Part 39

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 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.)

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.