Part 17

9. From whence can arise these exaggerated fears? Can it be, as is pretended, the mere communication of the fracture with a joint, that is productive of such serious affections? What relation, then, can reason discover between the cause and the effect? Does not experience answer in other cases, in a manner that admits of no reply, when it furnishes us with the analogy of fractures of the rotula, the olecranon, &c.?

Modern researches have entirely abolished the ancient theory of an effusion of callus into the joint, and with it one of the principal causes assigned by writers for the accidents and evils which they so much dreaded.

The admission of air into an articular cavity, would be, without doubt, in such cases, a consideration of more weight; but this does not occur except in fractures accompanied with wounds, and yet all those in the vicinity of joints, whether compound of not, are regarded as extremely dangerous. Besides, observation has oftentimes proven to Desault, that even the contact of air is not so dangerous as it has been commonly supposed, and many instances occurred to him in his practice, where, notwithstanding such a complication, a perfect cure was obtained.

10. It is, then, to the want of a skilful mode of treatment, and to the irritation experienced in the parts, in consequence of an ill-constructed apparatus being applied to them, that the accidents formerly mentioned (8) ought to be attributed. Such accidents never occurred to Desault, in any of the numerous cases that fell under his care. It is thus that in the fracture of the neck of the os femoris, the insufficiency of the means, is oftentimes productive of unfavourable results.

§ III.

OF THE REDUCTION, AND THE MEANS OF MAINTAINING IT.

11. The displacement here is, in general, inconsiderable, because, being drawn in contrary directions, by the muscles of the arm and fore-arm, the condyls separated from the bone remain stationary between these two forces. A fall, a percussion, or some other external cause, can alone produce a displacement, by communicating some degree of motion to the fragments. Now, from what was formerly said (5 & 6), the condyls may, under such an impulse, move either forward or backward, or else may separate from each other, leaving between them an intermediate void. Hence the apparatus ought to oppose to them a resistance in these four directions, namely, inward, outward, forward, and backward; a resistance which it will be easy to make, by means of four splints, placed in these directions, and properly retained by a roller. The two lateral splints, are particularly necessary, when the condyls are both separated from the body of the bone, and divided from each other (3). If one of them be still attached to the humerus (4), a splint on that side becomes less useful.

12. It is needless for the apparatus to extend as high up as in a fracture of the arm. What effect, in sustaining the fragments, would casts of a roller have, when applied to the body of the bone, above the place of division? Their only advantage would consist in compressing the brachial and triceps muscles, and in that way preventing their action.

On the other hand, the roller must be continued along the fore-arm, in order that the elbow joint may correspond, according to the judicious precept of Paul of Egina, to the middle of the bandage, which is in general more compact and solid, in the middle than in any other part, and also, that a slight compression may be thus made on the muscles attached to the condyls.

13. The pieces which compose the apparatus, are 1st, A roller five or six yards long, and three inches broad, made of soft linen or muslin, and rolled up in a ball. 2dly, Four splints (11), two of them flexible in the middle, in order that they may bend to fit the fold of the arm, and the elbow, and the other two very strong and inflexible, intended to be applied at the two sides.

14. Every thing being arranged, the reduction is effected in the following manner. One assistant is directed to make extension at the upper part of the arm, which he grasps with both his hands; another makes extension on the fore-arm half-bent, which he uses as a lever of the second kind, where one of his hands, being placed under the wrist, forms a fulcrum, while the other applied towards the fold of the arm, represents the power. The surgeon, in the mean time brings the condyls together, adjusts their level and apposition, both between themselves, and with the body of the bone, and then proceeds to the application of the apparatus, the limb being still kept in a half-bent position, as was long since recommended in such cases by Paul of Egina. “Si in vicinia cubiti brachium fractum est, etiam ipse cubitus deligandus, angulari figura servata.”

In this form of lever, the power is applied between the fulcrum and the weight to be moved, or the resistance to be overcome. TRANS.

15. The roller (13), wet with vegeto-mineral water, which facilitates its application, and prevents the swelling of the part, is fastened by one of its ends, about two-thirds down the fore-arm, and continued upwards by oblique and reverse casts, to the joint. The surgeon then passes a cast of the roller from the anterior and superior part of the fore-arm, to the posterior and inferior part of the arm (humerus), redescends by an oblique cast from the other side, over the fore-arm, and returning along the first track, makes a number of casts in the form of the figure of 8, round the joint, which he next covers by circular casts, applied so close to each other, as to leave no opening between them; he then proceeds upwards by oblique casts, as at the first, to the middle part of the arm (humerus), when the roller is given into the hand of an assistant.

The first of the splints (13) is now placed anteriorly on the fore-arm and arm, and, if it does not bend, in such a manner, as to accommodate itself to the fold of the arm, the vacant space beneath it is filled up with compresses, laid on top of each other, so as to make its compression uniform throughout. The second, being applied on the posterior side part of the arm, moulds itself to the projection of the elbow, while the other two occupy the sides. These are secured below by an assistant, while the surgeon resuming the roller, which he had just given out of his hand, fixes them firmly by circular casts descending along the arm and fore-arm.

The limb is then laid on a pillow, so disposed that the hand may be raised higher than the elbow, in order to prevent the subsequent swelling, which is oftentimes produced by the fracture, as has been already mentioned (7).

16. The effect of this bandage is simple, and has a particular relation to those directions and causes, in and by which, displacements might occur. The two lateral splints prevent the separation of the condyls from each other; the anterior and posterior ones prevent them from moving backward or forward; the muscles are compressed; the motion of the joint is prevented; and, in common, no great length of time is necessary for the reunion of the bone.

As soon as this is accomplished, it is of importance to move the limb in every direction, to prevent that stiffness, which is so commonly the consequence of fractures situated in the neighbourhood of joints. The following case, drawn up by Le-geulle, will furnish the reader with a detailed account of the treatment pursued, in such accidents, by Desault.

CASE I. Joseph Kisler, an ostler, aged forty-one, fell from a height of thirty feet, on the left side, his arm being undermost, and fractured the lower end of the humerus. A surgeon gave him immediate assistance, and, at the expiration of two days, he was carried to the Hotel-Dieu.

From the signs formerly mentioned (5 and 7), Desault discovered a fracture, consisting in a separation of the condyls from each other, by a longitudinal division, and from the body of the bone, by a transverse one. The usual apparatus (16) was applied, and, from a state of extreme anguish, which he had till now suffered, the patient experienced immediate relief.

In the mean time, a considerable swelling around the joint, pointed out the necessity of blood-letting, a low diet, and other antiphlogistic remedies. These were immediately had recourse to, and the limb was placed in the proper position (16).

Notwithstanding these precautions, the tumefaction and redness were increased on the following day. The bandage was applied anew, and wet from time to time with vegeto-mineral water.

On the following days, pain less severe, the bandage kept constantly wet with the same fluid.

Eighth day, the swelling almost gone; the apparatus, being loosened, was again reapplied.

Fifteenth day, the fragments, being examined, were found in regular contact, and already united by a substance of considerable firmness; the strictness of regimen gradually relaxed; solid food taken in small quantity.

Nothing new till the twenty-second day, when the splints were laid aside, having become useless, in consequence of the rapid progress of reunion: from this time till the completion of the cure, nothing was used but the simple roller.

On the twenty-fourth day, gentle flexion and extension of the arm and fore-arm were for a short time performed; these movements were attended with acute pain, notwithstanding which, the fortitude of the patient enabled him to persevere in them.

Thirtieth day, no pain accompanies the movements of the arm: the range of these movements visibly increased; the roller laid aside; from this time the range of motion increases rapidly.

On the thirty-seventh day, the patient was discharged perfectly cured, and free from every vestige of his disease, except a trifling stiffness, which was doubtless soon removed by the motions of the joint.