第14章

14. When a fractured clavicle is fairly broken across it is more easily treated, but when broken obliquely it is more difficult to manage. Matters are different in these cases from what one would have supposed; for a bone fairly broken across can be more easily restored to its natural state, and with proper care the upper part may be brought down by means of suitable position and proper bandaging, and even if not properly set, the projecting part of the bone is not very sharp. But in oblique fractures the case is similar to that of bones which have been torn away, as formerly described; for they do not admit of being restored to their place, and the prominence of the bone is very sharp. For the most part, then, it should be known, no harm results to the shoulder or to the rest of the body from fracture of the clavicle, unless it sphacelate, and this rarely happens. A deformity, however, may arise from fracture of the clavicle, and in these cases it is very great at first, but by and by it becomes less. A fractured clavicle, like all other spongy bones, gets speedily united; for all such bones form callus in a short time. When, then, a fracture has recently taken place, the patients attach much importance to it, as supposing the mischief greater than it really is, and the physicians bestow great pains in order that it may be properly bandaged; but in a little time the patients, having no pain, nor finding any impediment to their walking or eating, become negligent; and the physicians finding they cannot make the parts look well, take themselves off, and are not sorry at the neglect of the patients, and in the meantime the callus is quickly formed. The method of dressing which is most appropriate, is similar to that used in ordinary cases, consisting of cerate, compresses, and bandages; and it should be most especially known in this operation, that most compresses should be placed on the projecting bone, and that the greatest pressure should be made there. There are certain physicians who make a show of superior skill by binding a heavy piece of lead on the part in order to depress the projecting bone; but this mode of treatment does not apply to the clavicle, for it is impossible to depress the projecting part to any extent worth mentioning. There are others who, knowing the fact that the bandages are apt to slip off, and that they do not keep the projecting parts in their place, apply compresses and bandages like the others, and then having girt the patient with a girdle, where it is usually applied with most effect, they make a heap of the compresses upon of the compresses upon the projecting bone when they apply them, and having fastened the head of the bandage to the girdle in front, they apply it so as to bring the turns of it into the line of the clavicle, carrying them to the back, and then bringing them around the girdle they carry them to the fore part and again backward. There are others who do not apply the bandage round the girdle, but carry the rounds of it by the perineum and anus, and along the spine, so as to compress the fracture. To an inexperienced person these methods will appear not far from natural, but when tied, they will be found of no service; for they do not remain firm any length of time, even if the patient keep his bed, although in this position they answer best; and yet even when lying in bed, should he bend his leg, or should his trunk be bent, all the will be displaced; and, moreover, the bandaging is inconvenient, in as much as the anus is comprehended by it, and many turns of the bandage are crowded there in a narrow space. And in the method with the girdle, the girdle cannot be so firmly girt around, but that the turns of the bandage force the girdle to ascend, and hence of necessity all the other bandages must be slackened. He would seem to me to come nearest his purpose, although after all he effects but little, who would take a few turns round the girdle, few turns round the girdle, but would use the bandage principally to secure the former bandaging; for in this manner the bandages would be most secure, and would mutually assist one another. Every thing now almost has been said which applies to fracture of the clavicle. But this also should be known, that in fractures of the clavicle, it is the part attached to the breast which is uppermost, and that the piece attached to the acromion is the lowermost. The cause of this is, that for the most part the breast can neither be depressed nor raised, there being but a slight movement of the joint at the breast, for the sternum is connected together on both sides with the spine. The clavicle admits of most motion at the joint of the shoulder, and this arises from its connection with the acromion. And, moreover, when broken, the part which is connected with the sternum flies upward, and is not easily forced downward; for it is naturally light, and there is more room for it above than below. But the shoulder, the arm, and the parts connected with them, are easily moved from the sides and breast, and, on that account, they admit of being considerably elevated and depressed. When, therefore, the clavicle is broken, the fragment attached to the shoulder inclines downward, for it inclines much more readily with the shoulder and arm downward than upward. Matters being as I have stated, they act imprudently who think to depress the projecting end of the bone. But it is clear that the under part ought to be brought to the upper, for the former is the movable part, and that which has been displaced from its natural position.