Part 21

40. We may throw into two classes the numerous means, under all their variety of modifications, proposed for the reduction of luxations of the humerus. The one consists in forcing, by some mechanical power, the head of the bone into the cavity from which it had escaped, whether extension has been previously employed or not. The other is confined to disengaging it from the situation, into which it has been accidentally driven, leaving to the action of the muscles the care of its replacement.

In the first of these, art does every thing; in the second, it only gives the proper direction to the powers of nature. These latter give but one course or direction to the action of powers externally applied: in the former, the head of the bone always moves in the diagonal of two powers opposed to each other at an angle more or less acute.

41. A history of the means destined to act in the first mode, would be too tedious to be introduced in this place, would throw no light on the processes about to be proposed, and are detailed at full length in many authors, to which the reader is referred. It will be sufficient to observe, that they all act somewhat in the following manner. Some body, placed under the arm-pit, serves as a fulcrum, on which the arm is made to move like a lever of the first kind, the resistance to which is constituted by the displaced head of the humerus, while the power is applied either at the lower part of this bone, or at the wrist. The extremity of the humerus being directed upwards and inwards, moves its head in the opposite directions, towards the glenoid cavity, where it replaces it with more or less facility.

In this manner acted that machine so celebrated among the ancients and moderns, under the name of “Ambi Hippocratis,” whether it was employed in the precise form described by that prince of physicians, or with the additions and corrections, infinitely varied, which it has received from Paul of Egina, Ambrose Pare, Duverney, Freke, &c. By this, a double motion is communicated to the head of the humerus, which is, at the same time, directed, 1st, in the course above mentioned; and, 2dly, in such a manner, as to disengage it from the unnatural situation which it occupies.

42. Extension by the arm produces, in common, the second effect, and this is made in different modes. Sometimes the weight of the body on one side, and pulling by the luxated limb on the other, serve to produce it; and such was the mode of action of the ladder, the door, and the club, described in the treatise on fractures by Hippocrates, and revived in many modern works. At other times, the body was immoveably fixed, and a powerful extension made by the arm. This was the mode in which the machines of Oribasus operated, and also one of the methods formerly consecrated in the public places where the athletæ held their combats.

43. On some occasions, no extension is perceptibly made, but at the same time in which the extremity of the humerus is forced outwards by a body placed under the arm-pit, the surgeon pushes it upwards into the glenoid cavity: and such were the other modes of reduction practised by the masters in the athletic art. Hence it appears, that the first class of the numerous means, employed for the reduction of luxations, may be divided into those which consist in impulsion, those where mere extension is practised, and those where recourse is not had to either. My object here is not to examine into the inconveniences attending each of these means: a sufficient number of authors have already done this; particularly Petit and Bell. I shall only point out the disadvantages, which, being common to all, ought to induce them all to be excluded from a rational mode of practice.

44. The escape of the head of the bone through the ruptured and lacerated capsule, constitutes essentially the displacement under consideration. But, it is never possible to ascertain with precision the place of this rupture: how, then, can the head of the humerus be directed towards it by an artificial force?

45. However well prepared for the purpose the body may be, which is placed under the arm-pit, to serve as a fulcrum, always a chafing more or less troublesome, and oftentimes distensions and serious lacerations are the consequences of its application, when the body is suspended on it, as in the mode by the door, the club, &c. where Petit has seen a fracture of the neck of the humerus occur, and even a laceration, followed by an aneurism of the axillary artery.

46. Every one has not at his command the different means above mentioned (41 and 42), whence the difficulty of procuring them, or of constructing them, and the loss of time, precious in relation to the reduction, which is almost always easily accomplished in proportion to the expedition used; these charges apply, among many other means, to that machine so complicated, and so well known, under the name of the mitten of Petit.

(De mouffle de Petit.)

47. Supposing the luxation to be consecutive, how can mechanical means make the head of the bone retrace the route it has pursued in becoming displaced? For example, if to a displacement downwards has succeeded a displacement inwards, it will be necessary for the head to return downwards before it can re-enter its cavity. But, can the direction of the movements be thus varied? This whole apparatus of artificial means, for ever contradictory, oftentimes acts in an inverse direction to that of the muscular action, which is the essential and chief agent in the process of reduction.

Should the luxation take place upwards, the insufficiency of these means must be evident.

48. Perhaps, however, they may be employed with some advantage, when a primitive luxation downwards is quite recent, and the head of the bone is near to its cavity. In such a case the lower edge of the scapula presents to it an inclined plane, along which it can easily glide, when pushed by some external force. It is doubtless to this disposition of the bone to replace itself, that we must attribute the successes, greatly exaggerated, but in part real, on which the inventor of every machine endeavours to found the superior merit of his mode of operating.

But, in this case, it is useless to accumulate artificial forces, where natural ones are sufficient, and where the operator may, with his hands, effect the reduction the more easily, as he can with more accuracy vary the direction of his movements.

49. Thus Desault oftentimes employed a process which was attended with great success, and which, like some of the preceding, ought to be referred to impulsion. The patient being seated on a chair of a moderate height, he took hold of the hand of the affected side, placed it between his knees, and carried it downward and backward, for the purpose of making extension, and disengaging the head of the bone; while an assistant held the trunk with a view to counter-extension, which was sometimes effected to a sufficient degree, by the weight of the body and the efforts of the patient. At the same time the hands of the surgeon, applied to the arm, in such a manner that the fingers of each were in contact with the hollow of the arm-pit, and the thumbs with the external part of the arm, drew upwards and a little outwards the head of the humerus, which in common returned with ease into its natural cavity.

50. Petit mentions this process, not such as it is here described, but complicated with the use of a napkin passed under the arm-pit of the patient, and round the neck of the surgeon, who, by raising his head, drew the displaced extremity upwards. This additional mean, always unnecessary, and not judiciously constructed, is generally ineffectual, because, with it, the operator cannot at pleasure vary his movements. The hands alone are always sufficient, and a vast number of examples attest the efficacy of this method, when employed after the manner of Desault.

CASE VI. Nicholas Juan fell on his side, his arm being separated from his body, as he was crossing, in January 1790, the place Notre-Dame, opposite to the Hotel-Dieu. An acute pain was immediately experienced; a protuberance appeared suddenly under the arm-pit; and under the acromion a depression equally sudden. He was lifted up, and carried straight to the Hospital, where Desault was just beginning a clinical lecture. The luxation being manifested by these appearances, was immediately reduced by the foregoing means. A few days rest were enjoined on the patient, but, on the same evening, he proceeded on his way, blaming himself, for having lost half of his day’s journey.

51. In analogous cases of very recent luxations downwards, Desault twice or three times effected the reduction by means still more simple, as the following case, reported by Heraut, testifies.

CASE VII. Maria Louisa Favert fell, as she was descending a ladder, and having luxated her arm, was carried at her request, immediately after the accident, to the Hotel-Dieu. Desault perceiving the nature of the disease, placed, under the hollow of the arm-pit, his left hand, to serve as a fulcrum while with his right, applied on the inferior and external part of the arm, he approximated the humerus to the trunk, pushing it at the same time upwards. By this double movement, directed upwards and outwards, the head of the humerus re-entered its cavity without the least resistance. The arm was suspended in a sling for two days, and on the fourth the patient returned to her usual labour.

52. There exists some analogy between this method and one of those mentioned, by Hippocrates, to have been practised in ancient times, in the public games, where the exertions of body exposed those engaged to frequent luxations.

It is not only in luxations downwards, that the first of the simple processes which I have mentioned (49), may be applied. Primitive luxations inwardly, yield sometimes to its use, and the Journal of Surgery furnishes two instances of success in similar cases; one in a female sixty-three years of age, and the other in one of fifty-one, of a strong constitution, and in whom the reduction was effected without resistance.

53. But, in general, these means are ineffectual and it becomes necessary to have recourse to extension, which, when employed alone, forms the second class of means intended for reducing luxations of the humerus. Many writers have adopted this exclusively, though some practitioners, indulging their imagination in the vast field of invention, deserted the common track, and had recourse to various kinds of machinery. Celsus depended on extension alone, in common cases of luxation downward and forward. Albucasis employed no other means, Douey, Douglass, and Heister, among the moderns, reject unconditionally the use of machines, as always useless, and often dangerous. Finally, Dupoui and Fabre, examined and analysed with great exactness the process of extension, and pointed out, in every case, the means of rendering it advantageous, by managing in the best manner the extending forces, and in the luxation of the humerus, in particular, to prevent the inconvenience of straps placed under the arm-pit of the patient, demonstrated the inutility of the movement commonly called conformation. In these respects, surgery stands indebted to them for real advancement, and their doctrine, at this day, very generally known and received, was principally reduced to practice by Desault, who made it the basis of his method of reduction in all fractures and luxations.

54. To proceed to the reduction of a luxation of the humerus, it is necessary to have such a number of assistants as to be able, according to the resistance of the parts, to increase the force intended to overcome it. But two are commonly sufficient. They should furnish themselves with a linen ball, thick enough to project beyond the level of the pectoralis major and the latissimus dorsi, when placed in the axilla, and two straps, one formed of flannel doubled several times, four inches broad, and eight or nine feet long, the other of a napkin regularly folded. This latter is not often absolutely necessary.

Every thing being properly arranged, the patient is seated on a chair of a moderate height, or else laid on a table firmly fixed and covered with a simple mattress, in order that the trunk, by being in a horizontal position, may not prevent the motions communicated to the arm from being directed downwards.

55. Desault continued, for a long time, to place the patient in the first of these positions, which, though employed by practitioners generally, is by no means the most favourable. By adopting it indeed the arm may be very well drawn in a transverse direction; but if, as oftentimes happens, it becomes necessary to direct extension upwards or downwards, the assistant, then, being obliged to elevate himself, or to stoop, cannot, in either of these attitudes, exert his strength to advantage, but is confined and embarrassed, and cannot with ease vary, at the pleasure of the surgeon, the direction in which the arm is drawn.

As far as relates to the patient, that situation in which the body is only in part supported, is much more fatiguing than one where the whole of it reposes equally on a horizontal plain. Perhaps, in relation to the surgeon, it would be more advantageous, in enabling him to accomplish the process of conformation; but, as will be presently observed, this process is always useless. These considerations induced Desault, in the last years of his practice, to renounce the first position, and have recourse only to the second.

That is, to draw, or otherwise force the head of the os humeri, with his hands, towards the glenoid cavity, while the assistants are making extension and counter-extension. In doing this, he must pull the head upwards, if it be lodged in the axilla, backward if it be under the upper part of the pectoralis major, &c. Desault, however, contends that this assistance from the surgeon is unnecessary, and that extension and counter-extension are alone sufficient to effect the reduction. TRANS.

56. The patient being properly situated, under the arm-pit of the affected side is placed the linen ball, on which the middle of the first strap is then applied. The two ends of this strap being now brought obliquely upwards, before and behind the thorax, so as to meet on the top of the sound shoulder, and being held by an assistant, serve to fix the body, and to make counter-extension, nor does the action of the strap bear on the edges of the pectoralis major and latissimus dorsi, in consequence of the ball which projects beyond their edges. Were it not for this, these muscles, being pulled upwards, would draw in the same direction the humerus, to which they are attached, and would thus destroy the effect of the extension, which is made in the following manner.