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Fulcrum to the adducted side of the Ful- represented by "x," and will equal the crum. The Power operated at first before amount of Power overcome by the Arm of the Fulcrum for abduction, but now it Resistance when in that site. When the operates behind the Fulcrum, for the ad- Arm of Resistance turns to the abducted duction of the hand, which is "the Arm of side of the Fulcrum and is found at the Resistance.”
site of Colles' Deformity the amount of R-F is the "Arm of Resistance" and is Resistance will be represented by "X" represented by both hand and the lower minus against controlling the abducted end of the radius, jointly, because the hand hand, etc. is directed by the radio-carpal articulation, Follow the line of Resultant Force, the etc. The “Arm of Resistance" may now Arm of Power, with which we started to be likened to the spoke of a wheel, or the overcome, seen in Fig. 1 (Colles'). When radius of a circle with the Fulcrum as the the Arm of Resistance passes from the abhub or turning point. When RF moves ducted side of the Fulcrum to the straight from the straight line (Fig. 4) on its jour- splint (Fig. 2) and then on to the adducted ney through the arc of the circle the ex- side of the Fulcrum (Fig. 5) to the pocursion relatively increases the distance be- sition in the pistol-shaped splint (Fig. 3) tween Fulcrum and Resistance and rela- some muscle action estimated in the Retively pulls R-P along with it. As “R” sultant Force for abduction is wholly lost seeks to pull “P" upwards, the point "P" during the entire time the Arm of Resistmust actually approach "F" or there must ance is on the adducted side; it is lost bebe some equivalent action; and since "P" cause some of the former abduction Powbecomes closer to "F" the distance between er bears in a direct line from Resistance Fulcrum and Power lessens, relatively, and to Fulcrum, resulting in another "dead the Arm of Power shortens; and it re- center" (Fig. 3). This will lessen some sults that Power lessens and Resistance in- of the abduction power I am endeavoring creases at every stage of the change. Since to overcome. "P" is a fixed point (muscle origins) the It is to be remembered that muscle acts Arm of Power does not shorten in fact by in a direct line from insertion to origin, in actual linear measure, but the muscle accordance with my scheme-from R to stretching necessitated to follow "R” in the excursion of the Arm of Resistance is at- The other remaining Power which fortended with an increased loss of muscle merly abducted the hand operates in a repower which will be represented as the versed order, because the muscle acts beequivalent to shortening the Arm of hind the Fulcrum. Add this balance to the Power.
special adductors; they together form anWhen the “Arm of Resistance" is re- other and new line of Resultant Force, the versed from its position seen in the Arm of Power, which operates for adduc"original” scheme to its position found in tion and the hand is pulled still further a straight splint there is found a "dead away from the site of deformity. Hence, center.” The “Equilibrium of Power" ex- Resistance becomes increased to “x plus” ists, where the Resistance equals the Pow- against the forces to be overcome. The er. The amount of loss of Power will be Anatomical Mechanism producing re-dis
ber of the Proportion, and added to the splint or restraining apparatus in Colles' efforts for a CURE.
Fracture. No Anatomical Mechanism can change Scientific Surgical Principles. Every the Arm of Resistance from the pistol- fracture of the lower end of the radius shaped splint to Colles' Deformity scheme, within one inch of the lower articular surfor it is a mechanical impossibility; only face of the radius is called a Colles' Fracsome external force separate from the ture of the Radius. The lower fractured end tends to be displaced outwards and up- own temporary splint until the permanent wards and widens the wrist, etc. (See repair is completed. Before the formation Anatomical Mechanism).
of the provisional callus the ends of the In Colles' Fracture the deformity should bone are liable to slip, more or less, and be reduced and the ends of the damaged it is not wise to ignore this point in apbone kept in proper apposition by suitable plying the treatment. When plaster has splint or restraining apparatus until the been applied and prior to the commencefracture is repaired. No splint suffices ment of the process of the permanent reunless it overcomes all muscle action tend- pair it is impossible to ascertain, positiveing towards re-displacement, otherwise per- ly, whether or not there is perfect apmanent deformity may follow. This is position, and we should never guess about such a serious fracture that the surgeon
it. Many of the deformities which we should make every diligent effort to ob- meet are due to a lack of diligence in intain the best possible results, for most men
spection and the main aim of this paper is make their livelihood through the agency
to indicate the cardinal points in the proper of their hands and the many and delicate handling of this most important fracture movements of the hand and fingers are ab
after it has been properly adjusted. solutely necessary for the full and proper Some surgeons use the plaster cast imuse of that organ. It is different in the
It is different in the mediately or at least as soon as the swellcase of a limited joint in the lower ex- ing subsides and often with good results, tremity. A man can follow his usual oc- but the wisdom of this practice does not cupation with a limited joint which is used commend itself to the careful surgeon. mainly in locomotion, but he can not do so There may be many "so-called" authorities with a limited wrist or hand if engaged in
who claim that a high percentum of deany occupation above the class of laborer. formity in Colles' Fracture is consistent
A mild degree of angular deformity in with good surgery. If every case of Colles' a case of Colles' Fracture is consistent with Fracture were properly adjusted and the good results, but the many extreme de- correct ratio between CAUSE and REMformities which are often found, are not EDY established, and in most cases it can at all justifiable in the practice of good be established, there would be better results. modern surgery. The grooves found on Many deformities I believe are the sethe lower end of the radius lodge the ten- quence of negligence, perhaps not strictly dons of the muscles controlling the fingers legal but certainly moral negligence, and and these tendons work at best advantage modern surgery should demand that the in the 1.ormal lines which are nearly percentum of deformities be considerably parallel with the long axis of the radius. diminished. The usefulness of the tendons when they If muscle actions pull the hand outwards are compelled to work at adverse angles and upwards in Colles' Deformity the lessens in proportion to the degree of de- hand should be reversed fully to the opviation from their normal lines.
posite—to the inner side and well down. Inspection. It is never safe to put up To pull the hand to the middle line a Colles' Fracture in plaster cast before the (straight splint) is insufficient, it but partprovisional callus forms; this is nature's ly overcomes the causal forces. All the
New Series, Vol. V., No. 8
best authorities use the pistol-shaped splint. The usual violations on the CAUSE: They may have various names for their REMEDY side of my equation which dissplints but they all retain the cardinal lines turb the equation and prevent complete of pistol-shape.
substitution of COLLES' DEFORMITY After adjusting Colles' Deformity a tem- by CURE are on the CAUSE side:porary pistol-shaped splint should be used
Any external force without the confines which will permit frequent inspections of of the Anatomical Mechanism—such as the site of the fracture till the provisional
blows to the hand, accidental or otherwise, callus forms; when by actual inspection of etc., and on the REMEDY side: the site of fracture we know that the pro
The use by the surgeon of the plaster visional callus has formed and that the
cast before the formation of the provisional apposition is correct, the pistol-shaped callus, when he can only guess as to the plaster cast should be used for several
condition of the apposition of the fragweeks. Good results should follow this
ments before the permanent callus aptreatment with a minimum of deformity.
pears. This is a most unsurgical and unIf any special adverse conditions arise they
scientific practice being a violation of would positively demand opening the cast
scientific surgical principles. for another inspection.
In view of the foregoing discussions it EQUATION—CAUSE : REMEDY : : COLLES' DE- seems to be in violation of the well-known FORMITY : CURE.
Laws of Mechanics when the surgeon uses Knowing the Anatomical Mechanism the straight instead of the pistol-shaped which is the CAUSE in our equation, to- splint; such a restraining apparatus does gether with the Laws of Mechanics, per- not present the greatest possible opposition taining to Levers, and the Scientific Sur- either to limit or to overcome the congical Principles governing the application siderable muscle power tending toward reof splints for restraining apparatus in displacement, but permits certain muscles Colles' Deformity, which represent the to act at a mechanical advantage for an REMEDY, nearly every case of simple, abducted hand. Again, when he could uncomplicated Colles' Fracture can be re- have placed many such muscles when operduced to the side of my equation CAUSE: ating for an abducted hand at a mechanREMEDY—with the result CURE; and ical disadvantage, and given a decided if such known laws are applied intelligently mechanical advantage to nearly all those in every case we should never see a case other muscles which, when in operation, of severe angular deformity in uncom- favor only an adducted hand. plicated Colles' Fracture. Knowing the CAUSE and the exact
SURGICAL HINTS. REMEDY the same positive results should follow--the CAUSE completely restrained
Avoid multiple small incisions in palmar
abscess, since they prevent proper drainage by the REMEDY and the COLLES' DE
and may lead to stiffness of the liand. A FORMITY substituted by the CURE. single adequate incision is preferable for Not a single point in the REMEDY
these reasons, and also because it affords
a clear view of the site of disease, so that though can be violated and exact results
pus pockets are much less likely to be oversecured.
COMMON SENSE AT THE BEDSIDE.1 When I go to the bedside, after making
the necessary examinations, I ask myself :
"What shall I give this patient? What C. H. MAXWELL, M. D.,
therapeutic measures are indicated? Why Morgantown, W. Va.
are certain things to be used in this par“In that night did God appear unto
ticular case?" Then I ask myself after Solomon, and said unto him, “Ask what I
prescribing : "Just what effect will this shall give thee.' " "And Solomon said
treatment have on the patient? How will "Give me wisdom and knowledge that I
he be in an hour? or day? or week? Why may go out and come in before the peo
did I prescribe that particular line? How
does this particular treatment act?" SomeHe desired that he might show wisdom
times I can answer these questions, but and knowledge toward his people.
He generally I merely say: "It is orthodox, asked not for wealth, or power or length of
and I give it.” “The books" say it is good, days, but to have a right knowledge of
and I give it. I ask myself: “Why do the his relation toward his people.
books say so? Did the author have So it seems to me that the physician
definite scientific reasons for giving it? should pray for common sense at the bed
Did he know why he prescribed it, or did side. I feel that if I can put this faculty
his information come from farther back? into play I can have some show to benefit
Had the remedies been clinically tested by my patients. It matters little what fine
him? Or was he taking someone else's spun theories are put forth they will finally empirical say-so ?" fail if they do not meet this requirement.
A certain author says certain conditions “Did he impress you as a doctor? Did
call for certain remedies. I prescribe on he seem like a doctor?" was asked me af
his authority. At my next call I expect to ter I had been in consultation with the new
find a decided improvement, but my exdoctor. I asked myself the question:
pectations fall flat. Instead of finding my “How should a doctor seem?” The an
patient better, I find him worse. Now
where's the error? It lies in one of three swer came to my mind immediately. "He should seem just like a man who knows
places. The author erred, or I failed to what to do and how to do it.” It has al
make the proper diagnosis and application ways seemed absurd that a doctor should
of the treatment, or the remedy is inert.
How shall I know where the blame lies? never think thoughts of his own, or try to do work his own way instead of follow
I can eliminate the 3d condition by using ing in the trail of others.
only remedies put up by houses whose It seems to me that this society has not
name is an absolute guarantee of the purity been living up to its mission. We try to
and activity of the remedy. As to whether shove the responsibility off on the other
or not I have given a proper diagnosis, fellow, and try to get out of writing pa
that is more difficult to eliminate. But by pers. We must get out of it or our so
careful study and clinical experience I can ciety will become useless.
generally tell whether or not I am mis
taken. Then the trouble lies with the au*Delivered before the Monongalia County (W. Va.) Medical Society.
thor. Do we often stop to think that au