1. Our modern treatises on diseases are little else than fabrics
artfully constructed of materials confusedly scattered through the
writings of the ancients. Many of those materials oftentimes escape
our notice, and we find them only, after practice has disclosed them
to us, in the chambers of the sick. Thus, Hippocrates had an accurate
knowledge of spontaneous luxations of the os femoris, and has even left
an aphorism expressly on that subject. Yet this disease appeared to be
unknown to the physicians who came after him, till John Louis Petit,
having met with it in his practice, drew the attention of practitioners
to it, by a memoir respecting it, published among those of the Academy
of Sciences, in the year 1722.
2. The history of this affection, which was considered afterwards, _ex
professo_, in his course on diseases of the bones, has been sanctioned
by the assent of all practitioners, to whom it has since very
frequently occurred, and who have generally admitted as Louis observes,
the doctrine of Petit, respecting the cause on which it seems to depend.
3. Experience bears witness, that usually a fall on the great
trochanter, more rarely on the knee, or the sole of the foot, precedes
it, and has doubtless some share in producing it. But what is the
nature of the primary affection which, rising immediately from this
occasional cause, becomes the immediate cause of the luxation? Petit,
and with him the practitioners of the present day, have conceived, that
the different parts of the joint, being irritated and contused, pour
out, in consequence of the injury received, a superabundant quantity
of synovial fluid, which, not being absorbed with the same rapidity,
accumulates in the articular cavity, distends the capsule, and, by
degrees, forces the head of the os femoris from its natural cavity.
Hence astringent and tonic remedies, with alum, spirit of wine, &c. are
directed to be applied externally to the upper part of the diseased
thigh.
4. But this doctrine, and the practice which results from it, seem by
no means to accord with our knowledge of anatomy. The truth of this was
deeply impressed on the mind of Desault, who had frequent opportunities
of witnessing the disease.
CASE I. A young woman walking hastily along the street, slipped and
made a false step, in which the left thigh, being violently twisted,
supported for a moment the whole weight of the body.
A severe pain experienced at the moment, obliged her to stop at first,
but becoming easier afterwards, permitted her to proceed on her way,
and soon ceased entirely. A sensation of weight occurring in the
part about fifteen days afterwards, was at first troublesome to the
patient in walking. This sensation was afterwards succeeded by a dull,
deep-seated pain, accompanied by a swelling in the parts around the
joint.
During six or seven months the limb was observed to increase in
length gradually, but very slowly. At the expiration of that time,
a contraction took place suddenly, and, in one night, the diseased
thigh became shorter than the other by nearly two inches. The patient
was then admitted into the hospital, where, after some time, she sunk
under her disease. On opening the body the following appearances
were presented to Desault, who was then consulting surgeon to the
institution.
The cartilage of the acetabulum swollen to such a degree as to fill up
the whole extent of that cavity, was yellowish and inorganic, somewhat
resembling bacon, both in colour and consistence. A soft, spongy,
whitish substance projected in the middle of it, the remains no doubt
of the round ligament. The head of the os femoris, situated where it
is usually found in luxations outward and upward, was surrounded by a
cartilage equally tumefied.
5. Here the cause of the displacement of the os femoris was evident.
The cartilages becoming tumefied, in consequence of the contusion
and violence done to them, had by degrees, filled up the acetabulum,
forcing out in the same gradual manner the head of the bone. Hence
arose the original lengthening of the limb. But as soon as the head
had escaped from the lacerated capsule, the limb was drawn upwards and
consequently shortened, by the action of the muscles, and the weight of
the body pushing the pelvis downward.
CASE II. Some years afterwards, Desault had occasion to witness again
the same disease, in the person of a man aged thirty-seven, who put
himself under his care, but, being obliged to leave Paris, a short
time afterwards, retired into the country, where he died in about six
months, enfeebled and consumed by a hectic fever.
On opening the body, the surgeon of the place discovering the same
phenomenon as in the preceding case, made a preparation of the part,
and sent it to Desault, whose pupil he had been.
6. In this case the shortening was not so sudden as in the preceding
one. It appeared at first to be coming on, during five days, in an
imperceptible manner, when, fatigued with lying in bed, and having on
that day drank a little, the patient attempted to walk, supported only
by a cane. By evening, a shortening of two inches and a half had taken
place, an effect evidently produced by the weight of the body on the
diseased thigh. Hence the necessity of confining the patient to a state
of perfect rest, of preventing, in particular, standing and walking,
and all positions in which the diseased thigh would have to sustain the
weight of the body.
CASE III. Maria Genette was received into the Hotel-Dieu, in
consequence of a fall on the great trochanter. She had been attacked
by a pain in the joint of the thigh of the same side. Walking, which
was performed with difficulty, augmented the pain, and standing, though
more tolerable, could not be long continued. The thigh was evidently
longer than the other. To leave the disease to nature, and confine the
patient to a state of rest, constituted the practice of Desault. What
effect could the external use of astringents, recommended by Petit,
produce in such a disease? Some time after her admission, the patient
was attacked by dysentery, in consequence of which she was removed to
the medical ward, where she died.
On opening the body, the parts in the neighbourhood of the joint were
evidently tumefied, and the capsule was stretched from above downwards.
The head of the os femoris was situated on the external edge of the
acetabulum. The capsule, though greatly elongated was still in a state
of tension; and the articular cartilage was swollen to such a degree,
as nearly to fill up the cavity. The quantity of synovial fluid was
less than natural.
7. This case, taken at a period of the disease not far advanced,
fully confirms the inference deducible from the two preceding ones,
respecting the cause of spontaneous luxations. Here, indeed, the
capsule not having given way, the swelling having only just commenced,
and the synovia existing in but small quantity, the progress of nature
was evident. Here, also, occurred a sign not noticed by Petit; namely,
the elongation of the limb, which always, in such cases, precedes its
contraction.
From what we have said, it appears, 1st, that the efficient cause of
spontaneous luxations of the os femoris, is a swelling of the articular
cartilages, which alters and destroys their organization: 2dly, that
the presence of this swelling must necessarily render fruitless all
attempts that might be made to replace the head of the bone in its
cavity: 3dly, that the change in the organization of the cartilages,
renders astringents, discutients, and other external means applied
for the purpose of removing the tumefaction, entirely useless: 4thly,
that here, as in many other cases, art ought to confine itself to the
palliation of effects, and not attempt the removal of causes.