Billeder på siden

junction of the bones; and the slender bone (ulna?) has more to do with the insertion of the ligaments in the arm than the thick bone (radius ?). The configuration then of the articulations, and of the bones of the elbow, is such as I have described. Owing to their configuration, the bones at the knee are indeed frequently dislocated, but they are easily reduced, for no great inflammation follows, nor any constriction of the joint. They are displaced for the most part to the inside, sometimes to the outside, ⚫ and occasionally into the ham.' The reduction in all these cases is not difficult, but in the dislocations inward and outward, the patient should be placed on a low seat, and the thigh should be elevated, but not much. Moderate extension for the most part sufficeth, extension being made at the leg, and counter-extension at the thigh.

38. Dislocations at the elbow are more troublesome than those at the knee, and, owing to the inflammation which comes on, and the configuration of the joint, are more difficult to reduce if the bones are not immediately replaced. For the bones at the elbow are less subject to dislocation than those of the knee, but are more difficult to reduce and keep in their position, and are more apt to become inflamed and ankylosed.*

39. For the most part the displacements of these bones are small, sometimes toward the ribs, and sometimes to the outside; and the whole articulation is not displaced, but that part of the humerus remains in place which is articulated with the cavity of the bone of the fore-arm that has a protuberance (ulna?). Such dislocations, to whatever side, are easily reduced, and the extension is to be made in the line of the arm, one person making extension at the wrist, and another grasping the armpit, while a third, applying the palm of his hand to the part of the joint which is displaced, pushes it inward, and at the same time makes counter-pressure on the opposite side near the joint with the other hand.'

1 The Commentary of Galen is particularly valuable on this passage, as putting it beyond a doubt that, in dislocations at the knee, our author represents the femur as the bone which is displaced. In modern works the femur is generally considered as the fixed point. See Mr. Bransby Cooper's Lectures, and Mr.

Liston's Practical Surgery.

? No person possessed of a practical acquaintance with the subject can fail to perceive that, in the following descriptions of dislocation at the elbow-joint, our author comprises (and perhaps I may say confounds together) simple displacement of the trochlea of the humerus from the great sigmoid cavity of the ulna, and fractures of the humerus immediately above the epiphysis, accompanied with displacement of the bones of the fore-arm, See the Argument, and Dupuytren on Injuries of Bones, p. 102, &c., Sydenham Society edition. Dupuytren was well aware of the occurrence of abruption of the extremity of the humerus with displacement, although not without it. See § 46.

3 The case here described would seem to be dislocation of the radius at its upper extremity, an accident which has been described by Duverney, Desault, Sir Astley Cooper, and many other modern authorities. It is distinctly noticed by Oribasius (De Machinamentis, xiii. and xiv.). Our author, upon this supposition,

40. The end of the humerus at the elbow gets displaced (subluxated?) by leaving the cavity of the ulna. Such luxations readily yield to reduction, if applied before the parts get inflamed. The displacement for the most part is to the inside, but sometimes to the outside, and they are readily recognized by the shape of the limb. And often such luxations are reduced without any powerful extension. In dislocations inward, the joint is to be pushed into its place, while the fore-arm is brought round to a state of pronation. Such are most of the dislocations at the elbow.'

41. But if the articular extremity of the humerus be carried to either side above the bone of the fore-arm, which is prominent, into the hollow of the arm (?), this rarely happens; but if it do happen, extension in the straight line is not so proper under such circumstances; for in such a mode of extension, the process of the ulna (olecranon?) prevents the bone of the arm (humerus?) from passing over it. In dislocations of this kind, extension should be made in the manner described when treating of the bandaging of fractured bones of the arm, extension being made upward at the armpit, while the parts at the elbow are pushed downward, for in this manner can the humerus be most readily raised above its cavity; and when so raised, the reduction is easy with the palms of the hand, the one being applied so as to make pressure on the protuberant part of the arm, and the other making counter-pressure, so as to push the bone of the forearm into the joint. This method answers with both cases. And perhaps this is the most suitable mode of reduction in such a case of dislocation. The parts may be reduced by extension in a straight line, but less readily

[blocks in formation]

describes both the dislocations forward and backward. This is the explanation of the paragraph which Apollonius Citiensis would appear to sanction. (Schol. in Hippocrat., tom. i., p. 15.) Galen, however, in his Commentary preserved by Cocchi, would seem to refer it to the incomplete lateral luxations of the arm. A third interpretation of the meaning has been advanced by Bosquillon, and to it M. Littré at last inclines, namely, that it is incomplete dislocation backwards. His observations on this point show the great pains which the French editor takes in elucidating the text of his author; but I cannot say that I think he and his countrymen make out anything like a strong case in support of their opinion, and I still incline to agree with Apollonius in referring the case here described to dislocation of the radius. I leave the reader, however, to judge for himself.

1 This would certainly appear to be incomplete lateral luxation of the fore-arm. See the Argument.

This is evidently meant as a description of complete lateral luxation. Such a case of displacement is very uncommon; indeed, until lately, it was thought impossible. See Cooper's Surgical Dictionary, p. 391, Fifth edition, 1825. It is described, however, by Mr. Liston in the following terms: "Displacement of both bones laterally is met with, though rarely, the olecranon process being placed upon either the outer or inner condyle; in the latter case the head of the radius rests in the fossa on the posterior aspect of the humerus." (Practical Surgery, p. 124, Third edition.)

42. If the arm be dislocated forward-this rarely happens, indeed, but what would a sudden shock not displace? for many other things are removed from their proper place, notwithstanding a great obstacle,—in such a violent displacement the part (olecranon?) which passes above the prominent part of the bones is large, and the stretching of the nerves (ligaments?) is intense; and yet the parts have been so dislocated in certain cases. The following is the symptom of such a displacement: the arm cannot be bent in the least degree at the elbow, and upon feeling the joint the nature of the accident becomes obvious. If, then, it is not speedily reduced, strong and violent inflammation, attended with fever, will come on, but if one happen to be on the spot at the time it is easily reduced. A piece of hard linen cloth (or a piece of hard linen, not very large, rolled up in a ball, will be sufficient) is to be placed across the bend of the elbow, and the arm is then to be suddenly bent at the elbow, and the hand brought up to the shoulder. This mode of reduction is sufficient in such displacements; and extension in the straight line can rectify this manner of dislocation, but we must use at the same time the palms of the hands, applying the one to the projecting part of the humerus at the bend of the arm for the purpose of pushing it back, and applying the other below to the sharp extremity of the elbow, to make counter-pressure, and incline the parts into the straight line. And one may use with advantage in this form of dislocation the method of extension formerly described, for the application of the bandages in the case of fracture of the arm; but when extension is made, the parts are to be adjusted, as has been also described above.1

43. But if the arm be dislocated backward (but this very rarely happens, and it is the most painful of all, and the most subject to bilious fevers of the continual type, which prove fatal in the course of a few days), in such a case the patient cannot extend the arm. If you are quickly present, by forcible extension the parts may return to their place of their own accord; but if fever have previously come on, you must no longer attempt reduction, for the pain will be rendered more intense by any such violent attempt. In a word, no joint whatever should be reduced during the prevalence of fever, and least of all the elbow-joint."

44. There are also other troublesome injuries connected with the elbow-joint; for example, the thicker bone (radius ?) is sometimes par

1 This would seem to be dislocation of the fore-arm forwards. Whether or not it ever occurs without fracture of the olecranon, as our author's description seems to infer, I cannot pretend to determine. See the Argument.

2 There can be no mistake about the nature of the accident described in this paragraph; it is evidently the ordinary luxation of the elbow-joint, namely, displacement of the bones of the fore-arm backward. The following description of its leading character agrees exactly with our author's account of it: "The forearm is in a state of half-flexion, and every attempt to extend it produces acute pain." Cooper's Surgical Dictionary, p. 390, Fifth edition.)

tially displaced from the other, and the patient can neither perform extension nor flexion properly. This accident becomes obvious upon examination with the hand at the bend of the arm near the division of the vein that runs up the muscle. In such a case it is not easy to reduce the parts to their natural state, nor is it easy, in the separation of any two bones united by symphysis, to restore them to their natural state, for there will necessarily be a swelling at the seat of the diastasis. The method of bandaging a joint has been already described in treating of the appli cation of bandages to the ankle.'

45. In certain cases the process of the ulna (olecranon?) behind the humerus is broken; sometimes its cartilaginous part, which gives origin to the posterior tendon of the arm, and sometimes its fore part, at the base of the anterior coronoid process; and when this displacement takes place, it is apt to be attended with malignant fever. The joint, however, remains in place, for its whole base protrudes at that point. But when the displacement takes place where its head overtops the arm, the joint becomes looser if the bone be fairly broken across. To speak in general terms, all cases of fractured bones are less dangerous than those in which the bones are not broken, but the veins and important nerves (tendons?) situated in these places are contused; for the risk of death is more immediate in the latter class of cases than in the former, if continual fever come on. But fractures of this nature seldom occur.

46. It sometimes happens that the head of the humerus is fractured at its epiphysis; and this, although it may appear to be a much more troublesome accident, is in fact a much milder one than the other injuries at the joint.'

47. The treatment especially befitting each particular dislocation has been described; and it has been laid down as a rule, that immediate reduction is of the utmost advantage, owing to the rapid manner in which inflammation of the tendons supervenes. For even when the luxated parts are immediately reduced, the tendons usually become stiffened, and for a considerable time prevent extension and flexion from being performed to the ordinary extent. All these cases are to be treated in a similar way, whether the extremity of the articulating bone be snapped off, whether the bones be separated, or whether they be dislocated; for they are all to be treated with plenty of bandages, compresses, and cerate, like other fractures. The position of the joint in all these cases should be the same, as when a fractured arm or fore-arm has been bound up. For this is the most common position in all dislocations, displacements, and fractures; 1 This seems to be lateral displacement of the radius. See the Argument. * These are evidently fractures of the olecranon, near its extremity, and at its base, that is to say, at its connection with the coronoid process. See Sir Astley Cooper's Lectures, and Cooper's Surgical Dictionary.

3 This, beyond all doubt, is abruption of the epiphysis or trochlea of the humerus. See the Argument.

and it is the most convenient for the subsequent movements, whether of extension or flexion, as being the intermediate stage between both. And this is the position in which the patient can most conveniently carry or suspend his arm in a sling. And besides, if the joint is to be stiffened by callus, it were better that this should not take place when the arm is extended, for this position will be a great impediment and little advantage; if the arm be wholly bent, it will be more useful; but it will be much more convenient to have the joint in the intermediate position when it becomes ankylosed. So much with regard to position.'

48. In bandaging, the head of the first bandage should be placed at the seat of the injury, whether it be a case of fracture, of dislocation, or of diastasis (separation ?), and the first turns should be made there, and the bandages should be applied most firmly at that place, and less so on either side. The bandaging should comprehend both the arm and the fore-arm, and on both should be to a much greater extent than most physicians apply it, so that the swelling may be expelled from the seat of the injury to either side. And the point of the fore-arm should be comprehended in the bandaging,' whether the injury be in that place or not, in order that the swelling may not collect there. In applying bandages, we must avoid as much as possible accumulating many turns of the bandage at the bend of the arm. For the principal compression should be at the seat of the injury, and the same rules are to be observed, and at the same periods, with regard to compression and relaxation, as formerly described respecting the treatment of broken bones; and the bandages should be renewed every third day; and they should appear loose on the third day, as in the other case. And splints should be applied at the proper time (for there is nothing unsuitable in them, whether the bones be fractured or not, provided there is no fever); they should be particularly loose, whether applied to the arm or the fore-arm,' but they must not be thick. It is necessary that they should be of unequal size, and that the one should ride over the other, whenever from the flexion it is judged proper. the application of the compresses should be regulated in the same manner as has been stated with regard to the splints; and they should be put on in a somewhat more bulky form at the seat of the injury. The periods are to be estimated from the inflammation, and from what has been written on them above.

These rules for the adjustment of the parts in injuries of the elbow-joint are most important and apposite. Whether in dislocation, subluxation, abruption of the epiphysis of the humerus, fracture of the olecranon, and in fact, I believe in all injuries at the elbow-joint, the half-bent position at first will be found the best. See Sir Astley Cooper's Lectures, and all the best modern authorities. ? Meaning, no doubt, the olecranon.

3 The meaning in this passage is very doubtful, owing to the uncertainty about the proper reading. See Foës and Littré.

« ForrigeFortsæt »