Part 20

The patient being undressed, was placed on a bed nearly horizontal, on which had been previously spread the necessary pieces of apparatus, disposed in proper order. Desault then examined the wound, extracted a splinter of the bone, covered the wound with lint, and then proceeded to the application of the apparatus which he usually employed in such cases (128).

The extension was accompanied by no pain: on the other hand, it gave immediate relief: diluting drinks were prescribed. Next day, no pain; pulse a little raised; no dryness, nor any alteration of the skin; diet the same as on the preceding day; the apparatus wet with vegeto-mineral water. Fourth day, a new application of the apparatus, which had become relaxed; appearances of suppuration.

From this time the dressing was renewed every other day, till the sixteenth, when the wound was cicatrized. After this the apparatus was not touched except when deranged; it was only wet from time to time with vegeto-mineral water, and great pains were taken to keep up the extension. The apparatus was not laid aside till the sixty-fourth day, although the callus appeared to have acquired a state of solidity somewhat sooner.

The patient was soon in a situation to take exercise. The stiffness then disappeared rapidly, and, in about three weeks, he left the hospital, able to bend the leg to a right angle with the thigh, and under a full confidence that he would in a short time regain all the motions of the limb.

§ XXII.

OF THE SUBSEQUENT TREATMENT.

131. As soon as the consolidation is complete, the motions of the limb must commence. These, at first gentle and confined, must be afterwards, increased in extent, and more frequently repeated, till, at length, the limb should be exercised every day for two or three hours without intermission. The position and direction of the leg ought to be constantly changed. One while, the thigh should be elevated by a bolster, so as to flex the leg; at another time, the bolster should be fixed under the leg to keep it extended. The rotula must be moved in every direction, and, as soon as the patient can leave his bed, he should take exercise himself. These precautions are more necessary here than in any other fracture, because a stiffness of the parts adjacent to the joint, is always the inevitable consequence of a long state of rest. Certainly writers would not have considered anchylosis as the most favourable termination of such fractures, had they been acquainted with the effect of exercise and rest in that now under consideration.

132. Provided the mode of treatment here laid down be faithfully pursued, the affection is seldom accompanied by those numerous accidents, of which so much has been said. The callus is formed in the usual manner: and, on some occasions, where the patients have died at the Hotel-Dieu, in consequence of some affection not connected with the fracture, the two condyls have been found perfectly united together and to the body of the bone. An instance of this kind is recorded in the Journal of Surgery.

133. Let us, in the mean time, not speak too favourably of that, respecting which the ancients were accustomed to speak too unfavourably. Even the practice of Desault would expose our error. Sometimes the most assiduous attention, and the most careful application of the apparatus, have not been sufficient to prevent abscesses around the knee, and an anchylosis of the joint. Desault related a case where even a caries of the articulating surfaces occurred. But some extraneous circumstances appeared to have an influence in these instances: and it may be laid down as a general rule, that fractures of the lower extremity of the os femoris, require the same treatment with fractures of its other parts.

EXPLANATION OF THE SECOND PLATE.[30]

[30] For an account of an improvement of the splint, represented in this plate, projected by Dr. Physick, and now used in the Pennsylvania hospital, see Article II. of the Appendix. TRANS.

This figure represents the apparatus for permanent extension, employed by Desault in oblique fractures of the os femoris.

AA. The external splint, with a notch and a mortise in it at the lower end to fix the inferior extending roller.

BB. A bandage passing round the body, intended to secure this splint against the pelvis.

CC. The anterior splint, reaching only to the knee.

d d d d. The anterior bolster, extending along the whole limb, and secured by pieces of strong tape.

EE. A portion of the bandage of strips, seen between the anterior and the external lateral bolsters.

FF. The junk-cloth intended to be folded round the two lateral splints.

g g. The superior extending roller, passing round the end of the external splint, and fixed underneath on the tuberosity of the ischium.

H. The sub-femoral roller or strap, intended to prevent the bandage BB, which passes round the body, from slipping upwards.

K k. A roller usually passed round the foot, to prevent it from turning.

L. The inferior extending roller, fixed in the mortise and the notch of the external splint.

THOUGHTS

ON LUXATIONS OF THE OS FEMORIS, UPWARD AND FORWARD.

1. Few kinds of luxation of the os femoris occur in practice more rarely than this. Practitioners who have seen it, and those who, on the authority of others, have described it, without having seen it, have all given an unfavourable prognosis respecting it, for the following reasons: 1st, on account of the inevitable rupture of the round ligament: 2dly, on account of the distension, and even laceration of the capsule, and of the compression and overstretching of the nerves and blood-vessels: 3dly, on account of the great difficulty of reduction. The following case will prove, that in all these respects, the apprehensions of authors have been exaggerated, that the obstacles to reduction arise less from the nature of the displacement, than from the nature of the means employed to remedy it; and that, if properly directed, art would here be as successful as in other cases.

CASE. (Collected by C***). About the close of the winter which preceded the death of Desault, a porter was brought to the Hotel-Dieu, in consequence of a fall which he had received about two hours before, in the following manner. As he was carrying on his shoulders a heavy burden, his foot slipped, while his leg and thigh were directed backwards: he fell on his knee, his thigh maintaining still the same direction; so that the conjoined weight of his own body and of the burden which he carried, aided by the velocity of the fall, forcing the head of the os femoris, which pointed at the time forward and upward, against the distended capsule, lacerated it and drove the articulating end through the opening. Continuing still to act, it ruptured the ligament, which connects the extremity of the bone to the articulating cavity, and forced the head in front of the os pubis, where it could be easily felt.

At the moment of the fall, an acute pain was felt in the part; and the power of moving the limb was suddenly lost; the patient was carried home, where a surgeon who visited him, considered the accident as a fracture of the neck of the os femoris, and sent him to the Hotel-Dieu, to undergo the necessary treatment.

Desault having examined the parts, discovered, from the following appearances, not a fracture, but a luxation upward and forward. The limb was nearly an inch shorter[31] than natural; the point of the foot was turned outwards; the thigh being in a state of painful extension, could not be flexed on the body; adduction and abduction were alike painful; the great trochanter, being more approximated than usual to the anterior and superior spine of the os ilium, was also too far forward; finally, the projecting head of the bone could be felt, as I have already said, in the groin.

[31] A case of luxation of the head of the os femoris in a forward direction, but differing in some respects from the above, occurred lately in the Pennsylvania hospital under the care of Dr. Physick. The doctor reduced this luxation in the amphitheatre, in the presence of his class, by a process which was also somewhat different from that adopted by Desault.

In the case of Desault’s patient the luxated limb was shorter than the sound one: in that of Dr. Physick’s it was evidently longer. This was no doubt owing to the head of the os femoris having, in the former case, passed farther up towards the superior rim of the os pubis than it had in the latter. In both cases the protuberance formed by the head of the bone in the groin could be readily felt.

For the purpose of making counter-extension, Desault passed a strap between the scrotum and the thigh of the sound side: Dr. Physick, for the same purpose, passed the strap between the scrotum and the affected thigh. He conceived that by this mode he could act with more effect on the pelvis, and more effectually prevent the acetabulum of the affected side from being drawn in any measure downward by the extending forces. It would seem, that by making counter-extension, in such a case, on the sound side, the pelvis is made to rotate, so to speak, on its own axis, in the direction in which the counter-extension is made. The necessary effect of this rotation must be, a slight descent of the acetabulum of the affected side. But to retain the acetabulum firmly up is the true and only end of counter-extension. Dr. Physick appears therefore to have availed himself of the greatest mechanical advantage of which the situation of the parts admitted.

Again: Desault placed the strap on which extension was made just above the ancle: Dr. Physick placed the strap intended for the same purpose above the knee. His object in this was, to have the leg free and unincumbered, in order that he might be able to use the limb with more advantage, as a lever of the first kind, to assist in moving the head of the os femoris towards the acetabulum. The fulcrum of the lever into which the limb was thus converted, was a strap passed round the affected thigh a few inches below the groin, and drawn laterally with great force in a direction opposite to that in which the bone was displaced.

In this case extension and counter-extension were made by means of powerful sets of pullies. Notwithstanding this, these forces were not alone sufficient to subdue the resistance of the muscles. The reduction was not completed till muscular contraction had been weakened, and the patient reduced almost to a state of syncope, by the loss of nearly two quarts of blood. This copious evacuation, co-operating with the fatigue which the muscles of the limb necessarily sustained, in consequence of the powerful extension to which they were for some time subjected by the action of the pullies, overcame all resistance and the head of the bone was finally replaced. To exhaust the energy of the resisting muscles by forcible and permanent extension, and to weaken the action of the system generally, by copious blood-letting, appear to be the two most effectual modes of ensuring success in the reduction of all obstinate cases of luxation.

Another point of difference between these two cases of luxation remains yet to be mentioned. In Desault’s case the head of the os femoris was, as he tells us, displaced in a direction “upward and forward.” In Dr. Physick’s case, the direction of the displacement was downward and forward. This was proved beyond all doubt, by the circumstance of the affected limb being longer than the sound one. TRANS.

The reduction was effected in the following manner. The patient being laid on a firm table, spread with a mattress, a strap was fastened above the ancle, for the purpose of extension; another, intended for counter-extension was placed between the scrotum and the thigh of the sound side, and brought up the back and front of the pelvis, along the body, till it passed over the shoulder, where it was twisted together and secured.

Extension was then begun, precisely in the direction in which the thigh pointed; and, during the execution of it, a rotatory motion inwards was given to the limb. At the expiration of a few minutes, the head of the bone remaining almost immoveable, notwithstanding the efforts to dislodge it, Desault directed extension to be discontinued, and, taking hold of the thigh, moved it in every direction, with a view to enlarge the opening in the capsule, the narrowness of which he suspected to be the cause that prevented the reduction.

Extension was then resumed, and varied in every direction, while the surgeon endeavoured to give assistance by pushing the head of the bone forcibly downwards, with his thumbs, and the palms of his hands. Useless efforts; the displaced bone remained stationary.

Desault ordering extension to be again discontinued, recommenced the motions of the os femoris, and even increased their force, changing them in every direction, for the purpose of lacerating the capsule. After this, extension was again renewed, with better success than before. Indeed, on the very first effort, the head resumed, of itself, its natural situation, without any further assistance on the part of the surgeon.

The sufferings of the patient ceased almost instantaneously; towards evening a slight swelling appeared around the joint, over which an emollient cataplasm was applied. On the day following, all the unfavourable symptoms were gone, and in about a fortnight the patient was able to return to his usual exercises, which, however, he was directed to pursue, for some time, with moderation.

2. There are, in this case, two circumstances, on which the practitioner should fix his attention, and which may throw great light on the reduction of all luxations of the os femoris, as they will be found applicable to most accidents of the kind. These are, 1st, The narrowness of the opening in the capsule. 2dly, The inutility of the motion or process of conformation, when that opening has been enlarged.

3. We formerly observed, when treating of luxations of the humerus, that one of the obstacles to reduction was, the narrowness of the opening in the capsule; the same circumstance occurs here. That membrane, lacerated at the time when the head of the os femoris is driven against it, is dilated sufficiently to let the head escape: but, the edges of the lacerated membrane, coming together again, and being thus drawn tight around the neck of the bone, retain it in that position, and prevent the head from re-entering the acetabulum. Thus, in a fracture, where one of the extremities of the bone is protruded through the integuments, the opening in the skin, by closing tightly round that extremity, sometimes prevents its reduction.

4. In such a case, what is the first and most obvious indication? It is necessary to increase the extent of the opening in the capsule, by moving the limb in every direction. Some persons have deemed it impossible to tear this membrane anew. But, if we recollect, that the neck of the os femoris, being placed between the edges of the opening, must necessarily draw them asunder by the motions impressed on it, it is easy to conceive, that the angles, where these edges unite, will be torn, if the motions be carried to an inordinate degree: besides, experience proves here, as well as with regard to the humerus, the truth of the doctrine contended for. Are we to apprehend, as these same persons will have it, that serious accidents may be produced by such violent motions? Experience again answers in the negative. Nothing, then, can be more certain, than that this observation, respecting the opening in the capsule, is a great stride towards perfection in the treatment of luxations in general, and particularly of that now under consideration.

5. When this obstacle to reduction has been removed, it is then very readily effected, and that without the process of conformation. Indeed that process is almost always unnecessary. For what purpose should it be employed? Is it to increase the effect of extension, and thus disengage the head of the bone from the place which it accidentally occupies? In this point of view, it is nothing but a very feeble force, added to a very powerful one, which receives from it, therefore, but little assistance: it is much better, if necessary, to augment the extending forces themselves. Is it to push the head of the bone into its cavity, after the extensions have dislodged it? It is to the muscles, and not to the efforts of the surgeon, that the performance of this office belongs. Indeed, the surgeon must act altogether in the dark in this respect, as he cannot possibly ascertain the precise point where the opening in the capsule exists: he may, therefore, even push the head of the bone against a sound part of the capsule, and thus himself create an obstacle to the reduction, which he is attempting to favour.

6. The muscles, on the other hand, by their contraction, naturally draw the head of the bone into its place, because the direction of their fibres is such as obliges them to do it. The great art of managing luxations, then, consists, in ascertaining clearly the obstacles that prevent reduction, in removing them, and, then, committing the rest to extension, and the powers of nature properly directed.

MEMOIR XII.

ON SPONTANEOUS LUXATIONS OF THE OS FEMORIS.

1. Our modern treatises on diseases are little else than fabrics artfully constructed of materials confusedly scattered through the writings of the ancients. Many of those materials oftentimes escape our notice, and we find them only, after practice has disclosed them to us, in the chambers of the sick. Thus, Hippocrates had an accurate knowledge of spontaneous luxations of the os femoris, and has even left an aphorism expressly on that subject. Yet this disease appeared to be unknown to the physicians who came after him, till John Louis Petit, having met with it in his practice, drew the attention of practitioners to it, by a memoir respecting it, published among those of the Academy of Sciences, in the year 1722.

2. The history of this affection, which was considered afterwards, _ex professo_, in his course on diseases of the bones, has been sanctioned by the assent of all practitioners, to whom it has since very frequently occurred, and who have generally admitted as Louis observes, the doctrine of Petit, respecting the cause on which it seems to depend.

3. Experience bears witness, that usually a fall on the great trochanter, more rarely on the knee, or the sole of the foot, precedes it, and has doubtless some share in producing it. But what is the nature of the primary affection which, rising immediately from this occasional cause, becomes the immediate cause of the luxation? Petit, and with him the practitioners of the present day, have conceived, that the different parts of the joint, being irritated and contused, pour out, in consequence of the injury received, a superabundant quantity of synovial fluid, which, not being absorbed with the same rapidity, accumulates in the articular cavity, distends the capsule, and, by degrees, forces the head of the os femoris from its natural cavity. Hence astringent and tonic remedies, with alum, spirit of wine, &c. are directed to be applied externally to the upper part of the diseased thigh.

4. But this doctrine, and the practice which results from it, seem by no means to accord with our knowledge of anatomy. The truth of this was deeply impressed on the mind of Desault, who had frequent opportunities of witnessing the disease.

CASE I. A young woman walking hastily along the street, slipped and made a false step, in which the left thigh, being violently twisted, supported for a moment the whole weight of the body.

A severe pain experienced at the moment, obliged her to stop at first, but becoming easier afterwards, permitted her to proceed on her way, and soon ceased entirely. A sensation of weight occurring in the part about fifteen days afterwards, was at first troublesome to the patient in walking. This sensation was afterwards succeeded by a dull, deep-seated pain, accompanied by a swelling in the parts around the joint.

During six or seven months the limb was observed to increase in length gradually, but very slowly. At the expiration of that time, a contraction took place suddenly, and, in one night, the diseased thigh became shorter than the other by nearly two inches. The patient was then admitted into the hospital, where, after some time, she sunk under her disease. On opening the body the following appearances were presented to Desault, who was then consulting surgeon to the institution.

The cartilage of the acetabulum swollen to such a degree as to fill up the whole extent of that cavity, was yellowish and inorganic, somewhat resembling bacon, both in colour and consistence. A soft, spongy, whitish substance projected in the middle of it, the remains no doubt of the round ligament. The head of the os femoris, situated where it is usually found in luxations outward and upward, was surrounded by a cartilage equally tumefied.

5. Here the cause of the displacement of the os femoris was evident. The cartilages becoming tumefied, in consequence of the contusion and violence done to them, had by degrees, filled up the acetabulum, forcing out in the same gradual manner the head of the bone. Hence arose the original lengthening of the limb. But as soon as the head had escaped from the lacerated capsule, the limb was drawn upwards and consequently shortened, by the action of the muscles, and the weight of the body pushing the pelvis downward.

CASE II. Some years afterwards, Desault had occasion to witness again the same disease, in the person of a man aged thirty-seven, who put himself under his care, but, being obliged to leave Paris, a short time afterwards, retired into the country, where he died in about six months, enfeebled and consumed by a hectic fever.

On opening the body, the surgeon of the place discovering the same phenomenon as in the preceding case, made a preparation of the part, and sent it to Desault, whose pupil he had been.

6. In this case the shortening was not so sudden as in the preceding one. It appeared at first to be coming on, during five days, in an imperceptible manner, when, fatigued with lying in bed, and having on that day drank a little, the patient attempted to walk, supported only by a cane. By evening, a shortening of two inches and a half had taken place, an effect evidently produced by the weight of the body on the diseased thigh. Hence the necessity of confining the patient to a state of perfect rest, of preventing, in particular, standing and walking, and all positions in which the diseased thigh would have to sustain the weight of the body.

CASE III. Maria Genette was received into the Hotel-Dieu, in consequence of a fall on the great trochanter. She had been attacked by a pain in the joint of the thigh of the same side. Walking, which was performed with difficulty, augmented the pain, and standing, though more tolerable, could not be long continued. The thigh was evidently longer than the other. To leave the disease to nature, and confine the patient to a state of rest, constituted the practice of Desault. What effect could the external use of astringents, recommended by Petit, produce in such a disease? Some time after her admission, the patient was attacked by dysentery, in consequence of which she was removed to the medical ward, where she died.