Part 15

Every thing being properly arranged, the reduction, effected in the manner already stated (14), and the assistants still continuing the extension:

1st, The surgeon takes the first roller, wet with vegeto-mineral water, fixes one end of it by two circular turns on the upper part of the fore-arm, and carries it up along the arm by oblique turns, moderately tight, and overlapping each other about two-thirds of their breadth. Having reached the upper part of the limb, he makes some reversed turns to prevent the wrinkles that would be caused by the unevenness that occurs in this place. He then passes two casts of the roller under the opposite arm-pit, and bringing the ball to the top of the shoulder again, gives it into the hand of an assistant.

2dly, The first splint is then placed before, and reaches from the fold of the arm, to a level with the acromion. The second on the outside, reaching from the external condyle to the same level. The third behind, reaching from the olecranon to the fold of the arm-pit. The bolster placed between the arm and the thorax is a substitute for a fourth splint, which is by that rendered unnecessary. An assistant now secures them, by grasping them with his hand towards the curvature of the elbow, so as not to hinder the application of the remaining part of the bandage.

3dly, The surgeon takes hold of the roller again, descends by oblique and reversed turns along the splints, which he fixes by binding them moderately tight, and terminates the bandage at the upper part of the fore-arm, where he had commenced.

4. The assistants still continuing the extension, the surgeon places the bolster between the arm and the trunk, taking care that the thick end be uppermost, if the displacement be in an inward direction, but lowermost, if it be in an outward one, as is most commonly the case (7). The bolster is to be fastened at top by two pins to a cast of the roller.

5. The arm is now pressed towards the trunk, and fixed against the bolster, by means of the second roller. This roller is applied like that which, in fractures of the clavicle, fastens down the arm to the bolster, by the oblique turns c. c. (Fig. 3. plate I.), with this difference, that in the present case, the turns ought to be very tight below, and looser above, if the displacement be in an inward direction. But, on the other hand, if it be outwardly, they must be loose below, and tight above.

6. The fore-arm is now to be suspended in a sling, and the whole apparatus afterwards surrounded by a piece of linen, which, by protecting the casts of the roller from friction, prevents them from being disturbed.

21. If we now compare the action of this apparatus with the indications of cure formerly laid down (17), it will be easy to perceive, that, by it, they are extremely well fulfilled. Indeed, the arm, being firmly fixed against the trunk, cannot move, otherwise than by motions common to it and the trunk, and nothing can derange the lower fragment, which is equally immoveable. Nor can the shoulder communicate any motion to the superior fragment. The bolster being differently disposed, according to the direction in which the lower fragment is displaced, will serve to move it in an opposite direction.

Should this fragment be forced inwards, the thick head of the bolster will separate it to a distance from the thorax. It will be maintained in this state of separation, by the casts of the roller, which, being very tight below, will act on it as on a lever of the first kind, of which the bolster, forms the fulcrum, while the resistance to be overcome is the action of the latissimus dorsi, the pectoralis major and the teres major. The casts of the roller, by pressing the elbow to the body, will draw the fractured end of the bone in a contrary direction; and, in this respect, the bandage may be considered as an artificial muscle, forming a perfect antagonist to the natural ones.

22. If the displacement be in an external direction, as most commonly occurs (7), a contrary effect must be produced, as well by the pressure made by the bandage, on the upper extremity of the displaced fragment, as by the situation of the elbow which is directed outwards by means of the thick end of the bolster being placed lowermost. The external splint will also prevent the displacement outwards, as well by opposing to the bone a mechanical resistance, as in compressing the deltoid muscle, which is the principal cause of the displacement. The derangement of the lower fragment forward and backward, will be prevented by the two splints before and behind.

The displacement longitudinally, already checked by the weight of the limb, will be still further prevented, by the compression made on the muscles of the arm, which are the instruments of displacement, by the splints and the bandage.

23. To the advantage of keeping the fragments exactly in place, this apparatus unites that of not confining the patient, who is not obliged to keep his bed, and to whom a lying position is even, in general, more troublesome and injurious than an erect one. This observation applies to the treatment of fractures of the clavicle, of the scapula, and even of the fore-arm, when no accident has rendered them complicated.

Desault has cured several patients, but more particularly two, who, being obliged to travel daily, did not, except on the day of the accident, deviate in any measure from their usual mode of life.

An inexperienced surgeon sometimes applies the rollers too tight, in which case, a swelling of the fore-arm is the consequence. This is remedied by relaxing the bandage; but if, notwithstanding this, the swelling still continues, it will be necessary to extend the bandage from the hand to the shoulder.

§ VII.

OF THE SUBSEQUENT TREATMENT.

24. The pain ceases as soon as the apparatus is applied, because the fragments, now brought into perfect contact, cease to irritate the surrounding parts. Nor does it return during the treatment, as they are firmly retained, and not suffered again to separate.

It is rare that any serious accident follows this fracture, and, among the numerous examples met with by Desault, he has scarcely ever had one such to encounter: yet he generally paid but little attention to those internal means which are usually combined with external ones. In most cases, the patients pursued the regimen to which they had been accustomed.

In cases, where a considerable swelling attacked the upper part of the joint, a circumstance which occasionally occurs in practice, one or two bleedings, a diet more or less strict, and the use of diluent drinks, constituted the internal treatment. Of this the following case, related by Brochier, furnishes a detail.

CASE II. Maria Catharine Bardelle, aged forty-five, of a high complexion, fell, as she was carrying a heavy load, on the elbow of the right side, the arm being extended a little from the body. The neck of the humerus was fractured, and all the usual signs combined in pointing out the nature of the accident.

A surgeon was immediately called, who mistaking it for a luxation, made useless attempts to reduce it, tormented the patient for half an hour, and then left her to be sent to the Hotel-Dieu.

Desault discovered it at first sight to be a fracture, and foreseeing the consequences of the improper steps that had been taken, ordered blood-letting, and a low diet, after having effected the reduction, and applied the apparatus already described (20).

In the evening, a considerable swelling appeared around the articulation; the pains continued; a diluting drink composed of dog-grass and oxymel was prescribed. Second day, the swelling is gaining ground; pains increased; blood drawn again; diet and drink continued; apparatus is frequently wet with vegeto-mineral water, particularly at the upper part. Third day, a little better; pains diminished, swelling checked; weak soup is allowed. Fourth day, a diminution of the swelling; pains almost gone. Sixth day, the swelling has almost disappeared; light food; bandage, having become loosened, is reapplied.

Tenth day, tongue foul; nausea; want of appetite; symptoms of a bilious diathesis. Bitter drink is prescribed; the day following, a grain of tartar emetic is given in solution.

Thirteenth day, the patient is in her ordinary state; the apparatus is renewed. Twenty-fourth day, the reunion is evidently advancing. Thirty-second day, the consolidation is complete.

The patient now began to perform gentle motions with the limb, which she gradually increased, till about the fortieth day, when she was perfectly well, and free in all her motions.

25. I will here repeat an observation, already made, on the subject of the bandage for the clavicle, of which this is nothing else than a modification. In a short time the bolster sinking downward, the bandage becoming relaxed, and the splints less tight, do not effectually oppose a displacement, unless the bandage be daily examined, and reapplied, when it seems to act too feebly. There are many surgeons, who have not been fortunate in retaining the fragments with exactness, because, trusting too far to the action of the bandage, they have for a long time neglected to examine it; this remark is applicable to every apparatus composed of rollers.

26. Here, much more than in other cases, it is all-important that the limb be accustomed to motion, after the process of consolidation. Situated near to the joint, the fracture always leaves some stiffness in it, which time no doubt wears away, but which will sooner disappear under the above treatment.