616 



ABNORMAL CONDITIONS OF THE SHOULDER JOINT. 



and it is known that Desault had already ob- 

 served a similar occurrence. A Memoir, con- 

 taining six cases published in the Repertoire 

 d' Anatomic et de Chirurgie, by M. Flaubert, 

 surgeon in chief to the Hotel Dieu de Rouen, is 

 not well calculated to encourage practitioners 

 to attempt the reduction of old dislocations. 

 In five of these cases the reduction was fol- 

 lowed by serious accidents. M. Flaubert 

 observes, that in many cases when para- 

 lysis of the upper extremity had been attri- 

 buted to the dislocation itself, he believes it 

 was rather owing to the violent efforts made 

 for its reduction ; laceration of muscles and 

 extensive abrasion of the skin have been no- 

 ticed as the consequence of these efforts, and 

 even death from diffuse inflammation has oc- 

 curred ; but these accidents, whether the re- 

 sult of dislocation, or of the means used to 

 restore the bone to its place, must be consi- 

 dered as rare in this country, as from the 

 comments of Mr. Mar, and the observations 

 of the Editors of the Le9ons Orales of Du- 

 puytren, they seem to have been in Paris. 

 The latter observes, " Le hasard qui a fourni 

 a M. Flaubert, dans le court espace de trois 

 ou quatre ans, un ensemble de tous les acci- 

 dens les plus graves qui puissent determiner 

 la reduction, est vraiment extraordinaire : il 

 faut sans doute en chercher la cause dans des 

 circonstances particulieres, qui sont incon- 

 nues."* 



Alterations of the nerves. We have noticed 

 as belonging to the symptoms of dislocation 

 of the head of the humerus, that the patient 

 .complains of pain extending down the course 

 of the nerves of the arm and the forearm, 

 .and also of numbness. These symptoms 

 generally disappear when the dislocation is 

 reduced, but sometimes they persist. The 

 pressure which the nerves of the axillary 

 plexus undergo has naturally been referred to 

 as the cause of these unpleasant symptoms. 

 The nerves, besides being stretched, have been 

 sometimes even torn across; when this has oc- 

 cured the effects produced must long remain ; 

 such cases are very rare. Among all the nerves 

 in the vicinity of the shoulder-joint which 

 have been referred to as the seat of injury the 

 result of luxation of the humerus, the eircum- 

 flt-x nerve, which supplies the deltoid, is that 

 which has been found most frequently injured. 

 Indeed, from the manner it winds round the 

 neck of the humerus to arrive at its destina- 

 tion at the under surface of the deltoid mus- 

 cle, it can scarcely escape being stretched and 

 elongated, and such a lesion of this nerve 

 we may well expect to be followed by a pa- 

 ralysed condition of the deltoid muscle. The 

 circumflex nerve has been found compressed 

 by the dislocated head of the humerus, flat- 

 tened, and firmly adherent to the capsule of 

 the joint. We find in the Museum of Bartho- 

 lomew's Hospital, (Catalogue, p. 124, vol. i., 

 No. 42.,) a preparation of a shoulder-joint, 

 exhibiting a dislocation of the humerus, which 

 occurred eighteen months before death. " The 



* Lemons Orales, vol. iii. page 140. 



head of the humerus rests on the anterior 

 surface, near the inferior border of the sca- 

 pula. The tendons of all the capsular mus- 

 cles were entire ; the long tendon of the 

 biceps retains its attachment to the glenoid 

 cavity. The circumflex nerve is compressed by 

 the head of the dislocated bone, and was in con- 

 sequence flattened, and firmly adherent to the 

 capsule of the joint. The dislocation had been 

 followed by permanent paralysis of the del- 

 toid muscle." 



Artery. Luxations of the head of the hu- 

 merus havebeen found complicated with alesion 

 of the axillary artery. This we believe to be a 

 very rare occurrence. M. Flaubert of Rouen 

 cites cases of this lesion to have occurred in the 

 Hotel-Dieu de Rouen, as a consequence of 

 the efforts made by surgery to reduce old 

 luxations of the humerus. In the following 

 case, which the writer thinks of sufficient im- 

 portance to be here introduced, the laceration 

 of the axillary artery was recognised a few 

 minutes after the dislocation had occurred 

 and before any effort whatever had been made 

 to restore the humerus to its place. 



Case. John Smith, aet. 50, was thrown 

 down by a runaway horse one morning during 

 the summer of 1833; in about ten minutes after 

 this occurred, he was brought to Jervis Street 

 Hospital, when the writer, at that time one of 

 the surgeons of the institution, was prescribing 

 for the extern patients. The man was in a 

 cold perspiration, pallid, and apparently on 

 the verge of syncope. The writer imme- 

 diately observed that the patient had a dislo- 

 cation of his left humerus, into the axilla, 

 and, proceeding to point out, as was his cus- 

 tom, to the clinical class the diagnostic marks 

 of the luxation, he noticed that the cavity of 

 the axilla was filled up to a remarkable de- 

 gree. This sudden filling up of the axilla he 

 immediately concluded could be attributed to 

 no other source than to the laceration of a 

 large artery. He quickly sought for the pulse 

 in the radial and brachial artery of the dislo- 

 cated limb ; but no pulsation could be felt in 

 any artery below the site of the left subcla- 

 vian, while the pulse, though feeble, could be 

 readily felt at the heart, and in every external 

 artery of the system, except in those of the 

 dislocated arm.* The writer then observed to 

 the clinical class, that in this case there were 

 two lesions to be noticed, namely, a disloca- 

 tion into the axilla, the features of which 

 were very well marked, complicated with a 

 rupture of the axillary artery ; in a word, be- 

 sides the dislocation there was a diffused 

 aneurism ; the latter was unattended by any 

 pulsation, so that he conjectured the artery 

 was completely torn across. He did not long 

 deliberate as to what course was the best to 

 pursue under existing circumstances, because 

 he felt sure that, so far as the torn artery 

 was concerned, if the head of the humerus 

 was once restored to its place, this vessel 

 would be in at least as favourable a condition 



* Mr. Brassington, now a practising surgeon at 

 Port Rouines, was one of those present on this oc- 

 casion. 



