Part 48

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. 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, 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.

That is, without any assistance from the hands of the surgeon. TRANS.

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.