Part 6

OF THE MEANS OF RETAINING A REDUCTION.

25. Here all authors seem to have been directed by the same principle. This is to keep the shoulder of the affected side, 1st, drawn forcibly backwards, 2dly, approximated towards the shoulder of the sound side. Such was the practice of the Greek physicians, whom we have seen in common with Hippocrates, Celsus, and Paul of Egina, employing a kind of bandage, varied in its form, according to the displacement it was intended to remedy.

Above all others, we find an application of this principle, in the figure of 8 bandage, a particular form, which was employed in practice by Albulasis, an Arabian, and afterwards by his countrymen, as well as by Lanfranc, Guy of Chauliac, and their contemporaries. The use of this bandage was continued by Pare and his successors, and has been lately modified by several authors, such as Heister, Petit, Brunninghausen, &c.

26. But under whatever form it shows itself, its action is always the same, and always insufficient. On comparing its effect with the general principle, on which every apparatus for the clavicle should be constructed (20), we perceive, that it by no means answers the threefold indication, of retaining the shoulder backward, outward, and upward.

27. In relation to carrying the shoulder backward it loses half of its effect, because, its force being decomposed (so to speak) by the obliquity of its direction, is divided into two channels. One of these runs parallel to the shoulder and acts to no purpose, while the other, being perpendicular to it, is alone effective; hence it must act with a force equal to 10, in order to produce an effect equal to 5.

28. The indication, to draw the humeral fragment outward, far from being fulfilled, is here diametrically counteracted. The scapula, being approximated to that of the opposite side, draws the humeral fragment towards the trunk, making it underlap the internal one, and, in this respect, the figure of 8 bandage acts posteriorly in precisely the same manner, during the treatment, that the contractions of the muscles did anteriorly before the reduction.

29. Should the shoulder be supported, at such an elevation, as might have a constant tendency to destroy the influence of its own gravity? this is evidently prevented by the very oblique direction of the turns of the bandage. Suspending the arm in a sling, is the only way, in which that end can be attained. But does this mode always possess sufficient firmness and stability? The arm, not being here sufficiently fixed, may be constantly in motion, which, by deranging its situation, must communicate very troublesome and injurious movements to the fragments of the clavicle. One of the principal faults of all bandages consists, in not preventing these movements, by restraining the movements of the arm.

To the other disadvantages of this mode, need I add that of its making, by the turns of the bandage, an undue compression on the projecting edges of the arm-pit, and producing thereon troublesome and painful excoriations?

30. From the want of a mutual correspondence and fitness between the indications already enumerated (20), and the manner in which the figure of 8 bandage acts, it is evident that the former can never be satisfactorily fulfilled by the latter. Hence we may judge, what improvement the art has received from the iron cross of Heister, the compress of Petit, drawn transversely over the oblique turns of the bandage, the waistcoat which Brasdor fastened round the thorax of his patients, and the leathern apparatus, lately proposed by a German practitioner. These means, though diversified in their form, are similar in their effect, and, being nothing but modifications of the figure of 8 bandage, possess, like it, the radical fault of not offering a resistance directly opposed to the two-fold power, arising from the muscular action and the gravitation of the shoulder.

As to what remains, it will be sufficient to show the insufficiency of the process of reduction (22), by means of the knee placed between the shoulders, in order to demonstrate the existence of a like insufficiency in all those forms of apparatus, which, as Brasdor remarks, have for their object a continuance, during the treatment, of the effect produced by that process.

31. On the other hand, those indications will be fulfilled with exactness, by such a form of apparatus as will render permanent the action of the means of reduction which were employed by Paul of Egina, by certain Arabian physicians, and by Pare; which have been renewed by Desault, and tend to draw the shoulder upward, backward, and outward (23 and 24).

Pecceti appears, in the last century, to have had a faint view of the proper indication on this subject, when, under the article of fractures, he advises the ball to be suffered to remain under the arm during the treatment of the injury. But the figure of 8 bandage, united to this expedient, counterbalances its effect, rendering it of no avail, and Pecceti was therefore no more successful than others, in obtaining a cure of the fracture, unaccompanied by deformity.

32. An overlapping more or less perceptible never failed to accompany the consolidation or knitting of the bone, and here, as in many other cases, practitioners laboured to explain what they knew not how to prevent. The impracticability of surrounding the part, as in other fractures, with a circular bandage, appeared to Heister, Petit, and Duverney, to be the cause of this deformity. They supposed that to be a superabundant callus, which was nothing but a displacement of the fragments. These visionary hypotheses ceased to exist, as soon as this displacement was prevented by a proper apparatus.

Desault sought for this form of apparatus, as well as for his other bandages, in the multiplied application of means already known, without inventing new ones. Bandages and compresses, easy to be procured, and already rendered familiar to surgeons by daily use, served him for the construction of his apparatus, for which several machines had been already proposed.

33. The pieces of which this apparatus is composed, are,

1st. Three rollers, three inches broad; the two first, six, and the other eight, ells long, each one rolled up separately.

2dly. A bolster or pad (a, b, Fig. 1), made in the form of a wedge, out of pieces of old linen. Its length should be equal to that of the humerus, its breadth four or five inches, and its thickness at the base (a), about three inches.

3dly. Two or three long compresses.

4thly. A small sling for the arm, (Fig. 5).

5thly. A piece of linen large enough to cover the whole bandage.

Every thing being properly arranged, the following is the mode of applying the apparatus, which of itself reduces the fracture.

34. The patient being placed in a standing position, or, if his case render that impracticable, on a seat without a back, an assistant elevates the arm of the affected side, and supports it at nearly a right angle with the body (Fig. 2), while the surgeon places under the arm-pit the head of the bolster, which descends along the side of the thorax, and which another assistant, situated at the patient’s sound side, holds by the two upper corners.

35. The surgeon now takes one of the first rollers, applies the end of it on the middle of the bolster, fixes it there by two circular turns round the body, and passes a turn obliquely (a a) along the fore part of the thorax, ascending to the sound shoulder: the roller then descends behind, passes under the arm, and returning in front of the thorax, makes a circular turn and a half, horizontally. Having reached the hind part of the thorax, it reascends obliquely by the cast (b), as it had done before, and passes over, before, and under, the sound shoulder; having thus crossed the turn (a a), the roller again passes across the hind part of the thorax, and finishes by circular turns, which completely cover the bolster. A pin is now to be fixed in the place of crossing of the roller on the sound shoulder, to prevent the turn (a) from slipping downward.

The application of this first roller is intended for no other purpose, than firmly to fix the bolster which is held up by the two oblique turns before and behind, and secured against the body, by the subsequent circular turns.

36. The bolster being fixed, the surgeon applying one hand to its external surface, pushes it upwards, and, with the other, taking hold of the elbow, after having half-bent the fore arm, lowers the arm, till it is laid along the bolster. He then presses its lower extremity forcibly against the side of the thorax, pushing it upwards at the same time, and directing its upper extremity a little backwards.

The application of the bandage constitutes a part of the process of reduction. The humerus, now converted into a lever of the first kind, is drawn at its upper end from the shoulder, in proportion as its lower end, is approximated to the thorax. The scapulary fragment being drawn along with it, and directed at the same time upward and backward, comes into contact with the sternal fragment, and in an instant the deformity of the part disappears.

37. The arm being thus situated, is given in charge to an assistant, who retains it in the same position in which he received it from the surgeon, by pressing on it with one hand, and with the other supporting the fore arm half bent, and placed horizontally across the breast.

The second roller is next to be applied. The end of this is carried under the arm-pit of the sound side. It is then brought across the breast, over the superior part of the diseased arm, and extends across the thorax behind till it passes under the arm-pit. Two circular turns cover the first. The roller must then ascend to the lower part of the shoulder, by oblique turns (c. c. Fig. 3), each of which must be overlapped by the succeeding one, to the extent of about the third part of its breadth. It is necessary that these turns be applied in such a way, as to bind but very gently above, and to increase in tightness, as they descend nearer to the lower extremity of the humerus.