\^ / \x^a^\ ~Wf — -K. V, %4r \ef X ^ •^ BOTER'S SURGERY. A TREATISE ON SURGICAL DISEASES, AXD THE OPERATIONS SUITED TO THEM. BY BARON BftYER, Member of the Legion of Honour, Professor of Surgery of the Faculty of Medicine of Pari>; Principal Adjunct Surgeon of the Hospital de la Charite*, Member of aeveral National and Foreign learned Societies, &c flee. TRANSLATED FROM THE FRENCH BY ALEXANDER H. STEVENS, M. D. Professor of the Principles and Practice of Surgery is the Medical Institution of New-Yovk^ and of Queen's College, New-Jersey; one of the Consulting Physicians of the New-York Dispensary, &c WITH NOTES, AND AN APPENDIX, BY THE TRANSLATOR* VOL, II. NEW-YORK: TRINTED BY T. AND J. SWORDS, No. 160 PEARL-STREET. 1816. Anne* Sc/r-^.cHX.in. Southern District of JVero-Tork, ss. BE IT REMEMBERED, That on the eighteenth day of Jane, in the fortieth year of the Independence of the United States of (L. S.) America, Alexander H. Stevens, ot* the said District, hath deposited in this office the title of a book, the right whereof he claims as Proprietor, in the words and figures following, to -wit: " A Treatise on Surgical " Diseases, and the Operations suited to them. By Baron Boyer, Member of the " Legion of Honour, Professor of Surgery of the Faculty of Medicine of Paris, " Principal Adjunct Surgeon of the Hospital de la Charite, Member of sereral " National and Foreign learned Societies, &c. &c Translated from the French by *' Alexander H. Stevens, M. D. Professor of the Principles and Practice of Surgery " in the Medical Institution of New-York, and of Queen's College, New-Jersey; " one of the Consulting Physicians of the New-York Dispensary, etc. With Notes, " and an Appendix, by the Translator. Vol. II." 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 time therein mentioned;" and also to an Act, entitled, " An Act, supplementary to an Act, entitled, An Act for the Encouragement of Learning, by securing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during the times therein mentioned, and extending the benefits thereof to the Arts of Designing. Engraving, and Etching Historical and other Prints." THERON RUDD, Clerk of the Southern District of New-York* TABLE OF CONTENTS. CHAPTER I. Pag. Of FRACTURES in general........1 Article I.—Of the Differences of Fractures . . . ib. Article II.—Of the Causes of Fractures .... 9 Article III.—Of the Signs of Fractures .... 11 Article IV.—Of the Prognosis of Fractures . . 13 Article V.—Of the general Treatment of Fractures 16 Sect. I. Of the Means of Reduction ib. Sect. II. Of the Means of keeping Frac- tures reduced........IS Sect. in. Of tlie Means of preventing and treating the occasional Conse- quences of Fractures.....t\ Sect. IV. Of the Treatment of Com- pound Fractures.......25 Articie VL—Of the Consolidation of Fractures . 30 Sect. I. Of the Time in xvhich Callus is formed, and of the Circumstances which may favour, retard, or prevent its Formation........31 Sect. II. Of Local Circumstances neces- sary to the Consolidation of Fractures 32 Sect. III. Of the Different Opinions as to the Formation of Callus . . . ib. Sect. IV. Of the Conduct to he observed at the ordinary Period of the Consoli- dation of Fractures and of Preterna- tnralJoints........35 vol. ii. & *1 CONTENTS. CHAPTER II. FS£C Of FRACTURES of the Nose .......*6 CHAPTER III. Of FRACTURES of the Lower Jaw......*? CHAPTER IV. Of FRACTURE of the Vertebras ....... 50 CHAPTER V. Of FRACTURES of the Sternum ......63 CHAPTER VI. Of FRACTURES of the Ribs........54 CHAPTER VII. Of FRACTURES of the Pelvis.......56 Article I—Of Fractures of the Ossa Innominata . ib. Ar j icle II—Of Fractures of the Sacrum ... 57 Article III.—Of Fractures of the Os Cocygis . . 58 CHAPTER VIII. Of FRACTURES of the Scapula ......59 CHAPTER IX. Of FRACTURES of the Clavicle.......$1 CHAPTER X. Of FRACTURES of the Humerus......64 Article I—Of Fracture of the Body of the Humerus ib. Article il.—Of Fracture of the Neck of the Humerus 67 CONTENTS* \11 CHAPTER XI. I'age Of FRACTURES of the Bones of the Forearm . . 73 Article I.—Of Fracture of the Forearm .... ib. Article II.—Of Fracture of the Radius .... 75 Article III.—0/ Fracture of the Cubitus ... 77 Article IV.—Of Fracture of the Olecranon ... 78 CHAPTER XII. Of FRACTURES of the Bones of the Hand ... 81 Article I.—Of Fracture of the Bones of the Wrist ib. Article II.—Of Fracture of the Bones of the Meta- carpus ...............ib. Article III.—Of Fracture of the Phalanges of the Fingers...............82 CHAPTER XIII. Of FRACTURES of the Os Femoris.....§3 CHAPTER XIV. Of FRACTURES of the Patella ......1QS CHAPTER XV. Of FRACTURES of the Bones of the Leg .... 115 Article I.—Of Fracture of the Leg.....116 Article II__Of Fracture of the Tibia .... 120 Article IH.— Of Fracture of the Fibula . ... 121 CHAPTER XVI. Of FRACTURES of the Bones of the Foot . . . 12* CHAPTER XVII. Of the DENUDATION of the Bones......127 CHAPTER XVIII. »f WOUNDS of the Bones.........131 Tui LaNTENTS. CHAPTER XIX. Page Of NECROSIS ............135 CHAPTER XX. Of CARIES..............142 Article I.—Of Caries of the Bones qf the Cranium 146 Article II—Of Caries of the Vertebras .... 14f Article III.—Of Caries of tlie Sternum .... 152 Article IV.—<0f Caries of the Ribs......155 Article V.—Of Caries of the Bones of the Pelvis . ib* CHAPTER XXI. Of EXOSTOSIS, PERIOSTOSIS, SPINA-VEN- TOSA, and OSTEOSARCOMA......159 Article I—Of Exostosis.........160 Article II—Of Periostosis ........ 165 Article III.—Of Spina-Ventosa.......167 Article IV—Of Osteosarcoma.......172 CHAPTER XXII. Of the SOFTENING and qf the FRAGILITY of the Bones............ .so CHAPTER XXIII. Of SPRAINS.............18g CHAPTER XXIV. Of LUXATIONS in general........192 Article 1.-0/ the Differences of Luxations . " ib Article 11.-0/ the Causes of Luxations . . 198' Article m.-Of the Effects of Luxation* . .- . 200 Artjcle IV.-0/ the Signs of Luxations . . . . 20* Article V—Of the Prognosis of Luxations . . . 207 Article XL~Of the Treatment of Luxations . . 208 contents. ij CHAPTER XXV. Of LUXATIONS of the Lower Jaw.....216 CHAPTER XXVI. Qf LUXATIONS of the Vertebra:.......227 Article I.—Of Luxation of the Head upon the first Cervical Vertebra............ih# Article II—Of Luxation of the first Vertebra upon the second..............229 Article III.—Of Luxation of the Jive last Cervical Vertebrae...............231 Article IV—Of Luxation of the Bodies of the Vertebra: 235 CHAPTER XXVH. Of LUXATIONS of the Ribs........236 CHAPTER XXVIU. Of the SEPARATION of the Bones of the Pelvis . 239 CHAPTER XXIX. Of LUXATIONS of the Clavicle......247 Article I—Of Luxations of the Sternal Extremity ib. Article II.—Of Luxations of the Humeral Extremity qf the Clavicle.............251 CHAPTER XXX. Of LUXATIONS of the Arm...... . . 254 CHAPTER XXXI. Of LUXATIONS of the Forearm......267 Article I—Of Luxations of both the Bones qf the Forearm...............ik CHAPTER XXXII. Of LUXATIONS of the Bones of the Forearm from each other.............. 276 X CONTENTS. Pag be crushed to pieces, fractures of short bones almost al- ways depend on muscular action; which is the most tre- guent cause of fracture of the patella, of the olecranon, ana of the os calcis. The long bones, which serve as supporters or levers, are most exposed to fractures; therefore our remarks on fractures in general will be principally appli- cable to those of the long bones. 2d. In relation to the point or place of fracture : Bones may be fractured at different points of their length. The fracture most commonly takes place in their middle part, and then they are broken like a stick which is bent beyond its extensibility by two hands placed at its ends. Some- times, however, the fracture happens nearer the extremity of the bone, and in that case it is always more danger- ous, as we shall explain in speaking of the prognostic. Sometimes the bone is fractured in different parts of its length : this double fracture is produced, at times, by two different causes, which have acted successively or simul- taneously upon the different parts of the bone, or by the same cause which has acted at the same moment upon dif- ferent points of its length. These distinctions of fractures, which relate to the parts they occupy, are not mere scho- lastic subtilities; they have a very great influence upon the prognostic and treatment, as we shall see hereafter. 3d. In relation to the direction of the fraeture : A bone may be broken in different ways, and the fracture receives various names, according as its direction is different. In relation to the axis of the bone : It is transverse when the bone is divided by a rupture perpendicular to its length; oblique when the division of the bone is not perpendicular to its length, but removed from it more or less upon one side or the other, which renders the surface of the fracture greater, and causes greater difficulty in keeping together the broken fragments of the bone. Oblique fractures dif- fer from one another according to their greater or less ob- liquity ; according as they are oblique in their whole ex- tent, or partly oblique and partly transverse. A fracture is complicated when the bone is broken in different parts, and divided into a great number of pieces; for then the soft parts are more or less injured. Many authors have admitted another kind of fracture: for that which is said to happen parallel to the length of a long bone. Duverney, who does not doubt the possi* Of Fractures in general, • bitityof this fracture, mentions three cases of it in his Treatise on the Diseases of the Bones, vol. i. page 167.— J. L. Petit believes this kind of fracture imaginary : ho / gives a very good reason for it; he says, " There are no blows capable of fracturing a bone longitudinally, which would not have fractured it obliquely, or transversely, with a great deal of ease. Besides, supposing that this fracture might really exist, it would be impossible to dis- cover it upon the liviBg body through the thick contused parts which cover the bones, and to distinguish its effects from those of simple contusion of the bone." The opinion of J. L. Petit has prevailed, and practitioners now regard a longitudinal fracture of the great bone of the limbs, as impossible. We find, however, after gun-shot wounds, the bones splk lengthwise, even into their articulations: but these examples do not prove the possibility of simple longitudinal fracture. Whatever be the direction of a fracture, the division always extends throughout the thick- ness of the bone, which is completely separated into two parts; so that the distinction of fractures into complete and incomplete, admitted by many authors, is not well founded, since the bones are entirely broken: it never happens that, their continuity is preserved in part by means of some bony portion that has not suffered division. The elasticity of the bones, and the prompt and sudden causes which fracture them, do not permit them to be broken thus in- completely, or only in one part of their thickness. 4th. It is of very great importance to known the dif- ferent positions of the fragments, sinee the treatment con- sists almost entirely in remedying or in preventing these derangements. Nevertheless, we must not think that the displacement of the fragments is an absolutely essential symptom ; for we very rarely meet with it in members eomposed of two bones, when only one of them is fractur- ed ; neither does it happen in all fractures of the necks of bones, as we see certain fractures of the cervix femo- ris, whose fragments are not separated until the person attempts to walk, or imprudently moves the limb. We like- wise see fractures of the leg, in which there exists nei- ther displacement of the fragments, nor alteration in the form of the limb, especially when the tibia alone is frac- tured near its superior extremity, where it is wry thick : then the corresponding surfaces of the fragments, having considerable extent, separate with difficulty, if at all; and, besides, the fibula resists the action of causes which tend fr> effect a displacement. But when the two bones of the it Soger's Surgery. leg, or forearm are fractured at the same time, displace- ment usually happens, as in fractures of limbs formed only of one bone, in consequence of the small extent of the surfaces of the fragments, and of the great number of muscles that tend to displace them. Let us now examine in what directions the fragments can be displaced, and what are the causes of this displacement: the displace- ment can take place according to the thickness of the bone, its length, its direction, and its circumference. According to its thickness : In transverse fractures only do we observe this kind of displacement, and then the two fragments touch each other in some point of their sur- faces, or they are entirely separated from each other; in which last case, the limb is shortened by the riding of the fragments that slide up by the sides of each other. According to its length : This mode of displacement, in which the fragments of the fractured bone ride more or less upon one another, takes place in oblique fractures ; and even in transverse fractures, when the displacement, according to its thickness, has been such, that the surfaces of the fragments do not correspond. We shall see, in the end, that, whenever there is a shortening of the limb in fractures of the extremities, it is the inferior fragment that is displaced. We may class in the mode of displace- ment, of which we are speaking, that which happens in fractures of the patella, of the olecranon, and of the os calcis; but this last differs from the others in this, the fragments, instead of riding one upon the other, are sepa- rated according to the length of the bone, and remain separated by a more or less considerable interval. According to the direction of the bone : In this kind of displacement, the two fragments form an angle more or less projecting, and the bone appears curved. We observe this displacement principally in comminutive fractures: it sometimes happens in simple fraetures; for example, in the leg, when the member not.resting upon an exact horizontal plane, the heel is lower than the rest of the lee • then the angular projection of the fragments is anterior • it would have been posterior, if the heel had been too much elevated. According to the circumference of the bone : This dig- placement happens when the inferior fragments receive a rotator: motion, while the superior remains unmoved, as id the fractures of the cervix femoris; if the foot be badly secured by the apparatus, its weight, joined to that •f the legs and muscular action, draws it outwards, and Of Fractures in general. $ causes the inferior fragment to turn in this direction. Be- sides, the simple displacements of which we have just spoken, there are compound ones ; viz. those whicli hap- pen in several directions at the same time; such for ex- ample, as that which we observe in a fracture of the os femoris, when the inferior fragment being drawn inwards, the. point of the foot is inclined outwards. What are the causes of displacement ? The bones, pasT she organs of our movements, have not in themselves any power capable of producing displacement; but they are obedient to the impulse of exterior bodies, to the weight of the member, and to muscular action,—three causes of the displacement of fractures, which we shall successively ex- amine. The displacement may be produced by an external power, either at the moment in which the fracture hap- pens, and by the action even of the fracturing cause, or by the weight of the body, when the fracture precedes the fall, or by any other external cause which acts upon the fragments, at a shorter or longer period after the bone has been broken. The external force, which produces a fracture, acts, sometimes, upon the place where the bone breaks; some- times upon parts more or less distant from the fracture. In these cases, the action of this force is not entirely em- ployed in producing the solution of continuity; it is spent in causing the displacement of the fragments. Falls are the most common causes of fractures ; but sometimes the fall does not take place until after the leg or thigh is broken ; then the weight of the body produces the dis- placement, by pushing the superior fragment against the flesh, which it tears more or less. This happened to Am- brose Pare. This celebrated surgeon received a kick from a horse, and in order to avoid a repetition of the blow, immediately fell down, and the two bones of the left leg, which were broken, not only pierced the skin, but like- wise the stocking and boot. I have seen a case almost similar, in a young man of twenty years old, who, while standing up, received upon the middle part of his right thigh, a blow from the shaft of a carriage, which fractur- ed the femur. The weight of the body not being sup- ported by this thigh, he fell down; and, in his fall, the su- perior fragment not only pierced the muscles and the skin, but likewise his breeches. The weight of a limb n.-ay cause displacements according to the direction or circum- ference of the bone, as we have already raid. The move- ments given to a limb in lifting up the person, and in trans- 8 Boyer's Surgery. porting him to his bed, sometimes change the relation of the fra^nents, and occasion their displacement. But of all causes of the displacement of fractures, the most common and powerful is muscular action. Amongst the muscles which surround a fractured bone, some are attached to its whole length, and hold equally to both fragments; some arise from the bone above, and are inserted into that which is articulated with the inferior fragment, or into the frag- ment itself; others which come from a point more or less distant, terminate in the superior fragment. The muscles that surround the os feraoris, furnish us examples of these three dispositions: the triceps adductor is at- tached to the whole length of the bone; the biceps, the semi-mesn.'iranosus, the semi-tendinosus, arise from the pelvis, and are inserted into the leg, with which the infe- rior fragment is articulated, and whose movements it fol- lows ; the great adductor is inserted into this fragment itself, and the iliaeus, the psoas, the pectineus, etc. arise from the loins and pelvis to be inserted into the femur, not far from its superior extremity. The muscles that are attached to the two fragments, contribute very little to their displacement; they may, however, draw them both toward the side to which they are attached, and thus change the direction of the limb. The triceps adduetor, especially its mi J lie part, acts in this manner after fracture of the os femoris, and renders the thigh convex anteriorly. The coi'aco-brachialis tends to produce the same effect, when the humerus is fractured below its middle. But it is j/incipally to the muscles attached to the inferior fragment, or to the limb with which this fragment is ar- ticulated, that we mist attribute the displacement. If the humerus were fractured between its superior extremity and the insertion of the pectoralis major, this muscle, aided by the longissimus dorsi, and the teres major, would driw inward the inferior fragment, and displace it by car- rying it to the external side of the superior fragment, which remains immoveable, in consequence of its short- ness, and because nothing provokes the action of the mus- eles inserted into it. In fractures of the neck of the fe- mur, the superior fragment, shut up in the acetabulum, has no muscles attached to it: those that are attached to the inferior fragment, draw it upward and backward; and displacement in this direction is unavoidable. In every fracture, the inferior fragment following the move- ments of the member with which it is articulated, the muscles which are inserted into the bones of this lkab, be-' I Of Fractures in general. 7 eome very powerful causes of displacement: thus, after fracture of the femur, the biceps, the semi-riiembranosus, and semi-tendinosus, draw the leg, and, with it, the inferior fragment, upward, inward, and backward, and cause it to ascend upon the internal and posterior side of the superior fragment, whose extremity then projects to the anterior and external side. In fracture of the leg, the gastroc- nemii, the solsei and pcronei, by acting upon the foot, draw the inferior fragment of the tibia and fibula, and cause it to slide along the external and posterior side of the superior fragment: for in this, as in all other cases, the strongest muscles cause the displacement, by drawing towards them the inferior fragment npon which they act; and as the posterior muscles of the leg are more numerous and stronger than those of the anterior part, and as those of the external part ai*e not counterbalanced by any muscle, the displacement takes place backward and out- ward. We can then, by supposing a fracture in any point of a long bone, determine a priori, from our anatomical knowledge of the muscles, in what direction the displace- ment ought to take place, if no resistance be opposed to the muscular action, and the displacement depend solely upon this cause. Sometimes the muscles that are attached to the superior fragment alone, are sufficient to displace it. In fracture of the femur, just below the great trochanter, the psoas and iliac us muscles draw forward the end of the superior fragment, which lifts up the skin, and forms towards the bend of the groin a more or less considerable projection : but we must observe that, in general, displacement of the superior fragment i3 very rare; the inferior fragments alone is put out of its place. The manner in which the displacement of fractures takes place by the action of the muscles, explains a phenomenon that usnally accompanies them, and which is particularly observed in fractures of the femur, of the clavicle, and of the leg, viz. the projection of the superior fragment, or that which is nearest the trunk. We should be led to be licve, at first sight, that (his projection is formed by the superior fragment, which, in quitting its natural situa- tion, is drawn up above the inferior; but if we reflect a little, we shall see that the end of the superior fragment projects ; -because the inferior fragment is displaced, and drawn to that side where the strongest muscles are attach- ed. Thus we observe, if we reduce the inferior fragment to its natural place, the projection formed by the supe- 8 Boyer'mrSmrgery. rior fragment, disappears. If, instead of this, we inak'' use of tight bandages, or any machine to reduce the pro- jecting end, we never succeed; and if we persist in the employment of these means, inflammation will supervene, and perhaps gangrene of the skin, and other soft parts that cover the projecting point of the bone. In relation to the circumstances which accompany fractures: We distinguish them into simple, compound, complete, incomplete, and complicated. The fracture i* simple when only one bone is broken, and the soft parts have received only that degree of lesion inseparable fro#i the case, and without any accident that opposes the cura- tive indication, which consists in the re-union of the di- vided parts. A fracture is compound when the bone is broken in different places, or when the two bones which form a limb, as the forearm, are broken, without any other accident. By incomplete fracture, some authors under- stand that in which the two bones are broken at the same time; but according to the greater number, the fracture-is complete when the bone is entirely broken ; and incomplete when the continuity is preserved in part, by means of some bony portion which has not suffered division. Taken in this last sense, the distinction of fractures into complete and incomplete, is not admissible; since, as we have al- ready said, the solution of continuity always extends throughout the thickness of the bone. A-fracture is 'Complicated when it is accompanied by accidents which multiply the indications, and require the employment of different remedies, and different operations, in "order to effect the cure. Fractures may be complicated with con- tusion, with wounds, with the opening of a large blood ves- sel, with luxation and disease. The contusion and wound are often accompanied with inflammatory swelling, with fever, with acute pains, with convulsions, &c. All fractures are accompanied with a certain degree of contusion; for an external force cannot overcome the co- hesion of the parts of a bone, without acting at the same time upon the soft parts over it; and as these parts are between the wounding cause and the bone, which is hard, they must necessarily be bruised. Thus contusion can- not be regarded as a complication of fractures, unless it exist in a considerable degree, and requires partieular means, different from those we employ in simple fractures. A solution of continuity of the soft parts, whether it be occasioned by the fracturing cause, or produced by the fragments of the broken bone, which tear the muscles and Of Fractures in gtmeral. 9 skin, is always a complication of fraMure*. and is attended with more or less inflammatory swelling, according to the extent of the wound, and the nature of the torn parts. Fractures are sometimes accompanied with luxation ; but this complication is rare: it can only take placO when the luxation precedes the fracture, or when accidents are produced at the same moment, and by the same cause. After a fracture has happened, a luxation cannot lake place, in consequence of the small extent of surface Which the fragments oflfer to the action ol external causes* and their great mobility. The action, then, of these pow- ers is limited to moving the fractured ends, burring them in the soft parts, producing greater or less laceration. Fractures are complicated with other diseases; as scor- butus, syphilis, &c. and this complication is unfavourable, as it retards the formation of callus, and >omelimcs pre*. Vents it entirely. And, finally, an acute disease may oc* cur during a fracture, and render the cure more long ami difficult. ARTICLE II, Of the Causes of Fractures. The causes of fractures are distinguished into predis- posing and remote, and into efficient and proximate. The first are relative to the situation of the bones, lo the func-» tions they fulfil, to the age of the individual, and to the* diseases with which he may be affecied. The superficial bones are, in general, more exposed to fracture than the deep seated ones, which are covered by thick soft pails, which protect them from external violence. The use of certain bones exposes them to fracture ; the radius, in con* Sequence of its eennexion With the hand, is more exposed than the ulna; the clavicle is often broken, because it performs the office of an arch which holds the shoulder' from the trunk, and supports the efforts of the superior extremity. Old age ought to be arranged amongst the predisposing causes of fractures. As we grow old, our bones become more fragile, because they are eharged with a greater quantity of phosphate of lime. In old people, the quart* tity of this saline and inorganic part of the btines is very great in proportion to its fibrous and organic ,»;vrts, and fo# fhis reason the bones of old persons frrcafc with groat $i* VOTi. it. 2 U) Boyer's Surgery. cilhy. In children, on the contrary, the bones being more fibrous, and less charged with the calcareous phosphate, en- joy a greater degree of flexibility, yield and bend upon themselves, when the fracturing causes act upon it, and tend to break it. There are diseases which manifestly dispose to fractures ; there are certain virus that act upon the gelatinous parts of the bony system, destroy it, and render the bones very fragile. Thus we sometimes see women that are attacked with old and ulcerated fractures, break some of their bones from the slightest causes, in making a moderate move- ment, or merely in turning in their beds. The venereal vi- rus, the scorbutic and riekety, and many others which it is difficult to duly appreciate, may render the bones very fragile, as the most authentic observations of surgeons suf- ficiently prove. Some authors place cold among the pre- disposing causes of fractures; but if fractures are more frequent in winter than in summer', it is because falls are more common, and the bodies on which we fall are harder. The efficient causes of fractures act in overcoming the force of cohesion of the parts, and in lengthening the bone beyond its extensibility: they are external and internal ; the internal cause is muscular contraction, which often produces fracture of the patella, olecranon, and os calcis ; the external are more common : sometimes they act far from the place where the solution of continuity is produced, and sometimes their action is limited to the place where this solution of continuity is affected. When the fractur- ing powers are applied to the two ends of a bone, they cause a curve, and tend to approximate them: thus in a fall upon the shoulder, the clavicle being violently pressed on the sternum, is bent forward and fractured. If we fall upon our hands, the radius being pressed between the weight of the body and the earth, is bent towards its middle, and fractured in that point of its length. The natural curve Ot the bones determines as well the manner in which the tracturing cause acts as the place of the solution of conti- nuity. In this case the contusion would be less than if th©' cause of the fracture had acted upon the place in which solution of continuity happens. The ends of fragments pushed against the soft parts only produce a greater or less degree of laceration : but when an external power frac- tures a bone at the same place where it exerei.es its ac- tion, it bends the bone to the opposite side, and bruises the parts which it strikes. Thus, for example, a blow with a stick applied upon the middle of the clavicle, which is there Of Fractures in general. 11 only sustained by the soft parts, bends it downwards, and never fractures it without occasioning more or less contusion, and sometimes a contused wound. When the fracturing cause is applied with great force upon a hone equally supported on all its parts, it breaks it into many pieces ; and this kind of fracture, always very serious, and often accompanied with wounds and lacerations, is termed eomminutive. ARTICLE III. Of the Signs of Fractures. The signs of fractures are divided into rational and sen- sible. The first are pain and inability of moving the limb : but as these effects may be produced by luxation and contu- sion, as well as by fracture, they cannot serve alone to establish the diagnostic. The sensible signs are very sud- den changes that happen in the conformation of the limb, in its length, in its form, in its direction ; any separation, or inequality sensible to the touch, when the bone is su- perficial ; and, lastly, the crepitation produced by the rub- bing of the ends of the fragments against each other.— Whenever we observe a diminution in the length of an in- jured limb, before we pronounce this shortening to depend upon the riding of the fragments, we must see if the extre- mities of the bones have not abandoned their articular ca- vities, and inform ourselves if the person have not natural- ly, or in consequence of some old badly reduced fracture, one limb shorter than the other.—If we compare the length of the inferior extremities, wc must give to the pelvis an horizontal position, and place upon the same line the ante- rior and superior spinous processes of the os ilium ; for if these two prominences be not upon a level, the extremity towards which the pelvis inclines, will appear longer than the opposite extremity. They who know the conformation of our limbs, who justly appreciate the relation of (he pro- tuberances of the ends of bones, will easily perceive the changes that a fracture will produce in them. Whenever, by means of a fall or blow, (he limb is concave in a place where it ought to be convex or straight, and vice versa, this change of form and direction must be the result of a fracture with displacement. The internal side of the great toe, when the person is lying upon an horizontal plane,. If &&yerls 8urg*ry. ought to correspond to the inner edge of the patilla: tf this natural relation be ehanged, and the inner edge of 1*+ great toe corresponds to the external side of the patilla, there can be no doubt of a fracture of the two bones of tne leg. Bv pressing the fingers on tha part of the bone near- est the integuments, we perceive the inequalities which re- sult from the displacement of the fragments. This di- agnostic is particularly easy when the bones are covered with oily a slight thickness of soft parts. But in making these examinations, we must take care to touch very gently those parts where we see the splinters or points of bones sticking out ; for by pushing hard the sensible parts against the points ami edges of the bones, we convert a salutary examination with a cruel punishment. The crepitation, or the noise, which the broken ends of a bone make in rubbing against each other, is one of the principal signs of fracture. To make this necessary exami- nation with as little pain as possible, it is proper, if the limb be small, to fix the upper part with one hand, while the other gently moves the lower part. Where the size of the limb does not permit us to embrace it in this manner, the upper part is to he held by an assistant; so that in moving cautiously the lower end, we may cause a slight crepitation, which is sometimes audible to the ear, but which the surgeon commonly feels by the shock which the broken fragments communicate to his hands. A skilful practitioner distinguishes easily the crepitation from the crackling made by emphysematous tumours, when they are compressed, and from the noise which the articulations make when there is a want of synovia on their surfaces. Although it is easv, in general, to discover a fracture by the above sieis, there are cases in which it is almost im- possible to determine the nature of the accident, until the; expiration of the first three or four days. This difficulty in forming the diagnosis may depend upon several causes.: Sometimes the bone affected is situated so deeply, and shin rounded by muscular masse* so thick, that we cannot feel the solution of continuity, and the crepitation is not to ba perceived: in such cases, if the displacement be not con- siderable, as in certain fractures of the neck of the fe- mur, we may easily mistake the nature of the accident. Fractures of the bones of the forearm and of the leg* when only one of the bones is injured, being sometimes without displacement, arc then difficult to discover; the sound bone supporting that which is fractured, hinders the dis- placement to a certain degree, ami prevents any sensible- Of Fractures toi general. 18 alteration in the confer oration of the limb. And if we be called too late, and swelling and inflammation have already supervened about the fractured parts, we cannot often de- termine the nature of the accident. In this case, where is the praetitioner who has not herilated before he could de- termine whether there was fracture or not i and even though he should discover the fracture immediately, ho ought to wait for the abatement of the inflammation, before he should proceed to an exact reduction. When in spite of our most attentive examinations, we cannot discover a fracture, whose existence we suspect we ought to apply to the limb an apparatus to prevent displacement, and employ means proper to abate the swelling and inflammation. At the expiration of a few days, we shall either have discover- ed our error, and then we can take off the bandages whose application have produced us harm, or we shall be con- vinced in the reality of the fracture, and can pay that at- tention to it which it requires. , i ARTICLE IV. Of the Prognosis qf Fractures, The prognosis of fractures varies according to the kind of bone fractured, the place and direction of the frac- ture, the particular circumstances which accompanies it, and, lastly, the age and health of the individual. 1st. In relation to the kind of bone fractured. Fractures of superficial bones, and of those little surrounded with muscles, are eaderis paribus, more serious than fractures of hones surrounded by numerous and powerful muscles : thus a fracture of the clavicle is not so dangerous as that of the humerus. Fractures of tire superior extremities arc al- ways attended with less danger than those of the inferior: those of short bones, when they are produced by external violence, are in general more serious than those of long bones, because they are commonly accompanied with greater contusion and swelling of the soft parts, and fol- lowed by a considerable stiffness of the joints. 2diy. In relation to the point of fracture. Fractures are less dangerous when they take place in the middle of bones: in these cases, the fracturing cause oftentimes does not act upon the spot when the fracture happens, the soft parts are not much contused, and inflammation is less 14 Bayer's Surgery. to be dreaded. Fractures of the ends of bones may occa- sion a false anchylosis of the neighbouring joints : thus in a fracture of the femur above its condyles, the inflamma- tion extends to the knee joint, which contracts a stiffness that is only dissipated by degrees, and sometimes never completely removed: the* inflammation extends to the ar- ticular surfaces, and is attended with more serious symp- toms, because the contusion has been greater ; and, lastly, the splints having no hold upon the shorter fragment, the displacement more readily follows; for this reason that a fracture of the neck of the thigh bone is considered more serious than that of any other part of the bone. If a bone be broken in many places, the fracture is more se- rious, and the treatment more difficult; but it is still more serious wjien two parts of a limb are broken at the same time ; for instance, the thigh and leg. It is then almost impossible to reduce and unite the fracture of the thigh, without a diminution of its length. When the two bones of a limb are fractured, the case is more serious than when only one is broken. Sdly. In relation to the direction of the fracture. Trans- verse fractures are less serious than oblique, especially if the fragments remain supported by each other, and there is not a total displacement. Oblique fractures are more serious according to the degree of their obliquity; for then the fragments not being held in their places by each other, are more easily deranged from their mutual contact by the contraction of the muscles: hence we consider an oblique fracture of the body of femur os almost as difficult to re- duce as one of the neck of the bone. 4thly. In relation to the particular circumstances which accompany it. Simple fractures, whatever may be their situation and direction, are less dangerous than compli- cated fractures, and these are more or less serious accord- ing to the kind of complication. A slight contusion does not add much to the danger of the accident, but when the contusion is great, and the bone broken into numerous splin- ters, some of which are buried in the flesh, the inflammation rises to such a height, that in a few days gangrene seizes the limb, extends to the trunk, and causes the death of the patient. Fractures complicated with wounds are most serious of all; the danger and difficulty of cure are always proportioned to the splintering of the bone, and the lacera- tion of the soft parts. The accidents that follow these frac- tures are hemorrhage, inflammatory swelling, pain, fever, delirium, convulsions, gangrene, abscess, &c. The degree Of Fractures in general. IB and number of symptoms render the case more or less se- rious. When in a complicated fracture, the bones are un- covered, you must expect a long and difficult treatment, be- cause the naked bone must exfoliate. In general, fractures, complicated with contusion and wound, are more dangerous in the inferior than in the superior extremities; and as it is almost impossible to cure them without some defor- mity or shortening of the limb, we must warn the patient's friends of these circumstances, that they may not attribute to the fault of the surgeon that which unavoidably results from the nature of the case. ^ The complication of luxation renders fractures more se- rious, for then it is impossible to reduce the luxation before the consolidation of the fracture, and when that is accom- plished, the luxation cannot be reduced. And though we should be able to reduce the luxation before the union of the fracture, as we can sometimes in the gingly moid joints, the accident is very serious, as anchylosis is the almost in- evitable result. 5thh. In relation to the age and health of the indivi- dual. Fractures heal easier in young than in old persons, whose vital powers are weakened, and whose fluids are in a state of impoverishment very unfavourable to the forma- tion of callus. In extreme old age, the cure of fractures is yet more difficult, and sometimes impossible. Experi- ence proves that fractures are more easily consolidated in persons of a good temperament, and who enjoy good health, than in those wi.o have a taint of any general dis- ease ; as the scurvy, syphilis, &c. When these taints exist in a high degree, they so vitiate the actions of the solids, and the quality of the fluids, as to prevent entirely the formation of callus. Pregnancy, contrary to what au- thors have said, does not prevent the consolidation of frac- tures, and in no May adds to the aggravation of the acci- dent. But as there are examples of fractures in pregnant women, in which cases the consolidation did not take place until after delivery, we ought, in similar circum- stances, inform the friends, that the treatment may be long and difficult, so that if any accident happen, the fault may not be thrown upon the surgeon. ( « ) ARTICLE \". Of the General Treatment of Fractures. The general treatment of fractures includes threepria- eipal indications: 1st. To reduce the pieces of bones to their natural situation; sdly. To maintain them in this state ; Sdly. To prevent accidents, and to remedy them, if they come on. The first indication arises only in fractures with displacement; for in those in which the fragment! have not changed their relation, we have no need to make any attempts at reduction; all we have to do is to retain them in their situation. Section I. Of the Means of Reduction. The means we make use of in the reduction of fractures. are arranged under three principal heads, extension, coun- ter-extension, and coaptation ; but they vary according to the kind of displacement, and we generalize too much in supposing they are all necessary in every kind of frac- ture. There are cases in which extension and counter- extension are altogether useless, as in fractures of the pa- tella and olecranon, and in which the only displacement is a separation of the fragments. In order to reduce this kind of fracture, we give to the limb a position in which the muscles that are inserted into the superior fragment are relaxed, and then bring the fragments towards each other. We mean, by extension, the action by which we draw the lower fragment of the bone towards us, in order to put the fragments in their natural situation; counter- extension is an opposite action, which hinders the whole limb, or body, from obeying the efforts of extension. The hands of intelligent assistants are best calculated Ibr these operations; we very seldom dei'ive any benefit from the employment of pulleys and mechanical contri- vances, when the action of the muscles cannot be over- come by the hands of the assistants. These violent means only occasion great pain, and bring on a spasmodic con- traction of the muscles, whose resistance augments as we increase our efforts. This spasmodic re-action of the muscles is sometimes so considerable, that we should sooner rupture them, than lengthen them sufficienth to bring the ends of the bones into contact. If the re-action of the muscles be the effect of the irritation, swelling and Of Fractures in general. 17 pain, we had better wait until these symptoms subside, he- fore we proceed to the reduction. Formerly we were ad- vised to apply extension to the inferior fragment, and coun- ter-extension to the superior; but besides its being diffi. cult and sometimes impossible to lay hold of the two frag- ments (as in a fracture of the cervix femoris, for exam- ple) in making extension and counter-extension upon the bone that is broken, we compress the greater part of the inu.-*les. which surround it, and this compression pro- duces spasmodic contraction, which renders the exten- sion and counter-extension useless, and often hurtful. To avoid this iuconvenience, we must make extension upon the limb that is articulated with the inferior fragment, and counter-extension upon that which is articulated with the superior fragment. In a fracture of the leg, for ex- ample, the means of extension act upon the foot, and the counter-extension is applied to the thigh ; and in a frac- ture of the thigh bone, the extension acts upon the leg, and the counter-extension upon the pelvis. It is difficult to determine justly what degree of exten- sion should be employed. This varies according to the kind of displacement—the number and the power of the muscles which surround the fractures. Iu transverse frac- tures, when the displacement is in the direction of the thickness of the bone, moderate extension is sufficient, and we niuke use of it with the view of diminishing the rubbing of the surfaces of the fragments, which always have rough asperities ; but whatever be the direction of the fracture, when the fragments have slid up by the side of each other, in order to replace them, we must use counter-extension proportioned to the degree of shortness in the limb, and to the force of the muscles that produced it. Extension should be made gradually : if we draw sud- denly and with violence all at once, we shall cause a spas- modic contraction of the muscles, and perhaps rupture them, for their fibre a will not have had time to jield to the power that tends to lengthen them. Extension should be made in the direction of the inferior fragment, and con- tinued in that which is natural to the body, of the bone. In every fracture with displacement, when the necessa- ry extensions are made, we must endeavour to place the fragments in their natural situation. This is called coap- tation. The operation is differently effected, according to the kind of displacement. Although the reduction of fractures be, in general, easy, it sometimes happens that the first attempts at rudmjiiuu vox., if. 3 18 Bayer's Surgery, an not succeed : we must then look for the cause that bin ders the reduction. Sometimes the want of success arises from the forced exteusion of the member, and the unequal action of the muscles. We remove this obstacle by placing the limb in a state of semi-flexion, in which position all the muscles that pass over the fractured part, are equally re- laxed. At other times the difficulty depends upon the ex- tension being too feeble in proportion to the number and strength of the muscles, and then it is necessary to in- crease it to a sufficient degree. But our failures in at- tempts at reduction generally depend upon a convulsive contraction in the muscles, and the existence of inflamma- tion, great swelling, and pain. If, in these cases, we per- sist in our attempts to reduce the fracture, and make use of violent extension, we only augment the irritation and spasm, and often do very great injury. In such cases, be- fore attempting the reduction, we must endeavour to abate the irritation and pain, by blood-letting, low diet, diluents, emollient applications and anodynes. We are to continue the use of these means until we produce the desired effect; and then we may attempt the reduction. We judge if a reduction is well made, when all uneven- ness is removed, and the part has recovered its form, its length, and natural direction, and the*eminences of the bones and other external parts of the limb, have acquired their natural relations to each other. Section II. Of the Means of keeping Fractures reduced. When the bones are replaced in their natural situation. if they could be kept so by the power of the will, there would be nothing else to be done; but it often happens, that during sleep, in coughing, sneezing, &c. that they are again deranged. For this reason we are obliged to con- trive different means to maintain the limb immoveable dur- ing the time that nature employs in the consolidation of the fracture. This second indication is more difficult to fulfil than is generally thought ; and it is in this part of the treat- ment of fractures that the surgeon shows his experience and dexterity. The means we make use of to fulfil this indication, are position, repose, bandages, and other pieces of apparatus, such as splints, bandages, compresses, and constant extension. Position is a very important point in the treatment of fractures : it relates to the body and to the fractured limb. Of Fractures in general. 19 In fractures of the inferior extremities, the patient must remain in bed, until the entire formation of callus, This should only be three feet in breadth, otherwise it would be very inconvenient for the surgeon and for the as sistants; it should have no foot-board, and should consist entirely of matrasses without a feather bed. We ought to fasten to the wall a cord, which hanging within the reach of the patient's hands, enables him to raise and move himself as occasion may require. We should firmly at- tach to the foot of the bed, a plank, to which is nailed a block, covered with a soft cushion ; against this the pa- tient may support his foo<, by whicli he will derive a great relief from pain. It likewise serves to keep him from slipping towards the foot of the bed, and with the aid of the cord, helps to raise him When the calls of nature de* mand it. The suitable disposition of the bed is so im- portant an object for success in the treatment of fractures, that the surgeon ought to attend to its construction him- self. The construction of the bed, however, requires less attention in fractures of the superior extremities. The most favourable position of a fractured limb, is that in which all the muscles which pass over the broken part, and are inserted into the lower fragment, or to a part with whicli this portion is articulated, are equally relaxed; and in which the affected limb is equally supported in every part; and, in fine, in which it is least exposed to displace- ment, by the action of the muscles, the weight of the limb, or of the body. The natural position of our limbs is that in which they are placed during sleep, which is a state of semiflexion. This position, recommended by Hippocrates and Galen, has since been strongly advised by Pott, who appears to me to have exaggerated its advantages. In general, it is no doubt preferable to any other; but there are some exceptions, of which we shall speak hereafter. Every fractured limb must be supported equally in every part of its length ; otherwise the fractured ends will incline on each other, and the parts which support the,greatest weight will become painful, inflamed, and sometimes gan- grenous1. A pillow of chaff is preferable to every other support, because it may be accommodated to all the irregu- larities of the limb, and is less beating than a pillow of feathers. The most perfect rest must be maintained, for a move ment of the fractured ends on each other may prevent, 01 delay, their union. The patient must be dueled in \h\t w Boyer's Surgery. himself perfectly quiet; and we are to employ bandagesy pillows, splints, &c. The bandages which should be em- ployed for this purpose, are the roller, the eighteen-tail bandage, and that of Scultet, which is a bandage of strips/ The roller should be about three inches broad, and long enough to cover the whole limb. It is applied in the fol- lowing manner :—Having wet it with a resolvent liquid, we are to begin by making three turns over the fractured place; it is then to descend 'spirally to the lower ond of the limb, afterwards ascend to the fracture, pass three times around it, and then pass up to the connexion of the limb with the body, and back again to its inferior extremity. Each turn of tlie bandage should cover three-fourths of the preceding. The inequalities of the limb require to make frequent turns with the bandage, in order to make an equal pressure on every part, and to prevent it from falling into folds. The bandage must be applied so tight as to cause a slight tunic faction above and below it, without pain or redness. That part of the roller alone which is immediately over the frac- ture, has any effect in preventing its displacement; the parts above and below it are useful only in preventing the bad consequences of unequal pressure, and the irregular contraction of the muscles. It will, therefore, be readily perceived, that the effect of the roller is by no means verv great. J The eighteen-tail bandage is made of three pieces of linen as wide as the fractured bone is long, and long enough to go once and a half round the limb. It should be so constructed, that the piece which touches the limb is the shortest, the next a little•longer, and the third longer still; they are to be laid on each other, and sewed through the middle; each side is then to be split in two places, and at equal distances. Thus we make nine tails on each side. After having laid tiic bandage smoothly on the pillow which is to support the limb, and wet it with a resolvent liquid, we are to begin bv applying the tails of the upper piece of linen to the lowei part ot the limb, and the rest successively. The only ad- vantage which this bandage has over the roller is, that it can be applied without moving and raising the limb, which is always injurious. Scultet's bandage is composed of separate bands, three inches bread, and long enough to go round the limb once and a half, lhese bands are to be placed upon the linen which is to cover the splints, so that the first, which ought to correspond to the upper part of the limb, is covered bv the second m three-fourths of its width : and so of tli? Of Fractures in general. 21 others. AVe are to begin by applying the lowest, and the rest successively. This bandage is not perhaps quite so effectual as the roller, or the eighteen-tail bandage, in stea- dying the fracture ; hut it may be applied with greater ex- actness and uniformity without the least motion of the limb. and a part of it may be changed without removing the other. These advantages have led pi-aetilioners to prefer this ban- dage to all others, especially in complicated fractures of the lower extremities. Fanons are composed of two small sticks, of the size of the finger, covered wiih straw, which is kept on by a string wound around it. Those intended for the leg, must extend from above the knee to two or three inches below the foot; those for the thigh are of unequal length: the external one must extend from the crest of the ilium below the foot; the internal terminates in the groin. The fanons are to be rolled, one on each side, in the lateral parts of a piece of linen large enough to support the apparatus; they are to be tightened by three or four riblwns passed underneath. It is, however, previously necessary to fill the hollows of the lirnb. The use of the fanons is to maintain the fracture in its place, by preventing voluntary and involuntary motion; for which purposes they arc more effectual than any other part of the apparatus. They are particularly useful when we are obliged to transport the patient. Their round form, however, has one inconvenience—they do not prevent dis- placement of the fracture, unless they correspond exactly to the axis of the limb. Now, as both they and our limbs are round, it follows that, when we tighten the bands, they slip, and cease to correspond with the axis of the limb: hence they are generally abandoned. The same remark may he applied to another part of the apparatus, which consisted of two pieces of linen folded into a narrow strip, and twisted : o\er these the fanons were applied. Splints arc thin fiat pieces of wood, pasteboard, tin, or sole-leather*, which are applied to steady a fractured bone. They should be pliable enough to accommodate themselves to the form of the limb, and sufficiently firm to prevent the bones from getting out of place. In simple fractures of the arm, forearm (and even of the thigh and leg in children), we may employ indifferently splints of wood, pasteboard, or tin. The pasteboard splints have the advantage of becoming soft when they are wet, and thus accommodating themselves exactly to the shape of the limb, which they retain after becoming dry; but they 2Z Boyci^s Surgery. prevent us from using a resolvent liquid, which would keep them constantly wet. The length of the splints should always be at least equal to that of the fractured bone ; and, where the situation of the limb allows, they should exteud along its whole length; for, in general, the longer the splints are, the better they keep the fracture in place; but we should take care to keep their ends, which should be rounded, from pressing against the soft parts. The number of splints varies from two to four: in general, they should cover the whole circumference of the limb. We should avoid placing them over the prin- cipal vessels of a limb in compound fractures ; of course, no splint must be put opposite the wound. But, if we are obliged lo apply a splint over this part, a thick compress should be placed above and below the wound, so as to pre- vent it from being pressed upon. Splints are to be applied with a roller, and tightened with ribbons. When they are too hard to accommodate them- selves lo the form of the limb, we should fill the intervening space with lint, carded cotton, or wool. In simple fractures of the leg and thigh, splints made of wood are preferable, except in children. They should be made so thick as not to bend, their ends and sides should he rounded, and the spaces between the splints and the limb should be filled with little bags of chaff. It is necessary to put one of these bags under the thigh and leg, and accom- modate the shape of the pillow exactly to the lower surface of the limb. Splints prevent any lateral or longitudinal displacement of the hones ; but, in order to keep the limb froui rotating on its axis, they should always extend to the hand or foot, as the case may be. In transverse fracture, the splints, by preventing lateral displacement, also keep the bones from slipping by each other; but they have not this effect in oblique fractures, especially where the limb is covered with thick muscles: hence it is almost impossible for them to prevent a shorten- ing of the thigh. In some cases, this has led to the idea of making a constant extension of the limb by means of a ban- dage or machine, which draws, in contrary directions, the broken pieces of bone. Continued extension has been dis- approved of bv several authors, who consider it as a violent remedy, calculated to irritate the parts, and to excite the muscles to strong contraction, the effects of which are al- ways injurious. No doubt it would have all these inconve- niences, w.t» when the muscles are irritated, and spasmodically con- tracted ; but, if it be had recourse to when the irritation h totally dissipated, and simply with the view of preventing their retraction, it will be found highly useful: it not only prevents a shortening of the limb, but a stability which it gives the bones, singularly favours tire formation of callus. To derive from constant extension the utmost possible advantage, 1st. We should avoid compressing the muscles tvhich pass over the fracture, since their elongation is necessary to give the limb the length it has lost by the slipping of the fragments by each other. With this view, the extension must be applied upon the Hmb which articulates with the inferior extremity of the fractured bone, and the counter-extension upon that which articulates with its upper extremity. If wc applied these powers to the fractured bone, we should compress the muscles which pass over the fracture, and a spasmodic con- traction would result, that would render continued exten- sion useless, and even injurious. 2d. Extension, and counter-extension, should be applied to as large sutfaces as possible. The reason of this rule is evident, because external agents, acting upon a large sur- face with a given degree of pressure, compress each part less. The bandages should, therefore, be very broad. 3d. Extension, and counter-extension, must be made in a line parallel ivith the axis of the fractured bone. If the direction of these forces formed an angle with the axis of the bone, they would lose part of their power; and, to effect the end proposed, the force applied would have to be so great, that it would be extremely painful, and even insup- portable. 4lh. The extension should be made slowly, graduully, and fn almost an imperceptible manner. Muscles yield easily to force, which acts slowly; but if they lie suddenly and vio- lently slretched, a spasmodic contraction is excited; and they w ill be torn sooner than relax, if this extension be per- sisted in. 5th. The parts acted upon by extension and counter- extension, should be protected by bandages, or by a proper machine. This double indication is fulfilled by covering the parts on which the bandages act, with carded cotton, or wool, and filling the spaces left by Ihe depressions of the limb, with the same substance, so as to give it a ^irouhw form, ^i Buyer's Surgery. Bv;'t!«::idiug to these rule continued extension tan at ways be supported, even by the most delicate pal iritis; arid we* derive from it the precious advantage of restoring the limb to its natural length. Sei-tiox III. Of th* Means of preventing and treating the occasional Consequences of Fractures. In all fractures, except simple fractures of the upper ex- tremities, the patient should lake nothing but broth for the first days. One or more bleedings are generally proper, to- gether with the use of a cooling drink. After some time, we may gradually let the patient resume his usual diet. If we keep him too low, the consolidation of the fracture may be retarded. As the digestive functions are often impaired from the want of exe-rise, the use of bitters is proper. The bowels should be kept open by the use of injections, if ne- cessary. As to external remedies, we should avoid plasters and ointments, which irritate the skin, create an itching, and sometimes even erysipelas. The bandages are to be wet with a resolvent liquor, such as spirits of wine, a solution of the aeetite of lead, &c. Salt and water is an excellent resolvent; but it is not proper in this ease, because it dries on the linen, and makes it stiff. When we use the roller, and every thing goes on wel|, we should let it remain on for twelve or fifteen days at a time ; but if it be too tight, or become loose, we should re- apply it. When we use the eighteen-tail bandage, or that of Seultet, we may*remove it more frequently; and, in all cases, it is proper to watch the patient assiduously, lest the fracture become displaced. It frequently happens that frac- tures of the lower extremities, and especially of the leg, get out of place, on the third or fourth day, by the twitching of the muscles. In this case, we should renew the apparatus, after;having reduced it again. Although the callus is commonly firm about the thirtieth day, we should prevent motion until it is perfectly consoli- dated ; and, after removing the apparatus, we should cover the limb with a roller, in order to prevent edema; or to dissipate it, if it have come on. Some degree of stiffness always remains, wuich sometimes continues for a year or eighteen months. It is to be treated by frictions, relaxing applications, and baths. It may be prevented, in a consider- able degree, by gently moving the joints near the fracture* Of Fractures in general. 2$ after the consolidation is sufficiently advanced to render safe this very delicate operation, which ought always to be done by the surgeon himself. Section IV. Of the Treatment qf Compound Fractures. If great contusion accompany a fracture, we should use the bandage of strips wet with a resolvent liquor, and apply it with a moderate degree of tightness. The patient must be bled according to circumstances, and the apparatus must ecrtainly be removed on the next day. By neglect of (his precaution many limbs have become gangrenous, beeause the bandage is rendered excessively tight by the swelling of the parts. The limb is commonly found tumefied, tense, hard, and painful. It should be covered, in its whole ex- tent, with an emollient poultice, which is to be kept on by means of a bandage and the rest of the apparatus. >Vhen the contusion is excessive, and without wound in / the integuments, the epidermis is sometimes detached, so as to form small phlyetsemc filled with yellow serum, which a young praetilioner might mistake for gangrene. They are to be opened, and dressed with a little linen covered with cerate. By this treatment the swelling, tension, and pain generally subside in eight or ten days. We are then to leave off the poultices, tighten the bandages which confine the splints, and proceed as in simple fracture. In fractures without external wound, a large artery is rarely opened ; but if this do take place, the blood is in- jected into the cellular tissue of the limb, and produces a false primitive aneurhm. In such a case, we should not hesitate to cut down to the artery, and tie it above and be- low the wound. We should not mistake the opening of a large vein for that of an artery. Such was the case of a man who was brought into the hospital Charite, three or four days after having suffered a fracture, with severe con- tusion, "by falling from his cart. The leg was enormously swelled, and the skin of a violet marble colour. It was be- lieved that the anterior tibial artery was wounded : but, as the infilufetion did not increase, he was merely bled, and poultices were applied to the limb. The tension soon dimi- nished, and the swelling was resolved. If the upper fragment of a bone penetrate through (be soft parts, and if the fracture be transverse, and the exter- nal wound large, it may be easily reduced by a moderate degree of extension ; but if the fracture be oblique, and the bone terminate, as generally happens, by a long sharp VOL. II. * *t> JBoyer's Surgery. point, which comes out through a narrow opening, wo must enlarge the wound in order to replace it; however, if this be very difficult, it is belter to wait until the tension and spasm are dissipated by suppuration, at which time the reduction may be easily accomplished. If a bone remaia projecting through the soft parts, it becomes covered exter- nally with granulations, upon which the cicatrix is formed; thus leaving an unsightly projection at the part, after the cure. When the projecting portion of bone is very long, it is better to saw it off than to use any violence in reducing it. I effected, with some foree, the reduction of a fracture of the femur, in a young and vigorous patient, by enlarging the wound, through which projected the upper end of the femur, deprived of its periosteum to an extent of three inches. He seemed to do well at first, and I congratulated myself upon tire success of my practice; but, on the third day, the limb became prodigiously inflamed, with great ten- sion and swelling; and the gangrene which followed, not- withstanding my best endeavours to prevent it, quickly af- fected the trunk, and killed my patient. When, without too much violence, we reduee a compound fracture, the injury of the soft parts is to be treated as a simple wound, and every method is to be taken to prevent inflammatory symp- toms. When the bones of a limb are broken into several pieces, and to a considerable extent, and the soft parts are lacerated and bruised to such a degree that gangrene must inevitably result, amputation is the only means of saving life : this operation should then be performed as soon as pos- sible. Some authors indeed, disregarding the lessons of experience, have advised the defering of the operation for two or three days, until they could give a fair trial to the means of preventing mortification. It must, however, be confessed, that great theoretical acquirements, acute pene- tration, and long experience, are necessary to prevent us from unnecessarily depriving a patient of his limb ; and, on the other hand, from letting him die, by a vain attempt to preserve it. The embarrassment in which the surgeon is placed would be less, if he were not called upon to decide in an instant; hut such is the nature of ihe accident, that every moment of delay is of the utmost injury, and an houi lost may consign the patient to his grave. If we conclude it expedient to endeavour to preserve the limb, we are to proceed to the reduction, as in simple frac- ture, taking, however, still more care to prevent the un- equal contraction of the muscles, and the action of every cause which might excite in them a spasmodio action -t but Of Frocftires in general. 27 fhe swelling and tension of the soft parts render it almost always difficult to reduce the fractures of which we are treating. Extension, applied to the limb, would not fail to augment the inflammation and irritation, and to produce convulsive motions and gangrene of the parts. It is, there- fore, necessary to reduce the inflammation, by bleeding, poultices, anodynes, and the antiphlogistic regimen, before we proceed to the reduction. If the bone be broken into many pieces, and some of them be entirely, or almost, separated, they should be removed ; for, when they do not unite, they act as foreign bodies, keep up a constant irritation, and prevent the wound from heal- ing until they are discharged. They should be extracted with great circumspection, carefully avoiding to excite he- morrhage. Inci*ions are often necessary, in order to avoid tearing the soft parts. We must not, with a false humanity, content ourselves with making incisions too small for the easy extraction of the splinters. The conduct of Ambrose Pare, in this respect, is worthy of imitation. In a compli- cated fracture, which he suffered from a kick of a horse, he earnestly entreated a skilful surgeon who attended him, to forget that he was his friend, and not to spare him ; but to enlarge the wound with a razor, in order to put the bone in its place, and to extract, with his fingers, the splinters which were entirely detached. If hemorrhage accompany a compound fracture, we are, in the first place, to tie the vessel from which it proceeds ; after we have done this, and enlarged the wound if neces- sary, removed the separated fragments, reduced the frac- ture as well as the case will allow, and placed the limb in a proper position, the parts are to be covered with compresses wet with a resolvent liquid ; the bandage of strips i9 then to be adjusted, after being wet with the same fluid ; com- presses and splints are then to be placed on the sides and anterior part of the limb, and retained by bands drawn mo- derately tight. Inflammation, fever, severe pain, and some- times convulsion and delirium, supervene. The inflamma- tion rarely terminates by resolution; copious suppuration comes on; or, if the inflammation have been excesssive, gangrene may follow. During the inflammatory stage, bleeding, anodynes, and the antiphlogistic regimen, are necessary. Emollient poul- tices must be applied to the wound. When suppuration is established, the patient must take light nourishing food, bitters, and tonics, particularly bark: the wound is to be dressed with dry lint. The period at which this change of 2S Bayer's Surgery. treatment should take place, must be left to the judgment of the surgeon. In the first days of the accident, it is sufficient to dress the wound once in twenty-four hours ; bat, after suppura- tion has come on, the repetition of the dressings must be regulated by the quantity of pus ; if that be very great, the dressings should be renewed twiee in twenty-four hours. They should be applied with great care, avoiding the slight- est movement of the bones. If pus stagnate in the bottom of the wound, it must be absorbed by little dossils of lint. If this be not sufficient to prevent it from stagnating, the wound must be enlarged, or a counter-opening made in a depending part. When the bone or bones of a limb have not been broken into splinters, and the laceration of the soft parts has not been great, with proper treatment the wound suppurates moderately; the presence of pus does not prevent the for- mation of callus; and, if the patient be yonng and vigor- ous, the fracture may unite almost as well as if it had been simple. When the bones have been crushed, and the soft parts bruised and torn, the suppuration is very copious. In this case, if the fever soon abate, the suppuration diminish, and, at the same time, the bones become covered with granula- tions, without exfoliation, or after this process, we may form hopes of cure. The surgeon should then redouble his care and attention to second the salutary efforts of nature, and, above all, to keep the fragments in the best possible posi- tion. It is sometimes absolutely impossible to prevent the limb from shortening, and becoming crooked. It would be highly injurious to employ violent and repeated efforts in order to effect a reduction of the fracture; patients have often died in consequence of the' improper attempts of young surgeons to reduce these fractures with great exact- ness. As deformity is a necessary consequence of these fractures, the surgeon should advise the friends of the pa- tient, and the patient himself, that it is impossible to give him a well formed limb—-that the joints may remain stiff for a long time, and that a fistula may follow, whieh will not soon heal. But all fractures are far from terminating even so fa- vourably. Sometimes the suppuration, instead of diminish- ing, continues copious, and the pus becomes sanious; the wound does not diminish in size, its surface becomes bloated and spongy, the denuded bones remain detached: the patient loses his appetite and strength, and at length sinks wider Of Fractures in general. 29 hectic fever and diarrhoea. When matters have taken this turn in spite of our best endeavours, amputation is the only resource. It is true that some patients, after many of these symptoms have appeared, have escaped with their lives, without an operation ; but these rare cases do not invalidate the general rule. Amputation will be most likely to suc- ceed* if it be performed before the patient's strength is exhausted by copious suppuration, fever, and diarrhoea ; and this operation is most urgently called for, if frequent he- morrhages come on, and they cannot be stopped by any other means. In some cases, the inflammation is so intense, that gan- grene inevitably results. If it be confined to a small sur- face, and attack only the skin and cellular tissue, it does not add much to the danger of the case; but when it affects the whole thickness of the limb, its progress is often so rapid that the patient quickly dies. However, it is fre- quently arrested, and then amputation of the limb is indis- pensable ; but the operation should not be performed until the gangrene is defined, and the line of demarcation be- tween the dead and the living parts is formed. It was once believed that the progress of gangrene might be arrested by amputating, the moment it began to appear; but expe- rience has fully demonstrated the futility of this attempt; and many cases have happened, in which amputation has been unsuccessful, from having been performed before the proper period. There is only one case in which we should amputate before the gangrene is defined, this is when mor- tification is extending to a part beyond which we cannot amputate; and here its success is very doubtful. There are three different periods in which amputation may be performed: 1st. Immediately after the accident, and before the appearance of the symptoms, when the dis- order is such that the loss of the limb is certain. 2d. When the inflammation has terminated in sphacelus. 3d. When it has produced an extremely abundant suppuration. In the first case, the operation is performed to prevent the fatal symptoms which would otherwise inevitably result. The success of the operation, in this case, depends upon its being performed immediately, and before the parts are in- flamed. In the second case, amputation is performed, to remove the putrefying mass, and to spare nature the pro- cess of separation, to which probably she would not be equal. Lastly, in the third case, we amputate, in order to prevent the total exhaustion of strength, which would fol- low long-continued copious suppuration; and; in this case, 30 Bayer's Surgery, the operation should not be performed until we are con- vinced it would be unsafe longer to delay it. Fractures are sometimes complicated with luxation: when this takes place, we ought always, if possible, to re- duce the luxation before the fracture. When the joint, is ginglymoid, and the ligaments are torn, the luxation may be reduced without difficulty; but when the articulation is or- bicular, and surrounded by many muscles, and the fracture is near the joint, or below it, the reduction of the luxation is impracticable. The necessary extension would be highly injurious, and probably unsuccessful; we should, therefore, wait until the fracture has acquired sufficient solidity to support efforts for reduction ; and in order to prevent, as much as possible, the stiffness of the ligaments and soft parts, we should gently move the limb from lime to time, as soon as it can be done with safety. Notwithstanding these means, we can rarely reduce the luxation after the fracture is consolidated. There are, it is true, examples of the reduction of very ancient luxations ; but, in these cases, there has been no simultaneous fraeture ; and I am not aware that any luxation has ever been reduced after the fracture whieh accompanied it has united. When a fracture is complicated with any disease, such as scurvy for ex- ample, which may prevent a union of the bones, we should administer appropriate remedies. ARTICLE IV. Of tlie Consolidation of Fractures. Fractures are united by an unknown process of nature, in which the health is admitted to be perfect. This process is analogous to the oieatrization of the soft parts, and is called the formation of callus: the term callus is applied to a kind of knot, or hardness, which forms on the two contiguous ends of a fractured bone. We proceed to speak, first, of the time in which callus forms, and of the circumstances which may hasten, retard, or prevent it; we shall afterwards mention the local conditions necessary or favourable to the consoli- dation of fractures; we shall next state the different opi- nions of authors upon this process of nature, and offer the theory which appears to us most probable 5 lastly, we shall Qf Fractures in general. 34 point out what is to be done at the ordinary period of the consolidation of fractures, which will lead us to consider ligamentous union, and the resources of art in like cases. Section I. Of the Time in which Callus is formed, and of the Circumstances ^whicli may favour, retard, or pre- vent its Formation. It is impossible to assign an exact time in which a frac- ture will unite; it varies from twenty to seventy days, ac- cording to the age and temperament of the patient, the thickness of the bone, the weight it has to support, the difference of the season of the year, and the state of the health of the patient. 1st. Fractures unite more quickly in children than in adults or aged persons ; and the younger the child is, the sooner the callus will be formed. De la Motte saw two children, whose humeri, fractured in delivery, were united in twelve days. It has been said that, in tender infancy, an excess of callus is formed, which creates deformity; but experience does not confirm this assertion, which appears to be dictated by theory, rather than founded on obser- vation. 2d. A fracture unites much sooner in a robust man of a sanguine temperament, than in one who is feeble and cachec- tic. Ruysch and Van Swieten mention several cases, in which a concealed cachectic disposition prevented the for- mation of callus, though the patients were strong, and, to all appearance, healthy. 3d. The largest bones require the longest time to become consolidated : thus the femur requires more time than the tibia, and this last more than the humerus, &c. As the cal- lus remains for a long time weaker than the other parts of the bone, we should avoid straining it. Fractures of the tibia require fifty days at least to become firm enough to bear the whole weight of the body. 4th. Moderate warmth is most favourable to the union of a fracture: hence they become consolidated rather sooner in spring and autumn than in other seasons; but the effect of temperature is by no means striking. 5th. Fractures unite soonest in the roost healthy persons. Cancer, scurvy, and syphilis have a particular influence on the bones, and retard, and even sometimes prevent, the for mation of callus. Pregnancy does not appear to have any such effect; however, Fabricius Hildanus cites two facts, which tend to prove the contrary. At the period »f the 52 Bayer's Surgery. cessation of the menses, the formation of callus proceeds slovviv. and fractures are subject to the same anomalies as other diseases to which women are subject at this critical period of their life. Section II. Of local Circumstances necessary to the Con- solidation of Fractures. The local circumstances necessary to the solid union of a fracture without deformity, are, 1st. That the two fragments should enjoy a common life. 3d. That their broken sur- faces should correspond. 3d. That they should be kept per- fectly immoveable. If one of the pieces of bone receive loo little blood to nou- rish it, and to keep up its vital action, the fracture cannot unite. Thus, in certain fractures of the neck of the femur, in which the head of this bone being altogether detached, and the ligamentous tissue, which is reflected over it, as well as the vessels that pass through it, entirely torn, the upper fragment receives no other vessels than those which reach it through the round ligament, which are not sufficient for the work of consolidation j especially if, from the great age of the patient, the caliber of the vessels be excessively dimi- nished. An exact correspondence of the fractured surfaces is not absolutely necessary for their union, but a want of it always renders the formation of callus long and difficult. Thus, after fractures of the femur, where the bones have slipped by each other, and touch only at their sides, which are covered with periosteum, the fracture will hardly have begun to unite at the end of two months; and when the bones are united, a great shortening of the limb will have taken place. Rest is so essential a condition to the union of a broken bone, that, if moved every day, it would not unite ; the two ends would heal separately, like the sides of a wound that have not been kept in exact apposition; but the fractured surfaces do not become smooth and shining, and no orbicu- lar ligament is formed, as we shall have occasion to observe hereafter. Section III. Of the different Opinions as to the Forma- tion qf Callus. This has been a subject of everlasting dispute. The an- cients attributed it to the formation of a gelatinous liquor, ealied osseous juice, which hardened, and cemented the two Of Fractures in general. 33 fragments, like glue. Hence they advise, in order to pro- mote the formation of callus, that the patient should take farinaceous vegetables, and grains boiled in water, or the glutinous parts of animals, and especially make use of osteo- celle, of which Ilildanus relates such wonders. But, were it thus, the callus would be inorganic ; or we should have to admit that an inorganic liquid may become hard, and form an organic substance, which is absurd. It is demonstrated by observation, that callus is organized like the bones with which it becomes identified. According to Duhamcl, callus is formed by the perios- teum. When a bone is fractured, says this naturalist, the periosteum of the two fragments at first unite, they then swell, and form a ridge around the place of fracture; the other part of the periosteum also tumefies, softens, and forms a sort of jelly, which quickly changes to cartilage; this becomes vascular ; nuclei of bone form, multiply, and unite.; and when all the pei-iosteum adjacent to the frac- tured bone is thus hardened and ossified, it forms a kind of ring, which laps over the fragments, and keeps them united. Jn vain was Duhamel told, that, in sawing a bone which had been fractured, the fragments were found completely identi- fied, and not in simple contact, like two pieces of wood placed end to end, and confined by a band of iron. He answered, that the periosteum might extend from the cir- cumference towards the centre, and undergo the same changes as the bones themselves. Moreover, he supposed that, in some instances, the internal periosteum, or medul- lary membrane, generated elongations between the two fractured ends ; and, lastly, tliat, in young persons, the cartilages were capable of extension, and contributed to the perfect re-union of fractures. The system of Duhamel was long combated by Haller and Dethleef, who, after a course of well conducted expe- riments, reverted to the opinion of the ancients, that callus was formed by a gelatinous juice which exudes from the ends of the bone, and especially from the marrow, and collects around the fracture ; that this juice becomes or- ganized, is converted into cartilage, and lastly into bone. This system differs in no way from that of Duhamel, ex- cept that it supposes that the cartilage is produced by a fluid rather than by the periosteum. We think Duhamel attributed too much to this membrane; but Haller and Dethleef were certainly wrong, if they believed that inor- ganic lymph eoi'M thicken, and form an organized sub? vex. it. 5 34 Mayer's Surgery. stance.* It seems to us more natural to believe that the gelat4nous lymph contains, from the beginning, the rudi- ments of organization, which afterwards receive further de- velopement, and become visible, as it is generally agreed that the rudiments of all our organs are contained in the transparent mucilage from which the embryo seems to be formed. Bordenavc, whose experiments correspond exactly with those of Duhamel, Dethleef, and Haller, thought that the fractured bones re-united* in the same manner as soft parts. He grounded bis doctrine principally upon two observations that are generally credited. 1st. That the bones contain a vascular tissue destined lo circulate the nourishing fluid. 2d. That this tissue dilates during the re-union of fractures, as is proved by the swelling which takes place where the callus is formed, and without which it would not unite. " The soft divided parts," says this author, «« principally unite by means of cellular tissue ; the fractured bones also unite by means of vascular tissue. The cellular tissue swells Vhen 1 removed the dressings, 1 found a slight displacement, which I reme- died by a suitable extension, and continued the apparatus until the sixtieth day. At this time the coaptation was ex- act, but the callus was still so soft as to permit a slight motion at the place of fracture. After having exhorted the good lady to be patient, 1 applied a roller, with four splints of pasteboard, and, above these, splints of wood, and filled up the intervals with little bags of chaff. 1 continued this apparatus six weeks, at which time the fracture had become solid. Of Fractures in general. 37 Case II. M. G---- fell, and obliquely fractured the right leg a little below the middle part. M. Sal made, his surgeon, immediately reduced the fracture; and, the next day, M. Sabatier and myself were called in consultation. "We removed the dressings : the fracture appeared to be well reduced. In fifty days, the callus appearing to be so- lid, we removed the splints, and covered the limb with a roller. Three or four days after, the patient being seated on an easy chair, his servant suddenly withdrew a footstool from beneath his foot: he immediately felt acute pain at the place of fracture, and we found the bones moveable upon each other. We re-applied the apparatus: in two months the callus was firm. Some violet spots that appeared on his legs, led us to prescribe antiscorbutic plants, although the gums were firm : there was no other appearance of scurvy. The timidity of the patient prevented him from putting his foot to the ground, until six months after the accident. Case III. M. X----, aged thirty-five years, fell from his horse, and suffered an oblique fracture of the right leg below its middle part. In sixty days the callus still waj:'ed firmness, and the limb had shortened nearly two inches. Being called to the patient at this time, and finding the bones very moveable, I applied a machine for making ex- tension, and continued it eight weeks, when I bad the satis- faction to see the callus perfectly firm, and the limb of its natural length. Case IV. In 1790, a young man, nineteen or twenty years of age, enjoying good health, but thrown into a state of despair by having gambled away a large sum of money entrusted to him by a shopkeeper with whom he lived, jump- ed from the bridge of the Thuilleries into the river. He fell upon a raft, and broke his right thigh obliquely in the middle. The patient was brought to the hospital Charite, and the fracture treated in the usual manner. At the end of four months the fragments had slipped by each other, and were still very moveable. The consulting surgeons of the hospital, having been assembled upon a number of very serious cases, proposed several means for the treatment, of this ; such as moving the ends of the bone roughly against each other; cutting down to them, and scraping them with a scalpel; and, lastly, sawing them off. None of those, however, who advised these several means* counted much upon their good effects, and agreed that a preternatural joint would be formed, and the patient remain lame. Pity- ing the situation of the young man, and urged by his uncle, who was one of the monks of the house, I undertook his 88 Jboyev's Surgery. treatment. The limb was kept in a state of constant exten- sion by the ordinary bandage, which was carefully tight- ened every day. In three months, that is to say, seven months after the accident, the fracture was firmly united, and the limb was almost as long as the other. Case V. N. M. Ricard, aged 64 years, carman, of the village of Boulogne, entered the hospital Charite on the 85th March, 1799. forty days after a fracture of the thigh, which was badly reduced. The treatment, conducted by a quack, consisted in the application of four very short and small splints, and the use of a particular wash. The appa- ratus was taken off every day, and the limb moved, in order to sec if the fracture were uniting. The man entered the hospital with the following symptoms : The left thigh, frac- tured a little below its middle, was nearly five inches shorter than its fellow ; the upper fragment, tapered by the absorp- tion of its internal part, projected on the external side of the patella, which it almost touched; the lower part, which could be easily moved, also projected, though slightly, on the inside of the thigh. The fracture was exceedingly moveable. I applied a machine for constant extension, an engraving of which will be found at the end of this volume. On the first day, the limb recovered an inch of its length ; and it was gradually extended for ten days, when it was almost as long as the other. These new extensions excited so severe pain, that I was obliged to content myself with rendering the limb immoveable, and preventing ulterior shortening. In sixty days I removed the apparatus, and found the bone perfectly united. The pressure of the straps which held the foot to the foot-piece of the maehine, had caused some slight excoriations, and a considerable swelling of the ankle joint, which were soon cured. The limb re- mained shortened only two inches and a quarter. When a fracture is not consolidated at a proper period, the broken ends of the bone are covered with a fibrous substance, like thickened periosteum, and what is called a preternatural articulation is formed; but, I repeat, 1 have never found any thing which deserved the name of a joint—no capsular ligament, nor smooth and cartilaginous substances; on the contrary, in the preternatural articulation of the femur and humerus which I have dissected, arc constantly found a ligamentous substance, extending from one fragment to the other. It is possible, however, that, in other fractures, those of i he forearm for example, a disposition of parts may be formed, having a greater resemblance to an articu- lation. Mr. Silvester, physician of the Facility of Medicine Of Fractures in general. 39 of Paris, communicated to M. Bayle the following case, which is published in the Gazette of the Republic of Let- ters.* ** Some, years «inee, a man, in falling, broke his right arm a hand's breadth from the wrist, so that the two bones were completely separated. The man was afraid to have any thing done ; he would not even suffer bandages to be applied; on the contrary, he began by moving it, and, in the end, attained the power of bending it, even in the place of fracture. Thus he enjoyed, for a long time, the power of bending the limb at the joint and at the plaee of fracture. On dissecting his arm after his death, on the side next the elbow the bones were rounded off, and received into corresponding cavities in the lower pieces; the peri* esteum, which had been torn in the fracture, had become thick, so as to answer the purpose of a ligament; the edges of the cavities were much less elevated before than behind, so that a considerable degree of flexion could take place without much extension. 1)bc specimen is preserved in the cabinet of M. Duverney.MfHihuuius reports a fact nearly similar, in the ttmetjvfirst observation of the third hun- dred." When a preternatural articulation is formed m the arm, or forearm, ihe limb does not cease to be useful; but, if it be situated in the thigh or leg, the patient can only walk with crutches. Three methods have been proposed for the cure of such eases: 1st. To rub the bones against each other; 2d. To cut off their ends; and, 3d. To insert a seton, which last has been employed lately, with success, by Mr. Percy, and by Dr. Syng Physick, of Philadelphia.! The first plan was known to the ancients, since we find it described by Celsus, who had probably learned it of his predecessors. He uses the following expression :\ Si quan- do zero ossa nonqonferbvtrunt, quia empe sohita, saspe mote, sunt, in aperto jjjnde curalio est; poseunt enim coire. Si vekistus oceupanit, membrum tKtendendum est, ut aliquid losdatur: ossa inter se manu dividenda, ut eoncurren&o ex- aspertntur, et, si quid pingue est, eradulur, tolumque id quasi rectus fiat, magna tamen cura hekita, ne nervi muscutive l&dantur. The end proposed by this proceeding, ie to form a new wound in the bone, by rubbing the fragments against each other ; but when callus has begun to form, this retards the process of nature, and prevents -its consolidation. If, on July, 1685, page 718, etseq. { Lfta vui. cap. x f S'-c note A, 40 Buyer's Surgeiij. the other hand, the preternatural articulation be already formed, the means of which we are speaking will be insuf- ficient, and will lead to serious accidents, by tearing the adjacent soft parts. Re-section consists in sawing off the two ends of the bones, after having uncovered them by a longitudinal incision upon the fracture, then placing these ends in their natural situa- tion. The treatment afterwards must be as for a fracture complicated with wound. This painful and uncertain ope- ration was probably not unknown to the ancients; we cer- tainly know that they performed other analogous opera- tions, such as the re-section of superabundant callus and rupture of a fracture, in order to re-establish the length of the limb; they even went so far as to rasp the ends of the bone in preternatural articulations. Avicenna declares, that Hali Abbas witnessed the death of a philosopher in conse- quence of this operation. Guy-de-Chauliac blames this philosopher, and declares that he acted very foolishly in not getting along as well as he'could with his lameness. But we do not find, among the ancients, any example of this operation, and it is uncertain if they ever performed it. The parts covering the fracture are to be cut longitudinally on that side which is least covered with soft parts, avoiding, as much as possible, nerves and large vessels; the extre- inity of each part of the bone is then to be brought out and sawed oft', while the soft parts are protected by a piece of sheet-lead or pasteboard; the limb is afterwards to be treated as in a case of compound fracture. This operation is only practicable in the arm and leg. White is the first among the moderns who proposed this operation, and the able surgeon of whom he speaks, has perhaps alone practised it with success. Mr. White com- municated this case 10 the Royal Society of London, on the 27th of March, 1760. " Robert Elliot, aajdnine years, re- ceived a fail ,n the summer of 1759, and fractured the humerus near its middle. A bone-setter was immediately sent tor, who applied a bandage and splints, and treated the patient as well as he could for two or three months; but the bones did not unite, and the by was sent to the infir- mary of Manchester. On examination, we found the patient bad suffered Un oblique simple fracture, and that the extre- mities lapped over each other. The accident had happened six months before, and the limb was not only useless, but Durlliensorne. ^ <• Amputation was proposed, but I would not consent to it, as the union of the bone had not been prevented by age Of Fractures in general. 4,1 or disease, but by frequent motion of the limb during the formation of callus ; or rather the rough extremities of the bone had divided some part of a muscle which had insinu- ated itself between them. 1 proposed to the surgeons to cut down parallel to the length of the bones, to saw off the ends, and treat the case as a simple fracture. •' Some of the surgeons objected, 1st. That there was danger of wounding the humeral artery with the bistouri; 2d. That there was danger of tearing the artery in bringing out the two ends of the hui.e ; 3d. That there was no prece- dent for such an operation. It was easy to obviate the first objection, by cutting on the side of the arm opposite the brachial artery. I proposed, in preference, the interior and inferior part of the deltoid muscle, because the fracture was near this part. Thus we avoided the danger of wounding the vessels, prevented the pus from burrowing in the wound, and facilitated the application of the dressings. The second objection did not appear insuperable, when we considered that, in compound fractures, laceration of the principal ar- teries rarely happens ; and as the operation would be done with care, there could be very little danger of such an accident. The third, and last objection, was one which might be raised agaiimt every new discovery. *'• My proposal was finally adopted, and the operation was performed, in my presence, by a very skilful surgeon, on the 3d of January, 17(30. The patient did not lose a spoon- ful of blood, although no tourniquet was employed. When the operation was finished, the apparatus was applied, and the limb placed in ihe fracture-box. «• The wound bad nearly healed on the fifteenth day, when an erysipelas appeared, which extended over the arm. This yielded to fomentations and low diet. Six weeks after the operation, callus began to form, and it toon became hard/ The limb was almost as long as lb. other, very little smaller, and was gradually growing stronger, when the case was communicated to the Society.'* Since the time of White, the operation has been rarely practised, and almost always without biicifw. I peti'onued it once, but it did mit succeed. The following ia the account of the case. A ma,, aged thiily-six, had a fracture of the right arm, which did not consolidate i'-.r wa...t of care. It was above the middle of ihe buim-cua; the arm had long been useless, and the man was willing to suffer any thing but amputation. 1 cut down upon the fracture on the » Abridgment of the Phil. Trans, p^r. vli. p. 4\'i. vot,. II a *2 Boyer's Surgery. outer side of the arm, above the part where the radial nerve winds around the humerus, so as not to paralyze the extensor muscles of the fingers and band ; I then brought out the lower fragment, by elevating the elbow, and carry- ing it inwards; it was then sawed off. The dissection of the upper fragment was more difficult. It formed a very long cone, with a sharp apex. After this was sawed off, and the bones put in their place, an interval of nearly two inches separated them. In order to bring them together. I raised the elbow, and passed some turns with a roller under the forearm in a state of slight flexion, and carried them obliquely over the shoulder. For two days tlie patient did well; but, on the third day, in addition to the other febrile symptoms, the patient was affected with a well marked ery- sipelas, which covered the opposite arm, extended to the shoulder, and then affected the diseased extremity. The tension was extreme. Instead of pus, bloody sanies flowed from the wound; gangrene followed, and the patient died on t!*e sixth day from the operation. The method of employing the seton, is to pass it through the limb, between the ends of the fragments, to produce inflammation and the re-union of the parts. This method has been employed twice, with success; in one case, by Dr. Physick ; in the other, by M. Percy, before the opera- tion of Dr. Physick was known in France. We shall relate these two cases, from an interesting Thesis of M. Laroche, defended at the School of Medicine of Paris, in March, 1806; entitled, " A Dissertation on the want of Union in certain Fractures, especially in those of the Arm, and a new Means qf curing the false Articulations which result." The author saw M. Percy, at Augsburg, pass a seton through the cica- trices of a wound of the thigh, with comminution of the femur, which had not united. This celebrated surgeon, to whom military surgery owes so great obligations, proposed, by this means, to procure the discharge of any splinters of bone which might remain, and to excite the divided surfaces to re-union. The event answered M. Percy's expectations, and the patient walked with a crutch two months after the operation. Two years after this case, the following communication from Dr. Philip S. Physick, inserted in the Medical Repo- sitory, *d Hexade, vol. i. p. 122, was known in France. Of Fractures in general. «•£ " A €ase of Fracture of the Os Humeri, in which the broken Ends of the Bone not uniting in the usual Manner, a Cure was effected by Means of a Seton. Communicated to Dr. Edward Milter, by Vhilip S. thysick, M. D. " Isaac Patterson, a seaman, twenty-eight years of age, applied to me, in May, 1802, in consequence of a fracture of his left arm above Ihe 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 lllh of April, 1801, after having been at sea seven months, bis arm was fractured by a heavy sea breaking over the ship. Nothing was done for his relief until dext day, when the captain and mate bound it up, and applied splints over it. No swelling supervened, nor did he suffer any pain. Three weeks after this accident he arrived at Alexandria, when the state of the arm was examined by a physician, who told him, that the ends of the bone were not in a proper situation. After making an extension, the splints and bandages were again applied. He remained in Alexandria four months, when, finding his arm no stronger, he left off all dressings, and went on board the New-York frigate as steward. In this capacity he remained near the Federal City six months, and by being under the necessity of using his arm as much as possible, he found the connexion between the ends of the bones became looser and looser, till at length the arm bent as easily as if a new joint bad 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 conti- nuing the extension. Under this treatment he remained two months, but experiencing no benefit, he was advised to come to Philadelphia. On examining the arm, 1 found that the humerus had been fractured about two indies and a half above the elbow joint, and that the ends of the bone bad passed each other about an ineh :' 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 so flexible as to allow of motion in every direction ; and, by forcible ex- tension, 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. 44 He was admitted into the Pennsylvania hospital the latter end of May; but the weather becoming very hot. it 44 Bayer's Surgery. was judged best to defer any operation that might be neces- sary until the fall of the year. Unfortunately he then con- tracted a bilious fever, of which he was so ill that his life was despaired of for >,ome d.ivs. From this fever his reco- very was so slow, that it was not thought proper to perform any operation until December. It still remained to decide by what means a bony union of ihe humerus might most probably be effected. In the year 1785, v hen a student. I had seen a case in our bo-piial, similar to this in every essential circumstance, in which an incision was made down to the extremities of the fractured bone, which were then sawed off, thereby putting the parts into (he condition of a recent compound fracture. ]No benefit, however, was de- rived from this painful operation ; and, some months after- ward, the arm was amputated. This case had made a strong impression on my mind, and rendered me unwilling to per- form a similar operation. I therefore proposed lo some of the medical gentlemen of the hospital, who attended in con- sultation, that a seton-needle, armed v\ith a skein of <-i!k, should be passed through Ihe arm, and between the frac- tured extremities of the bone ; and that the seton should be left in this situation, until, by exciting im'lnmmution and suppuration, granulations should rise on the ends of ihe bone, which uniting, and afieivvatdr ossifying, would form the bony union that was wanting. This operation being agreed to. it was performed on" the 18th of December, 1802, twenty months after the accident happened. Before passing the needle, I desired the assistants lo make some extension of the arm, in order that the selon might be in- troduced as much as possible between the ends of the bone. Some lint and a pledget were applied to the orifices made by the seton-needle, and secured by a roller. The patient suffered very little pain from the operation. After a few days, the inflammation (which was not greater than what is commonly excited by a similar operation through the flesh, in any other pari) was succeeded by a moderate suppura- tion. The arm was now again extended, and splints applied. Ihe dressings were renewed daily for twehc weeks, during which time no amendment was perceived ; but, soon aftei? wards, 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 forma- tion of the new bony union went on rapidly, and, on the 4th of May, 1803, was so perfectly completed, thai the patient could move his arm. in all directions, as well as bcfo«-e the Of Fractures of the Nose. 45 accident happened. The seton was now removed, and the • mall sores occasioned by it healed up entirely in a few days. On the '28th May, 1803, he was discharged from the hospital, perfectly well; and he has since repeatedly told me. that his arm is as strong as it ever was.'' This interesting ease may give a just idea of the merit of the operation, and of Ihe talents of the surgeon who per- formed it. We would remark, however, that if the seton acted only on a small extent of the surface of the bones, it might fail. Lastly, when all other means have been employed with- out success, amputation is the only resource, and it may be performed if the patient imperiously demand it. After having finished the subject of fractures in general, we proceed to speak of particular fractures ; commencing with those of the nose. We shall treat of fractures of the cranium, in the article of Wounds of the Head. CHAPTER II. Of Fractures of the Nose. 7E include, under the head of Fractures of the Nose, those which interest the adjacent processes of the maxillary bone, as well as those which are confined to the ossa nasi, because these fractures result from the same vio- lence, and very often happen together. Fractures of the nose are produced by a blow, or by a fall, and are always attended with greater or less contusion of the soft parts. A simple fracture may take place in any direction: in this case there is no displacement: or the fracture may be comminutive, and the fragments of the bone driven in toward the nasal cavity. This last case is generally accompanied by a wound. The fracture may in- volve the lachrymal canal, and thus prevent the passage of the tears into the nose, either directly after the accident, or at a more remote period. The percussion that causes fractures of the nose, is very apt to extend to the head, and even to the brain : hence they are often followed by symptoms of concussion, com- pression, by collections of pus or blood in the brain, inflam- mation of its meninges, and fractures of the cranium by W iff Boner's Surgery. contre-eeup. The fracture of the cribriform process of the ethmoid bone has been thought to depend upon the shock communicated to it by the perpendicular plate of this same bone : but, if we consider that this plate is extremely thin, and, of course, very susceptible of fracture,—that it does nol articulate with the proper bones of the nose in young persons, and that the symptoms of which we have spoken have happened without fracture of the cribriform plate, we shall see how little credit this opinion is entitled to. Mhen fracture of the nose is simple, and unattended with displacement, it is difficult to ascertain its existence ; but this is of no importance, since we have only to treat the in- flammation which attends it. Fractures of the nose are by no means serious accidents, except by the deformity which they may occasion. They may, however, cause incurable fistula lachrymalis ; and, as injuries of the head, they may prove fatal. These circum- stances should not be lost sight of. When the fracture is simple, it is to be treated merely as a contusion ; if, how- ever, the fracture be compound or comminutive, and the fragments of bone be displaced, as generally happens, we are to raise them up into the nasal cavity into which they are driven. This may be done by introducing a cylinder into the nose, such as a director, for instance, and pressing it up- wards and forwards, while a finger of the other hand is pressed upon the outside of the nose, until the fragments are adjusted in their natural situation; of course, it would be impossible to make such reduction, if the fracture had existed for several days, and severe inflammation had come on. In this case we should reduce the inflammation, and then proceed to the reduction ; but we should not too long delay adjusting the bones in their place, for their displace- ment keeps up the inflammation, and, after a time, the re- duction becomes difficult, from the union of the fragments; and deformity is the consequence, as in the following case. A little girl, eight years old, received a kick from a horse, which fractured and crowded in the bones of the nose. Se- vere inflammation ensued, which the surgeons wished to see entirely dissipated before they proceeded to the reduction; it was, in fact, dissipated, but not until the reduction became impossible. A flattened nose, and an incurable fistula lachry- malis, was the consequence. When the bones are once reduced, to use the expression of J. L. Petit, it requires a greater force to push them in than it did lo raise them ; but if they are excessively broken, l\ will be proper to introduce a piece of a hollow gum-clastic Of Fractures of the Lower Jaw. 47 catheter into the nose, and press lint around it, so as to support every part. Compresses, wet with a resolvent li- quid, are to be lightly kept on the nose by means of a baud, or triangular handkerchief. CHAPTER III. Of Fractures of the Lower Jaw. THE superficial situation of this bone, and the extent of its surface, favour the action of causes capable of frac- turing it; but these causes are, in a great measure, coun- terbalanced by its great mobility. Hence fractures of the lower jaw are by no means common. No fracture ever takes place at the symphysis ; when it occurs between this part and the angle of the bone, the an- terior part is very prone to displacement. Fracture is very rare in that portion of the bone to which the masseter and pterygoid muscles are attached, the neck of the condyle, or even in the base of the coronoid process. Sometimes a portion of the alveolar ridge is broken off. The more oblique fractures of the lower jaw occur far- thest from the chin, and the obliquity is from above down- ward, and from before backward, which singularly favours the displacement of the fragments. The direction in which the displacement takes place de- serves particular attention. When the bone is broken on one side only, and in a portion of it anterior to the insertion of the masseter muscle, the displacement is proportioned to the distance of the fracture from the chin. In all these eases, the fragments are drawn asunder by the elevator and depressor muscles of the part. But when the fracture is double and oblique, the chin, which forms the middle piece, is drawn very much down, and somewhat backwards. When the fracture is in the part where the masseter and ptery- goid muscles are inserted, the bones are not at all displaced. If the condyle be broken off, it will be drawn forwards by the pterygoideus externus, while the jaw will retain its natural situation. The violence which causes fracture of the lower jaw, and which is always external, may act upon the point where the hone yields, or on a remote part. In the first case, the i8 Bayer's Surgery. force tends to straighten the bone, by pushing the chin in- ward*. Here the internal lamina of bone breaks first, and the fracture separates the outer lamina; successively. In the second, there is a tendencv to increase the natural curve ot the bone. This may take place from a fall or a blow upon the opposite side ; and here the external lamina; are first firefund. The bone never yields when the violence is not very considerable : hence we generally find fractures, in this part, attended with severe contusion, and even an ex- ternal wound. This fracture is commonly discovered without any diffi- culty. A blow, a fall on the part, difficulty of pronuncia- tion and mastication, and more or less pain, are presumptive sis>ns of its existence. But if, in passing the linger along the lower edge of the jaw, we perceive an irregularity in the position of the bones, and if the teeth partake of a cor- responding displacement, we cannot doubt the existence of a fracture. ^Mien the fracture is double, the deformity is >erv striking ; but if there be no displacement, we can dis- cover it by the means of crepitation only. In order to pro- duce this, we should endeavour to move the fragments late- rally upon each other. Fracture of the condyle may be readily known, provided no very considerable swelling have supervened. Simph- fracture of the lower jaw is not a serious accident, and it will get well without the -.fid of art. We have seen a porter that wruld not suffer anv dressing, and who did not cease from speaking or chewing when the pain permitted it. The fracture was, nevertheless, consolidated, with a de- formity, it is true, which might have been prevented. According to some authors, the laceration or division of the infericr dental nerve would occasion severe pain, con- vulsive motions of the iins, swelling of the cheek, deafness, bi'Zi/ingin the ears, iufi;.i;.mulion in the eyes, and a copious secretion of saliva. Although 1 have seen a great many fractures of the jaw. simple and compound, and many that resulted from gun-shot wounds. I have never wituessed these phenomena ; once only 1 saw a double fracture of the jaw, with severe contusion, followed by a paralysis of the depressor anguti oris and the depressor labii inferioris, which I attributed to tearing of the inferior dental nerve. A slight coniortimi of the mouth was the consequence. if th f"acini e be perpendicular lo the length of the bom , it is stitiicieni to bring the jaws together; but if the frac- tn:e be at once double and oblique, there is displacement in the direction of the thickness of the bone, and also in th*j Of Fractures of the Lower Jaw. 4» direction of its length. In this case, with the index-finger placed before the coronoid process, while the posterior frag- ment is to be kept back, the anterior piece taken hold of, with the index of the other hand on its inner side, and the thumb below, and thus drawn forward. Having thus reme- died the shortening of the bone, the displacement in the direction of its thickness may be removed, by placing the teeth together. As to the displacement of the upper portion, in fractures of the neck of the condyle, it can only be reme- died by displacing, in the same degree, the lower fragment: thus their natural relation is re-established. The jaws are now to be kept together: this may be done by passing a few circular turns of a bandage around the patient's nightcap, and fixing to it another band, which is to pass under the chin, previously protecting the parts by compresses wet with a resolvent liquid. Some authors prefer what is called a chexetre bandage; but it docs not answer better than the simple bandage of which we have spoken, and its applica- tion is much more difficult. These means are not sufficient in oblique and double frac- ture. In this case, in order to prevent deformity, difficulty of chewing and of pronouncing, it is necessary to place, be- tween the teeth of the portion that is not displaced and the upper jaw, a piece of linen, of a thickness proportioned to the extent of the displacement, and hollowed so as to admit tjie two ranges of teeth; at the same time we should tighten that part of the apparatus which supports its base and presses it upward, ami leave rather loose that part which passes over the external surface of the jaw. Hippocrates and Celsus recommend tying the teeth toge- ther with threads of silk or golden wires. This treatment may be useful when a portion of the alveolar ridge is se- parated, and the teeth have sufficient solidity, and there is space enough to admit the application of the ligature. In fractures of the neck of the condyle, before we apply the bandage, thick graduated compresses must be placed behind the angle of the jaw, in order to keep the inferior fragment forward. In every case, the patient must not speak or masticate until the fracture becomes firm. In simple fracture, if the apparatus be not too loose or too tight, or unless it require changing, from the quantity of saliva that runs upon it, it may remain on for ten or twelve days at a time; but, in oblique fractures, a tendency to dis- placement generally renders it necessary lo change it more frequently. In forty or fifty days the fracture is generally consolidated ; but if the patient have moved the fragments, VOL. II. " 50 Boyer's Surgery. the formation of callus is prevented, and a preternatural joint is formed, as I have seen in several instances. It is remarkable that this occurrence docs not much impede mas- tication. Compound fractures of the lower jaw require no particu- lar rules for their treatment; we shall only remark, that those which are caused by gun-shot wounds often unite without much deformity, and in a short time, provided the surgeon, when he dresses the wound, be careful to let his assistant keep the bones in place. CHAPTER IV. Of Fracture of the Vertebra. THE vertebrae are rarely fractured; 1st. By reason of their small size, which, like that of all other small bones, protects them, in a great measure, from the action of external violence; 2d. Their mobility; 3d. Their deep situation, in which they are protected by soft parts. How- ever, there are some parts of the vertebra; which, by their situation and structure, are exposed to fracture; such as the spinous and transverse processes. Violent percussion of the spine, whether it produce frae- ture or not, may affect the spinal marrow, and even the brain. These effects are most to be dreaded, when one or more of the posterior lamina: are fractured, and the pieces have pricked or compressed the spinal marrow. In these instances, palsy of the lower extremities ensues, together with that of the bladder and rectum ; the contents of these viscera are first retained, and afterwards discharged invo- luntarily ; the patient, constantly lying on his back, soon leels .;ai:*. in die sacrum : the skin inflames, and mortifies* the separation of the eschar forms an ulcer, that extends' and veaivens ihe patient. On the other hand, the collec' tion oi hveal matter and urine, and the introduction of air by tue bougie, irritate the rectum and bladder; the sides oi ihis last organ swell, the urine becomes thick and fetid a slow fever follows ;\nd the patient dies in a few weeks ' Sometimes, when the aillv.kn is in the hypogastrium, the paralysis extends upwards, and can*-.-* death, bv Imped- ing respiration. When the palsy is conliaed to the inferior Of Fracture of the Vertebra. 51 extremities, it is not always fatal. In some rare cases, gangrene and hectic fever do not follow, and action is re- established in the limbs, and sometimes even in the bladder and rectum. There is a great analogy between the phenomena we have described and injuries of the head : hence it has been sup- posed to be possible to perform the operation of the trepan, and raise the depressed portions, or evacuate any fluid that might be pressing on the spinal marrow. But the posterior lamina of the vertebra; is situated too deep for this opera- tion ; there are, moreover, no symptoms that indicate the proper place for the trepan to be applied ; and, lastly, ex- perience has shown that the same symptoms may arise from simple commotion, or stretching of the important parts, within the vertebral column. This is shown by a compari- son of the four following cases. A bag of flour, weighing three hundred weight, suddenly fell upon the nape of the neck of a porter when he least ex- pected it. He experienced a sharp pain in the bottom of the neck. When he was brought to the hospital Charite, the* spinous process of the seventh cervical vertebra was found more projectmg than natural, all the limbs were paralyzed, respiration was laborious, and the rectum and bladder with- out action. The patient died on the seventh day. On open- ing the body, we found a fracture of the posterior lamina on the seventh cervical vertebra, with depression of a frag- ment which strongly compressed the spinal marrow. A mason fell from a height of fourteen feet, and lost his recollection. When he came to himself, he found his legs paralyzed; the urine and fecal matter were first retained, and afterwards came away involuntarily; fever supervened, respiration became laborious, and the patient died twelve days after the accident. On opening the body, we found an effusion of bloody serum, which filled the canal of the dura mater, from the* inferior part to the middle of the back, and compressed the spinal marrow. A stocking-weaver fell on hi^ loins into a deep ditch, and immediately found his bladder, return, and lower extremi- ties in a state of paralysis. The symptoms were the same as in the preceding casei, and the patient soon died. On opening the body, we found neither fracture nor injury of the spinal marrow or of the neighbouring parts, nor effu- sion. A man, amusing himself with his friend^ in twisting his body, felt a violent straining, and experienced a sharp pain in the whole length of the vert-bs-d coin inn. Th;; next day, hz Bayer's Surgery. his lower limbs, rectum, and bladder, were paralyzed. The symptoms went on as usual, and he died in a few weeks. On opening the body, every thing appeared natural. The diagnosis of fractures of the vertebra; is always diffi- cult, on account of the deep situation of these bones, and the little confidence that can be placed in the rational signs. If, however, the fracture be extensive, we may see some deviation from the natural situation of the parts, and even produce crepitation ; but this is a very dangerous practice. Fractures of the vertebra; are almost always mortal; however, musket-balls may fracture one of the processes without producing any serious symptoms, and the patient may soon get well. In these cases, it is sometimes neces- sary to make incisions to extract the ball, loose splinters, or other foreign bodies. In all eases, we should pay less attention to the reduction of the fracture than to the general symptoms. A slight pressure is sometimes proper, to keep the spinous process reduced. Bleeding, general and local re- solvent fomentations, and camphorated liniments, to the ab- domen, are proper; the urine must be regularly drawn oif by a catheter, and the rectum must be emptied by injec- tions ; the excoriated parts must be protecred by linen covered over with cerate; if eschars form, sty rax must be applied to them ; the ulcers which they form should bo dressed with dry lint. If the patient be fortunate enough to recover the use of his limbs, he may perhaps derive a farther advantage from warm mineral springs. ( *« ) CHAPTER V. Of Fractures of the Sternum. THESE fractures are rare; the division is generally transverse or oblique, with or without displacement. Sometimes there are several fractures : when this is the ease, one of the fragments may be driven into the medias- tinum, and impede the action of the heart or lungs. Fractures of the sternum are always accompanied with contusion or wound of the integuments, and with a more or less serious affection of the organs in the chest. By reason of the elasticity of the cartilages, the sternum is easily pressed back, and the change of form produces a diminution of the capacity of the chest. Now this cavity, being always exactly filled, cannot undergo any considerable and rapid change of this kind, without subjecting the soft parts which it contains to compression, contusion, or even rupture. Very serious and fatal symptoms are sometimes occasioned in this man- ner. An effusion of blood, and of the medullary juice which exudes from the broken portions of the bone, may become infiltrated into the cellular tissue of the mediastinum, and give rise to inflammation, suppuration, or caries. Fractures of the sternum are readily known by the in- equalities of its surface, the movement of the fragments during respiration, and even by the crepitation which is sometimes caused by the motion of the chest. To these symptoms are often superadded depression of a part of the bone, pain, cough, and a difficulty of breathing. We must not, however, mistake a natural or acquired deformity for a recent fracture. A simple fracture of the sternum, if properly treated, is a very trifling accident: if, however, the parts be driven in, it may prove fatal. If the fracture be not reduced, and the bones consolidate in this unnatural situation, a dry cough, oppression, and palpitation, may result. The treatment of simple fractures of the sternum, with- out displacement, consists in preventing the motion of the chest in respiration, and the reduction of the inflammation. Thick compresses, moistened with a resolvent liquid, are to be applied to the sternum, and kept on by a bandage passed around the body, tight enough to oblige me patient lo re spire by the action of the diaphragn. alone. The patient must keep his bed ; his head and pclvi* must be raised, and the thighs bent so as to relax the sterno-clcido-mastoideus Oi Boyer's Surgery. and recti abdomenis muscles, which might move the frag- ments of the fracture. However trifling the inflammation of the soft parts may be, we should have recourse to emol- lient applications, venesection, and low diet. When the fracture is comminutive, and the bones are driven in, we should raise the fragments with a trepan, if necessary. But the fracture of the sternum, or rather the percussion of the chest, which has produced it, may give rise to a very serious inflammatory slate of the lungs, which is attended with obtuse pain, and may be confounded with the irritation, which always takes place during the first days of the fracture. Oppression accompanies both cases ; but, in fracture, the patient complains of a sense of weight, which he refers to the sternum. In traumatic peripneumony this symptom is not so striking ; the face is red, the conjunctiva is injected with blood; the patient is stupid, and in a tran- quil and transient delirium; he coughs, and sometimes raises blood; the thirst is urgent; the pulse bard, quick, and frequent. We must not lose a moment in combating these symptoms the moment they appear: the disease too often attacks the patient so suddenly, and with so little pain, that it often proves fatal before we are aware of any danger. CHAPTER VI. Of Fractures of the Ribs. FRACTURES of the ribs are rare, although the breast is exposed to violence and frequent percussions ; this arises from their length, curved form, oblique situation, the elasticity of the cartilages, and the mobility of their articu- lations ; moreover, some of the superior ribs are protected by the bones and muscles of the shoulder : for this reason, these last are seldom broken. Fractures most frequently happen in the middle ribs; those below escape by reason of their very great mobility. Fractures of the ribs are rare in infancy, and more common in adults. Fractures of the upper ribs are attended with danger, be- cause they can only arise from very great violence : those of the lower ribs are usually far less serious. The middle of the rib is generally broken, and the fracture is commonly Of Fractures of ihe Ribs. bv oblique. The fracture may be caused by violence acting directly on the part, and driving it in; or on the breast; m which last case the broken ends project outwards. The former accident may be attended with serious injury of the lungs, or pleura; in fact, the viscera of the chest always suffer more or less from the violence whicli causes the frac- ture. Sometimes the intercostal artery is wounded, and bleeds either externally or internally. We shall speak of this case, and of emphysema, under the head of Particular Wounds. Fracture of one or more ribs is attended with fixed pain in some part of the chest, which renders respiration painful and laborious, and prevents the patient from taking a long breath. Crepitation also lakes place from respiration, or it may be produced by pressing on the fractured part. In passing the finger along the rib, we perceive a part more sensible than the rest, but there is no displacement. What we have said of the prognosis of fractures of the sternum, applies equally to those of the ribs. Simple frac- tures of the ribs require only the application of a compress to the fracture, and a bandage around the body, supported by a scapufary, so as to prevent all motion of the chest. When the fragments have a tendency to sink in, we should place on the broken rib, opposite its anterior and posterior parts, two thick compresses, so as to bend the rib outwards; but when the fractured ends project outwards, a compress is to be placed on each side of the fracture, so as to keep them in. If passing a bandage around the body do not ren- der the ribs sufficiently immoveable, we may use a cloth, doubled around the shoulders, and passed round the body.* AY hen the fracture is simple, we need only prescribe some cooling drinks and low diet for a few days. If there be symptoms of inflammation of the lungs, we must bleed very freely, and prevent the patient from moving or talking. The cartilages of the fifth and eighth intermediate ribs have been found broken : the fragments were displaced ge- nerally in the same direction. They are easily reduced, especially during inspiration; but it is difficult to keep them in place. They have never been known to unite in any other position than that given them at the time of the fracture. It is remarkable that a bony ring is always the medium of union. Very little inconvenience results from the impossi- bility of keeping these fractures reduced ; all that need be done is, lo confine the parietes of the thorax. * See note B, ( 56 ) CHAPTER VII. Of Fractures of the Pelvis. ARTICLE I. Of Fractures of the Ossa Innominata. rT^HE situation of the ossa innominata, their form, and A the thickness of the soft parts which surround them, renders their fractures very difficult, and very rare. They can be broken only by enormous violence, such as falls from a height, the kick of a horse, the weight of a loaded carriage passing over the hips, etc. The two ossa innominata may be broken at the same time, but the fracture of one alone is more common. It is generally seated in the os ilium. These fractures are necessarily accompanied with severe contusion. Some serious injury of the internal organs takes place at the same time ; the spinal marrow may receive a concussion; blood may be effused into the pelvis, and the muscles, and other organs within the pelvis, may be se- verely bruised. From one, or all these circumstances, par- tial, or total loss of sense and motion in the lower limb, may ensue; blood, or black bilious matter, may be vomited, or passed per anum, cither immediately or after some time. I'o these symptoms are often added retention of urine, fever, painful tension of the abdomen, arising from inflammation of its viscera; abscess, gangrene, and death. The cause that produces a fracture of the ossa innomi- nata, may, at the same time, effect a displacement of the fragments. When the fracture takes place at the pelvis or ischium, the fragments may be pushed into the canal of the urethra, or into the bladder, and occasion an infiltration of the urine, or only compress and interrupt the functions of these organs ; or they may be driven into the scrotum, the labia, or the muscles of the internal parts of the thigh. But when the fracturing cause has not effected a displacement of ttie fragments, it seldom otherwise happens. r«1,iei tliaSnosis of fractures of the ossa innominata is very difficult, on account of the depth of the parts, and their want of displacement. They may be presumed to exist, v hen the pelvis has suffered great violence, when there is Of FracUires qf the Pelvis. B7 severe pain, and the motion of the trunk and lower extre- mities is difficult and painful. In a few instances crepitus may be perceived ; but we must not confound it with em- physema, which frequently accompanies large infiltrations or collections of blood. These fractures are generally fatal, and always very dangerous. The treatment consists in maintaining perfect rest, relax- ing the muscles inserted into the pelvis, applying resolvent liquids and a bandage around the pelvis, supported by a scapulary, and two bands under the thighs. If the bones be displaced, they must be reduced by such means as cir- cumstances require. When the urethra or bladder is in- jured, a catheter must be introduced to draw off the urine. It is sometimes necessary to cut down upon the splinters of bone, and remove them. Great attention should be paid to the state of the viscera of the abdomen, in order to prevent inflammation. One of the greatest difficulties in the treatment of these fractures, is the necessity of moving the patient for his natu- ral wants. This may be done by means of pullies fastened to the ceiling, with a band under the thighs, so that the patient may raise himself. When the fracture takes place at the pelvis, the swelling of the fragments, and their displacement, may ultimately occasion a difficulty of emptying the bladder, and require the habitual u.c of a bougie. ARTICLE II. Of Fractures of the Sacrum. Although more superficially situated than the other bones of the pelvis, the sacrum is less subject to fracture than these last, from its thickness, the spongy nature of its (is- sue, and the advantageous manner in which it supports the weight and efforts of the trunk. It, therefore, requires ex- cessive violence to frat tare this bone. On the other hand, its fractures are generally more serious than those of the ossa innominata; for, besides the violent contusion and la- ceration that accompany its fracture, there is almost always a commotion of the sa'ial nerves, which may terminate fatally. When the superior part of the sacrum is fractured (which seldom happens, from the thickness of the bone in that part}, vol.. II. s 5S Bayer's Surgery. there is no displacement, unless the bone have been crushed, and the fragments violently driven in. In this case, there will be considerable disorder in the external and internal soft parts. But, when the fracture takes place in the infe- rior part of the bone, which is much thinner, the fragments may be carried towards the rectum. It is difficult to ascer- tain the existence of these fractures, except they take place very near the os occygis. The prognosis and treatment of fractures of the sacrum, arc the same as of those of the ossa innominata and the vertebrae. ARTICLE III. Of Fractures of the Os Coccygis. These fractures seldom take place, although the bone is thin and small, on account of the great mobility of its diffe- rent parts. In persons advanced in age, in whom some of the Joints of this bone have become ancylosed, a fall upon the buttocks may produce this accident. The mobility of the fragments, and the acute pain felt on moving the lower extremities, by which the fragments of bone are acted upon by the glutsei muscles, sufficiently characterize it. This fracture requires only rest, the use of resolvent applications, and general remedies, according to circum- stances, C 59 ) CHAPTER VIII. Of Fractures of the Scapula. THE deep situation of the scapula, surrounded on all sides by thick muscles, and its extreme mobility, ren- der fractures of it very rare: they cannot be produced but by a direct and violent cause. Some of its parts, however, such as the acromion process and the inferior angle, not be- ing so deeply situated, are more frequently broken. Frac- tures of the coracoid process, and even of the neck of the scapula, are cited ; but they must be exceedingly rare, and can he caused only by excessive violence. When the body of the bone is broken, the fracture may extend either longitudinally or horizontally, or it may be comminutive. When there is a single vertical fracture, there is no displacement; but, when the fracture is horizon- tal, the lower fragment is drawn ^forwards by that portion of the serratus magnus which is inserted into it, while the upper portion is raised and drawn back by the levator sca- pula; and rhomboideus. In fracture of the acromion, which frequently happens near its base, the external portion is drawn down by the weight of the arm and the action of the deltoid muscle. When the fracture is situated above the inferior angle, so as to separate it from the rest of the bone, the inferior por- tion is drawn forwards and downwards by the serratus mag- nus, or forwards and upwards by the teres major and the latissimus dorsi, according as the fracture is situated more or less high up. In fracture of the coracoid process, the pcctoralis minor, the coraco-brachialis, and the short head of the biceps, which are inserted into this eminence, draw it downwards and forwards. It is evident that, after fracture of the neck of the sca- pula, this portion must be drawn downwards, by the weight of the arm and the action of the long head of the biceps. Most of these fractures arc easily discovered ; the vertical fracture is the most obscure ; however, even here, crepita- tion is generally perceptible. The displacement of the acro- mion process is very evident, by the irregularity that is felt along the spine of the scapula—the situation of (he arm, which hangs by the side of the body—the slight inclination of the shoulder*—and, lastly, the facility with which the 60 Boyer's Surgery. fractured end may be replaced in its natural situation, by raising the arm toward the shoulder, and pressing the elbow against the trunk, so that the bead of Ihe humerus pushes up the acromion process and the triangular ligament which unites it to the coracoid beak. Fracture of the coracoid process would be easily disco- vered, were it not attended with excessive swelling and con- tusion. The same may be said of fracture of the neck of the scapula. Fracture of the body of the scapula is not a very serious accident ; that of the acromion process, and of the inferior angle, are more difficult to keep in apposition. But frac- tures of the coracoid process are most difficult to manage : they often leave a permanent stiffness of the arm, with the loss of the power of raising the limb, atrophy, and some- times even palsy. If the fracture be comminutive, an ab- scess sometimes forms between the bone and subscapularis muscle. If the pus do not make its way to the axilla, per- foration of the scapula is necessary. When severe contusion of the external or internal soft parts accompanies these acci- dents, they become dangerous. In all fractures of the scapula, the arm is to be fixed against the side. This is all that need be done in a simple vertical fracture; and, in most cases, it is all we can do. It i*. fortunate, however, that an inexact consolidation of the fragments does not injure the actions of the arm. So simple vertical fracture we should place, between the arm and the trunk, folded compresses, to absorb the per- spiration : a bandage is then to be passed around the body and the affected arm, with several turns under the elbow and over the shoulder. Fracture of the acromion process is reduced, and kept in place, by fixing the arm by the side, and raising it parallel to iis axis. In addition to the treatment required in the last case, it is necessary to pass some turns of the bandage under the affected elbow, in front of the arm on the same side— over the corresponding shoulder—obliquely behind the ehest —under the axilla of the sound side—and oier the affected shoulder—behind the arm—and again under the affected elbow, so as to describe a figure of 8. It is impossible, however, to unite this fracture without deformity; but, for- tunately, this does not render the limb less useful. Fracture of the coracoid pyocess, and of the neck of the scapula, being always attended with violent contusion of the soft parts, requires much more attention to the treatment of the general symptoms, than to a nice reduction of the Of Fractures of the Clavicle. fit bones themselves. It is often necessary to cut down to the place of fracture, and remove the detached fragments ; and to raise those that are depressed, by the operation of the trepan, if requisite <£> CHAPTER IX. Of Fractures of the Clavicle. THESE are very frequent. They may result from vio- lence acting upon the two extremities of the bone, or at the place of fracture. In the first case, the most com- mon cause is a fall on the shoulder. The fracture is then in the middle of the bone, or a little without it; the outer fragment is carried downwards and inwards, by the weight of the arm and the action of the muscles. If a person fall upon his elbow, the external fragment may be pushed forward into the soft parts, and tear the bra- chial plexus, the subclavian artery, the cellular tissue, and even come out through the integuments; hut such cases are very rare. When the clavicle is fractured by violence applied directly to the part, it is always attended with more or less contusion, if the fracture be situated between its sternal extremity and the insertion of the ligaments which unite it to the coracoid process. In this case there is always displacement of the fragments. When, however, the bone is broken between the coracoid and acromion processes, the pieces maintain their natural situations. Nothing is easier than to discover a fracture of the cla- vicle; the displacement is generally perceptible, the arm hangs by the side of the body, the forearm is extended, and the whole extremity is rotated inwards. The patient in- clines his head and body to the affected side ; he gene- rally supports the forearm of that side with the opposite hand; he cannot raise his arm, or bring it forward ; and, above all, it is difficult for him to put his arm to his fore- head, or on the opposite shoulder; if obliged to do it, he bends the forearm, and inclines the head and trunk to- wards the affected side. The shoulder is lower, and nearer the axis of the body, than the other. By moving the arm, we may cause crepitation ; and, lastly, by pressing the arm b* Boyer's Surgery. upward and backward, we may give it its natural situation, and bring the fragments into contact. But many of these symptoms are wanting in those frac- tures in which there is little displacement; however, by ex- amining the part, we always perceive, near the acromion process, a slight depression, which disappears when we raise the shoulder. Simple fracture of the clavicle is a very trifling accident. When left to itself, ihe fragments still touch and unite, but with deformity. If there be contusion, or injury of the im- portant parts near this bone, the case is very dangerous. No fracture is more easy to reduce, nor more difficult to fci ep reduced. The indications in the treatment are three: 1st. To keep the humerus raised ; 2d. To keep its upper end outward; and, 3d. To keep the shoulder back. The most ancient treatment consisted in the use of a figure of 8 bandage, which was applied while the shoulders were drawn back. It is evident that this fulfils only the first indication ; besides, it soon gets loose; and, if tightened, it causes in- supportable pain, by its unequal pressure on the pectoralis major and latissimus dorsi. Petit endeavoured to obviate this inconvenience, by placing a compress on the back, from one shoulder to the other, and then applying the bandage, and tying the ends of the compress together; but this is no improvement. The cross of Heister, the corset of Brasdor, and the strap of Bruninghausen, have all the disadvantages of which we have spoken, except that they are less painful. Desault first hit upon the proper indications in fracture of the clavicle; yet he avows, with candour, that Paulus Egynita and Ambrose Pare entertained ideas analogous to his own. The apparatus of Desault consists in a wedge-like cushion, made of soft linen, maintained in the axilla, with its base up- wards, by means of a bandage passed around the thorax and over the sound shoulder; and two long bandages, which are applied as follows : The arm of the affected side, held hori- zontally during the application of the cushion, is brought down to the side ; by this means the head of the humerus is brought out; and, on the other hand, the elbow being car- ried a lillle forward, the shoulder is at the same time car- ried backward. Thus two indications are fulfilled. By raising the elbow, the reduction is completely effected All that remains to be done, is to fix the arm in this position. For this purpose, the first of the two bands is to be passed circularly around the arm and chest, from the elbow to the Of Fractures of the Clavicle. as ■boulder ; the second, passing from below the axilla of the sound side, rises obliquely over the affected shoulder, de- scends behind the arm of the same side, under the superior part of the forearm; thence it passes obliquely under the axilla of the sound side, behind the chest, and over the af- fected shoulder; it then re-descends before the arm, under the elbow of the same side, and rises obliquely behind the chest and under the sound shoulder, &c. continuing to pass this circuit three times, and finishing by passing a few times circularly around the body. It may be observed, however, that the wedge-like compress of linen under the axilla, often causes intolerable pain, and even deep ulceration, if it be not removed. Cotton answers the purpose much better, but it has not all the desirable firmness. The last band loses much of its action in the prolonged spiral turns which it takes from below the elbow of the affected side, under the axilla of the sound side, to the opposite shoulder; it is much more useful when it is simply passed under the elbow of the affected side to the opposite shoulder. Such as it is, and even with some alterations, which we shall presently describe, the apparatus is far from being perfect: it is fatiguing to the patient, incommodes his respi- ration, especially at first, and excites pain in the breast, par- ticularly in females. But, what is worst of all, the bandages soon become loose. To avoid this last inconvenience, and to employ the method of Desault, with an apparatus more simple and more easily tightened, without displacing the fracture, we have invented another.3* A pad, constructed upon the principles we have laid down, is supported, under the axilla of the affected side, by two bands, that are tied over the opposite shoulder ; a girdle of quilted linen, about five inches broad, is passed around the body, at the height of the elbows, and tightened by three buckles and straps fixed on its ends ; a bracelet of quilted linen, four or five fingers wide, is placed on the inferior part of the affected arm, and fastened by a band; four straps attached to the bracelet, two in front and two behind, are placed in the buckles of the girdle, and draw the elbow against the body, whilst the cushion in the axilla carries the head of the humerus, and upper part of the shoulder, out- ward ; by tightening the anterior straps, the elbow is brought forward; lastly, the weight of the arm is supported by a sling, which passes under the hand and forearm, and is fastened on the opposite shoulder. * 8ee plate I. %. 1, 2, and " r.i Boyer's Surgery. This apparatus is very simple, and easily tightened. In some patients, however, those who are asthmatic, for ex- ample, neither this apparatus nor any other can be sup- ported. Where the fracture is complicated, we must first reduce the inflammatory symptoms; and, in all these cases, we must be eontcnt with keeping the arm motionless near the trunk, and supporting its weight, as well as we can, by a good sling. We might here apply the apparatus recom- mended by Bell, had the necessity of fixing the arm im- moveably by the side occurred to him. After a simple fracture of the clavicle, the patient need not be confined ; however, he should not walk much, but preserve the sitting posture. When fracture takes place between the coracoid and acro- mion processes, it is sufficient to raise the arm, and bend it to the chest. The apparatus, therefore, which we have just mentioned, and a large sling, are sufficient. CHAPTER X. Of Fractures qf the Humerus. XI THEN the humerus is fractured below the insertion of VV the latissimus dorsi and teres major, it is called a fracture of the body of the bone; if above this part, the accident is termed a fraeture of the neck qf the humerus. ARTICLE I. Of Fracture of the Body of the Humerus. The arm may be fractured in any part of its length ; but the fracture is generally in the middle, a little below, and sometimes a little above, the insertion of the deltoid muscle • at other times, near the lower extremitv of the bone • the condyles have even been separated from' each other. 'The fracture may be transverse, oblique, or comminutive, simple or compound. This fracture is always caused by violence acting directly upon the part- PLATE I. Represents a Bandage for Fracture of the Clavicle. Fze. 1. A girdle of quilted linen, about five inches in breadth, and long; enough to go around the body at the height of the elbows. A A. The external side of the girdle. b b b b. Buckles for the straps of the bracelet. tec. Buckles to confine the girdle. d d d. Straps for the same purpose. Fig. 2. A bracelet of quilted linen, not so broad as the girdle, and long enough to extend around the lower part of the arm. A. The bracelet seen from the outer side. b b b b. Straps that pass into the buckles of the girdle. c c c c. Holes to receive the lacing string. d d. The lacing string. Fie. 3. The bandage applied. a a. The girdle. b b. The bracelet. c c. The straps of the bracelet received into the buckles of the girdle. d d. The lacing strings passed into the holes of the bracelet. e e. A wedge-like pad placed under the axilla. ff. Bands to confine it there. g g. A scapulary to support the girdle. A ^kllW „ Of Fractures of tlie Humerus. 65 When the fracture is below the insertion of the deltoid, this muscle drags (he upper portion outwards, and a littlo forward, while the other fragment is carried in a contrary direction by the triceps. When the arm is broken near the insertion of the brachi- alis intcrnus, the displacement is trifling, because this muscle counterbalances the action of the triceps. When the fracture is situated near the elbow, the fragments can only be dis- placed backwards or forwards, since the brachialis intcrnus and triceps are not inserted into this part of the bone, and the breadth of the humerus prevents the fragments from passing eaeh other laterally. When the fracture takes place above the insertion of the deltoid muscle, the inferior portion is carried outwards by the action of this muscle, while the upper part is drawn in- wards by the pectoralis major, the latissimus dorsi, and the teres major. The weight of the arm, however, prevents the bones from overlapping each other. Fracture of the body of the humerus is characterized by fixed pain, loss of motion, and deformity in the arm; the mobility of the fragments, and crepitation. In order to produce these last signs, the patient is to be seated, and the surgeon, placed at his side, is, with one hand, to move the elbow alternately inwards and outwards, while, with the other, he grasps the bone over the fracture. When a fracture of the arm is situated very high up, it may be confounded with luxation of the humerus; when it is situated very low down, it may be mistaken for luxation of the forearm ; or luxation may be taken for fracture, which last is attended with consequences far more serious. I could cite a great number of such cases, which I have cured; and many more, where, from the time since the accident had happened, it was impossible to prevent the total loss of the motions of the forearm. It must be con- fessed, that fracture of the lower extremity of the humerus is sometimes attended with so much inflammation and swell- ing, that the diagnosis is extremely difficult. Simple fracture of the humerus is not a very serious acci- dent, unless it be very near the elbow. In this case, it may cause severe inflammation, swelling of the ligaments, and a false ancylosis. Complicated fractures are more or less dan. gerous. The treatment of fractures of the humerus is very simple ; but as the apparatus necessarily compresses the lymphatics and veins, so as to impede their functions, swelling of tins forearm and hand quickly takes placi\ unless we apply a VOL II. 9 66 Bayer's Surgery. roller over the whole limb, beginning at the knuckles ami proceeding as far as the elbow : the bandage is then held until the reduction is effected. For this purpose, an assist- ant, placed at the sound side, steadies the shoulder; a se- cond takes hold of the elbow and extends it; and a third supports the hand; while ihe surgeon, placed on the affected side, presses the fraetured bones into their places. When the arm is restored to iis natural length and direction, and the external tuberosity of the humerus is in a line with the most projecting part of the shoulder, the redueiion is ac- complished. Ihe forearm is then bent, until it form an ob- tuse angle with the arm. With the remainder of the roller which was applied to the forearm, the arm is next to be covered, taking care to fill ihe hollow over the insertion of the deltoid muscle with lint or cotton—to apply the bandage moderately tight, in anticipation of swelling, and to place three or four circular turns around the fracture. Thin splints of wood or tin, rounded at the ends, and slightly hol- lowed, are now to be applied, one before and another be- hind ; if the limb be very small, we may employ three, which are to be placed at equal distances. An assistant is to support them, while the surgeon parses a roller from the shoulder to the elbow. The arm is to be brought near the trunk, and the forearm placed in a sling; and some turns in the bandage, including the arm and the trunk, render the former perfectly immoveable. If the sling were placed be- hind the bandage, and above the turns which it makes, the wrist and forearm might be carried backwards and for- wards, so as to rotate the inferior fragment in a very inju- rious manner. 'Ihe apparatus, thus applied, causes no pain, unless the parts be contused and swollen ; in which case the bandage must not be employed until these symptoms have subsided. The regimen is to be governed by the general principles we hate laiil down. We should, at first, renew the appara- tus every seventh or eighth day, and after wards less fre- quently, until ike fortieth or fiftieth day, and then we should cover the limb with a roller, in order to prevent edema. Thie treatment of fractures of the extremity of the hume- rus, even when simple, occasions much embarrassment to the surgeon; bein^ n«'ar the joint, they always cause in- fl'tn,:nation and swelling of the ligaments that have been in hated h% the cause that produced the fracture, and from which result* a f Fractures of the Bones qf the Hand. ARTICLE I. Of Fracture of ihe Bones of tlie Wrist. |7< RACTURE of the bones of the w rist can only ai isi 1? from very great violence acting directly upon them; such as the fell of a heavy body, a cannon or musket-ball, &c. Hence it is always accompanied with severe symptoms, which require more attention than the fracture itself; and, in some cases, they lead to the necessity of amputation. ARTICLE II. Of Fracture of tlie Bones of the Metacarpus. The bones of the metacarpus are seldom fractured; fliat •which is opposite to the little finger is broken more fre- quently than the others. A fracture of this kind can result only from direct violence. The fracture may be simple or compound ; it may extend to one bone only, or to several; the latter is most common, and more or less contusion always accompanies these cases. I shall relate a case, which will show what is proper to bo done, whether the fracture be simple or complicated. An armourer being engaged in proving cannon, an iron ring, which he was using to retain the fire in the match, was driven against the palm of Ids hand by the explosion of a piece. It buried itself so far, that it projected at the back of the hand, under the integuments. It was drawn out, the wound was dressed with lint, and the band covered with a poultice. On the fourth day, the patient complained of se- vere pain when he attempted to bend the ring-finger. I ex- amined the part very carefully, but it was not until the tenth or eleventh day that, in pressing upon lit flower end of the fourth metacarpal bone, 1 perceived a crepitation and mobility of the fragments, which showed that there was a fracture. When the inflammation and tumefaction had suh- vol. n. J' 82 Bayer's Surgery. sided, and the small wound had healed, I placed along the anterior and posterior parts of the fractured bone, two ob- long compresses, extending to the end of the finger; over these I applied two little splints, and kept the whole in place by a roller, which was passed first around the band, then around the three last fingers; thus embracing the me- dius and little-finger with the ring-finger, to which they answered the purpose of lateral splints. The pain entirely ceased after this apparatus was applied, and the cure was completed in six weeks. Comminutive fracture of several of the metacarpal bones may be attended with so great injury of the soft parts, that it becomes necessary to amputate at the wrist. But this operation should never be resorted to, unless the injury be inevitably irreparable, and the life of the patient would be endangered by deferring it. ARTICLE III. Of Fracture of the Phalanges of the Fingers. This is always accompanied with contusion. The dis- placement takes place in the direction of the bones, the ten- dons of the flexor muscles drawing towards them the infe- rior fragment. These fractures are easily known, and are not serious, unless the bone be crushed. There is no difficulty in placing the bones in exact apposition. The broken finger is then to be covered with a little roller, wet with a resolvent liquid, and splints are to be applied to the anterior and posterior parts: these are to be bound on by further turns of the roller. The adjoining fingers are then to be brought next that which is broken, and the whole enclosed in a bandage. Union takes place in twenty-five or thirty days. In the most complicated cases, we are not to despair of producing a re-union, but always bring the parts together as well as we can. It is time enough to amputate, when these endeavours fail. If the last phalanx be crushed, it is, however, better to amputate at once, than to endeavour to preserve the finger; for, at best, the cure would be long and difficult, on account of the inevitable exfoliation of the bone; and the part would be so deformed, as to ho rather inconvenient 'ban nsefnl. C 83 ) CHAPTER XI1L Of Fractures of the Os Femoris. THE great thickness of the soft parts around the fimm:, and the extreme mobility of its upper articulation, pre- vent, for the most part, the effects of external violence: on the other hand, its length and curvature, the angle formed with its neck, and the nature of its functions, cause it to be broken more frequently than the bones of the leg. The fracture which takes place above the trochanters, merits particular attention, and will be treated of in a dif- ferent chapter. The femur may be broken in any part of its length; but it is most commonly fractured at its middle. These frac- tures are generally oblique : in children, however, they are often transverse. External violence is the only cause of fracture of the femur: that which acts on the two ends, usually breaks ihe middle. A very great force may fracture any part to which it is directly applied. When the fracture takes place very high up, the upper extremity of the bone alone is displaced: in every other case, only the lower end is removed from its proper situa- tion. If the fracture be near the middle of the bone, the flexor muscles of the leg, and the adductor muscles of the thigh, which resemble the cord of an arc formed by the femur, bend it back, and form a projection in front; at the same time the lower end is drawn inwards, and the upper fragment projects on the outer side: the limb is then short- ened by the overlapping of the bones. If the limb be placed horizontally, the foot, being without the central hue of iho thigh, draws with it the lower end of the femur, and rotates. it outwards, so as to twist the fractured pieces. In oblique fractures, the tension of the flexor and adduc- tor muscles does not bend the pieces on each other, but causes an overlapping, to such a degree that the separated surfaces cease to touch each other: the lower fragment is drawn, by the adductors, above, and within the upper. The rotation outwards of the lower fragment, takes place as m the pre- ceding case. In children, in whom the fracture is almost always trans- verse, and in whom the muscles are not strong, the bones arc bent upon each other; but there is seldom any overlap- 5* Boyer-s Surgery. ping of the ends. The fractured femur is often bent back wards, but not shortened. When the fracture is directly above the condyles, the lower portion is displaced by other causes, and in another direction. The projection which they form behind the gas- trocnemii, plantaris, and popliteus muscles, bend the upper fragment forwards, and the lower portion is inclined back- wards, towards the bend of the knee. The inclination of the condyles upwards, causes a projection at the superior part of the patella, and gives the knee a singular appearance. When the thigh is broken immediately below the trochan- ter minor", the psoas and iliac muscles, inserted into this process, draw forward the upper fragment, and cause a pro- jection in the groin. When the trochanter major is separated from the femur, it is drawn upwards and backwards by the glutsei muscles. The general signs of fracture of the femur are, a fixed pain, inability to move the limb, its shortening, its crooked- ness, and a projection caused by the fractured ends; their mobility on each other, and the crepitus which this motion produces. Fracture of the femur is always a very serious accident. The ancients considered a shortening of the limb as a ne- cessary consequence even of a transverse fracture of this bone; and the ease is far more difficult to manage, if the fracture be oblique, or very high up. Fracture near the condyles is more easily retained in its situation ; but here there is danger of inflammation affecting the knee-joint, and eausing ancylosis, or a necessity of amputating the thigh. Fracture of the femur, arising from violence ap- plied directly to the broken part, is much more serious than that which is caused by violence acting upon the extremities of the bone, because it is always accompanied with severe contusion of the soft parts. When we are called to a case of fractured femur, wo should first arrange the bed. This must be a mattress about three feet wide, without a pillow or bolster. A folded sheet is to be placed under the breech, for the sake of clean- liness, as well as to move the patient. A cord is to be fastened to the ceiling, above the patient's breast, so that he can aid in raising himself without moving the fracture. The bed being thus prepared, the apparatus consists, 1st. Of a piece of linen large enough to extend the whole length of the limb, and to allow a splint on each side to be rolled three or four times in it, and still be two or three inches from the limb. 2d. As many bandages, three inches broad, Of Fractures of the Os Femoris. 85 and of different lengths, each long enough to pass once and a half around the part where it is applied, as will cover the 'whole limb. These bandages are to be laid across a piece of linen called a splint-band, so that they shall be covered by two-thirds of each other. 3d. Two splints, long enough to extend, one from the crest of the ilium, and the other from the ischium, beyond the sole of the foot. These splints are to be rolled in the sides of the splint-band, and in the ends of the bandages, so that the splints are applied to each other. A third splint is to be placed on the anterior part of the thigh, from the groin to the knee; or, what is better, half way dowH the leg. 4th. Two double compresses, suffi- ciently long to extend the whole length of the thigh, and broad enough to embrace three-fourths of its circumference. 5th. Three bags filled with chaff, rather longer than the several splints, and to be placed within them. 6th. Five ribbons, an inch broad, and long enough to go round the apparatus, and tie in a bow-knot. 7th. A resolvent liquid— salt and water in preference. The patient's clothes are to be cautiously removed; the pantaloons must be cut or ripped. It is better not to put the apparatus on the bed before the patient is adjusted there. In putting the patient on, the mattress, the surgeon should hold the limb above and below the fracture, while two as- sistants are charged, one with the leg, the other with the pelvis. ' After the patient has rested a few minutes, an assistant is to hold the lower part of the leg or foot; a second, the upper part of the thigh; and a third, the part where it is broken; and all together are to raise the limb; while the surgeon, unrolling part of the bandage, places the apparatus under the limb, taking care to see that it is high enough to embrace the upper part of the thigh: he also places three ribbons under the thigh and leg. The limb is then to be laid upon the apparatus. A strong assistant, placed on the fractured side, is charged to steady the pelvis, by pressing strongly on the two anterior and superior spinous processes of the ilium; a second puts his right hand around the heel, and the left over the meta- tarsus ; and draws gently, first, in the line of the lower fragment, and then in that of the limb. The surgeon, stand- ing on the affected side, gently presses the broken ends to- gether with the palms of the hands, and .adjusts them in their proper situation. It sometimes happens that the muscles, instead of yield- ing to the extension, contract strongly, and become hard S6 Boyer's Surgery. and swollen. If so, we must wait until the irritation and spasmodic contraction subside, which happens on the third or fourth day ; sometimes a little later. However, we must confine the fragments, in order to prevent ulterior displace- ment, whicli would keep up the irritation of the soft parts. While the assistants maintain the fracture reduced, the surgeon applies a resolvent liquid: he then places, before the thigh, the double compress, which is to cover its whole length, and of which the sides are to be brought out on each side of the limb, and fastened below; after which the strip bandages are to be applied, beginning with those below. The lateral splints are then to be rolled, one on each side of the splint-hand, until they are two inches from the limb. The interval is to be filled with the bags of chaff, which should be rendered thick opposite to the outside of the knee, and in places where the space is greatest, and vice versa. The third bag of chaff and splints are then applied, and fastened, by the ribbons, on the fore part of the thigh, beginning with the ribbon opposite to the fracture. A cradle is then to be placed over the limb, to support the bedclothes. If the apparatus have been badly applied, and we have occasion to remove it, we should begin by confining the pel- vis, and extending the leg in the manner we have described. A third assistant must steady the fracture, while the surgeon carefully takes off the splints and bandages. In ordinary cases, the apparatus should not be taken off for five days. At this time the swelling is generally so di- minished as to have loosened the bandages. It is proper, however, to tighten the ribbons every day, as they become relaxed. For four or five weeks, the apparatus is to be re- moved every fifth or sixth day, in order to ascertain the state of the fracture. After this period, it may remain on eight or ten days. The apparatus is required to be conti- nued forty days in children, and fifty days in adults. The union of the bones is usually firm in fifty or sixty days; but before removing the splints, we should ascertain if the frac- ture be sufficiently consolidated. This is done by placing one of the hands under the fracture and pressing it up- wards, and by directing the patient to raise the limb. If it be firm, we should apply a roller over the limb, to prevent edematous swelling. After all, with every possible care, there is generally a greater or less shortening of the limb. Sometimes the frac- ture does not unite at the usual period, and we are obliged to keep the patient in bed for five or six months; and even Of Fractures of the Os Femoris. 87 then the hones do not always unite, and a false joint is formed. Very often the patient begins to walk before the proper time; then the thigh bends backwards and inwards, and the fracture consolidates while Ihe bone is in this situ- ation. These inconveniences can only be avoided by apply- ing the apparatus used for fractures of the nock of the femur, and which have been advantageously used in all fractures of that hone. But there are serious objections even to this treatment, and many patients cannot support it. When the fracture is near the condyles, it is much more easily treated. It is proper to place a pad under the upper part of the thigh, to prevent the lower fragment from bend- ing backwards. In children, it is sufficient to apply a roller over the thigh, and splints of pasteboard, whicli need only extend to the foot. The apparatus should be covered with oiled silk, to prevent it from getting wet. As to the general treatment, if the patient he young and plethoric, a bleeding may be proper; in other eases, low diet is sufficient. After some days, when the irritation has subsided, solid food and a bitter infusion are indicated. In compound fracture of the femur, we arc to follow the general rules laid down for such accidents. Of Fracture of the Neck of the Femur. Considering the deep situation of the neck of the femur, and its shortness, we should be led to believe it almost in- susceptible of fracture. Nevertheless, there is no doubt that this accident is very frequent; and this is to be explained, by reflecting on its small size, its obliquity, and the thinness of the bony shell which covers its spongy substance. The neck of the femur may be fractured above the at- tachment of the capsular ligament, or below if. In the for- mer case, the fracture, which is within the joint, is gene- rally near the head of the bone, and transverse; aud the cartilaginous covering of its head is torn. In the second case, the fracture is wholly, or in part, without the joint; and its direction is almost always oblique, from above down- wards, and from within outwards, so that the great trochan- ter remains on the upper fragment. Sometimes ihe neck of the femur is broken, both above and below the insertion of the capsular ligament. Wc have seen several examples of this double fracture. In other instances, the trochanter alone is detached. The neck of the femur is occasionally comminuted by a gun-shot wound; at other times, the ex- 88 Boyer's Surgery. tremilies of the fracture are so rough and uneven as to di mmish, or even entirely prevent, displacement; and several eases have been seen, where one of the fragments, shaped like a wedge, was received into a corresponding angle in the other. Fracture of the neck of the femur is rarely com- plicated with w ound, unless in cases of gun-shot wounds; but there is generally more or less contusion, which leads to the necessity of using poultices, before we attempt to apply the splints. The most common cause of fracture of the neck of the femur, is a fall upon the trochanter major; so that, as Pro- fessor Sabatier observes, when a patient has fallen upon the trochanter, this is of itself a strong presumption that the neck of the thigh-bone is broken. However, a fall upon the feet or knees may cause the same accident. The manner in which the fracture takes place, is different in the two cases. In the first, while the great trochanter supports (he whole weight of the body, the head of the femur is pushed forcibly upwards and outwards by the acetabulum: here the ten- dency of the violence is to straighten the neck upon the body of the hone, and to destroy their inclination to each other. In the second, on the contrary, the feet or knees being stopped by the resistance of the ground, the upper part of the acetabulum presses the head of the bone down- wards, and increases its obliquity to the axis of the femur. In the first case, the inner part of the bone, and, in the se- cond, the outer part, yields first. However astonishing it may appear, it is not the less cer- tain, that the fractured pieces of bone are not immediately displaced. Some persons have walked home after fracturing the neck of the femur; in others, the bones have remained jii their natural position several days, and have changed their place while the surgeon was moving the limb to ascer- tain the nature of the case. We have seen a man who walked with a stick several days after an accident of this kind. In all these instances, the bones arc retained in situ by a strong fibrous covering spread over the neck of the femur, and by long projections of one piece received into corresponding cavities in the other. After a short time, however, the fragments always be- come displaced, and slip by each other, so as to shorten the limb, sometimes several inches, at other times only a few lines. The greatest shortening takes place when the bone is broken below the insertion of the capsular ligament; for this ligament, which is never torn, prevents extensive dis placement of a fracture within it. Of Fractures qf the Os Femoris. 89 The point of the foot and the knee are turned out by the weight of the limb, assisted by the action of the pyramida- lis, the glulsei, the obturatores, and the quadratus femoris. Some cases have been observed, in which the leg and foot have been turned inward. This circumstance was observed by Pare and J.-L. Petit, and has puzzled many later authors. We have never met with it. Before the bones are displaced, there are only three pre- sumptive signs of the existence of the fracture of the neck of the femur:—the circumstance of the patient's having had a fall on the trochanter, his inability to move the limb, and his feeling a severe pain at the upper part of the thigh, and especially in the groin. But almost always some degree of shortening takes place. In order to discover it, we are to place the patient on his back, and to compare exactly every remarkable point on the two limbs, from the anterior supe- rior spinous processes of the ossa ilii, to the malleoli interni; for disease may have altered the length of one of the legs. When the shortening of the limb arises from displacement of the fragments of the fracture, the trochanter major is ap- proximated to the crest of the ilium, and drawn a little backwards. Extension of the leg, made by drawing down the foot, restores the limb to its natural length. As soon as this ceases, it becomes shortened. The foot and knee being turned out, the patient, in lying on his back, inclines to the affected side; the limb is slightly flexed, and the heel lies in the hollow between the malleolus interims and the tendo Achillis of the sound side. But it is sometimes lower dow n, rarely higher. By taking hold of the foot and knee, we may easily ro- tate the limb inwards; but it does violence to the posterior part of the capsular ligament, unless we raise the trochan- ter major at the same time, and bring it forward, so as to relax the capsular ligament. While the limb is rotated, we should examine if the tro- chanter major revolve in an arc formed by the radius of the semidiametjer of the bone, or that of the length of its neck. It must, however, be confessed, that this sign is far from being so valuable as has been imagined. As to crepitation produced by rotating the thigh, we have never been able to distinguish it. Moreover, we believe that attempts to make it perceptible are not unattended with danger, by the irritation they excite. No author has mentioned a phenomenon which constantly occurs in the fracture of which we are treating. The pa- smj Beyer's Surgery* tient, lying on his back, cannot raise the limb entirely, and the efforts which he makes to do so are always painful, and produce only a slight and slow flexion of the leg and thigh ; and draw the heel along the bed towards the buttocks, with- out elevating it in the least degree. It is true, all this may occur after a severe contusion of the joint; but if the same phenomena lie witnessed when the swelling and irritation have subsided, we may be certain that there is a fracture; We believe that this phenomenon may even lead to tho presumption of the existence of a fracture without displace- ment. The signs of fracture of the neck of the femur may, therefore, be briefly stated to be, 1st. The shortening of the limb, and an approximation of the trochanter major to the crest of the ilium. 2d. The rotation of the limb outwards. •d. The facility of restoring the limb to its natural length and direction, by slightly extending it, and rotating it in- wards, 4th. The small circle, of which the motion of the tro- chanter, produced by rotating the limb, forms an arc. 5th. The impossibility of bending the thigh upon the pelvis, while the leg is extended. After a severe contusion of the ilio-femoral joint, the po- sition of the patient is the same as in fr-acture of the neck of the thigh-bone; but the want of shortening of the limb, and the movement of the trochanter major in an are of a eircle, of which the neck of the femur is the radius, sufficiently distinguish contusion from the injury of which we are treat- ing. However, these signs cease to be characteristic, if there be no displacement of the broken portions. It is impossible to eonfound luxation of the thigh down- wards (whether it be inwards or outwards) with fracture of the neck of the bone. In the two first cases, the limb is lengthened; in the third, it is shortened. Luxation upward is accompanied with shortening of the limb, but in a much greater degree than takes place in fracture. In both acci- dents, there is an approximation of the trochanter major to the crest of the ilium; but, when there is luxation, we can- not restore the limb to its natural length, as in fracture, ex- cept by very powerful extension and counter-extension. In luxation upwards and inwards, the point of the foot is turned inwards; the limb is fixed in this position, and cannot be ro- tated outwards. In some rare cases of fracture, the limb, it is true, acquires the same position; but then it can always? Of Fractures qf the Os Femoris: ff be easily rotated and restored to its natural length; and, moreover, the projection of the femur before the horizontal branch of the triceps, is sufficient to characterize the former accident. Diseases of the os innominatum, or of its articulation, may lengthen the limb, by thickening the bone, or changing its situation. In the first case, the lengthening of the limb distinguishes the disease from fracture; and, in the second case, although the limb appears shortened, the trochanter and the iliac crest preserve their natural relations ; besides, the shortening of the limb cannot be removed, and rotation readily takes place. Except, therefore, in those very un- common cases where no displacement of the fragments takes place, there is not the least difficulty in distinguishing frac- ture of the neck of the femur from every other accident; and this difficulty cannot last more than two or three days at farthest, and these should be employed in discussing the inflammation. Some authors believe that fracture of the neck of the thigh-bone never unites, and others, that it is necessarily followed by a shortening of the limb. It cannot be denied, that sometimes fractures of the neck of the thigh-bone do not unite; it has even happened that the superior fragment has become almost absorbed, and the articulation filled with sanious and fatty matter. We have seen one case of this kind, in which not only this destruction of parts took place, but there were in the joint, pieces of bone mixed with an oily sanies. It is remarkable that this destruction is very different from that which takes place from aneurismal tumours; the former process seems to be more mechanical, and to result from a greater diminution of the vital powers. Nothing like it is seen after other fractures, in which no bony anion has taken place, from the bones not having been kept gently in apposition; on the contrary, union takes place through the medium of a liga- mentous substance, A preternatural joint may thus he formed; but, if we except some uncommon cases of frac- ture of the neck of the humerus, the fragments are never destroyed; nor do we find their ends covered with (he wreck of their own substances, as in the cases of which we are speaking. It is also remarkable, that all the cases of want of union of fractures of the neck of the thigh.bone that have been cited by others, or which we have witnessed, have occurred in persons advanced in age; and that almost all of them have shown evident symptoms of scurvy. Can 93 Boyer's Surgery. any conclusion, as to the possibility of re-union in any ease, be drawn from such facts? Were not all these patients in a situation unfavourable for the union of a fracture ? More- over, these cases occurred at a time when the mode of re- taining the fracture reduced was unknown ; or were noticed by persons who, believing in the impossibility of a re-union, took no pains to produce it. There are examples of a re- union of the neck of the femur by an intermediate liga- mentous substance, which has been mistaken for bone in a diseased state: sometimes it has occupied the whole breadth of the fractured surface; at others, only a small space, but retaining the fragments firmly together. Lastly, in cases where the continued friction of the fragments has nearly destroyed one of them, we find generally the periosteum, or rather the capsular expansion which covers the neck of the femur, of a ligamentous density and consistence: by these means the pieces are often kept together, so that the patient can walk. This kind of union has been observed under the same unfavourable circumstances which wc have mentioned in the former case, and which have, given rise to the opinion, that it was the only union which could take place after a fracture within the capsular ligament. The analogy between this phenomenon and the ligamentous union of a fracture of the patella, leads to this conclusion, that the difficulty of retaining the fragments together, after a fracture of the neck of the femur, renders the formation of a preternatural joint much more liable to occur than in any other case. Public collections, and cabinets of pathology, are fiHed With specimens, which demonstrate the possibility and fre- quency of an immediate union of fractures of the neck of the femur. Besides the principal nutritive artery, which enters the femur at its posterior part, this bone receives others, that penetrate the spongy tissue of its extremities, and spread over its surface; the fibrous tissue that is reflected from the capsular and the round ligament, contains others, which go to the head of the femur.' It cannot, therefore, be said that these parts want sufficient vitality and vascularity for re-union; but the nutrition of the upper fragment is more or less weak, if the capsular ligament have been torn. Hence we see, in the morbid specimens, that the lower fragment is sw ollcn, and covered w ith osseous slalactiform processes, while the upper fragment is nearly absorbed. As to the opinion of some, who think it impossible to Of Fractures of the Os Femoris. 9.1 cure this fracture without deformity, we shall be able to appreciate its value, if we make a hasty survey of the treat- ment which has been employed at different periods. This may be distinguished into three kinds: 1st. That which consists merely in circular compression; 2d. 'that which consists in frequent reductions; and, 3d. That in which the limb has been subjected to the action of permanent exten- sion. The first, it is evident, can have little or no effect, on account of tiie depth of the hone. It was once thought that, as the shortening of the limb, after fraeture, was produced by muscular action, frequently repeated extension would produce a durable coaptation, by fatiguing the muscles and destroying their action. This method was adopted by men of great merit, and approved of by the Academy of Surgery. M. Sabat'tcr lias seen frac- tures treated in this way, which did not unite in eight or ten months. Certainly imperfect cures, obtainetl by sueh means, should not prejudice us against the possibility of uniting it by a better; but there are cases in which the neck of the thigh-bone, after being broken, has become consolidated, even under this imperfect treatment, and in old patients, which abundantly establishes the possibility of obtaining a perfect consolidation of the fracture of which we are treating. Nevertheless, it must he confessed that fracture of the neck of the femur is a very serious aceident, especially if very near the bead of the bone. The weak vitality of the upper portion renders the union difficult, particularly in aged patients; and if the coaptation be not exactly main- tained, union will not only be delayed, but may take place through the medium ef a ligamentous substance. Under a combination of unfavourable circumstances, even in simple fracture, the eure may be impossible; and a disease of the joint may be brought on, which will prove fatal. There is no difficulty in giving the limb its natural length and direction ; but it is not easy to bring the bones into co- aptation, nor have wc any means of knowing when they arc- so. The fibrous covering around the neck of the femur is generally more or less torn, and the direction of the ex- tension and counter-extension is not parallel to the fractured bone. On these accounts, they are with difficulty brought into coaptation. Extension ami rotation of the limb lo its proper length and direction, will certainly bring the frag- ments into contact, but do not necessarily produce a coapta- tion. This, however, is not essential to th: consolidation of ;?;:? fracture. If the bones to-tch in any part of their frac- / oi Boycr*s Surgery. lured ends, there is every probability of their re-union ; and we may be certain that they do touch, when the limb is restored to its natural length and direction.* Notwithstanding the great number of museles which sur- round the limb, it is brought to its natural length and direc- tion by very moderate force. The patient being laid on his back, one assistant steadies the pelvis, a second takes hold of the foot, and draws it downwards very gently, and, at the same time, rotates it inwards. To facilitate this last part of the reduction, the surgeon, placed on the outside of the pa- tient, also raises the trochanter major, and brings it for- ward, so as to remove the tension of the capsular ligament. The advice given by some practitioners, to carry the upper part of the thigh outwards, by pressing against its internal and upper part, iu order to prevent the fragments from rub- bing against each other during the extension, is altogether useless. We have shown that the displacement cannot be extensive; and, moreover, the force is not great enough to carry the femur inwards, so as to occasion an injurious grating of the fragments on each other. But it is as difficult to keep the fracture reduced, as it is easy to reduce it: as soon as the extension ceases, the action of the muscles displaces it. Lateral compression, which acts only on the circumference of the limb, is here altogether useless: the fracture is situated so high up, that the appara- tus cannot surround it; and the muscles, which have the greatest agency in displacing the fracture, are so placed, that their action cannot be repressed by any bandage. ReasOn and experience must soon have suggested to ob- serving practitioners, the idea of continuing the extension and counter-extension, by a permanent force, during the whole time necessary for the consolidation of the fracture. This was, in fact, tried at a very remote period, and it is doubtful if we know all the means that were employed in order to attain this object.f *" Although Hippocrates has not, in the exact words, spoken of frac- ture of the neck of the femur, there can be no doubt, from several pas- sages in his article on fractures of the thigh, that he had seen it. It is not improbable that the following passage is founded upon positive know- ledge of the nature of the accident: " Sed et omnia ossa tardius corrobo- rautiir, si non secundum naturam posita fuerint, itemque ea quiz non in ed- dem jigura quiescunt; et calli quoque debiliores ipsis obducuntur."—Vers. Vanderlindenii, lib. de Fract. XXV. •j- It is probable, for example, that we do not find in Hippocrates all that was known, in his time, of the proper means of maintaining reduced a fracture of the femur: this, at least, seems to result from several pas- sages, which we shall here cite: " Carries deligationem superabunt, non ab ipsa superabuntur. In eo igitur, de quo agitxir, intenno valida feri debrt, Of Fractures of the Os Femoris. 9j As nothing can prevent the constant tendency of the muscles to shorten themselves, some means of opposing ic are therefore nceessary, or their points of insertion must be approximated. The last method, which alone is effectual, was forgotten, merely because no means were known by which it could be practised. In order to estimate the value of the different methods of treating fractures of the femur, we shall first inquire if permanent extension be practicable, provided it be supportable. We shall then call to mind what we have said of the qualities which every apparatus should possess, and examine if these qualities are united in any of the different apparatus that have been devised. In order to judge of the possibility of exercising perma- nent extension of the thigh when the neck of the femur is broken, we must not forget that the desideratum is to pre- vent the fractured pieces from moving, and to hinder the muscles from shortening the limb. After the first days, the muscles have not any other tendency to shorten themselves than that which arises from their elasticity. This is very different from their contractility or irritability, and a very moderate force is sufficient to overcome it; and the coapta- tion of the broken bones removes the irritation which their displacement excites, and would otherwise keep up for a long time. In treating generally of the means of keeping fractures in plaee, and favouring their consolidation, we have reduced to five, the essential qualities of every apparatus for permanent extension. 1st. To avoid compressing the muscles which pass over the fracture, the elongation of which is necessary to the re- duction. 2d. To distribute the extending and counter-extending forces over as large a surface as possible. 3d. To cause them to act as nearly as possible in the direction of the injured limb. 4th. That they act slowly and almost insensibly, and that their power may be graduated. sic nullam ut in partem vertatur, nihilque deficiat.----Magnum enim de- decus est ac detrimentum, femur brevius efficere----Sanum enim crus longiw est, et id redarguit. Quare utilius fuerit, ut si quis male curandus sit, am- ln potius crura fracta habeat, quam alterum tantum."—De Fractur. XXIII. How could this result be so disgraceful to the burgeon, if it were com- mon ? In the same book, Hippocrates describes an apparatus for perma- nent extension of the leg. How could the necessity of a simitar treatment of the thigh have escaped observation, When tLs few cases :«:c mcri'ionei! In which it is proper in fracture of the leg-' 9o Mayer's Swgei*y, Mb. That the pai«ts on which they act, be protected from hard and unequal compression. Let us now inquire how far these qualities are united -in any apparatus now in use. We are, first, to consider the most ancient treatment, which is at once described and censured by Hippocrates, and which consisted in tying the foot to the foot-board of tire bed: " Neque," says ho, " ad recti! udinem qukquam prodest, sed etiam obest. Dum enim verlilur, reli- quum corpus ant hacf aut iliac, nihil prohibebit vinculum illud, quo minus et pes, et ossa pedi annexa, reliquum corpus sequanlur. Imo^si tes alligatus won fi isset. minus distorojlereti r."* Nothing can be added to increase the value of these remarks, nor is it destroyed by the change which this process afterwards underwent. It is the same which Guy-de-Chauliac described from Roger, except that there are, in the last, some imperfections not in the former: it wants a counter-extending power, and there is nothing to prevent the patient from slipping down the bed, when the extension is applied by the pulley and rope, one end of which is fastened to the limb, the other to a weight. Before the time of Desault, counter-extension was made by a band fastened to the head-board of the bed. We shall not fill our pages with a description of the different means of making permanent extension, employed by Hippocrates, Hildanus.f Belloc, Gooch, and Aiken. None of these ap- paratus prevent rotation of the limb outwards; and, more. ovfe^', the muscles passing over the fracture are compressed, the force of extension and counter-extension is supported by a small space, and the parts are not sufficiently protected by compresses. The methods of Belloc and Gooch have a fur- ther inconvenience, which is, that the extension, being sup- ported by the sides of the knee and foot, or by the knee alone, is not counterbalanced by the ischium, to wliieh the counter-extension is applied; so (hat its point is the only one which resists the shortening of the liinb.} * Lib. de Fract. XXXII. | We cannot avoid noticing here an historical error. Hildanus recom- mends, for fractures of the lower and middle parts of the thigh, a splint capable of being elongated by means of a double screw; and which, being placed on the internal part of the thigh, makes the extension by means of a strap above the knee, and another below it; and the counter-extension by pressing against the os pubis. This must not be confounded with the wrought-iron splint, wliieh he advises for fractures of the upper part of the femur, and which we shall hereafter describe. t We have not mentioned Avicenna among the authors who have recom- mended continued extension, because the passage, in which he is thought, by some, to refer to this process, appears to me to relate toother subjects. Of Fractures of the Os Femori§. 3? There is only one known process by which rotation of the limb outwards h prevented, which is that of Bruninghau- sen; but, unfortunately, he neglects all means of obviating the shortening of the limb, and even gives the name of re- duction to the simple rotation of the foot inwards. " This,"' says he, " is the most essential part of the treatment, and that which has been most neglected." There is too much truth in the latter part of this observation; for, although every practitioner regards rotation inwards as an uniform characteristic of this fracture, yet no one before Bruning- hausen endeavoured to prevent it. The thigh is so eon- vex in front, and so broad below in its lateral diameter, that, when the knees are brought together, the part of the bone above the point of contact, is, at the same time, before it; so that the limb being rotated inwards, and fastened to that of the opposite side, directly above the knee, rota- tion outwards is prevented, as well by the resistance of the condyles of the sound side (which tend to pass inward, be- cause the middle, and most curved portion of the femur re- tained by the ligature, cannot turn out), as by that of the posterior part of the ilio-femoral capsule. Thus the femur may be considered as a double lever of the second kind, the moveable portion of which is the most arched part of the bone, precisely that to which the bandage is applied; the points of support of the two levers, are the posterior end of the external condvle, and the part equidistant from the trochanter major and the surface of the fracture; lastly, the resistance represented by the weight of the limb, is half way from the extreme points and the point of coincidence of the two levers. In order to give more stability to his bandage, Bruning- hausen fastened it to a leather splint, the upper end of which passed around the pelvis ; and, to hinder the limb from be- ing bent, he tied the feet together. These means he after- wards abandoned; and it is easy to see how ill they are adapted to answer the purpose for which they were in- tended: it must, at (he same time, be allowed, that nothing can be better calculated to prevent rotation of the limb out- wards. But it does not appear that constant pressure of the knees against each other, is either necessary or supportable; on the other hand, the total neglect of extension and counter- extension, and constantly keeping the limb rotated inwards, tend to increase the shortening, unless the fracture be with- in the capsule. In the year 1777, A'ermundois, a very excellent and modest surgeon, invented a process, which, if it did not answer the VOTi. ir. 1.1 fr$ Boyer's Surgery. end proposed, was at least devised with a perfect knowledge of the indications to be fulfilled. He considered broad splints as best adapted to prevent the rotation of the limb outwards: the ankle was fastened to two splints, and the extension very properly made in the direction of the axis of the limb: coun- ter-extension was effected by two splints, the outer of which pressed against a cup of iron fixed to a band of leather, and the inner into another cup fastened to the same girdle, under the thigh. He afterwards simplified his method of making the extension, by passing a band over the groin, and obliquely upwards, to the superior part of the outer splint. This pro- cess differs very little from that of Desault, except in the oblique direction of the two heads of the extending bandage, which are carried towards the lower end of the outer splint. These two practitioners deserve great praise for having first discovered the method of applying continued extension by a simple process, which acts on the two ends of the frac- tured limb> and as nearly as possible in the direction of its axis. But Vermandois alone perceived the necessity of pre- venting the limb from rotating outwards, though he did not cflcet this object. Desault, on the other hand, appears to have entirely overlooked it; for, in fact, his apparatus in- creases the rotation outwards, which it is so essential to prevent. Both applied sufficient force to keep the bones im- moveable; hut the powers they employed cannot be gra- duated at pleasure. Lastly, their extension and counter- extension are not applied to a surface sufficiently large, and the parts are not sufficiently protected, by soft substances, from injury. Such is the state of this part qf surgery at the present time. We may readily see why the extended position of the thigh is not always successful, and why some practitioners of great merit have abandoned it entirely : hitherto, no ap- paratus has been invented which unites all the conditions ne- cessary to its success. We have endeavoured to combine all the essential qualities in a process which we have had very frequent occasion to employ, and we are assured that, if it have not all the advantages that could be desired, it answers all the most important indications. It is not, indeed, suffi- ciently simple to be in common use; but it keeps the frac- ture in a more steady and exact apposition than can be obtained by any other means. The apparatus consists of a machine, composed of a splint, a foot-piece, and a thigh-strap. The splint is four feet long, two inches and a half broad, four or five lines thick, and made of strong and somewhat r\ If PLATE n. Represents a Machine for constant Extension of the lover Extremities. Tig. 1. The inner side of the splint a a. An opening or cleft extending through the lower third of its length. b b. A regulating screw. c c. The square end of the screw, to which is fitted a wench to turn it. d d. A moveable box or nut, having an opening through which passes the screw, covered with two plates that slide on the sides of the splint. e e. Legs. /. The upper end of the splint. Fig. 2. The thigh strap. a a. Its middle portion stuffed. b. Its end armed with a strap. c. A buckle at the other end. d. A pocket, opening downwards, to receive a sort of crutch at the upper end of the splint. Fig. 3. The foot piece. A. The plate of the sole. B B. A split piece of raw sheep-skin-. Of Fractures qf the Os Femoris. 99 flexible wood. An opening, or cleft, extends through half the length of the splint; the end of this is armed with an iron trimming. This trimming represents three sides of an oblong square, and encloses the sides of the splints, to whicli it is attached by screws. In the opening of the splint a box is made to slide by means of a regulating screw, which passes through its centre. The regulating screw extends through the whole length of the. opening or cleft in the splint; and one end is made square, so as to be turned by a key; the other end of the regulating screw revolves on a plate of iron at the bottom of the cleft. To the sides of the box are attached two square plates of iron, which slide in the sides of the s|>unt. The two plates and the box have an opening perpendicular to that which receives the regulating screw; into this opening passes a hexagonal nut, by means of which a piece of iron (intended to support the foot-piece when the machine is in use) is fastened to the innermost of the two plates. This piece of iron is formed of two parts united at a right angle, one of which is parallel, the other perpendicular to the side of the splint. One of these parts is square, and has an opening, into which passes the screw that traverses in the box, to the internal plate whereof it is thus fixed. The second part is about six inches long, and two thirds of an inch broad; it has an oblong opening to receive a tenon of the foot-piece. Near its ends are two te- nons and thumb-screws; the former pass through mortices in the legs or supporters, which are secured by the thumb- screws. The legs are six inches long, and curved, their con- vex surfaces facing each other. The upper end of the splint is armed with a piece of iron, on the middle whereof is a tenon, in which is engaged the horizontal part of a crotchet, constructed as follows:—It is composed of two parts, which unite at a right angle. One of these parts is vertical, parallel to the plane of the splint, one inch and a half long, and of a semicircular form: it is received into the pocket of the thigh-strap. The other is horizontal, and perpendicular to the plane of the splint; it is three inches long, and has a longitudinal aperture, into which the tenon of the upper end of the splint is received; and the crotchet is retained in the place judged proper, by means of a thumb-screw. The foot-piece is of wrought-iron, covered with chamois leather, and furnished with a broad strap of soft skin, split, almost throughout its whole length, into two narrow straps. These pass around the foot and leg, so as to confine the for- mer to the foot-piece. On that side of it which is towards 100 Boyer's Surgery. the lower end of the splint, arc two tenons, placed iu the same vertical line, and one of which is engaged in the ob long aperture of the plate of iron which connects the sup- porters, so that the foot-piece may, by means of a thumb- screw, be retained at a greater or less distance from the splint. The horizontal plate also admits of being inclined in such a way as to rotate the foot-piece inwards or out- wards. The thigh-strap is formed of two straps of strong leather', united at an acute angle. These are two finger-breadths wide, covered with sheep's skin, and well stuffed. C)«e is long enough to pass obliquely around the upper- part of the thigh; the end is not stuffed, but has small round ooles. The other strap is three inches long, and has a buckle at its end. On the external side of the thigh, w here these two straps unite, is firmly fixed a semicircular piece of thick leather, that forms a pocket opening downwards, and into which is re- ceived the vertical portion of the crotchet.* To apply this machine, we are to place under the limb the piece of linen in which the splints are to be rolled, and five common bands, three under the thigh and two under the leg; a cushion stuffed with cotton, as long as the thigh- strap, and about three inches broad; this must be applied so as to bear exactly upon the ischium, and not upon the internal side of the thigh. Care must be taken to give the thigh-piece, and the cushion placed beneath it, a direc- tion nearly vertical, that they may not become displaced, and press out the internal side of the thigh: when this takes place, the constant pressure will produce ulceration of the integuments, and even of the muscles. In the next place, the sole of the foot and the lower part of the leg are to be adjusted with wads of cotton, and the foot-piece is to be ap- plied, the two straps of which are to be passed obliquely around the leg. These straps not being sufficient to seeure the foot-piece, it is further proper to pass a band, about two yards long, around the lower part of the leg, the strap, and the foot-piece. The fracture is now to be reduced, accord- ing to the principles already laid down. The crotchet of the upper end of the splint being then adjusted in the pocket of the thigh-strap, the regulating screw must be turned to the left, until the box is raised sufficiently for the foot-piece to be attached to the iron plate which connects the extremities of the supporters. By turning the screw to the right, tbc box and foot-piece are brought down towards the end of the * See plate II. fig. 1, 2, 3; and plate III fig. 1. V - J» TLATE III. Fig. 1. The apparatus applied. a a a a. The fractured limb. b b b. The machine for constant extension. c c. The regulating screw. d. The wench to turn the regulating screw. e e. The square box through which the screw passes, and which slides along the splint. /. The crutch which passes into the pocket. g. The thigh-stiap m situ. hh hh. The anterior splint. i i i i. Bags of chaff. k k k k. Bands to tighten the apparatus. I. A foot piece to which the foot is fixed. m m. Its legs. Fig. 2. A front view of a patella which, after having been broken, has united by an osseous medium. (See Plate IV. Fig. 1.) a b. The ends of the transverse fracture. c d. The two fragments inclined toward the point b. e. Traces of a longitudinal fracture. /. A part near the greatest breadth of the callus, that has not united. g h i. Irregularities which seem to depend upon the ossification of a part of the tendon of the extensor muscles of the leg, and of the fibrous tissue that covers the anterior surface of the patella. i Of Fractures of the Os Femoris. 101 splint: thus extension is made, and the pressure of the •-.•.rotehet of the splint upwards, stretches the thigh-strap, fixes the pelvis, and makes the counter-extension. Bags of chaff are then to be placed under the internal and anterior splint, between the machine and the external part of the, limb, and between the posterior part of the limb and the splint-bands, and the whole to be rendered secure by rib- bons. . Now, if wc examine the effects of this apparatus, we shall 1st. That it makes the extension and counter-extension upon parts distant from the fracture, and, consequently, that it does not irritate the muscles which pass o\cr it. 2d. That the extension and counter-extension arc distri- buted over as large a surface as the structure of the parts permits: thus the force of the extension is applied to the whole surface of the lower part of the leg and foot. The ihigh-strap acts upon the whole region of the ischium, and is free from the disadvantage of linen bands, which fall into folds, and slip off from the cushions that are placed under them. 3d, Extension and counter-extension are, as nearly as pos- sible, made in the direction of the axis of the limb: the ex- tension is exactly parallel to this axis, and the small degree of obliquity of the counter-extending force is inevitable, from the structure of the parts. It is easy to perceive that the projection of the crotchet, which may be increased at plea- sure, so as to profit by the depression below the os ilii, ren- ders this obliquity less than that of any other apparatus. 4th. We can regulate the extension and counter-extension at pleasure, and by almost insensible degrees: we should, however, be on our guard lest the patient secretly loosen the buckle of the thigh-strap. 5th. The parts are sufficiently protected from the effects of unequal pressure. 6th. The rotation of the limb outwards, and its shorten- ing, are prevented—an advantage which seems to have been totally forgotten in the treatment hitherto pursued.* But we are far from denying that permanent extension is unaccompanied with difficulties, or that a fracture of the neck of the thigh-bone can be united as exactly as any other fracture. The counter-extension cannot be made perfectly parallel to the axis of the limb, without putting a splint on the inside, the pressure of which upon the i^hium, experi- * See i.o'.c C to: Boyer's Surgery. ertcc has proved to be insupportable; neither are there any means of rendering the pelvis perfectly immoveable, for the bandage, which is passed around it and the upper extremity of a long splint, does not effect this object. Lastly, the calls of nature prevent us from keeping the limb perfectly at rest. Hence the fragments become more or less displaced, even after the application of the apparatus: their re-union may be thus retarded, and it is never perfect in the ordinary time; and, even after several months of rest and judicious ti'eatment, when the limbs appear equal, and the re-union of Ihe fragments solid, the moment the patient begins to walk, the limb gradually becomes shortened. There are. more- over, persons whose skin is so delicate and sensible, or pos- sesses so little vitality, that compression causes insupportable pain, or mortification of the integuments. From the first of these causes, permanent extension may be inapplicable to women; and, from the second, to aged persons, and those who are exhausted by previous disease. Whatever process we employ, we should pursue it with care, and always protect the soft parts from the consequen- ces of too great or unequal pressure. Mortification is not an unfrequent result of neglect of this precaution; but we may say, with Celsus, '* Non crimen artis, quod prqfessoris est." It is almost always necessary to delay the reduction of the fracture for seven or eight days, or even longer, if the irritation of the parts, and spasms of the muscles, have not subsided. After the reduction, we should be particularly careful to keep the fracture as much at rest as possible, by enabling the patient to lift his body, for the calls of nature, by means of a cord suspended over him, while his thighs are raised by a bandage passed under them. The bandages also become loose, and require to be fre- quently tightened, especially from the forty-fifth to the six- tieth day. After sixty or seventy days, rest alone is neces- sary ; and this should be continued for six weeks, or two months, according to the age and health of the patient, and the firmness of the union ; then the extending apparatus is discontinued. When the patient can bend the thigh upon the pelvis, with the leg extended, he may cautiously begin to walk with crutches; if walking prove painful, he must keep his bed for some time longer. Scarcely any degree of stiffness takes place in the artieu- lation of the thigh with the pelvis, but there is always more or less in the knee and ankle. Of Fractures of the Os Femoris. ion Although some persons cannot support the degree of ex- tension necessary to give the limb its natural length, yet such a degree of force as will prevent great displacement of the fragments, can almost always be employed with advan- tage, even though, in some few instances, the rotation of the limb outwards be all that we can remedy. Lastly, if continued extension be insupportable, or inadmissible even in this mo- derate degree, we may employ the ordinary treatment for fracture of the body of the femur. Fractures of the femur, even when improperly treated, are not necessarily followed by great deformity; those with- in the capsule often unite without much shortening of the limb. We have seen fractures of the neck of the femur, which were mistaken for contusions; and the patient having merely been kept at rest, the limb united, but with shorten- ing, and rotation outwards. We shall not enter into long details respecting the sepa- ration of the head of the femur, which differs in no respect from fracture. Fare has described the symptoms of this accident, and states, that it may be mistaken for a luxation. This acci- dent can only happen in early life, while the cartilage is of some thickness, long before the epiphysis is identified with the rest of the bone. Though the line of separation is dis- tinct at eighteen or twenty years of age, this accident always occurs in persons much younger. The causes that are capable of producing fracture of the neck, may also separate the epiphysis. But if a fall on the side produce neither of these accidents, and the patient be young, the three bones which form the os innominatum, and which meet in the centre of the acetabulum, may be sepa- rated. Ludwig relates a case of this kind. Excepting crepitation, the signs of separation of the epi- physis arc the same as those of fracture of the neck of the os femoris. The union, in the former case, is much more easy. We shall terminate this chapter with the following case, to confirm the propositions it contains, and especially to il- lustrate the utility of permanent extension. A printer, thirty-two years of age, was thrown upon the pavement by a horse: he fell on his side, and could not raise himself The day after the aceident, he was brought to the hospital, and I discovered a fracture of the neek of the femur. As there was much inflammation and tension of the parts, I directed emollient cataplasms, rest, and the antiphlogistic regimen. On the eighth day I applied my 104 Bayer's Surgery. apparatus, by means of which, in a short time, the limb was restored to its natural length. Pretty severe pain came on, and continued for the first ten days, but afterwards it sub- sided. On the twelfth day, the stomach became disordered, and an emetic was prescribed, with good effect. On the eighteenth day, the bands having become relaxed, a little shortening of the limb was perceived. I increased the ex- tension ; the pain in the limb returned; but, in three or four days, it ceased. On the sixtieth day, the apparatus was re- moved. The limb preserved its natural length and direction, and the patient soon after left the hospital, entirely cured, ® CHAPTER XIV. Of Fractures of the Patella. FRACTURE of the patella is almost always transverse, rarely oblique, and still more rarely longitudinal. Some- times the bone is divided in three or four pieces, and as it were comminuted. Longitudinal fracture is always caused by external vio- lence, and is accompanied with wound, contusion, or effu- sion of the blood into the articulation. Transverse frac- ture is sometimes occasioned by the same cause; but it is generally produced by violent contraction of the extensor muscles of the leg, and this may be occasioned without the muscles being convulsed: we know, from experience, that these muscles, in their natural state, when the body is in- clined backward, and a fall on the occiput is likely to hap- pen, are capable of producing it. In this case, the thigh being bent, the extensor muscles of the leg contract, bring the body upright, and prevent a fall backward: the posterior surface of the patella then rests only upon a point on the anterior part of the condyles of the femur, and is placed be- tween the ligament of the tibia and the action of the rectus and triceps cruralis muscles. If this action be stronger than the resistance of the patella, the continuity of the bone will be destroyed. The accident, in this case, happens the more easily, as, by the flexion of the thigh, the line of direction of the extensor muscles of the leg, and the ligament of the patella, is oblique, in respect to the vertical axis of this bone: so that these two powers, one of which acts upon the Of Fractures of the Patella. 105 superior, and the other upon the inferior part of the patella, bend it backward directly at its upper part, which rests upon the condyle of the femur: such is the mechanism by which muscular action produces fracture of the patella. It has been asserted, that dancers were particularly liable to fracture of the patella; but experience does not prove that they are more subject to this accident than persons of any other profession. The strain which the muscles exer- cise on this bone, while the leg is in a state of perfect extension, may, however, produce a rupture similar to that of a cord that is violently stretched. Thus fracture of the patella has occurred during a convulsive fit, while the pa- tient was laid on his face. But it is astonishing, in this case, that the patella can be exposed to such incalculable force as would be necessary to produce a fracture in this manner. There is no doubt that the causes which act directly on the patella, are capable of occasioning a solution of conti- nuity. Thus a fall, or a blow on the knee, may produce a fracture of this bone; but for a fall to produce the effect, the leg must be very considerably bent, and the patella car- ried as low as possible. In fact, the constant tendency of the muscles to contract, and the resistance of the inferior ligament of the patella, keep this bone at an equal distance from the tibia, of which it follows all the movements, vary- ing its position only in relation to the condyles of the femur. Now when the leg is bent to a right angle with the thigh, the patella is so situated, that a fall on the knee would merely press up the inferior part of this bone, and distend its ligament. In a greater degree of flexion of the leg, the patella is drawn to that point of the knee which ought to sup- port the whole weight of the body; and, in this case, it is exposed to all the violence of the shock. It has been said, that, in falls on the knees while they were bent, the patella rested on the femur above, and on the tibia below; and that a transverse fracture was thus rendered easy, by its want- ing support in the middle. But, if we examine attentively the relations of these three bones in strong flexion of the leg, we shall see that (lie patella cannot be placed in contact with the superior part of the tibia; and that it constantly rests, iu its middle part, upon the condyles of the femur, balanced between the resistance of the inferior ligament and that of the muscles. The fracture, therefore, must lake place opposite to this part. Now, if we reject upon the manner in which violent contraction of the extensor muscles of the leg is excited by the spontaneous effort of self-preser vation, we shall soe both the direc&on in which the violence vol.. ir. 1 * 106 Bayer's Surgery. nets, and that in which the fracture will probably take place, when it arises from this cause; at the same time, it is evi- dent that a fall on the ground, ora blow on the patella, may cause oblique fractures, and particularly longitudinal frac- tures; these cases, however, are Very rare. In these in- stances, the severity of the contusion, the exposure of the joint, or the effusion of blood into it, often leads to the ne- cessity of amputation. Commonly When, by the fall which has been the cause, or the'effect of the fracture, or by imprudent movements made to ascertain the nature of the accident, the limb has not been placed in a state of extreme flexion, the aponeurotic, or fibrous expansion, which covers the anterior part of the patella, is preserved, either wholly or in part, and the frag- ments are thus kept within a moderate distance of each other. We shall see hereafter, that the accident, in this case, is far less serious than when the bones are separated a great distance from each other. Whether there be rupture, or extension only, of this apo- neurosis, a certain degree of irritation and tumefaction always*results, which requires our first attention, as it pre- vents the application of the means for keeping the bones reduced. *l*here is always considerable separation of the fragments, whatever be the deviation in which the bone is broken: it may extend so far as several inches. Hitherto very few cases of longitudinal fracture have been noticed. Lamotte relates a case, in which he found the patient seated, and the leg slightly bent. In this posture, the fragments of the fracture were slightly separated late- rally. Is this phenomenon to be attributed to the displace- ment which the lateral ligaments of the knee suffer in flexion of the leg, by which they are moved a little backwards; or to the tension of the anterior part'of the capsule, if they be drawn in the same direction ? We may suspect a transverse fracture of the patella, if the patient being on his feet when the accident happened, then suddenly fell in consequence of it, and could not get up; if, after having been placed on his legs, he fall, the moment he attempts to advance; and if, on the other hand, holding and extending the leg with his arm, he be able to walk backward, dragging the foot upon the, ground. The separation of the bones is scarcely discernible through the integuments; and the fragments are easily brought into contact, by extending tye limb, and very slightly putting them together. If we then move them laterally, crepitation Of Fractures of the. Patella. 10; will be perceived* Bu,t these signs do not exist in s^fiioient. number to enable us to form a certain diagnosis, when there is much irritation and tumefaction. However, this is no in- convenience, because, in every instance, the first object is to discuss the inflammation before we apply any apparatus. The imperfection of the means employed for maintaining in contact the fragments of a fractured patella, has pro- duced cures more or less imperfect, and the bones have united at some distance from each other: hence it has been inferred that fractures of the patella did not unite like, others, or not at all; and surgeons, more occupied with physiological discussions than in observing the course of. nature, have advanced as reasons for this peculiarity in the structure of the bone, the communication of the fracture with the interior of the articulation, and the dilution of a pretended osseous juice by the synovia, &c. But it is now demonstrated, that the patella has all the qualities necessary to a perfect bony re-union, except the perpetual tendency of the muscles inserted into the. upper fragment to contract, and the impossibility of opposing this tendency, so as to keep the fragments in exact apposition; they therefore unite, at some distance from each other. The umde andj utility of this connexion varies, according tq the greater or less exactness with which the parts have been kept approxi- mated. This is what happens in such cases: It is not diflU cult to place the hones in contact, in transverse fracture, (especially when there, is no considerable tumefaction) by fully extending the leg, so as tq relax the extensor muscles; and pushing down the upper fragment, while the lower is kept steady. The fatty substance behind, the in$rjor liga- ment of the patella, has been falsely supposed, by some, to be interposed between the fractured hones. TJijs 0ea has no foundation in fact; yet, sfraogp as it may appear, the bones cannot be kept in contact; the apparatus con- stantly gets loose, and cannot be changed, often enough to prevent this effect from taking place; the separated sur- faces of the bone, and the ruptured aponeurosis, becopie in- flamed; the fibrous parenchymatous substance of the two surfaces of the bone becomes enlarged, and thickened; aud appears like a new formation, continuous, and qf a fibro- cellular structure. Thus the fracture re-unites. When the bones have been left far from each other, this medium of union is extremely weak; on the other hand, it becomes exceedingly strong, if the bones have been nearly approximated. From these observations, we see how much this accident 108 Boyer's Surgery, is aggravated by a fall the moment after it occurs, and how improper it is for a surgeon to bend the leg, in examining a patient who has suffered such an injury. The patella so rarely becomes directly united, that Fibrac challenged all the surgeons of Europe to produce an anatomical specimen of fracture of the patella consolidated by callus. It is true that the intermediate fibro-cellular substance never becomes converted into bone. When the fragments become feebly united, and at a dis- tance of four or five finger-breadths from each other, the actions of the extensor muscles can no longer be transmitted to the leg; these muscles become shortened, and walking is rendered difficult. We know several persons in Paris who are obliged to use a knee-cap in order to prevent flexion of the knee, and who canuot walk without the support of a cane or an arm; but when the fragments have been kept from separating from each other for a few lines, or even an inch, the use of the leg is perfectly restored. This obser- vation should prevent us from using any apparatus which keeps the bones together with great force, and thus exposes the soft parts to all the inconveniences of too strong pres- sure, and brings on stiffness and long immobility in the limb. What advantage is there gained to counterbalance these evil consequences, since a less perfect union equally replaces the limb in the exercise of its functions ? This remark has not escaped Bell, Pott, and Ravaton; who have observed, that, without obtaining a more perfect cure, the articulation of the knee remained much more stiff. How- ever, we should not fall into the contrary error, but take a sufficient degree of precaution to prevent the too great sepa- ration of the fragments. As to longitudinal fracture, we have never seen a case of it; but it is probable that the reduction of it is not difficult, and that the re-union is more exact. The patient spoken of by Lamotte, was cured in a short time; and he does not mention that there was any deformity. Even the most simple fracture of the patella is always at- tended with a certain degree of irritation, which, in twenty- four hours afterwards, is followed by swelling. In every case, therefore, we should delay applying a bandage until these symptoms have abated; the contrary conduct may be followed by stiffness of the knee and false ancylosis__ symptoms which have been unjustly attributed to the distil- lation of callus into the articular cavity. Three essential indications naturally present themselves in the treatment of these accidents : 1st. To place the limb Of Fractures of the Patella. 109 in such a position, that the muscles whicli act upon the pa- tella, and the ligament which unites it to the tibia, are in a state of the greatest possible relaxation. 2d. To keep the Timb in this position by means which counteract the action of the antagonist muscles. 3d. To press the two fragments toward each other. Some authors have thought that these three indications were included in the first, and that it was sufficient to keep the limb extended. It must be allowed, that, if the limb eould be kept extended for a sufficient length of time, the union might, in some cases, take place; but the muscles have a constant tendency to retract, and will not fail to ren- der the space between the fragments injuriously great, par- ticularly if no means be taken to prevent this retraction. In some cases, indeed, without any other means than extension of the limb, no solid union can take place. M. Sabatier considers it impossible, in all cases, to keep the limb extended. In the Memoirs of the Academy of Sciences he states, that two patients, on whom he had ap- plied the ordinary apparatus and extended the leg, could not support this position, and suffered such violent pain in the ham that he was obliged to remove the apparatus, and place the leg in a state of slight flexion. He advises that the patient should be placed on the side, with the thigh bent in an acute angle with the abdomen, so as to relax the ex- tensor muscles as much as possible, and to allow the leg to be slightly flexed. We have observed, with M. Sabatier, that constant extension produces severe pain in the ham; but, with us, it has not lasted long, or obliged us to change the position of the limb. We therefore think, if care be taken to dissipate the inflammatory symptoms before the application of the apparatus, we shall not be obliged to re- move it, or to place the patient on his side; for this position is sometimes insupportable, because the body rests on the trochanter major; moreover, it does not allow of any ap- plication to bring the fractured pieces together, or to oppose the action of the flexor muscles of the leg. Some surgeons have placed, behind the articulation of the knee, a solid body, which prevented flexion of the leg; but they did so, in order to protect the projecting parts of the ham from too hard compression. Desault first showed the utility of applying a long splint to the posterior part of the leg and thigh. We have, for a long time, employed an appa- ratus different from that of Desault; it is more simple, and we think it is more sure in its action. The pieces of Uiis apparatus are, a gutter of wood, two 'traps, five or six ii<> Bayer's Surgery. pieces of broad ribbon, or a roller. The gutter should be long enough to extend from the middle of the thigh to below the calf, and its sides should be high enough to embrace two thirds of the thickness of the limb; it is wider above than below, and covered on the inside with an undressed sheep's skin. About the middle of its length, the edges of this gut- ter present externally some round-headed nails, placed five or six lines from one another. The straps, which are an inch broad, and six or seven long, arc formed, in the middle of their length, of buffalo's skin, covered with sheep's skin, and stuffed with wool, like the belt of a herniary truss: of an equal length with this piece, are two others at the ends, made of sheep's skin, with holes punched in them two lines, apart. When the limb is placed in the gutter, the ham must correspond to the centre; the intervening spaces are to be filled with carded cotton. An assistant then brings the frag- ments together, while the surgeon passes one strap above the superior fragment, and another below the inferior, and fastens them to the sails, crossing each other: thus an ellip- tical space is left between the two straps, which is crossed transversely by the patella. The part is then to be wet with a resolvent liquid, and the bands passed around the gutter. This apparatus is delineated in plate III. The advantages of this machine are^that it leaves the fractured part uncovered, so that we may judge at any time of its situation; that it exercises strong compression, with- out endangering mortification; and that the straps may be loosened and tightened at pleasure, without deranging the other part of the apparatus. But, in most eases, patients complain, during the first hours of its application, of severe pain where the straps press against the patella: however, the pains are soon dissipated, in many cases, without even relaxing these bands, Fracture of the patella is ordinarily united in sixty or seventy days, with sufficient firmness to prevent elongation or rupture of the intermediate substance: in old persons, however, it is prudent to continue the apparatus eight or ten days longer. It has been advised to move the leg at an early period, in order to prevent stiffness of the knee: this doctrine appears reasonable, and we formerly taught it; but the fear of elon- gating or breaking the intermediate substance, has led us to a different practice, In general, we do not permit our patients to begin to move the leg before the expiration of two months; notwithstanding this, the knee soon becomes flexible, and we have never produced a false ancylosis; J'fafr.j. X Jv ^ ^•■>' ^ PLATE VII. Apparatus for Fracture of the Patella, Fig. 1. A gutter in which the limb is placed. A A. The concave side of the gutter. B B. The two straps. c c c c c. Studs. Fig. 2. The apparatus applied. A A. An outside view of the gutter. B B B. The affected limb. ' c c. Straps passing above and below the patella, with small holes, d d; to fasten them to the studs e e e e. fffff. Bands to confine the limb to the gutter. Of Fractures of the Patella. Ill whieh, moreover, is less to he dreaded than rupture, or even elongation, of the fibrous substance which unites the fragments. When severe contusion, wound, or other complications, accompanies fracture of the patella, the case is always very serious, generally requiring immediate amputation. If the patient survive the first inflammatory symptoms, he is com- monly worn down by the copious suppuration that follows, Whicli, if it do not cause his death, renders the 'knee stiff and motionless. Case I. A man, who had danced all night, perceived, to- wards morning, in the middle of a dance, a dull sound in his right knee. Some minutes after, as he was Walking in the 'ball-room, the same noise and sensation were repeated; and in an instant he fell, and could not rise. I perceived a fracture of the patella, and applied a simple uniting band- age ; that is to say, two oblong compresses, one above and the other below the patella, kept on by means of a roller passing in the form of a figure of 8. This was carefully applied as often as it became loose. On the forty-sixth day, the patient left the hospital, and the fracture was firmly united by an intermediate substance some lines thick, which did not incommode the movements of the limb. Case II. A ticket porter fell upon the ice, and suffered a simple fracture of the patella. He tried in vain to get up, and finally reached a house about sixty paces distant, by drawing himself on his back; he was there raised up, and, resting on another person's arm, he walked backwards to his house, which was about three hundred yards off. On the next day he was brought to the hospital: great tumefac- tion had supervened. I applied ponltiecs, and, eight days afterwards, began to treat it like the former case. The pa- tient left the hospital on the forty-fourth day; the fragments were then firmly united about six lines from each other. Case HI. A coachman, of strong constitution, thirty-six years old, Silting carelessly on his box while the horses were moving, made a violent extension of his legs to save himself from a fall; his right foot Slipped upon the foot-board; he immediately felt acute pain, and heard a singular noise in his right knee; nevertheless, he drove to Paris, wlikh was then ten miles distant. The next day I found him at the hospital Charite, with a fracture of the patella, the frag- ments of which were separated only an inch and a'half from each other, but the soft parts were already tense -and in- flamed. In twelve days, the inflammation being then re- duced, I applied the bandage as described above. During it it Bayer's Surgery. ihe first thirty-six hours the patient suffered sc\ere paiii, which then spontaneously abated. The dressings were chang- ed on the ninth and eighteenth days, and, on the thirty-lirsi, they were discontinued. The fragments were only separated by au interval of one or two lines, which could not be per- ceived externally. The patient soon began lo walk; and, on the thirty-eighth day, he left the hospital, completely cured. Case IV. On the 27th December, a man, aged sixty-five years, in descending from the side-walk of St. Michael's bridge, fell upon his right knee, and fractured the patella transversely. He was immediately brought to the hospital Charite, where I found the fragments very much separated, and admitting several fingers between them. At first I en- deavoured to combat the consequences of the contusion, and, on the eleventh day, I reduced the fragments. The limb was1 then placed in the machine of w hieh I have spoken. On the first day, the pains were very severe, and I was obliged to loosen the straps. I tightened them on the day following; the pain was re-excited, but it passed away of itself. In twenty-one days, 1 ceased to apply the straps; and, in five days afterwards, I removed the gutter. The separation of the fragments was scarcely perceptible; nothing could ap- proach more nearly to a cure by immediate bony union. The movements of the knee, which were at first painful, soon became free and easy. The patient left the hospital on the thirty-fifth day, walking with facility. Case V. J. C. Couct, a postillion, received a kick from a horse on the anterior part of the knee. The integu- ments were not divided, but tumefaction soon followed : not- withstanding this, being brought to the hospital the same day, I discovered a transverse fracture of the patella. By poultices, repose, and regimen, the inflammation was re- duced in six days, and the fracture was dressed with the uniting bandage. Severe pain came on at first, but, as the bandage became loose, it gradually abated. On the twen- tieth day, when the bandage was re-applied, the interval that separated the fragments was scarcely perceptible. On the thirty-sixth day I discontinued the apparatus; the pa- tient began to exercise the limb, the movements of the knee were gradually restored, and, in forty-nine days, he left the hospital, walking with ease. Case VI. A man, by the name of Gesselin, aged twenty- seven years, of a strong constitution, walking very fast at night, struck against a post; he fell, and, on raising himself, his right knee became excessively painful, and he lost the Of Fractures of the Patella. 113 use of the leg. He dragged himself to a neighbouring house as well as he could, and was brought to the hospital Charite the next day. I perceived a transverse fracture of the pa- tella, and the fragments were separated two fingers breadth. In ten days I reduced the inflammation, and then applied the uniting bandage. During the first twenty-four hours, the bandage excited severe pain ; but it gradually subsided. The same circumstances occurred every time I renewed the * bandage, which was on the ninth, sixteenth, and twentieth days. On the thirty-third day, which was forty-three days after the accident, 1 discontinued this apparatus, and merely applied a roller* The fracture had then united, but there remained, between the fragments, an interval of a finger's breadth, which did not deprive the patient of the use of his limb, or prevent him from walking. Case VII. A man, aged sixty-five years, having been rudely pushed in a quarrel, fell upon his right knee, and could not rise. The next day, the 16th of March, he was brought to the hospital; the knee was swollen and pain- ful, and the flexion of the leg impossible. I covered it with an emollient poultice, and prescribed rest and low diet: however, on the 17th, in taking hold of the upper and lower parts of the patella, and pushing them laterally in different directions, I perceived a crepitation, which I was disposed to attribute to the rubbing of the patella against the con- dyles of the femur, but which excited some suspicions of a fracture, the pieces whereof were kept in contact by the aponeurotic fascia that covered them. On the 21st, the swelling and pain being dissipated, I made a very careful examination, which left no doubt of the existence of frac- ture. I moved the fragments laterally; but, as they were scarcely at all displaced, 1 merely directed the patient to be kept quiet, with the limb extended on an inclined plane, the most elevated part of which was next the heel. On the 9th of April the patient began to walk, and the limb was quickly restored to all its functions. But, on the 29th, I perceived that the uniting medium of the fragments had become somewhat elongated; no injury, however, followed; the elongation did not increase, and the patient lejit the hos- pital, perfectly cured. After this chapter was printed, our respected colleague, M. Lallement, Professor to the Faculty of Medicine of Paris, communicated to us the following case, with the spe- cimen represented in plate III. flg. 2; and plate IV. fig. l. vol. n. "*5 11* Bayer's Surgery. In March, 1798, L. Maumillon, aged thirty-six years, » veteran soldier, of strong constitution, was thrown on a brick pavement by one of his comrades, with whom he was wrestling. He received the whole shook of the fall upon one of his knees, and immediately felt, in this part, a sense of tearing and crackling, with acute pain. He was unable to get up without help. M. Lallement saw the man a few minutes afterwards, and discovered a transverse fracture of the patella. There was a sensible interval between the frag- ments, which were easily brought together when the leg was extended. The fracture was reduced, and treated with the apparatus of Desault for two months, at the expiration of which time it appeared to have united. For a year the pa- tient walked with a cane, and afterwards entered the service. The movements of the limb were perfectly free, except that flexion of the leg was slightly limited. In August, 1810, the man died of apoplexy; and M. Lalle- ment having examined the knee where the fracture took place, found that the two fragments of the patella were firmly united, and cOuld not be made to move on each other in the slightest degree. This bone was then boiled ten hours, and stripped of the articular cartilage and the ten- dinous and aponeurotic fibres that covered its surface. It was then evident that the affected patella was six lines longer than the opposite one; that the fracture did not re- present a straight transverse line, but the form of an S re- versed: the superior fragment was more outward than the inferior, so that the axis of the first formed with that of the second, an angle of 130 degrees, with its sinus turned toward the external side of the knee. It is evident that, from this inclination, the external sides of the two fragments were put in contact; that the internal part of the superior frag- ment was separated from the rest by a vertical fracture; and that this portion, being displaced downwards, was also put in contact with the opposite point of the inferior frag- ment; but this part being obliquely displaced, and in a pa- rallel line to the inclined axis of the superior fragment, that portion of the principal fracture which belonged to it, could only be imperfectly joined to the inferior fragment: thus there remained a space that was filled with fibrous cellular tissue, which the boiling detached. It was evident that the re-union of the two extremities of the fracture was immedi- ately formed by true callus; but, in the interval, were a series of bony eminences, having an oblique direction, and parallel to the inclined axis of the superior fragments, se- parated by oblong spaces parallel to tho eminences. In that? 1L.V1U M . . Fio. 1. A posterior view of a patella fractured and united by bone. (Sec Plate III. Fig. 2.) a b. The ends of the transverse fracture. c d. The two principal portions of the bone, inclined towards the side a. r. Traces of another longitudinal fracture, crossing the first near the side b. f. The part corresponding to the greatest breadth of the callus, showing some evidences of its primitive fibrous texture. <;•■. Part of the articular surface. Fig. 2. A tumour occupying the lower extremity of the thigh, seen from the outer side, covered with soft parts. i. The situation of the patella. b. The ligament of the patella, sensible to the touch. c c c c c. Several tubercles in the surface of the tumour, capable of be- ing felt through the skin. d d. Other tumours forming. NT. B. The limb is represented in the greatest degree of flexion of which v.*as susceptible Wlifc Of Fractures of the Bones qf the Leg. IIS part the osseous tissue is more spongy ami cellular than at the point of re-union. This middle space has the appear- ance of a cellular fibre consecutively ossified. Upon tho anterior surface of the patella the bony reunion is more regular, although there is some slight appearance of stria, which resembles the ligamentous substance that naturally covers this substance, converted into a solid compact mass. There isa a narrow and deep groove opposite the defective part of the posterior re-union. ® CHAPTER XV. Of Fractures of the Bones of the Leg. THERE appears, at first sight, a great analogy in the structure of the leg and forearm: two parallel bones, articulated together at their extremities'—separated all the rest of their length by a spaee filled with ligamentous mem- brane—articulated at their superior part by an angnlar gin- glymus in the thigh, and with the foot by the same kind of articulation—affording attachment by their surface, and by means of an intermediate ligamentous membrane, to a num- ber of muscles destined to move the foot and toes: such is the structure of the tibia and fibula. But these two bones do not execute rotatory movement, and only one of them is articulated with the femur, and this alone transmits the weight of the body to the articulation of the foot, of which it forms the central part; while the other, whieh seems to be of no other use in the five superior sixths of its length, than to afford insertion to the muscles, extends, on the enter side of the articulation of the foot, even beyond the level ef the malleolus intcrnus, and has no other offlce than that of preventing the foot from being turned too far out- wards. These differences destroy all similarity between the causes, mechanism, signs, and treatment of fractures of the leg and those of the forearm. The two bones of the leg may be fractured at the same time, or either of them separately. We shall treat of them under the bead of Fractures of the Leg, of the Tibia, and of the Fibula, according as both, or either of these bones, may he affected. 116 Beyer's. Surgery. ARTICLE I. Of Fracture of ihe Leg. Fracture of the leg is more common than that of either of its bones alone. The fracture may be oblique or trans- verse ; the direction of the fracture is not only subject to many variations, but both bones may he broken in several points of their extent: the soft parts may, at the same time, be contused, or even torn, by the splinters of the fracture, or by the cause that has produced it. There is no well authenticated case of fracture of the leg produced by muscular action; it is always the result of vio- lence, applied either directly or mediately. Thus a fall 011 the feet often fractures the tibia, and generally about the middle, where the bone is smallest: it is sometimes frac- tured nearer the articulation of the knee. But, when the tibia is fractured in the middle of the leg, the fibula is ge- nerally fractured higher or lower, and sometimes even near one of its extremities. A violent percussion on the leg, when the foot is resting on the ground, may have this effect; and although the blow be on the tibia, if it be so violent as to effect a solution of continuity of this bone, and a displace- ment of the fragments, the fibula will be subsequently frac- tured. In this case, the last fracture will not be parallel to the first. Finally, the weight of a heavy body on the leg, when it is extended on the ground, such as the fall of a stone, or the wheel of a carriage passing over it, may not only fracture the two bones, but occasion contusion, and tearing of the soft parts. In fracture of the leg, displacement of the fragments may take place in all directions; and this displacement is accord- ing to the direction of the fraeture and the cause that pro- duced it. When the fracture is transverse, the displacement can only take place in the direction of the thickness of the fragments, particularly if it be in the superior part of the tibia. "When the fractured surfaces are large, the swelling of the soft parts may increase the small tendency of the fragments to become displaced. The fragments seldom pre- serve their natural relations, even if they correspond by large surfaces perpendicular to the length of the bone; the smallest movement of the limb will destroy their contact,. and cause them to pass each other. When the fracture is oblique, and%caused by a fall on the icct. this last kind ot Of Fractures of the Bones of the Leg. 117 displacement is inevitable. Most frequently the superior fragment presents a sharp point, directed downwards and in- wards, and projecting under the integuments which cover the internal surface of the tibia; while the inferior fragment is drawn backwards and downwards, by the muscles on the posterior part of the leg. If the fall have not been very se- vere, or from a great elevation, and especially if it have been moderated by a slight extension of the foot, the displacement may consist merely in a slight projection of the superior fragment, which it is difficult to prevent. It is remarkable that, notwithstanding the inclination of the surfaces by which the fragments correspond, and the tendency to ulterior dis- placement, which, it would seem, ought to follow, we do not observe a shortening of the limb, as occurs in the thigh in analogous cases, although the fractured fibula be inca- pable of resistance, and rollers have little efficacy in these instances. This observation, which, however, does not apply to compound fractures of the tibia, is explained by the in- sertion of most of the muscles along the whole length of the two bones. But, when the fall which has produced the frac- ture has been violent, it displaces the fragments at the same time: in this case, while the ground arrests the foot and the inferior fragment, the motion of the body pushes down the superior fragment obliquely in the direction of the fracture. Thus the latter distends, or perhaps penetrates, the soft parts. In like cases, the upper fragment has been known to bury itself in the ground. It is almost impossible for both bones of the leg to be broken without the limb being bent towards the posterior part. This results from the action of the muscles, some of which are attached to the posterior surface of the bone, and reflected behind the lower extremity of the tibia; and others are attached low down, posteriorly between the two bones, and form an angle with each other above. Both act in drawing backwards the opposite extremities of the frag- ments, while the last are supported by their corresponding surfaces, because the muscles of the anterior part of the interosseous space are parallel to the axis of the two bones, and especially of the tibia. Lastly, the displacement of the fragments is the more easy, as the point of the foot is naturally directed outward, and the greatest part of its size and weight is beyond the central line of the limb. This kind of displacement may be favoured by the oblique direction of the fracture. These causes are, however, never sufficient to carry the displace- ment to the extreme degree in which it occurs, in consc- 118 Boyer's Surgery. qurnce of inconsiderate movement, or by the weight of tbo bedclothes. The same may be said of displacement in which the point of the foot has been turned inwards, unless the fracture of the tibia be very oblique, and in a direction op- posite to that in which it almost uniformly happens, which we have never yet seen. Nothing is more easy than to discover a fracture of the two bones of the leg: their superficial situation* and their great tendency to become displaced, render the deformity and crepitation very evident. This fracture is much less serious than those of the thigh, because the limb is smaller and the displacement not so extensive, and may, moreover, be kept more perfectly motionless. When a fracture is near the ankle, the liga- ments become affected with chronic inflammation; whence a stiffness and difficulty of motion remain some time after the bones are united. As to the danger which accompanies compound fractures of the leg, we have already said enough under the head of Fractures in general. Reduction of a simple fracture of the leg is generally easy; extension indeed is hardly necessary; for, as we have already observed, the bones seldom ride upon each other: it is only necessary to place the limb and point of the foot in their natural situation. But, if the fracture be oblique, and the bones ride upon* each other, extension remedies the dis- placement only for a moment. From what we have just observed, it will be seen that the treatment of fracture of the kg is very simple; the tendency to lateral, longitudinal, or spiral displacement, is very easily counteracted by lateral compression; the pre- servation of the interosseous space is not an object of the greatest importance; hut particular attention is required as to the state of the fibula. Of this we shall speak more par- ticularly in the article on fractures of that bone. Fracture of the leg is to be kept in place by a bandage of strips, wooden splints, bigs of chaff, and ribbons. The pa- tient being undressed, and placed upon a suitable bed, the limb is to be supported by two assistants, one of whom takes hold of it below the patella, and the other at the foot. The limb being thus raised, the surgeon is to arrange, under- neath, the parts of the apparatus in the following order :— 1st. The pillow of chaff, as long as the leg, and almost square, covered with a napkin. 2d. A piece of linen or Splint bandage, as long as the piHow, and wider; below which are to be placed three ribbons, and above it the strips, of a number sufficient to eover the whole leg. The Of Fractures of the Bones of the Leg. 119 pillow must be perfectly horizontal, and shaped exactly to the posterior surface of the leg, so that every part may equally support the weight of the limb. The limb is now to be cautiously placed on the apparatus, and reduced. We know that the reduction is exact, when the great toe, the internal side of the patella, and anterior superior spinous process of the ilium, are brought in a line, and the limb is restored to its natural length. The bandages are then to be wet with a resolvent liquid; two square compresses are to be laid upon the anterior and lateral parts of the leg, and the bandages are to be applied in the order of their situa- tion. In eaeh side of the splint-bandage is to be rolled a splint, which should extend from above the knee to below the sole of the foot, and the spaces between the limb and each splint are to be very carefully filled with chaff, con- tained in bags that extend the whole length of the limb. A third bag is to cover the leg, from the knee to the ankle, on its anterior part, and over this a splint is to be applied of the same length : the ribbons are then to be tightened, and tied over the superior splint. If, after the application of the apparatus, the foot be strongly inclined in the direction of the extension, it majr be supported by a bandage, passing under the sole, and fastened to the splints on each side. If the pillow ou which the limb reposes be not properly adjusted, the heel, by supporting a disproportionate pres- sure, may inflame and mortify, leaving the tendon of Achil- les and the os ealcis denuded, and affected with necrosis. In very young patients, the roller and pasteboard splints are preferable. We should be careful to tighten the band- age as often as it becomes loosened, to change it entirely every eight days, and to keep it constantly wet with a resol- vent liquid. From the forty-fifth or fiftieth day we may use the roller, and soon afterwards we may allow the patient to walk with crutches, It is to be remarked, however, that the period of union k protracted in old patients, and in those in whom the bones have been obliquely fractured. They do not acquire sufficient strength to support the body before sixty days; and if the patient walk too soon, the leg will become bent backward* It has been proposed to employ continued extension in complicated fractures of the leg: it is much more important f.o attend to the means of preventing inflammation and its consequences. However, in certain cases of this nature, ex- tension has been employed with success: we have ourselves derived gueat advantage from it, in some eases of fracture 120 Bayer's Surgery. of the leg, with shortening, which had not united in the or- dinary period. Nevertheless, we are persuaded that, in most eases of fracture of the leg, the bones may be kept sufficiently motionless by the ordinary method. ARTICLE II. Of Fracture of the Tibia. When wc compare the size of the tibia with that of the fibula, and consider the solidity of the union of these bones with each other, we arc disposed to believe, at first sight, that the fibula can hardly escape when the tibia is broken ; but experience shows the contrary; in fact, the tibia alone supports almost all the weight of the body, which it receives from the femur, and transmits to the astragalus; moreover, being placed on the anterior part of the leg, and thinly co- vered with skin, it is more exposed than the fibula to the direct action of causes capable of fracturing it; and, lastly, the fibula, being thin and flexible, yields to violence without breaking. The tibia may be fractured in any part of its length: it is almost always broken transversely. Falls and blows which fracture it, sometimes act upon the extremities of the hone, sometimes at the place where the fracture occurs. The fragments very rarely become displaced ; the fibula acts like a splint, to steady the broken portions: they can only become displaced in a very trifling degree. We have, however, seen a fracture of the tibia very high up, caused "oy the kick of a horse, in which there was a marked dis- placement, in the direction of the bone, that could not be remedied; so that the tibia remained hollowed anteriorly. The very slight displacement of fracture of the tibia ren- ders the diagnosis very difficult; and the case is still more obscure, if the patient have been able to walk after the frac- ture, as has happened in many cases. We may suspect the existence of this fracture, if, after a fall or a blow, pain be felt in any part of the tibia, that is increased by placing the foot on the ground, or attempting to walk, and continuing beyond the ordinary period of pain produced by simple con- tusion ; if a slight edema appear over some part of the bone, and if the patient twitch his limb during sleep. We may bo sure that there is a fracture, if we feel any inequalities Of Fractures of the Boms of the Leg. l£l along |be edge of the tibia, by the motion of the fragments, and sometimes even by crepitation—obscure indeed, but such as will not escape an experienced surgeon. In general, fracture of the tibia is a very trifling acci- dent; it might perhaps be cured without the aid of art, if the patient would keep himself quiet in bed during the pro- per period. When the fragments of the fracture are displaced late- rally, they can be readily adjusted : the surgeon should push them in opposite directions, while two assistants make ex- tension and counter-extension. When the displacement takes place in the direction of the thickness of the bone, it is easily remedied. In order to keep a fracture of the tibia reduced, we may employ indifferently the bandage of strips, long splints, and bags of chaff; or a roller, with splints of wet pasteboard or thin wood. This last method is preferable, particularly for children. When fracture of the tibia is complicated with contusion or inflammation, we are to apply emollient and anodyne poultices before we adjust the apparatus. The fracture unites in about forty days; and as the joints of the knee and foot do not become very stiff or much swollen* the limb is quickly restored to its functions. ARTICLE III. Of Fracture of the Fibula. It is easy to conceive how the direct application of vio- lence may fracture any part of tho fibula, but it is not so oasy to understand how a force which acts on the foot alone, may produce this effect. The mechanism of this process has escaped almost every author, except Pott and Fabre. Tht fibula supports no part of the weight of the body; but, at its lower part, it limits the lateral movements of the foot outwards. Now, if any violent cause, such as a perpendicu- lar fall, draw the foot in a state of adduction or abduction, the astragalus, in the first case, presses, from the limb out- wards, the inferior end of the fibula; and, in the second oase, it presses the fibula from below upwards, with a force equal to the momentum of the body. In both instances, the violence is transmitted, on the one baud, to the ligaments which unite the lower extremities of the tibia and fibula, vot?. ir< 16 122 Bayer's Surgery. and which would be broken, if they were not uncommonly strong; and, on the other hand, to the superior articulation of the tibia; so that the natural curve of the fibula must be augmented, and thus it breaks in that part of its length which offers least resistance. The most important varieties of this fracture arise from its situation more or less distant from the inferior end of the hone. When the fracture arises from an immediate cause, it corresponds to the part where the violence has acted ; but, when it takes place according to the mechanism we have just explained, its situation is extremely variable. The moment the fibula is broken, the fragments are drawn towards the tibia, by the action of the muscles on the ante- rior surface, and the deepest of the posterior muscles of the leg, as well as by the tension which these muscles commu- nicate to the fascia of the leg. No longitudinal displacement can occur; the inferior fragment cannot be carried inwards, without the external ankle being dragged outwards. Now, the distance whieh separates the two malleoli being in pro- portion to the transverse diameter of the articular surface of the astragalus, which they embrace, this space cannot be in- creased, without destroying the natural relations of the ar- ticular surfaces; and as this change is effected by the sepa- ration of the external ankle, it follows, that the foot, being no longer supported outwardly, must incline habitually to that side. Ibis inclination of the foot is increased if the patient walk; the sole of the foot is then turned outwards, the weight ef the body being supported by its internal edge. The evidences of this fracture are derived from an atten- tive examination of the conformation of the bone : this.exa- mination is not difficult, so far as regards the two lower thirds, provided no considerable tumefaetion have arisen. The upper third of the bone is covered by a greater thickness of soft parts, and the slight deformity of a fracture is scarce- ly to be perceived. It is to be remarked, however, that, in this latter case, the fragments arc capable of being more extensively moved; and that, moreover, a mistake as to the nature of the case, is not so serious as in the other instance. Considerable tumefaction may prevent a discovery of frac- ture of the fibula, even when low down; but, when we suspect it, we should be extremely careful not to be de- ceived after the swelling is dissipated. In many cases where the diagnosis is obscure, we may be almost certain of a fracture, from the circumstances which attended the acci- dent. One of the most common of these, is a violent incli- nation of the foot to one side, which tends also to produce Of Fractures of the Bones qf tht Leg. 128 sprain or luxation of the foot: therefore fracture of the fibula is often complicated with this last accident. If, at the same time, (the fracture being very low down, and not disco- vered or reduced) it happen that the external ankle be strong- ly inclined outwards, the foot has a tendency to be luxated anew; the articular pulley of the astragalus is pushed under one of the malleoli, commonly the internal; the integuments are violently distended, and soon inflame or ulcerate, and even mortify: thus air enters the joint and destroys the pa- tient, or renders it necessary to amputate his leg. The cir- cumstance of a sprain, or luxation of the foot, especially in- wards, is a strong presumption of the existence of fracture of the fibula; and the case admits of little doubt, when, af- ter the reduction, the foot is so moveable that the exact re- lations of the articular surfaces do not continue, and there is a constant tendency to repeated luxation. Simple fracture of the fibula is a very trifling accident; all we can do towards placing the bones in apposition, is to depress the external ankle, and bring it to its natural dis- tance from the internal. The most important part of the reduction, and indeed all that is essential, is to restore the ankle to its natural situation. This fracture is very easily kept reduced by the bandage of strips, and two splints, one of which extends beyond the external edge of the foot, and presses it strongly inwards, while the other reaches only to the internal ankle. After forty days we may use a roller, and permit the pa- tient to walk with crutches. When the fracture is high up, the foot contracts very little stiffness, and the patient soon walks as well as ever. But, when the fracture is near the lower extremity of the bone, the ligaments and other soft parts inflame and swell, and the joint becomes stiff, and re- mains so for a long time. 12* Bayer's Surgery. CHAPTER XVI. Of Fractures of the Bones qf the Foot. THE small extent of the bones which form the foot, their shape, the strength of their connexions, and their spongy structure, render their fractures very rare and diffi- cult; in fact, they can only arise from direct violence; and, in these cases, the bones are generally comminuted. What we have said of fractures of the bones of the band, applies equally to those of the foot, excepting that of the os calcis, which, by reason of its length and its connexion with the strong muscles that extend the foot, is exposed to solutions of continuity, of which we shall treat particularly. This bone, placed almost horizontally below tlie point of the articulation of the leg with the foot—-extending beyond the joint, to receive the tendo Achillis, which is inserted into it at a right angle—bearing directly the action of the extensor muscles of the foot, being balanced between their contraction, the weight of the body, and the resistance of the ground, and thus forming a lever of the seeond kind, unites the conditions most favourable to the production of fracture by muscular action. Fractures of the os calcis, therefore, arise most frequently from this cause; and it is probable they would be still more common, were it not for the flatness of the bone behind, by which it is made capable of resisting very great violence in a vertical direction; if the tendo Achillis did not frequently break; and if, above all, the leg and thigh did not bend at the moment of a fall on the point of the feet. It is, in fact, remarkable, that this fracture takes place in circumstances where a fall on tho feet was not followed by flexion of the inferior extremities. This is exemplified in a ease of a woman of the hospital of Salpetnere, who, by means of a rope that was found too short, jumped out of a window, and stretched out her legs to reach the ground, and render her fall less dangerous. The cases of this rare fracture offer very little variety, and it would be surprizing that the swelling of the soft parts should render it difficult to distinguish the interval between the fragments, if we did not consider that the muscles, aponeuroses, and ligaments that surround the os calcis, and which are not broken by the cause that has pro- duced the fracture, permit onlv a rcrv moderate displace. ment. ' * Of Fractures of the Bones of the Foot. 125 Fracture of the os calcis (unless it be produced by a gun- shot wound, or some similar cause) takes place always in that part of the bone which is comprized between its articu- lation with the astragalus and its posterior extremit3'. It is always caused by a fall on the point of the foot, in which this part is caught in a state of violent extension. Some facts, however, would lead us to believe that a violent effort, without a fall, may produce the same effect. The immediate consequence of the solution of continuity, W the displacement of the part of the posterior fragment which the extensor muscles of the foot draw upward; hut the anterior part being held by the resistance of the soft parts that cover the inferior surface of the bone, the dis- placement is always moderate; and, in some cases, the con- tinuance of pain after the swelling subsides, alone leads to the suspicion of fracture. A fall on the point of the foot; inability to rise or walk; a sharp pain in the heel; a sensible depression of this part, higher up than in the natural state; a projection lower down, and towards the sole of the foot; the possibility of bringing the heel in its natural situation, and then giving it lateral movements while the foot is extended, and sometimes the lateral mobility of the fragments alone—are the signs which characterize this fracture. It is doubtful if crepitation have ever been perceived. It is not yet known if the fragments of this fracture be- come united by callus when they have been sensibly dis- placed : however doubtful this may be, persons who have been cured of it, have used their limbs as well as ever. It is undoubtedly easy to reduce the fragments of this fracture; there are indeed cases in which no reduction is necessary, and where, by rest alone, a cure, exempt from deformity, may be obtained. When the foot is extended, and the leg slightly flexed, the smallest force is sufficient to re- place the posterior fragment in its natural situation, and to effect an exact coaptation. But what has been said of frac- ture of the patella, of the olecranon, and neck of the femur, is also applicable to that of,,the os calcis—there is no means of resisting the tonic action of the museles; and fracture of the os calcis, besides this difficulty, has some which arc peculiar to itself. On the one hand, extension of the foot is a constrained position; the flexor muscles, being strongly stretched, contract with great force: on the other band, the power that is employed to push down the posterior frag- ment, must inevitably act upon the neighbouring parts, and. 12ti Buyer's Surgery. especially upon time tendo Achillis, which is thus bent and shortened. It has been proposed to .employ the slipper which J. L. Petii invented for the rupture of the tendo Achillis; but it is evident that this ingenious contrivance can answer no good purpose in fracture of the os calcis. It is pretended that the following bandage has been used with advantage. An oblong compress is confined on the sole of the foot and posterior part of the leg and thigh, by means of a roller; and, in order to keep the foot extended, and the leg bent in a still greater degree, the two ends of the ob- long compress are turned back several times in an opposite direction, under the first and last turns of the bandage; at the same time another thick compress is placed transversely above the posterior fragment, and a bandage passed over it in the form of a figure of 8; and, lastly, to this bandage some have added a splint, applied to the anterior part of the |eg and the back of the foot. . It is evident that we can effect nothing by this treatment, except extension of the foot, flexion of the leg, and com- pression of the muscles of the calf; but it will not exercise any particular and constant action on the posterior fragment of the fracture, or even keep the fragments fixed below in their natural situation. Nevertheless, if, as is asserted, these, and other analogous means, have been employed with success, we must conclude that this fracture may be cured without keeping the bones in their natural situation, and that it is sufficient to remove or diminish the tension of the soft parts, so as to prevent the too great separation of the fragments and the pain that would result; and, consequently, that the essential indications are sometimes merely to keep the limb at rest, and, in other cases, to preserve a particular position, and to compress the museles of die calf. If the extension of the foot were a less constrained attitude, it is probable that fracture of the os calcis would be perfectly cured by rest alone. We think that, where it is necessary to apply any apparatus, a splint, slightly curved, placed on the anterior part of the leg and on the back of the foot, co- vered with a bag of chaff, and kept on by two bandages? one of which embraces the foot and lower end of the splint, and the other the superior extremity of the splint and the upper part of the leg alone, without in any manner compressing the tendo Achillis, would answer the purpose extremely well. This apparatus is in imitation of the second, which Monro employed upon himself, when he broke the tendo Of the Denudation of the Bones. Hi Achillis; and however defective it may be, it promises more than any that has been offered. Fracture of the os calcis unites in forty or fifty days; however, patients should not walk until some time after- wards, and then with crutches, until (he fracture has ac- quired perfect solidity. A slight degree of swelling and a little stiffness remain, which time and exercise dissipate. CHAPTER XVII. Of the Denudation of the Bones. A 7IOLENCE exercised upon the soft parts which cover a V bone, may separate the periosteum. If this effect be produced by a sharp body, moving with little force and more or less parallel to the bone, its action may be confined to tho soft parts, which, in this case, are torn exactly in the point of their continuity with the bone. Thus the greatest part of the cranium has been completely stripped of its covering, Without the slightest violence to the bone itself. But, when the force is great, the body obtuse, and acting in a direction more or less perpendicular to the surface of the bone, the soft parts are torn and eontnsed, and the bone itself is more or less injured; the superficial lamina may be depressed, and the whole part which suffers this violence may become completely mortified. It would seem, in fact, that a violent shock or commotion of the bony tables is sufficient to deaden them, since we see exfoliation result from certain wounds with denudation of a bone, in which not the slightest depres- sion, or other alteration of their form, has been perceptible. Inflammation of the periosteum, when it terminates by suppuration, denudes the bone, and sometimes even brings on mortification of its outer laminse. Tbis is a natural con- clusion from certain facts of this kind, in which a very su- perficial exfoliation has been observed, and where there is no reason to suppose that any violence had been offered. These cases are very different from those in which, in con- sequence of an abscess more or less extensive, and attended with serious symptoms, a portion is separated throughout the whole thickness, and sometime* even of the whole cir eumference of a cylindrical bone. Mortification of so "great an extent cannot result from a simple affection -of the peri- 1$S Boyor's Surgery. osteum; the separation of this membrane, in such cases, ia a remote consequence of a specific cause, which has de- stroyed the life of the bone. Neither does a phlegmon en- danger the existence of an adjacent bone, unless the peri- osteum be directly affected. Our observations on this sub- ject do not, therefore, apply to those cases in whieh this membrane is primarily affected. So true it is that the bones possess all the vital properties of other organs, that mortification of their superficial lami- na? is produced by their being exposed to the action of air, irritating applications, or pressure. Thus a simple denuda- tion, improperly treated, may cause an exfoliation. Contu- sion, without external wound, if it cause a sensible depres- sion, will have the same effect. AVhen denudation has been produced by an external cause, and the accident is simple, and unaccompanied by depres- sion of the denuded bone, the parts are immediately re- united, if they be directly brought together, without giving time to the air, or any irritating body, to excite inflamma- tion in the soft parts, and to produce mortification of the superficial laminae. Wc have every reason to believe that the process of nature, in this case, is the same as that by which the immediate re-union of the soft parts is accom- plished. The impossibility of distinguishing, with accuracy, the cases when a re-union would be useful, and when it would be ineffectual; the great advantages resulting from a rapid cure obtained by immediate re-union, and the little inconve- nience of an unsuccessful attempt to procure it, establish a general rule, to replace the soft parts on a denuded bone always when there arc no signs of organic alteration. We shall not enlarge on the precautions proper to assure suc- cess in this method, as we have treated of them in the ar- ticle on Simple Wounds; we shall only observe, that vital action is less in the bones than in the soft parts; all the functions are executed in a slower manner. This want of harmony in parts that are put .in contact, occasions the re- union to proceed slowly; therefore, the means employed to keep the parts together, ought not be of an irritating nature, and they should be capable of acting for a longer space of time. When the parts have not been brought together, the fol- lowing is the process of nature in effecting a cure:—The soft parts inflame and suppurate; their sinking, by thinning the edges of the wound, fixes them to the circumference of the denuded bony surface; this last, sometimes in all its Of the Denudation qf the Bones. 129 parts, sometimes in a space of more or less extent along the flesh, assumes a light rose colour, which becomes deeper, and extends, by degrees, to all the rest of the denuded sur- face ; granulations soon appear, sometimes scattered on se- veral parts of the denuded bone, sometimes only towards the edges of the wound, from which they proceed to the circumference, and finally cover the whole bony substance, becoming confounded with those which arise from the edges of the wound. These become thin, and covered with a pel- licle, which dries, and leaves a cicatrix over the whole gra- nular surface. This process has been called insensible exfoliation, and it was believed that the laminse of bone which were succes- sively detached, were dissolved in the pus; but the term insensible exfoliation is vague, and the idea which it is meant to convey is incorrect. When the periosteum is stripped from a bone, and nature is left to effect a cure, the cicatrix becomes adherent to it; if the bone then be macerated, so as to remove all the soft parts, we find it rough, unpolished, and covered with spicule. When an exfoliation takes place in one part of a denuded bony surface, the rest being co- vered immediately with granulations, we find, afterwards, a depression over the spot in which the exfoliation took place. These facts are far from proving the separation of any la- mina of bone : the phenomena resemble those which accom- pany other affections of the bony tissue, in which there can- not be any separation or loss of substance. Is it not probable that the inequalities are the result of inflammation and tur- gescence of the osseous tissue during the healing process ? This opinion is confirmed by the fact, that, if we examine the bone at the expiration of some months, we no longer find it rough and unpolished, but of a natural appearance. Must we, to explain this phenomenon, suppose a new exfo- liation to take place ? When a portion of bone mortifies, it becomes detached from the living parts; and this process is termed exfolia^ tion. How it is effected we know not; but the following are the phenomena which accompany it:—The edges of the wound, as in the former case, inflame, swell, suppurate, drain, sink, and cicatrize; the dead bone loses its redness, becomes dry and brown, and its edges thin and pliable; granulations shoot through the bone where it is thin, and gradually detach it; the space left by the separation of the dead bone is covered with firm red granulations, adhering to the parts below, and continuous with those which arc issuing from the edges of the wound. All that is known of vol. it.. 17 ISO Bayer's Sui'gery. the mechanism of this process is, that the granulations., which are left bare by the separation of the bone, are form- ed of the vascular tissue of the bone rendered turgid by in- flammation, and containing vessels which carry red blood. Until the middle of the eighteenth century, physicians, misled by false hypotheses, were in the habit of using a great variety of applications to promote exfoliation -. such treatment did infinite injury. We are indebted to M. Te- non, one of the most respectable members of the ancient Aeademy of Surgery, for a series of simple experiments, from which it results, that the contact of air, the applica- tion of spirituous substances, or even of cold water, alike retard the process of exfoliation; that caustics produce a necrosis, which is long in getting well; and that warm water, fatty substances, and especially poultices, promote the growth of the granulations, and, consequently, the sepa- ration of the dead bone. To borrow the words of this inge- nious experimenter, " every thing which acts upon the bone must be studiously avoided." Belloste having observed that a denuded bone never got well until it was covered with granulations, and that these granulations appeared to arise from the deep-seated parts of the bone, thought he could prevent exfoliation, and abridge the work of nature, by perforating the bone in several parts of its surface. The granulations did, in fact, appear from the openings which he made; and, during this time, nature having finished her work on the rest of the denuded surface, he was firmly convinced of the efficacy of his treatment; and his practice has numerous advocates. But it is easy to conceive, that, when exfoliation ought not to take place, this process is useless; and, when exfoliation is necessary, it is of little consequence whether the dead portion be affected or not. It is even demonstrated, in this case, that the gra- nulations, which arise from the openings, and adhere to those which the lamen covers, and which are less bare after its separation, may, by swelling on the top, act like broad- headed nails, and retain the dead bone after it is otherwise completely detached. M. Tenon, who also tried this plan, found it neeessary to break the separated lamina of bone, in order to remove it. Nothing proves more completely the inutility of this practice, than the praise it received. Some have recommended it, because it hastened exfoliation; and others, because it prevented exfoliation. Monro justly re- marks, that Belloste derived, from repeating his dressings at distant intervals, those advantages whieh be attributed to bis perforations. Of Wounds of the Bones. 131 From all that has been said relative to the simple denu- dation of the bones, where their immediate re-union is im- practicable, it results that emollient poultices are alone admissible, and that every surgical operation is injurious, except in some rare cases, where the granulations enclose a portion of bone otherwise detached. In this case, a small incision across the circumference of the granulations, re- moves the difficulty. ® CHAPTER XVIII. Of Wounds qf the Bones. WOUNDS of the bones differ from each other in many respects. The instruments which produce them, vary in size, sharpness, and velocity: they may act obliquely or perpendicularly; may penetrate partly or wholly through the bone, or only a part of it, and fracture the rest. Wounds of the bones are generally very easily discovered; but, when the wounding instrument has aeted very obliquely, the wound of the soft parts not being parallel to that of the bone, the latter is not perceived, especially if a thin portioD of bone be entirely separated from the rest, and remain con- nected only to the soft parts. These wounds may generally be re-united, if the divided parts ean be kept from the contact of air. It is true, the time neeessary for the cure is longer than that which nature employs in the consolidation of fractures; but we do not see that exfoliation takes place, which many circumstances would seem to render almost inevitable. The time neces- sary for a cure is shortened, when the parts have been im- mediately brought together; if that have not been done, we must wait the formation of granulations, sometimes even the tedious process of exfoliation: it may also happen, if die parts have not been put immediately into contact, and kept perfectly still, that the fragments of a bone which has been completely divided do not re-unite, and that a preter- natural joint is formed. This accident is the more to be apprehended, because re-union takes place more slowly than in fractures. The most serious cases of wounds of the bones, are those hi which not only the bone or bones, but the principal ves- 132 Bayer's Surgery. sols ami nerves of the limb have been divided. In cases where this last circumstance does not obtain, we may al- ways hope for a re-union of the divided parts, especially in those limbs where there is but one bone. Wounds near an articulation are always serious, but particularly so, if they communicate with a large joint. Wounds made with a sharp instrument are less serious than others. From what has been said, we may see the propriety of the general rule, to place the divided parts in apposition, in almost every instance; if they do not unite, no injury re- sults from the trial, while the most serious consequences may ensue from neglect of this precept. The only exceptions to this rule are, in perpendicular wounds, where the instrument has not penetrated deep; and in very oblique wounds, in which a very small piece of bone has been separated, and remains attached to the soft parts, leaving little hope of the possibility of its re-union; and, even in this case, which is extremely rare, an exact apposi- tion of the soft parts, after the removal of the separated piece of bone, is a matter of the greatest importance. When the separated portion of bone is removed to a dis- tance from its natural situation, we should very carefully replace it; when there are several small irregular splinters, they should he removed, by cutting, with a bistouri, their attachment to the soft parts, before we proceed to replace the rest. In all cases of oblique wounds, we are not to forget that an exact coaptation of the divided bones is impossible, on account of the deformity they experience; that the intervals and small spaces will be filled np by the soft parts; and that the bones will unite much more slowly than the lips of the wound. Hence it is necessary to make a gentle, light, but constant compression, on a wound in which a bone has been affected; and the most perfect rest must be main- tained, even after the re-union of the external wound. The means of effecting this object are precisely similar to those employed in fractures; it is even necessary to ho more attentive to keep the parts in a state of perfect rest. We cannot, however, at first, tighten the bandages so as to effect this object with great exactness; hut, when the in- flammation has subsided, we are to use the utmost care in keeping the parts in perfect apposition. Lamotte says, he could have completed the cure of two fractures in the time which he was obliged to wait before he could reunite a complete division of a bone. As to seetion of the soft parts. ste shall not add any thing to what 1ms been said clsewh/rr Of Wounds of the Bones. 133 on that subject, except that, in some circumstances, it is impossible to conform to the general rules for the treatment of wounds. Thus, for instance, where the two bones of the forearm, the muscles on the back of the limb, and a part of those which correspond to the palmar side, have been di- vided, we cannot give the hand a position alike favourable to the antagonist muscles. • If any thing can prevent the fatal effects which follow the wound of a bone that communicates with a large joint, it is, without doubt, the immediate apposition of the parts; and we cannot insist too strongly on the necessity of effecting this with the utmost exactness. If, from improper treatment, or other circumstances, the parts have not united, and suppuration have taken place, even then we should carefully place the parts in contaet, and keep them in a state of the most perfect rest. Lafaye, in one of his interesting notes to the Operative Surgery of Dionis, relates, that a man was brought to M. de Lapeyronie, who had received the stroke of a hatchet on his arm. The bone and most of the muscles were cut; the forearm and hand were cold and livid, and remained at- tached only by a strip of soft parts corresponding to the in- ternal surface of the wound, and in which the large vessels were comprised. It was proposed to finish the amputation of the limb; but Lapeyronie, recollecting some examples of re-union in cases apparently desperate, resolved to try to save the limb. He brought the parts together, and left an opening in the dressings, in order conveniently to reach the wound. On the next day, the arm was swollen above the wound, and the pulsation of the radial artery was no longer perceptible. On the third day, there was a little heat and swelling in the hand and forearm, which went on increas- ing to the eighth day: the wound then appeared to have received new vigour. On the fourteenth day it began to re-unite; the eighteenth day, the cicatrix was far advanced, the limb was restored to its natural size, and the pulsations of the radial artery were sensible. A roller was substituted for the first apparatus, which was renewed every ten days. On the fiftieth day, the roller was discontinued; and, at the end of two months, only a slight numbness remained. The four following cases are extracted from Lamotte's Traite de Chirurgie, torn. ii. obs. ccclxxxiii-iv-v-vi. A man received a wound by an axe, which cut the tibia through its middle and inferior part, and interested the fibula. To prevent the return of hemorrhage, which had been copious, Lamotte stuffed the wound with dry lint, and la* Bayer's Surgery. applied an apparatus, such as is used in compound fractures, On the third day, he moistened with brandy the dressing with which he covered the ends of the bones and the wound. The same dressing was continued for more than ten weeks : at the end of this time, the splints were discontinued. The patient could scarcely walk with crutches more than six months afterwards, and the limb continued edematous for a very long time. i A man, going out of a bouse, and placing his foot on a log of wood which a servant was employed in splitting, re- ceived so violent a blow from the axe, that the instrument penetrated his shoe and foot, and stuck firmly in the wood. The foot, hlmost entirely divided, remained attached only by the last bone of the metatarsus. It bled very freely, but the hemorrhage had Ceased when Lamotte arrived* He brought the ports together, and kept them in contact by pieces of felt above and below, surrounded by compresses, and covered with a roller. On the fourth day, every thing was going on well. The dressings were changed every eighth day, until the fortieth: the pieces of felt were then oaiiuted. The patient rose—his wound was healed. Fo- mentations of wine were employed ; but Lamotte prevented him from walking for two months, doubting the firmness of the re-union. The cure was complete, and the limb reco- vered all its strength. A man, in a quarrel, received a sabre-cut, which com- pletely divided the lower part of the cubitus, and made a slight impression upon the radius. A dossil of lint, wet with brandy, was applied to the ends of the bone, and the rest of the wound was stuffed with lint, in order to prevent hemorrhage, which was apprehended, and which bad been profuse* A roller was applied, and over it a piece of strong pasteboard, confined by a second bandage. The hand was kept in a state of semi-flexion, and the subsequent dressings were wet with brandy throughout the whole extent of tho wound. The patient got well, " but," Lamotte observes, * not until twice the time necessary for the cure of a frac* fcire." ' In a single combat, a grenadier received a sabre-cut in • the arm. ** The instrument cut about two-thirds [of the thickness] of the humerus, near the elbow ; the rest of the hone was splintered, like a piece of wood that has been partly split.,, No bad symptoms occurred. Lamotte ap- plied the apparatus for compound fractures, and dressed the wound only once in four or five days. Tho re-union was complete in three months. C 135 ) CHAPTER XIX. Of Necrosis. NECROSIS has been distinguished by different names-. and. of late years particularly, the term dry caries has been applied indiscriminately to necrosis, and the disease to whicli the word caries is properly applied. According to the etymology of necrosis, it signifies a mortification of a greater or less extent of a bone. The celebrated Louis is the first who employed this term in a sense nearly similar to that in whieh it is now used: he limited its application to mortifica- tion of the whole thickness and circumference of a bone— an acceptation whieh, as we shall presently see, is not cor- rect. Every bone, and all their parts, are subject to this dis- ease ; but necrosis affects most frequently the more compact parts of the osseous structure, such as the flat bones, and the middle of those that are cylindrical. The tibia, the hu- merus, the femur, and the lower jaw, are the most frequent seats of this disease. Experience has not shown that age, sex, or particularity of constitution, predispose to a necrosis. In the flat bones, this disease may extend along one of the tables only. When any of the bones of the cranium) are affected, the disease is usually confined to the outer table. It has been known to affect the whole surface of the skull. In some rare cases, the diploe of flat bones is diseased. Veidman saw a case of this kind in the os innomiuatum. In the long bones, neerosis is constantly confined to the diaphysis, or body, unless it be produced by an external cause; but it may affect a circumscribed space of the exter- nal surface, or that which corresponds to the medullary cavity. It sometimes extends even to the articular extre- mities. When the mortified part separates, it discovers asperities and inequalities, whieh arise from the unequal depth of the disease in different parts. The causes of necrosis are external and internal. Almost all morbid poisons, but especially the venereal and scrofu- lous, may give rise to this disease. The psorfc,. rheumatic, and arthritic virus, may also produce it. Necrosis has like- wise followed the suppression of the menses, and habitual or periodical hemorrhage, Are we to believe that the disease 130 Bayer's Surgery. is the effect of the suppression of these evacuations, or a collateral effect of the same cause ? The action of a freezing temperature congealing the sur rounding soft parts; that of concentrated caloric, even below the degree necessary for burning; exposure to the air; the application of spirituous liquors, mineral acids, alkaline sub- stances, and caustic salts; contusion; constant pressure; comminutive fractures, especially those produced by gun- shot wounds—all these are eanses of necrosis. They act with much greater effect in producing necrosis in the com- pact portion of the bones, than in their spongy structure. The same internal causes which are apt to produce necro- sis of the compact structure, often give rise to caries in the reticulated texture. Does this arise altogether from the difference of structure ? The denudation of a hone, and the accidental separation of the periosteum, being sometimes followed with a mortifi- cation of the denuded portion, it has been unjustly concluded that the death of a bone depends exclusively on the separa- tion or disease of thisftnembrane. The periosteum and me- dullary membrane undoubtedly perform a very important part in the nutrition of the bones; but the innumerable in- osculations of the vessels are sufficient to continue the cir- culation of the fluids, and nourishment of the parts, without sensible injury from the simple slipping off of the periosteum. It cannot be doubted, that the causes which produce necrosis act directly upon the tissue of a bone: this becomes dead- ened to a greater or less extent, and the adjacent parts are successively affected with inflammation. Thus far necrosis differs in no respect from mortification of the soft parts. We shall consider, first, the cases in which the perioste- um is diseased at the time of the necrosis; and, secondly, that in which this membrane continues healthy. In the first instance, the disease commences with pain more or less acute, and which varies according to the na- ture of the disease which has produced this affection of the bone. Thus, for instance, it is worst at night, when the malady is venereal, and sometimes also when it is gouty or rheumatic. It is confined principally to a point in the sur- face of the hone; and a flat tumour soon forms, at first not circumscribed, doughy, soft, without inflammation of tin; skin, and more or less distinct, according to the thickness of the soft parts over it. After.a short time, the skin becomes red; a phlegmon is formed; but the fluctuation remains obscure to the last. However, tbe skin grows thin, and ulcerates; one or more openings form/ which soon Of Necrosis, is; unite, and give issue to pus, and an eschar, formed of the pe- riosteum and the cellular tissue, afterwards the pain almost ceases, the edges of the ulcer continue loose and vacillating, and the wound is imperfectly drained ; the granulations be- come pale and bloated; the opening contracts, and remains fistulous; tho bone continues denuded; at first it is pale, then it grows black, and the surface becomes ragged: things remain in this state a longer or shorter time, ac- cording to the greater or less thickness of the diseased por- tion of bone. After a length of time, the denuded part of the bone appears elevated, and, if struck with a probe, it emits a duller sound than healthy bone; it is painful when pressed, which was not the ease before; it becomes move- able, and sometimes drops of blood exude, apparently from the granulations around the circumference of the moveable portion. Some time afterwards it becomes completely de- tached, and the part below it is thickly covered with firm red granulations, continuous with those of the ulcerated sur- face, and which soon become the base of a solid cicatrix, adhering to the bone, and presenting an excavation propor- tioned to the loss of substance which the bone has sustained. It may be readily conceived that the progress of the dis- ease is somewhat modified, when it arises from an external cause, which has produced a wound or mortification of the skin and other soft parts which cover a bone. When necrosis extends quite through a bone and the peri- osteum of both its sides, granulations, formed from its pa- renchymatous substance, become the base of the cicatrix. There is no regeneration of parts to repair the lost sub- stance, either in this case, or when the disease is confined to a part only of the thickness of the bone. When necrosis affects only the medullary part of a bone, the external portion swells, and forms granulations; the sequestra be- comes separated, and is enclosed in the living bone. A new process of nature is then necessary for its discharge. When the periosteum of one or both sides of the bone is affected, the disease commences with much more serious symptoms, because a greater extent of bone is commonly mortified. The patient is affected with acute, deep-seated, and constant pain, occupying a greater or less extent; in- somnium, loss of appetite, fever, with an exacerbation to- wards evening, or during the night, and accompanied with pain, thirst, copious, but generally partial, sweats. Tim pe- riosteum becomes thickened, and more vascular; it sepa- rates from the dead bone, and the interval between them is filled with a gelatinous, or r-ither albumenous fluid, which, vol. u. 15 138 Boyer's Surgery. in time, becomes more consistent, adheres to, and is at length identified with the periosteum. Small spieulse and scales of bone are formed in this mass; they increase in number, and form a thick solid substance. Finally, the bony structure becomes evident, and the thin stratum of soft parts next the sequestra, forms a new internal periosteum. If the disease be seated in a flat bone, the phenomena will be different, according as the periosteum is preserved on both surfaces of the bone, or only on one; and also according as the mortification involves the internal periosteum or not. In this last case, there appears a soft, doughy, deep-seated, un- circumscribed tumour, painful on pressure, but without any external inflammation. After a time, fluctuation may be perceived, the skin inflames and ulcerates, a large quantity of pus is discharged, and the bone is found bare beneath the soft parts; new collections form, and open, the orifices re- maining fistulous; finally, the dead bone becomes loosened and detached, by the pressure of the granulations below. In those instances in which the periosteum of both sides of a broad bone remains unaffected, the sequestra becomes en* closed in a case, formed by the double layer of new bone united at its spongy extremities, which arc never affected. In this case, the separation of the sequestra is easy; but it cannot be removed without the aid of art. It does not appear that the dura mater, which performs the office of an internal periosteum to the bones of the cra- nium, is capable of that inflammatory process by which new bone is formed. Saviard saw the greater portion of a cra- nium lost by necrosis; and, in this case, the cicatrix re- mained thin, and agitated by the movements of the brain. We must not mistake for a new production, the thin ex- pansion which proceeds from the opening made by a trepan : this is simply the effect of the sinking of the two tables of the skull, and the swelling of its diploe. The symptoms of necrosis are somewhat modified, when it affects the whole thickness of the bone, and all, or nearly all, its circumference. If the periosteum be mortified while the medullary membrane preserves its vitality, the first of these parts becomes separated from the surrounding organs, and an enormous abscess forms, which opens in several places. During the process of suppuration, the medullary membrane inflames, swells, and thickens; its cellular la- mella; become more dense, and are confounded with their common covering, which separates from the medullary sur- face of the bone; and we find in the interval between them, :\ layer of albumen, like that of which we have already Of Necrosis. 13fl spoken. In this new substance wc soon sec red points ad- hering to the medullary membrane, and quickly confounded with it in colour and consistence, and forming an opaque, whitish, homogeneous body, in the centre of which bone is .developed. Sooner or later the sequestra separates, and escapes in small pieces, through the fistulous openings, while the new bone daily increases in volume and consist- ence. If the medullary membrane be mortified while the peri- osteum remains unaffected, the latter inflames, and swells in some points; suppuration takes place; the abscesses open, and we can pass a probe through the orifices to the cavity which contains the sequestra; the dead bone is discharged through these orifices, either wholly or in part; and if a portion remain behind for a length of lime, it will oucasion hectic fever. Necrosis rarely affects the articular ends of cylindrical bones; when it does, the case is highly dangerous. In most cases of necrosis, the sequestra is long, slender, and irregular. It appears externally at several points; but still it is nearly, or quite immoveable, even after it is en- tirely detached from the surrounding bone. Experiments made upon living animals.teach us, that, in cases of fracture, attended with the destruction of the peri- osteum, or that of the medullary membrane, or mortifica- tion of the bone, the reproduction takes place from the side of the two membranes which has been preserved; and that the new substance extends, without interruption, over the solution of continuity, and unites the hones. But we are ignorant of the manner in which a cure would take place, if necrosis should affect the body and whole articular extre- mity of a long bone. Necrosis is generally much more rapid in its progress, and much more dangerous, when it has been produced by external violence, than when it is a consequence of syphilis or scrofula. In the latter cases, the greater part of the tibia. humerus, and femur, has been known to conic out through fistulous openings; and, after a great length of time, nature has effected a cure, without the patient's having thought it worth while to take medical advice. Necrosis of a superficial part of a bone, involving the periosteum, first appears in the form of a tumour, accom- panied with acute and deep-seated pain. The tumour is. at. first, small, bard, and clastic; afterwards it enlarges soft- ens, and becomes fluctuating. When the tumour opens, (Im- bone is found rough, and it docs not appear red., o; covnrd 140 Boyer's Surgery. with granulations. After a time, the surface of the bone is elevated. When pressure is made upon it, paiu is excited, the sequestra is seen to move, and a few drops of blood are squeezed from beneath it. When necrosis affects the diploe and periosteum of a flat bone, or the medullary surface of a long bone, it causes, in the part, violent continued pain, which is increased in the evening or night, and attended with hectic fever. A mode- rate but extensive tumefaction next takes place, which gra- dually increases, becomes harder, and less sensible. Fistu- lous openings form in the part, which discharge a quantity of pus disproportioncd to the size of the tumour. The flow of pus is not promoted by pressure. A probe introduced, passes to a great depth, and touches a hard, rough, insen- sible mass of bone, at first fixed, but afterwards moveable and vacillating. Necrosis is not commonly a dangerous disease; but, when it is extensive and deep-seated, it may induce fatal colliqua- tive symptoms. Generally, however, the limb is restored lo its functions, unless the disease affect the articulations; in which case, amputation is commonly the only means of sav- ing the patient's life. In the treatment of necrosis, its exciting causes, such as syphilis, scrofula, &c. must be combated by appropriate re- medies. As to the local indications in superficial necrosis, they are very unimportant. It is proper only to make small openings through the skin, in order to discharge the matter, before that membrane is so thinned and disorganized that it will not re-unite. Occasionally it is necessary to enlarge the opening through the soft parts, after the sequestra has be- come loose; but, generally, nature requires no assistance of this kind. The treatment of deep-seated necrosis consists principally in the use of emollient, relaxing, and sedative remedies, ex- ternally and internally. As the disease continues a long time, we must not bleed the patient unnecessarily, nor keep him too low. When we are able to feel the seques- tra with a probe, we should endeavour to judge whether nature will he able to effect its separation. An operation for the removal of the sequestra is rarely necessary, and is always to be avoided if possible, since it necessarily weakens the new formed bone, destroys a portion of it, and some- times even occasions a new necrosis. The surgeon should, therefore, support the patient's strength, prescribe opiates, &c. and not operate until delay would endanger his life. If Of Mtbrosis. 141 the limb become bent, at one of the openings, by the action of the muscles, we may augur well, since its incurvation will probably permit the sequestra to come out. If we be obliged to remove the sequestra by art, we should make a semi-elliptical incision on each side of one of the largest and most superficial openings: the skin and soft parts included within these incisions are to be removed. If much blood flow, the wound ought to be covered with dry lint, and left until the next day. The opening through the new bone is then to be enlarged, so that we may get hold of one of the ends of the sequestra. A trepan is the bos', in- strument we can employ for this purpose. It is better to make several perforations with this instrument, than to use any violence in extracting the dead bone. It has been pro* posed to employ a strong bistouri; but, unless we operate prematurely, the bone will be found too hard to be divided with this instrument. If we be not careful to avoid pressing hard upon the new-formed bone, we run the risk of bending it, or of exciting great inflammation. After the sequestra is removed, the cavity of the wound is to be gently filled with lint; over this should be placed a piece of soft linen covered with cerate, and the whole co- vered by a poultice. The limb is then to be adjusted in a convenient position. Copious suppuration will follow; and slight exfoliations, from the parts which the instruments have divided, will take place; the new bone will gradually become smaller, and the cicatrix will at length close. After the cure, the patient must be kept at rest until the new bone has acquired sufficient solidity to perform its func- tions. ( i*2 ) CHAPTER XX. Of Caries. THE nature of caries is entirely unknown. Until very lately, it was confounded with necrosis. In the present state of our knowledge, it is impossible to give a definition of this disease; but its phenomena are evidently the result of vital properties. A carious bone is the seat of pain, more or less acute, constant, and affecting the health of the patient. Sometimes it is swollen, softened, pliable, and more or less partaking of the consistence of the soft parts. Sometimes it retains its natural coverings; when it is separated from them, fungus often arises from the exposed surface: ill-con- ditioned, sanious, fetid pus is secreted. Nature makes no effort to separate the affected hone, unless, perchance, tho disease change to necrosis. With this single exception, the disease makes constant progress; small bones, it is true, are separated; but this separation produces no favourable change, and bears no resemblance to necrosis.—Caries has been com- pared to ulceration of the soft parts. Though this com- parison may illustrate the difference between this affection and necrosis, yet it is far from being proved that caries is an ulcer of a bone. Caries most commonly affects the spongy structure of the bones: hence the bones of the carpus, those of the tarsus, the bodies of the vertebra), the thickest parts of. the scapula, and os innominatum, the whole of the sacrum, the sternum, the mastoid process of the temporal bone, and the extremi- ties of the long bones, are the most frequent seats of this disease. It attacks children most frequently, and makes more rapid progress in them than in older persons. Sometimes a carious bone preserves its natural form and consistence; but most commonly it is enlarged, dry, and brittle; or it becomes soft and compressible. Contusion is believed to be capable of causing caries, but we almost always find it connected with an internal cause, such as scrofula, scurvy, &c. We cannot decide whether the disease of the articular extremities of large bones, which arises from wounds of the joints, be truly earics or not. The presence of pus and the pressure of tumours are in, capable of causing this disease. The internal causes of caries are, syphilis, scrofula, scur- vy, cauccr, gout, and rheumatism; the metastases of tire Of Caries. 143 virus of small-pox, measles, and of critical translations of certain acute diseases. Syphilis produces caries more rarely than necrosis. When caries arises from syphilis, that disease must have existed a long time. In this case, the nasal fossa, the roof of the mouth, the mastoid process of the temporal bone, and the sternum, are the parts most frequently affected. Caries of the bones of the wrist, foot, ankle, knee, elbow, and shoulder, are commonly the consequences of scrofula. Scurvy is most apt to produce caries of the more compact parts of the bony system. In these cases, we find no swell- ing or exostosis of the affected bone—a circumstance which characterizes the highest degree of that disease. Cancer produces caries in no other manner than by ex- tending from the affected soft parts to an adjacent bone. Rheumatic white swellings, and lumbago, sometimes lead to caries of the bones of the knee and vertebra?. Gout also may produce caries of the bones of a joint in which it has long existed. The concretions and fistula? which occa- sionally form in that disease, leave the bone rough and earious. The pressure on the sacrum and other bones, which takes place in chronic diseases, is not of itself sufficient to cause caries; it must be aided by the translation of the general disease to the part. There is another cause of caries, of which no author has spoken, and which unhappily is too common—-I allude to masturbation. A great number of facts prove that it may produce deformity of the spine, and a greater number still, that it may cause a caries of the vertebrae. We have had numerous cases of caries of the vertebrae, the greater num- ber of which, excepting among scrofulous infants, were oc- casioned by the vice to which I allude. We cannot explain this fact. The signs of caries arc, 1st. A fixed pain, more or less violent, in a bone whose structure is favourable to the for- mation of caries. 2d. An abscess by congestion in a part more or less remote, commencing with a tumour, fluc- tuating from the beginning, and followed by inflammation of the integuments; but never preceded by subcutaneous in- flammatory congestion. 3d. The opening of this abscess re- maining fistulous, furnishing a disproportionate quantity of pus, which daily becomes more fetid, and affects the health of the patient. 4th. The discharge of very small irregular pieces of bone with the pus, and deformity of the part where the bone is affected. 144 Bayer's Surgery. A spontaneous cure of caries rarely takes place; but* when the disease depends upon syphilis or scrofula, it some- times gets well without the aid of art. The cure, however, takes place in different ways, in these two cases: in the for- mer, it becomes converted into necrosis, and the dead bone is separated like an eschar of the soft parts; and, in the latter, all the symptoms gradually subside, and the patient recovers, without any exfoliation taking place. This favour- able change is most likely to happen at the age of puberty. Without the aid of art, however, caries almost always proves fatal, by inducing colliquative symptoms; or it keeps the patient in a state of unnatural susceptibility to the general causes of disease. The general treatment of caries depends upon the disease which has given rise to it; commonly, however, caries con- tinues after its cause is destroyed. Local treatment then becomes necessary : this must vary according to the extent, situation, and nature of the disease. It is remarkable that almost all authors have recommended the application either of irritants or heat: though the latter of these remedies was misapplied to cases of necrosis, yet the unanimous con- sent of antiquity in favour of it as a remedy for caries, is certainly founded upon observation. When caries is superficial and recent, we may derive ad- vantage from topical baths and ablutions of a decoction of bitter herbs, or a weak solution of potash. The strength of the solution should only he so great as to impart an evident taste when applied to the tongue; the strength may after- wards, be increased but very gradually, lest it inflame the skin. This remedy, which I have often seen successful, re- quires to be used a long time. I knew a shoemaker who had caries of the ankle, for which amputation was judged necessary: some circumstances, however, delayed the ope- ration ; and the patient, in the mean time, bathed the part with ley, which produced ancylosis, and a cure. When a bone is laid bare, alkohol, or tincture of myrrh, aloes, &c. may be applied with advantage. It is not probable that these means ever succeed in curiqg caries when it is deep seated; in such cases, we must con- vert caries into necrosis, by producing a mortification of the affected bone, and inflammation of the surrounding parts. For this purpose we may employ mineral acids, liquid me- tallic salts, or any other liquid caustic. The ancients made great use of the actual cautery: this undoubtedly is the most powerful, certain, and expeditious means of cure; it is more conveniently applied than caus- Of Carles. 145 tics, acts to a greater depth, and is less apt to injure the soft parts; these may always be protected by covering them with wet cloths, or by passing the iron through a cannula. It is often necessary, before we apply the cautery, that the bone should be laid bare, unless it be very deep seated. We should have three or four irons ready, of suitable form and dimensions, and heated to a white heat. If the bone be affected with moist caries, or filled with fungus, the first iron docs little more than evaporate the fluids it contains, and it is necessary to apply several irons in suc- cession. The operation is not very painful; if, however, a severe and lacerating pain do succeed, and the fungus shoot up rapidly, there is reason to fear that the diseass is cancerous, and further cauterization would be more danger- ous than the malady it was intended to relieve. There are no means of judging when the action of the hot irons has extended to all the carious bone ; but we may form some judgment of the degree of cauterization neces- sary, by comparing the depth of the caries, (as ascertained by the introduction of a probe,) the humidity of the carious bone, and the quantity of fungus which penetrates it, with the size of the irons, and their degree of heat. If, a few days after the first cauterization, the patient experience no pain, nor the inflammatory symptoms which announce that the sequestra is about to be separated, or if the fungus be re- produced, the operation must be repeated. The success of this truly heroic remedy depends entirely upon this circumstance. When properly employed, the actual cautery is always suc- cessful, except in cancerous eases. It would be fortunate if every case of caries admitted of its application. The actual cautery cannot be applied to caries of a joint, nor to very extensive or deep seated caries. Sometimes it is necessary, first to remove the greater part of the caries, and cauterize the remainder. The actual cautery ought never to be applied to any part of the cranium, except the mastoid process. When caries, seated in an articulation, remains stationary, we can do no more than keep the paiient at ie.it, and give him tonics and a generous diet. If hectic fever supervene, and threaten the life of the patient, amputation is the only resource: but this operation should never be n sorted to until hectic symptoms take place. Resection of the articular extremities of carious bones has been proposed as a substitute for amputation. In our opinion, this operation is only applicable to caries of the shoulder ; because, in this case, the disease may be confined vox. 11. 13 146 Boyer's Surgery. to the head of the humerus, and, if it extend to the glenoid cavity of the scapula, the hot iron may be there applied. The whole operation is simple, though severe. In all other cases the preservation of the limb would be too dearly bought. Some cases of caries, from their extent and depth, are necessarily fatal. In such instances, we can only discharge the pus by small openings, and support the patient's health. ARTICLE I. Of Caries qf the Bones of the Cranium. These bones are more frequently affected with necrosis than caries. However, this last disease is not unfrcquently caused by syphilis. It most frequently attacks the mastoid pro- cess ; in which case the hearing is almost always destroyed. When the disease commences in the external table, a swelling of the soft parts is simultaneous with the affection of the bone. A doughy tumour forms, which is slightly painful, and adherent to the parts beneath: afterwards this inflames, opens, and discovers a diseased bone. When, on the contrary, the internal table of the bone is primarily af- fected, great pain takes place, and exists a long time in the same spot, without any appearance of disease. It is generally accompanied with vertigo, convulsions, lethargy, blindness, and other symptoms of compression of the brain. At length an external tumour appears, corresponding to the original scat of the pain; it is small in extent, slightly painful, and fluctuating from the commencement; its size is variable, and compression sometimes diminishes it. When the tumour ul- cerates, we perceive an opening through the cranium, of which the edges are thin, irregular, and tapered off, by the destruction of the internal table. Pressure does not pro- mote the discharge of pus, which is very abundant. When this second species affects the mastoid process, purulent mat- ter is discharged from the ear. In this case, the meninges, and even the brain, are generally affected. Of course the disease is very serious. Caries of the external table may generally be cured by the application of alcohol, tincture of myrrh, and aloes, or li- quid caustics; and these applications are without danger. But when the disease affects the internal table, it is far more difficult to manage. The actual cautery is inadmissible, Of Garies. *& except in caries of the mastoid process, and other applica- tions are ineffectual and dangerous. When the internal table of the cranium is carious, thu dura mater separates from it. This circumstance facili- tates the use of instruments, for the removal of the carious bone, and this should be effected as exactly as possible, by the rougine, trepan, centicular, a small round saw, &c. What is left of the carious bone should be destroyed by topical ap- plications, applied with all possible circumspect ion.* If, in the operation, we perceive that a portion of sound bone projects into the carious part, we must cautiously avoid injuring it, as it will serve to support the cicatrix, and di- minish the deformity. When fungus shoots out from the dura mater, as is gene- rally the case, it should be washed with some slightly sti- mulating lotion, as lime water, the water of Balaruc, kc. ARTICLE II. Of Caries of the Vertebra:. It is very important to understand this disease, because it is frequent and fatal. There are two remarkable varieties of it: in one the ca- ries is superficial; it appears only to attack the circumfer- ence of the body of one or more vertebra, while the rest of the bone remains unaffected. In the other, the whole body of one or more vertebra? is, from the beginning, softened or swollen. It sinks under the weight of the body ; the spina is bent backwards to a point; the spinal marrow is injured, and the parts below the seat of the disease are rendered weak, and occasionally paralytic. Pott first accurately de- scribed this particular kind of palsy of the lower extremi- ties, which now bears his name. In the first case, and sometimes in the second, the pus which is formed about the affected parts, runs along the cellular tissue, and forms abscesses by congestion. Of these we have already treated. The bodies of the vertebrse are most frequently affected; sometimes, however, the transverse processes become ca- * See the Memoires of the Academy of Surgery, vol. i. page 265, for an account of a very daring operation of this kind, performed by the cele- brated La Peyronie. 148 Bayer's Surgery. rious. The caries of the body alone requires particular con- sideration. This disease generally attacks children, at that period of life at whieh the scrofula, of which it is often the conse- quence, first Shows itself; it, also, is common among ado- lescents. The cause of this has been already stated. We cannot have a just idea of the frequency of the cause which has been pointed out; it is not only productive of the dis- ease among young persons, but even among children. Next to this cause and scrofula, rheumatism most frequently oc- casions caries of the vertebrae; it produces superlicial caries most frequently in adults. A blow, a fall, or a strain of the spine is often spoken of as a cause of this kind of caries ; but it is probable that these are only fortuitous occurrences, or effects of the disease. When caries of the spine is superficial, the patient com- plains of a constaut, deep seated, but moderate pain. The ligaments of the anterior part of the spine become separated, and in the interval thus formed, pus is deposited, which soon produces an abscess by congestion. When the spongy structure of the vertebrae is diseased to a great depth, the spinous processes of one or more of these bones is raised so as that its axis is nearly horizontal. This deformity is noticed before the occurrence of pain in the part. But it is generally preceded by a sensation of pricking in the thighs, weakness of the lower extremities, an uneasy sensation in the stomach, and constriction of the chest, which renders breathing difficult; the pain in the back is always moderate, and never increased by pressure. The patient, after some time, lays altogether on one side, with his legs slightly flexed, the neck strongly extended, and the face turned upwards. These last phenomena are remarkable, es- pecially when the dorsal vertebrse are the seat of the disease. The patient walks with his feet near each other, and with slowness and precaution; the hands are first left hanging by the side, and afterwards they are rested upon the ihigh ; in sitting down, the body is bent entirely on the pelvis. When the patient is about sitting down, he presses the palms of his hands against his thighs, and bends his body upon them. When he wishes to pick up any thing from the ground, he separates the lower extremities, bends the legs and thighs, supports the weight of his body with one hand on the corre- sponding thigh; with the other hand he takes hold of the object either on one side or between his knees, never before them. All these are so many contrivances to prevent motion of the vertebra either to one side or forward. As the disease Of Caries. ■!•*» progresses the weakness of the lower limbs increases; the feet are raised very little in walking; the patients stumble and fall; the legs cross each other; afterwards they cannot walk without aid; and, finally, they can neither walk nor stand. But even at this period of the disease, the efficacy of proper treatment would lead us to believe that the continuity of the vertebrse is not destroyed. The spinal marrow is probably stretched, by the change in the form of the vertebra;, and compressed by the swelling of the cellular tissue which sur- rounds it. This latter cause must have great influence, since we are often able to restore the functions of the lower limbs without relieving the curvature of the vertebra;. If the disease is left to progress, the affected vertebrse become dis- eased in every part, pus collects in front of the carious bones, an abscess by congestion is formed, and the patient at length dies. On dissection, we find the bodies of one or more ver- tebrse destroyed, as far back as the posterior lamina and transverse processes. The adjacent vertebrse are eroded and fallen in, so as to take the place of the lost substance, but not united to each other. Sometimes the intervertebral substance and ligaments are destroyed ; the process of the dura mater, which lines the vertebral canal, and the spinal marrow, are not visibly affected. We find, also, one or more cavities or sinuses filled with pus or carious matter. What is surprising, we frequently meet with irregular bony productions, generally oblong, stalactiform, and com- pact ; often larger than the body of a vertebra. We some- times find them floating in the pus, and at other times ad- hering to the inner surface of the sac. The difference between caries of the vertebrse and gibbo- sity is very great. In the latter disease there is never any formation of pus, or destruction of bone ; the curve almost always is lateral; the lower limbs are never affected. It is remarkable, also, that the paralytic affection of these parts, which takes place in caries of the vertebrse, differs from pa- ralysis properly so called, in this; that, in the latter, the museles are relaxed and often shrivelled; in the former, on the contrary, they continue firm and plump. This disease often makes alarming progress before its ex- istence is suspected.* As it is of the greatest importance to discover it as early as possible, we should carefully examine every child that is unable to walk at the ordinary period; 01 who, having began to walk, is uo longer able to do so; and even those, who, without apparent cause, become sad, sul- • See note D. 150 Boyer's Surgery. len. peevish, and indifferent to the amusements of their aSe- Scrofula, masturbation, and rheumatism, as causes of ca- ries of the vertebrse, are severally dangerous in the order in which they are mentioned. This disease is more dangerous in adults than in children. The most we can do in any case is to prevent an increase of the deformity, and this can only be effected by the prompt use of the most energetic means. When the disease terminates favourably, the dis- eased vertebrae fall together, and become hard and adhere. This evidently shows the inutility and absurdity of mechani- cal contrivances to straighten the spine. We are indebted to Pott, not only for the first accurate de- scription of this disease, but, also, for the proper mode of treating it. He proved, and the experience of all succeeding surgeons has proved, beyond doubt, that a copious suppu- ration, kept up for a long time in the subcutaneous cellular tissue, which surrounds the projecting part of the spine, is the surest and best remedy. We can safely assert, that this remedy has never deceived us; we have always found it successful, if employed before pus was formed, and we have always found that the patients have died when it has been neglected. We have even found it useful as a palliative re- ined v when an abscess by congestion has been already formed. We have not found setons or issues made with a knife or moxa so useful as these formed with caustic potash. We make one issue, in urgent cases two, on each side of the pro- jecting part of the spine. Each issue should be large enough to contain three or four pease, or, what is belter, a ball of iris of the same size. When the suppuration flags, it must be promoted by applying blister ointment; and, when this is not sufficient to keep up a copious flow of pus, we should form new issues, and heal up the old. The good effects of this treatment are soon manifest; but it must be continued a long time, several months, or even years, to effect a cure. At the same time general remedies should be administered according to the nature of the case. We believe issues are useful in every stage of caries of the spine; they ought to be formed even when they can only act as palliatives. Rest and irritating applications to the spine can do no in- jury, if employed conjointly wkh issues; but they are little capable of producing any amendment.* We beg leave to refer the reader to the chapter on abscess • See note E. Of Caries. M% by congestion, in the first volume of this work, for our opi- nion of the advantage of making a small oblique opening for the discharge of pus in such cases. We shall conclude this article with the following cases. Case I. A. Laporte, aged seventeen vears, fell from a height of thirty feet upon his right haunch. He lost his re- collection, and his urine came away involuntarily. No injury was discoverable. He was bled three times, and, at the end of six weeks, he could rise from his bed, and set in an easy chair. He had acute pain in the loins, and great weakness of the legs. Three months after the accident he entered the hospital Charite. The spinous processes of the sixth and se- venth dorsal vertebrse projected backwards; the paraplegia was almost complete. We learned that the man had long been guilty of an abominable vice. We formed two issues, one on each side of the tumour ; they were too small; we made others of a larger size. The relief was moderate and transient. Nothing could induce Laporte to abandon his vice, although the representation of his danger brought on paroxysms of despair. The disease made sensible but slow progress ; the pains in the back continued ; the paralysis ot the lower limbs became more complete; a new canes ap- peared at the junction of the last vertebra with the sacrum. The wretched man languished, his countenance sunk, the fear of death harrassed him, and he left the hospital m de- spair, seventy-five days after his entrance. Case II. On the 15th of January, 1809,1 was called to see a son of M. Gilmer. He had enjoyed good health until the aee of four years. There was a remarkable projection of the spinous process of the sixth dorsal vertebrse. A surgeon, who was consulted, made light of the matter, sayrng, that the ohild would outgrow the disease. At the age of nmc years the deformity had much increased; the child could walk verv well, but daily lost flesh. The surgeon applied a parti eular kind of corset. This subjected the patient to frequent couch and syncope, and it was relinquished after six months trial. For three years more, similar preposterous remedies were resorted to, and the child's health was fast declining. I was called to the boy, who was then fifteen years old. The curvature of the spine formed almost a right angle; the pa- raplegia was complete; the urine was discharged at long in tervals, and with difficulty ; respiration was very laborious; the f»ces were passed only once in three or four days, anrt involuntarily; the boy was often choaked, and frequently fell into syncope. I formed four issues around the tumour, eaeh large enough to hold four or five pca^e. 152 Boyer's Surgei'y. February 15—The suppuration copious ; the discharge of urine and f trees less painful; sensation of creeping pain and cramps sbooring through the lower extremities ; pains in the back and chest somewhat diminished; towards the end of two months motion of the toes and feet was restored. In the course of the month of March the lad felt a de- sire to pass his urine and fseces, which were afterwards dis- charged voluntarily and without pain ; movements of the leg3 still very slight. In the beginning of April the patient could stand, but was unable to walk. In the course of the month of May the patient was able to walk across his chamber. He took chicory for two months. In August the patient could walk a mile daily with the aid of a cane, and an arm. One month afterwards he walked without any assistance. At the present time, (March, 1810,) the patient has still four issues on his back. The deformity is the same as when 1 was first called to him, but he has grown. The dis- charge of urine and fseces is perfectly natural, and bis walk is firm ; some slight and transient pains are occasionally felt in the ribs. ARTICLE III. Of Caries of the Sternum. The spongy structure of the sternum, and the distance be- tween its tables, renders it peculiarly susceptible of caries. Scrofula often exercises its ravages upon this part; a com- mon symptom of confirmed syphilis is an exostosis or perios- tosis of the sternum; a critical abscess or contusion of this bone are also enumerated among the cause* of caries, but we doubt if the latter be capable of producing it without rhe aid of other concealed causes. We are much in Ihe dark respecting the phenomena of simple or healthy suppuration of the spongy structure of the bones. Scrofulous caries of the sternum may commence in the inner or outer surface of this bone. It occurs most fre- quently in children, and is often complicated with tubercles in the mediastinum, or lungs. Not only the whole of the sternum, but even the cartilages of the ribs are often carious. In each of these cases the pleura is pushed back and thick- ened- It often becomes converted into cartilage, and eveti Of Caries. 153 into bone: thus the pus which is formed between the ster- num and the mcdiaslinum is prevented from coming in contact with the viscera of the thorax. In some rare instances, however, in which the mediasti- num has mortified, or merely ulcerated, the heart has been exposed so as to be visible. But even in these cases the dis- eased membrane contracts a firm adhesion on the borders of the mortified or ulcerated part, and thus prevents auy exter- nal communication with the cavity of the lungs, which, un- like that of (lie heart, is never opened. Beside the general signs of caries, we find, in caries of the sternum, other symptoms which indicate the presence of pus behind that bone :—A probe passes easily into the fistulous openings whieh surround it; pus flows out in the movements of respiration ; if the lungs are affected, there is uneasiness and oppression in breathing, which leads the patient to choose a particular position to lie in, together with cough, expecto- ration, &c. Such cases generally prove fatal; but simple caries of the sternum may be cured. Even when left to nature a favour- able termination has been known to take place, by the exfoli- ation of the whole bone, which was detached in very small pieces. When the disease is superficial, and not extensive, the irri- tating applications, of which we have spoken, will be suffici- ent. In more serious cases it is necessary to remove, with a rougine, or some other similar instrument, the greater part of the carious portion of the bone, and then employ topical applications. But we should be cautious of applying liquid caustics, or the actual cautery. Whatever be the extent or the depth of the caries, it may always be removed without danger of injuring the parts behind, for the bone is isolated. The trepan and the lenti- cular arc the most convenient instruments. If the disease extend to the cartilages of the ribs, we may remove them also. We need not fear wounding the mammary artery. This vessel is buried in the subjacent soft parts, and, therefore, little liable to be wounded. But were this accident to hap- pen, the vessel might easily belied. In performing operations of this kind, the integuments over the diseased bone, unless very thin and disorganized, should be turned back, and not removed. If we are able to remove all the carious portion of the bone, we have only to heal the wound. If any diseased part has been left behind, we must apply to it suitable topical remedies. In some cases it is impossible to cicatrize the parts com vol. n. ^ 15* Bayer's Surgery. pletely. Thus, when the pericardium has been opened, the constant motion of the heart prevents it from forming the base of a cicatrix. Such was the fate of a young gentleman whose case is related by Harvey. In such instances, after destroying the caries, we must adapt an obturator to supply the want of the natural coverings of the chest. If the abscess behind the sternum be very large, if the pa- tient be hectic, all that can be done is to apply a trepan to the lower part of the sternum ; but, in this case, it would be still more advantageous if the abscess pointed near the xyphoid cartilage. In this case we should endeavour to mature it; for a depending fistulous opening would be preferable to an open- ing made with a trepan. We shall conclude this article with the following cases, which we hope will dissipate, from the minds of surgeons, every fear of an operation, apparently dangerous, but, in re- ality, very simple. Case I. A young man, in wrestling, received a blow oh the sternum, which was not properly treated. At the end of four months an abscess formed, which opened and cicatrized. Some months afterwards another tumour appeared. This also opened, but the opening remained fistulous. Several sur- geons were consulted, who agreed that the sternum was cari- ous, but declined operating, from the fear of penetrating into the cavity of the chest. M. Galien was called in. He un- dertook the operation, after stating to the young man's mas- ter, that its success would depend upon the state of the parts behind. He found that the disease did not involve the arteries and veins whicli pass along the posterior part of the sternum; but when he had removed the diseased bone the pericardium was found diseased, and the heart was exposed. Nevertheless, the patient was completely cured. Case II. M. M », after an acute disease, experienced pain in the sternum; abscesses formed; the openings of which remained fistulous, and discovered an extensive caries of the sternum. After remaining in this situation for several years, he placed himself under my care. The extent of the disease had intimidated every surgeon who had seen him. I was young, and had little reputation to lose. The patient had youth ami a strong constitution in his favour. He was willing to submit to any thing to be cured. There were se- veral lislube around ihe borders of the sternum, and parti- cularly toward the left side and the centre ; a probe passed to a great depth, I found that not only the sternum, but three cartilages of the ribs of the left side were diseased. The patient beint? laid on his back, I made two crucial inci ^f Cartes. 155 sions, and dissected hack the flaps until all the carious portion of the sternum was laid bare. I insulated the middle third of this bone with a chisel and small saw; I then divided the diseased cartilages more than two inches from the ster- num, and removed the whole. A vast abscess was brought to view. The bottom of it was formed by the pleura and medi- astinum united to each other, thickened, cartilaginous, even ossified in some parts, and firmly adhering to parietes of the chest, beyond the diseased parts. The left internal mam- mary artery, which ran over the superficies of the mediasti- num was opened in the operation, but it was easily tied. The integuments were replaced, and the wound healed as well as if it had been made in healthy parts.* ARTICLE IV. Of Caries of the Ribs. The most common seat of caries of the ribs is near their union with the spine, and this, most frequently, is connected with caries of the vertebrse. It will not be necessary to dwell long upon caries of the middle of the ribs. When it is superficial, and the health of the patient unimpaired, we need only to provide a depend- ing opening for the matter, and administer suitable internal remedies. But if an abscess form behind the ribs, as will generally take place when the caries is deep-seated, we should lay bare the carious part, and remove it. The pleura will form the base of a cicatrix, and, in time, acquire the consistence of cartilage, or even bone. The actual cautery is never applicable to eases of this kind, as it might inflame the lungs. ARTICLE V. Of Caries of the Bones of the Pelvis. The structure of the sacrum has so strong a resemblance to that of the sternum, that most of what we have said of * In the year ir91, my friend, M. Genouville, surgeon to the Military Hospital of Val-de-Grace, performed a similar operation, in my presence, with complete success. 156 Boyer's Surgery. the former applies also to the latter. When caries attacks the sacrum spontaneously, or from internal causes, that side of the bone which is next the pelvis is almost always affected. In these cases purulent collections take place, and appear in parts more or less distant, forming true abscesses by con- gestion, and accompanied with all the dangers attendant upon these diseases. We ought, therefore, to examine with the greatest attention abscesses and fistula? about the anus, peri nseum, and buttocks, especially if they have been preceded by deep-seated and constant pain in the region of the sacrum ; and never lose sight of the symptoms of abscesses by conges- tion, lest we fall into gross and fatal errors. The crest of the ilium, its tuberosity, and that of the ischium, are also very liable to caries. The deep situation of most of these parts, as well as the slow progress of the disease, allow the pus to remain for a great length of time, and pass to a great distance, without causing any alarming symptoms. The tumour which it produces is also very equi- vocal, on account of its form. When, therefore, we see soft, fluctuating, indolent tumours, with a large base about the pelvis, or upon the posterior or the internal part of the thigh, we should inquire if they have not been preceded by dull, deep-seated, fixed, and constant pain in some part of the bones particularly liable to caries. Unless we make these inquiries, the patients, not suspecting any connexion between the swelling and the pain, will leave us ignorant of the true nature of the disease. In all these cases the treatment is exactly similar to that of abscesses by congestion, which has already been laid down. Although the articulation of the sacrum with the bones of the ilium is very strong, external violence may pro- duce a divulsion of these bones, the secondary consequences of which are extremely serious. They may, also, become relaxed in females during the progress of gestation, and thus render it very painful, or even impossible to walk. In conse- quence of these causes, or from rheumatism, a caries of the articular surfaces results, or rather that particular affection which follows wounds of large joints on their exposure to the air. The progress of this disease is much more rapid than that of caries properly so called. The pain is acute and in- supportable. The patient is obliged to rest upon his back, a little inclined to ihe affected side; the corresponding inferior extremity is swollen and extended ; voluntary motion is lost, and movements communicated to it produce excruciating pain. The fever, which appears from the beginning, is vio- lent, and has the characters of inflammatory symptomatic Of Caries. 1B7 fever. Suppuration most commonly takes place, and the pus appears in the seat of the disease, behind the articulation, or it n.akes great progress towards the internal part of the pel- vis, and points somewhere along the anterior part of this ca- vity. This disease, which ought to be considered as an in- flammatory affection of an articulation, rather than caries, is almost always beyond the resources of art, and rarely is cured by the power of medicine. We have already suggested our doubts as to the nature of the affection of the posterior part of the sacrum, which arises from lying a long time on the back. In fact, in a great va- riety of cases, notwithstanding the alteration in the colour of the bone, which perhaps arises from the contact of putrid matters, its consistence is not changed. It is probable, there- fore, that this affection has more analogy to necrosis than caries, especially when we consider that exfoliation is not al- ways necessary for the cicatrization of the ulcers; and that, when it docs take place, nature requires no particular assis- tance, and the disease is always light. If. in some rare cases, ve observe true caries, it arises from an internal cause, whicli has acted particularly upon the bone, and not from mortification of the soft parts. M hen caries evidently exists in the sacrum, wc may use the actual cautery with safety. The part* of which the os coccygis is composed may be affected with caries. They are so small that they may be quickly separated from the soft parts, and may be extracted without difficulty after a certain time. The disease of the acetabulum, which is known by the names morbus coxendicum, or spontaneous luxation of the fe- mur, will be treated of hereafter. We shall terminate this article by two cases, which will show the danger of caries of the bones of the pelvis. Case I. A taylor, aged fifty years, of a bilious tempera ment, came to consult me for a flattened, circumscribed, in- dolent tumour, without alteration of the colour of the skin, and situated at the right posterior part of the pelvis, below the tuberosity of the ilium. The patient, from his youth, had been subject to wandering rheumatic pains. A fixed, but not intense pain towards the posterior spine of the bones of the ilium, had preceded the developement of the tumour in question. I directed a soap plaster to be applied, and advised the patient to call upon me from time to time. At the expi- ration of two months the tumour was larger than before, soft and fluctuating. The patient entered the hospital. A few days afterwards I opened the tumour with caustic. 158 Boyer's Surgery. A large quantity of sanious, inodorous matter was dis- charged for a month. At the end of this time the discbaigc was more copious and fetid; hectic fever and diarrhoea came on; the legs became anasarcous, and the patient died three months after he entered the hospital. On dissection, we found a fistulous sinus which extended from the external opening to the posterior spine of the bones of the ilium, pas- sing before the gluteus maximus. The bone was carious to a great depth. Case II. A healthy woman, aged thirty, by profession a cook, complained for a long time of a dull and deep-seated pain in the posterior part of the os ilium of the left side, with- out any sensible alteration of the form of the part. After- wards, however, ttie buttock swelled, but there was no pain, nor alteration of ihe colour of the skin. The patient pursued her employment without being much incommoded by the tu- mour. A fall upon this part caused it to sink ; but a new tu- mour formed in the posterior and upper part of the thigh, which, at length, extended to the ham. The patient con- sulted me ten months after the pain came on, and six months after the appearance of the tumour. It was prodi- giously large, indefined, occupying the whole buttock, indo- lent, without inflammation of integuments, and presenting a deep fluctuation. All the posterior part of the thigh, quite to the ham, formed a tumour, separated from the first by the angle of the buttock, without inflammation of the skin, indolent, soft, and fluctuating. By compressing, alternately, these two tumours, I perceived that the matter passed from one to the other. Notwithstanding the slightness of the pain which announced the commencement of the disease, I au- gurtd ill of the case. The patient having entered the hos- pital, I made three successive punctures, with a narrow bis- touri, at the most depending part of the tumour of the thigh, and carefully placed the lips of the wound in apposi- tion. The third puncture did not close, and the purulent, grumous matter, which was discharged after every opening, continued to flow through it. The matter then became felid, fever supervened; and the patient, perceiving herself sinking, desired to return home, where she died two months after- wards. An intelligent student, whom I had directed to examine the body, found an extensive caries of the posterior and superior part of the os ilium. C 159 ) CHAPTER XXI. Of Exostosis, Periostosis. Spina- Vtntosa, ami Osteo- sarcoma. THESE organic affections of the bones differ from each other as regards their seats, their causes, their pro- gress, and their terminations. We shall, however, consider them in this chapter, because they have one circumstance in common__that of altering the vital properties and the struc- ture of the organs they affect. In this circumstance, perhaps, they resemble caries, properly so called. Although we have numerous cases of these diseases on re- cord, they are far from furnishing a natural series of facts, in which we can trace any evident connexion between causes and effects. Organic affections of the soft parts inav generally be traced to some known cause, and the study of morbid ana- tomy daily increases the sum of our knowledge. But the organic affections of the parenchematous substances of the bones are concealed from view by the earthy inorganic mat- ter of these parts. Moreover, these diseases are of very long duration, their origin is obscure, and their termination is al- wavs uncertain. The same person can rarely follow the whole course of a case ; most of the histories, therefore, of these maladies are incomplete. We cannot too strongly recom- mend the study of this subject, which is yet in its infancy, notwithstanding the labours of many celebrated men.^ A circumstance which appears common to all affections of this kind, periostosis alone excepted, is, that the softening of the osseous tissue precedes every ulterior change. In spina- ventosa and osteo-sarcoma this is ineontcstible, but is not so evident in exostosis, especially in that kind in which the bone acquires the hardness of ivory: but if we consider that the bulk of the bone is increased, that the compression of tumours upon bones destroys rather than distends them, that in examining the substance of an exostosis, we may generally distinguish, very easily, the fibres diverging from each other towards the surface of the tumour; and that, in many tu- mours of this kind, we observe some parts hard, irregular, and voluminous; others, of which the cellular structure differs from its natural state only by the space its increased size and diminished density occupies, and others, in which the osseous tissue is reduced to a puffy or fatty substance: if, 1 say, we consider all these circumstance, it will be dif- ficult to avoid this conclusion. 160 Boiler's SurgCry. ARTICLE I. Of Exostosis. Exostosis is a tumour formed by an increased growth ot a part or the whole of a bone. We sometimes find an aug- mentation of volume and density in all the bones of the same porson, which probably is a species of this affection. Exostosis affects all the bones, but is observed most fre- quently in the bones of the cranium, the lower jaw, the cla- vicles, the sternum, the ribs, and the long bones of the extre- mities. Sometimes exostosis appears like a small mass superadded to the surface of a bone; sometimes it rises indistinctly, and resembles a section of a sphere; sometimes it is pointed, and, at other times, it is connected with the bone by a narrow pedicle. The external plate of a bone of the cranium has been seen covered with an exostosis, while the cerebral surface continued unaftected ; the whole circumference of the femur sometimes acquires an enormous size, while the medullary surface remains healthy. In other instances the whole thick- ness of the bone is diseased. When this takes place in a cylin- drical bone, the medullary cavity is diminished, or even obli- terated. In some very rare instances the bone acquires the hardness of ivory, without increasing in size. If this hap- pen to a cylindrical bone, the articular surface is commonly affected. When an exostosis is not very large, and is seated on the surface of a long bone, we may trace, with the eye, the di- vergence of the bony fibres; the intervals between them are filled with a new osseous substance, the organization of which is indistinct. The tumour is sometimes entirely cellular, and formed of broad plates enclosing large spaces, filled with a substance different from the marrow. This is what is termed laminated exostosis. Sometimes the portion of the bone grows in the form of a hollow sphere, with thick and hard sides, the cavity of which is filled with fungous ve- getations. This variety must not be confounded with osteo- sarcoma, from which it essentially differs, notwithstanding its apparent similarity. In other instances the tumour is en- tirely solid, and as hard as ivory, and the surface is continu- ous, like bone in its natural state; or it is unequal, irregular, mammalated, and in some degree stalactiform. A part of the tumour is often pulpy and lardaceous. It is not uncom- mon to find the same exostosis as hard as ivory in ©ne part, Of Exostosis. 161 lamellated in another, and partly filled with a semi-fluid gela- tinous substance. When the exostosis is very large, it renders the muscles and cellular tissue near it very thin. Small exostoses may injure the functions of certain organs: thus a joint may be rendered stiff, the uretha may be obstructed, the eye may be pushed from Ihe orbit, the brain may be compressed, or the lungs may be prevented from expanding, &e. when an exostosis is situated in the vicinity of any of these parts. Syphilis is the most common cause of exostosis ; but ex- ostosis is always a secondary symptom. Scrofula occasions it sometimes ; scurvy very rarely. J. L. Petit saw but only three cases of this latter kind, and these were on the lower jaw, and it may be doubted if they were not venereal. Can- cer never causes exostosis. Blows, falls, &c. on the part, can only be considered as exciting causes. Syphilitic exostosis is uniformly preceded by acute pain; at first in every part of the affected bone, afterwards in the spot where the tumour forms, and always increased at night. In the exostosis which arises from scrofula the pain is either very dull, or there is no pain at all. The exostosis which succeeds to a contusion comes on slowly, and is not painful, except at the time of the accident. Independently of these circumstances exostosis is acute or chronic. The cellular, or lamellated exostosis is deve- loped quickly, and it is always preceded by violent, acute, and intolerable pain, not much relieved by opiates, nor in- creased by pressure. The pain often causes severe sympto- matic fever; it is owing to the morbid action which is going on in the bone ; the soft parts do not partake of it, nor are they swollen. In the harder kinds of exostosis the pain is much more moderate, or it does not exist at all; the tumour increases slowly, and no constitutional irritation takes place. How- ever surprizing it may appear, exostosis may terminate by resolution, or even by metastasis. We have seen a voluminous exostosis occupying all the lower parts of the humerus: it was of syphilitic origin, and, after having resisted, a long time, scientific treatment, it disappeared quickly and completely on the occurrence of other syphilitic affections in the fauces. These cases, it is true, are extremely rare, and we may lay it down as a general rule, that exostoses are never resolved, even when they are idiopathic and purely lo- cal, and that the examples of this termination, whieh are cited, are cases of pcriostosis, the nature of whicli is c : tirely different; though its appearance is very similar. •"'*,. II. 21 162 Bayer's Surgery. In most cases of hard chronic exostosis, without pain or alteration of the bony tissue, the tumour remains stationary for life. This termination, which may be compared to the induration of tumours of the soft parts, is the most desirable, provided the exostosis do not impede the functions of any organ essential to life. But in cellular exostosis, a part of the tumour is generally pulpy or gelatinous, and the rest, still preserving its natural organization, forms one or more collections of pus. The soft parts ulcerate, and leave a portion of the tumour exposed: true caries sometimes supervenes, but this is then a primitive complication of the disease, and not the consequence of the ulceration. When the soft parts are thus ulcerated, the opening contracts and remains fistu- lous. Suppuration induces hectic fever, whicli may prove fatal. Spherical exostoses, with an internal cavity and hypersar- cosis, are not accompanied by violent pain, except in their commencement. When they have attained any considerable volume, they become almost indolent; but the successive growth of fungus in the cavity, distends and thins its sides, and may lead to fracture or ulceration; but the affection of the bony tissue is less dangerous than in the former spe- cies, where tumours have often been operated upon with success. Whereas any operation would be useless, and even dangerous in the preceding case. Another mode of termination of exostosis, not mentioned by authors, and which is most apt to occur in the hard and stalactiform kind, is that by necrosis. Large tumours of this kind lta\e been known to mortify, separate from the bone which was their base, and become surrounded with a sub- stance, in eveiy respewt similar to that which encloses seques- tra. This is. undoubtedly, the most fortunate of all termi- nations; but it is, also, the most rare; art may imitate it, but imperfectly. Exostosis appears in the form of a bard tumour, incompres- sible, united lo the bone, and immovable. These character- istics readilv enable us to distinguish its periostosis, which is always dough} and compressible. All other tumours, however intimate!} connected with the bone, may be slightly moved. But when the tumour appears in the internal sides of any of the bones which surround the cavities of the body, it is difficult to ascertain its existence, and we ean onh suspect it from the effects it produces. We may conclude that exostosis has arisen from syphilis, where this disease has existed a longtime, and the affection has become general. We infer, that it is scrofulous, when Of Exostosis. 16 J ihe patient has other symptoms of this disease, and no other cause is evident. It is very difficult to judge a priori what are the contents of an exostosis; but it is generally hard when the tumour has been slow in its progress, and vice versa: yet some scrofulous exostoses are chronic in their progress, without becoming vary hard. It is important to distinguish that state of an exostosis whieh is disposed to terminate by ne- crosis: it is marked by the same sjmptoms that announce the formation of a sequestrum. The haidest exostoses are generally the least dangerous. Some hard exostoses, after attaining a certain size, remain stationary, or are even capable of being somewhat dimi- nished. The medical treatment of exostosis consists in the destruc- tion of its internal cause. We shall onlv remark, that, in syphilitic eases, the mercury should be given for a long time, and in great quantity; that sudorifics, in large doses, are very advantageously combined with it; that a combination of sudoriiics, with some grains of potash or soda, has often been employed with benefit, after several ineffectual courses of mercury. The external application of laudanum, by means of com- presses, or added to poultices of linseed, is always useful in abating pain. Depleting remedies are rarely administered. When there is no pain, or after it has been relieved, we may cover the tumour with mercurial or soap plaster, or we may apply volatile liniment, solutions of potash, or of soda, pumpin.^s of hydro-sulphurous water, &c. These uieans, however, are generally insufficient, and our knowledge of the nature of the disease is too limited for us to lay down any internal treatment, further than to fulfil the general judications of each case. \\ hen an exostosis presses upon some important organ, and an operation is required, we should make around the tu- mour, if it have a narrow neck, two semi-elyptical incisions, raise (he flaps, and saw it off. If the bone be sound, the flaps should be rc-appiied. If we are obliged to wait the forma- tion of granulations from the surface of the bone, the pre- servation of the skin wiil facilitate the cicatrization of the wouqd. When the basis of the tumour is large, (as is commonly the case,) it is most conveniently removed with a chisel and mallet. The operation is much facilitated by divid- ing the bone down to its natural level, in several places, by a saw or trepan. The chisel should, also, cut obliquely, 164 Boyer's Surgery. in order to diminish the concussion. But, notwithstanding these precautions, the shock of this operation renders it in- admissible in exostosis of the head, to which the saw alone is adapted. Unless the tumours are very large, and skin greatly diseased, it should be preserved by making a crucial incision, and dissecting back the flaps. When the skin is diseased in consequence of the distension of a large tumour, the dis- eased parts may be removed, and the remainder re-applied, after Ihe formation of granulations. Notwithstanding the natural insensibility of the bones, these operations are not altogether without danger. Petit saw a young gentleman who died in consequence of an ill- advised and clumsy operation for the removal of an exostosis from the cranium. Yet the chisel was not employed, nor is there any mention of erysipelas of the face having taken place. In this extraordinary case, death seems to have been induced by the divisions made in substance of the tumour. In spherical exostosis, containing fungous granulations, we may, in imitation of Petit, cut away the thin parts of the sides of the tumour, with strong scissars, or bone nippers, tear out the fungus, remove the base of the tumour with a chisel or saw, and apply the actual cautery to the part from which the fungus grows. After this, exfoliation takes place, and the wound heals. When this species of exostosis is not so far advanced, and the integuments are still healthy, it is impossible to distin- guish it from the hard kind. But the moment the saw en- ters the cavity, we perceive, by the blood whicli escapes, that the tumour is not solid. We should then make another cut with the saw, by the side of the former. Thus the parts are placed in the same situation as if ulceration had taken place. If the bone is not very much diseased in cellular exostosis, the tumour may be extirpated by a single cut of the saw. When the base of the tumour is large, we may make a per- pendicular division of the tumour from the top to the base. In ibis state of the tumour the operation is simple, and gra- nulation takes place without exfoliation. But if the granu- lations are large, flabby, pale, and bleeding at the slightest touch, it is to be feared that the section has been made through the substance of the tumour, and not at its base, and that it will be reproduced, and require the use of the hot iron. If the exostosis is of very long standing, if the bony tis- sue is radically diseased, if the integuments have ulcerated Of Periostosis. 165 and furnish ill-conditioned pus, and if, lastly, the disease is complicated with caries, hectic fever, &e. any attempts to extirpate the tumour would be highly dangerous. Am- putation is then the only resource. ARTICLE II. Of Periostosis. Most authors have confounded this disease with that treated of in the preceding chapter. It is often a symptom of syphilis, and consists in an inflammation and thickening of the periosteum, attended with a specific disease of this membrane, and sometimes with necrosis of the superficial lamina of the bene. It attacks, most frequently, the same parts upon which venereal exostoses most commonly appear, viz. the cranium, especially the frontal, and the anterior part of the temporal regions, the front of the sternum, the external side of the radius, the internal side of the ulna, the internal side of the tibia, &c. In examining the structure of these tumours, we find them formed of thickened periosteum and cellular tissue, converted into an hemogeneous, greyish, doughy, compact substance, resembling an inflamed lymphatic gland, and still more like old cheese. Periostosis is always the effect of syphilis. It appears only in the advanced stage of that disease. Its formation may be excited or accelerated by external violence. These tumours are generally preceded by constant pain, more or less acute, and resembling venereal pains, especially in that they arc most severe at night. A swelling then takes place; at first this is moderate, tender to the touch, and circumscribed. Its circumference is insensibly con- founded with the bone on which it rests. The tumour ad- heres to the bone, is inseparable from it, and, in fact, ap- pears like an enlargement of the bone itself. If, to these characteristics, we add that periostosis, while yet small, ap- pears to be hard and incompressible, and that exostosis is, also, a common symptom of syphilis, we sec why they have been confounded. In the progress of the two diseases we perceive their dif- ferent characters. The periostosis is larger, softer, doughy, [pateuse,] but not retaining the impression of the finger, and not fluctuating, at least while the skin remains unaffected. i66 Bayer's Surgery. In some cases the pain ceases, the tumour continues sta- tionary for some time, and then diminishes and disappears en- tirely." This termination by resolution rarely takes place spontaneously, and is not generally brought about by the best directed efforts of art. More commonly after the tumour has acquired a certain size, it remains indolent, becomes harder, and continues in this state for life. This termina- tion by induration may be connected with exostosis. Lastly, it. sometimes happens that the skin which covers the tumour ulcerates, and matter is discharged; the bottom of the abscess is of a dull yellow colour; after some time, a greyish decayed substance is discharged, and the bone is left denuded or covered with red granulations, according as the mortification has affected the whole thickness of the pe- riosteum, or only a part of that membrane. This last termination of periostosis is the only danger which attends it. It resembles, in every respeet, necrosis produced by syphilis. The treatment of periostosis consists principally in the employment of remedies for syphilis, which is the cause of the tumour, and, in general, if the local disease have not ad- vanced very far, and if there be no locvd inflammation, we may procure resolution. Under less favourable circumstan- ces a degree of swelling aud hardness will remain, which, however, produces no other inconvenience than the defor- mity it occasions. But general remedies are inefficacious, if not administered before the inflammation takes place. In such cases the tumour follows the course we have described, unless we aid the general remedies by local applications and a suitable regimen. Emollient and anodyne poultices are very useful, when there is great pain and sensibility in the part. After these have been removed a mercurial plaster is proper. We should, also, rub a scruple, or half a drachm, of mercurial ointment on the part. Some authors advise the application of blisters, for three or four hours at a time, as a resolvent. They may have proved useful, but we con- sider them as dangerous remedies, on account of the inflam- mation which they may occasion, and which, as we have said, ought to be strongly guarded against If, in spite of timely aid, or from neglect of it, the tumour become fluctuating, we should immediately discharge the pus by means of a small opening made with a bistouri. This is preferable to caustic potash, which excites severe pain when applied to inflamed parts. Of Spina-Ventosa. 167 ARTICLE IIT. Of Spina-Ventosa. This disease was unknown to the ancients. What Hippo- crates says of certain organic affections, and whieh his eoni- mentators have translated by the Latin words sidtratio, gan- grana, teredo, &c. refers to the denudation, caries, or necro- sis of bones. Cehus appears to speak of this disease more positively, but his language is very obscure. The Arabians. however, had a particular name for it, which has been rendered into Latin by the terms rentum spina', spina: rento- sitas, rentum or fatum spineum, and sjiina-rcntosa. But they evidently confounded it with other diseases.* By spma-ventosa is understood a disease of the cylindrical bones, in which the sides of the medullary canal undergo a slow, successive, and sometimes an enormous distension, while, at the same time, they are considerably thinned, and even pierced in several points, or their tissue is exceedingly rarified. The scat of this disease is in the medullary cavity. Many authors have confounded this disease with caries. The latter disease, it is true, is often a consequence of the former; but, in these cases, it is by no means essential to, much less the cause of spina-venf osa. Neither is this a dis- ease of the marrow; for if the bone were destroyed simply by the compression of that substance, in an enlarged state, we should not find any rarefaction of its structure, but merely a loss of substance. J. L. Petit and others have confounded this disease with exostosis and caries ; considering them as varieties, or ra- ther as different grades of the same complaint. * To prove these assertions it will be sufficient to cite some passages from Avicenna. Ex ger. crem. vers. lib. iv. fen. 5, tr. 1, c. 9, de ventositate spins etcorruptione ossis: " Yentositatis spiuse causa sunt liumoies .icuti, penetrantes in os, et corrodentes ipsum." ('. 10, signn corpiptio'iis ossis: "Cum ossi acudit cmruptio, viclos enrnem stippr ipsum molleseere, rl mollem fieri. ct 'n cipit in via fa-tovis et virtus: et per.etrat per earn tenta facillime ad os. Et in ▼enit rem non firmam in se ipsa, im6 liabentem fracturaru, aut pulrefactionem." C. 11, ^uratio net unlike a very large potatoe, com- posed of four principal lobes, and subdivided bv an infinite number of little lobules; a large furrow passed along the anterior surface of the tumour in the situation of the com- mon tendon of the triceps and rectus anterior. Two other narrow, but very deep furrows passed first parallelly along the posterior surface, and afterwards diverged; one pass- ing downwards and inwards, and the other downwards and outwards, in the course of the two edges of the linea aspera. The periosteum, thickened, rendered more consistent, and giving attachment to fleshy fibres, was plainly discover- able on the outside of this mass. It passed directly from one lobule to the other, and sent off to the bottom of each furrow a process of hard libro-cellular substance, which was easilv detached from the tumour, but was torn out with great difficulty. This disposition of the periosteum resem- bled very strongly that of the pia mater, with the tunica * See the plates 4, 5, 6, antl the n-odel uc-posi'od lr\ the M«w.m of the Faculty of Pari-?. N*. '''■ VOIf. IT- 9> ira Boyer's Surgery* afachnoides, and the connexion of these membranes with the surface of the brain. The membranous covering of the tumour being carefully removed, the mass that was brought to view resembled car- tilage, re! soft and granular, and, on cutting deeply into it, we discovered numerous isolated spiculce, parallel to each other, and resembling osseous filaments, incompletely or- ganized, and partially solid. The point of a sealp^ plunged info this mass, encoun- tered^ at a certain depth, a bony substance, into which it stuckv The femur above the tumour was natural. A probe which was passed into the medullary cavity, was somewhat move- able, after it reached the middle of the tumour. The ligaments of the knee joint were natural. The syno- viale membrane, especially in front of the crucial ligaments, was injected, thickened, and hard. The muscles of the leg were of the natural colour and consistence, and larger than those of tlie opposite limb. At the two extremities of the tibia and fibula, on their an- terior and posterior sides, were several excrescences of a conical shape, formed of a thin shell of bone, containing a substance like that of the principal tumour. The lower half of the femur, with the tumour and the two bones of the leg, completely stripped of soft parts, weighed twenty-one pounds.* A point of fetid serum oozed from the tumour during the forty-eight hours it was left with the modeller. The femur being sawed longitudinally through the con- dyles, was found to have retained its natural form and con- sistence to one third of the height of the tumour by whieh it tyas merely surrounded. The condyles presented a very thin and fine net-work, with much larger cavities than natu- ral. In the interval between these two portions, and to an extent of about one eighth of the length of the bone, the sides of the bony cylinder were removed from its axis, and the lamellae of the compact structure were separated, diverging inwards and outwards, then changed to filaments more or less fine: thus converting this substance into an oreolar tissue. There were apertures in the sides of the tumour like those of a gun-barrel that has bursted. The medullary * Considerable weight must have been lost by evaporation duri.ig the lime employed in modelling and. making a drawing of the tumour, of whicli. no account could be taken. Of OsUS'Sarcoma. *?9 tissue was not diseased, and the cells were not filled with pus or fungus ; nor was (here any appearance of caries. From the circumference of this diseased part of the fe- mur, spieulse of bone passed like radii towards the periphery of the tumour, divided and sub-divided into an infinite num- ber of ramifications, confounded with one another. Tb« structure of the net-work was proved, by maceration, to be entirely different from that of the sides of the medullary cylinder, in which the primitive texture of the bone might be perceived. Some parts of the exterior net-work were en- tirely unconnected with the bone. The greatest part of the tumour was formed of the carti- laginous substance of which we have spoken. It filled the intervals in the periphery, between the external net-work. In several points it was changed, softened, and red, and appeared to the eye like gooseberry jelly; in other parts were seen cavities filled with bloody matter. In the poste- rior part were several other cavities, as large as a nut, witji irregular, grevish, or yellowish sides, containing a yellowish fetid ichor, and in every respect like cancerous abscesses. These cavities were distant from the primitive bone, and uu- connected with the external bony net-work. Nothing remarkable followed tbe operation. At the pre- sent time (October 2d, 1810) the cicatrix is complete; the patient enjoys good health, and the bony tumours which re- main are not painful, and have not increased in volume. Although the following case is not so interesting as (he preceding, because it relates only to the dissect ion of the.dis- eased part, it is important, inasmuch as it gives an idea of the changes which take place when caries is complicated with osteo-sarcoma, or when tbe latter exists without the former. It relates to a tumour formed in the haunch and in the sa- crum, which destroyed the patient by inducing a marasmus similar to that caused by cancerous affections. The tumour extended from the region of the sacrum to the anterior and internal part of the thigh. It raised and bad thinned the glulsei muscles and the fascia lata. Jl pushed in the colon, the bladder, and tbe iliac muscle. It included the sacrum, the inferior part of the os ilium, the horizontal branch of the pubis, and the ischium to its tu- berosity. This last, and tire body of the pubis were pre- served, moveable, and as if separated from the rest by the difference of their structure, and that of the diseased parts, with which they were in continuity. The tumour weighed eleven pound' and a qnorter. 11* 180 Boyer's Surgery. structure was that of a fine bony net-work, which appeared to be entirely wanting in certain parts, and of which the meshes were filled by a substance partly red and of a fleshy appearance; partly white, or greyish, and of a lardaceous ap- pearance. It enclosed several spaces, some filled with bloody matter, others with a yellowish fetid ichor. The sacro-ilac surface of the sacrum of the diseased side was carious. ® CHAPTER XXII. Of the Softening and qf Ihe Fragility of the Bones. IT seems natural to consider these as two distinct affections. A few facts seem to favour this opinion, and the doctrines to which chemistry has given birth appear to support it. But the chemists have not vet satisfactorily ascertained the dif- ferent proportions of the solidifying matter in diseased bones; a great number of facts prove that the bones of the same per- son, or even different parts of the same bone may be both sof- tened and rendered friable at the same time; and. lastly, the bones of patients, whose bones have been observed to be fra- gile during life, have not been proved to contain an unusual proportion of earthy matter. Indeed, there is reason to think that the highest degree of the cancerous diathesis mav ren- der rhe bones friable. Perhaps the same is true of syphilis. The»e fact^ make us lament the want of anatomical and of chemical examinations of bones thus diseased. The want of such examinations is fell the more sensibly since many un- suspected fractures, evidently of long standing, have beeu discovered after death, in persons whose bones were believed to be softened; and, in similar cases, the bones of subjects, in dissecting rooms, have been broken by a force which would not have had this effect in any other circumstances. >Ve can only point out this chasm in science, and invite the attention of practitioners to this subject. It roaj be inferred from what we have said, that there is hardly a case of simple softening of the bones: almost iu every instance tliey have been found, at the same time, de- prived of their solidity and of their elasticity, or. in other words, of the attraction of cohesion of their particles. We shall, therefore, now consider the bones as affected with this double and bingula; disease. Of the Softening and Fragility of the Bones. ±8i The term rachitis, or rakitis, has been applied to that affec- tion of the bony system in which the organs of which it i9 composed are deprived of their ordinary solidity, and in which the spine, and the long bones of tbe limbs, suffer vari- ous deformities, with or without fractures, produced by very slight causes. This disease generally occurs from the age of six months to four years. Children have been born with it. Young per- sons, and even adults and old persons have been known to be affected with it. But these last named cases are very ra re. Persons of a lymphatic and nervous temperament, of a weak constitution, and those who receive from their parents, or acquire a scrofulous diathe>is, are most disposed to rickets; yet some children, apparently of strong constitutions, and born of healthy parents, become affected with this disease. The exciting causes of rickets are a previous illness of long duration, intermittent fevers, living in a moist or low situation, an uuwhu!esome nourishment, an improper phy- sical education, too long suckling, the repercussion, a dis- ease termed crusta lactea, of tinea, herpes, &c. the presence of worms, a painful dentition, especially if uoeompanied with convulsion-, &c. We cannot consider scrofula as the cause of rickets in everv instance, for Ibis reason, that if this were admitted we should also have to allow that this disease of the bones constitutes the highest grade of scrofula, which has never been proved. Rickets has been thought a syphilitic disease ; but vte rarely find it following that malady; neither is it proved that rickets is a gouty or rheumatic affection, al- though the softening of the bones is generally preceded by deep-seated, acute, and obstinate pain, like those which oc- cur in these diseases. A disease which always presents the same phenomena can- not arise from different causes. This would be a deviation from the ordinary laws of nature. It appears probable that rickets arises from an unknown specific cause, which acts upon the whole system, of which tbe softening of the bones is only one symptom; and that the scrofulous, syphilitic, or any other disposition with which it may be combined, can fa- vour the devclopement of rickets, only by the debility it induces ; but that neither of these diseases is the essential '•aose of that disease. It is hardly necessary to refute ihe opinion of the chemists, that rickcS arises from the spontaneous formation of oxalic acH. It is entirely hypo- - helical. 182 Boyer's Surgery. When a child is affected with rickets it becomes sad and grave; it ceases to love its usual play ; exercise is painful; it wishes to be always lying down, sitting, or carried by its nurse. At this time the ends of the long bones become swollen, and the enlargement of the joints is the more strik- ing, on account of the thinness of the limbs. This first degree of the disease is characterized, in adult subjects, by pains, more or less acute, wandering or fixed, and of an equivocal kind. Exercise is at first painful, after- wards impossible. When the swelling of the joints has become apparent in children, an increase of the size of the head is also per- ceived. At the same time their imagination and judgment acquire ah astonishing power and maturity, and the expres- sion of the face is indicative of genius.* But. when the dis- ease takes place at a more advanced age, the sutures of the cranium are obliterated, the head cannot increase in size, and the patient becomes stupid. As the disease advances, and sometimes even from the commencement, the liver becomes more voluminous, and the abdomen is tumefied ;f the face is covered with wrinkles, and the cheeks, hanging in a fold, form a sort of tumour near the angles of the lower jaw ; dentition takes plaee slowly ; the teeth, when they first appear through the gums, are black and diseased, and soon become carious. Commonly tbe first state of tbe disease is accompanied with an irregular chronic fever; the sleep is disturbed, and the appetite deranged ; the stools are scanty and discoloured, and a copious flow of urine occurs, sometimes limpid, at other times thick, and containing a whitish sediment. Pains in the region of the spine soon announce that a de- formity is taking place in this part. The spine bends in va- rious directions, but always in curved lines, and never at an angle; tbe ribs of the breast become flattened and depressed, and the sternum projects forward like the breast of a fowl, or the prow of a vessel. The long bones soon become bent in the direction of their natural curves. At this advanced period of the disease convulsions, epi- lepsy, vomiting, strangury, transient blindness, and deaf- ness, and other nervous symptoms, are often observed. Buch- * Glisson (de Itachitide) expresses himself in these terms :—" Vultum videre est. Kiagiscompo'it'itn et severum, qukm wtas po-tuiartt. ut si in rem seriam ali-juam ineditabundi client" •j- tl/tscn has perfectly depicted this symptom :—,: Ai.domeu extiriiis quid cm, respect u neiupe nartiuiueonlinentinm, nine rum est; interiusvero. respeciu partium, ■ <>ntentaram, nejiihilpromhi'.-i:? ••:■ t«in:'"sus>.!:;in r".:\tv.-." Of the Softening and Fragility of the Bones. 18J Her remarks, that of eleven brothers, the greater part of whom died rickety, those who were exempt from this ma- lady, suffered serious convulsive diseases, and died in early childhood. The highest grade of rickets sometimes is cured sponta- neously by the progress of age, or some oiher natural cause. In this case the pains cease, the fever di*np;>ears, the belly subsides, and resumes its natural size and consistency; the appetite returns, and the digestive functions are restored; the bones recover their solidity in a deformed state; the strength is re-established; and the muscles, although rendered ex- tremely thin, acquire energy enough to execute the move- ments necessary for standing and walking, but with more or less difficulty. The head retains its preternatural size; and it is observed, that the patients who have this disease in their childhood, retain, throughout life, the vivacity which cha- racterizes the first stage of rickets. But when the disease is about to terminate fatally, the pains continue; the deformity of the chest causes more or less difficulty of breathing; the j.aiient is attacked with he- mopthisis, once or ofiener, and even phthisis pulmonaris, which has been unjustly attributed to the mechanical ob- struction to respiration. The muscles diminish in size, and they remain in a state of permanent contraction, which keeps the limbs constantly flexed, or in singular and odd po- sitions. The nails grow longer, become soft, bent, and al- tered in their structure. The patient is in a manner fastened to his bed, by reason of tbe severe pains whicli the slightest motion occasions. Most commonly in moving him one or more bones are broken ;* at length slow fever, diarrhoea, and marasmus put an end to the patient's existence; sometimes* however, he dies in convulsions before these symptoms occur. When we find, upon dissection, that the brain is enlarged, but not otherwise changed, occasionally there is a collection of serum in the ventricles-! The lungs are often found filled with tubercles, even when there is no symptom of phthisis pulmonaris. The glands of the mesentery arc swollen, tuberculous, sometimes even containing collections of steatomatous matter; but when the disease has passed through its periods slowly, these organs are found in their * It is certain, and yet very remarkable, that these solutions of conti- ■uity are capable of re-vinion, notwithstanding the great change in them which is caused by the disease. ■j- It is probable that this symptom of rickets has often been mistaken for ideopathic hydrocephalus; for when the symptom appears early, the pati , ?nt dies before any of the other phenomena of rickets are apparent 18i Boyer's Surgery. natural state. The liver is voluminous, the intestines and bladder distended and relaxed; the muscles are thin, pale. and yellowish; the bones are light, and of a red and brown colour; a large number of dilated blood vessel* pass into them; they are porous, spongy, soft, and com- pressible; they are moistened with a sort of sanies, which may be pressed out as from tanned leather after it has been macerated. The sides of the medullary cy linders of the long bones are very thin, while the bones of the cranium are thicker than natural, and more spongy. All the bones arc remarkable supple, but when bent beyond a certain de- gree they break, especially if bent suddenly. The medul- lary cavity of the long bones contains a reddish serum, very different from that of marrow.* Few chemical experiments have been made on rickety bones. All we have learnt from them is, that they contain a smaller portion of alkaline, or earthy salts ; but Ibis change is much less than has been believed, and the parenchyma is altered so much that it is completely dissolved by a mineral acid. It cannot be doubted that in the living parenchyma of the bones tbe principal seat of rickets exists. Those who have merely considered this disease as arising from a want of earthy salts, have regarded only its last symptom. How idle, therefore, is it to administer the phosphate of lime to rickety patients! All we know ' the etiology of rickets is, that, when the bones are once -jfi'cned, the weight of the body, the action of the muscles, and probably oilier un- known causes, produce the multiplied curvatures of the bones: for we cannot attribute to any known causes the cur- vatures of the spine, which take place in patients who are kept in a horizontal position from the commencement of the disease. The earlier rickets appears, tbe more serious it is. Acute diseases, especially eruptive fevers, when they affect rickety children, suspend the progress of the disease. An acute fe- ver, at first apparently symptomatic, but which afterwards assumes a regular and acute form, and even an eruption without fever, have been known to cure the disease. The crisis of puberty has not so much influence over rickets as scrofula, though it has, in some instances, produced an happy effect. Rickets frequently suspends its progress dur- * Many of the organic affections we have enumerated as following rickets, are evidently foreign to this disease. The number of them is, perhaps, more considerable than it appears. The study of morbid anatomy, a science almost new, and which we cannot too strongly recommend, can alone "Uicidate this subject. Of the Srftenitig and Fragility qf the Bones. 1SS ing spring and summer, and acquires fresh vigour in au- tumn and winter. Sometimes the disease remains stationary for a number of years, without any known cause. The com- plication of scrofula, syphilis, or scurvy, is always very dangerous. Convulsions, permanent spasms of the muscles, fractures, hectic fever, marasmus. &c. are, for the most part, fatal symptoms. When rickets attacks adults or aged persons, it is generally mortal. We do not believe that the muscles are ever capable of restoring to rickety bones their natural form, as certain writers have advanced. If we examine the treatment that has been proposed for rickets, we find it consists in the employment of various means for tbe cure of those diseases with which this may be combined. Preparations of mercury, antimony, iron, al- kalies, sulphur, &.c. have equally succeeded in cases to which they were suited; but we believe there is no exclusive or specific treatment of rickets. Tonics are generally ser- viceable; but we think that many cases of rickets have spontaneously come to a happy termination during the use of inefficient remedies. It is proper to advise a change of air, a transition (« high, warm, and dry situations; the use of nourishing ani- mal food, and of generous wine ; dry frictions, with aroma- tic substances over the whole body; tonics of every kind, among which we may enumerate the mercurial salts, the sul- phnrets, the oxydes or antimonial salts, sulphur, and sulphur- ous water -. the various preparations of bark may often be employed with advantage. These remedies must be administered with prudence and discrimination. There are three states of the disease. The first is characterized by great irritability, severe pain, want of sleep, and acute fever. 1 his state may return at various periods of the disease, and sometimes leads to an happy termination. Sedatives are here proper, and any stimulat- ing remedy is dangerous, at least until the calm takes place, which always succeeds this agitation of the system. This calm constitutes the second state of the disease: during which it appears to suspend its progress. It is in these intervals of pain and suffering that the efforts of na- ture towards a cure take place,* and this is the time to ad- minister our remedies. The third state of the disease is that of marasmus and * The distinction of these first two states of the disease is due to Pujol. a modest and enlightened physician, whose writings are worthy of !>e;n; studied. VOL. W. vi 186 Bayer's Surgery. diarrhoea. Active remedies can then be of no service, and they are generally improper on account of great debility and extreme excitability of the system. It is necessary to combine almost all exciting remedies with opium, and to use them in very small doses. As to the use of corsets, crosses, and other machinery, enlightened practitioners of the present day have renounced them ; and it is generally agreed that it is proper to leave to nature alone, aided by internal treatment, the task of straightening bones deformed by rickets. © CHAPTER XXIII. Of Sprains. A Sprain is the result of a violent movement, in which the joint has been wrenched, without the bones that com- pose it having suffered any sensible movement. The move- ments of the joints cannot be carried beyond their natural limits without straining or breaking the ligaments which unite the bones. Thus a sprain is always accompanied by the first of these circumstances, which is proper to it, and sometimes by the second. The term diastasis is applied to tbe lateral separation of two long bones, joined with each other by the sides, corre- sponding to their extremities, and particularly to injuries of this nature, which affect the fixed joints; such as those of the tibia with the fibula, and those of tbe bones of the pelvis with each other. But all these circumstances equally take place in sprains. The spherical joints, those that permit the most varied and extensive movements of the btines, are disposed in such a manner that their ligaments, protected by a great number of strong museles, cannot suffer any considerable extension but by great violence; and the displacement which necessa- rily follows must be permanent, by reason of the round form of one of the surfaces of the joints; a form that ean- not permit a spontaneous re-insertion. In the ginglymoid joints, on the contrary, and in those that resemble them in the small extent of their movements, the natural union of the bones is secured by the dispositions of the joints, and by the strength of the ligaments, but very of produce unnatural situations and relations of parts, which become permanent: but, if the force be suffici- ent to push the surfaces of the joints lieyond their respective bounds, the displacement becomes considerable, and their •ontact entirelv ceases. In the artluodial joints, also, tlie displacement is almost alway- incomplete. It will be seen that, according to this acceptation, the terms complete or in- complete do iiot apply to dislocations of the lower jaw, as existing on om side only, or on both. 4th. In recent luxations, although the soft parts have sut- fcred disorder from the displacement of the bone, yet the irritation that results has not existed long enough to produce inflammation of Ihe ligaments and of the cellular tissue, and spasmodic contractions of the muscles. In a lew days an infiammalorv tension affects the joint, and all efforts to lenlace the bone are useless, and only aggravate the accident. Bv degrees tbe parts become accustomed to the unnatural state in which thev have been plaecd. the inflammation ter- minates, and the'irritation disappears; but, at the same time, other changes take place, which render the reduction more and more difficult. Of these we shall treat particularly 111* 1*1* 3.lLCl*« 5th. Luxations without any disorder in the soft parts about the affected joint, more than inevitably follows such accidents, are termed simple. When the concomitant inpry ig sufficient to furnish eertain indications, it constitutes a complicated luxation. 196 Bayer's Surgery. Luxations may become complicated in consequence of contusion, inflammation, spasmodic contraction of the mus- cles, the tearing of these organs and the skin, compression or rupture of the vessels or the principal nerves of the mem- ber, or of fracture. In abandoning its natural situation, a bone necessarily tears, distends, and bruises the ligaments and other soft parts around the joint: hence eechymosis, collections of blood, &c. All these injuries are referable to contusion. When the violence which causes a luxation acts on the joint itself, the contusion is always great. Inflammation never immediately follows a luxation ; it is always a consequence of the contusion, eechymosis, and ef- fusion of blood, and appears some days after the accident. There is even in the first moments, particularly if the cause of the luxation have been violent, torpor in the joint and the neighbouring parts, that renders it much less sensi- ble than natural: hence, the consequences are less serious than they would otherwise be. But the greater the torpor is the more the inflammation that follows it is to be feared. When it has taken place, and the parts around the joint are swollen, hard, and painful to the touch, any force tend- ing to re-establish tbe natural relations of the articular sur- faces, will be useless, and even dangerous, by adding to the irritation already existing. In persons whose muscles have aequired a great power, and in those who are timid and fearful of suffering, when the inflammation has taken place, all the museular system, and particularly those muscles that surround the luxated joint, mav be in so violent a state of contraction as to baffle all endeavours to replace the bone. In cases of this nature, the contraclien of the muscles would be increased by at- tempts to lengthen them. When the inflammation is high, such attempts are not only unsuccessful, but very dangerous, as ihcj cause a rupture of the extended muscles, terrible in- flammation, mortification, (and particularly if in a great joint of the knee.) convulsions, tetanus, and even death. But the spasmodic contractions of muscles, whieh originate in fear altogether, are less to be dreaded, and do not oppose any great difficulty to the reduction. Very frequently ihe violence that occasions a luxation, ruptures, at the same lime, some of the muscles which surround the joint. It is very probable that all the injuries of this nature are not known in certain luxations ; there are cases wherein a certain number of these organs must necessa- sarily he broken. This circumstance does not add much to Of Luxations in general. 197 the severity of these accidents. It is probable, that in these instances, re-union takes place by a mechanism similar to the immediate adhesion of simple wounds; at least we are led to believe this, on considering the rapidity with which accidents of this kind disappear, and the quick return of the freedom of motion to the limb. But the case is very differ- ent when the luxated bone has torn, at Ihe sume time, the muscles, the cellular tissue, and the skin, and exposed the joint to the contact of air. This case, which is classed among contused wounds of the joint, is one of the most dangerous known; tbe principal danger depends upon tbe opening of the joint. Injuries, otherwise equally great, but not accompanied by this circumstance, are seldom at- tended with serious consequences in the first instance. W7e have seen a case in which the astragalus was almost completely turned round upon its own axis. It produced only very'slight symptoms in the first instance; but after- wards the articular pully of this bone having caused a mor- tification of the teguments which it distended, amputation of the leg was inevitable. It seldom happens that the vessels and the principal nerves of the member are pressed, extended, or broken by a luxated bone. These organs enjoy so great an ease of move- ment from the cellular tissue that surrounds them, that they are pressed to one side, and avoid injury. However, some of them are so disposed as with difficulty to escape injury; the circumflex nerve, for example, that surrounds tbe neck of tbe humerus, is sometimes so disorganized by a luxation of the head of that bone, that the deltoid muscle is para- ljzed, and the power of raising the arm is for ever lost. A luxation of the lower part of the humerus backwards will sometimes break the brachial artery, and cause a mortifica- tion in the arm and hand. In speaking of fractures, we have already observed, that they may accompany luxations; and we have explained the mechanism of this 'complication. When this complication takes place in a ginglymoid joint, each of these accidents may be treated at the same time, because the displacement is almost always incomplete; and even in this case, the destruc- tion of the ligaments is so extensive, that moderate eftbrts arc sufficient to reduce the luxation. But, in luxations of a spherical joint, a complication of fracture in the same bone is the more distressing, as to the last of these disorders alone attention can be paid in the first instance, and, by the linie. this is cured, the other will have become irremediable. 19b Boyer's Surgery. ARTICLE II. Of the Cannes of Luxations. Among the predisposing causes of luxation- may be classed certain natural dispositions'of the joints, morbid af- fections, and particular attitudes of the limbs. It was thought that the indentations in the sockets of <>ome of the joints, such, for instance, as the thigh, facilitated luxations : but these appearances are only perceptible in skeletons; in the fresh State the notches in the sides of the joints are filled up by substances of a particular nature, designed to augment the depth of the cavity, and give to it a certain degree of elasti- city, to allow a greater extent of motion, and render the union more exact. Thus, the notches on tbe edges of the cavities of the spherical joints, so far from favouring luxa- tions, prevent them, or, at least, render them more difficult. If the ligaments were the only means by which the bones were kept together, their strength or weakness would decide ihe frequency and direction of luxations; but the muscles that surround the joints are the most powerful bonds of union, although strength or weakness of the ligaments ought to be considered as influencing, in some degree, the frequency of luxations: hence, lateral luxations of the gin- glymoid joints, where the ligaments are the strongest, very often occur. Luxation of the humerus, downwards, is the most common; in the lower part alone the joint is deprived of supporting muscles. In this joint it is remarkable with what facility the capsular ligament is distended, when the muscles are paralyzed ; even when the deltoid alone has lost its action, the weight of the snperior extremity produces a lengthening of the ligaments and the other muscles, so that the surfaces of the joints separate, and an interval between them is plainly observed. Among the organic alterations, of which the joints are susceptible, some produce swellings in the cartilaginous layers that cover their surfaces and svnovial glands, and thus gradually fill up the cavities; others de stray the liga- ments ; in which cases trifling causes produce dislocation. These dislocations are symptomatic, but the term consecu- tive, which has been applied to them, is erroneous ; it more properly designates the ulterior displacement of bones al- ready luxated. In order more readily to conceive how certain attitudes of the, limb facilitate luxations, it is necessary to enter into Of lAixations in general. 199 some detail relative to the manner in which they are effected, and to give an exact idea of the natural union of the surfor ees of the joints. Whatever be the direction of the surface of a joint in relation to tbe axis of a bone of which it forms a pact, in order to its permanent union with the opposite surface, it is necessary that the imaginary line passing through the cen- tre of the first, which we call its axis, fall perpendicularly on the plane of the second. As long as these dispositions exist a displacement cannot take place; it can only happen when the line in question inclines with respect to the plane on which it falls, and forms an angle with it. In all the varied foi ins which nature has given to articular surfaces, the application of this general law is observed, and the disposi- tion of the parts is such that this relation remains nearly the same in almost all attitudes. Thus, in a spherical joint, where a head revolves in a round cavity; in the gingly- moid joints where the surfaces may be geometrically re- duced to a cvUnder, which revolves, in an analogous ca- vitv, the relations of the surfaces remain nearly as we have described them, while the bones do not execute any extensive movement. But, in articulations by arthrodya, where the surfaces, almost smooth, slide upon one another, the motions, circumscribed by the natural disposition of the parts, always take place in such a way that the axis of one surface of the joint rests absolutely perpendicular to the plane of the other, and the greatest violence is supported in # this direction. Now. the distribution of the museles and ligaments around the joints, and the length of both, tend to oppose all movements that could establish any other relation between the articular surfaces, and consequently produce luxation. It can, then, only be in movements of a cer- tain extent that the axis of one surface can incline on the plane of the opposite surface, and the natural relation is so well maintained by the resistance of the surrounding parts, that the angle of which we are speaking must be very acute to permit luxation easily to take place; the mus- cles can hardly ever produce a similar movement; but when surfaces of the joints are so placed that the axis of one falls obliquely on the other, they are in the most favourable posi tion for the production of*luxation by an external violence. It may then be said, that all extensive movements or at- titudes, however incapable in themselves of producing luxa tion, may efficaciously aid, and become the predisposing causes of it. Thus, an elevated posilio » of the arm is in- capably of producing a luxation of the humerus; but it. 200 Bayer's Surgery. when in that position, a fall on the elbow throw upon it the whole weight of the body, luxation takes place, and that attitude of the arm is carried much farther. The efficient cause of all luxations is violence. In the ginglymoid and arthrodial joints, the cffecls of a fall, and the violence given to the movements of a limb, may produce partial, and even complete luxations. But, in the sphe- rical joints, surrounded by numerous and strong muscles, those organs constantly unite with external violence in pro- ducing luxations. This co-operation of the muscular ac- tion is particularly remarkable in the joint of the humerus with the scapula. It would seem that the humerus would easily be luxated, because the cavity of the scapula is so su- perficial ; but, in fact, this disposition preserves the arm from luxation more than if the glenoid cavity were deeper ; its edge does not offer fulcrum lo push the humerus from its place, as is the case with the femur, Ihe neck of which leans on the edge of the cotyloid cavity, when the thigh is vio- lently carried upwards. The most extended and rapid move- ments may be given to the arm without exposing it to luxa- tion. In speaking of particular luxations, we shall carefully explain the mechanism of each, and «how the operations both of muscular action and external violence. ARTICLE III. Of the Effects of Luxations. A luxation never takes place without rupture of the liga- ments which confine the bone. In the spherical joints, one of the bones cannot abandon jts cavity without tearing the capsular ligament, and the ligaments within the joint, where there are any. It has been thought, that, in these luxations, the opening through the capsule might be so narrow as scarcely to give passage to the extremity of the bone; but it has always been found that this opening has been more than sufficient to re-admit the extremity of the bone; and some- times, instead of a simple opening, the capsular ligament has been seen completely torn the whole length of its con- nexion. In the ginglymoid and arthrodial joints, the smallest dis- placement cannot take place without rupture of their liga- ments ; some joints cannot suffer luxation without a simulta- Of Luxations in general. 201 neous or previous fracture of a portion. Thus, luxation of the forearm, forwards, cannot lake place without a frac- ture of ihe olecranon : a fracture of the fibula or of the mal- leolus intcrnus singularly favours the occurrence of lateral luxation of the foot. A certain portion of the ligaments always remains un- broken, and its resistance produces a certain attitude of the linb, which serves as a characteristic sign. Thus, the ro- tation of the leg outwards always accompanies the luxation of the thigh inwards, and vice versa: circumstances which ean only be attributed to that portion of the capsular liga- ment that has not been broken, and which inclines the great trochanter forwards or backwards. The muscle are often lacerated or bruised In certain lux- ations of the arm, for instance, the sub-scapularis muscle is exposed to extreme tension and laceration, &c. In luxations, great changes must necessarily take place in the relative positions of the bones and muscles. In those of the spherical joints nothing hinders an inclination of the bones; and it is effected by the tightened muscles, which es- tablish an equilibrium; vet the limb is unnaturally fixed, voluntary motion is entirely lost, and communicated motion occasions severe pain. But. in the ginglymoid joints, per- manent inclination of the limb towards the surface from which the bone is removed, cannot take place unless the bone be luxated in the direction of its movements. Thus, in the luxation of the lower arm backwards, ibis member is moderately flexed, and fixed in this position; because, the flexor and extensor muscles are equally tense: but, in la- teral luxations of the same joint, if ihe displacement be in- complete, tbe contact of the surfaces is still large enough to keep the limb straight, notwithstanding the extreme ten- sion of some of the surrounding muscles. Finally, when lateral luxation of a ginglymoid joint is complete, the bone tears all the adjacent soft parts, and the ligaments of one side of the joint, and some of the muscles; here the limb enjoys a facility of movement proportioned to the extent of the injury. In the spherical joints, where the dislocation is always complete, nothing can limit the extent of the dislocation, ex- cept an unbroken portion of the capsule, the adjacent mus- cles, or projecting bones, which always render the limb lon- ger or shorter than it naturally is; now, these organs, be- ing more or less ctxended, bruised, or rubbed, must expe* rience a considerable change: the soft parts become in- flamed and thickened; and acquire a sufficient consistency to 2W Beyer's Surgery. resist the greatest efforts. Muscles thus displaced, torn by a disjointed bone, of which they covered the extremities like a cap, from the permanent pressure and irritation, have been known to lose gradually their red colour, and all other attribirfes of muscular texture, their fibres become white and indistinct, so as to make them appear like li- gaments ; the cellular tissue between tbe muscles thus in- jured inflames, becomes dense, and contracts firm adhesions to the adjacent parts. The articular surfaee becomes inflamed, and the adhesive process equally unites the dislocated bone to the adjacent •oft parts. The medium of this union, generally very ex- tensive, rapidly acquires great consistency, at the same lime preserving its flexibility, and permitting all movements that are not prevented by adjacent bones, but opposing, with astonishing force, the return of the luxated bone to its natu- ral situation. Some authors have asserted, that the opening of the cap- sule of a dislocated spherical joint never heals, but that it suffers the synovia to escape, and lubricate the head of the displaced bone in its new situation. These circumstances occur only in the first moments of an unreduced luxation. Wben inflammation and its effects take place, the parts are confounded, and, if an attempt were made to separate them, they would be found in the state in which we have described them. The weight of the body, and the pressure of the luxated bone on the one that affords it a resting place occasions, af- ter some time, an excavation, more or less deep, surrounded by irregular and incomplete borders; the extremity of the dislocated bone is irregular, rough, and flattened, and pre- sents hardly any of the characters of an articular sur- face. We see only the union of two continuous surfaces, bound together like unconsolidated fragments of fractures, having made an impression on each other, and being capa- ble of some extent of motion. The entire thickness of the bone which serves for a rest- ing place of the disjointed one, is pushed in and displaced, as if it had been softened, so as to yield with great facility to compression. This phenomenon is remarkable in luxa- tions of the femur downwards and inwards, where the bead of the bone, being lodged in the foramen ovale, presses up the horizontal branch of the pubis, that forms a part of the cotyloid cavity, which is considerably diminished, its in- ferior side being pushed towards the centre. The impression of the luxated bone upon that which sup- Of Luxations in general. 3ft* ports it is remarkable, in whatever direction it rests upon it Thus, in luxation of the femur upwards and outwards, where the head of the bone lies very obliquely on the inferior and external face of the ilium, and where all the weight of the body, in standing or walking, tends to slide the head of the femur upwards, the impression still exists; and though there is no distinct excavation, like that of the acetabulum, there is, at least, a series of prominences and irregular ex- crescences around the part upon which the head of the fe- mur has pressed; sometimes even this point of the ilium is depressed, so as to form a projection on the corresponding internal side of the pelvis. Would the natural consequences of a luxation produce a softening of bones pressed together? Hie cavity of the joint undergoes changes similar to those of the jaw-bone when the teeth are removed; it flattens, the edges approximate, the bottom rises, and the cavity soon becomes incapable of admitting the bone which it formerly contained. Immediately after a dislocation, tho limb remains fixed in the position in which it is thrown f by degrees the pain and inflammation cease, the relaxed or tightened muscles become accustomed to their new state, and tbe power of motion is gradually restored. The limb sometimes recovers the power of making as extensive move* ments as in its natural state; at other times they are very limited or lost. This particularly happens in the gingly- moid joints, luxated in the direction of their movements. Thus, in luxations of the elbow, the corouoid proeess of the ulna lodged in the posterior cavity of the humerus pre- vents extension; and, on the other hand, the triceps brachi- alis muscle cannot suffer a sufficient lengthening to permit the olecranon to revolve, so as to flex the lower arm. Although, after some unreduced luxations, many, if not all the movements, may be re-established, the organs of nu- trition always become less active, as is evinced by the lean- ness of the muscles and the sensible diminution of the limb. This alteration is greatest in early youth. This remark did not escape Hippocrates. 20i Bayer's Surgery. ARTICLE IV. Of the Signs of Luxations. Luxations always cause pain and incapability of the limb for motion of every kind; there are, however, equivocal signs, which do not distinguish it from fracture, or even contusion. The signs of luxation are commemorative and present. We have shown that there must be a particular attitude of the limb to favour the action of external violence in order to cause a luxation ; in fact, it is almost impossible that luxa- tion should take place by violence applied directly to the joint; the action of the dislocating cause is the more effica- cious the farther it is exerted from the joint, and upon a longer arm of a lever. Luxation is probable when exter- nal violence acts on or near tbe extremity of a limb, placed likewise in a position that will push the extremity of this bone against the ligaments of its joint : thus, in a fall on the side, when the arm, far removed from the body, has to support all the weight on a part of its internal side, it is pro- bable luxation will take place, and even that the bone of the arm will escape by the inferior part of the capsular liga- ment. These commemorative circumstances may throw light as well on the nature of violence to which the bones are exposed as the direction of its action, and lead to presump- tion of luxation. 1st. Complete luxations cause a change in the length of the limb. In the ginglymoid joints this change can only be a shortening in proportion to the extent of the displacement; but, in a spherical joint, lire bone may be carried over or under the articular cavity; causing, in the first instance, a shortening; and, in the second, a lengthening of the limb; but, at the same time, as the direction of the limb is changed, it cannot always be placed parallel to its fellow: hence, it may be difficult to judge whether it is lengthened or shortened. The length of the limb must then be deter- mined by the eve or measurement. A disjointed bone can only be restored lo its natural length by replacing it in its proper cavity, which ordinarily requires considerable exer- tion ; but it is almost always easy to obtain the same result in cases where the shortening of a bone depends on a frac- ture. When once the natural length is re-established in luxations, ii remains; but. in fractures, the shortness re- turns after it has been removed. Finally, in no case of frac- Of I/uxations in general. 105 ture can there be lengthening of the limb, as is sometimes observed in luxations. 2d. In almost all complete luxations the axis of the limb is changed in its direction. This phenomenon arises from the resistance of a portion of the ligaments of the joint that has not been broken, and a spontaneous equilibrium of tbe muscles, the contraction of which inclines the limb to one side or the other. The tension of certain muscles, the pre- servation of a part of the ligaments, particularly in the spherical joints, give a rotary movement to the limb at tbe time of luxation. Thus, in luxations of the thigh, the point of the foot is turned inward or outward, according as the head of the femur goes lo the internal or external side of the joint. These two changes in the direction of the muscles are permanent when they depend on a luxation; whereas, in fractures, the same changes can be immediately removed without effort. 3d. The absolute immobility of a limb, its extraordinary mobility, and the loss of certain movements, are character- istic signs of luxation. In complete luxations of the gingly- moid joints, as of the forearm, for instance, the dislocated limb is absolutely or nearly without motion. In spherical joints, the painful tension of the muscles that surround the luxated bone permit scarcely any spontaneous movement; but generally a motion analagous to that which caused the displacement, can be imparted to it by the surgeon, but it causes pain. In a luxation of the humerus downwards, the elbow is, with difficulty, brought to the trunk, or carried forward or backward, but it is easily raised. Finally, in la- teral or complete luxations of the joints having alternate movements, the patient cannot execute any movements of the parts, but the member obeys every foreign impulse. ith. In luxations with the lengthening of the displaced limb, the general and uniform tension of the museles that run along it, makes them appear to be more closely applied to the circumference of the bone ; but the muscles that an- swer to the plane from which this disjointed bone is removed are extended and projecting, and either because they support the whole weight of the limb, or because they form, with the displaced bone, the two sides of an angle. This may be easily perceived in the deltoid muscles, in a luxation of the humerus downwards. On the contrary, in luxations where the limb is shortened, tbe muscles that run along its length are relaxed; but their elasticity, and the contraction pro- duced by irritation, accommodate them to the shortness of the member: hence the extraordinary swelling of their fleshy 206 Bayer's Surgery. parts, and the parts to which they correspond; a striking example of which is seen in a luxation of the thigh up- wards and outwards, where the muscles on the inside of the limb form a distinct and oblong tumour. The parts connected with a luxated bone undergo similar changes. Thus, in a luxation of the thigh, the correspond- ing buttock is flattened if the bone be carried inwards; but, if it be carried outwards, it is rounder, and the inferior part is either higher or lower than in its natural state, according as the luxation has been above or below. 5th. The circumference of the joint itself presents an al- teration in its form worthy of remark. To appreciate this symptom, anatomical knowledge is peculiarly necessary. When the end of a bone escapes from a cavity, instead of that round edge which before indicated the natural union of the parts, we now distinguish the head of the luxated bone in some part near the joint, and a flatness formed on the joint itself, by one of the neighbouring muscles stretched before the socket; we further perceive the round edge and the de- pression of Hie same cavity; the bony eminences situated near the joint, the round edges of which were insensibly lost in the general form of the limb, become more apparent. These remarks are peculiarly applicable to luxations of the humerus, and. in general, are very easily verified in luxations of all the spherical joints, even where swelling has taken place. Tbe form of our limbs, and the natural relations of the bones, are so evidently destroyed in luxations of the joints, that, when there is not inflammatory swelling, the first glance of the eye discovers the nature of the accident. The natural relations of remarkable processes near the joints being known, the smallest change of situation will immedi- ately strike an attentive observer; but it is not so perceptible when the soft parts are swelled and stretched. In this case, the processes are so deep as to prevent their being distinctly felt. Nevertheless, a person of some experience may form, at least, a probable conjecture respecting the nature of a lux- ation, and, when the swelling is abated, a new examination will clear up every doubt. It is of the utmost importance to seize tbe favourable moment, as soon as it arrives, to know the nature of the accident, as the distorted position in which the soft parts are held occasions the swelling to continue a longtime, and, if you wait to be assured of the existence of luxation until this has entirely subsided, it is then too late to attempt to reduce it, and the patient is for ever deprived of the free use of the limb. Of Luxations in general. 207 ARTICLE V. Of the Prognosis of Luxations. In general, every luxation that is not reduced deprives the patient, more or less, of the use of the member. Some useful movements in the limb are indeed restored, but they are always imperfect, and, in the most fortunate cases, the lengthening or shortening of the limb is not removed, nor its unnatural direction corrected. In complete luxation of the ginglymoid articulations the deformity always remains the same; the limb continues often nearly immoveable. There are, however, some exceptions to this general rule. The arthrodial joints rarely experience extensive luxations; as their movements are naturally very limited, their loss is no great consequence; thus, the scapular end of the clavicle may be dislocated, and not reduced, or but imperfectly, without injuring the motion of the arm. Luxation of the orbicular joints, as they take place more easily, so ihey are more readily reduced. * Complete dislocations of the gingly- moid joints, on the contrary, although less frequent, are more serious, as they are always attended with injury of the ligaments and soft parts : hence, we frequently see exam- ples of luxations in tliese joints complicated with wounds and projection of one of the articular surfaces. Never- theless, in complete luxations, particularly where the dis- placement is trifling, these accidents aie very simple, and are cured with great facility. The more recent a luxation, the more easily it is reduced. Simple luxations are much less serious than those accompanied by contusions, spasmo- dic contractions of the muscles, injury of some nerve or vessel, inflammatory swelling, fracture, or wound, and par- ticularly the projection of one of the surfaces of the joint through the soft parts. 'I his last case is one of the most se- rious known. Access of air into the joint, and the conse- quent inflammation of the synovial membrane, rapidly com- municates to all the muscular system, and particularly to all the muscles of the limb, an astonishing irritation, which renders extremely dangerous any attempts at reduction. 203 Boyer's Surgery. ARTICLE VL Of the Treatment of Luxations. To reduce a luxation, to keep it reduced, to foresee the consequent symptoms, and to combat them when they take place—such are the general indications which luxations pre- sent. We have before observed, that the more recent a luxation the easier the reduction ; therefore, when a luxation is not accompanied by any accident which absolutely forbids the reduclion, it cannot be effected too soon. Although the limb be not shortened, the irritation of the muscles increases every moment a bone is left unreduced; and the resistance which the muscles oppose to reduction, is proportioned to the irritation they have suffered. The extension and counter-extension ought to act on all the contracted muscles, and pull their extremities in oppo- site directions. In employing extending and counter-extending forces, no pressure should be made on the muscles that pass over the joint, the lengthening of which is necessary to Ihe reduclion of the luxation ; want of attention to this will cause an addi- tional contraction, and consequently oppose the reduction. But some muscles, after having covered a joint, extend the whole length of one of its bones, and are inserted in the fol- lowing bone. Such a disposition would lead to the inconveni- ence of which we have been speaking, if the force were ap- plied to the luxated bone itself, or to those which immedi- ately follow it: experience has fully proved, that the far- ther the force is applied from the luxation, the more cer- tain is its success; and it never answers better than when made to act at the extremity of the affected member. It is, therefore, of the utmost importance to exercise the extend- ing force as far as possible from tbe luxation. This princi- ple is the fruit of the experience of several centuries; for the idea of exercising extension and counter-extension to the bone they were intended to replace, was too natural not to have presented itself in tbe first instance; all an- tiquity recommended the application of the forces to the luxated bone. The veneration inspired by the ancients suffered this opinion to remain in force so long as anatomical knowledge was not permitted, critically and learnedi,>, to pronounce on a received opinion; and we can only go back Of Luxations in general. 209 to the time when the Academy of Surgery shewn in its greatest lustre, to find the origin of the contrary opinion. The force necessary to be employed in the extension and counter-extension ought to be proportioned to the number of muscles to be lengthened, and the degree of their contrac- tion. Sometimes their resistance is great, and is increased when the force is applied to the luxated bone. A number of different means have been devised to augment the force, and to overcome the resistance; as if the force alone were necessary, and if its actions were to be invariably in one direction during the whole time of a reduction. Theft means might be useful on account of their convenient ap- plication only; for otherwise an inevitable objection arises to their use from the impossibility of calculating the de- gree of their force: the skin and muscles have been often lacerated, without the least advantage in relation to the luxation itself. But these means have another radical fault, unless very complicated mechanical means be em- ployed ; their action must always be direct and parallel to the direction in which it commences. Now k will be seen that the proper mode of reducing a dislocated bone, is to vary the direction of the force, because the bone was not thrown from its natural situation by one direct movement. To the preceding considerations, equally applicable to extension and counter-extension, let us add the following, re- lative to eaeh in particular. We have already seen that the extension ought to be applied as far as possible from tbe lux* ated bone; thus, for the arms it ought to act on the wrist, and for the legs on the foot. The hands of a sufficient num- ber of assistants applied to tbe limb itself are certainly pre- ferable to any other means; although it is incontestable that in this way tbe exact force cannot be calculated; and it is difficult to canse to act together, and in eoneert, the hands of persons employed, who frequently pull unsteadily. But by employing intelligent assistants wo may approach to uni- formity, and the desirable perfection of regularly increased extension ; and, above all, we may vary, at pleasure, the di- rection of the extension—an incalculable advantage, not to be obtained by any other means. The force sometimes necessary requires a number of per- sons, and tho surface of the part may not be sufficiently large to permit all the power to be applied to the limb; for this reason bands are used. These ought to be made of solid materials, not subject to stretch, but so soft as not to hurt the skin; the simplest and best is linen. We con- stantly employ sheets or table-cloths folded lengthwise, like vol. if* 27 210 Bayer's Surgery. a band, three or four finger* wide, and sufficiently long for the middle to be applied or fastened round the wrist or bot- tom of the leg. A sufficient number of assistants may be placed at the ends. The direction of the extension is an essential point of which Hippocrates knew the importance. This astonishing man explicitly recommends the extension to be made in the di- recrion in which the luxation took place; that is to say. by placing, as much as possible, the member in the situation in which it must have been when the accident occurred: and the excellence of this principle was not denied until it was erroneously said, that the extension must be made in the direction in which the limb is thrown. In making extension in the manner pointed out by Hippocrates all the muscles are in an equal degree of tension, and the bone is carried towards ihe cavity of the joint by the very route it took in leaving it. The object of counter-extension is to oppose an equal and invariable force to the extension. Like this last, it ought to be applied as far as po-sible from Ihe injured joint. This precept cannot be conformed to when the luxation is very near-the trunk: it must then be so arranged that the bands employed for making counter-extension do not compress the muscles that pass over tbe joint. The force of counter-extension ought necessarily to be equal to that of extension ; but. as it is not necessary to vary the direction of the former during its action, like that of the second, less intelligent assistants than those destined to make the extension may be employed. Counter-extension ought always to be made in a direction perpendicular to the surface of the joint of the bone on which it acts. M hen the extension is carried lo a sufficient degree, which will be known by the lengthening of the limb and the flat- tening of the muscles that surround the joint, we are then to proceed to the coaptation ; that is to say, to the conduct- ing of the head of the bone into its cavity; to do which it is necessary lo act differently, according to the nature of the joint affected, and the kind of luxation it has suffered. The bead of the bone should be always conducted into its cavity bv the same course it took in coming out. This is not al- ways the shortest route the bone can take to re-enter. We arc, however, obliged to follow this route, even though it is not lie shortest, as much because it is the one formed by the disjointed bone, as because it conducts to the opening made in tbe capsular ligament. Louis has raised doubts as to the importance of this piecept, which most authors have Of Luxations in general. 211 regarded as a fundamental principle in the reduction of lux- ations. He expresses himself in this manner:—" It is not clearly proved that this dogma is as important in the prac- tice as specious in theory. It is said, that if ihe track al- ready made is not followed, another must be made, with difficulty to the operator and pain to the patient; that the head of the bone, arriving at its caviiy. finds no opening in the capsular ligament, which it pushes before if into the ca- vity, and which prevents an exact reduction, and causes pain, inflammation, abscesses, &c. 1 have seen in practice all these consequences, but they do not arise from thai cause. I have reduced many luxations, and I have never perceived that this precise route can be distinguished : the bone is al- ways reduced, or rather reduces itself by ihe only course it can lake to re-enter, after the obstacles that opposed its re- placement are removed, whether by methodical or einpiiical movements/' The doubts of Louis would be well founded] if he spoke of those luxations only in which Ihe displace- ment has not been very extensive. It is also just to agree with this celebrated surgeon, that ihe ill effects of misma- nagement are exaggerated, and that they depend more on the contusion that accompanies the luxation. But it is also incontestable, that, in luxations where a consecutive and extensive displacement has taken place, if we lose sight of this circumstance, great difficulty will be ex- perienced in the reduclion; not from the extension of the capsular ligament, or from its being pushed before the bone, but from the irritation of tbe muscles near which the head of the bone is directed. Thus, we believe the precept in question cannot be weakened by Ihe observations of Louis; and, when the head of a bone, after leaxing the caviiy, undergoes ulterior displacement by tbe contraction of the muscles, or by any other cause, it ought first to Ire brought to the place where it was immediately after the luxation, and then pushed into its caviiy. While the surgeon attends to the coaptation, the extension ought to be continued, but less forcibly, and in concert with ihe operator; the limb being, at the same time, gradually brought to its natural direction. In complete luxations of the ginglymoid joints the process of coaptation is generally (be same as that of which we have been speaking; but in incomplete luxations of ihcse joints the coaptation is made by pushing the displaced bone in a direction contrary to that in whicli it was luxated, whilst the bone with which it is articulated is fixed. In this case the extension ought to be moderate, because it&only object 21* Beyer's Surgery. is to diminish the friction of the surfaces of the joints at the moment of reduction. Considerable difficulties are sometimes encountered in the reduction of luxations; the source from whence they spring ought to be exactly known. A certain degree of fear augments the susceptibility and energy of the muscular contraction; so that the sight of the necessary preparations, and the apprehension of the pain that will attend it, may add much to the effect of the irritation already caused by the displacement. We have always found it useful, in robust patients, who evinced a good deal of in quietude, to call off their attention by conversing on some ether topic while the necessary preparations are making. Certain attitudes, although indifferent as to the luxated joint, favour the contraction of the museles, and oppose the reduction. We have sometimes reduced with great fa- cility a luxation of tbe humerus, by making the patient lay on his face, after several ineffectual efforts have been made in a sitting posture. In this case, it is extremely probable that the force with which the patient pressed the ground with his feet, as if to stiffen himself against the pain, produced a powerful contraction in all the muscles, particularly those that surround the luxated joint. This phenomenon a cele- brated physiologist* has called sympathetic energy of action. The contraction of the muscles that surround the luxated joist sometimes depends entirely upon the irritation pro- duced by the luxation itself. It is then attended with hard- ness and prominence of these organs: the contraction whieh arises from this cause occurs in recent luxations and in young and robust patients. At other times, the contraction of the muscles is connected with inflammation. In these latter cases, when the luxation has happened some time, say two or three days, the joint is stretched, the muscles are not so prominent, and any pressure made near the joint, as well as the least movement of the member, is ac- companied by severe pain. It is important to distinguish these cases; in the latter attention is only to be paid to the inflammation; it would be committing a great fault then to attempt a reduction of the luxation; besides, it is more than probable we would not succeed: it would indubitably aug- ment the inflamed state of the parts, and may give rise to serious accidents. In these cases, when a contraction is not joined to an inflammatory state, antispasmodic remedies may be given: opium, given in a full dose, may be very useful, if •Barthcrv Of Luxations in general 31S you seize the moment of its effects to try a reduction ; one or two copious bleedings, warm bathing for a long time, and a severe regimen, may produce good effects by the sudden de- bility they occasion. Mild emetics and nauseating medicines may also be employed with advantage. We once, with great facility, reduced a luxation of the humerus on a drunken postillion: there was so little contraction of Ihe muscles, that we could, without any other aid than our hands, replace the bone, whilst the students were occupied with the prepara- tions for the reduction. Facts of the same nature have in- duced certain practitioners to propose intoxication as a re- medy to be used in similar cases; but the difficulty is so easily removed by other means, that it is hardly worth while to have recourse to this expedient. Desault, persuaded that the opening of the capsular liga- ment of the spherical joints was so narrow as to cause dif- ficulty in the reduction, frequently caused the luxated limb to be violently moved, with a view of increasing the opening of the membrane. As soon as he experienced any resist- ance, in an attempt at reduction, he never failed to exe- cute this manoeuvre; and the reduction was always easily made afterwards. We cannot adopt the opinion of this great surgeon; but the facts that have passed under his eyes, and those of his numerous disciples, are not the less useful: they prove that extended movements may prevent the spasms of the muscles, and facilitate reduction. We have already observed, that in arr inflammatory state of the luxated joint, and Ihe neighbouring parts, instead of attempting, uselessly and dangerously, a reduction, wo should calm the irritation, and dissipate the inflammatory swelling. Bleeding, and the application of leeehes to the part may be advantageous. Too much haste cannot be made to put a stop to this state, which opposes the re-establish- ment of the natural relations of the bones, as the longer it remains the more difficult the reduclion becomes. As soon as the pain is calmed, the reduction is to be undertaken, without waiting for the swelling to be entirely removed: this phenomenon (occasioned by the difficulty of circulation) exists a long rime from the unnatural position of the parts; and, if we wait until it entirely disappears, the reduction will have become irreducible. But, if not called immedi- ately after the accident, if the swelling that first takes place have deceived us as to the nature of the case, or if mista- ken as to its true character, we did not attempt the reduc- tion at the proper time, at what epo*«h will it yet be time to undertake it? This is a most Jiiticu i question to answer. Examples are cited of luxations being reduced after several 214 Boytr's Surgery. months, and even at the end of two years. On the other hand, examples of luxation, much less ancient, merely of thirty or forty days, where every proper means have been unsuccessfully tried, are so numerous, that we are led to believe that the unexpected success obtained in these extra- ordinary circumstances, has depended on some unknown causes, which it is not easy to discover. It is very certain that luxations of the ginglymoid joints become sooner ineducable than those of the spherical joints* Ordinarily, when twenty-five or thirty days have passed, and the bone has not been replaced, the success is very doubtful, and it is more than probable that the patient re- mains lame. As to luxations in the spherical joints, although we have been fortunate enough to reduce some of six weeks, two months, or evcu longer standing, we are far from think- ing that these very rare and fortunate cases ought to serve as a general rule. Most of the patients who were (he sub- jects of these extraordinary cases were aged and feeble, and, consequently, the work by which nature attaches a luxated bone in its new situation, may have experienced some delay in its progress and developement.* It is very rare that, at the end of a month, a luxation, even in a sperical joint, is susceptible of reduction. It is in vain to cause extensive movements of the limb, with the intention of destroying the adhesions the bone may have contracted ; for when the parts on which it is thus fixed are moveable, you draw them with it: in the contrary case, great disorder is caused without ob- taining any favourable result with respect to the reduction. Without having experienced it, one cannot conceive the re- sistance met with in attempting to remove, from the place it occupies, a bone that has been souie time luxated, and all the force it is capable of eluding; the skin, and even the muscles may be torn and broken without moving the dis- placed bone. As we cannot know a priori of the degree of force with which a bone is fixed in its new position- as the time since which it has been in this state is no measure of it, any attempt at reduction ought to be with great circumspection, and it must be abandoned as soon as it is perceived that well combined efforts, carried as far as prudence permits, are without effect. A luxation is known to be reduced when, during the ope- ration, you hear a certain noise, produced by ihe return of the head of the bone into the cavity; the pain is consider- ably diminished, the member has recovered its length, its direction, and its natural shape, and can execute move- * See note F. Of Luxations in general. 215 ments that the luxation rendered impossible. We ought, however, to be careful not to make it execute any exten- sive movements in order to be assured that the reduction is made particularly in that direction which gave rise to the luxation; otherwise vac shall cause a new displacement, of which there are many examples. It is not so difficult to maintain the parts in their natural si- tuation, after hav ing effected Ihe reduction of a luxation, as to keep in their natural union the fragments of a fracture. To guard against luxation, it is sufficient to prevent such move- ment as the member had previous to the reduction. Ii is not important to act on the joint itself, but on the extremity of the bone, opposite, in its dislocated state, to that which has been luxated. After a luxation of the humerus, the arm is fixed against the trunk by means of a bandage that acts on the in- ferior part of the limb: in luxation of the lower jaw, (he bandage must pass under the chin ; in that of the femur, the patient must remain in bed with the thighs kept together by a bandage round the knees, &c. The applications necessary to the affected part differ according to its situation. It must always be observed that a luxation, and the manoeuvres necessary to reduce it, are the great causes of the irritation of die joint, and that the pain and swelling it manifests indicate the use of ano- dyne and emollient applications. Poultices, fomentations, and liniments of this nature should be applied whilst the pain and swelling exist; and, if it be judged necessary, bleeding, and the application of leeches around (he joint; afterwards discuticnt applications ought to be employed, with the view of dissipating the swelling, &e. We shall not here treat of the complication of luxations with fracture, wound penetrating into the joint, nor with the projection of the luxated bone through the torn liga- ments. The first has been sufficiently dwelt on in treating of Complication qf Fractures, and the two others shall be ex- amined when we come to Wounds of the Joints. We shall content ourselves at present by succinctly calling to mind, that, in luxations of the spherical joints, complicated with fracture, this last only is susceptible of reduction ; and that, when the callus has acquired sufficient solidity to sustain the necessary extensions, the luxation will generally have become too ancient 10 be reduced ; that, in similar complica- tions in the ginglymoid joints, both accidents may be treated at tbe same time ; because most frequently the luxation may be reduced without the aid of extension, by acting immedi- ately on the extremity of the luxated bone. ( 21* ) CHAPTER XXV. Of Luxation of the Lower Jaw. AMONG the joints formed exclusively by the bones of the head, that of the lower jaw alone is susceptible of luxation properly so called. The displacement of the other bones of (he same part is more exactly expressed by the words separation or diduction. AM persons are not exposed to luxations of the lower jaw. For this luxation to take place it is necessary that the line of direction of the neck of the condyles, as it passes back- wards, form, with the base of the cranium, an aeute an- gle ; whereas, in the natural state of the parts these linet form an obtuse angle; of course a dislocation ean only bap* pen when the separation of the jaws is carried to an extreme point. Now, we know that in infants, the branches of the inferior jaw form with its body, or rather with the plane of its base, a very obtuse angle, and that its parts are almost on the same line. By this disposition the condyles of the infe- rior jaw is articulated with the base of the cranium in an acute angle, the sinus of which is turned forward ; so that to form an obtuse angle forward with this same base, the infe- rior jaw would be depressed to a degree it could never reach, and which neither tbe length of the elevator muscles, the natural opening of the mouth, or even the situation of the vertebral column would permit. Hence luxations of the in- ferior jaw never take place in very young persons, notwith- standing the frequent occasions they have to open their Btoi-ths as wide as possible. They are most frequently seen at that epoch of life when the teeth are complete, and when the form of the inferior jaw is definitively fixed. Tins bone can only be lnxated by being carried before tbe transverse process of the temporal bone. If we consider the nature of the relations of the articular surfaces, it will be seen, that for the condyles to be luxated backward, ami pass under the projection formed by the auditory and the vaginal processes of the temporal bone, the lower jaw must be git ally depressed. It will also be seen, that one of the condyles can be carried outwards only as much as tlte oppo- site co-.dyle is carried inwards; and for this last to make this lateral movement, it must pass under the spinous pro* cess of the sphenoid bone; an effect that cannot be produc- ed without fracture of this process, which can never take Of Luxations of the Lower Jaw. 217 place but by a blow directly on one of the branches, or in the body of it. Iv'ost commonly the two condyles are luxated at the same time; it may, however, occur, that only one of them is lux- ated. These two sorts ought to be distinguished by giving to the last Ihe name of luxation of Ihe right or left condyle, and reserving to the first that of luxation of the inferior jaw—denominations much mote exact than complete or incomplete luxations, which give a false idea of the state of things. All causes capable of separating the jaws beyond their na- tural limits, are also capable of producing luxation of the inferior jaw. Of this number are gaping, efforts in vomiting, violent blows or falls on tbe chin, &c. To conceive the mechanism of this displacement it is necessary to make a few remarks on the disposition of the articular surfaces, and the mechanism of the movements of the jaw. 1st. The greatest diameters of the condyles of the inferior jaw have an oblique direction, nearly transverse; their surfaces ex- tend much farther backward than forward, and the neck which supports their eminences is sensibly bent forward. 2d. The surface of tire joint is composed of two parts; one concave and posterior, bounded behind by a fissure and (he auditory tube; the other anterior, convex form behind for- ward, and near (be zygoma. 3d. A cartilaginous substance in the joint follows ihe movements of tbe condyle, and carries with it the cavity with which it is, in fact, articulated; the late- ral external ligament (which alone unites the bones), inserted into tbe exterior end of the condyle, and into the tuberosity, at the end of Ihe zygoma, is directed obliquely upward and forward when the jaws are brought together, and in an op- posite direction when the mouth is open. 4th. The masseter muscle takes nearly a middle course between the body and the branches of the jaw, and carries this bone upward and slightly forward; the pterygoid and crotaphite muscles pro- duce exactly the same effect in that direction; the external pterygoid is designed to carry the neck of the condy le and the articular cartilage forward. The separation of the jaws, which results from depressing the inferior jaw, is not the effect of a simple movement of its own, but is a com- pound moth i,. (he centre of which is a little below ihe mid- dle branches of this bone, and as the chin goes downward and backwards, the condyles go forward, each respectively describing two opposite arcs of i. circle of unequal sizes; so that the condyles are placed under the transverse processes of the temporal bones, and they re-enter the glenoid oavk vol. ir> 28 218 Bayer's Surgery. ties of these bones when the chin is carried upward and for- ward. This being premised, it is necessary to distinguish the eases where the lowering the jaw, considered as a cause of luxation, is produced by the action of the muscles, from those where the same movement is occasioned by external violence, such as a blow, a fall on the chin. &c. In the first case, which takes place in gaping, in vomiting, &c. the contraction of the muscles inserted into the os hy- oides depresses the inferior jaw. As this movement increases, tbe external pterygoid and crotaphite muscles carry the con- dyles forward under the transverse processes of the temporal bones, and produce a double circular revolution in opposite directions, by the chin on one part, and the condyles on the other: at the same time, the condyles advancing under the transverse processes, and the chin being carried backward, the posterior surfaces of the condyles are carried below the convexity of the transverse processes, and the former lux- ated anteriorly by the external pterygoid muscle, which acts with increased energy, and with spasmodic contractions in the act of gaping. In the second case, when external violence acts on the chin, and carries it downward and backward, as may hap- pen in a fall in descending a stairs, or other similar cir- cumstance, the lower jaw revolves on the condyles, the gle- noid cavity being the centre of its movement, as it is not brought forward by the external pterygoid muscle, which is inert. In this circumstance, the lowering the jaw becoming more considerable by the continued action of the violence, the resistance of the external lateral ligaments, the obliquity of their direction, and even the involuntary contraction of the masseter, and of the internal pterygoid muscles, luxation takes place. This effect the more easily follows in this case without the action of the external pterygoid muscle, as the masseter and internal pterygoid contract during the action of the violence ; and as these muscles, by reason of their obli- quity, tend to carry the jaw forward, in bringing it nearer the maxilla superior, and as the lower part of this bone is inclined a little forward, the vertical axis of the condyle, and the super ior part of its neck do not correspond with that of the branches of the jaw. The first, if prolonged down- ward, would pass behind the angle of the jaw, and form, with the posterior branch, an angle of thirty-five degrees. On the other hand, the capsule of the joint cannot fail to be stretched by the rotation of the condyles, and of the arti- cular cartilages, the slight displacement of which facilitates Of Luxations of the Lower Jaw. 219 (he passage of the condyle under the transverse process of the temporal bone. Under these circumstances, if during the application of violence to the chin which carries it down- ward and backward, the elevator muscles of the jaw act, as will most frequently be tbe case from the effect of fear, &c. the condyles become the moveable point of the bone, and are pushed forward. The mechanism we have just explained differs from that by which most modern physiologists and pathologists have thought that this luxation took place. We shall not speak of the opinion, that, in a forced opening of the mouth, the coro- noid processes being carried below the malar eminences, they become the centre of that movement by which the internal pterygoid and masseter muscles thrust the condyles in the zy- gomatic fossa. This opinion applies only to cases of luxation by the action of Ihe muscles, and it, moreover, takes for granted a displacement of the jaw, which of itself constitutes Itxation. m . It is generally imagined, that, in depressing the inferior jaw. the condyles advancing under the temporal processes, the obliquity of the branches becomes such that they cross the middle line of direction of the internal pterygoid and masseter muscles, so that the inferior insertion of these muscles being then plaeed behind the condyles, they act on the angles of the jaw, and carry them upward and back- ward, by bringing the condyles further forward. This opinion, which strikes at first sight with such an ap- pearance of truth, has been generally adopted, and we our- selves a long time professed it. On attentive examination, however, it will be found incorrect. In fact, if the inferior zygomatic arch be divided into five equal parts from the tubercle, where the external lateral ligament of the maxil- lary ioint is inserted, to the bottom of the malar suture; the anterior four-fifths of that division marks the extent of the superior insertion of the masseter; if, then, we mark the central point of that space, and from this point draw a hori- zontal line, passing by the guttural region, it will be seen that this line falls exactly on the bottom of the pterygoul fossa; that is to say, on the point of the superior insertion oi the internal pterygoid muscle. Now, in order that, in a for- cible depression of the jaw, the branches of this bone cross the middle line of direction of the internal pterygoid and masseter muscles, the condyles must be carried so far tor- ward as to reach, and even to pass the line in question. But so extensive a displacement never took place ; it supposes a degree of separation of the jaws that is never met with in 250 Bayer's Surgery. similar eases: a displacement half so extensive cannot exist without a luxation. It then appears to us demonstrable, that, unless we suppose the condyles of the jaw to be displaced forwards, so as to be carried to the anterior part of the zy- gomatic fossa, and almost behind the spheuo-maxillary fur- rows, which has not been proved, and which appears impro- bable—it seems, I say, demonstrable, that, in a luxation of the jaw, tbe internal pterygoid and masseter muscles con- stantly remain before the condyles, and their agency in the production of this luxation does not materially differ from their natural action ; neither has the crolaphite any effect in relation to this luxation, and, if it could possibly have any, it would be that of preventing it. However, for a luxation of the inferior jaw to take place, the depressing of that bone must be carried so far that the most elevated and convex part of the articular surface of its condyles form a very acute angle with the plane of the trans- verse process of the temporal bone, and that the sinus be turned backward, and that, in this situation, the condyles receive an impulse forward capable of surmounting the resistance of the anterior part of the membrano of the joints. With the predisposition of which we have been speaking, an impulsion of tbe condyles forward, although moderate, may be sufficient to cause a luxation of the lower jaw. Gap- ing often occasions it. It has occurred several times suc- ecssively during tbe effort of vomiting, and in persons who«c age and good constitutions appeared to exclude the idea of any morbid predisposition. In this case it appears that the action of the external pterygoid muscle was suffici- ent to produce the luxation, unless we admit a combined ef- fortof tbe elevator and depressor muscles; which, indeed, is not without some appearance of probability. It is not known, by any authentic anatomical researches, how far the condyles of the jaw, after leaving the glenoid eavities of the temporal bones are carried forward. Judging from appearances in living subjects during the existence of luxation, it appears that the condyles do not go far from the transverse process of the temporal bone, and that they stop immediately before it. This is the case in luxations pro- duced intentionally on a dead subject. The capsular mem- brane of the joint is so pliable as to admit of this slight dis- placement without being torn, at least in most eases. It ap- pears equally certain, that ihe external lateral ligament is not tanked: ils superior insertion bci-ig situaicd in front of the inferior, the condyle is allowed to pass under the tran*- Of Luxations of the Lower Jaw. 221 verse process of the temporal bone; and when the first of these two parts has passed before the second, the length of the ligaments is still sufficient, because the condyle is a little raised. One condyle only is very seldom luxated. In this case, which equally requires a j»;reat depression of ihe jaw, one of the condyles execute.-, in the glenoid ca\ity, or under the transverse process, a Kind of rotation, or change, by virtue of which its external extremity is carried forward, whilst the opposite condyle is carried before the transverse process on its side, in a direction a little inward. In this movement the luxated condyle is further removed from Ihe tubercle where Ihe external lateral ligament is in- serted, and which must be forcibly extended, or even bro- ken. If, at the moment when a luxation of the inferior jaw takes place, the opening of the mouth be very great, and the distance diminish, in a short time the two ja*\s re-ap- proach, and the incisor teeth of each jaw are fixed at a dis- tance of about an inch and an half. This phenomenon, which sometimes takes place immediately after a luxation, can be attributed only to the action of the crotaphite muscle, the effect of which is the greater, as its insertion into the coro- noid process is then made at almost a right angle, and as there is no obstacle to the movement in question. This movement, however, cannot go so far as lo place the teeth in contact; and, on examination, it will be found that the jaws are arrested at the distance which ordinarily separates them. In this case, the immobility of tbe lower jaw is occasioned by the summit of the coronoid process resting on the inferior border of the maxilla superior. This remark has not es- caped the celebrated Monro. When the luxation takes place only on one side, the immediate re-approximation of the jaws conducts the summit of the coronoid process toward the base of the malar eminence of the superior maxillary bone, to that they generally touch; at the same time the last superior malar tooth, on the side of the luxation, rests on the most inclined part of the internal side of the anterior border of the coronoid process. Sometimes the contact that restricts the meeting of the jaws lak'-s place only in this last point; the coronoid process being too short for its summit at the same time, to reach the malar eminence. In luxations of the inferior jaw, this bone is lowered and fixed in ibis position, and the rows of teeth are sepa- rated by a spaci more or le-s considerable; seldom less than an hh h and a half, and hardly ever exceeding that extent. The teeth of the twojaws do not then correspond: the hiei- *<*• <•-** Bayer's Surgery. sors of the inferior are situated more forward, and if the appioximation of the jaws could be made, these teelb would be more in front than the incisors of the superior jaw. The molar teeth present the same want of correspondence, and each of the inferior meets half the posterior part of the preceding tooth of the superior jaw. The distance that se- parates the molar teeth in each jaw is so very small that it is with difficulty the finger can be inserted between them. The flow of saliva is augmented by the irritation and com- pression of the parotid glands, and the lips not being able to close, it cannot be retained, but involuntarily runs from the mouth. The articulation of sounds is difficult, and the consonant syllables cannot be pronounced. In at- tentively examining the formation of the parts immedi- ately before the auditory canal, and under the posterior origin of the zygoma we feel a depression, formed by the external side of the glenoid cavity of the temporal bone, in- stead of a projection, which, in its natural state is formed by the external side of the condyle. The cheeks and temples arc flattened by the lengthening of the muscles that form them, and we may feel through the cheek, and particularly in the interior of the mouth, a projection formed by the co- ronoid process. Such are the signs that characterize a luxa- tion of the two condyles of the inferior jaw ; but when one only is displaced, in addition to all these circumstances, the chin is considerably carried to the side opposite to that of the luxation; the depression produced by the dis- placement of the condyle is distinguishable before the au- ditory canal of the luxated side only, and the articulation of sounds is still possible, though very defective, the pa- tient stuttering when speaking. A combination of symptoms bo evident, it would seem, could not admit of any mis- apprehension ; yet there are practitioners so little experi- enced as to mistake a luxation in the inferior jaw for apo- plexy, and sometimes for a spasmodic contraction of the muscles thai are attached to the os hyoides. When a luxation of the inferior jaw is not reduced, this is what happens: in the first instance, the jaw remains immoveably fixed in the situation it was carried by the lux- ation ; the saliva at first flows in great abundance, after- wards in small quantities; mastication is impossible, but the diglutition of liquid aliments or drinks is effected by leaning the head backwards. Examples even have been seen of such an immobility of the jaw in the situation where it has been thrown by the luxation, that an anchylosis has been the con- sequence. This, however, is not always the case. Munro Of Luxations of the Lower Jaw. 223 saw a case where a luxation being unknown, and not reduced, after a certain period, the person recovered the faculty of elevating and lowering the jaw, without, however, being ahle to bri'ig Ihe teeth of the two jaws into contact. Other examples have been seen where the inferior jaw has gradually raised, so that the lips could be easily brought together and tbe person could retain the saliva, and swallow without difficulty. It is probable, that but for the obstacle which the os maxillare offers to the entrance of the coronoid process into the zygomatic fossa, the complete elevation of the infe- rior jaw would gradually take place, and that, by favour of a new joint, formed between the condyles and the an- terior part of the transverse apophysis of the temporal bone, the faculty of chewing would be re-established and exercised with facility. Ravatou saw a young recruit who could chew and speak two years after a luxation of one of the condyles of the jaw, though with difficulty; which is more astonish- ing in this case than after a luxation of the two condyles. The inconveniences of an unknown luxation of the inferior jaw are tbe loss of the power of pronouncing certain sounds, and the necessity of living some time on liquid aliments or soups, after which the faculty of chewing is re-established. We cannot conceive from whence originated the assertion attributed to the Prince of Medicine, that, if this luxation is not promptly reduced, the most fatal symptoms, lock- jaw and death, may be expected. It is uselessly that some authors have taken great pains to explain this passage. The crotaphite muscle is not more subject to inflammation than all the other organs of the same nature that surround a luxated bone ; and observation has not demonstrated that the inflammation of this muscle is more serious than that of any ether. It is impossible that this assertion can be the result of positive observation; the passage that contains it ought to be considered apocryphal; it bears none of the characters that distinguish the writings of Hippocrates. Generally the reduction of a luxation of the inferior jaw is easy, but the repetition is frequent. If, however, we are to believe certain authors, and even to judge from facts, this reduction is sometimes accompanied with great diffi- culty. We shall presently see on what that opinion is founded. There are only two indications to fulfil in the treatment of this luxation. Serious symptoms seldom occur, at least if the luxation have not been occasioned by some ex- ternal injury, and there be not, at the same time, contusion, which, however, can never be very dangerous. The only objects are to reduce the luxation, and keep it reduced. 22* Bayer's Surgery. To reduce a luxation of the lower jaw, the patient must \k placed on a low seat, his bead resting against the breast of an assistant, whose hands must be forcibly applied to his forehead: the surgeon, placed in front of the patient, carries his thumbs (bound round with linen) as far as po-sible be- tween the two last molar teeth of each jaw, and applies them on the two last inferior molares ; the body of the bone being embraced by the three lingers placed obliquely under the base of the jaw ; the surgeon presses directly down with his thumbs, so as to carry (lie whole jaw, downward while the condyles are a little separated from the anterior part of tire transverse processes of the temporal bone, the head being firmly held and fixed. This movement is to be ex- ecuted in a uniform manner, without either raising or de- pressing the chin; the condyles are then carried a little back- ward and downward, by pressing ihe thumbs on the inferior molar teeth, and on the base of the coronoid processes, whilst with the three following fingers the chin is raised and brought forward. A slight shock is then felt, the chin is brought up by the action of Ihe elevator muscles, which an- nounces that the luxation is reduced, and that the condyles have entered into their cavities. At this instant the teeth touch, and with such force and promptitude that the thumbs of tbe surgeon may be caught ; from which cause all authors have recommended promptly turning the thumbs on the ex- terior side of the molar teeth, between them and the cheeks. It must, however, be acknowledged that this danger is exag- gerated, and that you ought to be more fearful of withdraw- ing the fingers before the proper mano&uvrej for reducing the luxation are terminated, than of being bitten. It is true, the jaws are brought together immediately after the reduction is accomplished; but this movement is so feeble as to be easily moderated by Ihe thumbs engaged between the two*4 jaws, which more efficaciously act in this ca-e. as their whole length is then placed on the inferior dental arch. In those cases in whieh rhere is luxation on one side only, all the difference in the manoeuvres consists in forcibly act- ing on this side of the jaw alone. It appears, however, that this is the case where the greatest difficulty has been expo- rieneed. It is very probable that surgeons have often mista- ken the sort of luxation in question, and have acted equally on both sides, and, consequently, in pure loss on that side which was not luxated ; or, perhaps, the luxated condyle being car- ried further forward, the displacement was rendered more considerable, so that the exterior lateral ligament h'ing tight- ened, forcibly fixed the two bony pieces, and required a Of Luxations qf the Lower Jaw. ?& greater force, and a more extensive movement to separate them, and to bring the condyle under the transverse process quite to the glenoid cavity of the temporal bone. This last opinion appears to us very probable. The ancients have described a process for reducing the jaw, in favour of which Jean de yjgo cites his experience. Instead of the thumbs, two small wooden wedges are placed between the molar teeth; the surgeon forcibly holds these wedges; a band is then placed under the chin ; the flat parts pass on -the sides of (he head; an assistant draws the two ends of the band upward, whilst the surgeon acts with the wedges on the posterior part of the jaw. This pro- cess, as may be seen, is founded on an exact knowledge of the proper indications; but it has one real inconvenience, that of elevating the chin before the condyles are disen- gaged from the unnatural position they occupy. It is pre- ferable, however, to the one Ravaton saw employed with success by an empiric, and with which he appears so highly delighted: It consisted in applying, under the chin, a band of leather, the ends of which were fastened with twine to be twisted by a stick, at the top of the head, on a cap or flat piece of wood, whilst an assistant acted in the same mariner slowly under the chin. Ravaton says the ope- rator directed the condyles; but it is evident that his fingers could not employ a force proportioned to that of the leather fastenings, and, consequently, that tbe greatest force was not applied where it was most necessary. The empiric succeeded, after Ravaton and several others had in vain at- tempted a reduction by the ordinary means; but, it must be remarked, that one condyle only was luxated, of which they were assured at the moment of reduction. By adding to these means a kind of wedge placed between the molar teeth, or, what is still belter, a lever of the same materials, this process might be useful in some ancient luxations, provided the bandage was gradually relaxed in proportion as the lever acted; and the first was only used to sustain the chin at the same height with the angles of the jaw, and not employed to raise the chin until after the condyles were disengaged. A process, formerly recommended, and which, it is said, was successfully employed, consists in violently approx- imating the jaws by severe blows of the fist on the ch,in from below upwards. This is a barbarous operation, and can- not, in any manner, fulfil the proposed end; and, if it could have any result whatever, it would be an increase of the evil, or even of a fracture of the neck of the condyles of the jaw- vol. if. 29 226 Bayer's Surgery. It has been said, that the spasmodic contractions of the muscles of the jaw may oppose considerable obstacles to the reduction of a luxation of that bone, and that it is necessary to fatigue the muscles by long continued exten- sion. An observation of Lecat is cited, and another of Du- pouy, as proofs of this proposition. But Leeat acknowledges that his was a case of luxation of only one condyle, which had existed fifteen days; and, it will be found, that, in his embar- rassment, he employed a number of manoeuvres, which de- stroyed the effect of each other, and were incapable of ex- tending the elevator muscles ; finally, he took it in his head to seat the patient on the ground, while he stood and prac- tised anew the ordinary method. In this manner he suc- ceeded. «* The pressure I exercised with my thumbs," says he, *' would, in any other circumstance, have caused me violent pain." It is easy to conceive that only one condyle was displaced. This circumstance, and the time since the luxation had occurred, caused all the difficulty. As to the case of Dupouy, his success is attributed to his pressing with his thumbs on the inner side of the masseter muscles, from within outwards, for several minutes. Will any per- son believe that the least advantage was derived from that manoeuvre ? When the swelling of the parts, or the violent contraction of the muscles, has rendered all attempts at reduction fruitless, before re-commencing them, it will be proper to bleed the patient, steam the affected part, and apply emolli- ent poultices. To maintain the inferior jaw in its position, it is sufficient to support the chin by a bandage passing under it, the ends of which are fastened on the top of the head ; to prevent the patient from speaking and chewing for some time, and to nourish him at first with liquid aliments; to recommend him to apply his hand under his chin when gaping, and to make but small movements with the jaw when it is judged proper to permit any: it is essential not to neglect these pre- cautions. Nothing is more common than to see a luxation re-produced by gaping: it is frequently repeated several times in a few minutes, when the surgeon has neglected to fix the inferior jaw, and to render it immoveable for some time. Compresses, wet with resolvent liquids, should be applied before the ears to remove the swelling and to strengthen the parts. ( 227 ) CHAPTER XXVI. Of Luxations qf the Vertebra;. NOTWITH STAN DING the solid reasons which Hippo- crates has given, in his book De Jlrticulis, to prove that the vertebra; are not capable of being luxated like other bones, the contrary opinion was long maintained by respec- table authors, who oitpd facts to confirm it. But, if we ex- amine with attention the case* in question, we shall find them possessing the characters of fractures of the posterior lamina of tbe vertebrae. In several instances of this kind the fragments have been replaced in their natural situation; the compression of (he spinal marrow has thus been removed, and the symptoms have consequently disappeared. Thus we explain the alleged examples of luxations of the vertebrse, which, it is pretended, were reduced and cured. Where there has been opportunity for examination after death, frac- ture has almost always been discovered, either of the poste- rior lamina, or of the bodies of the bones; and, in the lat- ter cases, a part of the vertebral column has been found wrenched, but nothing like luxation has been seen. If there be any exceptions to this rule, they are very rare. We shall explain them critically. The structure of the vertebra;, and the nature of their union with one another is such, that luxa- tion ean hardly take place in the greater number of them. But, the structure of the two first vertebrse, and then- ture of their relations with each other, and with the occipi- tal bone, render them susceptible of luxation. ARTICLE I. Of Luxation of the Head upon the first Cervical Vertebra. The solidity of the joint properly called the occipital, with the first cervical vertebra, depends less on the ligaments of that joint than on the disposition of its articular surfaces. A stratum of soft fibro-cellular substance is placed between the anterior arch of the atlas and the anterior part of the great hole of the occiput, another in the back part; two sy- novial membranes, covered externally with dense cellular tissue, envelop the surfaces of the joint; the surface of the condyles of the occiput is turned down, and inclined out- 2£8 Bayer's forgery. ward; the lateral parts of the atlas are strongly inclined in- ward. Thus this joint is like a conical body, the summit of which is turned down and received into an analogous cavity, so that the first cervical vertebra must inevitably follow the occipital bone in all its movements. On the other hand, the second cervical vertebra, although articulated with the first, so as to permit a great extent of motion, is" not only very firmly fixed to it, but has an equally intimate union with the oCcipital borte : thus this joint derives great solidity from the proximity of that of the second vertetn'a vfitTr the third. Moreover, the disposition of the surfaces of the joint, and its small tendency to movement', adds much to the efficacy of that kind of supplementary symphysis. The movements of flexing, extending, and inclining the bead to one side take place almost exclusively between the several pieces of the cervical part of the spine. As to the movements of rotation, not only the particular mechanism of the articulation of the two first vertebrae with each other, but still more the insertion and the disposition of the mus- cles specially destined to these movements, evidently pv6\6 they do not fake place between the head and the first ver- tebra. The ligaments, therefore, which confine the os oc- cipiiis and the atlas are not exposed to great violence, since these bones scarcely move upon each other: hence there is no example of a displacement of articular surfaces of the occiput with the vertebral column, in consequence of ex- ternal violence. Even tbe large carnivorous animals, who prey upon tbe smaller, and who have occasion to make very violent movements of the head, furnish no example of this kind. In falls upon the head, in which the vertebral co- lumn is strongly flexed, though several vertebrse may be broken, the occipital bone is never luxated upon the atlas. In the bodies of persons who have died by the cord, the first vertebra is often found luxated upon the second, but never the occiput upon the first. But organic alterations may cause luxations of this kind, Daubcnion has related one case, of which the specimen was deposited in the King's Cabinet. Sandiforl has described five, which are found in the Museum of Leyden. We have seen one at the Charite, &c. Sometimes the articular sur- faces are softened. An exostosis may be formed upon the transverse process of (he atlas, by which this bone may be pu-hed forwards or backwards. The anterior arch, the pos- terior, or one of I be sides of the first vertebra has been seen to intercept a third, a half, or even two-thirds of tbe diame- ter of the foramen magnum: yet the patients have lived, at Of Luxations of the Vertebral. 22,9 least until tire exostosis which fixed the first vertebra had acquired great size, or until the head and most of the cer- vical vertebrse had become firmly anchylosed. The first ver- tebra is always found united to the os occipitis. The articu- lation of the atlas with the second vertebra, and the sym- physis of the occiput with the atlas, are also found to un- dergo remarkable changes. In one of the cases cited by Sandiforl, the lateral displacement of the two first ver- tebrse, in different directions, was so great that tbe opposite point of the rings of these two bones intercepted only a space of six fines opposite the foramen magnum. Ouverney met with a case in which one of the vertebrse was pushed for- wards, the other backwards, and the processus dentatus was approximated lo the posterior arch of the atlas by two thirds of the opening of this bone. In these cases the ligaments of tbe two fiTst vertebrse must have been destroyed, oral least so softened as entirely to have lost their consistence. Nothing is known of the symptoms which have accompa- nied these organic changes, nor of tbe mechanical lesions thcv have induced. As we are also ignorant of the nature of this disease, we can say nothing as to the treatment which would be proper. Perhaps future observation may discover some analogy between this malady and white swelling, and prove the happy effects of blisters, caustics, &c. ARTICLE II. Of Luxation of the first Vertebra upon the second. Independently of (he particular articulation of the pro- cessus denfatns of the second cervical vertebra with the an- terior arch Of the first, these bones enjoy an easy lateral movement, by means of two almost plane surfaces. An ex- tremely strong ligament is stretched transversely behind the processus dentatus, and between the lateral parts of the atlas; two other very firm ligaments pass from the top of the processus dentatus to the internal side of the condyles of the os occipitis: beside these, there are the accessory ligaments, and a ligament which extends from the anterior edge of the foramen magnum to the posterior part of the bodies of the fifth vertebra. This strong apparatus is intended to permit, and, at the same time, to limit the movements of rotation of the head upon the trunk, which chiefly take place in this triple arli* 230 Bayer's Surgery. culation; and this, although strongly protected, is almost exclusively the seat of sudden luxations of the vertebral co- lumn. The ligaments which surround the articulations of the first vertebra with the second are too weak to oppose any obstacle to luxation. They would yield to the slightest ef- fort which tends to carry the articular surfaces of the at- las, one before and the other behind. In order that this dis- placement should take place, the rotation of the head and the first cervical vertebra would have to be carried much further than the ligaments which pass from the atlas to the occipital bone would allow ; and from this would arise much more serious consequences, which wc shall presently ex- plain. The processus dentatus of the second vertebra may, 1st. Be carried directly backwards, breaking the transverse ac- cessory and lateral ligaments. &c. This displacement is the most rare, because the ligaments must all be broken at the same time, and by direct traction, which requires prodi- gious force. Hence it happens only in falls from a great height upon the posterior part of the head, by which it is forcibly bent upon the anterior part of the trunk. 2d. In a violent rotation of the head to one side, the lateral ligaments of the processus dentatus and its accessory are put upon the stretch, and twisted around this process; the momentum of tbe head is opposed by them alone, and not at all by the transverse ligament. If, at the same time, the head is in- clined to either side, one of the lateral ligaments, more tense than the other, yields first, and thus renders the rupture of both more easy. When the lateral and accessory ligaments are once boken, if the inclination of the head be carried still further, the processus dentatus may pass under the transverse ligament without breaking it. Louis, in endea- vouring to distinguish, among those who died by strangula- tion, the self-murderer from the victim of assassination, found, that they who were merely suspended by a cord died from strangulation ; but those who, after being swung from the gallows, were twisted, had the first vertebra luxated upon the second. The hangman of Lyons, who had reduced his infamous profession to its principles, always produced this effect by siding on the shoulders of the culprits, and rotating the head, and bending it to one side until he heard the crack, which informed him that he had effected disloca- tion of the first vertebra upon the second. In children, the processus dentatus not being completely developed, and the ligaments being longer in proportion,, Of Luxations of the Vertebroz. 231 and less firm, direct traction may stretch and break the lateral liganrents and their accessories, and permit the processus dentatus to pass under the transverse ligament. J. L. Petit saw a child, six or seven years of age, lifted up by a man (in order to see London, according to the vulgar say- ing) who took bold of the forehead and back of the head. The child struggled, became agitated, and died. It is to be regretted that there was no anatomical examination, though there is little doubt that the first vertebra was luxated upon the second ; and if this were the fact, it must be conceded, that a perpendicular force produced it, and that the processus dentatus passed under the transverse ligament; for there could have been neither sufficient rotation nor inclination of the head. Lastly, if the transverse and other lateral ligaments re- sist the force whicli tends to rupture them, and to produce a direct luxation backwards, and especially if the processus dentatus has attained its full length, and be somewhat nar- rower than usual at its neck, it may be fractured at that part, and the lateral articulations of the two first vertebrse are immediately destroyed. In certain provinces of France, in which the executioner applies his feet to the head of men who are hanging, so as forcibly to bend it, this fracture is more frequently met with than direct luxation. Every luxation of tbe first cervical vertebra, in which the natural relations of the processus dentatus are destroyed, is immediately fatal. Riolan mentions having seen a soldier who, after being hung, was restored, and whose head was inclined to one side, which he attributed to luxation of the first cervical vertebra, although the man could freely ro- tate his head. But, we shall presently see that nothing more could have taken place than the luxation of one of the oblique processes of these bones. The moment the proces- sus dentatus is broken, it presses upon the spinal marrow, bruises it, tears it, and produces instant death. ARTICLE III. Of Luxation of the five last Cervical Vertebroz. The convexity of the upper surfaces of the e bones in front, and the concavity of the corresponding inferior sur- faces, together with the thickness and elasticity of the inter- 2E2 Bayer's Surgery. vertebral substance, permit pretty extended movements of flexion and extension. One on each side of the superior vertebra is received into a cavity in tire inferior; thus late- ral movements fake place, and the inter-vertebral substance admits a slightly rotary motion. In each of these move- ments the oblique processes, which are almost horizontal, slide upon one another in opposite directions; in flexion and extension of the trunk the inferior slide upon the su- perior of the next vertebra, in a direction upward and outward; in lateral inclination of the body the inferior oblique process of the side towards which'the trunk is in- clined, passes upward, and that of the opposite side down- ward; lastly, in rotation of the trunk, one of these pro- cesses is carried upward and forward, and its fellow down- ward and backward. In these different movements the oblique processes slide upon one another—if they pass each other, so that all contact of the articular surfaces ceases, they cannot be returned lo their natural situation; they butt against one another, and the liead remains fixed in the position into which it is thrown. A eonsiderable num- ber of cases have occurred, in which one of the inferior oblique cervical processes has been luxated, and in which the head has been permanently inclined to the opposite side. Are tbe two inferior oblique processes of the same vertebra ever luxated at the same time ? To cause this displacement an extreme degree of rotation would be necessary; such as could only arise fi;om external violence. But one of the inferior- oblique processes may be luxated by muscular action. licsault related, in his lec- tures, the case of a lawyer, who produced oue of tliese luxa- tions, while sitting in his office with his back to the door, by turning his head suddenly round to see who was coming in. Chopart showed us a young man, aged twenty-four, who met with a similar accident by turning bis head too far round. This person's chin ever after rested upon the left shoulder, his face being turned to the same side. External violence may also cause a luxation of this kind, especially if it causes both a rotation of the head and inclination to one side. Thus it sometimes occurs in children, in unsuccessful attempts to make a somerset, or, as it is sometimes expres- sed, to go heels over head: if they are not strong enough to straighten the spine, while the head rests upon the ground it is bent forwards, and generally to one side, and almost all the weight of the body is thrown upon that side, and particularly upon the articulation of the oblique process opposite to the aide towards which the head is luxated. Of Luxations of the Vertebra. 233 When only one of these processes is luxated, a rotation and permanent lateral inclination of the bead and neck follow; the bead is carried to the side opposite to the luxation, fire face is. aho, fumed to this side, tbe patient cannot bring his neck to its natural position, or turn bis face to the opposite side. Rotation cannot be effected by taking hold of the head and endeavouring to bring it directly to its proper situation; the patient experiences a vague pain about tbe seat of the luxation; the spinous processes of the luxated vertebra, and of those which are situated above it, are displaced and carried lo Ihe side of the luxation, and incline thence ob- liquely lo the opposite side. This change in the situation and direction of the spinous processes of the vertebra? above tbe luxation succeeds instantly to the regular arrange- ment of those of the inferior vertebra;. The sterno-mas- loideus muscle, the scalenus, the trapezoides, &c. are in their natural state, and present rro sign of spasm, or any other affection capable of producing the remarkable situ- ation of the head and neck. This last characteristic dis- tinguishes the luxation in question from the divers kinds of wry neck, with which it has some resemblance. li has never been observed, that a luxation of only one of the oblique processes was followed by an inconvenience in the spinal marrow sufficient to pioduce palsy, or any other alteration in the functions of the nervous system ; for whilst tbe luxated process ri-es and goes forward, (hat of the op- posite sinks and goes backward : thence results a slight ro- tation, but too little to give any sensible twisting to the spi- nal marrow: on the oilier hand, all ihe vertebra is not raised ; iis posterior part only changes its situation, and this is at last reduced to a slight lateral inclination: thus, the distance which naturally separates the posterior lamina is not augmented; there is no stretching, nor compression of the spinal marrow. The only inconvenience which results is deformity, and a sharp pain in the commencement; but which diminishes in the end, and subsequently the anchylosis of the two vertebrse. It is not known what influence the simultaneous luxation of the two oblique inferior processes of the same vertebra ex- ercises on the spinal marrow and on its functions, as it is probable that the posterior lamina of the luxated vertebra would be removed from that of the follow-in;:;, the vertebral canal would certainly be lengthened, and consequently Ihe spi- nal marrow would be put upon the stretch. In a case of lux- ation of one of the oblique processes only, Desaujt would not undertake the reduction. I have frequently heard him relate., vol.. II. SO 334 Boyer's Surgery. in his lectures, that a child of eight or nine years of age was brought to him, who. in tumbling heels over head on a bed, luxated the right oblique inferior process of a cervical vertebra; tbe head was inclined on the left shoulder, ihe faee turned towards the same side: the he td was so firmly fixed, that it was impossible to bring it to its natural position, even by considerable efforts. Peyrilhe, who was present, wished the reduction should be attempted, but Desault dared not to undertake it, and, to excuse himself, he told the parents that he could not assure them the child would not die in the attempt. Monsieur Petit Radel relates that he saw brought to the hospital of Charite of Paris, an in- fant whose neck and head were inclined to one side. The accident happened by a fall several days before. They could not precisely determine the nature of the accident; but sus- pecting a luxation, they made such manoeuvres as the state of the case reasonably required. The child expired under the e\ es of those who held it. The body was examined: a luxation of one of tbe oblique inferior processes of one of ihe cervical vertebrse forwards was discovered. This will not be wondered at if we consider that to reduce this luxation, we must begin by augmenting the flexion of the spine in tbe direction of the displacement, in order to disengage the oblique process lodged before that of the following vertebra. Thus we see, that reason and experience alike teach us not to attempt a reduction of a luxation of one of the oblique pro- cesses. The accident is exempt from danger; the patient at the end of a little time has only a deformity, with which it is better to persuade him to live, than to attempt a measure, the suceess of which is not certain, and which may cause his death. Stronger reasons apply to a luxation of the two oblique pro- cesses of one vertebra. We have already remarked, that in this case tbe displaced vertebra must be inclined for- ward, and the spinal marrow stretched. Now, the tension of that organ cannot be augmented but with the greatest danger, and in the reduction it would be indispensable, in the first instance, to increase the displacement and curva- ture of the spine at the part affected. Of Luxations of tlie Vertebra?. 233 ARTICLE IV. Of Luxation qf the Bodies of the Vertebra. Luxation of the oblique processes, such as we have do scribed, and such as has been observed in ihe cervical re- gion, cannot take place in the dorsal or the lumbar vertebrae, for iheir processes have much greater elevation, and a verti- cal direction. But can the bodies of the vertebrae be lux- ated ? It was tlmught. that, in a violent flexion of the spine, produced by the fall of some heavy bodies on the superior part of the trunk, the spine being already curved: or by a fall from some elevated place on the nape of the neck or the buttocks, or by a violent effort that tended to produce a great extension of the spine, such as tumbling on the ground, &c. —ii was thought, I say, that in circumstances of this nature the posterior ligaments of the vertebral column and the car- tilages could be broken, and the superior part of the spine, by being carried forward or backward, experience a disloca- tion. When we reflect on tbe amazing strength of the inter- vertebral cartilages, upon the superficial situation of the ver- tebrae themselves, and their fragility, we shall be inclined to think them more liable to fracture than to luxation; and if we examine the facts upop which a belief of tbe pos- sibility of their being luxated is founded, we shall find (bat the posterior lamina of the vertebrae are uniformly broken, often crushed, and reduced to splinters, and that almost al- ways, when the body of a vertebra has been luxated, the se- paration of its ligaments tears off a piece of the bone itself. Hence we see these accidents have not the proper charac- teristics of luxation, and belong rather to the class of com- minutive fractures, complicated with severe injury of the spinal marrow and surrounding parts. Before concluding the subject of dislocations of the verte- brae we shall mention that there are facts which prove that in great flexion of the spine, the subspinous, the inter spi- nous, and the posterior ligaments may be broken. When the injury has not been great, and is confined to the inter- spinous and sub-spinous ligaments, patients have recovered, after remaining at rest for some time; but the rupture of the posterior ligament is always followed by paraplegia and death, arising, undoubtedly, from sudden distention of Mm spinal morrow. ( 236 } CHAPTER XXVII. Of Luxations of the Ribs. THE absolute silence of a great number of observing writers, in respeet to luxation of the ribs, was not re- marked until .1. L. Petit and Duvernev wrote their treatises on the diseases of the bones. Petit thought it very natural, that the solidity and flexibility of these bones exposed them more to fracture than luxation; and not, probably, knowing any fact in opposition to this conjecture, imitated the exam- ple of his predecessors. Some compilers, however, admit- ted the existence of these displacements, without even citing a single example; and we are astonished to find the name of Pair at the head of those who embraced that opinion. One of the correspondents of the Academy of Surgery, bowever, thinking he had observed a case of luxation of tbe vertebral extremity of one of the true ribs, communicated the fact to the Society in a memoir, in which he established a theory on the subject. The Academy adopted the obser- vations and propositions of the author; and the respect in- spired by that association gave credit to a doctrine which ap- pears to us to have been too lightly admitted. B'tte* says, *• the last of she true and the first of the false ribs, are alone susceptible of luxation, and the dis- placement can only take place forward. The luxating cause must always act upon the angle of the rib. or as near as pos- sible to the transverse process with which it is articulated, and in a very small space. The symptoms of this luxation are a sharp pain in the posterior part of the thorax, short and difficult respiration, a mobility of the luxated rib in all its length, a noise ^ isibie lo the hearing and feeling senses, the necessity of compressing the ribs on the affected side, near the sternum and the corresponding vertebrae, to ease the pain and difficulty of i espiration." In the first place, we observe, that the author founds his theory upon a single fact; and admitting this to have been well observed, we are not authorized to deduce general pro- positions from it. In the second place, il does not require great attention to discover, from his representation, the sym rtoms of a fracture of one of the ribs, near its articula- tion with the transverse process of the corresponding verte- bra. There remains not the smallest doubt of this if we put aside certain ambiguous expressions in his narrative. What is a noise that can be only felt and not heard ? It is on Of Luxations of the Ribs. 257 this subtile distinction that is founded, according to Buttet, the diagnosis of luxations from fractures of the ribs. Ac- cording to him, in these last the crepitation is sensible to ihe organs of feeling only: and in luxations it produces a manifest noise, as if we do not always observe a .sonorous crepitation, in ascertaining the existence of fractures. Be- sides, admitting a luxation of Ihe posterior extremity of the ribs, can the extremity of ihe displaced bone, covered with a cartilaginous substance, in rubbing against the body of the tor-responding vertebra, produce a silent crepitation sensible only to the touch? It is true, we may distinguish this sensa- tion, and the noise that accompanies it in luxations of the spherical articulations, although the two surfaces are co- vered with cartilaginous substances; but in these cases wo arc obliged lo use force, lire movements are very extended, and the he; (I of tbe luxated bone, in entering into the ca- vity, falls into a deep excavation; but in surfaces almost plane, moving freely and without obstacle upon each other, and in very circumscribed space, nothing but fracture can occasion crepitation, or any thing like it. Finally, the case cited by Buttet does not demonstrate the existence or possibility of luxation of Ihe ribs, because his patient being cured, he had no opportunity of making an anatomical examination. Some observers have applied the term luxation to cases of disarticulation of the ribs at either of their extremities, in consequence of the destruction of the vertebra; or ster- num, or of the ribs themselves, occasioned by aneurism, or other organic lesion. There is not a single, a well authenticated example of .a luxation of either of the extremities of the ribs; and this will not appear extraordinary when we reflect on the length of these bones, theii structure, suppleness, the flexibility of their cartilages, the solidity of their sternal and vertebral articulations, the number and Ihe thickness of the muscles that envelop them, and the facility with which these bones are broken, 6lv. What shall wc think, however, of the pre- cepts given, and propositions advanced by some authors,* such as Tucker, Heisfer, Ace. They have distinguished se- veral species of luxations of the posterior extremities of the ribs ; and have given several methods for reducing luxations upwaid and downward. They say, (hat when ihe luxated rib is carried inward and forward, the case is most dangerous. 1 bat ihis luxation maybe accompanied by a very serious inflammation of the lungs, and if the ordinary methods and different positions of the patient do not succeed in procuring 2S8 Boyer's Surgery. a reduction, wc must not hesitate to make an incision, and seize the rib to bring it to its natural situation, &c. It is evident they wrote on a case they never saw ; or if they have seen the accident they speak of, they have attributed to a pretended displacement effects caused by one or more frac- tures. We cannot, however, pay too great attention to these last kind of accidents, which arise from violent percussion of the thorax. The cartilages of some of the ribs are exposed to a par- ticular displacement, whicli may be classed with luxations, but of which there are few examples. The cartilages of the sixth, seventh, eighth, and ninth are bent upwards, their superior edges are concave, and in the middle they are con- siderably enlarged, so that they touch, and are articulated together, at one or several points of their respective edges. A synovial membrane is attached to their corresponding plane surfaces, and some fibrous fascia are distributed upon both surfaces of the cartilage. These articulations are sel- dom exposed to any considerable efforts. However, when the body is thrown backward, or falls backward, tbe violent contraction of tbe abdominal muscles, tending to re-esta- blish the equilibrium, may cause a rupture of these ligament- ous fibres, and a displacement of the cartilages, the inferior of which passes backwards, and then rises, pushing forward the superior, which appears to be the one which has suffered the displacement. In an observation of this kind,* reported by Martin of Bordeaux, the patient, an old man, in play- ing with a child, was thrown backward, on the back of a chair; his body was suspended in this attitude for some se- conds, the bead banging on one side, and the inferior extre- mities on the other. In the reiterated efforts he made to raise himself the displacement occurred. We have seen a similar case, and the accident was occasioned by similar cir- cumstances, j At the instant the displacement took place, the p,:tient experienced a sharp pain in the affected part, and the projection of the superior cartilage was immediately dis- tinguished; a little spasm of the muscles of the breast, and slight difficulty of breathing, have been known to follow di- rectly after the pain ; but it is probable, if the reduclion were effected by art, it would spontaneously take place in the movements of respiration; or, if it did not take place, the cartilage would contract new relations with the adjacent parts, and the movements of the thorax would be quite as free as ever. * Journal de Medicine, vol. i. | See note U. Of the Separation of the Bones of the Pelvis. 239 The reduction is extremely easy; it is sufficient slightly to compress the cartilage that projects externally ; it slides on the superior edge of the following one, and this last is soon brought to its natural situation. If any difficulty is experi- enced, it may be obviated by gently throwing the body back- ward, keeping the parts at rest, and applying compresses wet with resolvent liquid, is all that is afterwards necessary. CHAPTER XXVIII. Of the Separation of the Bones of the Pelvis. THE ancients believed that the separation of the bones of the pelvis was necessary to the expulsion of the foetus. Perhaps they were led to this conclusion by observing that this phenomenon takes place in certain domestic animals. What- ever be the fact in regard to this, Ihe opinion prevailed until the revival of letters. At this period some denied that any separation of the bones of the pelvis took place, and others maintained the contrary opinion. A. Pare gave a noble in- stance of honourable conduct. He strenuously supported the opinion which is contrary to tbe separation of the bones of the pelvis; but he made a public avowal of his error as soon as it was shown him. A woman, aged twenty-four years, being executed for infanticide, twenty days after her delivery, was dissected in the School of Surgery, in the month of Fe- bruary, 1575, in presence of a great number of learned per- sons. * Before the dissection was commenced, the right thigh was raised up, and it was distinctly seen that the os pubis of that side was higher than the other by at least half an inch': there was an interval of a fingers' breadth between ihe two ossa pubis. The motions communicated to tliese parts con- vinced every spectator that the sacro-iliac symphises were much more lax than natural. All were struck with admira- tion : they saw and felt tbe truth of the facts. Various opinions have prevailed on this question. The following is the real state of the ease: In the natural state, the articulations of the ossa pubis with each other, and of the sacrum with the ossa innominata do not allow of any motion, although the opposite sides of the two ossa pubis touch each other. In almost all women, in the course of pregnancy, and particularly in its latter stages, the ligaments that unite 2i0 Boyefs Surgery. the bones of the pelvis are slightly relaxed, as is proved by anatomical examination ; but this relaxation, which does no* always render perceptible a slight mobility of the bones of the pelvis, and which renders its circumference a little larger, does not facilitate the expulsion of the foetus, because tbe superior- brim of the pelvis does not form a regular cir- cle, and the slight enlargement which takes place does not increase its antero-posterior diameter. In some rare eases, the relaxation of the ligaments is carried much farther, so as to permit very evident and extensive movements of the three great bones of the pelvis. They have been known to admit of a separation of more than an inch in the parts in which they are mutually articulated with each other. l>\ some instances the ligaments have been found not only elon- gated, but so soft as to be easily torn by the fingers, or even destroyed. The patients, in whom this last circumstance has been observed, died of puerperal fever. Professor Bau- delocque and I met with an instance of this kind, and it ap- pears that the local affection in question may be considered as a symptom of that disease. The frequency of the occurrence of this relaxation would appear to prove that it was intended for some important pur- pose; but physiology has not yet discovered what this pur- pose is. Cases of extraordinary mobility cannot be fairly cited in proof of the uniform course of nature ; but this phenomenon is not most frequently met with in women Who are deformed, and thus deprived of the power of natural parturition; but even well formed females, who have bad an happy and easy delivery, have been exposed lo great danger from the occurrence of this separation. It seems that re- laxation to a certain degree is natural;—beyond that degree it is a serious disease. Notwithstanding this consideration, it is incontestable, that a moderate separation of the bones of ihe pelvis is a favour- able circumstance for the operation of dividing the sympliy- sis pubis. This operation, which has been the subject ot* everlasting discussion, and which has never been considered cooly and candidly, ought not, in our opinion, to be totally rejected. Numerous observations prove its utility in cases of moderate deformity of the pelvis; but it would be much more useful in cases where the bones are moveable upon each other, provided the mobility were not very great, and ihe moveable articulations were not the seat of acute pain. The analogy between the cases in question and another kind of separation of the bones of the pelvis, which comes on spontaneously, and which has been attributed to scrofula, Of the Separation of Ihe Bones of the Pelvis. 2*1 leaves ns in doubt if pregnancy is the only cause of the relax- ation of the symphysis of the pelvis which is observed after delivery ; however, it has not been remarked that (hose wo- men who, after delivery, gave evidence of a separation of the bones of the pelvis, showed any other symptom of scro- fula. It is a fact, worthy of observation, thai this relaxation has hardly ever been observed in rickety women with de- formed pelvis. This proves bow little effect the pressure of the foetus, or any other mechanical cause, has lo do with the production of this disease. They may, indeed, aggravate it when it exists, but we think they cannot cause it, unaided, and uninfluenced by pregnancy, or some morbid predispo- sition. A woman whose pelvis is relaxed towards the end of preg- nancy experiences pain in the pubis, or in the groin, and in the superior and posterior pari of Ihe bullock, opposite the articulations of the sacrum with ihe bones of ihe ilium. These pains are at first very slight, and are only felt during violent movements, after long continued exercise, or after efforts to lift heavy burdens; they gradually increase with the pro- gress of utero-gestation, and are sometimes so violent when tbe woman is brought to bed, as to render delivery tedious and difficult, by preventing the patient from using exertions to favour the contractions of the uterus. The action of this organ is sometimes suddenly suspended at each pain, and its contractions have neither the same energy, duration, or fre* quency. Sometimes, however, after the accouchmenl of a healthy woman, an evident relaxlion, and considerable move- ments of the bones of the pelvis upon each other, lake place, without having been preceded by pain or difficulty of walk- ing during pregnancy. Is this state of the articulations, ia such cases, the effect of delivery, or do tbe relaxation of the ligaments, and mobility of tbe bones of the pel vis, exist with- out any apparent symptom, or is Ihere any concealed disease which accouchment brings into action ? It does not appear to us probable, that the mere distension of the ligaments could break them if they were in iheir healthy stale. It has been said, that the bones of the pelvis become re- laxed only in women who had edema of the lower extremities, and who were weak and sickly. This is not ihe fact. This disease often occurs in females of strong constitutions, and in every respect, except that alone, perfectly healthy. The mobility of the bones of the pelvis is never very re- markable before delivery, except in some extraordinary cases. At this period it is generally very sensible; it pro- duces pain when the patient turns in bed. or even bends the vol. n. 31 242 Bayer's Surgery. thigh upon the pelvis. In some rare cases the same circum- stances produce, also, a grating sensation, and even an audible crepitation. If, then, we place one hand upon the pubes, and the other upon the upper part of the buttock, and direct an assistant to push the superior part of the thigh upward and outward, we shall perceive that the corresponding pubis fol- lows its motions. While the pains continue in the degree we have described them, the patient is unable to go about. If the disease be not complicated, and no new causes of irritation occur, the pains spontaneously cease, and the irritation subsides; the mo- bility, and sometimes even the crepitation continues, but the patient is enabled to go about. Standing and walking are per- formed at first with difficulty, and are always executed with tottering and lameness, which continue during life. In some instances, exercise occasions a return of the symptoms, and even death. In other cases, the cure, though imperfect, is permanent. In many women no preternatural mobility of the ossa in- nominata is perceived until they quit their bed, or even un- til they begin to work after their confinement. Slight pains, a sense of numbness in the lower extremities, an unsteady gait, and frequent falls, are the only symptoms that charac- terize this disease. Some cases seem to prove, that a slight degree of this affection will get well by the efforts of na- ture alone. Pain in the affected part denotes a higher degree of the complaint. There is then danger of inflammation, suppura- tion, and the complete destruction of the joints. Fistulous openings take place, and death always follows. There is no example of a case of this kind terminating by anchyjosis. We have already remarked, that those women in whom the ligaments of tbe pelvis were found, upon dissection, to have lost their consistence, or their continuity, died of pu- erperal fever. It is more than probable, that, had they es- caped this last disease, they would have died of the affection of the articulations. While there is pain it is proper to combat the inflammation of the ligaments (which, from the structure of the parts, must be chronic) by general bleeding, the application of leeches over the seat of the pain, emollient fomentations, and poultices, anodyne liniments, and, above all, by the most perfect rest and suitable diet. Baths would be useful, were it not for the necessity of avoiding every kind of motion. When the pain and irritation are removed, the next object is to strengthen the relaxed ligaments. Cold baths, topical Of the Separation of the Bones of the Pekis. 243 astringents, and tonics have been highly recommended for this purpose. But the state of pregnant and puerperal wo- men does not admit of the application of the cold bath; and the local application of tonics appears to Ire of doubtful effi- cacv. But the good effects of compressing tbe pelvis by a bandage passed around it; or, what is still belter, a leathern girdle, stuffed on its inner side, and buckled, are abundantly proved by experience. The patients always experience re- lief from them, and never fail to tighten the straps as soon as they become loose. Rest undoubtedly is beneficial in all cases; hut many women get well by wearing a girdle, with- out ceasing to pursue their usual occupations. There is another kind of separation of the bones of the pelvis, probably arising from scrofula, that oceurs in children and young persons. It affects only the symphysis pubis and one of the sacro-iliac articulations. Sometimes it comes on spontaneously ; at other times, after a fall, a blow, or long continued exercise. External causes have, in our opinion, little influence in the production of this disease. It commences with a pain in lire groin, buttock, and part of the affected limb. These are, for a long time, its only symptoms. At length the limb appears longer or shorter than that of the other side. This difference continues the same during a certain period; pain and numbness in the whole limb then follow, and walking is difficult or impossi- ble ; the leg and ihigh are not completely extended; the point of the foot is turned slightly outward; the respective dis- tances of the malleoli, trochanters and iliac crests of both limbs are tbe same, but the hip bones are not of the same height. This disease may continue a very long time. Its duration varies from one month to several years. Sometimes, after an attack of fever, or without any known cause, its corrrse is ar- rested ; but these cases are not generally permanent: the disease commonly returning, after a time, with increased violence. In a case, published by l'Heritier, in Foucroy's Journal, after the patient bad been two hours on horseback, the af- fected limb was two inches longer than the ether; after walking it was nearly as mueh shorter. When the limb was lengthened, the patient experienced severe pain; in order to relieve which, he walked until it became shortened. These variations in the length of the limb could not be produced by any other means, although crepitation took place in the sa- cro-iliac articulation when the leg was moved. There was, 244 Bayer's Surgery. at the same time, a disease of the hip joint, and almost com- plete anchylosis. When the disease has reached this point, the inferior extre- mity becomes considerably shrunk and weakened ; the pains and the swelling of the buttock increase, abscesses form around the sacroiliac articulation, fistuhe succeed, hec- tic fever ensues, and the patient dies, sooner or later, ac- cording to the facility with which the air enters the cavity of the joint. On dissection, the bones are found diseased. The diagnostic symptom of this disease is this; that in all the differences in the length of the limb which takes place the distance from Ihe trochanter major to the crest of the ilium always remains the same. By attending strictly to this circumstance we were once enabled to pronounce positively upon a case which had embarrassed many of the most emi- nent surgeons of Paris, and which had been mistaken for consecutive luxation of the hip joint, with which this affec- tion has some analogy. When this disease terminates favourably anchylosis pro- bably takes place in the diseased articulation; but this is not yel proved by observation. It is also \ery probable that the general treatment of scro- fulous affections of the joint would suit this case. But we know nothing from direct experience either1 of tbe effects of bitters, tonics, antiscorbutics, alkalies, &c. or of rubefacients, issues, moxa. setons, or radiated heat. The patient, whose case is related by 1'Heritier, experienced relief from an ap- paratus which supported the weight of the affected extre- mity on the opposite shoulder, at the same time that circular compression was made around the pelvis. This last effect was that from which the principal benefit was derived. Experience has demonstrated, that the articulations of the bones of the pelvis, notwithstanding their great strength, may be luxated by external violence. The os sacrum may be pushed forward; tbe ossa ilia may be displaced forward and upward; the bones of the pubis may be completely dis- articulated, and thus enjoy evident mobility. These luxations are always incomplete, and are necessa- rily attended with a rupture of all the connecting ligaments. Enormous force alone can cause such accidents: such as falls from a great height; the falling of a heavy body on the pelvis. Hence the luxation is generally the smallest part of the injury, which is commonly accompanied with commotion of the spinal marrow, efiusion of blood in the pelvis or abdomen, fee. Yet instances are related of luxa- Of the Separation of the Bones of the Pekis. £45 dons of the bones of the pelvis, or rather of rupture of some of its ligaments, by violent movements ; such as are made in fencing, etc. But we think there must have been some an- terior disease. The first effect of a luxation of the bones of the pelvis is an incapacity of standing, walking, or even moving the lower extremities. Acute pain, increased by motion, is felt in the groin, in the region of the pubis, and opposite the sa- oro-iliae articulation. One of the bones of the pubis is higher and more prominent than the other; the ossa innominata are susceptible of extensive movements. Such accidents may terminate fatally, in consequence of inflammation of the peritonaeum or the viscera of the pelvis and abdomen, or merely in consequence of suppuration be- tween the articular surfaces, or in the cellular tissue of the pelvis. An interesting case of luxation of the bones of the pelvis, which terminated favourably, is related in the Memoirs of the Academy of Sciences of Dijon. The left os innomi- natum was displaced upward. The reduction was delayed some days by the presence of inflammation; when that was removed, it was attempted, but the pain and inflammation re- turned. After some days it was tried again, but with the same result. The patient was confined to bed, but not so long as the surgeons wished. When he began to walk, the weight of the limb drew the bone to its place. The cure was perfect. Ought not this case to teach us not to endea- vour to reduce a luxation of the bones of the pelvis, but merely to moderate the inflammation ? We shall conclude this section with a few words in relation to the os coccygis. The base of this bone is connected to the sacrum by a sub- stance like that between the vertebrae; the periosteum passes from the coecyx to the sacrum in front; and this connex- ion is further strengthened by strong ligaments behind; the elasticity of these bonds of union permit the coccyx to move upon the sacrum, and tbe parts of this bone to move upon one another, but in a very limited degree, especially in adults. If the movements are carried beyond a certain point, the ligaments are broken. The pressure of the head of the foetus, in parturition, was long believed to push back the os eoceygis to a degree that would amount to a sprain, or even to a luxation, if the pel- vis was narrow. The tediousness of certain labour's were regarded as depending upon anchylosis of the os coccygis, and it was directed, in such cases, designedly to luxate it 246 Boyer's Surgery. backward, by introducing the finger into the rectum. But since accoucheurs have employed themselves in observing facts, instead of forming hypotheses, they have discovered that the antero-posterior diameter of the lower brim of the pelvis is large enough to admit the head of a full grown foetus, and that the retrocession of the coccyx is always very small, and never essential to delivery; and that tbe anchy- losis of this bone, and of the parts of whicli it is composed, can never oppose any considerable obstacle to delivery. SmHlie saw two women who had easy labours although the os coccygis was not capable of the slightest motion. It can never be proper to luxate this bone to facilitate the expul- sion of the foetus. It cannot be denied, however, that in some rare cases of great deformity of the pelvis the os coccygis is pushed very far back, and the ligaments strained by the head of the foetus; but no permanent displacement takes place. In such cases, the women experience pains in the lower part of the sacrum, increased by motion, coughing, sneezing, &c. The patients cannot sit, and are obliged to lay upon their backs. Rest soon dissipates these symptoms. Topical applications are inconvenient; attempts to reduce this pretended luxation would be highly injurious. Blows, falls upon the os coccygis, may distend its liga- ments, and push it forward; but the natural elasticity of the parts soon brings it back to its place. Yet the consequences of the contusion of the adjacent soft parts, which sometimes ac- companies these accidents, are, occasionally, very serious. J. L. Petit relates several cases of this kind, which occurred in women from the want of proper assistance. In cases of this nature, although there may be no marks of contusion, nor any eechymosis under the skin, pain is felt op- posite the apex of the sacrum, extending over all that bone, sometimes even toward the loins and the thigh, increased by every exertion, and especially by that which occurs in going to stool, together with a sense of weight in the region of the rectum, and, sometimes', even with dysentery. The pain either diminishes after several days, and gradually goes off, or it becomes pulsating, and an abscess forms in the region of tbe sacrum. In the treatment of these accidents the patients must maintain the most perfect rest until the inflammation has en- tirely subsided, and not the slightest pain remains. When they first leave their bed, they should sit upon a circular cushion, or a seat with an opening in the centre. AH topical applications of an emollient or anodyne kind Of Luxations of the Clavicle. 247 are'useful. We have seen excellent effects produced by opiate liniments, fomentations with a decoction of poppy heads, the leaves of night-shade, and byosciamus, cm- ployed soon after the accident. In diseases which confine patients a long time on their backs, the ligaments of the sacrum are sometimes destroyed. We saw a case of whieh the coccyx was entirely separated from the sacrum, and carried forwards. As cicatrization took place, it returned to its natural situation. <© CHAPTER XXIX. Of Luxations of the Clavicle. THE clavicle is exposed to frequent and considerable vio- lence. The smallness of its diameter, and its arched form render fractures a frequent consequence of falls upon the shoulder. This bone would, also, be often luxated if the mode of its articulation with the adjacent bones, and the small movements it executes, did not prevent. Thus luxa- tions of the clavicle are much more common than fractures. We shall treat, separately, of luxations of the sternal and of the humeral extremities. ARTICLE I. Of Luxations of the Sternal Extremity. Directed obliquely forward, outward, and downward, be- tween the scapula and the sternum, the clavicle articulates with this last at an obtuse angle, the sinus of which is turned forward, in consequence of the internal extremity being curved backward: hence, when the shoulder is carried back- ward, although the natural obliquity of the clavicle is greatly augmented, its axis continues perpendicular to the arti- cular surface of the sternum, and rarely forms an acute angle with it, unless at the moment of a sudden, unexpected external impulse. Another circumstance in the relation of the clavicle with the sternum merits great attention, and accounts foe the small 248 Bayer's Surgery. number of displacements which oecrir. There is a cavity in the superior lateral edge of the sternum, the sinus of which is turned obliquely upward and outward. This cavity is co- vered with a diarthrodial, cartilaginous substance, and re- ceives the extremity of the clavicle, which also presents a deep horizontal sinuosity, embracing a corresponding pro- jection of tbe sternum. This structure prevents luxations of the sternal extremity of the clavicle, or at least renders them very rare. There are, however, exanrples of this lux- ation forward, produced by very slight causes, in young per- sons and in females. There is no example of luxation of the clavicle either downward, upward, or backward. Luxation of this part for- ward is the only one of which an authentic case can be cited. The cause of these luxations was sudden external violence, which tended to carry the shoulder forcibly backward. In this movement the anterior part of the articulation must be stretched, and the ligaments, perhaps even a part of the in- ferior tendon of the sterno-cleido-mastoideus muscle, must be ruptured; it is probable, also, that the middle of the clavicle rests upon the first rib, which thus forms the ful- crum of the lever. We have seen a luxation of this kind, in a young lady, caused by violent attempts to draw her shoulders back, in order to make her sit gracefully. This force would not produce such an effect in persons more ad- vanced in age. An accident of this kind, however, has oc- curred in an adult, whose shoulders were drawn back while the body was pushed forward by a knee placed on the poste- rior part of the chest. The muscles take no part in producing this luxation. On the contrary, if the pectoralis major and Ihe serratus mag- nus had time to contract before or during the action of the violence, they would counterbalance it. It is very probable, for example, the luxation would not have taken place in the baker, cited by Desault, if he had foreseen, in time, the fall of his load, from the weight of which he was easing himself, by resting it on a post behind him. Some cases are mentioned of luxation of the sternal ex- tremity of the clavicle forward from fails, but without any details. If the fall took place drectly on ihe point of the shoulder, k is probable it would be fractured sooner lhan lux- ated. We think the resistance of the ground would act obliquely on this part so as forcibly to drive it backward. We believe no cause is capable of luxating the external extremity of the clavicle backward, except violent contu- sion directly upon the part; and in this case the luxation, Of Luxations of the Clavicle. 249 very probably, would be complicated with comminutive fracture. Luxation of the clavicle forward is easily discovered. The action of the cause that carried the shoulder, in a sudden manner, backward; a sharp pain in (he articulation ; a sen- sible depression of the shoulder, which is resting very near the breast ; the change of the direction of the clavicle; a tu- mour in front of the sternum and under the level of ihe other sternoclavicular articulation, formed by the internal displaced extremity of the clavicle; a depression, situated higher, and formed by the caviiy the clavicle Iras left; an inclination of the head and neck towards the side of ihe lux- ation ; the feebleness of the corresponding arm, and the dif- ficulty of moving it forward, and of elevating it—such are the phenomena that characterize this luxation. Luxation of the internal extremity of the clavicle forward, is an accident of very little moment, and is never followed by any serious consequences, all hough ihp greater part of the ligaments that surround Ihe articulation be torn. But, as it is impossible to keep this luxation exactly reduced, there always remains more or less deformity, which, how- ever, does not injure the functions of the clavicle; and when the pain is entirely dissipated, and the ligaments consoli- dated, the movements of the superior extremity are exe- cuted with the same facility as before the accident. The following is the manner of reducing a luxation of the internal extremity of the clavicle forward: The patient be- ing seated on a stool or chair, the surgeon standing on the side of the luxation, places one hand on the superior inter- nal part of the arm, and the other hand on the inferior ex- ternal part of it, above the elbow, and pushes this last part toward the body, while he carries the superior part of the arm outward; he thus convcils the humerus into a lever of the first kind, by which he acts directly on the clavicle, as in cases of fracture of this bone. In the combined efforts of the two hands, the shoulder must be brought backward and upward, and the elbow directed forward ; so that the direc- tion of the extension is parallel to the axis of the clavicle; that is to say, outward and backward, and a little upward. The wedge-like pad of Desault for fractures of the cla- vicle, may be placed in the axilla, instead of the band, which is then to be applied to the internal superior part of the arm, and serve as a fulcrum to the humerus. If the extension is not sufficient to bring the extremity of the clavicle into its cavity, it should be pushed backward. vol. ir. 82 150 Bayer's Surgery. As soon as the luxation is reduced, the shoulder is to be brought forward, and the elbow backward, to prevent the external extremity of the clavicle from going forward and being again displaced. The manoeuvres of which we have been speaking are applicable to luxation backward and up- ward ; with this difference, however, that, in ihe first case, after having disengaged the internal extremity of the clavicle by extension, the shoulder is to be forcibly carried backward, and, in the second, it must be carried upward. As soon as the bones are left to themselves, the extremity of the clavicle abandons the caviiy of the sternum, and the luxation is rc-produccd. Desault's apparatus prevenis, for a time, a recurrence of the luxation; but it quickly gets loose; the clavicle eludes its action, abandons the cavity of the sternum, and remains always more projecting than that of the opposite side. The pain, however, dissipates, the torn ligaments consolidate, motion gradually becomes easy, and the limb soon recovers all its functions. Although Desault's bandage for fractures of the clavicle has no other advantage in luxation of the external extremity of this bone than to render the deformity less, still it ought not to be neglected. It is necessary to renew it frequently, and to apply thick compresses on the internal extremity of the clavicle, which are to be kept on by several turns of the bandage. This bandage ought to be kept on until it is judged the ruptured ligaments are consolidated, which seldom takes place until the fortieth or fiftieth day. From what has been said respecting the reduction of lux- ation of the internal extremity of the clavicle, and the proper means of keeping it reduced, it will he seen, that the figure of 8 bandage, and other methods recommended by several authors, are useless : all these means act like ihe cause that produced the luxation, and, therefore, cannot be of the least advantage. Of Luxations of the Clavicle. 251 ARTICLE II. Of Luxations of the Humeral Exh'emity of the Clavicle. Luxations of the external extremity of the clavicle are very rare, because that part is strongly united with the sca- pula, and these two bones always move together and in the same direction, whether tbe shoulder be elevated or depres- sed, carried forward or backward. Most authors have admitted two kinds of luxation of the external extremity of the clavicle—one upward, the other downward. J. L. Petit says, that, although he has seen very few luxations downward, he thinks they ought to happen more frequently than luxations upward. On the contrary, it appears to us, that the obliquity of the articular surfaces, and the resting point which the base of the coracoid process offers lo the clavicle, must render a luxation downward very difficult, if not impossible: and our reasoning on this point accords with experience. A great number of facts attest the possibility of luxation upward and there is not one to prove that of luxation downward. Almost all cases of luxation of the humeral extremity of the clavicle upward have been occasioned by a fall on the point of the shoulder; for when a man falls on this part, the Weight of the body presses the scapula violently downward [towards the feet]; at this instant a mechanical instinct causes a contraction of the muscles of the shoulder, the ac- tion of the trapezium draws upward the clavicle with the greater effect, because the lever it presents has its fulcrum near the sternum, and, consequently, at a distance from where the power acts. This luxation, then, is the effect of two powers, one of which pushes the scapula downward, while the other draws the clavicle upward. But these two powers cannot produce the displacement unless they act with suffici- ent force to break the ligaments that surround the articula- tion, and even a part of those that unite the clavicle to the coracoid process. The soft parts that cover the joint have so little thickness, that it is very easy to discover this luxation. A project ion, formed by the humeral extremity of Ihe clavicle, is felt be- yond the level of the acromion; the facility with which this projection disappears, by drawing the shoulder outward and pushing the arm upward, and pressing, at the same time, on the extremity of the clavicle; a pain, more or less violent, increased by every movement of the arm, and particularly 252 Boyer's Surgery. by that of elevation—such are the signs that characterize this luxation. The most remark ible of nil is the projection formed by the humeral extremity of the clavicle. These signs are so evident, that it must be from want of attention if they are mistaken. J. L. Petit says they were mistaken for a fracture of the clavicle. Ancient authors attest their hav- ing been frequently taken for luxation of the humerus. Hip- poerates speaks of them in his treatise De JLrliculis. Galien has himself suffered by a similar mistake—" I have myself experienced," says he, *• that the clavicle, when luxated, may approach the acromion ; for when it was forcibly com- pressed by the bandage, it descended very low. I supported the inconvenience of this bandage forty days; the re-approxi- mation of the bones was such, that those who had seen them separated by an interval of three fingers breadth were struck with admiration; and those who had not seen them in that state could scarcely believe they had been luxated." Exten- sion and counter-extension were first made, under the idea that the humerus was luxated ; but after submitting to this treatment for some time Galien discovered the nature of this accident. This case is remarkable from the enormous sepa- ration of the bones, and the promptitude of the cure without deformity. It is difficult to coneeive how the bones could be sepa- rated three fingers breadth. We know, in this luxation, the inferior surface of the humeral extremity is resting upon the superior surface of the acromion, and the projection it forms, is always proportioned to its thickness. As to the cure, how shall we persuade ourselves that it was perfect in forty days, without leaving any trace of the accident, when it is de- monstrated by experience, that, however great the attention in the treatment, there always remains more or less defor- mity. Are not these considerations proper to raise doubts as to the nature of the accident that happened to Galien ? It is, however, certain, that luxation of the external extremity of the clavicle upward has been frequently mistaken for a luxa- tion of the humerus; and what may occasion this mistake is the depression under the projection formed by tbe extremity of the clavicle, which may be confounded with that which takes place tinder the acromion in luxation of the humerus. But in luxation of the clavicle the arm preserves its natural direction, and the head of the humerus is not found in the axilla. The reduction of this luxation is very easy. It is onlv ne- cessary to draw the shoulder outward and elevate it. while we press the end of the-elavicle to the internal and superior Of Luxations of the Clavicle. 253 part of the acromion. Although it is easy to reduce this luxa- tion, it is very difficult, or almost impossible lo keep it ex- actly reduced. The very small extent of articular surfaces, their obliquity, and the torn ligaments do not admit the slightest movements of the shoulder without again displacing the bone. The means proper to keep this luxation reduced must act in the same manner as those that effected the reduction ; that is to say, they must lower the humeral extremity of the cla- vicle, raise ihe scapula, carry it outward, and keep the arm fixed against the body. Desault's bandage for a fracture of the clavicle so modified that, after having placed the long and thick compresses on the humeral extremity of the clavi- cle, the turns of the bandage pass under the elbow, and al- ternately over the affected and opposite shoulder, is best cal- culated to fulfil the indications. This bandage, however, like all other linen ones, has the inconvenience of becoming loose, and, in this case, ihe shoulder and the arm noi being sup- ported, the scapula descends, and the articular surfaces lose their natural relations. It is doubtful if any means have yet been discovered capable of curing Ibis luxation without more or less deformity, which, however, does not injure the functions of the part. C 25* ) CHAPTER XXX. Of Luxations of the Arm. OF all the bones in the body the humerus is that which is most easily and most generally luxated. We shall easily see the reason of this, if we reflect upon the manner in which it is articulated with the scapula. A promi- nence, forming about the third of a sphere, situated at the upper extremity of the humerus, and directed backward and inward, is received into a superficial cavity, of an oval form, at the anterior angle of the shoulder blade. The ex- tent of this cavity, although increased by a fibrous ring, is much smaller than the head of the humerus; so that, in whatever position the arm is placed, the largest part of this eminence is without the cavity, and embraced by the capsu- lar ligament. This ligament, thin and loose throughout its whole extent, and especially at its inferior part, is rendered thick and firm above, by an accessory ligament, arising from tbe coracoid process. This formation of the joint gives to the humerus great facility in performing varied and ex- tensive motions, but, at the same time, renders it less firm, and more liable to luxation. Nature has endeavoured to ob- viate this inconvenience by several means:—1st. The cora- coid and acromion processes, and the triangular ligament, which extends from one to the other, form over the joint a kind of vault, which receives a part of the head of the hu- merus, and retains it when the arm is pushed upward. 2d. The glenoid cavity of the scapula being of an oval shape, with its greatest diameter in a vertical position, the eleva- tion of the arm, a movement in whicli luxation takes place, may be carried very far without the head of Ihe bone ceas- ing to rest upon this cavity. 3d. The tendon of the sub- icapularis muscle within or in front, that of the supra-spina- lis above, those of the sub-spinalis and tcres-minor without or behind, adhere strongly to the capsular ligament, arc identified with it, and, moreover, bound together by a dense cellular tissue, so as to form a very solid covering, calculated to oppose, to a certain degree, luxations of the humerus in the parts to which they correspond. 4th. The movements of the arm do not take place altogether in the articulation of the humerus and scapula, but depend, in a great mea- sure, upon the mobility of this last bone, which follows the motions of (he humerus, so that, in the greatest motions of the arm, the humerus is rarely inclined to the scapula te Of Luxations qf the Arm. 25fc such a degree as to produce luxation. Notwithstanding these circumstances, calculated to enable the articulation of the humerus to resist the violence to which it is exposed, it is very frequently dislocated: as often as all the other bones of the body. Almost all authors have written very vaguely upon luxa- tion of the humerus; the inaccuracy, ambiguity, and di- versity of their language, not only render their descriptions unintelligible, but show very plainly that the greater part of them have not taken nature for their model, and that they speak of things which they have never seen. It would be easy to prove this proposition by a critical analysis of the doctrine of the ancients and moderns upon this point of Pa- thology ; but this would lead us into too long details, and would add nothing which is essential to know on this subject. We shall only remark, that Hippocrates is much nearer the truth than those who have followed him. He does not deny the possibility of every kind of luxation except that in which the head of the humerus passes down into the axilla; but he declares that he has seen no other,* although he must. have had frequent occasions to witness this accident. In fact,, this kind of luxation is the most common, and it is not rare for men to see no other in the course of a long practice. The arm may be easily carried backward, so as to form an aeute angle with the glenoid cavity, and. if it has been forced in this direction by external violence, it may be luxated toward the internal side of the shoulder blade. This kind of luxation is much more rare than the first; and it appears that the resistance of the tendon of the sub-scapularis mus- cle prevents its frequent occurrence. A study of the causes which produce luxation of the arm will furnish other reasons for this difference. An opposite movement of the arm—-that in which it is car- ried forcibly toward the anterior part of the chest, by direct- ing the head of the humerus outward and backward, may throw it into the fossa sub-spinalis. The possibility of this luxation was long admitted without proof, then rejected, or considered as extremely doubtful. Judging from a sin- gle example, we find it is strictly possible, but very uncom- mon, since two or three cases can alone be cited. It appears probable, therefore, that a particular preternatural forma- • "Humeri verd articulura uno modoluxari novi, ad locum sub alis. Sursiim autem aunquam, neque ad externam partem. Non Cimen affirmaverim :>n luxeter ant non, ctiamsi habeam quoddicum de ipso- Sed neque in arteriorein purtem uuquam ▼idi, neque videtur mini unquarn eXcidisse . . • Nunquam vidi in aut< riorem partem elapsum; non lamen sdfirmarim nede hoc quiricm an ita Ptcidat, net nt;." Hippo- crate* De Artie, px V>r« WndprlmrtVn. So 1 256 Bayer's Surgery. tion of the joint has favoured the luxation,* and that the body hardly permits a motion of the arm forward great enough to allow all the necessary inclination of the articular surfaces to each other. A to luxation upward, if we understand by it that the humerus is carried directly between the acromion and cora- coid proces.se>, it is evidently impossible, without a simulta- neous fraciureof the apophysis, and the corresponding ex- tremity of the clavicle: but under this denomination has been described a luxation in which the humerus is carried be- low the clavicle, and on the internal side of the coracoid process. This luxation, considered as an immediate effect of external violence, has never been observed : it may, how- ever, take place, but by another mechanism, which we are going to explain. When the head of Ihe humerus has escaped at the inferior part of ihe articulation, as most generally happens, it rests upon a surface of very small extent: further exertions of the patient—new impulses in whatever way communicated, carry it inward. So. after tbe head of the humerus has es- caped at the internal side of the joint, whatever tends to bring the arm toward the body, may increase the extent of tbe dislocation, and carry the head of the humerus near the clavicle, below or to Ihe inner side of the coracoid process. Thus we see that luxation of the humerus upward never takes place except consecutively, and after a primitive luxation inward ; and, though this last sometimes occurs primitively, it may also occur consecutively. These remarks are im- portant, and may greatly influence our attempts to effect a reduction of a luxation downward. Luxations of the humerus are almost always produced by a fall, in which the elbow, being separated from the body, is pressed against a solid plane. Under these circumstances, the elevation of the arm is carried as far as the disposition of the articular surfaces will allow, and much further than the action of the muscles can carry it; ihe humerus is pushed forcibly against the glenoid cavity, and forms with it an acute angle, the point of which is turned downward; the head of the bone is driven against the lower part of the * We have seen, in a subject, a singular inclination of the glenoid ca- vity backward. It extended, also, to a. ^reat length in that direction, so that the humerus could easily be carried into the tcb-.u sub-spinalis. The subject, whose case has been published in the Journal de Medicine, vol. x. p. 586, and which we saw withM. Fi/eau, had a luxation < » he arm outward or backward, which was re-produced with grtiu facility, 'iius particula- rity is astonishing in an accident of so 1 .i\ an occurrence. Was it not caused by a preternatural structure of the joint? Of Luxations of the Arm. 257 capsular ligament: if this ligament is lacerated, a luxation downwards takes place. But this last effect would rarely fol- low if the muscles which bring tbe arm to tbe body did not aid in producing it. They act in ibis way : when a per- son falls upon his side, his first motion is to put out his arm to prevent his head from striking the ground ; thus the whole weight of the body is received upon the arm, and as the pec- toralis major, the latissimiis dorsi and teres major contract strongly to sustain the body, and thu* draw the arm towards the breast, they carry ihe head of the humerus out of its cavity ; because the elbow is resting upon a fixed point, while tbe upper part of the bone remains moveable. Luxation of the arm is then the result of external violence, and the sudden and strong contraction of ihe pectorals major-, the latissimiis dorsi, and the teres major. The effect is more certain, as these muscles are inserted near to the head of the humerus which thus becomes the moveable point of a lever of the third kind. Muscular action alone may prod nee 1 uxat ion of the h u merus downward. An example of this kind is cited, in which dis- location occurred during the exertion of lifting a burden to a considerable height, and the dMoeation has been said to arise from tbe compression of the head of the bone by ihe deltoid muscle. But if we call to mind the elaborate remarks of Winslow on the simultaneous action of the antagonist mus- cles, we shall readily see how I be pectoralis major, the la- tissimiis dorsi, and tbe teres major, concur with Ihe eleva- tors of the arm to produce its luxation. The sane mechan- ism must have taken place in another case, of which we have an account, where tbe humerus was almost uniformly dislocated at every accession of epileptic fits : the convulsive state of the muscles producing extreme elevation of the arm, which occasioned ihe head of the bone to slip out of the lower part of the cavity. When the arm is raised, so as to almost form a line with the axis of the body, and, at the same time, carried backward, a fall upon the side may increase the inclination of the hu- merus to the articular surface, and push its head against the internal part of the capsule, by breaking which it becomes dislocated in this direction. In this case Ihe resistance of the »round acts very obliquely upon the elbow : thus a great part of the effort is lost, and hence luxation is much more un- common than in the former case. Another cause of this dif- ference is, that the muscles can hardly contribute to this kind of luxation, on account of their direction in relation lo the bone. vol. ir. '' 358 Bayer's Surgery, A fall upon the side, while the arm is carried strongly forward and upward, may cause a dislocation outward or backward. But to produce this effect ihe resistance of the elbow must be great enough to over-come the obstacle which the trunk opposes to a movement of the arm sufficiently ex- tensive. In this case the humerus, resting upon the side of the chest, and having this point of support, it becomes a le- ver of the first kind, and is thus displaced outward. It is the opposition of the two movements of the humerus and scapula that ruptures the external part of the capsule, and dislodges the head of the bone. In this case the muscles have no concern in tbe dislocation, and for this reason it is so rare. It is not yet proved that the three kinds of primitive lux- ation of the humerus can be caused, at least in their simple state, by external violence applied to any other than the lower extremity of the arm. There are many examples of luxation, produced by violence, acting upon the prominence of the shoulder; but in all these cases there was, at the same time, a fracture of the scapula, or of the humerus.* As to displacements which take place consecutively to one of the primitive luxations of which we have spoken, the causes which produce them are the weight of the arm, which constantly tends to bring it near tbe trunk, and in a vertical line ; the action of the muscles, which contract on account of the irritation produced by the luxation ; external impulses, and other causes. In the luxation downwards, as the head of the humerus rests upon an oblique and small surface, the action of the muscles which pass over the joint, and especially of those which the lnxationhas put upon a stretch, cause the bone to slip inwards, and produce a consecutive luxation in that di- rection: So in luxation inwards, lire head of the humerus being lodged in tbe anterior part of the fossa sub-scapularis, this part of the shoulder-blade can oppose no resistance to the displaced bone, and the muscles easily draw it up. No one can doubt that the capsular ligament is uniformly broken who considers its thinness and want of strength. We have had many opportunities of observing, by dissection, the size of the opening, which is always larger than the head of the humerus—sufficiently large to allow of the return of * A case of this kind has lately been communicated to us by Mr. Houzelot, Physician at Meaux. The luxation took place outwards; but there was, at the same time, a fracture of the neck of the humerus. We have two drawings of this case, remarkable on account of this last circumstance, done by one of our pupils. Of Luxations of the Arm. 259 the bone without offering the least impediment. In luxation downwards, we have seen the head of the humerus lodged be- tween the long bead of the triceps and the sub-scapularis,and resting upon the internal border of the scapula. In luxa- tion inwards, we have seen, after dissection, the head of the humerus between the sub-scapular fossa, and the muscle of the same name. In one instance we have seen the fibres of this muscle separated, partly torn, and so disposed as to admit the head of the humerus in the interval between them, which, no doubt, would have entered had the pati- ent lived. In this case the violence had been very great, the patient having fallen from a considerable height; and it is easy to conceive that great violence is necessary to impel the head of the humerus between the sub-scapularis and ser- ratus major, as some authors have described this accident. Cases of luxation inwards have occurred with fracture of the upper pari of the humerus, when the inferior portion had torn the sub-scapular muscle. In these instances the pas- sage of the head of Ihe bone between this muscle and the serratus major must be very easy. But in consecutive dis- location upwards, consequent upon a simple luxation in- wards, it is not easy to conceive how the head of the hume- rus can be lodged under the pectoralis major, between the 3ub-scapularis and the serratus magnus. In order to pass un- der the inferior edge of the sub-scapularis, and to get within this muscle, the humerus must rotate, which action the other muscles oppose: if the bone penetrate the sub-scapu- laris. and reach the serratus magnus, it must, of necessity, afterwards approach the clavicle; lastly, it must pass be- tween the muscles in question and the shoulder-blade, and if the bone be raised so as to approach the clavicle, this muscle roust follow it, and constantly cover its internal side. Some authors speak of ruptures or displacements of the long head of the triceps. To one of these two circumstances have been attributed certain pains in the joint, remaining after reduction of tire bone, and which have ceased after moving the arm in certain directions. We know of no anatomical fact upon which this notion is founded, and we have dissected many luxated arms without discovering any injury of this sort. The signs of luxation of the arm are numerous and strik- ing: In luxation downwards, which is most common, the arm is somewhat lengthened, as wc may discover by look- ing at the patient from behind, and comparing the two el- bows, while the forearm is flexed; the arm is directed outwards, and the elbow removed some distance from the body. If we look steadily at the patient, cither from before 26J Bayer's Surgery. or behind, and prolong in our minds the axis of the humerus, we find that it falls, not on the centre of the shoulder, as it should do. but a little below, and within the inferior angle of the scapula. The shoulder will have lost its spherical form. In the natural slate tbe upper third of the external side of the arm presents a surface, more or less convex, accord- ing to the size of the deltoid muscle. If we pass our fingers over this part, and press a little, we feel the hu- merus. When luxation ha* taken place, this surface is flat, and forms, with tbe rest of the external side of the arm, a well marked angle, and our fingers will hardly feel the resistance of Ihe humerus. This is produced by the tense state of the deltoid muscle, whose points of attachment are removed further from each other; and the acromion, being no longer supported by tbe head of tbe humerus, appears more prominent than natural. This part of the shoulder, in place of its natural round form, presents a depression that corresponds to ihe glenoid cavity which the humerus has left. In the axilla is fell the projecting head of the bone, situated below the wek of the scapula. The triceps and coraco-brachialis are tense, the forearm moderately flexed, or kept so by the paiient himself, to whom cither flexion or extension would give great pain. The scapula is inclined outward, and ils anterior angle drawn back by the tension of the deltoid, coraco-brachialis, and triceps muscles, and by tbe weight of the arm. whieh lends to bring it nearer to the body. This inclinaiion of ihe shoulder, and the pains which attend it, cause Ihe patient to bend his head and body to that side, and to support the arm with the other hand. Spontaneous motion of the arm is lost, but, by taking hold of the elbow, we may carry it a Utile outward without causing much pain. Every other movement is excessively painful, especially that which brings the arm near the body. In luxation inward or outward, tbe arm preserves its natural length, or is a little shortened; and the forearm is not fixed in a state of demi-flexion, because the muscles are less stretched. In luxation inward, the arm is pointed outward and backward. The flattening of the shoulder, and the de- pression formed by ihe articular cavity, are not very appa- rent, except at the posterior part. The head of the hume- rus may be felt as well below the coracoid process as in the axilla, or it is plainly perceived within the neck of the sca- pula. The movement of the elbow forward is most painful, and vice versa. In luxation outward, on the contrary, the arm is pointed Of Luxations of the Arm. 261 inward and forward. Ihe deformity of the shoulder is most remarkable at its anterior part. The head of the humerus, which cannot be felt in the axilla, forms a projection at the external anterior angle of lire scapula, below the spine of that bone, and the base of the acromion process. When the head of the humerus is placed below the clavicle, and near that bone and the coracoid process, it is evident that the luxation first look place on the internal side of the joint; but it is only some time after a luxation that the iiium-Ics or other causes can effect a consecutive displacement. But this never happens after the inflammation has augmented the thickness and consistence of the soft parts around the luxated bone. . But when the head of the bone of the arm is placed on the internal side of the glenoid cavity of the scapula, bow is it to be known whether the humerus escaped by the infernal side, or bv the inferior part of tbe articulation, and, conse- quently, if its situation be the immediate effect of a luxation, or arise from a secondary displacement, in consequence of a luxation downward ? It is not always possible to learn from the patient what was the attitude of the arm when the fall happened. An ecchvmosis on the internal part of tbe elbow mav furnish some idea of it; but it requires so violent a fall to leave a mark of this kind, that should it not exist, no ne- gative conclusion ought to be formed. Is it not very probable, that the impossibility of distinguishing between a primary and a consecutive luxation inward, ha^ occasioned the diffi- culty of reducing, even by a methodical process, some recent luxations. # In a luxation downward, and sometimes even inward, when the pain is slight and of short duration, the humerus soon experiences a new displacement. In the first place it passes inward, and, in the second, upward. Tbe irritation pro- duced by the first displacement is augmented by the second, and occasions a severe inflammation, that fixes the bone in its new situation : resolution, however, takes place, ami the muscles, having recovered all their contractile powers, give more or less latitude and facility to the movement of the bone. Raising the arm is always the most easy and extensive movement; that of bringing it near the body is more diffi- cult, from the resistance of the deltoid muscle: the mostdri- ficult is that of carrving the arm in front of the breast, or toward the head or the back. These two last movements are almost entirely lost. .,.,.. To judge from the apparent ease with which the arm is moved before a luxation of the humerus has been reduced, 262 Boyer's Surgery. it would be thought tbe bone had acquired an advantageous situation by the displacement, and that the changes experi- enced by the muscles was of little importance. It has even been asserted, probably from the foregoing observation, that the scapulohumeral articulation was that, of all others, where an anchylosis most seldom occurred, as a conse- quence of an unreduced luxation. But the fact is, almost all the movements of Ihe arm depend on those of the scapula; the humerus contributes very little to them ; and the move- ments of the humerus upon the scapula are very restricted af- ter an unreduced luxation, but the great facility of moving the scapula allows the limb considerable latitude of motion. Luxation of the arm is seldom followed by any serious consequences, unless it be complicated with violent contusion or fracture, or improper and unsuccessful attempts at re- duction have been made. Sometimes, however, it happens that the violence which produced the luxation occasions in- flammatory swelling of Ihe joint and the surrounding parts; but this is dissipated by relaxing applications, provided a reduction is not persisted in. while the joint is in this state. Although the disorder of the soft parts that accompanies luxations of the humerus is inconsiderable, and is generally confined lo the tearing of the capsular ligament, and the contusion of the neighbouring parts—although the inflam- mation occasioned by it is generally slight, and although the distended and lengthened muscles become soon accustomed to these changes, and the natural movements of the limb are soon re-established :—still a luxation of the humerus becomes not less rapidly irreducible if not effected at an early period; it can seldom be accomplished after a month or six weeks. It is true, we have reduced a number of ancient luxations of the arm, and there are examples of others that have been re- duced at more advanced periods. Yet experience ha9 demon- strated l hat it is not less dangerous to mistake the accident in this case than when any other joint is affected, and that when time has been allowed for inflammation to fix the parts in an improper situation, the reduction becomes as difficult as in any other case. It is evident, from what has been already said relative to the general principles of the reduction of luxations, that ex- tension and counter-extension are essential in those of the humerus. The first of these ought to be applied to the wrist, and the second to the scapula, so as to prevent it from yield- ing to the force which stretches the arm ; the direction of the extending force ought to bring the limb back to the atti- tude it had when the luxation took place; so that the mem- Of Luxations of the Arm. 263 ber must not be brought to its natural position until the head of the luxated bone is conducted opposite to the articular cavity of the scapula. The patient is to be placed on a chair of ordinary height: this is Ihe most favourable position, because the body and the limb are thus completely isolated, whicli gives a facility to the reduction. Should any impediment to ihe reduction arise from the patient's pressing his feet forcibly on the ground, he may be laid on a table or bed, in a horizontal position. The patient being thus placed, a napkin, or table-cloth, should be laid in folds four or five fingers wide, and the mid- dle of it applied to the back of the wrist, and the ends twisted on the palmar side: these ends are to be acted upon by the assistants. A pad of an oblong form, large enough to extend beyond the great dorsal and pectoral muscles, must be placed in the arm-pit. A band, similar to the former, serves for coun- ter-extension : the middle of it is placed on the pad, and one of the extremities conducted obliquely in front, and the other behind, then crossed and twisted on the sound shoulder; the ends of this band are used by the assistants to resist the force of the extension. A folded napkin is used to retain the superior part of the scapula; the middle of it is to be placed on the prominent part of the acromion process, and one of the ends brought obliquely in front, the other behind, toward the lower and opposite side of the thorax. The ends of this last band must be held by an assistant, behind the patient. Finally, another assistant must prevent it from slipping, by pressing the palm of his hand against it. The scapula being extremely moveable, and suspended in the middle of the muscles thai surround it, if the counter- extension were made by the bandage placed in the arm-pit, as it bears only on its inferior angle, the extending force im- parted to this bone by muscles surrounding the joint, and particularly by the deltoid muscle, would give it a rotatory motion, by which its anterior angle would be carried down- ward and outward, and the inferior angle backward and out- ward. To avoid this inconvenience, a second bandage is placed on the acromion, by which the scapula is fixed. The extending and counter-extending powers being thus disposed, the operator places himself on the extern il side of the limb, and the assistants charged with making the coun- ter-extension, ought to draw in the direction in which the bandages have been placed; but those charged with making the extension ought first to place the limb in the position it 26* Bayer's Surgery. had when the accident happened ; and when the head of the humerus is on a level with the glenoid cavity, gently bring the limb to its natural situation, without disconliu-lingthe ex- tension. During this process, the operator should push the hu- merus in a direction contrary to thai in which it was luxated. When the luxation takes place downward, the extension should be made directly outward. The limb is then to be brought downward, and a little forward, until the arm touches the side. The surgeon ought lo direct the movement by which the assistants change the direction of the limb, and extend it; as the wrist is lowered, he must press his body against tbe external part of the elbow, and with his hands placed on the internal and superior part of the humerus, carry the head of this bone upward and outward. The suc- cess of this operation depends on the unison, and just propor- tion of the force of the extension and counter-extension, with the movement given to the limb by the operator himself. When luxation takes place inward, the extension ought tube made horizontally outward and backward, after which the limb is to be brought forward and downward, until it rests obliquely on the anterior part of the breast; but, before the arm arrives at this point, the surgeon ought to act with one hand on the posterior part of the elbow, and with the other on the anterior and superior part of lite humerus, so as to bring the head of this bone outward, and thus conduct it inte the glenoid cavity. When luxation takes place outward, the last manoeuvre must be made in an inverse direction, and the extension ought first to be made, so as to direct the limb horizontally outward and forward. The head of the bone is then to be conducted outward, downward, and backward. If a primary luxation happen downward, or inward, or a consecutive displacement of the bone have carried it inward or upward, the operator ought first to carry the head of the humerus down into the arm-pit, and thence into the glenoid cavity, by its inferior part, where the capsular ligament has been torn. When a luxation of the humerus is reducible, the simple means of which we have been speaking will generally suc- ceed, if proper care be taken to proportion the force of the extension and counter-extension to that of the muscles around the joint. When a luxation is reduced, the pain ceases, or consider- ably diminishes, the limb recovers its natural form, and can execute all its natural movements; it is, however, prudent to abstain from moving the bone, except to ascertain if the Of Luxations of the Arm. 265 reduction be effected, and particularly to avoid giving it that movement by which the accident happened; otherwise we ii.*k augmenting the irritation, and even occasioning a new displacement, as once happened to ourselves. The humerus cannot be luxated, unless Ihe arm be sepa- rated from Ihe body, and more or less raised. To keep it in its nlace after il is reduced, the arm should be confined by means of a bund around it and the body, or a bnad around the bodv and ihe arm respectively. The bandage should be applied near- the elbow ; the shoulder is lo be covered with compresses wet with resolvent liquids; the arm to be coiir tinued pressed against the body eight or ten days, after which it may be supported by a sling. As soon as the pain is dissipated (which will be according to the degree of conlur sion and irritation of the soft parts) the limb should be moved to prevent its contracting a stiffness from remaining a Ions time in the same position. These movements should be gradually augmented until the stiffness is entirely removed. Luxation of the humerus may be complicated with inllaut- malion, edematous swelling, and palsy. Luxation of tbe burner u> is seldom attended with much inflammation, unless in the fall which occasioned the luxa- tion, and the shoulder has been bruised; in whicli case, if the swelling be so considerable as to prevent the reduction, we should endeavour immediately to dissipate it. After a luxation of the arm. particularly if it be of long standing, an edematous swelling of the limb sometimes ap- pears, which denotes a difficulty in the circulation of the lymph, arising from apressurgon the veins and lymphatics. It rarelv occurs to a great degree, and is seldom seen in recent luxations. It soon diminishes after the reduction of tire luxation. Should it, how cur, continue, a methodical and regular compression of the whole length of the limb will dissipate it. . Palsy is a much more serious complication. It is occa- sioned by Ihe compression and contusion of the nerves that form the brachial plexus, by the head of the humerus when it escapes from its cavity. On reflecting on the situation or this plexus, we might be surprised that this accident does not more frequently happen, did we not consider that the muscles which surround the joint do not permit an extensive displacement, and thai ihe form of the head of the humerus occasions it to slide on the brachial plexus, and on the axil lary vessels, by which they escape a strong pressure. In some cases, this pressure extends to all the nerves that form the brachial plexus; then all the muscles of the arm and fore 266 Boyer's Surgery. arm are paralyzed. In other instances, it is confined to the circumflex nerve, whose spinal direction over the internal part of the humerus renders it more susceptible of this com- pression than the other nerves. Desault twice saw all the muscles paralyzed in consequence of a luxation of the arm. In one of these cases the palsy resisted all the efforts of art; in the other, irritating liniments restored the contract- ing power cf the muscles at the end of sixteen days. We have three times seen the deltoid muscle paralyzed after lux- ation of the humerus downward. In one of these cases it lost all contractile power, became much thinner, and the patient was unable to raise the arm. Paralysis of all the muscles of the arm is to be feared af- ter a luxation of the humerus, if, immediately after the ac- cident, the patient feel a numbness and eoldness in the limb; and if the hand and arm cannot make the natural movements, no doubt can exist of its existence. It is not so easy to dis- tinguish paralysis of the deltoid muscle, because the patient does not experience any sensation about this muscle, which might lead us to presume the circumflex nerve has been bruised and disorganized. It is not until after the cessation of the pain permits the voluntary movements of the limb that we can be certain of its existence. If, after a luxation of the humerus, paralysis be appre- hended, or have actually taken place, recourse must be had to irritating applications, such as the tincture of cantharides alone, or mixed with the balsam of Florence, volatile lini- ments, &e. But if they prove insufficient, we must apply blisters, and even moxa, placed above the clavicle, on the brachial plexus. All these means may be of use, when the nerves have but slightly suffered; but are without effect if these organs have been violently contused and disorganized. We shall close this chapter by mentioning a singular ac- cident, mentioned by Desault, which happened at the mo- ment of the reduction of a luxation of the humerus: A man, aged sixty years, had the left arm luxated forward for a month and a half; to reduce this luxation, Desault was obliged not only to renew several times the extensions and counter-extensions, with great force, but likewise to move the limb forcibly upward, forward, and outward, with a view of destroying the adhesions. Scarcely was the reduc- tion completed, when a tumour suddenly arose under the great pectoral muscle, extending to the hollow of the arm- pit, whicli soon acquired the size of a man's head. This ex- traordinary phenomenon astonished Desault, and all the as- sistants. This practitioner was a little embarrassed at first. Of Luxations of the Forearm, 267 and thought the artery was ruptured, but seeing none of the eharacteristics of an aneurismal tumour, he judged that it was occasioned by wind collected between the broken cellules of the cellular tissue. Compresses wet with vegeto-mineral water were applied to the swelled part; compression was exercised with a band- age, and the arm was confined to the body. The tumour gradually diminished, and at the end of thir- teen days no vestige of it remained. In its place a large eechymosis appeared, the resolution of which was completed in twenty-seven days. ® CHAPTER XXXI. Of Luxations qf the Forearm. UNDER this head we include, 1st, Luxations common to the radius and cubitus, properly called luxations of the forearm. 2d. Those of the superior extremity of the radius. 3d. Those of the superior extremity of the ulna. ARTICLE I. Of Luxations of both the Bones of the Forearm. The elbow joint placed in the centre of the lever formed by the arm, must necessarily be exposed to the operation of considerable and varied forces; it, therefore, required much strength. The great breadth of the articulation; the reci- procal furrows on its surfaces, in anteroposterior direction, that represent a cylinder received in an analogous cavity, formed by the other; a number of alternate projections and cavities, disposed transversely to the joint, and restricting its movements; an articular capsule; two strong fibrous la- teral ligaments; and, above all, numerous muscles, that co- ver the two sides of the forearm, and most of which give origin to two tendinous fascia which are inserted into the internal and external condyles of the humerus, and others form on each side of the joint a powerful harrier, capable of tension and resistance-.—Such are the means by which 26$ Bdyer9s Surgery. nature has protected the elbow joint from luxation. This jdint presents, in its structure, and the disposition of the surrounding parts, some very remarkable circumstances. 1st. The olecranon embraces the posterior part of articular pully of the humerus, and renders a luxation of the forearm impossible, unless that projection be fractured. 2d. The Cx<- ternal lateral ligament embraces the end of the radius, and confines it to the small sigmoid cavity of the cubitus ; which explains why certain luxations of the forearm are compli- cated with luxations of the superior extremity of the radius upon the ulna. 3d. The join! being surrounded by muscles, no considerable displacement occurs, without a great injury to the soft parts. 4th. The situation of the brachial ar- tery, the median, cubital, and radial nerves, on the lateral anterior part of the articulation, exposes them to serious in- juries by the luxated bones. Notwithstanding the strength of the elbow joint, the fore- arm is susceptible of luxation, either backward, forward, or laterally. A luxation forward is impossible, unless the ole- cranon be fractured; luxation backward is most frequent; those to one side seldom happen. Luxation of the forearm backward can never be incora* plete, if the end of the coronoid process be not pushed be- yond the vertical diameter of the joint of Ihe humerus. This last, from the obliquity of its surface, would fall into the great sigmoid cavity, when the force ceased. The coronoid process is brought, by a similar mechanism, into the cavity of the humerus destined lo receive the end of the olecranon when it has passed the projecting point of which we are speaking. Lux-.iiinn of the forearm backward has been supposed to be produced by violent extension alone. Admitting (his sup- position, in which the end of the olecranon will be the cen- tre of the movement described by the forearm* the tri- ceps brachialis and internal muscles would be broken, which is not the fact. A number of instances are known* in which lux;.»ions of this kind have been occasioned by a fall forward, ihe palm of the hand resting on the ground, and the forearm being half bent. In this attitude, and the fee- ble efforts of extension which accompany it, ihe momentum of the body in the fall is tiansmitled entirely to the lower end of the humerus, which, not being supported by the an- terior part of Ihe capsule, and by Ihe superior side of the coronoid process, that forms an inclined plane, must slip for- ward, and thus occasion a luxation of the forearm back- ward. In this position, the muscles have no agency in pro- Of Luxations of the Forearm. 263 during fhe luxation, but merely retain the muscles in the at- titude in which the displacement has taken place. When we reflect on the extent of Ihe articular -urfaees. and the distance they must"go before their correspondence totally eeases, it will be readily conceived, that all the soft parts which surround them must experience extreme violence in a luxation backward. The lateral ligaments are always bro- ken; sometimes tbe annular ligament of Ihe rudius yields sooner than the lateral external ligament, lo the inferior ex- tremity of which it is attached; the radius is then dislo- cated from the small sigmoid caviiy of the ulna and radius, backwards. It is piobable. if tbe inferior insertion of tlte brachialis and triceps muscles, and particularly ibis last, did not fid-.e place at a certain disiance from the joint, they would be frequently ruptured by the inferior extremity of the humerus. This, indeed, sometime-happens; tbe joint Is 1 ben very moveable, and has no uniform position. 'Ihe humerus has been known to break the muscles and pierce the skin. J. L. Petit mentions a case where a very fat lady fell on the palm of the hand, and luxated the forearm back- ward ; the humerus perforated the skin, and the end rested on the floor. It is difficult to conceive bow the median nerves, and the brachial artery, in a case of this kind, can escape a rupture. This artery has been lorn in a similar case, and gangrene terminated the life of Ihe patient. But ihe disorder of-the soft parts is almost always restricted to ihe tearing of theli- gtttnents; the inferior extremity of the humerus rests on the anterior parts of the ulna and radius, directly under the coronoid process; the joint is enveloped and supported by the biceps and brachialis muscles lliat icstiict the extent of the luxation. These muscles, pressed out by the side of the bone, are in a state of ten&ion. and keep the forearm half bent ♦ the coronoid process of the cubitus is lodged in the olecranon cavity of the humerus, and the olecranon process is thrown backward and upward. This luxation is easily known. The forearm is bent to a certain degree,.according as Ihe cubitus and radius have been curried, more or less behind the inferior extremity of tbe humerus. It is equally impossible to extend or bend it more, and when attempted, the patient experiences violent pain. Sometimes it, however can be moved in any direction, which indicates a considerable rupture of the ligaments. There is a projection at the bend of the arm. formed by the inferior extremity or fhe humerus. The olecranon, whicli, in the natural state of the joint, and when the forearm is bent, is 270 Bayer's Surgery. on a level with the external condyle of the humerus, and under the infernal, when a luxation takes place, is above the condyles, notwithstanding the flexion of the forearm. These changes, in relation of the olecranon to the condyle* of the humerus, sufficiently characterize the accident, and therefore merit attention. Another phenomenon sometimes deceives in this case; that is, a snapping, occasioned by the rubbing of the surfaces of tbe joint against each other, which may lead one to be- lieve there is a fracture. Nothing is more important than to be assured of the existence of this luxation, for, if not soon reduced, it becomes irreducible; we should, there- fore, examine the structure of the joint with great care, in every case in which ii has been exposed to causes capable of producing this luxation. If swelling have come on, it will be proper to delay pronouncing an opinion, until, by a new examination, after it has somewhat abated, we are enabled to pronounce positively on the aceident. Luxation of the forearm backward, if discovered in time, is not a serious accident; the reduction is usually easy* But after a month or six weeks have elapsed, the reduction is generally impossible. We had the good fortune, notwith- standing, to reduce a luxation of four weeks duration, in a child ten years of age; but it is rarely practible at this late period, which is precisely that at which the inflammation has abated sufficiently to allow us to see the state of the parts. In some young patients, in whom this reduction is left unre- duced, the pressure of the bones of the forearm upon the articular surface of the humerus changes its structure, but almost always the forearm remains fixed in a state of demi- flexion. The power of pronating and supinating the hand is entirely lost. A mistake may be attended with consequences still more serious, if the biceps and brachialis anterior muscles are rup- tered. In this case, there being nothing to counterbalance the action of the triceps, the forearm is extended; and if the luxation be not reduced, the joint becomes anchylosed in this position. When a luxation of the forearm backward is accompanied by rupture of the anterior museles, and the inferior end of the humerus pierces the skin, the case is very serious. The extremity of the humerus takes a very oblique direction, so that the opening of the capsular ligament, and that of tho integuments, are far from being parallel. We have wit- nessed a case of this kind, and the accident was not so bad as might naturally be expected. The case observed by J. Of Luxations of the Forearm. 271 L. Petit was more surprising, from the rapidity of its cure. In this instance, the patient was completely cured (except a little siiffness in ihe joint) in six week*. False anchylosis is greatly to be feared in accidents of this nature. The worst case of all is, when the humerus, escaping from the cavity formed by the bones of the forearm, tearing every thing in its way, ruptures the brachial artery, with or without breaking the median nerve. All hough commonly large ruptured vessel- do not bleed, yet, in this case, if we proceed to the reduction, it would be imprudent not to make a ligature on the artery. Still it is more than probable that the circulation will not continue in this situation, particu- larly if the median nerve w ere ruptured. 1 saw a case of this kind, in which the ligature was applied, and the luxation reduced; but gangrene affected the limb, and the patient died. There are several methods of reducing luxations of the forearm backward:—1st. The patient being seated, the surgeon places one of his elbows on the anterior part of the luxated joint, grasps the patient's hand between his, and carries it toward the shoulder, pressing his elbow downward. 2d. The patient being seated on a post bedstead, the bent part of the affected limb is placed round one of Ihe posts; the surgeon then seizes the shoulder and wrist, and brings them toward each other, by a forcible flexion, the elbow be- ing at the same time pressed against the bed-post. 3d. The patient being seated, two assistants draw the limbs, one the arm, the other the forearm, in a straight line, until the re- sistance of the muscles is overcome, and the articular sur- faces brought on a level; the surgeon then applies one hand to the arm, and with the other takes the inferior part of the forearm, and adds a violenl effort of flexion to the ex- tension already made. This process is more rational than the two first; but the following is preferable to it. The patient being seated on a stool, the surgeon places the fingers of both his hands united on the bend of the arm, and his two thumbs on the projection formed by the olecra- non; he is then to push the inferior extremity of the hume- rus backward, and tbe olecranon forward; two assistants take, one the shoulder, and the other the wrist, and make the extension and counter-extension; the surgeon uses his fingers as already indicated : when he perceives the articu- lar surfaces are near their natural situation, the assistant eharged with making the extension is ordered to draw the forearm in the direction of its flexion. In recent luxations, difficulties are seldom experienced; 272 Boyer's Surgery. m frequently the fingers alone are sufficient, particularly when the anterior muscles have been ruptured. But in ancient luxations, ihe extension and counter-extension must be made by bands, disposed as in luxations of the humerus; and in this case, previous forcible movements must be given to (Ire limb, to destroy or weaken the adhesions the parts have al- ready contracted. When Ihe inter-osseous ligament of the forearm is not broken, the ulna, in reluming to its natural place, draws the radius witn it, and these two bones are reduced at the same lime, although the force that effected the coaptation acted only on one of (hem. But when this ligament is bro- ken, the ulna may be replaced without the radius; or. if the two bones have been reduced at the same lime, the radius may be again displaced ; and. should il remain in this state, pronation, and especially supination, would be impossible. Although luxation of Ihe forearm backwards soon be- comes irreducible, still, when it is accompanied by very great inflammatory swelling, a reduction ought not to be at- tempted until Ibis is dissipated, or- considerably diminished. A contrary conduct may occasion serious accidents, of which there are many examples. W hen a luxation is ancient, we must not persist in the re- duction, after having ineffectually attempted it. by proper means. However great the deformity, it is better to leave it than expose the patient to very serious accidents. Wo have never attempted it in similar cases, without seeing a violent inflammation follow the unsuccessful attempts. When the extremity of the humerus penetrates through the soft parts, tlte reduction is not difficult. The patient ought then to be treated as for a complicated fracture. We know not, if a case of this kind (the patient being left lo nature for several days) has been observed. It would certainly be a very serious case. We think, if tho inflammatory symptoms were already developed, it would be wrong to attempt to reduce the luxation at litis moment. We should desist from replacing the projecting bone until these symptoms were dissipated. We have never had occasion to observe the terrible effects of a luxation complicated with an ulcer, the coming through of the humerus, and rupture of Ihe brachial artery. VVe think it wotrld be useless to attempt to save the limb. The violence of the shock, the disorder the parts have experi- enced, the prodigious swelling that must necessarily follow, would leave no hope of the circulation being continued in it, and amputation must immediately be performed. Of Luxations of tlie Forearm. 273 This luxation is known to be redueed by tlie appearance of the parts, and the facility of flexing and extending the arm, &ti. It i- then necessary lo assure ourselves if the radius was replaced at the same time with the cubitus; if not, it must be reduced immediately. The power of performing the movements of pronation and supination will show when it is in its natural (dace. To keep this luxation reduced, the forearm being bent to aright angle, the joint is lo be covered with long compresses wet with resolvent liquid, and kept in place by a figure of 8 bandage ; the dressing is to be removed every two or three days, and at eaeh time tlie hand is to be placed in a state of pronation and supination, to ascertain that the radius has preserved its natural position; should it have quitted it, and gone backwards, a splint must be applied along the pos- terior part of ihe radius, to prevent it from leaving the small sigmoid caviiy of the ulna. Emollient and anodyne poultices are employed when the luxation is accompanied with inflammation; and the dressing of which we have been speaking is not to be applied until the inflammation is dissipated. Movements of the limb ought to be made as soon as tbe state of tbe soft parts will permit, to prevent stiffness. We have never seen a luxation of the forearm forward accompanied and complicated wilh fracture of the olecranon $ and we doubt if (his case, which has been conceived possi- ble, has ever been observed. In such instances, we conceive the projection formed on the anterior and inferior part of the a.m by the superior extremity of the bone of the fore- arm, would be remarkable, and the limb very moveable. It would be impossible for the intcr-osscous ligament to escape being entirely torn; and it is extremely doubtful if coaptation of the two fragments could be effected. On the other band, such an accident could only be produced by enormous violence. An inflammatory swelling, propor- tioned to tbe intensity of the luxating cause, must be ex- pected. Thus contusion, or some degree of stiffness of the joint, being very probable, it would be prudent to pay no at- tention to the fracture, at least not to place the limb in a state of extension, in the vain hope of obtaining an exact re- union of the fragments. On the contrary, after having re- duced the luxation, place the limb at a right angle, and keep it so by proper bandages, and bring the olecranon lower down ; for if the forearm be like lo lose its principal mcve- ments, it is essential to place it in a position in which it can be of some "utility, which is that of flexion. vol. it. 35 27* Beyer's Surgery. S: Luxation of the forearm on either side of the humerus is very rare, not only because the surrounding parts of the elbow joint are furnished with powerful means of union, but because the reciprocal depressions and projections of the artieular surfaces prevent a displacement in this direction, and particularly because the forearm is not susceptible of any movement that ean facilitate luxation of this kind. The forearm may, however, be luxated outward and inward ; but the external violence capable of producing either must be very powerful, and act, at the same time, on the arm and forearm in contrary directions. J. L. Petit mentions an example of a servant that had the forearm caught in the spokes of a carriage in motion, and of another person who bad the same part under the body of a horse that fell with bim. Each suffered a lateral luxation of the forearm. The great breadth of the joint renders difficult a complete lateral dislocation of the forearm. Luxation of this kind is generally incomplete. In the last case, the articular surfaces still touch, but their relations are more or less changed. In other instances, the bones are pushed quite beyond their natural contact; the luxation is then complete, and if the forearm have beeu carried outward, not being held by any of the ligaments, it is carried upward, and there is then a real overlaping of the forearm on the arm. The external condyle of the humerus has too little elevation to oppose this new displacement: But if, on the contrary, the luxation take place toward the internal side, this last effect does not follow ; the bones of the forearm being supported by the in- ternal condyle of the humerus. There cannot be even an incomplete luxation of fhe forearm without a rupture of all the ligamentsit Even the muscles of the forearm, that form two large and powerful packets, one on each side the elbow joint, may be broken near their insertion. On this account, tbe luxated limb is rarely so flexed as in luxation backward. This phenome- non never exists when the luxation is complete. Very little attention is necessary to discover a complete luxation of the forearm, whether inward or outward; in- complete luxation, if of little extent, is more difficult to dis- cover. However, the projection formed on one side by the radius or the ulna, and on the other by the opposite side of the extremity of the humerus; the depression above one, and below the other of these projections; the rising formed by the biceps and brachialis muscles before, and by the tri- ceps behind the elbow; the inclination of the forearm and hand outward; and the feebleness and fixed state of the limb, Of Luxations of the Forearm. 276 are sufficiently characteristic of the accident. If swelling have already taken place, the diagnosis may be more diffi- cult, particularly if the displacement be trifling. Complete lateral luxations are more serious than those backward, on account of the intensity of the cause necessary to produce them, and the consequent injury of the soft parts* Incomplete luxations are neither serious nor difficult to re- duce. Should they not be reduced, the movements are more or less completely re-established, if care is taken to exer- cise them early. Reduction of the luxations we are now speaking of, is never difficult, because the soft parts that surround the joint are torn; most frequently extension is not necessary to bring the bones to their natural situation ; it is, however, prudent to extend the limb so as to prevent the bones from rubbing against each oilier during the coaptation. The patient should be sealed, and the surgeon, placing himself on the internal or external side of the luxated limb, according as the luxation has taken place inward or outward, takes hold of the joint in such a manner that the fingers of each hand press against the lower extremity of the humerus, while the thumbs are applied to the upper part of the bones of the fore- arm ; one assistant takes hold of the wrist, the second of the superior part of the arm, to make the extension and counter- extension in a straight line. When the luxation is not com- plete, slight extension is sufficient: but in complete luxation outward, the limb must be extended until it is restored to its proper length ; and when this is effected, the surgeon presses the two bones of the forearm in opposite directions, until be reduces them. By bending the forearm, he can then judge, from the natural appearance of the limb, and the free- dom of its movements, if the reduction is properly effected. He should then examine if the upper extremity of the ra- dius preserves its natural relations with the ulna. When the reduction is effeeted, the forearm should be bent to a right angle, and covered with compresses wet with a resolvent liquid. They are lo be kept on by a roller mode- rately tight. The arm is then to be placed in a sling. If there is a great tendency to a recurrence of Ihe luxation, splints of wood or paste-board should be applied. Tlie in- flammation is generally very violent, and requires a low diet, several bleedings, and the application of emollient and anodyne poultices. As soon as it has somewhat al;at h1, we should move the bones gently, to prevent stiffness of the joint. ( 276 ) CHAPTER XXXII. Of Luxations qf the Bones of the Forearm from each otlier. THE superior extremity of the radius may abandon the small sigmoid cavity of the ulna with which it is arti- culated ; and the round head at the lower end of the ulna, may also eseape from the sigmoid cavity of the radius, into which it is received. We shall treat of each of these acci- dents in a separate article, after staling some circumstances common to both. The structure of the forearm is such as to permit the up- per part of the radius to turn upon its axis, without prevent- ing a slight lateral inclination, or the movements of flexion and extension. In the movements of pronation and supina- tion, the hand turns in a circle, of which the styloid pro- cess of the ulna is Ihe centre. The inner side of the lower extremity of the radius describes an arch of a very small circle; the outer side moves in that of a larger circle : hence the radius deviates very little from the natural direction of its axis; were it not for this the superior ligaments would be put upon the stretch, and would resist the movement of pronation. In the prone position of the hand, its radial edge being turned forward and inward, the upper part of the radius is removed a little from the small head of the humerus with which it is articulated ; on the contrary, where the hand is In a supine position, the radius .is pressed against the hu- merus. However, the flexor muscles .of the fingers form, with the radius, a much larger angle than the extensor muscles. This will be evident, if we compare the situation of the pronator teres and pronator quadratus, with that of the supinator brevis, the only muscle which can limit excessive pronation.. Lastly, we make the strongest efforts to place the hand in a slate of pronation, and it is during these exertions especi- ally, that the forearm is exposed to dislocation. Of Luxations of the Banes of the Forearm. 277 ARTICLE I. Of Luxation of the Upper Extremity of the Radius. Tlie upper extremity of the radius can only be luxated backward. This luxation is most frequent among children, because, in them, the ligaments and tendons of the extensor muscles are weaker, and the sigmoid cavity of (he ulna is more superficial. It is always complete. The annular liga- ment is ruptured when the accident takes place directly from external violence. In some cases, however, of which we shall presently speak, the ligaments are merely stretched. In several instances this luxation has been occasioned by a fall upon the hand unexpectedly caught in a state of extreme pronation; but it is most generally caused by external violence, tending strongly to pronate the band: hence it occurs frequently in children who are lifted by the hand over a stream, or into tlie arms of another per- son ; and, also, when they are taken by the hand in play. In these circumstances, the hand being generally pronated very suddenly, the luxation is either immediately produced; or, by repetition of this improper practice, the ligaments which connect ihe upper end of Ihe radius with the hume- rus, become so much relaxed as to suffer the bone to be dis- placed. This accident is attended with severe pain in the seat of the injury ; the forearm is bent, and the hand remains fixed in a state of pronation ; tbe patient cannot supinate the hand; if the surgeon attempt to supinate it, the pain is much increased; the hand and fingers are kept moderately flexed; and. lastly, the upper end of the radius forms a pro- jection behind the small head of the humerus. A relaxation of the ligaments of the articulation of the radius with (he ulna is attended with the following symp* toms: The articulation is evidently loose; the head of the radius projects more than it should, and there is pain and swelling about the joint. The children fear to have the part examined, and cry when the hand is pronated or supi- nated, when the arm is flexed or extended, bul, above all, when we press upon (be joint. If we offer them a play-thing, they put out the well hand to receive it: if we oblige them to take it with the other, and they wish to put it to their mouth, they bend the hand, and incline the head as much as possible. If tbe forearm is moved during sleep, they awake crying. The proper treatment in this case is to apply a rol- 278 • Bayer's Surgery. ler, wet with a resolvent liquid, and to support the arm in a sling. If this treatment be neglected, and the causes of the relaxation are repeated, the end of the radius at length abandons the sigmoid cavity of the ulna, distending or tear- ing the annular ligament. When this luxation is not reduced, though no serious oon- sequences ensue, the movements of pronation and supination are, in some measure, impeded, and the hand is much less useful than it would otherwise be. In effecting the reduction, the patient should be seated on a chair, and the limb held at a proper height by two assist- ants ; one of whom takes hold of the hand, the other of the lower part of the arm. The surgeon, stationed on the af- fected side, places the four- fingers of one of his hands upon the bend of the elbow, and the thumb upon the posterior part of the projecting head of the radius; with the other hand he takes hold of the patient's wrist. While in this situation, the operator, and the assistant who has hold of the patient's band, acting in concert, bring the forearm to a state of su- pination and extension, while the thumb of the former pushes the head of the humerus into the sigmoid cavity of the ulna. The sudden disappearance of the projection formed by the head of the radius, and, in some instances, a noise, toge- ther with the return of the forearm to a state of supination, and the power of extending and bending it freely, are cer- tain signs of the reduction of the luxation. Children pronate and supinate the hand voluntarily, if we take pains to induce them to make these movements; but we should not carry our experiments too far, lest we re-produce the luxation. In order to prevent a return of this displacement, the forearm should be flexed, and slightly supinated. The joint is then lo be covered with oblong compresses, kept on by a roller moderately tight. The arm should be placed in a sling, and a folded towel should be laid along the anterior part of tbe forearm, to prevent the movement of prona- tion. When there is a mai-ked tendency to a repetition of the displacement, a splint of wood should be placed along the posterior part of this bone. After twenty days we may discontinue the use of the ap- paratus. In children, in whom we perceive the articulation to be relaxed, we should forbid the nurse to force the forearm to a state of pronation, by drawing upon the hand; or, if necessary, even confine the forearm to the body, as after a luxation. Of Luxations qf the Bones qf the Forearm. 279 ARTICLE II. Of Luxations of the Inferior Extremity of the Ulna. This accident has been improperly considered, by some authors as a luxation of the lower end of (he radius. Desault first proved (he reality of this luxation. Facts in confirmation of his opinion have since shown, beyond all doubt, ihe possibility of this accident, which the Royal Aca- demy of Surgery treated as chimerical. There are, in fact, two kinds of luxation of the lower extremity of the ulna; •ne backward, the other forward. These accidents are much more rare than luxations of the superior end of the radius. The displacement backward is most frequent: we have met with only one instance of lux- ation forward. Among the bodies brought to the amphitheatre for dissec- tion, in 1793, Desault found one of whom no account could be obtained, who evidently offered an example of luxation of the inferior extremity of the ulna backwaid: A hard prominence was perceived before the lower end of the fore- arm, and a depression on the opposite side. The part was carefully dissected: The hand was edematous; the tendons of the flexor muscles, pushed outward, adhered to each other, and to the spine; (he sigmoid cavity of the radius was filled with cellular substance; the inter-articular liga- ment, which is between the ulna and tbe os pyramidalc, scarcely touched the ulna, and had followed the radius back- ward ; the head of the ulna, situated before the sigmoid ca- vity of the radius, rested upon a sesamoid bone, to which it was attached by a capsular ligament. Both these kinds of luxation of the lower end of the ulna are occasioned by external violence, applied to tbe forearm or the hand. Desault published the case of a washer-woman, who luxated the lower end of the ulna backward, in wrench- ing clothes. In cases of this kind, the capsular ligament, which surrounds the articulation of the ulna with the sig- moid cavity of the radius, is put upon the stretch, and ex- posed to laceration; the triangular ligament, which goes from the radius to the ulna, protects it, in some measure, by moderating this movement. In order that the luxation take place, this ligament must lengthen enough to pass behind tbe head of the ulna. Some facts lead to the belief, that the lower end of the ulna may be luxated backward in a fail upon the hand. 280 Bayer's Surgery. In luxation backward, the forearm and band are in a state of extreme pronation, and Ihe two bones of the forearm evi- dently cross each other; the lower part of the forearm is much narrower than in its natural state; the forearm, hand, and fingers are fixed in a state of moderate flexion ; the ten- dons of the flexor muscles, gathered inlo a bundle, project on the ulnar edge of the radius; the inferior extremity of this bone seems to be above the level of the wrist, but this is a deception which arises from the change in the situa- tion of the radius and ulna. In luxation forward, we ob- serve the same crossing of the bones of the forearm ; the flexed slate of this part, and of the fingers, and the narrow- ness of the lower end of the limb; the forearm and hand are fixed in a state of supination, the projection of the ulna is perceived in front, and the tendons of the flexor muscles are pushed outward ; the inferior extremity of the ulna, in- stead of being parallel to the radius, is oblique, in a direc- tion downwards, outwards, and forwards. In each case there is acute pain, extending from the articulation over the forearm, and greatly increased when the slightest effort is made to pronate Ihe hand, or to extend Ihe arm. When the luxation is not reduced, the movements of pro- nation and supination are lost; ihe movements of the fin- gers are more or less embarrassed. To effect the reduction, the patient is to be seated, and the limb supported by two assistants, as in the case of luxation of the superior extremity of the radius; the surgeon, sta- tioning himself on the outer side of tbe limb, embraces the lower part of it with his hands, one on the ulnar edge, and the other on the radial edge, -o (hat the thumbs may be pressed into the interval between ihe two bones, on the side toward which the bone is displaced, and the fin- gers on the opposite side, and thus forces tbe bones in con- trary directions; when he perceives that they are somewhat separated, he directs the band to be sup'mated, if the luxa- tion be backward, and pronated, if the luxation be forward; at the same time pushing the ulna back to its place. Re- pealed trials are often necessary before we can succeed in ef- fecting the reduclion. After the reduction, it is very necessary to guard against a recurrence of the luxation, by laying thick compresses, and even a splint, along the ulna, extending to the hand. Case. In 1791, a woman of strong constitution, but spare, having drank some wine, was looking over some persons at play, in a coffee-house, and making observations on the game. One of the players, a stout man, highly offended, Of Luxations of ihe Bones qf the Forearm. 281 rose from his seat, took held of her right hand, and endea- voured to put her out of (be room. In lire bliugglr. the woman's band and forearm were forcibly stipulated ; she felt acute pain, and cried out that her wrisi was broken. 1 saw ber immediately afterward : The forearm wasbcni. (he hand flexed, and in a state of strong supination; Ihe leas( attempt to pronate the hand caused excruciating pain; ihe head of the ulna projected anteriorly; the ulna formed a very acute angle with the radius, passing downward, forward, and out- ward. Convinced that tlie lower extremity of ihe ulna was dislocated forward, 1 endeavoured lo reduce it after the manner I have laid down. rlhe fourth attempt was -uc- eesefuL The part was covered with compresses wet with brandy and water, and a bandage passed two or tljree times •round Ihcm. The next day, *ome tendency to displace- ment being discovered, a roller was carefully applied. This treatment was continued for fifteen days; the patient was then permitted cautiously to use the limb. The cure was oomplete. CHAPTER XXXIII. Of Luxations of the Bones of the Hand. IN this chapter we shall treat, 1st. Of luxations of the hand, or wrist; 2d. Of those of the bones of (he carpus; 4d. Of those of the hones of the metacarpus; and, 4th. •f those of the bones of the fingers. ARTICLE L Of Luxations of the Wrist. The three first bones of the carpus form a convexity, ob- long, in a transverse direction, inclined backward, and re- ceived into a cavity at the lower extremity of the radius. The ulna forms no part of this cavity ; but the lower part of the ligamento-cartilaginous substance, which pa-ses from the radius to the ulna, between the os pyrimadale and tho fatter bone, forms the internal part of the cavity in question. vol.. II. 36 t 282 Bayer's Surgery. This articulation is strengthened by a capsule, two lateral ligaments, and by the tendons of the muscles of the hands and fingers. These tendons contribute greatly to prevent luxations of the wrist, which are. consequently, rare. Notwithstanding this, the wrist may be luxated, and in four different ways, viz. backward, forward, inward, and outward. The two first named are the most frequent, and these luxations are generally complete; but tbe others are almost always incomplete. In all tliese luxations, the ligaments corresponding to the side toward which the luxation takes place, are lacerated, and the tendons are more or less distended. The most fre- quent cause of these accidents is a fall upon the palm or back of the hand, or upon the radial or cubital edge of it; or a sudded and unexpected impulse, communicated to the hand in the direction of its flexion, extension, or of its abduction or adduction. In whatever direction the luxation may take place, the hand loses (he power of moving, and the radius that of ro- tating. Beside these characteristics, eaeh particular kind of luxation of the hand has its peculiar symptoms. 1st. In the luxation forward, the hand is fixed in a state of exten- sion proportioned to the degree of the displacement; the fin- gers are more or less bent; the carpus projects at the ante- rior part of the articulation; a depression, or transverse fold is perceived below the inferior extremity of the radius; and the flexor museles are tense. 2d. In the luxation backward, the hand is fixed in a state of flexion; the fingers are ex- tended, or may be extended, without effort; the carpus forms a projection at the posterior part of the joint; there is a depression, or transverse fold, below the inferior extremity: of the forearm, on the palmar side ; and tbe extensor muscles are tense. 3d. In the luxation outward, the band is strongly inclined toward the ulnar edge of the forearm, and is fixed in this situation; and the external side of the carpus projects be- low the inferior extremity of the radius. 4th. In the luxation inward, the hand is strongly inclined toward the radial edge of the forearm, and the internal side of the carpus forms a projection below the inferior extremity of the ulna. In general, luxations of the wrist are very serious acci- dents, on account of the extensive laceration of the liga- ments, &c. in consequence of which there is extreme pain, inflammation, and collections of glairy or synovial matter in the sheaths of the tendons, and sometimes even abscesses. The cure is tedious; and the motions of the wrist are al- ways mere or less impaired, and sometimes lost. In many Of Luxations qf the Bones of the Hand. 283 instances, gangrene takes place, or an excessive suppura- tion, which renders amputation necessary to save the life of the patient, or terminates in caries of (he articular surfaces. M. Thomassin relates a case, which i9 a happy exception to the general termination of these accidents. A child, aged six years, in a fall from a horse, luxated the wrist of the left band. The extremity of the radius penetrated the inte- guments at the iniernal side of the wrist, between the radial artery and the bundle of flexor tendons, and projected out the distance of a finger's breadth; the ulna remained beneath the muscles, and extended beyond the os unciforme; notwith- standing which the cure was perfect. There remained only a slight swelling of the bone, which did not embarrass the movements of the joint. Incomplete luxatioqs of the wrist are easily reduced; but complete luxations, especially if attended with great inflam- mation and swelling, arc reduced with the utmost difficulty. Unsuccessful attempts at reduction add greatly to the seve- rity of the accident, by increasing the irritation. We should, therefore, employ the most powerful antiphlogistic reme- dies, and, after the inflammation is dissipated, if it be not then too late, proceed to the reduction in the following man- ner : The patient being seated, a strong assistant embraces the upper part of the forearm with his two hands; another assistant, still stronger and more intelligent, takes hold of the metacarpus, as near as possible to the wrist; the two assistants draw the limb in contrary directions, with a gradu- ally increased power, until the extension is sufficient; the surgeon, at this moment, pushes the bone in a direction op- posite to that in which it was displaced; at the same time di- recting the assistant, who has hold of the hand, to press the bone towards its natural cavity. After the reduction is effected, the joint is to be covered with oblong compresses, wet with a resolvent liquid, and a roller applied over the whole. This simple apparatus is sufficient in lateral luxations, but in luxations forward or backward, it is necessary to apply two splints, as in fractures of the forearm. In this luxation, above all others, we should guard against inflammation. If the patient experience but a moderate de- gree of pain, the apparatus should not be removed until the expiration of two or three days. This treatment is to Ire con- tinued until we think proper to move the hand in order to prevent its becoming stiff. However well the reduction may have been effected, a de- gree of swelling often remains, which greatly impede* the 284 Bayer's Surgery. movements of the wrist and fingers. Patients and unfa* structed surgeons are often led to think that the bones have not been reduced until ihey are convinced to the contrary by the gradual disappearance of the swelling. If abscesses form about or in the joint of the wrist, they should be opened as soon as there is evident fluctuation ; but we should he careful not to be deceived by false perceptions, and open the joint where there is no collection of pns. The formation of matter, however, is generally followed by an- chylosis of the wrist, and sometimes leads to the necessity of amputating the forearm. In cases where the radius projeet* externally, we should not hesitate to enlarge the opening of the skin, if necessary, in order to facilitate the reduction. ARTICLE II. Of Luxations qf the Bones of the Carpus upon each other. The os magnum may escape from the cavity formed by the scaphoides and semilunare, into whieh it is received. When the band is flexed, the head of the os magnum is inclined backward; it raises the capsular ligament; and, if this move- ment be carried very far, the capsule and the accessory liga- ment are torn, and the head of the os magnnm is luxated. This accident is not very common, and occurs more fre* quently in women than in men, and is caused by a fall upon the back of (he hand, or by grasping a body with the hand, and bending the wrist strongly. The signs of this accident are, a hard, circumscribed tu- mour in Ihe situation of the head of this bone, increased by flexion, and diminished by extension of the hand. In this position, a flight compression will cause it entirely to disap- pear. Scarcely any inconvenience results from this luxation. The tumour which it occasions is hardly perceptible in a woman whose hand is (hick. The bone is easily pressed into its place while the hand is extended, but it requires some pains to keep il there—more than most patients are wil- ling to submit to for so trifling an accident. Of Luxations of the Bones qf the Hand. 28£ ARTICLE III. Of Luxations of the Bones of the Metacarpus. The articulations of the bones of the metacarpus with those of (he carpus, are never the seat of luxations. The metacarpal bone of the thumb may be luxated back- ward, but in no other direction. The most frequent cause of this luxation is a fall upon the external edge of the hand, which, by forcibly flexing the thumb, lacerates the capsule, and (hrows the upper end of the bone out of its cavity, behind the trapezium. When this luxation exists, there is a hard tumour formed by the upper extremity of the luxated bone; the thumb and tbe first metacarpal bone are bent; ihepaiient cannot extend the finger, and, in attempts to do so, suffers acute pain. A great degree of swelling sometimes renders it difficult to as- certain the existence of this accident, and, if we merely apply poultices, it becomes irreducible; or if we even effect the reduction, as the capsular ligament will have formed adhe- sions in tbe situation in which it was thrown by the accident, tbe luxation easily recurs, and the movements of the thumb are ever afterwards embarrassed. To reduce this luxation, we are to direct one assistant to take hold of the thumb, and another to grasp the wrist; While they arc drawing in opposite directions, we are to push the head of the bone, forwards and downwards, into its eavity. A doll noise is heard at the moment of the reduclion, and tbe deformity disappears. A compress, wet with a resolvent lotion, and a small splint should be applied to the thumb, to prevent a recurrence of the lux- ation. If, however, there be much inflammation, the parts should be covered with poultices two or three days before we apply tbe compresses, &c. After the luxation has remained for some time unreduced, the bone may still be replaced, but the luxation immediately recurs. Madame de la P— fell upon tbe external edge of the left hand, and luxated the first bone of the metacarpus backward. A surgeon, who saw it, mistook the nature of the accident, and applied emollient poultices and resolvents. There remained a de- formity at the external side of the carpus, and the move- ments of the thumb were impaired, especially that of ex- tension. Two months after the accident, the luxation was easily reduced by another surgeon, who advised the applica- tion tf a splint and roller to prevent a recurrence of the ac- 286 Boyer's Surgery. cident; but these means were neglected. I saw the lady four months afterwards: The projecting end of the bone could easily be pushed into its place, and, while kept there by pres- sure the movements of the thumb were as free as ever; but the moment the pressure was removed the luxation returned. ARTICLE IV. Of Luxations of the Fingers. The first phalanx of the fingers and of the thumb, may be luxated backward, forward, and to either side. That of the thumb is more frequently luxated than all the rest. This bone is most generally displaced backward. Many persons have the power of producing this luxation at plea- sure. We do not know if this circumstance arise from a particular structure of the joint, or from a relaxation of its ligaments. Independently of any particular disposition of this kind, the thumb may be luxated backward when it is violently ex- tended by an external cause: The bone of the first phalanx passes up behind the head of the first metacarpal bone, tear- ing the capsular ligament and tendons of the extensor mus- cles; the lateral ligaments are not broken. It is scarcely possible to mistake this accident. The first phalanx is extended, so as to form almost a right angle with the metacarpal bone. Its head projects at the anterior part of the articulation. The last phalanx is bent, and, like the other, immoveable. This luxation, easily reducible at first, soon becomes irre- ducible if left to itself. I have attempted the reduction ten days after the accident without success. Desault, foiled in a similar case, proposed to make an incision behind the head of the luxated bone, and to introduce a lever to pry it into its place. But the patient would not submit to the operation. The difficulty of effecting a reduclion in these cases arises, no doubt, from the small hold which the thumb offers for ex- tension, and the resistance of the strong muscles which sur- round (he joint.* Tbe method of reducing this luxation is as follows: One assistant places his hands firmly around the patient's wrist.; another strong assistant extends the thumb; as soon as the * See note H. Of Luxations of the Thigh. 287 surgeon perceives that the bone has yielded to the extension, he pushes its head downward and forward, directing the se- cond assistant, at the same moment, to flex Ihe thumb. It is sometimes necessary to make the extension by means of a bandage. When the luxation is reduced, oblong compresses, wet with a resolvent liquid, are to be applied, their ends crossing on the back of the thumb. Over these we should pass a rol- ler, and place the hand in a sling. While there is much swelling, we may substitute poultices for the resolvent liquids. Luxations of the first and second phalanges of the fingers backward, and those to one side, are very rare, very easily discoverable, and requiring no particular directions for their treatment. ®» CHAPTER XXXIV. Of Luxations of the Thigh. THE strength of the articulation of the femur with the pelvis is such, that the thigh can only be luxated by very great external violence, and circumstances which rarely occur. In falls, the neck of the femur is broken more fre- quently than it is luxated. The thigh may be luxated in four different directions, viz. upward and outward, downward and inward, upward and forward, and downward and backward. The two first are the most frequent. The luxation upward and forward is very rare, and that downward and backward the least frequent of all: it can only take place secondarily. At whatever part of the acetabulum the head of the fe- mur escapes, the capsular ligament is always torn. In luxa- tions downward and inward, the round ligament may yield, and escape being broken; but it is always lacerated in the other kinds of luxations. In luxations upward and outward, the head of the femur passes, more or less, backward upon the dorsum of the ilium, between the fossa iliaca externa and the gluteus mini- mus, which it raises up, and by which, if I may use the ex- pression, it is capped. The capsular ligament, torn at its lower and external part, is stretched over the acetabulum; the glutsei, psoas, and Hiae museles, the pyramidalis, 288 Bayer's Surgery. the gemmi, the obttiratores, and the quadratus arc length- ened from the same cause. This luxation is always caused by a fall from a height, in whieh the thigh is carried forcibly forward and inward. In this movement the luxation is favoured by the contraction of the glutei muscles. The signs of this luxation are as follow; the thigh is shortened; the fold of the groin is higher than that of the opposite side; the thigh is thrown in a state of flexion and adduction; it is turned inward, as well as the knee and tbe point of the foot; the great trochanter is nearer the crest of the ilium than in the natural state; the head of the bone forms a tumour on the dorsum of the ilium, and the patient can neither extend the thigh, addnct it, nor rotate it outward; the j'movements of flexing, adducting, and rotating the thigh inward, may be made to a slight de- gree without increasing the pain ; if the patient walks while the reduction is yet unreduced, he touches (he point of the limb to the ground, but still finds the limb shorter than the other, and, of course, limps. All these phenomena are easily explained, except, perhaps, the rotation inward, which takes place, notwithstanding the gemini, the obtu rat ores, and the quadratus are put upon the stretch; this arises, probably, from the resistance of a portion of the capsular li gament that proceeds from the anterior and inferior spine of the ilium, and resists the actions of the muscles which turn the thigh outward. In luxation downward and inward, the head of the femur is lodged between the ligament which closes the foramen ovale and the obturator externus muscle. Tbe internal and inferior part of the capsular ligament is torn, but the round ligament is not ruptured; the glutei, pyramidal is, ge- mini, obturatores, and quadratus are in a state of tension; the adductors, elongated, form, at the inner side of the limb, a tense cord, that extends from the pubis below the middle of the thigh. This luxation is always caused by external violenee, whieh earries the thigh outward. In the abduction of (his limb, the head of the femur slips to the inner and lower part nf the acetabulum; a part of it is raised above the head of the cavity, and is only supported by the capsular ligament. Now, if this movenrent be suddenly carried very far, (as for instance, in a fall from an elevation, when the thigh, sepa- rated from the body, receives its whole weight) the capsular ligament is torn, and the head of the femur abandons the acetabulum. This luxation is favonred by the external and Of Luxations of the Thigh. 289 superior edge of the acetabulum, furnishing a fulcrum to the superior and outer part of the neck of the femur, by whieh the neck is prycd over the opposite side. The mus- eles have no agency in producing this accident; whieh is rare, because, in falls, the thighs are seldom separated. The signs of this luxation are as follow: The affected thigh is longer than the sound one: we perceive, below the groin, at the internal part of Ihe thigh, a tumour, formed by the head of the femur, placed in the foramen ovale; the buttock is flattened; the trochanter is no longer felt in its natural place; the fold of the groin is situated lower lhan that of (he opposite side, and, instead of describing a cres- cent, as in the natural state, it forms an obtuse angle, as if the middle of it were pinched up; the leg is slightly bent; the thigh separated from that of the opposite side; a hard chord is felt fn the situation of the abductor muscles; the foot and knee are turned outward by (he glutei muscles; the thigh cannot be turned inward, and any attempt to perform this movement causes acute pain, on account of the tension which it gives to the glutei muscles. If we put the patient on his legs, the luxated limb being longer than (hat of the opposite side, (he foot is raised by flexing (be knee; and, if the patient wishes to straighten the limb, he carries it forwanl, and to one side, making tbe foot deseribe an arch of a circle. Luxation upward and inward is much more rare than that of which we have spoken. We have, however, met with three instances of it, and there is a great number on record. The head of the femur is thrown upon the horizontal branch of Ihe pubis, under Ihe psoas and iliac muscles; the upper par-t of the capsular ligament and the round ligament are torn; tbe glutei, pyramidalis, gemini, quadratus, and ob- turator muscles are elongated—all the oilier muscles are re- laxed; (he femoral vessels, and crural nerve, are pushed in- ward, perhaps a little raised by the head of the femur: but the compression of these parts does not occasion gangrene of the limb in cases where tlie luxation is not reduced. The cause of this luxation is a great force which carries the femur backward, while the pelvis is pushed forward. It has never happened under any other circumstances. Tlie thigh is shorter, and slightly extended; the knee and point of the foot are turned much more outward than in the lux- ation downward and inward ; the great trochanter is raised and brought forward, almost in the same vertical line with the anterior superior spinous process of the ilium; the head of the femur is felt in the groin, and, within it, the pulsa- voi» ff. 37 290 Beater's Surgtry* tions of the femoral artery are plainly distinguishable. The patient complains of pain in tfie groin, the buttock is flat- tened, and ttje curved line, which separates it from the fJbigh, is higher than in the natural state. We cannot turn the thigh inward, and if we attempt to do it, the patient ex- periences great pain. . According to J. L. Petit, the whole limb becomes numb and swollen if the luxation is not immediately reduced. We have never seen this phenomenon, nor the tumefaction of the scrotum, which most authors, following Hippocrates, say, is more frequent in this luxation than in others. The luxa- ations we have met with were immediately reduced. We do not think tlie femur ean ever be luxated downward and backward; but it. may be carried in that direction after a luxation upward and outward ; that is to say, the head of the femur, thrown, in the first instance, upon the external iliac fossa, may, if the thigh be afterwards add acted by anj cause whatever, slip down before the upper part of the isehiatic notch; but it can never reach the junction of the ilium and ischium. This secondary luxation of the fe- M,ur may, therefore, be considered as a variety of the luxa- tjon upward and outward. The luxation downward and backward would be charac- terized by a strong flexion of the thigh, a turning of it in- ward, the impossibility of extending it or turning it out, and the removal of the trochanter major backward and down- ward, from tlie crest of the ilium. It would seem easy to distinguish between luxation of the thigh, and fractures of its neck, or separation of its head in young patients: yet Verdue, Ambrose Pare, and J. L. Petit acknowledge that they confounded them with eaeh other. We cannot, therefore, pay too much attention to the diag- nostic symptoms. . In fracture of the neck of the femur, the limb is shor- tened, and the point of the foot and knee are turned out- ward, but the limb is easily restored to its natural length and direction by slight extension of the foot. The luxation Upward and forward, which most resembles fractures of the neck of the femur, is accompanied by a shortening of the ..limb, and turning of tbe foot and knee outward; we cannot give tbe limb its natural length and direction without reduc- ing the luxation, which requires considerable force, and, moreover, the head of the femur is plainly distinguishable in the groin. In luxation upward and outward, tbe limb is shortened, as in fractures of the neck of the femur, but the foot is turned in. As to the luxation downward and inward Of Luxalt&ns of the Tliigh. 291 though the toe is turned out, as in fracture, the limb is lengthened. Considering the injury that must necessarily be done to the soft parts, in luxation of the femur, we should be in- clined to think that very serious consequences would result from it. But we know, from experience, that the pain and inflammation are soon dissipated after the bone is replaced* and patients have been known to walk eight or ten days after the accident. Even when the luxation is not reduced the pain and inflammation do hot continue very long, and the limb soon acquires the power of performing those motions which the luxation does not prevent. The reduction of a dislocation of the femur is among the most difficult, especially in robust patients. The luxations downward and inward, and upward and inward, are more easily reduced than those utoward and outward. After what period are luxations of the femur irreducible? We cannot answer this question with precision. J. L. Petit speaks of a child whose femur was luxated, in parturition* by the awkwardness of a midwife in drawing upon the feet. As the accident was not discovered until five years after-* ward, he thought this time quite too long to think of a re- duction, but adds, that luxations of one or tWo months stand- ing are easily reduced: Yet he eites no case in proof of this assertion. In the Memoirs of the Academy of Surgery a ease is related of a luxation of the thigh upward ami out- ward, which, after having been mistaken for two years, was then reduced. But this case was accompanied by particular circumstances, and we cannot draw any inference from an insulated fact of this kind. Nature, ever attentive to the remedying of the disorder! of the animal economy, restores the power of walking even when the femur is not reduced. In luxations upward and outward, the thigh remains short, and becomes shorter daily, until the head of the femur has made for itself a sort of articular cavity in the external iliac fossa ; the acetabu- lum becomes nearly, or quite obliterated; the gluteus mini- mus is emaciated, and serves as an orbicular ligament to the new articulation ; the head of the femur loses its spherical figure, is forced backward, and its neck becomes shorter; the person is lame, and walks on the point of the foot. If the luxation is downward and inward, the foramen ovale becomes the new articulating cavity; the obturator cx?er- hus, raised and pushed inward by the head of the femur, be- comes emaciated and ligamentous, and, sometimes, it and tbe 292 Bayer's Surgery. gluteus minimus even ossify. The lameness, in this case, arises from the too great length of the diseased limb, which always diminishes in size, in consequence of the muscles not being sufficiently exercised, or their actions being im- peded. With some differences, which will hereafter he pointed out, the method of reducing all luxations of the thigh is the same. The patient is laid upon a firm table, covered with a mattress, or upon a bedstead without a head-board or foot- board; or, if neither of these can be had, upon a trunnel bedstead, with several mattresses upon it. The patient be- ing thus placed, we may, sometimes, reduce the luxation by making a strong assistant take hold of the ankles, and draw the limb downward, while another assistant steadies tbe pel- vis ; but, most commonly, we are obliged to make use of a greater number of assistants: that they may act conveniently, a sheet should be laid in folds of five or six inches breadth, and the middle of it laid above the ankles, previously pro- tecting them with cottonwool, or compresses of linen ; the ends are now to be brought together, twisted, and given to the assistants. To make the counter extension, the middle of another sheet, folded like the former, is to be laid upon the internal part of the sound thigh, in like manner protected by some soft substance intervening; one of the ends of this bandage is to be passed over the fold of the groin, and the other behind upon the buttock of the same side, and, being brought toge- ther above the crest of the ilium, they are to be twisted and given to the assistants. This bandage alone is not sufficient to fix the pelvis: another should be so disposed as to em- brace the pelvis of the same side, in the space between the crest of the ilium and the trochanter major; the extre- mities are to be carried a little obliquely upward, across to the other side. By acting, at the same time, upon these two last bandages, the pelvis is fixed, and none of the muscles around the articulation arc compressed and made to contract, so as to increase the difficulty of the reduction. The surgeon, standing on (he external side of the limb, gives the signal to the assistants. Those who are to make the extension draw the bandages in tbe direction in which they bave received them ; those who are to make the counter-ex- tension act differently, according lo the kind of luxation to be reduced: In that upward and outward, the extension must be made obliquely inward, and a little forward; in the luxation downward and inward, the extension should be Of Luxations of the Thigh. 298 made obliquely outward; in that upward and inward, the extension should be made in a direction nearly parallel to the axis of the body :—in a word, the extension should always be made in that direction in which the limb is thrown by the accident. If Ihe head of the femur has been thrown outward and up- ward, Ihe surgeon, placing his two hands upon the trochanter major, presses it downward and inward;—if downward and inwaid, the surgeon places his hands around the internal and upper part of ihe thigh, and draws il upward and out- ward, while the assistants, without discontinuing the ex- tension, direct it inwaid :—if upward and inward, he presses the head of the femur downward and outward: As to (he luxation downward and backward, as it i* in almost every instance secondary, we should first endeavour to carry the head of the bone to the place it occupies in luxation upwaid and outward, and afterward acl accordingly:—in a word, we should make the head of the bone return by the same route it took in leaving its cavity. At the moment that tbe luxation is reduced, we hear a noise, produced by the striking of the head of the femur against Ihe acetabulum; the length and rectitude of the limb are restored ; it can be moved, and the pain ceases. Sometimes, after the reduction, the limb is a little longer than the other, which arises from the head of the femur not entering deeply into the acetabulum. This phenomenon ge- nerally disappears in a few days. The method jusi recommended generally succeeds; if it fails, machinery will seldom answer any good purpose. The surgeon should endeavour to discover the cause of the failure: Perhaps the extension and counter-extension have not been strong enough—if so, increase their force. Perhaps the mus- eles have contracted spasmodically—if so, let the patient he bled, placed into a bath, and put upon a very low diet, and let the local irritation be assuaged by emollient and anodyne applications. To keep the femur in place, the knees should be brought together-; the patient should be carried to bis bed, and a bandage passed round tbe lower part of the thigh, in the form of the figure 8. Compresses, or a poultice of an emol- lient or anodyne tendency, should be applied to tbe joint. The patient should not be allowed to walk until the pain is entirely dissipated, which generally requires a period of twenty or thirty days. Without these precautions, and that of walking with a stick, the recurrence of the spontaneous 294 Bayers Surgery. luxation of the femur is endangered. We shall add, in con- clusion, that, if we are ever so unfortunate as not to be able to reduce a luxation of the femur, that the patient should be confined to his bed for a very long time, and when he begins to walk, he should use crutches. CHAPTER XXXV. Of Spontaneous or Consecutive Luxations of the Femur. THE terms spontaneous luxation of the femur, consecu- tive luxation, morbus coxarius. &c. have been applied to a disease of the hip joint, in whieh the head of the femur, gradually pushed out of the acetabulum, ascends on the ex- ternal side of fhe os innominatum, or descends into the fora- men ovale. This disease was known to Hippocrates, who Speaks of it in the fifty-ninth or sixtieth Aphorism of the sixth section; but he is far from offering the exact description which has since been given, by J. L. Petit, in the Memoirs of the Academy of Sciences, for the year 1722; and by Mr. Sabatier, in the Memoirs of Ihe Royal Academy of Surgery. This disease may be produced by an external cause, or an internal cause, or by both conjointly. A violent contusion of the hip joint, produced by a fall on the trochanter major, the knee, or the feet, is not an unfre- qucnt cause of this disease; but, most frequently, it is only an occasional cause; and, still more often, the disease is the consequence of scrofula, rheumatism, gout, small-pox, measles, typhus fever, &c. It is more common in infancy than in adult age. J. L. Petit thus explains the mechanism of this luxation: ««In falls on the trochanter, the head of the femur is vio- lently pushed against the acetabulum, and, as it exactly fills this cavity, the cartilages, synovial glands, and the round li- gament are bruised: hence follow inflammation and suppu- ration. The synovia collects in the cavity of the joint, the capsular ligament becomes distended by it, and the head of the bone is gradually pushed out of its socket. This fluid, continuing to collect in the cavity, and not being dissipated by the movements of the part, relaxes the ligaments, which arc further distended by the action of the museles. Net \ Of Spontaneous Luxations of the Femur. 29fi only the capsule, but the round ligament is gradually elon- gated, and the pain continues to augment until this ligament, entirely relaxed or broken, leaves the bone free to take that course in which the action of the muscles shall direct it." This explanation appears, at first sight, to be plausible; but it is specious. If (here were any increased quantity of synovia, it would collect between the neck of the femur and the capsular ligament, and distend the latter; but it can ne- ver stretch this ligament, nor the muscles around the joint, and remove the bone from tbe cavity; for. if the synovia were to become thick, it would rather retain the bone in the acetabulum than displace it. It is certain, then, that Petit was mistaken, and we can give little weight lo his conjecture, which was not derived from any anatomical examination. In fact, I know of no examination whatever in the early state of the disease; but, probably, the synovial gland and the cartilage which covers the acetabulum and head of the femur are swollen, and this swelling, by destroying the proportions which ought to exist between the depth of the acetabulum and the size of the head of the femur, gives rise to the elongation of the limb, which, in almost every in- stance, takes place from the commencement of the disease. The examination of persons who have died of consecutive luxations of this kind, has shown that the synovial gland, which, in the sound state, fills a small depression of the ar- ticular eavity, is so swollen as to occupy every part of it. The cartilage which lines this cavity and the head of the fe- mur, has been found thickened and softened; sometimes the round ligament is destroyed; at other times tbe cavity of the joint is filled with stcatomatous concretions, and fetid floecu- lent pus, of various colours. The cartilage is eroded in some parts; but the most frequent lesion that is discovered is ca- ries of the edge of the cavity, and the absorption of bono which attends if. Not only are the different parts of the acetabulum and the head of the femur found in a morbid state, but also the dorsum of the ilium, on which the head of the femur rests after being luxated, in consequence of the disease, is softcnded, so that considerable portions of bone may be detached. The pus runs between the muscles, and collects in considerable quantities under the skin, and forms fistulae, which communicate with the cavity of the joint. In one particular kind of this disease, the caries is confined to the bottom of the cotyloid eavity, which becomes filled with ill-conditioned pus. This is discharged into the pelvis, and the patient dies, without any displacement of the femur. 296* Bayer's Surgery. From what has been said, it will be easily seen how a lux- ation of the femur may be oatised bv a swelling of the parts within the articulation. The head of the bone being raised to the edge of the cotyloid cavity, and then drawn up by the action of the glutei muscles. But when the luxation arises from a distension of the upper part of tbe acetabulum, the head of the bone is drawn up by the muscles, without being previously separated from the bottom of the joint. 1 say drawn up, because the supe- rior and outer part of the acetabulum is most often carious ; but, in some rare cases, the internal and lower part is des- troyed, and the bead of tbe bone is thrown upon the foramen ovale. It is of great importance to discover this disease as early as possible. We shall, therefore, describe its symptoms very particularly: They are different according to (he periods of the disease, and the cause which has produced it. The first period comprehends (he time from the commencement of the complaint to tbe escape of the bone from the acetabulum: it is characterized by pain, increase in the length of the limb, and lameness. These symptoms come on al the same time, but the pain is that of which Ihe patient complains the most. It is felt in the hip, and, generally, also in (he cor- responding knee: sometimes much more in the latter [dace than in the former. Thus practitioners are often mistaken as 10 the real seat of the disease. But we shall not be de- ceived if we press upon the knee : for this excites no pain, while the hip is exquisitely sensible lo the touch. The pain ■ is very acute when the disease has been caused by a severe eontusion, and is then often accompanied with a swelling of the superior part of the thigh, fever, and inability to move the limb. But when the disease depends upon an internal cause, the pain is generally moderate, dull, and deep-seated. In all cases it is increased by walking. We have seen pa- tients who, in the commencement of this affection, com- plained of pain in every part of the limb, and in whom the leg was bent and the foot extended, so that they walked upon the joint of the latter. The lengthening of the limb commences at the same time that the pain is felt: at first it is so inconsiderable as to es- cape the attention of practitioners who do not compare the limb exactly with the other; it increases as the disease pro- gresses, and is greatest at the time when (he head of the fe- mur is on (he point of leaving the acetabulum. In luxations oaused by the swelling of the synovial glands, and the carti- lages of the joint, the lengthening of the limb is much Of Spontaneous Luxations of the Femur. 297 greater than in those which take place in consequence of ca- ries of the border of the acetabulum. In the latter case, it is so small that some practitioners have denied its existence altogether. But we never saw a case in which it could not be observed, and we are convinced that it does always take place. To ascertain if the limb be lengthened, the patient should be laid upon his back; the anterior superior spinous pro- cesses of ihe ilium should be placed in the same transverse line. If the limb be lengthened, we then see the internal ankle and the patella lower than those of tbe opposite limb. If, at the same lime, we find the trochanter major further from the crest of the ilium than natural, we may be sure that the lengthening of the limb depends upon the removal of the head of tbe femur from the bottom of the acetabulum. Without this latter phenomenon, we cannot be certain that the lengthening of the limb does not depend upon a disease of the ilio-sacral articulation. Limping always attends the commencement of this dis- ease. It arises from (he lengthening of (he limb, and the pain in (he joint. When ihe palient attempts to bear the weight of his body upon the affected limb, the pain he feels obliges him soon lo support himself upon the other. Ihe lameness is greatest when the limb is most lengthened. Such are the symptoms of the firsi stage of this affection. The duration of these varies according to the age of the pa- tient, the violence of the disease, and the nature of the or- ganic affection of the parts. In children, it is shortest, on account of the lesser depth of the acetabulum, and the greater rapidity with which Ihe synovial gland enlarges; moreover, caries in them make a more rapid progress than in adults. We have seen children in whom the femur was luxated in two months; in adults the duration of the disease is shortest when the pain and irritation are most severe. We have known two patients in whom the pain was excessive, and who passed through the first stage of this disease in the course of an idiopathic fever. Both cases terminated in anchylosis. The second period of this malady commences with the luxation of the femur, and terminates with the termination of the disease. The escape of the head of the femur from the acetabulum enables Ihe surgeon always to pronounce with eertainty as to (he nature of the complaint. My experience leads me to believe, that when considerable shortening lakes place at once—when tbe pain is great, and there is no swel- ling of the upper part of the thigh, the luxation is produced by a swelling of the synovial gland and the articular carti- voz. 11. 38 298 Bayer's Surgery. lages; and that, in other cases, the displacement of the bone arises from caries. When the affected limb is much longer than the other for a great length of time, and yet is not turned inwards and outwards, and, at the same time, the patient is capable of rotating it, (though with pain) and an abscess by congestion is formed upon any part of the thigh, we may be certain that there is extensive caries of the bot- tom of the acetabulum. Such cases sometimes terminate fatally without luxation of the femur. When the head of the femur is removed from the cavity of the acetabulum, in consequence of a swelling of the sy- novial gland, it passes upward and outward, and the thigh becomes shorter than its fellow, and nearer to the axis of the body; the knee and the point of the foot are turned in- ward ; the trochanter major becomes more projecting, and is approximated to the crest of the ilium: in fine, there is every symptom of primitive luxation upwards and outwards. In some rare cases, the disease here stops; the pains are gradually dissipated; the head of the femur forms a new eavity, and the patient is able to walk with limping: but far more frequently, after the head of the femur is displaced, the buttock swells and becomes painful; the cellular tissue becomes thickened, and the skin tense and shining, so that the part has the appearance of a lymphatic tumour: some points at length soften and open, or are opened by art. In either case, the opening remains fistulous. It sometimes happens,, that the flow of pus, after having been very great, dimi- nishes ; that the pains abate, and all the symptoms gradu- ally subside, and, after several years, the disease happily terminates in an union of the so femoris with the os inno- minatum : but, most frequently, the fistule continue to fur- nish a great quantity of pus; at first thick and inodorous, afterwards thin, acrid, and fetid. This being absorbed and carried into the circulation, gives rise to hectic fever; the patient falls into a consumption, and dies. When this disease depends upon caries of the edge of the acetabulum, abscesses form quickly; sometimes even be- fore the luxation takes place matter collects in the upper part of the thigh, with all the appearances of an abscess by congestion, and not preceded by any inflammation of the part in which they appear, the pus having run along the interstices of the muscles from the articulation which is its source. In some cases, other abscesses, also, form at the groin, in consequence of an inflammation of this part. The openings of these abscesses remain fistulous. In its early stage this disease may often be cured; but Of Spontaneous Luxations of the Femur, 299 when luxation has taken place, the patient is inevitably ren- dered lame for life. Scrofula and debility increase the danger of this disease. W ben the luxation is produced by an exter- nal cause, it is less dangerous than when it arises from an internal cause. Ibe luxation which is caused by a swelling of (he synovia] gland, is not so often fatal as that which is occasioned by caries. Cases in which the head of the bone is thrown into the foramen ovale, being generally connected wilh extensive caries, are almost always fatal; and a fortiori those in which there is caries at the bottom of the aceta- bulum, are tbe most fatal of all. If called before lire luxation has taken place, we should endeavour to prevent it. If the patient have suffered a con- tusion of part, we should direct the most perfect rest and se- vere regimen: he should be bled several times during tlie first twenty-four hours, if his strength permit; we should apply fifteen or twenty leeches around the joint, renewing them the first or second day after; we should apply emolli- ent and anodyne applications to the part. A decided treat- ment seldom fails of success; but, unfortunately, few per- sons will submit to severe remedies, and still less to keep- ing the bed for several months for a disease which, to them, appears trifling. Most persons get up and walk as soon as the pain has become moderate; thus rendering the disease incurable. This luxation may be owing to an internal cause, which, either spontaneously, or in consequence of a fall, blow, a false step, or an immediate separation of the thighs, has set- tled in the bip joint. In these circumstances, the indication is to effect a revulsion of the morbid principle, and to re- move the internal disease. For the first of these objects, ihe actual cautery, moxa, caustics, cupping instruments, se- tons, and blisters, have been alternately recommended. We prefer the last. Our patients are kept in bed, and not suffered to make the slightest movement of the affected limb; we di- rect a large blister to be laid upon the upper and outer part of the thigh. This is kept on twenty-four hours, and dres- sed with cerate. In five or six days another blister is applied by the side of the other; then a third, &c. The blistering should be continued until the pain is entirely removed, and the limb restored to its natural length. It*somctimes bap- pens, that, after having done good for' a time, the blis- ters produce a contrary effect—augment the pain, and cause a spasm of the muscles of the thigh. When Ibis occurs, we should discontinue the use of them, and apply emollients, leeches, and baths. 300 Bayer's Surgery. As to the number of blisters, two or three are some- times sufficient: in other instances, twelve, or more, are re* quired. After they have removed every symptom of the disease, the patient must continue to keep his bed. From neglect of these precautions, we have known severe relapses. To prevent a return of the complaint, we often insert a seton, or form an issue in the arm. Toward the close of the dis- ease, sulphurous waters are useful; but we have seen them do much injury in the early stages. The internal treatment is various, according to circum- stances. If, notwithstanding every effort to arrest tbe disease, it con- tinues to progress, and the head of the femur is thrown into the foramen ovale, an abscess by congestion forms at the in- ternal, or at the posterior part of the thigh, and the patient dies. The abscesses ought never to be opened, unless the tension and pain in the parts render it unavoidable. When the head of the femur passes to the dorsum of the ilium, the case is not so hopeless. We should make the pa- tient extend the thigh as mueh as possible, and, when he be- gins to walk, we should advise him to bear upon the joint with great circumspection. After the irritation has subsided, we may use pnmpings and baths of sulphurous waters; but, unfortunately, it most often happens that abscesses form, and (he patient at length dies of heetie fever. After the luxation has taken place, the patient some- times gets off with an anchylosis: the pus becoming less abundant, thick, and inodorous; the appetite returning, &c. Under such circumstances, we should give bark and its dif- ferent preparations. De Haen recommended large doses of of this substance, with a milk diet. The fistulous openings should be covered with Nuremburg or diacholon plaster; the sores should be kept very clean, and, if tbe skin in- flame, we should apply an emollient poultice; the dis- charge of pus should be promoted by detergent injections made with a decoction of the leaves of black-walnut, St. John's wort, liverwort, &e. or by an alkaline solution, of a strength proportioned to the sensibility of the parts; the limb should be kept as much as possible at rest, and in a ver- tical direction. The anchylosis requires several years for its completion in adults; something less in children. Case I. The son of Count D. aged fourteen years, of a lymphatic temperament, strong and large for his age, with- out any known cause, felt a dull pain in tbe upper part of the left thigh, and in the knee of the same side, which made bim limp a little. Having laid him on his baek, and adjusted Of Spontaneous Luxations of the Femur. 301 the anterior superior spinous processes of the bones of tbe ilium, in the same transverse line, I discovered that ihe left thigh was four or five lines longer than the right. These symptoms left no doubt as to the nature of the affection. I advised that he should keep perfectly quiet in bed. and ap- plied successively several blisters around the affected joint, and prescribed bitters and anti-scorbutics. In a few weeks the lengthening of the limb was removed, and the pain dissi- pated, but I would not suffer the patient to get up and walk about until the expiration of two months. At this time walking caused no pain, and I hoped my patient was entirely well, when he imprudently made foreed motion of abduction in straddling a billet of wood. This brought back his for- mer symptoms. He was kept at rest six weeks more, and, to guard against the return of the disease, I applied a blister to his arm, and advised his parents to keep it open for a long time, and to continue the use of bitters and anti-scorbutics. The patient has had no return of his complaint. Case II. Mademoiselle P—, aged seventeen, of a lym? phatic, sanguine temperament, and of a delicate constitution, fell some pain in the hip joint, at the age of nine or ten years, which was regarded as arising from weakness of the muscu- lar system. At the age of sixteen she fell upon the left hip, mod increased the pain by dancing. In the winter of 1804, being then seventeen years of age. the violence of the pains, rendered excessive by long continued dancing, obliged this young lady to make known her situation lo her parents. The surgeon who was called in found the left leg six lines longer than the other. He prescribed perfect res( in bed, and applied a blister near the hip joint, and very judiciously endeavoured to promote the menstrual discharge. The blister increased the pain in the upper part of the thigh, and caused it to attack the knee. Ihe parents were unwilling to apply a second without further advice. Being ealied in consultation with the family surgeon, we applied three blisters in succession, with little diminution of the pain. After seven blisters were applied, the limb was re- stored to its natural length; but some slight pain remaining, two more were successively ordered. The patient, who had now been confined to her bed three months, was heartily tired of our treatment. She got up and sat in an easy chair, walked about the room with only a trifling lameness, which was afterwards dissipated by pumpings and baths of artificial Sulphurous water of Barege. She was afterwards perfectly well, and is the mother of several healiby children. Cask III. .Monsieur De N—, aged thirty-seven years, of a 302 Bayer's Surgery. good constitution, and having always enjoyed perfect health, strained Ihe thigh violently outward, in July, 1811. He was advised to keep the limb at rest, and apply brandy to the hii>. As soon as the pain had diminished, he insisted upon getting up and walking about; but he limped, and the pain was increased. This was his situation in the month of November following, at which time I was consulted. The right leg was four or five lines longer than the left. I advised rest and the application of anodynes, and, after- wards of resolvents; but, instead of following my advice, the patient submitted to the pumpings of artificial Barege water. The first pumping increased the pain ; and, before the sixth pumping, the part became exquisitely sensible to the touch; the muscles became convulsed, and the sufferings of the pa- tient became so acute as to deprive him of sleep; the length of the limb was increased. I now directed the application of leeches three successive times, embrocations with a lini- ment containing camphor and opium; emollient and ano- dyne poultices; cooling drinks; the internal use of opium, and a low diet. Notwithstanding these remedies, the pain Continued very acute for a month, and the patient could scarcely turn in bed. After this it gradually diminished, and. in three months and an half, the limb was restored to its natural length, and the pain had entirely left it. Mon- sier De N. then began to walk with crutches, which were afterwards discontinued as (he limb became stronger, and, ten months after the accident which caused his disease, he was entirely restored. Case IV. The child of Monsieur F—, aged six years, apparently of a good constitution, having a brown skin, black hair and eyebrows, without any appearance of glandular swelling, complained of a still pain in the left hip, which caused him to limp. The family physician attributed the pain to his growth, and did not advise any remedy. Six months from the commencement of the disease, I was con- sulted: The limb was then six lines longer than the other. I advised that the child should be kept in bed, and that seve- ral blisters should be successively applied around the affected joint, and that bitters and anti-scorbutics should be adminis- tered. Four blisters were applied in as many weeks: the pain diminished, and the limb was restored to its natural length. The fifth blister was followed by so much pain that it became necessary to have recourse to anodyne and narco- tic applications; notwithstanding whieh, the lengthening of the limb returned. Seven or eight months of alternate aug- mentation and diminution ef the pain ensued, but the length- Of Spontaneous Luxations of the Femur. 308 cuing of the limb went on increasing. At length the head of the femur left the acetabulum, and passed to the dorsum of the ilium : the limb then became an inch and an eighth lon- ger than Ihe other; the knee and the point of the foot were turned a little inward, and the pain almost entirely ceased; no inflammation nor swelling of the buttock occurred, ex- cept the projection of the head of the femur, which could be plainly felt under the glutei muscles. This led me to hope for a cure by anchylosis. The child was kept in bed for two months, with the thigh extended on the pelvis as much as possible. At the expiration of this lime, as the child com- plained of no pain when he moved a little, I permitted him to get up and walk with crutches. The limb gradually be- came strong, and its movements more extended. Case V. J. G—, a soldier, aged twenty-one years, under- went great fatigue, in Spain, during the campaigns of 1807 and 1808, and felt, in those years, vague rheumatic pains: sometimes in the loins ; at other times in the thighs. When he entered the Charite he complained of acute pain in the left hip-joint, extending over the thigh to the knee, and causing bim,to limp. Three blisters were successively applied around tbe joint, without relief. In the fifteenth day, the patient having turned in bed, the head of the femur abandoned the acetabulum, and the limb was shortened two inches. One month after his entrance into the hospital the patient had hectic fever, the pain increased, and he died of marasmus. Dissection. The glutei muscles were thinned; the head of the femur lay on the dorsum of the ilium, above and behind the acetabulum: this cavity was somewhat enlarged, and filled with a brown sanies; its sides were rough and perfo- rated ; the synovial gland was larger and denser than in its natural state; the capsular ligament was completely de- stroyed, except that part of it which contains the vessels that supply tbe joint. The head of the femur and its cartilage were diminished in size. Case VI. James Francis D—, aged twenty-eight years, felt pains in his hip, and limped for the space of two years pre- vious to his entrance into the Charite. At this time he was feverish ; the hip was swollen, the thigh and leg were con- stantly kept bent, and, in passing the fingers over the part, a deep and equivocal sense of fluctuation was perceived. We suspected that the internal side of the acetabulum was cari- ous, because the knee was abducted. Several blisters had been applied without relief. On the 5th of September, a puncture was made into the abscess, and a great quantity of inodorous and iil-eenditioned 301 Dover's Surgery. pus was discharged. On the 2d of January, another punc- ture was made, with the like result. The patient grew worse: he had diarrhea, lost his appetite, and could not sleep. On the 10th of January, the hip-joint became extremely painful and swollen, from the anterior part of the hip- joint lo the abdomen. On the 15th, a third puncture was made, and a quantity of white and well-digested pus was discharged. This, in some degree, relieved the patient. On the 16th, an eschar separated from the sacrum, leaving the bone exposed. On the 20th, a swelling of the knee, of which the patient had complained for some days, opened and dis- charged pus which had burrowed there. He died on the 23d of February. Dissection. Tbe muscles of the buttock and groin were, in a manner, dissected by the pus; the orbicular ligament was destroyed, and scarcely retained any trace of its fibrous structure; the head and neck of the femur were entirely denuded; the cartilaginous covering was absorbed; the acetabulum was much enlarged, especially at the internal part of its circumference; the pus had destroyed the leva- tor ani, and ran along the psoas lo the loins; it passed out of the pelvis with the latter muscle, and descended to the knee. Case VII. A shoemaker, aged seventeen years, in walk- ing in the woods, struck against the stump of a tree, and fell upon his left knee. This was followed by acute pain in the hip-joint of that side. It abated, however, and in four days he was able to resume his work: but there*was still a dull, heavy pain in the joint, which rendered it irksome for the man to stand or walk, and induced him to enter the hos* pital Charite, several month* after the accident: the left thigh was longer than the right: the slightest movement was painful, but neither the hip nor the knee were tender to the touch. Two blisters were immediately applied, one upon the trochanter, and the other upon the outer side of the knee. Under this treatment, the patient's health was so much improved, that, in two months, he left the hospital, and went to work. All the symptoms quickly returned? and a surgeon, who was consulted, mistaking the disease, advised the man to stir about. He grew worse very rapidly, and was brought to the Charite : poultices of flax-seed were applied, and an abscess, situated upon the middle and ante- rior part of the thigh, opened spontaneously; heelic fever followed, and the man died, six months after his second en- trance into the hospital. Of Luxations of the Patella. 305 Dissection. The abscess communicated with fhe joint by an opening below the arch of the pubis ; the femur was as if worm-eaten, and extremely friable; (here was an opening from the bottom of the acetabulum, leading to the pelvis. <© CHAPTER XXXVI. Of Luxations of the Patella. THE tendon of the extensor muscles of the leg is in- serted into the upper part of the patella; a strong li- gament connects it with the tibia below : at each side it is retained only by the capsular ligament and the aponeurosis. When the leg is flexed and extended, the patella slides up and down, and is pressed against the condyles of the femur, and. in this stale, is immoveable: in the extended stale of the limb, provided the extensor muscles of the leg are not in action, it may be pushed inwaid or outward. The patella is always displaced when the tibia is luxated ; but, in this chapter, we shall treat only of luxations of the patella unconnecled with displacement of the tibia. Strictly speaking, the patella is only capable of being luxated inward and outward. It may, indeed, descend ; but this is always a consequence of rupture of Ihe tendon of the extensor muscles of the leg. It may, also, ascend, if the ligament of the patella is broken. In the first case, if the leg is bent, the tibia will draw down Ihe hone, as it draws down the inferior fragmenl in fracture of Ibis bone; but, if the ffcris extended, the patella remains in its natural situa- tion • in the second ea-e, the retraction of (be extensor mtrssles of the leg will draw up the patella several fingers' breadth. Lateral luxations are generally caused by external vio- lence; but an excessive relaxation of the ligaments of the patella, and a particular conformation of lite condyles of the femur, may permit this bone to be luxated by Ihe con- traction of the muscles. According to most authors, the patella is more easily lux- ated inward than outward, from the internal condyle of the femur being less projecting than the other. This opinion is contradicted by experience. Luxation outward is most fre- quent; because the internal edge of Ihe palella, more pro* VOL. II. 39 joff- Boyer's Surgery. minent than the external, projects beyond the edge ef the femur, and is, consequently, more exposed to the action of the causes of luxation. In the first the patella entirely abandons the articular pulley of the femur, and its posterior surface is placed on the corresponding eminence of that bone. Complete luxa- tions of the patella are extremely rare. In most eases, this bone still remains upon the articular pulley of the femur, but its ordinary relations are changed. In the greatest possible flexion of the leg, the patella is too deeply sunk between the condyles of the femur, and too strongly pressed against the femur to yield to any external force; but when the leg is slightly bent, and, particularly, if it is extended, these cords are relaxed, the bone projects and yields to external force, and is displaced inward or out- ward, according to the direction given to it. Luxation of tbe patella outward, is generally caused by external violence acting upon the inner side of the bone, while the leg is extended, or very little bent; the patella is seldom thrown beyond the external edge of the femur, but usually rests on it; the anterior surface of the patella is turned inward, and the posterior surface outward; the inner edge is turned backward, and the outer edge forward. The patella cannot retain this position, but will slip down (he in- clined plane of the condyle, unless the ridge which divides its posterior surface vertically have been pushed beyond the external edge of the articular pulley. The signs of this luxation are as follows: the leg is ex- tended ; any attempt to bend it increases the pain; we feel the internal edge of the articular pulley, which the patella has left; Ibe patella forms a remarkable prominence on the internal side of the joint, and the articular cavity may be easily felt through the skin and capsular ligament. Luxation of the patella inwards can only be occasioned by a small body-—for the force of a large body would be resisted by the femur. This luxation, like that outward, is almost always incomplete. It is characterized by a tumour before tbe internal condyle; the anterior surface of the patella is inclined outward, its posterior surface inward, its external surface backward, and tbe internal forward; the external condyle of the femur may be felt in tbe depression which the patella has left; the leg is extended, and any attempt to bend it causes acute pain in the knee. If the luxation were complete, the visible cavity, in the natural situation of the patella, would sufficiently show the nature of the case. Luxations of the patella are not generally dangerous; Qf Luxations of the Patella. 307 Ibey may become so, however, if attended with severe con- tusion of (he knee. We should proceed to fhe reduction of these luxations without delay. The patient is to be laid upon his back, the leg extended upon the thigh, and the thigh bent upon the pelvis, and the whole limb supported by a solid plane, ca- pable of resisting the pressure we may make upon the knee. The surgeon Chen places the palm of his band upon the pa- tella, and forces it into its place. This plan almost always succeeds in incomplete disloca- tions on the first trial: but difficulties have been experienced in the reduction of complete dislocations; and Valentin, in bis Reeherehes critiques sur la Chirurgie Moderne, informs us, that a senior surgeon of one of the largest hospitals in Europe had the temerity to open the capsular ligament, in order to pass in an elevator lo pry the patella into its place. We need not dwell upon the dangers of such a procedure. At the moment of the reduction, we hear a noise, made by the patella striking against the surface of the joint; the leg may be freely bent and extended, and the pain is greatly diminished. After the reduction, the patient is to be confined to bed, with the leg extended ; the knee should be covered with compresses wet with a resolvent liquid, and secured by a roller. We should endeavour lo prevent inflamma- tion, by prescribing low diet and bleeding; and, if it comes on, we should apply emollient and anodyne poultices. When tbe pain is dissipated, we may begin to move the leg, and, afterwards, cautiously permit the patient to walk with crutches or a cane. There is seldom any tendency to a re- petition of the dislocation: however, I have lately seen a military gentleman who had luxated the patella outward, by a fall, and in whom the bone had repeatedly got out of place in walking. I advised him to wear a knee-cap, made of chamois leather, which has prevented the recurrence of the luxation* • Luxations of tbe patella are very rare: few eases areupon record, and most of these are even imperfectly related. The following is an abstract of a case related by Valentin. Count D—, in riding en horse-back, struck his right knee against another person, who was also mounted and passing in an op- posite direction. He experienced aeute pain, and cried out that he was wounded. He was taken from his horse, car- ried into a shop, and laid upon a mattress. A surgeon, who arrived, found the patella completely luxated, and endea- voured to reduce it. For this purpose he placed the limb 308 Bayer's Surgery. Upon a horizontal plane, drew the extensor muscles to- ward their insertions, and bad recourse to extension, as di- rected by Flatner. Notwithstanding his best directed efforts, the patella remained jammed against the external condyle. He next tried to place the Corrni upon his feet, but the at- tempt excited excruciating pain. In this dilemma, the Count's family surgeon. VI. Veyret, arrived. He took hold of the heel with his left hand, and raised the whole limb, pressing against the patella with the other hand. Tho leg being thus brought nearly to a right angle with the body, the patella became vacillating, and was easily reduced by pushing it toward the internal side ef the knee.* The Count got up, limped across the room, and got into his car- riage without much difficulty, and the pain was compara- tively trilling. A bleeding* and the application of com- presses wet with a resolvent liquid, completed the cure; and not the slightest pain was afterwards felt in the knee. Ravaton relates, in his book,ventitled, The Modern Prac- tice of Surgery, the case of a dragoon, who, while mounted on a spirited horse, rubbed the right patella against a wall, and luxated it outward. It projected more than three inches. The man was immediately brought to the hospital. Rava- ton reduced the luxation, after several trials, and tbe patient was entirely cured hi three weeks. In the course of a long practice, I have only seen the pa- tella once luxated. A large young man. sixteen or eighteen years of CHAPTER XXXTII. Of Luxations of the Tibia and Fibula. THE tibia may be luxated in four different directions, and its luxations may be complete or incomplete. The former are extremely rare. Heister says he reduced a complete luxation of the tibia backward in a fat robust man. It appears to us impossible that any complete luxation of the tibia backward should take place. We regret that Heister has not described his case more particularly. He merely observes, that no bad conse- quences followed the accident; merely a swelling and pain in the knee, which continued for a long time, and were re- moved by resolvent applications. The tibia is luxated back- ward in certain cases of white-swelling. The luxation of the tibia forwards is still more difficult than that backward. Lateral luxations are more common than the others: they are almost always incomplete; and the external condyle of the tibia is placed below tbe internal condyle of the fomur in the luxation inward, and vice versa. Of Luxations of the Tibia and Fibula. 311 In whatever side the tibia is luxated, the patella is always drawn with it, and is more or less displaced. The 402d case of Lamotte is an example of a completo luxation of the tibia outward: " A labourer sunk beneath a pile of earth, which fell upon him, and principally upon the lower half of his body. The right thigh and leg being supported by a solid plane below, were only bruised; but the extremity of the left thigh being raised by a little mound of earth, the upper part of the leg did not touch tbe ground, and was, consequently, luxated backward." A man was turning the wheel of a crane, by putting his feet alternately upon the spokes. The right foot having slipped, the left was caught between two spokes, and was carried inward, while the weight of the body drew the thigh in a contrary direction. These two cases illustrate the two modes in which the luxation of the tibia may be occa- sioned. In the luxation backward, we find the leg bent at a very acute angle, and incapable of being extended; the condyles of the femur and the patella form a round tumour, which terminates the thigh. Below this tumour is a depression, in whieh we may feel the ligament of the patella lengthened and tense; the hollow of the ham is filled by the upper ex- tremity of the tibia, which forms a remarkable tumour at the lower and posterior part of the thigh. The extensive destruction of the soft parts, which neces- sarily attends luxation forward, renders the diagnosis of this accident very easy. As to the diagnosis of lateral luxations of the tibia, the change of the direction of tbe axis of the tibia, with respect to that of the femur, renders it perfectly evident. Almost all authors agree, that complete luxations of Ihe tibia lead to the necessity of amputation; and that, when this operation is not performed, the most favourable result we can hope for is anchylosis, which often takes place even after incomplete luxations. Yet there are exceptions to the ordi- nary termination of these accidents. Lamotte's patient was able to return to work at the end of five weeks. Heisler's case of complete luxation backward is reported to have ter- minated in a perfect cure. In the incomplete luxation in- ward which occurred to us, the patient could walk about, and work, at tbe end of three weeks. The reduction of luxations of the tibia is seldom difficult: An assistant takes hold of the lower part of the leg with both bands, to make tbe extension; another grasps the lower part of the thigh. The extension should be made in the di- 312 Boyer's Surgery. rection in which the leg is thrown by the accident: when it is sufficient, the surgeon, stationed on the outside of the limb, places one hand on Abe condyles of the femur, and ihe other on the upper part of the tibia, and acts in contrary di- rections. The patella follows the tibia in its return lo its place; a noise is heard at the moment of tbe reduction, and the leg becomes capable of flexion and extension. After the reduction, the knee should be covered with com- presses wet with a resolvent liquid : these should be kept on by a roller, which is sufficient to prevent a recurrence of the accident; but, if there be a strong tendency to displace- ment, as I once saw after an incomplete luxation inwards, splints and pillows of chaff will be necessary, as in frac- ture of the thigh, and some degree of compression should he exercised on the side toward which the bone was dislo- cated. In the treatment of luxations of the tibia, it is of great importance to moderate the inflammatory symptoms. Bleed- ing, and the anti-phlogistic regimen, are indispensable. Re- solvent and repellent applications should be applied in the first instance. When inflammation and tension have come on, emollient poultices are proper. Resolution generally fol- lows ; but, in some cases, suppuration, and even gangrene, supervene. The moment the formation of pus is ascertained, we should make suitable openings, to prevent it from lodging in the joint. Amputation is the only resource after gangrene has taken place. The question has been discussed, whether amputation is not always proper immediately after complete luxation of the tibia: We think a prudent surgeon will not perform the operation, except in cases where the injury of the knee is so great as to render gangrene inevitable; and such cases very rarely occur. Of Luxations of the Fibula. Most authors who have written treatises on diseases of the bones, and general systems of surgery, seem to have consi- dered luxations of the fibula as hardly possible. The upper extremity is capable of slipping backward or forward, and might be luxated in these two directions, if its unusual size should, in any way, expose it to the action of external violence, acting in these directions: there would be no difficulty in pushing it back to its place. The lower end of the fibula is so strongly articulated with the tibia, that it cannot move, except by the yielding of its Of Luxations qf the Foot. 3IS ligaments. If these ligaments, and those which surround its upper articulation, arc relaxed, the articular surfaces have a direction more nearly vertical; under these circum- stances, if the foot be slightly twisted outward, the fibula, instead of being broken, as generally happens, may slip bo- dily upward. We have seen a luxation of this kind, in con- sequence of a luxation of Ihe foot outward. The two luxa- tions were reduced at Ihe same lime; by bringing the foot to its natural direction, the fibida was also replaced, and the patient recovered with a slight stiffness of the joint. This luxation is the only one of which the lower extremity of the fibula is susceptible. ® CHAPTER XXXVIII. Of Luxations of the Foot. THE astragalus is received into a quadrilateral cavity, formed by the inferior extremities of ihe tibia and fibula, and exactly fills the space between the two malleoli; the external of Which is lower than Ihe internal. The joint •of the foot is surrounded by a thin capsule, and is strength- ened by a large and thick internal lateral ligament, by three external lateral ligaments, and by the tendons of the ex- tensor and flexor muscles of lire foot and toes. It permits no other movements than those of flexion and extension: Tlie astragalus, confined on the sides by the malleoli and la- teral ligaments, cannot move inward or outward, except by the yielding of the ligaments that unite the inferior extre- mities of ihe tibia and fibula to these movements, which are extremely circumscribed. The lateral movements of the foot do not 1i;ke place in its articulation with the lep;. but in that of the astragalus with the scaphoides and os calcis, and of this last with tlie cuhoides. The movement by which the sole of the foot is turned inward, and its intertill edge up- ward, is easier and more extensive thai that in an inverse direction. Thus we see, that, in the violent turning of the foot inward and outward, the cifort is supported by the arti- culation of the tibia and fibula with the astragalus, and by that of the os calcis and scaphoides. It is. therefore, re- marked, that luxation of the astragalus upon the bones ef vol. if. 40 31* Bayer's Surgery. the leg is sometimes complicated with that of these bones npon the os calcis and scaphoides. The foot may be luxated inward, outward, backward, and forward. In whatever direction the luxation takes place, it may be simple or complicated, complete or incomplete. Lux- ations forward and backward are less frequent than those outward and inward: this last is most common. In the luxation inwards, the astragalus is turned upside- down ; the articular surface of its internal side, which, in its natural state, touches the internal ankle, is turned down- ward, and thrown below that eminence, while its superior surface is turned inward, and its external upward: tho external malleolus is approximated to the external edge of the foot, which is raised, while its internal side is sunk. This change of direetion of the astragalus is more or less considerable, according to the extent of the displacement. In luxation outward, the astragalus is displaced in a contrary direction, so that the superior surface becomes the external, the internal the superior, and the external the inferior. Lateral luxation of the foot may be simple or complicated. It is simple when the ligaments that surround the articula- tion have yielded, without being much broken, and the other soft parts have only experienced the stretching and disten- sion inseparable from a dislocation of a ginglymoid articu- lation. Lateral displacements of the foot may be com pli- cated with rupture, or unusual distension of the ligaments, separation of the fibula, fracture of the malleoli, projection of the astragalus upon the os calcis and scaphoides, &c. The astralagus has been fractured in the place where its head unites with its body; so that this last part was entirely isolated, and could easily be taken away. These different complications are common to luxations inward and outward; fractures of the malleoli and luxations of the astragalus upon the scaphoides and os calcis are however more frequent in the first than in the last case. Lateral luxation of the foot happen by tbe turning this part inward and outward; but for the power that causes this to produce a luxation, it must act with sufficient force, break the lateral ligaments and those of the malleoli. Thus these luxations seldom happen, except in falls from elevated places, when one of the edges of the foot does not touch the ground, or while the foot is violently pushed to one side, while the weight of the body, or any other cause, draws the leg to the opposite side. The deformity and impossibility of moving the foot are Of Luxations of the Foot 315 sufficiently characteristic of its lateral luxations. In that in- ward, tbe superior surface of the foot is directed inward, and the superior outward; the astragalus forms a tumour un- der Ihe internal malleolus. In luxation outward, the foot is adducted, so that the surface of Ihe sole is directed in- ward ; the astragalus forms an eminence under the external ankle. These changes of direetion of the foot are so appa- rent, that it is impossible to mistake the luxation, even if considerable swelling has taken place; this swelling, may, however, render the diagnosis difficult in the different com- plications of which lateral luxations of the foot are suscep- tible. We judge that the malleoli are fractured by their mobility, and the crepitation heard when they are compressed. Frac- ture of the external malleolus, which frequently accompanies luxation inward, is, however, sometimes so concealed by the swelling of ihe soft parts, that it is impossible to discover it In cases of doubt, we must conduct as if the fracture was evident, and pursue the proper means to prevent a consecu- tive deviation of the foot outward. Complication of diasta- sis, in this kind of displacement, is known by the mobility of the inferior extremity of the fibula when the luxation is re- duced. Tbe astragalus cannot be luxated without a simultaneous distension and rupture of the ligaments and the adjacent soft parts. Hence the inflammation that generally accompanies these luxations may lead to the necessity of amputation, in order to save the life of the patient. In less serious cases, we have always to fear stiffness of the joint, or even its an- chylosis. In other instances, after luxation the integuments are feeble, and repetition of the displacement is frequent, if the patient do not use some mechanical means to support the foot at the sides. All lateral luxations are not equally serious; those which are incomplete are least dangerous: they are generally cured in a short time, without any feebleness or stiffness in the limb. Complete luxations, accompanied with frac- ture, are not always the most serious, provided the frac- ture be .simple, without splintering of the bone. Lateral luxations of the foot, complicated with that of the astra- galus on the os calcis and scaphoides; and the isBue of the first of these bones through a wound of the integuments, would appear to produce the most formidable accidents, and require amputation; however, a great number of examples are known, in which the astragalus has been removed, and the patient cured. 316 Boyer's Surgery. Lateral luxations or the foot must be reduced without de- lay, otherwise tbe inflammatory swelling renders the reduc- tion painful and difficult. The patient should be laid on a bed ; an assistant takes hold of the inferior part of the leg with both hands, to make tbe counter-extension: another assistant seizes the foot with both hands, to make the exten- sion. The counter-extension must be made in the direction of the leg, while the extension draws the leg, first in the di- rection the displacement has given it ; and, when the liga- ments and tendons yield, the bone should be pushed in a con- trary direction to that given it during the dislocation. This manoeuvre is generally sufficient to effect the reduction. If the foot is luxated outward, the surgeon takes hold of the lower part of tbe leg with one hand, the thumb being placed above the external malleolus, and, at the same time, he pushes the lower part of the leg inwards, and turns the sole of tbe foot outwards. In a luxation inward, an inverse me- thod is to be pursued. When the luxation is reduced, the articulation is to be co- vered with oblong compresses wet with a resolvent liquid, which are to be kept on by means of a bandage, applied in the form of a figure of 8, passing alternately over the foot and under tbe sole ; pillows of chaff and splints of wood are then placed on the sides of the limb, and fixed as in a fracture of the leg, so as to keep tbe foot in its natural position. In all lateral luxations of the foot, inflammation is to be feared, and we must endeavour to prevent it by bleeding and prescribing a severe diet and cooling drinks. If there is neither pain nor swelling, resolvent fomentations are to be continued; the dressings should be renewed every five or six days, and as soon as tbe state of the parts will permit, slight movements should be given the foot, to prevent stiff- ness in the joint. If pain and swelling have taken place, bleeding must be continued, leeches must be applied around the articulation, and emollient and anody ne poultices directed. The parient must, not be permitted lo walk until the distended or broken ligaments are united, which is generally in about a month or six weeks. In luxation complicated with diastasis of the bones of the leg, compression, strong enough to keep them pressed toge- ther, must be made on the superior extremity of the bones and continued until the perfect reunion of the torn liga- ments takes place. Lateral luxations of Ihe foot, accompanied ,with fracture of the inferior extremity of the fibula, require great at- Of Luxations of the Fool. 317 tcntion. When the fracture is not discovered, or the luxa- tion is not reduced, the astragalus not being held by the ex- ternal malleolus, the foot becomes drawn outward by the action of the muscles, and luxation is insensibly reproduced; and, if this displacement is not perceived in time, it becomes impossible to remedy it, and the patient becomes lame. The slow and gradual deviation of the astragalus from its proper position is sometimes accompanied with inflammation, ulcer ration, and mortification of the skin on the inner side of the joint. If ihe ulceration penetrates to Ihe articulation, the limb, and even the life of the patient, may be lost. In case of luxation of the foot and fracture of the inferior extremity of the fibula, after reducing ihe fracture, the foot must be kept in its natural direction, by placing splints on the sides of the leg; the external one passing beyond the sole of the foot, and the internal one not lower than the malleolus: the compression of the splint on the outer side of the foot should be strongest. Luxations complicated with rupture of mo-t of the liga- ments, of tlie tendons, and of the skin, or i-sue of the astra- galus, or of the inferior extremity of the tibia, through a wound of the integuments, must be. carefully examined for us to determine if amputation ofthelinibis ihe only resource to save the life of the patient. This is a case which requires the greatest judgment and experience. If, after maturely examining all the circumstances of the case, it appears that amputation is the only means of saving the life of the pati- ent, the operation must be performed immediately, for delay- renders it almost always useless, and the patient expires. If an attempt to preserve the limb is deemed advisable, ^ when the astralagus has come through the wound of tbe in- teguments, and is confined in the passage, so that it is im-i possible to replace il, the opening of the wound must be so enlarged as to render the replacing of the bone easy. Ths same conduct is to be observed when the inferior extremity of the tibia has come through the skin, and the opening of the ligaments is not sufficiently large to permit it to return to its natural place. When luxation of the foot is accompanied by that of the astragalus on the os calcis and scaphoides, and the first of these bones has almost totally escaped by a large wound of the teguments, and the ligaments that united the two others are broken, it must be extracted by dividing the small portion of ligaments that yet hold it; for, in this case, the astragalus may be considered as a foreign body. After this operation, the tibia approaches the os calcis, the soft parts 318 Boyer's Surgery. that surround the articulation experience a relaxation that diminishes the pain and inflammatory tension; the large space, resulting from this extraction, quiekly diminishes; the articular surfaces of the tibia, the fibula, and os caleis, are soon covered with granulations; which unite, and the bones of the leg grow to the os calcis. The movements of the foot are lost, and the limb is shortened by the height of the astragalus, the patient walks tolerably well notwith- standing. The advantages ef the extraction of the astragalus in this case is proved by a great number of facts. Fabricius Hildanus reports, that a minister, in jumping over a hedge three feet high, completely dislocated the astragalus : it projected through the skin, and was held only by some fibres. The surgeon removed it, and employed the proper means to combat the inflammation. The patient walked without a stick, but with difficulty, and after a long confine- ment. M. Aubray, then surgeon in chief of the Hotel Dieu of Caen, relates a case of luxation of the foot, without fracture of the astragalus, in which, on the ninth day of the accident, after having made deep scarifications on the malleoli, and extracted some splinters of the fibula, he was astonished to perceive Ibe astragalus out of its place, pre- senting its trochlea, and making a right angle with the tibia. He immediately unbridled the wound, and isolated the bone, which appeared fractured in the middle of the anterior pro- ce-s that unites it to the scaphoides. Two days after- Wards he extracted the astragalus. The following day, the fever and swelling considerably diminished. Some purulent „ effusions were the only consequences that retarded the cure, which was complete at the end of three months, except an anchylosis of the foot; that did not prevent the patient from walking with ease and without help. We liave heard Ferrand, surgeon in chief of the Hotel Dieu of Paris, say, he successfully extracted the astraga- lus, in a luxation of the foot when this bone came through the skin; the patient, an officer of Invalids, who, after the cure, used to carry the bone in his pocket, to show as a proof of the danger of his wound. Desault three times extracted the astragalus with success. One of Ihe patients, a woman of fifty years of age, died, however, two months after the accident, of hospital fever. Being charged to dissect the limb, I remarked that the ti- bia was already almost entirely united to the os calcis, and there was not the smallest doubt but the patient would have recovered with an anchylosis, had she not died of another Of Luxations of (he Foot 319 disease. The same practitioner saw the extraction of the astragalus succeed in the practice of other surgeons. We read, in the «* Medicine eclairee par les Sciences Phy- siques,"* &c. by Fonrcroy, a case of a complete luxation of the astragalus, and its extraction, by M. Laumonier, surgeon in chief of the hospital of Rouen. On the 5th of August, 1790, Andrew Houdan was thrown from the hack of a carriage by a violent jolt; the right leg having got entangled in the spokes of the wheel while turn- ing, it twisted the articulation of the foot, and luxated the astragalus, by separating it from the tibia, fibula, and os calcis. Fifteen days after the accident, and after several attempts at reduction, the patient was brought to the hospi- tal of Rouen. The scaphoidien surface of the astragalus was black; the leg and foot very much swollen; the patient was pale, bloated, and feverish. The astragalus appeared to M. Laumonier to be altogether a foreign body, which it was proper to extract; the operation was performed on the day after the patient's entrance into the hospital, and was soon followed by a sensible melioration. But, on the eighth day, an abscess suddenly formed on the external ankle, tbe top of the foot, and ihe peroneus brevis; a counter opening removed the fever which accompanied the formation of mat- ter : from that time the patient went on improving. When M.Laumonier communicated the case to the Royal Society of Medicine, he hoped his patient would be able to use his foot, notwithstanding the loss of the astragalus, the posterior tendons of the leg, and the long flexor of the toes. A similar ease was communicated to the same society by M. Mauduyt: A soldier, thirty years of age, was severely wounded in Ihe foot by jumping over a wall that enclosed the town. A bone had pierced the tegumenis, and was partly outside: the surgeon, thinking it could not be replaced, cut tbe ligaments that were partly broken, and took it out. The cure was long and difficult: the patient could not walk until after eighteen months, and then slow and by lean- ing on a cane. M. Mauduyt saw the bone come out of Ihe foot, and knew it to be the astragalus. Finally, M. Deniel has inserted, in the periodical collec- tion of Ihe Society of Medicine, a ca»e of luxation of the fool, with issue of the astragalus, by a wound near ihe ex- ternal malleolus. The author of thi- communication, not- withstanding tbe opinion of his two associates, who were for amputation, decided to extract ibe astragalus the eighth * Tome ii. p 69. 320 lloyer's Surgery. day after the accident. At the end of three months and an half, the patient walked, with the assistance of a stick. It will be seen, from the examples we have cited, that the astragalus has been extraclcd, at periods more or less dis- tant, after the wound happened, and during the presence of severe constitutional irritation; that this extraction was easy, not painful, and constantly followed by a diminution of the symptoms; and, lastly, that the patients recovered with anchylosis of the foot, and could walk with facility, at first by the assistance of a cane, and, finally, without any help. We ought then, under similar circumstances, never to hesi- tate to extract the astragalus; for this is preferable to ampu- tation, which was formerly regarded as the only resource in such cases. In the different complications of the lateral luxation of the foot, after having effected the reduction, and applied the proper apparatus to keep tbe foot in its natural position, we should employ the most energetic anti-phlogistic means to combat the inflammation that always accompanies these accidents, and which, notwithstanding the best treatment, may terminate in gangrene or suppuration. Gangrene, provided it is confined to the skin, does not prevent the cure, but, when it extends to the bone, its pro- gress is sometimes so rapid, that the patient quickly ex- pires. At other times, the mortification stops, and nature draws a line between the living and dead parts. We have then the resource of amputation. When an abscess is formed, it must be opened early; Ihe matter is generally near the joint, and under the skin, but sometimes it is seated more deeply between the muscles, as may be seen in the 410th case of Lamotte : In a luxa- tion of the left foot, the inferior extremity of the tibia projected through the integuments, the fibula was broken two fingers' breadth above the external ankle, and the foot bent back against the external middle part of the leg. The luxation was easily reduced; violent inflammatory swelling followed; three abscesses were formed; the principal one was between the gastrocnemii and the plantaris, another at tbe internal superior part of the leg, and tbe third on its external superior part. These abscesses retarded the cure, which was not complete until the end of seven or eight months. When luxation of the foot is complicated with issue of the inferior extremity of the tibia, through a wound of the skin, if a part of the bone is denuded, it is sometimes co- vered with granulations, without exfoliation; sometimes Of Luxations of the Foot. 331 these granulations do not appear until a part of the unco- vered bone mortifies and exfoliates: but, when all the cir- cumference of the bone is denuded, if we leave the sepa- ration lo nature, it will not be effected in a long time, dur- ing which the patient is exposed to symptoms that may de- stroy him. To prevent these, and, at the same time, to ac- celerate the cure, M. Descbamps, surgeon in chief of iho Charite, determined to perform ihe resection of the inferior extremity of the tibia. He communicated the following case to the Society of Medicine of Paris, in 1811: "A man, thirty-two years of age, being thrown on his left side, re- ceived the momentum of a large piece of timber, on the right internal ankle. The third day after, M. Descbamps found the articulation of the foot completely operred in it» anterior parts; the trochlea of tbe astragalus was denuded; the internal malleolus was separated in a line almost fraus- verse lo the tibia; tlie fibula was fractured, and the integu- ments wounded near the lower third of ihe bone; one of the fragments projected outward; the foot was turned outward, and although the swelling extended to the lower part of the leg, the pain was not violent, and the patient was without fever. After having separated the fractured parts of the malleolus, he left the parts as he found them. The wound Was covered with emollient poultices, changed twice a day. Twenty days after the accident, the wound was in a good wny, but the tibia was two inche* and three-fourths lunger (bun the articulation. M. Descbamps performed Ihe re- section in a particular manner. He then sawed the extre- mity of the bone almost in contact with the astragalus, which permitted him lo place the foot inward into its natural situation. Every thing went on well, and, six months after- wards, the wound was entirely cicatrized. Tire wound, cor- responding to the fracture of the fibula, the frag uents of. Whieh overlapped each other, did not close until a month af- ter: the foot acquired strength; the patient wore a boot with a very thick sole, to support Ihe foot, and on this he walked. Anchylosis being inevitable after removing either the as- tragalus or the inferior extremity of the tibia, and much to be feared after all luxations, the foot must be kept at a right angle with the leg, to favour the exercise of its functions after the cure. In complicated luxations of the foot, when there is no ex- ternal wound, (a case extremely embarrassing and dan- gerous,) the reduction must be attempted immediately. It is generally very difficult, and sometimes imposnibte. The diili- VOL. II. *4 322 Bayer's Surgery. eulty does not arise from Ibe head of the bone being confined in the narrow opening of the capsule, but from Ihe astraga- lus being luxated on the tibia and tbe scaphoides, the ex- tending powers do not act on this bone, and the hand of the surgeon cannot push it into its natural (dace. Desault, unable to reduce a luxation of this kind by the usual method, and attributing his ill success to the narrow opening the as- tragalus had made in the capsule, laid the bone bare, and di- vided the ligaments, and then reduced the luxation with care. We also find, in the Surgical Journal of Ihe same practitioner, another case of double luxation of the astraga- lus, without wound: but in this Desault effected the reduc- tion with great facility, and the patient was cured on the thirty-ninth day. It is probable, that, in tliese two cases, the astragalus was so moveable that the pressure of the fin- gers was sufficient to push it into its natural place : but the astragalus may be so wedged between the tibia and os calcis, that it is impossible to reduce it, as in the following case. A man, thirty-six years of age, small, but very strong, fell from a horse: his foot was entangled in the stirrups, while the horse continued galloping: tbe astragalus was turned over inward upon the libia, and its head left the sca- phoides by the superior external part of the eavity of this bone, and formed a remarkable tumour under the skin. The patient was brought to the Charite, directly after the accident: 1 immediately attempted the reduction, but all my efforts were useless ; the astragalus was immovable, and did not yield to the pressure I exercised on it, while two strong assistants made the extension and counter-extension. The patient suffered very little, and I determined to abandon the luxation to itself, hoping, that if 1 prevented inflammation, the astragalus would unite to the bones between which it was confined, and the patient have the use of his foot, although deformed and turned outward. This appeared lo me prefer- able to amputation, or incision of the skin and ligaments, because, from the fixed stale of the astragalus, an incision would not render the reduction possible, and I feared the consequences of opening Ihe joint. The part was covered with emollient poultiees, and the limb placed in the appara- tus for fractures; the patient was put on the anti-phlogistic regimen, and bled three times in twenty-four hours; there was very little swelling; the pain was moderate, and, until the eighteenth day, hopes were entertained of a favourable termination; but, at this period, the skin that covered the tumour formed by the head of the astragalus and behind the external malleolus, began to turn red; a gangrenous eschar Of Luxations of the Foot. 323 soon appeared in these two places: the fall of the one cor- responding to the head of the astragalus, left tbe cartilage uncovered, already yellow and rough; the ulcer resulting from this eschar furnished a viscid yellow matter, proceed- ing from the destroyed synovia. At about tbe end of nine months, tbe pain became extremely violent, the suppuration very abundant, and of bad quality; a slow fever took place; the patient was sinking rapidly ; amputation then'ap- peared the only means of saving his life: it was performed with success. An anatomical examination showed the dou- ble luxation of the astragalus, and (he articular surfaces of this bone carious, as likewise those of Ihe tibia and fibula. Luxations of the foot forward and backward are much more rare than those to one side: the luxation forward is less frequent than that backward. In the displacement backward, the trochlea of the astraga- lus is lodged behind the inferior extremity of Ihe tibia, v> hich rests on Ihe neck and head of the former bone: in the luxation forward, the inferior extremity of the tibia is behind the trochlea of the astragalus, and corresponds to the posterior part of the superior surface of the os calcis : in both cases the capsular ligaments are ruptured, and the lateral liga- ments are partly or wholly broken. It is commonly said, that luxation backward lakes place when the foot is very much bent; but flexion of the foot can never be carried far enough to cause this luxation ; which, indeed, can scarcely happen, except in a fall or a jump on the feet, when they are forcibly extended, and strike against an inclined plane. In these circumstances, if the weight of the body is horn more on one foot than on the other, and the body, the thigh, and the leg so erect lliat the line of gravity of the superior parts fall on ihe articular pulley of the astragalus, Ihe tibia, the axis of which is then very obHque to this pulley, may slide downward and backward. In this manner the only luxation of tlie astragalus backward that I have met with took place. ^ The characteristics of these luxations are so evident that it is difficult to mistake them. The following case, how- ever, is an example to the contrary : A man fell on his feel, from a height of six feet: ihe weight of the body was re- ceived principally upon the right foot, the sole of which, m its whole extent, struck upon an inclined plane ; the interior extremitv of the tibia passed downward and forward upon the anterior pulley of the astragalus; so that this bone was luxated backward. The accident was taken for a 354 Boyei*S Surgery. sprain, and treated accordingly. I saw the patient a month after' it bad happened: the reduction was then impossible: I endeavoured to dissipate the swelling, which still existed: the movements of flexion and extension were almost entirely lost, and the patient walked afterwards as a person whose foot is anchy loscd with the leg. Luxations of the foot backward and forward are, in gene- ral, less serious than lateral luxations; when they are not reduced, the limb is not rendered useless, but its functions are performed with difficulty. To reduce luxations forward and backward, extension and counter-extension are necessary. In the latter accident, the foot must be pushed forward by one hand placed on the heel, and another on the lower part of the leg, which should be pushed backward, and vice versa. The after treatment is the same as in lateral luxations. We have already seen, that the astragalus, luxated in- ward or outward on the tibia, may be, at the same time, luxated on the os calcis. Independent of this mode of dis- placement, the astragalus may be luxated on the scaphoides, and preserve its natural relations with the bones of the leg and the os calcis: in this case, the oscuboides also must be luxated on Ihe os calcis. J. L. Petit twice met with this ac cident: in both instances it was occasioned by entangling the foot in the bar of iron that forms the bridge over the small gutter at a gate-way. It is to be regretted, that this great practitioner' does not mention the appearances of these lux- ations, and the means he employed to reduce them. He merely says, the accident is only known by tbe deformity thai indicates where the bones are lodged ; and, in speaking of the prognosis, that this luxation is less apt to produce bad symptoms than that of the foot; but the reduclion is more difficult, because we have less hold to make the exten- sions. 1 : ave seen incomplete luxation of the head of the astragalus in a man who fell from a house; the inflamma- tion was so great as to conceal the displacement at first, and when I could ascertain it by the tumour formed by the head of the astragalus, it was impossible to replace it: the move- ments of the foot were incommoded for a long time, be- cause the ankle joint had been sprained, but not the small- est deformity remained. The phalanges of ihe toes are very rarely luxated. All we have said of dislocations of the phalanges of the fingers applies to those of the toes. ( .#25 ) CHAPTER XXXIX. Of Wounds of the Joiuts. THE opening of the capsule is what constitutes a wound of a joint. There are many varieties of these acci- dents. In this chapter we shall treat of wounds of the ar- ticulations made by puncturing or cutting instruments, and we shall consider them both in relation to the instrument which has produced them, and the circumstance which ac- company them. We refer the reader to the chapter on sprains for what relates to contusions of the articulations, and to the article on gun-shot wounds, for the rules of prac- tice in contused wounds of the joints. Of Simple Punctured Wounds. Wounds made by puncturing instruments, without injury of any considerable nerve, or of a cartilage or bone, merely require to be placed in apposition. A surgeon determines whether a wound penetrates a joint by considering its direction, and comparing its extent with the form and breadth of the instrument. If synovia escape, the case admits of no doubt; but, in oblique wounds, this circumstance does not always take place. A viscid fluid may be discharged from the sheath of a tendon; we should not mistake this for synovia. In examining a wound near a joint, we should never introduce a probe : it might produce a very dangerous degree of irritation, and would separate the tender adhesions, which, perhaps, may have already commenced: moreover, it is of no practical use to know if the capsule is opened or not, for, in a doubtful case, we should act as if it were. In general, wounds of joints are not dangerous, if pro- perly treated: nevertheless, as very slight accidents of this kind have terminated fatally, we should be circumspect in our prognostic. The treatment of these wounds consists in approximating their edges, and keeping them in this situation in order to promote their re-union by the first intention. For this purpose, the part should be so placed that the integuments are relaxed; the lips of the wound should be brought toge- ther by slicking plaster; ihe part is then to be covered with compresses wet with a resolvent liquid, and over ihem a rol- ler is to be placed, moderately tight. If we fear tbe pati- 526* Boyer's Surgery. cnt may inconsiderately move the limb, we should take means to keep it still, for the most perfect rest is necessary. In the course of three or four days the wound is generally found re-united: sometimes the bottom alone has adhered, and the wound of the skin suppurates; but it heals soon af- terwards. Case 1. Mons. ---- had the left elbow joint opened, on the inner side, between the olecranon and the internal con- dyle of the humerus, by a very sharp piece of glass. The escape of synovia left no doubt of the nature of the acci- dent. I introduced a probe, and ascertained that there was no piece of glass remaining in the wound, and then brought its lips together with sticking plaster, and placed tlie fore- arm in a sling, directing bim to keep it quiet. The pa- tient was perfectly cured in five or six days. Case II. A man, in a duel, had the elbow joint opened by a small sword; sy novra escaped. He was brought to the Charite. I applied a plaster of diacholon cum guramis, and, in a few days, he was perfectly well. We shall have occasion to show that wounds of joints de not always terminate so favourably. Of Simple Incised Wounds. Simple incised wounds require only to be kept in exact apposition. If closed immediately, they generally do well, unless blood is effused into Ihe cavity of the joint. Com- presses wet with a resolvent liquid, and a roller moderately tight, should be applied; the most perfect rest should be maintained; the patient should be put upon low diet, and, jf necessary, he should be bled. Case I. A man received a sabre-cut, which laid open al- most all the posterior part of the wrist joint. The tendons of the extensores carpi radiales were divided, and Ihe action of the antagonist muscles, together with the weight of the hand, drew it to a state of flexion, so that the convexity formed by the scaphoides, the semilunare, and the pyra- mrdale, abandoned the cavity of the lower end of the ra- diis, and could be seen at the bottom of the wound. The man was immediately brought to me at the Charite: I closed the wound, by placing the hand and fingers in a state of the greatest extension possible, keeping them so by a suitable bandage. The wound healed bv the first intention, and the man was completely cured in fifteen days; but I thought proper to continue the use of the bandage fifteen days lon- ger, to allow the tendons to unite more firmly. The patrr Of Wounds of the Joints. 32: out was then allowed to move the hand, and, in a short time, it became as strong as the other. Case II. The wife of a shoemaker received a cut on the external side of the wrist. The tendons of the external ra- dial muscles, of the abductor longus, the long and short ex- tensors of tbe thumb, the radial artery, the external lateral ligament, and the capsule were divided; so that the outer third of the wrist joint was opened. A surgeon very im- properly filled the wound with lint to arrest the hemor- rhage. I saw the patient four or five hours after the acci- dent. After I had removed tbe bandages, and washed away the blood with which il was filled, my first care was to tie the radial artery, which I did by catching it with a dis- secting forceps; I then approximated the lips of the wound, by placing the hand in a state of strong abduction : the bot- tom of the wound healed by the first intention, but the ex- ternal part did not heal before the end of a month. During all this lime, the hand was constantly kept abducted. In or- der that the bandage might act more advantageously, I kept the fingers bent; the event showed that I did wrong, for the flexor muscles of the fingers became so much contracted that I was obliged to apply cones of linen, covered with ce- rate, gradually augmented in size, in order to straighten the fingers. A thread was attached to tbe apex of the cone, and passed between the fingers and palm of the hand, by means of an eyed probe ; by drawing upon the ends of the thread the cone was conducted to its place. This contrivance has often succeeded on similar occasions. Of Complicated Wounds of the Joints. If a person receive a wound of a joint, however simple, although he may be in good health, if he does not keep the part in a state of Ihe most perfect rest, we need not be sur- prised at the appearance of inflammation of the joint. The same thing will occur if there exist in the individual any of those morbid states of the system, whicli have been supposed to depend upon a taint of the fluids, a saburral state of the first passages, &e. If we consider, that almost all wounds of joints that are immediately closed, and in which there is no particular cir eumstance to prevent adhesion, unite, by ihe first intention, and that in cases where wounds are not closed, the most se- rious symptoms follow, we cannot avoid attributing ihesc consequences to the impression of air on the internal surface of the synovial membrane, and to the cartilages and fatty 328 Bayer's Surgery. substances within tbe joint. We know, by experience, that the action of air on parts that are not naturally exposed to it, and especially on serous membranes, is to excite inflam- mation. The synovial membrane is still more easily sensi ble to the impression of the atmosphere ; hot air cannot be regarded as the only cause of inflammation of joints that arc wounded, for it often succeeds to wounds so narrow and oblique that air cannot enter; and, in other cases, inflamma- tion takes place the day after the wound, too soon for air to produce any noxious effects. W7e are pursuaded, that wounds of the cartilages and bones, the improper application of lint, and of acrid irritating substances to exposed joints, the dressing necessary to stanch the blood, in cases which do not admit of the application of lire ligature, the morbid pre- disposition of lire patient, and errors in regimen, may all combine with air in giving rise to inflammation: perhaps, in some cases, it may arise exclusively from one of the above named causes. On the fifth or sixth day, in most cases, and sometimes on the second or third, the inflammation commences. It be- gins with acute pain, increased by the slightest motion ; the joint swells and becomes hot; the cellular tissue becomes edamatous ; tbe skin is tense and shining, but not unusually red ; tbe lips of the wound become pale, bloated, and thin, serous pus distils from them; tbe patient becomes fever- ish ; his countenance animated and warm ; respiration is ac celerated ; the tongue is dry; the thirst is very intense, and sometimes delirium supervenes; the swelling often extends to the whole limb, which, in such cases, becomes prodigi- ously swollen. To these symptoms suppuration succeeds; the joint is filled with pus; abscesses form, under the skin and between the muscles, in parts more or less remote from tbe joint; the articular ligaments become relaxed; the bones are loosened, and tlie articular surfaces may be made to grate upon each other; the collection of pus increases, and ex- tends, in some cases, to the trunk; the patient suffers ex- cruciating pain; he cannot enjoy a moment's rest, and, sooner or later, death closes the scene. If the strength of the constitution have resisted the first symptoms, long-con- tinued and copious suppuration, finally exhausts it; the features become sharp; hectic fever insensibly steals on; diarrhoea and colliquative sweats supervene, and the patient at length dies, unless we save him by a timely amputation. In some fortunate causes, the disease yields to the efforts of art; the pains diminish, and finally case; the pus becomes Of Wounds of the Joints. 32fl less copious, and of better quality; sleep and appetite re- turn to the patient; the edema of the limb subsides; the ulcers lieal; and, finally, the articular surfaces becoming united to each other, the patient is cured with a stiff joint. In forming our prognosis, we should consider the size of the joint and of the wound; whether the capsule only is di- vided, or whether the injury extends to the cartilages, bones, &e. We should reflect upon the state of tbe patient's health, the severity of tbe symptoms, &c. and from a consideration of all Ihe circumstances of the case, decide on the pro- priety of amputating, and fix a proper time for doing it: ne- ver forgetting the necessity of extreme caution in giving our opinion as to the ultimate result of tbe case; for unpromis- ing cases often do well, and others, apparently trifling, ter- minate in death or anchylosis. The indication in the treatment ef wounds of the joints, is, to diminish Ibe inflammation and prevent suppuration; if pus is formed notwithstanding, we should prevent it from burrowing in or about Ihe joint, and moderate the hectic symptoms which follow its absorption; we should bleed, ac- cording to the age and strength of the patient; prescribe eooling drinks, clysters and low diet, and, when the j;aiii is excessive, even anodynes and opiates; the part should be placed in a suitable position, and kept in a state of the most perfect rest;—such are the means of procuring resolution. They often fail, and pus is formed : this must be discharged by making sufficient openings, and giving them an extent proportioned to the magnitude of the abscess. When the joint is large, the incisions should divide the capsule, so that the pus may flow out freely, or be washed away by injec- tions. The exposure of the joint to the air is by no means so hurtful as the stagnation of pus within it. Practitioners are not agreed as to Ihe proper size of the incisions for evacuating pus from cavities that communicate with a joint. J. L. Petit advi-.es, that they should be made lare^e: •• We should not only make openings," says he, •' but make large openings, communicating with each other; so that every part of the joint may be washed by the injections. I know that the bones often become diseased and exfoliate; but this does not result from the presence of air admitted through the opening, but from the presence of pus in spite of the openings; we should, therefore, m.ke early inci- sions, and wash the interior surface of the joint by means of injections." David, on the contrary, thinks we should not be in haste to evacuate pus from a joint; and that, when we can no longer delay discharging it, u trochar should vol. II. *2 330 Boyer's Surgery. be employed. He says, he never saw any good result from the large incisions recommended by Petit. In our opinion, when an abscess of a joint has resulted directly from the inflammation produced by a wound of the capsule, or a contusion of the articulation, a comminutive fracture, or a gun-shot wound, we should open it as soon as fluctuation is apparent, and make the incisions large enough to admit of washing away the pus by injections. Otherwise caries of the bones and hectic fever will soon take place; and, although we expose the joint to the air by this practice, not so much injury results as would be occasioned by the stagnation of pus. The advantages of this method are esta- blished by very extensive experience. But when an abscess is the consequence of caries of the articular surfaces, as in white-swelling, disease of the hip- joint, &c. we ought not to make an artificial opening, un. less excruciating pains require it, or the formation of a na- tural opening is threatened; and in these cases a simple puncture is preferable to a large incision. After an opening is made, we should place the limb in such a position as will allow the pus to drain off, inject a mild bland fluid, and exercise a moderate degree of com- pression, if it can be borne. When the inflammation has ceased, we should desist from the anti-phlogistic regimen, and prescribe tonics—such as bitters, bark, succulent food of easy digestion, a moderate quantity of old wine, and aug- ment the allowance, if necessary, to prevent exhaustion. Instead of emollient poultices, we should apply fomentations of a decoction of Cinchona, with the addition of brandy, &c. and, if new abscesses form, they should be opened, and the dressings should be frequent, in proportion to the copi- ousness of the suppuration. When anchylosis is likely to result, the limb should be placed, at an early period of tbe disease, in such a position as will make it most useful: and, finally, when there is no other probable means of saving the patient, we should ampu- tate the limb. Case 1. A fencing-master bad the articulation of the first phalanx of the thumb with the first bone of the metacarpus opened lo the extent of six lines, by the point of a sabre. He washed the wound with a mixture of water, brandy, and salt. Four days passed without any remarkable occurrence. TbC pressure of a hard body on the palm of the hand, at the end of this time, excited hemorrhage and severe pain in the wound; Ihe swelling increased, and the man became fe- verish, and entered the Charite. By moving the bones upon Of Wounds of the Joints. 331 each otlier I could perceive their grating; several abscesses formed, and were successively opened. The thumb became anehylosed. Case II. A cabinet-maker divided the patella vertically by the blow of a hatchet. A surgeon applied the interrupted suture. Prodigious swelling followed, and mortification was threatened. M. Gelee was called in: he divided and re- moved the suture. He observed that the separation of the fragments of the patella increased the tension of the parts, and determined to cut away the smaller of the two. Emol- lient and resolvent applications were then applied; the swel- ling continued, and, notwithstanding an ill-conditioned sup- puration, the patient was cured with an anchylosis of the knee.* Case III. A young man received, in a duel, a sabrc-cut, which laid open the shoulder-joint; the scapular end of the clavicle, the deltoid, and a portion of tbe pectoralis major were divided. The patient was brought to the Charite im- mediately after the accident: I brought the lips of the wound together by raising the arm as much as possible, and plaeing pillows underneath it. He did well until the third day of the accident; and I began to have hopes of saving lus life, when a hemorrhage came on, which obliged me to remove tbe dressing: the bleeding vessel was so deep seated that I could not tie it; I was obliged to fill the wound with lint; inflammation and fever quickly followed; considerable abscesses formed, w hich required several incisions, and the patient died at the end of four weeks. On dissection, the joint was found filled with pus, and its cartilages were dis- eased. Case IV. In 1790, a man was brought to the Charite who had just received a sabre cut that opened the right wrist, on the outer side, to a considerable extent. One of the sisters of the hospital, instead of closing the wound, filled it with lint; the forearm and arm became prodigiously swollen, gangrene supervened, and the man died. Case V. A young man, aged eighteen years, received a sabre wound, which opened the elbow-joint and interested the external condyle of the humerus. The parts were not brought together before the second day: on the third, the pain was severe, and the man was restless; on the fourth, there was so much swelling that 1 determined lo substitute a poultice for the adhesive plasters; on the fifth, there was considerable fever, a copious flow of a thick, viscid fluid, " Jotrmal <\p Medicine Militaire, vol. iv. p 508. 334 Boyer's Surgery. evidently synovia, took place; by pressing around the joint, a greater quantity of pus was made to escape; the symptoms continued to become more violent, and amputation at length became necessary to save the man's life. Dissection of the limb. The edges of the wound formed a ridge infiltrated with lymph; the soft parts contained pus, the joint a sanious fluid; the external condyle of the hume- rus was entirely detached from the bone; disease was ex- tending lo the radios, and the cartilages were almost en- tirely destroyed. Case VI. A young man was brought to the Charite, in 1801, whose knee was laid open by a sabre wound, on the external and anterior part. I brought the lips of the wound together by sticking plaster; but the great tumefaction which tovk place rendered it necessary to substitute emolli- ent poultices. Several bleedings, and the most severe anti- phlogistic regimen did not prevent the swelling from extend- ing to the leg; fever set in; the pain became excessive, and a large abscess formed between the femur and the triceps Cruralis. The symptoms were exasperated on the following day, and the man died. On dissection, I found the patella completely divided, and the joint filled with pus. ( 333 ) CHAPTER XL. Of Foreign Bodies formed in the Joints. HARD, round, or flattened substances, generally cartila- ginous, are sometimes formed in the joints. The first example of articular concretions upon record is mentioned by Ambrose Pare :* " In 1557," says he, " I was requested by John Bourlier, a taylor, in the Rue St. Ho- nore, to open a collection of water in his knee; hi which I found a very white, hard, and polished stone, of the size of an almond. The man got well, and is still living. In 1691, Pechlinf published a detailed account of a carti- laginous and bony concretion formed in tbe knee-joint, from which it was extracted with success. The following is an abstract of the case: A young man, aged twenty years, well formed, and enjoying good health, fell upon tlie knee. He was taken home, and ihe joint was examined: a dis- placement of the bones being perceived, resolvent appli- cations were made to the part; the pain was dissipated, and, at the end of some days, the patient could walk with ease. Eight weeks afterwards, in handling the knee, be perceived, on its internal side, a hard, moveable tubercle, which, until then, had not caused any difficulty in walkr ing. This body sometimes appeared suddenly above the pa- tella, then below it, and sometimes at the 4des ; but always very near the ligament of that bone: occasionally it could not be perceived at all. While the man was walking, he wae often obliged suddenly to stop in order to keep himself from falling: by gently pressing the knee, he displaced the body, and recovered the use of the limb. Two years passed in this way, when he perceived that the tubercle increased in size, and consulted a surgeon. Various means were ineffec- tually tried to soften the tumour, until the patient at length insisted on having it extirpated, and the surgeon consented to perform the operation. He pushed the foreign body on the external side of the patella, toward the edge of the vas- tus externus muscle, and stretching Ihe skin tightly over it, he made an incision through the integuments and capsular ligament: the tubercle escaped, and with it a quantity of sy- novia : it was as large as the end of the middle finger, and its circumference was irregular; by drying, it shrunk and * Liv. xxv. chap. 15. p. 772. f Observation Physico-Medic. Ob*erv. xxxtiii. p. 506. 33* Boyer's Surgery. lost its transparency: it was cartilaginous, but there were several ossified points. Alexander Monro found, in the right knee of a woman who was executed, a bone, as large as a small bean, attached to a ligament, half an inch in length, and to the outer side of the tibia; the shell of this body alone was solid; the inte- rior side of the tibia was filled with a cellular substance con- taining fat. On examining the cartilage which covers the outer side of the articular surface of the tibia, he found that it had lost a portion of its substance, corresponding to the fo- reign body just described. No account of tbe symptoms. during the life of the woman, could bo procured. Ten years afterwards, in tbe year 97A6, Simson* ex- tracted, from the left knee of a man, a large body, of the shape of a French bean, and larger. It was a bony concre- tion, covered with cartilage. This writer acknowledges, with candour, that he was mistaken, even during the opera- tion, in regard to the true seat of the foreign body. He thought it was under the integuments, and he did not know that it was in the joint until he divided the capsule. Since the publication of the last case, similar ones have been described by many surgeons in England, Germany, and France, and the disease is, at present, well understood. Foreign bodies may be formed in any of tbe joints. Hal- ler found twenty in that of the lower-jaw of a decrepid old woman, whose heart and arterial system presented evident traces of ossification. They have also been met with in the elbow, wrist, and ankle-joint: but the knee-joint is, by far, the most common seat of them, and our observations will be confined to this part. Their size is various: Mr. Ford, an English surgeon, met with one as large as a chesnut, but this was of very unusual magnitude: Morgagni found five in the same joint no larger than raisin seeds. Their shape is often like that of a bean : but this is subject to great variety. They are almost always smooth. In some cases they are entirely detached; in other in- stances, they adhere to some part of the joint; generally, by a ligamentous thread, which allows them to move from one side, to the other. Sometimes they appear to be entirely cartilaginous; some- times the centre is bony; sometimes soft and cellular; they are, in some instances, entirely composed of bone. No swelling or dropsy usually takes place in the joint in * Medical Essays of Edinburgh, vol. ir. 37-3. Qf Foreign Bodies formed in the Joints. 335 which these bodies are formed: but there are a few excep- tions to this remark. Monro believed that these bodies were pieces of cartilage thai had been detached from the joint; some think that they are formed in the fatty substance, which is so abundant in the articulation of the knee ; others hold that they are com- posed of a collection of the particles which float in the svno- via, in the same manner as urinary calculi are formed in the bladder; Monro's hypothesis seems lo be disproved by the fact, that the discovery of these bodies is not generally pre- ceded by a fall or a blow. The presumptive signs of the existence of one or more fo- reign bodies in a joint, are, acute pain suddenly eoming on when the limb is moved in a particular direction, and render- ing it completely immovable; and a sudden cessation of the pain, and restoration of the limb to the easy exercise of its functions: the pain is sometimes so violent that patients, while walking, have been known to fall and faint, but others ex- perience no pain. Bell speaks of a patient who suffered so acutely from a slight motion of the leg, that he used to awake from a deep sleep in excruciating pain ; to prevent which he kept himself perfectly at rest. The pain, which is caused by the pressure of the articular surfaces upon the foreign body, returns at intervals more or less distant, and is always brought on by some exertion. These symptoms should lead us to examine the joint: If there be a foreign body within it, we shall probably feel it slipping under our fingers, from one side to the other, behind tbe patella, behind its ligament, and sometimes behind the extensor muscles of the leg. They are oftenest found on ihe inner side of the knee-joint, because there the capsule is most loose. The treatment consists in fixing the bodies in some part of the joint where they will create no inconvenience, or in ex trading them. Reimarus* informs us, that Middleton, observing that ene of his patients was not incommoded while the foreign body was under- the patella, kept it in this situation by means of an adhesive plaster and a bandage, and, aftei- several months, it could no longer be seen about the joint, and it appeared to have contracted adhesions. Middleton told Reimarus that he knew a similar instance of success, and that his treatment had failed in another case. Gooch tried • De Ttfmore Ligam?ntorum citck artieulgs, Funjo Axticulorura dictc. $.35. S36 Bayer's Surgery. it; and not hearing from his patient, concluded that he was relieved. I directed a patient, who had a foreign body in the knee- joint, to wear a knee-eap. It enabled him to walk without pain: he wore it for one year, and afterwards never suffered any inconvenience. Another patient was also relieved for a time by the same treatment, but not having heard from him, I cannot say what has been the ultimate result. It is impossible to say, whether compression produces an adhesion of Ihe foreign body to any part of the joint. Its success is by no means certain: yet, as it is a perfectly safe remedy, we should always try it, in the first instance. If it do not afford relief, and the patient is greatly incom- moded, an operation is then justifiable. If the patient is in good health, he requires no preparation; if he is plethoric, it will be proper to bleed him ; if he is subject to vague rheumatic pains, we should apply a blister to some remote part; the prima? vise should always be cleansed by emetics and purgatives. The operation should uot be performed during the prevalence of an epidemic which the patient might contract. The apparatus necessary for the operation are, a common bistouri, a forceps, a curette, a spatula, strips of sticking plaster, compresses, and a roller. The patient should lay in bed, on the affected side, with his leg extended, and placed upon a pillow. The surgeon should endeavour to bring the foreign body to the inner side of (he joint, and as near as possible to the upper insertion of the capsular ligament. If the body should be most easily got at on the outer side of the joint, we might, after the exam- ple of Hewit, operate on that side. Broomficld directs that the skin should be drawn up; Benjamin Bell advises that it should be drawn up; and De- sault, that it should be drawn to one side, before the patella. Others have operated with success without making the open- ing oblique. We think the precaution of making a valvular opening a useful one, though it is not, perhaps, so important as has been imagined. One assistant should draw the skin inward; the surgeon, holding (he foreign body between the thumb and fingers of the left, hand, makes, at one stroke, an incision through (be skin and capsule, large enough for the easy passage of the tubercle. If the first incision should not be sufficiently extensive, it would be better to enlarge it than to bruise and lacerate the sides of the wound by crowding the foreign body through it. Of Foreign Bodies formed in the Joints. 337 Perhaps ihe foreign body will escape of itself; if it do not, we may extract it by means of the curette or spatula; carefully avoiding to injure the capsule, or the cartilages of the joint. When there is any ligamentous connexiorf of the body we should divide it. It is better, in Ihe event of there being two foreign bodies in the joint, not easily remova- ble through one opening, to defer making a second until the first has united. As soon as the body is extracted, the assistant should* leave the skin to close over the incision through the capsule; the lips of the wound are then to be kept in contact with ad- hesive plaster, Upon which we should apply some compresses wet with a vegetb-mineral water, and over them a bandage. After the operation, the limb should be kept at rest, and extended, for eight or ten days; at the end of which time the wound will generally be found to have completely united. It will be prudent for tbe patient not to walk for fifteen or twenty days. The operation is rarely painful. Hemorrhage need not be feared, for, should any occur, compression would arrest it. Imprudence on the part of the patient is most to be appre- hended : to this Cause, or to the neglect of due preparation for the operation, want of success is generally attributable. The patient of Sittison, whose case we have spoken of, experienced excruciating pain in the knee, which was prodi- giously swollen. It is remarkable, that he complained of the greatest pain on the side opposite to that on which the incision Was made. He could not suffer his leg to be moved, in the slightest degree, without screaming with agony. Nar- cotics gave him all the little sleep he could enjoy ; bleeding, purgatives, and poultices afforded slight relief. Water in- jected into the joint was most beneficial: two men were al- ternately employed, one hour at a time, to inject it with a common clyster syringe. Although this diminished the pain and swelling, neither were removed completely until an is- sue was formed on the outer side of tbe knee. By means of this, and injections continued for the space of twelve months, the patient was perfectly cured. Reimarus says he saw Mr. Hewit extract a cartilaginous body from the right knee of a young man, aged twenty- three years. The incision was made near the external and superior part of the patella. The patient complained of a pretty sharp pain during the operation: but the remain- der of the day he was easy; he was bled. On the day fol- lowing he complained of acute pains in the knee and foot; another bleeding was prescribed without relief. The man 338 Bayer's Surgery. was feverish and restless; the knee swelled. On the next day, the lips of the wound were drawn asunder, and an opaque serous fluid escaped; some relief followed; another bleeding was prescribed, and poultices and fomentations were applied for four weeks; during which the pain con- tinued very acute, especially on that side of the limb which was opposite to the place of the incision. After some time tbe pains gradually diminished under the use of Peruvian liark, and the patient left the hospital with the knee some- what stiff and swollen. Mr. Ford operated upon a young man, who did well until the seventh day: at this period the patient beeame feverish, and his knee painful. Symptoms of the measles soon ap- peared, and the cure was retarded; but by bleeding and low diet, the patient was made well in a month. Desault extracted a foreign body from the knee of a pa- tient, aged forty-five or fifty years. The patient had been subject to vague rheumatic pains: the wound healed kindly; but, on the fifth day, the middle of the thigh became swol- len, and an abscess formed there, which required two months to heal. From these facts we infer, that all the bad consequences which occasionally follow the opening of the knee-joint for the extraction of foreign bodies formed within it, arise from the imprudence of the patient, from some latent disease, or from disorder of the first passages. All these sources of danger we think the surgeon can re- move, and, though some danger is inevitable, the risk of the operation is not such as should lead us to abandon it, much less resort to amputation, as is advised by Bell, in pre-, ference to opening the joint. ( 339 ) CHAPTER XLI. Of Dropsy of the Joints. IN the healthy state, the joints are lubricated by a viscid, albuminous fluid, called synovia. When this fluid is ac- cumulated so as to distend the capsule, it constitutes hydar- thrus, or articular dropsy; a disease not common—sometimes very serious, and always difficult to cure. It may affect any of the joints, but it most often attacks the knee. The hip- joint is, perhaps, the only one in which it has not been ob- served. The quantity of synovia which may be collected in a joint, is generally proportioned to the extent of tbe capsular ligament: but the same joint contains very different quanti- ties in different instances. As much as sixteen or twenty ounces have been found in the knee-joint; but the quantity is seldom so great. Synovia, accumulated in a joint, undergoes changes si- milar to those of all other secreted liquors that are retained in cavities formed to receive them; it becomes thick, more viscid, and of a fawn colour. Independently of these changes, which arise simply from a retention of the sy- novia, the various morbid states of the synovial mem- brane may render it turbid, thick, greyish, like whey, or give it a greater or less quantity of grounds, or albuminous flocculi. The progress of this disease is almost always slow ; but in some cases it is acute. It may be simple, or it may be connected with a diseased state of the joint. It is always local or idiopathic. Il arises from a destruc- tion of the equilibrium of the exhalations of the synovia and its absorption. It is said, that when the exhalation is in- creased, the disease is acute, and when the absorption is de- ficient, the disease is chronic. The remote causes of this disease are external and in- ternal. Among Ihe first we enumerate contusion, distor- tion of a joint, extreme cold, an ancient and neglected cold, the presence of a moveable foreign body in the knee, and, in general, whatever can mechanically irritate the arti- cular capsule, and produce a chronic latent inflammation of that membrane. Tbe internal causes are, a metastasis of erysipelas, or any other disease, hut the most frequent are rheumatic affections. Rheumatism has a predilection for the knee, and it often causes an effusion of synovia into the 340 Bayer's Surgery. joint, whicli, if not absorbed, constitutes hydarthrus. In acute rheumatism, the collection is formed suddenly; in chronic rheumatism, slowly and insensibly: in the former case, the dropsy is rarely considerable, and often disappears spontaneously; in the latter, it is \ery difficult, and always requires much time to effect its absorption. The exhalation produced by rheumatism is frequently seated in the cellular tissue which unites the inferior and anterior part of the femur with the triceps cruris muscle, and a tumour is formed, which resembles dropsy of the joint, so strongly, that it is often difficult to distinguish the two affections from each other. Hydarthrus appears under the form of a soft tumour, cir- cumscribed by the insertions of the capsular ligament; with- out change of the colour of the skin ; indolent, or causing very little pain, or impediment to the motion of the joint; yielding to the pressure of the finger, but not retaining its impression like edema. The tumour is most apparent at those parts where the capsular ligament is loosest and most thinly covered. At the wrist, it occupies the anterior and posterior part of the joint, but especially the former, while, at the sides, it is scarcely perceptible. At the ankle- joint, the tumour is more apparent, before the malleoli than at any other part. At the shoulder, it is scarcely percepti- ble, except in the interval between the deltoid muscle and the pectoralis major. The knee, which is the most frequent seat of articular dropsy, becomes swollen at its sides and in front, but not at the posterior part: the swelling is con- fined, in the first instance, by the insertions of the capsular ligament; but afterward this yields, and the tumefaction ex- tends upward between the femur and the triceps cruralis, which it raises. I have seen the tumour extend two thirds of the distance up the thigh. It is divided longitudinally by the patella; its ligament, and the extensor muscles of the leg, which are less prominent than the capsular ligament on each side, especially on the internal side; the leg is capa- ble of flexion and extension, nearly as well as in perfect health; and the tumour is harder when the leg is bent than when it is extended. To perceive the fluctuation, which is one of the best cha- racteristics of tlris disease, we should place the ends of two or three fingers of one hand upon one side of the tumour, and strike upon the opposite side with the end of Ihe middle finger of (he other hand. The fluctuation is, in general, very distinct. The patella being removed from the articu- lar pulley, if it be pressed backward, we perceive that if Of Dropsy of the Joints. 341 passes through a certain space before it strikes against the nones, and again is separated from them when the pressure is taken off. These symptoms sufficiently distinguish dropsy of the joint from white swelling, from encysted tumours, that sometimes form behind the triceps cruralis, from rheuma- tism, &c. It is very difficult to cause the absorption of synovia from a dropsical joint, and we are often obliged to leave the dis- ease to itself, or have recourse to an uncertain and danger- ous operation. The most favourable cases are those in which the disease is occasioned by rheumatism translated to the joint. In such instances, the collcetion is often absorbed in a short time ; but the disease is very apt to return. The worst result that can happen is the termination of the dropsy in white swelling. The indications in the treatment of articular dropsy are. first, to remove the inflammation of the ligaments, and, af- terwards, to obviate the debility of the lymphatic vessels which succeeds to it. When the rheumatic affection of a joint is moderate, and the pain is not acute, low diet, rest, the warmth of the bed, fomentations, and cataplasms, emollients and anodynes are generally sufficient to remove tbe inflammation ; but, in more severe cases, local, or even general bleeding, and a strict antiphlogistic regimen are required. As soon as the in- flammatory symptoms have abated, nothing will be more useful than to attract to the integuments the morbid princi- ple w hieh is fixed in Ihe joint, by the successive applica- tions of several weak blisters around the joint. Thus not only a copious discharge of scrum is kept up, but a con- stant irritation, which, in deep-seated inflammations, and those of serous membranes, is much more useful than the discharge itself. Stoll and other celebrated physicians em- ploy blisters in rheumatic affections, when the inflammation is at its acme. As this disease is almost always purely local, and inde- pendent of the general causes of dropsy, topical remedies chiefly are useful: diuretics, sudorifics, &c. are of little or no service. The external applications which have been employed with most advantage, are spirituous aromatic fomentations—re- solvent fumigations—volatile liniment, or liniments made with the balm of Florence, and the tincture of cantharides— bags filled with the powders of aromatic plants, slacked lime, and tbe muriate of ammonia—long-continued and re- ah-S Boyer*s Surgery. peated friction with flannel impregnated with an aromatic vapour-—the application of paper dipped in hot strong vine- gar, and frequently renewed—pumpings of warm water, with or without the muriate of soda, or sulphuret of potash— a bandage moderately tight. These different means, varied and combined according to circumstances, frequently suc- ceed : but the successive application of blisters is probably more powerful, both in preventing and curing the disease. Some practitioners employ mustard, and other rubefacients. We should avoid producing ulcerations of the skin. They are sometimes difficult to heal, and prevent us from continu- ing the irritating applications. We have often employed blisters with success, but never with success so marked as in the following case: A man, aged forty-two years, exposed, by his profession, to the incle- mencies of the weather, had experienced vague rheumatic pains for eighteen months previous to the 23d of July, 1812, when he entered Ihe Charite. The right knee had then been dropsical for three weeks, and the left for eight days. I ap- plied successively five blisters upon each knee. On the 1st of October, the patient left the hospital entirely cured. Moxa is employed if blisters do not succeed. Several cy- linders of cotton are burnt on one side of the knee: they ought not to be suffered to produce a deep ulceration. It would be useless to try this remedy if the bones had become carious. There is yet another resource, when these means fail—- the evacuation of the synovia. This operation is not always successful, and sometimes produces fatal constitutional irri- tation, or leads to the necessity of amputating the limb. It is evident that the discbarge of synovia does not restore the equilibrium between the exhalation and absorption of this liquid. The operation cannot, therefore, cure the dis- ease in any other way than by exciting an inflammation of the synovial membrane, which shall cause it to adhere to Ihe parts with which it is in contact; and such inflammation is always dangerous. Were the capsule perfectly healthy, and did the disease depend entirely upon the debility of the absorbents, a slight degree of inflammation, excited by a suitable injection, might, perhaps, effect a cure, by ob- literating, in some degree, the cavity of the joint; but the synovial membrane is almost always thickened by the pre- ceding inflammation, and an opening commonly causes it te suppurate; in which case, if the pus be small hi quantity, and can be discharged frequently, by a moderate opening, -the patient may be cured, with more or less stiffness of the Of Dropsy of the Joints. 343 • joint: under more unfavourable circumstances, he will pro- bably lose his life or his limb. In what cases are we justified in evacuating the synovia by an operation ? 1st. When dropsy of the joint is compli- cated with the presence of a foreign body, formed within it. The cases we have cited from Sitnson and Pare establish this rule. 2d. When Ihe disease is acutely painful, and pre- vents the limb from being moved; for, if under such cir- cumstances, the operation be not performed, the bones be- come carious, and the patient incurs greater risk of losing his life than he would by suffering the fluid to be discharged. The capsule may be opened with a trocar or bistouri-. The synovia is very rarely so thick as not to escape freely through the canula of a trocar; but tbe opening closes very soon, and the ulterior accumulation of synovia is not prevented. An incision is necessary in most cases. It should be made on one side of tlie joint, and in the most prominent and de- pending part, and the skin should be stretched, in order to make the opening valvular; the wound should not be closed, but should be covered by a dossil of lint, with cerate spread upon it; compresses, wet with a resolvent liquor, should then be applied. At the end of twenty-four hours, we sometimes find the joint as large as it was before the operation, the lips of the wound having become agglutinated; we should separate them, and introduce a small pledget of lint, or a strip of linen. After the operation, the patient should be bled, and put upon a strict antiphlogistic regimen, &c. When we are obliged to make several openings, a seton may be useful. Case I. A young man of weak constitution fell upon the right knee, at the beginning of his convalescence front'a ehronic disease. Tbe pain was so acute that he could rrot rise. Some hours after the fall, the knee became swollen, tense, red, and painful. Fever ensued, and the part was poulticed for seven days: the capsule of the joint became filled with a fluid, the fluctuation of which was evident. On the twenty-fifth day an incision was made through the side of the joint: ten ounces of serous fluid, like that of dropsies of other parts, escaped: the part was kept wet with resol- vent liquids. Twenty-four hours after the operation, the pain increased, and the swelling was as great as before; tbe incision was enlarged; more fluid escaped ; and a pledget of lint was introduced between the lips of the wound. In a few days another tumour formed on the internal side of the 344 Bayer's Surgery. knee: it was opened; one or two ounces of a puriform fluid, escaped through the divided capsule ; injections of rice wa- ter and honey were thrown into the joint; the symptoms moderated, and the patient was cured in the space of two or three months. At first it was very painful for him to bend his knee, which afterwards became more flexible, but never so much so as the other.* Case II. A man, aged twenty-four, had a dropsy of the knee, of four weeks standing, without any known cause. Warner made a lateral incision through Ihe skin and capsule, whicli gave issue to fourteen ounces of a thick gelatinous fluid, tinged with blood. After some days it became ne- cessary to enlarge the opening, which had become too small. Afterwards an abscess formed on the opposite side, which was opened. The patient was cured in the space of three months.f Case III. Schlichting was consulted by a Rabbi who had had a dropsy of the knee for eight years, and which had been treated without success in London, Paris, and differ- ent parts of Germany. He made a large incision by the side of the patella; a great quantity of a limpid fluid, that coagulated by heat, was discharged, and four glandular substances, of the size of nutmegs, were extracted. As the incision was large, the surgeons present ascertained by the sight and touch, that the bones of the joint were healthy. The capsular ligament had been ruptured long before, in consequence of the distention by the fluid within it. The interstices of the muscles, and the cellular tissue, were so infiltrated, that a probe could be passed to a great distance between them. After having ascertained the relations of the sinuosities, suitable incisions were made: a gelatinous fluid was constantly discharged through them. Tbe patient was feverish on the day following the opera- tion. Soon afterwards, a fleshy excrescence arose from the bottom of the wound, and separated its lips, causing much pain, and preventing the easy discharge of the fluid in the joint. Escarotics did not check its growth; the ligature was employed; the fungus shrunk, as if it had been burnt. At length, after the use of injections composed of myrrh and the spirits of turpentine, it became detached, and the wound was then closed with sticking plaster, for which a tight roller was afterward substituted, and kept on six days; at the end of this time, the wound was entirely healed. * Lassus Pathol. Chirurg-. t.I. p. 313. f Philosophical Transactions, for the year 1755, vol. xlix- P- 452. Of Dropsy of the Joints. 315 In two months the patient could move the limb and lupnort himself upon it,# Case IV. A negro woman, aged thirty-six years, of a bilious and robust temperament, came to i\\e hospital of the •Cape, in April, 1789, with the right knee swollen and pain- ful. Mr. Gay prescribed a poultice made with, the clay used by cutler's and vinegar, and had Ihe patient purged: she then left the hospital to resume her ordinary occupations. Some time afterwards she returned. The pain and swelling had considerably increased ; it was evident that an effusion had taken place into the caviiy pf the joint; a frpcur was immediately plunged jn; a transparent liquid escaped; in- jections of Goulard's water, rendered more active hy the addition of camphorated spirits, were thrown into the joint to wash away any of the fluid which might remain. The whole quantity evacuated was estimated at spven or eigtyt ounces. On the fifth day the swelling bad entirely ceased; only a slight oozing through the puncture continued, 'tlie pa- tient left the hospital, cured, twenty days after the opera- tion.! In Ihe following cases, the consequences resulting frpin opening the knee-joint were not so fortunate. Case V. A patient had dropsy of the knee. A lancet was plunged through the internal side of the tumour; nearly a pound of fluid was discharged; the wound was covered with lint and a small plaster; the knee was enveloped in aromatics and stimulants; the patient took purgatives and bydragogues. Notwithstanding these precautions, Ihe col- lection began to return in a few weeks. Another surgeon made a large incision into the joint, in the internal side of the knee; violent pain, fever, inflammation, and cqpipus suppuration followed. Amputation bepame necessary ^p save the patient's Hfc4 Case VI. Francis Jerome ----, aged forty-four years, entered the Charite on the 24th of August, 181 J, with dropsy of the left knee, of fifteen months duration: the. swelling was soft and fluctuating; it extended one third of flic dis- tance up the thigh ; Ihe skin was not red, nor were thp mo- tions of the knee limited or painful. No cause could be assigned for this disease* Many insig- nificant remedies had been tried, and at length blisters were applied; but they produced no favourable change. » Act. Phys. Medic. N'ut. cur. t. viii. p. CD f Recueil Periodique dt la Sock-' ' df Medicine, anrn-e 1767- ♦ Essay upon Dropsy, by Mo.-o the joungpr, P- 244. VOE. II. ii 3*6 Bdyer's Surgery. Before I ventured to open the tumour, t used blisters and various applications without success. It continued to in- crease, and I resolved to puncture it. On the 27th of September, a trocar, of the ordinary size, was plunged into the inferior and external part of the tifmour, in a direction obliquely upward and inward: six ounces of a yellow viscid fluid were discharged through the canula; the wound was covered with diacholon plaster, and a roller was applied tightly to the knee. On the 2Slh of October the tumour was as large as be- fore the operation: a second puncture was made, and se- venteen ounces of fluid, similar to the first, were evacuated. A few days afterwards, a new collection had began to form, and the patient left the hospital to put himself under the care of a quack, who promised lo cure him. The charlatan made a third puncture into the joint, in the same place where the last had been made, and left the canula in the wound. The knee 90on became very much swollen; Violent fever, and excruciating pain ensued; the canula was with* drawn after a few days, and a gum elastic bougie was intro- duced into the opening, which it exactly closed; emollient poultices were applied with some advantage. When the bougie was withdrawn, a great quantity of black sanious matter was discharged ; the patient used daily a bottle of a sudorific tisan, and, while sinking under copious sweats, hectic fever, and diarrhoea, he still regretted that the ex- haustion of his money deprived him of the further services of the charlatan, and obliged him to return to the hospital. On the 7th of December he was brought back: I found tbe tibia capable of being moved transversely upon the fe- mur, with a grating noise; a sanious fluid flowed in a stream from the opening when tbe patient bent the leg, and com- pressed the tumour with his hands; the limb was placed in an apparatus for fractures; injections of rice water and ho- ney were thrown into the joint; Peruvian bark was pre- scribed. But, in a short time the hectic symptoms, which had dis- appeared, returned with increased violence; the lower extre- mities became anasarcous, and the patient died on the 9lh of January, 1813. - Dissection. The cavity of tho tumour, whieh contained a fetid sanies, was divided into two parts; the upper and larger of which, formed by the distended capsular ligament, ex- tended one third of the distance up the thigh : it communi- cated with an abscess, situated between the gastroencemii and solceii muscles, and reached half way down the leg Of While SwelHng. 347 Tfet- second eavity. was situated behind the triceps cruralis muscle, and extended to the crural arch. Tlie surface of these cavities was black; the cartilages were absorbed; the tibia, femur, and patella were carious; the crucial and la- teral ligaments were destroyed. Facts of this kind are rare; but many undoubtedly would be on record if the cases which terminate in death were pub- lished with the same zeal as those that are successfully treated. ® CHAPTER XLII. Of White Siodling. WHEN a disease presents many varieties in its progress, symptoms, causes, and consequences, it is difficult to give it a name that conveys an accurate idea of it, or that is applicable to every case: such is the disease of which we are to treat in this chapter. Different names have been assigned to it, derived from one Qf more of its symptoms: it has been called white swelling, because the skin generally preserves its natural colour, and presents no mark of inflammation*—fungous tumour of a joint, on account of its stiffness and elasticity—lymphatic tumour or serous congestion of an articulation, because tbe lymph is effused and thickened in, the cellular tissue sur- rounding the ligament&rr-false anchylosis, because the dis: ease produces more or less difficulty of motion—and, lastly, rheumatic or scrofulous swelling, indicating its causes. White swelling is generally defined to be a chronic conges- tion of a joint, circumscribed, without change in the colour of the skin ; sometimes hard, and resisting the pressure of the finger; sometimes soft and elastic; sometimes so soft as to give an idea of fluctuation which does not exist; some- times indolent, but commonly very painful during the mo- tion of the articulation, which is rendered difficult or impos- sible. These congestions are seated in the ligaments and the cellular and fatty parts, called synovial glands* and even in bones and cartilages. This definition is only a simple enu- meration of the symptoms of white swelling, and is far from conveying an exact idea of its numerous and varied appear* smees; wliieh are hardly ajjke in any two cases. i$48 Boyer*s Surgery. Any joint may be affected with this disease, but the gin- glymoid joint* are most obnoxious to it; we are, however^ to except the joint of the femur With the os innominatum, where it is very cbmmon, and known under the name ot* consecutive luxation of the thigh, because it is almost al- ways attended with displacement of that bone. Of the gin- glymoid joints, the knee is most often affected; next to this the elbow, foot, and hand: the small joints are rarely the Seat t)f ihe complaint. White swelling may appear at any age ; but infancy and youth are most subject to it. It occurs most frequently in Winter and autumn, especially if the weather be damp. The disease sometimes commences with pain in the joint; which extends along the aponeuroses and tendons bf the neighbouring muscles. Sometimes this pain is dull and su- perficial, seated in the soft parts, and extending over the whole joint; sometimes it is acutej deep, and confined to one spot, which is commonly the centre of the articula- tion. In some instances, the swelling succeeds a pain in some other part of the body, and which had suddenly ceased ; or to an eruptive disease, such as the Small-pox, measles, &c; "White swelling, depending upon an internal cause, often commences during the night; the patient awakes, and finds hi* knee painful and swollen. In whatever manner the disease may commence, it al- ways appears in the form of a tumour, which presents the following characteristics. It rarely surrounds the whole articulation, but is almost always confined to a part of its cireumference. In the knee it Commences above the patella, and below this bone on the lateral parts of the joint, especially Ihe internal side; in the foot, it appears below and behind the malleoli; in the fingers, it generally occupies the whole articulation. The tutnour is circumscribed, immoveable, more or less hard, and elastic : not retaining the impression of the finger like edema, but conveying generally la sensation of softness, that gives an idea of fluctuation which does not really exist. It is more or less painful, particularly on pressure: sometimes, how- ever, it is indolent; the sliih preserves its natural colour; motion of the joint is painful and difficult. In some cases, tbe leg remains extended, but more commonly it is bent to a considerable degree, and extension causes great pain. In white swellings of the elbow, the forearm is always flexed ; in those of the wrist, there is a marked tendency to flexion* and to prevent incomplete luxation of the carpus backward* we are sometimes obliged to support the hand with a splint. Of While Swelling. Si9 Constant flexion produces a contraction of the flexor mus- cles and their tendons, which creates a hard ridge along tbe course of them. The total want of motion, which results from the stiffness of the muscles, soon renders the joint im- rirovCable ; frequently it is more or less anchyloscd. The disease may remain a long time in the state we have described, cease to be painful, and cause only a great weak- ness in the knee, producing more or less limping. But more frequently it continue* progressing without inter- ruption ; or if its progress has been suspended, and the com- plaint has remained stationary for a long time, it pursues its course again after a fall, a blow, or without any apparent Cause. The articulation becomes more swollen, and, if it be the knee, the hollow of the ham is tumefied and filled up; the pain increases, and is felt sometimes in one part of the articulation, sometimes in another; sometimes between the ham-strings, sometimes in the interior of the joint; it in- creases towards evening, and at every change in the wea- ther; motion especially aggravates it: yet there are some patients, however, who suffer little or not at all. The hard- ness of the tumour varies greatly as the disease progresses. But some white swellings are hard from the beginning, and some remain soft for a great length of time. This de- pends greatly upon the seat of the disease, which sometimes b in tbe bones, sometimes in the ligaments and surround- ing cellular tissue. The skin over ihe tumour becomes pale, shining, and thin; the subsuliatieous veins dilate and become varicose; the muscles of Ihe leg become thin and wasted; so that its bulk is greatly diminished; but occasionally it is increased by the infiltration of the cellular tissue ; the lower part of the thigh undergoes a remarkable diminution; the lymphatic glands of the groin become en- larged and tumefied. When the disease has made great progress, the "bones are softened, and tbe articular cartilages destroyed; lastly, abscesses form in the different parts of the tumour, whicli are attended wilh great pain and high fe- ver. These abscesses are situated more or less deeply, and frequently communicate with the joint. When they open of themselves, or when ihey are opened by the surgeon, a large quantity of matter is discharged, which rarely possesses the qualities of healthy pus. Il is generally a yellowish sero- purulent fluid, like whey, with some floeculi of albumen swimming on it. Sometimes, however, it is a3 consistent as pus; but it soon changes to a thin, ill-conditioned sanies. its discharge does not, in the least, diminish the swelling. The openings, which arc made to evacuate this liquid; sonif;- 35$ Boyev's Surgery. times heal quickly, and new abscesses form in different parts, which open and heal like tbe former. But generally the-te openings form articular fistula?. In the beginning, the disease does not at all affect the sys- tem, and it is only after a certain time that the general health becomes injured. This is produced, in part, by the violence of the pain, which prevents the patient from sleep- ing and eating, and partly by the absorption of the matter of the abscess. The effects of this absorption are scarcely per- ceptible before the abscess is opened; but after it bursts, or is cut into, the contact of air deteriorates the pus., and causes it to be fetid. Slow fever then supervenes, with noc- turnal sweats and colliquative diarrhoea, which reduce the patient, and prove fatal, unless checked by amputation. Dissection of the knee shows, that at first the seat of the disease i» in tbe soft parts alone, and that the bones, and car- tilages become subsequently affpetpd; while others are seated in the bone, the ends of which are softened and swollen, and the disease extends to the ligaments and other soft parts about the joint only in an advanced state of the disease* In that kind of white swelling which is seated principally outside of the joint, if we examine the knee before suppura- tion has destroyed its situation, we find the ligaments which Strengthen the articulation, the capsule itself, the cellular tissue about the joint, and especially that behind the liga- ment of the patella, that which connects the femur with the lower part of the triceps femows, as well as that which fills I lie space between the^eondyles of the femur, behind the crucial ligaments, infiltrated, and filled with a fluid, more or less thick, and converted into a soft, sppngy, fungous, homo- geneous mass. The skin and subcutaneous cellular tissue do not participate in the morbid changes of structure, except flint Ihe fat of the latter is rather more yellow and con- sistent than natural; sometimes, however, the cellular tis- sue is filled with glairy matter. In some cases, the cellular tissue between the ligaments is so thick and dense that it is hardly distinguishable from the ligaments themselves; so that every thing about the joint appears cartilaginous, or like in-. ter-vertebral substance. Thus the fatty substance behind the, ligament of the patella becqmes so condensed and thickened; as to form one undistinguishable mass. The periosteum, which covers the ends of the hones of the diseased articula- tion, is usually thicker ana> wore dense than natural. Tho large nerves whieh pass by the joint are more enlarged and * Seje note J; Of While Swelling. 3*1 more dense than natural. In the greasy fungous mass into Which the cellular substance and ligaments are converted, are found purulent collections, passing in different directions through this diseased part. The muscles around the arti- culation, and the cellular tissue between them are filled with glairy matter. Nevertheless, in the midst of the disorder* the flexor muscles, though retracted, preserve their natural colour and consistence. In the early stages of the disease we perceive no change within the joint: the synovia is healthy, but somewhat more abundant than natural—sometimes so much so as to raise the patella, and lead to the suspicion of dropsy of the joint. The consistence and colour of Ihe semilunar cartilages, and those which cover the ends of the bones, are not changed ; the bones themselves appear natural, but after a short lime they are more or less swollen; their spongy tissue is yellow, Softened, and may be easily penetrated with the edge of n scalpel. At a later period we find more or less sanious matter within the joint; the semilunar cartilages, and those Which cover the ends of the bones, are softened, and con- verted into a glairy substance, sometimes red, and destroyed wholly or in part; the substance of the bones is carious, and destroyed to a greater or less extent. What is worthy of remark is, that in the centre of this disorganization, we sometimes find portions of bone of the hardness and colour of Ivory. In that kind of white swelling which is seated principally in the bones, at whatever period of the disease we dissect the joint, we constantly find the articular extremities, and particularly the condyles of the femur, enlarged, and their spongy tissue yellowish, softened, and easily cut or pierced. In the beginning of tbe malady, the soft parts are Kftle af- feeted; but, in Ihe advanced periods of the disease, the liga- ments, the cellular tissue which surrounds them, and that which passes between their fibres, and the fafry cellular sub- stance, wliieh has been considered as synovial glands, are in- filtrated with viscous glairy matter, and are converted Into a fungous lardy substance; the bones swell and become *oft; they are affected with caries; their spongy structure is dis- solved and reduced to a fetid sanious matter. This sometimes happens even before the cartilages arc diseased, but after some time, these become affected and absorbed. Such are rttc organic alterations commonly produced by White swelling. They are extremely diversified; but it is sufficient to havte noticed tlie principal, and to observe that the disease is seareely the same in any two patients. 352 Bayer's Surgery. Tbe causes of white swelling are external and internal* Among the former have been enumerated physical injuries of the joint—such as wounds, contusion, distension, a forced march in cold, rainy weather, living in a damp situation. he. But this disease is rarely produced by an externa) cause alone, and when its appearance has been preceded by external violence, this is to be regarded merely as the ex- citing cause ; the real cause being internal. Among the in- fernal causes are placed rheumatism, scrofula, scurvy, and syphilis; Ihe morbific matter of fever, of small-pox, of measles, &c. carried to the joint by metastasis ; suppression of the menses, of an habitual hemorrhage, of the itch, &c. But rheumatism and scrofula probably produce three out of four cases of the disease : tbe former causes it most gene- rally in youth, and adult age, where there exists strength and plethora: scrofula produces it most commonly in child- hood. Rheumatism has a predilection for large joints, especially for the ligaments and adjacent cellular tissue, which it thickens and hardens, by causing an exudation of glairy matter. Hence it is observed, that these parts alone are affected in the commencement of white swelling caused by rheumatism. As for scrofula, it attacks, especially in infancy, the ex- tremities of the bones, in which it produces swelling, accom- panied, at first, with softening of the spongy substance, and subsequently caries and absorption. Thus scrofula com- mences in the bones, and affects the soft parts secondarily— but rheumatism, attacks the soft parts first, and the bones afterwards. It is easy to distinguish white swelling from the other af- fections to which the joints are subject; but we cannot al- ways determine precisely the species of this disease, which is, nevertheless, very important in the prognosis and treat- ment. It is possible, to a certain extent, when we are wit- ness of the first onset of the malady: but it too often hap- pens that we are not consulted until it has made some pror gress, and then, if tbe patients cannot give an exact de- scription of their symptoms, we cannot determine the spe- cies of the disease, because, from whatever cause it arises, it is alike in its latter stages. There is reason to suppose the tumour to be rheumatic, if the patient be a young man, or an adult of full and plethoric habit, who has previously had the rheumatism ; if the dis- ease appear during the autumn or winter, in damp, cold weather; if it commence with a.violent pain in all the joint, which extends to the surrounding muscles; if this violent Of White Swelling, 353 pain he quickly followed by a swelling of the soft parts that surround the joint, which presents a circumscribed tumour, elastic, more or less painful, without augmentation of heat, or change of colour in the skin, JSto. and if, in the com- mencement of the disease, this tumour is only an enlarge- ment of the soft parts, the bones not being affected, but be* coming so in a more advanced stage of the complaint. We should not confound white swelling produced by rheu- matism with rheumatic affections of the joints, commonly called gouty. Although these maladies are of the same spe- cies* they differ from each other in their symptoms, pro- gress, and termination. Gouty rheumatism affects several joints at the same time: it attacks both the small, the middle sized, and the large joints; most commonly all tbe articulations of one side of the body are affected at once. But what especially characterizes rheumatism, is the facility with which it moves from one part to another: it sometimes changes from one side of the body to another in twenty-four hours. These changes often take place for several days to- gether. White sweiling, on the contrary, is always station- ary. Moreover, in gouty rheumatism, the colour of the skht around the joint frequently is changed, and the heat of the part affected is more rapidly or sensibly increased than in white swelling. Although in gouty rheumatism the pain is more violent than in white swelling, the limb is never in a state of constant and permanent flexion; the enlargement of the joint, wbieb often continues in that disease after the fever has ceased, is still more easily distinguished from white swel- ling, by its want of elasticy, by the edema, by the absence of pain, by the little rigidity of the flexor muscles, and the facility with which this rigidity is dissipated. We have before observed, that a white swelling is consi- dered as serofulous when it commences in the hones of a joint. We may be certain of this fact if the patient be an infant or a youth—if the previous pain have been very acute, and confined to a circumscribed spot, whieh is generally the centre of the articulation—if the enlargement of the joint, whether slow or sudden, depend upon the swelling of the lower part of the femur, and very lktle upon the congestion of the soft parts; and, finally, if the patient be born of serofulous parents, or if there be or have been, in the for- mer part of his parents' life, svmptoms which indicate scro- fula. It is, however, to be observed, that white swellings, produced by scrofula, often appear when no previous indica- tion of the disease has existed, and even in infants of ap- parently sound constitutions, voir. it. ** 36*/ JBouer'a Surgery. As to white swelling produced by other eauses than rheu- matism and scrofula, their symptoms do not greatly vary from those we have mentioned. Thus, when white swelling follows the repelling of an herpatic affection, or of tbe itch, in a person of good constitution, who has never been affected with rheumatism or scrofula, wc cannot mistake its cause. The same may be said of white swelling which supervenes to suppression of the menses, or an habitual hemorrhage—of that which appears jn the course or towards the decline of any fever, of small-pox, of measles, &c. The prognosis of white swelling is generally very serious ; but more or less so according to the cause of the disease, its duration, its symptoms, the constitution of the patient, &c. White swellings caused by rheumatism, are generally least serious, especially if recent; we may then often arrest the progress of the disease, and even cure it entirely. In this case, the joint sometimes returns to its natural state, and freely performs all its motions; sometimes it retains a stiff- ness, which deprives it, in part or altogether, of this power. White swellings which depend altogether upon an external cause, in patients otherwise healthy, may be entirely cured. The worst cases are those produced by scrofula: they are seldom cured, and when they are, the joint almost always be- comes anchyloscd. From whatever cause a white swelling arise, if it be of long standing, attended with severe pain—if the bones and cartilages be swollen, softened, and carious, and the articu- lation filled with sanious matter—if fistulous openings have formed, through which is discharged sanious fetid pus, the disease is generally incurable. In this case, the violence of the pain, the slow, fever, copious sweats, and colliquative di- arrhoea bring on marasmus and death, if we do not hasten to amputate the limb. In some of these cases, however, nature, assisted try art, triumphs over the disease. Then the suppu- ration gradually diminishes, and the pus becomes of better quality; the slow fever, eopious sweats, and wasting diar- rhma diminish, the appetite returns, the digestion improves, the patient grows stronger, and gets off with an anchylosis. But these are rare cases: they do not justify us in delaying amputation. White swellings are generally most dangerous in feeble and cachectic persons. Infants bear the disease better than youths and adults. Among the infinite variety of remedies that have been proposed for the cure of white swelling, we have the morti- fication to find ourselves often unable even to palliate the dis- ease. Of WliUe Swelling. 355 Perfect rest at the limb is the first essential point in ihe treatment. Motion uniformly causes irritation and pain. White swellings caused by rheumatism being always, in the first instance, inflammatory, we should havo recourse to early bleeding, both general and local. When this has been carried to sufficient extent, blisters are to be applied : first a small one is to be placed on the an- terior part of the joint; then another on one side, and, be- fore this is healed, a third on the opposite side. This mode of blistering is much more efficacious than the successive application of large epispastics over the whole joint. The part, at the same time, should be wrapped in flannel. The diet must be suited to the phlogistic diathesis of the patient. These means generally dissipate the pain and inflammation: if they do not, we should have recourse to opiate and cam- phorated liniments, or a strong decoction of poppy heads, or of the leaves of nightshade, or henbane. But these reme- dies ought not to be used unless the pains be extremely se- vere, lest they fix the disease in the joint. When the inflammatory state has ceased, we should sub- stitute, for the foregoing remedies, frictions with dry flan- nel, impregnated with the vapour of succinum, volatile camphorated liniments, a plaster of styrax, sprinkled over with flowers of sulphur, poultices made with the root of rasped briony boiled in milk, Hack soap softened with cam- phorated spirits, bags filled with a mixture of powdered lime, tan, and the muriate of ammonia. Bell speaks very highly of mercurial frictions thrice a day, for one hour each time, and in such quantities only as to avoid salivation. I have of- ten employed mercurial frictions in this way, and with suc- cess. I attribute the benefit more to the frietion than to the action of the mercury. Rheumatic white swellings are often cured by the above named means; but sometimes a degree of stiffness remains in the limb, which renders motion painful or impracticable. This stiffness depends chiefly upon the retraction of the muscles, tendons, and ligaments, and is lo be treated in the way we shall point out in speaking of anchylosis. In white swelling produced by external violence, it is pro- per, in the first place, to moderate the inflammation by ge- neral and local bleeding, low diet, cooling and diluting drinks, and by fomentations and emollient poultices. After- wards, when the pain and tension have abated, we should employ resolvents, and enjoin the most perfect rest, until there is no danger of a return of the symptoms from using the limb. 3Stt JJou«r?* Surgery. . We should •prescribe the same remedies in white swelling produced by suppression of the menses, or an habitual he- morrhage, by repelled iteh, or other cutaneous affection, or by the metastasis of the morbific matter of any fever to the joint; and, in addition to them, if the disease be produced by a suppression of menstrual and other habitual discharge, we should either restore it, or replace it by bleeding. In cases of metastasis, of cutaneous affections, we must esta- blish a drain near tlie seat of the disease. The utmost diligence, employed even in the early stages of this complaint* does not always succeed in checking it; and when it is farther advanced, the chances of success are Still smaller, and remedies more powerful than those we have mentioned, become necessary. Le Dran and other practitioners recommended pumpings of warm water. To derive from them the utmost advantage, the water should be as warm as the patient can bear, and should deseend from an height of seven or eight feet. The size of the column of water should be proportioned to the sen- sibility of the tumour; and when the pain is very acute, the end of the pipe should be closed by a metallic plate pierced in several places : but when the part is not very sensible, the pipe may vary in diameter from six to sixteen lines, and have but one opening. The pumping should continue near an hour, and when it is finished, the patient should be put in bed, and the joint covered with bladders filled with water as warm as can be borne. These should be renewed occasionally for the space of two hours: after which, the joint should be co- vered with warm linen, and left to sweat. At night the ap- plication of hot bladders should again be made, and the pumpings repeated every day, or every alternate day. This treatment is suited to all species of white swelling, and to all periods of the disease; but is particularly useful in cases in which the soft parts alone are affected, and in which the complaint is not far advanced. We may augur favourably of its effects, if, after each operation, the joint sweats and becomes softer. A large pewter syringe, with a suitable tube adapted to it, may be substituted for more complicated apparatus. The pumpings or injections may be rendered more active by the addition of the muriate of soda, the muriate of am- monia, of potash, or soda; or, what is preferable, by em- ploying artificial or natural sulphurous water. By increas- ing the temperature of the water, or the force with which it impinges against the joint, we may add to the activity of this remedy, which has often effected surprising cures. Of White Swelling. 85? Our opinion of tbe utility of issues, $erpetuai blisters, and setons, which iiave been «o much celebrated in the treat- ment of wfcfte -swelling, is Ihr less favourable to these reme- dies than that ef most otlier surgeons, and after the bones and cartilages have become affected, wc have found them evidently injurious. Cauterization ts the remedy of which tlie good effects are most conspicuous. It is most beneficial in rheumatic white swellings; but it does not suit the first or inflammatory state of the disease, nor the very advanced periods of it, in which the bones and cartilages have become carious; but in the in- termediate stage it is highly serviceable. Farriers employ it with great success in the treatment of an analogous dis- ease of horses. Cauterization is also useful in white swelling produced by metastasis, suppression of any habitual discharge, &e. with the same restrictions as in rheumatic cases. But in scrofulous cases, in which the cartilages and bones are the primitive seat of the disease, cauterization would be highly injurious. The enthusiastic Peutenu, to wlrem is due the glory of having revived among us the practice of cauterization, ap- plied it indiscriminately to all cases of this disease; but a very extensive experience of later surgeons has fully established tbe exceptions laid down in the last paragraph. There are two methods of cauterizing diseased joints— with an hot iron, and with moxa. The ancients generally employed the first, but Hippocrates also recommends the latter in sciatica and gout.* The irons employed by the ancients for the cauterization ef joints were generally flat or olive shaped: they were ap- plied to different parts of the articulation, and caused eschars, more or lees deep, according to the heat of tbe instrument and the duration of its application. In some cases, how- ever, they used the euttllary cautery, which they passed lightly over different parts of the tumour, so as to produce long, narrow, and superficial eschars. This method of cau- terization, which alone is now in use, is termed by M. Percy transcurrent. We shall extraet from his Pyrotechnie €htrurgicaie the rules for its application. * Si vero in vnum iliquem loenro decubuei it dolor, et constiterit, neque medic:<- mentis expelleter, urito quocumu.ue loco dolor fortfe coiwederit; ted eum lino crude urito. • * • • Quod «i in pollieibui dolor rulinouatur, venal in polKce paululum supra articuti aodum inuriie; <^UJ aotcm per linum criidem fiat. Libro de affect, sect. 2, «ap. viH. SS8 Beyer's Surgery. « While the instrument is heating, the parts to which it is to be applied should be marked with ink, in order that the operation may be conducted without hesitation. The number of lines ought to be proportioned to the size of the articu- lation and to the volume of the tumour. In general they should be so far apart, that the inflammation which the fire occasions during the first days may not extend entirely across the interval between them. « The iron should be heated to a very bright red heat, and at first it ought to toueh the skin only for a moment, that the operation may be finished with one instrument. If we have cauterized too slightly by the first application, we may re-apply the iron, heated a second time, over the same parts, taking care not to bear too hard nor unsteadily. The essen- tial point is not to divide the integuments; for if they are opened, a troublesome fungus is sure to be formed. For the same reason should the cauterized lines not cross one ano- "The marks left by the cautery are of the colour of gold, and are so slight as to lead us to believe that a few days will efface them: but when the eschar separates we are asto- nished at its extent. "Immediately after the operation, the parts should be co- vered with dry flannel, or warm linen. When inflammation, swelling, and pain come on, we must substitute soothing ap- plications." Although the ancients speak highly of the actual cautery, in diseases of the joints, their works detail few cases of its successful use. Fabricius ab Aqua pendente merely men- tions that he cured a swollen and hardened knee by the appli- cation of five or six cauteries. Even M. Percy, who prefers the transcurrent cauterization, relates only three instances in which it effected a cure. In one case, that had resisted the use of moxa, he made upon the patella one longitudinal eschar, four inches in length-one parallel to it of dm same length on each side of that bone, and a fourth, naif as long as the others, on the internal condyle. He also appbed the hot iron to a patient who had white swelling of the elbow. The skin was burned in three converging lines, (like a goose s foot, but not united at an angle); they were two inches in length, and followed the course of the extensor museles. The patients scarcely complained of pain: one of them de- clared that the operation was far less painful than the ap- plication of moxa. The subject of the third case was a <[Ira- loon, aged thirty-six y^ears, whose elbow had been stiff for Eighteen months: the ends of the two bones were swelled, Of White Swelling. 359 and the soft parts bad a clayey feel. All imaginable reme- dies had been tried without success. M. Percy traced with a hot iron eight lines, each four inches long, viz. three on the outer side of the joint, three on the inner, and two, along- side of the olecranon; the operation lasted only half a mi- nute, aud all were astonished to hear the patient say he felt very little pain. There was a slight degree of inflammation for a few days. The eschars successively came away between the fifth and ninth days; the wound suppurated moderately, and, by the time they were healed, the arm was flexible and strong, and was reduced to half its former size. Hippocrates recommends burning tow upon the skin in obstinate siatica. The Egyptians, Arabs, Japanese, and Chinese employ combustible substances for cauterization, as we are in- formed by Kcemfper, Prosper Alpinus, and other enlight- ened travellers. The method of the Egyptians, tbe only one which we have adopted, was naturalized among us by Pouteau. The following is his process: " Bind a piece of linen, one inch broad and three inches long, around some raw cotton, as tight as possible. The linen is to be secured by a few stitches: we then have a cylin- der, an inch in diameter; cut it transversely half through with a sharp knife: we shall then have two cylinders, with a common base. It is this base which is to be laid on the skin, previously moistened with saliva, so as to make it ad- here. The lips of the cylinder being well fired, the cotton is to be applied to the part we wish to cauterize. We should then blow the fire with a bellows, a fan, or with the mouth. The fire never extends beyond the skin, even when two or three eylinders are successively applied to the same spot." In applying moxa to white swelling of the knee, if the whole joint is painful, we should burn a cylinder of cotton on each side of the patella. In the elbow, the lateral parts of the joint should lie selected; and in the ankle, we should apply two cylinders behind and below the malleoli; in the wrist, one upon the palmar and one upon the dorsal side of the joint: but in every case where there is one spot more painful than the rest, over that part the moxa should be ap- plied. We augur favourably of the effect of this remedy if, after several cauterizations, the pain and swelling diminish. The efficacy of moxa is proved by the experience of Pou- teau and other practitioners. In my own practice, several rheumatic white swellings, after having resisted the usual treatment, have yielded to two or more applications of this 36& Bayer's Surgery. . oo^erfuJremady: but whese the bones htwe been, pollen ^a pamfnh H has ekher afforded no rehef, or oidy iernpo^ ZJ. In fact, I believe it can never bo of permanent bane^ fit/and that it may even do much injury m> scrofulous afto. lions of the ioint. . .. A remedy, in some rc«pe«ts analogous to cautertzatmn, i* the application of irritating substance*to the.skin. Fabtm- ,*»ib Aqua pendente was con,uhed by a man'*»*%> whose km?e was so swollen as to be incapable of tfie lea* movement > he judged the case incurable. An C^»,°P£W ,uaded the gentleman to *nbmit to the application tf a. ir- rXne plaster, whieh Fabrieius believed to be made w,Uh TspecTes of nightshade [Clematis flammula];which ex«,ted lent inflammation. The knee soon became moveable, and STpalient was finally cured. M. Percy has ™****** remedy used by the Italian empiric: he does not state with what success. Undoubtedly it is capable of producing a very dOTeeraus inflammation of the bones, yet lam inclined to belieVe it might be employed with advantage in some cases; for I have seen * wbite swelling of hong standing, and very painful, gready relieved by an erysipelatous inflammation that took place around the joint. Abscesses often form notwithstanding curbed efforts to wvvent them. They may be seated in the submrtaneous eel- IXr ^sulor within the eavity of the joint When the. se- vere pmw obliges us to open them, we *hould make a simple Inncture wilh the bistouri. The introduction of a seton, Vhich some practitioners recommend* is improper-eve* The opening made with a bistouri can seldom be healed. Th^ pain which occurs in white swelling, and when matj tor is Arming, requires the external f?d internal, use oi opium; but in many cases it is unabated by both. imputation of the limb is, in many cases, the only means of preventing the patient from sinking under heeue symp- toms A judiciourpractitioncr wilt weigh all the circum- stances of the case previous to his dectdtng whether he 3 amputate the leg, or keep the limb slightly flexed, and Ta state of the most perfect rest, in tbe hope of curing the patient with a stiff joint. .«„«„# «, Simple debility, provided it is not so great as to prevent * suitable degree ef inflammation, is favourable to the success of amputation; but, on the contrary, the weakness whwn. Ts connected with a vitiation of the fluids, and which ,s cha- racterised by colliquative diarrhcea, marasmus, &c.s not refiev^ by Z operation, whieh, in faety accelerates the fa- tal termination of the diseaso Of White Swelling. 361 The simultaneous existence of several white swellings, a radical disease of any vital organ, and, finally, the co-exist- ence of symptoms that indicate Ihe activity of the virus which has produced the disease, contra-indicale the amputat- ing of the limb. There is another mode of removing the parts diseased by white swelling, besides amputation, which is termed resec- tion of the bones. It has been applied to the shoulder, knee, elbow, wrist, and ankle-joints. The idea of removing the upper end of the humerus, oc- curred about the same time to White and Vigarous: but the former first published bis case. His patient was a young man whose shoulder had been the scat of a large abscess, into which a large incision had been made near the axilla; the head of the humerus, deprived of its capsular ligament, could be distinguished through this opening; matter had in- sinuated itself under the arm ; the patient was exhausted by hectic symptoms. White made a long incision from the mid- dle of the arm to the acromion process. Taking hold of the patient's elbow, he then pushed the head of the humerus up- ward through the opening, and sawed it off with an amputat- ing saw. The patient was cured in four months; his arm was very little shortened, its form was not altered, and it was as useful as the other. Vigarous performed a similar operation, two years before White, upon a young man who had caries of the head of the humerus. A single incision was made parallel to the deltoid and the head of the bone; the bone was sawed two and a half inches below its head; but the operation was performed too late, and the patient died. It is to be remarked that the head of the humerus was found separated from the rest of the bone in both these cases. The resection of the head of the humerus has also been performed by David, by Bent of Newcastle, by Moreau, and by M. Roux. Tbe advantages of this operation are striking and need scarcely be mentioned: It is easily performed; it is not more dangerous than amputation at the shoulder joint, and when it is successful, the extensive movements of the scapula npon the trunk scarcely leave the patient to feel any incon- venience from the union of that bone to the humerus. This operation is also applicable to certain cases of spina-ventosa, earies, fracture of the bone by a bullet, etc. White's method of operating may be pursued with advant- age where the head of the humerus is detached and the gle- noid cavity not diseased. Boucher practised it with success in a case where the head of the humerus was shattered by a ball. vol. n. *6 S6Z Bayer's Surgery. But if the head of the bone be not detached, and if it be as large or larger than natural, it would be difficult to press it through a single opening made into a thick muscle and inte- rments that are swollen and hardened. Bent of Newcastle made first a large vertical incision on the internal side of the arm, and then, from each of its extremities, another perpendicular to the first, and passing horizontally outward; thurforming a long narrow flap, adhering at its external side. M. Sabatier proposes to form a triangular flap, by two oblique ineisions—one commencing from the top of the co- racoid proeess-the other from the base of the acromion, and uniting like a V four fingers breadth below the joint. Ihe elder Moreau made two square flaps, the superior adhering to the shoulder, and the inferior to the external part of the arm M. Roux advises that a single square flap should be made, very much as in La Fayes' method of amputating at the shoulder joint. The joint being thus laid open, the hu- merus is to be luxated upward and outward. The soft parts are next to be dissected from the bone, and a flat piece el wood is to be introduced behind the diseased portion of the humerus, which is easily sawed off; the circumflex arteries require to be tied; the parts of the glenoid cavity that are slightly affected, should be rasped or cauterized; those more deeply diseased are to be removed with a chisel and mal- let After Ihe flap is replaced, and the elbow somewhat ele- vated, and beund to the side, the patient is to remain in bed upon his back, that the pus may flow freely through the posterior opening. If the patient should recover from the oporation, his arm will be shortened: in other respects the result oi the operation is very different in different cases. The movements of Ihe arm are sometimes entirely restored; while, in other instances, the humerus is capable ot no otlier motions than those which are common to it and the sca- pula. In White's patient a second joint must have formed, for the arm could be preternaturally twisted on itself. M. Cbaussier dissected a patient whose scapula bad a round emi- nence fitted to a corresponding cavity of the humerus. In tbe third case there remains an interval between the bones, which is filled up with soft parts. The strength of: the.limb is thus diminished, and its mobility is increased. M. Saba- tier has seen two cases of this kind consequent to gun-shot wounds: the utility of the arm and hand was not impaired. White and Vernamdois have proposed to remove the upper end of the femur in cases of disease of the hip-joint; but such an operation is not justifiable. Of White Swelling. 363 Park of Liverpool is the first who devised and executed the operation of removing the extremities of the bones of the knee and elbow-joints. A robust Scotch sailor entered the Liverpool Hospital for a disease of the knee of ten years standing: The joint was much swollen, and the inte- guments greatly distended; tbe leg remained immoveably fixed at a right angle with the thigh ; the pain was very se- vere; suppuration and caries had evidently taken place. though the integuments were yet unopened. After several trials on the dead subject, Park sawed off the ends of the bones: hemorrhage, abscesses, and other consequences re- tarded the cure; but the patient recovered about thirteen months after the operation. Vernamdois, the Moreaus, father and son, M. Champyon, and several military surgeons have successively performed similar operations upon the knee, wrist and elbow-joints. Amputation and the resection of the ends of the bones arc not to be indifferently performed. The latter operation is not applicable to those cases in which the disease of the bone is very extensive, and tlie integuments much diseased j nor to those in which the muscles of the hand and fingers are atrophous, as Park states to have been the fact in an in- stance he met with. Experience does not enable us to de- cide between the comparative merits of resection and am- putation. The latter operation is the more difficult to per- form, and more dangerous in its consequences: but when it succeeds, its superior utility is striking—-more uniformly so, however, in the wrist and elbow than in the knee, for when even ligamentous union takes place, the limb is al- ways useful; but unless the tibia and femur unite firmly, the leg is rather burdensome than useful. As to the shortening of the lower extremity, which follows the operation of rc- section, as Park justly remarks, it is a real advantage, for it enables the patient to walk with a stiff knee, without moving his foot in the arc of a circle. Upon the whole, therefore, we tlrink that a prudent sur geon will abstain from sawing off the bones of the knee and ankle—perhaps also of the elbow and wrist, in cases of white swelling: at the same time we must do homage to the celebrated surgeons whose efforts have been directed to the improvement of our art, and remark, that future experience alone must decide in what cases resection is preferable to amputation. We shall conclude this chapter with a few remarks on the mode of removing the diseased ends of the bones. In operating upon the elbow, Park made an incision down 364 Bower** Surgery. to the olecranon, which he sawed off; the humerus was then luxated backward, and the end of it removed, as likewise the ends of the ulna and radius after they were detached from the soft parts. The Messrs. Moreau and M. Cbam- pyon followed a better method: The patient being laid upon his belly, or seated in a chair, an incision was made parallel to the crest over tbe internal condyle of the humerus, from a point two inches above the condyle to the level of the joint; a similar incision was then made on the opposite side; a third, passing transversely above the olecranon, united the other two. The incisions extended to the bone, from which the flaps were then dissected. The soft parts on the anterior surface of the humerus were next detached, care being taken lo keep the edge of the instrument close to the bone; the handle of a scalpel was then passed between the bone and the soft parts, previously isolated, in order to protect them from being injured by the saw. The lower end of the humerus was then sawed off, and separated from the liga- ments that connect it to the bones of the forearm. If the disease has extended to these bones it is also necessary to saw off their extremities. For this purpose the external in- cision is to be prolonged two inches further down; the trian- gular flap which it forms, with the transverse incision, being raised, the head of Ihe humerus is sawed off, and by length- ening the internal incision, the extremity may in like man- ner be removed. No carious portion of the bone is to be left behind. The lips of the wound are to be connected by a few stitches, and the limb is to be placed in a half bent position upon a pillow filled with chaff. In the resection of the knee, Park made two crucial inci- sions upon the anterior part of the joint; but the following method of Moreau appears to me preferable: On each side of the patella, directly before the flexor tendons of ihe leg, a longitudinal ineision is made, extending from above the condyles of the femur to those of the tibia; a transverse in- cision, below the patella, unites the two, and the flap, in- cluding the patella, is dissected upward. If the patella is diseased, it should be removed. The soft parts are then dis- sected from the posterior surface of the femur, the end of which is then sawed off and separated from the bones of the leg. To remove the ends of the tibia and fibula, a longi- tudinal incision is made along the cresl of the tibia, and the external incision is prolonged until it reach below the bead of the fibula. The quadrilateral flap is then raised, and the bone sawed off. We need scarcely mention the ne- cessity of avoiding the large nerves of the blood vessels. Of White Swelling. 365 After the operation the limb is placed either in the apparatus for compound fractures, or in a gutter covered with soft substances. The resection of the bones of the ankle-joint is more dif- ficult than that of the elbow or knee. We begin by making a longitudinal incision from the posterior and inferior par t of the external ankle, in a direction upward, and three inches in length ; from the lower end of Ihis incision another passes off at a right angle as far forward as the tendons of the peroneus brevis. On the inner side, another incision is made similar to the first, and from the lower end thereof (which is behind and below the internal ankle) another passes off in a horizontal direction, as far as the tibialis amicus: the horizontal incisions divide only the skin, tbe others ex- tend to the bone. The surgeon now dissects from each side the triangular flaps, and removes the external ankle with a chisel and mallet: the extremity of the tibia is next sawed off, bv introducing a narrow saw between its posterior surface and the soft parts behind, while the flesh in front of the bone is protected by the handle of a scalpel held between it and the anterior part of the bone. By twisting the foot out- ward, the separated portion of the tibia is easily dissected out, and, if necessary, a part of the astragalus is removed. The wound is stitched in two places, and lire foot is kept motionless by means of a sole, connected with two splints, applied to the sides of the leg. The younger Moreau informs us that he has successfully resected the bones of the wrist-joint. He does not state in what manner. M. Roux advises that incisions should be made along the external edge of the radius, and from the in- ternal edge of the ulna as far forward as possible, without injuring the large nerves and blood vessels, and terminating mferiorly opposite the joint; two transverse incisions, an external and an internal, beginning from the lower- ends ot these, reach backward as far as the extensor tendons, on the posterior surface of the joint. The lower ends of the radius and ulna are then successively laid bare and sawed off, and as many of the carpal bones as are diseased are re- moved. ( S66 ) CHAPTER XLIII. Of Anchylosis. BY the term Anchylosis is understood that state of a dia- throidal articulation in which the movements of the bones that form it are entirely or almost lost. Anchylosis is distinguished into complete and incomplete. In the former the bones are united together and continuous: in the latter, on the contrary, they are still moveable in a slight degree. Diseases which obstruct the movements of a joint, such as tumours, &c. should not be confounded with anchylosis. In some instances all the bones of the body unite to each other—but the disease is most commonly confined to a single joint, and the ginglymoid joints are much more frequently affected than the orbicular joints. Simple immobility of a joint, continued for a great length of time, may render it stiff. The Fakirs of India, who re- main several years in the same position, doing penance, produce anchylosis, in a greater or less degree, of almost all the joints. But this affection is almost always a conse- quence of fracture, luxation, sprain, wound of the joint, white swelling, and dropsy of the joint. Exostosis, or ossi- fication of the cartilages and ligaments, aneurism, wens, large abscesses, ulcers, burns, and gangrene, may also give rise to it. Anchylosis is also a termination, and not an unfavourable one, of certain diseases of the joints, produced by syphilis, gout, scrofula, and rheumatism. A certain degree of motion is necessary to promote tbe due secretion of synovia, to keep the ligaments supple, and to preserve the contractile power of the muscles. When a joint remains at rest for a long time, its surfaces lose their polish, and are incapable of sliding upon each other; the ligaments become stiff, and prevent motion of the joint; the museles become weak by inactivity; they contract, and be- come rigid, and the weakness of the circulation in the soft: parts around the joint renders them edematous. If, under these circumstances, the synovial membrane and articular surfaces become inflamed, they may adhere to each other in the same manner as the lungs adhere to the pleura costalis, or the liver to the peritoneum. This con- nexion of the articular surfaces, observed by Hunter in se- veral instances, is different from that species of anchylosis Of Anchylosis. 567 which arises from the ossification of the ligaments and the growing of the bones together, in consequence of granula- tions arising on their surfaces and secreting phosphate of lime. In the latter case the two bones become as one; whereas, in the former, if by any violence they are se- parated, their movements may be re-established. Job of Meekren* relates a case of anchylosis of the elbow, to which fomentations and poultices had been applied without success. The patient had a severe fall upon the forearm ; from that time it became moveable, and it was finally restored to the full exercise of its functions. The stiffness of joints, which arises in consequence of long rest after fractures that are not very near the arti- culations, merely requires that the limb should be gradually moved, as soon as the callus has acquired sufficient so- lidity ; but when the bone is broken near its extremity, inflammation is apt to extend to the joint and augment its stiffness; and if any circumstance render it necessary to continue the part in a state of rest for more than the usual time, it may be very difficult, or impossible, to restore the flexibility of the joint, and the articular surfaces may even become united together. J. L. Petit attributed the rigidity of joints, after fractures of the middle of the long bones, to tbe accumulation and thickening of synovia. Dissection has proved that joints rendered stiff by fracture contain a small quantity of synovia; that this fluid is not thickened, and that the rigidity depends, in these cases, entirely upon the ligaments, tendons, and other soft parts. The same author attributed the anchylosis that follows fractures in the vicinity of the joints, to the effusion of an osseous juice which thickens in the joint: but this hypo- thesis is contradicted by the fact that no bony formation, arising from the effusion and condensation of an osseous juice, has ever been discovered in a joint. We find, how- ever, in the fifth volume of the Memoirs of the Academy of Surgery, page 84, a singular case of irregular ossifica- tion, in consequence of a fracture of the upper part of the femur by a ball; this case was supposed to establish Petit's theory. It is easy to conceive how an unreduced luxation may pro- duce anchylosis. In the orbieular joints the movements may be gradually restored in a very considerable degree; whereas, in the ginglymoid joints, unless motion be commu- nicated to the limb every day, complete anchylosis will re • Observation lxiv. p. CQ' 368 Bayer's Surgery. suit; and fhe utmost care can only restore it to a very li mi ted exercise of its functions. Luxations of the ginglymoid joints that have been re- duced, and even sprains, may produce arr incomplete anchy- losis; inasmuch as it is necessary to keep the part in a state of rest for a great length of time. In the chapters on wounds and dropsy of the joints, we have sufficiently explained the manner in which anchylosis may take place, and how it should be treated. The retraction of the flexor muscles of the leg, which almost uniformly occurs in white swelling, keeps the limb completely motionless, and when all the other symptoms have been relieved, the joint still remains stiff, and every attempt to extend it excites great pain. The immobility is so great as to lead to the belief that the bones of the leg and thigh have united together by granulations from their respective surfaces; but this is, in fact, a rare occurrence, and, in almost all oases, tbe rigidity in question depends upon the retraction of the muscles and the stiffness of the ligaments and tendons; as is proved not only by dissection, but by tbe fact that persons in this situation are often cured by the long-continued use of emollient applications. In scrofulous white swellings, to the other causes of in- complete anchylosis is added an enlargement of the ends of the bones. Long-continued retraction of the muscles and rigidity of the ligaments and tendons may produce an im- moveable stiffness of a joint, though the bones be not united lo each other. I have met with several cases of this kind consequent to rheumatic while swelling. Any attempt to have moved the joint would have torn the muscles and tendons. Complete anchylosis may follow white swelling, a wound of the joint, and, in general, any disease in whieh the arti- cular surfaces are ulcerated. It is to be considered as a happy termination of those cases, and the surgeon should endeavour to promote it by keeping the limb perfectly at rest, and in a position that will best fit it for future uses. A large abscess, situated near a ginglymoid joint, by de- stroying the cellular substance, may cause the tendons to adhere to the adjacent parts, &c. firmly. This adhesion, con- nected with the thickening and stiffening of the ligaments, in consequence of inflammation, is a frequent cause of an- chylosis. t . When the skin and cellular substance around a joint are destroyed by gangrene, or by a deep burn, beside the adhe- sion of the tendons, and the stiffness of the ligaments whieh Of Anchylosis. 369 follow the cicatrizes, form bands that obstruct the move- ments of the articulation. Anchylosis, arising from these causes, is generally cura- ble ; but no relief can be afforded in those cases in which the tendons, deprived of their nourishing vessels, have ex- foliated. Thus, in some cases of whitlow, the flexor ten- does sloughing off» tn« fiB8er is kft in a state of perma- nent and insurable extension. In gouty persons, the articular ligaments are often in- erusted with a white friable substance, containing a large proportion of Ihe phosphate of lime. These incrustations very much limit, or even prevent tbe motions of the affected joints. r Bony matter may be deposited in the substance of the ligaments, and render them absolutely immoveable. In tho skeletons of aged persons, we oft^n find tbe ligaments of the pelvis, of the vertebral column, and several ribs, com- pletely ossified, so that several bones are united into one. Hard labour ofieu produces the same effects. They are not to be regarded as a disease, and should be distinguished from the general disposition to anchylosis of which we find several cases in books: ihe patients had generally been rheu- matic for a long time, and after death the ligaments of al- most all the joints were found so completely ossified that Ibe skeleton seemed to be formed of only one bone. To distinguish complete anchylosis from incomplete, we should bear in mind, Ural absolute immobility is a charac- teristic of the former. This sign is not absolutely conclu- sive ; but by considering whether the cause of the disease was of a nature to produce an ulceration of the cartilages of the joint, we shall, in general, be able easily to determine whether the bones have grown together or not. 1 ne dis- tinction is important, inasmuch as complete anchylosis is in- curable, and violent attempts to move the bones would do great mischief. . . Incomplete anchylosis, on the contrary, is almost alwavs capable of being removed. In ginglymoid joints, and m cases of long standing, it is more intractable than when it is seated in the orbieular joints. Age also adds to the difficulty of effecting a cure. . Except when anchylosis is seated in the lower jaw, it J* never dangerous. In that oase, however, it may cause mu- rasmus, by preventing the patient from taking solid food. In all cases where a false anchylosis is to be apprehended, the limb should be cautiously moved by the surgeon, in ordot vol. it. *7 870 Boyer's Surgery. to prevent that occurrence. This precaution is especially necessary in the ginglymoid joints. When these means have been neglected, or employed without success, and a joint has become rigid, the first eura- tive indication is to restore the natural flexibility and exten- sibility to the ligaments and muscles. For this purpose va- rious remedies have been employed; such as baths—lotions, with a decoction of marsh-mallow or linseed, or of broth made with tripe-—vapour baths—pumpings of warm water, and afterwards of a warm solution of muriate of soda, or of ammonia__warm sulphurous waters—frictions, withecld- pressed olive oil, and other fatty substances—the applica- tion of the omentum of a recently killed lamb to the joint, or of a fresh warm sheepskin—plunging the limb into the body of an animal just killed, &c. A surgeon should select from these remedies such as may best suit the circumstances of his patient. Several of them may be employed conjointly: thus, after having bathed the part, or exposed it to the vapour of warm water, or to the momentum of a column of falling water, we may direct it to he rubbed with hot olive oil for the space of half an hour. The frictions should not be confined to the joint, as commonly advised, but should extend over all the fleshy part of the retracted muscles. The bath and friction should be operated at least twice a day. Thus we may use, at the same time, fomentations and emollient poultices, baths, pump- ings, and frictions. If the cellular tissue be swollen, after having employed emollients for some time, we may add to them resolvents. As soon as the ligaments and other soft parts begin to re- lax, we should move the limb. If the knee be the part af- fected, we should cautiously flex and extend it; but without violence, and slowly; otherwise we might occasion dangerous inflammation. During the first trials, a crackling noise is beard. This arises from the stretching of the ligaments, and the friction of the articular surfaces deprived of the fluid, which naturally lubricates them. As soon as the sy- novia begins to be secreted, and the ligaments are elongated, the crackling is no longer heard. It would be improper for a surgeon to trust to another person, unless very intelligent, the making of these movements. Fear of pain would pre- vent the patient from having the proper motions communi- cated to the joint, and most probably the movements of the joint above that which is stiff would be mistaken for those of the diseased joint. Of Anchylosis. 371 When the anchylosis is of long standing, and the retraction of the flexor muscles very great, it is often necessary to use considerable foree to lengthen them: for this purpose we may employ with advantage mechanical means, not only to elon- gate their fibres, but also lo prevent I hem from retracting, Hildanus successfully applied a machine, of which we find an engraving in his Surgery, to extend the knee and elbow affected with false anchylosis. We have used a contrivance nearly similar with the greatest advantage. These ma chines extend the limb in a very gradual manner, and are particularly useful when the rigidity of the joint depends upon a spasmodic contraction of the muscles. In cases where machines are not necessary, it is useful to apply a long splint of wood on that side of the limb toward which it is flexed. When the forearm is stiff; and in a state of flexion, we may employ a remedy which Hildanus says he found successful in several instances, which consists in mak- ing Ibe patient carry a weight with the hand, and gradually augmenting it. This treatment often succeeds beyond all expectation. >Ve might relate several examples of its extraordinary success; but we shall confine ourselves to the following, from J. L. Verduc: ... A girl, aged ten or twelve years, had anchylosis of Ihe right knee, in consequence of a wound between the condyle of the tibia and the patella. The heel had been drawn up against the buttock for seven or eight months. Several sur- geons regarded the disease as incurable: notwithstanding which Verduc undertook to remove iL He began by employ- ing emollients; nfter which he used resolvents. These re- medies were applied twice a day for the space of five months. After fomenting the part for half an hour with an emollient decoction, as hot as could be borne, a very hot resolvent li- quid was poured upon the part. When the limb had become capable of a small degree ol extension, the leg was moved upon the thigh as long as the little girl could endure tho pain. A very thin splint, an inch in breadth, and nearly a foot in length, was then ap- plied behind the knee, and secured by a roller. As there was still a space between the splint and the ham, a very thick compress, enclosing a piece of stiff pasteboard, was laid over the knee, and several turns of a bandage were passed over tbe whole. Every morning and evening the leg was flexed and ex- tended forcibly. At these times a noise was heard, which arose from the rubbing of the condyles of the femur against SV2 Bayer's Surgety. those of the tibia. The patient suffered great pain from these operations, and it often became necessary td desist from4 them for seven or eight days together until she reco- vered. By these means the anchylosis was perfectly cured, and the girl now walks withont limping, or experiencing any inconvenience.* & CHAPTER XLIV. Of certain Deformities, produced by Derangement of the Natural Relations qf Articular Surfaces of the Bones, coming on gradually, and without External Violence. THE bones are not intended merely to support other or- gans. On some of them depend the size, the direction, and the form of the human body, and of each of its consti- tuent parts; and every change in the shape or natural direc- tion of the bones necessarily produces more or less alteration in the external form of Ihe body and deformity. Some deformities arise from a swelling, softening, and bending of the bones; as we observe in rickets. Others are the result of a slow and gradual deviation of these organs from their proper places, without any remarkable change of form or size. We shall here treat of these last: we have spoken of the others in a former chapter. When one or more bones are kept in the same position for a certain length of time, their articular surfaces acquire an unnatural shape, and, if they harden in that position, a deformity is produced, which art may prevent in its early stages, before the ossification is completed; but which is incurable when the bones have become hard and attained their full size. We proceed to consider the consequences of this unnatural direction of articular surfaces in different parts of the body. The head is naturally disposed to ineline forwards, be- cause iii, centre of gravity is anterior to its articulation with the first cervical vertebra. This tendency is constantly • L. Verduc, Trait6 des Bandages, chap. xxxv. p. 17$. Of Defonhities. 375 counter-bttlance* by tbe action of the posterior muscles of the neck, which ghes tbe cervical vertebrae a slight con- vexity behind. To this general cause of unnatural flexion of the head forwards are sometimes added others, such as short-sightedness, or mere weakness of sight, and the bad habit of looking at objects very near ihe eyes, when these organs are capable of distinguishing them at tbe usual dis- tance. Irt all these cases, the constant inclination of the head "forwards prevents the anterior parts of the cervical Vertebras from acquiring their natural thickness, and, if the bones become hard in this position, it h impossible to straighten the neck, and the head always remains beni for- wards. Ihe habit of leaning forward commonly commences when children begin to read and write. We ought, in these cases, to raise the book or the paper, and not suffer them to incline the head forwards: for this purpose a high table is neces- sary. The child should also sleep without a pillow. It is very useful to place something on the bead, a little before the apex, and make Ibe child carry it. By engaging him in a plav of this kind he will soon bold up his head habitually. If the neck be very considerably bent forwards, artd the above mentioned means have not proved sufficient, the child may wear a piece of leather, or thick pasteboard, around the neck. ,..«.* i • If the situation of tbe patient admit of it, we may derive still greater advantage from the use of a machine so con- structed as lo support the chin in an easy manner. Children often acquire the habit of inclining the head lo one side from sleeping constantly in a situation iu which the light always reaches them in the same direction. We may remedy this deformity by changing the position of the cra- dle. If the ehild is in its second year, the parents should give him his toys on the side opposite that toward which his head is inclined. # If these means should not be sufficient we may apply a bandage, or a suitable machine for keeping the head in its proper position, and it will be useful lo employ emollient applications to relax the retracted muscles on that side to- ward which the head is inclined. The shoulders are liable to various deformities, each of which we shall successively consider. When the shoulders are preteroaturally raised, the ncek appears short, and in a 37* Bayer's Surgery. manner buried between them: this deformity, though al- most always congenital, may also be acquired by the habit of continually raising the shoulders. In order to prevent it, we should carefully avoid, 1st, Raising children by the arms; 2d. Making them sit upon chairs, the arms of which are so high that they are obliged to raise their shoulders in order to rest their own arms upon them; 3d. Placing thein in the gocarts that are used in some countries: these ma- chines have the double inconvenience of raising the shoul- ders too much, and making children, who are too weak to bear their weight on their legs, to support themselves on their arms; 4th. In the last place, we should avoid letting them write, read, or play upon a table which is too high. In some cases the deformity of which we are treating is confined to one shoulder. If this do not depend upon a lateral curvature of the vertebral column, we may be cer- tain that it is the effect of a bad habit, which has been con- tracted, of standing constantly upon one foot, which ought to be corrected without delay. We may even cause the child to stand occasionally upon the foot corresponding to the side of which the shoulder is depressed. These means will be found sufficient to correct slight deformities; but where the difference in the height of the shoulder is consi- derable, we should cause the child to wear a corset, of which the opening for the arm corresponding to the depressed shoulder, is higher than that of the opposite side. Some have very incorrectly imagined, that the elevated shoulder might be depressed by placing upon it a weight, such, for example, as a piece of lead; but experience and sound philosophy unite in rejecting this remedy, the effect of which would be, in fact, to raise the shoulder it was in- tended to depress, as by that means only the equilibrium of the body can be preserved. We may apply a weight with advantage to the depressed shoulder, or make the child carry something heavy with the hand or arm of that side; or we may give him a long cane to hold in the hand of the de- pressed side, or a short one for the opposite hand. Children who contract the habit of bringing their arms forward, and resting them against the anterior part of the body, soon have round shoulders. In this situation of the arms, the shoulder-blades are removed from the spine, and eorrespond to the most convex part of the ribs, which pushes them backward, and causes them to project under the Of Deformities. 3.75 integuments; the clavicles become almost transverse; the resistance which they oppose to the scapula?, to prevent them from coming forward, exposes those bones to a pressure, which increases their curvatures and shortens them. If they harden in this situation, they prevent the shoulders from going back, and the person is ever afterward round shouldered; while, at the same time, the anterior and supe- rior part of the chest is much flattened. To prevent this deformity, the children who arc acquir- ing it should be made to wear corsets, which keep the shotil - ders back ; as they grow up we may make them take hold of a long stick, while their arms are extended horizontally, or make them cross their arms upon the sacrum or loins. They should sleep upon a flat bed, without any pillow. Lastly, we may use with advantage a broad bandage, passing in front of the shoulders and crossing behind the back in the form of the figure 8. The dorsal and lumbar vertebrse are not less exposed to be deformed by bad habits than those of the neck. In the natural state, the vertebra; of the back are convex posteriorly, and those of the loins anteriorly; there is no lateral inclination, except a very slight one to the left, near the third or fourth vertebra of the back; these curves do not exist in very young children. A deformed curvature of the spine may arise from seve- ral causes in the most healthy persons, and at any age. Work which requires constant stooping; the habit of carry- ing burdens upon the head or shoulders; the habitual use of the hoe and pick-axe may occasion it. Almost all old vin- tagers are much bent down, and it is well known how great a tendency old age has to bow down the head and increase the natural curvature of the back. When, from any causes analagous to those we have men- tioned, a child is acquiring a habit of stooping forward, in addition to a judicious use of the means we have recom- mended for straightening Ihe neck, it will be proper to pre- scribe tonics and a strengthening regimen; for a weak- ness of the muscles of the back is often the sole cause of the deformity. It is, however, very rare, that a bad habit produces any alteration of the spine. When, therefore, we see an infant deformed in that manner, we should inquire if there be no spasmodic eontraetien of the muscles ef the trnnk: in most 576 Boyer's Surgery. cases, however, wc shall find the evil to originate in an inter- nal disease, affecting the bones, and of whieh muscular weakness is but a symptom. We shall proceed to show how deformity of the spine may take place. . If the muscles of one side act with greater energy than those of tbe other, they necessarily incline the vertebrae ot that side toward them. . , Early youth is more subject than any other period ot lite to gibbositv and spasmodic diseases, and we often see muscu- lar action alone produce a deviation of the spine ; but these causes must continue to act some time for the bones and inter-vertebral substances to become affected. I have twice known a spasmodic contraction of the stemo-pleido-mas- toideiis, which had not continued long enough to have pro- duced this effect, followed by so great a shortening ot that muscle, that it was impossible to keep the head from rest- ing upon the corresponding shoulder, even after the spasm was removed. . . . Tbe treatment of cases of this kind, consists in the early and assiduous application of warm baths, camphorated and opiate liniments, fomentations, poultices, sulphurous w«- ters, pumpings, &c.-sclecting those which appear best adapted to the cause of the disease. Preternatural inflexions of the spine are rarely produced bv the causes of which we have just spoken, unaided by some 4ncral and local disease. We have elsewhere treated ot rickets and of caries of the vertebrae. What we are going ,o sav relates exclusively to affections of the spine, occurjng i longer or shorter time after the first dentition of children, who, without being decidedly rickety, have some latent dis- ease of the spine or other bones of tlie joint. 1 hese devia- tions occur in children born of parents affected with scro- fula, svphilis, cachexia, exhausted with age and indulgent* with women; or whose nurse, having some of these com- plaints, affords little or no milk, and supplies its place with boiled meat, or who suckles during prcgnaney. Children ip whom none of these circumstances obtain sometimes be, oome affected with a curvature of the spine during their con- valescence from acute diseases, especially eruptive diseases, such as small-pox, measles, be. above all, when they are exposed too soon to the open air, without being clad sufiir cientlv warm. _ , « Curvatures of the spine commonly appear from the age ot SW veai s to that of fifteen, and are much more frequently met with in girls than in boys. Tlie dorsal portion of the Of Deformities. 377 spine is almost always the principal, sometimes the exclu- sive seat of the disease; but sometimes, also, the lumbar yartebrse are affected. The inclination is seldom either for- ward or backward, but almost always lateral, and from the right side to the left. When both the dorsal and lumbar vertebra? are affected, they form curves in opposite direc- tions like those of an italic S. The effect of curvatures of the spine upon the form of the chest is very remarkable. The ribs which are attached to the convex side of the spine, become more curved back- ward, and push out the scapula, while the anterior portion of these ribs is straightened: the intercostal spaces are Ihus increased. These effects are reversed on the opposite side. There the chest is flattened, the ribs are approximated, the pap becomes more prominent, without being, in fact, larger; and the scapula, although not smaller, projects much less. . When Ihe deviation depends exclusively upon an affection of the vertebrse, the movements of the thorax are seldom impeded; but when the ribs are also involved in the disease, respiration is rendered difficult and laborious. The deformity of which we are treating usually takes place at an age when the pelvis has already acquired a con- siderable devclopement and solidity : hence that part is rarely distorted, except in cases where the deviation of the spine is very great, and involves the dorsal and lumbar vertebrse: the direction of the pelvis in relation to the spine then be- comes changed, and one of the hips is higher than the other. Not so when the curvature takes place in a rickety child, all of whose bones are equally softened. In these cases, the pelvis partakes of the deformity; in the former the spine only is distorted. The deviation of the vertebral column takes place in a manner so slow and gradual, lhat it is not generally noticed until it has made considerable progress. One shoulder is observed, indeed, to be raised, and to project more than the other; but this is attributed lo the child's having acquired the habit of leaning to one side, and nothing more is done than telling him lo constantly hold himself straight, and me- dical advice is not asked until the evil has become irremedi- It is of great importance te discover the disease at an early period, and to prescribe such remedies a* its internal euase renders necessary. A scrofulous taint is undoubtedly the most frequent cause of this affection: but the other VOL II. *8 378 Boyer's Surgery. diseases we have mentioned also give rise to it, and require appropriate treatment. The medicines that have been given with most advantage in scrofula, are bitter tonics, antiscorbutics, chalybeates, antimonials, sulphurous and chalybeate water, the carbo- nates of potash and soda. We should prefer mercury in all eases connected with syphilis, (whether inherited or not,) or with an abuse of remedies for the cure of that disease. It is, undoubtedly, the prevalence of the scorbutic taint, in large cities, that has led to the great success from the use of the sirop antiscarbuliaue, in the practice of Messrs. Portal and Salmade. Bark, and its different preparations, a strong decoction of hops, of the root of burdock, or of gentian, are the tonics whicli have proved to be most useful in cases of scrofula connected with debility. When it is practicable, the patients should also remove to a pure, warm, and dry air, to a situation with a southern aspect. Frequent exposure to the sun, with the proper pre- cautions for the heat, and the use of stoves in winter, are very beneficial. The clothing should always be warm for the season ; flan- nel should be worn next the skin; the patient should be rubbed with flannels impregnated with an aromatic vapour, or with alkoholic or balsamic liquors, such as lavender wa- ter, &c. The diet should be light, easy of digestion, and very nourishing. It should consist of the flesh of grown animals, such as beef and mutton, sapid and red meats; and succulent roots, such as those of carrots, turnips, parsnips, etc. together with antiscorbutic plants, such as onions, leeks, water-cresses, &c. Milk, and green or wilted fruit, and fari- nacious food, must be forbidden: a moderate quantity of coffee or chocolate is useful: good old wine, with water, and occasionally without it, is the best drink. The exercises of walking, running, swimming, wrestling, and whatever tends to impart strength to the body, will be found highly beneficial. The muscles of the side on which the spine concaves, which are always weaker than those of the opposite side, should be invigorated by frequent ex- ercise. In fact, the particular exercise of these organs is the best means to correct the deformity. To fulfil these in- dications, the child ought to be engaged in play with a kite, a ball, drawing a waggon with a cord, &c. or raising a weight with a pulley. We have had a wheel constructed to be turned by chil- dren. It is supported vertically. The winch by which jt is Of Deformities. 379 moved in its greatest ascent, is raised as high as the child can reach. Thus it brings into action precisely those mus- cles which we wish to strengthen, and is extremely useful, not only in cases of deformity of the spine, but also of mal- conformalion of the chest. Whale-bone eorsets, and other machines for correcting these deformities, are, in general, more injurious than use- ful. Judicious treatment will greatly diminish, though it will seldom entirely remove considerable deformities of the spine. But some cases admit of little relief. Weakly children, when they begin to walk, often become knock-kneed, or bow-legged : sometimes on both, and some- times on only one side. This is particularly apt to be the case with children who have used gocarts, whieh throw the weight of the body upon the legs before they are able to support it. The deformity sometimes takes place as late as ihe age of twelve years, but generally much earlier. It is easy to conceive how the knee may be bent m, if we reflect that the ossa femoris pass obliquely downward and inward, while Ihe upper surface of the tibia is horizontal, and the internal condyle of the femur lower than the ex- ternal. This structure, a necessary consequence of the breadth of the pelvis, is more remarkable in females, in con- sequence of the greater width of the female pelvis, and the greater separation of the upper portion of the thighs. Thus the knees have a natural tendency to bend inward. For these reasons, also, it rarely Irappens that deformity takes place, in a contrary direction, to any considerable de- cree, and it is generally accompanied with a curvature of the femur and of the tibia, which is not the case when Ihe knee is turned inward. There is a constant relation between the direction ol the femur with respect to the tibia, and that of the tibia with re- spect to the astragalus. In the natural stale, the femur forms with the tibia an obtuse angle, salient on the inner side; the tibia forms with the astragalus a similar an^Ie, ilioiigh less marked. When the inclination of the femur wrth the libra is increased, that of the tibia with the astragalus is increased also- the foot is consequently turned outward, and the weight 'of the body is supported chiefly by the inner side of the sole. 380 Bayer's Surgery. In the second case, when the knee is bent outward, the weight of the body is borne chiefly upon the outer edge of the foot. m , Debility is the cause of these deformities. To prevent them, we should leave children to themselves until they are able to walk without assistance. This rule is applicable to all children, but ought to be particularly observed in regard to those who, in their first attempts to walk, place their knees together. In addition to these precautions, it is often necessary to use topical and general tonics, and to apply mechanical means capable of remedying the deformity. During the night we should place, on the external side of the leg, a wooden splint, covered with a soft substance, and confined to the limb bv a roller moderately tight. During the day, the child should wear a laced boot, of which the sole is thickest on that side toward which the knee is inclined. Thus, when the knee is turned in, the sole should be thick- est on the inner side of the foot, and vice versa. The efficacy of this remedy is proved by daily experience. To derive from it the greatest advantage, it should compress the foot so as to prevent it from turning, and the lower sur- face of the foot should be kept in contact with the upper surface of the sole of the boot, and that part of his sole which is to be thickest should receive additions from time to time, and the inequality should be gradually carried to an exlent proportioned to the deformity. It is necessary, of course, to persist in this treatment for a considerable length of time—more or less, according to the extent of the defor- mity and the age of the patient. The soles of the foot, in the natural state, should press horizontally against the ground. If the foot touch the ground only by its internal side, or by its external side, the deformity is called a club-foot. The French term equin de- signates those cases in which only the point of the foot touches the ground. The Romans applied the term varri to those whose feet were turned inward, and valgi to those ■whose feet were turned outward. The former is the most frequent. The other varieties of this disease are very rare. One foot, or both, may be deformed. Congenital deformities of the foot have been attributed by seine to the uneasy position of the child in the womb; by Of Deformities. 381 others to the imagination of the mother. Neither hypothe- sis is satisfactory. The causes of deformity of the foot, after birth, are fractures, luxations, abscesses, laxity of the ligaments, the spasmodic contraction or relaxation of Ihe muscles. Duver- ney considered Ihe last as the sole cause of the club-foot. He grounded his opinion upon Ihe constant flaccidity and atrophy of the muscles destined to move the foot in a direc- tion opposite to lhat in which it is twisted. Scarpa, on the contrary, asserts that this relaxation does not precede, but that it follows the deformity. We believe that, in different cases, the relaxation may be boih a cause and an effect of the twisting of the foot. Children deform their feet by walking on one side when the opposite side is tender, in con- sequence of its being tbe seat of a pustule, wound, &c. es- pecially when parents and nurses are in too much haste to make them walk. When the foot is turned inward only in a slight degree, its inner edge is still capable of being made to touch the ground when the foot is pressed strongly against it. But when the deformity is more considerable, the whole weight of the body is borne by the external edge of the foot and the exter- nal ankle; the back of the foot becomes very convex, and the sole very concave; the great toe is separated from the rest, and is commonly pointed inward and upward; the two great toes sometimes touch each other in cases where both feet are deformed, and there is, of course, great difficulty in walking. Scarpa has discovered, by dissection, that the astragalus does not commonly participate in the deformity of the club- foot. It is important to recollect this fact in the application of machines. Scarpa also found lhat the bones of the tar- sus are not luxated in these cases, as was believed, but only turned in the direction of their shorter diameter. The mu- tual relations of these bones are not completely changed un- til a very late period of the disease. The probability of removing or diminishing this deformity is inproporlion to the facility of returning the foot to its na- tural situation. Except in cases where the bones of the tar- sus are anchylosed, the curative indication is always the same, viz. to draw the foot gradually towards its proper place by an external force, without occasioning pain, or great inconvenience, and without preventing the patient from walking while it is applied. Hippocrates well knew the advantages of suitable ma- chines, and Hildanus invented one which he applied with sue- 382 Boyer's Surgery. cess. Scarpa has also invented a very ingenious contrivance for the same purpose. It appears to me, however, to be un- necessarily complicated. We have employed, with great advantage, a more simple machine than that of the celebrated professor whom we last mentioned. It consists of a sole, to the heel of which is attached a plate of iron, consisting of two parts, one ho- rizontal, and the other vertical; the former passes between the two pieces of leather of which the heel is composed, and is fastened by a rivet; the latter rises about two inches above the sole: its upper end is somewhat longer than the rest,, and receives a screw riveted to the end of an clastic plate of iron, the breadth of which is one inch, and its length sufficient to extend above the calf of the leg. This plate is covered with velvet, or some other soft substance, and its spring is proportioned to the force we wish to employ. The sole also consists of two parts, a posterior and an ante- rior; to the first, which forma the heel, is attached the quarter; the second is the sole, properly so called. It sup- ports the upper-leather, which has no connexion with the quarter, and should he made of thick calf-skin, lined with sheep-skin. The posterior and concave part of this piece is to correspond with the convex and anterior part of the posterior piece. Eaeh of these parts is formed of two pieces of leather which are laid upon each other. A plate of iron, almost as large as the posterior piece, is then placed between the skins which form it, and riveted there. The middle and anterior part of this plate is traversed by a screw, which extends about two lines below it, and is riveted above. This screw corresponds to the centre of a second opening made in the lower piece of leather, and about eight lines iu diameter; in this opening lodges a screw, of which we shall speak presently. Another plate of iron, an inch in length, passes between the whole length of the anterior part of the sole, to which it is riveted, and extends back to the screw with which the posterior plate is armed, and is con- nected to the two pieces of leather which form the posterior part of the side, and terminates in a large round head, the centre of which has an opening for a screw, and is of suffi- cient size to permit the plate to move freely around the screw. A round nut, with apertures in its sides, so as to be turned with a forked screw-driver, fixes the anterior part of the soles in any position we wish to give the feet. The up- per leather is divided lengthwise, and the boot is laced on the top of the foot. The machine is kept on by a leathern strap and buckle over tbe instep, and another strap, much Of Deformities. 383 broader than this, and made of linen covered with velvet, to go around the leg, opposite to the upper end of the elastic plate. It is tightened by means of a buckle.* During the course of the treatment, we may employ a plate with a stronger spring than that first used. It need scarcely be stated, that neither this nor any other machine should be employed to deformities that are the ef- fects of rickets, of white swellings of the ankle joint, or of gouty or rheumatic affections of this part. The symptoms which accompany the turning of the foot outward, and the method of removing it, will be easily un- derstood by what has been said of the opposite deformity. The deformity of the foot which consists in an elevation of the heel and depression of the toes, depend.-, sometimes on a luxation of the foot forward, and may also arise from the disproportionate strength of the external muscles. In this case, the toes and corresponding extremities of the meta- tarsal bones alone touch the ground; they form a right angle with the rest of the foot: the skin, which covers the plantar side of the toes, becomes thickened, and the patient walks and stands unsteadily. Scarpa has proposed, for the cure of this deformity, a machine so constructed, that in propor- tion as the foot presses against the ground, its anterior part is gradually raised to a level with the heel. The wearing of narrow shoes often causes the extremity of one of the toes to rise over that which is next within it, and cross it at an acute angle. If this deformity exist in a great degree, and especially if it extend to several toes, it may render walking difficult and painful. In the commence- ment of this deformity, the wearing of broad shoes, and the proper application of a small bandage will remove it; but when it js of long standing it is incurable: those who are the subjects of it are obliged to wear broad shoes; and to place cotton each side of the deformed toe, to prevent the upper leather from pressing upon it. The first phalanx of one of the toes, most commonly that * This machine, and the other which we have described, were made by M. Oudet, an excellent artist, who lives at I'aris, in the Rue des Fosses Saint fiermaine-deS'Pres, n*o 19 384 Boyer's Surgery. of the third, may rise a little, so as to form an obtuse angle with the first bone of the metatarsus which supports it. while this phalanx is also extended, and the second and third pha- langes are more or less flexed, so that the end of the loe touches the ground in walking and standing. The toe be- ing thus compressed between the sole and the upper leather, becomes painful, and sometimes ulcerates. Walking, of course, is rendered extremely painful; and persons thus affected are at all times incapable of walking far, especially if the end of the nail touch the sole of the shoe. This deformity is the result of a slow and gradual relaxa- tion of the extensor muscle. When il io not considerable, the toe may be replaced in its proper situation; but as soon as if is lcft'lo itself, it returns to its unnatural place. When the disease is carried to a great degree, the toe is retained in its deformed situation, not so much by the retraction of the extensor muscle, as by the change in the articular surfaces of the bones. When proper precautions have not succeeded in preventing this deformity, it may be remedied by an operation which I have twice performed with the greatest success, and which consists in dividing and removing a transverse portion of tbe retracted muscle. The first person on whom I performed this operation, was a young man, seventeen or eighteen years of age, Ihe little toe of whose left foot was deformed in the way we have mentioned. It could be easily replaced, but it immediately returned to its unnatural position. The tendon of the extensor muscle raised the skin along its course, and formed a remarkable projection, whieh disappeared the mo- ment the toe was put into its proper place. The young man not being able to walk without great difficulty, although he wore very large shoes, was willing to suffer any operation that would relieve him. I made an incision, about an inch in length, along the extensor tendon, and divided it. The two ends immediately retracted, and left a large interval between them; which was still more increased when the toe was re- stored to its situation. I confined it in this position by means of a small bandage that pressed it against Ihe next toe. The incision was brought together by sticking plaster: it healed in four or five days. The use of the bandage was continued until the toe remained in its natural place without its assistance. Then the cure appeared complete; but the two ends of the divided tendon soon became re-united by means of a hard and solid substance, and at the expiration of six months, the deformity was as great as ever. I pro- posed to the patient to remove a portion of the tendon, and Of Deformities. 385 he submitted to it. By an incision similar to the first I re- moved an inch and an half. The subsequent treatment was the same as in the preceding case, and the relief was perma- nent. It is proper to observe, that the first division of the tendon was made at the upper end of (he incision. A little girl was born with a foot twisted inward. The deformity was removed by the use of tlie machine we have described, but the great toe remained drawn up by the re- traction of the extensor muscles, which also turned the point of the foot inward. The removal of a portion of the tendon of the muscle completely cured her. When there is no other resource, it becomes necessary to amputate the toe. A young man, seventeen or eighteen years of age, was the subject of a great deformity of the third toe of each foot, which almost prevented him from walking. I removed Ihe toe, and he afterwards walked with the greatest ease. Most of the family were the subjects of similar deformity. vol* II. 49 * TRANSLATOR'S NOTES TO VOLUME II. NOTE A, p. 39. THE late Mr. Birch, one of the surgeons of St. Thomas' Hospital, (whose assiduity in the instruction of his pupils it would be unjust not to mention with gratitude,) informed me that he had succeeded in procuring a firm osseous union, in several cases of ligamentous connexion of bones after fracture, by means of electricity. He stated, that, in his hands* that remedy had never foiled of success. One of his dressers, with whom I was intimately acquainted, saw two cases in which it produced the most happy effect. One of these patients, whom I often visited during his illness, entered St. Thomas' Hospital in the month of January, 1812, with an unconsoli- dated fracture of the tibia, below the middle, of thirteen months stand- ing. The kg below the fracture could be easily moved in any direction, and without exciting much pain. Shocks of electric fluid were daily passed through the space between the ends of the bones, both in the direction of the length of the limb and that of its thickness. The man, being somewhat weak, used bark and porter at the same time. After the limb was electerized, the ordinary apparatus for fractures of the leg was applied. A* the expiration of two weeks the limb had evidently become less flexible in the situation of tlie fracture; and after a continuance of the same treatment for six weeks, the man was able to walk, and left the hospital cured. In a recent British publication it is stated, that blisters have been applied, in a similar case, with success. We should certainly cause a fair trial to both these remedies before re- sorting to so serious an operation as that of introducing a seton between the bones. .... .i__ A late English surgeon, who,has written upon this subject, proposes the introduction of a seton, as originating with himself. NOTE B, p. 55. A sailor had several of his ribs fractured in a fall against the side of a boat and came under my care in a situation where the ordinary apparatus used in such cases could not be procured. Indeed there was scarcely any thing else at command than a quantity of coarse canvass used for sails o« vesseR $"88 Bayer's Surgery. I marked upon apiece of this, of suitable size, the distance between the shoulders measured acros_s the breast, and made openings for the arms, which were tlien passed through them. The ends of the canvass were then laced behind, in the manner of a corset, during a strong expiration. This apparatus soon put a period to the pain and difficulty of breathing which had been previously experienced, and enabled him to work without inconvenience. After wearing the corset about ten days, he thought pro per to have it loosened; but he was soon taught the impropriety of thip by a return of the pain in the place of fracture during inspiration. The simple apparatus employed in this, answers the purpose quite a-> well as any other. NOTE C, p. 101. The difficulty of preventing the lower part of the limb from being turned outward, in pursuing treatment adopted by the. English surgeons., appears to me almost insuperable. As to Desault's apparatus, it has a tendency rather to increase than to diminish the disposition of the foot to turn outward, and occasion the de- formity ; because the bandage for die extension, attached above the ankle, passes by the sides of the foot, not directly downward in the direction of the axis of the leg, but obliguely downward and out-ward through the mortice of the long splint, on the outside of the leg. This inconvenience is completely obviated by passing one end of the band over a block at- tached to the lower end of the splint, aecording to the improvement of Drs. Physick and Hutchinson. Another great advantage of the appa- ratus employed By Dr. Physick is, that it diminishes the obliquity with which the band for counter-extension acts upon the pelvis in respect to the axis of the limb, thereby diminishing part of the unavoidable pres- sure upon the groin. ' On the other hand, the pressure of tlie crutch or cushion at the up- per end of the long splint, against the axilla,, which is intended to take off some of the pressure against the pelvis, appears to me to be rather a defect than an advantage in Dr. P.'s apparatus. Let us suppose, for in- stance, the foree of the counter-extension to be equal to twelve pounds; the force of the extension will also be equal to twelve pounds. Now, if any portion, say two pounds, of the counter-extension be supported by the axilla, and removed, of course, from the pelvis, so much of that assemblage of bones as is moveable, viz. the outer, part, will be drawn down by a force equal to two pounds; and by the resistance of the acetabulum to the head of the femur it will be carried inwards; thus causing the frag- ments to form with each other a salient angle, toward the internal part of the thigh. If there be any objection to M. Boyer's machine, other than the difficulty of measuring the degree of force with which it acts, it is that it is too co mplicated for private practice. We think the apparatus of Dr. Physick, without the crutch, the upper end of the long splint terminating opposite 4hs lower end of the stsrnum, preferable, in most cases, to any other. Translator's Notes. S89 NOTE D, p. 149. Future experience alone can determine the value of the following ob- servations, which were extracted from a late publication on Diseases of the Spine, by Mr. Copeland, of London. " In most cases, and particularly where the disease is m the usual place, the superior dorsal vertebra, the great characteristic circumstance and symptom, is a commencing paralysis of the abdominal muscles. It is surprising how very early in the disease this symptom may be detected, when the attention is directed to it. It is sometimes described as an op- pression of breathing, tightness of the stomach, band tied round the belly, torpor of the abdomen, and by other expressions, in different pa- tients. It produces costiveness and retention of urine, m a more advanced stage: in short, in whatever of these symptoms you examine it, some function of the abdominal muscles is recognized to be impeded. No au- thor, who has mentioned this disease, has omitted this symptom under some name or other, although it has never, I believe, been fully ex- plained. " I have seen it called asthma, and prescribed for as such for several months: it is often called dyspepsia, and even diseased liver, from the sense of uneasiness and stricture over the region of the liver and sto- mach: sometimes is taken for a disease of the colon or rectum, from the costiveness and pain that accompany it. The bladder also being unable to perform its office, the cause of this impediment is sought for in the uretha or kidneys." "If the disease is in the neck, there will be pain and difficulty in the rotation and other motions of the head, and the oppressed breathing is one of the most strongly marked features. If the back is the seat of the disease, the oppression at the stomach, as it is called, or the torpor of the abdominal muscles, will be strongly marked. In tlie bona, both these indications are wanting, and the symptoms principally regard the bladder and rectum, whose offices are in a greater or less degree disturbed, ac- cording to the degree of pressure made on the nerves which supply them." Mr. Copeland admits, however, that the actual seat of the disease in the spine is often determined with difficulty from these early symptoms alone; but the diagnosis is aided, in these cases, by an attention to two circumstances; namely, the greater sensibility to pressure, and to tlie stimulus of heat, but especially the former. This is to be ascertained by carefnlly examining, with the fingers, the whole spinal column, in which the smallest degree of tenderness may be deemed evidence of morbid action within. Where this is not easily ascertained, the suscep- tibility to the stimulus of heat will often detect the morbid part. Thu? " a sponge, wrang out of hot water, and carried down the spine, will of- ten give a very acute degree of pain while passing over the part where disease is going on." This the author discovered by accident, in spong- ing the bites of leeches over a diseased spine: but his subsequent obser- vations have taught him that this peculiar sensibility is not quite uniform.. though it is often an auxiliary in determining the diagnosis. 390 Bayer's Surgery. NOTE E, p. 150. The opinion here stated with respect to the efficacy of re»t, is that of the great body of well informed surgeons of the present day. But Mr. Baynton, of Bristol, whom we have had occasion to mention with respect in the former volume of this work, maintains a very different opinion. We shall give our readers a full view of his doctrine and practice in caries of tlie vertebrae, and leave to their judgment and experience to decide on its merits. , Mr. Baynton recommends rest in a horizontal position, which, he says, " is as effectual in improving circulation, favouring the deposition of bones, and promoting absorption, as it is in preventing pressure and al- laying pain." In his early cases, the author conjoined with rest, the use of drains; in his later practice, he has not found them generally, if ever, necessary in the cure of diseases of the spine. In these cases, when a tonic remedy is indicated, he occasionally prescribes muriate of lime ; but does not place great confidence in its alleged beneficial effects in scro- fula. As rest is the chief means employed in the cure, it is essential that it should be obtained with the greatest ease to the patient, and that ex- coriation, and other inconveniences consequent on long confinements in bed, should be avoided. For these purposes the author suggests that " A crib, or narrow bedstead, must be proenred, six feet in length, or rather of a sufficient length to accommodate the patient; two feet one inch in height, from the floor of the apartment to the floor of the crib, where the mattress is placed; two feet five inches wide, with posts three feet seven inches high, containing castors, to be turned by a turner, as a common crib. " It must be provided with a rail floor, instead of sacking, and with side boards to raise up and down, which, when half raised, will resem- ble the raised flap of a table, and must be supported with sliders, that can be drawn in or out when required, and which, when wholly raised, will furnish sides to the crib, for security, or warmth at night. The cas- tors should be of brass, and of the strongest description. " This crib is to be fitted with a mattress, from three to four inches thick, that has been French or double stuffed with the best horse hair, made two inches shorter and two Inches narrower than the crib, in the clear of the sides, head and foot-board, for the purpose of affording room for raising the sides, and turning in the bed clothes. Its width will be sufficient for the accommodation of the patient, though its dimensions will admit of its being drawn through the door-ways of the patient's day and night apartments. Its height, when the mattress is laid upon it, will be just sufficient to raise the patient to the level of a common table." By this means, the patient may be readily removed from one apartment to another, and thus have the advantage of changing the atmosphere, and enjoying the pleasure of society. Mr. Baynton has annexed several cases which he treated with success. We attach so much respect to the autlior of " A new mode of curing Old Ulcers," that we are unwilling to omit inserting some of them, though our opinion is adverse to his practice. Translator's Notes. 391 rt The friends of Miss ——, about sixteen or seventeen years old, re- quested my attendance, at the village of Bishport, near Bristol, on the 5th of December, 1801. " On my arrival, I was introduced to three young ladies, who were sit- ing together in a parlour apartment, all apparently in good health, and remarkably cheerful. The parent of the lady who was to become my pa- tient asked me if I could discover the invalid ? On my replying in the ne- gative, she told me that her daughter, whom she then pointed out to me, was completely palsied by a disease of the spine, for which sea-bathing, and a mechanical apparatus for the removal of pressure, had been a long time used, without the slightest advantage. " She also informed me, that her application had been made to me in consequence of the recommendation of Mr. ——, a gentleman of the most distinguished eminence in London, for the advantage of whose opinion she had, by the advice of her physician, gone with her daughter to London, and had just returned. Having, previously thereto, procured a new set of mechanical apparatus, from a person, I believe, named Jones, by the advice of the gentleman above alluded to. " On examining the part, I found a considerable projection of two of the dorsal vertebrae, and the contiguous parts in a very tender state. " I also found that the sensibility of the legs, thighs, and other parts below the diseased, was so completely destroyed, as to render it impos- sible to excite the slightest sensation, by pinching, pricking, or any other means. "I considered it my duty to apprize the relations of this interesting and very amiable young lady, that much time ought not to be employed in the trial of this new apparatus, if relief were not experienced. It unfortu- nately happened that a period of more than five months was employed in its trial. " On the 15th of the following May, 1803, I was requested again to see this lady, and to adopt any means that I might consider to be likely to afford any chance of recovery. By this time a remarkable change had taken place. The cheerfulness and appearance of health, which, at my first visit, had been so astonishingly preserved, as to occasion no percep- tible difference between her and healthy companions, were entirely gone. Her general appearance was now so unfavourable as to occasion me to fear that her life could not be preserved until a trial could be given to the means I intended to have recourse to. " One point was gained by the apparently unfortunate state of circum- stances. A determination bad been made by the very anxious relatives, to adopt, implicitly, any means that might be recommended. *' She was immediately placed on an unyielding mattress, without a pil- low ; setons were inserted on each side of the diseased vertebrae, and in- structions were given, with the utmost care, that the lady should never be raised from the horizontal position, or moved for any other than na- tural purposes, or the dressing of the setons. A suitable regimen and medicines, adapted to the varying circumstances of the case, were then exhibited. The general health soon became improved; but it did not happen until the eleventh month that any sensation was experienced in 392 Bayer's Surgery. the palsied parts. About that time, a tingling was felt in the legs > and from that time the recovery proceeded so rapidly, that at the end of the fifteenth month she could walk without inconvenience, and by the end of the eighteenth month, could run, leap, and dance as well as ever she •ould in her life. " The protruded processes of the vertebrae continued to project, in con- sequence of the occurrence of anchylosis previously to the adoption of recumbency. " I have had frequent opportunities of hearing from this lady and her friends, that no tendency to relapse, nor any inconvenience, has been ex- perienced since the completion of her cure, a period of nearly ten years. " On the 17th of April, 1811, I was consulted by the friends of Miss ——, aged 15, on account of a disease of the spine, for which setons had been recommended. Upon examination a slight curvature was observed, and on pressing the processes, it was observed by the tenderness, that some of the dorsal vertebra were in an inflamed state. Absolute rest, iw the manner described, was therefore recommended; and as the gene- ral appearance indicated that a towie remedy was necessary, the muriate of lime was ordered. No material affection of the parts below the dis- eased had occurred, nor had the general health been much impaired. -1 did not see this lady a second time. She was removed to the coun- try, and the directions observed there. A perfect cure was obtained in six or seven months; of the exact time I am not certain. " Master W. Castle, son of Mr. Thomas Castle, of Portland-Square, Bristol, when about one year old, was observed to have lost his hearth, when It was observed he could not use his legs as he had been accustomed to do. On examining the spine I discovered that four of the lower dorsal vertebra were in a diseased and protruded state, and that great pain was occasioned by moderate compression, either of the bones or cartilaginous soft parts. Absolute rest, on a hair mattress, was strictly enjoined; the mnriate of lime, in appropriate doses, directed, and the constant care of a confidential servant ensured. The advantages resulting from these means were soon apparent. They continued progressively to increase un- til the cure was accomplished. At the end of the sixth montb, he was allowed to roll and play on a carpet In a short time after, he got on his feet without assistance, and has continued in perfect health from that time to the present The curve Is entirely removed." hi ■—i ; NOTE F„ p. 214 The success of the following extraordinary case of reduction of a dis>- location of the humerus of more than five months standing, does not ap- pear to fee attributable to any of the causes mentioned by Baron Boyer. We insert it not less with a view of recording a remarkable fact very creditable to Dr. MTCenzie than to state our opinion of the great efficacy of bloodletting ad deliquiura ammi, in facilitating t&o redaction of dis- locations- Translator's Notes. 393 Dr. Physick is believed to be the first who fully established the advant- age of this practice. The case alluded to was communicated to him in a letter from Dr. M'Kenzie, of which the following is an extract. " J. B. a seaman, aged about thirty-five years, was admitted into the Bal- timore hospital in the month of September, 1805, with a luxation of the os humeri. The account he gave of his case was, that while on a voyage to Liverpool, and two weeks after leaving this port, he fell from a consi- derable height, and dislocated his shoulder, and that an attempt was made by the captain of the ship to reduce it, but without success ; that upon his arrival at Liverpool repeated trials were made to effect reduction of the bone, but to no purpose, and he had now remained in this situation between Jive and six months. " Upon examining the shoulder, I found the head of the humerus un- der the pectoral muscles, where it had imbedded itself, and appeared to have formed considerable conned ■"" u-ltl»