Part 35

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, 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.

(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 (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.

(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.