Part 38

89. The point of the foot is usually turned outwards; a position which Sabatier, Bruninghausen, and most other practitioners regard as a necessary effect of the fracture, although Ambrose Pare and Petit have borne witness that it does not always exist. Two cases, reported on this subject by celebrated surgeons, have been thought unfounded by Louis, who has attributed them either to an error in language, or a mistake of the transcriber. But the practice of Desault has fully confirmed their possibility. The first patient whom he had under his care, at the hospital of Charity, after he was appointed surgeon in chief, laboured under a fracture which presented this phenomenon. Many other examples occurred to him afterwards, and he believed it might be laid down as an established principle, that, in fractures of the neck of the os femoris, the direction of the foot outwards is to that inwards as 8 to 2.

90. The common opinion is, that this direction outwards is to be attributed to the muscles that perform rotation. But, were that the case, 1st, it is evident that it would always exist: 2dly, all the muscles running from the pelvis towards the trochanter, except the quadratus, are in a state of relaxation, in consequence of the approximation of the os femoris to their points of insertion: 3dly, muscles in a state of contraction would not allow the point of the foot to be drawn so easily inwards. Is it not more probable, that the weight of the part draws it in the direction in which it is usually found.

91. From the foregoing considerations, it follows, that none of the signs of a fracture of the neck of the os femoris, is exclusively characteristic, that the whole of them, taken separately, would be insufficient, and that it is their assemblage alone which can throw on the diagnosis that light which is oftentimes wanting to it, even in the view of able practitioners. But after all, in the present case, as in every other one, should any doubt exist, it is right to take the safe side, and apply the apparatus, which is indeed useless but not dangerous if the disease does not exist, but indispensably necessary if it does.

§ XV.

OF THE PROGNOSIS.

92. The existence of a fracture being ascertained, what prognosis is to be formed respecting it? In answer to this general question, it will be sufficient, I think, to resolve the following particular ones. What accidents accompany the fracture in the first instance? What phenomena make their appearance during its reunion? In what manner does it affect the patient, as to his power of walking, after reunion has taken place.

93. If we attend to the opinion of authors, on this fracture, we will find that they represent it in very dismal colours, as if it were necessarily productive of the most serious effects. Inflammation of the parts adjacent to the neck of the os femoris, numerous and repeated abscesses arising from this inflammation, propagating themselves externally and communicating with the interior of the joint, gangrene itself, as Morgagni remarks in a particular case, convulsions of the limb, an œdema occurring in it, and a slow fever destroying the patient by degrees; such is the dismal catalogue of misfortunes, generally considered as necessarily attendant on the kind of fracture under consideration. Bruninghausen remonstrated against this fatal prognosis of authors, and Siebold, one of the most celebrated German practitioners, among a great number of cases that fell under his care, had no such accidents to encounter. Desault never experienced them. Doubtless they are prevented by our more exact and more skilful modes of treatment. It is thus that under a more judicious treatment, fractures of the olecranon and of the rotula, are no longer marked with those terrible consequences formerly attributed to them.

94. In as much as the organization of the os femoris, is nearly the same in its neck and in its body, it is difficult to conceive how the progress of nature can be different in fractures of these two parts; why the first, in being denied the power of healing or reunion should be, in this respect, distinguished from all other living parts of animals, which are particularly characterized by that power, when they have sustained a solution of continuity. Many practitioners, even at the present day, advocate this doctrine, which is built, one while, on the circumstance of the periosteum not being continued along the neck of the os femoris; another while, on a belief that the head of this bone cannot receive a sufficiency of nourishment for the work of consolidation, in consequence of being attached to the rest of the system, only by the round ligament, and again, on an opinion, that the synovial fluid, by wetting the divided surfaces, prevents their reunion.

95. But is the periosteum the only agent in the formation of callus? Modern experience has refuted this opinion, which, like many others, will therefore in a short time exist only in the history of our errors. Were it even true that the periosteum is here indispensably necessary, is not its place supplied by the fold of the capsule, which surrounds both the head and neck of the os femoris? Besides, why cannot callus be formed by that part which has had sufficient power to accomplish ossification, since it is universally acknowledged, that, in these two processes, the labour of nature is nearly the same.

96. The head of the bone, separated from the soft parts, and attached to the acetabulum by the round ligament, always receives through that ligament a sufficiency of nutriment to enable it to live in that cavity; for, there is no instance of its having suffered mortification in consequence of a fracture. Why, then, should it not partake of the properties of life, and particularly of the faculty of reunion when placed in regular apposition with the body of the bone?

97. What shall we say respecting the idea of the synovia wetting the divided surfaces, and by that means preventing their reunion? The history of fractures communicating with joints, better known at the present day, answers this objection, which is indeed nothing but the offspring of mere hypothesis. To these considerations, which are dictated by reason, and to which many more might be added, let us unite the proofs derived from experience, and we will find numerous examples of cures actually performed, particularly in latter times; the truth of this is attested by many cases collected by Desault, both at the hospital of Charity and the Hotel-Dieu. Bruninghausen and Siebold, have had equal success. Many analogous facts have been presented to the Academy of Surgery. In the cabinet of the School of Health, are deposited some preparations obtained from the cabinet of Desault, calculated to remove all difficulties and doubts from this subject.

98. We must acknowledge, however, that in persons advanced in years, the cure is always difficult, often very tedious, and sometimes impracticable, however carefully the treatment may be conducted. But this is only a necessary consequence of the laws of ossification, which, constantly accumulating in the bones too great a quantity of calcareous matter, seems to deprive them by degrees both of life and all its properties. Yet Lesne laid before the academy a case of reunion obtained in a subject at the advanced age of eighty-four.

99. The observations of some modern practitioners seem to prove, that the reunion here is not produced by a substance similar to common callus, but by a kind of ligamento-cartilaginous tissue, in like manner as in the rotula, and the olecranon. But why need we inquire after the means employed by nature? those of art must be the same. It will be always necessary to favour the reunion, by bringing the fragments into contact, and maintaining them so. Without this contact, either a cure will never be obtained, or the substance destined to effect a reunion, becoming deformed and too bulky, will impede motion.

100. Lameness has been long considered as the inevitable consequence of fractures of the neck of the os femoris. Ludwig, professor of surgery at Leipsick, has particularly advocated this opinion, which is supported by Sabatier, and Louis, who considered the total destruction of the neck of the bone, as the cause of the lameness. But few such examples are to be found on record. Ruisk has given an engraving of one. Lameness when it does take place, depends, as it does in oblique fractures of the body of the bone, on the overlapping of the fragments, to which no opposition has been made; so that the insufficiency of our means, and not the nature of the disease, gives rise to this accident, which Desault seldom experienced in his practice.

101. From what has been said, it appears, that, in all respects, authors have given a much more unfavourable prognosis in fractures of the neck of the os femoris than facts and the nature of the affection will justify, that the progress of these fractures is the same with that of all others, and that, when treated with equal skill, there is no reason why their termination should not be equally favourable.

§ XVI.

OF THE REDUCTION AND THE MEANS OF MAINTAINING IT.

102. Reduction, in this case, is attended in general with but little difficulty. The patient, lying on his back, is held under the arm-pits, and by the upper part of the pelvis, by assistants who make counter-extension in this way, without being obliged to pass, as recommended by the Academy of Surgery, a strap under the affected thigh (30). Another assistant makes extension, according to the method formerly described (29), drawing the point of the fragment very gradually in the direction opposite to that which it has taken in becoming displaced, and making the thigh at the same time rotate a little on its own axis. This gentle rotation renders success more certain.

103. If things be properly arranged, a slight effort is sufficient to bring the separated fragments into contact and to restore to the limb its natural form; for, as I have already observed (86), a facility of reduction is even one of the characters of this fracture. But it is very difficult for art to maintain permanently what she easily effects at the time of reduction, and on this account, our curative processes are oftentimes insufficient.

104. These processes may be considered under three classes, according as they relate 1st, to position; 2dly, to bandages; 3dly, to the forms of apparatus for making permanent extension.

In the first class must be included the method of Foubert, employed in ancient times, according to Louis, and which consists in placing the patient on a horizontal plain, while the limb is secured by simple splints, and the foot by a kind of shoe. But in a short time the muscular action, to which no resistance whatever is made, draws the lower fragment upwards, while the weight of the body pushes the pelvis downwards, and along with it the superior fragment. Hence a new reduction, the effect of which is again immediately destroyed as at first. Thus are new displacements succeeded by new replacements throughout the whole course of the treatment.

105. This method, almost universally adopted in latter times, and approved of by Louis, was in vogue at the hospital of Charity, when Desault entered it. Ought we then to be surprised, that the fracture was considered as incurable? Here indeed the plainest and most important indication is evidently disregarded. Nothing to retain the fragments in apposition, nothing to prevent them from being constantly moved. Does not the method of Foubert very closely resemble those experiments, in which, the bone of an animal is broken intentionally, and then to prevent a reunion and form an artificial joint, the fragments are kept in constant motion?

106. Will any better success attend the method of securing the leg, as Dalechamp recommends, to the foot of the bed? In such a case the trunk and the pelvis glide down along the inclined plain made by the pressure of the nates (14), and hence a constant cause of the shortening of the limb.

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. 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 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).

Le Spica de l’aine. TRANS.

(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).