16. All kinds of apparatus for fractures, being nothing but resistances
opposed by art, to the powers which produce displacement, it follows,
that they should all act in directions precisely opposed to the
directions of those powers. But, we have seen (7), that, in the present
case, these powers are, 1st, the action of external bodies, favoured
by the extreme mobility of the arm and shoulder; 2dly, the action
of the latissimus dorsi, the pectoralis major, and the teres major,
which carry the inferior fragment inward, or, what is more common, of
the deltoid muscle, which draws it outward; 3dly, the contractions of
the muscles of the arm, which have a slight tendency to draw the same
fragment upwards.
17. Therefore, 1st, to render the arm and shoulder immoveable; 2dly, to
carry the upper end of the lower fragment outward or inward, according
to the direction in which it is displaced; and, 3dly, to draw this
fragment downward, are the three indications that ought to be fulfilled
by every bandage intended for a fracture of the neck of the humerus.
The last merits less attention than the other two, because, as already
observed, the weight of the limb alone is nearly sufficient to answer
it.
18. Let us inquire, whether or not the kinds of apparatus, hitherto
employed, have been adequate to the fulfilment of these indications.
The ancients, in obedience to the precept of Hippocrates, fixed the
arm against the breast, and confined it there by a bandage recommended
by Celsus, and constantly employed by Paul of Egina. “_Præstat antem_,
says he, _brachium, ad thoracem moderate deligare, ut ne, si id
commoveatur, figuram avertat_.” Pare still preserved this process,
which the moderns have now entirely abandoned, and which, taken alone,
could properly fulfil only the first indication. The second indication
was less happily fulfilled, by a kind of bandage added to the first,
by Celsus, Paul of Egina, and the Arabians, the necessary effect of
which was, to force the lower fragment outwards. It is surprising that
Heister and Lamotte should have confined themselves to the use of this
for the retention of the fragments.
What shall we say of the eighteen-tailed bandage exclusively adopted
by Petit and Duverney? The arm, not being fixed by it, was liable to
be moved, and the fragments to be displaced by the least shock. There
was nothing to prevent the lower fragment from obeying the powers
tending to carry it either inward or outward. Indeed the bandage was of
no avail whatever in giving support to a fracture, as was observed by
Louis, in his “Dissertation on Petit’s Diseases of the Bones.”
Suppose the arm, as some have advised, to be supported only by a sling.
Not one of the indications just established (17) could by such means be
fulfilled.
Perhaps the bolster of tow proposed by Moscatti, would have surpassed
all these means, in the advantages it offered, had it not, by leaving
the arm moveable below, and the shoulder above, still favoured a
displacement.
Le Dran has also advised the use of a bolster composed of that of
Moscatti, and bole Armenian. It fixed the arm more firmly against
the trunk and in this respect, certainly approached nearer to the
attainment of the object in view.
19. It is obvious, from this comparison between the indications of
cure (17), and the means hitherto employed for the fulfilment of them
(18), that nothing satisfactory had yet been done, and that a proper
apparatus was still a desideratum. The success experienced by Desault,
in the use of that which we are about to describe, has perhaps proven,
that this desideratum exists no longer.
20. The pieces which compose it, are, 1st, Two rollers, the one from
five to six, and the other from eight to ten yards long, each one about
three inches wide: 2dly, Three strong splints, of different lengths,
each about two inches broad: 3dly, A small bolster made of linen,
from three to four inches thick, at one end, tapering like a wedge to
the other, and of a sufficient length to reach from the arm-pit to
the elbow; 4thly, A sling for the purpose of supporting the fore-arm;
5thly, A piece of linen to surround the whole apparatus.
Every thing being properly arranged, the reduction, effected in the
manner already stated (14), and the assistants still continuing the
extension:
1st, The surgeon takes the first roller, wet with vegeto-mineral water,
fixes one end of it by two circular turns on the upper part of the
fore-arm, and carries it up along the arm by oblique turns, moderately
tight, and overlapping each other about two-thirds of their breadth.
Having reached the upper part of the limb, he makes some reversed turns
to prevent the wrinkles that would be caused by the unevenness that
occurs in this place. He then passes two casts of the roller under the
opposite arm-pit, and bringing the ball to the top of the shoulder
again, gives it into the hand of an assistant.
2dly, The first splint is then placed before, and reaches from the fold
of the arm, to a level with the acromion. The second on the outside,
reaching from the external condyle to the same level. The third behind,
reaching from the olecranon to the fold of the arm-pit. The bolster
placed between the arm and the thorax is a substitute for a fourth
splint, which is by that rendered unnecessary. An assistant now secures
them, by grasping them with his hand towards the curvature of the
elbow, so as not to hinder the application of the remaining part of the
bandage.
3dly, The surgeon takes hold of the roller again, descends by oblique
and reversed turns along the splints, which he fixes by binding them
moderately tight, and terminates the bandage at the upper part of the
fore-arm, where he had commenced.
4. The assistants still continuing the extension, the surgeon places
the bolster between the arm and the trunk, taking care that the thick
end be uppermost, if the displacement be in an inward direction, but
lowermost, if it be in an outward one, as is most commonly the case
(7). The bolster is to be fastened at top by two pins to a cast of the
roller.
5. The arm is now pressed towards the trunk, and fixed against the
bolster, by means of the second roller. This roller is applied like
that which, in fractures of the clavicle, fastens down the arm to the
bolster, by the oblique turns _c. c._ (Fig. 3. plate I.), with this
difference, that in the present case, the turns ought to be very tight
below, and looser above, if the displacement be in an inward direction.
But, on the other hand, if it be outwardly, they must be loose below,
and tight above.
6. The fore-arm is now to be suspended in a sling, and the whole
apparatus afterwards surrounded by a piece of linen, which, by
protecting the casts of the roller from friction, prevents them from
being disturbed.
21. If we now compare the action of this apparatus with the indications
of cure formerly laid down (17), it will be easy to perceive, that, by
it, they are extremely well fulfilled. Indeed, the arm, being firmly
fixed against the trunk, cannot move, otherwise than by motions common
to it and the trunk, and nothing can derange the lower fragment, which
is equally immoveable. Nor can the shoulder communicate any motion
to the superior fragment. The bolster being differently disposed,
according to the direction in which the lower fragment is displaced,
will serve to move it in an opposite direction.
Should this fragment be forced inwards, the thick head of the bolster
will separate it to a distance from the thorax. It will be maintained
in this state of separation, by the casts of the roller, which, being
very tight below, will act on it as on a lever of the first kind,
of which the bolster, forms the fulcrum, while the resistance to be
overcome is the action of the latissimus dorsi, the pectoralis major
and the teres major. The casts of the roller, by pressing the elbow
to the body, will draw the fractured end of the bone in a contrary
direction; and, in this respect, the bandage may be considered as an
artificial muscle, forming a perfect antagonist to the natural ones.
22. If the displacement be in an external direction, as most commonly
occurs (7), a contrary effect must be produced, as well by the
pressure made by the bandage, on the upper extremity of the displaced
fragment, as by the situation of the elbow which is directed outwards
by means of the thick end of the bolster being placed lowermost. The
external splint will also prevent the displacement outwards, as well
by opposing to the bone a mechanical resistance, as in compressing
the deltoid muscle, which is the principal cause of the displacement.
The derangement of the lower fragment forward and backward, will be
prevented by the two splints before and behind.
The displacement longitudinally, already checked by the weight of the
limb, will be still further prevented, by the compression made on the
muscles of the arm, which are the instruments of displacement, by the
splints and the bandage.
23. To the advantage of keeping the fragments exactly in place, this
apparatus unites that of not confining the patient, who is not obliged
to keep his bed, and to whom a lying position is even, in general, more
troublesome and injurious than an erect one. This observation applies
to the treatment of fractures of the clavicle, of the scapula, and even
of the fore-arm, when no accident has rendered them complicated.
Desault has cured several patients, but more particularly two, who,
being obliged to travel daily, did not, except on the day of the
accident, deviate in any measure from their usual mode of life.
An inexperienced surgeon sometimes applies the rollers too tight, in
which case, a swelling of the fore-arm is the consequence. This is
remedied by relaxing the bandage; but if, notwithstanding this, the
swelling still continues, it will be necessary to extend the bandage
from the hand to the shoulder.
§ VII.