Part 8

That process or operation in which the surgeon uses his hands to effect the reduction and apposition of parts, which cannot be accomplished by extension and counter-extension alone. If a bone be broken into two or three pieces, mere extension and counter-extension will not bring all the fragments into their proper places, so as to restore the natural form of the part. In such cases, the surgeon uses his hands to aid the action of the extended muscles, and this is the process which our author denominates conformation. The term occurs in many places in the course of the work. TRANS.

A fragment which has penetrated the soft parts, but has not been long exposed to the air, disappears, and is replaced by extension, provided it be properly directed. Being retained afterwards in a state of constant extension, it can neither be displaced, nor cause pain by irritating the parts, which is the inevitable result of the figure of 8 bandage.

In cases of this kind, it is useful to protect the shoulder with a small splint, which may support the turns of the bandage, and prevent their pressure on the splinters, or the broken ends, which they might otherwise disturb. These precautions are alike indispensable when the fracture is double.

CASE IV. Francis Ricord, twenty-five years of age, was received in the month of July, 1790, into the Hotel-Dieu of Paris. On the preceding day, a piece of timber having fallen from a considerable height on his right shoulder, had broken the clavicle of that side into several pieces. Severe pains, which occurred at the moment of the accident, had continued throughout the night, and were still sensibly felt. The slightest motion of the part augmented them to such a degree, as to extort from the patient piercing cries.

The point of the shoulder being very much depressed, was also drawn perceptibly forward and inward; and a large echymosis, without any external wound, occupied its whole extent.

Desault being satisfied that the several fragments were all connected together, and that none of them was separated from the periosteum, placed, as in ordinary cases, the bolster under the arm, completed the reduction, and applied a splint along the course of the clavicle, after having, with his hands, brought the fractured pieces into contact. Confident, then, that the form of the part was perfectly restored, he applied the bandage, which was moistened with vegeto-mineral water, twice or thrice a day.

At the moment of reduction the pains ceased, and were felt no more till the fifth day, when the bandage being a little relaxed, admitted of a slight displacement of the fragments. This displacement was removed, and the pains along with it, by the reapplication of the apparatus.

During the six first days a very strict diet was enjoined. This, however, was dispensed with by degrees, till, on the thirteenth day, the patient returned to his usual regimen. On the seventeenth day, there remained nothing of the echymosis, but a yellow tinge, the customary consequence, of such an accident. The precautions inculcated in the preceding case, were employed also in this, and the patient was discharged perfectly cured, on the forty-second day from the time of his admission. Nor had he experienced, during his treatment, those severe and long continued pains, which, under a different management, so frequently accompany this kind of fracture.

EXPLANATION OF THE FIRST PLATE.

Fig. 1. A bolster made in the form of a wedge, intended to be placed between the arm and the side of the thorax.

a. Its base, which should fit the hollow of the arm-pit.

b. Its summit reversed, against which the elbow is to be applied.

Fig. 2. The first roller applied for the purpose of fixing the bolster against the side of the thorax.

a a. Oblique casts before, passing over the opposite shoulder, in order to hold it up.

b. Oblique casts from behind, crossing the first ones on the shoulder.

d d. Circular casts round the trunk, covering the bolster, which they fix laterally.

Fig. 3. The second roller, applied to fix the arm against the bolster.

a & b. Portions of the oblique casts of the first roller, left uncovered by this one.

c c. Turns of the second roller, covering those of the first, loose above, and tighter below, for the purpose of drawing the superior extremity of the humerus outwards.

d. Their passage over the side opposite to the bolster.

Fig. 4. The third roller intended to keep the point of the shoulder raised.

a a & b. Oblique casts of the first roller, remaining uncovered.

c c. Turns of the second, seen through the opening of those of the third.

d. Oblique casts of the third, ascending from the arm-pit over the shoulder of the diseased side, to descend again behind, along the arm, and pass under the elbow.

f k. A continuation of the preceding casts, reascending under the sound arm-pit, and from thence behind the thorax, over the diseased shoulder.

e. A continuation of the same casts, descending on the fore side of the arm, passing under the elbow, and ascending again under the arm-pit of the sound side.

g. The remainder of the roller, intended to be employed in circular turns, in order to secure the casts e, and prevent them from slipping outward.

Fig. 5. A sling which should be fastened to the oblique cast d (Fig. 4), to support the hand.