LUXATION. 



wards has frequently fucceeded one downwards, in confe- 

 quence of awkward efforts to reduce the bone. 



Symptoms of Luxations of the Shoulder. — In general, the 

 diagnofis of luxations of the flioulder is not attended with 

 much difficulty. As Hippocrates has obferved, whatever 

 may be the mode and fituation of the difplacement, a mani- 

 feft deprefhon may always be perceived under the acromion, 

 which procefs feems to projcA more than in the natural Hate. 

 Moving the humerus is very painful, and indeed moll of its 

 motions are either impeded, or very much limited. The 

 arm cannot be moved without the (houlder being alfo moved, 

 becaufe, the funftions of the joint being prevented, both 

 thefe parts form as it were only one. 



To fuch fymptoms, common to all diflocations of the 

 Ihoulder, are to be added thofe which belong to particular 

 cafes. If the luxation is downwards, the arm is fomewhat 

 longer than in the natural ftate ; it may be moved a little 

 way outwards ; but every attempt to carry it forwards or 

 backwards inevitably occafions acute pain. The elbow is 

 more or lefs raifed from the axis of the body by the aftion 

 of the deltoid, the long portion of the biceps, and the fupra- 

 fpinatus mufcles, which, being on the ftretch, contrad and 

 inchne the bone outwards. In order to avoid the pain 

 arifing from this pofition, the patient leans towards the 

 affefted fide, keeps his fore-arm half-bent, and reds his 

 elbow on his hip, fo that the arm may have a fixed point to 

 hinder all painful motions of the hmb. By tliis attitude 

 done. Default was accuftomed to recognize a luxation 

 downwards, and he was feldom deceived. Befides thefe 

 circumilances, v^ have to mention, that the diflocated head 

 of the bone always produces a hard and more or lefs evident 

 prominence in the hollow of the axilla. 



In addition to the fymptoms common to all luxations of 

 the (houlder, the diflocation inwards prefents the following : 

 the elbow is feparated from the ilde, and carried a little 

 backwards ; the humerus appears to be direfted towards the 

 middle of the clavicle ; moving the limb backwards is not 

 •very painful, but carrying it forwards is exquifitely fo ; a ma- 

 nifefl: prominence may be noticed under the peftoral mufcle; 

 the arm is fcarcely longer than in the natural ftate ; and the 

 patient's attitude refembles that of the foregoing cafe. 



Were a didocation outwards ever to happen, it would be 

 particularly chai-afterized by a hard tumour under the fpine 

 of the fcapula, by the inclination of the elbow forwards, 

 and its feparation from the fide ; and, laftly, by the length 

 of the limb appearing a httle increafed. 



A luxation upwards would be announced by a projeftion 

 behind the clavicle, an obvious (hortening of the arm, and its 

 unnatural direction. 



It is frequently much more eafy to afcertain the exiftence, 

 than the fpecies, of luxation of the (houlder. Indeed, fome- 

 times it is a moll difBcult matter to determine, whether a diflo- 

 cation inwards is primitive or confecutive, as the apparent 

 phenomena of each cafe are alike. The judicious and expe- 

 rienced Default taught, that this iiiterefting point is only 

 capable of being elucidated by attention to the hiftory of the 

 eafe, and the order in which the fymptoms prefented them- 

 felves. This excellent furgeon reprefents the diftindion as 

 of much practical importance, fince the proper mode of re- 

 ducing the two cafes is different, the head of the bone having 

 to defcribe a very (hort track in the primitive luxation, and 

 a more circuitous one in that which is conlecutive. 



Diflocations of the flioulder do not commonly give rife to 

 any accidental bad or troublefome fymptoms. Sometimes, 

 immediately after the occuirence, the joint is affedted with a 

 great deal of iwelhng ; but this complaint generally fubfides 

 very quickly, under the ufe of the aqua vegeto-mineralis. 

 J2 



In certain inllances, the prelTure of the head of the bone 

 on the axillary glands and veins produces an oedema of the 

 whole limb. Default feldom obferved this happen, except 

 where the reduftion had been delayed. The treatment he 

 recommends is to apply a roller to the limb, after reducing 

 the head of the bone. 



Another .iccident, which was feveral times obferved by 

 this dillinguiiiied furgeon, is a paialyfis of the limb, occa- 

 fioned, in the luxation inwards, by the preflTure of the head 

 of the bone on the axillary plexus of nerves. In fome 

 inftances, this affeAion proved incurable ; in others, it yield- 

 ed to the employment of llrong ammoniacal liniments. A 

 few obllinate cafes were cured by making an iffue jull over the 

 clavicle by means of the moxa ; but this laft method was as 

 frequently unaviiliig as fuccefsful. 



Rediid'ion of Luxations of the Shoulder. — The infinite variety 

 of modes propofed for rediif ingdiflocationsof thefliouldermay 

 be referred to two general claffes. Some confifl in replacing, 

 by a mechanical force, the head of the humerus in the cavity 

 from which it has efcaped, whether previous extenfion be 

 made or not. Others are reftrifted to difengaging the head 

 of the humerus from tin- fituation which it accidentally oc- 

 cupies, and the redutlion is left to be accompliflied entirely 

 by the aftion of the mufcles. 



The hiftory of all the methods intended to operate on the 

 firft principle would be tedious and unprofitable. Suffics 

 it to (late, that almoft all of them atl in the following man- 

 ner. Something being placed under the axilla, ferves as a 

 fulcrum, on which the arm is moved in the \. ay of a lever, 

 the refiftance being the luxated head of the humerus, and 

 the power being applied either to the lower part of this bone 

 or to the wrift. It was in this manner that the ambi of 

 Hippocrates afted, that machine fo renowned even in modern 

 times, and of which numerous modifications have been de- 

 vifed by Paulus ./Egineta, Ambrofe Pare, Duverney, Freke, 

 &c. By fuch an apparatus, the head of the humerus was 

 at once direfted towards the glenoid cavity of the fcapula, 

 and difengaged from its unnatural fituation. 



Extenfion of the arm ufually produces this fecond effeft, 

 and has been accomphlhed in a variety of ways. Some- 

 times the weight of the body on one fide, with the dragging 

 of the diflocated limb on the other, ferved to make the ex- 

 tenfion. It was on this principle that the ladder, the doof, 

 and the ftick operated, as defcribed by Hippocrates in hi» 

 , treatife on fraftures, and repeated by all fubfequent writers. 

 On other occafions, the trunk has been immuveably fixed, 

 while the arm was forcibly extended. This was the mode 

 purfued in employing the machines defcribed by Oribafius. 



Sometimes no perceptible extenfion at all was made, and 

 the head of the humerus, being propelled outwards by 

 fomething put under the axilla, was pu(hed by the furgeon 

 at once into the glenoid cavity. 



With Default, we fliall abftain from entering into a par- 

 ticular explanation of the objeftions to the preceding me- 

 thods. Petit and B. Bell have already detailed their difad- 

 vantages. Whoever confiders that the head of the bone has 

 efcaped through the ruptured and lacerated capfular liga- 

 ment, and that it is impofiible to know precifely the exaft 

 fituation of the opening, muft perceive how abfurd it is to 

 attempt to direft the head of the bone to it by any artificial 

 force. 



However well covered with foft materials the body may 

 be, which is put under the axilla for the purpofe of ferving 

 as a fulcrum, an unpleafant chaffing, or even dangerous de. 

 grees of ftretchingand laceration, may arife from its applica- 

 tion, when the trunk is fufpended over it, as in the employ- 

 ment of the door, ftick, &c. Bv fuch praftice. Petit faw 



thf 



