LUXATION. 



When any difficulty feems to oppofe the reduftion, the 

 bone fhould be moved in different diiedlions, after the requi- 

 fite cxtcnlion has been made, with due attention to the prin- 

 ciple juft laid down. This method will frequently anfwer 

 when iimplc extenfion will not, the head of the bone being 

 condufted by the movements towards the glenoid cavity. 



When the luxation was confecutive. Default, by means 

 of the firil exlenfioii in the diretSlion of the diflocated bone, 

 brought its head into the fituation where it was originally 

 lodged, aiid Lc '.hen aftcdjuit as if the cafe were altogether 

 a primitive one. Very often, whether the accident is of one 

 kind or the other, can only be diftinguifhed at the time of 

 the reduftion. In faft, when the extenfion is well managed, 

 the reduftion moftly happens fpontaneoiifly, and if the head 

 of the bone is luxated inwards conreeutively, it may be ob- 

 ferved defcending a'.ong the infide of the fcapula, and then 

 pafTing over the inferior part, and afcending towards the la- 

 ceration in the capfule. 



It has been ilnted that when the extenfion is properly ma- 

 naged, the reduction is effected almoll fpontaneoufly. What- 

 ever may be the kind of primitive luxation, it is evident that 

 the mufcles furrounding the articulation are on one fide 

 ftretched, and on the other relaxed. Hence a change in 

 their contratlions, and in the dirediion of thofecontraftions, 

 is neceffarily occafioned. This alteration is fuch, that if the 

 mufcles aft, inftead of pulling the head of the bone towards 

 the lacerated capfule, they drag it in quite a contrary direc- 

 tion, and thus produce a confecutive luxation. 



But it is very different, when, by means of extenfion, the 

 diredlion of the aftion of the mufcles has been reftified. 

 They now tend to pull the head of the bone towards the 

 ruptured capfule, ai>d indeed they do fo with much more 

 certainty than the furgeon, who is always ignorant of the 

 precife fituation of the opening in the capfule. On the 

 other hand, ^vhen the extenfion is ill made, and the natural 

 direftion of the mufcles has not been reftored, the head of 

 the bone is forced againll another part of the capfule ; and 

 hence the difficulty of reduiSlion fo frequently experienced. 



It follows from the preceding obfervations, firit ; that the 

 whole fliillin the treatment of luxations is to make the ex- 

 tenfion in an advantageous direftion. Secondly; that, in 

 general, what has been termed coaptation is almoft always 

 ufelefs. Thirdly ; that the redaftion of a luxation does not 

 confift in putting the head of the bone into its cavity again ; 

 but in placing the mufcles io a ftate in which they are enabled 

 to reduce the bone. 



B .t it is not to be denied that there are cafes where the ac- 

 tion of the mufcles being p?rverted,in cunfequence of the long 

 exillence of the diflocation, and the formation of adhcfions 

 to the furrounding parts, it becomes neceilary to refort to 

 means for forcing, as it were, the paffage of the. head of 

 the bone into the glenoid cavity. 



When the luxation has been reduced, the arm is to be 

 kept motionlefs for a few days, left the head of the bone 

 ftiould flip out of its place again. Surgeons have been ac- 

 cuftomed to apply the fpica bandage, though without theleaft 

 reafon, as it does no good whatfoever, becaufe it has no effeft 

 in confinmg the limb. The proper praftice is to keep the 

 arm quiet, and clofe to the fide with a roller and fling. De- 

 fault himfelf employed the bandage defcribed in the article 

 Fracture. See FraHure of the Clavicle. 



Method adopted hy En^ltjh Surgeons. — In this country, fur- 

 gical praftitioners always reduce diflocations of the Ihoulder 

 while the patient is in a fitting polhire, and, initead of 

 imitating the French, they adhere to the ancient mode of ap- 

 plying the extending force to the hi-xated bone itfelf, jutl 

 above the elbow. No doubt, they have been more influenced 



in fuch pradicc by the authority of Mr. Pott, than by any 

 real advantage attending the method. According to the no- 

 tions oS this latter gentleman, " all the force ufed in reducing 

 .the luxated head of a bone, be it more or lefs, be it by 

 hands, towels, ligatures, or machines, ought always to be 

 applied to the other extremity of the faid bone, and as much 

 as poffible to that only." Another maxim laid down by 

 Pott is, that in order to make ufe of an extending force with 

 all poflible advantage, and to excite thereby the lead pain 

 and inconvenience, it is neceffary that all parts, ferving to 

 the motion of the diflocated joint, or in any degree connefted 

 with it, be put into fuch a fiate as to give the fmallell pofli- 

 ble degree of refiftance. 



" This (fays Mr. Pott) I take to be the firll and great 

 principle by which a furgeon ought to regulate his conduit 

 in reducing luxations. This will (hew us why a knowledge 

 of all the mufcular and tendinous parts, aiding upon or in con- 

 neftion with the articulations, is abfoluiely neceHary for him 

 who would do his bnfinefs fcientifically, wiih fatisfaAion to 

 himfelf, or with eafeto his patient. It will fliew us that the 

 mere pofition of the limb below the luxated joint, is what 

 mull either relax or make tenfe the parts in connexion with 

 tiiat joint, and, confequently, that poflure is more than half 

 the bufinefs. It will ftiew us why fomelimes the luxated os 

 humeri flips in, as it were of its own accord, by merely 

 changing the pofition of the arm, when very violent attempts, 

 previous to this, have proved fuccef'^lefs. It will fliew us 

 why extending the arm in a ftraight line, horizontally, or fo 

 as to make a right angle with the body, mufl in fome in- 

 ftances render all moderate attempts fruitlefs. Why the 

 method of attempting reduSion by the heel in the axilla is 

 fo often fuccefsful, notwithflanding two very confiderable 

 difadvantages under which it labours ; w'a;. part of the force 

 being lojl in theelloiv, and the tenfe ilate of one head of the 

 biccp5 cubiti. Why the tying down the fore-arm in tlie com- 

 mon ambi is wrong for the fame reafons. Why the fore- 

 arm fliould at all times (let the method of rcduftion be what 

 it muy) be bent ; wa. becaufe of the refillance of the long 

 head of the biceps in an extended poRurc. Why, when 

 the OS humeri is luxated forward, or fo that its head lies 

 under the great perioral mufcle, the carrying of the extended 

 arm backward, fo as to put that mufcle on the ilretch, ren- 

 ders the reduction very ditHcult ; and why, on the con- 

 trary, the bringing the arm forward, fo as to relax the faid 

 mufcle, removes that difiiculty, and renders reduftioii eafy, 

 &c." 



In our opinion, fome of thefe obfervations do not fhew the 

 thing intended, quite as well as J.Ir. Pott feems to conceive. 

 We do not fee how all the parts, in connexion with a jointf 

 can be relaxed by pofture. We fee, it is true, how bending 

 the elbow relaxes the biceps, but then it puts the long head 

 of the triceps on the ftretch, wliich may alfo rcfiil the re- 

 duftion. As for the extending force being kjl in the elbow, 

 when applied bclow tlie diflocated bone, we have endeavoured 

 to prove the error of the fuppofition in our general remarks. 

 With refpeft to the lall part of the foregoing, we think the 

 explanation given by Bichat, in his edition of Default's 

 works, more corredt, namely, that when the luxated head of 

 the humerus lies forward under the pcftoral mufcle, carrying 

 the elbow forwards and inwards tends to throw the head of 

 the hone backwards and outwards, and then the mufcles are 

 enabled to aft with effeft in promoting the reduftion. 



To the truth of the enfuing remarks, delivered by Mr. 

 Pott, we have pleafure in affenting. That in the reduftion 

 of fuch joints as conilll of a round head moving in an aceta- 

 bulum, or focket, no attempt ought to be made for replacing _ 

 the faid head, until it has by extenfion been brought forth 



from 



