39. If to these indications we compare the mode of action of the
different pieces that unite in composing our common forms of apparatus
which do not make permanent extension, such as common bandages,
splints, compresses, bolsters, &c. we will perceive that they are
but ill calculated to fulfil them: and first of bandages. Whether
the common roller, or the eighteen-tailed bandage be employed,
their mode of operation is the same: their only action is, to add a
second exterior and artificial covering to the natural cutaneous and
aponeurotic covering of the thigh; to press against the fragments
the muscles which form for them a kind of natural case intended
to keep them in apposition; and to augment, by this pressure, the
lateral resistance of the soft parts. By this contrivance, lateral
displacements will, in part, be well guarded against, and, in this
respect, these bandages are useful in transverse fractures. But what
is there in them to prevent the two inclined plains of an oblique
fracture from sliding on each other? What provision is there in them
to secure the limb from the effects of motions and shocks which may
be accidentally impressed on it from without? Will the pelvis be kept
steady by them? or will muscular action be sufficiently checked and
kept under by them? The force of the muscles will indeed be slightly
diminished by means of compression; and to make this compression is
the principal use of these bandages in oblique fractures. But will mere
compression be sufficient to prevent a displacement in the longitudinal
direction of the bone, particularly if the rollers be slack, as certain
practitioners recommend, on the ground of the fallacious theory of
Duhamel, who conceived, that a constriction too tight, would injure the
action of the periosteum, which, according to him, is the sole agent
in the formation of callus? So much, then, for bandages, whose only
use is to prevent, by compression, the swelling of the limb, and to
diminish, in some degree, the contraction of the muscles, which they
press against the fractured bone.
40. These remarks apply equally well to the use of compresses; which
make but a very feeble resistance against a powerful cause, and cannot
be considered as any obstacle whatever to displacement. What can be
said of those surgeons who, from servile attachment to a particular
form of apparatus, do not consider a fracture as reduced, unless a
certain quantity of compress secured by a given quantity of roller, be
applied on the limb. Servile imitators in an art which calls for genius
in its votaries, they are only capable of following, without reflection
or judgment, the steps of their predecessors.
41. Bandages will do nearly as much harm as good in fractures of the
os femoris, if, as was practised by the ancients, they be formed
by a single roller surrounding the limb: in such a case, the limb
being necessarily raised up at each time of their reapplication,
will be exposed to continual displacements. Hence the ingenious
idea of applying to simple fractures of the lower extremities the
eighteen-tailed bandage, invented for compound fractures, and by means
of which the thigh may be suffered to remain at rest. But to this
bandage belongs also an inconvenience. The pieces which compose it,
being stitched together, cannot be separated, and if one of them be
soiled they must all be changed. Hence the superiority of the bandage
of slips, known in former times, and engraved by Scultel, but long
since forgotten, till Desault revived the use of it, and adopted it
exclusively, both in simple and in compound fractures.
42. Splints of different kinds, which form the second division of the
pieces of apparatus, used for fractures of the os femoris, have the
advantage of fixing the limb in a solid and firm manner, and securing
it from any displacement that might result from jolts, or muscular
contraction, arising from the inattention of patients: these prevent,
more effectually than bandages, any displacement laterally, and, on
this account, their use is sufficient, even without extension, in
transverse fractures: they also prevent, particularly if they be made
of wood, the rotatory motion of the thigh either outwards or inwards
(18). But if the division be oblique, will they prevent the gliding of
the fragments over one another, and the consequent shortening of the
limb? They can evidently produce this effect in no other way, than by
the forcible pressure made by the pieces of apparatus, particularly
by the straps or bandages that secure the splints, and then, to
make effectual resistance, it would be necessary to apply them with
such a degree of tightness as would endanger the life of the limb.
Will splints prevent the trunk from sinking downwards, and pushing
the superior fragment before it? Will they prevent the muscles from
acting on the lower fragment? Can they, in a word, fulfil all the
indications formerly pointed out (28)? Certainly they cannot. Splints,
then, are calculated only to prevent displacement in the lateral or
cross direction of the bone, and to secure, better than bandages, the
immobility of the limb. Whence it follows, that they ought not, in
this case, to be confined to the thigh alone, but should extend to the
leg, whose movements, if communicated to the os femoris, may derange
the contact of the ends of the bone. The neglect of this precaution,
contributed formerly not a little to displacement and deformity.
43. In former times a kind of splints was in use, which were made by
securing bundles of straw round sticks proportioned in length to the
length of the limb to which they were to be applied. But as these,
from being of a round or cylindrical form, touched the limb with but
a narrow surface, they did not retain the fracture with sufficient
firmness. They were, therefore, very properly exchanged for flat and
strong wooden splints, (such as Desault used) which retain the fracture
much better, in consequence of presenting to the limb a broad surface,
and thereby rendering it in some measure immoveable.
44. The bolsters for filling up interstices, being less intended to
prevent displacement, (in which respect they are, notwithstanding
useful) than to guard the limb from the immediate pressure of the
splints, usually consist of several folds of old linen; this is the
form adopted at the Hotel-Dieu; but to these Desault preferred small
pallets or bags filled with chaff, which, fashioned according to the
form and disposition of the limb, may, at the pleasure of the surgeon,
be made thicker or thinner, to suit the inequalities of the surface, in
consequence of the ease with which the chaff may be moved from one part
of the bag to another.
45. From the foregoing examination of the action of bandages and
splints, it appears, that the common apparatus, formed by their union,
but not calculated to effect a permanent extension, may perhaps answer
in cases of transverse fractures, which indeed but rarely occur, but
are always insufficient when the division is oblique, because they
cannot fulfil the double indication of drawing the inferior fragment
down, and retaining the superior one up (38).
§ VIII.