Part 2

CASE II. Claudius Laurat, aged twenty-seven, fell as he was carrying a heavy burden. In his fall his chin struck with violence against a beam that lay in his way. In an instant he experienced a sharp pain in his right temple, and found it almost impossible to move his jaw. Two hours afterwards a considerable swelling appeared in the part, extending from the angle of the jaw above the ear. The patient was admitted into the Hotel-Dieu, where the circumstances of the fall and the symptoms that followed, gave satisfactory evidence of a fracture of the condyle. It was reduced and supported as in the preceding case. On the day following, the swelling was removed, doubtless by means of the compression which had been made on it; the other symptoms (3), hitherto scarcely perceptible, became more obvious; the bandage was reapplied, and the disease terminated, in about twenty-nine days, in the same manner with that of case 1.

MEMOIR II.

ON THE FRACTURE OF THE CLAVICLE.

§ I.

1. Man enjoys an advantage which nature has bestowed on but few of the quadrupeds, namely, a power of moving his upper extremities in every direction. The clavicle being a kind of arch placed between the breast and shoulder, forms a centre, moveable indeed but solid, for these motions, a part of which can no longer be performed, when this arch, in consequence of being broken, ceases to afford them a point of support. Hence it follows, that the fracture of this bone may be said to reduce the individual who sustains it, when considered in relation to its functions, to a level with that numerous division of animals that are destitute of clavicles.

2. Few diseases of the kind are more frequently met with than this. The natural curve of the clavicle, its situation immediately under the skin, the want of a support to its middle part, the great proportion of spongy substance which enters into its composition, the projection of the shoulder exposing it to the action of external bodies; all these circumstances concur in rendering the accident frequent, particularly among that class of men subject, from their occupations, to violent exertions of the upper extremities.

Here then, more than in the generality of fractures, we should feel an interest in the advancement of the art of surgery; and yet, having hitherto employed in it but feeble means, our efforts have been attended with imperfect success. Hippocrates has observed, that some degree of deformity almost always accompanies the reunion of a fractured clavicle; all writers since his time have made the same remark; experience has confirmed the truth of it, and as much time has been spent in hypothetical speculations to explain the accident, as in serious inquiries how to prevent it. At length Desault proved that a feeble and unskilful mode of treatment was the sole cause of a want of success, and that, by being more correct and judicious, art might be as successful here, as in other fractures. In order to give a correct view of his practice in this disease, I will examine the causes, varieties, and signs of a fracture of the clavicle; the accidents of which it is susceptible; the mode and the causes of the displacement of the broken ends of the bone; the indications that arise out of those causes, and the manner of answering these indications as well during, as after, the reduction.

§ II.

OF THE CAUSES AND VARIETIES.

3. The action of external bodies is almost the only known cause of this fracture, whether these bodies strike the shoulder with violence, or the shoulder be forcibly driven against them. But this action is not in every case the same; its application is most frequently mediate or indirect, but is sometimes immediate or direct.

In the first case there is a true _counter-stroke_, the ordinary effect, either of a severe blow on the point of the shoulder, which is the most common occurrence; or, as happens less frequently, of a fall on the arm when it is extended for the purpose of guarding the body from the force of the accident. Under these circumstances, being pressed between the sternum, which makes resistance, and the body which acts on its extremity, the clavicle is bent in that direction which is most natural to it; but, not being sufficiently flexible, it gives way generally in the place where its curvature is the greatest. Thus the ribs are broken, when the sternum, by being violently driven backward, forces them to bend in the centre beyond their natural flexibility.

In the second case, the fracture occurs at the spot where the stroke is given. Here the momentum or quantity of force applied on the bone, surpassing the solidity which the bone possesses, its continuity is necessarily destroyed.

4. But in whatever way the fracture is produced, it is either oblique or transverse, single or double, in the middle or towards the extremities of the bone, simple or compound.

An oblique fracture is most frequently the effect of a _counter-stroke_; a transverse fracture is the more common result of the immediate action of external bodies; a counter-stroke seldom produces any thing but a simple fracture; while compound fractures are generally owing to a direct stroke. The one produces a solution of continuity in the middle of the bone, or thereabout; because in that part the curvature is most considerable. The other is almost always the cause of this solution, when it occurs at the extremities. To the latter alone, is a double division to be attributed. The reason of these differences is already so plain, that it would be a waste of time to dwell on an explanation of them.

§ III.

OF THE SIGNS.

5. The several phenomena that attend a fracture of the clavicle, taken together, leave in general but little doubt as to its existence, particularly when the fracture is oblique. As is the case in most other instances of the kind, so here, an acute pain is felt at the instant of the stroke; sometimes a cracking of the bone is distinctly heard by the person injured; on every occasion, it becomes suddenly impracticable to perform circular or rotatory motions with the arm; motions from before backwards can still be executed, but are difficult and painful, and, as I have already observed (1), the individual injured is reduced to the class of animals destitute of clavicles.

Oftentimes the shoulder of the injured side, being more or less depressed, loses its level with the other. It is also evidently drawn forward and inward. The distance between the acromion and sternum, on the affected side, is found on comparison, to be evidently less than on the opposite side. In almost every case, that portion of the fractured bone, which adheres to the sternum, forms a visible protuberance above and on the inside of the shoulder.

6. In the mean time the pain continues. The painful drawing or dragging occasioned by the weight of the arm forces the patient, for the purpose of relieving it, to bend his body towards the side affected, and incline his head in the same direction. This forms a peculiar attitude, which of itself was frequently sufficient to disclose to Desault the nature of the disease. We have oftentimes witnessed him establishing the truth of this diagnostic, by merely looking at patients entering the amphitheatre, who had been brought thither for the reduction of such fractures.

By this position, the pains are generally relieved, because the arm finds some degree of support; but should the patient wish to change his position, or perform any particular motions, the pains return almost as acutely as at first.

7. If to these signs, which are almost all of them founded in reason, we add those that are still more palpable to the senses, such as the mobility of the two broken ends of the bone; the crepitation produced by their friction against each other; the depression felt at the point of fracture, by passing the fingers over the upper surface of the bone; and the facility of restoring to it its natural form and direction, by moving the shoulder upwards, outwards, and backwards; it will be difficult to be mistaken respecting the nature of this fracture. This is perhaps more particularly the case, when the fracture is oblique, as this kind offers the most striking diagnosis, and cannot be involved in uncertainty, unless when a considerable swelling occurs in the parts around the fracture. But, even then, as the circumspection of the practitioner will necessarily direct his attention to this circumstance, the obscurity of the signs will have no unfavourable influence on the cure.

8. When the fracture is transverse, there is sometimes more difficulty attending the diagnosis. The corresponding inequalities of the divided surfaces may mutually penetrate each other and interlock, and thus prevent a displacement. Does any uncertainty on this score exist? Placing your fingers on the two extremities of the bone, order an assistant to move the arm in every direction, and the motions will be communicated to the clavicle; but, if a fracture exist, they will be most perceptible in the fragment adjoining the shoulder, and will separate it from that attached to the sternum. This method will seldom deceive us, is easily employed, and subjects the patient to but a momentary pain.

§ IV.

OF ACCIDENTS.

9. We do not generally find fractures of the clavicle accompanied by such accidents as the anatomical relations of the parts might lead us to apprehend. The external force being all expended in fracturing the bone, extends but feebly to the brachial plexus, which would be much injured by the shock, were the bone to yield, without breaking, to the action of external bodies striking against it. Hence, without doubt, would arise serious affections, as may be fairly inferred from the analogy of blows on the head and vertebral column, and as is indeed confirmed by certain cases reported by Desault.

CASE I. Two bricklayers were brought to the Hotel-Dieu, who had met with similar accidents. A piece of timber, thrown from a building, in which they were engaged, had struck them, the one on the external part of the left clavicle, the other about the middle of the right. A considerable wound pointed out in each the place on which the blow had been received. But the former, having escaped a fracture, experienced nothing but an acute pain, while the second had the bone broken in two places.

The customary apparatus was applied to the latter, and the treatment which we shall presently describe, being pursued, the result was that complete success which never failed to crown the attentions of Desault. In the other patient a considerable swelling made its appearance the day after the accident. On the third day a numbness and partial loss of the power of motion occurred in the arm of the affected side. Soon afterwards an insensibility came on, and by the seventh day, the paralysis of the arm was complete. It was not till after a tedious treatment, an account of which would be foreign from my present subject, that the limb recovered in part its original strength.

From whatever cause the fracture of the clavicle in this latter patient was prevented, it is evident, that the whole of the force employed to produce the fracture in the other, acted here on the brachial plexus, and gave rise, by means of concussion, to the accidents which followed.

10. The axillary artery, though running near to the clavicle, in common with the brachial nerves, experiences, notwithstanding, less frequently than they do, injurious effects from the fracture of this bone. I know not of any instance where a puncture from the broken ends of the clavicle has produced in this artery a false aneurism. To conclude, like all other fractures, that of which we are now treating, may be connected with wounds, splinters, &c. But in general, as Hippocrates remarks, the fracture of the clavicle assumes in common cases a mild aspect.

§ V.

OF DISPLACEMENT.

11. Most of the symptoms formerly mentioned (5 and 6) as accompanying a fracture of the clavicle, are evidently the result of a displacement of its broken ends. Yet this phenomenon, taken notice of by all authors, and considered by them as a necessary effect of the disease, does not occur in every case (8). There are instances, in cases of transverse fractures, where the extremity attached to the shoulder, has retained its natural position. Three examples of this kind occurred in the Hotel-Dieu in the course of the year 1787.

12. Instances have also been known, in which the sternal fragment, when fractured obliquely upwards, has supported the end of the humeral in such a manner as to prevent any derangement. Desault was accustomed to relate several cases, where similar occurrences took place; but, in general, this state of things is rare, in comparison with that in which the fragments lose their natural level.

Almost always, then, there is more or less of a perceptible overlapping (_chevauchement_) produced, either, by the elevation (a circumstance which is very rare) of the external fragment over the internal; or, (as commonly occurs) by the depression of the former beneath the latter.

13. Of the first of these modes of displacement (a mode but rarely mentioned by authors) a few examples are to be found among the observations of Desault, one of which he has recorded in his journal. Hippocrates speaks of the phenomenon as a thing that was familiar to him.

14. The second kind of displacement, that which we constantly find in practice, and which the laws of muscular action render almost inevitable, takes place in such a manner that the shoulder appears to obey the impulse of two powers, one of which draws it downwards, and along with it the external fragment of the clavicle, which is displaced by this power in the direction of its transverse diameter, or thickness. The other power approximates the shoulder to the breast, and draws it forward, carrying along with it the same fragment, which is by this means displaced in a longitudinal direction.

That we may the better understand them and their effects, let us, in our minds, separate these two powers, although they are perfectly simultaneous in their action. A knowledge of them will lead us to a knowledge of the resistances which ought to be opposed to them. But let us first remark, that the humeral fragment, being drawn downward and inward, takes sometimes such a direction, that its internal extremity passes backward under the sternal fragment, its external end continuing to point forward: this disposition can be understood from its natural direction.

15. The first of these powers, namely, that which depresses the point of the shoulder, appears to have escaped the notice of the ancient physicians of Greece, who attributed the apparent depression of this part, to the elevation of the sternal fragment, and, accordingly, endeavoured by making compression on the latter, to restore it to a level with the other. Hippocrates, more judicious than those who had preceded him, demonstrated that their doctrine, false in its principles, was still more dangerous in its consequences, and that the sternal fragment being immoveable, lost its relative position with respect to the humeral, only because the latter was depressed by the weight of the arm. This doctrine of the father of physic is satisfactorily proved, by a comparison of the sound shoulder with the diseased one, and has since been admitted by all practitioners. Indeed, the mere recollection that one of the uses of the clavicle is to support the shoulder at that level necessary for the performance of its functions, is alone sufficient to convince us, that, in case of its ceasing to fulfil that office, the shoulder must obey the laws of its own gravity, increased by that of the hand and arm.

16. The illustrious Petit, and with him Duverney, in acknowledging this cause of displacement, have added to it as another the action of the deltoid muscle on the external end of the bone; in this action, the end of the clavicle is the moveable point, while the humerus affords the fixed point. But how can we admit this cause, when the humeral fragment, in passing under the sternal, moves in a backward direction? So far is the deltoid muscle from drawing the bone downward, that here the bone rather draws the muscle in part backward, and yet, in such a case, the displacement is as perceptible as in any other. Besides, when the sternal fragment, broken obliquely upwards, supports the humeral and prevents a displacement, why does not the deltoid produce this displacement?

It is then in the weight of the arm and shoulder alone, that we must look for the passive power, which depresses them, and which produces a displacement in the direction of the transverse diameter or thickness of the clavicle.

17. A second power, highly active, co-operates with this. I allude to the permanent contraction of the muscles, that extend from the breast to the clavicle and shoulder: from this cause arises the displacement in the longitudinal direction of the bone.

The pectoralis major, the pectoralis minor, the subclavius, the serratus major, and the trapezius, unite their efforts in producing this displacement. These muscles are, in certain respects, antagonists to each other, but they all unite in drawing the shoulder forward and inward. None of them appears to act with more effect than the pectoralis major. To this, in particular, is to be attributed the displacement in a forward direction.

Except in the instances stated above, the action of the muscles is not immediate. They act only secondarily on the external fragment, which, being stedfastly attached to the scapula and humerus, is obedient to the motions impressed by the muscles on these two bones; motions which, in a sound state, the clavicle has a power of controlling.

18. To the weight of the lower extremity (15 and 16), and the spontaneous action of the muscles (17) must be added, as another cause of displacement, the motions which are communicated to the arm by external bodies, and which, being imparted ultimately to the clavicle, derange the fragments, by separating them, approximating them, or making them overlap each other, according to the direction in which they act.

19. When a fracture occurs at the extremity next the shoulder, no displacement of the fragments in general takes place. This circumstance is attributed to the action of the trapezius, which draws each fragment upwards with equal force. However this may be, it is doubtless to such cases that we must refer the complete cures, obtained without any retentive apparatus, by Gasparetti, Brown, and other writers. Hence also, without doubt, arise the difficulties experienced by certain practitioners, such as Duverney, with respect to the diagnosis of this disease. These fractures may be mistaken for fractures of the acromion, being situated so immediately in its vicinity.

§ VI.

OF THE REDUCTION.

20. On looking into the causes of that displacement (15 ... 18), so common in fractures of the clavicle, it appears that in almost every case, the external extremity of the humeral fragment is drawn, by a double power, downward, inward, and forward. Hence it follows, 1st. That the resistance opposed to this power, by the means used for the purpose of reduction, and the retentive apparatus subsequently employed, ought to be directed upward, backward, and outward, these directions being the reverse of those in which the powers of displacement act: 2dly. That, in as much as these powers, viz. the weight of the parts and the action of the muscles, are in constant operation, and, besides, as the motions of the arm are continually disturbing the fragments of the bone, the apparatus ought to be equally constant in its action, and should keep up, without any remission, the effect produced, at first, by the means of reduction. This principle is applicable to every case, and ought to be the standard of comparison, for determining the advantages or disadvantages of different bandages, and processes for the reduction of fractures of the clavicle.

21. But we are not to suppose, that these processes have heretofore manifested an exact application of this rule. Hippocrates directed to press the arm close to the ribs, and at the same time to push it upwards, in such a manner, as to make the shoulder appear as sharp and pointed as possible. Hence his precept, to lay the patient down on his back, the back being supported by some projecting body, and then to press the shoulders backward; hence again, when the humeral fragment is drawn inward, his advice to press the elbow close to the breast. This twofold expedient was attended with great difficulties, even under the direction of the father of medicine. Celsus only copied Hippocrates, adding nothing whatever to his mode of practice. Paul of Egina, more judicious in this case, conceived, that for the purpose of forcing the shoulder outward, and rendering it, agreeably to the idea of Hippocrates, very projecting and sharp, it would be advisable to place the fulcrum or point of support, not in the middle of the back, but under the arm-pit. A woollen ball was employed by him for this purpose, a practice which would, at once, have carried the art near to perfection, if, after being employed to reduce the fragments, this process had been continued for the purpose of retaining them in apposition.

22. No new method distinguished the surgery of the Arabians. It is necessary to come down to the time of Guy of Chauliac, before we meet with the method which is almost universally adopted at present, and which consists in placing between the shoulders, the knee of an assistant, whose hands are to be employed in drawing them forcibly backwards. But it is evident that this is only doing, while the patient is in an erect position, what Hippocrates did, after having laid him with his back on a projecting body. Here, then, the art seems to have degenerated, after the time of Paul of Egina: and, indeed, on comparing this process with the general principles already established (20), it will be immediately perceived, that the powers of replacement do not here act in an opposite direction to those of displacement.

Hence the difficulties of reduction, the time spent in the operation, and the sufferings by which it was sure to be accompanied. The fragments were brought together, it is true; but it was only by varying the movements, and changing their direction, that the point of contact was ultimately found.

23. Desault conceived, in the year 1768, that to reduce, in the most effectual manner, a fracture of the clavicle, it was necessary not only to push the shoulder backward and upward, as was commonly done, but, above all, to force it outward, and that the power destined to draw it in this latter direction, ought to act horizontally, according to the course of the clavicle, in the same way, as, in an oblique fracture of the thigh or leg, the extension for replacing the fragments is made in the direction of the bone.

24. As the union of the humerus to the clavicle, by means of the scapula, communicates to the one the movements of the other, it is easy, by placing the ball used by Paul of Egina, under the arm-pit, to convert the arm into a lever of the first kind.[2]

[2] That form of lever, where the weight to be raised or the resistance to be overcome, is at one end, the force at the other, and the fulcrum or prop between them. This form is well represented by the handle of a pump, where the piston is the weight or resistance, the hand of the drawer of water the force, and the iron pin, on which the handle works, the fulcrum or prop.

TRANS.

The lower extremity of the arm being then pressed towards the body, the upper end is separated from it, and becomes, with regard to the clavicle, what the efforts of an assistant who makes the extension, in a fracture of the leg, are to the foot of the patient.