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

by P.-J. Desault

Desault on examining him, found the bones of his foot to be situated as follows. The internal part of the os calcis corresponded to the lower extremity of the tibia: the back of the foot was directed outwards, and its external edge downwards: under the skin and in front of the tibia was the astragulus, resting on the scaphoide and first of the cuneiform bones, where it formed a considerable projection: on the back of the leg, the fibula corresponded to the tendo Achillis. The pains had been inconceivably great from the moment of the accident.

Imboldened by numerous instances of success in similar cases, Desault, notwithstanding the extent of the disease, attempted the reduction. One assistant took hold of the superior part of the leg to make counter-extension, and another, for the purpose of extension, grasped the metatarsus with one hand, and the heel with the other. While these were pulling in different directions, the surgeon applying his thumb on the astragulus, endeavoured to force it into its place. His efforts were ineffectual: the opening through the capsule of the astragulus being too narrow, would not suffer it to pass. Desault perceiving this, cut through the integuments which covered the bone, and having laid bare the capsule and the ligaments which strengthen it, made an incision into them of a sufficient extent, taking care to avoid the tendon of the tibialis anticus, which was brought into view. The openings being thus enlarged, admitted of an easy reduction, and all the parts resumed, without difficulty, their natural situation.

The reduction being effected, the wound was closed, and covered with some lint. A square compress was then placed on the back of the foot, while a long one was applied to its sole, and the whole secured by an apparatus similar to that described in the preceding case. The patient was confined to a very strict diet, and ordered to use diluting drinks.

Next day, a slight bilious diathesis; an emetic in solution given; apparatus renewed. Fourth day, an abscess on the malleolus externus opened; a copious discharge of pus. Eighth day, the parts in perfect contact; a favourable discharge from the wounds; dressings applied twice a day. Fifteenth day, a general œdema; aperient ptisans ordered. Twentieth day, the œdema gone: a bilious diathesis returned: in consequence of this, the wounds became pale: another emetic given. Twenty-seventh day, a very painful excoriation occurred on the heel: care taken not to let the foot rest on that part, as the sore appeared to be the effect of compression. Thirtieth day, the wounds in a favourable way: all the bones in exact contact. Fortieth day, apparatus laid aside, and a simple roller substituted in its place: wounds already cicatrizing. Fiftieth day, the limb put in gentle motion, which is gradually increased every day. Same dressing continued till the eightieth day: wounds not yet cicatrized. Hundred and twenty-seventh day, a considerable swelling around the joint: a splinter made its way out, and was followed in a few days by several more. In the fifth month an abscess formed on the heel, from which, when opened, another splinter escaped. In the mean time, the patient left the Hotel-Dieu. During his absence more splinters were discharged. Returning about a year afterwards with a small ulcer, he was dismissed again in a short time, perfectly cured, except a slight stiffness of the joint.

15. The reduction of this luxation of the foot presents a difficulty worthy of the attention of practitioners, as well on account of its own nature, as in consideration of the process which was employed on the occasion: I allude to the narrowness of the opening in the capsule. I mentioned, on a former occasion, the obstacles sometimes created by this circumstance to the reduction of luxations of the os humeri and the os femoris. It was impracticable in the present to enlarge the opening in the capsule, as could be done in those cases, by moving the head of the bone in all directions; because the bone was too small to afford any purchase to the surgeon. The only resource was, the use of the knife; and the operation was the more easily performed, on account of the capsule being situated immediately beneath the integuments, from which circumstance it could be the more speedily brought into view.

16. The apprehension of mischief resulting from the admission of air to the articulating surfaces, would no doubt, in this case, have restrained most practitioners: but, even supposing this apprehension to be well founded, ought it to deter the surgeon from adopting the only possible mean of effecting a reduction, and of thus putting an end to the alarming state of things arising from the displacement of the bones? Desault proved in numerous instances, that the apprehensions of authors respecting such cases have been greatly exaggerated, and that it is practicable to cure wounds that penetrate into the cavities of joints, in the same manner as if they were simple wounds, and with but very little more danger to the patient. Yet it would seem, that the tediousness of the cure and the exfoliation of the bones, arose, in the present case, from the opening made into the joint, and perhaps also, in part, from the disposition and habit of the patient. Finally, in those alarming injuries of the joints, unconnected with external wounds, where practitioners have looked to no resource but that of amputation, Desault has, in a short time, and without any dangerous occurrence, restored to the subjects the free use of their limbs. The following case, drawn up by Plaignault, is a proof of this.

Case V. Pierre Phipe, aged twenty-four, fell, on the 20th of February, 1788, from an elevation of more than twenty feet: lighting on his foot, he turned it outwards, sunk instantly to the ground, and was unable to rise again. He was carried home, and from thence to the Hotel-Dieu.

Desault examining him on his arrival, discovered a luxation of the foot outwards, and of the astragulus forward and upward: the patient’s sufferings were great. Convinced that the most effectual method to relieve these was to reduce the luxation, the surgeon undertook it immediately, pushed the astragulus into its place without difficulty, and with a report which was heard by every one present, while the bones of the foot were brought into their proper situation by means of extension. In an instant the pains vanished and the motions of the foot became easy. The necessary apparatus was applied. The activity of the pulse called for blood-letting, which was immediately performed. A low diet was prescribed.

On the two following days blood-letting was repeated, both on account of the active state of the pulse, and of a considerable swelling which took place in the joint. The apparatus was kept constantly wet with vegeto-mineral water. Eighth day, somewhat better: echymosis gone. Fifteenth day, the apparatus laid aside. From this time the foot was gently moved every day. Eighteenth day, the patient able to stand on the affected foot without pain. Twenty-sixth day, walks with the assistance of a staff. Thirty-ninth, walks without limping, and enjoys all the motions of the foot. Discharged.