Part 42

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.

On opening the body, the parts in the neighbourhood of the joint were evidently tumefied, and the capsule was stretched from above downwards. The head of the os femoris was situated on the external edge of the acetabulum. The capsule, though greatly elongated was still in a state of tension; and the articular cartilage was swollen to such a degree, as nearly to fill up the cavity. The quantity of synovial fluid was less than natural.

7. This case, taken at a period of the disease not far advanced, fully confirms the inference deducible from the two preceding ones, respecting the cause of spontaneous luxations. Here, indeed, the capsule not having given way, the swelling having only just commenced, and the synovia existing in but small quantity, the progress of nature was evident. Here, also, occurred a sign not noticed by Petit; namely, the elongation of the limb, which always, in such cases, precedes its contraction.

From what we have said, it appears, 1st, that the efficient cause of spontaneous luxations of the os femoris, is a swelling of the articular cartilages, which alters and destroys their organization: 2dly, that the presence of this swelling must necessarily render fruitless all attempts that might be made to replace the head of the bone in its cavity: 3dly, that the change in the organization of the cartilages, renders astringents, discutients, and other external means applied for the purpose of removing the tumefaction, entirely useless: 4thly, that here, as in many other cases, art ought to confine itself to the palliation of effects, and not attempt the removal of causes.

MEMOIR XIII.

ON THE FRACTURE OF THE ROTULA.