12. The reduction in this case is usually attended with but little
difficulty, and the great multiplicity of means hitherto used for that
purpose, demonstrate only the barrenness of the art.
Most of the machines destined to reduce the luxation of the humerus,
have been applied to this fracture. Thus the ladder,[11]* the door,†
and the club,‡ placed under the arm-pit, served at once the
purposes of counter-extension, and conformation, while the powers for
producing extension were applied to the elbow, and more rarely to the
wrist. Thus Hippocrates recommended a wooden cross, the effect and
mode of action of which are nearly the same. These means, in general,
besides being insufficient, are liable to a further objection, in
consequence of their acting on the edges of the pectoralis major,
latissimus dorsi, and teres major, which being thus forced upwards,
draw the fragment to which they adhere in the same direction, and
thereby constitute an obstacle to the reduction. (See what will be
advanced on the subject of luxations of the humerus.)
[11] (* L’echelle, † la porte, ‡ le baton.) These pieces of
machinery, though formerly in use, are now, I believe, in all parts
of the world, laid aside. It would be superfluous, therefore, to
consume time in describing either them, or their mode of operation.
TRANS.
13. To machines succeeded the use of straps, weights suspended to the
limb, &c. These processes were entirely useless, in as much as they
were intended only to increase the natural powers of the operator,
which are already more than sufficient of themselves. They will,
therefore, in a short time, exist only in the history of surgery.
Petit proposed to reduce this fracture, by first raising the arm to a
right angle with the body, and then directing one assistant to make
the requisite extension, by taking hold of the elbow with his hands,
while another grasped the point of the shoulder, for the purpose
of counter-extension. This method was attended with the threefold
inconvenience, of subjecting the patient to great fatigue and pain,
of weakening the extending powers, by bringing them too near to the
point required to be moved, and of irritating the muscles that draw the
lower fragment upwards, and thus exciting them to contract. Hence the
difficulties sometimes attendant on reduction, which is always simple
in itself, when, after the trunk is properly fixed, gentle extensions
are made by taking hold of the fore-arm in a half-bent state. The
following is the mode of reduction practised by Desault.
14. The patient is seated either on a chair or on the side of a bed.
The arm is slightly separated from the body, and carried a little
forward.
One assistant is directed to fix and secure the trunk in a proper
manner. This he does by pulling at the arm of the sound side,
taking hold of it near to the hand, and extending it in a direction
perpendicular to the axis of the body. This mode of counter-extension
is preferable to that commonly employed, which consists in applying
the hands to the upper part of the patient’s shoulder. Indeed, on the
one hand, the power being farther removed from the resisting force,
need not be so great. And, on the other, the body being entirely
unencumbered, renders it easy for the surgeon to apply the roller
without discontinuing, or in any way disturbing, the extension.
Another assistant makes extension on the fore-arm, which serves him
as a lever, where, one hand being placed behind or on the back of
the wrist, forms the point of support, (or fulcrum), while the other
applied to the anterior and middle part of the fore arm, on which it
makes pressure from above downward, represents the power; the fragments
to be brought into contact constitute the resistance.
The relaxation of the muscles produced by this semi-flexion of the
fore-arm, and the slight separation of the arm from the trunk, greatly
favour this mode of extension; a mode recommended by the ancients,
adhered to by the English, and which possesses the advantage of leaving
uncovered all that portion of the limb on which the apparatus is to be
applied, and by that means of allowing the hands of the assistant to
keep the same position during the whole time of the application.
A small degree of force, judiciously directed according as the
displacement is inward or outward, is sufficient to effect the
reduction, which even takes place of its own accord, under this
process. If the surgeon lays his hands on the place of fracture, it
is rather to examine the state of the fragments, than to assist in
bringing them into apposition.
§ VI.