Part 28

62. When this is completed, it is necessary to impress on the limb motions of flexion and extension, gradually increased every day. This is, as David properly observes, the most certain method of avoiding a stiffness, and even an anchylosis, too often the consequence of this fracture.

63. But that illustrious practitioner, in recommending this salutary remedy, has erred with regard to the mode in which it operates. To consume, by degrees, a superabundant callus in the interior of the articulation, and thus reduce it to a level with the articulating surfaces, is not, as he conceives, the effect which these motions produce. This opinion, founded on the ancient doctrine of an osseous juice, is refuted by the dissection of many bodies of patients that died during the treatment, and in which Desault discovered no trace, either of an effusion of osseous juice, during the reunion, or of its superabundance after this reunion had been completed.

The exercise communicated to the limb, appears to act principally by removing the congestion of the tendons and membranes surrounding the joint, which, being at first irritated by the fracture, are thrown into a state of engorgement; and further by dissipating a kind of numbness which affects the muscles after they have remained too long in a state of rest.

64. But whatever may be its mode of action, it ought to be gradually increased, according to the state of the parts, and continued for at least twenty days, a period sufficiently long to restore to the limb, in general, its natural motions.

65. It is seldom that after this methodical treatment, the patient is exposed to an anchylosis, a thing inevitable in such cases, according to most authors, A celebrated surgeon, believing the long continued extension of the fore-arm to be the cause of this accident, has advised here to abandon every kind of bandage, and to commit the cure entirely to nature. But this doctrine, contrary to the general principles of the reunion of divided parts, has not in its favour the result of experience, which proves that, under such neglect, the stiffness in the parts near to the joint is always as great as in other cases, that the reunion is more tedious and more deformed, and that sometimes it cannot be accomplished at all. The analogy of the inconveniences and disadvantages attributed to the method of Foubert, in fractures of the neck of the os femoris, constitutes another argument against this method, which is now almost entirely abandoned.

66. To the cases already published, proving the success of that which we have proposed, let us add one more, reported by Maublanc.

CASE IV. Silvan de la Noue, aged thirty, fell on his elbow, having his fore-arm bent, while the shoulder of the same side supported a heavy load. Acute pains at the instant of the fall; a sudden inability to extend the fore-arm; a considerable swelling appears almost immediately, around the joint; and a superficial echymosis at the hind part.

During the night the pains were augmented, the swelling increased, and, on the day following, February 9th, 1791, the patient was received into the Hotel-Dieu.

From the presence of the signs formerly mentioned (43), Desault recognized the fracture, and applied the apparatus (56), notwithstanding the swelling and echymosis, persuaded that the compression made by this apparatus on the tumefied parts, was the most effectual mode to remove the enlargement.

Next day, pains almost gone; swelling diminished; on the fifth day, the bandage become loose, by the almost entire disappearance of the swelling; a new application of it; the joint wet frequently with vegeto-mineral water.

Seventh day, usual regimen allowed; ninth day, a slightly bilious disposition; evacuants somewhat active administered, to remove it.

Thirteenth day, a third application of the apparatus; echymosis entirely gone.

Thirtieth day, the consolidation complete; the apparatus laid aside; from this time motions gradually impressed on the limb.

Fifty-eighth day, the patient discharged, free in all his motions, except a little stiffness, which exercise will soon remove. Since that time, it has been understood that the limb had completely recovered its natural functions.

MEMOIR IX.

ON THE LUXATION OF THE FORE-ARM.

§ I.

1. The solidity and security of joints are increased in proportion as the extent of their motions is diminished. This inverse proportion of these two properties to each other, is in a particular manner remarkable in the upper extremities, where the connexion of the humerus with the scapula, of the fore-arm with the humerus, and of the bones of the wrist among themselves, appear, in regular gradation, to acquire the one as they lose the other: hence, their predisposition to luxations is extremely different. We will examine those to which the fore-arm is subject.

2. An angular ginglymus unites to the humerus the bones of the fore-arm, which are again connected with each other by a double lateral ginglymus. Eminences and depressions, reciprocally receiving and received, constitute the first kind of articulation, where, proceeding from without inwardly, we find, 1st, the small head of the humerus, entering or rather joining the upper articular cavity of the radius, which moves on it: 2dly, the external groove of the humerus, receiving the rim of the same cavity of the radius: 3dly, a projection which, rising from the external edge of the coronoide cavity, extends to the corresponding edge of that of the olecranon, and is received into the external depression of the sigmoid cavity: 4thly, the large groove of the humerus, receiving the middle eminence of this same cavity: 5thly, a considerable projection, obliquely applied to the internal depression which receives it.

Not generally named in English works of anatomy.

Echancrure sigmoide.

3. These numerous connexions secure the solidity of the joint, which is still farther strengthened before by the coronoid apophysis, together with the fleshy and tendinous extremities of the biceps, and brachialis muscles, and by the olecranon behind; at the inferior part, by the anconeus; on the sides by two ligaments which descend from the two tuberosities, and strong muscular fasciæ running from the same parts. The whole articulation is also surrounded by a thick capsule, strengthened by numerous accessory fibres. With such powers of resistance, how can this joint suffer a luxation? Yet next to that of the os humeri, it is perhaps most frequently subject to this accident.

§ II.

OF THE KINDS AND CAUSES OF DISPLACEMENT.

4. Writers have admitted in general four kinds of displacement; backward, forward, outward, and inward. But all these are not alike frequent, as is proved by experience, and demonstrated by the relative situation of the parts.

5. In a backward direction the olecranon and the radius may pass up behind the humerus, as the coronoid apophysis offers but little resistance in consequence of its slight curvature. On the other hand, the kind of hook formed by the olecranon, prevents it and the radius from passing before the lower articulating extremity of the humerus, and therefore, without a fracture of the olecranon, a luxation in that direction is impracticable: at the sides, the two lateral ligaments, but more particularly the reciprocal joining or interlocking of the uneven articulating surfaces, present almost insurmountable obstacles to luxations laterally. Whence it follows, that luxation backward is much more frequent than the others; compared to lateral luxations, it is, at least, in the proportion of ten to one: with luxations forward, no comparison can be made; neither Petit nor Desault having ever met with such.

6. An external force produces the whole of these luxations, but according to each, this force must vary. In a fall sideways, suppose the hand be applied to the ground, with the arm extended, to save the body. It is evident that the resistance of the ground will tend to make the bones of the fore-arm pass upwards over the humerus, while the weight of the body pushing that bone downward and forward, will make it glide over the coronoid apophysis. Thus, the capsule, being distended before by the humerus, and behind by the bones of the fore-arm, will give way in one or the other place, or in both, as Desault observed in a man, who fell on his side, as he was carrying a heavy load: the weight of the body increased by the load, had such an effect, that the bones overlapped each other nearly two inches.

7. It appears from this, that a state of extension is the position most favourable to a displacement backwards; a doctrine by no means conformable to that of most practitioners, who consider a state of flexion as necessary to the accident. But, then, in what direction should the fall take place, in order that the olecranon may pass upwards? Applied as it is against the side of the cavity that receives it when the arm is extended, would not this apophysis prevent such passage? Whatever may be the mode of displacement, the olecranon, in passing upward and backward, may incline a little to the one or the other side.