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.