66. I will close this memoir by an examination into some circumstances,
which may either prevent reduction or render it difficult, and into
certain accidents that sometimes accompany it.
I have said that, on some occasions, the rupture of the capsule, being
too narrow to admit the head of the humerus to repass it, and return to
its cavity, constitutes one of the principal obstacles to a reduction
(24). To enlarge this passage, by further lacerating its edges, is
evidently the indication that here presents itself. This is fulfilled
by communicating to the bone great motion, either by circumduction, or
rotation on its own axis, forcing it suddenly in different directions,
particularly in that direction in which the luxation has been produced.
Its superior extremity must be, at the same time, pushed forcibly
against the ruptured capsule, which, by being thus pressed between two
resisting bodies, will suffer a more extensive rupture. Reduction,
oftentimes impracticable previously to these violent and varied
motions, takes place of itself as soon as they have been properly made.
Of this the practice of Desault furnishes many examples.
CASE VIII. In the Journal of Surgery are recorded two cases, one by
Anthaume, the other by Faucheron, which establish this doctrine.
John Seligni, a robust man, forty-four years of age, fell on the
point of his shoulder, on the 19th of July 1791; the pain, which was
increased by moving his arm, and the swelling which supervened almost
immediately, induced him to enter the Hotel-Dieu. The efforts of
assistants were at first insufficient, and it was not till after a
uniform extension continued for several minutes, that the head of the
humerus was drawn by the muscles against the glenoid cavity. The bone
appeared to enter the cavity, although the persons present did not hear
the collision or clashing of the articulating surfaces, which is almost
always perceived in cases of recent luxation: but immediately the
humerus was again displaced, without its being practicable to retain
it. On the occurrence of this phenomenon, Desault conceived that the
head of the bone had pushed before it the capsular ligament, through
which it could not pass, in consequence of the narrowness of the
opening which had been made at the time of the luxation. He proceeded
to move the arm forcibly in every direction, in order to enlarge the
opening, and immediately felt a kind of laceration, which satisfied
him that his views were accomplished. He then re-commenced extension,
which it was again necessary to continue, as at first, for some time,
in order to overcome the resistance of the muscles. The reduction was
attended with no further difficulty. The humerus continued still to
have a great tendency to be displaced, and it was necessary to employ,
for several days, a bandage similar to that for a fractured clavicle.
CASE IX. Maria Laurencier, aged sixty, fell on her right elbow, and
luxated the humerus of the same side. Eight hours afterwards she
came to the Hotel-Dieu, on the eighth of March, 1789. The reduction
was attempted in the usual manner; but, although the extensions were
properly directed, and the head of the humerus brought against the
glenoid cavity, it was still displaced again as soon as the limb was
let go, a circumstance which created a suspicion, that the opening of
the capsule was too narrow to allow the head of the bone to pass. The
assistants ceased making extension, and Desault, taking hold of the
lower extremity of the arm, impressed on it great motion, particularly
in the direction of the luxation, for the purpose of enlarging the
laceration of the capsule. The extensions were now renewed, and the
reduction succeeded with great ease.
67. A second obstacle, more difficult to be surmounted in the process
of reduction, is that arising from the long continuance of the
luxation. The head of the bone, having continued for a long time in the
bed into which it has been accidentally thrown, forms adhesions to it;
the surrounding cellular membrane becomes thickened, and makes, so to
speak, a new capsule for the head, which opposes its replacement, and,
when the reduction cannot be accomplished, supplies in some measure
the office of the old joint, by the movements which it allows to take
place.
Most writers, and Bell in particular, advise, in such a case, never to
attempt a reduction, which, being of no avail as to the luxation, might
prove dangerous to the patient, in consequence of the violence it would
do to the parts. This doctrine was for a time, the doctrine of Desault:
but experience, in his latter years, led him to a bolder practice.
68. The complete success which he experienced in luxations of fifteen
or twenty day’s standing, encouraged him to make the attempt, at
the end of thirty and thirty-five days, and we have, three or four
times, during the two last years of his life, seen him successful in
replacing, after the expiration of two and a half, and even three
months, the head of the bone which had escaped, both through the
inferior, and the internal side of the capsule.
However powerful, and however long continued the extensions were, none
of those terrible accidents occurred, with which we are threatened by
authors. Twice only did a phenomenon occur, which it was difficult to
foresee, and of which I will presently speak.
69. In cases of this kind, it is necessary, previously to making
extension, to move the bone very forcibly in every direction, in order
first to break the adhesions, to tear the condensed cellular membrane,
which serves as an accidental capsule, and to produce, so to speak, a
second luxation, with a view to make way for a perfect reduction of the
first. The straps being then applied, as in ordinary cases, serve the
purpose of extension, for the accomplishment of which the number of
assistants must be increased.
70. Oftentimes the first efforts are fruitless, and the luxated head
remains stationary, amidst the most violent efforts. Let the extensions
then be discontinued: renew the forcible motions of the limb: carry
the humerus upwards, downwards, forward, and backward: force the
resistances to give way; make the arm describe a large arch of a circle
round the place which it occupies; let the rotatory motions on its
own axis be impressed on it anew; and then recommence the extensions,
and let them be made in every direction. By these, the head, already
disengaged by means of preceding violent motions, will be brought to a
level with the glenoid cavity, and ultimately replaced.
It may not be improper to confirm by experience the truth of these
precepts, which might to some appear rash, in consequence of the
changes that seem likely to occur in the glenoid cavity, during the
absence of the head of the humerus. I will relate, among others, a case
reported by Giraud, second surgeon to the Hotel-Dieu.
CASE X. Maria Gauthier, thirty-four years of age, entered the
Hotel-Dieu, on the twentieth of June, 1790, to be cured of a luxation
of three months standing, produced originally by a fall on the arm,
which was separated, at the time, from the body and carried backward.
Different surgeons had, at different times, attempted the reduction,
but always without effect, and when every hope of a cure appeared to
have expired, Desault, imboldened by reiterated success, tried whether
or not he would be equally fortunate in this case.
The patient being placed in a horizontal position, as already directed
(55), great motions were first impressed on the limb: extensions were
then commenced, first in the direction of the luxation, and afterwards
forward and backward. Vain efforts; the head remains immoveable;
new motions are again made in every direction, and afterwards, the
extensions are renewed: the same want of success. The patient being
fatigued, the reduction was deferred till the day following, when the
same trials were, after a short time, attended with complete success.
The head being at first disengaged, and afterwards drawn slowly along
the track through which it had passed in becoming displaced, at
length re-entered the capsule. The arm, being supported by the usual
apparatus, soon became œdematous, and, notwithstanding the remedies
common in such cases, the swelling continued for two months. The
motions performed by the limb in the mean time, restored to it, by
degrees, its usual suppleness; and, on the sixty-eighth day after her
entrance, the patient was discharged cured.
To this case, I might subjoin many others, and, in particular, that
of John Putot, also reported by Giraud, and in which the means just
described (69 and 70), succeeded in the reduction of a luxation at the
expiration of the fourth month. But too great an accumulation of facts
distract the attention, and add nothing to conviction, especially when
they are already so plain as those just related.
71. But further, in cases of this kind, where a very old luxation
presents great obstacles to reduction, although the attempts made
to reduce it, do not actually force the head of the bone into the
capsule, still they may not prove entirely useless. By bringing the
head nearer to the glenoid cavity, or placing it even on that cavity,
and making it form new adhesions there, after having destroyed its old
ones, the motions of the limb will be facilitated. For, in cases, where
the luxation is not fairly reduced, these motions will be always less
impeded, in proportion as the head of the bone occupies a place less
remote from its natural situation.
72. A third obstacle, common to the reduction, of every kind of
luxation, is the muscular force, increased by the irritation of the
displaced bone, beyond its natural degree. So great, at times, is
this force, that the head of the bone cannot be moved, even by the
strongest efforts. What means should then be employed? 1st, Those
which diminish general irritability, such as blood-letting, bathing,
a relaxing regimen, &c. 2dly, Those which act locally, in diminishing
the irritability of the muscles of the shoulder. For example: the
application of emollient cataplasms or fomentations to the part; or,
what is still better, a powerful extension, continued for some time. In
consequence of such extension, the muscles of the part become fatigued,
whence their contractions are succeeded by a state of atony, of which
advantage may be taken to replace the bone. Frequently this extension
ought to be continued for a very long time; and we have known Desault
not to complete the reduction in less than half a day, or even a whole
day, the limb being suffered to remain all that time in the apparatus
for fractures of the clavicle, which draws the shoulder and muscles
outwards. Thus, in fractures of the thigh, where muscular contraction
prevents the contact of the fragments, permanent extension previously
employed, assists in producing this contact.
§ IX.