LUXATION. 



from the place where it is, and nearly to a level with the faij 

 focket. This will fliew us why the old method by the door, 

 or ladder, fometimes produced a fraClurc of tlie neck of the 

 fcapula, Mr. Pott himfelf has feen happen. Wliy, if a fuf- 

 ficient degree of extenfion be not made, the towel, over tlie 

 furgeon's fhoulder, and under the patient's axilla, muft 

 prove an iisipediment rather than aivaffiftance, by thriiiling 

 the head of the humerus under the neck of the icapula, in- 

 ftead of dircfting it into its focket. Why the gommon me- 

 thod of bending the arm, that is, the os humeri, downward, 

 before fufficient extenfion has been made, prevents the very 

 thing aimed at, by pufiiing the head of the bone under the 

 fcapula, which the continuation of the extenfion, for a few 

 feconds only, would have carried into its proper place. 

 When the head of the os humeri is drawn forth from the 

 axilla, and brought to a level with the cup of the fcapula, it 

 mull be a very great and very unneceffary addition of ex- 

 tendinij force, that will, or can keep it from going into it. 

 All that the furgeon has to do, is to bring it to fuch a level ; 

 the mufcles attached to the bone will do the reft. 



A very juft and important maxim, inculcated by Mr. Pott, 

 a::d indeed by every judicious furgical writer of recent date, 

 is, that whatever kind or degree of force may be found ne- 

 cefTary for the reduttion ef a luxated joint, fuch force 

 be employed gradually ; that the leffer degree be always lirll 

 tried, and that it be incrczfed graiialim. See Pott's Remarks 

 on Fratturcs and Diflocations, vol. i. of his works. 



After adverting to a kw impediments to the reduftion of 

 diflocated (houlders, we may here (not abruptly we hope) 

 take leave of the fubjecl, without expatiating on the methodi 

 purfued in this countr)', becaiife in faft the practice of De- 

 fault, as already related, differs from our's chicily in the ex- 

 tenfion being made at the wrift. If v.e fuppofe the elbow 

 bent, and the extending force applied juft above ihe joint, it 

 will be eafy to follow the diredlious already given, with re- 

 gard to the manner of making the extenfion, and the time 

 and mode of altering the polltion of the bone during the 

 procefs. 



We fhall conclude our account of diflocations of the 

 fhoulder, with noticing fome circuinftances which may tend 

 to render the reduftion difficult. 



The firft to which we ftiall requcft the reader's attention, is 

 the narrownefs of the lacerated opening in the capfular liga- 

 ment. The pradlice of Default, when he had reaion to 

 fufpeCl this kind of impediment, was to erideavour to di- 

 late the aperture by moving the humerus very freely and 

 forcibly in every direftion, and pufliing its head at the fame 

 time towards the glenoid cavity. 



The luxation not being recent, maybe another caufe hin- 

 dering the reduflion, and is fometimes an iiifurmountable 

 obftacle to fuccefs. The luxated head of the bone, after a 

 time, contracts adhefions : and the furrounding cellular fub- 

 fta:ice becomes condei^fed, and converted as it were into a 

 new kind of capfular ligament, which confines the bone in 

 its unnatural fituation. Molt furgical authors recommend 

 ti5 in fuch a cafe to make no endeavour to put the bone into 

 its place again, as the attempt would, in all probability, fail, 

 and might bring on ferious confequences, by reafon of the 

 violence which muft be exerted. Default once profcfled the 

 fame doctrine, but in the latter part of his life experience 

 led him to a bolder praftice. After being completely fuc- 

 cefsful in reducing fome luxations, whicli had exilled from 

 fifteen to twenty days, he was encouraged to attempt the 

 reduftion of others, which had happened from thirty to five 

 and thirty days ; and during the two years before his death, 

 be had, in Bichat's prefence, replaced diflocations of the 

 Jlioulder after ten weeks, and even three months, when the 

 Vox. XXI. 



head of the humerus had cfcaped cither at the inferior, or 

 internal part of the capfule. Notwithftanding the long con- 

 tinued cxtenfions which were employed, there were none of 

 the terrible confequences induced, with which authors have 

 intimidated the generality of sraflitioners. In two inftances, 

 a fudden and unaccountable emphyferaa of the fhoulder 

 took place, which yielded to the ufe of a bandage and the 

 falurnine lotion. See Qiuvres de Default par Bichat, torn. i. 



P- 377- . . * . 



In cafes of this kind, bef ire the extenfion is begun, the 

 hone fhould be freely moved about in every poflible direftion, 

 in order, in the firft inflance, to break the adhefions, lacerate 

 the condenfed cellular lubftance, that ferves as the accidental 

 capfule, and thus produce, as it were, a fccond luxation for 

 the purpofe of curing the firft. The means for extenfion 

 are then to be apphed as ufual, witli an increafed numbsr of 

 afliftants. In theie cafes we have feen the multiphed puljey 

 ufed with advantage, thougli it is certainly a dangerous ma- 

 chine, unlefs in careful hands. 



Frequently the firft attempts are unavailing, and the luxated 

 head of the bone continues immoveable, in the niidft of the 

 moft powerful efforts. The extenfion is then to be flopped, 

 and the bone moved about again in all direftions ; every re- 

 filtance is to be broken ; let the arm defcribc a large fcgmcnc 

 of a cu'cle in the place which it occupies ; and let it be ro- 

 tated on its axis. Then let extenfion be repeated in every 

 direction. 



For cafes proving the occafional efScacy of fuch practice, 

 we muft refer to Default's Oiuvres Chirurg. par Bichat, 

 torn. i. p. 375. 



In this excellent work it is obferved that, fuppofing the 

 attempts to fail, they are not entirely ufelefs ; for, by moving 

 the head of the bone fomewhat towards the glenoid cavity, 

 or even juft before itj they give the limb a greater freedom 

 of motion. 



A third obftacle to the reduftion of all luxations arifes 

 from the power of the mufcles, which power is exerted with 

 violence in confequence of the manner in which thefe organs 

 are ftretched. Sometimes the refiftance of the mufcles, in- 

 deed, abf'olutely hinders the head of the bone from being 

 at all moved, notwithftanding the extenfion is very confider- 

 able. In fuch a cafe, bleeding and the warm halli are to be 

 tried, in order to bring on a temporary weaknefs and re- 

 laxation, during which the attempts at reduftion may be 

 made with the beft profpeft of fuccefs. But a ftiU more 

 certain plan is long continued unremitting extenfion, which 

 is fure of fatiguing the refitting mufcles, and as foon as they 

 are worn out, the bone may eafily be replaced. Default in 

 certain cafes did not fucceed before the half, or even the 

 whole of the day had been fpent in keeping up the extenfion, 

 by means of his apparatiis for the broken clavicle, which 

 apparatus draws outward the fhoulder and alfothe muicies. 

 (See FuACTUKE of thi; Clavide.) The mufcles can only 

 fupport a violent contraftion a certain time. To pcrnnnent 

 extenfion, though moderate in degree, they cannot make 

 long reCflance, they become fatigued, they are incapable of 

 hindering the head of the bone from being moved in tiie 

 defired direftion, and the reduftion is accomplilhcd. 



We have feen that Mr. Pott and Default have particularly 

 adverted to the difEculty of reduftion, arifing from the bone 

 being prefledagainft the neck of the fcapula, when the elbow 

 was deprelTed, before the extenfion liad fufHciently difen- 

 gaged the head. Mr. Hey has alfo noticed this cbiiacle to 

 reduftion, as follows : " the difficulty of reducing a diflo- 

 cated humerus, not only arifes from the refiftance or com- 

 prelTion of the mufcles ; but alfo from the refiftance which 

 is made by the preflure of the glenoid procefs againft the 

 4 R neck 



