Part 47

6. If any resistance be met with, enlarge the opening and the extraction will become easy. Without this precaution, the edges of the wound, being bruised and irritated by the passage of the body, will swell, inflame, and unite again with difficulty.

7. When the extraction is finished, the assistant who draws the skin towards the inside of the joint, suddenly lets it go, when it returns to its natural situation. This causes the two incisions, which corresponded, at the time of the operation, to change their relative situation, the one remaining internal and the other becoming external.

8. Hence arises a twofold advantage; the entrance of air into the interior of the joint is prevented, and the external and loose portion of the capsule, being drawn inwards with the skin, unites with the condyl, if it be not brought into exact apposition with the other portion of the capsule, divided near its attachment.

9. The extraction being finished, it is then necessary to examine carefully, in order to ascertain whether or not the joint contain any more of these foreign bodies. On some occasions, when this is even the case, they cannot at the time be discovered. Desault himself was once deceived on this score, in consequence of which his patient was obliged to submit to a second operation.

10. The incision in the integuments is now united by means of adhesive plaster. Over this are laid compresses and a little lint, and the whole secured by a few turns of a roller drawn moderately tight.

11. The leg being then placed on a pillow, is kept in a state of extension, by means of a splint applied, for a few days, behind the joint.

29. If we examine but for a moment the process in this operation, we must perceive, that an incision made through the skin and capsule at a single stroke, is, in no respect, less advantageous than one made at two strokes, as recommended by all practitioners, and that, it is in the following respects greatly preferable to it: 1st, it shortens the operation very considerably: 2dly, it diminishes the pain: 3dly, it exposes the joint a much shorter time to the contact of the air.

30. The object of the operator is better answered by drawing the skin outward and towards the rotula, than by either depressing it, as Broomfield did, or raising it, as Bell does. Being more loose and more easily stretched in this direction, the opening in it is removed farther from that in the capsule, which prevents more certainly the access of air to the joint, and also favours the examination of the capsule.

31. In the mean time, the operation may succeed, even although the openings in the integuments and the capsule correspond to each other. Many English and German practitioners, without previously stretching and changing the natural situation of the skin, make a common incision, which they dress afterwards like a simple wound, and are yet no less successful than others in the result of their operations. This is a further proof of the fallacy of the ancient surgical doctrine, respecting the admission of air into the cavities of joints. Perhaps Desault might have omitted this precaution, had any operations of the kind occurred in his practice during the last years of his life.

32. The operation is seldom attended with much pain. Only one patient manifested signs of this in the practice of Desault. Nor have those operations of the kind performed in England been more painful, so that it may be laid down as a principle, that in most cases no primitive accident is to be dreaded.

33. With regard to hemorrhagy, as there is no large artery near the place of the incision, there is nothing to be apprehended on that score. Oftentimes there is scarcely any loss of blood at all, as may be seen in the first case published in the Journal of Surgery. But, even admitting that a small articular branch be divided, the reunion of the edges of the wound will be sufficient to check the hemorrhagy, in the same manner as in the operation for the hare-lip, the contact of the divided integuments of the lip, puts an end to the hemorrhagy from the small arteries of the part.

§ XIV.

OF THE SUBSEQUENT TREATMENT.

34. I have already said that but little is to be apprehended on the score of accidents subsequent to the operation (26). Out of the numerous operations of the kind performed lately in Europe, but few cases have proved troublesome in their consequences, and even these were influenced by some foreign circumstances. Thus, for example, one of the patients of Simson rode out on horseback a few hours after the operation, on a cold and stormy day, and thus produced a troublesome affection of the part. A similar remark may be made respecting the case formerly mentioned (27).

35. The apparatus or dressing remains untouched for the two or three first days, during which time it is necessary to wet it frequently with vegeto-mineral water. It is a certain truth, that the use of this liquid retards the suppuration of wounds, and that, when continued a due length of time, it keeps inflammation at that degree most proper for the process of healing.

36. On the removal of the dressing, the wound is sometimes so perfectly healed up, as not to exhibit the least discharge. At other times a slight suppuration takes place; but, at the end of a few days, the cure is complete. Under the care of Desault, it was always effected in eight or ten days.

37. Let us bring the doctrine just laid down to the test of experience. Five cases have been published on this point. I have selected two of them, both which occurred in the same subject, where we find the same operation twice performed with equal success.

CASE I. M. Vielle, aged nineteen, was attacked about the beginning of the year 1790, by a spontaneous swelling in the joint of the knee. Inconsiderable at first, but increased afterwards by a laborious journey, it disappeared at the end of two months, discovering to the touch, near the internal edge of the rotula, a foreign body, which was hard and moveable, and which somewhat impeded the motions of the joint.

About a month afterwards, the swelling returned, and, having continued for three months, disappeared again, when the body was found at the external side of the rotula, increased in size. Sundry external applications were tried for six months without success.

Weary of this unavailing practice, the patient came, in March, 1791, to consult Desault, who discovered a cartilaginous substance of a flat and circular figure. Its usual situation was at the external side of the joint, but it could be easily moved to the internal side, and could be turned on its own axis within the joint, nor did it occasion any pain, when suffered to remain at rest by the side of the rotula. But, when it passed behind the tendon of the extensor muscles, the patient was unable to stand, and he experienced severe pains when it made its way under the condyls or behind the rotula.

The indication was evident. Before the operation Desault prepared the patient by a proper regimen, and then, in the method already described (28), extracted a foreign body, whitish, and oval, fourteen lines in length, ten in breadth, and two and a half in thickness at its middle. It consisted of three pieces, united by a ligamentous substance, and was smooth on the side next the joint, but rough with irregular tubercles on the opposite side, and on its circumference. There was no loss of blood during the operation: the usual dressing was applied, after the most attentive examination, as to the existence of a second body.

Neither pain nor swelling supervened, and by the fourth day, the reunion was complete. In a short time motion was performed with as much ease as before the occurrence of the complaint. In the mean while, a degree of uneasiness remained in the joint; but barely perceptible at first, this uneasiness continued to increase; in about four months, symptoms of the existence of another foreign body made their appearance.

M. Vielle being now a distance from Desault, put himself under the care of his brother, who extracted a second body, in the manner already described, except that the incision was made at two strokes.

Dressing the same as in the preceding case, with this additional precaution, that the thigh and leg were covered by a roller, for the purpose of moderating the action of the muscles.

No fever, no pain; the reunion completed on the eighth day, except a small point in the centre of the wound, which suppurated slightly till the fourteenth. There was now neither difficulty in walking, nor the least sensation of pain. Since that time, M. Vielle has enjoyed the entire use of his limb.

OBSERVATIONS AND REFLECTIONS

ON FORMS OF APPARATUS FOR FRACTURES OF THE LEG.

§ I.