668
SURGERY.
quisite to bleed at the arm. When the luxation has been reduced,the parts must be retained in their situation, by placing the hmbin a relaxed position, and by applying appropriate bandages. Theshoulder-joint may be luxated by the head of the humerus fallingdownwards and backwards. The more usual kind of dislocation,however, is by the head being forced downwards and forwards.An upward luxation cannot happen without a fracture of the upperparts of the scapula. The signs of a dislocated shoulder are ina-bility to raise the arm, the head of the humerus being lelt out of Usproper place, while a vacui y is observed under the acromion.This luxation is often extremely easy of reduction. The surgeonshould be provided with assistants to extend the arm, by means, hnecessary, of a belt, or any substitute mr this placed round thearms, with long straps attached to it, by which to extend thelimb: another assistant is to draw back the shoulder-blade, whilethe operator, standing on the outside of (lie arm, directs the ex-tension according to the situation of the bone, and thus raises itinto the socket. Sometimes, when assistants are not at hand, anarm-dislocation may be reduced by placing it on the knee, andthus acting as with a lever. The arm especially if the patient hasbeen subject to the accident, may be supported in a sling sometime after the reduction. Luxation at the elbow is nol common;it is attended with a shortening of the fore-arm, a projection behindabove the elbow ; while in the bend of the elbow the extremity ofthe humerus may be felt. It is to be reduced by gradually ex-tending the fore arm rather in an oblique direction, and gently in-creasing the curvature of the elbow, and by endeavours to disen-gage the ends of the bones. After the reduction, the musclesshould be relaxed by preserving the elbow for some time rather ina bent position. When the fore arm is dislocated at the wrist,the rotatory motion of the hand is prevented. Alter the hones arereplaced, a tight tlannel-roller should be bound round the wri>t,and the arm supported in a sling. Dislocations of the thigh-boneare not very common. This bone is however susceptible of dis-placement in four different directions; upwards and obliquelybackwards, downwards, and a little forward, directly forward uponthe pubes, and backwards over the ischiatic notch In the first thelimb is shortened, and the knee turned inwards. When the neekof the thigh-bone is fractured (an accident which has been confounded with dislocation), the knee am) foot are on the contrarydirected outwards : the limb also in case of dislocation is movedwith more diffi ulty than when the neck of the bone is fractured.This dislocation is to he reduced by extension downwards andforwards. The patient is to be laid on his side, and a doublesheet may be placed under his thigh, which being attached to somefixed points, will serve to raise and support the limb during theproper extension. In a dislocation downwards and forwards, thesigns are reversed : the head of the thigh-bone may here be dis-tinctly felt in the perinamm. The extension in this case mint havean upward and outward direction ; its reduction is easier than inthe preceding case. In returning the bail of the bone into tin-socket, the surgeon must be careful to act cautiously : too preci-pitate a reduction is apt to push it again out of its place, and pro-duce an upward dislocation. When the dislocation is forwardupon the pubes, we are directed by some surgeons to lay the pa-tient on his side, and support thethigh by means of a pulley fixed tosome point above the limb : the operator thus assi-ted is to pressthe knee inwards. In the fourth kind of hip-dislocation (over theischiatic notch) the length of the limb is not interfered witli; buttlie accident may lie ascertained by the disappearance of thetrocanters. Here the reduction miM be attempted, by giving thebone an upward direction, while the knee is pressed inwards. Thelimb should not be used for some days after the reduction. Thepatella can only be dislocated upwards and downwards by a rup-ture of its ligament or tendons; in this case the bone will in-drawn up, and assume the appearance of fracture. It may how-ever be luxated to one or the other side. For reduction, the limbmust be extended ; and in lateral luxations the edge of the honeat the greatest distance from the joint may be depressed, by whichthe opposite edge is elevated, and may be returned into its place.The tibia is very seldom luxated at the knee-joint; when the ac-cident happens, it is easily delected. In reducing such a disloca-tion, the limb should be gently extended, and the bones replacedby the hand. Inflammation ought, with much solicitude, to beguarded against.
Than this, as it is now performed, scarcely any operation insurgery is more simple and secure. To preserve "the teguments,so as that they can be fairly brought over the stump, and properlyto lie, or otherwise secure the, bleeding vessels, constitute Ihepoints of practice in amputation ; and as we have previously shewnlank among the most important improvements in modern surgicalpractice. I he following are the general directions tor performingamputation: the tourniquet is first to he placed on the most con-venient part of (he limb for securing the larger arteries ; a circularincision is then to he made with the amputating knife (fig. 24,) orcommon scalpel, which is to pass all round the limb, and gothrough the skin and cellular substance; these are next to be dis-se- ted away from the muscles to such a distance as will allow thedivided ei'ges of the integuments to tome into contact over thestump The skin thus separated is to be drawn up from tile mus-cles, or turned bark upon them, and kept by an assistant in thissituation, while the operator now makes another incision at theedge of the reflected skin, beginning from beneath, and cutting ina circular direction down to the bone- The muscles are then tobe separated from the bone, as the skin before was from ihe mus-cles to such a distance, as to enable them afterwards completely tocover the end of the bone. The whole mass of flesh is then to bekept up from the bone by retractors, (fig. 25, and 26,) the perios-teum is to he divided all round in the place where the saw is to beapplied, but not all taken up from the bone : the saw, (fig. 27,) isnow to be used, and the hone divided with long firm strokes,taking especial care that (luring this part of the operation the as-sistant holds the limb with steadiness If here have been anysplinters of bone left, they should be immediately taken awaywith pincers, (fig. 28, Plate CLXV). The retractors are now tohe removed ; the principal arteries drawn up, and tied free fromthe nerves. Some warm wine, or other cordial, is to be given to(lie patient. The wound is to be cleared of blood, the musclesand skin are to he fairly laid together over the stump ; adhesiveplaster and the requisite bandaging applied, the patient taken tobed, and the wound treated in the common manner (see sectionon wounds). Unless any untoward circumstance arises, a com-plete cure will he thus made in the course of a few weeks. Bwill lie unnecessary here to enter into particulars concerning th edifferent parts to be operated upon, as every one who undertakesto perforin tlie operation lias seen it effected by some skilful sur-geon.
Of Distortions.
Distortions of tlie hones may arise from external injuries, fromdiseased c onstitutions, Irom a morbid state ot the bones, or a con-tracted state ot the musrlis, or both ; but the affection is most fi' 6 'quciilly owing to a weakly delicate constitution, as in rickety ° rseropludous cases. In the treatment of distortions of the spin®’particular attention ought to be paid to the cause of tlie disorder'It it appear to arise from the patient continuing tod long in an tparticular posture, every habit of this kind should be guardedagainst on the first appearance of the disease. If the patient fi* 8turned too much to one side, tlie reverse of this should lie advised-lie ought to sleep upon a firm hair-mattress, that his body l' eupon an equal surface. He should use an invigorating diet, d’ ecold bath, bark, and otln-r tonics. By a strict attention to t)> 3use of these remedies the disease has sometimes been retarded 111its progress. Various machines have been invented for removingdistortions of the spine by pressure; but considerable caution ’’here required, otherwise much injury may arise from it. Soii’^advantage, however, in certain eases, has been derived from 16use of the common collar, (fig. 2t), Plate CLXV.) or the sta)':and machinery adapted to them, (fig. 30,) invented in France , an ^alterwards brought into use in this country by Mr. Jones ot L ul1don, are found to be still better suited to this purpose. Wjm 1tlie distortion of a limb is ow ing to a curvature in a bone, if * 1case be recent, and especially il it occur in childhood, it may(iiiently be removed, without much difficulty, by making 11 g 1 - 3clua) hut constant pressure, by tlie use of the machinery, 011 1 ’convex side of live limb, till it recover its natural appearin' 6 'When the deformity occurs in the leg, a method lias been used, ' (several instances, which is to fix a firm splint of iron, lined v ’ 1 '
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