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

by P.-J. Desault

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.