P.-J. Desault

“ The muscles, on the other hand, by their contraction, naturally draw the head of the bone into its place, because the direction of their fibres is such as obliges them to do it. The great art of managing luxations, then, consists, in ascertaining clearly the obstacles that prevent reduction, in removing them, and, then, committing the rest to extension, and the powers of nature properly directed. ”

“ Whatever may be the mode and place of the fracture, its diagnosis presents difficulties which experience and habit may doubtless overcome, but which too frequently puzzle and embarrass the most enlightened practitioner. Let us endeavour to diminish them somewhat, by tracing, in their order of succession, the symptoms which characterize the accident.
85. At the time of the fall, a sharp pain is felt; sometimes a report is plainly heard; a sudden inability to move the limb occurs; the patient cannot rise, a circumstance, however, which does not always take place. ”

“ Experience bears witness, that usually a fall on the great trochanter, more rarely on the knee, or the sole of the foot, precedes it, and has doubtless some share in producing it. But what is the nature of the primary affection which, rising immediately from this occasional cause, becomes the immediate cause of the luxation? ”

“ When this obstacle to reduction has been removed, it is then very readily effected, and that without the process of conformation. Indeed that process is almost always unnecessary. For what purpose should it be employed? Is it to increase the effect of extension, and thus disengage the head of the bone from the place which it accidentally occupies? In this point of view, it is nothing but a very feeble force, added to a very powerful one, which receives from it, therefore, but little assistance: it is much better, if necessary, to augment the extending forces themselves. ”

“ Lateral luxations, that is, luxations at the sides have been divided into complete, when the two articular ranges of the arm and fore-arm, have lost their connexion entirely, and incomplete, when only one bone or one part of a bone has been separated from its natural connexion with the humerus. But what cause can act with sufficient force to produce the first kind of luxation, namely, that which is complete? In such an accident so great would be the extent of the wreck and ruin of the part, that without doubt amputation would be the only resource. ”

“ This it did, by destroying or gradually lengthening the medium of union, which already connected the overlapping fragments, by that means bringing their separated surfaces or ends into contact, and almost restoring to the bone its primitive form.
Art cannot always, with certainty, command such success, and perhaps, even at a less advanced period, a more rapid progress of reunion might leave but little ground for hope. But, could only an inch in length be gained by permanent extension, would it not be proper to have recourse to it, particularly as no inconvenience can result from the trial? ”

“ 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. ”

“ Here the practice of a great master, varying his means with the varying forms of disease, will serve as models to those who may meet with similar cases. Our experience is composed of the facts which we receive from reading, as well as of those derived from observation. Who would have a right to call himself a surgeon, if he had no other title to that name, but such as resulted exclusively from his own personal observation? ”

“ 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. ”

“ Sometimes only passive, it merely offers a resistance to the power which puts the bone in motion; thus, in a fall, the os femoris, being pressed between the ground which resists, and the weight of the body that bears on it, bends beyond the extent of its flexibility or pliancy, and finally gives way. At other times the influence of external bodies is actively and directly exerted in this accident: thus a stone, or a piece of timber, falling on the thigh, fractures the bone, in consequence of communicating to it a degree of motion greater than its power of resistance. ”

“ This apparatus is in no degree complex or troublesome. Simple and easy, it requires nothing for its construction but what the surgeon can easily obtain, and what he can even himself prepare. There exists a great analogy between it and the bandages which Desault used for the reunion of transverse wounds, and for fractures of the rotula and the olecranon. A truly great man does not estimate his merit, by the number of processes which he invents; he well knows that the perfection of art consists in producing numerous effects by few and simple means. ”

“ It would seem as if nature, always industrious to provide, amid the disorders of our organs, some resources for the exercise of their functions, has been desirous of preventing here, the inconvenience attendant on a failure of reduction, by rendering luxations backward much more difficult than those forward. Indeed if the fore-arm be kept constantly in a state of supination, it will be much less useful, than if it were always in a state of pronation, the situation in which most of the motions necessary to our existence are performed. ”

“ The extensor muscles, not being at all compressed, will act with their whole force on the upper fragment, and, on the slightest effort of the patient, overcome the resistance of the bandage, the action of which, being oblique with respect to the fragment, is inconsiderable, unless it be drawn very tight, and thus a displacement will again occur. This obliquity of the turns of the roller obliges the surgeon, either to draw it very tight, in which case a swelling is inevitable, or to make it but moderately tight, and then the apparatus will be insufficient to resist the action of the muscles. ”

“ Here genius seems to have been as prodigal of resources, as nature has been of obstacles. Indeed, to accomplish the reduction, we sometimes see the surgeon placing his elbow in the fold of the affected arm, interlocking his fingers with those of the same limb, and, then, bending with his whole force, both his own fore-arm, and that of the patient, to effect at the same time extension, counter-extension, and reduction or conformation: at another time we see him fixing the fold of the injured arm against some resisting body, such as a bed-post ”

“ 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. ”

“ Whatever form of apparatus may be employed to obtain it, it is permanent extension alone that can prevent the displacement, because it alone is founded on principles calculated to meet and obviate the causes by which displacement is produced. ”

“ Indeed, what cause is there to produce luxation in this latter joint. Is it from a forcible exertion of pronation or supination that this accident can occur? Surely not: for, on the one hand, as the lower articulation offers less resistance than the upper one, it is evident that, in either state of motion, it being the weakest, will be displaced first, and the motion being thus checked, can no longer operate to the displacement of the other. ”

“ Between these two points, namely, the axilla and the perineum, the same quantity and force of pressure is, by Dr. Physick’s improvement, divided, which, in the original apparatus of Desault, is borne by the perineum alone. The risque of excoriation and injury to the patient, then, in the former case, is to that which he runs in the latter, only as one to two, or nearly so. As it is no less the duty of the surgeon to prevent suffering than it is to remove deformity or to save life, Dr. Physick has certainly in this respect made an important step in the advancement of his profession. ”

“ As the displacement is most likely to occur downwards, particularly in motions of the arm, it is necessary that a continued resistance be opposed to this tendency. But this resistance should be made by the head of the humerus, which, if properly directed, will represent, during the treatment, a kind of splint, which art ought to render fixt and immoveable lest, being contiguous to the divided surfaces, it might derange, by its motions, the work of nature in effecting their reunion. ”

“ A severe pain always accompanies the motions of abduction, when they are communicated to the limb. If, while the hand is applied to the great trochanter, the limb be made to rotate on its axis, this bony protuberance is perceived to turn on itself as on a pivot, instead of describing, as it does in its natural state, the arch of a circle, of which the neck of the os femoris is the radius. This sign, which was first observed by Desault, is very perceptible, when the fracture is at the root of the neck, less, when it is in the middle, and very little, when it exists towards the head of the bone ”

“ The fore-arm, composed of two bones, neither of them very strong, and covered below by a small quantity of soft parts, is exposed still more than the humerus, to the action of external bodies, and is articulated at the upper end in such a manner, as not to yield, like it, in every direction to the impulses which it receives. From these considerations, it is one of those parts where fractures most frequently occur, and, in a comparative view of affections of this kind in the Hotel-Dieu, it has oftentimes held the first place. ”

“ The inflammation of the articulating surfaces and of the ligaments around the joint, ought to have more influence in constituting an unfavourable prognosis, than any circumstance that authors have mentioned. But experience proves, that, when judiciously treated, these fractures are not accompanied by that accident, and even that the swelling, which for the most part attends them, always yields more or less speedily, when a bandage, uniformly applied, presses equally on all parts around the joint, and thus forms a kind of discutient, while at the same time it retains the fragments. ”

“ Most of the cases which we have seen prove the impossibility of either standing or walking (6) . But, admitting that they were ruptures, are we authorized to pursue the mode of treatment there adopted? Certainly we are not. None of the indications formerly mentioned (16) is there fulfilled. What is there, under such circumstances, to prevent an involuntary motion from destroying the contact of the divided ends, by forcibly flexing the foot and extending the leg? The limb is not subject to any compression. Should such an accident happen, the cure must necessarily be tedious. ”

“ They have taken up an opinion, that luxations of the foot, differing in their symptoms from other luxations, require also a different mode of treatment; that reduction, by perpetuating the accidents of the case, must prove fatal, and that amputation ought to be adopted as the only resource. Cases do certainly at times occur, where a doctrine different from this would be fatal in its effects: such are those terrible lacerations, where the foot is entirely separated from the leg, except some shreds of flesh with a few tendons among them that still retain it. ”

“ The acromion being drawn outward, by the upper end of the os humeri, which, by means of a fulcrum placed under the armpit, is made to act as a lever of the first kind, is restored, without much trouble, to its natural contact with the corresponding surface of the clavicle. But, it soon becomes deranged again, unless it be retained in its place by a proper apparatus. Now, on what principle ought this apparatus to be constructed? To prevent the displacement, which generally occurs from without inwards, it ought evidently to act from within outwards. ”

“ 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. ”

“ It belongs to the surgeon to examine and ascertain, when the natural connexions of the joint are sufficiently confirmed. Then motions, at first gentle, are to be impressed on the limb; being afterwards gradually increased, they remove by degrees that stiffness, which usually follows a dislocation, particularly an old one. But if it has existed too long, to give the limb motion, is then the only resource: the new attachments or adhesions, contracted by the articulating surfaces in their displaced state, render reduction impracticable. ”