§ I.
1. CASE I. (Reported by Levacher). Catharine Belet, aged fifty-five, of
a strong and vigorous constitution, fractured her leg in the middle,
by a false step in alighting from a carriage. Being carried home, in
a careless manner, she was visited by a surgeon, who merely reducing
the fracture, but applying nothing to retain the reduction, sent the
patient to the Hotel-Dieu. She was conveyed on the same day to the
amphitheatre, where Desault discovered the existence of the affection
by the following signs.
Pain in the middle of the leg, less severe when the limb was at
rest, more so when it was suddenly moved; the patient absolutely
unable to support herself on it so as either to stand or walk since
the accident; inequalities sensible to the touch on the anterior
surface of the tibia; a shortening or contraction of about half an
inch; a preternatural mobility at the place of the fracture; evident
crepitation, produced by the rubbing of the fragments against each
other, when moved in contrary directions: a change in the direction
of the lower fragment, which was bent somewhat outwards. These signs,
added to the circumstance of the fall, evidently announced a simple
fracture of both bones. The reduction was effected in the following
manner.
One assistant made counter-extension by grasping the lower part of the
thigh with both his hands, the fingers being placed behind it, and his
thumbs corresponding to its anterior surface. Another made extension,
not as writers recommend, at the lower part of the leg, but on the foot
itself, which was taken hold of in such a manner that the fingers met
on its upper side, while the thumbs crossed each other on its sole. In
this way a lever of the first kind was formed, the resistance to which
was the fragment to be replaced, while its centre of motion was in the
joint.
Extension being directed at first in the course or line of the
displacement, till the limb had attained its usual length, was then
directed in such a way as to restore to the leg its natural form. By
this, the fragments being brought into apposition, united exactly
without the process of coaptation being employed.[34] The apparatus,
usually employed by Desault in such cases, was applied to maintain the
reduction: the different pieces of it had been previously arranged on a
pillow in the following order: 1st, four strong pieces of tape placed
at equal distances from each other; 2dly, a junk-cloth,[35] long enough
to reach from the knee beyond the sole of the foot; 3dly, a bandage of
strips, similar to that described for the thigh (page 246), arranged
in the usual mode; 4thly, two long compresses, the lower one of which
being the longest was turned back on the other; three bolsters had also
been prepared; these, being formed of several pieces of linen joined
together, were about one inch and a half thick: the broadest of these
was designed to be placed on the anterior part of the leg; the two
other lateral ones, though narrower, were a little longer, in order
that, by folding back on themselves, they might be accommodated to the
inequalities of the limb; 6thly, lastly, there were also prepared two
splints, an inch broad, three lines thick, and of the same length with
the junk-cloth.
[34] That is, without any assistance from the hands of the surgeon.
TRANS.
[35] Analogous in its form and uses to that employed in fractures
of the thigh. It may not be amiss, on this occasion to mention,
that in the form of apparatus for oblique fractures of the leg,
represented in the Appendix, plate III. no junk-cloth is necessary.
TRANS.
Every thing being ready, the assistants still keeping up extension
raised the leg a little, while a pillow was slipped under it, to
support it equally and uniformly throughout its whole length. The leg
was placed on this pillow in such a way as to correspond exactly to the
middle of the apparatus which was arranged in order on it, and was
previously wet with vegeto-mineral water.
On the anterior part of the leg was then applied a long compress,
extending from the knee to the upper part of the foot. Over this were
lapped the other two compresses, which had been previously placed in
order as part of the apparatus. These were then secured by the bandage
of strips, the application of which was begun at the lower strip next
to the foot, and continued successively upwards with the rest, making
them cross each other at the anterior part of the leg.
On the sides were placed the bolsters which were doubled at the ancle
to protect that part from the pressure it might otherwise sustain. The
splints were then applied along the external surfaces of the bolsters,
the edges of the junk-cloth having been previously folded round them,
in order to render their pressure the more close and steady. Along the
fore part of the leg was laid the largest of the bolsters, and the
whole was then secured by the four pieces of tape tied on the external
splint, with a degree of tightness sufficient to keep the fragments
immoveable.
A compress wet with vegeto-mineral water covered the foot, and was
secured by a roller, applied in such a manner, that its two ends,
crossing on the back of the foot, were fastened laterally to the two
splints.
The leg, being firmly fixed by this apparatus, and gently flexed by
means of a pillow placed under it, was protected by hoops from the
pressure of the bedcloaths. The fragments being now in complete
apposition irritated the parts no longer, in consequence of which the
pain ceased.
The patient being properly disposed in bed, remained tranquil and
easy throughout the remainder of the day. Diluting drinks and light
nourishment were prescribed.
Next day, no pain; patient composed; a slight swelling on the back of
the foot; the apparatus wet anew with vegeto-mineral water. Fourth day,
the bandages a little relaxed; the point of the foot turned somewhat
outwards; a new application of the apparatus. Seventh day, bilious
symptoms appear, loathing of food, nausea, and bitterness of the mouth.
Eighth day, tongue furred, inclination to vomit; loss of appetite; a
grain of tartar emetic given in solution; copious dejections; evidently
better: next day, appetite returned, tongue clean. Tenth day, a third
application of the apparatus, which had become too loose. Fifteenth
day, fresh bilious symptoms; further evacuations; success the same.
Twentieth day, consolidation evidently advancing; no deformity of
the limb; fourth application of the apparatus. Thirty-second day,
consolidation almost complete; the apparatus still kept on till the
forty-second day, when the patient was discharged perfectly cured.
2. This case, which is in no respect different from those that most
frequently occur in practice, presents us with a view of the mode
of reduction, the means of retention, and the subsequent treatment,
employed by Desault, in cases of the kind. The advantage of the
bandage of strips, which allows the limb to be uncovered without being
disturbed, is now generally acknowledged in fractures of the lower
extremities. In the treatment of these, practitioners reject entirely,
at present, the roller bandage, which was recommended by Petit,
Heister, and all the authors who preceded them, and which, by producing
a new displacement, at each time of reapplication, may entirely prevent
the fragments from uniting. The bandage of Scultet, brought into use
again by Desault, the form of which has been just described, is also
preferable to the eighteen-tailed bandage, which some practitioners
still employ.
3. The strips which compose the former bandage, being narrower than the
tails of the latter, can be more neatly applied to the leg, as they
more readily mould themselves to its inequalities; the compression made
by them is, therefore, more exact, more uniform, and consequently less
inconvenient. If one of the strips become soiled, it can be changed
without deranging the bandage. (Respecting this point, see what was
said on fractures of the thigh.) This bandage being less bulky than the
eighteen-tailed one, is therefore less troublesome to the patient.
4. The broad and strong splints which form a part of this apparatus,
have the following advantages over those previously used both by the
ancients and the moderns; 1st, they come in contact with and bear on
a larger extent of the surface of the limb; 2dly, they consequently
maintain the fragments in apposition with greater firmness and effect;
3dly, they prevent the rotation of the foot outwards, an accident
which very frequently occurs when the fracture is complete, that is,
when both bones are broken; 4thly, they remain constantly in their
place, without slipping either forward or backward, an inconvenience
necessarily attendant on the other splints, which, from their roundish
form, touch the limb in only one point or line.
5. To sustain the foot, Petit recommends a piece of a board to be
applied immediately to its sole, and supported by two bits of tape
fastened to the splints. This practice is adopted to some extent
even at present: but a simple roller, applied in the manner already
mentioned, is sufficient for the purpose; the tendency of the foot to
turn outwards is never so strong as not to be effectually resisted by
this expedient: besides, should the piece of board be placed ever so
little too vertically, it retains the foot in a state of inconvenient
and painful flexion.
6. The situation of the leg, gently flexed by means of a thick cushion
or pillow placed between it and the mattress, is, in all respects to
be preferred to the method of Pott, which is exclusively adopted by
Bell. What, indeed, can be the object of this latter method? To relax,
say they, the muscles, that tend to make the lower fragment overlap
the upper one. But is it not evident, that most of these muscles, not
being attached to the os femoris at all, cannot be influenced by this
position? To obtain the relaxation of the posterior muscles, it is
necessary to flex the foot; but, in such a case, the anterior muscles
are necessarily in a state of tension: this completely counter-balances
the relaxation of the others, and, therefore, there is nothing whatever
gained. It is certainly much best to allow the leg to be in a state of
moderate flexion, such as we assume when asleep, and which appears to
be the most natural.
7. The apparatus just described, produces on the fragments a twofold
action: 1st, by a kind of side walls formed by the splints, it prevents
their displacement laterally, and from this circumstance alone, is
fully sufficient for the retention of transverse fractures: 2dly, the
pressure of the rollers, splints, and bolsters, if these be applied
with sufficient tightness, prevents the lower fragment from mounting on
the upper one, and thus preserves the natural length of the limb. Hence
its advantages in oblique fractures; and, as the powers of displacement
are weaker here than in the thigh, this apparatus, is in general,
sufficient to counteract them.
8. It is true that cases do sometimes though rarely occur, where,
in consequence, of being irritated by splinters, or the points of
the fractured bone, or acted on by some other causes which make them
contract, the muscles overcome the resistance of the apparatus, and
make the fragments overlap. Under such circumstances, permanent
extension affords here the same advantages as in fractures of the thigh.
9. Most authors, to obtain the desired end in such cases, recommend
means calculated to act on the thigh. Thus, Manne proposes the use
of his glaussocome. Desault, under such circumstances, effected his
purpose by the apparatus described in the following case.
§ II.
10. CASE II. Pierre Bejol, aged thirty-seven, of a strong and vigorous
constitution, fell, as he was carrying a heavy load, over a beam which
lay in his way. His leg was fractured towards its lower part; he
was lifted up and carried home, where a surgeon, by making unskilful
efforts at reduction, gave him extreme pain.
A roller and a kind of round splint applied to each side of the
limb, forming the whole of the apparatus, and not being sufficient
to retain the fragments, soon allowed them to overlap each other
nearly two inches. The pains continue; a considerable swelling appears
around the fracture; the patient is greatly agitated; he is brought
to the Hotel-Dieu, where, from the deformity of the limb, Desault
was satisfied, at first sight, of the existence of a fracture; on a
more attentive examination, it was discovered to be complete and very
oblique.
The muscles being tense and in a state of violent contraction, drew the
inferior fragments very forcibly upwards; these were finally, however,
by means of well directed efforts, brought into perfect contact,
with the superior fragments: the difficulty now lay in maintaining
this contact. The age of the patient, his strength, and the almost
convulsive state of the muscles, gave reason to apprehend that a
displacement was about to occur. An attempt was made to prevent this in
the following manner.
The patient being laid on a bed properly prepared,
1st, The foot and the leg above the ancle, were covered by a bolster
or compress, round which was passed a strong roller intended for the
purpose of making extension. The ends of this roller, being left free,
were carried, one on the outside, and the other on the inside of the
limb.
2dly, Below the tubercle of the tibia was placed another bolster,
surrounding the leg, and on this, was secured another roller for the
purpose of counter-extension. The ends of this roller, after crossing
under the knee, were left hanging loose one on each side of the limb.
3dly, The two rollers being thus arranged, while the assistants, still
continued to make extension, the surgeon applied successively, and in
the order already mentioned, the compresses, the bandage of strips, and
the bolsters.
4thly, He then took two splints with notches in their lower ends, of
the same breadth with the splints already described, but long enough to
reach, each of them, from four inches above the knee to the distance of
four inches beyond the sole of the foot. One of these was applied on
the outside and the other on the inside of the leg.
5thly, The surgeon then taking hold of the two ends of the upper
roller, drew them over the upper ends of the corresponding splints,
while an assistant crossing the two ends of the lower roller under
the sole of the foot, drew the external end over the lower extremity
of the internal splint, and the internal end over the lower extremity
of the external splint. Carrying them, then, up along each side, he
brought them, at the middle of each splint, to meet the ends of the
upper roller, to which they were firmly secured by knots, so as to
make extension at the foot, and counter-extension at the knee. The two
fragments, being drawn by this apparatus, the one down and the other
up, could not again overlap.[36]
[36] For a view and description of an excellent form of apparatus
for oblique fractures of the leg, constructed on the principles of
that here described, see article III. plate III. of the Appendix.
TRANS.
On the same day the patient was bled copiously; a low diet was
prescribed; some diluting drinks were administered; and the whole
apparatus was frequently wet with vegeto-mineral water.
Next day, fever; restlessness; blood-letting repeated; the extending
rollers, having become relaxed, were tightened. Third day, evidently
better. Fifth day, a new application of the apparatus; some swelling
of the foot; a few small blisters on the leg; these were opened and
dressed with cerate spread on linen. Eighth day, the patient easy and
tranquil; a little shortening of the limb; a third application of
the bandage. Twelfth day, bilious symptoms appear. Thirteenth day,
an emetic given in solution; symptoms decline. Twentieth day, the
fractured limb in a favourable state; the roller for extension laid
aside; that formerly described employed in its place. Thirtieth day, an
appearance of consolidation. Thirty-fourth day, bilious symptoms recur;
further evacuations. Forty-third day, consolidation perfect; scarcely a
vestige of the fracture remains. Exercise is repeated for several days.
Fiftieth day the natural strength and motion of the part completely
restored.
11. The general end to be answered by every bandage intended to retain
a very oblique fracture of the leg, is evidently, 1st, to hold the
knee up, and with it the superior fragments; 2dly, to draw the lower
fragment down: from this twofold effect arises a twofold resistance
diametrically opposed to the powers of displacement, which are; 1st,
the slipping down of the trunk, which pushes the thigh before it, and
with it the upper fragments of the leg; 2dly, the action of the muscles
of the leg, drawing the foot upwards, and the lower fragment along with
it.
12. But, if to these indications we compare the bandage described in
the foregoing case, we will perceive that they are perfectly fulfilled
by it. Indeed the splints forming a kind of pullies which change the
direction of the rollers, we must count on the action of these rollers
only from the part of the limb which they surround, to the ends of the
splints over which they are reflected: whence it follows, that the
two ends of the upper roller, reflected over the superior extremities
of the splints, cannot be drawn down along each of these splints,
without that part of the rollers, which reaches from the leg to these
extremities, being drawn up, and with it the knee and the upper
fragment. In like manner, the ends of the lower roller cannot be drawn
up towards the ends of the upper one, without those portions of them
which run from the sole of the foot, being drawn down and pulling the
foot and the inferior fragments along with them.
13. Hence it follows, that by tying on each side, one end of the upper
roller to the corresponding end of the lower one with sufficient
tightness, the two indications above laid down (12) are accurately
fulfilled.
14. But, in general, the common bandage is sufficient, as I have
already mentioned, even in cases of oblique fractures, to prevent the
ascent of the lower fragments on the upper ones. Desault never employed
any others in the last years of his practice, and it was only in cases
of extraordinary disposition to muscular contraction, that he ever
had recourse to the second kind. By means of the common apparatus, he
was able to prevent the overlapping of the fragments from forming any
protuberance on the anterior and internal part of the leg.
15. We must acknowledge, however, that this apparatus is liable to the
same objection with most others intended for permanent extension. The
roller placed below the knee, for the purpose of counter-extension,
surrounds almost all the muscles, which tend to make the inferior
fragments overlap the superior ones, by drawing the foot upwards. By
pressing on and irritating these, it favours, and even excites their
contractions, and, by that means, gives rise to a shortening of the
limb, the very accident which the apparatus is intended to prevent.
This inconvenience induced Desault, in a particular case, to substitute
to the preceding apparatus, that used for permanent extension in
fractures of the thigh.