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

by P.-J. Desault

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

Extension on the foot, and counter-extension on the leg, dislodged the parts by degrees from their accidental situations, while, by the process of conformation, the surgeon endeavoured to bring them into their natural ones. This was soon effected without much violence: the unfavourable appearances soon vanished; the pain ceased; an apparatus similar to the former one was applied, and kept wet with a strong solution of common salt, instead of the vegeto-mineral water.

In the evening, the pulse being full, and somewhat raised, a moderate blood-letting was deemed necessary. Next day, the apparatus was kept constantly moist, and some part of it which had become relaxed was tightened. The pulse continuing full, a low diet was prescribed.

Fifth day, the apparatus taken off; contact between the bones perfect: a yellowish tinge bespoke an incipient resolution of the echymosis: a slight swelling of the leg: vesications formed on the part: these are opened and a quantity of acrid water discharged from them. Sixth day, light nourishment allowed; a small excoriation of the heel, which is dressed with cerate spread on a linen rag. Seventh day, regimen less strict; no bad symptoms supervene. Eighth day, the excoriation enlarged; same dressing. Tenth day, the excoriation become fungous: caustic is applied to remove it.

Twenty-eighth day, the discharge from the leg decreased; from this time the dressings are renewed only every other day. Thirty-second day, the ulcer is cicatrized: no pains in the leg. Thirty-ninth day, fracture of the fibula firmly united: no deformity remaining; the apparatus is laid aside: the joint remains stiff: motions performed by the limb difficult at first, but become gradually more free. Forty-sixth day, symptoms of bile; gentle evacuants. Fifty-fourth day, the patient is discharged cured, except a slight impediment in walking, which exercise will soon remove.

12. To this example, I might add many others, where similar displacements, properly treated, terminated with equal success: no pain; no swelling; no inflammation; and therefore, of course, no mortification. Yet these are occurrences of which authors speak, as if they were the usual consequences of such luxations, where, to a violent injury done to the soft parts, is added a fracture near to, or even communicating with, a joint. The erroneous opinions of the ancients and most of the moderns, respecting the dangers arising from such vicinity or communication, have contributed not a little to their unfavourable prognosis in the cases under consideration. Should the patient survive the disease, his inevitable lot, according to them, must be, a complete anchylosis of the leg with the foot. But, the preceding cases fully prove, that this apprehension is unfounded. A considerable time is doubtless necessary, for the recovery of motion, on account of the distension and rupture of the ligaments, the long continued inactivity of the parts, and the swelling which they have undergone. But this recovery can always be effected by means of exercise, gentle at first, increased afterwards, and regulated according to the principles so frequently laid down in the course of this work. Much more to be relied on is such exercise, than the long catalogue of discutient means, such as pumping of water on the parts, alkaline baths, mineral waters, and all other external applications, so often extolled as efficacious, and so often found entirely useless.

§ III.

LUXATION OF THE FOOT, COMPLICATED BY A SEPARATION OF THE BONES OF THE LEG, AT THEIR LOWER END.

Case III. (The following case was reported by Thevenot). I. Joseph Schneider, an ebonist, aged thirty-six, as he was walking in haste, on the 23d of March, 1792, fell forward, his foot being forced backward and outward. He experienced at the instant severe pains in the joint: he was unable to rise, and was therefore carried home, where a surgeon, after making a slight extension, applied a roller on the limb, and did nothing further. The patient experienced no relief. The pains increased; a swelling supervened; convulsive motions began to occur; and the patient was brought to the Hotel-Dieu, six days after the accident.

From the deformity of the foot, Desault immediately discovered that it was luxated. Its point was directed outwards, while its sole was turned in the same direction: beneath the malleolus internus, which was too prominent, was a tumour formed by the astragulus. The crepitation of the bones which was easily heard, the preternatural distance between the tibia and the fibula, the mobility of this latter bone, and the absence of the signs of a fracture, plainly showed that a separation of the two bones of the leg had taken place.