1st, The method employed in the first instance by the Arabians, adopted
afterwards by their successors in medicine, and proposed, at a still
later period, by Petit, Heister, and Duverney, and which consists in
fixing, at the head and foot of the bed, during the whole treatment,
straps intended for the purpose of extension.
2dly, The mode of extension, adopted by many practitioners, which
consisted in suspending to a strap fixed at the knee, and reflected
over some suitable body, a weight proportioned to the power of the
cause which it was intended to combat.
3dly, The ingenious idea of Bruninghausen, who, confining by a kind of
stirrup, the diseased leg against the sound one, made the latter serve
as a splint to retain the fractured limb on its proper line, and thus
preserve its natural length.
4thly, Under this class also must we arrange the means employed by
Desault, and which we will presently describe.
54. The second class of means invented for the purpose of making
permanent extension, in fractures of the thigh, comprehends:
1st, The Glossocome, the bed of Hippocrates,[24] and other machines,
used by the ancients, to effect a reduction, in fractures of the os
femoris, and, at the same time, to maintain the reduction, by being
left on the limb.
[24] (_Le lit d’Hippocrate._) As many of the machines mentioned
here have probably never been seen in this country, and as there
is, perhaps, scarcely one of them used, at present, in any country,
I shall not consume the time of the reader by troubling him with
descriptions of them. TRANS.
2dly, Numerous machines, invented for the purpose of suspending a
weight intended to make extension. These have been differently varied
and modified, more by the imagination than the judgment. Engravings of
some of them are to be found in Scultet, Fabricius of Hilden, Pare, &c.
3dly, The machine of Bellocq, proposed to the Academy of Surgery, a
description of which is contained in their memoirs, and which possesses
an advantage not found in the others, namely, that of taking its point
of extension at the lower part of the leg.
4thly, The machine of Nook, surgeon at Norwich, improved by Aitkin, an
engraving of which is given by Bell.
5thly, A new Glossocome, published in the works of Manne, and a great
number of other machines, the ephemeral offspring of the genius of
their authors, the utility of which experience has seldom confirmed,
and which were even dead-born in the opinion of practitioners. I barely
mention these, because a circumstantial description of them would lead
me from my subject.
55. We may discover at a single glance the comparative merits of
these two classes of apparatus. Extension produced by simple means,
such as straps, splints, &c. (50), may at all times, and under all
circumstances, be had recourse to; because the means necessary for
making it may always and every where be found. Are we desirous, on
the other hand, of having recourse to machines (54)? These are seldom
at hand, and oftentimes not to be obtained: the expense attending the
purchase of them, prevents most surgeons from procuring them. They no
doubt possess the advantage of multiplying forces, and rendering them
more powerful: but, I have already said (51), that a gentle resistance,
if long continued, is sufficient to overcome at length the contraction
of the muscles, though at first extremely active and energetic.
56. In the first point of view, the first class of means is doubtless
preferable to the second. But they both partake generally of the
inconvenience of placing the point of extension above the knee. I have
already mentioned the effects which this produces with respect to
muscular action, at the time of the reduction (28). To the injurious
effects there stated may be added the swelling of the limb, arising
from the compression made by the straps, the disadvantage of the
mobility of the leg, which is not fixed, and the motions of which,
being communicated to the thigh, may separate the fragments after they
have been brought into apposition. Further, the straps may readily
slip down over the knee, and thus leave the fragments subject to the
mischievous influence of muscular contraction.
57. To these general disadvantages, add those peculiar to each form of
apparatus, which are too tedious to be detailed at present, and you
will perceive, that the little success hitherto obtained from continued
extension, is owing, not to the nature of the measure itself, but to
the manner of employing it, and that, in the present case, as in cases
of fractured clavicles, another step towards perfection remained to be
made.
58. Desault, in the first instance, attempted only to improve the
ancient process, which consisted in fixing the straps for extension to
the foot and head of the bed. He remedied the inconvenience of fixing
the straps at the knee, by doing, throughout the whole treatment,
what Fabre and Dupouy did only at the time of reduction (29); that
is, he placed the seat of extension at the foot. The hold for
counter-extension was also changed. This he made by a bandage for the
body, fastened round the breast, and drawn only moderately tight, lest
it might impede the patient’s respiration. The rest of the apparatus
was nearly as I shall presently describe.
59. This was, for a long time, the only apparatus which Desault used.
He introduced it into the Hotel-Dieu, after having employed it at the
hospital of Charity, with great success. In the mean time, the utmost
care and attention were here indispensable: every day it was necessary
to examine the rollers several times, as they readily became relaxed.
The pelvis, not being well secured, could communicate motion to the
fracture: it was difficult to raise the patients to the close-stool.
Besides, the slightest disease of the chest, rendered the pressure
of the body-bandage insupportable. It was this very inconvenience
which, having, in a certain case, rendered the preceding apparatus
inadmissible, suggested to Desault the following one.
60. This consists, to speak in general terms, in taking the points of
extension, above, on the tuberosity of the os ischium of the diseased
side, and below, on the malleoli; in securing the straps or rollers,
destined for making extension, on the two ends of a strong splint,
placed along the outside of the limb; and in converting, so to speak,
the pelvis, the thigh, the leg, and the foot into one entire and solid
piece.
The pieces which compose it are, 1st, A common junk-cloth[25] (FFF
plate II.), accommodated to the size of the limb and the splints:
2dly, a bandage for the body (BB) and one passing under the thigh (H)
to secure the first on the side opposite to the fracture: 3dly, three
stiff splints, an inch and a half wide, the external one of which (AA)
being very strong, must be long enough to extend from the spine of
the ileum, to the distance of four inches below the sole of the foot.
This splint is hollowed out or notched at its lower end, and has a
mortise in it a little higher up. The upper splint (CC) occupies the
space included between the fold of the groin and the upper part of the
knee: and the internal one, which reaches from the upper and internal
fold of the thigh, to the sole of the foot: 4thly, three bolsters, an
external, an internal, and an upper one (d d d d) consisting of small
bags of chaff: 5thly, a bandage of strips (E) accommodated as to number
to the circumstances of the case, separate from one another, each three
inches broad, and long enough to go twice round the limb, arranged from
below upwards, and overlapping each other, about one third of their
breadth: 6thly, one long and two circular compresses, intended to be
applied immediately on the limb next to the skin: 7thly, two strong
rollers (g g and L) intended for extension and counter-extension, at
least an ell and a half long: 8thly, one long and thick compress, and a
sufficient number of bits of tape.
[25] (_Drap-fanon._) This is a piece of linen or muslin (Desault
appears to have used flannel, which is not however so good) spread
under the broken limb, reaching in length from one end of it to
the other, and wide enough to go about twice round it. It is to
be folded at its edges several times round the internal and the
long external splints, in order to retain them the better, and
make them bear with more steadiness and advantage on the limb. The
junk-cloth and these two splints, when properly applied, form a
kind of soft elastic case, in which the limb rests. This case is of
service in securing the bolsters in their places. The junk-cloth is
the outside piece of the apparatus, except the bits of tape which
go round and secure the whole. In arranging the different pieces,
therefore, on the bed or mattress, where the patient is to lie, the
surgeon places the tapes first, the junk-cloth next, the bandage of
strips next, and so on, in an order the reverse of that in which he
afterwards applies them on the limb. TRANS.
61. Every thing being ready, previously to putting the patient to bed,
the pieces of apparatus are to be arranged on that part of the bed
corresponding to the fractured thigh, in the order in which they are
to be successively applied. If the patient has been already laid in
the place where he is to remain, the limb must be raised with great
caution, and, during the extension, each piece gently slipped under it,
or the whole must be passed under at once, being first rolled round the
several splints, in such a manner, that the apparatus requires only to
be opened.
62. Extension is now made in the mode already pointed out (29 and 30),
and then the application of the apparatus is begun, for which the
surgeon must be situated on the external side of the fractured thigh,
while an aid, placed on the other side, gives him assistance.
1st, On the thigh, next to the skin, are first applied the long and
circular compresses, accurately spread out so as to have no wrinkles
in them, and previously wet with vegeto-mineral water. Around it are
then applied, in succession and from below upwards, each strip of the
bandage (EE) moderately tight.
2dly, The lower end of the leg is now covered with a thick compress,
intended to prevent the impression of the roller (L), which is fixed
in such a manner, that its middle is first laid on the tendo Achillis,
a little above the heel, while its two ends, crossing each other on
the upper part of the foot, are carried on each side to its sole,
where crossing again, they are then laid down till the close of the
application of the apparatus.
3dly, Along the thigh are placed laterally two bolsters, which, from
their thickness being easily increased or diminished in consequence of
the moveable nature of the chaff, mould themselves to the inequalities
of the limb.
4thly, Around the two lateral splints, the surgeon and his assistant
roll, each on his respective side, the two edges of the junk-cloth, so
that both splints, by being accurately applied on the bolsters, may
make a uniform compression on the whole part.
5thly, The third bolster (d d d d) is then applied on the anterior part
of the limb, and over it the splint (CC).
6. The bits of tape passed under the apparatus to the number of four
for the thigh, and three for the leg, are tied in succession on the
external splint, lest the knots, should they correspond to the thigh,
might, by their contact, prove troublesome. That one next to the
fracture is tied first, and they are all drawn as tight as the patient
can bear them without uneasiness.
7. The body-bandage is now fixed on the pelvis, in such a manner, as
to secure laterally the external splint, and is itself retained by the
sub-femoral bandage (H), that is, the bandage passing under the thigh.
8. A thick compress placed beneath the tuberosity of the ischium,
serves as a cushion or bolster to protect the part from the pressure
of the roller (g g) which, being passed first under the apparatus,
and drawn afterwards obliquely from within outwards, and from above
downwards, takes its points of bearing or action, in one part, on the
tuberosity of the ischium, and in the other, on the upper end of the
external splint, and is tied in the fold or hollow of the groin.
9. The two ends of the bandage (L) previously made to cross each other
on the sole of the foot, are passed the one through the mortise, and
the other through the hollow or notch in the lower end of the same
splint, and then, being drawn forcibly, are tied in a firm knot, so as
to act as a substitute for the hands of the assistant, who now lets go
the patient’s foot.
10. If the roller (g g) become relaxed, it is tightened again, and the
patient being laid in a suitable position, the limb is protected from
the pressure of the bed clothes, by a kind of basket placed over it.
11. A roller (K k) laid first on the sole of the foot, and then brought
across over its upper side, and fastened laterally to each splint,
serves to secure that part from turning outward or inward, and thus
prevents the rotation of the limb.
63. If the mode of operation of this bandage be compared with the
general indications formerly established (38) for all oblique fractures
of the os femoris, it will be easy to perceive that, conformably
to those indications, it tends, 1st, to draw the inferior fragment
downward; 2dly, to retain the superior one up; 3dly, and to prevent the
rotation of the lower fragment, and secure the immobility of the limb.
64. It is evident that the bandage or roller (g g) so unites the
pelvis to the external splint (AA), that the latter cannot be pushed
upwards, without drawing the former in the same direction, as well as
the superior fragment which adheres to it. But if, after this roller
is fixed, the lower one (L) be tightened, the first effect produced
is, to push the external splint forcibly upwards; the second, to draw
the leg, and with it the inferior fragment downwards; so that, by
fixing the roller (L) in the notch and mortise of the splint with the
necessary degree of tightness, extension and counter-extension are made
permanent. By this means the muscles, being kept on a stretch, lose by
degrees their power of contraction, which is still further diminished,
by the immoveable state in which they are kept, and by the compression
made on them by the bandage of strips. So that, on the one hand, the
inferior fragment will have no tendency to rise upwards, and even if it
had, it will meet with a sufficient resistance to prevent it; while, on
the other hand, the superior fragment will not be pushed downwards by
the pelvis.
65. To this advantage is added that of a state of perfect immobility.
The pelvis, the leg, the thigh, and the foot being firmly fixed on the
external splint, constitute one entire whole, all the parts of which
must retain, with respect to each other, the same relative position.
Should even a stroke be accidentally given to this assemblage of parts
now converted into a solid whole, each portion of it will move at the
same time, there will be no partial motion, and the relative position
of the parts will not be changed. Hence the advantage of being able to
raise the patient without apprehension; a most desirable circumstance
indeed, in a position so painful and so long continued (26). The
external splint, being extended beyond the sole of the foot, prevents
the lower fragment from obeying a tendency, which it sometimes has,
to displace itself by a rotation on its axis. Should this tendency
be towards the internal side, an occurrence much more rare, the
lengthening of the internal splint will effectually prevent it.
66. These considerations induced Desault to renounce his ancient
mode of making permanent extension, and employ this exclusively, in
the latter years of his practice. Like all other kinds of apparatus,
formed principally of rollers, this is very subject to become relaxed;
and requires, therefore, great attention on the part of the surgeon.
It ought to be examined attentively every day, particularly the two
extending bandages (L and g g). As soon as they become relaxed, they
must be immediately tightened again: without this precaution, the
effect of the apparatus will be lost. Be vigilant also, with respect to
the compress placed between the roller (g g) and the tuberosity of the
ischium. Should this slip, the roller being frequently tightened, and
pressing immediately on the skin, may produce excoriations and ulcers
difficult to be healed, particularly in females. The roller itself may
slip, and then, having no longer a solid point of support and action on
the tuberosity of the ischium, it makes extension in but an imperfect
manner.
67. One of the charges brought against this apparatus is, the facility
with which the upper roller becomes displaced, a facility that imposes
a degree of care and attention, of which few surgeons are capable, and
which, when bestowed even by Desault himself, did not always prevent
the shortening of the limb.
68. Further, the extension made on the fold of the thigh, partakes,
a little, of the inconvenience that accompanied the ancient mode of
reduction, namely, that of compressing and irritating the muscles of
the upper and internal part of the thigh (30). This inconvenience would
be still more sensible, if, for want of extending to a sufficient
distance up the pelvis, the upper splint should allow the roller to
cross the muscles at an angle somewhat acute, as it would then enclose
and press on the greater part of them.
69. If some unfavourable cases, resulting without doubt from these
inconveniences, did occur in the practice of Desault, a multitude
of successful ones still attest the advantages of this method; and
there is not a pupil who attended any time at the Hotel-Dieu, without
witnessing them. I will relate but one case, collected by Chorin, to
furnish a detail of the treatment subsequent to reduction, referring
the reader for further information to the Journal of Surgery.
CASE II. Theresa Little-John, aged 45 years, fell, drawn by the weight
of her own body, through a window in a balcony, from which she was
leaning. She was instantly taken up, carried to her own house, and from
thence to the Hotel-Dieu, which she entered on the 28th of October,
1790. From the signs mentioned (9), a fracture was discovered towards
the lower part of the thigh; its oblique disposition required an
apparatus to make permanent extension. This was applied in the usual
manner, and, in an instant, the patient, who had experienced, since her
fall, severe pain, became calm, and was completely relieved.
In the night, pains returned; agitation; some spasmodic motions; an
anodyne draught administered in the morning. In the course of the
day, these troublesome symptoms disappear; a slight swelling at the
ancle. Third day, no pain; swelling gone; aliment increased. Sixth
day, patient permitted to return to her usual regimen; extending
rollers relaxed; lower one tightened: eleventh day, apparatus renewed;
fragments in perfect contact: thirteenth day, limb moved incautiously;
a slight shortening; apparatus reapplied; extending bandages drawn
tight: sixteenth day, a disposition slightly bilious; evacuants
administered with success: twenty-fourth day, a third application of
the bandage: thirtieth day, progress in consolidation already very
evident; the limb straight: fortieth day, extending rollers laid aside:
fifty-second day, consolidation complete without the least deformity.
70. The muscular force, in children, being weak, and the weight
of the body inconsiderable, have, in general, much less influence
in producing a displacement in them than they do in adults. When,
therefore, fractures occur in subjects under six or seven years old,
the resistance, on the part of the apparatus, need not be so great. In
general the lateral pressure which it makes, and the bearing of its
different pieces against the limb, are sufficient to prevent the return
of deformity, when this has been perfectly removed by reduction.
71. In such cases Desault covered the thigh with a circular bandage,
made of a roller seven ells long, and three inches broad. Beginning
with this below, near to the condyls, he carried it upwards, by oblique
and reversed turns, to the pelvis, round which he threw a cast; then,
giving the ball into the hand of an assistant, he applied four splints,
one before, another behind, and one on each side: directing these to
be held at their lower part near to the knee, he resumed the roller,
and secured them firmly by a second series of circular and reversed
turns, descending to the lower extremity of the thigh. The limb was
then placed in a proper position, and, in general, of whatever kind
the fracture was, whether oblique or transverse, this simple bandage,
without the aid of permanent extension, was sufficient to retain it.
72. It would be difficult to determine the period necessary for the
consolidation of fractures of the os femoris. Numerous circumstances
concur to influence this work of nature, which is, in general, extended
beyond the term of forty days, vulgarly assigned to it by the people
at large. Besides, a stiffness of the limb, the inevitable effect of
its long state of rest, still adds to the length of the patient’s
confinement, by retarding the necessary motions, the return of which,
as in other similar cases, can be accelerated only by exercise.
73. Complicated fractures of the os femoris, being included in the
general class of solutions of continuity of that description, cannot
be at present particularly considered. We will only remark, that here,
in like manner, as in fractures of the clavicle, permanent extension
constitutes the most effectual method of preventing the pains,
oftentimes insupportable, occasioned by splinters or points of bone
irritating the soft parts, from being pressed against them by muscular
action in its tendency to shorten the limb.
§ IX.