Part 52

In the evening venesection was prescribed: the patient experienced sharp pains at the place of the fracture; a slight swelling occurred at the ends of the toes; an anodyne was prescribed. Next day, evidently better: venesection again. Fourth day, the patient is allowed to return to his usual regimen. Eighth day, apparatus removed for the first time; fragments in contact. Fifteenth day, a second application of the bandage. Nineteenth day, bilious symptoms. Twenty-first, an emetic given in solution. Thirty-second day, further evacuations: apparatus renewed. Forty-seventh day, consolidation complete. A stiffness remained in the part for some time, but this was gradually removed by exercise.

MEMOIR XVII.

ON COMPLICATED LUXATIONS OF THE FOOT.

§ I.

1. Complicated luxations of the foot, like complicated fractures, show themselves under such a variety of forms, are accompanied by so many peculiar affections, and so many different circumstances are connected with them, that it would be difficult to lay down rules applicable to their treatment in all cases. On this subject, indeed, art is in possession of certain general principles, liable however to numerous exceptions and modifications. In the treatment of such cases, who can fix the limits between reduction, and amputation or extirpation? Who can point out, with precision, where the one ceases to be useful and becomes hazardous; while the others constitute the only resources of art? Experience and talents alone are capable of deciding on these points, and that only in the chambers of the sick. It is, therefore, less by precept than example that practitioners ought to be instructed here.

2. To furnish suitable examples on this head constitutes my only object in the present memoir, which will consist of the histories of a few cases, with such inferences and remarks as the occasion may seem most naturally to suggest. Here the practice of a great master, varying his means with the varying forms of disease, will serve as models to those who may meet with similar cases. Our experience is composed of the facts which we receive from reading, as well as of those derived from observation. Who would have a right to call himself a surgeon, if he had no other title to that name, but such as resulted exclusively from his own personal observation?

3. However difficult it may be, as already observed, to speak in general terms, on the present subject, we may yet assert with safety, that authors have greatly exaggerated the danger of complicated luxations of the foot. Terrified at the extent and unpromising appearance of the accidents, these writers have lost that confidence in the powers of nature which we never ought to abandon. They have taken up an opinion, that luxations of the foot, differing in their symptoms from other luxations, require also a different mode of treatment; that reduction, by perpetuating the accidents of the case, must prove fatal, and that amputation ought to be adopted as the only resource. Cases do certainly at times occur, where a doctrine different from this would be fatal in its effects: such are those terrible lacerations, where the foot is entirely separated from the leg, except some shreds of flesh with a few tendons among them that still retain it.

4. But, provided the blood-vessels have escaped, and any hope of circulation and life in the part still remain, the success of reduction should always be first tried; and the following examples will show, what ought to be expected from this practice, when accompanied by skilful treatment.

§ II.

LUXATION OF THE FOOT, COMPLICATED BY A FRACTURE OF THE FIBULA, TIBIA, &C.

CASE I. (The following case was collected by Leveille.) Abraham Genty, aged forty-three, a dealer in wine, as he was running along the street, slipped, and made a false step on his left foot, which turned with its external edge under him, and its internal edge upwards. He fell, luxated his foot, and fractured the fibula.

The patient was carried home, where a surgeon who was ignorant of his profession being called, did nothing but apply a cataplasm to the foot. In the evening the parts began to swell, and were extremely painful; fever supervened, accompanied with great restlessness. Third day, to a rapid increase of all the symptoms was added a delirium; blood-letting from the jugular vein was prescribed to no purpose; things continued to grow worse till the sixth day, when the patient was brought to the Hotel-Dieu, in extreme danger.

The following was then the state of the parts. A considerable swelling around the joint; a projection of the malleolus internus, with a depression underneath it; a preternatural direction of the tibia before, and of the os calcis, behind; a depression near the lower end of the fibula; a crepitation readily perceived, on moving the fragments; a large tumour on the outside of the foot: with a depression and mobility of the malleolus externus.

The luxation was immediately reduced. Extension made on the foot and leg brought the parts into their proper situations, where they were retained by means of the bandage for fractures of the leg, and four compresses well secured by the bandage. One of these compresses, being placed on the malleolus internus, another on the outside of the foot, a third on the anterior and lower part of the tibia, and the fourth under the os calcis, prevented these different parts from being again displaced.

As soon as the apparatus was applied, the pupils remarked with astonishment, that the restlessness of the patient ceased, that his pains were relieved, and his delirium disappeared; he expressed his surprise at the state from which he had just recovered, and was now able to give an accurate account of his fall. He was scarcely put to bed, when he fell into a tranquil sleep, which lasted three hours. For six days previously he had not slept a moment.

In the evening, the patient was free from pain, and perfectly tranquil. Diluting drinks were prescribed, with twenty-five drops of Hoffman’s anodyne liquor: the apparatus was wet from time to time with vegeto-mineral water: the patient slept well throughout the night.

Next day, the apparatus renewed: the parts perfectly in place: swelling diminished; same means continued. Sixth day, the anodyne discontinued. Tenth day, swelling still less; echymosis gone; a yellow colour in the skin, an evidence that resolution is going forward. Twentieth day, swelling gone.

Thirtieth day, the fracture of the fibula healed; that bone slightly separated from the tibia: the circular roller drawn tighter; and a thick compress placed on the external malleolus, to bring it to its proper place. Forty-fifth day, the apparatus for a fractured leg removed, and a simple roller substituted in its place: the motions of the foot painful and contracted; a small gangrenous spot appeared on the heel. Fifty-fifth day, the ulcer which proceeded from this spot healed: motions of the part more free and extensive. Sixty-first day, the patient able to walk without assistance, though not without pain.

5. It is difficult to find an instance where the advantages of reduction have been more remarkable than in the preceding one. The patient had passed six days in pain, extreme agitation, and uninterrupted delirium: the foot was reduced, and these unfavourable appearances instantly vanished, and were succeeded by a state of tranquillity. Alarmed by such a state of things, the ancients would doubtless have proceeded to amputation. Let us examine into the motives which led Desault to an opposite line of practice, and then inquire into the cause of the success with which that practice was crowned.

6. Had amputation been performed here, it must have been for one of the two following reasons; 1st, for fear of gangrene; or 2dly, to remove the unfavourable symptoms that existed. The first apprehension would have been quite visionary, in as much as all the blood-vessels were sound. Would the second consideration have been any better founded? It was perfectly obvious, that the unfavourable symptoms which existed arose from the tension and overstretching of the parts, in consequence of the preternatural position of the bones of the foot. The indication was evident. Replace these bones in their natural situations, the strained parts will then necessarily become relaxed, and all the troublesome and alarming symptoms cease with the cause that produced them. Experience confirmed the justness of this reasoning.

7. But the mere replacement of the parts would be of very little avail, if it were not permanently maintained, and followed up by a judicious mode of treatment. Without such treatment there would doubtless be reason to apprehend all that train of troublesome consequences, of which authors speak in such frightful terms, and which arise, not from the nature of the luxation, but from the manner in which the patient is treated. A loose apparatus, incapable of preventing displacement, would allow the bones to be deranged anew, and to produce again an overstraining of the parts, accompanied with pain, swelling, &c. Irritating local applications, such as camphorated spirits of wine, &c. would increase these pains; emollients which are employed in other cases would keep up the swelling.

8. It follows from what has just been said, that an opposite mode of treatment ought to succeed the reduction, and this we see was the case in the preceding instance. There, when the bones were once reduced, all new displacement was prevented, because the apparatus was so constructed, as to counteract the tendency of the bones to be displaced. The external edge of the foot, which had been turned outwards, was now pushed inwards by a thick compress; the same means served to push outwards the internal malleolus, which had received by the accident an inclination inwards, and to push the anterior part of the tibia backward, and the os calcis forward, both of which were displaced, as has been remarked, in contrary directions. Two strong splints fixed the lateral compresses, while the anterior and posterior ones were firmly secured by rollers. In the midst of all these resistances, the foot being necessarily immoveable, no new displacement could occur.

9. A suitable and judicious position, in which the foot, raised a little higher than the leg, was placed on a pillow forming an inclined plain, prevented swelling, while gentle compression, made by a bandage, contributed to the same end. This end was also further attained by the external topical applications. To relieve pain and remove congestion, were here, as in sprains, the two indications to be fulfilled. To these indications the spirituous and the relaxing applications formerly in use, are alike opposed. Vegeto-mineral water, on the contrary, fulfils them extremely well. Hence the necessity of keeping the apparatus constantly wet with that liquid.

10. Regimen influences not a little the success of the treatment. A strict diet is necessary during the time of the inflammatory and unfavourable symptoms. Any excess might then prove fatal. Desault gave, in his lectures, an account of a woman, who had her foot luxated outward, and the astragulus forward. Her fever was considerable, her pains excruciating, and the swelling wore an alarming aspect. The luxations were reduced: all the threatening appearances vanished, and every thing seemed to promise a favourable termination of the disease. But, on the fiftieth day, the patient, having procured strong food, ate largely of it: in the evening all the unfavourable symptoms returned; the swelling became great, and a few days afterwards she died.

But if strong food be prejudicial during the time in which bad symptoms are to be dreaded, a diet too strict would be equally injurious when that time is passed. The weakened powers of the system would not be adequate to the purposes of a cure, particularly to the consolidation of the bone, should the case be a fracture. Desault, therefore, permitted the patient to increase his diet by degrees, and at length to return to his usual regimen.

11. The following case, reported by Giraud, proves still further the advantages of this simple mode of treatment, which, should it even fail, always allows the surgeon to avail himself of amputation, which is indeed the last resource of art, and should never be employed till rendered indispensable by the failure of all other means.

CASE II. Maria Constant, aged forty-six, descending a flight of stairs in haste, fell, and luxated her right foot outwards, the tibia inwards, and fractured the fibula near to the lower end.

Her cries brought assistance to her, and she was carried to the Hotel-Dieu. Giraud, who then officiated as surgeon in chief, visited her, and discovered that there existed both a luxation and a fracture, though most of the signs were rendered obscure by a considerable swelling: a slight echymosis occupied the back of the foot, and severe pains were experienced.