Part 27

On the two following days blood-letting was repeated, both on account of the active state of the pulse, and of a considerable swelling which took place in the joint. The apparatus was kept constantly wet with vegeto-mineral water. Eighth day, somewhat better: echymosis gone. Fifteenth day, the apparatus laid aside. From this time the foot was gently moved every day. Eighteenth day, the patient able to stand on the affected foot without pain. Twenty-sixth day, walks with the assistance of a staff. Thirty-ninth, walks without limping, and enjoys all the motions of the foot. Discharged.

§ V.

LUXATION OF THE FOOT, COMPLICATED WITH AN ESCAPE OF THE ASTRAGULUS, THROUGH THE CAPSULE AND THE LACERATED INTEGUMENTS.

17. When, in a luxation of the foot, the integuments, capsule, and ligaments are so lacerated, as to suffer the astragulus to escape, it would oftentimes be imprudent to attempt its reduction, as was done in the preceding cases. The violence already done to the parts around the joint is excessive; but this would be increased by the extension, and other efforts necessary in reduction. Whatever care might be taken, it would be difficult to prevent a vast swelling, long continued pains, and perhaps even a caries of the bone exposed to the air, with all those sufferings and dangers, to which such an accident gives origin. In such a case all the bones of the foot have been known to become carious, a state of things, which calls for the ultimate resources of art, and draws after it a train of evils, which it is always of the utmost importance to prevent.

18. What means are then to be employed? Two expedients only remain. 1st, the amputation of the foot; 2dly, the extirpation of the astragulus. The first is a cruel resource, which should never be adopted but in the last extremity, because it deprives the patient of a portion of himself, necessary to the performance of his functions. But the measure is forbidden by a reason still more powerful. Amidst the general disorder of the system, the severe pains experienced by the patient, the convulsions, and the delirium which oftentimes exists, what ground has the surgeon to hope for success? Will not the operation add to the number of these alarming appearances? Will it not aggravate them? May it not render them fatal? Both reason and experience reply in the affirmative.

19. In such a case, then, the extirpation of the astragulus is the expedient to be preferred. What, indeed, are its inconveniences? 1st, An inevitable anchylosis of the foot and leg: 2dly, a shortening of the affected limb. But a leg even in this state, is still better than a wooden leg, which is the necessary consequence of amputation: besides, a leg of the former description occasions no great inconvenience in either walking or standing, whereas one of the latter, produces extreme lameness: in the first case, a heel on the affected side somewhat higher than that on the other, is an easy method of removing the deformity. What, then, are such trifling disadvantages, when compared with the evils which they ward off? The extirpation of the astragulus is accompanied with but little pain. The want of this intermediate body between the leg and the foot, by producing a relaxation of the surrounding soft parts, prevents pain and swelling in such cases: should abscesses supervene, they will not, if properly treated, greatly retard the cure. In a word, experience coincides with this doctrine. Desault has seen it twice verified in the practice of other surgeons, and three times in his own. I have known of but one case of the kind, in which the termination was fatal, and there, a malignant fever, induced by the contaminated air of the hospital, certainly contributed to the death of the patient, which did not occur till two months after the reduction.

CASE VI. Desault usually gave in his lectures, the history of a case where the success of this practice was remarkable. A man was brought to the Hotel-Dieu, with a luxation of the foot, complicated with a fracture of the lower part of the leg, and a laceration of the ligaments and capsule, through which the astragulus had escaped by a luxation forward and upward, so as to have half of its anterior surface exposed. The extent of the injury seemed to call for amputation. But the youth, the vigour, and sound constitution of the patient, gave ground to hope that a process less desperate might succeed. The astragulus, already separated anteriorly, was extracted by dividing the attachments which held it to the os calcis, and the bones of the leg: the reduction was then effected without difficulty. The parts being replaced more readily in consequence of the removal of this bone, were retained so by means of a bandage similar to that for fractures of the leg, but modified so as to suit the particular case. The patient lost blood once or twice: the apparatus was kept constantly wet; a very strict regimen was prescribed for some days; but few troublesome symptoms occurred; a slight swelling took place, but was soon removed; a favourable suppuration came on; the dressing was renewed twice a day; some splinters escaped occasionally; several abscesses formed successively were opened, and healed up again: the wounds themselves closed, and the patient finally recovered, with an anchylosis, indeed, between the foot and leg, and a limb a little shorter than natural, but which still served the purposes of walking and standing.

20. To this example, I might add those of other patients treated at the Hotel-Dieu, in the same manner and with equal success. But what purpose would such an accumulation of facts answer? It would only fatigue the reader without adding to his conviction.

21. If the injury accompanying the luxation be so extensive, as to destroy the principal blood-vessels, and leave no hope of saving the limb, amputation becomes then the only resource, and the case assumes a resemblance to those where the limbs are shattered by cannon balls: the success then depends very much on the strength or weakness of the patient.

CASE VII. A man fell from a carriage: his foot becoming entangled between the spokes of the wheel, was almost separated from the leg. It adhered only by a small portion of skin behind, and by the tendons of the muscles which run to the toes both above and below.

Desault was called to the patient, whom he found in a most deplorable state: the pains which he suffered were excruciating: the parts around the wound were greatly swollen; a general spasm affected the system: amputation was judged necessary, but was deferred till the symptoms should be mitigated. The limb was dressed: next day, a gangrene began to affect the foot, which was then separated from the leg by cutting the tendons: the ends of the tibia and fibula exfoliated; the wound healed, and the patient now enjoys, in part, the functions and uses of the leg, by means of an artificial foot, framed and fitted on by an ingenious mechanic. Had the limb been too hastily amputated while the patient was affected with general spasms, fatal consequences would probably have ensued.

APPENDIX.

ARTICLE I.

The following interesting paper, extracted from the Medical Repository, Hexad: ii. vol. i. p. 122 ... 124, will give the reader a better idea, than he can receive from any other source, of Dr. Physick’s new and successful method of treating an old and obstinate fracture of the os humeri.

_A Case of Fracture of the Os Humeri, in which the broken ends of the bone not uniting in the usual manner, a cure was effected by means of a seton. Communicated to Dr. Miller by Philip S. Physick, M. D._

“Isaac Patterson, a seaman, twenty-eight years of age, applied to me in May, 1802, in consequence of a fracture of his left arm, above the elbow joint, which had taken place several months before; but the ends of the bone not having united, rendered his arm nearly useless to him.

“The history he gave me was, that on the 11th of April, 1801, after having been at sea seven months, his arm was fractured by a heavy sea breaking over the ship. Nothing was done for his relief until next day, when the captain and mate bound it up, and applied splints over it. No swelling supervened, nor did he suffer any pain, Three weeks after this accident, he arrived at Alexandria, when the state of the arm was examined by a physician, who told him, that the ends of the bone were not in a proper situation. After making an extension, the splints and bandages were again applied. He remained in Alexandria four months, when, finding his arm no stronger, he left off all dressings, and went on board the New-York frigate as steward: in this capacity he remained near the Federal City six months, and by being under the necessity of using his arm as much as possible, he found the connexion between the ends of the bones became looser and looser, till, at length, the arm bent as easily as if a new joint had been formed at the place of the fracture. From the frigate he went to Baltimore, where an attempt was made by machinery to extend the arm, and keep the ends of the bone in apposition, by continuing the extension. Under this treatment he remained two months, but experiencing no benefit, he was advised to come to Philadelphia.

“On examining the arm, I found that the humerus had been fractured about two inches and a half above the elbow joint, and that the ends of the bone had passed each other, about an inch: the lower fragment, or that nearest the elbow, was situated over, and on the outside of the upper portion of the bone. The connexion that existed between the ends of the humerus was so flexible, as to allow of motion in every direction, and by forcible extension, the lower end might be pulled down considerably, but never so low as to be on a line with the end of the upper extremity. He was admitted into the Pennsylvania hospital, the latter end of May; but the weather becoming very hot, it was judged best to defer any operation that might be necessary, until the fall of the year. Unfortunately he then contracted a bilious fever, of which he was so ill, that his life was despaired of for some days. From this fever his recovery was so slow, that it was not thought proper to perform any operation until December. It still remained to decide, by what means a bony union of the humerus, might most probably be effected. In the year 1785, when a student, I had seen a case in our hospital, similar to this in every essential circumstance, in which an incision was made down to the extremities of the fractured bone, which were then sawed off, thereby putting the parts into the condition of a recent compound fracture. No benefit, however, was derived from this painful operation, and some months afterward the arm was amputated. This case had made a strong impression on my mind, and rendered me unwilling to perform a similar operation. I therefore proposed to some of the medical gentlemen of the hospital, who attended in consultation, that a seton-needle, armed with a skein of silk, should be passed through the arm, and between the fractured extremities of the bone, and that the seton should be left in this situation, until by exciting inflammation and suppuration, granulations should rise on the ends of the bone, which uniting and afterwards ossifying, would form the bony union that was wanting. This operation being agreed to, it was performed on the 18th of December, 1802, twenty months after the accident happened. Before passing the needle, I desired the assistants to make some extension of the arm, in order that the seton might be introduced as much as possible between the ends of the bone. Some lint and a pledget were applied to the orifices made by the seton-needle, and secured by a roller. The patient suffered very little pain from the operation. After a few days the inflammation (which was not greater than what is commonly excited by a similar operation through the flesh, in any other part) was succeeded by a moderate suppuration. The arm was now again extended, and splints applied. The dressings were renewed daily for twelve weeks, during which time no amendment was perceived; but soon afterwards the bending of the arm at the fracture was observed to be not so easy as it had been, and the patient complained of much more pain than usual whenever an attempt was made to bend it at that place. From this time, the formation of the new bony union went on rapidly, and, on the fourth of May, 1803, was so perfectly completed, that the patient could move his arm, in all directions, as well as before the accident happened. The seton was now removed, and the small sores occasioned by it, healed up entirely in a few days. On the 28th May, 1803, he was discharged from the hospital; perfectly well, and he has since repeatedly told me that his arm is as strong as it ever was.”

To the preceding paper it is unnecessary to add, that the mode of treatment there stated might be adopted in similar fractures of other bones, provided a seton-needle could be passed near to the ends of the fragments, without any risque of wounding blood-vessels, nerves, or other parts of importance. It is thus that solitary facts minutely detailed and well substantiated, oftentimes grow into principles of extensive application.

ARTICLE II.

_An account of Dr. Physick’s improvement of Desault’s apparatus for making permanent extension in oblique fractures of the os femoris._

Dr. Physick having observed that in the application of Desault’s apparatus, the patient was sometimes injured by the pressure of the strap or roller _g g_ (plate 2) which passes under the tuberosity of the ischium for the purpose of making counter-extension, devised the following method of remedying this inconvenience, in which he succeeded to his wishes.

He directed the upper end of the long external splint to be formed like the head of a crutch, and the splint itself to be lengthened so as to reach and bear against the axilla of the affected side, which must be well defended from pressure by a bolster of flannel or some other soft material. By this expedient the Dr. evidently formed two points of counter-extension, instead of one, as is the case in the apparatus of Desault. Between these two points, namely, the axilla and the perineum, the same quantity and force of pressure is, by Dr. Physick’s improvement, _divided_, which, in the original apparatus of Desault, is borne by the _perineum alone_. The risque of excoriation and injury to the patient, then, in the former case, is to that which he runs in the latter, only as one to two, or nearly so. As it is no less the duty of the surgeon to prevent suffering than it is to remove deformity or to save life, Dr. Physick has certainly in this respect made an important step in the advancement of his profession.

But there is still another advantage derived from the lengthening of the external splint. In the original apparatus of Desault, the strap _gg_ intended for counter-extension, by passing no higher up than the spine of the ilium, runs too much across, and therefore acts too much on, the upper part of the thigh. By this it not only irritates the muscles of the part, and induces them to contract, but also tends to draw the upper fragment of the os femoris a little outward, and thus to render the thigh in some measure deformed. But, in the improvement of Dr. Physick, the strap _gg_ is secured in a mortise cut in the external splint, about midway between the spine of the ilium and the axilla. This strap, by being thus carried higher up on the body, does not run across the thigh at all. It consequently presses on and irritates the muscles much less, acts more in the direction of the os femoris, and has no tendency to draw the superior fragment outward.

Hence this improvement not only diminishes the patient’s sufferings, but gives him, perhaps, the best possible chance of having his limb preserved free from deformity.

Another improvement made on the lower end of the external splint by Dr. James Hutchinson deserves also to be mentioned. It was found that in the original apparatus of Desault, the strap or roller L (plate 2) used for the purpose of extension, had a tendency to draw the foot too much outward. This fault Dr. Hutchinson very ingeniously remedied, by attaching to the lower part of the external splint, a little above the mortise, a small block extending inwardly, at a right angle with the splint, so far as to be on a line with the middle of the sole of the foot. Over the end of this block, in which a notch is cut to receive them, the ends of the strap L are carried, previously to their being secured to the external splint. By means of this expedient extension is made precisely in the direction of the limb, and the inconvenience of drawing the foot outward is completely obviated.

Thus improved by Drs. Physick and Hutchinson, the apparatus of Desault for oblique fractures of the os femoris, leaves, perhaps, scarcely a remaining desideratum on the subject.

ARTICLE III.

EXPLANATION OF THE THIRD PLATE.

This plate gives a full view of an apparatus for making permanent extension, in oblique fractures of the leg, when both bones are broken. This apparatus was first devised and constructed several years ago, by Dr. James Hutchinson, then a pupil in the Pennsylvania hospital, and is now in general use among the practitioners of Philadelphia.

Fig. 1. Represents the leg and foot, with the apparatus applied.

A. A common roller, passed several times round the leg a little below the knee, on which counter-extension is made.

B. A silk handkerchief folded, or a strong roller made of soft muslin, passed once round the leg, just above the ancle, from behind forward. C. The place where its two ends cross each other to pass down along each side of the foot, as seen at _b_, to D, where they are secured by a knot drawn but moderately tight. _a a._ The same ends continued to E where they are again secured by a firm knot over the cross piece F, which passes between the two strong splints G G, that run on each side of the leg from a little above the knee, to the distance of four or five inches beyond the sole of the foot. This is the bandage by which extension is made, as will be mentioned hereafter.

H. Two bits of strong tape, each about two feet long, placed in the longitudinal direction of the leg, and firmly secured by the roller A, which passes over their middle. Two such bits of tape, are thus applied on each side of the leg, and their four ends, passing through four holes in the upper end of each of the splints G G, are secured on their outsides by firm knots as represented at H.

Fig. 2. A view of one of the splints G G, separated from the leg.

_a._ The four holes in the upper end, through which the bits of tape H pass.

_b._ The mortise in the lower end, which receives the cross-piece F.

Fig. 3. A view of the cross-piece F, which must be firmly fixed in one of the splints G G, but moveable in the mortise of the other, so that the splints may be taken asunder at pleasure.

The following is the method of applying this apparatus.

While extension and counter-extension are made by two assistants, the surgeon placing the bits of tape H on each side of the leg, secures them firmly by the roller A applied round the limb, with a proper degree of tightness. He then applies the middle of the handkerchief or roller B on the tendo Achillis, brings its ends across each other, before the leg at C, and carrying them down along each side of the foot, secures them by a knot at D. Letting go the ends of the handkerchief B, he next places on each side of the leg the splints G G, connects them at the lower end by the cross-piece F and secures them at the upper end by the tapes H. He then resumes the ends of the handkerchief B, carries them downward as seen at _a a_ and secures them by a firm knot at E round the cross-piece F.

From this view and explanation of the apparatus Fig. 1, I presume its construction, application, and mode of operation will be very easily understood. It is unnecessary therefore to add, that the extension and counter-extension made on the limb, will be directly proportioned to the degree of force with which the ends _a a_ of the handkerchief B are drawn over the cross-piece F. As action and reaction, in this case, must, as in all others, be equal, the splints G G will be pushed upward by the ends of the handkerchief B with precisely the same force that is applied on these ends to draw the foot and lower fragments downward. Hence the counter-extension made above on the roller A will be exactly equal to the extension made below by the handkerchief B.

I ought to have observed, that it is necessary to defend the soft parts, both above and below, from the pressure of the extending and counter-extending straps, by means of soft compresses applied next to the skin. This is particularly necessary on the instep C where the ends of the handkerchief B cross each other. It requires some attention on the part of the surgeon to prevent this spot from being excoriated, especially if it be found necessary to make a forcible extension.

If the fracture be simple, a bandage of strips previously applied round the limb from the ancle to the knee is highly useful. It secures the fragments more effectually from lateral displacement, and prevents the swelling of the leg. A simple roller applied with a moderate degree of tightness round the foot, is also of service in preventing a swelling in that part, as well as in removing it if it has already occurred.

This apparatus is still more strikingly useful in compound fractures, on account of the facility with which it enables the surgeon to apply the necessary dressings. These can be renewed as often as may be requisite, without giving the patient the least pain, without discontinuing extension, or in any measure whatever deranging the fragments. The surgeon can also, in all cases, discover by a single glance of his eye, whether or not the fragments are in proper apposition. It is right to secure the whole apparatus by three bits of tape passed round it, similar to those tied round the leg in the apparatus for fractures of the thigh, as represented in plate 2.

I shall only add, that the surgeon must employ such bolsters and compresses as he may find necessary to support the limb, and protect it from undue pressure, and that he must be vigilant to prevent, by frequent examinations, the extending and counter-extending straps from becoming relaxed.

For a few further remarks on the subject of this apparatus, the reader is referred to a paper published by Dr. Hutchinson, in the second number of the Philadelphia Medical Museum.

FINIS.

Inconsistencies:

armpit/arm-pit condyl/condyle coracoid/corocoid coronoid/coronoide expence/expense fixt/fixed forearm/fore-arm/fore arm inconveniencies/inconveniences plane/plain Scultel/Scultet teres-major/teres major

Corrections:

aingly → singly appplication → application backwaad → backward Bruningaushen → Bruninghausen cataloginous → cartilaginous ciscumstance → circumstance considerasion → consideration constanly → constantly controuling → controlling cotemporaries → contemporaries croud → crowd decieve → deceive divison → division Engravd → Engraved examing → examining exextremities → extremities faciæ → fasciæ follow- → following imitatators → imitators make → makes matrass → mattress nect → neck of of → of passsive → passive percieve → perceive recieves → receives resourse → recourse the the → the to to → to whould → would 1303 → 1803 (date) 67 → 66 (para numbering error)