112. It is more essential here than in fractures of the body of the os
femoris, to keep up extension with the utmost exactness, because, in
the present case, a much greater number of muscles being attached to
the lower fragment, very greatly augment the powers tending to displace
it. Hence the necessity of examining the apparatus every day, to see
whether or not any shortening of the limb has occurred, to tighten,
if they be relaxed, the rollers that make extension, and to renew the
application of the whole, if it be in any measure deranged.
113. The proper treatment here, as well as in most other fractures,
consists more in these attentions, taken collectively, than in the use
of internal means. It is to the want or neglect of such attentions,
that we ought to attribute the little success obtained by many surgeons
from the bandage of Desault.
CASE VII. A man, having fractured his thigh by a fall, called in a
surgeon, who, reducing the fracture, and retaining it by this bandage,
examined the state of the parts every day, and finding no derangement
of the splints, neglected attending to the rollers destined for making
extension. Seventh day, a shortening of two inches; a new reduction,
and a new application of the bandage; the same want of attention as
before; the same shortening at the expiration of a few days; the means
were then rejected, and declared, in a publication, to be insufficient.
How often do processes and modes of practice of great utility, by
being transmitted from person to person, or from book to book, lose at
length, that credit they are entitled to, and that approbation which
they ought to command!
114. Serious accidents so seldom accompany fractures of the neck of
the os femoris, that there is no necessity of employing numerous
means to remove them. A diet somewhat strict for a few days, diluting
drinks, and then a return to the patient’s usual mode of living, unless
something besides the fracture should forbid it, constituted the simple
treatment pursued by Desault in common cases. Any varieties resulting
from accidental circumstances, must fall under the general treatment of
fractures.
115. The period necessary for the healing of fractures of the neck
of the os femoris, is represented by most authors as being longer
than the term required in other similar affections. We read, in the
Memoirs of the Academy of Surgery, that oftentimes the cure is not
complete in less than three or four months. The reason of this will be
evident, if we consider, on the one hand, that the reunion is always
more tedious, in proportion as the contact of the fragments is more
frequently interrupted: and, on the other, that, in the means formerly
employed, there was nothing opposed to the powers of displacement.
Hence it follows, that, if skilfully treated, this fracture ought to
follow nearly the same course with others. It is this that confirmed
the superior excellence of the practice of Desault, who almost always
obtained a cure, all other things being equal, such as age, strength of
constitution, &c. in the space of forty-five or fifty-five days.
116. We discover, in general, that the cure is complete, from a
disappearance of the signs of the fracture, more particularly from the
motions of the great trochanter, in which circumduction[28] succeeds to
rotation on its own axis, when the limb is made to move on itself, that
is, to rotate outwards or inwards. The power of standing and walking
is an infallible evidence of this reunion; nor are these exertions
practicable, till the expiration of some time after it is completed;
this circumstance is owing to a stiffness remaining in the parts
around the joint, occasioned by long extension and a want of motion,
and which exercise alone can effectually remove. (See what has been
already said on this subject, in several parts of this work.)
[28] A motion or sweep describing the arch of a circle. TRANS.
117. Numerous cases may be adduced in favour of the doctrine laid down
in this memoir. But a sufficient number have been already published in
the Journal of Surgery. I shall subjoin only two, drawn up by Manoury
and Seveille.
CASE VIII. Maria ***, aged forty, falling on the great trochanter,
experienced a sudden pain, and heard a considerable report: she rose,
however, and with difficulty made her way home. On the day following, a
shortening of an inch was perceived in her thigh: the great trochanter
was drawn backward and upward: walking was now impracticable, the foot
remained turned inwards. Notwithstanding this latter circumstance,
Desault, being called to the patient, declared that a fracture existed,
which was evidenced in particular by a rotatory motion of the great
trochanter on its own axis. The necessary apparatus being applied,
was carefully examined every day by Manoury, to whom the patient was
intrusted. No shortening of the limb occurred, nor did any unfavourable
accident supervene, and, by the thirty-ninth day, the fracture was
exactly and firmly united; on the forty-third, the splints were
removed; and on the fiftieth, the patient could walk without assistance.
CASE IX. John Rignal fractured the neck of the os femoris by falling,
not as in the preceding case, on the great trochanter, but on the knee,
which was bent at the time of the fall, while the shoulder of the same
side supported a heavy load. He was brought to the Hotel-Dieu, where
the same signs, as in the preceding case, (except that here the foot
was turned inwards) furnishing ground for the same diagnosis, gave rise
to the same treatment, which, in fifty days, was followed by a result
equally favourable.