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

by P.-J. Desault

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.