A Treatise on Fractures, Luxations, and Other Affections of the Bones

by P.-J. Desault

MEMOIR XI.

ON THE FRACTURES OF THE THIGH.

§ I.

1. The os femoris, being in man, a moveable support for the weight of the whole body, appears to be better secured than the other bones, from accidents that might affect its continuity. The numerous masses of muscle that immediately surround it; the thick and compact layers or fasciæ that form its more exterior covering; and an articulation loose, and ready to yield, in every direction, to the motions impressed on it, all seem, on the one hand, calculated for its preservation.

2. But, on the other hand, being visibly curved in its middle, bent at its upper end almost at a right angle, longer in proportion in man than in quadrupeds, placed, in most falls, between the ground which resists, and the weight of the body which presses on it; it would seem, from these latter circumstances, to be less calculated to resist external force. And, if to these considerations be added those of the causes which have an immediate action on it, it will be easy to perceive, that, in a comparative scale of the bones most exposed to fractures, it holds, next to the bones of the leg, one of the highest grades. The proportion which its fractures bear to those of the leg, is, according to the observations of Desault, as one to three; but to that of most other bones it is equal if not superior.

3. The os femoris, being in its body irregularly cylindrical and curved behind, becomes larger towards its lower end, where it terminates in two articulating masses, which rest immediately on two corresponding surfaces of the os tibiæ; changing its direction above, it inclines towards the acetabulum, and inserts into that cavity a round head, supported by a neck which is entirely enclosed in the capsule of the joint.

4. From this different conformation of its different parts, arises such a variety in the fractures which occur in it, that they cannot be treated of under the same head. Hence the division into fractures of the body and of the extremities, which is borrowed from anatomists, and will be followed in the present memoir, where we will consider in order,

1st, The fractures of its body,
2dly, Those of its upper extremity,
3dly, Those of its lower extremity.

FRACTURES OF THE BODY OF THE OS FEMORIS.

§ II.

OF THE VARIETIES AND CAUSES.

5. The os femoris may be fractured indifferently at any point between its condyls and its neck. But the part where this accident most frequently occurs, is about the centre of the curve of the bone, where most of the motions and shocks impressed on it by external violence expend their force.

6. Whatever may be the seat of the fracture, its direction is sometimes transverse, but most frequently oblique, a variety which does not affect the real nature of the disease, but which possesses, as to its consequences, a very important influence. As in other affections of the kind, so here, the bone is sometimes affected alone, and, at other times, to a fracture simple or complicated by means of splinters, is added an injury done to the surrounding soft parts. Hence result compound fractures, differently varied, according to the nature of the parts affected, and to the extent and other circumstances of these affections. But, as Petit observes, this bone is less frequently shattered or crushed into several pieces, than those that are more superficially situated.

7. Extraneous causes are known to render falls more frequent in man than in other animals, and to multiply in him the fractures of the lower extremities, by multiplying the action of external bodies on these extremities. This action may be exerted on the os femoris in two modes. Sometimes only passive, it merely offers a resistance to the power which puts the bone in motion; thus, in a fall, the os femoris, being pressed between the ground which resists, and the weight of the body that bears on it, bends beyond the extent of its flexibility or pliancy, and finally gives way. At other times the influence of external bodies is actively and directly exerted in this accident: thus a stone, or a piece of timber, falling on the thigh, fractures the bone, in consequence of communicating to it a degree of motion greater than its power of resistance.

8. In common, the first mode of division is by a true counter-stroke, similar to that which fractures the clavicle, the ribs, &c. In the second mode, the fracture is always direct. The middle part of the bone is generally broken in a counter-stroke: wherever the direct stroke is received, that is the place of the fracture which it produces; the division, most frequently oblique in the first case, is sometimes perpendicular or transverse in the second. From a counter-stroke result most commonly simple fractures, while compound ones are usually owing to a direct stroke.

§ III.

OF THE SIGNS AND THE DISPLACEMENT.

9. In whatever manner a fracture of the os femoris may have occurred (7), its existence is characterized by the following signs: severe local pain at the instant of the accident; a sudden inability to move the limb; a preternatural mobility occurring in some particular part; a crepitation sometimes distinct, when the two fragments are rubbed against each other; and a deformity, which may be considered under the threefold relation, of length, thickness, and direction.[22] These signs, being common to most fractures, exhibit but few circumstances peculiar to those of the os femoris, except that of the deformity. Respecting this circumstance, in particular, it is essentially necessary to possess accurate ideas, because, having an incessant tendency to recur, especially in oblique fractures, it must constitute a primary object of attention during the treatment.

10. It may be laid down as a general principle, that all fractures of the os femoris are accompanied with some deformity; the exceptions to this rule are too few to be worthy of notice. If this deformity be considered in relation to length, it will be found that, in oblique fractures, the limb is always shorter than that of the opposite side, a circumstance which plainly points out an overlapping of the fragments. But, on examining the place of fracture, it is easy to discover, that this overlapping arises from the inferior fragment mounting upwards on the superior one, which itself remains immoveable. Now, what power, but the contraction of the surrounding muscles, can communicate to the inferior fragment a motion from below upwards? Attached, on the one hand, to the pelvis, and on the other to this fragment, to the rotula, the tibiæ, and the fibula, these muscles have on the former their fixed, and on the latter their moveable points, and, drawing the leg, the knee, and the inferior portion of the thigh upward, they produce the displacement and shortening either mediately or immediately. In this displacement, the adductores, the semi-tendinosus, the semi-membranosus, the rectus anterior, the rectus internus, &c. are the principal agents.

11. The following case communicated to Desault by a surgeon, who had been formerly his pupil, proves how great the influence of this cause is; a cause which is indeed generally acknowledged, but not sufficiently attended to by practitioners, with a reference to permanent extension. It is this that induces me to relate the case.

Case I. A carpenter falling under the ruins of his scaffold, was immediately taken up and carried home, where a surgeon discovered an oblique fracture of the os femoris, but without any displacement. The thigh, which appeared even a little longer than the other, was fixed in an apparatus too slack to prevent muscular action. Next day, the length of the thigh was the same, but the whole extremity was in a paralytic state, accompanied by an entire inability to discharge urine.

The moxa was proposed. The patient being placed in the position directed by Pott, for fractures of the os femoris, the fire was applied; some movements were the consequence; the application being repeated on the sixth day, the muscles instantly recovered their power of action, and then the shortening of the limb became evident, and still returning immediately after being removed by extension, rendered it necessary to have recourse to an apparatus calculated for permanent extension.

12. In this case, the muscular influence is evident. Indeed the shock having produced a temporary suspension of the excitability of the part, the fragments remained in place and in proper contact with each other: but the moxa having awakened the excitability again in the muscles of the thigh, they resumed their action and caused, as usual, the inferior fragment to mount on the superior.

13. Hence it follows, 1st, that it is principally to the action of the muscles that we must attribute the displacement, in the longitudinal direction of the bone; 2dly, that, as that action, being the effect of an inherent power, is constantly exerted, the limb must have a constant tendency to this displacement, particularly in oblique fractures, where the two extremities of the bone represent two inclined plains, which readily glide along each other.

14. To this must be still added another cause, which operates injuriously in the course of the treatment. However solid the bed may be on which the patient lies, the nates or buttocks, being the most projecting part of the body, soon form a depression in it; hence arises an inclination or descent of the plain or surface on which the body lies. The body therefore sliding downwards, pushes before it the superior fragment, and makes it overlap the inferior one. In consequence of this, the muscles, being irritated by the points of the bones, increase the force of their contractions, and, as we have already observed (10), draw the inferior fragment upwards. This double movement of the two ends of the bone in contrary directions, produces only a single effect, namely, the overlapping of these ends, but carries this overlapping to a higher degree.

15. Transverse fractures are less exposed to displacement, in the longitudinal direction of the bone, because the fragments when in contact, support each other. In such a case, the inferior fragment, drawn by the muscles, finds a point of resistance against the superior one, while the latter, when pressed downward by the weight of the body, pushes the former before it, and thus both preserve their relative position.

16. A deformity of the fractured os femoris, in the direction of its cross-diameter or thickness (9), always accompanies that in its longitudinal direction, and sometimes exists alone. This takes place when, in a transverse fracture the two ends of the bone, losing their contact, are carried, the one outward, and the other inward, or when the one remains in its place, while the other is separated from it. In such a case, the superior fragment is not, as in the preceding one, immoveable by means of muscular action; because the action of the pectineus, the psoas, the illiacus, and the first adductores, derange its natural direction, and contribute to its displacement.

17. The deformity of the limb, in relation to its direction, in other words, the crookedness of the limb (9) is either the result of the stroke which fractured it, or, what is more common, of the ill directed efforts of those who lift and carry the patient, and, by an improper position, bend the two fragments, so as to make them form an angle with each other. Desault was once called to a patient, whom he found seated on a bed, in such a manner, that the upper part of the thigh was in a horizontal position, and the lower, hanging with the leg in almost a perpendicular one. Doubtless the triceps femoralis, equally attached to both fragments, bends them by its contraction, and produces a change in the direction of the limb.

18. Whatever may be the kind of the deformity, whether in a longitudinal or lateral direction, the inferior fragment may either preserve the natural position in which it is placed, or experience a rotatory motion on its axis outwards, which is a common occurrence, or inwards, a circumstance which is more rare. This rotation always renders the displacement more serious, and ought to have an influence, as I shall presently observe, on the means of reduction.

§ IV.

OF THE PROGNOSIS.

19. Fractures of the os femoris, though seldom very distressing, in common cases, from any accidents that immediately accompany them, are sometimes rendered so, by inconveniences which are the consequences of them, when they are oblique. Celsus declared, that a shortening of the limb, more or less considerable, was always the result of such fractures. Most authors have copied and repeated this assertion, and, even at the present day, the opinion is advocated by a great number of practitioners. It must be acknowledged, that, if we compare the natural powers that are engaged in producing displacement (10...15), with the artificial resistance made by most of our forms of apparatus, we will perceive that there is between the two forces so great a disproportion in point of strength, that the former can never yield to the latter. But, is it in the nature of all forms of apparatus to be unable to overcome the force of the displacing powers? Cannot an equilibrium be established, so as to retain the fragments in contact? The remainder of the present memoir will throw some light on this problem, which will become less difficult of solution, if we call to mind, that the action of muscles, though very powerful at first, diminishes afterwards by degrees, in consequence of their being kept in a state of permanent extension; that even a weaker power may, by acting constantly, accomplish ultimately, what could not have been effected at once, by another power much stronger, if only momentarily applied; and that compression made by circular bandages, tends also to diminish the force and prevent the action of muscles.

Desault has cured, at the Hotel-Dieu, a vast number of fractures of the os femoris, without the least remaining deformity, and there are but few of his pupils who have not witnessed his success, some instances of which will be cited in this memoir.

20. It is, above all, from the well combined use of these two means, the extension and compression of the muscles, that that success was derived. The advantage of extension, in diminishing muscular force, is evident, particularly in the reduction of certain luxations, those of the humerus, for example, where we are frequently unable to succeed, till after having extended the muscles for a longer or shorter time.

Fractures of the rotula and of the olecranon, prove equally the utility of compression in effecting the same purpose; for, when the muscles are not compressed by a bandage, they draw the fragment upwards with a double and even treble force.

21. Accidents relating to complications of the fracture, such as splinters, wounds, &c. are to be classed with compound fractures in general, and cannot be treated of in this place.

§ V.

OF THE REDUCTION.

22. Two great indications enter into the treatment of fractures in general, and of that of the os femoris in particular; namely, to bring the fragments into proper contact, and to maintain them so. Let us examine each of these in all their details.

Hippocrates, and every practitioner since his time, have replaced the fragments by what they call extension, counter-extension, and coaptation.[23] This threefold method, though sanctioned by long usage, and rendered almost venerable by age, is by no means necessary at all times in practice, as will presently be observed. Previously to having recourse to it, it is necessary to place the patient in a suitable position. But this position varies: most of the moderns adopt, after the example of the ancients, a horizontal position: so that the thigh may be extended on the body, and the leg on the thigh. This is the common practice at present in France.

23. Pott imagined, on the contrary, that if the lower extremity were kept in a half-bent position, the muscles, being more relaxed, would offer less resistance to the efforts of the extension: he, therefore, proposed to bend the leg on the thigh, and the thigh on the pelvis, and to lay the patient on his side, a position, which, when first employed in reduction, was to be continued throughout the treatment, during which it would render the causes of displacement less active (10...15). Bell adopted this method, which indeed appears to be generally in use in England.

24. But the difficulty of making extension and counter-extension, with the limb thus situated, the necessity of making them on the fractured bone itself, and not on a part distant from the fracture, such as the lower part of the leg; the impossibility of comparing the diseased thigh with the sound one, to judge of the regularity of the conformation; the uneasiness occasioned by this position, if long continued, though it may at first appear the most natural; the troublesome and painful pressure of the body on the great trochanter of the affected side; the derangements to which the fragments are exposed when the patient goes to stool; the difficulty of fixing the leg with sufficient steadiness, to prevent it from affecting the os femoris by its motions; the evident impracticability of this method, when both thighs are broken; and, finally, experience, which, in France, has been by no means favourable to the position recommended by Pott: such were the considerations, which determined Desault to have recourse to it no more, after having tried it on two patients, in one of whom the limb was considerably shortened, notwithstanding the most scrupulous attentions.

25. Besides, all that is gained by the relaxation of some muscles, is lost, by the tension of several others. The knee cannot be bent without the triceps flexor being brought into action; an inconvenience the more serious, as this muscle acts immediately on both fragments. The rectus anterior, though relaxed by the flexion of the thigh, will be thrown into a state of tension by the flexion of the leg. The muscles attached posteriorly to the upper fragment, and even to the superior part of the lower one, will also in certain positions of the limb be rendered tense.

26. Hence it follows, that there can be no just comparison instituted as to the position proper for the limb, between fractures of the upper and those of the lower extremities; that, in the latter, the method pursued by the English surgeons presents an aggregate or general amount of inconveniences so great as to overbalance that of its advantages; and, that the position directed by Hippocrates and the other Greek physicians (22) ought to be adopted.

27. Having determined on the position, the operator proceeds to extension and counter-extension, which are to be made first in the direction of the limb as deformed or altered by the fracture, but must be changed afterwards according to the natural direction of the thigh. I need not here repeat the directions for this double operation: common to all fractures, they contain nothing particular, in relation to that of the thigh. But, on what part should extension be made? Petit, Heister, Duverney, and all their predecessors, recommend to apply the means or powers for making extension above the knee; a precept which is still to be found in the surgical department of the Encyclopedia. A strap surrounding the lower part of the thigh, aided by another placed at the ancle, serves, in this respect, to draw the inferior fragment downward.

28. Dupouy was the first to remark, that this practice rendered it necessary to employ great force, and that it would be better to make extension only on the foot. To this consideration Fabre added that of the inconvenience of the pressure made on the muscles, a pressure which, by irritating them and making them contract, multiplies the obstacles to the reduction.

Desault adopted their doctrine, from nearly the same views of the subject, introduced it into the Hotel-Dieu, and the success which attended it, in his practice, contributed not a little to bring it into general use.

29. For the purpose of making extension, he used the foot as a lever of the first kind. The two hands of an assistant, grasping it in such a manner, as to make the fingers cross on the back of it, while the thumbs, also crossing each other, corresponded to the sole, represented the power; the articulation represented the centre of motion, or fulcrum, and the leg together with the lower fragment, the resistance. The requisite motion was then communicated to the foot, and in that way was the extension effected. This mode is more advantageous than that usually employed, where the hands are applied to the lower extremity of the leg; for the force of the extending power is generally in the inverse ratio of its distance from the resistance intended to be overcome.

30. What I have said of extension (28), applies also to counter-extension. The strap, which was formerly placed for this purpose in the groin of the affected side, by compressing the adductores, and the rectus internus, produced in them a contraction, which, by drawing the lower fragment towards the pelvis, opposed obstacles to the reduction, which are seldom experienced, when, like Desault, the surgeon contents himself with having the trunk held by assistants, either exclusively at the hips, or both at the hips and under the arm-pits. The resistance being always easily overcome in this affection, renders it unnecessary to have recourse to more powerful means.

31. Hippocrates advises, in fractures of the os femoris, to aid extension by coaptation, performed with the hand. All practitioners, since his time, have added this third manœuvre or process to the two first, namely, extension and counter-extension. But, what effect can the hands produce, in most cases, on the bone through the thick covering of the soft parts? Are we able to communicate to it through such a mass whatever lateral movement we please? Being quite lost in the intervening soft parts, will our efforts reach the bone, in the direction which we give them? The muscles bring the fragments into contact, much better than we can, as soon as extension has removed their overlapping. Indeed, if well executed extension makes the lower fragment return along the same track which it pursued in becoming displaced, it will then be inevitably brought into contact with the upper one by the contraction of the muscles. Besides, in most oblique fractures, is it not evident, that the lower fragment must be made to slide from above downward, on the inclined plain presented by the upper one, and on which it has slided from below upward, in becoming displaced? Is it while extension is making that coaptation ought to be performed? Certainly not: because, if the extension be well directed, an attempt at coaptation will derange it; and if it be not well directed, its course ought to be changed. Is it after extension is finished that recourse ought to be had to coaptation? By no means: because if there be then any remains of deformity, it must be owing to extension having been improperly directed. The remedy, therefore, is, to renew the extension, and direct it properly.

32. Hence, it follows, in general, that coaptation is here a feeble assistant towards reduction; that if it renders any service, it is only in cases of displacement laterally, or in the direction of the cross-diameter of the bone; and that it is by giving the proper direction to extension, by managing it according to the disposition of the muscles, and by knowing when to augment and when to slacken it, that the fragments are brought into regular contact.

33. If the inferior fragment has experienced a rotatory motion on its own axis outwards or inwards (18), the assistant ought, in making extension, to turn the limb very gradually in the opposite direction.

34. Extension was formerly attended with difficulties, which are rarely met with at the present day. Oftentimes, if we give credit to authors, it was altogether useless to endeavour, in the first instance, to reduce the fracture, and restore the limb to its natural length, as the contraction of the muscles rendered the operation absolutely impracticable. Hence, applications of a soothing and sedative nature were employed, previously to an attempt at reduction. The following circumstances have been assigned as the cause of these difficulties. The upper strap, irritating and drawing upwards the adductores and the rectus internus, drew the lower fragment in the same direction, while the semi-tendinosus, semi-membranosus, biceps, &c. being drawn downwards by the lower strap applied over them, drew the pelvis also downwards, and, consequently, the superior fragment connected with it. From this double action arose a double motion directly opposed to that which ought to be produced by extension.

35. There are still cases, where the muscles, in consequence of being irritated by projections or points of bone, by the efforts of the assistants, and by a morbid state of the nerves, increase their contraction to such a pitch that no practicable force can bring the fragments into apposition. What means are then to be employed? All those, in general, that diminish irritability, varied according to circumstances, such as diet, venesection, &c. In such cases, Desault obtained the most happy effects, by placing the limb in a state of continued extension; fatigued by the permanent tension in which they are thus kept, the muscles relax by degrees; their force diminishes; at length they yield, and the reduction is accomplished.

§ VI.

OF THE MEANS OF MAINTAINING THE REDUCTION.

36. The mere reduction of a fracture of the os femoris, is but one step towards the cure. In this, more than in the fracture of any other bone, causes which act incessantly (13) tend to subvert the momentary work of art; it is here, then, in particular, that means ought to be devised for maintaining this work. But, the first of these means is a suitable position of the limb. I have already mentioned the inconveniences that result, both as to the reduction and subsequent treatment, from that proposed by Pott (24...26). The patient must, then, be laid horizontally on a plain exactly even, and not capable of being affected or rendered uneven by the weight of the body. Instead of feather beds generally used in other cases at the Hotel-Dieu, Desault, in cases of fractures, substituted firm and hard mattresses, which, not sinking in the least, by the pressure of the body, give no cause to apprehend those continual displacements, to which a soft bed exposes the patient. These mattresses supersede the advice of certain authors who direct a plank to be placed under the patient.

37. The second means, not less efficacious than the first, consist in the forms of apparatus, in which the limb is placed, and which, being differently modified according to the fancies of their different authors, present us with an assemblage of various splints, compresses, &c. To appreciate, with accuracy and correctness, the advantage and disadvantage of these, let us first unfold the curative indications which they ought to fulfil; we will then compare their mode of action with these indications, from whence will result, as necessary inferences, the object of our research.

38. The intention of every form of apparatus being, to prevent the displacement of the fragments, the causes of this displacement ought to be the basis or foundation of its mechanism and construction. But these causes in the present case are, 1st, the muscular action drawing the inferior fragment upwards (10); 2dly, the weight of the body pushing the superior fragment downwards (14); whence every form of apparatus intended to keep the os femoris in place when fractured obliquely, ought, 1st, to draw the lower fragment downward and retain it there; 2dly, to draw and retain upwards the superior fragment, and the trunk which bears on its upper end. This principle is applicable generally, and subject only to a few exceptions which I shall notice when treating of transverse fractures, where the displacement is lateral, or in the direction of the cross-diameter of the bone, or where no displacement at all exists. 3dly, The apparatus must also be so constructed as to prevent the rotatory motions of the lower fragment (18), and secure the immobility of the limb, lest by means of some motion being communicated to it, the fragments might be deranged.

§ VII.

OF THE MANNER IN WHICH THE DIFFERENT PIECES OF THE APPARATUS ACT.

39. If to these indications we compare the mode of action of the different pieces that unite in composing our common forms of apparatus which do not make permanent extension, such as common bandages, splints, compresses, bolsters, &c. we will perceive that they are but ill calculated to fulfil them: and first of bandages. Whether the common roller, or the eighteen-tailed bandage be employed, their mode of operation is the same: their only action is, to add a second exterior and artificial covering to the natural cutaneous and aponeurotic covering of the thigh; to press against the fragments the muscles which form for them a kind of natural case intended to keep them in apposition; and to augment, by this pressure, the lateral resistance of the soft parts. By this contrivance, lateral displacements will, in part, be well guarded against, and, in this respect, these bandages are useful in transverse fractures. But what is there in them to prevent the two inclined plains of an oblique fracture from sliding on each other? What provision is there in them to secure the limb from the effects of motions and shocks which may be accidentally impressed on it from without? Will the pelvis be kept steady by them? or will muscular action be sufficiently checked and kept under by them? The force of the muscles will indeed be slightly diminished by means of compression; and to make this compression is the principal use of these bandages in oblique fractures. But will mere compression be sufficient to prevent a displacement in the longitudinal direction of the bone, particularly if the rollers be slack, as certain practitioners recommend, on the ground of the fallacious theory of Duhamel, who conceived, that a constriction too tight, would injure the action of the periosteum, which, according to him, is the sole agent in the formation of callus? So much, then, for bandages, whose only use is to prevent, by compression, the swelling of the limb, and to diminish, in some degree, the contraction of the muscles, which they press against the fractured bone.

40. These remarks apply equally well to the use of compresses; which make but a very feeble resistance against a powerful cause, and cannot be considered as any obstacle whatever to displacement. What can be said of those surgeons who, from servile attachment to a particular form of apparatus, do not consider a fracture as reduced, unless a certain quantity of compress secured by a given quantity of roller, be applied on the limb. Servile imitators in an art which calls for genius in its votaries, they are only capable of following, without reflection or judgment, the steps of their predecessors.

41. Bandages will do nearly as much harm as good in fractures of the os femoris, if, as was practised by the ancients, they be formed by a single roller surrounding the limb: in such a case, the limb being necessarily raised up at each time of their reapplication, will be exposed to continual displacements. Hence the ingenious idea of applying to simple fractures of the lower extremities the eighteen-tailed bandage, invented for compound fractures, and by means of which the thigh may be suffered to remain at rest. But to this bandage belongs also an inconvenience. The pieces which compose it, being stitched together, cannot be separated, and if one of them be soiled they must all be changed. Hence the superiority of the bandage of slips, known in former times, and engraved by Scultel, but long since forgotten, till Desault revived the use of it, and adopted it exclusively, both in simple and in compound fractures.

42. Splints of different kinds, which form the second division of the pieces of apparatus, used for fractures of the os femoris, have the advantage of fixing the limb in a solid and firm manner, and securing it from any displacement that might result from jolts, or muscular contraction, arising from the inattention of patients: these prevent, more effectually than bandages, any displacement laterally, and, on this account, their use is sufficient, even without extension, in transverse fractures: they also prevent, particularly if they be made of wood, the rotatory motion of the thigh either outwards or inwards (18). But if the division be oblique, will they prevent the gliding of the fragments over one another, and the consequent shortening of the limb? They can evidently produce this effect in no other way, than by the forcible pressure made by the pieces of apparatus, particularly by the straps or bandages that secure the splints, and then, to make effectual resistance, it would be necessary to apply them with such a degree of tightness as would endanger the life of the limb. Will splints prevent the trunk from sinking downwards, and pushing the superior fragment before it? Will they prevent the muscles from acting on the lower fragment? Can they, in a word, fulfil all the indications formerly pointed out (28)? Certainly they cannot. Splints, then, are calculated only to prevent displacement in the lateral or cross direction of the bone, and to secure, better than bandages, the immobility of the limb. Whence it follows, that they ought not, in this case, to be confined to the thigh alone, but should extend to the leg, whose movements, if communicated to the os femoris, may derange the contact of the ends of the bone. The neglect of this precaution, contributed formerly not a little to displacement and deformity.

43. In former times a kind of splints was in use, which were made by securing bundles of straw round sticks proportioned in length to the length of the limb to which they were to be applied. But as these, from being of a round or cylindrical form, touched the limb with but a narrow surface, they did not retain the fracture with sufficient firmness. They were, therefore, very properly exchanged for flat and strong wooden splints, (such as Desault used) which retain the fracture much better, in consequence of presenting to the limb a broad surface, and thereby rendering it in some measure immoveable.

44. The bolsters for filling up interstices, being less intended to prevent displacement, (in which respect they are, notwithstanding useful) than to guard the limb from the immediate pressure of the splints, usually consist of several folds of old linen; this is the form adopted at the Hotel-Dieu; but to these Desault preferred small pallets or bags filled with chaff, which, fashioned according to the form and disposition of the limb, may, at the pleasure of the surgeon, be made thicker or thinner, to suit the inequalities of the surface, in consequence of the ease with which the chaff may be moved from one part of the bag to another.

45. From the foregoing examination of the action of bandages and splints, it appears, that the common apparatus, formed by their union, but not calculated to effect a permanent extension, may perhaps answer in cases of transverse fractures, which indeed but rarely occur, but are always insufficient when the division is oblique, because they cannot fulfil the double indication of drawing the inferior fragment down, and retaining the superior one up (38).

§ VIII.

OF PERMANENT EXTENSION, AND THE MEANS OF EFFECTING IT.

46. By what means then can this indication be effectually fulfilled? By that which will perpetuate, throughout the whole treatment, the action of those means by which reduction was effected; by that which, to the ever active power of the muscles, will oppose a resistance constant in its action; by that which, forming on the exterior of the thigh a kind of artificial muscle, may become an antagonist to the natural muscles of the part, and neutralize their efforts, by acting in a contrary direction, and which, by pushing up the pelvis and retaining it there, may prevent it from being pushed downward by the weight of the trunk (14). But what other mean than that of permanent extension, unites these advantages? Whatever form of apparatus may be employed to obtain it, it is permanent extension alone that can prevent the displacement, because it alone is founded on principles calculated to meet and obviate the causes by which displacement is produced.

47. The ancients, though less informed than we are respecting the nature of these causes, knew better how to appreciate their effects. All their forms of apparatus made a permanent extension, a measure which has been abandoned by most of the moderns, and regarded, even at present, in France, by a great number of practitioners, as always dangerous, and seldom useful. Let us set in opposition to the vain fears which it inspires, a few thoughts, and much experience.

48. It is from the very object which is proposed to be attained, that the first difficulties arise. What must we think of a limb in a state of preternatural tension, where all the parts being overstretched must experience an uneasiness not to be supported? I answer, that it is not a preternatural elongation that extension produces; on the contrary, being intended to prevent a preternatural shortening, it has for its object to restore the parts to their ordinary state, and to give to the muscles their habitual degree of tension, by opposing such contractions in them as are not habitual: under this point of view, it performs, in relation to the muscles, those very functions which are discharged by the bone itself, when sound and unbroken, as is fully experienced by all patients, when the apparatus is applied. Its use not only does not increase pain, but is alone calculated to diminish it, because, by bringing the fragments into apposition, it prevents the soft parts from being irritated by the points of the bones.

49. Is the swelling of the limb to be dreaded, as some pretend? But whence can this swelling arise? From the over-stretching of the parts? I have already proved that they are not over-stretched. From the pressure of the straps? Perhaps this cause might produce a swelling, if, as formerly, it were applied above the knee; but, by placing it, as Desault did, near to the ancle, by surrounding, with a thick compress, the lower part of the leg, where the straps pass, and by securing the foot with a tight bandage under the straps, if their action be dreaded, this fear must be done away; and, besides, experience, which is the only true test of the dangers of a process, by no means justifies the apprehension. The venæ saphenæ and the absorbents that accompany them, are free from the compression, which bears principally on the tendo Achillis, and the malleoli.

50. What shall we say in reply to the censure thrown on the process of permanent extension, in the memoirs of the academy, where it is charged with having been oftentimes productive of ulceration and even gangrene, in consequence of the pressure of the upper strap? What method can escape censure, if it be unskilfully pursued? What process will not be injurious, if mutilated and ill managed by ignorance or a want of discretion? To represent the thing properly, let us suppose the worst: a circular bandage, in consequence of being drawn too tight, produces mortification in the subjacent parts; must circular bandages be on this account entirely rejected? An unskilful hand, in an operation for cancer, opens the axillary artery; must we therefore cease to search under the arm-pit for schirrous glands?

51. Permanent extension is, say some, insufficient to overcome muscular action; it is opposing to a power equal to 1000, a resistance equal to only 100. But this force of the muscles, which is oftentimes so great at the time of reduction, diminishes gradually, by the pressure of the bandages, by the immobility of the limb, and, above all, by long continued extension; for a continued effort equal to 10, will soon perform what could not be effected by a temporary exertion of a force equal to 100. Let us pass over the more minute objections made against permanent extension, and search among the different modes of performing it, that to which practitioners ought to give a preference.

52. We may throw into two classes the general modes proposed by different authors for effecting permanent extension. Under the one are included those modes requiring simple means, such as straps, splints, &c. while the other embraces such as, from being complex, necessarily call for the use of different machines.

53. In the first class are comprehended:

1st, The method employed in the first instance by the Arabians, adopted afterwards by their successors in medicine, and proposed, at a still later period, by Petit, Heister, and Duverney, and which consists in fixing, at the head and foot of the bed, during the whole treatment, straps intended for the purpose of extension.

2dly, The mode of extension, adopted by many practitioners, which consisted in suspending to a strap fixed at the knee, and reflected over some suitable body, a weight proportioned to the power of the cause which it was intended to combat.

3dly, The ingenious idea of Bruninghausen, who, confining by a kind of stirrup, the diseased leg against the sound one, made the latter serve as a splint to retain the fractured limb on its proper line, and thus preserve its natural length.

4thly, Under this class also must we arrange the means employed by Desault, and which we will presently describe.

54. The second class of means invented for the purpose of making permanent extension, in fractures of the thigh, comprehends:

1st, The Glossocome, the bed of Hippocrates,[24] and other machines, used by the ancients, to effect a reduction, in fractures of the os femoris, and, at the same time, to maintain the reduction, by being left on the limb.

2dly, Numerous machines, invented for the purpose of suspending a weight intended to make extension. These have been differently varied and modified, more by the imagination than the judgment. Engravings of some of them are to be found in Scultet, Fabricius of Hilden, Pare, &c.

3dly, The machine of Bellocq, proposed to the Academy of Surgery, a description of which is contained in their memoirs, and which possesses an advantage not found in the others, namely, that of taking its point of extension at the lower part of the leg.

4thly, The machine of Nook, surgeon at Norwich, improved by Aitkin, an engraving of which is given by Bell.

5thly, A new Glossocome, published in the works of Manne, and a great number of other machines, the ephemeral offspring of the genius of their authors, the utility of which experience has seldom confirmed, and which were even dead-born in the opinion of practitioners. I barely mention these, because a circumstantial description of them would lead me from my subject.

55. We may discover at a single glance the comparative merits of these two classes of apparatus. Extension produced by simple means, such as straps, splints, &c. (50), may at all times, and under all circumstances, be had recourse to; because the means necessary for making it may always and every where be found. Are we desirous, on the other hand, of having recourse to machines (54)? These are seldom at hand, and oftentimes not to be obtained: the expense attending the purchase of them, prevents most surgeons from procuring them. They no doubt possess the advantage of multiplying forces, and rendering them more powerful: but, I have already said (51), that a gentle resistance, if long continued, is sufficient to overcome at length the contraction of the muscles, though at first extremely active and energetic.

56. In the first point of view, the first class of means is doubtless preferable to the second. But they both partake generally of the inconvenience of placing the point of extension above the knee. I have already mentioned the effects which this produces with respect to muscular action, at the time of the reduction (28). To the injurious effects there stated may be added the swelling of the limb, arising from the compression made by the straps, the disadvantage of the mobility of the leg, which is not fixed, and the motions of which, being communicated to the thigh, may separate the fragments after they have been brought into apposition. Further, the straps may readily slip down over the knee, and thus leave the fragments subject to the mischievous influence of muscular contraction.

57. To these general disadvantages, add those peculiar to each form of apparatus, which are too tedious to be detailed at present, and you will perceive, that the little success hitherto obtained from continued extension, is owing, not to the nature of the measure itself, but to the manner of employing it, and that, in the present case, as in cases of fractured clavicles, another step towards perfection remained to be made.

58. Desault, in the first instance, attempted only to improve the ancient process, which consisted in fixing the straps for extension to the foot and head of the bed. He remedied the inconvenience of fixing the straps at the knee, by doing, throughout the whole treatment, what Fabre and Dupouy did only at the time of reduction (29); that is, he placed the seat of extension at the foot. The hold for counter-extension was also changed. This he made by a bandage for the body, fastened round the breast, and drawn only moderately tight, lest it might impede the patient’s respiration. The rest of the apparatus was nearly as I shall presently describe.

59. This was, for a long time, the only apparatus which Desault used. He introduced it into the Hotel-Dieu, after having employed it at the hospital of Charity, with great success. In the mean time, the utmost care and attention were here indispensable: every day it was necessary to examine the rollers several times, as they readily became relaxed. The pelvis, not being well secured, could communicate motion to the fracture: it was difficult to raise the patients to the close-stool. Besides, the slightest disease of the chest, rendered the pressure of the body-bandage insupportable. It was this very inconvenience which, having, in a certain case, rendered the preceding apparatus inadmissible, suggested to Desault the following one.

60. This consists, to speak in general terms, in taking the points of extension, above, on the tuberosity of the os ischium of the diseased side, and below, on the malleoli; in securing the straps or rollers, destined for making extension, on the two ends of a strong splint, placed along the outside of the limb; and in converting, so to speak, the pelvis, the thigh, the leg, and the foot into one entire and solid piece.

The pieces which compose it are, 1st, A common junk-cloth[25] (FFF [plate II].), accommodated to the size of the limb and the splints: 2dly, a bandage for the body (BB) and one passing under the thigh (H) to secure the first on the side opposite to the fracture: 3dly, three stiff splints, an inch and a half wide, the external one of which (AA) being very strong, must be long enough to extend from the spine of the ileum, to the distance of four inches below the sole of the foot. This splint is hollowed out or notched at its lower end, and has a mortise in it a little higher up. The upper splint (CC) occupies the space included between the fold of the groin and the upper part of the knee: and the internal one, which reaches from the upper and internal fold of the thigh, to the sole of the foot: 4thly, three bolsters, an external, an internal, and an upper one (d d d d) consisting of small bags of chaff: 5thly, a bandage of strips (E) accommodated as to number to the circumstances of the case, separate from one another, each three inches broad, and long enough to go twice round the limb, arranged from below upwards, and overlapping each other, about one third of their breadth: 6thly, one long and two circular compresses, intended to be applied immediately on the limb next to the skin: 7thly, two strong rollers (g g and L) intended for extension and counter-extension, at least an ell and a half long: 8thly, one long and thick compress, and a sufficient number of bits of tape.

61. Every thing being ready, previously to putting the patient to bed, the pieces of apparatus are to be arranged on that part of the bed corresponding to the fractured thigh, in the order in which they are to be successively applied. If the patient has been already laid in the place where he is to remain, the limb must be raised with great caution, and, during the extension, each piece gently slipped under it, or the whole must be passed under at once, being first rolled round the several splints, in such a manner, that the apparatus requires only to be opened.

62. Extension is now made in the mode already pointed out (29 and 30), and then the application of the apparatus is begun, for which the surgeon must be situated on the external side of the fractured thigh, while an aid, placed on the other side, gives him assistance.

1st, On the thigh, next to the skin, are first applied the long and circular compresses, accurately spread out so as to have no wrinkles in them, and previously wet with vegeto-mineral water. Around it are then applied, in succession and from below upwards, each strip of the bandage (EE) moderately tight.

2dly, The lower end of the leg is now covered with a thick compress, intended to prevent the impression of the roller (L), which is fixed in such a manner, that its middle is first laid on the tendo Achillis, a little above the heel, while its two ends, crossing each other on the upper part of the foot, are carried on each side to its sole, where crossing again, they are then laid down till the close of the application of the apparatus.

3dly, Along the thigh are placed laterally two bolsters, which, from their thickness being easily increased or diminished in consequence of the moveable nature of the chaff, mould themselves to the inequalities of the limb.

4thly, Around the two lateral splints, the surgeon and his assistant roll, each on his respective side, the two edges of the junk-cloth, so that both splints, by being accurately applied on the bolsters, may make a uniform compression on the whole part.

5thly, The third bolster (d d d d) is then applied on the anterior part of the limb, and over it the splint (CC).

6. The bits of tape passed under the apparatus to the number of four for the thigh, and three for the leg, are tied in succession on the external splint, lest the knots, should they correspond to the thigh, might, by their contact, prove troublesome. That one next to the fracture is tied first, and they are all drawn as tight as the patient can bear them without uneasiness.

7. The body-bandage is now fixed on the pelvis, in such a manner, as to secure laterally the external splint, and is itself retained by the sub-femoral bandage (H), that is, the bandage passing under the thigh.

8. A thick compress placed beneath the tuberosity of the ischium, serves as a cushion or bolster to protect the part from the pressure of the roller (g g) which, being passed first under the apparatus, and drawn afterwards obliquely from within outwards, and from above downwards, takes its points of bearing or action, in one part, on the tuberosity of the ischium, and in the other, on the upper end of the external splint, and is tied in the fold or hollow of the groin.

9. The two ends of the bandage (L) previously made to cross each other on the sole of the foot, are passed the one through the mortise, and the other through the hollow or notch in the lower end of the same splint, and then, being drawn forcibly, are tied in a firm knot, so as to act as a substitute for the hands of the assistant, who now lets go the patient’s foot.

10. If the roller (g g) become relaxed, it is tightened again, and the patient being laid in a suitable position, the limb is protected from the pressure of the bed clothes, by a kind of basket placed over it.

11. A roller (K k) laid first on the sole of the foot, and then brought across over its upper side, and fastened laterally to each splint, serves to secure that part from turning outward or inward, and thus prevents the rotation of the limb.

63. If the mode of operation of this bandage be compared with the general indications formerly established (38) for all oblique fractures of the os femoris, it will be easy to perceive that, conformably to those indications, it tends, 1st, to draw the inferior fragment downward; 2dly, to retain the superior one up; 3dly, and to prevent the rotation of the lower fragment, and secure the immobility of the limb.

64. It is evident that the bandage or roller (g g) so unites the pelvis to the external splint (AA), that the latter cannot be pushed upwards, without drawing the former in the same direction, as well as the superior fragment which adheres to it. But if, after this roller is fixed, the lower one (L) be tightened, the first effect produced is, to push the external splint forcibly upwards; the second, to draw the leg, and with it the inferior fragment downwards; so that, by fixing the roller (L) in the notch and mortise of the splint with the necessary degree of tightness, extension and counter-extension are made permanent. By this means the muscles, being kept on a stretch, lose by degrees their power of contraction, which is still further diminished, by the immoveable state in which they are kept, and by the compression made on them by the bandage of strips. So that, on the one hand, the inferior fragment will have no tendency to rise upwards, and even if it had, it will meet with a sufficient resistance to prevent it; while, on the other hand, the superior fragment will not be pushed downwards by the pelvis.

65. To this advantage is added that of a state of perfect immobility. The pelvis, the leg, the thigh, and the foot being firmly fixed on the external splint, constitute one entire whole, all the parts of which must retain, with respect to each other, the same relative position. Should even a stroke be accidentally given to this assemblage of parts now converted into a solid whole, each portion of it will move at the same time, there will be no partial motion, and the relative position of the parts will not be changed. Hence the advantage of being able to raise the patient without apprehension; a most desirable circumstance indeed, in a position so painful and so long continued (26). The external splint, being extended beyond the sole of the foot, prevents the lower fragment from obeying a tendency, which it sometimes has, to displace itself by a rotation on its axis. Should this tendency be towards the internal side, an occurrence much more rare, the lengthening of the internal splint will effectually prevent it.

66. These considerations induced Desault to renounce his ancient mode of making permanent extension, and employ this exclusively, in the latter years of his practice. Like all other kinds of apparatus, formed principally of rollers, this is very subject to become relaxed; and requires, therefore, great attention on the part of the surgeon. It ought to be examined attentively every day, particularly the two extending bandages (L and g g). As soon as they become relaxed, they must be immediately tightened again: without this precaution, the effect of the apparatus will be lost. Be vigilant also, with respect to the compress placed between the roller (g g) and the tuberosity of the ischium. Should this slip, the roller being frequently tightened, and pressing immediately on the skin, may produce excoriations and ulcers difficult to be healed, particularly in females. The roller itself may slip, and then, having no longer a solid point of support and action on the tuberosity of the ischium, it makes extension in but an imperfect manner.

67. One of the charges brought against this apparatus is, the facility with which the upper roller becomes displaced, a facility that imposes a degree of care and attention, of which few surgeons are capable, and which, when bestowed even by Desault himself, did not always prevent the shortening of the limb.

68. Further, the extension made on the fold of the thigh, partakes, a little, of the inconvenience that accompanied the ancient mode of reduction, namely, that of compressing and irritating the muscles of the upper and internal part of the thigh (30). This inconvenience would be still more sensible, if, for want of extending to a sufficient distance up the pelvis, the upper splint should allow the roller to cross the muscles at an angle somewhat acute, as it would then enclose and press on the greater part of them.

69. If some unfavourable cases, resulting without doubt from these inconveniences, did occur in the practice of Desault, a multitude of successful ones still attest the advantages of this method; and there is not a pupil who attended any time at the Hotel-Dieu, without witnessing them. I will relate but one case, collected by Chorin, to furnish a detail of the treatment subsequent to reduction, referring the reader for further information to the Journal of Surgery.

Case II. Theresa Little-John, aged 45 years, fell, drawn by the weight of her own body, through a window in a balcony, from which she was leaning. She was instantly taken up, carried to her own house, and from thence to the Hotel-Dieu, which she entered on the 28th of October, 1790. From the signs mentioned (9), a fracture was discovered towards the lower part of the thigh; its oblique disposition required an apparatus to make permanent extension. This was applied in the usual manner, and, in an instant, the patient, who had experienced, since her fall, severe pain, became calm, and was completely relieved.

In the night, pains returned; agitation; some spasmodic motions; an anodyne draught administered in the morning. In the course of the day, these troublesome symptoms disappear; a slight swelling at the ancle. Third day, no pain; swelling gone; aliment increased. Sixth day, patient permitted to return to her usual regimen; extending rollers relaxed; lower one tightened: eleventh day, apparatus renewed; fragments in perfect contact: thirteenth day, limb moved incautiously; a slight shortening; apparatus reapplied; extending bandages drawn tight: sixteenth day, a disposition slightly bilious; evacuants administered with success: twenty-fourth day, a third application of the bandage: thirtieth day, progress in consolidation already very evident; the limb straight: fortieth day, extending rollers laid aside: fifty-second day, consolidation complete without the least deformity.

70. The muscular force, in children, being weak, and the weight of the body inconsiderable, have, in general, much less influence in producing a displacement in them than they do in adults. When, therefore, fractures occur in subjects under six or seven years old, the resistance, on the part of the apparatus, need not be so great. In general the lateral pressure which it makes, and the bearing of its different pieces against the limb, are sufficient to prevent the return of deformity, when this has been perfectly removed by reduction.

71. In such cases Desault covered the thigh with a circular bandage, made of a roller seven ells long, and three inches broad. Beginning with this below, near to the condyls, he carried it upwards, by oblique and reversed turns, to the pelvis, round which he threw a cast; then, giving the ball into the hand of an assistant, he applied four splints, one before, another behind, and one on each side: directing these to be held at their lower part near to the knee, he resumed the roller, and secured them firmly by a second series of circular and reversed turns, descending to the lower extremity of the thigh. The limb was then placed in a proper position, and, in general, of whatever kind the fracture was, whether oblique or transverse, this simple bandage, without the aid of permanent extension, was sufficient to retain it.

72. It would be difficult to determine the period necessary for the consolidation of fractures of the os femoris. Numerous circumstances concur to influence this work of nature, which is, in general, extended beyond the term of forty days, vulgarly assigned to it by the people at large. Besides, a stiffness of the limb, the inevitable effect of its long state of rest, still adds to the length of the patient’s confinement, by retarding the necessary motions, the return of which, as in other similar cases, can be accelerated only by exercise.

73. Complicated fractures of the os femoris, being included in the general class of solutions of continuity of that description, cannot be at present particularly considered. We will only remark, that here, in like manner, as in fractures of the clavicle, permanent extension constitutes the most effectual method of preventing the pains, oftentimes insupportable, occasioned by splinters or points of bone irritating the soft parts, from being pressed against them by muscular action in its tendency to shorten the limb.

§ IX.

OF PERMANENT EXTENSION IN OLD FRACTURES.

74. I will close this article by a few remarks on the advantages of permanent extension in old fractures. Nature reunites fractures differently, according to the relation of the divided surfaces to each other. Are those surfaces in perfect contact? If so, they are chiefly instrumental in the formation of callus, which then probably acts in a manner similar to the reunion of wounds. On the other hand, does an overlapping of the fragments separate the divided surfaces from each other; the reunion takes place then principally on the sides, by a kind of enlargement of the bones, produced no doubt by the periosteum. Such is the mode of consolidation, which, on opening dead bodies, is found in most oblique fractures of the os femoris, succeeded by a shortening of the limb.

75. Hence it follows, that this shortening, which would readily yield to extension, at the time of the fracture, becomes obstinate in its resistance, in proportion to the age of the accident. In such a case, indeed, the substances destined to reunite the overlapping fragments, acquiring daily more and more solidity, oppose to the reduction obstacles constantly increasing. Hence, most practitioners regard this reduction as beyond the resources of art, after the expiration of the twelfth or fifteenth day. Nor is this opinion entertained without some foundation, for at a later period, almost all efforts at reduction, however powerful, have proved unavailing. But that which cannot be performed by a very powerful effort, acting momentarily, is, notwithstanding, oftentimes easily attainable by a much weaker one, provided it be long continued. The following cases are in proof of this.

Case III. Ann Gallot, of Melun, aged sixty-nine, having fractured her right thigh, by falling down the steps of a cellar, remained twenty-two days without assistance, and without even knowing the nature of the accident, when, on consulting a surgeon, she was sent to the hospital at Versailles. From the long standing of the disease, a reduction being despaired of, and no one being willing even to undertake it, the patient was sent to the Hotel-Dieu, on the 27th of February, 1791.

A shortening of four inches distinguished the diseased thigh from the sound one. The overlapping was sensible to the touch: in the mean time, a slight mobility at the place of fracture, inspired a hope of being able, if not to restore to the limb its natural form, at least to diminish the contraction. Several efforts were made at first, but without success, as Desault foresaw. The apparatus for permanent extension was applied: on the day following, the extending rollers being a little relaxed, were again tightened. Fourth day, a sensible increase in the length of the limb; apparatus renewed. Ninth day, the left thigh but an inch longer than the other: eleventh day, equality in length almost re-established. After this, the apparatus was kept constantly applied and renewed from time to time.

Fortieth day, consolidation already perceptible: forty-sixth day, symptoms of a putrid fever have made their appearance: fiftieth day, symptoms worse; fifty-second, something better: fifty-fifth, worse again: fifty-seventh, dead. On opening the body, an oblique fracture was found, its surfaces very nearly in apposition, and already united by a very solid callus.

Case IV. Joseph Maugrin, a saddler, broke his thigh in the month of July, 1793. A surgeon being called to him, placed his limb in an old form of apparatus, which did not prevent a shortening, to the extent of an inch and a half, from showing itself on the following day: hence a new reduction, and a new application of the apparatus: but soon afterwards, another shortening; the same means to remove it; the same failure of means. Weary of such trials, the surgeon abandoned the limb to its fate, contenting himself with merely keeping it in the apparatus.

On the twenty-ninth day, Desault being called in consultation, and finding the thigh shorter by three inches than that on the opposite side, proposed permanent extension, persuaded that this expedient alone would soon be sufficient to re-establish the contact of the fragments. The proposal was acceded to. On the day following, the effects were already perceptible; the thigh was lengthened by almost an inch. By the sixth day, it was equal in length to the other: during this period, the extending rollers were tightened twice a day.

At the end of two months the consolidation was complete, and the patient walked perfectly well, except that there was a little shortening of the limb, trifling though indeed, compared to what would have been the consequence, had the original treatment been continued.

76. The lengthening of the limb, in these cases, was evidently owing to the continued action of the apparatus, which effected, in a length of time, what the momentary efforts of the surgeon could not accomplish. This it did, by destroying or gradually lengthening the medium of union, which already connected the overlapping fragments, by that means bringing their separated surfaces or ends into contact, and almost restoring to the bone its primitive form.

Art cannot always, with certainty, command such success, and perhaps, even at a less advanced period, a more rapid progress of reunion might leave but little ground for hope. But, could only an inch in length be gained by permanent extension, would it not be proper to have recourse to it, particularly as no inconvenience can result from the trial? To prevent deformity altogether, is the first object of art; but when that cannot be attained, to lessen it is the second.

FRACTURES OF THE UPPER END OF THE OS FEMORIS.

The history of fractures of the upper end of the os femoris, includes, 1st, Those of the great trochanter: 2dly, Those of the neck. These fractures, sometimes existing together, and at other times separately, are very different with regard to the frequency of their occurrence: the one taking place very rarely, has but slightly engaged the attention of practitioners, who have multiplied their researches with regard to the other, particularly in late years.

FRACTURES OF THE GREAT TROCHANTER.

§ X.

OF THE VARIETIES AND CAUSES.

77. Fractures of the great trochanter are the effect either of falls on that protuberance, or of the action of bodies striking against it. Oblique or transverse, situated sometimes at its summit, and sometimes at its base, these fractures may be either simple or complicated. They are rendered complicated sometimes by splinters and a swelling, as happens when a ball produces the division, and at other times by a fracture of the neck of the bone, an example of which we find in the Journal of Surgery, in the case of a man seventy years of age, who had been long subject to the itch.

78. Whatever the varieties may be, the fracture will be characterized, 1st, By a facility of moving the great trochanter in every direction, while the pelvis and the thigh remain without motion: 2dly, By a crepitation, arising from the friction of the divided surfaces against each other: 3dly, By there being no shortening of the limb, when the fracture exists alone: 4thly, By the fragments being brought together in abduction, and separated in adduction: 5thly, By the position of the great trochanter being higher and more anterior than natural. The presence of these signs is the more readily perceived, because, being superficially situated, this protuberance can be easily felt, and yields to the motions impressed on it.

§ XI.

OF THE REDUCTION, AND THE MEANS OF RETAINING IT.

79. The reduction is effected, by pushing the separated fragment in the direction opposite to that of its displacement, by bringing it to its natural level, and, in certain cases, by moving the thigh a little outwards; it is retained by means of some compresses placed by its sides, and secured by a roller directed obliquely from the sound hip towards that part of the thigh corresponding to the fracture, and representing a true spica bandage.

80. A fracture produced by a gun-shot wound, always renders large incisions necessary, for the purpose of extracting foreign bodies, and relaxing the aponeurosis of the fascia lata, which suffers too great a degree of tension in this place, and might, if not dilated, produce a very troublesome stricture. A fracture complicated by splinters, but without an external wound, and produced by a body striking against the part, seldom requires any particular apparatus, because, adhering as yet to the periosteum, the separated portions of the os femoris may unite again, either among themselves, or with the fragments.

FRACTURES OF THE NECK OF THE OS FEMORIS.

§ XII.

OF THE CAUSES.

81. The neck of the os femoris, being surrounded by a large mass of soft parts, and protected by the great trochanter, which forms its external boundary, is almost completely secured from the immediate action of external bodies, and consequently from direct fractures. Whenever it sustains a fracture, it is always by a true counter-stroke, resulting from a fall, sometimes on the great trochanter, and at other times on the sole of the foot or the knee. But fractures produced in the first mode, are much more frequently met with in practice, than those produced in the second, doubtless because, in the latter, the motion is weakened by the extent of parts through which it is distributed, previously to its arrival at the neck of the os femoris. Out of thirty observations made by Desault, on fractures of this description, twenty-four of them were produced by falls on the side. All those recorded by Sabatier, in his interesting memoir, appear to have been produced by similar falls.

§ XIII.

OF THE VARIETIES.

82. Fractures of the neck of the os femoris may occur, 1st, in the middle part of it, where it is smallest, and where nature has not thrown together, as she does in the middle of the long bones so often exposed to fractures, a great quantity of compact substance: 2dly, at its upper end, where it is united to the head of the bone: 3dly, at its junction with the great trochanter, where the solution of continuity may be outside of the joint, a circumstance which doubtless happens much more frequently than has been hitherto suspected.

83. The division, rarely oblique, is almost always transverse: sometimes, in the latter case, the neck remains enclosed or imbedded, as it were, in the body of the bone, being fractured in such a way, as to present a hollow or notch of greater or less depth. Several cases of this kind occurred to Desault; one of them, modelled in wax, is deposited in the collection of the School of Health, and the original preparation is in my possession. The fracture, though frequently simple, is sometimes complicated with that of the great trochanter.

Case V. A man having received a kick from a horse, on the external and upper part of the left thigh, fell down, and, not being able to move, was carried home. Desault being called to him, discovered, 1st, that the great trochanter, separated from the bone, yielded readily to every impression it received: 2dly, that the limb was perceptibly shortened; that the least effort was sufficient to restore to it its natural length; and, that the foot was turned outwards, all which are characteristic signs of a fracture of the neck.

§ XIV.

OF THE SIGNS.

84. Whatever may be the mode and place of the fracture, its diagnosis presents difficulties which experience and habit may doubtless overcome, but which too frequently puzzle and embarrass the most enlightened practitioner. Let us endeavour to diminish them somewhat, by tracing, in their order of succession, the symptoms which characterize the accident.

85. At the time of the fall, a sharp pain is felt; sometimes a report is plainly heard; a sudden inability to move the limb occurs; the patient cannot rise, a circumstance, however, which does not always take place. A case is recorded in the fourth volume of the Memoirs of the Academy of Surgery, where the patient walked home after the fall, and even rose up on the following day. Some examples of a similar nature fell under the notice of Desault, one of which he has recorded. The interlocking of the two fragments formerly mentioned (83), may serve to explain this fact, which is, however, in general, very rare.

86. A shortening almost always occurs in the broken limb, but this is more or less perceptible, according as the extremity of the fragments is retained by the capsule, or as, the division being without the cavity, no resistance is made to their displacement. The muscular action, drawing the lower fragment upwards, and the weight of the trunk, pushing the pelvis and the superior fragment downwards, furnish here, as in fractures of the body of the bone, the two-fold cause of this shortening. I will not repeat what has been already said on this subject (10...14); I will only observe, that, in the present case, the influence of the muscles is even more considerable, because, the lower fragment being much longer, is of course attached to a greater mass of muscular fibres. A slight effort is sufficient, in general, to remove this shortening, which, however, soon returns, when the effort ceases. This circumstance Goursault and Sabatier have observed, not to occur in certain cases, till some time after the accident. A tumefaction appears in the anterior and upper part of the thigh, almost always proportioned to its shortening, of which it appears to be the effect.

87. The projection of the great trochanter is almost entirely removed. That protuberance, being directed upward and backward, is approximated to the spine of the ilium. But if it be pushed in the opposite direction, it readily yields, and then, returning to its proper level, allows the patient to move the thigh.

88. The knee is a little bent. A severe pain always accompanies the motions of abduction, when they are communicated to the limb. If, while the hand is applied to the great trochanter, the limb be made to rotate on its axis, this bony protuberance is perceived to turn on itself as on a pivot, instead of describing, as it does in its natural state, the arch of a circle, of which the neck of the os femoris is the radius. This sign, which was first observed by Desault, is very perceptible, when the fracture is at the root of the neck, less, when it is in the middle, and very little, when it exists towards the head of the bone; these are circumstances, the cause of which it is unnecessary to unfold. In rotatory motions, the lower fragment, rubbing against the upper one, produces a distinct crepitation, a phenomenon which does not however always occur.

89. The point of the foot is usually turned outwards; a position which Sabatier, Bruninghausen, and most other practitioners regard as a necessary effect of the fracture, although Ambrose Pare and Petit have borne witness that it does not always exist. Two cases, reported on this subject by celebrated surgeons, have been thought unfounded by Louis, who has attributed them either to an error in language, or a mistake of the transcriber. But the practice of Desault has fully confirmed their possibility. The first patient whom he had under his care, at the hospital of Charity, after he was appointed surgeon in chief, laboured under a fracture which presented this phenomenon. Many other examples occurred to him afterwards, and he believed it might be laid down as an established principle, that, in fractures of the neck of the os femoris, the direction of the foot outwards is to that inwards as 8 to 2.

90. The common opinion is, that this direction outwards is to be attributed to the muscles that perform rotation. But, were that the case, 1st, it is evident that it would always exist: 2dly, all the muscles running from the pelvis towards the trochanter, except the quadratus, are in a state of relaxation, in consequence of the approximation of the os femoris to their points of insertion: 3dly, muscles in a state of contraction would not allow the point of the foot to be drawn so easily inwards. Is it not more probable, that the weight of the part draws it in the direction in which it is usually found.

91. From the foregoing considerations, it follows, that none of the signs of a fracture of the neck of the os femoris, is exclusively characteristic, that the whole of them, taken separately, would be insufficient, and that it is their assemblage alone which can throw on the diagnosis that light which is oftentimes wanting to it, even in the view of able practitioners. But after all, in the present case, as in every other one, should any doubt exist, it is right to take the safe side, and apply the apparatus, which is indeed useless but not dangerous if the disease does not exist, but indispensably necessary if it does.

§ XV.

OF THE PROGNOSIS.

92. The existence of a fracture being ascertained, what prognosis is to be formed respecting it? In answer to this general question, it will be sufficient, I think, to resolve the following particular ones. What accidents accompany the fracture in the first instance? What phenomena make their appearance during its reunion? In what manner does it affect the patient, as to his power of walking, after reunion has taken place.

93. If we attend to the opinion of authors, on this fracture, we will find that they represent it in very dismal colours, as if it were necessarily productive of the most serious effects. Inflammation of the parts adjacent to the neck of the os femoris, numerous and repeated abscesses arising from this inflammation, propagating themselves externally and communicating with the interior of the joint, gangrene itself, as Morgagni remarks in a particular case, convulsions of the limb, an œdema occurring in it, and a slow fever destroying the patient by degrees; such is the dismal catalogue of misfortunes, generally considered as necessarily attendant on the kind of fracture under consideration. Bruninghausen remonstrated against this fatal prognosis of authors, and Siebold, one of the most celebrated German practitioners, among a great number of cases that fell under his care, had no such accidents to encounter. Desault never experienced them. Doubtless they are prevented by our more exact and more skilful modes of treatment. It is thus that under a more judicious treatment, fractures of the olecranon and of the rotula, are no longer marked with those terrible consequences formerly attributed to them.

94. In as much as the organization of the os femoris, is nearly the same in its neck and in its body, it is difficult to conceive how the progress of nature can be different in fractures of these two parts; why the first, in being denied the power of healing or reunion should be, in this respect, distinguished from all other living parts of animals, which are particularly characterized by that power, when they have sustained a solution of continuity. Many practitioners, even at the present day, advocate this doctrine, which is built, one while, on the circumstance of the periosteum not being continued along the neck of the os femoris; another while, on a belief that the head of this bone cannot receive a sufficiency of nourishment for the work of consolidation, in consequence of being attached to the rest of the system, only by the round ligament, and again, on an opinion, that the synovial fluid, by wetting the divided surfaces, prevents their reunion.

95. But is the periosteum the only agent in the formation of callus? Modern experience has refuted this opinion, which, like many others, will therefore in a short time exist only in the history of our errors. Were it even true that the periosteum is here indispensably necessary, is not its place supplied by the fold of the capsule, which surrounds both the head and neck of the os femoris? Besides, why cannot callus be formed by that part which has had sufficient power to accomplish ossification, since it is universally acknowledged, that, in these two processes, the labour of nature is nearly the same.

96. The head of the bone, separated from the soft parts, and attached to the acetabulum by the round ligament, always receives through that ligament a sufficiency of nutriment to enable it to live in that cavity; for, there is no instance of its having suffered mortification in consequence of a fracture. Why, then, should it not partake of the properties of life, and particularly of the faculty of reunion when placed in regular apposition with the body of the bone?

97. What shall we say respecting the idea of the synovia wetting the divided surfaces, and by that means preventing their reunion? The history of fractures communicating with joints, better known at the present day, answers this objection, which is indeed nothing but the offspring of mere hypothesis. To these considerations, which are dictated by reason, and to which many more might be added, let us unite the proofs derived from experience, and we will find numerous examples of cures actually performed, particularly in latter times; the truth of this is attested by many cases collected by Desault, both at the hospital of Charity and the Hotel-Dieu. Bruninghausen and Siebold, have had equal success. Many analogous facts have been presented to the Academy of Surgery. In the cabinet of the School of Health, are deposited some preparations obtained from the cabinet of Desault, calculated to remove all difficulties and doubts from this subject.

98. We must acknowledge, however, that in persons advanced in years, the cure is always difficult, often very tedious, and sometimes impracticable, however carefully the treatment may be conducted. But this is only a necessary consequence of the laws of ossification, which, constantly accumulating in the bones too great a quantity of calcareous matter, seems to deprive them by degrees both of life and all its properties. Yet Lesne laid before the academy a case of reunion obtained in a subject at the advanced age of eighty-four.

99. The observations of some modern practitioners seem to prove, that the reunion here is not produced by a substance similar to common callus, but by a kind of ligamento-cartilaginous tissue, in like manner as in the rotula, and the olecranon. But why need we inquire after the means employed by nature? those of art must be the same. It will be always necessary to favour the reunion, by bringing the fragments into contact, and maintaining them so. Without this contact, either a cure will never be obtained, or the substance destined to effect a reunion, becoming deformed and too bulky, will impede motion.

100. Lameness has been long considered as the inevitable consequence of fractures of the neck of the os femoris. Ludwig, professor of surgery at Leipsick, has particularly advocated this opinion, which is supported by Sabatier, and Louis, who considered the total destruction of the neck of the bone, as the cause of the lameness. But few such examples are to be found on record. Ruisk has given an engraving of one. Lameness when it does take place, depends, as it does in oblique fractures of the body of the bone, on the overlapping of the fragments, to which no opposition has been made; so that the insufficiency of our means, and not the nature of the disease, gives rise to this accident, which Desault seldom experienced in his practice.

101. From what has been said, it appears, that, in all respects, authors have given a much more unfavourable prognosis in fractures of the neck of the os femoris than facts and the nature of the affection will justify, that the progress of these fractures is the same with that of all others, and that, when treated with equal skill, there is no reason why their termination should not be equally favourable.

§ XVI.

OF THE REDUCTION AND THE MEANS OF MAINTAINING IT.

102. Reduction, in this case, is attended in general with but little difficulty. The patient, lying on his back, is held under the arm-pits, and by the upper part of the pelvis, by assistants who make counter-extension in this way, without being obliged to pass, as recommended by the Academy of Surgery, a strap under the affected thigh (30). Another assistant makes extension, according to the method formerly described (29), drawing the point of the fragment very gradually in the direction opposite to that which it has taken in becoming displaced, and making the thigh at the same time rotate a little on its own axis. This gentle rotation renders success more certain.

103. If things be properly arranged, a slight effort is sufficient to bring the separated fragments into contact and to restore to the limb its natural form; for, as I have already observed (86), a facility of reduction is even one of the characters of this fracture. But it is very difficult for art to maintain permanently what she easily effects at the time of reduction, and on this account, our curative processes are oftentimes insufficient.

104. These processes may be considered under three classes, according as they relate 1st, to position; 2dly, to bandages; 3dly, to the forms of apparatus for making permanent extension.

In the first class must be included the method of Foubert, employed in ancient times, according to Louis, and which consists in placing the patient on a horizontal plain, while the limb is secured by simple splints, and the foot by a kind of shoe. But in a short time the muscular action, to which no resistance whatever is made, draws the lower fragment upwards, while the weight of the body pushes the pelvis downwards, and along with it the superior fragment. Hence a new reduction, the effect of which is again immediately destroyed as at first. Thus are new displacements succeeded by new replacements throughout the whole course of the treatment.

105. This method, almost universally adopted in latter times, and approved of by Louis, was in vogue at the hospital of Charity, when Desault entered it. Ought we then to be surprised, that the fracture was considered as incurable? Here indeed the plainest and most important indication is evidently disregarded. Nothing to retain the fragments in apposition, nothing to prevent them from being constantly moved. Does not the method of Foubert very closely resemble those experiments, in which, the bone of an animal is broken intentionally, and then to prevent a reunion and form an artificial joint, the fragments are kept in constant motion?

106. Will any better success attend the method of securing the leg, as Dalechamp recommends, to the foot of the bed? In such a case the trunk and the pelvis glide down along the inclined plain made by the pressure of the nates (14), and hence a constant cause of the shortening of the limb.

107. The second class of curative means, includes different forms of apparatus simply retentive. Pare, Petit, and Heister, recommend, as most useful, the Spica of the groin.[26] But what effect can this produce? What force applied in that part can keep the lower fragment down, and the pelvis up, secure the immobility of the limb, and prevent its rotation outwards? If the bandage be tight, it will compress the muscles unequally, make them contract, and thus become the cause of a contraction or shortening of the limb. In some respects, there is more advantage to be derived from the tin case lined with cloth on its inside, which Fabricius of Hilden applied to the external part of the thigh; a method which has been renewed since his time, by certain celebrated practitioners of Germany; from the pasteboard case proposed by Duverney as a substitute for that of tin; from the retentive plaster[27] of Buffle employed likewise by Arnaud; and from the splints adopted by most practitioners. But can these means, (so differently varied in form, yet still the same in their action), while they prevent displacement laterally or in the cross-direction of the bone, prevent it also in the longitudinal direction, which latter ought to be the principal object in view? Will they make any resistance to the muscular action? See what has been already said on splints, bandages, &c. (89...95).

108. The insufficiency of these forms of apparatus, arises from their not being constructed with a proper view or reference to the general principle that ought to be observed in the treatment of every fracture; namely, that the means intended to prevent displacement, ought to be founded on the causes that produce it. But, these causes here, are, 1st, The action of the muscles which draw the lower fragment upwards: 2dly, The weight of the body which pushes the pelvis downwards: 3dly, The weight and direction of the foot and leg, which tend to carry the toes outwards by a rotatory motion. Hence, the threefold indication or end of every apparatus, is, 1st, To keep the body of the bone down: 2dly, To retain the pelvis up: and 3dly, To secure the foot nearly in a right line with the leg.

109. The first consideration leads us naturally to the second. The means destined to fulfil this three-fold indication, must be constant in their action, since the causes which they have to combat act without remission. Hence the necessity of an apparatus for permanent extension. See what has been said on the nature of this expedient (46...51), on the different modes of effecting it (52...57), and particularly on the mode pursued by Desault (58...70).

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[28] 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.)

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.

121. But whatever may be the precise form and figure of the fracture, its signs are easily comprehended: a very perceptible separation oftentimes exists between the two condyls, increasing the transverse diameter of the knee. The rotula, sinking into this chasm between the condyls, renders the part more flat from before backwards, than it is in its natural state. If the rotula be pressed in a backward direction, the condyls are separated still further from each other. If, on the other hand, pressure be made on each side of the lower part of the os femoris, the condyls are brought together, and the knee resumes its usual shape. If we take hold of a condyl in each hand, it will be easy, by moving them alternately backward and forward, to make them rub against each other, and produce a crepitation which characterizes the fracture beyond a doubt.

122. If the upper fracture be oblique, a shortening of the limb more or less perceptible is always the effect of it: this appears to be principally owing to the weight of the body which pushes the upper fragment down, and to the action of the muscles which draws the lower ones up (10...14). In this case, the superior fragment, being forcibly pushed against the integuments, has sometimes lacerated, and even passed through them, giving rise to consequences of a serious nature. Desault has published a case of this kind. A similar effect has been produced, though more rarely, by the inferior fragment, in which case much mischief has arisen from the admission of air into the joint.

123. Sometimes when the upper fracture extends through the whole thickness of the os femoris, the extremity of the bone is turned round, so that the external condyl lies behind, the internal before, and the rotula on the outside, while the foot points in the same direction. A case of this kind is recorded in the Journal of Surgery. The body of the bone, being pressed into the chasm or interval between the two condyls, may prevent their reunion, by pushing them asunder, and thus give rise to various accidents.

124. Most of these phenomena will fail to occur, if the upper division, passing only half way through the bone, break off but one of the condyls, or if, passing through even the whole of the bone, it be perfectly transverse; but cases of this description are seldom met with.

§ XX.

OF THE PROGNOSIS.

125. I have little to add to the observations already made on the prognosis in fractures of the condyls of the os humeri. All that I have there said is applicable to the os femoris. As is the case with regard to the former fractures, so also here, the apprehensions of authors have been greatly exaggerated by their visionary doctrine respecting injuries of the joints: both reason and experience unite in showing such apprehensions to be unfounded.

I shall only observe, that in the present case, even more particularly than in fractures of the condyls of the os humeri, most of the unfortunate events that take place, are owing to the insufficiency of the means employed for effecting a cure. Indeed, as I have already observed (45), all those means can have no effect in opposing the continual tendency of the fragments to become displaced, if the upper fracture[29] of the os femoris be oblique. And in most cases, this fracture is oblique: hence it follows, 1st, that the bony points of the fragments being constantly pushed, during their displacement, against the ligaments that surround the joint, will perpetuate in them the irritation first produced by the fracture, and thus give rise to swelling, inflammation, and all the other morbid affections of the part, so much dreaded by authors, and attributed by them to the mere communication of the fracture with the joint: 2dly, that the best expedient to prevent such affections, is an apparatus that shall retain the divided surfaces in perfect contact with each other by means of permanent extension.

126. It is obvious that this extension will be less necessary, if the upper division of the os femoris be transverse, because, then, the condyls and the body of the bone will find a mutual point of support against each other.

§ XXI.

OF THE MEANS OF CONTACT BETWEEN THE FRAGMENTS.

127. Since the same causes, as in the preceding cases, tend here to destroy this contact, when the superior fracture is oblique (122), the apparatus ought, therefore, to be so constructed as to counteract these causes, that is, it ought, 1st, to draw the two condyls down; 2dly, to retain the pelvis up, and with it the superior fragment. This twofold indication relates only to the upper division of the bone, without any reference to that which separates the condyls; 3dly, it is necessary to counteract the tendency which the condyls may have to separate from each other.

128. Permanent extension, made in the manner already mentioned (60...63), fulfils the two first indications; while two lateral splints, and the bandage of strips fulfils the third. Desault, therefore, applied to this particular case his apparatus for permanent extension, modified only in such a way, that, instead of terminating at the knee, the bandage of strips was continued to a distance down the leg, in order that its action might be the more efficacious. For, it is well known, that it is at its middle part that the firmness and retentive power of a bandage are greatest, because the casts of the roller at the upper and lower ends, serve to secure those in the middle. The upper splint being altogether useless, was not employed.

129. If the superior fracture be transverse, the condyls, as I have already said, meet with resistance against the body of the bone, while they, on the other hand, support it in such a manner, as to prevent it from descending, though pushed by the weight of the body along the inclined plain made by the pressure of the nates. Here, then, permanent extension is generally useless, and all that is necessary is, to retain the condyls and prevent their separation by means of lateral pressure. The same apparatus may still be employed, provided the two rollers for extension be laid aside.

130. If a wound in the soft parts accompany the fracture, whether it be produced by the same cause, or by the subsequent passage of the fragments through the integuments, and whether it communicate with the articulation or not, it is necessary, as soon as suppuration has taken place, to renew the dressings every day or every other day, taking care, in the mean time, to supply, by the hands of an assistant, the want of extension by means of the apparatus. The following case, extracted from the Journal, exhibits a specimen of the treatment that ought to be adopted in similar cases.

Case XI. Claudius Legrange, aged thirty-one, and of a sound constitution, was wounded by the kick of a horse, on the internal condyl of the left os femoris. The violence of the pain obliged him to throw himself on a heap of straw, that lay at a little distance, and which he reached by hopping on his right foot. The pains were augmented by this, for at each step, the thigh being alternately bent or extended at the injured part, was moved sometimes backward and sometimes forward. The patient was brought to the Hotel-Dieu, a few hours after the accident.

The signs already specified (121 and 122) announced to Desault, a longitudinal fracture separating the two condyls, and terminated above by another fracture of the body of the bone, which descended obliquely from about five inches above the external condyl, to within two inches of the internal one.

The muscles of the thigh, by means of violent contraction, had drawn that portion of the os femoris attached to the external condyl upwards, and the superior fragment downwards. The sharp point of the latter had passed through the skin, and produced a wound of an inch and a half in extent, on the inside of the thigh, and a little above the condyl.

The patient being undressed, was placed on a bed nearly horizontal, on which had been previously spread the necessary pieces of apparatus, disposed in proper order. Desault then examined the wound, extracted a splinter of the bone, covered the wound with lint, and then proceeded to the application of the apparatus which he usually employed in such cases (128).

The extension was accompanied by no pain: on the other hand, it gave immediate relief: diluting drinks were prescribed. Next day, no pain; pulse a little raised; no dryness, nor any alteration of the skin; diet the same as on the preceding day; the apparatus wet with vegeto-mineral water. Fourth day, a new application of the apparatus, which had become relaxed; appearances of suppuration.

From this time the dressing was renewed every other day, till the sixteenth, when the wound was cicatrized. After this the apparatus was not touched except when deranged; it was only wet from time to time with vegeto-mineral water, and great pains were taken to keep up the extension. The apparatus was not laid aside till the sixty-fourth day, although the callus appeared to have acquired a state of solidity somewhat sooner.

The patient was soon in a situation to take exercise. The stiffness then disappeared rapidly, and, in about three weeks, he left the hospital, able to bend the leg to a right angle with the thigh, and under a full confidence that he would in a short time regain all the motions of the limb.

§ XXII.

OF THE SUBSEQUENT TREATMENT.

131. As soon as the consolidation is complete, the motions of the limb must commence. These, at first gentle and confined, must be afterwards, increased in extent, and more frequently repeated, till, at length, the limb should be exercised every day for two or three hours without intermission. The position and direction of the leg ought to be constantly changed. One while, the thigh should be elevated by a bolster, so as to flex the leg; at another time, the bolster should be fixed under the leg to keep it extended. The rotula must be moved in every direction, and, as soon as the patient can leave his bed, he should take exercise himself. These precautions are more necessary here than in any other fracture, because a stiffness of the parts adjacent to the joint, is always the inevitable consequence of a long state of rest. Certainly writers would not have considered anchylosis as the most favourable termination of such fractures, had they been acquainted with the effect of exercise and rest in that now under consideration.

132. Provided the mode of treatment here laid down be faithfully pursued, the affection is seldom accompanied by those numerous accidents, of which so much has been said. The callus is formed in the usual manner: and, on some occasions, where the patients have died at the Hotel-Dieu, in consequence of some affection not connected with the fracture, the two condyls have been found perfectly united together and to the body of the bone. An instance of this kind is recorded in the Journal of Surgery.

133. Let us, in the mean time, not speak too favourably of that, respecting which the ancients were accustomed to speak too unfavourably. Even the practice of Desault would expose our error. Sometimes the most assiduous attention, and the most careful application of the apparatus, have not been sufficient to prevent abscesses around the knee, and an anchylosis of the joint. Desault related a case where even a caries of the articulating surfaces occurred. But some extraneous circumstances appeared to have an influence in these instances: and it may be laid down as a general rule, that fractures of the lower extremity of the os femoris, require the same treatment with fractures of its other parts.

Plate 2. Tanner, Sc.

EXPLANATION OF THE SECOND PLATE.[30]

This figure represents the apparatus for permanent extension, employed by Desault in oblique fractures of the os femoris.

AA. The external splint, with a notch and a mortise in it at the lower end to fix the inferior extending roller.

BB. A bandage passing round the body, intended to secure this splint against the pelvis.

CC. The anterior splint, reaching only to the knee.

d d d d. The anterior bolster, extending along the whole limb, and secured by pieces of strong tape.

EE. A portion of the bandage of strips, seen between the anterior and the external lateral bolsters.

FF. The junk-cloth intended to be folded round the two lateral splints.

g g. The superior extending roller, passing round the end of the external splint, and fixed underneath on the tuberosity of the ischium.

H. The sub-femoral roller or strap, intended to prevent the bandage BB, which passes round the body, from slipping upwards.

K k. A roller usually passed round the foot, to prevent it from turning.

L. The inferior extending roller, fixed in the mortise and the notch of the external splint.

THOUGHTS ON LUXATIONS OF THE OS FEMORIS, UPWARD AND FORWARD.

1. Few kinds of luxation of the os femoris occur in practice more rarely than this. Practitioners who have seen it, and those who, on the authority of others, have described it, without having seen it, have all given an unfavourable prognosis respecting it, for the following reasons: 1st, on account of the inevitable rupture of the round ligament: 2dly, on account of the distension, and even laceration of the capsule, and of the compression and overstretching of the nerves and blood-vessels: 3dly, on account of the great difficulty of reduction. The following case will prove, that in all these respects, the apprehensions of authors have been exaggerated, that the obstacles to reduction arise less from the nature of the displacement, than from the nature of the means employed to remedy it; and that, if properly directed, art would here be as successful as in other cases.

Case. (Collected by C***). About the close of the winter which preceded the death of Desault, a porter was brought to the Hotel-Dieu, in consequence of a fall which he had received about two hours before, in the following manner. As he was carrying on his shoulders a heavy burden, his foot slipped, while his leg and thigh were directed backwards: he fell on his knee, his thigh maintaining still the same direction; so that the conjoined weight of his own body and of the burden which he carried, aided by the velocity of the fall, forcing the head of the os femoris, which pointed at the time forward and upward, against the distended capsule, lacerated it and drove the articulating end through the opening. Continuing still to act, it ruptured the ligament, which connects the extremity of the bone to the articulating cavity, and forced the head in front of the os pubis, where it could be easily felt.

At the moment of the fall, an acute pain was felt in the part; and the power of moving the limb was suddenly lost; the patient was carried home, where a surgeon who visited him, considered the accident as a fracture of the neck of the os femoris, and sent him to the Hotel-Dieu, to undergo the necessary treatment.

Desault having examined the parts, discovered, from the following appearances, not a fracture, but a luxation upward and forward. The limb was nearly an inch shorter[31] than natural; the point of the foot was turned outwards; the thigh being in a state of painful extension, could not be flexed on the body; adduction and abduction were alike painful; the great trochanter, being more approximated than usual to the anterior and superior spine of the os ilium, was also too far forward; finally, the projecting head of the bone could be felt, as I have already said, in the groin.

The reduction was effected in the following manner. The patient being laid on a firm table, spread with a mattress, a strap was fastened above the ancle, for the purpose of extension; another, intended for counter-extension was placed between the scrotum and the thigh of the sound side, and brought up the back and front of the pelvis, along the body, till it passed over the shoulder, where it was twisted together and secured.

Extension was then begun, precisely in the direction in which the thigh pointed; and, during the execution of it, a rotatory motion inwards was given to the limb. At the expiration of a few minutes, the head of the bone remaining almost immoveable, notwithstanding the efforts to dislodge it, Desault directed extension to be discontinued, and, taking hold of the thigh, moved it in every direction, with a view to enlarge the opening in the capsule, the narrowness of which he suspected to be the cause that prevented the reduction.

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.

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