56. The patient being properly situated, under the arm-pit of the affected side is placed the linen ball, on which the middle of the first strap is then applied. The two ends of this strap being now brought obliquely upwards, before and behind the thorax, so as to meet on the top of the sound shoulder, and being held by an assistant, serve to fix the body, and to make counter-extension, nor does the action of the strap bear on the edges of the pectoralis major and latissimus dorsi, in consequence of the ball which projects beyond their edges. Were it not for this, these muscles, being pulled upwards, would draw in the same direction the humerus, to which they are attached, and would thus destroy the effect of the extension, which is made in the following manner.
57. Two assistants take hold of the fore-arm above the wrist, or else a folded napkin is fixed on that part, having its two ends twisted around each other. These ends, thus folded together, are given to one or two assistants, who begin to pull in the direction of the humerus. To this first movement, intended to disengage the head of the bone from the bed which it occupies, another succeeds, which must vary according to the kind of luxation. If the luxation be downwards, the surgeon gradually approximates the arm to the trunk, at the same time that he pushes it gently upwards. By this process, the head of the bone, being drawn from the trunk, and brought towards the glenoid cavity, usually re-enters it with but little resistance.
If the luxation be inwards, the extremity of the humerus, after extension according to the direction of the bone, should be carried upward and forward, in order that its head may be directed backwards. Steps the very reverse of these must be pursued, if a luxation in an outward direction is to be reduced.
58. In general, when, by the first extension, the head of the bone is disengaged, the motion communicated to it by the subsequent ones, ought to be in a direction precisely opposite to that which it pursued in escaping from its cavity. But what are the variations of this direction? Extensive experience alone can clearly determine this point. Without experience the practitioner works in darkness. The minutiæ or particulars of the process of reduction, being different in different cases and according to different circumstances, can be neither foreseen, nor taught by precept.
59. If the head of the bone experience any difficulty in re-entering its cavity, it is necessary, when the extensions have been made, to communicate to the bone different movements, varied according to the different directions of displacement, and regulated by the principle just established. Oftentimes this method effects what extensions alone cannot; and the head of the bone, carried by these movements towards its cavity, enters it while they are performing.
60. If the luxation be consecutive, then the first extension made in the direction of the displaced bone, is intended to bring its head into the place where it was primitively lodged, in order that it may be afterwards acted on as if it were a case of primitive luxation. It is oftentimes only at the moment of reduction, that it is practicable to ascertain to which kind of luxation the accident belongs. Indeed, as in most cases, the reduction takes place of itself when the extensions are well executed, if the head be consecutively drawn inward, it is seen to descend along the internal part of the scapula, till it arrives near to the inferior part of that bone, and then to reascend towards the rupture in the capsule through which it passes into its natural situation.
61. I have said that when the extension is properly made, the reduction takes place almost spontaneously. Indeed whatever may be the kind of primitive luxation, it is evident, that the muscles surrounding the articulation must be stretched on one side, while they are relaxed on the other; whence there will necessarily arise a change both in their contractions, and in the direction of these contractions, and suchis the nature of this change, that, in case the muscles act, instead of bringing the head towards the rupture in the capsule, they will draw it in another direction, and by that means produce a consecutive luxation.
62. But, if the extensions render the muscles straight, and restore to them their primitive direction, then, obeying their natural irritability, which is still further increased, by means of the extension, they will draw the head to the rupture in the capsule, and force it to re-enter it, with much more certainty than this can be done by the efforts of the surgeon, who is always ignorant of the precise situation of this rupture. On the other hand, if the extension be not judiciously made how can it restore to the muscles their natural direction? In such a case, the head of the bone will be drawn towards some other part of the capsule than that where the rupture exists, and hence, the difficulties that so frequently occur, in reducing luxations of the humerus.
63. From these circumstances it follows; 1st, that the whole art in the treatment of luxations, consists in giving to the extending powers a proper direction; 2dly, that, in general, the process of conformation is unnecessary and useless; 3dly, that to reduce a luxation is not to replace the head of the bone in its cavity, by force, but to restore the muscles to such a state, as to enable them to replace it. Here, therefore, as in every other case, art is only the minister and handmaid of nature.
There are instances, however, where the muscles cannot act properly in consequence of the long standing or age of the luxation, and in consequence ofadhesions, more or less strong, having taken place between the surrounding parts. In such cases it is necessary to employ proper measures to force the head of the bone into its cavity, as it cannot be carried thither by the muscles.
64. Reason concurs with experience, which is on all subjects the best authority, in establishing the truth of this doctrine, respecting the reduction of luxations of the humerus. In this operation, Desault employed, in general, nothing but extensions, varied according to circumstances, until the muscles thrown into a favourable state, were themselves enabled to accomplish the reduction. The most immediate success constantly crowned his practice on this point. This success was, no doubt, owing to his judiciously remaining inactive himself, and suffering the muscles to do the work, after the necessary extensions had been made.
65. When the reduction is accomplished, if the arm, in consequence of being very moveable, appears likely to be displaced again, it is necessary, for a few days, to fix it in such a manner as to prevent all motion; an object which may be effectually attained by Desault’s bandage for fractures of the clavicle.
All writers recommend, for this purpose, the use of theSpicabandage.17But what service can this render? It does not restrain the motions of the humerus, which, hanging down the side, may move forward, backward, &c. and produce a new displacement; an accident that may be always prevented by the bandage proposed.
§ VIII.
66. I will close this memoir by an examination into some circumstances, which may either prevent reduction or render it difficult, and into certain accidents that sometimes accompany it.
I have said that, on some occasions, the rupture of the capsule, being too narrow to admit the head of the humerus to repass it, and return to its cavity, constitutes one of the principal obstacles to a reduction (24). To enlarge this passage, by further lacerating its edges, is evidently the indication that here presents itself. This is fulfilled by communicating to the bone great motion, either by circumduction, or rotation on its own axis, forcing it suddenly in different directions, particularly in that direction in which the luxation has been produced. Its superior extremity must be, at the same time, pushed forcibly against the ruptured capsule, which, by being thus pressed between two resisting bodies, will suffer a more extensive rupture. Reduction, oftentimes impracticable previously to these violent and varied motions, takes place of itself as soon as they have been properly made. Of this the practice of Desault furnishes many examples.
Case VIII.In the Journal of Surgery are recorded two cases, one by Anthaume, the other by Faucheron, which establish this doctrine.
John Seligni, a robust man, forty-four years of age, fell on the point of his shoulder, on the 19th of July 1791; the pain, which was increased by moving his arm, and the swelling which supervened almost immediately, induced him to enter the Hotel-Dieu. The efforts of assistants were at first insufficient, and it was not till after a uniform extension continued for several minutes, that the head of the humerus was drawn by the muscles against the glenoid cavity. The bone appeared to enter the cavity, although the persons present did not hear the collision or clashing of the articulating surfaces, which is almost always perceived in cases of recent luxation: but immediately the humerus was again displaced, without its being practicable to retain it. On the occurrence of this phenomenon, Desault conceived that the head of the bone had pushed before it the capsular ligament, through which it could not pass, in consequence of the narrowness of the opening which had been made at the time of the luxation. He proceeded to move the arm forcibly in every direction, in order to enlarge the opening, and immediately felt a kind of laceration, which satisfied him that his views were accomplished. He then re-commenced extension, which it was again necessary to continue, as at first, for some time, in order to overcome the resistance of the muscles. The reduction was attended with no further difficulty. The humerus continued still to have a great tendency to be displaced, and it was necessaryto employ, for several days, a bandage similar to that for a fractured clavicle.
Case IX.Maria Laurencier, aged sixty, fell on her right elbow, and luxated the humerus of the same side. Eight hours afterwards she came to the Hotel-Dieu, on the eighth of March, 1789. The reduction was attempted in the usual manner; but, although the extensions were properly directed, and the head of the humerus brought against the glenoid cavity, it was still displaced again as soon as the limb was let go, a circumstance which created a suspicion, that the opening of the capsule was too narrow to allow the head of the bone to pass. The assistants ceased making extension, and Desault, taking hold of the lower extremity of the arm, impressed on it great motion, particularly in the direction of the luxation, for the purpose of enlarging the laceration of the capsule. The extensions were now renewed, and the reduction succeeded with great ease.
67. A second obstacle, more difficult to be surmounted in the process of reduction, is that arising from the long continuance of the luxation. The head of the bone, having continued for a long time in the bed into which it has been accidentally thrown, forms adhesions to it; the surrounding cellular membrane becomes thickened, and makes, so to speak, a new capsule for the head, which opposes its replacement, and, when the reduction cannot be accomplished, supplies in some measure the office of the old joint, by the movements which it allows to take place.
Most writers, and Bell in particular, advise, in such a case, never to attempt a reduction, which, being of no avail as to the luxation, might prove dangerous to the patient, in consequence of the violence it would do to the parts. This doctrine was for a time, the doctrine of Desault: but experience, in his latter years, led him to a bolder practice.
68. The complete success which he experienced in luxations of fifteen or twenty day’s standing, encouraged him to make the attempt, at the end of thirty and thirty-five days, and we have, three or four times, during the two last years of his life, seen him successful in replacing, after the expiration of two and a half, and even three months, the head of the bone which had escaped, both through the inferior, and the internal side of the capsule.
However powerful, and however long continued the extensions were, none of those terrible accidents occurred, with which we are threatened by authors. Twice only did a phenomenon occur, which it was difficult to foresee, and of which I will presently speak.
69. In cases of this kind, it is necessary, previously to making extension, to move the bone very forcibly in every direction, in order first to break the adhesions, to tear the condensed cellular membrane, which serves as an accidental capsule, and to produce, so to speak, a second luxation, with a view to make way for a perfect reduction of the first. The straps being then applied, as in ordinary cases, serve the purpose of extension, for the accomplishment of which the number of assistants must be increased.
70. Oftentimes the first efforts are fruitless, and the luxated head remains stationary, amidst the most violent efforts. Let the extensions then be discontinued: renew the forcible motions of the limb: carry the humerus upwards, downwards, forward, and backward: force the resistances to give way; make the arm describe a large arch of a circle round the place which it occupies; let the rotatory motions on its own axis be impressed on it anew; and then recommence the extensions, and let them be made in every direction. By these, the head, already disengaged by means of preceding violent motions, will be brought to a level with the glenoid cavity, and ultimately replaced.
It may not be improper to confirm by experience the truth of these precepts, which might to some appear rash, in consequence of the changes that seem likely to occur in the glenoid cavity, during the absence of the head of the humerus. I will relate, among others, a case reported by Giraud, second surgeon to the Hotel-Dieu.
Case X.Maria Gauthier, thirty-four years of age, entered the Hotel-Dieu, on the twentieth of June, 1790, to be cured of a luxation of three months standing, produced originally by a fall on the arm, which was separated, at the time, from the body and carried backward. Different surgeons had, at different times, attempted the reduction, but always without effect, and when every hope of a cure appeared to have expired, Desault, imboldened by reiterated success, tried whether or not he would be equally fortunate in this case.
The patient being placed in a horizontal position, as already directed (55), great motions were first impressed on the limb: extensions were then commenced, first in the direction of the luxation, and afterwards forward and backward. Vain efforts; the head remains immoveable; new motions are again made in every direction, and afterwards, the extensions are renewed: the same want of success. The patient being fatigued, the reduction was deferred till the day following, when the same trials were, after a short time, attended with complete success. The head being at first disengaged, and afterwards drawn slowly along the track through which it had passed in becoming displaced, at length re-entered the capsule. The arm, being supported by the usual apparatus, soon became œdematous, and, notwithstanding the remedies common in such cases, the swelling continued for two months. The motions performed by the limb in the mean time, restored to it, by degrees, its usual suppleness; and, on the sixty-eighth day after her entrance, the patient was discharged cured.
To this case, I might subjoin many others, and, in particular, that of John Putot, also reported by Giraud, and in which the means just described (69 and 70), succeeded in the reduction of a luxation at the expiration of the fourth month. But too great an accumulation of facts distract the attention, and add nothing to conviction, especially when they are already so plain as those just related.
71. But further, in cases of this kind, where a very old luxation presents great obstacles to reduction, although the attempts made to reduce it, do notactually force the head of the bone into the capsule, still they may not prove entirely useless. By bringing the head nearer to the glenoid cavity, or placing it even on that cavity, and making it form new adhesions there, after having destroyed its old ones, the motions of the limb will be facilitated. For, in cases, where the luxation is not fairly reduced, these motions will be always less impeded, in proportion as the head of the bone occupies a place less remote from its natural situation.
72. A third obstacle, common to the reduction, of every kind of luxation, is the muscular force, increased by the irritation of the displaced bone, beyond its natural degree. So great, at times, is this force, that the head of the bone cannot be moved, even by the strongest efforts. What means should then be employed? 1st, Those which diminish general irritability, such as blood-letting, bathing, a relaxing regimen, &c. 2dly, Those which act locally, in diminishing the irritability of the muscles of the shoulder. For example: the application of emollient cataplasms or fomentations to the part; or, what is still better, a powerful extension, continued for some time. In consequence of such extension, the muscles of the part become fatigued, whence their contractions are succeeded by a state of atony, of which advantage may be taken to replace the bone. Frequently this extension ought to be continued for a very long time; and we have known Desault not to complete the reduction in less than half a day, or even a whole day, the limb being suffered to remain all that time in the apparatus for fractures of the clavicle, which drawsthe shoulder and muscles outwards. Thus, in fractures of the thigh, where muscular contraction prevents the contact of the fragments, permanent extension previously employed, assists in producing this contact.
§ IX.
73. It is rare that any serious accident follows the reduction of a luxation of the humerus. A swelling, more or less extensive, sometimes shows itself around the joint, particularly when extension has been forcible and long continued; but this, being, in general, easily removed, by means of discutients, does not demand particular attention.
74. Another accident which rarely occurs in practice, respecting which but little is to be found in surgical writings, and with which Desault occasionally met, is, a considerable emphysema, suddenly appearing at the time of reduction. In the midst of those powerful extensions, rendered necessary by the ancient state of the luxation, a tumour suddenly appears under the pectoralis major. By a rapid increase it extends itself towards the hollow of the arm-pit, the whole of which it soon occupies. It then propagates itself in a backward direction, and, in the space of a few minutes, its bulk is sometimes equal to that of the head of an infant. A practitioner, if unacquainted with the nature of this accident, might take it for an aneurism, produced by a sudden rupture of the axillary artery, in consequence of the violencedone to that vessel by the extensions of the limb. But, if attention be paid to the resistance of the tumour, to its want of pulsation, to the place of its first appearance, (which is usually under the pectoralis major, and not under the hollow of the arm-pit, to which it only propagates itself afterwards, as Desault has observed in similar cases that fell under his notice), to the action of the pulse still continuing, unless the patient should faint from debility, as happened to the subject of the following case, which we had occasion to witness at the amphitheatre, sometime previous to the death of Desault, and to the colour of the skin which suffers no change; if these circumstances be attended to, it will be difficult not to distinguish one of these accidents from the other. In that now under consideration, discutients applied to the tumour, such, for example, as vegeto-mineral water, and a gentle and regular compression made by the bandage intended to support the arm after reduction, are the most efficacious means that art can employ.
Case XI.Simon Cerisiat, sixty years of age, presented himself on the nineteenth of December, 1794, as the subject of a public consultation, which, every day preceded the clinical lecture of Desault, to receive advice for a luxation inwards, which he had suffered a month and a half before, and for the reduction of which no attempt had been yet made.
Convinced, by the example of luxations more ancient, of the practicability of reducing this, Desault undertook it immediately in the presence of his pupils.
The patient being laid on a table, firmly fixed and covered with a mattress, great motions were impressed on the luxated limb upward, forward, and outward, with a view to destroy the adhesions contracted with the surrounding parts. Extensions were then made in the manner already mentioned (66 and 67).
Nothing was gained by the first attempt, the head remaining immoveable, in the midst of the efforts to displace it. Further motions were made in every direction, to break if possible, the attachments which held it; and these were followed by further extensions.
While these were making in a forcible manner, the head was perceived to approach by degrees towards the glenoid cavity, near to the edge of which it reached in two minutes, and was at length replaced, by a sudden movement of the limb from behind forward.
Scarcely was the reduction accomplished, when a tumour rose suddenly under the pectoralis major, propagated itself towards the arm-pit, and occupied immediately its whole extent.
All the assistants, astonished at the phenomenon, knew not to what circumstance to attribute it. Desault himself, a little embarrassed, thought first of an aneurism suddenly produced by the violence of the extension. The pulse of the patient, being scarcely perceptible in the side affected, and a syncope which supervened, appeared at first to favour this suspicion: but immediately the absence of a fluctuation, of a pulsation, and of a change in the colour of the skin, the return of the pulse, the circumscription of the tumour, its resistance, and the sound caused by striking on it, produced a belief that it was owing, not to an effusion of blood, but to a disengagement of air that had been confined in the now lacerated cells of the cellular membrane.
Over the whole of the swelling were applied compresses wet with vegeto-mineral water, while a regular compression was made on it by means of a bandage, which, at the same time, kept the arm fixed against the trunk.
In the night there occurred severe pains around the articulation and the tumour, accompanied with high fever, both which symptoms disappeared on the following day. Third day, a diminution of the emphysematous swelling; and an entire cessation of fever and pain. Eighth day, tumour reduced to half its original size; the arm made to perform gentle motions, and disengaged from the apparatus; discutients continued. Thirteenth day, tumour entirely gone. In the place which it had occupied a large echymosis appeared, produced no doubt, by a rupture of the small vessels at the time of reduction, but which, till now, had not been perceptible externally, in consequence of the emphysematous swelling of the parts, and which was treated by the same means as the emphysema. Seventeenth day, a yellow tinge, mixed with the colour of the echymosis, an evidence of its resolution, which was complete by the twenty-seventh day.
During all this time, the patient had accustomed his limb to constant motion; a facility in the movement of it had thereby returned; and he was perfectlywell when he left the Hotel-Dieu, on the thirtieth day from the time of his admission, and the sixty-fifth from the occurrence of the accident.
§ I.
1. The fore-arm, composed of two bones, neither of them very strong, and covered below by a small quantity of soft parts, is exposed still more than the humerus, to the action of external bodies, and is articulated at the upper end in such a manner, as not to yield, like it, in every direction to the impulses which it receives. From these considerations, it is one of those parts where fractures most frequently occur, and, in a comparative view of affections of this kind in the Hotel-Dieu, it has oftentimes held the first place.
2. It would be useless to mention here the disposition of the bones which compose the fore-arm, their irregularly prismatical form, their thickness unequally distributed, their direction obviously different, and their motions differently combined. It is sufficient to observe, that, for the perfection of one part of these motions, a space, wide in the middle, and narrow at the ends, must separate the twobones, that, without this space the radius, impeded in its movements on the cubitus, would compress the muscles, restrain their action, and would be unable to perform the motions of pronation and supination; whence the fore-arm, being confined, as it were, to mere flexion and extension, would not, in its uses, correspond to our wants.
These things being premised, we will observe, that fractures of the fore-arm may have their seat, 1st, in both bones at the same time; 2dly, they may occupy but one of them: hence three kinds of fractures more or less different in their phenomena, their consequences, and their treatment.
§ II.
3. Fractures of both bones of the fore-arm, may occur either at the ends, or in the middle of the limb. Frequent in the middle, and somewhat common below, they seldom occur in its upper part, where the fleshy portions of numerous muscles, combined with a considerable thickness of the ulna, resist the motions which tend to produce them. The two bones, though most commonly broken on the same line, are, however, sometimes broken on different ones. The fracture is almost always single: at times, however, it is double, and Desault, in particular, was once called to a patient, over whose fore-arm the wheels of a carriage had passed, and had brokenit both in the middle and at the lower end, so that it evidently exhibited six fragments distinct from each other. The two middle ones, though completely insulated, united again to the others with but very little deformity. Like all other similar affections, these may be rendered compound by wounds, splinters, &c. circumstances which, as they fall within the general class of such injuries, will not be treated of at present.
14. They occur, in general, in two ways, being the result, sometimes of the action of external bodies, immediately applied, and at other times of the same action, operating by way of a counter-stroke. The occasional percussion of a body on the fore-arm, furnishes an example of the first mode of fracture. This is much more frequent, in general, than the other, which usually arises from a fall on the wrist; but, in such a case, as it is the large lower end of the radius that forms the principal point of articulation with the hand, that bone alone sustains almost all the force of the stroke, and is very generally the exclusive seat of the fracture.
§ III.
It is in general difficult to be mistaken with respect to the signs which characterize fractures of the fore-arm. A mobility of the limb where it was before inflexible; a crepitation almost always easily perceived; a depression, sometimes evident, at the place of division; a protuberance sometimes formed underthe skin by the fragments; pain produced by the motion of the part; a crack sometimes heard by the patient, at the moment of the accident; an inability to perform the motions of pronation and supination; the almost constant semi-flexion of the fore-arm; such, together with the phenomena common to all fractures, are those which essentially characterize this, and which must generally remove all doubts which the swelling of the limb may temporarily create respecting its existence.
6. There is a circumstance, however, where a fracture near to the joint of the wrist, may give rise to appearances similar to a luxation of that part. In both cases, indeed, a convexity behind, and a depression before, or the reverse, are perceived, and are the effect of a displacement of the fragments. But the styloid apophysis being carefully examined, will always determine, according as it is found above or below the deformity, from which of the two causes the deformity arises. Besides, a greater mobility in one than in the other affection, and a crepitation, will guard the practitioner from an error, into which I saw a surgeon fall in the presence of Desault, whom he called on to consult, in the case of a child six years old, which laboured under a supposed luxation.
§ IV.
7. Most of the phenomena which accompany fractures of the fore-arm (5), are evidently the result of a displacement of the fragments; a displacement, not, in general, very perceptible in the longitudinaldirection of the bones, because the muscular action, tending to produce it in that direction, is not very powerful. When it does occur in this way, it is most frequently the immediate effect of the stroke that produced the fracture.
8. But it is different with respect to a displacement in the cross direction of the bone. Here the cause of the separation of the broken ends, may be the same with the cause of their fracture, as happens in the passage of a carriage wheel over the limb, or in the falling of some body against it; and then, 1st, the fragments are separated from before backward, or contrarywise, and hence, a protuberance on the one side of the limb, and a depression on the other; 2dly, or else they are pressed against each other laterally from without inwards. From this latter cause arises that inequality which the limb exhibits at the place of the fracture; the slight depression which it manifests on its sides; and the protrusion or bulging out of its anterior and posterior surfaces, by means of the mass of muscles which are pushed in these directions, by the approximation of the fragments to each other.
9. A proper reduction removes the first kind of displacement, namely, that which occurs in the cross direction of the bone backward or forward (8); and unless an external force be applied anew, it does not again return. On the contrary, how exact soever the reduction may be, in the second kind, namely, that which takes place laterally from without inwards, the fragments are soon found to have approached each other again. Above, the pronator teres presses the superiorfragment of the radius against that of the ulna; below, the two fractured extremities are pressed against each other, by the contractions of the pronator quadratus. From this double cause arises, unless something prevent it, the contact of the four fractured ends, which have been sometimes found united together by a common callus, as is proven by several cases sent to Desault, and by the cases of different patients admitted into the Hotel-Dieu, after having undergone an improper treatment. In such cases, the movements of pronation and supination being entirely destroyed, are but imperfectly supplied, as Duverney remarks, by those of a rotation of the arm.
But if the four broken ends should not even be joined together by a common callus, still the space between the bones being evidently diminished, impedes muscular action and the motions of the limb depending thereon.
§ V.
10. It follows from what has been said on the displacement of the fragments (8), and on the causes which have a constant tendency to re-produce this displacement (9), that the extending forces, intended to remove it, should be, in general, less powerful than in most other fractures, because their principal object is, to restore to the limb its natural length, which is here but very little affected.
11. Previously to the application of these, it is necessary, according to the precept of Hippocrates, toplace the fore-arm in a middle state between pronation and supination, flexion and extension. This position is highly favourable to the relaxation of the muscles, and is that, above all others, as the father of medicine observes, which those who have sustained a fracture naturally assume, and which alone they can, for a long time, retain, without experiencing any inconvenience.
12. The fore-arm being thus placed, an assistant makes extension, by taking hold of the four fingers; a mode to be adopted in preference to that of Petit, who directs us to make extension at the wrist; for the real momentum or force of a power is in the inverse ratio of its distance from the place of resistance. At the same time, another assistant makes counter-extension on the humerus, which he grasps with both his hands, in such a manner, that his thumbs correspond to the back part of it, while his fingers cross each other anteriorly.
13. It further follows, from what was said (8 and 9), that the process of conformation, so often useless and even injurious, in other fractures of bones, is necessary here, to restore to the fragments that exact contact which they have lost, in a transverse direction. If the displacement be forward, the surgeon pushes both fragments backward, while the assistants maintain the extension. If the bones project backwards, they must be pushed in the contrary direction. As to a lateral displacement (8) in which the broken ends approach each other, it is not altogether useless, as Petit observes, to endeavour to remove it, by forcing the muscles into the space between thebones. This is done by making a moderate pressure on the anterior and posterior surfaces of the fore-arm, in order that the bones, being thus removed from each other, may come in contact with their broken ends. If this be done, when the apparatus is first applied, the reduction is attended with but little difficulty, and the ends of the fragments are easily retained in apposition.
§ VI.
14. Our forms of apparatus are nothing but means of continuing, for a long time, that state of things, which extension and the process of conformation temporarily produce at the time of reduction. This principle, though generally acknowledged, was particularly neglected in such fractures, as that now under consideration, till the time of Petit, who made it the basis of his practice. Before him, there was a common inconvenience attached to every kind of bandage. The two bones being pressed against each other, by circular rollers applied externally, were thus drawn in that very direction, in which the action of the pronator muscles already tended to displace them; because, the form of the fore-arm being irregular, made these rollers act more powerfully on its lateral parts, where it is very convex, than either behind or before, where it is very flat. It is well known that bandages will make the greatest pressureon the most projecting parts of the limbs round which they are applied; so that, if the fore-arm be bound or pressed on behind and before with a force equal to one, it will sustain laterally, that is, on its sides or edges, a pressure equal to two. Hence results, not only a tendency in the radius to approach the ulna, but also, a want of resistance in the muscles situated on the posterior and anterior sides of the fore-arm. For these muscles being, from their flatness, less compressed than the bones, give way, and do not, by forcing themselves between them, oppose the approach of the bones to each other.
15. Such was the disadvantage of the apparatus of Hippocrates, consisting of one roller applied immediately on the skin, of a many-tailed bandage intended to retain this, and of four splints, applied on the seventh day, and secured by another roller. Such was also the inconvenience of several bandages, proposed after the time of Hippocrates, by different authors, who modified his without improving it, and who, in attempting to alter it, even added to its imperfections. Thus, the compresses with which the limb was first covered, previously to the application of the rollers, served only, by becoming wrinkled, to render the compression unequal, fatiguing, and even painful to the patient. In like manner the pasteboard, which many authors, particularly Duverney, have substituted for splints, and which a majority of practitioners employ, even at the present day, soon becoming softened by moisture, bends without resistance, becomes incapable of preventing a displacement, and has at least the inconvenience of being useless.18
16. Is it to be wondered at then that a perfect cure of fractures of the fore-arm has been regarded as a thing of so much difficulty, and that most authors should have advised practitioners, as a thing of prudence, to warn the patient of its being impracticable to cure him, without the loss of the motions of pronation and supination? Thus, in like manner, it was formerly declared, that a constant deformity was the necessary consequence of fractures of the clavicle.
17. Petit first conceived, that he discovered, in the very means destined to prevent the displacement, the cause of its being continued, and that, in order to be effective, the bandage ought to do constantly what the hands of the surgeon do at the time of reduction (13); that is, it ought to oppose to the unremitting action of the pronators, a resistance equally unremitting, by pressing the muscles into the interstice between the bones. But, after having discovered the end to be attained, he accomplished it only in an imperfect manner. For by first applying a roller immediately round the fore-arm, he reproduced, in part, the very inconveniences and disadvantages he wished to prevent, by placing anteriorly and posteriorly two long and thick graduated compresses, intended to keep the bones asunder, by forcing the muscles between them.
18. Duverney, more judicious, proposed to place the graduated compresses of Petit on two circular compresses, previously applied round the fore-arm. But what availed these circular compresses? If they be drawn tight, will they not produce that approximation of the bones which the surgeon wishes to avoid? And if they be not tight, they will, in consequence of their loose and pliable state, form troublesome and inconvenient wrinkles, without being productive of any good to counterbalance this inconvenience.
19. It was from these different considerations, that Desault modified, as I am about to mention, the apparatus for fractures of the fore-arm. To a great degree of simplicity, this apparatus unites, when thus improved, great ease to the patient, and its advantages are proven by the freedom in the different movements of the arm always experienced by the numerous patients, whom he was called to attend. The pieces of the apparatus are, 1st, Two graduated compresses, one of them of such a length as to extend from the elbow to the wrist, and the other from the wrist to the fold of the arm on the inside. They are to be formed each of a single piece of linen, folded seven or eight times on itself, in such a manner, that the lower fold may be an inch wide, while the others, laid on top of each other, gradually diminish in width to the last. The thickness of these compresses ought to be less in very fat persons, where the anterior and posterior surfaces of the arm are more convex. 2dly, A roller about four yards and a half long, and four inches wide. 3dly, Four thin but stiff wooden splints,long enough to reach, one, from the fold of the arm to the wrist, the second, from the interval or hollow space between the olecranon and the condyl to the same part, the third from the internal condyl of the humerus to the styloid process of the ulna, and the fourth from the eternal condyl to the styloid apophysis of the radius. The breadth of the two first ought to be double that of the other two, as the latter occupy a space of but half the width of that occupied by the former.
20. Every thing being arranged, the reduction is to be executed as already directed (11–13); and while the extensions are still continued, the surgeon wets with vegeto-mineral water, or some other discutient liquid, the graduated compresses, and places them on the anterior and posterior part of the fore-arm, (which must be firmly supported in a state between that of pronation and supination, 11), in such a manner, that their broadest part or base may be in immediate contact with the limb. He then secures them with a roller wet with the same liquid, the casts of which, being first fixed at the place of the fracture, descend obliquely to the wrist, and are secured at the hand by being passed between the thumb and the fore-finger. Running across the back of the hand, the roller then reascends, either by oblique or reverse turns, according to the inequalities of the fore-arm, till it reaches the elbow. Here the surgeon relinquishes the roller, giving it into the hand of an assistant, and places the four splints on the parts already mentioned (19), while the hands of a second assistant secures them, by grasping them all at their lower end, next to the wrist. The surgeon then resumesthe roller, and, in order to fix the splints immoveably, descends with it along the fore-arm by circular casts, till he reaches the hand, where he finishes.
There is, in the application of this bandage, an essential precaution to be observed; which is, that as each turn of the roller passes over the graduated compresses, the surgeon ought to press on these compresses with the thumb and fore-finger of his left hand, in order that the muscles, by being forced into the interstice between the radius and ulna may prevent their approximation, which would produce an inequality in the compression made by the apparatus.
21. After the application of the apparatus, if the patient be obliged to keep his bed, the fore-arm is to be extended on a pillow, taking care to keep it always half-bent, and guarded by hoops from the weight of the bed-clothes. But if the fracture be not a compound one, and if the fall has done no injury to the system in general, it is unnecessary to confine the patient to a position wearisome, and oftentimes insupportable to many persons. Then the limb is to be suspended in a sling, which is always sufficient to support it, without having recourse to the kind of hollow case recommended by Bell, which is seldom at hand, and the use of which must be extremely inconvenient.
22. The subsequent treatment to be adopted in such fractures is simple and easy: to wet the apparatus daily, for a few days, with vegeto-mineral water, to obviate, by proper means, the accidents that may occur; to renew the application of the roller at the end of eight days, or perhaps later, according to the degree of its relaxation; to repeat this application twoor three times during the course of the treatment; to allow, at first, but light diet, which may be afterwards more solid, and given in larger quantity, and to admit finally of a return to the patient’s usual mode of living: such was, in cases of fracture, the practice of Desault, which was always attended with happy effects.
23. Sometimes a considerable swelling occurs, after the application of the bandage, on the back and face of the hand; small blisters appear between the fingers; the patient experiences sharp pains along the fore-arm; and other small blisters rise on its surface. It is then necessary to remove the apparatus, to open the blisters by pricking the cuticle, and dress the part with cerate spread on linen rags; replace the apparatus, making it less tight than before, taking care to renew it every day, till the excoriation be entirely gone. This accident, of no great consequence in itself, has frequently occurred to Desault, although the rollers were applied at first with but a moderate degree of tightness.
24. The consolidation being completed generally in twenty-four or twenty-five days, leaves, at this time, a little stiffness in the joints, in consequence of their having remained so long without motion: the movements of pronation and supination are performed but imperfectly. Their return is facilitated and hastened by frequent exercise of the limb, as well at its junction with the os humeri, as in its own proper joints; and, in general, by the fifteenth or twentieth day from the removal of the apparatus, things are in the same state in which they stood before the fracture.
§ VII.
25. The radius, which is the moveable and almost the only support or abutment of the hand, receives, in falls on that part, a much greater share of the shock than the ulna, which is joined to the hand by only a small surface. Hence, without doubt, arises the greater frequency of the fractures of the radius; fractures which, when produced by falls on the hand, are evidently the result of a counter-stroke. Oftentimes also this bone is broken by the immediate action of external bodies, because it is defended below with but a thin covering of muscles.
In whatever way the fracture may be produced, it occurs in the middle or at the extremities of the bone; very rare near its articulation with the os humeri, it is more common in its middle; but more frequent still at its lower end. The difference arises probably from this circumstance, that, in falls on the wrist or hand, the shock is weakened and lost in proportion as it is propagated upwards.
26. In such fractures, displacement is almost constantly observable in the thickness or cross direction of the bone and fore-arm, and is produced by the action of the pronator muscles, which, by forcing the fragments of the radius towards the ulna, tend to diminish the interval between the bones. The ulna remaining unbroken, always prevents any displacementin a longitudinal direction. The first kind of displacement is the more perceptible, in proportion as the fracture is nearer to the middle part of the radius, where the bones are at the greatest distance from each other. This displacement is seldom outwards, because the interosseous ligament prevents that: yet experience furnishes some exceptions to this rule.
Case I.Desault was called, in the month of July, 1781, to visit a mason, who, sleeping at the foot of a wall, with his fore-arm stretched out, received on the anterior part of it, a round stone, of the size of a bowl, which, falling from a scaffold, fractured the radius in its middle, and produced a large contusion, accompanied by an enormous swelling, to which the usual discutient remedies were applied. On the fifth day the swelling had in part disappeared; but then there was discovered a very evident protuberance of the inferior fragment, which, by pointing outwards, separated itself from the superior one, which remained nearly in its place. The interval between the bones was evidently increased below.
The fracture was reduced by pressing the lower fragment inwards, and, instead of employing graduated compresses the whole length of the limb, they reached only to its middle, along the part corresponding to the superior fragment. The roller was drawn a little tighter below than above, in order to keep the inferior part of the radius near to the ulna.
By being treated afterwards in the usual mode, the fracture was cured. But, in consequence of being over-stretched by the separation of the bones, the ligaments of the wrist became the seat of a tediouslymphatic swelling, which left behind it some degree of stiffness.
27. Examples of this kind occur too rarely to affect the general law relative to the direction of the displacement of a fractured radius, a displacement which, if not properly treated, makes the fragments unite in such a manner as to form an angle pointing inwardly towards the ulna, as is evinced by a perceptible depression under the cuticle. In such a case, from this contraction or narrowing of the interval between the bones, arise the inconveniencies already mentioned (9).
§ VIII.
28. The diagnosis of fractures of the radius is in general easy, when they occur at the lower end, or in the middle (25). In these two cases, a depression more or less perceptible, on the external side of the fore-arm; an inability to perform pronation or supination, by the action of the muscles alone; and a severe pain, necessarily resulting from moving the bone in this two-fold direction. Such are the particular signs or appearances which first disclose the existence and the place of the fracture. The reality of the accident is afterwards more fully confirmed by the signs common to all fractures, namely, the flexibility of the bone, the crepitation perceived by moving it in different directions, &c.
29. Desault cautioned his pupils not to confound this last sign or symptom with a kind of noise, sometimesheard in the sheaths of the tendons of the extensor longus, extensor brevis, and abductor longus; a noise resulting from a filtration of synovial fluid into the sheaths, or produced by some other cause. But, besides this crepitus in the sheaths being a very rare occurrence, it is always easy to distinguish it from a crepitation of the bone, by this circumstance, that the first is heard on merely pressing the parts, but the latter only by making the bony surfaces rub against each other. Besides, by an experienced ear there is no danger of any mistake being committed.
30. If the fracture exist at the upper end, the thick muscular covering which there surrounds the radius, renders the diagnosis more difficult. Petit has, however, thrown some light on the subject, by judiciously advising to place one hand on the upper extremity of the radius, and with the other to make the fore-arm rotate on this bone. The solution of continuity or fracture will be rendered evident, if, in the midst of these motions, the head remain stationary. But if, on the other hand, it rotate, it has sustained no injury. These two circumstances can be easily explained; but, it is not so easy for the practitioner to avail himself of them in every case. This precept may also be applied in cases where a considerable swelling, occupying the whole fore-arm, conceals from the touch of the surgeon the fragments of the bone, even when broken in the middle.
§ IX.
31. The reduction of a fracture of the radius is effected in nearly the manner already described for that of the two bones of the fore-arm (10–13), except that, here, the extension must be less, because there exists no displacement in a longitudinal direction (26).
To remove that which exists in a cross direction, an assistant whose business it is to make extension, places the hand in a state of adduction, for the purpose of removing the inferior fragment outwards. This precept cannot be applied to much advantage, if the division exist towards the upper end, on account of the interosseous ligament.
At the same time the surgeon endeavours to bring the ends of the bone into perfect contact, by pushing them in a direction opposite to that of their displacement; and when he has attained this end, he begins the application of a bandage or apparatus the same as that already described (19 and 20), with this difference, that as the ulna is here sound, and performs, in relation to the fractured radius, the office of a natural splint, it is unnecessary to place an artificial one between the internal condyl of the humerus, and the styloid apophysis of the ulna.
32. The consolidation or cure is here always more speedy than in the preceding cases, where nature, with the same amount of means and resources, hastwice the quantum of labour to perform, and where she supplies her deficiency of power, by the greater length of the time which she employs. In general the bone is united by the twentieth or twenty-fourth day.
33. When the fracture exists at the superior part of the radius, it is essential, after the removal of the apparatus, to make the limb very frequently perform all its natural motions. In such a case, indeed, the parts sometimes swell, become stiff, and an anchylosis of the fore-arm may be the consequence, as Ambrose Pare observes, in his book on fractures, where he says he has seen many accidents of this kind. Galen has remarked the same thing before him. The following case reported by Jeo. Dol**, confirms the truth of it.
Case II.Jane Rene was received into the Hotel-Dieu, in consequence of a fracture of the upper extremity of the radius, produced by a fall on that part, for which she was subjected to the treatment already described (31). The apparatus being removed at the expiration of twenty-five days, the consolidation was perceived to be complete. The motions of pronation and supination were impracticable; those of flexion and extension very much impeded. The patient was now ordered to have the fore-arm moved daily, in these several directions, for the space of an hour, and this space was even increased morning and evening, notwithstanding the pains which, at first, accompanied the exercise. On the eighth day pronation and supination could already be performed in a small degree; they became more and more free, in proportion as the exercise of the limb was longer continued; finally, on the twenty-second day fromthe removal of the apparatus, the patient was conducted, according to custom, to the amphitheatre, where all the pupils witnessed the perfect freedom of the motions.
Case III.A few days after this, a man, who had left the Hotel-Dieu about eight months before, while under treatment for a similar fracture, returned, to be the subject of a public consultation in consequence of a different disease.
Desault, on interrogating him, learnt from him that the treatment for the fracture had been continued at his own house (31), but that, when the apparatus was removed, no motion had been impressed on the limb, and that the surgeon had even kept it in a sling. The fore-arm was then examined; it was half bent, constantly in a state of pronation, and could not, by any force, be brought into a state of supination. The motions of flexion and extension, were so limited as to be scarcely sufficient for the common wants of the patient, who, under proper treatment, might have been cured like the preceding one, as Desault remarked to his pupils at the time.
34. The patient who was the subject of this second case, was sent to the mineral springs, but derived no benefit from the use of the waters. If this were a proper occasion, I could mention many instances where this remedy, so highly spoken of by many physicians of the present time, has had no effect, except to deprive the patient of more efficacious means, by making him lose that time, during which exercise frequently repeated, would have effected a cure, but which, coming too late, could be of no avail.
§ X.
35. The ulna, less frequently broken, in general, than the radius, scarcely ever suffers alone from falls on the wrist or hand. Most commonly its fracture is direct, and occurs, in particular, in cases where a person in falling, extends the fore-arm for the purpose of supporting himself, and strikes its internal part against some resisting body.
The division, though it does take place occasionally in all parts of the bone, occurs most frequently near to the lower end, where its slender size, compared to that of its upper end, its more projecting situation, and its thinner covering of soft parts, act as predisposing causes.
36. In whatever part it may exist, the touch must readily detect it, when the fingers are drawn along the internal surface of the ulna, which lies almost immediately under the skin. If moved in contrary directions, the fragments will also, by their mobility and crepitation, disclose the nature of the injury. A depression more or less perceptible is observed on the internal part of the fore-arm, produced by a displacement of the fragments, which are carried towards the radius, more particularly of the inferior fragment, as Petit has well observed, the superior one remaining almost immoveable.
§ XI.
37. The reduction does not differ from that of the radius (31), except in this, that the assistant who makes the extension, must place the hand in the opposite state, namely, that of abduction, in order that the fragments may be brought into contact, while the surgeon assists in this process, by pushing the broken ends of the bone in a direction opposite to that of their displacement.
As in the foregoing case, three splints are sufficient for the apparatus, where the radius, being unbroken, performs the office of a fourth.
The exercise of the limb, after the consolidation of the bone, is in general less necessary here, than in fractures of the radius (34), because the ulna, being an immoveable point of support for the motions of rotation, concurs in them only in a passive manner.
§ XII.
38. The ulna is surmounted, at its upper end, by a considerable appendix, curved before, where it corresponds to the articulation of the fore-arm, and is covered with cartilage; convex behind, where thereis nothing to separate it from the external integuments, and is attached at its upper end to the strong tendon of the triceps muscle, which appears to be incorporated with it. This appendix resembles greatly, in its structure, form, and uses, the rotula, from which it would differ in nothing, if the inferior ligament of the latter were ossified, so as to form a bony continuity between it and the tibia. It is exposed to fractures, perfectly similar to those of the rotula, but which differs so essentially from the other fractures of the ulna, as to call for a separate examination.
39. The ancients appear to have had but little knowledge of fractures of the olecranon, respecting which they have transmitted nothing to us, unless with Dalechamps, we find cause to recognize a reference to this affection in the following passage of Paul of Egina:Cubitus frangitur . . . circa partem ad cubiti gilbum.
Most of the moderns have spoken of it only in a vague manner; no one has described with accuracy the signs which characterize it; and few have given satisfactory ideas on its treatment. Petit has not spoken of it separately, and Duverney, who concludes with it his article respecting fractures of the fore-arm, has but imperfectly described for it a bandage which is in itself equally imperfect. Bell does not give us, on this point, an exposition of either his opinions or his practice.
Yet this fracture is by no means so rare as to justify the silence of authors, and its treatment merits a degree of attention beyond that which is requisite in most other fractures.
§ XIII.
40. The olecranon suffers fractures at its base and at its summit, but more frequently in the first, than in the second situation. The division, though very generally transverse, is sometimes oblique. Desault met with an instance of an oblique fracture of the olecranon in a man, who had sustained a violent blow on his fore-arm from a club.
41. The causes which produce it are, either muscular action, a circumstance that very rarely occurs, or the direct action of external bodies, which is by far the most common case. The reverse of this is true with regard to fractures of the rotula, which are almost always produced by the contraction of the muscles attached to that bone.
42. The olecranon has been at times separated from the ulna, by the act of throwing a stone with great force. In such cases, the fracture has been produced by the immediate action of the triceps muscle. This is the first mode of division.
The second occurs when a violent blow is received on the elbow, or, more particularly, from falls on that part: for example, if, when descending a flight of stairs, our heel slip and we fall backwards, the arm is suddenly thrown behind to save the body. In such a case, the olecranon striking forcibly against one of the steps, and being pressed between it and the weight of the body, is broken. In this way was the disease produced in a majority of the patients attended by Desault for fractures of the olecranon.
§ XIV.
43. We meet here with the same appearances and state of things, which constantly occur in fractures of the rotula. The triceps extensor, finding no longer in the continuity or sound state of the ulna, a resistance to its contractions, draws upwards the short fragment to which it adheres, produces between it and the lower one an interval more or less perceptible, and gives rise to the greater part of the other characteristic signs of the affection: these are, 1st, An interval or space between the fragments, corresponding to the posterior part of the articulation. This interval may be increased at pleasure, by increasing the flexion of the fore-arm, or by making the patient contract the triceps muscle, and may be again diminished, by bringing the arm into a state of extension: 2dly, An inability in the patient to extend the fore-arm spontaneously, which is the necessary result of the separation of the triceps from the ulna: 3dly, A constant semiflexion or half-bent state of the fore-arm, produced by the contractions of the biceps and brachialis internus muscles, to which no antagonists are now opposed: 4thly, An elevation, more or less perceptible, of the olecranon above the condyls, which, on the contrary, rise above it, when, in a natural state of the parts, the fore-arm is half-bent: 5thly, A facility of moving the upper fragment in every direction, without communicating any motion to the ulna; 6thly, A peculiar sensation experienced by the patient, towhom it seems, when he makes an effort to extend the fore-arm, as if some body or substance were detached or broken off from his elbow, and carried upwards. The patient may realize the justness of this sign, by comparing it with what he feels on attempting to extend the opposite fore-arm, placed in the same position.
44. If to these signs be added the circumstances which accompany the accident, the severe pain that is always felt, the crack which is sometimes heard by the patient, and the possibility of producing a perceptible crepitation, by rubbing the fragments in contrary directions, after having first brought them together, it will be difficult to be mistaken respecting the existence of the fracture, which indeed the swelling of the part alone can conceal from the practitioner, if, as sometimes happens, it be considerable. But then, being soon dispersed, either spontaneously, or by the action of discutients, it leaves the accident unmasked, accompanied by the signs just enumerated.
45. To the swelling is oftentimes added, an echymosis more or less considerable, when the accident has been produced by a fall on the elbow. But by this, no change is effected in the essential characters, which are always sufficient to distinguish a fracture from a luxation backwards, with which it has been sometimes confounded, as appears from many examples recorded in different works.
§ XV.
46. I will not dwell on the question, so much agitated of late, namely, whether or not the olecranon be susceptible of consolidation or reunion. Already has it been hundreds of times answered by experience. What could theory add to the conviction already impressed on us from that quarter? It was by exhibiting to the crowd of pupils who attended his clinical lectures, fractures of this kind perfectly reunited, that Desault refuted the weak arguments, of the periosteum not being able, in consequence of not covering the anterior surface of the olecranon, to produce a union between its fragments, of the synovia mixing with the matter of callus, diluting it, weakening it, preventing it from becoming sufficiently hard for the purpose of reunion, &c. We will only observe, that these ideas are borrowed from a theory which modern experiments have proven to be unfounded, and which, were it true, would be applied in the present case quite unphilosophically, since it would deny to certain parts of man the power or property of restoration or being healed, a property common to all the component parts of beings endowed with life, and which even constitutes one of their essential and discriminative characters.
47. Is the consolidation of the olecranon effected in the same mode as in other bones? The observations of many practitioners, Camper in particular, seem to prove that a ligamento-cartilaginous substance is alwaysthe medium of the union of fragments. Desault once found this substance in a corpse, but it was in a case where the fracture had been improperly treated, and where, of course, no inference could be drawn with regard to ordinary cases.
48. But of what import to us are the means which nature employs? The indication is still the same. The fragments must be always kept in contact, that the reunion may be immediate, and that, as David observes, in his memoir on motion and rest in surgical diseases, the apophysis may not, by becoming too long in consequence of the space occupied by the callus, impede the extension of the forearm on the os humeri.
§ XVI.
49. There are no fractures, the treatment of which demands more attention, or is surrounded with more difficulties, than that of the olecranon. Here art cannot, as in the thigh, and the clavicle, oppose to the ever active power of the natural muscles, a constant resistance produced by the action of a kind of artificial muscle, consisting in permanent extension. The superior fragment, being too small to give any purchase to extending forces, can be only pushed downwards, and kept in that position with a greater or less degree of stability and firmness, while the ulna, so to speak, is drawn to meet it. Whence it follows, that extension here is of little use, and that it is chiefly byposition or attitude, aided by a judicious conformation, that the reduction is effected.
50. The position has varied in the hands of different practitioners. Some have proposed that, in which the fore-arm is half-bent, so as to form a right angle with the os humeri. The example mentioned by David, is not the only one where recourse has been had to this. But, by rejecting the general principle respecting the reunion of parts, which requires them to be kept in perfect contact, this mode is exposed to a double inconvenience. The reunion is extremely slow in being accomplished, and, when ultimately obtained, is accompanied by the loss of one part of the movements of the limb, in consequence of the length of the callus. This callus must necessarily fill up the whole space that intervened between the fragments during the treatment, and being thus added to the natural extent of the olecranon, lengthens this appendix to such a degree, that, in extending the fore-arm, its summit or upper end comes too soon into contact with the cavity in the os humeri destined to receive it.
51. This practice appears to have been chiefly owing to an opinion then in existence, that an anchylosis being the necessary consequence of the fracture, it was proper to place the arm in that position in which it would be most likely to be still of some service.
52. We must not, however, by throwing the fore-arm into the greatest possible degree of extension, allow it to be drawn into the opposite extreme. From this error the same inconveniencies would result. In such a case, should the fragments touch each other, and press too hard at their posterior edges, they must inevitably leave an intervening vacuity or space between their anterior edges. Hence a greater thickness of callus on the one side than on the other, and consequently an impediment more or less troublesome in the motions of the joint. If the inferior fragment do not touch the superior one, it sinks into the olecranon cavity, leaves the other behind it, and hence another source of irregularity in the consolidation.
53. Between these two extremes (50 and 51), it remains to choose a middle course, and that position will be best, in which the fore-arm shall be, so to speak, in a state between semi-flexion and extension. By this the fragments, being brought into perfect contact, will experience no obstacle to a reunion, which will be therefore both speedy and uniform.
54. But it would be useless to place the limb in a proper position, if no means were made use of to retain it there. Being immediately submitted to the action and influence of a multitude of causes, it will lose its position, and the work of nature being interrupted, the consolidation will be retarded.