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

by P.-J. Desault

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

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

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

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

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

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

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

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