AN 
INAUGURAL ESSAY 
ON THE SURGERY OF THE 
DISLOCATED SHOULDER JOINT; 
Submitted to the consideration 
OF 
THE HON. ROBERT SMITH, PROVOST, 
And of the Regents and Medical Professors 
ffif tfje of fgarglanti, 
FOR THE DEGREE OF DOCTOR OF MEDICINE. 
BY ALEXANDER CLENDINEN, L. M. & C. E. M. 
OF YORK DISTRICT, SOUTH CAROLINA. 
Military Surgeon late in service of the United States: Vice President 
and Honorary Member of the Baltimore Medical Society. 
Omnes, eodem, cogimur....Horace, 
“De hoc multi multa,onmis aliquid, nemo satis.” 
Non enim tam Auctoritatis in disputando, quam rationis momenta quxrenda sunt. 
Cicero, 
BALTIMORE: 
PRINTED BY RALPH W. POMEROY, & CO 
NO. 12, LIGHT STREET. 
1815. TO DOCTOR WILLIAM H. CLENDINEN, 
OF BALTIMORE: 
Under whose direction I have pursued and closed ?ny 
Medical Studies; 
To the kind acts of whom, I owe my very 
existence as a professional character. 
To you, sir, I should be unjust, were I not 
thus publickly to acknowledge my gratitude 
for the numerous favours which have been 
bestowed upon me, while resident with you, 
by yourself and amiable companion: as well 
as the unremitting care and pains you have 
taken to facilitate my search, and enlarge my 
capacities. 
Allow me, then, to dedicate to you the first 
fruits of my youthful pen, as a trifling tribute 
of respect and esteem for your liberality. Not 
that in having done so, the obligations I am 
under shall be obliterated; but that I gladly 
seize the favourable oportunity of making 
known to you how sensibly I feel them, and 
the sincere wishes for your future health and 
happiness of 
Your affectionate brother and pupil, 
THE AUTHOR. TO 
THE MEDICAL PROFESSORS 
IN THE 
THIS DISSERTATION IS INSCRIBED, 
As a trifling memento of respect and esteem, for the po- 
liteness with which they have always honoured 
their friend and pupil, 
THE AUTHOR. TO THE 
BALTIMORE MEDICAL SOCIETY, 
This essay 
IS INSCRIBED, 
AS A FEEBLE TRIBUTE OF ESTEEM 
For the improvement I have derived from their discussions; 
and the honours which they have been pleased 
To confer on 
THE AUTHOR. “Where calm retirement’s sacred pleasures move, 
The hour contemplative, or friend they love; 
Tho’ noisy pride may scorn her silent toil. 
Fair are the fruits which bless her happy soil; 
There every plant of useful produce grows. 
There science springs, and there instruction flows; 
There true phylosophy erects her school, 
There plans her problems, and there forms herif 
There every seed of every heart began. 
And all that eases life and brightens man.” 
rule; 
Zimmerman. 
“In every human heart there lies reclin’d 
Some atom pregnant with ethereal mind; 
Some piastick power, some intellectual ray. 
Some genial sun beams from the source of day; 
Something that warms, and, restless to aspire. 
Wakes the young heart, and sets the soul on fire.” PRELIMINARY OBSERVATIONS. 
NATURE, who is provident in all her works, has 
conferred a portion of her riches and wisdom, on the ar- 
ticulation of the os brachii with the scapula. 
As man stands preeminent in the scale of animated 
creation, we see him possessing appropriate organs to en- 
able him to move in the sphere in which he is placed: 
we see him possessed of a figure that stands erect; a 
countenance that looks to the heavens; a voice to utter 
what the mind contemplates, &c. &c. 
To search into the economy of nature, is a pursuit 
which will richly reward even the naturalist, for we 
every where see traces of her wisdom and handy work. 
But it seems that there is no occasion on which a desire 
of knowledge, a willing admiration of the beauties of na- 
ture, is so strong as on first becoming acquainted with 
the structure and functions of the heart and lungs; upon 
the conjoined offices of which, all perfect life seems to 
depend. 
Sceptick! amid those wonders, can you find 
No art exhibited? no wise end design’d? 
What must have been the transports of the illustrious 
doctor Harvey, when his industry and perseverance 
brought him to a knowledge of the ebb and flow of the 
crimson ocean; upon which every thing that is correct 
or rational In medicine, has been founded. 10 
In this articulation we see beauty, harmony, and de- 
sign: we see a hone bedded in organized matter, which 
at once serves as a seat for it to rest upon, a covering 
to shield it against external injuries, and instruments to 
move it in every possible direction in subservience to the 
will; and when she commands the whole to be quiescent, 
it is fixed or balanced upon its axis. 
This bone serves as a point of articulation for the hu- 
merus, and as a very superficial cavity receives the large 
Hemispherical head of the humerus, or rather as the head 
is laid on the acetabulum scapula, it is calculated to ad- 
mit of great freedom of motion; but to this is added the 
mobility of the scapula, which gives the arm as great a 
superiority over the inferiour extremities, as its offices 
and situation demand in regard to motion, but not as to 
strength; for it is weak and liable to luxation, in propor- 
tion to its beauty and freedom of motion. But notwith- 
standing the immediate articulation is weak, there are 
certain concomitant circumstances, which render it im- 
possible for luxation to take place in several directions; 
and the scapula being moveable must serve to prevent 
luxation frequently; indeed, if it were suffered to move 
loose always, v hen the humerus is driven by any force 
contrary to the v, ’ll it could not take place at all; but 
the muscles around u acting on it, fix it, and preserve the 
natural relations; yet while they thus fix it, the power 
acting on the arm, drives the head off the glenoid 
cavity, thus bringing about the disarray in question. 
When we take a review of our science, we unavoidably 
observe the intimate connexion succeeding ages have 
preserved with the circumstances which were charactc- 
ristick of their predecessors; yet it does not present to us 
that regularly connected chain, which we see becoming 
more and more polished in other branches of literature. 11 
It is true the science of surgery generally, has made rapid 
strides towards a more perfect system; but it is equally 
true, that in certain points it has remained stationary for 
half centuries, nay, even whole ones; and has then gone 
back upon the old ground; which retrograde movement 
we have been under the necessity of calling an advance- 
ment in the science. 
In the subject of this essay, we have very little which 
can be termed a real improvement, since the invention of 
the Arnhe, by the father of the science, until very lately; 
for there is scarcely a method proposed for reduction, 
that is not a reliek of that pernicious machine. We have, 
it is true, to boast of reducing it when out longer than 
he did, and lately, that we can overcome the muscular re- 
sistance by venesection ad deliquium animi; but when we 
come to inquire how long the cases which we had boasted 
of had existed, and find that it docs not exceed a few 
weeks; that numbers have been sent away that had not 
suffered it *o remain more than a few days before they 
applied, without having it adjusted; we should at least 
have modesty enough to say we have not yet arrived at 
perfection. 
It appears that this joint has at all periods suffered 
injury more frequently, than any other; and from modern 
journals kept at publick institutions, it seems it has been 
dislocated oftener than all the other joints in the human 
machine. More attention has at all times been paid to 
the adjustment of it, than to acquire an accurate know- 
ledge of the anatomy of the parts concerned; but this is 
particularly applicable to (he ancients, who have indulged 
themselves in the vast field of invention, to make instru- 
ments to force the head into the socket; none of which were 
calculated to effect the object with any degree of cer- 
tainty; some of which were cruel in their application, 12 
others not founded upon the laws, either of mechanicks, 
science, or anatomy. 
A more matured knowledge of the parts interested, has 
brought us to the conclusion that it cannot be reduced 
without extension, and consequently, that there must be 
counter-extension. To effect these objects, we have a 
variety of methods: so that upon the whole, there is an 
exuberant detail of a confused nature, handed down to us 
upon it, which, although it were a laudable effort to bring 
order from chaos, it would be too tedious and uninter- 
esting, and would transcend the contracted limits of an 
inaugural essay, to carry the whole of it through the 
analytick process: but it becomes strictly necessary to 
endeavour to find out, and elucidate the cause of failure, 
amidst all that has been said upon it. 
The employment of the useful mariner, is of such a 
nature, that it subjects him to this accident perhaps more 
frequently, than any other class of men; and often pre- 
vents him from arriving at a port, where he can have it 
reduced, until (to use the common expression,) “it is too 
late.” Thus, although he prostrates himself at the altar 
of surgery, he is commanded to depart, and terminate his 
miserable days, perhaps in beggary! simply because his 
luxated shoulder cannot be reduced. Oh art! when you 
are disposed to boast, you “traverse the pathless ocean,” 
be humbled in the dust when you cast your eyes on this 
unfortunate object! But why is it “too late?” We can 
relax the muscles by phlebotomy: we can hold the body 
while a sufficient extension is made, even to pull the arm 
off the body, as has been unfortunately proven! What 
obstacle then presents itself? lias the glenoid cavity 
been filled up with synovia, bone, or any thing else? I 
apprehend not; nor does the head come up to it, with all 
the extension if it were; for the muscles have become 13 
shorter, and the head of the bone is tied to the scapula, 
by the capsular ligament, which has remained, and has 
become thickened; united to a part of the bone perhaps 
which it ought not; the head is attached to the contigu- 
ous parts; and the whole conjoined bring the scapula 
along when extension is made, so that it is not at all 
strange the articular surfaces cannot be placed in coap- 
tation, unless the scapula was held with the body, while 
the arm is extended. 
Although we have many methods proposed to support 
the scapula, none of them seem to have been planned to 
operate according to correct anatomical principles, with- 
out which, it is as impossible to make any advancement 
in surgery, as it is for a divine to preach without a 
knowledge of his bible; so that this deficiency in an ap- 
paratus is to be attributed entirely to a want of anato- 
mical investigation. Notwithstanding it requires a little 
mechanical invention, to apply an instrument according 
to the laws of anatomy, it is impossible to contemplate 
correctly the most trifling subject in surgery without 
calling them forth. Although this is an important truth, 
the pupil has rarely been quick in the apprehension of it, 
and when acquired, has fc<st frequently been inactive in the 
cultivation of the advantages attainable by it. But why 
is it neglected? Is it not one of the richest feasts, merely 
to trace the workmanship of his “first cause” in his own 
economy; yet how much more satisfaction is derivable 
from becoming acquainted with the laws by which that 
economy is regulated; the deviations from them which 
constitutes disease, and the remedy which will restore 
the healthy functions; thus guarding life as it were, from 
impending distractions; which it were impossible for him 
to do, if deficient in a knowledge of natural laws. 14 
Young men appear, not to be so highly impressed with 
the beauty, and imporlance of this study, as to make 
dissections pleasant, and when they come to practice, 
they are consoled daily by the mistakes of others equally 
ignorant. A slender and unwarrantable comfort! 
It is not from voluntary choice, I have engaged in this 
essay, but merely in conformity with the laws of the Uni- 
versity, whose honours I solicit. 
I shall first describe the bones and ligaments concerned 
in the humeral articulation; secondly, relate some expe- 
riments made upon that joint; and, thirdly, go on to 
speak of the dislocation, and the modes proposed for its 
relief. OSTEOLOGY. 
THE scapula is a thin bone of a triangular form; the 
fossa or side next the ribs is concave,* the dorsum or ex- 
teriour side is convex, is divided into two unequal parts 
by the spine, which is an acute ridge, crossing the dor- 
sum, leaving the lesser portion superiorly, and vice versa; 
the shorter side of the triangle is the superiour costa or 
border; the inferiour costa is seated anteriorly, is all that 
portion of the border from the neck down to the inferi- 
onr angle. The posteriour edge is the longest part of the 
triangle, and is called the basis of the scapula. The neck 
is that portion which narrows up and tends towards a point. 
On this is set the glenoid cavity, or articulating surface. 
When we look at the face of this surface, it has an oval 
or rather conical appearance, the base of which, is sea- 
ted inferiorly and the apex superiorly; the base is more 
than twice the width of the apex, is turned a little up 
like a cup as if nature were guarding against luxation 
where danger presents itself, whilst above, it is narrowed 
off almost to a point, to make room for the tendons of the 
muscles to play freely. The greatest diameter, or that 
from the base to the apex, is about an inch; the crucial 
diameter is not more than half that extent. 
When I lay a line from the apex to the base, and measure 
under it from the surface of the bone to the line, it is only 
five lines deep, and when I lay it across between the base 16 
ami apex, it does not measure more than two and a half 
lines, so that if it were not for a cartilage that ekes 
out the edges in the green subject, it would scarcely de- 
serve the name of a cavity. In laying these lines upon the 
surface, I have formed a cross or divided the glenoid cavity 
into four quarters which I shall have frequent occasion 
to mention in the subsequent part of this essay. 
The acromion is that high point which overhangs the 
head, forming indeed a part of the joint, for although the 
head docs not articulate immediately against it, the space 
between them is filled up by the more soft parts. This 
process goes off from the spine, turns round and lays its 
flat or somewhat concave surface next the head, over it, 
and defends it against luxation in an upward direction. 
The coracoid process is a thick crooked projection 
about an inch in length: it arises from a little behind the 
anteriour superiour edge of the glenoid cavity, but from its 
tortuous course it stands with its point rather anteriorly, 
and must be a great security against luxation. But John 
Bell says, “most probably when the arm is luxated in- 
wards, it is by starting over the point of this defending 
process.” Now, I cannot conceive, how so correct and 
so great an anatomist and surgeon could have sub- 
scribed to such a sentiment, particularly when he goes 
on in the next sentence to state that the coraco bra- 
chialis muscle arises from the point of this process, 
which must be broken up from its origin, if the head of 
the os humeri were to pass directly over the point, and 
he certainly cannot mean that it mounts over, above the 
point, breaks off the triangular ligament, and goes over 
on the lesser pectoral muscle. But when it starts over 
the point, it must be recollected that the coracoid muscle 
would not be all that would have to be lacerated for the 17 
second head of the flexor muscle* which arises with it, 
would also have to be broken up from its origin, which 
must be impossible, inasmuch as they are when conjoined, 
so exceedingly strong that no force can operate in the 
* This muscle has three heads very frequently: I have seen it 
in one or both arms of six subjects myself, with a third head ari- 
sing from the humerus just between the insertion of the coraco 
brachialis and the origin of the internal brachial muscle; it arises 
fleshy, bold, and strong, nearly the size of the little finger; it 
passes down under the interiour edge of the common belly of 
the biceps, over the brachialis interims, decussating its fibres and 
joins the other heads near the common tendon. 
The professor of anatomy did me the honour to demonstrate 
it to his class in the the first arm in which I saw it, and men- 
tioned that the late doctor Cocke had fallen in with it, but 
was confused by it, although an excellent anatomist; he suggested 
the ingenious opinion that some were ambidextra in consequence 
of this third head. I am induced to believe that it is a very free- 
qucnt occurrence, and has either been cut up from its origin and 
left adhering to the under part of the common belly or it has been 
let fall down upon the brachialis internus by anatomists in gene- 
ral. I have no doubt if doctor Cocke had lived, he would have 
been able to dissect it out distinctly and demonstrate it to his 
class. 
The following words of the minute anatomist Soemmering will 
serve to strengthen the opinion that it has often been cut up 
without being understood. He says, “nonnumquam os humeri 
fasciculum exilem ventri longiori addit, vel a musculo brachiali 
ininterno fasciculus carneusad musculumbicipitem propeeius ten- 
dinem inferiorem communem adcedit; nonnumquam ventris lon- 
gioris fasciculus ligamento capsulari tendineus inse ritur.” Now 
although it is evident he has seen, it is equally evident that he 
was undetermined about it, in short that he did not understand 
it. As it was found in the first instance in three subjects of five 
then in the room, and has been found in most muscular subjects 
when they were searched, and from these corroborations I cannot 
think it is a lusus naturae, but think it may be found in the gene- 
rality of muscular subjects in one or both arms. 18 
manner that would be necessary to break them up. Nei- 
ther has any surgeon whose writings I have examined, 
ever witnessed such an occurrence. 
The os humeri is cylindrical in the middle, but twists 
and becomes flat inferiorly; this flatness makes the elbow- 
joint and the outer parts of it form the condyles. It is 
somewhat rough superiorly, and becomes much larger to- 
wards the head, but the head itself, or the articulating 
surface forms but a small portion of this largeness, for it 
is a general swelling, and the two tuberosities form a con- 
siderable portion of it. 
The head is as it were the beginning of a sphere of 
which it is not quite half, but were it as complete as the 
head of the thigh bone, it would be much larger; it 
stands out not at right angles with the shaft, but ob- 
liquely. 
The neck is a rough, exceedingly small, depression im- 
mediately behind the head. 
The great trochanter or tuberosity is seated on the 
superiour and exteriour part of the bone, extending almost 
as high up as the super surface of the head. The exter- 
nal condyle, this tuberosity, and the apex of the glenoid 
cavity are in a range nearly when the arm hangs down 
by the side: but in luxation we find it different, as will 
be hereafter noticed. 
The lesser tuberosity is seated a little lower down, and 
more anteriorly. When I lay a line along the centre of 
the shaft, commencing between the two condyles on the 
anteriour side of the arm and ending at the super surface 
of the bone, which will be about three lines on the articu- 
lating surface, it passes directly over this tuberosity: but 
what 1 wish particularly noticed is, that it has left the 
greater portion of the head at one side of the line, which 19 
it is particularly necessary to notice in order to under- 
stand the luxation as well as reduction. 
The groove for the long head of the biceps is between 
these two tuberosities at first nearest the lesser, then going 
obliquely up to get round before the upper portion of the 
greater tuberosity. 
SYNDESMOLOGY. 
The head of the bone as well as the glenoid cavity is 
tipped with a diarthrodial cartilage, which is exceedingly 
smooth and lubricated with the synovia. They glide on 
each other with the greatest ease imaginable. The cap- 
sula is as smooth as they arc, which must make it im- 
possible that sub-luxation should exist a moment. 
The clavicle is bound to the scapula by three ligaments, 
i, e. the capsular, or that covering the end of the clavicle 
and the articular surface of the acromion; the conoid and 
trapezoid, serving to bind the clavicle to the coracoid 
process. 
The ligaments proper to the scapula are two in num- 
ber, the anteriour and posteriour; the former of which only 
interests us here. It arises thick and strong from the 
upper edge of the acromion; is inserted into that of the 
coracoid process, henee we give it the name of eoraeo- 
aeromion ligament. This ligament must effectually pre- 
vent luxation from taking place between these two pro- 
cesses. 
The capsular ligament arises from the margin of the 
glenoid cavity all round, and is inserted around the neck 
of the humerus. It surrounds the joint, is lax, well lu- 
bricated, and well adapted to admit loose and free motion. 
It is unfortunate that this ligament is weakest at the an- 
teriour and inferiour quarter of the socket where dislocation 20 
is liable to oecui*. Above it is strengthened by the ten- 
dons of the muscles. Posteriorly it appears rather 
stronger than it is anteriorly. 
I must here beg leave to deviate a little from the 
usual language of anatomists, while I say something on 
the long tendon of the flexor cubiti muscle. 
The head of the humerus has no ligament such as we 
find attached to the centre of the head of the thigh bone, 
to serve as its centre of motion. But the long tendon of 
the biceps performs an office similar to the ligamentum ro- 
tundum of the thigh; for the head of the humerus revolves 
round it, so that it is the centre of motion, although the 
principal part of the articulating surface or head is at one 
side of it. Therefore I think it may be properly called the 
ligamentum votundum of the humerus. Now this circum- 
stance, i. e. of the head rolling round this ligament or centre 
of motion, constitutes one of the differences between this 
joint and that of the thigh, which seems to have been quite 
too little attended to. For without understanding it cor- 
rectly, it appears to me to be impossible to become ac- 
quainted with the real state of things relating to the luxa- 
tion of the joint, and, of necessity, the reduction. But it 
is very easily understood, for the whole of it amounts to 
this, that instead of the centre of the head being tied to 
the centre of the socket, and the head twisting round this 
centre like a wheel round a pivot the centre of motion is 
tied to one side; i. c. the apex of the socket round which 
the head has to revolve in all the lateral and rotatory 
motions of the arm. And in luxation the head must in- 
variably be rolled around this ligament. For as it arises 
from the apex of the glenoid cavity within the capsule, 
bends a little over the head, a little around the great tube- 
rosity and gets into the groove which is rather before the 
arm bone: it is necessary that the arm should be roiled in 21 
order that the head should be turned so as to rupture 
the capsule and escape within the long head of the tri- 
ceps, which rolling must be still greater in forward luxa- 
tion: And reduction cannot take place unless the head 
is rolled back again through the rupture. I shall have 
frequent occasion to mention this ligament in the subse- 
quent part of this essay. 
EXPERIMENTS. 
Having procured suitable subjects at the University, I 
determined to investigate the phenomena of the luxation 
and reduction of this joint by experiments, the result of 
which were as follows: 
EXPERIMENT I. 
I laid a subject upon a table with his back up, seized 
the arm, elevated it forcibly with all my strength, but 
could not luxate it. I then got an assistant to support the 
scapula whilst I substituted the action of the pectoral and 
latissimus muscles with one hand on the superiour end of 
the bone, elevated it forcibly with the other at the elbow, 
but to my surprise instead of dislocating we fractured the 
humerus below the tuberosities near the insertion of the 
pectoralis and latissimus dorsi. 
EXPERIMENT 11. 
I now set about trying to luxate backward on the 
sound arm: turned over the subject upon his back with 
his shoulder projecting over the table just so as to let 22 
the neck of the scapula rest upon the edge, thereby sup- 
porting the scapula completely: I then got up on the table, 
took hold of the arm, brought it forward at right angles 
with the body, stood up with a foot on either side of the 
subject’s breast so as to keep it firm and prevent it from 
turning, directed the assistant to seize the elbow and 
press downward with his whole force, while I performed 
the same operation; but notwithstanding we made several 
violent efforts sometimes rolling the arm by making a 
handle of the fore-arm, and sometimes not, no dislocation 
was produced, when I was compelled to give it up although 
the subject was so favourably situated for it. 
EXPERIMENT 111. 
Having turned over the subject I determined to renew 
my efforts to luxate downwards with the addition of ma- 
king a handle of the fore-arm. After the assistant had 
laid hold of the scapula as in experiment first, thereby 
substituting the action of the muscles around it so as to 
fix it firmly, I laid hold of the elbow with one hand, and 
of the wrist with the other; then desired the assistant to 
exert himself in supporting the scapula whilst I forcibly 
elevated the arm with the hand at the elbow, at the same 
time rolling the arm with the other at the wrist outwards, 
and luxation was instantly produced, by rupturing the 
capsule as I afterwards proved by dissection, just within 
the long head of the triceps and inferiour angle of the 
cross laid out upon the glenoid cavity. 
I now extended the arm in order to reduce it but there 
was resistance to extension although there could be no 
muscular action: nor was the arm reduced until I rolled 
it while the extension was made; yet when I communica- 
ted that motion to it, reduction took place instantly. 23 
EXPERIMENT IV. 
Haying cleaned away the muscles so as to leave bare 
the capsular ligament anteriorly. I cut a hole in it com- 
mencing at the edge of the glenoid cavity below the cora- 
coid process and anteriour angle of the cross and carried 
it over to its insertion into the neck. I then carried the 
arm back and forced the head out at this rupture or split, 
by pushing at the elbow and rolling the arm as above. I 
here observed that the muscles inserted into the great 
trochanter were pretty much upon the stretch and slip- 
ped the knife under and cut them off so as to let the head 
out fairly. I now extended the arm without suffering it 
to roll in order to see if it would be reduced; but it was 
not, until it was rolled precisely similar to that in a down- 
ward direction and in a greater degree. 
I next made some more experiments at the inferiour 
rupture of the capsule but they were so similar to the 
above it is needless to relate them. I also experimented 
on it in an upward direction but as the result was (as 
every person of common sense would suppose,) unsuc- 
cessful, I shall not detail the methods used. 
EXPERIMENT V. 
I now cut off all the muscles so as to leave the arm 
and scapula adhering only by the capsule, passed out the 
head at the same slit as in the latter experiment, which 
again rolled the arm, twisted the capsule, and thereby shor- 
tened it, and prepared it to resist the necessary extension, 
for when I extended although every thing was taken away 
but the capsule, the head would not enter the socket. Indeed the extension might have been so much increased 
as after having first drawn the scapula a considerable 
distance, to have then torn the capsule entirely off before 
reduction would have taken place if the arm had not been 
suffered to roll. But as soon as this motion was commu- 
nicated to it, it reentered the socket with a very slight 
extension. 
EXPERIMENT VI. 
I wished to see how far the head could be carried with- 
out this ligament being torn entirely off. After cutting 
it considerably but having left the upper part adhering, 
I turned it round, pushed it over upon the breast and then 
upwards nearly against the clavicle, without effecting 
that consequence. 
From these experiments the following conclusions may 
be drawn. 
Ist. That luxation cannot take place directly down- 
wards in consequence of the long head of the triceps pres- 
sing up against the capsule even when the scapula is 
fixed, an artificial force substituted for the action of the 
pectoral, latissimus and terus major muscles, and a suf- 
ficient force exerted to fracture the bone. 
2d. That it cannot take place backwards under any 
circumstances whatever. Not in consequence of the cap- 
sule being much stronger posteriorly than it is anteriorly, 
but because of circumstances relating more to the pecu- 
liar mechanism of it: for although in the experiment 
from which the conclusion is drawn, it was much more 
favourably situated than can ever take place in the living 
subject unless it were gone about as deliberately as it was 25 
here, a fracture of the neck* of the scapula would be 
more likely to take place than a rupture of the capsule. 
It is evident that when the arm is brought forward across 
the breast, the head is so rolled in the socket as to turn 
up the round ligament in such a manner that it would of 
necessity have to be broken off when the arm is forced 
back sufficiently to rupture the capsule and pass out the 
head; so that it would be necessary to have the arm rol- 
led downwards and backwards while the force operates 
at the elbow, in order to disentangle this tendon, as well 
as to turn down and relax the subseapularis, which would 
have to be broken up from its insertion. But it is cer- 
tainly very evident that this kind of rolling cannot be 
communicated to the arm in falls, or in any of the common 
accidents; but if it were, the body would roll over so as 
to turn the other side downwards, unless it was wedged 
up by some means that would prevent it. Even then, the 
joint would be stronger than the attachments of the sca- 
pula to the clavicle which might give way, and leave 
nothing to prevent the scapula from being pushed off, but 
the pectoralis minor,f which would be a very slender 
support. Therefore it becomes necessary that the pa- 
tient’s back should be placed so neatly against something, 
as to support the scapula and let the neck project over 
* As J. Bell says, in speaking of the neck, “which no doubt 
sometimes, gives way and breaks,” I think it would here be very 
favourably situated for fracture to take place. 
t In a dissection which I made, this muscle was torn across 
without any rupture in the integumentj which was witnessed by 
some of my fellow graduates. I was however unable to learn 
how it had taken place or of what the subject died, and not ha- 
ving my attention directed to the dislocation of the joint at that 
time I neglected to examine minutely the state of it. 26 
the edge, which is as hard to conceive how it could acci- 
dentally be so fixed, as some of the above necessary cir- 
cumstances. 
Notwithstanding surgeons in general admit the possi- 
bility of the bone being luxated backwards, and some of 
them describe the pain accompanying it, together with a 
long catalogue of symptoms: yet as no case of it has 
ever existed any other where than in the imagination; and 
as the mechanism of the parts is such as to render it im- 
possible that it should ever exist any where else; I reject 
it unhesitatingly. 
3d. The conclusion may be drawn that when the sca- 
pula is supported or fixed, a force substituted for the pec- 
toral and latissimus, and the arm rolled by making a 
handle of the fore-arm, luxation will take place with a 
far less force than is required to fracture the bone: not 
exactly downwards in the centre of the glenoid cavity, 
but within the long head of the triceps and inferiour an- 
gle of the cross; therefore it is properly called luxation 
downwards and inwards. 
The mechanism of this luxation in the living subject 
must be as follows. When a person falls, he either catches 
at any object he may pass by, or plants his hand on the 
ground if he reaches it; in either case, the fore-arm be- 
comes a handle, and rolls the head around the ligamentum 
rotundum which is its centre of motion; at the same time 
the arm is converted into a lever of the first kind, the 
fulcrum of which is the pectoralis major, latissimus, and 
teres major, the power is at the elhowr, or rather the 
fore-arm, and the weight raised at the head. Agreeable 
to the laws of mechanicks the lever must either break, 
the prop move, or the weight he raised, if the force is 
strong enough; but it cannot break and raise the weight 
too, notwithstanding what has been said about the hume- rus being fractured and dislocated at the same time. Here 
the weight is raised; for the head ruptures the capsule 
and rolls out. 
It becomes necessary here to explain the manner in 
which the muscles become agents in the production of the 
disarray, which they unquestionably do, as is pi oven by 
the insurmountable difficulty experienced in attempting 
dislocation in the dead subject until a force is substituted 
for their action, and the well known fact that a dr 
animal in the shape of a man will fall perhaps an hun- 
dred times without injury to the joint, when the fall is such 
as would in ninety nine cases of the hundred, dislocate the 
arm of a rational being, or communicate some other in- 
jury perhaps more serious. 
When a man in his senses falls, he brings into action 
the whole of the muscles surrounding the scapula, all 
that have any operation on the arm and fore-arm calcu- 
lated to bring the arm into a situation that will support 
the body: those acting on the scapula fix it obstinately, 
those of the fore-arm plant the hand to save the elbow; 
the pectoralis major, latissimus, and teres major, operate 
to bring the arm in nearer the centre of gravity, but be- 
ing overpowered and foiled in their design they only bal- 
ance or fix it where they sieze on it, thereby preventing 
itfrom rising: or, becoming the fulcrum, prop, or centre of 
motion, and as the scapula is fixed the head passes down oft* 
the articulating surface, which could not take place if the 
articular cavity were not prevented from moving with it 
by the muscles around the scapula 
Luxation from blows has been denied by some, yet 
others entitled to equal credit have seen it, in fact I have 
seen a ease* myself which sets the existance of it beyond 
* This case was treated in a very clumsy manner for a frac- 
ture of the bone, and suffered to remain out six weeks; a mistake 
which could only originate from unpardonable ignorance. dispute with me: nor do I conceive it difficult to account 
for. When a person sees a blow approaching, the will 
sends its mandates to the muscles, they obey, contract 
around the scapula, and fix it: the arm is thrown up as 
it were to ward off the stroke; this motion rolls the arm, 
and the blow still finding its Avay to the superiour end of 
the bone rolls the head through the capsule. 
Again it appears (by this experiment,) that the arm 
must he rolled back again in the reduction, a circum- 
stance too little attended to by surgeons in general. 
4th. I infer that when luxation takes place forwards 
the arm is rolled in the same manner as in that down- 
wards, but in a greater degree: that the mechanism of it 
only differs in the arm being carried farther back and 
rolled more: and that the reduction is the same with the 
exception of the direction of the extension, and the de- 
gree of rolling it back again. 
sth. From the result of this experiment it may be con- 
cluded that the capsule will make resistance to exten- 
sion sufficient to draw the scapula along even in recent 
cases, because of the rolling motion of the arm when 
passing out, twisting it, and necessarily shortening it, and 
this ligament must become a more prominent resistance 
in old eases, for when inflamed, thickened, and united to 
parts of the bone to which it does not properly belong, 
and the action of the muscles sending the head of the 
bone farther back, will alter its form entirely: therefore 
in reduction of cases of this description it will have to be 
broken up from its preturnatural adhesions as well as 
the shortened muscles extended, and the cellular adhesions 
to the head torn up, which it appears almost impossible 
to accomplish without having the scapula well supported 
while extension is making. 29 
6th. I conclude that the head may be carried a con- 
siderable distance from the socket without tearing this 
ligament entirely off; and consequently that it may re- 
main slightly attached even in some consecutive cases 
forwards, and upwards, and will present itself as an ob- 
stacle to reduction in cases of this description. 
Upon the whole I conclude that there is only one fourth 
of the socket at which the disarray can take place, i. e. 
between the anteriour and inferiour angles of the cross 
or below the coracoid process, and before the long head 
of the triceps, in other words forwards and downwards, 
and downwards and inwards. In short, primitive luxa- 
tion may take place at any part of the cavity between 
these two angles of the cross and at no other.* 
* In occupying this groud, I am fully aware I differ from al- 
most all respectable authors; yet I conceive that my title to an 
opinion is as great as any of theirs, though at the same time the 
opinion should be incorrect. 
The Greek physicians divided the luxations into four direc- 
tions, as downward, upward, forward, and backward: sometimes 
their expressions differ, and perhaps their meaning. 
Hippocrates demonstrates the fallacy of their divisions and has 
the following words, “At vero humerus, inferiorem in par- 
turn excidit aliam in partem excidere non audivi.” Galen admits 
of four kinds. Oribazes and Paul of CEgina admit of three. 
Celsus who was certainly nearly correct says, “Humerus, modo 
in aliam excidit, modo in partem priorem.” 
Heister and Petit making great pretensions to anatomy, by which 
they attempted to tear down the whole fabrick before built, admit, 
of four kinds. They attempt to point out anatomically the part 
at which it escapes; as for instance, the latter speaks of dislocation 
forwards between the coracoid process and the clavicle. I should 
like to know what this is but upwards, as well as what “thunder- 
bolt” sent it there; for I cannot manage to get the head even of 
the dry bone between the two processes, without breaking off one 
or other of them. But what becomes of the coraco, acromion 30 
Consecutive luxation may succeed any primitive case 
when a secondary accident occurs. The head may pass 
either forwards or upwards, but it can never go back- 
wards, being prevented by the long head of the triceps 
muscle; nor can it go downwards. 
SYMPTOMS. 
The signs of all primitive luxations are pretty much 
the same, the principal difference is that when it is for- 
wards the arm is carried farther back, and the exteriour 
condyle is turned farther backward, indeed instead of its 
being in a range with the most salient part of the shoul- 
der, the internal one comes almost as near corresponding 
with it. 
ligament? Again, he speaks of backwards below the spine of the 
scapula; a case hard to conceive and I rather think harder to see. 
Duverney appears to be the first who divided this luxation into 
primitive and consecutive, he admits of downward only, to be 
primitive. Desault, Boyer, Pare, Freke, Fabre, D’Apouy, Cooper, 
&c. admit of three kinds, i. e. downward, inward, and outward, 
and however fallacious this division may be, it is generally receiv- 
ed by our surgeons; for although they differ a little in expression, 
and perhaps in meaning, their divisions amount at last to this or 
nearly so. But the fact is, we have so confused a mass of jargon 
that it is hard to understand what they mean by their expressions 
of downward, inward, forward, outward, backward, &c. indeed 
these words have been used by several who were divided in 
their meaning although the expressions were the same: others 
have used a different language to convey the same meaning. 
Benjamin Bell admits of four kinds none of which are cor- 
rect. 
Charles Bell adopts almost the same division of Celsus which 
is unquestionably very near correct. 
As the division I have adopted is founded upon experiment,, 
and as this shapeless mass would serve no other purpose 
than to confuse, I have been induced to place it in a foot note. 31 
As Hippocrates has observed, there is always a de 
pression underneath the acromion, which process appears 
more prominent than when the head has its proper rela- 
tion to it. The integuments on the exteriour side of the 
arm are more lax, and consequently feel softer: the arm 
cannot be brought forwards without excruciating torture. 
The fore-arm is in a state oi semi-flexion, and cannot be 
extended without giving pain. The patient cannot bring 
his hand to his head by performing a semicircle with it, 
but stoops his head to meet the hand on attempting it. 
When the arm is moved in any way, the scapula moves 
with it, as if the joint were anchylosed. 
The head of the bone is always to be felt in the axilla, 
but if the dislocation should be forwards, it will make a 
prominence more under the great pectoral muscle. 
If the case should be downwards, the arm will be 
somewhat longer than the other, but although we are 
advised to strip the patient in all cases, and examine the 
relative heights of the elbows,* this is not an unequivocal 
symptom, for in fractured clavicle the shoulder hangs 
down and the patient leans to the affected side, which 
causes that elbow to hang lower than the other. Nor do 
we find the elbow set upon the hip as we are told by 
respectable authority;! it is very hard to conceive how 
it would get to the hip.! Inflammation and swelling 
come on in the general shortly after dislocation takes 
place, but they have a tendency rather to prevent the 
disarray from being understood, than to give us any ad- 
monition of its existence or nature. 
* Vide Boyer on the bones as edited by Richrand, page 242. 
t Vide Desault as edited by Bichat, page 115, and others. 
\ They probably mean the ala of the os innoininatum instead 
of the os sedentaria. 32 
The symptoms of consecutive luxation are not materi- 
ally different from those of the primitive; if it should be 
forwards the elbow will stand back, the head will make 
a prominence upon the breast; should it go upward the 
arm will be somewhat shortened to appearance, &c. 
(Edema and paralysis sometimes take place, both of 
them are occasioned by the pressure of the head; the 
former on the lymphatics, and the latter on the nerves; 
when either exists reduction should immediately be re- 
sorted to if possible. 
REDUCTION. 
As the various methods which have been proposed and 
practised for the reduction are so very numerous, I shall 
not pretend to enumerate or investigate their inutility. 
Nor is it necessary that I should pay strict attention to 
any of them, but particularly to machines which operated 
by forcing the head into the socket, either with or with- 
out extension, as, for example, the ambi with its various 
alterations and presumed improvements, the method of 
hanging the patient over a high step of a ladder, the 
head of a door, a pole, &c. that of the heel in the axilla, 
and a number of other methods better calculated to frac- 
ture the humerus, ribs, &c. produce paralysis, oedema, 
cancer, aneurism, ecchymosis, &c. &c. which are all very 
justly exploded. 
These methods have all undergone sufficient investiga- 
tion by several surgical authors* who have come to the 
conclusion that no method but that by extension is 
proper. But although they speak of reduction by means 
of extension alone on the part of the surgeon, and trust 
* Desault and his followers. 33 
to the muscles to replace the hone,* it has certainly al- 
ways been necessary to make counter-extension, for al- 
though it is a kind of yis inertia?, if the patient is tied 
down or held by any means whatever, the force which 
holds him there is as great as the extending force, other- 
wise the body would be drawn along. 
Several methods have been employed to make the ex- 
tension. Sometimes different forms of machinery have 
been used, sometimes assistants have been employed, at 
other times the surgeon has affected to make it liiraself.f 
The pulley is the form of machinery in most common use, 
the number of which has been greatly multiplied, some- 
times indeed they have been increased so much, and so 
violent a force exerted as to produce and 
nearly take the arm off. They have sometimes been made 
to act horizontally, while the counter extension is accom- 
plished by tying the patient to a post, bench, table, or 
something similar, or he is held by assistants. At other 
times they act vertically,§ in which ease the weight of 
the patient makes the counter extension. 
Counter-extension is now most generally made by pas- 
sing a folded sheet or something similar under the axilla, 
which is carried round across the breast and back, either 
with or without some substance in the axilla, but most 
generally there is a pad, ball, or wedge of some kind 
placed in it. This is the method of Desault, whom, it is 
* Vide Desault as edited by Bichat, pages 125 and 133. 
t Vide Desault, page 125. 
f Vide Richrand’s Boyer on the bones, vol. 1, page 246. In 
this same page is recorded a melancholy case of torture by another 
form of machinery. 
§ See Keys cases, which will serve to shew the inutility of this 
method. to be lamented, most of our surgeons follow. In speak- 
ing of his assistants he says* “they should furnish them- 
selves with a linen ball, thick enough to project beyond 
the level of the pectoralis major, and the latissimus dorsi 
when placed in the axilla.” This ball will unquestiona- 
bly have the most pernicious effects in the axilla, if it is 
hard enough to keep the folded cloth off these muscles. 
Ist. It may produce all the evils enumerated above, 
when speaking of other methods of applying substances 
in the axilla, except fracture. 2d. It will press up the 
head of the bone into the neck of the scapula and there 
lock it effectually. 3d. It will effectually prevent the 
head from returning into the axilla, should the case be 
cither a forward or upward one,f as it must occupy the 
whole of the axilla. 4th. The pressure made by it on 
the inside of the muscles forming the axilla will stimulate 
them to spasmodick contraction: which evil will be in- 
creased by the sheet passing around them exteriorly. 
sth, It effectually prevents the surgeon from knowing 
what is going on in the axilla, or giving any assistance 
which is not infrequently necessary, for although the 
muscles are trusted to to replace the bone, they will un- 
questionably often disappoint those who rely upon them 
altogether: we have at once two of the muscles operating 
directly opposite to our wishes, i. e. the subscapularis and 
teres minor; and this ball will press upon them so as to 
prevent them from being extended, indeed even shorten 
them so as to hold the head down more firmly. 
Boyer and others have no doubt seen the evils of the 
ball; (which must be almost as bad as wood when pres- 
sed upon,) and have recommended softer materials. 
This is not only liable to most of the above objections, 
* As edited by Bichat. 
t Consecutive cases are here alluded to. 35 
but is not calculated to effect the object for which it is 
intended, inasmuch as it will let down the sheet upon the 
muscles forming the axilla, which will shorten them by 
bringing their points of origin and insertion nearer each 
other (even if means are taken to destroy the irritability 
of them, so as to prevent them from being stimulated 
into spasmodick contraction,) and thereby draw the head 
farther back, instead of reducing or suffering it to move 
forward. 
Desault* recommends another band to be placed on 
the acromion, and carried across anteriorly and posteri- 
orly, and obliquely downwards for the purpose of 
porting the scapula. When this is so applied as to take 
hold of the acromion it will press the deltoid and other 
soft parts into the socket so as to fill it up, which will 
prevent the head from reentering. This strap or any 
means used to depress the acromion in this manner will 
have a tendency to press the neck down upon the head 
which will assist the wedge below in locking the head in 
the neckj and this is certainly not a situation favourable 
for its reduction. Some other methods have been used 
for the purpose of supporting the scapula, as the sling, or 
split strap of Petit: the ring, or towel rolled up in the 
manner of a ring,| as related by doctor Potter in a case 
published in the Lycanun: but they are liable to gather 
up so as to press upon the pectoralis major, latissimus 
dorsi, and teres major, and will shorten or bring their 
points of origin and insertion nearer each other, indepen- 
dent of their being irritated to spasmodick contractions. 
* Boyer, Bell, and several other surgeons, recommend this 
method of supporting the scapula either by a bandage of some 
kind, by assistants, or both conjoined. 
f I am informed this was suggested by the late doctor Cocke: 
but the towel, or something similar, has been often used in o ther 
forms. 36 
As none of these means of making counter-extension, 
or supporting the scapula, appear to me calculated to ac- 
complish those objects in a correct manner, the latter of 
which, is unquestionably a very important desideratum, I 
shall beg leave to suggest the propriety of applying an 
aparatus which I have constructed to fasten the counter- 
extending instruments to, and at the same time support 
the scapula, a delineation of which I have given in the 
plate. 
The base of this instrument is intended to be placed 
against the side, when the arm is passed through the hole 
in the centre, so as to let the neck or upper part over the 
round of the shoulder behind the origin of the deltoid mus- 
cle,* and as it is hollowed out to fit the side and well cushioned, 
I conceive it to be well calculated to make a great share 
of the counter-extension upon, by fastening sheets or 
something of the kind in the rings of that end, which may 
be passed across to the opposite side anteriorly and pos- 
teriorly. The straps are somewhat raised off the walls 
of the body by passing over the edge of the aparatus and 
the anteriour one will pass below the mammae. When 
the screw is moved up above the latissimus dorsi and 
teres major, on their way from the angle of the scapula 
to the arm, there is a large open space left for them to 
pass through safe from pressure. The screw may be 
turned in order to pass the point (which is well eushiou- 
etyinjlf so as to take hold upon the inferiour costa of the 
scapula. There is nothing here that is in danger of in- 
jury except a branch of the subscapularis artery, which 
winds over the edge of the bone, but somewhat lower 
down than the screw, when raised to a proper height. 
The teres minor is more deeply seated than it will press, 
and goes up the edge of-the scapula so nearly that it can 
only be slightly pressed upon, if at all. 37 
The shoulder above this will press upon the superiour 
costa of the scapula and super edge of the spine. Here 
the scapula represents to us something similar to a wedge, 
the larger portion of which is its base. As this wedge is 
seized or held between points composed of materials 
which are unyielding, of course agreeable to the laws of 
mechanicks, it cannot enter any farther. 
The spine of the scapula and the clavicle form another 
wedge, which is held in the neck or superiour part of the 
apparatus which is also unyielding and consequently this 
wedge cannot enter. 
The large arch anteriorly is calculated to transmit the 
pectoralis major entirely clear of pressure: below this 
there is sufficient room left for the surgeon to feel in the 
axilla with his hand and render any assistance necessary. 
Or for persons who will not be persuaded to give up the 
pernicious practice of placing substances in the axilla to 
apply them. 
The rings above are intended to fasten another set of 
straps in, thereby dividing the force, but the most of it 
will be against the side. 
All these straps, sheets, or whatever is used may be 
fastened together and held by one or more assistants. 
They might be tied to a post if assistants could not be 
had, but this is not so convenient particularly when blee- 
ding is practised to produce syncope. 
When a luxation shall have remained long without re- 
duction there are several circumstances supposed to ren- 
der it often impracticable and always difficult: such as the 
idea that the synovia becomes inspissated, the socket is 
filled up with bone, the new' adhesions formed, the rup- 
ture in the capsule being too small,* the contraction or 
* This has been thought to present itself as an obstacle to the 
reduction of recent cases by Desault and his followers; but it is 38 
shortening of the muscles, the capsule being in part still 
attached to the scapula and head of the humerus, and the 
mobility of the scapula. 
I cannot subscribe to an opinion that the socket is fil- 
led up either by synovia or bone, but should the luxation 
be suffered to exist long enough, it will be in part at least 
absorbed and carried away, as the acetabulum in the hip 
joint is, as the alveolar processes in the jaws are when 
the teeth are extracted, and all other animal matter which 
becomes useless. 
The new adhesions together with the part of the cap- 
sule which remains untorn are the most formidable ob- 
stacles and render it indispensibly necessary to have the 
scapula supported in order that they may be broken up, 
so as to suffer the head to advance to the socket. 
The muscles can be relaxed by phlebotomy sufficiently 
to overcome their contractile resistance: but from their 
being out of use for a long time, the redundant part of 
them while in this situation is absorbed as well as the 
bone which is useless; examples of which we see every 
day in the streets, vulgarly called contracted ham-strings. 
Notwithstanding this is the stale of the muscles I am 
convinced by experiments made upon the muscles of the 
dead subject, they can be stretched beyond their natural 
length sufficiently to suffer the head to come up to the 
socket when they are relaxed by bleeding ad deliquium 
animi; which I conceive to be a state in which the pow- 
hard for me to conceive how the head would get out if it was too 
small to allow it to return, nor can I conceive that the edges of 
it can get into the neck of the humerus as it is so superficial in the 
dry bones, and is entirely filled up by the remaining sound part of 
the capsule itself in the green subject: neither is the capsule ca- 
pable of contracting. All that is wanting is to roll the head in. 
and by that means the twist is taken from the capsule. Vide ex- 
periments. 39 
ers of the muscular fibre are very analagous to that of 
the muscle of the dead subject. 
I now come to the conclusion that the following indi- 
cations must of necessity be fulfilled in order to accom- 
plish the reduction with the most certainty, the least pain 
to the patient, the least waste of time, and the greatest 
ease to the surgeon. Via: 
Ist. To overcome the resistance of the muscles by re- 
laxing them. 
2d. To make an adequate extension. 
3d. To make sufficient counter-extension; part of 
which must be on the scapula in order to keep the body 
and it together. 
4th. To roll the arm inwards, and make it retrace the 
rout it took in passing out. 
The first of these indications will be better fulfilled by 
bloodletting ad diliquium animi than any other. Some 
other means have been employed to accomplish this ob- 
ject, but they are not only inadequate, but are liable to 
other serious objections; as (for instance,) the use of opi- 
um and spirituous liquors which should not be encouraged 
if they were effectual, as it is giving encouragement to 
bad morals. 
The warm bath would perhaps answer were it persisted 
in sufficiently: but it is inapplicable to one sex, is 
always attended with some difficulty, and under certain 
circumstances (as on board ships,) cannot be had recourse 
to. Nor is it a favourable situation for operating, to 
have the patient in a bath, and if he is taken out he is 
exposed to cold, and the syncope goes off before reduc- 
tion can be completed. 
There is little doubt but in the general our patient will 
think it cruel to tie up his arm and bleed him for the express 
purpose of making him faint: but when he comes to uu- derstand that it is attended with no hazard, that instead 
of giving pain it secures him against it in the most effec- 
tual manner, and that it cannot be dispensed with; he can- 
not hesitate a moment to submit to it. 
The second indication will be much better accomplished 
by assistants than machinery of any kind whatever. Ist. 
Because the force can be better regulated according to 
the circumstances of the case; for it can certainly be in- 
creased sufficiently. 2d. The direction of the extension 
can be varied with greater facility. 3d. The danger of 
too great an accumulation of force is not so great. 
A dispute has arisen about the place most proper for 
applying the aparatus by which the extension is made. 
Pott and his followers apply it to the arm, Ist. because 
they conceive a part of the force is lost in the elbow- 
joint; 2d. they argue that the stretching of its ligaments 
injures the joint; 3d. they flex the fore-arm in order to 
relax the muscles. 
Desault, and most of our surgeons; (who have followed 
him,) deny the loss of any of the power in the joint; con- 
tend that if the flexor muscle is relaxed, the extensor is 
put upon the stretch, which they say is as much entitled 
to attention. They also contend that the bandages on the 
arm stimulate its muscles to spasmodiek contractions and 
therefore apply them to the fore-arm. 
That the force operates on the shoulder joint alike in 
both cases, I am not disposed to doubt: yet the elbow 
joint most unquestionably undergoes unnecessary torture, 
and perhaps serious injury. But I cannot agree that the 
extensor is entitled to as much attention as the flexor. 
Ist. Because there arc two heads of the latter from the 
scapula and but one of the former. 
2d. The long head of the flexor is entitled to particu- 
lar and separate attention as it is so much more inter- 41 
ested in the joint. The very circumstance of the fore-arm 
being in a state ol semi-flexior shows that it ought not to 
be extended; for as the long head in the groove is turned 
down with the head while it still adheres at its origin 
the muscle is shortened, and if we extend the fore arm, 
it must be put upon the stretch and perhaps the long 
tendon broke; even before the arm can he straightened. 
3d. It is strictly necessary that the round ligament the 
centre of motion, or long tendon of the flexor, should re- 
main relaxed in order to suffer the head to roll around it 
in passing into the socket; whereas if it is made tense 
the head will be bound between it and the long head of 
the extensor so as to prevent it from entering the socket. 
If the napkins or whatever is used are applied to the 
arm when deliquium animi is not produced it is very pro- 
bable the muscles will be stimulated to contractions; but 
whether or no such an application would then he sufficient 
to rouse them into spasms, becomes a query. It appears 
to me if a silk handkerchief, a folded piece of flannel, 
or some soft material were neatly applied around, immedi- 
ahove the condyles, that the muscles here have become so 
far tendinous that no application of that kind could rouse 
them into spasms when our patient is in that state 
I should therefore with Pott, 6cc. apply (he apparatus 
there, which will leave the fore-arm in a favourable sit- 
uation to fulfil the last indication by making a handle* 
of it to roll the head around the ligamentum rotundum. 
The aparatus for making the counter-extension, and 
supporting the scapula being properly fixed upon the 
shoulder, and the straps or sheets held by an adequate 
* Since this essay was written I have been politely favoured 
with an opportunity of reading Mr. Charles Bell’s operative sur- 
gery, and find that he recommends this method. 42 
number of assistants. The handkerchief or something 
similar is to be fixed upon the arm and held by a sufficient 
number of assistants. The patient is to be placed upon his 
feet* with a stool behind him. The surgeon is to tie up 
the sound arm and open a vein largely, in order to per- 
mit the blood to flow freely until he fall into syncope: 
he is then to be seated and the blood stopped. The sur- 
geon is then to place one hand in the axilla and the other 
upon the wrist of the affected arm: he is then to order 
the distracting forces to be set in operation; have them 
increased to a sufficient degree, and the arm extended in 
the proper direction, which will perhaps generally be 
more or less backward as the case may be, or forward or 
downward, and somewhat elevated. It will however have 
to be varied and rolled a little cautiously, but not thrown 
upwards, downwards, and rolled in every direction, in a 
most cruel and barbarous manner as we are advised, 
which cannot fail to tear off the capsule entirely, to pro- 
duce paralysis,! &c. 
The surgeon is nowr to roll the arm inwards with the 
hand at the wrist, at the same time advising the assis- 
tants to carry it somewhat forwards. While with the 
hand at the superiour end of the humerus he elevates the 
head to the socket: or in other words extends the sub- 
scapularis and teres minor muscles. 
* This position of the patient calls upon the brain for a greater 
supply of nervous energy than when a number of the muscles are 
idle, as in a horizontal or setting posture, which deprives the 
heart of it; while its stimulus flows (the blood,) in a sudden gush, 
and by this means the patient faints with a less waste of blood, 
than if he were bled in the ordinary posture. 
f For an account of a case of paralysis produced in this man- 
ner, see Desault as edited by Bichat, page 119. And now the reduction will be accomplished perhaps 
in a minute or two after syncope is induced, and the pa- 
tient will rise as if awaking out of sweet and sound sleep, 
without ever having had occasion to groan, while one of 
the severest operations in surgery has been accomplished; 
an operation which has taken a whole day in the hands 
of the most eminent surgeons, as will appear from the 
following extract from Bichat’s Desault. When speak- 
ing of some methods of overcoming the muscular resis- 
tance he says “what is much better, a powerful exten- 
sion continued for some time; in consequence of such 
extension, the muscles of the part become fatigued, 
whence their contractions are succeeded by a state of 
atony, of which advantage may be taken to replace the 
bone. Frequently this extension ought to be continued 
for a very long time, and we have hnown Desault not to 
complete the reduction in less than half a day, or even a 
whole day.” When this was much the best plan, which 
kept the patient in torture all that time, there was really 
room left for improvement, which I am happy to say, 
the world is indebted to our countryman doctor Physick 
for; for although venesection had been used by many, 
it seems never to have been carried to the proper extent 
until he advocated and practised it. 
But this practice of Desault certainly is better than 
many others, who would take a day or two in trying 
different methods,* and perhaps then only succeed by 
chance; when the arm was suffered to fall and roll in of 
itself,f or some other fortunate accident ensue. 
It is impossible to enumerate all the address that is ne- 
cessary in the reduction; several things may be suggested 
during the operation that are not here described. Ex* 
* Vide Key’s cases. 
t See case V. page 188 of Hey. 44 
perience and address are both requisite to accomplish it 
before the patient rouses from the state of syncope. 
In the case before mentioned,* which was out six 
weeks, I had the pleasure of assisting in the reduc- 
tion, which was accomplished in three or four minutes, 
even without any support to the scapula. And in other 
cases in which it had remained out a shorter time, it has 
been accomplished before the patient recovered from the 
state of syncope; but in these cases I have witnessed the 
necessity for a support to the scapula, which would affect 
that important purpose better than any thing yet in the 
possession of the surgeon: and have constructed the sup- 
porter, which I have here taken the liberty to present to 
the publick. If it should in future be proven to be de- 
fective in principle, I hope I cannot be sensured for at- 
tempting to fill up what appears to me to be a serious 
deficiency. 
The reduction may very frequently be accomplished 
without this apparatus or bleeding either in recent cases. 
The method here proposed has been chiefly directed to 
cases of long standing: for I should never think of being 
guilty of the deed of turning a patient away because ‘*it 
is too late,” even if it were out ten or twenty years. 
Notwithstanding an artificial socket may he formed; 
the motions of the arm are so contracted when the head 
is out of its place, that it is almost useless. But although 
the socket may be partly obliterated, if we replace the 
head into its natural situation, a new' socket may be 
formed there again, either of bone* or the more soft 
parts, which will admit of free motion. 
* Vide page 27. 
* See the second case related by doctor Henry Thomson in 
the London medical and surgical observations.; where, upon dis- 
section, (which is the best of all proofs in surgery,) a socket of 
osseous matter was found around the head. 45 
But if a new socket of bone should not be formed, 
there will at least be some bone there, and the coracoid 
and acromion process will assist in guarding the head, 
as will the muscles, while the cellular and ligamentous 
substances condense into a kind of artificial socket, if 
proper precautions are taken to retain the head in its 
place, and gentle motions are communicated to the arm 
frequently. 
I have to regret exceedingly that a torturing disease 
has deprived me of a great share of the short space of 
time allowed the pupil to prepare his thesis, after the 
first examination: which has compelled me to submit for 
examination, and publish to the world, what I had 
sketched off in great haste, without taking that gene- 
ral view of the opinions of the different authors who 
have written upon the subject, which I was preparing to 
do when taken sick. 
And I hope this will in some measure apologize for 
some opinions being made use of without noticing their 
authors; indeed there are some ideas advanced, which 
having become so much the common property of all 
surgeons who may adopt them, it is difficult to trace to 
any authority. 
Before I withdraw I must acknowledge my gratitude 
to the professors under whose auspices I have prosecuted 
my search for medical knowledge, for the advantages I 
have received from their lectures. No exertion on their 
part has been wanting, no aid withheld, that could con- 
tribute to improvement. From the institution I have 
nothing more to look for as an individual, but I will al- 
ways sincerely wish for its prosperity, and the individual 
happiness of the men whose talents, industry, and inde- 
fatigable diligence has reared it from nothing, and sup- 
ported it with honour. A FROST FIFO'- 
of the Supporter for Ih e left Scapula . EXPLANATION OF THE PLATE. 
A The centre of the superiour portion of the base of 
the apparatus. 
B The inferiour portion. The base is covered with 
cloth or morocco, under which sufficient cushioning of 
some elastick material is placed. The wood is curved 
considerably at this part of the instrument, but in addi- 
tion to this curve the cushioning is much thicker at C C in 
order to make it fit the sides. This is the portion upon 
which is made the greater part of the counter-extension. 
D The screw which has its button-like point received 
into a collar in the centre of the brass plate, upon the 
side of the apparatus, the edge of which is seen at E. 
F A brass frame, the sides of which pass on the front 
and back of the aparatus, on which is placed the cushion- 
ed point at G, which is intended to press in and take hold 
of the inferiour costa of the scapula, and keep its angle 
stationary. 
The top of the screw is at H, brazed in between the 
plates F, and making one short square of the frame 
which moves out and in upon the screw when turned. The 
frame and screw are moved together, the latter with its 
point in the collar, and the former around the part I 
which renders it capable of being raised or lowered, to suit 
the different sizes. It should be let down to its lowest, when 
the apparatus is passed over the shoulder of the larger 
size, in order to leave sufficient room above it, and then 
may be raised to leave an open space below it, for the 
safe transmission of the latissimus dorsi and teres major 
muscles. K The apex of the instrument, which stands over far- 
ther than the centre of the base. This bend lets the 
neck over the shoulder while the bass is fitted to the 
side. 
L The shoulder which presses against the spine and 
superiour costa of the seapula: it is well cushioned and 
is above the plane of the apex, owing to the curvature of 
the instrument. 
M The shoulder which presses against the anteriour 
edge of the clavicle between the origins of the pectoralis 
major and deltoids, therefore (as is necessary) it is so 
constructed as to lean over in order to get against that 
part, and is seen in a plane considerably above the re- 
mainder of the apparatus in consequence of this curve. 
N Is the large arch for the safe transmission of the 
pectoralis major. 
O O The two superiour rings with straps fastened 
into them which are to pass to the opposite side of the 
patient anteriorly and posteriorly, by which part of the 
counter-extension is made. 
P P The two inferiour rings, fixed into the dorsum of 
the apparatus, which have also two straps fastened into 
them to make counter-extension. The straps pass around 
the edges, and are thereby raised up, so as to prevent 
pressure on the parietes of the thorax. 
This apparatus may be varied in construction in seve- 
ral parts and act upon the same principle; I have made 
three, all of which differ in some particulars, but it is 
needless to explain their difference as they do not vary in 
principle. The supporter for the right side being nothing 
more than this reversed, to give a plate and explanation 
of it would be unnecessary. APPENDIX. 
SINCE the preceding essay was written, a ease of 
luxated shoulder joint has fallen under the care of my 
preceptor, in the reduction of which I had an opportunity 
of witnessing the advantages of the supporter suggested 
in the essay, a delineation of which is annexed thereto. 
The circumstances attending the case were as follow. 
April 16th, 1815, John Jenney, (who is a stout muscu- 
lar man twenty one years old,) having engaged in a per- 
sonal contest was thrown by his antagonist with violence 
upon the pavement, which fall dislocated the os humeri. 
He came to my preceptor’s office early next morning in 
order to obtain relief. On examination but little tume- 
faction had taken place; and the head was found rather 
under the pectoralis major making a prominence of that 
muscle; yet it was not fairly a forward luxation. The 
head must have ruptured the capsular ligament about 
mid-way between the anteriour and inferiour angles of 
the cross* in assuming that position. The arm was fixed 
backward with the exteriour condyle turned downwards 
posteriorly, the fore-arm in a state of semi-flexion and all 
the ordinary symptoms were present. Wishing to be more 
decided with respect to the impropriety of the general 
practice of applying the extending aparatus to the wrist 
and the importance assigned to their application upon the 
arm in the essay, I directed him to extend the fore-arm; 
but none of his efforts were at all sufficient to straighten 
it or change its flexion: I then applied considerable force to 
the wrist without being able to extend it, which occasioned 
great pain and caused him to cry out more than he after- 
Vide page 16. 50 
wards had occasion to do during the reduction. In short, 
I do not doubt in the least that if a sufficient force had 
been exerted, the long tendon of the flexor muscle would 
have been very much stretched and perhaps broken, which 
latter occurrence would no doubt favour a replacement of 
the bone, but this would not he accomplishing the kind of 
reduction which should be the object of the surgeon. In no 
other way I conceive can reapposition be effected than by 
the laceration of this ligament when the force applied ope- 
rates to keep it tense. 
The apparatus for counter-extension and scapular sup- 
port having been lodged with the Professor of Surgery; the 
reduction was defered until one o’clock in the afternoon 
when it was obtained and applied in the proper manner, 
i, e. the screw was let down to the inferiour part of the 
portion upon which it slides, and turned so as to draw back 
the cushioned point of the frame, thereby leaving room above 
it to let the arm through and pass the apparatus over the 
round of the shoulder, so as to let the proper portion press 
upon the clavicle at that part ot it which is between the 
origins of the pectoralis major and deltoides; then the ap- 
paratus was drawn down so as to receive that bone and the 
spine of the clavicle into its neck. The screw was now raised 
above the latissimus dorsi and teres major on their course 
from the angle of the scapula to the humerus; and was 
turned in order to press in the cushioned point so as to take 
hold upon the inferiour costa of the scapula. Napkins were 
now fastened into the rings, carried round on either side, 
and given to two assistants to make the counter-extension. 
A handkerchief was tied in the form of a ring around 
the arm above the condyles hut close upon them, and the 
fore-arm fixed in a flexed position nearly at right angles 
with the arm: other handkerchiefs were fastened into 
this on either side. These handkerchiefs were given to 
assistants by which they made the extension. 51 
The patient’s sound arm was now tied up and a vein 
opened with a spring lancet of the ordinary size. He was 
then directed to stand in an erect posture; the blood 
flowed in a usual stream. As the patient was very 
strong I became apprehensive he would not faint soon, 
and as there was another very good vein in the arm, I 
suggested the propriety of opening it also, lest there 
should be an unnecessary waste of blood by the abstrac- 
tion being too slow to produce syncope early.* This 
was however defered until about twenty ounces were 
drawn, when he became faint, and asked leave to sit down 
upon a stool which was provided for him. The blood 
now ceased to flow as it will always spontaneously do when 
syncope is approaching; which renders it unnecessary 
that the surgeon should occupy time in tying up the arm 
after the ordinary manner of stopping blood. The ban- 
dage was untied which was deemed sufficient security 
against the farther flow of blood. 
The distracting forces were now ordered into operation, 
whilst the arm was elevated at its superiour extremity, 
and rolled inwards by making a handle of the fore-arm, 
which brought the head nearly on the edge of the socket. 
But the patient not having been in a complete state of de- 
liquium animi now began to recover, and the blood again 
flowed. The bandage being now replaced by one of the 
young medical gentlemen present, encouraged the flowing 
of blood, which very soon produced syncope, and the head 
passed completely into the socket without any more exten- 
sion than the gentle degree that was kept up in order to re- 
tain what had been previously gained, and with a slight, 
elevation of the superiour end of the humerus, or exten- 
sion of the subscapularis and teres minor muscles. The 
noise occasioned by the two articulating surfaces coming 
* See essay page 42, for an explanation of this idea. into contact (which has often been noticed upon similar 
occasions,) was very distinctly heard in this case when 
reapposition took place, which was in less than five min- 
utes from the time the forces were brought into opera- 
tion. 
I cannot avoid saying here that the supporter effected 
the object for which it was applied better than I had 
calculated upon. Nor did it occasion the pain I expected 
its pressure upon certain points would have done, for the 
patient had no occasion to complain of its hurting him. 
The patient was found on the second evening after it was 
reduced, busily engaged in assisting to extinguish a fire 
which broke out in the city, which shows there must have 
been little contusion. 
Nor can I neglect to express the pleasure I feel in 
consequence of the approbation it has met with by the 
medical gentlemen present; but particularly my preceptor 
who had previously thought little of its utility. 
In this case it became necessary to exercise the most 
prompt means, as the patient was very muscular, as the 
head was carried far ou( of the socket, and as his arm 
had not before been dislocated. But I am fully conscious 
reduction can frequently be accomplished in recent cases 
without some of the means here exerted; especially if it 
should be a case where luxation has frequently occurred. 
Indeed if the surgeon were at hand shortly after the dis- 
array shall have taken place and were to take advantage 
of a state of swooning which not unfrequently supervenes 
the accident; he might accomplish reapposition by his own 
address, provided the patient shall be of a delicate struc- 
ture. But lam sorry to say that instead of attending to 
this, which is of real importance, it is a general prac- 
tice to use means for their recovery from the contingent 
and unimportant state of syncope.