generally almost at a right angle when using the pulleys, the scapula
being made fast by " a girt buckled on the top of the acromion," or by
a split cloth (Fig. 245).
Sir Astlej Coop«r> mode of making exUnsion with pallojs.
The instrument invented by Dr. Jarvis, of Portland, Conn., called the
adjuster, useless and even mischievous as we have found it in its appli-
cation to the treatment of fractures, possesses considerable merit as an
apparatus for reducing old dislocations, especially of the shoulder. The
principal advantage which may be claimed for it is, that while the forces
are being applied the limb may be moved pretty freely in all direc-
tions; thus enabling us to employ rotation at the same time that the
extension is made. We may also lift or depress, adduct or abduct
the limb without relaxing the extension. In the hands of American
surgeons it has occasionally been successful when other means have
failed. Dr. Jarvis has related a case presented at the Marine Hos-
pital, at Mobile, Tenn., of forty -two days' standing, which he reduced
on the second attempt, after other means had failed ;^ and Dr. May, of
Washington, reduced a similar dislocation at the end of six weeks,
by the same apparatus, without, however, having previously resorted
to any other means.'
I have myself used the apparatus occasionally, both in my hospital
and private practice, and can speak favorably of its operation.
I must not omit to mention the practice adopted by Prof. H. H.
Smith, of Philadelphia, accokrding to whom nearly all dislocations of
the shoulder, of a recent date, may be promptly and easily reduced
' Boston Med. and Surg. Joum., vol. xxxix. p. 215.
' Boston Med. and Surg. Joum., vol. xxxv. p. 454.
DISLOCATION OF THE HUMERUS DOWNWARDS. 559
\>j manipulation alone. His method consists, first, in flexing the fore-
SLvm upon the arm, while, at the same moment, the elbow is lifted from
the body; second, in rotating the humerus upwards and outwards,
employing the forearm as a lever ; and third, in reversing this last
movement, that is, rotating the humerus downwards and inwards while
at the same moment the elbow is carried again to the side.*
When the dislocation is into the axilla, this manoeuvre will generally
succeed; but if the head of the humerus has slipped forwards, even
only sufficient to engage itself slightly under the tendons of the
coraco-brachialis and biceps, the outward rotation of the humerus
will inevitably thrust the head further forward, and fasten it more
certainly underneath these tendons ; while the rotation of the humerus
in the opposite direction will alone often be sufficient to carry the
liead directly into the socket.
Ancient Luxations, — Finally, I ought to speak somewhat more in
detail of the manner of procedure and of the principles involved in
the reduction of old dislocations, or of dislocations requiring the inter-
position of mechanical appliances ; especially with a view to the more
complete exposition of my own practice in these cases.
If the dislocation is recent, but reduction is found impossible with-
out the aid of mechanical apparatus, the difficulty will be understood
to consist mainly, if not altogether, in the resistance offered by the
muscles. If, in a few exceptional cases, the capsule, or an untorn
tendon, or the margin of the glenoid fossa, present themselves as
obstacles, they must still be considered as unusual and extraordinary
impediments, the existence of which may be regarded rather as pos-
sible than probable.
Almost our sole purpose, then, it will .be understood, in all recent
cases requiring mechanical appliances, and in some ancient cases, is to
overcome the contraction of the muscles.
We prefer always to place the patient upon a mattress laid upon
the floor; two silk handkerchiefs, or two pieces of a cotton roller, are
then laid along the radial and ulnar sides of the humerus, and over
the middle of these, immediately above the condyles, a wetted roller
is applied, its end being made fast with a needle and thread rather
than with a pin. The upper ends of the longitudinal strips, or of the
handkerchiefs, are now turned down and tied to the opposite ends,
thus converting them both into lateral loops. For the purpose of
making counter-extension, a sheet is passed around the body under
the axilla, and made fast to a staple ; while an intelligent assistant is
to manage the scapula with his naked hands, either by pulling with
his fingers placed under the process, or by pushing with the palm of
his hand and ball of his thumb. The pulleys, secured to a staple
exactly opposite to that which holds the counter-extending band, are
made ready, but not for the present attached to the arm.
As soon as the patient is placed completely under the influence of
an anassthetic, the operator is ready to proceed with the reduction.
It is my maxim never to attempt to accomplish by complicated and
> H. H. Smith, Gross's Sarg., ed. of 1S63, p. 152.
560 DISLOCATIONS OF THE SHOULDER.
violent measures what may be done as well by more simple and
gentle means. I think it proper, therefore, to make several attempts
at reduction by manipulation alone, aided now by the ans^thetic, the
extending and counter-extending bands, &c., before resorting to the
pulleys. Seating himself upon the mattress, with his boots drawn, the
surgeon should bend the forearm to a right angle with the arm, and
planting one heel in the axilla, with one hand he should seize upon
the loops at the elbow, and with the other steady the hand and fore-
arm of the patient, while he proceeds to make firm traction for a few
seconds in the line of the body, or only a little out from this line.
Failing in this, he may direct the assistant to seize upon the scapula,
and make counter-extension ; still not succeeding, he may change his
foot from the axilla to the acromion process and pull directly outwards
at a right angle with the body, or he may swing himself gradually
around until he comes to be above the head of the patient, and the
foot presses firmly upon the top of the scapula ; now descending again
in the same direction, he will very probably find the limb reduced, or
capable of being reduced easily, by operating upon it as a lever by
laying it across the body while at the same moment it is rotated
If still the reduction is not accomplished, the pulleys must at once
be put in requisition. The sheet passed around the chest and fastened
to a staple, is only a means of supporting the body and rendering it
more steady ; as a means of counter-extension its value is inconsider-
able. To make fast the scapula, we must still rely mainly upon the
naked hands of strong men, or upon a strap drawn firmly across the
process and held in place by an assistant.
Whenever we employ extension without the aid of anadsthetics, as
sometimes we are compelled to do, it must be constantly borne in
mind that it is proposed to conquer the muscles by fatiguing them,
and that this cannot be done by a force suddenly applied, however
great it may be, but only by gentle, steady, and long-continued exten-
sion. The muscles, when attacked openly and vigorously, resist, and
will suffer laceration rather than yield, while, on the other hand, an
insidious but persevering approach seldom fails to end in their defeat
The same is true, but in a much less degree, when the patient is in-
sensible from ansBsthesia.
The forearm is again flexed, and the arm carried out to a right
angle with the body, the pulleys secured to the loops, and the assistant
takes hold upon the process, while the surgeon draws gently upon the
rope attached to the pulleys ; as soon as everything is moderately
tense, he is to desist for a few moments. Again the rope is drawn
upon gently, and again the progress of the extension is suspended.
In this way the operator is to proceed during half an hour, or two
hours, as the nature of the case may demand ; occasionally rotating
I the humerus, and occasionally lifting its head toward the socket.
I Meanwhile, it is understood that the principal counter-extension is
I made by the assistants, who must relieve each other, at the acromion
process. The sheet in the axilla, or rather against the side of the
chest) has some value in this respect when the arm is at a right angle
DISLOCATION. OF THE HUMEKUS DOWNWARDS. 561
ith the body, bat in itself it cannot control the scapula, only as it
Isolds the body to which the scapula is attached. Much, therefore, as
"N^'e may regret the inconvenience of making counter-extension by
Inlands alone, experience and anatomy alike must teach that here it is
tte only mode. If these dislocations are reduced often by other
methods, as no doubt they are, then it is only an evidence that in
t^faesd examples little or no counter-ex tension was necessary.
Sometimes the dislocation is not reduced when the extension is
^iven up, but if then a resort is promptly made to some one of the
simple methods already described, while the muscles are still ex-
hausted, it very often happens that the reduction is easily accom-
It will be prudent in all cases, in order to prevent a reluxation,
whether the dislocation is recent or ancient, as soon as its reduction
is effected, to place the arm in a sling and secure the elbow to the side
by a few turns of a roller. I do not think the axillary pad necessary,
and I am afraid it has sometimes done as much mischief as the dislo-
The following example will illustrate the variety of expedients to
which we are obliged sometimes to resort before our efforts prove
successful : —
Thomas Leeding, of Niagara* Co., N. Y., ast. 52. a laborer, and a
muscular man, dislocated his right arm into the axilla, by jumping
from the cars when they were in full motion. The blow was received
upon the shoulder. An intelligent country surgeon, assisted by
several other persons, attempted reduction within an hour after the
accident, but failed, and as the patient had some distance to travel, he
was not brought under my notice until eighteen hours had elapsed.
We first administered chloroform, and then, while an assistant held
firmly upon the acromion process, I pulled in the line of the body,
then outwards, and finally upwards, but to no purpose. Having then
applied Jarvis's "adjuster," and after the arm had been kept extended
at a right angle with the body fifteen minutes, we removed the appa-
ratus, and found the bone in its place.
John Harrington, 8Bt. 50, a very large and powerful man, fell while
intoxicated, and dislocated his left humerus into the axilla. No sur-
geon was called until the tenth day, when he first consulted Dr. Dud-
ley, who at once brought him to me. Without delay we applied the
pulleys, and placing the arm at a right angle with the body, we made
extension fifteen minutes; occasionally also rotating the arm. We
then removed the pulleys, and while an assistant held upon the acro-
mion process, with my heel in the axilla, I made extension in the line
of the axis of the body, then outwards, and finally upwards with my
foot upon the top of the scapula. I next seated my patient in a chair,
and drew his arm and axilla forcibly over my knee. The bone was
not yet reduced ; I therefore bled him twenty-four ounces, or until
partial syncope was induced, and proceeded to repeat most of these
processes, but with no better result. At this moment I determined
to use sulphuric ether, which had just been introduced as an ansdsthetic,
and while he was completely under its influence the pulleys were again
562 DISLOCATIONS OP THE SHOULDER.
applied, and the extension continued for some time, and until the rope
broke. He was then again placed in a chair, and the axilla brongbt
over my knee, when in a moment the reduction was accomplished.
John Bowles, of Buffalo, aged 45 years, an Irish laborer, tolerably
muscular, but spare. Bowles fell down a flight of stairs, and dislo-
cated his left humerus into the axilla. The shoulder became much
swollen, and was very painful, but he did not suspect a disloeation
and did not consult a surgeon. Eight weeks after the accident be
applied to me. There were present the usual signs of this dislocation,
but the arm was by careful measurement one inch and a half longer
than the other.
The reduction was accomplished on the same day, in presence of
Drs. Lee, Webster, Coventry, Ford, and Jewett. The time occupied
in the reduction was about two hours. An attempt was first made
with the heel in the axilla and with violent rotation and extension.
The same plan was repeated with the aid of ether, which was adminis-
tered freely. Jarvis's adjuster was now applied, with no result^ except
that, either in consequence of the force employed by the adjuster, or in
consequence of the free use of ether, or of both, he became convulsed
violently, which was accompanied by frothing at the mouth and other
grave symptoms. The adjuster was removed, and the exhibition of
ether discontinued. As soon as the convulsions ceased, and before
consciousness had returned, extension, rotation, &c., were again made
by hands. Finally, after all extension was relinquished, placing my
knee in the axilla, I reduced the bone by a very slight rotary action
upon the arm ; the bone was at once plainly in its socket^ but the
unusual length of the limb continued, being one inch and a half
longer, though it could be shortened to the same length as the other
by lifting the elbow. A pad was placed in the axilla, and the arm
secured with a sling and roller. The next day the arm remained in
place, but it was now only one inch longer than the other. At the
end of a fortnight it was only three-quarters of an inch longer, and
could be reduced to the same length by lifting ; the pain and swelling
about the shoulder, which never were great, were subsiding, and the
patient was dismissed.
However skilfully our efforts may be directed, they will be found
occasionally to fail ; either owing to adhesions which have taken place
between the head of the bone, or rather its capsule, and the adjacent
tendons, muscles, etc., to some extraordinary position of the head and
neck of the bone in its relation to ligamentous or tendinous structures,
to a filling up of the glenoid fossa, or to some other cause not fully
explained. Such failures have happened not only in the hands of
ignorant and unskilful surgeons, destitute of appliances, but also in the
hands of those who are the most expert, and who are the most com-
pletely provided with all the necessary apparatus. Indeed, if the truth
wert known, it would probably be found that the number of failures
has been greater than the successes. The records of surgery, however,
furnish a great many examples of ancient dislocations of the humerus
reduced after periods ranging from one month to six, or even longer.
Dieffenbach has been able to accomplish the reduction of a forward
DISLOCATION OP THE HUMERUS DOWNWARDS. 563
<5lislocation after two years, but not until he had out the tendons of
tlie pectoralis major, latissimus dorsi, teres major, and teres minor, and
In ad divided the ligaments surrounding the new joint.^
It would be unjust to the young surgeon not to call especial atten-
tion to the numerous examples of serious and even fatal accidents
^^hich have followed upon the attempts to reduce ancient luxations at
ttis joint. The late George 0. Blackman, of Cincinnati, a distin-
guished surgeon, having met with one of these unfortunate accidents
in bis own practice, has had the candor to make a public statement of
-the case and of the circumstances which attended it. In a letter to
the editor of theWesiem Lancet, published in the November number
Tor 1856, he writes as follows : —
"About the 10th ult, aided by yourself, I succeeded in reducing by
manipulation, without the pulleys, a dislocation into the axilla, of
eighty days' standing. The reduction was accomplished in a very few
minutes, under the influence of chloroform and ether, and the next
morning the patient left for the country, in a comfortable condition.
Since that I have received no tidings from him. Encouraged by the
result in this case, another patient, himself a physician, a tall, athletic
man, and about fifty years of age, decided to submit to the same mani-
pulation, although his arm had been dislocated for about sixteen weeks.
The dislocation was downwards and inwards, and about the tenth week
an unsuccessful attempt, by another surgeon, had been made with the
pulleys, to which the force of six men was applied for two and a half
hours. The patient being under the influence of chloroform and ether,
aided by yourself, Drs. Fries, Gary, Graham, and KauflFman, I com-
menced my manipulations, adducting, rotating, abducting, and elevat-
ing the arm. These efforts had been made for about ten minutes, and
the least possible violence employed, when a tumefaction appeared in
the pectoral region, which in a few minutes attained a considerable
size. Supposing that the axillary artery was ruptured, as no pulse
could be felt at the wrist, a ligature was immediately applied to the
vessel at the upper part of its course. The operation was performed
about 10 o'clock A.M., and compression of the pectoral region made
by means of a sponge and broad roller. On removing this the next
morning, the tumefaction had nearly disappeared. The patient con-
tinued comfortable, and about nine days after the application of the
ligature I was compelled to leave the city on a professional visit to
Indiana. I left on Friday afternoon and returned on Monday morning,
at which time I learned that my patient had died on Sunday morning,
from hemorrhage at the seat of ligature."
The following is a resume of similar accidents which have from
time to time occurred in the practice of other surgeons.
Desault twice observed, after attempts to reduce old luxations of the
shoulder, 'Uumeurs aeriennesy It is quite probable, however, that in
each case the tumor was caused by the rupture of a bloodvessel.'
Pelletan, also, attempting to reduce a luxation of four months' stand-
' Dieffenbach, Boat. Med. and Surg. Joum., vol. xxli. p. 883, from. Medicin.
« Desault, Joum. de Cliir., t. iv. p.. 801.
564 DISLOCATIONS OP THE SHOULDER.
ing. thought he produced a tumeur aerienne, but it being opened the
patient bled to death.* *
Malgaigne, attempting to reduce a dislocation of sixty-eight days'
Standing, was surprised by a sudden tumefaction in the axilla, and on
the shoulder, which caused so much alarm as to induce him to discon-
tinue his eflTorts. Ice was applied, and the hemorrhage, which he
thought came from muscular branches, was arrested' Verduc saw
the axillary artery ruptured in the same manner, in consequence of
which the pafient died.' J. L. Petit met with a similar case. Platner
mentions a case of rupture of both axillary artery and vein. C. Bell
reports an example of rupture of the artery with extensive laceration
of the muscles, and which demanded immediate amputation. Delpecb
ruptured the artery, and his patient died immediately.* Flaubert was
more fortunate, the effused blood being absorbed after a few days.
Froriep saw his patient die within one hour and a half after a rupture
of the axillary vein. John C. Warren, of Boston, tied the subclavian
artery to arrest the progress of an enormous aneurismal tumor in the
axilla, caused by the reduction of a recent dislocation.' Gibson, of
Philadelphia, lost two patients in attempting to reduce old luxations
of the humerus,* and he relates another fatal case occurring in the
practice of David, of Rouen. Leudet,'of Bouen, lost a patient in this
. way in 1824. In this latter case, and in both the cases occurring in
the practice of Gibson, there was a fracture, also, of the lower margin
of the glenoid cavity.
In addition to these lesions of arteries and veins caused by attempts
at reduction of dislocated shoulders, in both recent and ancient cases,
there are several examples recorded of sudden death when no such
lesions were disclosed in the autopsy. In the case reported by Lis-
franc death was ascribed to cerebral congestion. MM. Lenoir and
Larrey refer to cases, also, of lesions of the brachial plexus, causing
paralysis, yet these were recent cases, and the reduction was easily
Mr. Hutchinson, of London, reported in 1866 that inflammation, sup-
puration, and death had resulted from an attempt made to reduce an
old dislocation of the humerus, under his own observation.®
In the following case an attempt to reduce an ancient dislocation
of the humerus occasioned a fracture of the surgical neck.
Martha Hogan, aet. 70, of Brooklyn, N. Y., was admitted into the
Long Island College Hospital during the spring of 1860. The dislo-
cation had existed six weeks, and was subcoracoid. On the day of
admission an attempt was made to reduce it, both by Dr. Johnson and
myself, without an ansesthetic, in which we both failed. I then gave
her ether, and now discovered that she had a fracture of the second
> Pelletan, Chir. Clin., t. ii. p. 951. « Malgaigne, op. dt., p. 150.
3 Verduc, Operat. de la Chir., 1693, t. i. p. 559.
* Malgaigne, op. cit., p. 152.
» Warren, Amer. Joum. Med. 8ci., vol. xi. N. S. 1846.
« Gibson, Elements of Surg., vol. i. p. 824, 4th ed.
f Lisrranc, Lenoir, Larrey, Bui. de la Soc. Chir., i. i.
> Lond. Hosp. Reports, vol. ii. (See Cincinnati Joum. Med., Aug. 1866, p. 361.)
DISLOCATION WITH FRACTURE. 565
a.nd third ribs on the same side. The fractures were ununited. W^iile
msiTiipulating, pulling the arm gently and rotating, the surgical tt^h.
of the humerus gave way. She did not survive the iujury maliy
days, and the autopsy confirmed this diagnosis. I have seen the same
fracture caused by an attempt at reduction at Bellevue.
Norris has reported three cases of ancient dislocation into the
axilla, treated at the Pennsylvania Hospital; one, of four weeks'
standing, was reduced in thirty seconds by the aid of the pulleys ;
the second, which had existed seven weeks, was reduced by the same
means in about one hour; and the third, dislocated ten weeks, was
left unreduced after extension and counter-extension had been made
for an hour. In the second case, however, suppuration occurred in
or about the joint, and, on the tenth day, the abscess was opened,
giving exit to a large amount of pus. He left the hospital with the
parts about the shoulder still much hardened and stiff.^
Dislocation, witk Fracture of the Humerus near its Upper End.
We*have thus far omitted to speak of the treatment of dislocations
of the humerus accompanied with fracture near its upper end. The
older writers, almost without an exception, agree in declaring the re-
duction of these dislocations impossible, until the fracture had united.
And, so late as the year 1828, we have the report of a case treated in
this manner by a surgeon in Massachusetts. Dr. Warren, of Boston,
himself reduced the dislocation at the end of four weeks, when the
fracture was found to have united.*
But since the introduction of ansBsthetics immediate attempts at
reduction have more oflen proved successful ; and in no case can the
surgeon excuse himself for having omitted to make the eflfort.
Richet reports an example of this kind in a man sixty-eight years
of age, in whom the dislocation was complicated with a fracture of
the neck of the humerus. The attempt was not made until the fourth
day. when it proved successful without extension. The fracture was
afterwards adjusted and consolidated so that he recovered the com-
plete use of his arm.'
At a meeting of the New York Academy of Medicine, in May,
1856, Dr. Watson reported a case of fracture of the humerus near its
head, complicated with a dislocation into the axilla. The patient was
a robust man, past the middle age, and had received the injury by a
blow on the shoulder from a steam-engine. He was very much pros-
trated at the time of being admitted into the hospital, and the exami-
nation was not made until the following morning. The arm was then
found lying close to the side, but in other respects it presented the
usual signs of a dislocation. Ether was immediately administered ;
and while extension and counter-extension were applied, and a sweep-
ing motion given to the arm, drawing it from the body, firm pressure