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

by P.-J. Desault

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?