In reduction the following points are to be especially noticed. As every dislocation of the upper arm occurs only in a certain position, so must its extension also be made in a corresponding position, and according to the directions laid down. In this position the m. deltoides, supra-spinatus and infra-spinatus, which mostly oppose the reduction, are rendered lax. On this account the dislocation is often reduced with ease, immediately after its occurrence, by raising the arm to the horizontal posture, and placing the fingers in the arm-pit. The arm is not to be brought into its natural position, till the head of the bone has been restored to the place from which it has slipped. The head is usually carried back into the socket, rather by the action of the muscles, than by any force applied to it. By what has been said is explained the fitness of La MOTHE's (a) proposed mode of reduction. The patient is to be placed on a seat; the shoulder to be fixed by means of a cloth, folded lengthways, applied over it, and held by two assistants sitting on the ground; a third, standing on the uninjured side, draws horizontally a cloth laid round the chest. The Surgeon, standing on a table near the patient, grips the dislocated arm with both hands, raises it, gently drawing it up towards the patient's head, then pulls more forcibly, and thus almost without pain causes the head of the bone to rise up into its place. RUST (b) simplifies this treatment; the patient being seated on the ground, on a carpet or flat cushion, an assistant, kneeling on the side opposite the dislocated arm, grasps the injured shoulder with both hands locked in each other, the one of his arms being carried before, and the other behind the patient. Whilst he draws the shoulder strongly and steadily downwards, the Surgeon, standing on the same side as the dislocated arm, grasps it with both hands at the wrist and fore-arm, draws it somewhat towards him, in order to keep it constantly extended, and raises it, by a circular movement, above the head of the patient, so that the upraised arm is brought parallel with the long axis of the body. The Surgeon then draws the arm strongly towards him, as if he would raise the patient from the ground, and at the moment this is effected, the head of the bone slips back into its socket. If this do not happen, the Surgeon may now give the extension of the arm to an assistant, and kneeling by the patient, places both thumbs under the protruded head, and leads it, by pressing upwards, into its socket. He then fixes one thumb firmly in the arm-pit, with the other hand grasps the elevated arm above the elbow-joint, and draws it carefully down, when, if the head of the bone be not completely carried into its socket, its complete reduction must be attempted, by more firmly sliding it over the opposed thumbs, as if over a roller.

1034. Complete reduction is characterized by the natural form of the joint, the cessation of pain, and the free movement of the arm in every direction. To counteract the disposition which the upper-arm always has to become dislocated afresh, its motions should be prevented; the arm is to be put in a sling, or fastened with some circular turns of a bandage round the body, and some may be carried beneath the elbow and over the shoulder. For the first few days cold applications are to be applied over the shoulder to remove the bruising. If a paralytic state of the arm continue, (which there is always ground to fear if after the dislocation there ensue a sensation of cold, of going to sleep, and weight,) stimulating friction, douche-baths, blisters, moxas, and the like must be employed. This may arise also from palsy of the deltoid muscle.

1035. In this way the dislocation of the upper-arm-bone may ordinarily again be put to rights. If violent contraction of the muscles occur, we must attempt to diminish it by the remedies heretofore mentioned. A small opening in the capsular ligament is mentioned by many, as the obstacle to reduction in several cases, which may be imagined if the head of the bone return to its place without noise and be directly again dislocated; in such case the aperture of the capsular ligament must be attempted to be enlarged by moving the arm; numerous observations, however, oppose this notion.

(a) Busch, above cited.

(b) RUST, in his Magazin für die gesammte sert. de Methodo Mothiano humerum luxationi Heilkunde, vol. x. p. 181.-LEONHARDT, F., Dis- reponendi. Berlin, 1820. 8vo.

1036. Besides the modes of reducing dislocations of the upper-arm already given, the following still require to be mentioned :

1. In recent dislocation the patient may be laid on his back upon a table or sofa, in such way that the affected arm may be completely on the edge; a wetted roller is to be applied on the arm above the elbow, and over this a handkerchief is to be fastened. The Surgeon, standing with one foot on the ground, places the heel of the other in the patient's armpit, so that he finds himself in a half-sitting posture by the side of the patient. By means of the handkerchief he extends the arm for three or four minutes, in which way, under ordinary circumstances, the head is easily reduced. If more power be required, a towel instead of a handkerchief should be fastened around the arm, by which several persons may pull, whilst the heel is still in the arm-pit. In order to relax the m. biceps the fore-arm must be bent. In this mode of reduction there is less extension of the limb than lateral separation of the head of the arm-bone from the blade-bone. On this account probably has BERTRANDI (a) proposed, that the Surgeon should place himself between the legs of the patient as he lies in bed, and make use of his left foot if the dislocation be on the right, and his right foot if it be on the left side. SAUTER'S (b) treatment corresponds to this; the patient being placed on a seat, the dislocated arm is to be drawn down perpendicularly on the body, fixed in this direction by the one hand of the Surgeon at the elbow-joint, and drawn towards the ground, whilst with the other hand the head of the bone is thrust upwards; at the same time an assistant may further the extension, by drawing down the hand, but which is not always, nor ever with violence, to be done. In dislocation inwards the arm is to be inclined more forwards.

2. The patient, being seated on a low stool, the Surgeon separates the dislocated arm so far from the body, that he can put his knee into the armpit, and whilst he places his foot by the side of the stool, he puts one hand upon the arm-bone, immediately above the condyles, and the other upon the acromion, then presses the arm downwards over the knee, and in this way reduces the dislocation (c).

1037. If in very powerful persons, or in old dislocations, these modes of treatment be unsuccessful, and it be necessary to overcome the muscles by continued and gradually increased extension, the pulleys are to be employed as most convenient. The patient is to be put on a stool, the shoulder fixed with a retractor, and this attached to a hook fixed in the wall on the patient's sound side; the extension-bandage is to be put on above the elbow, and, by other bandages connected with the pulley, fastened to the other wall. The direction of the extension is to be similar to that made by assistants; and it must be made gradually, if intended to be kept up for some time. When it has attained sufficient degree, the Surgeon puts his knee in the arm-pit, places his foot on the stool, and raising the head of the bone, thrusts it gently into the socket, which, at the moment when the extension is left off, usually happens without any snap.

The various contrivances proposed for reducing dislocation of the upper-arm are in part superfluous, in part unsuitable, because the mechanical violence acts too much on the head of the bone itself; or the extension cannot be made after every one's favourite direction. To these contrivances belong the ambe of HIPPOCRATES, the machines of (a) Institutiones Chirurgica, vol. v. selgelenkes; in HUFELAND'S Journal, vol. xliii. (b) Ueber die Einrichtung des verrenkten Ach- pt. i. July, 1816, p. 39. (c) ASTLEY COOPER, p. 432.

VOL. I.

3 E

ORIBASIUS, PARÉ, GERSDORFF, SCULTETUS, PURMANN, PETIT; the reductors of RAVATON, HAGEN, FRECK, MENNEL, SCHNEIDER, BRunninghausen, and others.

1038. If the dislocation have existed some weeks, the arm must, previous to extension, be moved forcibly in every direction, for the purpose of loosening it, and the relaxation of the muscles must be effected by the means already mentioned. After the reduction of these old dislocations, an emphysematous swelling is often observed beneath the great pectoral muscle, which soon disappears under the use of dispersing remedies. WEINHOLD cut through the tendon of the m. pectoralis major, because it did not yield in an old dislocation (a). The dislocations at the shoulderjoint may often be satisfactorily reduced, even after a long time, especially in relaxed persons; the attempt at reduction, however, is not to be carried too far, as dangerous symptoms may ensue (b).

GIBSON noticed a rupture of the axillary artery in reducing an old dislocation. DIEFFENBACH (c), whilst making extension and counter-extension in the usual manner, in a dislocation of two years' standing, divided the tendons of the m. pectoralis major and latissimus dorsi, the m. teres major and minor, beneath the skin, and the false ligaments surrounding the new joint, upon which, with the extension made, the head suddenly returned into its socket, and he then applied over it a pasteboard apparatus.

1039. The Congenital Dislocation of the Upper-Arm-bone (Luxatio congenita Humeri) does not, according to R. W. SMITH (d), who first noticed it, happen so very rarely. In the early period of life, before the more perfect development of the bones, and before the more powerful action of the muscles, the external appearance of deformity may possibly escape observation; but when the shoulder-bones have attained to their perfect development, when the bony processes about the joints project, and especially when the muscles operating on the shoulder-joint and upper-arm acquire their full activity, then first are the characteristic marks of congenital dislocation not easy to be mistaken. SMITH has noticed two kinds of congenital dislocation, viz., the subcoracoid and the subacromial dislocation.

1040. In the congenital subcoracoid dislocation, the head of the upperarm-bone, when the arm hangs down on the side, is situated beneath the coracoid process, and the outer part of the glenoid cavity can be felt beneath the projecting acromion; if the elbow be drawn forward over the chest, the head of the upper-arm-bone slips backwards over the acromion, and completely leaves the unnatural part of the articular surface, which can now be distinctly felt; the shoulder has not its natural rounded form, but is flattened. The muscles of the shoulder and arm are much shrunk, and also the muscles passing from the chest to the blade-bone and upperarm, only the m. trapezius shows the least of this, and seems to be almost the only muscle, which still acts upon and moves the blade-bone; the diseased arm is nearly half an inch shorter. The motions of the arm are very much restricted; elevation and abduction are not possible, and even the forward and backward motions cannot be performed without corresponding movement of the blade-bone. Although the muscles of the forearm are not so much shrunk as those of the upper, yet flexion is so diffi

(a) ZWANZIG de Luxatione Ossis Humeri, et precipuè Incisione Aponeuroseos Musculi Pectoralis Majoris ad cur. Luxat, inveter. Hala, 1819.

(b) FLAUBERT, Mémoire sur plusieurs cas de Luxation, dans lesquels les efforts ont été suivi d'accidens graves; in Répert. gen. d'Anatomie et de Physiologie Pathologique, vol. iii. fasc. i.

(c) Vereinszeitung, 1839, No. 51.

(d) An Essay upon the original or congenital Luxations of the upper extremity of the Humerus; in Dublin Journal, vol. xv. p. 236.

FRORIEP'S N. Notizen, July, 1839. No. 225 and

227.

cult, on account of the atrophy of the m. biceps, that it can scarcely be brought to a right angle. Elevation is not performed gradually, but with a sudden jerk, in which the blade-bone also is considerably raised, the arm pressed to the side, and sometimes even the body bent to the other side, whilst the elbow-joint rests upon the crest of the hip-bone. The deformity exists from birth, but only first at the period of perfect development does it become more apparent. This congenital dislocation may exist on both sides at once.

1041. Examination after death of a case of subcoracoid dislocation on both sides, showed upon the one side scarcely a trace of the natural socket, but, on the contrary, immediately beneath the lower edge of the coracoid process, partially upon the ribs, partially on the axillary edge of the bladebone, a well-formed socket of an inch and a-half diameter; this reached to the under surface of this process, and was only separated from the upperarm by the capsule of the joint. The perfectly formed capsular ligament, extending from the undeveloped glenoid cavity, surrounded these articular surfaces. The perfectly natural tendon of the m. biceps arose from the point of the latter, and the capsular ligament was also quite natural. The head of the upper-arm-bone varied considerably from its rounded form; it was oval, and its long axis corresponded with that of the bone itself, which depended especially on the hinder part being deficient. The shaft was small and decidedly atrophic; the position of the head on the coracoid process varied, according to the rotation of the arm inwards or outwards. Upon the other side the deficiency of the articular surface was confined to its inner edge, which was entirely wanting for a thumb's space from above downwards. The inner edge of the joint-surface was formed by a long ridge, which passed down from the under surface of the coracoid process; the tendon of the m. biceps and the capsule were perfectly formed.

1042. SMITH saw and examined after death congenital subacromial dislocation on both sides. The coracoid process projected considerably, as did also the acromion; the joint-surface beneath was not, however, to be felt; the projection of the acromion, as well as the flattening of the shoulder, was less decided than in subcoracoid dislocation; the flattening was confined to the front of the joint. The head of the upper-arm-bone formed a distinct swelling on the back of the blade-bone, beneath and behind the point of the acromion, close on the under surface of its spine. The upper-arm did not stick out from the side, and the fore-arm was rotated inwards. Internal examination of the joint presented no trace of an articular cavity in the usual place, but a well-formed articular pit, surrounded by a capsular ligament, arising from the outer surface of the neck of the blade-bone, which was broader above, and completely reached the under surface of the acromion; the tendon of the m. biceps was perfect, and firmly attached to the upper and inner part of the unnatural joint's surface, the direction of which was forwards and outwards. The head of the upper-arm-bone exhibited the same oval form as in the subcoracoid dislocation, only that the fore part of the head was in this case deficient. The little tubercle formed a considerable projection, long and curved, so that it had remarkable resemblance to the coracoid process of the bladebone.

1043. That these dislocations are congenital and not of accidental occurrence, SMITH thinks he has found proof of, as regards subcoracoid

dislocation, in the absence of previous injury, in the joint not being the seat of pain, swelling, and the like, but especially in the unhurt condition of the capsule and of the tendon of the m. biceps, as well as in the simultaneous existence of a pes equinus in the same patient; in the form of the head of the upper-arm-bone being peculiar, and quite different from any change which he has noticed as consequent on disease or in old dislocation of the usual kind. SMITH is not disinclined to find a resemblance between this congenital dislocation and that described by many writers, as partial dislocation of the upper-arm-bone, as well as that arising sometimes from rheumatic affection of the shoulder-joint, (A. COOPER,) or as an unusual atrophy of the upper-arm (CURLING.) He also supposes that in subacromial dislocation, the absence of the natural joint-surface, the complete resemblance of both unnatural articular cavities, the uninjured state of the tendons and ligaments, as well as the peculiar form of the head of the upper-arm-bone, speaks in favour of the congenital existence of this dislocation. With the few examinations which have been as yet made of this subject, it is not, however, possible to determine with certainty whether the cause of the dislocation should always be sought for in an original deficient formation of the joint surfaces, or whether such dislocations be not produced by the peculiar position of the child, and during birth, and the particular changes subsequently found, on examination, do not depend on the long continuance of the dislocation, and the previously incomplete development of the bones, and so on.

In support of this opinion at least speaks an observation of GUILLARD (a), who reduced a congenital dislocation of the upper-arm-bone by horizontal extension after sixteen years. The reduction was effected after several futile attempts, and when effected it relapsed twice, and was again reduced. After the last reduction, however, the upper-arm for two years and a-half was not displaced, and the movements of the limb were almost entirely natural.

VII.-OF DISLOCATIONS OF THE FORE-ARM.

1044. These dislocations are distinguished into dislocations of the forearm from the upper-arm, and the separate dislocations of the spoke-bone and cubit.

A.-OF THE DISLOCATION OF THE FORE-ARM AT THE ELBOW-JOINT. (Luxatio Antibrachii, Lat.; Verrenkung des Vorderarmes, Germ.; Luration de l'Avant-bras, Fr.)

1045. Complete dislocations of the elbow occur but rarely, on account of the great strength of the joint, and are always accompanied with considerable tearing of the soft parts. The dislocation may be either backwrads or lateral, but dislocation forwards is impossible without simultaneous fracture of the olechranon.

1046. The dislocation backwards is the most common, and always the most complete. The coronoid process of the cubit gets behind the pulleylike joint-surface of the upper-arm-bone, and rests in the pit formed for receiving the olechranon. The joint-surfaces of the upper-arm-bone are thrown upon the front of the spoke-bone and cubit, between the coronoid process and the insertion of the m. biceps. If the lateral ligaments are torn, the muscles surrrounding the joint, the skin, and even the brachial

(a) Révue Médicale, Aug., 1840.