14. Our forms of apparatus are nothing but means of continuing, for
a long time, that state of things, which extension and the process
of conformation temporarily produce at the time of reduction. This
principle, though generally acknowledged, was particularly neglected
in such fractures, as that now under consideration, till the time of
Petit, who made it the basis of his practice. Before him, there was
a common inconvenience attached to every kind of bandage. The two
bones being pressed against each other, by circular rollers applied
externally, were thus drawn in that very direction, in which the action
of the pronator muscles already tended to displace them; because, the
form of the fore-arm being irregular, made these rollers act more
powerfully on its lateral parts, where it is very convex, than either
behind or before, where it is very flat. It is well known that bandages
will make the greatest pressure on the most projecting parts of the
limbs round which they are applied; so that, if the fore-arm be bound
or pressed on behind and before with a force equal to one, it will
sustain laterally, that is, on its sides or edges, a pressure equal to
two. Hence results, not only a tendency in the radius to approach the
ulna, but also, a want of resistance in the muscles situated on the
posterior and anterior sides of the fore-arm. For these muscles being,
from their flatness, less compressed than the bones, give way, and do
not, by forcing themselves between them, oppose the approach of the
bones to each other.
15. Such was the disadvantage of the apparatus of Hippocrates,
consisting of one roller applied immediately on the skin, of a
many-tailed bandage intended to retain this, and of four splints,
applied on the seventh day, and secured by another roller. Such
was also the inconvenience of several bandages, proposed after the
time of Hippocrates, by different authors, who modified his without
improving it, and who, in attempting to alter it, even added to its
imperfections. Thus, the compresses with which the limb was first
covered, previously to the application of the rollers, served only,
by becoming wrinkled, to render the compression unequal, fatiguing,
and even painful to the patient. In like manner the pasteboard, which
many authors, particularly Duverney, have substituted for splints,
and which a majority of practitioners employ, even at the present
day, soon becoming softened by moisture, bends without resistance,
becomes incapable of preventing a displacement, and has at least the
inconvenience of being useless.[18]
[18] On this point Desault is certainly mistaken. Paste-board, when
of a proper thickness and well applied, makes an excellent splint
for fractures of the fore-arm. It moulds itself to the form of the
arm, sits easy, and retains the fracture extremely well. TRANS.
16. Is it to be wondered at then that a perfect cure of fractures of
the fore-arm has been regarded as a thing of so much difficulty, and
that most authors should have advised practitioners, as a thing of
prudence, to warn the patient of its being impracticable to cure him,
without the loss of the motions of pronation and supination? Thus, in
like manner, it was formerly declared, that a constant deformity was
the necessary consequence of fractures of the clavicle.
17. Petit first conceived, that he discovered, in the very means
destined to prevent the displacement, the cause of its being continued,
and that, in order to be effective, the bandage ought to do constantly
what the hands of the surgeon do at the time of reduction (13); that
is, it ought to oppose to the unremitting action of the pronators,
a resistance equally unremitting, by pressing the muscles into the
interstice between the bones. But, after having discovered the end to
be attained, he accomplished it only in an imperfect manner. For by
first applying a roller immediately round the fore-arm, he reproduced,
in part, the very inconveniences and disadvantages he wished to
prevent, by placing anteriorly and posteriorly two long and thick
graduated compresses, intended to keep the bones asunder, by forcing
the muscles between them.
18. Duverney, more judicious, proposed to place the graduated
compresses of Petit on two circular compresses, previously applied
round the fore-arm. But what availed these circular compresses? If
they be drawn tight, will they not produce that approximation of the
bones which the surgeon wishes to avoid? And if they be not tight, they
will, in consequence of their loose and pliable state, form troublesome
and inconvenient wrinkles, without being productive of any good to
counterbalance this inconvenience.
19. It was from these different considerations, that Desault modified,
as I am about to mention, the apparatus for fractures of the fore-arm.
To a great degree of simplicity, this apparatus unites, when thus
improved, great ease to the patient, and its advantages are proven by
the freedom in the different movements of the arm always experienced
by the numerous patients, whom he was called to attend. The pieces of
the apparatus are, 1st, Two graduated compresses, one of them of such
a length as to extend from the elbow to the wrist, and the other from
the wrist to the fold of the arm on the inside. They are to be formed
each of a single piece of linen, folded seven or eight times on itself,
in such a manner, that the lower fold may be an inch wide, while the
others, laid on top of each other, gradually diminish in width to the
last. The thickness of these compresses ought to be less in very fat
persons, where the anterior and posterior surfaces of the arm are more
convex. 2dly, A roller about four yards and a half long, and four
inches wide. 3dly, Four thin but stiff wooden splints, long enough to
reach, one, from the fold of the arm to the wrist, the second, from the
interval or hollow space between the olecranon and the condyl to the
same part, the third from the internal condyl of the humerus to the
styloid process of the ulna, and the fourth from the eternal condyl to
the styloid apophysis of the radius. The breadth of the two first ought
to be double that of the other two, as the latter occupy a space of but
half the width of that occupied by the former.
20. Every thing being arranged, the reduction is to be executed as
already directed (11–13); and while the extensions are still continued,
the surgeon wets with vegeto-mineral water, or some other discutient
liquid, the graduated compresses, and places them on the anterior and
posterior part of the fore-arm, (which must be firmly supported in a
state between that of pronation and supination, 11), in such a manner,
that their broadest part or base may be in immediate contact with the
limb. He then secures them with a roller wet with the same liquid,
the casts of which, being first fixed at the place of the fracture,
descend obliquely to the wrist, and are secured at the hand by being
passed between the thumb and the fore-finger. Running across the back
of the hand, the roller then reascends, either by oblique or reverse
turns, according to the inequalities of the fore-arm, till it reaches
the elbow. Here the surgeon relinquishes the roller, giving it into the
hand of an assistant, and places the four splints on the parts already
mentioned (19), while the hands of a second assistant secures them, by
grasping them all at their lower end, next to the wrist. The surgeon
then resumes the roller, and, in order to fix the splints immoveably,
descends with it along the fore-arm by circular casts, till he reaches
the hand, where he finishes.
There is, in the application of this bandage, an essential precaution
to be observed; which is, that as each turn of the roller passes
over the graduated compresses, the surgeon ought to press on these
compresses with the thumb and fore-finger of his left hand, in order
that the muscles, by being forced into the interstice between the
radius and ulna may prevent their approximation, which would produce an
inequality in the compression made by the apparatus.
21. After the application of the apparatus, if the patient be obliged
to keep his bed, the fore-arm is to be extended on a pillow, taking
care to keep it always half-bent, and guarded by hoops from the weight
of the bed-clothes. But if the fracture be not a compound one, and if
the fall has done no injury to the system in general, it is unnecessary
to confine the patient to a position wearisome, and oftentimes
insupportable to many persons. Then the limb is to be suspended in
a sling, which is always sufficient to support it, without having
recourse to the kind of hollow case recommended by Bell, which is
seldom at hand, and the use of which must be extremely inconvenient.
22. The subsequent treatment to be adopted in such fractures is
simple and easy: to wet the apparatus daily, for a few days, with
vegeto-mineral water, to obviate, by proper means, the accidents that
may occur; to renew the application of the roller at the end of eight
days, or perhaps later, according to the degree of its relaxation; to
repeat this application two or three times during the course of the
treatment; to allow, at first, but light diet, which may be afterwards
more solid, and given in larger quantity, and to admit finally of a
return to the patient’s usual mode of living: such was, in cases of
fracture, the practice of Desault, which was always attended with happy
effects.
23. Sometimes a considerable swelling occurs, after the application of
the bandage, on the back and face of the hand; small blisters appear
between the fingers; the patient experiences sharp pains along the
fore-arm; and other small blisters rise on its surface. It is then
necessary to remove the apparatus, to open the blisters by pricking the
cuticle, and dress the part with cerate spread on linen rags; replace
the apparatus, making it less tight than before, taking care to renew
it every day, till the excoriation be entirely gone. This accident, of
no great consequence in itself, has frequently occurred to Desault,
although the rollers were applied at first with but a moderate degree
of tightness.
24. The consolidation being completed generally in twenty-four or
twenty-five days, leaves, at this time, a little stiffness in the
joints, in consequence of their having remained so long without
motion: the movements of pronation and supination are performed but
imperfectly. Their return is facilitated and hastened by frequent
exercise of the limb, as well at its junction with the os humeri, as in
its own proper joints; and, in general, by the fifteenth or twentieth
day from the removal of the apparatus, things are in the same state in
which they stood before the fracture.