LUXATION. 



ihe neck of the humerus frafturej, aiid the axillary artery- 

 ruptured, fo that an aneurifm was the confequciice. 



A wife objection, alfo made by Default to the ufe of any 

 apparatus of the foregoing kinds, is, that few furgeons are 

 provided with the inftrument, and therefore much iifeful time 

 would be loft in procuring it, when the eafe is adtually wait- 

 ing for relief. Befides, fays he, when the luxation is 

 confecutive, how can any mechanical contrivances have the 

 efieil of drawing back the head of the bone through the 

 track by which the difplacement has taken place ? For in- 

 ftance, if a luxation inwards has fucceeded one downwards, 

 the head of the bone ought to be drawn downwards before 

 being replaced in its natural cavity. How can the dircftion 

 of the extenlton be varied accordingly ? It is likewife to be 

 obfcrved, that every apparatus alluded to refifts the aftion of 

 the raulcles, which, in fa£t, ought to be the principal agent 

 m the reduftion. Were a luxation ever to happen upwards, 

 no apparatus could anfwer, as muft be moft evident. 



No doubt, however, when the head of the humerus is 

 luxated downward?, and is not Gtuated far from the glenoid 

 cavity, the machines to which we have alluded will often 

 ferve to effeft the reduftion with tolerable facility. But in 

 fuch cafes, there is no real occafion for artificial contrivances, 

 as natural means will be found quite fufficient. In (hort, the 

 reduftion may be executed with the hands, and with this 

 advantage, that the direftion of the movements may be re- 

 gulated aad varied with more precifion. 



The follo)ving method was fiequently purfued by Default 

 with fuccefs : the patient fat on a chair of middling height : 

 Default placed the hand of the luxated hmb between his 

 knees, which he moved backwards, fo as to make extenfion, 

 and difengage the head of the bone, while an affiftant held 

 back the trunk, and made the requifite counter-extenfion. 

 Default now took hold of the upper part of the humerus 

 with both his hands, and pufhed its head upwards and a little 

 outwards into the glenoid cavity. 



This mode is mentioned by Petit, though complicated 

 with the employment of a napkin, which was put under the 

 axilla, and over the furgeon's neck, who forced upwards the 

 head of the bone by drawing back his head. 



In recent luxations of the fhoulder downwards. Default 

 fometimes often found even a more fimple plan anfwer : he 

 put his left hand in the axilla to ferve as a fulcrum, while, 

 with the right, which was applied to the lower and external 

 part of the arm, he moved the humerus towards the trunk, 

 at the fame time pufhing the bone upwards. By this 

 double movement, direfted upwards and outwards, the 

 head of the humerus is put into its natural fituation. See 

 CEuvres Chirurgicales de Default, par Bichat, torn. i. 

 p. 363, 364. 



Mr. Hey notices, that if the head of the os humeri re- 

 mains in the axilla, and not far removed from the gle- 

 noid cavity, the redudlion may fometimes be executed 

 with a very fmall degree of extenfion. Thus, in the relation 

 of ©ne cafe, he obferves : " after I had put every thing in 

 proper order for the reduftion, I defired the alTiftants, who 

 were to make the extenfion, to keep the arm elevated at a 

 right angle with the body, till I rtiould direft them to begin 

 the extenfion. In doing this, they kept the arm a little 

 upon the ftretch, waiting for my orders. While tlie arm was 

 in this ftate, I placed my fingers below the head of the bone, 

 that I might be ready to co-operate with them ; and prelling 

 my fingers upwards into the axilla, that I might feel the 

 kead of the bone diftindlly, the reduftion was unexpeftedly 

 made by this gentle effort." Praft. Obferv. in Surgery, 

 p. 295 — 226, edit. 2. 

 The fame experienced furgeon once faw a luxated fhoulder 



reduced by the mere efforts of the patient, who, whilt 

 preparation for the reduftion was making, walked about in 

 pain, and after placing his hand on the back of a chair, anil 

 moving his body in different direftions, cried out, as if hurl 

 more than ufual. He then fat down, and faid that he was eafy, 

 and could move his arm belter. In fhort, the bone wa» 

 aftually reduced. P. 297. op. cit. 



Redudion of Luxations of the Shoulder by Meant of Extenfion, 

 at praSifed by Default. — There muft be an adequate nun»- 

 berof affiftants, in order to incrcafe, according to neceffity, 

 the force wliich is to overcome the refiftance experienced ; 

 but, in general, two are quite fufficient. A thick pad 

 ftiould be procured, for the purpofe of guarding the mar. 

 gins of the axilla from injury ; and the affiftants fhould be 

 furnifhed with a fheet, doubled into folds, about four inches 

 in breadth, and alfo with a towel folded in the fame manner. 



The patient is to fit on a lowifh chair, or he may be laid 

 on a ftrong immoveable table. Default long followed the 

 firft of thefe modes, according to ordinary cuftom, though, 

 as Bichat remarks, it is not in every refpcft the moft ad- 

 vantageous. In the fitting polture, indeed, the arm may be 

 very well extended tranfverfely ; but if, as often happens, it 

 IS neceffary to direft the extenfion upwards or outwards, the 

 afllftant, being then obliged to raife or lower himfelf, does 

 not poffefs equal power in the new poftuie, and finds himfelf 

 embarraffed, and incapable of varying the diredion of the 

 extenfion, according as the furgeon may think beft. 



As for the patient, he finds fuch pofture, in which the 

 trunk is only partly fupported, much more irkfome than that 

 in which the cheft lies equally upon an horizontal furface. 

 Motives of this kind induced Default, in the latter years of 

 his praftice, to renounce the fitting pofition. 



The patient's pofture being arranged, the linen pad is t» 

 be put under the axilla of the afFefted fide, and the middle 

 of the folded fheet is to be placed on fuch comprefs, while 

 the two ends are tp be carried obliquely before and behind the 

 cheft to the oppofite fhoulder, where, being held by an affift- 

 ant, they ferve to fix the trunk, and to make the counter- 

 extenfion. The pad hinders the fheet from prefGng on the 

 margins of the peftoralis major and latiffimus dorfi. Were 

 it not fo, thefe mufcles, being pulled upwards, would draw 

 the humerus in the fame direftion, and defeat the extenfion, 

 which is performed as follows. 



Default made two affiftants take hold of the fore-arm 

 above the wrift, or elfe he caufed the folded towel to be ap- 

 plied to this part, and confided to the care of one or two 

 affiftants, who were to begin the extenfion in the fame direc- 

 tion in which the diflocated bone lies. This firft movement, 

 intended to difengage the head of the humerus from the place 

 in which it happened to be lodged, was followed by another, 

 which varied according to the kind of luxation. When the 

 diflocation was downwards. Default gradually brought the 

 arm near the fide, at the fame'inftant that he pufhed it gently 

 upwards. By this artifice, the head of the bone was inclined 

 towards the glenoid cavity, into which it generally entered 

 without difficulty. 



When the luxation was inwards, the humerus was brought 

 upwards and forwards, after the firft extenfion in the direction 

 of the bone : thus its head was directed backwards. Were 

 a luxation to occur outwards, it woidd be neceffary to move 

 the humerus, during the extenfion, exaftly in a direftion 

 oppofite to that recommended in the foregoing inftance. 



As foon as the head of the humerus has been difengaged 

 by the firft extenfion, the movement communicated to the 

 bone by the fubfequent extenfion ought in general to be pre- 

 cifely in the contrary direftion to that in wliich the head of 

 the bone has efcaped. 



Whem 



