73. It is rare that any serious accident follows the reduction of a
luxation of the humerus. A swelling, more or less extensive, sometimes
shows itself around the joint, particularly when extension has been
forcible and long continued; but this, being, in general, easily
removed, by means of discutients, does not demand particular attention.
74. Another accident which rarely occurs in practice, respecting which
but little is to be found in surgical writings, and with which Desault
occasionally met, is, a considerable emphysema, suddenly appearing
at the time of reduction. In the midst of those powerful extensions,
rendered necessary by the ancient state of the luxation, a tumour
suddenly appears under the pectoralis major. By a rapid increase it
extends itself towards the hollow of the arm-pit, the whole of which it
soon occupies. It then propagates itself in a backward direction, and,
in the space of a few minutes, its bulk is sometimes equal to that of
the head of an infant. A practitioner, if unacquainted with the nature
of this accident, might take it for an aneurism, produced by a sudden
rupture of the axillary artery, in consequence of the violence done to
that vessel by the extensions of the limb. But, if attention be paid to
the resistance of the tumour, to its want of pulsation, to the place of
its first appearance, (which is usually under the pectoralis major, and
not under the hollow of the arm-pit, to which it only propagates itself
afterwards, as Desault has observed in similar cases that fell under
his notice), to the action of the pulse still continuing, unless the
patient should faint from debility, as happened to the subject of the
following case, which we had occasion to witness at the amphitheatre,
sometime previous to the death of Desault, and to the colour of the
skin which suffers no change; if these circumstances be attended to,
it will be difficult not to distinguish one of these accidents from
the other. In that now under consideration, discutients applied to the
tumour, such, for example, as vegeto-mineral water, and a gentle and
regular compression made by the bandage intended to support the arm
after reduction, are the most efficacious means that art can employ.
CASE XI. Simon Cerisiat, sixty years of age, presented himself on the
nineteenth of December, 1794, as the subject of a public consultation,
which, every day preceded the clinical lecture of Desault, to receive
advice for a luxation inwards, which he had suffered a month and a half
before, and for the reduction of which no attempt had been yet made.
Convinced, by the example of luxations more ancient, of the
practicability of reducing this, Desault undertook it immediately in
the presence of his pupils.
The patient being laid on a table, firmly fixed and covered with a
mattress, great motions were impressed on the luxated limb upward,
forward, and outward, with a view to destroy the adhesions contracted
with the surrounding parts. Extensions were then made in the manner
already mentioned (66 and 67).
Nothing was gained by the first attempt, the head remaining immoveable,
in the midst of the efforts to displace it. Further motions were made
in every direction, to break if possible, the attachments which held
it; and these were followed by further extensions.
While these were making in a forcible manner, the head was perceived
to approach by degrees towards the glenoid cavity, near to the edge
of which it reached in two minutes, and was at length replaced, by a
sudden movement of the limb from behind forward.
Scarcely was the reduction accomplished, when a tumour rose suddenly
under the pectoralis major, propagated itself towards the arm-pit, and
occupied immediately its whole extent.
All the assistants, astonished at the phenomenon, knew not to what
circumstance to attribute it. Desault himself, a little embarrassed,
thought first of an aneurism suddenly produced by the violence of the
extension. The pulse of the patient, being scarcely perceptible in the
side affected, and a syncope which supervened, appeared at first to
favour this suspicion: but immediately the absence of a fluctuation, of
a pulsation, and of a change in the colour of the skin, the return of
the pulse, the circumscription of the tumour, its resistance, and the
sound caused by striking on it, produced a belief that it was owing,
not to an effusion of blood, but to a disengagement of air that had
been confined in the now lacerated cells of the cellular membrane.
Over the whole of the swelling were applied compresses wet with
vegeto-mineral water, while a regular compression was made on it by
means of a bandage, which, at the same time, kept the arm fixed against
the trunk.
In the night there occurred severe pains around the articulation
and the tumour, accompanied with high fever, both which symptoms
disappeared on the following day. Third day, a diminution of the
emphysematous swelling; and an entire cessation of fever and pain.
Eighth day, tumour reduced to half its original size; the arm made to
perform gentle motions, and disengaged from the apparatus; discutients
continued. Thirteenth day, tumour entirely gone. In the place which
it had occupied a large echymosis appeared, produced no doubt, by a
rupture of the small vessels at the time of reduction, but which,
till now, had not been perceptible externally, in consequence of the
emphysematous swelling of the parts, and which was treated by the same
means as the emphysema. Seventeenth day, a yellow tinge, mixed with
the colour of the echymosis, an evidence of its resolution, which was
complete by the twenty-seventh day.
During all this time, the patient had accustomed his limb to constant
motion; a facility in the movement of it had thereby returned; and he
was perfectly well when he left the Hotel-Dieu, on the thirtieth day
from the time of his admission, and the sixty-fifth from the occurrence
of the accident.