was then sent to the hospital. Without attempting to describe mi-
nutely the various modes of extension and manipulation which I
employed, I will briefly state that, having placea her completely
under the influence of chloroform, the manipulations were made
assiduously during one hour, without success. On the following
morning she was bled freely from the opposite arm, and chloroform
again administered ; extension being made, in the presence of Prof.
Charles A. Lee and other gentlemen, with Jarvis's adjuster. After
more than an hour, the effort was again suspended. On the following
day we made a third attempt, the patient being completely under the
influence of chloroform, but with no better success. The chloroform
produced a condition approaching apoplexy, and it was not again
used. On the tenth day, assisted by Prof. James P. White and other
surgeons, we applied the compound pulleys, moving the arm in vari-
ous directions. Twice we thought the reduction was accomplished,
but as often as we proceeded to examine it attentively we found it
DISLOCATION OF THE SHOULDER DOWNWARDS. 549
was not. If it did ever pass into the socket, it was immediately
The woman after this refused to submit to any further attempts, and
she soon left the hospital, nor have I seen or heard from her since.
Sir Astley Cooper has thus described
the appearances presented on dissection ^^S- 288.
of a dislocation which had been long
unreduced: "The head of the bone
altered in its form; the surface towards
the scapula being flattened. A com-
plete capsular ligament surrounding the
bead of the os humeri. The glenoid
cavity entirely filled by ligamentous
matter, in which were suspended small
portions of bone, which were of new
formation, as no portion of the scapula
or humerus was broken. A new cavity
formed for the head of the os humeri
on the inferior costa of the scapula;
but this was shallow, like that from
which the bone had escaped." New socket, in an ancient Inxation of
When the dislocation into the axilla ^^^ â€¢hoolder downwards. (From Sir A.
remains unreduced, the consequences ^^^'-^
are always sufficiently grave, but they differ very much in degree, in
character, and in persistence, according as the arm has remained a
longer or shorter time unreduced, and according to the presence or
absence of complications. These conditions will be best illustrated
by a reference to examples.
Wm. S., a German, est. 51, fell down a flight of steps while intoxi-
cated, producing a dislocation of the left arm into the axilla. Eleven
hours after the accident, he was received into the Buffalo Hospital of
the Sisters of Charity. No attempt had been made to reduce the bone.
The reduction was effected by myself with tolerable ease, by extending
the arm perpendicularly above the head, while my foot pressed upon
the top of the scapula. The head of the humerus could be plainly felt
in the axilla, approaching the socket, until it seemed to be directly over
it, when, on lowering the arm, it was found to be reduced. After the
reduction, the patient could not raise the arm more than eight inches
from the body. The fingers, hand, and forearm were almost paralyzed.
Three weeks later, when he left the hospital, his arm had improved,
but he could not flex his fingers.
Mrs. G., 8Bt. 70, fell down a flight of steps, and dislocated her arm
into the axilla. She did not suspect the nature of the injury, and no
surgeon was called.' I was consulted one week after the accident, at
which time she was suffering great pain from the pressure of the head
of the bone upon the axillary nerves. We first attempted to reduce
the bone by resting the knee in the axilla while she was sitting, but
without success... We then placed her in bed, and with my knee in
the axilla, the acromion process being supported by the hands of an
assistant, we restored the bone after a few moments of pretty firm ex-
550 DISLOCATIONS OF THE SHOULDER.
tension downwards and outwards. Aflter the reduction she could not
raise her arm, but the pain was much abated. One month later, the
arm remained very weak. She could not raise it more than six inches
toward her head, but I could raise it to a right angle with the body
without causing pain. The whole hand felt numb, and was occasion-
ally painful. The deltoid muscle was slightly atrophied. There was
also a slight flatness under the acromion .process behind, and oa the
outer side, with a corresponding fulness in front.
Mary Ann Hasler, ast. 47, was admitted to the hospital, with a dis-
location of the right humerus into the axilla. The arm had been
dislocated three weeks, in consequence of a fall upon the upper and
outer part of the shoulder. An empiric, who saw it fifteen minotes
after the fall, and when the arm was not swollen, said it was not dis-
located. On the fifth day, a Catholic clergyman discovered that it
was out, and attempted to reduce it, but was not successful* When
she came under my notice, the arm was lengthened about one-qaarter
or one-half of an inch, and hung out from the body in a condition of
almost complete paralysis. There was very little swelling about the
shoulder or arm, and the head of the bone could be distinctly felt in
the axilla. The patient being rendered partially insensible by chloro-
form, I placed my heel in the axilla, and by pulling moderately about
thirty seconds in a direction slightly outwards from the lipe of the
body, the bone was reduced. Seven days after the reduction, she left
the hospital, the arm being yet quite useless, though not greatly
swollen. There was also a striking fulness in front of the head of
Wm. Gardner, of Painted Post, N. Y., set 75, dislocated the right
humerus into the axilla twenty years before I saw him, by falling
upon his hands with his arms extended. I found the arm weak and
atrophied, so that he could raise it but slightly outwards from his
side ; he was unable to move it forwards much beyond the line of his
body, but he could carry it back quite freely. The whole hand was
in a condition of partial ii^sensibility.
I have before mentioned the case of Maria Norrigan, the Swiss
woman, whose arm had been ^dislocated downwards seventeen years.
The deltoid muscle has become greatly wasted ; the head of the bone
can be felt obscurely in the axilla ; the arm is shortened perceptibly ;
the elbow hangs freely against the side ; the little and ring fingers are
numb, and also one-half of the forearm ; the whole hand and arm are
weak and atrophied'; she complains also occasionally of a troublesome
sensation of formication over the arm and hand ; she cannot straighten
her fingers perfectly; the elbow may be raised from the side to a right
angle with the body, but she cannot raise it herself more than one
foot ; she carries it back a little more freely than forwards.
In compound dislocations, the prognosis must always be regarded
as exceedingly grave. In the only example which has come under
my notice, the circumstances attending which I shall hereafter men-
tion in the general chapter devoted to compound dislocations, the
patient died from sloughing of the axillary artery. Mr. Scott has,
-however, reported a case, in a boy fourteen years of age, who recovered
DISLOCATION OF THE SHOULDER DOWNWARDS. 551
:rapidly after the redaction was effected, and in thirteen months his
sirm was nearly as useful as before.'
2}'ecUment, â€” The principles of treatment in this dislocation are very
^iinple and easy to be comprehended. I speak now of recent uncom-
plicated cases of dislocation into the axilla; and, notwithstanding the
"various and sometimes almost contradictory views whioh surgeons
liave entertained as to the best and most rational modes of procedure,
I continue to affirm that the laws which are to govern the reduction
in a great majority of cases are established and indisputable.
Observe now the obvious anatomical facts, and then consider the
The capsule is torn, generally extensively, along the inner and
lower margins of the socket. The head of the bone is lodged below
and slightly in advance of its natural position, in consequence of
which the points of origin and insertion of the deltoid muscle and the
supraspinatus are separated somewhat and their fibres rendered tense,
insomuch that'the arm is abducted and actually lengthened.
At first, and in the most simple cases, these are the only muscles
which are in a state of extreme tension, but after the lapse of a few
hours, or of a few days, nearly all the other muscles about the joint,
most of which were originally only in a condition of moderate exten-
sion, and some of which were rather relaxed than extended, sym-
pathize with those which are suffering the most^ and a general con-
traction and rigidity ensue, increased also at the last by the superven-
tion of inflammation and its consequencesi
What, from these simple premises, must; be the obvious practical
That in the simplest forms of the dislocation the most rational mode
of reduction will be to elevate the arm siifi&ciently to relax the over-
strained deltoid and supra-spinatus muscles, which bind the head of
. the bone in its new position, and to pull gently in the same direction,
in order to overcome the moderate resistance offered by several other
muscles, but whose tension cannot be relieved by the same manoeuvre.
Failing in this, that we shall increase the relaxation of the first
named muscles, by pulling at a right angle with the body, or even
directly upwards; and meanwhile, as we carry the arm more and
more upwards, we shall operate more powerfully against the resistance
of the other muscles.
If in all these modifications of the same procedure, we keep the arm
a little back of the axis of the body, we shall accomplish the indica-
tions the most perfectly.
Such are the conclusions which must be drawn from the anatomical,
or, as Mr. Pott would call it, the "physiological," argument ; and which
assumes as its basis that the muscles constitute the sole or the main
obstacle to the return of the bone to its socket. If any surgeon main-
tains that the premise is unsound, and that the restoration of the head
of the bone is opposed by. the untorn fibres of the capsules or by any
Â» Scott, Amer. Joum. of Med. Sci., vol. xx. p. 516, Aug. 1S87, from the London
Lancet for March 4, 1837.
552 DISLOCATIONS OF THE SHOULDER.
Other important circumstance than the action of the muscles (we speak
of ordinary cases), we shall content ourselves by referring him again
to the extensive laceration which this capsule generally sufiers;, and
to the constrained and almost uniform position of the arm, as a suffi-
cient reply to his objection.
It must not be forgotten that in all these modes of extension, for
with nearly all of them some slight degree of extension is found neces-
sary, there must be afforded some point of resistance beyond the bone;
and this it is really which has constituted one of the greatest impedi-
ments to reduction. It is not that the muscles are in such an extra-
ordinary state of extension or rigidity that they must be operated
against with great force; it is not that the margin of the glenoid fossa
is an elevated barrier, like the margin of the acetabulum, over which
the bone must be lifted before it can fall into its socket ; but the ex-
planation of the difficulty so often experienced in producing effective
extension and counter-extension is to be sought for mainly in the
fact that the scapula, upon which the humerus rests, is movable, being
held to the body by little else than muscles, which, in fact, bind the
scapula much less firmly to the body than the muscles of the shoulder
now bind the scapula to the arm ; while at the same time the scapula
itself presents very few points against which a counter-extending force
can be properly and efficiently applied.
Occasionally it will be only necessary to elevate the arm to an acute
angle, or to a right angle with the body, when, the resistance of the
deltoid and supra-spinatus being overcome, the bone will at once re-
sume its place. In several instances which have come under my notice
nothing more has been necessary ; and where it can be done, the least
possible pain and injury are inflicted. It is the method, therefore,
which in all recent cases I have first tried and would wish to recom-
mend. By it I have more than once succeeded when other and more
violent efforts have failed.
At other times it will be necessary to add to this simple manipula-
tion only a moderate degree of extension, such as the hands of the
surgeon can make, without the application of direct counter-extension
except what is effected by the weight and resistance of the body.
If, however, the bone refuse to move, we shall then be obliged to
consider upon what point and by what means we can best apply a
counter-extending force. Ample experience has taught me that the
extremity of the acromion process is the only available point when
we are making the extension in a line below a right angle, or in a
line downwards more or less approaching the axis of the body. It
has been supposed that the counter-extension could be made in the
axilla against the inferior margin of the scapula ; but several obstacles
are presented to the successful application of force at this point. The
axillary space is narrow and deep, so that even with the ingenious
contrivance of placing first a ball of yarn in the axilla, and upon this
the heel of the operator, it will be found exceedingly difficult to enter
the axilla without at the same time pressing with considerable force
against its muscular margins ; but to press upon the pectoralis major
and latissimus dorsi is to neutralize our own efforts. If, however.
DISLOCATION OF THE HUMERUS DOWNWARDS. 553
the heel or the ball does press fairly into the axilla, it will not find
the scapula readily, but it must impinge first upon the head of the
humerus, which is always a little to the inner side of the scapula. If
it ever is made to reach actually the inferior border of the scapula,
and I do not think it is, the efiect must be still only to tilt the scapula
upon itself by throwing back its lower angle, and not to separate the
glenoid cavity or its upper and anterior margin from the head of the
Whatever success, therefore, may have attended this mode of prac-
tice, either in my own hands or in the hands of other surgeons, must
be ascribed not to the counter-extension thus effected, but simply to
the operation of the heel as a wedge, which, by insinuating itself be-
tween the body and the head of the bone, has thrust it outwards and
upwards into its socket; or to its having acted as a fulcrum upon
which the humerus has operated as a lever.
It is to the extremity of the acromion process, then, that we must
apply our counter-extension when we are employing this mode of ex-
tension. The fingers or hands of a faithful assistant may answer the
purpose, or having removed his boot, the operator may often press
successfully with the ball of his foot, and the more he carries the arm
outwards the more secure will be his seat upon the process; or we
may adopt some of the contrivances for securing the process which
have been suggested by other surgeons ; such as a band crossing the
shoulder, and made fast to a counter-band, which passes through the
armpit and against the side of the body. Dr. Physick, of Philadelphia,
reduced a dislocation in this way as early as the year 1790, in the
case of a patient admitted to St. George's Hospital, in London, while
he was a student of medicine, and he subsequently taught the sanie
in his lectures. Physick directed that an assistant should press firmly
against the process with the palm of his hand. Dorsey and Hays ap-
prove of the same method,^ and perhaps a majority of American sur-
geons regarded it favorably.
If we pull directly outwards, at a right angle with the body, we
may still continue to press upon the acromion process with the foot;
or we may perhaps trust to the method of making counter-extension
first suggested by Nathan Smith, of New Haven, and subsequently
recommended by his son, Prof. Nathan E. Smith, of Baltimore. Says
Prof. N. R. Smith :^ " What surgeon of experience has not encountered
the difl&culty which almost always occurs in fixing the scapula ?" and
he then proceeds to give what seems to him the most efiectual mode
of rendering the scapula immovable, namely, to make the counter-
extension from the opposite wrist. By this method the trapezii are
provoked to contraction, and the scapula of the injured side is drawn
firmly toward the spine and the opposite scapula. In illustration of
the value of this procedure he relates the case of a gentleman who
Â» Physick, Amer. Joum. Med. Sci., vol. xix. p. 386, Feb. 1837. Doreey's Ele-
ments of Surgery, vol. i. p. 214. PhUadelphia, 1818.
* Smith's Med. and Surg. Memoirs, Baltimore, 1831, p. 387; also, Amer. Joum.
Med. Sci., July, 1861 ; also, American Med. Times, Nov. 9, 1861 ; paper by Stephen
554 DISLOCATIONS OP THE SHOULDER.
had suffered a dislocation of his left shoulder, and upon whom an
unsuccessful attempt at reduction had already been made by a re-
spectable surgeon. Dr. Smith being called, proceeded as follows:
Two gentlemen made counter-extension from the opposite wrist, while
N. R. Smith's method.
Dr. Smith and Dr. Knapp made extension from the wrist of the injured
side, at first pulling it downwards, but gradually raising it to the
horizontal direction, and then gently depressing the wrist. On the
efibrt being steadily continued for two or three minutes^ the bone
was observed to slip easily into its place.
But no position places the scapula so completely under our control
as that in which the arm is carried almost directly upwards and the
foot is placed upon the top of the scapula. By this method we may
succeed generally when every other expedient has failed, yet it is
painful, and I cannot but think that it increases the laceration of the
capsule, and does sometimes serious injury to the muscles about the
joint. La Mothe was the first to recommend this method,^ but a.s
early as the year 1764, Charles White, of Manchester, made fast a set
of pulleys in the ceiling, and, placing a band around the wrist of the
dislocated arm, he drew the patient up until the whole body was sus-
> La Mothe, Amer. Joum. Med. Sci., vol. xix. p. 387, Nov. 1836, from Melanges
de M6d. et Chir., Paris, 1812.
DISLOCATION OP THE HUMERUS DOWNWARDS. 555
â€¢pended. No pressure, however, was made upon the scapula from
above, which is no doubt the most essential part of the process.^ By
Xa Mothe's plan, Jobert succeeded after twenty-three days when all
the usual methods had failed.^ Sometimes this procedure is modified
"by placing the hand of the operator against the top of the scapula, as
is shown in the accompanying drawing (Fig. 240); and I have several
times succeeded in this way after other measures have failed.
La Motbe's mtthod, modified.
A gentle movement backwards or forwards, a slight rotation of the
limb, or suddenly dropping the arm toward the body, diverting the
attention of the patient, are little tricks of the operator, which now
and then prove successful.
Sir Astley Cooper thus describes his method of applying the heel
to the axilla (Fig. 241):â€”
Sir Attley Cooper*! method of applying extension with the heel in the AXllln.
* C. White, Amer. Joum. Med. Sci., Nov. 1886, from Med. Oba. and Inquiries,
vol. ii. p. 278, London, 1764.
Â« Ibid., vol. xxiii. p. 287, Nov. 1888.
556 DISLOCATIONS OF THE SHOULDER.
"The patient should be placed in the recumbent posture upon a
table or sofa, near to the edge of which he is to be brought; the sur-
geon then binds a wetted roller around the arm immediately above
the elbow, upon which he ties a handkerchief; then he separates the
patient's elbow from his side, and, with one foot resting upon the
floor, he places the heel of his other foot in the axilla, receiving the
head of the os humeri upon it, whilst he is himself in the sitting pos-
ture by the patient's side. He then draws the arm by means of the
handkerchief, steadily, for three or four minutes, when, under common
circumstances, the head of the bone is easily replaced; but if more
force be required, the handkerchief may be changed for a long towel,
by which several persons may pull, the surgeon's heel still remaining
in the axilla. I generally bend the
Fig. 242. forearm nearly at right angles with
the OS humeri, because it relaxes the
biceps, and consequently dimioisbes
He was also accustomed in some
cases to reduce the dislocation by
substituting the knee for the heel.
Placing the patient upon a low chair,
the axilla is laid over the knee of the
operator, and while one hand steadi^
the acromion process and scapula, the
other presses downwards upon the
lower end of the humerus (Fig. 242).
If some hours or days have elapsed
since the occurrence of the dislocation,
it will be necessary to resort to
chloroform or ether for the purpose
of paralyzing the muscles, as well as
with the view of preventing pain, and
sir A.tiey Cooper', method of operating it may bc ucccssary, in addition, to
with the knee in the axilla. rcsort to pulIcys, or to somc similar
permanent mode of extension. The
same measures also sometimes become necessary in very recent cases,
especially in muscular subjects.
In employing the pulleys we generally operate not exactly in a
line with the axis of the body, nor at more than a right angle, but
between an angle of 45^ and a right angle.
Mr. Skey has suggested a plan by which we may combine the -
principle of the heel in the axilla with the pulleys, but which pltfn
would, in my judgment, be very much improved by a counter-
extending force applied to the acromion process. I ought to say,
however, that Mr. Skey prefers that the scapula should not be fixed,
believing that the reduction is much more easily effected when the
glenoid cavity is drawn downwards in the act of making the exten-
"With all respect for the opinion of this distinguished surgeon, we
cannot precisely agree with him, and while we would be disposed to
I>ISLOCATION OF THE HUMERUS DOWNWARDS. 557
recommend in some cases a trial of his method of applying the pul-
leys, we would at the same time, or certainly in the event of its failure,
add the acromial support, and especially would we advise that the
arm should be more abducted. The following is Mr. Skey's method,
as described by himself: â€”
"There is no reason why, in very muscular subjects, or in old
dislocations, the same principle may not be applied conjointly with
Iron knob employed by Skey, instead of the heeL
the use of pulleys. For the purpose of retaining this admirable,
because most efficient principle, I employ a well-padded iron knob,
which may represent the heel, from which there extend laterally two
strong straight branches of the same metal, each ending in a bulb
or ring of about four inches in length, the o^ce of which is designed
to keep the margins of the axilla as free from pressure as possible."
The iron knob is to be pressed well up into the axilla and attached to
cords fa3tened to a staple; the patient lying upon his back or inclined
a little to the opposite side. The arm is then to be drawn downwards
by the pulleys, "as nearly as possible parallel to, and in contact with,
In this way Mr. Skey says that he has succeeded in reducing a
great many dislocations, whether occurring in very muscular men, or
after some days', or weeks', or even months' duration ; and he thinks
the plan especially applicable to cases which require long and per-
Fig. 244. '
Skey'a method of making extension and connter-extenslon with pnlleys.
Mr. Skey and many other surgeons prefer to make the extension
from the hand. I have succeeded as well, and it has seemed to be
Â» Skey, Operative Surgery, Amer. ed., p. 93.
558 DISLOCATIONS OF THE SHOULDER.
less painful to my patients, when I have followed the practice of Sir
Astley, and made the extension from the arm. Sir Astley always
made the extension more or less out from the line of the body, and