A Treatise on Fractures, Luxations, and Other Affections of the Bones

by P.-J. Desault

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.