Part 20

§ IV.

OF THE SIGNS.

28. The diagnosis of luxations of the humerus, presents in general, but few difficulties.

Whatever may be the mode or seat of the displacement, there always exists, as Hippocrates has observed, a manifest depression under the acromion, which exhibits a prominence more perceptible than in its natural state. The motions of the part are almost all accompanied with pain; the greater part of them are impracticable; all of them very much confined. The arm cannot move, without a synchronous motion of the shoulder, because, the articulation being no longer able to exercise its functions, these two parts constitute, so to speak, but one body.

29. Besides these signs, which characterize generally every species of luxation of the humerus, each species is marked by certain others peculiar to itself. If the displacement be downward, the arm is a little longer than in its natural state; it can be moved gently outwards; but an acute pain is the inevitable consequence of moving it forward or backward. The elbow is more or less removed from the axis of the body, by the action of the deltoid, the long portion of the biceps, and the supra-spinatus muscles, which, being unnaturally stretched, contract themselves and tend to carry the bone outward. The pains which result from this position, force the patient, in order to relieve them, to lean towards the affected side, to keep the fore-arm half-bent, the elbow resting on the hip, so that the arm, finding a place of support, may be freed from the painful movements, and from the disagreeable sensation produced by its own weight. From this attitude alone, was Desault in the habit of discovering luxations in a downward direction, and was rarely mistaken in his diagnosis. It is thus, that, in a fracture of the clavicle, the inclined position of the patient is oftentimes, at first sight, characteristic of the nature of his complaint. Beneath the hollow of the arm-pit there always exists a protuberance more or less perceptible, formed by the head of the humerus.

30. To the general signs of luxations of the humerus (28), that in an inward direction adds the following: the elbow, being separated from the trunk of the body, is carried a little backward; the humerus seems to direct itself towards the middle of the clavicle; motions backward are not very painful, while those in a forward direction are extremely so; under the pectoralis major a manifest protuberance exists; the arm is but little longer than in a natural state; the attitude is the same as in the preceding case.

31. Should a luxation in an outward direction occur, it would be particularly characterized by a hard tumour under the spine of the scapula, by the direction of the elbow forward, by its separation from the trunk, and by a little increase in the length of the arm.

A protuberance behind the clavicle, an obvious shortening of the arm, together with its direction, would plainly disclose a luxation upwards.

32. The signs discriminative of the nature of luxations of the humerus, are not always accompanied by the same degree of certainty as those that announce merely its existence. Thus, nothing is more difficult than to determine when a luxation inward is primitive, and when it is consecutive, the same phenomena being common to both. Nothing but an exact history of the disease, stating the order in which the phenomena have succeeded each other, can throw light on this point, which is the more interesting and important, as, according to the one or the other state of things, the processes of reduction ought to vary. In the first case, the head re-enters its natural cavity by a short route; whereas, in the second, it arrives there by a much longer one.

If, as Petit pretended, there exist luxations backward, sometimes primitive, and sometimes consecutive, the same remark may be applied to them with equal propriety.

33. Certain signs, common to luxations of the humerus, fractures of its neck, and dislocations of the scapulary extremity of the clavicle, might here create some uncertainty, if in the one, the absence of a tumour under the arm-pit, and of a depression under the acromion, did not prevent a mistake, which Hippocrates declared to be easily committed, into which, according to Galen, the masters of the art of wrestling fell, and which Pare cautions us to avoid; and if, in the other, the appearances proper to a fracture, did not prevent a mistake which would be serious in its consequences, and which sometimes results from the direction of the humerus, and the kind of protuberance formed in the arm-pit, by the end of the inferior fragment. (See Fracture of the neck of the humerus).

§ V.

OF ACCIDENTS PRODUCED BY THE LUXATION.

34. Luxations of the humerus are but rarely followed by any serious accidents. Sometimes a swelling more or less considerable appears, immediately after the fall, in and around the arm-pit. This is the effect of an increased irritability of the part, and is seldom of long duration. Desault’s remedy for it was the application of compresses wet with vegeto-mineral water, or of cataplasms moistened with the same liquid.

35. Several authors, particularly Bell, speak (as if it were a familiar accident) of an œdematous swelling of the whole upper extremity, caused, in inward luxations, by a compression of the axillary glands. This phenomenon has not often occurred in the Hotel-Dieu, except in luxations of long standing: and when it has been met with in certain cases, very happy effects have been produced, by the action, continued for several days, of a roller applied with considerable tightness after the reduction, and reaching from the fingers to the arm-pit.

CASE II. Maria ***, falling from some height, her elbow being separated from her body and directed backwards, luxated her shoulder inwardly. Several days elapsed before she received any surgical aid. She was afterwards admitted into the Hotel-Dieu, where the displacement was discovered through a very considerable swelling, which occupied the parts around the articulation of the humerus. The reduction was accomplished, and the swelling left to itself, which, far however from disappearing, with the cause that produced it, seemed to gain ground. A roller was then applied, and on the day following the tumefaction was reduced to half its former size. The same means are continued. The compression is gradually increased, and by the ninth day, the limb restored to its natural form, performs, as before, all its functions.

36. There is another accident, on which authors have dwelt a little, which was known to Avicenna, and which oftentimes fell under the notice of Desault. I allude to a paralysis of the upper extremity, the effect of compression made by the head of the bone, in inward luxations, on the nerves of the brachial plexus. This accident sometimes resists every expedient of art, as appears from the following case, collected by myself, in the Hotel-Dieu.

CASE III. Maria Dougour, fell on her right side, and experienced immediately all the signs of a downward luxation. A surgeon was called, who moved the bone violently in every direction; he made no extension; he kept the patient in torture for an hour; and at the expiration of that time pronounced the luxation irreducible, because the head of the bone, instead of returning into its natural cavity, had moved inwardly. Indeed, in the midst of his unskilful efforts, a consecutive luxation inwards had succeeded to a primitive one downwards.

On the same evening, an evident insensibility occurred in the part. A swelling, joined to a sense of coldness, accompanied it. On the fourth day, the paralysis was complete.

On the tenth day the patient was brought to the Hotel-Dieu, where the processes of art which we shall presently describe, replaced the bone, without removing the effects of its luxation.

To remedy this, irritating means were employed, simple at first, but multiplied and combined afterwards, and pushed so far as to occasion redness accompanied by small blisters. These were continued for three weeks; blistering plasters were applied; all in vain; the paralysis continued, and as long as a year afterwards the patient was still affected with it.

37. This accident is, in general, extremely obstinate, when, as in the preceding case, the nerves have experienced a long continued pressure. Under such circumstances, the most powerful means are often ineffectual. Moxa has been oftentimes used by Desault, which he applied over the clavicle, at the very origin of the brachial plexus. The success, with which he at first applied this remedy, did not always accompany his use of it, so that notwithstanding several cures performed by it, yet, to the majority of patients to whom it was applied, it was wholly useless.

39. But, if the head of the humerus make on the nerves but a momentary pressure, and the reduction be accomplished shortly after the paralytic symptoms occur, oftentimes then the insensibility disappears of itself, and the cure may be always greatly assisted by the application of powerful stimulants; such, for instance, as volatile liniment, composed of oil of almonds and ammonia, which Desault frequently employed, and of which he increased the strength, so as to render it rubefacient.

CASE IV. Joanna Saq luxated her arm, by falling on her right side, in the month of July, 1788. In the evening of the same day, all the precursory symptoms of paralysis made their appearance. The affection was complete on the day following.

The patient was brought to the Hotel-Dieu, where the reduction, being accomplished, afforded no relief. On the third day, the paralysis still continuing, the volatile liniment was directed, in the proportion at first of two drachms of ammonia to an ounce of the oil of almonds. This produced no effect. Being increased in strength on the fifth day, it still appeared to be useless. On the eighth it was made of such a degree of strength, as to occasion slight pustules over the whole of the diseased extremity. On this, motion began to return, feeble at first, but increasing by degrees, till by the sixteenth day, it was as free and perfect as in a natural state. During all the time, the liniment was applied twice a day over the arm and fore-arm, which were at the same time subjected to strong friction during the space of half an hour.

39. The pains which accompany luxations of the humerus, claim in general some attention from the practitioner. These have sometimes arisen to such a height, as to produce real disorder in the animal economy, particularly in luxations inwardly, where, resulting, no doubt, from the compression of the axillary nerves, they render immediate reduction more necessary, and are generally removed by it.

§ VII.

OF THE REDUCTION.