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 essentially the 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
mitten[15] of Petit.
[15] (_De mouffle de 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 the movements 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 rest were
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, and the 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 number of 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 reposes equally on a horizontal plain. Perhaps, in relation
to the surgeon, it would be more advantageous, in enabling him to
accomplish the process of conformation[16]; 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.
[16] That is, to draw, or otherwise force the head of the os
humeri, with his hands, towards the glenoid cavity, while the
assistants are making extension and counter-extension. In doing
this, he must pull the head upwards, if it be lodged in the axilla,
backward if it be under the upper part of the pectoralis major, &c.
Desault, however, contends that this assistance from the surgeon
is unnecessary, and that extension and counter-extension are alone
sufficient to effect the reduction. TRANS.
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 such is
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 of adhesions, 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 the _Spica_
bandage.[17] But 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.
[17] With the particular mechanism and mode of action of this
bandage, I am unacquainted. Nor are these matters of much moment,
as the bandage is, I believe, entirely out of use. TRANS.
§ VIII.