Part 3

The mode of reduction being established, it was necessary, in the next place, to invent a bandage, calculated to retain the broken ends of the bone in contact. Desault thought it practicable to unite these two points of treatment, in the same process, that is to say, to reduce, and at the same time to retain the fracture. Here the art is indebted to him for an improvement, which, I will venture to say, carries it near to perfection. To judge of this, it will be necessary only to take a hasty survey of the different kinds of apparatus proposed by different writers.

§ VII.

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.

The use of this second roller is, to supply the place of the hand of the assistant, in pressing the arm against the side of the thorax; its effect evidently is to draw the upper extremity of the arm outwards, and, as it is already directed backwards, to retain it in that position. The compression of the circular turns on the arm, being thus gradually augmented, becomes, on the one hand, more efficacious, because it acts on a greater surface, and on the other, less troublesome, because, being more divided, it is less felt at the lower extremity of the arm, where it bears with most force.

38. A third indication remains still to be fulfilled, namely, to retain the shoulder in its elevated position, and, by that means, to assist in the extension of the fragments, which already has some effect in preventing a depression.

To fulfil this indication, an assistant sustains the elbow in its elevated position, with one hand, and, with the other, supports the patient’s hand before his breast, while the surgeon fills with lint the hollow spaces around the clavicle. He then applies on the clavicle, at the place where it is fractured, the two long compresses, wet with vegeto-mineral water, or some other cooling liquid. Taking now the last roller, he fixes the end of it under the sound shoulder; from thence he brings it obliquely across the breast, over the long compresses, and carries it down behind the shoulder along the posterior part of the arm, till it passes under the elbow. From this point, he again carries it obliquely upwards across the breast to the arm-pit, then across the back, over the compresses, and brings it down again before the shoulder, along the front of the humerus till it again reaches the elbow. From thence the roller again ascends obliquely behind the thorax, passing under the arm-pit, where the first cast of the roller is covered, and from whence it again starts, to run the same course we have just described. This constitutes a second round, which covers in part the first, and forms a kind of double triangle (e, f, d), situated before the breast, and over the circular turns of the other rollers (c. c. Fig. 4). The remaining part of the roller, brought from behind forward, is employed in circular turns over the arm, and round the thorax, for the purpose of preventing the displacement of the first part. To make it the more secure, it is fastened with pins at its different places of crossing.

The sling (Fig. 4) is next passed under the hand, and fastened above to the ascending turns (d), and not to the circular (c c), which the weight of the hand would be likely to draw downward.

39. It is only necessary to examine the course of this third roller, to see, that, united to the sling, it is well calculated to support the external fragment, which the weight of the shoulder has a tendency to depress, on a level with the internal one. It supplies the place of the assistant, who raises the elbow and supports the hand of the patient, in like manner as the second roller performs the office of the assistant, who presses the lower part of the humerus against the side of the thorax.

On the other hand, the circular turns, by which the application of the third roller is finished, being directed from before backward, push in the same direction the arm and shoulder, which have been already carried that way, by the process of reduction, and thus retain them in their proper places.

Hence may be inferred the truth of the proposition, which we have been endeavouring to demonstrate; namely, that the bandage of Desault, constructed according to the general principle formerly established (20), for fractures of the body of the clavicle, is calculated to retain the external extremity of the humeral fragment upward, outward, and backward.

40. The casts of the rollers, thus surrounding the thorax, however well they may be secured, are yet liable to be displaced, particularly when the patient is in bed. This inconvenience may be avoided, by surrounding the whole with a piece of linen, leaving nothing uncovered, but the sound arm, which is at liberty to perform its usual motions.

The arm of the diseased side, being thus fixed in such a manner, as to constitute a whole or entire body with the thorax, follows its movements, without producing any displacement. It is thus, that by the apparatus for a continued extension of the thigh, the fragments of the _os femoris_, forming an immoveable whole with the pelvis, cannot change their situation, even in following the motions of the trunk.

Hence arises, in fractures of the clavicle, this advantage, that the patient is not obliged to keep his bed, but is able even to attend to his business, during the progress of the cure.

41. I will not dwell on the numerous objections urged by different authors against the bandage which has just been described. What answer, indeed, can be given to those writers, who fancy that they behold the patient in the greatest danger of immediate suffocation; who dread an approaching mortification of the arm of the diseased side; who allege, contrary to the rules of the art, that there is no impression made immediately on the clavicle, but on a neighbouring bone; who, &c. &c.? Twenty times in a year, has experience answered those objections, in the Hotel-Dieu; and there is not a pupil of Desault, who has not, as well in this, as in many other cases, seen that objections, plausible, indeed, when considered in the closet, or at a distance from a sick room, dwindle to nothing at the bed-side of the patient.

42. In those cases (which, as Hippocrates remarks, very rarely occur) where the external fragment projects over the internal one (12), the bandage must be somewhat varied, although the two principal indications, of drawing the shoulder backward and outward, must still, as in other cases, be fulfilled. The only additional circumstance, therefore, necessary to be attended to here, is, not to elevate the shoulder, by pushing it upwards. This may be easily avoided, 1st, by omitting to raise the elbow, when applying the bandage; 2dly, by drawing the third roller a little tighter than usual.[3]

[3] This paragraph is so obscure in the original, that a translation of it would be scarcely intelligible. Instead of a mere translation, therefore, I have given rather a comment on what I believe to be its true meaning. TRANS.

The fragments, being reduced to the same level, and brought into apposition, by this two-fold attention, will unite as in ordinary cases.

If the fracture exist at the end of the clavicle next to the humerus, the difficulty of their being displaced renders the application of the bandage less necessary. Prudence, however, demands that it be not altogether neglected.

§ VIII.

OF THE TREATMENT DURING THE FORMATION OF THE CALLUS.

The regimen to be pursued during the reunion of the clavicle, varies according to circumstances. It is impracticable to lay down general rules, applicable to all affections of this kind. Here, however, much more than in other cases, if the division of the bone be simple, and no unfortunate accident occur, it is always unnecessary to restrain the patient from his usual course of life, beyond the second or third day. But, though internal means are for the most part omitted in the treatment, the apparatus is a subject on which too much attention cannot be bestowed. With whatever degree of exactness it may be at first applied, it will soon become loose, and oppose a diminished resistance to the weight of the shoulder, and the action of the muscles. Hence, unless it be frequently examined, the fragments will be displaced. The following case furnishes a detail of the treatment subsequent to the reduction, to which, in ordinary cases, Desault had recourse.

CASE III. Mary Adel, aged thirty, as she was crossing a path covered with ice, in the severe winter of 1788, fell on the point of her left shoulder, and fractured the clavicle about the middle. Being brought to the Hotel-Dieu a few hours after the accident, she was dressed in the manner just described, and, as the fracture was simple, it was judged sufficient to make a slight diminution in the quantity of her aliment, during the two or three first days. The dressing was moistened every morning, with vegeto-mineral water, at the place corresponding to the fracture.

On the fourth day the piece of linen that surrounded the bandage was removed, for the purpose of examining the state of the parts. Every thing was found in its proper situation, and the covering was replaced till the seventh day, when the rollers appeared to be somewhat relaxed. The apparatus was taken off, and reapplied as at first, the compresses being carefully moistened with vegeto-mineral water, at the part lying over the fracture. After the third day the patient was permitted to return to her usual regimen. The third roller being a little deranged on the tenth day, it was taken off, and reapplied as at first, together with the sling. The fragments were examined and found in perfect contact. The patient was up during the whole day, walked about the house, and experienced no other inconvenience than that of not being able to use the left arm.

On the thirteenth day, the bandage was again reapplied, and allowed to remain till the sixteenth, when the patient having disturbed it, it was once more changed. At this period, the fragments, already firmly united, exhibited scarcely a vestige of the division they had sustained.

The reunion was complete by the twentieth day, when all the pieces of apparatus were dispensed with, except the bolster and the second roller, which were also removed two days afterwards, as they were found to be no longer necessary.

The continued inactivity of the limb, during the treatment, had occasioned a stiffness in the shoulder. This was gradually done away by making the patient move her arm in all directions, twice a day, each time, for the space of an hour.

On the twenty-ninth day she left the hospital, carrying with her nothing to remind her of the injury she had sustained. She was free from that uneasiness which is the consequence of a tedious and ill-managed treatment, during which the exercise of the limb has been neglected.

§ IX.

OF COMPLICATIONS.

44. We are in possession of but few observations particularly relative to the different complications, that may accompany fractures of the clavicle. The treatment, in such cases, varied according to circumstances, must be accommodated to the indications common to all fractures of this kind.

When splinters, displaced in different directions, whether adhering to the bone or not, irritate the soft parts, and, having passed through the integuments, appear without, most practitioners advise to remove them and cut off such parts as project beyond the fractured end of the bone, previously to reduction. This direction is founded on the severe pains which, in such cases, accompany the common treatment of the injury, and which the figure of 8 bandage always augments, by drawing the shoulder inward, and consequently pressing the soft parts against the projecting parts of the fragment, or the points of the splinters. But if the splinters, adhering as yet to each other and to the bone, by means of the periosteum, have not assumed the nature of foreign bodies, (that is, if they be not actually dead) it is always proper to replace them. It is here only that we meet with an occasion for that part of the process, of reduction denominated conformation,[4] which is never requisite in other cases.

[4] 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.