Part 1

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

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Footnotes have been renumbered and positioned below the relevant paragraphs.

A TREATISE

ON

FRACTURES, LUXATIONS,

AND OTHER

AFFECTIONS OF THE BONES,

BY P. J. DESAULT,

SURGEON IN CHIEF TO THE HOTEL-DIEU OF PARIS,

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

EDITED BY XAV. BICHAT;

WITH PLATES.

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

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

PHILADELPHIA:

PRINTED BY FRY AND KAMMERER, LÆTITIA COURT.

1805.

_District of Pennsylvania, to wit_:

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

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

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

D. CALDWELL, Clerk of the District of Pennsylvania.

CONTENTS.

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

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

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

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

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

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

MEMOIR VII. On the Luxation of the Humerus, 102

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

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

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

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

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

MEMOIR XIII. On the Fracture of the Rotula, 304

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

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

TRANS.

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

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

MEMOIR XVII. On complicated Luxations of the Foot, 379

APPENDIX.

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

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

ARTICLE III. Explanation of the third Plate, 409

PREFACE

BY THE TRANSLATOR.

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

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

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

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

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

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

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

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

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

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

A TREATISE

ON

FRACTURES, DISLOCATIONS, &c.

MEMOIR I.

ON THE FRACTURE OF THE CONDYLES OF THE LOWER JAW.

§I.

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

§II.

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

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

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

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

§ III.

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

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

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

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

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

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

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

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

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

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