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NATIONAL LIBRARY OF MEDICINE
             Washington
Founded 1836
U. S. Department of Health, Education, and Welfare
             Public Health Service 
 
 
A  TREATISE
ON
      FRACTURES, LUXATIONS,




                    AND




  OTHER AFFECTIONS OF THE BONES,




             BY P.  J. DESAULT,



     SURGEON IN CHIEF TO THE HOTEL-DIED 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.




                                  > /": "i.>'%
                                  \.s:\..tk.J.
SECOND E
HGLQW GEMERAL'S Cr7!Cii'
DITION.

]    -JUfc-;i4.-ia04-
         PHILADELPHIA



PUBLISHED BY KIM^ER & CONKATJT


       NO. 93, MARKET-STREET.

    Brown & Merritt, Printers, No. 24 Church Alley





             1811. 
District of Pennsylvania, to wic :
     BE IT REMEMBERED, That on the twentieth day oi February, in the
 twenty-ninth year of the independence of the United States of America, A
 D. 1805, Charles Caldwell, M.D. of the said district, hath deposited in this Of-
 fice, the Title of a Book, the Right whereof he claims as proprietor,  in the
 words following, to wit:
      " A Treatise on  Fractures, Luxations, and other Affections of the
 " Bones, by P. J. Desault, surgeon in chief to the Hotel-Dieu of Paris, wherein
 " his Opinions and "Practice, in such cases, are stated and exemplified.   Edit-
 " ed by Xav. Bichat;  with Plates.  Translated from the French, by Charles
 " Caldwell, M. D.  With Notes, and an Appendix containing several late im-
 " provements in surgery."
      In conformity to the act of the Congress of the United States, entitled,
 " An act for the encouragement of learning, by securing the copies of maps,
 charts, and books, to the authors and proprietors of such copies during the
 times therein mentioned:"  And also to the act, entitled, " An act supplemen-
 tary to an act, entitled, "An act for the encouragement of learning, by se-
 curing the copies of maps, charts, and books, to the authors and proprietors
 of such copies during the times therein mentioned," and extending the bene-
  fits 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,  .    .    15

                     MEMOIR II.
On the Fracture of the Clavicle,.....21
Explanation of the first Plate, .     .    .     :    .    .    50

                    MEMOIR III.
On the Luxation of the Clavicle,    .    .     .    .    .    52
      Luxation of the Sternal extremity,     .    .    .    53
              of the Humeral extremity,   ...    64

                    MEMOIR IV.
On Fractures of the Acromion, and of the lower angle of the
      Scapula,........67
   Fracture of the Acromion,      .....    ib.
           of the lower angle of the Scapula,     '.    .    73

                     MEMOIR V.
On the Fractures of the upper end or neck of the Humerus, ' 77

                     MEMOIR VI.
On the Fracture  of the  lower extremity of ftit Humerus,
   with a separation of the Condyls,    .    .     .    .99

                    MEMOIR VII.
On the Luxation of the Humerus,      .    .     .    .     Ill

                   MEMOIR VIII.
On the Fracture of the bones of the Fore-arm,     .    .     152
       Frarture of the Radius,     .    .    .    .    .     165
              of the Ulna,.....171
               of the Olecranon,    .*             .     173
f 
VI
                       MEMOIR  IX.
                                                             Page
On the Luxation of the Fore-arm,      .          .  •   .      187

                        MEMOIR X.
On the Luxations of the Radius over the' Ulna,    .     .     202
       Luxation of the lower extremity of the Radius,   .     206

                       MEMOIR  XL
215
216
255
 ib.
257
 On the Fractures of the Thigh,     ....
         Fractures of the body of the Os Femoris,
                  of the upper end of the Os Femoris,
                  of the great Trochanter,
                  of the neck of the Os Femoris,   .
                  of the lower extremity of the Os Femoris,  275
 Explanation of the second Plate,.....285
 Thoughts on Luxations of the Os Femoris upward and forward, 286

                        MEMOIR  XII.
 On spontaneous Luxations of the Os Femoris,       .     .    294

                       MEMOIR XIII.
 On the Fracture of the Rotula,  *.....297

                       MEMOIR XIV.
 On the formation of foreign bodies in the joint of the knee,   316
 Observations and Reflections on  forms of Apparatus * for
      fractures of the leg,......332

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

                    MEMOIR XV.
                                                    Page
On the Division of the Tendo Achillis,  .    .    .        344
                   MEMOIR XVI.
On the Fracture of the Os Calcis,      .     .    .    .    262
                   MEMOIR XVII.   ^
On Complicated Luxations of the Foot,      .    .    .    367
                  APPENDIX.

                     ARTICLE  I.
Dr. Physick's new and successful method of treating an old
   and obstinate fracture of the os humeri,    .    .    .    389
                     ARTICLE  II.
An account of Dr. Physick's improvement of Desault's ap-
   paratus for making permanent extension in oblique frac-
   tures of the os femoris,    ......393
                    ARTICLE  III.
Explanation of the third Plate,    .    .    .    ,    .    395 
 
       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 often-
 times extremely difficult in its nature. Prohibited from
 adding any thing to, or in any measure transgressing
 the bounds of, the meaning of his original, he is obli-
 gated to interpret that meaning with faithfulness and
 accuracy.   In  this latter point consists the difficulty of
 his task.   If several different readers oftentimes attach
 as many different meanings to parts and sentences  of
 works written in their own language, how much more
 likely will  this be to occur with respect to such as are
 written in a foreign language? For readers to differ  in
 the former case is common, in the latter unavoidable.
   The  translator of the following work is far from af-
 firming, that he has in no instance  deviated from the
 meaning of his original.  To hazard an assertion like
 this, would be  assuming to himself more than is con-
 sistent  with modesty, or,  perhaps,   with truth.   He
 trusts,  however,  that such deviations  are  very  rare,
"that if they do occur, they are but slight in themselves,
and never connected with facts or principles of practical
importance.  He can, at least, very confidently declare,
that they have never been the offspring of carelessness
or design.
                         2 
X
  Should any one open this volume in  quest of the
flowers  of fancy, or the embellishments  of style, he
will close it again without being gratified.  Ambitious
only of communicating new and useful matter, and too-
intent on things to be in  any measure choice of his
words, the celebrated original was regardless, perhaps
to a fault, of the ornaments  of diction.   Rich in  the
resources of a capacious and exalted intellect, he poured
forth his knowledge like precious  ore from the mine,
leaving to others of inferior capacities the humbler task
of refining and polishing it.
  With  such an example before him, the  translator
thought it best to follow in some measure  the footsteps
of his illustrious guide, without venturing to  chalk  out
a new and different track for himself. As  his principal
object, throughout the work,  has been to make  himself
clearly understood,  and that in as few words as practi-
cable, he has never hesitated, when they came in com-
petition, to sacrifice elegance to precision and  orna-
ment  to perspicuity.   He has even in some instances
been  guilty of  intentional tautology, for the purpose
of rendering his meaning the more  clear  and definite.
For this he flatters himself he need offer no apology
to those, who  prefer utility  to pleasure and sense to
sound.  And, as to readers  of an opposite  cast of mind,
should any such choose to sit in judgment on him, he
neither deprecates their censure nor  courts their appro-
bation.
   A circumstantial analysis  of the  following memoirs
would constitute a paper too  extensive to be introdu-
ced here in the  form of' a preface, and a mere outline
or general character of them would be altogether use-
less.   The translation  is now before  the public, and
every reader must judge of its merit for himself.  On 
xi
this point the translator will only observe, that the at-
tention which he has been necessarily led to bestow on
the work,  has been to him the best school of surgery
he ever attended,  as far as relates to affections  of the
bones.   Should  other  practitioners throughout   the
United States derive  equal  benefit from perusing his
translation, he will rejoice in a consciousness of having,
at least in one instance,  been of service to his country.
   Such are  the  extent and importance of  Desault's
improvements in some branches of practical surgery,
as to constitute a new epoch in the history of the pro-
fession.  His different forms of apparatus for fractures
and luxations are certainly more rational in their con-
struction, and more efficacious in their action, than
those of any other writer. But their excellence does  not
arise from these circumstances alone.  Their cheapness
and simplicity,  taken in conjunction with the ease  and
quickness  which they may be every where made  and
applied, greatly enhance  their value,  particularly to
practitioners in  the country.    If they be not already at
hand, they can be easily prepared by the surgeon or his
assistants, without any material loss of time.  The  suf-
ferings  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 implements  and
processes of every art become simple and easy, in pro-
portion as the art itself approaches perfection: and thus
that the truly great artist is known, not by the multi-
plicity and the complex  nature of his forms of appara-
tus,  but by the  numerous ends which he accomplishes
by means the  most simple and easy of construction.
  Several French practitioners, in projecting improve-
ments on the forms of apparatus of Desault, have evi- 
Xll
 dently rendered them more complex, more expensive,
 and therefore more difficult to be constructed or procur-
 ed, without adding in the smallest degree to the efficacy
 of their action.  This is particularly the case with respect
 to Boyer* in his attempt to substitute a new apparatus
 for a fractured  clavicle, in place  of that invented by
 Desault.  The latter can be constructed in a very few
 minutes by the surgeon or one of his assistants, with-
 out any expense, whereas, the former must be made by
 a workman employed for the purpose, and is necessa*
 rily attended with both cost and delay. Nor is it always
 practicable,  particularly in the country,  to procure a
 workman capable of making this apparatus.  But  this
 is not all.  On Desault's plan, the same apparatus
 for a fractured clavicle will fit, and may  be applied to,
 persons of different sizes and figures; whereas, on the
 plan of Boyer,  each patient  must have an apparatus
 constructed particularly for himself.   No practitioner,
 therefore, can hesitate a moment in deciding to which
 of these two forms of apparatus the preference is due. ,
   Similar remarks  may be made respecting Boyer's
 apparatus for making  permanent extension in oblique
 fractures of the os femoris.   It is much more complex
 and  difficult  to  be  constructed  than that of Desault.
 Nor does  it possess a single advantage over  it as  im-
 proved by Drs. Physick and Hutchinson.   In a word,
 the  forms of apparatus of Boyer may  answer well
 enough in hospitals and in cities, where the expense of
 such articles  is  not much regarded, and where work-
 men to make them can  be readily  procured.   But, as
the practitioner in the country is generally obliged to be
himself the constructor of the forms of apparatus which
he uses, and as he is not at all times prepared to meet
heavy expenses,  it is to those  recommended and em- 
xiii
ployed by Desault,  that he must necessarily have re-
course.
   With these remarks the translator submits to the good
sense and  candour  of  his countrymen the following
sheets,  as the offspring of some of his hours of leisure
from professional duties.   He hopes that the appendix
subjoined by himself will not be regarded as either an
useless or an unpleasing addition.  Every native of the
United States,  whose  bosom  glows as it ought, with
that noblest of passions, the amor patriar, will witness
with pride  and exultation the  improvements  that are
daily making in the arts and sciences,  by the industry
and enterprize of  his enlightened countrymen.  Such a
mind will enjoy in  anticipation  the glory of his coun-
try, at that period, when she will be able to reflect back,
with increased  splendour, the light which she has so
long been borrowing from the countries of Europe.
   The translator does not plead the want of time as an
 apology for any imperfections or errors which his trans-
 lation may exhibit.   Yet he believes it to be true,  that
 had he had  more time to bestow on  it, he could pro-
 bably have  rendered  it  more  worthy of public  pa-
 tronage.
   In behalf of this second edition, the translator has the
 pleasure to add, that it contains a correction of the only
 error (a very trivial one) which  has been discovered in
 the first. It is, therefore, submitted to the public under
 a belief, though not ostentatiously positive, yet some-
 what confident, that it exhibits no incorrect view of
 the meaning of the original. 
 
A TREATISE
                  ON

FRACTURES, DISLOCATIONS, &c.
                   MEMOIR I.

  ON THE FRACTURE OF THE CONDYLES OF THE
                   LOWER JAW.

                    SECTION I.

  1. THE lower jaw, a kind of moveable hammer,
destined, to use the words of a certain physiologist, to
triturate the aliments against the almost immoveable
anvil of the upper jaw, is more exposed to the action
of external bodies, and consequently to fractures, than
most of the other bones of the face.  But all parts of
it are not alike subject to such accidents.   Common
in its body, but less frequent in its branches or sides,
fractures sometimes occur in the  two processes in
which its branches terminate.  One of these processes,
concealed by the zygoma, embosomed in the temporal
muscle, and covered by the masseter, is less liable to
fractures than the other, which serves as the centre of
the  motions performed by the bone, and  is protected
externally only by the parotid gland. 
16
%
                   SECTION II.

   2.  A fracture of the condyle may sometimes arise
from a counter-stroke, as when, in consequence of some
external  force  being  applied from before backwards,
and from below upwards against the chin,  this process
is driven against the projecting rim of the glenoid ca-
vity ;  at other times it may  be the effect  of an imme-
diate or direct stroke,  as when a body in motion strikes
with force against the  region of the joint, and does vio-
lence  to that portion of the  bone.
   3. But in whatever manner the fracture may be pro-
duced, it generally occurs in the  slender  part of the
bone which supports  the condyle,  below the insertion
of the pterygoideus externus.  It is  characterized by
a pain more  or less  acute,  necessarily  accompanying
the motions  of the jaw;  by a difficulty more or less
considerable, in the performance of these motions ; by
a crepitation, oftentimes distinct, when, in consequence
of, the angle of the jaw being pushed forward, or  the
jaw itself alternately depressed and  elevated, the separat-
ed surfaces rub against each other; by an inequality of
surface sometimes perceptible directly over the fractured
condyle; by the ease with which, on being pushed for-
ward, it may be forced into the depression beneath the
zygoma; and by its remaining stationary,  during the
movements of the lower jaw, from which it is separated.
These signs, though  generally characteristic, are sub-
ject to an uncertainty proportioned to the swelling that
occurs in the part.
   4.  In this accident a displacement is almost always
produced by muscular action.  The pterygoideus ex-
ternus, being attached to the condyle, draws it forward 
17
and upward, towards the external wing of the pterygoid
apophysis, its fixed point  of insertion.  On the other
hand, the body of the  bone is  left behind, being held
by the masseter and external pterygoid muscles,  the
course of which  is opposed to a displacement in the
same direction; so that  there always exists a separation,
more or  less perceptible, between the two fragments of
bone.
   5.  Hence, if proper  means  be not used to restore
the contact between the broken ends of the bone,  the
following consequences will be likely to occur:   1st.
Their reunion will be tedious,  because  in every bone
this  process is,  in point of rapidity,  inversely propor-
tioned to the separation of the divided surfaces:  2dly.
This reunion may even entirely fail to take place, if the
bone be  subject to the  slightest movements, as I have
witnessed in a particular case, where the condyle,  not
being reunited to the other part,  exfoliated,  and was
in part discharged through the  external integuments:
3dly. Under such  circumstances,  the callus produced
in the. process of healing,  being situated  near to  the
joint, and rendered irregular and deformed  by the se-
paration of the parts, is  apt to impede muscular action,
and  do  a permanent injury to the  functions of  the
jaw.

                   SECTION III.

   6.  As the whole apparatus in this case consists in a
passive  resistance  to the active powers employed in
producing a displacement,  it follows from  what  has
been said (4)  that the bandage intended to prevent this
displacement,  and  by that means to guard against the
accidents  specified above (5) ought, either effectually
                         3 
18
 to bring back to its natural situation, the condyle which
 is drawn  forward, or pull in this last direction (that is,
 forward) the body of the bone which is still retained in
 its usual position, in order that it may thus be brought
 into contact with the condyle.
    The first of these measures is impracticable, in con-
 sequence of the situation of the condyles, which are too
 deeply enveloped by the surrounding parts, and offer a
 hold  too small to be acted on.   The  second, therefore,
 remains to be adopted, and is the more easily executed,
 in as  much as the angle of the jaw, from its projecting
 and being but  slightly covered  by  the -integuments,
 may without difficulty be directed from behind forward
 by a proper force.
   7.  The fingers of the surgeon temporarily supply this
 force, at the time of reduction;  but it is necessary that
 it should be permanently kept up by  means of the  ap-
 paratus. This end is attained, in the following manner:
   Place behind the angle of the jaw, which must be
 first pushed  forward, thick compresses, to fill up the
 hollow under the ear,  and form an  eminence higher
 than  the surface of  the surrounding  parts; pass over
 these  compresses, in an oblique manner, the bandage
 commonly used in lateral fractures of the bone, the ap-
plication of which must in this case commence on the
 sound side.
   These compresses, being more projecting  than  the
 surrounding surface,  will  necessarily sustain  a greater
 pressure, because the compression made by a bandage
 is in proportion  to the projection of the  part on which
it is  applied.   Hence,  being firmly supported, they
will retain the body of the bone  in a line with the dis-
placed condyle (4). 
19
  8. In addition to this mode of applying the bandage,
it is necessary that the  fractured  bone should be kept
in a state of perfect rest.  The internal pterygoid and
masseter muscles,  tending by their contractile efforts to
draw the angle of the jaw backwards, sometimes over-
come the resistance of the apparatus, and, by producing
a second  displacement,  give rise to the accidents for-
merly mentioned (5).
  Let the lower jaw be now brought into perfect con-
tact with the upper one, and not separated from it dur-
ing the first few days after the injury, except so far as
may be necessary for  the  admission of nourishing
broths.  Should a tooth have been lost, the space which
it occupied will furnish, without disturbing the bone,
an opening  for the conveyance of  nourishment to the
patient.  Let talking,  laughing, and every thing  that
might  produce a  separation between the body of th«
bone and the condyle,  be carefully avoided.  The  fur-
ther treatment of the  accident  should be such as  is
generally applicable to all fractures of bones, and need
not be at present particularly detailed.
  The following cases, reported by citizen Giraud, se-
cond  surgeon to the Hotel-Dieu,  will confirm the ad-
vantages of this mode of treatment.
  Case I.  Margaret Bessonet, aged  thirty-four,  was
admitted into the  hospital on the  10th of May, 1791.
On the preceding day she had received a violent fall on
her chin: a severe pain, and a preternatural mobility in
the left side of the jaw, had been the immediate conse-
quences of the accident: from these symptoms, taken
in conjunction with those formerly mentioned (3) De-
sault discovered that a fracture of the condyle existed,
which  he reduced and  supported in  the  usual man
ner(7V 
20
    After being somewhat uneasy during the first few
 days, the patient became reconciled to the action of the
 bandage, which, by inattention,  had been two or three
 times disturbed and put out of order, but which,  by
 being  carefully reapplied, and aided by the necessary
 precautions (8) restored to the bone its natural  form
 and solidity,  by the  thirtieth day, and  on the thirty-
 sixth the patient was discharged perfectly cured.  The
 only inconvenience she experienced, was a slight diffi-
 culty in the motions of the jaw, an effect naturally re-
 sulting from the long continued inactivity of the mus-
 cles, but which was soon removed by means of exercise.
   Case II. Claudius Laurat, aged  twenty-seven, fell
 as he was carrying a heavy burden.   In his fall his chin
 struck with violence against a beam that lay in his way.
 In an instant he experienced a sharp pain in his right
 temple, and found it  almost impossible to move his
jaw.  Two hours afterwards a  considerable swelling
 appeared in the part, extending from the angle of the
jaw above  the ear.  The patient was admitted into the
 Hctel-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 support-
 ed as in the preceding case.  Oii the day following, the
 swelling was removed, doubtless by means of the com-
 pression which  had been made on  it; the other symp-
toms (3)  hitherto scarcely perceptible, became more
 obvious; the bandage was reapplied, and  the disease
terminated,  in  about twenty-nine  days, in the same
 manner with that of case 1. 
V"
21
                  MEMOIR II.

     ON THE FRACTURE OF  THE  CLAVICLE.

                   SECTION I.

  1. Man enjoys an advantage which nature has be-
stowed on but few of the quadrupeds, namely, a power
of moving his upper extremities  in every direction.
The clavicle  being a kind of arch placed between the
breast and shoulder, forms a centre, moveable indeed
but  solid,  for these motions, a part of which can no
longer be performed, when this arch,  in consequence
of being broken, ceases to afford them a point of sup-
port.  Hence it follows, that the fracture of this bone
may be said  to  reduce  die  individual who  sustains it,
when considered  in relation  to  its functions,  to a
level with that numerous division of animals that are
destitute of clavicles.
   2.  Few diseases of the kind are more frequently met
with than this.   The natural curve  of the clavicle, its
situation immediately under the skin,  the  want of a
support to its middle part, the great proportion of spongy
substance which enters  into its composition, the pro-
jection of the shoulder exposing it to the action of ex-
ternal bodies; all these  circumstances  concur in ren-
dering the accident  frequent, particularly among that
class of men subject, from their occupations, to violent
exertions of the upper extremities.
   Here then, more  than in the generality of fractures,
we should feel an interest in the advancement of the
art of surgery; and yet,  having hitherto employed in it
but feeble means, our efforts have been attended with
imperfect success.   Hippocrates  has  observed,  that 
22
 some degree of  deformity  almost always accompanies
 the reunion of a fractured clavicle; all writers since his
 time have made the same remark; experience has con-
 firmed the truth of it, and as much time has been spent
 in hypothetical speculations to explain the accident, as
 in serious inquiries how to prevent it.   At length De-
 sault proved that a feeble and unskilful mode  of treat-
 ment was the sole cause of a want of success, and that,
 by being more  correct and judicious, art might be as
 successful here, as in other fractures.   In order to give
 a  correct view of his practice in this disease, I will ex-
 amine the causes, varieties, and signs of a fracture of
 the clavicle ; the accidents of which it is susceptible ;
 the mode and the causes of the  displacement  of the
 broken ends of the bone; the indications that arise out
 of those causes, and the manner of answering these  in-
 dications as well  during, as  after, the reduction.

                   SECTION II.

          OF THE CAUSES AND VARIETIES.

   3.  The action of external bodies is almost the only
 known  cause of this  fracture,  whether  these  bodies
 strike the shoulder with  violence, or the shoulder be
 forcibly driven against them.  But this action is not in
 every case the same ;  its application is most frequently
 mediate  or  indirect,  but is sometimes  immediate or
 direct.
   In the first case there is  a  true counter-stroke, the
 ordinary effect, either of a severe  blow on the point of
 the shoulder, which is the  most common occurrence;
 or, as happens  less  frequently, of a fall on  the arm
when it is  extended for  the purpose of guarding the 
23
body from the force of the accident.   Under these cir-
cumstances, being pressed between the sternum, which
makes resistance,  and the body  which acts on its ex-
tremity, 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 flexi-
bility.
   In the  second case, the fracture occurs at the spot-
where the stroke  is given.   Here the momentum  or
quantity of force applied on  the bone, surpassing the
solidity which the  bone possesses, its continuity is ne-
cessarily 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  intermediate action of external
bodies; a counter-stroke  seldom produces  any thing
but a  simple' fracture;  while compound fractures are
generally  owing to a direct stroke.   The one produces
a  solution of continuity in the middle of the bone, or
thereabout; because in that  part the curvature is most
considerable.   The other is almost always the cause of
this solution,  when it occurs at  the extremities.  To
the  latter alone, is a double  division  to be  attributed.
The reason of these differences is already so  plain,  that
it would  be a waste of time  to dwell on  an explanation
of them. 
24
                     SECT.  III.

                    OF THE SIGNS.

    5.  The several phenomena that attend a fracture of
 the clavicle, taken together,  leave in general but little
 doubt as to its existence, particularly when the fracture
 is oblique.   As is the case in most other instances of
 the kind,  so here, an acute pain is felt at the instant of
 the stroke;  sometimes a cracking of the bone is dis-
 tinctly heard by the person injured;  on every occasion,
 it becomes suddenly impracticable to perform circular
 or rotatory motions with the arm; motions from before
 backwards can still be executed, but are difficult and
 painful, and, as I have already observed (1) the indi-
 vidual injured is reduced to the class of animals desti-
 tute of clavicles.
    Oftentimes the shoulder of the injured  side, being
 more  or less depressed, loses its level with the other.  It
 is also evidently drawn forward and inward.   The dis-
 tance between the acromion and sternum,  on the affected
 side, is found on comparison, to be evidently less than
 on the opposite  side.  In almost every case, that por-
 tion of the fractured bone, which adheres to the sternum,
 forms a visible  protuberance above and on the inside
 of the shoulder.
   6. In the mean time the pain continues.   The pain-
 ful drawing or dragging occasioned by  the weight of
 the arm forces the patient, for the purpose of relieving
 it, to bend his body towards the side affected, and incline
.-his head in the same direction.   This forms a peculiar
 attitude, which of itself was frequently sufficient to dis-
 close to Desault the  nature of the  disease.   We have 
25
oftentimes witnessed him establishing the truth of this
diagnostic, by merely looking at patients entering the
amphitheatre,  who had been brought thither for the re-
duction of such fractures.
  By this position, the pains are generally relieved, be-
cause the arm finds some degree of support; but should
the patient wish to change his position, or perform any
particular motions, the pains  return almost as acutely
as at first.
   7.  If to these signs,  which are almost all  of  them
founded in reason,  we  add  those  that are still  more
palpable to the senses, such as the mobility  of the two
broken ends of the bone ;  the crepitation produced by
their friction against each  other; the depression felt at
the  point  of fracture,  by passing the fingers over the
upper surface of the bone ; and the  facility of restoring
to  it its natural form and direction, by moving the
shoulder upwards,  outwards, and  backwards;  it will
be difficult to be mistaken respecting the nature of this
fracture.  This  is perhaps more particularly  the case,
when the fracture is oblique,  as this kind offers the most
striking diagnosis,  and cannot be  involved in uncer-
tainty,  unless when a considerable  swelling  occurs  in
the parts around the fracture.  But, even then, as the
circumspection of the practitioner will necessarily direct
his attention to this circumstance, the obscurity of the
signs will have no unfavourable influence on the cure.
   8. When the fracture  is transverse, there is some-
times more difficulty attending the diagnosis. The cor-
responding  inequalities of  the divided surfaces  may
mutually penetrate each other and  interlock,  and thus
prevent a displacement.   Does any uncertainty on this
score exist? Placing your fingers on the two extremi-
ties of the bone, order an assistant  to move the arm in
                          4 
26
 every direction, and the motions will be communicated
 to  the  clavicle; but, if  a fracture exist, they will be
 most perceptible in the fragment adjoining the shoulder,
 and will separate it from that attached to the sternum.
 This method will  seldom deceive us, is easily employ-
 ed,  and subjects the patient  to but a momentary pain.


                     SECT. IV.

                  OF  ACCIDENTS.

   9. We  do not  generally find fractures of the clavi-
 cle  accompanied by  such accidents as the anatomical
 relations of the  parts might lead us to apprehend. The
 external force being all expended in fracturing the bone,
 extends but feebly to the brachial plexus, which would
 be much injured by the shock, were the bone  to yield,
 without  breaking, to the  action of external  bodies
 striking against  it.  Hence,  without  doubt,  would
 arise serious  affections, as may be fairly inferred from
 the analogy of blows on the head and vertebral column,
 and  as is  indeed confirmed by certain cases  reported
 by Desault.
  Case I.  Two bricklayers were brought  to the Ho-
 tel-Dieu, who had met with similar accidents.  A piece
 of timber, thrown  from a building, in which they were
 engaged, had struck them, the one on the external part
 of the left  clavicle, the other about the middle of the
 right.   A considerable wound pointed out in each the
 place on which the blow had been received.  But the
 former,  having escaped a fracture, experienced nothing
but an acute pain, while the second had the  bone broken
 in two  places. 
27
  The customary apparatus was applied to the latter,
and the treatment which  we  shall presently describe,
being pursued, the result was that  complete success
which never failed to crown the attentions of Desault.
In the other patient a considerable  swelling  made  its
appearance the day after the  accident.   On  the third
day a numbness and partial loss of the power of motion
occured in the arm of the affected side.   Soon after-
wards an insensibility came on, and by the seventh day,
the paralysis of the  arm was complete.  It was not  till
after  a  tedious treatment, an account of which would
be foreign from my present subject,  that the limb  re-
covered in part its original strength.
   From whatever cause the fracture of  the clavicle in
this latter patient was prevented,  it is evident, that  the
whole of the force employed to produce the fracture in
the other,  acted here on  the brachial plexus, and gave
rise,  by means of concussion,  to the accidents  which
followed.
   10. The axillary artery,  though running near to  the
 clavicle,  in common with the brachial nerves, experi-
ences,  notwithstanding, less  frequently  than  they  do,
injurious effects from the fracture of this bone. I know
not of any instance  where a puncture from the broken
ends of the clavicle has produced in this artery  a false
aneurism.  To conclude, like all other  fractures,  that
 of which we are now treating,  may  be  connected with
 wounds, splinters, &c.  But in general,  as Hippocrates
 remarks, the  fracture  of the  clavicle assumes in com-
 mon cases a mild aspect. 
27
   SECTION V.

OF DISPLACEMENT.
     11.  Most of the symptoms formerly mentioned
  (5 and 6)  as accompanying a fracture of the clavicle,
  are evidently the result of a displacement of its broken
  ends.   Yet this phenomenon, taken notice  of by all
  authors, and considered by the m 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 na-
  tural position.   Three  examples of this kind  occurred
  in the Hotel-Dieu in the  course of the year 1787.
     12.   Instances have  also been known,  in which the
  sternal fragment, when fractured obliquely upwards, has
 supported the end of the humeral in  such a manner as
 to prevent any derangement.   Desault was accustomed
 to relate several cases,  where similar  occurrences took
 place; but, in general,  this  state  of things is rare,  in
 comparison with that in which the fragments lose their
 natural level.
   Almost always, then, there is more or less of a per-
 ceptible  overlapping {chevauchement) produced, either,
 by the elevation (a circumstance which is  very rare) of
 the external fragment over the internal; or, (as com-
 monly occurs) by the depression of the former beneath
 the latter.
   13. Of the first of these modes  of displacement (a
 mode but rarely mentioned by authors) a few examples
are to be found  among the  observations  of Desault
one of which he has  recorded in his journal.  Hippo-
crates speaks of the phenomenon as a thing that was
familiar to him. 
28
   14. The second kind of displacement, that which we
constantly find in practice, and which the laws of mus-
cular action render almost inevitable, takes place in such
a manner that the shoulder appears to obey the impulse
of two powers,  one of which draws it downwards, and
along with it the external  fragment of the  clavicle,
which is displaced by this power in the direction of its
transverse  diameter, or thickness.  The other power
approximates the shoulder to the breast, and draws it
forward, carrying  along with it  the  same  fragment,
which is by this means displaced in a longitudinal di-
rection.
   That we may the better understand them and their
effects,  let usy in our minds, separate these two pow-
ers,  although they are perfectly simultaneous in their
action.  A knowledge of them will  lead us to a know-
ledge of the resistances which ought to  be opposed to
them.   But let us first remark,  that the humeral frag-
ment, being drawn downward and inward, takes some-
times such a direction, that its internal extremity passes
backward under the sternal fragment, its external end
continuing to point forward: this  disposition can  be
understood from its natural direction.
   15.  The first of these powers, namely, that which
depresses the point  of the  shoulder, appears to have
escaped the notice of the ancient physicians  of Greece,
who attributed the apparent depression of this part, to
the elevation of the sternal fragment, and, accordingly,
endeavoured by making compression on the latter, to
restore  it to a level with the other.   Hippocrates, more
judicious  than  those who had preceded him, demon-
strated 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 
30
  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 com-
  parison 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 con-
  vince us, that, in case of its ceasing to fulfil that office,
  the shoulder must obey the laws of its own  gravity, in-
  creased by that of the hand, and arm.
    16. The  illustrious Petit, and with him Duverney,
 in acknowledging this cause of displacement, have add-
 ed to it as another the action of the deltoid muscle on
 the external  end of the bone ; in this action, the end of
 the clavicle  is  the moveable point, while the humerus
 affords  the  fixed  point.  But how  can we admit this
 cause, when the humeral fragment, in passing under
 the sternal, moves in a backward direction ?  So far is
 the deltoid muscle from drawing the bone  downward,
 that here the bone rather draws the muscle in part back-
 ward, 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 hu-
 meral and prevents a  displacement, why does not the
 deltoid produce this displacement f
   It is then in the weight of the arm and shoulder alone
 that we  must look for the passive power,  which de'
 presses  them, and which produces a displacement in
 the direction  of the transverse diameter or thickness of
 the clavicle.
   17. A second power, highly active, co-operates with
this.  I  allude  to  the permanent contraction  of the
muscles, that extend  from the breast to the clavicle 
31
and shoulder! from this  cause arises the displacement
in the longitudinal direction of the bone.
   The pectoralis major,  the pectoralis minor, the sub-
clavius, 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 for-
ward and inward.   None of them  appears to act with
more effect than the pectoralis major.   To this, in par-
ticular, is to be attributed the displacement in a forward
direction.
   Except in the  instances stated above, the action of
the muscles is not immediate.   They act only second-
arily on the external fragment, which, being stedfastly
attached to the scapula and humerus, is obedient to the
motions impressed by the muscles on these two bones;
motions which, in a sound state, the clavicle has a power
of controlling.
   18.   To the Weight of the lower extremity (15 and
 16) and the  spontaneous  action  of the muscles (17)
 must  be  added, as another cause  of displacement, the
motions  which are communicated to the arm  by  ex-
ternal 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 ge-
 neral takes place.  This circumstance is attributed to
the action of the trapezius, which draws each fragment
upwards  with equal force.  However this may be, it is
doubtless to such cases  that  we must refer the com-
plete cures, obtained without any retentive apparatus, by
Gasparetti, Brown, and other writers.  Hence  also, 
32
 without doubt, arise  the difficulties  experienced by
 certain practitioners, such as Duverney, with respect to
 the diagnosis of this disease.   These fractures may be
 mistaken for fractures of the acromion, being situated
 so immediately in its vicinity.

                   SECTION  VI.

               OF  THE  REDUCTION.

   20.  On looking into the causes of that displacement
 (15.... 18)  so common in fractures  of the clavicle', it
 appears that in almost every case, the external extremity
 of the humeral fragment is drawn, by a double power,
 downward,  inward,  and  forward.   Hence it follows,
 1st. That the resistance opposed to this power, by the
 means used for the purpose of reduction arid the reten-
 tive  apparatus subsequently  employed,  ought  to  be
 directed upward,  backward, and outward, these direc-
tions being the reverse of those in which the powers of
 displacement act:  2dly.  That, in as  much as these
 powers, viz. the weight of the parts and the action of
 the muscles, are in constant operation, and, besides, as
the motions of the arm are continually disturbing the
fragments of the bone, the apparatus ought to be equally
constant in its action, and should  keep up,  without
 any  remission,  the  effect produced, at  first, by the
 means of reduction.  This principle is  applicable to
 every case, and ought to be the standard of comparison,
 for determining the advantages  or disadvantages of dif-
 ferent  bandages,  and processes for the  reduction  of
 fractures of the clavicle.
   21  But we are not to  suppose,  that these processes
have heretofore  manifested an exact  application of this 
33
rule.  Hippocrates directed to  press the arm  close to
the ribs, and at the same time to  push it upwards, in
such a manner, as to make the shoulder appear as sharp
and pointed as possible.   Hence his precept to lay the
patient down on his back, the back being supported  by
some projecting body, and then to press the shoulders
backward; hence again, when the  humeral fragment is
drawn inward, his advice to press the elbow close to the
breast.   This twofold expedient was attended with great
difficulties,  even under the direction  of the father of
medicine.   Celsus only  copied  Hippocrates,  adding
nothing whatever to  his  mode of practice.   Paul of
Egina, more judicious in  this case, conceived, that  for
the purpose of forcing the shoulder outward, and rend-
ering it, agreeably to the idea of Hippocrates, very
projecting  and sharp, it would be advisable  to  place
the fulcrum or point of support, not in the middle of
the back, but under the arm-pit.  A woollen ball was
employed  by him for this purpose, a practice  which
would,  at once, have carried the art near to perfection,
if, after being employed to  reduce the fragments, this
process had been continued for the purpose of retaining
them in apposition.
   22. No new method distinguished the surgery of the
Arabians.   It is necessary to come down to  the time
of Guy of Chauliac, before we meet with the method
which is almost universally adopted at present, and
which consists  in placing between the shoulders,  the
knee of an assistant, whose hands are to  be employed
in drawing them forcibly backwards.  But it is evi-
dent  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
                         5 
34
 Paul of Egina:  and, indeed, on comparing this process
 with the general principles already established (20) it
 will be immediately perceived, that  the powers of re-
 placement do not here act in an opposite direction to
 those  of displacement.
   Hence the  difficulties  of reduction, the time spent
 in the operation, .and  the  sufferings by which it was
 sure to be accompanied.  The fragments were brought
 together, it  is true;  but it was only by  varying  the
 movements, and changing their direction, that the point
 of contact was ultimately found.
   23. Desault conceived, in the year 1768, that to  re-
 duce,  in  the most effectual manner, a fracture of  the
 clavicle,  it was necessary  not only to push the shoulder
 backward and upward, as was  commonly done, but,
 above all, to force it outward, and that the power des-
 tined  to  draw it in this latter direction, ought  to  act
 horizontally, according to the  course  of the clavicle, in
 the same way, as, in an  oblique fracture of the thigh
 or leg, the extension for replacing the fragments is made
 in the direction of the bone.
   24.  As the union of the humerus to the clavicle,  by
 means  of the scapula,  communicates to  the one  the
 movements of the other, it is  easy, by placing the ball
 used by Paul of Egina,  under the arm-pit, to convert
 the arm into a lever of the first kind.*   The lower ex-
 tremity 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

   * That form of lever, where the weight to be raised or the resistance
to be overcome, is at one end, the force at the other, and the fulcrum or prop
between them. This form is well represented by the handle of a pump, where
the piston is the weight or resistance, the hand of  the drawer of water the
force, and the iron pin, on which the handle works, the fulcrum op prop.
                                                Trans. 
35
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 ne-
cessary, in«the next place, to invent a bandage, calcu-
lated to retain the broken ends of the bone in contact.
Desault thought it practicable to unite these two points?
of treatment, in the same process, that is to say, to re-
duce, and at the same time to retain the fracture.  Here
the art is  indebted  to him for an improvement, which,
I will venture to say, carries it near to perfection. To
judge of this, it will be necessary only to take a hasty
survey of the different kinds of apparatus proposed by
different writers.

                  SECTION VII.

   OF THE MEANS  OF RETAINING  A REDUCTION.

   25. Here all  authors seem to have been directed
by the same  principle.   This is  to keep the shoulder
of the affected  side, 1st, drawn forcibly backwards,
2dly, approximated towards the shoulder of the sound
side.  Such was the practice of the  Greek physicians,
whom we have seen in common with Hippocrates, Cel-
sus, and Paul of Egina, employing a kind of bandage,
varied in its form, according to the displacement it was
intended to remedy.
   Above all others,  we find  an application of this prin-
ciple, in the figure  of 8 bandage, a particular form,
which was employed in practice by Albulasis, an Ara-
bian, and  afterwards  by his countrymen,  as well as
by Lanfranc, Guy of Chauliac, and their cotemporaries.
The use of this bandage was continued by Pare and his 
36
  successors, and has been lately modified by several au-
  thors, such as Heister, Petit, Brunninghausen, &c.
    26.  But under whatever  form it shows itself, its
  action is always the same, and always insu^cient.  On
  comparing its effect with the general principle, on which
 every apparatus for the clavicle should be  constructed
 (20) we perceive, that it  by  no  means  answers  the
 threefold indication, of retaining  the  shoulder back-
 ward, 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 direction,
 is divided into two channels.  One of these runs paral-
 lel to the shoulder and acts to  no  purpose, while the
 other, being  perpendicular to it,  is alone effective;
 hence it must act with a force equal  to 10, in order to
 produce an effect equal to 5.
   28.  The indication, to draw the humeral fragment
 outward,  far from being fulfilled, is here diametrically
 counteracted.  The scapula,  being  approximated  to
 that of  the opposite side,  draws the humeral fragment
 towards the trunk,  making it underlap the internal one,
 and, in this respect, the figure of 8 bandage acts pos-
 teriorly in precisely  the same manner,  during the
 treatment,  that  the contractions of  the muscles did
 anteriorly before the reduction.
   29.  Should the shoulder  be  supported,  at such an
 elevation, as might have a constant  tendency to destroy
 the influence of its own gravity ? this  is evidently pre-
 vented by the very oblique direction of the turns of the
bandage.  Suspending the arm  in a sling, is the only
way, in which that end can be  attained.   But does this
mode always possess sufficient firmness and stability? 
37
The arm, not being here sufficiently fixed, may be
constantly in motion, which, by deranging its situation,
must  communicate very  troublesome and injurious
movements to the  fragments of the clavicle.  One of
the principal faults of all bandages consists, in not pre-
venting 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 ex-
coriations ?
   30.  From the want of a mutual correspondence and
fitness between the indications already enumerated (20)
and the manner in which the figure of 8 bandage acts,
it is evident that the former can never be satisfactorily
fulfilled by the latter.  Hence we may judge, what im-
provement the art has received from the iron cross of
Heister, the compress of Petit, drawn transversely over
the oblique turns of the bandage, the  waistcoat which
Brasdor fastened round the thorax of his patients, and
the leathern  apparatus, lately proposed by  a  German
practitioner.  These means,  though diversified in their
form, are similar in their effect, and, being nothing but
modifications of the figure of 8 bandage, possess, like
it, the radical fault of not offering a resistance directly
opposed to the  two-fold power,  arising from the  mus-
cular action and the gravitation of the shoulder.
    As to what remains,  it  will be sufficient to show the
insufficiency of the process of reduction (22) by means
of the knee placed between  the  shoulders, in order to
demonstrate the existence of a like insufficiency  in all
those forms of apparatus, which, as Brasdor remarks. 
38
  have for their object a continuance,  during the  treat-
  ment, of the  effect produced by that process.
    31.  On the other hand, those indications will be
 fulfilled with exactness, by such a form of apparatus as
 will render permanent the action of the means of reduc-
 tion which were employed by Paul of Egina, by certain
 Arabian physicians, and by Pare; which have been re-
 newed by Desault, and tend to draw the shoulder up-
 ward, backward, and outward (23 and 24).
   Pecceti appears, in the last century, to have had a
 faint view of the proper indication on this subject, when,
 under the article  of fractures, he advises the ball to be
 suffered to remain under the arm  during the treatment
 of the injury.  But the figure  of 8 bandage, united to
 this expedient, counterbalances its effect,  rendering it
 of no avail, and Pecceti was therefore no more success-
 ful than others, in obtaining a cure of the fracture, un-
 accompanied by deformity.
   32.  An overlapping more or less perceptible never
 failed to accompany the consolidation or knitting of the
 bone, and here, as in many other cases,  practitioners
 laboured  to explain what they knew not  how to  pre-
 vent.   The impracticability of surrounding the part,
 as in other fractures, with a  circular bandage, appeared
 to Heister, Petit, and Duverney,  to be  the cause of
 this deformity.  They supposed that to be a supera-
 bundant callus, which was nothing but a displacement
 of the  fragments.   These visionary hypothesis ceased
to exist, as soon as this displacement was prevented by
a proper  apparatus.
   Desault sought for  this form of apparatus, as well as
for his other   bandages,  in the multiplied application
of means already known, without inventing new ones.
Bandages and compresses, easy to be procured,  and 
39
already rendered familiar to surgeons by daily use, serv-
ed him for the construction of his apparatus, for which
several machines had been already proposed.
  33. The pieces of which this apparatus is composed, are,
  1st. Three rollers, three inches broad;  the  two first,
six,  and the other eight, ells long, each  one  rolled up
separately.
  2dly.  A bolster or pad (a, b,  Fig. 1.) made in the
form of a wedge, out of pieces of old linen. Its length
should be equal to that of the humerus, its breadth four
or five inches, and its  thickness at the base (a) about
three inches.
   3dly.  Two or three long compresses.
   4thly. A small sling for the arm (Fig. 5.)
   5thly. A  piece of linen  large enough to cover the
whole bandage.
   Every thing  being  properly arranged, the  following
is the mode of applying the  apparatus, which of itself
reduces the fracture.
   34. The patient being placed in a standing position,
or,  if his  case render  that  impracticable, on a seat
without a  back, an assistant elevates the arm of the af-
fected side,  and supports it at nearly a right angle with
the  body (Fig. 2) while the  surgeon places under the
arm- pit the head of the bolster,  which descends  along
the  side of the thorax, and which another  assistant,
 situated at the patient's  sound side, holds by  the two
 upper corners.
   35.  The  surgeon  now takes one of the first rollers,
 applies the end of it on the middle of the bolster, fixes
 it there by two  circular turns  round the body,  and
 passes a turn obliquely (a a) along the fore part of the
thorax,  ascending to the  sound  shoulder:  the roller
 then" descends behind, passes under the arm, and re- 
40
 turning in front of the  thorax, makes a  circular turn
 and a half, horizontally.  Having reached the hind part
 of the  thorax, it reascends obliquely by the cast (b) as
 it had done before, and passes over, before, and under,
 the sound shoulder; having thus crossed the turn (aa)
 the roller again passes across the hind part of the tho-
 rax,  and finishes by circular turns, which completely
 cover the bolster.   A pin  is now to be  fixed in the
 place of crossing of the  roller on the  sound  shoulder,
 to prevent the turn (a) from slipping downward.
   The application of this first roller is intended for no
 other purpose, than firmly to fix  the  bolster which is
 held up by the two oblique turns  before  and behind,
 and secured against the body, by the subsequent circu-
 lar turns.
   36. The bolster being fixed, the surgeon applying
 one hand to its external surface, pushes it upwards, and,
 with the other, taking  hold of the elbow,  after having
 half-bent  the  fore arm, lowers the arm,  till  it is laid
 along the  bolster.. He then presses its lower extremity
 forcibly against the side of the thorax, pushing it up-
 wards at the same time, and directing its upper extremi-
 ty a little backwards.
  The application of the bandage  constitutes a part  of
 the  process of reduction.  The humerus, now converted
 into a lever of the first  kind, is drawn  at its upper end
from the shoulder,  in  proportion  as its lower end,  is
approximated to the thorax.  The scapulary fragment
being drawn along with it, and directed at the same
time upward and backward, comes  into  contact with
the  sternal  fragment, and  in an instant the deformity
of the part disappears.
* 37. The arm being thus situated, is given in charge
to an  assistant, who retains it in the  same position in 
41
which he received* it  from the  surgeon,  by pressing
on it with one hand, and with the other supporting the
fore arm half bent, and placed horizontally across the
breast.
  The  second roller is next to be applied.   The end
of this  is carried under the arm-pit of the  sound  side.
It is then brought across the breast,  over  the superior
part of the diseased arm,  and extends across the tho-
rax behind till  it passes under the arm-pit.  Two cir-
cular turns cover the  first.  The roller must then as-
cend  to the  lower part  of the  shoulder,  by oblique
turns  (c. c. Fig. 3) each of which must be overlapped
by the succeeding one, to the extent of about the third
part of its breadth.   It is necessary that these turns be
applied  in such a way,  as to bind but very gently above,
and to increase in tightness, as they descend nearer to
the lower extremity of the humerus.
  The  use of this second roller is, to supply  the place
of the hand of the assistant, in pressing the arm against
the side of the thorax; its effect  evidently is to draw
the upper extremity of the arm outwards,  and, as it is
already directed backwards, to retain it in that position.
The compression of the circular turns on the arm, be-
ing thus gradually augmented, becomes,  on the one
hand, more  efficacious,  because  it  acts  on  a greater
surface,  and on the other, less troublesome,  because,
being more divided, it is less  felt at the lower extre-
mity 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.
                          6 
42
    To fulfil this indication, an assistant sustains the el-
  bow in its elevated position, with one hand, and, with
  the other, supports the patient's hand before his breast,
  while  the  surgeon fills with  lint the hollow spaces a-
  round the clavicle. He then applies on the  clavicle, at
  the place where it  is fractured, the two long compresses
  wet with vegeto-mineral water,  or  some  other cooling
  liquid.  Taking now the last roller, he  fixes  the  end
  of it under the sound shoulder;  from thence he brings
  it obliquely across the breast, over the long compresses,
  and carries it down behind the shoulder along the pos-
  terior  part of the arm,  till it passes under the elbow.
  From this point, he again carries it obliquely upwards
 across  the breast to the arm-pit, then across the back,
 over the  compresses,  and brings it down again before
 the  shoulder, along the front of the  humerus till it
 again reaches the elbow.  From thence the  roller again
 ascends obliquely behind the thorax, passing under the
 arm-pit, where the first cast of the roller is  covered, and
 from whence it again starts, to run the same course we
 have just described. This constitutes a second round,
 which covers in part the first, and forms a  kind of dou-
 ble  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. 
43
  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 rol-
ler performs the office of the assistant, who presses the
lower part of the humerus against the side of the tho-
rax.
  On the other hand, the circular turns, by which the
application of the third roller is finished,  being directed
from before backward,  push in the  same direction the
arm and shoulder, which have been already carried that
way, by  the process of reduction, and thus retain them
in their proper places.
  Hence may be inferred the truth  of the proposition,
which we  have  been endeavouring to demonstrate;
namely,  that the  bandage of Desault, constructed ac-
cording  to  the general principle  formerly  established
(20) for  fractures of the body  of the clavicle, is calcu-
lated to  retain  the external extremity of  the humeral
fragment upward, outward, and backward.
   40.  The casts of the rollers, thus  surrounding the
thorax, however well they may be secured,  are yet li-
able to  be displaced, particularly when  the  patient is
in bed<   This inconvenience may be avoided,  by sur-
rounding the whole with  a piece of linen, leaving no-
thing uncovered, but the sound arm, which is at liberty
to perform its usual motions.
  The arm of the diseased side, being thus  fixed in
such a manner, as to constitute a whole  or entire body
with the thorax,  follows  its  movements, without pro-
ducing- any displacement.   It is thus, that by the  appa- 
44
 ratus for a continued extension of the thigh,  the frag-
 ments of the os femoris, forming an  immoveable whole
 with the pelvis, cannot change their  situation,  even in
 following the motions of the trunk.
   Hence arises,  in fractures of the clavicle, this advan-
 tage,  that  the patient is not obliged to keep his bed,
 but is able even to attend to his business,  during the
 progress of the cure.
   41.  I will not dwell  on the  numerous  objections
 urged by  different  authors against the bandage which
 has just been described.  What  answer, indeed, can be
 given to those writers, who fancy that they behold  the
 patient in the greatest danger of  immediate suffocation;
 who dread an approaching  mortification of the  arm of
 the diseased side;  who allege, contrary to the rules of
 the art, that  there is no impression  made immediately
 on the clavicle, but on a neighbouring  bone; who,  &c.
 &c. ? Twenty times  in a year, has experience answered
 these 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,  in-
 deed, when considered  in  the closet,  or at a distance
 from a sick-room,  dwindle to nothing at the bed-side
 of the patient.
  42. In those cases (which, as Hippocrates remarks, very
 rarely occur) where  the  external or  humeral fragment
 projects over the internal or pectoral  one (12) the band-
 age need suffer but  a slight alteration.  The two prin-
 cipal indications, of drawing the shoulder backward  and
 outward, must still  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
/ 
45
allowing the third roller to be  a little  slacker than
usual.
  The fragments, being reduced to the same level, and
brought into apposition, by this two-fold attention, will
unite us in ordinary cases.
  If the fracture exist at the end of the clavicle next to
the humerus, the difficulty of  their being displaced
renders the application of the bandage less necessary.
Prudence, however, demands that it be not altogether
neglected.

                  SECTION VIII.

 OF THE TREATMENT  DURING  THE FORMATION  OP
                    THE  CALLUS.

   The regimen to be pursued during the reunion of the
 clavicle,  varies according to circumstances.  It is im-
 practicable 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 sim-
 ple, and  no unfortunate  accident occur,  it is  always
 unnecessary to restrain the patient from his usual course
 of  life, beyond the second  or third day.   But,  though
 internal means are for the most part omitted in the treat-
 ment, the apparatus  is a subject on which two much
 attention  cannot be bestowed.   With whatever degree
 of exactness it may be at first applied, it will soon be-
 come  loose, and oppose  a diminished resistance to the
 weight of the shoulder, and the  action of the muscles.
 Hence, unless it be frequently examined, the fragments
 will be displaced. The following case furnishes  a detail
of the treatment subsequent to the reduction, to which,
in ordinary cases, Desault had recourse. 
46
   Case III. Mary Adel, aged thirty, as she was cross-
 ing a path covered with ice, in the severe winter of
 1788, fell on the point of her left  shoulder, and frac-
 tured the clavicle about the middle. Being brought to
 the Hotel-Dieu a few hours after the accident, she was
 dressed in  the manner just described, and, as the frac-
 ture was  simple, it was judged sufficient  to  make a
 slight diminution in the quantity of her aliment, during
 the two or three first days.  The dressing was moisten-
 ed every  morning, with  vegeto-mineral water, at the
 place corresponding to the fracture.
   On the fourth day  the  piece of linen that surround-
 ed the bandage was removed for the  purpose of ex-
 amining the state of the parts.  Every thing was found
 in its proper situation, and  the  covering was replaced
 till the seventh day, when the rollers  appeared to  be
 somewhat relaxed.  The  apparatus was taken off, and
 reapplied as at first,  the compresses  being carefully
 moistened with vegeto-mineral water, at the part lying
 over the fracture.   After the third day the patient was
 permitted to return to  her usual regimen.  The third
 roller being a little deranged  on the tenth day,  it was
 taken off,  and reapplied as  at first, together with the
sling.  The fragments were  examined and found  in
 perfect contact.  The patient was up during the whole
day, walked about the house,  and experienced no other
 inconvenience than that of not  being  able to use the
left arm.
   On the thirteenth day,  the bandage  was again reap-
plied, and allowed to remain till the  sixteenth, when the
patient having disturbed it, it  was once  more changed.
At this period, the fragments,  already firmly  united,
exhibited  scarcely  a  vestige of the division they had
sustained. 
47
   The reunion  was complete by the twentieth day,
when all  the pieces of apparatus, were dispensed with,
except the bolster and the second roller, which were
also removed two days afterwards, as they were found
to be no longer necessary.
   The continued inactivity of the limb, during the
treatment, had occasioned a stiffness  in the shoulder.
This was gradually done away by making the  patient
move  her arm in all directions, twice a day, each time,
for the space of an hour.
   On the twenty-ninth day she left the hospital, carry-
ing with her nothing to remind her of the injury  she
had sustained.  She was free from that uneasiness which
is the  consequence of a tedious and ill-managed treat-
ment,  during which the exercise of the limb has been
neglected.


                   SECTION  IX.

                OF COMPLICATIONS.

   44. We  are in possession of but  few observations
particularly relative to  the different complications, that
may accompany fractures of the  clavicle.  The  treat-
ment, in such cases, varied according to circumstances,
must be accommodated to the  indications  common to
all  fractures of this kind.
   When splinters,  displaced  in different directions,
whether adhering to the bone or  not, irritate the soft
parts, and, having passed through the  integuments, ap-
pear without, most practitioners advise to remove them
and cut of such parts  as project  beyond the  fractured
end of the bone, previously to reduction.   This direc-
tion is  founded on the severe pains  which,  in such 
48
  cases,  accompany  the  common  treatment  of the in-
  jury, and which the figure of  8 bandage always  aug-
  ments, by drawing the shoulder inward, and consequent^
  ly pressing the soft parts against the projecting parts of
  the fragment, or the points of the  splinters.  But if the
  splinters, adhering as yet to each other and to the bone,
  by means of the periosteum, have not assumed the na-
  ture of  foreign bodies  (that  is, if they be not actually
  dead) it is always proper to replace them.   It is  here
  only that we meet with an  occasion for that part of the
  process, of reduction denominated conformation,* 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 direct-
  ed.   Being  retained  afterwards in  a state of constant
  extension, it can neither be displaced,  nor cause pain
  by irritating the parts, which is the  inevitable result of
 the figure of 8 bandage.
   In cases  of this  kind,  it is useful to protect the
 shoulder  with a small splint, which may support the
 turns of the bandage, and prevent their pressure on the
 splinters, Or  the broken ends, which they might other-
 wise disturb.  These precautions are alike indispensa-
 ble when the fracture is double.
   Case  IV. Francis Ricord, twenty-five years of age,
 was received in the month of July,  1790, into the Ho-\

   * That process or operation in which the surgeon uses his hands to effect
the reduction and apposition of parts, which cannot be accomplished by ex-
tension and counter-extension alone.  If a bone be broken into two or  three
pieces, mere extension and counter-extension will not bring all the fragments
into their proper places, so as to restore the natural form of the part. In such
cases  the surgeon uses his hands to aid the action of the extended muscles.
and this is the process which our author denominates conformation. The term
occurs in many places in the course of the work.                 Tr a jts. 
49
tel-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 occured at the mo-
ment of the accident, had continued  throughout the
night, and were still  sensibly felt.   The slightest mo-
tion 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 depress-
ed, was also drawn perceptibly forward and inward;
and a large echymosis, without any external wound, oc-
cupied  its whole extent.
   Desault being satisfied that the several fragments
were all connected together, and that none of them was
separated from  the periosteum, placed,  as in ordinary
cases, the bolster under the arm, completed the  reduc-
tion, and  applied a splint  along the  course of the cla-
vicle, after having, with his hands, brought the fractured
pieces into contact.   Confident, then,  that the form  of
the part was perfectly restored, he  applied the bandage,
which was moistened with vegeto-mineral water, twice
or thrice a day.
   At the moment  of reduction the pains ceased, and
were felt no more till the fifth day, when the bandage
being a little relaxed,  admitted of a slight displacement
of  the  fragments.  This displacement was  removed,
and the pains along with it, by the reapplication of the
apparatus.
   During the six first days a very strict diet was en-
joined.   This, however, was dispensed with by degrees,
till, on  the thirteenth  day,  the patient returned to his
usual regimen.  On the seventeenth day, there remain-
ed nothing  of the echymosis, but a yellow tinge, the
customary consequence of such an accident.   The pre-
                           7 
50
  cautions inculcated in the preceding case, were employed
  also in this,  and the patient was discharged perfectly
  cured,  on the forty-second day from the  time of his
  admission.   Nor had he experienced, during his treat-
  ment,  those  severe and long continued pains,  which,
  under a different management, so frequently accompany
  this kind of fracture.

        EXPLANATION OF THE FIRST PLATE.

 Fig. 1.   A  bolster made  in the form of a  wedge, in-
   tended to be placed between the arm and the side of
   the thorax.
 a.  Its base, which should  fit the hollow of the arm-pit.
 b. Its summit reversed, against which the elbow is to
   be applied.
 Fig. 2.  The first roller applied for the purpose of fix-
   ing the bolster against the side of the thorax.
 a a.  Oblique  casts before,  passing over the opposite
   shoulder, in order to hold it up.
 b. Oblique casts from behind, crossing the first ones on
   the shoulder.
 d d. Circular  casts round the trunk, covering the bol-
  ster, which  they fix laterally.
 Fig  3  The second roller, applied to fix the arm against
  the bolster.
 aVb. Portions of the oblique casts  of the  first roller
  left uncovered by this one.  "
c c.  Turns of the second roller,  covering those of the
  first, loose above, and tighter below, for the purpose
  of drawmg  the superior  extremity  of the humerus
  outwards.
d. Their passage over the side opposite to the bolster. 
51
 Fig. 4. The third roller intended to keep the point of
   the  shoulder raised.
 aa$3b.  Oblique  casts of  the  first  roller, remaining
   uncovered.
 c c.  Turns of the second, seen through the opening of
   those of the  third.
 d. Oblique casts of  the third, ascending from the arm-
   pit  over  the  shoulder  of the diseased sicle, to  de-
   scend again behind, along the arm, and pass under
   the  elbow.
fk. A continuation of the preceding casts, reascending
   under the sound arm-pit, and from thence behind the
   thorax, over the diseased shoulder.
 e. A  continuation of the  same  casts, descending on
   the  fore  side of  the arm, passing under the elbow,
   and ascending again under the arm-pit of the sound
   side.
 g. The remainder of the roller, intended to be employed
   in circular turns,  in order to secure the casts e, and
   prevent them from slipping outward.
 Fig. 5. A sling which should be fastened to the oblique
   cast d (Fig. 4) to support the hand. 
MEMOIR III.
      ON THE  LUXATION  OF THE  CLAVICLE.

                    SECTION I.
         •
   1.  The clavicle, which forms a moveable abutment
for the shoulder, and receives  and sets bounds to most
of the movements of that part, and of the arm, exhibits
at its extremities, two articulations,  essentially differ-
ent from each other in their form, dispositions and uses.
These differences  give rise to differences equally es-
sential with regard to the dislocations to which they are
subject.
   2.  On the sternal extremity, a small surface, convex
from  above downwards, and concave from before back-
wards, is fitted,  by means  of  an intervening  cartilage,
to a much smaller  surface of the sternum, concave and
convex in opposite directions.
   One capsule, two ligaments, viz.  the  interclavicular
and costo-clavicular ligaments,*  and the anterior por-
tion of the sterno-cleido-mastoideus muscle, strengthen
the connexion of these two surfaces, and tend, on one
hand, to prevent their luxation, while, on the other, this
luxation  is favoured and facilitated  by  the following
circumstances:  1st, the disproportion between the di-
mensions of the two  articulating surfaces: 2dly, the
mobility of the joint;  and 3dly, by  this joint's consti-
tuting a kind of centre for the motions of the  arm.

   * I find in English books  of anatomy no  appropriate names for these
two ligaments.  I am therefore obliged to translate the French terms for
them literally.  The anatomist will have  no difficulty in recollecting their
situation-                                          Trans. 
53
   3. On the humeral side, an elliptical surface, slightly
convex, and inclined downwards, is immediately joined to
a corresponding surface of the acromion, elliptical also,
a little  concave  and  directed  upwards.   Hence two
kinds of inclined planes, 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  considerations,
let us proceed to examine, in  particular, each kind of
luxation to which the clavicle is subject.

  LUXATION OF THE STERNAL EXTREMITY.

                      SECT. II.

   OF  THE  CAUSES AND  DIFFERENT  KINDS  OF
                  DISPLACEMENT. .

   4. The sternal articulation of the clavicle experiences
different changes, according to the different movements
of this bone.  If these movements be in  a backward
direction,  the  articulating surface  is turned forward,
straining the anterior part  of the capsule,  the corres-
ponding ligament, and the extremity of the sterno-cleido-
mastoideus muscle.   If,  on the other hand, they be in
a forward direction, the  posterior ligament, and the ad-
jacent  portion of the capsule  are  overstretched.  In
motions directed upwards, the costo-clavicular ligament,
and the external and inferior part of the capsule,  and in
   * I do not recollect any terms in English works of anatomy equivalent
tothese.                                          Trans. 
54
  those directed downwards, the inter-clavicular ligament,
  and the internal portion of the capsule, experience a
  similar degree of tension.
    5. Hence  it follows,  1st. That the natural move-
  ments of the shoulder may be regarded as predisposing
  causes of luxation, because at the part where tension is
  excessive,  the ligaments are disposed to give way, and
  suffer the sternal extremity  to escape :  2dly.  That the
  efficient causes will be,  all external forces acting on the
  clavicle in such a way as to increase its motions beyond
  their natural degree, and beyond the resistance which the
  ligaments are capable of making.   Thus a fall on the
  point of the shoulder, forcing it suddenly backward and
  inward, produces a luxation forward.  But, in general,
  as the strength of  the articular ligaments is superior to
 the resistance of the clavicle  itself, a fracture takes place
 more frequently than a luxation,  in  the proportion of
 nearly six to  one.
   Though falls on the point of the shoulder are often-
 times productive  of luxation of the clavicle, they are
 not the exclusive causes  of that accident.  Desault has
 seen  the sternal extremity forced from its cavity by the
 knee  being  pushed violently against  the middle of the
 back, while the shoulders were drawn at the same time
 backwards.
   Case  I.  A porter dislocated  his clavicle in the fol-
 lowing 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  shoulders in the"
same  direction, and at the instant of  his attempting to
retain it and  prevent it from falling, produced a luxation
of the clavicle. 
55
  7. It follows from what has been said respecting the
different states of the  articulation, during its various
motions (4) that the clavicle is not equally liable to be
luxated in  every  direction.   Inclining naturally  back-
ward, but a very slight degree of motion in that direc-
tion is  necessary, to  effect  a luxation  forward.  To
produce a  luxation backward or inward, it is necessary,
on  the other hand, that 'the  humeral extremity  of the
bone should  make a  sweep at least three times the
extent of that required in the preceding case.  Besides,
motions in this direction are  accompanied with pain,
particularly if they be made by force.   Luxation  down-
Ward is prevented, on the one hand, by  the cartilage of
the first rib, which presents to the bone an insurmount-
able barrier.   On the  other hand, to produce this kind
of  luxation, it would be necessary for the external ex-
tremity of the clavicle to be  forced upwards,  an occur-
rence  very seldom occasioned by falls.  Luxation up-
 ward, or over the superior edge of the  sternum, must
 be  the effect of  a  stroke,  which,  by  depressing die
 point  of the shoulder, and  forcing it at the same time
 forward, presses  the  sternal extremity against the  in-
 ternal and superior part of  the capsule,  which,  being
 thus lacerated, suffers a luxation to take place.  But
 such a derangement of the articulating surfaces  is very
 rarely  produced by falls.   Whence it follows,  that of
 the different kinds of luxation of the clavicle, that in a
 downward direction is altogether impracticable.   Those
 backward and upward, though possible,  occur but
 rarely in practice ; while that in a forward direction,  on
 the contrary, is not an unfrequent accident.   This tends
 to confirm the observations of practitioners, and particu-
 larly of Desault, whose immense collection on the subject
 furnishes  examples of the last kind of luxation only. 
56
     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 preternaturally distended, and  then the
  luxation is incomplete.

                     SECT.  III.

                   OF  THE  SIGNS.

     9. But whatever may be the causes or kind of the
 luxation, its diagnosis is always easy.   If it be forward,
 the direction  of the  stroke which the shoulder has re-
 ceived,  furnishes, at first, some ground of suspicion.
 The accident is certainly  known by the appearance of a
 hard and unnatural protuberance in front of the sternum,
 and behind the extremity of the sterno-cleido-mastoi-
 deus muscle,  by the existence of a sensible depression
 or hollow at the joint, and by the situation of the shoul-
 der, which is pushed  further backward,  and is less
 projecting and more approximated to the trunk, than in
 its natural state.   Add to  these,  a difficulty in perform-
 ing motions in a forward direction, which, when some-
 what forced, reduce,  in proportion as they are accom-
 plished,  the size of the protuberance formed  by  the
 displaced end.   The  head is  always inclined towards
 the side where the luxation exists;  an attitude which
 relieves the painful drawing or tension produced in the
 sternc-mastoideus  muscle, by the humeral  extremitv
 pushing it forward.
   10. A protuberance  over the  superior ed^e 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 
57
absence of the sternal extremity from its natural cavity,
the approximation of the shoulder to the thorax,  and
its depression  and diminished projection, compared to
its usual state, afford evidence of a luxation upwards.
  11. A luxation inward or backward, would be cha-
racterized by a projection of the shoulder exteriorly, by
a difficulty in performing  motions in a backward di-
rection,  by the  alarming effects,  which,  as  Petit re-
marks,  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 striking,
accordingly as the  membranes, lacerated  or only  dis-
tended, offer a greater or less resistance.

                     SECT. IV.

               OF THE REDUCTION.

   13. To reduce a luxation,  is,  in general, to make
the  bone re-enter its  cavity, by retracing, or returning
along, the same  route  which it  followed  in escaping
from it.  Now,  in a forward  luxation, the  displace-
ment is from behind forward, in an upward one from
below upward,  in an  inward  or backward  one from
before backward, but,  in each of the three, it is more
particularly  from without  inward.  In the  first case,
therefore, it is backward, in the second  forward, in the
third downward,  but, in each  of the three, more  par-
ticularly outward, that the powers for producing exten-
sion 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, Duver-
                        8 
58
 ney, Heister,  &c. and which consists  in  placing the
 knee  between the shoulders of  the patient, as a point
 of resistance, by the aid of which the shoulders may be
 drawn backward, fulfils  only half of the indication  of
 cure; because at the time that the humeral extremity
 is drawn backward, it is not directed sufficiently outward.
   Hence a difficulty of replacing the bone sometimes
 occurs,  a difficulty always removed, when,  pursuant
 to the method employed by Desault  in fractures of the
 clavicle (see Desault's method) the arm is made to serve
 as a lever of the first kind, to carry backward and out-
 ward,  the head of the bone, which is displaced in the
 opposite directions, when the luxation is forward.  This
 method possesses the advantage, not only of giving
 the powers of extension a proper direction, but also of
 increasing them to a degree  even beyond what is ne-
 cessary for  effecting a reduction, by  removing them
 further from the  resisting force.   Hence it is unneces-
 sary to adopt any particular measures for restoring and
 preserving the form  of the  part, as the extension is
 alone sufficient for that purpose.
  These principles, evidently applicable  in effecting a
 reduction, are still more strikingly so in the means des-
 tined for retaining it.  Let us  apply  what I have just
 said, to a case of dislocation in a  forward  direction.  It
 will be easy to transfer it afterwards to the other kinds
 of luxation.

                   SECTION 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.
 I his  disposition  is the reverse of  that of most other 
59
luxations, which are reduced indeed with  difficulty,
but  seldom afterwards  suffer a  displacement.   The
cause of this  we  find,  1st,  in  the  extreme  mobility
of die clavicle, to which all  the motions of the arm are
communicated ; 2dly, in this further consideration, that
most of the  muscles,  which have  their insertion to-
wards the shoulder,  tend  to draw  this bone inward,
when the ligaments,  in consequence  of  being either
broken  or distended, as happens in this accident, do
not offer a sufficient resistance.
   16. From this two-fold cause of displacement, arises
a two-fold indication in the arrangement and application
of the apparatus.  These are, 1st, to render the clavi-
cle immoveable, by restraining every kind of motion in
the shoulder and arm; 2dly,  to  retain the extremity of
the  clavicle outward, a direction opposed  to that in
which it has a tendency to be displaced. But if to those
indications we compare the forms of apparatus hitherto
used, we will readily perceive that they are insufficient
to fulfil them.
   17.  The  figure  of 8 bandage, so generally in  use,
and all the various modifications,  under which it has been
revived, without being improved, fix the clavicle in the
very direction most favourable to a  displacement, and
even do it in the very manner in which that accident is
sometimes brought about; as may be seen in the history
of the case of the porter (6).  This bandage does not, un-
der 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 consti-
tuting 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 34 and 37.) 
60
    18. Bell, in condemning the figure of 8 bandage, not
  so much because of its action being insufficient, as be-
  cause of its obstructing respiration, proposes, as a sub-
  stitute for it, a kind of machine analogous to the iron
  cross of Heister, which, being fixed by straps passing
  under the  arm-pit, and  round ,the neck and body, is
  intended to retain the parts firm and immoveable.  But
  the motions of the  arm not being restrained, nor the ac-
  tion of the muscles of the shoulder opposed by an an-
  tagonizing power, places this piece of apparatus in the
  same  class  with those, which, from not being devised
 and constructed on a proper view and conception of the
 causes of displacement, have no affinity to rational practice.
   19. The apparatus for a continued extention, invent-
 ed 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 clavi,
 cle.  2dly.  The  shoulder itself, being forcibly  drawn
 outward, with the upper extremity  of the humerus, bv
 the action of the kind of lever into which this bone is
 converted, and to which the bolster {a b Fig. 1) serves as
a fulcrum, cannot, by its movements, derange the lux-
 ated 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 direc-
tion, remains fixed between those two antagonizing for
ces, which thus destroy each other. Hence the apparatus
of Desault, when accurately applied, offers to both of
these powers of displacement, a resistance perfectly cal-
culated to combat them.
  20  We must, however,  admit  that this apparatus
partakes or one inconvenience, common  indeed to  all 
61
bandages, but which is perhaps more particularly appli-
cable to this in consequence of the numerous casts of the
rollers that form it, namely,  the great facility with which
it becomes relaxed.  Hence one cause of displacement,
which the most exact and scrupulous attention cannot
at all times prevent.
   Case I. Desault had, for  a long time, the care of a
patient, whose luxation, having been neglected for four
days, was reduced on the fifth,  by a surgeon,  who, for
the purpose of retaining it, employed  a bandage of a
particular kind.  An hour  afterwards,  a motion of the
shoulder  backward, displaced the luxated extremity:
a new reduction was the consequence;  on the day fol-
lowing, another displacement, and so on in succession,
for ten days, at the  expiration of which, Desault being
consulted, applied to the part the bandage formerly de-
scribed.
   On being examined the next day, the apparatus was
found in  a favourable  state.  On  the day following, a
slight displacement rendered necessary a new application
of the bandage,, which, this time, continued  longer
than before. But, about the expiration of the third day,
the projection of the bone was again considerable.  Fi-
nally, the patient  recovered, with  a  very  perceptible
protuberance in front of the sternum, and a difficulty of
motion,  great at first,  but  less afterwards,  and which
 exercise succeeded  ultimately in removing.
    21. The application of  the apparatus differs  from
 that intended for a fracture of the  clavicle, only in this,
 that it is of service  to  place  on the luxated extremity,
 graduated  compresses,* calculated to  make pressure

   * 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. 
62
  backward and outward, 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 be-
  ing directed backward, may be removed  from the place*
  through which  it has a tendency to escape.
    22.  Desault  almost always obtained a complete suc-
  cess by this  process, and by the most accurate attention
 to prevent the relaxation of the bandage. In the mean
 time, a stiffness, more or  less considerable,  always re-
 mains in the joint for  a long time after the  reduction,
 and it is not  unfrequently a month or two  before the
 part recovers its usual facility of motion.
   The following cases, collected by Brochier, confirm
 the doctrine for which I have been contending.
   Case II.  A  man luxated the clavicle by falling on
 the point of his  shoulder, and forcing it backward. He
 was immediately brought to the  Hotel-Dieu, where
 Desault demonstrated to his pupils, that the head of the
 bone, carried in front  of  the sternwn, was removed
 nearly an inch from its natural cavity,  the ligaments of
 which were  no doubt lacerated.
   Here, as  in the fracture of the clavicle, the applica-
 tion of the bandage answered the purpose of reduction,
 and removed the protuberance formed by the  extremity
 of the bone.
   The patient, being strong and vigorous, and having
 received besides a violent contusion,  was bled twice
 and confined to  a low diet.  On the following day  no
derangement; on the fourth day,  a slight displacement
of the bone,  the rollers a little  relaxed, bandage ap-

  *  The rupture in the capsule that surrounds the joint.       Trans. 
63
plied anew.  Eighth day, no sensible displacement.
Eleventh  day,  some  swelling around the joint; com-
presses, wet with vegeto-mineral water, ordered to be
frequently renewed.   Twentieth day, the  swelling al-
most gone, and no disposition to  a displacement; the
apparatus was removed; motions  at first  difficult, and
contracted.   Twenty-ninth day, more free and easy.
Thirty-fourth day, returned to their natural state.
   Case III. Mary Rivert luxated her clavicle, on the
seventh day of January 1789.  Being brought some time
afterwards, to the Hotel-Dieu, she was treated in the
same manner as the foregoing patient, and with the same
result, except that a  very slight protuberance remained
at the extremity of the bone, and  the confined state  of
the motions continued a little longer.   Desault related,
in his lectures, other instances of cures being perform-
ed without the least remaining deformity.
   After all, even supposing the method just  proposed,
to possess no other advantage, than that of diminishing
the protuberance of the bone, which, under other modes
of treatment, is  almost inevitable, and by that  means
preventing the motions of the part from being confined,
it would still, without doubt, be a great  step towards
the perfection of the art.
   23. Should  a  luxation backwards occur, the same
process of reduction should be adopted, with this differ-
ence, that the extension ought to be made forward and
outward; and  the same  apparatus should  be applied
for retaining the  parts, except that the humeral extre-
mity ought to  be directed a little backward, in order
that the sternal extremity, being carried forward,  may
be removed from the place of laceration in the cap-
sule. 
64
    In like manner, should the bone be luxated upwards,
 it would be necessary to draw the arm  outwards, and
 elevate slightly the point of the shoulder, for  the pur-
 pose of depressing the sternal extremity.


  LUXATION OF THE  HUMERAL EXTREMITY.

                    SECTION V.

            OF THE KINDS OF LUXATION.

   24. Luxations of  the humeral  extremity of the
 clavicle, take place, according to Petit,  in two ways,
 1st, under, and 2dly, over the acromion.  If we attend
 to the disposition of the articulating surfaces, the supe-
 rior of which rests  obliquely on the inferior; if we ex-
 amine, in particular, the  relative position of the coro-
 coid apophysis with respect to the elavicle, it  will  be
 difficult to conceive how the first kinoNjf luxation can
 occur, without being accompanied by a fracture.  Yet
 some facts added by Desault to the doctrine of  Petit,
 on this point, seem to demonstrate the possibility of the
 clavicle sliding under the  acromion.  As to  luxations
 forward  and backward,  the mobility of the shoulder,
 the facility with which it yields to motions impressed on
 it in these two directions,  and the want  of a resisting
 power, make the two bones that compose it,  move to-
 gether,  still preserving their relative position.
   The  luxation upward,  then, is that  which ought
chiefly to occupy the attention of the practitioner.  Yet
even this is less frequent than the luxation of the sternal
extremity,  on account of the very great strength  of the
retaining ligaments, which,  when this luxation  occurs,
must be, if not lacerated, at least very much distended. 
65
                  SECTION 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 plane slide along each
other, in such a manner, that that which belongs to the
acromion  is  pushed inward, while that of the clavicle
is  directed  outward.  The  capsule being stretched,
gives  way, and then the displacement is manifested by
a preternatural protuberance over the acromion; by a
stiffness in the motion of the shoulder; by the direction
of this part, which is evidently drawn inward and down-
ward; by the inclination of  the head of the patient to
the side affected; by a bending  of the body; and  by
severe pains in the luxated part.   These characters  are
essentially distinct, and ought to have prevented the
error  of Galen, who mistook a case of this kind for a
luxation of the os humeri downward. Hippocrates and
Ambrose  Pare have foreseen the possibility  of  this
mistake and even warned  young practitioners to be on
their guard against it.  But,  as citizen  Sabattier judi-
ciously  observes,  the position of the head of the  hu-
merus, under the arm, in a luxation of that bone, will
remove all  uncertainty respecting the nature  of  the
injury.

                  SECTION VII.

   OF THE REDUCTION  AND THE MEANS OF RE-
                    TAINING IT.

  26. The reduction,  in this case, is generally attend-
ed with but little  difficulty.  The acromion being drawn
                          9 
66
 outward, by the upper end of the os humeri, which,
 by means of a fulcrum placed under the arm-pit, is made
 to act as a lever of the first kind, is restored, without
 much trouble,  to  its natural  contact with the corres-
 ponding surface of the clavicle.  But, it soon becomes
 deranged again, unless it be retained  in its place by a
 proper apparatus.   Now, on what principle ought this
 apparatus to be  constructed ?  To prevent the displace-
 ment, which generally occurs from without inwards, it
 ought evidently to act from within outwards. Whence
 it follows, that the rollers in the  figure of 8  bandage,
 recommended in this case by all writers, instead of pre-
 venting, actually favour the displacement (17) because
 they act in the same direction with, and therefore assist,
 the powers that produce it.
 -  27.  Here,  in  like manner as in the preceding case,
 the bandage of Desault fulfils with precision the indica-
 tions 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 re-
mains, it is to be attributed to  the inefficacy  of the
means of execution, and not to the principles on which
they are founded. 
]Vf£MOIR  IV.
 ON FRACTURES OF  THE ACROMION,  AND OF THE
         LOWER  ANGLE OF THE SCAPULA.

                   SECTION  I.

          FRACTURE OF THE ACROMION.

  1. There  is no part of the scapula more liable to
fractures than the acromion.   Being but slightly cover-
ed by the soft parts, this  insulated kind of appendix
has not, in all  positions of  the humerus,  a solid point
of support.  A strong muscular force  oftentimes acts
on it with great energy.  Being large in front, it  pre-
sents in that direction a considerable surface to receive
the action of external bodies.   Whence it  follows, that
if it is not oftentimes broken, this is to be attributed, not
so  much to its natural disposition, as  to the position
which it generally assumes  in falls.
  2. The fracture,  which is almost always transverse,
is sometimes at the summit, and sometimes at the base
of this apophysis, and is usually produced by a  violent
shock from  a  body falling on the shoulder, by a blow
received on that part,  &c.
  3. But in whatever place it occurs, it greatly  resem-
bles a fracture of the humeral  extremity of the clavicle,
of which the acromion  appears like  a  continuation.
There is accordingly a strong  analogy between the
phenomena, the  consequences, and the modes of treat-
ing these two kinds of fractures. 
68
        4. This accident is characterized,  1st. By a severe
     pain experienced by the patient, at the place of the frac-
     ture.   This pain  is increased by the elevation of the
     arm, which, generally hangs motionless down along the
     side.   2dly.  If the  humerus be  removed  from the
     trunk,  the hand being at the same time placed on the
     acromion, the extremity of this apophysis is felt sinking
     downward, creating thereby  an evident depression in
     the part.   3dly. Generally, the two fragments lose, of
     their own accord, their relative position; and unless the
     precaution  about  to be mentioned be used,  their dis-
     placement b^eomes 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.
     %
                       SECTION II.

                   OF  THE  REDUCTION.

       5. Two  different processes have been long in use
     for the reduction  of  fractures of the acromion.  One
     consists in  elevating the  arm almost to a right ano-le
     with the body, in order,  as Heister remarks,  to throw
     the deltoid muscle in^o  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 hume-
     rus is  suffered to retain the position  it has assumed,
*   that is,  to hang down the side ; the surgeon then tak-
     ing hold of  the elbow, pushes it vertically from below
    upwards, in such a manner, that the head of the bone,
    pressing against the acromion, elevates and replaces it.'
       6. Petit seems to have adopted indiscriminately these
    two methods, one of which, however, is greatlv superior 
69
to the other.   Indeed, it is evident, that if the humerus
be removed  from the trunk, its head will necessarily
sink down in the glenoid cavity.  Being thus separated
from the  fractured apophysis, it  leaves  beneath  it a
hollow or  vacancy,  into  which the fragment will be
pushed, should it be in any measure,  compressed by
the casts  of  the roller, during the application of the
bandage.
   7. On  the other hand,  if the arm still  fixed against
the side, be pushed upwards,  it will afford to the acro-
mion a solid  point of support,  which,  during the appli-
cation 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 niaMi*
tain the reduction.

                   SECTION  III.

     OF THE MEANS  FOR  MAINTAINING  THE
                    REDUCTION.

   8. As the displacement is most likely to occur down-
wards, particularly in motions of the arm, it is necessary
that a continued resistance be opposed to this tendency. *
But this resistance should be made by the head of the
humerus,  which,  if properly  directed,  will  represent,
during the treatment, a  kind of splint, which art ought
to render  fixt and immoveable lest,  being contiguous
to the divided surfaces,  it  might derange, by  its  mo-
tions, the  work of nature in  effecting their  reunion.,
Hence it  follows, that  the precise and immediate in-
tention  of the whole  apparatus  destined to  support 
70
  fractures of the acromion apophysis, is, 1st,  to keep
  the head of the humerus constantly elevated or pushed
  upwards : 2dly, carefully to prevent all  motions of the
  arm and shoulder.
    9. If the means, heretofore employed in this fracture,
  be examined,  it  will be perceived  that they  by  no
 means fulfil this two-fold 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 additioHJJto this, Duverney judiciously  advises  to
 keep the sling  elevated, for  the  purpose  of keeping
 the head of the  humerus applied under the fractured
 pieces.  He employed also the spica-bandage  which
 has been equally recommended by Heister.
  *10. But, in the employment of these means, the arm,
 not being confined against the  trunk, can move with
 ease,  and  derange the fragments,  and,  therefore, the
 second indication is not fulfilled.   Will even the first be
 fulfilled? By no means.  The sling being soon deranged,
 by the movements of the arm,  which are  oftentimes
 involuntary, suffers it to sink down again, and then the
 fragments,  being no  longer  supported, are  displaced
 Hence the  difficulties attending the treatment, difficul-
 ties which have not esC&ped the notice of authors, and
 which Heister thus expresses :  « Nemo ita curarisolet,
 ut brachium postea, liberi sursum attollere queat » an
 observation, which the celebrated Cheselden made before
 him, in describing the scapula.
   11.  These inconveniences will be avoided, by fixing
the arm,  as  recommended by Desault, firmly against
* Une pelotte. 
71
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  com-
municate any others to the fragments,  which are sup-
ported by its head.   This  advantage can be easily
obtained, by means of the bandage, already described,
for fractures of the clavicle, modified agreeably to the
circumstances of the case, in which it is to act.
   12. A bolster or pad of an equal thickness in  all its
parts, is placed under the arm.  The arm is then to be
pressed down on this, in like manner as in^ie bandage
for the clavicle*   The fractured apophysis is now  to
be covered by two compresses; one  extending  from
the clavicle to  the spinous processes of the vertebrae,
while the other,  lying over this, and running in a co^
trary direction, crosses it at the place  of the  fracture.
 The whole  is then to be secured  by a roller, which
 starting from the  arm-pit of the sound side,  pursues
 nearly  the  same course with that destined, in fractures
 of the clavicle, to retain the shoulder  upwards.   (See
 what has been said on this subject, when treating of the
 structure of the bandage.)
    13. By this mean, the two-fold indication of keeping
 the humerus immoveable, and directed upwards (8)  is
 evidendy fulfilled, as I have already proven at full length,
 when treating of fractures of the clavicle;  and a reunion,
 without deformity,  may  be looked for,  of which we
 have an instance  in  the  following case,  recorded  by
 Derrecagaix.
    Case I. Nicholas Gay, aged twenty-nine, was struck,
 in passing under a decayed building, by a stone, which,
 having become loosened, fell on the point of his shoulder.
 In an instant he experienced severe pain, and a difficulty 
72
  of moving  his  arm,  particularly  upwards.    Soon
  afterwards there occurred  a swelling of the shoulder,
  and a large echymosis at the place where the blow was
  received.   The pain, not so acute during  a state of
  rest, was increased  by the motions of the  arm, and
  even by  leaning the head  towards the opposite side,
  which latter circumstance was, no doubt, owing to the
  contraction of the trapezius muscle.
    A surgeon being called, judged it sufficient to make
 use of discutient applications, to which the swelling
 and the echymosis appeared to yield in the course of a
 few days.   On a more accurate examination, a fracture
 was discovered, supposed to be in  the external part of
 the clavicle, and for which the patient was sent to the
 Hotel-Dieu.
  » The fracture was discovered to be in  the middle of
 the acromion,  which  it  divided  transversely.    The
 bandage already  mentioned (12) was applied, and, from
 the first day, the patient was left to  his usual regimen.
 Fifth day,  a renewal  of  the apparatus which  had 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 mo-
 tions of the part, which exercise removed by  degrees
and of which the patient felt  no remains after the forty ^
eighth day. 
73
 FRACTURE OF  THE LOWER ANGLE Otf
                THE SCAPULA.

                    SECT.  IV.

    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 characterized by a
displacement which is always perceptible.   On the one
hand, the fleshy portion of the serratus-major, which is
attached to the inferior fragment, draws it directly for-
ward, while it is drawn  upward by the teres-major, and
some of the fibres of the  latissimus dorsi.  On the
other hand, the body of the bone itself remains behind,
being held by the rhomboid muscles.  Hence arises a
separation, which renders it difficult to mistake the frac-
ture.  Should any  doubts still remain, let the shoulder
be drawn backwards and  the scapula along with  it:  let
the fingers be, at the same time, placed on the lower
angle, to ascertain whether or not  it  follows the mo-
tions 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.
10 
n
                   SECTION V.

     OF THE REDUCTION,  AND THE MEANS Of
                  RETAINING  IT.

   15.  Here, as  in all other  fractures, the means of
reduction must be founded  on the causes of displace-
ment.   To effect the replacement, therefore, it is neces-
sary, either to push backward and downward, the angle
which is displaced in a contrary direction, in order that
it  may be brought into contact  with the body of the
bone, or else to  drafv the body of  the  bone forward
and upward, that  it may meet  the displaced angle.  It
is thus,  that in  a fracture of the condyle, the body of
the jaw, is drawn into contact with the fragment.
   16. But the first mode of reduction is difficult, and
the means of maintaining it impracticable.  It is ne-
cessary, therefore, to have recourse to the second, which
is the more easily executed,  as the scapula follows the
movements of the arm, and as,  by drawing this limb
forward,  and the elbow of it outward, that bone is re-
moved 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  pos-
sesses another advantage,  as it throws into a state of
relaxation the muscles  which tend to displace the lower
fragment.
   Hence it follows,  1st. That here, in like manner  as
in fractures of the clavicle,  it  is not  on the fractured
bone, that the  force must act,  but  on the  humerus.
2dly. That the humerus ought to be,  during the whole
treatment, rmmoveably fixed,  because its motions, being 
75
communicated  to  the  scapula, must soon derange the
contact necessary to a reunion.
  18.  On  these principles  were founded the appara-
tus of Desault, and his process of reduction, which con-
sisted,  1st, in drawing the arm forward, and separating
the elbow a little from the thorax ; 2dly, in fixing the
fore-arm at an  angle  sufficiently acute,  to direct the
hand to the point of the  opposite shoulder ; and 3dly,
to bring afterwards into proper apposition and form, the
fragments  already approximated to each other by the
first movements.
   19.  To  retain this reduction, the arm and fore-arm
must be permanently  fixed in tim above position. This
object is attained in the following manner : 1st. A bol-
ster in form of a wedge, being placed between the arm
and the side, its apex situated  in the arm-pit, affords
the double advantage of keeping the elbow at a distance
from the thorax, and of rendering the position of the
arm less fatiguing by serving as a point of support to it.
2dly.  Compresses wet with some discutient liquid, are
applied on the part corresponding to the fracture.  3dly.
The whole is now to be secured by a roller, seven or
eight yards long.   The first turns of this roller,  must
secure  the hand of the  affected  side  on  the  sound
shoulder to which it had been applied, during the re-
duction, and running afterwards from before backwards,
pass over  the place of the fracture, for the purpose of
retaining  the compresses on it.  The  wedge-formed
bolster is  to  be  secured  on  the  thorax  by  circu-
lar turns  around it.  Then,  passing under the sound
arm-pit, after having  made these  circular  turns, the
roller  must be  brought behind again, conducted ob-
liquely over the shoulder of the diseased  side, along the
anterior part of the arm,  under the elbow, ?nd behind 
76
 the thorax, where it is carried obliquely, in order to
 pass again under the sound arm-pit.   From this place
 it  ascends again anteriorly over the  affected shoulder,
 redescends along the posterior part of the arm, repasses
 under the  elbow, returns under the  arm-pit, and ter-
 minates finally  in circular turns round the trunk,  and
 arm together.   Hence it may be observed, that, in the
 first turns of the roller,  this bandage  greatly  resembles
 the third roller applied in the fracture of the clavicle, to
 retain the point of the shoulder upward and backward,
 (Fig. 4. plate I.)
   20. By this, 1st. The movements  of the arm being
 entirely  impeded, thar cannot  have any influence on
 those of the shoulder;  hence, in this respect, the frag-
 ments are  suffered to remain in contact.  2dly.  The
 serratus-major and  teres-major muscles, being kept in
 a state of habitual relaxation,  can no longer draw the
 inferior fragment forward, which cannot, therefore, be
 separated from the body of the  bone.  3dly. Nor can
 the body of the bone, being permanently  held  in this
 situation, be removed from  the fragment; whence, in
 both  respects,  a displacement will be effectually pre-
 vented.  This threefold advantage is not possessed by
 any of the different kinds of apparatus hitherto  pro-
 posed, such as the sling and cross-bandage, employed
 by  Petit, which  have the fault of suffering the arm to
move  backward, of allowing the scapula to  be easily
 separated from its insulated angle, of retarding by that
means the cure, and even of preventing it entirely, while
by  the process just described, it is usually completed
by the thirtieth day. 
MEMOIR V.
   ON  THE FRACTURES OF  THE UPPER END  OPv
            NECK  OF THE  HUMERUS.*

                    SECTION I.

   1. The language of the surgeon differs, in this case,
from that  of  the anatomist, andby  the expression^
" fracture of the neck of the hu Jp-us," is here meant
not that of the slightest circular depression, which se-
parates the head from the tuberosities of the bone,  but
rather  that of the contracted or diminished portion of the
bone,  which commences at the tuberosities above,  and
being  continued down the body of the bone, receives
at its lower end the insertion of the tendons of the pec-
toralis-major, the latissimus dorsi, and the teres-major.
Many practitioners consider this neck or contracted por-
tion as extending even to the insertion of the  deltoid
muscle.
   2. Several facts, the truth of which it  is difficult to
call in  question, attest the possibility of a fracture of the
neck of the bone, so called in anatomical  language.   I
have myself seen in the humerus of a young man, aged
seventeen  years, the  head of the bone exactly separated
from  its  body, by  a division which  had but slightly
affected the upper extremity of the tuberosities.  But

   * For a very important improvement made by Dr. Physick in the treat-
ment of an old fracture of the os humeri, and which may be applied also to
similar fractures of other bones, see Article I, of the Appendix.     Trans 
78
the examples of this nature which occur in the annals of
surgery are too few, to enable us to lay down any gene-
ral principles for the treatment of such fractures.
                   SECTION II.

       OF THE VARIETIES AND  THE CAUSES.

   3. The operation of external bodies, active, when
 ihey are thrown against the shoulder, passive, when the
 shoulder, or the  arm, is  forcibly  driven against them,
 is always the caus^lf a  fracture  of the. neck of the
 humerus.  From the mechanism of the part, the divi-
 sion is sometimes direct,  and sometimes the effect of
 a counter-stroke.
   The first of these arises very generally from d fall on
 the point of the shoulder, and as  in such  a case,  the
 commotion  or shock  must be very  great, to extend
 with sufficient force through the thick mass which forms
 the deltoid muscle, that muscle sometimes suffers both
 contusion and an echymosis.  Blood  may even escape
 from a rupture of some of the arteries or veins of the
joint,  and form, as Desault has observed, a collection
 or tumour which it would be imprudent to  open.
  The other is the effect  of a fall  on  the elbow, sepa-
rated,  at the time,  some distance from the trunk, or on
the hand, which, by a natural instinct,  is thrown out,
together with the arm and fore-arm, in  order to break
the violence  of the fall.
  4. The varieties  of this kind of fracture originate,
1st,  from the spot which it occupies,  being either the
middle or the lower part,  rarely the upper part, of the
neck of the humerus:  2dly, from  the state of the sur- 
79
rounding soft parts, which sometimes remain quite na-
tural, and at other times become distended and tume-
fied.  This  circumstance always involves the diagnosis
in more or less uncertainty;  3dly,  from the direction
of the fracture, which is  sometimes transverse,  but
usually oblique, particularly when produced in the se-
cond mode, that is,  by a counter-stroke  (3);  4thly,
from the relative situation of the fragments, which may
remain in contact, an occurrence however but very rare,
or may separate from one another in a direction inward-
ly or upward;  and, 5thly, from different complications,
with which  it may be attended.

                              •
                   SECTION  III.

      OF THE SIGNS AND THE DISPLACEMENT.

   The whole  of the signs of a fracture of the neck of
 the humerus, taken together, characterize its existence
 in a manner sufficiently evident.   But it is not always
 an easy matter to  take a view of them all at once, and
 in such a case, there are more  difficulties attending the
 diagnosis here, than in any other  fracture of the hu-
 merus.
   An acute pain is felt at the instant of the fall; and
 sometimes a crack or report is plainly heard.  There is
 always a  sudden inability to move the limb, which, be-
 ing left to itself, hangs motionless.   But  if any exter-
 nal force act  on  it,  it yields to it without resistance,
 and may  be moved by it with great  ease in every  di-
 rection.
   These  motions  are accompanied  with  severe pain,
 and, if carried too far, may give rise to very trouble- 
80
 some affections, as have been observed in patients, where
 the fracture was mistaken for a luxation.
   Beneath  the acromion,  is discovered a. depression,
 always situated lower down, than that which accompa-
 nies 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 fragment a
 rotatory motion,  1st,  the head will be perceived to re-
 main motionless ;  2dly,  the friction of the two divided
 ends will produce  a crepitation more or less perceptible.
 This two fold sign/iyblways  decisive as to the exist-
 ence of a fracture ; nRit  the swelling of  the joint may
 occasionally prevent the practitioner from availing him-
 self of it.
   The fragments remain sometimes in contact, without
 experiencing any displacement, in which case, most of
 the signs not  manifesting themselves, the diagnosis is
 rendered more difficult.  But most frequentiy a dis-
 placement occurs, and then it is the  inferior fragment
 that is deranged, and not the superior one which is so
 short that it can be but little effected by the action of
 the muscles.
   7.  The displacement is in general  but slightly per-
 ceptible in the longitudinal direction of the bone, unless
 when, in a very oblique  fracture,  the fragments pre-
 sent points which  irritate the muscles, excite them to
 contraction,  and augment their force;  or, when a blow
 of great  violence,  continuing to  act after the bone
 is  broken,  causes  the  fragments to  overlap  each
 other.  Thus has the body of the bone  been forcibly
drawn upwards,  or driven  in the  same direction,  till
having passed through the deltoid muscle, and the ex- 
81
tefnal integuments, it has even risen considerably above
the level of its head.
  But in general, as Petit observes, the weight of the
limb hanging down the side, opposes to the action of
the muscles a sufficient degree  of  resistance; and it is
in the direction of the cross-diameter or thickness of the
bone, that the displacement most frequently occurs. It
is to be  observed, that the  lower fragment is driven
either inward or outward, rarely in any other direction,
In the first case,  which  is by far  the  most common,
the elbow is somewhat removed  from  the body, and
cannot  be brought near to it wjgiout pain;  in the se-
cond, which is more rarely mdMpth, it is moved in an
opposite direction.
   In the one, the contractions of the  deltoid muscle
and the natural curve of the humerus, in the other, the
united  action of the  pectoralis-major,  the latissimus
 dorsi, and the teres-major, appear to have an essential
 influence on the  displacement.
   In each case,  the displacement  is facilitated  by the
 mobility of the lower fragment, and of the shoulder,
 when an apparatus from being improperly constructed,
 fails to prevent the movements  of the  whole extre-
 mity.
   8. The signs which have just been detailed,  do not
 always furnish such luminous evidence,  particularly to
 an inexperienced practitioner,  as to prevent the occur-
 rence of very serious mistakes. Of this Desault related
 many examples in his lectures.
   Case. J. M*** Est*** falling on his elbow, frac-
 tured the neck of the  humerus. A surgeon was imme-
 diately called, who, finding a depression  beneath the
 acromion,  a protuberance in the hollow of the arm-pit,
 and the  humerus directed  outwards,  pronounced,
                         11 
82
without further examination, that there existed a luxa-
tion  in a downward  direction.   Wishing to reduce  it
immediately,  he employed, to no purpose, the common
processes.  Acute pains were the consequence.   The
opening in the  capsule being too narrow was irritated,
and the  member subjected to great violence of motion.
At  length the pains became insupportable;  the opera-
tors  gave over their  fruitless efforts, and  Desault was
called.
  He discovered the mistake  from the immobility of
the  head; from the  depression beneath the acromion
being lower down tiran in a luxation ; and from the
existence of a crep^mon.   A reduction was  effected
without loss of time; the apparatus was applied, but in
the evening a considerable  swelling occurred around the
arm-pit; soon afterwards inflammation was superadded;
a vast collection  of  matter  succeeded, and, notwith-
standing the utmost attention, it was  five months be-
fore the patient was restored to health.
  9. To this  example, I  could add others,  where the
most  serious  accidents have resulted from a similar
mistake.   It must be acknowledged, however, that, if,
in a fracture, the displacement  be inward and a little
forward,  the  greater part  of the signs herein  detailed
(5) apply equally to a fracture and a luxation: but  then,
as we have just seen in the preceding  case, the immo-
bility of the head, the place of the depression beneath
the  acromion,  and  the crepitation, will remove any
doubts that may be excited in the mind of the surgeon,
by the protuberance  in the arm-pit, the direction of the
arm, &c. &c. 
83
                   SECTION  IV.

                OF THE  PROGNOSIS.

   10.  A fracture of the neck of the humerus assumes,
in general, a character  not very troublesome; and if,
as Heister says,  " a fracture near the head is worse,
and  more difficult  to be  cured,"  this is less owing to
the nature and  seat of the disease, than to the difficulty
of keeping the  fragments in contact.
   Seldom  have the reunion of .the bone, and the re-
moval  of all the disagreeable efreJts accompanying the
accident, required a longer time than is necessary for
the cure of other fractures.  The numerous examples,
which  occurred in the  Hotel-Dieu, during  Desault's
direction of the surgical department, confirm the  truth
of this assertion, notwithstanding some doubts that may
have been raised respecting it,  by prejudices formerly
entertained, on the subject of fractures in the vicinity of
joints.
   From twenty-six to thirty days  are sufficient for the
reunion: this was the term commonly required in the
Hotel-Dieu.
   11.  If judiciously managed,  art  readily removes all
the accidents attendant on this fracture; but,  if other-
wise, the consequences are apt  to prove troublesome.
It is here,  much more particularly than  in  other pla-
ces,  that all deformity of the part ought to be prevent-
ed;  because, the neck of the humerus  being near to
the centre of the motions of the arm, will very essen-
tially impede those motions if it be not properly reunit-
ed.  A deformed  callus  has been  known to produce. 
84
 in the hollow of the arm-pit, a protuberance, which has,
 in part, prevented abduction,  and appeared to keep up
 an habitual swelling in the limb.
   It is, then, from the perfection of the apparatus, and
 not from the vicinity of the injury to  a joint, that the
 prognosis is to  be formed, both as to the consequences,
 and as  to the duration of the fracture.   Keep the frag-
 ments  in exact and regular contact, and there will be
 no obstacle to that success which seldom  forsook De-
 sault.

                    SECTION V.

                OF TmL REDUCTION.

   12.  The reduction in this case is usually attended
with but little difficulty, and  the great  multiplicity of
means hitherto used for that  purpose, demonstrate only
the barrenness of the art.
   Most of the machines  destined to reduce the  luxa-
tion of the humerus, have been applied to this fracture.
Thus the ladder,*  the door,f and  the  club,:}:  placed
under the  arm-pit,   served  at  once the purposes  of
counter-extension,  and conformation, while the powers
for producing extension  were applied  to the elbow,
and more  rarely to the wrist.   Thus Hippocrates re-
commended  a  wooden cross, the effect and  mode of
action of which are nearly the same.   These means, in
general, besides being insufficient,  are  liable  to a fur-
ther objection, in consequence of their  acting on the

  OL'echelle, f la porte, He baton.)  These pieces of machinery, thou**
formerly m use  are now, I believe, in all parts of the world, la,d aside  I
would be superfluous, therefore, to consume time in describ ng either them
or their mode of operation.                                  '
                                               Tran? 
85
edges  of the  pectoralis-major,  letissimus dorsi,  and
teres-major, which being thus forced upwards, draw the
fragment to which they adhere  in the same  direction,
and  thereby constitute an obstacle to the reduction.
(See what will be advanced on the subject of luxations
of the humerus.)
   13. To machines succeeded the use of straps, weights
suspended to the limb, &c. These processes were en-
tirely useless, in as much as they were intended only to
increase the natural powers of the operator, which are
already more than sufficient of themselves. They will,
therefore, in a short time,  exist only in the history of
surgery.
   Petit proposed to reduce this fracture, by first raising
the arm to a right angle with the body,  and then di-
recting one assistant  to make  the requisite extension,
by taking hold of the elbow with his hands, while ano-
ther grasped the point of the shoulder, for the purpose
of counter-extension.   This method was attended with
the  threefold inconvenience, of subjecting the patient
to great  fatigue and pain, of weakening  the extending              «
powers,  by bringing  them too near to the point re-
quired to be moved,  and of irritating the muscles that
draw the lower fragment upwards, and thus exciting
them to  contract.  Hence the difficulties sometimes
attendant on reduction, which is always simple in itself,
when,  after the  trunk is properly fixed,  gentle exten-
sions are  made by taking hold of the fore-arm in a
half-bent state.   The  following is the mode of reduc-
tion 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. 
86
    One assistant is directed to fix and secure the trunk
  in a proper manner.   This he  does by pulling at the
  arm of the sound  side, taking hold of it near to the
  hand,  and extending it in a direction perpendicular to
  the axis of the body.   This mode of counter-extension
  is preferable to that commonly employed,  which con-
  sists in applying the hands to the upper part of the pa-
  tient'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 en-
  tirely unencumbered,  renders it easy for the surgeon to
  apply the  roller without  discontinuing,  or in any way
  disturbing, the extension.
   Another assistant makes extension on the fore-arm,
 which serves  him as a lever,  where, one hand being
 placed  behind or on  the  back of the wrist, forms the
 point of support (or  fulcrum) while the other applied
 to  the  anterior and middle  part of the  fore-arm,   on
 which it makes pressure from  above downward, repre-
 sents the power; the fragments to be brought into con-
 tact 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   ad-
 hered to by the English, and which possesses the advan-
 tage 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 accord-
ing as the displacement is inward or outward, is suffi-
cient to effect the reduction, which even  takes place of
its own  accord, under  this process.  If the  surgeon 
87
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.


                   SECTION  VI.

OF THE MEANS OF MAINTAINING THE REDUCTION.

   16. All kinds of apparatus for fractures,  being no-
thing  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 ex-
ternal 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 up-
 wards.
   17. Therefore,  1st, to render the arm  and shoulder
 immoveable; 2dly,  to carry the upper end of the lower
 fragment outward or inward, according to the direction
 in which it is displaced;  and,  3dly, to draw this frag-
 ment 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 an-
 swer  it. 
88
    18. Let us inquire, whether or not the kinds of ap.
  paratus, hitherto employed,  have been adequate to the
  fulfilment of these indications.
    The ancients, in obedience to the precept of Hippo-
  crates, fixed the arm against the breast, and confined it
  there by a bandage  recommended by Celsus, and con-
  stantiy employed by Paul of Egina. " Prastat antem,
  says he,  brachium,  ad thoracem moderate deligare, ut
  ne, si id commoveatur, figuram  avertat."  Pare  still
  preserved this process, which  the moderns  have now
  entirely abandoned,  and which, taken alone, could pro-
  perly fulfil only the first indication.  The second indi-
  cation was  less happily fulfilled, by a kind of bandage
 added to the first, by Celsus,  Paul of Egina,  and the
 Arabians, the necessary effect of which was, to force the
 lower fragment outwards.  It is surprising that Heister
 and Lamotte should have  confined themselves to the use
 of this for the retention of the fragments.
    What shall we say of the  eighteen-tailed bandage
 exclusively adopted by Petit and Duverney ? The arm,
 not being fixed by it, was liable to be  moved,  and the
 fragments to be displaced by the  least shock.   There
 was nothing to prevent the lower  fragment from obey-
 ing the  powers tending to  carry  it either inward or
 outward.   Indeed the bandage was of no avail what-
 ever 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 sup-
ported only  by a sling. Not one of the indications just
established (17) could by  such means be fulfilled.
   Perhaps the bolster of  tow proposed by Moscatti,
would have  surpassed all these means, in the advantages
it offered, had it not, by leaving the arm moveable be- 
89
low, and the shoulder above, still favoured a displace-
ment.
  Le Dran has also advised the use of a bolster com-
posed of that of Moscatti, and bole Armenian. It fixed
the  arm  more firmly against the trunk, and in this re-
spect,  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 em-
ployed for the fulfilment of them (18) that nothing sa-
tisfactory had yet been done, and that a proper apparatus
was still adesideratum. The success experienced by De-
sault, in  the use of that which we are about to describe,
has perhaps  proven, that  this desideratum  exists  no
longer.
  20. The  pieces which  compose  it, are,  1st. Two
rollers, the  one from five to six, and the other from
eight  to ten yards  long,  each one about three inches
 wide: 2dly. Three strong splints, of different lengths,
each about two inches broad: 3dly.  A small  bolster
made of linen, from three to four inches thick, at one
end,  tapering like a wedge to the other, and of a 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 reduction,
effected  in the manner already stated (14) and the as-
sistants  still continuing the extension:
   1st. The surgeon takes the first roller, wet with ve-
geto-mineral water,  fixes one end of it by two circular
turns on the upper  part of the fore-arm, and carries it
up along the arm by oblique turns, moderately tight,
and overlapping each other about  two-thirds of their
                          12 
90
 breadth.  Having reached the upper part of the limb,
 he makes some reversed turns to prevent the wrinkles
 that would be caused by the unevenness that occurs
 in this place.  He then  passes two  casts of the roller
 under the opposite  arm-pit, and bringing  the ball to
 the top of the shoulder  again,  gives it  into  the hand
 of an assistant.
  2dly. The  first splint is  then placed before,  and
 reaches from the fold of the arm, to a level  with the
 acromion.   The second  on the outside, reaching from
 the external condyle to the same level.   The third 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  towards the curvature
 of the elbow, so as not to hinder the application of the
 remaining part of the bandage.
  3dly. Tfie 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.
  4thly. The assistants still continuing the extension,
 the surgeon places the bolster between the arm and the
 trunk, taking care that the thick end be uppermost, if
 the displacement be  in an inward direction,  but lower-
most,  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.
  5thly. The arm is now  pressed towards the trunk, and
fixed against the bolster,  by means of the second roller.
 This roller is applied like that  which, in fractures  of
the clavicle, fastens  down  the arm to  the bolster, by 
91
 the oblique turns c. c. (Fig. 3. plate I.) with  this dif-
 ference,  that  in  the present case, the  turns ought to
 be very tight below, and looser above,  if the displace-
 ment be in an inward direction.   But, on the other
 hand,  if it be outwardly, they must be loose below,
 and tight above.
   6thly. 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 apparatus
 with die indications of cure formerly laid down (17) it
 will be easy to perceive, that, by it, they are extremely
 well fulfiled.   Indeed,  the  arm, being  firmly  fixed
 against the trunk cannot move, otherwise than  by mo-
 tions common to  it and the  trunk, and nothing  can
 derange the lower fragment, which is equally immove-
 able.  Nor can the shoulder communicate any motion
 W the superior fragment.  The bolster being differently
 disposed, according to the direction in which the lower
 fragment is displaced, will  serve  to move it in an op-
 posite  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 sepa-
 ration, by  the casts  of the roller, which, being very
 tight below, will act on it  as  on a lever of the  first
 kind, of which the  bolster,  forms the fulcrum, while
 the resistance to be  overcome is the action of the latissi-
 mus 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 con-
trary direction ; and,  in this respect, the bandage max 
'   92
   be  considered as an artificial muscle, forming a perfect
  antagonist to the natural ones.
    22. If the displacement be in an  external direction,
  as most commonly occurs (7) a contrary effect must be
  produced, as well  by the pressure made by the band-
  age, on the upper extremity of the displaced fragment,
  as by the situation of the  elbow which is directed out-
  wards by means of the thick end of the bolster being
  placed lowermost.  The  external  splint will also pre-
  vent the displacement  outwards, as  well by opposing
  to the bone a mechanical resistance,  as in compressing
  the deltoid muscle, which is the principal cause of the
  displacement.   The derangement of the lower fragment
  forward and backward, will  be prevented by the two
  splints before and behind.
    The displacement  longitudinally, already checked
 by the weight of the limb, will be still further prevent-
 ed, 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 ex-
 actly  m place, this apparatus unites that of not confining
 the patient, who is not obliged to keep his bed, and to
 whom a lying position is even, in general, more trouble-
 some and injurious  than an erect one.  This  observa
 tion applies to the treatment of fractures of the clavi
 cle of the scapula, and even of the  fore-arm, when no
 accident has rendered them complicated.
   Desault has cured several patients, but more particu-
 larly two, who, being obliged to  travel daily,  did not
except on the day of the accident, deviate in any mea-'
sure from their usual mode of life.
  An inexperienced surgeon  sometimes applies the
rollers too tight, in which case, a  swelling of" the fore! 
93
arm is the consequence. This is remedied by relaxing
the bandage ; but if, notwithstanding this, the swelling
still continues,  it will be necessary to extend the band-
age from the hand to the shoulder.


                   SECTION  VII.

        OF  THE SUBSEQUENT  TREATMENT.

   24.  The pain ceases as soon as the apparatus is ap-
plied,  because  the fragments, now brought into perfect
contact, cease  to irritate the surrounding parts.   Nor
does it return  during the treatment, as they are firmly
retained, and not suffered again to separate.
   It is rare that any serious accident follows this frac-
ture, and,  among the numerous examples met with by
Desault, he has scarcely ever had one such to encoun-
ter : yet he generally  paid but little attention to those
internal means which are  usually combined with  ex-
ternal  ones.  In  most  cases, the patients pursued  the
regimen to which they had been accustomed.
   In cases, where a considerable swelling attacked the
upper part of the joint, a circumstance which occasion-
ally occurs in  practice, one or two  bleedings,  a diet
more or less strict, and the use of diluent drinks, consti-
tuted the  internal  treatment.   Of this the following
case, related by Brochier, furnishes a detail.
   Case II. Maria  Catharine Bardelle, aged forty-five,
of a high complexion, fell, as she was carrying a heavy
load, on the elbow of the right side, the arm being ex-
tended a little from the body.  The neck of the hume-
rus was fractured, and all the usual signs combined in
pointing out the nature of  the accident. 
94
   A surgeon was immediately called, who mistaking
 it for  a luxation, made useless attempts to reduce it,
 tormented the patient for half an hour, and then left her
 to be sent to the Hotel-Dieu.
   Desault discovered it at first sight to be a fracture,
 and foreseeing the consequences of the improper steps
 that had been taken,  ordered blood-letting, and a low
 diet, after  having effected the  reduction, and applied
 the apparatus already described (20).
   In the evening, a considerable swelling appeared
 around the articulation ; the pains continued ; a diluting
 drink  composed of dog-grass  and  oxymel was pre-
 scribed.  Second day, the  swelling is gaining ground;
 pains  increased; blood  drawn  again; diet and drink
 continued; apparatus is frequently wet  with  vegeto-
 mineral  water,  particularly at the upper part.   Third
 day, a little better; pains diminished, swelling check-
 ed;  weak soup  is allowed.  Fourth day, a diminution
 of the swelling; pains  almost   gone.   Sixth day, the
 swelling has almost disappeared; light food; bandage,
 having become loosened, is reapplied.
   Tenth day, tongue foul; nausea ;  want of appetite;
 symptoms  of a  bilious diathesis.  Bitter  drink is pre-
 scribed ; 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 re-
union is evidently advancing.   Thirty-second day, the
consolidation is complete.
  The patient now began  to perform gentle  motions
with the limb, which she gradually increased, till about
the fortieth day, when she  was perfectly well, and free
in all her motions. 
95
  25. I will here repeat an observation, already made,
on the subject of the bandage for the clavicle, of which
this is nothing else than a modification.   In a short time
the bolster sinking  downward, the  bandage becoming
relaxed, and the  splints less tight,  do  not effectually
oppose  a displacement, unless the bandage be daily
examined, and reapplied, when it seems to act too feebly.
There are many surgeons, who have not been fortunate
in  retaining  the fragments with exactness, because,
trusting too far to the action of the  bandage, they have
for a long time neglected to examine it; this remark is
applicable to every apparatus composed  of rollers.
   26. Here, much more than  in other  cases, it is alL
important that the limb be accustomed to motion,  after
the process of consolidation.   Situated near to the joint,
the fracture  always leaves some stiffness in it, which
 time no doubt wears away, but which  will sooner dis-
 appear under the above treatment.
                  SECTION VIII.

    REMARKS  ON  COMPLICATED  FRACTURES.

  27. Complicated fractures of the neck of the hume-
rus are to be classed with all other accidents of a simi-
lar nature, and it  would  be difficult here to lay down
such general rules as would be applicable to every case.
The practitioner must be always governed by circum-
stances.   The  necessity of the case  sometimes urges
him to the adoption of daring measures, which, in de-
veloping the resources of the art, do honor to the  ta-
lents of him who exercises it.   Of this the following
case is a proof. 
                          96

    Case III. Pierre Lena, aged fifteen,  as  he was  at
 work on a scaffold, forty feet from the ground, fell from
 that height on the corner of a stone.  He experienced
 instantly such severe  pains, that he was unable to rise.
 He was carried to the house of a surgeon,  who, be-
 lieving that  he had suffered  a  luxation, made fruit-
 less attempts to reduce it, produced in the part an enor-
 mous swelling, augmented  his pains  and all  to no
 purpose.
   The patient was carried to the Hospital of Charity,
 where Desault at  the time  was surgeon  in chief.   A
 fracture  of the neck of the humerus was discovered,
 through the  tumefaction and echymosis,  which  had
 overspread the  whole shoulder.   A suitable  bandage
 was applied.
   A few days afterwards, a manifest fluctuation, an evi-
 dence of an effusion of blood, disclosed  the  necessity
 of making an opening.   This was accordingly done,
 and the fingers being introduced into the part, several
 large splinters were discovered,  and a  sharp-pointed
 bone, the end of the lower fragment, pricking the del-
 toid  muscle,  and  occasioning, no  doubt,  the  pains
 which had hitherto continued without intermission.
   The indication  was evident.  To give vent to all
 the splinters, and  cut off the point of the bone, or to
 amputate the limb,  was the  only alternative that was
 left. Most of the practitioners that were consulted were
 in favour of the last measure.  But  Desault  ventured
 to repose a hope in the first, the successful issue of
 which would  be the certain preservation of the limb.
 He performed the  operation as follows :
   A large incision made in the posterior,  and one still
larger in  the anterior part  of the arm, enabled him to
remove with ease  all the splinters.   Then taking hold 
97
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 simi-
lar  to that intended for the retention of fractures.
   A suppuration taking  place, the patient  was dressed
every day.  Several abscesses were  formed during the
course of  the treatment; each time the pus was dis
charged by means of an  incision.
   At the end of four months, the bone was perceived
to be in a  state of necrosis.   The dressings Were regu-
larly continued ; but the patient, becoming tired of his
residence in the hospital, left it,  being able to move
without  difficulty, and  having, in  the upper part of
his  arm, a deep fistula,  from whence there was a con-
stant escape of ichorous  matter, and through which se-
 veral 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  ir-
 regular callus formed, which he removed, together with
 a portion of the soft parts corresponding to the fracture.
 At the end of two months  and a half, the patient was
 discharged perfectly  cured, except  a weakness in the:
 limb, which disqualified  him for hard labour.
   28. This case  may throw  considerable  light on the
difficult  question  relative to  amputations  at the joint.
 But this is not the place  to state the ideas of Desault
on that point of practice.
                         13 
98
   I will only observe,  that in many cases of gun-shot
 wounds, a similar treatment would probably save life,
 without exposing the  wounded  to the dangers of an
 operation, in  which so considerable a portion of the
 system  cannot be removed with impunity, and would
 secure to them a limb, for the preservation of which they
 ought  not to  shrink from the pains and hazards of a
 tedious treatment.   To sacrifice  a part for the  preser-
vation of the whole, is  the last resource of the art.  It
is necessary, before  resolving on this, to  exhaust those
previous ones  that might restore  the whole of our or-
gans to life and their proper functions. 
MEMOIR VI.
ON  THE FRACTURE OF  THE LOWER EXTREMITY
  OF  THE HUMERUS, WITH  A SEPARATION OF  THE
  CONDYLS.

  1. Fractures of the humerus, accompanied  with
a separation of the condyls, appear to have escaped the
notice of most authors who have written on diseases of
the bones.   The  ancients have transmitted nothing to
us on this point.   Petit, Duverney, and Bell, among
the moderns,  have made no mention  of it.  Heister
adverts  to this fracture of the bone, only to express an
unfavourable prognostic respecting it,  without deter-
mining  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 oc-
casions to observe it.
                   SECTION  I.

         OF  ITS VARIETIES AND SIGNS.

  2. These fractures, like those of the condyls of the
os femoris, are rarely the effect of a  counter-stroke.
They are almost  always  produced by the immediate
action of external bodies; such, for instance, as a fall
on the joint of the arm ; the wheel of a carriage passing
over this part, &c. &c.
  3. Whatever may be their cause, they generally occur
in such a manner, that a  longitudinal division separates 
100
 the condyls from each other, and, extending upwards to
 a greater or less distance, is  terminated by  another
 transverse  or oblique division, which passes  through
 the whole thickness  of the body of the  bone,  so that
 there are three fragments, and two fractures.
 .  4.  Sometimes the division is simple ; in which case.
 being directed outwards or inwards, it crosses the lower
 end of the humerus, obliquely from above downwards,
 and terminating at the joint, separates but one of the
 condyls  from the body of the bone, leaving the other
 adhering to it.
   5.  In the first case (3) there is  more deformity at
 the broken extremity of the humerus; and the mobility
 is also greater.  If the fingers, placed before or  behind,
 press on the limb in the direction of the longitudinal
 fracture, the two  condyls will be separated  from each
 other, the  one yielding in  an  outward,  and the other
 in an inward direction, leaving a fissure or opening be-
 tween 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 frac-
 ture,  pressure is made on the rotula.  The fore-arm is
 almost constantly in  a state of pronation.   When  we
 take hold of one  of the condyls in each hand,  and en-
 deavour  to  make them  move  in  opposite directions,
 they can be brought "alternately forward  or backward:
 and,  if their surfaces touch, a  manifest crepitation is
 heard.
   6.  In the second case (4) the condyls  cannot be  so
 easily separated from each other; but it is always prac-
ticable by taking hold of that one which is divided from
 the body of the bone, and moving it from before back-
 ward, to produce a  crepitation, which  is  a sufficient
 proof that a  fracture exists.  In a case where the exter 
101
nal condyl was alone separated, Desault found the limb
in a  constant state of supination, a position to be at-
tributed, without doubt, to the muscles attached to this
condyl.
   7. An acute pain, the almost inevitable effect of the
flexion or extension of the fore-arm, the habitual semi-
flexion of the limb, a tumefaction of it sometimes  su-
pervening,  and a swelling more  or less considerable,
around the joint, are symptoms which  accompany both
modes of division (3 and 4).  The fracture may further
be rendered complicated by means of wounds, splinters,
&c.  when  the  blow has  been  very severe,  or when a
pointed fragment has  made  its way through the sur-
rounding soft parts,  &c.

                   SECTION II.

                OF THE  PROGNOSIS.

   8. The preceding  assemblage of  signs, leaves in
general but little doubt on the subject of the diagnosis ;
but  is the establishment  of a solid prognosis attended
with the same facility ?
   If authors be  consulted, they will  be all found to
agree,  in considering the  communication of fractures
with a joint as a complication of a very serious nature.
A swelling of the adjacent parts,  their inflammation, a
continuance of the pains after the reduction, extensive
abscesses, a gangrene even of the soft parts, and a caries
of the  bones;  such, according to these authors, are the
almost  inevitable consequences of these kinds of frac-
tures,  of which an  anchylosis is the  most favourable
termination that can be expected.  Petit, Heister,  and
Duverney, do  not  describe the  evils-that accompany
these accidents.   Pare, in speaking of them, says, "In 
102
  such cases, the violence done to the tendons generally
  gives rise to great inflammation."
    9.  From whence can arise these exaggerated fears ?
  Can it be, as is pretended, the mere communication of
  the fracture with a joint, that is productive of such se-
  rious affections?  What relation, then, can reason dis-
  cover between the cause and the effect ?  Does not ex-
 perience answer in other cases,  in a manner that admits
 of no reply, when it  furnishes us with the analogy of
 fractures of the rotula,  the olecranon, &c. ?
   Modern researches have entirely abolished the ancient
 theory of an effusion  of callus into the joint, and with
 it one of the principal causes assigned by writers  for
 the accidents and evils which they so much dreaded.
   The admission of air into an articular  cavity, would
 be, without doubt, in  such cases, a consideration of
 more  weight; but this does not occur except in frac-
 tures  accompanied with wounds, and yet all  those in
 the vicinity of joints, whether  compound  or  not, are
 regarded as extremely dangerous. Besides, observation
 has oftentimes proven  to Desault, that even the contact
 of air  is not so dangerous as  it has been commonly
 supposed,  and many  instances occurred to  him in his
 practice, where, notwithstanding such a complication, a
 perfect cure was obtained.
  10.  It is, then, to the want of a skilful mode of treat-
 ment,  and  to the irritation experienced in the parts, in
 consequence of an ill-constructed apparatus being 'ap-
plied  to  them, that the accidents formerly  mentioned
(8)  ought  to  be  attributed.   Such  accidents never
occurred to Desault, in any of the numerous cases that
fell  under his  care.   It is thus that  in the fracture of
the  neck of the os femoris,   the insufficiency of the
means, is oftentimes productive of unfavourable results. 
103
                  SECTION III.

   OF THE REDUCTION,  AND  THE  MEANS  OF
                MAINTAINING  IT.

   11. The  displacement  here is,  in  general,  incon-
siderable, because, being drawn in contrary directions,
by the muscles of the arm and fore-arm, the condyls
separated from the  bone remain stationary between
these  two forces.   A fall, a percussion, or some other
external cause, can alone produce a displacement, by
communicating some degree of  motion to the frag-
ments.   Now, from what was formerly said (5 and 6)
the condyls may,  under such an impulse, move  either
forward or backward, or else may separate from each
other, leaving between  them  an  intermediate void.
Hence the apparatus ought to oppose to them a resist-
ance  in these four directions, namely, inward, outward,
forward, and backward; a resistance which it will  be
easy to make, by means of four splints, placed in these
directions, and properly retained  by a  roller. The two
lateral splints,  are particularly necessary, when the con-
dyls are both separated from the body of the bone, and
divided from each other (3).  If one  of them be still
attached  to the humerus (4) a splint  on that side be-
comes less useful.
   12. It is needless for the apparatus to extend as high
up as in a fracture of the arm.   What effect, in sus-
taining 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 com
pressing  the brachial and  triceps muscles,  and in that
way preventing their action. 
104
    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  solidj in the middle  than
 in any other part,  and also,  that  a slight compression
 may be thus  made  on the museles  attached  to ;the
 condyls.                                         ■
   13. The pieces  which compose the; apparatus, are,
 1st.  A roller, five  or six yards long, and three  inches
 broad,  made of soft linen or muslin, and rolled up  in
 a  biJL  2dly.  Four splints  (11)  two of them'flexible
 in the middle,  in order  that  they may bend to  fit the
 fold of the arm, and the elbow, and the other two very
 strong and inflexible, intended to  be applied at the two
 sides.                            ,.!,;.'.,
 . 14. Every thing being arranged, the reduction 'is
 effected in the following manner.   One assistant is di-
 rected to make extension at the upper part of the arm,
 which he grasps with both his hands; another makes
 extension on the fore-arm half-bent, which he  uses as
 a lever of the second kind,*  where one  of his hands,
 being  placed under the  wrist, forms a fulcrum,  while
 the other applied towards the  fold of the arm,  represents
 the  power.   The  surgeon,  in the mean  time  brings
 the condyls together, adjusts their level and apposition,
 both between themselves, and with  the  body  of the
 bone, and  then  proceeds to the application  of the ap-
paratus, the limb being  still  kept  in a half-bent posi-
tion, as was long since recommended in such cases by
 Paul of Egina.  "  Si in vicinia cubiti brachium  frac-

  * In tins form of lever, the power is applied between the fulcrum and the
weight to be moved, or the resistance to be overcome.          Trax s. 
105
turn est, etiam ipse cubitus deligandus, anguhri figura
servata."
   15.  The roller (13) wet with vegeto-mineral water,
which facilitates its application, and prevents the swell-
ing of the part,  is fastened by one of its ends,  about
two-thirds down the fore-arm, and continued upwards
by oblique and reverse casts, to the joint.  The sur-
geon 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 ob-
lique  cast from the other side, over the fore-arm, and
returning along the first track, makes a number of casts
in the form of the figure  of 8,  round the joint,  which
he next covers by circular casts, applied so close to
each other,  as to leave no opening between them; he
then proceeds upwards by oblique casts, as at the first,
to the middle part of the arm (humerus) when the roller
is given into the hand of an assistant.
   The first of the splints (13) is now placed anteriorly
on the fore-arm and  arm, and, if it does not bend, in
such a maimer, 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,  be-
ing applied on the posterior side part  of the arm, moulds
itself to the projection of  the elbow, while the  other
two occupy the  sides.   These  are  secured below by
an assistant, while the surgeon  resuming the roller,
which he had just  given  out of his hand, fixes them
firmly by circular casts descending along the arm and
fore-arm.
   The limb is then laid  on a pillow, so disposed that
the hand may be  raised higher than the elbow, in order
to prevent the subsequent swelling, which is oftentimes
                         14 
106
  produced  by the fracture, as has been already men-
  tioned  (7).
     16.  The effect of this bandage is simple, and has
  a particular relation to those directions and  causes, in
  and by which, displacements might occur.  The two
  lateral splints prevent the separation of the condyls from
  each other; the anterior and posterior ones prevent them
  from moving  backward or  forward;  the  muscles are
  compressed; the motion  of the joint is prevented; and,
  in common, no great length of time is necessary for the
  reunion of the bone.
    As soon as this is.accomplished, it is of importance
  to move the limb  in every direction, to prevent  that
  stiffness, which is  so commonly the consequence of
  fractures situated in the neighbourhood of joints. The
  following case, drawn up by Leguelle, will furnish the
  reader with a detailed account of the treatment pursu-
 ed, in such accidents, by Desault.
    Case I.  Joseph Kisler,  an ostler,  aged forty-one,
 fell from a height of thirty feet, on the left side, his arm
 being undermost, and fractured the lower end  of the
 humerus.   A  surgeon gave him immediate assistance,
 and, at the expiration of  two days, he was carried to
 the Hotel-Dieu.
   From  the signs formerly mentioned (5 and 7) Desault
 discovered a fracture,  consisting in a separation  of the
 condyls from each other, by a longitudinal division, and
 from the body of the  bone,  by a transverse  one.   The
 usual apparatus (16) was applied, and, from a state of
 extreme  anguish, which he had  till now suffered,  the
 patient experienced immediate relief.
   In the mean  time, a considerable swelling around the
joint, pointed out the necessity of blood-letting,  a low
 diet, and other  antiphlogistic  remedies.   These  were 
107
immediately had recourse to, and the limb was placed
in the proper position (16).
   Notwithstanding these precautions, the tumefaction
and redness were increased on the following day. The
bandage was applied anew, and wet from time to time
with vegeto-mineral  water.
   On the following days, pain less severe, the bandage
kept constantly wet with the same fluid.
   Eighth day, the swelling almost gone;  the apparatus,
being loosened, was again reapplied.
   Fifteenth day, the fragments, being examined, were
found in regular contact, and already united by a sub-
stance of  considerable firmness;  the  strictness  of re-
gimen 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 con-
sequence  of the rapid progress of reunion: from this
time till the completion of the cure, nothing was used
but the simple roller.
   On the twenty-fourth day, gentle flexion and exten-
sion of the arm and fore-arm were for a short time per-
formed ;   these movements were  attended with acute
pain, notwithstanding which, the fortitude of the patient
enabled him to persevere  in them.
   Thirtieth day, no  pain accompanies the movements
of the arm: the range of these movements visibly in-
creased ;  the roller laid aside ;  from this time the range
of motion increases rapidly.
   On the  thirty-seventh day, the patient was discharged
perfectly cured, and free from every vestige  of his dis-
ease,  except a trifling stiffness, which was doubtless
rsoon removed by the motions of  the joint. 
108
    17. When wounds,  splinters, or severe contusions,
  render these kinds of  fractures more complicated, an
  inflammation occurring on the articular surfaces, may
  cause them to  unite together, and  by that  means give
  rise to an  anchylosis.   But this accident, inevitable in
  such a case, according to writers, does not always occur,
  provided nature be  assisted, by a judicious mode of
  treatment,  in her attempt to reunite the broken  bone.
  Desault has established this  truth,  in many instances.
  Here,  as in  other joints, he has oftentimes  obtained
  a complete cure,  without the loss of motion, although
  the part had sustained the greatest violence.  Incisions,
  easily  made, the extraction of splinters,  a frequent re-
  newal  of dressings, a most vigilant care to prevent all
 jarring of t-he limb, and consequently all derangement
 of the contact of the fragments, an assemblage or com-
 bination of those minute attentions, which art cannot
 teach, which genius suggests, and  which characterize
 the true surgeon;  a precaution  (not to  be dispensed
 with) to make  the limb perform  motions,  gentle at
 first, but gradually increased  afterwards,  when the ad-
 hesion  of the parts has  acquired sufficient  solidity to
 admit of it;  such are, in general, the steps and circum-
 stances constituting the  bases of that treatment,  re-
 quisite  in these complicated  fractures, which, like all
 others,  appear, in each  case,  to assume a new aspect,
 and to present different indications.
   Case II. A person,  carrying  a heavy  burden, fell
 with  his elbow  on a sharp  corner of a  bar  of  iron
 The external condyl was broken, being separated from
 the body of the bone, by an  oblique division  running
into the joint.  Anteriorly, a large contusion ;  posterior-
ly, a transverse wound;  on the outside, the end of the 
109
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
when extracted, gave vent to an effusion of blood.   He
reduced, instead of cutting it off,  as authors have ad-
vised, the end of the  separated condyl, applied a  ban-
dage of strips,* and,  to prevent accidents, ordered a
strict diet, copious blood-letting,  and  diluting 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  swelling
around  the joint; more blood drawn.
   Sixth day,  considerably  better; all the apparatus
 renewed ;  suppuration beginning to appear.
   Tenth day,  a small abscess on the  external condyl
 opened, and a splinter  extracted posteriorly.
   Fifteenth day,  the  parts  assume a flattering  aspect;
suppuration  favourable; fragments  in contact;  from
this time  the  dressings are less frequent.

   * (Bandage a bandalettes.) This is a most convenient form of bandage,
 in fractures of the upper or lower extremities.  It is composed of strips of
 soft linen  or muslin, from two to three inches wide, and of a length accom-
 modated 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 overlap 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.  Tr a ns, 
110
   Twentieth  day,  a bilious diathesis;  edges  of the
 wounds livid ; loss of appetite; nausea ;  vomiting; an
 emetic  is administered.
   Thirtieth day, unfavourable  appearances gone; re-
 union commencing;  wounds visibly healing.  Fortieth
 day, all  external injuries healed,  except  the one situated
 anteriorly;  callus already very  firm;  gentle  motions
 performed  with the limb, which is still surrounded by
 the apparatus.
   Forty-seventh day, the  apparatus  become useless;
motions gradually increased; articulation already  to-
lerably  free.   Fifty-seventh  day, bilious  diathesis  re-
 turned ; low diet and evacuants.  Sixty-fifth day, the
patient discharged from the hospital; consolidation per-
fect;  wounds  entirely  healed;  motions  of extension
still  difficult  to be  performed in their full extent,  but
are recovered in a great  measure,  and  will doubtless,
in a short time, be  completely re-established, provided
the same mode of treatment be continued. 
MEMOIR VII.
       ON  THE LUXATION  OF THE HUMERUS.

                     SECTION I.

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

   1. Nature,  who, according  to  the  want  of dif-
 ferent species of animals, has varied the number of their
 articulations,  knows also how to vary their structure,
 according  to  the uses of the different parts  of  their
 bodies.  With great mobility, she has sometimes con-
 nected great  solidity and strength, as is the  case in the
 vertebral column;  in other instances, parts  very  solid
 and compact, are capable  of performing  but feeble
 motions, as  the  carpus,  the tarsus,  &c.  And, lastly,
 other parts, again, capable of great motion,  possess so
 little solidity and firmness as to be easily deranged by
 the  action  of external bodies.   Such,  in man, is the
 articulation of the humerus with the scapula, of the ster-
 num with the clavicle, &c.
   2. Hence there exist three  classes of  articulations,
 very different  from each other.   To the last, as enume-
 rated above,  belongs, in a particular manner, the his-
 tory of luxations, and, in this, as the  solidity varies,
 the frequency of dislocations is equally various ;  no lux-
ation occurs more frequently than that of the  humerus ;
indeed, in a comparative  catalogue of accidents of this 
112
 kind,  it  alone,  has,  during certain  years, occurred
 oftener,  in  the Hotel-Dieu,  than that of all  the other
 bones, taken collectively.
   3. Every thing seems to favour the  escape of  this
 bone from its natural cavity. 1st. On the part of the ar-
 ticulating surfaces, a  cavity somewhat  oval and very
 shallow,  aided by a slight cartilaginous ring, receives a
 half-spherical head, twice its  own diameter from above
 downwards, and three times as large from before back-
 wards.   2dly. On the part of  the ligaments, this arti-
 culation  is strengthened by only a simple capsule. This
 capsule is thin and  weak on its lower side,  a direction
 in which there is nothing to prevent a luxation, while
 it is thicker on its upper side,  where the acromion and
 coracoid apophyses, and a  strong ligament,  present an
obstacle  almost  insurmountable.  3dly.  As far as re-
 spects  the muscles and the motions of the joint, strong
 and numerous bundles of fibres surrounding the arti-
 culating  surfaces, communicate to them  motions easily
 performed in every direction,  and which,  by pushing
 the head of  the  humerus against the different parts of
 the capsule, distend it, predispose it to  laceration,  and
 indeed even rupture  it, when the quantum of their
 force is  superior to its resistance.  4thly.   As far as
 relates  to external bodies, what bone is  more exposed
 to their action than this, particularly among that class
 of persons, engaged, for a livelihood, in hard labour ?
   4. Subject to the influence of these different predis-
 posing 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  dif-
 ferent  position of its  superior extremity;  so that, to 
113
this two-fold mobility of the articulating surfaces, is to
be attributed,  in a great measure, the stability of their
connexion.

                   SECTION II.

       OF THE KINDS  OF THIS LUXATION.

   5.  The  upper articulation of the  humerus, though
predisposed, in general,  to luxations, is not equally so
in every direction. There is a point  at which luxation
cannot take  place.  There are others, where, though
possible,  this accident has never been observed.   It is
necessary, therefore, before examining the  mechanism
of this luxation,  to mention with precision, the direc-
tions in which it may occur.   On  this point, writers
have differed in  a very  singular manner.  Sometimes,
to express die same thing, they have used a  different
language; and,  at  other  times,  have, by  the same
words, expressed things widely different. Always agree-
ing as to. certain modes of dislocation, they have been
 divided as to others;  while, in the midst of those con-
 trarieties, the surgeon being embarrassed,  is  at a loss
on what ground to found  his practice.
   6.  The ancients, knowing but little of the natural re-
lation of the parts surrounding the joint, were  ignorant
 of the  accidental  ones, which these several parts as-
 sume, in the case now under our consideration. Hence,
 without  doubt, arises the confusion, of their  opinions
 on the subject.
   Many  admitted of four kinds of luxations; a great
 number acknowledged only three; some subscribed to
 but two; while  others  believed  in the possibility of
 none but one.
                          15 
114
  7. The first divided differently the directions in which
the  bone might be luxated.   Some contended for lux-
ations  upward, downward,  forward,  and backward;
and such was the opinion of the first .Greek physicians,
predecessors to the father of medicine, who has trans-
mitted the opinion to us  accompanied  with a  de-
monstration of its fallacy.  Others have divided them
into those  that take place downward, upward, outward,
and forward.   This division is adopted by Galen, who
yet  produces only an example of a  forward  luxation,
and does nof give us to understand what he means by
a luxation upward and inward.
  8. The  second distinguished the modes of this lux-
ation, sometimes into  downward, forward, and  back-
ward; as was the case with Oribazes;  at  other times,
into downward, outward, and inward, according to the
opinion of Paul of Egina, who,  no doubt, adopted ex-
actly the preceding division,  expressing it only in  dif-
ferent words; sometimes into downward,  forward,  and
upward; such was the sentiment  of Albucasis, who,
notwithstanding, considered a  luxation upward,  as  a
very difficult, and very rare occurrence.
  9. The  third were  of opinion, that,  in undergoing a
displacement, the head of the humerus  could be carried
only downward, under the arm-pit,  which is the most
common direction, or forward, a course which it takes
more rarely.   Celsus is almost the only writer who has
contended for this division.  " Humerus, says he, modo
in alam excidit, modo in partem prior em."
  10. Lastly. The fourth believe, with  Hippocrates, in
none but a displacement downwards, the  only  one
which that physician  lias met with in his practice. " At
vero humerus, inferior em in partem excidet; aliam in
partem excidere non audivi" 
115
  11. The moderns, in borrowing from the  ancients
their divisions of luxations,  did not, like them, deter-
mine a priori and in a vague manner, the precise spot
and direction  of displacement; but ascertained these
points by subsequent observation, with more precision,
in proportion as a knowledge of anatomy shed light on
them.   They also paid particular attention to the es-
sential difference between primitive and  consecutive
luxations.
  12. Petit admitted  of four kinds of luxations,  1st,
downward, on the edge of  the  scapula: this is a very
rare occurrence : 2dly, outward, under the spine of that
bone, a kind very difficult to be primitively produced.
3dly,  inwards,  under the  hollow of the arm-pit. 4thly,
forward,  between the corocoid apophysis and  the cla-
vicle.  With  this illustrious  practitioner, Heister ac-
knowledged four kinds of  displacements; but,  here
again,  was a new variety, both in expression,  and  in
meaning.  The one says, downward,  under the arm-
pit, the other forward,  under the pectoralis-major; the
one, backward, under the scapula, the other outward,
under  its spine.  According to Duverney, luxations
are never primitively in any other direction than down-
ward;  the  others being only the  subsequent  effect  of
muscular action.
  13. In the midst of these very complicated modes of
treating a very simple subject, it is necessary,  first,  in
order to acquire definite ideas, to divide luxations of the
humerus into primitive, which are the immediate effect
of external violence,  and consecutive,  which succeed
the primitive, through the influence of causes which I
am  about to consider.
  Let us suppose  four lines to inscribe, in form of a
parellelogram,  the oval  surface of the  glenoid cavity, 
116
one  representing the superior edge, another the  infe-
rior, a third the internal, and the fourth the external.
  14. It it evident that the head of the humerus can-
not be displaced towards  the  superior edge.   In that
direction, must be encountered, the acromion and coro-
coid apophyses, the strong ligament  passing between
them, the tendons of the  triceps  and  supra-spinatus
muscles, and the fleshy mass of the deltoid; all which,
taken together,  constitute an  insurmountable obstacle
to the escape of the head of the bone upwards. Besides,
what power could carry it upwards? In order that this
kind of luxation might take place,  it would be neces-
sary, that the head of the bone should be carried out-
wards at the same  time,  as well  as  upwards, a cir-
cumstance  which is  impossible,  because  the trunk
prevents the  lower  extremity (the elbow) from being
directed sufficiently  inward to produce such an effect.
   15. On the contrary,  in other directions, but very
little resistance is to be met with.  Towards the inferior
edge of  the cavity, the long portion of the triceps ; the
tendon  of the subscapularis, towards the internal edge;
and towards the external edge, the tendons of the  infra-
spinatus,  and teres-minor, yield with ease  to  a  force
directed against them, and permit the occurrence of
primitive luxations,  downward,  inward, and outward.
Downward, between the tendon of the long portion of
the triceps,  and that of the subscapularis; inward, be-
tween the subscapulary muscle and fossa;* and out-
ward, between  the fossa infra-spinatus and the  muscle
of the same name.  These  modes of displacement are
not alike frequent, as will be mentioned presently.

  * (La fosse sous-scapulaire.) I know of no English anatomical term for
this.  I therefore translate it  literally. The same  is true with  respect to
"fossa saus-epineuse," translated here, fossa infra-spinata.         Trans. 
117-
  16. Having escaped from its cavity, and being primi-
tively placed in one of these three situations,  die head
of the humerus oftentimes changes its position. Then,
to a primitive luxation  downward  or  inward,  suc-
ceeds a consecutive  or secondary one ; but never to a
luxation in an outward  direction, if such ever occur,
because the  spine of the scapula  forms an obstacle
to it.
  A secondary luxation  inward, may succeed a primi-
tive one downward, there is nothing to oppose the head
of the humerus in the course it takes, to enter between
the  subscapulary muscle and fossa.  If, on  the other
hand,  it be disposed to pass to the external  side, the
tendon of the triceps opposes it;  and, notwithstanding
what Petit has advanced, there is  no secondary luxa-
tion in that direction.
   17. It  sometimes happens, that, having escaped ei-
ther 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  dis-
placement must  take place in a  slow manner,  and
when it has taken place,  art can seldom remove it, on
account of the strong adhesions formed by the bony
 surfaces.   Thus,  in the example mentioned, there was
 a new cavity formed behind the clavicle, and the hu-
 merus adhered to the surrounding parts by a kind of
 new ligaments.
   18. It appears from what has been said, that the hume-
 rus is subject to four different kinds of displacement.
 1st, Downward: 2dly, outward, mboth. of which direc-
 tions the luxation is always primitive;  3dly, inwards, 
118
 where it is sometimes primitive, and sometimes conse-
 cutive ; 4thly, upwards, where it can  never be other-
 wise than consecutive.
  The second and fourth are very rare occurrences, and
 bear so small a proportion to the others, that  the lat-
 ter alone ought to command the attention of the  prac-
 titioner.

                  SECTION  III.

      OF THE CAUSES AND THE MECHANISM.

  19. The causes and the mechanism of luxations of
 the humerus, vary according  as  the  displacement is
 primitive or consecutive.
  The  action of external bodies, directed against the
 arm, but more particularly falls, where this part strikes
 forcibly against a resisting body, give rise in  general
 to primitive luxations, and, according as it is differently
 situated at the time of the fall, the humerus determines,
 by its position, the different kinds.
  20. If it be separated from the trunk, without being
 carried either  before or behind it, if the elbow be ele-
vated,  and the fall be on  the side,  the weight of the
body, being almost  entirely supported  by this  bone,
pushes its upper extremity downward, distends the in-
ferior part of the capsule, lacerates it, and produces  a
luxation downward, in which it may even be favoured
by the  action of the  pectoralis-major, the latissimus
 dorsi, and the teres-major, as has been judiciously ob-
 served by Fabre.  In such a case,  these muscles,  in-
 voluntarily contracting to  support  the trunk,  act like
 the power or force in  a lever of the second kind, the
 resistance to which is formed bv the head  of the  bone. 
                        119

which they draw downward, while the lower extremity
of the humerus, resting on the ground, constitutes the
fulcrum.  Some authors even regard, as an immediate
cause of luxation,  the powerful contraction of the del-
toid muscle, which depresses the head of the bone,
and forces it through the lower side of the capsule,  a
mode of displacement, the existence of which observa-
tion incontestibly  establishes.  The case of a scriven-
er, so   often cited,  is well  known,  who in lifting  a
book of records luxated his humerus  in a  downward
direction.
   21. The mechanism of a primitive luxation inwards,
differs a little  from the preceding.   The elbow, being
at once  separated from the trunk, and carried back-
ward, the person falls: the weight of the body rests on
the humerus; the capsule  is  lacerated in its fore-part;
and a displacement in the same direction supervenes.
   22.  In a  luxation outwards,  the elbow is carried
forward, towards  the  opposite shoulder; the  capsule
being stretched outwardly, gives way in that part, pro-
 vided  the  humerus be  acted on by a sufficient power.
But what can this power be ? In a fall, the  arm being
pushed against the trunk, and  stopped by it, cannot
 carry its motion to a sufficient extent  to produce a la-
 ceration of the capsule.  Hence a luxation outwards
 must be  extremely rare.  Indeed  no instance of  it is
 to be found in books of surgery.  Desault, in particular,
 never witnessed it.   Besides, when in a fall,  the arm,
 separated  from the body, is carried backward or for-
 ward, the weight of the  body acts obliquely on it, and
 it is but partially subjected to the action of the latissir
 mus dorsi,  the pectoralis-major,  and the teres-major.
 So that no kind of luxation ought from these consider-
 ations, to be very frequent,  except that in a downward 
120
 direction, where the  influence of both causes is direct.
 Yet luxation inwards is common enough, and in many
 instances Desault has observed this primitive mode of
 displacement, though many modern authors doubt the
 fact, believing with Hippocrates, that, primitively,  all
 luxations are downwards.
   23.  It may so happen  diat in a primitive luxation,
 the capsule  is only greatly stretched, in which  case,
 the articulating surfaces  are but  partially  displaced;
 but  this membrane  more frequently suffers a rupture,
 through which the head of the bone escapes.  To this
 phenomenon writers, in general, have  paid too little
 attention,  notwithstanding the opening of dead bodies
 has  oftentimes demonstrated  its existence to  practi-
 tioners, particularly to Desault, who has  given  two
 examples of it modelled in wax; one, of a luxation in-
 ward, and the other downward, both found in subjects
 that died in the Hotel-Dieu.   Bell relates some analo-
 gous 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 dis-
 location of the humerus  something similar to this oc-
 curs.  The  capsule is sufficiently lacerated to allow
 the head to escape;  but  the opening,  being then too
 narrow, forms around the neck of the bone a noose or
 kind of collar, which prevents it from re-entering the
 place which  it originally occupied.  Thus, in the frac-
 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 die lux-
ation : the capsule is  pressed in folds against the glenoid
cavity, and, interposing itself between it and the head 
121
of the humerus, renders fruitless the efforts  of the sur-
geon who would replace the  bone.   Desault was the
first who observed this  practical fact, two instances  of
which are recorded in his journal, and which has fre-
quently since occurred in the Hotel-Dieu.  In such a
case, the head is in  general extremely moveable, be-
cause,  being entirely  without  the capsule, there is no-
thing to impede its motion.
   25. When, to a primitive luxation a consecutive one
succeeds, several causes may concur in its production.
If a second fall happen, the arm, being separated from
the body, the head of the humerus  having  nothing  to
retain  and secure  it, obeys, with  great facility, the
power tending to displace it in that direction,  and suf-
fers a fresh removal from the  bed which it accidentally
occupies.
   Case I.  A man  fell in descending  a ladder, and
luxated his humerus in a downward direction.  Desault
being immediately called, discovered the nature of the
disease,  but deferred the  reduction  till evening.   In
the interval, the patient went  to get  into a chaise: his
foot slipped, and he  fell  a second time.   The  pains
became more severe  than at the time of the first acci-
dent; and  Desault, on his  return,  instead  of finding,
as in the morning, the head of the humerus under the
hollow of the arm-pit,  discovered it to be behind the
pectoralis-major.
   26.  Muscular action is  one permanent cause of a
new displacement.    Suppose the  humerus  luxated
downward, the pectoralis-major, and the deltoid  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,
                        16 
122
 Thus we have often witnessed a luxation inwards sue-
 ceeding to a luxation downwards, in consequence of
 unskilful attempts to reduce it.

                     SECT.  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 displace-
ment, there always exists, as Hippocrates has observed,
a manifest depression  under the acromion, which exhi-
bits a prominence more perceptible than in  its natural
state.  The motions of the part are almost all accom-
panied with pain;  the greater part of them are impracti-
cable;  all  of  them very much confined.   The arm
cannot move, without a  synchronous motion of the
shoulder, because, the articulation being no  longer able
to exercise its functions, these two parts constitute,  so
to speak, but one body.
  29. Besides these signs, which characterize generally
every species of luxation of the humerus, each species
is marked  by certain others peculiar  to itself.   If the
displacement be  downward,  the arm is a little longer
than in its natural state ; it can  be moved gently out-
wards ; but an acute pain is the inevitable consequence
of moving  it forward or backward. The elbow is more
or less removed  from the axis of the  body,  by the
action of the  deltoid, the long  portion of the biceps,
and the supra-spinatus muscles,  which,  being unnatu-
rally stretched, contract themselves and  tend to carry
the  bone outward.  The pains which result from this
position, force the patient, in order to  relieve them,  to 
123
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 produ-
ced by its own weight.  From this attitude alone, was
Desault in the habit of discovering luxations in a down-
ward direction, and was rarely mistaken in his diagno-
sis.   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. Be-
neath the hollow of the arm-pit there alwajs exists a
protuberance more  or less  perceptible, formed by die
head of the  humerus.
   30. To the general signs of luxations of the  hume-
rus (28) that in an inward direction  adds the follow-
ing : the elbow,  being separated from the  trunk of the
body, is carried a little backward;  the humerus seems
to direct itself towards the middle of the clavicle; mo-
tions backward are not very painful,  while those in a
forward direction are extremely so; under the pectora-
lis-major a manifest protuberance exists;  the  arm  is
but little longer than in a natural state ; the attitude is
the same as in the preceding case.
   31. Should a luxation in an outward direction occur,
it would be particularly characterized by a hard tumour
 under the spine of the scapula, by the direction of the
 elbow forward, by its separation from the  trunk,  and
 by a little increase in the length of the arm.
    A protuberance  behind the clavicle,  an  obvious
 shortening of the arm, together with its direction, would
plainly disclose a luxation upwards.
    32.  The signs discriminative of the nature of luxa-
 tions of the humerus, are not always accompanied by
 the same degree of certainty  as those that announce 
124
merely its existence.   Thus, nothing is more difficult
than to determine when a  luxation inward  is primi-
tive, and when it is consecutive, the same phenomena
being common to both.  Nothing but an exact history
of the disease,  stating the order  in which the phe-
nomena have succeeded each other, can throw light on
this point, which is the more interesting and important,
as, according  to the one or the  other state of things,
the processes of reduction ought to vary.   In the first
case, the head re-enters its natural cavity by a short
route; whereas, in  the second,  it  arrives  there  by a
much longer one.
  If,  as Petit  pretended, there exist luxations back-
ward, sometimes primitive, and sometimes consecutive,
the same remark may be applied to them with equal
propriety.
  33.  Certain signs, common to luxations of the hu-
merus, fractures of its neck, and dislocations of the
scapulary extremity of the clavicle,  might  here create
some uncertainty, if in the one, the absence of a tu-
mour under the arm-pit, and of a depression under the
acromion, did  not prevent a mistake, which Hippocrates
declared to be easily.committed, into which, according
to Galen, the  masters  of the art of wrestling fell, and
which Pare  cautions us to  avoid; and if, in the other,
the appearances proper to a  fracture, did not  prevent a
mistake which would be serious in its consequences, and
which sometimes results  from die direction of the hu-
merus, and the kind  of protuberance formed in the
arm-pit, by the end  of  the inferior fragment.  (See
Fracture of the neck of the humerus). 
125
                  SECTION V.

  OF ACCIDENTS PRODUCED BY THE LUXATION.

  34. Luxations of the humerus  are but rarely fol-
lowed by any serious accidents. Sometimes a swelling
more  or less considerable  appears, immediately after
the fall, in and around the  arm-pit.   This is the effect
of an increased irritability of the part, and is seldom of
long duration.  Desault's remedy for it was the appli-
cation of compresses wet with vegeto-mineral water, or
of cataplasms moistened with the same liquid.
   35.  Several  authors, particularly  Bell, speak (as if
it were a  familiar accident) of an edematous swelling
of the whole upper extremity, caused, in inward luxa-
tions,  by a compression of the axillary  glands.  This
phenomenon has not often occurred in the Hotel-Dieu,
except in luxations  of long standing: and when it has
been met with in certain cases, very happy effects have
 been produced,  by the  action, continued for several
 days,  of  a roller applied  with considerable  tightness
 after the reduction, and  reaching  from the fingers to
 the arm-pit.
    Case  II. Maria ***, falling from some height, her
 elbow being  separated  from  her  body and  directed
 backwards,  luxated her  shoulder  inwardly.  Several
 days elapsed before she  received any surgical aid. She
 was  afterwards admitted  into the  Hotel-Dieu,  where
 the displacement was discovered through a very con-
 siderable  swelling,  which occupied the parts around
 the articulation  of  the humerus.   The reduction was
 accomplished, and the  swelling  left  to itself, which,
 far however from disappearing, with  the cause that pro- 
t26
 duced it, seemed to gain ground.  A roller was then
 applied, and on the day following the tumefaction was
 reduced to half its  former size.   The  same means
 are continued. The compression is gradually increased,
 and by the ninth day, the limb restored to its natural
 form, performs,  as before, all its functions.
  36. There is another accident, on which authors, have
 dwelt a little, which was known to Avicenna, and which
 oftentimes fell under the notice of Desault.   I allude
 to a paralysis of the upper extremity, the effect of com-
 pression made by the head of the bone, in inward lux-
 ations, on the nerves of the brachial plexus.  This ac-
 cident sometimes resists every  expedient of art, as ap-
 pears  from the following case,  collected by myself, in
 the Hotel-Dieu.
 Case III.  Maria Dougour, fell on her right side, and
 experienced immediately all the signs of a downward
 luxation.  A surgeon was called, who moved the bone
 violently in  every direction  ; he made  no extension;
 he kept the  patient in  torture for an hour; and at the
 expiration of that time pronounced the luxation irre-
 ducible, because the head of the bone, instead of re-
 turning into its natural cavity, had moved inwardly. In-
 deed,  in the midst of  his unskilful  efforts, a consecu-
 tive luxation inwards had succeeded to a primitive one
 downwards.
  On the same evening, an evident insensibility occur-
 red in the part.  A swelling, joined to a sense of cold-
ness, accompanied it.   On the fourth  day, the paralysis
 was complete.
  On  the tenth  day the patient was  brought to the
Hotel-Dieu, where the processes of art which we  shall
 presently describe, replaced the bone, without remov-
 ing the effects of its luxation. 
127
  To remedy this, irritating means  were employed,
simple at first, but multiplied and combined afterwards,
and pushed so far as to occasion redness accompanied
by  small  blisters.  These  were continued  for three
weeks; blistering plasters were applied;  all in vain;
the paralysis  continued,  and as long as  a year after-
wards 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 in-
effectual.  Moxa has been oftentimes  used by Desault,
which he applied over the clavicle, at the very origin
 of the brachial plexus.   The  success, with which  he
 at first applied this remedy, did not always accompany
 his use of it, so that notwithstanding several cures per-
 formed by it, yet, to the  majority of patients to whom
 it was applied, it was wholly useless.
   39. But,  if the head  of the humerus make on the
 nerves but  a momentary pressure,  and  the  reduction
 be accomplished shortly after the paralytic symptoms
 occur,  oftentimes then  the insensibility disappears of
 itself, and the cure may  be always greatly assisted by
 the application  of powerful stimulants; such, for in-
 stance, as volatile liniment, composed of oil of almonds
 and ammonia, which  Desault frequently employed, and
 of which he increased the strength, so as to render it
  rubefacient.
    Case IV. Joanna Saq luxated her aim, by falling on
  her  right side,  in the month of  July,  1788.  In the
  evening of the same  day, all  the precursory symptoms
  of paralysis made their appearance.   The affection was
  complete on the day following. 
128
   The patient was brought to the Hotel-Dieu, where
 the  reduction, being accomplished, afforded  no relief.
 On the third day, the paralysis still continuing, the vola-
 tile liniment was directed, in the proportion at first of two
 drachms of ammonia to an ounce of the oil of almonds.
 This produced no effect.   Being increased  in strength
 on the fifth day, it still appeared to be useless. On the
 eighth it  was made of such a degree of strength, as to
 Occasion slight pustules over the whole of the diseased
 extremity.   On this,  motion began  to return, feeble
 at first, but increasing by degrees, till by the sixteenth
 day, it was as free and perfect as in a natural state.
 During all the time, the liniment was applied twice a
 day over the  arm and fore-arm, which were at the same
 time subjected to strong friction during the space of half
 an hour.
   39.  The pains  which accompany luxations  of the
 humerus, claim in general some  attention from the
 practitioner.   These have  sometimes arisen to such a
 height, as to produce real disorder in the animal econo-
 my,  particularly in luxations  inwardly, where, result-
 ing,  no doubt, from the compression of the axillary
 nerves, they render immediate reduction more necessary,
 and are generally removed  by it.

                  SECTION 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 em- 
129
 ployed or not.   The other is  confined to disengaging
 it from the situation, into which it has been accident-
, ally driven,  leaving to the action of the muscles the
 care of its replacement.
   In the  first of these,  art does every  thing ;, in the
 second, it only gives the proper direction to the powers
 of nature.   These latter  give  but one course or direc-
 tion to the action of powers externally applied :  in the
 former, the head of  the bone always moves in the dia-
 gonal of two powers opposed to each other at an angle
 more or less acute.
    41. A history of the means destined to act in the first
 mode, would be too tedious  to be introduced in this
 place, would throw no light on the processes about to
 be proposed, and are detailed at  full length in many
 authors, to  which the reader is referred.  It  will be
 sufficient to observe, that they all act somewhat  in the
 following manner. Some bod), placed under the arm-
  pit, serves  as a fulcrum, on which the arm is made to
  move like  a lever of the first kind,  the resistance  to
  which is constituted by the displaced head of the hu-
  merus, while the power is applied either at the lower
  part of this bone, or at  the wrist.   The  extremity  of
  the  humerus  being directed upwards and inwards,
  moves  its head in the opposite directions, towards the
  glenoid cavity, where it replaces it with more or less
  facility.
    In this  manner  acted that machine so  celebrated
  among the ancients and moderns, under the name  of
  " Ambi Hippocratis," whether it was employed in the
  precise form described by that prince of physicians, or
  with the additions  and corrections, infinitely varied,
  which it has  received from Paul of Egina, Ambrose
  Pare, Duverney, Freke, &c.  By this, a double motion
                           17 
                        130

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 disen-
gage it from the unnatural situation which it occupies.
  42. Extension  by  the arm produces, in common,
the second effect,  and this is made in  different modes.
Sometimes the weight of the body on one side, and
pulling by the luxated limb on the other, serve to pro-
duce it; and such was the mode of action of the ladder,
the door,  and  the club,  described  in the  treatise on
fractures by Hippocrates, and revived in many modern
works.  At other times, the body was immoveably
fixed, and a powerful  extension  made by the  arm.
This was  the mode in which the machines  of Oribasus
operated,  and also one of the methods formerly con-
secrated in  the public places where the athletae  held
their combats.
  43. On some occasions, no extension is perceptibly
made, but at the same  time  in which the extremity of
the humerus is forced outwards by a body placed un-
der the arm-pit, the surgeon pushes it upwards into the
glenoid  cavity : and such were the  other modes of re-
duction practised by the masters in the athletic art. Hence
it appears, that the first class of the numerous means,
employed  for  the reduction  of luxations,  may  be di-
vided into those which consist in impulsion, those where
mere extension is practised, and those where recourse
is not had to either.  My object here is not to examine
into the inconveniences attending each of these mean's:
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. 
131
   44.  The escape of the head of the bone through the
ruptured and lacerated capsule,  constitutes  essentially
the displacement under consideration.   But,  it is never
possible  to  ascertain with precision the  place,  of this
rupture: how, then, can the head of the humerus be
directed towards it by an artificial force ?
   45.  However well prepared for the purpose the body
may be, which is placed under the arm-pit, to serve as
a fulcrum, always a chafing more or less  troublesome,
and  oftentimes distensions and  serious lacerations are
the consequences of its  application, when the body is
suspended on it, as in the mode  by  the door, the club,
&c.  where Petit has  seen a fracture of the neck of the
humerus occur, and even a laceration, followed by an
aneurism of the axillary artery.
   46.  Every one has not at his command the different
means above mentioned  (41 and 42) whence the diffi-
culty of procuring them, or of constructing them, and
the loss of time, precious in relation to the  reduction,
which  is almost always easily accomplished  in propor-
tion  to  the  expedition  used;  these  charges apply,
among many other means, to that machine so compli-
cated,  and so  well known,  under the name of the mit-
ten* of Petit.
   47.  Supposing the luxation to be consecutive, how
can mechanical means make the head of the bone re-
trace the route  it has pursued in becoming displaced ?
For example, if to a displacement downwards has suc-
ceeded a displacement inwards, it will be necessary for
the head to return downwards before it can  re-enter
its cavity.   But, can the direction of the movements
fie thus  varied?  This  whole  apparatus of artificial
* (De movffle de Petit.) 
132
 means, for ever contradictory, oftentimes acts in an in-
 verse direction to that of the muscular action, which is
 the essential and chief agent in the process of reduction.
   Should the luxation take place upwards, the insuffi-
 ciency of these means must be evident.
   48. Perhaps,  however, they may be employed with
 some advantage, when a primitive luxation downwards
 is quite recent, and the head of the bone is near to its
 cavity.   In  such a case the lower edge of the scapula
 presents to  it an inclined plane,  along which  it can
 easily glide, when pushed by some external force.  It
 is doubtless to this disposition  of the  bone to replace
 itself, that we  must attribute the successes, greatly ex-
 aggerated, but in part  real,  on which the  inventor of
 every machine endeavours to found the superior merit of
 his mode of operating.
   But, in this case, it is useless to accumulate artificial
 forces, where natural ones  are sufficient, and where the
 operator may, with his  hands,  effect the reduction the
 more easily, as he can with more  accuracy Vary the
 direction of his movements.
   49. Thus Desault oftentimes  employed a process
 which was  attended  with great success, and which,
 like  some of  the  preceding, ought  to be  referred to
 impulsion.   The patient being seated on a chair of a
 moderate height, he took hold of the hand of the af-
 fected  side,  placed it between  his knees, and carried
 it  downward and backward, for the purpose of making
 extension, and  disengaging  the  head of  the  bone;
 while an assistant held the trunk with a view to counter-
extension, which was sometimes effected to a sufficient
degree, by the weight of the body and the efforts of the
patient.   At the same time the hands of the surgeon,
 applied to the arm, in such a  manner that the fingers of 
133
each were  in  contact with the hollow of the arm-pit,
and the thumbs with the external part of the arm, drew
upwards and  a little outwards the head of the hu-
merus,  which in  common returned with ease into its
natural  cavity.
   50.  Petit mentions this process, not such as it is here
described,  but complicated with the  use of a napkin
passed under the arm-pit of the patient, and round the
neck of the surgeon, who, by raising his head, drew
the  displaced  extremity upwards.   This  additional
mean,  always  unnecessary, and  not judiciously con-
structed, is generally ineffectual, because, with it, the
operator cannot at pleasure vary his movements.  The
hands alone are always sufficient, and a vast number of
examples  attest the efficacy of this method, when em-
ployed after the manner of Desault.
   Case VI.  Nicholas Juan fell on his side, his arm
being  separated from his body, as he was crossing, in
January 1790, the place Notre-Dame, opposite to the
Hotel-Dieu.   An acute pain  was immediately ex-
perienced ; a  protuberance appeared suddenly under the
arm-pit; and under the acromion a depression equally
sudden.  He was  lifted up,  and carried straight to
the  Hospital, where  Desault was just beginning a
 clinical lecture.   The  luxation  being manifested  by
 these  appearances,  was immediately reduced  by the
 foregoing  means.  A few days rest were enjoined on
 the patient, but, on the same evening, he proceeded
 on his way, blaming himself,  for having lost half of his
 day's journey.
   51.  In  analogous cases of  very recent luxations
 downwards,  Desault twice or three times effected the
 reduction  by  means still more simple, as the following
 case,  reported by Heraut, testifies. 
134
   Case VII.  Maria  Louisa Favert fell,  as  she was
 descending a ladder,  and having luxated her arm, was
 carried at  her request, immediately  after the accident,
 to  the Hotel-Dieu.   Desault perceiving the nature of
 the disease, placed,  under the hollow of the  arm-pit,
 his left hand, to serve as a fulcrum, while with his right,
 applied on  the inferior and external part of  the arm, he
 approximated the humerus to the  trunk, pushing it at
 the  same  time  upwards.  By this double movement,
 directed upwards and outwards, the head of the humerus
re-entered  its cavity without the least resistance.   The
 arm was suspended in a sling for two days,  and on the
 fourth the patient returned to her usual labour.
  52. There exists some analogy between this method
 and one of those mentioned, by Hippocrates,  to have
 been practised in ancient  times,  in the public games,
 where  the  exertions  of body exposed those who en-
 gaged to frequent luxations.
  It is not only in luxations  downwards, that  the first
 of the simple processes which I  have mentioned (49)
 may be applied.   Primitive  luxations inwardly,  yield
 sometimes  to its use,  and the Journal of Surgery fur-
 nishes two instances of success in similar cases ;  one
 in a female sixty-three years of age, and the other in
 one of fifty-one,  of a strong constitution, and in whom
 the  reduction was effected without resistance.
  53. But,  in general, these means are ineffectual and
 it becomes necessary to have recourse to  extension,
 which, when employed alone, forms the second class of
 means intended for reducing luxations of the humerus.
 Many writers have adopted  this exclusively, though
 some practitioners, indulging their imagination in the
 vast field of invention, deserted the common track, and
had recourse to various kinds of machinerv.  Celsus 
135
depended on  extension alone,  in  common cases  of
luxation downward and forward. • Albucasis employed
no other means, Douey, Douglass, and Heister, among
the moderns,  reject  unconditionally the use of ma-
chines, as always useless, and often dangerous. Finally,
Dupoui and Fabre,  examined and analysed with great
exactness the process of extension,  and pointed out,
in every  case, the means of rendering it advantageous,
by managing in the best manner the extending forces,
and  in the luxation of the humerus, in particular, to
prevent  the inconvenience of straps placed under the
arm-pit of the patient, demonstrated the inutility of the
movement commonly called  conformation.   In these
respects, surgery stands  indebted to them for real ad-
vancement, and their doctrine, at this day, very generally
known and received, was principally reduced to prac-
tice by Desault,  who made it the basis of his method
of reduction in all fractures and luxations.
   54. To proceed to the reduction  of a luxation of the
 humerus, it  is necessary to have such a number of as-
 sistants  as to be able, according to the resistance of the
 parts, to  increase the force  intended  to overcome it.
 But two are commonly  sufficient.   They should fur-
 nish themselves  with a linen ball, thick enough  to pro-
 ject beyond  the level of the pectoralis-major and the
 latissimus dorsi, when  placed  in  the  axilla, and two
 straps, one formed of flannel doubled several times, four
 inches  broad, and  eight  or nine  feet long, the other
 of a knapkin regularly folded.  This latter is not often
 absolutely necessary.
    Every thing being properly  arranged, the patient  is
 seated on a chair of a moderate height, or  else  laid on
 a table  firmly fixed and covered with a simple mattress,
 in  order that  the trunk,  by being in  a horizontal po- 
136
sition, may not prevent the motions communicated to
the arm from being directed downwards.
   55. Desault  continued, for a long time to place the
patient in the first of these positions, which, though em-
ployed by practitioners generally,  is by no means the
most favourable.   By adopting it indeed the arm may
be very well drawn in a transverse direction ;  but if, as
oftentimes happens, it becomes necessary  to direct ex-
tension upwards or downwards, the assistant, then, being
obliged to elevate himself,  or to stoop, cannot, in either
of these attitudes,  exert his strength to advantage, but
is confined and embarrassed, and cannot with ease vary,
at the pleasure of  the surgeon,  the direction in which
the arm is drawn.
   As far as relates  to the patient, that situation in which
the body is only in part supported, is  much  more fa-
tiguing than  one where the whole of it  reposes equally
on a horizontal plane.  Perhaps, in relation to the sur-
geon, it would be  more advantageous,  in enabling him
to accomplish the process of conformation ;* but, as
will be presently observed, this process is always use-
less.   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 strap is then applied.  The
two ends of this strap being now brought obliquely up-

  * That is, to draw, or otherwise force the head of the os humeri, with his
hands, towards the glenoid cavity, while the assistants are making extension
and counter-extension.  In  doing this, he must pull the head upwards, if it
be lodged in the axilla, backward if it be under the upper part of the pecto-
ralis-major, &c.  Desault, however, contends that this assistance from the
surgeon is unnecessary, and that extension and CQunter-extension are alone
sufficient to efi'ect the reduction.                         Tr a ns. 
137
wards, before and behind the thorax, so as to meet on
the top  of the sound shoulder, and being held by an
assistant, serve to fix the body, and to make counter-
extension, nor does the action of the strap bear on the
edges of the pectoralis-major and latissimus dorsi, in
consequence of the ball which projects beyond their
edges. Were it not for this, these muscles, being pulled
upwards, would draw in the same direction the humerus,
to which they are attached, and would thus destroy the
effect of the extension, which is made in the following
manner.
   57. Two assistants take hold of the fore-arm above
 the wrist, or else a folded napkin is fixed on that part,
 having its two ends twisted around each other.   These
 ends, thus folded together, are given to one or two as-
sistants, who begin to pull in the direction of the  hume-
rus.  To this first movement, intended to disengage the
head of the bone from the bed which it occupies, another
 succeeds, which must vary  according to the kind of
luxation.  If the luxation be downwards, the surgeon
gradually approximates the  arm to the trunk,  at the
same time that he pushes it gently upwards.  By this
process, the head of the bone, being drawn from the
trunk, and brought towards the glenoid cavity, usually
 re-enters it with but little resistance.
   If the luxation be inwards,  the extremity of the hu-
 merus, after extension according to the direction of the
 bone, should be carried upward  and forward, in order
 that  its head  may  be  directed backwards.  Steps the
 very reverse of these must be pursued,  if a luxation in
 an outward direction is to be reduced.
   58. In general, when, by the first extension, the head
 of the bone is disengaged, the motion communicated to
 it by the subsequent ones,  ought to be in a direction
                         18 
138
precisely opposite  to that which it pursued in escaping
from its cavity.  But what are the variations of this di-
rection ? Extensive experience alone can clearly deter-
mine  this point.   Without experience the practitioner
works in darkness.  The minutiae or particulars of the
process of reduction, being different in different cases
and according to different circumstances, can be  neither
foreseen, nor taught by precept.
  59. If the head of the bone experience any difficulty
in re-entering its cavity, it  is necessary, when the ex-
tensions  have been made, to communicate to the bone
different movements,  varied according to the different
directions of displacement, and regulated by the prin- x
ciple just established.   Oftentimes tiiis method effects
what extensions alone cannot;  and the head of the bone,
carried  by these movements towards its cavity, enters
it while they are performing.
  60. If the luxation be consecutive, then the first ex-
tension made in the direction of the displaced bone, is
intended to bring  its  head into the place where it was
primitively  lodged, in order that it  may be  afterwards
acted on as if it were a case of primitive luxation.  It
is oftentimes only at the moment of reduction, that it is
practicable to ascertain to  which kind  of  luxation the
accident belongs.  Indeed as in most cases,  the reduc-
tion takes place of itself when the extensions are well
executed, if the head be consecutively drawn inward, it
is seen to descend along the internal part of the scapula,
till it arrives near  to the inferior part of that bone, and
then  to  reascend  towards the rupture in the  capsule
through which it passes into its natural situation.
  61. I have said that when the extension  is properly
made, the reduction takes place almost spontaneously.
Indeed whatever may be the kind of primitive luxation, 
139
 it is evident, that the muscles surrounding the articula-
 tion must be stretched on one side, while they are re
 laxed on the other; whence there will necessarily arise a
 change both in their contractions, and in the direction of
 diese contractions, and such is the nature of this change,
 that, in case the muscles act, instead of bringing the
 head towards the rupture in the capsule, they will draw
 it  in another  direction,  and by that means produce a
 consecutive luxation.
    62.  But, if  the   extensions  render  the   muscles
- straight, and restore  to them their primitive direction,
 then, obeying  their natural  irritability, which is  still
 further increased, by means of the extension, they will
 draw the head to the  rupture in the capsule, and force it
 to re-enter it,  with much more certainty than this can be
 done by the efforts  of the surgeon,  who is always ig-
 norant of the  precise situation of this rupture.  On the
 other hand, if the extension be not judiciously made how
  can it restore  to the muscles their natural direction? In
  such a case, the head of the bone will be drawn towards
  some other part of the capsule than that where the rup-
 ture exists, and hence, the difficulties that so frequently
  occur,  in reducing luxations of the humerus.
    63.  From  these  circumstances it follows; 1st,  that
  the whole art in the treatment of luxations, consists in
  giving to the extending powers a proper direction;  2dly,
  that, in general, the process of conformation is unneces-
  sary and useless, 3dly, that to reduce a luxation is not to
  replace the head of the bone in its cavity, by force, but
  to restore the muscles to such a state, as to enable them
  to replace it.   Here, therefore, as in every other  case,
  art is only the minister and handmaid of nature.
     There are  instances,  however, where the muscles
  cannot act properly in consequence of the long standing 
140
or age of the luxation, and in consequence of adhesions,
more or less strong, having taken place between the
surrounding parts.  In  such cases it is necessary to
employ proper measures to force the head of the bone
into its  cavity, as it cannot be carried  thither by the
muscles.
   64.  Reason  concurs with experience, which is  on
all subjects the best authority, in establishing the truth
of this doctrine, respecting the reduction of luxations
of the humerus.  In this operation, Desault employed,
in general, nothing but extensions, varied according to
circumstances, until the muscles thrown into a favour-
able state,  were themselves enabled to  accomplish the
reduction.   The most  immediate  success constantly
crowned his practice on this point.   This success was,
no doubt, owing to his judiciously remaining inactive
himself, and suffering the muscles to do  the work, after
the necessary extensions had been made.
   65.  When the reduction is accomplished, if the arm,
in consequence of being very moveable, appears likely
to be displaced again, it is necessary, for a few days, to
fix it in such a manner as to prevent all motion ; an ob-
ject  which  may be effectually attained  by  Desault's
bandage for fractures of the clavicle.
   All writers recommend, for this purpose, the use of
the Spica bandage.* But what-service can this render?
It does not restrain the motions of the humerus, which,
hanging down the side, may move forward, backward,
&x.  and produce a new displacement; an accident that
may be always prevented by the bandage proposed.

  * With the particular mechanism and mode of action of this bandage, I
am unacquainted.  Nor are these matters of much moment, as the bandage
is, I believe, entirely out of use.                         Tra ns. 
141
                 SECTION VIII.

  OF  CIRCUMSTANCES  RENDERING  REDUCTION
                    DIFFICULT.

  66. I will close this memoir by an examination into
some circumstances, which  may either prevent reduc-
tion or render it difficult,  and into certain accidents that
sometimes accompany it.
  I have  said that, on some occasions, the rupture of
the capsule, being too narrow to admit the head of the
humerus to repass it, and return to its cavity, consti-
tutes one  of the principal obstacles to a reduction (24.)
To enlarge this passage, by further lacerating its edges,
is evidently the indication that here presents itself. This
is fulfilled by communicating to the bone great motion,
either by circumduction, or rotation on its  own axis,
forcing it suddenly in different directions, particularly
in that  direction  in which the luxation has  been pro-
duced.   Its  superior extremity  must be,  at the same
time, pushed forcibly against the ruptured capsule,
which,  by being thus pressed  between two resisting
bodies, will suffer a more extensive rupture. Reduction,
oftentimes impracticable  previously to these violent and
varied motions, takes place of itself as soon as they have
been properly niade.  Of this the practice of Desault
furnishes many examples.
   Case  VIII.  In the Journal of Surgery  are recorded
two cases, one by Anthaume, the other by Faucheron,
which establish this doctrine.
   John Seligni, a robust man, forty-four years  of age,
fell  on  the point of his  shoulder, on the 19th of July 
142
1791; the pain, which was increased  by moving his
arm, and the swelling which supervened almost imme-
diately, induced him to enter the Hotel-Dieu.   The ef-
forts 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 ap-
peared to enter the cavity, although the persons present
did not hear the collision or clashing of the articulating
surfaces,  which is almost always perceived in  cases of
recent  luxation:  but  immediately the humerus was
again displaced, without its being practicable to retain
it.  On the occurrence of this  phenomenon,  Desault
conceived that the head of the bone had pushed before
it the capsular ligament, through  which it could not
pass in consequence of the narrowness  of the  opening
which had  been at the time of the luxation.   He pro-
ceeded to move the arm forcibly in every direction,  in
order to  enlarge the opening, and immediately felt  a
kind of laceration,  which satisfied  him that his views
were accomplished.  He then re-commenced extension,
which it  was again necessary to continue, as at first, for
some time, in order to overcome the resistance of the
muscles.   The reduction was attended with no further
difficulty.  The humerus continued still to have a great
tendency to be displaced, and it  was necessary to em-
ploy,  for several days, a bandage similar to that for a
fractured clavicle.
   Case  IX.  Maria  Laurencier, aged  sixty, fell on
her right elbow, and luxated the humerus of the same
side.   Eight hours  afterwards she came to  the Hotel-
Dieu, on the eighth of March,  1789.  The reduction
was attempted in the usual manner; but, although the
extensions were properly directed, and the head of the 
143
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 open-
ing of the capsule  was too narrow to allow the head of
the bone to pass.   The  assistants ceased making ex-
tension, 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 en-
larging  the laceration of the capsule.  The extensions
were now renewed, and  the reduction succeeded with
great  ease.
 . 67. A second obstacle, more difficult to  be surmount-
ed in  the process of reduction, is that arising from the
long  continuance  of the  luxation.  The head of the
bone, having continued for a long time in the bed into
which it has been accidentally  thrown, forms adhesions
to it; the  surrounding cellular  membrane  becomes
thickened,  and makes, so to speak, a new capsule for
the head, which opposes its replacement, and, when the
reduction cannot  be  accomplished, supplies in  some
measure the office  of the old joint,  by the movements
which it allows to  take place.
   Most writers, and Bell in particular, advise, in such
a case, never to attempt a reduction, which, being of no
avail  as to the luxation, might prove dangerous  to the
patient,  in  consequence of the violence it would do to
the parts.  This doctrine was for a time, the doctrine
of Desault: but experience, in his latter years, led him
to a bolder  practice.
   68. The complete success which he experienced in
luxations of fifteen or twenty days standing, encouraged
him to make the attempt, at the end of thirty and thirty-
five days, and we have, three or four times, during the
two last years  of his life, seen him successful  in re- 
144
placing, after the expiration of two and a half, and even
three months, the head of the bone which had escaped,
both through the inferior, and  the internal side of the
capsule.
  However powerful, and however long continued the
extensions were, none of those terrible accidents occurr
red, with which we are threatened by authors.  Twice
only did a phenomenon occur, which it was difficult to
foresee, and of which I will presently speak.
  69.  In cases of this kind, it  is necessary, previously
to making extension, to move the bone very forcibly ill
every direction, in order first to  break the adhesions, to
tear the condensed cellular membrane, which serves as
an accidental capsule, and to produce, so to  speak,  a
second luxation, with a view to make way for a per-*
feet reduction of the first.  The  straps being then ap*
plied, as in ordinary cases, serve the purpose of extension,
for the accomplishment of which the  number of assist-
ants must be increased.
  70. Oftentimes the first efforts are fruitless, and the
luxated head remains stationary, amidst the most  vio~
lent efforts.   Let the  extensions then be discontinued;
renew the forcible motions of the limb:  carry the hume-
rus  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-com-
mence the extensions, and let them be made  in every
direction.  By these,  the  head, already disengaged by
means of preceding violent motions, will be  brought
to a level with  the glenoid cavity, and ultimately re-
placed. 
145
  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 that seem
likely to occur in the glenoid cavity, during the absence
of the head  of  the  humerus.   I  will relate,  among
others, a case reported by Giraud,  second  surgeon to
the Hotel-Dieu.
   Case X.  Maria Gauthier, tliirty-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 back-
 ward.  Different surgeons had,  at different times,  at-
 tempted  the reduction, but always  without  effect,
 and  when every hope  of a cure  appeared  to have
 expired,  Desault, imboldened  by reiterated success,
 tried whether or not he would  be equally  fortunate in
 this case.
    The patient  being placed in a horizontal  position,
 as already directed  (55) great motions  were first  im-
 pressed on the limb : extensions were then commenced,
 first in the direction of the luxation, and afterwards
 forward and backward.  Vain efforts;  the head re-
 mains immoveable;  new  motions are  again made in
 every direction, and  afterwards,  the extensions are re-
 newed :  the same want  of success.   The  patient being
 fatigued,  the reduction was deferred till the day follow-
  ing, when the  same trials were, after a  short  time, at-
  tended with complete  success.   The  head  being at
  first disengaged, and afterwards drawn slowly along the
  track through which  it had passed in becoming  dis-
  placed,  at  length  re-entered the capsule.   The  arm,
  being supported by the usual apparatus, soon became
                          19 
146
edematous, and, notwithstanding the remedies common
in such cases, the swelling  continued for two months.
The motions performed by the limb in the mean time,
restored to it, by degrees,  its usual  suppleness;  and,
on the  sixty-eighth day after her entrance; the patient
was discharged cured.
   To this case,  I might subjoin  many others, and, in
particular, that of John Putot, also reported by  Giraud,
and  in  which the means just described  (69 and  70)
succeeded in the  reduction of a luxation at the expira-
tion  of the fourth month.   But too great an accumu-
lation of facts distract the attention, and add nothing to
conviction, especially when they are already so plain as
those just related.
   71.  But further, in cases of this kind, where a very
old luxation presents great obstacles to reduction, al-
though the attempts made to reduce it, do not actually
force the  head of the bone into the capsule, still they
may not prove entirely useless.  By bringing the head
nearer to  the glenoid cavity, or placing it even on that
cavity,  and making it form new adhesions there, after
having  destroyed its old ones, the motions of the limb
will  be facilitated.  For, in cases, where the luxation
is not fairly reduced, these motions will be always less
impeded,  in proportion as the head of the bone occu-
pies a place less remote from its natural situation.
   72.  A  third obstacle, common to the reduction of
every kind of luxation,  is the  muscular force, increased
by the irritation of the displaced bone, beyond its na-
tural degree.   So great, at times,  is this force, that the
head of the bone cannot be moved, even by the strong-
est efforts.   What means  should then be employed ?
 1st.  Those which diminish general irritability, such as
blood-letting, bathing, a relaxing  regimen, &c.  2dly. 
147
Those which act locally, in diminishing the irritability
of the muscles of the shoulder.   For example : the ap-
plication of  emollient cataplasms or fomentations to
the part;  or, what is still better, a powerful extension,
continued for some time.   In consequence of such ex-
tension, the muscles of the part become fatigued, whence
their contractions are succeeded by a state of atony, of
which advantage may be  taken to  replace the bone.
Frequently this extension ought to be continued for a very
long time; and we have known Desault not to complete
the reduction in less than  half a day, or even a whole
day, the limb being suffered to  remain all that time in
the apparatus for fractures  of the clavicle, which draws
the shoulder and  muscles outwards.  Thus, in 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.


                   SECTION  IX.

   OF ACCIDENTS CONSEQUENT TO  REDUCTION.

   73.  It is rare  that any serious accident follows the
 reduction of a luxation of the  humerus.  A swelling,
 more or less extensive, sometimes shows itself around
 the joint, particularly when extension has been forcible
 and long continued ; but  this, being, in  general, easily
 removed, by  means of discutients, does not demand
 particular attention.
    74. Another accident which rarely occurs in practice,
 respecting  which  but  little is  to be found in surgical 
148
 writings, and with which Desault occasionally met, is,
 a considerable  emphysema, suddenly appearing at the
 time of reduction.  In the  midst of  those powerful
 extensions, rendered necessary by the ancient state of
 the luxation, a tumour suddenly appears  under the
 pectoralis-major.   By a rapid increase it extends itself
 towards the hollow of the arm-pit, the whole of which
 it soon occupies.   It then  propagates itself in a back-
 ward direction,  and, in the  space of a few minutes,  its
 bulk is sometimes equal to that of the head of an in-
 fant. A practitioner, if unacquainted with the nature of
 this accident, might take it for an aneurism, produced
 by a sudden rupture of the axillary artery, in conse-
 quence of the violence done to that  vessel by the ex-
 tensions of the limb.  But, if attention be paid to the
 resistance of  the  tumour, to its want of pulsation,  to
 the place of its first appearance  (which is usually under
 the pectoralis-major,  and  not under  the hollow of the
 arm-pit, to which it only propagates  itself  afterwards,
 as Desault has observed in similar cases that fell under
 his notice) to the  action of the pulse still continuing,
 unless the patient should faint from debility, as  happen-
 ed to the subject of the following case,  which we had
 occasion to witness at the amphitheatre, sometime pre-
 vious to the death of Desault, and to the colour of the
 skin which suffers  no change;  if these circumstances
 be attended to, it will be difficult not to distinguish one
 of these accidents from the other.  In that now under
 consideration, discutients applied to the tumour, such,
for example, as vegeto-mineral water, and a gentle and
regular compression made by the bandage  intended to
support the arm after reduction, are the most efficacious
means that art can employ. 
149
  Case XL Simon Cerisiat, sixty years of age, pre-
sented himself on the nineteenth of December,  1794,
as the subject of a  public consultation, which,  every-
day preceded the clinical lecture of Desault,  to receive
advice for a luxation inwards, which he had suffered a
month and a half before, and for the reduction of which
no attempt had been yet made.
  Convinced, by the example of luxations  more an-
cient,  of  the  practicability of  reducing  this, De-
sault undertook it immediately in the presence of his
pupils.
  The patient being  laid on a table, "firmly fixed and
covered with a mattress, great motions were  impressed
on  the luxated limb upward, forward, and  outward,
with a view to destroy the adhesions contracted with
the surrounding parts.  Extensions were then made in
the manner already mentioned (66 and 67.)
  Nothing was  gained by the first attempt, the head
remaining immoveable, in the midst of the efforts to
displace it.   Further motions were made in  every di-
rection, 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  towards
the glenoid cavity,  near to the edge of which it  reach-
ed  in two minutes,  and  was at length replaced, by a
sudden movement of the limb from behind  forward.
   Scarcely was the reduction  accomplished, when a
tumour rose suddenly under the pectoralis-major, pro-
pagated itself towards the arm-pit, and  occupied im-
mediately its whole extent.
   All the assistants, astonished  at the phenomenon,-
knew not to what  circumstance  to attribute it.  De- 
150
sault himself,  a little  embarrassed, thought first of an
aneurism  suddenly produced  by the violence of the
extension.   The  pulse of the patient, being scarcely
perceptible in the side  affected, and a syncope which
supervened, appeared  at first to favour this suspicion;
but immediately the  absence of  a fluctuation,  of  a
pulsation, and of a change  in the  colour of the skin,
the return of the pulse, the circumscription of the tu-
mour,  its resistance, and the sound caused by striking
on it,  produced a belief that it  was owing, not to an
effusion of blood,  but to a disengagement of air that
had been confined in the now lacerated cells of the cel-
lular membrane.
  Over the whole of the swelling were  applied com-
presses wet with vegeto-mineral water, while a regular
compression was made on it by means of a bandage,
which, at  the  same  time, kept the arm fixed against
the trunk.
  In the night  there occurred severe pains around the
articulation and the tumour,  accompanied writh high
fever, both which symptoms disappeared on the follow
ing day.   Third day,  a diminution of the emphysema-
tous swelling;  and an entire cessation of fever and pain.
Eighth day, tumour  reduced  to half its  original size;
the arm made  to perform gentle motions, and disen-
gaged  from  the apparatus;  discutients  continued.
Thirteenth day, tumour entirely gone.   In the place
which  it  had occupied,  a large echymosis appeared,
produced no doubt, by a rupture of the  small vessels
at the time of reduction, but which, till  now, had not
been  perceptible externally, in consequence  of the
emphysematous swelling  of  the parts,  and which was
treated by the same means as the emphysema.  Seven- 
151
teenth day,  a yellow tinge, mixed with the colour4 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
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.

                    SECTION I.

   1. The fore-arm, composed of two bones, neither
of them  very strong, and  covered below by a small
quantity  of soft parts,  is exposed  still more  than the
humerus, to the action of  external bodies, and is ar-
ticulated 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 oc-
cur, 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 disposi-
tion of the bones which compose the fore-arm, their ir-
regularly prismatical form, their  thickness unequally
distributed, their direction obviously different,  and their
motions  differently  combined.  It is  sufficient to ob-
serve, that, for the perfection of one part of these mo-
tions,  a space,  wide in the  middle, and narrow at the
ends,  must separate the two bones, that,  without this
space the radius, impeded  in its movements on the cu-
bitus,  would compress the muscles,  restrain their ac-
tion, and would be unable  to perform  the motions
of pronation  and supination ;  whence the  fore-arm,
being  Confined  as  it were, to mere  flexion and ex- 
153
tension, would not,  in its uses, correspond to our
wants.
  These things being premised,  we will observe, that
fractures of the fore-arm may have their seat, 1st,  in
both bones at the same time ;  2dly, they may occupy
but one of them : hence three kinds of fractures more
or less different in their phenomena, their consequences,
and their treatment.


      FRACTURE  OF THE  FORE-ARM.

                  SECTION II.

      OF  THE  VARIETIES AND THE CAUSES.

   3. Fractures of both bones of the fore-arm may
occur either at the ends, or in the  middle of the limb.
Frequent in the middle, and somewhat common below,
they seldom occur in its upper part, where the fleshy
portions of numerous muscles,  combined with a con
siderable thickness of the ulna, resist the motions which
tend to produceThem.  The two bones, though most
commonly broken on  the  same  line,  are,  however,
sometimes broken on different ones.  The fracture is
almost always  single : at times,  however, it is double,
and Desault, in particular, was once called to  a patient,
over whose fore-arm the wheels of a carriage had passed,
and had broken it both in the middle and at the lower end,
 so that it evidently  exhibited six fragments distinct
from each other.  The two middle ones, though com-
pletely insulated, united again to the others with but
very little deformity.   Like all other similar affections,
these may be rendered compound by wounds, splinters,
&x.  circumstances which, as thev fall within  the gene-
                        20 
154
  ral  class of such  injuries, will not be treated of at
  present.
    4. They occur, in general, in two ways, being the
  result, sometimes of the action of external bodies, im-
  mediately  applied,  and at other times of the same
  action,  operating by way of a  counter-stroke.  The
  occasional percussion of a body  on the fore-arm, 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 the fracture.

                   SECTION  III.

          OF  THE  SIGNS OR  APPEARANCES.

    5. It is in general difficult to be mistaken with respect
 to the signs which  characterize fractures of the fore-
 arm.  A mobility of the limb where it  was before in-
 flexible;  a crepitation almost always easily perceived;
 a depression, sometimes evident, at  the  place of divi-
 sion ;  a protuberance sometimes formed  under the skin
 by the fragments ; pain produced by  the motion of the
 part;  a crack sometimes heard by the patient,  at the
 moment of the  accident; an inability to perform the
 motions of pronation and supination; the almost con-
 stant semi-flexion of the fore-arm ; such, together with
 the phenomena common to all fractures, are those which
essentially characterize this, and which must generally
remove all doubts which the swelling of the limb may
 temporarily create respecting its existence. 
155
  6. There is a circumstance, however, where a frac-
ture near to the joint of the wrist, may give rise to ap-
pearances similar to a luxation of that part.   In both
cases, indeed, a convexity  behind, and a depression
before, or the reverse, are perceived, and are the effect
of a displacement of the fragments.  But the styloid
apophysis being carefully examined, will always deter-
mine according as it is found above or below the de-
formity,  from which of  the two causes the  deformity
arises.   Besides,  a greater mobility in one than in the
other affection, and a crepitation, will guard the practi-
tioner from an error, into which I saw a surgeon fall in
the presence of Desault, whom he called on to consult,
in the  case  of a child six  years old, which laboured
under a supposed luxation.

                   SECTION IV.

                OF  DISPLACEMENT.

   7. Most of the phenomena  which accompany frac-
tures of the fore-arm (5) are evidently the result of a
displacement of the fragments ; a displacement, not, in
general,  very perceptible in the longitudinal direction of
the bones, because the muscular action, tending to pro-
duce 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 frac-
ture.
   8. But it is different with respect to a displacement in
the cross direction of the bone.  Here the  cause of the
separation  of the broken ends, may be the same with the
cause of their fracture, as happens in the  passage of a
carriage wheel over the limb, or in the falling of some 
156
body against it; and then, 1st, the fragments are sepa-
rated from before backward, or contrarywise, and hence,
a protuberance on the  one side of the limb, and a de-
pression on  the  other;  2dly,  or  else they are  pressed -
against each other laterally from without inwards. From
this latter cause arises that inequality  which the limb
exhibits at the place of the fracture; the slight depres-
sion which it manifests on its sides ; and the protrusion
or bulging out of its anterior and posterior surfaces, by
means of the mass of muscles which are pushed in these
directions, by the approximation of the fragments to each
other.
   9. A proper reduction removes the first kind of dis-
placement, namely, that which occurs in the cross di-
rection of the bone backward or forward (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
fragment of the radius against that of the ulna; below,
the two fractured  extremities are pressed against each
other, by the contractions of  the pronator quadratus.
From this double cause arises, unless something prevent
it, the contact of the four fractured ends, which have
been sometimes found united  together by a common
callus, as is  proven by several cases sent-to Desault, and
by the cases of different patients admitted into the Hotel-
Dieu, after  having undergone  an improper treatment.
In such cases, the  movements of pronation and supina-/
tion  being entirely destroyed, are but imperfectly sup-
plied, as Duverney remarks,  by  those  of a rotation
of the arm. 
157
  But if the four broken ends should not even be joined
together by a common callus, still the space between the
bones being evidently diminished, impedes muscular
action and the motions of the limb depending thereon.


                   SECTION  V.

                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 displace-
ment (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 neces-
sary, according to the precept of Hippocrates to place the
 fore-arm  in a middle state  between pronation and su-
 pination,  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 as-
 sume, and which alone they can, for a long time, retain,
 without experiencing any inconvenience.
    12. The  fore-arm  being  thus  placed, an assistant
 makes extension, by taking hold of the four fingers ; a
 mode to  be adopted in preference to that of Petit, who
 directs us to make extension at the wrist; for the real
 momentum or force of a power is in the inverse ratio of
 its distance  from the place  of resistance.  At the same
 time, another assistant  makes counter-extension on the
 humerus, which he grasps with both his hands, in such 
158
 a manner, that his thumbs correspond to the back part of
 it, while his fingers cross each other anteriorly.
   13. It further follows, from what was said (8 and 9)
 that the process of conformation,  so  often useless and
 even injurious, in  other fractures of bones, is necessary
 here, to restore to the fragments that exact contact which
 they have lost, in a transverse direction. If the displace-
 ment be forward,  the  surgeon pushes both fragments
 backward, while the assistants maintain the extension. If
 the bones project  backwards, they must be pushed in
 the contrary direction.  As to a lateral displacement (8)
 in which the broken ends approach each other, it is not
 altogether useless,  as Petit observes, to endeavour to re-
 move it,  by forcing the muscles into the space between
 the bones. This is  done by making a moderate pressure
 on the anterior and posterior surfaces of the fore-arm, in
 order that the bones,  being thus removed from each
 other, may come in contact with their broken ends.  If
 this be done, when the apparatus is first applied, the re-
 duction is attended with but little difficulty, and the
 ends of the fragments are easily  retained in apposition.

                   SECTION VI.

      OF  THE MEANS OF  MAINTAINING  THE
                    REDUCTION.

   14. Our forms  of apparatus are nothing but  means
of continuing, for a long time, that state  of things,
which extension and the process of conformation tem-
porarily produce at the time of reduction.  This prin-
ciple, though generally  acknowledged, was particularly
neglected in such fractures, as that now under consider-
ation, till the time of Petit, who made it the basis of 
159
his practice.  Before him, there was a common incon-
venience attached to every kind of bandage.  The two
bones  being pressed against  each other,  by circular
rollers applied externally, were thus drawn in that very
direction, in which the action of the pronator muscles
already tended to displace them ; because, the form of
the fore-arm being irregular, made these rollers act more
powerfully on its lateral parts, where it is very convex,
than either  behind or before, where it is very flat.   It
is  well known  that bandages will make  the greatest
pressure on the most projecting parts of the limbs round
which they are applied; so  that, if the  fore-arm be
bound  or pressed on behind  and before  with a  force
equal to one, it will sustain laterally, that is, on its sides
or edges, a pressure equal to two.  Hence results, not
only a tendency  in the radius to approach  the ulna, but
also, a want of resistance in the muscles situated on the
posterior and anterior sides of the fore arm.  For these
muscles being, from their flatness, less compressed than
the bones, give way, and do not, by forcing themselves
between them,  oppose the  approach of  the bones to
each other.
   15.  Such was the disadvantage of the  apparatus of
Hippocrates, consisting of one  roller applied immediate-
ly  on the skin, of a many-tailed bandage intended to re-
tain this, and of four splints, applied on the seventh day,
and secured by another roller.   Suclj was also the in-
convenience of  several  bandages, proposed after the
time of Hippocrates, by different authors, who modified
his without improving  it,  and who,  in attempting
to  alter it, even added to its imperfections.  Thus, the
compresses  with which the limb was first covered, pre-
viously to the application of the rollers, served only, by
becoming wrinkled, to render the compression unequal 
160
 fatiguing, and  even painful to  the  patient.  In  like
 manner the pasteboard, which many authors, particular-
 ly Duverney, have substituted for splints, and which a
 majority  of  practitioners employ, even at the present
 day, soon becoming softened by moisture, bends with-
 out resistance, becomes incapable of preventing a dis-
 placement, and has at least the inconvenience of beirtg
 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 prudence,  to warn
 the patient of its being impracticable to cure him, with-
 out the loss  of the   motions of pronation  and supina-
 tion ?  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 ef-
 fective, the bandage ought to do constantly what the
 hands of the  surgeon do at the time of reduction (13;)
 that is,  it ought to oppose  to the unremitting action  of
 the pronators, a resistance equally unremitting, by press-
 ing the muscles into the interstice between  the bones.
But, after having discovered the end to be attained, he
 accomplished it only in an  imperfect manner.   For by
 first applying a  roller immediately round the fore-arm,
 he reproduced, in part, the very inconveniences and dis-
advantages he wished to prevent, by placing anteriorly

  * On this  point Desault is certainly mistaken.  Paste-board, when of a
 proper thickness and well applied, makes an excellent splint for fractures of
 the fore-arm. It moulds itself to the form of the arm, sits easy, and retains
 the fracture extremely well.                             Tr a x s 
161
and posteriorly two long and thick graduated compres-
ses, intended to keep the bones asunder, by forcing the
muscles between them.
  18. Duverney, more judicious,  proposed to place
the graduated compresses of Petit on two circular com-
presses, previously applied  round the fore-arm.  But
what  availed these circular  compresses ?  If they  be
drawn tight, will they not produce that approximation of
the bones which the surgeon wishes to avoid? And if
they be not tight, they will, in consequence of their loose
and pliable state, form  troublesome and inconvenient
wrinkles, without being productive of any good to coun-
terbalance this inconvenience.
  19.  It was from these different  considerations, that
Desault modified, as I am about to mention, the appa-
ratus for fractures  of the fore-arm.   To a great degree
of simplicity, this apparatus unites, when thus improved,
great ease to  the patient, and its advantages are proven
by the freedom in the different movements of  the arm
always experienced by the  numerous patients, whom
he was called to attend.   The pieces of the apparatus
are,  1st. Two graduated compresses, one  of them of
such a length as to extend from the elbow to the wrist,
and the other from the wrist to the fold of the  arm on
the inside.   They  are to be  formed each of a single
piece  of linen, folded seven  or eight times on  itself, in
such a manner, that the lower fold may be an inch wide,
while the others, laid on top of each other, gradually
diminish in width to the last.   The thickness  of these
compresses ought to be less in very fat persons, where
the anterior and  posterior surfaces of the arm are more
convex.  2dly. A roller about four yards and a half long,
and four inches wide. 3dly.  Four thin but stiff wooden
splints, long enough to reach, one,  from the fold of the
                         21 
162
arm to the wrist, the second, from the interval or hollow
space between the olecranon and the condyl to the same
part, the third from the internal condyl of the humerus
to the styloid process of the ulna, and the fourth from
the external condyl to the styloid apophysis of the radius.
The breadth of the two first ought to be double that of
the other two, as the latter  occupy a space  of but half
the width of that occupied by the former.
  20.  Every  thing  being  arranged, the reduction is
to be executed as already directed (11—13);  and while
the extensions are still continued, the surgeon wets with
vegeto-mineral water, or some  other  discutient liquid,
the graduated compresses, and places them on the an-
terior and posterior  part of the  fore-arm (which must
be firmly supported  in a state between that of pronation
and supination, 11) in such a manner, that their broad-
est 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 relin-
quishes the roller, giving it into the hand of an assistant,
and places the four splints on the parts already mention-
ed (19) while the hands of a  second assistant secures
them, by grasping them all at their lower end, next to
the wrist.  The surgeon then resumes the roller, and, in
order to fix the splints immoveably,  descends with it
along the fore-arm by circular casts, till he reaches the
hand, where he finishes. 
163
  There is, in the application of this bandage, an essen-
tial precaution to be observed ; which is,  that as  each
turn of the roller passes over the graduated compresses,
the surgeon ought  to press on these  compresses with
the thumb and fore-finger of his left hand,  in order that
the muscles, by  being forced into the interstice between
the radius and ulna may prevent their approximation,
which would produce an inequality in the compression
made by the apparatus.
   21. After the application of the  apparatus, if the
patient be obliged to keep  his  bed, the. fore-arm  is to
be extended on  a pillow, taking care to keep it always
half-bent, and guarded by hoops from the weight of the
bed-clothes.   But if the fracture be  not  a compound
one, and if the fall has  done no injury to the system in
general,  it is  unnecessary  to confine  the  patient to  a
position  wearisome, and  oftentimes  insupportable to
many persons.  Then the  limb is to be suspended in a
sling which is always sufficient to  support it, without
having recourse  to the kind  of hollow case recommended
by Bell, which is seldom at hand, and the use of which
must be extremely  inconvenient.
   22. The subsequent treatment to be adopted in such
fractures  is simple and easy:  to  wet the  apparatus
daily, for a few  days, with  vegeto-mineral water, to ob-
viate, by proper means, the accidents that may occur;
to renew the application of the  roller at the end of eight
days, or perhaps later,  according to  the  degree of its
relaxation;  to repeat this application two or three times
during  the  course  of the treatment;  to allow, at first,
but light diet, which may be afterwards more solid, and
given in larger quantity, and to admit finally of a return
to  the patient's usual mode of living:  such was,  in 
164
 cases of, fracture, the practice of Desault, which was
 always attended with happy effects.
   23. Sometimes a considerable swelling occurs, after ■
 the application of the bandage, on the back and face of
 the hand;  small blisters appear between the fingers;
 the patient experiences sharp  pains along the fore-arm;
 and other small blisters rise on  its surface.  It is then
 necessary to remove the apparatus, to open the blisters
 by pricking  the cuticle, and dress  the part with cerate
 spread  on linen rags;  replace the apparatus, making it
 less tight than before, taking care to renew it every day,
 till the excoriation be entirely gone.  This accident,  of
 no great consequence in itself, has frequently occurred
 to Desault, although the rollers were applied at first with
 but a moderate degree of tightness.
   24.  The consolidation being completed generally  in
 twenty-four or twenty-five days, leaves, at this time, a
 little  stiffness in  the joints,  in  consequence  of  their
 having  remained so long without motion: die move-
 ments of pronation and supination  are performed but
 imperfectly.   Their return  is facilitated  and hastened
 by frequent exercise of the limb, as well at its junction
 with the os humeri, as in its  own  proper joints;  and
in general,  by the fifteenth  or twentieth  day  from the
removal of the apparatus, things are in the  same state in
 which they stood before the fracture. 
.165
        FRACTURE OF THE RADIUS.

                  SECTION 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
die ulna, which is joined to the hand by only a small sur-
face.  Hence, without doubt, arises the greater frequen-
cy of the fractures of the radius ; fractures which, when
produced by falls on  the hand, are evidently the result
of a counter-stroke.  Oftentimes also this bone is broken
by the  immediate action of external bodies, because it
is defended below with but a thin covering of muscles.
  In  whatever way  the fracture may be produced,  it
occurs in the middle  or at the extremities of the bone ;
very rare  near its articulation with the os humeri, it  is
more common in its middle;  but more frequent still  at
its lower end.   The difference arises probably from this
circumstance,  that, in falls on the wrist or  hand, the
shock  is weakened and lost in proportion  as it is propa-
gated 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 the fragments of
the radius towards the ulna, tend to diminish the interval
between  the bones.   The ulna  remaining  unbroken,
always prevents any displacement  in a longitudinal
direction.  The first kind of displacement is the more
perceptible, in  proportion as the fracture is nearer to the 
166
 middle part of the radius, where the  bones are at the
 greatest distance from each other.   This displacement
 is seldom outwards, because the interosseous ligament
 prevents that:  yet experience furnishes  some  excep-
 tions to this rule.
   Case I.  Desault was called, in the month of July,
 1781, to visit a mason,  who, sleeping at the foot of a
 wall, with  his fore-arm  stretched out, received on the
 anterior part of it, a round stone, of the size of a bowl,
 which, falling from a scaffold, fractured the radius in its
 middle, and produced a large contusion, accompanied
 by an enormous swelling, to which the usual discutient
 remedies were applied.   On the fifth  day the swelling
 had in part  disappeared;  but then there was discovered
 a very  evident protuberance of the  inferior fragment,
 which, by pointing outwards,  separated itself from the
 superior one, which remained nearly in its place.   The
 interval between  the  bones was evidently increased
 below.
   The fracture was reduced by pressing the  lower frag-
 ment  inwards, and, instead of  employing graduated
compresses the whole  length of the limb,  they reached
 only to its middle, along the part corresponding to the
 superior fragment.  The roller was drawn a little tighter
 below than above, in order to keep the inferior part of
 the radius near to the ulna.
   By being treated afterwards in the usual mode, the
 fracture was cured.  But,  in  consequence of being
 pver-stretched by the separation  of the bones, the li°a-
 ments of the wrist became the seat of a  tedious lvm-
 phatic 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 displace- 
167
ment of a fractured radius, a displacement which, if not
properly  treated,  makes the fragments unite in  such a
manner as to form an angle pointing inwardly towards
the ulna, as is evinced by a perceptible depression under
the cuticle.   In such a case, from this  contraction or
narrowing of the interval  between the bones, arise the
inconveniences'already mentioned (9).


                  SECTION VIII.

                  OF THE SIGNS.

   28.  The  diagnosis  of  fractures  of the  radius is in
general easy, when they occur at the lower end, or in
the middle (25).  In these two cases, a depression more
or less perceptible, on the external side of the fore-arm ;
an inability to perform pronation or supination, by the
action of the muscles  alone; and a severe pain, neces-
sarily resulting from  moving  the bone in this two-fold
direction.   Such are die particular signs or appearances
which first  disclose the existence and the place of the
fracture.   The reality of the accident is afterwards more
fully confirmed by the signs common to  all fractures,
namely,  the flexibility of the bone, the crepitation per-
ceived by moving it in different directions, &c.
   29.  Desault cautioned his pupils not to confound
this last  sign or symptom with  a kind of noise,  some-
times heard in the sheaths of the tendons of the exten-
sor  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 oc-
currence, it is always easy to distinguish it from a cre-
pitation of the bone, by this circumstance, that the first 
168
 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 stationary.  But if, on the
 other hand, it rotate, it has sustained no injury.  These
 two circumstances  can be easily explained;  but,  it is
 not so  easy for the practitioner to avail himself of them
 in every case.  This precept may also  be applied in
 cases where  a  considerable  swelling, occupying  the
 whole fore-arm, conceals from the touch of the surgeon
 the fragments of the bone, even when broken in the
 middle.

                   SECTION  IX.

    OF  THE  REDUCTION, AND  THE MEANS OF
                MAINTAINING IT.

   31.  The reduction of a fracture of the radius is effect-
 ed  in nearly  the manner already described for that of
the two  bones of the fore-arm (10—13) except that,
here, the extension must be less, because there exists no
displacement in a longitudinal direction (26).
  To remove that which exists in a cross direction, an
assistant whose business it is to make  extension, places
the hand in a state of adduction, for the purpose of re- 
169
moving the inferior fragment outwards.   This precept
cannot be applied to  much advantage, if the division
exist  towards the upper end, on  account of the in-
terosseous ligament.   At the same time the surgeon
endeavours to bring the ends of the bone into perfect
contact, by pushing them in a direction opposite to that
of their displacement; and when he has attained this
end, he begins the application of a bandage or appara-
tus the same as that  already described  (19 and 20)
with this difference, that as the ulna is here sound, and
performs, in  relation to the fractured radius, the office
of a natural splint, it is unnecessary to place an artificial
one between  the internal condyl of the humerus, and
the styloid apophysis of the ulna.
   32. The consolidation or cure is here always  more
speedy than in the preceding cases, where nature, with
die same amount of means  and resources, has twice the
quantum of labour to  perform, and where she supplies
her  deficiency of  power,  by the greater length of the
time which she employs.   In general the  bone is united
by the twentieth or twenty-fourth day.
   33. When the  fracture  exists at the superior part of
the radius, it is essential, after the removal of the ap-
paratus, to make the limb very frequently perform  all
its natural motions.   In such a case,  indeed, the parts
 sometimes swell, become stiff, and an anchylosis of the
 fore-arm may be the consequence, as Ambrose Pare ob-
 serves, 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  re-
 ported by Jeo. Dol**, confirms the truth of it.
   Case II.  Jane Rene was received into the  Hotel-
 Dieu, in consequence of a fracture of the upper  extre-
 mity of the  radius, produced by a fall on that part,  for
                          22 
170
 which  she  was  subjected to the treatmeht already
 described (31).   The apparatus being removed at the
 expiration of twenty-five days, the consolidation was
 perceived to be complete.   The motions of pronation
 and supination were impracticable ;  those of flexion and
 extension very much impeded.  The patient was now
 ordered  to  have  the fore-arm  moved daily, in  these
 several directions, for the space of an hour, and this space
 was even increased morning and  evening, notwith-
 standing the pains which, at first, accompanied the ex-
 ercise.   On the eighth day  pronation and supination
 could already be  performed in a  small  degree; they
 became more and  more free, in proportion as the exer-
 cise of the limb was longer continued;  finally, on the
 twenty-second day from  the removal of the apparatus,
 the patient was conducted, according to custom,  to the
 amphitheatre, where all the pupils witnessed the perfect
 freedom of  the motions.
   Case III. A few days after this, a man, who had left
 the Hotel-Dieu about eight months before, while under
 treatment for a similar fracture,  returned, to be the sub-
ject of a public consultation in consequence of a differ-
 ent disease.
   Desault, on interrogating him, learnt from him that
 the treatment for the fracture had been continued at his
 own house (31) but that,  when the apparatus was re-
 moved,  no  motion had been impressed  on the  limb,
 and that the  surgeon had  even kept it in a sling.   The
 fore-arm was then examined; it was half  bent,  con-
 stantly 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 
171
cured like the*preceding one, as Desault remarked to
his pupils at the time.
  34. The patient who was the subject of this second
case, was sent to the mineral springs, but derived no
benefit from the use of the waters.  If this were a proper
occasion, I could mention many  instances where this
remedy, so highly spoken of by many physicians of the
present time, has had no effect, except to deprive the pa-
tient of more efficacious means, by making him lose that
time, during which exercise frequently repeated, would
have effected a cure, but which, coming too late, could
be of no avail.


         FRACTURE OF THE ULNA.

                    SECTION X.

         OF THE CAUSES AND THE SIGNS.

   35. The ulna, less frequently  broken, in  general,
 than the radius, scarcely ever suffers alone from falls on
 the wrist or hand.  Most commonly its fracture is direct,
 and occurs, in particular, in cases where a person in
 falling, extends the fore-arm for the purpose of sup-
 porting  himself, and strikes  its  internal part against
 some resisting body.
   The division, though it does take place occasionally
 in all parts of the bone, occurs most frequently near to
 the lower end, where its slender size, compared to that
 of its upper end, its' more projecting situation, and its
 thinner  covering  of  soft parts,  act  as predisposing
 causes.
   36. In  whatever part it  may exist, the touch must
 readily detect  it, when the  fingers are drawn along the 
172
 internal surface of the ulna, which lies almost immedi-
 ately under the skin.   If moved in contrary directions,
 the fragments will also, by their mobility and crepita-
 tion, disclose the  nature of the injury.   A depression
 more or less perceptible is observed on the internal part
 of the fore-arm, produced by a displacement of the frag-
 ments, which are carried towards the radius, more par-
 ticularly of  the inferior  fragment,  as  Petit  has well
 observed, the superior one remaining almost immove-
 able.

                   SECTION  XI.

  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 opposite  state,
namely, that of abduction, in order that the fragments
may be brought into  contact, while the surgeon assists
in this process, by pushing the broken ends of the bone
in a direction opposite to that of their displacement.
   As in the foregoing case, three splints  are sufficient
for the  apparatus, where the radius, being unbroken,
performs the office of  a fourth.
   The exercise of the  limb, after the consolidation  of the
bone, is in general less necessary here, than in fractures
of the radius (34) because the ulna, being an immoveable
point of support for the motions of rotation, concurs in
them only in a passive manner. 
173
     FRACTURE OF THE OLECRANON.

                   SECTION 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 there
is nothing to separate it from the external integuments,
and is attached at its upper end to the strong tendon of
the  triceps  muscle, which appears to be incorporated
with it.   This  appendix  resembles greatly,  in  its
structure, form,  and  uses, the rotula, from  which  it
would differ in nothing, if the  inferior ligament of the
latter were  ossified, so as  to  form a bony continuity
between it  and the tibia.  It  is exposed to  fractures,
perfectly  similar to those of  the rotula,  but  which
differs so essentially  from the other fractures of the
ulna, as to call for a separate examination.
   39. The ancients appear to have had but little know-
ledge of fractures of the olecranon,  respecting which
they have transmitted nothing to  us, unless with Da-
lechamps, we find cause to  recognize a reference to this
affection in  the following passage of Paul of Egina:
Cubitus frangitur—circa partem ad cubiti gilbum.
   Most of the moderns have spoken of it  only in a
vague manner; no  one has described  with accuracy the
signs which characterize it;  and  few have  given sa-
tisfactory  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 
174  *
but imperfectly described for if a bandage which is in
itself equally imperfect.   Bell  does  not give us,  on
this point,  an exposition of either  his opinions or his
practice.
  Yet this fracture is by no means  so rare as to justify
the silence of authors, and its treatment merits a degree
of attention beyond that which is requisite in most
other fractures.


                 SECTION 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  ge-
nerally  transverse, is sometimes oblique.   Desault met
with an instance of an oblique fracture of the olecranon
in a man,  who had sustained a violent blow  on his
fore-arm from a club.
   41.  The  causes which produce  it are,  either 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 true
with regard to fractures of the  rotula, which are almost
always produced by  the contraction of the muscles at-
tached  to that bone.
   42.  The olecranon has been at times separated from
the ulna, by the act of throwing a stone with great force.
In such cases, the fracture has been produced by the
immediate action of the  triceps  muscle.   This is the
first mode of division. 
-  175
  The second occurs when a violent blow is received
on the elbow, or, more particularly, from falls on that
part:  for example, if, when  descending a  flight  of
stairs, our heel slip and we  fall backwards, the arm is
suddenly thrown behind to  save the body.  In such a
case, the olecranon striking forcibly against one of the
steps, and being pressed between it and the weight  of
the body, is broken.  In this way was the disease pro-
duced in a majority of the patients attended by Desault
for fractures of the olecranon.
                 SECTION  XIV.

                  OF THE SIGNS.

  43.  We  meet here with the same appearances and
atate of things, which constantly occur in fractures of
the rotula. The triceps extensor, finding no longer in the
continuity  or sound state of the ulna, a resistance to
its contractions, draws upwards the short fragment to
which it adheres, produces between it and the lower one
an interval more or less perceptible, and gives rise to
the greater  part  of the  other  characteristic signs  of
the affection :  these are,   1st. An interval or space  be-
tween  the fragments, corresponding to the posterior
part of the articulation.  This interval may be increased
at pleasure,  by increasing the flexion of the fore-arm,
or by making the patient contract the triceps muscle,
and  may be  again  diminished, by bringing the arm
into  a state of extension:  2dly.  An  inability  in the
patient to extend the  fore-arm spontaneously, which
is the  necessary result of the separation of  the triceps
from the ulna: 3diy. A  constant semiflexion or half- 
176
bent state of the fore-arm, produced by the contractions
of the biceps and brachialis internus muscles, to which
no  antagonists are now opposed :  4thly. An elevation,
more or less perceptible, of the olecranon above the
condyls, which, on the contrary,  rise above it, when,
in a natural state of the parts, the fore-arm is half-bent:
5thly. A  facility  of  moving the upper fragment  in
every direction, without communicating any motion to
the ulna:  6thly. A peculiar sensation experienced by
the patient,  to whom it seems, when he makes an ef-
fort to extend  the fore-arm, as if some body  or sub-
stance were detached or broken off from his  elbow,
and carried upwards.   The patient may realize the just-
ness of this sign,  by comparing it with what  he feels
on attempting to extend the opposite fore-arm, placed
in the same position.
  44.  If  to these signs  be  added the circumstarices
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 percepti-
ble crepitation, by rubbing the fragments in contrary
directions, after having first brought them together, it
will be  difficult to be  mistaken respecting the existence
of the fracture, which indeed the  swelling of the  part
alone can conceal  from the practitioner,  if, as some-
times happens, it  be  considerable.  But then, being
soon dispersed, either spontaneously, or by the action
of discutients, it leaves the accident unmasked,  accom-
panied 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 luxa- 
177
tion backwards, with which it has been sometimes con-
founded, as appears from  many  examples recorded in
different works.
                  SECTION XV.

               OF  THE PROGNOSIS.

  46. I will not  dwell on the question, so much agi-
tated of late, namely,  whether or not the olecranon be
susceptible of consolidation  or reunion.  Already has
it  been hundreds of  times  answered  by experience.
What could theory  add to the conviction already im-
pressed 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  ante-
rior surface of the  olecranon, to produce a union be-
tween  its fragments, of the synovia mixing with the
matter of callus, diluting it, weakening  it, preventing
it from  becoming sufficiently hard for the purpose of
reunion, &c.  We  will only observe, that these ideas
are borrowed from  a theory which modern experiments
have proven to be unfounded, and which, were it true,
would be applied in  the present case quite unphiloso-
phically,  since it wculd deny to  certain parts of man
the power or property of restoration or being healed, a
property common to all the component parts of beings
endowed with life,  and which even  constitutes  one of
their essential and discriminative characters.
    47.  Is the consolidation  of the olecranon effected in
the same mode as in other bones?   The observations
                        23 
178
of many practitioners, Camper  in  particular, seem to
prove that a ligamento-cataloginous substance is always
the medium of the union of fragments.  Desault once
found this  substance  in a corpse,  but it was in a case
where the fracture had  been improperly treated, and
where, of course, no  inference  could be  drawn with
regard to ordinary cases.
   48. But of what  import to us are the means which
nature employs?  The  indication is still the same.
The fragments must be always kept  in contact,  that
the reunion may be immediate, and that, as David ob-
serves,  in  his memoir  on motion and  rest  in surgi-
cal diseases, the apophysis may not, by  becoming too
long  in consequence of  the space occupied by the
callus,  impede the extension of the  fore-arm on the
os humeri*
                  SECTION XVI.

  OF  THE  MEANS OF CONTACT BETWEEN  THE
                   FRAGMENTS.

  49. There are no fractures,  the treatment of which
demands more attention,  or is  surrounded with  more
difficulties, than that of the olecranon.   Here art can-
not, as  in the thigh, and the  clavicle, oppose to the
ever active power  of the natural muscles,  a constant
resistance produced by the  action of a kind of  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 
179
speak, is drawn to meet it.  Whence it follows, that
extension here is of little use,  and that it  is chiefly by
position or attitude, aided by a judicious conformation,
that the reduction is effected.
   50.  The position has varied in the hands of different
practitioners.  Some have proposed that,  in which the
fore-arm is half-bent, so as to form a right angle with
the os humeri.   The example mentioned by David,  is
not the only one where recourse has been had to this.
But, by rejecting  the general principle respecting the
reunion of parts, which requires them to be kept in per-
fect contact,  this mode is exposed to a double incon-
venience.  The reunion is extremely slow in being ac-
complished, and, when ultimately obtained,  is accom-
panied by  the loss of one part of the movements of the
limb, in consequence of the length of the callus.  This
callus must necessarily fill up the whole space that inter-
vened between the fragments during the treatment, and
being thus added to the natural extent of the olecranon,
lengthens  this appendix to  such a degree, that, in ex-
tending the fore-arm, its summit or upper end comes
too soon into contact with  the cavity in the os humeri
destined to receive it.
   51. This practice appears to have been chiefly owing
to an opinion then in existence, that an anchylosis being
the necessary consequence of the fracture, it was proper
to place the arm in that position in which it would  be
most likely to be still of some service.
   52. We must not, however,  by throwing the fore-
arm into the greatest possible degree of extension, allow
it to be drawn into the opposite extreme.   From this
error the same inconveniences would result.   In such
a case,  should  the fragments  touch each other, and
press too hard at their posterior edges,  they must ine- 
180
 vitably leave an  intervening vacuity or space between
 their anterior edges.   Hence a greater  thickness of
 callus on the one side than on the other, and consequent-
ly an  impediment more or  less troublesome  in the
 motions of the joint.  If the inferior fragment  do not
 touch the superior one, it sinks into the olecranon cavity,
 leaves the  other behind it, and hence another source of
irregularity in the consolidation.
  53. Between these two extremes (50 and 51) it re-
mains to choose a middle course, and that position will
be best, in which the fore-arm shall be, so to speak, in
a state  between semi-flexion and extension.  By this
the fragments, being brought into perfect contact, will
experience  no  obstacle to  a reunion,  which will be
therefore both speedy and uniform.
  54. But it would be useless to place the limb in a
proper position, if no means  were made use of to retain
it there.  Being  immediately submitted to the  action
and influence of a multitude of causes, it will lose its
position, and the work of nature being interrupted, the
consolidation will be retarded.
  Hence appears, both the  necessity of placing a solid
body, as Desault did, before the whole of the limb, to
prevent its flexion, and the insufficiency of the appa-
ratus proposed by Duverney and others, who directed
to lay a thick compress on the fracture, to surround the
elbow then by a circular one, to secure the  whole by a
kind of figure of 8 bandage,  similar to that used  in
blood-letting, and, finally, to place the limb on a pillow,
without further precaution.
  55. Position alone evidently acts only on the lower
fragment,  which it directs towards the upper one.  But
it is also necessary to draw the upper fragment towards
the lower one, and fix it there, and this is certainly the 
181
most difficult point;  because, the triceps muscle having
a constant  tendency to  contract, opposes its action to
the  approximation of the  fragments, and indeed pre-
vents it, if as in the means usually proposed and adopt-
ed,  the pieces of the bandage glide easily over each
other.
   56.  These  considerations  determined  Desault to
search for  some means which, being more efficacious
than those already in use, might better fulfil the indica-
tions of the fracture.  He accordingly invented the ap-
paratus which we are about to describe;  some ideas
of this apparatus are indeed borrowed from other band-
ages.  The success which attended the use of it at the    •
Hotel-Dieu, will, without doubt, introduce it generally
into rational  practice, where  the  insufficiency of the
old forms of apparatus is acknowledged.
   1st. The fore-arm being placed in the position alrea-
dy directed (53) two assistants retain it in that situation,
while the surgeon applies on its lower part the end of a
roller five or six yards long, and about for inches wide,
wet with  some  discutient liquid,  making with it, at
first, one or two circular turns to fasten it.   Then as-
cending from below upwards, he covers the whole of
the fore-arm with oblique and reverse turns moderately
tight.
  2dly. Having arrived at the joint, he stops, and makes
an assistant draw the skin  of the elbow upwards, lest,
being loosened and wrinkled by means of the extension,
it might get between the fragments and  create an im-
pediment  to  their reunion.  Then, taking hold of the
olecranon,  he draws it down  towards the ulna,  and
passes behind it,  as a substitute for his fingers which
have hitherto  kept it firmly fixed, a cast of the roller,
which  he brings from the anterior part of the fore-arm 
182
 above the elbow.   Descending again  with the  roller
 along the external side of the arm, and returning across
 the anterior part, he pursues again the same course, so
 as to make the casts of the roller lie on each other, and
 surround the elbow like a kind of figure of 8.
   3dly.  The surgeon proceeds  now by oblique turns,
 to the upper part of the arm, where he  fixes the roller,
 by a circular turn, and gives it into the  hand, of an as-
 sistant.   He next applies along the arm and fore-arm, a
 splint very strong, but a little bent at the place which
 corresponds to the joint, in order  to prevent too great an
 extension of  the limb: then, resuming the roller, he
 employs it,  in a descending direction,  to  secure  the
 splint.
   4thly. The  apparatus  being applied, the limb  is
 placed  on a pillow, so as  to  be equally  supported
throughout its length, and is protected by hoops  from
the weight of the bed-clothes.
   57. To the bandage  which we have  just described,
Desault added formerly a strip of linen, to be placed all
along the posterior part of the arm, secured first  at its
upper end by  circular casts, which began above; this
strip was secured afterwards by oblique casts, as far as,
to the place where it met the olecranon,  separated from
the ulna.  Here the surgeon, quitting the roller, took
hold of  the  bit of linen, and drew it  downwards, and
along with it the circular casts  of the roller, together
with the muscles on which these casts  were applied,
and also the fragment which the muscles drew upwards.
An assistant then secured it here, while the surgeon,
after having made some casts in  form of the figure of
8, descended  to the  inferior  part  of  the fore-arm,
where the end of  the  strip was made fast  by  tight
 circular turns.  (See fracture of the rotula.) 
183
  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 from separating
by their relaxation, and by that means, to retain the frag-
ments in apposition.   But, on  the one  hand,  may not
the superior fragment be drawn by the hand, as well
as by a roller employed for the purpose ? And, on the
other ,  if the  circular casts  of the roller be liable to be-
come relaxed, why not the strip of linen also ? These con-
siderations induced Desault to lay it aside,  and use the
bandage in the form just described.
   59. The advantages it offers are far from being equi-
vocal.   1st. The limb is kept in a state of invariable
extension by  the anterior splint, and, on this account,
there can be no displacement on the part of the inferior
fragment.   2dly.  The  bandage, which accurately en-
velopes the whole limb, restrains the action of the mus-
cles by  compressing them, and prevents  in part the
contractions of the triceps ; while the casts in the form
of the figure of 8, applied with skill and precision, hold
down the  superior fragment, and render it difficult for
it to be  displaced.   3dly. Without the application of a
roller over the whole limb, a swelling more or less con-
siderable, would probably be the effect of the constric-
tion at  the elbow,  which must necessarily be some-
what tight, because, as the turns of the roller, in form
of the  figure of 8, act  on  the olecranon obliquely,  if
 they be too  loose,  they will slip and  not perform the
office of retention.
   60.  Like all kinds of apparatus composed of rollers,
 this ought  to be frequently examined,  lest, by becom-
 ing relaxed, it should not make sufficient resistance  to
the triceps, which  is always  disposed to draw  itself
upwards.   There can  be no period fixed on for the re- 
184
application of the apparatus;  the  moment it begins to
become slack, it ought to be renewed : three or four
times during the course of the treatment are generally
sufficient.  Should a considerable  swelling give reason
to suspect that the constriction is too  great,  it will
be necessary to remove the bandage in order to  apply
it anew.
  61. The period necessary for the reunion of fractures
of the olecranon varies, according as the  bandage is
more or less exactly  kept in its place.   Among ten
cases of  this kind, collected in the Hotel-Dieu,  four
united in twenty-four days, three in twenty-eight, and
three in thirty-two.  Hence, taking the mean term, all
other circumstances being alike, the  process of  cure
requires  about twenty-six days.
  62.  When this  is completed, it is necessary to im-
press on the limb motions of flexion and extension,
gradually increased every day.  This is,  as David
properly observes, the most certain method.of avoiding
a stiffness, and even an anchylosis, too often the conse-
quence of this  fracture.
  63.  But that illustrious practitioner, in recommend-
ing this  salutary remedy, has erred with regard  to the
mode in which it operates.  To consume, by degrees,
a superabundant callus in the interior of the articulation,
and  thus reduce it to a level with  the articulating sur-
faces,  is not, as he conceives the effect which  these
motions   produce.   This  opinion,  founded  on the
ancient doctrine of an osseous juice,  is refuted by the
dissection of many bodies of patients that died during
the treatment, and in which Desault discovered no trace,
either of an effusion of osseous juice, during the re-
union, or of its superabundance after this  reunion had
been completed. 
185
   The exercise communicated to the limb, appears to
act principally by removing the congestion of the  ten-
dons  and  membranes surrounding  the joint, which,
being at first irritated by the fracture, are thrown into a
state of engorgement; and further by dissipating a kind
of numbness which affects the muscles  after they have
remained too long in  a state of rest.
   64. But whatever may be its mode of action, it ought
to be gradually increased,  according to the state of the
parts, and continued for at least twenty days, a period
sufficiently long to restore to  the limb, in general, its
natural motions.
   65. It is seldom that after this methodical treatment,
the patient is exposed to an anchylosis, a thing inevi-
table  in such cases,  according  to most  authors.  A
celebrated surgeon, believing the long continued exten-
sion of the fore-arm  to  be the cause of this accident,
has advised here to abandon every kind of bandage, and
to commit the  cure entirely to nature.  But this doc-
trine, contrary to the  general principles of the reunion
of divided parts, has not in its favour the result of ex-
perience,  which proves  that,  under such neglect, the
stiffness in the parts near to the joint is always as great
as in other cases, that the reunion is  more tedious and
more deformed, and that sometimes it cannot be accom-
plished 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 al-
most 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.
                        24 
186
   Case IV. Silvan de la Noue,  aged thirty, fell on
his elbow, having his fore-arm bent, while the shoulder
of the same side supported a heavy load.   Acute pains
at the instant of the fall;  a sudden inability to extend
the fore-arm;  a considerable swelling appears almost
immediately, around the joint; and a superficial echy-
mosis at the hind^art.
  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 mentioned
(43) Desault recognized the  fracture, and applied the
apparatus (56) notwithstanding the  swelling and echy-
mosis, persuaded that the compression made by this
apparatus on the tumefied  parts, was the most effectual
mode to remove the enlargement.
  Next day, pains almost gone ; swelling diminished ;
on the fifth day, the bandage  become loose, by the al-
most entire  disappearance of  the swelling ; a new ap-
plication of it; the joint  wet frequently with vegeto-
mineral water.
   Seventh  day,  usual  regimen allowed;  ninth day, a
slightly bilious disposition; evacuents somewhat active
administered, to remove it.
   Thirteenth day, a third application of the apparatus;
echymosis entirely gone.
   Thirtieth day, the consolidation  complete ; the ap-
paratus  laid aside;  from  this time motions gradually
impressed on the limb.
   Fifty-eighth day,  die patient discharged, free in all
his motions, except a little stiffness, which exercise will
soon remove.   Since that  time, it has been understood
that the limb had   completely  recovered its  natural
functions. 
MEMOIR  IX.
     ON THE LUXATION  OF  THE  FORE-ARM.

                   SECTION I.

  1. The  solidity and security of joints are increased
in proportion as the extent of their motions is diminish-
ed.   This inverse proportion of these two properties to
each other, is in a particular manner remarkable in the
upper extremities, where the connexion of the humerus
with the scapula,  of the fore-arm with the humerus, and
of the bones of the wrist among themselves, appear, in
regular gradation, to acquire the one  as they lose the
other: hence, their predisposition to luxations  is  ex-
tremely different.  We  will examine those to  which
the fore-arm is subject.
  2.  An angular ginglymus unites to the humerus the
bones of the fore-arm, wliich are  again connected  with
each other by a double lateral ginglymus.   Eminences
and depressions, reciprocally  receiving and received,
constitute the first kind of articulation, where proceed-
ing from without inwardly, we find, 1st, the small head
of the humerus, entering or rather joining the upper ar-
ticular cavity of the radius, which moves on it: 2dly,
the external groove  of the humerus, receiving the rim
of  the  same  cavity  of the radius:  3dly, a projection
which, rising from the external edge of the  coronoide*
cavity, extends to the corresponding edge of that of the
olecranon, and is received into the external depression
* Not generally named in English works «f anatomy. 
188
of the sigmoid cavity :*  4thly, the large groove of the
humerus, receiving the middle eminence of this same
cavity:  5thly, a considerable projection, obliquely ap-
plied to the internal depression which receives it.
  3. These numerous connexions secure the solidity of
the joint,  which is still farther strengthened before by
the coronoid apophysis, together with the fleshy and
tendinous extremities of  the  biceps,  and brachialis
muscles, and by the olecranon behind;  at the inferior
part, by the anconeus; on the sides by two ligaments
which descend from the two tuberosities, and strong
muscular facias running from the same parts.   The
whole articulation is also  surrounded by a thick cap-
sule,  strengthened  by  numerous  accessory  fibres.
With such powers  of resistance, how can this joint
suffer a luxation ? Yet next to that of the os humeri, it
is perhaps most frequently  subject to this accident.

                    SECTION II.

  OF THE KINDS AND 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 coronoid
apophysis offers but little  resistance in consequence of
its slight curvature.   On  the other hand, the kind of
hook formed by  the  olecranon, prevents  it  and the
radius from passing before the lower articulating extre-

                  *  Echancrure sigmoide. 
189
mity of the humerus,  and therefore, without a fracture
of the olecranon, a luxation in that direction is imprac-
ticable: at the sides, the two lateral Ugaments,  but
more particularly the  reciprocal joining or interlocking
of the uneven articulating surfaces, present almost in-
surmountable obstacles to luxations laterally.  Whence
it follows, that luxation  backward is much more fre-
quent than the others ; compared to lateral luxations, it
is, at least in the proportion of ten to one : with lux-
ations forward,  no comparison can be made; neither
Petit nor Desault having ever  met with such.
   6. An external  force  produces the whole of these
luxations, but according to  each, this force must vary.
In a fall sideways, suppose  the hand  be applied to the
ground, with the arm extended, to save the body.  It is
evident  that the resistance  of the ground  will tend to
make the bones of the fore arm pass upwards over the
humerus, while  the  weight of the body pushing that
bone downward and forward will make it glide over the
 coronoid apophysis.  Thus, the capsule, being distend-
 ed before by the humerus, and behind by  the bones of
 the  fore-arm, will give way in one or the other place, or
 in both, as Desault observed in a man, who fell on his
 side as he was carrying a heavy load :  the weight of the
 body increased by the load, had such an effect, that the
 bones overlapped each other nearly two inches.
   7. It appears from this, that a state  of extension is the
 position most favourable to a displacement backwards ;
 a doctrine by no means conformable to  that of most
 practitioners, who consider a state of flexion as necessary
 to the accident.  But, then, in what direction should the
 fall take place, in order that the olecranon may  pass up-
 wards ?  Applied as  it is against the side of the cavity
 that receives it when the arm is extended, would  not 
190
this  apophysis prevent such passage ?  Whatever may
be the mode of displacement, the olecranon, in passing
upward and backward, may incline a little to the one or
the other side.
  8. I have already said, that without a fracture of the
olecranon, no luxation forward can occur (5). But what
cause can act with sufficient power on the parts to pro-
duce both accidents at the same time ? It would be ne-
cessary that a fall which had produced a fracture should
be succeeded by another fall;  but in such a case, the
fore-arm would be half-bent, and it is in a state of ex-
tension 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 articu-
lar ranges of the arm and fore-arm, have lost their con-
nexion entirely,  and incomplete, when only one bone
or one part of a bone has been separated from its natural
connexion with the humerus.   But what  cause can
act with sufficient force to produce the first kind of lux-
ation, namely,  that which is complete ? In such an ac-
cident so great would be the extent of the  wreck and
ruin of the part, that without doubt amputation would
be the only resource.
  10.  The  second kind  of lateral  displacement is the
result of a stroke which forces violently the extremity
of the fore-arm outward or inward.   A footman,  says
Petit, in falling from a carriage,  had his arm entangled
between the spokes of the wheel, and suffered in con-
sequence a luxation outwards.   Another produced one
inwardly,  by being thrown from his horse,  and falling
with his arm under him, on rough ground.   Strokes of
this kind may, as that author remarks, vary in a singular
manner.   But, in general, in all of them, the fore-arm
must represent a lever of the  first  kind,  where the 
191
  power acts on the end next the hand;  the resistance
  being  in  the joint, and the fulcrum in the middle.


                       SECT. III.

                     OF THE SIGNS.

     11. To form an idea of the signs or appearances of a
  luxation backwards, let  us examine,  for  a moment,
  the natural situation of the olecranon, and  the condyls
  of the humerus.   As these eminences are easily felt
  under the skin, a knowledge and  recollection of their
  situation  will  serve  as  a standard of comparison,  to
  judge of the changes they experience in a luxation.
  When the fore-arm is extended, the olecranon is on a
  level with the internal  condyl, and  a  little above the
  external one.  In a state of flexion,  it descends below
  this level, and is then farther below the internal than
  the external condyl.  In either situation, it is nearer to
  the  first  than to the second, the  radius  separating it
  from the latter.
     12. But,  when a luxation has taken place, this apo-
'  physis, still  remaining on a level with the two condyls,
  even although the fore-arm be half-bent, is oftentimes
   separated from the internal one, and driven towards the
   other: a preternatural  protuberance  announces this
   change of  position  of  the olecranon.  The  coronoid
   apophysis,  whose posterior surface  glides in  the large
   groove of the humerus, corresponds  to this groove now-
   only with its anterior surface :   sometimes the olecranon
   cavity*  receives  its extremity.  The  radius  passes
   backward over the small head of the humerus.   At the

     * That deep depression in the os humeri,  which, in a natural state of
   the parts, receives the upper eniof the olecranon process.        Trans. 
192
fold of the arm, a transverse  protuberance,  more per-
ceptible on the internal side, announces the presence of
the displaced articular  extremity of  the os  humeri.
Over this  extremity are reflected the  biceps and the
brachialis  muscles  in  a state  of violent distension.
These muscles, greatly irritated by such distension, con-
tinue in a state of habitual contraction, in consequence
of which, they keep the fore-arm half-bent.   Nor can
the anconeus muscle, which is necessarily relaxed act
so as to prevent this semiflection.   Severe pains would
be  the  consequence  of attempts to  extend the fore-
arm ; the limb is  in a  state  of  pronation; yet I find
among the cases collected by Desault, several examples
where supination  existed; this state is explained by
the relaxed condition of the pronator muscles.  At the
level of or opposite to the coronoid cavity is a depres-
sion or hollow manifesting the absence of the apophy-
sis of that name.
   13.  Should chance give rise to a luxation forward,
an interior projection of the two bones of the fore-arm,
and above all, of the coronoid eminence, a depression
corresponding  to the olecranon -cavity,  the  extremity
of the humerus carried backward and  downward, the
rigid extension of the fore-arm,  a protuberance behind
formed by the fractured  olecranon (5) and severe pains,
necessarily resulting from attempts to bend the limb,
&c. would constitute the principal characteristic signs
of the displacement.
   14.  In lateral luxations, a protuberance  at the in-
ternal or external side of the articulation, always shows
of what kind it is. If the displacement be to the inter-
nal 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 
193
behind  the  internal articular eminence x>f that bone,
which then rests on the external depression of the great    ^
sigmoid cavity.   Hence, as Petit judiciously observes,
arises the direction of the fore-arm outward, the above
eminence presenting a manifest obliquity in that direc-
tion.   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 con-
dyl of  that bone.   This is  what some authors  call a
complete luxation.   Others  reserve that name for cases
where  the  two articular ranges have lost their corres-
pondence or apposition entirely.
   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 sig-
moid cavity; the small head of this bone, to the exter-
nal depression; the radius projects outwards ; and the
humerus makes a protuberance inwardly.
   16.  After all, these changes of situation vary remark-
 ably, and it belongs to  theory rather than practice, to
 trace their  history, with precision.  In  general,  luxa-
 tions outwardly happen more frequently than those in-
 wardly, a circumstance which is fully explained by the
 structure of the  joint.   In both, the lateral ligaments
 are almost  always lacerated.
   A swelling more or less considerable accompanies
 all the different kinds of luxation, and  is sometimes
 carried so far as to involve the diagnosis in great 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. 
194
                   SECTION IV.

               OF THE REDUCTION.

   17.  The means of reduction vary  according to the
different kinds of displacement.  They are all, however,
founded on nearly the same principles, and it will be
easy to form proper ideas of them, when we shall have
given an account of the means necessary to be employ-
ed in luxations backward, of which the  others are only
modifications.
  Here genius seems to have been as prodigal of re-
sources, as nature has been of obstacles.   Indeed, to
accomplish the reduction, we sometimes  see  the sur-
geon 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 confor-
mation : at another time we see him fixing the fold of
the  injured arm against some resisting body, such as a
bed-post; and while  an assistant, then, pushes the dis-
placed olecranon against this bodyr, he himself, pressing
on  the shoulder with one hand, and grasping the fore-
arm with the other, bends it forcibly,  in order, by that
means, to produce a replacement:  again, a body of some
size, being placed in the fold of the  arm, serves as a
fulcrum, on which the fore-arm, being suddenly flexed,
moves and acts like  a lever  of the first  kind, of which
the  power, being applied at  the extremity  next the
hand,  draws it backward  and upward,  and by that
means pushes in a contrary direction its  luxated end,
where  the resistance is made.   On some occasions, the
fore-arm of the diseased side, bent at a right angle, is 
195
placed on a horizontal table, and, while the lower ex-
tremity of the humerus  is thus  resting  on the table,
the surgeon pushes  it backward with one hand,  and
with  the  other, taking hold of the extremity of the
fore-arm, draws it in a contrary direction.
   18.  The ancients employed the three first modes.
Pare has had engravings of them made: Scultel has
also given figures of them as practised by Hippocrates.
The  Arabians knew of  no other modes, nor did their
descendants, who were only compilers from them. The
practitioners of our own day still continue their use.
But,  in general, they are chargeable with  the numerous
inconveniences and faults of producing intense pain, of
not being completely under the direction of the surgeon,
of bringing the point of luxation too near to the place
on which counter-extension is made, and of  bruising
and doing violence to the parts:  nor do they disengage,
by means of previous extension, the luxated ends of
the bones, to facilitate their replacement in their natural
situations.
   This last charge is not applicable to the last of the
processes proposed by Petit. But, here,  the extending
forces are most commonly insufficient;  the  surgeon,
having both his hands engaged, is not able to act on
the joint to assist in the replacement: and the counter-
extension made is too near to the point of luxation.
   19. In common  cases, Desault employed a method
as simple and more efficacious, which few writers have
recommended, and none have described with accuracy.
   The patient is, indifferently, either seated or standing.
The fore-arm being half-bent, an assistant takes hold of
the extremity next the hand, to make extension; ano-
ther,  to make counter-extension,  takes hold of the
humerus a little below its middle, with both hands, the 
196
fingers crossing before, and the thumbs behind.   The
extension is made gradually, and when it begins to move
the olecranon, and draw it from the place it accidentally
occupies, the surgeon, to aid in the reduction, grasps the
lower end of the humerus with both hands, crosses his
fingers in the fold of the arm, applies his thumbs to the
olecranon, and drawing the  first  backward, pushes at
the same time the latter forward; thus, he  favours, on
the one hand extension, and on the other counter-exten-
sion, and in that way finishes the reduction.
   20. This method is  most commonly practised with
success,  in recent luxations, where  we have oftentimes
seen the  reduction effected at the Hotel-Dieu, by the
simple process of pushing, as just mentioned, the ole-
cranon forward,  the  humerus being  held backward,
without any previous extension, while the fore-arm was
merely supported by die assistants.
   21. But the luxation being oftentimes of long stand-
ing, presents very great difficulties.   What means must
then be employed ?  It is an established principle, that
the force with which a power acts,  is in direct propor-
tion to its distance from the point of resistance.   Aug-
ment  this distance, and  the extending  forces,  being
doubled and even trebled, will more easily dislodge the
luxated extremity.   But  this indication is fulfilled, by
two long straps,  formed each of  a  towel folded several
times, one of which is fixed above the wrist, and the
 other round  the humerus a little below its middle.
Extension is then made  at their extremities,  and is
almost always sufficient, when aided by skilful efforts of
the surgeon (19) to  accomplish the  reduction.   The
application of a strap  round  the humerus is  never ne-
 cessary, unless when the resistance is very great;  be-
 cause, in counter-extension, it is requisite only to with- 
197
stand or bear against the efforts of extension, but not to
act in a contrary direction.
  22. But in cases of this kind, the strap, placed, as we
have directed, round the lower part of the humerus, has
sometimes the  disadvantage of compressing too much
the brachialis and the biceps muscles, and thus prevent-
ing them from acting; this inconvenience is particularly
felt in old luxations, where  great  force is employed;
for, the more active then the contraction of these mus-
cles is, the more it will aid the surgeon in his efforts to
draw the bones into their natural situation, when once
disengaged  by  extension, from  that which they had
accidentally occupied.   If, in such a case, we impede
the contraction of these muscles, how can they fulfil this
office?
   23. It was this which, in certain cases, induced De-
sault 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 hollow,
and crossing, not on the top of the opposite  shoulder,
but behind that of the diseased side.  By this contri-
vance the humerus  was drawn or rather held back, by
a force acting perfectly in the line of its direction.  But
is not this force situated  too near to  the  centre of
motion ? The strap for  making extension, fastened at
the wrist, answers very well, as has been already men-
 tioned (21).
   24. Should the luxation be  forward, the extension
 must be directed according to the state  and position
 in which the fore-arm is found, which is always extend-
 ed.   The hands of assistants alone (19) or straps (21)
 may  then  serve to make  the  extension,  which the
 surgeon must aid,  by grasping,  in a direction the  re-
 verse of that in the preceding case, the lower extremity 
198
of the humerus, that is, by crossing his fingers behind,
and placing his thumbs on the coronoid apophysis, to
push it downward and backward.
  25. The strap for counter-extension, would in such
a case always afford the greatest advantage, by being
placed exacdy 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 neces-
sarily in a state of extension, sufficiently explains this;
finally, the reduction of the   luxation  must be suc-
ceeded 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 lit-
tle from  that of luxations backwards.   The displaced
extremities  must be  first  dislodged by  previous  ex-
tension (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 displace-
ment 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. 
199
                   SECTION  V.

     OF  THE MEANS OF  MAINTAINING THE
                   REDUCTION.

  27. Luxations of the fore-arm have, oftentimes, a
great disposition to occur anew, after having been re-
duced, 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 :  suppose
the  parts  even  remaining  in  contact,  the  slightest
motion may  derange  this contact,  and  give rise to a
necessity  for a new reduction,  more  difficult,  often-
times,  than the  first.   Hence it is always prudent to
employ a  retentive apparatus for some time.
 ■ 28. But, on  what  principle  and for what  purpose
ought it to be applied ?  The motions communicated to
the fore-arm by external bodies, but, more particularly,
the action of the muscles inserted in the bones that have
been reduced, are here the causes of their displace-
ment.  Hence,  1st, to render the limb  immoveable;
2dly, to push the  articular ends of  the  bones in a
direction opposite to  that ir which they are drawn by
the  muscles,  and have a  tendency to be displaced:
such is  the  twofold  indication  of the  bandage; an
indication not fulfilled by the kind  of bandage and the
sling which Petit proposed, and which leave the arm
free to move, and the muscles  free to act.
   29. Desault employed the following apparatus: 1st.
The arm and fore-arm  are first  covered by oblique
 turns of a roller, intended both to protect them from 
200
the  impression of splints, and to  diminish die power
and action of the muscles, by the pressure made on
them: 2dly. Behind the olecranon is to be placed a
thick compress, designed to retain it downwards, and
which must be secured by a strong splint, situated he-
hind, and curved at the elbow, to accommodate it to
the flexion  of the fore-arm:  3dly.  On the sides  are
placed two other splints, chiefly necessary in lateral
luxations :  4thly. The whole is to be secured by the
remaining part of the roller,  by which the arm and
fore-arm are already covered.
   In this bandage, the immobility  of  the arm is  se-
cured by the splints, while the olecranon is pushed by
the  compress, in a direction the reverse of that of its
displacement.   But these circumstances constitute the
double indication that was to be fulfilled (28).
   30. The  period at which these means may  be dis-
pensed with, is undetermined.  It belongs to the sur-
geon to examine and ascertain, when the natural con-
nexions of the joint  are sufficiently confirmed.   Then
motions, at first  gentle,  are  to  be impressed  on the
limb; being afterwards  gradually increased, they  re-
move by degrees  that  stiffness, which usually  follows
a  dislocation, particularly an old one.   But if it has
existed too long,  to give the limb motion, is then the
only  resource:  the new attachments   or  adhesions,
contracted by the articulating surfaces in their dis-
placed  state,  render  reduction  impracticable.  We
must then confine ourselves merely  to increasing the
extent of the motions, which  the displaced fore-arm
is  yet capable of performing.
   31. There is,  in  general,  all other  things being
favourable,  a hope of accomplishing the  reduction,
till the  end of the second  month after the accident. 
201
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 propor-
tioned to  their distance from  these cavities.
26 
MEMOIR  X.
   ON THE  LUXATIONS OF  THE  RADIUS OVER
                  THE  ULNA.

   1st.  Most  authors  who have  written on the  lux-
ations 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 Duverney alone has treated at  some  length.
Those of its lower extremity, though more frequent,
and more easily produced, appear to have almost en-
tirely escaped the attention of the  French practitioners,
who  have transmitted nothing to  us on  that point,
owing, no doubt, to  their having had  no  knowledge
of it from experience.   But since, at the present day,
a sufficient number of facts are collected on the  sub-
ject, 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.

                   SECTION  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- 
203
ment, by means of two small articulating surfaces, the
one at its upper  end, slightly convex,  broad within,
and narrow  without,  corresponding 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 from each other,  with
respect to their motions, the connexion of their sur-
faces, and the ligaments which strengthen them.  Let
us  specify these  differences; they will  serve to shed
light on those that  exist between  the displacements of
the two extremities of the radius.
   3.  At  its upper  end,  the radius,  in performing
pronation and supination, moves only on its own axis;
at its lower  end, it rolls round the axis of the ulna:
therefore, being  farther  removed from their centre,
its  motions must have both a greater range and greater
force,  in the latter  case than in the  former.   The
head of the radius, turning on itself within  the annu-
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  without in-
wards during pronation, keeps the capsule posteriorly
in a state of tension, and draws  it against the im-
moveable head  of the  ulna,  which tends  to  pass
through it,  if the motion  be forcible.  The  same
phenomenon occurs  in a  contrary  direction, during
supination;  the radius is  directed backward, and the
ulna inward.   Being in this case distended before, and
relaxed behind,  the capsule is disposed to  laceration
anteriorly. 
204
   4.  In addition to this disposition, the ligaments of
the two  articulations  are  disproportioned  in  their
strength.   Thin  and weak  at the lower articulation,
thick and firm at the upper  one, they are in this respect
strikingly different.   The  head of the  radius, resting
against the small but firmly fixed head of the humerus,
finds  there, in  most of its movements, an obstacle to
displacement.  On the contrary, its lower end, drawing
along with it  in  its movements, the  bones  of the
carpus  which  are connected  with it,  derives from
them no solid  support.

                   SECTION 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 luxation
in this  latter joint.   Is it  from a forcible exertion of
pronation  or supination that this accident can occur ?
Surely  not: for, on the one  hand, as the lower articu-
lation offers  less  resistance than  the  upper one,  it is
evident that, in  either  state of motion, it being the 
205
weakest, will be displaced first,  and the motion being
thus checked, can no longer operate to the displacement
of the other.   On the other hand, however forcible the
motion may be, there will be in the upper articulation,
nothing but a rotation of the bone on its own axis (3).
How, then, without being carried  forward, backward,
&c. can the head be  displaced ?  Indeed, it  would be
necessary that all the fastenings or bonds of attach-
ment muscular and ligamentous, should be first  bro-
ken.  But these are  too strong,  and the motion is
too weak.  Can  the displacement be produced  by a
blow impressed on the radius  from below upwards ?
By no  means:  because the head  of the  humerus
making,  in this case, a solid resistance will not permit
it to escape from the  capsule (4). • Can it arise from
a violent  extension or  flexion  of the  fore-arm ?  No.
This  effort  being  altogether confined  to  the ulna,
affects the radius in but a very  faint  degree.
   7. It appears from hence, that the accidental luxation
of the  upper end of the radius,  suddenly  produced by
external  causes, must, if it  ever occur, be extremely
rare.  But it is not so with respect to luxations which
take place slowly in  this joint, particularly in children,
where, in consequence of repeated efforts, the ligaments
become relaxed.  But this kind of displacement, being
almost always complicated with a swelling of the joint,
and sometimes not to be reduced byr the expedients of
art, cannot be comprised in my present plan.
   9. But experience would seem to have at times ex-
posed the fallacy of these considerations and reasonings,
founded merely on the structure of the parts.   Duver-
ney relates some instances of luxations of the head of
the radius, produced suddenly by external causes. Two
other practitioners are  also of  opinion that they  have 
206
                                                 •
 witnessed similar  displacements.  But did they  ex-
 amine the subject  with all that attention which it re-
 quired ? A similar case was reported to the Academy of
 Surgery,  by  one of its associates;  but doubts were
 entertained with regard to its reality: and, ultimately,
 there were so few  facts in its  favour, and such strong
 presumptions against  it, that Desault was induced to
 deny the  luxation altogether, till its reality should, by
 new proofs, be more certainly established.
   After all, if it should occur, the same  signs which
 announce the  luxation, when the ligaments,  in  conse-
 quence of being gradually  relaxed or in some way dis-
 tended, permit the head of the  radius to be insensibly
 displaced, would then appear as the sudden effect of ex-
 ternal violence.

   LUXATION  OF  THE LOWER EXTRE-
            MITY  OF THE RADIUS.

                  SECTION III.

        OF  THE KINDS OF DISPLACEMENT.

   9.  The  causes  which produce the displacement of
 the lower  end of the  radius, are the same with those
 that give rise to other similar affections. 1st. The con-
 vulsive action of the pronator and  supinator muscles,
 is doubtiess a  rare cause of the accident, since Desault
 never met  with an instance of it. 2dly. The action of
 external bodies, which, by forcibly and suddenly pro-
 ducing the motions of pronation, rupture the posterior
portion of the capsule,  or, by those of supination, lace-
rate its anterior portion.
   10. Hence two kinds of displacement, the one for-
ward, the other backward.   The first is somewhat fre- 
207
quent? the second  is much  less so.   The latter was
never seen by Desault but once,  and that was in the
corpse of a man who had had both his arms luxated, but
respecting the circumstances of which he could receive
no information.  The other kind occurred frequently in
his practice, of which five  examples have been already
published.  The difference no doubt arises  from this
circumstance, that the  greater part of our  powerful
motions are performed only in the direction of pronation.
This appears  to be proven by  the following circum-
stances.
   11. If, in several dead bodies, we lay bare the bones
of the fore-arm,  still united by their ligaments, and push
the extremity of the radius forcibly backwards, that is,
 in the direction of supination, a laceration will as readily
occur in the  anterior part of the capsule, as it will in
 its posterior part, when,  by forcibly  pushing the same
 extremity forward, the motion of pronation is perform-
 ed.  Hence the difference  does not arise from the  struc-
 ture, but from the direction of the motions impressed on
 the limb.

                    SECTION IV.

                   OF THE  SIGNS.

    12. The signs which characterize a luxation of the
 radius forward, are, 1st. The constant pronation of the
 limb :  2dly. An inability in it to assume the state of su-
 pination, 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 situ-
 ated more anteriorly than  natural: 5thly. The constant
 adduction, and almost constant extension of the  wrist: 
208
6thly. The semiflexion of the fore-arm, and very often of
the fingers: this position is generally assumed  by the
fore-arm, in affections of the bones that form it, and, in
the present case, cannot  be changed without  consider-
able  pain: 7thly. A swelling  more or  less extensive,
which sometimes appears around the articulation, at the
moment of the accident,  and which never fails to occur
afterwards, unless the reduction be immediately effected.
This occurrence may conceal the  state of the articu-
lation, and make  the accident  be  considered,  at  first
sight, as a sprain, as Desault witnessed in certain cases,
where the disease had been mistaken  by the surgeons
who were first called to the persons injured.  It is easy
to conceive of the sad  consequences  of this mistake,
which, by preventing any effort at reduction, gives the
articular  surfaces time  to form adhesions, and thus
oftentimes renders the mischief irreparable.
   13.  If to these  signs be added, the  severe pains ex-
perienced by the patient, the circumstances of the  fall,
in which the fore-arm is  violently drawn into a state of
pronation, we will have a view of every thing that can
here aid the practitioner in his diagnosis.
   14.  Most of the foregoing signs, taken in the oppo-
site sense, would characterize  a luxation of the radkis
backward, should it occur:  such, for example, as a
forced supination of the  limb, an inability as Jo prona-
tion, the pains that would result from this movement if
performed by  force, the  tumour formed anteriorly by
the extremity of the ulna,  the posterior situation  of
the large head of the radius, and the abduction of the
wrist.
   15.  The dead body, in which Desault observed this
kind  of displacement  (9)  being dissected  with care,
exhibited in the articular parts, the following diseased 
209
state.   The tendons of the flexor muscles, pushed out*
wards, adhered to one another and to the skin ; a sub-
stance of a cellular texture  filled up the sigmoid cavity
of the  radius,  and occupied the place  of the cartilage
which naturally invests it:  the inter-articular  ligament,
which passes between the ulna and the os pyramidalis,
scarcely touched the head of the ulna, having followed
the radius backwards ; and  the head of the ulna, situat-
ed before the sigmoid cavity  of the radius,  rested on
one of the fossa, sesamoidea, to which  it was attached
by a capsular ligament.


                   SECTION V.

               OF  THE  REDUCTION.

   16.  Extension so important in the reduction of other
luxations, renders scarcely  any service  in this :  impul-
sion alone answers the  purpose.   If the displacement
be  forward,  it is reduced in the following manner:
The patient sits or stands indifferently;  the latter posi-
tion,  however, has sometimes this advantage over the
former, that by placing the  part to be operated on more
on a level  with the hands of die surgeon, it  gives him
both  more readiness and more force in his  motions:
one assistant supporting the elbow, separates the arm
a little from the body ; while another taking hold of the
hand and fingers, gives them also an equable support.
   17. The surgeon grasps the extremity of the fore-
arm,  with both hands,  one placed on its internal, and
the other  on  its  external side,  so that  his two  thumbs
may  meet before, between the ulna and the radius, and
the fingers behind.   He then exerts  himself to separate
the two bones from each other, by pushing  the radius
                         27 
210
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 supi-
nation,  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 dis-
placement, by two  forces, the one exerted directly on
it, and the other acting indirectly, the radius is forced
outwards, and the ulna, returning through  the opening
in the capsule, is replaced in the sigmoid cavity.
   18.  Should a  luxation  of  the  radius  backwards
ever occur, the same process executed  in an  inverse di-
rection, would serve the purposes of reduction.   The
surgeon with  his fingers  would have to press the ex-
tremity of the  radius forward and inward,  while a for-
cible pronatory movement impressed  by the assistant
on the hand intrusted to  him, would  favour the effort
and finish the reduction.
   19.  The disappearance of  the signs (12....14) of the
luxation bespeak its reduction.   In general the pain is
entirely removed;  sometimes a perceptible  sound,  or
report, caused by the passage of the bone through the
opening in the capsule, announces the replacement.
   20.  When the luxation is of long standing, it is al-
ways attended with more or less difficulty, occasioned
by the  adhesions  of  the  surrounding soft parts  to the
articulating surfaces,  by the  thickening of the capsule,
which diminishes the size of its opening, by the rigidi-
ty contracted  by  the whole part,  &c.  It is, in such
cases, useful to employ emollient applications for some
time previously to attempting the reduction, in order
to produce such a relaxation,  and diminution of the
congestion, as may favour the efforts of the surgeon. 
211
  21.  The first patient  whom Desault  visited at the
Hotel-Dieu in quality of surgeon in chief, had a luxa-
tion forward,  of more than two months standing, in
which the use of these means facilitated the reduction :
but they are sometimes  insufficient, and then the ra-
dius remains immoveable, and the fore-arm performs
its motions but  partially.
  22.  It would  seem as if nature, always industrious
to provide, amid the disorders of our organs, some re-
sources for the exercise  of their  functions,  has  been
desirous of preventing here, the inconvenience attend-
ant on  a failure of reduction, by rendering luxations
backward  much more   difficult  than those  forward.
Indeed if the fore-arm be kept constantly in a state of
supination, it will be  much less useful, than if it were
always  in a state of pronation, the situation in which
most of the motions necessary  to our  existence are
performed.

                   SECTION VI.

        OF THE SUBSEQUENT TREATMENT.

   23.  When the reduction is finished, the articulating
surfaces have sometimes a great  tendency  to be dis-
placed, by the different movements of the fore-arm, a
tendency of which  we may easily form  an idea,  if we
observe, that  in a state  of pronation,  the head of the
ulna presses against the back part of the strained cap-
sule, and  consequently against its opening,  when the
luxation has been forward: a contrary  state of things
occurs in  a luxation  backward.   Whence it is always
prudent to avoid, for  some time,  the motions of prona-
tion and supination, according to the  direction of the
displacement. 
212
   24. Should the tendency to displacement be  very
 great, it will be necessary to adopt the simple method
 pointed out in a case already published by Desault.
   Case I. The case  was a luxation forward,  which
 was easily  reduced.  But the  easier the reduction, the
 more difficult was it to retain the replaced parts.   This
 was at length  accomplished, by fixing the fore-arm in
 a state of supination, and applying  one thick com-
 press behind the  ulna, while  the  radius was pushed
 backward  by another compress, placed on its anterior
 part, both  secured by a common roller.   This appa-
 ratus was continued for the space  of a  month, after
 which the  reduced  bones remained in their natural
 situation.   The patient began, at first, to perform gen-
 tle  motions of the  wrist,  avoiding  those of pronation,
 on  which he afterwards ventured by degrees, and with
 great caution.
  25. These gentle  motions frequently repeated, when
 a displacement  is no longer to be apprehended, remove
 that unavoidable rigidity which, for some time, occu-
 pies the parts  around  the joint.  It is advisable,  for
 some time,  to apply on the hand and extremity  of the
 fore-arm,  compresses wet with some discutient liquor,
 to  prevent the  swelling resulting  perhaps  from the in-
 activity 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.
  Ca^e I. Desault was  called to  visit  a child  five
years old, supposed to be labouring under a fracture of
the arm.  He learnt  from the parents of the child, that,
as  it was lying in  a very low bed,  a young  man who
was playing with it, had taken  hold  of its fore-arm, and 
213
 drawn it towards him, twisting it forcibly at the same
 time in the direction of pronation; that the effort had
 been accompanied by a report, and the child had im-
 mediately experienced an acute pain throughout the
 whole limb, but more particularly along the posterior
 part of the fore-arm.
   When Desault saw the patient,  no swelling  had as
 yet supervened;  the arm  was removed from the body,
 and carried a little  forward, while the fore-arm, half-
 bent, was kept in a state  between pronation and supi-
 nation.  There  existed, at its lower  and back part, a
 preternatural tumour,  formed  by the head of the ulna
 carried behind the sigmoid cavity of the radius.  The
 hand was a little extended, and in a state of adduction.
 The patient carefully preserved that position, and, as
 soon as  it was changed,  or  the part affected touched,
 manifested signs of the most acute pain.
   From these appearances, Desault discovered imme-
 diately a luxation of the radius forward, which was re-
 duced in the manner  already mentioned (16 and 17.)
 By this  process,  the  bones, being a  little separated
 from each other, were replaced with facility.  The suf-
 fering  of the patient was  immediately at an end j the
 limb resumed its natural state,  and performed its func-
 tions as freely as  before;  lest  some congestion might
 be the consequence, the  injured parts  were  covered
 by compresses  wet with  camphorated spirits:   these
 were secured by a  bandage moderately tight,  and no
 accident  whatever supervened.
   Case II.  On the 29th of January, 1789, Madeleine
 Fuser, a washer-woman,  thirty-four years of age, had
 the lower extremity  of the radius luxated forward.
   Just as she had finished wringing a sheet, another
: washer-woman, who was assisting her to wring it, giv- 
214
ing it a forcible jerk, did  violence to her  left arm,
which was at the time in a state of strong pronation.
   The woman experienced immediately a severe pain,
accompanied by a sensation as if something had been
torn.   The sheet dropt from her hand, and she  fell on
the ground.  Believing that she  had received only a
sprain, she neglected to apply for aid,  and did not en-
ter the Hotel-Dieu till the sixth day after the accident.
   There was then a litde swelling at the lower part of
the fore-arm and at  the  wrist: the latter was extended
and in  a state of adduction;  the  fingers were  bent.
This  woman  suffered but  little,  when her hand was
supported and kept still; but the  pains became severe,
when she attempted to move it.   It was plainly per-
ceived that the radius was  placed before the ulna, and
that the bones overlapped each other.
   Process of  reduction the same as in the preceding
case.   It was accompanied by a kind of report, and its
completion was clearly announced by the restoration of
the natural shape of the limb, and by the freedom of its
motions.   Compresses  wet with  vegeto-mineral water
were applied to the wrist.
  This patient remained fifteen days in the hospital, at
the end of which, she performed with ease the motions
of the wrist and hand. 
MEMOIR  XI.
       ON  THE  FRACTURES  OF THE THIGH.

                    SECTION I.

  The bs femoris, being in man, a moveable support
for  the weight of the whole body, appears to be better
secured than the other bones, from accidents that might
affect its continuity.   The numerous masses of muscle
that immediately surround  it; the thick and  compact
layers  of fasciae  that form its  more exterior covering;
and an articulation loose,  and ready to yield, in every
direction, to the motions impressed on it, all seem, on
the  one hand, calculated for its preservation.
  2. But,  on the other hand, being  visibly curved in
its middle, bent at its upper end almost at a right angle,
longer in proportion in man than in quadrupeds, placed,
in most falls, between the ground which resists, and the
weight of the body which presses on it; it would seem,
from these latter circumstances, to be less calculated to
resist external force.   And, if to these considerations
be added those of the causes which have an immediate
action  on it, it  will be easy to perceive, that, in a com-
parative scale  of the bones most exposed to fractures,
it holds,  next  to the bones of the  leg,  one of the
highest grades.   The  proportion wliich  its  fractures
bear to those of the leg, is, according to the  observa-
tions of Desault, as one to  three; but to that of /most
other bones it is equal  if not  superior. 
216
   3.  The  os femoris being in its body irregularly cy-
 lindrical and curved behind, becomes larger towards its
 lower end, where it terminates in two articulating mas-
 ses, which rest immediately on two corresponding sur-
 faces 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 en-
 tirely 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 ana-
 tomists,  and will be followed in the present memoir1,
 where we will consider in order,
   1st. The fractures of its body,
   2dly.  Those of  its upper extremity,
   3dly.  Those of its lower extremity.

   FRACTURES OF THE  BODY OF  THE
                  OS  FEMORIS.

                   SECTION  II.

        OF  THE VARIETIES  AND CAUSES.

   5. The os femoris may be fractured indifferently  at
 any point between its condyls and its  neck.  But the
 part  where  this accident most frequently  occurs,  is
about the centre of the  curve of the bone, where most
 of the motions and shocks impressed on it by external
violence expend their force.
   6. Whatever may be the  seat of the fracture,  its di-
rection is sometimes tranverse, but most frequently ob-
lique, a  variety which does  not affect the real nature  of 
217
the disease, but which possesses, as to its consequen-
ces, a very important influence.   As in other affections
of the  kind,  so here, the bone is sometimes affected
alone, and, at other times, to a fracture simple or com-
plicated by means of splinters, is added an injury done
to the surrounding soft parts.  Hence result compound
fractures, differently varied, according to the nature of
the parts affected,  and to the extent and other circum-
stances of these affections.   But, as Petit observes, this
bone is less frequently shattered or crushed into several
pieces, than those that are more superficially situated.
   7.  Extraneous causes are known to render falls more
frequent in man than in other animals, and to multiply
 in him the fractures  of the lower extremities, by mul-
 tiplying the  action of external bodies on these extremi-
 ties.   This  action may be exerted on the os femoris in
 two modes.   Sometimes only passive, it  merely offers
 a resistance to the power which puts the bone in motion;
 thus,  in a fall, the os  femoris, being pressed between
 the ground  which resists, and the weight of the body
 that bears on it, bends beyond  the extent of its flexi-
 bility or  pliancy, and finally gives way.  At other
 times the influence of external bodies is actively and di-
 rectly exerted in this accident:  thus a stone, or a piece
  of timber,  falling on the thigh, fractures  the  bone, in
  consequence of communicating to it  a degree of motion
  greater than its power of resistance.
    8.  In common, the first mode of division is by a true
  counter-stroke, similar  to  that  which  fractures  the
  clavicle, the ribs, &c.   In the second mode, the fracture
  is always direct.  The middle part of the bone is gen-
  erally broken in a counter-stroke:'  wherever the direct
  stroke is received, that is  the place  of the fracture
  which it   produces; the  division,  most  frequently
                            28 
213
oblique  in  the  first  case,  is sometimes  perpendicular
or transverse  in the second.   From a  counter-stroke
result most  commonly simple fractures,  while com-
pound ones are usually  owing to a direct stroke.


                   SECTION  III.

    OF  THE  SIGNS AND  THE  DISPLACEMENT.

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

  * (La longueur, l'epaisseur, et la direction.)  That is, the thigh may  be
shorter than natural, owing to the ends of the broken bone overlapping
each other; it may  have a protuberance on one side, in consequence of
these ends being separated or displaced laterally; or the direction of the
limb may be changed, by a bend or angle being produced in the bone at
the place of the fracture.                             Trans 
219
some deformity; the  exceptions  to  this rule  are too
few to be worthy of notice.  If this deformity be con-
sidered in relation to length, it will be  found  that, in
oblique fractures, the limb is always  shorter than that
of the opposite side, a circumstance which plainly points
out an overlapping of the fragments. But, on examining
the place of fracture, it is easy  to discover,  that this
overlapping arises from the inferior fragment mounting
upwards on the  superior one, which itself remains im-
moveable.  Now, what power, but the contraction of
the surrounding muscles,  can  communicate  to the
inferior fragment a  motion from below  upwards ? At-
tached, on the one hand, to the pelvis, and on the other
to this fragment, to  the rotula,  the tibiae,  and the
fibula, these  muscles have on the  former their fixed,
and on the latter their moveable points, and, drawing
the leg,  the  knee, and the  inferior  portion  of the
thigh  upward,  they produce the displacement and
shortening either mediately  or immediately.   In this
displacement,  the  adductores,  the  semi-tendinosus,
the semi-membranosus, the  rectus anterior, the rectus
internus, &c. are the principal agents.
   11.  The following  case  communicated to Desault
by a surgeon, who had been formerly his pupil, proves
how great the influence of this cause is ; a cause which
is indeed  generally acknowledged, but  not sufficiently
attended to by practitioners,  with a reference to perma-
nent extension.   It is this  that induces  me to relate
the case.
   Case  I. A carpenter  falling under the ruins of his
scaffold,  was immediately taken up and carried home,
where a  surgeon discovered an oblique fracture of the
os femoris, but without any displacement.   The thigh,
which appeared  even a little longer than the other, was 
220
fixed in an  apparatus  too  slack  to prevent muscular
action.   Next day, the length of the thigh was the
same, but the whole extremity was in a paralytic state,
accompanied by an entire inability to discharge urine.
   The moxa was proposed.   The patient being placed
in the position directed by Pott, for fractures of the os
femoris,  the fire was applied; some  movements  were
the consequence ; the application being repeated on the
sixth day, the muscles instantly recovered their power
of action, and then the shortening of the limb became
evident,  and still returning immediately after being re-
moved by extension, rendered it necessary to have re-
course to an apparatus calculated for permanent exten-
sion.
   12.  In this case, the muscular influence  is evident.
Indeed the shock having produced a temporary suspen-
sion of the excitability of the part, the fragments re-
mained in place and in proper contact with each other :
but the moxa having awakened the excitability again in
the muscles of the thigh, they resumed their action and
caused, as usual, the inferior fragment to mount on the
superior.
   13. Hence it follows, 1st, that it is principally to the
action of the muscles that we  must attribute the dis-
placement, in the longitudinal direction of the bone;
2dly, that,  as that action, being the effect of  an  inhe-
rent power, is constantly exerted,  the  limb  must have
a constant tendency to  this displacement,  particularly
in oblique fractures, where the two extremities of the
bone represent two inclined planes, which readily glide
along each other.
   14.  To this  must  be still added  another cause,
wThich operates injuriously in the course of the treat-
ment.  However solid the bed may be on  which the 
221
patient lies, the nates or buttocks, being die most pro-
jecting part of the body, soon form a depression in it;
hence arises  an  inclination or descent of the plane or
surface on which the body lies.  The body therefore
sliding downwards,  pushes before it the superior frag.
ment, and makes  it overlap the inferior  one.   In con-
sequence  of this, the muscles,  being irritated by the
points of the bones, increase the force of their contrac-
tions, and, as we have already observed (10) draw the
inferior fragment upwards.  This double movement of
the two ends of the bone in contrary directions, pro-
duces  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 dis-
placement, in the longitudinal  direction of the bone,
because the  fragments  when  in contact, support each
other.   In such a  case, the inferior fragment, drawn
by the muscles, finds a point of resistance against the
superior one, while the latter, when pressed downward
by the weight of the body,  pushes the former before
it,  and thus  both  preserve their relative position.
   16.  A deformity of the fractured os femoris,  in the
direction of its cross-diameter or  thickness (9) always
accompanies  that  in its  longitudinal  direction,  and
sometimes exists alone.   This  takes place when, in a
transverse  fracture  the  two ends  of the bone,  losing
their  contact, are  carried,  the  one outward,  and the
other inward, or when the one remains in its  place,
while the other  is separated from it.   In such a case,
the superior fragment is not,  as in the preceding one,
immoveable by means of muscular action;  because the
action of the pectineus, the psoas, the illiacus, and the 
222
 first adductores,  derange its natural direction, and con-
 tribute to its displacement.
   17. The deformity of the limb,  in  relation to its di-
 rection, in other words, the crookedness of the limb (9)
 is either the result of the stroke which fractured it, or,
 what is  more common,  of the ill directed efforts of
 those who lift and carry the patient, and,  by an impro-
 per position,  bend  the  two fragments, so as to make
 diem form an angle  with each other.  Desault was once
 called to a patient,  whom he found seated on a bed, in
 such a manner, that the upper part of the thigh was in a
 horizontal position,  and the lower, hanging with the leg
 in almost a perpendicular one.  Doubtless the  triceps
 femoralis, equally attached  to both fragments, bends
 them by its contraction, and produces a change in the
 direction of the limb.
   18. Whatever  may be the  kind of the deformity,
 whether  in a longitudinal or lateral  direction, the infe-
 rior fragment may either  preserve  the natural position
 in which it is placed, or experience a rotatory motion on
 its axis outwards, which is a common occurrence, or
 inwards,  a circumstance which is more rare.  This ro-
 tation always  renders the displacement more serious,
 and ought to have an influence, as I shall presently ob-
 serve, on the means  of reduction.

                   SECTION IV.

               OF  THE PROGNOSIS.

  19.  Fractures of the os femoris, though seldom very
distressing,  in common cases, from  any accidents that
immediately accompany them, are sometimes rendered
so,  by inconveniences which  are the consequences of 
223
them, when they are oblique.   Celsus declared, that a
shortening  of the limb,  more or less considerable, was
always the result of such fractures.  Most authors have
copied and repeated  this assertion, and,  even at the
present day, the opinion is advocated by a great number
of practitioners.   It must be acknowledged, that, if we
compare the natural powers that are engaged  in pro-
ducing displacement (10.... 15) with the artificial resist-
ance made by most of our forms of apparatus, we Will
perceive that there is between the two forces so great
a disproportion in point of strength, that the former can
never yield to the latter.  But, is it in the nature of all
forms of apparatus to be unable to overcome the  force
of the displacing powers ? Cannot an equilibrium be es-
tablished, so as to retain the fragments in contact? The
remainder of the present memoir will  throw some light
on this problem, which will become less difficult of so-
lution, if we call to mind, that the  action  of muscles,
though very powerful at first, diminishes afterwards by
degrees, in consequence of their being kept in a state
of permanent extension;  that  even a weaker power
may, by acting constantly, accomplish ultimately, what
could not have been effected at once by another power
much stronger, if only  momentarily applied ; and that
compression made by circular bandages, tends also to
diminish the force and prevent the action of muscles.
   Desault has cured, at the  Hotel-Dieu, a vast number
 of fractures of the os  femoris,  without the least re-
 maining deformity, and there are but few of his pupils
 who  have  not witnessed his success,  some instances of
 which will be cited in this memoir.
   20. It is, above all,  from the well combined use of
these two means,  the extension and compression of the
muscles, that  that success was derived.  The ac[- 
224
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 fre-
quently unable to succeed, till after having extended
the muscles for a longer or shorter time.
   Fractures of the rotula and of the  olecranon, prove
equally the utility of compression  in effecting the same
purpose;  for, when the muscles are not compressed by
a  bandage, they draw the  fragment  upwards with  a
double and even treble force.
   21. Accidents relating  to complications of the frac-
ture, such as splinters, wounds, &c. are to be classed
with compound fractures in  general, and cannot be
treated of in this place.


                    SECTION  V.

               OF  THE REDUCTION.

   22.  Two great indications enter  into the treatment
of fractures in general, and of that of the os femoris in
particular; namely, to bring the fragments into proper
contact, and to maintain them so.  Let us examine each
of these in all their details.
   Hippocrates, and every practitioner since his time,
have replaced the fragments by what they call extension,
counter-extension,  and coaptation.*  This three-fold
method, though sanctioned by  long usage, and rendered
almost venerable by age, is by no means necessary at all
times in  practice, as will  presently be observed.   Pre-
viously to having recourse to  it, it is necessary to place
the patient in, a suitable  position.  But  this position

  * A term of nearly the same import with " conformation."    Tbans. 
225
varies: most of the moderns adopt, after the example of
the ancients, a horizontal position: so that the thigh
may be extended on the body, and the leg on the thigh.
This is the common practice at present in France.
   23. Pott  imagined, on the contrary, that if the lower
extremity were kept in a half-bent position, the muscles,
being more relaxed, would offer less resistance to  the
efforts of the extension:  he, therefore,  proposed to
bend the leg on the thigh, and the thigh on the pelvis,
and to lay the patient on his side, a position, which,
when first employed in reduction, was to be continued
throughout the treatment, during which it would render
the causes of displacement less  active (10...15).  Bell
adopted this method, which indeed appears to be gene-
rally in use in England.
   24. But the difficulty of making extension and coun.
 ter-extension, with the limb thus situated, the necessity
 of making them on the fractured bone itself, and not on
 a part distant  from  the fracture, such as  the lower
 part of the  leg ;  the impossibility  of comparing the
 diseased  thigh  with the sound one, to judge of the
 regularity of the conformation; the uneasiness occasion-
 ed by this  position,  if long continued, though it  may
 at first appear the most natural; the troublesome and
 painful pressure of the body on the great trochanter of
 the affected side; the derangements to which the  frag-
 ments 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 mo-
 tions ; the evident impracticability of this method, when
  Both thighs are broken ; and, finally, experience, which,
  in France, has been by no means  favourable to the
  position recommended by Pott:  such were the consi-
  derations, which determined Desault to have  recourse
                          29 
226
to it no more, after having tried it  on two patients, in
 one of whom the limb was considerably shortened, not-
withstanding the most scrupulous attentions.
  25.  Besides, all that is gained by the relaxation of
some muscles,  is lost by the tension  of several others.
The knee cannot  be bent without the triceps  flexor
being brought into action;  an inconvenience the more
serious, as this muscle acts immediately on  both frag-
ments.   The rectus anterior,  though  relaxed by the
flexion of the thigh, will be thrown into a state of ten-
sion by the flexion of the leg.  The muscles  attached
posteriorly to the upper fragment, and even to the  su-
perior part of the lower  one,  will also in certain posi-
tions of the limb be rendered tense.
  26.  Hence it follows, that there can be no just com-
parison instituted as to the position proper for the limb,
between fractures of the upper and those of the lower
extremities ;  that, in the latter, the method pursued by
the English surgeons presents an aggregate or general
amount of inconveniences  so great as to overbalance
that of its advantages; and, that  the position directed
by  Hippocrates and the  other Greek physicians (22)
ought to be adopted.
  27. Having determined on the position, the operator
proceeds to  extension and counter-extension,  which
are to be made  first in the direction of the limb as de-
formed or altered by the fracture, but must be  changed
afterwards according to the  natural  direction of  the
thigh.   I need not here repeat the directions  for this
double operation: common to all fractures, they con-
tain nothing particular, in relation to that of the  thigh.
But, on what part should extension  be made ?  Petit,
Heister, Duverney, and all their predecessors, recom-
mend to apply the means or powers for making exten- 
227
sion above the knee;  a precept which is  still to  be
found in the surgical department of the Encyclopedia.
A strap surrounding the lower part of the thigh, aided
by another placed at the ancle,  serves, in this respect,
to draw the inferior  fragment downward.
  28. Dupouy was'the first to remark, that this practice
rendered it necessary to employ great force,  and that it
would be better to make extension only on the foot.
To this consideration Fabre added that of the inconve-
nience 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, con-
tributed not a little to bring it into general use.
  29. For the  purpose of making extension, he used
the foot as a lever of the first kind.  The two  hands of
an assistant, grasping it in such a  manner, as to make
the fingers cross on the back of it, while the thumbs, also
crossing each other,  corresponded to the sole, represent-
ed the power;  the  articulation represented  the centre
of motion, or fulcrum,  and the leg together  with  the
lower fragment, the resistance.   The requisite motion
was  then communicated to  the  foot, and in that way
was the  extension effected. This mode is more' advan-
tageous than that usually employed, where the hands
are applied  to the lower extremity of the leg; for  the
force of the extending power is generally in  the inverse
ratio of its distance from the resistance intended  to be
overcome.
   30.  What I  have said of extension  (28)  applies  al-
so to counter-extension. The strap, which was former-
ly placed for this purpose in the groin of the affected side, 
228
by compressing the adductores, and the rectus internus,
produced in them a contraction, which, by drawing
the lower fragment towards  the pelvis, opposed obsta-
cles to the reduction, which are  seldom experienced,
when, like Desault, the surgeon contents himself with
having the trunk held by assistants, either exclusively
at the hips,  or both at the hips and under the arm-pits.
The resistance being always easily overcome in this af-
fection, renders it unnecessary to have recourse to more
powerful means.
  31.  Hippocrates advises, in  fractures  of the os fe-
moris, to aid extension by coaptation,  performed with
the hand.  All practitioners, since  his time, have ad-
ded this third  manoeuvre or process to the two first,
namely, extension and counter-extension.   But,  what
effect  can the hands produce,  in  most cases, on the
bone through the thick covering of the soft parts ? Are
we able  to  communicate to it through  such  a  mass
whatever lateral movement  we please ?   Being  quite
lost in the intervening soft parts, will our efforts reach
the bone, in the direction which we give  them ? The
muscles bring the fragments into contact, much better
than we can, as soon as extension has removed their
overlapping.  Indeed, if well executed extension make
the lower fragment return along the same track which
it pursued in becoming displaced, it will then be inevit-
ably brought into contact with the  upper one  by the
contraction of the muscles.   Besides,  in  most oblique
fractures, is it not evident,  that the  lower fragment
must be made to slide from above downward, on the
 inclined plane presented by the upper one, and on which
it has slided from  below upward, in  becoming dis-
placed ?  Is it while extension  is making that  coapta-
tion ought to be performed ? Certainly not: because, 
229
if the extension be well directed, an attempt at coapta-
tion will derange it;  and if it be not well directed, its
course ought to be changed.   Is it after extension is
finished that recourse ought  to be had to coaptation ?
By no means: because if there be then any remains of
deformity, it  must be owing to extension having been
improperly directed.  The remedy, therefore, is, to re-
new the extension, and direct it properly.
   32.  Hence,  it follows, in  general, that coaptation is
here a feeble assistant towards reduction; that if it ren-
ders any service, it is only in cases of displacement la-
terally, or in  the direction of the cross-diameter of the
bone ; and that it is by giving the proper direction to
extension, by managing it according to the disposition
of the muscles, and by  knowing when to augment and
when to  slacken it, that the fragments are brought into
regular contact.
   33. If the inferior fragment has experienced a rotato-
ry 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 difficul-
ties, which are  rarelyr met with at the present day.   Of-
tentimes, if we give credit to authors, it was altogether
useless to endeavour, in the first instance, to reduce the
fracture,  and  restore the limb to its natural length, as
the contraction of the muscles rendered the  operation
absolutely  impracticable.  Hence,  applications of a
soothing and sedative nature were employed, previous-
ly to an attempt at reduction.  The following circum-
stances  have been assigned as the *cause of these diffi-
culties.   The upper strap, irritating and drawing up-
wards the adductores and the rectus internus, drew the
lower fragment in the same  direction, while the semi- 
230
 tendinosus,  semi-membranosus,  biceps,  &c.   being
 drawn downwards by the lower strap applied over them,
 drew the pelvis also downwards, and, consequently, the
 superior fragment connected with it.  From this double
 action arose a double  motion directly opposed to that
 which ought to be produced by extension.
   35. There are still cases, where the muscles, in con-
 sequence of  being irritated by projections or points of
 bone, by the efforts  of the assistants, and by a morbid
 state of the nerves, inerease their contraction to such a
 pitch that no practicable force can bring the fragments
 into apposition.  What means are then to be employ-
 ed ? All those, in general, that diminish irritability, vari-
 ed  according to circumstances,  such as diet,  venesec-
 tion,  &c.  In  such cases, Desault obtained the  most
 happy effects, by placing  the limb  in a state of con-
 tinued extension;  fatigued by the permanent tension
 in which they are thus kept, the muscles relax by de-
 grees ; their force diminishes ;  at length they yield, and
 the reduction is accomplished.


                    SECTION  VI.

      OF THE MEANS  OF  MAINTAINING  THE
                    REDUCTION.

  36. The mere reduction  of a fracture of the  os femo-
 ris, is but  one step  towards the cure.  In this,  more
 than in the fracture of any other bone,  causes 'which
 act incessantly (13) tend to subvert the momentary work
 of art; it is here, then, in particular, that means ought
to be devised for  maintaining  this work.  But, the
first of these means  is a suitable position of the  limb.
I have already mentioned the inconveniences that result, 
231
both as to the  reduction  and subsequent  treatment,
from that proposed by Pott (24....26).   The patient
must, then, be laid horizontally on a plane exactly even,
and not capable of being affected or rendered uneven by
the weight of the body.  Instead of feather beds gener-
ally used in other cases at the Hotel-Dieu, Desault, in
cases of fractures, substituted firm and hard mattresses,
which, not sinking in the  least, by the pressure of the
body, give no cause to  apprehend those  continual dis-
placements, to which a soft bed exposes the  patient.
These  mattresses supersede the advice of certain au-
thors who direct a plank to be placed under the patient.
   37.  The second  means, not less efficacious than the
first, consist in the  forms of apparatus,  in  which  the
limb is placed,  and which, being differently modified
according to the fancies of their different authors,  pre-
sent us  with an assemblage of various  splints, com-
presses,  &c.   To  appreciate, with accuracy and  cor-
rectness, 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 draw-
ing  the  inferior  fragment  upwards  (10;)  2dly,  the
weight of the body pushing the superior fragment down-
wards  (14;) whence every form of apparatus  intended
to keep the os femoris in place when fractured oblique-
ly, ought, 1st, to draw  the lower fragment  downward
and retain it there; 2dly,  to  draw and retain  upwards 
232
the superior fragment, and the trunk which bears on
its upper end.  This principle is applicable  generally,
and subject only to a few exceptions which I shall no-
tice when  treating of transverse fractures, where the
displacement is lateral, or in the  direction of the cross-
diameter of the bone, or where  no displacement at all
exists.   3dly.  The apparatus must also  be so  con-
structed as to prevent the rotatory motions of the  low-
er fragment (18) and secure the immobility of the limb,
lest by means of some motion being communicated to
it, the fragments might be deranged.

                  SECTION 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  per-
manent extension, such as common bandages, splints,
compresses, bolsters,  &c. we will perceive  that  they
are but  ill  calculated to fulfil them :  and first of band-
ages.   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  apo-
neurotic covering of the thigh ; to press against the frag-
ments of the muscles which  form for  them  a kind of
natural case intended to keep  diem 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  frac- 
233
tures.  But what is there in them to prevent the two in-
clined planes of an oblique fracture from sliding on each
other? What provision is therein  them to secure the
limb from the effects of motions and shocks which may be
accidentally impressed on it from without ? Will the pel-
vis be kept steady by them ?  or will muscular action be
sufficiently  checked and kept under by them? The force
of the muscles will  indeed  be slightly  diminished by
means of compression;  and to make this compression
is the principal use of these  bandages in oblique frac-
tures. But will mere compression  be sufficient to pre-
vent a displacement in the longitudinal direction  of the
bone, particularly if the rollers be slack, as certain prac-
titioners recommend, on the  ground  of the fallacious
theory of Duhamel, who conceived that a constriction too
tight, would injure the action of the periosteum, which,
according to him, is the sole  agent in the formation of
callus ?  So much, then, for bandages, whose only use
is to prevent, by compression, the swelling of the limb,
and to diminish, in some degree, the contraction  of the
 muscles, which  they press against the fractured bone.
   40. These remarks apply equally well to the use of
compresses;  which make but a very feeble resistance
against a powerful cause, and cannot be considered as
any obstacle whatever to displacement.  What can be
 said of those surgeons who, from servile attachment to
a particular form of apparatus, do  not consider a frac-
ture  as reduced, unless a certain quantity of compress
 secured by a  given quantity of roller, be applied on the
limb.  Servile imitators in an art which calls for genius
in its votaries, they are only capable of following, with-
out reflection or judgment, the steps of their predeces-
sors.
                         30 
234
   41. Bandages will do nearly  as much harm as good
 in fractures of the os femoris, if, as was practised by the
 ancients, they be formed by a single roller surrounding
 the limb:  in such a case, the limb being necessarily
 raised up at each time of their reapplication, will be ex-
 posed to continual displacements.  Hence the ingenious
 idea of applying to simple fractures  of the lower extre-
 mities the  eighteen-tailed bandage,  invented  for com-
 pound fractures, and by means of which the thigh may
 be  suffered to  remain  at rest.   But to this bandage
 belongs  also an  inconvenience.   The pieces  which
 compose it, being stitched together, cannot be  separa-
 ted, and if one of them be soiled they must all be chang-
 ed.   Hence  the superiority of the  bandage  of slips,
 known in former times, and engraved by  Scultel, but
 long since  forgotten, till Desault revived the use of it,
 and adopted it exclusively,  both in simple and in com-
 pound fractures.
  42. Splints of different kinds, which form the second
 division of the pieces of apparatus, used for fractures of
 the os femoris, have the  advantage of fixing the limb in
 a solid and firm  manner, and securing it from any dis-
 placement that might result from jolts, or muscular con-
 traction, arising  from the inattention  of patients : these
 prevent, more effectually than bandages, any displace-
 ment  laterally, and,  on  this  account, their use is suffi-
 cient, even without extension, in transverse fractures:
 they also prevent, particularly if they  be made of wood,
 the rotatory motion of the thigh  either outwards  or in-
 wards (18).  But if the division be  oblique, will they
 prevent the gliding of the fragments over one another,
and the consequent shortening of the limb ? They can
 evidently produce this effect in no other way, than by
 the  forcible pressure made by the pieces of apparatus. 
235
particularly by the straps or  bandages'that secure the
splints, and then, to make effectual resistance, it would
be necessary to apply them with such a degree of tight-
ness as would endanger the life of the limb. Will splints
prevent the trunk from sinking downwards, and pushing
the superior fragment before it ?  Will they prevent the
muscles from acting on the lower fragment ? Can they,
in a word, fulfil all the indications formerly pointed out
(28)? Certainly they cannot.  Splints, then, are calcu-
lated only to prevent displacement in the lateral or cross
direction of the bone, and to secure,  better than band-
ages, 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 move-
ments, 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 dis-
placement and deformity.
   43.  In former times  a kind  of splints was in use,
which were made by securing bundles of straw round
sticks proportioned in length  to the length of the limb to
which they were to be applied. But as these, from being
of a round or cylindrical form,  touched the limb with
but a narrow surface,  they did  not retain the fracture
with sufficient firmness.   They were,  therefore, very
properly exchanged for flat and  strong wooden splints,
(such as Desault used) which retain the fracture much
better, inconsequence  of presenting to the limb a broad
surface, and thereby rendering it in some measure im-
moveable.
   44. The bolsters for filling up interstices,  being less
intended to prevent displacement (in which respect they
are, notwithstanding useful) than to guard  the limb
from the  immediate  pressure of the splints, usually 
236
consist of several folds of old linen; this is fne form adopt-
ed at  the Hotel-Dieu; but to these Desault preferred
small pallets or bags filled with chaff, which, fashioned
according to the form and disposition of the limb, may,
at the pleasure  of the  surgeon, be  made thicker  or
thinner, to suit the  inequalities of the  surface, in  con-
sequence of the ease with which the chaff may be mov-
ed 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 ap-
paratus, formed by their  union, but not calculated  to
effect a permanent extension, may perhaps answer in
cases of transverse fractures,  which indeed but rarely
occur, but are always insufficient  when  the division is
oblique, because they cannot fulfil the double indication
of drawing the inferior fragment down,  and retaining the
superior one up  (38).

                  SECTION  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  beeome an  antagonist to  the  natural
muscles  of the part,  and  neutralize  their efforts,  by
acting in a contrary direction, and  which, by pushing
up the  pelvis  and  retaining  it there,  may  prevent 
237
it from being  pushed downward by the weight of the
trunk (14). But what other mean than that of permanent
extension, unites these advantages ? Whatever form of
apparatus may be employed to obtain it, it is permanent
extension alone that can prevent the displacement, be-
cause it alone is  founded on principles  calculated  to
meet and obviate the causes  by which  displacement is
produced.
   47.  The ancients, though less informed than we are
respecting  the nature of these causes, knew better how
to appreciate their effects.  All their forms of apparatus
made a permanent extension, a measure which has been
abandoned by most  of the  moderns, and regarded, even
at present,  in  France, by a great number of practitioners,
as always  dangerous, and seldom useful. Let us  set
in opposition to the vain fears which it inspires, a few
thoughts, and much experience.
   48.  It is from the  very object  which  is  proposed
to be  attained, that the first difficulties  arise.   What
must we think of  a  limb in a state  of preternatural
tension, where all the parts being overstretched must
experience an uneasiness  not to be  supported? I 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 object
 to restore the parts  to their ordinary  state, and to give
to the muscles their habitual degree of tension, by op-
 posing such contractions in  them as are  not  habitual 2
 under this point of view, it performs, in relation to the
 muscles, those very functions which are discharged by
 the bone itself when  sound  and unbroken, as is fully
experienced by all patients, when the  apparatus is ap-
 plied.  Its use not  only does not increase  pain, but is
 alone  calculated to diminish it, because, by  bringing 
238
the fragments into apposition, it prevents the soft parts
from being irritated by the points of the bones.
   49.  Is the swelling  of the limb  to  be dreaded  as
 some  pretend ?  But  whence can this swelling arise ?
From the over-stretching of the parts ? I have already
proved that they are not over-stretched.  From the press-
ure of the straps ? Perhaps this cause might produce a
swelling, if, as formerly, it were applied above the knee;
but, by placing it, as Desault did, near to the ancle, by
surrounding, with a thick compress, the lower part  of
the  leg, where the straps  pass, and by securing the
foot with a tight bandage  under the  straps, if their ac
tion be dreaded, this fear must be done away ;  and be-
sides, experience, which is the only true  test of the
dangers of a process, byr  no  means  justifies the appre-
hension.   The venae saphense and  the absorbents that
accompany them, are free from the compression, which
bears principally  on the tendo Achillis,  and the mal-
leoli.
   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 muti-
lated and ill managed by ignorance or a want  of discre-
tion ? To represent the thing properly, let us suppose the
worst: a circular bandage,  in consequence  of being
drawn too tight, produces mortification in the  subjacent
parts;  must circular bandages be on this account entire-
ly rejected ? An unskilful hand, in an operation for can-
cer, opens the axillary artery ; must we therefore cease
to search under the arm-pit for schirrous glands ? 
239
   51.  Permanent extension is, say some, insufficient
to overcome muscular action;  it is opposing to a pow-
er equal to 1000, a resistance equal to only 100.  But
this force of the muscles, which is oftentimes so great
at the time of reduction,  diminishes gradually,  by the
pressure of the bandages, by the immobility of the limb,
and, above all, by long continued extension;  for a con-
tinued effort equal to 10, will soon perform what could
not  be effected  by a temporary exertion  of a force
equal to 100.   Let us pass  over the more minute ob-
jections 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 per-
manent 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 ma-
chines.
   53.  In the first class are comprehended:
   1st. The  method employed in the first instance by
the Arabians, adopted afterwards by their successors
in medicine,  and proposed, at a still later period, by
Petit,  Heister, and Duverney, and  which consists in
fixing, at the head and foot of the bed, during the whole
treatment, straps intended for the purpose of extension.
   2dly. The mode of extension, adopted by many prac-
titioners, 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 
240
the sound one, made the latter serve as a splint to retain
the fractured limb on its proper line, and thus preserve
its natural length:
   4thly. Under  this class also must  we  arrange the
means employed by Desault,  and which we will pre-
sently describe.
   54. The second class of means invented for the pur-
pose of making permanent extension,  in  fractures of
the thigh, comprehends.
   1st.  The Glossocome, the bed of Hippocrates,* and
other machines, used by the ancients, to effect a reduc-
tion, 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 modified,  more
by the imagination than the judgment.   Engravings of
some of them are to be found in Scultet, Fabricius of
Hilden, Pare, &c.
   3dly. The machine of Bellocq, proposed to the Aca.
demy of Surgery, a description of which is contained in
their memoirs, and  which possesses an advantage not
found in the others,  namely, that  of taking its point of
extension at the lower part of the leg.
   4thly. The  machine of Nook,  surgeon at  Norwich,
improved by Aitkin, an engraving of which is given by
Bell.
   5thly. A new Glossocome, published in the works of
Manne,  and a great number of  other machines, the
ephemeral offspring of the genius of their  authors, the

  (Z* lit d'Hippocrate.) As many of the machines mentioned here have
probably never been seen in this country, and as  there is, perhaps, scarcely
one of them used, at present, in any country, I shall not consume the time of
the reader by troubling him  with descriptions of them.          Trans. 
241
utility of which experience has seldom confirmed, and
which were even dead-born in the opinion of practition-
ers.  I barely  mention these, because a circumstantial
description of them would lead me from my subject.
  55. We may discover at a single glance the compara-
tive merits of these two classes of apparatus.  Exten-
sion produced  by simple means, such as straps, splints,
&c. (50) may at all times, and under all circumstances,
be had  recourse to;  because the  means  necessary for
making it may always and every where be found.  Are
we desirous, on the  other hand, of having recourse to
machines (54) ? These are seldom at hand, and often-
times not to be obtained:  the expense attending the pur-
chase of them, prevents most surgeons from procuring
them.   They  no  doubt possess the advantage of mul-
tiplying  forces, and rendering them more powerful:
but, I have already said (51) that a gentle resistance, if
long continued, is sufficient to overcome at length the
contraction of the muscles, though at first extremely ac-
tive and energetic.
   56.  In the first point of view, the first class of means
is doubtless preferable to the second.   But they both
partake generally  of the inconvenience  of placing the
point of extension above the  knee.  I have already men-
tioned the effects  which this produces with respect to
muscular action, at the time of the reduction (28). To
the injurious  effects  there  stated may  be added the
swelling  of the  limb, arising from  the compression
made by the straps, the disadvantage of the mobility of
the leg, which is not fixed,  and the motions of which,
being communicated to the thigh, may separate the frag-
ments  after they  have been  brought into apposition.
Further, the  straps may readily slip down over the
                        31 
242
knee, and thus leave the fragments subject to the mis-
chievous influence of muscular contraction.
   57.  To these general disadvantages, add those pecu-
liar to each form of apparatus, which are too tedious to
be detailed at present, and you will perceive,  that the
little success hitherto obtained from continued exten-
sion, is owing,  not to the nature of the measure itself,
but to the manner  of employing it, and that,  in the
present case,  as  in cases of fractured clavicles, another
step towards  perfection remained to be made.
   58.  Desault, in the first instance, attempted only to
improve the ancient process, which consisted in  fixing
the straps for extension to the foot and head of the bed.
He remedied the inconvenience of fixing the straps at
the knee, by doing, throughout the whole treatment,
what Fabre  and Dupouy did only at  the  time of re-
duction (29); that is, he placed the seat of extension at
the foot.   The  hold for counter-extension was also
changed.  This he made by a bandage  for the body,
fastend 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 utmost
care and attention were here indispensable:  every day
it was  necessary to examine the rollers several times, as
they  readily became relaxed.   The  pelvis, not being
well secured, could  communicate motion to the frac-
ture :  it was difficult to raise the patients to the close-
stool.   Besides, the slightest disease  of the chest, ren-
dered the pressure of the body-bandage insupportable. 
243
It was this very inconvenience which, having, in a cer-
tain case, rendered the preceding  apparatus  inadmissi-
ble, suggested to Desault the following one.
   60. This consists,  to speak in general terms, in tak-
ing the points of extension, above, on the tuberosity of
the os ischium of the diseased side,  and below, on the
malleoli; in securing the straps or rollers, destined for
making extension, on the two  ends of a strong splint,
placed along the outside of the limb ;  and in converting,
so to speak, the pelvis, the thigh, the leg, and the foot
into one entire and solid piece.
   The  pieces which compose it are, 1st.  A common
junk-cloth*  (FFF plate II.) accommodated  to the size
of the limb and the splints:  2dly, a bandage for the bo-
dy (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
           t
   {* Drapfanon.)  This is  a piece of linen or muslin (Desault appears to
have used flannel, which is  not however so good) spread under the broken
limb, reaching in length from one end of it to the other, and wide enough to
go about twice round it.  It is to be folded at its edges several times round the
internal and the long external splints, in order to retain them the better, and
 make them bear with more steadiness and advantage on the limb. The junk-
 cloth and these two splints, when properly applied, form a kind of soft elastic
 case, in which the limb rests. This case is of service in securing the bolsters
 in their places.  The junk-cloth is the outside piece of the apparatus, except
 the bits of tape wliich go round and secure the whole.  In arranging the dif-
 ferent pieces,  therefore, on the bed or mattress, where the patient is to lie, the
 surgeon places the tapes first, the junk-cloth next, the bandage of strips next,
 and so on, in an order the reverse of that in which he afterwards apphes them
 on the limb.                                           Trans 
244
groin and the upper part of the knee: and the internal
one, which reaches from the upper and internal fold of
the thigh, to  the sole of the foot:  4thly, three bolsters,
an external, an internal, and an upper one (d d d d) con-
sisting of small bags of chaff: 5thly, a bandage of strips
(EE) accommodated as to number to the circumstan-
ces of the case,  separate from one  another, each three
inches broad, and long enough to go twice round the
limb, arranged from below upwards,  and overlapping
each other, about one third of their breadth:  6thly, one
long and two circular compresses, intended to  be ap-
plied 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 ar-
ranged on that  part of the bed  corresponding to the
fractured thigh,  in the order in which they are to be
successively  applied.   If  the patient  has been  already
laid in the place where  he  is to remain, the limb  must
 be raised with great caution, and, during the extension,
each piece gently  slipped  under it, or the whole must
be passed under  at once,   being first  rolled round the
 several splints, in such  a manner, that the apparatus re-
 quires 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 sit-
 uated on the external side of the fractured  thigh, while
 an aid, placed on the other side, gives him assistance.
    1st.  On die thigh, next to the skin, are first applied the
 long and circular compresses, accurately spread out so 
245
as to  have no  wrinkles in them,  and previously wet
with vegeto-mineral water.   Around it are then applied,
in succession and from below upwards, each strip of the
bandage (EE) moderately  tight.
   2dly. The lower end of the leg is now covered  with
a thick  compress, intended to  prevent the  impression
of the roller (L) which is fixed in such  a manner, that
its middle is first laid on  the  tendo Achillis, a  little
above the heel, while its two ends, crossing each other
on the upper part of the  foot, are  carried on each side
to its sole, where crossing again,  they are then laid
down till  the close of the  application of the apparatus
   3dly. Along the thigh are  placed laterally two 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 inequalities of the
limb.
   4thly.  Around the two lateral splints,  the surgeon
and his assistant roll, each on his respective side, the
two  edges of  the junk-cloth,  so that both splints, by
being accurately applied on the  bolsters,  may  make a
uniform compression on the whole part.
   5thly.  The  third bolster (d d d d) is then applied on
the  anterior part of the limb, and over  it the splint
 (CC).
   6. The bits of tape passed under the apparatus  to
 the number  of four for the thigh, and three for  the leg,
 are tied in succession  on the external  splint,  lest the
 knots,  should they  correspond to the thigh, might, by
 their contact, prove troublesome.   That one next to the
 fracture is tied first, and they are all  drawn as tight as
 the patient can bear them without uneasiness.
   7. The body-bandage is now  fixed on the pelvis, in
 such a manner, as to secure laterally the external splint, 
                         246

 and is itself retained by the sub-femoral bandage (H)
 that is, the bandage passing under the thigh.
   8. A thick compress placed beneath the tuberosity
 of the ischium, serves as a cushion or bolster to protect
 the  part from the  pressure of the roller (g g)  which,
 being passed first  under the  apparatus, and  drawn af-
 terwards  obliquely from  within  outwards, and  from
 above downwards,  takes its points of bearing or action,
 in one part, on the  tuberosity of the ischium, and in the
 other, on the upper end of the  external splint, and is
 tied in the fold or hollow of the groin.
   9. The two ends of the bandage (L) previously made
 to cross each other on the sole  of the foot, are pass-
 ed the one  through the mortise, and the other through
 the  hollow  or  notch  in  the lower  end of the same
 splint,  and then, being drawn forcibly are tied  in a
 firm knot, so as  to act as a substitute for the hands of
 the assistant, who now lets go the patient's foot.
   10. If the roller  (g g) become relaxed, it is tightened
 again, and the patient being laid in a suitable position,
 the  limb is protected  from  the  pressure  of the  bed
 clothes, by a kind of basket placed over it
   11. A roller (K k) laid first on the sole  of the  foot,
and  then brought  across  over  its  upper side,   and
fastened laterally to each  splint,  serves to  secure that
part from turning outward or inward,  and thus prevents
the rotation  of the limb.
  63.  If the mode of operation of this bandage be com-
pared with the general  indications formerly  established
(38) for all oblique fractures of the os femoris, it will be
easy to perceive that, conformably to  those indications,
it tends, 1st, to draw the inferior fragment downward ;
2dly, to retain the superior one up ; 3dly, and to  pre- 
247
vent the rotation of the lower fragment, and secure the
immobility of the limb.
   64. It is evident that the bandage or roller (g^) so
unites the pelvis  to  the external splint (AA) that the
latter cannot be pushed upwards,  without.drawing the
former in the same  direction, as  well as the superior
fragment which adheres to it.  But if, after this roller is
fixed, the lower one (L)  be tightened,  the  first effect
produced is, to  push the external splint forcibly 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
the necessary degree of tightness, extension  and coun-
ter-extension are made  permanent.   By this   means
 the muscles, being kept on a stretch,  lose  by degrees
 their power of contraction, which  is still further dimin-
 ished, by the immoveable state in which they are kept,
 and by the compression made on them by the bandage
 of strips.   So that, on the one hand, the inferior frag-
 ment will have no tendency to rise upwards, and even
 if it had, it will meet with a sufficient resistance to pre-
 vent it; while,  on the other hand, the superior frag-
 ment will not be pushed downwards by the pelvis.
    65.   To  this advantage is added that of a state of
 perfect immobility.  The pelvis, the leg, the thigh, and
 the foot being firmly fixed on the external  splint, con-
 stitute  one entire  whole,  all the parts of which must
 retain,  with respect to  each other, the same relative
 position.   Should even  a stroke  be accidentally given
 to this assemblage of parts now converted  into a solid
 whole, each portion of  it will move at the same time,
 there will be no partial motion,  and the relative posi-
  tion of the  parts will not be changed.  Hence  the ad-
  vantage of being able to raise the patient without ap- 
24$
prehension; a most desirable circumstance indeed, in
a position so painful and so long continued (26).  The
external splint, being extended beyond the sole of the
foot, prevents  the lower fragment from obeying a ten-
dency, which it sometimes has, to displace itself by a
rotation on its  axis. Should this tendency  be towards
me internal side, an occurrence, much more rare, the
lengthening of the internal splint will effectually pre-
vent it.
  66.  These  considerations induced Desault  to  re-
nounce his ancient mode of making permanent exten-
sion, and  employ this  exclusively, in the latter years
of his practice.  Like all other kinds of  apparatus,
formed principally of rollers, this is very subject to  be-
come relaxed; and requires,  therefore, great attention
on the part of the surgeon.   It ought to be examined
attentively  every day,  particularly  the two extending
bandages (L and gg). As soon as they become relax-
ed, they must be immediately tightened  again : with-
out this precaution, the effect of the apparatus will be
lost.  Be vigilant also, with  respect  to the  compress
placed between  the roller (g g) and the tuberosity  of
the ischium.   Should  this slip, the  roller being fre-
quently 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 appara-
tus is, the  facility with which the upper roller becomes
displaced, a facility that imposes a degree of care and
attention, of which few surgeons are capable, and which, 
249
when bestowed even  by Desault  himself, did not al-
ways prevent the shortening of the  limb.
  68. Further, the extension made on the fold of the
thigh,  partakes, a little, of  the inconvenience that ac-
companied the ancient mode of reduction, namely, that
of compressing and irritating  the  muscles of the up-
per and internal part of the thigh (30).  This inconve-
nience would be still  more sensible, if, for want of ex-
tending to a sufficient distance up the pelvis, the upper
splint should allow the roller to cross the muscles at  an
angle somewhat  acute, as it  would  then  enclose and
press on the greater part of them.
  69.  If  some unfavourable  cases, resulting without
doubt from these inconveniences, did occur in the prac-
tice of Desault, a multitude of successful ones  still at-
test the advantages of this method; and there is not a
pupil who attended any time at the Hotel-Dieu,  with-
out witnessing them.   I will  relate but one  case, col-
lected by Chorin,  to  furnish  a detail of the treatment
subsequent to reduction, referring the reader for fur-
ther information to the Journal of Surgery.
  Case II.  Theresa Little-John,  aged 45 years, fell,
drawn by the weight  of her own body, through a win-
dow in a balcony, from which she was  leaning.   She
was instandy taken up,  carried to her own house, and
from thence to the  Hotel-Dieu, which she entered on
the 28th of October, 1790.  From the signs mentioned
(9) a fracture was discovered  towards the lower part of
the thigh ; its oblique disposition required an  apparatus
to  make  permanent  extension.  This  was applied in
the usual  manner,  and, in an instant, the patient, who
had experienced,  since her fall,  severe pain,  became
calm, and was completely relieved.
                        32 
250
   In the night, pains returned;  agitation; some spas-
 modic motions;  an anodyne draught administered in
 the morning.  In the course of the day, these trou-
 blesome symptoms disappear; a slight swelling at the
 ancle.  Third day,  no pain; swelling gone ;  aliment
 increased.   Sixth day, patient  permitted to return to
 her usual  regimen ;  extending rollers relaxed; lower
 one tightened; eleventh day, apparatus renewed; frag-
 ments in perfect contact:  thirteenth day,  limb moved
 incautiously ; a slight shortening; apparatus reapplied;
 extending bandages  drawn tight : sixteenth day, a dis-
 position slightly bilious;  evacuants administered with
 success : twenty-fourth day, a third application of the
 bandage:  thirtieth day, progress  in  consolidation al-
 ready  very evident; the limb  straight :  fortieth day,
 extending rollers  laid aside :  fifty-second  day, consoli-
 dation complete without the least deformity.
   70.  The muscular force, in children, being weak, and
 the weight of the  body inconsiderable, have, in general,
 much less influence in producing a displacement in them
 than they do in adults.   When, therefore,  fractures  oc-
 cur  in subjects under six or seven years old, the resis-
 tance, 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 suffi-
 cient 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 re-
versed turns, to the pelvis, round which he threw a cast;
then, giving the  ball into  the hand of an assistant, he
 applied four splints,  one before, another  behind,  and 
251
one  on each side; directing these to be held at their
lower part near to the knee, he  resumed the roller, and
secured them firmly by a second series of circular and
reversed turns, descending to the lower extremity of the
thigh.   The limb was then placed in a proper position,
and,  in general, of whatever  kind the fracture was,
whether oblique  or transverse, this  simple bandage,
without the aid of permanent extension,  was sufficient
to retain it.
   72.  It  would be difficult to determine the period ne-
cessary for  the  consolidation of fractures of the os fe-
moris.  Numerous  circumstances  concur to influence
this  work of nature, wliich is, in general, extended be-
yond the term of forty days, vulgarly assigned to it by
the people at large.  Besides, a stiffness of the limb, the
inevitable effect of its long state  of rest, still adds to the
length  of the patient's confinement, by retarding the ne-
cessary motions, the return of which, as in  other simi-
lar cases, can be accelerated only by exercise.
   73.   Complicated fractures of the os femoris, being
included in the general class of solutions of continuity
of that description, cannot be at present particularly con-
sidered.  We will only remark, that here, in like man-
ner, as in fractures of the clavicle, permanent extension
constitutes the most effectual method of preventing the
pains,  oftentimes insupportable, occasioned by splinters
or points of bone irritating the soft parts,  from being
pressed against them by muscular action in its tendency
to shorten the limb. 
252
                   SECTION IX.

 OF PERMANENT EXTENSION IN  OLD FRACTURES.

   74.  I will close this article by a few remarks on the
advantages of  permanent  extension in old fractures.
Nature reunites fractures differently, according to the
relation of the divided surfaces  to each other.   Are
those surfaces in perfect contact ? If so, they are chiefly
instrumental  in the formation of callus,  which  then
probably acts  in a  manner  similar to the reunion of
wounds.  On the other hand, does an overlapping of
the fragments separate the divided surfaces from  each
other;  the reunion takes place then principally on the
sides, by a kind of enlargement of the bones, produced
no doubt by the periosteum.   Such is the mode of con-
solidation, which,  on opening dead bodies,  is found in
most oblique fractures of the os femoris, succeeded by
a shortening of the limb.
   75.  Hence  it  follows, that this  shortening, which
would readily yield to extension, at the time of the  frac-
ture, becomes obstinate in its resistance, in proportion to
the age of the  accident.   In  such a case,  indeed, the
substances destined to  reunite the  over-lapping frag-
ments, acquiring  daily more and  more solidity, oppose
to the reduction obstacles constantly increasing.  Hence,
most practitioners regard this reduction as beyond the
resources of art, after the expiration of the twelfth or
fifteenth day.   Nor is this opinion  entertained without
some foundation, for at a later period, almost all efforts
at reduction,  however powerful, liave proved unavailing.
But that which cannot be performed by a very power-
ful effort, acting  momentarily, is, notwithstanding, of- 
253
tentimes easily attainable by a much weaker one,  prp-
vided it be long continued.   The following cases are in
proof of this.
   Case III.  Ann Gallot, of Melun, aged  sixty-nine,
having  fractured her right thigh, by falling down the
steps of a cellar, remained twenty-two days without as-
sistance, and without  even knowing the nature of the
accident,  when, on consulting a surgeon, she was sent
to the hospital at  Versailles.   From the long standing
of  the disease, a reduction being dispaired of,  and no
one being willing even to undertake it, the patient was
sent to the Hotel-Dieu, on the 27th of February, 1791.
   A shortening of four inches distinguished the  dis-
eased thigh from the sound one.  The overlapping was
sensible to the touch : in the mean time, a slight mobility
at the place of fracture, inspired a  hope of being able,
if not to restore  to the limb its natural  form, at least
to diminish the contraction.   Several efforts  were made
at first, but witout success,  as Desault foresaw.   The
apparatus for permanent extension was applied : on the
 day following, the extending rollers being a little relaxed,
were again tightened.  Fourth day, a sensible increase
in the length  of the limb;  apparatus renewed.  Ninth
day, the left thigh but an inch longer than  the other:
 eleventh  day, equality in  length almost re-established.
 After this, the  apparatus was kept constantly  applied
and renewed from time to time.
   Fortieth  day,   consolidation already  perceptible:
 forty-sixth day, symptoms of a putrid fever have  made
 their appearance :  fiftieth day,  symptoms worse ; fifty-
 second,  something  better:  fifty-fifth,   worse again:
fifty-seventh,  dead.   On  opening the body,  an oblique
 fracture  was  found,  its  surfaces  very nearly in ap
 position, and  already united by a very solid callus. 
254
  jCase 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-
paratus, which did  not prevent a shortening, to the
extent of an  inch and a half,  from showing itself on
the following day: hence a new reduction, and a new
application of the apparatus:  but  soon  afterwards,
another  shortening;  the same  means to  remove it;
the same failure of means.  Weary  of such trials the
surgeon  abandoned  the limb  to its  fate,  contenting
himself  with  merely  keeping it in  the apparatus.
  On the twenty-ninth day, Desault being called in con-
sultation, and finding the thigh shorter by three inches
than that on the opposite side, proposed permanent ex-
tension, 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 com-
plete, and the patient walked perfectly well,  except that
there was a little  shortening of the limb, trifling though
indeed,  compared to what would have been the conse-
quence,  had the original treatment been continued.
  76. The lengthening of the limb, in these cases, was
evidently owing to the continued action of the apparatus,
which effected, in a length of time, what the momentary
efforts of the surgeon  could not accomplish.  This  it
did, by  destroying or gradually lengthening  the medium
of union, which already  connected the overlapping frag-
ments, by that means bringing their separated surfaces 
255
or ends into contact, and almost restoring to the bone
its primitive form.
  Art cannot always, with  certainty, command such
success,  and perhaps, even at a less advanced period,
a more rapid progress of reunion might leave but little
ground for hope.   But, could only an inch in length be
gained by permanent extension, would it not be proper
to have recourse  to it, particularly as no inconvenience
can  result from  the  trial? To  prevent deformity al-
together, is the first object of art; but when that cannot
be attained, to lessen it is the  second.


  FRACTURES  OF  THE UPPER END OF
               THE OS  FEMORIS.

   The history of fractures of the upper end of the os
femoris,  includes, 1st. Those of the great trochanter:
 2dly. Those of the neck.  These fractures, sometimes
 existing together, and at other times separately, are very
 different with regard to the  frequency  of their occur-
rence : the one taking place very rarely, has but slightly
engaged the attention of practitioners, who have multi-
plied their researches with regard to the  other,  particu-
larly in late years.


    FRACTURES OF THE GREAT  TRO-
                    CHANTER.

                   SECTION  X.

         OF THE VARIETIES AND  CAUSES.

   77. Fractures  of the great trochanter are the effect
either of falls on that protuberance, or of the  action of
t 
256
bodies striking against it.  Oblique or transverse, situ-
ated sometimes at its summit, and  sometimes at its
base, these fractures may be either simple or compli-
cated.   They are rendered complicated sometimes by
splinters and a  swelling,  as happens when a ball produ-
ces the  division, and at other times, by a fracture of the
neck of the bone, an example  of which we find in the
Journal  of Surgery,  in the case of a man seventy years
of age, who had been long subject to the itch.
  78. Whatever  the varieties may  be, the fracture will
be characterized,  1st. By a facility of moving  the great
trochanter in every direction, while the pelvis and the
thigh remain without motion i 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 frag-
ments being brought together in abduction,  and sepa-
rated 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  per-
ceived,  because,  being superficially situated, this pro-
tuberance can be  easily felt, and yields to the motions
impressed on it.

                   SECTION XL

 OF THE  REDUCTION,  AND  THE MEANS  OF RE-
                    TAINING  IT.

  79. The reduction is  affected, by pushing  the sepa-
rated fragment in the  direction opposite to that of its
displacement, by bringing it to its natural level,  and, in
certain cases, by  moving the thigh  a little outwards;  it
is retained  by means  of some compresses placed by 
257
its  sides,  and secured by a roller directed obliquely
from the sound hip towards that part of the thigh cor-
responding to the fracture, and representing a true spica
bandage.
  80. A fracture produced by a gun-shot wound, al-
ways renders large incisions necessary, for the purpose
of extracting foreign bodies, and relaxing the aponeu-
rosis of the fascia lata,  which suffers too  great a degree
of tension  in this place, and might, if not dilated, pro-
duce a very troublesome stricture.  A fracture com-
plicated by  splinters,  but without  an external  wound,
and produced by a body striking against the part, sel-
dom requires any  particular  apparatus,  because, ad-
hering as  yet to the periosteum, the separated portions
of the os femoris may unite again, either among them-
selves, or with the fragments.

  FRACTURES OF THE NECK OF THE OS
                    FEMORIS.

                  SECTION XII.

                  OF THE CAUSES.

   81.  The neck of the os femoris, being surrounded by
a large mass of soft parts, and  protected by the  great
trochanter, which forms its external boundary, is al-
most completely secured from the immediate action of
external bodies, and consequently from direct fractures.
Whenever it sustains a fracture, it is always by a true
counter-stroke,  resulting from a fall, sometimes on the
great trochanter, and at  other times on the  sole of the
foot or  the knee.  But  fractures produced  in the first
mode, are much more frequently  met with in practice,
than those produced in the second, doubtless  because, 
258
 in the latter, the motion is weakened by the extent of
 parts through which it is  distributed, previously to its
 arrival at the neck of the os femoris.  Out of thirty ob-
 servations made by Desault, on fractures  of this des-
 cription,  twenty-four of them were produced  by falls
 on the side.  All those recorded  by  Sabatier, in his
 interesting memoir,  appear to have  been produced by
 similar falls.

                  SECTION XIII.

                OF  THE  VARIETIES.

   82. Fractures of the neck of the os femoris may oc-
 cur,  1st,  in the middle part of it, where it is smallest,
 and where nature has not thrown together, as she does
 in the middle  of the long bones so often exposed to
 fractures, a great quantity of compact substance : 2dly,
 at its  upper  end,  where it  is united to the head of the
 bone  : 3dly, at its junction with the great  trochanter,
 where the solution of continuity may  be  outside of
 the joint, a circumstance  which  doubtless  happens
 much more frequently than  has   been hitherto sus-
 pected.
   83. The  division, rarely oblique, is  almost   always
 transverse :  sometimes, in the latter case, the neck re-
 mains enclosed or embedded, as it were, in the bodyr
 of the bone, being fractured in such a wayr,  as  to pre-
 sent a hollow or notch of greater or  less depth.   Seve-
 ral cases of tiiis kind occurred to Desault; one of them,
modelled  in wax,  is deposited in the collection of the
 School of Health, and the original preparation is in my
possession.   The  fracture, though  frequently  simple,
is sometimes complicated  with  that of the great tro-
chanter. 
259
  Case V. A man having received a kick  from a
horse, on the external and upper part of the left thigh,
fell  down, and, not being  able to move, was carried
home.   Desault being called to  him, discovered, 1st,
that the  great  trochanter,  separated  from  the bone,
yielded readily to every  impression  it received:  2dly,
that the limb was perceptibly shortened; that the least
effort was sufficient to restore to it its natural  length;
and, that the foot was turned outwards, all which  are
characteristic signs of a fracture of the neck

                    SECT. XIV.

                  OF THE' SIGNS.

  84. Whatever may be  the  mode  and place of the
fracture,  its diagnosis presents difficulties which expe-
rience and habit may doubtless overcome,  but which
too frequently  puzzle and embarrass the most enlight-
ened practitioner.  Let us endeavour to diminish them
somewhat, by tracing, in their order of succession,  the
symptoms which characterize the accident.
  85. At the time  of  the  fall, a sharp pain is felt;
sometimes a report is plainly heard ; a sudden inability
to move the limb occurs;  the patient cannot rise, a  cir-
cumstance, however, which does not always take place.
A case is recorded in the  fourth  volume of the Me-
moirs of the Academy  of Surgery, where  the patient
walked  home  after the fall,  and even rose up on the
following  day.   Some examples of a similar  nature fell
under the notice of Desault, one  of which  he has re-
corded.    The interlocking of  the two fragments  for-
merly mentioned  (83) may serve  to explain this  fact,
which is, however, in general,  very rare.
  86. A shortening almost always occurs in the broken 
260
limb, but this is more  or less perceptible, according
as the  extremity of the fragments  is  retained by  the
capsule, or as, the division being without the cavity,
no resistance is made  to  their displacement.  The
muscular action, drawing  the lower fragment upwards,
and the weight of the trunk, pushing the pelvis  and the
superior'  fragment downwards, furnish here,  as in frac-
tures 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  circum-
stance Goursault and Sabatier have observed, not to oc-
cur in certain  cases, till  sometime after  the accident.
A tumefaction appears in the anterior and upper part of
the thigh, almost always proportioned to its shortening,
of which it appears to be the effect.
   87.  The projection of the  great trochanter is  almost
entirely removed.  That  protuberance,  being directed
upward and backward, is  approximated to the  spine of
the ilium.  But if it be pushed in the opposite direction,
it readily yields, and then,  returning  to  its proper level,
allows the patient to move the thigh.
   88.  The knee is a little bent.   A severe pain always
accompanies the motions  of  abduction,  when they are
communicated to the limb.  If, while  the  hand is ap-
plied 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 
261
neck of the os femoris is the radius.  This sign, which
was first observed by Desault, is very perceptible, when
the fracture is at the root of the neck, less, when it is in
the middle, and very little,  when  it exists towards the
head of the bone ;  these are circumstances, the cause of
which it is unnecessary to unfold.   In rotatory motions,
the lower  fragment, rubbing against the upper one, pro-
duces a distinct crepitation, a phenomenon which does
not however always  occur.
   89.  The point of the foot is usually turned outwards;
a  position which Sabatier,  Bruninghausen,  and most
other practitioners  regard as a necessary effect of the
fracture, although Ambrose Pare and Petit have borne
witness that it does  not always exist.   Two cases, re-
ported on this subject by  celebrated surgeons,  have
been thought unfounded by Louis, who has attributed
them either to an error in  language, or a  mistake of the
transcriber.  But the practice of Desault has fully  con-
firmed their possibility.   The first patient whom he had
under his care, at the Hospital of Charity, after he was
appointed surgeon in chief,  laboured  under a fracture
which presented this phenomenon.   Many other exam-
ples  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 out-
wards is to be attributed to the muscles that perform ro-
tation.  But, were that the case, 1st, it is evident that it
would always exist: 2dly, all the muscles running  from
the pelvis towards the trochanter, except the quadratus,
are in a state of relaxation, in consequence of the ap-
proximation of the  os femoris to  their points of inser- 
262
 tion:  3dly, muscles in a state of contraction would not
 allow the point of the  foot to be drawn so easily in-
 wards.  Is it not more probable, that the weight of the
 part draws it in the direction in which it is usually found.
   ■91. From the  foregoing  considerations,  it follows,
 that none of the signs of a fracture of the neck, of the os
 femoris, is exclusively characteristic, that the whole of
 them, taken  separately, would be insufficient, and that
 it is their assemblage alone which can throw on the diag-
 nosis that light which is oftentimes wanting  to it, even
 in the view of able practitioners.  But after all,  in the
 present case, as in every other one, should any  doubt
 exist, it  is right to take the safe side, and apply the ap-
 paratus,  which is indeed useless but not dangerous if the
 disease does not exist, but indispensably necessary if it
 does.


                   SECTION XV.

                OF 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 particular  ones.  What acci
 dents accompany  the fracture in  the first  instance ?
 What phenomena  make  their appearance  during its
 reunion ? In  what manner does it affect the  patient, as
 to his power of walking, after reunion has taken place.
   93.  If we attend to the opinion of authors, on this
fracture,  we will find that they represent it in very dis-
 mal colours,  as if it were necessarily productive of the
most serious effects.   Inflammation of the parts adjacent
to the neck of the os femoris; numerous and repeated 
263
abscesses arising  from this inflammation,  propagating
themselves externally and  communicating with the in-
terior of the joint, gangrene itself, as Morgagni remarks
in a particular case, convulsions of the limb, an oedema
occurring in it, and a slow fever destroying the patient
by degrees; such is the dismal catalogue of misfortunes,
generally considered as necessarily attendant on the kind
of fracture under consideration.   Bruninghausen re-
monstrated against this fatal prognosis of authors, and
Sibeold, one of the most celebrated German practition-
ers, among a great number of cases that fell under his
care, had no such accidents to  encounter.  Desault ne-
 ver experienced them. Doubtless  they are prevented by
our more exact and more skilful  modes of treatment.
 It is  thus  that under a more judicious treatment, frac-
tures of the  olecranon and of  the rotula, are no longer
 marked with those terrible consequences formerly at-
 tributed 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 different in fractures of these  two parts; why the
 first, in being denied the power of healing or reunion
 should be, in this respect, distinguished from all other
 living  parts of animals,   which  are particularly cha-
 racterized by that power, when they have  sustained a
 solution of continuity.  Many practitioners, even at the
 present day, advocate this doctrine, which is built, one
 while, on the circumstance of the periosteum not being
 continued along the neck of  the os femoris;  another
 while, on a belief that  the head of this bone  cannot
 receive a sufficiency of nourishment for the work  of
 consolidation, in consequence of being attached to the
 rest of the .system, only  by  the  round ligament, and 
264
again, on an opinion, that the synovial fluid, by wetting
the divided surfaces, prevents their reunion.
   95. But is  the periosteum  the only  agent  in  the
formation of callus ? Modern  experience has refuted
this opinion, which, like many  others, will therefore in
a short  time exist only in the history of our  errors.
Were it even  true that the periosteum is  here indis-
pensably necessary,  is  not its  place  supplied by  the
fold of  the capsule,  which surrounds both  the head
and neck  of the os femoris ? Besides, why  cannot
callus be formed by that part which has had sufficient
power to accomplish ossification,  since it is  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  ligament a
sufficiency   of nutriment  to enable it to live in  that
cavity;  for, there is  no instance of its having suffered
mortification in consequence of a fracture.   Why, then,
should  it  not partake  of the  properties of  life,  and
particularly of the faculty of reunion  when  placed in
regular apposition with the body of the bone?
   97. What shall we say respecting  the idea  of  the
synovia wetting the divided surfaces, and by that means
preventing their reunion ?  The history of fractures com-
municating with joints, better  known at the present
day, answers this  objection,  which is indeed nothing
but the offspring of  mere hypothesis.   To  these con-
siderations, which are dictated by reason, and to which
many more might be  added,  let us  unite the proofs
derived from  experience, and  we  will find  numerous
examples of cures actually performed,  particularly in
latter times; the truth of this is attested by many cases 
265
collected by Desault, both at the Hospital of Charity
and the Hotel-Dieu.   Bruninghausen and Siebold, have
had equal success.   Many analogous facts have been
presented to the Academy of Surgery.   In the cabinet
of the School of Health, are deposited some preparations
obtained from  the  cabinet  of Desault,  calculated  to
remove all difficulties and doubts from  this subject.
   98.  We must acknowledge, however, that in per-
sons advanced in years,  the cure is always difficult,
often very tedious, and sometimes impracticable, how-
ever carefully the treatment  may be  conducted.  But
this is  only a necessary consequence  of the laws of os-
sification, 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 proper-
ties.  Yet Lesne laid before the academy a case  of
reunion obtained in a subject  at the advanced age  of
eighty-four.
   99.  The observations  of some  modern practitioners
seem to prove, that the reunion here is  not produced
by a  substance similar  to common callus, but by a
kind of ligamento-cartilaginous tissue, in like  manner
as in  the rotula, and the olecranon.  But why need
we inquire after the means employed by nature ? those
of art must be the same.  It will be always necessary
to favour the reunion, by bringing the fragments into
contact, and maintaining  them so.  Without this con-
tact, either a cure will never be obtained, or the sub-
stance destined to effect a reunion, becoming deformed
and too bulky, will impede motion.
   100. Lameness has been long considered as the in-
evitable consequence of fractures of the neck of the os
femoris.  Ludwick,  professor of  surgery at Leipsick,
has particularly advocated this  opinion, which is sup-
                        34 
266
ported  by Sabatier, and  Louis, who considered the
total destruction of the neck of the bone,  as  the cause
of the lameness.   But few such examples are to  be
found  on record.   Ruisk  has given an engraving of
one.  Lameness when it does take place, depends, as
it does in oblique  fractures of the  body of the  bone,
on the overlapping of the fragments,  to which no op-
position  has been made ;  so that the  insufficiency of
our means, and not the nature of the disease, gives
rise to this accident, which Desault seldom experienced
in his practice.
  101.  From what has been said, it  appears, that, in
all  respects,  authors have  given a  much more unfa-
vourable prognosis  in  fractures of the neck of the os
femoris than facts and the nature of  the affection will
justify, that the progress of these fractures is the same
with that of all others, and that, when treated with equal
skill,  their is  no reason why their termination should
not be equally favourable.


                 SECTION  XVI.

  OF THE REDUCTION AND THE MEANS OF MAIN-
                   TAINING IT.

   102. Reduction, in this case, is attended in gene-
ral  with but little difficulty.  The patient, lying on his
back,  is held under the arm-pits,  and by the upper
part of the pelvis, by assistants who  make counter-ex-
tension in this way,  without being  obliged to pass, as
recommended by the Academy of Surgery, a strap un-
der the affected thigh (30).  Another assistant makes
extension,  according to the method formerly described 
267
(29) drawing the  point of the fragment very gradually
in the direction opposite to that which it has  taken  in
becoming displaced, and making the thigh at the same
time rotate a little on its own axis.  This  gentle rota-
tion renders success more certain.
  103.  If things  be properly arranged,  a slight effort
is sufficient to bring the separated fragments into contact
and to restore  to the limb its natural form; for, as I
have  already observed (86) a facility of  reduction is
even one of the characters of this  fracture.   But it is
very difficult for art  to maintain permanendy what she
easily effects at die time of reduction, and on this ac-
count,  our curative  processes are oftentimes  insuf-
ficient.
   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
plane, while the limb is  secured by simple splints, and
the foot by a kind  of shoe.  But in  a short time the
 muscular  action, to  which no resistance whatever  is
 made, draws  the lower fragment upwards,  while the
 weight of the body pushes the pelvis downwards, and
 along with it the superior fragment.  Hence a new re-
 duction, the effect of which  is again immediately de-
 stroyed as at first.  Thus  are new displacements suc-
 ceeded by new  replacements, throughout  the whole
 course of the treatment.
    105. This  method,  almost universally adopted  in
 latter times, and approved of by Louis, was in vogue
 at the Hospital of Charity,  when  Desault entered  it. 
268
Ought we  then  to be  surprised,  that  the  fracture
was considered as incurable ? Here indeed the plainest
and most important indication is evidently disregarded.
Nothing to retain the fragments in apposition,  nothing
to prevent them from being constantly moved.  Does
not the method of Foubert very closely resemble those
experiments, in which, the bone of an animal is broken
intentionally, and then  to prevent a reunion and form
an artificial  joint, the  fragments are kept in  constant
motion ?
   106. Will any better success attend the method of
securing the leg, as Dalechamp recommends, to the
foot of the bed ? In such a case the trunk and the pelvis
glide  down  along the inclined plane made by the pres-
sure of the nates. (14) and hence a constant cause of the
shortening of the limb.
   107. The second class of curative means,  includes
different  forms of apparatus simply retentive.  Pare,
Petit, and Heister,  recommend, as most useful, the
Spica of the groin.* But what effect can this produce?
What force applied in that part can  keep the lower
fragment  down,  and the  pelvis up, secure  the immo-
bility of the limb, and prevent  its rotation  outwards ?
If the bandage be tight, it  will compress the  muscles
unequally, make them contract, and thus become the
cause of a contraction or shortening of the limb.  In
some respects, there is more advantage to be derived
from the tin case lined with cloth on its inside, which
Fabricius of Hilden applied to the external part of the
thigh; a method which has been  renewed since his
time, by  certain celebrated practitioners of Germany;
from the pasteboard  case proposed by Duverney as a
f Le Spica de I'aine
Thans. 
269
substitute for that of tin; from  the retentive plaster*
of Buffle employed likewise by Arnaud; and from the
splints adopted by most practitioners.  But can these
means (so differently varied in form, yet still the same
in their action) while they prevent  displacement later-
ally or in  the cross-direction of the bone, prevent it
also in the  longitudinal direction, which latter ought to
be the principal object in view ?  Will they  make any
resistance to the muscular action ? See what has been
already said on splints, bandages, &c. (89....95).
   108. The  insufficiency of these forms of apparatus,
arises from their not being  constructed with a proper
view or reference to the general principle that ought to
be observed in the treatment of every fracture ; namely
that the means intended to prevent displacement, ought
to be founded on  the  causes that  produce it.   But,
these  causes here, are,  1st. The  action of the  muscles
which draw  the lower  fragment upwards: 2dly. The
weight of the body which pushes the pelvis downwards:
3dly. The weight  and direction of the foot and leg,
which tend to carry the toes outwards by a rotatory mo-
tion.  Hence, the threefold indication or end of every ap-
paratus, is, 1st. To keep the body of the bone down:
2dly. To retain the pelvis up : and 3dly, to secure the
foot nearly in a right line with the leg.
  109.  The first consideration leads us naturally to the
 second.   The means destined to fulfil  this threefold
 indication, must be constant in their action, since the
 causes which they  have to combat act without remis-
 sion.  Hence the necessity of an apparatus for perma-
 nent extension.  See what has been said on the nature
   *  (Vecusson.) The literal meaning of this word is an escutcheon, or a coat
 of arms.  But when used in surgical language, it signifies a retentive or
 strengthening plaster. Such I conceive its meaning to be in  the present
  instance.                                         Trans. 
270
of this expedient (46....51) on the different  modes oi
effecting it (52....57) and particularly on the mode pur-
sued by Desault (58....70).
   110.  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  two rollers,
running one  from the pelvis,  and the  other  from the
foot, are  firmly tied.  The first  of these rollers holds
the pelvis up, and the  second draws the foot  down:
hence the two first indications are fulfilled.  The  third
is also fulfilled  by the extension  of the  limb,  which
prevents its rotation outwards, by means  of  the  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 previously
applied round the  limb,  and oppose in some measure
its motions laterally, are here entirely useless.  Being
all indeed applied on the lower fragment, what purpose
could they answer towards fixing  it against the upper
one ?  They could do nothing but compress the mus-
cles, and by that means diminish  their  power of  con-
traction :   but extension alone produces this effect.
Desault rejected the bandage altogether, and contented
himself with the use of splints and bolsters, as appears
from the following case reported by Couteau.
   Case VI.  Maria Nof, as she was running on the ice,
in the severe winter of 1788,  slipped,  and falling on
the great trochanter,  fractured the neck  of the os femo-
ris.  She  was immediately carried to the Hotel-Dieu,
where the  signs formerly mentioned (60....66) disclo-
sed at once the nature of her disease.  The shortening
of the limb was less than in ordinary cases. 
271
  The apparatus was applied in the following manner.
The junk-cloth, the body-bandage, and the bits of tape,
were laid on the bed, in the order already mentioned
(60): the patient was then placed in such a manner that
the  affected thigh corresponded exactly to the  middle
of them.  The reduction being effected, the two splints
were applied, one on the external and the other on the
internal side of the limb ; on each side,  and along the
anterior part of the thigh, the bolsters were laid: three
bits of tape for the leg, four for the thigh, and the body-
bandage for the  pelvis,  served to secure the splints.
One end of a roller, which had been  previously fixed
on  the upper side of the foot, passing through the mor-
tise on the external splint,  and being tied to the other
end which passed through  the hollow or notch, pro-
duced extension, while counter-extension was made by
means of another roller  directed obliquely from the tu-
berosity of the ischium over the superior part of the
same splint, which it drew downwards.  This  was the
same apparatus formerly described (60....66) except as
to the bandage of strips, the compresses, and the ante-
rior 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 ap-
paratus was frequently tightened; and was renewed six
times at different intervals.
   A bilious disposition shewed itself on the seventeenth
day.   This was removed  by an emetic given in solu-
tion, and after this nothing remarkable occurred.   On
the fifty-second day the  state of the parts was exa-
mined.   The consolidation was almost accomplished; 
272
by the sixtieth day  it was complete, and the patientf
was  discharged a few  days afterwards, experiencing
only a slight degree of  lameness.

                 SECTION XVII.

       OF THE SUBSEQUENT TREATMENT.

  112. It is more essential here than in fractures of the
body of the os femoris, to keep up extension with the
utmost exactness, because, in the present case, a much
greater number of muscles being attached to the lower
fragment, very greatly augment the powers tending to
displace it.  Hence the necessity of examining the ap-
paratus 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 ap-
plication of the whole, if it be in any measure deranged.
  113.  The proper treatment here, as well as in most
other fractures, consists more in these attentions, taken
collectively, than in the use of internal means.   It is to
the want or neglect of such attentions, that we ought to
attribute the  little success obtained by many surgeons
from the bandage of Desault.
  Case  VII.  A man, having fractured his thigh by a
fall, called in a surgeon, who, reducing the fracture, and
retaining it by this bandage,  examined the state of the
parts every  day,  and finding no  derangement of the
splints,  neglected attending to the rollers destined for
making extension.   Seventh day, a shortening of two
inches ;  a new reduction, and a new application of the
bandage;.the same  want of attention as before; the
same shortening at the expiration of  a few days; the
means were then rejected, and declared,  in a publica- 
273
tion,  to be insufficient.   How  often do  processes and
modes of practice of great utility, by being transmitted
from  person to person, or from book to book, lose at
length, that credit they are entitled to, and that approba-
tion which they ought to command!
   114.  Serious accidents so seldom  accompany frac-
tures  of the neck of the os femoris, that there is no ne-
cessity of employing numerous means to remove them.
A diet somewhat strict for a few days, diluting drinks,
and then a return to the patient's usual mode of living,
unless something besides the fracture should forbid it,
constituted die simple treatment pursued  by Desault in
common cases.  Any varieties  resulting  from acciden-
tal circumstances, must fall under the general  treatment
of fractures.
   115. The period necessary for the healing of fractures
of the neck of the os femoris,  is represented by  most
authors as being longer than the term required in other
similar  affections.   We  read,  in the  Memoirs of the
Academy of Surgery, that oftentimes the cure  is not
complete in less than three or four months. The reason
of this will be evident, if we consider, on the  one hand,
that the reunion is always more tedious, in proportion as
the contact of the fragments is more  frequently interrupt-
ed : and, on the other, that, in the  means formerly em-
ployed, there was nothing opposed to the powers of
displacement.   Hence it follows, that, if skilfully treat-
ed, 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 al-
ways 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.
                       35 
                        274

   116.  We discover, in general, that the cure is com-
plete, from a disappearance of the signs of the fracture,
more particularly from the motions of the great trochan-
ter, in which  circumduction* succeeds  to rotation on
its own axis, when the limb is made to move on itself,
that  is,  to rotate outwards  or inwards.   The power of
standing and  walking is an infallible  evidence of this
reunion ; nor are these exertions practicable, till the ex-
piration of some time after it is completed; this circum-
stance is owing to a stiffness remaining in the  parts
around the joint,  occasioned by long extension and a
want of motion, and which exercise alone can effectual-
ly remove.  (See what has been already said on this
subject, in several parts of  this work.)
   117.  Numerous  cases may be adduced in favour of
the doctrine laid down in this memoir.  But a sufficient
number have  been  already  published in the  Journal of
Surgery.  I shall subjoin only two, drawn up by Ma-
noury 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 dif-
ficulty made her way home.  On the dayT following, a
shortening of  an inch was  perceived  in her thigh :  the
great trochanter was drawn backward  and upward:
walking was now impracticable, the foot remained turn-
ed inwards.   Notwithstanding this latter circumstance,
Desault, being called to  the patient, declared that a frac-
ture existed, whieh was evidenced in particular by a ro-
tatory motion of the great trochanter on its own axis.
The necessary apparatus being applied, was  carefully
examined every day by Manoury, to  whom the patient
 was intrusted.  No  shortening of the  limb occurred,
     * A motion or sweep describing the arch of a circle.   Trans. 
275
hor  did any unfavourable accident  supervene,  and,
by the thirty-ninth day, the fracture  was exactly and
firmly united; on the forty-third, the  splints were re-
moved ; and on the fiftieth, the patient could walk with-
out 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 sup-
ported a heavy load. He  was brought to the Hotel-
Dieu, where the same signs, as in the preceding case,
(except that here the foot was turned inwards) furnish-
ing  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, being
thicker  than the rest of  the bone, and protected from
the action of external bodies by a thinner covering of
soft parts, is yet better secured from fractures than the
other parts, for  the  following reasons:  1st, because
counter-strokes, so frequently the cause of fractures of
the body and neck of the bone, can effect this part but
rarely: 2dly, because the os femoris, being more movea-
ble at a distance from the centre of its motions, yields
more easily to whatever strokes and impressions it there
receives;   3dly,  because   motion,  when distributed
through a greater bulk of matter, has less power to des*
troy  its continuity. . 
276
                 SECTION XVIII.

      OF THE VARIETIES  AND THE CAUSES.

   119.  The fractures  which  occur in the  lower ex-
tremity of  the os femoris,  are of two  kinds very dif-
ferent form each other. Sometimes  situated above the
condyls, they only separate  these from the body of the
bone : at other times, affecting the condyls themselves,
they extend into the very joint.   My attention shall at
present  be  confined  exclusively to the latter kind, as
the other may, in almost every respect, be classed with
the fractures  which have  been already considered.
Most authors have  neglected to treat of fractures of
this kind, under a distinct  head, from a persuasion,
that, owing to their communication with the joint, they
ought to be ranked among complicated fractures, which
are known to require  a  mode of treatment very dif-
ferent from that  employed in such as are  simple. But
I shall presently show what regard ought to  be paid to
this ancient opinion.
   120.  The  division presents itself, in  general, under
two different  forms:  1st, running obliquely from above
downwards, and from within outwards or from without
inwards, it may  separate a greater  or  smaller  portion
of one of the condyls from the rest of the bone:  2dly,
these  two  bony  protuberances may be  divided from
each other by a longitudinal fracture, meeting  anodier
transverse or oblique fracture, which by either passing
through the whole thickness of the bone, separates both
condyls from it, or  extending only half way  through
it, separates but one of them.  The fracture is single
in the first case, but double in the second.  The latter 
277
occurs in  practice more frequently  than the former.
Both are usually produced directly, that is, by the im-
mediate action  of external  bodies. Yet the following
fact seems to evince that the accident may, possibly at
least, arise from a counter stroke.
  Case X. The corpse of a man of forty, was brought
into the amphitheatre  of Desault, soon after he became
a public teacher. One of the pupils, on preparing to
dissect the body, discovered a preternatural mobility in
one of the condyls.   The  knee was examined.  A
double fracture was found, accompanied by a separation
of the two condyls. On inquiry it was ascertained that
the corpse come  from the Hotel-Dieu.  It was further
discovered,  with certainty,  that  the injured subject, in
jumpmg  through a window, had alighted on his feet,
and  that  he  experienced instantly a severe  pain in
his knee,  and fell on the ground,  unable to  support
himself.
  Here, no doubt but the condyls, by being violently
pressed between the  weight of the  body and  the ar-
ticulating surfaces of the tibia,  had  been fractured by
a counter-stroke.

                    SECT. 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
flat  from  before  backwards, than  it is  in  its natural 
278
 state.   If the rotula be pressed in a backward direc-
 tion, the  condyls  are separated still further from  each
 other.  If,  on the other hand, pressure be  made on
 each side  of the lower part of the os femoris, the condyls
 are  brought  together,  and the  knee resumes its usual
 shape.  If we take hold of a condyl in each  hand,  it
 will be easy, by  moving them  alternately backward
 and forward,  to make them rub against each other, and
 produce a crepitation which characterizes the  fracture
 beyond a  doubt.
   122. If the upper fracture be oblique, a shortening of
 the limb more or less perceptible is always the  effect of
 it:  this appears to be principally owing to the weight of
 the body  which pushes the upper fragment down, and
to the action of the muscles which draws the  lower
 ones up (10.... 14.) In  this case, the superior fragment,
 being  forcibly  pushed against the  integuments,  has
 sometimes lacerated, and  even passed through them,
 giving rise to consequences of a serious  nature.  De-
 sault has  published a case of this kind.   A similar ef-
 fect has been produced, though more rarely, by the
 inferior fragment,  in which  case  mucu  mischief has
 arisen from the admission of air into the joint
   123.  Sometimes when the upper fracture   -.tends
•through the whole thickness of the os femoris, the ex-
 tremity of the bone is turned round, so that the exter-
 nal condyl lies behind, the internal before,  and the ro-
 tula on the outside, while the foot points in the same
 direction.   A case of this kind is recorded in the Jour-
 nal of Surgery.  The body of the  bone, being pressed
 into the chasm or interval between the two condyls, may
 prevent their reunion, by pushing them asunder, and
 thus give  rise to various accidents. 
279
   124.  Most of these phenomena will fail to occur, if
the upper  division, passing only half way through the
bone, break off but one of the condyls, or if,  passing
through even the  whole of the bone, it be perfectly
transverse; but cases of this description are seldom met
with.

                  SECTION XX.

                OF THE PROGNOSIS.

   125. I have little to add to the observations already
made on the prognosis in fractures of the condyls  of
the os humeri.  All that I have there said is applicable
to the os femoris.   As is the case with regard to  the
former fractures,  so also here, the  apprehensions of
authors have been greatly exaggerated by their vision-
ary  doctrine respecting injuries of  the joints : both
reason  and  experience  unite in  showing such appre-
hensions to be unfounded.
   I shall only observe,  that in the present  case, even
 more particularly than in fractures of the condyls of the
 os humeri,  most of the unfortunate events that take
 place, are owing to the insufficiency of the  means emr
 ployed for effecting a cure.  Indeed, as I have already
 observed (45) all those means can have no effect in  op-
 posing the continual tendency of the fragments to  be-
 come displaced, if the upper  fracture*  of the os fe-
 moris be oblique.   And in most cases,, this fracture is
 oblique :  hence  it follows, 1st, that the bony points of
 the fragments being constantly pushed, during their
 displacement, against  the ligaments that  surround the

   * That which forms the superior boundary of the longitudinal fracture by
 whi(jh the cwidyls are separated from m-.h other.              Trans. 
280
joint, will perpetuate in them the irritation first produ-
ced by the fracture, and thus give rise to swelling, in-
flammation, and all the other morbid affections of the
part, so much  dreaded by authors, and  attributed by
them to the mere  communication of the  fracture with
the joint:  2dly, that the best expedient to prevent such
affections, is an apparatus  that shall retain the divided
surfaces in perfect contact with each other by means of
permanent extension.
   126. It is obvious that  this extension will  be less
necessary, if the  upper division of  the  os femoris be
transverse, because, then, the condyls and the body of
the bone  will find  a  mutual point of support against
each other.

                   SECTION XXI.

   OF  THE  MEANS OF CONTACT BETWEEN  THE
                   FRAGMENTS.

   127. Since  the  same causes,  as  in the  preceding
cases, tend here to destroy this contact,  when  the 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 the su-
perior 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 neces-
sary to counteract the tendency which the condyls may
have to separate from each  other.
   128. Permanent extension, made in the manner al-
ready mentioned (60....63) fulfils  the two first indica-
tions;  while two  lateral splints,  and the bandage of
strips fulfils the third.  Desault therefore, applied to 
281
this particular case his apparatus for permanent exten-
sion, modified only in such a way, that, instead of ter-
minating at the knee, the bandage of strips was continu-
ed to a distance down the leg, in order that its action
might be the more efficacious.   For, it is well known,
that it  is at its middle part that the firmness and reten-
tive power of a bandage are greatest, because the casts
of the roller at the upper  and lower ends, serve to se-
cure those in the middle.  The upper splint being al-
together useless, was not employed.
   129. If the superior fracture be transverse, the con-
dyls, as I have already said, meet with resistance against
the body of the bone, while they, on the other hand, sup-
port it in such a manner, as to prevent it  from  de-
scending, though  pushed by  the weight of the body
along the inclined plane made by the pressure of the
nates.  Here, then, permanent extension is generally
useless, and all that is necessary is,  to retain the con-
dyls and prevent  their separation by means of lateral
pressure.  The same apparatus may still be employed,
provided the two rollers for extension be laid aside.
    130. If a wound  in the soft  parts accompany  the
 fracture, whether it be produced by the same cause, or
 by the subsequent passage of the fragments through the
 integuments, and whether it communicate with  the ar-
 ticulation or not, it is necessary as soon as suppuration
 has taken place, to renew the dressings every day or eve-
 ry other  day, taking care, in the mean time, to supply,
 by the hands of an assistant, the want of extension by
 means of the apparatus.   The following case, extracted
 from  the Journal, exhibits a specimen of the treatment
 that ought to be adopted  in similar cases.
«   Case XL  Claudius Legrange, aged thirty-one,  and
 of a sound constitution,  was wounded bv the kick of
                          36 
282
a horse, on the  internal condyl of the left os femoris.
The violence of the pain obliged him to throw himself
on a heap of straw, that lay at a little distance, and which
he reached by hopping  on his right foot.   The pains
were  augmented  by this,  for  at each  step, the thigh
being alternately bent or extended at the injured part,
was moved  sometimes backward and  sometimes for-
ward.  The patient was brought to the Hotel-Dieu, a
few hours after the accident.
  The signs already specified (121 and 122) announced
to Desault,  a longitudinal fracture  separating the two
condyls,  and terminated above by another fracture  of
the body of the  bone, which descended obliquely from
about five inches above the external condyl, to within
two inches of the internal one.
  The muscles of the  thigh,  by means of violent con-
traction,  had drawn that portion of the os femoris at-
tached to the external  condyl upwards,  and the supe-
rior  fragment downwards.   The  sharp point of the
latter had  passed through the skin,  and produced  a
wound of an inch and a half in extent, on the inside of
the thigh, and a little above the condyl.
  The patient being undressed, was placed on a bed
nearly horizontal, on which had been previously spread
the necessary pieces of apparatus,  disposed  in proper
order.  Desault then examined the wound, extracted
a splinter of the bone, covered the wound with lint, and
then proceeded to the application of the apparatus which
he usually employed in such cases (128).
 The extension was accompanied by no pain:  on the
other hand, it  gave immediate relief:  diluting drinks
were  prescribed.   Next day,  no pain; pulse a little
raised; no dryness, nor any alteration of the  skin; diet*
the same as on  the preceding day : the  apparatus wet 
257
with vegeto-mineral water.   Fourth day, a new appli-
cation  of the  apparatus, which had become  relaxed;
appearances of suppuration.
  From this time the dressing was renewed every other
day, till the sixteenth, when the wound was cicatrized.
After this the apparatus was not touched except when de-
ranged ; it was only wet from time to time with vegeto-
mineral water, and great pains were taken to keep up
the  extension.  The apparatus was  not laid aside till
the  sixty-fourth  day, although the callus appeared to
have acquired a state of solidity somewhat  sooner.
  The patient was soon in a situation to take exercise.
The stiffness  then disappeared rapidly, and, in about
three weeks,  he left the hospital, able to bend the leg
to a right angle with the thigh,  and under a full con-
fidence that he would in a short time regain all the mo-
tions of the limb.
                        SECTION XXII.

              OF  THE SUBSEQUENT TREATMENT.

         131. A soon as the consolidation is complete, the
       motions of the limb must commence.  These, at first
       gentle and confined, must be afterwards,  increased in
Is      extent, and more frequently repeated, till, at length,
       the limb should be exercised every day for two or three
       hours without  intermission.  The position  and direc-
       tion 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 
284
 patient can leave his bed, he should take exercise him-
 self.  These precautions are more necessary here than
 in any other  fracture,  because a  stiffness of the parts
 adjacent to the joint, is always  the  inevitable conse-
 quence of a long state of rest.  Certainly writers would ,
 not have considered anchylosis as the most favourable
 termination of such fractures,  had they  been acquaint-
 ed with  the effect of exercise and rest in that now un-
 der consideration.
   132.  Provided  the  mode of  treatment  here  laid
 down be faithfully pursued,  the affection is seldom ac-
 companied 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 pa-
 tients have died at the Hotel-Dieu, in consequence  of
 some affection not connected with  the fracture, the two
 condyls have  been  found perfectly united together and
 to the body of the bone.  An instance of this kind  is
 recorded  in the Journal of Surgery.
   133. Let us, in the mean time, not  speak too fa-
 vourably  of that,  respecting which the  ancients were
 accustomed to  speak  too unfavourably.   Even the
 practice of Desault would expose  our error.  Some-
 times the most assiduous attention, and the most care-
 ful application of the apparatus, have not been sufficient
 to prevent  abscesses  around the knee, and an anchy-
 losis of the joint.  Desault related a case where even a
 caries of the articulating surfaces occurred.  But some
extraneous circumstances appeared to have an influence
in these instances :  and it may be laid down as a gene-
ral  rule, that fractures of the  lower extremity of the os
femoris, require the same treatment with fractures of
its other  parts. 
285
      EXPLANATION  OF  THE SECOND PLATE.*

 This  figure represents  the  apparatus for permanent
   extension, employed by Desault in oblique fractures
   of the os femoris.
 AA. The external splint, with a notch and a mortise in
   it at the lower end to fix the inferior extending roller.
 BB.  A bandage passing  round the body, intended to
   secure this splint against the pelvis.
 CC.  The anterior splint, reaching only to the knee.
 d d d d. The anterior bolster extending along the  whole
   limb, and secured by pieces of strong tape.
 EE.  A portion of the bandage of strips, seen between
   the anterior and the external lateral bolsters.
 FF. The junk-cloth intended to  be folded round the
   two lateral splints.
 g g.  The  superior extending roller, passing round the
   end of the external splint, and fixed underneath  on
   the tuberosity of the ischium.
 H. The sub-femoral roller or strap, intended to pre-
   vent the bandage BB, which  passes  round the bo-
   dy, from slipping upwards.
 K k.  A roller usually passed round the foot, to prevent
  it from turning.
 L. The inferior extending roller, fixed in the mortise
  and the notch of the external splint.

  * For an account of an improvement of the splint, represented in this
plate, projected by Dr. Physick, and now used in the Pennsylvania Hospital,
see Article II, of the Appendix.
                                                Trans- 
286
                   THOUGHTS
  ON LUXATIONS  OF THE OS FEMORIS,  UPWARD
                  AND FORWARD.

   1. Few kinds of luxation of the os femoris occur in
practice more rarely than this.   Practitioners who have
seen it, and those who, on the authority of others, have
described it, without having seen it, have all given an
unfavourable prognosis respecting it, for the following
reasons : 1st, on account of the inevitable rupture of the
round ligament: 2dly, on account of the distension, and
even laceration of the capsule,  and of the compression
and overstretching of the  nerves and blood-vessels:
3dly, on account  of the great  difficulty of  reduction.
The following case will prove, that in all these respects,
the apprehensions  of authors  have been exaggerated,
that  the  obstacles to reduction arise less from the na-
ture  of the displacement,  than  from the nature of the
means employed to remedy it; and that, if properly di-
rected,  art would here  be as successful  as in  other
cases.
   Case. (Collected by C***). About the close of the
winter which preceded the death of Desault, a porter
was  brought to the Hotel-Dieu,  in consequence  of a
fall which he had received about two hours before, in the
following manner.   As he was carrying on his shoulders
a  heavy burden,  his foot slipped, while his leg and
thigh were directed backwards: he fell on his knee, his
thigh maintaining  still the same direction; so that the
conjoined  weight  of his own body and of the burden
which he carried,  aided   by  the velocity of the  fall,
forcing the head of the os femoris, which  pointed at
the time forward and upward, against the distended cap- 
287
sule, lacerated it and drove the articulating end through
the opening.   Continuing  still  to act,  it ruptured the
ligament, which  connects the extremity of the bone to
the articulating cavity, and forced the head in front of
the os pubis, where it could be easily felt.
   At the moment of the fall, an acute  pain was felt in
the part; and the power of moving the limb  was sud-
denly lost; the patient was carried home, where a sur-
geon who visited him, considered the accident as a frac-
ture  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 luxa-
tion upward and forward.  The limb was  nearly an inch
shorter* than natural; the point of the foot was turned

   * A case of luxation of the head of tD.eos femoris in  a forward direction,
but differing in some respects from the above, occurred lately in the Pennsylva-
nia Hospital under the care of Dr. Physick.- The doctor reduced this luxation
|nthe amphitheatre, in the presence of his class, by a process which was also
somewhat different from that adopted by Desault.-
   Inthe 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 die os femoris having, in the former case, passed farther
up towards the superior rim of the os pubis than it had in the latter.  In both
cases the protuberance formed by the head of the bone in the groin could be
readily felt.
   For the purpose of making counter-extension, Desault passed  a strap be-
tween the scrotum and the thigh of the sound side: Dr. Physick, for the same
purpose, passed the strap between the scrotum and the affected thigh.  He
conceived that by this mode he could act with more advantage on the pelyis,
and more effectually prevent the acetabulum of the affected side  from being
drawn in any measure downward by the extending forces. It would seem, that
by making counter-extension, in such a case, on the  sound side, the pelvis is
made to rotate, so to speak, on its own axis, in the direction in which the coun-
ter-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 ap-
pears therefore to have availed himself of the greatest mechanical advantage
of which the situation of the parts admitted-- 
288
outwards; the thigh being in a state of painful exten*
sion, could not be flexed on the body ; adduction and ab-
duction were alike  painful; the great trochanter, being
more approximated than  usual to the anterior and su-
perior spine of the os ilium, was also too far forward;
finally ^ the projecting head of the bone could be felt, as
I have already said, in the groin.
   The reduction  was effected in the following manner.
The patient being  laid on a firm table, spread with a
mattress, a strap was  fastened above  the ancle, for the
purpose of extension ; another,  intended for' counter-
extension was placed  between the scrotum and the thigh
of the sound side, and brought up  theJiack and front of

   Again: Desault placed the strap on which extension was made just above
the ancle:  Dr. Physick placed the strap intended for the same purpose above
the knee;  His object in this was, to have the leg free and unincumbered, in or-
der 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 aceta-
bulum.  The fulcrum of the lever into which the limb was thus converted,
was a strap passed round the  affected thigh a few inches below the groin, and
drawn laterally with great force in a direction opposite to that in which the
bone was displaced.
   In this case extension and  counter-extension were made by means of pow-
erful sets of pullies.  Notwithstanding this, these forces were not alone suffi-
cient to subdue the resistance of the muscles.  The reduction was not com-
pleted till muscular contraction had been weakened, and the patient reduced
almost to a state of syncope, by the loss of nearly two quarts of blood.  This
copious evacuation, co-operating with the fatigue which the muscles of the
limb necessarily sustained, in  consequence of the powerful extension to which
they were for some time subjected by the action of the pullies, overcame all
resistance and the head of the bone was finally replaced.  To exhaust the en-
ergy of the resisting  muscles by forcible and permanent extension,  and to
weaken the action of the system generally, by copious blood-letting,  appear
to be the two most effectual modes of ensuring success in the reduction of all
obstinate cases of luxation.
   Another point of difference between these two cases of luxation remains yet
to be mentioned.  In Desault's case the head of the os femoris was, as he tells
us, displaced in a direction " upward and forward."  In Dr. Physick's case,
the direction of the displacement was downward and forward. This was prov-
ed beyond all doubt, by the  circumstance of the affected limb being  longer
than the sound one.                                        Trans. 
289
the pelvis, along the body, till it passed over the "shoul-
der, where it was twisted together and secured.
  Extension was then begun, precisely in the direction
in which the thigh pointed; and,  during the execution
of it, a rotatory motion inwards was given to the limb.
At the expiration of a few minutes, the head of the bone
remaining almost immoveable,  notwithstanding the ef-
forts  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 di-
rection, while the surgeon endeavoured to give assis-
tance by pushing the head of the bone  forcibly down-
wards,  with his thumbs, and the palms of  his  hands.
Useless efforts;  the displaced bone remained stationary.
  Desault ordering extension to be again discontinued,
recommenced the motions of the os femoris, and even in-
creased their force, changing them in every direction, for
the purpose of lacerating the capsule.  After this, exten-
sion was again renewed, with better success than before.
Indeed, on the very first effort, the head resumed, of it-
self, its natural situation, without any further assistance
on the part of the surgeon.
   The sufferings of the patient ceased almost instanta-
neously ; towards evening a slight swelling appeared
 around the joint, over which an emollient cataplasm was
applied.  On the day following, all the unfavourable
 symptoms were gone, and in about a fortnight the patient
 was able to return to his usual exercises, which, howe-
 ver, he was directed to pursue, for some time, with mo-
 deration.
                          37 
290
  2. There are,  in this case, two circumstances,  on
which the practitioner should fix his attention, and which
may throw great light on the reduction of all luxations
of the os femoris, as they will be found applicable to
most accidents of the kind.   These are, 1st.  The nar-
rowness of the opening in the capsule.  2dly. The in-
utility of the motion or process of conformation, when
that opening has been enlarged.
  3. We formerly observed, when treating of luxations
of the humerus, that one of the  obstacles to reduction
was, the narrowness of the opening in the capsule; the
same circumstance occurs here.   That membrane, lace-
rated  at the time when  the head of the os femoris is
driven against it,  is dilated sufficiently to let the head
escape:  but,  the edges of  the  lacerated  membrane,
coming together again,  and being  thus drawn  tight
around the  neck of the  bone, retain it in that position,
and prevent the head from re-entering the acetabulum.
Thus, in a fracture, where one of the  extremities of the
bone is protruded through the integuments, the opening
in the skin, by closing  tightly round that extremity,
sometimes prevents its reduction.
  4. Ill such a case, what is the first and most obvious
indication ? It is  necessary to increase the extent of the
opening in the capsule, by moving the limb in every di-
rection.  Some persons  have deemed it impossible to
tear this membrane anew.  But, if we recollect, that the
neck of the os femoris, being placed between the edges
of the opening, must necessarily draw them asunder by
the motions impressed on it,  it is easy to conceive, that
the angles, where these edges unite, will be torn, if the
motions be carried to an inordinate degree : besides, ex-
perience proves here, as well as with regard to the hume-
rus, the truth of the doctrine contended for.   Are we to
apprehend,  as these same persons will have  it,  that 
291
serious accidents may be produced by such violent mo-
tions ? Experience again answers in the negative.   No-
thing, then, can be more certain, than that this observa-
tion,  respecting the opening in the capsule, is a great
stride towards perfection in the treatment of luxations in
general, and particularly of that now under consideration.
   5. When this obstacle to reduction has been removed,
it is then very readily effected, and that without the pro-
cess of conformation.   Indeed that process is almost al-
ways unnecessary.   For what purpose should it be em-
ployed ? Is it to increase the effect of extension,  and
thus  disengage  the head of the bone from the place
which it accidentally occupies? In this point of view,
it is nothing  but a very  feeble force, added to a very
powerful one, which receives from  it,  therefore, but
little assistance :  it is much better, if necessary, to aug-
ment the extending  forces themselves.   Is it to  push
the head of the bone into its cavity, after the extensions
have dislodged it? It is to the muscles, and not to the
efforts of the surgeon, that the performance of this office
belongs.   Indeed, the  surgeon must act altogether in
 the dark in this respect, as he cannot possibly ascertain
 the precise point where the  opening in the capsule ex-
 ists : he  may, therefore,  even push the head of the bone
 against a sound part of  the capsule,  and thus himself
 create an obstacle to the reduction, which he is attempt-
 ing to favour.
    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 clearly  the
  obstacles that  prevent reduction,  in removing them,
  and,  then,  committing  the rest  to extension, and  the
  powers of nature properly directed. 
MEMOIR XII.
    ON  SPONTANEOUS  LUXATIONS  OF  THE  OS
                     FEMORIS.

   1. Our modem treatises on diseases are little else
than fabrics artfully constructed of materials confusedly
scattered through the writings of the  ancients.  Many
of those materials  oftentimes  escape our  notice, and
we find them only, after practice has disclosed them to
us, in the chambers of the  sick.  Thus,  Hippocrates
had  an  accurate knowledge of spontaneous luxations
of the os femoris, and has even left an aphorism ex-
pressly on  that subject.   Yet this disease  appeared to
be unknown  to the physicians who came after him, till
John Louis Petit, having met with it  in his  practice,
drew the attention of practitioners to it, by a memoir
respecting it, published  among those of the Academy
of Sciences, in the year 1722.
  2. The  history of this affection,  which was 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 what is the nature of the 
293
primary affection which, rising immediately from  this
occasional cause, becomes the immediate  cause of the
luxation ? Petit, and with him the  practitioners of the
present day, have conceived, that the different parts of   »
the joint, being  irritated and  contused,  pour out, in
consequence of the injury  received, a  superabundant
quantity of  synovial fluid, which, not being absorbed
with the same rapidity, accumulates in the articular
cavity, distends  the  capsule,  and, by  degrees, forces
the  head of the  os femoris from  its natural cavity.
Hence astringent and tonic remedies, with alum, spirit
of wine, &c. are directed to be applied externally  to
the upper part of the diseased thigh.
   4. But this doctrine, and the practice which results
from it, seem by no means to accord with  our know-
ledge of anatomy.   The truth of this was deeply im-
pressed  on the mind of Desault,  who had frequent
opportunities  of witnessing the  disease.
   Case I. A  young  woman walking  hastily along
the  street, slipped and made a  false  step, in which
the  left thigh,  being violently, twisted,  supported for
a moment the whole weight of the  body.
   A severe pain experienced  at the moment, obliged
her  to stop at  first, but becoming easier afterwards, per-
mitted her to proceed on her way, and soon ceased en-
tirely.  A sensation  of weight  occurring in the part
about fifteen days afterwards,  was  at first troublesome
to the patient in walking.   This sensation was after-
wards succeeded by a  dull, deep-seated pain, accom-
panied by a swelling  in the parts around the joint.
   During six or seven months the limb was observed
to increase in length gradually, but very slowly.  At
the  expiration of  that  time, a contraction took place
 suddenly, and, in one  night, the  diseased thigh  be- 
294
came 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 pre-
sented to Desault, who was then consulting surgeon to
the institution.
   The cartilage of  the  acetabulum swollen to such a
degree as to fill up the whole extent of that cavity, was
yellowish and  inorganic, somewhat resembling bacon,
both in colour and consistence.   A soft,  spongy,
whitish substance projected in the middle of it, the re-
mains no doubt of the round ligament.  The head of
the os femoris, situated where it is usually found in
luxations outward and  upward, was surrounded by a
cartilage equally tumefied.
   5. Here  the cause of the displacement of the os fe-
moris was evident.   The cartilages becoming tumefied,
in consequence of the contusion and violence done to
them, had by degrees, filled up the acetabulum, forcing
out in the same gradual manner the head of the bone.
Hence arose  the original lengthening of the limb.
But as soon as the head  had escaped from the lacerated
capsule, the limb was drawn upwards and consequently
shortened, by the action of the muscles, and the weight
of the body pushing the pelvis downward.
   Case II. Some years afterwards, Desault had  oc-
casion 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 af-
terwards, 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 dis-
covering the same  phenomenon  as in the preceding 
2S5
case, made a preparation of the part, and sent it to De-
sault, whose pupil he had been.
  6. In this case the shortening was not so sudden as in
the preceding one.  It appeared at first to be coming
on, during five days, in an imperceptible manner, when,
fatigued with lying in bed, and having on that day drank
a little, the patient attempted to walk, supported only
by a cane.   By evening,  a  shortening of two inches
and a half had taken place, an effect evidently produced
by the weight  of the  body  on the diseased thigh.
Hence  the necessity of confining the patient to a state
of perfect rest, of preventing, in particular, standing and
walking, and all positions  in which the diseased thigh
would have to sustain the weight of the body.
   Case  III. Maria Genette  was  received  into the
Hotel-Dieu,  in consequence of a  fall  on the great tro-
chanter.  She had been  attacked by a pain in the joint
of the thigh  of  the same side.  Walking,  which was
performed with difficulty, augmented the pain,  and
standing, though more  tolerable, could  not  be long
continued.   The  thigh  was evidently longer than the
other.  To leave  the disease to nature, and confine the
patient to a state of rest,  constituted the practice of De-
sault.   What effect could the external use of astrin-
gents,  recommended by Petit,  produce in such a dis-
ease?  Some time after her admission, the  patient was
attacked  by dysentery,  in consequence of which she
was removed to the medical  ward, where she died.
    On opening the body, the parts  in the  neighbour-
 hood of the joint  were evidently tumefied, and the cap-
 sule was stretched from above  downwards.   The head
 of the  os femoris was situated on the external edge  of
 the acetabulum.   The  capsule,  though  greatly elon-
 gated was still  in a state of tension ;  and the articular 
296
cartilage was swollen to  such a degree, as nearly to fill
up the cavity.   The quantity of synovial fluid was less
than natural.
   7. This case, taken at a period of the disease not far
advanced, fully  confirms the inference  deducible from
the two preceding ones, respecting the cause of spon-
taneous  luxations.   Here,  indeed,  the  capsule  not
having given way, the swelling having only just com-
menced, and  the  synovia existing in but small quan-
tity, the  progress of nature was evident.   Here, also,
occurred  a sign not noticed by Petit; namely,  the
elongation of  the limb,  which always,  in  such  cases,
precedes its contraction.
   From  what we have said, it appears,  1st, that the ef-
ficient cause of spontaneous luxations of the os femoris,
is a swelling of the articular cartilages, which alters and
destroys  their organization: 2dly,  that the presence of
this swelling must necessarily render  fruitless  all at-
tempts that might be made to replace the head of the
bone in its cavity:  3dly, that the change in the organi-
zation of the cartilages renders astringents, discutients,
and other external means applied  for  the purpose of
removing the  tumefaction, entirely  useless :  4thly, that
here, as in many other cases,  art ought to confine itself
to the palliation  of effects, and not attempt the removal
of causes. 
MEMOIR XIII.
       ON  THE  FRACTURE  OF THE ROTULA.

                    SECTION I. /

  1. The rotula, a sort of bony production of the sesa-
moid kind, attached to the tendon common to  the ex-
tensors of the leg, represents a moveable pulley, intend-
ed to slide on that formed by the separation of the con-
dyls of the os femoris.  It protects  the joint which it
covers, and,  in  point  of structure, use, and situation,
gready resembles the  olecranon, from which it differs
only in this, that instead of being a continuation or pro-
cess of the tibia as the  olecranon is of the ulna, it is
only attached to that bone by a strong and thick lig-
ament which is inserted into its tuberosity.  Hence it
follows,  that between  the injuries of the one  and the
other there must be a great analogy : and indeed most
of the signs characteristic  of fractures of the  olecranon,
are characteristic also of  those of the rotula,  and the
treatment which, in such  cases,  is suitable for the for-
mer, differs but little from that required by the  latter.


                  SECTION  II.

         OF  THE VARIETIES AND  CAUSES.

   2. Fractures of the rotula may,  in  general, assume
any direction, transverse, longitudinal,  or oblique : but
the first kind occurs in practice much  more frequently
                          38 
298
than the others; and so great indeed is the disproportion,
that it has almost exclusively attracted the  attention of
authors, in the numerous forms of apparatus invented
to retain the fragments.
   3. A shattering of the bone, the effect of a violent
blow; a contusion; an echymosis; an effusion of blood
into the adjacent soft parts ; one or more wounds of the
soft parts, with or without an opening into the joint; a
swelling,  the degree of which varies greatly, according
to the state* of the fracture, and the  disposition of the
subject, but which is constantly present; a double divi-
sion of the bone,  one of which,  being  longitudinal,
forms an angle with the other, which is transverse ;  and
a concomitant fracture of the condyls of the os femoris,
or of the tibia: such are the varieties and complications,
of which  the fracture  under  consideration is suscep-
tible.
   4. But this fracture may be produced in two modes.
1st, by the action of external bodies : 2dly, by that of
the extensor muscles.  The first mode of division takes
place in falls on the knee, or when a body in motion
strikes against it, and,  in this case, there is no counter-
stroke, the rotula being too  small for such  an occur-
rence, and always sustaining the fracture where it  re-
ceives the blow.   In the second, the fall is only subse-
quent to the fracture, and, as Camper has well observed,
is most frequently the effect of it.  For instance,  the
line of gravity of the body is by some cause,  removed
behind it; the anterior muscles contract themselves to
bring it forward again; the extensors act on the rotula;
it is broken, and a fall  ensues.   Again,  the  leg is sud-
denly thrown into a state of violent extension ;  the  ex-
tensors act with great force; a fracture is  the  conse-
quence, and the  patient falls.   A soldier once fractured 
299
his rotula in kicking at his serjeant j thus the olecra-
non, in  like  manner, has heen broken by throwing a
stone.   A man in the HotehDieu, fractured the rotula
of each  knee, in the operating room, by means of con*
vulsive  motions, produced by the operation of litho-
tomy.
   5. The action of external bodies, can alone produce
a longitudinal fracture, as when a person falls  on a sharp
projecting piece of timber :  but this may also produce
a transverse fracture.  On the other  hand, muscular
action can never give rise to  any but  the  latter kind,
since the direction  of this fracture is at a right angle
with that of the extensors.   A fracture resulting from
the action of external bodies,  is oftentimes accompanied
by a wound, a contusion, or  a shattering of the part
(2); a fracture, arising from  muscular action, is always
simple, except as to a swelling around the joint.  The
latter cause may, instead of fracturing the rotula, rup-
ture 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.

                   SECTION III.

     OF  THE SIGNS  AND THE DISPLACEMENT.

   6. In longitudinal fractures the diagnosis is always
 accompanied with more or less difficulty,  because the
 extensor muscles,  drawing by their  contractions  the
 two  fragments equally upwards,  and the inferior liga-
 ment holding them equally down, tend to keep them in
 apposition, and to prevent them from separating. Some- 
300
 times also the ligamentous  production which covers
 the rotula, remains entire and serves to keep the frag-
 ments together.  It will be necessary, therefore, should
 the existence of such a fracture be suspected, to move
 the two sides of the rotula  in opposite directions, by
 pressing them to the right and to the left, in order to
 arrive at  certainty  on the subject.  Should a  wound
 exist, as is oftentimes the case (5) the diagnosis is less
 difficult.
   7.  If the  division  be  transvere, the diagnosis be-
 comes then as plain  and easy, as it is difficult and ob-
 scure in cases where it is longitudinal.   In such a case,
 a considerable separation or  space exists between the
 two fragments, sensible to the touch, when the hand is
 placed on the knee.   In this  separation, the fragments
 are not displaced by the  same  means.  The superior
 fragment being attached to the extensors is drawn up-
 wards with great force by  these muscles,  the action of
 which the rotula no longer  resists.   The lower frag-
 ment, on the other hand, being attached only to  the in-
 ferior ligament, is not moved by any muscle, and can-
 not be displaced in any other  way than by the motions
 of the leg with which it is still connected.
  8.  Hence it follows, 1st, that, in a state of extension,
 the separation is the least possible,  because it is then
produced on  the part  of the superior fragment only;
2dly,  that in a state of  flexion  it is greatest, because
 then both fragments concur alike in producing it; 3dly,
that it may be increased or diminished by varying the
degrees of flexion.
  9.  This fracture is further characterized  by the fol-
 lowing circumstances, namely, a practicability of mov-
ing the  fragments transversely in  opposite  directions,
and  of  producing,  by that means,  some  degree of 
301
crepitation,  provided they be first brought close toge-
ther; by the pain which accompanies  these motions;
by the swelling common to every kind of fracture of the
rotula, and which, if very great,  may involve the other
signs in more or less  uncertainty; by  a difficulty  of
standing; and an almost entire loss of the power of walk-
ing, in consequence of the extensors being no longer
able to communicate motion to the leg, unless when
the fracture exists very low down, near to the inferior
ligament.
   10. The touch will  always discover in what  part of
die bone the fracture is situated, which, if it be oblique,
will partake more or less of the characters of the longi-
tudinal or the transverse,  accordingly as it  approaches
to the one or the Other.


                     SECT.  IV.

                OF THE PROGNOSIS.

   11. Many authors have pretended that fractures  of
the rotula cannot be  cured, and it even appears that the
Academy of Surgery adopted this opinion, on receiving
a memoir from  a Flemish physician, which contained
several  facts tending to establish that principle.  But
what  do these facts  prove ?  That in some particular
cases, reunion did not take place, but they do not show
that this was owing to  the nature of the  fracture.
   12. But,  what, in such cases, could prevent  a cure
from  taking place ?  The structure of the rotula differs,
say they, from that of the other bones.  Now, admitting
this difference of structure to be real,  it certainly ap-
proaches to the structure of tendons to which indeed it
bears a strong affinity.  But, who does not know, that, 
302
 when tendons are divided, they unite as readily as bones?
 Besides, is not the power of reunion common to every
 part endowed with life ? I have already shown, when
 treating of other fractures that communicate with joints,
 what credit is due to those hypotheses so often revived
 but never confirmed, nay even clearly proved to be un-
 founded, such as, an effusion of callus into the joint, a
 failure of reunion from a want of periosteum on the pos-
 terior part of the bone, the synovia diluting the matter
 of  callus, and thus preventing it from being duly pre-
 pared,  &c.
  13.  The  inflammation of the articulating  surfaces
 and of the ligaments around the joint,  ought to have
 more influence in constituting an unfavourable  progno-
 sis, than any circumstance that authors have mentioned.
 But experience proves, that, when judiciously treated,
 these fractures are  not accompanied by that accident,
 and even that the swelling, which for the most part at-
 tends them, always yields more or less speedily, when a
 bandage, uniformly applied, presses equally on all parts
 around the joint, and  thus  forms a kind of discutient,
 while at the same time it retains the fragments.
  14.  Pare, Fabricius of Hilden, and a number of other
writers, have pretended, that some degree of lameness
must always be the consequence of this fracture.  But,
from what causes must this lameness so certainly arise ?
Is it from a want of reunion in the part ?  I have already
shown (11 and 12) that this apprehension is wholly un-
founded.  Is it from an anchylosis ?  This accident can-
not take place, except  either in consequence of inflam-
mation occurring in the articulating surfaces (and I have
already shown how that  may be avoided (13) or of a
stiffness in the ligaments, and I shall hereafter  make it.
appear that that  may be  readily prevented by motion. 
303
Is it from the fragments being drawn asunder, and in
that  state united by an intermediate  substance of too
great an extent? I shall prove, that a  bandage properly
constructed, is always sufficient to keep these fragments
in contact.
   From these considerations it appears,  that writers
have, in general, without sufficient cause, given an un-
favourable prognosis, in relation to fractures of the rotu-
la, which have, indeed, a great affinity to other affections
of the same kind.


                   SECTION V.

OF 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 muscles;
and, in relation to the lower one, the flexion of the leg;
whence it follows, that the means of preserving contact
between these fragments are,  1st, all those  that are cal-
culated for the  prevention of muscular  action;  2dly,
such as may  keep the limb in a state  of permanent ex-
tension.   Hence two leading curative indications must
be fulfilled by the bandage constructed for fractures of
the rotula : the last of these indications presents in gene-
ral but little difficulty ; but, with regard to the other,
the case is different.  To fulfil the latter,  it  is necessary
first,  to weaken the contractile force of the muscles,
and by  that means diminish the effort which they make
to draw the  superior fragment upwards; and then, to
oppose  to them  a  proper mechanical resistance, which, 
304
by  acting in a direction the very reverse of that in
which they act, may countervail their efforts.
  16. But the force of contraction is diminished, 1st,
by throwing  the muscular fibres into a state of relaxa-
tion ; this end is best attained by bending the thigh on
the  pelvis:  2dly, by making  compression over the
whole limb, by means of  a  circular  bandage,  which,
by confining the muscles,  tends to restrain and weaken
their action.  Thus it is known that the advantage of
the bandage employed to unite transverse wounds, con-
sists chiefly in that compression which, by diminishing
muscular action, prevents the retraction of their edges.
Another advantage resulting from the bandage in this
case is, that it prevents the swelling of the limb.
  17.  As to the mechanical resistance, which must act
in a direction opposite to that of the contraction of the
muscles, and, by that means, prevent the displacement
of the superior fragment, it cannot in the present case,  ,
be of the same nature as in fractures of the thigh, the
clavicle, &c. where permanent extension is practised.
The superior fragment offers too  small a purchase for
any  extending forces to act on.   This resistance must
be made, then, by placing some body above this fragT
ment, and retaining it in that situation with a force suf-
ficient  to hinder the fragment from rising upwards:
such as a few turns of a  roller drawn tight, a bit of
leather, some hollow compresses,  &c.
   18. It is evident from the  foregoing  principles,
that every bandage  intended to  retain  a transverse
fracture of the rotula,  ought to be calculated Jo main-
tain the following state of things:  1st, the extension of
the leg on the thigh; 2dly, the flexion of the thigh on
trie pelvis; 3dly, a uniform compression over the whole
limb; and, 4thly, some mechanical resistance properly 
305
secured above the superior fragment:  the  three last
expedients relate to the displacement of that  fragment
alone;  while the first has a relation to that of the lower
one.  Let us examine  whether or not the  bandages,
hitherto employed by different authors, be  calculated
for these purposes.
   19.  M. Valentin, believing that position  alone was
sufficient to retain the fragments in contact,  neglected
the application of apparatus  entirely,  which he even
considered as hurtful, in  consequence of the swelling
it produced; but experience soon proved the  in-
sufficiency of this method.  The slightest  movement,
or the  least  effort on the part  of the  patient, made  the
extensor muscles contract, which, drawing the superior
fragment upwards, separated it from the lower  one ;
and, as the time  of reunion is in direct proportion to
the distance of the fragments  from each other, it must,
under  such treatment,  have been necessarily tedious,
and sometimes must have even failed altogether.
   20.  As to a swelling being produced by the 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
 resistance, this accident  is not  to be  apprehended, as
 is proved by the  practice of Desault, who  never  met
 with it;  on the  contrary,  a bandage  properly con-
 structed and applied, is calculated to prevent swelling

   Mere position, then, though  always of   service m
 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) namelv, that  which  relates only  to the
                          39
i 
306
lower fragment; while those that relate  to the upper
one, remain still to be fulfilled.
  21. Most  authors have employed, with a  view to
these, a kind of figure of 8 bandage, known in art by
the name  of Kiastre,*  and  approved  of by Petit,
Heister, &c.   This  is made of a roller formed into two
balls, which are brought across  each other alternately
under the  ham, passing  over  two  hollow  or forked
compresses,  that enclose the two   fragments of the
rotula.
  But the unequal  pressure  which this makes on the
unequally  projecting  parts of the  knee,  renders  its
application extremely painful particularly below, where
the pasteboard covering applied by Louis, immediately.
 on the skin,  afforded  but a  feeble  protection to the
 tendons of the flexors.  Besides, it did not prevent the
 swelling, which is indeed a necessary  consequence both
 of this unequal pressure, and of the openings left between
 the casts  of the bandage.   This  swelling is  taken
 notice of by all writers, and is, according to them, one
 of  the troublesome circumstances attending  the frac-
 ture.  The  third indication  is not all  fulfilled  (18).
   22. The extensor muscles, not being at all compres-
 sed, will act with their whole force on the upper  frag-
 ment, and, on the  slightest effort of the  patient, over-
 come the resistance of the bandage, the action of which,
 being oblique with respect  to the fragment, is incon-
 siderable,  unless it be drawn very tight, and thus a dis-
 placement will  again occur.   This obliquity of the
 turns  of the roller  obliges the surgeon,  either to draw
 it very tight, in which case  a  swelling is inevitable, or
 to make  it  but  moderately tight, and then the appa-
* 1 know not of any English term equivalent to this.  T. 
307
ratus  will  be insufficient to resist the action of the
muscles.
  23. Most of the objections to the ancient apparatus
for fractures of the rotula, apply also both to that pro-
posed by Ravaton  in his surgery, and to that which
Bell employs in his  practice.   Both of these,  while
they fail in making  sufficient resistance to muscular
action, as well as in fulfilling the third  condition  laid
down as necessary to every bandage (18) contribute to
the swelling, and can rarely produce a perfect contact
between the fragments.   Thus Bell has well observed,
that the  reunion is rarely perfect,  and that there is al-
ways a separation more or less perceptible.
  24. The complication, the intricacy, the expense,
and  other more weighty  inconveniences  of  the  ma-
chine described  by Garengeot in his treatise on instru-
ments, and employed, for the first time, by  Arnaud,
and also of that  which was proposed and used by So-
lingen,  have, long since, entirely banished them from
among the means of reduction.
  25. Some  practitioners  have  advised the  uniting
bandage used in cases of transverse wounds, which is
formed, as is well known, of two small rollers or strips
placed in the longitudinal direction of the limb, one  of
them having holes in it, to which the divisions of the
other are fastened.  Both of these are first secured by
circular turns ; being then drawn in opposite directions
so as to meet, they draw the parts on  which  they are
applied in the same directions.  But the action of this
bandage is confined  to  the integuments, and would
have of course  but a feeble influence on the fragments
beneath.   It is also attended with this further inconve-
nience,  that by wrinkling the integuments, and throw -
me them into folds, it might press them down between 
308
the fragments, and  thus prevent their  contact.  Be-
sides, it is liable to most of the objections urged against
the preceding one.
   26. This view of the means employed by different
practitioners, to counteract the causes of displacement
in this fracture, are sufficient to convince us,  that the
difficulties  hitherto experienced in the treatment of  it,
have arisen from the feebleness of the former, and the
strength  of the latter.   So great indeed have been these
difficulties,  that some  authors, conceiving a  reunion
impossible, have, in  conformity to  such an opinion,
though contrary to all  the  rules and  principles of the
profession, advised us  to abandon  the  patient to him-
self.  But I have already exposed the  fallacy  of that
opinion, respecting the want of a healing power in the
rotula (12) an opinion which,  if generally adopted,
would give rise to consequences of the most serious
nature.  In the present case, as in all other fractures,
the contact of the fragments ought to be the chief ob-
ject 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 de-
 clares that such a separation will enable the  patient,
 after his recovery,  to walk with more ease.   Flajani ad-
 vances the  same opinion in a dissertation on the sub-
 ject.
    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. 
309
  28. But, on the one hand, it  is difficult to conceive,
on what this opinion of these authors can be founded;
while, on the other, reason declares, in the plainest and
most forcible terms, that the more the state of a bone,
after it has been broken, differs from its natural state,
the less free will be the exercise of  its functions,  and,
that the perfection of the treatment of fractures consists,
in leaving behind it no vestige of the accident.
   29. This truth was frequently confirmed in the expe-
rience 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 obser-
ved, that, when  the  separation of the fragments was
 considerable, and the ligamento-cartilaginous substance
 uniting them was of some extent,  standing and walk-
 ing were  performed  with much difficulty; that the
 patient was exposed to frequent falls, from the want of a
 proper correspondence, in point of strength and motion,
 between the two limbs; and  that on the contrary, the
 less extensive the separation  and  the substance that
 filled it up were, the more free and easy were the mo-
 tions of the part, which still remained, however,  some-
 what defective and imperfect,  unless every vestige of
 the division was obliterated.
    Paul of  Egina long  since observed, that, when no
 means of reduction were employed, though the patient
 might  walk tolerably well on  a level surface, he  could
 not, without difficulty go up an ascent.
    30. From what has been said,  it follows, 1st, that in
 the treatment of this fracture, the perfect  contact of
 the fragments ought to be  the principal object of the
 practitioner ;  2dly, that the kinds of apparatus employ-
 ed by  different authors, are but ill calculated for the at-
 tainment of  this end, because they fulfil but  imper- 
310
 fectly the indications formerly laid down (18).  Let
 us see whether or not the apparatus of Desault be any
 better suited to this purpose.
   31. The bandage, which he employed in this case,
 analogous to that for fractures  of the olecranon,  is
 composed, 1st, of one splint, two  inches broad, and
 long enough to reach from the tuberosity of the ischi-
 um, to a little above the  heel;  2dly, of two rollers,
 five or six yards  long, and  nearly three inches wide;
 3dly, of another single roller, with two holes about the
 middle of it, a little longer than the  injured limb of the
 patient, along the fore part of which  it must be ex-
 tended.
   32. Every thing being arranged for the application
 of the apparatus,
   1st. One  assistant  secures  the pelvis, in  the same
 manner as in fractures of the lower  extremities; while
 another keeps the  leg in a state of perfect extension on
 the thigh, and the thigh on the pelvis.
   2dly.  The surgeon, then, standing by  the side of
 the fractured limb,  extends along the anterior part of
 the leg and thigh the roller with holes in it, having pre-
 viously wet it with  vegeto-mineral  water, taking care
 to  make  the  two openings correspond  to the lateral
 parts of the rotula, that, by being thus better adapted to
 its shape, it may not be thrown into wrinkles.
   3dly.  He then  secures it on the top of the foot, by
 three circular casts of a roller placed one over the other,
 three or four inches above its  lower end which must
next be turned  up over the three first casts, and made
fast by two  other ones.   Then,  while  the  compress
 roller* is  secured above by an assistant, he passes up
   * The roller or strip with holes in it, which is extended along the fore part
ofthe limb, serving, in some measure, the purpose of a compress.   Trans 
311
along the leg by oblique and reverse turns,  according
to the inequalities of the limb.
   4thly.  Having arrived at the lower part of the knee,
he pushes the lower fragment upwards, and  makes be-
low it two or three  circular turns to secure it.  He
then gives the roller into the hands of an assistant, and
directing  him who holds the long compress roller, to
draw it forcibly upwards, pushes the integuments of the
knee in the same direction, lest, by becoming interposed
between the fragments, they might prove  an  obstacle to
their reunion.  Passing then the fingers of his left hand
through the holes in the compress-roller he places them
behind the superior fragment  and pushes  it forcibly
downwards.
    5thly.  When the reunion of the fragments is exact,
 without any  space intervening, he resumes the roller,
 and  passing it obliquely under the ham, and bringing
 it up again behind the superior fragment, withdraws
 his fingers which held this fragment down.  In place
 of his fingers, he then applies two  or three  tight circu-
 lar casts, covers the knee  with several oblique casts in
 form of the figure of 8, so  as to leave no opening be-
 tween them, and, then, continues the bandage up along
 the thigh, securing by it the compress-roller  extended
 along the fore part of the limb.
    6thly.  When he has arrived at the upper part of the
 limb,  the assistant   who  holds the compress-roller,
 drawing it forcibly  upwards, doubles  down its  end
 over the circular casts.  The surgeon next fixing this
 end by several  additional casts, descends  again along
 the thigh,  covers  the knee by  a few more oblique
 turns, and finishes with the  roller on the leg.
    33. This first  part of the bandage  evidently fulfils
  the third and fourth indications (18).   The compres- 
312
 sion of the roller on the muscles weakening their ac-
 tion and  impeding their motions prevents their ten-
 dency to draw the superior fragment upwards :  while
 the circular casts passed behind this fragment,  acting
 in opposition to the muscular contractions,  prevents it
 from  moving upwards  in obedience to them.   The
 long compress-roller, stretched on the fore  part of the
 limb, being first secured below, and  then drawn forci-
 bly 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  supe-
 rior fragment,  and prevents also those on the leg from
 slipping down and withdrawing their support from the
 inferior  fragment.  As there remains no vacant   space
 between  the  circular turns, their pressure is uniform
 throughout: no swelling can  consequently  supervene
 (20.)
  34. But the first and second indications remain still
 to be fulfilled (18 :) it is necessary to prevent the se-
 paration 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  pelyis, and
to maintain permanently, by the apparatus, that double
position, which the assistant maintains only  during the
 operation.
  35. To obtain  the first effect different means have
 been employed;  but none answers so well, to extend
 the limb and retain it immoveably in that  state, as a
 long and  strong splint, placed, as Desault did it, sub-
 sequently  to the application of the first part of the ban-
dage,  along the posterior part of the  limb.   An  assis-
tant 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. 
313
  36. To obtain the extension of the thigh, it is ne-
cessary to place on the top of each other, two or three
bolsters or little bags filled with chaff, so disposed as
to form  an  inclined  plane, considerably elevated to-
wards the heel above the level of the bed,  but which,
gradually descending to the same level towards the
tuberosity of the ischium, forms a  supporting basis on
which the whole limb may rest in a uniform manner.
By  this twofold extension  of the leg and of the thigh,
the  lower fragment is kept up immoveably, and the
muscles are  kept in a state of relaxation.
  Hence it follows, that this bandage fulfils extremely
well the conditions laid down (18) and that it ought to
be preferred to all the others (19....25) which answered
the indications only in part.
  37. Whatever may be  the advantages of this ban-
dage over the others, it must still be acknowledged to
have its  inconveniences.   The rollers become relaxed
in a short time ; their compression is less  active; the
muscles, being less confined, contract more readily;
hence the necessity of frequently repeating the applica-
tion of the  apparatus, a circumstance which is  very
troublesome, on account of the roller which composes it,
and covers  the whole limb.  The resistance of it even
when it is recentiy applied, is not always equal to the
power of the muscles, whence the most assiduous atten-
tion is necessary, to obtain such a consolidation as to
leave no trace of  the fracture behind.   Few persons
eyer possessed, like Desault, the art of overlooking no-
thing that might in any way  contribute to the success of
his  treatment:  from this, no less than from the excel-
lence Of his processes, arose the number of his cures.
Let us confirm, by a few examples selected from among
                        40 
314
a great many, the doctrine here laid down.  The fol-
lowing 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, were a
surgeon, on discovering the nature of his disease, advi-
sed him to be taken to the Hotel-Dieu.
   He was conveyed thither on the day following, and,
in the interval,  a  considerable swelling  had occurred a-
round the joint.  The usual bandage was employed ;
the  pains  ceased immediately after its application; a
copious blood-letting  was directed, and a low diet was
prescribed.
   The whole apparatus was  wet with vegeto-mineral
 water, two or  three  times a  day.   On the  next day
 some light food was allowed,  and the quantity increas-
 ed 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 plane formed
 by  the bolsters was carefully  examined, and put in or-
 der again as often as it became deranged.
   Fifteenth day, a new application of the apparatus:
 twentieth day, an evacuation in consequence of a bilious
 disposition.  Nothing  particular occurred  from this
 time till the completion of the cure, which took place
 on the  sixty-seventh day after the accident :  no de-
 pression existed at the place  of the fracture: the mo-
 tions were perfectly  free;  these  were aided,  by daily
 exercising the knee joint for some time.
    Case  II. Vincent Grenier, aged thirty-eight, mak-
  ing a false step, fell  on the rotula, and fractured it, on
  the 6th of June, 1791 :  lie was brought to the Hotel- 
315
Dieu, where Desault  demonstrated to  his pupils, by
the usual signs the existence of the disease : a conside-
rable swelling had already taken place.   The bandage
formerly described was applied:  the same precaution
as in the preceding case;  apparatus examined  every
day ;  renewed  as often as relaxed; extension  main-
tained with great  exactness.   On the  forty fifth day,
the consolidation was nearly effected; on the fifty-
second it was  complete, the joint was exercised for
some time, and  on the seventy-seventh day the cure
being in all respects  complete,  the patient was dis-
charged. 
MEMOIR  XIV
  ON  THE FORMATION OF  FOREIGN  BODIES IN
            THE  JOINT OF  THE  KNEE.

  1. The history of foreign bodies divides itself na-
turally into two great sections; the one includes those
that are introduced from without; the other such as are
formed within our own  systems.   This latter section
may be  again  divided into  two classes ;  to the first
class belong bodies altogether inorganic, such as  the
different kinds of  stones ; to the second,  those which
are truly  organic,  and become foreign only by being
situated  in  places  where they impede the  functions,
such  as  cartilaginous or bony productions, existing ac-
cidentally within the joints.
   On the subject of the latter class, art is much more
deficient than she  is with regard to the former. Let us
endeavour to assist her a little, by giving a  sketch of
the opinions and  practice  of Desault  with respect to
these productions.
   2. Before his time, the surgery of France appears to
have contained scarcely a record of this affection. Des-
cribed only in  some ancient  works, such  as the writ-
ings  of Pare, it had  been  forgotten by the moderns,
when numerous instances of it were suddenly met with
by English and German surgeons, and soon afterwards
by Desault, who illustrated  and confirmed the practice
of his predecessors in it, and even added something
of his own. 
317
  3. All the joints may become the seat of these con-
cretions ; 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 pf the knee.
To these alone shall the following observations be con-
fined, because these  alone have fallen under the notice
of Desault.

                   SECTION II.

               OF  THE  VARIETIES.

  4. Concretions of the joints do not always assume
the same aspect. They vary greatly as to number, size,
figure, structure, &c.  In general, these bodies exist
singly ; sometimes, however, two of them are found in
the same joint, and then they may be extracted  either
at the  same time,  or in succession, as  was once done
by  Desault.   Some English surgeons have also met
with two concretions,  and Morgagni  has found even
twenty-five, in the same joint.
   5. They vary also in size.  The largest ever met with
by  Desault,  was fourteen lines in its  longest, and ten
in its shortest diameter.   Six lines diameter in every
direction, was the measure of the smallest  one that oc-
curred in his practice.
   6. Their figure is sometimes lenticular and smooth
 on both sides,  sometimes unequal, rough  in one part,
even hi another, concave on one side,  convex on  the
opposite,   sometimes  marked  around  the  circum-
ference and sometimes not  with reddish points,  and
having occasionally  a  stem  of a cellular texture  and 
318
of some length, as may be seen in a paper by Thedem
They usually consist of a single mass, but are in some
cases divided into several lobules united by a kind of
ligaments, as in the fourth case related in the Journal of
Surgery.  Though most frequently detached and float-
ing in the interior of the joint, they have yet been found
adhering by  means  of small portions  Of  cellular sub-
stance, loose and capable of being stretched,  or tight,
hard, and even of a ligamentous nature.
  7. If,  from  the external  figure, we  pass to  the
structure of these  bodies, we will find them existing
in three different states.   Sometimes  purely 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, particularly Morgagni, who has
even  found in the same joint,  some bodies of a bony
and others of a cartilaginous nature.  Hence it appears,
that this  variety of structure is to be attributed  to the
longer or shorter standing of the disease, that  every
concretion must pass successively through these three
states, and that there is a great analogy  between the
formation of such bodies and natural  ossification.
  8. If we  examine a body  of the third  kind cut in
two  through the  middle,  we will find it red and vas-
cular in the centre, like an epiphysis,  even when it is
floating  in the  joint perfecdy loose and free from ad-
hesion.
  9. Bell, in his  treatise on surgery, speaks of a kind
of tumour,  at first  soft, membranous, and  adhering
to the internal surface of the capsule,  but which,  ac-
cording to him, may become afterwards hard and solid, 
219
and be detached so as to float  loose in the joint.   But
are not these tumours different in their nature  from
those destined to be converted into bone ? Do  they,
in fact, ever undergo the changes mentioned by  Bell ?
Desault having  never met with any  of  them, was
unable to offer an opinion on the subject.   In the mean
time, an observation  made by Monro, may serve  to
throw some light on the  question: he once saw, in one
of these productions, a cellular nucleus surrounded by
a covering of bone.
   10.  Though  usually simple  and free  from 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 drawing off
a collection of water.  Simson, on extracting a similar
 body, gave  vent to four ounces  of water.   But, as on
 the one  hand,  a dropsy  of a joint oftentimes  exists
 without these foreign bodies; so, on the other, these
 bodies are  almost always found disconnected from
 dropsy.  Nor is there any  affinity between the  ac-
 knowledged causes of an accumulation of synovia, and
 the  presence of these  bodies; so that  when the two
 diseases  do exist  together,  it is altogether probable,
  that they are independent of each other.


                    SECTION III.

                   OF THE CAUSES.

    11. The formation of articular concretions succeeds
  frequently to blows  or falls  received on  the joint, in
  which case, a swelling more or less considerable in  the 
320
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, disap-
pear during the continuance of the body in the part.
   12. Sometimes no external injury contributes to the
formation of the body, and then,  a  spontaneous swell-
ing precedes its detection,  as Desault observed in two
patients,  where nothing was known to have concurred
in the production of the disease.   Constant  rest  increa-
ses this swelling, while exercise and a temperate mode
of life diminish it.
   13. But what can be the immediate  cause of these
tumours ? Are  they, as some allege, an  aggregation or
crystallization of particles of matter conveyed into the
interior of the joint by the synovia, in the same man-
ner as the rudiments of a stone are  conveyed into the
bladder by the urine ? Their organic appearance  and
the vessels that pervade them, are unfavourable to such
an opinion.   Can tiiey be, agreeably to the conjecture
of Theden, articular glands bruised by means of  strokes
or falls ? Or are they, as  some  authors will have it,
portions of the cartilage of the joint, detached by the
same causes ? How then will their spontaneous forma-
tion be explained ?
   But why trouble ourselves about the cause, provided
we can remedy the effects ? Nature conceals from us
the means, and discloses to  us nothing but the results.
Theories are fluctuating; but experience  is still the
same:  let us search, then, by an  attention  to facts, for
that  which we cannot learn from first principles. 
321
                    SECT.  IV.

                  OF THE SIGNS.

  14. The phenomena which announce the presence of
foreign bodies in the joint of the knee,  are sometimes
clothed in a character of such- evidence, that they can-
not be mistaken; at other  times  the nature of the dis-
ease eludes the most accurate researches :  the cause of
this variety may be easily perceived.
  As the joint presents  different depressions and emi-
nences, and as the bodies,  being  usually loose and de-
tached, may travel through its whole extent, they pro-
duce different effects, according to the particular situa-
tions which they occupy.   If lodged in a depression,
they are  not compressed, and cannot, of course, give
rise  to any troublesome affection.  If they bear on an
eminence,  such  as the  condyls, or the posterior part of
the rotula,  they are forcibly compressed, and must de-
range,  in some  measure,  the functions of the joint.
Hence the precise nature of the  affection  cannot be at
all times derived from the state of the symptoms.
   15.  Sometimes the  patient can stand and walk with
perfect freedom  and ease, while,  at other times, a sud-
den pain seizing him, obliges him to sit down,  or even
causes him to fall, if there be nothing at  hand to sup-
port him.   This pain subsists for  a longer or shorter
time.  One motion produces it, and sometimes another,
made in an opposite  direction,  removes it.   But  in
common it is of some continuance,,  and then the patient
is obliged  to keep his bed.
   16. If the state of the joint be examined, it  will be
found more or less swollen, when the pain is very acute.
When the pain  ceases, the swelling in  part disappears.
                         41 
322
It is never sufficient to prevent the fingers, when drawn
along the external surface of the joint, from discover-
ing the presence of the foreign body, when it forms a
protuberance under the integuments.  It is then found
sometimes above the rotula, by the side of the tendon
of the extensor muscles, and that is the place where it
usually produces least pain;  at other times, it is low-
er down, in front of the condyls, and by the side of the
rotula.   It is occasionally found immediately behind
the tendon  of the extensor muscles; in this  case so
acute is the  pain, that the patient is generally unable to
stand.   But it is when it  is situated behind the rotula,
near to the projecting ridge which runs across its pos-
terior surface, that it gives rise to the most serious affec-
tions.
  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 awaken-
ed by severe pain, in consequence of the foreign body be-
ing moved by this change.  It happens, in certain cases,
that it disappears, and lies concealed for some time, in
the back part of the joint.   During this period the joint
performs all  its functions with freedom and ease.  De-
sault made this remark, in the case of a captain of dra-
goons, 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, experien-
cing no uneasiness, considered himself perfectly cured,
when the body suddenly reappeared, in consequence of
a hasty extension of the leg.
  18. If the body, when  projecting under the integu-
ments, be gently compressed,  it yields to the pressure,
changes its situation, and, according to the impression 
323
it has received, moves either to the internal or the exter-
nal side of the joint, or reciprocally from  one side to
the other, passing also behind the rotula, behind the in-
ferior 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 poste-
rior one, and then resume its primitive situation.  De-
sault met with an instance, in which the patient himself
was in the habit of turning the body round in this man-
ner.
   19.  Bell, in conformity to  the distinction of articular
concretions into cellular and solid, attributes to each di-
vision its  peculiar signs.   In the first case, the pains,
being rather obtuse than sharp, are constant; in the se-
cond,  they are extremely acute,  but disappear and re-
turn at intervals.  Supposing  the division to be a real
one, cases  of the last description certainly occur much
more frequently than those of the first.

                   SECTION V.

               OF THE TREATMAENT.

   20.  Fi*om what has  been said it follows, 1st, that
these cartilages floating through the joints, do mischief
mechanically (14) by coming into contact with the ar-
ticular surfaces:  2dly,  that  to obviate this mischief, it
is necessary either to prevent their contact, by fixing the
bodies in a spacious part of the joint, and thus doing
constantly  what nature  does  on certain occasions, or to
extract them through an opening made into the articu-
lar cavity.
   21.  Hence, art can have recourse to but two methods
Of cure, all hope of discussing these tumours by exter- 
324
nal applications being, as Bell observes, entirely extin-
guished.
   22.  The  first method  was proposed by Middleton
and Gooch, who having brought the foreign body into
a situation where it produced no pain, endeavoured to
confine it there a length of  time sufficient to  make it
form adhesions with the corresponding part of the cap-
sule.   As we are not informed of the result of the ex-
periments of these two physicians, we are left to our
own conjectures on the subject.
  23. Are these foreign bodies capable of forming ad-
hesions ? Supposing they are, will the internal  surface
of the capsule attach itself to them at the pleasure of
the surgeon? Even admitting the existence  of both
these conditions, by what means can the bodies be kept
stationary for a length of time sufficient for the forma-
tion of these adhesions ?  Will they not be displaced
by the slightest motion ? Besides, experience seems to
be unfavourable to the expedient.  I have already said
(17) that, in  a certain case,  the  foreign  body  disap-
peared  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 in-
crease 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 de-
grees, 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 die performance of 
325
this extraction, an incision must first be made through
the integuments and the capsule.
  26. This operation, simple and easy in itself, has
given rise to apprehensions as  to  its consequences,
which have long prevented practitioners from under-
taking it.
  It was in former times a maxim in surgery, that
wounds of the joints are, if not mortal, at least extreme-
ly  dangerous, in consequence  of their admitting air
into contact with the articulating surfaces.  But obser-
vation has demonstrated the fallacy of this doctrine, and
Desault in particular, has thrown great light on the sub-
ject, as I have frequently  had  occasion  to mention  in
the  course of this work;  so that, at the present day,
 it  is clearly  ascertained,  that,  if judiciously  treated,
these wounds are seldom productive of serious conse-
quences.
   27. Hence  it follows, that the operation we are con-
 sidering, when skilfully performed, never gives rise to
 any dangerous or disagreeable affections.  Experience
 has proved the truth of this assertion in the practice of
 Theden,  Simson, Gooch, Broomfield, Bell,  and De-
 sault, the latter of whom performed the operation five
 times with complete success.   The only case in which
 he was less, fortunate,  was that of a man, in whom the
 wound of the integuments closed up at first without
 any accident, but which was succeeded by two absces-
 ses, one  in the thigh, and the other in the leg, but with-
 out any  affection of the  interior of the joint.  This
 patient was subject to a wandering rheumatism, which
 oftentimes attacked the lower extremities, and was per-
 haps in the present case the chief cause of the unfavour-
 able occurrences. 
326
   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 Transac-
 tions of a society in Edinburgh.   Since that, the ope-
 ration has been frequently repeated, and more than ten
 instances  of it were already on record,  when Desault
 first performed it in France.   His method,  somewhat
 different from that of others, was as follows:
   1st. The patient must be laid on a bed, or seated on
 a high chair. The first position, however, is  to be pre-
 ferred because when it is adopted the patient need not be
 moved after the operation.
   2dly. The leg is extended on the  thigh, in order to
 relax the anterior part of the capsule of the joint.
   3dly. The surgeon then searches for the foreign body,
 moves it to the internal side of the joint, against the at-
 tachment of the capsule, and secures it between his
thumb and the fore-finger of his left hand, while an as-
 sistant draws the skin over the fore part of the rotula.
   4thly. Taking then a common bistoury, he makes,
 on the protuberance formed by the body, a longitudinal
incision of an extent proportioned to its size, through
both the integuments and the capsule, so as to lay the
body bare at the first stroke.
   5thly. Sometimes the  body escapes immediately of
its own accord, in  consequence of the  compression
made on it by the fingers.  If its  passage out be not
spontaneous, a small scoop or  a taper-pointed spatula
passed under it, answers  the purpose of extracting it.
But, in the introduction of these instruments, it is ne-
cessary to avoid touching the articulating surfaces with
their ends,  lest, by  being irritated, they  might swell,
and give rise to troublesome accidents. 
I
                        327

  6. If any resistance be met with,  enlarge the open-
ing and the  extraction will become easy.  Without
this precaution, the edges of the wound, being bruised
and irritated by the passage of the body, will swell, in-
flame, and unite again with difficulty.
  7. When the extraction is finished, the assistant who
draws  the skin towards the inside of the joint, suddenly
lets it go, when it returns to its natural situation.  This
causes the two incisions, which  corresponded,  at the
time of the operation, to change their relative situation,
the one remaining internal and the other becoming ex-
ternal.
   8. Hence arises a twofold advantage; the entrance
of air into  the  interior of the joint is  prevented,  and
the external and  loose  portion of the  capsule,  being
drawn inwards with the skin, unites with the condyl,  if
it be not brought into exact apposition with the other
portion of the capsule, divided near its attachment.
   9.  The extraction being finished, it is then necessary
to examine carefully, in order to ascertain whether or
not the joint contain any more of these foreign bodies.
 On some occasions, when this is even the case, they
 cannot at the time be discovered.   Desault himself was
 once deceived on this score, in consequence of which
 his patient was obliged to submit to a second operation.
   10.  The  incision in the integuments is now united
 by means of adhesive plaster.   Over this are laid com-
 presses and a little lint, and the whole secured by a few
 turns  of a roller drawn moderately tight.
    11.  The leg being then placed on a  pillow, is kept
 in a state of extension, by means of a splint applied, for
 a few  days, behind the joint.
   29.  If we examine  but for a moment the process  in
 this operation, we must perceive, that an incision made 
328
through the skin and  capsule at a single stroke, is, in
no  respect, less advatageous  than one  made at two
strokes, as recommended by all practitioners,  and that,
it is in the following respects greatly preferable to it:
1st, it shortens the operation very considerably : 2dly,
it diminishes the pain: 3dly, it exposes the joint a much
shorter time to the contact of the air.
  30. The object  of the  operator is better answered
by drawing the skin outward  and towards the rotula,
than by either depressing it, as Broomfield did,  or rais-
ing it,   as  Bell does.   Being  more loose and  more ea-
sily stretched in this  direction, the opening in it is re-
moved farther from that in  the capsule, which prevents
more certainly the access of air to the joint,  and also
favours the examination of the capsule.
  31. In  the mean  time,  the  operation may  succeed,
even although the openings in the integuments and the
capsule correspond to each other.  Many English and
German practitioners, without  previously stretching
and changing the natural situation of the skin, make a
common incision, which they  dress  afterwards  like a
simple wound, and are yet no less successful than others
in the result of their operations. This  is a further proof
of the fallacy of the ancient surgical doctrine, respecting
the admission of air  into the cavities of joints.   Per-
haps Desault might have omitted this precaution, had
any operations of the kind occurred in his  practice du-
ring 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. 
329
  33. With regard to hemorrhagy, as there is no large
artery near the place of the incision, there is nothing to
be apprehended on that score.  Oftentimes there is
scarcely any loss of blood at all, as may be  seen in the
first case published  in the Journal  of Surgery.  But,
even admitting that a small articular branch be divided,
the reunion of the edges of the wound will be sufficient
to check the hemorrhagy,  in the same manner as in the
operation for the hairlip, the contact of the divided in-
teguments  of the lip, puts an end  to the hemorrhagy
from the small arteries of the part.

                  SECTION XIV.

        OF THE  SUBSEQUENT TREATMENT.

   34. I have already said that but little is to  be appre-
 hended on the  score of accidents subsequent to the
 operation (26).  Out of the numerous operations of the
 kind performed lately  in  Europe,  but few cases have
 proved troublesome in their consequences, and  even
 these were influenced by  some foreign circumstances.
 Thus, for example, one of the patients of Simson rode
 out on horseback a  few hours after the operation,  on a
 cold and stormy day, and thus produced a troublesome
 affection of the part.  A similar remark  may  be made
 respecting the  case formerly mentioned (27).
   35. The apparatus or dressing  remains  untouched
 for the two or three first days,  during which time it is
 necessary to wet it frequently with vegeto-mineral wa-
 ter.  It is  a certain truth, that the  use of this liquid re-
 tards the suppuration  of wounds, and that,  when con-
 tinued a due length of time, it keeps inflammation at that
 degree most proper for the process of healing. 
330
  36. On the removal of the dressing, the wound is
sometimes so perfectly healed up, as not to exhibit the
least discharge. At other times a slight suppuration takes
place; but, at the end of a few days, the cure is complete.
Under the care of Desault, it  was always effected in
eight or ten days.
  37. Let us bring the doctrine just laid down to  the
test of experience.  Five cases have been published on
this  point.  I have selected two of them, both which
occurred in the same  subject, where we find the same
operation twice performed with equal success.
  Case I. M. Vielle, aged nineteen, was  attacked a-
boutthe beginning of the year 1790, by a spontaneous
swelling in the joint of the knee.  Inconsiderable at first,
but increased afterwards by a laborious journey, it dis-
appeared at  the end of two months, discovering to the
touch, near the internal edge of the rotula, a  foreign
body, which was hard and moveable, and which some-
what 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 applica-
tions were tried for six  months without success.
   Weary of this unavailing practice, the patient came,
in March, 1791, to consult Desault, who discovered a
 cartilaginous  substance of a flat and circular figure.  Its
 usual situation was at the external side of the  joint, but
 it could be easily moved to the internal side, and could
 be turned on its own axis  within the joint, nor did it
 occasion any pain, when suffered to remain at rest by
 the side of the rotula.  But, when it passed behind the
 tendon of the extensor muscles, the patient was unable 
331
to stand, and he experienced severe pains when it made
its way under the condyls or behind the rotula..
   The  indication was evident.   Before the  operation
Desault prepared the patient by a proper regimen,  and
then,  in the method already  described (28)  extracted
a  foreign body,  whitish,  and oval,  fourteen  lines in
length,  ten in  breadth, and two and a half in  thickness
at its  middle.   It consisted of three pieces, united by
a ligamentous substance, and was smooth on the side
next  the joint, but rough  with irregular tubercles on
the opposite side,  and on its circumference.   There
was no  loss  of blood  during  the operation: the usual
dressing was applied,  after the  most  attentive ex-
amination, as to the existence of a second body.
   Neither pain  nor swelling  supervened, and  by the
fourth day, the reunion was complete.   In a short time
motion  was performed with as much  ease as before
the occurrence of the complaint.  In  the mean while,
a degree of uneasiness remained in the joint; but barely
perceptible  at  first,  this uneasiness continued  to
increase; in about  four  months,  symptoms  of  the
existence  of  another  foreign body  made  their  ap-
pearance.
   M. Vielle being now a distance from Desault, put
himself under the care of his brother, who extracted
a  second body,   in  the  manner  already  described,'
except that the incision was made at two strokes.
   Dressing  the same as in the  preceding case, with
this additional precaution, that the  thigh and leg were
covered by a roller, for the purpose of moderating the
action of the muscles.
   No fever, no pain; the  reunion  completed  on the
eighth day,  except a small point in  the centre of the
wound, which suppurated slightly till the fourteenth. 
332
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.

                  SECTION I.

   1. Case  I.  (Reported  by  Levacher).   Catharine
Belet,  aged fifty-five, 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 nothing;
to retain the reduction, sent the patient to  the Hotel-
Dieu.   She was conveyed  on the same day to the
amphitheatre, where  Desault discovered the existence
of the affection by the following signs.
   Pain in the middle of the leg, less severe when the
limb was at rest, more so when  it was suddenly moved;
the patient absolutely unable  to support  herself on it
so  as  either to  stand or walk since  the  accident;
inequalities  sensible  to the  touch  on  the anterior
surface of the tibia;  a shortening or contra ction  of
about half an inch;  a preternatural mobility at the place
of the fracture; evident crepitation, produced by the
rubbing of the  fragments  against each  other, when
moved in contrary directions : a change in the direction
of the  lower fragment,  which  was  bent somewhat
outwards.  These signs,  added  to the  circumstance
of the  fall, evidently announced a simple fracture  of 
333
both bones.   The reduction was effected in the follow-
ing manner.
  One assistant made counter-extension by grasping the
lower part of the thigh with both his hands, the fingers
being placed behind it, and his thumbs corresponding to
its  anterior surface.   Another  made  extension, not as
writers recommend, at the lower part  of the leg, but on
the foot itself, which was taken hold of in such a man-
ner 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 die fragment to be replaced, while its centre
of motion was in the joint.
  Extension being directed at first in the  course or line
of the displacement, till the limb had attained its usual
length, was then  directed in  such a way as to restore to
the leg its natural form.   By this, the fragments being
brought  into apposition, united  exactly without the
process  of coaptation  being  employed.*   The ap-
paratus,  usually  employed by Desault in such cases,
was applied  to   maintain  the  reduction: the  differ-
ent pieces of it  had  been  previously arranged  on a
pillow in the following order:  1st, four strong pie-
ces of tape placed at equal  distances from each other;
2dly,  a  junk-cloth,f long enough to  reach from the
knee beyond the sole  of the foot; 3dly,  a bandage of
 strips, similar to that described for the thigh  (page
244) arranged in the usual mode ;  4thly, two long com-
 presses,  the  lower one of which being the longest was

   * That is, without any assistance from the hands of the surgeon.  Trans.
   *■ Analogous in its form and uses to that employed in fractures of the thigh.
 It may not be amiss, on this occasion to mention, that in the form of appara-
 tus for oblique fractures of the leg, represented in the Appendix, plate m,
 no junk-cloth is necessary.                             Trans. 
                         334

 turned back on the other; three bolsters had also been
 prepared ; these, being formed of several pieces of linen
 joined together, were about one inch and a half thick :
 the  broadest of these was designed to be placed on the
 anterior  part  of the leg;  the two other lateral ones,
 though narrower,  were a little  longer, in order that, by
 folding back on themselves, they might  be accommo
 dated to the inequalities of the limb; 6thly, lastly, there
 were also  prepared  two  splints, an  inch broad, three
 lines thick, and of the same length with the junk-cloth.
   Every thing being ready,  the assistants  still keeping
 up extension raised the  leg a little, while a pillow  was
 slipped under it,  to support it equally and uniformly
 throughout its whole length.  The leg was placed on
 this  pillow  in such a way as to correspond exactly to
 the middle of the apparatus which was arranged in order
 on it, and was previously wet with vegeto-mineral water.
   On the anterior part of the leg was then applied a long
compress, extending from the knee to the upper part of
 the foot.   Over this were lapped the other two com-
 presses,  which had been  previously placed in  order as
 part  of the apparatus.   These were then secured by the
 bandage  of strips,  the application of which was  begun at
 the lower strip next to the foot, and continued succes-
 sively upwafds with the  rest, making them cross each
 other at the anterior part of the leg.
   On the  sides were placed the bolsters  which were
doubled  at the ancle to protect  that part from the pres-
 sure  it might otherwise sustain.   The splints were then
applied along the  external surfaces of the bolsters,  the
edges of the junk-cloth having been previously folded
round them, in order to render their pressure the more
close and steady.  Along the fore  part of the  leg was
laid the largest of  the bolsters,  and the whole was then 
335
secured by the four pieces of tape tied on the external
splint, with a degree of tightness sufficient to keep the
fragments immoveable.
   A compress wet with vegeto-mineral water covered
the foot, and was secured by a roller, applied in such a
manner, that its two ends, crossing on the back of the
foot, were fastened laterally to the two splints.
   The leg, being firmly fixed by this apparatus, and
gently flexed by means of a pillow placed  under it, was
protected by hoops from the pressure of the bed-clothes.
The  fragments being now in  complete apposition irri-
tated the parts no  longer, in consequence  of which the
pain ceased.
   The patient being properly disposed in bed, remained
tranquil ,and easy throughout the remainder of the day.
Diluting  drinks  and light  nourishments  were  pre-
scribed.
   Next day, no pain ; patient composed; a slight swell-
 ing on the back of the foot; the apparatus wet anew
 with vegeto-mineral water.  Fourth day,  the bandages
 a little relaxed: the point of the foot turned somewhat
 outwards; a new application of the apparatus.   Seventh
 day, bilious symptoms appear, loathing of food, nausea,
 and bitterness of the mouth.   Eighth day, tongue furr-
 ed, inclination  to vomit; loss of appetite ;  a  grain of
 tartar emetic given  in  solution; copious dejections;
 evidently  better: next day, appetite returned,  tongue
 clean.  Tenth day, a third application of the apparatus,
 which had  become too  loose.   Fifteenth  day,  fresh
 bilious  symptoms;  further evacuations; success the
 same.  Twentieth day, consolidation evidently advan-
 cing ; no deformity of the limb; fourth  application of
 the"  apparatus.   Thirty-second  day,  consolidation  al-
 most complete; the apparatus still kept on till the for- 
336
ty-second day,  when the patient was discharged per-
fectly cured.
   2. This case, which is in no respect different from
those that most frequently occur in practice, presents
us  with a view of the mode of reduction, the means
of retention, and the subsequent treatment, employed
by Desault,  in  cases of the kind.   The  advantage  of
the bandage of strips,  which allows the limb to  be
uncovered without being disturbed,  is, now generally
acknowledged  in fractures  of  the lower extremities.
In  the treatment of  these, practitioners reject entirely,
at present, the roller bandage, which was recommended
by  Petit,  Heister, and all the  authors who preceded
them, and which, by producing a new displacement, at
each time of reapplication,  may entirely prevent  the
fragments from uniting.    The bandage of Scultet,
brought into use again by Desault, the form of which
has been just described,  is also preferable to the eigh-
teen-tailed bandage, which  some practitioners still em-
ploy.
   3. The strips which compose the former bandage,
being  narrower than the tails of the latter,  can  be
more neatly applied to the leg, as they more  readily
mould themselves  to its inequalities; the compression
made by them is, therefore, more exact, more uniform,
and consequently  less  inconvenient.  If one  of  the
strips become soiled, it can be changed without de-
ranging  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 
337
moderns; 1st, they come in  contact with and  bear on
a larger extent of the surface of the limb; 2dly, they
consequently  maintain  the  fragments  in apposition
with greater firmness and effect; 3dly, they prevent the
rotation of the foot outwards, an accident which very
frequently occurs when the fracture  is complete, that
is, when both bones are broken; 4thly,  they remain
constantly in their place, without slipping either forward
or backard,  an inconvenience necessarily attendant on
the other splints, which,  from  their roundish form,
touch the limb in only one point or line.
  5. To sustain the foot,  Petit recommends a piece
of a board to be applied immediately to its sole, and sup-
ported by two bits of tape fastened to the splints.  This
practice is adopted to some extent even at present: but
a simple roller,  applied in the manner already men-
tioned,  is sufficient for the purpose; the tendency of
the foot to turn  outwards is never so strong as not to
be  effectually  resisted  by  this expedient:  besides,
should the piece of board be placed ever so little too
vertically, it retains the foot in a state of inconvenient
and painful flexion.
  6. The situation of the leg, gently flexed  by means
of a thick cushion or pillow placed  between it and the
mattress, is, in all respects to be preferred to the method
of Pott, which is exclusively adopted by Bell.  What,
indeed, can be  the object of this  latter method ?  To
relax,  say they, the  muscles, that tend  to make  the
lower fragment  overlap the  upper  one.  But  is it not
evident, that most of these muscles, not being attached
to the os femoris at all, cannot be  influenced  by this
position? To  obtain the relaxation of the  posterior
muscles, it  is necessary to flex the foot; but, in  such
a case  the  anterior  muscles are necessarily in a  state
                         43 
338
of tension: this completely counterbalances the relaxa-
tion of the others,  and,  therefore,  there  is  nothing
whatever  gained.  It is certainly much  best to allow
the leg to be in a state of moderate flexion,  such as
we  assume when asleep, and which  appears to be the
most natural.
  7. The apparatus  just  described, produces  on the
fragments a twofold action:  1st, by a kind of side
walls formed by  the  splints, it prevents their displace-
ment laterally, and from this circumstance alone, is fully
sufficient for the retention of transverse fractures : 2dly,
the pressure of the rollers, splints, and bolsters, if these
be applied with sufficient tightness, prevents the lower
fragment  from mounting  on  the upper one, and thus
preserves the natural length  of the  limb.   Hence its
advantages in oblique fractures; and, as the powers of
displacement are weaker here than in the thigh, this ap-
paratus, is in general, sufficient to counteract them.
   8. It is true that  cases do sometimes  though rarely
occur, where,  in consequence, of  being irritated  by
splinters,  or the points of  the fractured bone, or acted
on  by some other causes which make them  contract,
the muscles overcome the  resistance  of the apparatus,
and make the fragments overlap.  Under  such circum-
stances, permanent extension  affords  here the same ad-
vantages as in fractures of the thigh.
  9. Most authors, to obtain the desired end in such
cases, recommend means calculated to act on the thigh.
Thus, Manne proposes the use of his glaussocum. De-
sault, under such circumstances, effected his  purpose
by  the apparatus described in the following case. 
339
                   SECTION II.

  10. Case II. Pierre Bejol, aged thirty-seven, of a
strong and vigorous constitution, fell, as he was carry-
ing a heavy  load, over a beam which lay in his way.
His leg was fractured  towards  its lower part; he was
lifted up and carried home, where a surgeon,  by mak-
ing  unskilful  efforts at reduction, gave him extreme
pain.
  A roller and a kind of round splint applied to each
side of the limb, forming the whole of the apparatus,
and not being  sufficient to retain the fragments, soon
allowed them to overlap each other nearly two inches.
The pains continue ; a considerable swelling appears
around the fracture ;  the patient is greatly  agitated; he
is brought to the Hotel-Dieu, where, from the deformi-
ty of the limb, Desault Mas satisfied, at first sight,  of
the existence of a fracture; on a more attentive exami-
nation, it was  discovered to be complete and very ob-
lique.
  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 main-
taining this contact. The age of the patient, his strength,
and the almost convulsive state of the muscles, gave
reason to apprehend that a displacement was about to
occur.   An attempt was  made to prevent this in the
following manner.
   The patient being  laid  on  a bed properly prepa-
red,
   1st.  The foot and  the  leg above the ancle,  were
covered by  a  bolster  or  compress, round which was 
340
passed a strong roller intended for the purpose of mak-
ing extension.  The ends of this roller, being left free,
were carried, one on the outside, and the  other on the
inside of the limb.
  2dly.  Below the tubercle  of the tibia  was placed
another bolster, surrounding  the leg, and on this,  was
secured another roller for the purpose of counter-ex-
tension.  The ends of this roller,  after crossing under
the knee, were left hanging loose  one  on each* side of
the limb.
  3dly. The two rollers being  thus arranged,  while
the assistants, still continued to  make extension, the
surgeon applied successively, and in the  order already
mentioned, the compresses, the bandage of strips,  and
the bolsters.
  4thly. rje then took two splints with notches in their
lower ends,  of the same breadth with the splints already
described, but long enough  to  reach, each  of  them,
from four inches  above the knee  to the distance  of
four inches beyond the sole of the foot.   One of these
was applied on the outside  and the other  on the inside
of the leg.
  5thly. The surgeon then taking hold of the two ends
of the upper roller, drew them over the upper ends of
the corresponding splints,  while an assistant crossing
the two ends of the lower roller under  the sole  of the
foot, drew the external end over  the lower extremity
of the  internal  splint, and the internal end  over  the
lower extremity of the external splint.  Carrying them,
then, up along each side, he brought them, at the mid-
dle of each splint, to meet the ends of the upper  roller,
to which they were firmly  secured by knots, so  as to
make extension at the foot,  and  counter-extension at
the knee.  The two fragments, being drawn by this ap- 
341
paratus, the one down and the other up,  could not a-
gain overlap.*
   On the same day the patient was bled copiously ; a
low diet was prescribed; some diluting drinks were ad-
ministered  and  the  whole  apparatus was frequently
wet with vegeto-mineral water.
   Next  day, fever; restlessness; blood-letting repeated;
the extending rollers, having become relaxed,were tight-
ened.   Third day, evidently better.   Fifth day, a  new
application of the apparatus; some swelling of the foot;
a few small blisters on the leg; these  were opened and
dressed  with cerate spread  on linen.  Eighth day, the
 patient easy and tranquil; a little shortening of the limb;
 a third application of the bandage.   Twelfth  day, bi-
 lious  symptoms appear.   Thirteenth day, an  emetic
 given in solution ; symptoms decline. Twentieth day,
 the fractured limb in a favourable state ; the roller for
 extension laid aside ; that formerly described employ-
 ed in its place.   Thirtieth day, an appearance of con-
 solidation. Thirty-fourth day, bilious symptoms recur;
 further  evacuations.  Forty-third  day,  consolidation
 perfect;  scarcely a vestige  of the  fracture  remains.
 Exercise  is repeated for several days. Fiftieth day, the
 natural  strength and motion of the part completely re-
 stored.
    11.  The general end to be answered by every  ban-
 dage intended to retain a  very oblique fracture of the
 leg, is  evidently, 1st, to  hold the knee up, and with it
 the superior fragments;  2dly, to draw the lower frag-
 ment down:  from  this twofold effect arises a twofold
 resistance diametrically opposed to the powers of dis-
    * For a view and description of an excellent form of apparatus for oblique
 fractures of the leg, constructed on the principles of that here described, see
 article HI, plate HI, of the Appendix.                     •  lRANS 
                        342

placement, which are: 1st, the slipping down of the
trunk, which pushes the thigh before it, and with it
the upper  fragments of the leg; 2dly, the action of
the muscles of the leg,  drawing the foot upwards, and
the lower fragment along with it.
   12. But, if to these indications we compare the ban-
dage described in the foregoing case, we will perceive
that they are perfectly fulfilled by it.  Indeed the splints
forming  a  kind of pullies which change the direction
of the  rollers,  we must count on the action of these
rollers only from the part of the limb which they sur-
round, to the ends of the splints over which they are
reflected: whence it follows, that the two ends of the
upper roller,  reflected over the superior extremities of
the splints, cannot be drawn down along each of these
splints,  without that part of the rollers,  which reaches
from the leg to these extremities, being drawn up, and
with it the knee and the upper fragment. In like manner,
the ends of the lower roller cannot  be drawn  up to-
wards the  ends of the upper  one, without those por-
tions of them which run from the sole of the foot, being
drawn down and pulling the foot and the inferior frag-
ments along with them.
   13.  Hence it follows, that  by tying on each side,
one end of the  upper roller  to the corresponding end
of the lower one with sufficient tightness, the  two indi-
cations above laid down (12) are accurately fulfilled.
   14.  But, in general,  the common bandage is suffi-
cient, 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-
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 se- 
443
cond kind.  By means  of the common apparatus, he
was able to prevent the overlapping of the fragments
from forming any protuberance on the anterior and in-
ternal part of the leg.
   15. We must acknowledge, however,  that this ap-
paratus  is liable to the same objection with most others
intended for  permanent  extension.  The roller placed
below the knee, for the purpose of counter-extension,
surrounds almost all the  muscles, which  tend to make
the inferior fragments overlap the superior ones, by
drawing the foot upwards.   By pressing on and irritat-
ing these, it favours,  and even excites their contrac-
tions, and, by that means, gives  rise to a shortening
of the limb,  the very accident which the apparatus is
intended to prevent. This inconvenience induced De-
sault, in a particular case, to substitute to  the prece-
ding apparatus, that used for permanent extension in
fractures of the thigh. 
MEMOIR  XV.
   ON  THE "DIVISION OF THE TENDO ACHILLIS.

   1. It might be supposed that a work on diseases of
the soft parts, would be a more  proper place for this
article, than the present one, where my express object
is to treat of affections of the hard parts.   What indu-
ces me to insert it here is,  the analogy  which exists
between a division of the tendo achillis and a fracture
of the  os calcis, the  light which the treatment of the
one throws on that of the other, and the example of the
celebrated Petit, who, in  his work on diseases of the
bones, speaks also of this division.


                   SECTION I.

         OF THE CAUSES AND. VARIETIES.

   2. The division of the tendo achillis is the result,
either, 1st,  of the action of a cutting  instrument;  or,
2dly, of muscular action; hence two very different modes
of its production, the one by a wound, the other by a
rupture.   The first is not a very rare accident because
the projection of the tendon exposes  it oftentimes to
the stroke of external bodies :  the second, though but
little noticed by  the ancients, has been frequently ob-
served by the moderns, since their attention was called
to it by Petit.
   3. The manner  in which the  division is produced
by a wound, has nothing particular in it: that by a rup-
ture, takes  place in  the following  manner.   A man 
345
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 lifte of gravity not falling on the ground,
the weight of the body throws the feet into a state of
violent flexion, the  muscles contract with great force,
to prevent a fall backwards,  and, at that instant, the
tendon  is  ruptured,  in consequence of being drawn
downwards by the  violent flexion of the foot, and up-
wards by the effort of the muscles: hence it appears
that Petit was deceived with regard to  the mechanical
cause  of the rupture, which he considered as taking
place at the moment of the patient's alighting on his
feet, when, as  he said, the tendons were  surprised, so
to speak, into a state of too great tension.   It is easy to
apply  the principles  of  this particular case to  others
that may happen,  and where the position may not be
the same ; such as, when we leap on a table, &c. Some-
times slighter efforts have produced the effect;  and, as
Louis observes, dancers have sometimes ruptured the
tendo achillis by making a powerful exertion on the
 point of the foot, as well as by other motions.
   4.  Divisions produced in the first  mode, may be situ-
 ated  in  any part of the tendon.  Those produced  in
 the second, occur  more particularly about its middle :
 to  that part the effort or  strain  is most forcibly deter-
 mined, and  there the resistance is the  weakest.   The
 rupture of the tendon  may,  according to Petit, be
 either complete or  incomplete;  but, if we consider the
 simultaneous contraction of the gastrocnemii and soleus
 muscles, and  the  intimate manner  in which their two
 tendons are united at a considerable distance above the
 heel  it will be difficult to conceive  how these tendons
 can be ruptured separately.   With regard to divisions
 produced by cutting instruments, the case is different,:
                         44
I 
346
 there, the weapon may pass half way through the tendon
 either from behind or laterally; and perhaps divisions
 of this kind are much more frequently incomplete than
 otherwise, in consequence of the great resistance of the
 tendinous fibres.


                      SECT. II.

                    OF THE  SIGNS.

    5. The  superficial situation of  the tendo achillis, al-
  ways renders the diagnosis of its division easy.   It can
  be rendered difficult only by the  occurrence of a con-
  siderable swelling, an accident that rarely happens.   If
  there be an external wound,  the depth to which the  in-
  strument has penetrated, and the possibility of some-
  times feeling the ends of the tendon between the-edges
1  of the wound,  are the first evidences  of  its division.
  If, on the other hand, the tendon be only ruptured, then
  at the moment  when the rupture happens, a report is
  heard by the patient, not sharp, and like the  crack of a
  whip, as is said to take place when the plantaris muscle
  is ruptured, but more dull and flat, according to the ac-
  count given to Desault by  a patient, whom he interro-
  gated on the subject.
     6.  In either case,  there occurs suddenly, if not an
  entire inability, at least, an extreme difficulty in either
   standing  or walking: hence the patient  falls, and is
   unable to  rise again; but, in  divisions that  are only
   partial or incomplete (4)  this sign does not occur.   Be-
   tween the divided ends of the tendon there exists a de-
   pression  sensible to the touch.   This  depression is in-
   creased by the flexion  of the foot, but diminished and
   even entirely removed by its extension. 
347
  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 re-
main uninjured, are  capable of producing that motion.
Some have alledged that the calf of the leg must be in-
creased in size by the swelling  of the gastrocnemii and
soleus muscles, in consequence of their state of contrac
tion; but modern experience has shown, that there is
but little reliance to be placed on that appearance.


                    SECTION III.

                OF  THE  PROGNOSIS.

    8 Divisions of the tendons are not in general dange-
 rous.   These organs,  being insensible in their^nature,
 are not painful when  ruptured, as is proved both by
 experiments on living animals, andby the observations
 of surgeons  who have had such affections under their
 care more particularly of Monro, who experienced the
 acciaent in his own person.  No inflammation super-
 venes  and if a swelling be sometimes the consequence,
 itTsTn general soon dispersed, leaving  behmdit nothing

 SCt Whence  arose then the  exaggerated fears of the
 ancfenVs respecting injuries of this kind?  Doubts
 Zml opinion  which was then entertained,  that ten-
  trom an up                 ^ ^^  Hence ^
  dons ^ ne^e^onvulsions,  and even death itself,

  S^S  apprehended, as the consequence oi
 
348
 injuries done to  these organs.  Lamotte, among  the
 moderns,  still  entertained these prejudices,  when,  in
 speaking of affections of the tendo achillis,  he said,
 "So dangerous are  they in their  consequences, that
 they can seldom be brought to a favourable 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 ap-
 plied externally, the imprudent administration of oily
 substances, and, still more, the motions of the patient,
 contributed not a little to the production of those acci-
 dents, which no longer  occur in  the  practice of the
 moderns, since the nature and treatment of the disease
 is better understood.  It has been  proved, by late ob-
 servations, that the division of the tendo achillis  is apt
 to produce some diminution in the size of the affected
 leg.   But this soon  disappears, nor does it, indeed,
 even occur, if, by a proper application of the bandage,
 a speedy union of the divided part be obtained*   The
 patients of Desault never experienced it.


                  SECTION  IV.

          OF  THE INDICATIONS OF CURE.

   11. That I may present, in order, what I have  to
 offer on the  treatment of the  division of the  tendo
 achillis, 1st, I will lay down,  with  precision,  the 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 
349
relation or correspondence that subsists between these
indications,  and the apparatus employed by Desault, I
will prove that it fulfils them sufficiently, and is, there-
fore, to be preferred to every other.
   12.  To bring the edges of the division into contact,
and to retain  them so, are here, as in  other  simple
wounds, the two general principles of treatment.   The
first of the principles presents an easy indication; it is
only to extend the foot forcibly on the leg.   The indi-
cations that arise out of the other, are more difficult to
be fulfilled.
   13.  To form a proper idea of these, let us call to
mind what it  is that prevents the contact of the divided
ends.    As far as relates tothe lower end, it is the flexion
of the  foot on the leg, and with respect to the upper one,
the contractions of the gastrocnemii and soleus muscles,
which are not now opposed by the continuity of the ten-
don.   Therefore,  1st, to keep the foot permanently ex-
tended ; and, 2dly, to oppose the action of these muscles,
are the two general indications or objects of every appa-
ratus destined to  retain the two ends of the tendon in
contact.
   14.  But,  the action of the muscles may be  opposed
in different ways; 1st, by keeping the muscles them-
selves in a  state of relaxation.   This relaxation may be
easily  effected,  as far as relates to the gastrocnemii, in
consequence of their insertion into the posterior part of
the cpndyls 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, be-
cause it ought to bear chiefly on the fleshy portion, and
not on the tendon, otherwise it will depress its divided
ends,  destroy their contact, and make them unite, not 
350
 with each other, but with the adjacent parts, and thus
 produce considerable lameness.  At the same time that
 care is taken not to depress the divided ends, these ends
 must not be permitted to move from side to side, a kind
 of displacement which may  readily occur, in  conse-
 quence of the  hollow or depression situated on each
 side of the tendon.  But,  the only expedient to attain
 this twofold purpose, is, to place in these hollows, some
 soft substance, lint,  for example,  which may project
 sufficiently to protect the tendon behind, and to retain it
 laterally.
   15. This compression,  that ought to be made by the
 bandage,  appears to have escaped all writers, as none of
 them have given it a place among their means of cure.
 Yet, do we not plainly perceive, that, by confining the
 muscles,  impeding  their contractions, and reducing
 their irritability by its long continued use, it must tend
 to prevent the superior end from being drawn upwards
 and thus separated  from the inferior one? Will not
 compression, in this case, be similar to the effect of the
 uniting bandage, in transverse wounds, where the great
 number  of circular casts which cover the limb, are
 particularly intended to weaken muscular action,  analo-
 gous to what  takes place in hare-lip, where the com-
 presses do as much good by compressing the muscles,
 as by bringing together the edges of the divided lip ?
But further, besides reducing  the force of the muscles,
 does not this compression serve to prevent the swelling
 of the limb, an effect almost inevitably resulting from
 its state of rest and deficiency of action ?  So far, then,
 from being, as Louis says, one of the inconveniences
of the first  bandage of Petit,  it constitutes one of its
 principal titles to  a preference among practitioners. 
351
  16. It appears from what has been just advanced
(13.... 15) that the following are the three ends to be at-
tained by every bandage, intended to retain the divided
ends of the tendo achillis in contact; 1st, the immo-
bility of the foot in a state of permanent extension on
the leg ; 2dly, the immobility of the leg, in a state, of
semiflexion, on the thigh;  3dly, a judicious and well
directed compression made on the  whole leg and foot,
but bearing on  the tendon with  only sufficient force,
to keep it from moving backward or laterally.  Let us
 compare the methods of authors with these indications.


                    SECTION V.

      OF THE DIFFERENT METHODS  OF CURE.

    17.  The treatment recommended by authors may be
 reduced to three general methods.   The first consists
 in rejecting all  artificial aid, and leaving  the cure to
 nature and the position of the limb.   To  the second
 belongs the use of sutures, intended to retain the edges
  of the division together.  The third includes the dif-
  ferent kinds  of apparatus  employed  for the  same
  purpose.
    18. First method.  Chronological order places this
  method after the others.  But this order must be dis-
  regarded by him, whose object is things rather than
  time.  The history  of the sciences  calls sometimes
  for the approximation of distant  periods, and, at other
  times, for the separation of those already approximated.
     19. Several practitioners, in France and England,
  have  lately  proscribed the  use  of all external  means.
  Pibrac and Dupouy were of opinion, that the  mere
  precaution of the patient not to flex the foot, assisted 
352
by constant rest, was sufficient.  Hoin and Gauthier
mentions  many cases in confirmation of this doctrine.
M. J. Rodbard, surgeon at Ipswich, having ruptured
his own tendon about three inches above  the  heel in
leaping over a little rivulet, instead of confining him-
self to bed, continued in the exercise of his profession.
He walked  every day, without any other precaution
than that  of not flexing the foot,  and five years after-
wards, he was able,  as he mentions,  w to walk, run,
mount or alight from his horse,  without pain,  in a
word,  the affected leg performed its functions  as well
as the other one." We have  an account of a patient
who was cured without a bandage by A. Petit.
   20.  Was there indeed a  true rupture of the tendon,
in all these cases, particularly in those where the patients
continued to  walk as before the accident?  Most of the
cases which we have seen prove  the impossibility of
either  standing  or walking (6).   But, admitting that
they were ruptures,  are we authorized  to pursue the
mode of treatment there adopted ? Certainly we are not.
None  of  the indications  formerly mentioned  (16) is
there fulfilled.   What is  there, under such circum-
stances, to  prevent an  involuntary  motion from de-
stroying 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 ac-
cident happen, the cure must necessarily be tedious.
Besides, if  the  ends  be separated,  a  reunion  cannot
take place, except by an intermediate substance,  which,
by filling up the vacant  interval between them, must
lengthen the  tendon.   In  consequence of this, die
muscles will be impeded  in  their  contractions, and
the foot in  its motions, as Desault has oftentimes obser-
ved in animals, which he left to themselves, after  having? 
353
divided the tendo achillis.  Thus, in a fracture of the
rotula, the motion of the limb is very much impaired,
when  the.  ligamento-cartilaginous   substance  which
unites the fragments is too long.
  21. Hence it follows, that here, in like manner as in
other ruptures of the tendons,  art must  assist  nature,
because  without the former ,the powers of the latter
will be insufficient.
  22. Second method.  The ancients pursued a course
not less uncertain, and much more dangerous.  Sutures,
sanctioned  by  general   custom,  were extended to
wounds in the tendons, and were even more especially
employed  in such  cases, because  the tendinous  end
being drawn forcibly and greatly displaced by the con-
traction of the fleshy portion in which it terminates; it
was deemed necessary to oppose to this force a greater
resistance.
   23. What useful end was attained by this practice ?
 Muscular action was left perfectly free ; and'  the only
 thing done was  an attempt made  to resist its effect.
 But, in a short time the tendinous-ends, in consequence
 of being forcibly stretched by  the contractions of the
 muscles, either  gave way  at  the  points where  the
 stitches  were introduced, or, in case they did not  give
 way,  became swollen,  painful,  and inflamed,  in  con-
 sequence of the violent distension which they suffered:
 hence the serious affections produced by such treatment
 (9 and 10).                                .
    24. The ancients, then, were mistaken, with respect
 to the indications  in this disease, which are, not to
 resist muscular  contraction left free and unimpeded,
 but to check  and prevent this contraction,,by the means
 formerly pointed out (16).  It is a principle generally
 acknowledged at the present  day,  that sutures ought
                          A'5 
354
not to be used  as a mean of approximating divided
parts, but  only  to keep  the edges  of parts  already
approximated in perfect contact.   But, in the  present
case,  the means of approximation being sufficient for
the purpose  of  exact contact, sutures are altogether
unnecessary.  This,  however, does not hold  true  in
every case, though certain practitioners, who have too
generally rejected the use of sutures, contend that it
does.  Finally,  however,  these  means  have  been
excluded from  the  treatment  of the division of the
tendo achillis, and  the  doctrine  of  the Academy  of
Surgery, though  erroneous in many  other cases, has
established, with  regard to the  present one, the  true
practice.
   25.  Third method.  It is to  the celebrated Petit
that we are indebted for  that methed of  treating the
division of the  tendo achillis,  which consists merely
 in position  maintained  by 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 treatment,
for the purpose of continuing the contact also.   This
was  a  happy  idea, the simplicity of which  recom-
mended it  to  practitioners, and wliich, being  once
discovered,  has formed the common basis of all the
numerous  processes devised since by different authors.
   26. When we consider the action of these several
 processes, and compare it with the indications formerly
 laid down (16) we may divide the processes themselves
 into three general classes.  Thus, some of them fulfil
 only the first and third  of .these indications,  namely,
 the permanent  extension of the foot,  and a  regular
 compression  made  on the leg;  others fulfil only  die
 first and second, the latter of which consists in keeping 
355
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 re-
spect to one or two of the leading indications.  I shall
examine  nothing, therefore,  but  the  disadvantages
peculiar to each.
   27.  To the first  class  belongs, almost exclusively,
the first bandage invented by Petit.   It  is formed by
a long compress, placed longitudinally behind the leg
and  foot,  and secured by a roller applied regularly on
these parts.   The two ends of the compress, being re-
flected back,  are  then knotted together behind the leg
so as to extend  the  foot.  This expedient  is simple
and  ingenious, and would be preferable to all others,
were it not that,  besides the charge of not fulfilling the
second general indication (16)  it is further liable to the
following  objections!  1st,-the  compression which it
makes is injudicious  and ill-directed, because it  bears
not only on the fleshy portion  of the leg,  but also on
the divided tendon, which being more projecting and
therefore more exposed, has its two  ends  pressed down
and  separated : 2dly, in some  cases, it does not main-
tain the extension of the foot with sufficient certainty:
3dly, it does not prevent  displacement in a lateral di-
rection.
  28.  To the second class belong,  1st, the celebrated
slipper of Petit, substituted by that author for his first
bandage;   this machine was  composed  of  a  slipper
fixed to the  foot, of a knee-piece* secured  on the

   *  (Gcnouilliere); I believe this was a pirr ~~" apparatus made of lea-
ther somewhat similar to the top of a boot, and secured  on the limb just
above the knee.                                    Trans. 
356
    lower part of the thigh, and of a strap running from
    the one and fastened to the other, to extend at pleasure
    the foot on the leg, and to flex the leg on the thigh:
    2dly, the bandage of Duchanoy,  made in imitation of
    'the preceding apparatus, and consisting of a simple
    sock  surmounted  by a roller, which running along the
    back part of the leg,  was fastened to another roller ap-
    plied  round the lower part of the thigh.  Besides the
v    general objection  of not at all fulfilling the  third indi-
    cation (16) these  processes are liable  also to th/a  fgJR
    lowing ones ; 1st,  they fatigue the toes by the constant
    pressure of the slipper and the sock, as MonMp;pe-
    rienced in his own pejjson, to  such an exJgipPhat he
    was unable to support their use; 2dly,- the  slipper is
    quite too complicated, and is therefore  seldom at hand
    when wranted.   The apparatus 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 was
    to be fastened by a buckle to  a  kind of guetre or spat-
    terdash, 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 ap-
    paratus of Schneider, Avho rested satisfied with main-
    taining the extension  of the foot, by  a splint placed an-
    teriorly.   Besides various  other  objections  to them,
    diese are all  chargeable, alike,  with the radical fault,
    of not fulfilling the second and third indications (16).
       30.  From this comparison of the indications  (16)
    with the means destined to fulfil them,  it appears that
    there were material defects on the part of the latter. Let
    us examine whether or not  that of Desault was better
    calculated for the purpose.   It is, so to speak, nothing 
357
but a modification of the apparatus of Petit (27) but
such a modification as amounts to  an  improvement in
principle, and entitles it to be called the  apparatus of
Desault.
   31.  The pieces which compose it are;  a  compress
two inches broad, and long  enough to reach from the
lower part of the thigh  to the distance of  four inches
beyond the foot; a roller five or six.yards long and two
inches wide ;  a sufficient quantity of lint; and two
long graduated compresses.
   32.  Every thing being ready;
   1st. An assistant supports the  foot and leg,  the for-
mer 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 widi vegeto-mineral water is laid directly over
the division  of the tendon; if it be a  simple rupture,
 this precaution is unnecessary. Under the foot, up be-
hind the leg, and the lower part of the thigh,  is then ex-
 tended the long compress, which is to  be  secured in
 that situation by the hands of the assistants.
   3dly. The hollows situated at the sides of the tendo
 achillis, are then filled up with pledgets  of dry lint,
 surmounted by tl>e two long graduated compresses,
 which retain the pledgets, and must project a little be-
 yond the tendon, because they are liable to be render-
 ed flat by pressure.
   4thly. The surgeon now taking the roller, makes at
 first several circular turns round the toes, fixing the long
 compress there,  the end of which, being reflected over
 tjiese first casts, is secured by a  few additional ones
 which f over the whole' foot, and are afterwards directed
 obliquely above and below  the division, round  which 
358
is formed a kind of figure of 8, that brings the edges of
the wound into perfect contact.  If there be no wound
of the integuments, it is necessary to take care, least the
skin interposing between the  divided ends of the ten-
don, should separate them, and thus prevent their re-
union.  Ascending, then, by circular casts, along the
whole leg, and even to the  lower part of the thigh, the
surgeon there turns  down  the  upper end of the long
compress, and securing it by a few more circular casts,
finishes the application of the roller.
  5thly.  The apparatus being thus applied, and the ex-
tension of the foot and the  flexion of the leg firmly se-
cured by it, the leg is then placed on a pillow or  bol-
ster,  one  side of which corresponding  to the  angle
which the leg forms with the thigh, assists in keeping
it half-flexed.
  6thly.  Should the long compress prove insufficient
to keep the foot extended, or  should  it,  by becoming
relaxed too soon,  render frequent reapplications of the
apparatus necessaiy (circumstances which rarely  hap-
pen when the bandage is  well applied) a splint placed
anteriorly, as was the case in Schneider's apparatus (29)
completely remedies the defect.
  33. On comparing this  apparatus with the indica-
tions  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 perma-
nently secured, both by the long compress, and by the
splint when it is employed: 2dly, the same compress,
aided by the bolster or pillow placed under the leg,
maintains the flexion of the leg on the thigh : 3dly. The
muscles are effectually compressed;  their action is im-
peded in part by  the compression of the circular ban-
dage, which does not bear on the tendon, in conse-
> 
359
quence of the bolsters of lint placed on each side of it:
these  bolsters  prevent the tendon both from  moving
laterally, and from being depressed: hence it  follows,
that the action of the circular bandage is precisely con-
formable 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 ad-
vantage not to be derived from any of the forms of ap-
paratus used by preceding authors.
   34.  This apparatus is in no degree  complex or trou-
blesome.   Simple and easy, it requires nothing for its
construction but what the surgeon can easily obtain, and
what he  can  even himself prepare.   There  exists a
great analogy between it and the  bandages which De-
sault used for the reunion of transverse wounds, and for
fractures  of the rotula and the  olecranon.   A truly
great man does not estimate his merit, by the number
of processes which he invents ;  he well knows that  the
 perfection of art consists in producing numerous effects
 by few and simple means.
    35. We will  confirm, by two  cases, the  principles
 laid down in this  memoir.   One of these relates to a
 division of the  tendon, connected with a wound, and
 was  reported by Bezard; the other by Manouri,  and
 relates to a simple rupture of the tendon.
    Case  I. J. B. Lavigne,  aged thirty, as he was going
 down into a cellar without light, struck his leg against
 the edge of a sharp saw, which completely divided the
 tendo achillis.   The patient was immediately  carried to
 the Hotel-Dieu.   The wound of the integuments  was
 transverse, two inches long, and had its edges  but
 slightly  separated from each other.   The ends of the,
 tendon,  in contact during the extension of the  foot,
 were separated two inches when it was flexed. 
T
360
  The usual apparatus was applied (32) and the limb
placed on a bolster, in a position favourable for the re-
laxation of the posterior muscles.
  In  the  evening, wound painful;  pulse  raised;  a
copious blood letting;  low  diet.   Next day, more
blood taken away;  antiphlogistic regimen,  which was
continued for several days, till the symptoms were gone:
no troublesome accident occurred.  Tenth day, the ap-
paratus taken off;  the wound partly healed ; the appa-
ratus  reapplied, and continued till  the  twentieth day,
when the  perfect reunion  of the parts rendered its fur-
ther use unnecessary.   From this time the patient be
gan to walk on  crutches.   Thirty-sixth  day,  could
walk well without his crutches.   At this period, a small
abscess occurring in his heel, induced him to'remain in
the Hotel-Dieu two Weeks longer, when he was  dis-
charged perfectly cured.
  Case II. M. Delp, leaping with some of his young
contpanions, ruptured the tendo achillis,  about two in-
ches above the os calcis.  Both standing and walking
became instantly  impracticable:  the  patient falling
down, was taken up, carried home, and from thence to
Paris, where he arrived in  the evening.  Desault being
immediately called to him, found him affected with all
the signs of a division of the tendon ;  such as, a hollow
between its divided ends, which was increased by the
flexion of the foot, diminished -by its extension,  &c.
The  usual apparatus was immediately applied, ijand as
the patient felt but little pain, only a moderate blood-let-
ting was  prescribed.   Next  day, no alteration in the
treatment; antiphlogistic regimen;  low diet continued
for some days, when the patient  was permitted to return
to his usual mode of living.  Ninth day, apparatus re-
moved for the first time : a slight separation of the ends
s 
                        361

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  application  of
the bandage : every thing found in a good state ;  but,
the patient being, from sprightliness, too much inclined
to exert himself, a splint was applied anteriorly to pre-
vent the  extension of  the  foot.  Seventeenth day,  a
fourth application of the apparatus, which was not mov-
ed again till  the thirtieth.   At this period, the reunion
was somewhat advanced: fortieth day, almost complete.
Fiftieth day, the patient was permitted to leave his bed,
and take very gentle exercise, which he continued to in-
crease gradually, till the sixtieth day, when he was dis-
charged cured.   Doubtless the tediousness of this case
was owing to the  slight  separation which existed for
some time between the fragments.
46 
MEMOIR XVI.
      ON THE FRACTURE OF THE OS CALCIS.

                   SECTION I.

  I. The os calcis, being a short  and thick bone, has
such a power of resistance, that it is but seldom fractur-
ed.   Such an accident does, however, sometimes occur,
and may arise from two causes, 1st, the action of exter-
nal  bodies, which is rare :  2dly, the contraction of the
gastrocnemii and soleus muscles, from which it almost
always proceeds.  Thus, the rotula is more frequently
broken  by the action of the extensor muscles, than by
blows received  on the bone from without: there is,
however, this difference between the effects of muscular
contraction in these two cases,  namely, that in the for-
mer, the rupture of the tendo achillis is common, and
the fracture of the os calcis very rare ;  whereas in the lat-
ter,  on  the  contrary, the  rotula is oftentimes  broken,
while the tendon of the extensors remains  almost al-
ways sound.  This phenomenon  is explained by the
difference between the thickness of the two bones, be-
tween 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 
36a
 groove of the bone, externally to some ligamentous at-
 tachments, and behind  to  the insertion of the tendo
 achillis.
   3. It is known,  1st, by an evident  inequality under
 the heel: 2dly, by an elevation, sensible to the touch,
 of the posterior fragment  above its usual level: 3dly,
 by an almost  entire inability either to stand or walk:
 4thly, by severe pain being the inevitable consequence
 of moving the foot: 5thly, by its being practicable to
 increase the displacement by flexing, and to diminish
 it by  extending the foot:  6thly, by the facility  with
 which the posterior fragment may be moved in every
 direction  by  taking hold  of it with  one hand,  and
 steadying the foot with the other: 7thly, by a swelling
 more or less considerable, which frequently  appears
 around the divided surfaces.
   4.  The  ancients gave in  general an unfavourable
 prognosis respecting this kind of fracture.  Hippocrates
 was apprehensive of some injury  being done  to  the
 surrounding  parts.  Pare considered the case mortal,
 on account of the laceration of numerous vessels which
 are connected  with the bone.  Most of the moderns
 adopt  these principles, not for the foregoing reasons,
 but on  account of the vicinity of the accident to the
joint  of the  foot.   The practice  of Desault  cannot
throw much light on this subject, as he never had more
than one or two such cases of fracture under his care;
but the  analogy  of other fractures,  situated in  the
neighbourhood of joints and even extending into them,
induces us to believe, that, if properly treated, fractures
of the os calcis will terminate as  favourably as those
of other bones. 
364
                   SECTION II.

   5.  If we attend to the signs just mentioned (3) we
will perceive that they  almost all  result  from  the
displacement of the  fragments.   But,  whence / arises
this displacement? As far as the anterior fragment  is
concerned in it, it arises  from,  and is increased by,
the  flexion of the foot;  and, as far  as relates to the
posterior one, it  is to be attributed to the contraction of
the muscles attached to the tendo  achillis, which is
itself inserted in that fragment.   Hence it follows, that
the  apparatus intended  to prevent  this displacement,
ought,  1st, to keep the foot permanently extended on
the leg: 2dly, to prevent the action of the muscles, by
keeping them in a state of habitual relaxation by means
of the constant flexion  of the leg on  the  thigh, by
making on those whose contractions are dreaded,  such
a  regular and  well  directed  compression  as  may
disqualify them  for contracting; and, lastly,  by placing
behind the posterior fragment some resisting substance,
to prevent it from rising upwards.
   6. If to these indications  we compare Desault's ap-
 paratus for a rupture of the tendo achillis, as described
 in the preceding memoir, we will readily perceive, 1st,
 that it perfectly fulfils that  indication which relates  to
 the anterior fragment; 2dly, that that one which relates
 to the posterior  fragment will be equally well  fulfilled
 by the half flexed state of the leg, by the compression
 made on the muscles,  and by a thick compress, not
 very  broad,  laid transversely above the fragment,  se-
 cured 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 frac- 
365
ture.   This compress is the oniy modification of 'the
apparatus requisite to accommodate it to the particular
case now under consideration.
  7. In applying the figure of 8 bandage here, as well
as in the case of a fractured rotula, to prevent the ascent
of the fragment, it  is necessary to use the  utmost care
ta$|free the integuments from wrinkles both above and
below the fracture, lest by  getting between the frag-
ments, they might keep them asunder, and thus impede
their reunion.
  8. Desault used  to relate in his lectures, the case of
a woman whom he had formerly seen receiving a frac-
ture of the os calcis, by falling from a great height.   I
cannot state the case fully, because I am not in posses-
sion of all the facts.   The following one however drawn
up  during the  first years of Desault's practice in  the
Hotel-Dieu, will furnish an example of his  mode of
treatment.
   Case.  A man, likely to be arrested by some one who
pursued him,  leapt  from a window nearly twelve feet
high.   In lighting, his  feet struck on a beam which
lay in his  way,  in such a manner, that the  fore part of
them only was  supported.  He made an effort to recover
his equilibrium, but as the line of gravity  of his body
had nothing to rest on, he fell backwards,  rose in order
to make his escape, but fell a second time unable to rise
again.
   When  assistance  came to him,  he complained of a
severe pain in his heel, and said, that on  falling, he had
heard  a considerable  report.   He  was  taken up, and
assisted in walking  to the Hotel-Dieu, where he did not
arrive without pain, being able  to bear  only on the
point of the diseased foot, and suffering' greatly if he at-
tempted to put his heel to the ground. 
366
   From  the signs mentioned  (3)  Desault perceiving
 that there existed a fracture of the  os calcis, made ar-
 rangements for reducing it.   This he did by extending
 the  foot  on the leg, and  drawing down  the exterior
 fragment from  the  elevation to which muscular con-
 traction had raised it, so as to bring it into  perfect con-
 tact with the body of the bone.  He then applied dae
 common apparatus  for a rupture of the tendo achillis,
 with the modification already pointed out (6).
   In  the evening  venesection was prescribed: the
 patient experienced sharp pains at the place of the frac-
 ture ;  a slight  swelling occurred at the ends  of the
 toes;  an anodyne was prescribed.   Next day, evident-
 ly better : venesection again.   Fourth day, the  patient
 is allowed to return to his usual regimen.  Eighth day,
 apparatus removed for the first time; fragments in con-
 tact   Fifteenth day, a second application of the band-
 age.   Nineteenth day  bilious symptoms.   Twenty-
 first, an emetic  given in solution.   Thirty-second day,
■further evacuations:  apparatus renewed. Forty-seventh
 day, consolidation  complete.   A  stiffness remained
 in the  part for  some time, but this was gradually re-
 moved by exercise. 
                MEMOIR XVII.

   ON  COMPLICATED LUXATIONS  OF THE FOOT,

                   SECTION I.

   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 excep-
tions and modifications.  In the treatment of such cases,
who can fix the limits between reduction,  and  ampu-
tation or  extirpation ? Who can point out, with pre-
cision,  where the one ceases to be useful  and becomes
hazardous; while the others constitute  the only re-
sources of art ? Experience and talents alone are capa-
ble of  deciding on these points, and that only  in the
chambers of the sick.  It is, therefore, less by precept
than example that practitioners ought to be instructed
here.
  2. To  furnish suitable examples  on this head 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 
368
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 ?                        4fc
  3. However difficult it may be, as already observed,
to speak in general terms, on the present subject, we •
may yet assert with safety, that authors have  greatly
exaggerated the danger of complicated luxations of the
foot.  Terrified at the extent and unpromising appear-
ance of the accidents, these writers have lost that con-
fidence  in the powers of nature which we never ought
to abandon.   They have  taken  up an  opinion,  that
luxations of the foot, differing in their symptoms from
other luxations, require also a different  mode of treat-
ment ; that reduction, by perpetuating the accidents of
the case, must prove fatal, and that amputation ought to
be adopted as die only resource.  Cases  do certainly
at times occur, where a doctrine  different  from  this
would be fatal  in  its effects: such are those  terrible
lacerations, where the foot is entirely separated from
the leg,  except some shreds of flesh with a few tendons
among them that still retain it.
  4. But, provided the blood-vessels have escaped, and
any hope of circulation and life in the part still remain,
the success of reduction  should always be first tried;
and the following examples will show,  what ought to
be expected from this practice,  when accompanied by
skilful treatment. 
369
                  SECTION II.

  LUXATION OF  THE FOOT, COMPLICATED BY  A
     FRACTURE  OF  THE FIBULA,  TIBIA,  &.C.

  ^se  I. (The following case was collected by Le-
veille.)   Abraham Genty, aged forty-three, a dealer in
wine, as he was running along the street,  slipped, and
made a false step on his left foot, which turned with  its
external edge under him, and its internal edge upwards.
He fell, luxated his foot,  and fractured the  fibula.
  The patient was carried home, where a surgeon who
was ignorant of his profession being called, did nothing
but apply a cataplasm to the foot.  In the  evening the
parts began to swell, and were extremely painful; fever
supervened, accompanied with great restlessness. Third
day, to a rapid increase of all the  symptoms was added
a delirium ; blood-letting from the jugular vein was pre-
scribed to no purpose ; things continued to grow  worse
till the sixth day, when the patient was brought to the
Hotel-Dieu, in extreme danger.
   The following was then the  state of the parts.  A
considerable swelling around the joint; a  projection of
the malleolus internus, with a depression underneath it;
a preternatural direction  of the tibia before, and of the
os  calcis, behind ; a depression near the lower end of the
fibula; a crepitation readily  perceived, on moving the
fragments; a large tumour on the outside  of the foot:
with a depression  and  mobility of the malleolus ex-
tenius.
   The luxation was immediately reduced.  Extension
made on the foot and leg brought the parts into  their
proper situations,  where they were retained by means 
370
of the bandage for fractures of the leg, and  four com-
presses  well  secured by the bandage.  One of these
compresses,  being  placed on the malleolus internus,
another on the outside of the foot, a third on the anterior
and lower part of the tibia, and the fourth under the os
calcis, prevented these  different parts from being a^in
displaced.                                       «r
   As sdon as the apparatus was applied, the pupils re-
marked with astonishment, that the restlessness of the
patient  ceased, that his pains  were relieved, and his de-
lirium disappeared; he expressed  his surprise at the
state  from which he had just recovered,  and was now
able to give an accurate account of his fall.  He was
 scarcely put to bed, when he fell into a tranquil sleep,
 which lasted three hours.  For  six days previously he
 had not slept a moment.
   In the evening, the patient was  free from  pain, and
 perfectly tranquil.   Diluting drinks  were prescribed,
 with twenty-five drops of Hoffman's anodyne  liquor:
 the apparatus was wet from  time to time with  vegeto-
 mineral water: the patient  slept  well throughout the
 night.
    Next day, the  apparatus renewed:  the parts per-
 fectly  in place:  swelling diminished; same means con-
 tinued.  Sixth day, the anodyne discontinued.  Tenth
 day, swelling still less ;  echymosis gone ; a yellow co-
 lour in the skin, an evidence that resolution is  going
  forward.   Twentieth day, swelling gone.
    Thirtieth day, the fracture of the fibula healed ; that
  bone  slightly separated from the tibia: the circular rol-
  ler drawn tighter ;  and a thick compress placed  on the
  external  malleolus,  to bring  it  to  its proper  place.
  Forty-fifth day, the apparatus for a fractured leg re-
  moved, and a simple roller substituted  in its  place: 
371
the motions of the foot painful and contracted; a small
gangrenous spot appeared on: the heel.  Fifty-fifth day,
the ulcer which proceeded from  this spot healed: mo-
tions of the part more free and extensive.   Sixty-first
day, the patient able to walk without assistance, though
not without pain.
   5. It is difficult to find an instance where the advan-
tages of reduction have been more  remarkable than in
the preceding one.   The patient had passed six days
in pain, extreme agitation, and uninterrupted delirium:
the foot was reduced,  and these  unfavourable appear-
ances instantly vanished, and were succeeded by a state
of tranquility.  Alarmed by such a  state of things, the
ancients  would doubtless have proceeded to amputa-
tion.   Let us examine into the motives which led De-
sault to an  opposite line of practice, and then inquire
into the  cause of the success with which that practice
was crowned.
   6. Had amputation  been  performed here,  it  must
have been for one of the two following reasons; 1st, fox
fear of gangrene ;  or 2dly, to remove the unfavourable
symptoms that existed.   The first apprehension would
have been quite visionary, in as much as all the blood-
vessels were sound.  Would the second consideration
have been any better  founded? It was perfectly ob-
vious, that the unfavourable symptoms which existed
arose from  the tension and overstretching of the parts,
in consequence  of  the  preternatural position of the
bones of the foot.  The  indication was  evident.   Re-
place these bones in their natural situations, the strain-
ed parts will  then necessarily become relaxed, and all
the troublesome and alarming symptoms cease with the
cause that produced them.   Experience  confirmed the
justness  of this reasoning. 
372
   7.  But the mere replacement of the parts would be
of very little avail, if it were  not permanently main-
tained, and followed up by a judicious mode of treatr
ment.   Without such treatment there would doubtiess
be reason to  apprehend all that train of troublesome
consequences, of which authors speak in such fright-
ful terms, and which arise, not from the nature of the
luxation,  but from the manner in which the patient is
treated.  A loose  apparatus,  incapable  of preventing
displacement, would allow the bones  to be deranged
anew,  and to produce again an  overstraining of the
parts, accompanied with pain, swelling,  &c.  Irritating
local  applications,  such  as camphorated  spirits  of
wine,  &c. would  increase  the'se pains;  emollients
which are employed in other cases would keep up the
swelling.
   8.  It follows  from what has just been said, that an
opposite mode of treatment ought to succeed the re-
duction,  and this we see was the case in  the preceding
instance.   There,  when the bones were once reduced,
all new displacement was prevented, because the appa-
ratus was so constructed, as to counteract the tendency
of the bones to  be displaced.  The external  edge of
the foot, which  had been turned outwards,  was now
pushed inwards  by a thick compress; the same means
served to push outwards the internal malleolus, which
had received by the accident  an inclination inwards,
and to  push the  anterior  part of the tibia backward,
and the os calcis forward, both of which were displa-
ced,  as  has  been remarked,  in  contrary directions.
Two  strong splints fixed the lateral compresses, while
the anterior and posterior ones were firmly secured by
rollers.   In the  midst of all these resistances,  the foot 
373
being necessarily immoveable,  no new displacement
could occur.
  9. A suitable and judicious position, in which the
foot, raised a little higher than the leg, was placed on
a pillow forming an inclined plane, prevented swelling,
while gentle compression, made by a bandage,  contri-
buted to the same end.   This end was also further at-
tained by the external topical applications.  To relieve
pain and remove congestion, were here,  as in sprains,
the two indications to be fulfilled.  To these indications
the spirituous and the relaxing applications formerly in
use, are alike opposed. Vegeto-mineral water,  on the
contrary, fulfils them extremely welf". Hence the neces-
sity of keeping the apparatus constantly wet with  that
liquid.
  10. Regimen influences not  a  little the  success of
the treatment.   A strict diet is necessary during the
time of the inflammatory and unfavourable symptoms.
Any excess might then prove fatal.  Desault gave, in
his lectures, an account of a woman, who had her  foot
luxated  outward, and the astragulus  forward.   Her
fever was  considerable,  her pains excruciating,  and
the swelling wore an alarming aspect.   The luxations
were reduced :  all the threatening appearances vanished,
and every thing seemed to promise a favourable termi-
nation of the  disease.   But, on the fiftieth day, the
patient,  having procured strong food, ate largely of it:
in the evening all the unfavourable symptoms returned;
the swelling became great,  and a few days  afterwards
she died.
  But if strong food be prejudicial during the time in
which  bad symptoms  are  to be dreaded, a diet too
strict would be  equally  injurious  when that time is
passed.   The weakened  powers of the system would 
374
 not be adequate to the purposes of a cure, particular-
 ly 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 in-
 deed the last resource of art, and should never be era-
 ployed till  rendered indispensable by the failure of all
 other means.
   Case II.  Maria Constant,  aged forty-six, descend-
 ing a flight of stairs in haste, fell, and luxated her right
 foot  outwards, the  tibia inwards,  and fractured the
 fibula near to the lower end.
  Her cries brought assistance to her, and she was car-
 ried to the Hotel-Dieu. Giraud, who then officiated as
 surgeon in chief, visited her, and discovered that there
 existed both a luxation and a fracture, though most of
 the signs were  rendered obscure  by a considerable
 swelling: a slight echymosis occupied the back of the
 foot, and severe pains were experienced.
  Extension on the foot, and counter-extension on die
leg, dislodged the parts by degrees from their acciden-
 tal situations, while, by  the process of conformation,
 the surgeon  endeavoured to bring them into their na-
tural ones.   This was soon effected without much vio-
lence : 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 com-
mon salt, instead of the vegeto-mineral water.
  In the evening, the pulse being  full, and somewhat
raised, a moderate blood-letting was deemed necessary. 
375
Next day, the apparatus was kept constantly moist,and
some  part  of it which had become relaxed was tight-
ened.   The pulse continuing full, a low diet was pre-
scribed.
   Fifth day, the apparatus taken off; contact between
the bones perfect: a yellowish tinge bespoke an  inci-
pient resolution of the echymosis: a slight swelling of
the leg:  vesications  formed on the part: these are
opened and a quantity of  acrid water discharged from
 them. Sixth day, light nourishment allowed;  a  small
 excoriation of the heel, which is  dressed with cerate
 spread on a linen rag.  Seventh day, regimen less strict;
 no bad symptoms supervene. Eighth day, the excoria-
tion enlarged; same dressing.   Tenth day, the excoria-
 tion  become fungous : caustic is applied  to remove it.
    Twenty-eighth day, the discharge from the leg de-
 creased ; from this time the dressings are  renewed only
 every other day.  Thirty-second day, the ulcer  is ci-
 catrized : no pains in the leg.   Thirty-ninth day, frac-
 ture of the fibula firmly united : no deformity remain-
  ing ; the apparatus laid aside :  the joint remains stiff :
  motions performed by the limb  difficult at first,  but
  become gradually more free.   Forty-sixth day,  symp-
  toms of bile ; gentle evacuants.   Fifty-fourth day, the
  patient is discharged cured, except a slight impediment
  in walking, which exercise will soon remove.
    12.  To this  example,  I might add  many  others,
   where  similar  displacements, properly treated,  termi-
   nated with equal success: no pain ; no swelling; no
   inflammation ; and therefore, of course, no mortification.
   Yet these are occurrences of which authors speak, as if
   they were the  usual consequences of such luxations,
   where, to a violent injury done to the soft parts, is ad-
   ded a fracture  near to, or even communicating with a 
376
joint. The erroneous opinions of the ancients and most
of the moderns, respecting the dangers  arising from
such vicinity or communication, have contributed not
a little to their unfavourable prognosis in the cases un-
der consideration.   Should, the patient survive  the dis-
ease, his inevitable lot, according to them, must be, a
complete anchylosis of the leg with the foot.  But, the
preceding cases fully prove, that  this apprehension is
unfounded.   A considerable time is  doubtless neces-
sary, for the recovery of motion, on account of the dis-
tension and rupture of the ligaments, the long continued
inactivity of the parts, and the  swelling which they have
undergone.  But this recovery can always be  effected
by means of exercise, gentle  at first,  increased  after-
wards, and regulated according to the principles so fre-
quently 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 wa-
ter on the parts, alkaline baths, mineral waters, and all
other external applications, so often extolled as effica-
cious, and so often found entirely useless,

                   SECTION III.

LUXATION OF THE FOOT, COMPLICATED BY A SE-
  PARATION  QF  THE  BONES  OF   THE LEG,  AT
  THEIR LOWER END.

  Case  III.   (The following case was  reported  by
Thevenot.)  I. Joseph Schneider, an ebonist, aged thir-
ty-six, as he was walking in haste, On the 23d of March,
1792, fell forward, his foot being forced backward and
outward.  He experienced at the instant severe pains in
the joint: he was unable to rise, and was therefore car- 
377
 ried home, where a surgeon, after making a slight ex-
 tension, applied a roller on the limb,  and did nothing
 further.  The patient experienced no relief.  The pains
.^increased; a swelling supervened ; convulsive motions
 began to occur; and the patient was  brought  to  the
 Hotel-Dieu, six days after the  accident.
    From the deformity of the foot, Desault immediately
 discovered that it was luxated.  Its point was directed
 outwards, while its sole was turned in the same direc-
 tion : beneath  the malleolus internus, which was too
 prominent,  was a tumour  formed by the  astragulus.
 The  crepitation of the  bones  which was easily heard,
 the preternatural distance  between the tibia and the
 fibula, the mobility of this latter bone, and the absence
 of the signs of a fracture, plainly showed that a separa-
 tion of the two bones of the leg had taken place.
     A reduction was immediately effected by means of
  extension and counter-extension, and was announced
  when it took place by a report distinctly  heard.  It was
  then retained by a bandage, calculated to answer a two-
  fold  purpose ; 1st, to approximate, and keep together,
  the two bones of the leg : 2dly, to secure the contact
  and immobility of the bones of the foot.
     Blood-letting was prescribed:  an  anodyne  mixture
  administered ; low diet;  in the night severe pains were'
  felt; next day,  they were increased; on dressing the
  limb, nothing amiss discovered; all the parts in perfect
  contact: no vestige of separation between the tibia and
  the fibula:  a new apparatus applied  ; and kept constant-
  ly moist.  Third day, the patient better : fifth day, the
  fibulaa little separated from the tibia: the circular ban-
  dage drawn   tighter to  reduce it  to its  place again.
  Tenth day, every thing  in its natural state : no pains:
  swelling gone.   Fifteenth day, a simple roller substi-
48 
378
 uted in place of the bandage for a fracture of the leg.
 Nineteenth day,  the patient began to walk, with the as-
sistance of a stick:  twenty-third day, walks easily :
twenty-eighth day,  is  dismissed  perfectly cured, and
nearly free in all  his motions.
   13. The separation of the bones of the leg, at their
lower end, does  not constitute a very serious complica-
tion of luxations of the foot, although the contrary is as-
serted by several authors.   Desault met with this acci-
dent 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 in-
wards, 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.


                  , SECTION IV.

 LUXATION  OF   THE  FOOT,   ACCOMPANIED  BY  A
   DISPLACEMENT  OF  THE  ASTRAGULUS AT ITS
   ARTICULATION WITH  THE OS SCAPHOIDE.

   14. Petit never met with more than two instances of
 that displacement of the astragulus,  now under consi-
 deration.   His general prognosis on  the subject is more
 favourable than that  respecting other luxations of the 
379
 foot, with which he never saw the present luxation of the
 astragulus complicated, as  occurred in the following
 cases.   Had such complex  cases fallen  under his  no*
 tice, there can  be little doubt, but he would have  de-
 clared amputation to be the  only resource of art on the
 occasion.
   But the experience of Desault demonstrates to us
 here, as well as in the preceding cases, the great extent
 to which we ought to carry our confidence in the powers
 of nature, when skilfully guided  by the hand of  art.
 The following  case was communicated to me by Le-
 veille.
   Case IV. John Baptist Landrin,  a  postilion, aged
 thirty-six, was  brought to the Hotel-Dieu, on the 19th
 of February, 1791.
   On the morning of the same day, a horse on which he
 was mounted having fallen,  his foot was caught under
 the belly  of the animal.   As soon as he was disencum-
 bered of the vast weight, he endeavoured to rise, but in
 vain.   The pains  which he experienced in his foot were
 extreme.  He was carried home, where some surgeons,
 having ascertained that his foot was luxated, but being
 unable to reduce it, sent him to the Hotel-Dieu.
  Desault on examining him, found the bones of his foot
 to be situated as  follows.  The internal part of the os
 calcis corresponded to the lower extremity of the tibia :
 the back  of the  foot was directed outwards, and its
 external edge downwards : under the skin and in front
 of the tibia was  the astragulus, resting on the scaphoide
 and first of  the cuneiform bones, where  it formed a
 considerable projection:  on  the back  of the  leg,  the
fibula corresponded to the tendo achillis.   The pains
had been inconceivably great from the  moment of the
 accident. 
380
   Imboldened by numerous  instances of  success  in
 similar cases,  Desault,  notwithstanding  the extent of
 the  disease, attempted the reduction.  One assistant
 took  hold  of the  superior part of  the  leg to make
 counter-extension,  and  another, for  the  purpose  of
 extension, grasped the metatarsus with one  hand, and
 the heel with .the other.   While these were pulling in
 different directions,  the  surgeon applying  his  thumb
 on the astragulus,  endeavoured to  force  it into its
 place.   His  efforts  were  ineffectual :   the  opening
 through the capsule of the astragulus being too narrow,
 would  not suffer it to pass.   Desault  perceiving  this,
 cut through  the integuments which covered the bone,
 and  having  laid bare the capsule and the  ligaments
 which  strengthen it, made an incision into  them of a
 sufficient extent, taking care to avoid the tendon of the
 tibialis  anticus, which  was brought  into view.  The
 openings being  thus  enlarged,  admitted  of an  easy
 reduction, and all the parts resumed, without difficulty,
 their natural  situation.
   The reduction being effected,  the wound was closed,
 and  covered with some lint. A  square compress was
 then placed on the back of the foot,  while a ljeng one
 was applied to  its sole,  and the whole secured  by an
 apparatus  similar to  that described in the preceding
 case.  The patient was confined to a very strict diet,
 and ordered to use diluting drinks.
   Next day, a  slight bilious diathesis;  an emetic in
 solution given; apparatus renewed.   Fourth day, an
abscess on the malleolus  externus opened;  a copious
discharge  of pus.   Eighth  day, the  parts  in perfect
 contact;  a  favourable discharge  from  the wounds;
dressings applied twice a day.   Fifteenth day, a general
 oedema; aperient ptisans ordered.  Twentieth day, the 
381
oedema  gone: a  bilious diathesis returned: in  con-
sequence of  this,  the  wounds became pale: another"
emetic  given.  Twenty-seventh  day, a very painful
excoriation occurred on the heel: care taken not to let
the foot rest on that part, as the sore appeared to be the
effect of compression.   Thirtieth day, the wounds in a
favourable  way:  all  the   bones in  exact  contact.
Fortieth day, apparatus laid aside, and a simple roller
substituted  in its  place : wounds already cicatrizing.
Fiftieth day, the limb put in gentle motion,  which is
gradually increased every day.  Same dressing  con-
tinued till the eightieth day : wounds not yet cicatrized.
Hundred and twenty-seventh day, a considerable swel-
ling around the joint:  a splinter  made  its way out and
was followed in a few days by several more. In the fifth
month an abscess formed on the heel, from which, when
opened, another splinter escaped. In the mean time the pa-
tient left the Hotel-Dieu.   During his absence more
 splinters were discharged.  Returning about a year
 afterwards with a  small  ulcer, he was dismissed again
 in a' short  time, perfectly  cured, except a  slight stiff-
 ness of the joint.
    15.  The reduction of this luxation of the foot pre-
 sents a difficulty worthy the attention of practitioners,
 as well on account of its own nature, as in consideration
 of the process which was employed on  the occasion : I
 allude  to the narrowness of the opening in the capsule.
 I  mentioned, on a former occasion,  the obstacles some-
 times 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 tco small to  afford any purchase to the surgeon. 
382
The only resource was, the use of the knife ; andtheojte-
ration was the more easily performed, on account of the
capsule being situated  immediately beneath the integu-
ments, from  which circumstance it could be the more
speedily brought into view.
   16. The apprehension of mischief resulting from the
admission of air to the articulating surfaces, would no
doubt, in this case, have restrained most practitioners:
but, even supposing this apprehension to be well found-
ed, ought it to deter the surgeon from adopting the only
possible  mean  of effecting a reduction,  and of thus
putting  an end to the  alarming state of things arising
from the displacement of the bones ?  Desault proved in
numerous instances, that the apprehensions of authors
respecting such cases  have been greatly exaggerated,
and that it is practicable to cure wounds that penetrate
into the cavities of joints, in the same manner as if they
were  simple  wounds,  and  with  but very little more
danger  to the  patient.   Yet it would  seem, that the
tediousness of the cure and the exfoliation of the bones,
arose, in the  present case, from the opening made into
the joint, and perhaps also,  in part, from the disposition
and habit of the patient.  Finally, in those  alarming
injuries  of   the  joints, unconnected  with external
wounds, where practitioners have looked to no resource
but that of amputation, Desault has, in a short time, and
without any dangerous occurrence, restored to the sub-
jects 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 out-
wards, sunk instantly to the ground, and was unable to 
383
rise again.   He was carried home, and from thence to
the Hotel-Dieu.
  Desault examining him  on his arrival, discovered a
luxation of the foot outwards, and of the astragulus for-
ward 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 with-
out 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 exten-
sion.   In an instant the pains vanished and the motions
of the foot became easy.  The necessary apparatus was
applied.  The activity of  the pulse called for blood-
letting, which  was  immediately performed.   A  low
diet was prescribed.
   On the two following days blood-letting was repeated,
both on account of the active  state of the pulse, and of
a considerable  swelling which took place in the joint.
The apparatus  was kept constantly wet with  vegeto-
mineral water.  Eighth day, somewhat better : echy-
mosis  gone.  Fifteenth day, the apparatus laid aside.
From this time the foot was gently moved every day.
Eighteenth day, the patient able to  stand on the affect-
ed  foot without pain.   Twenty-sixth day, walks with
the assistance of a staff.   Thirty-ninth,  walks with-
out limping, and enjoys all the motions of the foot.
Discharged. 
384
                    SECTION V.

 LUXA.TION 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.  Whatever care might be taken, it would
 be difficult to prevent a vast swelling, long continued
 pains, and perhaps even  a caries of the bone exposed to
 the air, with all those sufferings and dangers to  which
 such an accident gives origin.  In  such  a case  all the
 bones of the foot have been known to become carious,
 a state of things, which  calls  for the ultimate resources
 of art, and draws after it a  train  of evils, which it is
 always of the utmost importance to prevent.
   18. What means are then to be employed? Two
 expedients only remain.  1st. The amputation of the foot;
 2dly,  the extirpation of the astragulus.  The  first is
 a cruel resource,  which should  never  be adopted but
 in the last extremity, because it deprives the patient of
 a portion of himself, necessary to the performance of
 his functions.  But the measure  is forbidden by a reason
 still more  powerful.  Amidst  the  general disorder of
 the system, the severe pains experienced by the patient,
 the convulsions, and the delirium which oftentimes ex- 
385
ists, what ground has the surgeon to hope for success?
Will not the operation add  to the number  of  these
alarming appearances ?  Will  it not aggravate them ?
May it not render them fatal ? Both reason and expe-
rience reply in the affirmative.
   19. In such a case, then, the extirpation of the as-
tragulus is the expedient to  be preferred.  What in-
deed, are  its inconveniences  ? 1st.  An inevitable  an-
chylosis of the foot and leg :  2dly, a shortening of the
affected limb.  But a leg even in this state, is still better
than a wooden leg, which is the necessary consequence.
of amputation : besides, a leg of the former description
occasions no great inconvenience in either walking or,
standing, whereas one of the latter, produces  extreme
lameness:  in the first case, a heel on the affected side
somewhat  higher  than  that on the  other, is  an easy
method of removing  the deformity.  What, then,  are
such trifling  disadvantages, when compared  with the
evils which they ward off? The extirpation of the as-
tragulus is accompanied  with but  little  pain.  The
want of this intermediate body between the leg and the
foot, by producing a relaxation of the surrounding soft
parts, prevents pain and  swelling in such cases : should
abscesses  supervene, they will not, if properly treated,
gready retard the cure.   In a word, experience coin-
cides with this doctrine.   Desault has seen  it twice
verified  in the practice of other  surgeons, and three
times in his own.   I have known  of but one case of
the kind, in which the termination was fatal, and there,
a malignant fever, induced by the contaminated air of
the hospital,  certainly contributed to the death of the
patient,  which did not occur till two months after the
reduction.
                        49 
386
  Case VI.  Desault usually gave in his lectures, the
history of a case where the success of this practice was
remarkable.   A man was brought to the Hotel-Dieu,
with a luxation of the foot,  complicated with a fracture
of the lower part of the leg, and a laceration of the liga-
ments  and capsule,  through which the astragulus had
escaped by a luxation forward and upward, so as to have
half of its anterior surface exposed.   The extent of the
injury  seemed  to call for amputation.  But the youth,
the vigour, and sound constitution of the patient, gave
ground to hope that a process less desperate might suc-
ceed.   The  astragulus, already separated  anteriorly,
was extracted by dividing the attachments which held it
to the  os calcis, and the bones of the leg :  the reduction
was then affected without difficulty.  The parts being
replaced more readily in consequence of the removal of
this bone, were retained so by means of a bandage simi-
lar to that for fractures of the leg, but modified so as to
suit the particular case.  The patient lost blood once or
twice : the apparatus was kept constantly wet; a very
strict  regimen  was prescribed for some days; but few
troublesome symptoms occurred;  a  slight  swelling
took place, but was soon removed; a favourable suppu-
 ration came on ; the dressing was renewed twice a day;
 some  splinters escaped occasionally; several abscesses
 formed successively were opened, and healed up again:
 the wounds themselves closed, and the patient finally re-
 covered, with  an anchylosis, indeed, between the foot
 and leg, and a limb a little shorter than  natural, but
 which still served the purposes of walking and standing.
    20. To  this example,  I might  add those of other
 patients treated at the Hotel-Dieu, in the same manner
 and with equal success.   But what  purpose would 
387
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 be-
comes then the only resource,  and the case assumes a
resemblance to those where the limbs are shattered by
cannon balls : the success then depends very much on
the strength or weakness of the patient.
  Case VII.   A man  fell from a carriage: his foot
becoming entangled between the spokes of the wheel,
was almost separated from  the leg.   It adhered only
by a small portion of skin behind, and by the tendons
of the muscles which run to the toes both above and
below.
  Desault was called to the  patient, whom he found in
a most  deplorable state: the  pains which he suffered
were excruciating: the  parts  around the  wound were
greatly swollen; a general spasm affected  the system :
amputation was judged necessary, but was deferred till
the symptoms should be mitigated.   The limb was
dressed: next day, a gangrene  began to affect the foot,
which was then separated from the leg by cutting the
tendons; the ends of the tibia and fibula exfoliated;
the wound healed, and the patient now enjoys, in part,
the functions and uses of the leg, by means of an artifi-
cial foot, framed and  fitted on by an ingenious me-
chanic.   Had  the limb  been  too hastily amputated
while the patient was affected with general spasms,  fa-
tal consequences would probably have ensued. 
 
APPENDIX.
                   ARTICLE I.

   The following interesting paper, extracted from the
 Medical Repository, Hexad.  ii. vol. i.  p. 122.... 124,
 will give the reader a better idea, than he  can receive
 from any other source, of Dr. Physick's new and suc-
 cessful method of treating an old and  obstinate fracture
 of the os humeri.

 A Case of Fracture of the  Os Humeri, in which the
   broken ends of the bone not uniting in the usual man-
   ner, a cure was effected by means of a seton.  Com-
  municated to  Dr.  Miller by Philip  S.  Physick,
  M. D.

   " Isaac Patterson, a  seaman, twenty-eight years of
 age, applied tome in May, 1802, in  consequence of a
 fracture of his left arm, above the elbow joint, which
 had taken place several months before ; but the ends of
 the bone not having  united, rendered his arm nearly
 useless to him.
  "  The history he gave me was, that  on the  11th of
 April, 1801,  after having been at sea seven  months,
his arm was fractured by a heavy sea breaking over the
ship.  Nothing was done for his relief until next day,
when the captain  and  mate bound it up, and applied
splints over it.   No swelling supervened, nor did he
suffer any pain.   Three  weeks after this accident, he 
390
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 mak-
ing an extension, the splints and bandages were again
applied. He remained in Alexandria four months, when,
finding his arm no stronger, he left off all  dressings, and
went on board the New-York frigate as steward : in this
capacity he remained near the Federal City six months,
and by being under  the necessity of using his arm as
much as possible, he found the connexion between the
ends of the bones became looser and looser,  till, at
length, the arm bent as easily as if a new joint had been
formed at the place of the fracture.  From the frigate
he went to Baltimore, where an attempt was made by
machinery to extend  the arm, and keep the ends of the
bone in apposition, by continuing the extension.  Un-
der this treatment he remained two montiis, but expe-
riencing no benefit, he was  advised to  come to Phila-
delphia.
  "  On examining the arm, I found that the humerus
had been fractured about two inches and a half above
the elbow joint, and that the ends of the bone had pas-
sed each other, about an inch: the lower fragment, or
that nearest the elbow, was situated over, and on the out-
side of the upper portion of the bone.   The connexion
that existed between the ends of the humerus was ^o
flexible, as to allow of motion in every direction, and by
forcible extension, the lower end might be pulled down
considerably, but never so low as to be on a line with
the end of the upper extremity.  He was  admitted into
the Pennsylvania Hospital, the latter end of May ;  but
the weather becoming very  hot,  it was judged  best to
defer any operation that  might be necessary, until the
fall of the year.  Unfortunately he then contracted a bi- 
391
lious fever, of which he was so ill, that his life was des-
paired of for some days.  From this fever his recov ery
was so slow, that it was not thought proper to perform
any operation until December*  It  still remained to de-
side, by what  means a bony union of the  humerus,
might most probably  be affected.   In the year  1785,
when a student, I had seen a case in our hospital, simi-
lar to this in every essential circumstance, in which  an
incision was made down to the extremities of the frac-
tured bone, which were then sawed off, thereby putting
the parts into the condition of a recent compound frac-
ture. No benefit, however, was derived from this pain-
ful operation, and some months afterward the arm was
amputated.  This case had made  a strong impression
on my  mind, and  rendered me unwilling to perform
a similar operation.  I therefore  proposed to some of
 the medical gentlemen of the hospital, who attended in
 consultation, that a seton-needle,  armed with a skein
 of silk, should be passed through the arm, and between
 the fractured extremities of the bone, and  that the  se-
 ton should be left in this situation,  until by  exciting
 inflammation and suppuration, granulations should rise
 on the ends of the bone,  which uniting and afterwards
 ossifying, would form the bony  union that was want-
 ing.    This operation  being agreed to, it was performed
 on the 18th of December, 1802, twenty months after
 the accident  happened.   Before passing the  needle, I
  desired the assistants to  make  some extension of the
  arm, in  order that the seton might  be introduced as
 much as possible between the ends of the bone.  Some
  lint and a pledget were applied to the  orifices made by
  the seton-needle, and secured by a roller.  The patient
  suffered very little pain from the operation.   After a few
  days the inflammation (which was not greater than what 
392
is commonly  excited by a similar operation through
the flesh, in any other part) was succeeded by a mode-
rate suppuration.  The arm was now again extended,
and splints applied. The dressings were renewed daily
for twelve  weeks, during which time no amendment
was perceived : but soon afterwards the bending of the
arm at the fracture was observed to be not so easy as it
had been, and  the patient complained of  much more
pain than usual whenever an attempt was made to bend
it at that place.   From this  time, the formation of the
new bony union went on rapidly, and, on  the fourth  of
May, 1803, was so perfectly  completed, that the patient
could move his arm, in all directions, as well as before
the accident happened.   The seton was now removed,
and the small sores occasioned by it, healed up entirely in
a few days.  On the 28th May, 1803, he was discharg-
ed from the hospital, perfectly well, and he has since re-
peatedly 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, with-
out any risque of wounding blood-vessels, nerves,  or
other parts of importance.  It is thus  that solitary facts
minutely detailed and  well substantiated, oftentimes
grow into principles of extensive application. 
393
                   ARTICLE  II.

An account of Dr. Physick's improvement of Desault's
   apparatus for making permanent extension in oblique
  fractures of the os femoris.

   Dr. Physick having observed that in the application
of Desault's apparatus, the patient was sometimes in-
jured by the pressure  of the strap or roller g g  (plate
2) which passes  under the  tuberosity of the ischium
for the purpose  of making counter-extension, devised
the following method of remedying this inconvenience,
in which he succeeded to his wishes.
   He directed the upper end of the long external splint
to be formed like the head of a crutch, and the splint
itself to be lengthened so as to reach and bear against
the axilla  of the  affected  side, which must be well
defended from pressure by a bolster of flannel or some
other soft material.  By this expedient the Dr. evident-
ly formed two points of counter-extension, instead of
one, as is the case  in the  apparatus of  Desault.  Be-
tween these two points, namely, the axilla and the pe-
rineum, the same  quantity and force of pressure is, by
Dr. Physick's improvement, divided,  which, in  the
original apparatus  of Desault, is borne by the perineum
alone.  The risque of excoriation  and injury to  the
patient, then, in the former  case, is to that which he
runs  in  the  latter, only as  one to two, or nearly so.
As it is no less the duty of the surgeon to prevent suf-
fering than it  is to remove  deformity or to save  life,
Dr. Physick has certainly in this respect  made an im-
portant step in the advancement of his profession,
                         50 
394
  But there is still another advantage derived from the
lengthening of the external splint.   In the original ap-
paratus  of Desault, the strap gg intended for counter-
extension, by  passing  no higher up than the spine
of the ilium, runs too much across, and therefore acts
too much on, the upper part of the thigh.   By this  it
not only irritates the muscles of the part, and induces
them to contract, but  also  tends to draw the  upper
fragment of the os femoris a little outward, and thus
to render the thigh in some measure  deformed.  But,
in the improvement  of  Dr. Physick, the strap gg  is
secured in a mortise cut in the  external splint,  about
midway between the spine of the ilium arid the axilla.
This strap, by being thus carried higher up on the body,
does not run across the  thigh at all.  It consequently
presses  on  and irritates the muscles much less, acts
more in the direction of the os femoris, and has no
tendency to draw the superior fragment outward.
   Hence this improvement not only diminishes the pa-
tient's sufferings, but gives him, perhaps, the best pos-
sible chance of having  his limb preserved free from
deformity.
  Another improvement made on the lower end of the
external splint  by  Dr.  James  Hutchinson, deserves
also to be mentioned.   It was found that in  the ori-
ginal 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. Hut-
chinson  very  ingeniously remedied, by attaching to
the lower part  of the external splint, a little above the
mortise, a .small block  extending inwardly, at a right
angle with the  splint, so far as to be on a line with the
middle  of the  sole of the foot.  Over the end of this
block, in which a notch is cut to receive them, the ends 
395
of the  strap L are carried,  previously to their being
secured to the external  splint.  By means of this ex-
pedient extension is made precisely in the direction of
the limb, and the inconvenience  of drawing the  foot
outward is completely obviated.
  Thus improved by  Drs.  Physick and Hutchinson,
the apparatus of Desault for oblique fractures of the os
femoris, leaves, perhaps, scarcely a remaining desidera-
tum on the  subject.

                  ARTICLE III.

      EXPLANATION OF THE  THIRD  PLATE.

  This plate  gives a full  view  of an  apparatus for
making permanent  extension, in  oblique fractures of
the leg, when both bones are broken.  This apparatus
was first devised and constructed several years ago, by
Dr. James Hutchinson, then a pupil in the Pennsylvania
hospital,  and is  now in   general  use among  the
practitioners of Philadelphia.
  Fig.  1. Represents  the leg and foot, with  the ap-
paratus applied.
  A. A common roller,  passed several times round the
leg- a little below the knee, on which counter-extension
is made.
  B. A silk  handkerchief  folded, or a strong roller
made of soft muslin,  passed  once round the leg, just
above the ancle, from  behind  forward.   C. The place
where its  two ends cross  each  other  to  pass clown
along each side of the foot,  as seen at b, to D, where
they  are  secured by  a  knot drawn but  moderately
tight,  a a. The  same  ends  continued to E where
they  are again secured by a firm  knot  over  the cross
piece F, which  passes between the two strong splints 
396
G G,  that run on each  side  of the  leg  from a little
above  the knee, to  the distance of four or five  inches
beyond the  sole of the foot.  This is the  bandage by
which   extension is  made,  as  will  be  mentioned
hereafter.
   H. Two  bits of strong tape,  each about two feet
long, placed  in the longitudinal  direction of the leg,
and firmly secured by the roller A, which  passes over
their middle.   Two such bits of tape, are thus applied
on each side of the leg,  and their four ends,  passing
through  four holes in the  upper end of each  of the
splints G G, are secured  on their outsides by firm knots
as represented at H.
   Fig. 2. A view of one  of the splints G G,  separated
from the leg.
   a. The four holes in the  upper end, through which
the bits of tape H pass.
   b. The mortise in  the  lower  end which receives
the cross-piece F.
   Fig. 3. A view of the  cross-piece F, which must be
firmly  fixed  in one of the splints G G, but  moveable
in the  mortise  of the other, so that the splints may be
taken asunder at  pleasure.
   The following is the method of applying  this appa-
ratus.
   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 handker-
chief or roller  B on the  tendo achillis, brings its ends
across each other, before  the leg at C, and carrying them
down  along  each side of the foot, secures them by a
knot at D.   Letting go  the ends of the handkerchief B, 
397
he next places on each side of the leg the splints G G,
connects them at the lower end by the cross-piece F,
and  secures  them  at  the upper  end by the tapes H.
He then resumes the ends of the handkerchief B, carries
them downward as seen at a a and secures them by a
firm knot at E round the cross-piece F.
   From this  view and explanation of  the apparatus
Fig. 1, I presume  its construction, application, and
mode of operation will be very easily understood.  It
is unnecessary therefore to add, that the extension and
counter-extension made on the limb, will be directly
proportioned to the degree  of force  with which the
ends aaof the handkerchief B arc  drawn  over the
cross-piece F.   As action and reaction, in this  case,
must, as in all others, be equal, the splints G G will be
pushed upward by the ends of the handkerchief B with
precisely the same force that is applied on these ends to
draw the foot and lower fragments downward.   Hence
the counter-extension made above on the  roller A will
be exactly equal to the extension made below by the
handkerchief B.
   I ought to have observed, that it is necessary to de-
fend the soft parts, both above and below, from the  pres-
 sure of the  extending and  counter-extending straps,
 by means of soft compresses applied next to the skin.
 This  is  particularly necessary on the instep C where
 the ends of the handkerchief B cross each other.  It
 requires  some  attention on the part of the surgeon to
 prevent the 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 limb  from the ancle to the
 knee is highly  useful.   It secures the fragments  more
 effectually from lateral displacement, and prevents the 
398
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  com-
pound fractures, on account of the facility with which
it enables the surgeon to apply the necessary dressings.
These can  be renewed as  often as may be requisite,
without giving the patient the least pain, without dis-
continuing extension, or in  any measure whatever de-
ranging the fragments.  The  surgeon can also, in all
cases, discover by a single glance of his eye,  whether
or not the fragments are in proper apposition.   It is
right  to secure the whole  apparatus by three bits of
tape passed round it, similar to those tied round the leg
in the apparatus for fractures of the thigh, as represent-
ed in plate 2.
   I shall only add,  that the"surgeon must employ such
bolsters and compresses as he may find necessary to
support the limb, and protect it from undue pressure,
and that he must be vigilant to prevent, by frequent
examinations,   the  extending and counter-extending
straps from becoming relaxed.
   For a few further remarks on the subject of this ap-
paratus, the reader is referred to a paper published by
Dr. Hutchinson, in the second number of the Philadel-
phia Medical Museum.
THE END. 
 
 
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