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SURGICAL ESSAYS
BY
/J/f
ASTLEY COOPER, F.R.S.
SURGEON TO GUY’S H03PIT
AND
BENJAMIN TRAVERS, F.R.S.
SURGEON TO ST, THOMAS7 S HOSPITAL.
PART II.
PRINTED FOR
LONGMAN, HURST, REES, ORME AND BROWN, PATERNOSTER ROW ;
E. COX, BOROUGH ;
. A. CONSTABLE AND CO. EDINBURGH ;
SMITH AND SON, GLASGOW; AND HODGES AND Mf ARTHUR,
DUBLIN.
1819
/
/
< -5
,fT
f f
*
G* WOODFALL, PRINTER, ANGEL COURT, SKINNER STREET,
LONDON
It was intended that an Essay , which Mr. Travers had 'prepared for this Volume , should have succeeded Mr. Cooped s ; hut on account of the length of the Paper on Dislocations , and of that contributed by Mr. Travers , it has been judged better to reserve it for a Third Part, which will appear in the course of a few Months , and two short Essays of Mr. Coo- ped s have been substituted for that of Mr. Travers.
CONTENTS*
Essay I. On Dislocations continued, and on Frac- tures of the Hip and Knee-Joint.
Essay II. On Unnatural Apertures in the Urethra.
Essay III. On the Encysted Tumours,
Digitized by the Internet Archive in 2017 with funding from Wellcome Library
https://archive.org/details/b29326801_0002
On Dislocations continued.
CASES
OF
DISLOCATIONS
OF THE
THIGH-BONE.
By Mr. ASTLEY COOPER.
IT is a curious circumstance, and one of which I was informed by Mr. Cline, that Mr. Samuel Sharpe, who was Surgeon to Qpy’s Hospital, and had a large share of practice in this me- tropolis, did not believe that a dislocation of the thigh-bone ever occurred.
This want of knowledge in a very excellent surgeon, for the time at which he lived, can only be imputed to the few opportunities which then offered of pursuing morbid anatomy, for he must frequently have seen the accident in the living subject, but never having examined it in the dead, was led to believe that the ap- pearances of dislocation had arisen from some other cause.
Since the publication of my former essay on Dislocations of the Thigh, the following cases of this accident have occurred within my know-
ON DISLOCATIONS OF
ledge, the circumstances of which I shall shortly detail from my notes, before I proceed to con- sider the other objects of this essay.
CASE I.
Dislocation of the lejt Femur on the Dorsum Ilii .
James Ivory, aged 71, of Pottensend, Herts, on the 7th of February, 1810, whilst working in a clay-pit about twenty-five feet below the surface of the earth, had a large quantity of clay fall in upon him, while he was in the act of stooping with his left knee bent rather behind the other, and lie was in this situation buried under the earth. He was however soon removed from his perilous situation, and, being carried home, a surgeon was immediately sent for, who, aware of the accident being a dislocation, directly employed some men to extend the limb, whilst he attempted to push the head of the bone into the acetabulum ; but all his efforts were unavail- ing, as unfortunately for the patient pullies were not employed. The appearances of the limb at present, and it is now7 nine years from the accident, are these; the limb is three inches and a half shorter than the other, and the patient is obliged to wear a shoe having an additional sole of three inches on that side, which lessens, though it does not prevent, his halt in walking ; when he stands, the foot of the injured limb rests upon the other ; the toes are turned inwards, and the knee, which is ad- vanced upon the other, is also inverted, and rests upon the side of the patella of the sound limb
THE THIGH-BONE.
3
and upon the vastus internus ; it is also bent, and cannot be completely extended. The thigh, from the unemployed state of several of the muscles, is very much wasted ; but the semitendinosus, semimembranosus and biceps, owing to the shortened state of the limb, form a considerable rounded projection on the back part of the thigh. The trochanter major is seven-eighths of an inch nearer to the spine of the ileum on the injured side than on the other. On viewing him behind, the trochanter is seen to project on the injured side much further than on the other ; the situation of the head of the bone on the dorsum ilii is easily perceived, and when the limb is rotated inwards it is still more obvious. The spinous processes of the ilia are of an equal height. When sitting, the foot is turned very much inwards, and the knee is placed behind the other, whilst the toe only reaches the ground. When fatigued he experiences pain in the op- posite hip, and in the thigh of the injured limb. This unfortunate man has an arduous task to gain his bread by his labour, as he can- not stoop but with the greatest difficulty, and is therefore obliged to seek those employments which least require that position. When he attempts to take any thing from the ground he bends the knee of the injured limb at right angles with the thigh, and throws it far back. He can now stand for a few seconds upon the dislocated limb, but it was twelve months before he could do so. When in bed it is painful to him to lie on the injured side. His hip is, without any apparent cause, much weaker at some times than at others. When sitting down to evacuate
B 2
4
ON DISLOCATIONS OF
bis feces, he is obliged to support himself by resting the injured knee against the tendo achillis of the other leg, placing his right hand on the ground. He now walks with two sticks ; at first he employed crutches, and these he used for twelve months, when he was enabled to trust to one crutch and a stick, until his limb acquired greater strength. In getting over a stile, he raises the injured leg on two steps, and then turns over the sound limb ; but this he cannot accomplish when the steps are far apart, and he is frequently obliged either to turn back or to take a circuitous route. When lying with his face downwards, the dislocated hip projects very much upwards. He sometimes falls in walking, and wyould very frequently do so, but that he takes excessive care, as the least push against him throws him down. The knee being bent, part of the shortening of the limb depends upon that circumstance. I give this case to shew the evil that results from a disloca- tion of the hip remaining unreduced ; and it proves that dislocation of the thigh may occur in a strong healthy man after he has arrived at the age of sixty.
CASE II.
Dislocation of the Right Thigh hi the Foramen
Ovale .
A gentleman was thrown from his horse on the 4th of January, 1818. The accident was occasioned by the animal suddenly starting to the right side, and endeavouring to keep his
THE THIGH-BONE.
seat by the pressure of the right thigh against the saddle, he was thrown, and from the fall received a severe contusion upon his head, which produced alarming symptoms ; on the following day it was observed that the right thigh was useless, and that the knee was raised and could not be brought into a straight line with the other, having at the same time a di- rection outwards, rendering it necessary to tie it to the other knee ; the symptoms of injury to the head precluded, at this time, the possi- bility of an attempt at reduction. In fourteen days he was so far recovered as to enable him to sit up, and in a month he began to walk with crutches. On November 1st, 1818, X first saw him, and the appearances of the injured limb then were as follows. The thigh was longer than the other by the length of the patella j the knee was advanced, and when in the recum- bent posture, the injured leg could not be drawn down to the same length with the other. The upper part of the thigh-bone was thrown down- wards, so as to render the hollow of the groin on the injured side deeper than the other. The toes were rather everted, but were capable of resting on the ground when the body was erect, though the heel could not. The head of the bone could not be felt, and the trochanter was much less prominent than usual ; when the upper part of the thigh-bone was pressed against the acetabulum, and moved, there was a sensa- tion of cartilaginous rubbing, which, although not easily described, is readily distinguished from the crepitus occasioned by a fractured bone. When sitting, the injured leg was two inches longer than the other $ and to that degree
6
ON DISLOCATIONS OF
the knee was projected beyond the sound one. In progression the knee was bent, and the body being thrown forwards, he rested chiefly upon his toe, and halted exceedingly in walking. The sartorius and gracilis muscles were very much put upon the stretch. At first he suffered much from pain in the dislocated hip and thigh, but is now free from pain unless he attempts to stand on that limb only ; his toe at first was with diffi- culty brought to the ground, but lie is now im- proved in walking, for when he first made trial with the assistance of a crutch and stick he could not exceed half a mile, but is now capable of walking two miles. In flexion his thigh admits of considerable motion, but he cannot extend it further than to bring the barn to the plane of the other patella. The knees cannot be brought to- gether, but he advances one before the other in the attempt ; he can sit without pain, but the jolting of a carriage hurts him exceedingly ; and the attempt to sit on horseback produces ex- cessive suffering. He cannot straighten his leg when his body is erect, nor can he stoop to tie his shoe on the injured side. Pain is produced by resting on that hip in bed. No attempt was made to reduce the limb ; the injury to the head might have rendered it dangerous in the commencement ; and at the time I saw him there was no chance of success.
CASE III,
Dislocation on the Dorsum llii .
Mary Bailey, aged seven years, was admitted into Guy’s Hospital June 16, 1819, under the
THE THIGH-BONE*
7
care of Mr. Astley Cooper, for a dislocation of the os femoris upwards on the dorsum ilih This accident was occasioned by the child swinging on the shaft of a cart, which being insecurely propt, suddenly gave way, and she fell to the ground upon her side. The nature of the accident was exceedingly evident ; the limb on the dislocated side was at least two inches shorter than the other ; the toe rested on the tarsus of the opposite foot, and was turned inwards ; the knee was also inverted, and rested on the other. The child was admitted into the hospital at half past five in the afternoon, the accident having happened a little more than half an hour. Where so little resistance was ex~ pected the pullies appeared unnecessary, and towels were substituted, one being applied above the knee and the other between the pudendum and thigh, then bending the knee and bringing the thigh across the other just above the knee, gradual extension was made, and in about four minutes the head of the bone suddenly snapt into its socket. On the seventh day the child was walking in her ward, and suffered little inconvenience.
To Mr. Daniel, one of Mr. 'Lucas’s dressers, I am obliged for the foregoing particulars ; he having reduced the limb in the presence of many of the students.
CASE IV.
Dislocation of the Head of the Thigh-hone into
the Ischiatic Notch ,
John Cockburn, a strong muscular man, aged
8
ON DISLOCATIONS OF
33, was admitted into Guy’s Hospital on the 3 1 st of J uly, 1819. While carrying a bag of sand at Hastings on the 24th of June, he slipped and dislocated the left hip-joint, and the following is the account he gives of the accident ; that the foot on the affected side was plunged sud- denly into a hollow in the road, which turned his knee inwards, when his body fell with vio- lence forwards. Two attempts were made to reduce the dislocation by pullies on the day of the accident, which did not succeed, and it was consequently repeated on the 27th of June, which was also unsuccessful, although it was continued each time nearly an hour. He was directed to Guy’s Hospital by Mr. Stewart, sur- geon at Hastings. It was found upon examina- tion, after he had been admitted, that the thigh was dislocated backwards into the ischiatic notch, the limb was a little shortened, the knee and foot were turned inwards, and the toe rested on the ball of the great toe of the other foot ; the head of the bone could not be felt, the trochanter major was opposite the acetabulum, the rim of which could be distinctly perceived. The body being fixed, the thigh could be suf- ficiently flexed nearly to touch the abdomen. The patient was carried into the operating theatre soon after his admission, and when two pounds of blood had been taken from him, and he had been nauseated by two grains of tar-
tarized antimony, extension was made with the
*
pullies in a right line with the body, and the upper part of the thigh was raised while the knee was depressed ; the extension was continued at least for an hour and a half, during which time he took two grains more of tartarized antimony.
THE THIGH-BONE.
9
bv which he was thoroughly nauseated ; the attempts, however, at reduction, did not suc- ceed. On the 3rd of August, the tenth day from the accident, Mr. Astley Cooper succeeded in reducing it in the following manner: He ordered so much blood to be taken from the arm as to produce a feeling of faintness. A table was placed in the centre between two staples, upon which the patient was laid on his right side ; a girt was passed between the scro- tum and the thigh, and carried over the pelvis to the staple behind him; and thus the pelvis was, as far as possible, fixed : a wetted roller was carried around the lower part of the thigh just above the knee, and a leather strap buckled on it, to which the pullies were fixed, and to a staple before the limb. The body was bent at right angles with the thigh, and it crossed the upper part of the other thigh : then the extension with the pullies was begun, and gradually increased until it became as great as tlfe patient could bear. An assistant was then directed to get upon the table, and to carry a strong band under the upper part of the thigh, by which he lifted it from the pelvis so as to give an oppor- tunity for the head of the bone to be turned into its socket. Mr. South, who held the leg, was directed to rotate the limb inwards, and the bone, in thirteen minutes, was heard to snap suddenly and violently into its socket.
James Chapman,
Dresser at Guy’s Hospital , to \ whom I am m - debted for the foregoing statement
10
ON DISLOCATIONS OP
I believe, in this case, I should not have sue- ceeded,but from attention to two circumstances; first, I observed that the pelvis advanced with- in the strap which was employed to confine it, so that the thigh did not remain at right an- gles ; and I was obliged to bend the body for- wards to preserve the right angle during exten- sion; and secondly, the extension might have been continued for any length of time, yet the limb would never have been reduced but by the rotation of the head of the thigh-bone towards the acetabulum.
CASE V.
Dislocation of the Thigh Bone into the Iscliiatic
Notch .
DEAR SIR,
William Dawson, aged 34, on the 15th of August, 1818, while spending his harvest-home with several of his companions, became quarrel- some with one of them, who threw him down, and trod upon him. Upon extricating himself and endeavouring to rise, he found some serious injury to his right thigh rendering him incapable of standing ; and in this state he was dragged by his associates, for many hundred yards, into a stable, where he lay till the next morning. I then saw him lying upon a mattress, with the hip and thigh, on the right side, prodigiously swollen and painful ; and I was particularly struck with the appearances of the knee and foot on the same side, which were very much turned inwards, but the limb was scarcely short-
THE THIGH-BONE.
11
ened. I ordered him to be carefully conveyed home upon a shutter supported by six men, a distance of about half a mile. From the im- mense swelling and general enlargement of the whole of the thigh, and of the soft parts around the pelvis, it was impossible to ascertain exactly the state of the injury; but it was fully im- pressed upon my mind, that there was some un- usual dislocation of the head of the thigh-bone. He was accordingly ordered immediately to lose blood both by general and topical means, with emollient poultices to the whole of the swollen parts ^ brisk purgatives were also administered, succeeded by saline medicines, and a quiet position enjoined for eleven days ; by which time the swelling began somewhat to subside. Still the precise nature of the injury was not satisfactorily evident: but it was thought by Mr. Nunn of Colchester, and Mr. Travis of East Bergholt, who had kindly come over to wit- ness it, that there was a luxation. The only difficulty we had to reconcile this to ourselves, was the belief, in our minds, that no author had noticed this accident to have taken place with- out an alteration in the length of the limb, ex- cept it might be Mr. Astley Cooper, in his new publication, which we neither of us had yet seen. We accordingly had recourse to a mi- nute examination of the skeleton; when we immediately fancied we could account for this sort of luxation not being attended with the usual marked signs of displacement of the head of the bone, excepting the knee and foot being turned inwards ; for we noticed, that if the head of the bone be luxated sideways into the ischiatic
12
ON DISLOCATIONS OF
notch, it would produce scarcely any difference in the length of the limb. Trusting that a little further delay might not be attended with any material disadvantage, but give a chance for the entire subsidence of all inflammation and swelling, we proposed meeting again as soon as we conveniently could, by which time we might consult Mr. Cooper’s book. On Sunday the 30th of August we accordingly met, which was fifteen days after the accident, and from the complete removal of all swelling the whole of the femoral bone was satisfactorily traced to its rounded head, which was lodged in the ischiatic notch. Upon referring to the essays which we had now before us, we had the case delineated and described ; and as it was exhibited in a plate, we had only to imi- tate, in order to accomplish the reduction of the bone. In the presence of two or three other medical gentlemen who had now joined us, we commenced the operation ; and as it would be unnecessary to state every particular, after the manner in which the position of the patient, the fixing of the pullies and towels, are demon- strated by this publication ; suffice it for me to remark, that, after ten or twelve minutes’ gra- dual extension, the reduction of the bone was most readily and admirably accomplished.
Preparatory to commencing the operation, we took thirty ounces of blood from the arm ad deliquium , and afterwards, while fixing the pullies, &c. we gave four grains of tartarized antimony, at intervals, to produce nausea.* — Im- mediately after the operation we gave one grain of opium, applied sedative lotions to the parts.
TIIE TIIIGH-BONE.
and proceeding carefully for about a fortnight, the patient was enabled to move about upon crutches, and was shortly after sent home per- fectly well.
I am,
JOHN ROGERS.
Manningtree,
August 1 5th, 1818.
REMARK.
The relation of the foregoing case, from the kind manner in which Mr. Rogers has expressed himself, may savour a little of vanity; but I shall readily suffer this imputation, as my greatest gratification will ever be to find that my humble endeavours may in the slightest degree have con- duced to the advantage of my professional bre- thren, or to the benefit of those who may be placed under their care.
The dislocation in the ischiatic notch has been, as far as I know, in every author who has written on the subject, incorrectly described : for it had been stated, that the limb was length- ened in this accident; and I need scarcely men- tion the mischiefs in practice from so mistaken an opinion ; but one I here must give. A gen- tleman wrote to me from the country, in these words : “ I have a case under my care of injury to the hip; and I should suppose it a dislocation into the ischiatic notch, but that the limb is shorter instead of being longer as authors state it to be this error must have arisen from their having examined a pelvis separated from the skeleton, and observed that the ischiatic notch
14
ON DISLOCATIONS OF
was below the level of the acetabulum when the pelvis was horizontal — although it is above the acetabulum in the natural oblique position of the pelvis, at least as regards the horizontal axis of the two cavities. It is to be remembered that there is no such accident as a dislocation of the hip downwards and backwards.
CASE VI.
Dislocation on the Dorsum Ilii.
MY DEAR SIR,
William Sharpe, an athletic young man, in wrestling received a fall, his antagonist falling with and upon him, their legs being so entan- gled that he cannot say how he came to the ground. He complained of great pain in the hip, and was incapable of rising. About twenty minutes after the accident I found him lying on his belly in the field where it had occurred, and the left limb in a trifling state of abduction, shortened, and the knee and foot turned inwards, the prominency of the trochanter gone, and the head of the bone obscurely felt on the dorsum ilii. He was conveyed home, and, in order to reduce the dislocation, for such I considered it, I placed the man on his right side diagonally across a four-post bedstead. The centre of a large sheet rolled up was placed at its extremi- ties, passing in front and behind the body, and fastened to the upper bed-post, as low as pos- sible. The centre of a napkin, rolled in like manner, was then applied upon the dorsum ilii, between its crista and the dislocated bone $ and
THE THIGH-BONE.
each extremity being brought under the sheet (forwards and backwards) was reflected over it and tied in the centre, by which means I thought to keep the pelvis secure ; the counter-extend- ing force was applied above the ancle (it appear- ing to me to interfere less with the muscles upon the thigh:) first, rolling round a wetted towel, and then, placing upon this the end of a long or jack-towel: three men were now directed to pull gradually and steadily; and when I per- ceived the head of the femur was brought down to the edge of the acetabulum, I raised it a little with my clasped hands placed under the upper part of the thigh, and immediately the head of the bone entered the cotyloide cavity with a smart snapping noise. The man had consider- able pain about the hip and knee for some time, but is now quite well.
I am. Dear Sir,
YoufS, truly,
HENRY OLDNOW.
Nottingham,
August 8th, 1819,
CASE VII.
Dislocation of the Ischiatic Notch .
Mr. Wickham, jun. of Winchester, had the kindness to inform me of a case of this disloca- tion which had been admitted into the Winches- ter Hospital, under the care of Mr. Mayo, one of the surgeons of that institution, whose per- mission I have to state the following circum- stances.
16
ON DISLOCATIONS OF
John Norgott, aged 40, was brought to the hos- pital on 27th December, 1817, from the neigh- bourhood of Alton; twelve days had elapsed since the accident happened, without his being aware of the nature of the injury* He reported that his horse had fallen with him and on him, so that one leg was under the horse, whilst his body was in a half-bent position, leaning against a bank ; lie was of middle stature, but very muscular; the leg was but very inconsiderably shorter than the other, and but little advancing over it; in fact, the immobility of the limb was the chief criterion of the dislocation ; for the head of the bone was thrown into the ischiatic notch. The mode of reduction was simple: Mr* Mayo had the limb extended by the pullies, so as to bring the head of the bone to the edge of the acetabulum, and then tilted over it by a towel fastened round the patients thigh, and neck of an assistant* The man remained three or four weeks before he was allowed to leave the house; but on the 4th of February he was discharged, cured.
Winchester,
August 10, IS! 9.
CASE VIII.
Mr. Mayo also mentions the case of William Hepdy, who came into the hospital in August 1812: the dislocation had taken place seven weeks before, and was reduced the day after his admission ; he was discharged, cured, on the 18th of November. This was a dislocation on the dorsum ilii.
S
THE THIGH-BONE,
17
CASE IX.
Of Dislocation on the Dorsum IliL
Happening to be in Chester in September, 1818, I walked through the wards of the neat, and apparently, to me, excellently conducted infirmary of that city. Mr. Bagnall, surgeon in Chester, mentioned to me a case of dislocation, of the thigh upon the dorsum of the ilium, which I immediately proceeded to examine. The man’s name was John Chesers, and he had been admitted under the care of Mr. Row- lands ; the bone was dislocated upwards, the affected thigh was shorter than its fellow, the knee was inclined inwards and forwards, and the foot pointed inwards ; every attempt to ro- tate the foot outwards was productive of consi- derable pain at the hip. When I had con- cluded my examination of this case, I was in- formed by Mr. Bagnall, that a man had been admitted two months before under the care of Mr. Bennett, one of the surgeons of the infir- mary, with a dislocation of the thigh ; and having requested of Mr. Bennett the particu- lars of this accident, he was so kind as to send me the following account.
CASE X.
Dislocation on the Dorsum llii .
John Forster, aged 22 years, was admitted into the Chester Infirmary July 10th, 1818, with a dislocation of the thigh on the dorsum iiii,
c
IB
ON DISLOCATIONS OF
occasioned by a cart passing over the pelvis. Upon examination I found the leg shorter than the other, and the knee and foot turned in- wards. The patient being firmly confined upon a table, I extended the limb by pullies for fifty minutes without success, and he was returned to bed for three hours ; after which he was put in the warm bath for twenty minutes, and the extension was repeated for fifteen minutes un- successfully; I therefore took twenty-four ounces of blood from him, and gave him forty drops of tinct. opii, continuing the extension, but not succeeding in producing faintness, I gave small doses of a solution of tartrite of antimony, which in a quarter of an hour produced nausea ; in ten minutes afterwards I succeeded in reducing the limb, and in less than a fortnight he left the infirmary quite well.* — Unfortunately, he began to work hard immediately, and brought on an inflammation in the hip, of which he has not recovered.
S. R, BENNETT.
Chester .•
CASE XL
Dislocation on the Dorsum Hit.
/
Mr. Tripe, surgeon at Plymouth, has sent to the Medico-Chirurgical Society, an account of a case of dislocation of the thigh-bone on the dorsum ilii, which had happened seven weeks and one day prior to his making an extension to reduce it, by which he was so fortunate as to succeed in restoring the bone to its natural situation.
the thigh-bone. 19
It appears then, by these examples, that in eleven cases, seven were dislocated upon the dorsum ilii ; three in the ischiatic notch ; and one in the foramen ovale.
It is really highly gratifying to observe the difference of knowledge in the Profession at the present period when compared with that of fifty years ago. What should we think of a surgeon in the metropolis, in the present day, with all his opportunities of seeing disease in the large hospitals of this town, who doubted the existence of a dislocation of the thigh, when we find our provincial surgeons immediately detect the na- ture of these injuries, and directly succeed in their attempts to reduce them. Let them never forget, however, that it is to their knowledge of anatomy that they are indebted for this superb ority, and, more especially, to morbid anatomy.
In my former essay I endeavoured to describe the different situations into which the thigh* bone is thrown in the dislocations of the hip- joint, and the various appearances which these luxations produce ; at the same time pointing out what I have found to be the best means for their reduction. It was then my intention to have described the dislocations of the knee" joint, but, upon more consideration, I thought it better to continue the account of the injuries incident to the upper part of the thigh-bone, before I entered into a description of those of Contrasted
... . A with dislo-
other joints, because it would give me an op- cation, portunity of directly contrasting the symptoms which such fractures produce, with the distin-
c 2
20
ON FRACTURES OF THE NECK
Difference of opinion.
Compara- tive fre- quency of the two ac- cidents.
Fracture of two kinds,
guishing marks of dislocation, and thus enable the young surgeon readily to discriminate the one accident from the other. It must be con- fessed that there is some difficulty in distin- guishing the fractures of the hip-joint from its luxations, and that much difference of opinion subsists as to the process nature employs in the restoration of these fractures ; for whilst one surgeon maintains that all attempts to cure them are unavailing, another asserts that they admit of union like fractures of other bones of the body. I shall therefore proceed to state what has occurred to me upon these points, both from my observation on persons suffering under this accident, and my examination of those after death, in whom this accident had happened, as well as the effects which are pro- duced by breaking the upper part of the thigh- bone, in experiments on inferior animals*
ON
FRACTURES OF THE NECK OF THE
THIGH-BONE.
Such accidents are more frequent than dislo- cations of the os femoris, which is evinced by the comparative number we admit into our hos- pitals, being seldom without an example of the fractured neck of the thigh-bone, whilst the cases of dislocation upon the average do not ex- ceed one in a year.
The fracture of the neck of the thigh-bone is of two kinds: tirst, that in which the bone
5
OF THE THIGH-BONE.
21
is broken transversely through the cervix with- in the capsular ligament ; and secondly, when it is fractured externally to the ligament, either through the root of the cervix or through the trochanter major ^ the former of these may be called the internal, and the latter the external fracture, as regards the relative situation of* the bone with respect to the capsular ligament.
Of the Fracture of the Neck of the Bone within the Capsular Ligament .
The appearances which are produced by this fracture are as follow : the leg becomes from one to two inches shorter than the other, for the junction of the trochanter major being de- stroyed by the fracture, the trochanter is drawn up by the muscles, and carries with it the neck of the bone as high as the ligament will permit, and consequently the trochanter rests upon the edge of the acetabulum and upon the ileum above it. This difference in the length of the limbs is best observed by desiring the patient to place himself in the recumbent posture on his back, when, by comparing the malleoli, it will be found that one leg is from one to two inches shorter than the other ; but the retrac- tion thus produced is easily removed, by draw- ing down the shortened limb, when it will ap- pear of the same length with the other ; but immediately this extension is removed, the ac- tion of the muscles quickly forces it into its former position ; and this appearance may be
internal and exter- nal.
Diagnostic marks of fracture within the ligament.
Length.
O
22 ON FRACTURES OF THE NECK
repeatedly produced by extending the limb. This evidence of the nature of the accident continues until the muscles acquire a fixed contraction, which enables them to resist any extension which is not of the most powerful
Foot turned kind. Another circumstance which marks the
outwards.
nature of this injury, is the foot and knee being turned outwards ; and this state depends upon the numerous and strong rotatory muscles of the hip-joint, which proceed from the pelvis to be inserted into the thigh-bone, and to which, very feeble antagonists are provided, a part of the glutmus medius and minimus, the obtura- tores, the pyriformis, the gemini and quadratus, the pectinalis and triceps all assist in roll- ing the thigh-bone outwards, whilst a part of the glutseus medius and minimus, and the ten- sor vagina femoris are the agents of the rota- tion inwards. It has been denied that the muscles are the cause by which this eversion is produced, and it has been attributed to the mere weight of the limb ; but any one may satisfy himself that it is in part owing to the muscles, by feeling the resistance which is made to an attempt at rotation inwards of the neck of the bone. This difficulty is also in some measure attributable to the length of the cervix femoris, which remains attached to the tro- chanter major, because in proportion to its length, by resting against the ileum it is pre- vented turning inwards. Directly the bed- clothes are removed, two circumstances strongly arrest the attention of the surgeon, namely, the diminished length of the injured limb, and the eversion of the foot and knee. In the dis-
OP THE THIGH-BONE,
23
location upwards, the head and neck of the bone prevents the trochanter from being drawn backwards, whilst the broken and shortened neck of the thigh-bone in the fracture of this part readily admits it, and hence the reason why the foot is inverted in the one case and everted in the other.
Three or four hours must elapse before this appearance is in its most decisive state, as the muscles require some time to retract, and this is the reason that the accident has been mis- taken for dislocation. The surgeon having been called directly after the accident had happened, and before the muscles had acquired that fixed state of contraction they afterwards possess, he is led to mistake the nature of the injury ; and from this cause patients, even in hospital prac- tice, have been exposed to painful and useless extensions.
The patient, when perfectly at rest in the Degree of horizontal posture, suffers but little, but any pam’ attempt at rotation is painful, and more espe- cially the rotation inwards, because the broken extremity of the bone then rubs against the lining of the capsular ligament, upon which it is drawn by the action of the muscles. The pain which is felt in this accident is in the up- per and inner part of the thigh, opposite the insertion of the iliacus and psoas muscles, into the trochanter minor, or sometimes just below this point. The perfect extension of the limb may be easily effected, but flexion is more diffi- Degree of cult and somewhat painful, and its degree de- mol,on’ pends upon the direction in which the bone is
24
ON FRACTURES OF THE NECK
Subdue tion of the tro- chanter.
4
Appear- ances in the erect posi- tion.
V
bent, for if the flexion be outwards, it is ac- complished with ease and but little suffering ; but if it be attempted by directing the thigh towards the pubes, the act of bending the limb is with difficulty accomplished, and is attended with very severe suffering, but it is easier or more difficult in proportion as the neck of the bone be shorter or longer.
In this accident the trochanter major is drawn upwards towards the ileum, but the broken neck of the bone attached to the trochanter is placed nearer the spine of the ileum than the trochanter itself, and in this situation it after* wards remains ; by which alteration of position the trochanter projects less on the injured side, because it is no longer supported by the neck of the bone as in its natural state, but rests in close apposition to the ileum.
In order to form a still more decided judg- ment of this accident, after the patient has been examined in the recumbent posture, let him be directed to stand by his bed-side, supported by an assistant, so as to bear his weight upon the sound limb ; immediately he does this, the sur- geon observes most distinctly the shortened state of the injured leg, from the toes resting on the ground but the heel not reaching it, the everted foot and knee, and the diminished pro- minence of the hip ; then ordering the patient to bear upon the injured limb, he finds himself incapable of doing it but with considerable pain, which seems to be produced by the psoas and iliacus muscles being put upon the stretch in the attempt, as well as by the pressure of
OF THE THIGH-BONE.
25
the broken neck of the bone against the capsu- lar ligament*.
A crepitus, like that which accompanies other fractures, might be expected to occur in these accidents, but that is not the case when the patient is resting on his back with the limb shortened; but if the leg be drawn down, so as to bring the limbs to the same length, the crepitus is sometimes observed by the broken ends of the bone being thus brought into con- tact ; but the rotation inwards most easily de- tects it. When the patient is standing upon the sound limb, with the injured unsupported, hy rotating it inwards the crepitus will some- times be perceived.
To the circumstances I have already men- tinned, as strongly characterizing this accident, must be added the period of life at which it usually occurs, for the fracture of the neck of the thigh-bone within the capsular ligament seldom happens but at an advanced period of life. Old age, however, is a very indefinite term ; for in some it is as strongly marked at sixty as in others at eighty. That regular de- cay of nature which is called old age, is at- tended with changes that are easily detected in the dead body; and one of the principal of these is found in the bones, for they become thin in their shell, and spongy in their texture.
The process of absorption and deposition differ at different periods of life; in youth the arteries, which are the builders of the body,
* The greater or less projection of the trochanter, how- ever, will depend upon the length of the fractured cervLx I'enjoris.
Crepitus,
Age,
Changes Ij% age in the bones.
26
ON FRACTURES OF THE NECK
Slight causes of
this frac- ture.
deposit more than the absorbents remove, and hence is derived the great source of the growth of the body* In the middle period of life the arteries and absorbents so nearly preserve an equilibrium of action, that with a due portion of exercise the body remains in a stationary state, while in old age the balance is destroyed by the arteries doing less than the absorbents, and hence the person becomes diminished in weight, more from a diminution of arterial ac- tion than from an increase of the absorbent.
This is well seen in the natural changes of the bones, their increase in youth, their bulk, weight, and little comparative change during the adult period, and the lightness and softness they ac- quire in the more advanced stages of life ; this is so obvious, that the bones of old persons may be cut with a pen-knife, which is capable of making no impression on them at the adult period? Even the neck of the thigh-bone in old persons is sometimes undergoing an interstitial absorption, by which it becomes shortened, al- tered in its angle with the shaft of the bone, and so changed in its form as to give an idea, upon a superficial view, of its having been the subject of fracture ; but it requires very little knowledge of anatomy to distinguish in the skeleton the bone of advanced age from that of the middle period of life.
This state of bone favours much the pro- duction of fractures, and the slightest causes will often produce them in old age. In London the most frequent source of this accident is from a person, when walking on the edge of the ele- vated footpath, slipping upon the carriage pave-
o
OF THE THIGH-BONE.
meet ; and though a distance but of a few inches, from occurring so suddenly and unex- pectedly, it produces a fracture of the neck of the thigh-bone. I was informed by a person who had sustained a fracture of this kind, that being at her counter, and suddenly turning to a drawer behind her, some projection in the floor caught her foot, and preventing its turning with the body, the neck of the thigh-bone was frac- tured. A frequent cause of this accident is, however, a fall upon the trochanter major ; but X have dwelt particularly on the slight causes which produce it, that the young surgeon may be upon his guard respecting it, as he might otherwise believe that so important an injury could scarcely be the result of so slight an acci- dent, and that excessive violence was necessary to break the neck of the thigh-bone : such an opinion is as liable to be injurious to his repu- tation, as that of confounding this accident with dislocation.
It very rarely occurs under fifty years of age; and dislocation seldom at a more advanced pe- riod, although there are exceptions to this rule: for I have myself once seen this fracture at thirty-eight years of age, and a dislocation of the thigh at sixty-two; but between fifty and eighty is the most common period: for, from the different state of the bone, the same violence which would produce dislocation in the adult occasions fracture in age. But when dislocation does occur between sixty and seventy years, it is in persons whose constitutions are particu- larly strong, and in whom age has not produced those changes in their bones which 1 have ah* ready endeavoured to point out.
28
ON FRACTURES OF THE NECK
Union of this frac- ture.
Much difference of opinion has existed upon the subject of the union of the fractured neck of the thigh-bone ; it has been asserted, that these fractures unite like those of other parts of the body; but the dissections which I made in early life, and the opportunities I have since had of confirming these observations, have convinced me that the transverse fracture of the cervix femoris within the capsular ligament, does not unite by bone, a circumstance which I have always taught in my lectures ; this is a most essential point, as the reputation of the surgeon hinges upon it. I was called to a case of this fracture, in which the medical attendant had been promising, week after week, an union of the fracture, and the restoration to the patient
of a sound and useful limb. After many weeks
*/
the person became anxious for further advice ; I did all in my power to lessee the nature of the mistake this' gentleman had made, by telling the patient she would probably ultimately walk, al- though with some lameness ; and taking the surgeon into another room, asked him upon what grounds he was led to suppose there would be union; to which he replied, he was not aware but the fracture of the neck of the thigh-bone would unite like those of other bones of the body ; the case, however, proved unfortunate for his character, as this patient did not recover in the degree they usually do. Young medical men find it so much an easier task to speculate than to observe, that they are too apt to be pleased with some sweeping conjecture, which saves them the trouble of observing the proces- ses of nature ; and they have afterwards, when they embark in their professional practice, not
r
OF THE THIGH-BONE.
29
only still every thing to learn, but also to aban- don those false impressions which hypothesis is ever sure tQ create, before they can be safely trusted'. — Nothing is known in our profession by guess : and 1 do not believe, from the first dawn of medical science to the present mo- ment, that a single correct idea has ever ema- nated from conjecture : it is right, therefore, that they who are studying their profession should be aware that there is no short road to know- ledge ; and that observations on the diseased living, examination of the dead, and experi- ments upon living animals, are the only sources of true knowledge ; and that induction from these are the sole basis of legitimate theory.
In all the examinations which I have made of transverse fractures of the cervix femoris en- tirely within the capsular ligament, I have never met with a bony union, or of any which did not admit of motion of one bone upon the other. To deny its impossibility would be pre- sumptuous, under all the varieties of direction, extent of fracture, and degree of violence by which it has been produced, for there is scarcely a general rule which does not admit of excep- tion ; but, all I wish to be understood to say is, that if it ever does happen, it is an extremely rare occurrence, and that I have not yet met with a single example of it*.
Having thus stated what is the common re- Cause of
. the want of
suit or these cases, as regards their want of union.
\
* In Mr. Cross’s account of his visit to the French Hos- pitals, some interesting matter upon this subject will be found.
so
ON FRACTURES OF THE NECK
Want of
proper ap- position.
union, ^ I shall now proceed to give the rea- sons which may be assigned for the absence of ossilic union in the transverse fracture of the neck of the thigh-bone within the capsular ligament.
The first reason which I should state is the want of proper apposition of the bones ; for if the broken extremities be in any part of the body kept asunder, ossific union is pre- vented.
A boy, who had a compound fracture of the tibia, without the fibula being broken, and having the protruded end sawn off, the two extremities were prevented from coming in contact by the fibula, and union never oc» curred. — My friend, Mr. Smith, an excellent surgeon at Bristol, had a similar case under his care, in which a portion of the tibia had been sawn off8, and the fibula remaining whole, prevented ossific union*.
# The particulars of the case were as follows : — The boy was admitted into the Bristol Infirmary for disease of the tibia ; and the diseased portion not extending more than from two to three inches in length, that part of the bone was re- moved by the saw. In a month the limb had acquired so much firmness, that the boy was permitted to walk about the ward, which he was able to perform tolerably well, and in six weeks no doubt was entertained of ossification having taken place in the uniting substance; at this time he sickened with the small-pox, and died. — Upon examination, the edges of the extremities of the tibia were absorbed and rounded, and on the inferior portion a bony callus had formed, about three- quarters of an inch in extent; no earthy matter was discover- able in the greater part of the space originally occupied by the diseased bone, but a tough though thin ligamentous band extended from the superior to the inferior portion of the tibia. See Medical Records and Researches.
31
OF THE THIGH-BONE.
This fact is easily seen by experiment on other animals; I sawed seven-eighths of an inch of the radius from a rabbit, and the ends of the bones were not united to each other, but only to the ulna. In another rabbit I took out one- ninth of an inch of the radius with the same re- sult ; I also sawed off the extremity of the os calcis, and suffered it to be drawn up by the action of the gastrocnemius muscle, and it united only by ligament. See Plate.
The neck of the thigh-bone, when broken, is under similar circumstances ; for, by the con- traction of the muscles it is no longer in apposi- tion with the head of the bone, and is therefore prevented uniting ; but if this were the only obstacle, it would be argued that the retraction of the thigh-bone might be prevented by ban- daging and extension : and the truth of this cannot be denied, although it is extremely diffi- cult to preserve the limb in this position, as the patient in evacuating his ffoces and urine, or by the slightest change of position, produces instant contraction of the limb, by calling into action those powerful muscles which pass from the pelvis to the thigh-bone.
The second reason which prevents a bony union in these fractures, is the want of pressure of one bone upon the other, even where the length of the limb is preserved ; and this I con- sider as the principal cause, and which will operate in preventing an ossific union in all cases where the capsular ligament is not torn ; and in those I have had an opportunity of examining it has not been lacerated. The cir- cumstance to which I allude, is the secretion of
Abseiace <r»F
continued
pressure.
32
ON FRACTURES OF THE NECfc
a quantity of fluid into the joint ; from the in- creased determination of blood to the capsular ligament and synovial membrane, a superabund- ance of serous synovia, that is, synovia much less mucilaginous than usual, distends the liga- ment, and entirely prevents the contact of the bones, by pushing the upper end of the body of the thigh-bone from the acetabulum. After a time, this fluid becomes absorbed, but not until the inflammatory process has ceased, and liga- mentous matter has been effused into the joint, from the interior of the synovial membrane* That pressure between the broken extremities of bones is necessary to their union is further shewn by the following circumstances. If two broken bones overlap each other, on that side on which they are pressed together, there is an abundant ossiflc deposit ; but on the opposite side where there is no pressure, scarcely any change is observed. So also wre find if the ends of the bone be drawn from each other by the action of muscles, as sometimes happens in the fractures of the Os Femoris, Tibia, Os Humeri, Radius et Ulna, that union is not effected until the surgeon, by a strong leather bandage tightly buckled around the limb, compels the bones to press upon each other, and thus support the necessary inflammation for the production of ossiflc union. When a fracture occurs amidst muscles, those which are inserted into the frac- tured part of the bone have generally a tendency to keep the extremities of the bones together, with some few7 exceptions; but when a fracture occurs in the neck of the thigh-bone, the mus- cles have only an influence upon one portion of
THE THIGH-BONE*
S3
the fractured bone ; and this influence serves to draw one part from the other.
The third reason which may be assigned for the want of union of this fracture, is the little action proceeding in the head of the thigh- bone when separated from its cervix, its life being solely supported by the ligamentum teres which has some few vessels ramifying from it to the head of the bone. Little effusion of car* tilage takes place, and but little bone is thrown out to fill the cancelli; yet it is certain that when the patient begins to employ the limb, the one portion of bone is occasionally applied against the other, and it would therefore be expected that a greater change in the head of the bone should take place ; but on account of its slight vital power, this is not found to be the fact. X must observe, however, from the same circum- stances happening in fracture of the patella, that want of apposition and pressure are the principal causes of the absence of union in the fracture of the neck of the thigh-bone. . But still it must be allowed that the changes which are taking place in the head of the bone, after this fracture, are less than those which occur in any other fracture in the body, excepting in that of the patella, and that they seem even to differ in kind, because, instead of the common cartilaginous effusion which always precedes the formation of bone, a large quantity of liga- mentous matter is thrown out from the surface of the cancellated structure upon the head of the thigh-bone.
The appearances which are found on the dissection of these injuries are as follow :
D
Little ac- tion in the head of the bone.
S4
ON FRACTURES OF THE NECK OF
niwecfioo The head of the bone remains in the acetate-
ture. luni attached by the ligamentum teres. There are, upon parts of the head of the bone, very small ossific deposits, covered by the articular cartilage.
Bon*. The cervix is sometimes broken directly trans-
versely, at others with obliquity* The cancel- lated structure of the broken surface of the head of the bone and of the cervix is hollowed by the occasional pressure of its neck attached to the trochanter, and consequent absorption ; and this surface is sometimes partially coated with a cartilaginous deposit, which is in some parts studded with slight depositions of ossific matter in spots, so as to fill the cancelli, and produce a structure of a yellow colour upon the bone, which is rendered firm and smooth by friction, as we see in other bones which rub upon each other when their articular cartilages are absorbed. Portions of the head of the bone sometimes are broken off, and these are found either attached by means of ligament, or float- ing loosely in the joint covered by a ligamen- tous matter ; but these pieces do not act as ex- traneous bodies, so as to excite inflammation, and thus produce their discharge, any more than those loose portions of bone covered by cartilage, which are found so frequently in the knee, and sometimes in the hip and elbow joints. Some ossific matter is effused on die neck of the bone connected with the trochan- ter, which is rendered short by an absorbent process ; so as in some cases scarcely to project beyond the trochanter. (See Plate.) The ap- pearance of the cancelli of the cervix femoris
THE THIGH-BONE.
2S
differs much after this accident, being in some cases scarcely filled, and in others partially co- vered by a thin pellicle of cartilage, which, re- ceiving afterwards an ossific deposit, puts on a yellower appearance than the original bone, and is smooth on its surface ; generally, however, the cancelli are also partially covered by a liga- mentous structure.
The capsular ligament enclosing the head and neck of the bone becomes much thicker than natural, but the synovial membrane which lines it undergoes the greatest change from in- flammation, being very much thickened, not only where it lines the capsular ligament, but also upon the neck of the bone, as far as the edge of the fracture.
Within the articulation a large quantity of serous synovia is found ; by which term I mean to express, that the synovia is less mucilaginous, and contains more serum than usual : this fluid, by distending the ligament, separates for a time one portion of bone from the other ; it is pro- duced by the inflammatory process, and be- comes absorbed when the irritation in the part subsides. I do not know the exact period at which this change takes place, but have seen it in the recent state of the injury. Into this fluid is poured a quantity of ligamentous matter, by the adhesive inflammation excited in the syno- vial membrane, and flakes of it are found pro- ceeding from its internal surface, uniting it to the edge of the head of the bone. Thus the cavity of the joint becomes distended in part by an increased secretion of synovia, and in part by the solid effusion which the adhesive inflamma-
D 2
Ligament and syuo- vial mem- brane.
Effjsiftn into the joint.
New liga- ment.
ON FRACTURES OF THE NECK OR
Union by ligament.
Experi-
ments.
tion produces: the synovial membrane reflected on the cervix femoris is sometimes separated from the fractured portions, so as to form a band from the fractured edge of the cervix to that of the head of the bone; bands also of ligamentous matter pass from the cancellated structure of the cervix to that of the head of the bone, serv- ing to unite, by this flexible material, the one broken portion of bone with the other.
The trochanter is drawn up, more or less, in different accidents ; and in those cases in which it is very much elevated, I have known a consi- derable ossific deposit take place upon the body of the thigh-bone between the trochanter major and trochanter minor. When the bone has been macerated, its head and cervix are much lighter and more spongy than they are in the healthy state, excepting on those parts most exposed to friction, where they are rendered hard by a slight deposition of ossific matter, which has sometimes a polished surface.
It appears then, from this account of the dis- section of those whose bodies are examined after having suffered from this fracture, that no ossific union is produced ; that nature makes slight at- tempts for its production upon the neck of the bone, and upon the trochanter major; but scarce- ly any upon the head of the bone ; and that if any union be produced, it is by ligament only.
These circumstances, which I have stated for many years in my lectures, and supported, a3 far as I was able, by the dissection of these fractures in the human subject, led me to pro- secute the inquiry by experiments upon other animals. I found it difficult to succeed in
THE THIGH-BONE.
breaking the bone in the direction I wished ; and after a great number of experiments, was only in four instances successful ; the prepara- tions of which 1 have preserved. (See Plate.)
EXPERIMENT I.
The neck of the thigh-bone was fractured in a rabbit, on October 28th, 1818; and on De- cember 1st, 1818, as the wound had been some time healed, I dissected the animal®
Appearances on Dissection.— The capsular li- gament was much thickened, the head of the bone was entirely disunited from its neck, but- adhered by ligament to the capsular and syno« vial membranes; the broken cervix, which was very much /shortened, played on the head of the bone, and had smoothed it by attrition ; the head of the thigh-bone had not undergone any ossific change.
EXPERIMENT II.
The neck of the thigh-bone was broken in a dog, November 12th, 1818, and the animal was killed on the 14th of December following.
Dissection.— The trochanter was much drawn up by the action of the muscles, so that the head and cervix were not in direct apposition. The capsular ligament was much thickened, and contained a large quantity of synovia.
The joint was lined by adhesive matter of a ligamentous appearance, adhering to the head of the bone, which did not seem to be changed by any ossific process ; but the thigh-bone
S3
ON FRACTURES OF THE NECK OF
Lon git mil- nal fracture.
around the capsular ligament, and the trochan- ter major, and a little below it, was enlarged ; we find, therefore, by this dissection, what ap- pears in the human subject after this accident, happens in other animals ; and motion, want of apposition, and pressure, with the little ossific action, in the head of the bone under these circumstances, produce the deficiency of bony union, as in man.
Having ascertained this, I was next anxious to learn if the head and neck of the thigh-bone would unite under circumstances in which ap- position and pressure were maintained ; and for this purpose made the following experiment :
EXPERIMENT III.
§
I divided the neck and head of the thigh-bone longitudinally, by placing a knife on the ante- rior part of the trochanter major, and striking if down towards the acetabulum. The dog was killed twenty-nine days after, and the following appearances presented themselves :
A portion of the trochanter major had been broken off, and was only united by cartilage ; the head and neck of the bone which had been lon- gitudinally broken, were united ; but the neck was joined by a larger quantity of ossific deposit than that which joined the separated portions of the head of the bone, and so irregularly as to make a beautiful preparation, and shews the circumstance most clearly. (See Plate.) This bone may be seen in the collection at St. Tho- mas’s Hospital. — Whether the union began ex-
1 O
ternal ly to the ligament, and proceeded inwards.
TUI THIGH-BONE.
m
or whether on the whole surface at once, it is impossible to ascertain ; but the coalescence was firm, though, as I have stated, I thought more so at the neck than at the head of the bone.
Thus, then, it appears, that if the bones be applied to each other, if they be pressed to- gether, and in a state of rest, ossific union can be Union of produced in a longitudinal fracture, although the ossific deposition is extremely slight when compared with that of other bones. This prin- ciple will be further explained by experiments on the fracture of the patella. The great differ*' ence, between the longitudinal and the trans- verse fracture of the cervix femoris, consists in this, that in the longitudinal, as both parts of the head of the bone are remaining in the aceta- bulum, they are pressed firmly together, and this contact produces their union, even under the slightest ossific action $ beside which, the broken head and neck of the bone have sources of nourishment independent of the ligamentum teres ; whilst, in the transverse fracture, the actions of the muscles have a constant tendency to separate the portions of bone, and the effu- sion of synovia and of ligamentous matter into the joint, prevent a continued contact of the fractured surfaces of the bones.
The fracture of the neck of the thigh-bone may be confounded with the dislocation of the os femoris upon the dorsum ilii, in the ischiatie notch, and upon the pubes ; as in all of these the limb is shorter.— From the two former, it may be distinguished by the eversion of the foot, and by the flexibility of the limb in the fracture j. and from the latter, by the bail of
40
ON FRACTURES OF THE NECK OF
Treatment,
the os femoris being felt in the groin, which happens in the dislocation on the pubis; other- wise the eversion of the foot in both cases might lead to their being confounded. — (See Essay on Dislocation, in the first Part.)
With respect to the treatment of the fractured cervix femoris within the capsular ligament, those who believe a union can be effected after a transverse fracture, will extend the limb so as to bring the bones in apposition by drawing down the trochanter, and by applying splints upon the thigh, and straps around the pelvis, to force the cervix femoris against its head ; and the best means for the purpose will consist of an apparatus described in the succeeding pages, and delineated in one of the plates. And some sur- geons have thought that in this wray their efforts have been effectual in producing an union : but, from the history of the cases, it is clear they have not distinguished the fracture within, from that which is external to the ligament, in which union of the bone occurs as in other bones of the body: those, on the contrary, who have observed these accidents well, who see the fracture oc» c urring at very advanced age, who only dis- cover a crepitus when the bone is drawn down and rotated inwards, in whom the limb is con- siderably shortened, and the degree of pain they suffer comparatively slight to the fracture of the body of the bone, will be disposed to avoid con- fining the patient to any long or continued ex- tension as being likely to be productive of ill health, without the probability of producing union.— -Tiie mode, therefore, wdiich we now adopt in these cases, is as follows We place a
THE THIGH-BONE®
41
pillow under the whole length of the limb, and put another across this under the patient’s knee; and thus, by keeping it elevated, we procure an easy bent position of the limb : in this situation the patient remains, until the inflammatory pro- cess consequent to this accident, has ceased, which is from a fortnight to three weeks ; we then allow the patient to rise from her* bed, and to sit upon a high chair, to prevent a degree of flexion which would be painful ; in a few days crutches are allowed, upon which the pa- tient is then capable of taking exercise ; after a time the crutches may be laid aside, a stick substituted for them, and in a few months the person is able to use that limb without any adventitious support. The degree of recovery, Degree of in these cases, is as follows : if the patient be re< overy* very corpulent, the aid of crutches will be for a long time required; if less bulky, a stick only will be sufficient ; and where the weight of the body is inconsiderable, the person is able to walk without either of these aids, but drops a little at each step on that side, unless a shoe be worn having a sole of equal thickness to the dimi- nished length of the limb. In every case, how- ever, in which there is the smallest doubt, if it be a fracture within, or external to the ligament, it will be proper to treat the case as if it were the fracture which I shall next de- scribe, and which readily admits of union.
Now and then this accident is destructive to Danger of. life in very old and infirm persons, from the ex- hausted state of their frame.
} x
* This accident more frequently occurs in the female than jn the male.
42
ON FRACTURES OF THE NECK OF
Symptoms.
The surgeon must be careful of the opinion which he gives of the result of these cases; lame- ness is, in the transverse fracture, sure to follow; but its degree cannot, at the first of the accident, be exactly estimated.
it is gratifying to find opinions which have been long delivered, confirmed by the obser- vations of intelligent and observing persons ; and therefore it was with pleasure I read the ac- counts of the dissection of several cases of frac- ture of the cervix femoris, by my friend Mr. Collis, (who is a man excellently informed in his profession,) and who has published in the Dublin Hospital Reports, the dissection of seve- ral of these accidents, and found a similar want of ossific union in the fracture within the liga- ment.
Of Fractures of the Cervix Femoris external to
the Capsular Ligament .
The symptoms of.this accident in some re- spects so closely resemble those of the fracture internal to the ligament, as to require much attention to accurately distinguish them ; but the result is entirely different : so that a favour- able opinion may be given as to the restoration of the bone by an ossific union.
In this accident the injured leg is a little shorter than the other ; the foot and toe on that side are everted, from the loss of support which the body of the thigh-bone sustains in conse- quence of the fracture ; much pain is felt at the hip, and on the inner and upper part of the thigh*
THE thigh-bone.
}
43
and the joint losea its usual roundness. These, then, are all marks of similarity between the two accidents; but still there are many distinguishing signs. First; This accident occurs frequently at the earlier periods of life ; for it happens in the young, and in the adult under fifty years of age; I have known it at a later period, but less fre- quently; therefore, when the above symptoms are seen at any age under fifty years, it will be generally found to be a fracture external to the capsular ligament, and capable of having ossific union produced in it, and, consequently, of com- plete recovery.— The first case of this accident I ever saw, was in a man of middle age, at St. Thomas’s Hospital, under Mr. Cline, senior, who had most of the symptoms of a fractured cervix femoris within the capsular ligament. He was placed in bed with his thigh extended over a pillow, and splints were applied ; the man re- covered with an ossific union, which was ascer- tained by dissection, as he died of a fever at the period at which he was to have been discharged from the hospital ; and upon examination of the limb, the thigh-bone was found united ; the fracture having been external to the cap- sular ligament through the trochanter major.
These cases may be in some measure distin- guished by the severity of the accident which produces them, whilst the internal fracture, as we know, happens from very slight causes, this, on the contrary, is produced either from severe blows, from falls from a considerable height, or from laden carriages passing over the pelvis.
It may be also generally known by the crepi- tus which usually attends it upon slight motion,
o
Diagnostic
marks.
Union of the bone.
Causes
severe.
Crepitus,
ON FRACTURES OF THE NECK OF
44
Trochanter cTravvn forwards more than upwards.
Hollow of the groin filled.
Severe
pain.
Tirol) vrry Tittle short- er.
Rotation
greater.
for it is rarely necessary to draw the limb down* to distinguish the grating of one bone upon the other, and this happens from the less retraction of the limb ; I have however seen a case where the crepitus could not be discovered unless the thigh was extensively moved.
The broken trochanter is in these cases drawn forwards, so as to be placed before the head of the bone nearer to the spine of the ileum than it is naturally seated. When the patient is sitting, on the healthy side, there is naturally a depres- sion in the groin, into which the hand readily sinks, but upon the fractured side this is not the case, for that part is occupied by the extremity of the broken bone, forming a prominence there, which is very distinct.
This accident is generally marked by much greater severity of suffering than the fracture within the ligament, more especially upon mo- tion, for then the broken ends of the bone rub violently against the muscles, and produce ex- cruciating pain, which does not happen in an equal degree in the fracture within the ligament.
The limb is shorter, but .not to the same ex- tent as in the internal fracture, for it rarely amounts to an inch ; this, however, will greatly depend upon its obliquity, and upon the degree of laceration of the surrounding parts, admitting of a greater or less retraction of the muscles.
In the external fracture, the rotation of the limb is more extensive than in the internal, be- cause there is no cervix remaining attached to the shaft of the bone. If the upper part of the trochanter major be fixed at the time the body of* the bone is rotated, and the fracture is through
THE THIGH-BONE
45
the trochanter, the rotation of the thigh may be performed without giving motion to the cervix femoris.
Lastly, this accident may be distinguished by the ossific union which occurs in it, but this can only be ascertained at the distance of from eight to twelve weeks from the time of the injury*
Upon the dissection of these cases, the seat of the fracture is found to vary, sometimes it is at the part at which the cervix joins the trochanter major. Mr, Travers shewed me a specimen of this accident, in which the bone was divided into
A
several portions. First, the trochanter minor was detached from the shaft of the thigh-bone* Secondly, an oblique fracture passed through the trochanter major, so as in part to detach it from the body of the bone. Thirdly, the head and cervix femoris were broken from the tro- chanter, and the fracture passed in part exter- nally and in part within the capsular ligament*
My friend Mr. Roux, sent me from Paris one of these cases, which was broken through the junction of the cervix with the trochanter, in- cluding a part of the latter. (See Plate.) In another plate, the fracture will be seen extending obliquely from the trochanter minor through the trochanter major, and the drawing is from a bone which has been long in my possession, and which is now in the Museum at St. Tho- mas's Hospital ; it appears in this case, the thigh had been placed on its outer side du- ring union, as it has united with the condyles exceedingly everted* Mr. Oldnow, surgeon at Nottingham, sent for my inspection two excel- lent specimens of this fracture, in which the neck of the thigh-bone was broken at its junction
Ossifle mi. on.
Dissection.
46
ON FRACTURES OF THE NECK OP
Difference of opinion reconciled.
with the trochanter major. The trochanter ma- jor itself was also broken off; the trochanter mi- nor formed a distinct fracture; the broken cervix femoris had become united to the shaft of the bone ; the trochanter minor was reunited to the thigh-bone, but was drawn higher than its natural situation.' The trochanter major was in one of the specimens, completely united to the body of the bone, but not in the other. Thus the thigh-bone, at the trochanter, was divided into four parts, viz. the head and neck as one part, the trochanter major as a second, the trochanter minor as a third, and the body of the bone mak- ing the fourth ; the bones uniting with very little shortening.
Although, then, this accident has some of the marks of the internal fracture of the neck of the bone, yet it unites by bone, and it will be seen that the union is similar to that of other bones external to the joints ; cartilage is first deposited, and then the matter of bone, because in this case it can be brought into apposition, and the ends of the bones are confined together by the surrounding muscles; one portion is pressed against the other, and the neck of the bone sinks deeply into the cancellated structure of the trochanter, and thus direct approach and pressure are preserved when the fracture is at the junction of the cervix with the trochanter, and the nutrition of each extremity of the bone is well supported by the vessels which proceed to it from the surrounding parts.
We now see the reason of the difference of opinion respecting the union of the fracture of the neck of the thigh-bone. In the internal the bones .Ire not applied to each other, and the
THE THIGH-BONE.
47
nutrition of the head of the bone is imperfect, but in the external the bones are held together by the surrounding parts, and easily kept so by external pressure.
Much time is required in some of these acci- dents to produce a complete ossific union ; and the head and neck of the bone received into the cancel!! move for a long period in their new situ- ation, although so far locked in as to prevent their separation. Mr. Travers has the most valuable specimen of this state of the bone which I have had an opportunity of seeing, and of which he has had the kindness to send me the following account :
“ Richard Norton, aged 60, fell upon the curb-stone of the foot pavement, and struck the upper and outer part of his left thigh with great violence. He was admitted into St. Tho- mas’s Hospital on the 24th of January, 1818. The tension was then considerable ; the line of the tensor vaginal femoris formed an arch, the limb was shortened, the foot inclined outwards; the motion of the limb free in all directions ; but it was painful, more especially when the knee was carried over the opposite thigh. The crepitus of the trochanter major was distinctly felt in these motions, and the swelling of the parts, with the extensive crepitus, gave an idea that the accident was a comminuted state of the trochanter, and that the base of the cervix fe- moris was broken, hence the shortening of the leg and the eversion of the foot. After the use of evaporating lotions, for some days the tension subsided, so as to allow of the application of the long outer splint and two thigh splints well bedded. On the 4th of March the splints
48
ON FRACTURES OF THE NECK Qp
were removed, and union appeared to hav^ taken place, for the limb had resumed its natu- ral figure, but was a little shorter than the other. In the course of a month more he began to use his crutches. On the 15th of April he was placed under the physician, for defect in his general health; and when he was upon the point of quitting the hospital he was seized with spasms in his chest, of which he suddenly expired.
“ Upon examination, some old adhesions of the pleura and water in the chest and peri- cardium were found. The fracture was through the trochanter, as had been supposed, extend- ing some way down the bone, and it apparently had united, with very slight deformity ; but on maceration, the head and neck of the bone be- came loose in the thigh bone, and a fracture was found there, which locked the head and cervix in a shell of bone formed around them.
6t B. TRAVERS.”
•i f
.■» , .. * <
Mr. Travers having sent me the bone, the following are the appearances of this curious case. The head and cervix had been separated from the trochanter major and body of the bone. The upper part of the thigh-bone was obliquely split, so as to receive the cervix femoris into the cancelli. This fracture of the thigh-bone separated the posterior portion of the trochanter major from the body of the thigh-bone, and the trochanter minor was removed with it. An union had taken place between the fractured portions of the trochanter, at a slight distance from each other, and thus a hollow was left, into which the cervix femoris was received, and it had not yet become united by ossifie deposit, for upon
\
THE THIGH-BONE.
maceration the neck of the bone had free play in the cavity in which it had been received, and from which it could not be removed.
In the treatment of this injury we used to preserve the length of the limb by applying a roller around the foot of the injured leg, and by binding the foot and the ancles firmly to- gether to prevent their retraction, and thus render the uninjured side the splint to that which is fractured, giving it a continued support. But as this plan makes the passage of the eva- cuations difficult, and it does not press the frac- tured portions firmly together, although it ren- ders the length of the limbs equal, I adopt the following plan :
The patient is to be placed on a mattress on his back, the thigh is to be brought over a double inclined plane composed of three boards, one be- low which is to reach from the tuberosity of the ischium to the patient’s heel, and the two others above have a joint in the middle by which the knee may be raised or depressed $ a few holes should be made in the board admitting a peg which prevents any change in the elevation of the limb but that which the surgeon directs ; over these a pillow is thrown to place the patient in as easy a position as possible*. (See Plate.)
* The construction of this inclined plane is so little com- plicated, that it may be made at the instant of two common boards, one of which is to be sawn through nearly at the mid- dle, and if hinges cannot be immediately procured, the boards may be lashed together by cords ; for the principle of this machine, I believe we are indebted to Mr. White, of Manches- ter, who had one made of iron, and hollowed to adapt it to the form of the leg and thigh, but this machine was too heavy and too complicated for use. Mr. James, of Hoddesdon, improved
E upon
49
Treatment.
ON FRACTURES OF THE NECK OF
When the limb has been thus extended, a long splint is to be placed upon the outer side of the thigh to reach above the trochanter major, and to the upper part of this is fixed a strong leather strap which buckles around the pelvis, so as to press the one portion of bone upon the other ; and the lower part of the splint is to be fixed with a strap around the knee to prevent its po- sition being moved ; the limb must be kept as steady as possible for eight weeks, at the end of
tipon Mr. White’s idea, by having the instrument made of wood, with moveable splints upon the sides, which were to be adapted to the limb, and this construction rendered it more portable and less complicated than before ; but as the addition of splints rendered the instrument less easy of adaptation, I thought it better to have it made merely an inclined plane, and to apply splints, or not, as occasion might require. I have now been in the habit for near twenty years of employ- ing this instrument in fractures of the thigh-bone, and also of recommending it in my lectures, and do firmly believe that it will be found the best means of keeping the limb constantly extended, and preventing that contraction of muscles which is so apt to occasion deformity. When the thigh and leg are placed upon the machine, the patient rests upon his back, the knee is slightly bent, and the foot rests upon the heel, and the position is one of great ease to the patient. Although we are ready to acknowledge the high merit of the contrivances of Pessault and Boye for fractures of the thigh, yet upon the whole we give a preference both to this instrument and to the position which we have just described, and which we have been in the habit of adopting in these eases. The same re- sult may be produced by a long pillow reaching from the tu- berosity of the ischium to the foot, and by a second rolled up under the knee ; but the extension is neither so perfect at the moment, or so continued as when the limb is on the inclined plane, and it requires infinitely more care to prevent con- traction. While I strongly recommend this double inclined plane, I should think myself dishonest if I did not acknow- ledge the source from which it was derived.
THE THIGH-BONE.
which time the patient may be permitted to rise from his bed if the attempt does not give him much pain ; he is still to retain his outer splint for a fortnight, with the straps which I have mentioned, round the pelvis, and by this treat- ment he ultimately recovers a very good use of Recov his limb. The following case shews the usual Case- results of this accident when it is very severe.
Mr. Peggler, of Wanstead, aged 46, on the 13th of November, 1817, fell while walking, on a glass bottle which he had in his pocket, and when he attempted to raise himself from the ground he found he was not able to stand. In a quarter of an hour he felt great pain and could not bear the slightest weight of his body on the injured limb. Mr. Constable, of Woodford, was sent for, and he gave me this account. The foot at first did not appear to turn out, but when the patient was put into bed and laid on his back it became everted, the leg appeared somewhat shorter, but was with but little difficulty pulled down to its natural length ; the foot was be- numbed, and continued so for twelve months.
He was placed in bed with a bolster under the hip, to prevent displacement of the bone, and his knees and ancles were tied together.
On the December following, about Christmas,
I met Mr. Constable to visit a patient with a severe injury of the head, and he then requested me to see Mr. Peggler, whom I found inca- pable of turning in his bed without assistance, and the attempt gave him great pain ; his in- jured leg was a little shorter than the other, with the trochanter drawn forwards towards the spine of the ileum, and could be felt consider-
£2 ON FRACTURES OF THE NECK OF
ably separated from that portion of the trochan- ter connected with the neck of the bone ; the foot was turned outwards, he could not sit, and the least attempt to raise himself produced ex- cruciating suffering ; in the horizontal position I brought him to the foot of the bed to make as accurate an examination as I could of the nature of the accident, and could have no hesi- tation in pronouncing it a fracture through the trochanter. In less than a month he began to use his crutches, and continued their use for three months ; he then laid aside one crutch and employed a stick and crutch, and in a short time needed the support of a stick only ; but it was twelve months before he recovered the entire use of his limb. The leg is still nearly an inch shorter than the other ; the portion of the trochanter connected with the thigh-bone, has united with the fore part of the trochanter joined to the neck of the bone, and is consequently much nearer the spine of the ilium than usual ; the foot also is slightly everted, but he walks extremely well ; this day week he walked ten miles from home and re- turned the same day, and this day, July 28, 1819, he has walked from Wanstead to my house, and intends to walk back, a distance of near twenty miles.
This history of Mr. Peggler’s accident is so similar to the cases of fracture through the tro- chanter major, which I have had an opportu- nity of seeing, that their detail would only be- come a useless repetition, the only variations that X have seen having been in the distinctness of the crepitus accompanying them, which is
THE THIGH-BONE.
less in proportion as the fracture approaches the capsular ligament.
I have received from Mr. Oldknow, of Not- tingham, an account of some cases of the frac- ture external to the ligament, which occurred in persons very advanced in years, so that, as age is not a certain criterion, it becomes neces^ sary to pay the utmost attention to the other dis- criminating marks of this not unfrequent injury.
Of Fractures below the Trochanter .
The thigh-bone is sometimes broken just be- low the trochanter major and minor, and a most difficult accident it is to manage, and miserable distortion the consequence, if it be ill treated. The upper end of the bone is drawn forwards and upwards, so as to form nearly a right angle with the body of the thigh-bone; the cause of this is evidently the contraction of the iliacus inter- ims and psoas muscles, assisted perhaps by the pectinalis and first head of the triceps, which participate in the irritation the fracture pro- duces, and are thrown into a state of spasmodic contraction ; to give a better idea of this effect, (see Plate) in which the bone will be observed to be united not only with extreme shortening, but with a hideous projection forwards. If pressure be made upon the projecting bone in this case, it only adds to the patient’s suffering, and to the degree of irritation of the limb, with- out preserving the bone in its proper situation. It will be seen that this fracture, although unit- ing, exceedingly overlaps, and that the union is very feeble, shewing what I have already
53
54
ON DISLOCATIONS
mentioned, the circumstance of fracture thus placed having the ossific deposition only on that side where the inflammation was kept up by the pressure of one bone lying on the other ; this preparation may be seen at the Anatomical Mu- seum at St. Thomas’s Hospital.
To prevent this horrid distortion and imper- fect union, two principles are required to be strictly observed \ the one is to elevate the knee very much over the double inclined plane, and the other to place the patient in a sitting posi- tion, well supporting him by pillows during the progress of its union \ the degree of elevation of the body which is required will be readily as- certained by observing the approximation of the fractured extremities of the bones $ and this po- sition is demanded, to relax the psoas and ilia- cus muscles, and thus prevent the elevation of the upper part of the bone. In this way, and thus only, can the great deformity I have de- scribed be prevented. When by this posture the extremities of the bones are brought into proper apposition, and all projection of its up- per portion is removed, either the splints may be applied which are commonly used in fracture of the thigh-bone, or, what is better, a strong leather belt lined with some soft material, should by means of several straps be buckled around the limb.
OF DISLOCATION OF THE KNEE.
The broad surfaces of bone by which the os femoris rests upon the tibia are calculated to
OF THE KNEE.
55
prevent the ready dislocation of this joint, which would be otherwise very liable to happen, from the superficial nature of the articulating cavities on the head of the tibia, and also from the great violence to which this joint is frequently exposed.
The depressions upon the head of the tibia are however rendered deeper by the addition of the semi-lunar cartilages which rest upon the bone, they receive the condyles of the os fe- moris, and are attached by ligaments to the edge of the tibia. The fore part of the joint is defended by the patella, which has two unequal articular surfaces to play upon the condyles of the os femoris ; the head of the fibula forms no part of the knee-joint, but is attached with the tibia from an half to three-fourths of an inch be- low its head.
The junction of the os femoris, tibia and pa- tella, is produced by means of a capsular liga- ment, which proceeds from the os femoris to the head of the tibia, and is attached to the edge of the patella where it divides into two portions, forms wings to that bone, and takes the name of alar ligaments. On its outer side the capsu- lar ligament is covered and greatly strengthened by the tendinous expansions which are derived from the vasti muscles, arid which proceed to the head of the tibia. Internally the ligament is lined by the synovial membrane, which is folded within the cavities on the extremities of the bones, and is reflected from the ligament to the edge of the articular cartilages, and it is believed forms a covering to the articular earth
Structure of the knee.
Bone,
Ligaments.
ON DISLOCATIONS
lages, Beside the capsular there are several peculiar ligaments. First , the ligamentum pa- tellae, which is stretched from the lower part of the patella to the tubercle of the tibia. Secondly , the external lateral or femoro fibular ligament, which passes from the os femoris to the head of the fibula, and which divides into two external lateral ligaments. Thirdly , the inter- nal lateral or femoro tibial ligament being at- tached to the os femoris, and to the head of the tibia. Fourthly , the oblique or popliteal liga- ment, which proceeds from the external condyle of the os femoris obliquely to be inserted into the head of the tibia. Fifthly , the crucial liga- ments which pass from the depression between the condyles of the os femoris behind ; the one to a projection between the articular surfaces of the head of the tibia, and the other to a de- pression behind that projection, so that these ligaments cross each other from before back- wards. The patella has a muscular connection with the os femoris by the insertion of the rec- tus, vasti, and cruralis, and by the ligamentum patellae it is united with the tibia, and laterally it is joined to the capsular and alar ligaments. This ligamentous junction of the three bones is very firm, but it allows of free flexion and ex- tension with some degree of rotatory motion when the knee is bent ; but although great strength of union is produced of the joint, still excessive violence and extreme relaxation will occasionally lead to its dislocation.
OF THE KNEE.
57
On Dislocations of the Patella .
The patella is liable to be dislocated in three Tire!
c 1 directions.
directions ; namely, outwards, inwards, and upwards. In its lateral dislocation the bone is Symptoms, most frequently thrown on the external condyle of the os femoris, where it produces a great pro- jection ; and this circumstance, with an inca- pacity of bending the knee, is the strong evi- dence of the nature of the injury.
The most frequent cause of the accident is Cause, from a person, in walking or running, falling with his knee turned inwards, and the foot out- wards, and thus, by the action of the muscles to prevent the fall, the patella is drawn over the external condyle of the os femoris, and when the person attempts to rise, he finds himself unable to bend his leg, and the muscles and ligaments of the patella are all forcibly on the stretch.
This accident generally occurs in those who have some inclination of the knee inwards, which, under the action of the extensor muscles, gives a direction to the patella outwards. — The internal dislocation is much less frequent, and it internal, happens from falls upon a projecting body, by which the patella is struck upon its outer side, or by the foot being, at the time of the fall, turned inwards.
What the state of the ligament in these cases
is, I have had no opportunity of learning, having never dissected a limb in which this accident had happened.
The inode of reduction in either case con-
Mode of reduction.
58
ON DISLOCATIONS
sists in pursuing the following plan. The pa- tient is placed in a recumbent posture, and an assistant raises the leg by lifting it at the heel ; the advantage of which is, that it extends the limb in the greatest possible degree ; then the surgeon presses down that edge of the patella which is most remote from the joint, be it one luxation or the other ; and this pressure raises the inner edge of the bone over the condyle of the os femoris, and it is immediately drawn, by the force of the muscles, into its situation.
My friend, Mr. George Young, informed me, that he was called to a case of dislocation of the patella outwards, in which the reduction of the patella was very difficult. The patient was a female, who, by a fall in walking, had the patella drawn over the external condyle of the os fe- moris, where it remained. He employed, most perseveringly, pressure upon the edge of the patella, without being able to succeed, but at last reduced it in the following manner. He placed the patient’s ancle upon his shoulder, and thus most completely extended the limb, and obtained a fixed point of resistance at the knee. Then grasping the patella with the fingers of his right hand, he pressed the outei4 edge of the patella with the ball of his left thumb and pushed it into its place.
An evaporating lotion of spirits of wine and water is to be applied, and in two or three days the limb may be bandaged, and it is soon re- stored to its natural uses, although it is some- what weaker than before.
When the botie is dislocated from relaxa*
Dislocation from re- laxation.
OF THE KNEE.
39
tion, (See First Part of these Essays) the patella is drawn upon the external condyle of the os femoris from very slight accidents, or from sud- den action of the muscles. My neighbour, Mr. Hutchinson, who has seen a great deal of sur- gery, informs me, he has very frequently seen this accident, and that the tendency to it has arisen, in a large proportion of cases, from the relaxation produced by excessive indulgence in onanism.
The reduction, in these cases, is effected in the same manner as has been before described.
After the reduction, to prevent any recurrence of the accident, and to support the weakened ligament, a laced knee cap, with a strap and buckle above and below the patella is to be worn.
On the Dislocation of the Patella upwards.
In this dislocation the ligament of the patella Upwards, is torn through by the action of the rectus fe- i dgament moris muscle, and the immediate effect of the lacc,ated' injury is to draw the patella upwards upon the fore part of the thigh-bone. — The appearances symptoms which this accident presents, are very decisive of the nature of the injury; for, besides the ele- vation of the patella, and its easy motion from side to side, a deep depression is felt above the tubercle of the tibia from the absence of the ligament : the patient immediately loses the power of bearing upon that limb, as the knee bends under each attempt, and he would fall if he persisted in throwing the weight of his body upon it. A considerable degree of inflamma- tion follows.
60
ON DISLOCATIONS
Treatment.
Four
directions.
Local depletion and evaporating lotions are to be used for from four to seven days, and then a roller is to be applied around the foot and upon the leg, to prevent it from swell- ing, the leg is to be kept extended by a splint behind the knee, and a bandage composed of a leather strap is to be buckled around the lower part of the thigh ; to this is to be at- tached another, which is to be carried on each side of the leg, and under the foot, and is to be buckled to the circular strap ; thus the bone is gradually drawn down, so as to allow of an union of the ligament. In a month the knee may be slightly bent, and as much passive mo- tion daily given as the patient is able to bear ; by these means the ruptured ligament becomes united, and the patella retains its motion. With very great attention this becomes perfect : for so it happened in a case which I saw with Mr. Burrowes, in Bishopsgate Street. Mr. B. paid great attention to the case, and the patient re- covered without any diminution of the natural powers of the part, the patella being gradually drawn down, until the ends of the ligament were approximated and coalesced.
On dislocation of the Tibia at the Knee-Joint
These dislocations occur in four different directions ; but two of them are incomplete and lateral, while the others are perfect luxations, the tibia being thrown either backwards or for- wards.
The lateral dislocations are but rare. In the
61
OF THE KNEE.
dislocation inwards, the tibia is thrown from its internal, situation, so that the condyle of the os femoris rests upon the external semilunar cartilage, and the tibia projects much on the inner side of the joint, so as at once to disclose the nature of the injury. The first case of this kind which I ever witnessed was brought to St. Thomas’s Hos- pital whilst X was apprentice there ; and X re- member being struck with three circumstances in the case : the first was the great deformity of the knee from the projection of the tibia ; secondly, the ease with which the bone was reduced by direct extension ; and, thirdly, the little inflammation which followed upon what appeared to be so serious an injury; for the man was discharged from the hospital, having suffered little local or constitutional irritation.
The tibia is now and then thrown upon the External, outer side of the knee-joint, the condyle of the os femoris being placed in the situation of the inner semilunar cartilage, or rather behind it, when an equal deformity is produced, as in the other dislocation. The reduction of the limb is equally easy with the former, and the pa- tient recovers with little diminution of the powers of the part. Xt seems to me, that in both these dislocations the tibia is rather twisted upon the os femoris, so that the condyle of the os femoris, with respect to the tibia, is thrown somewhat backwards, as well as outwards or inwards.
CASE.
One of the aldermen of the city of London, case.
62
ON DISLOCATIONS
Case of
dislocation
inwards.
riding down High gate-hill during the night, and not being aware of a rail being placed across a part of the road which was repairing, the horse ran against the rail, and turning quickly, threw his rider over the rail, whilst his leg was confined between it and the horse, so that his body was on one side of the rail, and his leg on the other : the result of this was, that he partially dislocated his tibia outwards, throwing the condyle of the os femoris inwards. Being immediately taken to a public-house, the tibia was easily replaced, and being, some hours after, taken home, means were used to reduce the swelling and inflamma- tion which in him became considerable. When he attempted to bear upon the limb he found the capsular ligament very feeble, and he was obliged to have a knee-cap made of very strong leather to support and connect the bones ; and by the aid of this bandage he gradually reco- vered, and was enabled to walk well and to do duty on horseback, as a light horse volunteer, before twelve months had expired.
CASE.
I was consulted by Mr. Richards respecting Mr. Bovill, a gentleman from Barbadoes, who had dislocated his knee. I made a few notes on the case at the moment, which were as follow. The gentleman was thrown from a gig ; the tibia was dislocated, and the fibula broken a little be- low its head. The head of the tibia projected much on the inner side of the condyle of the os femoris. My friends, Mr. Caddell and Mr.
OF THE KNEE.
63
Richards, surgeons in Barbadoes, saw him in a quarter of an hour after the accident ; the leg was extended from the thigh-bone, in a bent position of the limb ; the extension was a long time con- tinued, and the force was employed by several persons for half an hour before the luxation was reduced. It became excessively swollen, and re- mained so for many weeks, the climate probably being unfavourable to his recovery; but at length the inflammation and its consequences were overcome by local depletion. When I saw him, eighteen months had elapsed from the accident, and he could not then bend the joint at right angles with the thigh ; there was also an unna- tural lateral motion of the joint, from the in- jury which the ligaments had sustained. The fracture of the fibula had injured the peroneal nerve, as was evident from the numbness of which he complained in the course of its distribution.
The tibia is now and then dislocated in the direction forwards. In this accident, when the person is recumbent, the external marks of the injury are these. The tibia is elevated, the thigh-bone is depressed, and is thrown some- what to the side as well as backwards. The os femoris makes such pressure on the popli- teal artery, as to prevent the pulsation of the anterior tibial artery on the* foot ; the pa- tella and tibia are drawn by the rectus muscle forwards. Such were the appearances in a man of the name of Briggs, brought into Guy’s Hospital in the year 1 802, not only with this accident, but with a compound fracture of the tibia of the other leg, with dislocation of the head of the fibula. Mr. Lucas was obliged to
Dislocation of the tibia forwards.
4
*
64
ON DISLOCATIONS
Dislocation of t he tibia backwards.
Case by Dr. Walsh man.
amputate the compound fracture, and the man is now living at Walworth. The limb in this case was easily reduced, by extending the thigh from above the knee, and by drawing the leg from the thigh and inclining the tibia a little downwards. Directly as it was reduced the popliteal artery ceasing to be compressed, the pulsation in the anterior tibia! was restored. The head of the tibia is sometimes dislocated backwards, behind the condyles of the os fe- moris, producing the following appearances : a shortened state of the limb, a projection of the condyles of the os femoris, and depression at the ligament of the patella, and the leg is bent forwards. The following case, for which I am indebted to my friend Dr. Walshman, who has ever been a man of close observation in his profession, and always practised it with atten- tion, judgment, and with honor.
CASE.
*
Mr. Luland, residing near the Elephant and Castle, at Newington Butts, a very robust and muscular man, on the 4th of January, 1796, dislocated his shoulder and knee at the same instant. The accident happened in the follow- ing manner : it being a very severe frost, and the ground very slippery, he being in his cart, the horse fell. Mr. Luland was thrown under the front rail of the cart and luxated the tibia backwards, whilst his shoulder fell on the saddle and dislocated the os humeri into the axilla. The head of the tibia was completely dislocated backwards, reaching behind the condyles of
OF THE KNEE.
ilie femur into the ham; the tendinous connec- tion of the patella to the rectus muscle was ruptured ; the external condyle of the os fe- moris very protuberant, the leg shorter, and there was a depression just above the patella.
The patient felt most excruciating pain when c^e. the limb was moved, but there was not any considerable degree of suffering when it was at rest. The reduction was effected in the following manner : two men extended the limb upwards, one from the groin and the other from the axilla, whilst two others extended the leg from a little above the ancle in the opposite direction; and they gradually increased the force of their extension till the bone was reduced. The patient was placed on his back, and Dr. Walshman directed the head of the bone to its natural situation. Dr. W. then ap- plied a flannel roller on the knee, placed the patient in bed with his limb upon a pillow, and directed the part to be kept wet with an eva- porating lotion. He remained in this state a fortnight, free from pain; the Dr. slightly moved the part every other day, as far as he could without giving pain. In about a month Mr. Luland began to walk on crutches. Ten weeks after the accident he was able to sit at his dinner-table, and in five months he had given up the use of his crutches, and appeared per- fectly recovered, being able to use that limb as well as the other. He died of dropsy, February 18, 1819.
Dr. Walshman’s treatment of this case was highly judicious. He suffered the parts, as he observes in his letter, to remain at rest till the
F
66
ON DISLOCATIONS
From re- laxation.
Mr Hey’s idea.
adhesive inflammation had united the lacerated ligament, and then, and not till then, began with passive motion.
On partial Luxations of the Thigh-hone from the Semilunar Cartilages •
Under extreme degrees of relaxation, or in cases where there has been an increased secre- tion into a joint, the ligaments become so much lengthened as to allow the cartilages to glide upon the surface of the tibia, and particularly when pressure is made by the thigh-bone on the edge of the cartilage. That excellent practical surgeon, Mr. Hey, of Leeds, whose death will be severely deplored in the district in which he practised, and lamented by those in the profes- sion who have its improvement at heart, was the flrst who clearly described the symptoms and cause of these accidents, and suggested a mode of treatment, which is ingenious, scientific, and generally successful. The most frequent cause of the accident is from a person in walking striking his toe when the foot is everted against any projection (as the fold of a carpet), he im- mediately feels pain in the knee, which is un- able to be completely extended. I have known this accident also happen from a person having suddenly turned in his bed, and the clothes not suffering the foot readily to turn with the body, the thigh-bone has slipped from its semi- lunar cartilage. I have also known it occur from a sudden twist of the knee inwards when the foot was turned out.
The explanation of this accident is as follows:
OF THE KNEE.
67
The semilunar cartilages which receive the con- dyles of the os femoris are united to the tibia by ligaments, and when these ligaments become ex- tremely relaxed and elongated, the cartilages are easily pushed from their situation by the condyles of the os femoris, which are then brought into contact with the head of the tibia, and when the limb is attempted to be extended the edges of the semilunar cartilages prevent it. How then is the bone to be again brought upon the cartilages ? Why, as Mr. Hey has advised, by bending the limb back as far as is possible, which enables the cartilage to slip into its natural situation, from the pressure of the thigh-bone being re- moved in the bent position, and the leg being brought forwards it can then be completely ex- tended, because the condyles of the os femoris are again received on the semilunar cartilages. This plan is not however invariably success- ful, as the following case will shew. A lieu- tenant in the army had this accident repeat- edly happen to him, and the limb was as often reduced by the above means; but at length in turning in bed, from the pressure of the bed- clothes on his foot, the accident recurred. He came to town; but bending the limb had now no effect in enabling him to extend the joint, I therefore advised him to visit Mr. Hey at Leeds; but I learnt that in this case the joint was never reduced. I also made the following notes of the case of a gentleman who came to my house.
Mr. Henry Dobley, ast. 37, has often dislocated his knee by turning the foot inwards and the thigh-bone outwards, by accidentally slipping in walking on uneven ground, or under sudden
Explana- tion of the accident*
Mode of i eduction.
Sometimes
unsuccess-
ful.
68
ON DISLOCATIONS
Different mode of re- duction.
Particular bandage re- quired.
Case.
exertions of the limb \ considerable pain is im- mediately produced, accompanied with a great deal of swelling. His mode of reducing it is as follows : he sits upon the ground, and then bending the thigh inwards and pulling the foot outwards, the subluxation of the os femoris being external, the natural position of the limb becomes restored. A knee-cap laced tightly around the knee is the usual preventive of the return of this accident, but it is not sufficient in Mr. Dobley, without the addition of straps, and more especially of a very strong leather one just below the patella.”
A young lady was brought to my house who was frequently the subject of this accident, but in her the cartilages had beqti several times easily replaced, and the return of the accident prevented by a bandage composed of a piece of linen with four rollers attached to it, (see Plate,) which were tightly bound above and be- low the patella, and she said, answered its in- tended purpose better than any other.
Great alteration takes place in the form and size of the knees, in some of these cases, from a chronic rheumatism sometimes attending them. I made the following notes of a case of this kind, about which I was consulted, but I have seen several similar to it.
CASE.
Lady D — — , a year and a half ago fell and twisted her thigh-bone inwards at the knee, producing great pain on the inner side of the joint. Her ladyship immediately restored the
OF THE KNEE*
69
parts to their situation, by pressing the thigh outwards and the leg inwards, previous to which she could not move the joint. For a fortnight she was scarcely able to betid or straighten the knee, and the muscles felt to her to be in a state of cramp. She then began to stand upon the limb by the aid of crutches, but when she bore upon it considerably it suddenly bent back, with pain and subsequent swelling, and she felt the condyles at the time slip from the semilunar cartilages upon the head of the tibia. Any sudden motion produced the same effect for fifteen months, and each of these accidents threw her back for several weeks; the pain ex- tended from the knee to the toe. For three months previous to her last accident she walked on crutches, and even at times with only the aid of a stick; when about two months since, in endeavouring to raise herself from a sofa, and turning quickly round to take her stick, the left knee gave way, as if the bone had slipped from its place, the thigh-bone being at the time twisted outwards ; pain and swelling succeeded, and she has never been able to stand upright since. Her joints are all of them remarkably flexible, as the elbow may be easily bent backwards to form an angle with the os humeri. When a girl she had frequently the sensation of putting the knees out of joint, but they soon got well. The knees are now swollen, and effusion has taken place into the joints of a considerable quantity of synovia. When she attempts to stand she cannot straighten her knees, but would fall forwards if not sup- ported. The principal treatment is to produce
ON DISLOCATIONS
absorption of the fluid which is effused, and then to give due support to the ligaments. For the first of these she was desired to apply blisters, which were directed to be kept dis- charging for a considerable time, and after they were healed she was ordered to make pressure upon the joints by a strong bandage, which was to be occasionally removed to give an oppor- tunity of employing friction.
In the dissection of these cases the ligament
* ■ - .■ * +'
is found extremely thickened ; little pendulous ligamentous and cartilaginous bodies are seen suspended from it, a thick edge of cartilage projects from that of the articular cartilage, and a part of the latter is absorbed. When the bone is macerated, a great addition of ossific matter is found to have been made to the edges of the condyles of the os femoris.
On Compound Dislocations of the Knee-joint .
| f v * ' - ‘
Of this I have only seen one instance, and I conclude it to be therefore a rare occurrence 5 and there are scarcely any accidents to which the body is liable which more imperiously de~ mand immediate amputation than these.
CASE.
On Monday, August 26th, 1819, at eleven p. m. I was sent for by Mr. Oliver, surgeon at Brentford, to visit Mr. Pritt, who I was in? formed had fallen from the box of a mail-coach, and most severely injured his knee. I met, at the house to which he was carried, Mr. Oliver
OF THE KNEE*
71
and Mr. Hunter of Richmond, surgeons, and immediately proceeded to examine the knee. A large opening was found in the integuments, through which the external condyle of the os femoris projected, so as to be opposite the edges of the skin. The os femoris was thrown behind the tibia on its outer side, but not so much on the inner, so that the external con- dyle of the thigh-bone was dislocated back- wards and outwards; and the axis of the thigh- bone was twisted, and the internal condyle ad- vanced upon the head of the tibia. We made attempts to reduce the condyle, but it could only be effected with extreme difficulty; and the bone, directly the extension was removed, slipped into its former situation. The joint being freely opened by the accident the bone dislocated, and when reduced easily slipping from its place, accompanied with an extremely irritable constitution, decided me at once to propose the amputation of the limb, which being acceded to, it was immediately per- formed. The symptoms of constitutional irrita- tion which followed the operation became ex- tremely severe, and he being delirious on the 31st, Mr. Oliver applied leeches to his tem- ples, a blister under the occiput, and gave the saline medicine with camphor and the pulv* ipec. comp. On the following day I was sent for to visit him, but being absent from London, my most able and excellent friend Mr. Cline, senior, visited him, and ordered him.
Tine. Opii. gtt. v®
Pulv. Castor, gr. x.
Mist. Camphor, yiss. M.
Ft. Haustus 4ta quaque hora su-mendus*
72
ON DISLOCATIONS
Soon after the second draught was administered he fell asleep, and after several hours’ repose he awoke perfectly sensible. He gradually reco- vered, and left Brentford on the 25th of Octo- ber, with a small wound still remaining: on the stump.
Dissection. I brought home the limb and carefully dis- sected it. Under the skin there was great ex- travasation of blood in the cellular membrane surrounding the knee; the vastus internus mus- cle had a large aperture torn in it, just above its insertion into the patella; the tibia projected forwards and the patella was drawn to the outer side of the knee, being no longer in a line with the tubercle of the tibia. Looking at the joint posteriorly, both heads of the gastrocnemius externus muscle were lacerated ; the capsular ligament was so completely tom posteriorly that both the condyles of the os femoris were seen projecting through the laceration in the gas- trocnemius; neither the sciatic nerve, the pop- liteal artery and vein, the lateral nor the crucial ligaments were ruptured. (See Plate.)
It is probable that all compound dislocations of the knee-joint will require a similar practice, unless the wound be so extremely small as to admit readily of its immediate closure.
On Dislocation of the Knee from Ulceration.
In the progress of chronic diseases of the joints, inflammation beginning in the synovial membrane and proceeding to ulcerate the arti- cular cartilages and bone, at length affect the Ligaments capsular ligament and even sometimes the pe- culiar ligaments of the joints; the bones are
OF THE KNEE.
73
thus becoming unconnected, the muscles irri- tat edby participating in the inflammation draw the limb into distorted positions, and thus one bone becomes gradually displaced from the other. In the hip -joint this is most frequently seen from the oblique bearing of the thigh-bone on the pelvis. In the knee it is also not unu- sual that the thigh-bone shall be placed out of its natural line with the tibia, projecting either on the one side or upon the other ; but now and then most remarkable distortions are pro- duced by the irritative and spasmodic action of the muscles succeeding the ulcerative process of the ligaments, of one of which I have given a plate ; it was removed by amputation by Mr. Cline, sen. in St. Thomas’s Hospital, and had been the consequence of what is vulgarly called the white swelling of the knee-joint ; the leg was placed forwards at right angles with the thigh, so that when walking on his crutches he had the most grotesque appearance, as the bot- tom of his foot first met the eye when he was advancing. Upon inspection of the patella it was found anchylosed to the os femoris, and the tibia was also joined by ossific union to the fore part of the condyles of the thigh-bone.
This state of parts may be prevented by op- posing the action of the muscles when their irritability first begins to produce distortion, by the application of splints, and by the exhibition of opium to diminish the irritability of the system. Thus I have seen in cases of ulcera- tion of the hip-joint, the irritative action of the flexor muscles diminished, and the distortion prevented by drawing down the limb and keep-
Excessive
distortion.
Case.
How pre-: vented.
74
ON FRACTURES
Transverse
or longi- tudinal.
Symptoms.
ing it in the extended position, but it is a most painful extension to the patient, and should be very gradually accomplished.
On Fractures of the Knee-joint*
I shall now, pursuing my former plan, de- scribe the fractures to which the bones entering into the composition of this part are liable, and first the
Fractures of the Fatetta.
This bone is generally broken transversely, but sometimes, though rarely, longitudinally* It is liable also to simple and compound fracture, but fortunately the latter is but of rare occur- rence.
When the patella is transversely broken, the upper part of the bone is drawn from the lower, its superior portion of the bone being elevated by the action of the rectus muscle, which is inserted into its upper part, whilst the lower portion is still retained in its natural situation by the ligament of the membrane which passes to the tubercle of the tibia.
The degree of separation thus produced de- pends on the extent of laceration of the liga- ment, for when the ligament is but little torn the separation will be half an inch, but under great extent of injury the bone is drawn five inches upwards ; the capsular ligament and ten- dinous aponeurosis covering it, being then greatly lacerated ; and this is the greatest ex- tent of separation which I have seen. The acci-
OF THE KNEE.
75
dent may be at once known by the depression between the two portions of bone, and by the fingers passing readily down to the condyles of the os femoris into the joint as far as the in- teguments will permit, and by the elevated por- tion of bone moving readily on the lower and fore part of the thigh. The power of ex ten d- ing the limb is lost, and likewise that of sup- porting the weight of the body on that limb if the person be standing, for the knee bends for- wards from the loss of action in the extensor muscles. The pain of this accident is not very severe, and a simple fracture is not dangerous, for the constitution feels it but little. In a very few hours after the accident has occurred, a consider- able degree of extravasation of blood takes place upon the fore part of the joint, so that the appear- ance is livid, having often a gangrenous charac- ter, but this disappears in a few days. Consi- derable inflammation and fever succeed, an^l more especially there is a great degree of swel- ling in the fore part of the joint, both from the free secretion of synovia, and the effusion arising from inflammation. No crepitus is felt in this fracture, for the bones cannot be brought sufficiently near each other to give this general discriminating mark of other fractures.
The separation of the bones is much in- creased by bending the knee, as it removes the lower from the upper portion of bone, pulling down the tibia^ligamentuny; patellm, and lower part of the bone from the upper.
This accident arises from two causes : first, Causes, from blows upon the bone produced by falls open the knee, or received upon the patella in
76
ON FRACTURES
Flows or action of rouscles.
Explana- tion of ft„
Mode of pnion.
the erect position of the body ; and secondly , from the action of the extensor muscles upon the bone.
A gentleman walking in the country, and not used to jumping, leaped a ditch of consi- derable breadth ; and when he reached the op- posite bank he was in danger of falling and ran forward several steps, and with difficulty reco- vered himself. Whilst in this attempt to save himself from a fall, he felt the patella snap, and I was sent for to him, and found his pa- tella broken, and the portions of bone consi- derably separated.
A lady, descending some stairs, set her heel near the edge of one of the stairs, and was in danger of falling, when throwing her body somewhat backwards to prevent the fall and to straighten the knee, the patella became broken.
That a bone should thus break by the action of muscles appears at first sight incomprehensi- ble, but the solution of this circumstance is easily given. When the knee is bent, the patella is drawn down on the end of the condyles, so as to bring the upper edge of the bone forwards, and at that moment it is the patella is broken, by the rectus muscle not acting in a line with the bone but at right angles with it or nearly so, and upon its upper edge more particularly.
With respect to the mode of union of this bone, whether the separation be great or inconsi- derable, it is effected by an intervening ligamen- tous substance. The bone itself undergoes but little alteration ; the lower portion, joined by ligament to the patella,, has its broken cancel- lated structure still apparent, although a little
OF THE KNEE.
smoothed. The upper portion of bone has its broken cancelli covered by a slight ossific de- posit, so that there is more ossific action in the upper than in the lower portion of the bone, and certainly much less than in bones which do not form a part of the joints. The internal articular surface of the bone preserves its na- tural smoothness. Blood is immediately depo- sited in the place of the injured ligament, but this in a few days is absorbed. Inflammation arises and pours out adhesive matter, which extends from one edge of the lacerated liga- ment to the other, and even between the bones, to each of which it is firmly united. (See Plate.) Vessels shoot from the edges of the ligament and render the new substance organized, and pro- duce a ligamentous structure similar to that from which the vessels shoot ; this substance is not however always perfect, for I have seen aper- tures in it ; but this will greatly depend upon the extent of the laceration of the ligament, and the too early use of the limb. In the dog and in the rabbit, or almost any other quadruped, it is possible by experiment to trace the mode of union of this bone.
EXPERIMENT I.
I drew the integuments much aside in a rab- bit, and dividing them, placed a knife upon the patella and struck it lightly with a mallet; the bone was broken and directly drawn up. I let the integuments go, and the wound was not opposite the fracture. In forty-eight hours I killed the animal and examined the part.
78
ON FRACTURES
The bones were separated three-quarters of atl inch, and the intervening part filled with coa- gulated blood.
EXPERIMENT II.
I repeated the former experiment, and killed the animal on the eighth day, and found most of the blood absorbed and adhesive matter oc- cupying the space between the bones.
experiment III.
The former experiment repeated ; the ani- mal examined on the fifteenth day. The adhe* sive matter had acquired a smooth and some- what ligamentous character.
EXPERIMENT IV.
The same division of the bone being made, it was examined on the twenty-second day, when the new ligament was complete.
EXPERIMENT V.
The same repeated in five weeks. The part was injected, and vessels were found proceed- ing from the edge of the ligament into the adhesive matter, now become ligamentous. So that at the end of five weeks the vascularity is complete, and some vessels proceed from the bone and find the ligament. Upon the dog these processes may be equally well observed,
OF THE KNEE. 79
but they are not quite so rapidly produced in a large dog as in the rabbit.
The parts were dissected and preserved after these experiments both in the dog and rabbit, and I have them in the collection at St. Thomas’s Hospital, where they may be always seen.
EXPERIMENT VI.
In a rabbit, having divided the bone, I sewed together the two portions by conveying a needle and thread through the tendinous covering of the bone, but the ligatures separated, and the bones still united by ligament.
EXPERIMENT VII.
I divided the bone, and cut the rectus muscle through, yet the patella united by ligament.
I could not either in the dog or in the rabbit succeed in producing a bony union in the trans- verse fracture.
Yet I once saw in a patient of my kind friend, M. Chopart, at Paris, a case which ap- peared to me to be united by bone, the separa- tion was so small, but I should now suppose I was mistaken.
A ligamentous union of the transverse fracture of the patella is, then, probably that which con- stantly occurs ; or if there be an exception, it is very rare. But still the principle which is to guide Ligament- the surgeon’s conduct is, to make that ligament as short as as short as possible. If the ligament be of great IS possibIe’ length, there is a proportionate weakness ; for as soon as the accident has happened, the rec- tus muscle retracts and draws up the bone, and in proportion to the retraction suffered
80
ON FRACTURES
Treatment.
to remain, is the degree of shortening of the muscle, and consequently the diminution of its power. Those, therefore, who have had the bones widely separated, when they walk quickly, do it with a halt, and are very liable to fall, and to break the other patella. Let then f,he muscle be brought as nearly as it can be into its natural length, and although complete apposition of the bone is very rarely effected, yet the ligamentous union is rendered as short as circumstances will permit, and the patient will recover the entire use of the limb.
The idea which was formerly entertained of the danger of squeezing the callus into a projection in the inner side of the bone so as to destroy the smoothness of its internal surface is not at all tenable.
When called to this accident the surgeon places the patient in bed upon a mattress, ex- tends the limb upon a well padded splint placed behind the thigh and leg, to which it is tied, and which splint should be hollowed. An eva- porating lotion is then applied upon the knee consisting of Liq. Plumbi s . acetat. dibit. 5. v. with Spir. Vini 5. i. ; and no bandage should be at first employed. The body should be slightly raised in bed to relax the rectus muscle, and the heel should be raised to bring up the lower portion of the patella. If, on the succeeding day or two, there be much tension or ecchymosis, leeches should be applied, and the lotion should be continued ; when, after a few days, the ten- sion has subsided, then, and not till then, should bandages be employed. I have seen the greatest suffering and swelling produced by the early application of bandages in these cases, even so
OF THE KNEE.
81
as to threaten sloughing of the skin when there had been much contusion. The means which are most frequently employed in the treatment of this case are as follow. A roller is applied from the foot to the knee, to prevent the swelb ing of the leg, and the upper portion of bone is pressed downwards as far as it can be with- out violence, towards the lower, so as to les- sen the retraction of the muscles and produce the approximation of the portions of bone. Then rollers are applied above and below the joint, confining a piece of broad tape next the skin on each side, which crosses the rollers at right angles; these portions of tape are bent down and tied over the rollers so as to brine; them near each other, and thus to keep down the upper por- tion of bone. Sometimes, instead of the tape on each side, a broad piece of linen is bent over the rollers on the fore part of the joint, and is there confined so as to approximate the pieces of bone, and to bind down the upper portion of the patella, that its lower broken edge may not turn forwards.
But the mode I prefer is as follows: A leather strap is buckled around the thigh, above the broken and elevated portion of bone,andfrom this circular piece of leather, another strap is passed under the middle of the foot, the leg being ex- tended, and the foot raised as much as possible. This strap is brought upon each side of the leg, and buckled to that which is fixed around the lower part of the thigh. The strap may be confined to the foot by a tape tied to it, and to the leg at any part in the same manner ; and
G
82
ON FRACTURES
State of the muscle.
this is the most convenient bandage for the fractured patella and for the patella dislocated upwards by the tear of its ligament.
In this position, and thus confined, the limb is to be kept for five weeks in the adult, and for six weeks at a more advanced age.
Then a slight passive motion is to be begun, and this must be done gently and with so much circumspection, that the ligament, if not firmly united, shall not give way, and the bones recede. If the union be found sufficiently firm to bear it, the passive motion is to be employed from day to day until the flexion of the limb be com* plete.
If passive motion be not used, it appears that the action of the extensor muscles would never return ; for those who are kept in bed, with the joint at rest, do not in many months acquire any power of bending and extending the limb ; but when passive motion has been used, the patient is placed on a high seat and directed to swing the leg, by which motion is given to the rectus, and if the mind be then directed to the contraction of that muscle, its powers will be gradually renewed. When the rectus muscle has been shortened, and the upper portion of bone is drawn from the lower, all the disposition to action in that muscle ceases $ and it does not seem disposed to recover its voluntary action until it becomes again elongated, which is effected after the union of the ligament, by bending the knee ; and from this point of elon- gation the muscle begins to contract.
A young woman was brought into my house
8
OF THE KNEE.
in her father’s arms, and he said, u X am obliged to carry her, for she has lost the use of her legs, having broken both her knee-pans eight months ago, and she has never been able to use her limbs since/’— Passive motion was directed, and she was ordered to try to extend her legs when they were bent. At first she could effect but little however, by re- peated trials, she gradually recovered the use of her limbs. Mr. John Hunter, who raised sur- gery into a science, and who seems to have been the first who attended to the principles on which the practice of surgery ought to be regulated, always dwelt most ably upon this subject in his lectures. Patients, from the pain which passive motion produces, and the slow return of action in the muscles, are indisposed to suffer the one or to make trials of the other ; but without them there can be no recovery.
The degree of approximation of the bone is, as I have stated, a matter of great consequence. The bone is rarely, if ever, brought into con- tact so as to be united in the transverse frac- ture by ossific union ; but the less the dis- tance between the bones, the greater is the power which the muscle reacquires : for, in proportion as the muscle is shortened is it weakened | therefore the surgeon should bring the bones as near together as he can to render the ligamentous union as short as is possible, and consequently to leave the muscle with as much of its original power as the nature of the accident permits.
ss
Case.
Degree of approxima- tion.
84
ON FRACTURES
Ligamen- tous union
\
Union by ligament, in experi - ments.
Of the 'perpendicular Fracture of the Patella .
We have in the collection at St. Thomas’s Hospital a patella, one-fourth of which has been broken off; the edge is smooth, and no ossific union of the piece from which it had been se-
JL
parated appeared to have been produced.
A gentleman consulted me who had about one-third of the patella separated from the other part of the bone ; it had united by ligament, for there was free motion between the fractured piece of bone and that from which it had been removed. He recovered quickly from this in- jury, and it influenced his power of walking very little.
These circumstances surprised me, because I saw no reason why the bone should not be united when broken perpendicularly, as I thought the muscles would have a tendency to bring the parts together. I made it therefore a subject of experiment.
EXPERIMENT I.
July 31st, 1818, I broke the patella of a dog, by placing a knife upon it in the longitudinal di- rection, having first drawn the integuments aside.
and on the 12th of September following I ex- amined the part, when I found the two portions of bone considerably separated from each other, and united by ligament. The cause was as fol- lows: when I had divided the bone, the knee became bent, the condyles of the os femoris
OF THE KNEE.
I
85
pressed against the inner side of the patella, and thrust the parts asunder, and only a ligamentous union had taken place. (See Plate.)
EXPERIMENT II.
August 2d, 1818, I broke in the same man- ner the patella of a rabbit, and examined the parts on September 3rd, when I found the two portions of bone widely separated, and united only by ligamentous matter, I now began to think it impossible for the patella to unite by bone, but determined to make another experi- ment to determine this point
EXPERIMENT III.
I divided the patella longitudinally in a dog, but took care that the division should not ex- tend into the tendon above or to the ligament below it, so that there should be no separation of the two portions, I examined it three weeks after, and found it united ; no separation exist- ing between the two portions*. (See Plate.)
It appears, then, that under longitudinal and transverse fracture, a ligamentous union is gene- rally produced, and that it arises from the sepa- ration produced in the bone ; and that if it cannot separate, but its parts remain in contact, then ossific union will be produced.
In the summer of 1819, Mr. M. was thrown from his gig as he was passing along the Strand,
* Th£ bone was, under maceration, found united in part by bone, and in part by cartilage, not yet completely ossified.
Union by bona.
86
ON FRACTURES
Treatment.
From
Violence or ulceration.
Case.
and fractured Ins patella by the fall transversely , and the lower portion of the bone was also bro- ken perpendicularly, so that it was divided into three pieces. The transverse fracture united as usual by ligament; but the perpendicular, by bone. Mr. Parrott, of Tooting, who also attend- ed the case, writes in these words:—' u Dear Sir, I have great pleasure in replying to your letter; the longitudinal fracture of the patella of Mr, M. has become very firmly consolidated, but there is a line or ridge to be traced upon the surface of the bone, which marks distinctly the place where it had been separated.
JOHN PARROTT, JUN.?'
Tooting.
4
In the longitudinal or perpendicular fracture of the patella, the best treatment is, to extend the leg, to use local depletion, and evaporating lotions ; in a few days to apply a roller around the limb, and then a laced knee-cap with a strap which buckles around the knee above and below the patella.
Of compound Fracture of the Pa tella .
These occur from injury, or from an ulcera- tive process under peculiar circumstances.
The cases which I have seen of this accident, are as follows :
CASE I.
A man was admitted into Guy’s Hospital, under Mr* W. Cooper, with a compound fracture of this bone; violent inflammation followed; sup-
OF THE KNEE,
puration ensued, with the highest degree of con- stitutional irritation ; and no opportunity was given for amputation from the great swelling of the thigh ; and this man died. The bone is in the museum of St, Thomas’s Hospital, as dis- united as at the first moment of the accident.
CASE IL
A man was admitted into St* Thomas’s Hos- Case» pital, under the care of Mr. Birch, with a frac- ture of the patella and a small wound extend- ing into the joint. The knee was fomented and poulticed ; inflammation and suppuration followed ; and this man in a few days died with the highest symptoms of constitutional irrita- tion.
CASE III.
Mr. Hawker, surgeon, called me to visit a Case, man who was just arrived in London ; who was at work at a warehouse up one pair of stairs, and hearing the signal for dinner, and seeing the doors of the warehouse open, he walked quickly out and fell into the street. By this fall he had a compound fracture of the patella.
The limb was attempted to be saved. The joint suppurated, the discharge became exces- sively great, and the symptoms of irritation ran so high that I thought he would not recover; but he became somewhat better, and i advised him to go into the country. I afterward heard that he gradually recovered with an anchylosed joint.
ON FRACTURES
CASE IV.
Mr. Redhead, residing at Kennington Cross, aged 89 years, was thrown from his gig on the 18th of June, 1819, against a cart-wheel. His knee came violently in contact with the wheel, which fractured his patella and opened the joint. Mr. Dixon, of Newington Butts, wafc sent for, and he found that the knee had bled freely from a wound on its outer side, from which the synovia freely escaped, and which readily admitted his finger to the shattered patella. The accident happened at ten o’clock, and I was sent for by Mr. Dixon, and when X met him at four o’clock I found a wound through which I readily passed my finger into the joint, and the patella was not broken transversely, but, as I have ex* pressed it, shattered, that is, broken into several pieces, and a small piece which was separated from the rest 1 removed. It was agreed be- tween Mr. Dixon and myself that the limb should be attempted to be saved, for the patient was of a spare habit, and from bis great com- posure shewed he was not of an irritable consti- tution. 1 passed a suture through the integu- ments, knowing the difficulty of keeping the wound closed on account of the continued escape of synovia, but taking the utmost care that the ligament should not be included in the suture. Adhesive plaister was also applied over the wound, and rollers, lightly put on, which were kept constantly wet with spirits of wine and water. The leg was placed in the ex- tended position, and he was ordered not to
OF THE KNEE,
89
move it in the slightest degree, and to live on fruit.
Saturday . He had passed a very good night, and was free from pain or fever.
Sunday night . He was restless, and it was thought delirious.
Monday morning . He had a dose ofGl. Ricini, which relieved him from his feverish feelings.
Tuesday . He stated he had a good night, and he afterwards had no bad symptom. As there was no swelling, no inflammation, and scarcely any pain, the suture was not removed until the 30th of June, when the adhesive plaister was renewed. He recovered without any untoward accident. Mr. Dixon ordered him from bed in a month. At the end of five weeks Mr. D, gave the joint slight passive motion, and on the 7th of August he walked across his room.
If the laceration be extensive, or the contu- sion very considerable in these cases, the ope- ration of amputation will be required \ but if the wound be small, and the patient unirri table, and no sloughing of the integuments or liga- ment is likely to occur from the nature of the accident, it will be best to try to save the limb ; and the treatment of Mr. Redhead’s case is that which I should pursue. The principal object is to produce adhesion immediately, and every means in our power must be used to effect it. I know well that sutures are generally objec- tionable, and I never employ them, if I can pos- sibly succeed without them, but in moveable parts, in those which are unsupported, and in those through which a secretion is liable to
t
90
ON FRACTURES
force its way, they are not only justifiable but
highly necessary.
A compound fracture of the patella will be sometimes produced by an ulcer in the follow- ing manner.
CASE.
ulceration. A wo man was admitted into Guy’s Hospital in 1816, with a simple fracture of the patella* which had long been united by a ligament of about three inches in extent. Ulcers were formed upon different parts of the body, and unfortu- nately one of these upon the integuments over the union of the patella. It became sloughy* and extended through the new ligament to the joint which it laid open ; violent constitutional irritation succeeded ; a copious suppuration was produced, and no opportunity was given of am- putating the limb, for the inflamed and swollen state of the thigh forbad it. This woman died.
On Oblique Fractures of the Condyles of the Os
Femoris into the Joint .
Rare, These cases are of rare occurrence, but when
they happen it is difficult to prevent deformity, and to restore the patient to a sound and useful limb. They are known by the great swelling of the joint with which they are accompanied, by the crepitus which is felt in moving the joint, and by the deformity with which they if either are attended. The fracture is sometimes of the inner and sometimes of the outer condyle, and the bone is split down into the joint.
OF THE KNEE*
91
Whether the external or internal condyle is Treatment, broken, the same treatment is required* The limb is to be placed upon a pillow in the straight position, and evaporating lotions and leeches are to be used to subdue the swelling and in- flammation. When this object has been effected, a roller is to be applied around the knee, and a piece of stiff pasteboard, about sixteen inches long, and sufficiently wide to extend entirely under the joint, and to pass on each side of it, so as to reach to the edge of the patella, is to be dipped in warm water, and applied under the knee and confined by a roller. When this is dry it has exactly adapted itself to the form of the joint, and this form it afterwards retains, so as best to confine the bones. Splints of wood or tin may be used on each side of the joint, but they are apt to make uneasy pressure. In five weeks passive motion of the limb may be gently begun, to prevent anchylosis. I prefer the straight position in these cases, because the tibia presses the extremity of the broken con- dyle into a line with that which is not injured.
Examples of compound fractures of the com Compound dyles are very unfrequent ; the following was fracturc‘ under the care of Mr. Travers in St. Thomas’s Hospital, who was so kind as to send me the following history of it.
Michael Dixon was admitted into St. Tho- mas’s Hospital, September 17th, 1816, for a fracture of the lower extremity of the femur, occasioned by his legs being entangled in the spokes of a carriage-wheel in motion. There was much displacement of the fractured bone, and a small wound opposite the external con-
92
ON FRACTURES
dyle. Upon examination, it was evident that the fracture had extended nearly in the di- rection of the axis of the bone, in addition to a transverse fracture of the shaft of the bone above the joint ; the external condyle was moveable and thrown out of its place du-
X.
ring the accident, as if it had been drawn by the leg which was twisted inwards. The limb was laid in a fracture-box, in a semiflexed posi- tion on the heel 5 the constitutional disturbance was very slight.
Oct. 5. The external condyle is still moveable \ the integuments over it are ulcerated: so as to denude the bone ; the health remains good.
Nov. 5. The broken bone protrudes and ap- pears to be dead ; it is surrounded by fungous granulations, and there is but little discharge.
Nov . 18. The protruded bone was gently twisted off by forceps shewing it to be the ex- ternal condyle with its articular surface ; there still protruded a small portion of bone, but this soon healed over ; the limb was now placed in an extended position, as anchylosis was consi- dered unavoidable.
Dec . 1. The boy has recovered almost the perfect use of his limb, and is enabled to bend and extend it without pain.
Dec . 6. The boy was discharged from the hospital. The wound was healed, and he can walk tolerably well with a stick.
On the February following he called at the hospital, walking without any support, and having free use of the joint.
Fractures of the Body of the Femur just
I
OF THE KNEE* 93
above the condyles require the bent posh Fractures
* A * just above
tion of the knee, to prevent deformity, which the con- is sore to follow if the limb be placed m <tyles* the straight position, and most miserable union I have thus seen produced. The thigh ought to be put over the double inclined plane, to constantly extend the condyles in a line with the shaft of the hone, and a roller is to be applied around the lower parts of the thigh-bone, to assist in pressing the bones to- gether. These cases I have seen occur in per- sons prior to the age of twenty years, and it has appeared to me that the epiphysis has been broken off, but I have also known it happen in very old persons, and in one instance prove de- structive to life.
The Head of the Tibia is sometimes obliquely oblique broken, and if it be fractured into the joint the th1oibi?in- treatment which it requires is similar to that tothejoint‘ which is necessary in the oblique fracture of the condyle of the os fern oris, that is, first, the straight position of the limb, because the femur preserves the proper position of the frac- tured tibia, by Being a splint to its upper portion, keeping the articular surfaces equal ; secondly, a roller, to press one part1 of the broken surface against the other ; thirdly, a splint of pasteboard, to assist in the preserva- tion of that pressure \ and fourthly, early pas- sive motion to prevent anchylosis.
But if the fracture of the tibia be oblique, Fracture
. . * lust below
but not into the joint, then it is best to place the joint, the limb upon the double inclined plane ; and as the cause of deformity is the elevation of the lower portion of the tibia, which is drawn up
94
I
Union with the tibia.
Produced by violence or relaxa- tion.
ON FRACTURES OF THE KNEE*
on either side of the knee-joint, as the frac- ture is in the inner or outer side of the tibia, the weight of the leg keeps the limb constantly extended, as it hangs over the angle of the in- clined plane, and thus brings the bone into as accurate apposition as the case permits.
On Dislocations of the Head of the Fibula.
The fibula joins the tibia, three-quarters of an inch below the articulation of the knee. Its head is inclosed in a capsular ligament which unites it to the tibia, to which it is also joined through the greater part of its length by the in- terosseous ligament.
This bone is liable to dislocation both from violence and from relaxation. I have only seen one case of it from violence, and in that in- stance it was connected with the compound fracture of the tibia.
■ Briggs, of whose dislocation of the tibia
I have given an account, had at the upper part of the other leg a compound fracture of the tibia and dislocation of the head of the fibula. The limb was attempted to be saved, but the constitutional irritation ran so high that ampu- tation was obliged to be performed, which was done by my colleague Mr. Lucas, and the man did well.
Dislocations of the head of the fibula from relaxation are more frequent, and the head of the bone is in these cases thrown backwards, and is easily brought into its natural connection with the tibia, but it directly again slips from Its position* This state produces a consider-
#
ON DISLOCATIONS OF THE ANCLE®
95
able degree of weakness and fatigue in walk- ing, and the person suffers much from exercise. As in these cases there is a superabundant secretion of synovia and distension of ligament, repeated blistering is required to promote ab- sorption, and afterwards a strap is to be buckled around the upper part of the leg, to bind the bone firmly in its natural situation, which gives support and at least prevents the increase of the malady.
ON DISLOCATIONS OF THE ANCLE-
JOINT.
The bones which enter into the composition of the ancle-joint are the tibia, fibula, and astraga- lus. The tibia forms an articulating surface at its lower part, which rests upon the astragalus, and there is a projection on the inner side of the lower portion of the bone which forms the malleolus internus, and this part is articulated with the side of the astragalus. The fibula projects beyond the tibia at the outer ancle, and forms there the malleolus externus, which has also an articulating surface for the astra- galus. The astragalus, which is the superior tarsal bone, rises between the malleoli, and the lower part of the tibia moves upon it prin- cipally in flexion and extension.
Thus then nature has strongly protected this part by the deep socket formed by the two bones of the leg and by the ball of the astraga- lus, which is received into it.
Structure of thejoint.
Bones.
96
ON DISLOCATIONS OF
Capsular
ligament.
Peculiar
ligaments.
Dislocation
snwards.
A capsular ligament, lined by a synovial membrane, joins the tibia and fibula to the as- tragalus. A strong ligament unites the tibia to the fibula, but without any intervening arti- cular cavity, as the ligament proceeds from one surface of bone and is received into the other.
The peculiar ligaments joining the tibia and fibula to the tarsus consist of a deltoid liga- ment, which proceeds from the tibia to the astragalus, os calcis and os naviculare. The fibula is united at its lower end by three ex- cessively strong ligaments, one anteriorly from the malleolus externus to the astragalus, one inferiorly to the os calcis, and the third to the astragalus posteriorly ; and it is the strong union of this bone which leads to its being more frequently fractured than dislocated ; and even when the tibia is luxated the fibula is fractured in two of the species of dislocation of the ancle, and generally in all ; but when the tibia is thrown outwards I have known the fibula escape a fracture.
I have seen the tibia dislocated at the ancle in three different directions, forwards, inwards, and outwards ; but a fourth species of dislo- cation is said to occur occasionally, viz. back- wards.
Of the simple Dislocation of the Tibia inwards .
This is the most frequent of the dislocations of the ancle ; the tibia, in this accident, has its internal malleolus thrown inwards, which is so forcibly projecting against the integuments as to
THE ANCLE.
threaten their bursting. The foot is thrown outwards, and its inner edge rests upon the ground ; about three inches above the outer ancle there is a deep depression, and a general tume- faction, from extravasation, surrounds the joint.
Upon dissection, the internal appearances are as follow : the end of the tibia rests upon the inner side of the astragalus, instead of on its upper articulatory surface, and if the accident has oc- curred from a person jumping from a consider- able height, the lower end of the tibia, where it is connected to the fibula by ligament, is split off, and remains connected with the fibula, which is also broken from two to three inches above the joint, and the broken end of the fibula is carried down upon the astragalus occupying the natural situation of the tibia ; the malleolus externus of the fibula remains in its natural situa- tion, with two inches of the fibula and the split portion of the tibia ; the capsular ligament at- tached to the fibula at the malleolus externus and the three strong fibular tarsal ligaments, re- main uninjured.
This accident generally happens by jumping from a considerable height, or in running vio- lently with the toe turned outwards, when the foot is suddenly checked in its motion while the body is carried forwards upon the foot, and the ligaments on the inner side of the ancle give way.
For the reduction of this dislocation the pa- tient is to be placed upon a mattress properly pre- pared, and is to rest on the side on which the injury has been sustained ; he is then to bend the leg at right angles with the thigh, so as to relax the gastrocnemii muscles as much
H
97
Symptoms,
Dissection,
Mode of reduction.
98
ON DISLOCATIONS OF
Treatment.
as is possible, and an assistant grasps the foot, and gradually draws it into a line with the leg. The surgeon fixes the thigh and presses the tibia downwards, and thus forces it upon the articulating surface of the astragalus. Great force is required if the limb be placed in the extended position, from the resistance the gas- trocnemii give ; and it is pleasing to observe, after most violent attempts, a well-informed sur- geon gently bend the limb, and, under a com- paratively slight extension, return the parts to their natural situation.
When the limb lias been reduced, it is still to remain upon its outer side in the bent position, with the foot well supported ; a many-tailed ban- dage is placed over the part to prevent it slipping from its place, and this is to be kept wet with an evaporating lotion. Two splints are then to be applied ; and that upon which the outer part of the limb rests is to have a foot-piece, to give support to the foot, prevent its eversion, and preserve it at right angles with the leg. If much inflammation succeeds, leeches are to be applied to the parts, and the constitution will require relief by taking blood from the arm, and by attention to the bowels ; but I shall say no more on this subject until I describe compound dislocation. A person who has had this accident maybe removed from his bed in five or six weeks, long straps of plaister being passed around the joint to keep the parts together, and he may be suffered to walk on crutches ; but from ten to twelve weeks elapse before be has the free motion of his foot ; and much friction and pas- sive motion are required after eight weeks to restore the motion of the joint.
THE ANCLE*
99
Vf the simple Dislocation of the Tibia forwards.
In this accident the foot appears much short- symptoms, ened, the heel proportionally lengthened, and the toes are pointed downwards. Upon dissection Dissection, the tibia is found to rest upon the upper surface of the os naviculare and os cuneiforme in- ternum, quitting all the articulatory surface of the astragalus, excepting a small portion on its fore part, against which the tibia is applied*
The fibula is broken, and its fractured end ad- vances with the tibia, and is placed by its side ; its malleolus externus remains in its natural situa- tion, but the fibula is broken about three inches above the joint ; the capsular ligament is tom through on its fore part ; the deltoid ligament is only partially lacerated, and the three ligaments of the fibula remain unbroken. This accident Cause* arises from the body falling backwards whilst the foot is confined, or from a person jumping from a carriage in rapid motion, with the toe pointed forwards.
The treatment consists in attending to the foU Reduction, lowing rules : the patient is placed in bed on his back ; one assistant grasps the thigh at its lower part, and draws it towards the body, and another pulls the foot in a line a little before the axis of the leg, and the surgeon pushes down the tibia to bring it into its place. The same prin- Treatment, ciples are held in view in this mode of reduction as in the former, with respect to the relaxation of the muscles. A many-tailed bandage must be lightly applied dipped in an evaporating
100
ON DISLOCATIONS Of1
Symptoms.
C ase.
lotion ; and the local and constitutional treat- ment is the same as in the dislocation inwards.
As to position, it is best to keep the patient upon the heel resting on a pillow, and to have a splint properly guarded on each side the leg, having foot-pieces to keep the foot well sup- ported at right angles with the leg, so as to pre- vent the muscles again drawing it from its place* As in live weeks the fibula will be united, there will then be no danger in taking the patient from his bed j and gentle passive motion may be begun*
Of the partial Dislocation of the Tibia forwards*
This bone is sometimes partially luxated for- wards, so as to rest half on the os naviculare, and half on the astragalus. The fibula, in this accident, is broken ; the foot appears but little shortened, nor is there any considerable projection of the heel. The signs of this acci- dent are as follow : The foot is pointed down- wards, and a difficulty is experienced in the attempt to put it flat on the ground : the heel is drawn up, and the foot is in a great degree im- moveable.
The first case of this kind which I saw, was in a very stout lady who resided at Stoke Newing- ton, and had by a fall, as she said, sprained her ancle. When I examined the limb, I found the foot immoveably fixed and pointed downwards, attended with great pain just above the ancle. I attempted to draw the foot forwards and bend it, but could not succeed. Some years after I saw this lady at Bishop Stortford, walking
THE ANCLE*
101
upon crutches ; her toe was pointed, and she was unable to bring any other part of the foot to the ground ; the degree of distortion was less than that which occurs in the complete luxation of the bone forwards ; but now all tension hav- ing been subdued, the nature of the injury was more evident, though I should not have known it decidedly, but from an examination of a foot shewn me by my friend and late appren- tice, Mr. Tyrrell, who was so kind as to give me the parts, and of which I have given a plate. The articular surface of the lower part of the tibia was divided into two ; the ante- rior part was seated upon the os naviculare ; the posterior upon the astragalus; these two articulatory surfaces were formed at the lower extremity of the bone, both of which had been rendered smooth by friction. The fibula was found fractured. (See Plate.) The result of this dissection clearly proves the necessity which exists in these accidents, however slight they may at first sight appear, of not resting satisfied until the foot be returned into its natu- ral position ; for if neglected in the commence- ment, severe inflammation and tension will pre- vent even a forcible extension being afterwards useful ; and if still longer neglected, the changes in the state of the muscles, and the union of the fibula will preclude the possibility of a reduction, even under the most violent attempts. The mode of reduction and after-treatment will in no respect differ from that required in the perfect dislocation of the bone, either as respects the re- laxation of the muscles, the bandages, or the local and constitutional treatment.
Dissection,
Treatment.
102
ON DISLOCATIONS OF
Symptoms.
Dissection.
Of the simple Dislocation of the Tibia outwards*
This luxation is the most dangerous of the three, for it is produced by greater violence, is attended with more contusion of the integu- ments, more laceration of ligament, and greater injury to the bone ; the foot is thrown inwards, and its outer edge rests upon the ground. The malleolus externus projects the integuments of the ancle very much outwards, and forms so decided a prominence that the nature of the injury cannot be mistaken ; the foot and the toes are pointed downwards.
In the dissection of this accident, it is found that the malleolus internus of the tibia is ob- liquely fractured and separated from the shaft of the bone ; the fractured portion sometimes consists only of the malleolus, at others, the fracture passes obliquely through the articular surface of the tibia, which is thrown forwards and outwards upon the astragalus, before the malleolus externus. The astragalus is some- times fractured, and the lower extremity of the fibula is broken into several splinters. The deltoid ligament remains unbroken, but the capsular ligament is on its outer part torn ; the three fibular tarsal ligaments remain whole in most cases, but when the fibula is not broken, they are ruptured ; none of the ten- dons are lacerated, and haemorrhages scarcely ever occur to any extent, as the large arteries generally escape injury. This accident happens either by the wheel of a carriage passing over the
THE ANCLE.
103
leg, or by the foot being twisted inwards in jumping or falling.
The mode of reduction consists, in placing Reduction, the patient upon his back, in bending the thigh at right angles with the body, and the leg at right angles with the thigh ; the thigh is then grasped under the ham by one assistant, and the foot by another ; and thus an extension is made in the axis of the leg, whilst the surgeon presses the bone inwards towards the astragalus.
The limb, in the simple dislocation, is to be laid upon its outer side, resting upon a splint, with a foot-piece, and a pad is to be placed upon the fibula, just above the outer angle, and extending a few inches upwards, so as in some measure to raise that portion of the leg, and support it so as to prevent the tibia and fibula slipping from the astragalus, as well as to lessen the pressure of the malleolus externus upon the integuments, where they have sustained injury.
The local and general treatment will be the Treatment, same as in the former cases, although more de- pletion is required as greater inflammation suc- ceeds ; the greatest care is required that the foot does not become twisted inwards or pointed downwards, as either of these states prevents the limb from being afterwards useful. Passive mo- tion should be given to the joint in six weeks from the accident, when the patient may rise from his bed, and be allowed to walk upon crutches, unless great swelling of the ancle prevents it. In general in these cases from ten to twelve weeks elapse before the cure is complete.
104
ON COMPOUND DISLOCATIONS OF
On the compound Dislocation of the Ancle-joint.
Opening into the joint.
t/jcal
effects.
These accidents take place in the same direc- tion as the simple dislocations, and the bones and ligaments suffer in the same manner as in those dislocations. The only difference therefore in these cases is, that the joint is laid open by a wound in the integuments and ligaments, opposite to the laceration of the skin, by which the synovia escapes, and through which the ends of the bone protrude ; this opening in the integuments is generally occasioned by the bone, but sometimes by the pressure of some uneven surface on which the limb was thrown.
The bones being replaced by the same means as are employed in the simple dislocation, the effect of this accident upon the parts composing the joint is as follows. The synovia, as I have stated, escapes by a large wound in the mem- brane secreting it, and in a very few hours in- flammation begins ; and when an additional quantity of blood is first determined to the part an abundant secretion issues from this membrane, and is discharged through the wound \ the liga- ments participate in the inflammation as well as the extremities of the bones, which enter into the composition of the joint. The inflammation of the internal secreting membrane of the joint in about five days proceeds to suppuration ; at first but little matter is discharged, but it continues until it becomes very abundant, and the lacerated parts of the ligaments and perios- teum also secrete matter. Under this process of suppuration the cartilages become partially
THE ANCLE.
105
or wholly absorbed, but generally partially only ; but the ulceration of the cartilage is a very slow process and attended with severe constitutional irritation, and often lays the foundation of ex- foliation of the extremities of the bones. When they are completely absorbed, granulations arise from the surface of the bones and from the inner side of the synovial membrane, and these inosculate and fill up the cavity between the extremities of the bones. Sometimes we find after accidents to joints, that the adhesive pro- cess occurs at one part and that the cartilage is not absorbed, whilst granulations are formed at others where the cartilage was removed by ul- ceration, and I have seen after inflammation in joints the cartilages remain and their surfaces adhere.
This inosculation of granulations nor the pro- cess of adhesion, do not lead to permanent an- chylosis, for if passive motion be begun as soon as the parts from cessation of pain and inflamma- tion will permit, motion will be restored, not always entirely, but with very little diminution ; and the other parts of the tarsus will acquire such an extent of motion as to render the deficiency in the mobility of the ancle joint but little appa- rent; the aperture in the ligament is filled by granulations; and with respect to the extremities of the bone, when they are joined by ossilic union, it is by the deposit of cartilage and by a secretion of phosphate of lime, in the usual man- ner in which bones are formed and repaired.
Thus then the compound dislocation of the ancle is leading to inflammation over a very extensive secreting surface, as well of bone
V
lOQ ON COMPOUND DISLOCATIONS OF ’
as of ligament ; it next produces an extended suppuration over the lining of the joint, which leads to much constitutional derangement, and further it becomes the source of an ulcerative process, more or less extensive according to the treatment pursued, by which the cartilage is partly or wholly removed, and by which the ir- ritative fever is supported for a great length of time ; and the ulceration sometimes extends over the extremities of the dislocated bones, leading to great additional constitutional irrita- tion and continued disease from exfoliation,
constitu- These local effects are accompanied by the
. tionaf . . 1 , . . J .
effects. common symptoms of constitutional irritation. In two or three days from the accident, or sometimes as early as twenty-four hours, the patient complains of pain in his back and in bis head, shewing the influence of the acci- dent on the brain and spinal marrow. The tongue is furred, white if the irritation be slight, yellow if greater, and brown almost to black- ness if it be considerable ; the stomach is disor- dered, there is loss of appetite, nausea, and some- times vomiting; the intestines cease to secrete, and the glands connected with them, as the liver, &c. ; costiveness is therefore an attendant sign. The skin has its secretion stopped, it is hot and dry ; the kidneys also have their secretion di- minished ; the urine is high-coloured and small in quantity. The heartbeats more quickly and the pulse becomes hard, which is the pulse of constitutional irritation from local inflamma- tion, and in great degrees of it becomes irregular and intermittent ; the respiration is quicker in sympathy with the quicker circulation ; the
THE ANCLE,
1 07
nervous system becomes additionally affected in high degrees of local irritation ; restlessness, watchfulness, delirium, subsultus, and sometimes tetanus occur* These are the usual effects of local irritation upon the constitution, occurring in different degrees according to the violence of the injury, the irritability of the constitution, and the powers of restoration.
The cause of the violence of these symptoms is the wound which is made into the joint, and the great efforts required for its repair, for when there is no wound, and the process of adhesion can unite the part, little local inflammation or constitutional irritation occur ; and if this be the cause of the violence of the symptoms, the principle in the treatment of this accident is easily comprehended, and it consists in closing the wound as completely as is possible, to assist nature in the adhesive process by which the wound is to be closed, and to tender suppu- ration and granulation less necessary for the union of the opened joint.
The first question which arises upon this sub- ject is the following : Is amputation generally necessary in compound dislocations of the ancle ? My answer is, certainly not ; thirty years ago it was the usual practice to amputate limbs for this accident, and it was then thought abso- lutely necessary for the preservation of life by some of our best surgeons 5 but so many limbs have been of late years saved, indeed I may say so great a majority of cases, that such advice would now be considered not only injudicious but cruel. It is far from being my intention to state that amputation is never required, but 1
Cause of the symp- toms.
Principle of cure.
Is amputa- tion re- quired?
108
ON COMPOUND DISLOCATIONS OF
Treatment*
A rterv divided.
Loose pieces of bone.
only to observe that in by far the greater number of these accidents, that this operation is unne- cessary.
But before I give the proofs of what I have advanced, let me state the mode of treatment which is to be pursued in these cases.
When the surgeon examines the limb, he finds a wound of greater or less size, according to the degree of the injury. The extremity of the tibia projects if the dislocation of the tibia be inwards ; and the tibia and fibula are protruded, if the dislocation of the former be at the outer ancle. The ends of the bones are often covered with dirt, from their hav- ing reached the ground. The foot is loosely hanging on the inner or outer side of the leg, according to the direction of the dislocation. Sometimes, though very rarely, a large artery will be divided ; and it is surprising that the pos- terior tibial artery so generally escapes; the ante- rior tibial being the only vessel I have known tom. The arrest of haemorrhage is the first object ; and for this purpose, if the anterior tibial artery be wounded, it must be secured by ligature. The extremity of the bone is to be washed with warm water, as the least extrane- ous matter admitted into the joint will pro- duce and support a suppurative process, and the utmost care should be taken to remove every portion of it adhering to the end of the bone.
If the bone be shattered, the finger is to be passed into the joint, and the detached pieces are to be removed ; but this is to be done hi the most gentle manner possible, so as to da
THE ANCLE.
309
too unnecessary injury ; and if the wound be so small as to admit the finger with difficulty, and small loose pieces of bone can be felt, the integu- ments should be divided with a scalpel upwards, to allow of such portions being removed without violence ; the incision should be so made as to leave the joint with as much covering of integu- ment as possible. The integuments are some- times nipped into the joint by the projecting bone, and it cannot be reduced, when this is the case, without making an incision upwards, to allow of the skin being brought from under the bone ; and when the edges of the incised wound are afterwards brought together, no ad- ditional evil arises from the extension of the wound.
The mode of reducing the bone is (in oilier respects) similar to what we have already de- scribed, when speaking of simple dislocation, by bending the leg upon the thigh, so as to relax the muscles before the extension is made. When the bone has been reduced, a piece of lint is dipped in the blood and applied wet over the wound upon which the blood coagulates, and forms the most natural, and as far as I have seen, the best covering to the wound. A many-tailed band- age is then applied, the portions of which should not be sewn together, but passed under the leg, so that any one piece may be removed when it becomes stiff, and by fixing another to its end, it can always be applied afresh, without any disturbance to the limb ; this bandage is to be kept constantly wet with spirits of wine and water. A hollow splint, with a foot-piece at right angles, is to be applied on
Integu-
ments.
Reduction.
no
Constitu- tional treat- ment.
ON COMPOUND DISLOCATIONS OF
the outer side of the leg, in the dislocation in- wards, and the leg is to rest upon its outer side: but in the dislocation outwards it is best to keep the limb upon the heel, with a splint both upon the outer and on the inner side, with an aperture in the splint opposite to the wound.
The patient’s knee is tobe slightly bent in each dislocation, to relax the gastrocnemius muscle. The foot must be carefully prevented being pointed ; great care being taken to keep it at right angles with the leg, otherwise the limb will be useless when the wound is healed. The pa- tient is to be placed on a mattress, and a pillow is to reach from half way above the knee to beyond the foot, and another is to be rolled under the hip, to support the upper part of the thigh-bone.
Blood-letting must be bad recourse to or not according to the powers of the constitution, as it is necessary to bear in mind that the patient has a great trial of his powers to undergo, and will require, in the end, all the support which his strength can receive. Purgatives must also be used with the utmost caution, for there cannot be a worse practice, when a limb has been placed in a good position, and adhesion is proceeding, than to disturb the processes of nature by the frequent changes of position which purges produce ; and I am quite sure, that in cases of compound fracture, I have seen pa- tients destroyed by their frequent administra- tion. That which is to be done by bleeding, and emptying the bowels, should be effected at the first hour of the accident, before the adhesive inflammation arises ; after which the liquor am-
Ill
THE ANCLE.
mon i ac acetatis and tinctura opii, form the pa- tient’s best medicine, with a slight aperient at in- tervals.
If the patient complains of considerable pain spec^^J in the part in four or five days, the bandage may be raised, to examine the wound ; and if there be much inflammation, a corner of the lint should be lifted from the wound to give vent to any matter which may have formed ; but this ought to be done with great circumspection, as it is in dan- ger of disturbing the adhesive process if that be proceeding without suppuration. By this local treatment it will every now and then happen that the wound will be closed by adhesion, but if in a few days it be not, and suppuration take place, the matter should havean opportunity of escaping ; and the lint being removed, simple dressings should be applied. After a week or ten days if there be suppuration with much surrounding in- flammation, poultices should be applied upon the wound, leeches in its neighbourhood and upon the limb at a distance the evaporating lotion should still be employed ; but as soon as the in- flammation is lessened, the poultices should be discontinued, as they encourage too much secre- tion, and relax the blood-vessels of the part, %
so as to prevent the restorative process.
If the cure proceeds favourably, in a few weeks the wound is healed with little suppuration. If Result, less favourably, acopious suppuration takes place, the wound is longer in healing, and exfoliation of the extremity of the bone still further retards the cure. The motion of the joint is not always lost, but is sometimes in a great degree restored ; but this depends upon the greater or less
112
ON COMPOUND DISLOCATIONS OF
Cases,
extent of suppuration or ulceration. The pa- tient after three months walks with crutches un- der the most favourable circumstances, but is many months in others, and he bears upon the foot at different periods of time in different de- grees of injury, as in compound fracture when adhesion is not at first produced, only that the patient is in these cases longer in recovering.
I shall now proceed to state the cases which have induced me to say amputation, as a gene- ral rule, is improper in these cases.
The first circumstance which led me to doubt the true judgment of the opinion which recom- mended an indiscriminate amputation of these injuries, was this—
CASE I.
I was, many years ago, going into the country with a friend of mine, and we met with a sur- geon in our journey, who put this question— “ What do you do in compound dislocations of the ancle joint V9 I do not recollect the reply, but he proceeded to say, I have had a case of compound dislocation of the ancle joint under my care, in which I told the patient he must lose his limb ; not approving this advice, his friends sent for another surgeon, who said he thought he could save it ; the patient placed himself under his care, and the man, he added, was recovering.
CASE IL
More than twenty years ago I received from Mr. Lynn, of Woodbri dge, now Dr. Lynn, the
THE ANCLE*
HS
Astragalus of a man, broken into two pieces, which *he had taken from a dislocated ancle- joint. His letter is as follows :
DEAR SIR,
J. York, aged 52 years, being pursued by some bailiffs, jumped from the height of seve- ral feet to avoid them. The tibia and a part of the astragalus protruded at the inner ancle. X immediately returned the parts into their na- tural situation. Suppuration ensued, and in five weeks a portion of the astragalus sepa- rated, and another piece a week afterwards, which when joined formed the ball of that bone. In three months the joint was filled with granulations ; it soon afterwards healed, and the man recovered with a good use of the limb.
\ *
Yours, &c«
JAMES LYNN.
CASE III.
I attended a compound fracture of the ancle- joint, in the year 1797, with Mr. Battlev, who then practised as a surgeon in St. Paul’s Church- yard, and is now a chemist and druggist in Fore Street, of the first respectability and cha- racter ; an account of which I shall give in the words of Mr. Battley.
In the month of September, 1797, a gen- tleman, lodging in Duke Street, Smitlrfield, in a fit of insanity threw himself from a two-pair of stairs window into the street, his feet first reaching the ground. He got up without as-
i
114
ON COMPOUND DISLOCATIONS OF
sistance, knocked violently at the outer door of the house, and ascended the stairs without the least assistance, bolted the door after him, and got into bed. He refused to open the door, and it was obliged to be forced. A neighbour- ing surgeon was sent for, who, on viewing the case, proposed an immediate amputation, which was not acceded to by his friends, but Mr. Cooper and myself were requested to take charge of the case. On examination there was found a compound dislocation of the ancle- joint ; the tibia was thrown on the inner side of the foot, and when the finger was passed into the wound the astragalus was discovered to be shattered into a number of pieces ; the loose and unconnected portions of bone were re- moved and the tibia replaced, after which lint, dipped in the oozing blood, was wrapped around the lacerated parts, and the limb was placed on its outer side, with the knee considerably bent. The parts were ordered to be kept cool by the frequent application of an evaporating lotion. The patient remained as quiet as could be ex- pected, under his state of mind, until the third or fourth day, when a considerable inflamma- tion appeared in the joint, and greatly increased the previous irritable state of his constitution. Leeches, fomentations, and poultices were ap- plied to the limb, blood was taken from the arm, and purgative medicines were given, and afterwards saline medicines with sudorifics. Extensive suppuration ensued, and continued for six weeks or two months, when it began to lessen and healthy granulations appeared on the whole wounded surfaces , and about this time
THE ANCLE*
the state of his mind began to improve, and it continued to amend as his leg advanced in re- covery. At the end of four or five months the suppurated parts had filled up, the joint healed, and his mind recovered its natural tone. At the end of nine months he returned to his employment, but the ancle-joint was stiff. In two years he had so far recovered as to walk without the aid of a stick ; and at the end of three or four years was able to pursue his avo- cations nearly as well as at any former period of his life.
RICHARD BATTLEYe
t
CASE IV.
On Compound Dislocation of the Tibia inwards.
I was sent for on the 1 1th of August, 1814, by Mr. Richards, of Seal, in Kent, to visit Mr. Knowles, a farmer, residing at TythamFarm, aged 48, who had been thrown from his chaise against the hinder wheel of a waggon, dislo- cated his tibia inwards, and fractured both the tibia and fibula.
/ . f •
Mr. Richards was immediately called to the case, reduced the dislocation, and endeavoured to heal the wound by adhesion. When I saw him, which was ten days after the accident, the wound wore a favourable aspect. The dis- charge was abundant, but not in a degree to excite alarm, and all I had to do was to praise the judgment which had led to the preservation of the limb, and to direct the continuance of the means which had been employed for that purpose.
i 2
- >
115
116
ON COMPOUND DISLOCATIONS OF
Before I ventured to state the case to the public, I wrote to Mr. Richards, who informs me that Mr. Knowles’s wound is perfectly healed, and that he walks without the use of a stick.
CASE V.
*
For the following details I am obliged to Mr. Rowley, apprentice to Mr. Chandler, surgeon to St. Thomas’s Hospital.
DEAR SIR,
tn answer to your inquiries, I beg leave to forward you the particulars of Elizabeth Chis- nell’s case, who was admitted into St. Thomas’s Hospital, Saturday, May 29th, 1819, with a com- pound dislocation of the left ancle outwards, occasioned by her slipping from the footpath into the road-way. The wound communicating with the joint was situated upon the outer part of the leg, and was about four inches in extent, through which the fibula projected two inches, but it was not fractured ; the ligaments con- necting the malleolus externus and the astraga- lus were lacerated. From the inclination of the sole of the foot inwards, the whole articulating surface of the joint was so displaced as to allow two fingers to pass readily across, when I found the extremity of the tibia fractured. The parts were easily returned to their original situation by extending the foot, the leg having been first bent upon the thigh. During the reduction the integuments became confined between the malleolus externus and astragalus, so as to re- quire an incision upwards by the side of the fibula, before it could be extricated ; but that
THE ANCLE.
117
being done, its lips were brought together by four sutures, and straps of adhesive plaister. Splints were applied, and the common applica- tions to subdue the consequent inflammation used.
June 1. The adhesive plaister and sutures were removed, owing to the wound and adja- cent soft parts around the ancle being in a state of slough. Poultice of linseed meal were or- dered to be used daily.
June 5. The sloughs are separated, the sore is granulating, the discharge profuse ; a collec- tion of matter has formed upon the inside of the leg, which was discharged by puncture. The Avound was ordered to be dressed, and a roller was gently applied. The constitution during this time was but little affected. Bark and porter were ordered by Mr. Chandler.
August 7* The wounds are almost healed ; the girl sits up daily, and in a few days she will be allowed to walk. During the progress of her cure the constitutional disturbance has been trifling, indeed not more than in some favour- able cases of simple fracture ; it may be also well to observe that her bowels were regular during the whole time, so as to preclude the necessity of any laxative medicine, nor did she take any other medicine but the bark.
I remain, &c. &c*
a. ROWLEY,
Dresser at St. Thomas's Hospital .
The following accident I was requested to visit by Mr. Clarke, surgeon, in Great Turn- stile, Lincoln’s Inn Fields ; and Mr. Clarke has
118
ON COMPOUND DISLOCATIONS OF
had the kindness to send me the following par- ticulars.
CASE VL
Mr. George Carruthers, aged 22 years, had a compound dislocation of the ancle-joint in- wards, with fracture of the tibia, on the 6th of October, 1817. The accident had happened by the overturn of a stage-coach at Kilburn, from whence he was brought to his house at Lambeth. The end of the tibia projected through the integuments of the inner ancle to the extent of from two to three inches, and the bone wras tightly embraced by the skin. The tibia was fractured, only a small portion of it remaining attached to the joint ; the bleeding was stated to have been copious, but it had subsided before Mr. Clarke saw him \ the fibula was badly fractured.
For the reduction of the protruded parts it became necessary to make an incision in the in- teguments, to loosen them on the tibia ; and when the bone was restored to its place simple dressings were spread over the wound. A many- tailed bandage, wetted with an evaporating lo- tion and splints were applied, and the limb was placed in the slightly bent position upon a quilted pillow. Bleeding was had recourse to, gentle purgatives given, and saline medicines. Symp- toms of great constitutional excitement natu- rally arose from so severe a local injury. Ab- scesses formed on the leg, and some exfolia- tions materially retarded the cicitrization of the wound, and produced considerable exhaustion of his strength. Openings were made into the
THE ANCLE,
119