1st, One assistant secures the pelvis, in the same manner as in
fractures of the lower extremities; while another keeps the leg in a
state of perfect extension on the thigh, and the thigh on the pelvis.
2dly, The surgeon, then, standing by the side of the fractured limb,
extends along the anterior part of the leg and thigh the roller with
holes in it, having previously wet it with vegeto-mineral water, taking
care to make the two openings correspond to the lateral parts of the
rotula, that, by being thus better adapted to its shape, it may not be
thrown into wrinkles.
3dly, He then secures it on the top of the foot, by three circular
casts of a roller placed one over the other, three or four inches above
its lower end which must next be turned up over the three first casts,
and made fast by two other ones. Then, while the compress roller[33] is
secured above by an assistant, he passes up along the leg by oblique
and reverse turns, according to the inequalities of the limb.
[33] The roller or strip with holes in it, which is extended along
the fore part of the limb, serving, in some measure, the purpose of
a compress. TRANS.
4thly, Having arrived at the lower part of the knee, he pushes the
lower fragment upwards, and makes below it two or three circular turns
to secure it. He then gives the roller into the hands of an assistant,
and directing him who holds the long compress roller, to draw it
forcibly upwards, pushes the integuments of the knee in the same
direction, lest, by becoming interposed between the fragments, they
might prove an obstacle to their reunion. Passing then the fingers of
his left hand through the holes in the compress-roller he places them
behind the superior fragment and pushes it forcibly downwards.
5thly, When the reunion of the fragments is exact, without any space
intervening, he resumes the roller, and passing it obliquely under the
ham, and bringing it up again behind the superior fragment, withdraws
his fingers which held this fragment down. In place of his fingers, he
then applies two or three tight circular casts, covers the knee with
several oblique casts in form of the figure of 8, so as to leave no
opening between them, and, then, continues the bandage up along the
thigh, securing by it the compress-roller extended along the fore part
of the limb.
6thly, When he has arrived at the upper part of the limb, the assistant
who holds the compress-roller, drawing it forcibly upwards, doubles
down its end over the circular casts. The surgeon next fixing this end
by several additional casts, descends again along the thigh, covers the
knee by a few more oblique turns, and finishes with the roller on the
leg.
33. This first part of the bandage evidently fulfils the third and
fourth indications (18). The compression of the roller on the muscles
weakening their action and impeding their motions prevents their
tendency to draw the superior fragment upwards: while the circular
casts passed behind this fragment, acting in opposition to the
muscular contractions, prevents it from moving upwards in obedience to
them. The long compress-roller, stretched on the fore part of the limb,
being first secured below, and then drawn forcibly upwards, presses
the casts of the roller against each other, and prevents those that
correspond to the thigh from slipping upwards, and thus abandoning the
superior fragment, and prevents also those on the leg from slipping
down and withdrawing their support from the inferior fragment. As there
remains no vacant space between the circular turns, their pressure is
uniform throughout: no swelling can consequently supervene (20).
34. But the first and second indications remain still to be fulfilled
(18): it is necessary to prevent the separation of the lower fragment,
by the extension of the leg on the thigh, and to throw the muscles into
a state of relaxation by extending the thigh on the pelvis, and to
maintain permanently, by the apparatus, that double position, which the
assistant maintains only during the operation.
35. To obtain the first effect different means have been employed; but
none answers so well, to extend the limb and retain it immoveably in
that state, as a long and strong splint, placed, as Desault did it,
subsequently to the application of the first part of the bandage, along
the posterior part of the limb. An assistant must hold the end of this
splint, while the surgeon secures it in its place by the second roller
(31): in this way the extension of the leg is effected.
36. To obtain the extension of the thigh, it is necessary to place on
the top of each other, two or three bolsters or little bags filled
with chaff, so disposed as to form an inclined plain, considerably
elevated towards the heel above the level of the bed, but which,
gradually descending to the same level towards the tuberosity of the
ischium, forms a supporting basis on which the whole limb may rest in a
uniform manner. By this twofold extension of the leg and of the thigh,
the lower fragment is kept up immoveably, and the muscles are kept in a
state of relaxation.
Hence it follows, that this bandage fulfils extremely well the
conditions laid down (18), and that it ought to be preferred to all the
others (19 ... 25), which answered the indications only in part.
37. Whatever may be the advantages of this bandage over the others,
it must still be acknowledged to have its inconveniences. The rollers
become relaxed in a short time; their compression is less active;
the muscles, being less confined, contract more readily; hence the
necessity of frequently repeating the application of the apparatus, a
circumstance which is very troublesome, on account of the roller which
composes it, and covers the whole limb. The resistance of it even
when it is recently applied, is not always equal to the power of the
muscles, whence the most assiduous attention is necessary, to obtain
such a consolidation as to leave no trace of the fracture behind. Few
persons ever possessed, like Desault, the art of overlooking nothing
that might in any way contribute to the success of his treatment: from
this, no less than from the excellence of his processes, arose the
number of his cures. Let us confirm, by a few examples selected from
among a great many, the doctrine here laid down. The following cases
were collected by Julian and Bezard.
CASE I. Francis Leclert, of a sanguine temperament, fell on the 7th of
October, 1790, on his right knee, and produced a transverse fracture
of the rotula. He was not able to rise; he was carried home, where a
surgeon, on discovering the nature of his disease, advised him to be
taken to the Hotel-Dieu.
He was conveyed thither on the day following, and, in the interval, a
considerable swelling had occurred around the joint. The usual bandage
was employed; the pains ceased immediately after its application; a
copious blood-letting was directed, and a low diet was prescribed.
The whole apparatus was wet with vegeto-mineral water, two or three
times a day. On the next day some light food was allowed, and the
quantity increased by degrees, till in a short time the patient
returned to his usual regimen. Eighth day, the swelling being almost
gone, the bandage had become relaxed it was therefore reapplied. Every
day the inclined plain formed by the bolsters was carefully examined,
and put in order again as often as it became deranged.
Fifteenth day, a new application of the apparatus: twentieth day, an
evacuation in consequence of a bilious disposition. Nothing particular
occurred from this time till the completion of the cure, which took
place on the sixty-seventh day after the accident: no depression
existed at the place of the fracture: the motions were perfectly free;
these were aided, by daily exercising the knee joint for some time.
CASE II. Vincent Grenier, aged thirty-eight, making a false step, fell
on the rotula, and fractured it, on the 6th of June, 1791: he was
brought to the Hotel-Dieu, where Desault demonstrated to his pupils, by
the usual signs the existence of the disease: a considerable swelling
had already taken place. The bandage formerly described was applied:
the same precaution as in the preceding case; apparatus examined
every day; renewed as often as relaxed; extension maintained with
great exactness. On the forty-fifth day, the consolidation was nearly
effected; on the fifty-second it was complete, the joint was exercised
for some time, and on the seventy-seventh day the cure being in all
respects complete, the patient was discharged.