Part 19

107. The second class of curative means, includes different forms of apparatus simply retentive. Pare, Petit, and Heister, recommend, as most useful, the _Spica_ of the groin.[26] But what effect can this produce? What force applied in that part can keep the lower fragment down, and the pelvis up, secure the immobility of the limb, and prevent its rotation outwards? If the bandage be tight, it will compress the muscles unequally, make them contract, and thus become the cause of a contraction or shortening of the limb. In some respects, there is more advantage to be derived from the tin case lined with cloth on its inside, which Fabricius of Hilden applied to the external part of the thigh; a method which has been renewed since his time, by certain celebrated practitioners of Germany; from the pasteboard case proposed by Duverney as a substitute for that of tin; from the retentive plaster[27] of Buffle employed likewise by Arnaud; and from the splints adopted by most practitioners. But can these means, (so differently varied in form, yet still the same in their action), while they prevent displacement laterally or in the cross-direction of the bone, prevent it also in the longitudinal direction, which latter ought to be the principal object in view? Will they make any resistance to the muscular action? See what has been already said on splints, bandages, &c. (89 ... 95).

[26] _Le Spica de l’aine._ TRANS.

[27] (_L’ecusson._) The literal meaning of this word is an escutcheon, or a coat of arms. But when used in surgical language, it signifies a retentive or strengthening plaster. Such I conceive its meaning to be in the present instance. TRANS.

108. The insufficiency of these forms of apparatus, arises from their not being constructed with a proper view or reference to the general principle that ought to be observed in the treatment of every fracture; namely, that the means intended to prevent displacement, ought to be founded on the causes that produce it. But, these causes here, are, 1st, The action of the muscles which draw the lower fragment upwards: 2dly, The weight of the body which pushes the pelvis downwards: 3dly, The weight and direction of the foot and leg, which tend to carry the toes outwards by a rotatory motion. Hence, the threefold indication or end of every apparatus, is, 1st, To keep the body of the bone down: 2dly, To retain the pelvis up: and 3dly, To secure the foot nearly in a right line with the leg.

109. The first consideration leads us naturally to the second. The means destined to fulfil this three-fold indication, must be constant in their action, since the causes which they have to combat act without remission. Hence the necessity of an apparatus for permanent extension. See what has been said on the nature of this expedient (46 ... 51), on the different modes of effecting it (52 ... 57), and particularly on the mode pursued by Desault (58 ... 70).

110. The mechanism of his apparatus for permanent extension is the same here as in fractures of the body of the bone. The limb is secured against a strong splint, to the two ends of which two rollers, running one from the pelvis, and the other from the foot, are firmly tied. The first of these rollers holds the pelvis up, and the second draws the foot down: hence the two first indications are fulfilled. The third is also fulfilled by the extension of the limb, which prevents its rotation outwards, by means of the outside splint, which passing beyond the sole of the foot keeps it immoveable.

111. The bandage of strips and compresses, which in fractures of the body of the bone, are previously applied round the limb, and oppose in some measure its motions laterally, are here entirely useless. Being all indeed applied on the lower fragment, what purpose could they answer towards fixing it against the upper one? They could do nothing but compress the muscles, and by that means diminish their power of contraction: but extension alone produces this effect. Desault rejected the bandage altogether, and contented himself with the use of splints and bolsters, as appears from the following case reported by Couteau.

CASE VI. Maria Nof, as she was running on the ice, in the severe winter of 1788, slipped, and falling on the great trochanter, fractured the neck of the os femoris. She was immediately carried to the Hotel-Dieu, where the signs formerly mentioned (60 ... 66) disclosed at once the nature of her disease. The shortening of the limb was less than in ordinary cases.

The apparatus was applied in the following manner. The junk-cloth, the body-bandage, and the bits of tape, were laid on the bed, in the order already mentioned (60): the patient was then placed in such a manner that the affected thigh corresponded exactly to the middle of them. The reduction being effected, the two splints were applied, one on the external and the other on the internal side of the limb; on each side, and along the anterior part of the thigh, the bolsters were laid: three bits of tape for the leg, four for the thigh, and the body-bandage for the pelvis, served to secure the splints. One end of a roller, which had been previously fixed on the upper side of the foot, passing through the mortise on the external splint, and being tied to the other end which passed through the hollow or notch, produced extension, while counter-extension was made by means of another roller directed obliquely from the tuberosity of the ischium over the superior part of the same splint, which it drew downwards. This was the same apparatus formerly described (60 ... 66), except as to the bandage of strips, the compresses, and the anterior splint, which running only from the fold of the groin, had no effect in retaining the fragments.

The treatment was simple. No general disease of the system existing, the patient returned, in a few days, to her usual regimen. Being visited every day, the apparatus was frequently tightened; and was renewed six times at different intervals.

A bilious disposition shewed itself on the seventeenth day. This was removed by an emetic given in solution, and after this nothing remarkable occurred. On the fifty-second day the state of the parts was examined. The consolidation was almost accomplished; by the sixtieth day it was complete, and the patient was discharged a few days afterwards, experiencing only a slight degree of lameness.

§ XVII.

OF THE SUBSEQUENT TREATMENT.

112. It is more essential here than in fractures of the body of the os femoris, to keep up extension with the utmost exactness, because, in the present case, a much greater number of muscles being attached to the lower fragment, very greatly augment the powers tending to displace it. Hence the necessity of examining the apparatus every day, to see whether or not any shortening of the limb has occurred, to tighten, if they be relaxed, the rollers that make extension, and to renew the application of the whole, if it be in any measure deranged.

113. The proper treatment here, as well as in most other fractures, consists more in these attentions, taken collectively, than in the use of internal means. It is to the want or neglect of such attentions, that we ought to attribute the little success obtained by many surgeons from the bandage of Desault.

CASE VII. A man, having fractured his thigh by a fall, called in a surgeon, who, reducing the fracture, and retaining it by this bandage, examined the state of the parts every day, and finding no derangement of the splints, neglected attending to the rollers destined for making extension. Seventh day, a shortening of two inches; a new reduction, and a new application of the bandage; the same want of attention as before; the same shortening at the expiration of a few days; the means were then rejected, and declared, in a publication, to be insufficient. How often do processes and modes of practice of great utility, by being transmitted from person to person, or from book to book, lose at length, that credit they are entitled to, and that approbation which they ought to command!

114. Serious accidents so seldom accompany fractures of the neck of the os femoris, that there is no necessity of employing numerous means to remove them. A diet somewhat strict for a few days, diluting drinks, and then a return to the patient’s usual mode of living, unless something besides the fracture should forbid it, constituted the simple treatment pursued by Desault in common cases. Any varieties resulting from accidental circumstances, must fall under the general treatment of fractures.

115. The period necessary for the healing of fractures of the neck of the os femoris, is represented by most authors as being longer than the term required in other similar affections. We read, in the Memoirs of the Academy of Surgery, that oftentimes the cure is not complete in less than three or four months. The reason of this will be evident, if we consider, on the one hand, that the reunion is always more tedious, in proportion as the contact of the fragments is more frequently interrupted: and, on the other, that, in the means formerly employed, there was nothing opposed to the powers of displacement. Hence it follows, that, if skilfully treated, this fracture ought to follow nearly the same course with others. It is this that confirmed the superior excellence of the practice of Desault, who almost always obtained a cure, all other things being equal, such as age, strength of constitution, &c. in the space of forty-five or fifty-five days.

116. We discover, in general, that the cure is complete, from a disappearance of the signs of the fracture, more particularly from the motions of the great trochanter, in which circumduction[28] succeeds to rotation on its own axis, when the limb is made to move on itself, that is, to rotate outwards or inwards. The power of standing and walking is an infallible evidence of this reunion; nor are these exertions practicable, till the expiration of some time after it is completed; this circumstance is owing to a stiffness remaining in the parts around the joint, occasioned by long extension and a want of motion, and which exercise alone can effectually remove. (See what has been already said on this subject, in several parts of this work.)

[28] A motion or sweep describing the arch of a circle. TRANS.

117. Numerous cases may be adduced in favour of the doctrine laid down in this memoir. But a sufficient number have been already published in the Journal of Surgery. I shall subjoin only two, drawn up by Manoury and Seveille.

CASE VIII. Maria ***, aged forty, falling on the great trochanter, experienced a sudden pain, and heard a considerable report: she rose, however, and with difficulty made her way home. On the day following, a shortening of an inch was perceived in her thigh: the great trochanter was drawn backward and upward: walking was now impracticable, the foot remained turned inwards. Notwithstanding this latter circumstance, Desault, being called to the patient, declared that a fracture existed, which was evidenced in particular by a rotatory motion of the great trochanter on its own axis. The necessary apparatus being applied, was carefully examined every day by Manoury, to whom the patient was intrusted. No shortening of the limb occurred, nor did any unfavourable accident supervene, and, by the thirty-ninth day, the fracture was exactly and firmly united; on the forty-third, the splints were removed; and on the fiftieth, the patient could walk without assistance.

CASE IX. John Rignal fractured the neck of the os femoris by falling, not as in the preceding case, on the great trochanter, but on the knee, which was bent at the time of the fall, while the shoulder of the same side supported a heavy load. He was brought to the Hotel-Dieu, where the same signs, as in the preceding case, (except that here the foot was turned inwards) furnishing ground for the same diagnosis, gave rise to the same treatment, which, in fifty days, was followed by a result equally favourable.

FRACTURES OF THE LOWER EXTREMITY OF THE OS FEMORIS.

118. The lower extremity of the os femoris, being thicker than the rest of the bone, and protected from the action of external bodies by a thinner covering of soft parts, is yet better secured from fractures than the other parts, for the following reasons: 1st, because counter-strokes, so frequently the cause of fractures of the body and neck of the bone, can affect this part but rarely: 2dly, because the os femoris, being more moveable at a distance from the centre of its motions, yields more easily to whatever strokes and impressions it there receives: 3dly, because motion, when distributed through a greater bulk of matter, has less power to destroy its continuity.

§ XVIII.

OF THE VARIETIES AND THE CAUSES.

119. The fractures which occur in the lower extremity of the os femoris, are of two kinds very different from each other. Sometimes situated above the condyls, they only separate these from the body of the bone: at other times, affecting the condyls themselves, they extend into the very joint. My attention shall at present be confined exclusively to the latter kind, as the other may, in almost every respect, be classed with the fractures which have been already considered. Most authors have neglected to treat of fractures of this kind, under a distinct head, from a persuasion, that, owing to their communication with the joint, they ought to be ranked among complicated fractures, which are known to require a mode of treatment very different from that employed in such as are simple. But I shall presently show what regard ought to be paid to this ancient opinion.

120. The division presents itself, in general, under two different forms: 1st, running obliquely from above downwards, and from within outwards or from without inwards, it may separate a greater or smaller portion of one of the condyls from the rest of the bone: 2dly, these two bony protuberances may be divided from each other by a longitudinal fracture, meeting another transverse or oblique fracture, which by either passing through the whole thickness of the bone, separates both condyls from it, or extending only half way through it, separates but one of them. The fracture is single in the first case, but double in the second. The latter occurs in practice more frequently than the former. Both are usually produced directly, that is, by the immediate action of external bodies. Yet the following fact seems to evince that the accident may, possibly at least, arise from a counter stroke.

CASE X. The corpse of a man of forty, was brought into the amphitheatre of Desault, soon after he became a public teacher. One of the pupils, on preparing to dissect the body, discovered a preternatural mobility in one of the condyls. The knee was examined. A double fracture was found, accompanied by a separation of the two condyls. On inquiry it was ascertained that the corpse came from the Hotel-Dieu. It was further discovered, with certainty, that the injured subject, in jumping through a window, had alighted on his feet, and that he experienced instantly a severe pain in his knee, and fell on the ground, unable to support himself.

Here, no doubt but the condyls, by being violently pressed between the weight of the body and the articulating surfaces of the tibia, had been fractured by a counter-stroke.

§ XIX.

OF THE SIGNS.

121. But whatever may be the precise form and figure of the fracture, its signs are easily comprehended: a very perceptible separation oftentimes exists between the two condyls, increasing the transverse diameter of the knee. The rotula, sinking into this chasm between the condyls, renders the part more flat from before backwards, than it is in its natural state. If the rotula be pressed in a backward direction, the condyls are separated still further from each other. If, on the other hand, pressure be made on each side of the lower part of the os femoris, the condyls are brought together, and the knee resumes its usual shape. If we take hold of a condyl in each hand, it will be easy, by moving them alternately backward and forward, to make them rub against each other, and produce a crepitation which characterizes the fracture beyond a doubt.

122. If the upper fracture be oblique, a shortening of the limb more or less perceptible is always the effect of it: this appears to be principally owing to the weight of the body which pushes the upper fragment down, and to the action of the muscles which draws the lower ones up (10 ... 14). In this case, the superior fragment, being forcibly pushed against the integuments, has sometimes lacerated, and even passed through them, giving rise to consequences of a serious nature. Desault has published a case of this kind. A similar effect has been produced, though more rarely, by the inferior fragment, in which case much mischief has arisen from the admission of air into the joint.

123. Sometimes when the upper fracture extends through the whole thickness of the os femoris, the extremity of the bone is turned round, so that the external condyl lies behind, the internal before, and the rotula on the outside, while the foot points in the same direction. A case of this kind is recorded in the Journal of Surgery. The body of the bone, being pressed into the chasm or interval between the two condyls, may prevent their reunion, by pushing them asunder, and thus give rise to various accidents.

124. Most of these phenomena will fail to occur, if the upper division, passing only half way through the bone, break off but one of the condyls, or if, passing through even the whole of the bone, it be perfectly transverse; but cases of this description are seldom met with.

§ XX.

OF THE PROGNOSIS.

125. I have little to add to the observations already made on the prognosis in fractures of the condyls of the os humeri. All that I have there said is applicable to the os femoris. As is the case with regard to the former fractures, so also here, the apprehensions of authors have been greatly exaggerated by their visionary doctrine respecting injuries of the joints: both reason and experience unite in showing such apprehensions to be unfounded.

I shall only observe, that in the present case, even more particularly than in fractures of the condyls of the os humeri, most of the unfortunate events that take place, are owing to the insufficiency of the means employed for effecting a cure. Indeed, as I have already observed (45), all those means can have no effect in opposing the continual tendency of the fragments to become displaced, if the upper fracture[29] of the os femoris be oblique. And in most cases, this fracture is oblique: hence it follows, 1st, that the bony points of the fragments being constantly pushed, during their displacement, against the ligaments that surround the joint, will perpetuate in them the irritation first produced by the fracture, and thus give rise to swelling, inflammation, and all the other morbid affections of the part, so much dreaded by authors, and attributed by them to the mere communication of the fracture with the joint: 2dly, that the best expedient to prevent such affections, is an apparatus that shall retain the divided surfaces in perfect contact with each other by means of permanent extension.

[29] That which forms the superior boundary of the longitudinal fracture by which the condyls are separated from each other. TRANS.

126. It is obvious that this extension will be less necessary, if the upper division of the os femoris be transverse, because, then, the condyls and the body of the bone will find a mutual point of support against each other.

§ XXI.

OF THE MEANS OF CONTACT BETWEEN THE FRAGMENTS.

127. Since the same causes, as in the preceding cases, tend here to destroy this contact, when the superior fracture is oblique (122), the apparatus ought, therefore, to be so constructed as to counteract these causes, that is, it ought, 1st, to draw the two condyls down; 2dly, to retain the pelvis up, and with it the superior fragment. This twofold indication relates only to the upper division of the bone, without any reference to that which separates the condyls; 3dly, it is necessary to counteract the tendency which the condyls may have to separate from each other.

128. Permanent extension, made in the manner already mentioned (60 ... 63), fulfils the two first indications; while two lateral splints, and the bandage of strips fulfils the third. Desault, therefore, applied to this particular case his apparatus for permanent extension, modified only in such a way, that, instead of terminating at the knee, the bandage of strips was continued to a distance down the leg, in order that its action might be the more efficacious. For, it is well known, that it is at its middle part that the firmness and retentive power of a bandage are greatest, because the casts of the roller at the upper and lower ends, serve to secure those in the middle. The upper splint being altogether useless, was not employed.

129. If the superior fracture be transverse, the condyls, as I have already said, meet with resistance against the body of the bone, while they, on the other hand, support it in such a manner, as to prevent it from descending, though pushed by the weight of the body along the inclined plain made by the pressure of the nates. Here, then, permanent extension is generally useless, and all that is necessary is, to retain the condyls and prevent their separation by means of lateral pressure. The same apparatus may still be employed, provided the two rollers for extension be laid aside.

130. If a wound in the soft parts accompany the fracture, whether it be produced by the same cause, or by the subsequent passage of the fragments through the integuments, and whether it communicate with the articulation or not, it is necessary, as soon as suppuration has taken place, to renew the dressings every day or every other day, taking care, in the mean time, to supply, by the hands of an assistant, the want of extension by means of the apparatus. The following case, extracted from the Journal, exhibits a specimen of the treatment that ought to be adopted in similar cases.

CASE XI. Claudius Legrange, aged thirty-one, and of a sound constitution, was wounded by the kick of a horse, on the internal condyl of the left os femoris. The violence of the pain obliged him to throw himself on a heap of straw, that lay at a little distance, and which he reached by hopping on his right foot. The pains were augmented by this, for at each step, the thigh being alternately bent or extended at the injured part, was moved sometimes backward and sometimes forward. The patient was brought to the Hotel-Dieu, a few hours after the accident.

The signs already specified (121 and 122) announced to Desault, a longitudinal fracture separating the two condyls, and terminated above by another fracture of the body of the bone, which descended obliquely from about five inches above the external condyl, to within two inches of the internal one.

The muscles of the thigh, by means of violent contraction, had drawn that portion of the os femoris attached to the external condyl upwards, and the superior fragment downwards. The sharp point of the latter had passed through the skin, and produced a wound of an inch and a half in extent, on the inside of the thigh, and a little above the condyl.