Part 18

17. When wounds, splinters, or severe contusions, render these kinds of fractures more complicated, an inflammation occurring on the articular surfaces, may cause them to unite together, and by that means give rise to an anchylosis. But this accident, inevitable in such a case, according to writers, does not always occur, provided nature be assisted, by a judicious mode of treatment, in her attempt to reunite the broken bone. Desault has established this truth, in many instances. Here, as in other joints, he has oftentimes obtained a complete cure, without the loss of motion, although the part had sustained the greatest violence. Incisions, easily made, the extraction of splinters, a frequent renewal of dressings, a most vigilant care to prevent all jarring of the limb, and consequently all derangement of the contact of the fragments, an assemblage or combination of those minute attentions, which art cannot teach, which genius suggests, and which characterize the true surgeon; a precaution (not to be dispensed with) to make the limb perform motions, gentle at first, but gradually increased afterwards, when the adhesion of the parts has acquired sufficient solidity to admit of it; such are, in general, the steps and circumstances constituting the bases of that treatment, requisite in these complicated fractures, which, like all others, appear, in each case, to assume a new aspect, and to present different indications.

CASE II. A person, carrying a heavy burden, fell with his elbow on a sharp corner of a bar of iron. The external condyl was broken, being separated from the body of the bone, by an oblique division running into the joint. Anteriorly, a large contusion; posteriorly, a transverse wound; on the outside, the end of the condyl projecting through the soft parts, which it had lacerated: such were the complications of a fracture, for which the patient was admitted into the Hotel-Dieu, on the seventh day of January, 1794.

On examining the state of the parts, Desault discovered, in the transverse wound, two splinters which when extracted, gave vent to an effusion of blood. He reduced, instead of cutting it off, as authors have advised, the end of the separated condyl, applied a bandage of strips, and, to prevent accidents, ordered a strict diet, copious blood-letting, and diluting drinks.

(Bandage a bandalettes.) This is a most convenient form of bandage, in fractures of the upper or lower extremities. It is composed of strips of soft linen or muslin, from two to three inches wide, and of a length accommodated to the size of the limb, on which they are to be applied. These strips are not sewed together, but merely laid along side of each other, or rather spread in such a way that their adjoining edges may overlap a little. Being thus arranged, on the bed or mattress, where the patient is to lie, the broken limb is placed on them, when the surgeon, taking them, one by one, folds them round it, so as to form a very perfect and neat covering. The number of these strips must be regulated by the extent of the limb, or, at least, of that portion of the limb, which they are intended to cover. TRANS.

Compresses wet with vegeto-mineral water, kept the apparatus constantly moist.

On the day following, the dressing was renewed superficially; severe pains in the part; abated towards evening; almost gone next day; low diet continued.

Fourth day, pains returned; an incipient swelling around the joint; more blood drawn.

Sixth day, considerably better; all the apparatus renewed; suppuration beginning to appear.

Tenth day, a small abscess on the external condyl opened, and a splinter extracted posteriorly.

Fifteenth day, the parts assume a flattering aspect; suppuration favourable; fragments in contact; from this time the dressings are less frequent.

Twentieth day, a bilious diathesis; edges of the wounds livid; loss of appetite; nausea; vomiting; an emetic is administered.

Thirtieth day, unfavourable appearances gone; reunion commencing; wounds visibly healing. Fortieth day, all external injuries healed, except the one situated anteriorly; callus already very firm; gentle motions performed with the limb, which is still surrounded by the apparatus.

Forty-seventh day, the apparatus become useless; motions gradually increased; articulation already tolerably free. Fifty-seventh day, bilious diathesis returned; low diet and evacuants. Sixty-fifth day, the patient discharged from the hospital; consolidation perfect; wounds entirely healed; motions of extension still difficult to be performed in their full extent, but are recovered in a great measure, and will doubtless, in a short time, be completely re-established, provided the same mode of treatment be continued.

MEMOIR VII.

ON THE LUXATION OF THE HUMERUS.

§ I.

GENERAL REMARKS ON THE JOINTS, AND ON THAT OF THE HUMERUS IN PARTICULAR.

1. Nature, who, according to the wants of different species of animals, has varied the number of their articulations, knows also how to vary their structure, according to the uses of the different parts of their bodies. With great mobility, she has sometimes connected great solidity and strength, as is the case in the vertebral column; in other instances, parts very solid and compact, are capable of performing but feeble motions, as the carpus, the tarsus, &c. And, lastly, other parts, again, capable of great motion, possess so little solidity and firmness as to be easily deranged by the action of external bodies. Such, in man, is the articulation of the humerus with the scapula, of the sternum with the clavicle, &c.

2. Hence there exist three classes of articulations, very different from each other. To the last, as enumerated above, belongs, in a particular manner, the history of luxations, and, in this, as the solidity varies, the frequency of dislocations is equally various; no luxation occurs more frequently than that of the humerus; indeed, in a comparative catalogue of accidents of this kind, it alone has, during certain years, occurred oftener, in the Hotel-Dieu, than that of all the other bones, taken collectively.

3. Every thing seems to favour the escape of this bone from its natural cavity. 1st, On the part of the articulating surfaces, a cavity somewhat oval and very shallow, aided by a slight cartilaginous ring, receives a half-spherical head, twice its own diameter from above downwards, and three times as large from before backwards. 2dly, On the part of the ligaments, this articulation is strengthened by only a simple capsule. This capsule is thin and weak on its lower side, a direction in which there is nothing to prevent a luxation, while it is thicker on its upper side, where the acromion and coracoid apophyses, and a strong ligament, present an obstacle almost insurmountable. 3dly, As far as respects the muscles and the motions of the joint, strong and numerous bundles of fibres surrounding the articulating surfaces, communicate to them motions easily performed in every direction, and which, by pushing the head of the humerus against the different parts of the capsule, distend it, predispose it to laceration, and indeed even rupture it, when the quantum of their force is superior to its resistance. 4thly, As far as relates to external bodies, what bone is more exposed to their action than this, particularly among that class of persons, engaged, for a livelihood, in hard labour?

4. Subject to the influence of these different predisposing causes, the humerus would be constantly liable to luxations, did not the scapula, moveable like itself, furnish it, by accompanying its motions, with a point of support, differently disposed, according to the different position of its superior extremity; so that, to this two-fold mobility of the articulating surfaces, is to be attributed, in a great measure, the stability of their connexion.

§ II.

OF THE KINDS OF THIS LUXATION.

5. The upper articulation of the humerus, though predisposed, in general, to luxations, is not equally so in every direction. There is a point at which luxation cannot take place. There are others, where, though possible, this accident has never been observed. It is necessary, therefore, before examining the mechanism of this luxation, to mention with precision, the directions in which it may occur. On this point, writers have differed in a very singular manner. Sometimes, to express the same thing, they have used a different language; and, at other times, have, by the same words, expressed things widely different. Always agreeing as to certain modes of dislocation, they have been divided as to others; while, in the midst of those contrarieties, the surgeon being embarrassed, is at a loss on what ground to found his practice.

6. The ancients, knowing but little of the natural relation of the parts surrounding the joint, were ignorant of the accidental ones, which these several parts assume, in the case now under our consideration. Hence, without doubt, arises the confusion, of their opinions on the subject.

Many admitted of four kinds of luxations; a great number acknowledged only three; some subscribed to but two; while others believed in the possibility of none but one.

7. The first divided differently the directions in which the bone might be luxated. Some contended for luxations upward, downward, forward, and backward; and such was the opinion of the first Greek physicians, predecessors to the father of medicine, who has transmitted the opinion to us accompanied with a demonstration of its fallacy. Others have divided them into those that take place downward, upward, outward, and forward. This division is adopted by Galen, who yet produces only an example of a forward luxation, and does not give us to understand what he means by a luxation upward and inward.

8. The second distinguished the modes of this luxation, sometimes into downward, forward, and backward; as was the case with Oribazes; at other times, into downward, outward, and inward, according to the opinion of Paul of Egina, who, no doubt, adopted exactly the preceding division, expressing it only in different words; sometimes into downward, forward, and upward; such was the sentiment of Albucasis, who, notwithstanding, considered a luxation upward, as a very difficult, and very rare occurrence.