74. I will close this article by a few remarks on the advantages
of permanent extension in old fractures. Nature reunites fractures
differently, according to the relation of the divided surfaces to each
other. Are those surfaces in perfect contact? If so, they are chiefly
instrumental in the formation of callus, which then probably acts in
a manner similar to the reunion of wounds. On the other hand, does an
overlapping of the fragments separate the divided surfaces from each
other; the reunion takes place then principally on the sides, by a kind
of enlargement of the bones, produced no doubt by the periosteum. Such
is the mode of consolidation, which, on opening dead bodies, is found
in most oblique fractures of the os femoris, succeeded by a shortening
of the limb.
75. Hence it follows, that this shortening, which would readily yield
to extension, at the time of the fracture, becomes obstinate in its
resistance, in proportion to the age of the accident. In such a case,
indeed, the substances destined to reunite the overlapping fragments,
acquiring daily more and more solidity, oppose to the reduction
obstacles constantly increasing. Hence, most practitioners regard
this reduction as beyond the resources of art, after the expiration
of the twelfth or fifteenth day. Nor is this opinion entertained
without some foundation, for at a later period, almost all efforts at
reduction, however powerful, have proved unavailing. But that which
cannot be performed by a very powerful effort, acting momentarily, is,
notwithstanding, oftentimes easily attainable by a much weaker one,
provided it be long continued. The following cases are in proof of this.
CASE III. Ann Gallot, of Melun, aged sixty-nine, having fractured her
right thigh, by falling down the steps of a cellar, remained twenty-two
days without assistance, and without even knowing the nature of the
accident, when, on consulting a surgeon, she was sent to the hospital
at Versailles. From the long standing of the disease, a reduction
being despaired of, and no one being willing even to undertake it, the
patient was sent to the Hotel-Dieu, on the 27th of February, 1791.
A shortening of four inches distinguished the diseased thigh from the
sound one. The overlapping was sensible to the touch: in the mean
time, a slight mobility at the place of fracture, inspired a hope of
being able, if not to restore to the limb its natural form, at least
to diminish the contraction. Several efforts were made at first, but
without success, as Desault foresaw. The apparatus for permanent
extension was applied: on the day following, the extending rollers
being a little relaxed, were again tightened. Fourth day, a sensible
increase in the length of the limb; apparatus renewed. Ninth day, the
left thigh but an inch longer than the other: eleventh day, equality
in length almost re-established. After this, the apparatus was kept
constantly applied and renewed from time to time.
Fortieth day, consolidation already perceptible: forty-sixth day,
symptoms of a putrid fever have made their appearance: fiftieth day,
symptoms worse; fifty-second, something better: fifty-fifth, worse
again: fifty-seventh, dead. On opening the body, an oblique fracture
was found, its surfaces very nearly in apposition, and already united
by a very solid callus.
CASE IV. Joseph Maugrin, a saddler, broke his thigh in the month of
July, 1793. A surgeon being called to him, placed his limb in an old
form of apparatus, which did not prevent a shortening, to the extent
of an inch and a half, from showing itself on the following day: hence
a new reduction, and a new application of the apparatus: but soon
afterwards, another shortening; the same means to remove it; the same
failure of means. Weary of such trials, the surgeon abandoned the limb
to its fate, contenting himself with merely keeping it in the apparatus.
On the twenty-ninth day, Desault being called in consultation, and
finding the thigh shorter by three inches than that on the opposite
side, proposed permanent extension, persuaded that this expedient alone
would soon be sufficient to re-establish the contact of the fragments.
The proposal was acceded to. On the day following, the effects were
already perceptible; the thigh was lengthened by almost an inch. By the
sixth day, it was equal in length to the other: during this period, the
extending rollers were tightened twice a day.
At the end of two months the consolidation was complete, and the
patient walked perfectly well, except that there was a little
shortening of the limb, trifling though indeed, compared to what would
have been the consequence, had the original treatment been continued.
76. The lengthening of the limb, in these cases, was evidently owing to
the continued action of the apparatus, which effected, in a length of
time, what the momentary efforts of the surgeon could not accomplish.
This it did, by destroying or gradually lengthening the medium of
union, which already connected the overlapping fragments, by that means
bringing their separated surfaces or ends into contact, and almost
restoring to the bone its primitive form.
Art cannot always, with certainty, command such success, and perhaps,
even at a less advanced period, a more rapid progress of reunion might
leave but little ground for hope. But, could only an inch in length be
gained by permanent extension, would it not be proper to have recourse
to it, particularly as no inconvenience can result from the trial? To
prevent deformity altogether, is the first object of art; but when that
cannot be attained, to lessen it is the second.