Part 26

The following was then the state of the parts. A considerable swelling around the joint; a projection of the malleolus internus, with a depression underneath it; a preternatural direction of the tibia before, and of the os calcis, behind; a depression near the lower end of the fibula; a crepitation readily perceived, on moving the fragments; a large tumour on the outside of the foot: with a depression and mobility of the malleolus externus.

The luxation was immediately reduced. Extension made on the foot and leg brought the parts into their proper situations, where they were retained by means of the bandage for fractures of the leg, and four compresses well secured by the bandage. One of these compresses, being placed on the malleolus internus, another on the outside of the foot, a third on the anterior and lower part of the tibia, and the fourth under the os calcis, prevented these different parts from being again displaced.

As soon as the apparatus was applied, the pupils remarked with astonishment, that the restlessness of the patient ceased, that his pains were relieved, and his delirium disappeared; he expressed his surprise at the state from which he had just recovered, and was now able to give an accurate account of his fall. He was scarcely put to bed, when he fell into a tranquil sleep, which lasted three hours. For six days previously he had not slept a moment.

In the evening, the patient was free from pain, and perfectly tranquil. Diluting drinks were prescribed, with twenty-five drops of Hoffman’s anodyne liquor: the apparatus was wet from time to time with vegeto-mineral water: the patient slept well throughout the night.

Next day, the apparatus renewed: the parts perfectly in place: swelling diminished; same means continued. Sixth day, the anodyne discontinued. Tenth day, swelling still less; echymosis gone; a yellow colour in the skin, an evidence that resolution is going forward. Twentieth day, swelling gone.

Thirtieth day, the fracture of the fibula healed; that bone slightly separated from the tibia: the circular roller drawn tighter; and a thick compress placed on the external malleolus, to bring it to its proper place. Forty-fifth day, the apparatus for a fractured leg removed, and a simple roller substituted in its place: the motions of the foot painful and contracted; a small gangrenous spot appeared on the heel. Fifty-fifth day, the ulcer which proceeded from this spot healed: motions of the part more free and extensive. Sixty-first day, the patient able to walk without assistance, though not without pain.

5. It is difficult to find an instance where the advantages of reduction have been more remarkable than in the preceding one. The patient had passed six days in pain, extreme agitation, and uninterrupted delirium: the foot was reduced, and these unfavourable appearances instantly vanished, and were succeeded by a state of tranquillity. Alarmed by such a state of things, the ancients would doubtless have proceeded to amputation. Let us examine into the motives which led Desault to an opposite line of practice, and then inquire into the cause of the success with which that practice was crowned.

6. Had amputation been performed here, it must have been for one of the two following reasons; 1st, for fear of gangrene; or 2dly, to remove the unfavourable symptoms that existed. The first apprehension would have been quite visionary, in as much as all the blood-vessels were sound. Would the second consideration have been any better founded? It was perfectly obvious, that the unfavourable symptoms which existed arose from the tension and overstretching of the parts, in consequence of the preternatural position of the bones of the foot. The indication was evident. Replace these bones in their natural situations, the strained parts will then necessarily become relaxed, and all the troublesome and alarming symptoms cease with the cause that produced them. Experience confirmed the justness of this reasoning.

7. But the mere replacement of the parts would be of very little avail, if it were not permanently maintained, and followed up by a judicious mode of treatment. Without such treatment there would doubtless be reason to apprehend all that train of troublesome consequences, of which authors speak in such frightful terms, and which arise, not from the nature of the luxation, but from the manner in which the patient is treated. A loose apparatus, incapable of preventing displacement, would allow the bones to be deranged anew, and to produce again an overstraining of the parts, accompanied with pain, swelling, &c. Irritating local applications, such as camphorated spirits of wine, &c. would increase these pains; emollients which are employed in other cases would keep up the swelling.

8. It follows from what has just been said, that an opposite mode of treatment ought to succeed the reduction, and this we see was the case in the preceding instance. There, when the bones were once reduced, all new displacement was prevented, because the apparatus was so constructed, as to counteract the tendency of the bones to be displaced. The external edge of the foot, which had been turned outwards, was now pushed inwards by a thick compress; the same means served to push outwards the internal malleolus, which had received by the accident an inclination inwards, and to push the anterior part of the tibia backward, and the os calcis forward, both of which were displaced, as has been remarked, in contrary directions. Two strong splints fixed the lateral compresses, while the anterior and posterior ones were firmly secured by rollers. In the midst of all these resistances, the foot being necessarily immoveable, no new displacement could occur.

9. A suitable and judicious position, in which the foot, raised a little higher than the leg, was placed on a pillow forming an inclined plain, prevented swelling, while gentle compression, made by a bandage, contributed to the same end. This end was also further attained by the external topical applications. To relieve pain and remove congestion, were here, as in sprains, the two indications to be fulfilled. To these indications the spirituous and the relaxing applications formerly in use, are alike opposed. Vegeto-mineral water, on the contrary, fulfils them extremely well. Hence the necessity of keeping the apparatus constantly wet with that liquid.

10. Regimen influences not a little the success of the treatment. A strict diet is necessary during the time of the inflammatory and unfavourable symptoms. Any excess might then prove fatal. Desault gave, in his lectures, an account of a woman, who had her foot luxated outward, and the astragulus forward. Her fever was considerable, her pains excruciating, and the swelling wore an alarming aspect. The luxations were reduced: all the threatening appearances vanished, and every thing seemed to promise a favourable termination of the disease. But, on the fiftieth day, the patient, having procured strong food, ate largely of it: in the evening all the unfavourable symptoms returned; the swelling became great, and a few days afterwards she died.

But if strong food be prejudicial during the time in which bad symptoms are to be dreaded, a diet too strict would be equally injurious when that time is passed. The weakened powers of the system would not be adequate to the purposes of a cure, particularly to the consolidation of the bone, should the case be a fracture. Desault, therefore, permitted the patient to increase his diet by degrees, and at length to return to his usual regimen.

11. The following case, reported by Giraud, proves still further the advantages of this simple mode of treatment, which, should it even fail, always allows the surgeon to avail himself of amputation, which is indeed the last resource of art, and should never be employed till rendered indispensable by the failure of all other means.

CASE II. Maria Constant, aged forty-six, descending a flight of stairs in haste, fell, and luxated her right foot outwards, the tibia inwards, and fractured the fibula near to the lower end.

Her cries brought assistance to her, and she was carried to the Hotel-Dieu. Giraud, who then officiated as surgeon in chief, visited her, and discovered that there existed both a luxation and a fracture, though most of the signs were rendered obscure by a considerable swelling: a slight echymosis occupied the back of the foot, and severe pains were experienced.

Extension on the foot, and counter-extension on the leg, dislodged the parts by degrees from their accidental situations, while, by the process of conformation, the surgeon endeavoured to bring them into their natural ones. This was soon effected without much violence: the unfavourable appearances soon vanished; the pain ceased; an apparatus similar to the former one was applied, and kept wet with a strong solution of common salt, instead of the vegeto-mineral water.

In the evening, the pulse being full, and somewhat raised, a moderate blood-letting was deemed necessary. Next day, the apparatus was kept constantly moist, and some part of it which had become relaxed was tightened. The pulse continuing full, a low diet was prescribed.

Fifth day, the apparatus taken off; contact between the bones perfect: a yellowish tinge bespoke an incipient resolution of the echymosis: a slight swelling of the leg: vesications formed on the part: these are opened and a quantity of acrid water discharged from them. Sixth day, light nourishment allowed; a small excoriation of the heel, which is dressed with cerate spread on a linen rag. Seventh day, regimen less strict; no bad symptoms supervene. Eighth day, the excoriation enlarged; same dressing. Tenth day, the excoriation become fungous: caustic is applied to remove it.

Twenty-eighth day, the discharge from the leg decreased; from this time the dressings are renewed only every other day. Thirty-second day, the ulcer is cicatrized: no pains in the leg. Thirty-ninth day, fracture of the fibula firmly united: no deformity remaining; the apparatus is laid aside: the joint remains stiff: motions performed by the limb difficult at first, but become gradually more free. Forty-sixth day, symptoms of bile; gentle evacuants. Fifty-fourth day, the patient is discharged cured, except a slight impediment in walking, which exercise will soon remove.

12. To this example, I might add many others, where similar displacements, properly treated, terminated with equal success: no pain; no swelling; no inflammation; and therefore, of course, no mortification. Yet these are occurrences of which authors speak, as if they were the usual consequences of such luxations, where, to a violent injury done to the soft parts, is added a fracture near to, or even communicating with, a joint. The erroneous opinions of the ancients and most of the moderns, respecting the dangers arising from such vicinity or communication, have contributed not a little to their unfavourable prognosis in the cases under consideration. Should the patient survive the disease, his inevitable lot, according to them, must be, a complete anchylosis of the leg with the foot. But, the preceding cases fully prove, that this apprehension is unfounded. A considerable time is doubtless necessary, for the recovery of motion, on account of the distension and rupture of the ligaments, the long continued inactivity of the parts, and the swelling which they have undergone. But this recovery can always be effected by means of exercise, gentle at first, increased afterwards, and regulated according to the principles so frequently laid down in the course of this work. Much more to be relied on is such exercise, than the long catalogue of discutient means, such as pumping of water on the parts, alkaline baths, mineral waters, and all other external applications, so often extolled as efficacious, and so often found entirely useless.

§ III.

LUXATION OF THE FOOT, COMPLICATED BY A SEPARATION OF THE BONES OF THE LEG, AT THEIR LOWER END.

CASE III. (The following case was reported by Thevenot). I. Joseph Schneider, an ebonist, aged thirty-six, as he was walking in haste, on the 23d of March, 1792, fell forward, his foot being forced backward and outward. He experienced at the instant severe pains in the joint: he was unable to rise, and was therefore carried home, where a surgeon, after making a slight extension, applied a roller on the limb, and did nothing further. The patient experienced no relief. The pains increased; a swelling supervened; convulsive motions began to occur; and the patient was brought to the Hotel-Dieu, six days after the accident.

From the deformity of the foot, Desault immediately discovered that it was luxated. Its point was directed outwards, while its sole was turned in the same direction: beneath the malleolus internus, which was too prominent, was a tumour formed by the astragulus. The crepitation of the bones which was easily heard, the preternatural distance between the tibia and the fibula, the mobility of this latter bone, and the absence of the signs of a fracture, plainly showed that a separation of the two bones of the leg had taken place.

A reduction was immediately effected by means of extension and counter-extension, and was announced when it took place by a report distinctly heard. It was then retained by a bandage, calculated to answer a twofold purpose; 1st, to approximate, and keep together, the two bones of the leg: 2dly, to secure the contact and immobility of the bones of the foot.

Blood-letting was prescribed: an anodyne mixture administered; low diet; in the night severe pains were felt; next day, they were increased; on dressing the limb, nothing amiss discovered; all the parts in perfect contact: no vestige of separation between the tibia and the fibula: a new apparatus applied; and kept constantly moist. Third day, the patient better: fifth day, the fibula a little separated from the tibia: the circular bandage drawn tighter to reduce it to its place again. Tenth day, every thing in its natural state: no pains: swelling gone. Fifteenth day, a simple roller substituted in place of the bandage for a fracture of the leg. Nineteenth day, the patient began to walk, with the assistance of a stick: twenty-third day, walks easily: twenty-eighth day, is dismissed perfectly cured, and nearly free in all his motions.

13. The separation of the bones of the leg, at their lower end, does not constitute a very serious complication of luxations of the foot, although the contrary is asserted by several authors. Desault met with this accident several times in the course of his practice, but never saw it terminate otherwise than favourably. But here, as in all other cases, the most minute attention is necessary to ensure success, the want of which is more frequently owing to the negligence of the surgeon, than to the deficiencies of the art. The bandage employed after reduction ought to act principally from without inwards, and in a direction perpendicular to the axis of the lower part of the leg, in order to approximate the two bones. It will be of some service, in this respect, to place on each bone a compress, which, projecting more than the rest of the circumference of the limb, will be more compressed, and on that account, contribute to the end in view.

§ IV.

LUXATION OF THE FOOT, ACCOMPANIED BY A DISPLACEMENT OF THE ASTRAGULUS AT ITS ARTICULATION WITH THE OS SCAPHOIDE.

14. Petit never met with more than two instances of that displacement of the astragulus, now under consideration. His general prognosis on the subject is more favourable than that respecting other luxations of the foot, with which he never saw the present luxation of the astragulus complicated, as occurred in the following cases. Had such complex cases fallen under his notice, there can be little doubt, but he would have declared amputation to be the only recourse of art on the occasion.

But the experience of Desault demonstrates to us here, as well as in the preceding cases, the great extent to which we ought to carry our confidence in the powers of nature, when skilfully guided by the hand of art. The following case was communicated to me by Leveille.

CASE IV. John Baptist Landrin, a postilion, aged thirty-six, was brought to the Hotel-Dieu, on the 19th of February, 1791.

On the morning of the same day, a horse on which he was mounted having fallen, his foot was caught under the belly of the animal. As soon as he was disencumbered of the vast weight, he endeavoured to rise, but in vain. The pains which he experienced in his foot were extreme. He was carried home, where some surgeons, having ascertained that his foot was luxated, but being unable to reduce it, sent him to the Hotel-Dieu.

Desault on examining him, found the bones of his foot to be situated as follows. The internal part of the os calcis corresponded to the lower extremity of the tibia: the back of the foot was directed outwards, and its external edge downwards: under the skin and in front of the tibia was the astragulus, resting on the scaphoide and first of the cuneiform bones, where it formed a considerable projection: on the back of the leg, the fibula corresponded to the tendo Achillis. The pains had been inconceivably great from the moment of the accident.

Imboldened by numerous instances of success in similar cases, Desault, notwithstanding the extent of the disease, attempted the reduction. One assistant took hold of the superior part of the leg to make counter-extension, and another, for the purpose of extension, grasped the metatarsus with one hand, and the heel with the other. While these were pulling in different directions, the surgeon applying his thumb on the astragulus, endeavoured to force it into its place. His efforts were ineffectual: the opening through the capsule of the astragulus being too narrow, would not suffer it to pass. Desault perceiving this, cut through the integuments which covered the bone, and having laid bare the capsule and the ligaments which strengthen it, made an incision into them of a sufficient extent, taking care to avoid the tendon of the tibialis anticus, which was brought into view. The openings being thus enlarged, admitted of an easy reduction, and all the parts resumed, without difficulty, their natural situation.

The reduction being effected, the wound was closed, and covered with some lint. A square compress was then placed on the back of the foot, while a long one was applied to its sole, and the whole secured by an apparatus similar to that described in the preceding case. The patient was confined to a very strict diet, and ordered to use diluting drinks.

Next day, a slight bilious diathesis; an emetic in solution given; apparatus renewed. Fourth day, an abscess on the malleolus externus opened; a copious discharge of pus. Eighth day, the parts in perfect contact; a favourable discharge from the wounds; dressings applied twice a day. Fifteenth day, a general œdema; aperient ptisans ordered. Twentieth day, the œdema gone: a bilious diathesis returned: in consequence of this, the wounds became pale: another emetic given. Twenty-seventh day, a very painful excoriation occurred on the heel: care taken not to let the foot rest on that part, as the sore appeared to be the effect of compression. Thirtieth day, the wounds in a favourable way: all the bones in exact contact. Fortieth day, apparatus laid aside, and a simple roller substituted in its place: wounds already cicatrizing. Fiftieth day, the limb put in gentle motion, which is gradually increased every day. Same dressing continued till the eightieth day: wounds not yet cicatrized. Hundred and twenty-seventh day, a considerable swelling around the joint: a splinter made its way out, and was followed in a few days by several more. In the fifth month an abscess formed on the heel, from which, when opened, another splinter escaped. In the mean time, the patient left the Hotel-Dieu. During his absence more splinters were discharged. Returning about a year afterwards with a small ulcer, he was dismissed again in a short time, perfectly cured, except a slight stiffness of the joint.

15. The reduction of this luxation of the foot presents a difficulty worthy of the attention of practitioners, as well on account of its own nature, as in consideration of the process which was employed on the occasion: I allude to the narrowness of the opening in the capsule. I mentioned, on a former occasion, the obstacles sometimes created by this circumstance to the reduction of luxations of the os humeri and the os femoris. It was impracticable in the present to enlarge the opening in the capsule, as could be done in those cases, by moving the head of the bone in all directions; because the bone was too small to afford any purchase to the surgeon. The only resource was, the use of the knife; and the operation was the more easily performed, on account of the capsule being situated immediately beneath the integuments, from which circumstance it could be the more speedily brought into view.

16. The apprehension of mischief resulting from the admission of air to the articulating surfaces, would no doubt, in this case, have restrained most practitioners: but, even supposing this apprehension to be well founded, ought it to deter the surgeon from adopting the only possible mean of effecting a reduction, and of thus putting an end to the alarming state of things arising from the displacement of the bones? Desault proved in numerous instances, that the apprehensions of authors respecting such cases have been greatly exaggerated, and that it is practicable to cure wounds that penetrate into the cavities of joints, in the same manner as if they were simple wounds, and with but very little more danger to the patient. Yet it would seem, that the tediousness of the cure and the exfoliation of the bones, arose, in the present case, from the opening made into the joint, and perhaps also, in part, from the disposition and habit of the patient. Finally, in those alarming injuries of the joints, unconnected with external wounds, where practitioners have looked to no resource but that of amputation, Desault has, in a short time, and without any dangerous occurrence, restored to the subjects the free use of their limbs. The following case, drawn up by Plaignault, is a proof of this.

CASE V. Pierre Phipe, aged twenty-four, fell, on the 20th of February, 1788, from an elevation of more than twenty feet: lighting on his foot, he turned it outwards, sunk instantly to the ground, and was unable to rise again. He was carried home, and from thence to the Hotel-Dieu.

Desault examining him on his arrival, discovered a luxation of the foot outwards, and of the astragulus forward and upward: the patient’s sufferings were great. Convinced that the most effectual method to relieve these was to reduce the luxation, the surgeon undertook it immediately, pushed the astragulus into its place without difficulty, and with a report which was heard by every one present, while the bones of the foot were brought into their proper situation by means of extension. In an instant the pains vanished and the motions of the foot became easy. The necessary apparatus was applied. The activity of the pulse called for blood-letting, which was immediately performed. A low diet was prescribed.