Part 14

Seldom have the reunion of the bone, and the removal of all the disagreeable effects accompanying the accident, required a longer time than is necessary for the cure of other fractures. The numerous examples, which occurred in the Hotel-Dieu, during Desault’s direction of the surgical department, confirm the truth of this assertion, notwithstanding some doubts that may have been raised respecting it, by prejudices formerly entertained, on the subject of fractures in the vicinity of joints.

From twenty-six to thirty days are sufficient for the reunion: this was the term commonly required in the Hotel-Dieu.

11. If judiciously managed, art readily removes all the accidents attendant on this fracture; but, if otherwise, the consequences are apt to prove troublesome. It is here, much more particularly than in other places, that all deformity of the part ought to be prevented; because, the neck of the humerus being near to the centre of the motions of the arm, will very essentially impede those motions if it be not properly reunited. A deformed callus has been known to produce, in the hollow of the arm-pit, a protuberance, which has, in part, prevented abduction, and appeared to keep up an habitual swelling in the limb.

It is, then, from the perfection of the apparatus, and not from the vicinity of the injury to a joint, that the prognosis is to be formed, both as to the consequences, and as to the duration of the fracture. Keep the fragments in exact and regular contact, and there will be no obstacle to that success which seldom forsook Desault.

§ V.

OF THE REDUCTION.

12. The reduction in this case is usually attended with but little difficulty, and the great multiplicity of means hitherto used for that purpose, demonstrate only the barrenness of the art.

Most of the machines destined to reduce the luxation of the humerus, have been applied to this fracture. Thus the ladder,* the door,† and the club,‡ placed under the arm-pit, served at once the purposes of counter-extension, and conformation, while the powers for producing extension were applied to the elbow, and more rarely to the wrist. Thus Hippocrates recommended a wooden cross, the effect and mode of action of which are nearly the same. These means, in general, besides being insufficient, are liable to a further objection, in consequence of their acting on the edges of the pectoralis major, latissimus dorsi, and teres major, which being thus forced upwards, draw the fragment to which they adhere in the same direction, and thereby constitute an obstacle to the reduction. (See what will be advanced on the subject of luxations of the humerus.)

(* L’echelle, † la porte, ‡ le baton.) These pieces of machinery, though formerly in use, are now, I believe, in all parts of the world, laid aside. It would be superfluous, therefore, to consume time in describing either them, or their mode of operation. TRANS.

13. To machines succeeded the use of straps, weights suspended to the limb, &c. These processes were entirely useless, in as much as they were intended only to increase the natural powers of the operator, which are already more than sufficient of themselves. They will, therefore, in a short time, exist only in the history of surgery.

Petit proposed to reduce this fracture, by first raising the arm to a right angle with the body, and then directing one assistant to make the requisite extension, by taking hold of the elbow with his hands, while another grasped the point of the shoulder, for the purpose of counter-extension. This method was attended with the threefold inconvenience, of subjecting the patient to great fatigue and pain, of weakening the extending powers, by bringing them too near to the point required to be moved, and of irritating the muscles that draw the lower fragment upwards, and thus exciting them to contract. Hence the difficulties sometimes attendant on reduction, which is always simple in itself, when, after the trunk is properly fixed, gentle extensions are made by taking hold of the fore-arm in a half-bent state. The following is the mode of reduction practised by Desault.

14. The patient is seated either on a chair or on the side of a bed. The arm is slightly separated from the body, and carried a little forward.

One assistant is directed to fix and secure the trunk in a proper manner. This he does by pulling at the arm of the sound side, taking hold of it near to the hand, and extending it in a direction perpendicular to the axis of the body. This mode of counter-extension is preferable to that commonly employed, which consists in applying the hands to the upper part of the patient’s shoulder. Indeed, on the one hand, the power being farther removed from the resisting force, need not be so great. And, on the other, the body being entirely unencumbered, renders it easy for the surgeon to apply the roller without discontinuing, or in any way disturbing, the extension.

Another assistant makes extension on the fore-arm, which serves him as a lever, where, one hand being placed behind or on the back of the wrist, forms the point of support, (or fulcrum), while the other applied to the anterior and middle part of the fore arm, on which it makes pressure from above downward, represents the power; the fragments to be brought into contact constitute the resistance.

The relaxation of the muscles produced by this semi-flexion of the fore-arm, and the slight separation of the arm from the trunk, greatly favour this mode of extension; a mode recommended by the ancients, adhered to by the English, and which possesses the advantage of leaving uncovered all that portion of the limb on which the apparatus is to be applied, and by that means of allowing the hands of the assistant to keep the same position during the whole time of the application.

A small degree of force, judiciously directed according as the displacement is inward or outward, is sufficient to effect the reduction, which even takes place of its own accord, under this process. If the surgeon lays his hands on the place of fracture, it is rather to examine the state of the fragments, than to assist in bringing them into apposition.

§ VI.

OF THE MEANS OF MAINTAINING THE REDUCTION.

16. All kinds of apparatus for fractures, being nothing but resistances opposed by art, to the powers which produce displacement, it follows, that they should all act in directions precisely opposed to the directions of those powers. But, we have seen (7), that, in the present case, these powers are, 1st, the action of external bodies, favoured by the extreme mobility of the arm and shoulder; 2dly, the action of the latissimus dorsi, the pectoralis major, and the teres major, which carry the inferior fragment inward, or, what is more common, of the deltoid muscle, which draws it outward; 3dly, the contractions of the muscles of the arm, which have a slight tendency to draw the same fragment upwards.

17. Therefore, 1st, to render the arm and shoulder immoveable; 2dly, to carry the upper end of the lower fragment outward or inward, according to the direction in which it is displaced; and, 3dly, to draw this fragment downward, are the three indications that ought to be fulfilled by every bandage intended for a fracture of the neck of the humerus. The last merits less attention than the other two, because, as already observed, the weight of the limb alone is nearly sufficient to answer it.

18. Let us inquire, whether or not the kinds of apparatus, hitherto employed, have been adequate to the fulfilment of these indications.

The ancients, in obedience to the precept of Hippocrates, fixed the arm against the breast, and confined it there by a bandage recommended by Celsus, and constantly employed by Paul of Egina. “Præstat antem, says he, brachium, ad thoracem moderate deligare, ut ne, si id commoveatur, figuram avertat.” Pare still preserved this process, which the moderns have now entirely abandoned, and which, taken alone, could properly fulfil only the first indication. The second indication was less happily fulfilled, by a kind of bandage added to the first, by Celsus, Paul of Egina, and the Arabians, the necessary effect of which was, to force the lower fragment outwards. It is surprising that Heister and Lamotte should have confined themselves to the use of this for the retention of the fragments.

What shall we say of the eighteen-tailed bandage exclusively adopted by Petit and Duverney? The arm, not being fixed by it, was liable to be moved, and the fragments to be displaced by the least shock. There was nothing to prevent the lower fragment from obeying the powers tending to carry it either inward or outward. Indeed the bandage was of no avail whatever in giving support to a fracture, as was observed by Louis, in his “Dissertation on Petit’s Diseases of the Bones.”

Suppose the arm, as some have advised, to be supported only by a sling. Not one of the indications just established (17) could by such means be fulfilled.

Perhaps the bolster of tow proposed by Moscatti, would have surpassed all these means, in the advantages it offered, had it not, by leaving the arm moveable below, and the shoulder above, still favoured a displacement.

Le Dran has also advised the use of a bolster composed of that of Moscatti, and bole Armenian. It fixed the arm more firmly against the trunk and in this respect, certainly approached nearer to the attainment of the object in view.

19. It is obvious, from this comparison between the indications of cure (17), and the means hitherto employed for the fulfilment of them (18), that nothing satisfactory had yet been done, and that a proper apparatus was still a desideratum. The success experienced by Desault, in the use of that which we are about to describe, has perhaps proven, that this desideratum exists no longer.

20. The pieces which compose it, are, 1st, Two rollers, the one from five to six, and the other from eight to ten yards long, each one about three inches wide: 2dly, Three strong splints, of different lengths, each about two inches broad: 3dly, A small bolster made of linen, from three to four inches thick, at one end, tapering like a wedge to the other, and of a sufficient length to reach from the arm-pit to the elbow; 4thly, A sling for the purpose of supporting the fore-arm; 5thly, A piece of linen to surround the whole apparatus.