Part 15

CASE I. The case was a luxation forward, which was easily reduced. But the easier the reduction, the more difficult was it to retain the replaced parts. This was at length accomplished, by fixing the fore-arm in a state of supination, and applying one thick compress behind the ulna, while the radius was pushed backward by another compress, placed on its anterior part, both secured by a common roller. This apparatus was continued for the space of a month, after which the reduced bones remained in their natural situation. The patient began, at first, to perform gentle motions of the wrist, avoiding those of pronation, on which he afterwards ventured by degrees, and with great caution.

25. These gentle motions frequently repeated, when a displacement is no longer to be apprehended, remove that unavoidable rigidity which, for some time, occupies the parts around the joint. It is advisable, for some time, to apply on the hand and extremity of the fore-arm, compresses wet with some discutient liquor, to prevent the swelling resulting perhaps from the inactivity and sprain of the parts. This was the practice of Desault.

I will close this memoir by two cases, extracted from the Journal of Surgery, in order to confirm, by experience, what has been already settled in theory.

CASE I. Desault was called to visit a child five years old, supposed to be labouring under a fracture of the arm. He learnt from the parents of the child, that, as it was lying in a very low bed, a young man who was playing with it, had taken hold of its fore-arm, and drawn it towards him, twisting it forcibly at the same time in the direction of pronation; that the effort had been accompanied by a report, and the child had immediately experienced an acute pain throughout the whole limb, but more particularly along the posterior part of the fore-arm.

When Desault saw the patient, no swelling had as yet supervened; the arm was removed from the body, and carried a little forward, while the fore-arm, half-bent, was kept in a state between pronation and supination. There existed, at its lower and back part, a preternatural tumour, formed by the head of the ulna carried behind the sigmoid cavity of the radius. The hand was a little extended, and in a state of adduction. The patient carefully preserved that position, and, as soon as it was changed, or the part affected touched, manifested signs of the most acute pain.

From these appearances, Desault discovered immediately a luxation of the radius forward, which was reduced in the manner already mentioned (16 and 17). By this process, the bones, being a little separated from each other, were replaced with facility. The suffering of the patient was immediately at an end; the limb resumed its natural state, and performed its functions as freely as before; lest some congestion might be the consequence, the injured parts were covered by compresses wet with camphorated spirits; these were secured by a bandage moderately tight, and no accident whatever supervened.

CASE II. On the 29th of January, 1789, Madeleine Fuser, a washer-woman, thirty-four years of age, had the lower extremity of the radius luxated forward.

Just as she had finished wringing a sheet, another washer-woman, who was assisting her to wring it, giving it a forcible jerk, did violence to her left arm, which was at the time in a state of strong pronation.

The woman experienced immediately a severe pain, accompanied by a sensation as if something had been torn. The sheet dropt from her hand, and she fell on the ground. Believing that she had received only a sprain, she neglected to apply for aid, and did not enter the Hotel-Dieu till the sixth day after the accident.

There was then a little swelling at the lower part of the fore-arm and at the wrist: the latter was extended and in a state of adduction; the fingers were bent. This woman suffered but little, when her hand was supported and kept still; but the pains became severe, when she attempted to move it. It was plainly perceived that the radius was placed before the ulna, and that the bones overlapped each other.

Process of reduction the same as in the preceding case. It was accompanied by a kind of report, and its completion was clearly announced by the restoration of the natural shape of the limb, and by the freedom of its motions. Compresses wet with vegeto-mineral water were applied to the wrist.

This patient remained fifteen days in the hospital, at the end of which, she performed with ease the motions of the wrist and hand.

MEMOIR XI.

ON THE FRACTURES OF THE THIGH.

§ I.

1. The os femoris, being in man, a moveable support for the weight of the whole body, appears to be better secured than the other bones, from accidents that might affect its continuity. The numerous masses of muscle that immediately surround it; the thick and compact layers or fasciæ that form its more exterior covering; and an articulation loose, and ready to yield, in every direction, to the motions impressed on it, all seem, on the one hand, calculated for its preservation.

2. But, on the other hand, being visibly curved in its middle, bent at its upper end almost at a right angle, longer in proportion in man than in quadrupeds, placed, in most falls, between the ground which resists, and the weight of the body which presses on it; it would seem, from these latter circumstances, to be less calculated to resist external force. And, if to these considerations be added those of the causes which have an immediate action on it, it will be easy to perceive, that, in a comparative scale of the bones most exposed to fractures, it holds, next to the bones of the leg, one of the highest grades. The proportion which its fractures bear to those of the leg, is, according to the observations of Desault, as one to three; but to that of most other bones it is equal if not superior.

3. The os femoris, being in its body irregularly cylindrical and curved behind, becomes larger towards its lower end, where it terminates in two articulating masses, which rest immediately on two corresponding surfaces of the os tibiæ; changing its direction above, it inclines towards the acetabulum, and inserts into that cavity a round head, supported by a neck which is entirely enclosed in the capsule of the joint.

4. From this different conformation of its different parts, arises such a variety in the fractures which occur in it, that they cannot be treated of under the same head. Hence the division into fractures of the body and of the extremities, which is borrowed from anatomists, and will be followed in the present memoir, where we will consider in order,

1st, The fractures of its body, 2dly, Those of its upper extremity, 3dly, Those of its lower extremity.

FRACTURES OF THE BODY OF THE OS FEMORIS.

§ II.

OF THE VARIETIES AND CAUSES.

5. The os femoris may be fractured indifferently at any point between its condyls and its neck. But the part where this accident most frequently occurs, is about the centre of the curve of the bone, where most of the motions and shocks impressed on it by external violence expend their force.

6. Whatever may be the seat of the fracture, its direction is sometimes transverse, but most frequently oblique, a variety which does not affect the real nature of the disease, but which possesses, as to its consequences, a very important influence. As in other affections of the kind, so here, the bone is sometimes affected alone, and, at other times, to a fracture simple or complicated by means of splinters, is added an injury done to the surrounding soft parts. Hence result compound fractures, differently varied, according to the nature of the parts affected, and to the extent and other circumstances of these affections. But, as Petit observes, this bone is less frequently shattered or crushed into several pieces, than those that are more superficially situated.

7. Extraneous causes are known to render falls more frequent in man than in other animals, and to multiply in him the fractures of the lower extremities, by multiplying the action of external bodies on these extremities. This action may be exerted on the os femoris in two modes. Sometimes only passive, it merely offers a resistance to the power which puts the bone in motion; thus, in a fall, the os femoris, being pressed between the ground which resists, and the weight of the body that bears on it, bends beyond the extent of its flexibility or pliancy, and finally gives way. At other times the influence of external bodies is actively and directly exerted in this accident: thus a stone, or a piece of timber, falling on the thigh, fractures the bone, in consequence of communicating to it a degree of motion greater than its power of resistance.

8. In common, the first mode of division is by a true counter-stroke, similar to that which fractures the clavicle, the ribs, &c. In the second mode, the fracture is always direct. The middle part of the bone is generally broken in a counter-stroke: wherever the direct stroke is received, that is the place of the fracture which it produces; the division, most frequently oblique in the first case, is sometimes perpendicular or transverse in the second. From a counter-stroke result most commonly simple fractures, while compound ones are usually owing to a direct stroke.

§ III.

OF THE SIGNS AND THE DISPLACEMENT.

9. In whatever manner a fracture of the os femoris may have occurred (7), its existence is characterized by the following signs: severe local pain at the instant of the accident; a sudden inability to move the limb; a preternatural mobility occurring in some particular part; a crepitation sometimes distinct, when the two fragments are rubbed against each other; and a deformity, which may be considered under the threefold relation, of length, thickness, and direction.[22] These signs, being common to most fractures, exhibit but few circumstances peculiar to those of the os femoris, except that of the deformity. Respecting this circumstance, in particular, it is essentially necessary to possess accurate ideas, because, having an incessant tendency to recur, especially in oblique fractures, it must constitute a primary object of attention during the treatment.

[22] (_La longueur, l’epaisseur, et la direction._) That is, the thigh may be shorter than natural, owing to the ends of the broken bone overlapping each other; it may have a protuberance on one side, in consequence of these ends being separated or displaced laterally; or the direction of the limb may be changed, by a bend or angle being produced in the bone at the place of the fracture. TRANS.

10. It may be laid down as a general principle, that all fractures of the os femoris are accompanied with some deformity; the exceptions to this rule are too few to be worthy of notice. If this deformity be considered in relation to length, it will be found that, in oblique fractures, the limb is always shorter than that of the opposite side, a circumstance which plainly points out an overlapping of the fragments. But, on examining the place of fracture, it is easy to discover, that this overlapping arises from the inferior fragment mounting upwards on the superior one, which itself remains immoveable. Now, what power, but the contraction of the surrounding muscles, can communicate to the inferior fragment a motion from below upwards? Attached, on the one hand, to the pelvis, and on the other to this fragment, to the rotula, the tibiæ, and the fibula, these muscles have on the former their fixed, and on the latter their moveable points, and, drawing the leg, the knee, and the inferior portion of the thigh upward, they produce the displacement and shortening either mediately or immediately. In this displacement, the adductores, the semi-tendinosus, the semi-membranosus, the rectus anterior, the rectus internus, &c. are the principal agents.

11. The following case communicated to Desault by a surgeon, who had been formerly his pupil, proves how great the influence of this cause is; a cause which is indeed generally acknowledged, but not sufficiently attended to by practitioners, with a reference to permanent extension. It is this that induces me to relate the case.

CASE I. A carpenter falling under the ruins of his scaffold, was immediately taken up and carried home, where a surgeon discovered an oblique fracture of the os femoris, but without any displacement. The thigh, which appeared even a little longer than the other, was fixed in an apparatus too slack to prevent muscular action. Next day, the length of the thigh was the same, but the whole extremity was in a paralytic state, accompanied by an entire inability to discharge urine.

The moxa was proposed. The patient being placed in the position directed by Pott, for fractures of the os femoris, the fire was applied; some movements were the consequence; the application being repeated on the sixth day, the muscles instantly recovered their power of action, and then the shortening of the limb became evident, and still returning immediately after being removed by extension, rendered it necessary to have recourse to an apparatus calculated for permanent extension.

12. In this case, the muscular influence is evident. Indeed the shock having produced a temporary suspension of the excitability of the part, the fragments remained in place and in proper contact with each other: but the moxa having awakened the excitability again in the muscles of the thigh, they resumed their action and caused, as usual, the inferior fragment to mount on the superior.

13. Hence it follows, 1st, that it is principally to the action of the muscles that we must attribute the displacement, in the longitudinal direction of the bone; 2dly, that, as that action, being the effect of an inherent power, is constantly exerted, the limb must have a constant tendency to this displacement, particularly in oblique fractures, where the two extremities of the bone represent two inclined plains, which readily glide along each other.

14. To this must be still added another cause, which operates injuriously in the course of the treatment. However solid the bed may be on which the patient lies, the nates or buttocks, being the most projecting part of the body, soon form a depression in it; hence arises an inclination or descent of the plain or surface on which the body lies. The body therefore sliding downwards, pushes before it the superior fragment, and makes it overlap the inferior one. In consequence of this, the muscles, being irritated by the points of the bones, increase the force of their contractions, and, as we have already observed (10), draw the inferior fragment upwards. This double movement of the two ends of the bone in contrary directions, produces only a single effect, namely, the overlapping of these ends, but carries this overlapping to a higher degree.

15. Transverse fractures are less exposed to displacement, in the longitudinal direction of the bone, because the fragments when in contact, support each other. In such a case, the inferior fragment, drawn by the muscles, finds a point of resistance against the superior one, while the latter, when pressed downward by the weight of the body, pushes the former before it, and thus both preserve their relative position.

16. A deformity of the fractured os femoris, in the direction of its cross-diameter or thickness (9), always accompanies that in its longitudinal direction, and sometimes exists alone. This takes place when, in a transverse fracture the two ends of the bone, losing their contact, are carried, the one outward, and the other inward, or when the one remains in its place, while the other is separated from it. In such a case, the superior fragment is not, as in the preceding one, immoveable by means of muscular action; because the action of the pectineus, the psoas, the illiacus, and the first adductores, derange its natural direction, and contribute to its displacement.

17. The deformity of the limb, in relation to its direction, in other words, the crookedness of the limb (9) is either the result of the stroke which fractured it, or, what is more common, of the ill directed efforts of those who lift and carry the patient, and, by an improper position, bend the two fragments, so as to make them form an angle with each other. Desault was once called to a patient, whom he found seated on a bed, in such a manner, that the upper part of the thigh was in a horizontal position, and the lower, hanging with the leg in almost a perpendicular one. Doubtless the triceps femoralis, equally attached to both fragments, bends them by its contraction, and produces a change in the direction of the limb.

18. Whatever may be the kind of the deformity, whether in a longitudinal or lateral direction, the inferior fragment may either preserve the natural position in which it is placed, or experience a rotatory motion on its axis outwards, which is a common occurrence, or inwards, a circumstance which is more rare. This rotation always renders the displacement more serious, and ought to have an influence, as I shall presently observe, on the means of reduction.

§ IV.

OF THE PROGNOSIS.

19. Fractures of the os femoris, though seldom very distressing, in common cases, from any accidents that immediately accompany them, are sometimes rendered so, by inconveniences which are the consequences of them, when they are oblique. Celsus declared, that a shortening of the limb, more or less considerable, was always the result of such fractures. Most authors have copied and repeated this assertion, and, even at the present day, the opinion is advocated by a great number of practitioners. It must be acknowledged, that, if we compare the natural powers that are engaged in producing displacement (10 ... 15), with the artificial resistance made by most of our forms of apparatus, we will perceive that there is between the two forces so great a disproportion in point of strength, that the former can never yield to the latter. But, is it in the nature of all forms of apparatus to be unable to overcome the force of the displacing powers? Cannot an equilibrium be established, so as to retain the fragments in contact? The remainder of the present memoir will throw some light on this problem, which will become less difficult of solution, if we call to mind, that the action of muscles, though very powerful at first, diminishes afterwards by degrees, in consequence of their being kept in a state of permanent extension; that even a weaker power may, by acting constantly, accomplish ultimately, what could not have been effected at once, by another power much stronger, if only momentarily applied; and that compression made by circular bandages, tends also to diminish the force and prevent the action of muscles.

Desault has cured, at the Hotel-Dieu, a vast number of fractures of the os femoris, without the least remaining deformity, and there are but few of his pupils who have not witnessed his success, some instances of which will be cited in this memoir.

20. It is, above all, from the well combined use of these two means, the extension and compression of the muscles, that that success was derived. The advantage of extension, in diminishing muscular force, is evident, particularly in the reduction of certain luxations, those of the humerus, for example, where we are frequently unable to succeed, till after having extended the muscles for a longer or shorter time.

Fractures of the rotula and of the olecranon, prove equally the utility of compression in effecting the same purpose; for, when the muscles are not compressed by a bandage, they draw the fragment upwards with a double and even treble force.

21. Accidents relating to complications of the fracture, such as splinters, wounds, &c. are to be classed with compound fractures in general, and cannot be treated of in this place.

§ V.

OF THE REDUCTION.

22. Two great indications enter into the treatment of fractures in general, and of that of the os femoris in particular; namely, to bring the fragments into proper contact, and to maintain them so. Let us examine each of these in all their details.

Hippocrates, and every practitioner since his time, have replaced the fragments by what they call extension, counter-extension, and coaptation.[23] This threefold method, though sanctioned by long usage, and rendered almost venerable by age, is by no means necessary at all times in practice, as will presently be observed. Previously to having recourse to it, it is necessary to place the patient in a suitable position. But this position varies: most of the moderns adopt, after the example of the ancients, a horizontal position: so that the thigh may be extended on the body, and the leg on the thigh. This is the common practice at present in France.

[23] A term of nearly the same import with “conformation.” TRANS.

23. Pott imagined, on the contrary, that if the lower extremity were kept in a half-bent position, the muscles, being more relaxed, would offer less resistance to the efforts of the extension: he, therefore, proposed to bend the leg on the thigh, and the thigh on the pelvis, and to lay the patient on his side, a position, which, when first employed in reduction, was to be continued throughout the treatment, during which it would render the causes of displacement less active (10 ... 15). Bell adopted this method, which indeed appears to be generally in use in England.

24. But the difficulty of making extension and counter-extension, with the limb thus situated, the necessity of making them on the fractured bone itself, and not on a part distant from the fracture, such as the lower part of the leg; the impossibility of comparing the diseased thigh with the sound one, to judge of the regularity of the conformation; the uneasiness occasioned by this position, if long continued, though it may at first appear the most natural; the troublesome and painful pressure of the body on the great trochanter of the affected side; the derangements to which the fragments are exposed when the patient goes to stool; the difficulty of fixing the leg with sufficient steadiness, to prevent it from affecting the os femoris by its motions; the evident impracticability of this method, when both thighs are broken; and, finally, experience, which, in France, has been by no means favourable to the position recommended by Pott: such were the considerations, which determined Desault to have recourse to it no more, after having tried it on two patients, in one of whom the limb was considerably shortened, notwithstanding the most scrupulous attentions.

25. Besides, all that is gained by the relaxation of some muscles, is lost, by the tension of several others. The knee cannot be bent without the triceps flexor being brought into action; an inconvenience the more serious, as this muscle acts immediately on both fragments. The rectus anterior, though relaxed by the flexion of the thigh, will be thrown into a state of tension by the flexion of the leg. The muscles attached posteriorly to the upper fragment, and even to the superior part of the lower one, will also in certain positions of the limb be rendered tense.

26. Hence it follows, that there can be no just comparison instituted as to the position proper for the limb, between fractures of the upper and those of the lower extremities; that, in the latter, the method pursued by the English surgeons presents an aggregate or general amount of inconveniences so great as to overbalance that of its advantages; and, that the position directed by Hippocrates and the other Greek physicians (22) ought to be adopted.