Part 16

27. Having determined on the position, the operator proceeds to extension and counter-extension, which are to be made first in the direction of the limb as deformed or altered by the fracture, but must be changed afterwards according to the natural direction of the thigh. I need not here repeat the directions for this double operation: common to all fractures, they contain nothing particular, in relation to that of the thigh. But, on what part should extension be made? Petit, Heister, Duverney, and all their predecessors, recommend to apply the means or powers for making extension above the knee; a precept which is still to be found in the surgical department of the Encyclopedia. A strap surrounding the lower part of the thigh, aided by another placed at the ancle, serves, in this respect, to draw the inferior fragment downward.

28. Dupouy was the first to remark, that this practice rendered it necessary to employ great force, and that it would be better to make extension only on the foot. To this consideration Fabre added that of the inconvenience of the pressure made on the muscles, a pressure which, by irritating them and making them contract, multiplies the obstacles to the reduction.

Desault adopted their doctrine, from nearly the same views of the subject, introduced it into the Hotel-Dieu, and the success which attended it, in his practice, contributed not a little to bring it into general use.

29. For the purpose of making extension, he used the foot as a lever of the first kind. The two hands of an assistant, grasping it in such a manner, as to make the fingers cross on the back of it, while the thumbs, also crossing each other, corresponded to the sole, represented the power; the articulation represented the centre of motion, or fulcrum, and the leg together with the lower fragment, the resistance. The requisite motion was then communicated to the foot, and in that way was the extension effected. This mode is more advantageous than that usually employed, where the hands are applied to the lower extremity of the leg; for the force of the extending power is generally in the inverse ratio of its distance from the resistance intended to be overcome.

30. What I have said of extension (28), applies also to counter-extension. The strap, which was formerly placed for this purpose in the groin of the affected side, by compressing the adductores, and the rectus internus, produced in them a contraction, which, by drawing the lower fragment towards the pelvis, opposed obstacles to the reduction, which are seldom experienced, when, like Desault, the surgeon contents himself with having the trunk held by assistants, either exclusively at the hips, or both at the hips and under the arm-pits. The resistance being always easily overcome in this affection, renders it unnecessary to have recourse to more powerful means.

31. Hippocrates advises, in fractures of the os femoris, to aid extension by coaptation, performed with the hand. All practitioners, since his time, have added this third manœuvre or process to the two first, namely, extension and counter-extension. But, what effect can the hands produce, in most cases, on the bone through the thick covering of the soft parts? Are we able to communicate to it through such a mass whatever lateral movement we please? Being quite lost in the intervening soft parts, will our efforts reach the bone, in the direction which we give them? The muscles bring the fragments into contact, much better than we can, as soon as extension has removed their overlapping. Indeed, if well executed extension makes the lower fragment return along the same track which it pursued in becoming displaced, it will then be inevitably brought into contact with the upper one by the contraction of the muscles. Besides, in most oblique fractures, is it not evident, that the lower fragment must be made to slide from above downward, on the inclined plain presented by the upper one, and on which it has slided from below upward, in becoming displaced? Is it while extension is making that coaptation ought to be performed? Certainly not: because, if the extension be well directed, an attempt at coaptation will derange it; and if it be not well directed, its course ought to be changed. Is it after extension is finished that recourse ought to be had to coaptation? By no means: because if there be then any remains of deformity, it must be owing to extension having been improperly directed. The remedy, therefore, is, to renew the extension, and direct it properly.

32. Hence, it follows, in general, that coaptation is here a feeble assistant towards reduction; that if it renders any service, it is only in cases of displacement laterally, or in the direction of the cross-diameter of the bone; and that it is by giving the proper direction to extension, by managing it according to the disposition of the muscles, and by knowing when to augment and when to slacken it, that the fragments are brought into regular contact.

33. If the inferior fragment has experienced a rotatory motion on its own axis outwards or inwards (18), the assistant ought, in making extension, to turn the limb very gradually in the opposite direction.

34. Extension was formerly attended with difficulties, which are rarely met with at the present day. Oftentimes, if we give credit to authors, it was altogether useless to endeavour, in the first instance, to reduce the fracture, and restore the limb to its natural length, as the contraction of the muscles rendered the operation absolutely impracticable. Hence, applications of a soothing and sedative nature were employed, previously to an attempt at reduction. The following circumstances have been assigned as the cause of these difficulties. The upper strap, irritating and drawing upwards the adductores and the rectus internus, drew the lower fragment in the same direction, while the semi-tendinosus, semi-membranosus, biceps, &c. being drawn downwards by the lower strap applied over them, drew the pelvis also downwards, and, consequently, the superior fragment connected with it. From this double action arose a double motion directly opposed to that which ought to be produced by extension.

35. There are still cases, where the muscles, in consequence of being irritated by projections or points of bone, by the efforts of the assistants, and by a morbid state of the nerves, increase their contraction to such a pitch that no practicable force can bring the fragments into apposition. What means are then to be employed? All those, in general, that diminish irritability, varied according to circumstances, such as diet, venesection, &c. In such cases, Desault obtained the most happy effects, by placing the limb in a state of continued extension; fatigued by the permanent tension in which they are thus kept, the muscles relax by degrees; their force diminishes; at length they yield, and the reduction is accomplished.

§ VI.

OF THE MEANS OF MAINTAINING THE REDUCTION.

36. The mere reduction of a fracture of the os femoris, is but one step towards the cure. In this, more than in the fracture of any other bone, causes which act incessantly (13) tend to subvert the momentary work of art; it is here, then, in particular, that means ought to be devised for maintaining this work. But, the first of these means is a suitable position of the limb. I have already mentioned the inconveniences that result, both as to the reduction and subsequent treatment, from that proposed by Pott (24 ... 26). The patient must, then, be laid horizontally on a plain exactly even, and not capable of being affected or rendered uneven by the weight of the body. Instead of feather beds generally used in other cases at the Hotel-Dieu, Desault, in cases of fractures, substituted firm and hard mattresses, which, not sinking in the least, by the pressure of the body, give no cause to apprehend those continual displacements, to which a soft bed exposes the patient. These mattresses supersede the advice of certain authors who direct a plank to be placed under the patient.

37. The second means, not less efficacious than the first, consist in the forms of apparatus, in which the limb is placed, and which, being differently modified according to the fancies of their different authors, present us with an assemblage of various splints, compresses, &c. To appreciate, with accuracy and correctness, the advantage and disadvantage of these, let us first unfold the curative indications which they ought to fulfil; we will then compare their mode of action with these indications, from whence will result, as necessary inferences, the object of our research.

38. The intention of every form of apparatus being, to prevent the displacement of the fragments, the causes of this displacement ought to be the basis or foundation of its mechanism and construction. But these causes in the present case are, 1st, the muscular action drawing the inferior fragment upwards (10); 2dly, the weight of the body pushing the superior fragment downwards (14); whence every form of apparatus intended to keep the os femoris in place when fractured obliquely, ought, 1st, to draw the lower fragment downward and retain it there; 2dly, to draw and retain upwards the superior fragment, and the trunk which bears on its upper end. This principle is applicable generally, and subject only to a few exceptions which I shall notice when treating of transverse fractures, where the displacement is lateral, or in the direction of the cross-diameter of the bone, or where no displacement at all exists. 3dly, The apparatus must also be so constructed as to prevent the rotatory motions of the lower fragment (18), and secure the immobility of the limb, lest by means of some motion being communicated to it, the fragments might be deranged.

§ VII.

OF THE MANNER IN WHICH THE DIFFERENT PIECES OF THE APPARATUS ACT.

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.

OF PERMANENT EXTENSION, AND THE MEANS OF EFFECTING IT.

46. By what means then can this indication be effectually fulfilled? By that which will perpetuate, throughout the whole treatment, the action of those means by which reduction was effected; by that which, to the ever active power of the muscles, will oppose a resistance constant in its action; by that which, forming on the exterior of the thigh a kind of artificial muscle, may become an antagonist to the natural muscles of the part, and neutralize their efforts, by acting in a contrary direction, and which, by pushing up the pelvis and retaining it there, may prevent it from being pushed downward by the weight of the trunk (14). But what other mean than that of permanent extension, unites these advantages? Whatever form of apparatus may be employed to obtain it, it is permanent extension alone that can prevent the displacement, because it alone is founded on principles calculated to meet and obviate the causes by which displacement is produced.

47. The ancients, though less informed than we are respecting the nature of these causes, knew better how to appreciate their effects. All their forms of apparatus made a permanent extension, a measure which has been abandoned by most of the moderns, and regarded, even at present, in France, by a great number of practitioners, as always dangerous, and seldom useful. Let us set in opposition to the vain fears which it inspires, a few thoughts, and much experience.

48. It is from the very object which is proposed to be attained, that the first difficulties arise. What must we think of a limb in a state of preternatural tension, where all the parts being overstretched must experience an uneasiness not to be supported? I answer, that it is not a preternatural elongation that extension produces; on the contrary, being intended to prevent a preternatural shortening, it has for its object to restore the parts to their ordinary state, and to give to the muscles their habitual degree of tension, by opposing such contractions in them as are not habitual: under this point of view, it performs, in relation to the muscles, those very functions which are discharged by the bone itself, when sound and unbroken, as is fully experienced by all patients, when the apparatus is applied. Its use not only does not increase pain, but is alone calculated to diminish it, because, by bringing the fragments into apposition, it prevents the soft parts from being irritated by the points of the bones.

49. Is the swelling of the limb to be dreaded, as some pretend? But whence can this swelling arise? From the over-stretching of the parts? I have already proved that they are not over-stretched. From the pressure of the straps? Perhaps this cause might produce a swelling, if, as formerly, it were applied above the knee; but, by placing it, as Desault did, near to the ancle, by surrounding, with a thick compress, the lower part of the leg, where the straps pass, and by securing the foot with a tight bandage under the straps, if their action be dreaded, this fear must be done away; and, besides, experience, which is the only true test of the dangers of a process, by no means justifies the apprehension. The venæ saphenæ and the absorbents that accompany them, are free from the compression, which bears principally on the tendo Achillis, and the malleoli.

50. What shall we say in reply to the censure thrown on the process of permanent extension, in the memoirs of the academy, where it is charged with having been oftentimes productive of ulceration and even gangrene, in consequence of the pressure of the upper strap? What method can escape censure, if it be unskilfully pursued? What process will not be injurious, if mutilated and ill managed by ignorance or a want of discretion? To represent the thing properly, let us suppose the worst: a circular bandage, in consequence of being drawn too tight, produces mortification in the subjacent parts; must circular bandages be on this account entirely rejected? An unskilful hand, in an operation for cancer, opens the axillary artery; must we therefore cease to search under the arm-pit for schirrous glands?

51. Permanent extension is, say some, insufficient to overcome muscular action; it is opposing to a power equal to 1000, a resistance equal to only 100. But this force of the muscles, which is oftentimes so great at the time of reduction, diminishes gradually, by the pressure of the bandages, by the immobility of the limb, and, above all, by long continued extension; for a continued effort equal to 10, will soon perform what could not be effected by a temporary exertion of a force equal to 100. Let us pass over the more minute objections made against permanent extension, and search among the different modes of performing it, that to which practitioners ought to give a preference.

52. We may throw into two classes the general modes proposed by different authors for effecting permanent extension. Under the one are included those modes requiring simple means, such as straps, splints, &c. while the other embraces such as, from being complex, necessarily call for the use of different machines.

53. In the first class are comprehended:

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.