Chapter III: Part 3

The fracture was discovered to be in the middle of the acromion, which it divided transversely. The bandage already mentioned (12) was applied, and, from the first day, the patient was left to his usual regimen. Fifth day, a renewal of the apparatus which had become relaxed: seventh day, a fresh displacement, in consequence of an unguarded motion: a fresh application of the bandage, which continued in its place till the sixteenth day, when it was replaced anew: thirty-second day, reunion complete; a stiffness in the motions of the part, which exercise removed by degrees, and of which the patient felt no remains after the forty-eighth day.

FRACTURE OF THE LOWER ANGLE OF THE SCAPULA.

§ IV.

OF THE SIGNS OR APPEARANCES AND DISPLACEMENT.

14. Next to the acromion, the lower angle of the scapula is that portion of the bone most liable to be fractured. The usual causes of it are, falls on the side, or blows received on the part. It is characterized by a displacement which is always perceptible. On the one hand, the fleshy portion of the serratus-major, which is attached to the inferior fragment, draws it directly forward, while it is drawn upward by the teres-major, and some of the fibres of the latissimus dorsi. On the other hand, the body of the bone itself remains behind, being held by the rhomboid muscles. Hence arises a separation, which renders it difficult to mistake the fracture. Should any doubts still remain, let the shoulder be drawn backwards and the scapula along with it: let the fingers be, at the same time, placed on the lower angle, to ascertain whether or not it follows the motions of the bone; if it does, there is no division: but if, on the contrary, it remains stationary, the existence of the fracture is evident.

§ V.

OF THE REDUCTION, AND THE MEANS OF RETAINING IT.

15. Here, as in all other fractures, the means of reduction must be founded on the causes of displacement. To effect the replacement, therefore, it is necessary, either to push backward and downward, the angle which is displaced in a contrary direction, in order that it may be brought into contact with the body of the bone, or else to draw the body of the bone forward and upward, that it may meet the displaced angle. It is thus, that in a fracture of the condyle, the body of the jaw, is drawn into contact with the fragment.

16. But the first mode of reduction is difficult, and the means of maintaining it impracticable. It is necessary, therefore to have recourse to the second, which is the more easily executed, as the scapula follows the movements of the arm, and as, by drawing this limb forward, and the elbow of it outward, that bone is removed from the spinous processes of the vertebræ, and directed in such a manner, as to be brought into contact with its inferior fragment. This situation possesses another advantage, as it throws into a state of relaxation the muscles which tend to displace the lower fragment.

Hence it follows, 1st, That here, in like manner as in fractures of the clavicle, it is not on the fractured bone, that the force must act, but on the humerus. 2dly, That the humerus ought to be, during the whole treatment, immoveably fixed, because its motions, being communicated to the scapula, must soon derange the contact necessary to a reunion.

18. On these principles were founded the apparatus of Desault, and his process of reduction, which consisted, 1st, in drawing the arm forward, and separating the elbow a little from the thorax; 2dly, in fixing the fore-arm at an angle sufficiently acute, to direct the hand to the point of the opposite shoulder; and 3dly, to bring afterwards into proper apposition and form, the fragments already approximated to each other by the first movements.

19. To retain this reduction, the arm and fore-arm must be permanently fixed in the above position. This object is attained in the following manner, 1st, A bolster in form of a wedge, being placed between the arm and the side, its apex situated in the arm-pit, affords the double advantage of keeping the elbow at a distance from the thorax, and of rendering the position of the arm less fatiguing by serving as a point of support to it. 2dly, Compresses wet with some discutient liquid, are applied on the part corresponding to the fracture. 3dly, The whole is now to be secured by a roller, seven or eight yards long. The first turns of this roller, must secure the hand of the affected side on the sound shoulder to which it had been applied, during the reduction, and running afterwards from before backwards, pass over the place of the fracture, for the purpose of retaining the compresses on it. The wedge-formed bolster is to be secured on the thorax, by circular turns around it. Then, passing under the sound arm-pit, after having made these circular turns, the roller must be brought behind again, conducted obliquely over the shoulder of the diseased side, along the anterior part of the arm, under the elbow, and behind the thorax, where it is carried obliquely, in order to pass again under the sound arm-pit. From this place it ascends again anteriorly over the affected shoulder, redescends along the posterior part of the arm, repasses under the elbow, returns under the arm-pit, and terminates finally in circular turns round the trunk, and arm together. Hence it may be observed, that, in the first turns of the roller, this bandage greatly resembles the third roller applied in the fracture of the clavicle, to retain the point of the shoulder upward and backward (Fig. 4. plate I.)

20. By this, 1st, The movements of the arm being entirely impeded, they cannot have any influence on those of the shoulder; hence, in this respect, the fragments are suffered to remain in contact. 2dly, The serratus-major and teres-major muscles, being kept in a state of habitual relaxation, can no longer draw the inferior fragment forward, which cannot, therefore, be separated from the body of the bone. 3dly, Nor can the body of the bone, being permanently held in this situation, be removed from the fragment; whence, in both respects, a displacement will be effectually prevented. This threefold advantage is not possessed by any of the different kinds of apparatus hitherto proposed, such as the sling and cross-bandage, employed by Petit, which have the fault of suffering the arm to move backward, of allowing the scapula to be easily separated from its insulated angle, of retarding by that means the cure, and even of preventing it entirely, while, by the process just described, it is usually completed by the thirtieth day.

MEMOIR V.

ON THE FRACTURES OF THE UPPER END OR NECK OF THE HUMERUS.[10]

[10] For a very important improvement made by Dr. Physic in the
treatment of an old fracture of the os humeri, and which may be
applied also to similar fractures of other bones, see Article I. of
the Appendix. TRANS.

1. The language of the surgeon differs, in this case, from that of the anatomist, and by the expression, “fracture of the neck of the humerus,” is here meant not that of the slight circular depression, which separates the head from the tuberosities of the bone, but rather that of the contracted or diminished portion of the bone, which commences at the tuberosities above, and being continued down the body of the bone, receives at its lower end the insertion of the tendons of the pectoralis major, the latissimus dorsi, and the teres major. Many practitioners consider this neck or contracted portion as extending even to the insertion of the deltoid muscle.

2. Several facts, the truth of which it is difficult to call in question, attest the possibility of a fracture of the neck of the bone, so called in anatomical language. I have myself seen, in the humerus of a young man, aged seventeen years, the head of the bone exactly separated from its body, by a division which had but slightly affected the upper extremity of the tuberosities. But the examples of this nature which occur in the annals of surgery are too few, to enable us to lay down any general principles for the treatment of such fractures.

§ II.

OF THE VARIETIES AND THE CAUSES.

3. The operation of external bodies, active, when they are thrown against the shoulder, passive, when the shoulder, or the arm, is forcibly driven against them, is always the cause of a fracture of the neck of the humerus. From the mechanism of the part, the division is sometimes direct, and sometimes the effect of a counter-stroke.

The first of these arises very generally from a fall on the point of the shoulder, and as in such a case, the commotion or shock must be very great, to extend with sufficient force through the thick mass which forms the deltoid muscle, that muscle sometimes suffers both contusion and an echymosis. Blood may even escape from a rupture of some of the arteries or veins of the joint, and form, as Desault has observed, a collection or tumour which it would be imprudent to open.

The other is the effect of a fall on the elbow, separated, at the time, some distance from the trunk, or on the hand, which, by a natural instinct, is thrown out, together with the arm and fore-arm, in order to break the violence of the fall.

4. The varieties of this kind of fracture originate, 1st, from the spot which it occupies, being either the middle or the lower part, rarely the upper part, of the neck of the humerus: 2dly, from the state of the surrounding soft parts, which sometimes remain quite natural, and at other times become distended and tumefied. This circumstance always involves the diagnosis in more or less uncertainty; 3dly, from the direction of the fracture, which is sometimes transverse, but usually oblique, particularly when produced in the second mode, that is, by a counter-stroke (3); 4thly, from the relative situation of the fragments, which may remain in contact, an occurrence however but very rare, or may separate from one another in a direction inwardly or upward; and, 5thly, from different complications, with which it may be attended.

§ III.

OF THE SIGNS AND THE DISPLACEMENT.

The whole of the signs of a fracture of the neck of the humerus, taken together, characterize its existence in a manner sufficiently evident. But it is not always an easy matter to take a view of them all at once, and in such a case, there are more difficulties attending the diagnosis here, than in any other fracture of the humerus.

An acute pain is felt at the instant of the fall; and sometimes a crack or report is plainly heard. There is always a sudden inability to move the limb, which, being left to itself, hangs motionless. But if any external force act on it, it yields to it without resistance, and may be moved by it with great ease in every direction.

These motions are accompanied with severe pain, and, if carried too far, may give rise to very troublesome affections, as has been observed in patients, where the fracture was mistaken for a luxation.

Beneath the acromion, is discovered a depression, always situated lower down, than that which accompanies the fracture of that apophysis. If one hand be placed on the head of the bone, while the other is employed in moving the lower fragment in different directions, or, while an assistant, engaged in making the necessary extension, communicates to this fragment a rotatory motion, 1st, the head will be perceived to remain motionless; 2dly, the friction of the two divided ends will produce a crepitation more or less perceptible. This twofold sign is always decisive as to the existence of a fracture; but the swelling of the joint may occasionally prevent the practitioner from availing himself of it.

The fragments remain sometimes in contact, without experiencing any displacement, in which case, most of the signs not manifesting themselves, the diagnosis is rendered more difficult. But most frequently a displacement occurs, and then it is the inferior fragment that is deranged, and not the superior one which is so short that it can be but little effected by the action of the muscles.

7. The displacement is in general but slightly perceptible in the longitudinal direction of the bone, unless when, in a very oblique fracture, the fragments present points which irritate the muscles, excite them to contraction, and augment their force; or, when a blow of great violence, continuing to act after the bone is broken, causes the fragments to overlap each other. Thus has the body of the bone been forcibly drawn upwards, or driven in the same direction, till having passed through the deltoid muscle, and the external integuments, it has even risen considerably above the level of its head.

But in general, as Petit observes, the weight of the limb hanging down the side, opposes to the action of the muscles a sufficient degree of resistance; and it is in the direction of the cross-diameter or thickness of the bone, that the displacement most frequently occurs. It is to be observed, that the lower fragment is driven either inward or outward, rarely in any other direction. In the first case, which is by far the most common, the elbow is somewhat removed from the body, and cannot be brought near to it without pain; in the second, which is more rarely met with, it is moved in an opposite direction.

In the one, the contractions of the deltoid muscle and the natural curve of the humerus, in the other, the united action of the pectoralis major, the latissimus dorsi, and the teres-major, appear to have an essential influence on the displacement.

In each case, the displacement is facilitated by the mobility of the lower fragment, and of the shoulder, when an apparatus from being improperly constructed, fails to prevent the movements of the whole extremity.

8. The signs which have just been detailed, do not always furnish such luminous evidence, particularly to an inexperienced practitioner, as to prevent the occurrence of very serious mistakes. Of this Desault related many examples in his lectures.

CASE. J. M*** Est*** falling on his elbow, fractured the neck of the humerus. A surgeon was immediately called, who, finding a depression beneath the acromion, a protuberance in the hollow of the arm-pit, and the humerus directed outwards, pronounced, without further examination, that there existed a luxation in a downward direction. Wishing to reduce it immediately, he employed, to no purpose, the common processes. Acute pains were the consequence. The opening in the capsule being too narrow was irritated, and the member subjected to great violence of motion. At length the pains became insupportable; the operators gave over their fruitless efforts, and Desault was called.

He discovered the mistake from the immobility of the head; from the depression beneath the acromion being lower down than in a luxation; and from the existence of a crepitation. A reduction was effected without loss of time; the apparatus was applied, but in the evening a considerable swelling occurred around the arm-pit; soon afterwards inflammation was superadded; a vast collection of matter succeeded, and, notwithstanding the utmost attention, it was five months before the patient was restored to health.

9. To this example, I could add others, where the most serious accidents have resulted from a similar mistake. It must be acknowledged, however, that, if, in a fracture, the displacement be inward and a little forward, the greater part of the signs herein detailed (5) apply equally to a fracture and a luxation: but then, as we have just seen in the preceding case, the immobility of the head, the place of the depression beneath the acromion, and the crepitation, will remove any doubts that may be excited in the mind of the surgeon, by the protuberance in the arm-pit, the direction of the arm, &c. &c.

§ IV.

OF THE PROGNOSIS.

10. A fracture of the neck of the humerus assumes, in general, a character not very troublesome; and if, as Heister says, “a fracture near the head is worse, and more difficult to be cured,” this is less owing to the nature and seat of the disease, than to the difficulty of keeping the fragments in contact.

Seldom have the reunion of the bone, and the removal of all the disagreeable effects accompanying the accident, required a longer time than is necessary for the cure of other fractures. The numerous examples, which occurred in the Hotel-Dieu, during Desault’s direction of the surgical department, confirm the truth of this assertion, notwithstanding some doubts that may have been raised respecting it, by prejudices formerly entertained, on the subject of fractures in the vicinity of joints.

From twenty-six to thirty days are sufficient for the reunion: this was the term commonly required in the Hotel-Dieu.

11. If judiciously managed, art readily removes all the accidents attendant on this fracture; but, if otherwise, the consequences are apt to prove troublesome. It is here, much more particularly than in other places, that all deformity of the part ought to be prevented; because, the neck of the humerus being near to the centre of the motions of the arm, will very essentially impede those motions if it be not properly reunited. A deformed callus has been known to produce, in the hollow of the arm-pit, a protuberance, which has, in part, prevented abduction, and appeared to keep up an habitual swelling in the limb.

It is, then, from the perfection of the apparatus, and not from the vicinity of the injury to a joint, that the prognosis is to be formed, both as to the consequences, and as to the duration of the fracture. Keep the fragments in exact and regular contact, and there will be no obstacle to that success which seldom forsook Desault.

§ V.

OF THE REDUCTION.

12. The reduction in this case is usually attended with but little difficulty, and the great multiplicity of means hitherto used for that purpose, demonstrate only the barrenness of the art.

Most of the machines destined to reduce the luxation of the humerus, have been applied to this fracture. Thus the ladder,[11]* the door,† and the club,‡ placed under the arm-pit, served at once the purposes of counter-extension, and conformation, while the powers for producing extension were applied to the elbow, and more rarely to the wrist. Thus Hippocrates recommended a wooden cross, the effect and mode of action of which are nearly the same. These means, in general, besides being insufficient, are liable to a further objection, in consequence of their acting on the edges of the pectoralis major, latissimus dorsi, and teres major, which being thus forced upwards, draw the fragment to which they adhere in the same direction, and thereby constitute an obstacle to the reduction. (See what will be advanced on the subject of luxations of the humerus.)

[11] (* L’echelle, † la porte, ‡ le baton.) These pieces of
machinery, though formerly in use, are now, I believe, in all parts
of the world, laid aside. It would be superfluous, therefore, to
consume time in describing either them, or their mode of operation.
TRANS.

13. To machines succeeded the use of straps, weights suspended to the limb, &c. These processes were entirely useless, in as much as they were intended only to increase the natural powers of the operator, which are already more than sufficient of themselves. They will, therefore, in a short time, exist only in the history of surgery.

Petit proposed to reduce this fracture, by first raising the arm to a right angle with the body, and then directing one assistant to make the requisite extension, by taking hold of the elbow with his hands, while another grasped the point of the shoulder, for the purpose of counter-extension. This method was attended with the threefold inconvenience, of subjecting the patient to great fatigue and pain, of weakening the extending powers, by bringing them too near to the point required to be moved, and of irritating the muscles that draw the lower fragment upwards, and thus exciting them to contract. Hence the difficulties sometimes attendant on reduction, which is always simple in itself, when, after the trunk is properly fixed, gentle extensions are made by taking hold of the fore-arm in a half-bent state. The following is the mode of reduction practised by Desault.

14. The patient is seated either on a chair or on the side of a bed. The arm is slightly separated from the body, and carried a little forward.

One assistant is directed to fix and secure the trunk in a proper manner. This he does by pulling at the arm of the sound side, taking hold of it near to the hand, and extending it in a direction perpendicular to the axis of the body. This mode of counter-extension is preferable to that commonly employed, which consists in applying the hands to the upper part of the patient’s shoulder. Indeed, on the one hand, the power being farther removed from the resisting force, need not be so great. And, on the other, the body being entirely unencumbered, renders it easy for the surgeon to apply the roller without discontinuing, or in any way disturbing, the extension.

Another assistant makes extension on the fore-arm, which serves him as a lever, where, one hand being placed behind or on the back of the wrist, forms the point of support, (or fulcrum), while the other applied to the anterior and middle part of the fore arm, on which it makes pressure from above downward, represents the power; the fragments to be brought into contact constitute the resistance.

The relaxation of the muscles produced by this semi-flexion of the fore-arm, and the slight separation of the arm from the trunk, greatly favour this mode of extension; a mode recommended by the ancients, adhered to by the English, and which possesses the advantage of leaving uncovered all that portion of the limb on which the apparatus is to be applied, and by that means of allowing the hands of the assistant to keep the same position during the whole time of the application.

A small degree of force, judiciously directed according as the displacement is inward or outward, is sufficient to effect the reduction, which even takes place of its own accord, under this process. If the surgeon lays his hands on the place of fracture, it is rather to examine the state of the fragments, than to assist in bringing them into apposition.

§ VI.

OF THE MEANS OF MAINTAINING THE REDUCTION.

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.

OF THE SUBSEQUENT TREATMENT.

24. The pain ceases as soon as the apparatus is applied, because the fragments, now brought into perfect contact, cease to irritate the surrounding parts. Nor does it return during the treatment, as they are firmly retained, and not suffered again to separate.

It is rare that any serious accident follows this fracture, and, among the numerous examples met with by Desault, he has scarcely ever had one such to encounter: yet he generally paid but little attention to those internal means which are usually combined with external ones. In most cases, the patients pursued the regimen to which they had been accustomed.

In cases, where a considerable swelling attacked the upper part of the joint, a circumstance which occasionally occurs in practice, one or two bleedings, a diet more or less strict, and the use of diluent drinks, constituted the internal treatment. Of this the following case, related by Brochier, furnishes a detail.

CASE II. Maria Catharine Bardelle, aged forty-five, of a high complexion, fell, as she was carrying a heavy load, on the elbow of the right side, the arm being extended a little from the body. The neck of the humerus was fractured, and all the usual signs combined in pointing out the nature of the accident.

A surgeon was immediately called, who mistaking it for a luxation, made useless attempts to reduce it, tormented the patient for half an hour, and then left her to be sent to the Hotel-Dieu.

Desault discovered it at first sight to be a fracture, and foreseeing the consequences of the improper steps that had been taken, ordered blood-letting, and a low diet, after having effected the reduction, and applied the apparatus already described (20).

In the evening, a considerable swelling appeared around the articulation; the pains continued; a diluting drink composed of dog-grass and oxymel was prescribed. Second day, the swelling is gaining ground; pains increased; blood drawn again; diet and drink continued; apparatus is frequently wet with vegeto-mineral water, particularly at the upper part. Third day, a little better; pains diminished, swelling checked; weak soup is allowed. Fourth day, a diminution of the swelling; pains almost gone. Sixth day, the swelling has almost disappeared; light food; bandage, having become loosened, is reapplied.

Tenth day, tongue foul; nausea; want of appetite; symptoms of a bilious diathesis. Bitter drink is prescribed; the day following, a grain of tartar emetic is given in solution.

Thirteenth day, the patient is in her ordinary state; the apparatus is renewed. Twenty-fourth day, the reunion is evidently advancing. Thirty-second day, the consolidation is complete.

The patient now began to perform gentle motions with the limb, which she gradually increased, till about the fortieth day, when she was perfectly well, and free in all her motions.

25. I will here repeat an observation, already made, on the subject of the bandage for the clavicle, of which this is nothing else than a modification. In a short time the bolster sinking downward, the bandage becoming relaxed, and the splints less tight, do not effectually oppose a displacement, unless the bandage be daily examined, and reapplied, when it seems to act too feebly. There are many surgeons, who have not been fortunate in retaining the fragments with exactness, because, trusting too far to the action of the bandage, they have for a long time neglected to examine it; this remark is applicable to every apparatus composed of rollers.

26. Here, much more than in other cases, it is all-important that the limb be accustomed to motion, after the process of consolidation. Situated near to the joint, the fracture always leaves some stiffness in it, which time no doubt wears away, but which will sooner disappear under the above treatment.

§ VIII.

REMARKS ON COMPLICATED FRACTURES.

27. Complicated fractures of the neck of the humerus are to be classed with all other accidents of a similar nature, and it would be difficult here to lay down such general rules as would be applicable to every case. The practitioner must be always governed by circumstances. The necessity of the case sometimes urges him to the adoption of daring measures, which, in developing the resources of the art, do honour to the talents of him who exercises it. Of this the following case is a proof.

CASE III. Pierre Lena, aged fifteen, as he was at work on a scaffold, forty feet from the ground, fell from that height on the corner of a stone. He experienced instantly such severe pains, that he was unable to rise. He was carried to the house of a surgeon, who, believing that he had suffered a luxation, made fruitless attempts to reduce it, produced in the part an enormous swelling, augmented his pains, and all to no purpose.

The patient was carried to the Hospital of Charity, where Desault at the time was surgeon in chief. A fracture of the neck of the humerus was discovered, through the tumefaction and echymosis, which had overspread the whole shoulder. A suitable bandage was applied.

A few days afterwards, a manifest fluctuation, an evidence of an effusion of blood, disclosed the necessity of making an opening. This was accordingly done, and the fingers being introduced into the part, several large splinters were discovered, and a sharp-pointed bone, the end of the lower fragment, pricking the deltoid muscle, and occasioning, no doubt, the pains which had hitherto continued without intermission.

The indication was evident. To give vent to all the splinters, and cut off the point of the bone, or to amputate the limb, was the only alternative that was left. Most of the practitioners that were consulted were in favour of the last measure. But Desault ventured to repose a hope in the first, the successful issue of which would be the certain preservation of the limb. He performed the operation as follows.

A large incision made in the posterior, and one still larger in the anterior part of the arm, enabled him to remove with ease all the splinters. Then taking hold of the pointed extremity of the inferior fragment, he drew it through the anterior opening, and cut it off with a saw and a pair of cutting forceps. He then replaced it with his fingers, and fixing the head of the bone in its proper position, applied an apparatus somewhat similar to that intended for the retention of fractures.

A suppuration taking place, the patient was dressed every day. Several abscesses were formed during the course of the treatment; each time the pus was discharged by means of an incision.

At the end of four months, the bone was perceived to be in a state of necrosis. The dressings were regularly continued; but the patient, becoming tired of his residence in the hospital, left it, being able to move without difficulty, and having, in the upper part of his arm, a deep fistula, from whence there was a constant escape of ichorous matter, and through which several splinters were discharged, in the space of six months which he passed at his own house.

About the expiration of this period he returned to the Hospital of Charity. Desault had, in the mean time, left this institution to take charge of the Hotel-Dieu. Amputation was proposed to the patient as his only resource. He refused to comply, and went to Desault, who, examining the state of the parts, found an irregular callus formed, which he removed, together with a portion of the soft parts corresponding to the fracture. At the end of two months and a half, the patient was discharged perfectly cured, except a weakness in the limb, which disqualified him for hard labour.

28. This case may throw considerable light on the difficult question relative to amputations at the joint. But this is not the place to state the ideas of Desault on that point of practice.

I will only observe, that in many cases of gun-shot wounds, a similar treatment would probably save life, without exposing the wounded to the dangers of an operation, in which so considerable a portion of the system cannot be removed with impunity, and would secure to them a limb, for the preservation of which they ought not to shrink from the pains and hazards of a tedious treatment. To sacrifice a part for the preservation of the whole, is the last resource of the art. It is necessary, before resolving on this, to exhaust those previous ones that might restore the whole of our organs to life and their proper functions.

MEMOIR VI.

ON THE FRACTURE OF THE LOWER EXTREMITY OF THE HUMERUS, WITH A SEPARATION OF THE CONDYLS.

1. Fractures of the humerus, accompanied with a separation of the condyls, appear to have escaped the notice of most authors who have written on diseases of the bones. The ancients have transmitted nothing to us on this point. Petit, Duverney, and Bell, among the moderns, have made no mention of it. Heister adverts to this fracture of the bone, only to express an unfavourable prognostic respecting it, without determining the mode in which it is to be remedied. Yet it is by no means rare to meet with examples of it in practice. Desault, in particular, has had frequent occasions to observe it.

§ I.

OF ITS VARIETIES AND SIGNS.

2. These fractures, like those of the condyls of the os femoris, are rarely the effect of a counter-stroke. They are almost always produced by the immediate action of external bodies; such, for instance, as a fall on the joint of the arm; the wheel of a carriage passing over this part, &c. &c.

3. Whatever may be their cause, they generally occur in such a manner, that a longitudinal division separates the condyls from each other, and, extending upwards to a greater or less distance, is terminated by another transverse or oblique division, which passes through the whole thickness of the body of the bone, so that there are three fragments, and two fractures.

4. Sometimes the division is simple; in which case, being directed outwards or inwards, it crosses the lower end of the humerus, obliquely from above downwards, and terminating at the joint, separates but one of the condyls from the body of the bone, leaving the other adhering to it.

5. In the first case (3), there is more deformity at the broken extremity of the humerus; and the mobility is also greater. If the fingers, placed before or behind, press on the limb in the direction of the longitudinal fracture, the two condyls will be separated from each other, the one yielding in an outward, and the other in an inward direction, leaving a fissure or opening between them. The part at the same time expands in breadth. Thus, the two condyls of the os femoris, are seen to separate from each other when in a similar fracture, pressure is made on the rotula. The fore-arm is almost constantly in a state of pronation. When we take hold of one of the condyls in each hand, and endeavour to make them move in opposite directions, they can be brought alternately forward or backward: and, if their surfaces touch, a manifest crepitation is heard.

6. In the second case (4), the condyls cannot be so easily separated from each other; but it is always practicable by taking hold of that one which is divided from the body of the bone, and moving it from before backward, to produce a crepitation, which is a sufficient proof that a fracture exists. In a case where the external condyl was alone separated, Desault found the limb in a constant state of supination, a position to be attributed, without doubt, to the muscles attached to this condyl.

7. An acute pain, the almost inevitable effect of the flexion or extension of the fore-arm, the habitual semi-flexion of the limb, a tumefaction of it sometimes supervening, and a swelling more or less considerable, around the joint, are symptoms which accompany both modes of division (3 and 4). The fracture may further be rendered complicated by means of wounds, splinters, &c. when the blow has been very severe, or when a pointed fragment has made its way through the surrounding soft parts, &c.

§ II.

OF THE PROGNOSIS.

8. The preceding assemblage of signs, leaves in general but little doubt on the subject of the diagnosis; but is the establishment of a solid prognosis attended with the same facility?

If authors be consulted, they will be all found to agree, in considering the communication of fractures with a joint as a complication of a very serious nature. A swelling of the adjacent parts, their inflammation, a continuance of the pains after the reduction, extensive abscesses, a gangrene even of the soft parts, and a caries of the bones; such, according to these authors, are the almost inevitable consequences of these kinds of fractures, of which an anchylosis is the most favourable termination that can be expected. Petit, Heister, and Duverney, do not describe the evils that accompany these accidents. Pare, in speaking of them, says, “In such cases, the violence done to the tendons generally gives rise to great inflammation.”

9. From whence can arise these exaggerated fears? Can it be, as is pretended, the mere communication of the fracture with a joint, that is productive of such serious affections? What relation, then, can reason discover between the cause and the effect? Does not experience answer in other cases, in a manner that admits of no reply, when it furnishes us with the analogy of fractures of the rotula, the olecranon, &c.?

Modern researches have entirely abolished the ancient theory of an effusion of callus into the joint, and with it one of the principal causes assigned by writers for the accidents and evils which they so much dreaded.

The admission of air into an articular cavity, would be, without doubt, in such cases, a consideration of more weight; but this does not occur except in fractures accompanied with wounds, and yet all those in the vicinity of joints, whether compound of not, are regarded as extremely dangerous. Besides, observation has oftentimes proven to Desault, that even the contact of air is not so dangerous as it has been commonly supposed, and many instances occurred to him in his practice, where, notwithstanding such a complication, a perfect cure was obtained.

10. It is, then, to the want of a skilful mode of treatment, and to the irritation experienced in the parts, in consequence of an ill-constructed apparatus being applied to them, that the accidents formerly mentioned (8) ought to be attributed. Such accidents never occurred to Desault, in any of the numerous cases that fell under his care. It is thus that in the fracture of the neck of the os femoris, the insufficiency of the means, is oftentimes productive of unfavourable results.

§ III.

OF THE REDUCTION, AND THE MEANS OF MAINTAINING IT.

11. The displacement here is, in general, inconsiderable, because, being drawn in contrary directions, by the muscles of the arm and fore-arm, the condyls separated from the bone remain stationary between these two forces. A fall, a percussion, or some other external cause, can alone produce a displacement, by communicating some degree of motion to the fragments. Now, from what was formerly said (5 & 6), the condyls may, under such an impulse, move either forward or backward, or else may separate from each other, leaving between them an intermediate void. Hence the apparatus ought to oppose to them a resistance in these four directions, namely, inward, outward, forward, and backward; a resistance which it will be easy to make, by means of four splints, placed in these directions, and properly retained by a roller. The two lateral splints, are particularly necessary, when the condyls are both separated from the body of the bone, and divided from each other (3). If one of them be still attached to the humerus (4), a splint on that side becomes less useful.

12. It is needless for the apparatus to extend as high up as in a fracture of the arm. What effect, in sustaining the fragments, would casts of a roller have, when applied to the body of the bone, above the place of division? Their only advantage would consist in compressing the brachial and triceps muscles, and in that way preventing their action.

On the other hand, the roller must be continued along the fore-arm, in order that the elbow joint may correspond, according to the judicious precept of Paul of Egina, to the middle of the bandage, which is in general more compact and solid, in the middle than in any other part, and also, that a slight compression may be thus made on the muscles attached to the condyls.

13. The pieces which compose the apparatus, are 1st, A roller five or six yards long, and three inches broad, made of soft linen or muslin, and rolled up in a ball. 2dly, Four splints (11), two of them flexible in the middle, in order that they may bend to fit the fold of the arm, and the elbow, and the other two very strong and inflexible, intended to be applied at the two sides.

14. Every thing being arranged, the reduction is effected in the following manner. One assistant is directed to make extension at the upper part of the arm, which he grasps with both his hands; another makes extension on the fore-arm half-bent, which he uses as a lever of the second kind,[12] where one of his hands, being placed under the wrist, forms a fulcrum, while the other applied towards the fold of the arm, represents the power. The surgeon, in the mean time brings the condyls together, adjusts their level and apposition, both between themselves, and with the body of the bone, and then proceeds to the application of the apparatus, the limb being still kept in a half-bent position, as was long since recommended in such cases by Paul of Egina. “_Si in vicinia cubiti brachium fractum est, etiam ipse cubitus deligandus, angulari figura servata._”

[12] In this form of lever, the power is applied between the
fulcrum and the weight to be moved, or the resistance to be
overcome. TRANS.

15. The roller (13), wet with vegeto-mineral water, which facilitates its application, and prevents the swelling of the part, is fastened by one of its ends, about two-thirds down the fore-arm, and continued upwards by oblique and reverse casts, to the joint. The surgeon then passes a cast of the roller from the anterior and superior part of the fore-arm, to the posterior and inferior part of the arm (humerus), redescends by an oblique cast from the other side, over the fore-arm, and returning along the first track, makes a number of casts in the form of the figure of 8, round the joint, which he next covers by circular casts, applied so close to each other, as to leave no opening between them; he then proceeds upwards by oblique casts, as at the first, to the middle part of the arm (humerus), when the roller is given into the hand of an assistant.

The first of the splints (13) is now placed anteriorly on the fore-arm and arm, and, if it does not bend, in such a manner, as to accommodate itself to the fold of the arm, the vacant space beneath it is filled up with compresses, laid on top of each other, so as to make its compression uniform throughout. The second, being applied on the posterior side part of the arm, moulds itself to the projection of the elbow, while the other two occupy the sides. These are secured below by an assistant, while the surgeon resuming the roller, which he had just given out of his hand, fixes them firmly by circular casts descending along the arm and fore-arm.

The limb is then laid on a pillow, so disposed that the hand may be raised higher than the elbow, in order to prevent the subsequent swelling, which is oftentimes produced by the fracture, as has been already mentioned (7).

16. The effect of this bandage is simple, and has a particular relation to those directions and causes, in and by which, displacements might occur. The two lateral splints prevent the separation of the condyls from each other; the anterior and posterior ones prevent them from moving backward or forward; the muscles are compressed; the motion of the joint is prevented; and, in common, no great length of time is necessary for the reunion of the bone.