In cases, where a considerable swelling attacked the upper part of the joint, a circumstance whichoccasionally 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.
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 upperpart 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.
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.
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, extendingupwards 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 sufficientproof 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.
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 isthe 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.
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 particularlynecessary, 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 heuses as a lever of the second kind,12where 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.”
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.
As soon as this is accomplished, it is of importance to move the limb in every direction, to prevent that stiffness, which is so commonly the consequence of fractures situated in the neighbourhood of joints. The following case, drawn up by Le-geulle, will furnish the reader with a detailed account of the treatment pursued, in such accidents, by Desault.
Case I.Joseph Kisler, an ostler, aged forty-one, fell from a height of thirty feet, on the left side, his arm being undermost, and fractured the lower end of the humerus. A surgeon gave him immediate assistance, and, at the expiration of two days, he was carried to the Hotel-Dieu.
From the signs formerly mentioned (5 and 7), Desault discovered a fracture, consisting in a separation of the condyls from each other, by a longitudinal division, and from the body of the bone, by a transverse one. The usual apparatus (16) was applied, and, from a state of extreme anguish, which he had till now suffered, the patient experienced immediate relief.
In the mean time, a considerable swelling around the joint, pointed out the necessity of blood-letting, a low diet, and other antiphlogistic remedies. These were immediately had recourse to, and the limb was placed in the proper position (16).
Notwithstanding these precautions, the tumefaction and redness were increased on the following day. The bandage was applied anew, and wet from time to time with vegeto-mineral water.
On the following days, pain less severe, the bandage kept constantly wet with the same fluid.
Eighth day, the swelling almost gone; the apparatus, being loosened, was again reapplied.
Fifteenth day, the fragments, being examined, were found in regular contact, and already united bya substance of considerable firmness; the strictness of regimen gradually relaxed; solid food taken in small quantity.
Nothing new till the twenty-second day, when the splints were laid aside, having become useless, in consequence of the rapid progress of reunion: from this time till the completion of the cure, nothing was used but the simple roller.
On the twenty-fourth day, gentle flexion and extension of the arm and fore-arm were for a short time performed; these movements were attended with acute pain, notwithstanding which, the fortitude of the patient enabled him to persevere in them.
Thirtieth day, no pain accompanies the movements of the arm: the range of these movements visibly increased; the roller laid aside; from this time the range of motion increases rapidly.
On the thirty-seventh day, the patient was discharged perfectly cured, and free from every vestige of his disease, except a trifling stiffness, which was doubtless soon removed by the motions of the joint.
17. When wounds, splinters, or severe contusions, render these kinds of fractures more complicated, an inflammation occurring on the articular surfaces, may cause them to unite together, and by that means give rise to an anchylosis. But this accident, inevitable in such a case, according to writers, does not always occur, provided nature be assisted, by a judicious mode of treatment, in her attempt to reunite the broken bone. Desault has established this truth, in many instances. Here, as in other joints, he has oftentimes obtained a complete cure, withoutthe loss of motion, although the part had sustained the greatest violence. Incisions, easily made, the extraction of splinters, a frequent renewal of dressings, a most vigilant care to prevent all jarring of the limb, and consequently all derangement of the contact of the fragments, an assemblage or combination of those minute attentions, which art cannot teach, which genius suggests, and which characterize the true surgeon; a precaution (not to be dispensed with) to make the limb perform motions, gentle at first, but gradually increased afterwards, when the adhesion of the parts has acquired sufficient solidity to admit of it; such are, in general, the steps and circumstances constituting the bases of that treatment, requisite in these complicated fractures, which, like all others, appear, in each case, to assume a new aspect, and to present different indications.
Case II.A person, carrying a heavy burden, fell with his elbow on a sharp corner of a bar of iron. The external condyl was broken, being separated from the body of the bone, by an oblique division running into the joint. Anteriorly, a large contusion; posteriorly, a transverse wound; on the outside, the end of the condyl projecting through the soft parts, which it had lacerated: such were the complications of a fracture, for which the patient was admitted into the Hotel-Dieu, on the seventh day of January, 1794.
On examining the state of the parts, Desault discovered, in the transverse wound, two splinters which when extracted, gave vent to an effusion of blood. He reduced, instead of cutting it off, as authors have advised, the end of the separated condyl, applied abandage of strips,13and, to prevent accidents, ordered a strict diet, copious blood-letting, and diluting drinks.
Compresses wet with vegeto-mineral water, kept the apparatus constantly moist.
On the day following, the dressing was renewed superficially; severe pains in the part; abated towards evening; almost gone next day; low diet continued.
Fourth day, pains returned; an incipient swelling around the joint; more blood drawn.
Sixth day, considerably better; all the apparatus renewed; suppuration beginning to appear.
Tenth day, a small abscess on the external condyl opened, and a splinter extracted posteriorly.
Fifteenth day, the parts assume a flattering aspect; suppuration favourable; fragments in contact; from this time the dressings are less frequent.
Twentieth day, a bilious diathesis; edges of the wounds livid; loss of appetite; nausea; vomiting; an emetic is administered.
Thirtieth day, unfavourable appearances gone; reunion commencing; wounds visibly healing. Fortieth day, all external injuries healed, except the one situated anteriorly; callus already very firm; gentle motions performed with the limb, which is still surrounded by the apparatus.
Forty-seventh day, the apparatus become useless; motions gradually increased; articulation already tolerably free. Fifty-seventh day, bilious diathesis returned; low diet and evacuants. Sixty-fifth day, the patient discharged from the hospital; consolidation perfect; wounds entirely healed; motions of extension still difficult to be performed in their full extent, but are recovered in a great measure, and will doubtless, in a short time, be completely re-established, provided the same mode of treatment be continued.
§ I.
1. Nature, who, according to the wants of different species of animals, has varied the number of their articulations, knows also how to vary their structure, according to the uses of the different parts of their bodies. With great mobility, she has sometimes connected great solidity and strength, as is thecase in the vertebral column; in other instances, parts very solid and compact, are capable of performing but feeble motions, as the carpus, the tarsus, &c. And, lastly, other parts, again, capable of great motion, possess so little solidity and firmness as to be easily deranged by the action of external bodies. Such, in man, is the articulation of the humerus with the scapula, of the sternum with the clavicle, &c.
2. Hence there exist three classes of articulations, very different from each other. To the last, as enumerated above, belongs, in a particular manner, the history of luxations, and, in this, as the solidity varies, the frequency of dislocations is equally various; no luxation occurs more frequently than that of the humerus; indeed, in a comparative catalogue of accidents of this kind, it alone has, during certain years, occurred oftener, in the Hotel-Dieu, than that of all the other bones, taken collectively.
3. Every thing seems to favour the escape of this bone from its natural cavity. 1st, On the part of the articulating surfaces, a cavity somewhat oval and very shallow, aided by a slight cartilaginous ring, receives a half-spherical head, twice its own diameter from above downwards, and three times as large from before backwards. 2dly, On the part of the ligaments, this articulation is strengthened by only a simple capsule. This capsule is thin and weak on its lower side, a direction in which there is nothing to prevent a luxation, while it is thicker on its upper side, where the acromion and coracoid apophyses, and a strong ligament, present an obstacle almost insurmountable. 3dly, As far as respects the muscles and the motionsof the joint, strong and numerous bundles of fibres surrounding the articulating surfaces, communicate to them motions easily performed in every direction, and which, by pushing the head of the humerus against the different parts of the capsule, distend it, predispose it to laceration, and indeed even rupture it, when the quantum of their force is superior to its resistance. 4thly, As far as relates to external bodies, what bone is more exposed to their action than this, particularly among that class of persons, engaged, for a livelihood, in hard labour?
4. Subject to the influence of these different predisposing causes, the humerus would be constantly liable to luxations, did not the scapula, moveable like itself, furnish it, by accompanying its motions, with a point of support, differently disposed, according to the different position of its superior extremity; so that, to this two-fold mobility of the articulating surfaces, is to be attributed, in a great measure, the stability of their connexion.
§ II.
5. The upper articulation of the humerus, though predisposed, in general, to luxations, is not equally so in every direction. There is a point at which luxation cannot take place. There are others, where, though possible, this accident has never been observed. It is necessary, therefore, before examining the mechanism of this luxation, to mention with precision, the directions in which it may occur. On thispoint, writers have differed in a very singular manner. Sometimes, to express the same thing, they have used a different language; and, at other times, have, by the same words, expressed things widely different. Always agreeing as to certain modes of dislocation, they have been divided as to others; while, in the midst of those contrarieties, the surgeon being embarrassed, is at a loss on what ground to found his practice.
6. The ancients, knowing but little of the natural relation of the parts surrounding the joint, were ignorant of the accidental ones, which these several parts assume, in the case now under our consideration. Hence, without doubt, arises the confusion, of their opinions on the subject.
Many admitted of four kinds of luxations; a great number acknowledged only three; some subscribed to but two; while others believed in the possibility of none but one.
7. The first divided differently the directions in which the bone might be luxated. Some contended for luxations upward, downward, forward, and backward; and such was the opinion of the first Greek physicians, predecessors to the father of medicine, who has transmitted the opinion to us accompanied with a demonstration of its fallacy. Others have divided them into those that take place downward, upward, outward, and forward. This division is adopted by Galen, who yet produces only an example of a forward luxation, and does not give us to understand what he means by a luxation upward and inward.
8. The second distinguished the modes of this luxation, sometimes into downward, forward, and backward; as was the case with Oribazes; at other times, into downward, outward, and inward, according to the opinion of Paul of Egina, who, no doubt, adopted exactly the preceding division, expressing it only in different words; sometimes into downward, forward, and upward; such was the sentiment of Albucasis, who, notwithstanding, considered a luxation upward, as a very difficult, and very rare occurrence.
9. The third were of opinion, that, in undergoing a displacement, the head of the humerus could be carried only downward, under the arm-pit, which is the most common direction, or forward, a course which it takes more rarely. Celsus is almost the only writer who has contended for this division. “Humerus, says he,modo in alam excidit, modo in partem priorem.”
10. Lastly, The fourth believe, with Hippocrates, in none but a displacement downwards, the only one which that physician has met with in his practice. “At vero humerus, inferiorem in partem excidit; aliam in partem excidere non audivi.”
11. The moderns, in borrowing from the ancients their divisions of luxations, did not, like them, determine a priori and in a vague manner, the precise spot and direction of displacement; but ascertained these points by subsequent observation, with more precision, in proportion as a knowledge of anatomy shed light on them. They also paid particular attention to the essential difference between primitive and consecutive luxations.
12. Petit admitted of four kinds of luxations, 1st, downward, on the edge of the scapula: this is a very rare occurrence: 2dly, outward, under the spine of that bone, a kind very difficult to be primitively produced. 3dly, inwards, under the hollow of the armpit. 4thly, forward, between the corocoid apophysis and the clavicle. With this illustrious practitioner, Heister acknowledged four kinds of displacements; but, here again, was a new variety, both in expression, and in meaning. The one says, downward, under the arm-pit, the other forward, under the pectoralis major; the one, backward, under the scapula, the other outward, under its spine. According to Duverney, luxations are never primitively in any other direction than downward; the others being only the subsequent effect of muscular action.
13. In the midst of these very complicated modes of treating a very simple subject, it is necessary, first, in order to acquire definite ideas, to divide luxations of the humerus into primitive, which are the immediate effect of external violence, and consecutive, which succeed the primitive, through the influence of causes which I am about to consider.
Let us suppose four lines to inscribe, in form of a parallelogram, the oval surface of the glenoid cavity, one representing the superior edge, another the inferior, a third the internal, and the fourth the external.
14. It is evident that the head of the humerus cannot be displaced towards the superior edge. In that direction, must be encountered, the acromion and corocoid apophyses, the strong ligament passing between them, the tendons of the triceps and supra-spinatusmuscles, and the fleshy mass of the deltoid; all which, taken together, constitute an insurmountable obstacle to the escape of the head of the bone upwards. Besides, what power could carry it upwards? In order that this kind of luxation might take place, it would be necessary, that the head of the bone should be carried outwards at the same time, as well as upwards, a circumstance which is impossible, because the trunk prevents the lower extremity (the elbow) from being directed sufficiently inward to produce such an effect.
15. On the contrary, in other directions, but very little resistance is to be met with. Towards the inferior edge of the cavity, the long portion of the triceps; the tendon of the subscapularis, towards the internal edge; and towards the external edge, the tendons of the infra-spinatus, and teres minor, yield with ease to a force directed against them, and permit the occurrence of primitive luxations, downward, inward, and outward. Downward, between the tendon of the long portion of the triceps, and that of the subscapularis; inward, between the subscapulary muscle and fossa;14and outward, between the fossa infra-spinatus and the muscle of the same name. These modes of displacement are not alike frequent, as will be mentioned presently.
16. Having escaped from its cavity, and being primitively placed in one of these three situations, thehead of the humerus oftentimes changes its position. Then, to a primitive luxation downward or inward, succeeds a consecutive or secondary one; but never to a luxation in an outward direction, if such ever occur, because the spine of the scapula forms an obstacle to it.
A secondary luxation inward, may succeed a primitive one downward; there is nothing to oppose the head of the humerus in the course it takes, to enter between the subscapulary muscle and fossa. If, on the other hand, it be disposed to pass to the external side, the tendon of the triceps opposes it; and, notwithstanding what Petit has advanced, there is no secondary luxation in that direction.
17. It sometimes happens, that, having escaped either from the internal part, or from the inferior part of the capsule, the head passes behind the clavicle, and forms there a secondary luxation upwards, as has been observed by Ambrose Pare, and by Gallien, and of which an example or specimen was preserved in the cabinet of Desault. But, here, the secondary displacement must take place in a slow manner, and when it has taken place, art can seldom remove it, on account of the strong adhesions formed by the bony surfaces. Thus, in the example mentioned, there was a new cavity formed behind the clavicle, and the humerus adhered to the surrounding parts by a kind of new ligaments.
18. It appears from what has been said, that the humerus is subject to four different kinds of displacement. 1st,Downward: 2dly,outward, in both of which directions the luxation is always primitive;3dly,inwards, where it is sometimes primitive, and sometimes consecutive; 4thly,upwards, where it can never be otherwise than consecutive.
The second and fourth are very rare occurrences, and bear so small a proportion to the others, that the latter alone ought to command the attention of the practitioner.
§ III.
19. The causes and the mechanism of luxations of the humerus, vary according as the displacement is primitive or consecutive.
The action of external bodies, directed against the arm, but more particularly falls, where this part strikes forcibly against a resisting body, give rise in general to primitive luxations, and, according as it is differently situated at the time of the fall, the humerus determines, by its position, the different kinds.
20. If it be separated from the trunk, without being carried either before or behind it, if the elbow be elevated, and the fall be on the side, the weight of the body, being almost entirely supported by this bone, pushes its upper extremity downward, distends the inferior part of the capsule, lacerates it, and produces a luxation downward, in which it may even be favoured by the action of the pectoralis major, the latissimus dorsi, and the teres major, as has been judiciously observed by Fabre. In such a case, these muscles, involuntarily contracting to support the trunk, act like the power or force in a lever of the second kind, the resistance to which is formed bythe head of the bone, which they draw downward, while the lower extremity of the humerus, resting on the ground, constitutes the fulcrum. Some authors even regard, as an immediate cause of luxation, the powerful contraction of the deltoid muscle, which depresses the head of the bone, and forces it through the lower side of the capsule, a mode of displacement, the existence of which observation incontestibly establishes. The case of a scrivener, so often cited, is well known, who in lifting a book of records luxated his humerus in a downward direction.
21. The mechanism of a primitive luxation inwards, differs a little from the preceding. The elbow, being at once separated from the trunk, and carried backward, the person falls: the weight of the body rests on the humerus; the capsule is lacerated in its fore-part; and a displacement in the same direction supervenes.
22. In a luxation outwards, the elbow is carried forward, towards the opposite shoulder; the capsule being stretched outwardly, gives way in that part, provided the humerus be acted on by a sufficient power. But what can this power be? In a fall, the arm being pushed against the trunk, and stopped by it, cannot carry its motion to a sufficient extent to produce a laceration of the capsule. Hence a luxation outwards must be extremely rare. Indeed no instance of it is to be found in books of surgery. Desault, in particular, never witnessed it. Besides, when in a fall, the arm, separated from the body, is carried backward or forward, the weight of the body acts obliquely on it, and it is but partially subjectedto the action of the latissimus dorsi, the pectoralis major, and the teres major. So that no kind of luxation ought from these considerations, to be very frequent, except that in a downward direction, where the influence of both causes is direct. Yet luxation inwards is common enough, and in many instances Desault has observed this primitive mode of displacement, though many modern authors doubt the fact, believing, with Hippocrates, that, primitively, all luxations are downwards.
23. It may so happen that in a primitive luxation, the capsule is only greatly stretched, in which case, the articulating surfaces are but partially displaced; but this membrane more frequently suffers a rupture, through which the head of the bone escapes. To this phenomenon writers, in general, have paid too little attention, notwithstanding the opening of dead bodies has oftentimes demonstrated its existence to practitioners, particularly to Desault, who has given two examples of it modelled in wax; one, of a luxation inward, and the other downward, both found in subjects that died in the Hotel-Dieu. Bell relates some analogous facts, and another English surgeon has also had occasion to meet with them.
24. Oftentimes, in compound fractures, one of the fragments passes through the integuments. In the dislocation of the humerus something similar to this occurs. The capsule is sufficiently lacerated to allow the head to escape; but the opening, being then too narrow, forms around the neck of the bone a noose or kind of collar, which prevents it from re-entering the place which it originally occupied. Thus, in the fracturesof which I have just spoken, the aperture in the skin does not, at times, admit of the reduction of the fragment, without a previous dilatation.
In this case, an attempt is made to reduce the luxation: the capsule is pressed in folds against the glenoid cavity, and, interposing itself between it and the head of the humerus, renders fruitless the efforts of the surgeon who would replace the bone. Desault was the first who observed this practical fact, two instances of which are recorded in his journal, and which has frequently since occurred in the Hotel-Dieu. In such a case, the head is in general extremely moveable, because, being entirely without the capsule, there is nothing to impede its motion.
25. When, to a primitive luxation a consecutive one succeeds, several causes may concur in its production. If a second fall happen, the arm, being separated from the body, the head of the humerus having nothing to retain and secure it, obeys, with great facility, the power tending to displace it in that direction, and suffers a fresh removal from the bed which it accidentally occupies.
Case I.A man fell in descending a ladder, and luxated his humerus in a downward direction. Desault being immediately called, discovered the nature of the disease, but deferred the reduction till evening. In the interval, the patient went to get into a chaise: his foot slipped, and he fell a second time. The pains became more severe than at the time of the first accident; and Desault, on his return, instead of finding, as in the morning, the head of the humerus under thehollow of the arm-pit, discovered it to be behind the pectoralis major.
26. Muscular action is one permanent cause of a new displacement. Suppose the humerus luxated downward, the pectoralis major, and the deltoid muscles draw its superior extremity upward and inward, which, offering to their action but a feeble resistance, changes its position and that in a two-fold direction.
27. The different motions of the arm may also, according to their direction, produce the same effect. Thus we have often witnessed a luxation inwards succeeding to a luxation downwards, in consequence of unskilful attempts to reduce it.
§ IV.
28. The diagnosis of luxations of the humerus, presents in general, but few difficulties.
Whatever may be the mode or seat of the displacement, there always exists, as Hippocrates has observed, a manifest depression under the acromion, which exhibits a prominence more perceptible than in its natural state. The motions of the part are almost all accompanied with pain; the greater part of them are impracticable; all of them very much confined. The arm cannot move, without a synchronous motion of the shoulder, because, the articulation being no longer able to exercise its functions, these two parts constitute, so to speak, but one body.
29. Besides these signs, which characterize generally every species of luxation of the humerus, eachspecies is marked by certain others peculiar to itself. If the displacement be downward, the arm is a little longer than in its natural state; it can be moved gently outwards; but an acute pain is the inevitable consequence of moving it forward or backward. The elbow is more or less removed from the axis of the body, by the action of the deltoid, the long portion of the biceps, and the supra-spinatus muscles, which, being unnaturally stretched, contract themselves and tend to carry the bone outward. The pains which result from this position, force the patient, in order to relieve them, to lean towards the affected side, to keep the fore-arm half-bent, the elbow resting on the hip, so that the arm, finding a place of support, may be freed from the painful movements, and from the disagreeable sensation produced by its own weight. From this attitude alone, was Desault in the habit of discovering luxations in a downward direction, and was rarely mistaken in his diagnosis. It is thus, that, in a fracture of the clavicle, the inclined position of the patient is oftentimes, at first sight, characteristic of the nature of his complaint. Beneath the hollow of the arm-pit there always exists a protuberance more or less perceptible, formed by the head of the humerus.
30. To the general signs of luxations of the humerus (28), that in an inward direction adds the following: the elbow, being separated from the trunk of the body, is carried a little backward; the humerus seems to direct itself towards the middle of the clavicle; motions backward are not very painful, while those in a forward direction are extremely so;under the pectoralis major a manifest protuberance exists; the arm is but little longer than in a natural state; the attitude is the same as in the preceding case.
31. Should a luxation in an outward direction occur, it would be particularly characterized by a hard tumour under the spine of the scapula, by the direction of the elbow forward, by its separation from the trunk, and by a little increase in the length of the arm.
A protuberance behind the clavicle, an obvious shortening of the arm, together with its direction, would plainly disclose a luxation upwards.
32. The signs discriminative of the nature of luxations of the humerus, are not always accompanied by the same degree of certainty as those that announce merely its existence. Thus, nothing is more difficult than to determine when a luxation inward is primitive, and when it is consecutive, the same phenomena being common to both. Nothing but an exact history of the disease, stating the order in which the phenomena have succeeded each other, can throw light on this point, which is the more interesting and important, as, according to the one or the other state of things, the processes of reduction ought to vary. In the first case, the head re-enters its natural cavity by a short route; whereas, in the second, it arrives there by a much longer one.
If, as Petit pretended, there exist luxations backward, sometimes primitive, and sometimes consecutive, the same remark may be applied to them with equal propriety.
33. Certain signs, common to luxations of the humerus, fractures of its neck, and dislocations ofthe scapulary extremity of the clavicle, might here create some uncertainty, if in the one, the absence of a tumour under the arm-pit, and of a depression under the acromion, did not prevent a mistake, which Hippocrates declared to be easily committed, into which, according to Galen, the masters of the art of wrestling fell, and which Pare cautions us to avoid; and if, in the other, the appearances proper to a fracture, did not prevent a mistake which would be serious in its consequences, and which sometimes results from the direction of the humerus, and the kind of protuberance formed in the arm-pit, by the end of the inferior fragment. (SeeFracture of the neck of the humerus).
§ V.
34. Luxations of the humerus are but rarely followed by any serious accidents. Sometimes a swelling more or less considerable appears, immediately after the fall, in and around the arm-pit. This is the effect of an increased irritability of the part, and is seldom of long duration. Desault’s remedy for it was the application of compresses wet with vegeto-mineral water, or of cataplasms moistened with the same liquid.
35. Several authors, particularly Bell, speak (as if it were a familiar accident) of an œdematous swelling of the whole upper extremity, caused, in inward luxations, by a compression of the axillary glands. This phenomenon has not often occurred in the Hotel-Dieu, except in luxations of long standing: and when it has been met with in certain cases, very happy effects have been produced, by the action, continued for several days, of a roller applied with considerable tightness after the reduction, and reaching from the fingers to the arm-pit.
Case II.Maria ***, falling from some height, her elbow being separated from her body and directed backwards, luxated her shoulder inwardly. Several days elapsed before she received any surgical aid. She was afterwards admitted into the Hotel-Dieu, where the displacement was discovered through a very considerable swelling, which occupied the parts around the articulation of the humerus. The reduction was accomplished, and the swelling left to itself, which, far however from disappearing, with the cause that produced it, seemed to gain ground. A roller was then applied, and on the day following the tumefaction was reduced to half its former size. The same means are continued. The compression is gradually increased, and by the ninth day, the limb restored to its natural form, performs, as before, all its functions.
36. There is another accident, on which authors have dwelt a little, which was known to Avicenna, and which oftentimes fell under the notice of Desault. I allude to a paralysis of the upper extremity, the effect of compression made by the head of the bone, in inward luxations, on the nerves of the brachial plexus. This accident sometimes resists every expedient of art, as appears from the following case, collected by myself, in the Hotel-Dieu.
Case III.Maria Dougour, fell on her right side, and experienced immediately all the signs of a downward luxation. A surgeon was called, who moved the bone violently in every direction; he made no extension; he kept the patient in torture for an hour; and at the expiration of that time pronounced the luxation irreducible, because the head of the bone, instead of returning into its natural cavity, had moved inwardly. Indeed, in the midst of his unskilful efforts, a consecutive luxation inwards had succeeded to a primitive one downwards.
On the same evening, an evident insensibility occurred in the part. A swelling, joined to a sense of coldness, accompanied it. On the fourth day, the paralysis was complete.
On the tenth day the patient was brought to the Hotel-Dieu, where the processes of art which we shall presently describe, replaced the bone, without removing the effects of its luxation.
To remedy this, irritating means were employed, simple at first, but multiplied and combined afterwards, and pushed so far as to occasion redness accompanied by small blisters. These were continued for three weeks; blistering plasters were applied; all in vain; the paralysis continued, and as long as a year afterwards the patient was still affected with it.
37. This accident is, in general, extremely obstinate, when, as in the preceding case, the nerves have experienced a long continued pressure. Under such circumstances, the most powerful means are often ineffectual. Moxa has been oftentimes used by Desault, which he applied over the clavicle, at the veryorigin of the brachial plexus. The success, with which he at first applied this remedy, did not always accompany his use of it, so that notwithstanding several cures performed by it, yet, to the majority of patients to whom it was applied, it was wholly useless.
39. But, if the head of the humerus make on the nerves but a momentary pressure, and the reduction be accomplished shortly after the paralytic symptoms occur, oftentimes then the insensibility disappears of itself, and the cure may be always greatly assisted by the application of powerful stimulants; such, for instance, as volatile liniment, composed of oil of almonds and ammonia, which Desault frequently employed, and of which he increased the strength, so as to render it rubefacient.
Case IV.Joanna Saq luxated her arm, by falling on her right side, in the month of July, 1788. In the evening of the same day, all the precursory symptoms of paralysis made their appearance. The affection was complete on the day following.
The patient was brought to the Hotel-Dieu, where the reduction, being accomplished, afforded no relief. On the third day, the paralysis still continuing, the volatile liniment was directed, in the proportion at first of two drachms of ammonia to an ounce of the oil of almonds. This produced no effect. Being increased in strength on the fifth day, it still appeared to be useless. On the eighth it was made of such a degree of strength, as to occasion slight pustules over the whole of the diseased extremity. On this, motion began to return, feeble at first, butincreasing by degrees, till by the sixteenth day, it was as free and perfect as in a natural state. During all the time, the liniment was applied twice a day over the arm and fore-arm, which were at the same time subjected to strong friction during the space of half an hour.
39. The pains which accompany luxations of the humerus, claim in general some attention from the practitioner. These have sometimes arisen to such a height, as to produce real disorder in the animal economy, particularly in luxations inwardly, where, resulting, no doubt, from the compression of the axillary nerves, they render immediate reduction more necessary, and are generally removed by it.
§ VII.
40. We may throw into two classes the numerous means, under all their variety of modifications, proposed for the reduction of luxations of the humerus. The one consists in forcing, by some mechanical power, the head of the bone into the cavity from which it had escaped, whether extension has been previously employed or not. The other is confined to disengaging it from the situation, into which it has been accidentally driven, leaving to the action of the muscles the care of its replacement.
In the first of these, art does every thing; in the second, it only gives the proper direction to the powers of nature. These latter give but one course or direction to the action of powers externally applied:in the former, the head of the bone always moves in the diagonal of two powers opposed to each other at an angle more or less acute.
41. A history of the means destined to act in the first mode, would be too tedious to be introduced in this place, would throw no light on the processes about to be proposed, and are detailed at full length in many authors, to which the reader is referred. It will be sufficient to observe, that they all act somewhat in the following manner. Some body, placed under the arm-pit, serves as a fulcrum, on which the arm is made to move like a lever of the first kind, the resistance to which is constituted by the displaced head of the humerus, while the power is applied either at the lower part of this bone, or at the wrist. The extremity of the humerus being directed upwards and inwards, moves its head in the opposite directions, towards the glenoid cavity, where it replaces it with more or less facility.
In this manner acted that machine so celebrated among the ancients and moderns, under the name of “Ambi Hippocratis,” whether it was employed in the precise form described by that prince of physicians, or with the additions and corrections, infinitely varied, which it has received from Paul of Egina, Ambrose Pare, Duverney, Freke, &c. By this, a double motion is communicated to the head of the humerus, which is, at the same time, directed, 1st, in the course above mentioned; and, 2dly, in such a manner, as to disengage it from the unnatural situation which it occupies.
42. Extension by the arm produces, in common, the second effect, and this is made in different modes. Sometimes the weight of the body on one side, and pulling by the luxated limb on the other, serve to produce it; and such was the mode of action of the ladder, the door, and the club, described in the treatise on fractures by Hippocrates, and revived in many modern works. At other times, the body was immoveably fixed, and a powerful extension made by the arm. This was the mode in which the machines of Oribasus operated, and also one of the methods formerly consecrated in the public places where the athletæ held their combats.
43. On some occasions, no extension is perceptibly made, but at the same time in which the extremity of the humerus is forced outwards by a body placed under the arm-pit, the surgeon pushes it upwards into the glenoid cavity: and such were the other modes of reduction practised by the masters in the athletic art. Hence it appears, that the first class of the numerous means, employed for the reduction of luxations, may be divided into those which consist in impulsion, those where mere extension is practised, and those where recourse is not had to either. My object here is not to examine into the inconveniences attending each of these means: a sufficient number of authors have already done this; particularly Petit and Bell. I shall only point out the disadvantages, which, being common to all, ought to induce them all to be excluded from a rational mode of practice.
44. The escape of the head of the bone through the ruptured and lacerated capsule, constitutes essentiallythe displacement under consideration. But, it is never possible to ascertain with precision the place of this rupture: how, then, can the head of the humerus be directed towards it by an artificial force?
45. However well prepared for the purpose the body may be, which is placed under the arm-pit, to serve as a fulcrum, always a chafing more or less troublesome, and oftentimes distensions and serious lacerations are the consequences of its application, when the body is suspended on it, as in the mode by the door, the club, &c. where Petit has seen a fracture of the neck of the humerus occur, and even a laceration, followed by an aneurism of the axillary artery.
46. Every one has not at his command the different means above mentioned (41 and 42), whence the difficulty of procuring them, or of constructing them, and the loss of time, precious in relation to the reduction, which is almost always easily accomplished in proportion to the expedition used; these charges apply, among many other means, to that machine so complicated, and so well known, under the name of the mitten15of Petit.
47. Supposing the luxation to be consecutive, how can mechanical means make the head of the bone retrace the route it has pursued in becoming displaced? For example, if to a displacement downwards has succeeded a displacement inwards, it will be necessary for the head to return downwards before it can re-enter its cavity. But, can the direction of themovements be thus varied? This whole apparatus of artificial means, for ever contradictory, oftentimes acts in an inverse direction to that of the muscular action, which is the essential and chief agent in the process of reduction.
Should the luxation take place upwards, the insufficiency of these means must be evident.
48. Perhaps, however, they may be employed with some advantage, when a primitive luxation downwards is quite recent, and the head of the bone is near to its cavity. In such a case the lower edge of the scapula presents to it an inclined plane, along which it can easily glide, when pushed by some external force. It is doubtless to this disposition of the bone to replace itself, that we must attribute the successes, greatly exaggerated, but in part real, on which the inventor of every machine endeavours to found the superior merit of his mode of operating.
But, in this case, it is useless to accumulate artificial forces, where natural ones are sufficient, and where the operator may, with his hands, effect the reduction the more easily, as he can with more accuracy vary the direction of his movements.
49. Thus Desault oftentimes employed a process which was attended with great success, and which, like some of the preceding, ought to be referred to impulsion. The patient being seated on a chair of a moderate height, he took hold of the hand of the affected side, placed it between his knees, and carried it downward and backward, for the purpose of making extension, and disengaging the head of the bone; while an assistant held the trunk with a view to counter-extension, which was sometimes effected to a sufficient degree, by the weight of the body and the efforts of the patient. At the same time the hands of the surgeon, applied to the arm, in such a manner that the fingers of each were in contact with the hollow of the arm-pit, and the thumbs with the external part of the arm, drew upwards and a little outwards the head of the humerus, which in common returned with ease into its natural cavity.
50. Petit mentions this process, not such as it is here described, but complicated with the use of a napkin passed under the arm-pit of the patient, and round the neck of the surgeon, who, by raising his head, drew the displaced extremity upwards. This additional mean, always unnecessary, and not judiciously constructed, is generally ineffectual, because, with it, the operator cannot at pleasure vary his movements. The hands alone are always sufficient, and a vast number of examples attest the efficacy of this method, when employed after the manner of Desault.
Case VI.Nicholas Juan fell on his side, his arm being separated from his body, as he was crossing, in January 1790, the place Notre-Dame, opposite to the Hotel-Dieu. An acute pain was immediately experienced; a protuberance appeared suddenly under the arm-pit; and under the acromion a depression equally sudden. He was lifted up, and carried straight to the Hospital, where Desault was just beginning a clinical lecture. The luxation being manifested by these appearances, was immediately reduced by the foregoing means. A few days restwere enjoined on the patient, but, on the same evening, he proceeded on his way, blaming himself, for having lost half of his day’s journey.
51. In analogous cases of very recent luxations downwards, Desault twice or three times effected the reduction by means still more simple, as the following case, reported by Heraut, testifies.
Case VII.Maria Louisa Favert fell, as she was descending a ladder, and having luxated her arm, was carried at her request, immediately after the accident, to the Hotel-Dieu. Desault perceiving the nature of the disease, placed, under the hollow of the arm-pit, his left hand, to serve as a fulcrum while with his right, applied on the inferior and external part of the arm, he approximated the humerus to the trunk, pushing it at the same time upwards. By this double movement, directed upwards and outwards, the head of the humerus re-entered its cavity without the least resistance. The arm was suspended in a sling for two days, and on the fourth the patient returned to her usual labour.
52. There exists some analogy between this method and one of those mentioned, by Hippocrates, to have been practised in ancient times, in the public games, where the exertions of body exposed those engaged to frequent luxations.
It is not only in luxations downwards, that the first of the simple processes which I have mentioned (49), may be applied. Primitive luxations inwardly, yield sometimes to its use, and the Journal of Surgery furnishes two instances of success in similar cases; one in a female sixty-three years of age, andthe other in one of fifty-one, of a strong constitution, and in whom the reduction was effected without resistance.
53. But, in general, these means are ineffectual and it becomes necessary to have recourse to extension, which, when employed alone, forms the second class of means intended for reducing luxations of the humerus. Many writers have adopted this exclusively, though some practitioners, indulging their imagination in the vast field of invention, deserted the common track, and had recourse to various kinds of machinery. Celsus depended on extension alone, in common cases of luxation downward and forward. Albucasis employed no other means, Douey, Douglass, and Heister, among the moderns, reject unconditionally the use of machines, as always useless, and often dangerous. Finally, Dupoui and Fabre, examined and analysed with great exactness the process of extension, and pointed out, in every case, the means of rendering it advantageous, by managing in the best manner the extending forces, and in the luxation of the humerus, in particular, to prevent the inconvenience of straps placed under the arm-pit of the patient, demonstrated the inutility of the movement commonly called conformation. In these respects, surgery stands indebted to them for real advancement, and their doctrine, at this day, very generally known and received, was principally reduced to practice by Desault, who made it the basis of his method of reduction in all fractures and luxations.
54. To proceed to the reduction of a luxation of the humerus, it is necessary to have such a numberof assistants as to be able, according to the resistance of the parts, to increase the force intended to overcome it. But two are commonly sufficient. They should furnish themselves with a linen ball, thick enough to project beyond the level of the pectoralis major and the latissimus dorsi, when placed in the axilla, and two straps, one formed of flannel doubled several times, four inches broad, and eight or nine feet long, the other of a napkin regularly folded. This latter is not often absolutely necessary.
Every thing being properly arranged, the patient is seated on a chair of a moderate height, or else laid on a table firmly fixed and covered with a simple mattress, in order that the trunk, by being in a horizontal position, may not prevent the motions communicated to the arm from being directed downwards.
55. Desault continued, for a long time, to place the patient in the first of these positions, which, though employed by practitioners generally, is by no means the most favourable. By adopting it indeed the arm may be very well drawn in a transverse direction; but if, as oftentimes happens, it becomes necessary to direct extension upwards or downwards, the assistant, then, being obliged to elevate himself, or to stoop, cannot, in either of these attitudes, exert his strength to advantage, but is confined and embarrassed, and cannot with ease vary, at the pleasure of the surgeon, the direction in which the arm is drawn.
As far as relates to the patient, that situation in which the body is only in part supported, is much more fatiguing than one where the whole of it reposesequally on a horizontal plain. Perhaps, in relation to the surgeon, it would be more advantageous, in enabling him to accomplish the process of conformation16; but, as will be presently observed, this process is always useless. These considerations induced Desault, in the last years of his practice, to renounce the first position, and have recourse only to the second.