2 3 8 



APPLIED ANATOMY. 



weight will have dragged the head of the humerus into place. This same object can 

 be carried out, but not so well, by having the patient lie on the floor and pulling the 

 arm directly upward by means of a rope and pulley. Here the weight of the body 

 acts as the counter force. 



Other means, such as the heel in the axilla, etc. , may be found described in 

 works on surgery, but it is to be remembered that the objects to be sought are (i) to 

 overcome the action of the deltoid by abducting the arm, (2) to overcome the axillary 

 muscles pectoralis major, latissimus dorsi, and teres major by traction, and (3) to 

 loosen the capsule and open the tear to its widest extent by rotation while the head 

 is pushed with the hand toward and over the lower and anterior edge of the socket. 



FIG. 250. Diagram to show how rotation influences the size of the rent in the capsule. The square rep- 

 resents the rent in the capsule and the circle the head of the humerus. If the humerus is rotated too much in 

 the direction of the arrows, either to the right or left, the opening in the capsule is so narrowed as to obstruct 

 the passage of the head. 



Indirect Method. The indirect or lever method has been best systematized 

 by Kocher of Berne, although Henry H. Smith, a former professor of surgery in the 

 University of Pennsylvania, taught a similar method previously (see H. H. Smith's 

 "Surgery," n vols. , also Packard's " Minor Surgery," p. 204, and Ashhurst's "Sur- 

 gery," 2d Ed., Phila. 1878, p. 284). Kocher's method is as follows: First Step. 

 Flex the forearm until it forms a right angle with the arm, then, with the elbow 

 touching the side of the body, rotate the arm outward 90 degrees until the forearm 

 points directly outward (Fig. 251). This causes the head of the bone to rotate out- 

 ward and leave the side of the chest to take a position close to the glenoid cavity. 

 Second Step. The arm being held in this position', the elbow is raised forward until 



FIG. 251. Kocher's method of reducing dislocation of the shoulder: First step Flex the forearm at a right 

 angle to the arm; bring the humerus alongside the chest, the elbow nearly touching the side, and rotate outward 

 as far as the arm will go without undue force. 



it forms a right angle or a little more with the long axis of the body. This relaxes 

 the coracobrachialis muscle, releases the lesser tuberosity, which may be caught against 

 it, and allows the head to pass outward and ascend from its low position up into the 

 glenoid cavity (Fig. 252). Third Step. Carry the arm obliquely inward, place 

 the hand on the opposite shoulder and bring the elbow down to the surface of the 

 chest, the humerus pointing diagonally downward and inward as in the Velpeau 

 position for fractured clavicle (Fig. 253). 



The mechanism, as readily demonstrated on the cadaver, is as follows: The 

 head lies to the inner side of the glenoid cavity with the tense posterior portion of 

 the capsule passing backward. When external rotation is made the capsule is wound 

 around the head and upper portion of the neck and the head moves out. In some 

 instances the head will not only move out but will likewise move up and be drawn at 



