92. The existence of a fracture being ascertained, what prognosis is to
be formed respecting it? In answer to this general question, it will
be sufficient, I think, to resolve the following particular ones. What
accidents accompany the fracture in the first instance? What phenomena
make their appearance during its reunion? In what manner does it affect
the patient, as to his power of walking, after reunion has taken place.
93. If we attend to the opinion of authors, on this fracture, we will
find that they represent it in very dismal colours, as if it were
necessarily productive of the most serious effects. Inflammation of the
parts adjacent to the neck of the os femoris, numerous and repeated
abscesses arising from this inflammation, propagating themselves
externally and communicating with the interior of the joint, gangrene
itself, as Morgagni remarks in a particular case, convulsions of
the limb, an œdema occurring in it, and a slow fever destroying the
patient by degrees; such is the dismal catalogue of misfortunes,
generally considered as necessarily attendant on the kind of fracture
under consideration. Bruninghausen remonstrated against this fatal
prognosis of authors, and Siebold, one of the most celebrated German
practitioners, among a great number of cases that fell under his care,
had no such accidents to encounter. Desault never experienced them.
Doubtless they are prevented by our more exact and more skilful
modes of treatment. It is thus that under a more judicious treatment,
fractures of the olecranon and of the rotula, are no longer marked with
those terrible consequences formerly attributed to them.
94. In as much as the organization of the os femoris, is nearly the
same in its neck and in its body, it is difficult to conceive how the
progress of nature can be different in fractures of these two parts;
why the first, in being denied the power of healing or reunion should
be, in this respect, distinguished from all other living parts of
animals, which are particularly characterized by that power, when they
have sustained a solution of continuity. Many practitioners, even at
the present day, advocate this doctrine, which is built, one while,
on the circumstance of the periosteum not being continued along the
neck of the os femoris; another while, on a belief that the head of
this bone cannot receive a sufficiency of nourishment for the work of
consolidation, in consequence of being attached to the rest of the
system, only by the round ligament, and again, on an opinion, that the
synovial fluid, by wetting the divided surfaces, prevents their reunion.
95. But is the periosteum the only agent in the formation of callus?
Modern experience has refuted this opinion, which, like many others,
will therefore in a short time exist only in the history of our errors.
Were it even true that the periosteum is here indispensably necessary,
is not its place supplied by the fold of the capsule, which surrounds
both the head and neck of the os femoris? Besides, why cannot callus
be formed by that part which has had sufficient power to accomplish
ossification, since it is universally acknowledged, that, in these two
processes, the labour of nature is nearly the same.
96. The head of the bone, separated from the soft parts, and attached
to the acetabulum by the round ligament, always receives through that
ligament a sufficiency of nutriment to enable it to live in that
cavity; for, there is no instance of its having suffered mortification
in consequence of a fracture. Why, then, should it not partake of the
properties of life, and particularly of the faculty of reunion when
placed in regular apposition with the body of the bone?
97. What shall we say respecting the idea of the synovia wetting the
divided surfaces, and by that means preventing their reunion? The
history of fractures communicating with joints, better known at the
present day, answers this objection, which is indeed nothing but the
offspring of mere hypothesis. To these considerations, which are
dictated by reason, and to which many more might be added, let us unite
the proofs derived from experience, and we will find numerous examples
of cures actually performed, particularly in latter times; the truth
of this is attested by many cases collected by Desault, both at the
hospital of Charity and the Hotel-Dieu. Bruninghausen and Siebold,
have had equal success. Many analogous facts have been presented to
the Academy of Surgery. In the cabinet of the School of Health, are
deposited some preparations obtained from the cabinet of Desault,
calculated to remove all difficulties and doubts from this subject.
98. We must acknowledge, however, that in persons advanced in years,
the cure is always difficult, often very tedious, and sometimes
impracticable, however carefully the treatment may be conducted. But
this is only a necessary consequence of the laws of ossification,
which, constantly accumulating in the bones too great a quantity of
calcareous matter, seems to deprive them by degrees both of life and
all its properties. Yet Lesne laid before the academy a case of reunion
obtained in a subject at the advanced age of eighty-four.
99. The observations of some modern practitioners seem to prove, that
the reunion here is not produced by a substance similar to common
callus, but by a kind of ligamento-cartilaginous tissue, in like manner
as in the rotula, and the olecranon. But why need we inquire after the
means employed by nature? those of art must be the same. It will be
always necessary to favour the reunion, by bringing the fragments into
contact, and maintaining them so. Without this contact, either a cure
will never be obtained, or the substance destined to effect a reunion,
becoming deformed and too bulky, will impede motion.
100. Lameness has been long considered as the inevitable consequence
of fractures of the neck of the os femoris. Ludwig, professor of
surgery at Leipsick, has particularly advocated this opinion, which is
supported by Sabatier, and Louis, who considered the total destruction
of the neck of the bone, as the cause of the lameness. But few such
examples are to be found on record. Ruisk has given an engraving of
one. Lameness when it does take place, depends, as it does in oblique
fractures of the body of the bone, on the overlapping of the fragments,
to which no opposition has been made; so that the insufficiency of our
means, and not the nature of the disease, gives rise to this accident,
which Desault seldom experienced in his practice.
101. From what has been said, it appears, that, in all respects,
authors have given a much more unfavourable prognosis in fractures of
the neck of the os femoris than facts and the nature of the affection
will justify, that the progress of these fractures is the same with
that of all others, and that, when treated with equal skill, there is
no reason why their termination should not be equally favourable.
§ XVI.