Part 22

57. Two assistants take hold of the fore-arm above the wrist, or else a folded napkin is fixed on that part, having its two ends twisted around each other. These ends, thus folded together, are given to one or two assistants, who begin to pull in the direction of the humerus. To this first movement, intended to disengage the head of the bone from the bed which it occupies, another succeeds, which must vary according to the kind of luxation. If the luxation be downwards, the surgeon gradually approximates the arm to the trunk, at the same time that he pushes it gently upwards. By this process, the head of the bone, being drawn from the trunk, and brought towards the glenoid cavity, usually re-enters it with but little resistance.

If the luxation be inwards, the extremity of the humerus, after extension according to the direction of the bone, should be carried upward and forward, in order that its head may be directed backwards. Steps the very reverse of these must be pursued, if a luxation in an outward direction is to be reduced.

58. In general, when, by the first extension, the head of the bone is disengaged, the motion communicated to it by the subsequent ones, ought to be in a direction precisely opposite to that which it pursued in escaping from its cavity. But what are the variations of this direction? Extensive experience alone can clearly determine this point. Without experience the practitioner works in darkness. The minutiæ or particulars of the process of reduction, being different in different cases and according to different circumstances, can be neither foreseen, nor taught by precept.

59. If the head of the bone experience any difficulty in re-entering its cavity, it is necessary, when the extensions have been made, to communicate to the bone different movements, varied according to the different directions of displacement, and regulated by the principle just established. Oftentimes this method effects what extensions alone cannot; and the head of the bone, carried by these movements towards its cavity, enters it while they are performing.

60. If the luxation be consecutive, then the first extension made in the direction of the displaced bone, is intended to bring its head into the place where it was primitively lodged, in order that it may be afterwards acted on as if it were a case of primitive luxation. It is oftentimes only at the moment of reduction, that it is practicable to ascertain to which kind of luxation the accident belongs. Indeed, as in most cases, the reduction takes place of itself when the extensions are well executed, if the head be consecutively drawn inward, it is seen to descend along the internal part of the scapula, till it arrives near to the inferior part of that bone, and then to reascend towards the rupture in the capsule through which it passes into its natural situation.

61. I have said that when the extension is properly made, the reduction takes place almost spontaneously. Indeed whatever may be the kind of primitive luxation, it is evident, that the muscles surrounding the articulation must be stretched on one side, while they are relaxed on the other; whence there will necessarily arise a change both in their contractions, and in the direction of these contractions, and such is the nature of this change, that, in case the muscles act, instead of bringing the head towards the rupture in the capsule, they will draw it in another direction, and by that means produce a consecutive luxation.

62. But, if the extensions render the muscles straight, and restore to them their primitive direction, then, obeying their natural irritability, which is still further increased, by means of the extension, they will draw the head to the rupture in the capsule, and force it to re-enter it, with much more certainty than this can be done by the efforts of the surgeon, who is always ignorant of the precise situation of this rupture. On the other hand, if the extension be not judiciously made how can it restore to the muscles their natural direction? In such a case, the head of the bone will be drawn towards some other part of the capsule than that where the rupture exists, and hence, the difficulties that so frequently occur, in reducing luxations of the humerus.

63. From these circumstances it follows; 1st, that the whole art in the treatment of luxations, consists in giving to the extending powers a proper direction; 2dly, that, in general, the process of conformation is unnecessary and useless; 3dly, that to reduce a luxation is not to replace the head of the bone in its cavity, by force, but to restore the muscles to such a state, as to enable them to replace it. Here, therefore, as in every other case, art is only the minister and handmaid of nature.

There are instances, however, where the muscles cannot act properly in consequence of the long standing or age of the luxation, and in consequence of adhesions, more or less strong, having taken place between the surrounding parts. In such cases it is necessary to employ proper measures to force the head of the bone into its cavity, as it cannot be carried thither by the muscles.

64. Reason concurs with experience, which is on all subjects the best authority, in establishing the truth of this doctrine, respecting the reduction of luxations of the humerus. In this operation, Desault employed, in general, nothing but extensions, varied according to circumstances, until the muscles thrown into a favourable state, were themselves enabled to accomplish the reduction. The most immediate success constantly crowned his practice on this point. This success was, no doubt, owing to his judiciously remaining inactive himself, and suffering the muscles to do the work, after the necessary extensions had been made.

65. When the reduction is accomplished, if the arm, in consequence of being very moveable, appears likely to be displaced again, it is necessary, for a few days, to fix it in such a manner as to prevent all motion; an object which may be effectually attained by Desault’s bandage for fractures of the clavicle.

All writers recommend, for this purpose, the use of the Spica bandage. But what service can this render? It does not restrain the motions of the humerus, which, hanging down the side, may move forward, backward, &c. and produce a new displacement; an accident that may be always prevented by the bandage proposed.

With the particular mechanism and mode of action of this bandage, I am unacquainted. Nor are these matters of much moment, as the bandage is, I believe, entirely out of use. TRANS.

§ VIII.

OF CIRCUMSTANCES RENDERING REDUCTION DIFFICULT.

66. I will close this memoir by an examination into some circumstances, which may either prevent reduction or render it difficult, and into certain accidents that sometimes accompany it.

I have said that, on some occasions, the rupture of the capsule, being too narrow to admit the head of the humerus to repass it, and return to its cavity, constitutes one of the principal obstacles to a reduction (24). To enlarge this passage, by further lacerating its edges, is evidently the indication that here presents itself. This is fulfilled by communicating to the bone great motion, either by circumduction, or rotation on its own axis, forcing it suddenly in different directions, particularly in that direction in which the luxation has been produced. Its superior extremity must be, at the same time, pushed forcibly against the ruptured capsule, which, by being thus pressed between two resisting bodies, will suffer a more extensive rupture. Reduction, oftentimes impracticable previously to these violent and varied motions, takes place of itself as soon as they have been properly made. Of this the practice of Desault furnishes many examples.

CASE VIII. In the Journal of Surgery are recorded two cases, one by Anthaume, the other by Faucheron, which establish this doctrine.

John Seligni, a robust man, forty-four years of age, fell on the point of his shoulder, on the 19th of July 1791; the pain, which was increased by moving his arm, and the swelling which supervened almost immediately, induced him to enter the Hotel-Dieu. The efforts of assistants were at first insufficient, and it was not till after a uniform extension continued for several minutes, that the head of the humerus was drawn by the muscles against the glenoid cavity. The bone appeared to enter the cavity, although the persons present did not hear the collision or clashing of the articulating surfaces, which is almost always perceived in cases of recent luxation: but immediately the humerus was again displaced, without its being practicable to retain it. On the occurrence of this phenomenon, Desault conceived that the head of the bone had pushed before it the capsular ligament, through which it could not pass, in consequence of the narrowness of the opening which had been made at the time of the luxation. He proceeded to move the arm forcibly in every direction, in order to enlarge the opening, and immediately felt a kind of laceration, which satisfied him that his views were accomplished. He then re-commenced extension, which it was again necessary to continue, as at first, for some time, in order to overcome the resistance of the muscles. The reduction was attended with no further difficulty. The humerus continued still to have a great tendency to be displaced, and it was necessary to employ, for several days, a bandage similar to that for a fractured clavicle.

CASE IX. Maria Laurencier, aged sixty, fell on her right elbow, and luxated the humerus of the same side. Eight hours afterwards she came to the Hotel-Dieu, on the eighth of March, 1789. The reduction was attempted in the usual manner; but, although the extensions were properly directed, and the head of the humerus brought against the glenoid cavity, it was still displaced again as soon as the limb was let go, a circumstance which created a suspicion, that the opening of the capsule was too narrow to allow the head of the bone to pass. The assistants ceased making extension, and Desault, taking hold of the lower extremity of the arm, impressed on it great motion, particularly in the direction of the luxation, for the purpose of enlarging the laceration of the capsule. The extensions were now renewed, and the reduction succeeded with great ease.

67. A second obstacle, more difficult to be surmounted in the process of reduction, is that arising from the long continuance of the luxation. The head of the bone, having continued for a long time in the bed into which it has been accidentally thrown, forms adhesions to it; the surrounding cellular membrane becomes thickened, and makes, so to speak, a new capsule for the head, which opposes its replacement, and, when the reduction cannot be accomplished, supplies in some measure the office of the old joint, by the movements which it allows to take place.

Most writers, and Bell in particular, advise, in such a case, never to attempt a reduction, which, being of no avail as to the luxation, might prove dangerous to the patient, in consequence of the violence it would do to the parts. This doctrine was for a time, the doctrine of Desault: but experience, in his latter years, led him to a bolder practice.

68. The complete success which he experienced in luxations of fifteen or twenty day’s standing, encouraged him to make the attempt, at the end of thirty and thirty-five days, and we have, three or four times, during the two last years of his life, seen him successful in replacing, after the expiration of two and a half, and even three months, the head of the bone which had escaped, both through the inferior, and the internal side of the capsule.

However powerful, and however long continued the extensions were, none of those terrible accidents occurred, with which we are threatened by authors. Twice only did a phenomenon occur, which it was difficult to foresee, and of which I will presently speak.

69. In cases of this kind, it is necessary, previously to making extension, to move the bone very forcibly in every direction, in order first to break the adhesions, to tear the condensed cellular membrane, which serves as an accidental capsule, and to produce, so to speak, a second luxation, with a view to make way for a perfect reduction of the first. The straps being then applied, as in ordinary cases, serve the purpose of extension, for the accomplishment of which the number of assistants must be increased.

70. Oftentimes the first efforts are fruitless, and the luxated head remains stationary, amidst the most violent efforts. Let the extensions then be discontinued: renew the forcible motions of the limb: carry the humerus upwards, downwards, forward, and backward: force the resistances to give way; make the arm describe a large arch of a circle round the place which it occupies; let the rotatory motions on its own axis be impressed on it anew; and then recommence the extensions, and let them be made in every direction. By these, the head, already disengaged by means of preceding violent motions, will be brought to a level with the glenoid cavity, and ultimately replaced.

It may not be improper to confirm by experience the truth of these precepts, which might to some appear rash, in consequence of the changes that seem likely to occur in the glenoid cavity, during the absence of the head of the humerus. I will relate, among others, a case reported by Giraud, second surgeon to the Hotel-Dieu.

CASE X. Maria Gauthier, thirty-four years of age, entered the Hotel-Dieu, on the twentieth of June, 1790, to be cured of a luxation of three months standing, produced originally by a fall on the arm, which was separated, at the time, from the body and carried backward. Different surgeons had, at different times, attempted the reduction, but always without effect, and when every hope of a cure appeared to have expired, Desault, imboldened by reiterated success, tried whether or not he would be equally fortunate in this case.