Chapter X: Part 10

4. But this fracture may be produced in two modes. 1st, by the action of external bodies: 2dly, by that of the extensor muscles. The first mode of division takes place in falls on the knee, or when a body in motion strikes against it, and, in this case, there is no counter-stroke, the rotula being too small for such an occurrence, and always sustaining the fracture where it receives the blow. In the second, the fall is only subsequent to the fracture, and, as Camper has well observed, is most frequently the effect of it. For instance, the line of gravity of the body is, by some cause, removed behind it; the anterior muscles contract themselves to bring it forward again; the extensors act on the rotula; it is broken, and a fall ensues. Again, the leg is suddenly thrown into a state of violent extension; the extensors act with great force; a fracture is the consequence, and the patient falls. A soldier once fractured his rotula in kicking at his serjeant; thus the olecranon, in like manner, has been broken by throwing a stone. A man, in the Hotel-Dieu, fractured the rotula of each knee, in the operating room, by means of convulsive motions, produced by the operation of lithotomy.

5. The action of external bodies, can alone produce a longitudinal fracture, as when a person falls on a sharp projecting piece of timber: but this may also produce a transverse fracture. On the other hand, muscular action can never give rise to any but the latter kind, since the direction of this fracture is at a right angle with that of the extensors. A fracture resulting from the action of external bodies, is oftentimes accompanied by a wound, a contusion, or a shattering of the part (2); a fracture, arising from muscular action, is always simple, except as to a swelling around the joint. The latter cause may, instead of fracturing the rotula, rupture the common tendon of the muscles, or, what is more common, the inferior ligament. Desault has seen many examples of this: Petit has also observed several, and Sabatier has sometimes met with them. External violence seldom produces this double accident.

§ III.

OF THE SIGNS AND THE DISPLACEMENT.

6. In longitudinal fractures the diagnosis is always accompanied with more or less difficulty, because the extensor muscles, drawing by their contractions the two fragments equally upwards, and the inferior ligament holding them equally down, tend to keep them in apposition, and to prevent them from separating. Sometimes also the ligamentous production which covers the rotula, remains entire and serves to keep the fragments together. It will be necessary, therefore, should the existence of such a fracture be suspected, to move the two sides of the rotula in opposite directions, by pressing them to the right and to the left, in order to arrive at certainty on the subject. Should a wound exist, as is oftentimes the case (5) the diagnosis is less difficult.

7. If the division be transverse, the diagnosis becomes then as plain and easy, as it is difficult and obscure in cases where it is longitudinal. In such a case, a considerable separation or space exists between the two fragments, sensible to the touch, when the hand is placed on the knee. In this separation, the fragments are not displaced by the same means. The superior fragment being attached to the extensors, is drawn upwards with great force by these muscles, the action of which the rotula no longer resists. The lower fragment, on the other hand, being attached only to the inferior ligament, is not moved by any muscle, and cannot be displaced in any other way than by the motions of the leg with which it is still connected.

8. Hence it follows, 1st, that, in a state of extension, the separation is the least possible, because it is then produced on the part of the superior fragment only; 2dly, that in a state of flexion it is greatest, because then both fragments concur alike in producing it; 3dly, that it may be increased or diminished by varying the degrees of flexion.

9. This fracture is further characterized by the following circumstances, namely, a practicability of moving the fragments transversely in opposite directions, and of producing, by that means, some degree of crepitation, provided they be first brought close together; by the pain which accompanies these motions; by the swelling common to every kind of fracture of the rotula, and which, if very great, may involve the other signs in more or less uncertainty; by a difficulty of standing; and an almost entire loss of the power of walking, in consequence of the extensors being no longer able to communicate motion to the leg, unless when the fracture exists very low down, near to the inferior ligament.

10. The touch will always discover in what part of the bone the fracture is situated, which, if it be oblique, will partake more or less of the characters of the longitudinal or the transverse, accordingly as it approaches to the one or the other.

§ IV.

OF THE PROGNOSIS.

11. Many authors have pretended that fractures of the rotula cannot be cured, and it even appears that the Academy of Surgery adopted this opinion, on receiving a memoir from a Flemish physician, which contained several facts tending to establish that principle. But what do these facts prove? That in some particular cases, reunion did not take place, but they do not show that this was owing to the nature of the fracture.

12. But, what, in such cases, could prevent a cure from taking place? The structure of the rotula differs, say they, from that of the other bones. Now, admitting this difference of structure to be real, it certainly approaches to the structure of tendons to which indeed it bears a strong affinity. But, who does not know, that, when tendons are divided, they unite as readily as bones? Besides, is not the power of reunion common to every part endowed with life? I have already shown, when treating of other fractures that communicate with joints, what credit is due to those hypotheses so often revived but never confirmed, nay even clearly proved to be unfounded, such as, an effusion of callus into the joint, a failure of reunion from a want of periosteum on the posterior part of the bone, the synovia diluting the matter of callus, and thus preventing it from being duly prepared, &c.

13. The inflammation of the articulating surfaces and of the ligaments around the joint, ought to have more influence in constituting an unfavourable prognosis, than any circumstance that authors have mentioned. But experience proves, that, when judiciously treated, these fractures are not accompanied by that accident, and even that the swelling, which for the most part attends them, always yields more or less speedily, when a bandage, uniformly applied, presses equally on all parts around the joint, and thus forms a kind of discutient, while at the same time it retains the fragments.

14. Pare, Fabricius of Hilden, and a number of other writers, have pretended, that some degree of lameness must always be the consequence of this fracture. But, from what causes must this lameness so certainly arise? Is it from a want of reunion in the part? I have already shown (11 and 12) that this apprehension is wholly unfounded. Is it from an anchylosis? This accident cannot take place, except either in consequence of inflammation occurring in the articulating surfaces, (and I have already shown how that may be avoided, 13) or of a stiffness in the ligaments, and I shall hereafter make it appear that that may be readily prevented by motion. Is it from the fragments being drawn asunder, and in that state united by an intermediate substance of too great an extent? I shall prove, that a bandage properly constructed, is always sufficient to keep these fragments in contact.

From these considerations it appears, that writers have, in general, without sufficient cause, given an unfavourable prognosis, in relation to fractures of the rotula, which have, indeed, a great affinity to other affections of the same kind.

§ V.

OF THE REDUCTION AND THE MEANS OF MAINTAINING IT.

15. I have already observed (7), that the causes of the separation of the fragments are, as far as respects the upper one, the contraction of the extensor muscles; and, in relation to the lower one, the flexion of the leg; whence it follows, that the means of preserving contact between these fragments are 1st, all those that are calculated for the prevention of muscular action; 2dly, such as may keep the limb in a state of permanent extension. Hence two leading curative indications must be fulfilled by the bandage constructed for fractures of the rotula: the last of these indications presents in general but little difficulty; but, with regard to the other, the case is different. To fulfil the latter, it is necessary first, to weaken the contractile force of the muscles, and by that means diminish the effort which they make to draw the superior fragment upwards; and then, to oppose to them a proper mechanical resistance, which, by acting in a direction the very reverse of that in which they act, may countervail their efforts.

16. But the force of contraction is diminished, 1st, by throwing the muscular fibres into a state of relaxation; this end is best attained by bending the thigh on the pelvis: 2dly, by making compression over the whole limb, by means of a circular bandage, which, by confining the muscles, tends to restrain and weaken their action. Thus it is known that the advantage of the bandage employed to unite transverse wounds, consists chiefly in that compression which, by diminishing muscular action, prevents the retraction of their edges. Another advantage resulting from the bandage in this case is, that it prevents the swelling of the limb.

17. As to the mechanical resistance, which must act in a direction opposite to that of the contraction of the muscles, and, by that means, prevent the displacement of the superior fragment, it cannot, in the present case, be of the same nature as in fractures of the thigh, the clavicle, &c. where permanent extension is practised. The superior fragment offers too small a purchase for any extending forces to act on. This resistance must be made, then, by placing some body above this fragment, and retaining it in that situation with a force sufficient to hinder the fragment from rising upwards: such as a few turns of a roller drawn tight, a bit of leather, some hollow compresses, &c.

18. It is evident from the foregoing principles, that every bandage intended to retain a transverse fracture of the rotula, ought to be calculated to maintain the following state of things: 1st, the extension of the leg on the thigh; 2dly, the flexion of the thigh on the pelvis; 3dly, a uniform compression over the whole limb; and, 4thly, some mechanical resistance properly secured above the superior fragment: the three last expedients relate to the displacement of that fragment alone; while the first has a relation to that of the lower one. Let us examine whether or not the bandages, hitherto employed by different authors, be calculated for these purposes.

19. M. Valentin, believing that position alone was sufficient to retain the fragments in contact, neglected the application of apparatus entirely, which he even considered as hurtful, in consequence of the swelling it produced; but experience soon proved the insufficiency of this method. The slightest movement, or the least effort on the part of the patient, made the extensor muscles contract, which, drawing the superior fragment upwards, separated it from the lower one; and, as the time of reunion is in direct proportion to the distance of the fragments from each other, it must, under such treatment, have been necessarily tedious, and sometimes must have even failed altogether.

20. As to a swelling being produced by the bandage, this never occurs, unless when some openings are left, through which the integuments protruding become tumefied: but, when the pressure is uniform throughout, when the fluids find throughout an equal resistance, this accident is not to be apprehended, as is proved by the practice of Desault, who never met with it; on the contrary, a bandage properly constructed and applied, is calculated to prevent swelling (16).

Mere position, then, though always of service in this affection, is not alone sufficient, because it fulfils only the first of the indications or principles laid down with respect to every form of apparatus for transverse fractures (18), namely, that which relates only to the lower fragment; while those that relate to the upper one, remain still to be fulfilled.

21. Most authors have employed, with a view to these, a kind of figure of 8 bandage, known in art by the name of _Kiastre_,[32] and approved of by Petit, Heister, &c. This is made of a roller formed into two balls, which are brought across each other alternately under the ham, passing over two hollow or forked compresses, that enclose the two fragments of the rotula.

[32] I know not of any English term equivalent to this. T.

But the unequal pressure which this makes on the unequally projecting parts of the knee, renders its application extremely painful, particularly below, where the pasteboard covering applied by Louis, immediately on the skin, afforded but a feeble protection to the tendons of the flexors. Besides, it did not prevent the swelling, which is indeed a necessary consequence both of this unequal pressure, and of the openings left between the casts of the bandage. This swelling is taken notice of by all writers, and is, according to them, one of the troublesome circumstances attending the fracture. The third indication is not all fulfilled (18).

22. The extensor muscles, not being at all compressed, will act with their whole force on the upper fragment, and, on the slightest effort of the patient, overcome the resistance of the bandage, the action of which, being oblique with respect to the fragment, is inconsiderable, unless it be drawn very tight, and thus a displacement will again occur. This obliquity of the turns of the roller obliges the surgeon, either to draw it very tight, in which case a swelling is inevitable, or to make it but moderately tight, and then the apparatus will be insufficient to resist the action of the muscles.

23. Most of the objections to the ancient apparatus for fractures of the rotula, apply also both to that proposed by Ravaton in his surgery, and to that which Bell employs in his practice. Both of these, while they fail in making sufficient resistance to muscular action, as well as in fulfilling the third condition laid down as necessary to every bandage (18), contribute to the swelling, and can rarely produce a perfect contact between the fragments. Thus Bell has well observed, that the reunion is rarely perfect, and that there is always a separation more or less perceptible.

24. The complication, the intricacy, the expense, and other more weighty inconveniences of the machine described by Garengeot in his treatise on instruments, and employed, for the first time, by Arnaud, and also of that which was proposed and used by Solingen, have, long since, entirely banished them from among the means of reduction.

25. Some practitioners have advised the uniting bandage used in cases of transverse wounds, which is formed, as is well known, of two small rollers or strips placed in the longitudinal direction of the limb, one of them having holes in it, to which the divisions of the other are fastened. Both of these are first secured by circular turns; being then drawn in opposite directions so as to meet, they draw the parts on which they are applied in the same directions. But the action of this bandage is confined to the integuments, and would have of course but a feeble influence on the fragments beneath. It is also attended with this further inconvenience, that by wrinkling the integuments, and throwing them into folds, it might press them down between the fragments, and thus prevent their contact. Besides, it is liable to most of the objections urged against the preceding one.

26. This view of the means employed by different practitioners, to counteract the causes of displacement in this fracture, are sufficient to convince us, that the difficulties hitherto experienced in the treatment of it, have arisen from the feebleness of the former, and the strength of the latter. So great indeed have been these difficulties, that some authors, conceiving a reunion impossible, have, in conformity to such an opinion, though contrary to all the rules and principles of the profession, advised us to abandon the patient to himself. But I have already exposed the fallacy of that opinion, respecting the want of a healing power in the rotula (12), an opinion which, if generally adopted, would give rise to consequences of the most serious nature. In the present case, as in all other fractures, the contact of the fragments ought to be the chief object of the surgeon’s efforts.

27. But ought this contact to be perfect and exact? Several authors, particularly Bell, have conceived, that the motions of the limb can be performed as well with a slight separation of the fragments. Pott even declares that such a separation will enable the patient, after his recovery, to walk with more ease. Flajani advances the same opinion in a dissertation on the subject.

From this doctrine arose a new mode of treatment, which consisted in not suffering the fragments to be at rest. They were accordingly, during the cure, put frequently in motion, the more effectually to prevent an anchylosis, which is sometimes the consequence of this fracture.

28. But, on the one hand, it is difficult to conceive, on what this opinion of these authors can be founded; while, on the other, reason declares, in the plainest and most forcible terms, that the more the state of a bone, after it has been broken, differs from its natural state, the less free will be the exercise of its functions, and, that the perfection of the treatment of fractures consists, in leaving behind it no vestige of the accident.

29. This truth was frequently confirmed in the experience of Desault, who had an opportunity of seeing numerous fractures of the rotula, both in the Hotel-Dieu, and in his private practice. He always observed, that, when the separation of the fragments was considerable, and the ligamento-cartilaginous substance uniting them was of some extent, standing and walking were performed with much difficulty; that the patient was exposed to frequent falls, from the want of a proper correspondence, in point of strength and motion, between the two limbs; and that, on the contrary, the less extensive the separation and the substance that filled it up were, the more free and easy were the motions of the part, which still remained, however, somewhat defective and imperfect, unless every vestige of the division was obliterated.

Paul of Egina long since observed, that, when no means of reduction were employed, though the patient might walk tolerably well on a level surface, he could not, without difficulty go up an ascent.

30. From what has been said, it follows, 1st, that in the treatment of this fracture, the perfect contact of the fragments ought to be the principal object of the practitioner; 2dly, that the kinds of apparatus employed by different authors, are but ill calculated for the attainment of this end, because they fulfil but imperfectly the indications formerly laid down (18). Let us see whether or not the apparatus of Desault be any better suited to this purpose.

31. The bandage, which he employed in this case, analogous to that for fractures of the olecranon, is composed, 1st, of one splint, two inches broad, and long enough to reach from the tuberosity of the ischium, to a little above the heel; 2dly, of two rollers, five or six yards long, and nearly three inches wide; 3dly, of another single roller, with two holes about the middle of it, a little longer than the injured limb of the patient, along the fore part of which it must be extended.

32. Every thing being arranged for the application of the apparatus,

1st, One assistant secures the pelvis, in the same manner as in fractures of the lower extremities; while another keeps the leg in a state of perfect extension on the thigh, and the thigh on the pelvis.

2dly, The surgeon, then, standing by the side of the fractured limb, extends along the anterior part of the leg and thigh the roller with holes in it, having previously wet it with vegeto-mineral water, taking care to make the two openings correspond to the lateral parts of the rotula, that, by being thus better adapted to its shape, it may not be thrown into wrinkles.

3dly, He then secures it on the top of the foot, by three circular casts of a roller placed one over the other, three or four inches above its lower end which must next be turned up over the three first casts, and made fast by two other ones. Then, while the compress roller[33] is secured above by an assistant, he passes up along the leg by oblique and reverse turns, according to the inequalities of the limb.

[33] The roller or strip with holes in it, which is extended along
the fore part of the limb, serving, in some measure, the purpose of
a compress. TRANS.

4thly, Having arrived at the lower part of the knee, he pushes the lower fragment upwards, and makes below it two or three circular turns to secure it. He then gives the roller into the hands of an assistant, and directing him who holds the long compress roller, to draw it forcibly upwards, pushes the integuments of the knee in the same direction, lest, by becoming interposed between the fragments, they might prove an obstacle to their reunion. Passing then the fingers of his left hand through the holes in the compress-roller he places them behind the superior fragment and pushes it forcibly downwards.

5thly, When the reunion of the fragments is exact, without any space intervening, he resumes the roller, and passing it obliquely under the ham, and bringing it up again behind the superior fragment, withdraws his fingers which held this fragment down. In place of his fingers, he then applies two or three tight circular casts, covers the knee with several oblique casts in form of the figure of 8, so as to leave no opening between them, and, then, continues the bandage up along the thigh, securing by it the compress-roller extended along the fore part of the limb.

6thly, When he has arrived at the upper part of the limb, the assistant who holds the compress-roller, drawing it forcibly upwards, doubles down its end over the circular casts. The surgeon next fixing this end by several additional casts, descends again along the thigh, covers the knee by a few more oblique turns, and finishes with the roller on the leg.

33. This first part of the bandage evidently fulfils the third and fourth indications (18). The compression of the roller on the muscles weakening their action and impeding their motions prevents their tendency to draw the superior fragment upwards: while the circular casts passed behind this fragment, acting in opposition to the muscular contractions, prevents it from moving upwards in obedience to them. The long compress-roller, stretched on the fore part of the limb, being first secured below, and then drawn forcibly upwards, presses the casts of the roller against each other, and prevents those that correspond to the thigh from slipping upwards, and thus abandoning the superior fragment, and prevents also those on the leg from slipping down and withdrawing their support from the inferior fragment. As there remains no vacant space between the circular turns, their pressure is uniform throughout: no swelling can consequently supervene (20).

34. But the first and second indications remain still to be fulfilled (18): it is necessary to prevent the separation of the lower fragment, by the extension of the leg on the thigh, and to throw the muscles into a state of relaxation by extending the thigh on the pelvis, and to maintain permanently, by the apparatus, that double position, which the assistant maintains only during the operation.

35. To obtain the first effect different means have been employed; but none answers so well, to extend the limb and retain it immoveably in that state, as a long and strong splint, placed, as Desault did it, subsequently to the application of the first part of the bandage, along the posterior part of the limb. An assistant must hold the end of this splint, while the surgeon secures it in its place by the second roller (31): in this way the extension of the leg is effected.

36. To obtain the extension of the thigh, it is necessary to place on the top of each other, two or three bolsters or little bags filled with chaff, so disposed as to form an inclined plain, considerably elevated towards the heel above the level of the bed, but which, gradually descending to the same level towards the tuberosity of the ischium, forms a supporting basis on which the whole limb may rest in a uniform manner. By this twofold extension of the leg and of the thigh, the lower fragment is kept up immoveably, and the muscles are kept in a state of relaxation.

Hence it follows, that this bandage fulfils extremely well the conditions laid down (18), and that it ought to be preferred to all the others (19 ... 25), which answered the indications only in part.

37. Whatever may be the advantages of this bandage over the others, it must still be acknowledged to have its inconveniences. The rollers become relaxed in a short time; their compression is less active; the muscles, being less confined, contract more readily; hence the necessity of frequently repeating the application of the apparatus, a circumstance which is very troublesome, on account of the roller which composes it, and covers the whole limb. The resistance of it even when it is recently applied, is not always equal to the power of the muscles, whence the most assiduous attention is necessary, to obtain such a consolidation as to leave no trace of the fracture behind. Few persons ever possessed, like Desault, the art of overlooking nothing that might in any way contribute to the success of his treatment: from this, no less than from the excellence of his processes, arose the number of his cures. Let us confirm, by a few examples selected from among a great many, the doctrine here laid down. The following cases were collected by Julian and Bezard.

CASE I. Francis Leclert, of a sanguine temperament, fell on the 7th of October, 1790, on his right knee, and produced a transverse fracture of the rotula. He was not able to rise; he was carried home, where a surgeon, on discovering the nature of his disease, advised him to be taken to the Hotel-Dieu.

He was conveyed thither on the day following, and, in the interval, a considerable swelling had occurred around the joint. The usual bandage was employed; the pains ceased immediately after its application; a copious blood-letting was directed, and a low diet was prescribed.

The whole apparatus was wet with vegeto-mineral water, two or three times a day. On the next day some light food was allowed, and the quantity increased by degrees, till in a short time the patient returned to his usual regimen. Eighth day, the swelling being almost gone, the bandage had become relaxed it was therefore reapplied. Every day the inclined plain formed by the bolsters was carefully examined, and put in order again as often as it became deranged.

Fifteenth day, a new application of the apparatus: twentieth day, an evacuation in consequence of a bilious disposition. Nothing particular occurred from this time till the completion of the cure, which took place on the sixty-seventh day after the accident: no depression existed at the place of the fracture: the motions were perfectly free; these were aided, by daily exercising the knee joint for some time.

CASE II. Vincent Grenier, aged thirty-eight, making a false step, fell on the rotula, and fractured it, on the 6th of June, 1791: he was brought to the Hotel-Dieu, where Desault demonstrated to his pupils, by the usual signs the existence of the disease: a considerable swelling had already taken place. The bandage formerly described was applied: the same precaution as in the preceding case; apparatus examined every day; renewed as often as relaxed; extension maintained with great exactness. On the forty-fifth day, the consolidation was nearly effected; on the fifty-second it was complete, the joint was exercised for some time, and on the seventy-seventh day the cure being in all respects complete, the patient was discharged.

MEMOIR XIV.

ON THE FORMATION OF FOREIGN BODIES IN THE JOINT OF THE KNEE.

1. The history of foreign bodies divides itself naturally into two great sections; the one includes those that are introduced from without; the other such as are formed within our own systems. This latter section may be again divided into two classes; to the first class belong bodies altogether inorganic, such as the different kinds of stones; to the second, those which are truly organic, and become foreign only by being situated in places where they impede the functions, such as cartilaginous or bony productions, existing accidentally within the joints.

On the subject of the latter class, art is much more deficient than she is with regard to the former. Let us endeavour to assist her a little, by giving a sketch of the opinions and practice of Desault with respect to these productions.

2. Before his time, the surgery of France appears to have contained scarcely a record of this affection. Described only in some ancient works, such as the writings of Pare, it had been forgotten by the moderns, when numerous instances of it were suddenly met with by English and German surgeons, and soon afterwards by Desault, who illustrated and confirmed the practice of his predecessors in it, and even added something of his own.

3. All the joints may become the seat of these concretions; Haller found many of them in that of the lower jaw; Bell mentions, as a very rare occurrence, their existence at the junction of the foot with the leg. Some authors have met with them in the wrist; but none are more common, or merit more particular attention, than those that exist in the joint of the knee. To these alone shall the following observations be confined, because these alone have fallen under the notice of Desault.

§ II.

OF THE VARIETIES.

4. Concretions of the joints do not always assume the same aspect. They vary greatly as to number, size, figure, structure, &c. In general, these bodies exist singly; sometimes, however, two of them are found in the same joint, and then they may be extracted either at the same time, or in succession, as was once done by Desault. Some English surgeons have also met with two concretions, and Morgagni has found even twenty-five, in the same joint.

5. They vary also in size. The largest ever met with by Desault, was fourteen lines in its longest, and ten in its shortest diameter. Six lines diameter in every direction, was the measure of the smallest one that occurred in his practice.

6. Their figure is sometimes lenticular and smooth on both sides, sometimes unequal, rough in one part, even in another, concave on one side, convex on the opposite, sometimes marked around the circumference and sometimes not with reddish points, and having occasionally a stem of a cellular texture and of some length, as may be seen in a paper by Theden. They usually consist of a single mass, but are in some cases divided into several lobules united by a kind of ligaments, as in the fourth case related in the Journal of Surgery. Though most frequently detached and floating in the interior of the joint, they have yet been found adhering by means of small portions of cellular substance, loose and capable of being stretched, or tight, hard, and even of a ligamentous nature.

7. If, from the external figure, we pass to the structure of these bodies, we will find them existing in three different states. Sometimes purely cartilaginous, sometimes completely bony, they at other times partake of both these states, in which case a bony nucleus is covered with a cartilaginous crust. Out of five cases, recorded by Desault, three are of the first, and two of the third kind. Many authors have met with the second kind, particularly Morgagni, who has even found in the same joint, some bodies of a bony and others of a cartilaginous nature. Hence it appears, that this variety of structure is to be attributed to the longer or shorter standing of the disease, that every concretion must pass successively through these three states, and that there is a great analogy between the formation of such bodies and natural ossification.

8. If we examine a body of the third kind cut in two through the middle, we will find it red and vascular in the centre, like an epiphysis, even when it is floating in the joint perfectly loose and free from adhesion.

9. Bell, in his treatise on surgery, speaks of a kind of tumour, at first soft, membranous, and adhering to the internal surface of the capsule, but which, according to him, may become afterwards hard and solid, and be detached so as to float loose in the joint. But are not these tumours different in their nature from those destined to be converted into bone? Do they, in fact, ever undergo the changes mentioned by Bell? Desault having never met with any of them, was unable to offer an opinion on the subject. In the mean time, an observation made by Monro, may serve to throw some light on the question: he once saw, in one of these productions, a cellular nucleus surrounded by a covering of bone.

10. Though usually simple and free from complication, this affection may, according to some authors, give rise occasionally to a dropsy in the joint. Pare is the first who has made mention of this: he found one of these bodies in a patient’s knee, into which he had made an incision for the purpose of drawing off a collection of water. Simson, on extracting a similar body, gave vent to four ounces of water. But, as on the one hand, a dropsy of a joint oftentimes exists without these foreign bodies; so, on the other, these bodies are almost always found disconnected from dropsy. Nor is there any affinity between the acknowledged causes of an accumulation of synovia, and the presence of these bodies; so that when the two diseases do exist together, it is altogether probable, that they are independent of each other.

§ III.

OF THE CAUSES.

11. The formation of articular concretions succeeds frequently to blows or falls received on the joint, in which case, a swelling more or less considerable in the surrounding soft parts, showing itself from the first, and remaining for some time, at length allows the foreign body to be perceived, and does not, in general, disappear during the continuance of the body in the part.

12. Sometimes no external injury contributes to the formation of the body, and then, a spontaneous swelling precedes its detection, as Desault observed in two patients, where nothing was known to have concurred in the production of the disease. Constant rest increases this swelling, while exercise and a temperate mode of life diminish it.

13. But what can be the immediate cause of these tumours? Are they, as some allege, an aggregation or crystallization of particles of matter conveyed into the interior of the joint by the synovia, in the same manner as the rudiments of a stone are conveyed into the bladder by the urine? Their organic appearance and the vessels that pervade them, are unfavourable to such an opinion. Can they be, agreeably to the conjecture of Theden, articular glands bruised by means of strokes or falls? Or are they, as some authors will have it, portions of the cartilage of the joint, detached by the same causes? How then will their spontaneous formation be explained?

But why trouble ourselves about the cause, provided we can remedy the effects? Nature conceals from us the means, and discloses to us nothing but the results. Theories are fluctuating; but experience is still the same: let us search, then, by an attention to facts, for that which we cannot learn from first principles.

§ IV.

OF THE SIGNS.

14. The phenomena which announce the presence of foreign bodies in the joint of the knee, are sometimes clothed in a character of such evidence, that they cannot be mistaken; at other times, the nature of the disease eludes the most accurate researches: the cause of this variety may be easily perceived.

As the joint presents different depressions and eminences, and as the bodies, being usually loose and detached, may travel through its whole extent, they produce different effects, according to the particular situations which they occupy. If lodged in a depression, they are not compressed, and cannot, of course, give rise to any troublesome affection. If they bear on an eminence, such as the condyls, or the posterior part of the rotula, they are forcibly compressed, and must derange, in some measure, the functions of the joint. Hence the precise nature of the affection cannot be at all times derived from the state of the symptoms.

15. Sometimes the patient can stand and walk with perfect freedom and ease, while, at other times, a sudden pain seizing him, obliges him to sit down, or even causes him to fall, if there be nothing at hand to support him. This pain subsists for a longer or shorter time. One motion produces it, and sometimes another, made in an opposite direction, removes it. But in common it is of some continuance, and then the patient is obliged to keep his bed.

16. If the state of the joint be examined, it will be found more or less swollen, when the pain is very acute. When the pain ceases, the swelling in part disappears. It is never sufficient to prevent the fingers, when drawn along the external surface of the joint, from discovering the presence of the foreign body, when it forms a protuberance under the integuments. It is then found sometimes above the rotula, by the side of the tendon of the extensor muscles, and that is the place where it usually produces least pain; at other times, it is lower down, in front of the condyls, and by the side of the rotula. It is occasionally found immediately behind the tendon of the extensor muscles; in this case so acute is the pain, that the patient is generally unable to stand. But it is when it is situated behind the rotula, near to the projecting ridge which runs across its posterior surface, that it gives rise to the most serious affections.

17. The body passes from one place to another, on the least motion, and sometimes, as Bell observes, the patient, on changing his position during sleep, is awakened by severe pain, in consequence of the foreign body being moved by this change. It happens, in certain cases, that it disappears, and lies concealed for some time, in the back part of the joint. During this period the joint performs all its functions with freedom and ease. Desault made this remark, in the case of a captain of dragoons, from whom, for the first time in his practice, he extracted one of these bodies, and who, for six months previously, had been able to perform all the motions of the joint freely, without pain. This person, experiencing no uneasiness, considered himself perfectly cured, when the body suddenly reappeared, in consequence of a hasty extension of the leg.

18. If the body, when projecting under the integuments, be gently compressed, it yields to the pressure, changes its situation, and, according to the impression it has received, moves either to the internal or the external side of the joint, or reciprocally from one side to the other, passing also behind the rotula, behind the inferior ligament, or sometimes behind the tendon of the extensor muscles. In these alternate displacements, it may in some cases be turned round, in such a manner that its anterior surface will take the place of its posterior one, and then resume its primitive situation. Desault met with an instance, in which the patient himself was in the habit of turning the body round in this manner.

19. Bell, in conformity to the distinction of articular concretions into cellular and solid, attributes to each division its peculiar signs. In the first case, the pains, being rather obtuse than sharp, are constant; in the second, they are extremely acute, but disappear and return at intervals. Supposing the division to be a real one, cases of the last description certainly occur much more frequently than those of the first.

§ V.

OF THE TREATMENT.

20. From what has been said it follows, 1st, that these cartilages floating through the joints, do mischief mechanically (14), by coming into contact with the articular surfaces: 2dly, that to obviate this mischief, it is necessary either to prevent their contact, by fixing the bodies in a spacious part of the joint, and thus doing constantly what nature does on certain occasions, or to extract them through an opening made into the articular cavity.

21. Hence, art can have recourse to but two methods of cure, all hope of discussing these tumours by external applications being, as Bell observes, entirely extinguished.

22. The first method was proposed by Middleton and Gooch, who having brought the foreign body into a situation where it produced no pain, endeavoured to confine it there a length of time sufficient to make it form adhesions with the corresponding part of the capsule. As we are not informed of the result of the experiments of these two physicians, we are left to our own conjectures on the subject.

23. Are these foreign bodies capable of forming adhesions? Supposing they are, will the internal surface of the capsule attach itself to them at the pleasure of the surgeon? Even admitting the existence of both these conditions, by what means can the bodies be kept stationary for a length of time sufficient for the formation of these adhesions? Will they not be displaced by the slightest motion? Besides, experience seems to be unfavourable to the expedient. I have already said (17) that, in a certain case, the foreign body disappeared for six months, remaining, no doubt, during that whole time, in the same place: but, if it could not, on that occasion, form adhesions, if a motion was sufficient to produce its reappearance, can we expect that art will be more fortunate in her attempts?

24. But, even admitting that the foreign body does form these adhesions with the capsule, if it should increase in size in the part of the joint which it occupies, becoming in a short time disproportioned to its extent, it will impede motion as before, and produce, by degrees, nearly the same affections.

25. From these considerations it follows, that the only expedient which can promise a radical cure is, the extraction of the foreign body. In the performance of this extraction, an incision must first be made through the integuments and the capsule.

26. This operation, simple and easy in itself, has given rise to apprehensions as to its consequences, which have long prevented practitioners from undertaking it.

It was in former times a maxim in surgery, that wounds of the joints are, if not mortal, at least extremely dangerous, in consequence of their admitting air into contact with the articulating surfaces. But observation has demonstrated the fallacy of this doctrine, and Desault in particular, has thrown great light on the subject, as I have frequently had occasion to mention in the course of this work: so that, at the present day, it is clearly ascertained, that, if judiciously treated, these wounds are seldom productive of serious consequences.

27. Hence it follows, that the operation we are considering, when skilfully performed, never gives rise to any dangerous or disagreeable affections. Experience has proved the truth of this assertion in the practice of Theden, Simson, Gooch, Broomfield, Bell, and Desault, the latter of whom performed the operation five times with complete success. The only case in which he was less fortunate, was that of a man, in whom the wound of the integuments closed up at first without any accident, but which was succeeded by two abscesses, one in the thigh, and the other in the leg, but without any affection of the interior of the joint. This patient was subject to a wandering rheumatism, which oftentimes attacked the lower extremities, and was perhaps in the present case the chief cause of the unfavourable occurrences.

28. It is to the English that we are indebted for the first operation performed for the extraction of these bodies. An account of this is given in the Transactions of a society in Edinburgh. Since that, the operation has been frequently repeated, and more than ten instances of it were already on record, when Desault first performed it in France. His method, somewhat different from that of others, was as follows.

1st, The patient must be laid on a bed, or seated on a high chair. The first position, however, is to be preferred, because when it is adopted, the patient need not be moved after the operation.

2dly, The leg is extended on the thigh, in order to relax the anterior part of the capsule of the joint.

3dly, The surgeon then searches for the foreign body, moves it to the internal side of the joint, against the attachment of the capsule, and secures it between his thumb and the fore-finger of his left hand, while an assistant draws the skin over the fore part of the rotula.

4thly, Taking then a common bistoury, he makes, on the protuberance formed by the body, a longitudinal incision of an extent proportioned to its size, through both the integuments and the capsule, so as to lay the body bare at the first stroke.

5thly, Sometimes the body escapes immediately of its own accord, in consequence of the compression made on it by the fingers. If its passage out be not spontaneous, a small scoop or a taper-pointed spatula passed under it, answers the purpose of extracting it. But, in the introduction of these instruments, it is necessary to avoid touching the articulating surfaces with their ends, lest, by being irritated, they might swell, and give rise to troublesome accidents.

6. If any resistance be met with, enlarge the opening and the extraction will become easy. Without this precaution, the edges of the wound, being bruised and irritated by the passage of the body, will swell, inflame, and unite again with difficulty.

7. When the extraction is finished, the assistant who draws the skin towards the inside of the joint, suddenly lets it go, when it returns to its natural situation. This causes the two incisions, which corresponded, at the time of the operation, to change their relative situation, the one remaining internal and the other becoming external.

8. Hence arises a twofold advantage; the entrance of air into the interior of the joint is prevented, and the external and loose portion of the capsule, being drawn inwards with the skin, unites with the condyl, if it be not brought into exact apposition with the other portion of the capsule, divided near its attachment.

9. The extraction being finished, it is then necessary to examine carefully, in order to ascertain whether or not the joint contain any more of these foreign bodies. On some occasions, when this is even the case, they cannot at the time be discovered. Desault himself was once deceived on this score, in consequence of which his patient was obliged to submit to a second operation.

10. The incision in the integuments is now united by means of adhesive plaster. Over this are laid compresses and a little lint, and the whole secured by a few turns of a roller drawn moderately tight.

11. The leg being then placed on a pillow, is kept in a state of extension, by means of a splint applied, for a few days, behind the joint.

29. If we examine but for a moment the process in this operation, we must perceive, that an incision made through the skin and capsule at a single stroke, is, in no respect, less advantageous than one made at two strokes, as recommended by all practitioners, and that, it is in the following respects greatly preferable to it: 1st, it shortens the operation very considerably: 2dly, it diminishes the pain: 3dly, it exposes the joint a much shorter time to the contact of the air.

30. The object of the operator is better answered by drawing the skin outward and towards the rotula, than by either depressing it, as Broomfield did, or raising it, as Bell does. Being more loose and more easily stretched in this direction, the opening in it is removed farther from that in the capsule, which prevents more certainly the access of air to the joint, and also favours the examination of the capsule.

31. In the mean time, the operation may succeed, even although the openings in the integuments and the capsule correspond to each other. Many English and German practitioners, without previously stretching and changing the natural situation of the skin, make a common incision, which they dress afterwards like a simple wound, and are yet no less successful than others in the result of their operations. This is a further proof of the fallacy of the ancient surgical doctrine, respecting the admission of air into the cavities of joints. Perhaps Desault might have omitted this precaution, had any operations of the kind occurred in his practice during the last years of his life.

32. The operation is seldom attended with much pain. Only one patient manifested signs of this in the practice of Desault. Nor have those operations of the kind performed in England been more painful, so that it may be laid down as a principle, that in most cases no primitive accident is to be dreaded.

33. With regard to hemorrhagy, as there is no large artery near the place of the incision, there is nothing to be apprehended on that score. Oftentimes there is scarcely any loss of blood at all, as may be seen in the first case published in the Journal of Surgery. But, even admitting that a small articular branch be divided, the reunion of the edges of the wound will be sufficient to check the hemorrhagy, in the same manner as in the operation for the hare-lip, the contact of the divided integuments of the lip, puts an end to the hemorrhagy from the small arteries of the part.

§ XIV.

OF THE SUBSEQUENT TREATMENT.

34. I have already said that but little is to be apprehended on the score of accidents subsequent to the operation (26). Out of the numerous operations of the kind performed lately in Europe, but few cases have proved troublesome in their consequences, and even these were influenced by some foreign circumstances. Thus, for example, one of the patients of Simson rode out on horseback a few hours after the operation, on a cold and stormy day, and thus produced a troublesome affection of the part. A similar remark may be made respecting the case formerly mentioned (27).

35. The apparatus or dressing remains untouched for the two or three first days, during which time it is necessary to wet it frequently with vegeto-mineral water. It is a certain truth, that the use of this liquid retards the suppuration of wounds, and that, when continued a due length of time, it keeps inflammation at that degree most proper for the process of healing.

36. On the removal of the dressing, the wound is sometimes so perfectly healed up, as not to exhibit the least discharge. At other times a slight suppuration takes place; but, at the end of a few days, the cure is complete. Under the care of Desault, it was always effected in eight or ten days.

37. Let us bring the doctrine just laid down to the test of experience. Five cases have been published on this point. I have selected two of them, both which occurred in the same subject, where we find the same operation twice performed with equal success.

CASE I. M. Vielle, aged nineteen, was attacked about the beginning of the year 1790, by a spontaneous swelling in the joint of the knee. Inconsiderable at first, but increased afterwards by a laborious journey, it disappeared at the end of two months, discovering to the touch, near the internal edge of the rotula, a foreign body, which was hard and moveable, and which somewhat impeded the motions of the joint.