A Course of Lectures ON PAIN, AND THE THERAPEUTIC INFLUENCE OF MECHANICA AND PHYSIOLOGICAL REST IN ACCIDENTS & SURGICAL DISEASES

1862 The Lancet  
INJURY to the medium of union between the shaft and lov piphysis of the femur is not very rare ; and I think, fr what I have seen in private and public practice, that it is pathological state not unfrequently overlooked and the lo symptoms misinterpreted. Any injury to the epiphysis itsE or to the soft tissue uniting it to the shaft of the thigh-hOJ requires the aid of mechanical rest for its relief or cure; a here is a case in point. Disease between the shaft and lower epiphysis of the femur,
more » ... uppuration; abscesses opened ; cured by " rest." Fanny H-, aged ten years, was admitted into my was on April 13th, 1859. 'When three years old she had a f over the end of a bed, which stunned her, and when taken she could not put her right foot to the ground; and the kr became flexed, so that the great toe was two or three incl from the ground. In a short time, however, she became mu improved ; but her father has noticed ever since that time slight weakness in her walking. On April 21st her right was very slightly shortened, say a quarter of an inch; t knee-joint could not be either extended or flexed perfect There was pain on pressing a spot one inch above the knee-joi both on its outer and its inner side; the temperature was mu increased at both points, and some swelling existed there. T upper part of the popliteal space was hard, full, hot, and teni with pain at intervals occarring twice or thrice a day, and la ing about ten minutes. A long straight splint was put the limb, extending from the axilla to the foot; she was order one grain of iodide of potassium with infusion of bark thl times a day, and poppy fomentations to the swollen part. April 23rd.-The long splint could not be borne, and it w removed. 27th.-No improvement. The patient suffers very muc The limb was then placed upon a double inclined iron split and swung. Six leeches applied upon each side of the kne Two grains of mercury with chalk and three grains of .Dove powder to be taken night and morning, and some saline feb fuge during the day. A hemlock poultice was-applied ov the painful part. May 9th.-There is distinct fluctuation of abscess. to felt under the vastus internus, anterior to the tendon of t adductor magnus. An opening was made through the skin aI fascia lata with a lancet; a grooved director was then push, through the vastus internus, and formed a guide to the dressin forceps, which were thus introduced into the abscess, fro which about two ounces of healthy pus quickly flowed. June 7th.-A deep sub-muscular abscess was opened on t] outer side of the knee, and sixteen days subsequently anoth opened of itself in the popliteal space. July 20th. -The leg has been at rest, swinging upon the ire splint, and the knee can now be perfectly straightened, an without pain. There is no distinct swelling, but a little gener thickening of the lower part of the femur immediately abo the knee-joint. The wounds have all closed. The iron splir is to be left off, and a firm leathern splint is to be applied, e as to keep the limb straight and the seat of the disease ut disturbed. This mechanical support was continued throug several weeks, and during that, and for a longer period, st was not allowed to put the foot to the ground in order to bes any weight upon it. She ultimately got quite well, without an untoward symptom. I have no doubt that this was a case of disease between the shaft and epiphysis of the femur resulting from injury to, an inflammation of, the sofc medium of union between these tw portions of the bone. Disease of this part is not, I think, ofte referred to, but I am convinced it is not of unfrequent occui rence. !. I bad intended to adduce some facts tending to prove th2 one kind of loose cartilage may be absorbed from the kne! joiur, by retaining the loose cartilage accurately at rest in cot tact with the same part of the synovial membrane during severa r weeks, and by employing counter-irritation over it ab. th same time. 1 think 1 might be able to sustain that propos tion, but time will not permit me at present. I am anxious to impress upon the profession generally m 1 strong conviction that in all cases of accidental injury or ( infl.t,mmation of the knee-joint, as well as in every disease ( . this articulation, the knee should be kept uninterruptedly a rest and straight, or nearly so, until its reparation is complete for I believe that as soon as sufficient importance is given t such views we shall cease to witness those nnmerous and extra ordinary deformities about the knee-joilit, resulting entirelyfrom the want of mechanical resistance to that muscular force, whic induces excessive bending of the tibia backwards, or a disloca tion of the tibia and fibula outwards and backwards, of whic you may find so many specimens in the metropolitan an other pathological museums. A fixed rigid splint will eertainl prevent such deformities-I feel positive about it-provide, e the splint be sufficiently resisting. A gutta percha splint wi s not accomplish it, not being sufficiently strong. A firm padded splint of leather, wood, or iron ought to be placed alon the posterior and lateral part of the joint; and I may add tha in all such cases it is advisable that the limb be swung, as i = cases of fractures of the leg. During many years past I hav swung nearly all my cases of acute disease of the knee-joint . and I have found it contribute immensely to the comfort of th t patient. Here are two or three cases in illustration of the deformit; which ensues from the non-employment of mechanical rc'sistanc to disturbing muscular force, and of the method of proceeding to be adopted in order to remedy the deformity which may hav occurred. Case of diseased knee joint; the knee ,flexed, and the tibia par tiall dislocated backwards; the biceps tendon divided, ayu the limb straightened; cured by " mechanical rest. " A young lady, J. M -----, when she was two years old had fall upon her right knee, and she suffered afterwards fron symptoms of acute inflammation of the joint, followed by con traction of the ham-string muscles, and extreme flexure of thi ' knee. Two abscesses, one ia the popliteal region, and one abov, the knee, were associated with this diseased joint. She has no ! been able to walk without crutches since the accident, ha, . employed very inconvenient instruments for the purpose o . putting the leg straight, and thinks she received more hartr than good from their application. On March 29th, 1860, sh, came under my care in Guy's Hospital; she was then eighteet years old. When standing upon the left leg, the heel of thE right foot was between four and five inches above the ground. . The patella was fixed firmly by bone to the femur. C'blorofortr was given by the house-surgeon, and forcible extension wa: employed, but we could not straighten the timb ; The tender ' of the biceps muscle was therefore divided abont one; inc!: before reaching the head of the fibula; forcible extension of the knee was continued, and the limb straightened, after which a straight wooden splint was applied to the limb upon its pos terior aspect. After the operation, ice in a bag was constantly applied to the knee, in order to prevent the occurrence o; any inflammation, and five grains of Dover's powder was ordered to be taken at night. On the 13th of April, within a fortnight of the forcible extension, her leg was straight ; and very comfortable. The splint was constantly applied until May 21st.
doi:10.1016/s0140-6736(02)41847-8 fatcat:sgzhoq7b35c6ja6d66pgqwqk6y