§ I.
1. Complicated luxations of the foot, like complicated fractures, show
themselves under such a variety of forms, are accompanied by so many
peculiar affections, and so many different circumstances are connected
with them, that it would be difficult to lay down rules applicable
to their treatment in all cases. On this subject, indeed, art is in
possession of certain general principles, liable however to numerous
exceptions and modifications. In the treatment of such cases, who can
fix the limits between reduction, and amputation or extirpation? Who
can point out, with precision, where the one ceases to be useful and
becomes hazardous; while the others constitute the only resources of
art? Experience and talents alone are capable of deciding on these
points, and that only in the chambers of the sick. It is, therefore,
less by precept than example that practitioners ought to be instructed
here.
2. To furnish suitable examples on this head constitutes my only object
in the present memoir, which will consist of the histories of a few
cases, with such inferences and remarks as the occasion may seem most
naturally to suggest. Here the practice of a great master, varying his
means with the varying forms of disease, will serve as models to those
who may meet with similar cases. Our experience is composed of the
facts which we receive from reading, as well as of those derived from
observation. Who would have a right to call himself a surgeon, if he
had no other title to that name, but such as resulted exclusively from
his own personal observation?
3. However difficult it may be, as already observed, to speak in
general terms, on the present subject, we may yet assert with safety,
that authors have greatly exaggerated the danger of complicated
luxations of the foot. Terrified at the extent and unpromising
appearance of the accidents, these writers have lost that confidence in
the powers of nature which we never ought to abandon. They have taken
up an opinion, that luxations of the foot, differing in their symptoms
from other luxations, require also a different mode of treatment; that
reduction, by perpetuating the accidents of the case, must prove fatal,
and that amputation ought to be adopted as the only resource. Cases do
certainly at times occur, where a doctrine different from this would be
fatal in its effects: such are those terrible lacerations, where the
foot is entirely separated from the leg, except some shreds of flesh
with a few tendons among them that still retain it.
4. But, provided the blood-vessels have escaped, and any hope of
circulation and life in the part still remain, the success of reduction
should always be first tried; and the following examples will show,
what ought to be expected from this practice, when accompanied by
skilful treatment.
§ II.
LUXATION OF THE FOOT, COMPLICATED BY A FRACTURE OF THE FIBULA, TIBIA,
&C.
CASE I. (The following case was collected by Leveille.) Abraham Genty,
aged forty-three, a dealer in wine, as he was running along the street,
slipped, and made a false step on his left foot, which turned with
its external edge under him, and its internal edge upwards. He fell,
luxated his foot, and fractured the fibula.
The patient was carried home, where a surgeon who was ignorant of his
profession being called, did nothing but apply a cataplasm to the foot.
In the evening the parts began to swell, and were extremely painful;
fever supervened, accompanied with great restlessness. Third day, to a
rapid increase of all the symptoms was added a delirium; blood-letting
from the jugular vein was prescribed to no purpose; things continued
to grow worse till the sixth day, when the patient was brought to the
Hotel-Dieu, in extreme danger.
The following was then the state of the parts. A considerable swelling
around the joint; a projection of the malleolus internus, with a
depression underneath it; a preternatural direction of the tibia
before, and of the os calcis, behind; a depression near the lower
end of the fibula; a crepitation readily perceived, on moving the
fragments; a large tumour on the outside of the foot: with a depression
and mobility of the malleolus externus.
The luxation was immediately reduced. Extension made on the foot and
leg brought the parts into their proper situations, where they were
retained by means of the bandage for fractures of the leg, and four
compresses well secured by the bandage. One of these compresses, being
placed on the malleolus internus, another on the outside of the foot,
a third on the anterior and lower part of the tibia, and the fourth
under the os calcis, prevented these different parts from being again
displaced.
As soon as the apparatus was applied, the pupils remarked with
astonishment, that the restlessness of the patient ceased, that his
pains were relieved, and his delirium disappeared; he expressed his
surprise at the state from which he had just recovered, and was now
able to give an accurate account of his fall. He was scarcely put to
bed, when he fell into a tranquil sleep, which lasted three hours. For
six days previously he had not slept a moment.
In the evening, the patient was free from pain, and perfectly tranquil.
Diluting drinks were prescribed, with twenty-five drops of Hoffman’s
anodyne liquor: the apparatus was wet from time to time with
vegeto-mineral water: the patient slept well throughout the night.
Next day, the apparatus renewed: the parts perfectly in place: swelling
diminished; same means continued. Sixth day, the anodyne discontinued.
Tenth day, swelling still less; echymosis gone; a yellow colour in the
skin, an evidence that resolution is going forward. Twentieth day,
swelling gone.
Thirtieth day, the fracture of the fibula healed; that bone slightly
separated from the tibia: the circular roller drawn tighter; and a
thick compress placed on the external malleolus, to bring it to its
proper place. Forty-fifth day, the apparatus for a fractured leg
removed, and a simple roller substituted in its place: the motions of
the foot painful and contracted; a small gangrenous spot appeared on
the heel. Fifty-fifth day, the ulcer which proceeded from this spot
healed: motions of the part more free and extensive. Sixty-first day,
the patient able to walk without assistance, though not without pain.
5. It is difficult to find an instance where the advantages of
reduction have been more remarkable than in the preceding one.
The patient had passed six days in pain, extreme agitation, and
uninterrupted delirium: the foot was reduced, and these unfavourable
appearances instantly vanished, and were succeeded by a state of
tranquillity. Alarmed by such a state of things, the ancients would
doubtless have proceeded to amputation. Let us examine into the motives
which led Desault to an opposite line of practice, and then inquire
into the cause of the success with which that practice was crowned.
6. Had amputation been performed here, it must have been for one of the
two following reasons; 1st, for fear of gangrene; or 2dly, to remove
the unfavourable symptoms that existed. The first apprehension would
have been quite visionary, in as much as all the blood-vessels were
sound. Would the second consideration have been any better founded? It
was perfectly obvious, that the unfavourable symptoms which existed
arose from the tension and overstretching of the parts, in consequence
of the preternatural position of the bones of the foot. The indication
was evident. Replace these bones in their natural situations, the
strained parts will then necessarily become relaxed, and all the
troublesome and alarming symptoms cease with the cause that produced
them. Experience confirmed the justness of this reasoning.
7. But the mere replacement of the parts would be of very little avail,
if it were not permanently maintained, and followed up by a judicious
mode of treatment. Without such treatment there would doubtless be
reason to apprehend all that train of troublesome consequences, of
which authors speak in such frightful terms, and which arise, not from
the nature of the luxation, but from the manner in which the patient
is treated. A loose apparatus, incapable of preventing displacement,
would allow the bones to be deranged anew, and to produce again an
overstraining of the parts, accompanied with pain, swelling, &c.
Irritating local applications, such as camphorated spirits of wine,
&c. would increase these pains; emollients which are employed in other
cases would keep up the swelling.
8. It follows from what has just been said, that an opposite mode
of treatment ought to succeed the reduction, and this we see was
the case in the preceding instance. There, when the bones were once
reduced, all new displacement was prevented, because the apparatus
was so constructed, as to counteract the tendency of the bones to
be displaced. The external edge of the foot, which had been turned
outwards, was now pushed inwards by a thick compress; the same means
served to push outwards the internal malleolus, which had received by
the accident an inclination inwards, and to push the anterior part
of the tibia backward, and the os calcis forward, both of which were
displaced, as has been remarked, in contrary directions. Two strong
splints fixed the lateral compresses, while the anterior and posterior
ones were firmly secured by rollers. In the midst of all these
resistances, the foot being necessarily immoveable, no new displacement
could occur.
9. A suitable and judicious position, in which the foot, raised a
little higher than the leg, was placed on a pillow forming an inclined
plain, prevented swelling, while gentle compression, made by a bandage,
contributed to the same end. This end was also further attained by the
external topical applications. To relieve pain and remove congestion,
were here, as in sprains, the two indications to be fulfilled. To these
indications the spirituous and the relaxing applications formerly in
use, are alike opposed. Vegeto-mineral water, on the contrary, fulfils
them extremely well. Hence the necessity of keeping the apparatus
constantly wet with that liquid.
10. Regimen influences not a little the success of the treatment.
A strict diet is necessary during the time of the inflammatory and
unfavourable symptoms. Any excess might then prove fatal. Desault
gave, in his lectures, an account of a woman, who had her foot luxated
outward, and the astragulus forward. Her fever was considerable, her
pains excruciating, and the swelling wore an alarming aspect. The
luxations were reduced: all the threatening appearances vanished, and
every thing seemed to promise a favourable termination of the disease.
But, on the fiftieth day, the patient, having procured strong food, ate
largely of it: in the evening all the unfavourable symptoms returned;
the swelling became great, and a few days afterwards she died.
But if strong food be prejudicial during the time in which bad symptoms
are to be dreaded, a diet too strict would be equally injurious when
that time is passed. The weakened powers of the system would not be
adequate to the purposes of a cure, particularly to the consolidation
of the bone, should the case be a fracture. Desault, therefore,
permitted the patient to increase his diet by degrees, and at length to
return to his usual regimen.
11. The following case, reported by Giraud, proves still further the
advantages of this simple mode of treatment, which, should it even
fail, always allows the surgeon to avail himself of amputation, which
is indeed the last resource of art, and should never be employed till
rendered indispensable by the failure of all other means.
CASE II. Maria Constant, aged forty-six, descending a flight of stairs
in haste, fell, and luxated her right foot outwards, the tibia
inwards, and fractured the fibula near to the lower end.
Her cries brought assistance to her, and she was carried to the
Hotel-Dieu. Giraud, who then officiated as surgeon in chief, visited
her, and discovered that there existed both a luxation and a fracture,
though most of the signs were rendered obscure by a considerable
swelling: a slight echymosis occupied the back of the foot, and severe
pains were experienced.
Extension on the foot, and counter-extension on the leg, dislodged
the parts by degrees from their accidental situations, while, by the
process of conformation, the surgeon endeavoured to bring them into
their natural ones. This was soon effected without much violence: the
unfavourable appearances soon vanished; the pain ceased; an apparatus
similar to the former one was applied, and kept wet with a strong
solution of common salt, instead of the vegeto-mineral water.
In the evening, the pulse being full, and somewhat raised, a moderate
blood-letting was deemed necessary. Next day, the apparatus was kept
constantly moist, and some part of it which had become relaxed was
tightened. The pulse continuing full, a low diet was prescribed.
Fifth day, the apparatus taken off; contact between the bones perfect:
a yellowish tinge bespoke an incipient resolution of the echymosis:
a slight swelling of the leg: vesications formed on the part: these
are opened and a quantity of acrid water discharged from them. Sixth
day, light nourishment allowed; a small excoriation of the heel, which
is dressed with cerate spread on a linen rag. Seventh day, regimen
less strict; no bad symptoms supervene. Eighth day, the excoriation
enlarged; same dressing. Tenth day, the excoriation become fungous:
caustic is applied to remove it.
Twenty-eighth day, the discharge from the leg decreased; from this time
the dressings are renewed only every other day. Thirty-second day, the
ulcer is cicatrized: no pains in the leg. Thirty-ninth day, fracture of
the fibula firmly united: no deformity remaining; the apparatus is laid
aside: the joint remains stiff: motions performed by the limb difficult
at first, but become gradually more free. Forty-sixth day, symptoms of
bile; gentle evacuants. Fifty-fourth day, the patient is discharged
cured, except a slight impediment in walking, which exercise will soon
remove.
12. To this example, I might add many others, where similar
displacements, properly treated, terminated with equal success: no
pain; no swelling; no inflammation; and therefore, of course, no
mortification. Yet these are occurrences of which authors speak, as if
they were the usual consequences of such luxations, where, to a violent
injury done to the soft parts, is added a fracture near to, or even
communicating with, a joint. The erroneous opinions of the ancients and
most of the moderns, respecting the dangers arising from such vicinity
or communication, have contributed not a little to their unfavourable
prognosis in the cases under consideration. Should the patient survive
the disease, his inevitable lot, according to them, must be, a complete
anchylosis of the leg with the foot. But, the preceding cases fully
prove, that this apprehension is unfounded. A considerable time is
doubtless necessary, for the recovery of motion, on account of the
distension and rupture of the ligaments, the long continued inactivity
of the parts, and the swelling which they have undergone. But this
recovery can always be effected by means of exercise, gentle at first,
increased afterwards, and regulated according to the principles so
frequently laid down in the course of this work. Much more to be relied
on is such exercise, than the long catalogue of discutient means, such
as pumping of water on the parts, alkaline baths, mineral waters, and
all other external applications, so often extolled as efficacious, and
so often found entirely useless.
§ III.
LUXATION OF THE FOOT, COMPLICATED BY A SEPARATION OF THE BONES OF THE
LEG, AT THEIR LOWER END.
CASE III. (The following case was reported by Thevenot). I. Joseph
Schneider, an ebonist, aged thirty-six, as he was walking in haste, on
the 23d of March, 1792, fell forward, his foot being forced backward
and outward. He experienced at the instant severe pains in the joint:
he was unable to rise, and was therefore carried home, where a surgeon,
after making a slight extension, applied a roller on the limb, and
did nothing further. The patient experienced no relief. The pains
increased; a swelling supervened; convulsive motions began to occur;
and the patient was brought to the Hotel-Dieu, six days after the
accident.
From the deformity of the foot, Desault immediately discovered that it
was luxated. Its point was directed outwards, while its sole was turned
in the same direction: beneath the malleolus internus, which was too
prominent, was a tumour formed by the astragulus. The crepitation of
the bones which was easily heard, the preternatural distance between
the tibia and the fibula, the mobility of this latter bone, and the
absence of the signs of a fracture, plainly showed that a separation of
the two bones of the leg had taken place.
A reduction was immediately effected by means of extension and
counter-extension, and was announced when it took place by a report
distinctly heard. It was then retained by a bandage, calculated to
answer a twofold purpose; 1st, to approximate, and keep together, the
two bones of the leg: 2dly, to secure the contact and immobility of the
bones of the foot.
Blood-letting was prescribed: an anodyne mixture administered; low
diet; in the night severe pains were felt; next day, they were
increased; on dressing the limb, nothing amiss discovered; all the
parts in perfect contact: no vestige of separation between the tibia
and the fibula: a new apparatus applied; and kept constantly moist.
Third day, the patient better: fifth day, the fibula a little separated
from the tibia: the circular bandage drawn tighter to reduce it to its
place again. Tenth day, every thing in its natural state: no pains:
swelling gone. Fifteenth day, a simple roller substituted in place
of the bandage for a fracture of the leg. Nineteenth day, the patient
began to walk, with the assistance of a stick: twenty-third day, walks
easily: twenty-eighth day, is dismissed perfectly cured, and nearly
free in all his motions.
13. The separation of the bones of the leg, at their lower end, does
not constitute a very serious complication of luxations of the foot,
although the contrary is asserted by several authors. Desault met
with this accident several times in the course of his practice, but
never saw it terminate otherwise than favourably. But here, as in all
other cases, the most minute attention is necessary to ensure success,
the want of which is more frequently owing to the negligence of the
surgeon, than to the deficiencies of the art. The bandage employed
after reduction ought to act principally from without inwards, and in
a direction perpendicular to the axis of the lower part of the leg, in
order to approximate the two bones. It will be of some service, in this
respect, to place on each bone a compress, which, projecting more than
the rest of the circumference of the limb, will be more compressed, and
on that account, contribute to the end in view.
§ IV.
LUXATION OF THE FOOT, ACCOMPANIED BY A DISPLACEMENT OF THE ASTRAGULUS
AT ITS ARTICULATION WITH THE OS SCAPHOIDE.
14. Petit never met with more than two instances of that displacement
of the astragulus, now under consideration. His general prognosis on
the subject is more favourable than that respecting other luxations
of the foot, with which he never saw the present luxation of the
astragulus complicated, as occurred in the following cases. Had such
complex cases fallen under his notice, there can be little doubt, but
he would have declared amputation to be the only recourse of art on the
occasion.
But the experience of Desault demonstrates to us here, as well as in
the preceding cases, the great extent to which we ought to carry our
confidence in the powers of nature, when skilfully guided by the hand
of art. The following case was communicated to me by Leveille.
CASE IV. John Baptist Landrin, a postilion, aged thirty-six, was
brought to the Hotel-Dieu, on the 19th of February, 1791.
On the morning of the same day, a horse on which he was mounted having
fallen, his foot was caught under the belly of the animal. As soon as
he was disencumbered of the vast weight, he endeavoured to rise, but in
vain. The pains which he experienced in his foot were extreme. He was
carried home, where some surgeons, having ascertained that his foot
was luxated, but being unable to reduce it, sent him to the Hotel-Dieu.
Desault on examining him, found the bones of his foot to be situated as
follows. The internal part of the os calcis corresponded to the lower
extremity of the tibia: the back of the foot was directed outwards, and
its external edge downwards: under the skin and in front of the tibia
was the astragulus, resting on the scaphoide and first of the cuneiform
bones, where it formed a considerable projection: on the back of the
leg, the fibula corresponded to the tendo Achillis. The pains had been
inconceivably great from the moment of the accident.
Imboldened by numerous instances of success in similar cases, Desault,
notwithstanding the extent of the disease, attempted the reduction.
One assistant took hold of the superior part of the leg to make
counter-extension, and another, for the purpose of extension, grasped
the metatarsus with one hand, and the heel with the other. While these
were pulling in different directions, the surgeon applying his thumb
on the astragulus, endeavoured to force it into its place. His efforts
were ineffectual: the opening through the capsule of the astragulus
being too narrow, would not suffer it to pass. Desault perceiving
this, cut through the integuments which covered the bone, and having
laid bare the capsule and the ligaments which strengthen it, made
an incision into them of a sufficient extent, taking care to avoid
the tendon of the tibialis anticus, which was brought into view. The
openings being thus enlarged, admitted of an easy reduction, and all
the parts resumed, without difficulty, their natural situation.
The reduction being effected, the wound was closed, and covered with
some lint. A square compress was then placed on the back of the foot,
while a long one was applied to its sole, and the whole secured by an
apparatus similar to that described in the preceding case. The patient
was confined to a very strict diet, and ordered to use diluting drinks.
Next day, a slight bilious diathesis; an emetic in solution given;
apparatus renewed. Fourth day, an abscess on the malleolus externus
opened; a copious discharge of pus. Eighth day, the parts in perfect
contact; a favourable discharge from the wounds; dressings applied
twice a day. Fifteenth day, a general œdema; aperient ptisans ordered.
Twentieth day, the œdema gone: a bilious diathesis returned: in
consequence of this, the wounds became pale: another emetic given.
Twenty-seventh day, a very painful excoriation occurred on the heel:
care taken not to let the foot rest on that part, as the sore appeared
to be the effect of compression. Thirtieth day, the wounds in a
favourable way: all the bones in exact contact. Fortieth day, apparatus
laid aside, and a simple roller substituted in its place: wounds
already cicatrizing. Fiftieth day, the limb put in gentle motion, which
is gradually increased every day. Same dressing continued till the
eightieth day: wounds not yet cicatrized. Hundred and twenty-seventh
day, a considerable swelling around the joint: a splinter made its
way out, and was followed in a few days by several more. In the fifth
month an abscess formed on the heel, from which, when opened, another
splinter escaped. In the mean time, the patient left the Hotel-Dieu.
During his absence more splinters were discharged. Returning about a
year afterwards with a small ulcer, he was dismissed again in a short
time, perfectly cured, except a slight stiffness of the joint.
15. The reduction of this luxation of the foot presents a difficulty
worthy of the attention of practitioners, as well on account of its own
nature, as in consideration of the process which was employed on the
occasion: I allude to the narrowness of the opening in the capsule. I
mentioned, on a former occasion, the obstacles sometimes created by
this circumstance to the reduction of luxations of the os humeri and
the os femoris. It was impracticable in the present to enlarge the
opening in the capsule, as could be done in those cases, by moving the
head of the bone in all directions; because the bone was too small to
afford any purchase to the surgeon. The only resource was, the use of
the knife; and the operation was the more easily performed, on account
of the capsule being situated immediately beneath the integuments, from
which circumstance it could be the more speedily brought into view.
16. The apprehension of mischief resulting from the admission of air
to the articulating surfaces, would no doubt, in this case, have
restrained most practitioners: but, even supposing this apprehension
to be well founded, ought it to deter the surgeon from adopting the
only possible mean of effecting a reduction, and of thus putting an end
to the alarming state of things arising from the displacement of the
bones? Desault proved in numerous instances, that the apprehensions
of authors respecting such cases have been greatly exaggerated, and
that it is practicable to cure wounds that penetrate into the cavities
of joints, in the same manner as if they were simple wounds, and with
but very little more danger to the patient. Yet it would seem, that
the tediousness of the cure and the exfoliation of the bones, arose,
in the present case, from the opening made into the joint, and perhaps
also, in part, from the disposition and habit of the patient. Finally,
in those alarming injuries of the joints, unconnected with external
wounds, where practitioners have looked to no resource but that of
amputation, Desault has, in a short time, and without any dangerous
occurrence, restored to the subjects the free use of their limbs. The
following case, drawn up by Plaignault, is a proof of this.
CASE V. Pierre Phipe, aged twenty-four, fell, on the 20th of February,
1788, from an elevation of more than twenty feet: lighting on his foot,
he turned it outwards, sunk instantly to the ground, and was unable to
rise again. He was carried home, and from thence to the Hotel-Dieu.
Desault examining him on his arrival, discovered a luxation of the
foot outwards, and of the astragulus forward and upward: the patient’s
sufferings were great. Convinced that the most effectual method to
relieve these was to reduce the luxation, the surgeon undertook it
immediately, pushed the astragulus into its place without difficulty,
and with a report which was heard by every one present, while the
bones of the foot were brought into their proper situation by means of
extension. In an instant the pains vanished and the motions of the foot
became easy. The necessary apparatus was applied. The activity of the
pulse called for blood-letting, which was immediately performed. A low
diet was prescribed.
On the two following days blood-letting was repeated, both on account
of the active state of the pulse, and of a considerable swelling which
took place in the joint. The apparatus was kept constantly wet with
vegeto-mineral water. Eighth day, somewhat better: echymosis gone.
Fifteenth day, the apparatus laid aside. From this time the foot was
gently moved every day. Eighteenth day, the patient able to stand
on the affected foot without pain. Twenty-sixth day, walks with the
assistance of a staff. Thirty-ninth, walks without limping, and enjoys
all the motions of the foot. Discharged.
§ V.
LUXATION OF THE FOOT, COMPLICATED WITH AN ESCAPE OF THE ASTRAGULUS,
THROUGH THE CAPSULE AND THE LACERATED INTEGUMENTS.
17. When, in a luxation of the foot, the integuments, capsule, and
ligaments are so lacerated, as to suffer the astragulus to escape, it
would oftentimes be imprudent to attempt its reduction, as was done in
the preceding cases. The violence already done to the parts around the
joint is excessive; but this would be increased by the extension, and
other efforts necessary in reduction. Whatever care might be taken, it
would be difficult to prevent a vast swelling, long continued pains,
and perhaps even a caries of the bone exposed to the air, with all
those sufferings and dangers, to which such an accident gives origin.
In such a case all the bones of the foot have been known to become
carious, a state of things, which calls for the ultimate resources of
art, and draws after it a train of evils, which it is always of the
utmost importance to prevent.
18. What means are then to be employed? Two expedients only remain.
1st, the amputation of the foot; 2dly, the extirpation of the
astragulus. The first is a cruel resource, which should never be
adopted but in the last extremity, because it deprives the patient of
a portion of himself, necessary to the performance of his functions.
But the measure is forbidden by a reason still more powerful. Amidst
the general disorder of the system, the severe pains experienced by the
patient, the convulsions, and the delirium which oftentimes exists,
what ground has the surgeon to hope for success? Will not the operation
add to the number of these alarming appearances? Will it not aggravate
them? May it not render them fatal? Both reason and experience reply in
the affirmative.
19. In such a case, then, the extirpation of the astragulus is the
expedient to be preferred. What, indeed, are its inconveniences? 1st,
An inevitable anchylosis of the foot and leg: 2dly, a shortening of the
affected limb. But a leg even in this state, is still better than a
wooden leg, which is the necessary consequence of amputation: besides,
a leg of the former description occasions no great inconvenience in
either walking or standing, whereas one of the latter, produces extreme
lameness: in the first case, a heel on the affected side somewhat
higher than that on the other, is an easy method of removing the
deformity. What, then, are such trifling disadvantages, when compared
with the evils which they ward off? The extirpation of the astragulus
is accompanied with but little pain. The want of this intermediate
body between the leg and the foot, by producing a relaxation of the
surrounding soft parts, prevents pain and swelling in such cases:
should abscesses supervene, they will not, if properly treated, greatly
retard the cure. In a word, experience coincides with this doctrine.
Desault has seen it twice verified in the practice of other surgeons,
and three times in his own. I have known of but one case of the kind,
in which the termination was fatal, and there, a malignant fever,
induced by the contaminated air of the hospital, certainly contributed
to the death of the patient, which did not occur till two months after
the reduction.
CASE VI. Desault usually gave in his lectures, the history of a case
where the success of this practice was remarkable. A man was brought
to the Hotel-Dieu, with a luxation of the foot, complicated with
a fracture of the lower part of the leg, and a laceration of the
ligaments and capsule, through which the astragulus had escaped by a
luxation forward and upward, so as to have half of its anterior surface
exposed. The extent of the injury seemed to call for amputation.
But the youth, the vigour, and sound constitution of the patient,
gave ground to hope that a process less desperate might succeed. The
astragulus, already separated anteriorly, was extracted by dividing the
attachments which held it to the os calcis, and the bones of the leg:
the reduction was then effected without difficulty. The parts being
replaced more readily in consequence of the removal of this bone, were
retained so by means of a bandage similar to that for fractures of
the leg, but modified so as to suit the particular case. The patient
lost blood once or twice: the apparatus was kept constantly wet; a
very strict regimen was prescribed for some days; but few troublesome
symptoms occurred; a slight swelling took place, but was soon removed;
a favourable suppuration came on; the dressing was renewed twice a
day; some splinters escaped occasionally; several abscesses formed
successively were opened, and healed up again: the wounds themselves
closed, and the patient finally recovered, with an anchylosis, indeed,
between the foot and leg, and a limb a little shorter than natural, but
which still served the purposes of walking and standing.
20. To this example, I might add those of other patients treated at the
Hotel-Dieu, in the same manner and with equal success. But what purpose
would such an accumulation of facts answer? It would only fatigue the
reader without adding to his conviction.
21. If the injury accompanying the luxation be so extensive, as to
destroy the principal blood-vessels, and leave no hope of saving the
limb, amputation becomes then the only resource, and the case assumes
a resemblance to those where the limbs are shattered by cannon balls:
the success then depends very much on the strength or weakness of the
patient.
CASE VII. A man fell from a carriage: his foot becoming entangled
between the spokes of the wheel, was almost separated from the leg. It
adhered only by a small portion of skin behind, and by the tendons of
the muscles which run to the toes both above and below.
Desault was called to the patient, whom he found in a most deplorable
state: the pains which he suffered were excruciating: the parts around
the wound were greatly swollen; a general spasm affected the system:
amputation was judged necessary, but was deferred till the symptoms
should be mitigated. The limb was dressed: next day, a gangrene began
to affect the foot, which was then separated from the leg by cutting
the tendons: the ends of the tibia and fibula exfoliated; the wound
healed, and the patient now enjoys, in part, the functions and uses
of the leg, by means of an artificial foot, framed and fitted on by
an ingenious mechanic. Had the limb been too hastily amputated while
the patient was affected with general spasms, fatal consequences would
probably have ensued.