Part 11

The patient, being strong and vigorous, and having received besides a violent contusion, was bled twice, and confined to a low diet. On the following day, no derangement; on the fourth day, a slight displacement of the bone, the rollers a little relaxed, bandage applied anew. Eighth day, no sensible displacement. Eleventh day, some swelling around the joint; compresses, wet with vegeto-mineral water, ordered to be frequently renewed. Twentieth day, the swelling almost gone, and no disposition to a displacement; the apparatus was removed; motions at first difficult, and contracted. Twenty-ninth day, more free and easy. Thirty-fourth day, returned to their natural state.

CASE III. Mary Rivert luxated her clavicle, on the seventh day of January 1789. Being brought some time afterwards, to the Hotel-Dieu, she was treated in the same manner as the foregoing patient, and with the same result, except that a very slight protuberance remained at the extremity of the bone, and the confined state of the motions continued a little longer. Desault related, in his lectures, other instances of cures being performed without the least remaining deformity.

After all, even supposing the method just proposed, to possess no other advantage, than that of diminishing the protuberance of the bone, which, under other modes of treatment, is almost inevitable, and by that means preventing the motions of the part from being confined, it would still, without doubt, be a great step towards the perfection of the art.

23. Should a luxation backwards occur, the same process of reduction should be adopted, with this difference, that the extension ought to be made forward and outward; and the same apparatus should be applied for retaining the parts, except that the humeral extremity ought to be directed a little backward, in order that the sternal extremity, being carried forward, may be removed from the place of laceration in the capsule.

In like manner, should the bone be luxated upwards, it would be necessary to draw the arm outwards, and elevate slightly the point of the shoulder, for the purpose of depressing the sternal extremity.

LUXATION OF THE HUMERAL EXTREMITY.

§ V.

OF THE KINDS OF LUXATION.

24. Luxations of the humeral extremity of the clavicle, take place, according to Petit, in two ways, 1st, under, and 2dly, over the acromion. If we attend to the disposition of the articulating surfaces, the superior of which rests obliquely on the inferior; if we examine, in particular, the relative position of the corocoid apophysis with respect to the clavicle, it will be difficult to conceive how the first kind of luxation can occur, without being accompanied by a fracture. Yet some facts added by Desault to the doctrine of Petit, on this point, seem to demonstrate the possibility of the clavicle sliding under the acromion. As to luxations forward and backward, the mobility of the shoulder, the facility with which it yields to motions impressed on it in these two directions, and the want of a resisting power, make the two bones that compose it, move together, still preserving their relative position.

The luxation upward, then, is that which ought chiefly to occupy the attention of the practitioner. Yet even this is less frequent than the luxation of the sternal extremity, on account of the very great strength of the retaining ligaments, which, when this luxation occurs, must be, if not lacerated, at least very much distended.

§ VI.

OF THE MECHANISM AND THE APPEARANCES.

25. A fall on the point of the shoulder is the most frequent cause of this luxation. The two articulating surfaces, representing an inclined plain, slide along each other, in such a manner, that that which belongs to the acromion is pushed inward, while that of the clavicle is directed outward. The capsule being stretched, gives way, and then the displacement is manifested by a preternatural protuberance over the acromion; by a stiffness in the motion of the shoulder; by the direction of this part, which is evidently drawn inward and downward; by the inclination of the head of the patient to the side affected; by a bending of the body; and by severe pains in the luxated part. These characters are essentially distinct, and ought to have prevented the error of Galen, who mistook a case of this kind for a luxation of the os humeri downward. Hippocrates and Ambrose Pare have foreseen the possibility of this mistake and even warned young practitioners to be on their guard against it. But, as citizen Sabattier judiciously observes, the position of the head of the humerus, under the arm, in a luxation of that bone, will remove all uncertainty respecting the nature of the injury.

§ VII.

OF THE REDUCTION AND THE MEANS OF RETAINING IT.

26. The reduction, in this case, is generally attended with but little difficulty. The acromion being drawn outward, by the upper end of the os humeri, which, by means of a fulcrum placed under the armpit, is made to act as a lever of the first kind, is restored, without much trouble, to its natural contact with the corresponding surface of the clavicle. But, it soon becomes deranged again, unless it be retained in its place by a proper apparatus. Now, on what principle ought this apparatus to be constructed? To prevent the displacement, which generally occurs from without inwards, it ought evidently to act from within outwards. Whence it follows, that the rollers in the figure of 8 bandage, recommended in this case by all writers, instead of preventing, actually favour the displacement (17), because they act in the same direction with, and therefore assist, the powers that produce it.

27. Here, in like manner as in the preceding case, the bandage of Desault fulfils with precision the indications of cure, because, by it, the point of the shoulder is, particularly, drawn outward; and if, in certain cases, a slight projection of the humeral extremity still remains, it is to be attributed to the inefficacy of the means of execution, and not to the principles on which they are founded.

MEMOIR IV.

ON FRACTURES OF THE ACROMION, AND OF THE LOWER ANGLE OF THE SCAPULA.

§ I.

FRACTURE OF THE ACROMION.

1. There is no part of the scapula more liable to fractures than the acromion. Being but slightly covered by the soft parts, this insulated kind of appendix has not, in all positions of the humerus, a solid point of support. A strong muscular force oftentimes acts on it with great energy. Being large in front, it presents in that direction a considerable surface to receive the action of external bodies. Whence it follows, that if it is not oftentimes broken, this is to be attributed, not so much to its natural disposition, as to the position which it generally assumes in falls.

2. The fracture, which is almost always transverse, is sometimes at the summit, and sometimes at the base of this apophysis, and is usually produced by a violent shock from a body falling on the shoulder, by a blow received on that part, &c.

3. But in whatever place it occurs, it greatly resembles a fracture of the humeral extremity of the clavicle, of which the acromion appears like a continuation. There is accordingly a strong analogy between the phenomena, the consequences, and the modes of treating these two kinds of fractures.

4. This accident is characterized, 1st, By a severe pain experienced by the patient, at the place of the fracture. This pain is increased by the elevation of the arm, which, generally hangs motionless down along the side. 2dly, If the humerus be removed from the trunk, the hand being at the same time placed on the acromion, the extremity of this apophysis is felt sinking downward, creating thereby an evident depression in the part. 3dly, Generally, the two fragments lose, of their own accord, their relative position; and unless the precaution about to be mentioned be used, their displacement becomes manifest, being produced by the weight of the arm, and the contractions of the deltoid muscle. 4thly, The head is inclined to the affected side.

§ II.

OF THE REDUCTION.

5. Two different processes have been long in use for the reduction of fractures of the acromion. One consists in elevating the arm almost to a right angle with the body, in order, as Heister remarks, to throw the deltoid muscle into a state of relaxation, and then to be able, with the fingers, to place the fragments in their natural situation. In the other mode, the humerus is suffered to retain the position it has assumed, that is, to hang down the side; the surgeon then taking hold of the elbow, pushes it vertically from below upwards, in such a manner, that the head of the bone, pressing against the acromion, elevates and replaces it.