A Treatise on Fractures, Luxations, and Other Affections of the Bones

by P.-J. Desault

MEMOIR VII.

ON THE LUXATION OF THE HUMERUS.

§ I.

GENERAL REMARKS ON THE JOINTS, AND ON THAT OF THE HUMERUS IN PARTICULAR.

1. Nature, who, according to the wants of different species of animals, has varied the number of their articulations, knows also how to vary their structure, according to the uses of the different parts of their bodies. With great mobility, she has sometimes connected great solidity and strength, as is the case in the vertebral column; in other instances, parts very solid and compact, are capable of performing but feeble motions, as the carpus, the tarsus, &c. And, lastly, other parts, again, capable of great motion, possess so little solidity and firmness as to be easily deranged by the action of external bodies. Such, in man, is the articulation of the humerus with the scapula, of the sternum with the clavicle, &c.

2. Hence there exist three classes of articulations, very different from each other. To the last, as enumerated above, belongs, in a particular manner, the history of luxations, and, in this, as the solidity varies, the frequency of dislocations is equally various; no luxation occurs more frequently than that of the humerus; indeed, in a comparative catalogue of accidents of this kind, it alone has, during certain years, occurred oftener, in the Hotel-Dieu, than that of all the other bones, taken collectively.

3. Every thing seems to favour the escape of this bone from its natural cavity. 1st, On the part of the articulating surfaces, a cavity somewhat oval and very shallow, aided by a slight cartilaginous ring, receives a half-spherical head, twice its own diameter from above downwards, and three times as large from before backwards. 2dly, On the part of the ligaments, this articulation is strengthened by only a simple capsule. This capsule is thin and weak on its lower side, a direction in which there is nothing to prevent a luxation, while it is thicker on its upper side, where the acromion and coracoid apophyses, and a strong ligament, present an obstacle almost insurmountable. 3dly, As far as respects the muscles and the motions of the joint, strong and numerous bundles of fibres surrounding the articulating surfaces, communicate to them motions easily performed in every direction, and which, by pushing the head of the humerus against the different parts of the capsule, distend it, predispose it to laceration, and indeed even rupture it, when the quantum of their force is superior to its resistance. 4thly, As far as relates to external bodies, what bone is more exposed to their action than this, particularly among that class of persons, engaged, for a livelihood, in hard labour?

4. Subject to the influence of these different predisposing causes, the humerus would be constantly liable to luxations, did not the scapula, moveable like itself, furnish it, by accompanying its motions, with a point of support, differently disposed, according to the different position of its superior extremity; so that, to this two-fold mobility of the articulating surfaces, is to be attributed, in a great measure, the stability of their connexion.

§ II.

OF THE KINDS OF THIS LUXATION.

5. The upper articulation of the humerus, though predisposed, in general, to luxations, is not equally so in every direction. There is a point at which luxation cannot take place. There are others, where, though possible, this accident has never been observed. It is necessary, therefore, before examining the mechanism of this luxation, to mention with precision, the directions in which it may occur. On this point, writers have differed in a very singular manner. Sometimes, to express the same thing, they have used a different language; and, at other times, have, by the same words, expressed things widely different. Always agreeing as to certain modes of dislocation, they have been divided as to others; while, in the midst of those contrarieties, the surgeon being embarrassed, is at a loss on what ground to found his practice.

6. The ancients, knowing but little of the natural relation of the parts surrounding the joint, were ignorant of the accidental ones, which these several parts assume, in the case now under our consideration. Hence, without doubt, arises the confusion, of their opinions on the subject.

Many admitted of four kinds of luxations; a great number acknowledged only three; some subscribed to but two; while others believed in the possibility of none but one.

7. The first divided differently the directions in which the bone might be luxated. Some contended for luxations upward, downward, forward, and backward; and such was the opinion of the first Greek physicians, predecessors to the father of medicine, who has transmitted the opinion to us accompanied with a demonstration of its fallacy. Others have divided them into those that take place downward, upward, outward, and forward. This division is adopted by Galen, who yet produces only an example of a forward luxation, and does not give us to understand what he means by a luxation upward and inward.

8. The second distinguished the modes of this luxation, sometimes into downward, forward, and backward; as was the case with Oribazes; at other times, into downward, outward, and inward, according to the opinion of Paul of Egina, who, no doubt, adopted exactly the preceding division, expressing it only in different words; sometimes into downward, forward, and upward; such was the sentiment of Albucasis, who, notwithstanding, considered a luxation upward, as a very difficult, and very rare occurrence.

9. The third were of opinion, that, in undergoing a displacement, the head of the humerus could be carried only downward, under the arm-pit, which is the most common direction, or forward, a course which it takes more rarely. Celsus is almost the only writer who has contended for this division. “Humerus, says he, modo in alam excidit, modo in partem priorem.”

10. Lastly, The fourth believe, with Hippocrates, in none but a displacement downwards, the only one which that physician has met with in his practice. “At vero humerus, inferiorem in partem excidit; aliam in partem excidere non audivi.”

11. The moderns, in borrowing from the ancients their divisions of luxations, did not, like them, determine a priori and in a vague manner, the precise spot and direction of displacement; but ascertained these points by subsequent observation, with more precision, in proportion as a knowledge of anatomy shed light on them. They also paid particular attention to the essential difference between primitive and consecutive luxations.

12. Petit admitted of four kinds of luxations, 1st, downward, on the edge of the scapula: this is a very rare occurrence: 2dly, outward, under the spine of that bone, a kind very difficult to be primitively produced. 3dly, inwards, under the hollow of the armpit. 4thly, forward, between the corocoid apophysis and the clavicle. With this illustrious practitioner, Heister acknowledged four kinds of displacements; but, here again, was a new variety, both in expression, and in meaning. The one says, downward, under the arm-pit, the other forward, under the pectoralis major; the one, backward, under the scapula, the other outward, under its spine. According to Duverney, luxations are never primitively in any other direction than downward; the others being only the subsequent effect of muscular action.

13. In the midst of these very complicated modes of treating a very simple subject, it is necessary, first, in order to acquire definite ideas, to divide luxations of the humerus into primitive, which are the immediate effect of external violence, and consecutive, which succeed the primitive, through the influence of causes which I am about to consider.

Let us suppose four lines to inscribe, in form of a parallelogram, the oval surface of the glenoid cavity, one representing the superior edge, another the inferior, a third the internal, and the fourth the external.

14. It is evident that the head of the humerus cannot be displaced towards the superior edge. In that direction, must be encountered, the acromion and corocoid apophyses, the strong ligament passing between them, the tendons of the triceps and supra-spinatus muscles, and the fleshy mass of the deltoid; all which, taken together, constitute an insurmountable obstacle to the escape of the head of the bone upwards. Besides, what power could carry it upwards? In order that this kind of luxation might take place, it would be necessary, that the head of the bone should be carried outwards at the same time, as well as upwards, a circumstance which is impossible, because the trunk prevents the lower extremity (the elbow) from being directed sufficiently inward to produce such an effect.

15. On the contrary, in other directions, but very little resistance is to be met with. Towards the inferior edge of the cavity, the long portion of the triceps; the tendon of the subscapularis, towards the internal edge; and towards the external edge, the tendons of the infra-spinatus, and teres minor, yield with ease to a force directed against them, and permit the occurrence of primitive luxations, downward, inward, and outward. Downward, between the tendon of the long portion of the triceps, and that of the subscapularis; inward, between the subscapulary muscle and fossa;[14] and outward, between the fossa infra-spinatus and the muscle of the same name. These modes of displacement are not alike frequent, as will be mentioned presently.

16. Having escaped from its cavity, and being primitively placed in one of these three situations, the head of the humerus oftentimes changes its position. Then, to a primitive luxation downward or inward, succeeds a consecutive or secondary one; but never to a luxation in an outward direction, if such ever occur, because the spine of the scapula forms an obstacle to it.

A secondary luxation inward, may succeed a primitive one downward; there is nothing to oppose the head of the humerus in the course it takes, to enter between the subscapulary muscle and fossa. If, on the other hand, it be disposed to pass to the external side, the tendon of the triceps opposes it; and, notwithstanding what Petit has advanced, there is no secondary luxation in that direction.

17. It sometimes happens, that, having escaped either from the internal part, or from the inferior part of the capsule, the head passes behind the clavicle, and forms there a secondary luxation upwards, as has been observed by Ambrose Pare, and by Gallien, and of which an example or specimen was preserved in the cabinet of Desault. But, here, the secondary displacement must take place in a slow manner, and when it has taken place, art can seldom remove it, on account of the strong adhesions formed by the bony surfaces. Thus, in the example mentioned, there was a new cavity formed behind the clavicle, and the humerus adhered to the surrounding parts by a kind of new ligaments.

18. It appears from what has been said, that the humerus is subject to four different kinds of displacement. 1st, Downward: 2dly, outward, in both of which directions the luxation is always primitive; 3dly, inwards, where it is sometimes primitive, and sometimes consecutive; 4thly, upwards, where it can never be otherwise than consecutive.

The second and fourth are very rare occurrences, and bear so small a proportion to the others, that the latter alone ought to command the attention of the practitioner.

§ III.

OF THE CAUSES AND THE MECHANISM.

19. The causes and the mechanism of luxations of the humerus, vary according as the displacement is primitive or consecutive.

The action of external bodies, directed against the arm, but more particularly falls, where this part strikes forcibly against a resisting body, give rise in general to primitive luxations, and, according as it is differently situated at the time of the fall, the humerus determines, by its position, the different kinds.

20. If it be separated from the trunk, without being carried either before or behind it, if the elbow be elevated, and the fall be on the side, the weight of the body, being almost entirely supported by this bone, pushes its upper extremity downward, distends the inferior part of the capsule, lacerates it, and produces a luxation downward, in which it may even be favoured by the action of the pectoralis major, the latissimus dorsi, and the teres major, as has been judiciously observed by Fabre. In such a case, these muscles, involuntarily contracting to support the trunk, act like the power or force in a lever of the second kind, the resistance to which is formed by the head of the bone, which they draw downward, while the lower extremity of the humerus, resting on the ground, constitutes the fulcrum. Some authors even regard, as an immediate cause of luxation, the powerful contraction of the deltoid muscle, which depresses the head of the bone, and forces it through the lower side of the capsule, a mode of displacement, the existence of which observation incontestibly establishes. The case of a scrivener, so often cited, is well known, who in lifting a book of records luxated his humerus in a downward direction.

21. The mechanism of a primitive luxation inwards, differs a little from the preceding. The elbow, being at once separated from the trunk, and carried backward, the person falls: the weight of the body rests on the humerus; the capsule is lacerated in its fore-part; and a displacement in the same direction supervenes.

22. In a luxation outwards, the elbow is carried forward, towards the opposite shoulder; the capsule being stretched outwardly, gives way in that part, provided the humerus be acted on by a sufficient power. But what can this power be? In a fall, the arm being pushed against the trunk, and stopped by it, cannot carry its motion to a sufficient extent to produce a laceration of the capsule. Hence a luxation outwards must be extremely rare. Indeed no instance of it is to be found in books of surgery. Desault, in particular, never witnessed it. Besides, when in a fall, the arm, separated from the body, is carried backward or forward, the weight of the body acts obliquely on it, and it is but partially subjected to the action of the latissimus dorsi, the pectoralis major, and the teres major. So that no kind of luxation ought from these considerations, to be very frequent, except that in a downward direction, where the influence of both causes is direct. Yet luxation inwards is common enough, and in many instances Desault has observed this primitive mode of displacement, though many modern authors doubt the fact, believing, with Hippocrates, that, primitively, all luxations are downwards.

23. It may so happen that in a primitive luxation, the capsule is only greatly stretched, in which case, the articulating surfaces are but partially displaced; but this membrane more frequently suffers a rupture, through which the head of the bone escapes. To this phenomenon writers, in general, have paid too little attention, notwithstanding the opening of dead bodies has oftentimes demonstrated its existence to practitioners, particularly to Desault, who has given two examples of it modelled in wax; one, of a luxation inward, and the other downward, both found in subjects that died in the Hotel-Dieu. Bell relates some analogous facts, and another English surgeon has also had occasion to meet with them.

24. Oftentimes, in compound fractures, one of the fragments passes through the integuments. In the dislocation of the humerus something similar to this occurs. The capsule is sufficiently lacerated to allow the head to escape; but the opening, being then too narrow, forms around the neck of the bone a noose or kind of collar, which prevents it from re-entering the place which it originally occupied. Thus, in the fractures of which I have just spoken, the aperture in the skin does not, at times, admit of the reduction of the fragment, without a previous dilatation.

In this case, an attempt is made to reduce the luxation: the capsule is pressed in folds against the glenoid cavity, and, interposing itself between it and the head of the humerus, renders fruitless the efforts of the surgeon who would replace the bone. Desault was the first who observed this practical fact, two instances of which are recorded in his journal, and which has frequently since occurred in the Hotel-Dieu. In such a case, the head is in general extremely moveable, because, being entirely without the capsule, there is nothing to impede its motion.

25. When, to a primitive luxation a consecutive one succeeds, several causes may concur in its production. If a second fall happen, the arm, being separated from the body, the head of the humerus having nothing to retain and secure it, obeys, with great facility, the power tending to displace it in that direction, and suffers a fresh removal from the bed which it accidentally occupies.

Case I. A man fell in descending a ladder, and luxated his humerus in a downward direction. Desault being immediately called, discovered the nature of the disease, but deferred the reduction till evening. In the interval, the patient went to get into a chaise: his foot slipped, and he fell a second time. The pains became more severe than at the time of the first accident; and Desault, on his return, instead of finding, as in the morning, the head of the humerus under the hollow of the arm-pit, discovered it to be behind the pectoralis major.

26. Muscular action is one permanent cause of a new displacement. Suppose the humerus luxated downward, the pectoralis major, and the deltoid muscles draw its superior extremity upward and inward, which, offering to their action but a feeble resistance, changes its position and that in a two-fold direction.

27. The different motions of the arm may also, according to their direction, produce the same effect. Thus we have often witnessed a luxation inwards succeeding to a luxation downwards, in consequence of unskilful attempts to reduce it.

§ 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.

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[15] of 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[16]; 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.

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.

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.[17] 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.

§ 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.

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.

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