Part 17

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.

OF PERMANENT EXTENSION IN OLD FRACTURES.

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.