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

by P.-J. Desault

104. These processes may be considered under three classes, according as they relate 1st, to position; 2dly, to bandages; 3dly, to the forms of apparatus for making permanent extension.

In the first class must be included the method of Foubert, employed in ancient times, according to Louis, and which consists in placing the patient on a horizontal plain, while the limb is secured by simple splints, and the foot by a kind of shoe. But in a short time the muscular action, to which no resistance whatever is made, draws the lower fragment upwards, while the weight of the body pushes the pelvis downwards, and along with it the superior fragment. Hence a new reduction, the effect of which is again immediately destroyed as at first. Thus are new displacements succeeded by new replacements throughout the whole course of the treatment.

105. This method, almost universally adopted in latter times, and approved of by Louis, was in vogue at the hospital of Charity, when Desault entered it. Ought we then to be surprised, that the fracture was considered as incurable? Here indeed the plainest and most important indication is evidently disregarded. Nothing to retain the fragments in apposition, nothing to prevent them from being constantly moved. Does not the method of Foubert very closely resemble those experiments, in which, the bone of an animal is broken intentionally, and then to prevent a reunion and form an artificial joint, the fragments are kept in constant motion?

106. Will any better success attend the method of securing the leg, as Dalechamp recommends, to the foot of the bed? In such a case the trunk and the pelvis glide down along the inclined plain made by the pressure of the nates (14), and hence a constant cause of the shortening of the limb.

107. The second class of curative means, includes different forms of apparatus simply retentive. Pare, Petit, and Heister, recommend, as most useful, the Spica of the groin.[26] But what effect can this produce? What force applied in that part can keep the lower fragment down, and the pelvis up, secure the immobility of the limb, and prevent its rotation outwards? If the bandage be tight, it will compress the muscles unequally, make them contract, and thus become the cause of a contraction or shortening of the limb. In some respects, there is more advantage to be derived from the tin case lined with cloth on its inside, which Fabricius of Hilden applied to the external part of the thigh; a method which has been renewed since his time, by certain celebrated practitioners of Germany; from the pasteboard case proposed by Duverney as a substitute for that of tin; from the retentive plaster[27] of Buffle employed likewise by Arnaud; and from the splints adopted by most practitioners. But can these means, (so differently varied in form, yet still the same in their action), while they prevent displacement laterally or in the cross-direction of the bone, prevent it also in the longitudinal direction, which latter ought to be the principal object in view? Will they make any resistance to the muscular action? See what has been already said on splints, bandages, &c. (89...95).

108. The insufficiency of these forms of apparatus, arises from their not being constructed with a proper view or reference to the general principle that ought to be observed in the treatment of every fracture; namely, that the means intended to prevent displacement, ought to be founded on the causes that produce it. But, these causes here, are, 1st, The action of the muscles which draw the lower fragment upwards: 2dly, The weight of the body which pushes the pelvis downwards: 3dly, The weight and direction of the foot and leg, which tend to carry the toes outwards by a rotatory motion. Hence, the threefold indication or end of every apparatus, is, 1st, To keep the body of the bone down: 2dly, To retain the pelvis up: and 3dly, To secure the foot nearly in a right line with the leg.

109. The first consideration leads us naturally to the second. The means destined to fulfil this three-fold indication, must be constant in their action, since the causes which they have to combat act without remission. Hence the necessity of an apparatus for permanent extension. See what has been said on the nature of this expedient (46...51), on the different modes of effecting it (52...57), and particularly on the mode pursued by Desault (58...70).

110. The mechanism of his apparatus for permanent extension is the same here as in fractures of the body of the bone. The limb is secured against a strong splint, to the two ends of which two rollers, running one from the pelvis, and the other from the foot, are firmly tied. The first of these rollers holds the pelvis up, and the second draws the foot down: hence the two first indications are fulfilled. The third is also fulfilled by the extension of the limb, which prevents its rotation outwards, by means of the outside splint, which passing beyond the sole of the foot keeps it immoveable.

111. The bandage of strips and compresses, which in fractures of the body of the bone, are previously applied round the limb, and oppose in some measure its motions laterally, are here entirely useless. Being all indeed applied on the lower fragment, what purpose could they answer towards fixing it against the upper one? They could do nothing but compress the muscles, and by that means diminish their power of contraction: but extension alone produces this effect. Desault rejected the bandage altogether, and contented himself with the use of splints and bolsters, as appears from the following case reported by Couteau.

Case VI. Maria Nof, as she was running on the ice, in the severe winter of 1788, slipped, and falling on the great trochanter, fractured the neck of the os femoris. She was immediately carried to the Hotel-Dieu, where the signs formerly mentioned (60...66) disclosed at once the nature of her disease. The shortening of the limb was less than in ordinary cases.