Part 45

35. To obtain the first effect different means have been employed; but none answers so well, to extend the limb and retain it immoveably in that state, as a long and strong splint, placed, as Desault did it, subsequently to the application of the first part of the bandage, along the posterior part of the limb. An assistant must hold the end of this splint, while the surgeon secures it in its place by the second roller (31): in this way the extension of the leg is effected.

36. To obtain the extension of the thigh, it is necessary to place on the top of each other, two or three bolsters or little bags filled with chaff, so disposed as to form an inclined plain, considerably elevated towards the heel above the level of the bed, but which, gradually descending to the same level towards the tuberosity of the ischium, forms a supporting basis on which the whole limb may rest in a uniform manner. By this twofold extension of the leg and of the thigh, the lower fragment is kept up immoveably, and the muscles are kept in a state of relaxation.

Hence it follows, that this bandage fulfils extremely well the conditions laid down (18), and that it ought to be preferred to all the others (19 ... 25), which answered the indications only in part.

37. Whatever may be the advantages of this bandage over the others, it must still be acknowledged to have its inconveniences. The rollers become relaxed in a short time; their compression is less active; the muscles, being less confined, contract more readily; hence the necessity of frequently repeating the application of the apparatus, a circumstance which is very troublesome, on account of the roller which composes it, and covers the whole limb. The resistance of it even when it is recently applied, is not always equal to the power of the muscles, whence the most assiduous attention is necessary, to obtain such a consolidation as to leave no trace of the fracture behind. Few persons ever possessed, like Desault, the art of overlooking nothing that might in any way contribute to the success of his treatment: from this, no less than from the excellence of his processes, arose the number of his cures. Let us confirm, by a few examples selected from among a great many, the doctrine here laid down. The following cases were collected by Julian and Bezard.

CASE I. Francis Leclert, of a sanguine temperament, fell on the 7th of October, 1790, on his right knee, and produced a transverse fracture of the rotula. He was not able to rise; he was carried home, where a surgeon, on discovering the nature of his disease, advised him to be taken to the Hotel-Dieu.

He was conveyed thither on the day following, and, in the interval, a considerable swelling had occurred around the joint. The usual bandage was employed; the pains ceased immediately after its application; a copious blood-letting was directed, and a low diet was prescribed.

The whole apparatus was wet with vegeto-mineral water, two or three times a day. On the next day some light food was allowed, and the quantity increased by degrees, till in a short time the patient returned to his usual regimen. Eighth day, the swelling being almost gone, the bandage had become relaxed it was therefore reapplied. Every day the inclined plain formed by the bolsters was carefully examined, and put in order again as often as it became deranged.

Fifteenth day, a new application of the apparatus: twentieth day, an evacuation in consequence of a bilious disposition. Nothing particular occurred from this time till the completion of the cure, which took place on the sixty-seventh day after the accident: no depression existed at the place of the fracture: the motions were perfectly free; these were aided, by daily exercising the knee joint for some time.

CASE II. Vincent Grenier, aged thirty-eight, making a false step, fell on the rotula, and fractured it, on the 6th of June, 1791: he was brought to the Hotel-Dieu, where Desault demonstrated to his pupils, by the usual signs the existence of the disease: a considerable swelling had already taken place. The bandage formerly described was applied: the same precaution as in the preceding case; apparatus examined every day; renewed as often as relaxed; extension maintained with great exactness. On the forty-fifth day, the consolidation was nearly effected; on the fifty-second it was complete, the joint was exercised for some time, and on the seventy-seventh day the cure being in all respects complete, the patient was discharged.

MEMOIR XIV.

ON THE FORMATION OF FOREIGN BODIES IN THE JOINT OF THE KNEE.

1. The history of foreign bodies divides itself naturally into two great sections; the one includes those that are introduced from without; the other such as are formed within our own systems. This latter section may be again divided into two classes; to the first class belong bodies altogether inorganic, such as the different kinds of stones; to the second, those which are truly organic, and become foreign only by being situated in places where they impede the functions, such as cartilaginous or bony productions, existing accidentally within the joints.

On the subject of the latter class, art is much more deficient than she is with regard to the former. Let us endeavour to assist her a little, by giving a sketch of the opinions and practice of Desault with respect to these productions.

2. Before his time, the surgery of France appears to have contained scarcely a record of this affection. Described only in some ancient works, such as the writings of Pare, it had been forgotten by the moderns, when numerous instances of it were suddenly met with by English and German surgeons, and soon afterwards by Desault, who illustrated and confirmed the practice of his predecessors in it, and even added something of his own.

3. All the joints may become the seat of these concretions; Haller found many of them in that of the lower jaw; Bell mentions, as a very rare occurrence, their existence at the junction of the foot with the leg. Some authors have met with them in the wrist; but none are more common, or merit more particular attention, than those that exist in the joint of the knee. To these alone shall the following observations be confined, because these alone have fallen under the notice of Desault.

§ II.

OF THE VARIETIES.

4. Concretions of the joints do not always assume the same aspect. They vary greatly as to number, size, figure, structure, &c. In general, these bodies exist singly; sometimes, however, two of them are found in the same joint, and then they may be extracted either at the same time, or in succession, as was once done by Desault. Some English surgeons have also met with two concretions, and Morgagni has found even twenty-five, in the same joint.

5. They vary also in size. The largest ever met with by Desault, was fourteen lines in its longest, and ten in its shortest diameter. Six lines diameter in every direction, was the measure of the smallest one that occurred in his practice.

6. Their figure is sometimes lenticular and smooth on both sides, sometimes unequal, rough in one part, even in another, concave on one side, convex on the opposite, sometimes marked around the circumference and sometimes not with reddish points, and having occasionally a stem of a cellular texture and of some length, as may be seen in a paper by Theden. They usually consist of a single mass, but are in some cases divided into several lobules united by a kind of ligaments, as in the fourth case related in the Journal of Surgery. Though most frequently detached and floating in the interior of the joint, they have yet been found adhering by means of small portions of cellular substance, loose and capable of being stretched, or tight, hard, and even of a ligamentous nature.

7. If, from the external figure, we pass to the structure of these bodies, we will find them existing in three different states. Sometimes purely cartilaginous, sometimes completely bony, they at other times partake of both these states, in which case a bony nucleus is covered with a cartilaginous crust. Out of five cases, recorded by Desault, three are of the first, and two of the third kind. Many authors have met with the second kind, particularly Morgagni, who has even found in the same joint, some bodies of a bony and others of a cartilaginous nature. Hence it appears, that this variety of structure is to be attributed to the longer or shorter standing of the disease, that every concretion must pass successively through these three states, and that there is a great analogy between the formation of such bodies and natural ossification.

8. If we examine a body of the third kind cut in two through the middle, we will find it red and vascular in the centre, like an epiphysis, even when it is floating in the joint perfectly loose and free from adhesion.

9. Bell, in his treatise on surgery, speaks of a kind of tumour, at first soft, membranous, and adhering to the internal surface of the capsule, but which, according to him, may become afterwards hard and solid, and be detached so as to float loose in the joint. But are not these tumours different in their nature from those destined to be converted into bone? Do they, in fact, ever undergo the changes mentioned by Bell? Desault having never met with any of them, was unable to offer an opinion on the subject. In the mean time, an observation made by Monro, may serve to throw some light on the question: he once saw, in one of these productions, a cellular nucleus surrounded by a covering of bone.

10. Though usually simple and free from complication, this affection may, according to some authors, give rise occasionally to a dropsy in the joint. Pare is the first who has made mention of this: he found one of these bodies in a patient’s knee, into which he had made an incision for the purpose of drawing off a collection of water. Simson, on extracting a similar body, gave vent to four ounces of water. But, as on the one hand, a dropsy of a joint oftentimes exists without these foreign bodies; so, on the other, these bodies are almost always found disconnected from dropsy. Nor is there any affinity between the acknowledged causes of an accumulation of synovia, and the presence of these bodies; so that when the two diseases do exist together, it is altogether probable, that they are independent of each other.

§ III.

OF THE CAUSES.

11. The formation of articular concretions succeeds frequently to blows or falls received on the joint, in which case, a swelling more or less considerable in the surrounding soft parts, showing itself from the first, and remaining for some time, at length allows the foreign body to be perceived, and does not, in general, disappear during the continuance of the body in the part.

12. Sometimes no external injury contributes to the formation of the body, and then, a spontaneous swelling precedes its detection, as Desault observed in two patients, where nothing was known to have concurred in the production of the disease. Constant rest increases this swelling, while exercise and a temperate mode of life diminish it.