SURGERY. 
7-42 
motion of the joint is destroyed. The arm is 
to be supported, and but very gently extend- 
ed, and the bones pushed into their proper 
position, which is to be preserved by band- 
ages or splints. The metacarpal bones when 
dislocated are to be managed in a similar man- 
ner. When the thumb or lingers are dislo- 
cated, the phalanx is to be held by an as- 
sistant, while the surgeon elevates the dislo- 
cated end, and replaces it. 
Luxations of the inferior extremities. 
Dislocations of the thigh-bone are not very 
common. This bone is however susceptible 
of displacement in four different directions ; 
upwards and obliquely backwards, down- 
wards and a little forward, directly forward 
upon the pubes, and backwards over the 
ischiatic notch. 
in the first the limb is shortened, and the 
knee turned inwards. When the neck of the 
thigh-bone is fractured (an accident which 
has" been confounded with dislocation), the 
knee and foot are on the contrary directed 
outwards.: the limb also in case of disloca- 
tion is moved with more difficulty than when 
the neck of the bone is fractured. 
This dislocation is to be reduced by exten- 
sion downwards and forwards. The patient 
is to be laid on his side, and a double sheet 
may be placed under his thigh, which being 
attached to some fixed points, will serve to 
raise and support the limb during the proper 
•extension. 
In a dislocation downwards and forwards, 
the signs are reversed ; the head of the thigh- 
bone may here be distinctly felt in the peri- 
turum. The extension in this case must 
have an upw T ard and outward direction ; its 
reduction is easier than in the preceding case. 
In returning the ball of the bone into the 
•socket, the surgeon must be careful to act 
cautiously; too precipitate a reduction is apt 
to push it again out of its place, and produce 
-an upward dislocation. 
When the dislocation is forward upon the 
pubes, we are directed by some surgeons to 
lay the patient on his side, and support the 
thigh by means of a pulley fixed to some 
point above the limb : the operator thus assist- 
ed is to press the knee inwards. In the fourth 
kind of hip-dislocation (over the ischiatic 
notch) the length of the limb is not interfered 
with ; but the accident may be ascertained 
by the disappearance of the trocanters. Here 
the reduction must be attempted, by giving 
the bone an upward direction, while the knee 
is pressed inwards. The limb should not be 
used for some days after the reduction. 
The patalla can only be dislocated upwards 
and downwards by a rupture of its ligament 
or tendons; in this case the bone will be 
drawn up, and assume the appearance of 
fracture. It may however be luxated to one 
or the other side. For reduction, the limb 
must be extended ; and in lateral luxations 
the edge of the bone at the greatest distance 
from the joint may be depressed, by which 
the opposite edge is elevated, and may be 
returned into its place. 
The tibia is very seldom luxated at the 
knee-joint ; when the accident happens, it is 
easily detected. In reducing such a disloca- 
tion, the limb should be gently extended, and 
the bones replaced by the hand. Inflamma- 
tion ought, with much solicitude, to be guard- 
.ed against. 
Dislocations of the ancle-joint are very 
rare. Indeed they are scarcely possible 
without a fracture ot the end of the fibula. In 
reduction an extension of the foot, even with 
the leg, should be made, till the bones are 
readjusted. Luxations of the tarsal bones 
are to be treated in a similar manner. When 
the metatarsal bones and toes are dislocated, 
the reduction is to be effected as in the meta- 
carpus and lingers. 
Luxations of the spine, coccyx, ribs , and 
clavicle. 
In consequence of the firm ligamentous 
connection of the vertebral bones, dislocation 
seldom happens without fracture. W hen it 
does, it is almost invariably fatal. When the 
coccyx is displaced, it may be generally felt 
protruding. It is to be reduced by pressure 
with the lingers. This bone is sometimes 
forced inwards, and occasions much pain, 
tenesmus, and sometimes a suppression of 
urine. In this case the finger is to be intro- 
duced into the anus, and the pressure made 
outwards. Dislocations of the ribs are ex- 
ceedingly uncommon. All that can be ef- 
fected towards the reduction is to bend the 
body backwards, in order to press out the 
rib. 
When the clavicle is dislocated the end 
projects forwards under the skin., near its 
common place of junction with the breast- 
bone. The reduction is to be made by push- 
ing the protuded bone in with the lingers, 
while an assistant pulls back the arms and 
shoulders. The arm must afterwards be pro- 
perly supported in a sling. 
Luxations of the bones of the head and face. 
When the cranial bones are separated, 
the head must be supported by a bandage. 
If one of the nasal bones is luxated inwards, 
it is to be ele vated and reduced by inserting a 
tube into the nostril covered with lint. If 
the luxation is outward, the bone is to be 
pressed in by the fingers, and a double head- 
ed roller applied round the face. To reduce 
luxations of the lower jaw, which are not 
very unfrequent, the thumbs protected by a 
covering of leather, are to be thrust as far as 
possible between the jaws, and then the lin- 
gers being applied on the outside of the angle 
of the jaw, attempts should be made to bring 
it forward till it moves a little. It is then to 
be pressed forcibly down. 
Of amputation. 
Than this, as it is now performed, scarcelv 
any operation in surgery is more simple and 
secure. To preserve the teguments, so as 
that they can be fairly brought over the 
stump, and properly to tie, or otherwise se- 
cure the bleeding vessels, constitute the 
points of practice in amputation ; and, as we 
have previously shewn, rank among the most 
important improvements in modern surgical 
practice. 
The following are the general directions for 
performing amputation : The tourniquet is 
first to be placed on the most convenient part 
of the limb for securing the larger arteries ; a 
circular incision is then to be made with the 
amputating knife (fig. 71) or common scalpel, 
whish is to pass all round the limb, and go 
through the skin and cellular substance ; 
these are next to be dissected away from the 
muscles to such a distance as will allow the 
divided edges of the integuments to come 
into contact over the stump. The skin thus 
separated is to be drawn up from the muscles* 
or turned back upon them, and kept by an 
assistant in this situation, while the operator 
now makes another incision at the edge of 
the reflected skin, beginningfrom beneath, and 
cutting in a circular direction down to the 
bone. The muscles are then to be separated 
from the bone, as the skin before was from 
the muscles, to such a distance, as to enable 
them afterwards completely to cover the end 
of the bone. The whole mass of flesh is then 
to be- kept up from the bone by retractors 
(fig. 72 and 73) ; the' periosteum is to be di- 
vided all round in the place where the saw is 
to be applied, but not at all taken up from 
the bone : the saw (lig. 74) is now to be used, 
and the bone divided with long firm strokes, 
taking especial care that during this part 
of the operation the assistant holds the limb 
with steadiness. If there have been any 
splinters of bone left, they should be imme- . ] 
cfiately taken away with pincers (fig. 75). 
The retractors are now* to be removed ; the 
principal arteries drawn up, and tied free 
from the nerves. Some warm wine, or other 
cordial, is to.be given to the patient. Ihe 
wound is to be cleared of blood, the muscles 
and skin are to be fairly laid together over 
the stump; adhesive plaster and the requisite 
bandaging applied, the patient taken to bed, 
and the wound treated in the common man- 
ner (see section on wounds). Unless any 
untoward circumstance arises, a complete cure 
will be thus made in the course of a few 
weeks. 
After this general statement of the mode in 
which amputation is to be performed, we 
might now be expected, as in our accounts of 
fracture and luxation, to go over the separate 
parts which at different times come to be 
operated upon. Such minuteness, however, 
would he inconsistent with our plan and 
limits, and we shall merely observe, that in all 
cases of amputation the above rules apply; 
that the surgeon must be determined by his 
own judgment respecting the particular point 
at which a limb should be amputated ; it will 
of course be regulated by contingencies, but 
as a leading rule it may be observed, what 
indeed is almost too obvious to require no- 
tice, that in general as much as possible of 
the limb should be preserved. 
When joints, are to be operated upon 
in the way of amputation, further direc- 
tions are necessary. Amputation at the 
larger joints ought indeed, in every instance, 
if possible, to be avoided; for a wound in a 
joint is, as we have already seen, invariably 
hazardous. When, however, in consequence 
of abscesses in these parts, compound frac- 
tures at the union of bones, caries, or other 
diseases, it becomes necessary to amputate 
at the joints, it will be necessary, after first 
securing the artery, to make a circular inci- 
sion, as in common cases of amputation ; then 
on each side of the limb another cut is to be 
made in a longitudinal direction, from the 
joint to the circular incision, and passing 
down to the bone; the ligaments of the joint 
are now to be divided, and the limb remov- 
ed. If during the operation any branches of 
arteries have been divided, these are to be 
taken up or secured, the wound is to be 
cleared of blood, and the muscles and skin 
brought neatly and fairly together. The 
