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

by P.-J. Desault

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.