next, the bandage of strips 
 next, and so on, in an order the reverse of thr^t in which he 
 afterwards applies them on the limb. Tr.a-ns. 
 
B4B 
 
 mid internal fold of tlie thigh, to the sole of the foot*. 
 4thiy, three bolsters, an external, an internal, and aii 
 upper one (d d d d) consisting of small bags of 
 chaff: 5thly, a bandage of strips (EE) accommodated 
 as to number to the circumstances of the case, 
 separate from one another, each three inches broad, 
 and long enough to go twice round the limb, ar- 
 ranged from below upwards, and overlapping each 
 other, about one third of their breadth: 6thly, one 
 long and two circular comprcsses, intended to be 
 applied immediately on the limb next to the skin : 
 7thly, two strong rollers (g g and L) intended for 
 extension and counter- extension, at least an ell and 
 a half long: 8thly, one long and thick compress, and 
 a sufficient number of bits of tape. 
 
 61. Every thing being ready, previously to 
 putting the patient to bed, the pieces of apparatus 
 are to be airanged on that part of the bed corres- 
 ponding to the fractured thigh, in the order in 
 which they are to be successively applied. If the 
 patient has been already laid in the place where he is 
 to remain, the limb must be raised with great caution, 
 and, during the extension, each piece gently slipped 
 under it, or the whole must be passed under at once, 
 being first rolled round the several splints, in such 
 a manner, that the apparatus requires only to be 
 opened. 
 
 62. Extension is now made in the mode already 
 pointed out (29 and 30), and then the application of 
 the apparatus is begun, for which the surgeon must 
 be situated on the external side of the fractured thigh, 
 while an aid, placed on the other side, gives him 
 assistance. 
 
247 
 
 1st, On the thigh, next to the skin, are first 
 applied the long and circular compresses, accurately- 
 spread out so as to have no wrinkles in them, and 
 previously wet with vegeto- mineral water. Around 
 it are then applied,, in succession and from below 
 upwards, each strip of the bandage (EE) moderately 
 ti#it. 
 
 2dly, The lower end of the leg is now covered 
 with a thick compress, intended toprevent the im- 
 pression of the roller (L), which is fixed in such a 
 manner, that its middle is first laid on the tendo Achil- 
 Us,, a little above the heel, while its two ends, crossing 
 each other on the upper part of the foot, are canied 
 on each side to its sole, where crossiiig again, they 
 are then laid down till the close of the application of 
 the apparatus. 
 
 3dly, Along the thigh are placed laterally two bol- 
 sters, which, from their thickness being easily increas- 
 ed or diminished in consequence of the moveable 
 nature of the chaff, mould themselves to the inequali- 
 ties of the limb. 
 
 4thly, Around the two lateral splints, the surgeon 
 and his assistant roll, each on his respective side,, the 
 two edges of the junk-cloth,, so that both splints, by 
 being accurately applied on the bolsters, may make 
 a uniform compression on the whole part. 
 
 5tlily, The third bolster (dddd) is then appli- 
 ed on the anterior part of the limb, and over it the 
 splint (CC). 
 
 6. The bits of tape passed under the apparatus to 
 the number of four for the thigh, and three for the leg, 
 are tied in succession on the external splint, lest the 
 knots, should they correspond to the thigh,, might, by 
 
248 
 
 their contact, prove troublesome. That one next to 
 the fracture is tied first, and they are all drawn as tight 
 as the patient can bear them without uneasiness. 
 
 7. The body-bandage is now fixed on the pelvis, 
 in such a manner, as to secure laterally the external 
 splint, and is itself retained by the sub- femoral ban- 
 dage (H), that is, the bandage passing under the thigh. 
 
 8. A thick compress placed beneath the tubero- 
 sity of the ischium, serves as a cushion or bolster to 
 protect the part fixDm the pressure of the roller (g g) 
 which, being passed first under the apparatus, and 
 drawn afterwards obliquely from within outwards, 
 and from above downwards, takes its points of bear- 
 ing or action, in one part, on the tuberosity of the 
 ischium, and in the other, on the upper end of the ex- 
 ternal splint, and is tied ip the fold or hollow of tlie 
 groin. 
 
 9. The two ends of the bandage (L) previously 
 made to cnoss each other on the sole of the foot, arc 
 passed the one through the mortise, and the other 
 through the hollow or notch in the lower end of the 
 same splint, and then, being drawn forcibly, are tied 
 in a firm knot, so as to act as a substitute for the hands 
 of tlie assistant, who now lets go the patient's foot. 
 
 10. If the roller (g g) become relaxed, it is tight- 
 ened again, and the patient being laid in a suitable 
 position, the limb is protected from the pressure of 
 the bed clothes, by a kind of basket placed over it. 
 
 11. A roller (K k) laid first on the sole of the 
 foot, and then brought across over its upper side, and 
 fastened laterally to each splint, senses to secure tliat 
 part from turning outward or inward, and thus pre- 
 sents the rotation of tiie limb. 
 
249 
 
 63. If the mode of operation of this bandage be 
 compared with the general indications formerly esta- 
 blished (38) for all oblique fractures of the os femo- 
 ris, it will be easy to perceive that, conformably to 
 those indications, it tends, 1st, to draw the inferior 
 fragment downward ; 2dly, to retain the superior one 
 up; 3dly, and to prevent the rotation of the lower 
 fragment, and secure the immobility of the limb. 
 
 64. It is evident that the bandage or roller (g g) so 
 unites the pelvis to the external splint (A A}, that the 
 latter cannot be pushed upwards, without draw ing the 
 former in tlie same direction, as well as the superior 
 fragment which adheres "to it. But if, after this roller is 
 fixed, the lower one (L) be tightened, the first effect 
 produced is, to push the external splint forcibly up- 
 wards ; the second, to draw the leg, and with it the 
 inferior fragment downwards ; so that, by fixing the 
 roller (L) in the notch and mortise of the splint with 
 tht necessary degree of tightness, extension and coun- 
 ter-extension ai'c made permanent. By this means 
 the muscles, being kept on a stretch, lose by degrees 
 their power of contraction, which is still further di- 
 minished, by the immoveable state in which they are 
 kept, and by the compression made on them by the 
 bandage of strips. So that, on the one hand, the in- 
 ferior fragment will have no tendency to rise upwards, 
 and even if it had, it will meet with a sufficient resist- 
 ance to prevent it; while, on the other hand, the 
 superior fi-agment will not be pushed downwai'ds by 
 the pelvis. 
 
 65. To this advantage is added that of a state of 
 perfect immobility. The pelvis, the leg, the thigh. 
 
250 
 
 and the foot being firmly fixed on the external splint, 
 constitute one entire whole, all the parts of which 
 must retain, with respect to each other, the same re- 
 lative position. Should even a stroke be accidentally- 
 given to this assemblage of parts now converted into 
 a solid whole, each portion of it will move at the same 
 time, there will be no partial motion, and the relative 
 position of the parts will not be changed. Hence the 
 advantage of being able to raise the patient without 
 apprehension; a most desirable circumstance indeed, 
 in a position so painfiil and so long continued (26). 
 The external splint, being extended beyond the sole 
 of the foot, prevents the lower fragment from obey- 
 ing a tendency, which it sometimes has, to displace 
 itself by a rotation on its axis. Should this tendency 
 be towards the internal side, an occurrence much 
 more rare, the lengthening of the internal splint will 
 effectually prevent it. 
 
 67. These considerations induced Desault to re- 
 nounce his ancient mode of making permanent ex- 
 tension, and employ this exclusively, in the latter 
 years of his practice. Like all other kinds of appara- 
 tus, formed principally of rollers, this is very subject 
 to become relaxed; and requires, therefore, great 
 attention on the part of the surgeon. It ought to be 
 examined attentively every day, particulai'ly the two 
 extending bandages (L and g g). As soon as they be- 
 come relaxed, they must be immediately tightened 
 again : without this precaution, the effect of the ap- 
 paratus will be lost. Be vigilant also, with respect to 
 the compress placed between the roller (g g) and the 
 tuberosity of the ischium. Should this slip, the roller 
 
251 
 
 being frequently tightened, and pressing immediately 
 on the skin, may produce excoriations and ulcers 
 difficult to be healed, particularly in females. The 
 roller itself may slip, and then, having no longer a 
 solid point of support and action on the tuberosity of 
 the ischium, it makes extension in but an imperfect 
 manner. 
 
 67. One of the charges brought against this ap- 
 paratus is, the facility with which the upper roller be- 
 comes displaced, a facility that imposes a degree of 
 care and attention, of which few surgeons are capable, 
 and which, when bestowed even by Desault himself, 
 did not always prevent the shortening of the limb. 
 
 68. Further, the extension made on the fold of 
 the thigh, partakes, a little, of the inconvenience that 
 accompanied the ancient mode of reduction, namely, 
 that of compressing and irritating the muscles of the 
 upper and internal pait of the thigh (30). This incon- 
 venience would be still more sensible, if, for want of 
 extending to a sufficient distance up the pelvis, the 
 upper splint should allow the roller to cross the mus- 
 cles at an angle somewhat acute, as it would then 
 enclose and press on the greater part of them. 
 
 69. If some unfavourable cases, resulting without 
 doubt from these inconveniences, did occur in the 
 practice of Desault, a multitude of successful ones 
 still attest the advantages of this method; and there 
 is not a pupil who attended any time at the Hotel- 
 Dieu, without witnessing them. I will relate but one 
 case, collected by Chorin, to furnish a detail of the 
 treatment subsequent to reduction, referring the rea- 
 der for further information to the Journal of Surgery. 
 
252 
 
 Case II. Theresa Little- John, aged 45 yearSj 
 fell, drawn by the weight of her own body, through 
 a window in a balcon}^, from which she was leaning. 
 She was instantly taken up, carried to her own house, 
 and from thence to the Hotel-Dieuy which she enter- 
 ed on the 28th of October, 1790. From the signs 
 mentioned (9), a fracture was discovered towards the 
 lower part of the thigh; its oblique disposition re- 
 quired an apparatus to make permanent extension. 
 This was applied in the usual manner, and, in an in- 
 stant, the patient, who had experienced, since her 
 fall, severe pain, became calm, and was completely 
 relieved. 
 
 In the night, pains returned; agitation; some 
 spasmodic motions; an anodyne draught adminis- 
 tered in the morning. In the course of the day, these 
 troublesome symptoms disappear; a slight swelling 
 at the ancle. Third day, no pain; swelling gone; 
 aliment increased. Sixth day, patient permitted to 
 return to her usual regimen; extending rollers re- 
 laxed ; lower one tightened : eleventh day, apparatus 
 renewed; fragments in perfect contact: thirteenth 
 day, limb moved incautiously ; a slight shortening ; 
 apparatus reapplied ; extending bandages drawn 
 tight : sixteenth day, a disposition slightly bilious ; 
 evacuants administered -wdth success : twenty-fourth 
 day, a third application of the bandage: thirtieth day, 
 progress in consolidation already very evident; the 
 limb straight: fortieth day, extending rollers laid 
 aside : fifty- second day, consolidation complete with- 
 out the least deformity. 
 
2B3 
 
 70. Tlie muscular force, in children, being weak, 
 and the weight of the body inconsiderable, have, in 
 general, much less influence in producing a displace- 
 ment in them than they do in adults. Wheli, there- 
 fore, fractures occur in subjects under six or seven 
 years old, the resistance, on the part of the apparatus, 
 need not be so great. In general the lateral pressure 
 which it makes, and the bearing of its different pieces 
 against the limb, are sufficient to prevent the return 
 of deformity, when this has been perfectly removed 
 by reduction. 
 
 71. In such cases Desault covered the thigh with 
 a circular bandage, made of a roller seven ells long, 
 and three inches broad. Beginning with this below^ 
 near to the condyls, he carried it upwards, by oblique 
 and reversed turns, to the pelvis, round which he 
 threw a cast; then, giving the ball into the hand of 
 an assistant, he applied four splints, one before, ano- 
 ther behind, and one on each side : directing these to 
 be held at their lower part near to the knee, he resu- 
 med the roller, and secured them firmly b}^ a second 
 series of circular and reversed turns, descending to 
 the lower extremity of the thigh. The limb was then 
 placed in a proper position, and, in general, of what- 
 ever kind the fracture was, whether oblique or trans- 
 verse, this simple bandage, without the aid of perma- 
 nent extension, was sufficient to retain it. 
 
 72. It would be difficult to determine the period 
 necessary for the consolidation of fractures of the os 
 femoris. Numerous circumstances concur to influ- 
 ence this work of nature, which is, in general, ex- 
 tended beyond the term of f^prty days, vulgarly 
 
254 
 
 assigned to it by the people at large. Besides, a 
 stiffness of the limb, the inevitable effect of its long 
 state of rest, still adds to the length of the patient's 
 confinement, by retarding the necessary motions, the 
 return of which, as in other similar cases, can be ac- 
 celerated only by exercise. 
 
 73. Complicated fi^actures of the os femoris, 
 being included in the general class of solutions of 
 continuity of that description, cannot be at present 
 particulai'ly considered. We will only remark, that 
 here, in like manner, as in fractures of the clavicle, 
 permanent extension constitutes the most effectual 
 method of preventing the pains, oftentimes insup- 
 portable, occasioned by splinters or points of bone 
 irritating the soft parts, from being pressed against 
 them by muscular action in its tendency to shortea 
 the limb. 
 
 § IX. 
 
 OF PERMANENT EXTENSION IN OLD ERACTURES. 
 
 74. I will close this article by a few remarks on 
 the advantages of peririanent extension in old frac- 
 tures. Nature reunites fractures differently, accord- 
 ing to the relation of the divided surfaces to each 
 other. Are those surfaces in perfect contact? If so, 
 they are chiefly instrumental in the formation of 
 callus, which then probably acts in a manner similar 
 to the reunion of wounds. On the other hand, does 
 an overlapping of the fragments separate the divi- 
 ded surfaces from each other; the reunion takes 
 place then principally on the sides, by a kind of 
 
255 
 
 enlargement of the bones, produced no doubt by the 
 periosteum. Such is the mode of consolidation, 
 which, on opening dead bodies, is found in most 
 obhque fractures of the os femoris, succeeded by a 
 shortenmg of the Hmb. 
 
 75. Hence it follows, that this shortening, which 
 would readily yield to extension, at the time of the 
 fracture, becomes obstinate in its resistance, in pro- 
 portion to the age of the accident. In such a case, 
 indeed, the substances destined to reunite the over- 
 lapping fi'agments, acquiring daily more and more 
 solidity, oppose to the reduction obstacles constantly 
 increasing. Hence, most practitioners regai'd this 
 reduction as beyond the resources of art, after the 
 expiration of the twelfth or fifteenth day. Nor is this 
 opinion entertained without some foundation, for at a 
 later period, almost all efforts at reduction, however 
 powerful, have proved unavailing. But that which 
 cannot be performed by a very powerful effort, acting 
 momentarily, is, notwithstanding, oftentimes easily 
 attainable by a much weaker one, provided it be long 
 continued. The following cases are in proof of this. 
 
 Case HI. Ann Gallot, of Melun, aged sixty- 
 nine, having fractured her right thigh, by falling 
 down the steps of a cellar, remained twenty-two days 
 without assistance, and without even knowing^ the 
 nature of the accident, when, on consulting a sur- 
 geon, she was sent to the hospital at Versailles. 
 From the long standing of the disease, a reduction 
 being despaired of, and no one being willing even to 
 undertake it, the patient was sent to the Hotel- Dieu, 
 on tlie 27th of Februaiy, 1791. 
 
QK 
 
 ^O 
 
 A shortening of four inches distinguished the 
 diseased thigh from the sound one. The overlap, 
 ping was sensible to the touch : in the mean time, 
 a slight mobility at the place of fracture, inspired 
 a hope of being able, if not to restore to the limb its 
 natural form, at least to diminish the contraction. 
 Several efforts were made at first, but without suc- 
 cess, as Desault foresaw. The appai^atus for perma- 
 nent extension was applied: on the day following, 
 the extending rollers being a little relaxed, were 
 regain tightened. Fourth day, a sensible increase in 
 the length of the limb; apparatus renewed. Ninth 
 day, the left thigh but an inch longer than the other : 
 eleventh day, equahty in length almost re-established. 
 After this, the apparatus was kept constantly applied 
 and renewed from time to time. 
 
 Fortieth day, consolidation already perceptible : 
 forty-sixth day, symptoms of a putrid fever have 
 m.ade tlieir appeai'ance : fiftieth day, symptoms worse; 
 fifty-second, something better: fiifty-fifth, Avorse 
 again: fifty-seventh, dead. On opening the body, 
 an oblique fracture vvas found, its surfaces very 
 nearly in apposition, and already united by a veiy 
 solid callus. 
 
 Case IV. Joseph Maugrin, a saddler, broke his 
 thigh in the month of July, 1793. A surgeon being 
 called to him, placed his limb in an old form of ap- 
 pai'atus, which did not prevent a shortening, to the 
 the extent of an inch and a half, from showing itself 
 on the following day : hence a new reduction, and 
 a new application of the apparatus : but soon after- 
 wards, another shortening; the same means to 
 
257 
 
 remove it; the same failure of means. Weary of 
 such trials, the surgeon abandoned the limb to its 
 fate, contenting himself with merely keeping it in 
 the apparatus. 
 
 On the twenty -ninth day, Desault being called 
 in consultation, and finding the thigh shorter by three 
 inches than that on the opposite side, proposed per- 
 manent extension, persuaded that this expedient 
 alone would soon be sufficient to re-establish the 
 contact of the fragments. The proposal was acceded 
 to. On the day following, the effects were already 
 perceptible; the thigh was lengthened by almost an 
 inch. By the sixth day, it was equal in length to the 
 other : during this period, the extending rollers were 
 tightened twice a day. 
 
 At the end of two months the consolidation was 
 complete, and the patient walked perfectly well, ex- 
 cept that there was a little shortening of the limb, 
 trifling though indeed, compared to wliat would have 
 been the consequence, had the original treatment 
 been continued. 
 
 76. The lengtliening of the limb, in these cases, 
 was evidently owing to the continued action of the 
 apparatus, which effected, in a length of time, what 
 the momentary eflPorts of the surgeon could not ac- 
 complish. This it did, by destroying or gradually 
 lengthening the medium of union, which already 
 connected the overlapping fragments, by that means 
 bringing their separated surfaces or ends into contact, 
 and almost restoring to the bone its primitive form. 
 
 Art cannot always, with certainty, command such 
 success, and perhaps, even at a less advanced period, 
 
 34 
 
258 
 
 a more rapid progress of reunion might leave but lit- 
 tle ground for hope. But, could only an inch in length 
 be gained by permanent extension, would it not be 
 proper to have recourse to it, particularly as no in- 
 convenience can result from the trial? To prevent 
 deformity altogether, is the first object of art ; 
 but when that c^inot be attained, to lessen it is the 
 second. 
 
 FRACTURES OF THE UPPER END OF 
 THE OS FEMORIS. 
 
 The history of fractures of the upper end of the 
 OS femoris, includes, 1st, Those of the great trochan- 
 ter: 2dly, Those of the neck. These fractures, 
 sometimes existing together, and at other times 
 separately, are very different with regard to the fre- 
 quency of their occurrence: the one taking place 
 very rarely, has but slightly engaged the attention of 
 practitioners, who have multiplied their researches 
 with regard to the other, particularly in late years, 
 
 FRACTURES OF THE GREAT TRO- 
 CHANTER. 
 
 OF tH£ VARIETIES AND CAUSES. 
 
 17, Fractures of the great trochanter are the effect 
 either of falls on that protuberance, or of the action 
 of bodies striking against it. Oblique or transverse, 
 situated sometimes at its summit, and sometimes at 
 
 ■''m^ 
 
259 
 
 its base, these fractures may be either simple or 
 complicated. They are rendered complicated some- 
 times by splinters and a swelling, as happens when a 
 ball produces the division, and at other times by a 
 fractiu'e of the neck of the bone, an example of which 
 we find in the Journal of Surgery, in the case of a 
 man seventy years of age, who had been long subject 
 to the itch. 
 
 78. Whatever the varieties may be, the fracture 
 will be characterized, 1st, By a facility of moving 
 the great trochanter in every direction, while the pel- 
 vis and the thigh remain without motion : 2dly, By 
 a crepitation, arising from the friction of the divided 
 surfaces against each other: 3dly, By there being no 
 shortening of the limb, when the fracture exists alone : 
 4thly, By the fragments being brought together in 
 abduction, and separated in adduction: 5thly, By 
 the position of the great trochanter being higher and 
 more anterior than natural. The presence of these 
 signs is the more readily perceived, because, being 
 superficially situated, this protuberance can be easily 
 felt, and yields to the motions impressed on it. 
 
 §XI. 
 
 OF THE REDUCTION, AND THE MEANS OF RE- 
 TAINING IT. 
 
 79. The reduction is effected, by pushing the 
 separated fragment in the direction opposite to that 
 of its displacement, by bringing it to its natural level, 
 and, in certain cases, by moving the thigh a little 
 outwai'ds; it is retained bv means of some com- 
 
260 
 
 presses placed by its sides, and secured by a roller 
 directed obliquely from the sound hip towards that 
 part, of the thigh corresponding to the fracture, and 
 representing a true spica bandage. 
 
 80. A fracture produced by a gun-shot wound, 
 always renders large incisions necessaiy, for the pur- 
 pose of extracting foreign bodies, and relaxing the 
 aponeurosis of the fascia lata, which suffers too great 
 a degree of tension in this place, and might, if not 
 dilated, produce a very troublesome stricture. A 
 fracture complicated by splinters, but without an ex- 
 ternal wound, and produced by a body striking against 
 the part, seldom requires any particular apparatus, 
 because, adhering as yet to the periosteum, the se- 
 parated portions of the os femoris may unite again, 
 either among themselves, or with the fragments. 
 
 FRACTURES OF THE NECK OF THE OS 
 FEMORIS. 
 
 §xn. 
 
 OF THE CAUSES. 
 
 81. The neck of the os femoris, being surround- 
 ed by a large mass of soft parts, and protected by the 
 great trochanter, which forms its external boundary, 
 is almost completely secured from the immxcdiate ac- 
 tion of external bodies, and consequently from direct 
 fractures. Whenever it sustains a fracture, it is al- 
 ways by a true counter- stroke, resulting' from a fall, 
 sometimes on the great trochanter, and at other times 
 
261 
 
 on the sole of the foot or the knee. But fractures 
 produced in the first mode, are much more frequently 
 met with in practice, than those produced in the se-. 
 cond, doubtless because, in the latter, the motion is 
 weakened by the extent of parts through which it is 
 distributed, previously to its amval at . the neck of 
 the OS femoris. Out of thirty observations made by 
 Desault, on fractures of this description, twenty-four 
 of them were produced by falls on the side. All those 
 recorded by Sabatier, in his interesting memoir, ap- 
 pear to have been produced by similar falls. 
 
 § XIII. 
 
 OF THE VARIETIES. 
 
 82. Fractures of the neck of the os femoris may 
 occur, 1st, in the middle part of it, where it is small- 
 est, and where nature has not thrown together, as she 
 does irl the middle of the long bones so often exposed 
 to fractures, a great quantity of compact substance : 
 2dly, at its upper end, where it is united to the head 
 of the bone : 3dly, at its junction with the great tro- 
 chanter, where the solution of continuity may be out- 
 side of the joint, a circumstance which doubtless 
 happens much more frequently than has been hitherto 
 suspected. 
 
 83. The division, rarely oblique, is almost always, 
 transverse : sometimes, in the latter case, the neck 
 remains enclosed or imbedded, as it were, in the body 
 of the bone, being fractured in such a way, as to pre- 
 sent a hollow or notch of greater or less depth. Seve- 
 ral cases of this kind occurred to Desault; one of 
 
^62 
 
 them, modelled in wax, is deposited in the collection 
 of the School of Health, and the original preparation 
 is in my possession. The fi-acture, though frequently 
 simple, is sometim.es complicated with that of the 
 great trochanter. 
 
 Case V. A man having received a kick from a 
 horse, on the external and upper part of the left thigh, 
 fell down, and, not being able to move, was carried 
 home. Desault being called to him, discovered, 1st, 
 that the great trochanter, separated from the bone, 
 yielded readily to every impression it received : 2dly, 
 tliat the limb was perceptibly shortened; that the 
 least effort was sufficient to restore to it its natural 
 length; and, that the foot was turned outwards, all 
 which are characteristic signs of a fracture of the neck. 
 
 ^ XIV. 
 
 OF THE SIGNS. 
 
 €4. Whatever may be the mode and place of the 
 fracture, its diagnosis presents difficulties which ex- 
 perience and habit may doubtless overcome, but 
 which t(;>o frequently puzzle and embarrass the most 
 enlightened practitioner. Let us endeavour to dimi- 
 nish them somewhat, by tracing, in their order of 
 succession, the symptoms which characterize the 
 accident. 
 
 85. At the time of the fall, a sharp pain is felt; 
 sometimes a report is plainly heard ; a sudden inabili- 
 ty to move the limb occurs; the patient cannot rise, 
 a circumstance, however, which does not always take 
 place. A case is recorded in the fourth volume of the 
 
263 
 
 Memoirs of the Academy of Surgery, where the pa- 
 tient walked home after the fall, and even rose up on 
 the following day. Some examples of a similar na- 
 ture fell under the notice of Desault, one of which he 
 has recorded. The interlocking of the two fragments 
 formerly mentioned (83), may serve to explain this 
 fact, which is, however, in general, very rare. 
 
 86. A shortening almost always occurs in the 
 broken limb, but this is more or less perceptible, 
 according as the extremity of the fragments is retain- 
 ed by the capsule, or as, the division being without 
 die cavity, no resistance is made to their displacement. 
 The muscular action, di'awing the lower fragment 
 upwards, and the weight of the trunk, pushing the 
 pelvis and th6 superior fragment downwards, furnish 
 here, as in fractures of the body of the bone, the two- 
 fold cause of this shortening. I will not repeat what 
 has been already said on this subject (10... 14); I will 
 only observe, that, in the present case, the influence 
 of the muscles is even more considerable, because^ 
 the lower fragment being much longer, is of course 
 attached to a greater mass of muscular fibres. A 
 slight effort is sufficient, in general, to remove this 
 shortening, which, however, soon returns, when the 
 effort ceases. This circumstance Goursault and Sa- 
 batier have observed, not to occur in certain cases, 
 till some time after the accident. A tumefaction ap- 
 pears in the anterior and upper part of the thigh, 
 almost always proportioned to its shortening, of which 
 it appears to be the effect. 
 
 87. The projection of the great trochanter is al- 
 most entirely removed. That protuberance, being. 
 
264 
 
 directed upward and backward, is approximated to 
 the spine of the ilium. But if it be pushed in the op- 
 posite direction, it readily yields, and then, returning 
 to its proper level, allows the patient to move the 
 thigh. 
 
 88. The knee is a little bent. A severe pain 
 always accompanies the motions of abduction, when 
 they are communicated to the limb. If, while the 
 hand is applied to the great trochanter, the limb be 
 made to rotate on its axis, this bony protuberance 
 is perceived to turn on itself as on a pivot, instead 
 of describing, as it does in its natural state, the arch 
 of a circle, of which the neck of the os femoris is the 
 radius. This sign, which was first observed by 
 Desault, is very perceptible, when the fracture is at 
 the root of the neck, less, when it is in the middle, 
 and very little, when it exists tQwards the head of the 
 bone ; these are circumstances, the cause of which it 
 is unnecessaiy to unfold. In rotatory motions, the 
 lower fragment, rubbing against the upper one, pro- 
 duces a distinct crepitation, a phenomenon which 
 does not however always occur. 
 
 89. The point of the foot is usually turned out- 
 wards; a position which Sabatier, Bruninghausen, 
 and most other practitioners regard as a necessary 
 effect of the fracture, although Ambrose Pare and 
 Petit have borne witness that it does not always 
 exist. Two cases, reported on this subject by cele- 
 brated surgeons, have been thought unfounded by 
 Louis, who has attributed them either to an error in 
 language, or a mistake of the transcriber. But the 
 practice of Desault has fully confirmed their possibi- 
 
265 
 
 lity. The first patient whom he had under his cai^e, 
 at the hospital of Charity, after he was appointed 
 surgeon in chief, laboured under a fi^acture which 
 presented this phenomenon. Many other examples 
 occurred to him afterwards, and he believed it might 
 be laid down as an established principle, that, in 
 fractures of the neck of the os femoris, the direction 
 of the foot outwards is to that inwards as 8 to 2. 
 
 90. The common opinion is, that this direction 
 outwards is to be attributed to the muscles that 
 perform rotation. But, were that the case, 1st, it is 
 evident that it would always exist: 2dly, all the 
 muscles running from the pelvis towards the trochan- 
 ter, except the quadi'atus, ai-e in a state of relaxation, 
 in consequence of the approximation of the os femo- 
 ris to their points of insertion : 3dly, muscles in a 
 state of contraction would not allow the point of the 
 foot to be drawn so easily inwards. Is it not more 
 probable, that the weight of the part draws it in the 
 direction in which it is usually found. 
 
 91. From the foregoing considerations, it follows, 
 that none of the signs of a fracture of the neck of 
 the OS femoris, is exclusively characteristic, that the 
 whole of them, taken separately, would be insuffi- 
 cient, and that it is their assemblage alone which can 
 throw on the diagnosis that light which is oftentimes 
 w^anting to it, even in the view of able practitioners. 
 But after all, in the present case, as in every other 
 one, should any doubt exist, it is right to take the 
 safe side, and apply the apparatus, which is indeed 
 useless but not dangerous if the disease does not 
 
 exist, but indispensably necessary if it does. 
 
 35 
 
266 
 
 OP THE PROGNOSIS. 
 
 92. The existence of a fracture being ascertained, 
 what prognosis is to be formed respecting it? In an- 
 swer to this general question, it will be sufficient, I 
 think, to resolve the following paiticular ones. What 
 accidents accompany the fracture in the first instance? 
 What phenomena make their appearance during its 
 reunion? In what manner does it affect the patient, 
 as to his power of Avalking, after reunion has taken 
 place. 
 
 93. If we attend to the opinion of authors, on 
 this fracture, we will find that they represent it in 
 very dismal colours, as if it were necessarily produc- 
 tive of the most serious effects. Inflammation of 
 the parts adjacent to the neck of the os femoris, nu- 
 merous and repeated abscesses arising from this 
 inflammation, propagating themselves externally and 
 communicating with the interior of the joint, gan- 
 grene itself, as Morgagni remarks in a particular 
 case, convulsions of the limb, an cedema occurring 
 in it, and a slow fever destroying the patient by de- 
 grees ; such is the dismal catalogue of misfortunes, 
 generally considered as necessarily attendant on the 
 kind of fracture under consideration. Bruninghausen 
 remonstrated against this fatal prognosis of authors, 
 and Siebold, one of the most celebrated German 
 practitioners, among a great number of cases that 
 fell under his care, had no such accidents to en- 
 counter. Desault never experienced them. Doubt- 
 
267 
 
 less they are prevented by our more exact and more 
 skilful modes of treatment. It is thus that under a 
 more judicious treatment, fractures of the olecranon 
 and of the rotuia, are no longer marked with those 
 terrible consequences formerly attributed to them. 
 
 94. In as much as the organization of the os fe- 
 moris, is nearly the same in its neck and in its body, 
 it is difficult to conceive how the progress of nature 
 can be diflPerent in fractures of these two parts ; why 
 the first, in being denied the power of healing or 
 reunion should be, in this respect, distinguished from 
 all other living parts of animals, which ai'e particularly 
 characterized by that power, when they have sustain- 
 ed a solution of continuity. Many practitioners, even 
 at the present day, advocate this doctrine, which is 
 built, one while, on the circumstance of the perios- 
 teum not being continued along the neck of the os 
 femoris; another while, on a belief that the head of 
 this bone cannot receive a sufficiency of nourishment 
 for the work of consolidation, in consequence of being 
 attached to the rest of the system, only by the round 
 ligament, and again, on an opinion, that the synovial 
 fluid, by wetting tlie divided surfaces, prevents their 
 reunion. 
 
 95. But is the periosteum the only agent in the 
 formation of callus? Modem experience has refuted 
 this opinion, which, like many others, will therefore 
 in a short time exist only in the history of our errors. 
 Were it even true that the periosteum is here indis- 
 pensably necessary, is not its place supplied by the 
 fold of the capsule, which suiTounds both the head 
 and neck of the os femoris? Besides, why cannot 
 
268 
 
 callus be formed by that part which has had sufficient 
 power to accomplish ossification, since it is univer- 
 sally acknowledged, that, in these two processes, the 
 labour of nature is nearly the same. 
 
 96. The head of the bone, separated from the 
 soft parts, and attached to the acetabulum by the 
 round ligament, always receives through that liga- 
 ment a sufficiency of nutriment to enable it to live in 
 that cavity ; for, there is no instance of its having suf- 
 fered mortification in consequence of a fi-acture. 
 Why, then, should it not partake of the properties of 
 life, and particularly of the faculty of reunion when 
 placed in regular apposition with the body of the 
 bone? 
 
 97. What shall we say respecting the idea of the 
 synovia wetting the divided surfaces, and by that 
 means preventing their reunion? The history of frac- 
 tures communicating with joints, better known at the 
 present day, answers this objection, which is indeed 
 nothing but the offspring of mere hypothesis. To 
 these considerations, which are dictated by reason, 
 and to which many more might be added, let us unite 
 the proofs derived from experience, and we will find 
 numerous examples of cures actually performed, par- 
 ticularly in latter times; the truth of this is attested 
 by many cases collected by Desault, both at the hos- 
 pital of Charity and the Hotel-Dieu. Bruningaushen 
 and Sieboid, have had equal success. Many analo- 
 gous facts have been presented to the Academy of 
 Surgery. In the cabinet of the School of Health, are 
 deposited some preparations obtained from the cabi- 
 net of Desault, calculated to remove all difficulties and 
 doubts from this subject. 
 
269 
 
 98. Wc must acknowledge, however, that in per- 
 sons advanced in years, the cure is always difficult, 
 often very tedious, and sometimes impracticable, 
 however carefully the treatment may be conducted. 
 But this 'is only a necessary consequence of the laws 
 of ossification, which, constantly accumulating in the 
 bones too great a quantity of calcareous matter, 
 seems to deprive them by degrees both of life and all 
 its properties. Yet Lesne laid before the academy a 
 case of reunion obtained in a subject at the advanced 
 age of eighty-four. 
 
 99. The observations of some modem practi- 
 tioners seem to prove, that the reunion here is not 
 produced by a substance similar to common callus, 
 but by a kind of ligamento- cartilaginous tissue, in 
 like manner as in the rotula, and the olecranon. But 
 why need we inquire after the means employed by 
 nature? those of art must be the same. It will be 
 always necessary to favour the reunion, by bringing 
 the fragments into contact, and maintaining them so. 
 Without this contact, either a cure will never be ob- 
 tained, or the substance destined to effect a reunion, 
 becoming deformed and too bulky, wall impede mo- 
 tion. 
 
 100. Lameness has been long considered as the 
 inevitable consequence of fractures of the neck of the 
 OS femoris. Ludwig, professor of surgery at Leipsick, 
 has particularly advocated this opinion, which is 
 supported by Sabatier, and Louis, who considered 
 the total destruction of the neck of the bone, as the 
 cause of the lameness. But few such examples are to 
 be found on record. Ruisk has p'iven an enffravins^ of 
 
270 
 
 one. Lameness v/hen it does take place, depends, as 
 it does in oblique fractures of the body of the bone, 
 on the overlapping of the fragments, to "vvhich no 
 opposition has been made; so that the insufficiency 
 of our means, and not the nature of the disease, gives 
 rise to tliis accident, v/hich Desault seldom expe- 
 rienced in his practice. 
 
 101. Fromx what has been said, it appeal's, that, 
 in all respects, authors have given a much more un- 
 favourable prognosis in fractures of the neck of the 
 OS femoris than facts and the nature of the affection 
 will justify, that the progress of these fractures is 
 the same with that of all others, and that, when treat- 
 ed with equal skill, there is no reason why their 
 termination should not be equally favourable. 
 
 §.XVI. 
 
 OF THE REDUCTION AND THE MEANS OF MAIN- 
 TAINING IT. 
 
 102. Reduction, in this case, is attended in 
 general with but little diflicult3\ The patient, lying 
 on his back, is held under the arm-pits, and by the 
 upper part of the pelvis, by assistants who make 
 counter- extension in this "^v^ay, without being obliged 
 to pass, as recommended by the Academy of Sur- 
 gerv, a strap under the affected thigh (30). Another 
 assistant makes extension, according to the method 
 formerly described (29), drawing the point of the 
 fragment very gradually in the direction opposite to 
 that which it has taken in becoming displaced, and 
 making the thigh at the same time rotate a little on 
 
271 
 
 its o^vn axis. This gentle rotation renders success 
 more certain. 
 
 103. If things be properly arranged, a slight effort 
 is sufficient to bring the separated fi-agments into 
 contact and to restore to the limb its natural form ; 
 for, as I have already observed (86), a facility of 
 reduction is even one of the characters of this frac- 
 ture. But it is very difficult for art to maintain per- 
 manently what she easily effects at the time of 
 reduction, and on this account, our curative processes 
 ai'e oftentimes insufficient. 
 
 104. These processes may be considered under 
 three classes, according as they relate 1st, to position; 
 2dly, to bandages; 3dly, to the forms of apparatus 
 for making permanent extension. 
 
 In the first class must be included the method 
 of Foubert, employed in ancient times, according 
 to Louis, and which consists in placing the patient 
 on a horizontal plain, while the limb is secured by 
 simple splints, and the foot by a kind of shoe. But 
 in a short time the muscular action, to which no 
 resistance whatever is made, draws the lovv'er frag- 
 ment upwards, while the weight of the body pushes 
 the pelvis downwards, and along with it the superior 
 fragment. Hence a new reduction, the effect of 
 which is again immediately destroyed as at first. 
 Thus are new displacements succeeded by new re- 
 placements throughout the w^hole course of the 
 treatment. 
 
 105. This method, almost universally adopted 
 in latter times, and appro\'ed of by Louis, was in 
 vogue at the hospital of Charity, when Desault en- 
 
 c 
 
272 
 
 tered it. Ought we then to be sui*prised, that the 
 fracture was considered as incurable? Here indeed 
 the plainest and most important indication is evident- 
 ly disregarded. Nothing to retain the fragments in 
 apposition, nothing to prevent them from being con- 
 stantly moved. Does not the method of Foubert 
 very closely resemble those experiments, in which, 
 the bone of an animal is broken intentionally, and 
 then to prevent a reunion and form an artificial 
 joint, the fragments are kept inconstant motion? 
 
 106. Will any better success attend the method 
 of securing the leg, as Dalechamp recommends, to 
 the foot of the bed? In such a case the trunk and 
 the pelvis glide down along the inclined plain made 
 by the pressure of the nates (14), and hence a con- 
 stant cause of the shortening of the limb. 
 
 107. The second class of curative means, includes 
 different forms of apparatus simply retentive. Pare, 
 Petit, and Heister, recommend, as most useful, the 
 Spica of the groin.* But what effect can this pro- 
 duce ? What force applied in that part can keep the 
 lower fragment down, and the pelvis up, secure the 
 immobility of the hmb, and prevent its rotation out- 
 wards? If the bandage be tight, it will compress the 
 muscles unequally, make them contract, and tlius 
 become the cause of a contraction or shortening of 
 the limb. In some respects, there is more advantage 
 to be derived from the tin case lined with cloth on 
 its inside, which Fabricius of Hilden applied to the 
 external part of the thigh ; a method which has been 
 
 * Le Sjiica de I'aine. Trans. 
 
273 
 
 renewed since his time, by certain celebrated practi- 
 tioners of Germany ; from the pasteboard case pro- 
 posed by Duvemey as a substitute for that of tin ; 
 from the retentive plaster* of Buffle employed like- 
 wise by Arnaud; and from the splints adopted by most 
 practitioners. But can these means, (so differently 
 varied in form, yet still the same in their action), while 
 they prevent displacement laterally or in the cross- 
 direction of the bone, prevent it also in the longitudi- 
 nal direction, which latter ought to be the principal 
 object in view? Will they miake any resistance to 
 the muscular action? See what has been already said 
 on splints, bandages, &c. (89.. ..95), 
 
 108. The insufficiency of these forms of appara- 
 tus, arises from their not being constructed with a 
 prbper view or reiference totlie general principle that 
 ought to be observed in the treatment of every frac- 
 ture; namely ,^ that the means intended to prevent 
 displacement, ought to be founded on the causes that 
 produce it. But, these causes here, are, 1st, The ac- 
 tion of the muscles which draw the lower fragment 
 upwards : 2dly, The weight of the body which pushes 
 the pelvis downwards : 3dly, The weight and direc- 
 tion of the foot and leg, which tend to carry the toes 
 outwards by a rotatory motion. Hence, the threefold 
 indication or end of every apparatus,^ is, 1st, To keep 
 the body of the bone down : 2dly, To retain the pel- 
 
 * fL'ecusson.J The literal meaning o£ this word is an es- 
 cutcheon, or a coat of arms. But when used in surgical lan- 
 guage, it signifies a retentive or strengthening plaster. Such I 
 conceive its meaning to be in the present instance. 
 
 Trans. 
 36 
 
274 
 
 vis up : and 3dly, To secure the foot nearly in a 
 right line with the leg. 
 
 109. The first consideration leads us naturally to 
 the second. The means destined to fulfil this threes 
 fold indication, must be constant in their action, 
 since the causes which they have to combat act with- 
 out remission. Hence the necessity of an apparatus 
 for permanent extension. See what has been said ott 
 the nature of this expedient (46.... 51), on the differ- 
 ent modes of effecting it (52.... 57), and particularly 
 on the mode pursued by Desault (5 8.... 70). 
 
 1 10. The mechanism of his apparatus for perma- 
 nent extension is the same here as in fractures of the 
 body of the bone. The limb is secured against a 
 strong splint, to the two ends of which t^ro rollerSy 
 nmning one from the pelvis, and the other fi-om the 
 foot, are firmly tied. The first of these rollers holds 
 the pelvis up, and the second di'aws the foot down : 
 hence the two first indications are fulfilled. The third 
 is also fulfilled by the extension of the limb, which 
 prevents its rotation outwards, by means of the out- 
 side splint, which passing beyond the sole of the foot 
 keeps it immoveable. 
 
 111. The bandage of strips and compresses, 
 which in fractures of the body of the bone, are pre- 
 viously applied round the limb, and oppose in some 
 measure its motions laterally, are here entirely use- 
 less. Being all indeed applied on the lower fragment, 
 what purpose could they answer towards fixing it 
 against the upper one ? They could do nothing but- 
 compress the muscles, and by that means diminish 
 their power of contraction : but extension alone pro- 
 
S7S 
 
 duces this effect. Desault rejected the bandage alto- 
 gether, and contented himself with the use of spHnts 
 and bolsters, as appears frora the following case re- 
 ported by Couteau. 
 
 Case VI. Maria Nof, as she was running on 
 the ice, in the severe winter of 1788, slipped, and 
 laUing on the great trochanter, fractured the neck of 
 the OS femoris. She was immediately carried to the 
 Hotel-Dieu, where the signs formerly mentioned 
 (60.... 66) disclosed at once the nature of her disease. 
 The shortening of the limb was less than in ordinary 
 cases. 
 
 The apparatus was applied in the following man- 
 ner. The junk-cloth, the body-bandage, and the bits 
 of tape, were laid on the bed, in the order already 
 mentioned (60) : the patient was then placed in such 
 a manner that the affected thigh corresponded exact- 
 ly to the middle of them. The reduction being 
 eflPected, the two splints were applied, one on the ex- 
 ternal and the other on the internal side of the limb ; 
 on each side, and along the anterior part of the thigh, 
 the bolsters were laid: three bits of tape for the leg, 
 four for the thigh, and the body-bandage for the 
 pelvis, served to secure the splints. One end of a 
 roller, which had been previously fixed on the upper 
 side of the foot, passing through the mortise on the 
 external splint, and being tied to the other end Vv^hich 
 passed thi'ough the hollow or notch, produced exten^ 
 sion, while counter-extension was made by means 
 of another roller directed obliquely from the tubero- 
 sity of the ischium over the superior part of the same 
 splint, which it drew downwards. This w^as the same 
 
276 
 
 apparatus formerly described (60.... 66), ^cept as 
 to the bandage of strips, the compresses, and the an- 
 terior splint, which running only from the fold of the 
 groin, had no effect in retaining the fragments. 
 
 The. treatment was simple. No general disease 
 of the system existing, the patient returned, in a few 
 days, to her usual regimen. Being visited every day, 
 the appai'atus was frequently tightened; and was re- 
 newed six times at different intervals. 
 
 A bilious disposition shewed itself on the seven- 
 teenth day. This was removed by an emetic given in 
 solution, and after this nothing remarkable occurred. 
 On the fifty-second day the state of the parts was ex- 
 amined. The consolidation was almost accomplished? 
 by the sixtieth day it was complete, and the patient 
 was discharged a few days afterwards, experiencing 
 only a slight degree of lameness. 
 
 §XVIL 
 
 OF TH£ SUBSEQUENT TREATMENT. 
 
 112. It is more essential here than in fractures of 
 the body of the os femoris, to keep up extension with 
 the utmost exactness, because, in the present case, a 
 much greater number of muscles being attached to 
 the lower fragment, very gi-eatly augment the powers 
 tending to displace it» Hence the necessity of exa- 
 mining the apparatus every day, to see whether or not 
 any shortening of the limb has occurred, to tighten, 
 if they be relaxed, the rollers that make extension, 
 and to renew the application of the whole, if it be in 
 any measure deranged. 
 
277 
 
 113. The proper treatment here, as well as io 
 most other fractures, consists more in these atten- 
 tions, taken collectively, than in the use of internal 
 means. It is to the want or neglect of such attentions, 
 that we ought to attribute the little success obtained 
 by many surgeons from the bandage of Desault. 
 
 Case VII. A man, having fractured his thigh by 
 a faU, called in a surgeon, who, reducing the fracture, 
 and retaining it by this bandage, examined the state 
 of the parts every day, and finding no derangement of 
 the splints, neglected attending to the rollers destined 
 for making extension. Seventh day, a shortening of 
 two inches; a new reduction, and a new application 
 of the bandage ; the same want of attention as before ; 
 the same shortening at the expiration of a few days; 
 the means were then rejected, and declared, in a pub- 
 lication, to be insufficient. How often do processes 
 and modes of practice of great utility, by being trans- 
 mitted from person to person, or from book to book, 
 lose at length, that credit they are entitled to, and that 
 approbation which they ought to command ! 
 
 114. Serious accidents so seldom accompany 
 fractures of the neck of the os femoris, that there is 
 no necessity of employing numerous means to remove 
 them. A diet somewhat strict for a few days, dilut- 
 ing drinks, and then a return to the patient's usual 
 mode of living, unless something besides the fracture 
 should forbid'it, constituted the simple treatment pur- 
 sued by Desault in common cases. Any varieties 
 resulting from accidental circumstances, must fall 
 under the general treatment of fractures. 
 
278 
 
 115. The period necessary for the healing of frac- 
 tures of the neck of the os femoris, is represented by 
 most authors as being longer than the term required 
 in other similar affections. We read, in the Memoirs 
 of the Academy of Surgery, that oftentimes the cure 
 is not complete in less than three or four months. 
 The reason of this will be evident, if we consider, on 
 the one hand, that the reunion is always more tedious, 
 in proportion as the contact of the fragments is more 
 frequently interrupted : and, on the other, that, in the 
 means formerly employed, there was nothing opposed 
 to the powers of displacement. Hence it follows, that, 
 if skilfully treated, this fracture ought to follow nearly 
 the same course with others. It is this that confirmed 
 the superior excellence of the practice of Desault, 
 who almost always obtained a cure, all other things 
 being equal, such as age, strength of constitution, &c. 
 in the space of forty-five or fifty-five days. 
 
 116. We discover, in general, that the cure is 
 complete, from a disappearance of the signs of the 
 fracture, more particularly from the motions of the 
 great trochanter, in which circumduction* succeeds 
 to rotation on its own axis, when the limb is made to 
 move on itself, that is, to rotate oatwards or inwards. 
 The power of standing and Vvalking is an infallible 
 evidence of this reunion; nor are these exertions 
 practicable, till the expiration of some time after it is 
 completed; this circumstance is owing to a stiffness 
 remaining in the parts around the joint, occasioned 
 hy long extension and a want of motion, and which 
 
 * A motion or sweep describing the arch of a circle. Trans-, 
 
279 
 
 exercise alone can effectually remove* (See what lias 
 been already said on this subject, in several parts of 
 this work.) 
 
 117. Numerous cases may be adduced in favour 
 ©f the doctrine laid down in this memoir. But a suf- 
 ficient number have been already published in the 
 Journal of Surgery. I shall subjoin only two, drav^^n 
 up by Manoury and Seveille. 
 
 Case VIII. Maria ***, aged forty, falling on 
 the great trochanter, experienced a sudden pain, and 
 heard a considerable report : she rose, however, and 
 with difficulty made her way home. On the day fol- 
 lowing, a shortening of an inch was perceived in her 
 tliigh : the great trochanter was drawn backward and 
 upward: walking was now impracticable, the foot 
 remained turned inwards. Notwithstanding: this lat- 
 ter circumstance, Desault, being called to the patient, 
 declared that a fracture existed, which was evidenced 
 in particular by a rotatory motion of the great tro- 
 chanter on its own axis. The necessary apparatus 
 being applied, was carefully e]stamined eveiy day by 
 Manoury, to whom the patient was intrusted. No 
 shortening of the limb occurred, nor did any unfa- 
 vourable accident supervene, and, by the thirty-ninth 
 day, the fracture was exactly and firmly united ; on 
 the forty -third, the splints were removed ; and on the 
 fiftieth, the patient could walk without assistance. 
 
 Case IX, John Rignal fractured the neck of the 
 OS femoris by falling, not as in the preceding case, 
 on the great trochanter, but on the knee, which was 
 bent at the time of the fall, while the shoulder of the 
 same side supported a heavy load. He was brought 
 
280 
 
 to the Hotel-Dieu, where the same signs, as m the 
 preceding case, (except that here the foot was turned 
 inwards) furnishing ground for the same diagnosis, 
 gave rise to the same treatment, which, in fifty days, 
 was followed by a result equally favourable. 
 
 FRACTURES OF THE LOWER EXTRE- , 
 MITY OF THE OS FEMORIS. 
 
 118. The lower extremity of the os femoris, be- 
 ing thicker than the rest of the bone, and protected 
 from the action of external bodies by a thinner cover- 
 ing of soft parts, is yet better secured from fractures 
 than the other paits, for the following reasons : 1st, 
 because counter-strokes, so frequently the cause of 
 fi-actures of the body and neck of the bone, can affect 
 this part but rarely : 2dly, because the os femoris, 
 being more moveable at a distance from the centre 
 erf its motions, yields more easily to whatever strokes 
 and impressions it there recieves: 3dly, because 
 motion, when distributed through a greater bulk of 
 matter, has less power to destroy its continuity. 
 
 § XVHI. 
 
 OF THE VARIETIES AND THE CAUSES. 
 
 119. The fractures which occur in the lower 
 extremity of the os femoris, ai'e of two kinds very 
 different from each other. Sometimes situated above 
 the condyls, they only separate these from the body 
 of tlie bone: at other times, affecting the condyls 
 
281 
 
 themselves, they extend into the very joint. My 
 attention shall at present be confined exclusively to 
 the latter kind, as the other may, in almost every 
 respect, be classed with the fractures which have 
 been already considered. Most authors have neglect- 
 ed to treat of fractures of this kind, under a distinct 
 head, from a persuasion, that, owing to their com- 
 munication with the joint, they ought to be ranked 
 among complicated fi-actures, which are known to 
 require a mode of treatment very different from that 
 employed in such as are simple. But I shall pre- 
 sently show what regard ought to be paid to this 
 ancient opinion. 
 
 120. The division presents itself, in general, 
 under two different forms: 1st, runfting obliquely 
 frpm above downwards, and from within outwards 
 or from without inwards, it may separate a greater 
 or smaller portion of one of the condyls from the 
 rest of the bone : 2dly, these two bony protuberances 
 may be divided from each other by a longitudinal 
 fracture, meeting another transverse or oblique frac- 
 ture, which by either passing through the whole 
 tliickness of the bone, separates botii condyls from 
 it, or extending only half way through it, separates 
 but one of them. The fracture is single in the 
 first case, but double in the second.. The latter 
 occurs in practice more frequently than the former^ 
 Both are usually produced directly, that is, by the 
 immediate action of external bodies. Yet the follow- 
 ing fact seems to evince that the accident may,, 
 possibly at least, arise from a counter stroke. 
 
 37 
 
282 
 
 Case X. The corpse of a man of forty, was 
 brought into the amphitheatre of Desault, soon 
 after he became a pubhc teacher. One of the pupils, 
 on preparing to dissect the body, discovered a pre- 
 ternatural mobility in one of the condyls. The knee 
 was examined. A double fracture was found, ac- 
 companied by a separation of the two condyls. On 
 inquiry it was ascertained that the corpse came from 
 the Hotel-Dieu. It was further discovered, with 
 certainty, that the injured subject, in jumping 
 tlii'ough a window, had alighted on his feet, and 
 that he experienced instantly a severe pain in his 
 knee, and fell on the ground, unable to support 
 himself. 
 
 Here, no doubt but the condyls, by being vio, 
 lently pressed between the weight of the body and 
 the articulating surfaces of the tibia, had been frac- 
 tured by a counter-stroke. 
 
 § XIX. 
 
 OF THE SIGNS. 
 
 121. But whatever may be the precise form and 
 figure of the fracture, its signs are easily compre- 
 hended: a very perceptible separation oftentimes 
 exists between the two condyls, increasing the trans- 
 verse diameter of the knee. The rotula, sinking 
 into this chasm between the condyls, renders the 
 part more fiat from before backwards, than it is in 
 its natural state. If the rotula be pressed in a back- 
 ward direction, the condyls are separated still further 
 from each other. If, on the other hand, pressure be 
 
283 
 
 made on each side t)f the lower part of the os femo- 
 fiis, the condyls are brought together, and the knee 
 resumes its usual shape. If we take hold of a con- 
 dyl in each hand, it will be easy, by moving them 
 alternately backward and forward, to make them 
 rub against each other, and produce a crepitation, 
 which characterizes the fracture beyond a doubt. 
 
 122. If the upper fracture be oblique, a shorten- 
 ing of the limb more or less perceptible is always 
 the effect of it : this appears to be principally owing 
 to the weight of the body which pushes the upper 
 fegment down, and to the action of the muscles 
 which draws the lower ones up (10.... 14). In this 
 case, the superior fragment, being forcibly pushed 
 against the integuments, has sometimes lacerated, 
 and even passed through them, giving rise to con- 
 sequences of a serious nature. Desault has publish- 
 ed a case of this kind. A similar effect has been 
 produced, though more rarely, by the inferior frag- 
 ment, in which case much mischief has arisen from 
 tlie admission of air into the joint. 
 
 123. Sometimes when tJie upper fracture extends 
 through the whole thickness of the os femoris, the 
 Extremity of the bone is turned round, so that the 
 external condyl lies behind, the internal before, and 
 the rotula on the outside, while the foot points in 
 the same direction. A case of this kind is recorded 
 in the Journal of Surgery. The body of the bone, 
 being pressed into the chasm or interval between 
 the two condyls, may prevent their reunion, by 
 pushing them asunder, and thus gi^'e rise to various 
 accidents. 
 
284 
 
 124. Most of these phenomena will fail to occur, 
 if the upper division, passing only half way through 
 the bone, break off but one of the condyls, or if^ 
 passing tlirough even the whole of the bone, it be 
 perfectly transverse; but cases of this, description 
 are seldom met with. 
 
 §XX. 
 
 OF THE PROGNOSIS. 
 
 125. I have httle to add to the observations 
 already made on the prognosis in fractures of the 
 condyls of the os humeri. All that I have there 
 said is applicable to the os femoris. As is the case 
 with regard to the former fractures, so also here, 
 die apprehensions of authors have been greatly ex- 
 aggerated by their visionary doctrine respecting in- 
 juries of the joints : both reason and experience unite 
 in showmg such apprehensions to be unfounded. 
 
 I shall only observe, that in the present case, 
 even more particularly than in fractures of the con- 
 dyls of the OS humeri, most of the unfortunate events 
 that take place, are owing to the insufficiency of the 
 means employed for effecting a cure. Indeed, as I 
 have already observed (45), all those means can 
 have no effect in opposing the continual tendency of 
 the fragments to become displaced, if the upper frac- 
 ture* of the OS femoris be oblique. And in most 
 cases, this fracture is oblique : hence it follows, 1st, 
 
 * That which forms the superior boundaiy of the longi- 
 tudinal fracture by Avhich the condyls ^re separated from each, 
 other^ Trans.. 
 
285 
 
 that the bony points of the fragments being con- 
 stantly pushed, during their displacement, against 
 the ligaments that surround the joint, will perpetuate 
 in them the irritation first produced by the firacture, 
 and thus give rise to swelling,^ inflammation, and all 
 the other morbid affections of the part, so much 
 dreaded by authors, and attributed by them to the 
 mere communication of the fracture with the joint: 
 2dly, that the best expedient to prevent such affec- 
 tions, is an apparatus that shall retain the divided 
 surfaces in perfect contact with each other by means 
 of permanent extension, 
 
 126. It is obvious that this extension wdll be less 
 necessary, if the upper division of the os femoris be 
 transverse, because, then, the condyls and the body 
 of the bone will find a mutual point of support against 
 each other. 
 
 ^ XXL 
 
 OF THE MEANS OF CONTACT BETWEEN THE 
 FRAGMENTS. 
 
 127. Since the same caTises, as in the preceding 
 cases, tend here to destroy this contact, when the su- 
 perior fracture is oblique (122), the apparatus ought, 
 therefore, to be so constructed as to counteract these 
 causes, that is, it ought, 1st, to draw the two condyls 
 down ,• 2dly, to retain the pelvis up, and with it tlie 
 superior fragment. This twofold indication relates 
 only to the upper division of the bone, without any 
 reference to that which separates the condyls ; 3dly, 
 it is necessary to counteract the tendency which the 
 condyls may have to separate from each other. 
 
286 
 
 128. Penticineiit extension, made in the manner 
 already mentioned (60.... 63), fulfils the two first in- 
 dications ; while two lateral splints, and the bandage 
 of strips fulfils the third. Desault, therefore, applied 
 to this particular case his apparatus for permanent 
 extension, modified only in svich a way, that, instead 
 of terminating at the knee, the bandage of strips was 
 continued to a distance down the leg, in order that its 
 action might be the more efficacious. For, it is well 
 kno^'m, that it is at its middle part that the firmness 
 and retenti\Te power of a bandage are greatest, because 
 the casts of the roller at the upper and lower ends, 
 serve to secure those in the middle. The upper splint 
 being altogether useless, was not employed. 
 
 129. If the superior fracture be transverse, the 
 condyls, as I have already said, meet with resistance 
 against the body of the bone, while they, on the other 
 hand, support it in such a manner, as to prevent it 
 from descending, though pushed by the weight of 
 the body along the inclined plain made by the press- 
 ure of the nates. Here, then, permanent extension is 
 generally useless, and all that is necessary is, to re- 
 tain the cond}' Is and prevent their separation by means 
 of lateral pressure. The same apparatus may still be 
 employed, provided the two rollers for extension be 
 laid aside. 
 
 130o If a wound in the soft paits accompany the 
 fi^acture, whether it be produced by the same cause, 
 or by the subsequent passage of tlie fragments 
 through the integuments, and v^hether it communi- 
 cate with the articulation or not, it is necessar}*, as 
 soon as suppuration has taken place, to renew the 
 
287 
 
 dressings ever}' day or every other day, taking care, 
 in the mean time, to supply, by the hands of an as- 
 sistant, the want of extension by means of the appa- 
 ratus. The following case, extracted from the Jour- 
 nal, exhibits a specimen of the treatment that ought 
 to be adopted in similar cases. 
 
 Case XI. Claudius Legrange, aged thirty-one, 
 and of a sound constitution, was wounded by the 
 kick of a horse, on the internal condyl of the left os fe- 
 moris. The violence of the pain obliged him to throw 
 himself on a heap of straw, that lay at a little distance, 
 and which he reached by hopping on his right foot. 
 The pains were augmented by this, for at each step, 
 the thigh being alternately bent or extended at the 
 injured part, was moved sometimes backward and 
 sometimes forward. The patient was brought to the 
 Hotel-Dieu, a few hours after the accident. 
 
 The signs already specified (121 and 122) an- 
 nounced to Desault, a longitudinal fracture separat- 
 ing the two condyls, and terminated above by another 
 fracture of the body of the bone, which descended 
 obliquely from about five inches above the external 
 condyl, to withm two inches of the internal one. 
 
 The muscles of the thigh, by means of violent 
 contraction, had drawn that portion of the os femoris 
 attached to the external condyl upwards, and the su- 
 perior fragment downwards. The sharp point of the 
 latter had passed through the skin, and produced a 
 wound of an inch and a half in extent, on the inside 
 of the thigh, and a little above the condyl. 
 
 The patient being undressed, was placed on a 
 bed nearly horizontal, on which had been previously 
 
288 
 
 spread the necessary pieces of apparatus, disposed in 
 proper order. Desault then examined the wound, 
 extracted a sphnter of the bone, covered the wound 
 with hnt, and then proceeded to the apphcation of the 
 apparatus which he usually employed in such cases 
 (128). 
 
 The extension was accompanied by no pain : on 
 the other hand, it gave immediate relief: diluting 
 diinks were prescribed. Next day, no pain ; pulse a 
 little raised; no diyness, nor any alteration of the 
 skin ; diet the same as on the preceding day ; the ap- 
 pai-atus wet with vegeto- mineral water. Fourth day, 
 a new^ application of the apparatus, which had become 
 relaxed; appearances of suppuration. 
 
 From this time the dressing was renewed every 
 other day, till the sixteenth, when the wound w^as cica- 
 trized. After this the apparatus was not touched except 
 u^en deranged; it was only wet from time to time with 
 vegeto- mineral water, and great pains were taken to 
 keep up the extension. The apparatus was not laid 
 aside till the sixty-fourth day, although the callus ap- 
 peared to have acquired a state of solidit}^ som^ewhat 
 sooner. 
 
 The patient M^as soon in a situation to take exer- 
 cise. The stiffness then disappeared rapidly, and, in 
 about tliree weeks, he left the hospital, able to bend 
 the leg to a right angle with the thigh, and under a 
 full confidence that he would in a short time regain 
 all the motions of the limb. 
 
289 
 § XXII. 
 
 OF THE SUBSEQUENT TREATMENT. 
 
 131. As soon as the consolidation is complete, the 
 motions of the hmb must commence. These, at first 
 gentle and confined, must be afterwards, increased in 
 extent, and more frequently repeated, till, at length, 
 the limb should be exercised every day for two oi: 
 three hours without intermission. The position and 
 direction of the leg ought to be constantly changed. 
 One while, the thigh should be elevated by a bolster, 
 so as to flex the leg; at another time, the bolster 
 should be fixed under the leg to keep it extended.- 
 The rotula must be moved in every direction, and, 
 as soon as the patient can leave his bed, he should 
 take exercise himself. These precautions ai'e more 
 necessary here than in any other fi^acture, because a 
 stiffness of the parts adjacent to the jomt, is always 
 the inevitable consequence of a long state of rest. 
 Certainly writers would not have considered anchy- 
 losis as the most favourable termination of such fi-ac- 
 tures, had they been acquainted with the effect of ex- 
 ercise and rest in that now under consideration. 
 
 132. Provided the mode of treatment here laid 
 down be faithfully pursued, the affection is seldom 
 accompanied by those numerous accidents, of which 
 so much has been said. The callus is formed in the 
 usual manner: and, on some occasions, where the 
 patients have died at the Hotel-Dieu, in consequence 
 of some affection not connected with the fi-acture, the 
 
 two condyls have been found perfectlv united together 
 
 38 
 
290 
 
 and to the body of the bone. An instance of this kind 
 is recorded in the Journal of Surgery. 
 
 133. Let us, in the mean time, not speak too 
 favourably of that, respecting which the ancients were 
 accustomed to speak too unfavourably. Even the 
 practice of Desault would expose our en'or. Some- 
 times the most assiduous attention, and the most 
 carefiil application of the apparatus, have not been 
 sufficient to prevent abscesses around the knee, and 
 an anchylosis of the joint* Desault related a case 
 where even a caries of the articulating surfaces occur- 
 red. But some extraneous circumstances appeared 
 to have an influence in these instances : and it may be 
 laid down as a general rule, that fractures of the lower 
 extremity of the os femoris, require the same treat- 
 ment with fractures of its other parts » 
 
291 
 
 EXPLANATION OF THE SECOND PLATE.* 
 
 This figure represents the apparatus for permanent 
 extension, employed by Desault in obUque frac- 
 tures of the OS femoris. 
 
 AA. The external splint, with a notch and a mortise 
 in it at the lower end to fix the inferior extend- 
 ing roller. 
 
 BB. A bandage passing round the body, intended to 
 secure this splint against the pelvis. 
 
 CC. The anterior splint, reaching only to the knee. 
 
 dddd. The anterior bolster, extending along the 
 whole limb, and secured by pieces of strong tape. 
 
 EE. A portion of the bandage of strips, seen between 
 the anterior and dac external lateral bolsters. 
 
 FF. The junk-cloth intended to be folded round the 
 two lateral splints. 
 
 g g. The superior extending roller, passing round the 
 end of the external splint, and fixed underneath 
 on the tuberosity of the ischium. 
 
 H. The sub-femoral roller or strap, intended to pre- 
 vent the bandage BB, which passes round the 
 body, from slipping upwards. 
 
 K k. A roller usually passed round the foot, to pre- 
 vent it from turning. 
 
 L. The inferior extending roller, fixed in the mortise 
 and the notch of the external splint. 
 
 * For an account of an improvement of the splint, repre- 
 sented in this plate, projected by Dr. Physick, and now used in 
 the Pennsylvania hospital, see Article IL of the Appendix. 
 
 Trans, 
 
292 
 
 THOUGHTS 
 
 ON LUXATIONS OF THE OS FEMORIS, UPWARD 
 AND FORWARD. 
 
 1. Few kinds of luxation of the os fcmoris 
 occur in practice more rarely than this. Practitioners 
 •who have seen it, and those who, on the authority of 
 others, have described it, without having seen it, have 
 all given an unfavourable prognosis respecting it, for 
 the following reasons: 1st, on account of the inevit- 
 able rupture of the round ligament : 2dly, on account 
 of the distension, and even laceration of the capsule, 
 and of the compression and overstretching of the 
 nerves and blood-vessels: 3dly, on account of the 
 great difficulty of reduction. The following case will 
 prove, that in all these respects, the apprehensions of 
 authors have been exaggerated, that the obstacles to 
 reduction arise less from the nature of the displace- 
 ment, than from the nature of the means employed to 
 remedy it; and that, if properly directed, art would 
 here be as successful as in other cases. 
 
 Case. (Collected by C***). About the close 
 of the winter which preceded the death of Desault, 
 a porter was brought to the Hotel-Dieu, in conse- 
 quence of a fall which he had received about two 
 hours before, in the following manner. As he was 
 canying on his shoulders a heavy burden, his foot 
 slipped, while his leg and thigh were directed back- 
 wai'ds: he fell on his knee, his thigh maintaining 
 still the same direction; so that the conjoined weight 
 of his own body and of the burden which he caiTied, 
 
293 
 
 aided by the velocity of the fall, forcing the head of 
 the OS femoris, which pointed at the time forward 
 and upAvard, against the distended capsule, lacerated 
 it and drove the articulating end through the opening. 
 Continuing still to act, it ruptured the ligament, 
 which connects the extremity of the bone to the ar- 
 ticulating cavit}^, and forced the head in front of the os 
 pubis, where it could be easily felt. 
 
 At the moment of the fall, an acute pain was 
 felt in the part; and the power of moving the limb 
 was suddenly lost; the patient was carried home, 
 where a surgeon who visited him, considered the 
 accident as a fracture of the neck of the os femoris, 
 and sent him to the Hotel-Dieu, to undergo the 
 necessary treatment. 
 
 Desault having examined the parts, discovered, 
 from the following appearances, not a fracture, but 
 a luxation upward and forward. The limb was 
 nearly an inch shorter* than natural; the point of 
 
 * A case of luxation of the head of the os femoris in a for- 
 ward direction, but differing in some respects from the above, 
 occurred lately in the Pennsylvania hospital under the care of 
 Dr. Physick. The doctor reduced this luxation in the amphi- 
 theatre, in the presence of his class, by a process which was 
 also somewhat different from that adopted by Desault. 
 
 In the case of Desault's patient the luxated limb was shorter 
 than the sound one : in that of Dr. Physick's it was evidently 
 longer. This was no doubt owing to the head of the os femoris 
 having, in the former case, passed farther up towards the supe- 
 rior rim of the OS pubis than it had in the latter. In both cases 
 the protuberance formed by the head of the bone in the groin 
 could be readily felt. 
 
 For the purpose of making counter-extension, Desault 
 passed a strap bet^Yeen the scrotum and the thigh of the sound 
 
^94 
 
 the foot was turned outwards; the thigh being in 
 a state of painful extension, could not be flexed on 
 the body; adduction and abduction were alike pain- 
 ful ; the great trochanter, being more approximated 
 than usual to the anterior and superior spine of the 
 OS ilium, was also too far forward; finally, the pro- 
 jecting head of the bone could be felt, as I have 
 already said, in the groin. 
 
 side: Dr. Physick, for the same purpose, passed the strap be- 
 tween the scrotum and the affected thigh. He conceived that 
 hy this mode he could act with more effect on the pelvis, and 
 more effectually prevent the acetabulum of the affected side 
 from being drawn in any measure downward by the extending 
 forces. It would seem, that by making countei'-extension, in 
 such a case, on the sound side, the pelvis is made to rotate, so 
 to speak, on its own axis, in the direction in which the counter- 
 extension is made. The necessary effect of this rotation must 
 be, a slight descent of the acetabulum of the affected side. But 
 to retain the acetabulum firmly up is the true and only end of 
 counter-extension. Dr. Physick appears therefore to have 
 availed himself of the greatest mechanical advantage of which 
 the situation of the parts admitted. 
 
 Again : Desault placed the strap on which extension was 
 made just above the ancle : Dr. Physick placed the strap in- 
 tended for the same purpose above the knee. His object in this 
 was, to have the leg free and unincumbered, in order that he 
 might be able to use the limb with more advantage, as a lever 
 of the first kind, to assist in moving the head of the os femoris 
 towards the acetabulum. The fulcram of the lever into which 
 the limb was thus converted, was a strap passed round the af- 
 fected thigh a few inches below the groin, and drawn laterally 
 with great force in a direction opposite to that in which the 
 bone was displaced. 
 
 In this case extension and counter-extension were made by 
 Bieans of powerful sets of pullies. Notwithstanding this, these 
 ferces were not alone sufficient to subdue the resistance of the 
 
295 
 
 The reduction was eJEFected in the following man- 
 ner. The patient being laid on a firm table, spread 
 with a mattress, a strap was fastened above the ancle, 
 for the purpose of extension ; another, intended for 
 counter- extension was placed between the scrotum^ 
 and the thigh of the sound side, and brought up the 
 back and front of the pelvis, along the body, till it 
 passed over the shoulder, where it was twisted to- 
 gether and secured^ 
 
 Extension was then begun, precisely in the 
 direction in which the thigh pointed; and, during 
 the execution of it, a rotatory motion inwards was, 
 given to the limb. At the expiration of a few mi- 
 nutes, the head of the bone remaining almost im-- 
 
 muscles. The reduction was not completed till muscular con- 
 traction had been weakened, and the patient reduced almost ta 
 a state of syncope, by the loss of nearly two quarts of blood.. 
 This copious evacuation, co-operating with the fatigue which 
 the muscles of the limb necessarily sustained, in consequence 
 of the powerful extension to which they were for some time 
 subjected by the action of the pullies, overcame all resistance. 
 and the head of the bone was finally replaced. To exhaust the 
 energy of the resisting muscles by forcible and permanent ex- 
 tension, and to weaken the action of the systena generally, by 
 copious blood-letting, appear to be the two most effectual 
 modes of ensuring success in the reduction of all obstinate 
 cases of luxation. 
 
 Another point of difference between these two cases o£ 
 luxation remains yet to be mentioned. In Desault's case the 
 head of the os femoris was, as he tells us, displaced in a direc- 
 tion " upward and forward." In Dr. Physick's case, the direc- 
 tion of the displacement was downward and forward. This waa 
 proved beyond all doubt, by the circumstance of the affected 
 limb being longer than the sound one.. Trans.. 
 
296 
 
 moveable, notwithstanding the efforts to dislodge 
 it, Desault directed extension to be discontinued, 
 and, taking hold of the thigh, moved it in every 
 direction, with a view to enlarge the opening in the 
 capsule, the narrowness of which he suspected to be 
 the cause that prevented the reduction. 
 
 Extension -was then resumed, and varied in every 
 direction, while the surgeon endeavoured to give' 
 assistance by pushing the head of the bone forcibly 
 downwards, with his thumbs, and the palms of his 
 hands. Useless efforts ; the displaced bone remained 
 stationary. 
 
 Desault ordering extension to be again discon- 
 tinued, recommenced the motions of the os femoris, 
 and even increased their force, changing them in 
 every direction, for the purpose of lacerating the cap- 
 sule. After this, extension was again renewed, with 
 better success than before. Indeed, on the very first 
 effort, the head resumed, of itself, its natural situa-. 
 tion, without any further assistance on the part of 
 the surgeon. 
 
 The sufferings of the patient ceased almost in- 
 stantaneously ; towards evening a slight swelling ap- 
 peared around the joint, over which an emollient 
 cataplasm was applied. On the day following, all the 
 unfavourable symptoms were gone, and in about a 
 fortnight the patient ■v'i^as able to return to his usual 
 exercises, which, however, he was directed to pur- 
 sue, for some time, with moderation. 
 
 2. There ai^e, in this case, two circumstances, on 
 which the practitioner should fix his attention, and 
 which may thi'ow great light on the reduction of all 
 
Q91 
 
 luxations of the os femoris, as they will be found ap- 
 plicable to most accidents of the kind. These are, 
 1st, The naiTowness of the opening in the capsule. 
 2dly, The inutility of the motion or process of con- 
 formation, when that opening has been enlarged. 
 
 3. We formerly observed, when treating of lux- 
 ations of the humerus, that one of the obstacles to 
 reduction was, the narrowness of the opening in the 
 capsule ; the same circumstance occurs here. That 
 membrane, lacerated at the time when the head of 
 the OS femoris is driven against it, is dilated suffi- 
 ciently to let the head escape : but, the edges of the 
 lacerated membrane, coming together again, and be- 
 ing thus drawn tight ai'ound the neck of the bone, 
 detain it in that position, and prevent the head from 
 re-entering the acetabulum. Thus, in a fracture, 
 where one of the exti-emities of the bone is protruded 
 through the integuments, the opening in the skin, by 
 closing tightly round that extremity, sometimes pre- 
 vents its reduction. 
 
 4. In such a case, what is the first and most obvi-' 
 ous indication? It is necessary to increase the extent 
 of the opening in the capsule, by moving the limb in 
 every direction. Some persons haye deemed it im- 
 possible to tear this membrane anew. But, if we 
 recollect, that the neck of the os femoris, being pla- 
 ced between the edges of the opening, must neces- 
 sarily draw them asunder by the motions impressed 
 on it, it is easy to conceive, that the angles, where 
 these edges unite, will be torn, if the motions be 
 carried to an inordinate degree : besides, experience 
 proves here, as well as with regard to the humerus, 
 
 39 
 
298 
 
 the truth of the doctrine contended for. Are we to 
 apprehend, as these same persons will have it, that 
 serious accidents may be produced by such violent 
 motions? Experience again answers in the negative. 
 Nothing, then, can be more certain, than that this 
 observation, respecting the opening in the capsule, is 
 a great stride towards perfection in the treatment of 
 luxations in general, and particularly of that now un- 
 der consideration* 
 
 5. When this obstacle to reduction has been 
 removed, it is then very readily effected, and that 
 without the process of conformation. Indeed that 
 process is almost always unnecessary. For what pur- 
 pose should it be employed? Is it to increase the 
 effect of extension,, and thus disengage the head of 
 the bone from the place which it accidentally occu- 
 pies? In this point of view, it is nothing but a very 
 feeble force, added to a very powerful one, which 
 receives from it, therefore, but little assistance : it is 
 much better, if necessary, to augment the extending 
 forces themselves* Is it to push the head of the bone 
 into its cavity, after the extensions have dislodged it? 
 It is to the muscles, and not to the efforts of the sur- 
 geon, that the performance of this office belongs. In- 
 deed, the surgeon must act altogether in the dark in 
 this respect, as he cannot possibly ascertain the pre- 
 cise point where the opening in the capsule exists : 
 he may, therefore, even push the head of the bon& 
 against a sound part of the capsule, and thus himself 
 create an obstacle to the reduction, which he is 
 attempting to favour. 
 
299 
 
 ' 6. The muscles, on the other hand, by their con- 
 traction, naturally draw the head of the bone into its 
 place, because the direction of their fibres is such as 
 obliges them to do it. The great art of managing 
 luxations, then, consists, in ascertaining cleai'ly the 
 obstacles that prevent reduction, in removing them, 
 and, then, committing the rest to extension, and the 
 powers of nature properly directed* 
 
 MEMOIR XII. 
 
 «Kr SPONTANEOUS LUXATIONS- OF THE OS 
 FEMTORIS. 
 
 1. Our modern treatises on diseases are little else 
 than fabrics artfully constructed of materials confu- 
 sedly scattered through the writings of the ancients.- 
 Many of those materials oftentimes esca^DC our no- 
 tice, and we find them only, after practice has dis- 
 closed them to us, in tlie chambers of the sick. 
 Thus, Hippocrates had an accurate knowledge of 
 spontaneous luxations of the os femoris, and has 
 even left an aphorism expressly on that subject. 
 Yet this disease appeared to be unknown to the 
 physicians who came after him, till John Louis Petit, 
 having met with it in his practice, drew the attention 
 of practitioners to it, by a memoir respecting it, 
 published among those of the Academy of Sciences, 
 in the year 1722. 
 
300 
 
 2. The history of this affection, which wag con- 
 sidered afterwards, ex professo, in his course on 
 diseases of the bones, has been sanctioned by the 
 assent of all practitioners, to whom it has since very 
 frequently occurred, and who have generally admitted 
 as Louis observes, the doctrine of Petit, respecting 
 the cause on which it seems to depend, 
 
 3. Experience bears witness, that usually a fall 
 on the great trochanter, more rarely on the knee, 
 or the sole of the foot, precedes it, and has doubtless 
 some share in producing it. But Avhat is the nature 
 of the primary affection which, rising immediately 
 from this occasional cause, becomes the immediate 
 cause of the luxation ? Petit, and with him the prac- 
 titioners of the present day, have conceived, that the 
 different parts of the joint, being irritated and contu- 
 sed, pour out, in consequence of the injury received, 
 
 a superabundant quantity of synovial fluid, which, 
 not being absorbed with the same rapidity, accumu- 
 lates in the articular cavity, distends the capsule, 
 and, by degrees, forces the head of the os femoris 
 from its natural cavity. Hence astringent and tonic 
 remedies, with alum, spirit of wine, &c. are di- 
 rected to be applied externally to the upper part of 
 the diseased thigh. 
 
 4. But this doctrine, and the practice which 
 results from it, seem by no means to accord with 
 our knowledge of anatomy. The truth of this was 
 deeply impressed on the mind of Desault, who had 
 frequent opportunities of witnessing the disease. 
 
 Case I. A young woman walking hastily along 
 the street, slipped and made a false step, in which 
 
301 
 
 the left thigh, being violently twisted, supposed for 
 a moment the whole weight of the body. 
 
 A severe pain experienced at the moment, obli- 
 ged her to stop at first, but becoming easier after- 
 wards, permitted her to proceed on her way, and 
 soon ceased entirely. A sensation of weight occur- 
 ring in the part about fifteen days afterwards, was 
 at first troublesome to the patient in walking. This 
 sensation was afterwards succeeded by a dull, deep- 
 seated pain, accompanied by a swelling in the paits 
 around the joint. 
 
 During six or seven months the limb was obser- 
 ved to increase in length gradually, but very slowly. 
 At the expiration of that time, a contraction took 
 place suddenly, and, in one night, the diseased thigh 
 became shorter than the other by nearly two inches. 
 The patient was then admitted into the hospital, 
 where, after some time, she sunk under her disease. 
 On opening the body the following appearances were 
 presented to Desault, who was then consulting sur- 
 geon to the institution. 
 
 The cartilage of the acetabulum swollen to such 
 a degree as to fill up the whole extent of that cavity, 
 was yellowish and inorganic, somewhat resembling 
 bacon, both in colour and consistence. A soft, 
 spongy, whitish substance projected in the middle of 
 it, the remains no doubt of the round ligament. The 
 head of the os femoris, situated where it is usually 
 found in luxations outward and upward, was sur- 
 rounded by a cartilage equally tumefied. 
 
 5. Here the cause of the displacement of the os 
 femoris was evident. The cartilages becoming tume- 
 
302 
 
 £cd, in consequence of the contusion and violence 
 done to them, had by degrees, filled up the acetabu- 
 lum, forcing out in the same gradual manner the 
 head of the bone. Hence arose the original lengthen- 
 ing of the limb. But as soon as the head had escaped 
 from the lacerated capsule, the limb was drawn up- 
 wards and consequently shortened, by the action of 
 the muscles, and the weight of the body pushing the 
 pelvis doAvnward. 
 
 Case II. Some years afterwards, Desault had 
 occasion to witness again the same disease, in the 
 person of a man aged thirty- seven, who put himself 
 under his care, but, being obliged to leave Paris, a 
 short time afterwards, retired into the country, where 
 he died in about six months, enfeebled and consumed 
 by a hectic fever. 
 
 On opening the body, the surgeon of the place 
 discovering the same phenomenon as in the prece- 
 ding case, made a preparation of the part, and sent it 
 to Desault, whose pupil he had been. 
 
 6. In this case the shortening was not so sudden 
 as in the preceding one. It appeared at first to be 
 coming on, during five days, in an imperceptible 
 manner, \vhen, fatigued with lying in bed, and hav- 
 ing on that day drank a little, the patient attempted 
 to walk, supported only by a cane. By evening, a 
 shortening of two inches and a half had taken place, 
 an effect evidently produced by the weight of the 
 body on the diseased thigh. Hence the necessity of 
 confining the patient to a state of perfect rest, of pre- 
 venting, in particular, standing and walking, and all 
 positions in which the diseased thigh would have to 
 sustain the ^veight of the body. 
 
303 
 
 Case III. Maria Genette was received into the 
 Hotel-Dieu, in consequence of a fall on the great tro- 
 chanter. She had been attacked by a pain in the joint 
 of the thigh of tlie same side. Walking, which was 
 performed with difficulty, augmented the pain, and 
 standing, though more tolerable, could not be long 
 continued. The thigh was evidently longer than the 
 other. To leave the disease to nature, and confine 
 the patient to a state of rest, constituted the practice 
 of Desault. What effect could the external use of 
 astringents, recommended by Petit, produce in such 
 a disease ? Some time after her admission, the patient 
 was attacked by dysentery, in consequence of which 
 she was removed to the medical ward, where she 
 died. 
 
 On opening the body, the paits in the neighbour- 
 hood of the joint were evidently tumefied, and the 
 capsule was stretched from above downwards. The 
 head of the os femoris was situated on the external 
 edge of the acetabulum. The capsule, though greatly 
 elongated was stilt in a state of tension ; and the ar- 
 ticular cartilage was swollen to such a degree, as 
 nearly to fill up the cavity. The quantity of synovial 
 fluid was less than natural. 
 
 7, This case, taken at a period of the disease not 
 fer advanced, fully confirms the inference deducible 
 from the two preceding ones, respecting the cause of 
 spontaneous luxations. Here, indeed, the capsule 
 not having given way, the sv\eil3ng having only just 
 commenced, and the synovia existing in but small 
 quantity, the progress of nature was evident. Here, 
 also, occurred a sign not noticed by Petit; namely. 
 
304 
 
 the elongation of the limb, which always, in such 
 cases, precedes its contraction. 
 
 From what we have said, it appears, 1st, that the 
 efficient cause of spontaneous luxations of the os fe- 
 moris, is a swelling of the articular cartilages, which, 
 alters and destroys their organization : 2dly, that the 
 presence of this swelling must necessarily render 
 fruitless all attempts that might be made to replace 
 the head of the bone in its cavity: 3dly, that the 
 change in the organization of the cartilages, renders 
 astringents, discutients, and other external means ap- 
 plied for the purpose of removing the tumefaction, 
 entirely useless : 4thly, that here, as in many other 
 cases, art ought to confine itself to the palliation of 
 effects, and not attempt the removal of causes. 
 
 MEMOIR XIII. 
 
 ON THE FRACTURE OF THE ROTULA. 
 
 §1. 
 
 1. The rotula, a sort of bony production of tlie 
 sesamoid kind, attached to the tendon common to 
 the extensors of the leg, represents a moveable pul- 
 ley, intended to slide on that formed by the separation 
 of the condyls of the os femoris. It protects the joint 
 which it covers, and, in point of structure, use, and 
 situation, greatly resembles the olecranon, from which 
 it differs only in this, that, instead of being a continu- 
 
ation or process of the tibia as the olecranon Is of thcf 
 ulna, it is only attached to that bone by d strong atid 
 thick li^ment which is inserted into its tuberosit}^ 
 Hence it follows, that betvveen the injuries of the ond 
 and the other, there must be a great analogy : and in- 
 deed tno^t of the signs characteristic of fractures of thd 
 olecr^oU, are characteristic also of those of the rdi 
 tula, and the treatment which, in such cases, is suit- 
 able for the former, diifets but little from that required 
 by the latter. 
 
 OF THE VARIETIES AND CAUSES, 
 
 2. Fractures of the rotula may, iii gertefal, as!- 
 Sume any direction, transverse, IbngitudinaOi, or ob- 
 lique: but the first kind occUrs in practice much 
 ftiore frequently than the others ; and so gi'eat indeedi 
 is the disproportion, that it has almost exclusively 
 attracted the attention of authors, in the iiumerotii 
 forftis of apparatus invented to retain the fragments. 
 
 3. A shattering of the bone, the effect of a vio-' 
 lent blow; a contusion; an echymosis; an cffUsiofi 
 of blood into the adjacent soft parts ; one or tticitt 
 wounds of the soft parts, with or without an opening 
 into the joint; a swelling, the degree of which varies 
 greatly, according to the state of the fracture, and the 
 disposition of the subject, but which is constantly 
 present; a double division of the bone, one of which, 
 being longitudinal, forms an angle with the other, 
 -T^hich is transverse; and a concomitant fracture of 
 
 the cond^-^ls of the os femoris, or of the tibia : such 
 
 40 
 
306 
 
 are the vaiieties and complications, of which the frac' 
 ture under consideration is susceptible. 
 
 4. But this fracture may be produced in two 
 modes. 1st, by the action of external bodies: 2dly, 
 by tliat of the extensor muscles. The first mode of 
 division takes place in falls on the knee, or when a 
 body in motion strikes against it, and, in this case, 
 there is no counter- stroke, the rotula being too small 
 for such an occuiTcnce, and always sustaining the 
 fracture where it receives the blow. In the second, 
 the fall is only subsequent to the fracture, and, as 
 Camper has well observed, is most frequently the 
 effect of it. For instance, the line of gravity of the 
 body is, by some cause, removed behind it; the an- 
 terior muscles contract themselves to bring it forward 
 again; the extensors act on the rotula; it is bro- 
 ken, and a fall ensues. Again, the leg is suddenly 
 thrown into a state of violent extension; the exten- 
 sors act w ith great force ; a fi-acture is the conse- 
 quence, and the patient falls. A soldier once fi-actur- 
 ed his rotula in kicking at his serjeant; thus the ole- 
 cranon, in like manner, has been broken by throwing 
 a stone. A man, in the Hotel-Dieu, fractured the 
 rotula of each knee, in the operating room, by means 
 of convulsive motions, produced by the operation of 
 lithotomy. 
 
 5. The action of external bodies, can alone pro- 
 duce a longitudinal fracture, as when a person falls on 
 a sharp projecting piece of timber : but this may also 
 produce a transverse fracture. On the other hand, 
 muscular action can never give rise to any but the 
 latter kind, since the direction of this fracture is at a 
 
307 
 
 right angle with that of the extensors. A fracture 
 resulting from the action of external bodies, is often- 
 times accompanied by a wound, a contusion, or a 
 shattering of the part (2) ; a fracture, arising from 
 muscular action, is always simple, except as to a 
 swelling around the joint. The latter cause may, 
 instead of fracturing the rotula, rupture the common 
 tendon of the muscles, or, what is more common, the 
 inferior ligament. Desault has seen many examples 
 of this : Petit has also observed several, and Sabatier 
 has sometimes met with them. External violence 
 seldom produces this double accident. 
 
 HII. 
 
 OF THE SIGNS AND THE DISPLACEMENT. 
 
 6. In longitudinal fractures the diagnosis is always 
 accompanied with more or less difficulty, because the 
 extensor muscles, drawing by their contractions the 
 two fragments equally upwards, and the inferior liga- 
 ment holding them equally down, tend to keep them 
 in apposition, and to prevent them from separating. 
 Sometimes also the ligamentous production which 
 covers the rotula, remains entire and serves to keep 
 the fragments together. It will be necessary, there- 
 fore, should the existence of such a fracture be sus- 
 pected, to move the two sides of the rotula in oppo- 
 site directions, by pressing them to the right and to 
 the left, in order to arrive at certainty on the subject. 
 Should a wound exist, as is oftentimes the case (5) 
 the diagnosis is less difficult. 
 
50$ 
 
 7. If the diyisipii be transverse, the diagnosis be- 
 comes then as plain and easy, as it is difficult and 
 obscure in cases where it is longitudinal. In such a 
 case, a considerable separation or space exists he-. 
 tween the twp fragments, sensible to the touch, w^en 
 the hand is placed on the knee. In this separation, 
 the fragments are not displaced by the same mean?. 
 The superior fragment being attached to the exten- 
 sors, is drawn upwards with great force by these 
 muscles, the action of which the rotula no longer 
 resists. The lower fragment, on the other hand, 
 being attached only to the inferior ligament, is not 
 moved by any muscle, and cannot be displaced in 
 any other way than by the motions of the leg with 
 which it is still connected. 
 
 8. Hence it follows, 1st, that, in a state of exten- 
 sion, the separation is the least possible, because it 
 is tlien produced on the part of the superjior fragment 
 only; 2dly, that in a state of flexion it is greatest, 
 because then both fragments conciir alike in produ- 
 cing it ; 3dly, that it may be increq.sed or diminishe^^ 
 by vaiying the degrees of flexion. 
 
 9. This fracture is further characterized by the 
 following circumstances, namely, a practicability of 
 moving the fragments transversely in opposite dir 
 rections, and of producing, by that means, some 
 degree of crepitation, provided they be first brought 
 close together; by tl^e pain vdiich accompanies these 
 motions; by the swelling common to every kind of 
 fracture of the rotula, and which, if yery great, may 
 involve tlie other signs in more or less uncertainty ; 
 by a difficulty of standing; and an almost entire loss 
 
309 
 
 of the power of walking, in consequence of the e^c- 
 Jensors being no longer able to coiiimunicate motion 
 to the leg, unless when the fracture exists vejy low 
 (iown, near to the inferior ligament. 
 
 10. The touch v/ill always discover in what part 
 of the bone the fracture is situated, which, if it be 
 oblique, will partake more or less of the characters of 
 the longitudinal or the transverse, accox'dingly as it 
 approaches to the one or the other. 
 
 § IV. 
 
 OF THE PROGNOSIS. 
 
 11. Many authors have pretended that fractures 
 of the rotula cannot be cured, and it even appears 
 that the Academy of Surgery adopted this opinion, 
 on receiving a memoir from a Flemish physician, 
 which contained several facts tending to establish 
 that principle. But what do these facts prove? That 
 in some particular cases, reunion did not take place, 
 but they do not show that this w^as owing to the na- 
 ture of the fracture. 
 
 12. But, what, in such cases, could prevent a 
 cure from taking place? The structure of the ro- 
 tula differs, say they, from that of the other bones. 
 Now, admitting this difference of structure to be 
 j^eal, it certainly approaches to the structure of tendons 
 to which indeed it bears a strong affinity. But, who 
 does not know, that, when tendons are divided, they 
 lanjte ^s readily as bones? Besides, is not the power 
 of reunion common to every part endowed with life? 
 I have already shown, when treating of other frac- 
 
310 
 
 turcs that communicate with joints, what credit is 
 due to those hypotheses so often revived but never 
 confirmed, nay even clearly proved to be unfounded, 
 such as, an effusion of callus into the joint, a failure 
 of reunion from a w^ant of periosteum on the poste- 
 rior part of the bone, the synovia diluting the mat- 
 ter of callus, and thus preventing it from being duly 
 prepared, &c. 
 
 13. The inflammation of the articulating sur- 
 faces and of the ligaments around the joint, ought to 
 have more influence in constituting an unfavourable 
 prognosis, than any circumstance that authors have 
 mentioned. But experience proves, that, when judi- 
 ciously treated, these fractures are not accompanied 
 by that accident, and even that the swelling, which 
 for the most part attends them, always yields more 
 or less speedily, when a bandage, uniformly applied, 
 presses equally on all parts around the joint, and thus 
 forms a kind of discutient, while at the same time 
 it retains the fragments. 
 
 14. Pare, Fabricius of Hilden, and a number of 
 other wTiters, have pretended, that some degree of 
 lameness must always be the consequence of this 
 fracture. But, from what causes must this lameness 
 So certainly arise? Is it from a want of reunion in 
 tihe part? I have already shown (11 and 12) that this 
 apprehension is wholly unfounded. Is it from an an- 
 chylosis? This accident cannot take place, except 
 either in consequence of inflammation occurring in 
 the articulating surfaces, (and I have already shown 
 how that may be avoided, 13) or of a stiffiiess in the 
 ligaments, and I shall hereafter make it appear that 
 
311 
 
 that may be readily pi^eyented by motion. Is it from 
 the fragments being drawn asunder, and in that state 
 united by an intermediate substance of too great an 
 extent? I shall prove, that a bandage properly con- 
 structed, is always sufficient to keep these fragments 
 in contact. 
 
 From these considerations it appears, that writers 
 have, in general, without sufficient cause, given an 
 unfavourable prognosis, in relation to fractures of the 
 rotula, which have, indeed, a great affinity to other 
 affections of the same kind. 
 
 i«F THE REDUCTION AND THE MEANS OF MAIN- 
 TAINING IT. 
 
 15. I have already observed (7), that the causes 
 of the separation of the fragments are, as far as respects 
 the upper one, the contraction of the extensor mus- 
 cles; and, in relation to the lower one, the flexion of 
 the leg; whence it follows, that the means of pre- 
 serving contact between these fragments are 1st, all 
 those that are calculated for the prevention of mus- 
 cular action; 2dly, such as may keep the limb in a 
 state of permanent extension. Hence two leading 
 curative indications must be fulfilled by the bandage 
 constructed for fractures of the rotula: the last of 
 these indications presents in general but little diffi- 
 culty; but, with regard to the other, the case is 
 different. To fulfil the latter, it is necessary first, 
 to weaken the contractile force of the muscles, and 
 by that means diminish the effort wMch they make 
 
M2 
 
 to draw the superior fragment upwards; aiid then," 
 to oppose to them a proper mechanical resistance,* 
 which, by acting in a direction the very reverse of 
 that in which they act, may counitervail their efforts. 
 
 16. But the force of contraction is dimihished, 1st, 
 by tliro\^dng the muscular fibres into a state of relaxa- 
 tion; this end is best attained by bending the thigh on 
 the pelvis : 2dly, by making compression bver th^ 
 whole limb, by means of a circular bandage, Which, 
 by confining the muscles, tends to restrain and weak- 
 en their action. Thus it is kno^vn that the advantage 
 of the bandage employed to unite transverse wounds, 
 consists chiefly in that compression wliich, by dimi- 
 nishing muscular action, prevents the retraction of 
 their edges. Another advantage resulting fi-om the 
 bandage in this case is, that it prevents the swelling 
 of the limb. 
 
 17. As to the mechanical resistance, which must 
 act in a direction opposite to that of the contraction 
 of the muscles, and, by that means, prevent the dis- 
 placement of the superior fragment, it cannot, in the 
 present case, be of the same nature as in fractures of 
 the thigh, the clavicle, &:c. where permanent exten- 
 sion is practised. The superior fragment offers too 
 small a purchase for any extending forces to act on. 
 This resistance must be made, then, by placing some 
 body above this fragment, and retaining it in that 
 situation with a force sufficient to hinder the fragment 
 fi'om rising upwards : such as a few turns of a roller 
 drawai tight, a bit of leather, some hollow com- 
 presses, &c. 
 
5U 
 
 18. It is evident from the foregoing principles, 
 that every bandage intended to retain a transverse 
 fracture of the rotula, ought to be calculated to main- 
 tain the following state of things: 1st, the extension 
 of the leg on the thigh; 2dly, the flexion of the thigh 
 on the pelvis; 3dly, a uniform compression over the 
 whole limb ; and, 4thly, some mechanical resistance 
 properly secured above the superior fragment: the 
 three last expedients relate to the displacement of that 
 fragment alone ; while the first has a relation to that 
 of the lower one. Let us examine whether or not the 
 bandages, hitherto employed by different authors, be 
 calculated for these purposes. 
 
 19. M. Valentin, believing that position alone 
 was sufficient to retain the fragments in contact, ne- 
 glected the application of apparatus entirely, which 
 he even considered as hurtful, in consequence of the 
 swellmg it produced ; but experience soon proved 
 the insufficiency of this method. The slightest move- 
 ment, or the least effort on the part of the patient, 
 made the extensor muscles contract, which, drawing 
 the superior fragment upwards, separated it from the 
 lower one ; and, as the time of reunion is in direct 
 proportion to the distance of the fragments from each 
 other, it must, under such treatment, have been 
 necessarily tedious, and soriietimes must have even 
 failed altogether. 
 
 20. As to a swelling being produced by the ban- 
 dage, this never occurs, unless when some openings 
 are left, through which the integuments protruding 
 become tumefied : but, when the pressure is uniform 
 throughout, when the fluids find throughout an equal 
 
 41 
 
314 
 
 tesistance, this accident is not to be apprehended, as 
 is proved by the practice of Desault, who never met 
 with it; on the contrary, a bandage properly con- 
 structed and applied, is calculated to prevent swell- 
 ing (16). 
 
 Mere position, then, though always of service in 
 this affection, is not alone sufficient, because it fulfils 
 only the first of the indications or principles laid down 
 with respect to every form of apparatus for transverse 
 fractures (18), namely, that which relates only to the 
 lower fi-agment; while those that relate to the upper 
 one, remain still to be fulfilled. 
 
 21. Most authors have employed, with a view ta 
 these, a kind of figure of 8 bandage, known in art by 
 the name of Kiastre^'^ and approved of by Petit, 
 Heister, Sicc. This is made of a roller formed into- 
 two balls, which are brought across each other alter- 
 nately under the ham, passing over two hollow or 
 forked compresses ^ tliat enclose the two fragments of 
 the rotula. 
 
 But the unequal pressure which this makes on 
 the unequally projecting parts of the knee, renders 
 its application ex:tremely painful, particularly below, 
 where the pasteboard covering applied by Louis, im- 
 mediately on the skin, afforded but a feeble protec- 
 tion to the tendons of the flexors. Besides, it did not 
 prevent the swelling, which is indeed a necessary 
 consequence both of this unequal pressure, and of 
 the openings left between the casts of the bandage. 
 This swelling is taken notice of by all writers,, and 
 is, according to them, one of the troublesome cir- 
 
 * I know not of any English tenn equivalent to this. T- 
 
315 
 
 cumstances attending , the fracture. The third indi- 
 cation is not ail fulfilled (18), 
 
 22. The extensor muscles, not being at all com- 
 pressed, will act widi their whole force on the upper 
 fragment, and, on the slightest effort of the patient, 
 overcome the resistance of the bandage, the action of 
 which, being oblique with respect to the fragment, 
 is inconsiderable, unless it be drawn very tight, and 
 thus a displacement will again occur. This obliquity 
 of the turns of the roller obliges the surgeon, either 
 to draw it very tight, in which case a swelling is in- 
 evitable, or to make it but moderately tight, and then 
 the apparatus will be insufficient to resist the action 
 of the muscles. 
 
 23. Most of the objections to the ancient appara- 
 tus for fractures of the rotula, apply also both to that 
 proposed by Ravaton in his surgery, and to that 
 which Bell employs in his practice. Both of these, 
 while they fail in making sufficient resistance to mus- 
 cular action, as well as in fulfilling the third conditijor^ 
 laid down as necessary to every bandage (18), contri- 
 bute to the swelling, and can rarely produce a perfect 
 contact between the fragments. Thus Bell has well 
 observed, that tiie reuniqn is rarely perfect, and that 
 there is always a separation more or less perceptible. 
 
 24. The complication, the-iiitricacy, the expense,^ 
 and other more weighty inconveniences of the ma- 
 chine described by Garengeot in his treatise on in- 
 struments, and employed, for the first time, by 
 Arnaud, and also of that which was proposed and 
 used by Solingen, have, long since, entirely banished 
 them from among the means of reduction. 
 
516 
 
 
 
 25. Some practitioners have advised the uniting 
 bandage used in cases of transverse wounds, which is 
 formed, as is well known, of two small rollers or 
 strips placed in the longitudinal direction of the limb, 
 one of them having holes in it, to w^hich the divisions 
 of the other are fastened. Both of these are first 
 secured by circular turns; being then dra^vn in op- 
 posite directions so as to meet, they draw the parts 
 on \vhich they are applied in the same directions* 
 But the action of tliis bandage is confined to the inte- 
 guments, and would have of course but a feeble 
 influence on the fragments beneath. It is also attend* 
 ed with this further inconvenience, that by wrinkling 
 the integuments, and tin owing them into folds, it 
 might press them dowii between the fragments, and 
 thus prevent their contact. Besides, it is liable to most 
 of the objections urged against the preceding one. 
 
 26. This view of the means employed by different 
 practitioners, to counteract the causes of displacement 
 in this fracture, are sufficient to convince us, that the 
 difficulties hitherto experienced in the treatment of it, 
 have arisen from the feebleness of the former, and the 
 strength of the latter. So great indeed have been 
 these difficulties, that some authors, conceiving a re- 
 union impossible, have, in conformity to such an 
 opinion, though contrary to all the rules and principles 
 of the profession, advised us to abandon the patient to 
 himself. But I have already exposed the fallacy of 
 that opinion, respecting the Vv^ant of a healing power 
 in the rotula (12), an opinion which, if generally 
 adopted, w'ould give rise to consequences of the most 
 serious nature. In the present case, as in all other 
 
^17 
 
 fractures, the contact of the fragments ought to be the 
 chief object of the surgeon's efforts. 
 
 27. But ought this contact to be perfect and exact? 
 Several authors, particularly Bell, have conceived, 
 that the motions of the limb can be performed as well 
 with a slight separation of the fragments. Pott even 
 declares that such a separation will enable the patient, 
 after his recovery, to walk with more ease. Flajani 
 advances the same opinion in a dissertation on the 
 subject. 
 
 From this doctrine arose a new mode of treatment, 
 which consisted in not suffering the fragments to be 
 at rest. They were accordingly, during the cure, put 
 frequently in motion, the more effectually to prevent 
 an anchylosis, which is sometimes the consequence 
 of this fracture. 
 
 28. But, on the one hand, it is difficult to con- 
 ceive, on what this opinion of these authors can be 
 founded; while, on the other, reason declares, in the 
 plainest and most forcible terms, that the more the 
 state of a bone, after it has been broken, differs from 
 its natural state, the less fi'ee will be the exercise of 
 its functions, and, that the perfection of the treatment 
 of fractures consists, in leaving behind it no vestige 
 of the accident. 
 
 29. This truth was frequently confirmed in the 
 experience of Desault, who had an opportunity of 
 seeing numerous fractures of the rotula, both in the 
 Hotel-Dieu, and in his private practice. He always 
 observed, that, when the separation of the fragments 
 was considerable, and the ligamento- cartilaginous 
 substance uniting them was of some extent, standing 
 
318 
 
 and walking were performed with much difficulty; 
 that the patient was exposed to frequent falls, from 
 the want of a proper coiTespondence, in point of 
 strength and motion, between the two limbs; and 
 that, on the contrary, the kss extensive the separa- 
 tion and the substance that filled it up were, the 
 more free and easy were the motions of the part, 
 which still remained, however, somewhat defective and 
 imperfect, unless every vestige of the division was 
 obliterated, 
 
 Paul of Egina long since observed, that, when 
 no means of reduction were employed, though the 
 patient might walk tolerably well on a level surface, 
 lie could not, without difficulty go up an ascent. 
 
 30. From what has been said, it follows, 1st, 
 that in the treatment of this fracture, the perfect 
 contact of the fragments ought to be the principal 
 object of the practitioner; 2dly, that the kinds of 
 apparatus employed by different authors, are but ill 
 calculated for the attainment of this end, because they 
 fulfil but imperfectly the indications formerly laid 
 down (18), Let us see whether or not the appara- 
 tus of Desault be any better suited to this purpose. 
 
 31. The bandage, wliich he employed in this 
 case, analogous to that for fractures of tlie olecranon, 
 is composed, 1st, of one spUnt, two inches broad, 
 and long enough to reach from the tuberosity of the 
 ischium, to a little above the heel; 2dly, of two 
 roUers, five or six yards long, and neaily three inches 
 wide; 3dly, of another single roller, with two holes 
 about the middle of it, a little longer than the injured 
 lim.b of the patient, along the fore part of which it 
 must be extended. 
 
319 
 
 32. Every thing being arranged for the applica- 
 tion of the apparatus, 
 
 1st, One assistant secures the pelvis, in the 
 same manner as in fractures of the lower extremities; 
 while another keeps the leg in a state of perfect ex- 
 tension on the thigh, and the thigh on the pelvis. 
 
 2dly, The surgeon, then, standing by the side 
 of the fractured limb, extends along the anterior part 
 of the leg and thigh the roller with holes in it, having 
 previously wet it with vegeto- mineral water, taking 
 care to make the two openings correspond to the 
 lateral parts of the rotula, that, by being thus better 
 adapted to its shape, it may not be thrown into 
 wrinkles. 
 
 3dly, He then secures it on the t€^ of the foot, 
 by three circular casts of a roller placed one over 
 the other, three or four inches above its lower end 
 which must next be turned up over the three first 
 casts, and made fast by two other ones. Then, 
 while the compress roller* is secured above by aa 
 assistant, he passes up along the leg by oblique and 
 reverse turns, according to the inequalities of the 
 limb. 
 
 4thly. Having arrived at the lower part of tl^ 
 knee, he pushes the lower fragment upwards, and 
 makes below it two or three circular turns to secure 
 it. He then gives the roller into the hands of an, 
 assistant, and directing him who holds the long com- 
 press roller, to draw it forcibly upwards, pushes the 
 
 * The roller or strip with holes in it, which is extended 
 along the fore part of the limb, serving, in some measure, the 
 purpose of % compress. Trans. 
 
^ 320 
 
 integuments of the knee in the same direction, lest, 
 by becoming interposed between the fragments, they 
 might prove an obstacle to their reunion. Passing 
 then the fingers of his left hand through the holes in 
 the compress-roller he places them behind the supe- 
 rior fragment and pushes it forcibly do^vnwards. 
 
 5thly, When the reunion of the fragments is 
 exact, without any space intervening, he resumes 
 the roller, and passing it obliquely under the ham, 
 and bringing it up again behind the superior frag- 
 ment, withdraws his fingers which held this fragment 
 down. In place of his fingers, he then apphes two or 
 three tight circular casts, covers the knee with seve- 
 ral oblique casts in form of the figure of 8, so as to 
 leave no opening between them, and, then, continues 
 the bandage up along the thigh, securing by it the 
 compress-roller extended along the fore part of the 
 limb. 
 
 6thly, When he has arrived at the upper part 
 of the limb, the assistant who holds the compress- 
 roller, drawing it forcibly upwards, doubles down its 
 end over the circular casts. The surgeon next fix- 
 ing this end by several additional casts, descends 
 again along the thigh, covers the knee by a few 
 more oblique turns, and finishes with the roller on 
 the leg. 
 
 33. This first part of the bandage evidently fulfils 
 the third and fourth indications (18). The compres- 
 sion of the roller on the muscles weakening their 
 action and impeding their motions prevents their 
 tendency to draw the superior fragment upwards; 
 while the circular casts passed behind this fragment, 
 
321 
 
 acting in opposition to the muscular contractions, 
 pre^^ents it from moving upwards in obedience to 
 them. The long compress-roller, stretched on the 
 fore part of the limb, being first secured below, and 
 then drawn forcibly upwards, presses the casts of 
 the roller against each other, and prevents those that 
 correspond to the thigh from slipping upwards, and 
 thus abandoning the superior fragment, and prevents 
 also those on the leg from slipping down and with- 
 drawing their support from the inferior fragment. As 
 there remains no vacant space between the circular 
 turns, their pressure is uniform throughout: no 
 swelling can consequently supervene (20). 
 
 34. But the first and second indications remain 
 still to be fulfilled (18): it is necessar}^ to prevent the 
 separation of the lower fragment, by the extension of 
 the leg on the thigh, and to throw the muscles into 
 a state of relaxation by extending the thigh on the 
 pelvis, and to maintain permanently, by the appara- 
 tus, that double position, which the assistant main- 
 tains only during the operation. 
 
 35. To obtain the first effect different means have 
 been employed; but none answers so well, to extend 
 the limb and retain it immoveably in tliat state, as a 
 long and strong splint, placed, as Desault did it, sub- 
 sequently to the application of die first part of the 
 bandage, along the posterior part of the limb. An 
 assistant must hold the end of this splint, while the 
 surgeon secures it in its place- by the second roller 
 (31): in this way the extension of the leg is effected. 
 
 36. To obtain the extension of the thigh, it is 
 necessary to place on the top of each other, two or 
 
 42 
 
322 
 
 three bolsters or little bags filled with chaff, so dis- 
 posed as to form an inclined plain, considerably ele- 
 vated towards the heel above the level of the bed, 
 but which, gradually descending to the same level 
 towards the tuberosity of the ischium, forms a sup- 
 porting basis on which the whole limb may rest in a 
 uniform manner. By this twofold extension of the leg 
 and of the thigh, the lower fragment is kept up im- 
 moveably, and the muscles are kept in a state of 
 relaxation. 
 
 Hence it follows, that this bandage fulfils ex- 
 tremely well the conditions laid down (18), and that 
 it ought to be preferred to all the others (19.... 2 5), 
 which answered the indications only in part. 
 
 37. Whatever may be the advantages of this ban- 
 dage over the others, it m.ust still be acknowledged 
 to have its inconveniences. The rollers become re- 
 laxed in a short time ; their compression is less active ; 
 the muscles, being less confined, contract more rea- 
 dily ; hence the necessity of frequently repeating the 
 application of the apparatus, a circumstance which is 
 very troublesome, on account of the roller which 
 composes it, and covers the whole limb. The resist- 
 ance of it even when it is recently applied, is not 
 always equal to the power of the muscles, whence 
 the most assiduous attention is necessary, to obtain 
 such a consolidation as to leave no trace of the frac- 
 ture behind. Few persons ever possessed, like De- 
 sauit, the art of overlooking nothing that might in 
 any way contribute to the success of his treatment: 
 from this, no less than from the excellence of his pro- 
 cesses, arose the number of his cures. Let us con- 
 
323 
 
 firm, by a few examples selected from among a great 
 many, the doctrine here laid down. The following 
 cases were collected by Julian and Bezard. 
 
 Case I. Francis Leclert, of a sanguine tempera- 
 ment, fell on the 7th of October, 1790, on his right 
 knee, and produced a transverse fracture of the 
 rotula. He was not able to rise ; he was carried 
 home, where a surgeon, on discovering the nature of 
 his disease, advised him to be taken to the Hotel- 
 Dieu. 
 
 He was conveyed thither on the day following, 
 and, in the interval, a considerable swelling had oc- 
 curred around the joint. The usual bandage was 
 employed ; the pains ceased immediately after its ap- 
 plication; a copious blood-letting was directed, and 
 a low diet was prescribed. 
 
 The whole apparatus was wet with vegeto- mine- 
 ral water, two or three times a day. On the next day 
 some light food was allowed, and the quantity in- 
 creased by degrees, till in a short time the patient 
 returned to his usual regimen. Eighth day, the 
 swelling being almost gone, the bandage had become 
 relaxed it was therefore reapplied. Every day the 
 inclined plain formed by the bolsters was carefully 
 examined, and put in order again as often as it be- 
 came deransred. 
 
 Fifteenth day, a new application of the apparatus : 
 twentieth day, an evacuation in consequence of a 
 bilious disposition. Nothing particular occurred from 
 this time till the completion of the cure, which took 
 place on the sixty -seventh day after the accident: no 
 depression existed at the place of the fracture : the 
 
524 
 
 motions were perfectly freej these were aided, by 
 daily exercising the knee joint for some time. 
 
 Case IL Vincent Grenier, aged thirty-eight, 
 making a false step, fell on the rotula, and fractured 
 it, on the 6th of June, 1791 : he was brought to the 
 Hotel-Dieu, where Desault demonstrated to his pu- 
 pils, by the usual signs the existence of the disease : 
 a considerable swelling had already taken place. The 
 bandage formerly described was applied: the same 
 precaution as in the preceding case ; apparatus ex- 
 amined every dayj renewed as often as relaxed; 
 extension maintained with great exactness. On the 
 forty -fifth day, the consolidation was nearly effected ; 
 on the fifty-second it was complete, the joint was 
 exercised for some time, and on the seventy-serenth 
 day the cure being in all respects complete, the pa- 
 tient was discharged. 
 
325 
 
 MEMOIR XIV. 
 
 ON THE FORMATION OF FOREIGN BODIES IN 
 THE JOINT OF THE KNEE. 
 
 1. The history of foreign bodies divides itself 
 naturally into two great sections; the one includes 
 those that are introduced from without; the other 
 such as are formed within our own systems. This 
 latter section maybe again divided into two classes; to 
 the first class belong bodies altogether inorganic, such 
 as the difierent kinds of stones; to the second, those 
 which are truly organic, and become foreign only by 
 being situated in places where they impede the func- 
 tions, such as cartilaginous or bony productions, 
 existing accidentally within the joints. 
 
 On the subject of the latter class, art is much more 
 deficient than she is with regard to the former. Let 
 us endeavour to assist her a little, by giving a sketch 
 of the opinions and practice of Desault with respect 
 to these productions. 
 
 2. Before his time, the surgery erf France appears 
 to have contained scarcely a record of this affection. 
 Described only in some ancient works, such as the 
 writings of Pare, it had been forgotten by the modems, 
 when numerous instances of it were suddenly m^t 
 with by English and German surgeons, and soon af- 
 terwards by Desault, who illustrated and confirmed 
 the practice of his predecessors iivit, and even added 
 something of his ovvn. 
 
326 
 
 3. All the joints may become the seat of these 
 concretions; Haller found many of them in that of the 
 lower jaw; Bell mentions, as a very rare occurrence, 
 their existence at the junction of the foot with the leg. 
 Some authors have met with them in the wrist; but 
 none are more common, or merit more particular at- 
 tention, than those that exist in the joint of the knee. 
 To these alone shall the following observations be 
 confined, because these alone have fallen under the 
 notice of Desault. 
 
 OF THE VARIETIES. 
 
 4. Concretions of die joints do not always assume 
 the same aspect. They vary greatly as to number, 
 size, figure, structure, &:c. In general, these bodies 
 exist aingly ; sometimes, however, two of them are 
 found in the same joint, and then they may be ex- 
 tracted either at the same time, or in succession, as 
 was once done by Desault. Some English surgeons 
 have also met with two concretions, and Morgagni 
 has found even twenty-five, in the S9.me joint. 
 
 5. They vaiy also in size. The largest ever met 
 with by Desault, was fourteen lines in its longest, 
 and ten in its shortest diameter. Six lines diameter 
 in every dii'ection, was the measure of the smallest 
 one that occurred in his practice. 
 
 6. Their figure is sometimes lenticular and 
 smooth on both sides, sometimes unequal, rough in 
 one part, even in another, concave on one side, con- 
 vex on the opposite, sometimes marked around the 
 
327 
 
 circumference and sometimes not with reddish 
 points, and having occasionally a stem of a cellular 
 texture and of some length, as may be seen in a paper 
 by Theden. They usually consist of a single mass, 
 but ai'e in some cases divided into several lobules 
 united by a kind of ligaments, as in the fourth case 
 related in the Journal of Surgery. Though most fre- 
 quently detached and floating in the interior of the 
 joint, they have yet been found adhering by means of 
 small portions of cellular substance, loose and capable 
 of being stretched, or tight, hard, and even of a liga- 
 mentous nature. 
 
 7. If, from the external figure, we pass to the 
 structure of these bodies, w^e will find them existing 
 in three different states. Sometimes purely cartila^- 
 ginous, sometimes completely bony, they at other 
 times partake of both these states, in which case a 
 bony nucleus is covered with a cartilaginous crust. 
 Out of five cases, recorded by Desault, three are of 
 the first, and two of the third kind. Many authors 
 have met with the second kind, particulai'ly Morgagni, 
 who has even found in the same joint, some bodies 
 of a bony and others of a cartilaginous nature. Hence 
 it appears, that this variety of structure is to be attri- 
 buted to the longer or shorter standing of the disease, 
 that every concretion must pass successively through 
 these thi-ee states, and that there is a great analogy 
 between the formation of such bodies and natural 
 ossification. 
 
 8. If we examine a body of the third kind cut in 
 two through the middle, we will find it red and vas- 
 cular in the centre, like an epiph3^sis, even when it is 
 
328 
 
 floating in the joint perfectly loose and free from ad«( 
 hesion. 
 
 9. Bell, in his treatise on surgery, speaks of a 
 kind of tumour, at first soft, membranous, and adher- 
 ing to the internal surface of the capsule, but which, 
 according to him, may become aftei-wards hard and 
 solid, and be detached so as to float loose in the joint. 
 But are not these tumours different in their nature 
 from tliose destined to be converted into bone? Do 
 they, in fact, ever undergo the changes mentioned by 
 Bell ? Desault having never met with any of them, 
 was unable to offer an opinion on the subject. In the 
 mean time, an observation made by Monro, may 
 serve to throw some light on the question : he once 
 sa^v, in one of these productions, a cellular nucleus 
 surrounded by a covering of bone. 
 
 10. Though usually simple and fi-ee from com- 
 plication, this affection may, according to some 
 authors, give rise occasionally to a dropsy in the 
 joint. Pare is the first who has made mention of this: 
 he found one of these bodies in a patient's knee, into 
 which he had made an incision for the purpose of 
 di'awing off" a collection of water. Simson, on extract- 
 ing a similar body, gave vent to four ounces of v/ater. 
 But, as on the one hand, a dropsy of a joint often- 
 times exists without these foreign bodies; so, on the 
 other, these bodies are almost always found discon- 
 nected from dropsy. Nor is there any afliinity between 
 the acknowledged causes of an accumulation of 
 synovia, and the presence of these bodies ; so that 
 when the tv/o diseases do exist together, it is alto- 
 gether probable, that they are independent of each 
 other. 
 
32^ 
 §IIL 
 
 OF THE CAUSES. 
 
 11. The formation of articular concretions suc- 
 ceeds frequently to blows or falls received on the 
 joint, in which case, a swelling more or less con- 
 siderable in the surrounding soft parts, showing 
 itself from the first, and remaining for some time, at 
 length allows the foreign body to be perceived, and 
 does not, in general, disappear during the continu- 
 ance of the body in the part, 
 
 12. Sometimes no external injury contributes to 
 the formation of the body, and then, a spontaneous 
 swelling precedes its detection, as Desault observed 
 in two patients, where nothing was known to have 
 concurred in the production of the disease. Constant 
 rest increases this swelling, while exercise and a tem- 
 perate mode of life diminish it. 
 
 13. But what can be the immediate cause of 
 these tumours? Are they, as some allege, an aggre- 
 gation or crystallization of particles of matter con^^ 
 veyed into the interior of the joint by the synovia, in 
 die same mamier as the rudiments of a stone are con^ 
 veyed into the bladder by the urine ? Their organic 
 appearance and the vessels that pervade them, are 
 anfevourable to such an opinion. Can they be, agree- 
 ably to the conjecture of Theden, articular ^ands 
 bruised by means of strokes or falls? Or are they, 
 as some authors will have it, portions of the car- 
 tilage of the joint, detached by the same causes? 
 How then will their spontaneous formation be ex- 
 plained? 43 
 
S30 
 
 But why trouble ourselves about the cause, pro- 
 vided we can remedy the effects? Nature conceals 
 from us the means,, and discloses to us nothing but 
 the results. Theories are fluctuating ; but experience 
 is stiilthe same: let us search, then, by an attention 
 to facts, for that which we cannot learn firomi. first 
 principles. 
 
 ^ IV. 
 
 OF tHE SIGNS. 
 
 14. The phenomena which announce the presence 
 of foreign bodies in the joint of the knee, are some- 
 times clothed in a character of such evidence, that 
 they cannot be mistaken ; at other times, the nar.ure 
 of the disease eludes the most accurate researches : 
 the cause of this variety may be easily perceived. 
 
 As the joint presents different depressions and 
 eminences, and as the bodies, being usually loose 
 and detached, may tmvel thi'ough its whole extent, 
 they produce different effects, according to the par- 
 ticular situations which they occupy. If lodged in a 
 depression, they are not compressed, and cannot, of 
 course, give rise to any troublesome affection. If 
 they bear on an eminence, such as the condyls, or 
 the posterior part of the rotula, they aie forcibly 
 compressed, and must derange, in som.e measure, 
 the functions of the joint. Hence the precise nature 
 of the affection caimot be at all times derived from the 
 State of the symptoms, 
 
 15. Sometimes the patient can stand and walk 
 with perfect freedom and ease, while, at other times, 
 a sudden pain seizing him, obliges him to sit down, 
 
331 
 
 or even causes him to fall, if there be nothing at hand 
 ^o support him. This pain subsists for a longer or 
 shorter time. One motion produces it, and some- 
 times another, made in an opposite direction, removes 
 it. But in common it is of some continuance, and 
 then the patient k obliged to keep his bed- 
 
 16. If the state of the joint be examined, it will 
 'be found more or less swollen, when the pain is very- 
 acute. When the pain ceases, the swelling in part 
 disappears. It is never sufficient to prevent the fin- 
 gers, when dra^vn along the external surface of the 
 joint, from discovering the presence of the foreign 
 body, when it forms a protuberance under the inte- 
 guments. It is then found sometimes above the 
 rotula, by the side of the tendon of the extensor 
 muscles, and that is the (place where it usually pro- 
 duces least pain; at other times, it is lower down, in 
 ir-ont of the condyls, and by the side of the rotula. 
 It is occasionally found immediately behind the ten- 
 don of the extensor muscles ; in this case so acute is 
 the pain, that the patient is generally unable to stand. 
 But it is when it is situated behind the rotula, near to 
 the projecting ridge Avhich runs across its posterior 
 surface, that it gives rise to the most serious affections. 
 
 17. The body passes from one place to another, 
 on the least motion, and sometimes, as Bell observes, 
 the patient, on changing his position during sleep, is 
 awakened by severe pain, in consequence of the fo- 
 reign body being moved by this change. It happens, 
 in certain cases, that it disappears, and lies concealed 
 for some time, in the back part of the joint. During 
 ihis period the joint performs all its functions with 
 
302 
 
 freedom and ease. Desault made this remark, in the 
 case of a captain of dragoons, from whom, for the first 
 time in his practice^ he extracted one of these bodies, 
 and who, for six months previously, had been able to 
 perform all the motions of the joint freely, without 
 pain. This person, experiencing no uneasiness, con- 
 sidered himself perfectly cured, when the body sud- 
 denly reappeared, in consequence of a hasty extension 
 of the leg. 
 
 18. If the body^, when projecting under the inte- 
 guments, be gently compressed, it yields to the pres- 
 sure, changes its situation, and, according to the im- 
 pression it has received, moves either to the internal 
 or the external side of the joint, or reciprocally from 
 one side to the other, passing also behind the rotula, 
 behind the inferior ligament, or sometimes behind the 
 tendon of the extensor muscles. In these alternate 
 displacements, it may in some cases be turned round, 
 in such a manner that its anterior surface will take the 
 place of its posterior one, and then resume its primi- 
 tive situation. Desault met with an instance, in which 
 the patient himself was^ in the habit of turning the 
 body round in this mamier. 
 
 19. Bell, in conformity to the distinction of arti- 
 cular concretions into cellular and solid, attributes to 
 each division its peculiar signs. In the first case, the 
 pains, being rather obtuse than sharp, are constant; 
 in the second, they are extremely acute, but disap- 
 pear and return at intervals. Supposing the division 
 to be a real one, cases of the last description certainly 
 occur much more fi*equently than those of the first. 
 
333 
 
 OF T8E TREAtMENt. 
 
 20. From what has been said it follows, 1st, that 
 these cartilages floating through the joints, do mischief 
 mechanically (14), by coming into contact with the 
 articular surfaces : 2dly, that to obviate this mischief, 
 it is necessary either to prevent their contact, by fix- 
 ing the bodies in a spacious part of the joint, and thus 
 doing constantly what nature does on certain occasi- 
 ons, or to extract tiiem through an opening made into 
 the articular cavity. 
 
 21. Hence, art can have recourse to but two me- 
 thods of cure, all hope of discussing these tumours 
 by external applications being, as Bell observes, 
 entirely extinguished. 
 
 22. The first method was proposed by Middleton 
 and Gooch, who having brought the foreign body 
 into a situation where it produced no pain, endea- 
 voured to confine it there a length of time sufficient to 
 mskc it form adhesions with the corresponding part 
 of the capsule. As we are not informed of the result 
 of the experiments of these two physicians, we are 
 left to our own conjectures on the subject. 
 
 23. Are these foreign bodies capable of forming 
 adhesions? Supposing they are, will the internal sur- 
 face of the capsule attach itself to them at the pleasure 
 of the surgeon? Even admitting the existence of 
 botla diese conditions, by what means can the bodies 
 fee kept stationary for a length of time sufficient for 
 ^e formation of these adhesions? Will they not be 
 
5U 
 
 displaced by the slightest motion? Besides, experi- 
 •ence seems to be unfa\^urable to the expedient, I 
 have already said (17) that, in a certain case, the 
 foreign body disappeared for six months, remaining, 
 no doubt, during that whole time, in the same place : 
 but, if it could not, on that occasion, form adhesions, 
 if a motion was sufficient to produce its reappearance, 
 can we expect that art will be more fortunate in her 
 attempts? 
 
 24. But, even admitting that the foreign body 
 does form these adhesions with the capsule, if it 
 should increase in size in the part of the joint which 
 it occupies, becoming in a short time disproportioned 
 to its extent, it will impede motion as before, and 
 produce, by degrees, nearly the same affections. 
 
 25 From these considerations it follows, that the 
 only expedient which can promise a radical cure is, 
 the extraction of the foreign body. In the perform- 
 ance of this extraction, an incision must first be ma^ 
 through the integuments and the capsule, 
 
 26. This operation, simple and easy in itself, has 
 ^iven rise to apprehensions as to its consequences, 
 which have long prevented practitioners from under- 
 taking it. 
 
 It was in former times a maxim in surgeiy, that 
 ^vounds of the joints are, if not mortal, at least ex- 
 tremely dangerous, in consequence of their admit- 
 ting air into contact with the aiticulating surfaces. 
 But observation has demonstrated the fallacy of this 
 doctrine, and Desault in paiticuW, has tlirovvTi great 
 light on the subject, as I have fi'equently had occasion 
 to mention in the course of this uT)rk: so that, at 
 
3S5 
 
 the present day, it is clearly ascertained, that, if jadi- 
 ciously treated, these wounds are seldom productive 
 of serious consequences. 
 
 27. Hence it follows, that the operation we are 
 considering, when skilfully performed, never gives, 
 rise to any dangerous or disagreeable affections. Ex- 
 perience has proved the truth of this assertion in the 
 practice of Theden, Simson, Gooch, Broomfield,. 
 Bell, and Desault, the latter of whom performed the 
 operation five times with complete success. The 
 only case in which he was less fortunate, was that of 
 a man, in whom the wound of the integuments closed 
 up at first without any accident, but which was suc- 
 ceeded by two abscesses, one in the thigh, and the 
 other in the leg, but without any afiection of the in- 
 terior of the joint. This patient was subject to a wan- 
 dering rheumatism, which oftentimes attacked the 
 lower extremities, and was perhaps in the present 
 case the chief cause of the unfavourable occurrences. 
 
 28. It is to the English that we are indebted for 
 the first operation performed for the extraction of 
 these bodies. An account of this is given in the 
 Transactions of a society in Edinburgh. Since that, 
 the operation has been firequently repeated, and more 
 than ten instances of it were already on record, when 
 Pesault first performed it in France. His method, 
 somewhat different from that of others, was as fol- 
 lows. 
 
 1st, The patient must be laid on a bed, or seated 
 on a high chair. The first position, however, is to 
 be preferred, because when it is adopted, the patient 
 need not be moved after the operation^ 
 
336 
 
 2dly, The leg Is extended on the thigh, in Ofd<^ 
 to relax the anterior part of the capsule of the joints 
 
 3dly, The surgeon then searches for the foreign 
 body, moves it to the internal side of the joint, 
 against the attachment of the capsule, and secures it 
 between his thumb and the fore-finger of his left 
 hand, while an assistant draws the skin over tlie fore 
 part of the rotuia. 
 
 4thly, Taking then a common bistoury, he makes, 
 on the protuberance formed by the body, a longitu- 
 dinal incision of an extent proportioned to its size, 
 through both the integuments and the capsule, so as 
 to lay the body bare at the first stroke. 
 
 Stilly, Sometimes the body escapes immediately 
 of its own accord, in consequence of the compression 
 made on it by the fingers. If its passage out be not 
 spontaneous, a small scoop or a taper-pointed spatula 
 passed under it, answers the purpose of extracting it. 
 But, in the introduction of these instruments, it is 
 necessary to avoid touching the articulating surfaces 
 with their ends, lest, by being irritated, they might 
 swell, and give rise to troublesome accidents. 
 
 6. If any resistance be met with, enlarge the open- 
 iTig and the extraction will become easy. Without 
 this precaution, the edges of the wound, being bruis- 
 ed and irritated by the passage of the body, will swell, 
 infiame, and unite again with diificulty. 
 
 7. When the extraction is finished, the assistant 
 who draws the skin towards the inside of the joint, 
 suddenly lets it go, v. hen it returns to its natural situ- 
 ation. This causes the two incisions, which corres- 
 ponded, at the time of the operation, to change their 
 
337 
 
 relative situation, the one remaining internal and 
 the other becoming external. 
 
 8. Hence arises a twofold advantage ; the entrance 
 of air into the interior of the joint is prevented, and 
 the external and loose portion of the capsule, being 
 draM^n inwards with the skin, unites with the condyl, 
 if it be not brought into exact apposition with the 
 other portion of the capsule, divided near its attach- 
 ment. 
 
 9. The extraction being finished, it is then ne- 
 cessary to examine carefully, in order to ascertain 
 whether or not the joint contain any more of these 
 foreign bodies. On -some occasions, when this is 
 even the case, they cannot at the time be discovered. 
 Desault himself was once deceived on this score, in 
 consequence of which his patient was obliged to 
 submit to a second operation. 
 
 10. The incision in the integuments is now united 
 by means of adhesive plaster. Over this are laid 
 compresses and a little lint, and the whole secured 
 by a few turns of a roller drawn moderately tight. 
 
 11. The leg being then placed on a pillow, is kept 
 in a state of extension, by means af a splint applied, 
 for a few days,/behind the joint. 
 
 29. If we examine but for a moment the process 
 in this operation, we must perceive, that an incision 
 made through the skin and capsule at a single stroke, 
 is, in no respect, less advantageous than one made 
 at two strokes, as recommended by all practitioners., 
 and that, it is in the following respects greatly pre- 
 ferable to it: 1st, it shortens the operation very 
 
 considerably : 2dly, it diminishes the pain : 3dly, it 
 
 44 
 
338 
 
 exposes the joint a much shorter time to the contact 
 of the air. 
 
 30. The object of the operator is better answered 
 by drawing the skin outwai'd and towards the rotula, 
 than by either depressing it, as Broomfield did, or 
 raising it, as Bell does. Being more loose and more 
 easily strotched in this direction, the opening in it is 
 removed farther from that in the capsule, which pre- 
 vents more certainly the access of air to the joint, 
 and also favours the examination of the capsule. 
 
 31. In the mean time, the operation may succeed, 
 even although the openings in the integuments and 
 the capsule correspond to each other. Many English 
 and German practitioners, without previously stretch- 
 ing and changing the natural situation of the skin, 
 make a common incision, which they dress after- 
 wards like a simple wound, and are yet no less suc- 
 cessful than others in the result of their operations. 
 This is a further proof of the fallacy of the ancient 
 surgical doctrine, respecting the admission of air into 
 tl^p cavities of joints. Perhaps Desault might have 
 omitted this precaution, had any operations of the 
 kind occurred in liis practice during the last years of 
 his life. 
 
 32. The operation is seldom attended with much 
 pain. Only one patient manifested signs of this in 
 the practice of Desault. Nor have those operations 
 of the kind performed in England been more painful, 
 so that it may be laid down as a principle, that in 
 most cases no primitive accident is to be dreaded. 
 
 33. With regard to hemorrhagy, as there is no 
 large artery near the place of the incision^ there is 
 
339 
 
 nothing to be apprehended on that score. Oftefitimes 
 there is scarcely any loss of blood at all, as may be 
 seen in the first case published in the Journal of Sur- 
 gery. But, even admitting that a small articular 
 branch be divided, the reunion of the edges of the 
 wound will be sufficient to check the hemorrhagy, 
 in the same manner as in the operation for the hare- 
 lip, the contact of the divided integuments of the lip, 
 puts an end to the hemorrhagy from the small arteries 
 of the part. 
 
 §XIV. 
 
 OF THE SUBSEQUENT TREATMENT. 
 
 34. I have already said that but little is to be ap- 
 prehended on the score of accidents subsequent to 
 the operation (26). Out of the numerous operations 
 of the kind performed lately in Europe, but few cases 
 have proved troublesome in their consequences, and 
 even these were influenced by some foreign circum- 
 stances. Thus, for example, one of the patients of 
 Simson rode out on horseback a few hours after the 
 operation, on a cold and stormy day, and thus pro- 
 duced a troublesome affection of the part. A similai' 
 remark may be made respecting the case formerly 
 mentioned (27). 
 
 35. The apparatus or dressing remains uhtauched 
 for the two or three first days, during which time it 
 is necessary to wet it fi^equently with vegeto- mineral 
 water. It is a certain truth, that the use of this liquid 
 retards the suppuration of wounds, and that, when 
 continued a due length of time, it keeps inflammation 
 at that degree most proper for the process of healing. 
 
340 
 
 26. On the removal of the dressing, the wound is 
 sometimes so perfectly healed up, as not to exhibit 
 the least discharge. At other times a shght suppura- 
 tion takes .place; but, at the end of a few days, the 
 cure is complete. Under the care of Desault, it was 
 ^ways effected in eight or ten days. 
 
 67. Let us bring the doctrine just laid down to 
 the test of experience. Five cases have been pub- 
 lished on this point. I have selected two of them,, 
 both which occurred in the same subject, where we 
 find the same operation twice performed with equal 
 success. 
 
 Case I. M. Vielle, aged nineteen, was attacked 
 about the beginning of the year 1790, by a spontane- 
 ous swelling in the joint of the knee. Inconsiderable 
 at first, but increased afterwards by a laborious jour- 
 ney, it disappeared at the end of two months, disco- 
 vering to the touch, near the internal tdge of the 
 rotula, a foreign body, which was hard and moveable, 
 and which somewhat impeded the motions of the 
 joint. 
 
 About a month afterwards, the swelling returned, 
 and, having continued for three months, disappeared 
 again, when the body was found at the external side 
 of the rotula, increased in size. Sundry external ap- 
 plications were tried for six months without success.. 
 
 Weary of this unavailing practice, the patient 
 came, in March, 1791, to consult Desault, who dis- 
 covered a cartilaginous substance of a flat and circular 
 figure. Its usual situation v/as at the external side of 
 the joint, but it could be easily moved to the internal 
 side, and could be turned on its own axis within the 
 
341 
 
 joint, nbr did it occasion any pain, when suffered to 
 remain at rest by the side of the rotula. But, when 
 it passed behind the tendon of the extensor muscles, 
 the patient was unable to stand, and he experienced 
 severe pains when it made its way under the condyls 
 ©r behind the rotula. 
 
 The indication was evident. Before the operation 
 Desault prepared the patient by a proper regimen, 
 and then, in the method already described (28), ex- 
 tracted a foreign body, whitish, and oval, fomteen 
 lines in length, ten in breadth, and two and a half in 
 thickness at its middle. It consisted of three pieces^ 
 united by a ligamentous substance, and was smooth 
 on the side next the joint, but rough with irregular 
 tubercles on the opposite side, and on its circumfer- 
 ence. There was no loss of blood during the opera- 
 tion: the usual dressing was applied, after the most 
 attentive examination, as to the existence of a second 
 
 . Neither. pain nor swelling supervened, and by the 
 fourth day, the reunion was complete. In a short 
 time motion was performed with as much ease as 
 before the occurrence of the complaint. In the mean 
 while, a degree of uneasiness remained in the joint; 
 but barely perceptible at first, this uneasiness conti- 
 nued to increase; in about four months, symptoms 
 of the existence of another foreign body made their 
 appearance. 
 
 M. Vieile being now a distance from Desault,. 
 put himself under the care of his brother, who ex- 
 tracted a second body, in the manner already describ- 
 ed, except that the iacision was made at tv/o strokes. 
 
I 342 
 
 Dressing the same as in the preceding case, with 
 this additional precaution, that the thigh and leg were 
 covered by a roller, for the purpose of moderating 
 the action of the muscles. 
 
 No fever, no pain ; the reunion completed on the 
 eighth day, except a small point in the centre of the 
 wound, which suppurated slightly till the fourteenth. 
 There was now neither difficulty in walking, nor the 
 least sensation of pain. Since that time, M. Vielle 
 has enjoyed the entire use of his limb. 
 
 OBSERVATIONS AND REFLECTIONS 
 
 ON FORMS OF APPARATUS FOR FRACTURES OF THE 
 
 LEG. 
 
 u. 
 
 1. Case I. (Reported by Levacher). Catharine 
 Beiet, aged fifty-live, of a strong and vigorous con- 
 stitution, fractured her leg in the middle, by a false 
 step in alighting from a carriage. Being carried home, 
 in a careless manner, she was visited by a surgeon, 
 who merely reducing the fracture, but applying no- 
 thing to retain the reduction, sent the patient to the 
 Hotel-Dieu. She was conveyed on the same day to 
 the amphitheatre, where Desault discovered die ex- 
 istence of the affection by the following signs. 
 
 Pain in the middle of the leg, less severe when 
 the limb yv?^s at rest, more so when it vvas suddenly 
 moved; the patient absolutely unable to support her- 
 self on it so as either to stand or walk since the acci- 
 dent; inequalities sensible to- the touch on the ante- 
 
343 
 
 rior surface of the tibia; a shortening or contraction 
 of about half an inch ; a preternatural mobility at the 
 place of the fracture; evident crepitation, produced 
 by the rubbing of the fragments against each other, 
 when moved in contrary directions : a change in the 
 direction of the lower fragment, which was bent 
 somewhat outwards. These signs, added to the cir- 
 cumstance of the fall, evidently announced a simple 
 fracture of both bones. The reduction was effected 
 in the following manner. 
 
 One assistant made counter- extension by grasping 
 the lower part of the thigh with both his hands, the 
 fingers being placed behind it, and his thumbs cor- 
 responding to its anterior surface. Another made 
 extension, not as writers recommend, at the lov/er 
 part of the leg, but on the foot itself, which was taken 
 hold of in such a manner that the fingers met on its 
 upper side, while the thumbs crossed each other on 
 its sole. In this way a lever of the first kind was 
 formed, the resistance to which was the fragment to 
 be replaced, while its centre of motion was in the 
 joint. 
 
 Extension being directed at first in the course or 
 line of the displacement, till the limb had attained its 
 usual length, was then directed in such a way as 
 to restore to the leg its natural form. By this, the 
 fragments being brought into apposition, united ex- 
 actly without the process of coaptation being em- 
 ployed.* The apparatus, usually employed by De- 
 
 * That is, without any assistance from the hands of the 
 surgeon. Trans. 
 
sault in such cases, was applied to maintarn the 
 reduction : the different pieces of it had been pre- 
 I'iously aiTanged on a pillow in the follo-wing order: 
 1st, four strong pieces of tape placed at equal dis« 
 lances from each other; 2dly, a junk- cloth,* long 
 enough to reach from the knee beyond the sole erf" 
 the foot; 3diy, a bandage of strips, similar to that 
 described for the tliigh (page 246), arranged in the 
 usual mode ; 4thly, two long compresses, the lower 
 one of which being the longest was turned back on 
 the other; three bolsters had also been prepared; 
 these, being formed of several pieces of imen joined 
 togetlier, were about one inch and a half thick : the 
 broadest of these was designed to be placed on the 
 anterior pail of the leg; the two other iatei-ai ones, 
 though narrower, were a little longer, in order that, 
 by folding back on themselves, they might be ac^ 
 commodated to the inequalities of the limb; 6thly, 
 lastly, there were also prepared two splints, an inch 
 broad, thi'ee lines thick, and of the same length with 
 the junk- cloth. 
 
 Every thing being ready, the assistants still keep- 
 ing up extension raised the leg a little, while a pil- 
 low was slipped under it, to support it equally and 
 uniformly throughout its whole length. The leg was 
 placed on this pillow in such a \^'ay as to corp^spond 
 exactly to the middle of the apparatus which was 
 
 * Analogous in its form and uses to that employed in frac- 
 tures of the thigh. It may not be amiss, on tliis occasion to ^ 
 mention, that in the form of apparatus for obhque fractures of 
 the leg, represented in the Appendix, plate III. no junk-cloth is 
 necessary. Trans, 
 
345 
 
 arranged in order on it, and was previously wet wltK 
 vegeto-mineral water. 
 
 On the anterior part of the leg was Aen ^plied 
 a long compress, extending irom the knee to the 
 tqjper part of the foot. Over this were lapped the 
 other two compresses, which had been previously 
 fdaced in order as part of the apparatus. These were 
 then secured by the bandage of strips, the application 
 of which was begun at the lower strip next to the 
 foot, and contiiiued successively upwards with the 
 rest, making them cross each other at the anterior 
 part of the leg. 
 
 On the sides W€re placed the bolsters which 
 were doubled at the tmcle to protect that part from 
 the pressure it might otherwise sustain. The sphnts 
 were then applied along the external surfaces of the 
 bolsters, the edges of tl^ junk- cloth having been 
 previously folded round them, in order to render 
 iheir pressure the more close and steady. Along the 
 fore part of the leg was laid the largest of the bolsters, 
 and the whole was then secured by the four pieces 
 of tape tied on the external splint, with a degree 
 of tightness sufficient to keep the fragments im- 
 moveable. 
 
 ' A compress wet with vegeto-minergj water 
 covered the foot, and was secured by a roller, appli- 
 ed in such a manner, that its two ends, crossing on 
 the back of the foot, were fastened laterally to the 
 two splints. 
 
 The leg, being firmly fixed by this apparatus, 
 and gently flexed by means of a pillow placed under 
 
 it, was protected by hoops from the pressure of the 
 
 45 
 
346 
 
 bedcloaths. The fragments being now in complete 
 apposition irritated the parts no longer, in conse- 
 quence of which the pain ceased. 
 
 The patient being properly disposed in bed, re- 
 mained tranquil and easy throughout the remainder" 
 of die day. Diluting drinks and light nourishment 
 were prescribed. ; 
 
 Next day, no pain; patient composed; a slight 
 swelling on the back of the foot ; the apparatus wet 
 anew with vegeto- mineral water. Fourth day, the 
 bandages a little relaxed; the point of the foot turned 
 somewhat outwai'ds ; a new application of the appa- 
 ratus. Seventh day, bilious symptoms appear, loath- 
 ing of food, nausea, and bitterness of the mouth. 
 Eighth day, tongue furred, inclination to vomit ; loss 
 of appetite ; a grain of tartar emetic given in solution ; 
 copious dejections; evidently better: next day, ap- 
 petite returned, tongue clean. Tenth day, a third 
 application of the apparatus, which had become too : 
 loose. Fifteenth day, fresh bilious symptoms; fur-, 
 ther evacuations; success the same. Twentieth day, 
 consolidation evidently advancing; no deformity of 
 the limb; fourth appplication of the apparatus. Thir- 
 ty-second day, consolidation almost complete ; the 
 apparatus still kept on till the forty-second day, when 
 the patient was discharged perfectly cured. 
 
 2. This case, which is in no respect different 
 from those that most frequently occur in practice, 
 presents us with a view of the mode of reduction, the 
 means of retention, and the subsequent treatment, 
 employed by Desault, in cases of the kind. The ad- 
 vantage of the bandage of strips, which allows the. 
 limb to be uncovered without being disturbed, is 
 
347 
 
 now generally acknowledged in fractures of the lower 
 extremities. In the treatment of these, practitioners 
 reject entirely, at present, the roller bandage, which 
 was recommended by Petit, Heister, and all the au- 
 thors who preceded them, and which, by producing 
 a new displacement, at each time of reapplication, 
 may entirely prevent the fragments from uniting. 
 The bandage of Scultet, brought into use again by 
 Dcsault, the form of which has been just described, 
 is also preferable to the eighteen-tailed bandage, 
 which some practitioners still employ. 
 
 3. The strips which compose the former bandage, 
 being narrower than the tails of the latter, can be 
 more neatly applied to the leg, as they more readily 
 mould themselves to its inequalities; the compres- 
 sion made by them is, therefore, more exact, more 
 uniform, and consequently less inconvenient. If one 
 of the strips become soiled, it can be changed with- 
 out deranging the bandage. (Respecting this point, 
 see what was said on fractures of the thigh. ) This 
 bandage being less bulky than the eighteen-tailed 
 one, is therefore less troublesome to the patient. 
 
 4. The broad and strong splints which form a part 
 of this apparatus, have the following advantages over 
 those previously used both by the ancients and the 
 moderns; 1st, they come in contact with and bear 
 on a lai'ger extent of the surface of the limb ; 2dly,- 
 they consequently maintain the fragments in apposi- 
 tion with greater firainess and effect; 3dly, they pre- 
 vent the rotation of the foot outwards, an accident 
 which very frequently occurs when the fracture is 
 complete, that is, when both bones are broken; 4thiy, 
 they remain constantly in their place, without slip- 
 
ping either forward or backward, an incoftvenietiofr 
 necessarily attendant on the other splints, which, 
 from their roundish form, touch the limb in only onfe 
 point or line, ^ 
 
 5. To sustain th€ foot, Petit recommends a piece 
 of a board to be applied immediately to its sole, and 
 supported by two bits of tape fastened to the splints^ 
 This practice is adopted to some extent even at pre- 
 sent: but a simple roller, applied in the manner alrea« 
 dy mentioned,^ is sufficient for the purpose ; the ten- 
 dency of the foot to turn outwaj'ds is never so strong 
 as not to be effectually resisted by this expedient: 
 besides, should the piece of board be placed ever so 
 little too vertically^ it retains the foot in a state of in- 
 convenient and painful flexion. 
 
 6. The situation of the leg, gently flexed by 
 means of a thick cushion or pillow placed between it 
 and the mattress, is, in all respects to be preferred to 
 the method of Pott, wliich is exclusively adopted by 
 Bell. What, indeed, can be the object of this latter 
 method? To relax, say they, the muscles, that tend 
 to make the lower fragment overlap the upper one*. 
 But is it not evident, that most of these muscles, not 
 being attached to the os femoris at all, cannot be infiu- 
 -cnced by this position? To obtain the relaxation oC 
 the posterior muscles, it is necessary toflex the foot j 
 but, in such a case, the anterior muscles ai*e neces- 
 sarily in a state of tension: this completely counter- 
 balances the relaxation of the others, and, therefore., 
 there is nothing w^iatever gained. It is certainly muohfe 
 best to allow the leg to be in a state of moderate flexi* 
 on, such as we assume when asleep, and which, ap- 
 pears to be the most natui'al. 
 
349 
 
 7. The apparatus just described, produces on the 
 fragments a twofold action : 1st, by a kind of side 
 walls formed by the splints, it prevents their displace- 
 ment laterally, and from this circumstance alone, is 
 fully sufficient for the retention of transverse fi'aetures : 
 2dly, the pressure of the rollers, splints, and bolsters, 
 if these be applied with sufficient tightness, prevents 
 the lower fragment from mounting on the upper one, 
 and thus preserves the natural length of the limb. 
 Hence its advantages in oblique fractures; and, as 
 the powers of displacement are weaker here than in 
 the thigh, this apparatus, is in general, sufficient to 
 eoimteract them. 
 
 8. It is true that cases do^ sometimes though 
 rarely occur, where, in consequence, of being irritat- 
 ed by splinters, or the points of the fractured bone> 
 or acted cai by som« other causes which make them 
 eontract, the m^uscles overcome the resistance of the 
 apparatus, and make the fragments overlap. Under 
 such circumstances, permanent extension affi:^rds here 
 the same advantages as in fractures of the thigh. 
 
 9. Most authors, to obtain the desired end in such 
 eases, recommend means calculated to act on the 
 thigh. Thus, Manne proposes the use of his glaus- 
 socome. Desault, under such circumstances, effected 
 his purpose by the apparatus described in th6 follow- 
 ing case. 
 
 10. Case II. Pierre Bejol, aged thirty- sevea^ of 
 a strong and vigorous constitution, fell, as he was 
 carrying a heavy load, over a beam which lay in his 
 
350 
 
 way. His leg was fi-actured towards its lower part; 
 he was lifted up and carried home, where a surgeon, 
 by making unskilful efforts at reduction, gave him 
 extreme pain. 
 
 A roller and a kind of round splint applied to each 
 side of the limb, forming the whole of the apparatus, 
 and not being sufficient to retain the fragments, soon 
 alloAA'ed them to overlap each other nearly two inches. 
 The pains continue; a considerable swelling appears 
 around the fracture; the patient is greatly agitated; 
 he is brought to the Hotel-Dieu, where, from the 
 deformity of the limb, Desault was satisfied, at first 
 sight, of the existence of a fracture ; on a more atten- 
 tive examination, it was discovered to be complete 
 and veiy oblique. 
 
 The muscles being tense and in a state of violent 
 contraction, drew the inferior fragments very forcibly 
 upwards; these were finally, however, by means of 
 well directed efforts, brought into perfect contact, 
 with the superior fragments : the difficulty now lay 
 in maintaining this contact. The age of the patient, 
 his strength, and the almost convulsive state of the 
 muscles, gave reason to apprehend that a displace- 
 ment was about to occur. An attempt was made to 
 prevent this in the following manner. 
 
 The patient being laid on a bed properly pre- 
 pared, 
 
 1st, The foot and the leg above the ancle, were 
 covered by a bolster or compress, round which was 
 passed a strong roller intended for the pui'pose of 
 making extension. The ends of this roller, being 
 
351 
 
 left free, were carried, one on the outside, and the 
 other on the inside of the limb. 
 
 2dly, Below the tubercle of the tibia was placed 
 another bolster, surrounding the leg, and on this, 
 was secured another roller for the purpose of counter- 
 extension. The ends of this roller, after crossing 
 tinder the knee, were left hanging loose one on each 
 side of the limb. 
 
 3dly, The two rollers being thus arranged, while 
 the assistants, still continued to make extension, the 
 surgeon applied successively, and in the order al- 
 ready mentioned, the compresses, the bandage of 
 strips, and the bolsters. 
 
 4thly, He then took two splints with notches in 
 their lower ends, of the same breadth with the splints 
 already described, but long enough to reach, each of 
 them, from four inches above the knee to the distance 
 of four inches beyond the sole of the foot. One of 
 these was applied on the outside and the other on 
 the inside of the leg. 
 
 5thly, The surgeon then taking hold of the two 
 ends of the upper roller, drew them over the upper 
 ends of the corresponding splints, while an assistant 
 crossing the two ends of the lower roller under the 
 sole of the foot, drew the external end over the lower 
 extremity of the internal splint, and the internal end 
 over the lower extremity of the external splint. Car- 
 rying them, then, up along each side, he brought 
 them, at the middle of each splint, to meet the ends 
 of the upper roller, to which they wTre finiily se- 
 cured by knots, so as to make extension at the foot, 
 and counter-extension at the knee. The two frag- 
 
a52 
 
 ments, being drawn by this apparatus, the one down 
 and the other up, could not again overlap.* 
 
 On the same day the patient was bled copiously; 
 a low diet was prescribed; some diluting drinks were 
 administered; and the whole apparatus was frequent- 
 ly wet with vegeto- mineral water. 
 
 Next day, fever; restlessness; blood-letting re-r 
 peated; the extending rollers, having become relaxed, 
 were tightened. Third day, evidently better. Eifth 
 day, a new application of the apparatus ; some swelL 
 ing of the foot; a few small blisters on the leg; these 
 were opened and dressed with cerate spread on linen. 
 Eighth day, the patient easy and tranquil; a little 
 shortening of the limb; a third application of the 
 bandage. Twelfth day, bilious symptoms appear. 
 Thirteenth day, an emetic given in solution; symp- 
 toms decline. Twentieth day, the fractured limb in 
 a favourable state; the roller for extension laid aside; 
 that formerly described employed in its place. Thir- 
 tieth day, an appearance of consolidation. Tliirty- 
 fourth day, bilious symptoms recur; further evacua- 
 tions. Forty-third day, consolidation perfect; scarcely 
 a vestige of the fracture remains. Exercise is repeat- 
 ed for several days. Fiftieth day the natural strength 
 and motion of the part completely restored. 
 
 11. The general eaid to be answered by every 
 bandage intended to retain a veiy oblique fracture of 
 the leg, is evidently, 1st, to hold the knee up, and 
 
 * For a view and description of an excellent form of appa- 
 ratus for oblique f\*actures of the leg, constructed on^ the prin- 
 ciples of that here d^cribedj see article III. plate III. of the 
 Appendix. Thahs. 
 
353 
 
 with it the superior fragments; 2dly, to draw the 
 lower fragment down : from this twofold effect arises 
 a twofold resistance diametrically opposed to the 
 powers of displacement, which are ; 1st, the slipping 
 down of the trunk, which pushes the thigh before it, 
 and with it the upper fragments of the leg; 2dly, the 
 action of the muscles of the leg, drawing the foot up- 
 wards, and the lower fragment along with it. 
 
 12. But, if to these indications we compare the 
 bandage described in the foregoing case, we will 
 perceive that they are perfectly fulfilled by it. In- 
 deed the splints forming a kind of puUies which 
 change the direction of the rollers, we must count 
 on the action of these rollers only from the part of 
 the limb which they surround, to the ends of the 
 splints over which they are reflected: whence it 
 follows, that the two ends of the upper roller, reflect- 
 ed over the superior extremities of the splints, can- 
 not be drawn down along each of these splints, v»^ith- 
 out that part of the rollers, which reaches from the 
 leg to these extremities, being drawn up, and with 
 k the knee and the upper fragment. In like manner, 
 the ends of the lower roller cannot be drawn up 
 towards the ends of the upper one, without those 
 portions of them which run from the sole of the foot, 
 being drawn down and pulling the foot and the infe- 
 rior fragments along with them. 
 
 13. Hence it follows, that by tying on each side, 
 one end of the upper roller to the corresponding end 
 of the louver one with sufficient tightness, the two 
 indications above laid down ( 12) ai'e accurately ful- 
 filled. 
 
 46 
 
354 
 
 ;^ '■ 14. But, in general, the common bandage is suf^ 
 ficient, as I have already mentioned, even in cases of 
 oblique fractures, to prevent the ascent of the lower 
 fragments on the upper ones. Desault never employ w 
 ed any others in the last years of his practice, and it 
 was only in cases of extraordinary disposition to mus- 
 cular contraction, that he ever had recourse to the- 
 second kind. By means of the common apparatus, 
 he was able to prevent the overlapping of the frag- 
 ments from forming any protuberance on the ante-- 
 rior and internal part of the leg. 
 
 15. We must acknowledge, however, tl^t this, 
 apparatus is liable to the same objection with most 
 others intended for permanent extension. The roller 
 placed below the knee, for the purpose of counter- 
 extension, surrounds almost all the muscles, which 
 tend to make the inferior fragments overlap the supe- 
 rior ones, by draw ing the foot upwards. By pressing 
 on and irritating these, it favours, and even excites 
 their contractions, and, by that means, gives rise to 
 a shortening of the limb, tlie very accident which 
 the apparatus is intended to prevent. This inconve- 
 nience induced Desault, in a particular case, to sub- 
 stitute to the preceding apparatus, that used for 
 permanent extension in fractiures of the thigh. 
 
355^ 
 MEMOIR XV. 
 
 ON THE DIVISION OF THE TENDO ACHILLIS. 
 
 1. It might be supposed that a work on diseases 
 of the soft parts, would be a more proper place for 
 this article, than the present one, where my express 
 object is to treat of affections of the hard parts. What 
 induces me to insert it here is, the analogy which 
 exists between a division of the tendo Achillis and a 
 fracture of the os calcis, the light which the treatment 
 of the one throws on that of the other, and the exam- 
 ple of the celebrated Petit, who, in his work on 
 diseases of the bones, speaks also of this division. 
 
 OF TH<E CAUSES AT^D VARIETIES. 
 
 2. The division of the tendo Achillis is the result, 
 either, 1st, of the action of a cutting instrument; or, 
 2dly, of muscular action : hence two very different 
 modes of its production, the one by a wound, the 
 other by a rupture. The first is not a very rare acci- 
 dent, because the projection of the tendon exposes it 
 oftentimes to the stroke of external bodies : the se- 
 cond, though but little noticed by the ancients, has 
 been frequently observed by the modems, since their 
 attention was called to it by Petit. 
 
 3. The manner in which the division is produced 
 by a wound, has nothing particular in it; that by a 
 rupture, takes place in the following manner, A man 
 
356 
 
 leaps over a ditch, but his spring or exertion is too 
 weak ; he reaches the opposite bank only with the 
 ends of his feet : the Hne of gravity not faUing on the- 
 ground, the weight of the body throws the feet into 
 a state of violent flexion, the muscles contract with 
 great force, to prevent a fall backwards, and, at that 
 instant, the tendon is ruptured, in consequence of 
 being drawn downwards by the violent flexion of the 
 foot, and upwards by the effort of the muscles : hence 
 it appears that Petit was deceived with regard to the 
 mechanical cause of the rupture, which he considered 
 as taking place at the moment of the patient's alight- 
 ing on his feet, when, as he said, the tendons were 
 surprised, so to speak, into a state of too great ten- 
 sion. It is easy to apply the principles of this parti- 
 cular case to others that may happen, and where the 
 position may not be the same; such as, when we 
 leap on a table, &c. Sometimes slighter efforts have 
 produced the effect; and, as Louis observes, dancers 
 have sometimes ruptured the tendo Achillis by mak- 
 ing a po\\'erful exertion on the pomt of the foot, as 
 well as by other motions. 
 
 4. Divisions produced in the first mode, may be 
 situated in any part of the tendon. Those produced 
 in the second, occur more particularly about its mid- 
 dle : to that part the effort or strain is most forcibly 
 determined, and there the resistance is the weakest. 
 The rupture of the tendon may, according to Petit, 
 be either complete or incomplete ; but, if we consi- 
 der the simultaneous contraction of the gasti'ocnemii 
 and soleus muscles, and the intimate manner in which 
 their tvro tendons ai'e united at a considerable dis- 
 
357 
 
 tance above the heel, it will be difficult to conceive 
 how these tendons can be ruptured separately. With 
 regard to divisions produced by cutting instruments, 
 the case is different: there, the weapon may pass 
 half way through the tendon either from behind or 
 laterally; and perhaps divisions of this kind are 
 much more frequently incomplete than otherwise, 
 in consequence of the great resistance of the tendi- 
 nous fibres. 
 
 § II. 
 
 or THE SIGNSr. 
 
 5. The superficial situation of the tendo Achiftis, 
 always renders the diagnosis of its division easy. It 
 can be rendered difficult only by the occurrence of 
 a considerable s"\velling, an accident that rarely hap- 
 pens. If there be an external wound, the depth to 
 which the instrument has penetrated, and the possi- 
 bility of sometimes feeling the ends of the tendon 
 between the edges of the wound, are the first eviden- 
 ces of its division. If, on the other hand, the tendon 
 be only ruptured, then at the moment when the rup- 
 ture happens, a report is heard by the patient, not 
 sharp, and like the crack of a whip, as is said to take 
 place when the plantaris muscle is ruptured, but 
 more dull and flat, according to the account given to 
 Desault by a patient, whom he interrogated on the 
 subject. 
 
 6. In either case, there occurs suddenly, if not an 
 entire inability, at least, an extreme difficulty in either 
 standing or walking: hence the patient falls, and is 
 
$5B 
 
 unable to rise again ; but, in divisions that are only- 
 partial or incomplete (4), this sign does not occur. 
 Between the divided ends of the tendon there exists 
 a depression sensible to the touch. This depression 
 is increased by the flexion of the foot, but diminished 
 and even entirely removed by its extension. 
 
 7. The patient can spontaneously flex the foot, 
 none of the flexor muscles being affected, and this 
 flexion may be carried even beyond what is natural, 
 because the divided tendon forms no obstacle to it 
 behind. Spontaneous extension is also practicable, 
 in as much as the peroneus longus, tibialis posticus, 
 &c. which remain uninjured, are capable of producing 
 that motion. Some have alleged that the calf of the leg 
 must be increased in size by the swelling of the gas- 
 trocnemii and soleus muscles, in consequence of their 
 state of contraction; but modem experience has 
 shown, that there is but little reliance to be placed on 
 that appearance. 
 
 ..OP THE PROGNOSIS. 
 
 8. Divisions of the tendons are not in general dan- 
 gerous. These organs, being insensible in their na- 
 ture, ai'e not painful when niptured, as is proved both 
 by experiments on living animals, and by the obser- 
 vations of surgeons who have had such affections 
 under their care, more particularly of Monro, who 
 experienced the accident in his own person. No 
 inflammation supervenes, and if a swelling be some* 
 times the consequence, it is in general soon dispersed, 
 leaving behind it nothing serious. 
 
559- 
 
 9. Whence arose then the exaggerated fears of 
 the ancients respecting injuries of this kind? Doubt- 
 less from an opinion which was then entertained, that 
 tendons and nerves were of the same nature. Hence 
 the severe pains, the convulsions, and even death 
 itself, which, according to them, frequently happened, 
 and was always to be apprehended, as the consequence 
 of injuries done to these organs. Lamotte, among the 
 modems, still enteitained these prejudices, when, in 
 S5>eaking of affections of the tendo Achillis, he said, 
 '* So dangCTOus are they in their consequences, that 
 they can seldom be brought to a favourable termina- 
 tion." 
 
 10. Doubtless the unskilful treatment, employed 
 by the ancients, in cases of this kind, the use of the 
 bloody suture without proper means to retain the 
 parts in a suitable situation, the abuse of irritating 
 remedies applied externally, the imprudent adminis- 
 tration of oily substances, and, still more, the motions 
 erf the patient, contributed not a little to the produc- 
 tion of those accidents, which no longer occur in the 
 practice of the moderns, since the nature and treat- 
 ment of the disease is better understood. It has been 
 fsroved, by late observations, that the division of the 
 tendo Achillis is apt to produce some diminution in 
 the size of the affected leg. But this soon disappears,, 
 i»or does it, indeed, even occur, if, by a proper appli- 
 cation of the bandage y a speedy union of the divided 
 part be obtained. The patients of Desault never ex- 
 perienced it. 
 
360 
 
 OF THE INDICATIONS OF CURE. 
 
 LI. That I may present, in order, what I have to 
 offer on the treatment of the division of the tendo 
 AchiUis, 1st, I will lay down, with precision, the indi« 
 cations of cure that arise out of this division : 2dly, 
 with these indications I will compare the means used 
 by different authors, by which the insufficiency of 
 almost all of them will be demonstrated: 3dly, by 
 showing the relation or correspondence that subsists 
 between these indications, and the apparatus employ- 
 ed by Desault, I will prove that it fulfils them suffici- 
 ently, and is, therefore, to be preferred to every other. 
 
 12. To bring the edges of the division into con- 
 tact, and to retain them so, are here, as in other simple 
 wounds, the two general principles of treatment. 
 The first of the principles presents an easy indication; 
 it is only to extend the foot forcibly on the leg. The- 
 indications that arise out of the other, are more diffi- 
 cult to be fulfilled. 
 
 13. To form a proper idea of these, let us call to 
 mind what it is that prevents the contact of the divid- 
 ed ends. As far as relates to the lower end, it is the 
 flexion of the foot on the leg, and with respect to the 
 upper one, the contractions of the gastrocnemii and 
 soleus muscles, which ai'e not now opposed by the 
 continuity of the tendon. Therefore, 1st, to keep 
 the foot permanently extended; and 2dly, to oppose 
 the action of these muscles, are the two general indi- 
 cations or objects of every etpparatus destined to 
 retain the two ends of the tendon iu contact. 
 
S61 
 
 ■ 14. But, the action of the muscles may be op- 
 posed in different ways ; 1st, by keeping the muscles 
 themselves in a state of relaxation. This relaxation 
 may be easily effected, as far as relates to the gas- 
 trocnemii, in consequence of their insertion into the 
 posterior part of the condyls of the os femoris : it is 
 sufficient, for this purpose, to keep the leg half-bent 
 on the thigh: 2dly, by a judicious and well directed 
 compression made on the muscles. I say judicious 
 and well directed, because it ought to bear chiefiy on 
 the fleshy portion, and not on the tendon, otherwise 
 it will depress its divided ends, destroy their contact, 
 and make them unite, not Avith each other, but v/ith 
 the adjacent parts, and thus produce considerable 
 lameness. At the same time that care is taken not 
 to depress the divided ends, these ends must not be 
 permitted to move from side to side, a kind of dis- 
 placement which may readily occur, in consequence 
 of the hollow or depression situated on each side of 
 the tendon. But, the only expedient to attain this 
 twofold purpose, is, to place in these hollows, some 
 soft substance, lint, for example, which may project 
 sufficiently to protect the tendon behind, and to re- 
 tain it laterally. 
 
 15. This compression, that ought to be made by 
 the bandage, appears to have escaped all writers, as 
 none of them have given it a place among their means 
 of cure. Yet, do we not plainly perceive, that, by 
 confining the muscles, impeding their contractions, 
 and reducing their irritability by its long continued 
 use, it must tend to prevent the superior end from 
 
 being drawn upwards and thus separated from the 
 
 47 
 
362 
 
 Hiferitjf one ? Will not compression, in this case, he: 
 similar to the effect of the uniting bandage, in trans- 
 verse \\ ounds, where the great number of circular 
 casts Vvhich cover the limb,, are particularly intended 
 to weaken muscular action, analogous to what takes 
 place in hare-lip, where the compresses do as much 
 good by compressing the muscles, as by bringing 
 together the edges of the divided lip? But further^- 
 besides reducing the fcH-ce of the muscles, does not» 
 this compression, serve to prevent the swelling of the- 
 limb, an effect almost inevitably resulting from; its 
 state of rest and deficiency of action? So far, then,. 
 from being, as Louis says, one of the inconveniencies. 
 of the first bandage of Petit, it constitutes one of its. 
 principal titles to a preference among practitioners. 
 
 16. It appears from what has been just advanced^' 
 (13.... 15), that the following are the three ends to- 
 be attained by every bandage, intended to retain the 
 divided ends of the tendo Achillis in contact; 1st, 
 the immobility of the foot in a state of permanent 
 extension on the leg; 2dly, the immobility of the 
 leg, in a state of semiflexion, on the thigh; 3dly, a- 
 judicious and well directed compression made on the 
 whole leg and foot, but bearing on the tendon with 
 only sufficient force, to keep it from moving back-^ 
 wai'd or laterally. Let us compai'e the methods of 
 authors with these indications. 
 
§.63 
 
 tOF THE DIFFERENT METHODS OF CUHE. 
 
 17. The treatment recommended by authors 
 may be reduced to three general methods. The first 
 consists in rejecting all artificial aid, and leaving the 
 cure to nature and the f)osition of the limb. To the 
 second belongs the use of sutures, intended to retain 
 the edges of the division together. The third in- 
 cludes the different kinds of apparatus employed for 
 the same purpose. 
 
 18. First method. Chronological order places 
 this method after the others. But this order must be 
 disregarded by him, whose object is things rather 
 than time. The history of the sciences calls some- 
 times for the approximation of distant periods, and, 
 at other times, for the separation of those already 
 approximated. 
 
 19. Several practitioners, in France and England, 
 have lately proscribed the use of all external means, 
 Pibrac and Dupouy were of opinion, that the mere 
 precaution of the patient not to flex the foot, assisted 
 by constant rest, was sufficient. Hoin and Gauthier 
 mention many cases in confirmation of this doctrine. 
 M. J. Rodbard, surgeon at Ipswich, having ruptured 
 his own tendon about tliree inches above the heel 
 in leaping over a little rivulet, instead of confining 
 himself to bed, continued in the exercise of his pro- 
 fessiom He walked every day, without any other 
 precaution than that of not flexing the foot, and five 
 years afterwards, he was able, as he mentions, " to 
 
364 
 
 walk, run, mount or alight fi-om his horse, without 
 pain, in a word, the affected leg performed its func- 
 tions as well as the other one." We have an account 
 of a patient who was cured without a bandage by A. 
 Petit. 
 
 20. Was there indeed a true rupture of the ten- 
 don, in all these cases, particularly in those where the 
 patients continued to walk as before the accident? 
 Most of the cases which we have seen prove the im- 
 possibility of either standing or walking (6). But, 
 admitting that they were ruptures, are we authorized 
 to pursue the mode of treatment there adopted? Cer- 
 tainly we are not. None of the indications formerly 
 mentioned (16) is there fulfilled. What is there, 
 under such circumstances, to prevent an im-oluntary 
 motion from destroying the contact of the divided 
 ends, by forcibly flexing the foot and extending the 
 leg? The limb is not subject to any compression. 
 Should such an accident happen, the cure must ne- 
 cessarily be tedious. Besides, if the ends be sepa- 
 rated, a reunion cannot take place, except by an in- 
 termediate substance, which, by filling up tlie vacant 
 interval between them, must lengthen the tendon. 
 In consequence of this, the muscles will be impeded 
 in their contractions, and the foot in its motions, as 
 Desault has oftentimes observed in animals, which 
 he left to themselves, after having divided the tendo 
 Achillis. Thus, in a fracture of the rotula, the mo- 
 tion of the limb is very much impaired, when die 
 ligamento-cartilaginous substance which unites th^. 
 fragments is too long. 
 
565 
 
 21. Hence it follows, that here, in like manner as 
 in other ruptures of the tendons, art must assist na- 
 ture, because without the former the powers of the 
 latter will be insufficient. 
 
 22. Second method. The ancients pursued a 
 course not less uncertain, and much more dangerous. 
 Sutures, sanctioned by general custom, were extend- 
 ed to wounds in the tendons, and were even more 
 especially employed in such cases, because the tendi- 
 nous end being drawn forcibly and greatly displaced 
 by the contraction of the fleshy portion in which it 
 terminates, it was deemed necessary to oppose to this 
 force a greater resistance. 
 
 23. What useful end was attained by this practice? 
 Muscular action v/as left perfectly free ; and the only 
 thing done was an attempt made to resist its effect. 
 But, in a short time the tendinous ends, in conse- 
 quence of being forcibly stretched by the contractions 
 of the muscles, either gave way at the points where 
 the stitches were introduced, or, in case they did not 
 give way, became swollen, painful, and inflamed, in 
 consequence of the violent distension which they suf- 
 fered : hence the serious affections produced by such 
 treatment (9 and 10). 
 
 24. The ancients, then, were mistaken, with 
 respect to the indications in this disease, which are, 
 not to resist muscular contraction left free and unim- 
 peded, but to check and prevent this contraction, by 
 the means formerly pointed out (16). It is a princi- 
 ple generally acknowledged at the present day, that 
 sutures ought not to be used as a mean of approxi- 
 mating divided paits, but only to keep the edges of 
 
S66 
 
 parts already approximated in perfect contact. But, 
 in the present case, the means of approximation being 
 sufficient for the purpose of exact contact, sutures are 
 altogether unnecessar}\ This, however, does nol: 
 hold true in eveiy case, though certain practitioners, 
 who have too generally rejected the use of sutures, con- 
 tend that it does. Finally, however, these means have 
 been excluded from, the treatment of the division of 
 the tendo Achillis, and the doctrine of the Academy 
 of Surgery, though erroneous in many other cases, 
 lias established, v/ith regard to the present one, the 
 irue practice. 
 
 25. Third method. It is to the celebrated Petit 
 that we are indebted for that method of treating the 
 division of the tendo Achillis, which consists merely 
 in position maintained hy apparatus. Having ascer- 
 tained that the extension of the foot brought the 
 fragments into contact, he conceived the idea of con- 
 tinuing this extension throughout the whole treat- 
 ment, for the purpose of continuing the contact also. 
 This was a happy idea, the simplicity of which recom- 
 mended it to practitioners, and which,, being once 
 discovered, has formed tlie common basis of all the 
 numerous processes devised since by different authors. 
 
 26. When we consider the action of tliese several 
 processes, and compare it with the indications for-: 
 merly laid down (16), we may divide the processes 
 themselves into three general classes. Thus, some 
 of them fulfil only the first and third of these indica- 
 tions, namely, the permanent extension of the foot, 
 and a regular compression made on the leg; others 
 fulfil only the fii:st and second, the latter of wliich 
 
3^" 
 
 cOTisists* hi keeping the leg constantly flexed on the 
 thigh; while those of the third and last class, fulfil 
 the first indication only. This manner of classing the 
 processes, will shorten the consideration of each of- 
 them individually, since it is evident that each class 
 is chargeable with one general inconvenience, namely^ 
 that of being deficient with respect to one or two of 
 the leading indications. I shall examine nothings 
 therefore, but the disadvantages peculiar to each. 
 
 27. To the first class belongs, almost exclusively^ 
 the first bandage invented by Petit. It is formed by 
 a long compress, placed longitudinally behind the- 
 leg and foot, and secured by a roller applied regularly " 
 on these parts. The two ends of the compress, being" ' 
 reflected back, are then knotted together behind the- 
 leg so as to extend the foot. This expedient is sim- 
 ple and ingenious, and would be preferable to all 
 others, were it not that, besides the charge of not' 
 fulfilling the second general indication (16), it is fur- 
 ther liable to. the following objections : 1st, thev 
 compression which it makes is injudicious and ill 
 directed, because it bears not only on the fleshy por- 
 tion of the leg, but ako on the divided tendon, which 
 being more projecting and therefore more exposed, 
 has its two ends pressed down and separated : 2dly, 
 in somepcases, it does not maintain the extension of 
 the foot with sufiicient certainty : 3dly, it does not 
 prevent displacement in a lateral direction, 
 
 28. To the second class belong, 1st, the celebra- 
 ted slipper of Petit, substituted by that author for his 
 first bandage ; this machine was composed of a slip- 
 
561? 
 
 per fixed to the foot, of a knee-piece* secured on the 
 lower part of the thigh, and of a strap running from 
 the one and fastened to the other, to extend at plea- 
 sure the foot on the leg, and to flex the leg on the 
 thigh : 2dly, the bandage of Duchanoy, made in. 
 imitation of the preceding apparatus, and consisting 
 of a simple sock surmounted by a roller, which run- 
 ning along the back part of the leg, was fastened to 
 another roller applied round the lower part of the 
 thigh. Besides the general objection of not at all ful- 
 filling the third indication (16), tliese processes are 
 liable also to the following ones ; 1st, they fatigue 
 the toes by the constant pressure of the slipper and 
 the sock, as Monro experienced in his own person, 
 to such an extent that he was unable to support tlieir 
 use; 2dly, the slipper is quite too complicated, and 
 is therefore seldom at hand when wanted. The ap- 
 paratus of Duchanoy, does not possess sufficient 
 solidity and steadiness. 
 
 29. In the third class are included, 1st, the first 
 machine of Monro, formed of a slipper similar to 
 that of Petit, surmounted by a strap of leather, which 
 w^as to be fastened by a buckle to a kind of guetre or 
 spatterdash, fixed on the upper part of the leg; 2dly, 
 the second apparatus of the same author, subject, 
 like the other, to several inconveniences; 3dly, the 
 simple apparatus of Schneider, who rested satisfied 
 with maintaining the extension of the foot, by a splint 
 
 * fGenoiiilliere.J I believe this was a piece of apparatus 
 made of leather, somewhat similar to the top of a boot, and 
 -secured on the Umb just above the knee. Trans. 
 
36^ 
 
 |)Iac€d anteriorly. Besides various other objections 
 to them, these are all Chargeable, alike, with the 
 radical fault, of not fulfilling the second and third 
 indications (16). 
 
 30i From this comparison of the indications (16) 
 with the means destined to fulfil them, it appears 
 that there were material defects on the part of the 
 latter. Let us examine whether or not that of De- 
 sault was better calculated for the purpose. It is, so 
 to speak, nothing but a modification of the apparatus 
 of Petit (27), but such a modification as amounts to 
 kti improvement in principle, and entitles it to be 
 called the apparatus of Desault. 
 
 31. The pieces which compose it are; a com- 
 press two inches broad, and long enough to reach 
 from the lower part of the thigh to the distance of 
 four inches beyond the foot; a roller five or six yards 
 long and two inches wide; a sufficient quantity of 
 iint; and two long graduated compresses. 
 
 32. Every thing being ready ; 
 
 1st, An assistant supports the foot and leg, thd 
 former in a state of great extension, and the latter 
 half-flexed: another assistant supports the thigh, 
 grasping it about its middle. 
 
 2dly, If there be a wound of the integuments, a 
 little lint wet with vegeto- mineral water is laid direct- 
 ly over the division of the tendon; if it be a simple 
 rupture, this precaution is unnecessary. Under the 
 foot, up behind the leg, and the louver part of the 
 thigh, is then extended the long compi*ess, which is 
 to be secured in that situation by the hands of the 
 
 assistants. 
 
 48 
 
370 
 
 3dly, The hollows situated at the sides of the 
 tendo Achiliis, are then filled up with pledgets of dry 
 lint, surmounted by the two long graduated com- 
 presses, which retain the pledgets, and must project 
 a little beyond the tendon, because they are liable 
 to be rendered flat by pressure. 
 
 4thly, The surgeon now taking the roller, makes 
 at first several circular turas round the toes, fixing 
 the long compress there, the end of which, being 
 reflected over these first casts, is secured by a few 
 additional ones which cover the whole foot, and are 
 after\^'ards directed obliquely above and below the 
 division, round which is formed a kind of figure of 
 8, that brings the edges of the wound into {>erfect 
 contact. If there be no wound of the integuments, 
 it is necessary to take care, lest the skin interposing 
 between the divided ends of the tendon, should se- 
 parate them, and thus prevent their reunion. Ascend- 
 ing, then, by circular casts, along the whole leg, and 
 even to the lower part of the thigh, the surgeon 
 there turns down the upper end of the long compress, 
 and securing it by a few more circular casts, finishes 
 the application of the roller. . 
 
 5thly, The apparatus being thus applied, and the 
 extension of the foot and the flexion of the leg firmly 
 secui'ed by it, the leg is then placed on a pillow or 
 bolster, one side of which corresponding to the angle 
 which the leg forms with the thigh, assists in keep- 
 ing it half- flexed. 
 
 6thly, Should the long compress prove insuffi- 
 cient to keep the foot extended, or should it, by be- 
 coming relaxed too soon, render frequent reapplica- 
 
-371 
 
 lions of the apparatus necessaiy, (circumstances 
 which rarely happen when the bandage is well ap- 
 plied), a splint placed anteriorly, as was the case in 
 Schneider's apparatus (29), completely remedies the 
 defect. 
 
 33. On comparing this apparatus with the indi- 
 cations formerly laid down, in the present disease 
 (16), we find it evidently calculated to fulfil them 
 with great exactness. 1st, The extension of the 
 foot is permanently secured, both by the long com- 
 press, and by the splint when it is employed : 2dly, , 
 the same compress, aided by the bolster or pillow 
 placed under the leg, maintains the flexion of the 
 leg on the thigh: 3dly, The muscles are effectually 
 compressed ; their action is impeded in part by the 
 compression of the circular bandage, which does not 
 bear on the tendon, in consequence of the bolsters 
 of lint placed on each side of it : these bolsters pre- 
 vent the tendon both fi^om moving laterally, and from 
 being depressed: hence it follows, that the action of 
 the circular bandage is precisely confonnable to the 
 principles already established (14 and 15); and that 
 the whole of the apparatus, taken together, fulfils 
 perfectly all the indications (16); this is an advantage 
 not to be derived from any of the forms of appai-atus 
 used by preceding authors. 
 
 34. This apparatus is in no degree complex or 
 troublesome. Simple and easy, it requires nothing 
 for its construction but what the surgeon can easily 
 obtain, and what he can e\^en himself prepare. There 
 exists a great analogy between it and^the bandages 
 which Desault used for tlie reunion of transverse 
 
372 
 
 wounds, aiid for fractures of the rotula aixj the olecra- 
 non. A truly great man does not estimate his merit, 
 t)y the number of processes which he invents ; he well 
 knows that the perfection of art consists in producing 
 numerous effects by few and simple means. 
 
 35. We will confirm, by two cases, the principles 
 laid down in this memoir. One of thes^ relates to £^ 
 division of the tendon, connected with a wound, and 
 was reported by Bezard; the other by Maiiouri, an<J 
 relates to a simple rupture of the tendon. 
 
 Case I. J. 3« Lavigne, aged thirty, as he was 
 going down into a cellar without light, struck his leg 
 against the edge of a sharp saw, which completely 
 divided the tendo Achillis. The patient was immedi- 
 ately carried to the Hotel-Dieu. The wound of the 
 integuments was transverse, two inches long, and 
 had its edges but slightly separated from each other. 
 The ends of the tendon, in contact during the exten^ 
 sion of the foot, were separated two inches \vhen it 
 was flexed. 
 
 The usual apparatus was applied (32), and the 
 limb placed on a bolster, in a position favourable for 
 the relaxtition of the posterior muscles. 
 
 In the evening, wound painful; pulse raised; a 
 copious blood-letting; low diet. Next day, mca?e 
 blood taken away ; antiphlogistic regimes, which 
 was continued for several days, till the symptoms 
 were gone : no troublesome accident occurred. Tenth 
 day, the apparatus taken off; the wound partly healed; 
 the apparatus reapplied, and continued till the twen- 
 tieth day, when the perfect reunion of the parts ren- 
 dered its further use unnecessary, jfron) ^i^ tijm 
 
373 
 
 the patient began to walk on crutches. Thirty-sixth 
 day, could walk well without his crutches. At this 
 period, a small abscess occumng in his heel, induced 
 him to remain in the Hotel-Dieu two weeks longer, 
 when he was discharged perfectly cured. 
 
 Case II. M. Delp, leaping with some of his 
 young companions, ruptured the tendo Achillis, 
 about two inches above the os calcis. Both standing 
 and walking became instantly impracticable : tlie pa- 
 tient falling down, was taken up, carried home, and 
 j&om thence to Paris, where he aiTived in the even- 
 ing. Desault being immediately called to him, found 
 him affected with all the signs of a division of the 
 tendon; such as, a hollow between its divided ends, 
 which was increased by the flexion of the foot, dimi- 
 nished by its extension, he. The usual apparatus 
 was immediately applied, and as the patient felt but 
 little pain, only a moderate blood-letting was pre- 
 scribed. Next day, no alteration in the treatment; 
 antiphlogistic regimen ; low diet continued few some 
 days, when the patient was permitted to return to his 
 ijsual mode of living. Ninth day, apparatus removed 
 for the first time : a slight separation of the ends of 
 the tendon; and a wrinkle in the skin interposed be- 
 tween them: a new application of the bandage, 
 taking care to free the integuments from wrinkles. 
 Twelfth day, a relaxation of the rollers; a third ap- 
 plication of the bandage : every thing found in a good 
 ^tate ; but, the patient being, from sprightliness, too 
 much inclined to exert himself, a splint was applied 
 anteriorly to prevent the extension of the foot. Seven- 
 teenth day, a fourth application of the apparatus. 
 
374 
 
 which was not moved again till the thirtieth. At this 
 period, the reunion was somewhat advanced : fortieth 
 day, almost complete. Fiftieth day, the patient was 
 permitted to leave his bed, and take very gentle ex- 
 ercise, which he continued to increase gradually, till 
 the sixtieth day, when he was discharged cured. 
 Doubtless the tediousness of this case was owing to 
 the slight separation which existed fQr some time 
 between the fragments. 
 
 MEMOIR XVI. 
 
 ON THE FRACTURE OF THE OS CALCIS. 
 §1. 
 
 1. The OS calcis, being a short and thick bone, 
 has such a power of resistance, that it is but seldom 
 fractured. Such an accident does, however, some- 
 times occur, and may arise from two causes, 1st, the 
 action of external bodies, which is rare : 2dly, the 
 contraction of the gastrocnemii and soleus muscles, 
 from which it almost always proceeds. Thus, the 
 rotula is more frequently broken by the action of the 
 extensor muscles, than by blows received on the bone 
 from without: there is, hovv-ever, tliis difference be- 
 tween the effects of muscular contraction in these two 
 cases, namely, that in the former, the rupture of the 
 tendo Achillis is common, and the fracture of the os 
 calcis very rai'e ; wliereas in the latter, on the contrary, 
 
375 
 
 the rotula is oftentimes broken, while the tendon of 
 the extensors remains almost always sound. This phe- 
 nomenon is explained by the difference between the 
 thickness of the two bones, between the length of the 
 two tendons, and between the power of the causes. 
 
 2. Be the cause of the fracture what it may, it 
 generally occurs in that portion of the os calcis, called 
 its great tuberosity, which projects behind the astra- 
 gulus, which corresponds above and below to a large 
 quantity of cellular membrane, inwardly to the great 
 groove of the bone, externally to some ligamentous 
 attachments, and behind to the insertion of the tendo 
 Achillis. 
 
 3. It is known, 1st, by an evident inequality un- 
 der the heel : 2dly, by an elevation, sensible to the 
 touch, of the posterior fragment above its usual level : 
 3dly, by an almost entire inability either to stand or 
 walk : 4thly, by severe pain being the inevitable 
 consequence of moving the foot: 5thly, by its being 
 practicable to increase the displacement by flexing, 
 and to diminish it by extending the foot: 6thly, by 
 the facUity with which the posterior fragment may be 
 moved in every direction by taking hold of it with 
 one hand, and steadying the foot with the other: 
 7thly, by a swelling more or less considerable, which 
 frequently appears around the divided surfaces. 
 
 4. The ancients gave in general an mifavourable 
 prognosis respecting this kind of fracture. Hippo- 
 crates was apprehensive of some injury being done 
 to the surrounding paits. Pare considered the case 
 mortal, on account of the laceration of numerous 
 vessels which are connected with the bone. Most of 
 
3?6 
 
 the moderns adopt these principles, not for th6 fore- 
 going reasons, but on account of the vicinity of the 
 accident to the joint of the foot. The practice Of 
 Desault cannot throw much light on this subject, as 
 he never had more than one or two such cases of frac-* 
 ture under his care ; but the analogy of other frac- 
 tures, situated in the neighbourhood of joints and 
 even extending into them, induces us to believe, that^ 
 if properly treated, fractures of the os calcis will ter- 
 minate as favourably as those of other bones. 
 
 5. If we attend to the signs just mentioned (3)y 
 we will perceive that they almost all result from the 
 displacement of the fragments. But, whence arises 
 this displacement? As far as the anterior fragment is 
 concerned in it, it arises from, and is increased by, 
 the flexion of the foot; and, as far as relates to the 
 posterior one, it is to be attributed to the contraction 
 of the muscles attached to the tendo Achillis, which 
 is itself inserted in that fragment. Hence it follows, 
 that the apparatus intended to prevent this displace- 
 ment, ought, 1st, to keep the foot permanently ex:- 
 tended on the leg : 2dly, to prevent the action of the 
 m^uscles, by keeping them in a state of habitual re- 
 laxation by means of the constant flexion of the leg 
 on the thigh, by making on those whose contractions 
 are dreaded, such a regular and well directed com- 
 pression as may disqualify them for contracting; and, 
 lastly, by placing behind the posterior fragment some 
 resisting substance, to prevent it from rising up- 
 wards. 
 
377 
 
 6. If to these indications we compare Desault's 
 apparatus for a rupture of the tendo Achillis, as de- 
 scribed in the preceding memoir, we will readily 
 perceive Ist, that it perfectly fulfils that indication 
 which relates to the anterior fragment; 2dly, that 
 that one wliich relates to the posterior fragment will 
 be equally well fulfilled by the half flexed state of the 
 leg, by the compression made on the muscles, and 
 by a thick compress, not very broad, laid transversely 
 above the fragment, secured by the long roller, and 
 afterwards by a circular bandage, which must form 
 here, as in the case of a fractured rotula, a kind of 
 figure of 8 around the fracture. This compress is the 
 only modification of the apparatus requisite to ac- 
 commodate it to the particular case now under 
 consideration. 
 
 7. In applying the figure of 8 bandage here, as 
 well as in the case of a fractured rotula, to prevent 
 the ascent of the fragment, it is necessary to use the 
 utmost care to free the integuments from wrinkles 
 both above and below the fracture, lest by getting 
 between the fragments, they might keep them asun- 
 der, and thus impede their reunion. 
 
 8. Desault used to relate in his lectures, the case 
 
 of a woman whom he had formerly seen receiving 
 
 a fracture of the os calcis, by falling from a great 
 
 height. I cannot state the case fully, because I am 
 
 not in possession of all the facts. The following one 
 
 however drawn up during the first years of Desault's 
 
 practice in the Hotel-Dieu, will furnish an example 
 
 of his mode of treatment. 
 
 49 
 
378 
 
 Case. A man, likely to be arrested by some 
 one who pursued him, leapt frbm a window nearly 
 twelve feet high. In lighting, his feet struck on a 
 beam v/hich lay in his way, in such a manner, that 
 the fore part of them only was supported. He made 
 an effort to recover his equilibrium, but as the line 
 of gravity of his body had nothing to rest on, he fell 
 backwards, rose in order to make his escape, but felt 
 a second time unable to rise again. 
 
 When assistance came to him, he complained of 
 a severe pain in his heel, eaid said, that on falling, he 
 had heard a considerable report. He was taken up^ 
 and assisted in walking to the Hotel-Dieu, where he 
 did not arrive without pain, being able to bear only 
 on the point of the diseased foot, and suffering greatr. 
 ly if he attempted to put his heel to the ground. 
 
 From the signs mentioned (3), Desault perceiv- 
 ing that there existed a fracture of the os calcis, made 
 arrangements for reducing it. This he did by ex- 
 tending the foot on the leg, and drawing down the 
 exterior fragment from the elevation to which mus- 
 cular contraction had raised it, so as to bring it into 
 perfect contact with the body of the bone. He then 
 applied the common apparatus for a rupture of the 
 tendo Achillis, with the modification already pointed 
 out (6). 
 
 In the evening venesection was prescribed : tlie 
 patient experienced sharp pains at the place of the 
 fracture; a sliglit swelling occurred at the ends of 
 the toes; an anodyne was prescribed. Next day, 
 evidently better: venesection again. Fourth day, the 
 patient is allowed to return to his usual regimen. 
 
379 
 
 Eighth day, apparatus removed for the first time; 
 fragments in contact. Fifteenth day, a second appU- 
 cation of the bandage. Nineteenth day, biUoiis symp- 
 toms. Twenty-first, an emetic given in solution. 
 Tliirty- second day, further evacuations: apparatus 
 renewed. Forty-seventh day, consolidation complete. 
 A stiffness remained in the part for some time, but 
 this was gradually removed by exercise. 
 
 MEMOIR XVII. 
 
 ON COMPLICATED LUXATIONS OF THE FOOT^ 
 
 u. 
 
 1. Complicated luxations of the foot, like com^ 
 plicated fractures, show themselves under such a va- 
 riety of forms, are accompanied by so many peculiar 
 affections, and so many different circumstances are 
 connected with them, that it would be difficult to lay 
 down rules applicable to their treatment in all cases* 
 On this subject, indeed, art is in possession of certain 
 general principles, liable however to numerous ex- 
 ceptions and modifications. In the treatment of such 
 cases, who can fix the limits betw^een reduction, and 
 amputation or extirpation? Who can point out, with 
 precision, where the one ceases to be useful and be- 
 comes hazardous; while the others constitute the 
 only resources of ait? Experience and talents alone 
 
380 
 
 are capable of deciding on these points, and that only 
 in the chambers of the sick. It is, therefore, less by- 
 precept than example that practitioners ought to be 
 instiTiCted here. \^ 
 
 2. To furnish suitable examples on this head con- 
 stitutes my only object in the present memoir, which 
 will consist of the histories of a few cases, with such 
 inferences and remarks as the occasion may seem most 
 naturally to suggest. Here the practice of a great 
 master, varying his means with the varying forms of 
 disease, will serve as models to those who may meet 
 with similar cases* Our experience is composed of 
 the facts which we receive from reading, as well as of 
 those derived from observation. Who would have a 
 right to call himself a surgeon, if he had no other title 
 to that name, but such as resulted exclusively from 
 his own personal observation? 
 
 3. However difficult it may be, as already observ- 
 ed, to speak in general terms, on the present subject, 
 we may yet assert with safety, that authors have great- 
 ly exaggerated the danger of complicated luxations 
 of the foot. Terrified at the extent and unpromising 
 appearance of the accidents, these writers have lost 
 that confidence in the powers of nature which we 
 never ought to abandon. They have taken up an 
 opinion, that luxations of the foot, differing in their 
 symptoms from otlier luxations, require also a differ- 
 ent mode of treatment; that reduction, by perpetuat- 
 ing the accidents of the case, must prove fatal, and 
 that amputation ought to be adopted as the only re- 
 source. Cases do certainly at times occur, where a 
 doctrine different from this would be fatal in its effects: 
 
381 
 
 such are those terrible lacerations, where the foot is 
 entirely separated from the leg, except some shreds 
 of flesh with a few tendons among them that still 
 retain it. 
 
 4. But, provided the blood-vessels have escaped, 
 and any hope of circulation and life in the part still 
 remain, the success of reduction should always be 
 first tried; and the following examples will show, 
 what ought to be expected from this practice, when, 
 accompanied by skilful treatment. 
 
 MI. 
 
 LUXATION OF THE FOOT, COMPLICATED BY A 
 FRACTURE OF THE FIBULA, TIBIA, &C. 
 
 Case I. (The following case was collected by 
 Leveille.) Abraham Genty, aged forty-three, a dealer 
 in wine, as he was running along the street, slipped, 
 and made a false step on his left foot, which turned 
 with its external edge under him, and its internal 
 edge upwards. He fell, luxated his foot, and frac- 
 tured the fibula. 
 
 The patient was carried home, where a surgeon 
 who was ignorant of his profession being called, did 
 nothing but apply a cataplasm to the foot. In the 
 evening the parts began to swell, and were extremely 
 painful; fever supervened, accompanied with great 
 restlessness. Third day, to a rapid increase of all the 
 symptoms was added a delirium ; blood-letting from 
 the jugular vein was prescribed to no purpose; tilings 
 continued to grow worse till the sixth day, when the 
 patient was brought to the Hotel-Dieu, in extreme 
 danger. 
 
'SB2 
 
 The following was then tlie state of the parts. A 
 considerable swelling around the joint; a projection 
 of the malleolus internus, with a depression under- 
 neath it; a preternatural direction of the tibia before, 
 and of the os calcis, beliind ; a depression near the 
 lower end of the fibula; a crepitation readily per- 
 ceived, on moving the fragments ; a large tumour 
 on the outside of the foot : with a depression and 
 mobility of the malleolus externus. 
 
 The luxation was immediately reduced. Exten- 
 sion made on the foot and leg brought the parts 
 into their proper situations, where they were retained 
 by means of the bandage for fractures of the leg, and 
 four compresses well secured by the bandage. One 
 of these compresses, being placed on the malleolus 
 internus, another on the outside of the foot, a third 
 on the anterior and lower pait of the tibia, and the 
 fourth under the os calcis, prevented these different 
 parts from being again displaced. 
 
 As soon as the apparatus was applied, the pupils 
 remarked with astonishment, that the restlessness of 
 the patient ceased, that his pains were relieved, and 
 his delirium disappeared; he expressed his surprise 
 at the state from which he had just recovered, and 
 ^vas now able to give an accurate account of his fall. 
 He was scarcely put to bed, when he fell into a tran- 
 quil sleep, which lasted three hours. For six days 
 previously he had not slept a moment. 
 
 In the evening, the patient was free from pain, 
 and perfectly tranquil. Diluting drinks were prescri- 
 bed, with twenty-five drops of Hoffman's anodyne 
 liquor: the apparatus was wet firom time to time 
 
CtHo 
 
 with vegeto-mineral water: the patient slept well 
 thi'oughout the night. 
 
 Next day, the apparatus renewed: the parts per- 
 fectly in place: swelling diminished; same means 
 continued. Sixth day, the anodjTie discontinued. 
 Tenth day, swelling still less; echymosis gone; a 
 yeUow colour in the skin, an evidence that resolution 
 is going forward. Twentieth day, swelling gone. 
 
 Thirtieth day, tlie fracture of the fibula healed; 
 tliat bone slightly separated from the tibia : the circu- 
 lar roller drawn tighter ; and a thick compress placed 
 on the external malleolus, to bring it to its proper 
 place. Forty-fifth day, the apparatus for a fi:-actured 
 leg removed, and a simple roller substituted in its 
 place : the motions of the foot painful and contracted; 
 a small gangrenous spot appeared on the heel. Fifty- 
 fiMi day, the ulcer which proceeded from this spot 
 healed : motions of the part more free and extensive. 
 Sixty-first day, die patient able to walk without 
 assistance, though not without pain. 
 
 5. It is difficult to find an instance where the 
 advantages of reduction have been more remarkable 
 than in the preceding one. The patient had passed 
 six days in pain, extreme agitation, and uninterrupt- 
 ed delirium : the foot was reduced, and these unfa- 
 vourable appearances instantly vanished, and were, 
 succeeded by a state of tranquillity. Alarmed by 
 such a state of things, the ancients would doubtless 
 have proceeded to amputation. Let us examine into 
 the motives which led Desault to an opposite line of 
 practice, and then inquire into the cause of the suc- 
 cess with which that practice was crowned. 
 
384 
 
 6. Had amputation been performed here, it must 
 have been for one of the two following reasons; 1st, for 
 fear of gangrene ; or 2diy, to remove the unfavoura- 
 ble symptoms that existed. The first apprehension 
 would have been quite visionary, in as much as all 
 the blood-vessels were sound. Would the second 
 consideration have been any better founded? It was 
 perfectly obvious, that the unfavourable symptoms 
 which existed arose from the tension and overstretch- 
 ing of the parts, in consequence of the preternatural 
 position of the bones of the foot. The indication was 
 evident. Replace these bones in their natural situa- 
 tions, the strained parts will then necessarily become 
 relaxed, and all the troublesome and alarming symp- 
 toms cease with the cause that produced them. 
 Experience confirmed the justness of this reasoning. 
 
 7. But the mere replacement of the parts would 
 be of very little avail, if it were not permanently 
 maintained, and followed up by a judicious mode of 
 treatment. Without such treatment there would 
 doubtless be reason to apprehend all that train of 
 troublesome consequences, of which authors speak 
 in such frightful terms, and which arise, not from the 
 nature of the luxation, but from the manner in which 
 the patient is treated. A loose apparatus, incapable 
 of preventing displacement, would allow the bones 
 to be deranged anew, and to produce again an over- 
 straining of the parts, accompanied with pain, swell- 
 ing, &c. Irritating local applications, such as cam- 
 phorated spirits of wine, &,c. would increase these 
 pains ; emollients which are employed in other cases 
 would keep up the swelling. 
 
385. 
 
 8. It follows from what has just been said^ that an 
 opposite mode of treatment ought to succeed the re- 
 ductipn? and this we see was the case in the preceding 
 insta??ce. X^^^?i^:' when the bones were once reduced^ 
 all new displjjcernent was prevented, because the ap- 
 paratus was so constructed, as to counteract the 
 tendency of the bones t,o ^9 displaced. The external 
 edge of the foot, which had been turned outwardS;, 
 ■V^as now pusl>ed inwards by a thick compress ; the 
 same means served to push outwards the internal 
 X39,alleolus, which |iad received by the accident an 
 in9ljiiia,tion inwards, and to push the anterior part of 
 tlf^9 tibia backward, and the os ca,lcis forward, both 
 9f which were displaced, as has been remarked, iri 
 contrary directions. Two strong splints fixed the 
 lateral copapresses, while the anterior and posterior 
 9nes were firmly secured by rpljers. In the midst of 
 all these resistances^ the foot being necessarily inx- 
 ijpoyeable, no new displacement could occur. 
 
 9. A suitable and judicious position, ^n which 
 th? foot, raised a little higliier than the leg, was placed 
 on a pillow forming an inclined plain, prevented! 
 ^welling, while gentle compression, made by a ban- 
 dage, contributed to the same end. T^is end was 
 also further attained by the external topical applica- 
 tions. To relieve p^in and remove congestion, \yere 
 here, as in sprains, the two indications to be fulfiUedl 
 To these indications the spirituous and the relaxing 
 applications formerly in use, ai^e alike opposed. Ve- 
 geto- mineral water, on the contrary, fulfils then; 
 extremely well. Hence the necessity of keeping th?» 
 apparatus constantly wet with that liquid. 
 
 50 
 
386 
 
 10. Regimen influences not a little the success of 
 the treatment. A strict diet is necessary during the 
 time of the inflammatory and unfavourable symptoms. 
 Any excess might then prove fatal. Desault gave, in 
 his lectures, an account of a woman, who had her 
 foot luxated outward, and the astragulus forward. 
 Her fever was considerable, her pains excruciating, 
 and the swelling wore an alarming aspect. The lux- 
 ations were reduced : all the threatening appearances 
 vanished, and every thing seemed to promise a fa- 
 vourable termination of the disease. But, on the 
 fiftieth day, the patient, having procured strong food, 
 ate largely of it : in the evening all the unfavourable 
 symptoms returned ; the swelling became great, and 
 a £&w^ days afterwards she died. 
 
 But if strong food be prejudicial during the time 
 in which bad symptoms are to be dreaded, a diet too 
 strict would be equally injurious when that time is 
 passed. The weakened powers of the system would 
 not be adequate to the purposes of a cure, particularly 
 to the consolidation of the bone, should the case be 
 a fracture. Desault, therefore, permitted the patient 
 to increase his diet by degrees, and at length to return 
 to his usual regimen. 
 
 11. The following case, reported by Giraud, 
 proves still further the advantages of this simple 
 mode of treatment, which, should it even fail, always 
 allows the surgeon to avail himself of amputation, 
 which is indeed the last resource of art, and should 
 never be employed till rendered indispensable by the 
 failure of all other means. 
 
 Case II. Maria Constant, aged forty- six, des- 
 ^ cending a flight of stairs in haste, fell, and luxated 
 
387 
 
 Jier right foot outwards, the tibia inwards, and frac- 
 tured the fibula near to the lower end. 
 
 Her cries brought assistance to her, and she was 
 carried to the Hotel-Dieu. Giraud, who then officiated 
 as surgeon in chief, visited her, and discovered that 
 there existed both a luxation and a fracture, though 
 most of the signs were rendered obscure by a con- 
 siderable swelling: a slight echymosis occupied the 
 back of the foot, and severe pains were experienced. 
 
 Extension on the foot, and counter- extension on 
 the leg, dislodged the parts by degrees from their ac- 
 cidental situations, while, by the process of confer- ^ 
 mation, the surgeon endeavoured to bring them into 
 their natural ones. This was soon effected without 
 much violence: the unfavourable appearances soon 
 vanished; the pain ceased; an apparatus similar to 
 the former one was applied, and kept wet with a 
 strong solution of common salt^ instead of the vege- 
 to- mineral water. 
 
 In the evening, the pulse being full, and some- 
 what raised, a moderate blood-letting was deemed 
 necessary. Next day, the apparatus was kept con- 
 stantly moist, and some part of it which had become 
 relaxed was tightened. The pulse continuing full, a 
 low diet was prescribed. 
 
 Fifth day, the apparatus taken off; contact be- 
 tween the bones perfect : a yellowish tinge bespoke 
 an incipient resolution of the echymosis : a slight 
 swelling of the leg : vesications formed on the part : 
 these are opened and a quantity of acrid water dis- 
 charged from them. Sixth day, light nourishment 
 -allowed; a small excoriation of the heel, which is 
 
3^8 
 
 dreissed witTi cerate spread on la linen rag. 'SeveKt!i 
 day, regimen less strict; no bad symptoms super- 
 Vene. Eighth day, the excoriation enlarged; same 
 (dressing. Teiith day, the excoriation become fuh- 
 ]^ous: caustic is applied to remove it. 
 
 Twenty-eighth day, the discharge frdm the leg 
 decreased; from this time the dressings are fenewed 
 only every other day. Thirty- second day, the ulcer 
 ils cicatrized : no pains in the leg. Thirty-ninth day, 
 fracture of the fibula firmxly united: ho deformity 
 remaining; the apparatus is laid aside: the joint re- 
 mains stiff: motions performed by the limb difficult 
 at first, but become gradually more free. Forty- 
 sixth day, symptoms of bile ; gentle evacuants. Fifty- 
 fourth day, the patient is discharged ciured, except a 
 slight impediment in walking, which exercise will: 
 soon remove » 
 
 12. To this example, I might add many others^ 
 where similar displacements, properly treated, termi- 
 nated with equal success • no pain; no swelling; no 
 inflammation; arid therefore, of course, no mortifi- 
 cation. Yet these are occurrences of which authors 
 speak, as if they were the usual consequences of such 
 luxations, where, to a violent injury done to the soft 
 parts, is added a fracture near to, or even communi- 
 cating with,^ a joint. The eiToneous opinions of the 
 ancients and most of the modems, respecting the 
 dangers arising from such vicinity or communication, 
 Ihave contributed liot a little to their unfavourable 
 prognosis in the cases under consideration. Should 
 the patient survive the disease, his inevitable lot, ac- 
 cording to them^ must be, a complete anchylosis of. 
 
380 
 
 ^e leg with the foot. But, the preceding cases fully 
 prove, that this apprehension is unfounded. A con- 
 siderable time is doubtless necessary, for the recovery 
 bf motion, on account of the distension and rupture 
 •^f the ligaments, the long continued inactivity of the 
 -parts, and the swelling which they have undergone. 
 But this recovery can always be effected by means of 
 'exercise, gentle at first, increased afterwards, and 
 regulated according to the principles so frequently 
 laid down in the course of this work. Much more to 
 be relied on is such exercise, than the long catalogue 
 of discutient means, such as pumping of water on the 
 parts, alkaline baths, mineral waters, and all other 
 external applications>. so often extolled as efficacious, 
 and so often found entirely useless. 
 
 ^ iiii. 
 
 r 
 LUXATION OF THE FOOT, COMPLICATED BY A 
 
 SEPARATION OF THE BONES OF THE LEG, AT 
 
 THEIR LOWER END. 
 
 Case III. (The following case Vv^as reported by 
 Thevenot). I. Joseph Schneider, an ebonist, aged 
 
 ^thirty- six, as he was walking in haste, on the 23d of 
 March, 1792, fell forward, his foot being forced back- 
 ward and outward. He experienced at the instant 
 
 ■ severe pains in the joint : he was unable to rise, and 
 was therefore carried home, where a surgeon, after 
 
 'inaking a slight extension, applied a roller on the 
 
 ' limb, and did nothing further. The patient experi- 
 enced no relief. The pains increased; a swelling 
 supervened; convulsive motions began to occur; and 
 
390 
 
 the patient was brought to the HoteLDieu, six days 
 after the accident. 
 
 From the deformity of the foot, Desault immedi- 
 ately discovered that it was luxated. Its point was 
 directed outwards, while its sole was turned in the 
 same direction : beneath the malleolus intemus, which 
 was too prominent, was a tumour formed by the 
 astragulus. The crepitation of the bones which was 
 easily heard, the preternatural distance between the 
 tibia and the fibula, the mobility of this latter bone, 
 and the absence of the signs of a fracture, plainly 
 showed that a separation of the two bones of the leg 
 had taken place. 
 
 A reduction was immediately effected by means 
 of extension and counter-extension, and was an- 
 nounced when it took place by a report distinctly 
 heard. It was then retained by a bandage, calculated 
 to answer a twofold purpose ; 1st, to approximate, 
 and keep together, the two bones of the leg : 2dly, 
 to secure the contact and immobility of the bon.es of 
 the foot. 
 
 Blood-letting was prescribed: an anodyne mix- 
 ture administered; low diet; in the night severe 
 pains were felt; next day, they were increased; on 
 dressing the limb, nothing amiss discovered; ail the 
 parts in perfect contact : no vestige of separation be- 
 tween the tibia and the fibula : a new apparatus ap- 
 plied; and kept constantly moist. Third day, the 
 patient better: fifth day, the fibula a little separated 
 from the tibia : the circular btmdage drawn tighter to 
 reduce it to its place again. Tenth day, every thing 
 in its natural state: no pains: swelling gone, Fif- 
 
391 
 
 0- 
 
 teenth day, a simple roller substituted in place of the 
 
 bandage for a fracture of the leg. Nineteenth day, 
 
 the patient began to walk, with the assistance of a 
 
 stick: twenty-third day, walks easily : twenty-eighth 
 
 day, is dismissed perfectly cured, and neai'ly free 
 
 in all his motions. 
 
 13. The separation of the bones of the leg, at 
 
 their lower end, does not constitute a very serious 
 
 complication of luxations of the foot, although the 
 
 contrary is asserted by several authors. Desault 
 
 met with this accident several times in the course of 
 
 his practice, but never saw it terminate otherwise 
 
 than favourably. But here, as in all other cases, the 
 
 most minute attention is necessary to ensure success, 
 
 the want of which is more frequently owing to the 
 
 negligence of the surgeon, than to the deficiencies 
 
 of the art. The bandage employed after reduction 
 
 ought to act principally from without inwards, and in 
 
 a direction perpendicular to the axis of the lower part 
 
 of the leg, in order to approximate the two bones. 
 
 It will be of some service, in this respect, to place 
 
 on each bone a compress, which, projecting more 
 
 than the rest of the circumference of the limb, will 
 
 be more compressed, and on that account, contribute 
 
 to the end in view. 
 
50% 
 
 IV. 
 
 LUXATION OF THE FOOT, ACGOM-RANIRD BV A 
 DISPLACEMENT OF THE ASTRAGFLUS AT ITSt 
 ARTICULATION WITH THE OS SCAPHOIDE. 
 
 14. Petit never met with n^ore tlj£ia two iijstan- 
 ces of that displacement of the astraguLus, now under 
 consideration. His general prognosis on, the subject^ 
 is more favourable than that respecting other luxa- 
 tions of the foot, with which he never saw t^ie preseixt 
 luxation of the astragalus complicated, as occurred, 
 in the following cases. Had such complex cas^ 
 fallen und,er his notice, there can be little doubt, but 
 he would hixve declared amputation to be the op,^, 
 resourse of art on die occasion. 
 
 But the experience of Desault den^onstrates to^ 
 US here, as well as in the preceding cases, the gi^ea.t 
 extent to which we ought to carry our confidence in 
 the powers of nature, when skilfully guided by th^ 
 hand of art. The foUo^ying case was communicate^ 
 to me by Leveiile. 
 
 Case IV. John Baptist Landrin, a postilion, aged 
 thirty-six, was brought to the Hote^-Dieu, on tl^^ 
 19th of February, 1791. 
 
 On the morning of the same day, a horse on 
 which he was mounted having fallen, his foot was 
 caught under the belly of the animal. As soon as he 
 was disencumbered of the vast weight, he endea- 
 voured to rise, but in vain. The pains which he ex- 
 perienced in his foot were extreme. He was carried 
 home, where some surgeons, having ascertained that 
 
593 
 
 his foot was luxated, but being unable to reduce it, 
 sent him to the Hotel-Dieu. 
 
 Desault on examing him, found the bones of his 
 foot to be situated as follows. The internal pait of 
 the OS calcis corresponded to the lower extremity of 
 the tibia : the back of the foot was directed outwards, 
 and its external edge downwards : under the skin 
 and in fi'ont of the tibia was the astragulus, resting 
 on the scaphoide and first of the cuneiform bones, 
 where it formed a considerable projection: on the 
 back of the leg, the fibula corresponded to the tendo 
 Achillis. The pains had been inconceivably great 
 from the moment of the accident. 
 
 Imboldened by numerous instances of success 
 in similar cases, Desault, notwithstanding the extent 
 of the disease, attempted the reduction. One assist- 
 ant took hold of the superior part of the leg to make 
 counter-extension, and another, for the purpose of 
 extension, grasped the metatarsus with one hand, and 
 the heel with the other. While these were pulling in 
 different directions, the surgeon applying his thumb 
 on the astragulus, endeavoured to force it into its 
 place. His efforts were ineffectual : the opening 
 through the capsule of the astragulus being too nar- 
 row, would not suffer it to pass. Desault perceiving 
 this, cut through the integuments which covered the 
 bone, and having laid bare the capsule and the liga- 
 ments which strengthen it, made an incision into 
 them of a sufficient extent, taking care to avoid the 
 tendon of the tibialis anticus, which vv^as brought into 
 view. The openings being thus enlarged, admitted of 
 an easy reduction, and all the parts resumed, without 
 difficulty, their natural situation. 
 
 51 
 
394 
 
 The reduction being effected, the wound was 
 closed, and covered with some lint. A square com- 
 press was then placed on the back of the foot, while 
 a long one was applied to its sole, and the whole se- 
 cured by an apparatus similar to that described in the 
 preceding case. The patient was confined to a very- 
 strict diet, and ordered to use diluting diinks. 
 
 Next day, a slight bilious diathesis ; an emetic 
 in solution given; apparatus renewed. Fourth day, 
 an abscess on the malleolus externus opened; a co- 
 pious discharge of pus. Eighth day, the parts in 
 perfect contact ; a favourable discharge from the 
 wounds; dressings applied twice a day. Fifteenth 
 day, a general oedema ; aperient ptisans ordered. 
 Twentieth day, the oedema gone: a bilious diathesis 
 returned : in consequence of this, the wounds became 
 pale: another emetic given. Twenty- seventh day, 
 a very painful excoriation occurred on the heel : care 
 taken not to let the foot rest on that pait, as the sore 
 appeared to be the effect of compression. Thirtieth 
 day, the wounds in a favourable way : all the bones 
 in exact contact. Fortieth day, appai'atus laid aside, 
 and a simple roller substituted in its place : wounds 
 already cicatrizing. Fiftieth day, the limb put in 
 gentle motion, which is gradually increased every 
 day. Same dressing continued till the eightietii day : 
 v/ounds not yet cicatrized. Hundred and t^^enty- 
 seventh day, a considerable swelling around the joint : 
 a splinter made its ^^ay out, and was followed in a 
 few days by several more. In the fifth month an ab- 
 scess formed on the heel, from which, when opened, 
 another splinter escaped. In the mean time, the pa- 
 tient left the Hotel-Dieu. During his absence more 
 
395 
 
 splinters were discharged. Returning about a year 
 afterwards with a small ulcer, he was dismissed again 
 in a short time, perfectly cured, except a slight stiff- 
 ness of the joint. 
 
 15. The reduction of this luxation of the foot pre- 
 sents a difficulty worthy of the attention of practiti- 
 oners, as well on account of its own nature, as in con- 
 sideration of the process which was employed on the 
 occasion : I allude to the narrowness of the opening 
 in the capsule. I mentioned, on a former occasion, 
 the obstacles sometimes created by this circumstance 
 to the reduction of luxations of the os humeri and 
 the OS femoris. It was impracticable in the present 
 to enlarge the opening in the capsule, as could be done 
 in those cases, by moving the head of the bone in all 
 directions^; because the bone was too small to afford 
 any purchase to the surgeon. The only resource was, 
 the use of the knife; and the operation was the more 
 easily performed," on account of the capsule being 
 situated immediately beneath the integuments, from 
 which circumstance it could be the more speedily 
 brought into view. 
 
 16. The apprehension of mischief resulting from 
 the admission of air to the articulating surfaces^ would 
 no doubt, in this case, have restrained most practiti- 
 oners : but, even supposing this apprehension to be 
 well founded, ought it to deter the surgeon from 
 adopting the only possible mean of effecting a reduc- 
 tion, and of thus putting an end to the alarming state 
 of things aiising from the displacement of the bones? 
 Desault proved in numerous instances, that the appre- 
 hensions of authors respecting such cases have been 
 
S9Q 
 
 greatly exaggerated, and that it is practicable to cure 
 ^vounds that penetrate into the cavities of joints, 
 in the same manner as if they were simple wounds, 
 and with but very little more danger to the patient. 
 Yet it would seem, that the tediousness of the cure 
 and the exfoliation of the bones, arose, in the present 
 case, from the opening made into the joint, and per- 
 haps also, in part, from the disposition and habit of 
 the patient. Finally, in those alarming injuries of the 
 joints, unconnected with external wounds, where 
 practitioners have looked to no resource but that of 
 amputation, Desault has, in a short time, and without 
 any dangerous occurrence, restored to the subjects 
 the free use of their limbs. The following case, 
 drawn up by Plaignault, is a proof of this. 
 
 Case V. Pierre Phipe, aged twenty-four, fell, 
 on the 20th of February, 1788, from an elevation of 
 more than twenty feet : lighting on his foot, he turned 
 it outwards, sunk instantly to the ground, and was 
 unable to rise again. He was carried home, and from 
 thence to the FIotel-Dieu. 
 
 Desault examining him on his arrival, discovered 
 a luxation of the foot outwards, and of the astragulus 
 forwaixl and upward : the patient's sufferings were 
 great. Convinced that the most effectual method to 
 relieve these was to reduce the luxation, the surgeon 
 undertook it immediately, pushed the astragulus into 
 its place without difficulty, and with a report which 
 was heard by every one present, while the bones of 
 the foot were brought into their proper situation by 
 means of extension. In an instant the pains vanish- 
 ed and the motions of the foot became easy. The 
 
397 
 
 necessary apparatus was applied. The activity of the 
 pulse called for blood-letting, which was immediately 
 performed. A low diet was prescribed. 
 
 On the two following days blood-letting was re- 
 peated, both on account of the active state of the 
 pulse, and of a considerable swelling which took 
 place *.n the joint. The apparatus was kept constant- 
 ly wet with vegeto-mineral water. Eighth day, 
 somewhat better: echymosis gone. Fifteenth day, 
 the apparatus laid aside. From this time the foot was 
 gently moved every day. Eighteenth day, the pa- 
 tient able to stand on the affected foot without pain. 
 Twenty-sixth day, walks with the assistance of a 
 staff. Thirty-ninth, walks without limping, and en- 
 joys all the motions of the foot. Discharged. 
 
 § V. 
 
 LUXATION OF THE FOOT, COMPLICATED WITH AN 
 ESCAPE OF THE ASTRAGULUS, THROUGH THE 
 CAPSULE AND THE LACERATED INTEGUMENTS. 
 
 17. When, in a luxation of the foot, the integu- 
 ments, capsule, and ligaments are so lacerated, as to 
 suffer the astragulus to escape, it would oftentimes be 
 imprudent to attempt its reduction, as was done in 
 the preceding cases. The violence already done to 
 the parts around the joint is excessive; but this 
 would be increased by the extension, and other 
 efforts necessary in reduction. V/hatever cai'e might 
 be taken, it would be difficult to prevent a vast 
 swelling, long continued pains, and perhaps even a 
 caries of the bone exposed to the air, with all those 
 
398 
 
 sufferings and dangers, to which such an accident 
 gives origin. In such a case all the bones of the 
 foot have been known to become carious, a state of 
 things, which calls for the ultimate resources of art, 
 and draws after it a train of evils, which it is always 
 of the utmost importance to prevent. 
 
 18. What means are then to be employed? Two 
 expedients only remain. 1st, the amputation of the 
 foot; 2dly, the extirpation of the astragulus. The 
 first is a cruel resource, which should never be 
 adopted but in the last extremity, because it deprives 
 the patient of a portion of himself, necessary to the 
 performance of liis functions. But the measure is 
 forbidden by a. reason still more powerful. Amidst 
 the general disorder of the system, the severe pains 
 experienced by the patient, the convulsions, and the 
 delirium which oftentimes exists, what ground has 
 the surgeon to hope for success? Will not the ope- 
 ration add to the number of these alarming appear- 
 ances? Will it not aggra-s'ate them? May it not 
 render them fatal? Both reason and experience reply 
 in tlie affirmative. 
 
 19. In such a case, then, the extirpation of the 
 astragulus is the expedient to be preferred. What, 
 indeed, are its inconveniences? 1st, An inevitable 
 anchylosis of the foot and leg: 2dly, a shortening of 
 the affected limb. But a leg even in this state, is still 
 better than a wooden leg, which is the necessary con- 
 sequence of amputation : besides, a leg of tlie former 
 description occasions no great inconvenience in either 
 walking or standing, whereas one of the latter, pro- 
 duces extreme lameness : in the first case, a heel on 
 
699 
 
 the aiFected side somewhat higher than that on the 
 other, is an easy method of removing the deformity. 
 What, then, are such trifling disadvantages, when 
 compared with the evils which they ward off? The 
 extirpation of the astragulus is accompanied with but 
 little pain. The want of this intermediate body be- 
 tween the leg and the foot, by producing a relaxation 
 of the surrounding soft parts, prevents pain and swell- 
 ing in such cases : should abscesses supervene, they 
 v/ill not, if properly treated, greatly retard the cure. 
 In a word, experience coincides with this doctrine. 
 Desault has seen it twice verified in the practice of 
 other surgeons, and tliree times in his owTi. I have 
 known of but one case of the kind, in which the ter- 
 mination M^as fatal, and there, a malignant fever, in- 
 duced by the contaminated air of the hospital, cer- 
 tainly contributed to the death of the patient, which 
 did not occur till two months after the reduction. 
 
 Case VI. Desault usually gave in his lectures, 
 the history of a case where the success of this prac- 
 tice was remarkable. A man was brought to the 
 Hotel-Dieu, with a luxation of the foot, complicated 
 with a fracture of the lower part of the leg, and a 
 laceration of the ligaments and capsule, through 
 which tlie astragulus had escaped by a luxation for- 
 ward and upward, so as to have half of its anterior 
 surface exposed. The extent of the injury seemed 
 to call for amputation. But the youth, the vigour, 
 and sound constitution of the patient, gave ground to 
 hope that a process less desperate might succeed. 
 The astragulus, already separated anteriorl}'-, was 
 extracted by dividing the attachments w^hich held it 
 
400 
 
 to the o3 calcis, and the bones of the leg: the reduc- 
 tion was then effected without diificulty. The parts be- 
 ing replaced more readily in consequence of the remo- 
 val of this bone, were retained so by means of a 
 bandage similar to that for fractures of the leg, but 
 modified so as to suit the particular case. The pa- 
 tient lost blood once or twice : the apparatus was 
 kept constanly wet ; a very strict regimen v^^as pre- 
 scribed for some days; but fevv^ troublesome symp- 
 toms occurred; a slight swelling took place, but was 
 soon removed; a favourable suppuration came on; 
 the dressing was renewed twice a day ; some splinters 
 escaped occasionally ; several abscesses formed suc- 
 cessively were opened, and healed up again: the 
 wounds themselves closed, and the patient finally 
 recovered, with an anchylosis, indeed, between the 
 foot and leg, and a limb a little shorter than natural, 
 but which still served the purposes of walking and 
 standing. 
 
 20. To this example, I might add those of other 
 patients treated at the Hotel- Dieu, in the same man- 
 ner and with equal success. But what purpose would 
 such an accumulation of facts answer? It would only 
 fatigue the reader without adding to his conviction. 
 
 21. If the injury accompanying the luxation be so 
 extensive, as to destroy the principal blood-vessels, 
 and leave no hope of saving the limb, amputation 
 becomes then the only resource, and the case as- 
 sumes a resemblance to those v/here the limbs are 
 shattered by cannon balls : the success then depends 
 veiy much on the strength or weakness of the pa- 
 tient. 
 
401 
 
 Case VII. A man fell fi-om a carriage : his foot 
 becoming entangled between the spokes of the wheel, 
 was almost separated from the leg. It adhered only 
 by a small portion of skin behind, and by the tendons 
 of the muscles which run to the toes both above and 
 below. 
 
 Desault was called to the patient, wlxim he found 
 in a most deplorable state : the pains which he suffer- 
 ed were excruciating: the parts around the wound 
 were greatly swollen ; a general spasm affected the 
 system : amputation was judged necessary, but was 
 deferred till the symptoms should be mitigated. The 
 limb was diessed : next day, a gangrene began to 
 affect the foot, which was then sepai'ated from the 
 leg by cutting the tendons : the ends of the tibia and 
 fibula exfoliated; the wound healed, and the patient 
 now enjoys, in part, the functions and uses of the leg, 
 by means of an artificial foot, framed and fitted on by 
 an ingenious mechanic. Had the limb been too 
 hastily amputated while the patient was affected with 
 general spasms, fatal consequences would probably 
 have ensued. 
 
 .^-2 
 
APPENDIX. 
 
 ARTICLE I. 
 
 The following interesting paper, extracted from 
 the Medical Repository, Hexad: ii. vol. i. p. 122.... 
 124, will give the reader a better idea, than he can 
 receive from any other source, of Dr. Physick's new 
 and successful method of treating an old and obsti- 
 nate fracture of the os humeri. 
 
 A Case of Fracture of the Os Humeri^ in which the 
 broken ends of the bone not uniting in the usual 
 manner^ a cure was effected by means of a seton. 
 Communicated to Dr. Miller by Philip S. Phy- 
 sick, M. D. 
 
 " Isaac Patterson, a seaman, twenty-eight years of 
 age, applied to me in May, 1802, in consequenpe of 
 a fracture of his left arm, above the elbow joint, which 
 had taken place several months before ; but the ends 
 of the bone not having united, rendered his arm nearly 
 useless to him. 
 
 " The history he gave me w^as, that on the 11th 
 of April, 1801, after having been at sea seven months, 
 his arm was fractured by a heavy sea breaking over 
 the ship. Nothing was done for his relief until next 
 day, when the captain and mate bound it up, and ap- 
 plied splints over it. No swelling supervened, nor 
 did he suffer any pain. Three weeks after this acci- 
 
404 
 
 dent, he arrived at Alexandria, when the state of the 
 arm was examined by a physician, who told him, that 
 the ends of the bone were not in a proper situation. 
 After making an extension, the spUnts and bandages 
 were again appHed. He remained in Alexanekia four 
 months, when, finding his arm no stronger, he left 
 off all dressings^ and went on board tire New- York 
 frigate as steward : iii this capacity he remained near 
 the Federal City six nionths, and by being under the 
 necessity of using his arm as much as possible, he 
 found the connexion between the ends of the bones 
 became looser and looser, tilly at length, the arm bent 
 as easily as if a nev/ joint had been formed at the 
 place of the fracture^ From the frigate he went ta 
 Baltimore,, where an attempt was made by machinery 
 to extend the arm, and keep the ends of the bone in 
 apposition, by continuing the extension. Under this, 
 treatment he remained two months, but experiencing 
 no benefit, he was advised to come to Philadelphia. 
 ' '^'On examining the arm, I found that the humerus 
 had been fractured about two inches and a half above 
 the elbow joint^ andthat the ends of the bone had pas- 
 sed each other, about an inch : the lower fragment, or 
 that nearest the elbow, was situated over, and on the 
 outside of the upper portion of the bone. The con- 
 nexion that existed between the ends of the humerus 
 was so flexible, as to allow of motion in every direct 
 tion', and by forcible extension, the lower end might 
 be pulled down considerably, but never sa low as to 
 be on a line with the end of tlie upper extremity. He 
 was admitted into the Fennsylvania hospital, the lat* 
 ter end of May ; but tlie weather becoming very hot^ 
 
405 
 
 it was judged best to defer any operation that might 
 l3e necessary, until the fall of the year. Unfortunately 
 he then contracted a bilious fever, of which he was 
 so ill, that his life was despaired of for some days. 
 From this fever his recovery was so slow, that it was 
 not thought proper to perform any operation until 
 December. It still remained to decide, by what 
 means a bony union of the humerus, might most pro- 
 bably be effected. In the year 1785, when a student, 
 I had seen a case in our hospital, similar to this in 
 eveiy essential circumstance, in w^hich an incision 
 was made down to the extremities of the fractured 
 bone, which were then sawed off, thereby putting 
 the parts into the condition of a recent compound 
 fracture. No benelit, however, was derived from 
 this painful operation, and some months afterward 
 the arm was amputated. This case had made a 
 strong impression on my mind, and rendered me un- 
 willing to perform a similar operation. I therefore 
 proposed to some of the medical gentlemen of the 
 hospital, who attended in consultation, that a seton- 
 needle, armed with a skein of silk,, should be passed 
 through the arm, and between the fractured extremi- 
 ties of the bone, and that the seton should be left in 
 this situation, until by exciting infkmmation and sup- 
 puration, granulations should rise on the ends of the 
 bone, which uniting and afterwards ossifying, w^ould 
 form the bony union that was wanting. This opera- 
 tion being agreed to, it was performed on the 18th of 
 December, 1802, twenty months after the accident 
 happened. Before passing the needle, I desired the 
 assistants to make some extension of the arm, in or- 
 
406 
 
 der that the seton might be introduced as much as 
 possible between the ends of the bone. Some lint 
 and a pledget were applied to the orifices made by the 
 seton-needle, and secured by a roller. The patient 
 suffered very little pain from the operation. After a 
 few days the inflammation (which was not greater 
 than what is commonly excited by a similar operation 
 through the flesh, in any other part) was succeeded 
 by a moderate suppuration. The arm was now again 
 extended, and splints applied. The dressings were 
 renewed daily for twelve weeks, during which time 
 no amendment was perceived; but soon afterwards 
 the bending of the arm at the fracture was observed to 
 be not so easy as it had been, and the patient com- 
 plained of much more pain than usual whenever an 
 attempt was made to bend it at that place. From this 
 time, the formation of the new bony union went on 
 rapidly, and, on the fourth of May, 1803, was so 
 perfectly completed, that the patient could move his 
 arm, in all directions, as well as before the accident 
 happened The seton was now removed, and the 
 small sores occasioned by it, healed up entirely in a 
 few days. On the 28th May, 1303, he was dischai'g- 
 ed from the hospital; perfectly well, and he has since 
 repeatedly told me that his arm is as strong as it 
 ever was." 
 
 To the preceding paper it is unnecessary to add, 
 that the mode of treatment there stated might be 
 adopted in similar fractures of other bones, provided a 
 seton-needle could be passed near to the ends of the 
 fragments, without any risque of wounding blood- 
 vessels, nerves, or other parts of importance. It is 
 
407 
 
 thus that solitary facts minutely detailed and well 
 substantiated, oftentimes grow into principles of ex- 
 tensive application. 
 
 ARTICLE 11. 
 
 An account of Dr. Physick^s imprcDement of De- 
 saulfs apparatus for making permanent extension 
 in oblique fractures of the osfemoris. 
 
 Dr. Physick having observed that in the appli- 
 cation of Desault's apparatus, the patient was some- 
 times injured by the pressure of the strap or roller 
 gg (plate 2) which passes under the tuberosity of 
 the ischium for the purpose of making counter-ex- 
 tension, devised the following method of remedying 
 this inconvenience, in which he succeeded to his 
 wishes. 
 
 He directed the upper end of the long external 
 splint to be formed like the head of a crutch, and the 
 splint itself to be lengthened so as to reach and bear 
 against the axilla of the aflPected side, which must 
 be well defended from pressure by a bolster of flan- 
 nel or some other soft material. By this expedient 
 the Dr. evidently formed two points of counter-ex- 
 tension, instead of one, as is the case in the apparatus 
 of Desault. Between these two points, namely, the 
 axilla and the perineum, the same quantity and force 
 of pressure is, by Dr. Physick's improvenuent, dii}i~ 
 dedy which, in the original apparatus of Desault, is 
 borne by the perineum alone. The risque of exco- 
 riation and injury to the patient, then, in the former 
 
408 
 
 case, is to that ^vhich he runs m the latter, t)nly as 
 one to two, or nearly so. As it is no less the duty of 
 the surgeon to pre\'ent suffering than it is to remove 
 deformity or to save life, Dr. Physick has ceitainly in 
 this respect made an important step in the advance- 
 ment of his profession. 
 
 But there is still another advantage derived from 
 the lengthening of tlie external splint. In the original 
 apparatus of Desault, the strap ^^ intended for coun- 
 ter-extension, by passing no higher up than the spine 
 of the ilium, runs too much across, and therefore 
 acts too much on, the upper pait of the thigh* By 
 this it not only irritates the muscles of the part, and 
 induces them to contract, but also tends to draw the 
 upper fragment of the os femoris a little outward, and 
 thus to render the thigh in some measure deformed. 
 But, in the improvement of Dr. Physick, the strap 
 gg is secured in a mortise cut in the external splint, 
 about midway between the spine of the ilium and 
 the axilla. This strap, by being thus carried higher 
 up on the body, does not run across the thigh at all. 
 It consequently presses on and irritates the muscles 
 much less, acts more in the direction of the os femo- 
 ris, and has no tendency to draw the superior frag- 
 ment outward. 
 
 Hence this improvement not only diminishes the 
 patient's sufferings, but gives him, perhaps, the best 
 possible chance of having his limb preserved free 
 from deformity* 
 
 Another improvement made on the lower end of 
 the external splint by Dr. James Hutchinson de- 
 serves also to be mentioned. It was found that in 
 
the original apparatus of Desault, the strap or roller 
 L (plate 2) used for the purpose of extension, had a 
 tendency to draw the foot too much outward. This 
 fault Dr. Hutchinson very ingeniously remedied, by 
 attaching to the lower part of the external splint, a 
 little above the mortise, a small block extending in- 
 wardly, at a right angle with the splint, so far as to 
 be on a line with the middle of the sole of the foot. 
 Over the end of this block, in which a notch is cut 
 to receive them, the ends of the strap L are carried, 
 previously to their being secured to the external 
 splint. By means of this expedient extension is 
 made precisely in the direction of the limb, and the 
 inconvenience of drawing the foot outward is com- 
 pletely obviated. 
 
 Thus improved by Drs. Physick and Hutcliin- 
 son, the apparatus of Desault for oblique fractures of 
 the OS femoris, leaves, perhaps, scarcely a remaining 
 desideratum on the subject. 
 
 . ' ARTICLE III. 
 
 EXPLANATION OF THE THIRD PLATE. 
 
 This plate gives a full view of an apparatus for 
 making permanent extension, in oblique fractures of 
 the leg, when both bones are broken. This appara- 
 tus was first devised and constructed several years 
 ago, by Dr. James Hutchinson, then a pupil in the 
 Pennsylvania hospital, and is now in general use 
 among the practitioners of Philadelphia. 
 
 Fig. 1. Represents the leg and foot, with the ap- 
 paratus applied. 
 
 53 
 
410 
 
 A. A common roller, passed several times round 
 the leg a little below the knee, on which counter-ex- ' 
 tension is made. 
 
 B. A silk handkerchief folded, or a strong roller 
 made of soft muslin, passed once round the leg, just 
 above the ancle, from behind forwaiti. C. The 
 place where its two ends cross each other to pass 
 down along each side of che foot, as seen at ^, to D, 
 where they are secured by a knot drawn but moder"- 
 ately tight, a a. The same ends cominucd to E 
 where they are again secured by a firm knot over the 
 cross piece F, which passes between the two strong 
 splints G G, that run on each side of the leg from a 
 little above the knee, to the distance of four or five 
 inches beyond the sole of the foot. This is the ban- 
 dage by which extension is made, as will be men- 
 tioned hereafter. 
 
 H. Two bits of strong tape, each about two feet 
 long, placed in the longitudinal direction of the leg, 
 and firmly secured by the roller A, which passes 
 over their middle. Two such bits of tape, are thus 
 applied on each side of the leg, and their four ends, 
 passing tlirough four holes in the upper end of each 
 of the splints G G, are secured on their outsides by 
 firm knots as represented at H. 
 
 Fig. 2. A view of one of the splints G G, separ- 
 ated fi'om die leg. 
 
 a. The four holes in the upper end, through 
 which the bits of tape H pass. 
 
 b. The mortise in the lower end, which receive^ 
 the cross-piece F, 
 
411 
 
 Fig. 3. A view of the cross-piece F, \Yhich must^ 
 be firmly fixed in one of the splints G G, but move- 
 able in the mortise of the other, so that the splints 
 may be taken asunder at pleasure. 
 
 The following is the method of applying this ap- 
 paratus. 
 
 While extension and counter-extension are made 
 by two assistants, the surgeon placing the bits of 
 tape H on each side of the leg, secures them firmly by 
 the roller A applied round the limb, with a proper 
 degree of tightness. He then applies the middle of 
 the handkerchief or roller B on the tendo Achiilis, 
 brings its ends across each other, before the leg at 
 C, and carrying them down along each side of the 
 foot, secures them by a knot at D. Letting go the 
 ends of the handkerchief B, he next places on each 
 side of the leg the splints G G, connects them at the 
 lower end by the cross-piece F and secures them at 
 the upper end by the tapes H. He then resumes 
 the ends of the handkerchief B, carries them down- 
 ward as seen ^t a a and secures them by a firm knot 
 at E round the cross-piece F. 
 
 From this view and explanation of the apparatus 
 Fig. 1, I presume its construction, application, and 
 mode of operation will be very easily understood. It 
 is unnecessary therefore to add, that the extension 
 and counter-extension made on the limb, will be 
 directly proportioned to the degree of force with 
 which the ends a a of the handkerchief B are dra^^oi 
 bver the cross-piece F. As action and reaction, in 
 this case, must, as in all others, be equal, the splints 
 G G will be pushed upward by the ends of the hand- 
 
4i^ 
 
 kefishief B with precisely the same force that is 
 applied on these ends to draw the foot and lower 
 fragments do^vnward. Hence the counter-extension 
 made above on the roller A will be exactly equal to 
 the extension made below by the handkercliief B. 
 
 I ought to have observed, that it is necessary to 
 defend the soft paits, both above and below, from 
 the pressure of the estcndbig and counter- extending 
 straps, by means of soft compresses applied next to 
 the skin. This is particulaiiy necessaiy on the instep 
 C where the ends of the handkerchief B cross each 
 other. It requires some attention on the part of the 
 surgeon to prevent this spot from being excoriated, 
 especially if it be found necessary to make a forcible 
 extension. 
 
 If the fracture be simple, a bandage of strips pre- 
 viously applied round the hmb from the ancle to the 
 knee is highly useful. It secures the fi^gments more 
 effectually from lateral displacement, and prevents 
 the swelling of the leg. A simple roller applied with 
 a moderate degree of tightness round the foot, is also 
 of service in preventing a swelling in that part, as 
 well as in removing it if it has already occurred. 
 
 This apparatus is still more strikingly useful in 
 compound fractures, on account of the facility with 
 which it enables the surgeon to apply the necessary 
 dressings. These can be rene-^^ed as often as may 
 be requisite, without giving the patient the least 
 pain, without discontinuing extension, or in any 
 measure whatcv^er deranging the fragments. The 
 surgeon can also, in all cases, discover by a single 
 glance of his eye, whether or not the fragments are 
 
413 
 
 in proper apposition. It is right to secure the whole 
 apparatus by three bits of tape passed round it, 
 similar to those tied round the leg in the apparatus 
 for fractures of the thigh, as represented in plate 2. 
 
 I shall only add, that the surgeon must employ 
 such bolsters and compresses as he may find neces- 
 sary to support the limb, and protect it from undue 
 pressure, and that he must be vigilant to prevent, by 
 frequent examinations, the extending and counter- 
 extending straps from becoming relaxed. 
 
 For a few further remarks on the subject of this 
 apparatus, the reader is referred to a paper published 
 by Dr. Hutchinson, in the second number of the 
 Philadelphia Medical Museum. 
 
 FINIS, 
 
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