SECT. CXIV.—ON DISLOCATION OF THE SHOULDER.
The head of the arm, which is articulated with the cavity of the scapula, is often dislocated; but neither upwards, owing to the coronoid process of the scapula, which prevents it, nor often backwards, owing also to the scapula, nor forwards owing to the tendon of the biceps muscle and the acromion. Sometimes, though rarely, it is dislocated inwards and outwards, but frequently, and particularly in those who are lean, downwards. In such persons, however, as it is readily dislocated, so is it also reduced; but in those who are brawny, on the other hand, it is not readily dislocated, and is reduced with difficulty. In some cases from a blow suspicions of dislocation are formed, although none has taken place, owing to the violent inflammation which supervenes. Wherefore, dislocation downwards may be thus ascertained. The affected shoulder, when compared with the sound one, appears very different, the upper part of the arm, whence the dislocation took place, seeming hollow; and (as mentioned with regard to the sub-luxation of the acromion,) the top of the shoulder appears sharper than natural; and the dislocated head of the arm is distinctly felt in the armpit. The elbow also is removed to a distance from the ribs; or, if you attempt it, you can only bring it to the ribs with difficulty; neither can the hand be raised to the ear, owing to the stretching of the elbow; nor can any other varied motions be performed with it. In children, then, and in recent and inconsiderable displacements of the bone, it may be often reduced, as Hippocrates remarks, by the protuberant knuckle of the middle finger of the clenched hand of the surgeon, or of the sound hand of the patient, if he be not a child. But the following are more effectual modes of reduction. Having bathed the man and used relaxing affusions, let him be laid on the ground in a supine posture, and apply a moderately-sized ball, either of leather or some other soft thing to the armpit; and the surgeon being seated with his face turned to the patient upon the affected side, if the right shoulder he dislocated, let him put the heel of his right foot upon the ball previously fitted to the armpit, or if the left, that of the left foot; and seizing the hand of the affected arm, let him pull down to the feet, at the same time making counter-extension by the heel in the armpit, while an assistant, standing behind the head, pulls at the other shoulder in an opposite direction, to prevent the body from being dragged along. There is another mode of reduction, namely, by suspending the patient upon a person’s shoulder. A young man taller than the patient, or standing on some elevated object, by his affected side, (the patient also being in a standing posture) is to apply his shoulder below the patient’s armpit, while he stretches and pulls the patient’s hand towards his own belly, so that the rest of the patient’s body is suspended at the back of the person who supports him. But if the patient be light, another light child is to be suspended from him. For while the arm and the rest of the body are pulled downwards oppositely, the shoulder put under the armpit, readily replaces the dislocated limb. And the same thing may be done by means of the instrument called a pestle. It is a long piece of wood which is erected on the ground upon some other firm object. Its upper extremity, then, being rounded, and neither very thick nor thin, is applied below the armpit of the patient, who either stands or sits, according to the length of the pestle, and the hand being stretched along the pestle and pulled downwards, while the rest of the body is balanced on the opposite side and weighs downwards, the reduction takes place either spontaneously, or with the assistance of another person pulling down. And this may be done with the step of a ladder, as we described when treating of the extension for a fractured arm. Here some round body is to be fitted to the step of the ladder, such as will suit the armpit of the patient, and propel the head of the arm. But if, owing to the oldness of the accident, or the hardness of the body, we find the reduction difficult, we must have recourse to the method by the means of the instrument called ambe. The ambe is a piece of wood about two cubits in length, of the breadth of three fingers, and about two fingers’ breadth in thickness, having the one extremity round and adapted for the hollow of the armpit, like the extremity of the pestle. Having then wrapped its end with linen rags, in order that it may be softer, we adjust it under the head of the humerus in the armpit, and stretching the hand along the wood, we bind it at the arm, fore-arm, and wrist; then bringing the hand with the wood over a transverse piece of wood, fastened between two erect pedestals, or again over the step of a ladder, so that the armpit may be fitted transversely to the step, we draw the hand downwards, and allow the rest of the body to hang suspended on the opposite side; for then the limb will return to its place. After the reduction, we must apply to the armpit a secure and moderately-sized ball of wool, which, if there is no inflammation present, is to be dry, but if there is inflammation, it is to be dipped in oil. Around this, the shoulder, and the other armpit, a bandage is to be put on in the form of the Greek letter Χ, so that the decussation may take place above the affected shoulder; and the arm is to be bound to the sides; and the elbow and hand are to be slung by the neck, so that the limb may not fall out again while the dislocation is recent. After the seventh day or later, having loosed the bandages, we must have recourse to moderate friction, so that the body being rendered firmer, the joint may become less liable to luxations. But if the limb is often dislocated, either owing to its humidity (flabbiness), or from its being long subject to the accident, we must proceed to burning, as formerly described. But since sometimes the fœtus in utero or the child, while growing, sustains a dislocation of the part which is not reduced, the flesh upon the shoulder is nothing reduced from the natural, nor is the hand obstructed in any of its operations, but the bone remains shorter, not increasing in size; and such persons are called weasel-armed. But in the case of the thigh, the bone does not grow and the limb wastes; for, not being able to sustain the weight of the body, it is not exercised. And with regard to all the other members, if they remain unreduced the parts below are greatly impaired.
Commentary. Hippocrates delivers his opinions respecting dislocations at the shoulder-joint with singular modesty and a remarkable air of truth. He says, that he had never met with a case in which the head of the humerus was not lodged in the armpit, and expresses a doubt whether in reality there be dislocations inwards or backwards. “I will not affirm,” he adds, “whether or not dislocation forwards may take place, only this I can say that I have never seen it.” (De Articulis.) Galen, in his commentary on this work, mentions that he had seen five cases of the uncommon kinds of dislocation, four of which were dislocations forwards. They occurred mostly among the athletæ. In one case, of which he relates the particulars, he effected the reduction with his heel placed in the armpit. Galen states distinctly, that it is the retraction of the muscles which proves the great obstacle to reduction. (Ed. Basil, v, 585.) Hippocrates has described several methods of reduction, most of which are mentioned by our author. By the fist placed in the armpit, as described by our author. By the heel, as likewise described by him. He adds one advice not distinctly given by our author, to apply the ball placed in the armpit on the side within the head of the humerus, and not upon it. The process by suspending the patient upon the shoulder of another person is next described by him. Those by the pestle and ladder are afterwards clearly described. He then describes the ambe and the application of it to the reduction of dislocations in nearly the same terms as our author. We may here mention, by the way, that the description of the ambe given by Boyer, does not correspond exactly to the instrument recommended by Hippocrates. See drawings of Hippocrates’s ambe in Heister’s ‘Surgery’ (x, 4); in Scultet’s ‘Arsenal de Chirurgie’ (xxii, 1); and in Littré’s edition of Hippocrates (iv, 91.) Hippocrates describes other less important processes of reduction with a Thessalian chair, and a door. He remarks, that persons in a reduced habit of body are most liable to dislocations, and illustrates this position by some very acute observations on the occurrence of these accidents in cattle. After reduction, he directs that a ball of soft wool should be placed in the armpit and secured with a bandage and a sling; and he attaches great importance to well-regulated friction afterwards.
Celsus mentions two kinds of dislocation at the shoulder-joint, namely, downwards and forwards. He describes the methods of reduction by the hand, and by a wooden instrument (spathula lignea) resembling the ambe of Hippocrates. His description of the latter method is very distinct. His mode of reducing dislocations inwards merits attention. The man is to be laid on his back, and a strip of cloth or a thong of leather being placed in the armpit, its two ends are to be brought behind the patient’s head and given in charge to an assistant, while another takes hold of the arm; the surgeon is then to push back the patient’s head with his left hand, while with the other he raises the fore-arm and arm, and pushes the bone into its place. After reduction the armpit is to be stuffed with wool, and suitable bandages applied.
Oribasius treats of dislocations downwards, outwards, and forwards; and gives a very elaborate description of complicated machines for reducing them. Of these it is impossible to convey any correct idea without proper plates. We must be content, therefore, with referring the reader to his work. (De Machinamentis.)
Albucasis describes three kinds of dislocation at the shoulder, namely, downwards, inwards, below the pectoral muscle, and upwards, about which he expresses himself somewhat doubtful. He denies the possibility of dislocations forwards and backwards, the former being prevented by the muscles and latter by the scapula. His methods of reduction are exactly the same as those mentioned by Paulus.
Avicenna expresses himself as being doubtful whether any dislocation takes place at the shoulder except downwards, at least, he adds, he had no experience of any other case. He gives the symptoms of it very accurately, and describes all the methods of reduction mentioned by our author. He approves of the cautery to obviate the tendency to repeated dislocations.
Haly Abbas questions the occurrence of dislocations upwards, forwards, inwards, or backwards. He appears, therefore, to agree with Hippocrates in considering that downwards as the only unequivocal case of dislocation. He recommends the processes of reduction described by our author.
Rhases remarks, that owing to the shallowness of the glenoid cavity and the weakness of the ligaments the bones at the shoulder are more subject to luxations than those of any other joint. He describes the symptoms very accurately. The top of the shoulder, he says, is sharper than natural, the head of the humerus is felt in the armpit, the arm cannot be brought to the sides without pain, nor raised to the head at all. He remarks correctly that when the accident happens during delivery or in childhood, the arm does not grow to its natural size. He mentions that venesection is often of great use in reducing dislocations. He also recommends the warm bath. He denies the possibility of a dislocation in any other direction except downwards.
The ancient modes of reduction are recommended and described by Guy of Cauliac (v, 2); and Theodoricus (ii, 47.)