The lectures of Boyer upon diseases of the bones, arranged into a systematic treatise

Front matter

THE LECTURES OF BOTER

UPON

DISEASES OF THE BONES,

CHAPTER I. Of Fractures in ceneral n

§ I. Of the different Species of Fraclure . . . . ib.

§ 2. Of the Causes of Fraclures 1 8

§ 3. Of the Signs of Fractures 19

§ 4. *The Prognosis of Fractures 21

§ 5 . Of the Treatment of Fraclures ...... 2 3

CHAP. VII. Of Fractures of the Bones of the Pelvis . 64

§ I. Of Fraclures of the Sacrum ........ ib.

§ 2. Of Fraclures of the Os Coccygis . . . . . 65 § 3. Of Fraclures of the Ossa innominata ... 66

CHAP. VIIL Of Fractures of the Scapula 68

CHAP. IX. Of Fractures of the Clavicle 72

CHAP, X.

Of Fractures of the Humerus 78

VI CONTENTS.

CHAP. Xr. PAGE

§ I. Of ' Fraaures cf both the Bones ..... 84

§ 2. Of Fraaures of the Radius 87

§ 3- Of Fractures of the Cubitus 88

§ 4. Of Fradures of the Olecranon 89

CHAP. XII.

Of Fractures of the Bones of the Hand . . 93

§ I. Of Fraaures of the Bnes of 'the Carpus . ib.

§ 2. Of Fraaures of the Bones of the Metacarpus ib.

§ 3. Of Fractures of the Phalanges of the Fingers . . 94

CHAP. XIU.

Of Fractures of the Thigh 96

CHAP. XIV.

Of Fractures of the Neck of the Femur . . 102

CHAP. XV.

Of Fractures of the Patella 129

CHAP. XVI.

Of Fractures of the Bones of the Leg . , . 143

§ 1 . Of Fraaures of both the Bones ....... ib.

§ 2. Of Fraaures of the Tibia . . 1 47

§ 3. Of Fraaures of the Fibula 148

CHAP. XVII.

Of Fractures of the Bones of the Foot . . 152

CHAP. XVIII.

Of Wounds, and Denudation, of Bones . . . 154

CHAP. XIX.

Of Necrosis 157

CHAP. XX.

Of Caries 164

CHAP. XXI.

Of Exostosis 1 7&

CHAP. XXII.

Of Osteo-sarcoma • I & 2

CONTENTS, VU

VOLUME II.

Chap. I. Page

CHAP. IT.

Of the Fragility of Bones 197

CHAP. IV. Of Luxations in general ■ . . 204

§ 1. Of the Differences of Luxations 205

§ 2. Of the Causes of Luxations 207

§ 3. Of the Symptoms of Luxation ....... 209

§ 4. Of the Prognosis in Luxations 211

CHAP. V. Of Luxations of the Lower Jaw 220

CHAP. vr.

Of Luxations of the Vertebra 225

§ 1. Of Luxations of the Head from the first Vertebra . 226 § 2. Of Luxations of the first cervical Vertebra from the

second ib.

CHAP. X. Of Luxations of the Fore-arm 251

§ 1. Of Luxations of the Fore-arm from the Humerus . • ib. § 2. Of Luxations of the superior Extremity of the Radius

from the Ulna • 255

§ 3. Of Luxations of the inferior Extremity of the Ulna . 257

Vlll CONTENTS.

CHAP. XT* page

Of Luxations of the Hand 259

§ I . Of Luxations of the Wrist ib.

§ 2. Of Luxations of the Bones of the Carpus and Met a-

carpus 261

§ 3. Of Luxations of the Fingers 262

Of the Deviations of Bones, and the Means used for Preventing and Correcting the Deformity arising from them 314

A TREATISE :

Eft.

Introduction

BONES are subject to the same diseases as the soft parts. This assertion may at first appear to be made at random, but its truth will be proved by the explanation into which we are about to enter. Hardness, which is their distinctive quality, does not belong to them in every stage of their existence ; their soft and gelatinous state in the embryo is changed in a more advanced stage of life to that of cartilage, which finally hardens by the deposition of a neutralized combination of lime and phosphoric acid, in its parenchymatous structure. To this saline inorganized substance is to be ascribed whatever difference is found between the bones and soft parts. When deprived of this substance, whether artificially, by immersion in an acid, or by the operation of the disease called rachitis, they become soft and flexible, and are reducible, by long maceration, to a cellular structure, in which vessels of every species are seen to ramify.

The existence, however, of the phosphate, and of a small quantity of carbonate of lime in bones, has a great influence on their diseases; the circulation is in some degree obstructed by the presence of this inorganized matter, and all the vital properties are thereby rendered more obscure. Thus all the diseases of the bones, which depend on a greater or less excitement of these properties, are slow in their progress, and of the chronic kind, although similar affections of the soft parts would produce acute diseases. A solution of continuity, for instance, or a simple wound of the soft parts, heals and reunites in two or three days, if the parts be brought into immediate contact, but a wound or

IO INTRODUCTION.

fracture of a bone requires twenty days at least, not unfrequentlsf forty or fifty, and even several months in some cases; and in general it may be said, that the cure will be slow in proportion to the person's age; because, as years increase, the proportion of the saline part of the bones increases also.

How much greater is the duration of exostosis than of phlegmon or any other swelling of the soft parts? Is not necrosis, which is the true gangrene of the bony substance, equally slow? Is not the separation of the living from the mortified part slower than in the gangrene of soft parts? This long duration of these diseases, and the tardy succession of their symptoms, will be greater or less in proportion to the greater or less relative quantity of saline matter in the bones; whence it follows, that their progress will be quicker in the infant than in the adult, and, ceteris paribus, that they will be slower in old age than at any other period.

The best and most ancient division of the diseases of the bones is that which distributes them into two orders; the first of which comprehends whatever affects each bone singly, in its substance or continuity; the second comprehends their diseases in the joints, and in their points of contact one with another. But it is to be oberved, that the diseases of this second order may affect also the substance of the bones, as, frequently, in cases of white or lymphatic swellings of the joints, caries of the extremities of the bones accompanies the morbid affection of the surrounding soft parts.

The first order of the diseases of the bones comprehends their fractures, wounds, exostosis, necrosis, and caries, the ricketty softening of the bones, their friability, and that morbid state known by the name of spina ventosa, or osteosarcoma.

The second order embraces sprains, luxations, dropsy of the articulations, the diseases arising from preternatural substances generated in the articulations, white or lymphatic swellings, and anchylosis.

It shall be shewn in the sequel, that the assistance of art is indispensable, and efBcacious in the greater number of these diseases* Whatever relates to fractures shall first be considered: Of ail the diseases of the bones they are the most frequent; to none is a strict attention more necessary; in the treatment of none is the utility of the surgical art more evident.

II Chapter I

OF FRACTURES IN GENERAL.

FRACTURE is defined a solution of continuity of one or of several bones, resulting from a force of extension disproportionate to, and exceeding their natural extensibility. We shall not, in imitation of the greater part of authors, add, " produced by some external cause*," for though the most usual cause of fractures be some external force, yet muscular force is sometimes the sole cause. It is this alone that always occasions the fracture of the patella, olecranon, and calcaneum. This definition might be applied to a solution of continuity produced by a cutting instrument, and therefore very different from fracture properly so called; but a rigorous precision of language is not to be expected, particular*- ly in medical subjects.

SECTION I. Of the different Species of Frablure

Fractures differ from one another in five respects; 1st, as to the bone affected; 2d, as to the part of the bone; 3d, as to the direction of the fracture; 4th, as to the relative position of the fractured portions; 5thly, and finally, as to the attending circumstances by which the fracture may be either simple, or variously complicated. We proceed to consider them successively in these respects. The fractured bone may be broad, such as the scapula, or bones of the pelvis; or short, as the calcaneum and astragolos; or belong to the class of long bones, as is most frequently the ease. The situation and use of the broad bones do not expose them much to be fractured, with the exception, however, of those of the cranium; in which case, the fracture is less to be at-? tended to than the affection of the brain, which it almost necessarily occasions.

The fracture of short bones is still less frequent, on account of the equality of the three dimensions; and if not produced by an external force or weight, which crushes, or rather grinds the part, is almost always produced by muscular contraction, which is by much the most frequent cause of the fracture of the patella, of the olecranon, and calcaneum. The long bones, whether they serve as pillars, as levers, or as arch-ending points of support and resistance, are much exposed to fracture, and are more frequently fractured than any other class of bones; therefore, all that is to be said of fractures in general, is principally applicable to them.

These bones may be fractured in different points of their length, and that happens most frequently in the point of bisection; in which case, the fracture is produced, like that of a stick bent beyond its natural extensibility, by a force applied at each extremity. These bones may, however, be fractured more or less near their extremities; sometimes even it happens in their extreme points, as shall be explained in treating of the fractures of the neck of the femur and humerus. Sometimes, too, the same bone is fractured in different points, whether it be caused by a weight falling on a fragment of a single fracture, or whether a cause of that nature alone, and exclusively of any pre-existing fracture, break the bone into several distinct splinters. This last species of fracture, which the ancients termed " nut-like," in allusion to the breaking of a nut by a hammer, is distinguished by the descriptive name of comminutive fracture.

The differences relative to the part of the bone fractured, establish a distinction of great importance, and not purely scholastic, as is imagined by some; for these differences influence the treatment and prognosis, as shall be proved. Thus, in a fracture of the middle part of a bone, though, on account of the bone being less thick in that part, and the contiguous surfaces therefore less extensive, the fractured portions are more easily and more widely separable one from the other, yet this kind of fracture is the least dangerous; because, in such cases, the cause is seldom applied to the part fractured, and for that reason the surrounding soft parts are injured equally seldom. Another reason of this difference is, that a less force suffices to break the bone in the midt le than in any other part; besides, the means usually employed to keep the fractured portions in just contact are more effectual, because they are longer. Add to all this, that inflammation, stiffness, and anchylosis of the joint, are less likely to happen than when the bone is fractured near the articulation.

With respect to the direction of the fracture, there are several distinctions to be made. It is called transverse when its direction is perpendicular to the axis of the bone; oblique, when it deviates from the perpendicular. In this respect also, the comrninu-* live fracture is to be considered as of a particular species. This fracture of the bone into several pieces of different directions, is always attended with contusion of the surrounding soft parts. Another species of fracture of a longitudinal direction has been admitted by Duverney> of which he quotes two cases, and compares it to the cracks which sudden drying causes in a board that had been impregnated with humidity. J. L. Petit has, with reason, denied the possibility of this species of fracture ; arguing, that the cause which could fracture a bone longitudinally would fracture it more easily transversely, and must necessarily have done so. The cases of these pretended fractures related by Duverney are by no means satisfactory; for it is very difficult to ascertain the existence of such a fracture through the skin, periosteum, and intermediate parts. Heister admits its possibility however, and even asserts, that the panaris is for the most part owing to the longitudinal fracture of the finger-bones; but this erroneous opinion has been amply refuted by Louis at the conclusion of his discourse on Petifs Treatise on the Diseases of the Bones. We adopt the opinion of this latter author, and reject as impossible, the longitudinal fracture, unless that name be applied to longitudinal splinters of comminutive fracture, as is most likely to happen when the fracture is occasioned by a gun-shot.

The most important distinction of fractures is that resulting from the different situations of the fractured portions; the knowledge of their derangements is of the greatest importance, because the principal object in the treatment of fractures is to prevent or remedy these derangements. The separation of the fractured parts is not, however, essential to the disease, for it often happens that the leg is fractured without any change in the form of the limb; and this is particularly the case when the tibia alone is fractured at its superior extremity, because its diameter is considerable in that part, and the extensive surfaces in contact cannot separate without difficulty: the fibula also contributes to retain the fractured portions in their natural situation. But when both bones of the fore-arm or leg are fractured, it rarely happens that the derangement of the parts is not the distinctive sign and proof of the accident. This derangement attends, almost without exception, the fracture of the thigh and arm, these members being each formed of a single bone, and surrounded by very powerful muscles. The causes of this derangement, and its varieties, shall next be considered.

It may happen in the direction of the diameter of the bone, be parallel to, or form an angle with the axis, or merely affect the pircumference.

When a bone is fractured transversely, the contiguous surfaces may remain in partial contact, or be totally separated. In a fracture of the tibia, for instance, the inferior portion of the bone may be pushed inward, and totally separated from the superior; or the external part of the former may be placed in contact with the internal of the latter. This incomplete derangement in the direction of the diameter of the bone, does not produce any shortening of the limb; but when this derangement is complete, then follows that parallel to the axis of the bone. The derangement in the direction of the diameter happens when the fractured bone is of a considerable size, as the tibia, for instance, and the fracture transverse; and when the proper means of keeping the parts in their natural situation have been too long neglected. But if the fracture be oblique, the surfaces not extensive, and the accident neglected, the derangement in the direction of the axis takes place, and the limb is shortened. In this last-mentioned might be included the fracture of the patella, olecranon, and calcaneum; with this difference, however, that in the latter cases the fractured ends recede one from the other, and are always found separated by a greater or less distance, instead of passing one by the other, as in the former case.

The third species, viz. that in which two fragments form an angle one with the other, has not been mentioned by authors, and takes place principally in cases of comminutive fracture. It might happen, however, in a simple fracture of the leg, as may easily be conceived by supposing the foot placed on an inclined plane; in which case the angle formed would be salient anteriorly, if the heel were lower than the fore part of the foot, posteriorly if the contrary.

The fourth species, or that affecting the circumference, is produced by the rotation of the inferior fractured portion on the superior, in such a manner as that the part which was anterior becomes internal or external. We have an instance of this species of derangement in the fracture of the neck of the femur; when the foot being ill supported by the apparatus, and obeying its weight, aided by that of the leg and by the contraction of the muscles, turns outward, and carries the inferior fragment in the same direction; in which case, the anterior part of the body of the bone corresponds no longer to the anterior part of the neck.

The bones being but passive instruments of loco-motion, possess not, in their own organization, any cause of the change of situation which takes place, but yield to exterior causes, to the weight of the member, and to muscular contraction; whence it appears, that the causes of this change of situation may be very

Of FRACTURES IN GENERAL. t$

Various. The cause of the fracture may also be the cause of the derangement of the fractured portions; as when the thigh, for instance, is fractured by a fall from some height: if the weight of the body, pressing on the inferior extremity which bears on the ground, bends the femur forward, the force will not be entirely spent in producing the fracture, but will, in addition, produce a greater or less derangement of the fractured portions.

The celebrated Ambrose Pare has offered, in his own case, a fracture and separation of the bones produced by the same cause. This eminent surgeon received a kick from a horse on the leg 5 with such force, that the lower fractured portion abandoned entirely the upper, which, impelled by the weight of the body, pierced the flesh, integuments, stocking, and gaitre, and drove its pointed extremity even into the earth.

The weight of the limb suffices alone to produce the angular derangement, or that affecting the circumference, as has been already explained, when treating particularly on that subject. Another cause is, the impulse frequently communicated to the limb, by the assistants, during the dressing: but of all these causes, the most powerful is the contraction of the muscles.

Of the muscles which surround a fractured bone, some are attached to that bone in a great part of its length, and therefore in many cases to both portions of the fractured bone. Others extend from the bone which is superior to that fractured, to that which articulates with the lower portion, or to the lower fragment itself; there are still others which terminate in the upper fragment, the other extremity of which may be more or less distant. The muscles of the thigh offer examples of these three different dispositions. The triceps is attached to the whole length of the femur; the biceps, semi-tendinosus, and semi-membranosus, descend from the pelvis to the leg, to which the lower part of the femur is articulated, and all the movements of which it obeys-, the great adductor muscle has its insertion in the lower part of the femur itself: finally, the psoas, iliacus, pectineus, &c. &c. descend from the loins and the pelvis, and have their insertion near the superior extremity of the femur.

The muscles which are attached to both portions of the fractured bone, contribute very little to their change of situation; but may, however, draw them both to the side on which they are inserted, and thus change the direction of the limb. The triceps, and more particularly its middle part, acts thus on the fractured femur, and renders the thigh convex anteriorly. The brachialis anterior tends to produce the same effect, when the humerus is fractured below its middle part. But the change from l6 OF FRACTURES IN GENERAL.

the natural situation is principally owing to the muscles which are inserted into the lower portion of the fractured bone, or the limb with which it articulates. Let us suppose the fracture of the humerus between its superior extremity and the insertion of the great pectoral muscle; this muscle, aided by the latissimus dorsi and teres major, draws the inferior portion inward and upward, and causes it to ascend on the interior side of the superior, which rests motionless on account of its shortness, and because the muscles, which are inserted into it, are not acted on by any cause that excites them to action. In the fracture of the neck of the femur, the superior portion of the fractured bone has no muscle inserted into it, and remains motionless in the articulating cavity. Those muscles which, on the contrary, are attached to the lower portion, draw it upward and backward, and render its being displaced in that direction inevitable.

The lower portion being acted on by the limb to which it is articulated, follows all its motions, and is liable to be displaced by the action of the muscles which are inserted into it. Thus, in fractures of the body of the femur, the biceps, semitendinosus, and other muscles, draw the leg, and with it the inferior portion, upward, inward, and backward, and cause it to ascend on the internal, and a little on the posterior side of the superior portion, the inferior extremity of which projects, in that case, on the anterior and external side.

In the fractures of the leg, the gastrocnernii muscles, &c, draw the inferior portion upward and backward, with the foot; for in this, as in every similar case, the stronger muscles displace the lower portion of the fractured bone, and draw it in their direction: hence it is, that in this case the portion is drawn backward as well as upward, because the muscles are more numerous and larger on the back part of the leg than on any other. Therefore, when a fracture takes place in any part of a bone, it is easy to determine, from a knowledge of the muscles, what species of derangement will follow, if there be no counteracting cause. Finally, the muscles which have their insertion in a superior fragment, may produce its separation from the inferior. "When the femur is fractured immediately below the small trochanter, the iliac and psoas muscles draw forward the inferior extremity of the superior fragment, which raises the skin and projects more or less. It is to be observed, however, that the displacing of this fragment is very rare, whilst the inferior fragment is displaced in almost every case.

Hitherto we have considered the derangements of fractures as simple, but they may be complicated; as for example, when in a simple fracture of the femur, the lower fragment has ascended upward and inward, and the foot being ill supported inclines externally at the same time. The derangement in this case will be composed of the four species already described.

There are other differences still which depend on the fractures being simple or compound. A simple fracture is that in which the soft parts have received no other injury than that necessarily produced by the fracture; for it is easy to conceive, that a fracture cannot take place without lacerating more or less the periosteum, the small blood-vessels, and the muscular fibres contiguous to the fracture; some degree of contusion and of swelling follows necessarily, and the skin of the part becomes livid and yellow in two or three days. A fracture is compound when it is accompanied by circumstances which require particular modes of treatment; such are a much greater degree of contusion than ordinary; a solution of continuity of the surrounding soft parts, whether that be immediately produced by the fracturing cause, or by the fragments penetrating through the skin, after having lacerated the intermediate soft parts: this happens when the fracture is very oblique and the fragments pointed. This compound fracture may be rendered still more complex, by the rupture of a large blood-vessel, whether an artery or vein, and by the effusion of blood in the cellular texture, which would be its necessary consequence.

Fractures are but rarely accompanied with luxation; in which case the luxation must necessarily precede the fracture; for the fracture once effected, the fragments are not susceptible of luxation: any motion which may be communicated to them can only impel them into the surrounding soft parts producing more or less laceration.

Finally, fractures may be accompanied with other morbid affections, whether pre-existing to the fracture, succeding that accident, or operating as its predisposing cause. Thus persons affected with a fracture, are also often affected at the same time with a vitiated state of the solids and humours; such are, for instance, the scurvy, scrofula, the venereal disease, or cancer. Add to all this, that the irritation caused by a fracture may be the occasion of an acute fever, which generally changes to the reigning epidemic.

We shall not treat here of the distinction of fractures into complete and incomplete; because these denominations appear to us unfounded, and fit only to lead into error. By complete fractures, authors mean those in which both bones of a limb are at the same time fractured; as those of the leg or fore-arm: incomplete, those in which only one of these bones is fractured, the other not being 3

1 8 OF THE CAUSES OF FRACTURES.

injured; but it is evident that in this case the fracture is complete ; for to the term incomplete, we can only attach the idea of a bone partially fractured, an occurrence utterly impossible.

SECTION n.

Of the Causes of Fra&ures.

The causes of fractures are as various as the means by which? that effect may be produced ; and, like the causes of other dis^- eases, may be divided into predisposing, and remote. In the first class of causes are ranged the situation and functions of the bones, the age of the individuals, and their diseases, if affected by any. Superficial bones are more easily fractured than those which are covered by a considerable depth of soft parts. The functions of some bones render them more liable to be fractured than others; thus the radius, which supports the hand, and serves in some respect as a handle to it, is more liable to be fractured than the cubitus. The clavicula, which preserves the shoulder and sternum in their proper position, and supports on its arched extremity all the motions of the superior extremity, is on that account frequently fractured. The gradual accumulation of phosphate of lime in the cellular structure of the bones, renders them brittle in proportion as we advance in life. In old age the proportion of the inorganized to the organized part is so great, that the bones are then fractured by the slightest cause. In childhood, on the contrary, the fibrous and organized part prevails, and communicates its properties to the bone, which is then flexible and elastic. An advanced period of life is then, to be reckoned as one of the predisposing causes of fractures. Certain acrimonies affect the osseous system, by attacking its organized part, and reducing it to the same state as- in old age, and render it even still more brittle. Thus, women affected with old and ulcerated cancers, have been known to fracture their bones, in performing the natural and ordinary motions of the body, or merely in changing their position in bed; instances of which are recorded by Louis and Saviard. In cases of this nature, all the bones of the body being equally affected, several fractures happen at the same time, and reduce the sufferer to the lowest state of wretchedness. The principal indication in such cases is not that of the fracture, as it is only a symptom of a more dangerous disease, the cure of which ought principally to be attended to. A certain degree of cold has been nun*-

OF THE CAUSES OF FRACTURES. If

"ber.ed among the predisposing causes of fracture ; but if this accident be more frequent in winter than in summer, it is because persons are then more liable to accidents from falling.

Every efficient cause acts in overcoming the natural cohesion of the osseous particles, by separating these particles, and lengthening the bone beyond its natural extensibility; the force thus acting, may have been applied on the part fractured immediately, or on some distant part. When the cause of the fracture is applied to both ends of a bone, the bone is curved by the approximation of its extremities; thus it is, that, by falling on the shoulder, the clavicle, forcibly pressed against the sternum, is curved and fractured, as if by what the French term contrecoup. In falling on the knees, the femur, pressed between the weight of the body and the ground, bends about its middle part, and the fracture takes place there. In these and similar cases, the natural curvature of the bones contributes, with the force applied, to determine the fracture in a certain part; and in such cases the contusion is less considerable than if the fracture had been produced by a force immediately applied to the fractured part ; for the action of the fractured extremities on the surrounding soft parts is then the only cause of laceration or irritation. But a force which fractures a bone exactly on the part which it strikes, bends it to the opposite side, and wounds or lacerates the soft parts. Thus a blow of a stick on the middle part of the clavicle, where the fleshy parts give it but a trifling support, bends it downward and backward, and fractures it, but never without producing a greater or less contu^ sion, and sometimes a contused wound. If the fracturing force strike a bone equally supported in all its parts, the fracture will be of the comminutive species, that is, in several fragments: the Contusion is always great in such cases.