Part 23

The patient being placed in a horizontal position, as already directed (55), great motions were first impressed on the limb: extensions were then commenced, first in the direction of the luxation, and afterwards forward and backward. Vain efforts; the head remains immoveable; new motions are again made in every direction, and afterwards, the extensions are renewed: the same want of success. The patient being fatigued, the reduction was deferred till the day following, when the same trials were, after a short time, attended with complete success. The head being at first disengaged, and afterwards drawn slowly along the track through which it had passed in becoming displaced, at length re-entered the capsule. The arm, being supported by the usual apparatus, soon became œdematous, and, notwithstanding the remedies common in such cases, the swelling continued for two months. The motions performed by the limb in the mean time, restored to it, by degrees, its usual suppleness; and, on the sixty-eighth day after her entrance, the patient was discharged cured.

To this case, I might subjoin many others, and, in particular, that of John Putot, also reported by Giraud, and in which the means just described (69 and 70), succeeded in the reduction of a luxation at the expiration of the fourth month. But too great an accumulation of facts distract the attention, and add nothing to conviction, especially when they are already so plain as those just related.

71. But further, in cases of this kind, where a very old luxation presents great obstacles to reduction, although the attempts made to reduce it, do not actually force the head of the bone into the capsule, still they may not prove entirely useless. By bringing the head nearer to the glenoid cavity, or placing it even on that cavity, and making it form new adhesions there, after having destroyed its old ones, the motions of the limb will be facilitated. For, in cases, where the luxation is not fairly reduced, these motions will be always less impeded, in proportion as the head of the bone occupies a place less remote from its natural situation.

72. A third obstacle, common to the reduction, of every kind of luxation, is the muscular force, increased by the irritation of the displaced bone, beyond its natural degree. So great, at times, is this force, that the head of the bone cannot be moved, even by the strongest efforts. What means should then be employed? 1st, Those which diminish general irritability, such as blood-letting, bathing, a relaxing regimen, &c. 2dly, Those which act locally, in diminishing the irritability of the muscles of the shoulder. For example: the application of emollient cataplasms or fomentations to the part; or, what is still better, a powerful extension, continued for some time. In consequence of such extension, the muscles of the part become fatigued, whence their contractions are succeeded by a state of atony, of which advantage may be taken to replace the bone. Frequently this extension ought to be continued for a very long time; and we have known Desault not to complete the reduction in less than half a day, or even a whole day, the limb being suffered to remain all that time in the apparatus for fractures of the clavicle, which draws the shoulder and muscles outwards. Thus, in fractures of the thigh, where muscular contraction prevents the contact of the fragments, permanent extension previously employed, assists in producing this contact.

§ IX.

OF ACCIDENTS CONSEQUENT TO REDUCTION.

73. It is rare that any serious accident follows the reduction of a luxation of the humerus. A swelling, more or less extensive, sometimes shows itself around the joint, particularly when extension has been forcible and long continued; but this, being, in general, easily removed, by means of discutients, does not demand particular attention.

74. Another accident which rarely occurs in practice, respecting which but little is to be found in surgical writings, and with which Desault occasionally met, is, a considerable emphysema, suddenly appearing at the time of reduction. In the midst of those powerful extensions, rendered necessary by the ancient state of the luxation, a tumour suddenly appears under the pectoralis major. By a rapid increase it extends itself towards the hollow of the arm-pit, the whole of which it soon occupies. It then propagates itself in a backward direction, and, in the space of a few minutes, its bulk is sometimes equal to that of the head of an infant. A practitioner, if unacquainted with the nature of this accident, might take it for an aneurism, produced by a sudden rupture of the axillary artery, in consequence of the violence done to that vessel by the extensions of the limb. But, if attention be paid to the resistance of the tumour, to its want of pulsation, to the place of its first appearance, (which is usually under the pectoralis major, and not under the hollow of the arm-pit, to which it only propagates itself afterwards, as Desault has observed in similar cases that fell under his notice), to the action of the pulse still continuing, unless the patient should faint from debility, as happened to the subject of the following case, which we had occasion to witness at the amphitheatre, sometime previous to the death of Desault, and to the colour of the skin which suffers no change; if these circumstances be attended to, it will be difficult not to distinguish one of these accidents from the other. In that now under consideration, discutients applied to the tumour, such, for example, as vegeto-mineral water, and a gentle and regular compression made by the bandage intended to support the arm after reduction, are the most efficacious means that art can employ.

CASE XI. Simon Cerisiat, sixty years of age, presented himself on the nineteenth of December, 1794, as the subject of a public consultation, which, every day preceded the clinical lecture of Desault, to receive advice for a luxation inwards, which he had suffered a month and a half before, and for the reduction of which no attempt had been yet made.

Convinced, by the example of luxations more ancient, of the practicability of reducing this, Desault undertook it immediately in the presence of his pupils.

The patient being laid on a table, firmly fixed and covered with a mattress, great motions were impressed on the luxated limb upward, forward, and outward, with a view to destroy the adhesions contracted with the surrounding parts. Extensions were then made in the manner already mentioned (66 and 67).

Nothing was gained by the first attempt, the head remaining immoveable, in the midst of the efforts to displace it. Further motions were made in every direction, to break if possible, the attachments which held it; and these were followed by further extensions.

While these were making in a forcible manner, the head was perceived to approach by degrees towards the glenoid cavity, near to the edge of which it reached in two minutes, and was at length replaced, by a sudden movement of the limb from behind forward.

Scarcely was the reduction accomplished, when a tumour rose suddenly under the pectoralis major, propagated itself towards the arm-pit, and occupied immediately its whole extent.

All the assistants, astonished at the phenomenon, knew not to what circumstance to attribute it. Desault himself, a little embarrassed, thought first of an aneurism suddenly produced by the violence of the extension. The pulse of the patient, being scarcely perceptible in the side affected, and a syncope which supervened, appeared at first to favour this suspicion: but immediately the absence of a fluctuation, of a pulsation, and of a change in the colour of the skin, the return of the pulse, the circumscription of the tumour, its resistance, and the sound caused by striking on it, produced a belief that it was owing, not to an effusion of blood, but to a disengagement of air that had been confined in the now lacerated cells of the cellular membrane.

Over the whole of the swelling were applied compresses wet with vegeto-mineral water, while a regular compression was made on it by means of a bandage, which, at the same time, kept the arm fixed against the trunk.

In the night there occurred severe pains around the articulation and the tumour, accompanied with high fever, both which symptoms disappeared on the following day. Third day, a diminution of the emphysematous swelling; and an entire cessation of fever and pain. Eighth day, tumour reduced to half its original size; the arm made to perform gentle motions, and disengaged from the apparatus; discutients continued. Thirteenth day, tumour entirely gone. In the place which it had occupied a large echymosis appeared, produced no doubt, by a rupture of the small vessels at the time of reduction, but which, till now, had not been perceptible externally, in consequence of the emphysematous swelling of the parts, and which was treated by the same means as the emphysema. Seventeenth day, a yellow tinge, mixed with the colour of the echymosis, an evidence of its resolution, which was complete by the twenty-seventh day.

During all this time, the patient had accustomed his limb to constant motion; a facility in the movement of it had thereby returned; and he was perfectly well when he left the Hotel-Dieu, on the thirtieth day from the time of his admission, and the sixty-fifth from the occurrence of the accident.

MEMOIR VIII.

ON THE FRACTURE OF THE BONES OF THE FORE-ARM.

§ I.

1. The fore-arm, composed of two bones, neither of them very strong, and covered below by a small quantity of soft parts, is exposed still more than the humerus, to the action of external bodies, and is articulated at the upper end in such a manner, as not to yield, like it, in every direction to the impulses which it receives. From these considerations, it is one of those parts where fractures most frequently occur, and, in a comparative view of affections of this kind in the Hotel-Dieu, it has oftentimes held the first place.

2. It would be useless to mention here the disposition of the bones which compose the fore-arm, their irregularly prismatical form, their thickness unequally distributed, their direction obviously different, and their motions differently combined. It is sufficient to observe, that, for the perfection of one part of these motions, a space, wide in the middle, and narrow at the ends, must separate the two bones, that, without this space the radius, impeded in its movements on the cubitus, would compress the muscles, restrain their action, and would be unable to perform the motions of pronation and supination; whence the fore-arm, being confined, as it were, to mere flexion and extension, would not, in its uses, correspond to our wants.

These things being premised, we will observe, that fractures of the fore-arm may have their seat, 1st, in both bones at the same time; 2dly, they may occupy but one of them: hence three kinds of fractures more or less different in their phenomena, their consequences, and their treatment.

FRACTURE OF THE FORE-ARM.

§ II.

OF THE VARIETIES AND THE CAUSES.

3. Fractures of both bones of the fore-arm, may occur either at the ends, or in the middle of the limb. Frequent in the middle, and somewhat common below, they seldom occur in its upper part, where the fleshy portions of numerous muscles, combined with a considerable thickness of the ulna, resist the motions which tend to produce them. The two bones, though most commonly broken on the same line, are, however, sometimes broken on different ones. The fracture is almost always single: at times, however, it is double, and Desault, in particular, was once called to a patient, over whose fore-arm the wheels of a carriage had passed, and had broken it both in the middle and at the lower end, so that it evidently exhibited six fragments distinct from each other. The two middle ones, though completely insulated, united again to the others with but very little deformity. Like all other similar affections, these may be rendered compound by wounds, splinters, &c. circumstances which, as they fall within the general class of such injuries, will not be treated of at present.